Overview of Quality Assurance and Enhancement

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Overview of Quality Assurance and Enhancement

• A Framework for Best PracticeVal BradleyHuman
  Services Research Institute

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Changing Quality Landscape

• Exposure of fault-lines in the system (e.g., CMS
  and the press)
• Emergence of self-determination
• Olmstead decision and proposed closures
• Struggles with MIS applications
• Direct support staff shortages
• Expansion of supports to individuals on the
  waiting list

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23 States have been sued for wait listing
individuals with developmental disabilities for
Medicaid long-term services
Gary Smith, HSRI, 2003
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• Decreasing/static funding coming on top of
  already strained providers
• Increasing federal expectations
• Inefficient business model (e.g., clumsy rate
  structures, etc.)

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Signs of Change in Performance Management

• No longer just better than the institution
• Rooted in outcomes
• Emphasis on enhancement and CQI
• Changing role of the state
• Changes in experiences of families and people
  with mental retardation
• Changes in accreditation approaches

Inclusion
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More Signs of Change

• Movement away from prescriptive standards to
  individualized risk management
• Collaborative development of standards
• Inclusion of consumer and family participation
  in oversight

Satisfaction
Consensus
CQI
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CMS Quality Initiative
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Purpose of National Technical Assistance

• To provide training and technical assistance to
  CMS Central and Regional Offices and states in
  quality assurance and improvement in HCBS waiver
  services for individuals with developmental
  disabilities.

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Major Tasks

• To assess identify trends in quality issues
  flowing from Regional Office HCBS waiver reviews
• To provide on-site and short-term technical
  assistance to the states to address specific
  quality and health and welfare concerns
• To provide technical assistance to Regional
  Offices regarding the content of HCBS waiver
  reviews, applications, renewals or amendments

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Major Tasks

• To respond to crisis situations at the request of
  CMS in order to provide Regional Offices and/or
  states with rapid access to potential remedies
  and resources.
• To provide national consultation and technical
  assistance regarding quality assurance and
  improvement in the implementation in HCBS
  waivers for people with developmental disabilities

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National Technical Assistance

• Resources available on HCBS.org
• 5 State Monitoring Review
• Root Cause Analysis
• Suggested Criteria
• Quality Framework
• Future Lessons learned, state examples, etc.
• Toolkits (e.g., state licensing and monitoring)
• Web-based conferences
• Match making between and among states
• Facilitated conference calls

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Status of State Requests

Active (8) Active/Short Term (5) Initial
Exploration (4) Referred (8) Completed (0)
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Regional Office Trainings

• November Case management (Hill and Mitchell)
• December Behavior management policies (Hitzing
  and Mullen)
• March Health and Medication (White-Scott
• Videos will eventually be available on line

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Other CMS Initiatives

• Participant Experience Survey
• Systems Change Grants
• Development of Protocol guidelines
• Identification of best practice
• Systems Change grants
• Independence Plus template
• Support for individuals moving out of
  institutions
• TA for elderly and disabled waiver services

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Emergence of Performance Indicators

• First appeared in behavioral and acute care
• Provide some cues for managing these complex
  systems
• Highlight impact of cost containment
• Illuminate whats working
• Provide early warning signs

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Characteristics of Performance Indicators

• Reflect major organizational or system goals.
• Address issues that can be influenced by the
  organization or system
• Have face validity

• Point a direction
• Reflect rates or major events
• Related to associated standards

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Participating NCI States
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HCBS Quality Framework
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Participant Access

• Information and Referral
• Intake and Eligibility            
• User-friendly processes
• Eligibility determination
• Referral to community services
• Individualization of services
• Prompt initiation

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Participant-Centered Service Planning and Delivery

• Participant-Centered Planning
• Adequate assessment
• Free choice of providers
• Responsive service plan
• Participant direction
• Service Delivery
• Ongoing service and support coordination
• Provision of needed services
• Ongoing monitoring
• Responsiveness to changing needs

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Provider Capacity and Capabilities

• Availability of individual and agency providers
• Review of provider qualifications
• Monitoring of providerperformance

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  Participant Safeguards

• Prevention and investigation of abuse, neglect
  and exploitation
• Tracking of major andunusual incidents
• Ensuring safety of housing and environment
• Regulation of behavior interventions
• Standards for medication management
• Provisions for personal safety and security
• Preparation for natural disasters and other
  public emergencies

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  Participant rights and responsibilities

•    Ensure that participants  
• Exercise civic and human rights
• Participate in decision making authority
• Have provisions for alternate decision making
• Have access to due processand grievance
  mechanisms

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Participant Outcome and Satisfaction

• Participant satisfaction
• Participant outcomes

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System Performance

• Conduct system performance appraisals
• Support quality improvement
• Ensure cultural competency
• Support participant stakeholder involvement
• Maintain financial integrity

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Review of Outcome-Focused Monitoring Mechanisms
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Immediate Challenges

• Quality assurance for individual providers
• Sustainability of person-centered QA
• Effectiveness and efficiency of current processes
• Integration of information
• Development of internal QA systems

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• Integration of quality assurance responsibilities
  across the system
• Involvement of families and people with
  disabilities
• Improvement in up-front quality expectations
  upfront (e.g., Pennsylvania).
• Transparency of QA systems and development of a
  demand for information

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Continuous Quality Improvement

• Close the loop
• Information from quality assurance
• drives decision making!
• 
  Therefore.

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Continuous Quality Improvement
Plan of correction Provider Qualification
Benchmarking Strategic Planning
Analysis of specific trends
Real time tracking of incidents and follow-up
Trends Analysis
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Conclusions and Recommendations
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Important Next Steps

• Place individual outcomes at the center of the
  system
• Enlist assistance of consumers and families
• Identify key areas of performance
• Create a quality management entity
• Make results available and accessible

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• Develop uniform reporting of critical health and
  safety events
• Develop staff credentialing and expand training
  options
• Reassess roles and responsibilities of case
  managers
• Refine performance contracting
• Develop quality management entity

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• Expand understanding of participant centered
  planning
• Develop a technical assistance capacity
• Implement risk management and health assessments
• Build integrated data systems
• Develop hotlines and ombudspersons

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Lessons for Providers

• Develop internal quality improvement plans
• Work with states to streamline QA/QE procedures
• Continue to work to upgrade the status of direct
  support professionals
• Enlist people with disabilities and families
• Continue to train staff in person-centered
  principles
• Assume that quality assurance will become
  morecomprehensive and systematic

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Final Words

• Beware the Continuous Improvement of Things
  Not Worth Improving
• W. Edwards Deming

CAUTION