Improving the Performance of the Public Mental Health System

MCPP Healthcare Consulting

Improving the Performance of the Public Mental Health System: Quality Assessment and Improvement


Berwick’s QuestionHow can one tell whether or not a healthcare organization is really serious about improving its quality, instead of simply engaging in defensive measurement to protect itself against the demands of outsiders for information?

Don Berwick, The Basic Concepts of Quality Improvement, unpublished paper, 1987


Quality Assessment and Improvement

DefinitionsThe Quality EnvironmentThe Quality Assessment ComponentDMAI—An Ongoing ProcessFundamental Principles of Quality Management


DefinitionsPerformance measurement is the “regular collection and reporting of data to track work produced and results achieved”Performance measure is “the specific quantitative representation of capacity, process, or outcome deemed relevant to the assessment of performance”Performance standard is “ a generally accepted, objective standard of measurement such as a rule or guideline against which an organization’s level of performance can be compared”


DefinitionsPerformance management is “the use of performance measurement information to help set agreed-upon performance goals, allocate and prioritize resources, inform managers to either confirm or change current policy or program directions to meet those goals, and report on the success in meeting those goals”Performance measurement is “NOT punishment”

Guidebook for Performance Measurement , Turning Point Project


DefinitionsTwo of the primary uses for the results of performance measurement are for: Making comparisons of performance levels Improving the quality of the processes and

outcomes of the organization The American College of Mental Health Administration (ACMHA) applied these distinctions between comparison and quality improvement in the proposed Consensus Set of Indicators for Behavioral Health


DefinitionsIn the ACMHA project, five national accreditation entities reached consensus on a set of performance measures (CARF [The Rehabilitation Commission], the Council on Accreditation, the Council on Quality and Leadership in Support of Persons with Disabilities, JCAHO and NCQA) but not on the specifications

for measurement They concluded that it was “important to recognize that selecting appropriate measures depends on the purpose of assessing performance”They designated measures as either a comparison measure or a quality improvement measure to clarify the intended use of each measure and its data set


DefinitionsFor comparison purposes, the standards and measures should provide sufficiently valid and reliable quantification such that comparison across the system’s programs and departments can be made. By identifying the highest level of performance or outcome (the benchmark), an organization can duplicate those work processes to achieve higher performance overall. For improving quality, some standards and measures lend themselves more to internal monitoring of performance and local accountability and are most suitable for supporting the improvement of the organization rather than for comparability among organizations.


DefinitionsBalanced Budget Act (BBA) of 1997 was a substantial rewrite of the Medicaid and Medicare program rules. Final rules were passed on 6/14/02; protocols and checklists then rolled out. Details in the protocols and checklists are critical for an understanding of BBA impact.

External Quality Review Organization (EQRO) is an independent entity that meets competence criteria for conducting Medicaid EQR activities; EQROs are being selected through state procurement processes to review the operations of risk bearing organizations contracting with state Medicaid agencies.


DefinitionsManaged Care Organization (MCO) is Medicaid’s term for a health plan that provides health care services to Medicaid enrollees Examples include Group Health Cooperative, Community

Health Plan of Washington and Molina

Prepaid Inpatient Health Plan (PIHP) is Medicaid’s term for a health plan that provides a more limited range of services than an MCO, for specialty services such as mental health Examples include the Washington State Regional Support

Networks (RSNs) and Oregon’s Mental Health Organizations (MHOs)


The Quality EnvironmentCrossing the Quality Chasm: a New Health System for the 21st Century, Institute of Medicine (IOM) 2001 Redesign of the health care system based on 10 new

rules Build organizational supports for change, including the

incorporation of care process and outcome measures into daily work and revising financial methods to support quality work

Priority Areas for National Action: Transforming Health Care Quality, IOM 2003—20 priority areas selected including major depression (screening and treatment) and severe and persistent mental illness (focus on treatment in the public sector)


The Quality EnvironmentCurrently an IOM Committee is studying how to adapt the Quality Chasm recommendations to Mental Health and Addictive Disorders In December 2004, a meeting was co-hosted by the National Council for Community Behavioral Healthcare (NCCBH), RWJ Center for Health Care Strategies and SAMHSA to frame a National Initiative for Behavioral Health Care Quality Improvement (CMS participated in this effort, an opportunity to generate their support as well as to foster relationships)


The Quality EnvironmentThe Institute for Healthcare Improvement (IHI) and Don Berwick, MD, have led the healthcare dialogue from its early beginnings IHI is a healthcare industry focal point through National Forums, trainings, and Breakthrough Series that target reducing adverse drug events, medical errors or reducing delays and waiting times throughout the systemIHI partnered with Health Resources and Services Administration (HRSA) in developing and staffing the Health Disparities Collaboratives for Federally Qualified Health Centers (asthma, diabetes, depression)


The Quality EnvironmentNational Committee for Quality Assurance (NCQA), created jointly by healthcare purchasers and HMOs to assess, measure and report on the quality of care provided by managed care organizations

Measures performance through HEDIS®, a standardized measurement system for MCOs

Accredits MCOs using standards grounded in QI—accreditation is based on a combination of accreditation survey scores and scores on HEDIS® measures (33 of 100 points)

MAA incorporates most of the NCQA quality standards in MCO contracts, collects selected HEDIS® performance measures, and uses NCQA accreditation for a major part of the EQRO review


The Quality EnvironmentJoint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation process has shifted from “survey preparation and scores to continuous operational improvement in support of safe, high-quality care”ORYX® core measure data are used to continually assess key performance areas, and eventually will be incorporated into the organization’s performance report as core measures are adopted for programsJCAHO prepared the CMS protocols for BBA EQROs to use in review of Medicaid MCOs and PIHPs


The Quality EnvironmentBBA requires EQROs to operate within specific protocols: Determine Compliance with Federal Medicaid

Managed Care Regulations Validate performance measures and methods

of calculating measures of performance Validate Performance Improvement Projects

(PIPs) and methods of conducting a PIP Conduct an Information Systems Capabilities

Assessment (ISCA)


BBA rules require that the MHD and PIHPs have a Quality Assessment and Performance Improvement Program (QAPI) that includes mechanisms to detect both under-utilization and over-utilizationMHD is “expected to continuously and consistently monitor the appropriateness and quality of the consumer care delivery system” in PIHPsMHD infrastructure is charged with reviewing statewide mental health data, recommending system improvements, and designing and implementing quality improvement projects and processes

The Quality Environment


The Quality EnvironmentSample questions from the EQRO protocol include: Have any recent QAPI activities been

implemented to monitor compliance with established standards for timeliness of access to care and member services?

What types of information does the program provide to support recredentialing of providers?

How does your PIHP detect over- and under-utilization? Provide examples.

How are enrollee and provider data from all components of your network used in your QAPI?


The Quality EnvironmentSo we have a QAPI and PIPs—it’s all about the bureaucracy, right?—wrong, the work must have relevance to the organizational vision, mission and goals—it’s about achieving your purpose and serving your consumersRequires leadership commitment and a deep understanding of the vision and mission of the system and/or organizationIf you cannot tell 1) how a project specifically relates to your agency’s vision and mission, or 2) (worse) if you cannot tell how your agency’s mission and vision relate to quality, the project should be sidelined until you can…

Hayes and Nelson, A Handbook Of Quality Change Implementation For Behavioral Health


The Quality Assessment Component

Are your system decisions made in a “data-free environment”?How do you know if your agency is achieving its goals?How do you know when you should initiate a PIP?How will you decide on implementing practice guidelines?How will you know if (and why or why not) the PIP or practice guideline is successful?



JCAHO ORYX® Core Measurement Sets: Data Quality Principles (Handout 1) May vary by setting or by key issue Relate to the basic principles of care, process oriented

Performance measure categories considered useful in the accreditation process

Clinical Health status Perception of care/service

Categories not considered useful include: Financial measures Utilization measures, unless related to a standard of quality



For JACHO Behavioral Health, requirements differ by type of organization

Organizations providing 24 hour care: Select a minimum of six clinical, health status or perception of

care measures from the set of JCAHO approved measures Measures must focus on the clients that receive 24 hour services

Organizations providing non-24 hour care and/or 24 hour care for an ADC of less than 10:

Select at least six measures from any relevant source, Share data, analytic conclusions and actions taken with surveyor In future will be expected to select and enroll in a listed

performance measurement system when core measures relevant to their services are identified



NCQA HEDIS® BH Measurement Sets (Handout 2) Follow up after hospitalization for mental illness Antidepressant medication management Mental health utilization—inpatient discharges and

average length of stay Mental health utilization—percentage of members

receiving services Chemical dependency utilization—inpatient discharges

and average length of stay Initiation and engagement of AOD dependence

treatment Identification of AOD services



PIHP Measurement Sets Verity examples (Handout 3)

ACMHA Indicators (Handout 4)PIHP Master Calendar (Handout 5)Pilot Measurement of Initiation and Engagement (Handout 6)



INITIATION and ENGAGEMENTMeasurement Model for Adult Mental Health

(Simplified)

INITIATION: Completion of IP Index event or next encounter with specified condition(s) within 14 days after Index date

ENGAGEMENT: Two more OP encounters (or one IP) with specified condition(s) within 30 days after Initiation date

time

Service-Free Period: No encounters for specified conditions for at least 120 days

Index: First encounter with specified condition after Service-Free Period

30 days14 days

From: Carter Center, April 19, 20042nd Forum on Performance Measures


ABCDEF Mental Health Initiation and Engagement Analysis, July 2003 through June 2004Overview

A new standard is emerging that speaks to important questions about what happens after a client has had their initial contact with themental health system. Has treatment been initiated on a timely basis? Has the client been actively engaged in care?

To answer "Yes" to the above two questions, the emerging consensus says that a 2nd visit should occur with 14 days of iniital contactand a 3rd and 4th visit should occur within 30 days after the second visit. (Source; 2nd Forum on Performance Measures, Carter Center, April 2004)

Day 1 Day 14 Day 44

First Visit

Episode Data Analysis

# % # % # % # % # % # % # %All Ages 1,688 100% 849 50% 456 27% 383 23% 525 31% 199 12% 125 7%

Note: The 1,688 episodes were for 1,576clients; 3 clients had 3 episodes, and 106 clientshad 2 episodes (per Episode definition).

DefinitionsEpisode: Services provided to a client wherethere wasn't a break in service longer than 119days. If a longer break occurred, a new episodebegan.Initiation Standard: A client must have asecond visit within 14 days after the first visit tomeet the Initiation Standard.Engagement Standard: A client who met theInitiation Standard must have a 3rd and 4th visitwithin 30 days after the 2nd visit (4 visits in 44days).

Total EpisodesStandard (2nd visit, 14 days) No Second Visit

Met Initiation

3rd and 4th Visits: Engagement2nd Visit: Inititiation

Second Visit Too Late

Didn't Meet Initiation Standard

No Fourth Visit

Didn't Meet Engagement Standard

Fourth Visit Too Late

Met Engagement Standard

Met Initiation Standard

849(50% of Total)

Fourth Visit Too Late 125 (7%)

No Fourth Visit199 (12%)

Met EngagementStandard

525(31% of Total)

Second VisitToo Late383 (23%)

No Second Visit456 (27%)



The quality assessment component requires that a group of selected indicators are regularly tracked and reportedThe data should be regularly analyzed through the use of control charts and comparison charts (Stay tuned for details!)These indicators should tell you if you are achieving your agency goals and objectivesThese indicators can provide the basis for deciding when a PIP might be indicated and the baseline information for measuring the future impact of PIPs



The quality organization does not wait to be told (via regulations or requirements) what processes, procedures, or programs to implement. Instead the quality organization proactively implements a program that it recognizes it may have to alter as standards or regulations are developed…

Consider the ACMHA list of indicators as a starting place—it includes measures of what quality service means to consumers

From Hayes and Nelson, A Handbook Of Quality Change Implementation For Behavioral Health



Quality assessment is an absolutely necessary, but not sufficient, step to change from a “data-free environment” to a “culture of measurement”


DMAI—An Ongoing ProcessLiving in a the “plan-do, plan-do” world?Too busy fighting fires to “close the loop”?Quality assessment indicators must have relevance to the organizational vision, mission, goals and objectivesPIPs based on goals and objectives must use a Design/Measure/Analyze/Improve cycle


MHD Implementation and Design Group has designated a standard methodology for the infrastructure to use in assessing, choosing, developing, monitoring and evaluating QI opportunities and outcomesThe Design, Measure, Analyze and Improve (DMAI) model is:

Congruent with and supported by JCAHO Data driven—integrates trending, tracking, analysis

and action into day-to-day processes Already used by numerous providers and at least one

RSN

DMAI—An Ongoing Process


DMAI—An Ongoing ProcessIMPROVING ORGANIZATION PERFORMANCE

TREATMENT OF DEPRESSION

OBJECTIVES: USE EFFECTIVE TREATMENT FOR DEPRESSION

PROCESSES: DISCOVER THE EFFECTIVENESS OF METHOD A + B + CTO FIND IF EFFECTIVE AT LEAST 1 SIGMA (BEYOND INITIAL AVERAGE SCORE) POSITIVE CHANGE

DESIGNDESIGN

MEASUREMENT: CORE MEASUREMENT SET FOR DEPRESSION

MEASURE

COMPARATIVE INFORMATION: JCAHO CORE MEASURE SET DATA. ARE OTHER TREATMENTS AS EFFECTIVE OF MORE EFFECTIVE?

STATISTICAL TOOLS & IMPROVEMENT PRIORITIES & JCAHO PRIORITY

INTERPRET TO IMPROVE

IMPROVEMENT/INNOVATION:USE CORE MEASURE SET WITH TREATMENT A + B + C

ANALYZEANALYZE

D.M.A.I. CYCLE

From: Joint CommissionCAMH: 2001 Comprehensive Accreditation Manual for Hospitals



DMAI—an Ongoing Process

Design—two steps at the beginning Establish objectives of the project Establish the processes used to meet the

objective

Measure Establish the specific outcome and process

measures the project will use for baseline and post implementation measurement


DMAI-An Ongoing ProcessAnalyze—two types of analysis Use statistical and numerical methods Use comparative methods

Improve Implement revised processes until analysis of

measures indicates that the objectives have been met


DMAI—An Ongoing Process

DMAI adds clarity about objectives into the cycle— this is implied, but not specified in the PDCA or PDSA, and two types of analyses are specified

Plan

Do

Check

Act

SystemDesign

ServiceDelivery

InformationReporting/Analysis

SystemRevision


Fundamental Principles of Quality Management

1. Know your customers and what they need2. Focus on processes3. Use data for making decisions4. Understand variation in processes5. Use teamwork to improve work6. Make quality improvement continuous7. Demonstrate leadership commitment


1. Know Your CustomersIdentify “customers” and their needs—in healthcare there are usually two sets of customers

The people who use your services are the primary customers

The purchasers of your services also have requirements

Set goals based on their needs and DMAI objectives based on the goalsMonitor performance and satisfaction to target performance improvementopportunitiesImprove or redesign how work is done

Design

Improve


2. Focus on Processes85% of poor quality is a result of poor work processes, not of staff doing a bad jobWhen things go wrong, it is often at the point of the “handoff” in the processAttend to improving the overall design, not just one part—some of the most complex and poor quality processes are the result of “improving” and creating “work arounds” at some steps instead of redesigning the entire process

Design

Improve


Focus on ProcessesAdvice from NCQA, JCAHO and others—measure processes that are

High-risk High-volume Problem prone

AndCan be tracked and reported as summary or aggregate statisticsAre being selected by other organizations to allow statistically valid comparisons to be made (for purposes of benchmarking)

Design

Improve


3. Use Data to Make Decisions

Use performance assessment data to target improvementUse data analysis tools to develop informationAnalyze data to identify root cause Use data to monitor performance outcomes

DMAI


Use Data to Make DecisionsCollection of data on clinical outcome alone does not provide useful information about what led to the outcome, or how it can be replicated or improvedPairing collection of outcome data with data on key process performance measures associated with the outcome will provide information on the consistency of the process of careStatistical analysis of these sets of data tells an organization whether it is improving performance on outcomes while improving consistency

MeasureAnalyze


Use Data to Make DecisionsGenerating Information

Information Needs

Questions

Data

Analysis

Communication

From: Methods and Tools of Quality Improvement Institute for Healthcare Improvement

MeasureAnalyze


Use Data to Make Decisions“Symptom” is the indication of a problem, but not a statement of cause“Theory” is the preliminary diagnosis about the cause“Analysis” includes data that confirms or rules out theories“Solution”is the change that will best address the cause“Information” is data that confirms whether the solution is having the expected impact

DMAI


Use Data to Make DecisionsIMPROVING ORGANIZATION PERFORMANCE




DESIGNDESIGN


MEASURE





ANALYZEANALYZE

D.M.A.I. CYCLE


DMAI



Use Data to Make Decisions

Check SheetBar ChartHistogramPareto ChartControl ChartRun Chart

Affinity DiagramBrainstormingProcess Flow ChartInterrelational DiagraphMatrix DiagramTree DiagramCause and Effect Diagram

Numerical ToolsConceptual Tools

DMAI


Use Data to Make DecisionsConceptual tools support theory generation regarding root causes, a key step in the PIP processRoot causes: In the logical chain of causes Directly and economically controllable Can be considered a constant part of (or deficiency

in) the process under study If eliminated, the problem disappears or is drastically

reduced (the Pareto Principle or 80-20 rule)Initiating a PIP that defines a desired solution, rather than a process to be studied can be hazardous to your QAPI’ s health!

Design


Use Data to Make DecisionsBrainstorming for root causes—theory generation thrives on divergent thinking, so no idea is a bad one…

What can go wrong in the process we are studying? Problems in hand-offs between steps Problems in execution within steps

Look at machines, materials, methods, measurements, and people

Cause-effect or Fishbone diagram (Handout 7) Organizes and displays theories Encourages divergent thinking Demonstrates the complexity of the problem Encourages scientific analysis (rule-out)

Failure to use a Cause-effect diagram or use of an incomplete one, can be hazardous to a PIP’s health!

Design


Use Data to Make DecisionsNumerical tools support analysis of PIP theories, measurement of PIP implementation and ongoing assessmentSpecific theories are needed to drive data collection and analysisData collection and analysis leads to “the vital few” root causes by narrowing the competing theories of cause

Look for clusters of causes that can be tested together Use stratifying variables to localize the problem and identify

likely causes Do Pareto analysis of symptoms and theories

MeasureAnalyze


Use Data to Make DecisionsTo Show Use Data Needed

Simple percentage or magnitude comparisons

Bar charts, pie charts or summary statistics

Simple tallies by category (At least 30 cases)

Trend Line graphs Time-ordered measurements (At least 12 sets of data points)

Distributions Histograms Forty or more measurements

Correlations Scatter diagrams Forty or more paired measurementsFrom Methods and Tools of Quality Improvement

Institute for Healthcare Improvement

DMAI


Use Data to Make Decisions

The Four Dimensions of Variability

Center: average, median or mode

Spread: range or standard deviation

Shape

Sequence: trend

From Methods and Tools of Quality Improvement

Institute for Healthcare Improvement

MeasureAnalyze


Use Data to Make DecisionsThe average by itself is not a good summary of data, use a variety of numerical summaries (Handout 8)Measures of center include:

Average/Mean: the total data values divided by the total number of observations

Median: the middle value in the data set, half of the data value lie above, half lie below the median

Mode: the most frequently occurring values in the set of data

Use histograms to look at overall variation patterns Use line graphs to look at patterns over time

MeasureAnalyze


Use Data to Make DecisionsPareto Principle

In any group of things that contribute to a common effect, a relative few contributors will account for the majority of the effect

These few contributors are call the “vital few” while the many other contributors are called the “useful many”

The “vital few” hold the greatest potential gain from quality improvement efforts

Pareto Diagram—A fact based tool for priority setting in quality improvement efforts (Handout 9)

MeasureAnalyze


Use Data to Make DecisionsControl charts (Handout 9) Variation in performance data is the result of a

complex system of causes Variation in this system of causes has

characteristics of random variation Used for ongoing quality assessment, control

charts can help decide when to take action on the process based on the data

Statistics provide “standard” distributions and mathematical methods for testing common and special cause variation

MeasureAnalyze


4. Understand VariationSources of variation include: machines, materials, methods, measurements, people, environmentControl charts are pictures of trend data with an extra feature—the range of variation built into the systemCommon cause variation occurs if the process is stable— variation in data points will be random and obey a mathematical law—it is said to be in statistical control, with a large number of small sources of variationIf an organization reacts to random variation in a process that is stable/in statistical control, it is called tampering and leads to further complexity, increasing variation and mistakes

MeasureAnalyze


Understand VariationSpecial cause variation arises because of specific circumstances which are not part of the process all the time and may or may not ever recur—if the recurrence is periodic, clues to the root cause may emerge Not in statistical control is:

One data point above or below the upper/lower control limits (three standard deviations)

Two out of three consecutive data points beyond two standard deviations

Of five consecutive data point, four are on the same side of the mean and beyond one standard deviation

Eight consecutive data points are on the same side of mean

Need to investigate special cause variation before making any conclusions about performance level

MeasureAnalyze


Understand VariationDon’t redesign an entire process (a PIP) when there is special cause variation, because there is not a consistent process to improve or stable baseline data to measure the impact of PIP implementationA sentinel event is a special cause variation requiring root cause analysisExamine specific incident(s) of special cause variation and make changes to a single element only after very careful analysisFailure to distinguish between common and special cause variation can be hazardous to organizational performance!

MeasureAnalyze


Understand Variation Control chart analysis is done before comparison analysis to ensure a given process is stable before evaluation of relative performance levelComparison charts are based on multiple organizations’ performance data (or on standards/benchmarks that have been adopted) and are used to evaluate relative performance levelIf the process is stable, the only way to make improvements is to fundamentally change some aspect of the process—through a redesign of the process or PIPUse benchmark data to create a new control chart that “raises the bar” on consistency of expected average performance and control limits

MeasureAnalyze


5. Use TeamworkPIPs need buy-in from all stakeholdersProcess being studied is stable, but complexCreative ideas are neededDivision of labor is neededProcess often crosses functionsSolution generally affects many

Improve

Design


Use TeamworkThose who do the work

Have theories about the cause Have the detailed knowledge needed for conceptual analysis tools

such as fishbone diagrams Have the clinical and intuitive judgment needed for design work Have ideas about improving the processes

Improving processes means change—involvement in planning change and having staff that are seen as leaders for the change will be critical to successful implementationOpen, safe communication is critical for improving processes (Handout 10)

Design

Improve


Use TeamworkProvide every team with a clear charge and support resources

Teams should adopt working agreements (everything from cell phone rules to decision procedures) Teams should have assigned roles of facilitators and recorders

The team process has some predictable stages that it is useful to keep in mind:

Forming Storming Norming Performing

Improve

Design


6. Make QI ContinuousIMPROVING ORGANIZATION PERFORMANCE




DESIGNDESIGN


MEASURE





ANALYZEANALYZE

D.M.A.I. CYCLE


DMAI



Make QI ContinuousQI is a system-wide approach to assessing and continuously improving quality of the processes and services over time See inter-relationships, not parts Understand the flow of work, not the one-time

snapshot Detail the work processes Determine cause and effect relationships Identify points of highest leverage Improve and innovate, not just change for

change’s sakeA way of doing business, not the exclusive responsibility of one individual or a committee

DMAI


Make QI Continuous Use quality assessment to identify areas for improvement Charge PIP team and provide support Provide DMAI training Use tools to understand root causes Use data for baseline and analysis Design process improvement to address root causes

Train ... train ... train …staff on the newly designed process improvementEvaluate the impact of process improvementsIf you don’t get the results you expected…….use assessment to understand why, revise accordingly and try again

DMAI


Make QI ContinuousMeasure improvement over time and compared to benchmarks

Health of the people served Customer satisfaction Cycle time Accuracy/consistent features Financial performance

Quality assessment is critical to measure the impact of PIPs and practice guidelines

Measurement of baseline rates Initial and second remeasurement after implementation Plan to ensure demonstrated improvement can be maintained over

time

EQROs are looking for performance measurement over time

DMAI


7. Demonstrate Leadership Commitment

Build a QAPI culture Connect the organization’s strategic plan to performance improvementKnow and use quality principlesEncourage all staff to use quality improvement in daily workReward improvements Assure adequate QAPI infrastructure for quality assessment and improvement activities

DMAI


Demonstrate Leadership Commitment: QAPI Culture

Clearly stated and enacted constancy of purpose—a deep understanding of the vision and missionRegular review of key indicator dataDecisions made on data rather than hunches or opinionsLong range view supports search for root causes and permanent solutions rather than quick fixesFocus on systems rather than individualsContinued identification of improvement opportunitiesPublicize successes (Handout 11)Clear communication agency-wide regarding the commitment to quality and the change processes necessary to implement improvement

DMAI


Demonstrate Leadership Commitment: QAPI Infrastructure

Governance Oversight and accountability

Program structure Who will do what when, with what processes for

recommending or decidingStaff Support for ongoing monitoring and analysis, for

training and facilitating improvement activitiesData system Collect data and report in a user friendly way

DMAI


Demonstrate Leadership Commitment: QAPI Description

GoalsOrganizational structures, responsibilities, and flow of information Quality council/committee Method for selecting PIP projects, charging PIP

work teamsScope Programs/services/staff included Processes included

Process for using quality assessment results to plan changes

DMAI


Demonstrate Leadership Commitment: QAPI Work Plan

GoalsImportant aspects of care/services Activities that involve a high volumes, high

degree of risk and/or tend to produce problems for patients or staff

Monitoring activities associated with important aspects of care/services Methods of measurement, frequency,

timelines for reportingConsumer satisfaction monitoring

DMAI


Demonstrate Leadership Commitment: QAPI Work Plan

Planned PIPs (in process, new) and timelinesEvaluation of PIPs now implemented and timelinesAnnual evaluation of QAPI workplan and program description, with proposed revisions

DMAI


Berwick’s AnswerQuality improvement is grounded in values,It begins with a commitment at the top of the organization,It takes money,It has mechanisms for horizontal integration of quality measurement and control up and down the line of management and is relevant to front line staff,It requires statistical sophistication,The focus is on design, not simply on performance,Management is responsive and looks for ways to remove obstacles to improvement, andThere is a strategy to drive out fear

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Improving the Performance of the Public Mental Health System

Health & Medicine