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Music Only 9/18/17 Course # - ID-2017-45 1 Quality Management Certification - Module 103, Part 1
Music Only
9/18/17
Course # - ID-2017-45 1
Quality Management Certification - Module 103, Part 1
This webcast includes spoken narration.
To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation.
The written version of the narration appears to the right of the screen.
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Quality Management Certification - Module 103, Part 1
Welcome to Module 103, Part 1, first of a two‐part webcast focused on Quality Management Planning.
The Quality Management Planning webcast is part of the broader series of lessons covering ODP’s core philosophies, operational components and business practices.
This webcast is also third in a series of lessons within ODP’s QM Certification Program. Through this program, ODP staff and stakeholders expand their understanding of QM and their skills in applying QM to support and enhance the lives of individuals with an Intellectual Disability and/or autism. You and your supervisor may want you to revisit this webcast and complete ODP’s QM Certification Program at a future time.
Before beginning our session today, let’s briefly recap some of the highlighted information presented in QM Module 102, Using Information and Tools for Quality Management, Parts 1 and 2. In Module 102, we learned about the:
*Importance of data*Concepts of performance measurement*Collecting and organizing data and*Analyzing, displaying and reporting data
Understanding and putting to use these concepts and practices are key to implementation of ODP’s Quality Management Strategy.
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Quality Management Certification - Module 103, Part 1
Our discussion today begins with a review of our training objectives for Module 103, Part 1.
The objectives include:
*Carrying QM Priorities through to QM Plans and*Writing Goals and Objectives
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Quality Management Certification - Module 103, Part 1
Recall from our discussions in training Modules 101 and 102 that ODP’s Quality Management (QM) Strategy is developed as a comprehensive program to include a “balance” of quality planning, quality assurance and quality improvement components.
Founded on its Mission, Vision and Values, ODP implemented its Quality Management Strategy—using standardized structure and processes—to increase organization‐wide recognition and understanding of the need to use objective data and reporting.
Goals of ODP’s QM Strategy are to advance individuals’ Everyday Lives, identify opportunities for systemic quality improvements, support management decision‐making, satisfy regulatory requirements, and evaluate the effectiveness of planned change.
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Quality Management Certification - Module 103, Part 1
ODP’s Executive Leadership plays a critical role by developing standardized structure and processes, collaborating with the Information Sharing and Advisory Committee (ISAC) to set priorities for systemic quality improvement, determining whether services provided are leading to desired results, including
*Supporting everyday lives for individuals with an Intellectual Disability and/or autism*Safeguarding health and safety and implementing promising practices, and *Overseeing program compliance.
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Quality Management Certification - Module 103, Part 1
When ODP identifies improvement opportunities, a Quality Management planning methodology is initiated to document and track progress in accountable ways. A Quality Management Plan:*Establishes quality assurance and quality improvement projects*Guides the activities of an organization toward achieving better quality outcomes, and *Includes a continuous process, a cycle of assessment, analysis and action for improvement.
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Quality Management Certification - Module 103, Part 1
To facilitate the process of priority‐setting and QM Plan development system‐wide, we’ve learned in previous Modules that ODP collaborates with stakeholders in developing and publishing Everyday Lives: Values in Action and the companion document ISAC Recommendations, Strategies, and Performance Measures, both found on MyODP.org using the link provided on this screen.
Continuously Improving Quality is, in itself, one of these ISAC priorities, Recommendation #9, calling for all stakeholders to work together as we engage in the process of measuring how well services assist people to achieve the lives they desire.
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Quality Management Certification - Module 103, Part 1
Recall from Module 101 that ISAC recommendations are 13 in number and are designed to move Everyday Lives values into action by promoting the essential elements required:
*Assuring Effective Communication*Promoting Self‐Direction, Choice and Control*Supporting Families throughout the Lifespan*Promoting Health, Wellness, and Safety*Supporting People with Complex Needs*Developing and Supporting Qualified Staff, *Simplifying the System,
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Quality Management Certification - Module 103, Part 1
*Improving Quality*Expanding Options for Community Living*Increasing Community Participation*Providing Community Services to Everyone, and*Evaluating Future Innovations based on Everyday Lives Principles.
Each recommendation is designed to improve opportunities for people with Intellectual Disabilities and/or autism to live full, everyday lives.
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Quality Management Certification - Module 103, Part 1
In addition to the ISAC Recommendations, ODP’s priorities include achieving compliance with CMS waiver assurances, risk and incident management policies, and regulatory requirements.
Achieving compliance with waiver assurances means that, depending on the roles and responsibilities of AEs, SCOs, and Providers respectively, each of these entities must adhere to the Quality Improvement Strategy outlined in ODP’s approved waivers. Waiver Appendices that apply are:
*Appendix A – Administrative Authority*Appendix B – Level of Care Evaluations*Appendix C – Qualified Providers*Appendix D – Service Plans*Appendix G – Health and Welfare, and *Appendix I – Financial Accountability.
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Quality Management Certification - Module 103, Part 1
Achieving compliance with risk and incident management policies may involve reviewing and evaluating practices to: *Prevent, reduce and eliminate incidents of abuse, neglect and exploitation and ensure appropriatecorrective actions are taken when such incidents do occur,*Manage the approval, use and oversight of restrictive intervention according to policy and procedure, *Prevent, reduce and eliminate restraints, and*Ensure individuals’ medical needs are met safely.
Later in our presentation, we will discuss how stakeholder groups consider these priorities, conduct an internal evaluation of their performance, and identify specific opportunities for improvements that will be incorporated into a QM Plan.
First, let’s talk about what a QM Plan looks like…
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Quality Management Certification - Module 103, Part 1
Building a QM Plan involves inclusion of specific criteria. We discussed some of these criteria in Module 102 but let’s break down our list, one at a time… and then provide some examples.
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Quality Management Certification - Module 103, Part 1
The following criteria are to be included in a QM Plan document:
*Goals and outcomes*Target objectives that support each goal*Performance measures used to evaluate progress in achieving the target objectives*Data source for each performance measure*Responsible person for the QM Plan *Action plans to support the attainment of target objectives*Frequency of data reporting.
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A Goal is:*Related to an organization’s mission, vision, values and quality framework
*Written in broad non‐specific general terms and
*The “ideal” to be achieved
For example ‐ Individuals are safe in their homes and communities.
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Quality Management Certification - Module 103, Part 1
A Desired Outcome is a desired result.
In quality management, we can have people outcomes, process outcomes or system outcomes.
An example of a People outcome is: People are free of abuse, neglect, and exploitation.An example of a Process outcome is: Individuals receive a fall risk assessment.An example of a System outcome is: Distribution of new waiver enrollees is equitable.
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Quality Management Certification - Module 103, Part 1
A Target Objective states the level of performance an organization desires to achieve within a specified period of time and can be established by considering baseline data and benchmarks.
For example ‐ Incidents of physical restraints will be decreased by 20% to 20 by June 30, 2017.
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Quality Management Certification - Module 103, Part 1
A Baseline is built by tracking an organization’s performance over time, generally at least one year, and provides an objective assessment of current level of performance. A baseline answers the question, “Where are we now?”
For example: Number of restraints for FY 16‐17 = 25 restraints.
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Quality Management Certification - Module 103, Part 1
A benchmark refers to the best or most desirable performance, whether internal, such as best Provider performance, or external, such as best performance of a similar organization or performance expected by a regulatory body.
A benchmark is used to establish a level of performance the organization strives to achieve through quality management activities. A benchmark answers the question, “Where are we going?”
For example: In the updated quality requirements, CMS incorporates a benchmark of 86% for performance measures.
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Quality Management Certification - Module 103, Part 1
A performance measure:*May be a simple number, or count, or a*Percentage
For example: *The number of restraints that occurred during a year would be a simple count. *The number of physical restraints divided by the total number of restraints would be a percentage.
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Quality Management Certification - Module 103, Part 1
A data source is stored data collected according to specific requirements that aim to ensure reliability and validity of the data. Data sources include logs, checklists, a person’s chart, formal databases and surveys.
For example: HCSIS, which is the Home and Community Services Information System.
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Quality Management Certification - Module 103, Part 1
A responsible person refers to the title of the person in your organization who is ultimately responsible for managing or coordinating the activities that will lead to the achievement of the goal and desired outcome, including the periodic monitoring, analysis and reporting of performance.
For example: Employment Lead, Nurse Manager
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Quality Management Certification - Module 103, Part 1
While data are collected and tracked on a more frequent basis, frequency as the term is used on the QM Plan refers to the schedule for summarizing and reporting progress toward achieving goals and desired outcomes to an oversight group.
A reporting calendar is often developed and shared within organizations to establish the frequency of reporting for leaders, managers, responsible parties, and staff.
For example: Quarterly
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Quality Management Certification - Module 103, Part 1
Now let’s see what the QM Plan criteria we have talked about so far look like when inserted into a QM Plan template.
As you can see from the diagram, we have identified our goal, desired outcome, target objective and performance measure with data source, responsible person and frequency of reporting.
The example you are viewing uses a QM Plan template developed by ODP. If you develop your own template, be sure to incorporate all the required QM Plan criteria.
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Quality Management Certification - Module 103, Part 1
Let’s talk about how ODP, AEs, SCOs, and Providers develop and implement QM Plans and Action Plans to achieve quality improvements.
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Quality Management Certification - Module 103, Part 1
Each stakeholder group in our complex, multi‐layered system plays a unique role and accepts accompanying responsibilities to promote the best possible outcomes for individuals ODP serves and supports. The greatest successes we achieve are the result of ODP and stakeholder groups working together.
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Quality Management Certification - Module 103, Part 1
The starting point for each of us in developing QM Plans and Action Plans is a thoughtful consideration of ODP’s priorities described earlier in this Module in light of our place in the organizational structure, our specific roles and responsibilities, and the processes we carry out every day.
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Quality Management Certification - Module 103, Part 1
For example, if the mission of our organization is to provide employment supports and services, a focus area for our QM Plan and Action Plan will align with ISAC Recommendation #3, Increase Employment, and will be to ensure Person‐Centered Service Planning and Delivery specifically in the area of supporting individuals to become and remain successfully employed.
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Quality Management Certification - Module 103, Part 1
Contained within the quality improvement strategy for Waiver Appendix G, Health and Welfare, is the following performance measure:
Number and percent of critical incidents finalized within the required time frame.
This performance measure pertains directly to Provider organizations as Providers strive to finalize critical incidents in EIM within 30 days.
Providers should examine their organizations’ track records when it comes to timely finalization of critical incidents to determine if performance is such that systemic, or organization‐wide, improvement activities are warranted.
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Quality Management Certification - Module 103, Part 1
Additional review of performance data associated with functions and processes AEs, SCOs, and Providers perform should continue to inform the task of setting QM Plan priorities.
Data that may be considered include:
*ISAC performance data supporting each Recommendation
*Results from QA&I Process reviews
*HCSIS data
*Compliance with waiver assurances
*Incident management data
*Results of IM4Q surveys
*Review of complaints and grievances.
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Quality Management Certification - Module 103, Part 1
Hopefully, the answer to the question, “Should all ODP priority areas be incorporated into your QM Plan?” is now clear. The answer to this question is NO.
ODP’s expectation is that AEs, SCOs and Providers review their major functions, processes, roles and responsibilities, consider ODP’s priority areas, study their local performance data related to these priorities, and then determine which of those areas are most in need of improvement in their organization.
AEs, SCOs, and Providers may also include improvement activities in their QM Plans that address areas, separate from ODP priority areas, considered unique to their agencies.
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Quality Management Certification - Module 103, Part 1
In other words…
Stakeholders should prioritize areas for improvement in which they plan to focus their attention.
Prioritization is necessary to ensure that performance improvement activities are manageable and effective in enhancing services, supports, and outcomes for individuals and to ensure that available resources are used wisely.
Stakeholders should prioritize areas in which they plan to focus quality improvement efforts while considering ODP priorities and their own unique needs.
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Quality Management Certification - Module 103, Part 1
Once you’ve completed your review and chosen the focus areas you will include in your QM Plan, develop and document your rationale for the decisions you made in any given year for future reference.
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Quality Management Certification - Module 103, Part 1
ODP evaluates QM Plans and Action Plans of AEs and SCOs, and AEs evaluate QM Plans of Providers as part of ODP’s Quality Assessment and Improvement (QA&I) Process.
ODP and AEs look for each entity’s QM Plan and Action Plan to demonstrate alignment with ODP’s Mission, Vision, Values, and QM Priorities as well as for inclusion of opportunities for improvement specific to the performance results of each entity.
As part of this review, AEs and SCOs are asked to submit their QM Plans and Action Plans to ODP for review in the year the entity undergoes Full QA&I Process Review. ODP may also review an entity’s QM Plan and Action Plan upon request.
AEs conducting Provider QA&I Reviews request QM Plans and Action Plans of Providers for review in the year the Provider undergoes Full QA&I Process Review and may also evaluate a Provider’s QM Plan and Action Plan upon request.
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Quality Management Certification - Module 103, Part 1
QM Plans and Action Plans are developed and maintained on a Fiscal Year cycle.
AEs, SCOs, and Providers use their performance results on annual Self‐Assessment reviews and in Full QA&I Process Reviews to help guide decision‐making about QM Plan priorities and to update existing Action Plans when necessary.
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Quality Management Certification - Module 103, Part 1
To achieve system‐wide improvement, ODP recognizes the critical importance of ongoing collaboration and teamwork among ODP, AEs, SCOs and Providers.
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Quality Management Certification - Module 103, Part 1
The QA&I Process provides unique opportunities for ODP to work with AEs and SCOs and for Assigned AEs to work with designated Providers to identify focus areas for quality improvement and in the subsequent development, implementation, and evaluation of QM Plans and supporting Action Plans.
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Quality Management Certification - Module 103, Part 1
Another opportunity for team work exists when AEs and SCOs that support individuals registered with each respective AE collaborate in identifying and achieving QM Plan objectives in which both AEs and SCOs play key roles, such as person‐centered service planning process, ensuring effective communication, and promoting employment.
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Quality Management Certification - Module 103, Part 1
Now that you have considered ODP’s list of priorities and local performance in identified areas, consulted with other stakeholder groups when choosing opportunities for improvement, and completed a QM Plan document, it’s time to forge ahead with the QM Planning process.
What happens next? We will discuss how to plan for and implement improvement activities (using Action Plans) in Module 103, Part 2.
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Quality Management Certification - Module 103, Part 1
Electronic resources supporting this Module, including QM Plan and Action Plan templates, are available online on MyODP.org at the links provided on this slide. If you have not yet received a user name and password to access MyODP, instructions for obtaining a login are on the website’s home page.
This concludes Part 1 of Module 103, Quality Management Planning.
Now that you have viewed this presentation, we suggest that you meet with your supervisor to discuss in more detail the information provided in this webcast and your roles and responsibilities for quality management within your position.
Please be sure to view Part 2 of this QM Certification Module found where you accessed this webcast.
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Quality Management Certification - Module 103, Part 1
This webcast has been developed and produced by the Pennsylvania Department of Human Services, Office of Developmental Programs in partnership with The Columbus Organization.
Thank you for participating in this lesson.
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Quality Management Certification - Module 103, Part 1
