Provider Training

April 24, 2015

Presenter Introductions Selenna Moss, MHA, BS, RHIT, CHP

Partners BHM Chief Compliance and Quality Officer

Joel D. Leonard, MPACenterPoint Quality Management Director

Carolyn Shoaf LRT/CTRS CenterPoint QM Compliance Manager

Marsha Johnson, BS, QPPartners BHM QM Analyst

Elizabeth Pritchard, MSWCenterPoint QM Specialist, MH/SA

Logistics

Sign In

Restrooms

Breaks

Vending Machines

Completion Certificates

Post-training Evaluations

Key Points

Quality Improvement (QI) is vital

QI programs can be implemented by anyone

There are a lot of resources and tools available to assist your quality improvement efforts

The ABC’s of Quality Improvement

What is a Quality Improvement (QI) Program?

Systematic activities that are organized and implemented to monitor, assess, and improve an organization’s quality of health care (HRSA)

The Value & Importance of Effective QI Programs Enhances marketability

Provides better information for decision making

Supports implementation of the organization’s mission and vision

Identifies opportunities for improvement

Documents and evaluates the performance of key areas

Promotes coordination and collaboration

Assists in meeting regulatory, accreditation, and oversight organization requirements

Work Smarter – Not Harder

Scalability

LIP

Small Provider Agency

Medium Provider Organization

Large Provider Organization

Institute for Healthcare Improvement (IHI): Triple Aim

Institute of Medicine (IOM): Chasing the Quality Chasm

• Safety

• Effectiveness of Care

• Patient Centeredness

• Timeliness

• Efficiency

• Equitability

Six Aims to Improvement

in Healthcare

QI Plans: DefinedA QI Plan:

• Is an organizational work-plan

• Includes essential information on quality assurance/quality improvement (QA/QI)activities

• Updated regularly

• Outlines clinical focus areas

• Is an outgrowth of evaluation of QI activities, organizational priorities and program requirements

Why Do QI Plans?

• State/Federal Requirements

• LME-MCO Contractual Requirements

• Accreditation Requirements

• Current Industry Best Practices

• Research

How Do I Begin?

• Organizational Assessment- Identify Strengths/Weaknesses

• Identify Barriers (i.e. structure, resources, communication, performance measurement, staff, priorities)

• Identify External Requirements

QI Plan- 5 Key Elements

• Introduction

• Structure & Leadership

• Quality Improvement Objectives

• Performance Measurement

• Implementation & Evaluation

Source: Health Resources and Services Administration (HERSA)

Key Element 1: Introduction

The Introduction includes:

• Mission, Vision, Scope of Services

• Definitions of Key Concepts/Quality Terms

• Quality Statement

• Quality Model and Method

Mission, Vision, Scope of Service

Begin the QI Plan with a brief description of your agency, including:

• Agency Mission and Vision

• Services Provided

• Size of Agency

• Geographic Area

Definitions of Key Concepts/Terms

• Define the key concepts and quality terms for consistency

• Frequently Used Terms:

Quality Assurance

Quality Improvement

Continuous Quality Improvement

Quality of Care/Service

Quality Statement• Quality Statement- a description of your QI Program’s

goals and objectives

What do you want for your consumers, employees and community?

The answer to this question is your quality statement!!

• Connect Quality Statement to Mission, Vision and Strategic goals

• Include Accrediting Body Requirements (URAC, NCQA, Joint Commission)

Model & Methodology• Your quality model is your foundation

• Choose a model and use it as a guide for your QI planning

• Frequently Used Models:

PDSA- Plan, Do, Study, Act Six Sigma- Define, Measure, Analyze,

Improve, Control (DMAIC)

Key Element 2: Structure & Leadership

This element of the QI Plan includes a description of :

• Organizational Structure and Support

• Resources to Support QI Activities

• Training

Organizational Structure & Support

• Leadership Structure and Support of QI ActivitiesExecutive Management Board of Directors

• Committee Structure and Support of QI ActivitiesQuality Improvement CommitteeAgency Sub-Committees

• Stakeholder Involvement

QI Staff Structure & Support

• Role and Responsibilities of QI Staff:

Implementation of QI Activities

QI Plan writing and updates

Monitoring of QI Plan Performance

Gathering and validation of data

Training/Education

Resources to Support QI Activities

• Determine what is needed to achieve objectives:

Staff

Funding

Equipment

Training/Development

Training

• Describe training on the QI Process/Plan Include reason for training Include participants Identify training by topic, required intervals and

designated staff

• Include Training on Important Topics: NC TOPPS Evidence Based Practice (EBP) False Claims Act (FCA)

Key Element 3: QI Objectives• QI Plan versus Quality Improvement Project (QIP)

QI Plan Strategic Plan for Quality Improvement (Long-

Term Outcome) Ongoing monitoring and evaluation tool

QIP A QIP is born out of the QI Plan A QIP is the short-term goal utilized to meet the

long-term outcome identified in the QI Plan

QI Objectives Should Include

• Clinical Objectives Based on clinical performance measures Derived from evidence-based clinical guidelines

• Operational Objectives Set in consideration of the organization’s strategic

mission Support the organization’s growth and development

QI Objectives- Think S.M.A.R.T

• Specific- What are you going to do?

• Measureable- Is it measureable?

• Attainable- Can you get it done within time frame?

• Relevant- Will obtain the desired results?

• Time- How long will it take you?

Key Element 4: Performance Measurement • Performance Measurement is the process of

regularly assessing the results produced by the program.

• It involves identifying processes, systems and outcomes that are integral to the performance of the service delivery system, selecting indicators of these processes, systems and outcomes, and analyzing information related to these indicators on a regular basis.

Purpose of Measurement & Assessment

• Assess the stability of processes or outcomes

• Identify problems and opportunities to improve

• Assess the outcome of the care provided

• Assess whether a new or improved process meets performance expectations

Measurement & Assessment Involves

• Selection of a process or outcome to be measured

• Identification and/or development of performance indicators

• Aggregating data

• Assessment of performance

• Taking action

• Reporting

Performance Measures to Include

Performance Measures to include in QI Plan (if applicable)

• Risk Management

• NC TOPPS

• Evidence Based Practice (EBP)

• Incident Reporting

• First Responder

• Failure to Provider Backup Staffing Reports

Selection of Performance Indicator

• Performance Indicator: a quantitative tool that provides information about the performance process, services, functions or outcomes.

• Selection of a Performance Indicator is based on the following considerations:

Relevance

Clinical importance

Performance Indicator Characteristics

Factors to consider in determining which indictor to use:

• Scientific Foundation

• Validity

• Resource Availability

• Meaningfulness

Assessment of Performance Indicator

Assessment is accomplished by comparing actual performance on an indicator with:

• Self over time

• Pre-established standards

• Evidence Based Practice Information

• Similar behavioral health providers

Key Element 5: Implementation & EvaluationSuccessful implementation requires a strong infrastructure

• Review and Update QI Plan

• Prioritize Objectives/Goals/Projects

• Leadership Commitment

• Staff and Consumer Input

• Communicate with Relevant Individuals/Groups

• Staff Education and Training

Annual Evaluation

Review and update the QI Plan annually

Review should include:

• Progress on QI Objectives

• Training Completed & Effectiveness

• Progress On/Completion of QIPs

• Information from oversight agencies

• Changes to QI Plan For Coming Year

• Communication of Annual Review Results

QIP BenefitsQIPs are an efficient and effective method of solving a problem and/or improving a process.

Uses data to drive decision making

Focuses on results

A methodical process

Avoids wasting time/effort/resources

Helps identify the “root cause” so that the results are sustainable over time

Where to Begin?

Identify a problem that needs solving What are you getting complaints about?

What is a hindrance for your staff?

Are you out of compliance for a rule/regulation?

Identified risk management areas

Identify a process that needs improving Is something taking too long?

Would you like improve satisfaction scores?

Are staff/clients asking for a better way to do something?

Is there an agency goal?

A Topic is Chosen, What Next?

Give the project a name

Identify who will be affected by the project Clients or staff?

Who will be the key staff responsible for the project?

Identify the start and end dates for the project

Identify exactly what you want to improve

Why did you select the project?

What measures/data can be used to measure the problem and interventions?

Gain approval for the project within your agency

Identify Data and Analyze

What is your BASELINE data? What numbers measure the current state of things?

Admissions, turn over rate, length of time waiting, number of incidents or complaints, etc…

Look at the relationship between the measures

Spikes or dips in the data?

Trends? (should be 3 measures to identify a trend)

What happened to explain the results of the measures?

What is Causing the Problem?

Is this a knowledge/education issue?

Provide training

Is the problem an insufficient work process?

Identify key people to identify the work flow

Change the policy/procedure

Train staff, supervise and monitor by measuring

Identify what is needed for success?

IT/forms/prompts?

Identify Interventions

Identify actions to reduce/eliminate the problem OR improve the outcome.

Brainstorm all options (involve key “front-line” staff)

Select ONE action to take

What data is needed to evaluate if the action works?

Implement Your Intervention

Create a standard template to document your QIP

Use an interdisciplinary team to bring different perspectives and skills. Include “front line staff” and key stakeholders

Gain approval from leadership to begin the QIP

Gain “buy in” from staff as you implement

Share the who/what/where/when/why

Share the results of the re-measure data

Recognize the effort/result for changing processes

After the Intervention: Collect Data for Re-measures

Measure “apples to apples”

Same measure as your BASELINE data

# of calls / complaints / falls / denials

Same timeframe

Quarterly /monthly / weekly

Document re-measures on the QIP form

Tips for Data Collection

Clearly define the exact data being collected

What is the source of the data?

Reliable?

Collected electronically or manually?

Decide who will collect it and how often

Do resources need to be dedicated to data collection?

Make assignments and give deadlines for reporting

Make the data collection part of the current flow of work.

Additional Considerations

Are you using a billing warehouse? They can provide you with data

Excel

What do you have already available?

What are you currently required to do as part of your day to day work?

Do you receive any measures from outside sources?

Measuring Progress

Gather your numbers and compare re-measures

Sometimes a visual comparison gives more insightGraphs, charts, etc…

Is this measure showing you what you need?

Be specific and objectiveSometimes data results will surprise you!

Avoid rejecting results that do not validate your initial assumptions about the outcome

Be open to exploring alternate “root causes” or interventions

QIP Analysis

Did you reach the goal? Continue to measure for 1 year to assure gains continue

If improvement occurred, was it the result of the planned intervention or something else? This is “face validity”

If you did not reach goal, what barriers were encountered? What did you learn? What benefits came from the effort?

What are the next steps?Gain approval to end the project

Keep the goal, extend the project with new interventions

Start a new project with different goal or different measures

Provider QIP Highlight

QIP Activity

Quality Improvement Toolbox

Next Steps

If you don’t have a QI Program, implement one

If you do, look to improve it

Participate in your Provider Forums and Provider Quality Improvement committees

Stay abreast of resources

Attend trainings

Always focus on a cycle of continuous improvement efforts