The Quality Conundrum

Achieving Safety, Healthand Valued Outcomes

How Did We Get Here?

Initial concentration on rudiments of custodial careEvolution of programmatic standards that reflected growth in our understanding of people’s needs and our own expertiseIncreased concern about the efficacy of our interventionsAttention to the outcomes of services and supports from the perspective of the customer

Valued Outcomes

Individualization

Integration/Inclusion

Relationships/Social Connections

Health and Safety

Personal Growth

Choice and self-determination

Dignity

Consumer Satisfaction

Signs of Change in Performance Management

No longer just better than the institutionRooted in outcomesEmphasis on enhancementChanging role of the stateChanges in experiences of families and people with mental retardation Changes in accreditation approaches

Outcomes

Expectations

Inclusion

More Signs of Change

Movement away from prescriptive standards

Emphasis on CQI

Exploration of self-assessment

Collaborative development of standards

Inclusion of customer satisfaction

Satisfaction

CQI

Consensus

The Two Faces of QA: One: Control

Function Characteristics Mechanisms Quality control: to assure minimum performance

Protection from harm

Clear indicators

Immediate response

Licensure Certification Incident

reporting & review

The Two Faces of QA: Two: Enhancement

Function Characteristics Mechanisms

Quality enhancement: to encourage optimal performance

Related to personal outcomes

Identification of strengths and limits

Collaborative

Training

Technical assistance

Performance-based contracting

CQI

Pri

nci

ple

s Facilitate individual choice

Support relationships and

community membership

Encourage natural supports

Ensure health, well-being

and safety

Foster productivity and

participation in meaningful

work

Maximize self-determination

Support families

Build staff and provider

capacity

Person Centered Systems or Support Should:

Public Quality Assurance Responsibilities

Assuring that individuals are free from abuse, neglect, and exploitation;Protecting the rights of individuals and families;Assuring accountability in the use of public dollars;Assuring that individuals have access to necessary professional services;Evaluating the effectiveness if service and supports;Assessing the performance of service providers

Changing Quality Landscape

Exposure of fault-lines in the system (e.g., HCFA and the press)

Expansion of supports to individuals on the waiting list

Emergence of self-determination

Olmstead decision

Struggles with MIS applications

Direct support staff shortages

Myths and Cautions

Choice is the only thing that matters

Health and safety are synonymous with outcomes

Providers are ready for outcomes

There is a correlation between “best practice” and consumer satisfaction”

Critical ConstraintsDrain of knowledgeable staff frompublic sector

Consolidation of providers

Management of multiple systems

“Generic” approaches to quality

Increasing gray areas in public jurisdiction

Pressure from HCFA

Lack of collaboration with sister agencies

Important Next StepsPlace individual outcomes at the center of the system Enlist assistance of consumers and familiesIdentify key areas of performanceLink technology with need for informationLook at the costs and benefits of existing approaches

Make results available and accessibleGet serious about uniform reporting of critical health and safety events

More Recommendations

Develop Staff credentialing and expand training options

Reassess roles and responsibilities of case managers

Refine performance contracting

Expand understanding of person-centered planning

Emergence of Performance Indicators

First appeared in behavioral and acute careProvide some “cues” for managing these complex systemsHighlight impact of cost containmentIlluminate what’s workingProvide early warning signs

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

Consumer Involvementin Assuring Quality

Choice among providers/ purchasing decisions

Designing and refining QA mechanisms

Grievance/appeals process

Consumer satisfaction surveys

Membership on policy-making board

Telecommunications networks

“Consumer Reports”

Health and Safety ImperativesEnsure adequate number of service coordinatorsBuild individualized health and safety plansScreen and train employeesTrain individuals and familiesIncrease federal fundingDevelop hotlines and ombudspersons

Continuous Quality Improvement

Leadership at the senior levelEngagement of multipleconstituenciesIdentification of emergingissues and prioritiesDevelopment of an benchmarksIdentification of change strategiesMeasurement of progress

What Do You Do With the Information?

Include at your web site

Prepare annual reports to the legislature

Develop provider profiles

Use with sister agencies

Monitor managed care initiatives

Use in allocation decisions

Final Words

“Beware the Continuous Improvement of Things Not Worth Improving”

W. Edward Deming