Report of the Quality Management

REPORT OF THE QUALITY MANAGEMENT

AND IMPROVEMENT SYSTEM

WORK GROUP

STRATEGIC OBJECTIVE 4 OF THE

DMR STRATEGIC PLAN

PREPARED

AUGUST 2002

TABLE OF CONTENTS

Page

Introduction and Overview of the Report 3

Rationale and Purpose of the Quality Management and Improvement System 4

Description of the Quality Management and Improvement System 5

Stakeholders and Users of the Quality Management and Improvement System 7

Information Included as Part of the QMIS System 7

Priority Outcomes and Process Measures 8

Quality Assurance Components 11

Report Formats and Frequency 12

Systems and Processes for Implementing the QMIS 22

Phase in Schedule 23

Appendices

Appendix A – Group Members

Appendix B - Unedited List of Outcomes / Process Measures

Appendix C - Summary of Database Analysis

Introduction and Overview of Report

The Quality Management and Improvement System (QMIS) Work Group was formed to develop recommendations for Strategic Objective #4 of the Department of Mental Retardation (DMR or “Department”) Strategic Plan: 2001-2004. Strategic Objective 4 called for the development of an effective quality management system. Two goals were identified within this broad objective:

-  To measure key indicators and utilize information to promote service excellence

-  To strengthen, integrate, and utilize oversight and monitoring systems to ensure continuous improvement, quality outcomes and necessary safeguards for individuals

The work group which was comprised of individuals from within and outside of the Department began meeting in March, 2001 and completed its design work in August, 2002. (Please see Appendix A for a listing of group members).

The report which follows synthesizes and summarizes the work completed by the group.

The report details the purpose of a QMIS system, the stakeholders, what services are to be included, what the critical quality measures will be, and what quality assurance components will feed information into the system. The report also specifies how and with what frequency information will be reported on and shared, and what systems and processes will be put in place to assure that information is continually analyzed and used for organizational learning and growth. Finally, the report outlines implementation steps and projected timelines.

The final part of the report contains appendices which assist the reader in understanding information used by the committee to develop many of its recommendations.

I’d like to take this opportunity to thank the members of workgroup #4, particularly those who attended meetings faithfully throughout the past year. Despite heavy workloads and many competing priorities, participants shared their time, wisdom and expertise graciously and willingly. The QMIS design which follows represents the combined commitment of every member of the group to a quality management system which is aimed at continual self examination and service improvement to the individuals we support. Thank you all.

I. Rationale and Purpose of the Quality Management and Improvement System

Over the past few decades, the Massachusetts service system for individuals with mental retardation has undergone a major transformation. What was largely a facility based system is now a community based system offering a vast array of home, work and support services. Services are geared to supporting and enhancing the quality of lives of individuals and are offered in settings geographically dispersed throughout the state. While this transformation has brought increased service options and enhanced consumer satisfaction, it also has created many new challenges. As a public agency with accountability to a variety of stakeholders, the Department of Mental Retardation must be able to assure that, however, decentralized, services are of a high quality. DMR must be able to evaluate, monitor and continually assure that individuals are healthy, safe, and enjoy a high quality of life. In addition, as individuals and families begin to assert more control over their own services, they are re-defining quality and are rightfully asking for more and better information regarding services and supports. To address its own needs as well as those of its primary stakeholders, DMR must have well developed quality assurance mechanisms as well as a quality management and improvement system that collects, analyzes and uses data to support organizational learning, provides individuals, families and DMR managers with the information they want and need, and leads to service improvement.

The DMR Quality Management and Improvement System (QMIS) detailed in this report, attempts to address this important public policy imperative. If it is to be responsive to the needs of both internal and external stakeholders, the QMIS must be an integrated, “user friendly” information system that draws together relevant person-centered and organizational information in the least intrusive way possible in order to assure that critical indicators of quality outcomes and necessary safeguards are analyzed and utilized to promote service and systemic improvements. The QMIS system must:

1. Establish key agreed upon outcomes and use the information generated about the outcomes for day to day decision making and as benchmarks for service improvement over time;
2. Draw in and utilize information from a variety of perspectives;
3. Facilitate easy access to information by primary stakeholders and DMR’s side partners in easy to understand formats at regular intervals;
4. Work collaboratively with individuals, their families, and providers to use the information to support continuous improvement over time;
5. Collect only usable and useful information in a timely and efficient manner;
6. Use the information generated by the QMIS system for decision making consistently throughout the Department;
7. Close the loop by building in systems to follow-up on areas needing improvement;
8. Be dynamic, subject to review and revision so that the QMIS remains responsive to changing individual, organizational needs and society’s values;
9. Create an environment that fosters organizational learning and growth.

II. Description of the Quality Management and Improvement System

What the system is:

·  The QMIS is designed to provide our primary stakeholders and important side partners pertinent information about quality so that they can make both short-term decisions and longer term systems improvements. The system is designed to collect information around specific outcomes that stakeholders agree are the benchmarks of quality in services and supports.

·  The information and data is derived from the many distinct quality assurance components DMR uses to monitor the quality of individuals’ services. These components are collected on both a local and systemic level and are collected routinely and/or periodically.

·  The QMIS system reports on the quality of services and supports through the lens of outcomes that have been determined to be critical indicators of quality. The outcomes are heavily focused on individuals, but also include provider organizational outcomes as well as internal DMR management outcomes.

·  Information is gathered from the many QA components of DMR, synthesized, analyzed and presented in an array of formats, including “real time” access to information as well as management reports at designated intervals. Reports can be generated for individuals, areas, regions, providers and statewide. Frequency of reports is based on need for information by various stakeholders.

·  Information generated from management reports will be used for tracking and monitoring, contract decisions, short and long term planning, analysis of patterns and trends, and most critically for organizational learning and service improvement.

(Please refer to Table 1 for a schematic description of the QMIS system)

6

Gg Strategic objective #4 2nd Version - 6/10/04

DMR TABLE 1

QUALITY MANAGEMENT AND IMPROVEMENT SYSTEM

INPUT/

QA COMPONENTS /

OUTCOMES/

PROCESS/
MEASURES / INTEGRATION
AND
ANALYSIS / UTILIZATION

OF

INFORMATION / OUTCOMES

↓ ↓ ↓ ↓ ↓

↓ ↓ ↓ ↓ ↓

Service Coordinator
Visits/ISP / People are supported to have the best possible health / ·  /

Reports by Individual

/ / Tracking
and
Monitoring /

Action/Follow Up

Survey & Certification / People are protected from harm / ·  /

Reports by Provider

/ / Contracts/
Service Decisions / Service Improvement
Medication Occurrences / People live and work in safe environments / ·  /

Reports by Area/Region

/ / Planning / Organizational Learning
Mortality/Reports/
Reviews / People’s rights are protected / ·  /

Reports Statewide

/ / Identification of Patterns/Trends
Incident/Critical
Incident Reports / → / People are connected to their community / → / → / →
Investigations / People are supported to make decisions
Risk Management
Restraint Reports
Core Indicators

6

Gg Strategic objective #4 2nd Version - 6/10/04

III. Stakeholders and Users of the Quality Management and Improvement System

The QMIS is designed to meet the needs of stakeholders who want the information on an ongoing basis.

Key stakeholders are those individuals most directly affected by the quality of the services and supports and include:

1. Individuals who are the primary users of services and most affected by the outcome of services,
2. guardians and involved family members
3. DMR managers and staff who would use the QMIS when designing, implementing and/or monitoring services.

Side Partners include:

1. Providers (public and private)
2. Advisor and Advocates:

·  Area and regional boards, SAC, Boards of Trustee for Facilities, Human Rights Advisory Committee

·  Governor’s Commission

·  Advocacy Groups (e.g., MASS, ARC/Mass, MFOC, COFAR, Advocacy Network

3. Overseers:

·  EOHHS

·  Centers for Medicaid and Medicare Services (CMS)

·  DMA

·  DPH

·  DPPC

·  Legislature

·  State Auditor

Boundary partners include:

1. media
2. taxpayers/citizens
3. medical community
4. courts, police, DA’s office
5. community, grass roots or generic organizations
6. housing authorities
7. schools

IV. Information Included as part of the QMIS system

The QMIS system when completed will be able to provide information regarding both individual, service and system outcomes.

Individual Information:

Through the various quality assurance mechanisms in place, DMR will be able to report on health, safety and other quality of life domains for the individuals it supports. This information can be used to facilitate prompt and effective response to individual issues. It can also be used more broadly to analyze patterns and trends across all services and to plan more strategically for the future.

Service Information:

Priority emphasis will be placed on providing information about DMR purchased services to DMR eligible individuals, since these are the areas over which DMR has the most direct responsibility and concurrent ability to influence positive change. Currently DMR has the ability to collect information on the following services:

·  Residential, including 24 hour and less than 24 hour homes and home provider services,

·  Employment supports

·  Community based day supports

·  Site based respite services

·  Facilities

Next steps include the development of processes to evaluate:

·  Individual supports,

·  Family support

V. Priority Outcomes and Process Measures

The cornerstone of any effective quality management and improvement system is the development of a set of outcomes that stakeholders agree are important benchmarks of quality. Without these outcomes, clear targets and goals for quality services could neither be measured nor achieved over time. While it is anticipated that both outcomes and process measures may change over time, as a reflection of stakeholder priorities or evolving definitions of quality, the following measures reflect a consensus regarding those considered to be the first tier or highest priority for the initial stages of implementation of the QMIS. (Please refer to Appendix B for a full listing of all the outcomes which were considered by both the work group and internal and external stakeholders.)

PEOPLE ARE SUPPORTED TO HAVE THE BEST POSSIBLE HEALTH / 1.  % of individuals receiving health care screening according to standards from a PCP who is familiar with the individual
2.  % of individuals having dental exams at regular intervals recommended by dentist
3.  % of medications safely administered
4.  Appropriate referrals are made and assessments received for individuals in need of further mental health assessment
5.  % of individuals who need and have access to specialty health care, including Adaptive Equipment
PEOPLE HAVE ECONOMIC RESOURCES TO MEET THEIR NEEDS / 1.  % of individuals whose income, entitlements and benefits, from all sources, are maximized
2.  Individual funds are properly managed
PEOPLE ARE PROTECTED FROM HARM / 1.  % of investigations where protective actions are taken when a person is subject of a complaint
2.  CORI checks are completed according to requirements
3.  # of incidents tracked by location and type
4.  Proportion of people who have risk management plans
5.  Proportion of people who are victims of crime as compared to general population
6.  Proportion of families reporting that staff are available to communicate with individuals and families who use modes of communication other than English
PEOPLE LIVE AND WORK IN SAFE ENVIRONMENTS / 1.  % of individuals whose homes and work locations are safe and well maintained
2.  % of individuals reporting that they feel safe at work, home and in neighborhood
PEOPLE UNDERSTAND AND PRACTICE THEIR HUMAN AND CIVIL RIGHTS / 1.  % of individuals who report they have another person they can go to if they have a concern
2.  % of individuals reporting their rights are affirmed
PEOPLE’S RIGHTS ARE PROTECTED / 1.  % of instances where prior to implementing a restrictive intervention, other less intrusive clinically appropriate strategies have been considered and/or tried
2.  % of individuals and their supporters who know how and where to file a complaint
3.  % of restraints (including holds in a behavior plan) for DMR population
4.  % of individuals with Level I, II, III behavior plans
5.  % of restraints resulting in injury to the person
6.  % of individuals who are prescribed antipsycotic medications who need and have a Roger’s monitor
PEOPLE ARE SUPPORTED TO MAKE THEIR OWN DECISIONS / 1.  % of individuals who are supported to make choices about important life decisions
2.  % of individuals whose input is sought for staff hiring and performance
PEOPLE USE INTEGRATED COMMUNITY RESOURCES AND PARTICIPATE IN EVERYDAY COMMUNITY ACTIVITIES / 1.  % of individuals who access community resources for things they need and desire on a regular basis
PEOPLE AER CONNECTED TO AND ARE VALUED MEMBERS OF THEIR COMMUNITY / 1.  % of individuals who are involved in activities that connect them to other people in the community
PEOPLE GAIN/MAINTAIN FRIENDSHIPS AND RELATIONSHIPS AT HOME, WORK / 1.  % of people who report they have a special best friend in their lives
INDIVIDUALS MAINTAIN CONNECTIONS WITH THEIR IMMEDIATE AND EXTENDED FAMILY MEMBERS / 1.  % of individuals who report being satisfied with opportunities and support to see, talk with their family when they want to
INDIVIDUALS’ INFORMED CHOICES ABOUT THEIR RELATIONSHIPS ARE HONORED AND RESPECTED / 1.  % of individuals who have education and support to understand and safely express their sexuality
PEOPLE ARE SUPPORTED TO DEVELOP AND ACHIEVE THEIR PERSONAL GOALS / 1.  % of individuals who are supported to develop an individualized plan that identifies their desires and needs
2.  % of individuals who report they accomplished something that was important to them this year
INDIVIDUALS ARE SUPPORTED TO OBTAIN WORK / 1.  Average monthly wage of people who receive work supports
2.  Average number of hours worked per month during previous year
PEOPLE RECEIVE SERVICES FROM QUALIFIED PROVIDERS / 1.  Tracking of levels of certification to determine changes over time
2.  Safeguard issues are identified and corrected
3. Additional oversight mechanisms are in
place for providers subject to certification
and those not subject to certification
PROVIDERS RECRUIT AND RETAIN A QUALIFIED DIVERSE WORKFORCE / 1.  % of direct support professionals who demonstrate essential competencies to carryout their job responsibilities
2.  Average length of service for current staff
PROVIDERS HAVE MECHANISMS TO IMPROVE THEIR SERVICES AND SUPPORTS OVER TIME / 1.  % of individuals and families who express satisfaction with their services
2.  % of providers that have their own mechanisms to evaluate their services and use the information for service improvement
PROVIDERS HAVE RESPONSIVE SYSTEMS TOSAFEGUARD INDIVIDUALS / 1.  Providers have effective on-call systems and contingencies for staff coverage
2.  Providers take immediate action when incidents occur
3.  providers have effective safety plans that include contingencies for emergencies
4.  Providers staff are trained in mandated reporting requirements and are knowledgeable about what constitutes abuse, neglect
PARTICIPANTS IN THE FEDERAL WAIVER PROGRAM HAVE THEIR NEEDS ASSESSED AND ADDRESSED / 1.  Participants in waiver have an annual level of care assessment.
2.  Participants and informal caregivers have input into the plan of care and are given the choice between and among services and providers.
3.  Participants’ health, safety and habilitative needs are assessed and addressed in the plan of care.

VI. Quality Assurance Components