Quality Improvement Program
Fiscal Year 2015-2016
Community Mental Health & Substance Abuse Services of St. Joseph County
QUALITY IMPROVEMENT PROGRAM
INTRODUCTION
The Michigan Department of Health & Human Services (DHHS) requires that each specialty Prepaid Inpatient Health Plan (PIHP) have a quality assessment and performance improvement program (QAPIP) which meets the specified standards in the contract with DHHS. In addition to the QAPIP, DHHS requires each Community Mental Health Services Program (CMHSP) to have a Quality Improvement Program (QIP). The description that follows provides the QIP for the Community Mental Health and Substance Abuse Services of St. Joseph County (CMHSAS-SJC) for fiscal year 2015/16.
PURPOSE
The purpose of the QIP for CMHSAS-SJC is to:
1. Continually evaluate and enhance organizational processes that most influence organizational effectiveness and efficiency.
2. Monitor and evaluate the systems and processes related to the quality of clinical care and non-clinical services that can be expected to affect the health status, quality of life and satisfaction of persons served by CMHSAS-SJC.
3. Identify and assign priority to identified opportunities for performance improvement.
4. Create a culture that has a customer focus; one that includes stakeholder input and participation in problem solving.
MISSION, VISION, VALUES
This Quality Improvement Program and Plan is tailored to help achieve the agency mission and vision. Our activities will be guided by those organizational values we believe to be critical to our success.
MISSION
We enhance the lives of the citizens we serve by providing a range of individualized mental health, substance abuse, wellness and recovery services.
VISION
Community Mental Health and Substance Abuse Services of St. Joseph County will be the premier behavioral health care agency providing an excellent system of care for citizens in need by focusing on wellness and recovery.
STATEMENT OF ORGANIZATIONAL VALUES
We will ensure that services are delivered in a manner that is:
- Customer centered
- Community based
- Welcoming and accessible
- Outcome based and valued by customers
- Offered by competent, friendly, and helpful employees
- Supportive of cultural diversity
QUALITY IMPROVEMENT STRUCTURE
The Quality Improvement Structure for Community Mental Health and Substance Abuse Services of St. Joseph County is outlined through a graphic presentation on the next page, followed by a narrative description of key elements of the structure.
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accountability to Governance
The ultimate responsibility for the quality of organizational services is retained by the Governing Board. The role of the Board is to support and promote ongoing improvement in organizational processes and outcomes. The Board responsibilities for the Quality Improvement Program (QIP) include:
- Oversight of the QIP, including documentation that the Board has approved the overall QIP and annual QI plan.
- Review of QIP reports, including actions taken, progress in meeting QI objectives, and improvements made.
- Assures that action has been taken where indicated and directs the operational QIP be modified to accommodate review findings and issues of concern within CMHSAS-SJC.
ManageR/Suppervisor Team – The Quality Management Committee
The Manager/Supervisor Team includes the Executive Director, Medical Director, Clinical Director, Program Supervisors, Financial Director, Billing Coordinator, Corporate Compliance Officer and Recipient Rights Officer. The role of the Management Team includes the function of the organization’s Quality Management Committee. In this role, the Manager/Supervisor Team will operationalize the Quality Improvement Plan as established by the Board, including setting priorities for improvement efforts throughout the agency. The Manager/Supervisor Team is responsible to monitor and report progress toward established goals at Board Meetings. Last, the Manager/Supervisor Team is responsible to ensure that agency staff has the capacity (training, encouragement, etc.) to successfully address prioritized improvement opportunities.
The Medical Director will provide consultation on the agency’s QI Plan as needed, receive copies of written performance reports that are provided to the Board and help establish improvement priorities for the agency.
CUSTOMERS
Customers are those individuals or families that directly receive the services offered by CMHSAS-SJC. The satisfaction of persons receiving services with our agency will be greatly enhanced when we involve those customers in the identification and prioritization of improvement opportunities. We must always listen to our customers’ input toward improvement opportunities. Likewise, we must continually measure trends in customer satisfaction levels. Customer input is collected in a variety of ways, including active submission of membership on the Board of Directors, Manager/Supervisor Committee, the Customer Advisory Committee, satisfaction and needs assessment surveys, focus groups, participation on Project Teams, etc.
CUSTOMER ADVISORY COMMITTEE
The Customer Advisory Committee (CAC) is responsible to provide input (improvement suggestions) to the Manager/Supervisor Team based on the review of qualitative and quantitative performance information. The CAC will also review draft planning and policy items, such as the agency’s strategic plan. In the future, the CAC members may serve as agency liaisons with external auditors, legislators, community stakeholders, etc.
CMHSAS-SJC PERFORMANCE IMPROVEMENT PROJECT TEAMS
CMHSAS-SJC is a participating member of all region-wide Performance Improvement Projects. In addition to these projects, the Manager/Supervisor Team will initiate a CMHSAS-SJC Performance Improvement Project Team when a need for organizational improvement is identified and a team approach is beneficial. Teams will be comprised of individuals representing operational areas that contribute to, or are affected by, changes in processes that result in improved outcomes. Customers will be invited to participate on these teams whenever possible. Each Team is accountable to the Manager/Supervisor Team.
ENROLLEE RIGHTS AND RESPONSIBILITIES
The following are assessment activities conducted by the Office of Recipient Rights or Quality Management:
- Monitor and assure that customers have all the rights established in Federal and State law.
- Investigate and follow-up on rights complaints;
- Review incident, accidents and sentinel events and investigate as needed;
- Look for trends and making suggestions to prevent reoccurrence;
- Review customer death reports and investigating any unexpected death to identify potential system improvements; and
- Share trends and process improvements made with stakeholders.
STAKEHOLDERS
In addition to customers, stakeholders are those individuals or organizations that have a valid interest in the agency’s processes and outcomes. Some of our most important stakeholders are staff members, funding sources, regulatory bodies and fellow human service agencies in our community. Funding sources usually outline performance standards in written documents such as contracts and standards manuals. Input from staff and fellow human service agencies will be collected via surveys, suggestion boxes, etc. Staff and stakeholders’ input and satisfaction must be monitored on an ongoing basis.
COMMUNICATION
It is important that the groups described above receive information about prioritized needs, improvement projects and changes in performance. This type of feedback reinforces perceptions of the value of quality improvement. This type of feedback also promotes consideration of additional opportunities for meaningful improvement. Feedback will be provided by means of Board reports, results of regulatory audits, interoffice communications, etc.
PERFORMANCE IMPROVEMENT
Quality improvement activities are customer-focused, and to improve the quality of clinical care and the outcomes of persons served. Ongoing input must be collected from both persons receiving services as well as other stakeholders using a variety of methods. Methods to collect input include surveys, monitoring of customer progress, tracking of rights violations and incident reports, community forums, and performance reports generated by stakeholders such as the MDHHS.
Data is used to determine performance levels and must be accurate, valid and reliable to produce meaningful performance information. Without good data, we cannot be assured that our conclusions are accurate, or can we be assured that we are directing precious resources toward improvement opportunities that are most important to our customers and other stakeholders. Simply put, bad data results in bad decisions. We must take steps necessary to ensure that data is complete, accurate, valid and reliable. Current literature provides guidance to plan for and ensure data integrity.
Quality indicators are those measures that reflect performance in areas that are most important to our customers and other stakeholders. Quality indicators include the areas of effectiveness of care, efficiency of operations, accessibility to services and satisfaction among customers and other stakeholders. These indicators are more meaningful when compared to established standards, trends over time and/or comparison with performance of similar organizations.
Quality and performance indicators and reports are used to determine significant trends and to plan, design, measure, assess and improve services, processes and systems. Quality improvement activities monitor the quality of care against established standards and guidelines. Improvement strategies are used to eliminate undesired outliers, ensure the proper use of practice guidelines, and optimize desire customer outcomes. Remedial action is taken whenever inappropriate or substandard services are furnished as determined by substantiated recipient rights complaints, clinical indicators, or other quality indicators.
Sources of quality and performance indicators include:
- DHHS Performance Indicator System Reports (also referenced as the Michigan Mission-Based Performance Indicator System [MMBPIS])
- DHHS Boilerplate Reports
- Behavior Treatment Data and Reports
- Health & Safety Reports
- Clinical/Medical Records Review Reports
- Utilization Management Reports, including under-utilization and overutilization based on medical necessity and other established criteria and the mechanisms to correct under-utilization and overutilization
- Accreditation Survey Report
- Quality Improvement Reports
- Customer Services Reports, including assessments of member experiences with services (including quality, availability and accessibility of care) and reports on customer grievances and appeals.
- Incident and Event Reports
- Performance Indicator and Outcomes Reports, such as CAFAS (Child and Adolescent Functional Assessment Scale)
- MDHHS Contract Compliance Reports (e.g., DHHS Site Review, Rights System Assessment, Compliance Examination)
- Stakeholder Survey Reports, such as, Consumer Survey, Employee Survey, and Community Needs Survey
- Provider Monitoring Reviews (including the verification of provider and individual qualifications and credentials)
- Corporate Compliance and Risk Management activities (including verification of the delivery of Medicaid services)
- Staff Productivity Reports
- Demographic Reports on Persons Served
The Manager/Supervisor Team will determine any quality and performance indicators in addition to those established by the PIHP that will be monitored depending on each department’s specific customer group, service delivery activities, and requirements of the State Department of Community Health and CARF standards.
ANNUAL REVIEW OF THIS PLAN
This Quality Improvement Plan will be evaluated and revised on an annual basis, and reviewed and approved by the CMHSAS-SJC Board.
QUALITY IMPROVEMENT GOALS FOR FY 15/16
The broad quality improvement goals include:
1. Everyone shares responsibility for continuous quality improvement of processes and customer outcomes.
2. We work together as a team.
3. We prioritize the processes that have the most impact on outcomes persons served desire.
4. We aspire to meet or exceed all performance standards established by funding sources, particularly MDHHS.
5. We maintain feedback loops so internal staff are aware of improvements in performance and outcomes.
6. We share performance and outcome information with our customers and other stakeholders on an ongoing basis. Examples of methods include annual reports, press releases, presentations to focus groups, etc.
7. We actively engage in PIHP standing committees and ad hoc workgroups.
The following page outlines the specific quality improvement objectives for 2015/16:
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community mental health and substance abuse services of st joseph county
QUALITY IMPROVEMENT PLAN
Objectives for 2015/16
Key for Acronyms:CARF / = / The Commission on Accreditation of Rehabilitation Facilities / NCQA / = / National Committee for Quality Assurance
DHHS / = / Formerly Michigan Department of Community Health / PIHP / = / Prepaid Inpatient Health Plan
HEDIS / = / Healthcare Effectiveness Data & Information Set / QM / = / Quality Management
MDHHS
MMBPIS / =
= / Michigan Department of Health & Human Services
Michigan Mission-Based Performance Indicator System / SWMBH
TEDS / =
= / Southwest Michigan Behavioral Health
Treatment Episode Data Set
# / GOAL / OBJECTIVES/ACTION STEPS / MEASURES
1 / Maintain current three (3) year accreditation with CARF standards / A. Review and respond to all applicable changes in CARF standards for 2016
B. Submit Annual Conformance to Quality Report to CARF within due date.
C. Begin initial preparation for March/April 2017 survey. / September 30, 2016
2 / Ensure conformance and timeliness of required quality management data and reports to SWMBH including
- Michigan Mission-Based Performance Indicator System (MMBPIS)
- Event Reporting
- TEDS Completeness
B. Submit Improvement Plans to the PIHP where the goal has not been achieved during the most current 2 out of the last 3 quarters / Ongoing monitoring and response as needed
3 / Achieve the standards as set forth by the Southwest Michigan Behavioral Health (SWMBH) / A. Actively participate in SWMBH quality management meetings and initiatives
B. Any new standards set by SWMBH will be communicated to Manager/Supervisor team, and discussed to ensure awareness and engage activities needed to achieve the standards / September 30, 2016
4 / Ensure adequate monitoring of subcontract service providers / A. Conduct provider monitoring reviews of providers that meet the requirements of SWMBH and that provide useful information for monitoring the quality of services provided.
B. Obtain copies or assure access of relevant provider monitoring reviews from other CMHSP’s/PIHP’s of providers in which CMHSAS-SJC contracts. / September 30, 2016
5. / Prepare the CMHSAS-SJC provider system for the changes in requirements of the performance indicators and assessment tools. / A. Work with SWMBH to move towards HEDIS measures as per MDHHS requirements.
B. Work with SWMBH on implementing the Level of Care Utilization System (LOCUS). Components of the assessment generate a needs list which is used to guide the treatment planning process. / September 30, 2016 and as per SWMBH and/or MDHHS requirements.
6. / Prepare for accreditation as a Certified Community Behavioral Health Clinic / A. Review NCQA and CARF standards for population health accreditation.
B. Determine whether to immediately prepare for NCQA accreditation or to expand CARF accreditation as a “stepping” stone for NCQA accreditation. / September 30, 2016
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