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Quality Improvement Plan

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Quality Improvement Plan

Introduction



 

The Alcohol and Drug Addiction Services Board of Cuyahoga County (ADASBCC) has been committed to continuous quality improvement (CQI) since 1996.   The Board’s 1997-2002 Strategic Plan identifies the pursuit of continuous quality improvement in all organizational activities.  The Quality Improvement Plan will provide a framework for the vision of incorporating quality improvement concepts and tenets within all organizational activities.

Since 1997, many steps have been taken that demonstrate a commitment to quality improvement.   Board staff and provider agencies have been trained on the concepts of quality improvement.  In its own organizational practices, the Board has utilized CQI teams to set policy, to improve communication, and to develop structural processes to increase efficiency within departments and the organization as a whole.  Continuous quality improvement techniques have been utilized for problem resolution as well as for systems development.  Quality improvement activities support the Board shift from departmental approaches to more systems approaches that will improve current technical assistance activities.

All of these efforts have assisted the Board in promoting the strategic goal of reengineering the Board as a managed care entity with a purchase-of-service and performance-based contracting orientation.  Developing this goal more fully is the next step to operationalizing the Board’s role as network manager.

Historically, the Board has adopted a reactive stance to the issues and concerns that arise from either the internal or external pressures of the immediate environment.  Quality improvement, however, can remove the impetus of a reactive stance and instead, support a proactive position that allows the Board to address issues of performance, viability, and quality.

Over the past three years, the Board has examined various aspects of quality to assess provider services and the quality of those services.  Additionally, the Board has begun to assess its internal strategies to develop proactive and timely interventions.  The Board has begun to consider various indicators that will reliably measure effectiveness, efficiency, and quality.  It is our goal to manage the system with all its attendant variations in a manner that promotes positive outcomes.

 

Purpose

 

The purpose of the Board’s Quality Improvement Plan is to increase Board and provider performance by providing a systems-based perspective on the quality management of the funding, program monitoring, and evaluation activities of the Board.

Objectives

1)      To increase the efficiency and effectiveness in the delivery of treatment and prevention services within the community

2)      To balance the increasing demands of quality, access, and costs

3)      To increase provider compliance levels to minimally accepted standards, rules, guidelines, and regulations

4)      To incorporate, implement, and perform ongoing monitoring of quality improvement activities within the Board and provider network

Mission Statement

The mission statement of the Alcohol and Drug Addiction Services Board of Cuyahoga County is to minimize the harmful impact of substance abuse and dependency by developing, maintaining, and advancing a coordinated network of comprehensive services focused on wellness/prevention and recovery.

Core Values in Strategic Plan

Ø      The Board will pursue Continuous Quality Improvement in all organizational activities

Ø      The Board values a scientific, rational approach to problem-solving

Ø      The Board emphasizes a customer-centered philosophy that addresses the needs of families and significant others

Ø      The Board stresses cooperation within our organization and with other agencies

Ø      The Board believes that partnerships will strengthen the capacity to achieve its mission

Ø      The Board values an outcome orientation in evaluating success

Ø      The Board values and rewards cost-effectiveness in management practices

 

 

Quality Improvement

Why continuous quality improvement?  The quality improvement model is based on several values:

  1. The definition of quality includes the needs of the “customers”, which is not restricted to just the client, but includes other agencies and systems that interact with an organization (Jost, 27).   For the Board, customers include, but are not limited to:  internal Board staff, the client, the providers, the Board of Trustees, County Commissioners, ODADAS, and any other collaborative partnerships in the community.

  1. Quality improvement emphasizes the importance of improving the system on a continuous basis and takes the blame away from people or faulty processes.  The focus centers on raising the performance level by focusing on the system and/or process, rather than solely on any one deficiency (Jost, 27).  This idea is incorporated into the business practices not only on the organizational level, but also on the individual level by the commitment and personal responsibility of each person to the success of the organization.

  1. Quality improvement relies heavily on data as a means to identify problems and determine appropriate action. Emphasis on data works to remove the focus on people and replaces it with concrete information by which to organize system improvements that are based on rational observation.  Continuous monitoring is necessary to determine effectiveness. 

Quality Assessment

 

Donabedian, scholar of quality assessment, noted that there are three elements to quality assessment (25): 


Structure             Process              Outcome

In order to fully implement a viable quality improvement plan, all three elements need to be considered in the application of the various areas that the Board is currently constructing in the QI plan.

The key is this:  Quality management=organizational performance=quality improvement. (Guide to Quality Management, 299). The goal of the Board is to become the quality manager for a system of providers that render treatment and prevention services to the residents of Cuyahoga County.

Definition of Quality

For the Board, there are five determinants of quality.

Ø      Cost effective services

Ø      Clinically appropriate, accessible, and available services that are customer focused

Ø      Customer satisfaction

Ø      Improved client functioning

Ø      Optimal organizational efficiency

 

Cost Effective Services

 

In reviewing providers for cost effectiveness, the Board has looked at the fiscal methods of the provider, the independent auditor reports, and the accuracy of cost projections and number of units.  However, there is no comparison of cost based on services provided and of what rudiments within the same service offered differ across two different agencies.  As the Board moves forward in a purchase of service environment, these differences in services should be reduced to their discrete elements in order to make comparative cost analyses.

Clinically Appropriate, Accessible and Available Services That Are Customer Based

The Board has monitored providers for accessible and clinically appropriate services.  Each provider is required to use the ODADAS Levels of Care that assists in determining appropriate placement of clients.  The Board conducts compliance reviews to assess the clinical documentation.  The Board monitors the accessibility of services across the network on an ongoing basis.  To address some of the outstanding issues, the Board has developed an access workgroup to develop countywide access standards.   In addition, quality improvement staff will monitor the waiting list of each provider monthly. 

Customer Satisfaction

 

The Board has addressed consumer complaints as they have been reported.  As part of the compliance reviews, consumers have been asked about their experiences at particular agencies.  Quality Improvement staff will develop a client satisfaction survey and in addition to the consumer feedback sessions, the Board will better be able to address areas of dissatisfaction in a more timely and proactive manner.

Improved Consumer Functioning

 

It is the goal of treatment to provide positive outcomes for the client.  The question has been raised, however, as to what qualifies successful treatment.  As a result, the Board is beginning to look at outcomes across the network. The Persistent Effects of Treatment (PETS) project is currently reviewing data from the CSM System and developing outcome studies.  Additionally, the Board will add outcome variables to the evaluation efforts of providers to begin collecting data from standardized variables across the network.

 

Optimal Organizational Efficiency

Over the last five years, the Board has emphasized to providers the importance of a strong infrastructure.  The Board has encouraged providers to develop policies, procedures, and processes within their organizations in order to promote optimal efficiency.  To further assist the providers, Board staff will continue to provide technical assistance in these areas.  Also, quality improvement staff will assist providers in the implementation of CQI within their organizations.

There are numerous methods to address these areas.  The thresholds of performance in some instances have already been established through federal, state, or county regulations and guidelines.  The indicators that are set will determine when the provider or the Board intervenes to identify deficiencies in the process and plan improvements to optimize performance.

Methodology

The Board will follow the FOCUS-PDCA process originally developed by the Hospital Corporation of America for its internal CQI teams (Guide to Quality Management, 25). 

Ø      Find a process to improve

Ø      Organize a team that knows the process

Ø      Clarify current knowledge

Ø      Understand variation

Ø      Select a potential process improvement

Ø      Plan

Ø      Do

Ø      Check

Ø      Act

Selected areas of improvement are developed from known/suspected problem areas, organizational goals for quality, findings from audits and other reviews, staff suggestions, ODADAS Guidelines, and organizational desire for increased efficiency and effectiveness. 

 

Structure

Quality Improvement Staff

 

The Board’s Table of Organization lists quality improvement under the Department of Research and Evaluation.  The quality improvement staff is comprised of the following:

Ø      The Director of Research and Evaluation has oversight of the quality improvement program.

Ø      The Manager of Quality Improvement is responsible for the daily management of the external and internal components of the quality improvement program.  

Ø      The Quality Improvement Officer is responsible for monitoring the provider’s quality assurance/improvement, utilization review, peer review, waiting list management, and program evaluation activities.

Ø      The Quality Improvement Specialist is responsible for conducting compliance reviews, internal reviews, and organizational analyses of the providers.

 

The Board will execute a Quality Council that will function as the decision-making body for the organization’s QI efforts, both for internal operational processes and system-wide issues that affect the provider network.  Members of the Quality Council will include:

Ø      Deputy Director

Ø      Director of Program Services

Ø      Director of Research and Evaluation

Ø      Director of Finance

Ø      MIS Manager

Ø      Manager of Quality Improvement

Ø      Manager of Compliance and Program Development

Ø      MACSIS Manager

Ø      Manager of Administrative Services

Identified areas needed for quality improvement efforts will be solicited from Board staff or staff may make suggestions to one of the Council members. 

The Quality Council will meet quarterly to review current QI efforts and/or decide when another team needs to be considered.  The Manager of Quality Improvement will be the responsible party for updating the Quality Council and Board staff on QI activities.



The Executive Director will approve all quality improvement teams and via the use of team charters.

Team charters guide all QI teams to ensure that group goals are in alignment with the Board’s vision, philosophy, and mission as well as outlining the goals each team needs to accomplish in order to be effective.  Team charters detail the expected outcomes of each team in an established timeline.  Formal minutes will be kept and an evaluation process to measure effectiveness of the teams will occur at the end of the project to assess the degree to which goals have been met.

Quality improvement teams (QI teams) are interdisciplinary and will include members who are affected by the process.

The status of QI activities will be reported to the Board of Trustees on a quarterly  basis at minimum.  Written reports of project status will be incorporated into the annual QI plan and submitted in accordance within ODADAS guidelines.  Reporting activities of the QI plan will include those elements required by ODADAS such as aggregate data on waiting list management activities, major unusual incidents, client grievances, peer review activities, and any client or provider satisfaction survey results.

Provider QI Committee

 

The Provider QI Committee will address provider issues affecting the network.  It is the Board’s intent to work collaboratively with the providers on monitoring and evaluating services.  Providers on the committee and Board staff will choose an activity and work together to establish a systematic approach to common problems facing the provider network.  

Updates of the projects that the Provider QI Committee undertakes will be reported to the Quality Council and Board of Trustees, respectively, on a quarterly basis. 

Confidentiality

The Board adheres to the Federal Confidentiality Law, Title 42 C.F.R.  that governs confidentiality for substance abuse. Documentation of the Quality Improvement program is confidential and is maintained by the Manager of Quality Improvement.  Agendas, meeting minutes, and/or data will be shared within the appropriate guidelines with contracted providers, accreditation entities, and State or Federal authorities.  Aggregate data exclusive of specific client identifying information will be shared and reported as appropriate.   The Board will protect all client identifying information according to guidelines set by ODADAS and Title 42 C.F.R..

Customer satisfaction surveys, interviews, and focus groups will be voluntary and  anonymous if so desired by the consumer. 

Current Team Activities

In FY01, the Board began assessing its organizational processes while preparing for fee-for-service implementation.  With the implementation of the fee-for-service model, the Board has identified the need to restructure its monitoring practices to proactively develop more effective and timely interventions when and if problems occur in the provider network.  Restructuring is not merely a matter of compliance, but of improvement in the Board’s response to concerns and of playing a more active role in managing the provider network in an environment of increasing accountability.

In 1999, the Board convened a Fee-for-Service (FFS) Workgroup to review implementation of a fee-for-service model.  A number of policies, procedures, and processes were created in order to build an infrastructure to facilitate the transition from grant based funding to fee-for-service.  In FY02, the workgroup will reconvene on a short-term basis to evaluate the effectiveness of the policies and procedures and make needed adjustments.

The Compliance Review Team was developed and is responsible for developing a comprehensive compliance protocol that covers fiscal, clinical, Medicaid, and Non-Medicaid compliance requirements as identified in the Board’s Service Contract.  Once provider reviews are conducted, findings are reported to providers and integrated into the provider’s technical assistance plan.  The provider review also includes consumer interviews to assess the quality of care from the client’s perspective and questions on accessibility of services, overall satisfaction of services, and appropriateness of staff.  This will allow the Board to gather timely feedback from consumers and provide additional data to supplement quantitative data that the Board gathers as a part of the more formal Consumer Satisfaction survey.

The Provider Review Team is an interdepartmental group. The goals of the team are (1) to increase communication between staff across Board departments; (2) to coordinate technical assistance and training activities; (3) to reduce duplication of effort between Board staff; and (4) to increase the follow-up and follow through activities at the Board and provider level.  The team meets quarterly to address compliance issues for all providers. 

The Information System Strategic Steering Committee will develop the new Information System (IS) that will replace the current CSM System.  The team will also review the federal Health Insurance Portability Accountability Act (HIPAA) requirements and identify specific changes the Board will need to make to ensure compliance with HIPAA regulations. 

The Health and Safety Committee will monitor issues of safety for both Board staff and visitors to the Board offices.  Representatives from every department will be on the committee.  This team will create evacuation plans, conduct safety drills, train staff in First Aid techniques, and develop procedures around emergencies and infection control.

The Performance Management Committee will develop objective performance measures that will monitor the level of agency performance in such areas as Fiscal, MACSIS, Quality Improvement, and Program Services.  Measures under consideration will include productivity percentages, compliance scores, timeliness of report submission, percentage of claims rejection, and compliance with ODADAS Standards in Quality Improvement areas.

The Deputy Director and the Executive Director of the Board will review products developed by any QI team.  As is customary for protocols, policies, and procedures, provider input will be solicited.  All policies, procedures, and protocols will be submitted to the Board of Trustees for their review and/or approval.

Corporate Compliance Plans

Corporate Compliance Plans are written in order to establish, ensure and maintain compliance with all applicable laws that a particular organization is governed by, throughout that organization.  Corporate Compliance Plans demonstrate a pro-active, or preventative, approach.

The Board will develop a Corporate Compliance Plan in an effort to reduce the risk associated with both HIPAA and Medicaid. 

According to Quality Improvement with Corporate Compliance Plans and the Office of the Inspector General, components of a Corporate Compliance Plan include:

Ø      A statement of corporate philosophy

Ø      Facility operation procedures and policies

Ø      Employee standards of conduct, policies and procedures

Ø      Compliance education for employees

Ø      Methods that monitor, prevent and detect violations of compliance

An effective Corporate Compliance Plan contains the following elements:

Ø      A commitment of the governing body, evidenced by:

    1. Resolution by the Board of Trustees (governing body)
    2. Resource allocation

Ø      Written policies, procedures and standards of conduct

Ø      Designation of a Compliance Officer and a Corporate Compliance Committee

Ø      Effective training and education regarding compliance matters

Ø      Effective communication throughout the organization

Ø      Enforcement of standards through prompt, public and uniform disciplinary actions

Ø      Internal monitoring and auditing

Ø      A timetable for completion and monitoring

A well-designed Compliance Program can:

Ø      Enhance client care with increased accuracy of documentation

Ø      Speed and optimize proper payment of claims

Ø      Minimize billing errors

Ø      Encourage employees to report fraudulent or erroneous findings

Ø      Avoid conflicts with self-referral/anti-kickback statutes and false claims

Ø      Reduce the chance of an audit by Healthcare and Finance Administration (HCFA) or the Office of Inspector General (OIG)

Ø      Reduce penalties up to 95% by having a Corporate Compliance Plan in place if organization is audited and fined for Medicaid violations

Ø      Promote efficient organizational processes

Training

The Board has in the past provided quality improvement training to Board staff and the provider network through a consultant firm.  Future plans are to contract with a consultant to train providers on quality improvement concepts and how to implement a quality improvement program and a corporate compliance plan within their own agency.  This training is in addition to technical assistance provided by Board staff in the areas of quality improvement.

Credentialing of Clinical Staff

 

As part of the compliance protocol, Board staff will insure that clinical staff providing treatment services are appropriately credentialed and licensed in accordance with ODADAS standards. 

 

 

 

Needs Assessment

As outlined in the Community Plan, the Board uses several methods to identify treatment and prevention needs in the community. These methods include: Board prevention and treatment utilization data, client/consumer focus groups, special population groups, surveys, consumer satisfaction data, research data, consumer and youth council feedback, and planning groups with key stakeholders.

Collaborations

The Board has always performed collaborative planning with other county entities in the provision of alcohol and other drug services.  The Board has worked closely with the Department of Children and Family Services to provide access to treatment to the Temporary Assistance to Needy Families (TANF) and Ohio Works First (OWF) populations as mandated by welfare reform initiatives.  Five ODADAS certified providers serve as lead agencies on site in the Neighborhood Family Services Centers to provide on-site assessments and referral to providers for alcohol and other drug treatment.

The Board has also collaborated with the Corrections Planning Board in planning activities designed to provide treatment to the criminal justice population.  The Board also subsidized Correction Board funding for the Residential Offender programs that will serve both male and female offenders.

Additionally, the Board continues to work with the Board of County Commissioners through the Health and Human Services Council and the County Family and Children First Council. Also, the Board is still in collaboration with the mental health system through the joint planning initiatives and the SAMI project.

Consumer Feedback

The Board has a strong commitment to offering an avenue for consumers to contribute feedback to the Board and provider agencies on access, cost, and quality issues. The Board’s strategic plan “supports the active involvement of consumers in defining, advocating for, and evaluating services.” To this end, the Board has a Consumer Advisory Council whose primary purpose is to provide input in the ongoing monitoring of client care issues in Cuyahoga County.  Functions of the Council are to:

Ø      Promote fair and equitable treatment of clients

Ø      Provide feedback to the Board in its community planning efforts

Ø      Support the provision of quality services

Ø      Assist the Board in identifying the needs of specific consumer populations

Ø      Assist the consumer through the grievance process as needed

Ø      Assist in the provision of raising community awareness of the Board’s network of providers and programs

For FY02, the Board must refine its relationship with the Consumer Advisory Council and identify areas of need.  Previously, the role of the CAC was mainly one of raising community awareness of the need for AOD services.  This year’s goal is to further strengthen the collaborative nature of the relationship between the Board and the Consumer Advisory Council and promote more active involvement in the realization of the other functions of the CAC.

Consumer Appeals Process

 

One of the Board’s goals in the 1997-2002 Strategic Plan is to “support the active involvement of consumers” in advocacy efforts.  The Board affirms this stance in the development of the Consumer Appeals Policy, which will allow consumers who have a grievance to advocate for themselves regarding issues of concern regarding treatment and prevention related issues.

The Board’s Consumer Appeals Policy outlines the standardized process that the Board will use to address grievances. The Board supports the rights of consumers to receive quality services that meet the needs of the consumer. The Department of Program Services has the responsibility to resolve complaints and grievances to the satisfaction of the consumer, provider, and the Board.

Quality Improvement staff will ensure that each provider has a grievance and appeals policy and procedures that address the means by which the provider resolves complaints and grievances regarding any treatment or other services related area.

 

For client grievances and appeals, the Board’s Grievance Officer will review and maintain specific client information in client complaints and grievances.  Quality Improvement staff will collect on a quarterly basis aggregate data regarding the number of grievances filed at the Board level.

Data collected will be the amount of time it takes from the point of filing to the point of resolution, number of complaints, and area of complaint.  Reporting to ODADAS will take place via the annual community plan or community plan update.  Providers will also be notified via an annual report that will detail the information in a format that guarantees the confidentiality of both the consumer and provider.

 

 

 

 

 

 

Major Unusual Incidents

The Board is statutorily responsible to ensure the health and safety of clients served in the community.  ODADAS Standards and the Board’s Service Contract stipulate the duties of the providers in the event of occurrences that impact the quality care of clients/consumers.

The Board will collect data and report on major unusual incidents within the provider network.  Major Unusual Incidents are defined as:




Ø      Death of client, staff, volunteer, student or others either on the agency premises or engaged in agency related purposes

Ø      Any injuries to client, staff, volunteer, student, or others either on the premises or engaged in agency related purposes

Ø      Neglect of a client, such as physical neglect, or failure to provide needed treatment, care, or service to maintain health and safety

Ø      Violations of the Drug Free Workplace Act

Ø      Physical, sexual, or verbal abuse of a client, staff, volunteer, student or other by another person either on the premises or engaged in agency related purposes

Ø      Any event that causes a disruption or impedes the ability of the provider to conduct business

Major unusual incidents will be submitted to the Board and ODADAS within 72 hours of an occurrence.  Major unusual incidents will contain the following information:

1.      Date of incident

2.      Narrative description of what occurred, including injuries

3.      How agency analyzed and resolved the incident (root cause analysis)

4.      Subsequent action plan that identifies strategies that will reduce future incidents

5.      Name of person submitting information

Quality Improvement staff will review major unusual incidents for accurate completion of the form.  In addition, QI staff will review for provider’s process for analysis and resolution of the incident.  For major unusual incidents that involve client abuse or neglect, major unusual incident forms will be forwarded to the appropriate Program Services staff for follow-up.

 

Referral Process Improvement

The Board’s Referral and Waiting List Policy outlines goals for ensuring access for potential clients.  There are a number of avenues for clients to access treatment.  Currently, the Board utilizes the Neighborhood Family Service Centers (NFSC) for the assessment and treatment referral for TANF clients in a collaborative effort with county welfare reform initiatives. The forensic population accesses treatment through Treatment Alternatives to Street Crime (TASC) and Juvenile TASC.  Clients involved with the Department of Children and Family Services (DCFS) can access prevention and treatment services through the Cleveland Cares Plus Unit and the provider panel.

The Board will implement other mechanisms to monitor access to treatment services through:

1.      The review of linkages between systems

2.      The development of a Board level referral survey

3.      The review of Behavior Health (BH) and Creative Socio-Medics (CSM) data to track client referrals through the system

In an effort to ensure access, the Board will also develop access standards for use across the provider network.  The workgroup responsible for the development of the access standards will be comprised of both Board and provider staff. 

Independent Peer Review/Utilization Review

In the area of independent peer and utilization review, the Board utilized independent consultants to conduct an independent peer review of all its contracted providers, including the Medicaid only agencies.  While required by ODADAS to conduct a peer review on 5% of its providers, the Board wanted to establish the level of appropriateness, quality, and efficacy of treatment services for all the providers and work on improvements from the baseline findings.  The review included utilization, admission, intake process and procedures, assessments, ODADAS Levels of Care, treatment planning, progress notes, treatment reviews, appropriateness of referrals, treatment services, discharge planning, continuing care planning and treatment referral outcomes.  The consultants also conducted a utilization review to assist the Board in evaluating the effective and efficient use of program resources and services.

Overall results indicated that documentation needed to better reflect quality and effectiveness of care.  Areas that needed improvement were treatment planning, documentation of continued stay, discharge summaries, more detailed information on the assessment, such as developmental history, and case management activities to better coordinate the client’s care (Brown and Associates, 3-4).

An aggregate report of the Independent Peer Review conducted by the consultants will be submitted annually to ODADAS via the Quality Improvement Plan.

Peer Review/Utilization Review Requirements

The Board will continue to utilize a consultant to conduct peer reviews of its’ provider organizations at the recommended percentage at least once a year.  Treatment providers selected will be representative of the total population of the network providers.  The sample selection method will be included in the narrative report.

Requirements for Peer/Utilization Review Committee members will be:

Ø      Credentialed or licensed in alcohol and drug treatment

Ø      Peer Review Committee members should be representative of the various disciplines within the agency

Ø      Peer Review members should be knowledgeable about the modality under review

Ø      Peer Review members should be culturally competent

 

The following items will be included in the peer/utilization review:

  1. Admission criteria/intake process
  2. Assessments, including adherence to the ODADAS Levels of Care Protocols
  3. Treatment Planning that will include at minimum appropriate referrals, prenatal care, HIV and TB services
  4. Documentation of implementation of treatment services
  5. Continued stay review
  6. Discharge and continuing care planning
  7. Indication of treatment outcomes

Utilization Management

The Board will formalize the review of utilization trends within the ADAS network.  Standardized reports will be developed and disseminated to the providers that identify utilization trends including:

Ø      Service analysis reports

Ø      Length of stay

Ø      Service analysis by client

Ø      Productivity of provider and utilization of board funding

Ø      Type of disposition at case closure

Ø      Highest cost cases

Ø      Diagnosis and use of services

Ø      Referral source

Ø      Provider profiling

Initial efforts will focus on identifying baseline trends and investigation of sentinel events and patterns that are outside the norm within the provider network. The Board will also develop reports that track utilization by Substance Abuse Prevention and Treatment (SAPT) populations as well as individual funding initiatives.

Satisfaction Surveys

Client Satisfaction

One of the strategic goals that the Board outlined in 1997 was “to support the active involvement of consumers in defining, advocating for, and evaluating services.”  The client satisfaction survey can be one method to evaluate the effectiveness and quality of services.

As part of the ODADAS Guidance Manual requirements, the Board will conduct a client satisfaction survey.  Currently, Board QI staff are considering North Carolina’s Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Consumer Satisfaction Survey Protocol, developed by the Mental Health Consumer Oriented Report Card.  The consumer survey measures are both reliable and valid.  The areas measured are overall satisfaction, access to services, appropriateness of services, and self-assessment of outcomes.

As part of the compliance protocol, a consumer survey will be included that will be conducted face-to-face on-site at the agency. There will be a minimum of four standard questions as well as questions regarding problems that the client may be experiencing at that specific agency.  Feedback from these interviews will be included as part of a compliance report that is sent to the provider within 30 days of the review.

Once a year the Board will conduct a client satisfaction survey and report the findings via the Community Plan to ODADAS.  The Board will report the findings to the Board of Trustees and the provider network.  If a particular agency desires access to its own specific findings, the Board will provide the questionnaires, the responses, and the data analysis.

 

 

Provider Survey

The Board has surveyed providers on Board activities at various times throughout the course of the year.  As part of the allocation process, providers are surveyed on their responses to the allocation review process, whether the process was fair and understandable; providers are solicited for their feedback on any improvements that need to be made.  As part of the Board retreat and Director’s Meeting, providers are asked for their opinions on various areas that might need improvement:  MIS System, MACSIS, training needs, i.e., documentation, the use of the CIAI-C, levels of care training, etc. 

 

The Board will develop a provider satisfaction survey to be administered on an annual basis.  The provider satisfaction survey will be sent to all providers in the network and will cover these four areas: 

v     Appropriateness

v     Service Reimbursement

v     Planning Participation

v     Evaluation Participation 

Results of the survey will be reported to the Board of Trustees, the providers, and ODADAS via the Community Plan.

Outcomes

The University of Akron in collaboration with the Board has completed the 12-month outcome evaluation study as part of the Target Cities project.  This study tracked 1380 clients who received services via the Board’s provider network.  The study examined changes in the following variables: drug usage (past 30 days and change in using status), criminal involvement (illegal activity, incarceration, and arrests), employment (full time employment, current employment, and hours worked per week), income (changes in the type of income received), health insurance coverage (changes in types of insurance from public assistance to private insurance), and current living arrangements (changes in type of housing). Comparisons were performed using sociodemographic variables, treatment service models, services received, and treatment episodes.

The Board is continuing to work with the University of Akron and now WESTAT to track these same 1380 clients another 24 months under the Persistent Effects of Treatment Study (PETS).  This study will utilize the same research instrument and data collection methods that were used under the Target Cities outcome study but will add a more detailed analysis of treatment data to determine what type of treatment service array equates to long term positive outcomes.  The data provided from both the Target Cities outcome study and PETS will result in tracking of research subjects for a period of 36 months post treatment.

The Board will begin to review outcome variables that can be included on the evaluations that providers conduct on an annual basis.  By including several outcome measures variables on the agency’s evaluation, the Board will be able to review outcomes across the provider network.

The Board will also continue to explore the availability of research dollars for outcome studies.  The goal is to develop an outcome based system that will track clients post-treatment for 12 months.

Evaluation of the Quality Improvement Plan

 

For FY02, the evaluation of the Quality Improvement Plan will be based on the

following objectives:

1.      Adherence of the QI plan to ODADAS Guidelines

2.      Successful implementation of the plan during FY02

3.      The establishment of baseline measures

4.      Performance of QI teams in achieving goals, objectives, and outcomes as identified in team charters

On a continuous basis, the Board will measure improvement through the evaluation of QI teams as reflected in the minutes generated as the result of each meeting, the assessment of the improvement and whether it achieved its intended effect, and the discussion of activities through the reporting to the QI Council and the Board of Trustees.

Members of the Quality Council will appraise the quality improvement plan objectives and the QI teams on a quarterly basis.  On an annual basis, the quality improvement plan will be adjusted as necessary in conjunction with the submission of various components to ODADAS via the Community Plan.

 

 

Provider Monitoring



 

Quality Improvement Plans

Quality improvement plans must be developed and completed annually by the providers with approval from the agency’s governing authority.  According to ODADAS Guidelines and Treatment Standards, quality improvement plans, at minimum, need to include waiting list management policies and procedures, risk management functions, peer review, customer and referral source satisfaction surveys and data methodology, grievance policies and procedures, as well as any internal quality improvement activities the agency is currently involved with.

Once the providers have submitted their Quality Improvement Plans (QI) and Board staff has conducted an initial review, the Board will offer technical assistance on the agencies’ plans. The provider’s QI plans will be incorporated into the overall Board QI plan via a provider section that will describe the provider’s efforts and improvements within their own agencies. 

To this end, the Board is currently gathering information from the providers:  waiting list policies, evaluations, QA/QI plans, client satisfaction surveys, grievance procedures, and referral source surveys.  Apart from these materials, the Board will also develop a brief survey regarding level of knowledge and implementation of CQI in order to better target future training and technical assistance needs.  After the initial evaluation of QI plans and other information required by ODADAS Standards, QI plans will be reviewed annually.

Board QI staff will assist the providers in implementing quality improvement activities within their own agencies.  This will occur via training, establishing technical assistance for providers, continuous monitoring of provider QI activities, and performance management indicators.

Consumer Appeals Process

 

The Board will ensure that each provider has a grievance and appeals policy and procedure that is in compliance with ODADAS Standards and that addresses the means by which the provider resolves complaints and grievances regarding any treatment or other service related area.

Additionally, in order to evaluate the performance of providers in the area of complaints and grievances, the Board will actively monitor and report on the status of both complaints and formal grievances on a quarterly basis. 

Grievance Requirements

The provider will be required to complete the aggregate Grievance Form on a quarterly basis to report individual grievances.

The form will have the following information:

A.    Type of grievant:

1.      Consumer

2.      On behalf of the consumer by another (i.e., significant other, spouse, parent, etc.)

B.     Type of grievance, i.e. access, treatment services, staff

C.     Status of grievance

Ø      Is the grievance filed?

Ø      Is the grievance still under investigation?

Ø      Is the grievance resolved?

Ø      Is the grievance resolution under appeal?

Waiting List Management

It is the Board’s goal to ensure timely access to alcohol and drug services within in the provider network.  Waiting list management by the Board will be part of the QI plan in order to evaluate the productivity and responsiveness of the provider network.  Quality Improvement staff will work with Program Services staff in the monitoring of the accessibility of services.

All treatment providers are required to have a waiting list policy in accordance with SAPT and ODADAS guidelines.  Contact with clients on the waiting list shall be maintained in order to engage the client in treatment.  Activities are to include at minimum, telephone contact, but can also include office visits and home visits as necessitated by clinical need.

Waiting List

The Board will monitor the waiting list activities of providers in its network.  The providers will submit the waiting list report to the Board on a monthly basis.  The Board will monitor the provider’s waiting list and waiting list activities to ensure access is in accordance with SAPT access timelines and ODADAS Standards. 

Upon review of the monthly reports of waiting list status, QI staff will notify Program Services of any compliance or access issues.  Program Services will then provide technical assistance around managing waiting lists.

Furthermore, Board QI staff will gather and review all providers’ waiting list policies and ensure compliance with SAPT and ODADAS guidelines.  The review will assess policies and procedures regarding contact with referral sources, interim services offered, and mechanisms for discharging clients from the waiting list.

The Board will report on the waiting list status to the Board of Trustees on a quarterly basis and to ODADAS via the Community Plan or Community Plan Update.  The Board will also issue a report to the provider network annually via the Community Plan or Community Plan Update.

Access Requirements

Pregnant Women

Pregnant women cannot be placed on agency waiting lists.  If the provider does not have a slot available, then referral must be made to the Board and notification submitted in writing to ODADAS within 5 business days. The Board must refer the client to another treatment provider and notify ODADAS within 5 business days that the client has been admitted into an appropriate facility.  If the Board cannot place the client into the appropriate modality, then ODADAS must be notified that the county does not have the capacity to serve the client.  If the client cannot be placed anywhere, then the Board is responsible for ensuring that interim services are made available within 48 hours.

Medical/Psychiatric Emergency

Clients with medical or psychiatric emergencies will not be placed on agency waiting lists.  Agencies will refer the client to the appropriate medical or psychiatric facility for care.

Intravenous Drug Users

IVDU clients that call or visit an agency must be admitted within 14 days of contact or within 120 days of contact if interim services were available to the client within the first 48 hours and provided consistently during the interim period.

Non-Emergency

Clients can be placed on agency waiting lists only if an assessment cannot be offered within 3 working days of contact.  In the event of the unavailability of a slot in the level of care assigned by the assessment, clients can be placed on a waiting list only if services cannot be offered within 5 working days.

Medically Indigent

The medically indigent within each priority population will receive priority for alcohol and drug services at each facility.

Peer Review/Utilization Review

The Board will request on a quarterly basis a report from providers that summarizes their peer review and utilization criteria, policy and procedures, and  results to ensure compliance with ODADAS Standards.

Beginning in Fall 2001, in an effort to better monitor the peer reviews that providers conduct, the Provider CQI Committee will investigate the feasibility of standardizing the minimal peer review requirements across all providers.  Additional review items can be chosen by the agency.  This will allow the Board to make systems based comparisons. 

The providers are required to conduct peer reviews/utilization review quarterly within their own organizations.

Peer/Utilization Reviewers Requirements:

Ø      Credentialed or licensed in alcohol and drug treatment

Ø      Conducted by clinical staff who are qualified to provide the same alcohol and drug addiction services as services under review

Ø      Members will not review their own records

ODADAS standards require that at least the minimum be addressed in peer review/utilization review activities:

  1. Assessments were thorough, complete, and timely
  2. Problems, goal, and objectives on the treatment plan were based on the assessment findings
  3. Provided services were related to the treatment plan goals and objectives
  4. Documentation in the clinical record accurately reflects the services that were provided
  5. Ensuring that the admission, continued stay, and discharge is appropriate based on the ODADAS Levels of Care Protocol, including the methodology, frequency, and content of these activities

 

 

 

 

 

Customer Satisfaction Surveys

The Board will review the surveys, data collection methods, data analysis, and findings of the providers regarding their client satisfaction surveys on an annual basis. 

Requirements

Treatment And TASC Providers

All treatment and TASC providers will make an attempt to contact all persons served either immediately or within one month of case closure for participation in the client satisfaction survey.  The client satisfaction survey must measure five content areas: 

v     Accessibility

v     Appropriateness

v     Acceptability

v     Overall Satisfaction

v     Recommendations for Future Improvements 

The survey protocol must be a reliable and valid instrument (results must be consistent with repeated application and the instrument must measure what it is supposed to measure).  Data collection, data analysis, and reporting of findings must be consistent with practices of survey research.  Confidentiality must be maintained and anonymity must be offered in survey participation and in the reporting of the findings.  Participation must be voluntary.

Prevention Providers

An attempt will be made to contact all persons who have received direct recurring

prevention services for participation in the consumer satisfaction process.

The consumer satisfaction survey must measure five content areas: 

v     Accessibility

v     Appropriateness

v     Acceptability

v     Overall Satisfaction

v     Recommendations for Future Improvements 

The survey protocol must be a reliable and valid instrument (results must be consistent with repeated application and the instrument must measure what it is supposed to measure).  Data collection, data analysis, and reporting of findings must be consistent with practices of survey research.  Confidentiality must be maintained and anonymity must be offered in survey participation and in reporting of the findings.  Participation must be voluntary.

 

Referral Source Surveys

 

Requirements

 

Treatment and TASC Providers

Treatment and TASC providers will conduct referral source satisfaction on an annual basis.  Reasonable attempts must be made to contact a sample of referral sources.  The referral source satisfaction survey must measure four areas: 

v     Access

v     Program information

v     Client information

v     Overall satisfaction

 

Evaluation

 

As part of the ODADAS Standards, providers are required to conduct program evaluation activities.  The Board reviews this data as part of our annual allocation process.  In reviewing the data, there is a wide variation of results obtained, variables measured, instruments utilized, and overall agency expertise in program evaluation.    Unfortunately due to the diversity of the outcomes, it is extremely difficult to use this information to create network summary reports.  So the Board will be implementing several goals:

Ø      To improve the overall evaluation efforts being conducted by providers

Ø       Develop an inventory of our provider evaluative efforts

Ø      Examining the feasibility of standardizing the evaluation efforts to create network outcome measures

As part of the FY02 continuation funding application, providers will be asked to describe their methodologies regarding evaluation efforts.  Details regarding data collection and data analysis will be reviewed. 

 








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