1. ODP Community Services Quality Management Developing the Administrative Entity Quality Management Quarterly Report WebEx February, 2010 Ann Ligi, ODP Quality Management Lead – East Jodie Enterline, ODP Quality Management Lead – West

2. 9/7/2014 Learning Objectives  Explain AE QM Quarterly Report Expectations  Learn about Data Organization, Analysis and Reporting  Understand the Application of the PDCA Model 2

3. 9/7/2014 AE Performance Objectives  AE QM Quarterly Report Includes all required elements Template is used Timely submission  Data Organization Tables and charts are used  PDCA Model is appropriately applied PDCA follow up occurs Action plan is updated ongoing basis  Performance is monitored ongoing 3

4. 9/7/2014 Reports Timeline Reports Due1 st Q2 nd Q AE submits QM Quarterly Report electronically to Regional Program Manager April 30, 2010July 31, 2010 Feedback to AE June 15, 2010September 15, 2010 4

5. 9/7/2014 Report Generation Timeline Actions1234 Prior to QM Meeting Retrieve data Organize data (prepare tables, charts) Generate DRAFT report Provide to group prior to meeting During QM Meeting Discuss & interpret findings Interpret & Analyze data; Identify patterns & trends; Apply C (check) of PDCA Determine A (act) of PDCA; i.e. Maintain or Revise Action Plan Determine PDCA Follow Up; Finalize draft report After QM Meeting Finalize report Submit by due date 5

6. 9/7/2014 AE QM Quarterly Report Template Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives. Administrative Entity:Date:Submitted by: Focus Area and Desired Outcome: Objective: Performance MeasuresFindings and Analysis Incorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist. Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed. Describe how key stakeholders are involved in the achievement of QM Plan objectives. Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors. 6

7. 9/7/2014 ODP QM Quarterly Report Evaluation Tool  Show evaluation tool and go through the questions. 7

8. 9/7/2014 Complete the top section of the Quarterly Report using information from the AE Annual QM Plan Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives. Administrative Entity: ABCDate: April, 2010Submitted by: ABC QM Manager Focus Area and Desired Outcome: Safeguards People are free from restraint Objective: Reduce Incidents of Restraint by 20% by December 31, 2010 Performance MeasuresFindings and Analysis Incorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist. Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed. Number of restraints. Number of individuals restrained. Data Source: HCSIS – Data Warehouse Describe how key stakeholders are involved in the achievement of QM Plan objectives. Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors. 8

9. 9/7/2014 Performance Measures were identified in the AE Annual QM Plan 2010 QM Plan Administrative Entity Name: ABC Focus Area: Safeguards GOALOUTCOMETARGET OBJECTIVE PERFORMANCE MEASURES/ DATA SOURCE(S)/FREQUENCY/RESPONSIBLE PERSON People are safe and secure in their homes and communities People are free from restraint. Reduce Incidents of Restraint by 20% by December 31, 2010 Baseline: Calendar Year 2009 = 100 restraints 10 individuals Number of restraints. Number of individuals restrained. Data Source: HCSIS, Data Warehouse Frequency: Monthly Person Responsible: ABC QM Manager 9

10. 9/7/2014 Transfer the Performance Measures from the QM Plan to the Quarterly Report Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives. Administrative Entity: ABCDate: April, 2010Submitted by: ABC QM Manager Focus Area and Desired Outcome: Safeguards People are free from restraints Objective: Reduce Incidents of Restraint by 20% by December 31, 2010 Performance MeasuresFindings and Analysis Incorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist. Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed. Number of restraints. Number of individuals restrained. Data Source: HCSIS – Data Warehouse Describe how key stakeholders are involved in the achievement of QM Plan objectives. Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors. 10

11. 9/7/2014 AE QM Quarterly Report: Findings and Analysis Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives. Administrative Entity:Date:Submitted by: Focus Area and Desired Outcome: Objective: Performance MeasuresFindings and Analysis Incorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist. Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed. Describe how key stakeholders are involved in the achievement of QM Plan objectives. Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors. 11

12. 9/7/2014 Completing the Findings and Analysis Section  Organize data – table  Graphically display the data  Analyze the data (CHECK) After review of the data, what did we conclude? If we conclude that we are not on track to achieve our objective, then why? (barriers) 12

13. 9/7/2014 AE QM Quarterly Report: PDCA Follow-up Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives. Administrative Entity:Date:Submitted by: Focus Area and Desired Outcome: Objective: Performance MeasuresFindings and Analysis Incorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist. Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed. Describe how key stakeholders are involved in the achievement of QM Plan objectives. Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors. 13

14. 9/7/2014 Completing PDCA Follow-up Section  If you identified barriers to achieving your objective, identify what you are doing or will do, to overcome the barriers. (ACT) These should be actions/activities on your Action Plan  If you’re on track to reach your objective, identify what activities will be taken to sustain achievement and continue progress. 14

15. 9/7/2014 AE QM Quarterly Report: Key Stakeholder Involvement Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives. Administrative Entity:Date:Submitted by: Focus Area and Desired Outcome: Objective: Performance MeasuresFindings and Analysis Incorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist. Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed. Describe how key stakeholders are involved in the achievement of QM Plan objectives. Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors. 15

16. 9/7/2014 Completing Key Stakeholder Involvement Section  Who are Key Stakeholders? Waiver participants, their family members or representatives, and Waiver providers including SCOs.  What kind of “involvement”? Involved in the identification of local quality management priorities Involved in QI activities (meetings, planning, implementation, reporting etc.)  See Section 5.15 of the 09-10 AE Operating Agreement 16

17. 9/7/2014 AE QM Quarterly Report: Reporting to the MH/MR Board of Directors Administrative Entity QM Quarterly Report Review and analysis of progress made to date to achieve Annual QM Plan objectives. Administrative Entity:Date:Submitted by: Focus Area and Desired Outcome: Objective: Performance MeasuresFindings and Analysis Incorporate data and data analysis where available. Include barriers to achievement of objectives where obstacles exist. Plan-Do-Check-Act (PDCA) Cycle Follow-up Describe follow-up activities including how barriers, if present, will be addressed. Describe how key stakeholders are involved in the achievement of QM Plan objectives. Describe how and on what schedule progress in implementing the 2010 AE QM Plan is reported to the County/Joinder MH/MR Board or Board of Directors. 17

18. 9/7/2014 Completing the Reporting to the MH/MR Board of Directors section  Document how frequently you report QI activities to the Board of Directors. 18

19. 9/7/2014 QUESTIONS? 19

20. 9/7/201420

21. 9/7/2014 PDCA Model  Plan how the improvement will be accomplished. Write an action plan that specifies actions taken to achieve the annual target objective.  Do it. Implement the improvement plan. This includes education of staff and management about the process change.  Check the effect of the improvement Collect and analyze data Identify lessons learned. Determine the success or failure of the plan.  Act Hold the gains or Re-strategize steps in action plan and implement them Continue to monitor and evaluate progress. 21

22. 9/7/2014  Determine baseline performance  Analyze baseline data  Develop an Action Plan for the improvement  Implement the plan The PDCA Cycle - PLAN 22

23. 9/7/2014 The PDCA Cycle - DO  Once you have a PLAN……. Conduct training Implement (Just Do It!) Use a Data Collection Tool 23

24. 9/7/2014 The PDCA Cycle - CHECK  Review and analyze the performance data  Did the improvement work or not? If not successful, what were the barriers? 24

25. 9/7/2014 The PDCA Cycle - ACT  Based on success or lack of success in achieving your objective, ACT to maintain gains or modify your plan 25

26. 9/7/2014 QUESTIONS? 26

27. Data Organization, Analysis and Reporting

28. DATA INFORMATION KNOWLEDGE INFORMED DECISIONS

29. 9/7/2014 DATA - Organizing Data  Steps: 1. Retrieve data 2. Organize into a table 29

30. 9/7/2014 DATA – Retrieve Data - Sources  HCSIS/Data Warehouse  AE Data Collection Tools  Surveys  Comprised of individual cases, data elements  See example  30

31. ABC Communication Tracking Tool Name: Date of ISP: Information Reviewed Check Appropriate Item  Complete, as Needed Assessment/s Completed: Needed ? Indicate if Yes (Date)  Verbal Non-verbal  Communication Needs, If Non-Verbal:Communication Supports/System Notes System Type Available In Working Order Repair Needed Utilized Training Needed Training Provided  ________________  Follow up needed Yes/No 9/7/2014 Data Collection Tool Example ABC Communication Tracking Tool - ABC Communication Tracking Tool 31

32. 9/7/2014 Aggregate the Data Multiple Cases/Month = Data Draft 1-7-10 One case done in month All cases done in month Data for that month JulyAugustSeptember # of individuals (# of ISPs) # Non-Verbal # w Comm. System 32

33. 9/7/2014 DATA – Organize Data into Tables  Tables Columns  Categories  Variables  Time Rows  Individual cases  Aggregate totals See examples  33

34. 9/7/2014 Example Table ABC Primary Incidents FY 2008-2009 Incident Category JulyAugustSepOctNovDecJanFebMarAprMayJuneTotal Abuse 212219232117231725302712257 Death 91154697615813497 Emergency Closure 220216151420071 Emergency Room Visit 909380728272757781758285964 Fire 716114104 54 779 Hospitalization 42303735244441383141 27431 Individual To Individual Abuse 344037273236393446374843453 Injury Requiring Treatment Beyond First Aid 91694967897479 Law Enforcement Activity 102210 1518131012201814172 Medication Error 8890958364977782877791841,015 Missing Person 89144118 8131622115 Misuse of Funds 7212285445251378 Neglect 1113742561161110187 Psychiatric Hospitalization 10814111214151012191316154 Reportable Disease 0110001200128 Rights Violation 02051103754129 Suicide Attempt 0000000000000 Restraint 676269816349718661626453788 Total 4154093994093404023914504204184463784,877 34

35. 9/7/2014 Example Table – 1 st Q of Calendar Year MeasureJan ‘10Feb’10Mar ‘10 YTD Total 1 st Q Restraints13111438 Ind. restrained4545 35

36. 9/7/2014 Organized Data - Tables MeasureJan ‘10Feb’10Mar ‘10 YTD Total 1 st Q Restraints13111438 Ind. restrained4545 Note: YTD Total is not 13 because we count each unique individual once. Finding: 5 individuals, 38 restraints Some individuals experienced multiple restraints during the first quarter. 36

37. 9/7/2014 INFORMATION – Transforming Data into Information  Create a chart/graph of the data Histogram/Bar Chart Line Chart/Run Chart 37

38. 9/7/2014 INFORMATION - Bar Chart 38

39. 9/7/2014 INFORMATION – Line Chart 39

40. 9/7/2014 INFORMATION – Bar Chart 40

41. 9/7/2014 INFORMATION - Line Chart 41

42. 9/7/201442

43. 9/7/2014 KNOWLEDGE: Findings and Analysis  Based on the review of the Information, what can we conclude? Be aware of the potential to misinterpret data  Are we on track to reach our objective?  If we are not on track to reach our objective, do we have information that can help us to identify why we are not on track? 43

44. 9/7/2014 Example Findings and Analysis  See sample report 44

45. 9/7/2014 INFORMED DECISIONS – Recommendations and Follow -up  As a result of the analysis, identify recommendations and follow-up actions to be taken 45

46. 9/7/2014 Example Recommendations and Follow-up  See separate sample report document 46

47. 9/7/2014 WRAP UP  AE QM Quarterly Report Includes all required elements Template is used Timely submission  Data Organization Tables and charts are used  PDCA Model is appropriately applied PDCA follow up occurs Action plan is updated ongoing basis  Performance is monitored ongoing 47

48. 9/7/2014 QUESTIONS? 48

49. 9/7/2014 Next Steps  WebEx will be posted  Technical Assistance 9/7/201449

50. 9/7/2014 For further Technical Assistance Contact:  Ann Ligi ODP QM Lead – East c-aligi@state.pa.us 570-443-4218  Jodie Enterline ODP QM Lead – West c-jenterli@state.pa.us 814-432-0205 50