Presentation on theme: "Regulatory Compliance & Quality Management"— Presentation transcript:
1 Regulatory Compliance & Quality Management April 15, 2011Rebecca Carson, RN, MSNPsychiatric Facilities CoordinatorDMH-MIMH LEADERSHIP TRAINING INSTITUTE
2 WHY regulate Mental Health Facilities and Service Providers? Regulatory Compliance: Why Regulate?WHY regulate Mental Health Facilities and Service Providers?
3 Insure safety of vulnerable citizens Regulatory Compliance: Why Regulate?Insure safety of vulnerable citizensInsure safety of the general publicMONEYInsure we are getting the service for which we paidInsure we are getting reasonable quality of service for which we paid
4 Regulatory Compliance: Who Regulates? Federal GovernmentU.S. Code (Public Laws)—Establish intent & authorityFederal Code of Regulations (FCRs)Interpret & Provide Operational InstructionsState GovernmentRevised Statutes of Missouri (RSMo)—Establish intent & authorityState Code of Regulations (CSRs)County/Municipal OrdinancesUsually life safety; Zoning issues
5 Regulatory Compliance: Learning the “Lingo” LicensureMinimum requirements to do businessTo perform a services, such as a professional licenseTo provide a service/function, such as operate a residential facilityCertificationRequirements to participate in a particular service or programUsually required for reimbursementCan reflect a special designation or achievementCan give you “deemed status” for some licensesAccreditationMost often VOLUNTARY , with rare exceptionsGoal=Quality; “Good Housekeeping Seal”Can give you “deemed status” for some licenses &/or certifications“Deemed Status”—Determined to be equivalent; able to substituted for other requirement
6 Regulatory Compliance: Learning the “Lingo” Accreditation continued…………Major Players---The Joint Commission (TJC)CMS grants deeming status for hospitals (5000), PRTCHospitals, Behavioral Health OrganizationsHome Care, Laboratory, LTCCommission on Accreditation of Rehab Facilities Inter’l (CARF)CMS acknowledged accreditor for DMECouncil on Accreditation (COA)Largely “kid” and family serving agenciesDet Norske Vertas Healthcare Inc. (DNV)CMS grants deeming status for hospitals (27)Healthcare Facilities Accreditation Program (HFAP)Division of AOA, American Osteopathic AssociationCMS grants deeming status for hospitals (200)The Council on Quality & Leadership (CQL)Used to be known as Accreditation Council for MR or other DD Persons
7 Regulatory Compliance: Learning the “Lingo” Accreditation continued…………How to compare—What has meaning for your organization---Not all created equalOrganizational FocusClinical/AdministrativeOutcomes/ProcessOrganizational Structure; Governance LeadershipNon-for-Profit/ For ProfitAccreditation RequirementsParticipation requirements, GeneralStandardsSurvey Process/FrequencyAnnual/TriennialAnnounced/UnannouncedPaper/OnsiteComplaint processSurveyors (Qualifications)Employees or volunteersScoring Process/Decision ProcessStatus of AccreditationSatisfies other standards (Deeming)Public/Professional ReputationAccreditation CategoriesPrograms coveredCostUsually based on size of organization, but can vary $10K-$15 K/yr.Patient SafetyContinuous ImprovementTQM, CQIISOLean Six Sigma
8 Regulatory Compliance: Special Oversight-Complaint Driven FederalHIPAAEMTALADepartment of Justice Investigations/LitigationADA –Olmstead DecisionTelecommunications, Fair Housing, Voting Accessibility ActsAir Carrier Access, Architectural Barriers, Rehabilitation ActsIndividuals w/ Disabilities Education ActsCivil Rights of Institutionalized Persons Act (CRIPA)StateDHSS-Vulnerable Person ProtectionRSMo &DHSS/DMH/DSS Memo of Understanding – Facilities OnlyDSS-Children’s Division—Abuse/NeglectRSMo ; 13 CSR &
9 Regulatory Compliance: Hospital: Licensure Missouri Hospital License—RSMo Chapter 197Survey/Determination Responsibility=Dept of Health & Sr. Services (DHSS)Applies to all hospitals, BUT DHSS has elected not to survey DMH operated hospitals; DMH views regulations as Standard of PracticeDMH does not license psychiatric hospitals, DHSS doesHospitals: 19 CSR thruPsych Hospitals: 19 CSR thru
10 Regulatory Compliance: Hospital: Certification Certification— “qualified, eligible for reimbursement”Most important = Hospital Certification from CMS [A-tags]US Department of Health & Human Services, Centers for Medicare & Medicaid ServicesMO DHSS serves as contracted surveyors for CMSMust be certified/”deemed” certified to bill/collect Medicare or Medicaid dollarsSome private insurances tie their reimbursement to CMS certification as wellPsych Hospitals treated differently ! ! !Must also meet Special Conditions of Participation [B-tags]Allowed to designate “Distinct Part” of hospital for certificationIMD Rule [“Institutions for Mental Disease”]> 16 beds; care=primarily MH; Ages 22-64Correctional institutions vs Hospitals
11 Regulatory Compliance: Hospital: Accreditation Accreditation — “Voluntary” standards complianceMost importantDeemed Status for Hospital Certification from CMS [A-tags]Deemed Status for Special Psych CoPs [B-tags] NEW ! ! !Considered Standard of Practice for hospitalsAll DMH hospitals achieved in 1990; all now except for SWPRCOther benefitsCredibility; “good housekeeping seal”Requirement to be “training/practicum” sites for professionalsRecruitment/RetentionHelps us “keep up” with changing/improving practiceLeverage with Legislature/GovernorPsychiatric Residential Treatment Centers: [Cottonwood & Hawthorn Residential] Youth, Medicaid reimbursable, must accredited + CMS [N-tags]
12 Regulatory Compliance: Community Providers: Residential Community Residential –[Non-Hospitals]LicensureMO DHSS LicensedSkilled Nursing Facilities (SNF), Intermediate Care Facilities (ICF; ICFMR) Residential Care Facilities (RCF), Assisted Living Facilities (ALF) [CSR Title 19 Division 30]MO DMH Co-Licensed DHSSRCFs that have 1 MRDD consumer and/or 50% or greater MI consumers [CSR Title 9 Division 40 Chapter 3]DMH Standards focus=treatment programMO DMH Licensed Only [CSR Title 9 Division 10 & 40]Psychiatric Group HomesTherapeutic Foster Homes
13 Regulatory Compliance: Community Providers: Residential Community Residential [Non-Hospital]CertificationMO DHSS OnlySkilled Nursing Facilities (SNF), Intermediate Care Facilities (ICF; ICFMR) Residential Care Facilities (RCF), Assisted Living Facilities (ALF) [CSR Title 19 Division 30 Chapter 81]Title XIX-Medicaid; Title XVIII-Medicare – Federal/State reimbursement for long term careMO DMH OnlyIntensive Community Psychiatric Rehabilitation [9 CSR Amended 2/24/2011]Amendment permits the necessary supports for Intensive Residential Treatment Services (IRTS) NEW !!!Inpatient Redesign effort to move long term hospitalized individuals into the communityAccreditation— Available, but not big role as yet
14 Regulatory Compliance: Community Providers: Outpatient Community OutpatientLicensureIndividual Practitioners—Professional LicensureDIFP-Department of Insurance, Financial Institutions and Professional RegistrationDivision of Professional Registration--Business RegistrationSecretary of State--MO DHSS Licensed OnlyAdult Day Care; Child Day Care (May or may not impact our MH Community Providers) [CSR Title 19 Division 30]MO DMH Licensed Only [CSR Title 9 Division 40]MI & DD Day Programs – Non Medicaid CertifiedCertified Programs are “deemed” to have met licensure requirements
15 Regulatory Compliance: Community Providers: Outpatient Community OutpatientCertificationMO DMH OnlyUsually tied to Medicaid reimbursement, ADA exceptionADA & CPS “Core Rules” --- Combined 20019 CSR 10-Chapter 7Division Specific9 CSR 30-Chapter 3, Alcohol & Drug Abuse Programs9 CSR 30-Chapter 4, Mental Health ProgramsMSAPCB- Substance Abuse Professional Credentialing;AccreditationAvailable, but not big role as yet but growingIncrease with large hospital acquisition of CMHCsCMHCs seeking “deemed status” for licensure/certification requirementsContract & Billing Audits --- Although not “regulatory”, intertwined
16 General Constructs & Overview Only Regulatory Compliance: Disclaimer & Last ThoughtsGeneral Constructs & Overview OnlyDo not assume everyone speaks the same languageThe devil is in the details ! ! !If you’re responsible for it, do your homeworkRegulatory compliance does not automatically assure quality ! ! !
17 Regulatory Resources ACCREDITATION Commission on Accreditation of Rehab Facilities Inter’l (CARF);Council on Accreditation (COA);Det Norske Vertas Healthcare Inc. (DNV);Healthcare Facilities Accreditation Program (HFAP);The Council on Quality & Leadership (CQL);REVISED STATUTES OF MISSOURI (RSMo);Department of Mental Health, Chapter 630 RSMoDivision of Alcohol & Drug Abuse, Chapter 631 RSMoDivision of Comprehensive Psychiatric Services, Chapter 632 RSMoDivision of Developmental Disabilities, Chapter 633 RSMoDepartment of Social Services; Chapter 660 RSMoPublic Health & Welfare; Chapters 188, 189, 190, 191, 192, 194, 195,196, 197MISSOURI CODE OF STATE REGULATIONS ( CSR)Department of Mental Health, Title 9Department of Health & Senior Services, Title 19Department of Social Services, Title 13
18 Regulatory Resources FEDERAL LAW; http://www.gpoaccess.gov/uscode/ FEDERAL CODE OF REGULATIONS;HIPAA;EMTALA; https://www.cms.gov/EMTALA/Department of Justice; Division of Civil Rights;Civil Rights of Institutionalized Persons;Olmstead Decision;CMS REGULATIONS & INTERPRETATIVE GUIDELINESHospitals, A Tags;Psych Hospitals, B Tags;Psych Residential Treatment Facilities, N-Tags;
19 QM starts with asking the right questions ! ! ! Quality ManagementQM starts with asking the right questions ! ! ![and it never stops……….continuously seeking to improve !]
20 WHAT constitutes Quality? Quality ManagementWHAT constitutes Quality?
21 “I can’t define it, but I know it when I see it” Quality Defined“I can’t define it, but I know it when I see it”You better know how to define it if you want to stay employed or stay in business“Common person” standardLicking, Missouri“Political” realityA.K.A “How does it play out in the headlines?”Established criteriaPublished standards“Evidence Based Practices”
22 Key Responsibilities Identified What are my key responsibilities; what am I responsible to produce; for what am I accountable?
23 Example : Areas of Responsibility in Health Care Consumer and Employee SafetyElimination/Reduction in physical Plant HazardsInfection ControlDisaster PreparednessConsumer SatisfactionComfortStaff ResponsivenessAppropriate & Efficient AdmissionsTriage and screening processesAppropriate & Effective Care & TreatmentRight Treatment ProgramRight MedicationsConsumer Progress/Outcome MeasuresUtilization ReviewAppropriate & Effective DischargesReadmissionsPost discharge complications/SuicidesCost Effective Fiscal ManagementBudget outliersPrice increases/decreasesOptimal Utilization of Human ResourcesRight number and right mix of employeesRight and up to date employee competencies
24 How do know if I am meeting my key responsibilities? Meeting Key ResponsibilitiesHow do know if I am meeting my key responsibilities?Was what I produced satisfactory?
25 Your job is to acquire and take care of 20 ducks. Ask More Questions---Duck ExerciseYour job is to acquire and take care of 20 ducks.You want to be successful at your job.How do you keep your job?
26 Your owner/boss (taxpayers) Your VP of Finance (legislature) Duck Exercise: RolesYOU (manager of ducks)Your owner/boss (taxpayers)Your VP of Finance (legislature)The vendor (he who has ducks to sell)The competition (he who also cares for ducks)
27 What are my key responsibilities? QM of DucksWhat are my key responsibilities?What questions should I ask to determine if I’m meeting my responsibilities?
28 Performance Measurement QM = Asking the Right QuestionsQUESTIONSQM TechnologyDid we get that for which we paid?Contact ComplianceDoes what we purchased or what we perform meet minimum standards?Quality AssuranceIs what we’re doing healthy and/or safe?Have we mitigated against loss or damage?Risk ManagementCan we get better performance or better product? Can we exceed standards or move towards “best practices”?Quality ImprovementIs what we purchased or what we’re doing achieving the outcomes we sought?Performance MeasurementHow do we compare? Do we achieve similar outcomes as that of our peers? Are we competitive in the marketBenchmarkingWhat can we learn from an extremely good experience or an adverse event?Sentinel EventAnalysis
29 Identify key responsibilities to monitor Basic Tools of QM—A PlanNeed a plan:Identify key responsibilities to monitorMethods to monitorThink sampleThink intermittent samplingAreas for improvement focusThink strategicFix existing problemsPrevent problemsChange system to address root cause of problemManage innovationQuality improvement approachCQI, TQM, Lean Six Sigma, ISO
30 Basic Tools of QM— Improvement Process Identify the problem, issue or opportunity for improvementGather relevant data and informationBrainstorm possible solutionsSelect a solution to trialDevelop an implementation planEstablish a baseline to measure againstImplement the planEvaluate the results of the solution against the baselineIf solution fails to resolve problem or render improvement, REPEAT THE ABOVE STEPSIf solution is somewhat successful, consider fine tuning or modifying solution; implement and re-evaluateIf problem resolved or improvement achieved, adopt the solution as final practice…..and move on to new problems or opportunities for improvement
31 Check whether the test worked; achieved the desired result. Basic Tools of QM— PDCA CyclePDCA Cycle:Plan to improve your operations by first finding what things are going wrong.Do changes designed to solve the problems on a small scale first; test to minimize disruption.Check whether the test worked; achieved the desired result.Act to implement changes on a larger scale if test is successful.PlanDoCheckActShewhart CycleDeming Wheel
32 Quality improvement is a continuous effort. Basic Tools of QM— QI According to Marty Martin-FormanQuality is, first of all, leadership responsibility; it cannot be delegated to the “Quality Department.”Quality improvement is a continuous effort.QI is dependent on leadership at all levels of the organization.Quality planning must begin with a clear delineation of customers, what they need or want from the organization, and what quality characteristics will be adopted as the most important.
33 Basic Tools of QM— QI According to Marty Martin-Forman In health care or mental health, the definition of quality is shared by the customer or client and by the experts or specialist.QI requires discipline to go through the PDCA cycle. All levels of management and organizations resist the check and act phases.Data will free employees. Data that supports improvement plans drives out fear and empowers managers and employees.QI is not a democratic process. QI is leader driven and requires a vision of how things must be.
34 Basic Tools of QM— QI According to Marty Martin-Forman QI is not a democratic process. QI is leader driven and requires a vision of how things must be.QI requires repetitive education and training. One shot education is insufficient. Key concepts and tools need to be integrated into multiple learning opportunities.Quality is a function of everyone in the organization; team work is basic to QI efforts.
35 Five Mistakes That Commonly Doom Quality Improvement Basic Tools of QM— QI According to Marty Martin-FormanFive Mistakes That Commonly Doom Quality ImprovementLack of:Top Management InvolvementMiddle Management LeadershipIntegrationContinuous Training
36 Ten Pillars of Continuous Improvement…………… Basic Tools of QM— QI According to Marty Martin-FormanTen Pillars of Continuous Improvement……………1. Management Vision and Commitment2. Accountability3. Measurement and Feedback4. Problem-Solving and Process ImprovementCommunication6. Staff Development and Training7. Physician Involvement8. Reward and Recognition9. Employee Involvement and Empowerment10. Reminders and Refreshers
37 Basic Tools of QM— Root Cause Analysis RCA Goal: What happened --Why did it happen -- What to do to prevent it from happening againRoot Cause Analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.Root Cause Analysis is:Inter-disciplinary, involving experts from the frontline servicesInvolving of those who are the most familiar with the situationContinually digging deeper by asking why, why, why at each level of cause and effect.A process that identifies changes that need to be made to systemsA process that is as impartial as possible
38 Basic Tools of QM— RCA continued…… To be thorough, a Root Cause Analysis must include:Determination of human & other factorsDetermination of related processes and systemsAnalysis of underlying cause and effect systems through a series of why questionsIdentification of risks & their potential contributionsDetermination of potential improvement in processes or systemsTo be credible, a Root Cause Analysis must:Include participation by the leadership of the organization & those most closely involved in the processes & systemsBe internally consistentInclude consideration of relevant literatureA Bazooka not a BB gun !
39 Defensiveness = The Enemy Basic Tools of QM—BenchmarkingBenchmarking is the process of measuring your current products, services and processes against other products, services and processes to identify opportunities for improvement.Against yourself - Past performance; or other units/disciplines within organizationAgainst those outside the organization closest in comparison to your “business”Against those outside that are similar, but somewhat different to your “business”Against “Best Practice”Defensiveness = The Enemy
40 A Quality Scorecard or Dashboard : Basic Tools of QM— Scorecards/DashboardsA Quality Scorecard or Dashboard :An Executive or Top Management toolbrief document, usually 1 pageSummarizes critical operations and performanceCan be a “snapshot” of current operations and performance [DASHBOARD]Can be a comparison of measures over a specific time [SCORECARD]Can offer comparison to a set standardCan monitor one complex process or multiple
43 Good quality management leads to good decision making ! QM: Parting ShotsInvestigation vs. Quality Improvement ActivityInvestigation seeks to assign culpability; who did what whenQI seeks to understand why, and to create systems that prevent mistakesA “just culture” recognizes that people makes mistakes, and seeks ways to help them avoid mistakes in the future; engineers success.CLOSE the LOOP ! ! ! --- Did your solution really solve the problem or improve the process?Good quality management leads to good decision making !
44 Quality Management Raw Data Relevant Other Data Trend Analysis TASKS/TOOLS/ACTIVITIESQUALITY PROCESSES & TECHNOLOGYBenchmarksCertificationInvestigationsAuditsContract MonitoringHearings/AppealsOutcome MeasuresConsumer GrievancesStandardsRegulationsBest PracticesConsumer Satisfaction SurveysDrillsPolicies/ProceduresHR Exit InterviewsAccreditationORYXTreatment metricsScorecardsBudgetsInjury reportsEnvironmental RoundsCQI, TQMLean Six SigmaRCAEtc.RiskManagementContractComplianceQualityAssuranceQualityImprovementPerformanceMeasurementSentinelEventAnalysisDATAINFORMATION PRODUCTSRaw DataRecommendationsRelevant Other DataTrend AnalysisOpportunity IdentificationCritical Decision PointsRight PersonRight ServiceRight TimeRight AmountResulting inRIGHTOUTCOMESACTIONTreatment or ManagementDECISIONS(Clients, Families, Staff, Providers)RECOVERY &SELF DETERMINATIONof CONSUMERTRACKING and OVERSIGHT(Executive Function)4/2011
45 ISOInternational Organization for Standardization (ISO)- When an organization's quality system has been assessed against ISO standards by an accredited independent certification body, then the quality system is registered, and can be used as evidence of quality assurance in tendering for contracts. Quality systems produced in accordance with these quality system requirements are subject to regular third party assessment based on documented, objective evidence of compliance;
46 Lean Six SigmaLean Six Sigma -- builds on the knowledge, methods and tools derived from decades of operational improvement research and implementation. Lean approaches focus on reducing cost through process optimization. Six Sigma isabout meeting customer requirements and stakeholder expectations, and improving quality by measuring and eliminating defects. The Lean Six Sigma approach draws on the philosophies, principles and tools of both.
47 TQMTotal Quality Management -- is an approach to the art of management that originated in Japanese industry in the 1950's and has become steadily more popular in the West since the early 1980's. Total Quality is a description of the culture, attitude and organization of a company that aims to provide, and continue to provide, its customers with products and services that satisfy their needs. The culture requires quality in all aspects of the company's operations, with things being done right first time, and defects and waste eradicated from operations.
48 Quality Management Resources Agency for Healthcare Research and Quality (AHRQ)--American Health Quality Association (AHQA)--Baldrige Performance Excellence Program (Baldrige Award, Healthcare Section) --Institute for Healthcare Improvement (IHI)--Institute of Medicine, Quality & Patient Safety --Crossing the Quality Chasm: A New Health System for the 21st Century, 2001Improving the Quality of Health Care for Mental & Substance Use Conditions: Quality Chasm Series, 2006“Just Culture” Community --Leadership Response to a Sentinel Event, IHI Toolkit --
49 Quality Management Resources Miller, Ken; The Change Agent’s Guide to Radical Improvement. ASQ Quality Press: Milwaukee, WI, 2002Missouri Center for Patient Safety (MOCPS) –Missouri Quality Award –Osborne, David & Gaebler, Ted – Reinventing GovernmentPeters, Tom –In Search of Excellence;Thriving on Chaos: Handbook for a Management Revolution;Excellence in the Public SectorRoot Cause Analysis –VA --Human Services Research Institute --Quality Management Resources
50 Quality Management Resources Senge, Peter – The Fifth DisciplineSluyter, GV & Mukherjee – Total Quality Management for Mental Health and Mental Retardation Services: A Paradigm for the 90’s. Annandale, VA: National Association of Private Residential ResourcesQuality Management Resources