Presentation on theme: "1 Regulatory Compliance & Quality Management April 15, 2011 Rebecca Carson, RN, MSN Psychiatric Facilities Coordinator DMH-MIMH LEADERSHIP TRAINING INSTITUTE."— Presentation transcript:
1 Regulatory Compliance & Quality Management April 15, 2011 Rebecca Carson, RN, MSN Psychiatric Facilities Coordinator DMH-MIMH LEADERSHIP TRAINING INSTITUTE
2 Regulatory Compliance: Why Regulate? WHY regulate Mental Health Facilities and Service Providers?
3 Regulatory Compliance: Why Regulate? Insure safety of vulnerable citizens Insure safety of the general public MONEY Insure we are getting the service for which we paid Insure we are getting reasonable quality of service for which we paid
4 Regulatory Compliance: Who Regulates? Federal Government U.S. Code (Public Laws)Establish intent & authority o Federal Code of Regulations (FCRs) Interpret & Provide Operational Instructions State Government Revised Statutes of Missouri (RSMo)Establish intent & authority o State Code of Regulations (CSRs) Interpret & Provide Operational Instructions County/Municipal Ordinances Usually life safety; Zoning issues
5 Regulatory Compliance: Learning the Lingo Licensure Minimum requirements to do business To perform a services, such as a professional license To provide a service/function, such as operate a residential facility Certification Requirements to participate in a particular service or program Usually required for reimbursement Can reflect a special designation or achievement Can give you deemed status for some licenses Accreditation Most often VOLUNTARY, with rare exceptions Goal=Quality; Good Housekeeping Seal Can give you deemed status for some licenses &/or certifications Deemed StatusDetermined to be equivalent; able to substituted for other requirement
6 Regulatory Compliance: Learning the Lingo Accreditation continued………… Major Players--- o The Joint Commission (TJC) CMS grants deeming status for hospitals (5000), PRTC Hospitals, Behavioral Health Organizations Home Care, Laboratory, LTC o Commission on Accreditation of Rehab Facilities Interl (CARF) CMS acknowledged accreditor for DME o Council on Accreditation (COA) Largely kid and family serving agencies o Det Norske Vertas Healthcare Inc. (DNV) CMS grants deeming status for hospitals (27) o Healthcare Facilities Accreditation Program (HFAP) Division of AOA, American Osteopathic Association CMS grants deeming status for hospitals (200) o 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 compareWhat has meaning for your organization---Not all created equal o Organizational Focus Clinical/Administrative Outcomes/Process o Organizational Structure; Governance Leadership Non-for-Profit/ For Profit o Accreditation Requirements Participation requirements, General Standards o Survey Process/Frequency Annual/Triennial Announced/Unannounced Paper/Onsite Complaint process o Surveyors (Qualifications) Employees or volunteers o Scoring Process/Decision Process o Status of Accreditation Satisfies other standards (Deeming) Public/Professional Reputation o Accreditation Categories Programs covered o Cost Usually based on size of organization, but can vary $10K-$15 K/yr. o Patient Safety o Continuous Improvement TQM, CQI ISO Lean Six Sigma
8 Regulatory Compliance: Special Oversight- Complaint Driven Federal HIPAA EMTALA Department of Justice Investigations/Litigation ADA –Olmstead Decision Telecommunications, Fair Housing, Voting Accessibility Acts Air Carrier Access, Architectural Barriers, Rehabilitation Acts Individuals w/ Disabilities Education Acts Civil Rights of Institutionalized Persons Act (CRIPA) State DHSS-Vulnerable Person Protection RSMo & DHSS/DMH/DSS Memo of Understanding – Facilities Only DSS-Childrens DivisionAbuse/Neglect RSMo ; 13 CSR &
9 Regulatory Compliance: Hospital: Licensure Missouri Hospital LicenseRSMo Chapter 197 Survey/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 Practice DMH does not license psychiatric hospitals, DHSS does Hospitals: 19 CSR thru Psych 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 Services MO DHSS serves as contracted surveyors for CMS Must be certified/deemed certified to bill/collect Medicare or Medicaid dollars Some private insurances tie their reimbursement to CMS certification as well Psych Hospitals treated differently ! ! ! Must also meet Special Conditions of Participation [B-tags] Allowed to designate Distinct Part of hospital for certification IMD Rule [Institutions for Mental Disease] > 16 beds; care=primarily MH; Ages Correctional institutions vs Hospitals
11 Regulatory Compliance: Hospital: Accreditation Accreditation Voluntary standards compliance Most important Deemed Status for Hospital Certification from CMS [A-tags] Deemed Status for Special Psych CoPs [B-tags] NEW ! ! ! Considered Standard of Practice for hospitals All DMH hospitals achieved in 1990; all now except for SWPRC Other benefits Credibility; good housekeeping seal Requirement to be training/practicum sites for professionals Recruitment/Retention Helps us keep up with changing/improving practice Leverage with Legislature/Governor Psychiatric Residential Treatment Centers: [Cottonwood & Hawthorn Residential] Youth, Medicaid reimbursable, must accredited + CMS [N-tags]
12 Regulatory Compliance: Community Providers: Residential Community Residential –[Non-Hospitals] Licensure MO DHSS Licensed Skilled 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 DHSS RCFs that have 1 MRDD consumer and/or 50% or greater MI consumers [CSR Title 9 Division 40 Chapter 3] DMH Standards focus=treatment program MO DMH Licensed Only [CSR Title 9 Division 10 & 40] Psychiatric Group Homes Therapeutic Foster Homes
13 Regulatory Compliance: Community Providers: Residential Community Residential [Non-Hospital] Certification MO DHSS Only Skilled 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 care MO DMH Only Intensive 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 community Accreditation Available, but not big role as yet
14 Regulatory Compliance: Community Providers: Outpatient Community Outpatient Licensure Individual PractitionersProfessional Licensure DIFP-Department of Insurance, Financial Institutions and Professional Registration Division of Professional Registration-- Business Registration Secretary of State-- MO DHSS Licensed Only Adult 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 Certified Certified Programs are deemed to have met licensure requirements
15 Regulatory Compliance: Community Providers: Outpatient Community Outpatient Certification MO DMH Only Usually tied to Medicaid reimbursement, ADA exception ADA & CPS Core Rules --- Combined CSR 10-Chapter 7 Division Specific 9 CSR 30-Chapter 3, Alcohol & Drug Abuse Programs 9 CSR 30-Chapter 4, Mental Health Programs MSAPCB- Substance Abuse Professional Credentialing; Accreditation Available, but not big role as yet but growing Increase with large hospital acquisition of CMHCs CMHCs seeking deemed status for licensure/certification requirements Contract & Billing Audits --- Although not regulatory, intertwined
16 Regulatory Compliance: Disclaimer & Last Thoughts General Constructs & Overview Only Do not assume everyone speaks the same language The devil is in the details ! ! ! If youre responsible for it, do your homework Regulatory compliance does not automatically assure quality ! ! !
17 Regulatory Resources ACCREDITATION Commission on Accreditation of Rehab Facilities Interl (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 RSMo Division of Alcohol & Drug Abuse, Chapter 631 RSMo Division of Comprehensive Psychiatric Services, Chapter 632 RSMo Division of Developmental Disabilities, Chapter 633 RSMo Department of Social Services; Chapter 660 RSMo Public Health & Welfare; Chapters 188, 189, 190, 191, 192, 194, 195,196, 197 MISSOURI CODE OF STATE REGULATIONS ( CSR) Department of Mental Health, Title 9 Department of Health & Senior Services, Title 19 Department of Social Services, Title 13
18 Regulatory Resources FEDERAL LAW; FEDERAL CODE OF REGULATIONS; HIPAA; EMTALA; https://www.cms.gov/EMTALA/https://www.cms.gov/EMTALA/ Department of Justice; Division of Civil Rights; Civil Rights of Institutionalized Persons; Olmstead Decision; CMS REGULATIONS & INTERPRETATIVE GUIDELINES Hospitals, A Tags; Psych Hospitals, B Tags; Psych Residential Treatment Facilities, N-Tags;
19 Quality Management QM starts with asking the right questions ! ! ! [and it never stops……….continuously seeking to improve !]
20 Quality Management WHAT constitutes Quality?
21 Quality Defined I cant 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 standard Licking, Missouri Political reality A.K.A How does it play out in the headlines? Established criteria Published 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 Safety Elimination/Reduction in physical Plant Hazards Infection Control Disaster Preparedness Consumer Satisfaction Comfort Staff Responsiveness Appropriate & Efficient Admissions Triage and screening processes Appropriate & Effective Care & Treatment Right Treatment Program Right Medications Consumer Progress/Outcome Measures Utilization Review Appropriate & Effective Discharges Readmissions Post discharge complications/Suicides Cost Effective Fiscal Management Budget outliers Price increases/decreases Optimal Utilization of Human Resources Right number and right mix of employees Right and up to date employee competencies
24 Meeting Key Responsibilities How do know if I am meeting my key responsibilities? Was what I produced satisfactory?
25 Ask More Questions---Duck Exercise Your 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 Duck Exercise: Roles YOU (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 QM of Ducks 1.What are my key responsibilities? 2.What questions should I ask to determine if Im meeting my responsibilities?
28 QM = Asking the Right Questions QUESTIONSQM Technology Did we get that for which we paid?Contact Compliance Does what we purchased or what we perform meet minimum standards? Quality Assurance Is what were doing healthy and/or safe? Have we mitigated against loss or damage? Risk Management Can we get better performance or better product? Can we exceed standards or move towards best practices? Quality Improvement Is what we purchased or what were doing achieving the outcomes we sought? Performance Measurement How do we compare? Do we achieve similar outcomes as that of our peers? Are we competitive in the market Benchmarking What can we learn from an extremely good experience or an adverse event? Sentinel Event Analysis
29 Basic Tools of QMA Plan Need a plan: Identify key responsibilities to monitor Methods to monitor Think sample Think intermittent sampling Areas for improvement focus Think strategic Fix existing problems Prevent problems Change system to address root cause of problem Manage innovation Quality improvement approach CQI, TQM, Lean Six Sigma, ISO
30 Basic Tools of QM Improvement Process Identify the problem, issue or opportunity for improvement Gather relevant data and information Brainstorm possible solutions Select a solution to trial Develop an implementation plan Establish a baseline to measure against Implement the plan Evaluate the results of the solution against the baseline If solution fails to resolve problem or render improvement, REPEAT THE ABOVE STEPS If solution is somewhat successful, consider fine tuning or modifying solution; implement and re-evaluate If problem resolved or improvement achieved, adopt the solution as final practice…..and move on to new problems or opportunities for improvement
31 Basic Tools of QM PDCA Cycle PDCA 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. PlanDoCheckAct Shewhart Cycle Deming Wheel
32 Basic Tools of QM QI According to Marty Martin-Forman Quality 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 Basic Tools of QM QI According to Marty Martin-Forman Five Mistakes That Commonly Doom Quality Improvement Lack of: 1.Top Management Involvement 2.Middle Management Leadership 3.Integration 4.Continuous Training
36 Basic Tools of QM QI According to Marty Martin-Forman Ten Pillars of Continuous Improvement…………… 1. Management Vision and Commitment 2. Accountability 3. Measurement and Feedback 4. Problem-Solving and Process Improvement 5.Communication 6. Staff Development and Training 7. Physician Involvement 8. Reward and Recognition 9. Employee Involvement and Empowerment 10. 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 again Root 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 services Involving of those who are the most familiar with the situation Continually 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 systems A 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 factors Determination of related processes and systems Analysis of underlying cause and effect systems through a series of why questions Identification of risks & their potential contributions Determination of potential improvement in processes or systems To be credible, a Root Cause Analysis must: Include participation by the leadership of the organization & those most closely involved in the processes & systems Be internally consistent Include consideration of relevant literature A Bazooka not a BB gun !
39 Basic Tools of QMBenchmarking Benchmarking 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 organization Against 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 Basic Tools of QM Scorecards/Dashboards A Quality Scorecard or Dashboard : An Executive or Top Management tool brief document, usually 1 page Summarizes critical operations and performance Can 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 standard Can monitor one complex process or multiple
41 Dashboard Example: Airline Company
42 Basic Tools of QM CPS Facility Scorecard
43 QM: Parting Shots Investigation vs. Quality Improvement Activity Investigation seeks to assign culpability; who did what when QI seeks to understand why, and to create systems that prevent mistakes A 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 !
Raw Data Trend Analysis Recommendations Critical Decision Points Relevant Other Data Risk Management Contract Compliance Quality Assurance Quality Improvement Performance Measurement Sentinel Event Analysis Quality Management QUALITY PROCESSES & TECHNOLOGY INFORMATION PRODUCTS Opportunity Identification Treatment or Management DECISIONS (Clients, Families, Staff, Providers) ACTION Right Person Right Service Right Time Right Amount Resulting in RIGHT OUTCOMES RECOVERY & SELF DETERMINATION of CONSUMER TRACKING and OVERSIGHT (Executive Function) TASKS/TOOLS/ACTIVITIES Certification Investigations Audits Contract Monitoring Hearings/Appeals Outcome Measures Consumer Grievances Standards Regulations Best Practices Consumer Satisfaction Surveys Drills Policies/Procedures HR Exit Interviews Accreditation ORYX Treatment metrics Scorecards Budgets Injury reports Environmental Rounds CQI, TQM Lean Six Sigma RCA Etc. 4/2011 Benchmarks DATA
45 ISO International 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 Sigma Lean 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 is about 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 TQM Total 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 21 st Century, 2001 Improving 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 -- ClinicalAEsWhitePaper.htm ClinicalAEsWhitePaper.htm
49 Quality Management Resources Miller, Ken; The Change Agents Guide to Radical Improvement. ASQ Quality Press: Milwaukee, WI, 2002 Missouri Center for Patient Safety (MOCPS) – Missouri Quality Award – Osborne, David & Gaebler, Ted – Reinventing Government Peters, Tom – In Search of Excellence; Thriving on Chaos: Handbook for a Management Revolution; Excellence in the Public Sector Root Cause Analysis – VA -- Human Services Research Institute -- results/f48163a7e2236d30af8535ccbbe315aa/http://www.hsri.org/publications/search- results/f48163a7e2236d30af8535ccbbe315aa/
50 Quality Management Resources Senge, Peter – The Fifth Discipline Sluyter, GV & Mukherjee – Total Quality Management for Mental Health and Mental Retardation Services: A Paradigm for the 90s. Annandale, VA: National Association of Private Residential Resources. 1993