1. Quarterly Reporting
Expectations & Best Practices
March 9, 2018

2. Objectives
Understand RMHP Program expectations on quarterly narrative reporting and supporting documentation.
Review & critique examples of narrative reports and supporting documentation.
Develop an action plan aimed at improving documentation processes within your own practice.

3. What’s the point? Program Expectations
Quarterly Narrative Reports and supporting documentation
What’s the point?
Narratives developed to capture work that was done in that quarter. They do not change from quarter to quarter.
Supporting documentation – should be PDSA documentation, finalized policies and procedures, process maps, etc.
Whats the point: demonstrate value, the twinkie truck theory, have a plan for spread and sustainability, have a “new employee” hire process, demonstrate competency – get paid for what you actually do. (staff turnover, training, APMs, PCMH etc.)
Leverage your QIA and CI for support in developing strong processes for documentation.

4. Completing the Narrative
Qualitative and Quantitative information in the narrative:
Explanations should be thorough; paint a picture for the reader of what was implemented. Share your challenges and successes. What did you learn? What do you plan to change?
Other areas include quantitative data – be aware of what your are submitting.
Risk Stratification for example:
- Filling out the care management statistics (total’s should equal your empanelment number)

5. Supporting Documentation
PDSA – Plan, Do, Study, Act
Breaks down change into manageable, bite-sized, time-limited chunks.
Minimizes risks and expenditures of time and money
Submitting supporting documentation:
PDSA’s – why do you do these???? Because they minimize risk and save money and time. They allow you to break down your changes into small, manageable pieces. Appropriate documentation should include:
Develop an Aim Statement: Setting time-specific, measurable goals or aims will increase the likelihood that improvements to your practice will last. An aim statement is an explicit description of the team’s desired outcomes and should be expressed in a measureable and time-specific way. Work with your QIA on developing and submitting your aim statements. What are we trying to accomplish? Why is it important? Who is the specific target population? When will this be completed? How will this be carried out? What is/are our measurable goal?
PDSA Planning Worksheet: PDSA Planning Worksheets will assist your practice in documenting each cycle of your PDSA as well as identifying what was learned during the cycle. Fill out one worksheet per cycle and turn into your QIA.
­­­­­­­­­­­­­­­­­­­­­­­­­Final Summary Report: This report is designed to summarize your Process Improvement project and serves as the final documentation for closing a PDSA. These processes will move into Quality Control and should be included in your plan for sustainability and spread.

6. Supporting Documentation
Process Mapping
Many practices would rather identify a procedure in their practice using process mapping. This is acceptable. If it is too burdensome to write out a several page document on a policy/procedure, process map can work great.

7. Supporting Documentation
Policies and Procedures
P&P’s include: written policy, what the procedure is and a section for quality control (aka, sustainability). How to get started???? If your end goal is PCMH, start there:
An effective policies and procedures guidebook is written in a clear and concise manner. It should be so easy to follow that anyone – a new employee, a veteran staff member, a member of your board of directors, or even a patient – can read it and understand the concepts and what is expected of him or her. Specifically, the informative role your policies and procedures guidebook plays is as follows:
For employees: The guidebook outlines what is expected of employees in their roles within the organization and exactly how to fulfill that role to the organization’s expectations.
For patients and their family members or caregivers: The guidebook lets them know what to expect from providers when receiving services, and what steps or rules to follow to best achieve their desired results.
For everyone: The guidebook delineates the organization’s philosophy, how it performs activities, and what resources are available for assistance and clarification.
A helpful way of envisioning the role of a policy and procedure guidebook is to keep in mind five basic questions: Why, What, How, Who, When.
“Why” identifies the purpose and content of the policy.
“What” identifies what you expect to happen in the implementation of this process.
“How” identifies the method you will use to complete this process.
“Who” identifies the person(s) involved in this process and their role(s).
“When” identifies expectations to set and, one hopes, exceed when possible.
The following are ways you can ensure development of a successful policies and procedures guidebook for your organization.
Use a consistent form so that readers are not confused.
Write in simple language.
Use action verbs.
Make statements concise.
Number each policy and procedure for ease of reference and modification.
Date each policy when developed, as well as each revision.
Identify the purpose of each policy.
Define in detail the procedure(s) to implement each policy.
Use position titles rather than employee names.
State the purpose of each policy.
Review and update the policies and procedures at least annually to ensure they comply with changing regulations, needs, and medical home expectations.
Appoint one individual who will be responsible to keep the guidebook current, distribute updates, and ensure an appropriate line of communication with all employees and providers.
Require appropriate director, managers, supervisors and other lead employees to acknowledge in writing their understanding of all new and revised policies and procedures.

8. Other Documentation Patient flyers with important clinic updates
A plan for measuring and tracking Continuity of Care
Care management process and risk stratification algorithm.

9. Exercise
We want you to critique several examples of documentation that has been submitted to us over the years.
Directions: evaluate these from the perspective that you are evaluating whether another practice has essentially “passed” the milestone.
10 Minutes: Narrative Reports
3 minute report out
10 Minutes: Supporting Documentation

10. What do we need documented? What type of documentation?
QI Tracker
What do we need documented?
What type of documentation?
Person Responsible
Due Date/Review Date

11. Q&A