1. 24-Hour Access to Care and Crisis Services 1-866-875-1757 Customer Services 1-855-250-1539 Training for Providers Developed by CoastalCare Quality Management Department 1

2. WHAT IS QUALITY MANAGEMENT? WHAT IS QUALITY MANAGEMENT? Quality Assurance vs. Quality Improvement Quality Assurance (QA) is a much needed set of activities to ensure compliance with rules, regulations, and requirements. It provides the basic foundation for a quality improvement model and methodology. Quality Improvement (QI) is a planned, systematic, organization- wide approach for monitoring, analyzing, and improving organizational and provider performance. QI promotes the ongoing participation of all staff, consumers, providers, family members, and other stakeholders in problem-solving efforts across functional and hierarchal boundaries. 2

3. ADDING THE TWO ELEMENTS TOGETHER PRODUCES A COMPREHENSIVE APPROACH TO ASSURING QUALITY CARE: QUALITY ASSURANCE + QUALITY IMPROVEMENT = Quality Management 3

4. TRAINING OBJECTIVES WHAT YOU WILL LEARN Quality Management Plan Requirements What you need in your plan Annual Quality Management Plan Review Requirements 4

5. WHY DO QUALITY MANAGEMENT PLANS? 1.Administrative Rules/Provider Monitoring 2.Accreditation Requirements 3.Current Industry Best Practices 4.Critical Access Behavioral Health Agency (CABHA) 5. Research has shown a direct relationship between the quality of organizational functioning and consumer performance in treatment outcomes 5

6. DEVELOPING THE INITIAL QM PLAN *******required elements******* 6 Agency Introduction Quality Statement Model & Methodology QM Objectives QM Structure, Scope of Activities, Stakeholder Participation Quality Improvement Projects Performance Measures Best Practices/Evidenced Based Practices Annual Review Process for the Plan

7. 1 ST – INTRODUCE YOUR AGENCY 1. Describe - y our mission, vision, values, goals 2. Organization – o utline your structure (Include your board if you have one)- Provide an Organizational Chart 3. Services Who? C onsumer population focus Where? Geographic area you serve What? Services you offer 4. Accreditation Agency- Who accredits you? 7

8. QUALITY STATEMENT Review your strategic goals What do you want your agency to be for your consumers, employees and community? The answer to this question is your quality statement! Connect this to your agency’s vision, mission statements and strategic goals If you are accredited – outline what your accreditation body requires for quality management 8

9. DESCRIBE YOUR QUALITY MODEL AND METHOD Your model is your foundation Choose a model and use it as your guide for planning for quality 2 Methods used frequently in care agencies are PDSA and Six Sigma Both provide a framework for improving quality 9

10. PLAN, DO, STUDY, ACT (PDSA): FREQUENTLY USED MODEL 10 Act PlanDo Study PDSA

11. SIX SIGMA MODEL- (DMAIC) DEFINE, MEASURE, ANALYZE, IMPROVE, CONTROL DEFINE the problem and set the goal. Focus on outcome and process. Write a problem statement. Develop a charter – identify who is the customer and their requirements. Map the process to identify areas for improvement. Identify the benefits for improvement. MEASURE the defects or process operation. Develop a tool to collect needed data. Look at data you may be already collected to help measure. 11

12. SIX SIGMA – (DMAIC) continued ANALYZE the data and discover the causes of the problem. Use brainstorming techniques, bar graphs, etc., to help analyze. Identify the process that needs improving (identify the root cause) IMPROVE the process to remove causes of defects. Test solutions on a small scale to see if they work. If it doesn’t, try another process. Fail small, fail often. CONTROL the process to make sure defects don’t recur. Establish standard measures to maintain performance. 12

13. QM Structure, Scope, and Activities – How are you going to make it happen? 1. QM Plan – Identify who writes it 2. QM Committee Who? Are stake holders included? Meeting Schedule Explanation of Role/Function Documentation of meetings – Minutes kept/distributed

14. IMPORTANT – REMEMBER STAKEHOLDERS & RESOURCES 14 EXPLAIN HOW YOUR STAKE HOLDERS ARE INVOLVED IN THE QM PROCESS. WHAT RESOURCES IN YOUR ORGANIZATION ARE DEDICATED TO YOUR QM PROGAM?

15. QM STRUCTURE – APPROVAL, MONITORING AND DATA Approval of Plan - Who? How? Is board involved? How is approval documented? Monitoring Plan– How are you going to monitor the performance of your QM Plan? Data – How are you going to use data? 15

16. EXPLAIN HOW QUALITY MANAGEMENT FITS INTO YOUR AGENCY Identify your agency subcommittees that pertain to QM – Incident Reporting, Client Rights, Complaint/Grievance, QA Review of Records/Peer Review, Other Explain the process for reporting these committees or activities to the QM Committee Monitor - how does your agency monitor performance measures? 16

17. QM OBJECTIVES –NEED TO OUTLINE THINK SMART Specific – What are you going to do, with, or for whom? Measureable – Is it measureable? Can you measure it? (IT NEEDS TO BE EASUREABLE) Attainable – Can you get it done in proposed time in your environment with the resources (money and people) that you have? Relevant – Will your objectives lead to desired results, achieve your mission/vision? Time – How long will it take you? 17

18. EVIDENCE BASED PRACTICE (EBP): INCLUDE IT! Describe which EBP(s) your agency uses or plans to use. Explain how you implement and monitor this? How do you know that your clinicians are using it and for the intended population? 18

19. RISK MANAGEMENT INCLUDE HOW YOUR AGENCY HANDLES RISK MANAGEMENT 19

20. INCLUDE HOW YOU HANDLE NC SNAP AND NC TOPPS NC SNAP- IDENTIFY YOUR PROCESS TO ENSURE COMPLIANCE WITH THE SUBMISSION REQUIREMENTS NC TOPPS – IDENTIFY THE PROCESS FOR USING NC TOPPS DATA/OUTCOMES FOR IMPROVING QUALITY (QI) IDENTIFY PROCESS TO ENSURE COMPLIANCE WITH NC TOPPS OUTCOME MEASURES 20

21. EXPLAIN HOW QM TRAINING WILL BE PROVIDED IN YOUR AGENCY Outline - your training plan for staff and identified others on Quality Management: Be sure to include Annual/New Employee/Special updates Identify by Topic/Required Interval/designated staff Board Members External Customers Training on important topics NC SNAP Training NC TOPPS Evidence based Practice/Best Practice 21

22. QUALITY IMPROVEMENT PROJECTS (QIPS) – DESCRIBE THE PROCESS QIPs -EXPLAIN HOW YOUR QIP PROCESS IS DESIGNED TO IMPROVE CUSTOMER CARE OR ORGANIZATION OPERATION These projects are developed in response to identified problems, gaps, performance issues, accreditation requires or other performance initiatives. Select your projects based on your quality management criteria and priorities Discuss how your agency selects, approves, implements, monitors, analyses the outcome of QIPS 22

23. QIPs – TOOLS TO USE Improvement projects are driven by: Collecting available data Baseline data Use of applicable QI tools and techniques *Find QI tools on the CoastalCare website under Quality Management 23

24. QIPs –SUBMISSION TO COASTALCARE State services providers shall complete at least three (3) annual QIPs These need to contain a narrative summary with data charts Submit to the CoastalCare Quality Management Department by September 30 th for the previous fiscal year (Fiscal year July 1 thru June 30) CoastalCare evaluates your QIPs and provides feed back to your agency QIP training for providers and the evaluation form is available on the CoastalCare website. 24

25. PERFORMANCE MEASURES FOR YOUR QM PLAN – IDENTIFY THESE Identify and quantify the critical aspect of your agency and services. What are you measuring? Include clinical, business, and risk management measures (Self auditing of claim payments, medical necessity documentation, voluntary paybacks?) Look at high risk, high volume and problem areas. What are you required to monitor? NC TOPPS, NC-SNAP, First Responder, Incident Reporting, FEM/Provider Monitoring Scores 25

26. ANNUAL QUALITY MANAGEMENT PLAN REVIEW DEVELOP A FORMAT –describes your process for your annual review (when, who and, how it is documented) ANSWER THESE QUESTIONS 1. What worked? 2. What needs improvement – i.e. structure, model, activities or methods? 3. Changes made/recommended to your QM 4. How staff and stakeholders know of changes? 5. Put the discussion and recommendations in your QM Committee Minutes 26

27. COASTALCARE PROCESS FOR PROVIDER’S QM PLAN EVALUATION 27 CoastalCare uses a check list to review our provider’s Quality Management Plans The check list can help you in developing your plan and in your annual review - It is located on the CoastalCare website Process is designed to help your agency and CoastalCare improve services to our customers

28. Tools to help you develop and review your Quality Management Plans Quality On the CoastalCare website under Quality Management you will find:  Provider Quality Management Plan Template  Provider Quality Management Plan Annual Review Template *These templates are set up so you can follow the headings and type in your agency information. Save it as a Word Document, add your information and delete instructions and sample items. You can cut and paste information charts and data on these as needed.

29. For Questions QM@coastalcarenc.org Aimee Dietsch, MA Performance Improvement Manager CoastalCare 3809 Shipyard Boulevard Wilmington, NC 28403 910-550-2600 910-550-2665 fax www.coastalcarenc.org 29