1. DEPARTMENT OF HOMELAND SECURITY (DHS) MEDICAL QUALITY MANAGEMENT (MQM) IMPLEMENTING CONTINUOUS QUALITY IMPROVEMENT MQM DIRECTIVE 248-01 & INSTRUCTION 248-01-001 1 Latousha Leslie RN BSN, MS Latousha.Leslie@hq.dhs.gov Medical Quality Management Analyst Office Of Health Affairs Workforce Health and Medical Support Division

2. CONTINUOUS QUALITY IMPROVEMENT Performance Measures Performance Improvement Clinical Competency Risk Management & Assessment Records Management Credentialing Standard Operating Procedures & Protocols 2 MQM Quality Framework

3. 3 DHS MQM STRATEGIC PLAN IMPLEMENTATION Strategic VisionMission PrioritiesGoalsObjectives Performance Improvement Activities Quality MeasuresData

4. MQM STRATEGIC VISION AND MISSION Strategic Vision Provide guidance to DHS Components on the quality improvement of health care services delivered to DHS personnel and charges that is appropriate, timely, safe, and effective. Mission Priority Promote continuous quality improvement of medical services provided by DHS 4

5. IOM High Value ChecklistOHA relevance/MQM Strategic Plan Governance priority —visible and determined leadership by CEO and Board Leadership buy-in, support, and enforcement Culture of continuous improvement—commitment to ongoing, real-time learning Teaching, reinforcing Focus PDCA, standardize practices, identify/create efficiencies Infrastructure fundamentalsMQM Directive and Instruction, conduct site visits, provide recommendations, templates, dashboards, gather resources IT best practices—automated, reliable information to and from the point of care Start w/ ePCR and MCMS; use best practices from USCG and industry (i.e. ONC and others) Evidence protocols—effective, efficient, and consistent care Update SOPs HCQC wrkg grp, standardize documentation Resource utilization—optimized use of personnel, physical space, and other resources Sharing resources, lessons learned, contracts, etc. Care delivery prioritiesRecommend performance metrics for priority gaps Integrated care—right care, right setting, right providers, right teamwork Track and analyze NM/AE/SE to improve care delivery, OHA continuous NPDB checks, core competencies of staff, ICE peer review process Shared decision making—patient–clinician collaboration on care plans Encourage family involvement and contact; review CRCL reports to see compilation of issues Targeted services—tailored community and clinic interventions for resource-intensive patients Identify most frequent treatment, conditions, and diagnosis to implement quality metrics- may be regional specific for ICE facilities; use HCQC measure wrk grp Reliability and feedbackQuarterly HCQC meetings Embedded safeguards—supports and prompts to reduce injury and infection Use HCQC wrkg grp to keep standards current, Components have initial screenings for infectious dz in a timely manner, use of PPE; communicate and encourage reporting to OHA MQM and/or Occ Hlth Internal transparency—visible progress in performance, outcomes, and costs Establish core DHS and Component specific measures, collect and analyze Dashboards; provide technical assistance to Components 5

6. HCQC TEAMSITE DHS CONNECT 6 http://mgmt-ociosp.dhs.gov/oha/hcqc/sitepages/home.aspx

7. HCQC RESOURCES Component Dashboards Component Measure Activity Plan MQM Master Resource Planning Guide National Quality Strategy (NQS) National Prevention Strategy (NPS) National Quality Forum (NQF) National Priorities Partnership (NPP) Institute for Healthcare Improvement (IHI) Institute of Medicine (IOM) Agency for Health Research & Quality (AHRQ) Centers for Medicaid and Medicare Services (CMS) National Committee on Quality Assurance (NCQA) 7

8. CONTINUOUS QUALITY IMPROVEMENT TOOLS TREND ANALYSIS (DASHBOARD ) 8

9. NQF MEMBERSHIP REQUEST FORM 9