1. Quality Improvement in California’s County Mental Health Programs Presentation to 12 th Annual Patients’ Rights Advocacy Training Conference Sacramento October 8, 2004 Doug Mudgett, RN, AMHS State Department of Mental Health, County Operations

2. Introduction A little bit about myself and my background Why I am here today, my DMH “QI” role Why I believe in Quality Improvement Keeping the focus of everything we do as a “system” on the people receiving services, on the quality and relevance of what we provide, and on the belief in Recovery De-mystifying Quality Improvement, give you an overview, and sparking an interest in you

3. Discussion Topics 1. Why are we all here today? 2. What is QI? 3. Past, present, future of QI in counties? 4. What is your role in this?

4. Why are we all here today? Why are you here today? What do you want to get out of this discussion? What do you know about Quality Improvement (QI)? Have you participated, or been asked to participate, in your county? What does “Quality” mean to you?

5. What is QI in general? A systematic, deliberate, and continuous process and effort to improve the services we provide to individuals.

6. Breaking it down Systematic The process is based on an organized and structured “problem-solving” approach Deliberate In order for QI to be successful, there must be belief in it, effort must be given to promoting its sustainability, and it must permeate and connect everything the organization does Continuous It is virtually a never-ending process…basic mantra: “no matter how good we think we are doing, there is always room for improvement

7. A Little History Origins in 1950’s, ’60’s, and ’70’s The “Gurus”: Deming, Juran, and Crosby Deming considered “godfather” of Total Quality Management”, or TQM, which reshaped and transformed Japanese manufacturing industry Largely a statistical process control approach at decreasing “variance” in product quality Delighting and satisfying customer expectations Continuous Quality Improvement, an offshoot of TQM, evolved significantly during the late 1980’s and early 1990’s and was applied to health care

8. Why History is Important for QI in County Mental Health Originally a Quality Assurance activity “Monitoring adherence to standards” QI vs. QA What is the difference between QI and QA, and what are their complementary and distinct roles? Take-home Point QI and QA are not the same.

9. QI vs. QA Quality Improvement goes way beyond Quality Assurance. Perhaps the defining difference lies in the fact that in addition to focusing on processes, correcting problems, analyzing data, and making decisions based on information, QI adds the focus on “Improvement”, distinct going beyond standards, and attitude-belief-passion in betterment is central. This has been a significant paradigm shift for health care in general, and County mental health services in particular.

10. Continuous Quality Improvement Customer/Consumer Focus The unifying driving element Process Oriented Belief that most quality issues and problems are the result of processes, not people. Data Driven Uses data as an indispensable tool for guiding, evaluating, and validating “success”. All Levels of Organization All levels must be encouraged and supported to participate.

11. PDCA Cycle Plan-Do-Check-Act or “Deming Wheel” Act PlanDo Check PDCA Focus on Consumer Outcomes/Benefit Within a Recovery Model or Vision

12. Current Picture of QI in County Mental Health Programs The most immediate current drivers for Quality Improvement in counties come from the Managed Care Contract (MHP Contract) with the State DMH, California Code of Regulations Title 9 requirements, and language in WIC regarding quality management programs, and the role of External Quality Review (EQR) including Performance Improvement Project (PIP) evaluation. DMH Medi-Cal Oversight (“Compliance”) continues its evaluation responsibility based on “QA”.

13. QI Oversight & Consultative Players DMH & CMS EQRO Board of Supes MH Boards & Commissions DMH Medi- Cal Oversight DMH Medi- Cal Policy DMH County Operations CIMH-Contract CMS Medicaid Waiver, and CFR 438 “APS” External Quality Review Organization Required by New Medicaid Regs resulting From “BBA 97” Vested interest In “Value”, i.e. Quality of services to County’s residents for the County Dollars spent Oversight and Guidance of MH system Quality with emphasis of Consumer & Family Member Involvement

14. Broad Forces Impacting County QI Quality Improvement Regulations Fed-State Consumer Voice MHP Contract Professional Ethics Industry Movement

15. What is your role in QI? Becoming familiar with QI Gauging your county’s interest in asking for your involvement Contributing a valuable specialized perspective Realizing the importance of, and advocating for fidelity to, keeping the focus on the consumer and their outcomes in a Recovery framework.

16. QI Learning Progress Diagram Reconciling “Theory” With “Reality” Reconciling “Theory” With “Reality” Involvement & Practice Knowledge & Skills Acquisition Phase 1 “Acquiring” Phase 1 “Acquiring” Phase 2 “Implementing” Phase 2 “Implementing” Phase 3 “Integrating” Phase 3 “Integrating”

17. County QI Participants Providers Consumers Director QI Coordinator IT / IS “Data” ADVOCATES Consumers’ Benefit

18. Closing Questions, Discussion, and Comments