Transcript Sandhills Center LME

Sandhills Center LME
Quality Management
Program
Quality Management Program
Statement of Purpose
 To ensure services (internal and external)
are appropriately monitored and
continuously improved.
 An emphasis on communication,
interdepartmental, structured
communication and total agency teamwork.
 Integrate Quality Management into the
entire organization.
Design
 To comply with URAC Standards,
DMH/DD/SAS Rules and incorporates the
Centers for Medicare and Medicaid Services
(CMS) Quality Framework.
 The Quality Framework includes the
following functions for design of the Quality
Management Program: Discovery;
Remediation and Continuous Improvement.
 Discovery – collecting data and direct
participant experience in order to assess the
ongoing implementation of the program,
identifying strengths and weaknesses.
 Remediation – Taking action to remedy
specific concerns that are identified
 Continuous improvement – utilizing data,
data and more data to engage in actions
that emphasize continuous improvement.
PDCA
 Additionally, the Quality Management Program utilizes the
Plan, Do, Check, Act (PDCA) Quality Improvement Model.
 Plan – Analyze the problem, establish a solution plan and
set goals
 Do – Implement the solution
 Check – Evaluate the solution
 Act – Monitor for continuous improvement and implement
system change.
 The QM Program balances Quality Assurance and Quality
Improvement activities in that Quality Assurance activities
inform and spark the Quality Improvement process.
Oversight and Responsibility of
the QM Plan
 The Board of Directors has ultimate responsibility for oversight and
effectiveness of the QM Program.
 The CEO is administratively responsible for the direction and overall
functioning of the QM Program and ensures allocation of adequate
resources and staffing.
 The Chief Clinical Officer/Medical Director is responsible for oversight
of the QM Program and advises on clinical issues.
 The QM Director manages the day to day operations related to the
implementation of the QM Program.
 The Board of Directors reviews and approves QM Plan annually
 The Board of Directors receives quarterly reports of all QM activities
including Satisfaction Survey results, Complaints and Incidents.
Quality Management Committee &
QM Structure
Committee structure
Four (4) major committees:
Quality Management
Care Management/Utilization
Management
Health Network
Customer Services
Sandhills Center Committee and Management/Leadership Teams
Board
of Directors
LME
Executive
Management
Team
Quality
Management
Client
Rights
Complaints &
Grievances
Customer
Services
Regulatory
Compliance
CT&R
Consumer and
Family Advisory
Committee
(CFAC)
Care /
Utilization
Management
Clinical
Leadership
Team
Health
Network
Clinical
Advisory
Committee
Network
Leadership
Council
Dispute
Resolution
Panel
Credentialing
Committee
Regulatory Compliance Committee
Board of Directors
CEO
BOD
CTR
HUM
NET
Regulatory Compliance
Standing Committee
Chair- Reg Compliance Officer
Care
Coord
BOD
Administration
Finance
HR
MEM
QM
IT
Support
Quality Management
Quality Management Information Flow
Quality
Management
Committee
QM Subcommittees
Customer Services
Care/Utilization Management
Health Network
Regulatory Compliance
Program &
Ancillary
Team Meetings
QM Program Committees
Responsibilities
 Oversight of the day to day operations of the
Quality Management Program and compliance
with rules, regulations and URAC standards;
 Define performance measures to ensure
compliance and review data related to the
indicators;
 Communicate activities and findings back to the
Quality Management Committee through
Executive Summaries and Task Logs.
Quality Management
Committee
 Serve as the main conduit of change for the
organization.
 Provide oversight of the Sandhills Service
Management System, operations, functions,
processes and practices.
 Provide a forum for problem solving and
addressing processes for improvement.
Quality Management Committee
 Is made up of Department Heads from each
section
 Is chaired by the Medical Director
 Identifies quality indicators, measures and
activities as required by contracts with DMA
and DMH/DD/SAS
 Establishment of performance benchmarks
for all internal and external quality indicators
Quality Management Committee
Activities
Review Care Management/UM, Health Network and
Customer Services task logs and Executive Summaries;
 Review and promote further discussion of data analysis;
 Review and recommend approval of Policies &
Procedures, Decision Support Tools, Scripts;
 Review satisfaction data for improvement opportunities;
 Approval and monitoring of program specific QIPs;
 Reviews QM Plan annually
Quality Management Committee
Activities (cont’d)
 Monitor Access to LME Services;
 Monitor Complaints and Appeals;
 Provide oversight of monitoring of network
providers and recommend sanctions, as
necessary;
 Review, approve and track Marketing and
Communication Materials;
 Monitor Compliance with delegation policies and
procedures;
Quality Management Committee
Activities (cont’d)
 Ensure all staff, the Provider Advisory
Council, Consumer and Family Advisory
Council and Board of Directors have a
mechanism to provide input into the Quality
Management Program; and
 Oversee the Regulatory Compliance
Program.
Quality Improvement Projects
 Exemplify the process of continuous quality improvement;
 Allow for data collection, measurement and analysis that
indicates problems that may require corrective action and
improvement.
 Each Program maintains at least two QIPs at any given
time:
 At least one project must focus on error reduction and/or member
safety and
 At least one project must focus on members, that relates to
specified key indicators or quality and involves a senior clinical staff
member if the QIP is clinical in nature.
Quality Improvement Projects
 QM staff tracks QIPs for 1 year after
closure to ensure achieved benchmarks are
maintained.
Global CQI Committee
 Sandhills Center will establish a Global
Continuous Quality Improvement Committee
 This committee will be a sub-committee of
the Quality Management Committee
 Will be chaired by a CABHA provider and by
a specialty provider
 Its membership will include representation
from all provider groups
Global CQI Committee
 The group will analyze data, identify barriers
and assist in implementing interventions to
improve quality of care through out
Sandhills.
 This group will make recommendations to
the Sandhills Quality Management
Committee
Quality Management Program
Evaluation
Annual Evaluation
Comprehensive analysis of:
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Accomplishments;
Committee activities;
Results of Quality Improvement activities; and
Trending of indicator data.
May result in the proposal of new activities or
establishment/revision of Policies & Procedures.
Assists in the identification and establishment of new
priorities/goals for the Quality Management Program.
Every Sandhills Center Person and Program
is an Important Piece
of our
Quality Management Puzzle
Incident Reporting Requirements
 IRIS a web based incident reporting
system for reporting and documenting Level
II and III incidents involving members
receiving MH/I/DD/SAS services.
 Information relating to IRIS is found at
http://www.ncdhhs.gov/mhddsas/ , click on
IRIS Technical Manual
Incident Reporting Requirements
 Purpose of IRIS is to ensure that serious adverse
events are addressed quickly
 And analyzed for ways to prevent future
occurrences and improve the service system
 There are three levels of incidents
Level I addressed internally, NOT entered into
IRIS and reported to Sandhills Center on a
quarterly basis
Incident Reporting Requirements
 Level II Incidents must be documented and
submitted in IRIS within 72 hours
consecutive hours of learning of the incident
and addressed internally by the provider
 Deaths from natural causes are Level II
incidents
Incident Reporting Requirements
 Level III incidents must be submitted in IRIS
within 72 consecutive hours of occurrence
and verbally reported to Sandhills Center.
 All deaths from unknown causes are Level
III incidents.
 Once additional information is learned, it
must be entered into IRIS as well
Incident Reporting Requirements
 If IRIS is unavailable at any time, providers
must still meet the time lines for submission
of an incident by faxing a paper copy of the
incident report to the proper agencies.
Incident Reporting
 Incident types:
 Under the care of a provider ( that means
has received service within 90days prior to
the incident)
 Allegations of Abuse, Neglect or Exploitation
 Consumer Injury
Incident Reporting Con’t
 Medication Errors
 Absences
Incident Reporting Contacts
Angie Kivett
Sandhills Center
108 West Walker Ave
Asheboro, NC 27203
telephone - 336-625-4351
fax 336-625-3661 or
[email protected]
Incident Reporting Contacts con’t
DMH/DD/SAS Quality Management Team
Complaint Intake Unit
3004 Mail Service Center
Raleigh, NC 27600-3004
Fax: 919-715-3604
Voice 919-733-0696
[email protected]
Incident Reporting Contacts con’t
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Division of Health Services Regulations
27111 Mail Service Center
Raleigh, NC 27511-2711
Fax 919-715-7724
Phone 200-624-3004 or
[email protected]