Department of Homeland Security (DHS) Medical Quality Management

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Transcript Department of Homeland Security (DHS) Medical Quality Management

DEPARTMENT OF HOMELAND SECURITY (DHS) MEDICAL QUALITY MANAGEMENT (MQM)

IMPLEMENTING CONTINUOUS QUALITY IMPROVEMENT MQM DIRECTIVE 248-01 & INSTRUCTION 248-01-001

Latousha Leslie RN BSN, MS [email protected]

Medical Quality Management Analyst Office Of Health Affairs Workforce Health and Medical Support Division

CONTINUOUS QUALITY IMPROVEMENT

MQM Quality Framework

• • • • • • • Performance Measures Performance Improvement Clinical Competency Risk Management & Assessment Records Management Credentialing Standard Operating Procedures & Protocols 2

DHS MQM STRATEGIC PLAN IMPLEMENTATION

Strategic Vision Mission Priorities Goals Objectives Performance Improvement Activities Quality Measures Data

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

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

HCQC TEAMSITE DHS CONNECT

http://mgmt-ociosp.dhs.gov/oha/hcqc/sitepages/home.aspx

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

CONTINUOUS QUALITY IMPROVEMENT TOOLS TREND ANALYSIS (DASHBOARD

)

# of Health Unit visits

2 500 2263 2 000 1 500 1 000 1742 1035 873 1388 1004 1699 1210 500 0 558 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 1560 2 500 2 000 1 500 1 000 500 0

# of Health Unit visits 2263

Q1 2012

1560

Q2 2012

Health Unit Survey Rating

40 35 30 25 20 15 10 5 0 3,88 3,97 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Aver… 5,0 4,0 3,0 2,0 1,0 0,0