SANDHILLS CENTER LME- MCO. Quality Management Program Orientation

Transcription

1 SANDHILLS CENTER LME- MCO Quality Management Program Orientation

2 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.

3 Design To comply with URAC Standards, DMH/I/DD/SAS and DMA 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 Improvements.

4 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.

5 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.

6 Oversight and Responsibility of the QM Program 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.

7 Quality Management Committee & QM Structure Committee structure Four (4) major committees: Quality Management Care Management/Utilization Management Health Network Customer Services

8 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; and Communicate activities and findings back to the Quality Management Committee through Executive Summaries and Task Logs.

9 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.

10 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; Establishes performance benchmarks for all internal and external quality indicators.

11 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; Review QM Plan annually;

12 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;

13 Quality Management Committee Activities (cont d.) Ensure all staff, the Network Leadership Council, Global CQI Committee, Consumer and Family Advisory Council and Board of Directors have a mechanism to provide input into the Quality Management Program; and Promote use of data driven material across all departments.

14 Quality Improvement Projects Exemplify the process of continuous quality improvement; and Allow for data collection, measurement and analysis that indicate 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.

15 Quality Improvement Projects All QIPs must meet URAC requirements and two have to be approved by DMA for the first year of the contract, with a third one added the second year. QIPs are tracked one year after closure to ensure achieved benchmarks are maintained.

16 Global CQI Committee Sandhills Center has a Global Continuous Quality Improvement Committee which is a sub-committee of the Quality Management Committee; Is chaired and co-chaired by providers; Its membership will include representation from all provider groups;

17 Global CQI Committee (cont d.) The group will analyze data, identify barriers and assist in implementing interventions to improve quality of care through out Sandhills; and This group will make recommendations to the Sandhills Quality Management Committee.

18 Monitoring Activities Part of Credentialing process-site specific Health and Safety Reviews; Routine and Post Payment Reviews for Agencies and LIPs; Review of complaints, incidents and quality of care concerns.

19 Agency Monitoring The workbook, including all worksheets utilized are found at ovidermonitoring/index.htm#tools. There are two links; one for agencies and one for LIPs. Agencies providing outpatient services only are reviewed, using LIP tools. You, as the provider, will get a copy of the summary sheet within 15 work days of the review.

20 Routine reviews (con t.) Post payment reviews will include 30 events pulled from paid claims data found in the most recent 6 months, mainly focusing on the first 90 days of this period (example Jan-June 2013, with Jan-March data pulled). Plans of Corrections will be requested for all out-of-compliance items.

21 Routine reviews (con t.) Note: The worksheets are scored automatically, not by monitoring staff. The Plan of Correction Policy has not changed, so if one is required, the requirements regarding time frames are the same as you are accustomed to.

22 Other Types of Reviews Complaints and incidents will be reviewed, using the same tools as routine review, however only the tools that are pertinent to the issue will be utilized, for example, record review, personnel tool (s), medication tool (s), if applicable.

23 Use of Data Collected From Reviews Data collected from monitoring reviews will be utilized in compiling provider profiles. It may also be used to determine where training might be needed; and Used for quality improvement projects or in other quality management analysis.

24 Quality of Care Concerns QOC concerns can come from any of the groups referenced previously, as well as from external sources. Each is reviewed by QM Director and Medical Director and disposition determined, which may include either desktop or onsite review. Can be referred to the Clinical/Financial Risk Management Committee, Program Integrity or for independent psychiatric review in the case of polypharmacy or inappropriate diagnosis.

25 Quality Management Program Evaluation Annual Evaluation Comprehensive analysis of: 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.

26 Incident Reporting Requirements IRIS is 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 Click on IRIS (NC Incident Response Improvement System, then IRIS Technical Manual.

27 Incident Reporting Requirements If IRIS is unavailable at any time, providers must still meet the timelines for submission of an incident by faxing a paper copy of the incident report to the proper agencies. Quarterly Level I incidents are due to the LME-MCO by the 10 th of the month following the end of the quarter.

28 Incident Reporting Contacts Angie Kivett Sandhills Center 108 West Walker Ave Asheboro, NC fax or or Debbie Powell Sandhills Center 201 N. Eugene Street, Suite A Greensboro, NC fax or debbiep@sandhillscenter.org

29 Contacts con t DMH/DD/SAS Quality Management Team Complaint Intake Unit 3004 Mail Service Center Raleigh NC Fax Voice Contact DMHQuality@dhhs.nc.gov

30 Contacts con t Division of Health Services Regulations Mail Service Center Raleigh, NC Fax or Rita Horton@dhhs.nc.gov