/PCA CORRECTIVE ACTION PLAN

Transcription

1 /PCA CORRECTIVE ACTION PLAN PCA Name: Wyoming Primary Care Association PCA #: U58CS06849 PCA Contact: Jan Cartwright Project Officer: Stephanie Crist Applicable Dates: October 3, January 3, 2017 This is the Corrective Action Plan (CAP) to be completed by the PCA. Completion of the CAP is mandatory and failure to comply may result in a condition. All required actions should be completed 90 days after the PCA receives this CAP or by January 3, Interwoven into the CAP are Performance Improvement Areas (PIAs). These PIAs are optional, but highly recommended, and to be discussed with the PCA Project Officer. At the end of the CAP there are additional PIAs included as part of a Performance Improvement Plan (PIP). All CAP activities should be completed by the assigned due date, timeline for completing PIP activities are at the PCA s discretion. The site findings are in the blue tabs, CAP activities are in the burgundy tabs, and PIP activities are in the green tabs. PCA CEO/ED Signature of CAP agreement: X Date: X 1

2 SV/ 3. SV T/TA conducted on Performance Improvement to strengthen clinical and financial performance Revise Work Plan to include specific quality improvement processes and activities that will help the HCs improve clinical measures identified by the Wyoming HCs in the Needs Assessment and in the BPHC Wyoming Performance Profile. The outcomes must be quantifiable, measurable and reasonable outcome(s) that the HCs will achieve/realize by a specific date. No specific T/TA provided to HCs for improving specific clinical and financial measures; all generic training Did not identify which specific clinical measures it would help HCs achieve and/or improve in work plan (WP). Did not state what specific reportable outcomes of which clinical measures would show improvement in number and scale. WYPCA used vague terms numbers and scales and did not define in WP. WYPCA did not produce any evidence that it addressed data sharing with the HCs, what best practices they wanted to develop, and what measures the HCs wanted to benchmark. REQUIRED CORRECTIVE ACTIONS 11/4/16 Brenda Burnett, Quality Director PROGRESS TO /COMMENTS Completed 11/2/16, please review Revised WYPCA 2016 Clinical Project Work Plan in EHB. Made requested changes to original 2016 Clinical Project Work Plan per request of P.O. Submitted on 11/18/16. Revise Work Plan to include specific quality improvement processes and activities that will help the HCs improve financial measures identified by the Wyoming HCs in the Needs Assessment and in the BPHC Wyoming Performance Profile. The outcomes must be quantifiable, measurable and reasonable outcome(s) that the HCs will achieve/realize by a specific date. Develop a system for prioritizing the TA WYPCA will provide, or make provisions for contract consultants to provide the needed TA. 11/4/16 Brenda Burnett, Quality Director 11/23/16 Kathy Johnson, Completed 11/2/16, please review Revised WYPCA 2016 Financial Project Work Plan Made requested changes to original 2016 Clinical Project Work Plan per request of P. O. Submitted on 11/18/16. Completed 11/23/16, led all PCA staff in review of several system examples as provided by the Mid-Atlantic Association of Community Health 2

3 Develop a system for tracking, monitoring, evaluating, and cancelling if necessary, any TA activity that it directly provides, or makes provisions for Contract consultants to provide. 11/23/16 Kathy Johnson, Centers and the Association of Utah Community Health and also drafted several prototypes for review before finding a platform that will make system available to all staff and that would allow for clear monitoring of the WYPCA Work Plan. Please review Draft WYPCA 2016 Work Plan Matrix in EHB. Completed 11/23/16, the Draft WYPCA 2016 Work Plan Matrix will also serve to track, monitor, evaluate, or cancel any Training and Technical Assistance activities provided by the WYPCA or Contract Consultants. Develop a system for closing the loop after Training or Technical Assistance is provided, as well as determining when to follow up with a HC to learn if the HC implemented any of the processes and strategies offered during the TA and/or if any the HC noted any improvement. Develop Data Sharing Agreements and secure the written signatures on those HCs-WYPCA Data Sharing Agreements from each HC 12/15/16 Kathy Johnson, Hold off Jan Cartwright, Completed 12/30/16. The WYPCA 2016 Work Plan Matrix has been finalized and is in use to assist with follow-up from any Training or Technical Assistance event to determine efficacy of that T/TA effort, any improved outcomes or even if further T/TA is needed. A draft policy regarding T/TA efficacy and outcomes/follow-up has been included with the December 30 HRSA submission. The WYPCA Board will review and approve the policy in the next month. PROGRESS TO /COMMENTS is reviewing other PCA Data Sharing Agreements to draft a WYPCA specific policy to share with Board of Directors in early PCA staff is also reviewing data aggregation software and the resources needed to purchase. 3

4 SV/ SV Emergency Preparedness (EP) No T/TA regarding Emergency Preparedness provided. WYPCA is not assessing the needs before, during or after an emergency. WYPCA is not coordinating at the regional, state or community level before, during and after an emergency. Request a copy of CHAMPS EP and Response Plans to use as a guide in developing WYPCA s Plan. Develop and document relationships with State Emergency Preparedness and Response staff with the governor s office, state, and local communities. REQUIRED CORRECTIVE ACTIONS 11/4/16 Mary Lynne Shickich, Health Policy Director 11/23/16 Mary Lynne Shickich, Health Policy Director PROGRESS TO /COMMENTS Made contact with Region VIII staffer in Colorado who handles EP. Reviewed CHAMPS materials on EP, updated to WYPCA. Linked to State of Wyoming EP website, reviewed/gathered materials information with WYPCA staff. Also in touch with Tina at Mass League to join EMAC in place of WYPCA ED who had attended meetings and conference calls. ed EP staff and superiors in Wyoming Department of Health with expectation to meet in next two weeks. Completed 10/31/16. Completed 12/20/16. Health Policy Director had a conference call with Dave Edwards, the State Hospital Preparedness Program Coordinator in lieu of an in person meeting due to inclement weather. Regional state staff working on EP are identified in a letter included with the December 30 HRSA submission. WYPCA develop an EP and Response Plan that they will follow before, during and after an emergency or disaster. 12/30/16 Mary Lynne Shickich, Health Policy Director Completed 12/30/16. Using EMP templates from CCHN, NACHC and information from other sources, WYPCA has drafted an EP Plan included with the December 30 HRSA submission. The WYPCA Board will review and approve the policy in the next month. 4

5 Incorporate and link WYPCA EP and Response Plans to the Wyoming HCs EP and Response Plans. Incorporate question on health center TA needs around EP into the needs assessment Hold off 11/23/16 Jan Cartwright,, Kathy Williams, PROGRESS TO /COMMENTS Completed 11/23/16, working with CHAMPS, the regional PCA and all PCAs in Region VIII, WYPCA staff ensured that EP questions were included in the Needs Assessment, which will be sent to the field on November 30 with responses due on December 9 to allow for information to be included in the PCAs Competitive applications. Develop a list of emergency contacts and phone numbers 12/30/16 Mary Lynne Shickich, Health Policy Director, Kathy Williams, Completed 12/30/16. WYPCA has uploaded the letter that identifies state staff working regionally on EP to the Board website to encourage Health Centers to include this information in their EP plans. The document has been included in the December 30 HRSA submission. Also included is the have produced Key Contacts for WYPCA Succession Policy/Plan. 5

6 SV/ SV Newly Funded WYPCA will document contact with the four health centers funded within the past three years and document start up needs. WYPCA will document start up T/TA that was provided to newly funded health centers. WYPCA will develop a procedure for reaching out to and providing start up T/TA to newly funded health centers in Wyoming. WYPCA had not provided, at the time of the Site Visit, specific implementation start-up T/TA to its NAP. It should be noted that in the prior year, WYPCA did provide TA to communities developing NAP applications. REQUIRED CORRECTIVE ACTIONS 11/4/16 Jan Cartwright, 11/4/16 Jan Cartwright, 12/15/16 Jan Cartwright, PROGRESS TO /COMMENTS Develop a Health Center Start-Up Tool Kit. 12/15/16 Hannah Wickey, Communications Manager Documentation of startup needs is included on file CAP responses for Newly Funded CHCs uploaded to EHB. Documentation of startup T/TA is included on file CAP responses for Newly Funded CHCs uploaded to EHB. Completed 12/30/16 - A policy regarding outreach to newly funded health centers is drafted and included in the December 30 HRSA submission. The WYPCA Board will review and approve the policy in the next month. With the announcement of a New Access Point award in Wyoming on 12/15/16, WYPCA staff has met with the awardee to offer media and day one assistance. PROGRESS TO /COMMENTS Completed 12/12/16. Health Center start-up tool kit includes elements from national level with updates on state level processes and organizations. WYPCA Supplement to NACHC s Funded! Now What? guide has been distributed to the NAP awardee and uploaded to the WYPCA Board website. It is included in the 6

7 WYPCA will ask three health centers funded for 1-2 years about their participation in NACHC and Peer Learning Teams for newly funded health centers. 11/4/16 Jan Cartwright, December 30 HRSA submission. The additional state information is meant to assist the New Start leadership with contact information at the WYPCA, Wyoming Medicaid and others who can assist with helping the New Start more comprehensively begin operations. Information from Heritage Health Center and other documentation is on file CAP responses for Newly Funded CHCs submitted to HRSA on 11/4/16. Only other New Start within last two years has closed. PCA PERFORMANCE IMPROVEMENT PLAN SV/ 1. SV T/TA activities based on identified T/TA needs Develop written policies and procedures regarding the monitoring and evaluation of TA provided to HCs. Develop written policies and procedures for how to aggregate and apply the evaluation of trainings and webinars provided to the HCs into PCA TA strategy. WYPCA does not have written procedures regarding the evaluation of all trainings and TA offered to its HCs though it offers evaluations after all trainings. WYPCA conducts only verbal feedback from a HC on TA provided by its staff and by a contract consultant, but that feedback is not consistently acquired for each TA provided. January 2017 January 2017 Brenda Burnett, Quality Director Brenda Burnett, Quality Director PROGRESS TO /COMMENTS Recommend that WYPCA develop criteria and a system for prioritizing what T/TA should be followed January 2017 Hannah Wickey, Communications 7

8 when providing T/TA to HC members and nonmembers. Manager with Brenda Burnett, Quality Director, Kathy Williams, 8

9 SV/ 2. SV T/TA conducted to improve program compliance in at least 3 of 4 Program Requirement categories Recommend that WYPCA develop a system that tracks what TA is provided to which HC, the topic/issue, the date, and by which WYPCA staff. Ensure that all WYPCA staff have access to the system to enter information and view what other WYPCA staff have done. WYPCA provision of T/TA for helping the HC meet Performance Requirements was verified. However, WYPCA does not have a system for prioritizing what T/TA should be provided when where, and how. WYPCA does not have a written system in place for identifying and tracking what TA is provided when and to which HC or by which WYPCA staff person WYPCA does not have a mechanism in place that stipulates what topic/issue that generated the TA, or a mechanism for all WYPCA staff to know what was said or done as TA. January, 2017 Hannah Wickey, Communications Manager with Brenda Burnett, Quality Director, Kathy Williams, PROGRESS TO /COMMENTS 9

10 SV/ SV Other: contracts WYPCA does not have written contract procedures that the WYPCA must follow when procuring services, technical assistance, training, and consultation, etc. from a consultant or consulting Firm. WYPCA does not have specific criteria that must be included in a WYPCA consultant contract and memorandum of agreement (MOA). Develop written policies and procedures for procuring services, goods, trainings, technical assistance, grant development, etc. from consultants. WYPCA develop a list of specific criteria and safe guards that it should include in any consultant contract and in any MOA. Such criteria may include, but not be limited to, the following: Overall purpose of the contract/moa o Training o Technical assistance o Assessment o Resources o Grant review and edit o Grant development o Policy and procedure development Desired qualifications of consultant, trainer, grant writer, etc. Specific objectives (what is the consultant 11/4/16 Jan Cartwright, 12/15/16 Jan Cartwright, PROGRESS TO /COMMENTS WYPCA already had a Board approved procurement policy that is included on the WYPCA Board website for hiring consultants or purchasing goods and services. That policy is linked here for the December 30 HRSA submission. Completed 12/30/16. Criteria to be followed in all consultant contracts or any MOAs is included in the December 30 HRSA submission. 10

11 supposed to do-action oriented, measurable) Time frames Expected outcomes-deliverables o Report (includes the action taken to achieve the objectives, resources provided and to whom, results of the TA, recommendations, etc., follow up required) o Training presentation outline o PowerPoint o Handouts Time frames for drafts (if applicable), final deliverables Terms for payment Penalties if consultant does not meet deliverables and time frames 11