WTCMHMR QUALITY MANAGEMENT PLAN FY2010 FOUNDATION

WTCMHMR QUALITY MANAGEMENT PLAN FY2010 FOUNDATION A recovery-focused behavioral health care organization recognizes its responsibility to make continual evaluations of the quality and effectiveness of its services. [Personal Outcome Measures in Consumer-Directed Behavioral Health] Process accountability means achieving desired outcomes using procedures and methods that are legal, ethical and clinically appropriate. [Personal Outcome Measures in Consumer-Directed Behavioral Health] An organization should establish policies and procedures that provide guidance for provider decision making and allow for flexibility in individualizing service delivery for the consumers while at the same time hold the local authority and provider network accountable to their legal, contractual and regulatory guidelines. The QA Plan will focus on the mission of WTCMHMR Quality Services for Quality Life and will seek to incorporate all major components of the vision statement in the ongoing monitoring activities. Page 1 of 15

UMission Statement: Quality Services for Quality Life UVision Statement: MISSION AND VISION STATEMENTS Create a superior system of care to meet individualized needs through the provision of quality services shaped by partnerships and built upon integrity, mutual respect and compassion for those served. PURPOSE West Texas Centers for MHMR (WTCMHMR) has developed the following Quality Management Plan (QMP) to have a systematic and objective way to measure, assess and improve the clinical services offered to persons with mental retardation and mental illness. The QMP assists in assuring that basic standards of care are met and provides the framework to obtain feedback from stakeholders and providers regarding the way the Center conducts business. Quality for the organization and its network of providers is represented as a set of standards and expectations in the form of targets, objectives and outcomes. The Quality Management Committee will serve as the communication tool for the various departments within the organization and will work to develop recommendations for improvement as needed. UPerformance Contract: FOCUS It is critical to the base of operation for WTCMHMR to remain in compliance with requirements outlined in the Performance Contract with the Department of State Health Services (DSHS), the Department of Aging and Disability Services (DADS) and the Department of Assistive and Rehabilitative Services (DARS). Management teams within each division of the organization are responsible for strict adherence to performance contract expectations and monitoring compliance with established outcomes and accuracy of data submitted. Percentages of compliance established within each performance contract are utilized as minimum acceptable compliance measures. UOutcomes For People: U Focuses on evaluating questions such as are people getting better?, are our services effective?, and do people achieve their goals as a result of the services they receive? The ongoing assessment for all our programs will be to Page 2 of 15

see if people are getting better, achieving their personal outcomes and living independent lives through the use of our services and supports. We will also be looking to see that the center is putting the mission, vision and value statements into practice as services evolve and change. It is important that we view consumers and family members as partners in the process of their recovery and seek their assistance throughout all phases of treatment decisions. UClinical Practice of Providers:U Clinical practices in all program areas will focuses on the effectiveness and efficiency of services. Throughout the course of the fiscal year, services will be evaluated for compliance to payer requirements as well as compliance with basic core elements of quality services. The core elements will include but not be limited to: effectiveness of service planning and validation of diagnosis being treated consumer progress or lack of progress in treatment clinical justification for services authorized (medical necessity) consumer participation in treatment Other elements that are unique to a specific service type or program will be included as needed. Quality Management activities will be accomplished through each program area developing, implementing and monitoring quality review activities targeting areas of deficiency as identified through data collection, internal or external reports, or other similar mechanisms. Each program area will report review results and follow-up activities quarterly to the Quality Management Committee. The Quality Management Committee will make recommendations as indicated. Data from each programs quality review process will be submitted to and maintained by the WTC Risk Management Director. UUtilization Management (UM): WTCMHMR leadership insists upon intense UM review to insure equal access to services, efficiency and cost effectiveness. The Utilization Management Committee meets a minimum of quarterly to monitor the use of clinical resources to assist the promotion, maintenance and availability of high quality care in conjunction with effective and efficient utilization of resources. Specific items tracked and monitored are identified through the performance contract. Page 3 of 15

UCustomer Satisfaction: The concept of customer satisfaction is interlaced throughout all monitoring and review activities, always assessing the level of satisfaction of those who utilize our services. The intent of this domain is to bring customer satisfaction to the forefront and monitor that the Center is not only looking at the basic satisfaction with given services, but that we are responsive to the needs and requests of our customers on an ongoing basis. UOrganizational Self Assessment: U Regular ongoing consumer satisfaction surveys will be conducted by the Local Planning Committee. Data from these surveys will be compiled and reports to program areas, PNAC group and other stakeholders on a regular basis. Program surveys are also shared with West Texas Centers Board of Trustees. Individual program areas perform differing tasks related to organizational self assessment as outlined below. Mental Health Program: Mental Health Division uses various tools to assess the abilities and performance of the four Regional Program Managers. These self assessments are done on at three year intervals. An Organizational Feedback Survey is given to peers, subordinates and supervisors/management ancillary staff. This survey rates the Manager on 10 skills. Examples of skills included are communication, personal impact and problem solving/decision making. Peers and subordinates perspective of manager performance may vary greatly from that their supervisors or external stakeholders. During 2010 this assessment process will again be done. In addition, each of the 4 Regional Program Managers will be assessed using the following instruments: 1. Personal Assessment to Lead; 2. Understanding Human Needs Survey; 3. Assumption about People and What Motivates Them; 4. SELF assessment which looks at how the manager relates to people; 5. Assessment for Volatility. These five assessments are shared with the Manager on an individual basis with intentions to increase self awareness as well as to compare themselves to managers universally. Page 4 of 15

Mental Retardation: The Texas Home Living program as well as the Home and Community Based Service program require annual self assessment type reviews. These reviews are performed by administrative and program staff within the Center and are focused on the following areas: Customer Satisfaction Complaints Abuse and Neglect Continuous Quality Improvement Critical Incidents Data obtained through these reviews is shared with those staff responsible for that particular area. Additionally this information is discriminated through various leadership and other committee venues. Regular comparisons are made to insure improvements and corrective actions are taken as required or indicated. Early Childhood Intervention (Little Lives ECI): Yearly assessments of Little Lives ECI referral sources are conducted. From these results a child find plan is developed to target referral sources that have a lot percentage of referrals for the year. These plans include visits, presentations, and information sharing. During these events organizational self-assessment also occurs as feedback regarding the full array of service delivery is obtained. Planning for future growth during the year is conducted annually and a budget submitted identifying staffing, capital expenditures and other items needed to accommodate the projected growth. New initiatives for this year will include a training needs assessment along with expected program changes. ROLES AND RESPONSIBILITIES UQuality Management Committee:U The committee will meet a minimum of quarterly with an agenda that includes reports and data from each of its members departments as well as pertinent reports and data from the Center s standing committees and Local Planning & Network Advisory Council. The committee will be responsible for: Reviewing all data presented for assessment of program specific quality management activities. Reviewing results of any internal and external record reviews and surveys Monitoring WTCMHMR s performance and data accuracy in relation to data verification and other quality monitoring activities required by payers Page 5 of 15

Reviewing implementation of internal quality management plans from Mental Health, Mental Retardation and Early Childhood Intervention (ECI) Developing recommendations for improvement with Mental Health, Mental Retardation or ECI Collected data will be aggregated and analyzed to effectively assess the organization s performance and to determine the following: Strengths and weaknesses Outliers Effectiveness of designed processes Level of performance and stability of providers Opportunities for improvement Membership will be assigned by the Chief Executive Officer. assigned for FY2010 are as follows: The members Chief Executive Officer Deputy Director for Operations Deputy Director for Administration (DDA) (co-chair) Risk Management Director (co-chair) Director for Utilization Management Mental Retardation Director ECI Director Mental Health Director Mental Health Director of Operations WTCMHMR Rights Officer As the committee meets at least quarterly, it has authority to form focus groups that meet more frequently to address specific issues as indicated. The Deputy Director for Administration and/or the Risk Management Director will be responsible for the following: Guide development of QM Plan with input from local planning entities and staff Serve as contact with DSHS and DADS for all quality issues Represent WTCMHMR on Quality Management Consortium Serve as the designated link between Quality Management, Utilization management, Risk Management and Corporate Compliance Assure integration and consistent communication (specifically related to quality management) across all systems of care and layers of management Serve as chair of Quality Management Committee Monitor and participate in implementation of WTCMHMR s Local Planning and Network Development. Page 6 of 15

Monitor implementation and ongoing WTCMHMR s QM Plan Reporting All quality management reports and activities will be funneled through the DDA to the Quality Management Committee, the Planning & Network Advisory Council, and the Executive Committee for the Center as needed or required. Department heads will be held responsible for development of plans of improvement as indicated and for dissemination of appropriate information to their staff. The Director of Utilization Management will serve as the link between the QM Committee and the UM Committee and will make periodic reports to the QM Committee to assure collaboration and consistent communication is achieved. Reduction of Abuse, Neglect and Exploitation The incidents of abuse, neglect and exploitation are closely monitored on a continuous basis by the Consumer Risk Manager. Reports on abuse, neglect and exploitation are presented periodically to the Quality Management Committee (QMC) as well as the WTC Risk Management Committee for evaluation and assessment. Statistics on abuse, neglect and exploitation are also examined quarterly from information provided by the Client Abuse and Neglect Reporting System. This report presents a statewide perspective and is included in quarterly assessments. Trends are analyzed and training provided to employees which incorporate preventive strategies. Consumer Rights Protection Process All employees are given rights protection orientation when employed by the Center. Training on specific problem areas is provided during annual refresher training. Rights violations and concerns can be reported to the Consumer Risk Manager, Office of Client Services and Rights Protection, and Advocacy Incorporated. The phone numbers for the Center s Consumer Risk Manager and external advocacy agencies are posted in all residences, Centers and vocational training areas operated by West Texas Centers for MHMR. All rights violations for persons with mental retardation are reported to the Center s Human Rights Committee. Rights restrictions requests must be reviewed and approved through the Human Rights Committee which will report to the QM Committee and the Risk Management Committee. Page 7 of 15

Crisis Services Specific tools to be utilized to monitor and assess effective delivery of Mental Health crisis services will be defined within the performance contract and will have indicators identified to assess fidelity to the model as well as the quality of services performed within the service delivery model itself. The Quality Management department will work closely with the Utilization Management department to assure that established performance measures are met and that fidelity to the service model is upheld in practice. The local community needs will be analyzed by comparing the data to established targets set by DSHS and by benchmarking with other Centers. Crisis service assessments and reviews will be reported to the Utilization Management Committee. The Utilization Management Director will provide the link to the Quality Management Committee in regard to crisis services. This review of provider performance data will facilitate management decisions for the organization. Local Planning and Network Development WTCMHMR is committed to the development and expansion of our Mental Health provider network. We are committed to providing choice for our consumers and their families. WTCMHMR has completed the Local Planning and Network Development plan and received approval. Implementation of the plan has begun and will continue through the plan year with an open enrollment process. Quality Management Committee Initiatives WTCMHMR will require provider quality management plans for Mental Health, Mental Retardation and ECI have been submitted. These program specific plans are actively in place for FY2010. Each provider was held responsible for the development, implementation and reporting of their individual quality management plan. Plans are concentrated around those program areas indicated through internal reviews, DVC, surveys or management initiatives as needing additional improvement. Some separate initiatives of the Quality Management Committee and the Planning and Development Committee will include: Customer satisfaction: The QM Division will, in conjunction with program PNACs develop, distribute and compile customer satisfaction surveys. These survey results will be documented and forwarded to the appropriate program management staff, shared with the individual PNAC and the WTC Board of Trustees. Mental Health Only: Participation in the Mystery Caller Project developed by the DSHS Quality Management Department to assess access to Page 8 of 15

routine mental health services and ensure compliance with Community Standards. Mental Retardation Only: Ongoing measurement and assessment of service quality, critical incidents, consumer incidents and injuries, rights violations, abuse and neglect, results of on-site safety/environmental inspections which include the review of adherence to Fire Safety Codes. Participation in the Mystery Caller Project developed by the Texas Council Quality Management and Mental Retardation consortiums. Individual program specific quality management plan outlines are as follows: Quality Management Plan Little Lives ECI Program FY 2010 OUTCOME: Early intervention programs serve young children with disabilities and their families. For children, the overarching goal of services is to enable young children to be active and successful participants during the early childhood years and in the future in a variety of settings in their homes, with their families, in childcare or school programs, and in the community. For families, the overarching goal is to enable families to provide appropriate care for their child and have the resources they need to participate in desired family and community activities. Effective programs support families in their quest to have a satisfactory quality of life for themselves and their child by providing needed services and supports in a timely and appropriate fashion. AUDITING STRATEGY Each new Family Service Coordinator will be monitored for the quality of their work in relation to quality services, ECI policies, and local procedures Each family will receive a satisfaction survey to determine satisfaction with PERSON RESPONSIBLE Director & Team Supervisors Administrative Services Coordinator SURVEYS EVALUATION METHOD Each Family Service Coordinator will have 5% of their caseload audited per month. This includes initial, 6 month and annual charts. Every family upon closure of services will receive a satisfaction survey to complete by mail. Each month team supervisors Page 9 of 15

services Each referral source will be sent a satisfaction survey ECI families will receive initial services in a timely manner ECI families will receive service in their natural environment ECI families will receive an IFSP within 45 days of referral(exclude families that have requested to wait) ECI Program will deliver an appropriate amount of services to families Transition services will be offered to families within the State timelines Director PROGRAM DEVELOPMENT Direct Service Staff Family Service Coordinators Family Service Coordinators Direct Service Staff Family Service Coordinators will call a family and conduct a family survey by telephone. 80% of families will feel ECI helped their families At the end of the year the results will be sent to the Deputy Director for Administration (QM Director) Each referral source that called with referrals during the year will be sent a satisfaction survey. The results will be sent to the Deputy Director for Administration (QM Director) at the completion of the survey. 90% of ECI families will receive their first service within 28 days if the initial IFSP 98% of ECI families will receive their services in the natural environment 95% of ECI families will receive their initial IFSP within 45 days of referral ECI program will deliver a minimum of 2 hours of service per month per family. 95% of ECI families will receive transition services within timelines established by the State ECI Quality Management Plan Mental Health Division FY10 There will be three areas that the division will focus on during FY10: Page 10 of 15

1) Ongoing monitoring of the quality of access to services, service delivery and continuity of services with special emphasis on timeliness of services: 1. WTCMHMR will insure that an individual requesting services and being screened for services by Avail Solutions will have access to the assessment by an LPHA within 14 days. 2. WTCMHMR will insure that documentation supports that an individual received face-to-face contact with a QMHP-CS within one hour (60 minutes) when the individual is determined to be in an emergent crisis. 3. WTCMHMR will insure that when a person is deemed to be in an emergent crisis that the individual will have had a Face to Face visit with a Psychiatrist within 12 hours. NOTE: This will be reviewed twice during FY10 and data sent to the Director of Quality Management. The first review will be in January, 2010 and the second review in July, 2010. 2) Oversight of MH waiting list monitoring activities to ensure clients assigned and LOCA 8 (waiting on all services) are monitored at least once every 30 days from the date the clients is placed on the waiting list. 1. WTCMHMR will insure that at a minimum 90% of clients assigned to LOCA 8 are monitored every 30 days. Note: This will be reviewed two times in FY10. The first review will be in February, 2010 and the second review in June 2010. 3) Oversight to ensure compliance with and the quality of the resiliency and disease management practices to include monitoring fidelity to the service models defined by DSHS and requiring providers to participate in oversight: 1. WTCMHMR will insure that documentation of skills training and psychosocial rehabilitation provided to both adults, adolescents and children are documented as being incremental in nature when teaching the new skill. 2. WTCMHMR will insure that the curriculum utilized in providing skills training to children and adolescents is clearly identified in the progress note. 3. WTCMHMR will insure that documentation of the crisis services include the response of the individual and if appropriate the response of the LAR and family members to the service provided during the crisis. NOTE: This will be reviewed two times in FY10. The first review will be in March, 2010 and the second review in June, 2010. Page 11 of 15

Quality Management Plan Mental Retardation Division FY2010 On-going Evaluation Frequency: Quarterly MR Leadership staff will review service quality issues, critical incident report data, consumer incidents and injuries, rights issues, abuse and neglect allegations/confirmations, and results from safety/environmental inspections which will include a review of the completion of Fire Marshall inspections. This review will be conducted to determine trends (ex: by location/area, service type, staff, and consumers). The review will evaluate existing systems and/or procedures, relevant to the data, to determine if they are effective and appropriate or in need of revision. These types of issues will be addressed initially and as they occur. Critical Incident Reporting Frequency: Critical Incident reports will be compiled monthly. Critical Incident reporting will occur monthly prior to the end of the month for the previous month. Data will be collected by Nurses and the Psychologist for data entry. MR Service Coordination and HCS Case Management Frequency: Quarterly Service Coordination: Three consumer records, per month, will be reviewed during the first six months of employment to monitor job performance and compliance with Center and funding requirements. Five consumer records, per quarter, for each Service Coordinator will be reviewed after the initial six month review period ends to monitor job performance and compliance with Center and funding requirements. Consumer Rights Frequency: Quarterly The Human Rights Committee will review/approve all rights limitations proposed to be implemented by the Center. Meeting minutes will be sent to the QM Committee. Page 12 of 15

Consumer & Family Satisfaction Frequency: Annual WTCMHMR will conduct an annual consumer and family satisfaction survey. Results will be reported and analyzed in total and by each funding source (GR, TxHmL, & HCS). MR Leadership staff will review the results of the survey to determine if existing systems and/or procedures, or other practices, are effective and appropriate to ensure consumer and family satisfaction. In conjunction with the program quality management initiative, the Centers Quality Management Department will begin the following record mental health review process in March 1, 2010. This process is anticipated to proactively identify issues, concerns and trends which were once associated with the DSHS data verification process. These reviews will begin March 1, 2010. WTC MH Quality Management Administrative Chart Review Plan: March-August FY2010 WTC Mental Health Program internal quality management activities are designed to focus on the program process and program documentation/authorization elements as required through RDM. In order to broaden quality management activities, the Quality Management department at the Administration level will focus primarily during the final six months of the FY2010 year, on Medicaid reimbursable services. Random chart selection will be through the WTC Reimbursement department. Medicaid reimbursed services during the period of each review (quarterly) will be selected as indicated below: 20- Physician & Nursing services 25-Psychosocial Rehabilitation services 20-Skills services 10-Case Management services 5-Crisis services Reporting and Review The reviewer will review the quality of the services provided in these specific areas in accordance with procedure codes and TAC requirements. Record reviews will include noting patterns or trends, identifying and recognizing program excellence and assess the processes to determine effectiveness. Coordination with program management staff will occur in order to implement corrective action or training. The QM department will monitor corrective actions through re-reviews as indicated. Page 13 of 15

Reviewer will use the QM audit forms developed by QM Consortium; these tools include the review instruments for general chart audit-treatment plans, progress notes, and case level psychosocial rehabilitation and skills training. Immediate notification to program staff will occur should a potential billing problem be noted, otherwise, a quarterly base line billing service review will be presented to Program Management staff as identified by the Deputy Director of Operations. This review will occur prior to the quarterly QM meeting and should provide an opportunity for information sharing and planning. It is expected the Program quality management activities will be coordinated and potentially some consolidation of activities will occur as early efforts of both groups are available for review. Summary results of these reviews will be made to the QM Committee at quarterly meetings. Corporate Compliance West Texas Centers maintains and updates as needed a comprehensive Corporate Compliance plan. This plan outlines the Centers Code of Conduct as well as all aspects of the Corporate Compliance program. The plan identifies policies and procedures, training and investigative processes along with prevention activities related to and required by the Deficit Reduction Act of 2005(DRA) inclusive of the False Claims Act Section 6032 requirements. West Texas Centers will not discharge, demote, suspend, threaten, harass or discriminate against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer. Retaliation related to any report of potential fraud or abuse related to any business activity of the Center will not be tolerated. Reference: False Claims Act, Whistleblower Protections. All West Texas Centers for MHMR employees and contractors participate in compliance training whereby a system is in place to document that such training has occurred. Training materials will identify the Center contact person(s) available to respond to questions specific to compliance training or regulatory issues. Employees and contractors are made aware of their compliance obligations as a condition of employment or as a condition of the contract, respectively. Adherence to policies will be addressed within the Center s orientation and ongoing training programs, employee job descriptions and contracts. Employees and contractors will be expected to demonstrate a sufficient level of understanding as a result of compliance training. If a particular compliance issue or risk issue develops, the Compliance Officer may recommend that identified persons attend training addressing the risk issue. Curriculum established and presented to both West Texas Centers employees and contractors will include explanation and emphasis regarding the Federal False Claims Act, Section 6032 of the DRA to include administrative remedies for false claims, and whistleblower protections. Page 14 of 15

Conclusion The Board of Trustees for WTCMHMR, Chief Executive Officer, Planning Advisory Councils, Executive Committee and staff has made a long-term commitment to the implementation and evaluation of the quality management process. This will enable us to achieve a higher degree of excellence in service provision as well as management and support. The Center will continually invite consumer, family and public opinion and use this as a gauge to determine where the Center is in its efforts toward achieving and maintaining the quality management goals. This plan will be reviewed and modified annually or as deemed necessary by the Quality Management Committee, Executive Committee, Planning and Network Advisory Council and/or the Board of Trustees. Approval: Initial implementation of many of the initiatives outlined in this plan began September 1, 2009. The actual final approval of the plan was delayed pending information from the Department of State Health Services regarding continuation of the DVC component. Once the determination was made to discontinue the DSHS Data Verification process, this Quality Management draft plan was reviewed and approved by the Quality Management Committee on February 8, 2010. West Texas Centers Board of Trustees approved the final plan on March 12, 2010. Additional detail and information will be developed and incorporated into the plan as necessary and required. Signature on file dated 3-12-2010 Signature on file dated 3-12-2010 Gail Wells, Deputy Director for Administration Shelley Smith, LMSW Chief Executive Officer Date Date Signature on file dated 3-12-2010 West Texas Centers for MHMR Board Chairman, Ben Lockhart Date Page 15 of 15