Overview of Quality Assurance and Enhancement

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Overview of Quality Assurance and Enhancement

• A Framework for Future Directions, Trends and
  Promising PracticesJune Rowe and Sarah
  TaubHuman Services Research Institute

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Changing Quality Landscape

• Exposure of fault-lines in the system (e.g., GAO
  report, etc.)
• Emergence of self-determination
• Olmstead decision and proposed closures
• Struggles with MIS applications
• Direct support staff shortages
• Expansion of supports to individuals on the
  waiting list

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23 States have been sued for wait listing
individuals with developmental disabilities for
Medicaid long-term services
Gary Smith, HSRI, 2003
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• Decreasing/static funding coming on top of an
  already strained provider network
• Increasing federal expectations regarding a
  quality framework
• Inefficient business model (e.g., clumsy rate
  structures, redundant, sometimes conflicting
  monitoring processes)

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Signs of Change in Performance Management

• No longer just better than the institution
• Rooted in outcomes
• Emphasis on enhancement and CQI
• Changing role of the state
• Changes in experiences of families and people
  with developmental disabilities
• Changes in accreditation approaches

Inclusion
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More Signs of Change

• Movement away from prescriptive standards to
  individualized risk management
• Collaborative development of standards
• Inclusion of consumer and family participation
  in oversight (e.g., PA MN)

Satisfaction
Consensus
CQI
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• CMS is also opening up the discussion about
  quality..
• The Quality Framework

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HCBS Quality Framework
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Participant Access

• Information and Referral
• Intake and Eligibility            
• User-friendly processes
• Eligibility determination
• Referral to community services
• Individualization of services
• Prompt initiation

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Participant-Centered Service Planning and Delivery

• Participant-Centered Planning
• Adequate assessment
• Free choice of providers
• Responsive service plan
• Participant direction
• Service Delivery
• Ongoing service and support coordination
• Provision of needed services
• Ongoing monitoring
• Responsiveness to changing needs

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Provider Capacity and Capabilities

• Availability of individual and agency providers
• Review of provider qualifications
• Monitoring of providerperformance

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Participant Safeguards

• Prevention and investigation of abuse,
  neglect and exploitation
• Tracking of major and unusual incidents
• Ensuring safety of housing and environment
• Regulation of behavior interventions
• Standards for medication management
• Provisions for personal safety and security
• Preparation for natural disasters and other
• public emergencies

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Participant rights and responsibilities

• Ensure that participants  
• Exercise civic and human rights
• Participate in decision making authority
• Have provisions for alternate decision making
• Have access to due processand grievance
  mechanisms

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Participant Outcome and Satisfaction

• Participant outcomes
• Participant satisfaction

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System Performance

• Conduct system performance appraisals
• Support quality improvement
• Ensure cultural competency
• Support participant stakeholder involvement
• Maintain financial integrity

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Continuous Quality Improvement

• Close the loop
• Information from quality assurance
• drives decision making!
• 
  Therefore.

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Continuous Quality Improvement
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What does this means for how states are thinking
about quality?Example 1 5 state licensing
study
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Person-Centered Outcomes

• Respect and dignity
• Rights and responsibilities
• Personal safety and risk
• Abuse neglect (critical incidents)
• Environment
• Individuals funds
• Health and Medication
• Community inclusion and integration
• Independence and Autonomy
• Choice and decision-making

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Strong relationship of person-centered outcomes
to service planning

• Individual involvement in planning
• Identifying peoples preferences, choices (e.g.,
  services, housemates, work) and personal goals
• Assessing/evaluating peoples needs for support
• Developing strategies for implementing goals
• Monitoring peoples progress

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Survey Methodology

• Person centered survey process have the
  following in common
• A representative sample of individuals served
  by the agency
• Surveys are completed through
• Documentation Review
• Interviews with individuals, staff, family, case
  managers
• All surveys include observation of individuals in
  the location where they receive services
• Surveys also include a review of agency
  documentation
• related to organizational strength and
  stability
• Staff orientation/training
• Incidents/Investigation reports
• Internal QA Plans

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Safeguarding Outcomes Requirements

• Most uniformly prescriptive set of requirements
  and outcomes
• Rights
• Informing individuals and family members about
  individual rights and responsibilities
• Abuse, neglect and exploitation
• Reporting allegations of abuse
• Investigate allegations, take action if the
  investigations are substantiated
• Protect individuals from harm
• Restrictive procedures
• Psychotropic medications, behavior support plans,
  and restraints
• Require
• Assessments
• Behavior support plans
• Data collection and monitoring
• External review
• Prohibitions or limitations on some restrictions
• Staff competency

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• Medications prescriptive requirements for
  management and administration of medications
• Health More prescriptive requirements for
  medications than health, although monitoring of
  health is growing
• Routine examinations
• Identification of health care needs
• Access to health care services
• special diets nutritional meals
• Environmental
• Greatest requirements larger residential living
  situations and/or residences that provided
  24-hour staffing and site-based day supports
• Less prescriptive for more independent living
  situations, people lived in their own apartments
  and/or received less than 24-hour supports
• Accessibility required when needed

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More emphasis on staffing and staff competency

• Less emphasis on staff educational level and
  degrees
• Staff ratios less prescriptive tied into
  individual needs
• Staff knowledge and competency seen as an
  essential safeguard!
• Some training required before staff can work
  alone with individuals
• Emergency procedures (e.g., evacuation)
• Abuse/neglect reporting,
• Knowledge support strategies for the individual
• Administration of medications (if the state has a
  delegated staff giving medications)
• Human rights
• Incident reporting
• First aid and CPR
• Medication administration certification in many
  states

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• Example 2
• Monitoring Individual
• Providers

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QA/QI for Individual Providers

• Why now?
• Increased self-direction
• Services more individualized
• Vulnerabilities
• Isolation of both the provider and individual
• Who is responsible for the skills and
  competencies of the provider?
• Oversight for provider quality left largely in
  the hands of the individual/family

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Challenges to Our Notions of Quality

• Preventive, upfront
• person-centered QA is key
• Basic qualifications, skills and competencies
• Identifying the persons needs for support,
  risks, and degree of monitoring in the planning
  process
• Individual and family competencies to effectively
  manage individual providers

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Individual Providers More Person-Centered QA

• Self-monitoring by educated individuals and
  families
• Ongoing monitoring by the case manager/support
  coordinator is critical for early
  detection/prevention of problems

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Monitoring the Quality of Individual Providers

• Consumer affairs or ombudsman office
• Published report cards on independent providers
• Person-centered review processes
• Citizen/peer networking and quality councils
• Consumer/family surveys

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• Given the changing landscape what are our
  immediate challenges and potential solutions for
  sustainability?

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Improving the Sustainability ofPerson-Centered
Monitoring

• Improve the effectiveness and efficiency of
  current processes
• Integrate information (FL, PA)
• Develop internal QA systems
• Integrate quality assurance responsibilities
  across the system (MA)

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Improve Sustainability

• Involve families and people with disabilities
  (PA)
• Improve up-front quality expectations upfront
  (PA)
• Increase transparency of QA systems and
  development of a demand for information (CT)
• Explore quality assurance for individual
  providers (UT, OR, NH)

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Conclusions and Recommendations
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Important Next Steps

• Place individual outcomes at the center of the
  system
• Enlist assistance of consumers and families
• Identify key areas of performance
• Create a quality management entity
• Make results available and accessible

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• Develop uniform reporting of critical health and
  safety events
• Develop staff credentialing and expand training
  options
• Reassess roles and responsibilities of case
  managers
• Refine performance contracting

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• Expand understanding of participant centered
  planning
• Develop a technical assistance capacity
• Implement risk management and health assessments
  (OR, MA, CA)
• Build integrated data systems (CA, FL, PA)
• Develop hotlines and ombudspersons

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Lessons for Providers

• Develop internal quality improvement plans
• Work with states to streamline QA/QE procedures
• Continue to work to upgrade the status of direct
  support professionals
• Enlist people with disabilities and families
• Continue to train staff in person-centered
  principles
• Assume that quality assurance will become
  morecomprehensive and systematic

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Final Words

• Beware the Continuous Improvement of Things
  Not Worth Improving
• W. Edwards Deming

CAUTION