The Quality Conundrum

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The Quality Conundrum

• Achieving Safety, Healthand Valued Outcomes

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How Did We Get Here?

• Initial concentration on rudiments of custodial
  care
• Evolution of programmatic standards that
  reflected growth in our understanding of peoples
  needs and our own expertise
• Increased concern about the efficacy of our
  interventions
• Attention to the outcomes of services and
  supports from the perspective of the customer

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Valued Outcomes

• Individualization
• Integration/Inclusion
• Relationships/Social Connections
• Health and Safety

• Personal Growth
• Choice and self-determination
• Dignity
• Consumer Satisfaction

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Signs of Change in Performance Management

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

Outcomes
Expectations
Inclusion
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More Signs of Change

• Movement away from prescriptive standards
• Emphasis on CQI
• Exploration of self-assessment
• Collaborative development of standards
• Inclusion of customer satisfaction

Satisfaction
Consensus
CQI
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The Two Faces of QA One Control
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The Two Faces of QA Two Enhancement
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Public Quality Assurance Responsibilities

• Assuring that individuals are free from abuse,
  neglect, and exploitation
• Protecting the rights of individuals and
  families
• Assuring accountability in the use of public
  dollars
• Assuring that individuals have access to
  necessary professional services
• Evaluating the effectiveness if service and
  supports
• Assessing the performance of service providers

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Changing Quality Landscape

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

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Myths and Cautions

• Choice is the only thing that matters
• Health and safety are synonymous with outcomes
• Providers are ready for outcomes

• There is a correlation between best practice
  and consumer satisfaction

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Critical Constraints

• Drain of knowledgeable staff frompublic sector
• Consolidation of providers
• Management of multiple systems
• Generic approaches to quality
• Increasing gray areas in public jurisdiction
• Pressure from HCFA
• Lack of collaboration with sister agencies

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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
• Link technology with need for information
• Look at the costs and benefits of existing
  approaches

• Make results available and accessible
• Get serious about uniform reporting of critical
  health and safety events

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More Recommendations

• Develop Staff credentialing and expand training
  options
• Reassess roles and responsibilities of case
  managers
• Refine performance contracting
• Expand understanding of person-centered planning

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Emergence of Performance Indicators

• First appeared in behavioral and acute care
• Provide some cues for managing these complex
  systems
• Highlight impact of cost containment
• Illuminate whats working
• Provide early warning signs

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Characteristics of Performance Indicators

• Reflect major organizational or system goals.
• Address issues that can be influenced by the
  organization or system
• Have face validity

• Point a direction
• Reflect rates or major events
• Related to associated standards

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Consumer Involvementin Assuring Quality

• Choice among providers/ purchasing decisions
• Designing and refining QA mechanisms
• Grievance/appeals process
• Consumer satisfaction surveys
• Membership on policy-making board
• Telecommunications networks
• Consumer Reports

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Health and Safety Imperatives

• Ensure adequate number of service coordinators
• Build individualized health and safety plans
• Screen and train employees
• Train individuals and families
• Increase federal funding
• Develop hotlines and ombudspersons

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Continuous Quality Improvement

• Leadership at the senior level
• Engagement of multipleconstituencies
• Identification of emergingissues and priorities
• Development of an benchmarks
• Identification of change strategies
• Measurement of progress

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What Do You Do With the Information?

• Include at your web site
• Prepare annual reports to the legislature
• Develop provider profiles
• Use with sister agencies
• Monitor managed care initiatives
• Use in allocation decisions

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Final Words

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

CAUTION