This document discusses quality improvement (QI) processes and plans. It outlines the benefits of a QI process, including identifying patterns/trends, reducing risks, and establishing priorities. An effective QI plan includes records reviews, health/safety reviews, input from served persons, utilization reviews, risk management, and performance indicators. Selection criteria for record reviews include length of care and representation. The review process involves forms, reviewer teams, record reviews, agreement on ratings, and feedback. Data is collected, reported quarterly, and used to identify action steps and monitor improvements. Continuous quality improvement involves ongoing data collection, analysis, and identification of performance concerns. Defining performance indicators helps establish a common focus and definition of good business, practice,

1. QUALITY IMPROVEMENT:
UNDERSTANDING THE
PROCESS
House of New Hope
1/2008

2. Benefits of a QI Process
Old View of QI:
• Adversarial: “what’s wrong”
• “No news is good news”
• Use process to catch mistakes and
omissions early
• Do it because required to
• Helps to improve audit results
1/2008

3. Benefits of a QI Process
New View:
• “Nobody is perfect”-information on “how we are doing”
is essential
• Identifies patterns and trends
• Eliminates gaps
• Reduces agency risks
• Assists in establishing priorities in service delivery
• Defines “best practices”
• Helps to define training needs
• Provides data to make management decisions around
services
1/2008

4. What is Quality Improvement?
• Quality Improvement: a
structured process that
selectively identifies and
improves all aspects of care and
service on an ongoing basis
through the use of disciplined
inquiry, teamwork and targeted
actions.
1/2008

5. Agency Quality Improvement
Plan
Elements:
• Records Review: compliance and quality
• Health and Safety
• Input from Persons Served: Satisfaction
surveys
• Utilization Review (efficient use of services)
• Risk Management
• Outcomes: Performance Indicators
1/2008

6. What Makes Quality
Improvement Plans Effective?
• Staff and Administrative Ownership
o It’s everyone’s responsibility
o Belief in the process: use of data to make
decisions
• Feedback on the process
o Ability to see it’s effectiveness
• Strategic Planning
o Ability to apply what’s been learned to present and
future decisions
1/2008

7. Compliance Focus
ODJFS
o Is it in the record?
o Did you complete it on time?
ODMH
o Is the service necessary?
o Are your interventions appropriate?
o Are your interventions effective?
1/2008

8. Compliance Focus
CARF
• How are you doing? (Data Collection)
• How do you know?
(Performance Indicators)
• Can you demonstrate why you made a
particular decision?
(Evidence based practices;
management by data)
1/2008

9. Types of Review
• Clinical Records Review
o Assures completion of required documents
• Qualitative Peer Review
 Assures quality documentation
 Addresses Medical Necessity (established
need for services)
o Addresses principals of good practice
 Continuity of Care
 Integrated Services
1/2008

10. Selection Criteria
• Length of Care:
 30 to 60 days
 90 to 270 days
 270 days or more
 Discharge
 Hospitalization
o Representative of all staff and programs
o Random
o Integrity: Prohibition of self review
1/2008

11. QI Process
Forms
• Each record will be reviewed for clinical
completeness and quality of documentation
Reviewer Teams
• no less than two persons to a team;
• no reviewing of own record
Record Review
• Agreement on ratings
• Positive Constructive Feedback
1/2008

12. Clinical Records Review
Compliance categories needing Correction
• C/C: Compliant and Complete-(contains all
required elements and completed within required
time frames
• C/I: Compliant/Incomplete-Compliant, such as
form is present, but may be missing elements.
• N/I: Non-compliant/Incomplete-information is not
present, requires completion
1/2008

13. Compliance Categories not able to be
Corrected
N/C: Non-compliant, complete-form is present
but not completed within required timeframe (i.e.
cannot be corrected)
N/A: Not applicable-use ONLY when time
frames or circumstances do not require
completion
e.g. Assessment not complete: youth in care
for 20 days—rating is N/A
1/2008

14. Data Collection Process
• Reviewer Team completes record review
• Completed review is turned in to Director of
Care Management
• Staff requested to make corrections as
indicated
• Corrections completed by designated time
frame
• Identify next set of records for review
1/2008

15. Reporting Process
• Results of reviews are reported in aggregate on
a quarterly basis
• Action steps for system improvement are
identified
• Reviewed by staff, management, board of
trustees
• Results are continuously monitored to identify
effectiveness of changes
• If no improvement, identify new action steps
1/2008

16. Continuous Quality Improvement
• Performance improvement will highlight
processes and systems that need to be
improved and follow-up with a plan of action to
improve the outcomes.
• The process is continuous.
• Data continues to be collected and analyzed.
• Services continue to identify performance
concerns or goals: “performance indicators”
1/2008

17. Agency Mission Statement Helps to:
• Establishing a Common Value and
Philosophy of Care
“The mission of House of New Hope is
to transform the lives of vulnerable
children in need of safe and permanent
families, by providing treatment-
oriented, culturally sensitive and cost
effective community based services.”
1/2008

18. Performance Indicators
Help to:
• Establish a Common Focus
• Establish a Common Definition of:
o Good Business
o Good Practice
o Good Service Delivery
1/2008

19. Defining Service Performance
Indicators
• Outcomes: How do you know you are doing a
good job with your clients?
• Responsiveness
• Satisfaction
• Effectiveness
o Improvement in functioning
o Reduction in symptoms
• Permanence
o Reduced disruptions
1/2008

20. Defining Agency Performance
Indicators
• Licensing
o Recruitment
o Annual Number of Completed Home studies
o Reduced withdrawals
• Transportation
o Safety
o Met all appointments
• Training
o Applies knowledge gained
o Rule violations
o Satisfaction with training
1/2008

21. Defining Agency Indicators
• Fiscal
o Contract compliance
o Billing hours budgeted met
1/2008

22. What measures
do you use to determine
that you are effective in
your work?
1/2008