Quality Assurance Plan
The Local Business Plan describes a quality management process to meet the State Plan requirements, including how the LME will address the following:

There was wide variability in how plans defined quality management and the components that comprised a Quality Assurance Plan (QAP). While many plans would articulate and define the components of their QAP, it was not always clear how the components related to each other and to the goal of assuring quality. Plans often consisted of a listing of many committees but it was unclear how these various committees related to each other and what exactly they were accountable for. A few plans identified the involvement of consumers and families but clearly this is an area that consumers and families can plan a vital role and this role should be reflected in all plans.

In many cases, quality seemed to be equated with the review of critical incidents and risk reduction although this may be as much of function of how they were asked to report this section. The Division should review its expectations and clarify and broaden it beyond a function that is primarily monitoring role.

Plans did not reflect standard provider profiling dimensions. Many plans seemed to equate provider profiling with provider credentialing. Again, this is an area where the Division’s leadership is needed. It will be important to have state identified provider profiling dimensions so that providers do not have to respond to multiple expectations, and to allow for comparisons across the state.

It is unclear how most plans would relate quality improvement to client rights. This is not necessarily a problem with the plans. The state has not given clear guidance on the role of the client rights committees and other rights activities within reform efforts.

Many plans used consumer satisfaction instruments as their quality improvement measure because it was cited by the Division as an outcome measure. While necessary, client satisfaction is not a sufficient measure of quality. This appears to be a case of using what is currently available instead of using state of the art measures of quality. This is an area that should not be defined by each area program. The Division needs to take leadership in developing quality improvement and outcome measures so that these can be compared across programs.

It was generally unclear how all the data generated was going to be used to improve quality. LMEs should be provided with technical assistance as needed in order to develop an interactive quality improvement process that integrates all data collected and uses it in ongoing improvement efforts across the LME and provider network.

New River had perhaps the most detailed QAP, citing not only functions, but responsibilities for each component along with goals for the next three years.

Policy Identification for Best Practice for Each Target
The Local Business Plan describes a policy that adopts state identified best practices for each target population and individual outcome-based goals.

Two programs had no specific comments on this section. Most made general statements about the need to provide best practice services for different populations. One recognized importance of fidelity to models of best practice. Smoky Mtn. identified a general process of how to move current services toward best practice models. Mecklenburg had a very detailed process for identifying best practices, measuring adherence to practice guidelines, reporting exceptions and requesting exemptions from requirements. It should again be noted that the Division’s identification of best practices for all target populations is not yet complete, and many LMEs may be waiting for this document before they begin their specific best practices policy development.

MIS Capabilities, Consumer Status and Outcomes
The local business plan describes management information systems capabilities sufficient to meet State Plan requirements including the ability to effectively track service events, track outcome data related to public funding and generate performance indicators.

One plan did not address this section. One reported they were already meeting requirements. Some programs listed the software package they intended to use for billing and medical records. Most listed the various tools and outcome measures to be used. Piedmont noted that outcomes would be part of provider contracts. Again, we would submit that this should not be an area that each area program defines or there will be no capacity to compare across programs and dimensions. It is clear that there is a greater need for planning and implementation of MIS capabilities. One major task will be linking a distributed provider network system with the LME and to the state.

Use of Performance Indicators in Planning
Performance indicators

One plan did not address this section. Across plans, performance indicators and outcomes were not uniform. Many plans made broad statements (e.g. "will help generate recommendations for corrective actions…") Pathways had the most well developed outline of system of indicators, measures used, and purpose of those measures. But overall, there was so much variability in this section it is impossible to determine any trends. For the most part, some entity was identified with responsibility for reviewing information. But what information was reviewed, by whom, for what purpose was significantly different from LME to LME. There was not a clear use of indicators in a strategic planning process.

It is evident from this review that of models and protocols for "best practice" quality management systems need to be developed. The state should immediately begin work with LMEs and seek national consultants to help develop these models and provide training and technical assistance to ensure quality and consistency of a QM process across the state. This will be one of the primary functions of the LME but one with which many have limited experience beyond the monitoring function. Fortunately, there is considerable national experience in this area and we should seek it. In addition, consumers and families should be involved in the full range of QA/QI activities.