HOW WILL QUALITY OF SERVICES BE ASSURED

HOW WILL QUALITY OF SERVICES BE ASSURED?

To ensure quality of services you need:

To identify and define what quality means and how you will measure and evaluate quality
A system to provide oversight and monitoring (Quality Assurance)
A system to identify problems and be able to take actions to improve quality (Quality Management and Quality Improvement)

Defining Quality: Quality Domains, Indicators, and Outcomes

Report Cards

Periodic report cards will be issued for the MH/DD/SA System. These reports of system quality will consist of an easy to understand evaluation format (such as letter grades) for a range of performance and consumer outcome measures. System quality domains and sample indicators for a report card are below.

System Quality Domains and Sample Report Card Indicators

Domains	Sample Indicators
Access	Penetration rate (percent of eligible consumers who access service) Timeliness of receipt of service Adequacy of provider network (capacity)
Quality of Care	Engagement/retention in treatment Continuity of care and care-givers Completion of consumer-driven, clinically appropriate and evidence-based service plans Consumer/family education
Administrative Processes	Collaboration in planning, including consumers, families, and agencies Effectiveness of system QI processes and activities Training, competency, service standards, best practices
Consumer Outcomes	Core Indicators Project Client Outcomes Inventory

Quality Assurance

The state plan identifies Quality Assurance activities to address the following functions:

1. Provide consumer protection, an early-warning system for harm-avoidance. Policies and procedures must be developed and implemented to assure that:

Consumers are free from physical and chemical restraints, except in instances when the use of such interventions are therapeutically indicated, and explicitly authorized and implemented in accordance with state law, rules, and policies;
Consumers are protected from abuse, neglect and exploitation, and procedures are in place to detect, report, and investigate related cases thoroughly and take prompt and effective remedial actions where indicated;
Serious incidents are promptly and effectively reported, tracked and appropriate follow-up actions are taken to rectify individual misconduct and/or systemic shortcomings that are identified as a result of such investigations;
All deaths within publicly operated, licensed, or certified programs and facilities are thoroughly investigated and fully reported according to law, and prompt steps are taken to rectify any underlying factors contributing to the death; and
Prompt actions are taken to protect the safety and health of program participants in the case of natural disaster or when other unforeseen crises occur.

2. Individual service planning. LMEs and service providers must have the capacity to develop comprehensive, individualized, person-centered plans for treatment, service, and/or support and must assure that all prescribed services and supports are delivered in a timely, effective manner, in accordance with the terms of each individual’s service plan. Quality needs to be built in at the front end of the service system via top-notch service planning. For this reason, the service system must have the capacity to:

Complete comprehensive assessments of the service/support needs of participants, including the capability to perform or acquire any medical, psychological and/or social evaluations that might shed light on an individual’s service/support needs; and
Assist individuals, with the help of family members and significant others, to prepare person-centered plans that take into account their capabilities, interests, aspirations, and treatment and person support needs. Local/area-wide service systems also must have in place systematic methods of reviewing the quality, appropriateness and comprehensiveness of individual service plans and a process for initiating plan revisions based on the results of such reviews.

3. Safeguard consumer’s rights. The Department of Health and Human Services, LMEs, and service providers must have the capacity to protect the rights of all individuals applying for or enrolled in publicly funded MH/DD/SA services. All components of the service system have a fundamental obligation to ensure that the individual rights of program participants are respected and observed. In carrying out its responsibilities in this area, the service system must:

Afford individuals and their families clear channels for filing complaints and having their grievances considered by responsible officials at succeeding levels of the service system, with the aim of achieving resolutions satisfactory to all;
Assure that due process rights of individuals and families (including legal guardians) under federal, state, and local laws and regulations are fully protected;
Assure that individuals are afforded the opportunity to choose among available community service and support providers who meet established qualifications; and
Establish human rights functions within designated types of provider agencies to oversee related activities and reconcile potential ethical/moral conflicts that sometimes arise in applying individual rights to particular situations. The rights protection mechanisms employed within the service system (e.g., confidential telephone hot lines, ombudsperson, certified mediators; etc.) should be consumer-friendly.

4. Qualified provider oversight. The Department and LMEs must have the capacity to ensure that providers of services and supports meet the qualifications and other operating standards/requirements established by the state. As the state moves toward direct enrollment, the ability of providers to directly bill the state instead of going through area programs for payment, this oversight becomes even more critical. State and local government have an obligation to ensure that each service provider operates in compliance with applicable state standards and/or requirements. Among the activities that the state must have in place to ensure ongoing compliance are effective methods of:

Verifying the qualifications of service/support providers;
Assuring that all pre-service and in-service training and continuing education requirements are met;
Conducting periodic licensure and certification reviews as well as analyzing and reporting the results;
Overseeing the implementation of correction plans, the imposition of sanctions such as fines or penalties, and termination as well as other follow-up actions resulting from provider oversight reviews; and
Arranging technical assistance to help providers rectify deficiencies and formulate and carry out service improvement plans. In addition, the State must have the capacity to review and enforce performance provisions contained in contractual agreements (e.g., achieving specified levels of consumer satisfaction, or holding administrative costs below a certain percentage of total expenses.)

The state plan proposes that the Division of Facility Services serve as the regulatory agent for the state oversight of licensed MH/DD/SA services. As the regulatory agent, DFS will be responsible for conducting annual or biennial inspections of facilities or services. Results of these inspections shall be published and used as quality indicators for performance.

The local managing entity shall be responsible for conducting local monitoring of providers within the network. This local monitoring shall focus on the quality of clinical and programmatic delivery and should not be a "licensure" inspection. Providers who have received national recognized accreditation shall participate with the local monitoring activities but will not be subject to annual DFS inspections unless local monitoring prompts complaints or need of onsite investigations.

Professional licensure for professional practitioners shall be utilized as indicators of qualifications of service. Providers of non-facility based services shall be subject to licensure in the future.

Direct enrollment requirements shall be directly linked with licensure and also performance of quality indicators. Ability to meet outcomes will be standards to measure effectiveness and eventually payment of services. This shift has many implications and should be the one of final steps of implementation. As an interim step, reports of provider performance will be published and will be an integral part of education clients and families in their selection of providers as well as a factor used in examination of provider rates.

Memorandum of Agreements will be required for direct enrolled providers who provide services to target populations. These MOAs will be standardized and established by a participatory process including state staff, LME staff, providers and consumer/family representatives. Direct enrolled providers who are not providers of services to target populations but do deliver services within a specific area will be encouraged to also have formal linkages to the LME.

5. On-site monitoring of outcomes. The Department and LMEs must have the capacity to monitor the performance of the service delivery system. In addition to overseeing the compliance of provider agencies and individual practitioners with state-established standards and other requirements, the State must have methods of independently verifying that enrolled individuals/families are being appropriately served. Instead of focusing on the prerequisites of effective services (inputs), as traditional licensure certification surveys have, these reviews should concentrate on the benefits derived by consumers and families (outcomes). The types of monitoring activities that fit into this category include:

Consumer and Family Advisory Committees will obtain input from consumers and families

Assessments of the effectiveness of local/area-wide services coordination/case management systems in terms of the availability and quality of such services, as well as the effectiveness with which case managers or service coordinators perform their various individual guidance/systemic advocacy and administrative support roles;
The completion of consumer-centered quality reviews (i.e., on-site monitoring of program participant – usually applying a sampling methodology – in order to reach generalizations about agency/system-wide performance); and
Independent, third party monitoring by peer review and stakeholder teams (i.e., parents, self-advocates, and neighbors) to assess the quality of life of program participants.

6. Financial integrity. The Department and LMEs must have the capacity to ensure that public funds are disbursed and managed in an accountable manner. The State has an obligation to ensure that tax dollars are used effectively, efficiently and in accordance with the requirements of law. This means that the State’s quality management system must include methods of assuring that:

Payment claims are submitted timely and verified for accuracy and completeness;
Annual audits are conducted of the financial accounts of all service agencies/organizations in accordance with accepted auditing standards and practices, and any questionable transactions are identified and resolved; and
The personal accounts of individuals participating in publicly financed programs are secured and audited on a regular basis to prevent any fraudulent transactions. In addition, the State must maintain an active program of fraud prevention and detection that includes the capacity to investigate alleged incidents of misappropriation of funds and the imposition of penalties to punish transgressors and prevent re-occurrences.

7. Healthcare coordination. LMEs and other service providers must collaborate with local health care providers to address the health status of individuals who receive publicly funded long-term MH/DD/SA services/supports, and to facilitate access of these individuals to appropriate, high quality health, mental health, and substance abuse prevention and treatment services. The system needs to have methods in place to:

Ensure coordination with primary care and other healthcare providers;
Assess and address co-occurring mental health or substance abuse problems; and
Monitor the therapeutic effectiveness of prescription medications (including, in particular, psycho-active and anti-convulsive medications). Prescription medications should not be used in the absence of specific psychiatric diagnosis and a properly designed treatment plan.

8. Consumer satisfaction and outcome monitoring. LMEs, providers, and State facilities must have the capacity to obtain structured feedback from individuals and families, as well as comparative data on system-wide performance (both longitudinally and across jurisdictions) in areas deemed critical to achieving overriding systemic goals. Among the basic components of a consumer-oriented assessment system are:

Individual and family satisfaction measures;
Indicators of comparative performance in key outcomes areas (e.g., employment, integrated community living, etc.); and
Quality of life measures. Typically, data are gathered from a random sample of service recipients using statistically valid and reliable data collection instruments. Consumers and family members should be involved in the design and implementation of the assessment system and should have full access to the resulting information and data, consistent with privacy safeguards.

Quality Management and Improvement

The quality management means using information and data to identify problems and concerns and have a system in place to use the information to continuously improve the quality of treatments, services, and supports provided to consumers. Components of this system include:

Utilization review activities at institutions as well as LMEs;
Utilization management on all services provided with public system funding using standardized review criteria;
Quality assurance, including licensure, credentialing, program monitoring, and financial audits;
Quality improvement activities conducted across system entities.

This system will have a Division level Quality Improvement Committee (DQIC), which serves as the overarching QI entity for the system, oversees and approves quality improvement activities and results generated by the Division, Local Quality Improvement Committees (LQIC), and other components within the system. In addition, there is also a local quality improvement committee for each of the LMEs in the State.

Network providers will be required to develop and implement quality improvement activities. These activities are subject to periodic review by the LME responsible for that network. Problems in service/support delivery and other opportunities for improvement are acted upon by local entities, and quality issues that effect other system provider entities are brought to the attention of the Local Quality Improvement Committee for review and action.

Staff Competencies, Education and Training

A competency-based system for qualified providers of services has been developed to achieve measurable outcomes and raise the level of quality and consistency statewide. Recognition is given to already existing licensing and certification boards. The following are the seven core competencies that are required to meet minimal standards;

Technical knowledge
Cultural awareness
Analytical skills
Decision-making
Interpersonal skill
Communication skills
Clinical skills