Home Care Quality Management Program Orientation to Quality - - PowerPoint PPT Presentation
Home Care Quality Management Program Orientation to Quality Management Program requirements and a presentation of the process New survey process discussion A lot of group participation and small group exercises "Golden
Home Care Quality Management Program
requirements and a presentation of the process
exercises
(plan, do, study and act) of a Quality Management Program (QMP)
successfully use a QMP
in to day to day operations with relative ease
establish a quality management program"...
to the size and type of agency.
evaluate the quality of consumer care and safety.
Chapte ter r II - Quality ty Management nt Program Require remen ents ts
potential problems Zero Deficiencies!
A process of monitoring performance to ensure excellence and detect areas of deficiency. The process (as we describe it) consists of planning, doing, studying and acting.
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
Step 1: identify areas for improvement
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
Proactive & Responsive Tasks and Process Review
Routine tasks that, when carried out
appropriately, serve to identify potential problems and prevent them from occurring.
and staff
The evaluation and response to an
unexpected outcome, in order to identify problems that were not prevented through proactive activities.
Each agency has numerous processes in place to keep the agency running. Proactively evaluate how well they work.
Assessment of the System for Prevention of Missed Visits
What proactive activities may be reviewed to determine the effectiveness
Step 2: gather and assess data
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
determining the depth of the problem
need to gather it?
Include everyone to some degree Don't over think the process Avoid burdensome tracking mechanisms Be creative about how you gather your data
The collection of data, from numerous sources and over a period
Visit Note Submission
week of 9/2/13 week of 9/9/13 week of 9/16/13 On Time 26 29 31 Late 14 11 9
Informative data may be drawn from many existing processes
Supervisory visits
positive/negative
The process of looking at tracked data to identify patterns that show the depth of the problem
Is the problem isolated or widespread?
1 2 3 A B C
Tallies, Charts, ts, Graph phs, Check cklis ists Take ke Credit and Validate Conclu lusions
Review of consumer complaints shows quality of CNA care is a repeated subject.
What data may be tracked and what resulting trends might illustrate the cause of the problem?
Tracking Trends
A Real Life Scenario
As a result, employee termination was the only response No action to assure client safety throughout agency No investigation of employee practices Assumed to be an isolated event
Step 3: analyze the cause
What are the causes of this problem?
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
The action you take must address the root of the problem and related factors, otherwise the problem will likely reoccur.
Is the cause:
compliance;
When determining cause, consider:
input;
The more varied the data, the more thorough the analysis
Supervisory visits are being missed or are late. Based
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
Planning: In Review
Step 4: implement the action
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
Prioritize Address the Cause Set Goals and Thresholds for Success
Inspectors will evaluate to ensure actions are prioritized based on potential for outcome to consumers
Can't emphasize enough... If you don't make changes to address the cause, you're just spinning your wheels.
Goals should be clear and communicate exactly what is expected
What: What do we want to accomplish? Why: What are the benefits to accomplishing this goal? Who: Who is involved? "The agency will decrease the incidence of late visit note submissions – and improve timely quality assurance as result - through process improvement, staff reeducation and reinforcement by leadership"
Develop concrete criteria for measuring progress toward meeting your goal A measurable goal answers:
accomplished? "Within the first 2 weeks of implementation, 80% of visit notes will be submitted within the required timeframe. After 2 months, visit notes will be submitted in a timely manner 95% of the time."
Goals must be realistic and attainable. Push the team to meet the goal but do not overwhelm.
Are the benchmarks realistic and take into account a learning and adjustment period?
Relevant goals drive the agency forward. A relevant goal answers:
change?
needs?
Giving a goal a timeframe for completion helps focus efforts and instills a sense of urgency A time-specific goal answers:
months, 6 weeks, today?
Analysis shows the cause of late supervisory visits is that the scheduler failed to inform field supervisors when consumers were due for a visit. What are some possible actions to address the cause?
quickly
your problem in your quality management activities.
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
Do: In Review
Prioritize, Set Goals and Address the Cause
Step 5: monitor results
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
Continue to collect and analyze data
trending
goals
implemented
frequency in QMP documentation
Data collected following an action shows the changes you've made aren't fixing the problem. What are some common reasons changes are ineffective?
you are implementing the action
identify areas for improvement data analyze the cause
Do
implement the action
Plan
Study Act
monitor results standardize improvements maintain change
Go back to analyzing the cause and implement a new plan
Step 6: standardize improvements
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
achieve buy in!
routine
processes
in the action
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
Step 7: maintain change
improvement over a period of time
business
upholding standards of care
identify areas for improvement gather and assess data analyze the cause Do implement the action Plan Study Act monitor results standardize improvements maintain change
disclosure notice, and background check reconciliation
management program as a focus area (includes data from many sources, including complaints and incidents)
quality management program
quality management program
suspected
are sufficient to reduce the likelihood of a reoccurrence
components described in Chapter II General Licensing Rules, section 3.1
reviewed and approved by your Governing Body
steps in place to address concerns and assure quality