Quality Enhancement Provider Handbook

QUALITY ENHANCEMENT

PROVIDER HANDBOOK

Developed jointly by the

Louisiana

Office of Aging and Adult Services

Office for Citizens with Developmental Disabilities

This document was developed under grant CFDA 93-779 from the U.S. Department of Health and Human Services, Centers for

Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of

Health and Human Services, and you should not assume endorsement by the federal government.

Issued: August 1, 2008

TABLE OF CONTENTS

Introduction 1

Foundations 3

A. Developing Mission, Vision, Values, and Guiding Principles 3

B. Establishing a Quality Council 4

C. Establishing an Organizational Infrastructure to Support Quality 5

D. Identifying Quality Outcomes and Developing Performance Indicators 6

Learning 9

A. Identifying Data 9

B. Collecting Data 11

C. Aggregating and Analyzing Data 11

D. Assessing the Quality of Your Services 13

Responding 14

A. Developing a Quality Enhancement Plan 14

B. Writing Goals, Objectives, Action Plans, and Benchmarks 14

C. Selecting and Prioritizing Quality Enhancement Projects 17

Implementing 18

A. Implementing Your Quality Plan 18

Evaluating 19

A. Evaluating Fidelity of Implementation of Your Plan 19

B. Evaluating Effectiveness of Your Plan 19

C. Reviewing and Updating Your Quality Enhancement Plan 20

D. Reviewing and Updating Your Quality Management Strategy 20

Summary 22

Resources 23

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INTRODUCTION

The Office of Aging and Adult Services (OAAS) and the Office for Citizens with

Developmental Disabilities (OCDD) jointly developed this handbook which describes

promising practices for creating a Quality Management (QM) Strategy for organizations

that support people who are elderly and/or people with disabilities. This handbook

includes the following sections and components:

 Foundations

♦ Developing Mission, Vision, Values, and Guiding Principles

♦ Establishing a Quality Council

♦ Establishing an Organization Infrastructure to Support Quality

♦ Identifying Quality Outcomes and Developing Performance Indicators

 Learning

♦ Identifying Data

♦ Collecting Data

♦ Aggregating and Analyzing Data

♦ Assessing the Quality of Your Services

 Responding

♦ Developing a Quality Enhancement Plan

♦ Writing Goals, Objectives, Action Plans, and Benchmarks

♦ Selecting and Prioritizing Quality Enhancement Projects

 Implementing

♦ Implementing the Quality Enhancement Plan

 Evaluating

♦ Evaluating Fidelity of Implementation of Your Plan

♦ Evaluating Effectiveness of Your Plan

♦ Reviewing and Updating of Your Quality Enhancement Plan

♦ Reviewing and Updating of your Quality Management Strategy

Our intention is to provide guidance to support coordination and service provider

agencies in developing a comprehensive and continuous quality enhancement (QE)

process to improve the quality of services for older adults and individuals with physical

and developmental disabilities. No two organizations are identical; they provide

different services to different populations in different geographic areas and have

different stakeholders and different organizational cultures. Therefore, this handbook

suggests that your organization consider these differences when including outcomes

and performance indicators in your Quality Management Strategy, when deciding on

data collection, and when including goals and objections in your Quality Enhancement

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Plan. Your organization will develop a comprehensive Quality Management Strategy

that reflects its uniqueness.

The handbook will show you how key concepts, such as outcomes/indicators based on

the mission, vision, values, guiding principles and stakeholder input, come together;

how information/data is reviewed and acted upon by various parts of the organization;

and how the quality teams fit into the process to form a continuous quality improvement

system as indicated in the Quality Enhancement Process policies of OAAS and OCDD.

Providers are expected to develop or modify their existing process to engage in quality

enhancement activities that identify and respond to opportunities to improve the

provision of supports and services to people who are elderly and people with

disabilities.

A key component of the Quality Enhancement Process is the flow chart below that

illustrates how information flows within the quality process for an organization.

Provider Quality Information Flow

Quality Indicators

Agency Vision/Mission; Values; Guiding

Principles; Licensing; Federal and State

Regulations/Statutes; QE Goals;

Stakeholder Feedback, etc.

Service Delivery System

Individual and Family Support, Nursing Facilities, Intermediate Care

Facilities for Persons with Developmental Disabilities, Support

Coordination, Waiver Services (New Opportunities Waiver, Supports

Waiver, Children’s Choice, Elderly and Disabled Waiver, Adult Day

health Care Waiver), Long-Term Personal Care Services, etc.

Data Review Teams(s)

QUALITY

COUNCIL

Data

Data Reports

Management

Team

Data and Recommendations

Recommendations

Feedback

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FOUNDATIONS

The first step toward developing your organization’s Quality Management Strategy is

developing or reviewing your organization’s vision and mission. Your organization

should be clear about what it does, how it expects to improve, and the desired

outcomes. Your organization may also develop a statement of values or guiding

principles. Additionally, effective Quality Enhancement Strategies include stakeholder

representation on a Quality Council and establishment of an infrastructure within the

organization which will support your quality enhancement efforts.

Developing Mission, Vision, Values, and Guiding Principles

Your organization’s mission, vision, values, and guiding principles guide your quality

enhancement activities toward outcomes and goals that are important to your

organization and your stakeholders. Periodically, review your vision and mission to

assure that they continue to reflect the goals of your organization and stakeholders.

Mission

A mission statement concisely describes the purpose of the organization. Consider the

following when developing or revisiting your mission statement:

 The nature of your business

 The types of products or services provided

 Your markets / customers

 Your organizational culture

An example of a mission statement follows:

The Office for Citizens with Developmental Disabilities is committed to providing

quality services and supports, information, and opportunities for choice to people

of Louisiana with developmental disabilities and their families.

Vision

A vision statement should be a vibrant and vivid picture of your organization as it

efficiently and effectively carries out its mission. It should be outcome oriented.

Consider the following questions when developing your vision statement:

 What are we trying to accomplish?

 What is the overarching goal we are trying to reach?

 Why do we do what we do?

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To illustrate, the following is the vision statement adopted by OCDD:

Building relationships and supporting choices.

Values and Guiding Principles

Values and guiding principles represent the core priorities of the organizational culture

and reflect the deeply held beliefs of the organization and its stakeholders. Consider

the following questions when you develop a statement of values or guiding principles:

 What drives us as we conduct our business?

 What are the constraints that we want to impose upon our activities?

 What are the opportunities that we want to embrace?

Stakeholders Input

A variety of mechanisms, such as workgroups, focus groups, or surveys, can be used in

developing your mission and vision, values, and guiding principles. Regardless of the

mechanisms used, obtain input from a variety of stakeholders including:

 People who are elderly and people with disabilities and their families

 Your staff

 Your Board of Directors

 Your community

Establishing a Quality Council

Your organization should establish a Quality Council, which is a key component in

establishing your organization’s Quality Management Strategy. The council is an

advisory group whose role is to assist your organization in developing meaningful

outcomes and performance indicators and setting priorities for quality improvement.

Membership

Ideally, the membership of your Quality Council will be composed of stakeholder

representatives. You should strive to include people to whom your organization

provides services, their families, representatives from advocacy organizations, and

community leaders. The exact composition is determined by the population you serve,

advocacy groups that are active in your geographic area, and the interest and

commitment that you can obtain from local leaders in government, business, religious,

and community organizations.

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Size

The size of the Quality Council varies from organization to organization. The council

should be large enough to include a wide variety of stakeholders but small enough to be

a “working group.”

Role of the Quality Council

The Quality Council will help you to better support people who are elderly and people

with disabilities and better serve your community by assisting your organization to:

 Identify quality outcomes and performance indicators,

 Assess performance,

 Prioritize quality enhancement goals and objectives, and

 Evaluate implementation and effectiveness of your quality enhancement plan.

The Quality Council members are “guiders” who will help your organization as you

develop your Quality Management Strategy and quality enhancement initiatives. Other

considerations, such as funding requirements or direction from your Board of Directors,

also will impact these decisions.

Establishing an Organizational Infrastructure to Support Quality

Quality is the responsibility of every section and every employee within an organization.

Executive management’s role is to provide direction and leadership. Supervisory staff’s

role is to oversee the provision of supports and services to assure that the services

meet the organization’s standards and that opportunities for excellence are realized.

Staff that directly provides services or support coordination have one of the most

important roles; they are an organization’s eyes and ears and hands. Without every

employee’s commitment, quality management efforts of an organization may not result

in achievement of the organization’s quality goals.

Although quality is every employee’s responsibility, some of the staff within an

organization has responsibility to facilitate quality management activities and assist all

staff to fulfill their quality responsibilities. An organization’s Quality Unit is comprised of

those staff members who coordinate the quality efforts of an organization. The size of

the Quality Unit varies, depending on the size of the organization. In a small

organization, the “unit” may be one or two persons. In a large organization, there may

be a section devoted to coordinating quality management activities.

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Functions of the Quality Unit

The functions of the Quality Unit may vary slightly from organization to organization.

Typical functions include:

 Assisting in the development of discovery methods which enable an

organization to collect information and data related to the quality of services,

 Working with information technology staff in the development of databases

which support the collection of information and so that data may be

aggregated and analyzed for trends and patterns,

 Analyzing data and writing reports which summarize trends and patterns that

emerge,

 Facilitating the review of quality data by internal and external groups which

provide recommendations to executive management,

 Gathering action plans from staff who have responsibility for implementing

quality enhancement projects,

 Gathering status reports on quality enhancement projects so that the

organization can evaluate implementation,

 Gathering data to evaluate effectiveness of quality enhancement projects,

and

 Providing training, technical assistance, and support to all staff on the

organization’s Quality Management Strategy, quality enhancement projects,

and their responsibilities pertaining to discovery, data entry and management,

remediation, and quality enhancement.

Identifying Quality Outcomes and Developing Performance Indicators

An important function of your Quality Management Strategy is the identification of

quality outcomes and performance indicators. In order to have a broad range of quality

outcomes, utilize the seven (7) focus areas of the Centers for Medicare and Medicaid

Services (CMS) Quality Framework as you identify and organize your quality outcomes.

Your organization will develop a few quality outcomes specific to your organization in

each focus area. This will assure that your measurements of quality, your performance

indicators, cover all areas of long term supports and services program design.

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Focus Areas of the CMS Quality Framework

The CMS Quality Framework’s seven (7) focus areas are:

Participant Access: Are the preferred services of the people that you support

available to them; how quickly can they be obtained?

Participant-Centered Service Planning and Delivery: Do the individualized

support plans of the people that you support reflect their needs and

preferences; are these services delivered?

Provider Capacity and Capabilities: Does your organization have the capacity

and capabilities to meet the needs and preferences of the people you

support; does your agency meet the requirements of all applicable federal

and state regulations?

Participant Safeguards: Are the people you support free from abuse, neglect,

exploitation, and extortion; are potential risks identified and strategies

developed to mitigate risks taking into account the preferences of the person

receiving supports; do the people you support receive needed medications

and health services?

Participant Rights and Responsibilities: Are the people you support informed

of their rights and responsibilities; are they supported to exercise their civil

rights; are all restrictions reviewed and approved by a human rights

committee before implementation?

Participant Outcomes and Satisfaction: How satisfied are people with the

services that your organization provides; are the people that you support

achieving their short-term personal goals and long-term dreams; how do the

people that you support fare on quality of life indicators?

System Performance: How efficient and effective are your services; how well

does your performance align with your vision, mission, values, and guiding

principles; do you keep abreast of proven and promising practices and update

your practices, as appropriate?

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Quality Outcomes and Performance Indicators

Quality outcomes are the results of program operations or activities and may be direct

or indirect, for example, improved health vs. changed attitudes or beliefs. Performance

indicators are designed to measure the extent to which performance objectives are

being achieved on an ongoing basis. One outcome may be that “people have the best

possible health.” Performance indicators to measure how well your organization is

supporting people to have the best possible health might include: number of

emergency room visits, number of major illnesses or accidents, percentage of people

who have a physical exam each year, percentage of people who have breast or colon

cancer screenings, mortality rates, etc.

The following strategies will help your organization to develop quality outcomes and

performance indicators:

 Review your mission, vision, values, and guiding principles,

 Obtain input from your Quality Council, your Board of Directors, your staff,

and other stakeholders,

 Review information about what people want from the services that your

organization provides, such as results from surveys or focus groups,

 Review requirements that you must follow, such as licensing regulations and

funding requirements,

 Determine the quality outcomes that you and your stakeholders would like to

see for the people that your agency supports and for your agency as a whole,

 Review the seven (7) focus areas to see if you have identified quality

outcomes in each area. (Add additional quality outcomes to broaden the

scope of your Quality Management Strategy, if necessary.), and

 For each quality outcome, determine what your performance indicators will

be; that is how you will measure how well you are doing.

Once you have identified your quality outcomes and performance indicators and

established an organizational infrastructure to support quality, you are ready to develop

processes to systematically learn about the quality of your services.

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LEARNING

Most organizations collect various types of information and data. However, many

organizations do not use this information and data to learn about the quality of their

services or to drive their quality enhancement efforts. Learning is the first stage of a

quality system; it is the jumping off point to enhancing quality. Without comprehensive

information, you can only use your assumptions about your services for decision-

making by all levels within your organization. Information can help you build a plan and

focus resources on the things that need attention. This makes your efforts more

efficient and effective. After you have developed your quality outcomes and

performance indicators for each outcome, identify data sources for the performance

indicators, either existing data sources or potential data sources. You must then have

or develop ongoing processes to collect the data, aggregate and analyze the data, and

use the analyses to assess the quality of your services.

Identifying Data

Identifying data is a two step process: 1) identifying existing data, and 2) identifying

data that are needed.

Identify Existing Data

Organizations may vary on the information and data they have available. Some typical

types of existing information include:

 Satisfaction Surveys: This may include both customer and staff satisfaction.

 Results of Regulatory Reviews: This may include licensing results or any

other external monitoring that was conducted.

 Incident Reports: This includes all incidents that are required to be reported

both internally and externally, including abuse or neglect reports.

 Complaint Reports: This includes all complaints made about your services

and their resolution.

 Internal Reviews: This may include any assessment completed by your

organization to determine how well your organization is adhering to internal

policies or external regulations, e.g., chart reviews, timeline adherence,

turnover information, etc.

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To gather and organize this information:

 Meet with your staff members to determine what data they have,

 Make a list of all the data that your staff identifies, and

 Review the data and determine:

♦ What is it telling you,

♦ Is it useful to determine the quality of your services,

♦ How often is it collected,

♦ Who collects the data and who submits it,

♦ Where does it go,

♦ Is the data aggregated, and

♦ Is the data analyzed to determine patterns and trends?

Identify Needed Data

Your organization’s performance indicators, administrative and management data

needs, and policies and procedures will influence the information you need to collect.

State program offices or licensing standards may also determine what you collect within

your organization.

In the preceding step, you identified what data you currently collect. Next you will:

 Make a list of what information and data you need,

 Compare the list of needed data with the list of currently collected data, and

 Determine what data is missing – where there are gaps.

Once you have identified the additional data that needs to be collected, you need to

decide:

 How will this information be collected,

 How will this information be put into a database or alternative format that

supports analysis, and

 How will the data be used?

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Other considerations as you develop data sources include:

 Reliability: Is your measure reliable; does it measure something consistently?

 Validity: Is your measure valid; does it measure what it is supposed to

measure?

 Sampling: Is your sample size large enough to generalize your results within

a desired confidence level, and is your sample representative of the

population that your want to measure?

When you have accomplished the steps described above, you should have a

comprehensive list of all the data that is needed and collected.

Collecting Data

Now that you have identified the data you currently collect, identified the data you need,

and determined how you will collect additional data to fill the gaps, you have the

beginnings of a data management system.

You will need to frequently review the information and data that you are collecting and

determine if there is a need for:

 Any changes in the frequency of collection,

 Any changes in how you collect the data,

 Any changes in what data is to be collected, and

 Any revisions to your data sources.

Aggregating and Analyzing Data

The usefulness of information and data is realized when it is aggregated and analyzed

for trends and patterns.

Aggregating Data

 What do we mean when we say aggregate data?

The definition of “aggregate” is to gather together in a mass constituting a

whole.

 Why aggregate data?

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By aggregating data, you can more easily identify areas that are not

distinctive but more generally affect the quality of your services. When you

look at individual data (e.g., one critical incident report for a person), you

respond to the immediate safety needs and initiate strategies to reduce the

chance of a similar incident occurring in the future for that person. However,

if several similar types of critical incidents are occurring for several of the

people you support, you will need to take a more comprehensive approach,

such as developing staff training programs or changing policies and

procedures to prevent these types of critical incidents from reoccurring.

Analyzing Data

 What is data analysis?

Data analysis means to process information or data that has been collected in

order to draw conclusions. It involves systematically applying logical or

statistical techniques to describe, summarize, and compare data using

narratives, charts, graphs, or tables. Analyses often involve looking for trends

and patterns.

 What do we mean when we say we are looking for trends and patterns in the

data?

Trending means examining data over time to identify general drift or

tendencies for increases or decreases in the data. For example, have

mortality rates been decreasing or increasing over the past several years?

When we look for patterns, we are looking for relationships. For example, are

people reporting less satisfaction with availability of medical services in the

rural areas that you serve as compared to the urban areas? Are there

differences in satisfaction with your services depending upon which staff

members people interact with?

Another important factor to consider as you are analyzing your data for

patterns is convergence of data, that is, looking for common themes among

different data sources. For example, if survey data show that people are not

satisfied with your services, what does the data on staff turnover, attendance,

staff training, and complaints look like?

A process that may be used to help you identify underlying factors that have

contributed to or have directly caused a major adverse event or systems

failure is called Root Cause Analysis (RCA). A detailed description of

everything that happened before, during and immediately after the adverse

event occurred forms the initial stages of the RCA. Flowcharts may be used

to provide visual illustrations of the interrelationships between the activities of

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the various organizational units that may have had any involvement with the

incident under study. This is followed by brainstorming to identify factors that

may have influenced or contributed to the incident and a rigorous process of

classifying and prioritizing these factors to identify the true root cause.

Additional time is then spent identifying possible solutions, resulting in the

selection of those solutions that appear to be the most effective and cost

efficient.

Assessing the Quality of Your Services

After you have analyzed your data, identify those things that you do well and those

areas that need improvement. List these and compare the lists to determine if there are

conflicts between the lists. If there is a conflict, continue drilling down to figure out why.

The reason may be due to:

 The way data is collected or reported,

 The reliability or validity of one or more of the measures, or

 The sample selection methodology for one or more of the measures.

If any of the above reasons is affecting your results, review your processes for gathering

data and the types of data being collected and possibly make adjustments.

Now, examine the list of the areas needing improvement. Prioritize these according to:

 Mission and vision of your organization,

 Safety and well being of the people in services, and

 Expectations and desires of your stakeholders.

As you are prioritizing, also consider:

 Availability of resources to improve performance in each area,

 Time it will take to realize improved performance, and

 Benefits derived to your organization and to the people that you support.

Once the prioritization is completed, you can decide which areas you will address in

your Quality Enhancement Plan.

Steven D. Staugaitis, Ph.D.,”Root Cause Analysis,” March 2002, pp. 3-6.

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RESPONDING

In the preceding section, you learned about your current data system and you prioritized

opportunities for improvement. Now it is time to design your Quality Enhancement Plan.

Developing a Quality Enhancement Plan

The Quality Enhancement Plan is a valuable tool that:

 Provides a systematic, organized way to focus efforts on improvement of

processes,

 Specifies desired outcomes, both on the participant level and the

organizational level,

 Assists staff in identifying and concentrating on actions needed for

improvement, and

 Provides a mechanism to communicate service delivery expectations.

As you develop your Quality Enhancement Plan, you will need to answer the following

questions:

 Where are we now?

 Where do we want to be?

 How are we going to get there?

 When will we get there?

Writing Goals, Objectives, Action Plans, and Benchmarks

Components

Your Quality Enhancement Plan should include the following components:

 Goals

 Objectives

 Activities / Action Plans

 Benchmarks

Goals

Goals are related to the mission and vision statements and are based on the services

that the organization provides. They are written in broad, general terms and project an

“ideal.” Goals are not specific or measurable. For example, “Our waiver participants

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will be healthy.” Goals are not the continuation of what already exists, but rather

express what the organization hopes to bring about through its quality enhancement

activities.

Objectives

Objectives are the stepping stones that assist you in realizing your goals. They are the

“how to” of goal achievement. They are the realistic targets for the organization.

Objectives are written in an active tense and use robust verbs such as “plan,” “write,”

“conduct,” “produce,” as opposed to “learn,” “understand,” “feel.” They will always

answer the following question: Who is going to do what, when, why, and to what

standard? For example, an objective for the goal above might be: By June 2009, our

organization will have a 10% reduction in the number of hospitalizations for preventable

conditions.

One tool that can be very helpful in writing objectives is the SMART Objectives

acronym. This acronym encompasses five important elements to develop sound, valid,

and meaningful objectives.

1. Specific – What exactly are we going to do and for whom?

The program states a specific outcome, or a precise objective to be

accomplished. The outcome is stated in numbers, percentages, frequency,

reach, scientific outcome, etc. The objective is clearly defined.

2. Measurable – Is it measurable and can we measure it?

The objective can be measured and the measurement source is identified. If

the objective cannot be measured, the question of the cost of non-

measurable activities must be addressed and considered relative to the size

of the investment. All activities should be measurable at some level.

3. Achievable – Can we get it done in the proposed timeframe and in view of

political, financial, and organizational constraints?

The objective or expectation of what will be accomplished must be realistic

given the organizational capacity, time period, resources allocated, etc.

4. Relevant – Will this objective lead to the desired results?

The outcome or results of the objective directly supports the outcomes of the

organization’s long range plans or goals.

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5. Time-framed – When will we accomplish this objective?

The target date for achieving the objective must be clearly stated. This will

give you the capability to organize your quality activities and efforts around

process improvement.

Activities / Action Plans

After you have identified your objectives to achieve your goals, identify one or more

activities (and action plans for each activity) to address each objective. These activities

and action plans will:

 Tell how the objective will be achieved,

 Be specific and detailed,

 List exactly what needs to be done,

 Include target completion dates, and

 Identify the person(s) responsible to implement each action step listed.

Activities and action plans explain exactly how you are going to achieve your objective.

For example, to reduce hospitalizations for psychiatric stabilization, you might have

several activities – developing protocols, training staff, developing tracking mechanisms,

etc. The action plans for each activity will identify who does what and in what

sequence.

Benchmarks

As you write your plan, you will include benchmarks to enable you to compare progress

toward achieving your benchmark (where you want to be) as compared to a baseline

(where you are now). Benchmarks will be utilized to evaluate the effectiveness of your

actions. This evaluation of the achievement of your objectives is critical to the success

of your Quality Enhancement Plan. How else will you know that your activities and

action plans have produced the desired result?

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Selecting and Prioritizing Quality Enhancement Projects

Tips for selecting quality enhancement projects include:

 Obtain ideas from your staff and stakeholders on potential quality

enhancement projects that could impact your organization’s performance in

areas prioritized for improvement.

 As you evaluate potential quality enhancement projects, take into

consideration consistency with your organization’s mission and vision and

with the expectations and desires of your stakeholders.

 As decisions are made about projects under consideration for inclusion in

your Quality Enhancement Plan, also take into account: 1) the anticipated

impact of each project under consideration on the quality of life of people

receiving services and the quality of care provided by your organization and

2) the resources and amount of time needed for implementation.

 Recognize that improvements in administrative processes show quicker

returns than improvements in the more “clinical” supports and services.

 Beware of superficial change such as training programs with low content or

new forms to document the same old process.

 Know that quality enhancement objectives that concentrate on improving a

process using a demonstrated technique may be more effective and efficient

than designing a new process using an unproven technique.

 Ensure that the improvement fits into the existing workflow and is a realistic

strategy.

Your Quality Enhancement Plan will provide a process to systematically identify

opportunities for improvement and to resolve problems. It will also provide means to

detect small or developing problems and fix them before they get out-of-hand and to

detect potential problems and institute actions to prevent them from occurring at all. In

the next section, you will learn how to implement your Quality Enhancement Plan.

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IMPLEMENTING

A plan is just a piece of paper unless the activities and action steps on the plan are

actually implemented. An integral part of your Quality Management Strategy is

evaluating implementation fidelity (i.e., are you doing what your plan said you would

do?) and plan effectiveness (i.e., are you achieving your desired results?).

Implementing Your Quality Enhancement Plan

As you begin the implementation phase, the strategic planning for quality enhancement

has been completed – quality has been defined by all stakeholders, outcomes have

been prioritized, and performance indicators have been selected. The data collection

process has been organized. Goals, objectives, activities and action steps, and

benchmarks for quality enhancement have been developed.

Purposes

Implementation of a quality enhancement initiative has two purposes.

 The first purpose is to improve current or create new processes which will

result in improved performance on quality outcomes.

 The second purpose, which is equally important, is to begin and maintain a

culture of quality improvement in your organization.

Thus, each quality enhancement activity is also a demonstration project to show that

quality enhancement works, how quality enhancement works, why quality enhancement

works, and what benefits may be achieved through quality enhancement activities.

Costs and Benefits

An organization’s management should be aware that implementation of a quality

improvement initiative may take several thousand dollars of training resources,

employee time, and other capital investments. However, the return on investment for

quality activities has been shown repeatedly to be four to five times the value of the

investment. The improvement usually takes months to years to demonstrate the cost

savings; the overall change in organizational culture is often a ten (10) year project. So,

be patient in reaping the benefits of your efforts to create and maintain a quality

enhancement process.

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QUALITY ENHANCEMENT EVALUATING

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EVALUATING

Evaluating involves monitoring the implementation of the Quality Enhancement Plan

and determining the effectiveness of the Quality Enhancement Plan.

Evaluating Fidelity of Implementation of Your Plan

“Evaluating fidelity of implementation” of your plan is just a fancy way of saying “are you

doing what you said you would do?” Are the activities and actions occurring as

specified in your Quality Enhancement Plan? Are you meeting your timelines? Are you

collecting data so that you can measure your progress toward meeting the goals and

objectives that you have established?

For each quality enhancement activity, the person identified on the plan as being

responsible for overseeing implementation will be required to periodically provide a

status report on implementation of the various action steps. A rollup of the status

reports for all current activities will be provided to management and communicated to all

stakeholders so that they may be kept abreast of the implementation status of the

various quality enhancement activities designed to improve performance for the goals

and objectives within your Quality Enhancement Plan.

Evaluating Effectiveness of Your Plan

Monitoring is used to answer the question "how are we doing?" specifically "are we

doing better since implementing the improvement?" Bar charts, graphs, or other

statistical processes are used to analyze data collected to monitor the quality

enhancement intervention. Satisfaction surveys are usually analyzed using

percentages, but "stories" and narrative comments are also valuable data. You will

evaluate progress toward achieving the goals and objectives in your Quality

Enhancement Plan and overall improvement in your performance indicators.

Organizations will use the data management process to evaluate progress toward

achieving objectives. Achieving objectives will lead to goal attainment, which in turn will

result in increased quality of service delivery. As well, feedback from people in

services, their families and other stakeholders will be needed to assure that the plan is

effective and that it is enhancing service delivery.

If your evaluation shows that the activities and action steps within your Quality

Enhancement Plan are not feasible or that they are not achieving the result that you

expected, you will need to revise your Quality Enhancement Plan. You may find that

your Quality Management Strategy needs to be modified to include new discovery

methods, data collection and analysis processes, remediation mechanisms, or quality

enhancement design changes. Therefore, the next section explores reviewing and

updating your Quality Enhancement Plan and Quality Management Strategy.

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QUALITY ENHANCEMENT EVALUATING

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Reviewing and Updating Your Quality Enhancement Plan

To be effective in today’s environment, the quality strategies of organizations must be

dynamic. Quality enhancement goals and objectives and quality management

strategies must be continuously reviewed and updated. Data on your performance

indicators must be continuously reviewed and updated. How often data is analyzed and

reviewed will depend upon many factors. Licensing data is generally available annually

but data from an internal review of performance on licensing standards may be

available quarterly. Critical incident data may be reviewed monthly. Review of

infrequent events, such as deaths, may occur immediately after the event has occurred.

As you review the reports of trends and patterns, you are looking for potential areas to

initiate quality enhancement goals and objectives.

Your Quality Enhancement Plan will not an “annual” plan; it will be a plan that is

continuously updated to include new quality enhancement projects as needs or

opportunities arise. Each quality enhancement activity will remain in your plan for as

long as it takes to implement the activity and to assure the effectiveness of the activity in

improving performance; this may be for several months or it may be for several years.

Details of the plan (e.g., specific action plans, target dates, etc.) will be altered if

needed. Projects that prove to be ineffective will be reconsidered. New goals,

objectives, and activities will be added, as appropriate.

Reviewing and Updating Your Quality Management Strategy

At least annually, you will evaluate your Quality Management Strategy. This evaluation

includes, but is not limited to, the following questions:

 Do we need to revisit our Outcomes and Performance Indicators?

 Is our Quality Council working for us? Do we need to modify its functions,

change membership, or alter frequency of meetings?

 Is our quality infrastructure within our organization effective? Do we need

make any changes to better support staff in their various responsibilities

related to the provision of quality services to the elderly and people with

disabilities?

 Are our discovery methods effective in providing us with the information we

need to manage our organization and provide quality services?

 Do our information technology systems meet our needs or do we need to

update our systems?

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QUALITY ENHANCEMENT EVALUATING

PROVIDER HANDBOOK

 Do we need to make any changes in the data reporting, analysis, and review

processes?

 Are our remediation and quality enhancement processes effective? Do we

need to change anything?

These reviews and revisions of your Quality Enhancement Plan and Quality

Management Strategy will enable your quality efforts to evolve over time so that your

organization will be prepared to meet new challenges and opportunities as they arise.

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QUALITY ENHANCEMENT SUMMARY

PROVIDER HANDBOOK

SUMMARY

This handbook describes how to develop and update your Quality Management

Strategy and Quality Enhancement Plan.

 The outcomes and performance indicators that your organization develops

will depend upon: the vision, mission, values, and guiding principles of your

organization; input received from your stakeholders; and emergence of new

proven and promising practices in your field.

 The specific discovery methods or information technology systems you use

will be different from organization to organization and will certainly change

over time within an organization; and sometimes, external factors, such as

licensing regulations or funding requirements, may impact what data you

collect and how often you collect the data.

 Finally, the goals, objectives, or activities you include in your Quality

Enhancement Plan will be based upon your analysis of your performance

data, that is, your perceived needs and opportunities for improvement.

This handbook was developed to provide you with guidance so that your quality efforts

will prove effective in helping your organization to efficiently provide people who are

elderly and people with disabilities with quality supports and services which enable them

to achieve their personal outcomes and goals.

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QUALITY ENHANCEMENT RESOURCES

PROVIDER HANDBOOK

RESOURCES

http://www.hsri.org/docs/QF_RootCauseAnalysis.doc

Written by Steven Staugaitis, the guide provides an overview of root cause

analysis adapted to address some of the unique issues and concerns found

in support systems that assist individuals with cognitive and other

developmental disabilities.

http://www.hsri.org/docs/QF_sampleguide.pdf

This is a user-friendly, step-by-step approach to explaining sampling,

identifying alternatives among different sampling techniques, and

understanding how to use these techniques for specific purposes in a quality

management strategy.

http://www.cms.hhs.gov/HCBS/downloads/7_workbook.pdf

Improving the Quality of Home and Community Based Services and Supports

is a workbook created by the Muskie School of Public Service to help state

waiver managers assess and improve quality management processes.

http://nps718.dhs.vic.gov.au/ds/disabilitysite.nsf/sectionthree/support_provider_quality#

check

This is a link is to an Australian organization that has developed QM tools

and concepts expressly for disability providers. It contains a few self-

assessment charts.

http://www.hcbs.org/moreInfo.php/nb/doc/1239/Quality_Management_in_the_Quality_C

ycle

Wisconsin’s Quality Management Cycle - an educational piece that could be

used to train staff and the pubic generally about quality management terms

and principles.

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When printing copies,

insert cost of printing

statement here.

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