Monitoring the Effectiveness of the QM Plan The Quality Management Plan is reviewed and updated annually. New or modified targets and outcomes for each year are established by the Executive Council and/or Quality Management Committee, based on State contracts and local goals and objectives. All available input from consumers and the public, as well as employees and pay sources, is incorporated into the Plan. Quality Management staff ensure the completeness and relevancy of the QM Plan through ongoing reviews of changes to standards, laws, Rules, regulations, licensing and/or accrediting requirements, to determine if a revision to the QM Plan is needed. The ACCESS Board of Trustees, Executive Director, and the Quality Management Committee approve the plan annually, or at each revision. The Quality Management Plan is posted on the “public” drive on the center’s computer network, which is available to all employees. The Plan is also posted on the ACCESS website. Key Quality Indicators, FY2018 Indicator Method Frequency Target Targets and measures from State Performance Contracts Reports from CARE, MBOW, local data Quarterly or as indicated Meet standards Protocols for Medicaid reimbursement In-house audits Monthly 95% Data accuracy Audits Variable 95% Direct service/billing time (service delivery & access to services measure) In-house report from local database Semi-Annual ,or more often >50% Staff Mandatory On-line Training Record of completion Annual 100% Staff Training for On-call In-house test over information needed to perform on-call/crisis duties Prior to duties assigned Passing score on on-call test Staff Training for CANS/ANSA Completion of on-line training Prior to duties assigned Passing score on CANS/ANSA test Complaints; Allegations of Abuse and Neglect In-house investigations and reporting to state agencies Per occurrence Within designated time frame TRR implementation (service delivery measure) Reports from MBOW; QM/UM oversight & audits; fidelity reviews of Evidence Based Practices Variable Meet standards Texas Resiliency & Recovery (TRR) Activities HHSC CANS/ANSA calls & training; in-house monitoring of CMBHS batching; Peer Specialist Integration Ongoing Meet required deadlines and training requirements; increase integration of Peers into Center functions
New Generation Medication Compliance QM staff chart reviews Ongoing Meet HHSC standards Certification of residential and other service programs by State Agencies Survey and audit process Per State schedule Re-certification Crisis Redesign Services QM review of crisis call logs & crisis response times & follow-up/linkages; CARE reports & MBOW Ongoing Meet standards Continuity of Services Reports from CARE; review by QM staff Monthly Meet standards 1115 Waiver Projects Reports on Waiver activities/outcomes; Expansion of Peer Support Activities and COPSD Services Monthly Meet HHSC/CMS Benchmarks YES Waiver Compliance MBOW Reports; QM & Mgmt program audits Monthly Meet HHSC standards ADA Compliance Review/update of ADA Plan& implementation Annual Meet standards Veterans Service Program Implementation Plan Service delivery reporting to TexVet Quarterly Meet HHSC standards CMS Emergency Preparedness Plan Implementation Review/Revise Safety Plan Ongoing Meet CMS standards CQI Project: Rationale for CQI Project: Past results on HHSC Mystery Caller reviews indicated a need to gain insight into the organization’s responsiveness and access to care and address any concerns. Goal: Increase Customer Satisfaction and Access to Services Objective 1: Maintain scores on HHSC Mystery Caller audits to 90% or better Milestones: Continue customer service training for front-line staff Provide customer service training to all front-line staff and to new staff as they on-board. Implementation Date: 1st Quarter FY18 & Ongoing Staff/Area Responsible: HR, QM, MH Program Managers