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Sandhills Center LME

Sandhills Center LME. Quality Management Program Orientation for Hospitals and LIPs. Quality Management Program Statement of Purpose. To ensure services (internal and external) are appropriately monitored and continuously improved.

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Sandhills Center LME

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  1. Sandhills Center LME Quality Management Program Orientation for Hospitals and LIPs

  2. Quality Management Program Statement of Purpose • To ensure services (internal and external) are appropriately monitored and continuously improved. • An emphasis on communication, interdepartmental, structured communication and total agency teamwork. • Integrate Quality Management into the entire organization.

  3. Design • To comply with URAC Standards, DMH/DD/SAS and DMA Rules and incorporates the Centers for Medicare and Medicaid Services (CMS) Quality Framework. • The Quality Framework includes the following functions for design of the Quality Management Program: Discovery; Remediation and Continuous Improvement.

  4. Discovery – collecting data and direct participant experience in order to assess the ongoing implementation of the program, identifying strengths and weaknesses. • Remediation – Taking action to remedy specific concerns that are identified • Continuous improvement – utilizing data, data and more data to engage in actions that emphasize continuous improvement.

  5. PDCA • Additionally, the Quality Management Program utilizes the Plan, Do, Check, Act (PDCA) Quality Improvement Model. • Plan – Analyze the problem, establish a solution plan and set goals • Do – Implement the solution • Check – Evaluate the solution • Act – Monitor for continuous improvement and implement system change. • The QM Program balances Quality Assurance and Quality Improvement activities in that Quality Assurance activities inform and spark the Quality Improvement process.

  6. Oversight and Responsibility of the QM Program • The Board of Directors has ultimate responsibility for oversight and effectiveness of the QM Program. • The CEO is administratively responsible for the direction and overall functioning of the QM Program and ensures allocation of adequate resources and staffing. • The Chief Clinical Officer/Medical Director is responsible for oversight of the QM Program and advises on clinical issues. • The QM Director manages the day to day operations related to the implementation of the QM Program. • The Board of Directors reviews and approves QM Plan annually • The Board of Directors receives quarterly reports of all QM activities including Satisfaction Survey results, Complaints and Incidents.

  7. Quality Management Committee & QM Structure Committee structure Four (4) major committees: Quality Management Care Management/Utilization Management Health Network Customer Services

  8. QM Program Committees Responsibilities • Oversight of the day to day operations of the Quality Management Program and compliance with rules, regulations and URAC standards; • Define performance measures to ensure compliance and review data related to the indicators; • Communicate activities and findings back to the Quality Management Committee through Executive Summaries and Task Logs.

  9. Quality Management Committee • Serve as the main conduit of change for the organization. • Provide oversight of the Sandhills Service Management System, operations, functions, processes and practices. • Provide a forum for problem solving and addressing processes for improvement.

  10. Quality Management Committee • Is made up of Department Heads from each section • Is chaired by the Medical Director • Identifies quality indicators, measures and activities as required by contracts with DMA and DMH/DD/SAS • Establishment of performance benchmarks for all internal and external quality indicators

  11. Quality Management Committee Activities Review Care Management/UM, Health Network and Customer Services task logs and Executive Summaries; • Review and promote further discussion of data analysis; • Review and recommend approval of Policies & Procedures, Decision Support Tools, Scripts; • Review satisfaction data for improvement opportunities; • Approval and monitoring of program specific QIPs; • Reviews QM Plan annually

  12. Quality Management Committee Activities (cont’d) • Monitor Access to LME Services; • Monitor Complaints and Appeals; • Provide oversight of monitoring of network providers and recommend sanctions, as necessary; • Review, approve and track Marketing and Communication Materials; • Monitor Compliance with delegation policies and procedures;

  13. Quality Management Committee Activities (cont’d) • Ensure all staff, the Network Leadership Council, Global CQI Committee, Consumer and Family Advisory Council and Board of Directors have a mechanism to provide input into the Quality Management Program; and • .Promotes use of data driven material across all departments

  14. Quality Improvement Projects • Exemplify the process of continuous quality improvement; • Allow for data collection, measurement and analysis that indicates problems that may require corrective action and improvement. • Each Program maintains at least two QIPs at any given time: • At least one project must focus on error reduction and/or member safety and • At least one project must focus on members, that relates to specified key indicators or quality and involves a senior clinical staff member if the QIP is clinical in nature.

  15. Quality Improvement Projects • All QIPs have to meet URAC requirements and 2 have to be approved by DMA for the first year of the contract with a 3rd one added the second year. • QM staff tracks QIPs for 1 year after closure to ensure achieved benchmarks are maintained.

  16. Global CQI Committee • Sandhills Center has a Global Continuous Quality Improvement Committee which is a sub-committee of the Quality Management Committee • Is chaired and co-chaired by providers • Its membership will include representation from all provider groups

  17. Global CQI Committee • The group will analyze data, identify barriers and assist in implementing interventions to improve quality of care through out Sandhills. • This group will make recommendations to the Sandhills Quality Management Committee

  18. QM Monitoring for LIPs • Complaints • Quality of Care Concerns • Gold Star Performance Profile Reviews • -Preliminary occurs annually • -Preferred occurs every 3 years

  19. QM Monitoring Tools • The tools utilized for these reviews are on Sandhills Center website and on the Division of Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services website. • They include chart reviews, personnel record review and paid claims data.

  20. Quality of Care Concerns • QOC concerns can come from any of the groups referenced previously as well as from external sources • Each reviewed by QM Director and Medical Director and disposition determined • Can be referred to the Clinical/Financial Risk Management Committee or to Program Integrity

  21. Quality Management Program Evaluation Annual Evaluation Comprehensive analysis of: • Accomplishments; • Committee activities; • Results of Quality Improvement activities; and • Trending of indicator data. May result in the proposal of new activities or establishment/revision of Policies & Procedures. Assists in the identification and establishment of new priorities/goals for the Quality Management Program.

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