1. Quest for Quality What contractors should know Cady Clark, MSN, RN, Branch Manager Patricia Palm, MS, RNC Claudia Himes-Crayton, BSN, RN Emily Garrison, RN, Graduate Student

2. Objectives • Identify elements of the Quality Management Process • Identify components of the QM plan • Identify continuous monitoring activities • Develop a corrective action plan

3. Why the Quest for Quality is Necessary • To improve patient care • To gain an ongoing, dynamic process through program evaluations • To set priorities and allocate resources based on objective information • To increase job satisfaction for staff • To increase team building within staff • To meet regulatory and funding requirements

4. Elements of the Quality Management Process • Agency’s mission supports the QM process • Multi-disciplinary committee • Committee meetings and minutes • Internal QM review plan • Monitoring activities

5. Components of the QM Plan • A Work Plan • Audit Tools • Monitoring Schedule • Quality Committee Meeting Schedule and Minutes

6. Agency Internal Work Plan

7. Continuous Monitoring Activities • Evaluate administrative areas • Evaluate the eligibility and billing functions • Conduct ongoing clinical record reviews • Evaluate the effectiveness of corrective actions • Conduct client satisfaction surveys and use results to make improvements

8. Process for Improvement • Lean Management • A systematic approach analyzing the flow of information and materials in order to eliminate waste, process variation and imbalance while striving for continuous improvement. Lean – Institute for Healthcare Improvement (curiouscat.net/library/leanthinking.cfm

9. Processes for Improvement • Focus • The FOCUS model provides a process for identifying root causes of quality problems and for planning changes to improve a process • http://www.aafp.org/fpm/FPMprinter/990400fm/25.html?print=yes

10. Process for Improvement • PSDA: Plan – Do – Study – Act • The PDSA cycle is a process for planning and testing improvements Plan, Do, Study, Act (http://psnet.ahrq.gov/glossary.aspx#p)

11. Corrective Action Plans • Finding • Document the finding, and the criterion • Internal Action Plan • Explain how the issue was or will be corrected • Attach revised policies, procedures, training outlines and/or list of staff who attended the training

12. Corrective Action Plan • Timeline • List the date or planned date of corrective action • Staff Responsible • List the staff responsible for making corrections • Follow-up • Indicate the method of follow-up to ensure the action taken is effective • Ex. Eligibility Records are reviewed • Note how often the follow-up will occur

13. Corrective Action Plan

14. Corrective Action Plan

15. Corrective Action Plan

16. Defining Quality Q M Measuring Quality Improving Quality Corrective Action Plan

17. QMB Website http://www.dshs.state.tx.us/qmb