LifeWays Operating Procedures

Transcription

1 STAKEHOLDER INPUT AND CUSTOMER SATISFACTION PURPOSE: This operating procedure is to detail the processes used to obtain input from all stakeholders and how the input shall be utilized in decision-making. DEFINITIONS Stakeholder Anyone who affects or is affected by LifeWays Community Mental Health and its Provider Network s actions, including but not limited to: network providers; Board of Directors; LifeWays staff; consumers of service; community partners; and, general community. Method/Body The method to implement a tool for collecting input from stakeholders and/or the body of experts used to solicit input. Subgroup The stakeholder subgroup that is targeted for input. Frequency The rate of occurrence/recurrence that the stakeholder input is collected. Qualitative Structured interviews, focus groups, or survey comments that yield data, which can be statistically examined through the use of proper coding, and are critical sources of information for improvement. Information can be more subjective. Quantitative Highly structured and systemic approach to collecting data on key areas, which can later be quantified by analysts to identify trends and areas for improvement. Information is more objective. PROCEDURE Seeking stakeholder input shall be conducted in a strategic way that employs planned methods for obtaining quantitative and/or qualitative input. Input obtained shall be used for continuous quality improvement and agency strategic planning and involve relevant stakeholder groups in problem solving. The goal of strategic and intentional input methods is to promote a customerfocused orientation and create the systems and opportunities for continuous improvement. It is critical to the agency to have strong processes for collection and application of input methods to ensure stakeholder s needs and expectations are achieved while balancing compliance and clinical best practice. STAKEHOLDER INPUT SCHEDULE The Stakeholder Input Schedule (Attachment A) will be reviewed and updated by the Quality Improvement Team each year as part of the quality management program evaluation to ensure mechanisms are valuable and effective. The schedule is a dynamic document that may be adjusted Page 1 of 5

2 by the agency to meet new or changing needs. The Quality Improvement Team will coordinate the administration methods within the agency. When input is gathered, the Quality Improvement Team will aggregate the data and present the results in a professional format for agency decision making and quality improvement. INPUT AND ADMINISTRATION METHODS Stakeholder input can be obtained using quantitative and/or qualitative methods depending on the stakeholder group and objective. There are three main sources of input: 1. Structured Surveys/Questionnaires: The predominant method of data collection will be through the structured questionnaire. In addition to traditional administration methods, other methods such as focus groups or interviews can be employed within the survey to supplement the administration and increase the response rate of the targeted group. 2. Stakeholder Representative Groups: The agency has established multiple forums of representatives whereby qualitative input is gathered. The input may be focused on population, project, programming, process, etc. 3. Individual Stakeholder Report: Additional stakeholder input may be received through individual report, such as complaints, comments or concerns. The input may be solicited or unsolicited and may or may not be focused on a specific population, project, program, process, etc. SURVEY/QUESTIONAIRRE PROCESS Responsibility of LifeWays: The Quality Improvement Team is responsible for survey design and administration according to the Stakeholder Input Schedule. Surveys are distributed at the frequency identified in the schedule to the identified stakeholder and subgroup. Various methods may be used to improve response rate so that the results can be generalized to the entire population. Population groups will be defined by the agency s quality management program to target areas or programs of interest. LifeWays is also responsible for complying with the state reporting requirements related to customer satisfaction. Special surveys unique to a pilot or grant or other ad-hoc purpose may be conducted as required or requested. The Quality Improvement Team will assist in the development, administration and aggregation of the results. Page 2 of 5

3 The Quality Improvement Team is responsible for assembling any survey data in an aggregate report format to facilitate problem-solving and decision-making. Results shall be made available to stakeholders and include action steps for improvement where needed. The Quality Improveement Team is responsible for monitoring the action plan to ensure successful implementation. Responsibility of Accredited Providers for Customer Survey: Contracted providers are required per their accreditation standards to conduct an assessment of satisfaction. In an effort to not duplicate the survey process, accredited providers that are contracted with LifeWays are expected to conduct this process and submit their results to LifeWays in an aggregate format on an annual basis (by January 31). The report must include compiled survey scores, significant findings, and actions being taken to address less-than-desired performance. The methodology accredited providers use is not prescribed by LifeWays. However, LifeWays has established a set of standardized questions to be answered on a 5-point scale for all providers to include in their surveys. This will provide for an aggregate network-wide satisfaction data set for the community mental health system. The standardized satisfaction survey questions are as follows: 1. I like the services that I received. 2. I was able to get all the services I thought I needed. 3. Staff helped me obtain the information I needed so that I could take charge of managing my illness or disability. 4. I, not staff, decided my treatment goals. 5. Staff believed that I could grow, change and recover. 6. As a direct result of the services I received, I am better able to take care of my needs. 7. Staff was sensitive to my cultural/ethnic background (e.g., race, religion, language, etc.). FOCUS GROUPS LifeWays administers consumer focus groups when targeted topics are identified. These focus groups gather qualitative information about services received by members of the focus group, as well as satisfaction with LifeWays. The Quality Improvement Team shall assemble the data for internal review. ACTION PLANNING Page 3 of 5

4 The purpose of creating a system for continuous stakeholder input is to use this information to inform: Continuous quality improvement; Community messaging; Strategic planning; Network capacity planning; and, Budget and programming needs The results of stakeholder input shall be analyzed and presented to the Leadership Council and any other relevant forums (i.e., Quality Improvement Council, Consumer Advisory Council) for problem-solving and decision-making. It is critical that the input be assembled in a way that provides actionable information. Each dataset should receive a corresponding action plan that is developed and/or approved by Leadership Council and reviewed periodically to ensure full implementation. The Quality Improvemeent Team will guide the agency in both identifying improvement opportunities within the input results and developing an acceptable action plan that informs the appropriate processes/systems. Concerns or issues specific to a department are communicated to the appropriate department lead for evaluation and action. The agency grievance and appeal procedures are utilized when necessary. Finally, the results of all input methods shall be summarized and utilized in the agency s strategic planning process, annual evaluation and periodic progress reports/modification to plan. Leadership reserves the right to modify the stakeholder input schedule as needed to meet the needs of the agency. REFERENCES MDHHS/CMHSP Managed Mental Health Supports and Services Contract Reporting Requirements/Consumer Satisfaction Surveys CARF: Input from Persons Served Attachment Stakeholder Input Schedule Form #80301-A LifeWays Operating Procedures Provider Communications Grievance and Appeals HISTORY (REVIEWED/REVISED) Effective 06/05/2001 Reviewed/Revised: 07/03, 05/04, 05/05, 11/06, 06/07, 04/09, 7/11, 7/12, 9/13, 9/14, 8/15, 8/16 Page 4 of 5

5 Page 5 of 5