Big Bend Community Based Care. Quality Management Plan FY 11/12

Transcription

1 Big Bend Community Based Care Quality Management Plan FY 11/12

2 1. Philosophy and Purpose of the Quality Management Plan Big Bend Community Based Care s (BBCBC) core value is the belief that all children have the right to grow up safe, healthy and fulfilled in families that love and nurture them. This value stems from our agency Mission and Vision (Attachment 1). One of the commitments that we make to demonstrate this core value is that we employ an analytic and systemic approach to planning and performance management. BBCBC s Quality Management (QM) Plan is designed to assure quality and promote the continuous improvement of services for children and families. Based on the four Keys to Success identified in the agency s Strategic Plan, the QM Plan outlines our collection, analysis and use of data related to: Community Engagement, Managing Revenue, Quality of Services, and Professional Development. The plan seeks to assess the organizational performance of our Lead Agency (see BBCBC s Organization Chart in Attachment 2), and the service delivery and client outcomes of our Network (see Attachment 3). Its primary purpose is to define how BBCBC will work to strengthen practice by improving the timeliness, accessibility, quality and effectiveness of services that increase natural and enduring community supports for children and families. This purpose is based upon the BBCBC s belief that: Improving services is a continuous process. Training, education and quality are ongoing processes focused on strategies that encourage best practice, compliance and accountability for the children and families we serve. Providing cost effective, quality services and promoting positive outcomes for children and their families are the responsibilities of all staff, service providers and licensed caregivers. Reliable and objective data are essential to improving services. Assuring quality services requires the input and feedback from our key stakeholders. Good outcomes are achieved through consistent monitoring, evaluation and sharing of best practices. There is never an excuse for poor quality service. Mistakes should be used as tools for learning. 1

3 2. Overview of Quality Management System A. Quality Delivery System Model BBCBC s role and responsibilities as a Child Welfare Lead Agency are different from that of a child welfare service agency. Its duties are varied and layered, thus require a specific quality management approach that addresses its many roles. To better define, manage and monitor our work, BBCBC utilizes a Quality Delivery System (QDS) Model that defines key responsibilities, explains the flow of work and the integration of quality assurance and improvement. 2

4 B. Definitions 1) Quality Assurance (QA) A system that validates internal practices and uses sound principles of evaluation to ensure that data is collected accurately, analyzed appropriately, reported, and acted upon. The QA function looks at the entire system of care. Products of the QA function include reports that validate data at the agency, unit and case manager level, which evaluates the impact of practice on in process and end process measurements, and provide recommendations for actions. 2) Quality Improvement (QI) An internally driven process that is conducted and initiated by the staff actually providing or supervising the service. QI provides opportunities for all staff to use data and make improvements in their operational processes and daily work environment. QI is an ongoing process that is dynamic and occurs as a result of action planning that is designed to provide program improvement. 3) Continuous Quality Improvement (CQI) The progression toward desired improvements in process, products or outcomes through incremental steps, with periodic review and readjustment of objectives. This concept calls for perpetual organizational reexamination, not only of problem areas, but even those areas that are running smoothly. It presumes that times change, customer needs change and organizational resources change. These changes require adaptation to stay on a quality path and perhaps even reach higher level of achievement. 4) Quality Management (QM) System A set of policies, processes and procedures required for planning and implementation of the core work of an organization. QM integrates the various internal processes within the organization and intends to provide a process approach for implementing the work. QM enables the organization to identify, measure, control and improve the various core processes that will ultimately lead to improved performance. 3

5 C. Quality Management System Processes and Flow Chart BBCBC uses Deming s cycle as a foundation for its quality management and improvement efforts. Our implementation of Deming s cycle is displayed below. BBCBC Quality Management Process Flow Chart Board of Directors Staff Stakeholders Community Partners State Requirements Quality Management Processes Strategic Planning Directors & BBCBC Staff Executive Leadership Quality Management Team BBCBC Network Implementation Training Internal QM External QM Quality Delivery System Monitoring Additional Financial Audits Contract Monitoring & Evaluation Stakeholder Input Additional Case Management Assessments Corrective Actions Data Reporting &Analysis PQI Committee DCF Reports Board of Dissemination Directors Mtgs. Monthly Web Publication Monthly Directors Mtg. Monthly Network Mgt Mtg. Quarterly Performance Mtg. 4

6 D. Quality Management Organization, Roles and Structure The responsibility for BBCBC s QM efforts ultimately resides with the Quality Management Director (QMD). The QMD supervises staff dedicated to quality operations, assurance and improvement activities. This staff includes four Quality Assurance Specialists (QAS) and one Quality Assurance Analyst (QAA). The QAS all have significant experience in child welfare, including case management and supervision, foster home management, investigations, and adoptions. All QAS are certified in Green Belt data analysis and those with case management backgrounds (rather than investigations) are certified as Child Welfare Professionals by the Florida Certification Board. The QAA has experience in managing data systems, analysis and presentation. In addition to BBCBC staff, the quality assurance specialists of our case management and adoptions partner agencies assist us with the implementation of QM activities. QM Staff Organizational Structure Big Bend Community Based Care Chief Executive Officer Quality Management Director Quality Assurance Analyst Circuit 2 Quality Assurance Specialists Circuit 14 Quality Assurance Specialists Partner Agency QA/Certified Reviewers 5

7 3. Quality Management System Components A. Quality Management Plan BBCBC s Quality Management Plan incorporates input from the agency s Board of Directors, partner agencies, services providers, prevention colleagues, and staff. The agency s Mission, Vision and Values underlie both the agency s Strategic and QM Plans. Additionally, BBCBC incorporates modifications to the Florida Department of Children and Families (DCF) Quality Assurance Model annually. BBCBC updates its QM Plan annually and updates QM structure and processes on an ongoing basis to address changing needs and requirements. This document provides a view of the work that is planned to assure quality and continuous improvement within our system of care and in the implementation of our strategic plan. B. Internal Processes 1. BBCBC will be initiating a system to monitor its internal functions using the QDS Internal Compliance Review (ICR) process depicted in the diagram below. The ICR is designed to review key processes that are defined in BBCBC s Operating Policies & Procedures and are graphically depicted in the agency s process flowcharts and system control documents. BBCBC s Operating Policies & Procedures, process flowcharts and control system documents are designed to address requirements from state and federal law and Florida Administrative Code within the agency s system of implementation. The QDS process flow for internal monitoring is included on the next page. This ICR system is planned for use by Human Resources, Intake, Placement, Licensing Attestation, Contracts, QM and Accounting, and other processes as identified by the Executive Leadership. 2. In addition to QDS processes, BBCBC s fiscal/financial processes undergo annual monitoring by an independent, certified public accounting agency. Any findings are addressed by the unit with primary responsibility for the identified activity. Corrective actions are approved by the appropriate supervisor and leadership. Copies of the monitoring reports and any corrective actions are provided to the Board of Directors and DCF. 6

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9 C. External Processes 1. Quality of Services 1. Quality Service Reviews In FY 11/12, BBCBC will implement quality reviews of five cases per quarter using the State s newly adopted Quality Service Review (QSR) process. QSR is a broad term for a set of processes and tools designed to review human service systems. It is based on an in depth case review method involving multiple stakeholders, and uses a performance appraisal process to assess how service recipients benefit from services and how well service systems address their needs. The QSR process is based on the premise that each individual child and family case can be used as a test of the service system at a particular place and time. The approach looks at each individual within the context of his/her home and community. By doing so, the QSR is able to examine the pattern of status and performance results and to develop a better understanding of what is really happening for the child and family and to what the current situation may be attributable. 2. Quality Reviews of Children with a Permanency Goal of Another Planned Permanent Living Arrangement BBCBC will continue to review cases for children with a permanency goal of Another Planned Permanent Living Arrangement to support Florida s efforts to assure the appropriateness of the permanency goal and the quality of services to support that goal. Review data will be entered into the Florida Web Systems Portal quarterly to assure inclusion in the State s follow up reporting to the U.S. Department of Health and Human Services. 3. Practice Reviews for Case Management Services BBCBC will implement a quality assurance review model derived from Florida s Quality Practice Standards for Case Management to monitor and assure high quality case management related services (including traditional case management, adoptions services, Independent Living, and Family Preservation services). Our review tool integrates practice items from the Standards with sub contract monitoring, CFSR and State requirements to address key aspects of safety, permanency and well being compliance and quality. BBCBC will pilot a bi annual case practice review schedule during FY 11/12. Each subcontracted case management organization (CMO) will be subject to review twice annually. The sample size is set at 10% of the sub contractor s service population. Each CMO sample 8

10 will be randomly selected and stratified by permanency goal to assure a diverse mix of cases. Individual cases are to be randomly selected for review within each stratum. Case Practice Reviews will be scheduled in coordination with BBCBC s Contracts Administration Unit to assure timely quality and compliance data can be easily incorporated into contract monitoring. Critical Life, Health, or Safety Threats If any critical life, health, or safety threats are identified during the course of quality assurance activities, BBCBC Quality Assurance Specialists (QAS) 1. Addressing any child safety concerns with the Dependency Case Manager and the Dependency Case Manager Supervisor immediately upon discovery 2. Facilitating and/or providing assistance in assuring child safety 3. Informing the appropriate BBCBC Operations Manager 4. Informing the Quality Management Director as soon as possible after onsite notifications 5. Assuring appropriate action and follow up are initiated to assure child safety 6. Documenting the child safety concern and follow up actions as a formal Request for Action (RFA) in FSFN 7. Confirming that documentation of the identified child safety concern, RFA, follow up actions and the resolution of the concern are documented in FSFN and in the child s case file 8. Maintaining a copy of the RFA, documentation of completed follow up actions and the resolution of the concern with the Case Practice Review documentation. The QDS Process Flow Chart for Case Practice Review Process is included on the following page. 9

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12 4. Additional Case Management Related Quality Assurance: Quality Supervisor Reviews & Reviews of Quality Practice for Children Prescribed Psychotropic Medications BBCBC operating policy requires that case management unit supervisors to complete case reviews at least every ninety days on all open cases, as well as requiring that QAS complete quarterly assessments of a small sample of those reviews. QAS use the Supervisor Review and Psychotropic Medications review items from the Standards in their review and share feedback and recommendations with each supervisor individually. 5. Practice Reviews for Other Sub Contracted Services Quality and compliance reviews of other sub contracted services (such as foster home management, visitation and family intervention services) will use review tools also integrates related practice items from the Standards with sub contract monitoring, CFSR and State requirements for those services. The sample size is set at 10% of the sub contractor s service population. Each subcontractor sample will be randomly selected and stratified by relevant service categories to assure a diverse mix of records for review. Individual records are to be randomly selected for review within each stratum (if applicable). Practice Reviews for these sub contractors will be scheduled in coordination with BBCBC s Contracts Administration Unit to assure timely quality and compliance data can be easily incorporated into contract monitoring. 6. BBCBC Executive Management Discretionary Reviews BBCBC s QM Team also complete discretionary reviews determined by the Executive Management Team.. 2. Sub Contract Monitoring BBCBC monitors each new sub contractor twice during its initial contract year. In subsequent contract years, the frequency and extent of monitoring is dependant upon an Annual Risk Assessment, the sub contractor s accreditation status and previous monitoring data. BBCBC revisits sub contractors required to complete corrective action plans and revisits to verify evidence of implementation and effectiveness of corrective actions. 11

13 BBCBC conducts management and monitoring activities through on site visits to providers and the review of required reports. Administrative review components are completed by BBCBC s Contracts Administration Unit. Quality of service delivery components are assessed via the Practice Review processes described in sections C.2 and C.3 above. The sample size is set at 10% of the sub contractor s service population, and adjusted if needed based on the sub contract s assessed risk level. Cases/records for review are random number selected from the population of clients served by the provider during the Contract Monitoring review period. Following each monitoring, exit meetings are held with the contract provider staff following the review to provide preliminary findings and gather additional information needed to ensure a comprehensive final report can be completed. BBCBC s Contract Administrator and the QAS then compile and analyze the data obtained from the monitoring to assess compliance with requirements and quality standards and summarize overall performance. If necessary, contract providers are instructed to submit a Corrective Action Plan (CAP) to the Contract Administrator to address specific findings. CAPs must document how the contract provider will address deficiencies and items that warrant Quality Improvement activities. BBCBC then uses the CAP in ongoing monitoring for the provider. A final report is completed for each sub contract monitoring review. The report includes both summary and detailed data for compliance and quality. This report is disseminated to the subcontract provider, BBCBC s Chief Executive Officer (CEO), Chief Operations Officer (COO), Chief Financial Officer (CFO), Client Services Director (CSD), and QMD. The QDS macro of this process is seen on the following page. 12

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15 3. Stakeholder Input Surveys BBCBC surveys stakeholders such as Foster Parents, community leaders, court system representatives, and lead agency and network employees annually. These surveys are completed primarily electronically, with mail surveys for those without internet access. Survey results are reported to the Board of Directors and Executive Leadership directly and to staff and the community via electronic means (via our website and/or ed reports) and the Annual Report for the agency, which is also posted on our website. The data collected are reviewed as part of Monthly Directors Meetings or at Monthly and/or Quarterly Management Meetings with sub contractor Program Managers, as applicable. Corrective actions are developed within these meetings, with follow up by the COO, CDS and QM staff to assure completion, assess results, and revise corrective actions, as necessary. Stakeholder survey results are also included in data provided to and used by BBCBC s Executive Leadership to develop and update the agency s longterm and short term Strategic Plans. QDS macros for these surveys follow on the next two pages. 14

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18 4. Complaints and Grievances All complaints or grievances, whether submitted directly from the complainant or through the DCF Tracker System, are addressed by BBCBC s Operations Managers. The Operations Managers investigate concerns, seek resolution to complaints, and design strategies to improve processes involved in complaint, if needed. BBCBC plans to revise its internal operating policy related to complaints and grievances during FY 11/12 due to inefficiencies noted with the current procedure. Though official complaints and grievances are few, the process of addressing and resolving concerns can require time and coordination to complete. Until this procedure can be revised, Operations Managers will report to Executive Leadership on any open complaint or grievance during weekly management meetings, monthly Directors meetings and at any critical point in the process. Once the procedure has been revised and approved by BBCBC s Board of Directors, the new tracking process will be initiated and data will be reported accordingly. 4. Measurements, Reporting and Data Uses A. Program Data 1. Management Reports BBCBC has a centralized yet program specific data collection process used to support the quality management system. Management data is analyzed at least monthly to support organizationwide planning and correction of problem areas. An example of a management report that is analyzed, disseminated and used to make changes in daily practice is the Client Status Summary Report, which includes: Client Counts Last Face to Face Visit Last Supervisor Review Fingerprint/Photo/Birth Certification Status Judicial Reviews It is provided to case manager supervisors in both Circuits weekly. An additional benefit is its ability to identify and prioritize the task due next and provide the case manager with the number of days until the task is due. Other management reports that are run, analyzed and disseminated are included in Attachment. 2) Performance and Quality 17

19 BBCBC holds Quarterly Performance Meetings to review sub contractor performance on contract measures. These meetings are hosted by the CEO, COO and the agency s Directors and other key staff. Meeting attendants are sub contractor agency CEOs and Program Managers, as well as additional staff at their discretion. Quarterly Quality Improvement Workshops focus on quarterly performance, quality and trend data for selected measures. These workshops focus on analysis of the data, identified barriers to performance and planning action steps to address deficiencies. Systemic and recurring issues are identified for root cause analysis and countermeasure development. Countermeasures are developed and implemented, then reviewed during the following quarterly meeting.. A version of the contract performance measure data presented is included in BBCBC s Performance Measures Report included in Attachment 7. 3) Subcontractor Reports and Invoices Partner agencies/sub contractors are required to submit monthly reports along with their invoices each month to the Contracts Unit. The reports required are specific to the type of contract/services provided and directly reflect progress or compliance with contracted activities, federal and state reporting requirements, and service descriptions, as well as services data not available via the SACWIS system (i.e., foster care licensing packets completed, progress toward adoption targets and service outcome measures.) Data is complied from the reports in a formal tracking system under the Contract Coordinator s direction. This data is compiled periodically (based upon the contract s specific timelines) and are shared with the CEO, COO and QMD. Sub contractors are required to document corrective actions taken or to be taken to improve performance in areas found deficient. The Contract Administrator provides technical support to sub contractors on administrative issues. Quality Management staff provide technical support to sub contractors on performance and quality matters. The success of action items is determined by subsequent data collected and re addressed as needed. B. Agency Management Data 1. Management Reports The QDS system employed by BBCBC provides Leadership with both internal management and performance reporting on an ongoing basis. Data is reviewed at least quarterly (as appropriate 18

20 for the measure) by Executive Leadership. Corrective or follow up actions are assigned to staff as needed. Attachment 8 lists the Lead Agency Management Data reviewed by the CEO, COO and CFO. 2. Performance Reports BBCBC s performance report, as defined by our contract with DCF, is represented in the monthly Performance Measures Report (Attachment 4) and the Community Report Card (Attachment 9). These reports are prepared monthly and are published on BBCBC s website The QDS Process Flow Chart for data dissemination is included below. 19

21 C. Stakeholder Data Community input is collected from stakeholders annually and includes information from partner agencies, the court system, guardians ad litem, medical providers, counselors, and foster parents. Stakeholder surveys are completed annually. For the QDS Flow Charts for Foster Parent and Stakeholder surveys, see pages 15 and 16. D. Quality Management Calendar Quality control, assurance and improvement activities are calendared to provide data on performance as close to real time as possible. The annual Activity Calendar is provided here: 20

22 5. Quality Management and Training Integration A. Training System Design Beginning in December 2009, BBCBC changed its method of providing training from a contracted duty and has assumed responsibility for training for the Network. The Training Team includes one Coordinator and three Training Specialists responsible for pre service and in service training for all child welfare professional positions within BBCBC s Network. Network and Lead Agency staff training is tracked for annual and certification requirements via an automated system. Training needs assessments and evaluations are regularly administered to identify future training needs and areas of particular interest to staff. The Training Team participates quarterly in both the Performance Management Meetings and Quality Improvement Workshops and assists QM staff in implementing quality improvement activities identified and developed in those venues. B. Training System Components 1. Network Provider Orientation Training orientation training is now required for all new lead agency staff and provider staff. This orientation provides an overview of the Lead Agency, its Mission, Vision and Values; the agency s system of care; and quality control, assurance and improvement system. 2. Network Case Management Services Training pre service training is provided directly by BBCBC Training Team and incorporates the State s newest curriculum requirements. BBCBC s Pre Service Curriculum fully integrates the QPS throughout. In service training is also provided by the BBCBC Training Team as described in Section A, above, and tracked in the database/tracking system. 3. Foster Parent Training foster parent/quality parenting initiative (QPI) training and inservice are provided by the BBCBC Training Team and foster home management network providers trained in the new QPI system. 4. Lead Agency Staff Training The BBCBC Training Team develop training opportunities for Lead Agency staff as depicted in the process flow below. This staff training is also tracked via the training database and provides information on staff training hours for our Human Resources section and personnel files. 21

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24 6. Quality Management and Strategic Planning The BBCBC Board of Directors, Network providers, community partners and management establish and maintain a 3 year long term strategic plan for the Network, as well as annual strategic/budget plans. These plans are developed using a planning process that includes a review of the Network mission, vision and values, its strengths and weaknesses, goals and objectives, resources and changing funding and regulatory environments. Planning is developed around the four Keys to Success: Community Engagement, Managing Revenue, Quality of Services, and Professional Development. Whether long or short term, the strategic planning process includes a situational analysis. The analysis includes both a needs assessment and ongoing quality assurance and improvement data. The needs assessment for short term plans may be abbreviated or more informal than that used for the long term plan, however, both focus on demographic information and changes in the service population, trends in programs, survey data and analysis of strengths and weaknesses in relation to these variables. By policy, these data form the foundation for BBCBC s strategic planning. Quality assurance mechanisms for initiatives developed are integrated into the planning process so that Deming s cycle (Plan, Do, Check, Act) can be completed and quality in process and program can be maintained. The QDS process flow chart for BBCBC s Strategic Planning, including the Check or quality management aspect, follows on the next page. 23

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26 7. Accreditation Status Big Bend Community Based Care received notification of Network Lead Agency Accreditation by the Council on Accreditation (COA) on December 23, BBCBC was expedited through COA s Pre Commission Review Report (PCR) process as our Peer Review found all fundamental practices standards in compliance during the review. As such, no response was required of BBCBC prior to the issuance of the COA Final Accreditation Report. BBCBC received our Final Accreditation Report on January 4, 2010 effective until December 31, BBCBC s quality management efforts were noted in the Final Accreditation Report with the following statement: The PQI processes in this organization are exceptional. The theme throughout is that everyone is apart of the process and the material gathered is used in real time to make real change and improvement in all aspects of the organization. BBCBC is continuing to enhance our administrative and leadership activities in implementing COA s standards and will complete annual status reports for COA. Additionally, four members of BBCBC s Management Team intend to pursue certification as COA Peer Reviewers. 25

27 Attachment 1: Mission, Vision and Values 26

28 Attachment 2: Case Status Summary Report 27

29 Attachment 3: FSFN/Other Program Management & Performance Reports Adoption Finalizations Adoptions Finalized within 24 months Birth Verification Compliance Cases Active by Primary Worker In Home Cases Active by Primary Worker Out of Home Children Entering Out of Home Care within 12 Months of Reunification Children in Out of Home Care More than 12 Months Children Reunified within 12 Months Children Seen Exit Interviews with Children Fingerprints Compliance Foster Home Licensing Report Incident Reports Inquiry, Complaint and Grievances Judicial Reviews Timeliness Maltreatment in Out of Home Care Median Length of Stay Percent of Children with More Than 2 Placements within 12 Months of Removal Photograph Compliance Quality of Case Practice Data Residential/Facility Care Utilization Reduction in Out of Home Care Supervision and Case Reviews Utilization Data Children Served In Home, Out of Home, by Licensed Care Type 28

30 Attachment 4: Performance Measures Report 29

31 Attachment 5: Community Report Card 30

32 Attachment 6: BBCBC Accreditation 31