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ODP Community Services Quality Management Developing the Administrative Entity Quality Management Quarterly Report. WebEx February, 2010 Ann Ligi, ODP Quality Management Lead – East Jodie Enterline, ODP Quality Management Lead – West. Learning Objectives.

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ODP Community Services Quality Management Developing the Administrative Entity Quality Management Quarterly Report

WebEx

February, 2010

Ann Ligi, ODP Quality Management Lead – East

Jodie Enterline, ODP Quality Management Lead – West


Learning Objectives

  • Explain AE QM Quarterly Report Expectations

  • Learn about Data Organization, Analysis and Reporting

  • Understand the Application of the PDCA Model


AE Performance Objectives

  • AE QM Quarterly Report

    • Includes all required elements

    • Template is used

    • Timely submission

  • Data Organization

    • Tables and charts are used

  • PDCA Model is appropriately applied

    • PDCA follow up occurs

    • Action plan is updated ongoing basis

  • Performance is monitored ongoing


Reports Timeline


Report Generation Timeline


AE QM Quarterly Report Template


ODP QM Quarterly Report Evaluation Tool

  • Show evaluation tool and go through the questions.


Complete the top section of the Quarterly Report using information from the AE Annual QM Plan


Performance Measures were identified in the AE Annual QM Plan


Transfer the Performance Measures from the QM Plan to the Quarterly Report


AE QM Quarterly Report: Findings and Analysis


Completing the Findings and Analysis Section

  • Organize data – table

  • Graphically display the data

  • Analyze the data (CHECK)

    • After review of the data, what did we conclude?

    • If we conclude that we are not on track to achieve our objective, then why? (barriers)


AE QM Quarterly Report: PDCA Follow-up


Completing PDCA Follow-up Section

  • If you identified barriers to achieving your objective, identify what you are doing or will do, to overcome the barriers. (ACT)

    • These should be actions/activities on your Action Plan

  • If you’re on track to reach your objective, identify what activities will be taken to sustain achievement and continue progress.


AE QM Quarterly Report: Key Stakeholder Involvement


Completing Key Stakeholder Involvement Section

  • Who are Key Stakeholders?

    • Waiver participants, their family members or representatives, and Waiver providers including SCOs.

  • What kind of “involvement”?

    • Involved in the identification of local quality management priorities

    • Involved in QI activities (meetings, planning, implementation, reporting etc.)

  • See Section 5.15 of the 09-10 AE Operating Agreement


AE QM Quarterly Report: Reporting to the MH/MR Board of Directors


Completing the Reporting to the MH/MR Board of Directors section

  • Document how frequently you report QI activities to the Board of Directors.


QUESTIONS?


Applying

PDCA


PDCA Model

  • Planhow the improvement will be accomplished.

    • Write an action plan that specifies actions taken to achieve the annual target objective.

  • Do it.Implement the improvement plan.

    • This includes education of staff and management about the process change.

  • Checkthe effect of the improvement

    • Collect and analyze data

    • Identify lessons learned.

    • Determine the success or failure of the plan.

  • Act

    • Hold the gains or

    • Re-strategize steps in action plan and implement them

    • Continue to monitor and evaluate progress.


The PDCA Cycle - PLAN

  • Determine baseline performance

  • Analyze baseline data

  • Develop an Action Plan for the improvement

  • Implement the plan


The PDCA Cycle - DO

  • Once you have a PLAN…….

    • Conduct training

    • Implement (Just Do It!)

    • Use a Data Collection Tool


The PDCA Cycle - CHECK

  • Review and analyze the performance data

  • Did the improvement work or not?

    • If not successful, what were the barriers?


The PDCA Cycle - ACT

  • Based on success or lack of success in achieving your objective, ACT to maintain gains or modify your plan


QUESTIONS?


Data Organization, Analysis and Reporting


INFORMATION

KNOWLEDGE

INFORMED

DECISIONS

DATA


DATA - Organizing Data

  • Steps:

    • 1. Retrieve data

    • 2. Organize into a table


DATA – Retrieve Data - Sources

  • HCSIS/Data Warehouse

  • AE Data Collection Tools

  • Surveys

  • Comprised of individual cases, data elements

  • See example 


Data Collection Tool Example

ABC Communication Tracking Tool

ABC Communication Tracking Tool -

EXAMPLE


Aggregate the DataMultiple Cases/Month = Data

All cases done in month

One case done in month

Data for

that month

Draft 1-7-10


DATA – Organize Data into Tables

  • Tables

    • Columns

      • Categories

      • Variables

      • Time

    • Rows

      • Individual cases

      • Aggregate totals

    • See examples 


Example Table


Example Table – 1st Q of Calendar Year


Organized Data - Tables

Note: YTD Total is not 13 because we count each unique individual once.

Finding: 5 individuals, 38 restraints

Some individuals experienced multiple restraints during the first quarter.


INFORMATION – Transforming Data into Information

  • Create a chart/graph of the data

    • Histogram/Bar Chart

    • Line Chart/Run Chart


INFORMATION - Bar Chart


INFORMATION – Line Chart


INFORMATION – Bar Chart


INFORMATION - Line Chart


KNOWLEDGE: Findings and Analysis

  • Based on the review of the Information, what can we conclude?

    • Be aware of the potential to misinterpret data

  • Are we on track to reach our objective?

  • If we are not on track to reach our objective, do we have information that can help us to identify why we are not on track?


Example Findings and Analysis

  • See sample report


INFORMED DECISIONS – Recommendations and Follow -up

  • As a result of the analysis, identify recommendations and follow-up actions to be taken


Example Recommendations and Follow-up

  • See separate sample report document


WRAP UP

  • AE QM Quarterly Report

    • Includes all required elements

    • Template is used

    • Timely submission

  • Data Organization

    • Tables and charts are used

  • PDCA Model is appropriately applied

    • PDCA follow up occurs

    • Action plan is updated ongoing basis

  • Performance is monitored ongoing


QUESTIONS?


Next Steps

WebEx will be posted

Technical Assistance

6/10/2014


For further Technical Assistance Contact:

  • Ann Ligi

    ODP QM Lead – East

    [email protected]

    570-443-4218

  • Jodie Enterline

    ODP QM Lead – West

    [email protected]

    814-432-0205


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