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

1. 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

2. Learning Objectives • Explain AE QM Quarterly Report Expectations • Learn about Data Organization, Analysis and Reporting • Understand the Application of the PDCA Model

3. 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

4. Reports Timeline

5. Report Generation Timeline

6. AE QM Quarterly Report Template

7. ODP QM Quarterly Report Evaluation Tool • Show evaluation tool and go through the questions.

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

9. Performance Measures were identified in the AE Annual QM Plan

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

11. AE QM Quarterly Report: Findings and Analysis

12. 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)

13. AE QM Quarterly Report: PDCA Follow-up

14. 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.

15. AE QM Quarterly Report: Key Stakeholder Involvement

16. 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

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

18. Completing the Reporting to the MH/MR Board of Directors section • Document how frequently you report QI activities to the Board of Directors.

19. QUESTIONS?

20. Applying PDCA

21. 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.

22. The PDCA Cycle - PLAN • Determine baseline performance • Analyze baseline data • Develop an Action Plan for the improvement • Implement the plan

23. The PDCA Cycle - DO • Once you have a PLAN……. • Conduct training • Implement (Just Do It!) • Use a Data Collection Tool

24. The PDCA Cycle - CHECK • Review and analyze the performance data • Did the improvement work or not? • If not successful, what were the barriers?

25. The PDCA Cycle - ACT • Based on success or lack of success in achieving your objective, ACT to maintain gains or modify your plan

26. QUESTIONS?

27. Data Organization, Analysis and Reporting

28. INFORMATION KNOWLEDGE INFORMED DECISIONS DATA

29. DATA - Organizing Data • Steps: • 1. Retrieve data • 2. Organize into a table

30. DATA – Retrieve Data - Sources • HCSIS/Data Warehouse • AE Data Collection Tools • Surveys • Comprised of individual cases, data elements • See example 

31. Data Collection Tool Example ABC Communication Tracking Tool ABC Communication Tracking Tool - EXAMPLE

32. Aggregate the DataMultiple Cases/Month = Data All cases done in month One case done in month Data for that month Draft 1-7-10

33. DATA – Organize Data into Tables • Tables • Columns • Categories • Variables • Time • Rows • Individual cases • Aggregate totals • See examples 

34. Example Table

35. Example Table – 1st Q of Calendar Year

36. 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.

37. INFORMATION – Transforming Data into Information • Create a chart/graph of the data • Histogram/Bar Chart • Line Chart/Run Chart

38. INFORMATION - Bar Chart

39. INFORMATION – Line Chart

40. INFORMATION – Bar Chart

41. INFORMATION - Line Chart

43. 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?

44. Example Findings and Analysis • See sample report

45. INFORMED DECISIONS – Recommendations and Follow -up • As a result of the analysis, identify recommendations and follow-up actions to be taken

46. Example Recommendations and Follow-up • See separate sample report document

47. 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

48. QUESTIONS?

49. Next Steps WebEx will be posted Technical Assistance 6/10/2014

50. For further Technical Assistance Contact: • Ann Ligi ODP QM Lead – East c-aligi@state.pa.us 570-443-4218 • Jodie Enterline ODP QM Lead – West c-jenterli@state.pa.us 814-432-0205