Permanent Injunction
- 44. The Commonwealth, through DBHDS, will collect and analyze data at least annually regarding the management needs of individuals with identified complex behavioral, health, and adaptive support needs to monitor the adequacy of management and supports provided. DBHDS will develop corrective actions based on its analysis as it determines appropriate, track the efficacy of the actions, and revise as it determines necessary to address the deficiency. To implement the preceding steps, the Commonwealth will take the following actions:
- DBHDS will use data from the Skilled Nursing Review detailed in Paragraph 39(c), the IMNR process for individuals with complex medical needs, data from the care concerns process, data from the BSPARI quality reviews, and data from the Quality Service Reviews to monitor the adequacy of management and supports provided. Within six months of the date of this Order, DBHDS will develop a report consolidating the information from these sources to provide a comprehensive summary of the management and support provided to individuals with complex needs. This summary will be completed annually.
- DBHDS will continue to implement the IMNR process for no less than 70 people annually who have complex medical, behavioral, or adaptive support needs (Tier 4) to include onsite visits, reviews of specific health care documentation, and a factual questionnaire administered by qualified nursing professionals to primary caregivers most familiar with the person’s health care needs.
Settlement Agreement
The Commonwealth shall collect and analyze consistent, reliable data to improve the availability and accessibility of services for individuals in the target population and the quality of services offered to individuals receiving services under this Agreement. The Commonwealth shall use data to:
a. identify trends, patterns, strengths, and problems at the individual, service delivery, and systemic levels, including, but not limited to, quality of services, service gaps, accessibility of services, serving individuals with complex needs, and the discharge and transition planning process;
b. develop preventative, corrective, and improvement measures to address identified problems;
c. track the efficacy of preventative, corrective, and improvement measures; and
d. enhance outreach, education, and training.
The Commonwealth shall collect and analyze data from available sources, including, the risk management system described in Section V.C. above, those sources described in Sections V.E-G and I below (e.g., providers, case managers, Quality Service Reviews, and licensing), Quality Management Reviews, the crisis system, service and discharge plans from the Training Centers, service plans for individuals receiving waiver services, Regional Support Teams, and CIMs.
About Data Quality and Analysis
DBHDS created a Data Quality Monitoring Plan to ensure that it is collecting and analyzing consistent reliable data. Under the Data Quality Monitoring Plan, DBHDS assesses data quality—including the availability, validity, and reliability of data—and makes recommendations to the Commissioner, as needed, regarding ways to remediate data quality issues. DBHDS analyzes the data collected to identify trends, patterns, and strengths at the individual, service delivery, and system level in accordance with its Quality Improvement Plan.
DBHDS, in accordance with its Quality Management Plan, utilizes a system for tracking the Performance Management Indicators (PMIs) associated with the eight domains listed in V.D.3.a-h. The same system is utilized to monitor the efficacy of preventative, corrective, and improvement measures and to develop and implement preventative, corrective, and improvement measures where PMIs indicate health and safety concerns. DBHDS uses this information to guide the actions of its Quality Improvement Committee as it identifies areas of needed improvement at a systemic level and makes/implements recommendations to address those areas.
Authorizing Authority
Processes, Protocols and Standards
Guidelines, Charters, Plans, Other
Instruments and Tools
For more information about Data Quality and Analysis, please visit the Office of Clinical Quality Management (OCQM) webpage.