Settlement Agreement Provision

V.D.2

V.D.4

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Compliance Indicators

V.D.2

1. DBHDS develops 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 validity and reliability of data and makes recommendations to the Commissioner on how data quality issues may be remediated. Data sources will not be used for compliance reporting until they have been found to be valid and reliable. This evaluation occurs at least annually and includes a review of, at minimum, data validation processes, data origination, and data uniqueness.
2. DBHDS analyzes the data collected under V.D.3.a-h to identify trends, patterns, and strengths at the individual, service delivery, and system level in accordance with its Quality Improvement Plan. The data is used to identify opportunities for improvement, track the efficacy of interventions, and enhance outreach and information.
3. At least annually, DBHDS reviews data from the Quality Service Reviews and National Core Indicators related to the quality of services and individual level outcomes to identify potential service gaps or issues with the accessibility of services. Strategic improvement recommendations are identified by the Quality Improvement Committee (QIC) and implemented as approved by the DBHDS Commissioner.
4. DBHDS quality committees and workgroups, including Mortality Review Committee, Risk Management Review Committee, Case Management Steering Committee, and Key Performance Area (KPA) workgroups, establish goals and monitor progress towards achievement through the creation of specific KPA Performance Measure Indicators (PMI). These PMIs are organized according to the domains, as outlined in the Settlement Agreement in V.D.3.a-h. PMIs are also categorized as either outcomes or outputs:
   1. Outcome PMIs focus on what individuals achieve as a result of services and supports they receive (e.g., they are free from restraint, they are free from abuse, and they have jobs).
   2. Output PMIs focus on what a system provides or the products (e.g., ISPs that meet certain requirements, annual medical exams, timely and complete investigations of allegations of abuse).
5. Each KPA PMI contains the following:
   1. Baseline or benchmark data as available.
   2. The target that represents where the results should fall at or above.
   3. The date by which the target will be met.
   4. Definition of terms included in the PMI and a description of the population.
   5. Data sources (the origins for both the numerator and the denominator)
   6. Calculation (clear formulas for calculating the PMI, utilizing a numerator and denominator).
   7. Methodology for collecting reliable data (a complete and thorough description of the specific steps used to supply the numerator and denominator for calculation).
   8. The subject matter expert (SME) assigned to report and enter data for each PMI.
   9. A Yes/No indicator to show whether the PMI can provide regional breakdowns. 
6. DBHDS in accordance with the Quality Management Plan utilizes a system for tracking PMIs and the efficacy of preventative, corrective, and improvement measures, and develops and implements preventative, corrective, and improvement measures where PMIs indicate health and safety concerns. DBHDS uses this information with its QIC or other similar interdisciplinary committee to identify areas of needed improvement at a systemic level and makes and implements recommendations to address them.
7. DBHDS demonstrates annually at least 3 ways in which it has utilized data collection and analysis to enhance outreach, education, or training.
8. DBHDS collects and analyzes data (at minimum a statistically valid sample) at least annually regarding the management of needs of individuals with identified complex behavioral, health and adaptive support needs to monitor the adequacy of management and supports provided. DBHDS develops corrective action(s) based on its analysis, tracks the efficacy of that action, and revises as necessary to ensure that the action addresses the deficiency. 

V.D.4

The Commonwealth collects and analyzes data from the following sources:

1. Computerized Human Rights Information System (CHRIS): Serious Incidents – Data related to serious incidents and deaths. 
2. CHRIS: Human Rights – Data related to abuse and neglect allegations. 
3. Office of Licensing Information System (OLIS) – Data related to DBHDS-licensed providers, including data collected pursuant to V.G.3, corrective actions, and provider quality improvement plans. 
4. Mortality Review 
5. Waiver Management System (WaMS) – Data related to individuals on the waivers, waitlist, and service authorizations. 
6. Case Management Quality Record Review – Data related to service plans for individuals receiving waiver services, including data collected pursuant to V.F.4 on the number, type, and frequency of case manager contacts. 
7. Regional Education Assessment Crisis Services Habilitation (REACH) – Data related to the crisis system. 
8. Quality Service Reviews (QSRs) 
9. Regional Support Teams 
10. Post Move Monitoring Look Behind Data 
11. Provider-reported data about their risk management systems and QI programs, including data collected pursuant to V.E.2 
12. National Core Indicators 
13. Training Center reports of allegations of abuse, neglect, and serious incidents 

Reports

• Data Quality Monitoring Plan May 2019 
• Data Quality Monitoring Plan Fall 2019
• Data Quality Monitoring Plan Source System Annual Update, June 2021
• Data Quality Monitoring Plan Source System Annual update, June 2022
• Data Quality Monitoring Plan Annual Update 9.28.23