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Reporting

Settlement Agreement Provision

The Commonwealth shall begin collecting and analyzing reliable data about individuals receiving services under this Agreement selected from the following areas in State Fiscal Year 2012 and will ensure reliable data is collected and analyzed from each of these areas by June 30, 2014. Multiple types of sources (e.g., providers, case managers, licensing, risk management, Quality Service Reviews) can provide data in each area, though any individual type of source need not provide data in every area:

a.    Safety and freedom from harm (e.g., neglect and abuse, injuries, use of seclusion or restraints, deaths, effectiveness of corrective actions, licensing violations);

b.    Physical, mental, and behavioral health and well-being (e.g., access to medical care (including preventative care), timeliness and adequacy of interventions (particularly in response to changes in status);

c.    Avoiding crises (e.g., use of crisis services, admissions to emergency rooms or hospitals, admissions to Training Centers or other congregate settings, contact with criminal justice system);

d.    Stability (e.g., maintenance of chosen living arrangement, change in providers, work/other day program stability);

e.    Choice and self-determination (e.g., service plans developed through person centered planning process, choice of services and providers, individualized goals, self-direction of services);

f.     Community inclusion (e.g., community activities, integrated work opportunities, integrated living options, educational opportunities, relationships with non-paid individuals);

g.    Access to services (e.g., waitlists, outreach efforts, identified barriers, service gaps and delays, adaptive equipment, transportation, availability of services geographically, cultural and linguistic competency); and

h.   Provider capacity (e.g., caseloads, training, staff turnover, provider competency).

Reports

Compliance Indicators

V.D.3

DBHDS has established three Key Performance Areas (KPAs) that address the eight domains listed in V.D.3.a-h. DBHDS quality committees and workgroups, including Mortality Review Committee, Risk Management Review Committee, Case Management Steering Committee and KPA workgroups, establish performance measure indicators (PMIs) that are in alignment with the eight domains that are reviewed by the DBHDS Quality Improvement Committee (QIC). The components of each PMI are set out in indicator #5 of V.D.2. The DBHDS quality committees and workgroups monitor progress towards achievement of PMI targets to assess whether the needs of individuals enrolled in a waiver are met, whether individuals have choice in all aspects of their selection of their services and supports, and whether there are effective processes in place to monitor individuals’ health and safety. DBHDS uses these PMIs to recommend and prioritize quality improvement initiatives to address identified issues. The assigned committees or workgroups report to the QIC on identified PMIs, outcomes, and quality initiatives. PMIs are reviewed at least annually consistent with the processes outlined in the compliance indicators for V.D.2. Based on the review and analysis of the data, PMIs may be added, deleted, and/or revised in keeping with continuous quality improvement practices.

  1. The KPA workgroups and assigned domains (V.D.3.a-h) are:
    1. Health, Safety and Well Being KPA workgroup encompasses the domains of:
      1. Safety and Freedom from Harm
      2. Physical, Mental, and Behavioral Health and Well being
      3. Avoiding Crises
    2. Community Integration and Inclusion KPA workgroup encompasses the domains of:
      1. Community Inclusion
      2. Choice and Self-Determination
      3. Stability
    3. Provider Competency and Capacity KPA workgroup encompasses the domains of:
      1. Provider Capacity
      2. Access to Services
  2. The DBHDS Quality Management Plan details the quality committees, workgroups, procedures and processes for ensuring that the committees and/or workgroups establish PMIs and quality improvement initiatives in the KPAs on a continuous and sustainable basis.
  3. Each KPA workgroup will:
    1. Establish at least one PMI for each assigned domain
    2. Consider a variety of data sources for collecting data and identify the data sources to be used
    3. Include baseline data, if available and applicable, when establishing performance measures
    4. Define measures and the methodology for collecting data
    5. Establish a target and timeline for achievement
    6. Measure performance across each domain
    7. Analyze data and monitor for trends
    8. Recommend quality improvement initiatives
    9. Report to DBHDS QIC for oversight and system-level monitoring
  4. DBHDS collects and analyzes data from each domain listed in V.D.3.a-h. Within each domain, DBHDS collects data regarding multiple areas. Surveillance data is collected from a variety of data sources as described in the Commonwealth’s indicators for V.D.3.a-h. This data may be used for ongoing, systemic collection, analysis, interpretation, and dissemination and also serves as a source for establishing PMIs and/or quality improvement initiatives.
  5. The Office of Data Quality and Visualization will assess data quality and inform the committee and workgroups regarding the validity and reliability of the data sources used in accordance with V.D.2 indicators 1 and 5.
  6. The Quality Management Annual Report will describe the accomplishments and barriers for each KPA.

V.D.3.a-h

V.D.3.a

  1. The Health, Safety and Well Being KPA workgroup will finalize surveillance data to be collected for “safety and freedom from harm,” at minimum including:
    1. Neglect and abuse
    2. Injuries
    3. Use of seclusion or restraints
    4. Effectiveness of corrective action
    5. Licensing violations
    6. Deaths
  2. The Health, Safety and Well Being KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • Abuse, neglect and exploitation
    • Serious incidents and injuries (SIR)
    • Seclusion or restraint
    • Incident Management
    • National Core Indicators – (i.e. Health, Welfare and Rights)
    • DMAS Quality Management Reviews (QMRs)

V.D.3.b

  1. The Health, Safety and Well Being KPA workgroup will finalize surveillance data to be collected for “Physical, mental, and behavioral health and well being.”
  2. The Health, Safety and Well Being KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • SIR
    • Enhanced Case Management (ECM)
    • National Core Indicators – (i.e. Health, Welfare and Rights)
    • Individual and Provider Quality Service Reviews (QSRs)
    • QMRs 

V.D.3.c

  1. The Health, Safety and Well Being KPA workgroup will finalize surveillance data to be collected for “avoiding crises,” at minimum including:
    1. Number of people using crisis services
    2. Age and gender of people using crisis services
    3. Known admissions to emergency rooms or hospitals
    4. Admissions to Training Centers or other congregate settings
    5. Contact with criminal justice system during crisis
  2. The Health, Safety and Well Being KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • Crisis Data
    • QMRs
    • QSRs
    • Waiver Management System (WaMS)
    • CHRIS

V.D.3.d

  1. The Community Inclusion/Integrated Settings KPA workgroup will finalize surveillance data to be collected for “stability,” at minimum including data related to living arrangement, providers, and participation in chosen work or day programs.
  2. The Community Inclusion/Integrated Settings KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • Employment
    • Housing
    • NCI – (i.e., Individual Outcomes)
    • QSRs
    • WaMS

V.D.3.e

  1. The Community Inclusion/Integrated Settings KPA workgroup will finalize surveillance data to be collected for “Choice and self-determination.”
  2. The Community Inclusion/Integrated Settings KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • Employment
    • Community Engagement/Inclusion
    • QSRs
    • NCI – (i.e., Individual Outcomes)
    • WaMS

V.D.3.f

  1. The Community Inclusion/Integrated Settings KPA workgroup will finalize surveillance data to be collected for “community inclusion,” at minimum including data related to participation in groups and community activities, such as shopping, entertainment, going out to eat, or religious activity.
  2. The Community Inclusion/Integrated Settings KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • Employment
    • Community Engagement/Inclusion
    • QSRs
    • Housing
    • Regional Support Teams
    • Home and Community-Based Settings
    • NCI – (i.e., Individual Outcomes)
    • WaMS

V.D.3.g

  1. The Provider Competency and Capacity KPA workgroup will finalize surveillance data to be collected for “access to services,” at minimum including:
    1. For individuals on the waitlist, length of time on the waitlist and priority level, as well as whether crisis services, Individual and Family Support Program funding, or a housing voucher have been received
    2. Ability to access transportation
    3. Provision of adaptive equipment for individuals with an identified need
    4. Service availability across geographic areas
    5. Cultural and linguistic competency
  2. The Provider Competency and Capacity KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • NCI – (i.e., System Performance)
    • WaMS
    • Individual and Family Support Program (IFSP)
    • Provider Data Summary
    • QSRs 

V.D.3.h

  1. The Provider Competency and Capacity KPA workgroup will finalize surveillance data to be collected for “Provider capacity,” at minimum including:
    1. Staff receipt of competency-based training
    2. Demonstration of competency in core competencies
    3. Demonstration of competency in elements of service for the individuals they serve
  2. The Provider Competency and Capacity KPA workgroup will develop, initiate, and monitor performance measures with a set target.  Measures may be selected from, but not limited to, any of the following data sets:
    • Staff competencies
    • Staff training
    • QSRs
    • Provider Data Summary
    • QMRs
    • Licensing Citations 

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