QI PLAN – GOALS AND OBJECTIVES – FY 2020



GoalNumberDomainDepartmentReportingStaffReport(s)DueStandard/RationaleMeasure/GoalReportFormatProgress/Outcome#1Effective-nessAccessABA ProgramABA ProgramSupervisorCCO02/202006/2020Best PracticesFY 2014, 2015, 2016, 2017, 2018 & 2019 GoalsTo evaluate the effectiveness of Sanilac CMH’s Medicaid Autism Benefit program.Implement Inner Observer Agreement (IOA) checks on trained staff at least 2 times a year to ensure fidelity of treatment plete 2 community based education presentations on autism or ABA for outside agencies.All individuals that are part of the State ABA benefit will receive parent training at least quarterly.Verbal Reports#2AccessABA ProgramContract Monitoring04/202008/2020Community NeedFY 2019 GoalsMonitor provider network for choice availability and ensure at least one provider is available.Verbal Report#3Effective- nessAccessAdministrationHCBS Coordinator/JSC Supervisor02/202006/2020State of Michigan HCBS WaiverFY 2018 & 2019 GoalImplement HCBS Program and Residential rule requirements with all involved programs and Specialized/Contract homes by:Providing residential providers with training and updates at each quarterly Home Provider Meeting.Adding at least 2 new Community Integration events at JSC in the next 6 months.Verbal Reports#4EfficiencyAdministrationIT Supervisor04/202008/2020EfficiencyFY 2018 & 2019 GoalFacility and IT Replacement PlanA master plan will be developed that will look at long term replacement needs (5 years, 10 years, 20 years)All four physical locations will be included in the master plan along with all technology needs.Include both (2) residential homes owned by CMH.Verbal Reports#5EfficiencyAdministrationIT Supervisor02/202006/2020EfficiencyFY 2018 & 2019 GoalResearch methods and report on possible solutions for efficiencies utilizing technology both short and long termVerbalReport#6Effective-nessAccessEfficiencyChildren’sChildren’sSupervisor04/202008/2020EffectivenessAccessEfficiencyBest PracticeSED and Children’s Waiver Implementation:Identify a coordinator and staff who will enter data into the WSA.Create a policy/procedure to address how SED and Children’s Waiver should be addressed within the Agency.Children’s Supervisor/ department staff will meet with DHHS at least quarterly to help improve collaboration efforts.#7EfficiencyAccessEffective-nessClinicalCIOCCOClinical Supervisors02/202006/2020EfficiencyFY 2015, 2016, 2017, 2018 & 2019 GoalSanilac CMH Clinical Departments will increase/maintain their billable time within departmental standards.Step One: A baseline will be determined by 01/30/2020.Step Two: CCO, CIO and Clinical Supervisors will meet to determine productivity goals per staff by 03/30/2020.Step Three: Create and implement plans/policy/process to assist in increasing productivity by 06/30/2020.Step Four: Evaluate changes by pulling secondary baseline. Make changes to plans/policy/process as appropriate by 9/30/2020.FromDataMgmt.VerbalReportVerbalReportFrom Data Mgmt. plus verbal report#8Effective- nessEfficiencyClinicalCIOCOO02/202006/2020CollaborationMeaningful UseIntegrated Health CareImplement the ability for Sanilac CMH’s EMR to direct email one of our county hospitals.VerbalReport#9AccessEffective- nessEfficiencyClinicalCCOClinical Supervisors02/202006/2020CollaborationIntegrated Health CareAppropriate Sanilac CMH clinical staff will continue to meet, at least quarterly, with the Care Managers at local hospitals to help improve collaboration.Verbal Report#10AccessEffective- nessEfficiencyClinicalCCOClinical Supervisors02/202006/2020CollaborationIntegrated Health CareBest PracticesHold discussion with local hospital partners to look at ways to have a co-location to help improve integrated health practices.Verbal Report#11AccessClinicalCCOClinical Supervisor02/202006/2020Community NeedJail/Court Liaison staff will visit state hospitals and forensic centers at least monthly.Verbal Report#12AccessEffective- nessClinicalCCO02/202006/2020Best PracticesCurrent committee will meet monthly to review recidivism cases and provide appropriate recommendations.Verbal Report#13AccessEffective- nessSatisfac- tionCommunityLivingSupportsProgramSupervisor04/202008/2020Best PracticesHCBWSBy 09/30/2020, the CLS program will assist a minimum of 10 individuals in becoming a participating member in an ongoing community group, event, or service. Reduce dependence on CLS sponsored groups/activitiesCreate greater community connectionsVerbal Report#14AccessEffective- nessSatisfac- tionCommunityLivingSupportsProgramSupervisor04/202008/2020Best PracticesHCBWSBy 09/30/2020, the CLS program will assist in the successful transition of 6 people to a more independent living arrangementPartner with Care Managers to identify potential candidates for independent living.Explore shared housing options for individuals.#15Effective-nessEfficiencyHuman ResourcesHuman Resource Manager04/202008/2020AdministrationFY 2019 GoalTo implement quarterly trainings to increase efficiency and effectiveness of the Administrative group in all areas (such as time management, discipline, communication etc.) Investigate trainings and resources available locally and onlineCreate a schedule of trainingsProvide trainingsVerbal Report#16AccessEffective- nessHuman ResourcesHuman Resource Manager04/202008/2020AdministrationOver the 2020 fiscal year the HR department will enhance our visibility to local and regional educational entities in order to promote and enhance our employee candidate pool.Over the first quarter the HR department will obtain a list of local and regional educational entities and schedule activities with a minimum of 4 entities for the remainder of the fiscal year.Over the second and third quarters the HR department will participate directly or obtain appropriate staff to participate in presentations/ job fairs to the scheduled locations.At the end of the fiscal year, the HR department will provide an analysis of the events and the impact it has had on the Agency’s employment pool.Verbal Report#17AccessEffective- nessJSCJSC Supervisor04/202006/2020State of Michigan HCBS WaiverEvaluate and develop an effective program to address HCBS Waiver Rules.Review current staff vs. individual ratios.Provide at least one community activity this year that is open to the public.#18AccessEffective- nessSatis-factionPreventionCEO/ Prevention Department02/202008/2020CollaborationFY 2019 GoalDevelop and provide a community education program, including website updates, Facebook posts, articles, radio spots to promote Sanilac CMH services to the community.Provide semi-annual reports to QI Committee on the activities completed.VerbalReport#19AccessPreventionMental Health First Aid Trainer02/202008/2020Best PracticesFY 2017, 2018 & 2019 GoalProvide MHFA and YMHFA trainings to residents of Sanilac County in order to reduce stigma associated with mental illness and enhance the community’s ability to assist individuals with mental health issues.Provide YMHFA and MHFA to the community as needed.Report the locations/ organizations that have requested training on a semi-annual basis. Highlighting new or unique sites.Provide the QI Committee with results of the surveys semi-annually and a summary of the year’s trainings on 08/2020.VerbalReport#20EfficiencyEffective-nessRecipient RightsRecipient Rights Officer04/202008/20202017 & 2019 MDHHS ReviewsFY 2019 GoalQuarterly, ORR will pull a sampling of Incident Reports, one from each provider that Sanilac CMH contracts with, to ensure that the field “Corrective Measures Taken to Remedy and/or Prevent Recurrence” is completed properly by supervisory staff.If it is found that the field is not completed properly by a specific contract provider, a larger sampling will be reviewed.If it is found that the provider is consistently not completing this area correctly, additional training with the supervisor will take place.ORR will report on all supervisory staff trainings that take place.Verbal Report#21AccessEffective-nessSatis-factionVocational ProgramProgramSupervisor02/202006/2020Agency needFY 2019 GoalBy 08/30/2020 the vocational training program will successfully transition 15 individuals to community employment or to MRS for employment placement services.Verbal Report#22AccessEffective-nessSatis-factionContract Management/CCOCIO/CCO04/202008/2020Agency needEvaluate current contract home provider network and ensure that we have the appropriate skilled providers to address individual needs within our contract system.Verb Report#23AccessEffective- nessSatis- factionData ManagementData Coordinator02/202006/202008/2020Region 10 initiativeBest PracticesSanilac will participate in the Tobacco Cessation (PIP) with Region 10. Baseline data on tobacco cessation products prescribed for those we serve that use tobacco products will be pulled by 10/01/2019Updates will be provided to Region 10 and QI Committee regarding educational material and trainings provided to staffUpdates will be provided to Region 10 and QI Committee regarding educational material and trainings provided to individuals we serve.Updated data on tobacco cessation products prescribed for those we serve that use tobacco products will be pulled by 05/2020.Verbal report#24Effective- nessEfficiencySanilac CMH Practice Transformation TeamDCFO02/202006/202008/2020EffectivenessMichigan Practice Transformation ProjectLook at how to implement incentive payments to our residential system to help reduce our current out of county placements.Verbal report#25 Effective-nessEfficiencySanilac CMH Co-Occurring Monitoring treatment programClinic Services SupervisorCCO2/20206/20208/2020EffectivenessCo-Occurring Treatment Monitoring A team will be developed to come up with a recommendation for administration for a more effective co-occurring monitoring system. Policy/Procedure will be developed to outline the approved co-occurring monitoring practice. Staff will be trained on approved practice and appropriate staff will be assigned lead. Verbal report ................
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