NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS



REVISIONS TO POLICY STATEMENT: YES NO OTHER REVISIONS: YES NO

APPLIES TO:

All service and administrative levels of the organization.

POLICY:

To ensure Northpointe consistently and continuously designs processes well and systematically monitors, analyzes, and improves performance to improve individual outcomes and deliver Value to our recipients.

PURPOSE:

The Quality Improvement Program provides a structured system-wide method of identifying areas of improvement, monitoring and evaluating efforts as they relate to the quality of care provided to all service recipients of Northpointe. High volume and/or high-risk service areas will receive needed priority within the system

DEFINITIONS:

Value: Quality divided by Cost

Service Recipients: persons receiving services from Northpointe or a Northpointe contracted provider (Trico, Goodwill, etc.).

Stakeholders: Northpointe staff, Board of Directors, Dept. of Community Health, recipients, former recipients, guardians, Community representatives, County Boards of Commissioners, local agencies, schools, law enforcement, public at large, etc.

Organizational Performance Indicator: Performance indicators selected by leadership to monitor overall organizational performance.

Departmental Performance Indicator: Performance indicators selected by a department(s) and/or manager(s) to monitor departmental performance.

Core Program Performance Indicator: CARF requires one effectiveness and one efficiency performance indicator, and satisfaction indicators for each accredited core program or program seeking accreditation.

PROCEDURES:

• Northpointe maintains a muti-disciplinary Quality Improvement Team for the purpose of evaluating all aspects of the quality improvement program. The QI team meets monthly.

• Members of the QI team include QI Manager, County Directors, Recipient Rights Officer, Community Housing Director, Director of Community Inclusion, OAS/Crisis services manager, Clinical Care Managers, Medical Records/Access Manager, Director of Nursing and an RN, ELMER Support Specialist. The Medical Director is a member of the team and will provide input as needed. Additional staff will attend as needed..

• The QI Team routinely reviews Performance Improvement projects and Outcomes reports, New Directives from MDHHS, CARF and other governing bodies, policies and procedures, ELMER updates, Safety updates, Quality Record Reviews, Recipient Rights reports which will include reports on BTC and physical restraint, Plans of Correction, Suggestions for Improvement, Recipient suggestion or complaints, Critical Incidents, Quality Data reports. This list is not all inclusive as items will be added to the agenda as needed.

• Minutes are taken and maintained by the Board Secretary and send to all QI members for review.

1. Northpointe will develop and implement a Quality Assessment and Performance Improvement Plan (QAPIP). The QAPIP will be reviewed and updated as necessary (at least annually); and will require annual Board approval. The QAPIP Plan will include the following elements:

• Organizational performance improvement goals and objectives

• Quality Improvement Structure

• Roles and responsibilities of QI Teams

• Organizational Performance Indicators (PIs)

2. The following methods are used to initiate Quality Improvement Projects:

a) Suggestion for Improvement

Purpose: To provide an avenue for any staff member to make suggestions for improvement.

This form (QI.103) is to be completed by any staff identifying an area for improvement. Upon completion, this form is forwarded to the QI Manager. The QI Manager will forward to appropriate team/manager for response. Once the appropriate manager has reviewed and noted their response on the form, it will be returned to the QI Manager who will bring to the QI Team for review, before returning to the originator. This may initiate a QI Project Initial Report.

b) Quality Record Review Process (QRC)

Purpose: Ongoing quality assurance reviews of clinical records, processes, and significant events as they relate to clinical documentation and record keeping. Chart reviews are performed monthly on clinical records of recipients; a minimum of one chart per clinician is reviewed quarterly. Clinical Supervisors complete the chart review with the staff member and issues are noted on the QRC form (QI.107) and then addressed immediately, if applicable. Cumulative reports are run by the Quality Improvement Manager and any trends are discussed in QI Team meetings. Corrective processes are implemented to correct any ongoing identified problem.

c) QI Project Initial Report

Purpose: To initiate a QI Project to ensure ongoing improvement efforts are made throughout Northpointe.

Any team/department that has identified an opportunity for improvement specific to their area(s) of responsibility, or has identified a need for an intensive review of an organizational process. Suggested QI Projects should be discussed with their immediate supervisor for approval. The immediate supervisor will forward copy to their department head and a copy to the QI Manager. QI Projects may be initiated by utilizing “Suggestion for Improvement” (QI.103) or a “Process Change” Form (QI.104).

d) Quality Improvement Project Progress Report

Purpose: To track and monitor QI project progress in order to show evidence of improvement and improvement sustained over time.

This report (QI.105) is to be completed by the person(s) identified on the Initial Report. A copy will be forwarded to the QI Manager each time a measurement has been added (e.g., monthly, quarterly, etc.)

3. Problem Solving Methodology and Process

Methods of problem solving create a common language that provides a degree of precision and clarity needed to identify, analyze, and resolve important issues. Following is a brief explanation of the steps to follow:

a) All reported data will be analyzed to identify trends/patterns that will initiate the implementation of improvement strategies and to conduct ongoing monitoring of improvement initiatives to ensure progress towards improvement and that improvement is sustained over time. An opportunity for improvement may exist, if the data reveal:

• Undesirable pattern or trend (3 consecutive quarters of not meeting established threshold/goal will necessitate more intensive assessment.);

• Undesirable variation(s) from that of recognized industry standards;

• Performance that is good but could be improved.

A close examination of the process or outcome of care is central to the improvement process and will yield a greater understanding of the variables that potentially affect or influence an indicator/event. Therefore, whenever warranted, a close examination of the indicator or event is suggested. This analysis will provide detailed information about the process or outcome that is being studied and should reveal the causes of performance. A root cause analysis is an example of an intensive process of searching out and identifying the causes of performance.

b) The next step is to identify the specific underlying factors that may have led to the indicator in question. Some, but not all, of these factors may be controllable. Contributing factors may include:

• Individual factors, including psychological, economic, social, and physiological variables;

• Organizational factors, such as adequate staffing and staff training;

• Provider factors, which influence the type of assessments and treatments a person may receive and their effectiveness;

• Environmental factors, such as adequacy of space for the number of individuals living in that space;

c) Next, narrow the list of potential contributing factors and respective interventions, to focus on the most relevant factors capable of being influenced or changed. Develop a plan for improvement interventions. Important elements of the plan include determining who will be involved and what will be required to implement.

d) Observe the effects of the intervention. After selecting the improvement intervention, continue collecting indicator data in the same manner as before. This allows comparison of indicator data before and after the intervention. Allow sufficient time for the intervention to produce measurable effects. Some actions may have more immediate effect than others.

e) Once satisfied that sufficient time has elapsed to observe the effects of the intervention, analyze the indicator data and draw conclusions from the observed effects.

f) The results of the intervention shall be communicated through routine reports and at least quarterly.

g) The conclusions drawn from evaluating the results of the improvement intervention will either support full implementation of the intervention or call for re-evaluation. Make the intervention policy or re-design as appropriate.

h) Continue to monitor the PI or QI Project. Continued assessment is a critical aspect of performance improvement as it ensures that the improved performance is maintained over time.

4. Setting Priorities for QI Initiatives:

The following criteria are helpful in setting priorities, with highest priority given to projects that directly affect recipient care, and can be used as a guide:

• expected impact on individual outcomes;

• expected impact on organizational outcomes;

• expected impact on performance;

• selecting high-risk, high-volume, or problem-prone processes to monitor;

• the relationship of the potential improvement to the dimensions of performance and functions of accredited bodies, DCH, and other regulations;

• the organization’s resources.

CONFIDENTIALITY

Confidentiality is a cornerstone in any QI program. Individuals engaged in quality improvement activities must maintain the confidentiality of the information. Reference to individual providers or members shall be impersonal in that those individuals are referred to by numbers or initials only, except when a specific reference is essential to meeting the goals of the Quality Assessment and Performance Improvement Program.

All written records, reports or any work product or communication related to quality improvement activities are to be considered privileged and confidential information. Any release of information is subject to legal approval. (Pursuant to Michigan Statutes, Act No. 168 of 1972.)

Northpointe’s procedures, committee minutes and recipient clinical records are open to review by accrediting bodies and to state and federal regulatory agencies, when applicable. (Members are notified of this via the “Privacy Notice.”) Information sharing is strictly limited to the specific purposes of the reviewing party. Confidentiality of Northpointe documents is governed by Northpointe’s confidentiality policies, in accordance with applicable promulgated HIPAA standards and within legal time frames for compliance.

CROSS REFERENCES:

Quality Improvement Plan

Clinical Record Quality Assurance Review policy

Suggestion for Improvement Form QI.103

QI Initial Report Form QI.104

QI Project Progress Report Form QI.105

Clinical Record Quality Assurance Review Form QI.107

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