Introduction. Quality Improvement Principles

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2 Intrductin San Jaquin Cunty Behaviral Health Services (SJCBHS) is cmmitted t service excellence and cntinuus quality imprvement. Tward this end, SJCBHS has implemented a Quality Imprvement Prgram that mnitrs the quality f services prvided. A cmpnent f SJCBHS Quality Imprvement Prgram is the develpment, implementatin and mnitring f a Quality Imprvement Wrk Plan. The Quality Imprvement Wrk Plan serves as the fundatin f SJCBHS cmmitment t cntinuusly imprve the quality f treatment and services prvided. The Plan als prvides a radmap fr activities that are designed t achieve the gals and bjectives identified in the Plan. Quality imprvement activities are reprted n and reviewed in quarterly meetings f the Quality Imprvement Cuncil, the Steering Cmmittee and the Cmpliance Steering Cmmittee meetings. The fllwing infrmatin prvides an verview f SJCBHS Quality Imprvement Principles, Cntinuus Quality Imprvement Activities, the Annual Evaluatin prcess, and ends with the Quality Imprvement Wrk Plan gals and bjectives. Quality Imprvement Principles Quality Imprvement is defined as a systematic apprach t assessing services and imprving them. SJCBHS apprach t quality imprvement is based n the fllwing principles: Recvery riented: Services prvided shuld prmte and preserve wellness and expand chices t meet individually defined gals. Emplyee Empwerment: Effective quality imprvement initiatives shuld invlve peple at all levels f the rganizatin in imprving quality. Leadership Invlvement: Strng leadership, directin and supprt f quality imprvement activities are essential t perfrmance imprvement. Invlving rganizatinal leadership assures that quality imprvement initiatives are cnsistent with SJCBHS missin, visin, and values and cmpliment the rganizatin s Strategic Plan. Data Driven Decisin Making: Successful quality imprvement prcesses shuld incrprate feedback lps, using data t develp practices and measure results. Page 2

3 Preventin ver Crrectin: Cntinuus quality imprvement includes designing prcesses that achieve psitive utcmes rather than fixing prcesses that d nt prduce desired results. These principles serve as a cmpass t guide quality imprvement activities. Cntinuus Quality Imprvement Activities The purpse f quality imprvement activities is t imprve the utcmes f existing services and/r t design new services. Tward this end, SJCBHS quality imprvement activities include: Cllecting and analyzing data t measure against the gals, r priritized areas f imprvement that have been identified; Identifying pprtunities fr imprvement and deciding which activities t pursue; Identifying relevant cmmittees internal r external t ensure apprpriate exchange f infrmatin with the Quality Imprvement Cuncil; Obtaining input frm prviders, beneficiaries and family members in identifying barriers t delivery f clinical care and administrative services; Designing and implementing interventins fr imprving perfrmance; Measuring the effectiveness f the interventins; Incrprating successful interventins int SJCBHS peratins as apprpriate; and Reviewing grievances, standard appeals, expedited appeals, fair hearings, expedited fair hearings and prvider appeals. Quality Imprvement Cuncil The Quality Imprvement Cuncil (C) is a frmal bdy that has respnsibility fr reviewing the quality f services prvided by SJCBHS and its cntracted prviders. The C recmmends plicy decisins, reviews and evaluates the results f activities, including Perfrmance Imprvement Prjects (PIPs), institutes needed actins, ensures fllw up f prcesses and dcuments its decisins and actins taken. The C reviews and analyzes the results f the Page 3

4 activities f the Review Subcmmittee and the Activities Subcmmittee and makes recmmendatins regarding any impediment t quality f care, quality utcmes, timeliness f care and/r access t service. The C meets quarterly and its membership includes members f SJCBHS Senir Management, Prgram Managers, prviders, cnsumers and family members. Annual Evaluatin An annual evaluatin f the effectiveness f Quality Imprvement activities is cmpleted. The annual evaluatin is cnducted by the Quality Imprvement Cuncil and is kept n file. The evaluatin summarizes prgress assciated with each f the Quality Imprvement Wrk Plan gals and bjectives, and includes actin taken in respnse t these utcmes. Based upn the evaluatin, revisins may be recmmended. Any revisins are dcumented within the Plan. Quality Imprvement Wrk Plan The fllwing gals and bjectives were develped by the Quality Imprvement Cuncil and reflect SJCBHS cmmitment t ensure: Services are prvided in a timely and efficient manner, with apprpriate crdinatin and cntinuity f care; Risk t cnsumers, prviders and thers is minimized, and errrs in the delivery f services are prevented; Services prvided include cultural sensitivity; and Services are apprpriate t each cnsumers needs and are available when Page 4

5 Timeliness T ensure timely access t quality behaviral health treatment 1 Ensure 75% f clients are scheduled fr an initial assessment within 10 business days r less frm their first request fr services. Adult Services: 10.3 Children & Yuth Services: 9.04 All Services: 9.67 Surce: FY 14/15 EQRO Self Assessment f Timely Access the length f time frm initial cntact t first appintment. quarterly Cuncil meeting, prgrams, including cntractrs. Cuncil, All prgrams, including cntractrs. Identify and address barriers t timely access Ad Hc Cmmittee t be established as Page 5

6 Timeliness T ensure timely access t quality behaviral health treatment 2 Average length f time frm first request fr services t first psychiatry appintment will be 30 days r less. Adult Services: 22 days Children & Yuth Services: days All Services: 23.9 days Surce: FY 14/15 EQRO Self Assessment f Timely Access the length f time frm initial cntact t first psychiatry appintment. Explre strategies fr expanding the availability f psychiatrists including enhancing telemedicine and using psychiatrists wh cntract with health plans. prgrams, including cntractrs. Ad Hc Cmmittee t be established as quarterly Cuncil meeting. prgrams, including cntractrs. Page 6

7 Timeliness T ensure timely access t quality behaviral health treatment 3 Wait time frm request t clinician evaluatin, fr an urgent appintment in Crisis Interventin Services, will be reduced t less than tw hurs. 2:03 (hurs:minutes) Surce: Quality Imprvement Cuncil Meeting Minutes access data fr timely appintments fr urgent cnditins. quarterly Cuncil meeting. IS, Cuncil, 24 Hur Services IS, Cuncil, 24 Hur Services Page 7

8 Timeliness T ensure timely access t quality behaviral health treatment 4 Ensure the average length f time fr a fllw up appintment after hspital discharge is 7 days r less. Adult Services: 7 days Children & Yuth Services: 5 days Surce: FY 14/15 EQRO Self Assessment f Timely Access access data regarding scheduling fllw up appintments after hspitalizatin. If warranted, explre the feasibility f expanding pst PHF Clinic. prgrams. Ad Hc Cmmittee t be established as quarterly Cuncil meeting. prgrams. Page 8

9 Timeliness T ensure timely access t quality behaviral health treatment 5 Less than 15% f persns hspitalized will be readmitted within 30 days f discharge. Adult Services: 14.8% Children & Yuth Services: 6.0% All Services: 10.4% Surce: FY 14/15 EQRO Self Assessment f Timely Access data regarding readmissins. quarterly Cuncil meeting. Prgrams prgrams, including cntractrs. Page 9

10 Timeliness T ensure timely access t quality behaviral health treatment 6 N shws fr Clinicians/Nn Psychiatrists will be 15% r less. Adult Services: 20.7% Children & Yuth Services: 10.2% All Services: 15.4% Surce: EQRO Self Assessment f Timely Access n shws data. quarterly Cuncil meeting, prgrams including cntractrs. Identify and address reasn(s) fr n shws Ad Hc Cmmittee t be established as needed prgrams, including cntractrs. Page 10

11 Timeliness T ensure timely access t quality behaviral health treatment 7 N shws fr Psychiatrists will be 15% r less. Adult Services: 20.4% Children & Yuth Services: 8.7% All Services: 14.5% Surce: FY 14/15 EQRO Self Assessment f Timely Access n shws data. quarterly Cuncil meeting, prgrams including cntractrs. prgrams including cntractrs. Identify and address reasn(s) fr n shws Ad Hc Cmmittee t be established as Page 11

12 Access Ensure timely and apprpriate access t specialty mental health treatment 1 100% f test calls answered by the 24/7 line will prvide timely and accurate infrmatin, in all languages and be dcumented accrdingly. 50% f the calls were recrded in the lgbk; 57% f the calls had the date recrded in the lgbk; 50% f the calls had the name f the caller recrded; 64% f the calls that used an interpreter r language line recrded; 53% f the calls had the initial request fr service r cncern recrded in the lgbk; Mnitr benchmarks tracking timely and apprpriate access t mental health services. Identify and address bstacles t apprpriate call respnse and dcumentatin. Cnduct test f the 24 hurs call line and the fllw up system. IS, Cuncil, Access, Subcmmittee 50% f the calls recrded the dispsitin in the lgbk. Data Surce: 14/15 Quality Imprvement Wrk Plan Annual Evaluatin Page 12

13 Access Ensure timely and apprpriate access t specialty mental health treatment 2 Assess the capacity f the service delivery system, including mnitring the current number, types and gegraphic distributin f mental health services within the delivery system Nne the number, types and gegraphic distributin f services within the SCJBHS system f care. quarterly Cuncil meeting. IS, Cuncil, Access Cuncil, All prgrams Page 13

14 Access Ensure timely and apprpriate access t specialty mental health treatment 3 Increase the penetratin rate t 2.9% amng eligible Hispanics. 2.36% Surce: FY 14/15 Quality Imprvement Wrk Plan Annual Evaluatin utilizatin rates by age, diagnsis, gender and preferred language. quarterly Cuncil meeting. Identify barriers t unserved/underserved ppulatins and strategies fr imprvement. prgrams, including cntractrs prgrams including cntractrs Ad Hc Cmmittee t be established as Page 14

15 Access Ensure timely and apprpriate access t specialty mental health treatment Assess capacity t ensure cntinuity and crdinatin with physical health care. Nne Identify preliminary indicatrs t begin t evaluate Primary Care/Behaviral Health integrated services. Cuncil, Ad Hc Cmmittee t be established as 4 quarterly Cuncil meeting. prgrams including cntractrs Page 15

16 Quality T ensure that the quality f care and services delivered by SJCBHS meets standards established by SCJBHS and its regulatry agencies. 90% f clients will be satisfied with BHS services. Disseminate survey results t internal and external stakehlder, quarterly. 91% Surce: SJCBHS Survey Administer and analyze required and lcal/prgram specific satisfactin surveys. Infrm stakehlders f the results f the beneficiary satisfactin survey., Cmpliance, Cmpliance 1 Explre the feasibility f develping and/r expanding a family/supprt system satisfactin survey. quarterly Cuncil meeting. needed Cuncil, Cmpliance prgrams including cntractrs. Page 16

17 Quality T ensure that the quality f care and services delivered by SJCBHS meets standards established by SCJBHS and its regulatry agencies. 70% f grievances will be addressed within 30 days f receipt and the remaining 30% will be addressed within 60 days f the date f receipt. 46.9% were respnded t within 30 days and 53.1% were respnded t within days. Surce: FY 14/15 Wrk Plan Annual Evaluatin grievances, appeals and state hearing actins, including type, gender, race and language as part f the tracking system. IS, 2 Explre strategies fr enhancing the grievance mnitring/tracking system. quarterly Cuncil meeting. Cuncil prgrams including cntractrs Page 17

18 Quality T ensure that the quality f care and services delivered by SJCBHS meets standards established by SCJBHS and its regulatry agencies. Acrss all SJCBHS systems f care, study, analyze and cntinuusly imprve medicatin practices. Nne medicatin mnitring practices in utpatient clinics. IS, Cuncil, Medical Directr 3 Establish baseline and identify targets fr imprvement. Determine feasibility f establishing practice guidelines. prgrams including cntractrs Medical Staff Medical Staff Page 18

19 Quality T ensure that the quality f care and services delivered by SJCBHS meets standards established by SCJBHS and its regulatry agencies. 90% f requests fr change f prvider will be prcesses within 30 days f receipt. 49% Surce: FY 14/15 Wrk Plan Annual Evaluatin requests fr change f prvider. IS,, All prgrams, including cntractrs 5 Explre the current prcesses fr addressing requests t change prviders and, if warranted recmmend strategies fr imprving current prcesses. quarterly Cuncil meeting Ad Hc Cmmittee t be established as needed Qi prgrams including cntractrs Page 19

20 Staff Develpment & Prductivity Imprve staffs capacity t advance client utcmes. 1 Develp and implement strategies t enhance cultural cmpetence and linguistic cmpetence amng SJCBHS staff and partners, including develping a system t mnitr linguistic cmpetence. Nne Mnitr the implementatin f the Cultural Cmpetency Plan Develp recmmendatins fr staff training and develpment. Identify training/educatinal pprtunities t enhance the array f culturally and linguistically cmpetent skill sets, Cuncil, Cuncil, Cultural Cmpetence Cmmittee Page 20

21 Staff Develpment & Prductivity T ensure that the quality f care and services delivered by SJCBHS meets standards established by SCJBHS and its regulatry agencies. Reduce disallwances related t dcumentatin. 2.14% Surce: FY 14/15 Wrk Plan Annual Review Update/Disseminate Clinical Training Manual Update dcumentatin training Implement updated clinical dcumentatin training Ad Hc Cmmittee t be established as Ad Hc Cmmittee t be established as Trainers Cnduct cmprehensive clinical recrd review., Review Subcmmittee 2 FY 14/15 Mnitr Unbilled Services Reprt, including analyzing trends. McFlp data. quarterly Cuncil meeting. prgrams including cntractrs Page 21