BUSINESS CASE FOR CRITICAL INCIDENT SYSTEM FOR DISABILITY SERVICES

BUSINESS CASE FOR CRITICAL INCIDENT SYSTEM FOR DISABILITY SERVICES Business Case Development Participants Name Phone Email Terri Richard, Project Director, 206-4637 Teresa.Richard@DADS.state.tx.us Quality Assurance & Quality Improvement in Home and Community-Based Services Real Choice Grant Scott Barto, Project Director, 206-5798 Scott.Barto@DADS.state.tx.us Critical Incident Reporting System for Mental Retardation Services and Advisory Subject Matter Expert to the QA/QI Grant Taskforce Shirley Zirkle, Contracted 206-5874 Shirley.Zirkle@MHMR.state.tx.us Business Analyst Joye Saladino, Administrative Assistant 206-4706 Joye.Saladino@MHMR.state.tx.us

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TABLE OF CONTENTS 1. BUSINESS CASE OVERVIEW. 3 1.1 PURPOSE OF BUSINESS CASE... 3 1.2 EXECUTIVE SUMMARY. 3 1.3 CRITICAL INCIDENT MANAGEMENT SYSTEM OBJECTIVES 5 1.4 ANALYSIS SCOPE 5 1.5 ADDITIONAL CONSIDERATIONS. 6 1.6 CONSTRAINTS.. 6 1.7 SCHEDULING CONSIDERATIONS 6 2. BENEFIT SUMMARY 6 3. APPENDIX... 7 3.1 DEFINITIONS AND ACRONYMS... 7 3.2 FEDERAL OR STATE LEGISLATION REFERENCES.. 8 3.3 BACKGROUND AND STATISTICS.... 9 3.4 QA/QI IN HOME AND COMMUNITY-BASED SERVICES GRANT... 9 3.5 CENTERS FOR MEDICARE AND MEDICAID SERVICES DOCUMENTS. 9 3.6 OTHER STATE CRITICAL INCIDENT REFERENCES.. 9 3.7 WINGSPREAD WHITE PAPER ON QUALITY... 9 3.8 HEALTH AND SAFETY ALERTS....9 3.9 LAWSUIT EXAMPLES.....10 3

1. BUSINESS CASE OVERVIEW 1.1 PURPOSE OF BUSINESS CASE The purpose of this document is to recommend that DADS proceed to the next phase in the development of a comprehensive critical incident management system. The Business Case Development Participants have completed a cursory analysis of critical incident systems and needs. This document provides the background to support an executive management decision to commit resources to conduct an in-depth study to determine scope and cost for the development of a comprehensive critical incident management system. This undertaking is considered to be particularly important and timely in order to accommodate response to new CMS guidelines for 1915(c) waivers (see Appendix, 3.5 Centers for Medicare and Medicaid Services, Draft Waiver Application/Appendix G: Participant Safeguards). 1.2 EXECUTIVE SUMMARY Background: Safety is a major concern of the general public and of policymakers at the State and Federal levels. As a result of the State s response to the Olmstead decision, moving a major population of consumers into the community, there are new challenges to providing consumer safeguards. The ability to capture critical incident data that is useful, analyze that data in a meaningful way, use this analysis to make refinements and improvements, is fundamental to providing effective safeguards. For the purposes of this document, critical incidents are those events that directly involve harm, or risk of harm to individuals and are generally unexpected or unpredictable. Knowledge of these events is gained by multiple mechanisms including complaints, reports of abuse, neglect or exploitation, and other required reporting of incidents. Critical incidents may also come to light by other means including survey and certification activities and satisfaction surveys. A first-phase umbrella strategy for provider reporting of critical incident data was implemented across all mental retardation funding streams in fiscal year 2004 (see Appendix, 3.3 Background and Statistic). Aggregate statistical data is reported monthly under a set of defined reporting requirements. While this system has a definite utility for contract oversight and quality improvement activities, it also has some serious limitations. The system was implemented essentially as a stopgap measure for quality assurance mechanisms that had been in force. It was the understanding of TDMHMR s executive management team that this was a first phase in a building block approach to critical incident management. The chief concern is the lack of person, place and time data. The following identifies Texas Department of Mental Health and Mental Retardation s progress in critical incident reporting: September 1997 MRA s began submitting aggregate critical incident data on paper September 2003 TDMHMR began analysis for automated system 4

2003-2004 Incident reporting guidelines developed 2003 Critical Incident statistics included in Quarterly MR Risk Assessment February-April 2004 Provider contracts/agreements amended to include aggregate critical incident reporting requirements March-May 2004 Waiver providers began reporting aggregate critical incident data into the automated Critical Incident Reporting System Problem Statement: The current critical incident system does not provide the means to track individual critical incidents; therefore it does not provide a means of determining critical incident disposition, timeliness of response or outcome of investigations. It also does not provide a means of identifying person outliers (for example: one person is the reason for the large number of physical restrains by a specific provider) that might skew trend analysis. Currently multiple systems are used for critical incident reporting related to disability services. Critical incidents span across departmental responsibilities of DADS and DFPS. Within DADS, critical incidents span across programs and funding streams for disability services. House Bill 2292 directs Texas health and human services agencies to eliminate duplicative administrative systems (see Appendix, 3.2 Federal or State Legislation References). Presently there are significant differences in both the scope of incident surveillance and in data captured for reporting, investigation, follow up and resolution. Fragmented data systems present barriers to coordination, efficient staff resourcing and oversight. The key concerns with the current process are: Inability to track individual incidents Inability to identify at-risk individuals from repeat critical incidents Inability to identify outliers that would help provide a complete analysis of critical incidents Inability to track numbers of restraints with individuals who have behavior intervention plans that authorize restraints Inability to provide proposed CMS regulatory reporting, including tracking incident disposition, timeliness of response and outcome of a critical incident investigation Inability to produce alerts about program practices based on trend analysis Fragmented data collection systems Recommendation: The Department should conduct an in-depth analysis of options for the creation of a comprehensive, evidence-based, best practices critical incident management system. This system should provide the following capability: To track the details of an individual incident from initial intake and investigation through final disposition To track follow-up on investigations and remediation To produce alerts on defined criteria aimed at prevention To identify duplicated events that represent the same critical incident 5

To strategically analyze patterns, trends and inconsistencies so that the Department can provide the optimum response to risk To produce uniform reports that include data required by CMS for waiver program renewal and monitoring Fully integrated with the Department s Client Assignment and Registration System (CARE) Fully integrated with the Department s Compliance, Assessment, and Regulatory Enforcement System (CARES) Integration with other HHS department critical incident systems (specifically DFPS) for related critical incident status reporting 1.3 CRITICAL INCIDENT MANAGEMENT SYSTEM OBJECTIVES The following are the major objectives for the development of a comprehensive critical incident management system: Increase effectiveness and efficiency in ensuring the health and welfare of people receiving services Meet reporting requirements (Federal, State and Public) Improve capability for data validation Increase cost efficiency through elimination of redundancies and more accurate targeting of staff resources Improve contract monitoring capabilities Improve services through prevention activities Empower providers to evaluate their own program and make system improvements on a program-by-program basis 1.4 ANALYSIS SCOPE While automation needs are critical to this project, the scope of analysis is broader. During the next phase, analysis of the following should be considered: Automation requirements Internal and external stakeholder input Personnel resources Funding options Standardization of critical incident reporting across HHS departments Review of new Federal reporting requirements (see Appendix, 3.5 Centers for Medicare and Medicaid Services, Draft Waiver Application/Appendix G: Participant Safeguards) Scope of incident surveillance reporting requirements Triaged investigations of critical incidents Policies and procedures for state operations related to critical incidents State rules and regulations regarding critical incidents State contract amendments and monitoring Investigator training and certification HHS department critical incident data systems and architectures Data issues (retention, access and security) Non, under and false reporting of critical incidents 6

Quality review activities (support of provider quality improvement initiatives, inter-department management review, regulatory review and prevention activities) Providing public information in support of making informed choices in provider selection Review of best practices in other states (see Appendix, 3.6 Other State Critical Incident References) 1.5 ADDITIONAL CONSIDERATIONS Fair representation of critical incident data needs to give due consideration to the fact that incident rates are influenced by a number of factors including but not limited to vigilance in reporting and characteristics of people in services. Higher numbers do not necessarily equate to a concern about a provider s quality of services. Data reporting and disclosure needs to be addressed responsibly so that providers do not feel they are being punished for vigilant reporting practices or serving people with greater behavioral or medical challenges. 1.6 CONSTRAINTS Existing funding Examination of and revision of policies, procedures, rules, regulations and contracts/agreements is labor intensive and time consuming 1.7 SCHEDULING CONSIDERATIONS To proceed with system development requires a detailed analysis of options and cost In this, the second year of the QA/QI Grant, there are product expectations related to the development of a critical incident management system (see Appendix, 3.4 QA/QI in Home and Community-Based Services Grant, QA/QI in Home and Community-Based Services Grant Application) Stakeholder input to the QA/QI grant activities is scheduled and ongoing (see Appendix, 3.4 QA/QI in Home and Community Based Services Grant, QA/QI Taskforce Website) Every three/five years the waiver programs are scheduled for renewal 2. BENEFIT SUMMARY Extended cause and effect analysis, analysis of groups of incidents, and the potential use of a history of cases for enhanced development of strategies to mitigate risk Increased monitoring to help ensure that people living in the community receive quality services in a safe environment Substantial improvement of critical incident reporting Ability to provide continued progress in the monitoring of community-based waiver services Ability to meet increased reporting requirements 7

Advocate support A system where provider organizations are more accountable to the citizens of Texas for the services they provide Early identification of at risk individuals can be used to support and focus response intervention strategies A system that supports providers in establishing their own quality improvement initiatives Reduce State s litigation risk (see Appendix, 3.9 Lawsuit Examples) Possible reduction in incarceration rates, psychiatric hospitalization, use of hospital emergency rooms, victimization, and associated court costs To provide a mechanism for multiple levels of response and investigation dependent on critical incident review criteria Potential use of Quality Assurance and Quality Improvement in Home and Community-Based Services Real Choice Grant funds 3. APPENDIX 3.1 DEFINITIONS AND ACRONYMS Term Centers for Medicare and Medicaid Services (CMS) Client Assignment and Registration System (CARE) Compliance, Assessment, and Regulatory Enforcement System (CARES) Olmstead Outlier Definition The federal agency that administers Medicaid programs The Department s automated system for services to the disabled The Department s automated system for services to the aging Olmstead refers to a Supreme Court ruling in June of 1999 under Title I of the Americans with Disabilities Act about the states obligations to provide community services to individuals with disabilities. The Supreme Court held unequivocally that unnecessary institutionalization and isolation of individuals with disabilities constitutes discrimination under the ADA. A statistical term that refers to a data point that is located far from the rest of the data; given a mean and standard deviation, a statistical distribution expects data points to fall within a specific range; those that do not are called outliers and should be investigated. 8

3.2 FEDERAL OR STATE LEGISLATION REFERENCES HB 2292, 78 th Texas Legislature requires health and human services agencies to consolidate organizational structures and functions, eliminate duplicative administrative systems, and streamline processes and procedures related to health and human services. HB 2292 also addresses a consumer-directed services program. This business case proposal is further applicable because it would provide the consumer with information about providers so they can make informed choices in consumer-directed services. It would also contribute to the bill s direction to develop a system to monitor the (consumer-directed services) program to ensure adherence to existing applicable program standards. http://www.hhsc.state.tx.us/crcg/relatedlegislation/hb_2292.html Health Insurance Portability and Accountability Act of 1996 The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions (45 C.F.R. pt. 162 (2003)) and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data (45 C.F.R. pts. 160 and 164 (2003)). Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care. http://www.cms.hhs.gov/hipaa/ 3.3 BACKGROUND AND STATISTICS Critical Incident Background Document: Will be handed out at the meeting. 3.4 QA/QI IN HOME AND COMMUNITY-BASED SERVICES GRANT QA/QI Taskforce Website: http://www.dads.state.tx.us/business/mental_retardation/qaqi/taskforce.html QA/QI in Home and Community-Based Services Grant Application: http://www.dads.state.tx.us/business/mental_retardation/qaqi/index.html 3.5 CENTERS FOR MEDICARE AND MEDICAID SERVICES CMS Quality Framework: http://www.cms.hhs.gov/medicaid/waivers/frameworkmatrix.asp Draft Waiver Application/Appendix G: Participant Safeguards: 9

http://www.nasmd.org/overviewofdraftrevisedapplication8-23-04.pdf CMS Waiver Protocol: www.cms.hhs.gov/medicaid/waivers/waiverrevprotocol.asp http://www.cms.hhs.gov/medicaid/1915c/proto1-2.pdf Section 1915(b) Waiver Program, Independent Assessment: Guidance to States http://www.cms.hhs.gov/states/letters/smd1222a.pdf GAO Report on Federal Oversight of HCBS Waivers: http://www.gao.gov/atext/d03576.txt 3.6 OTHER STATE CRITICAL INCIDENT REFERENCES NEW MEXICO: DOH/DHI Incident Management System Six Month Report DD Waiver Residential and Habilitation Providers: http://dhi.health.state.nm.us/elibrary/imbdocs/ims_6monthtrendsdata2004.pdf New Mexico Department of Health Incident Management System Trends Data SFY 2003: http://dhi.health.state.nm.us/elibrary/imbdocs/ims_trendsdata2002.pdf New Mexico Department of Health Mortality Review Committee Annual Report: http://164.64.82.101/elibrary/mortalityreport2002.pdf New Mexico Community Based Services Incident Reporting and Investigation Requirements: http://dhi.health.state.nm.us/elibrary/imbdocs/7.14.3nmac-final.pdf OHIO: Ohio s ODMR/DD MUI Registry Unit Provider Assessment Review: http://odmrdd.state.oh.us/includes/mui_rule/2004%20provider%20assessment %20Tool%20Draft.pdf Ohio s Incident Reporting and Tracking System: http://www.cms.hhs.gov/promisingpractices/datareadinessoh.pdf PENNSYLVANIA: Pennsylvania s Incident Management Rule: www.pabulletin.com/secure/data/vol32/32-17/744.html 3.7 WINGSPREAD WHITE PAPER ON QUALITY WINGSPREAD WHITE PAPER ON QUALITY Building a Comprehensive Quality Management Program for Public Developmental Disabilities Service Systems: 10

http://www.thearclink.org/news/article.asp?id=308 3.8 HEALTH AND SAFETY ALERT EXAMPLES Physical Restraints Alert: http://dhi.health.state.nm.us/elibrary/healthalerts/alertphysicalrestraints.pdf Preventing Physical Abuse in Agencies Alert: http://odmrdd.state.oh.us/includes/alertdocuments/alert_preventingabuse_2.1 7.04.pdf Bathing Injury Alert: http://dhi.health.state.nm.us/elibrary/healthalerts/alertinjuredwhilebathing.pdf 3.9 LAWSUIT EXAMPLES Physical Restraints Alert: Patient Suffers in System With-out Oversight: http://www.toddlertime.com/5150/restraint/day-3.htm Abuse of Those Considered Mentally Ill: http://www.woatusa.org/cat/catreport/mental.html Abuse of Disabled Found in Community-Based Homes: http://www.tennessean.com/local/archives/01/04/07186005.shtml As Care Declines, Cost Can Be Injury, Death http://www.washingtonpost.com/wp-dyn/articles/a47732-2004may22.html How and When to Report Abuse is Unclear to Workers at Facilities: http://www.ent-net.com/news/reports/center/center4.htm Attorney General Abbot Files Lawsuit in Sexual Assault of Mentally Challenged Woman: http://www.oag.state.tx.us/oagnews/release.php?id=302 Puerto Rico to Improve Conditions at it s Mental Retardation Facilities: http://www.usdoj.gov/opa/pr/1999/april/148cr.htm U.S. Probes D.C. Group Homes: http://www.babcockcenter.org/reading/booarticleiii.htm 11