Gratiot County Community Mental Health Services
Review of Total Quality Management Plan
January 2002
Agency Mission
Empowering individuals, through supportive services, to improve the quality of their lives.
Question: Is the mission viable, do people know it and use it to guide practice?
Answer: The mission is posted in each agency location and is included on the satisfaction survey, in agency marketing materials, and other agency documents.
Steering Committee Purpose Statement
To facilitate and monitor the development and implementation of processes that improve the quality of services to our consumers
Agency Strategic Plan
Question: Does the plan assess community needs?
Answer: Yes.
Question: How has needs assessment been carried out?
Answer:
1) Annual community needs assessment - MDCH budget preparation.
2) Feedback from consumer satisfaction surveys and suggestion review are used in making program development decisions.
3) A survey specific to community education and information needs was conducted with community agencies, consumers, and community members.
Question: do the programs in place naturally flow from the plan?
Answer: Yes.
Question: Does the plan in place contain long and short term directions?
Answer: Yes, 1-2 year steps and 5+ year steps.
Question: How will staff be made aware of the plan? How is the plan guiding agency practice?
Answer:
1) The plan is posted on TQM bulletin boards at each location following Steering Committee and Board approval.
2) Each department has developed quality indicators to be tracked and monitored and is responsible for addressing the goals of the strategic plan. Progress will be monitored through the QI process, reviewed with staff, and reported to the Board of Directors on a regular basis.
Question: What programs does the agency have?
Answer: The agency provides a full array of services, including Ancillary Services, Case Management, Child Waiver, Collaborative Community Services, Community Integration Training, Community Living Supports, Critical Incident Stress Management, Family Support Services, Geriatric Outreach, Home Based Services, Individual and Group and Family Therapy, Infant Mental Health, Intensive Behavioral Health, Nursing, OBRA, Psychiatric, Psychosocial Rehabilitation, Respite, Specialized Residential, Supports Coordination, 24 Hour Emergency, Vocational, and Wraparound.
Question: How does each program fit the mission and strategic plan?
Answer: Program descriptions include outcome measures. A program evaluation system is in development for the agency as a whole.
Information Systems
Question: How is information collected?
Answer: Reports are generated from the provider MIS system, or collected by designated staff if information is not available in the system. Reports needed to meet MDCH data reporting requirements and to increase staff efficiency in collecting information are continually being developed. The agency is in the process of a transition to a new provider MIS system, Our affiliation with Clinton-Eaton -Ingham Community Mental Health will play a key role in this transition.
Question: What information is collected?
Answer: Information required by the department directors to manage their areas of responsibility, administrative and financial information, MDCH reporting data, human resource information, consumer satisfaction survey results, and data necessary for quality improvement processes and monitoring.
Question: Are the service plans automated?
Answer: As noted above, the agency will be changing provider MIS systems, with an implementation goal of 10/1/03. Clinical components and their uses are being explored as part of the planning process.
Question: Who provides quality improvement teams with data from IS?
Answer: Data is provided to QI teams on an as needed basis. The IS department has assisted department clerical staff and supervisors in establishing several reports and databases to enable staff responsible for reporting or monitoring goal progress to have access to data when needed.
Question: How often is data compile and by whom?
Answer: Data is collected as required for performance indicator reporting, or as needed by QI teams or department directors for monitoring department goal and quality indicator progress and service use, and as required to report information to the Board of Directors.
Coaching and Oversight
Question: Who will ultimately be in charge of the QI process?
Answer: The Director of Special Services serves as the QI Coordinator for the agency TQM system. The TQM program is implemented and monitored through committee. Department directors are responsible for TQM activities and participation within their respective departments. Quality improvement is included on the agenda for each department meeting, monthly at minimum. All staff are expected to participate in TQM efforts.
Team Structure
Question: How will all staff be included?
Answer: Staff are involved in the TQM process. Staff involvement includes participation in the selection of TQM projects, department meetings, involvement in work teams, monitoring of TQM projects and quality indicators, and through membership on standing committees. All staff are encouraged to initiate the TQM process by submitting an Employee Input Opportunity form when it is determined that a process is in need of improvement. Also, TQM training for new staff is included in the orientation process.
Question: Who besides staff will be included and how will this happen?
Answer: Consumers and other stakeholders are asked to participate on work teams and/or committees as appropriate. Progress reports and consumer satisfaction survey results are shared with the Board of Directors.
Question: How many levels of teams are there?
Answer: Teams include work teams, standing committees, and the steering committee. Committees and work teams have also been established at the affiliation level.
Question: How many members on each team?
Answer: The steering committee consists of eight members, representing all areas of the agency. Standing committee and work team membership varies dependent upon representation needed to accomplish responsibilities assigned.
Reporting Format
Question: What format is used to track meetings? Where is the information kept?
Answer: Minutes of each meeting are kept on file. Upon completion of a project, the team is responsible for reporting to the standing committee or department to which the project was assigned, and to the steering committee. The team leader or recorder is responsible for forwarding a copy of the meeting minutes and reports to the QI Coordinator. A file is kept on all TQM issues.
Question: How will data be reported to stakeholders? How will information be shared?
Answer: Upon approval of the final report by the steering committee, the results of the work team are shared with staff affected by the process through department meetings, memorandum, posting on TQM bulletin boards at each location, or distribution of the written process. If a policy is created or revised, it is reviewed with staff after board approval. Consumer satisfaction survey reports are posted on the client advisory bulletin boards in the lobby areas of locations that provide direct services to consumers. Policies and procedures related to service delivery are reviewed with the Client Advisory Panel.
Consumer Input
Question: Who are the agency customers?
Answer: Customers include consumers, staff, board members, and contractors
Question: How is information collected?
Answer: Input is received through consumer involvement activities, consumer satisfaction surveys, suggestion boxes, and at Client Advisory Panel and Board of Directors meetings (minutes available for review)
Question: Is there an annual customer involvement plan?
Answer: A plan for consumer involvement is addressed throughout the AFP process. Consumers will be employed to assist with administration and customer service activities. Consumer education and self-advocacy activities are being planned by the agency QI team. Consumers are invited to participate in quality improvement activities as appropriate.
Question: How is data stored?
Answer: Electronic and paper copies are kept by department directors, the QI coordinator, and the IS department.
Question: How is the data analyzed?
Answer: Input from customers is forwarded to the department director responsible for the program area for resolution and follow-up. Input is also discussed at weekly administrative meetings and monthly committee and client advisory panel or departmental meetings. Consumer input may also result in the generation of an input form to initiate a work team, and is assigned to a department or standing committee for resolution.
Question: How has the data been used to make program changes?
Answer: Outcomes of work teams are implemented through policy and procedure changes and recommended improvement to service delivery processes.
Incentives
Question: Is participation in the quality improvement process part of all job descriptions?
Answer: Participation in the QI process is required through the TQM policy, procedures, job descriptions, and provider contracts.
Question: What mechanism of rewards exists for excellence in team work? What recognition exists for participation?
Answer: Employee recognition systems include the following:
1) Employee of the Month Award
2) Employee of the year award
3) Y.E.A. Board - informal recognition by peers and supervisors
4) emailed staff recognition announcement and profile
5) Individual recognition by supervisor
In addition, teamwork training has been completed within individual programs upon request, and a client recognition program is in the process of being established.
Question: What sanctions exist for nonparticipation?
Answer: Nonparticipation in QI efforts is addressed by an individual's supervisor and reflected in the performance evaluation.
Recommended Annual TQM Goals
1) Implement the utilization system developed by the UR workteam.
2) Establish and monitor in the area of clinical qualitative and quantitative file reviews.
3) Implement a program evaluation process which includes goals for each program area.
4) Periodic review and monitoring of quality indicators.
5) Review process toward strategic plan on a regular basis.
6) Provide training for consumers and providers that participate in QI activities.
7) Implement a structure for an affiliation wide measurement system and performance improvement indicators.
8) Implement measures to monitor the Michigan Mission Based Performance Indicator System (MMBPIS).
9) Establish and monitor quality standards relative to staff performance criteria.
10) Implement a centralized affiliation wide customer satisfaction process.
11) Increase consumer input in the planning, development, evaluation of services, and decision making process; and in customer service activities.
12) Implement the corporate compliance plan.