Quality Improvement in California’s County Mental

Health Programs

Quality Improvement in California’s County Mental

Health ProgramsPresentation to 12th Annual Patients’ Rights

Advocacy Training ConferenceSacramento October 8, 2004

Doug Mudgett, RN, AMHS

State Department of Mental Health, County Operations

IntroductionIntroduction

• A little bit about myself and my background• Why I am here today, my DMH “QI” role• Why I believe in Quality Improvement• Keeping the focus of everything we do

as a “system” on the people receiving services, on the quality and relevance of what we provide, and on the belief in Recovery

• De-mystifying Quality Improvement, give you an overview, and sparking an interest in you

Discussion TopicsDiscussion Topics

1. Why are we all here today? 1. Why are we all here today?

2. What is QI? 2. What is QI?

3. Past, present, future of QI in counties?3. Past, present, future of QI in counties?

4. What is your role in this? 4. What is your role in this?

Why are we all here today?Why are we all here today?

• Why are you here today? What do you want to get out of this discussion?

• What do you know about Quality Improvement (QI)?

• Have you participated, or been asked to participate, in your county?

• What does “Quality” mean to you?

What is QI in general?What is QI in general?

A systematic, deliberate, and continuous process and effort to improve the services we provide to individuals.

Breaking it downBreaking it down

• SystematicThe process is based on an organized and

structured “problem-solving” approach• Deliberate

In order for QI to be successful, there must be belief in it, effort must be given to promoting its sustainability, and it must permeate and connect everything the organization does

• ContinuousIt is virtually a never-ending process…

basic mantra: “no matter how good we think we are doing, there is always room for improvement

A Little HistoryA Little History

• Origins in 1950’s, ’60’s, and ’70’s • The “Gurus”: Deming, Juran, and Crosby• Deming considered “godfather” of Total Quality

Management”, or TQM, which reshaped and transformed Japanese manufacturing industry

• Largely a statistical process control approach at decreasing “variance” in product quality

• Delighting and satisfying customer expectations• Continuous Quality Improvement, an offshoot of

TQM, evolved significantly during the late 1980’s and early 1990’s and was applied to health care

Why History is Importantfor QI in County Mental Health

Why History is Importantfor QI in County Mental Health

• Originally a Quality Assurance activity

“Monitoring adherence to standards”

• QI vs. QA

What is the difference between QI and QA, and what are their complementary and distinct roles?

• Take-home Point

QI and QA are not the same.

QI vs. QAQI vs. QA

• Quality Improvement goes way beyond Quality Assurance. Perhaps the defining difference lies in the fact that in addition to focusing on processes, correcting problems, analyzing data, and making decisions based on information, QI adds the focus on “Improvement”, distinct going beyond standards, and attitude-belief-passion in betterment is central.

• This has been a significant paradigm shift for health care in general, and County mental health services in particular.

Continuous Quality ImprovementContinuous Quality Improvement

• Customer/Consumer FocusThe unifying driving element

• Process OrientedBelief that most quality issues and

problems are the result of processes, not people.

• Data DrivenUses data as an indispensable tool for

guiding, evaluating, and validating “success”.• All Levels of Organization

All levels must be encouraged and supported to participate.

PDCA CyclePlan-Do-Check-Act or “Deming Wheel”

PDCA CyclePlan-Do-Check-Act or “Deming Wheel”

Act

Plan Do

Check

PDCAPDCA

Focus on ConsumerOutcomes/BenefitWithin a RecoveryModel or Vision

Current Picture of QI in County Mental Health Programs

Current Picture of QI in County Mental Health Programs

• The most immediate current drivers for Quality Improvement in counties come from the Managed Care Contract (MHP Contract) with the State DMH, California Code of Regulations Title 9 requirements, and language in WIC regarding quality management programs, and the role of External Quality Review (EQR) including Performance Improvement Project (PIP) evaluation.

• DMH Medi-Cal Oversight (“Compliance”) continues its evaluation responsibility based on “QA”.

QI Oversight & Consultative Players

QI Oversight & Consultative Players

DMH & CMS

EQRO Boardof Supes

MH Boards& Commissions

•DMH Medi-Cal Oversight•DMH Medi-Cal Policy•DMH CountyOperations•CIMH-Contract•CMS MedicaidWaiver , and CFR 438

• “APS”External QualityReview Organization•Required by New Medicaid Regs resultingFrom “BBA 97”

Vested interestIn “Value”,i.e. Qualityof servicesto County’sresidentsfor the County Dollars spent

Oversight andGuidance of MH systemQuality with emphasis ofConsumer &Family MemberInvolvement

Broad Forces Impacting County QIBroad Forces Impacting County QI

Quality Improvement

Regulations Fed-State

Consumer Voice

MHPContract

Professional Ethics

IndustryMovement

What is your role in QI?What is your role in QI?

• Becoming familiar with QI

• Gauging your county’s interest in asking for your involvement

• Contributing a valuable specialized perspective

• Realizing the importance of, and advocating for fidelity to, keeping the focus on the consumer and their outcomes in a Recovery framework.

QI Learning Progress DiagramQI Learning Progress Diagram

Reconciling “Theory”

With “Reality”

Reconciling “Theory”

With “Reality” Involvement & Practice Involvement & Practice Knowledge & Skills Acquisition

Knowledge & Skills Acquisition

Phase 1“Acquiring”

Phase 1“Acquiring”

Phase 2“Implementing”

Phase 2“Implementing”

Phase 3“Integrating”

Phase 3“Integrating”

County QI ParticipantsCounty QI Participants

Providers

Consumers

Director

QI CoordinatorIT / IS“Data”

ADVOCATESConsumers’ Benefit

Closing Questions, Discussion, and Comments

Closing Questions, Discussion, and Comments