Sandhills Center LME
Quality Management
Program Orientation
for Hospitals and LIPs
Quality Management Program
Statement of Purpose
• To ensure services (internal and external)
are appropriately monitored and
continuously improved.
• An emphasis on communication,
interdepartmental, structured
communication and total agency
teamwork.
• Integrate Quality Management into the
entire organization.
Design
• To comply with URAC Standards,
DMH/DD/SAS and DMA Rules and
incorporates the Centers for Medicare and
Medicaid Services (CMS) Quality Framework.
• The Quality Framework includes the following
functions for design of the Quality Management
Program: Discovery; Remediation and
Continuous Improvement.
• Discovery – collecting data and direct
participant experience in order to assess the
ongoing implementation of the program,
identifying strengths and weaknesses.
• Remediation – Taking action to remedy specific
concerns that are identified
• Continuous improvement – utilizing data, data
and more data to engage in actions that
emphasize continuous improvement.
PDCA
• Additionally, the Quality Management Program utilizes
the Plan, Do, Check, Act (PDCA) Quality Improvement
Model.
• Plan – Analyze the problem, establish a solution plan
and set goals
• Do – Implement the solution
• Check – Evaluate the solution
• Act – Monitor for continuous improvement and
implement system change.
• The QM Program balances Quality Assurance and
Quality Improvement activities in that Quality
Assurance activities inform and spark the Quality
Improvement process.
Oversight and Responsibility of
the QM Program
• The Board of Directors has ultimate responsibility for oversight and
effectiveness of the QM Program.
• The CEO is administratively responsible for the direction and
overall functioning of the QM Program and ensures allocation of
adequate resources and staffing.
• The Chief Clinical Officer/Medical Director is responsible for
oversight of the QM Program and advises on clinical issues.
• The QM Director manages the day to day operations related to the
implementation of the QM Program.
• The Board of Directors reviews and approves QM Plan annually
• The Board of Directors receives quarterly reports of all QM activities
including Satisfaction Survey results, Complaints and Incidents.
Quality Management Committee
& QM Structure
Committee structure
Four (4) major committees:
Quality Management
Care Management/Utilization
Management
Health Network
Customer Services
QM Program Committees
Responsibilities
• Oversight of the day to day operations of the
Quality Management Program and compliance
with rules, regulations and URAC standards;
• Define performance measures to ensure
compliance and review data related to the
indicators;
• Communicate activities and findings back to the
Quality Management Committee through
Executive Summaries and Task Logs.
Quality Management Committee
• Serve as the main conduit of change for
the organization.
• Provide oversight of the Sandhills Service
Management System, operations,
functions, processes and practices.
• Provide a forum for problem solving and
addressing processes for improvement.
Quality Management Committee
• Is made up of Department Heads from
each section
• Is chaired by the Medical Director
• Identifies quality indicators, measures and
activities as required by contracts with
DMA and DMH/DD/SAS
• Establishment of performance
benchmarks for all internal and external
quality indicators
Quality Management Committee
Activities
Review Care Management/UM, Health Network and
Customer Services task logs and Executive
Summaries;
 Review and promote further discussion of data
analysis;
 Review and recommend approval of Policies &
Procedures, Decision Support Tools, Scripts;
 Review satisfaction data for improvement
opportunities;
 Approval and monitoring of program specific QIPs;
 Reviews QM Plan annually
Quality Management Committee
Activities (cont’d)
Monitor Access to LME Services;
 Monitor Complaints and Appeals;
 Provide oversight of monitoring of
network providers and recommend
sanctions, as necessary;
 Review, approve and track Marketing
and Communication Materials;
 Monitor Compliance with delegation
policies and procedures;
Quality Management Committee
Activities (cont’d)
Ensure all staff, the Network Leadership
Council, Global CQI Committee,
Consumer and Family Advisory Council
and Board of Directors have a mechanism
to provide input into the Quality
Management Program; and
.Promotes use of data driven material
across all departments
Quality Improvement Projects
• Exemplify the process of continuous quality
improvement;
• Allow for data collection, measurement and analysis that
indicates problems that may require corrective action
and improvement.
• Each Program maintains at least two QIPs at any given
time:
 At least one project must focus on error reduction and/or
member safety and
 At least one project must focus on members, that relates to
specified key indicators or quality and involves a senior clinical
staff member if the QIP is clinical in nature.
Quality Improvement Projects
• All QIPs have to meet URAC
requirements and 2 have to be approved
by DMA for the first year of the contract
with a 3rd one added the second year.
• QM staff tracks QIPs for 1 year after
closure to ensure achieved benchmarks
are maintained.
Global CQI Committee
• Sandhills Center has a Global Continuous
Quality Improvement Committee which is
a sub-committee of the Quality
Management Committee
• Is chaired and co-chaired by providers
• Its membership will include
representation from all provider groups
Global CQI Committee
• The group will analyze data, identify
barriers and assist in implementing
interventions to improve quality of care
through out Sandhills.
• This group will make recommendations to
the Sandhills Quality Management
Committee
QM Monitoring for LIPs
• Complaints
• Quality of Care Concerns
• Gold Star Performance Profile Reviews
•
-Preliminary occurs annually
•
-Preferred
occurs every 3 years
QM Monitoring Tools
• The tools utilized for these reviews are on
Sandhills Center website and on the
Division of Mental Health,
Intellectual/Developmental Disabilities
and Substance Abuse Services website.
• They include chart reviews, personnel
record review and paid claims data.
Quality of Care Concerns
• QOC concerns can come from any of the
groups referenced previously as well as
from external sources
• Each reviewed by QM Director and
Medical Director and disposition
determined
• Can be referred to the Clinical/Financial
Risk Management Committee or to
Program Integrity
Quality Management Program
Evaluation
Annual Evaluation
Comprehensive analysis of:




Accomplishments;
Committee activities;
Results of Quality Improvement activities; and
Trending of indicator data.
May result in the proposal of new activities or
establishment/revision of Policies & Procedures.
Assists in the identification and establishment of new
priorities/goals for the Quality Management Program.