DEPARTMENT OF HOMELAND SECURITY (DHS)
MEDICAL QUALITY MANAGEMENT (MQM)
IMPLEMENTING CONTINUOUS
QUALITY IMPROVEMENT
MQM DIRECTIVE 248-01 &
INSTRUCTION 248-01-001
Latousha Leslie RN BSN, MS
Latousha.Leslie@hq.dhs.gov
Medical Quality Management Analyst
Office Of Health Affairs
Workforce Health and Medical Support Division
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CONTINUOUS QUALITY
IMPROVEMENT
MQM
Quality Framework
Performance Measures
Performance Improvement
Clinical Competency
Risk Management &
Assessment
• Records Management
• Credentialing
• Standard Operating
Procedures & Protocols
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DHS MQM STRATEGIC PLAN
IMPLEMENTATION
Strategic Vision
Mission Priorities
Goals
Objectives
Performance
Improvement Activities
Quality Measures
Data
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MQM STRATEGIC
VISION AND MISSION
Strategic Vision
• Provide guidance to DHS Components on the quality
improvement of health care services delivered to DHS
personnel and charges that is appropriate, timely, safe, and
effective.
Mission Priority
• Promote continuous quality improvement of medical services
provided by DHS
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IOM High Value Checklist
OHA relevance/MQM Strategic Plan
•Leadership buy-in, support, and enforcement
Governance priority —visible and determined
leadership by CEO and Board
• Culture of continuous improvement—commitment •Teaching, reinforcing Focus PDCA, standardize practices,
to ongoing, real-time learning
identify/create efficiencies
Infrastructure fundamentals
•MQM Directive and Instruction, conduct site visits, provide
recommendations, templates, dashboards, gather resources
• IT best practices—automated, reliable information •Start w/ ePCR and MCMS; use best practices from USCG and
to and from the point of care
industry (i.e. ONC and others)
•Update SOPs HCQC wrkg grp, standardize documentation
• Evidence protocols—effective, efficient, and
consistent care
•Sharing resources, lessons learned, contracts, etc.
• Resource utilization—optimized use of personnel,
physical space, and other resources
Care delivery priorities
•Recommend performance metrics for priority gaps
• Integrated care—right care, right setting, right
providers, right teamwork
• Shared decision making—patient–clinician
collaboration on care plans
• Targeted services—tailored community and clinic
interventions for resource-intensive patients
Reliability and feedback
•Track and analyze NM/AE/SE to improve care delivery, OHA
continuous NPDB checks, core competencies of staff, ICE
peer review process
•Encourage family involvement and contact; review CRCL
reports to see compilation of issues
•Identify most frequent treatment, conditions, and diagnosis
to implement quality metrics- may be regional specific for
ICE facilities; use HCQC measure wrk grp
•Quarterly HCQC meetings
• Embedded safeguards—supports and prompts to
reduce injury and infection
•Use HCQC wrkg grp to keep standards current, Components
have initial screenings for infectious dz in a timely manner,
use of PPE; communicate and encourage reporting to OHA
MQM and/or Occ Hlth
• Internal transparency—visible progress in
performance, outcomes, and costs
•Establish core DHS and Component specific measures,
collect and analyze Dashboards; provide technical
assistance to Components
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HCQC TEAMSITE
DHS CONNECT
http://mgmt-ociosp.dhs.gov/oha/hcqc/sitepages/home.aspx
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HCQC RESOURCES
• Component
Dashboards
• Component Measure
Activity Plan
• MQM Master Resource
Planning Guide
• National Quality
Strategy (NQS)
• National Prevention
Strategy (NPS)
• National Quality Forum
(NQF)
• National Priorities
Partnership (NPP)
• Institute for Healthcare
Improvement (IHI)
• Institute of Medicine
(IOM)
• Agency for Health
Research & Quality
(AHRQ)
• Centers for Medicaid and
Medicare Services (CMS)
• National Committee on
Quality Assurance
(NCQA)
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CONTINUOUS QUALITY IMPROVEMENT TOOLS
TREND ANALYSIS (DASHBOARD)
2,500
# of Health Unit visits
# of Health Unit visits
2263
2,000
1742
1699
1,500
1035
1,000
500
1388
873
1004
2,500
1560
2,000
1560
1,500
1210
1,000
558
500
0
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2010 2010 2010 2010 2011 2011 2011 2011 2012 2012
Q1 2012
Health Unit Survey Rating
40
35
30
25
20
15
10
5
0
2263
Q2 2012
Health Unit Survey Rating
5.0
4.0
3.97
3.88
3.0
Aver…
3.88 3.97
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
2.0
1.0
0.0
Overall Average
2010
2011
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NQF MEMBERSHIP REQUEST FORM
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