INTEGRATED QUALITY MANAGEMENT FUNCTION
PURPOSE: Prescribes the systematic process for integrating and synthesizing information
from all quality management functions to evaluate the performance of the service delivery
system. This process assures the health and welfare of consumers, while meeting their needs
and supporting them to achieve personal goals.
DEFINITIONS
Agency Action Plan Tracking System:
A Regional Center database designed to track
issues identified through the Quality Management Functions that require action. Issues
tracked will be identified though indicators categorized by health, safety, rights, services, and
money, in addition to the Missouri Quality Outcomes.
Agency Action Plan Tracking System Summary Reports: A tally of the information
gathered by the Agency Action Plan Tracking System. There are several types of reports
available, including provider issues, specific consumer issues, and regional issues.
Indicator:
A key value or quality characteristic used to measure, over time, the
performance, processes, and outcomes of an organization or some component of service
delivery.
Outcome: An agreed upon result of action to be taken as outlined in the Quality
Management Plan, that resolves issues, prevents reoccurrence and increases opportunities for
implementation of the Missouri Quality Outcomes.
Service Monitoring Checklist: An optional tool that services coordinators may use to assist
in reviewing the five Indicators or areas of service specified in the Service Monitoring
Guidelines. It describes identified issues/concerns and findings, with recommendations and
immediate action taken following a service monitoring visit.
Quality Management Function: A process to monitor and affect services being provided,
focusing upon health and welfare of consumers, meeting their needs and supporting them to
achieve personal goals. The Regional Center Statewide Quality Management Functions are:
Service Monitoring, Incident Response System, Fiscal Review, MOAIDD Visit, Health
Inventory Planning System (Nursing Review), Death Review, Personal Plan Review, and
Licensure and Certification Survey. There are other quality management functions that are
local or from outside the Division.
Quality Management Plan: Written outcome-based strategies outlining actions formulated
from the integration or synthesis of information gathered utilizing the Agency Action Plan
Tracking System. Quality Management Plans are written for the provider, Regional Center,
and Division of MRDD for the purpose of increasing performance above current levels
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Quality Management Team: Regional Center staff designated by the Regional Center
Director to perform statewide Quality Management Functions.
Quality Management Referral Form: A document describing issues, concerns and
findings identified, with recommendations and immediate action taken following a Quality
Management Function.
OVERVIEW
Currently, there are twelve (12) quality management functions (some existing, some
underdevelopment) each of which has its own guidelines, process and designated
implementation staff. The Integrated Quality Management Function integrates and
synthesizes information from the twelve (12) quality management functions resulting in
written outcome-based plans for providers, regional centers and the Division of Mental
Retardation and Developmental Disabilities.
The systematic process for developing the written outcome-based plans begins when staff
responsible for implementing a specific quality management function documents on the
Quality Management Referral Form or Service Monitoring Guidelines Checklist any issues
and/or concerns that were identified and recommendations made. Staff shall submit the
referral form to the Regional Center Quality Management Team; a designated member of the
team shall enter the necessary information in the Agency Action Plan Tracking System
(AAPTS) database. Concerns/issues are tracked in the categories of health, safety, rights,
services, and money. Positive findings related to the Missouri Quality Outcomes shall be
tracked in the AAPTS as well.
Designated staff of the Regional Center Quality Management Team will review and analyze
the most current AAPTS Summary Report for the provider of services and/or the consumer
for patterns or trends when concerns are identified and entries are made into the data base.
Staff shall integrate all information from the AAPTS Summary Report to assist in developing
and updating provider, regional center, and division quality management plans. The plans
will address the issues identified from the AAPTS Summary Report, indicate progress made
and include any identified positive outcomes. When issues or concerns are specific to a
consumer, the service coordinator will update the consumer’s personal plan accordingly, if
necessary.
Following is the plan development process for each plan type:
Provider Quality Management Plan
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The purpose of the Provider Quality Management Plan is to address the identified
issues, both positive and negative.
When issues or concerns are identified, designated staff will review the most
current AAPTS.
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The Quality Management Team and other involved Regional Center staff shall
meet face-to-face, depending on the circumstances, with provider staff to share
information and discuss possible causes and solutions for all issues identified in
the AAPTS. The meeting is the first step in the development of the Quality
Management Plan.
The Quality Management Team will develop or update a Provider Quality
Management Plan in partnership with staff from the Regional Center and the
provider.
The Quality Management Team shall distribute the plan to the Provider and
appropriate Regional Center staff, maintaining a copy in the Provider file.
The Provider Quality Management Plan is driven by identified issues and/or
activities related to the Missouri Quality Outcomes. The Plan shall be updated as
needed. The Plan is an ongoing document that includes all issues and progress
made, including positive findings. The regional center must review/update the
plan at least annually, or more often if indicated by the Plan.
The Provider Quality Management Plan shall consist of the core components:
o
o
o
o
o
o
o
o
o
o
Provider Name
Regional Center
People Present
Review Dates (past, present,
and future)
Demographic Information
Possible causes for identified
issues
Agreed upon Outcomes to resolve
identified issues
DMH authority source
Category Indicator
Action Steps
o
o
o
o
Responsible Parties
Timelines
Progress
Positive Findings and the
related Missouri Quality
Outcomes
o Signature of Regional Center
representative and Provider
representative
o Distribution list
Regional Center Quality Management Plan
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The purpose of the Regional Center Quality Management Plan is to identify and
address regional trends.
The Regional Center Quality Management Team will analyze the AAPTS
Summary Report data on a six-month basis to identify regional trends. The team
will share the findings with the Regional Center Director.
The Regional Center Director and/or Quality Management Team will share
regional trend information with the district deputy and providers.
Designated Regional Center staff will develop an ongoing Regional Center
Quality Management Plan to address regional trends, and monitor progress and
update the plan as needed.
Division Quality Management Plan
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The purpose of the Division Quality Management Plan is to identify and address
statewide trends.
The Statewide Quality Framework Integrated Team (QFIT), comprised of
representatives from each Regional Center Quality Management Team, shall
review the Regional Center Quality Management Plans at least annually.
QFIT shall identify statewide trends based on the integration of all the regional
center quality management plans.
QFIT will develop a Division of MRDD Statewide Quality Management Plan to
address statewide trends, including issues that relate to other systems. The
proposed plan to the Division’s Management Team.
The Division of MRDD Quality Framework Unit shall review, at least annually,
the Statewide Management Plan and share progress made with the Division,
Department, providers, and consumers.
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