CAMBRIDGE COUNSELING CENTER

QUALITY IMPROVEMENT PLAN

 JULY 2005 – DECEMBER 2006 

APPROVED BY THE EXECUTIVE TEAM

June 5, 2005

James Coughenour, Executive Director

Susan Lynch, Director of Operations

Elizabeth Coughenour, MSW, LISW, Clinical Director

INTRODUCTION

Cambridge Counseling Center is responsible for promoting the development of a mental health system that maximizes the quality of life of each consumer.   It is also the policy of the Center to deliver services to consumers in the least restrictive manner possible.

Cambridge Counseling Center is committed to developing and maintaining the highest possible quality of care. It is the intent of the Executive Team that this policy shall be implemented through careful adherence to appropriate standards, statutes, rules, regulations and ethics. Cambridge Counseling Center is responsible for the operation of a Quality Improvement Program that aims to monitor, protect, and enhance the quality of consumer care offered by the services of our center.

Cambridge Counseling Center aims to fulfill its mission to consumers, staff, and our community. The organization’s leaders, directors, clinical staff, and support staff are committed to plan, design, measure, assess, and improve performance and the Quality Improvement process in order to fulfill our mission.

As part of our commitment, this written Quality Improvement Plan for Cambridge Counseling Center has been established and will be modified as determined by our annual reviews.

This plan is designed to provide a consistent process for improving the care provided, improving the satisfaction of our consumers, comparing performance against benchmarks and reducing inefficiencies.    Quality Improvement activities cross all programs and services in order to respond to the needs of the consumer, staff, and community.

Included in this system is the management of information that includes consumer specific, aggregate, and comparative data. Both outcomes and processes are included in the overall approach.

The continuous Quality Improvement process is an organizational approach. The program crosses all functions, programs, employees, and focuses on key improvements to promote long-term gains.

AUTHORITY

The Executive Team, who has ultimate responsibility for the quality of care and services provided, establishes the Quality Improvement Program.

Through Quality Improvement activities, the Executive Team is given information it needs in order to fulfill the Center’s mission and the responsibility for quality consumer care. The Quality Improvement Team selected by the Executive Director, implements quality Improvement initiatives. There is a Quality Improvement Coordinator, appointed by the Executive Director, who is responsible for communication, coordination of pertinent information to team members, leaders and other appropriate personnel.

PURPOSE

Quality Improvement and Quality Improvement activities at the Cambridge Counseling Center are developed to ensure that the Center meets its responsibilities to person’s served, staff, and the community. Activities are designed to meet the following objectives:

1. To assure that services rendered are within acceptable standards of practice.
2. To provide a means whereby consumer care meets the highest possible standards within a clean, safe, and therapeutic environment.
3. To promote efficient and effective services.
4. To assure that the clinical and clinical support staff objectively and systematically monitor and evaluate the quality and appropriateness of important aspects of care and services on an ongoing basis.
5. To assure that as problems or opportunities to improve care and services are identified, appropriate action is taken and follow-up occurs, resulting in problem resolution and improved care and services.
6. To provide mechanisms for assuring accountability of each clinical staff member for the care they provide.
7. To provide ongoing review and revision of Quality Improvement and the Quality Improvement Program.
8. To minimize risks within the Center through the development and implementation of risk management activities.
9. To provide annual evaluation and revision as appropriate to the Quality Improvement Program.

ORGANIZATION

The Quality Improvement Program is composed of the following standing committees:

1. Executive Team
2. Quality Improvement Team
3. Safety and Risk Management Team
4. Utilization Management Team
5. Audit Team
6. Staff Development Committee
7. Cultural Competence Committee
8. Corporate Compliance Committee
9. Clients Rights Committee

The QI Coordinator is responsible for the coordination and integration of the Quality Improvement activities within Cambridge Counseling Center and serves as a liaison among programs, services and other committees/teams. Supervisors within the Center are responsible for implementing an ongoing system to monitor and evaluate the quality and appropriateness of consumer care and services. The system encompasses the scope of care and services provided within each program. The QI Coordinator shall recommend specific responses and time frames for action to its findings and shall assess the effectiveness and efficiency of such actions after their implementation.

Executive Team

The Executive Team is composed of the Executive Director, Director of Operations, and Clinical Director.  The QI Coordinator also serves on the team. Executive Team members are selected and assigned by the Executive Director. Executive Team meetings are held at least monthly.

Quality Improvement Team

The Quality Improvement Team is composed of staff members who represent key elements of the Center. Selection is based on the needs of the Center, and strengths, knowledge, abilities, and skills of individual staff members. All staff members have the opportunity to participate as a team member based on the needs of the QI Team and the Center. Other individuals may be asked to attend particular meetings based on the needs of the team.  The team may also consist of consumers.  Quality Improvement Team meetings are held at least monthly.

Safety and Risk Management Team

The Safety and Risk Management Team is composed of the Safety Coordinator, Quality Improvement Coordinator, and other staff members.  The Safety and Risk Management Team members are selected and assigned by the Executive Director. Safety and Risk Management Committee meetings are held at least quarterly. The Quality Improvement Coordinator is responsible for directing the implementation, monitoring, and evaluation of all adverse incidents within the Center.

Utilization Team

The Utilization Team meetings are based on the needs of the Center, strengths, knowledge, abilities, and skills of the individual staff members. The Utilization Team meets as needed for project reviews.

Audit Team

The Audit Team is a standing committee composed of clinical staff members and QI staff that represent various programs of the Center. Team members are selected and assigned by the Quality Assurance Coordinator.   The Audit Team is responsible for quarterly Center audits and meets once per month.

Staff Development Committee

The Staff Development Committee members are selected and assigned by the Executive Director. The Staff Development Committee meets as needed.

Cultural Competency Team

The Cultural Competency Team members are selected and assigned by the Executive Director.  The Cultural Competency Committee meets at least quarterly.

Corporate Compliance Committee

A Corporate Compliance Committee shall be appointed by the Executive Director and shall be chaired by the Corporate Compliance Officer (CCO). The Committee shall meet no less than ten times a calendar year.

Client’s Rights Committee

The Client’s Rights Committee is composed of the designated Client Advocate and representatives from clinical and clinical support areas throughout the Center. Committee members are selected and assigned by the Executive Director. The Client’s Rights Committee will convene when efforts to process advocacy issues are not met to the consumer’s satisfaction by the Consumer Advocate.

SCOPE

The scope of the Quality Improvement Program shall encompass all clinical services; clinical records review, utilization review, and review of safety/risk management data. The following teams and committees are established to routinely organize, manage, monitor, and report on aspects of care and critical areas of operation. Membership is designated by the Executive Director based on the strengths and abilities of individuals and what is in the overall best interest of the organization.

Cambridge Counseling Center’s Quality Improvement program focuses on the quality of care areas concerning the delivery and outcome of treatment clinical services.

The scope of Quality Improvement activities also includes:

1. Monitoring and Evaluation System

Quality Improvement monitoring activities include:

1.      Clinical Records Completeness Reviews

2.      Clinical Records Quality of Care Reviews

3.      Clinical Records Billing Audits

4.      Corporate Compliance Audits

5.      Utilization Review

6.      Clinical Outcome Review - including development, implementation, and report of efficiency and effectiveness measures within each service area.

7.      Consumer Satisfaction Review

8.      Review of Service data and Reports

2. Scope of Committee/Teams

Executive Team: the responsibilities of Executive Team include:

1. Implementation of CCC Directives
2. Approves and directs implementation of agency policies and operational procedures
3. Approval of Credentialing and Clinical Privileging standards
4. Ensures that client care and services meet all state, federal, regulatory and accreditation standards.
5. Review and approval of credentialing and clinical privileging activity including:

1.      Review all privileging applications and documentation

2.       Designation of privileging status of clinical staff members

3.       Ensure credential folder of each clinician is updated at least annually and Includes: Curriculum vitae, copy of diplomas, copy of licenses or certification, including current renewals, delineation of professional service privileged to render, and Quality Improvement data pertinent to the individual’s pertinent practice.

Quality Improvement Team: The Quality Improvement Team is also involved in planning, prioritizing, strategy development, monitoring, educating, and promoting the acquisition and application of the knowledge necessary for improvement of quality. This includes recommendations for any special teams, committees or task forces chosen to address specific opportunity for improvement. Quality Improvement or project teams may be utilized to facilitate and assess progress towards goals and objectives, specified in the Strategic Plan. This strategic plan is based on community and consumer needs. These recommendations are provided to the Quality Improvement Team whose responsibilities include:

1. Organizational planning and Quality Improvement
2. Review and evaluate program goals and objectives to ensure coordination with the overall philosophy and purpose of each program.
3. To initiate Continuous Quality Improvement Teams by suggesting initial membership appointments, identifying mission and objectives, and to assure adequate resources to facilitate effective team functioning. Work groups will encourage participation of staff from all levels in the organization.
4. Review, monitor and evaluate short and long term outcomes.
5. Review, monitor and evaluate aspects of care dealing with the rights of the person served and consumer satisfaction.
6. Review, monitor and evaluate aspects of staff development and overall satisfaction.
7. To initiate teams in the areas of:
1. Consumer satisfaction
2. Clinical Outcome/Effectiveness
3. Development of Clinical Practice Guidelines
4. Other projects or areas as determined appropriate
5. To identify and reduce structural barriers to the Quality Improvement process.
8. Facilitate smooth and consistent operation between teams, committees and programs to promote organizational quality in the delivery of services to persons served.

Safety and Risk Management Committee: The Safety and Risk Management Committee is responsible for investigating and reporting on specific functions and aspects of care dealing with risk management issues. Adverse Incidents are investigated, evaluated, and reported on a quarterly basis, at a minimum, and monthly where feasible. This information will be utilized on a routine basis to improve accessibility, health, safety and other pertinent risk management issues that have a direct or indirect impact on the community, consumers, staff, and the Center as a whole. These functions and responsibilities are systematic and ongoing to include appropriate and timely responses for addressing areas of concern or deficiency.

A reportable incident is defined as any unusual occurrence outside of the normal activities of the facility. Incidents are reported whether they occur within the facility, the parking lot, or other areas of the building. Examples of reportable incidents include, but are not limited to:

1. Injuries or accidents of consumers, visitors, or staff.
2. Any medical emergency involving a consumer, visitor, or staff that requires first aid or medical assistance.
3. Any evidence of burglary.
4. Theft from consumers, staff, or visitors.
5. Accidents that do or do not result in an injury, i.e., slipping on a walkway, falling, etc.
6. Potential safety or health hazards observed.
7. Threats of any nature, i.e. telephone, verbal, directed towards consumers, staff or visitors.
8. Any incident that gives cause for concern for the welfare of consumers, staff or visitors.
9. Instances of abuse or neglect.

In addition to investigating critical incidents for tracking as defined above, certain major incidents of a more urgent nature must be referred to the Executive Director who may appoint a QCRB to respond to incidents such as:

1. Homicide involving a consumer, staff or visitor.
2. Suicide of an active consumer or staff member.
3. Major injuries to clients, visitors or staff.
4. Any other major occurrence or tragic event at the discretion of the Executive Director.

The goals of the Safety and Risk Management Committee include: 

1. To assure implementation of a center-wide safety program that includes development of policy and procedures and subsequent staff training relating to fire safety, disaster preparedness, hazard reporting, etc.
2. To assure tracking and documentation system for all incidents, including follow up and implementation of any corrective action until follow up is no longer indicated.
3. To review safety and incident related data and to identify trends and patterns associated with risks or to identify problem areas.
4. To conduct root cause analysis on incidents as appropriate.
5. To provide thorough investigation on all sentinel events.
6. To promote Quality Improvement activity through identifying opportunities towards maximizing safety of physical and therapeutic environment and reducing Center, staff and consumer risks.

Utilization Team: The responsibilities of the Utilization Team include directing the implementation, monitoring, and evaluation of trends and patterns pertaining to Utilization Management within the Center. The Utilization Management process uses various ongoing and systematic techniques related to specific aspects of care delineated in the DMH Audit and Utilization Review Tool.

Audit Team: The responsibilities of the Audit Team include ongoing monitoring and professional review of a representative sample of opened and closed medical records of persons served across all programs. Clinicians utilize the audit and utilization review tool to review medical records for Corporate Compliance, Quality Improvement and accuracy.

Staff Development Committee: The Staff Development Committee meets as needed to plan for assessment of staff training needs and assure that the mechanisms are in place to maximize compliance with minimum training requirements and the provision of training opportunities to meet priority needs identified by staff. Specific responsibilities of the Staff Development Committee include:

1. Identification of training needs of clinical and clinical support staff.
2. Promote staff awareness of internal and external training opportunities.
3. Identify opportunities and strategies for enhancement of staff development activities.
4. Plan required training opportunities through in-house training.

Corporate Compliance Committee: The purpose of the Corporate Compliance Committee is to:

1. Advise regarding and implement all aspects of corporate compliance.
2. Examine existing standards and procedures, assess alternative courses of action, determine a course of action and implement the necessary policies and procedures.
3. Design and implement a monitoring program consistent with Corporate Compliance Plan utilizing the Audit Tools.

Client’s Rights Committee: The purpose of the Client’s Rights Committee is:

1. To ensure effective resolution of consumer concerns and/or possible rights violations.
2. To advocate for the rights of the persons served.

Records, Reports, and Dissemination

1. All teams and committees integrated into QI activities shall submit written data summaries relative to their respective areas on a quarterly basis. These summaries shall include all findings, recommendations, actions taken, results of action taken and any other relevant information as deemed appropriate. The QI Team and Executive Team will formally review these summaries.
2. The Quality Improvement Coordinator is responsible for communication, coordination, and dissemination of pertinent information to all team members, committee chairs, supervisors, and other appropriate personnel.
3. A written report of all pertinent QI activities is prepared by the QI Coordinator and submitted to the Executive Director on a quarterly basis. The report is then submitted to Cambridge Counseling Center Quality Improvement Team.
4. Committee chairpersons and/or project team leaders will participate in presentation of summaries to the Executive Team through written reports and participation in Staff meetings when required.

OBJECTIVES OF QUALITY IMPROVEMENT ACTIVITIES

Cambridge Counseling Center is in the process of developing the essential components of a continuous Quality Improvement program. The facility has determined that a strong Quality Improvement Program with supplementation by improvement/design teams is the most effective use of current resources. The main emphasis is to improve the quality of the organization in fulfilling its mission and vision addressing efficacy, appropriateness, availability, timeliness, effectiveness, continuity, safety efficiency, respect and caring. These components include, but are not limited to:

1. Enhancement of the Quality Improvement program from past experience.
2. Focus on efficiency of the processes and desired outcomes (benchmarking).
3. Collaboration of activities.
4. Education/training on identified issues.
5. Use of improvement teams for complex issues

CONTINUOUS QUALITY IMPROVEMENT MODEL

The Executive Team and Quality Improvement Team provide direction for planning, strategy development, monitoring, educating and promoting the acquisition and application of the knowledge necessary for improvement of quality. This includes guidance to any special teams chosen to address specific opportunity for improvement through the use of Total Quality Management and Continuous Quality Improvement philosophies and strategies. Cambridge Counseling Center employs a systematic approach for improving the organization’s performance by improving existing processes. The trams/committees involved in the review of performance activity will make decisions on what improvement needs to be made.  In cases where priorities need to be set, assistance may be obtained from committee, team organization leaders.

A. Measurement

Performance measurement will be continuously and consistently monitored. Monitoring will focus on consumer care processes and outcomes. The focus will include components of the process that will look at performance (including individual), coordination, integration, outcomes and improvement. A variety of analytical tools may be utilized to evaluate the total care provided. Data sources include, but are not limited to:

1. Clinical Records
2. Outcomes Data
3. Incident Reports
4. Statistics and historical patterns of performance
5. Monitoring results
6. Consumer Satisfaction Questionnaire
7. Safety Statistics
8. Infection Control Data
9. Referral sources
10. Cost Analysis

Repeated measurement over time allows a focus on the process’ stability or a particular outcome’s predictability. All teams and staff will be responsible for gathering data on their performance that addresses the needs, expectations, and reaction of consumers and staff.

B. Improvement Cycle

The following Quality Improvement cycle will be utilized in the development of projects and Quality Improvement activities:

1. Planning - Identification of goals related to improving performance.
2. Design - Identification of processes, functions and services consistent with the organization’s mission, vision, and plan.
3. Measurement:
1. Defining responsibility and scope of services.
2. Defining and prioritizing stakeholders.
3. Defining Objective Domains (Effectiveness, Efficiency, Access, Stakeholder Input/Satisfaction).
4. Defining indicators - goals or benchmarks.
4. Assessment - Collection of data essential to facilitate improvement.
5. Improvement - Establishing priorities for improvements and innovations

.

It is the intent of Cambridge Counseling Center to be proactive in improving treatment and processes. Improvements to treatment and efficiency are the expected outcome of the QI program. The process and all activities are to support that intent. The process is to make good things happen in a constructive way and not just to engage in the activities.

C.  Assessing the Process

Cambridge Counseling Center has a systematic process for assessing the collected data (measurement) in order to achieve quality care delivery that is available, timely, effective, continuous, safe, efficient, and caring. These measurements will look at the performance of the process over time and make comparisons to internal and/or external data sources as available and appropriate.

The following mechanisms are utilized for reviewing and assessing consumer care:

1.  Accessibility Status Reports Regarding the Removal of Barriers

1. Risk Management Reports
2. Quality Improvement Reports such as Consumer Satisfaction and Clinical Outcome Reports.
3. Recommendations of Committees or Teams.
4. Clinical Records Audits and Completeness Reports.

Evidence of assessment may be found in records of meetings, reports of assessment, conclusion and strategies, Clinic records documentation, as well as education and training notes.

METHODS

Each team member, coordinator, or supervisor has the responsibility to monitor, evaluate, and Report on activities within their respective areas of responsibility. The methods for conducting these QI measures is a planned, systematic and ongoing process to thoroughly and consistently maintain and improve the overall quality of care and service provided, as well as to improve the organizational quality.

A.  Monitoring

The monitoring process is designed to identify patterns and/or trends in effectiveness and efficiency of care and service delivery, significant clinical events, risk management issues, utilization management issues, and outcomes of care and services.

B. Evaluation Process

The evaluation process is designed to determine the presence or absence of an opportunity to improve on an aspect of care, a problem in the quality and appropriateness of care, and to determine how to interpret, address, and resolve problem areas.

C. Aspects of Care

Aspects of care are routinely identified, implemented, and measured based on critical areas of importance, both internal and external to the Center. They are further defined by their effect or impact on consumers, staff, and community, their frequency of occurrence, and risk areas to all those involved with the Center.

D. Indicators

Indicators are routinely established to monitor specific criteria with each aspect of care. These are objectively measurable and based on current baseline data. These should reflect processes of care and services and/or outcomes of care and services.

E. Thresholds

Thresholds should be established for each indicator to utilize for cutoffs to measurements and levels of acceptability.

F. Data Collection

Data is collected and assimilated for each indicator.  Framework Reports of the data and findings are compiled thru the GRID and presented to the Executive Team.

G.  Action Taken

Results of data collection and recommendation for actions to take are routinely incorporated into the decision making process of programs and governing authorities.

CONFIDENTIALITY

The deliberations and findings of the Quality Assessment and Improvement related committees or teams are confidential in nature. Consumer related information and staff related findings follow the guidelines within the Cambridge Counseling Center Confidentiality Policy. Relevant staff related from Quality Assessment and Improvement activities are considered in renewal/revision of individual clinical privilege and appraisal of non-clinically privileged staff members.

ANNUAL EVALUATION

The Quality Assessment and Improvement Program is to be evaluated annually by the Quality Improvement Team and the Executive Team, or at any time such action is indicated. The annual evaluation data will be incorporated in the Center’s Annual Management Report that is prepared at the end of the year. The Management Report created by the Executive Team.  As a result of the review, the Quality Improvement and Improvement Plan is reviewed/revised each fiscal year based on activities as documented in the Annual Management Report.