Fixing individual problems as they occur is an essential component of CQI, but if the same type of problem occurs repeatedly, it would be helpful for the state to step back and assess what systemic causes might be responsible. Having determined the potentially largest contributor(s) to the problem, the state is then in a position to develop an intervention to prevent future occurrences of the problem. Examining summary discovery and remediation data over several months is a good way to determine if there are trends indicating the need to go beyond interventions to address individual problems and initiate those that are more systemic and would result in better performance.
While Remediationfocuses on addressing individual problems, Improvementfocuses on making adjustments to the systems processes or procedures in order to prevent or minimize future individual problems. When system improvements work, discovery data improve.
Typically, the discovery metrics of the performance measures enable the state to assess whether an improvement action actually resulted in better performance; for example, the state will conduct a pre-post analysis using the performance measure data to evaluate the impact of the improvement action. The pre data is the performance on a measure(s) prior to the implementation of the improvement intervention, and the post data constitutes performance on the same measure(s) in the months following the intervention.
If the improvement action is effective, the state will see improvement in the performance measures. If improvement is not achieved after a reasonable amount of time has passed (i.e., sufficient time to allow for full implementation of the improvement action), the state needs to go back to the drawing board and figure out why the improvement project did not work. One reason why an intervention might not be successful is because the intervention really did not occur as it was designed (e.g., a newly instituted procedure was not followed). The other reason for failure is that the intervention was not the right intervention. If a state does not get the results anticipated, it needs to assess both possible causes. In most instances, states are very astute about targeting the right intervention, and more often than not a new procedure has the intended result.
Example of a Quality Improvement Project
A State was concerned that the compliance rate on its performance measure Percent of service plans that address participants risk consistently hovered around an unacceptable 75 percent for several months. The States waiver manual specifies that risks should be evaluated during an assessment and enumerates the various aspects of risk (i.e., health risks, behavioral risks, cognitive risks, fragility of the informal support system, etc.). Yet, case managers practice did not always meet the States expectations as stated in the manual.
When the Quality Unit, as part of their quality monitoring, reviews participants service plans and discovers that risk has not been addressed, the case manager is required to revise the service plan and then the Quality Unit must follow-up to verify that the service plan has indeed been updated. Continually having to remediate these individual instances of non-compliance are costly to the State (in addition to the lack of compliance possibly jeopardizing the health and welfare of program participants).
To improve the situation, the State decided to reconfigure its assessment form by adding a risk assessment protocol that must be completed by the case manager during every assessment. After reviewing other states approaches to risk assessment, the Quality Unit and Program Operations staff developed its own protocol, piloted it with a small group of case managers, and revised it based on the pilots findings. Prior to rollout of the new Risk Assessment Protocol, Program Operations staff conducted multiple training sessions in the use of the new protocol for case managers and supervisory personnel throughout the State. They also assigned one of their staff as a go to person to answer questions case managers might have when using the new protocol.
Because the Quality Unit conducts record reviews on an ongoing basis, it was able to assess the effect of the new Risk Assessment Protocol. Three months after the new protocol was implemented, 86 percent of service plans addressed risk, and after 6 months, the compliance rate was at 97 percent; but by month 12 it had fallen back to 90 percent. Upon investigation, the State determined that the decrease was attributed to new case managers who had not received the initial training on the new protocol. In order to sustain a high compliance rate, the State is exploring the development of an online training module that all new case managers must view, combined with close supervision for their first 3 months of employment.
While the States initial quality improvement project was successful, the success was not sustained. Thus, they continue to fine tune their training processes to achieve their goal of high compliance rates.
CMS expects states to engage in CQI activities, especially if there is consistent non-compliance over a period of several months. States are required to specify in the waiver application the party responsible for assessing the need for, prioritizing, and implementing quality improvement activities, as well as the states processes for conducting these activities. They also are required to specify how they will assess the impact of the changes they made and whether they resulted in quality improvements. See Box below for an example of a quality improvement project.
Quality improvement is a necessary and essential component in any CQI endeavor, and states should design deliberate processes to ensure that the waiver programs performance undergoes routine evaluation to identify and improve its operation. At least once during the waivers approved period, and as part of its quality improvement responsibilities, CMS expects a state to evaluate the effectiveness of its quality monitoring processes (i.e., to determine if the states monitoring processes work as well as they were intended). This evaluation provides an opportunity for the state to consider exploring more efficient and/or effective approaches to its quality monitoring processes. Appendix H of the waiver application requires states to describe how and when they will conduct this self-review.