We value and request input from our stakeholders. If you wish to make a comment about our Performance Improvement plan, please email our Exctive Director
Quality Council shall continue to meet monthly during the next fiscal year with the chair of each committee reporting on their various activities. Committees represented on the Quality Council and their respective chairpersons are:
Audits, Miranda Herrington-Nunez
Business, Jeanette Betts
Consumer Rights / Corporate Compliance, Ramona Price
Equal Employment Opportunity, Donna Jones and Stacy Walton
Medical Oversight, Laurie Leonard
Outcomes, Jean Buchanan
Peer Review, Sean Massie
Personnel and Training, Tracy Brister
Risk Management and Safety, Ramona Price
The tasks of each committee shall be to collect data, monitor existing operations, review annual goals and objectives for the fiscal year, and report any trends to maximize performance and efficiency of the organization.
The PI Plan shall be submitted to the Southern Star Executive Committee for approval. A review of the PI Plan will be conducted at the end of the fiscal year and shall report the outcome of all objectives set forth in this plan.
Goals were derived from each committee chair, group discussion in Quality Council, and the review of outcome data. The goals set forth for this fiscal year:
Goal #1: Improve knowledge of agency managers regarding the performance improvement process. Carried forward from previous year.
Strategy: QC chair to invite one manager to each monthly meeting of the Quality Council, on a rotating basis.
Goal #2: Develop extended leadership and continuity with the Quality Council. Carried forward from previous year.
Strategy: Review appointment and rotation guidelines, revise as needed, and follow.
Strategy: Identify prospects for committee leadership positions.
Goal #1-The agency will conduct training on the new audit policy and audit tool for all managers.
Strategy: The audits subcommittee will conduct training by January 2009 to all clinical managers on the new audit policy and the new audit tool, to ensure all procedures are followed correctly.
Goal #2-The agency will improve APS Quality Improvement score to 80 or above during the year through staff training and education.
Strategy: The UM Department will conduct quarterly documentation training to each unit. UM's training will emphasize any areas that were deficient in the past audit. If any particular individual needs one on one training, the UM manager will schedule that training with pertinent staff.
Goal #3-The agency will train all direct care staff on electronic entry of MICP assessment/treatment plan.
Strategy: The UM Department will conduct by December 2008 training for all direct service staff on initial entry of treatment plans into the Mitchell McCormick system, to begin implementation of an electronic medical record.
Goal #1- The agency will insure an appropriate check and balance process for all accounting functions within the agency, including those at outlying units. Carried forward from previous year.
Strategy: The Business Department will review existing check and balance procedures for all accounting functions and develop specific check and balance procedures as needed within the agency.
Goal #2- The agency will enhance 3rd party payer processing and billing.
Strategy: The Business Department will continue to participate in state association's revenue cycle work group and receive other appropriate technical training as needed and available.
Goal #3-The Business Office will improve overall efficiency.
Strategy: The Business Department will meet quarterly to review existing processes and procedures for possible improvements.
Goal #4-The Business Office will improve requisition/purchase order process and the leave process.
Strategy: The Business Office will consult with our software provider, Mitchell & McCormick, to streamline our requisition/purchase order process and leave process.
Goal #1-Provide education to all staff annually on consumer rights.
Strategy: Consumer Rights education will be reviewed by December 31 and modified to provide training to all new employees and annually to other staff.
Goal #2- The agency will improve the knowledge of agency managers and staff regarding consumer/staff accidents/incidents.
Strategy: The committee will review existing reporting procedures, make modifications, and Implement new reporting procedures for accidents/incidents by December 31, 2008.
Goal #3- Re-establish an active, viable, working, corporate compliance committee using the recruitment procedure described in the policy on Committee Membership, Policy # 400.55.
Strategy: The Corporate Compliance Officer will work with the Personnel Department to recruit for interested staff to become members of the Corporate Compliance Committee by December 31, 2008.
Goal #4- In conjunction with Personnel and Training, the agency will insure that current staff will receive Corporate Compliance training annually, and new employees receive Corporate Compliance training within 60 days of hire.
Strategy: In conjunction will Personnel and Training, the committee will develop the schedule and insure that Corporate Compliance is on the training calendar monthly and staff begin receiving training annually and new staff are on the training roster within 60 days of hire. The Corporate Compliance Officer and other identified trainers will insure the availability of trainers each month.
Goal #5- Recruit at least one (1) additional person to serve as a trainer for the Corporate Compliance training that is conducted monthly.
Strategy: At least one committee member will be recruited as a trainer by December 31, 2008.
Goal #6- Recruit and train at least two (2) additional members of the Corporate Compliance Committee to serve as investigators for corporate compliance complaints.
Strategy: Corporate Compliance Committee members will be identified by December 31, 2008. Training will be conducted by current investigators if no formal training is available.
Goal #1- The agency will insure recruitment activities comply with EEO standards.
Strategy: The committee will continue to review promotional opportunities and lateral transfers for current employees.
Strategy: The committee will continue to review hiring processes for applicants; e.g. screening criteria, interview team, interview questions and answers, and scoring distribution.
Goal #2- The committee will oversee and develop activities of the Employee Incentive Team.
Strategy: Participate with EIT to establish employee recognition
programs.
Strategy: Participate with EIT to re-establish agency newsletter.
Goal #1-The Forms Committee will insure all clinical forms are filed uniformly in chart.
Strategy: The committee will develop indexes using current forms and update index as new forms are added. Committee will continue to monitor and assess agency time line for moving to electronic medical records and how it impacts paper forms in chart.
Goal #2- The Forms Committee will continue to review the accuracy and relevancy of new forms or revisions submitted to committee.
Strategy: The committee will review forms for accuracy and relevancy by December 31, 2008 and present to Quality Council for approval.
Goal #3- The Forms Committee will develop new master form book with all current forms.
Strategy: The committee will review and discontinue all forms no longer in use by December 31, 2008.
Goal #1- The agency will promote good health practices within the workplace and with agency consumers.
Strategy: The committee will explore plans for an Employee Health Fair and make recommendations to senior management. Carried forward from previous year.
Strategy: The committee will finalize and implement policy and procedures for dealing with HIV exposure on the job.
Strategy: The committee will continue to provide newsletters for staff with focus on health and safety issues.
Goal #2- Ensure that appropriate medical management is practiced within the agency.
Strategy: The committee will develop and/or review all medical management policies and procedures of the agency by December 31, 2008.
Goal #1- The agency will continue to improve outcome management system, including development, review and trending of outcome findings.
Strategy: The committee will continue to re-establish outcomes to create more meaningful goals for the organization, with focus on the strategic and operational plans, by meeting quarterly to review goals and modify as needed.
Strategy: The committee chair will communicate with managers the need for promptness of delivering information each month and convey how receiving timely information from managers is vital to achieve the overall purpose of the Outcomes Committee.
Goal #1- Evaluate and continue to review the qualifications for MHP status.
Strategy: The committee will conduct a meeting to be held by December 31 to review current qualifications according to DHR guidelines.
Goal #1- The agency will continue efforts to recruit and retain a highly qualified and diverse work force to meet the needs of MFBHC consumers.
Strategy: Identify qualified candidates by advertising in community newspapers, utilizing internet-based advertising, job fairs and college internship programs on a continuous basis. Training for existing staff will be reviewed on an ongoing basis to insure training subjects are pertinent to meet the needs of our consumers.
Strategy: Insure the interview process is organized, efficient, responsive and respectful of each candidate's time and interest.
Goal #2- Develop and offer new cost-effective training opportunities to agency staff that will enable them to provide quality services to consumers.
Strategy: The committee will research and develop on-line and on-site training in areas that will enhance the skills and qualifications of providers in order to benefit agency consumers.
Strategy: The Personnel Department will utilize the computer lab for training, and instruct staff in use of on-line courses.
Strategy: The Personnel Department will seek on-line and on-site training opportunities for continuing education credits for licensed staff.
Goal #1- The agency will reduce number of delinquent drills.
Strategy: The committee will provide quarterly training for units with delinquent drills to improve timeliness.
Goal #2- The agency will insure all staff within the agency is competent in safety procedures and drills.
Strategy- The committee will work with each unit and keep a rotating list of staff to insure competency of personnel in safety procedures.
Southern Star Community Services recognized a successful year in its performance improvement initiatives. Over the course of the fiscal year, its Quality Council (QC) was able to achieve over 80% of its performance improvement goals, as summarized below by each committee:
Goal #1: Improve knowledge of agency managers regarding the performance improvement process.
Strategy: QC chair to invite one manager to each monthly meeting of the Quality Council, on a rotating basis.
Outcome: Various managers at Southern Star visited during meetings this year. Overall, this was successful as each manager came away from the meetings with a clearer understanding of Quality Council and its performance improvement functions within the agency.
Goal #2: Develop extended leadership and continuity with the Quality Council.
Strategy: Review appointment and rotation guidelines, revise as needed, and follow.
Strategy: Identify prospects for committee leadership positions.
Outcome: There were no changes with the appointment and rotation guidelines this fiscal year. Several new staff members were identified and appointed to key committee leadership positions. Staff assigned this year were Judy Slade, chair for Forms Committee; Jean Buchanan, chair for Outcomes Committee; Ramona Price, chair for Consumer Rights; and Miranda Herrington, chair for UM Audits.
Goal #1: Improve record documentation audit process, with emphasis on timely reporting of results and trends to managers.
Strategy: Revamp quarterly audit process under new supervisory lines, and define expectations re timely reporting of results and trends.
Outcome: The agency implemented procedures that improved audit procedures significantly and insured that charts are reviewed more closely than before. Some key changes are as follows:
" QC has developed and implemented audit procedures that include standardized review of records by program managers. Every quarter managers are utilizing a peer review process to formally audit 10% of their charts, in addition to self-auditing their charts. QC oversees this activity quarterly, and submits reports to managers and the executive committee.
" Procedures for all audits have been formulated in a new Southern Star policy on audits; #800.14, Internal Chart Review. Procedures have been revised to further improve the auditing process, for timely reporting, and identifying trends. Specific guidelines have been developed for managers to follow, including random checks of charts in units under their supervision and guidelines to review at least one chart of each direct service staff monthly. Formal guidelines were also established for systematic peer review audits. Another noteworthy aspect of this policy is guidelines for concurrent review, an internalized system for review of progress notes, before being finalized for billing.
" The Utilization Management Department has audited 10%
of charts
at each worksite, with the audit findings shared with each manager for his or
her review. Findings from audits are discussed with the UM manager and presented
in the monthly Clinical manager's meeting. An overall agency documentation training
is planned at the time to assist in improving record documentation. Within three
to four days after the audit, respective managers have results from the audits
in hand. Additionally, policy and procedure has been revised to further improve
the auditing process, timely reporting and identifying trends.
" Specialized Audits continue through the Utilization Management (UM) department and Developmental Disabilities Services (DD) Staff. UM continues to document internal audits of 10% of charts at one worksite each month, with DD specialty audits conducted on a periodic basis.
Goal #2: Improve quality of record documentation by treatment staff.
Strategy: Develop and conduct detailed documentation training
for new direct care employees and annual refresher training for all direct care
staff. Identify and recruit sufficient trainers to provide monthly training.
Outcome: All new direct care employees are individually trained
in development of treatment plans. MICP training is scheduled every first and
third Fridays of each month. At that time, any employee is welcomed to participate
in training as a refresher. APS is willing to provide training if trainers are
available.
Outcomes:
Goal #1: Improve outcome management system, including development, review and
trending of outcome findings.
Strategy: Re-establish outcomes to create more meaningful goals
for the organization, with focus upon the strategic and operational plans.
Strategy: Establish working outcome committee with quarterly
meetings to review outcomes on a continuous basis, report trends, and/or modify
outcomes as needed.
Outcome: This year QC also reviewed its outcome management
process and procedures. A working outcomes committee, beginning in October 2007
and chaired by Jean Buchanan, now features members represented from each disability
and area of expertise within each disability. This committee meets quarterly
to review outcomes and make needed changes if necessary.
In February of 2008, The Quality Council hosted an outcome management workshop
conducted by Fred Richmond. Over 50 employees attended two sessions. New, more
meaningful goals were created, and the critical elements of outcomes development
and management were explained. All outcomes have been turned in, consumer satisfaction
report information has been compiled and summarized, and the yearly Outcomes
Report will be ready on August 12, 2008.
Goal #1: Ensure appropriate check and balance process for all accounting functions within the agency, including those on outlying units.
Strategy: Develop specified check and balance procedures for all outlying accounting functions within the agency.
Outcome: The Business Office further strengthened segregation of duties in outpatient clinics for handling cash by having additional clerical staff splitting the different phases; i.e., one clerk handles taking payments from consumers; another clerk enters payments against consumers' accounts and the third clerk reconciles the payments posted to cash collected.
Periodic audits are being done for consumers funds kept at group homes. Any problems are reported to the Deputy Director in charge of support services and further training given to staff responsible for the funds.
Goal #2: Enhance 3rd part payer processing and billing
Strategy: Participate in state association's revenue cycle
work group and receive other appropriate technical training as needed and available.
Outcome: The Administrative Services Manager has participated in all conference
calls for the Revenue Cycle Process Improvement Committee of the Georgia Association
of Community Service Boards. The goals of the Committee are still not complete
but the end product will be shared with all CSBs.
Goal #3: Improve overall efficiency of business office.
Strategy: Conduct business office review of its processes and procedures and
make needed modifications to increase efficiency.
Outcome: The review has not been completed but one improvement begun during
the fiscal year and later implemented was direct deposit. With the upgrade to
the Windows-based M&M system, the Administrative Services Manager is anticipating
changes to the requisition and purchase order processes.
Consumer Rights and Critical Incidents:
Goal #1: Improve responsiveness to consumer needs and complaints.
Strategy: Identify and recruit new members to serve on committee.
Strategy: Ensure the development of a corrective action for any consumer rights abuses immediately after investigation is completed.
Outcome: Meetings are held monthly regarding consumer rights and critical investigations and several of the members suggested additional staff to serve on the Consumer Rights Committee, with representation from all major service areas within Mental Health, DD and Substance Abuse.
Goal #2: Increase knowledge and effectiveness of committee members.
Strategy: Conduct internal training for new committee members and develop refresher training for existing members.
Outcome: Monthly meetings are held to discuss any problems. A refresher training has been established for all members. All employees are mandated to attend Consumer Rights refresher training on a yearly basis.
Goal #3: Increase outreach to consumers served by the agency in order to promote consumer rights and safeguard against abuses.
Strategy: Develop consumer rights focus groups on outlying units and implement over course of fiscal year.
Outcome: Consumer Rights Focus Groups on outlying units were not implemented this year. This goal will be carried forward to next year's PI Plan.
Goal #1: Integrate investigative functions of agency to promote efficiency and timeliness.
Strategy: Study feasibility of incorporating some corporate compliance and consumer rights functions and committee members into a larger consolidated group, and make recommendations to senior management.
Strategy: Utilize similar investigative techniques for corporate compliance investigations as those utilized by consumer rights committee.
Outcome: An initial study resulted in a trial period to incorporate the existing committees. For several months Wendy Nelson, Consumer Rights Committee Chair, attempted to consolidate these functions with the consumer rights committee, but corporate compliance duties were later returned to Linda Kidd, Corporate Compliance Chair. The issue of an integrated investigation team needs to be carried forward to the next year for further study and resolution.
Goal #2: Increase staff knowledge and awareness of corporate compliance; e.g., purpose, reporting procedures.
Strategy: Develop internal annual refresher staff training
on corporate compliance, and incorporate training with monthly consumer rights
training.
Outcome: In actuality, the strategy listed under Goal # 2 is somewhat misleading.
For the purposes of review, corporate compliance training has been offered annually
to the entire agency. In order to reduce cost, and ensure better attendance,
the decision was made to have training sessions monthly and have approximately
30 employees attend. Annually, the goal is to have all employees trained in
corporate compliance. The cycle then repeats itself.
The question became whether to incorporate this training with consumer rights. Again, for review purposes, a formal training session is required for all new employees in consumer rights, and then an annual hand-out is distributed to all agency employees. If an issue or complaint arises, the staff involved must take the formal class again. Because of the differences in the way the agency provides these training sessions, and reports of satisfaction from the training department within Personnel, this overall goal for combining the training sessions with corporate compliance and consumer rights was studied, found to be impractical, and discontinued.
Strategy: Appoint Human Resources (HR) director as committee chair, with committee-appointed co-chair, effective October 1, 2007.
Outcome:
The EEO Committee reorganized this year with new goals. On October 1, 2007 the
committee came under the direction of the HR director, Donna Jones. The committee
developed an Employee Incentive and Retention Plan, which included workplace
incentives for staff, faithful service, and specific agency goals. The committee
also developed internal reviews for all personnel exit interviews and developed
an annual cultural diversity workshop for all staff.
This goal was accomplished by the appointment of HR Director as committee chair and liaison with the Executive Committee and the EEO Committee elected a co-chair, effective October 1, 2007.
Goal #2: Improve employee retention and morale.
Strategy: Develop a detailed employee incentive and retention plan, including workplace incentives for performance, faithful service, and agency goals.
Outcome: Employee incentives and retention were addressed in October 2007 by the establishment of an Incentive Plan and Recognition Program to encourage, award and retain outstanding employees. The bonus incentive plan recognizes long-term service, superior individual performance and teamwork.
Goal #3: Promote fairness in the workplace.
Strategy: Ensure review of all personnel exit interviews by committee members, with trending of findings for senior management review.
Strategy: Provide annual cultural diversity/sensitivity workshop as mandatory
training requirement for all staff.
Outcome: The EEO Committee reviewed all personnel exit interviews and following-up
any trends of findings for senior management review. All staff are provided
annual cultural/sensitivity training and the EEO Committee continues to monitor
those surveys, noting any trends of findings for senior management review:
Forms Committee:
During this fiscal year a committee was re-established to formally review and
adopt all forms utilized by the agency in its consumer records. The Forms Committee,
re-established in November 2007 and chaired by Judy Slade, has developed and
tightened procedures for using only approved forms, and has assisted the agency
in monitoring quality and consistency of forms, as well as preventing unauthorized
forms from being filed in the consumer records. Specific performance improvement
goals will be developed by the revitalized committee for the new fiscal year.
Goal #1: Promote good health practices within the workplace and with agency consumers.
Strategy: Explore plans for an Employee Health Fair and make recommendations to senior management.
Outcome: This goal was not met and needs to continue for next year.
Strategy: Finalize and implement policy and procedures for dealing with HIV exposure on the job.
Outcome: This goal was not met and needs to continue for next year. Every contact made with surrounding drug stores and hospitals has turned up nothing helpful to the program. Laurie Leonard, committee chair, attended a conference in Atlanta on HIV and met a nurse that may be able to provide assistance. Laurie has current contact with her and is receiving information to complete this goal.
Strategy: Continue to provide newsletters for staff with focus on health and safety issues.
Outcome: Incomplete
Goal #2: Ensure that appropriate medical management is practiced within the agency.
Strategy: Develop and/or review all medical management policies and procedures of the agency.
Outcome: This is an ongoing goal. Policies and Procedures have been reviewed and the committee is currently working on some revisions.
Goal #1: Increase activities and effectiveness of committee.
Strategy: Identify and recruit new members to the committee.
Strategy: Establish quarterly meeting schedule for the committee
Outcome: The goal was not met and needs to be continued for the next year.
Goal #2: Improve clinical knowledge and skills of non-licensed clinical staff.
Strategy: Develop training standards for non-licensed Qualified Professionals
and other non-licensed clinical staff, and implement training curriculum in
conjunction with training office.
Outcome: This goal has been partially met. Implementation of a computerized
training module is being considered. This computerized training module will
allow staff to be trained on a variety of topics without the expense of travel.
This goal will be carried forward into next year's PI Plan.
Goal #1: Coordinate new training opportunities within the agency.
Strategy: Implement monthly and annual training in identified areas, once training curriculum is developed; e.g., documentation training, corporate compliance training, non-licensed staff clinical training, etc.
Outcome: This goal has been partially met by offering a monthly Corporate Compliance training as well as program-specific trainings, i.e., documentation, MAP, various pharmaceuticals, PSR, MICP, etc.
Goal #2: Provide training opportunities for employees in the most effective and efficient manner.
Strategy: Review training roster periodically and add or delete trainers as appropriate.
Outcome: This goal has been met by adding additional trainers in CPR/First Aid, Supervision of Medications, Cultural Diversity and Corporate Compliance.
Strategy: Emphasize and encourage the use of the computer lab and training room to offer more on-line classes for staff.
Outcome: This goal has been met. Employees are able to access computer lab for various on-line trainings including M & M, Defensive Driving, and e-courses for professional CEUs. It is also noted that a feasibility study has been undertaken to consider adoption of an e-learning program for staff training, as referenced under Peer Review above.
Strategy: Continue to orient employees with the use of the computer lab on annual flexible benefits changes. Provide education and assistance to employees regarding online enrollment and changes.
Outcome: This goal has been met. All eligible employees are required to enroll in health and flexible benefits on-line. Employees are continually becoming more proficient in the use of this program.Goal #1: Ensure accessibility of agency services and facilities to consumers, staff, and the public.
Strategy: Review, update, and monitor the agency's annual Accessibility Plan.
Outcome: The Accessibility Plan was reviewed and noted changes were made to meet the agency's changing needs in the area of speech and communication.
Goal #2: Ensure a safe and coordinated agency response to any disaster.
Strategy: Review, update, and monitor the agency's annual Disaster Plan.
Outcome: The Disaster Plan was reviewed by the Executive Committee and changes were recommended. The plan addressed the agency's changing needs and the assurance of a safe and coordinated agency response to disaster. The plan is presently undergoing final revisions.
Goal #3: Strengthen activities and outreach of the committee.
Strategy: Identify and recruit new members to the committee as needed.
Outcome: Risk Management Committee recruited new members and performed basic training with the DD group homes.
In establishing the Performance Improvement Plan for FY 2009, The Quality Council will incorporate unmet or partially met goals of the FY 2008 plan, as appropriate, into next year's goals.