Quality Improvement and Compliance Oversight Role Overview
Explore the responsibilities of Amy Strasser-Garcia, the Director of Quality Improvement and Customer Care. From training staff to managing compliance and audits, delve into the essential duties and recent audit feedback for Beacon (Carelon) and BHA. Learn about the ongoing CDPHE/BHA audit and the steps being taken to ensure compliance with appointment scheduling and progress note documentation.
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Presentation Transcript
INTRODUCTION Amy Strasser-Garcia
DIRECTOR OF QUALITY IMPROVEMENT AND CUSTOMER CARE Training staff Assisting with problem solving Supervise 4 direct and 12 indirect Update forms (paper and electronic) Recently took over compliance in January (Critical Incident Reports, Breaches, Violations of fraud and abuse Work closely with Yolanda and Jana to manage data, Avatar, coding, lists, CCAR s
DUTIES MAC (Member Advisory Committee) In charge of Medical Records department In charge of Client Advocacy (Lea Chavez) Auditing-Completing Internal and External Audits On the Diversity, Equity and Inclusion committee Office signage, appearance, functionality Special projects (writing or updating policies and procedures, researching EHR)
AUDIT RESULTS/FEEDBACK BEACON(CARELON) AUDIT 02-3-23 Administrative section-100% Assessment section-100% Treatment plan section- 90.28%- Missing signature, how will parent participate in treatment, vague discharge goal, making goals measurable and timely Progress notes section-98.61% Member progress towards goals was not always clearly documented Coordination of Care- 100%
BHA AUDIT 02-2023 Hours posted on the psych door and patient rights signage in the lobby (fixed while auditors were still here) Suicide Prevention training to annual Relias training Original, wet signature needed, no more verbal or typed No phone sessions allowed since Feb 1stfor psychotherapy, assessments & TP Must be documentation for attempts to outreach a cl prior to DCing them Documentation for no shows
CDPHE/BHA AUDIT CONTINUED We missed the required appt time window for almost all appts. For example: screening completed and an assessment must be completed within 7 days of that screening and that isn t happening. A treatment plan needs to be completed within 14 days. To ensure that we meet this, every clinician must block two appts in their schedule for every week, one AM and one PM for new clients. There are no exceptions for anyone unless you are on a freeze and it is agreed upon by your supervisor. Progress notes do not match the goals and objectives that in the treatment plan. Evidence of what goals were worked on, what the client was learning/practicing, what the clinician saw and evidence of clinical judgement was not found. Supervisors will work with their clinicians and case managers to ensure that progress notes are aligning with the assessments and treatment plans. Treatment plans were not measurable, not updated within 6 months. All staff, regardless of licensure, will be required to send their assessments and treatment plans to supervisors effective immediately. Some minor changes to office layout (clients cannot be in areas where food is stored)
SIGNAL AUDIT 02-22-23 At the audit we were mandated to participate in a utilization review where I send information for a randomly requested chart to Signal every month due to concerns around documenting specifics for ASAM scores. There have been no problems in every audit for the past 5 months or so and we anticipate not having to do these after the next yearly audit.
MAC (MEMBER ADVISORY COUNCIL)
MAC The BHA/other contracts requires we start a Member Advisory Council. The Member Advisory Council was created to give our clients/members a voice in their care and help create the best environment of care/member experience possible.
MAC Member s time is valued and compensated and the group works to provide feedback and act as a sounding board for many quality improvement projects for the center. The hope if for SLVBHG to find innovative ways to improve member experience going forward and offer client driven solutions to problems.
PURPOSE Serve as a link between client and leadership Identify issues of concern before they become a problem Provide expert opinion about challenging issues Propose creative ideas about programming Review client facing materials for readability and relevance Demonstrate to the community that we are truly client driven
IMPLEMENTED THUS FAR The Member Advisory Council with incentives Staff surveys and data collection on surveys Relaying MAC concerns and ideas to directors, leadership and supervisors to relay to their staff Looking into minimal funding for fidgets for screeners
THINGS TO CONSIDER IN THE FUTURE Assistance with intake packets for some Electronic signatures Proposal to an addition to Assessment in regards to what triggers client and what calms then as they addressed aesthetics and environment as a huge factor in their success Proposal for inspirational quotes in the lobby. Welcome packet (map, journal, brochure, etc.)
