Office Of Clinical Quality and Risk Management - Current Projects
This ongoing initiative works with facilities to integrate the various state, federal and other regulations and guidelines into a single set of practice requirements to guide facilities in assessing and treatment planning with individuals having a mental illness or mental retardation.
Automated Treatment Planning
This project will examine the feasibility of adopting a single standard for automating the documentation of treatment planning. Guided by a Steering Committee of facility clinical leaders and administrators and supported by a Technical Work Group of IT and clinical “end-user” personnel, this project will review available public domain, off-the-shelf treatment planning software, and examine the feasibility of in-house software development.
The Office of Clinical Quality and Risk Management is working with Facilities and Community Service Boards to provide training to staff as it relates to the principles and concepts of Applied Behavior Analysis. The training is being done in partnership with George Mason University who is providing graduate level classes in the course work.
Behavior Intervention Training
The Office of Clinical Quality and Risk Management is chairing a workgroup that is charged by the Facility Directors and the Commissioner to provide recommendations for alternatives to the current behavior intervention training. The workgroup will be reviewing proprietary and public domain training programs as part of this process.
Behavioral Treatment Procedures
The Clinical Quality and Risk Management Office, working closely with facility behavioral treatment professionals, is developing operational policies and standardized procedures for the development and implementation of individualized behavioral treatment plans. The procedures will address functional assessments, analogue functional analysis, behavioral procedures, data collection and reliability assessment, and performance management procedures. The final document will establish training and education requirement to insure that behavioral treatment procedures are developed, implemented, and monitored by professionals trained in behavioral analysis.
The Clinical Quality and Risk Management Office is working in concert with facility Health Information Managers to update policies, procedures, and practices for clinical records management. New and updated procedures will include, consent, confidentiality, audits, documentation requirements, regulatory compliance, the management of records during disasters, and documentation for treatment planning. The procedures will establish a mechanism for continuous evaluation and updating of the procedures.
The Clinical Quality and Risk Management Office provides ongoing updates and technical assistance on JCAHO principles, standards and survey process and organizes a support process for facility accreditation through quarterly meetings with facility Medical Directors, QM Directors and Health Information Management Directors to offer information and facilitate information-sharing on JCAHO processes. The Clinical Quality and Risk Management Office also assists facility staff to prepare for accreditation surveys and works to identify systemic trends relative to JCAHO survey process.
The Clinical Quality and Risk Management Office coordinates and administers the Interstate Transfer process including the review and processing of interstate compact applications and the coordination of information exchange among facility staff, service providers and family members.
The Clinical Quality and Risk Management Office, in collaboration with staff from the Mental Health facilities, is conducting a one-year retrospective and a one-year prospective study of individuals admitted to our facilities with significant medical conditions. Over the years, there have been a number of individuals admitted to our facilities whose medical/surgical condition has either exceeded or stretched the capacity of the hospital to provide needed medical care. These types of admissions are relatively low-volume, however they pose considerable risk and potential for compromised health care.
The Office of Clinical Quality and Risk Management is working with the Mental Health Facilities to develop a psychosocial rehabilitation (PSR) training package. This package will include shared information from all of the mental health facilities in an effort to provide the best practices at all the facilities.
The goal of the DBHDS is to improve the lives of the persons receiving care in or from its facilities and other service providers. When fully implemented, the QMDS will quantify the provision of care on key dimensions and examine the impact of these care dimension on client outcomes.
The Clinical Quality and Risk Management Office works closely with the behavioral health and intellectual disability facility Quality Management Directors in monitoring and evaluating facility-specific and system-wide quality management programs. The Office reviews facility QM Plan and Report submissions and facilitates quarterly Facility QM Director meetings to promote standardized quality management and performance improvement processes and outcomes.
The Seclusion and Restraint Data Set will provide ongoing data on facility use of seclusion, mechanical restraint, and physical restraint. This data set will allow Central Office managers and senior administrators to monitor facility compliance with HCFA and JCAHO standards. The data set also will allow the Office of Clinical Quality and Risk Management to evaluate the incidence, appropriateness, restrictiveness, and medical risk associated with the use of these procedures. Finally, the data set will allow facilities the option of defining facility specific fields for evaluation and documentation procedures unique to their population and needs.
State Incentive Grant for Reduction of Seclusion and Restraint
The Office of Clinical Quality and Risk Management is currently implementing a federal grant to build capacity for reducing the use of seclusion and restraint.
References compiled in conjunction with this grant
References compiled in conjunction with this grant
The Legislature has tasked the Department with developing treatment resources for civilly committed sexually violent predators and other sexually aggressive persons. This project supports this initiative through consultation with facilities and others, remaining current with national and international developments in care of this population, and providing training on assessing and treating sex offenders through the Institute for Law, Psychiatry, and Public Policy.
The Office of Clinical Quality and Risk Management is working with the Training Directors at the fifteen facilities to develop standardized training for staff in areas that are common at all of the facilities. The group will be exploring various methods to provide the training to include teleconferencing, videos, computer based and regionally.
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