Update on Quality Improvement Activities and Meeting DOJ Targets for Performance

December 14, 2020

The significant “take-aways” form the QIC meeting today were:

• The Risk Management Review Committee Annual Report for FY20 asks “Does the SIS level make individuals more vulnerable?” We might suggest that there may be a correlation, but it seems unlikely that there is a causal relationship.
• It also asks to “identify changes in routines/practices due to COVID that had a “positive” impact on reducing illnesses or conditions as reportable incidents to determine efficacy in the replication after the pandemic has ended.”  Undoubtedly “stay at home” orders reduced opportunities for injury or illness, but is hardly seems to be something to which we aspire.  Reductions in ER visits were also no doubt directly related to COVID fears – this may speak directly to our over use the the ERs as we seek to err on the side of safety!  Unplanned ER visits do account for approximately 50% of the serious incidents
• Analysis will continue on the cases of substantiated neglect which make up more than 1/2 of the  substantiated cases of abuse, neglect & exploitation. We hope that part of this analysis is looking at the seniority of the staff involved – neglect is often the staff’s failure act timely, or appropriately; a circumstance that perhaps occurs more frequently with inexperienced staff regardless of the training received.
• The Incident Management Unit has started to provide care concern protocols which serve as triggers for providers that a care concern may exist and that the provider should reassess the care plan:
  • Three or more unplanned medical hospital admissions, ER visits or psychiatric hospitalizations within 90 days,
  • Two or more unplanned medical hospital admissions or ER visits for the same condition/reason within 30 days 
  • Any combination of 3 or more incidents of any type within 30 days
  • Two or more unplanned hospital admissions or ER visits for any combination of falls, choking, UTI, aspiration pneumonia or dehydration with 90 days
  • Any incidents of decubitus ulcers or bowel obstruction

And – HSAG reported that:

• They are making the sign up for PQR reviews a bit more efficient,
• Within 30 days of completion of all of the elements of the PQR and PCRs a report will be completed and uploaded to SharePoint,
• 400 of the 562 PQRs have been completed in Round 1 and 750+ PCRs have all elements completed with 1,500 in progress
• Looking ahead – they will try to identify excluded individuals early in the process, they are looking at options for scheduling and documentation uploads will be into “Dropbox” in the next round this will eliminate the need for encryption and password protection.
• Round 2 will begin when Round 1 is complete and DBHDS has set the period of responding to the report; agency directed respite will be included in Round 2 as will follow-up on the identified items for the provider in the report from Round 1.