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The Stepwise Tutorial to Qcc100 Form

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Instruction of Qcc100 Form

I.am I on muted now yes good morning good.morning here hi Mary I mean I want to.just hold on for one sec we're just.trying to figure out some of the.technology and we'll be right with you.okay can you hear me okay.good morning I'd like to welcome all of.you today to nice arcs quality.improvement initiative I know most of.you on the call I've met most of you in.person I do know that we have a fairly.large group and there may be some.individuals who have not met me yet my.name is Eric geyser I'm the assistant.executive director for quality.improvement in compliance I've been with.nice art since April and one of the.tasks that I was given when i first.started was to try to move quality.improvement forward in the nicer.organization overall so today we're.going to focus on quality some of the.steps we are going to take as an.organization to quality for and.hopefully answer some questions and take.some feedback from all of you today a.couple of housekeeping items many of you.might have better luck on the telephone.rather than listening to the conference.over computer speakers but that is.certainly you can go either way with.that I will allow you know the phones to.be unmuted if background noise becomes.excessive i will put everyone on mute.and unmute at times for periodic.questions comments and feedback so that.being said we'll get right into it I.don't think we're going to take the full.two hours but that will depend on the.feedback that we get from all of you.ok so the agenda for today really seven.items we want to cover work we're gonna.have some opening remarks from Marianne.Bruner who is our chairperson for our.quality standards Oversight Committee.will go through some background on the.quality improvement program and how this.all came to be I do want to take time to.acknowledge the members of the Oversight.Committee and also the professional work.group for all their hard work and their.effort and then we'll get into the steps.that we're going to undertake as an.organization to implement the quality.framework which includes development of.quality improvement plans for each.chapter and annual quality metrics which.we would ask chapters to submit to us on.an annual basis and then we'll have a.time for some conclusion and some.questions and answers okay that being.said i'm going to turn over the audio to.Marianne Bruner for some opening.comments Marianne are you with us.Marianne I'm here okay sorry okay can.you hear me yes okay very good I yes I.good morning everyone I I'm suffering a.relapse of the flu so if i have a.coughing jag please forgive me i just.like to make some initial comments here.on behalf of the quality standards.oversight committee and its professional.work group comprised of chapter quality.improvement staff from many chapters.across the state i welcome you to our.first webinar on nice arcs quality.improvement initiative as you may have.read in the recent chapter bulletin on.nice arcs quality improvement we are.about what we are about to review as the.result of a diligent effort over a.two-year period that establishes a solid.framework from measuring and ensuring.quality of life for the people we.support it is no longer sufficient to.say that we are doing good work because.we are dedicated to our mission we are.now in an environment that demands proof.also and most important we have evolved.in the field of developmental.disabilities to recognize and foster.self-determination personal choice and.person-centered planning in an effort.that enables our people to grow grow and.thrive the people we support their.families and our staff must not only.have an active voice in what we do but.also must have a sense of satisfaction.to the fullest extent possible that life.goals desires and interests can and are.being realized what we will present.today represents the beginnings of our.best effort to embark upon a statewide.initiative that provides overarching.stand.cheers and quality metrics that indeed.will reflect the proof of our dedicated.labor this quality improvement process.is all about acknowledging and.applauding our successes and with.supportive expertise offering assistance.to improve any areas that need to be.corrected or strengthened as pioneers in.the statewide quality initiative we.embrace your thoughts and feedback as.together we engage in this most.important effort I want to especially.acknowledge the enormous and outstanding.effort of our nice arc staff Eric geyser.and Tanya Seberg for shepherding us to.this point and now I will turn this over.to Eric to walk us through nice arcs.quality improvement program ok Thank You.Miriam the first slide I wanted to put.up a definition from merriam-webster of.quality this quality one of the.challenges we have in terms of quality.is what does it mean how do we define it.in terms of its formal definition.quality can stand for how good or bad.something is in terms of where we want.to go with quality the third definition.really applies where we want to use.quality to perform high level of value.or excellence in the services that we.provide so we use quality to measure and.we also hope to reach high quality as we.continue.okay so a little background on quality.what is quality quality is one of those.things that you kind of know it when you.see it when you go into a program it's a.very hard thing to divide define for the.health care field the analogy I like to.use is you're an experienced let's say.in a restaurant where you go for a meal.a lot of factors go into how you might.define whether or not that's a quality.experience obviously the food itself the.ambiance in the room of the staff.attentiveness of the price and value for.the meal so these are all things that.might go into the equation of your.overall quality experience what makes it.particularly challenging in our field is.that when we go to the restaurant that's.our experience what we're trying to do.in terms of quality in this field is.measure the overall experience for the.individuals that we serve so that that.makes it kind of uniquely challenging.and something as Marianne indicated that.I'm not aware that anyone else in the.country has really perfected the the.measurement of quality yet so this will.evolve over time and we're just at the.beginning stages of our quality.initiative some things are pushing.quality forward one of the things that's.pushing quality forward is the managed.care initiative in New York State the.Disco's quality will be a key component.of measuring outcomes for individuals.who are enrolled in our disco or other.discos I'm sure all of you have seen for.Medicaid or Medicare different plans.advertising we're a three and a half.star plan or a four star plan those are.based on quality metrics and the amount.of reimbursement that managed care.companies get are dependent on the.quality that is being measured at the.managed care company so quality is going.to be very very important as we move.towards managed care it's also going to.become easier as we move towards managed.care because as a managed care.organization we will have access to all.of the claims data and we will be able.to do huge amount of data.analysis on treatment on types of.services people are getting a timeliness.of appointments timeliness of.prescription fills things of that nature.that right now we really can't do we.also have OPWDD emphasizing equality of.recently in last year two years OPWDD.has been pushing quality for extensively.and not only are they pushing it forward.you know verbally and through guidance.but there are regulations that are that.will be coming out probably later this.year that are going to require a quality.components the draft opwdd governance.regulations which have not come out yet.but have come out for some common.indicate that a quality improvement.plans will be required for providers.that they will need to be reviewed and.approved by the Board of Directors.annually and that the quality.improvement plan shall include goals and.objectives and a process for measuring.compliance and quality of the services.provided so I think nice art is taking.the lead and trying to get out ahead of.this but certainly there are a lot of.other contributing factors pushing.quality for and OPWDD is certainly one.of those a little background on nice.arcs quality initiative as Marianne.indicated back in 2012 the board of.governors of nice arc established of the.quality standards Oversight Committee.which Marianne is the chairperson of and.the resolution essentially reiterated.nice our commitment to quality.established a quality initiative and.began to discuss quality metrics how are.we going to measure this thing called.quality the resolution also established.a quality standards professional work.group and the way I like to think of it.is the the quality standards oversight.committee kind of set set sends the SSD.the goal and the agenda for the.organization and then the professional.work group actually puts the nuts and.bolts of how do we.get the quality improvement program.going and the professional work group is.made up of quality professionals from.many of our chapters the overall goal.for all of this of course is to put in a.quality framework across the.organization and we're going to do that.by assisting all of the chapters in.developing quality improvement plans and.then developing a system of reporting.and metrics which we will be able to.utilize here at state office and.feedback to the chapters in terms of how.we are doing in terms of our quality of.care so these are the responsibilities.as outlined in the resolution the qso.see is going to assist the chapters in.developing the quality improvement plans.the qso see through me and nice art.state office will be collecting and.analyzing data from chapters we will be.reporting quality concerns and.organizational quality trends the nicer.governing body a couple of other things.that we do as well for each instance.where a program receives a forty five or.six day letter 60-day letter from OPWDD.nice arc actually makes a site visit or.multiple site visits and assists the.chapter and responding to those.situations we make sure that the.chapters are responding to deficiencies.appropriately and thoroughly and we.arrange a quality training programs.throughout the year and we'll discuss a.an upcoming one in February towards the.end of this training just to acknowledge.the members of the quality standards.Oversight Committee again Marianne is.the chairperson and the individuals.listed below have all volunteered a lot.of their time and effort towards moving.quality for and I do want to acknowledge.all they've done to push this very.important agenda for four.I also want to take a special moment to.thank and acknowledge all of the people.who have contributed to the professional.work group these are all the individuals.who have participated in the process.they have really done the nuts and bolts.in terms of the work coming up with the.metrics and the definitions and feedback.on quality improvement plans and sample.plans and that's in addition to all of.their regular duties and.responsibilities at their individual.chapters so they've really contributed a.lot of their own time and effort so we.thank them and we also want to thank.their executive directors for allowing.them to participate and move our whole.organization for okay so what is absolve.you are asking now what what's required.of me what is this all about how much.work is there going to be involved my.goal today is that you'll leave.hopefully not overwhelmed with the work.and I think I think as we start to go.through some of the requirements you'll.see that most of this material is.already being done at the chapter level.it's really about putting it into a.comprehensive plan a written plan.getting the board approval of that plan.and then of course the data submission.to nice arc and most of the data is.stuff that you're already accumulating.and reporting on at the chapter level so.I hope you won't feel too overwhelmed as.we start to go through this it's just a.little qualifier just like anything else.this is we're at the very beginning of.the initiative it's a work in progress.we've had a lot of debate and discussion.about the metrics and the quality.improvement program and this will.improve over time so there may be.changes that happen along the way but we.certainly will be cognizant of all the.time constraints that all of you have.out in the field.okay before I go on maybe I'll just stop.for a minute and see if anyone has any.questions at this point okay hearing.none will go right into the quality.improvement plan so what what are our.expectations as an organization in terms.of a quality improvement plan okay first.of all we recognize that there are a lot.of time challenges the Justice Center.regulatory changes Oh made CMS we we.understand and recognize how busy all of.you are we wanted to give ample time to.develop these quality improvement plans.we all came to the agreement that six.months would be a reasonable amount of.time so we're really looking at the end.of July and early August of 2014 the.Oversight Committee and the professional.work group developed user-friendly.guidelines I sent out an email earlier.this morning that had the quality.improvement program guidelines to you.along with a couple of other documents.which will touch on a little bit later.and we're going to go through them in.this slideshow as well one of the.documents that i sent out this morning.is a qi p evaluation tool so what you.can do with this tool is when you are.developing your own quality improvement.plan you can use it to make sure that.you have all of the required elements.covered and included in your plan I.should also note that here at nicer when.we receive a quality improvement plan in.six months we will also use that quality.improvement evaluation tool just to make.sure that all of the components are in.there we will be providing sample.plans and guidance materials we.recognize that some chapters like to do.things independently and with less.guidance other chapters may need more.guidance we presently have for quality.improvement plan samples that we are.going to be sending out probably in the.next week after after this video.conference and it ranges from very.prescriptive very detailed to just.high-level topics that the chapter could.build upon so you really will have a.variety of sample or model plans to.choose from as you work in the next six.months to develop your own unique plans.okay I also want to let folks know that.we are not going to be overly.prescriptive we are not telling the.chapters how to do this what to write.what to say and we recognize that.there's a lot of different ways to.measure quality so we are not going to.be analyzing your submissions to the.extent where we're going to quote.unquote nickel and dime you work one.piece missing or this piece missing we.just want to make sure that the major.content areas are covered and being.measured in some way appropriately so.just to give everyone peace of mind okay.so what is what are the required.elements in the quality improvement plan.well first is that your quality.improvement plan will need to address in.some way certification reviews okay the.number of reviews the number of.deficiencies so in your quality.improvement plan you're going to need to.address how you manage a program.certification reviews how you respond to.statements of deficiencies.recommendations best practices how plans.of corrective action are developed and.position posted do you know what she.told me what they thought it would be a.good idea because if I could ask.everyone to place their phones on mute.okay thank you hang on i'm going to put.everyone on mute okay there we go sorry.about that i'll open up the lines up.every few slides for questions and.comments okay so there will also be a.report on plan approval and need for.additional improvement and this will.become clearer i think when you get the.model plans you'll see how this.information is incorporated into the.quality improvement plan okay the second.element that's a required part of the.plan would be your chapter incident.review committee annual report and data.this is stuff that the chapters are.already doing we know in 624 there is a.requirement for the development of an.annual report and review of trends and.patterns you would simply want to.formalize that process into your overall.chapter quality improvement plan when is.that done who is it done by who is it.presented to what recommendations will.come out of those types of reviews on an.annual basis so again that's that's work.that's already being done it's just that.it hasn't been pulled into one formal.quality document the third element is.quality improvement reviews by non.regulatory agencies so and that there.may not be many of these but on occasion.there may be some but you may be.reviewed by let's say I pro or jayco.they may come in and do various types of.quality reviews certainly when that.happens you would want to incorporate.into your program how you'll handle.those types of reviews and how you'll.respond to those the fourth element is.self audits a self audits are already.occurring at all.chapters we know through the compliance.regulations that there has to be a.system of risk assessment and also self.auditing that occurs it's just the basic.part of the function of the work we do.but we probably need to pull that into.the plan and again formalize the process.for how that's going to occur how are we.going to assess what risk areas we have.in our captors how are we going to.determine which areas we want to audit.and when we have findings from our self.audits how are we going to respond to.those audits and ensure that any.deficiencies are corrected so that.process itself should be outlined in.your quality improvement plan and again.you probably already have a process for.doing this it's just a matter of putting.pen to paper and formalizing it into.this quality program okay the fifth.element is satisfaction levels of the.people we support there are.questionnaires and surveys that we will.be sending out as samples that will.hopefully measure of this satisfaction.levels obviously we know many of the.chapters are involved with cql and.that's certainly one component that.could be used but you may want to expand.it to include satisfaction levels for.family members or guardians for those.individuals who maybe can't articulate.or have difficulty articulating their.feedback in terms of the services that.are provided so a number of chapters.have already employed a various.satisfaction surveys and again we will.be sending out guidance materials and.survey samples to all of you for.consideration and potential use the six.component obviously and certainly not.least the staff members that work for us.and provide the critical services we.need to know if we are providing them.the tools that they need to provide.quality services we need to know where.they're not feeling support.and we need to provide them with the.training and the the talent and the.abilities to allow them to do the the.work that we need and expect for the.individuals we serve again just like.with number five we will be sending out.a variety of satisfaction tools for four.employees and you certainly are more.than welcome to use those survey.instruments I do know that many chapters.if not all the chapters already have.some sort of questionnaire or self.assessment for staff members that they.turn in on an annual basis you certainly.can go ahead and continue to use that.it's just a matter of again formalizing.the process by which that will be done.and what will you do with the.information once you have it okay item.seven is an assessment of the quality of.life of the people we support now seven.and five they there is some overlap I I.recognize that item number five I guess.would be geared more towards chapters.that haven't employed cql two dates or.number five could also apply to parents.or guardians in terms of their.perception of the services we are.providing seven is total emphasis on cql.and most of the chapters are in some are.already working with cql have begun the.process some are farther along in that.process than others there are a few.chapters that have not participated in.cql to date a couple of things on cql.cql is not something that nice arc is.necessarily pushing although we.certainly believe in cql but it is.something that is really being pushed by.OPWDD and recent guidance and seminars.that we have attended indicate that.while they're not going to require the.use of cql per se they are going to be.requiring that chapters measure for all.21 performance outcome measures that cql.uses.so I to me that's kind of code for you.really are going to need to use cql so.we're going to encourage chapters that.haven't begun the process to incorporate.into their quality improvement plans how.they're going to start to initiate this.ql programs within their own chapters.and those of you that are already using.it how you are using it what are you.doing in terms of measurement the.formality of that and how are you using.the results and and pushing quality.forward through that cql process the.eight element is to human resource.issues such as staff retention OSHA.reportable injuries staffing levels and.staff development programs such as.training programs again these are all.things that are most likely occurring at.all of your chapters although they may.be occurring in different departments.such as the human resource department.human resource department is required to.obtain data and information on.ultraportable injuries but by pulling.that information into our overall.quality improvement program we can start.to get a better sense of what's going on.for the individuals who work for us the.staffing levels and where deficiencies.might lie and staff training needs so.will will be pulling in information from.a number of different areas into this.overall quality improvement program okay.the ninth and I would argue maybe the.most important is board governance and.review with an attestation of the.quality improvement plan you know the.board governance historically has been.one of financial oversight and.stewardship and certainly that is very.important but as we move forward the.board is going to need to become more.involved in what's really going on in.the programs that you offer and become.more invested in where there are.problems that those problems are getting.rectified there's a number of pieces of.this I apologize for this being so small.the first bullet obviously we want to.make sure that the chapter has an.updated mission statement and the board.reviews the mission statement to make.sure that it is consistent with the.desire of the chapter to provide the.services that they are providing.obviously now in regulations there is a.requirement for board participation on.the Standing Committee for instant.review at least one board member has to.be on the incident review committee.although you certainly could have more.there's nothing prohibiting additional.involvement from the board I certainly.think that would be a very proactive.position one thing that we are going to.emphasize is we really want our board.members to be visiting our program sites.we really need to get additional eyes on.all of the programs that we offer and to.do this we have developed a number of.different templates which our site visit.templates that a board member could use.to go to a program to evaluate how does.it look remember we go back to the old V.you know it when you see it your board.members don't need to be sophisticated.and regulations or rules or requirements.they can get a sense using a simple.checklist or template as to whether or.not the program is clean weather.interactions are positive whether there.are physical plant issues so your.quality improvement plan is going to.need to incorporate that that.expectation of your board members that.they are going to need to be out at some.sites throughout the year and report.back on what they find obviously your.board will want to know and we'll need.to know how the chapter is doing on self.surveys and regulatory surveys many of.you are already doing this through your.corporate compliance committees and.giving feedback to the chapters on how.audit.are going or self disclosures just to.make sure the board is fully informed.again you're going to want to formalize.how that happens and how you're going to.feed that information back to the board.also kind of in line with that previous.bullet board awareness of the state or.federal regulatory authority.communications so if you get.deficiencies if you get a statement of.deficiencies or a 45 or 60 day letter.that is something that certainly the.board should be aware of and should be.monitoring and overseeing to make sure.that the chapter is addressing it.appropriately okay also board assurance.that senior management has the means to.assess adequacy of staffing levels staff.competence and staff performance with a.mechanism to address deficiencies many.boards will have HR committees obviously.or training and development committees.again so a lot of this works already.occurring it's just a matter of.formalizing the process and how that all.impacts on quality for the services we.provide board assurance that the chapter.has a plan for ongoing staff development.and training and board assurance that.expectations for ethical conduct be.communicated and reinforced for chapter.employees volunteers and board members.okay and lastly and certainly not least.we want board assurance that the.chapters practices are consistent with.self advocacy for the people that we are.supporting and that individuals are.living in the least restrictive.environments with the most choice.available to them so these are all.things that can be done through your.regular board meetings certainly you.could develop forms that you know these.items have been incorporated into the.plan and the board could sign off.acknowledging those things but again I.believe these things are already.occurring at all of our chapters it's.just a matter of getting it all in one.place.as I mentioned earlier there is a.quality improvement evaluation tool.there's nothing fancy about it it.essentially just goes through those nine.elements that we just went through now.and you can just kind of check off that.you've covered all of the areas and and.once you've checked that off your plan.should be ready to be submitted we will.also be evaluating the plans as they get.submitted to us here at nice art so you.can kind of you'll know in advance.whether or not your plan meets the.expectations just by using of evaluation.tool I sent this out in the attachments.earlier this morning okay let me stop.here before we move on to the quality.the data submissions that will be.required in an annual basis and see if.there are any questions or concerns or.comments on the quality improvement plan.let me unmute everyone okay.okay can people here make an ace any.feedback if think if you you may have.your own phones on mute because i have.unmuted all the lines okay all right.seeing no questions we will continue on.to the data submission to nice arc and.this is really where we're going to take.information provided by at the chapter.level we're going to synthesize it and.analyze it and provide feedback to the.chapters on how they're doing and how we.are doing overall as an organization.okay I put this slide into the slideshow.I guess just to make sure that everyone.understands that we we appreciate some.of the challenges with data data if used.incorrectly and unfairly can be you know.very damaging it cannot they can tell a.very biased story so we are certainly.aware of that we know there are lots of.differences between the chapters and all.of the programs in those chapters and.we're not out to get individual chapters.so to speak what we are trying to do.though is establish a mechanism where we.can hope to see the overall quality of.the organization we do not plan to use.the data in a negative way to attack a.chapter certainly there may be questions.that come up we reach out to a chapter.and ask some additional questions but.we're certainly not going to ever do a.slide show where we say chapter a had.100 deaths and chapter be had two deaths.so chapter be must be much better than.chapter a obviously a lot of factors go.into that in fact questions could be.raised wider chapter B's def reports so.low perhaps they're not reporting as.they should be are the sizes of those.two chapters similar or are there.differences in the number of people.they're serving which would certainly.account for some of the additional dep.reports so we will be very cognizant of.that as we start to manipulate and.analyze the data ok this is the nicer.quality indicators reporting form it may.look a little overwhelming but I think.as we start to look at some of the.metrics included here you'll see that.most of these things are already being.reported or gathered either you know by.the quality department the compliance.Department the HR department again it's.a matter of pulling it all together and.reporting it consistently so that we'll.be able to analyze it and we'll look at.each of these in more detail.your first question is probably when the.data report will be do it will be on an.annual basis that most likely will be.due februari of the following year so.for example this year's data would.probably be submitted in February or.early march of 2015 that should allow.enough time for incidents or staffing.changes that occur in late January to.kind of work their way out so that the.data will be more consistent and our.goal is really to allow you time to get.a quality data and to coordinate with.your incident review committee analysis.and report we don't want to duplicate.efforts but if we can knock off two.things at one time we think that it will.reduce the burden on the chapter and.you'll see a lot of the metrics are.specifically related to incident review.committee an incident management okay.I'll just check in is any questions on.what we've covered so far for the data.submissions.okay all right so we will go right into.the metrics and what we are looking for.and what will well I provided you all.this morning was a what's called a data.dictionary the data dictionary provides.definitions for all of these metrics so.that we can make sure that all the.chapters are reporting consistent.information to us and we spent a great.deal of time going over these metrics.and the definitions to make sure that.they made sense some of these may change.as we go forward but where this is our.starting point and we will we will.certainly adjust as we get feedback okay.so some metrics that we are looking for.in terms of general program and.operation okay number one the.approximate number of full-time.equivalent staff and you can see the.definition below we are looking for.full-time equivalent this is the same.figure that is reported in your CFR data.and reports so that should be pretty.easy to obtain we are looking for staff.related injuries as defined by OSHA some.of you may be saying well what how does.OSHA define that I've actually developed.some guidance on the OSHA definitions of.injuries your HR departments should know.what that is and they should already be.collecting data but but it's a matter of.pulling that data into the data.submission report for nicer the.approximate number of unduplicated.individuals served in all programs again.we we don't want to count an individual.if they're getting residential and then.the.day program and they're getting MSC.three times we would count that.individual unduplicated manner we'd.count that as one individual and this.will give us some way to kind of.normalize and stratify the data so we.can see how many people you're serving.versus how many people other chapters.are serving and it gives us some sense.of whether your data is in line for the.size and characteristics of the chapter.as other chapters okay number of.participants and day activities the.total number of individuals being served.in day activities and supports and we.have provided a list it could be they.have day treatment day programs provoke.workshops community have rested or some.we're making a distinction from folks.that are just receiving day activity.services to the number of participants.in certified residential programs such.as IRAs ICF's community residences and.supported and supportive housing so.we'll have a number for individuals.being served four day activities and.individuals being served in residential.programs these are numbers that the.chapters already have and we do.recognize too that there may be.individuals who are in both okay but it.gives us again another way to look at.the data more fairly across chapter with.a wide range of characteristics we.struggled with this last element we are.asking for the number of participants.gainfully and competitive competitively.employed and we had a lot of debate.about what that really meant but what we.are not looking for as individuals who.are in a workshop setting we are looking.to see the number of individuals that.you serve who are who have been.gainfully employed and we're defining.that in jobs earning at least a minimum.wage okay so that could be out in the.community it could also be within your.program let's say you hire an individual.with a disability to perform routine.tasks around the chapter but.you're treating that individual as an.employee of the chapter certainly that.would count okay so we are not looking.again for individuals in a workshop.setting we believe that that would.probably be captured in number for day.activities but if your individual is.gainfully employed and earning minimum.wage or more certainly they would be.kept captured in this category.statements of deficiencies and i want i.do want to qualify this section by just.letting you know that we also here at.state office do receive all the.statements of deficiencies and all the.polkas and we do enter a lot of data.into our system but this will be an.opportunity for us to make sure that.we're getting all the same information.that you're getting also there are some.programs that even if there are no.deficiencies that are identified still.receive a statement of deficiencies.which doesn't make a lot of sense but.this will help us make these statistics.more consistent so we would want to know.the number of reviews conducted at the.chapter during the year okay we would.want to know the number of certification.reviews that actually resulted in the.chapter responding via a plan of.corrective action and by looking at.these two figures of course we can get a.sense of how many of your reviews what.percentage of your reviews are resulting.in some sort of formal response and then.we can look at that percentage across.all the chapters to see you know what.chapters are struggling may have higher.levels of deficiencies and may be.required to write focus more frequently.than others number of 45 or 60 day.letters received we will also know about.that here at state office that this is.kind of a good checks and balances just.to make sure that we have been informed.and notified of all of these incidents.and again you know we are required to.make.a site visit if a chapter gets a 45 or.60 day letter vote now incidents is the.third component of the data submission.we made this conform to all the.regulatory changes and the Justice.Center and the new definitions so this.all of these things will be already.being completed for your incident review.annual report the first is the number of.reportable incidents as they are defined.now in 624 the number allegations of.abuse and neglect and again it's.allegations we just want to know overall.how many allegations were made and we.can use that number to compare it.against how many of those allegations.were substantiated and that makes the.abuse and neglect data a little a little.more robust because we recognize some.chapters are going to be reporting more.things as allegations of abuse and.neglect and some chapters may report.things less there there is some.interpretation in terms of the current.definitions so by capturing the data.this way we think it will give us kind.of a leg up on how to synthesize of.those numbers we also want to know the.number of pending abuse and neglect.investigations so at the end of the year.we recognize not every investigation.will be closed certainly with the.Justice Center and how long some of.their investigations are taking there.are going to be many cases that at the.end of the year are still going to be.open we may have to back out some of.those open or pending cases of the data.analysis to make sure that what we're.reporting back to chapters and the.organization is accurate we're also.looking for I know I spoke about.reportable incidents but we're also.looking for notable occurrences again.that's defined in part 6 24 those are.the occurrences that are reported to.OPWDD and not necess.early the Justice Center the number of.individual deaths as a reminder deaths.are presently required to be reported to.state office within five days of the.discovery of the death we have certainly.seen improvement in the reporting more.consistent reporting but we also know.that some chapters have struggled to get.us all all of the information and things.can slip through the cracks so again.this is just a metric where we can.verify that we've received notification.from you throughout the year of the.deaths that have occurred in your.programs seven the number of incidents.or occurrences resulting in law.enforcement notification okay and we for.the purposes of our data we're not.including reports to the Justice Center.as law enforcement notification we are.considering just those that are reported.to a police department or state police.if they come to your program in response.to a situation or an incident metric.eight is the number of program.participant injuries resulting in.notable occurrences now there is.actually a definition one of one of the.items in notable occurrences is injuries.there are minor injuries and there are.major injuries and all of these would.need to be reported to OPWDD we'd like.to know how many you're having at your.program that are either minor or more.serious but again this is numbers that.you're already tracking and trending.ok before i get into the next steps i'll.open it up again for any feedback or.questions about any of the metrics or.data points that we've just gone through.Marianne are you on the line ok.yes Eric yes yes okay I'm just wondering.um wanting some feedback from our.participants at this point I mean as.eric has indicated several times much of.this data if not all we are already.collecting in various forms and.reporting it what are people thinking at.this point in terms of what's been hold.on Mary Ann I'm sorry about that okay.sorry about that Miriam we're trying to.make sure we're trying to make sure the.audio is allowing folks to speak and I'm.not sure it is I I don't think as I the.screen said I was muted before so I was.just asking for people's feedback up to.this point given Eric that you repeated.several times that much if not all of.this data is being collected how are.people feeling at this point regarding.the kinds of metrics and data that we're.talking about okay looks you know it.looks like we're having some difficulty.allowing individuals to communicate I am.getting some questions through the chat.box rod and we will we'll see if we can.unmute everyone it's uh we're we're.having some technical challenges we may.not be able to get that feedback right.now okay so I'll just continue with the.next steps okay chapters have already.received the q IP guidance document and.the q IP evaluate.tool as I've mentioned there will be.other items coming there will be sampled.qi p plans sample survey tools and that.include like satisfaction surveys for.employees and for parents and guardians.as well as board members site visit.materials this morning i sent to.everyone the data reporting form and the.data form dictionary and that will.include some guidance on what an OSHA.injury it defined as but again your HR.departments should certainly know that.information ok I just wanted to mention.a couple of other things I know there.are a few questions in our chat box i'll.i'll try to go through them but at the.end of februari we will be having our.first actually our second quality.Oversight Committee webinar the webinar.will be on individuals with disabilities.and Crime Victimization the moat the.facilitators Scott Modell I know Scott.quite well he is with the state of.Tennessee he's the deputy commissioner.of their Department of Children's.Services and he's a tremendous presenter.were really fortunate to have him.participating and I'm hoping all of you.on this call today will be able to.participate in that webinar which I'll.be sending some information out as well.on that in the upcoming days okay I'm.going to go to the chat box I'll try to.answer some of these questions.okay well the first question is will the.PowerPoint presentation before it yes we.will be sending out the PowerPoint to.all of the chapters it's also being.recorded so it will be available for.individuals to listen although we've had.trouble getting the dialogue going.certainly people will be able to listen.to me do the presentation ok the next.comment is some of the assurances for.the board are already happening through.their knowledge on topics and oversight.but some of it is more passive than.implied in our queue IP governance.that's number nine will there be.feedback directly to the board on best.practices or practical methods to.achieve their assurances not filtered.through QA staff yes I mean obviously.we're going to work with all of the.chapters on how to improve communication.and increase the board involvement and.an oversight in terms of these quality.metrics but we're going to start with.formalizing the process for doing that.and then we can work on the formal.implementation of making that occur a.question came in where will CSS be.reported csss something that we actually.discussed quite a bit there is no.special category for CSS but individuals.as we discussed individuals who are in.the CSS program if they're receiving day.program or day services they'd be.captured in that metric if they're.receiving residential of services they.would be captured in residential.component so there is no separate.category for the CSS in and of itself.okay there's a question and a comment.about the qcc 100 we understand you know.that there have been some changes to the.form there have been us I guess chapters.have been told to report deaths and Irma.but we have not been provided a paper.copy electronic copy of the form or data.data that's been collected I understand.that question there is a mechanism when.you enter a data a death report into.Irma by which you can print out the.information that you have entered into.Irma I sent out guidance on how to print.out those reports a few times I.certainly can send that out again but.it's a there's a functionality within.Irma that will allow you to print out.those deaf reports in their entirety.okay next question is do FTEs include.subs and temps again you're going to be.using the full time equivalent number.that you use in your CFR report so and.i'm actually not aware of how those.individuals are captured presently but.we're looking for full-time equivalent.staff members as you would report in the.CFR one question is nice arc open to.modifying the quality indicators yes.we're open to all of your feedback even.though we're having some difficulty.getting it today as you certainly can.send me an email but all of this is open.to review and consideration because.we're really starting down a path that.really hasn't been traveled before so if.you have some thoughts on how we can do.this in a better way or a different way.I don't view it as criticism I'm welcome.to hearing it and I encourage you to.reach out to me.okay one question came in for the data.metric number seven will you be.requesting the number related to police.contacts only fire alarms minor.accidents no injury no we're actually.only asking in data point number seven.for those times where the police respond.in person to the facility for an.incident or an occurrence another.question we already we already do most.of the information being requested with.state ed OCFS audits ssay audits would.they be included in the evaluation form.submitted to nicer no we're not looking.specifically for those types of audits.in terms of the data that's being.reported back to nicer but certainly you.could absolutely and should incorporate.how you're handling those types of.audits and responding to deficiencies.and concerns as they're being identified.and that would come through in your.quality improvement plan okay februari.may be too early to submit the q IP.particularly in relation to incident.data from the prior year that's good.feedback I will be discussing this with.our quality standards professional work.group and seeing if what is a more.reasonable time frame to get that data.in to us and if it's too close of a time.frame we certainly can expand it we have.some time to play with that date.is there a category for MSC that's a.very good question i would I personally.I haven't asked the professional work.group to question I personally would.probably include that in like a day.service it certainly is not a.residential service there will not be a.separate category unless we make one so.i'm gonna i'm going to hold on that.answer until I consult with the.professional work group the final.question that we have do we want the.total number of both 624 and 6 25 deaths.as both require qcc 100s that's a very.good question our guidance at this point.is if you complete a QC c100 regardless.of whether it's a 6 20 4 or 6 25 we.would like you to submit that to state.office within five business days of the.discovery of the death okay there are no.other questions that I see ya era Eric.yeah I yes I I would just like to.re-emphasize something that you said a.few moments ago and that is your your.feedback and continued discussion is.totally welcome none of us has a pointer.on this quality assurance urology.improvement process and so we really.want this to be interactive and and we.want the benefit of your wisdom and.experience in the doing so please get.back we is as we continue to move.through this process that interaction is.going to be critically important.okay i will be getting out of the.powerpoint to everyone as well as some.additional materials and guidance in the.upcoming days thank you all very much.for participating feel free to reach out.with me I apologize for some of the.technical issues that we had in terms of.the interactive nature of this we will.certainly work that out before the next.conference and again thank you all for.your commitment to moving quality for.within the organization yes thank you.thank you Eric.

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Qcc100 Form FAQs

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How do I fill out the form of DU CIC? I couldn't find the link to fill out the form.

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