Key for Acronyms: CARF = The Commission on Accreditation of Rehabilitation Facilities NCQA = National Committee for Quality Assurance DHHS = Michigan Department of Health & Human Services PIHP = Prepaid Inpatient Health Plan HEDIS = Healthcare Effectiveness Data & Information Set QI = Quality Improvement HEDIS = Healthcare Effectiveness Data & Information Set QM = Quality Management MMBPIS = Michigan Mission-Based Performance Indicator System SWMBH = Behavioral Health LOCUS = Level of Care Utilization System TEDS = Treatment Episode Data Set STATUS MEASURES/ # GOAL OBJECTIVES/ACTION STEPS DATE 1 Maintain current three (3) year Review and respond to all applicable changes in CARF September 30, 2016 -All revisions to 2016 CARF standards accreditation with CARF standards for 2016 were reviewed and incorporated in policy standards Submit Annual Conformance to Quality Report to CARF and/or practices as applicable. within due date. -The Annual Conformance to Quality was Begin initial preparation for March/April 2017 survey. submitted to CARF and accepted. -Preparation for the April 2017 survey was initiated and is on-course 2 Ensure conformance and Continue to minimize the number of outliers and conduct Ongoing monitoring -The goals were achieved on all indicators timeliness of required quality analysis of outliers as they occur and response as overall for the year. MH TEDS management data and reports to Submit Improvement to the PIHP where the goal has needed completeness was particularly challenging including not been achieved during the most current 2 out of the last as there were numerous issues that Michigan Mission-Based 3 quarters needed to be resolved from the State and Performance Indicator SWMBH as well as CMHSAS-SJC. System (MMBPIS) Event Reporting TEDS Completeness 3 Achieve the standards as set Actively participate in SWMBH quality management September 30, 2016 -CMHSAS-SJC continues to actively forth by the Southwest Michigan meetings and initiatives participate in SWMBH quality Behavioral Health (SWMBH) Any new standards set by SWMBH will be communicated to management meetings and initiatives. Manager/Supervisor team,(MST) and discussed to ensure -New standards and initiatives were awareness and engage activities needed to achieve the communicated to MST for implementation. standards Support was requested from SWMBH as needed.
Key for Acronyms: CARF = The Commission on Accreditation of Rehabilitation Facilities NCQA = National Committee for Quality Assurance DHHS = Michigan Department of Health & Human Services PIHP = Prepaid Inpatient Health Plan HEDIS = Healthcare Effectiveness Data & Information Set QI = Quality Improvement HEDIS = Healthcare Effectiveness Data & Information Set QM = Quality Management MMBPIS = Michigan Mission-Based Performance Indicator System SWMBH = Behavioral Health LOCUS = Level of Care Utilization System TEDS = Treatment Episode Data Set # GOAL OBJECTIVES/ACTION STEPS MEASURES/ DATE STATUS 1 Maintain current three (3) year accreditation with CARF standards Review and respond to all applicable changes in CARF standards for 2016 Submit Annual Conformance to Quality Report to CARF within due date. Begin initial preparation for March/April 2017 survey. September 30, 2016 -All revisions to 2016 CARF standards were reviewed and incorporated in policy and/or practices as applicable. -The Annual Conformance to Quality was submitted to CARF and accepted. -Preparation for the April 2017 survey was initiated and is on-course 2 Ensure conformance and timeliness of required quality management data and reports to including Michigan Mission-Based Performance Indicator System (MMBPIS) Event Reporting TEDS Completeness Continue to minimize the number of outliers and conduct analysis of outliers as they occur Submit Improvement to the PIHP where the goal has not been achieved during the most current 2 out of the last 3 quarters Ongoing monitoring and response as needed -The goals were achieved on all indicators overall for the year. MH TEDS completeness was particularly challenging as there were numerous issues that needed to be resolved from the State and SWMBH as well as CMHSAS-SJC. 3 Achieve the standards as set forth by the Southwest Michigan Behavioral Health (SWMBH) Actively participate in SWMBH quality management meetings and initiatives Any new standards set by SWMBH will be communicated to Manager/Supervisor team,(MST) and discussed to ensure awareness and engage activities needed to achieve the standards September 30, 2016 -CMHSAS-SJC continues to actively participate in SWMBH quality management meetings and initiatives. -New standards and initiatives were communicated to MST for implementation. Support was requested from SWMBH as needed.