quality assessment & performance improvement qapi work ......quality assessment &...

Health & Human Services Department

Behavioral Health and Recovery Services Division

Jei Africa, PsyD, MSCP, CATC-V, Behavioral Health Director

Dawn Kaiser, LCSW, CPHQ, Quality Manager

QAPI

Quality Assessment & Performance Improvement

Work Plan

FY 2018-2019

Quality Assessment & Performance Improvement Work Plan FY18-19

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Marin County MHP QAPI Work Plan FY 18-19 Rev. 12/2018

Quality Management Program Description

The Marin Mental Health Plan’s (MHP) Quality Management (QM) program is responsible for monitoring the MHP’s effectiveness and for providing

support to all areas of MHP operations by conducting performance monitoring activities which include, but are not be limited to: utilization

management, utilization review, provider appeals, credentialing and monitoring, resolution of beneficiary grievances, and analysis of beneficiary

and system outcomes. The QM program’s activities are guided by the relevant sections of federal and state regulations, including Title 42 of the

Code of Federal Regulations, California Code of Regulations Title 9, California Welfare and Institutions Code, as well as the MHP’s performance

contract with the California Department of Health Care Services (DHCS). The QM program is embedded in the Behavioral Health and Recovery

Services Division (BHRS) within the Health and Human Services Department (HHS) of the County of Marin.

The QM program consists of seven licensed staff, including the Quality Improvement Coordinator (1 FTE), the Quality Management Unit Supervisor (1

FTE), and five cross-trained (mental health and substance use services) Utilization Review Specialists (4.5 FTEs). The QM program also includes two

data analysts (2 FTE), two administrative staff (2 FTE) and a .25 FTE consulting contractor. The QM program is overseen by a licensed QM Division

Director (1 FTE), who is additionally responsible for Access and Information Technology, for a total workforce of 11.75 FTEs. QM staff carry out their job

responsibilities as defined by their individual professional disciplines and scopes of practice. The Information Technology Team (3 FTE dedicated to

BHRS) participates in the data reporting and analysis function s of QM and provides essential technical support services to the entire BHRS Division.

The different programs and committees within the QM program provide structure for the quality improvement and oversight responsibilities of the

organization.

The Utilization Management (UM) program is a component of the QM program. The UM program, led by the Quality Improvement Coordinator,

assures that beneficiaries have appropriate access to specialty mental health services. Program activities include: the evaluation of medical

necessity determinations, and continuous monitoring of the appropriateness and efficiency of services.

The Administrative Compliance Committee is led by QM, Fiscal, Administrative, and Information Technology representatives. The BHRS Administrative

Services Manager (ASM), Assistant Chief Fiscal Officer (CFO), IT Supervisor, and Quality Management Unit Supervisor take primary responsibility for

setting and sponsoring the work of the committee, whose additional members include QM, IT, Fiscal and Administrative and Compliance leads.

During committee meetings, stakeholders identify and discuss issues across the BHRS system that relate to the Electronic Health Record (EHR) system,

the practice management system, policies and procedures, documentation processing, credentialing and onboarding of new staff and contractors

and other administrative tasks that are essential to providing quality services to consumers and family members.


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Quality Improvement Program:

The Quality Improvement program, led by the Quality Management Unit Supervisor, monitors the overall service delivery system with the aim of

improving processes of care provision and increasing consumer and family member satisfaction and outcomes. QI is also responsible for continuous

monitoring and improvement of the provider network, ensuring that Marin MHP meets access requirements including capacity and geographical

distribution of services provided to Marin County Medi-Cal beneficiaries.

The Quality Improvement Committee (QIC) is a combined mental health (MH) and substance use services (SUS) committee, and is comprised of a

diverse group of stakeholders, including representatives from MH and SUS administration and clinical programs, the Mental Health Board,

peers/family members, the Patient Rights Advocate, and contractors/community partners from both MH and SUS agencies. QM staff are responsible

for facilitating a quarterly QIC meeting to review findings from a range of compliance and quality improvement activities, including specified DMC-

ODS data elements, and to obtain input into these and other areas for improvement.

The Incidence and Grievance Subcommittee of the QIC is attended by the Medical Director, QI Coordinator, QM Division Director, Adult Services

Division Director, Youth and Family Division Directors, Program Manager Crisis Continuum of Care, Program Manager Adult Services and on ad hoc

basis Program Supervisors. It is a standing group that meets quarterly to evaluate and analyze trends of grievances, appeals, fair hearings, and

unusual occurrences to identify issues or trends that require implementation of system changes. It also makes improvement recommendations to the

system such as additional trainings policies, workflows and operational changes. The subcommittee is led by the QI Coordinator. Findings from this

meeting are presented to the QIC stakeholders as required.

The Policy and Procedure Subcommittee meets monthly to draft and/or update new or existing policies and procedures as needed.

The MHP has an active Cultural Competency Advisory Board (CCAB) which is comprised of BHRS management and staff, contract agency

providers, consumer advocates, consumers, community leaders and stakeholders. There are working subcommittees within the Board responsible for

discrete content areas such as training, policies, and access. The 20+-member board is tasked to analyze data, review existing improvement plans,

examine practice approaches and make recommendations related to policy, service delivery, staffing and training needs, and system

improvements. QM staff provide data for the CCAB, and there is shared participation in both the QIC and CCAB on the management, staff and

consumer level.


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Quality Assessment and Performance Improvement Work Plan

The intent of the Quality Assessment and Performance Improvement (QAPI) Work Plan is to create systems whereby data

relevant to the performance of the MHP is available in an easily interpretable and actionable form. This year’s plan

continues the work of the previous plan’s work of improving the capture, analysis and use of data to support contractual

compliance, performance management and decision making. Performance improvement activities focus on improving

provider network adequacy, accessibility, timeliness and outcomes of services and serve to enhance the MHP’s daily work

of supporting the recovery and resiliency of the consumers and family members in our community.

The QAPI Work Plan is evaluated and updated annually. The elements of this QAPI Work Plan are informed by the quality

improvement requirements of the Marin MHP - DHCS contract as well as feedback received from the CalEQRO review and

DHCS Triennial audit findings and recommendations. This fiscal year, all QAPI Work Plan goals are specific, measurable,

achievable, and time-bound (SMART) to facilitate ongoing monitoring and year-end progress evaluation. All goals have a

target completion date of June 30th, 2019. Accompanying each goal are a list of objectives toward achieving the goal.

SMART goal development, monitoring, and evaluation is consistent with the Marin County Health and Human Services

Department, Strategic Performance Management initiative.


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I. Network Adequacy and Availability of Services

Goal Objectives Baseline

1. Timely Access to Services

Monitor quarterly, the

MHP’s ability to meet

statewide timeliness

standards and achieve

95% compliance with

all standards (a-d) for

adult, children/youth

and foster youth

beneficiaries.

1. Monitor wait times between initial

request and first appointment for

adults, children/youth and foster

youth using the following standards:

a. Initial request to first offered

assessment appointment – 10

business days

b. Screening to completed

assessment – 10 business days

c. Initial request (completed

assessment) to psychiatry

appointment – 15 business days

d. Service request for urgent

appointment to actual

encounter – 48 hrs. (no prior

authorization required) / 96

hours (prior authorization

required)

Timely access to requested services – For FY17-18, the average

compliance rate for all standards a-d was 58.3% for children, adults,

and foster youth combined (2.3 out of 4 standards met); 58.3% for

adults (2.3 out of 4 standards met); 75% for children/youth (3 out of

4 standards met); 75% for foster youth (3 out of 4 standards met):

Average Wait Times for FY17-18

a b c d %

Compliance

Adults 1.5

days

11.6

days

19.9

days

1.3

hrs.

58.3%

Children/Youth 1.6

days

13.8

days

23.7

days

1.05

hrs.

50%

Foster Youth 1.6

days*

3.8

days **

22.9

days***

N/A

****

75%

Standard Met? Yes Yes for

foster

youth;

No for

adults

and

children

No

Yes 58.3%

Combined

* Foster youth (n=5); **Foster Youth (n=5); ***Foster Youth (n=9)

**** There were no foster youth during FY17-18 with a request for urgent

appointment (n=0) and therefore no data available.

Data Source(s): ShareCare (SC) Scheduler, Clinician’s Gateway (CG) EMR progress

notes, ShareCare Admissions, Access Log, Transition Team Log, Mobile Crisis

Response Team (MCRT) Log, YFS Medication Evaluation Referral

Tracking Log.


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2. Provider Network Adequacy

Marin MHP will maintain and monitor a network of providers that is sufficient to provide adequate access to specialty mental health services as evidenced by 90% of providers compliance with criteria (a-h) as reported in the monthly Provider Directory.

1. MHP will provide county programs and

contracted agencies with a tool to track

changes/additions to the provider network

monthly.

2. BHRS will analyze geographic location of providers

and their accessibility to beneficiaries to meet

network adequacy standards of 30 miles or 60

minutes between beneficiaries and available

providers and will monitor hours of operation are

sufficient to provide services as reported in the

Network Adequacy Certification Tool quarterly.

3. BHRS will update Provider Directory monthly to

include all Medi-Cal certified provider agencies

(county and contractors) including the following

criteria:

a. Provider name and contact information

b. Whether or not provider is accepting new

beneficiaries

c. Services provided

d. Specialties

e. Cultural capabilities and/or cultural

competency training completed

f. Linguistic capabilities

g. Office hours and accessibility for persons with

disabilities

h. Individual provider NPI and license number, if

applicable

Provider network adequacy – Marin County is meeting

the standard of 30 miles or 60 minutes between

beneficiaries and providers as evidenced by Network

Adequacy Certification Tool (NACT) submissions to date

(April and October 2018).

As of October 2018, 13 out of 39 (33%) Medi-Cal

certified provider agencies are in compliance with

criteria a-h as evidenced by inclusion in the November

Provider Directory. Of the providers not yet in

compliance, 14/39 (36%)are out of county agency

providers and serve a limited number of Marin County

beneficiaries. The remaining 12 providers are within

Marin County.

Data Source(s): NACT quarterly submission (October 2018); Provider

Directory (November 2018)


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3. Provider Linguistic Capacity

Ensure services are provided in the client's preferred language by utilizing bilingual staff and/or qualified interpreters, when preferred by the client, as documented in the medical record 100% of the time.

1. Ensure that preferred

language is documented in

the client’s medical record

and that the language in

which services were

provided is documented

for every service.

2. Ensure that when preferred

by client, interpretation or

bilingual staff was utilized to

provide services in the

client’s preferred language

(or if not preferred, client

declined offer of

interpretation/service in

preferred language) and

this is documented in the

medical record) 100% of

the time.

Provider linguistic capacity – 89% of clients served during FY17-18 had

services provided in their preferred language, as documented in the

EMR.

n = 65100

Preferred language, as documented in the EMR, is Spanish for 9% of

clients served (Marin’s threshold language) and 5% Vietnamese and

other languages.

Data Source(s): ShareCare (SC) Scheduler, Clinician’s Gateway (CG) EMR progress

notes, ShareCare Admissions

Encounters % Encounters

Rendered in Clt's Preferred Language(includes the use of interpreter/language line)

89%

Language Provision Not Recorded 2%

Services Not Provided in Clt's

Preferred Language9%

Preferred Language % Active Clients

English 85%

Spanish 9%

Vietnamese 2%

Other Languages 3%

Not Captured 3%


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4. Cultural Competency of Service Providers

At least 90% of Marin MHP

providers will complete a

minimum of 4 hours of

cultural competency

training annually.

1. Track number of hours of cultural

competency training completed per

provider using a spreadsheet provided by

BHRS.

2. Monitor hours completed monthly to ensure

that all providers are in compliance with this

requirement.

3. BHRS will provide cultural competency

training opportunities for staff and contract

providers several times per year as specified

in Marin’s Cultural Competency Plan.

Provider cultural competency – Out of 175 BHRS staff

tracked during FY17-18, 65% completed a minimum 4

hours of cultural competency training. Cultural

competency training data was not available for

contract providers during FY17-18.

Data Source(s): BHRS Cultural Competency Training Tracking Log

Cultural Competence

Training

#

Employees

%

Completed

Completed ≥ 4 hours 114 65%

Completed < 3 hours 4 2%

Did not completed CCT 57 33%

Total 175 100%


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5. Change of Provider

Requests

Ensure change of

provider requests are

resolved by oral or

written response to

the beneficiary within

10 business days of

receipt.

1. Track and trend change of

provider requests (as reported

orally or in writing on Change of

Provider Request form and report

to QIC and management

annually.

2. QM will log the request and

provide one of the following

responses to the beneficiary

within 10 business days of

receipt:

a. Provider will be changed as

requested by client;

b. Change of provider request

will be denied and client will

be notified of the reason for

denial.

Change of provider requests – For FY17-18, 34 change of

provider requests were received; 29 pertaining to medical staff

and 5 pertaining to non-medical staff. 28 out of 29 requests

were approved; 1 was denied due to clinical factors that were

addressed with the client instead of changing providers. 5

requests were withdrawn by the client during the processing

period. No significant trends were noted. Timeliness of change

of provider resolution was not tracked during FY17-18.

Type of

Provider

#

Requests Approved Withdrawn Denied

Pending

Medical

Staff 29 23 5 1

0

Non-

Medical

Staff

5 5 0 0

0

Data Source(s): Change of Provider Log


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6. Access to SMHS – 24/7 Phone Line

Marin MHP will conduct 10

test calls per quarter, during

and after business hours, a

minimum of 1 conducted in

a language other than

English and will achieve an

average rating of 90%

compliance with 6 required

elements.

1. Conduct 10 test calls per quarter using test call

scripts/worksheets that capture all required

elements.

2. Ensure at least one test call per quarter is

conducted in a language other than English to

test capacity to link beneficiaries with an

interpreter as needed.

3. Ensure that test calls are conducted both during

and after business hours in order to assess both

Access team and Optum services.

4. Review adherence to test call requirements on a

quarterly basis and provide feedback and training

to Access team and Optum at least one time per

year.

24/7 Access line – 77% compliance with 6 required

elements in FY17-18.

An average of 8.25 test calls were conducted per

quarter (range: 6-10 calls), 2 of which were

conducted in a language other than English

(average of .5 per quarter). Average compliance

with 6 required elements was 77% (range: 51-90%)

for FY17-18.

Data Source(s): Quarterly data for FY17-18 (based on 24/7 Test

Call Quarterly Update Report Forms submitted to DHCS)


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II. Care Coordination and Continuity of Care


7. Client Engagement with SMHS – No Show Rates

Achieve less than or equal

to 10% no-show rates to

psychiatry and non-

psychiatry scheduled SMHS

appointments for adults,

children/youth and foster

youth.

1. Monitor no-show rates to scheduled SMHS

appointments and achieve rates of 10% or less

a. No Show appointment rates –

psychiatry appointments – ≤10%

b. No show appointment rates –

non-psychiatry SMHS

appointments – ≤10%

Average No-show rates to scheduled SMHS

appointments:

Psychiatry Other SMHS

Adults 12.4% 1.3%

Children/Youth 9.6% 5.1%

Foster Youth 10.1% 4.6%

Data Source(s): ShareCare (SC) Scheduler, Clinician’s

Gateway (CG) EMR progress notes, ShareCare Admissions,

Access Log, Transition Team Log, Mobile Crisis Response Team

(MCRT) Log, YFS Medication Evaluation Referral Tracking Log.


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8. Client Engagement with SMHS – Service Provision

By 6/30/19, increase the

number of BHRS clients who

receive two services

(defined as one assessment

and one billable specialty

mental health service)

within 14 calendar days by

10%.

1. Track number of days from first assessment to next

billable SMHS appointment within 14 calendar

days for all BHRS clients who had an initial

assessment appointment during FY18-19.

2. Follow-up appointment may consist of any of the

following billable services, provided with the client:

a. Assessment

b. Targeted Case Management

c. Intensive Care Coordination (ICC)

d. Plan Development

e. Medication Support Services

f. Therapy (individual, group, or family)

g. Rehabilitation (individual or group)

h. Intensive Home-Based Services (IHBS)

i. Collateral

j. Therapeutic Behavioral Services (TBS)

k. Crisis Intervention

Client service provision – During FY17-18, 21% of

clients under 18 years of age, and 47% of adult

clients, received at least one billable specialty

mental health service (SMHS) within 14 days of

their initial assessment appointment.

Overall, 39% of clients received at least one

billable SMHS within 14 days of initial assessment

with an average of 8 days between

appointments.


Gateway (CG)


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9. Post-psychiatric Hospitalization Follow-Up

Provide post-psychiatric

hospitalization follow-up

appointment within 7 days

of discharge. Achieve

performance rate of 10% or

less readmission rates within

30 days of discharge.

1. Monitor:

a. Post-psychiatric hospitalization follow-

up – 7 days after discharge

b. Psychiatric inpatient readmission

rates within 30 days – ≤10%

Follow-up appointment post-psychiatric

hospitalization

Adults 4.8

days

Children/Youth 5.9

days

Foster Youth* 0.6

days

* There were five foster youth clients during FY17-18 with a

hospitalization (n=5).

Baseline: Post-psychiatric hospitalization

readmission

Adults 15%

Children/Youth 6%

Foster Youth** 14%

**(n=7)


Gateway (CG) EMR progress notes, ShareCare Admissions,

Access Log, Transition Team Log, Mobile Crisis Response Team

(MCRT) Log, YFS Medication Evaluation Referral Tracking Log.


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III. Performance Improvement


10. Utilization Review –

Clinical

Documentation

Improve quality of

clinical documentation

as evidenced by < 5%

disallowance rates for

60% of programs

reviewed during FY18-

19.

1. Provide clinical documentation training to all new

clinical staff within two months after hire.

2. Provide at least two authorization and clinical

documentation trainings for fee for service

contractors annually.

3. Offer clinical documentation trainings for

staff/contractor participation on an ongoing basis,

at least 4x per year, that address all current

documentation standards.

4. Update Clinical Documentation Manual as needed.

5. Decrease UR disallowance rate for programs with a

prior disallowance rate > 5% to less than 5% by

conducting re-reviews and/or training for those

programs/providers within 6 months.

UR disallowance rate was < 5% for 3 out of 20, or

15% of programs reviewed during FY17-18.

Total programs reviewed during FY17/18 = 20

15% had a disallowance rate < 5%

Data Source: UR Tracking 7/2017 to 6/2018

> 5%< or equal

to 5%

# Programs

Reviewed17 3

DISALLOWANCE RATE


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11. Utilization Review –

Frequency and rate of review

Review a minimum of 5% of medical records from every BHRS program and contract provider program reviewed annually and provide UR results to provider within 30

calendar days.

1. Continue to review a minimum of 5% of medical

records.

2. Conduct re-reviews of programs that have high

disallowance rates (>5%) following UR review

(>5%) within 12 mos.

3. Continue to provide completed reports to

programs within 30 calendar days of the

utilization review.

During FY 17-18, the UR team had an average

completion time of 28 days from UR to issuance of

a completed report to the program reviewed.

# UR Time to Report

(calendar days)

Q1 1 26

Q2 5 26

Q3 7 29

Q4 7 30

Average = 28 days


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12. Utilization

Management –Monitor Safe and Effective Medication Practices

Ensure that all clients who are prescribed medication have a current, signed medication consent form on file, including all required elements (and any required JV-220 forms), 100% of the time.

1. QM staff and Medical Director or designee will

conduct two medication monitoring reviews

quarterly, including review of required consent

forms and any JV-220 forms, if applicable.

2. Medication consent form will meet all

requirements outlined in CCR, Title 9, Section 851,

whether on paper or in electronic form, including

evidence that prescribers have reviewed all side

effects and potential risks of medication use with

each patient. Consent must include: a. The nature of the patient’s mental condition;

b. The reasons for taking such medication, including

the likelihood of improving or not improving without

such medication, and that consent, once given,

may be withdrawn at any time by stating such

intention to any member of the treating staff;

c. The reasonable alternative treatments available, if

any;

d. The type, range of frequency and amount

(including PRN orders), method (oral or injection),

and duration of taking the medications;

e. The probable side effects of these drugs known to

commonly occur, and any particular side effects

likely to occur with the particular patient;

f. The possible additional side effects which may

occur to patients taking such medication beyond

three months. The patient shall be advised that such

side effects may include persistent involuntary

movement of the face or mouth and might at times

include similar movement of the hands and feet,

and that these symptoms of tardive dyskinesia are

potentially irreversible and may appear after

medications have been discontinued.

3. QM staff/Medical Director will support corrective

action activities as required and report to Senior

Management annually.

During FY 17-18, QM staff conducted 11 medication

monitoring reviews. Of these reviews, findings

included medication consents that either were

incomplete or missing in 11 out of 11 reviews.

A total of 68 (65%) out of 104 charts reviewed either

were missing medication consents entirely, the

prescriber did not obtain a new consent when

medications were prescribed outside the dosage

range indicated on the existing consent, or the

chart had a consent form that was missing required

elements (a-f of CCR, Title 9, Section 851). There

were no records indicating whether or not JV-220

forms were reviewed during these reviews, nor if

they were applicable in the review sample (15% of

charts were for youth clients).


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13. Outcomes -- Improve data collection and reporting to support decision making For adult FSP clients referred for vocational rehabilitation services, increase percentage of clients engaged in employment by 10%.

1. The FY16-17 data of clients from adult FSP

programs (Odyssey, STAR, TAY) who

participated in the FSP for at least one

year and who participated in vocational

rehabilitation services will be used to

establish baseline.

2. “Engaged in employment” includes:

a. Competitive, paid employment in the

community that is also open to

individuals without a disability

b. Supported employment: competitive

employment (a) plus ongoing on-site or

off-site job related support services

provided.

c. Transitional employment/enclave:

paid job in the community that is only

open to individuals with a disability AND

may be time-limited OR part of a group

of disabled individuals who are working

as a team

d. Paid, In-house work, only open to

individuals with a disability

e. Non-paid (volunteer) work experience

that exposes the individual to the

standard expectations of employment

f. Other gainful/employment activity

that increases the client’s income or

participation in classes providing

instruction on issues pertaining to getting

a job.

g. For TAY clients <18 years, enrolled

in school

In FY 16-17, out of all clients referred from 3 of Marin’s FSP

programs, 60 clients successfully participated in vocational

rehabilitation services (VRS).

Full Service

Partnership /

number of clients

who participated

in VRS

% Engaged in

Employment /

number of clients

Odyssey

n = 18

26%

STAR

n = 13

50%

TAY

n = 29

79%

n = 60 (All FSP clients referred for VRS)

** No baseline data available


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14. Outcomes -- Improve data collection and reporting to support decision making For adult FSP clients who meet criteria of ‘homeless’ per Partnership Assessment Form (PAF), decrease number of days homeless by 50%.

1. The FY16-17 data of clients from adult FSP

programs (HOPE, Odyssey, STAR, TAY)

who qualified as homeless per PAF

assessment completed upon entry into

program, and who have participated in

the FSP for at least one year will be used

to establish baseline.

2. A Key Event Tracking (KET) form showing

that client is no longer homeless will be

compared to the PAF data to identify

the decrease in number of days

homeless following admission to and at

least one year of participation in an FSP.

3. Homeless is defined as:

a. Homeless, including people residing

on the street or in their cars

b. Person residing in an emergency

shelter/temporary housing (including

people living with friends but paying

no rent)

Adult FSP clients with a history of homelessness, who have

participated in an FSP for at least one year (n = 229), showed

a combined 62% average decrease in number of days

homeless. The percentage of decrease by program is

included in the following table:

Full Service

Partnership /

number of clients

% Decrease in

number of days

homeless

HOPE

n = 45

68%

Odyssey

n = 89

65%

STAR

n = 66

58%

TAY

n = 29

55%

n = 229 (All FSP clients with homeless days)

Average decrease for all adult FSPs combined = 62%


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Goal(s) Objectives Baseline

15. Beneficiary/Family

Satisfaction – Performance Outcomes and Quality Improvement (POQI) based on Consumer Perception Survey Completion

For clients prescribed medications, improve prescriber’s review of side effects with beneficiary/family members as evidenced by decreased client disagreement with the statement “review of side effects” by at least 10%.

1. Performance Outcomes and Quality

Improvement (POQI) data will be

collected using the applicable

consumer satisfaction survey (MHSIP

Consumer Survey for adults, Youth

Services Survey for youth 13-17 years,

Youth and Youth Services Survey for

Families, for parents of youth under 18

years) per DHCS schedule.

2. Client response rate is determined by the

percentage of clients expected to

participate (clients who had service

appointments during the data collection

weeks were available to participate).

3. Provide training and monitoring to

ensure that prescribers thoroughly

discuss side effects with clients

prescribed medication, including:

e. The probable side effects of these

drugs known to commonly occur, and

any particular side effects likely to

occur with the particular patient;

f. The possible additional side effects

which may occur to patients taking

such medication beyond three

months. The patient shall be advised

that such side effects may include

persistent involuntary movement of

the face or mouth and might at times

include similar movement of the

hands and feet, and that these

During FY 17-18, an average of 44% of expected client

respondents (clients served during the data collection weeks)

participated in completing surveys.

FY 17-18

Client participation rate during POQI data collection week: NOV % MAY %

Adult 47% 43%

Youth 25% 50%

Total 44% 44%

POQI data was analyzed to determine which survey

responses had the most agreement and most disagreement

by program. A significant number of adult client respondents

disagreed with the statement, “informed of side effects.” 18%

of STAR FSP clients, 29% of Skilled Nursing Facility clients, 13% of

Buckelew MAIL clients, and 40% of Marin Housing Authority

endorsed such disagreement.

Because these adult clients did not feel they were well

informed of medication side effects, improvement is needed

in ensuring that prescribers thoroughly cover criteria e and f,

of CCR, Title 9, Section 851, medication consent requirements.


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symptoms of tardive dyskinesia are potentially

irreversible and may appear after

medications have been discontinued.

4. Report POQI results to county staff,

contractors, and clients at least 1x

annually.

5. Continue analysis of survey data to

inform quality improvement goals.

quality assessment & performance improvement qapi work ......quality assessment &...

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