SFMHP QUALITY MANAGEMENT PROGRAM

• Structure
• Quality of Care Reporting
• Documentation/Peer Review
• Outcomes
• Consumer Satisfaction
• Performance Review
• Provider Performance Profiling
• Treatment Approach
• Professional Office Standards

Below is a list of those functions which a provider must perform as a requirement for participation in the SFMHP. Each item is followed by the page number in this section of manual where the specific requirements are detailed, and a SFMHP Policy Number when applicable. Copies of all policies may be obtained by calling the Health Information Office at (415) 255-3485. Copies of the complete Quality Management Plan for the SFMHP can be obtained by calling the Quality Management Office at (415) 255-3434.

Introduction

The SFMHP is committed to the provision of quality mental health services to all of its members. The Quality Management Program (QMP) is designed to assure the quality of clinical care as well as its availability, accessibility and coordination. The Quality Management Program is founded on the principles of continuous quality improvement.

The structure and processes of the Quality Management Program are described in detail in the SFMHP Quality Management Plan.

The structure of the Quality Management Program is designed to satisfy regulatory and organizational requirements and to establish processes that will result in improved consumer care. The work of the QMP is organized into quality improvement activities which are overseen by a quality improvement committee structure which reports directly to the local mental health director.

These Quality Improvement processes are designed to obtain input from all stakeholders in the SFMHP. Consumers and family members participate at the highest level of quality management policy advisement in the Quality Policy Council.

The following indicators processes and indicators are used by the QMP to review, evaluate and plan improvements in care. Each of these indicators are regularly reviewed in the QMP structure.

A critical function of the Quality Management Program is to analyze risk data through various measures, one of which is the Quality of Care Reporting System (QOC System). Under the QOC Reporting System, all providers of mental health services are required to report certain quality of care concerns using prescribed procedures and forms which are described in detail in Policy #1.04-4 Quality of Care Reporting in Appendix 18. Specifically, providers must report the following types of occurences within 24 hours: violent behavior/assaults, physical sexual assault/misconduct, suicide attempts, medication issues resulting in severe adverse drug reactions, violation of professional code of ethics, client death, occurences that require reports to licensing agencies, physical damage to facility caused by a client, accidents on-site resulting in serious injury and other occurrences which in your judgment threaten the welfare, safety, or health of a resident, visitor, volunteer, student or employee. Such reports must be faxed to the Quality Improvement Office at (415) 252-3033. Contact people for questions about the policy and reporting requirements are Michele Friedman, R.N. (415) 255-3482 and Miriam Damon, R.N., (for Child/Adolescent matters) 255-3761.

The appropriate QI committees shall have access to relevant clinical records to the extent permitted by state and federal laws. This function provides the QMP with a process to review routine care at individual and system wide levels. QI reviews may be conducted on a sample of consumer cases using a standardized protocol to evaluate compliance with clinical standards and compliance with documentation requirements. The basis for the protocol is the state-mandated documentation requirements. The State-mandated requirements are as follows:

For Initial Assessment, Plan of Care and Progress Charting, SFMHP expects that all clients will receive a comprehensive biopsychosocial assessment that includes at minimum the following areas:

• Identifying information
• Chief complaint
• Presenting problem and previous treatment history (including outcome, response to medication, etc.)
• Medications: dosage, frequency, dates of initial prescriptions and refills;
• Client informed consent
• Mental status examination
• Psychosocial assessment
• Substance abuse assessment including documentation of past and present use of substances (including tobacco, alcohol, and other drugs)
• Relevant physical health conditions including current medical problems
• Five axis DSM-IV diagnosis
• Known allergies or adverse reactions to medication
• Preliminary plan for treatment describing modalities, frequency, etc.
• Description of clients strengths and weaknesses in achieving client plan goals

Whenever the assessment indicates a coexisting substance abuse or medical disorder it is the responsibility of the provider to assure that appropriate collateral referrals are made. When concurrent medical problems are identified, providers should refer the client to and coordinate ongoing treatment with the primary care physician.

For On-Going Documentation, the SFMHP expects providers to complete SFMHP assessment and case review forms and maintain appropriate records of contact with clients in a locked storage area that ensures safety and confidentiality. At a minimum, records should include:

• Names of clients present for each session
• Dates seen
• Special concerns or risks to patient or others (including any action taken)
• Relevant mental status update
• Diagnosis and treatment plan update (if applicable)
• Intervention/treatment procedures
• Collateral contacts with other healthcare and social service providers
• Progress and outcome of treatment interventions

Client records are subject to SFMHP audit. Treatment records must be maintained for 7 years or the minimum period required by applicable state and federal law.

For annual reviews and updates of client plans of care, the SFMHP expects the following items to be present:

• Diagnoses consistent with the treatment plan
• Specific, observable or quantifiable goals
• Proposed duration of intervention
• Focus of intervention consistent with client plan goals and reflecting client participation when feasible
• Signature by licensed provider

The Outcomes Project is a system wide process to measure outcomes of services. It employs industry standard instruments. All providers are expected to participate in appropriate outcome evaluation efforts. It is anticipated that one or two outcomes instruments will be completed at intake, annually, and at discharge for all clients receiving high intensity services. Outcomes measurement for clients seen episodically will be based on occasional samples. Providers will be expected to expedite this process.

For clients receiving intensive services, regular (usually annual) client satisfaction surveys will be done and organizational providers will be expected to participate in the process of data collection. Samples of other clients may be asked to complete the instruments and providers will be expected to expedite this process, possibly through the distribution of forms to clients selected by the SFMHP.

Contracts with all providers clearly outline quality improvement expectations and functions. Assurance and compliance with such functions is the responsibility of the provider's program monitor. A periodic program review includes an evaluation of the provider's quality improvement work.

Contracts with practitioner providers are reviewed by the Provider Systems Office.

QM and Provider Systems staff and the Quality Improvement Committees regularly review data generated from the above activities according to timelines and procedures detailed in the Quality Management Plan. Providers will be profiled using this information and this profile information will be reviewed by the Practitioner Review Committee, one of the Quality Management Program's Quality Improvement Committees. Providers with practice patterns not meeting SFMHP standards are referred for comprehensive review.

SFMHP uses a targeted treatment model focused on resolving acute psychiatric symptoms and ameliorating other problems identified by the client. Within this framework, the following provider requirements apply:

• Provides comprehensive assessment
• Identifies key target symptoms
• Sets realistic treatment goals
• Conveys appropriate expectations for assessment and treatment
• Actively provides treatment services of sufficient intensity and type to meet clinical requirements
• Coordinates with other healthcare and social service providers as necessary

SFMHP providers deliver services in a professional office setting with the following minimum requirements:

• Clearly visible signs identifying the space as a professional office
• A clearly marked waiting area
• Overall professional environment guaranteeing confidentiality