Framework for a Quality Management Program
CMS has developed a Quality Framework which provides an excellent model for constructing a viable and practical approach to dealing with the quality aspects of a waiver. This Quality Framework contains three distinct functions: Discovery, Remediation and Improvement. Just as the NHTD waiver has adopted this approach, it is expected waiver providers will also. By incorporating these three functions into its quality activities, providers can better meet the responsibility of identifying problems, understanding the extent of each problem and developing appropriate interventions to resolve the problem.
The Discovery function focuses on the ability and willingness to become aware of those events that may compromise the waiver's pursuit of meeting its assurances to the federal government. On a more concrete level, are there policies and procedures in place that will identify issues of concern to the participant, provider, community or program? Do we know when a participant experiences neglect or other critical incident? Do we know when waiver policies and procedures have a negative impact on providers' ability to meet the standards established for hiring qualified staff? Do we have a way of documenting and sharing best practices? These are the types of questions that must be positively responded to if the NHTD waiver is to understand whether it is successful in fulfilling its primary goals.
Once Discovery processes are in place, the QMP must respond to individual situations via Remediation and, when necessary, to initiate Improvements on a system-wide level. The Remediation processes established to provide amelioration of an individual's problem must be ones that can be carried out in a timely and efficient manner. Overwhelmingly, situations requiring Remediation would be considered Serious Reportable Incidents (SRI) (refer to Section X - Incident Reporting Policy and Complaint Procedure). Such events must be catalogued by both the waiver (through the QMS) and provider to understand whether they are isolated events or if a pattern has developed.
Improvement on a system-wide basis is also essential in order for the waiver to respond to changes in healthcare and other environments. Resource and reimbursement concerns, along with the shifting interests and needs of participants and providers, must be considered as the waiver continues to mature and grow. New barriers and concerns may evolve and must be managed. System-wide improvements, clarifications or changes to existing policies and procedures will impact the other two components of the QMP - Discovery and Remediation. These improvements may also be reflected in changes to the basic waiver design or to its policies and procedures. Often, the system-wide improvements being sought are based on the recognition that there are faults within the Discovery or Remediation functions that cannot be corrected in any other way. This type of self-correcting closed loop model of improvement -where feedback from the system is used to initiate changes in that system-provides the opportunity for an ongoing quality improvement process.