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LifeWays’ Quality Improvement Department offers resources and support to LifeWays employees, Board members, consumers, and our provider network. Our goal is to develop and implement effective and high quality processes and services that improve outcomes for our consumers.
LifeWays Policy and Operating Procedures:
08-01 Quality Assessment and Performance Improvement Program
08-01.01 Quality Improvement Plan
LifeWays maintains a strategic plan that is used to communicate organizational goals and is integrated into the Quality Improvement Plan. LifeWays uses Baldrige Health Care Criteria for Performance Excellence to guide the strategic planning process. Baldrige is a nationally recognized best practice standard in quality management. Most importantly, Baldrige provides a valuable framework that can help LifeWays plan, perform, and measure results in an uncertain environment. The strategic plan is monitored monthly by the Quality Improvement Council.
LifeWays is committed to quality services and measuring performance of our Community Mental Health System. LifeWays has measures of performance both internally and externally. We also monitor performance of our provider network. The following tools are used to monitor performance:
The Provider Scorecard – measures both successes and opportunities in the key areas of timeliness, utilization, outcomes and quality standards. The report is published quarterly. The report includes: inpatient screening, screening to intake, intake to ongoing, hospital discharges, ER utilization, hospital recidivism, CAFAS/PECFAS Outcomes, data errors, billing verification reviews, certification reviews, youth & family and adult satisfaction.
8-02.03 MIMBPIS Reporting
The input of our various stakeholders is very important to achieving our strategic goals. LifeWays offers many opportunities for our stakeholders to provide input. The purpose of creating a system for continuous stakeholder input is to use this information to inform:
LifeWays has been awarded the highest level of accreditation by CARF International. CARF Accreditation was awarded to LifeWays for Service Management Network with Access Center. CARF accreditation demonstrates to customers that our organization is committed to reducing risk, addressing health and safety concerns, respecting cultural and individual preferences, and providing the best quality of care.
LifeWays requires that all providers of the network receive accreditation from a recognized accrediting body, such as: CARF, JCAHO, COA
LifeWays is regulated by the Michigan Department of Health & Human Services, Mid-State Health Network, and Centers for Medicare and Medicaid Services. LifeWays demonstrates compliance with regulatory standards through site visits conducted by Mid-State Health Network, Michigan Department of Health & Human Services, and the Health Services Advisory Group.
It is expected that all providers comply with standards and participate and provide information as requested during audits of regulatory compliance.
08-02.02 Performance Indicator Development and Monitoring
The LifeWays Quality Improvement Team is responsible for facilitating process improvement activities. The goal is to ensure key processes that impact our service delivery system are highly effective, cost-efficient and lead to improved treatment outcomes. LifeWays utilizes a Lean process improvement model and monitors the results through process and outcome metrics. Lean is an improvement process that is achieved by:
1) Removing waste (ex/ duplicate work),
2) Increasing efficiency (ex/ multiple hand-offs), and
3) Elevating quality (ex/ treatment outcomes)
To request a process improvement, complete the Performance Improvement Request form as indicated in the Process Improvement Facilitation procedure.
08-03.02 Quality Improvement Process Facilitation
It is expected that Network Providers, as a part of their accreditation, are completing a thorough root cause analysis (RCA) in the event a consumer is involved in a sentinel event. The format of the RCA is not dictated. The RCA must include all providers serving the individual.
08-02.10 Sentinel Events and Root Cause Analysis
Technical requirements change from year to year, based on the Medicaid Specialty Supports and Services contract guidelines (Contract Attachments). Please see the Medicaid Provider Manual for more information.
Link: Michigan Department of Health and Human Services Medicaid Provider Manual
To ensure LifeWays maintains a health records system that documents care and services provided to an individual, as well as provides information for data-driven business decisions.
08-05 Health Information Management
The Quality Improvement Program at LifeWays is comprised of multiple committees and focus areas, all of which are monitored by the QIC. Attention on specific areas is identified so that input and outcomes on focus areas is reported to the Council and, therefore, the Board of Directors. Information about each focus area is provided through reports, meeting minutes, committee snapshots, or any means necessary to provide information to the Council as outlined in the QIP Reporting Schedule. The following are the focus areas for the QIC:
The primary responsibilities of the QIC include:
Additional QIC responsibilities include, but are not limited to:
The QIC participates in the development of each annual QIP through recommending goals and priorities for the upcoming fiscal year. These recommendations may include modifications to the current quality improvement system or implementation of new initiatives, goals or priorities to continue the continuous quality improvement process. Once the QIP plan is finalized, the QIC is responsible for conducting ongoing monitoring of the Quality Improvement Program and provide recommendations for improvement.
Includes: Role of the Quality Department; Quality Improvement Plan; Strategic Planning; Performance Monitoring; Stakeholder Input; Accreditation; Regulatory Compliance; Service Fidelity and Outcomes Monitoring; Process Improvement; Sentinel Event and Root Cause Analysis; Technical Requirement and Practice Guidelines; Quality Improvement Council.
Attachment: How to Generate BH-TEDS Records (BH-TEDS User Manual)Electronic Medical Record (EMR) updated 12/28/17