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DETROIT WAYNE MENTAL HEALTH AUTHORITY

Quality Improvement

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Corine Smith Mann, Chief Strategic Officer/Quality Director at Detroit Wayne Mental Health Authority, earned her Bachelor’s degree and subsequently a Master’s in Social Work from Wayne State University.  She brings a broad range of clinical and administrative experience in mental health, substance use disorder (SUD), and child and family services.  Licensed by the State of Michigan in micro and macro practice as a Licensed Social Worker (LMSW) and Marriage and Family Therapist (LMFT), and certified as an advanced alcohol and drug counselor (CAADC) and Certified Prevention Consultant – Reciprocal (CPC-R).

She has worked in both the public and private sector, outpatient SUD and community mental health, residential and inpatient (mental health and SUD), and managed behavioral health.  She brings more than thirty-five (35) years of experience, passion and commitment to improving the quality of supports and services to persons served by DWMHA.

In her current role, Mrs. Mann is responsible for Strategic Planning and directing the Quality Improvement Unit at DWMHA.  

 
What are Quality Functions & Processes?

 

Quality Mission
 
The Quality Improvement unit of the Authority is committed to ensuring the supports and services provided to the persons in our community by the provider network is of the highest quality and exceeds our customer’s expectation.

 

Quality Vision
 
DWMHA will be the benchmark of excellence and value in behavioral health care by providing exemplary services that are both patient-centered and evidence-based.
 
Quality Values/Guiding Principles
 
There are four (4) values or main principles of quality improvement:
  1. Focus on the customer. Services should be designed to meet the needs and expectations of customer.  An important measure of quality is the extent to which customer needs, desires and expectations are met.

  2. Understanding work as a system and processes.  Providers need to understand the service system and its key processes in order to improve them.  Using tools of process engineering allows simple visual images of these processes and systems.

  3. Teamwork.  Because work is accomplished through processes and systems in which different people fulfill different functions, it is essential to involve the process owners  in the improvement.  This brings their insights to the understanding of changes that need to be made and to the effective implementation of the appropriate processes, as well as the development of ownership of the improved processes and systems.

  4. Focus on the use of data.
    Data are needed to analyze processes, identify problems, and measure performance.  Changes can then be tested and the resulting data analyzed to verify that the changes have actually led to improvements.

 

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Quality Assessment Performance Improvement Program

The Quality structure is described in the Authority’s Quality Assessment Performance Improvement Program (QAPIP).  This aligns with the regulatory requirements of the Michigan Department of Health and Human Services (MDHHS), External Quality Review (EQR), and best practice for total quality management.

The QAPIP is facilitated by the Quality Unit within the Authority, and includes but is not limited to the ten (10) functions identified in the Application for Participation.  The Quality Unit is organized around four (4) core functions:  Performance Improvement, Performance Measurement, Performance Monitoring and External Quality Review/Accreditation. The Authority retains ultimate responsibility for these functions, but may require the MCPNs, and direct contractors to perform these functions.
 
It is an expectation by MDHHS that at a minimum the Authority provide the following ten *functions:

  1. Developing an annual Quality Assessment and Performance Improvement Program (QAPIP) plan and report.
  2. Standard-setting.
  3. Conducting performance assessments
  4. Conducting on-site monitoring of providers in the provider network.
  5. Managing regulatory and corporate compliance,
  6. Managing outside entity review processes (e.g., external quality review, PIHP accreditation),
  7. Conducting research,
  8. Facility quality improvement process,
  9. Facility provider education and oversight,
  10. Analyzing critical incidents and sentinel events.

*All of these functions are not the direct responsibility of the Quality unit but may be connected through the Quality Improvement Program Structure under the Quality Improvement Steering Committee.

 

Performance Improvement Function

This function is responsible for total quality management/continuous quality improvement activity.  This involves the development of annual Quality Assessment and Performance Improvement plans, reports and implementation of the QAPIP.  Performance Improvement includes the facilitation of the Quality Improvement Steering Committee (QISC).
 
The QISC oversees the quality function and is composed of key units within the Authority, providers, consumers and practitioners.  It reports to the Program Compliance Committee of the Board of Directors.  The QISC receives performance reports from the Authority Units and has a functional subcommittee structure that reports to it.
 
External Quality Review (ERQ) and Accreditation

These functions are responsible for coordinating outside entity review processes.  This will specifically address EQR and our plan to pursue accreditation by National Council on Quality Assurance (NCQA).  EQR is a Balance Budget Act requirement of CMS that MDHHS contract with an independent entity to review the quality of the Prepaid Inpatient Health Plans (PIHPs) as a condition of the waiver.  MDHHS contracts with Health Services Advisory Group (HSAG) out of Arizona.   They conduct three reviews annually: Compliance Monitoring, Performance Measure (ISCAT) Validation, and Performance Improvement Project (PIP) Validation.
 
Performance Monitoring Function

The Performance Monitoring function is responsible for compliance monitoring of our entire system.  The Authority through its performance monitoring will set standards, conduct performance assessments, conduct remote and on-site monitoring of providers in the network; monitor facility quality improvement process, and facility provider education and oversight. 

Additionally, the performance monitors are responsible for other key functions required by MDHHS. All MDHHS and Integrated Care Organization (ICO) site visits, corrective action plans and improvement plans are coordinated by the performance monitoring staff.  New program enrollment reviews and Medicaid Enrollment reviews are conducted by the performance monitors.  This involves a site visit to ensure any new program or program requiring Medicaid enrollment meet the minimum requirement for participation in our network.
 

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What is Strategic Planning
 
Strategic Planning is a process that seeks to set a strategic direction and plan to advance the organization’s interests and ensure long-term growth and sustainability.   It does this by setting policy priorities, developing action plans for continuous quality improvement on the micro and macro level.
 
The overall purpose of an organizational strategic plan is to support the organization’s business through continuous quality improvement. This primarily means developing a cascading process to engage and inform stakeholders including MCPNs, providers, employees, persons served, family, advocates, the community and the general public in our quality improvement activity. 
 
The function of the Strategic Plan is to provide a strategy and action items for the Quality Assessment Performance Improvement Plan (QAPIP) at Detroit Wayne Mental Health Authority.  The Strategic Plan will serve as the guiding map for all internal and external quality improvement, including annual quality improvement and strategic objectives within the authority, the MCPNs, and providers, including responsibility assignments, performance measurements and evaluation.
 
 

Additional Resources

The work of the Quality Improvement Unit is supported by an interdisciplinary team of professionals:

Mary Allix, LLPC, CADS, CAADC

Josephine Austin, BSN, RN

Marjorie Creswell-Hall, LLPC

Danielle Dobija, LLP

Belinda Evans-Ebio, LMSW

Aline Hedwood, Mgmt. Assist

Shara Johnson, LP

  Gail Parker, LMSW

  Carla Spight-Mackey, LMSW

  April Seibert, MA

  V. Gail Simpson, LMSW

  Allison Smith, PMP

  Starlit Smith, LMSW

  Patricia Springs, LMSW