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Quality Improvement Sample Plans Providers across all service categories share their quality improvement project. A great resource for ideas on Quality Improvement project specific to your service category and information to include when submitting your quality improvement plan.

Case Management

Customized Living

Day Services

Includes providers who offer Day Training& Rehabil i tat ion, Adult Day, and Structured

Day Program services

Employment

Includes providers who offer Supported Employment and Prevocat ional services

Foster Care/Residential

Includes providers who offer Foster Care, Residentia l Care, Supportive Living, and

Respite Care services

Home Care

includes providers who offer Home Care services such as Personal Care Assistance,

Ski l led Nursing, Private Duty Nursing, Home Health Aide, and

Therapies

Intermediate Care Facilities

In-home Supports/ ILS

Includes providers who offer independent l iv ing ski l ls , chore, homemaker, nutrit ion,

delivered meals, and other home support services.

Case Management Provider Quality Improvement Projects

Case Management Sample Projects

Case Management Sample Project #1

Services Affected:

o Case Management o Day Services

Areas of Improvement:

o Increases person-centeredness of services o Uses participant feedback to improve services o Promotes positive behavior interventions

This project requires:

o Staff Training o Surveys

Briefly describe your project:

A client satisfaction survey will be updated to include the components of person centered service and positive behavior intervention services. Case managers will send out a mass mailing to all the service participants or their legal representative. Results will be tallied and action will be taken on the areas that fall below satisfaction rating. In future annual teamings, another survey will be given out to follow up on any changes recommended. The case managers will update the individual service plans ISPs or CSSP with person centered language and positive behavior intervention information as appropriate in each case and monitor the client choice and satisfaction with the assessment and services to address the client's individual needs.

How will you know your project is successful?

Success will be noted if 50% of the surveys are returned for review. Success will also be achieved if 85% of the respondents are satisfied with their services. Success will be monitored with 100% of the ISP/CSSP plans including the person centered language and positive behavior services.



Services Affected:

o Case Management


o Increases capacity of the direct service workforce o Implements new management or organizational strategies o Increases person centeredness of services


o Staff Training o New Staff


We reorganized our Social Service and Public Health Divisions to both provide more streamlined intake and assessment services for all persons in the community, as well as to implement MnCHOICEs. The reorganization, which commenced September of 2013 and is still in process, involved creating a new Intake and Assessment unit, moving 2 Public Health Nurses to the Intake & Assessment Unit and developing new intake processes. The overarching philosophy of the reorganization was to align internal practices with the needs of those persons coming through our doors. The team continues to review and modify practices based on feedback of all parts of the system clients, staff, administration and DHS.


Improving our initial screening timeframes from a 2013 average of 68% for CCB and 47% for AC/EW new waiver recipients to exceed the 80% screening compliance standard. Increased consumer/customer satisfaction as evidenced by favorable survey results identifying positive feedback.

Identify the performance measures you will use to measure the success:

Performance measure: MnCHOICE assessments for new CADI, CAC & TBI recipients will be completed within 20 days Baseline, if applicable: 68%

Goal: 85%

Performance measure: MnCHOICE assessments for new AC & EW recipients will be completed

within 20 days Baseline, if applicable: 47% Goal: 85%



Services Affected:

o Case Management


o Improves coordination of long term services and supports with other health and wellness services

o Uses participant feedback to improve services o Implements new management or organizational strategies



o Revising organizational policies


Case managers who are also care coordinators must have a broad base of knowledge to do their job. This project will explore whether specialization of caseloads improves efficiency, reduces the amount of time searching for program information, impacts staff satisfaction, and increases or maintains client satisfaction with their case manager.


Staff will demonstrate increased efficiency in meeting deadlines, 95% of the client satisfaction surveys will report timely CM responses to needs, "experts" will be developed within the agency for program areas, and caseloads will be streamlined.


Performance measure: Client satisfaction surveys rate case manager responsiveness, availability, and how to contact them Baseline, if applicable: Data is collected at initial 6 month visit Goal: 95% of returned surveys will report responsiveness, availability, and indicate knowledge of their

current case manager/care coordinator's name and contact information

Performance measure: Caseloads will be streamlined and more specialized to match the case manager's interests and abilities. Baseline, if applicable: Current caseloads are comprised of both over/under 65 programs and MCO clients. Goal: Staff will self-report satisfaction with caseloads and will identify areas of "specialty" as a resource for their coworkers.



Services Affected:

o Case Management


o Increases Independence

o Increases choice of community based services o Improves choices for independent living


o Staff Training o HCBS recipient training

o Surveys


Our county’s case managers are partnering with STAR Services to develop alternatives to corporate foster care for people with disabilities who are waiver recipients.

o Increase the knowledge of case managers about individualized housing options and resources. Two surveys were done; One to determine if case managers have assisted any of their clients in moving, and what challenges they see. Another was for case managers to identify clients that are interested in moving to individual housing. 30 clients were identified.

o Case managers are working with these clients and families to inform them of individual- controlled options. The identified clients are included in the planning process. STAR Services is developing relationships with local landlords and to reduce barriers for clients.


10 of the 30 clients will move from corporate foster care to an individual housing option and 11 clients will be diverted from corporate foster care. Three new individual housing options will be developed and 85% of the identified clients will be successful and will not reenter CFC placement


Performance measure: % of clients that were moved out of corporate foster care into an individual

housing option

Baseline, if applicable: Goal: Identify 30 clients and move out at least 10

Performance measure: Increase number of individual housing options & their locations throughout the

County

Baseline, if applicable: Goal: 3 new options



Services Affected:

o Case Management


o Increases capacity of the direct service workforce

o Implements new technologies that improve care o Increases employment options for participants


o Staff Training o New technology for staff


This project entails the implementation of Service Quality Assurance System (SQAS), a program specific to Case Management that creates a monthly review of each case manager’s caseload according to a set of standards and job expectations. In SQAS there are 12 standards for which job expectations are developed. Standards cover aspects of case management such as assessment completion and service plan development, or service delivery. One or more job expectations are developed for each standard. Performance measurements are developed for each job expectation and reported monthly. Data is pulled directly from SSIS into SQAS for display on the first of every month. Case Managers will review monthly findings for their specific caseload with their supervisor on a monthly basis.


This project will be successful when results show that goals for each job expectation are being met for all cases on a monthly basis. For this reporting request, two performance measures have been developed to monitor overall case manager compliance monthly with two specific job expectations.


Performance measure: Percent of non TCM clients seen face to face twice a year at 6 month intervals

Baseline, if applicable: Baseline data will be taken for the month of March, 2015

Goal: 100% of non TCM clients are seen two times a year at 6 month intervals.

Performance measure: Percent of service plans renewed every 365 days.

Baseline, if applicable: Baseline data will be taken for the month of March, 2015

Goal: 100% of service plans are renewed within 365 days.



Services Affected:

o Case Management


o Increases community engagement o Improves coordination of long term services and supports with other health and wellness

services o Increases person centeredness of services


o Staff training o Changing business practices o Revising organizational policies


We are going to develop a formal process for Public Health and Social Service staff to meet and collaborate on cases. Public Health and Social Service staff will benefit from regular consultation with one another about case management and by tapping into one another's areas of expertise to better serve our HCBS waiver participants.


We will have better collaboration between staff, case managers will have increased knowledge about all programs in each division, and will be able to provide more person centered and integrated services.


Performance measure: Attendance at meetings.

Baseline, if applicable: 75% of staff will be in attendance at all meetings.

Goal: All staff will attend a monthly collaborative staff meeting between Public Health and Social Services.

Customized Living Sample Projects

Customized Living Quality Improvement Projects

Customized Living Sample Project #1

Services Affected:

o Customized Living o Home Care o In Home Supports /Independent Living Skills


o Reduces the rate of accidents, falls, infections or other adverse health events o Improves coordination of long term services and supports with other health and wellness services

o Promotes positive behavior interventions




Project # 1 Decrease hospitalizations/ER visits- Develop hospital partnership, establish joint comprehensive accountability with client’s self-management /expectations to prevent hospitalizations, implement The SBAR Technique, and increase telephonic/skype communication for early identification of issues. Project #2 Reduce falls in clients residing in ALF- Improve clients /families understanding of their role in self-managing and preventing their falls by incorporating best practice strategies that are client specific recommendations from Clinicians.


Project # 1 When the Client maintains/improves their own self-management of their disease, prevents deterioration of their health and hospitalizations/ER visits. Project #2 When the Client understands and incorporates fall prevention strategies that are recommended and sustains no falls.


Performance measure: Number of unplanned hospitalizations in the last 6 months Baseline, if applicable: Goal: State & National Average for Home Health Compare (16%)

Performance measure: Number of falls in the target month Baseline, if applicable: Goal: Reduction by 15%



Services Affected:

o Customized Living


o Uses participant feedback to improve services o Implements new management or organizational strategies


o Changing business practices o Surveys


We plan to implement a program called Rounding for Outcomes, a method used by Quint Studer in his book Hard Wiring for Excellence. Rounding for outcomes goes beyond typical rounding on floors (saying hello and "being visible"). Rounding for outcomes requires management staff to round with specific goals in mind, asking pointed questions. Managers will be expected to ask staff questions like, "Do you have to tools you need to do your job?" or "Do you have any colleagues who have done a great job today that I should thank?" Staff will be required to check in with residents and say, "Is there anything I can do for you? I have time," and "Are there any staff that have done a good job today? What did they do that was great?"


Staff morale will improve Staff will have better access to the tools they need Communication will be improved Residents will be better cared for because staff will be happier in the workplace


Performance measure: Employee satisfaction

Baseline, if applicable: An extensive employee satisfaction survey was completed using a 5 point

likert scale. Select questions scoring below a ‘4’ will be re-surveyed quarterly to monitor for improvement. The goal is that Rounding for Outcomes will positively impact morale and will improve the score on the selected survey questions.

Goal: Receive a score of 4 or better on focus questions selected. Resurvey with the same selected questions

quarterly to monitor for improvement.

Performance measure: Improved resident satisfaction survey regarding staff relationships

Baseline, if applicable: Baseline score of Care of Staff 79, Competency of Staff 73, Responsiveness

of Staff 70

Goal: Improve each score by 5%



Services Affected:

o Customized Living


o Improves Health

o Reduces the rate of accidents, falls, infections or other adverse health events o Uses participant feedback to improve services


o Staff Training o Caregiver training


With an increase in the aging population and the need for placement, we will be implementing packages in our assisted living in order to keep clients safe, healthy, at home, and hopefully see problems before they are a concern. We currently have only ala carte services and a package will allow us to be able to see the client monthly to be able to assess any areas of concern. Currently many clients transition to Nursing Home even though the Assisted Living could have managed their needs. Our area has a lack of openings for clients so the longer we can keep the clients in their homes the better. Our packages will include a call button, nurse visits, monthly vital sign checks, and possibly cleaning.


Retention of clients by taking on services when needed to keep them at home as long as possible, assessing this at each discharge. We will measure this by implementing a quarterly survey to all residents to see if they feel we are meeting their needs and the satisfaction of the services.


Performance measure: Resident satisfaction

Baseline, if applicable: Goal: 95% satisfaction of services and needs being me



Services Affected:

o Customized Living


o Improves Health

o Improves people's ability to perform everyday activities o Increases Independence




We will be encouraging our clients to do more for themselves and be an active participant in their life. We will give verbal cues for each client to assist with his/her cares. The staff will also sit down with our clients and help them develop a menu that is healthy and balanced to reduce health issues. Staff will also encourage some form of exercise for the clients. Staff will document what activities the client was offered in a chart and if they did it. All staff will have an in service for this process.


We will review monthly with Residential Coordinator on progress. We will then suggest more ideas or meet with the client to encourage. We will know if we are successful by increased activity log and independent skills documented.


Performance measure: % of Clients who did some form of daily exercise

Baseline, if applicable: 50% are doing some form of exercise

Goal: To increase the percentage to 100%

Performance measure: % of clients who have added one or more independent skill to day

Baseline, if applicable: 25% are currently adding tasks

Goal: 100% is the goal to have everyone adding at least one skill

Day Services Quality Improvement Projects Projects from services that include Day Training & Rehabilitation, Adult Day, and Structured Day

Day Service Sample Projects

Program services

Day Services Sample Project #1

Services Affected:

o Day Services


o Increases person centeredness of services o Improves retention and stability of direct care staff o Increases community engagement


o Staff Training o Caregiver training o Revising organizational policies


Average daily absenteeism for our Day Services is 10.4%. We tracked expected daily attendance vs actual number of daily absences to determine our percentage of absenteeism for each center and averaged the 3. Our project is to continue tracking daily rates as well as the reasons for the absences. Tracking will help us identify & analyze causal factors for absenteeism. In addition to this data, it is anticipated that our approach will involve getting clients, caregivers & staff engaged to provide input in determining focus areas. This information will allow us to create solutions/ programming changes & possible policy changes to increase attendance. Potential approaches may include client &caregiver education & interventions, staff training on approaches & responsiveness.


Absenteeism will be decreased by 2%. We are anticipating higher satisfaction levels for clients served, family caregivers and staff, as well as other unanticipated outcomes.


Performance measure: daily attendance

Baseline, if applicable: 10.4% daily absence

Goal: 8.4%



Services Affected:

o Day Services


o Uses participant feedback to improve servic

es o Improves retention and stability of direct care staff o Implements new management or organizational strategies


o Staff Training o Changing business practices o Surveys


Our agency will be working to improve communication between stakeholders (i.e. people we serve) and staff. Specifically we wish to improve the promptness of communications, address whether or not persons receive the "correct" answers to their questions, and improve their overall satisfaction with communication. We will create a survey and gather survey responses from stakeholders throughout the year and follow up with comments directly when needed.


When stakeholders overwhelmingly report they are satisfied with communication with our agency. Specifically, of the surveys returned, if 90% or above report feeling they are satisfied with their communication with our agency


Performance measure: % of people who returned surveys indicating proper communication

Baseline, if applicable: Goal: >= 90% people report proper communication



Services Affected:

o Day Services


o Increases person-centeredness of services o Uses participant feedback to improve services

o Implements new management or organizational strategies




Our project focuses on providing more opportunities for persons served to offer feedback in program planning processes and creating and offering a leadership training course for our management and administrative teams. The individuals we serve will participate in focus groups beginning in January 2015 which will guide person centered programs to focus on increased employment, health and wellness initiatives, and opportunities for creative pursuits through the arts. Our leadership training course for our management and administrative teams will focus on several topics including: servant leadership, time management, office computer technology, management training techniques, conflict resolution, stress reduction and wellness, person centered planning, and customer service skill building.


We will evaluate the effectiveness of our project by conducting follow up focus group meetings with persons served by 12/2015 to measure progress and satisfaction. Management and administrative teams will complete feedback surveys following each training session to determine the overall value.


Performance measure: The percentage of people stating that they are meeting the person centered outcomes they set for themselves during the last year. Baseline, if applicable: 96% stated they are meeting the outcomes selected

Goal: 98% is the goal we are targeting

Performance measure: The satisfaction noted on the feedback surveys following each training session Baseline, if applicable: no current baseline

Goal: 70% is the satisfaction rating we are targeting



Services Affected:

o Day Services


o Improves people's ability to perform everyday activities o Improves Health


o Staff Training o HCBS recipient training o New equipment for people served in the program


The development of the Pinewood Personal Fitness Program is to motivate persons to strive for a lifetime of personal fitness, with an emphasis on health related components of physical fitness the process of becoming fit, as well as achieving a degree of fitness within the program. Comprehensive/tailored physical education improvement includes: PACER fitness test, exercise room, adapted physical exercises, power walking at the community indoor track, ongoing wellness instruction and discussion. To support these components, nutritional education is included. Personal fitness directly impacts energy, work, recreation, balance, social development, physical/mental/emotional health in a positive way.


Anticipated results include increased strength, stamina, flexibility, and weight loss with side benefits of team building, listening, increased cooperation and increase in self-esteem. Data should indicate satisfaction among participants in the program as well as physical improvements noted.


Performance measure: Active participation in the program. Baseline, if applicable: Will vary according to ea. individual's level of physical ability.

Goal: Increased endurance, flexibility, strength



Services Affected:

o Day Services


o Improves people's ability to perform everyday activities o Increases community engagement


o HCBS recipient training


In 2014/2015 we will implement experiential arts programs for up to 50 adults with intellectual/developmental disabilities. The goal is to expand cognitive/experiential opportunities for consumers through a variety of arts disciplines. The interactive creative process fosters abstract thinking and problem solving. These art creation skills are also the tools relied on in day to day lives to spontaneously interact, assess a situation and react accordingly, transmit unspoken social cues, and express ourselves. Activities are geared to help the participants gain more of those tools. Additional funding is required to implement this project. We will look to resources such as Minnesota State Arts Board and the Metropolita Regional Arts Council in addition to our Annual Appeal.


1 to 2 Arts programs will be funded and implemented each year. 90% of the DTH consumers will participate in at least one Arts activity during the year. In addition to art product, staff will report on improvement in goal areas listed above.


Performance measure: At least two Arts program will be funded and implemented in 2014/2015 Baseline, if applicable: No Arts program before 2014

Goal: Two Arts projects implemented by the end of 2015

Performance measure: 90% of consumers participate Baseline, if applicable: No Arts program before 2014

Goal: 90% participation (max. enrollment is 57)

Employment Sample Projects

Employment Quality Improvement Projects Projects from services that include Supported Employment and Prevocational services

Employment Sample Project #1

Services Affected:

o Employment o Day Services


o Increases access to competitive employment o Increases person-centeredness of services o Implements new management or organizational strategies


o Staff Training o HCBS recipient training o Changing business practices


Through this project, an employment planning tool called the Personal Employment Plan (PEP) will be developed. The PEP will help people with disabilities identify specific employment goals and actions needed to reach outcomes. Included in the PEP will be work preferences; employment history; skill assessment; support needs; and specific, measurable commitments from the person and their support team in order to accomplish their employment goals. In order to implement the PEP we will combine existing service plans and assessment tools with best practices related to customized employment and job development. We’ll then pilot the PEP to gather feedback from people served and improve upon the format before rolling it out to all job seekers.


The success will demonstrate improved community employment placement and internal processes. We will have a PEP template that is ready to be rolled out across the organization and demonstrated placement success in the pilot.


Performance measure: Increase the number of Personal Employment Plans created. Baseline, if applicable: 0

Goal: 24

Performance measure: Place 50% of people who have Personal Employment Plans in community integrated employment. Baseline, if applicable: 0

Goal: 12



Services Affected:



o Increases community engagement

o Increases access to competitive employment o Increases person centeredness of services


o Staff Training o Transportation for people served in the program


An increase variety of community opportunities will be offered for individuals to experience informed choice activities pertaining to integrated employment. By adding more work experiences, individuals to gain exposure to new options and environments. These career exploration opportunities will include business tours, job shadowing and /informational interviews. Once an individual has been able to choose vocational interest areas, then a plan will be made to participate in activities in the community. Upon the completion of participation of the project an online survey will be offered regarding this experience.


We will monitor data through on line surveys upon completion of the project along with documentation on individual progress reviews.



Services Affected:




o Increases person-centeredness of services o Uses participant feedback to improve services




Our Quality Improvement Plan is to support staff development in areas related to participant engagement and inclusion in order to continue providing quality services within the program. Staff will be empowered and encouraged to increase training in all areas, but focusing on areas of need according to specific individuals and locations. Staff will involve professional networks and partnerships to enhance and enlarge community engagements for themselves and participants. Tools that will guide us will include The Campaign for Disability Employment and the National Service Inclusion Project. This will expectantly sustain our program's success in handling the ever changing needs of our participants.


Program staff will be able to better respond to participant needs, interests and abilities as well as assist individuals and their teams in navigating though concerning situations.


Performance measure: 75% of program participants will report satisfaction with services Baseline, if applicable: Goal:

Performance measure: Program staff will gain awareness and increase abilities in strengthening their service delivery by participating in 6 exercises related to the National Service Inclusion Project throughout the year. Baseline, if applicable: Goal:



Services Affected:



o Improves people's ability to perform everyday activities

o Increases person-centeredness of services

o Improves retention and stability of direct care staff


o Staff Training o Revising organizational policies


We will be focusing on the reduction of direct staff turnover, which includes our job coaches and employment specialists. We will be trying to eliminate most of the job coaching positions and have them replaced with employment specialist (ES) positions. We will be using the Individualized Placement & Support model for most of our direct support staffing needs. Under this model, the ES positions will have a reduced caseload, to no more than 25 consumers. They will also provide all the necessary supports for each of those consumers, so the consumers have more time build positive relationships with the staff. To make these changes happen, most of the current job coaches will require a significant amount of additional program training. Additional outside training sources may be needed.


We will know we are successful when our staff turnover rate is reduced and our average staff longevity increases. We will also be looking at our consumer satisfaction rate and the number of consumers that move from center based employment to supported employment, which we are already tracking.


Performance measure: Direct Staff turnover rate per year

Baseline, if applicable: 62.4% in 2014

Goal: 40%

Performance measure: Average direct staff longevity in years

Baseline, if applicable: 5 in 2014

Goal: 6



Services Affected:




o Increases access to competitive employment o Increases employment options for participants


o New Staff o New technology for people served in the program

o New equipment for people served in the program


Our project is to increase the choices and opportunities of the people we serve through vocational training. A staff dedicated to community job development/placement was added. Along with added staff we implemented a program called eTrac. eTrac is an interactive online vocational training program for adults with developmental and acquired cognitive disabilities. It promotes computer literacy and strong basic job skills. eTrac is designed to improve outcomes for people seeking competitive or supported community based employment, and to offer increased access to the community through the use of technology. We currently have 89 people enrolled in the course. We have had 12 persons complete the 45 hour course and are searching and applying for jobs in the community.


When a continuum of choices is available to all persons served to achieve the most independent vocational option possible. When through the use of this program we are able to place more individuals in jobs that will be of their choice.


Performance measure: Move a majority of those enrolled in eTrac through the complete

program.(45hours)

Baseline, if applicable: Currently 89 enrolled

Goal: Move a minimum of 67 individuals through complete program in the next year.



Services Affected:

o Employment



o Increases access to competitive employment o Increases employment options for participants




We will utilize a formal program to assist individuals that we support transition from High School or Sheltered Employment to Community Employment. We will use a person centered approach to assist people in realizing their goals of working at competitive jobs in their communities. The program will start upon the person’s admission to our program and will be made up of the following six categories.

Category One: Employer Expectations and Needs (Work Adjustment Training) Category Two: Job Search Process (Job Seeking Skills Training) Category Three: Individual Career Vision Category Four: Expansion of Occupational Interests Category Five: Volunteering Category Six: Development of Work Goals Concentrating on the development of skills in each category will assist the transition into work.


Our project will be determined successful upon, successful completion of the program and a satisfaction survey. This will prove that they have learned the knowledge and skills needed to transition into competitive employment and that they are happy with our program.


Performance measure: Each person's completion of the transition program.

Baseline, if applicable: Goal:

Performance measure: Baseline, if applicable: Goal:

Foster Care/Residential Sample Projects

Foster Care/Residential Quality Improvement Projects

Foster Care/ Residential Sample Project #1

Services Affected:

o Foster Care/Residential


o Increases person-centeredness of services o Improves retention and stability of direct care staff


o Staff Training o Changing business practices


We will implement more person centered thinking by having all staff and residents fill out a personal profile. These profiles will be displayed on a "wall of fame" in a common area of the home. We will also launch an in depth training and coaching curriculum, incorporating Mastermind studies of relevant topics, such as "Everyone Communicates, Few Connect," "The 15 Invaluable Laws of Growth," and "Sometimes You Win, Sometimes You Learn."


The project will be deemed a success when all personal profiles are complete, all staff have attended at least 1 Mastermind Program, and can pass a competency quiz demonstrating knowledge of the material.


Performance measure: Mastermind Competency Quizzes Baseline, if applicable: Goal: 100% of current staff Pass final quiz by the end of 2015

Performance measure: Personal Profile Completion Baseline, if applicable: Goal: 100% of profiles are completed and displayed by 5/30/2015



Services Affected:



o Improves people's ability to perform everyday activities o Increases Independence o Improves Health


o HCBS recipient training o Caregiver training o Transportation for people served in the program


To teach residents to cook simple meals and understand the nutritional value in what they choose to make.


As they cook or bake more often and we talk about the nutrition in each option, they will learn to do it more independently.



Services Affected:



o Increases community engagement o Uses participant feedback to improve services o Improves retention and stability of direct care staff


o Staff Training


We are establishing a goal to increase community engagement by our residents and one of the ways we hope to do this is assisting our residents to plan and participate in activities in the community to attend either individually, with direct staff assistance, or as a group with their other housemates. We will solicit feedback from our residents about their interests and help them to seek out activities that match those interests. We will also follow up after the activity to gauge their response and satisfaction.


We will solicit feedback from our residents about their interests and help them to seek out activities that match those interests. We will also follow up after the activity to gauge their response and satisfaction.



Services Affected:



o Increases person centeredness of services

o Uses participant feedback to improve services o Increases choice of community based services


o Staff Training o New equipment for staff o Changing business practices


Our organization will implement a program that encourages our consumers to actively participate in the writing of their quarterly reports. We are dedicated to involving the consumers in an effort to provide more active and person-centered care. The baseline is zero as we have not involved consumers in the past and our goal is to have at least 50% consumer participation by the end of 2015. The likelihood of participation will be related to the cognitive ability of each consumer.


It is our belief that as this process is embraced by all team members it will generalize to other areas involving team opinions and participation. As consumers are more actively involved in their treatment their quality of life will naturally increase.


Performance measure: Number of reports that clients actively participated in

Baseline, if applicable: 0%

Goal: 50%



Services Affected:




o Increases person centeredness of services o Uses participant feedback to improve services


o Staff Training o HCBS recipient training o New equipment for staff


Plan, develop and build raised gardens in backyard. Develop plans appropriate for each individual resident to learn gardening for the purpose of raising flowers and produce for use in our home and for the enjoyment of the friends and family.


The raised gardens will be built. The produce and flowers will be harvested. Produce will be canned. Flowers will be shared with friends and family.



Services Affected:



o Improves Health o Promotes positive behavior interventions


o Caregiver training


Use pets therapy to reduce the anxiety that our clients struggle with. By talking to, petting and stroking animals, the clients will be able to focus better on the real problem rather than being caught up in fear. Reducing anxiety will promote a more positive environment which also reduce anxiety levels.


There will be reduced outbursts, less conflict, easier personal resolution. Improved health with fewer hospitalizations.


Performance measure: Number of days of hospitalization

Baseline, if applicable: 60

Goal: 30 or less

Performance measure: Reducing anxiety medications

Baseline, if applicable: 8

Goal: 7

Home Care Sample Projects

Home Care Quality Improvement Projects Projects from services such as Personal Care Assistance, Skilled Nursing, Private Duty Nursing, Home Health Aide, and Therapies

Home Care Sample Project #1

Services Affected:

o Home Care


o Improves people's ability to perform everyday activities o Reduces the rate of accidents, falls, infections or other adverse health events o Uses participant feedback to improve services


o Staff Training o Surveys o Changing business practices


Create training for staff with a caregiver checklist of areas that should be addressed when working with their clients. Information on what they should and should not be doing as well as things to look for, i.e. a falls assessment for safety in the home, good hygiene practices in the workplace and who to report concerns to. This information can be given to the PCA's during the QP visits in the event they have any immediate questions regarding their roles.


Along with the training information, a survey will also be included to find out if the information that was given to them was helpful and ask if there is any other areas of concern they would like addressed.


Performance measure: Quality of Care

Baseline, if applicable: Goal: 75% Good to Excellent



Services Affected:

o Home Care


o Increases person-centeredness of services o Increases Independence

o Reduces the rate of accidents, falls, infections or other adverse health events


o Staff Training o Revising organizational policies


A team was developed consisting of 3 RN’s and 1 PT. The team meets 1x per week to go over any re- hospitalizations that occurred in the week prior. The team researches if there were any signs that the hospitalization could have been prevented, and provide clinicians the results of team discussions. This ensures that staff are mindful at all times of a patient’s current status. We can learn from things we have missed prior to this patient being hospitalized. At each admission and recertification the clinician will get a list of diagnosis to help determine care plan needs for the patient. Everyone is learning on a continual basis as to why patients were hospitalized and what we can do better to prevent unnecessary hospital readmissions


We will know our project is successful if our re-hospitalization rates drop from the 20% that they are at currently. Our goal is to be at or below the state level which is currently at 11%. The National rate for re hospitalization is at 16%.


Performance measure: # of Hospital readmission Baseline, if applicable: 20% currently for Oct/Nov 201

Goal: Goal is to be at or below State level of 11%



Services Affected:

o Home Care o Customized Living o In Home Supports /Independent Living Skills


o Increases Independence o Improves Health o Reduces the rate of accidents, falls, infections or other adverse health events




We are working to improve the quality and quantity of drug education provided to our home care clients about the medications that they take. Studies show that clients who know about and understand the medications they are prescribed, are more complaint with taking their medications and more attuned to the possibility of experiencing adverse side effects & reporting them to their nurse and/or Dr.


We utilize the CASPER Reports that are generated by the OASIS data, which is collected as part of the client assessment and then submitted to the state & then Centers for Medicare & Medicaid Services. Our agency tracks this data on a quarterly basis and we have set a goal of obtaining a 91% result.


Performance measure: Drug Education on all Medications During all Episodes of Care Baseline, if applicable: 87.5%

Goal: 91% or higher



Services Affected:

o Home Care o Foster Care/Residential


o Improves people's ability to perform everyday activities o Increases community engagement o Uses participant feedback to improve services


o Staff Training o New Staff o New technology for staff


We will develop a questionnaire to parents; asking 3 behaviors they would like to decrease and 3 everyday activities they would like to see improvement in. Also can use the ABC charting method which can provide important feedback, and use this information in developing the care plan with the parents and PCA. Also inform parents of the benefits of community involvement, develop a 5 point comprehensive questionnaire for families on how to improve services.


Increasing ability to perform everyday activities decrease behaviors due to frustration and anxiety. Increasing performance of everyday activities gives children confidence and success.



Services Affected:

o Home Care o In Home Supports /Independent Living Skills o Case Management


o Improves coordination of long term services and supports with other health and wellness services

o Increases capacity of the direct service workforce o Implements new management or organizational strategies


o Staff Training o Changing business practices

o Revising organizational policies


Our home care staff recently decided to change our intake process for home care referrals. In the past it has been "whomever is available" to take information or referrals from clinics, hospitals, families, etc. This has worked for the most part, but taking several phone calls per days can cut into productivity of the work day. We hope by streamlining our referral/intake process we will develop consistency, communication and accessibility to services. We have developed a calendar in our agency wide email app stating who is on intake/referral for that day/week.


Office support staff will be able to verbalize and demonstrate how to send a referral to the appropriate intake worker. We will be able to track daily time on how much time staff is spending on intake and referrals. We will be able to discuss our successes and failures.



Services Affected:

o Home Care o In Home Supports /Independent Living Skills


o Improves people's ability to perform everyday activities o Reduces the rate of accidents, falls, infections or other adverse health events o Uses participant feedback to improve services




Our project is to help keep the fall rate of the HCBS recipients we serve below the national average. In order to do that, we plan to implement a process of safety measures that our quality improvement team and employees will help carry out to make this project a success. We will provide home safety trainings for our employees so that they will better understand and recognize dangerous or hazardous situations in the homes of our recipients. In addition, we will put together a home safety check list that our employees will use to help identify and keep track of the home safety environment of our recipients.


Our employees will complete the home safety check list at each visit with the recipients to keep track of the home safety environment of the recipients they serve and record/report any falls that may occur. At the project’s end, we will gather all data collected to see if we meet our goal.


Performance measure: Fall rate in all of our HCBS recipients.

Baseline, if applicable: According to the CDC, 1 in 3 (33%) seniors age 65 and older falls at least

once each year.

Goal: Less than 1 in 3 of our recipients have a fall in their home during the one year time frame of our

project.



Services Affected:

o Home Care


o Increases person centeredness of services

o Improves retention and stability of direct care staff o Implements new management or organizational strategies


o Staff Training o New technology for staff o Revising organizational policies


To address the issue of getting information to our clients and keeping staff on the same page, we have decided to implement the use of monthly newsletters that will be used on a consistent basis for communication and training purposes. By doing so all employee's will be notified of any and all changes to come to the company as well as mandatory meetings, policy updates, rate changes, etc... Clients will also benefit from this by staying informed on the changes and policies of the company. This change also allows room for feedback on improvement from our staff and clients to improve the quality of services provided to the community.


A turnaround within the improved compliance of the staff as well as the clients. We will continue to monitor the feedback from the staff to the agency on how well the clients adapt to the change.


Performance measure: Retention and stability of direct care staff

Baseline, if applicable: Goal: 100%.

Performance measure: Increase person centeredness of services %.

Intermediate Care Facility Sample Projects

Intermediate Care Facilities (ICF) Quality Improvement Projects

ICF Sample Project #1

Services Affected:

o ICF Services


o Increases Independence o Uses participant feedback to improve services o Increases person centeredness of services


o Staff Training o Revising organizational policies o Changing business practices


This project looks to expand our ability to provide person centered services that will meet the needs of individuals more fully in the future. In 2015 we intend to do this through the development of several staff members to be capable of facilitating formal Person Centered Plans and begin providing them for individuals who may have a life transition coming up. Before we will be able to facilitate these plans with individuals, we'll need to develop our process and train members of our staff to the facilitation process. We have identified members of our team who will serve as PCP facilitators. In the beginning of the year we will enhance our comfort level with PCT tools.


The project will be successful if we have developed a new Person Centered Planning process which can be replicated for individuals we serve as they are in need. We will have 3 individuals who have had outside training in Person Centered Principles capable of facilitating.


Performance measure: Customer Satisfaction

Baseline, if applicable: 80% Very Good to Excellent, 20% Good

Goal: 95 % Excellent



Services Affected:

o ICF Services o Foster Care/Residential


o Increases community engagement o Increases capacity of the direct service workforce o Increases person centeredness of services


o Staff Training o Caregiver Training o Changing business practices


We are going to implement strategies through which our staff and consumers can work together to provide more opportunities to access the community frequently for events and social opportunities than they could plan as individual homes. We are going to share ideas and opportunities between service sites, communicating events and plans throughout the organization so that staff and consumers have the resources to share transportation and supervision (if appropriate) for a variety of community and surrounding area events.


We will collect data on how often programs and individual service sites share resources to attend an event or plan a social gathering involving other homes or programs. We will know our project is successful if we see an increase in shared resources to maximize community opportunities.


Performance measure: Monthly, a minimum of 4 service sites will plan and invite others from the organization to an event or a socialization opportunity. Baseline, if applicable: Goal: Programs and/or service sites will collaborate with other sites/programs to increase community event and socialization opportunities for consumers.



Services Affected:

o ICF Services


o Increases community engagement o Increases person centeredness of services



o Changing business practices


Our project focuses on community engagement. We will identify people with a connection to a community resource, activity, or association that is not dependent on us to maintain. We are defining these as "durable" connections in that they are strong and have the potential to last a long time. We plan to contact all of the people we support to find out what connections exist, what contributes to success, and barriers to building or new connections. Different approaches in gathering information will be used for direct and indirect services. We plan to identify 8 10 examples representing the services we provide, work with the staff who have been instrumental supporting these connections, and develop training materials that can be used throughout the organization to share what works.


More participants will have increased community engagement. All staff will have a much better understanding on the importance of community engagement and their role in supporting durable connections. Staff will be more proficient in both identifying barriers, as well as generating solutions.


Performance measure: Number of individuals with "durable connections" to the community Baseline, if applicable: Baseline data to be collected at project initiation Goal: Increase number of individuals by 15%

Performance measure: Number of staff with demonstrated skills in supporting community connections Baseline, if applicable: Baseline data to be collected at project initiation Goal: 90% of full time program staff will demonstrate skills in supporting community connections

In-home Supports/ILS Sample Projects

In-home Supports and ILS Quality Improvement Projects Projects from services that include independent living skills, chore, homemaker, nutrition, delivered meals, and other home support services.

In-home Supports/ILS Sample Project #1

Services Affected:

o In Home Supports /Independent Living Skills o Home Care


o Uses participant feedback to improve services o Increases person-centeredness of services o Promotes positive behavior interventions


o Staff Training o Caregiver training o Revising organizational policies


Implement procedure/s regarding emergency preparedness of clients and family members in the event of an emergency in the home care setting.

Educate staff regarding emergency preparedness with in the community for the home care client's they serve.


Clients and families will be able to verbalize what measures they will take in a variety of situations requiring emergency preparedness in the home. Staff will be able to verbalize their role in emergency preparedness of the home care client.


Performance measure: Measurement of goals met utilizing % of home care clients educated. Baseline, if applicable: Goal: 90% of clients educated by December 2015

Performance measure: Measurement of goals met utilizing % of staff educated. Baseline, if applicable: Goal: 100% of staff trained by December 2015



Services Affected:



o Increase client's overall satisfaction


o Staff Training o Caregiver training o Surveys


To provide up front support and training to its homemakers and aides providing homemaker services. The supervisor will observe new employee homemaker services and provide direct hands on training to the staff. A follow up call will be places to the clients to ensure their satisfaction. If they are not satisfied, an additional visit will be made by the supervisor to aid the staff in additional training. In doing general supervision of the current homemaker, if it is found that they are not performing, additional hands on training will be provided. By providing upfront training and support, we believe this will increase the client's overall satisfaction.


Through our surveys to clients, we will be able to receive feedback on client satisfaction through a rating system as well as overall comments by clients.


Performance measure: Client Satisfaction Baseline, if applicable: Client rates the company a 9 or 10, 61% of the time

Goal: 70%

Performance measure: Clients would use our services in the future Baseline, if applicable: 91% said they would.

Goal: 93%



Services Affected:



o Improves people's ability to perform everyday activities



o Staff Training o Caregiver training


Improvement in ambulation by assessment of client’s ability to safely ambulate and scoring results. Tools to facilitate success: Physical therapy evaluation order received for clients who need assistance to ambulate / recent decline in ability to ambulate. Contact with physician after initial assessment done if there are no specific orders from the provider. Written home exercise program given to client, client verbalized and demonstrates understanding. Assessment and documentation of compliance per physical therapists and / or RN.


Exceed national benchmarks


Performance measure: Frequency patient was able to better walk and move around Baseline, if applicable: 64%

Goal: 64%



Services Affected:

o In Home Supports /Independent Living Skills o Home Care o Foster Care/Residential



o Improves Health


o Staff Training o Caregiver Training


Improve home care client's ability to safely & independently administer oral medications in home setting. Home care nursing staff will education clients & family/caregivers on medication administration including teaching proper use of medication, purpose of the medications, and side effects. Nurses will work with clients/caregivers on tools to assist in setting up medications and reordering medications; assistance in using alternative medication set up processes, i.e. having pharmacy set up prepackaged scripts for daily use; possible implementation of electronic med boxes.


There will be an improvement in the Med.Compare Score and ongoing assessment of medication compliance by visiting nursing staff.


Performance measure: Percentage of clients who get better at managing oral medications

Baseline, if applicable: 20% baseline

Goal: Meet or exceed State percentage



Services Affected:

o In Home Supports /Independent Living Skills o Foster Care/ Residential o Employment o Case Management


o Improves Health o Reduces the rate of accidents, falls, infections or other adverse health events


o New Staff o Changing business practices


Our agency will strive to reduce the number of critical incidents experienced by persons served. Safety committee reviews critical incidents quarterly to determine patterns, identify preventable incidents, and prepare recommendations for Program and Training Managers to develop best practices. Review of incidents includes these categories: abuse/neglect, AWOL, behavioral, financial exploitation, law enforcement, med errors, medical emergency, HIPAA, and vehicle accidents. Safety committee is comprised of members from several departments the Executive Director, Nursing, Program, Human Resources, Training, Maintenance, and Direct Support Professionals. Emphasis on prevention and staff training.


There will be a reduction in the number of critical incidents.


Performance measure: Quarterly and annual review of total number of critical incidents

Baseline, if applicable: # critical incidents 2013– 198; 2014– 245; 2015- present – 104

Goal: 15% reduction, 2015 - 208

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