Plan of Action Training 7.11

05/01/23 Quality Management Program 1

Quality Management Quality Management ProgramProgram

A&D Chart Audits A&D Chart Audits and Writing a and Writing a ““Plan Plan

of Actionof Action””


Goals for this TrainingGoals for this Training

Assist staff to better understand the Assist staff to better understand the chart audit process, any resultant chart audit process, any resultant ““Plan Plan of Action,of Action,”” and their connections to and their connections to client outcomes.client outcomes.

To better understand how client outcome To better understand how client outcome is connected to staff attitudes towards is connected to staff attitudes towards personal and supervisory accountability.personal and supervisory accountability.

Understand the purpose, structure, and Understand the purpose, structure, and proper completion of a proper completion of a ““Plan of ActionPlan of Action”” through discussion and training through discussion and training scenarios.scenarios.


CHART AUDITS CHART AUDITS Chart Audits indicate a correlation Chart Audits indicate a correlation

betweenbetween

the presence (and any required frequency the presence (and any required frequency

of that presence) of items required by of that presence) of items required by DBH,DBH,

ACA, and A&D Services within the file ACA, and A&D Services within the file

being audited. being audited.


The Chart AuditThe Chart Audit Reflects the accredidating (ACA), licensing Reflects the accredidating (ACA), licensing

(DBH), and legal requirements (CRS) of (DBH), and legal requirements (CRS) of providing treatment within a TC or Out-Patient providing treatment within a TC or Out-Patient treatment environment.treatment environment.

Provides a template for staffProvides a template for staff’’s treatment s treatment documentation.documentation.

Is a Is a ““roadmaproadmap”” to use to meet, not only ACA, to use to meet, not only ACA, DBH, & CRS requirements, but also DBH, & CRS requirements, but also ““treatmenttreatment”” (Evidence Based Treatment) requirements as (Evidence Based Treatment) requirements as indicated by program descriptions. indicated by program descriptions.

Is a means of a clinician to work towards the Is a means of a clinician to work towards the ““best client outcomebest client outcome”” within their program. within their program.


What are the Audit Tools?What are the Audit Tools?

Chart Audit Tool *Chart Audit Tool * Documentation Tool *Documentation Tool * Chart Audit Report Chart Audit Report Tool *Tool *

General Notes on General Notes on Audit *Audit *

*Use *Use ““Chart Audit Tool PacketChart Audit Tool Packet”” for for handoutshandouts


What are the Struggles?What are the Struggles? Other than the chart/documentation Other than the chart/documentation

requirements, what other requirements exist requirements, what other requirements exist for your job? for your job? (List on the white board)(List on the white board)

Considering your chart/documentation Considering your chart/documentation requirements and other job requirements, how requirements and other job requirements, how do you prioritize? do you prioritize? (Not a rhetorical question: (Not a rhetorical question: Really, what is your typical priority?)Really, what is your typical priority?)

List 5 parts of your job you think are the List 5 parts of your job you think are the most important and/or you accomplish the most?most important and/or you accomplish the most?

Which our your personal strengths become Which our your personal strengths become weaknesses in completing your tasks?weaknesses in completing your tasks?


How Do We Work?How Do We Work?One Daily Task

5pm

4pm

3pm

2pm

1pm

noon

11am

10am

9am

8am

Level 1 Level 2 Level 3 Level 4

Level 4: I work at it because it is the right thing to do

Level 3: I work at it because it helps someone

Level 2: I work at it because I can get something in return

Level 1: I work at it so I don’t get into trouble


WE ARE NEVER FULLY WE ARE NEVER FULLY MATURE. WE STRUGGLE MATURE. WE STRUGGLE AT MATURITY, AS MUCH AT MATURITY, AS MUCH AS WE STRUGGLE IN AS WE STRUGGLE IN TAKING RESPONSIBILITY TAKING RESPONSIBILITY FOR OUR ACTIONS …FOR OUR ACTIONS …


How do We Grow, Because How do We Grow, Because of the Challenges?of the Challenges?



CourageCourage



CooperationCooperation



BoundariesBoundaries



CuriosityCuriosity



TrustTrust



Self-CareSelf-Care


““Plan of ActionPlan of Action”” Detail:Detail:

Concisely describe the problem Concisely describe the problem area, problem being addressedarea, problem being addressed

Concisely describe each step needed Concisely describe each step needed to correct this problemto correct this problem

Concisely specify staff(s) Concisely specify staff(s) responsible for each step of the responsible for each step of the problem and determine a reasonable problem and determine a reasonable time to target the completion of time to target the completion of this step of the problemthis step of the problem


““StatusStatus”” Have staff responsible for Have staff responsible for ““stepssteps”” provide an update on a weekly basisprovide an update on a weekly basis

Based on this report, do adjustments Based on this report, do adjustments need to be made on that specific need to be made on that specific step?step? Add the adjustment to the Add the adjustment to the ““Action PlaAction Plan,n,”” i.e., add a new staff to a step, i.e., add a new staff to a step, determine a new target date, etc?determine a new target date, etc?

Continue weekly status checks to see Continue weekly status checks to see how well the change is workinghow well the change is working

CDOC Clinical Services CQI(Facility)______________________Plan of Action CQI Manager Signature: ______________

(Check one)

DateDateAction Action

Item(sItem(s))

Action PlanAction Plan Responsible Responsible PartyParty

Target Target Completion Completion

DateDateStatusStatus Date Date

CompletedCompleted

Date Date Plan Plan BeginsBegins

What is the What is the problem with problem with this item?this item?

What are the steps that can What are the steps that can most simply and effectively fix most simply and effectively fix this problem?this problem?

What staff(s) What staff(s) are responsible are responsible for the Action for the Action Plan?Plan?

What is an What is an adequate adequate amount of amount of time to time to determine if determine if the Action the Action Plan works?Plan works?

To be completed at To be completed at each each ““target target completion date.completion date.””

When it is apparent When it is apparent the problem is the problem is fixed.fixed.

CQI Internal Audit Management Plan GoalsCQI Case ReviewCQI Committee Chart Audit

CDOC Clinical Services CQI(Facility)______________________Plan of Action CQI Manager Signature: ______________

(Check one)

DateDateAction Action Item(s)Item(s) Action PlanAction Plan Responsible Responsible

PartyPartyTarget Target

Completion Completion DateDate

StatusStatus Date Date CompletedCompleted

7/13/117/13/11 Treatment Plan Treatment Plan (TP): (14 days (TP): (14 days from program from program entry) indicated entry) indicated 65% 65%

1. TC staff will learn to use a 1. TC staff will learn to use a ““Teaming Program Calendar.Teaming Program Calendar.”” 2. Each clinician will keep 2. Each clinician will keep current their current their ““TP Teaming TP Teaming Calendar.Calendar.””3. TC Supv. will meet with 3. TC Supv. will meet with clinicians weekly to review clinicians weekly to review their their ““TP Teaming Calendar.TP Teaming Calendar.””

1. TC Supv. will 1. TC Supv. will set up training.set up training.2. Primary 2. Primary clinicians clinicians receiving a receiving a newly admitted newly admitted client.client.3. TC Supv.3. TC Supv.4. TC Supv.4. TC Supv.

1. 7/21/111. 7/21/112. Immed. 2. Immed. after after trainingtraining3. Immed. 3. Immed. after after trainingtraining

CQI Internal Audit Management Plan GoalsCQI Case ReviewCQI Committee Chart Audit


Using the Using the ““POAPOA”” Tool Tool Begin a new Begin a new ““POAPOA”” tool yearly. tool yearly. Otherwise, use the same tool Otherwise, use the same tool throughout the year.throughout the year. Use one tool to maintain a consistent Use one tool to maintain a consistent record.record.

This will enable the program to cross-This will enable the program to cross-reference old problems if they re-appear reference old problems if they re-appear and maintain a fluid log of problem-and maintain a fluid log of problem-solving efforts.solving efforts.

As you type within each column, it will drop down As you type within each column, it will drop down vertically and not expand horizontally.vertically and not expand horizontally.

To add a row to the table: Table>Insert>Row belowTo add a row to the table: Table>Insert>Row below

Documents

Plan of Action Training 7.11