Implementation Plan for the Solution - Personal Statement Example

Section D: Implementation Plan for the Solution Purpose of the Implementation The systemic changes that are proposed through the approval and implementation of this project aims to improve quality customer satisfaction to a minimum of 90% compliance rating with the CARF. Six members of the upper management personnel comprise the new QAPI committee. This committee will meet weekly to educate, analyze, validate, and build communication across the organization with all stakeholders. Solution Implementation Steps A written plan to outline QAPI activities for the improvement of customer service shall be prepared by the QAPI committee. This team is to be led by the Compliance Officer. Blais (2002) argues that “changes in power structure are particularly difficult to manage” (p. 24). The Corporate Compliance Officer will encourage a collaborative effort from all management personnel to ensure the objective of this project proposal is met. A weekly formal written report shall be done to document the weekly initiatives taken to address concerns during the weekly meetings. Managers report to the Compliance Officer the progress of their staff training. Before proceeding with the implementation of the proposal, it should gain the approval of the organizational Board of Directors. Such proposal shall be reviewed every 90 days. The Board will meet for two sessions in the duration of the project. The preliminary proposed project is designed to last for six months after which, a request for permanent approval will be sought from the Board of Directors. At the start of the project, information on the organisation’s customer service will be collected from many sources on a weekly basis. Evidenced-based practice together with the basic score card will be utilized ( see appendix A) in the promotion of quality services across the organization, within many departments promoting quality customer services.. The sources of information will include: referral process; self-administered questionnaires that will be distributed to members, family, and the guardians or other parties responsible for the care of the member receiving services; medical records; management systems; and internal processes used by management. This information will be collected and analyzed weekly by the different responsible managers. The QAPI committee as a whole will review and analyze all data monthly. All data will be assessed using quality indicators identified in the BSC and CARF Quality Indicators. These quality indicators promote a collaborative effort in achieving the outcomes through communication and involvement of all stake holders, including customer satisfaction, and organization responsiveness, (Tsasis & Owens, 2009). Communication, respect and good treatment of staff shall be maintained to reduce or altogether diffuse any conflict that may exist among the managers and members as each person will be personally responsible for working and functioning as a team (Benson and Decanis, 1995, p 211) . To ensure the validity of data, the Compliance Officer or other authorized representative of the QAPI committee will conduct training on the collection of accurate data with the members of the QAPI team. Before the project begins, a project initiative letter of the QAPI committee (see Appendix B) will be sent to all members and their families explaining the project initiatives, in particular, the evaluation of their services. The letter explains the purpose of the questionnaire and its potential impact on improving community services and quality outcomes. It will inform recipients how to access the company’s website to send this information electronically. This letter is sent to all active patients and within one month after of discharge of services in the promotion of QAPI efforts in achieving its goal of 90-100% efficiency in customer satisfaction through this proposal. The time that has elapsed is assumed to have settled objectivity of feedback from the patients. Each Case manager per area will manage the collection and organization of the data within his or her normally allotted daily work load. He or she then submits this to his or her delegate on the QAPI committee. Once the initial patient referral (see appendix C) is generated through all departments by the Administrative Office Manager, the Case manager will track the referral and present it to the Nursing Director to trend, etc in correlation to the QAPI efforts. The Administrative staff will make phone calls to members to ask them about their services using a formal call format. Members will be called on a bi-weekly basis to evaluate services appropriately per the member, family, or guardian. This information will lend validity to the project’s evaluation of the actual quality of services. Any problem patterns identified on the evaluation forms shall be entered on a problem sheet and forwarded to the Executive Director and the QAPI committee on a timely basis. Organized data collected is forwarded to the Nursing Director every 5th of each month. Trainings are conducted by the Case manager every second Wednesday of the month to encourage team work and keep each member of the team informed of the initiatives within the QAPI proposal. The Training report will be forwarded to the Nursing Director, by the following Wednesday after each monthly meeting (See Appendix D). The Nursing Director will also be responsible for confirming the validity of the data in areas of member satisfaction as collected using the Monthly Quality Scale Member Survey (see Appendix E), noting any current issues or problems of the members and families being served. Through a collaborative effort new ways of communication across departments will improve customer satisfaction quality, and control costs, Blais (2002). Members and Staff surveys will be disseminated quarterly ( see appendix F & G) to likewise gain feedback on company customer quality initiatives from members and staff. This encourages the staff to be a part of the process knowing their opinions matter. According to Blais (2002), listening, giving and receiving feedback often enhances professional feedback and effective communication “this often helps the individual to acquire self-awareness, while assisting the collaborative team to develop an understanding and effective working relationship” (p. 29). The State of Georgia and affiliated agencies and institutions are included in the Community QAPI Program. Monthly the department Manager will include all outside monitoring reports to the QAPI committee through normal reporting procedures of the outside monitoring agency review. The data obtained shall be organized in a report consisting of comparative tables, graphs, and charts every three months. The Compliance Officer, along with the entire QAPI committee, will review each in order to monitor quality and value. These reports will also detail all recommendations from each evaluator for submission to the Board of Directors. This board will have the ultimate power to approve or deny any recommendations of individual evaluators or from among themselves. They decide if the recommendations, per quality indicators, are valid and send their final recommendations or approvals back to the Compliance Officer to disseminate policy or procedure changes to the Management. According to Huber (2006), health quality standards (see Appendix B) have been developed for use in measuring the implementation of a particular strategy in a work setting project. For the six core areas of interest (safety, effectiveness, patient-centeredness, timeliness, efficiency and equitability), quality aspects should be assessed both quantitatively and qualitatively across these areas. A simpler approach with high impact and efficiency coupled with low costs is targeted for this proposal to gain approval with the Board of Directors. Resources Needed for Solution Implementation Resources needed for the implementation of the proposal include staff who provide direct care to members, Case Managers, Nursing Director, Executive Director, Compliance Officer, and Board of Directors. Effective communication among each stakeholder is essential. Provision of quality services to patients is part of the job description for salaried employees, so additional expense in terms of labor costs are minimized for this project initiative. All of the QAPI processes, monitoring, analyzing, data collection, et.al, will be conducted during the normal shift of employees. Further, external evaluations conducted by State Reviewers will pose no cost to the company, as this is a normal part of their QAPI program. In fact, State surveyors welcome the opportunity to evaluate member service outcomes. The Compliance Officer who will shoulder much of the responsibility for this project will be compensated a contract fee of $1500 per month. Each Member of the Board is paid $300 per member per session with the Board consisting of five active members (see appendix H) . For two sessions during the proposed period, the cost will be $3,000. The QAPI committee members are all working staff who will be allotted six hours out of their normal workday to meet once per month, and three hours once a month for educational meetings, classes for project-related QAPI activities related to determining member satisfaction of services outcomes. The direct care staff will require additional training to increase the accuracy of their information being charted for improved member services. There are 32 direct care professionals providing this service through Walton Community Services, Inc. The project will require four hours of in-service training on for them on the documentation of member services. The cost of four hours of training for 32 staff with an average hourly rate of $14.00 is equivalent to $1,792. Indirect costs (see Appendix H) for equipment or services such as computers; training manuals/materials; and printing for completed web-based surveys, evaluations and exit surveys should be minimal. Monitoring Solution Implementation During the implementation of the project, regular spot checks will be conducted by department heads to determine if the project directives are being followed. Weekly meetings are outlined and scheduled, along with the monthly meetings. The QAPI committee members who will compile data will be responsible for filing periodic reports by the specified deadlines, promoting a built-in monitoring method. The task of monitoring project implementation will be handled by the Compliance Officer and assisted by the heads of departments (e.g., Executive Director, Nursing Director, and Case managers). Weekly customer quality of services monitoring will be conducted telephonically by the Administrative Services department and forward to their managers according to QAPI program objectives in improving patient services. Paperwork check sheets on the monitoring of internal processes’ procedural and regulatory compliance are turned in monthly. These reports are submitted to the Nursing Director and are processed into the QAPI proposal. Using Planned Change Theory Lewin’s Theory of Change on three stages will be utilized by QAPI members throughout this proposal. To create a motivation to change, Lewin’s concept of unfreezing will be implemented. Secondly, the effect of this unfreezing is to promote an understanding for change to move forward. Thirdly, refreezing the learning and involvement of all staff within the organisation is to be maintained in order to uphold the met goals of QAPI initiatives of improving patient services. All members of the team will be educated on the Certification of Accreditation of Rehabilitative Facilities s (CARF) requirements of compliance in obtaining and sustaining quality customer services. Solution Feasibility The feasibility of the solution proposed lies with evidence-based practice, utilization of the basic scorecard and promotion of collaborative efforts of everyone at the organisation. It is very realistic, logical, and practical to be applied in within the work setting. Objectives are expected to be achieved through the implementation of new concepts, meanings and standards (Schein, 2002) if collaboration and effective communication and management of patient and staff services are kept in place. According to Resnik, & Dobrykowski (2005), “providers that actively utilize, analyze, and interpret outcomes information benefit in many ways. Ultimately, patients will benefit when effective and efficient types of services are identified and offered” ( p.7). Evaluation Plan for the Solution The selective quality measurements (see appendix E) will be utilized in evaluating and establishing the outcome measures in the quality of customer services. The Compliance Officer will ensure that all managers are educated on the quality level outcomes utilized this measurement tool. The quality indicators identified within this proposal are easily recognized and developed to be applied to particular programs using available resources without straining the company’s resources. Validity and Reliability Validity determines the appropriateness and the usefulness of the content being examined (Burns & Grove, 2009). Continued improvement and monitoring of customer service outcomes is mandated by CARF and has been incorporated into the policy and procedures manual of the organization. The continued monitoring processes of the organisation’s patient satisfaction ratings will validate the appropriateness and effectiveness of the proposed solution for this proposal. Evaluation of the Plan Targeting a minimum of 90% in customer satisfaction of service standards is good measure in the healthcare industry. It gauges overall success of the project. According to White (2009), seven themes related to quality management activities emerged from a study conducted on quality management data involving staff and plan evaluation namely: (a) coaching; (b) educating and training; (c) facilitating and coordinating; (d) communicating and reporting; (e) managing data; (f) leading quality efforts; and (g) supporting quality efforts. This research project will follow the outline used in the White (2009) study to evaluate the overall success of this project to supplement the proposed measurement for this proposal to achieve at least a 90% customer satisfaction rating. Using the project monitoring tools ( see appendix I and J ) reviewed by QAPI members, gaps will be identified and recommendations will be made to correct, terminate, or continue with the program. This is determined by the Compliance Officer who holds a master degree in organizational strategic management, as she analyzes the data prior to the completion of the final report to the board. Her qualifications of having over ten years of organizational team building experience and being a CARF surveyor in the past, brings with her regulatory knowledge and strategic planning ideas to lead a team to success in achieving customer satisfaction. Feasibility of the Plan The plan for implementing the project is quite feasible. The data used for evaluation is the very data collected as part of the project initiatives. With an elaborate plan in place to compile data weekly, monthly, and quarterly, a separate evaluation will not be necessary. The results and recommendations submitted to the Board are complemented by the targeted project data so the Board can make a well-informed decision about the continuation of the project. Utilizing a plan change concept and collaborative efforts of everyone involved in the QAPI initiatives, it is with confidence to expect success in this project. References Hashmi, K. (2003). “Introduction and Implementation of Total Quality Management (TQM)”. Retrieved on September 5, 2009, from http://www.isixsigma.com/library/content/c031008a.asp Hinshaw, S. (2001). "A Continuing Challenge: The Shortage of Educationally Prepared Nursing Faculty". Online Journal of Issues in Nursing. Vol. 6, No. 1 PNA Business Wire (2009) “United States Senator Richard J. Durbin and Health Care and Community Leaders Meet to Develop Plan of Action for Geriatric Care”. Retrieved on September 04, 2009, from General OneFile via Gale: http://find.galegroup.com/itx/start.do?prodId=ITOF Libeowitz, S. (1994 ) “Policy Analysis: Why Health Care Cost So Much”. Cato Policy Analysis No. 211.Cato Institute Mion, L. (2003). "Care Provision for Older Adults: Who Will Provide?" Online Journal of Issues in Nursing. Vol. 8 No. 2, Manuscript 3. Rabbani F, Jafri SM, Abbas F. Pappas G. Brommels M. Tomson G. (2007) . Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2007 Sep-Oct;29(5):21-34. Walton Community Services, Inc. (2009). Quarterly Staff Evaluations. Found at http://www.waltoncommunityservices.com/ Appendix A Walton Community Services Inc. 3401 Florence Rd. Ste. 100 Powder Springs, Ga. 30127 October 12, 2009 Ms. ____________________________ ________________________________ ________________________________ Dear __________________________: Thank you for allowing Walton Community Services Inc to be your community provider of services. We continue to find ways in building your confidence in us and satisfaction in our services through a collaborative team effort. To further improve our services, we have created a professional team to monitor the maintenance of quality. Please be informed that some of these team members will be calling you and checking on the services you received through company on a bi- weekly basis. Walton Community Services, Inc. aims to achieve at least a 90% overall rating in meeting your expectations in our services. We are requesting that you go to www.waltoncommunityservices.com and fill out the survey at least every other month. You can return it in the mail, fax, or email. This will assist Walton in meeting your expectations. If you leave our services for any reason, we also ask that you complete the exit survey so that we can learn from any mistakes we might have done so we can do better in the future. If you have questions, please contact us. The Executive Director,___________, can be reached at _______________. Just provide your name and the nature of your call and you will be directed to the person concerned. Please also inform us of any changes in your needs as we shall be happy to help you evaluate those needs and offer you the appropriate services which will help you achieve your new goals. Again, thank you for choosing Walton Community Services. Sincerely, _________________________ Appendix B Objectives Measures Applied To Frequency of Measure Data Source Obtained by Goal Effectiveness Maximize the number of responses to patient surveys in conjunction with increasing the overall satisfaction level in order to maintain 90% or higher. The percentage of patients who report that WCS meets or exceeds their expectations All patients Bi -monthly Patient surveys and patient exit survey Executive Director 90%-100% Efficiency Maximizing the accessibility of the patient services Patient compliance of services, in meeting satisfaction. Referral process efficiency and professionalism of services. All patients Bi-monthly Referral process, and timeliness of services, efficiency Executive Director 90%-100% Satisfaction Maximize satisfaction of Patients Overall percentage of patients who express satisfaction. All patients. Bi -monthly Patient surveys and patient exit surveys Executive Director 90%-100% Efficiency Use of automated systems to increase overall proficiency to patients served. Overall data released to stakeholders with minimal discrepancies. All Stakeholders Annually Monthly data reports submitted via Microsoft Office, care manager pro, CIS Portal, GHP Portal, and QuickBooks Executive Director 90%-100% Satisfaction Patients and all other stakeholders have maximized satisfaction with reportable data. Number of Patients who report being satisfied with their services. All LC II residents Quarterly Quarterly survey results Executive Director 90%-100% Appendix C Walton Community Services Referral form Patient Name: _______________________ D.O.B _____________________________ Current Address:________________________________________________________________ M.C.D.____________________________ S.S# _______________________________________ City, ____________________ State _______________ Zip Code ________________________ Services Requested (circle all applicable : Mon Tues Weds Thurs Friday Saturday Sunday Hours per day/week (total): ______________________________________________________ Cost Share/Payment Source: ______________________________________________________ Cost of Services Quoted: _________________________________________________________ Service Area Requested: _________________________________________________________ Case Manager: _________________________________________________________________ Client/Family Contact: ___________________________________________________________ Name, Telephone: ______________________________________________________________ Address Street, City,State,Zip_____________________________________________________ Notes/Special Needs/Requests/Risk Assessment; _____________________________________ Referred to another Service: United Way, Salvation Army, etc. __________________________ Staff Accepting the Call: _____________________ Time: _______ Date: _____________________ Appendix D Work Activity Schedule Outline of QAPI Activities In promoting Customer Satisfaction Activities Time Frame and Implementation Responsible Participants QAPI Committee Member to Retrieve, Analyze, Synthesize Data, Report, etc. 1.0 Organization and collection of data Week 1-24 Administrative Personnel Case Managers Nursing Director 2.0 Monthly Educational Meetings Monthly – Weds. Of the Month. Dept. Managers – Case Managers Nursing director 3.0 Proposal Component a. Procurement of Materials Copying and Duplicating Services Week 1-3 QAPI Committee, Exec. Dir., Compliance Officer Administrative Services Executive Director 4.0 Study Instruments (Survey) Weeks 3-6 Administrative Services Case Managers Selected respondents Nursing Director Executive Director 5.0 Evaluation Weeks 6-9 QAPI committee, Executive Director Nursing Director Compliance Officer Nursing Director Executive Director Compliance Officer 6.0 Submission of Report to Board of Directors Week 10-12 Compliance Officer Executive Director Compliance Officer Appendix E Quality levels Taken from: http://www.psychservices.psychiatryonline.org/content/vol50/issue12/images/large/BL10T1.jpeg Appendix F Walton Community Services – Monthly QUALITY Scale Member Survey For each item identified below, circle the number to the right that best fits your judgment of its quality. Use the scale above to select the quality number. Description/Identification of Survey Item Scale Poor Good Excellent 1. Staff Arrival to Home on Time 1 2 3 4 5 2. Staff Performance of Duties 1 2 3 4 5 3. Reception from Office when called 1 2 3 4 5 4. Caring attitude of staff person providing service 1 2 3 4 5 5. Professionalism of Office personnel 1 2 3 4 5 6. Knowledge of staff about your care 1 2 3 4 5 7. Respecting of your rights 1 2 3 4 5 8. Notice or call from office when staff is late 1 2 3 4 5 9. Coordination and ability to talk with Case Manager about a problem or issue 1 2 3 4 5 10. Respecting of your Rights by all staff in home 1 2 3 4 5 11. Weekly service check via telephone from Office Personnel 1 2 3 4 5 12. Quality of your services Overall 1 2 3 4 5 Please email form back, hit the attached upload link. Thank you WALTON COMMUNITY SERVICES Appendix G STAFF SURVEY (You may fill in this information if you choose) Name: Quality scale: 1 - 2 Poor 3-4 Good 5- Excellent For each item identified below, circle the number To the right that best fits your judgment of its quality. Use the scale above to select the quality number. 1. The atmosphere of Walton community service is warm and refreshing 1 2 3 4 5 2. You are able to discuss patient problems or issues, rapidly when need. 1 2 3 4 5 3. Staff from the office treats you with dignity and respect when talking with you 1 2 3 4 5 4. You receive timely notification of in-services and required trainings. 1 2 3 4 5 5. The members show you respect when you work in their homes 1 2 3 4 5 6. You are able to talk to your Supervisor or Boss as you need 1 2 3 4 5 7. You would recommend services from this company to someone else 1 2 3 4 5 8. The Administrative staff treated you in a professional manner when you are called or when you called the office 1 2 3 4 5 9. The Case manager, Manager, Nursing Director responds to your needs 1 2 3 4 5 10. When you call the on-c all service (after hours) your call is returned within 30mins. 1 2 3 4 5 11. This company allows flexibility in your scheduling 1 2 3 4 5 12. You feel a part of the organization services overall through the company 1 2 3 4 5 13. You are feel involved in decision making processes. 1 2 3 4 5 14. You attend in-services and educational classes as scheduled 1 2 3 4 5 15. What would you recommend as a company improvement? ____________________________________________________________________________________________________________________________________________________________ Please email to office upon completion to: compliance@waltoncommunityservices.com Appendix H 3.2 Financials: Budgetary requirements for the entire project. Project Component Time Frame Projected Cost ($) 1.0 Proposal Component a. Preparation of information letter to all members9( 6hours x $ 14.00/hr) b. Copying/Formulation of letter c. Mailing of letter ( 70 stamps .43 plus $3.00) Week 1-3 $84.00 $18.00 $33.10 2.0 Study Instruments (Education, Meetings,etc) a. Education of staff ( 32 staff x 14.00/hr x 4hours of training Weeks 3-6 $1,792.00 3.0 Evaluation a. Board of Directors ( 300.00 x 5 Board Members x 2 meetings) B. Compliance Officer ( 1500.00 x 6mths) 4.0 Re-Evaluation of Program Effectiveness and Continuance 6months Weekly ( meeting 2–3 hours week) 6–7 months $3,000.00 $9,000.00 No cost associated with re-evaluation of outcomes 4.1 Miscellaneous a. (1 survey assistant) b. Professional Fee c. Others $1,000.00 Total $14,927.10 Appendix I Figure 4:Member Telephonic Services Checks ck placement on page MEMBER NAME Last, First Telephone No. PersonProviding the Information STAFF member that provides your services BEST TIME TO CALL IS STAFF ON TIME? STAFF STAY FOR FULL SHIFF/Service MEMBER COMMENT (If Any)                                                                                                                                                         Read More