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Additionally, a data integrity review/audit tool and process will be developed by December2013.Community BH Key Performance Indicator Data IntegrityThe majority of the data that comprises the CBH KPIs is received from providers via a monthlyprogrammatic report. Over the past 3 months, this report has transitioned from one received byprogram staff via e-mail to an online database where providers import the data directly via aportal. Currently the online database is live for Case Management, Intensive Case Managementand Community Support Teams. In SFY2014, Assertive Community Treatment and SupportedEmployment providers will begin using the portal. Once the data is received by DBHDD thedata must pass a logic safeguard validation and is reviewed by staff with programmatic oversightof each specific program before it is accepted. Feedback is given to providers when errors oromissions occur and they are required to re-complete and re-send their data once corrected.Technical Assistance is provided as needed.DD KPI Data IntegrityEvery two weeks, the analyst working with Delmarva runs a report to identify any incorrect ormissing data from the database. This process generates a report from data collected as part of thePCR and QEPR processes which is reviewed by managers, who correct any identified errors.In order to ensure proper handling of possible missing data or data errors, a Data CorrectionProtocol has been developed to track data errors and necessary correction. For approved reviewsor reports, all changes in the data are documented in the “Reopen Review Log”. This informationis reviewed periodically by the quality improvement regional manager for possible trends. Afterthe data in the report have been corrected, a new report is generated and distributed as necessary.SummaryThe sections above reference the multitude of quality related activities taking place acrossDBHDD. Key activities that have taken place between December 2012 and June 2013 includethe inaugural DBHDD QM system review; a revision of the DBHDD QM Plan; the revision,standardization and reconfiguration of the KPI dashboard format; the development of a datadefinition/data collection plan document; the development of a Performance Measure EvaluationTool (PMET); the development of a report which focuses on incident trends and patterns; theinitiation of a comprehensive system wide review of the DD QM system by an externalcontractor; the implementation of DBHDD QM training for staff utilizing web based modulesand significant communication with and training of providers on cognitive therapy (BeckInitiative) and suicide prevention. Additionally a review of KPIs currently being tracked in thehospital, community behavioral health and DD areas has begun.During the upcoming six months, quality management activities will focus on using the PMET toevaluate the current KPIs, developing new and/or modifying existing KPIs, obtaining consumerinput into new KPIs, rolling out two additional QM web based training modules for staff, furtherrefining the KPI dashboard format, and analyzing & utilizing data trends/patterns to makeprogram decisions or changes.33
Appendix A Community Behavioral Health Outcomes FrameworkAccessibility Safety Effectiveness Efficiency1. ACT referral toenrollment.2. GCAL – Averagespeed to answer.3. GCAL –Abandonment rate.4. Mobile crisisresponse time.OIMI – trendreports:1. Substantiatedabuse, neglect &exploitation.2. Death by suicide.3. Suicide attemptsthat result inmedicalhospitalization4. Unexpecteddeaths.5. Seclusion orrestraint useresulting in injuryrequiringtreatment.Community Behavioral HealthOutcomes FrameworkPotential KPIs:1. Recidivism2. FunctionalImprovement3. Housing4. EmploymentPotential KPIs:1. Cost perconsumer2. Length of time inservice3. Special needs4. ResourceconsumptionExperience ofCarePotential KPIs:1. Consumersatisfaction2. Family’sperspective ofconsumerimprovement3. Life improvement4. SocialconnectednessDraft34
Page 1 and 2: Georgia Department of BehavioralHea
Page 3 and 4: Data Reliability Process ..........
Page 5 and 6: Discussed the feasibility of settin
Page 7 and 8: The Statewide Quality Improvement C
Page 9 and 10: Hospital System Key Performance Ind
Page 11 and 12: 10. Average number of jail/prison d
Page 13 and 14: 2. Good but Paid Life: The ISP supp
Page 15 and 16: 96% of respondents from Georgia and
Page 17: The Office of Public Relations goal
Page 21 and 22: In an effort to further align the a
Page 23 and 24: communication, promoting provider c
Page 25 and 26: individuals with complex needs. DBH
Page 27 and 28: To help expand the use of QPR in Ge
Page 29 and 30: Program Quality Council, the Develo
Page 31 and 32: DD QM Reviews of ProvidersQuality E
Page 33: The average percent of positive out
Page 37 and 38: Goal: 3 Assess and improve the effe
Page 39 and 40: Appendix C Hospital System Quality
Page 41 and 42: communicate priorities to OIT, asap
Page 43 and 44: Develop a QM training plan forprovi
Page 45 and 46: QM system withparticipation from DD
Page 47 and 48: Finalize the audit toolIdentify the
Page 49: Appendix F Hospital System KPI Dash
Page 73: Appendix H Developmental Disabiliti
Page 82 and 83: Systems to expand and maintain CT-R

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