1. 02/19/16 Quality Management Program 1
Quality ManagementQuality Management
ProgramProgram
A&D Chart AuditsandA&D Chart Auditsand
Writing aWriting a ““Plan of ActionPlan of Action””

2. 02/19/16 Quality Management Program 2
Goals for this TrainingGoals for this Training
 Assist staff to better understand the chart auditAssist staff to better understand the chart audit
process, any resultantprocess, any resultant ““Plan of Action,Plan of Action,”” and theirand their
connections to client outcomes.connections to client outcomes.
 To better understand how client outcome isTo better understand how client outcome is
connected to staff attitudes towards personal andconnected to staff attitudes towards personal and
supervisory accountability.supervisory accountability.
 Understand the purpose, structure, and properUnderstand the purpose, structure, and proper
completion of acompletion of a ““Plan of ActionPlan of Action”” through discussionthrough discussion
and training scenarios.and training scenarios.

3. 02/19/16 Quality Management Program 3
CHART AUDITSCHART AUDITS
Chart Audits indicate a correlation betweenChart Audits indicate a correlation between
the presence (and any required frequencythe presence (and any required frequency
of that presence) of items required by DBH,of that presence) of items required by DBH,
ACA, and A&D Services within the fileACA, and A&D Services within the file
being audited.being audited.

4. 02/19/16 Quality Management Program 4
The Chart AuditThe Chart Audit
 Reflects the accredidating (ACA), licensing (DBH), and legalReflects the accredidating (ACA), licensing (DBH), and legal
requirements (CRS) of providing treatment within a TC or Out-requirements (CRS) of providing treatment within a TC or Out-
Patient treatment environment.Patient treatment environment.
 Provides a template for staffProvides a template for staff’’s treatment documentation.s treatment documentation.
 Is aIs a ““roadmaproadmap”” to use to meet, not only ACA, DBH, & CRSto use to meet, not only ACA, DBH, & CRS
requirements, but alsorequirements, but also ““treatmenttreatment”” (Evidence Based(Evidence Based
Treatment) requirements as indicated by programTreatment) requirements as indicated by program
descriptions.descriptions.
 Is a means of a clinician to work towards theIs a means of a clinician to work towards the ““best clientbest client
outcomeoutcome”” within their program.within their program.

5. 02/19/16 Quality Management Program 5
What are the Audit Tools?What are the Audit Tools?
 Chart Audit Tool *Chart Audit Tool *
 Documentation Tool *Documentation Tool *
 Chart Audit Report Tool *Chart Audit Report Tool *
 General Notes on Audit *General Notes on Audit *
*Use*Use ““Chart Audit Tool PacketChart Audit Tool Packet”” for handoutsfor handouts

6. 02/19/16 Quality Management Program 6
What are the Struggles?What are the Struggles?
 Other than the chart/documentation requirements, what otherOther than the chart/documentation requirements, what other
requirements exist for your job?requirements exist for your job? (List on the white board)(List on the white board)
 Considering your chart/documentation requirements and otherConsidering your chart/documentation requirements and other
job requirements, how do you prioritize?job requirements, how do you prioritize? (Not a rhetorical(Not a rhetorical
question: Really, what is your typical priority?)question: Really, what is your typical priority?)
 List 5 parts of your job you think are the most important and/orList 5 parts of your job you think are the most important and/or
you accomplish the most?you accomplish the most?
 Which our your personal strengths become weaknesses inWhich our your personal strengths become weaknesses in
completing your tasks?completing your tasks?

7. 02/19/16 Quality Management Program 7
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

8. 02/19/16 Quality Management Program 8
WE ARE NEVER FULLYWE ARE NEVER FULLY
MATURE. WE STRUGGLEMATURE. WE STRUGGLE
AT MATURITY, AS MUCHAT MATURITY, AS MUCH
AS WE STRUGGLE INAS WE STRUGGLE IN
TAKING RESPONSIBILITYTAKING RESPONSIBILITY
FOR OUR ACTIONS …FOR OUR ACTIONS …

9. 02/19/16 Quality Management Program 9
How do We Grow, BecauseHow do We Grow, Because
of the Challenges?of the Challenges?

10. 02/19/16 Quality Management Program 10
How do We Grow, BecauseHow do We Grow, Because
of the Challenges?of the Challenges?
CourageCourage

11. 02/19/16 Quality Management Program 11
How do We Grow, BecauseHow do We Grow, Because
of the Challenges?of the Challenges?
CooperationCooperation

12. 02/19/16 Quality Management Program 12
How do We Grow, BecauseHow do We Grow, Because
of the Challenges?of the Challenges?
BoundariesBoundaries

13. 02/19/16 Quality Management Program 13
How do We Grow, BecauseHow do We Grow, Because
of the Challenges?of the Challenges?
CuriosityCuriosity

14. 02/19/16 Quality Management Program 14
How do We Grow, BecauseHow do We Grow, Because
of the Challenges?of the Challenges?
TrustTrust

15. 02/19/16 Quality Management Program 15
How do We Grow, BecauseHow do We Grow, Because
of the Challenges?of the Challenges?
Self-CareSelf-Care

16. 02/19/16 Quality Management Program 16
““Plan of Action”Plan of Action”
 Detail:Detail:
 Concisely describe the problem area,Concisely describe the problem area,
problem being addressedproblem being addressed
 Concisely describe each step needed toConcisely describe each step needed to
correct this problemcorrect this problem
 Concisely specify staff(s) responsible forConcisely specify staff(s) responsible for
each step of the problem and determine aeach step of the problem and determine a
reasonable time to target the completion ofreasonable time to target the completion of
this step of the problemthis step of the problem

17. 02/19/16 Quality Management Program 17
““Status”Status”
 Have staff responsible forHave staff responsible for ““stepssteps”” provideprovide
an update on a weekly basisan update on a weekly basis
 Based on this report, do adjustmentsBased on this report, do adjustments
need to be made on that specific step?need to be made on that specific step?
 Add the adjustment to theAdd the adjustment to the ““Action Plan,Action Plan,”” i.e.,i.e.,
add a new staff to a step, determine a newadd a new staff to a step, determine a new
target date, etc?target date, etc?
 Continue weekly status checks to see howContinue weekly status checks to see how
well the change is workingwell the change is working

18. CDOC Clinical Services CQI
(Facility)______________________Plan of Action
CQI Manager Signature: ______________
(Check one)
DateDate
ActionAction
Item(s)Item(s)
Action PlanAction Plan
ResponsibleResponsible
PartyParty
TargetTarget
CompletionCompletion
DateDate
StatusStatus
DateDate
CompleteComplete
dd
DateDate
PlanPlan
BeginsBegins
What is theWhat is the
problem withproblem with
this item?this item?
What are the steps that canWhat are the steps that can
most simply and effectively fixmost simply and effectively fix
this problem?this problem?
What staff(s)What staff(s)
are responsibleare responsible
for the Actionfor the Action
Plan?Plan?
What is anWhat is an
adequateadequate
amount ofamount of
time totime to
determine ifdetermine if
the Actionthe Action
Plan works?Plan works?
To be completed atTo be completed at
eacheach ““targettarget
completion date.completion date.””
When it is apparentWhen it is apparent
the problem isthe problem is
fixed.fixed.
CQI Internal Audit Management Plan GoalsCQI Case ReviewCQI Committee Chart Audit

19. CDOC Clinical Services CQI
(Facility)______________________Plan of Action
CQI Manager Signature: ______________
(Check one)
DateDate
ActionAction
Item(s)Item(s)
Action PlanAction Plan
ResponsibleResponsible
PartyParty
TargetTarget
CompletionCompletion
DateDate
StatusStatus
DateDate
CompletedCompleted
7/13/117/13/11 Treatment PlanTreatment Plan
(TP): (14 days(TP): (14 days
from programfrom program
entry) indicatedentry) indicated
65%65%
1. TC staff will learn to use a1. TC staff will learn to use a
““Teaming Program Calendar.Teaming Program Calendar.””
2. Each clinician will keep2. Each clinician will keep
current theircurrent their ““TP TeamingTP Teaming
Calendar.Calendar.””
3. TC Supv. will meet with3. TC Supv. will meet with
clinicians weekly to reviewclinicians weekly to review
theirtheir ““TP Teaming Calendar.TP Teaming Calendar.””
1. TC Supv. will1. TC Supv. will
set up training.set up training.
2. Primary2. Primary
cliniciansclinicians
receiving areceiving a
newly admittednewly admitted
client.client.
3. TC Supv.3. TC Supv.
4. TC Supv.4. TC Supv.
1. 7/21/111. 7/21/11
2. Immed.2. Immed.
afterafter
trainingtraining
3. Immed.3. Immed.
afterafter
trainingtraining
CQI Internal Audit Management Plan GoalsCQI Case ReviewCQI Committee Chart Audit

20. 02/19/16 Quality Management Program 20
Using theUsing the “POA” Tool“POA” Tool
 Begin a newBegin a new ““POAPOA”” tool yearly. Otherwise, usetool yearly. Otherwise, use
the same tool throughout the year.the same tool throughout the year.
 Use one tool to maintain a consistent record.Use one tool to maintain a consistent record.
 This will enable the program to cross-reference oldThis will enable the program to cross-reference old
problems if they re-appear and maintain a fluid logproblems if they re-appear and maintain a fluid log
of problem-solving efforts.of problem-solving efforts.
 As you type within each column, it will drop down verticallyAs you type within each column, it will drop down vertically
and not expand horizontally.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