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| Autumn 2003 |
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In the spring of 2002 a support group from the Human Services Research Institute, funded by the Centers for Medicare and Medicaid, journeyed to Montana to provide technical support on the design of a Quality Management System for the Developmental Disabilities Program. The process was spawned over a three-day period. Out of this process, the Quality Management Task Force developed two themes. The first was an over-all picture of what a Quality Management System would look like in Montana including the goals and objectives, and who would advise the State office on Quality Assurance matters. The second theme to emerge was Incident Investigations. Out of the second theme, three distinct topics emerged; the need for a central database to track trends, the need for an incident reporting policy and the need for an investigation process separate from Adult Protective Services.
The desired outcome was to design a Quality Management System that would assure health and safety for all individuals in Developmental Disabilities Services. Prior to the technical support offered by the Centers for Medicare and Medicaid the State of Montana had no Incident Reporting data-base with State-wide information on types of injury, location of injury, cause of injury, cause of incident, type of incident or location of incident. If the State Central Office needed this information they would have to call the Regional Office and request the paper copies be pulled from the file and the information sent for review. With this process there wasn't any way to track incident trends statewide and therefore no way to analyze and improve the health and safety of individuals in service.
The Incident Reporting process varied from region to region and from provider to provider. The forms used were as varied as the people who used them. Most consisted of long narratives that documented the incident, where it happened, what led up to the incident, what happened and what was the outcome. However, this lengthy narrative did not lend itself to quantifying data and therefore analyzing and tracking trends was not possible. It was determined that a new form, one that could be standardized and used throughout the State by community providers, both large and small, as well as the residential facility at Boulder was needed if the State was to develop a Quality Management System to move services into the 21st Century.
The Human Resources Technical Assistance Staff offered a template for the Reporting Form. This was adapted and put out to providers and State Staff to provide input and direction. Many hands helped to shape the content. In November of 2002 at the State Developmental Disabilities Conference, State Staff presented a panel discussion to inform conference attendees of the goal and objectives of the Quality Management Task Force. The draft Incident Reporting Form was distributed to those in attendance. Input and feedback was accepted until April of 2003 when the Incident Reporting Database contract was awarded to Integrated Technology, a Helena based database design company. In order to build the database the form needed to have a final content and format.
As of September 30th the database is built and is undergoing testing on the Department of Public Health and Human Services data servers. Once the testing is complete a group of providers, (five in all will be trained, including the Montana Developmental Center at Boulder) will begin piloting the form and the database. Once the pilot group has worked with the database and the system is providing the reports expected, i.e. reports statewide on types of incidents: for example, choking, medication error: cause of incident, accident, emotional distress, location of incident -- both general: apartment, group home, and specific: living room, hallway, type of injury: scrape, blocked airway, cause of injury: seizure, self-injury, location of injury: throat, hand, all Developmental Disabilities Providers will be trained. Training will be provided at computer labs in all of the five regions of the State. An Incident Reporting Database Provider Training Manual will also be available for all provider trainees.National consultants confirm the fact that the ability to track incident trends state-wide helps State Administrators and providers to effectively provide greater health and safety assurances for individuals in Developmental Disabilities Services. Through data-analysis a State Provider and a State DD Director will be able to have a more comprehensive picture of health and safety issues as they pertain to individuals in Developmental Disabilities Services by provider, by region and the State in its entirety and be able to create policies and procedures for Direct Care Staff that enable them to provide healthier and safer environments for individuals in their care with Developmental Disabilities.
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Quality Matters, Autumn 2003: Contents | Article 1 | Article 2 | Article 3 | Print Version