January 2025
Ensuring Quality and Mitigating Risk
My name is Ryan Lemmon, and I am the Director of Quality & Performance Improvement at Mainstay Life Services. I started working at Mainstay in November 2023, and I have enjoyed working with my department to improve the lives of the people we support and the quality of services we provide. One of my favorite functions of my job is writing the Quality Management Plan (QMP) for the organization and conducting Quality Management activities. These activities are the focus of this blog.
All providers of services for people with intellectual disabilities and autism (ID/A) MUST have a QMP, or a document that outlines and governs quality management activities for a certain timeframe; our current plan is for 1 year. Essentially, a QMP should include (at a minimum) measurable quality goals (i.e., reduce medication errors by 25%), objectives (what actions will be done to achieve the goals), the person responsible for conducting the objectives, all start dates, and all end dates. This essentially creates a project management plan that helps the organization reach their QM goals. Currently, our QM goals are:
- Improving the Health Risk Screening Tool (HRST) fidelity
- Reducing falls and serious injuries relating to falls
- Improving Enterprise Incident Management (EIM) fidelity and reducing the occurrence of certain critical incidents
- Improving the sense of belonging the people we support feel
- Offering pertinent wellness initiatives
One common theme between all our QM goals is the ability of Mainstay to be proactive in addressing risk, as opposed to being reactive. This involves collecting reliable data, using data to forecast risk, and working with pertinent teams to avoid or mitigate risk.
The QM process takes time. Previous QMP’s have focused on establishing reliable data sources (reporting in the General Event Report (GER) & HRST, for example), understanding important variables, and creating baselines for our organization so progress can be measured. For example, to address falls and serious injuries, we established a standardized process of reporting falls in the GER (establishing a reliable data source), found that variables such as psychotropic medications, health care level, different HRST items, and age (among others) correlate with falls (understanding important variables), and were able to get a baseline for the number of falls (for both the organization and for specific people we support) that occurred over a period of time. After this was done, we created standard operating procedures for communicating fall data with program staff to discuss data and outcomes.
With this data and process documented, we are now transitioning to predicting the risk of undesirable outcomes (falls, medication errors, etc.). Essentially, this entails collecting valuable past data, performing various statistical analyses, and creating risk models that provide a numerical value for the risk of certain undesirable outcomes that could occur for certain people, locations, teams, etc. Again, using falls as an example, we have created a formula that generates a numerical score (on a scale of 1-100) using variables we know are correlated with falls (using a statistical validation process). The people who have the highest scores are the ones with the highest risk of falling / experiencing serious injuries from falling. We can then work with their teams to avoid or mitigate this risk by creating person-centered interventions targeted at the root causes of their risk.
Is this data infallible? No, of course not. As with any predictive measure, there is a margin of error that should be expected. However, it serves as an outstanding tool to discern who is at a higher-than-average risk and initiate important conversations. We have begun applying this process to other outcomes we want to avoid / mitigate, such as medication errors, behavioral health crisis events, serious illnesses (chronic or acute illnesses that require hospitalization), etc. Though it has taken time, the QMP has driven the organization forward in the different goal areas outlined in the plan.
I hope this blog demonstrates the work we are doing to ensure quality services and mitigate risk for the people we serve!