Quality Assurance

Scope

The Quality Assurance program as specified by this review plan relates to the process by which the treatment provided to all clients of Valeo is to be observed and documented. Further, it relates the process for any required changes to maintain or improve the quality of treatment. This includes treatment provided by all staff giving direct services in every service department of this Agency. This plan and all of its future addendums or modifications is available for review or perusal by any or all clients of Valeo, staff and administration of Valeo, Board of Directors of Valeo, any individual, group or organization of Valeo, any State of Kansas reviewing authority (e.g., SAPTR, SRS), and any United States Federal reviewing authority.

Objectives

  • Maintain and improve quality of care and treatment to all clients provided services by Valeo
  • Objectively and systematically monitor treatment provided by Valeo
  • Evaluate the appropriateness of treatment, paying particular attention to the strengths, needs, abilities, preferences & active involvement of clients in planning and decisions regarding services to be provided
  • Evaluate the quality of treatment and services
  • Discover possibilities to improve the quality of service
  • Discover any problems in the provisions of service
  • Discover methods to implement resolution of any problems or delinquencies in the delivery of treatment and services
  • Secure and maintain all data required to accomplish the above objectives

Organization of the Quality Assurance Program

  • Board(s) of Directors for Valeo Behavioral Health Care; Valeo Community Residence Program (CRP); Valeo Recovery Center (VRC) are the governing bodies. The ultimate responsibility for the assurance of maintaining and improving the quality of all programs, services and treatment is borne by the Board(s). The Board(s) also specifically designate the CEO as responsible for the operation of programs, services, treatment and policy making.

  • CEO for Valeo. The CEO is appointed by the Board. The daily operation of the Agency including the assurance of maintaining and improving the quality of all programs, services and treatment is the responsibility of the CEO. The CEO reports to the Board any and all pertinent information needed by or requested by the Board regarding issues of operation pertaining to the Quality Assurance Program.

  • Continuous Quality Enhancement Team (CQE Team). The CQE Team is made up of a representation of all areas within Valeo, with the Quality Assurance Manager as the Facilitator. This team is the "hub" for all agency data collection, tracking, trending and development of the Agency's Quality Management Report. This team oversees all other quality teams. The essential function is to collaborate with the Quality Assurance Manager in monitoring, documenting and ensuring compliance with licensing, regulations, CARF and improving processes at Valeo to assure efficiency, effectiveness and customer satisfaction. This Team also monitors all outcome trends within the agency by reviewing the Quality Management Report on a quarterly basis.

  • Quality Assurance Manager. This position serves to assist in implementing the decisions of the CQE Team, CEO, or Board and to gather pertinent information for consideration of the CQE Team, such as: quarterly program reports, summaries of client satisfaction surveys, staff satisfaction surveys, UM data, training, ethical standards for all staff, community involvement and data from regulatory entities (SRS, CARF, SAPTR).

  • Risk Management Team. This team is facilitated by the Risk Manager and is comprised of the Quality Assurance Manager, the Chief Operations Officer and the Operations Manager. The team meets on a weekly basis and reviews incident reporting, tracking and trending.

  • AIMS Team. The Aims Team is responsible for coordinating the data collection required by the State of Kansas. This data includes admission information for all clients of Valeo. Monthly reporting is done on all clients receiving targeted services as reflected in Client Status Reports or CSR's. This team is comprised of staff directly involved with collection of data and data entry, including IT staff, Consumer Account staff, Quality Assurance Manager and CSS staff.

  • UM Team. This team, facilitated by the Compliance Auditor is comprised of the Quality Assurance Manager, Medical Director, Qualified Mental Health Professional (QMHP) reviewers, Medical staff Doctors, Health Information Management (HIM) staff and program managers for Outpatient Psychotherapy Services and Outreach Case Management Services. The UM Team monitors service utilization (via the UR process, collaborates on documentation practices and procedures and compiles data to track trends in terms of areas of improvement in what and how we document in the client medical record.

  • Health & Safety Team. This team functions as an information gathering/troubleshooting unit. Information comes to this group from the individual building teams who monitor the environment within each building, conduct drills and complete drill reports noting any discrepancies that require addressing. The Health & Safety Team meets on a quarterly basis to discuss issues identified by the building teams and to review policies and procedures pertaining to building maintenance and/or health/safety issues.

  • Community Needs Assessment Team. This team is fluid with all staff and a variety of community members. The functions include discussions of community needs and feedback regarding crisis services; human resource demographics, senior services, translation needs, suggestion box reporting, Valeo's annual report, and treatment/services needs. The team meets on a monthly basis.

  • HIPAA Team. This team is responsible for coordinating the implementation of federal regulations pertaining to privacy and security of protected health information. The team must coordinate efforts for Agency compliance as outlined by the government. The HIPAA Team consists of 3 groups: Transaction & Code Set Group; Privacy Group and Security Group.

  • Continuing Education (CE) Team. This team is comprised of a variety of staff representing many of the programs throughout the Agency. Its primary focus is to assess and meet the training/education needs of Valeo staff, while continuing to offer community-wide educational courses recognized by the Kansas Board of Nursing, the Behavioral Sciences Regulatory Board and various other governing boards. The CE Team meets once a month to explore future training opportunities and evaluate recent and/or on-going mandatory trainings that are available to staff regularly and consistently.

Valeo BHC and Valeo CRP Policy Manuals, revised June, 2004 supercede all prior policies and are located on the intranet. All recommendations regarding policy changes are introduced to the CQE Team and will be presented to the CEO for approval. Upon approval, the appropriate staff will present the new policy at the regularly scheduled Management Team meeting.

Ethical Standards

Valeo BHC/VRC/CRP realized that individuals seek services at a very sensitive point in their life, often in crisis, and are extremely vulnerable. Staff has a responsibility to maintain the highest standards possible in the development and implementation of treatment/services plans, which are responsive to the needs of each individual client.

Corporate Compliance Program

It is the goal of Valeo's Compliance Program to demonstrate our strong commitment to honest and responsible conduct as a provider of behavioral health services and drug & alcohol treatment services. It is also the goal of this program to identify and prevent criminal and/or unethical business and professional conducts through the distribution of information regarding health care regulations and laws related to fraud and abuse and related issues.

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