Step 4: Develop an Action Plan to Improve The Service System & Monitor Progress
Key Activities
- Identify the strengths and challenges of the system of care for CSHCN based on the existing data
- Target priority areas for implementation
- Identify the steps to improve measurement capabilities
With Step 4, we see our efforts turn to action by disseminating information gathered to improve the system of health care. This is a shift from planning improvements to implementation of quality improvements. This step involves developing an Action Plan for (1) identifying implementation strategies for improving the system of care, and (2) enhancing measurement and monitoring capacity.
At this point, it is critical that the State Leadership Team include the top administrators of the division to ensure the plan has the needed support by top decision-makers. Equally important is ensuring representation from community-level providers who will play a key role in implementation, and family representatives to ensure the plan truly is addressing the needs of families.
Activity 1: Identify the Strengths and Challenges of the System of Care for CSHCN Based on the Existing Data
The Action Plan is based on the data results gathered to date. Specifically, the leadership team interprets the data results for the purpose of action planning by answering the questions:
- What appears to be working well for CSHCN and families in terms of the 6 core measures?
- What appear to be the challenges or greatest needs of CSHCN and their families?
- Based on these needs, what improvements are needed to the system of care?
Sample Agenda
A sample agenda is available to download as a Word Document (10K) and is provided below for review.
Sample agendaStep 4: Develop an Action PlanDate: Time: Location: Attendees: Meeting Purpose:
Agenda:
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Activity 2: Target priority areas for implementation
To develop the Action Plan, the leadership team must apply a process for identifying potential implementation strategies and reach decisions regarding those strategies that are the most appropriate. A typical process includes the following:
- Brainstorming implementation alternatives
- Discussing these alternatives to determine which are likely to be the most effective and efficient.
- Reviewing the selected strategies with other administrators, providers within the represented agencies.
Once the key implementation strategies are identified, an Action Plan is created, serving as a blueprint for working toward achieving needed improvements. Essential components of an action plan include:
- Desired long term outcomes
- Specific objectives describing activities to be performed
- Persons responsible
- Target dates for completion.
- Status and current date
Sample Agenda
A sample agenda for an Action Plan Meeting is available to download as a Word Document (10K) and is provided below for review.
Sample AgendaStep 4: Action Plan MeetingDate: Time: Location: Attendees: Meeting Purpose:To develop an action plan to improve the system and monitor progress Agenda
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M&M Action Plan to Improve Measurement Capabilities
Desired outcome: Develop standard data to monitor the M&M indicators that could be collected across programs with the Dept. of Health, with potential expansion to other departments.
This action plan should be viewed as providing further delineation of the goals for improving measurement capabilities. A sample Action Plan Protocol to improve measurement is featured below, and is available for download as a Word document (10K).
Additionally, a blank action plan protocol is available for download as a Word document (10K).
| Tasks: | Outcome/Indicator | Person(s) Responsible | Expected Completion Date | Status |
|---|---|---|---|---|
| 1. Review existing questions currently used in Health programs as well as pertinent questions from other validated surveys (Nt'l Survey of CSHCN CAHPS, PRAMS, etc.) that pertain to the indicators to help guide development of new questions to be asked across programs. | All indicators for outcomes 1,2, 3 | John Smith, Jane Jones | December 21, 2002 | Waiting on CAHPS; expected Jan. 1, '03 |
| 2. Reach agreement on development of standard wording/data reporting to provide data across Health programs re: CSHCN indicators. | All indicators for outcomes 1,2, 3 | M&M data subcommittee, then entire leadership team | Initiate Jan. 22, 2002; complete by March 1, 2002 | |
| 3. Incorporate agreed-upon wording/data collection re: CSHCN indicators into individual program data collection procedures. | All indicators for outcomes 1,2, 3 | Dept. of Health participating programs | June, 2002 | |
| 4. Integrate data across programs re: CSHCN indicators. | All indicators for outcomes 1,2, 3 | Dept. of Health Statistics- Susan Moloney | November, 2002 | |
| 5. Pilot reporting of data on CSHCN indicators for the Title V block grant. | All indicators for outcomes 1,2, 3 | Susan Moloney and Mike Earl | March, 2003 | |
| 6. Review data results to determine improvement in achieving the targets set for the M&M indicators. | All indicators for outcomes 1,2, 3 | M&M leadership team | April, 2003 |
Activity 3: Identify the Steps to Improve Measurement Capabilities
Action Plans are invaluable tools in clarifying goals and maintaining focus. The Team decides on enhanced measurement strategies that could include child or family impact, cost, time to implement, and human resources available. Below is a list of questions the leadership team can use to scrutinize and guide measurement improvements:
- Is the full scope of indicator captured in the data source?
- Are the data considered to be reliable and valid?
- Is the frequency of data collection sufficient to allow monitoring over time?
- Does the data source capture the broad population of CSHCN?
An example of one state's review of their data is provided below. Note that potential strategies for improving measurement are also recorded on this table.
| Indicators for Outcome #2: All children with special health care needs will receive coordinated ongoing comprehensive care within a medical home. | Current Data Sources | For Whom & how often reported? |
Adequacy of Data: 1. Full scope of indicator captured? 2. Data set reliable / valid? 3. Frequency of data collection? 4. Broad pop. Of CSHCN? |
Status |
|---|---|---|---|---|
|
1. % of CSHCN with a regular source of primary medical care through a primary care provider. |
a. Title V PM #3: Children with SHCN (i.e. CSHCN program family survey) or b. Utah Child Health Survey, 2000 (Title V Needs Assessment) c. CAHPS |
a. Children enrolled in some of CSHCN programs (clinics); usually collected every 5 years. b. Randomized household survey identifying broader pop. of CSHCN; ; there are no plans to continue in light of SLAITS c. Medicaid children with disabilities acc. To SSI definition; collected every 2 yrs. |
1. yes 2. yes 3. yes 4. Medicaid mgd. Care only |
1. Nt'l survey of CSHCN (will replace UT child health survey) 2. Collect data across multiple CSHCN programs 3. AAP survey of physicians, (if Utah sample is broad enough). |
Strategies Learned from M&M Partner States to Improve Measurement Capabilities
The M&M State teams developed ways to enhance their measurement capabilities to better gauge their progress in achieving the 6 core measures and the M&M indicators. It is important to note that states did not receive any funding from the M&M project to develop these enhanced measurement strategies. Rather, these approaches were created based on the partnership opportunities that developed within the State teams to join forces in their shared vision. These measurement strategies are described below.
The following examples illustrate several states' measuring and monitoring strategies.
South Carolina's Interagency Family Survey
As part of its ongoing measurement process, Children's Rehabilitative Services (CRS) redesigned its records review tool to evaluate the extent to which their CSHCN program services are implementing practices that support all six CSHCN outcomes. Part of the self-assessment process, conducted annually by regional CRS program staff, involves reviewing in-house records to ascertain the quality of services being provided. For example, a sample of client treatment plans is reviewed to ensure that the child's medical home is documented and that a copy of the treatment plan is sent to the medical home provider. Information regarding insurance status, documentation of appropriate referrals based on screening activities, and documentation of a needs assessment are reviewed. This process guides the regional offices in the improvement of services for children and families within their community.
The summarized data for the entire measurement process is used to guide planning for CRS. South Carolina also redesigned its Family Satisfaction Survey to include questions on the CSHCN outcomes and indicators to obtain family input regarding medical home, adequacy of insurance, well child checks, coordination of services, and supports for transition to adult life. This information is useful in guiding the priorities of the CRS program to ensure that it meets their customer's needs.
Oregon's Medical Home Surveys
Oregon's Medical Home Project, administered by Shriners Hospital and Oregon's Child Development and Rehabilitation Center, created two parallel surveys to measure the extent to which children served by Oregon's CSHCN program have a medical home. Family surveys measure accessibility, coordination, and the extent to which families partner with their medical home in decision-making. A companion survey is then administered to the primary care providers identified by the families surveyed through the CSHCN program. Together these surveys are used to assist in designing a training and support system for physicians to help them meet the needs of children and families.
Vermont's Parent to Parent Focus Groups
Parent to Parent of Vermont is a key partner with Vermont's CSHCN program in ensuring that services are family centered, accessible, and coordinated. Parent focus groups conducted by Parent to Parent staff provided valuable information related to Outcome #5: community-based services are organized so families can use them easily. For example, focus groups revealed the extent to which families were struggling with obtaining supports, such as respite and child care, as well as supported living options as children approached adulthood. Vermont used this information in setting state CSHCN program priorities, which are reflected in block grant and SSDI reports. Planning is now underway to develop activities for CSHCN clinics that support youth in their transition to adulthood.
Arizona and Utah Telephone and Household Surveys
As described in the insert entitled "Use of National and State-wide Surveys to Measure and Monitor Achievements for CSHCN Outcomes," both Arizona and Utah conducted randomized telephone household surveys to measure the extent to which the six CSHCN outcomes have been achieved for the broader population of children with special health care needs. These surveys offer potential for serving to guide system improvement when the results are used to drive the policies, practices, and activities of state CSHCN programs. For example, Utah's statewide Child Health Survey results identified the need to focus on transition to adulthood, which is reflected in the Utah's priority planning.
Ohio's Primary Health Care Survey
The Ohio Bureau for Children with Medical Handicaps (BCMH) conducted a survey to examine the quality of primary health care for children and families who receive their services. This mailed survey gathered information via parent report that pertained to the medical home, e.g., the percent of children who had a regular primary care provider, the percent of children whose provider communicates in a way that is clear and understandable, and the percent of providers who coordinate with other agencies serving their child. This information is being used to guide improvements in BCMH's program to ensure that children served in their program have a medical home. Additionally, Ohio used the results of this survey to help them identify and recruit families who might be interested in partnering in various advisory activities.
Step 4: Checklist
- Conduct meeting to identify strengths and challenges based on available data.
- Prioritize challenges.
- Identify potential strategies to address priorities.
- Determine steps to implement strategies, identifying persons responsible, and target dates for completion.