-Quality Improvement

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1. Role of the Quality Improvement

LifeWays’ Quality Improvement Department offers resources and support to LifeWays employees, Board members, consumers, and our provider network.  Our goal is to develop and implement effective and high quality processes and services that improve outcomes for our consumers. 

2. Quality Improvement Plan

LifeWays Policy and Operating Procedures: 

08-01.01 Quality Improvement Plan

3. Strategic Planning

LifeWays maintains a strategic plan that is used to communicate organizational goals and is integrated into the Quality Improvement Plan.  LifeWays uses Baldrige Health Care Criteria for Performance Excellence to guide the strategic planning process.  Baldrige is a nationally recognized best practice standard in quality management.  Most importantly, Baldrige provides a valuable framework that can help LifeWays plan, perform, and measure results in an uncertain environment.   The strategic plan is monitored monthly by the Quality Improvement Council. 

4. Performance Monitoring

LifeWays is committed to quality services and measuring performance of our Community Mental Health System.  LifeWays has measures of performance both internally and externally.  We also monitor performance of our provider network.  The following tools are used to monitor performance:

The Provider Scorecard – measures both successes and opportunities in the key areas of timeliness, utilization, outcomes and quality standards.  The report is published quarterly.   The report includes: inpatient screening, screening to intake, intake to ongoing, hospital discharges, ER utilization, hospital recidivism, CAFAS/PECFAS Outcomes, data errors, billing verification reviews, certification reviews, youth & family and adult satisfaction. 

5. Stakeholder Input

The input of our various stakeholders is very important to achieving our strategic goals.  LifeWays offers many opportunities for our stakeholders to provide input.  The purpose of creating a system for continuous stakeholder input is to use this information to inform:

  • Continuous quality improvement
  • Community messaging
  • Strategic planning
  • Network capacity planning
  • Budget

8-03.01 Stakeholder Input and Customer Satisfaction

6. Accreditation

LifeWays has been awarded the highest level of accreditation by CARF International.  CARF Accreditation was awarded to LifeWays for Service Management Network with Access Center.  CARF accreditation demonstrates to customers that our organization is committed to reducing risk, addressing health and safety concerns, respecting cultural and individual preferences, and providing the best quality of care. 

LifeWays requires that all providers of the network receive accreditation from a recognized accrediting body, such as:  CARF, JCAHO, COA

7. Regulatory Compliance

LifeWays is regulated by the Michigan Department of Health & Human Services, Mid-State Health Network, and Centers for Medicare and Medicaid Services.  LifeWays demonstrates compliance with regulatory standards through site visits conducted by Mid-State Health Network, Michigan Department of Health & Human Services, and the Health Services Advisory Group. 

It is expected that all providers comply with standards and participate and provide information as requested during audits of regulatory compliance. 

8. Process Improvement

The LifeWays Quality Improvement Team is responsible for facilitating process improvement activities.  The goal is to ensure key processes that impact our service delivery system are highly effective, cost-efficient and lead to improved treatment outcomes.  LifeWays utilizes a Lean process improvement model and monitors the results through process and outcome metrics.  Lean is an improvement process that is achieved by:

  1. Removing waste (ex/ duplicate work),
  2. Increasing efficiency (ex/ multiple hand-offs), and
  3. Elevating quality (ex/ treatment outcomes)

To request a process improvement, complete the Performance Improvement Request form as indicated in the Process Improvement Facilitation procedure.

08-03.02 Quality Improvement Process Facilitation

9. Sentinel Event and Root Cause Analysis

It is expected that Network Providers, as a part of their accreditation, are completing a thorough root cause analysis (RCA) in the event a consumer is involved in a sentinel event. The format of the RCA is not dictated. The RCA must include all providers serving the individual.

08-02.07 Sentinel Events and Root Cause Analysis (updated 4/22/21)

10. Technical Requirement and Practice Guidelines

Technical requirements change from year to year, based on the Medicaid Specialty Supports and Services contract guidelines (Contract Attachments).  Please see the Medicaid Provider Manual for more information.

Link:  Michigan Department of Health and Human Services Medicaid Provider Manual

11. Health Information Management

To ensure LifeWays maintains a health records system that documents care and services provided to an individual, as well as provides information for data-driven business decisions.


08-05.01 Behavioral Health Treatment Episode Data Set (BH-TEDS) (updated 4/19/21)
08-05.02 Electronic Medical Records Management (updated 4/13/21)
08-05.03 Data Validation and Management
08-05.05 Uses of Multiple Data Platforms

12. Quality Improvement Council

The Quality Improvement Program at LifeWays is comprised of multiple committees and focus areas, all of which are monitored by the QIC. Attention on specific areas is identified so that input and outcomes on focus areas is reported to the Council and, therefore, the Board of Directors. Information about each focus area is provided through reports, meeting minutes, committee snapshots, or any means necessary to provide information to the Council as outlined in the QIP Reporting Schedule. The following are the focus areas for the QIC:

The primary responsibilities of the QIC include:

  1. Review the various progress reports made to QIC by committees, focus areas, and the strategic plan;
  2. Make recommendations for quality improvement to QIC, Leadership, and the Board of Directors via the QI & CR; and
  3. Monitor the progress made on recommendations and identified actions for quality improvement.

Additional QIC responsibilities include, but are not limited to:

  • Development, implementation, and evaluation of the QIP;
  • Establishment of the Quality Improvement Program goals and objectives;
  • Continuous review of consumer demographics and epidemiological trends;
  • Ensuring quality improvement activities are relevant to and beneficial for the populations served;
  • Identifying opportunities for improvement;
  • Implementing the Lean Process to reduce waste and increase the value of services provided;
  • Approving all Quality Improvement process activities;
  • Establishing priorities and timeframes for improvement activities;
  • Assigning responsibility for action;
  • Reviewing audit findings and recommending improvements;
  • Monitoring achievement toward standard or accreditation;
  • Identifying training needs related to process improvement and other quality improvement related topics; and
  • Monitoring plans of correction and follow-ups to ensure that interventions are occurring according to the plans in and have resulted in actual, sustained improvements.

The QIC participates in the development of each annual QIP through recommending goals and priorities for the upcoming fiscal year. These recommendations may include modifications to the current quality improvement system or implementation of new initiatives, goals or priorities to continue the continuous quality improvement process. Once the QIP plan is finalized, the QIC is responsible for conducting ongoing monitoring of the Quality Improvement Program and provide recommendations for improvement.

Attachment: How to Generate BH-TEDS Records (BH-TEDS User Manual)Electronic Medical Record (EMR)