Chapter 1 – Health Care Governance and Administration

1.2.4 Quality Management Program, Statewide Governance

• Purpose

  • To maintain a statewide Quality Management Committee (QMC) to provide oversight to the California Correctional Health Care Services (CCHCS) Quality Management (QM) Program. The structure and processes described in this procedure are designed to:

  • Support implementation of a sustainable, high-performing, integrated health care services delivery system.

  • Promote continuous health care system evaluation and improvement.

  • Promote a culture of teamwork and continuous learning and innovation.

• Responsibility

  • The Statewide Chief Quality Officer (CQO) is responsible for statewide planning, implementation, evaluation and improvement of the QM Program.

• Procedure

  • Overview

    • The statewide QMC:

      • Oversees organization-wide performance management activities, across programs and disciplines, and provides oversight to critical functions within the performance management system including statewide planning, prioritization, design and development of tools and training, evaluation, and improvement.

      • Ensures that the organization’s approach to performance improvement is strategic and, where appropriate, standardized.

      • Oversees efforts to build statewide quality improvement capacity including initiatives to promote skills development at individual institutions and organization-wide in areas such as program evaluation, problem analysis, prioritization of improvement initiatives, and use of evidence-based approaches to performance improvement.

      • Establishes standardized improvement tools, techniques and processes, and supports efforts to implement an organizational culture of continuous learning and improvement.

      • Serves as a supplement to the traditional reporting structure, providing regular interdisciplinary forums for managers, supervisors, and line staff to manage improvement activities.

    • The scope of the statewide QMC is separate and distinctly different from the statewide Medical Peer Review Committee (MPRC). The statewide MPRC evaluates and monitors individual clinician practice issues while the statewide QMC oversees organization-wide system performance and improvement activities.

  • Statewide Quality Management Committees Activities

    • The statewide QMC works with field leadership, headquarters program-specific subcommittees and workgroups to:

    • Support institutions in the successful implementation of an integrated health care delivery system through improvement initiatives, onsite technical assistance, assessments, and other activities.

    • Establish/update improvement plan with statewide improvement priorities and objectives.

    • Support institutions in identifying improvement priorities and achieving strategic alignment between improvement priorities and day-to-day program activities.

    • Manage statewide improvement initiatives designed to accomplish annual performance objectives.

    • Provide oversight to the statewide performance measurement system, including selection of measures, and ensure dissemination of relevant, accurate, and timely measurement information to headquarters and institution staff through the Dashboard and Institution Scorecards, including standardized processes for data reporting and validation.

    • Support the implementation of the statewide patient safety program, including a health incident reporting system and a defined process for the tracking and analysis of significant events including but not limited to sentinel events.

    • Coordinate with relevant committees and program areas at headquarters and regional level that oversee statewide program policy and operations to share performance information and implement improvement initiatives (e.g. Joint Clinical Executive Team and Clinical Operations Team).

    • Coordinate technical assistance activities by staff at headquarters and regional teams designed to support improvement initiatives.

    • Refer issues to other committees or programs, such as the statewide MPRC, when they do not fall under the purview of the QMC.

    • Implement statewide training and staff development programs to orient all health care staff to the QM Program, promote the development of quality improvement skills, and support staff at all reporting levels to participate in quality improvement.

    • Establish uniform processes and tools for the analysis of system performance problems, development of solutions, and testing and evaluation of interventions.

    • Establish forums for sharing lessons learned and disseminating best practices.

    • Actively foster an organizational culture of continuous learning, improvement, and innovation by clearly communicating performance improvement principles to staff; evaluating CCHCS governance structures and processes, policies, procedures, practices, training programs, and communications against those principles; and providing input to ensure alignment.

    • Establish a process to periodically review the statewide QM Program to evaluate the overall effectiveness of the QM Program.

  • QMC Membership and Meeting

    • QMC Chairperson

      • The statewide CQO and another executive leader chosen by the QMC members shall serve as Co-Chairpersons. The Co-Chairpersons are responsible for ensuring that the QMC meets at least quarterly, the committee agenda reflects the responsibilities and actions described in this procedure, and committee decisions are appropriately documented.

    • QMC Voting Members

      • Deputy Director, Statewide Mental Health Program

      • Deputy Director, Statewide Dental Program

      • Statewide, Chief Nurse Executive

      • Statewide, Chief Medical Executive

      • Director, Allied Health Services

      • Deputy Director, Medical Services

      • Deputy Director, Strategic Management

      • Director, Policy and Risk Management Services

      • Chief Information Officer, Information Technology Services

      • Deputy Director, Human Resources

      • Director, Administrative Support Services

      • Director, Corrections Services

      • Chief Executive Officer(s)

      • Statewide, Chief Quality Officer

      • Representative, Division of Adult Institutions

      • Other members nominated by one of the voting members and approved by the QMC. All voting members may choose a designee to serve in their stead.

    • QMC Meetings

      • The committee shall meet no less than quarterly. Each member has one vote and a quorum is designated as 50% of members.

      • The committee shall document each meeting through formal minutes and provide them to QMC members for review no later than one week prior to the next meeting.

    • Reporting Structure

      • The statewide QMC reports to the highest ranking health care official and executive staff at least annually on progress in meeting annual performance improvement objectives and patient safety goals.

      • Statewide program-specific subcommittees and institution QMCs shall report quality improvement and patient safety activities to the statewide QMC at least annually or more often as appropriate.

    • QMC and Subcommittees

      • The statewide QMC shall coordinate and communicate with subcommittees to establish and sustain a high-performing health care system consistent with the Primary Care Model and existing policies and procedures, state and federal law, and community standards of care. Examples of subcommittees may include:

        • Patient Safety Program

        • Mental Health Program

        • Dental Program

        • Medical Program

        • Pharmacy and Therapeutics

        • Diagnostic Services

        • Utilization Management

        • Health Information Management

        • Continuing Medical Education

        • Clinical Guidelines

        • Resource Management

      • Each Subcommittee Chairperson is responsible for reporting subcommittee program performance improvement activities, such as development and implementation of initiatives and improvement projects, to the statewide QMC on a routine basis through appropriate documentation (e.g., minutes) and verbal reporting.

      • All subcommittees shall meet at least as frequently as required in existing policy.

• Revision History

  • Effective: 01/2002
    Revised: 12/2012