Quality is a subjective but critical part of an effective and efficient service as long as it conforms to an applicable requirement, or has features and characteristics to satisfy stated or implied needs.
Regardless of various definitions of quality, a system formalized to document the structure, policy, procedure, and responsibilities to manage the process around maximizing customer satisfaction at the lowest overall cost to the organization is a quality management system. However, quality management goes beyond product and service quality to focus on the means to achieve it. And that brings me to why I always provide to my clients a quality analysis of my consulting engagement with them during and after the consulting relationship.
There are several methods for quality improvement ranging from service improvement, process improvement, and people based improvement. With a focus on process and people based improvement, the following is a selective quality analysis of my Regulatory Compliance Investigation consulting role at the Jewish Board in New York.
The PDCA (plan, do, check, act) is one of few quality improvement methods. Here, I will be applying the PDCA for the purpose of process improvement relevant to my role as a Regulatory Compliance Investigation consulting. PDCA is a control and continuous improvement of processes through the application of an iterative four-step management method.
THIS IS A COPY OF MY WEEK 1 QUALITY ANALYSIS REPORT WHEN I CONSULTED THE JEWISH BOARD
Statement Of The Problem
As a Regulatory Compliance Investigation consultant, I receive reports of grievance, inappropriate behaviors and allegation of fraud, waste, and abuse, as well as audit reviews and deficiency statements. I do situation review of the reports to determine and construct plans on how effectively to respond to reports and incidents in a way that reduces or eliminates any risk exposure to the client (The Jewish). However, instead of focusing on the core process of an investigator, I spend a lot of time coordinating with senior management on how I intend to progress with my plan for review or actual investigation of a given report.
Below is a 7-Step personal Plan-Do-Check-Act (PDCA) for transparency of use of my time, to help you understand how my time at work is spent and why there was no time during preliminary consulting observation for ad hoc compliance projects.
Step 1: THEME SELECTION:
Task/Role Analysis
• Who are my clients?
– Individuals with developmental and intellectual disabilities
– People with history of drug and substance abuse
– Homeless
– Orphans
– Troubled youths and children
• What are my services relevant to my role?
– Investigate situations or allegations of:
> Agency exposure to risks or potential risks
> Abuse, waste, fraud of agency resources
> Inappropriate staff behaviors
> Acts of abuse, significant incidents affecting or interfering with care and supports
> State and agency mandated investigations and review
• What are my clients’ needs?
– Residential services
– Habilitation and reintegration services
– Referrals, case management and coordination
– Housing
– Counseling
-- Foster care
-- Primary Education
• What are my clients’ measures and expectations for how I meet those needs?
– Investigate and find amicable resolutions to clients’ grievances
– Investigate acts of abuse or neglect against clients
– Investigate inappropriate staff behavior that interferes with agency & state’s policies
– Investigate and resolve staff grievances
• Do my services meet or exceed their needs?
– Yes (based on response to project requirements)
• What is my process for satisfying their needs?
– Administrative
– Planning
– Miscellaneous
• What actions are needed to improve my process?
– Delegation
– Autonomy
– Elimination of red tapes
Process Details:
Pareto Analysis
Plan Coordination
Please view my Data Collection tool live here.
RESTATEMENT OF THE PROBLEM:
As a Regulatory Compliance Investigation consultant, I receive reports of grievance, inappropriate behaviors, and allegations of fraud, waste, and abuse, as well as audit reviews and deficiency statements. I do a situation review of the reports to determine and construct plans on how effectively to respond to reports and incidents in a way that reduces or eliminates any risk exposure to the client (The Jewish). However, instead of focusing on the core process of an investigator, I spend a lot of time coordinating with senior management on how I intend to progress with my plan for review or actual investigation of a given report.
I spent 52% of the time (i.e. 18.20 hours out of 35 hours) explaining and justifying my process and plan for investigating a report.
Step 3: CAUSAL ANALYSIS
Issue Statement: As an investigator, I spent 52% of my time on explaining and justifying my process and plan for investigating a report which is far more than all other individual activities of the role combined.
Why Root Cause Analysis
Fishbone Root Cause Analysis
Step 4: SOLUTION PLANNING & IMPLEMENTATION
● Solution Statement:
○ The senior program management’s demand to know the detailed nature and scope of my investigation plan and process stems from the lack of understanding of the process as well as the lack of awareness of the State regulations expectations and evolving agency policy and procedure around independence and autonomy of incident reporting and investigation. As a result, instead of seeing the investigative process as a process of identifying issues and developing solutions, they fear the exposure that the investigation explores. To remedy this, senior management may benefit from training around the investigation and the need to keep it outside the influence of senior managers.
● Implementation
There is no evidence that senior program managers have been trained in the regulatory expectations around incident management--reporting and investigation, hence, in-service training for executives will be helpful. There is evidence that this lack of awareness causes the investigator to almost always seek senior program managers’ understanding of an incident, the process to investigate and seek approval of what to investigate.
The possible roadblocks to implementation that I can see are the senior managers’ impression that they have no direct role in investigation to make such training required for them. There could also be an issue of availability, especially where you want to have team training so that there is the opportunity for discussion of issues and expectations.
Step #5 EVALUATION:
● Primary Target: To reduce the number of time spent on justifying the investigative plan and the investigative process
● Ancillary targets: Spend more time on the actual investigation so as ensure a thorough process and a timely completion
● An evaluation and reaction plan
○ Specific metrics: training log or training transcript of senior program managers
○ Only Training Attendance will be measured or logged in
Step 6: STANDARDIZATION
To formalize the changes in order to sustain the gain from the training sessions, the training engagement will involve discussion of establishing a central coordination point for each senior director. Emphasis will be made on maintaining the neutrality and objectivity of the investigations through the reduction or elimination of the understanding that senior directors have to approve an investigation plan and process before it can be conducted.
The desired standard of work which involves coordinating on scheduling and cooperating with the investigation will be communicated along with feedback from the training sessions. Efforts will be made to clearly communicate the investigator’s outreach to the senior directors for informational reasons. Following the training, the below steps will be communicated as the expectations in line with agency and state policy and procedures:
1. When incidents of abuse, neglect, or waste, abuse, fraud, and inappropriate behaviors are reported to the Compliance consultant, the following will occur:
a. Contacts will be made to the program director to request proactive measures to stop or put measures in place to minimize the occurrence or its effects and risk
> this will include separating the perpetrator from the victim while the investigation is being planned and conducted
> Staff and labor-related issues are immediately referred to HR/Labor relations
> Other actions will be requested based on the nature of the report
b. The senior director overseeing the program will be informed of the incident, and the request made as a result of the report as well as the tentative date of the investigation
c. Investigator will reach out to the program to schedule a date and time for a site visit and other investigatory purposes.
2. The investigator will share the findings and recommendations of the investigation with the senior director before disseminating it to the program level
a. The senior director should make no attempt to influence the findings or recommendations by expressing or making input into the investigation.
For a template of this analysis to help you or staff assess the quality of their processes, contact compliance@amakaconsulting.net
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