Purpose:     To provide for the objective and systemic monitoring, evaluation and coordination of the quality, appropriateness and cost-effectiveness of patient care, resolve identified problems and improve the Agency’s performance.

Policy:        The governing body shall establish and maintain an ongoing Quality Assessment and Performance Improvement Program comprised of a system of measures that captures significant outcomes that are essential to optimal care, and are used in the care planning and coordination of services and events. The QAPI committee is appointed by the Administrator and approved by the governing body. The Clinical Manager is responsible for the day to day QI activities. The frequency and detail of the data collection has been set forth by the governing body.

The governing body is responsible for ensuring the following:

1. That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained;

2. That the agency wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness;

3. That clear expectations for patient safety are established, implemented, and maintained; and

4. That any findings of fraud or waste are appropriately addressed

Procedure:

A. Monitoring of the QAPI Program

1. The QAPI Committee will be responsible for the ongoing monitoring of the QAPI Program. Findings are to be used by the Agency to correct identified problems and revise policies, if necessary.

2. The QAPI Committee will review the plan at least quarterly within a calendar year and revise the plan if needed.

B. QAPI Committee Membership Qualifications and Frequency of Meetings

1. At a minimum, the QAPI Committee must consist of at least (1) the Administrator; (2) the Clinical Manager; (3) a therapist (one person may represent all therapies, e.g., PT, OT, SLP, SW, provided however, that should be the therapy being delivered); (4) representation from an unskilled discipline.

NOTE:  A nurse cannot represent the therapies and a therapist cannot represent the skilled nurses.

2. The QAPI Committee must meet at least quarterly and more often if needed.

3. Members are trained on QAPI activities which includes:

·   The purpose of QAPI activities

·   Persons responsible for coordinating QAPI activities

·   Individual’s role in QAPI

·   QAPI outcomes 

FOCUS:

1. This agency’s performance improvement activities shall:

a.  Focus on high risk, high volume, or problem‐prone areas;

b. Consider incidence, prevalence, and severity of problems in those areas; and

c.  Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.

2. Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions.

3. The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained.

4. Prevention and reduction of medical errors.

5. This agency shall use the data collected to—

a.  Monitor the effectiveness and safety of services and quality of care;

b. Determine and define problematic areas for the purpose of conducting performance improvement projects; and

c.  Identify opportunities for improvement.

6. This agency shall document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.

SCOPE:

The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations.

The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.

PROGRAM:

This QAPI program shall show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. The following measures (at a minimum) will be used to capture significant outcomes that are essential to optimal care and will be used in care planning and coordination of services and events. (Assessment of these measures will be through data collection, which at a minimum will consist of clinical record review, patient interviews, and patient satisfaction reports).

1. An analysis of services furnished to existing and prior patients. (Utilization Review). The following elements are considered within the plan:

·       Program objectives

·       All patient care disciplines

·       Description of how the program will be administered and coordinated

·       Methodology for monitoring and evaluating the quality of care

·       Priorities for resolution of problems

·       Monitoring to determine effectiveness of the action

·       Oversight and responsibility for reports to the governing body

·       Documentation of the review of its own program

·       Annual Evaluation

2. The QAPI committee will review at least the following:

a.  Prior QAPI Action Plans and their outcomes

b. Program Evaluation

c.  Negative patient care outcomes

d. Patient Care

e.  Operating Systems

f.  Direct observation of clinical performance

g. Issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff

h. Infection control activities

i.   Communicable diseases

j.   Incidents/Accidents

k. Worker Compensation Claims

l.   Track and Trend Employee Turnover Rates

m.   At least one important aspect related to the care provided

n. At least one important administrative aspect of function or care

o. Emergency preparedness review

p. Medication administration and errors

q. Adverse Drug Reactions

r.  Emergent care services, hospital admissions and re-admissions

s.  On call responses

t.   Supervision appropriate to the level of service

u. Staffing Patterns and Performance

v. Provision of services appropriate to the patients’ needs

w. OBQM and OBQI reports

x. Quality indicator data, including measures derived from OASIS and other relevant data to ensure a data driven program.

y. OASIS Submission Statistics

z.  OASIS Error Summary Report

aa.   Determination that services have been performed as outlined in the plan of care as well as revised and updated as necessary.

bb.  An analysis of patient complaint and satisfaction survey data.

cc. Complete Chart Audits as defined in Policy 4.005.1 Clinical Record Review/Quarterly Review

dd.  Compliance with completing employee performance evaluations.

ee.   Review and evaluation of coordination of services through documentation of written reports, telephone consultation, or case conferences.

ff. Patient and Staff Complaints (ongoing monitoring)

gg.  Effectiveness and safety of all services provided, including

·       the competency of the agency’s clinical staff

·       the promptness of service delivery

·       appropriateness of the agency’s responses to patient complaints and incidents

·       review all incidents

3. The annual QAPI report includes, but is not limited to:

·   The effectiveness of the QAPI program

·   The  effectiveness,  quality  and  appropriateness  of  care/service  provided  to  the  patients,  care/service  areas and community served, including culturally diverse populations

·   Effectiveness of all programs including care/service provided under contractual arrangements

·   Utilization of personnel

·   Review and revision of policies and procedures, and forms used by the organization

·   Summary of all PI activities, findings and corrective actions

·   The Annual Evaluation

4. Each performance improvement activity/study includes the following items:

·   A description of indicator(s) to be monitored/activities to be conducted

·   Frequency of activities

·   Designation of who is responsible for conducting the activities

·   Methods of data collection

·   Acceptable limits for findings

·   Written plan of correction when thresholds are not met

·   Plans  to  re-evaluate  if  findings  fail  to  meet  acceptable  limits  in  addition  to  any  other  activities required under state or federal laws or regulations

5. Must use the evaluation process to correct identified problems and, if necessary,
             to revise policies

·       This agency must document corrective action to ensure that improvements are sustained over time.

·       This agency will immediately correct identified problems that directly or potentially threaten the patient care and safety.

·       In-service education will be provided to all staff in relation to new policies or process to be changed.

6. The QAPI committee will meet 30 days after implementing the QAPI Action Plan for the purpose of evaluating the effectiveness of any changes and to make modifications as needed.
   
   

7. At the conclusion of every QAPI meeting a QAPI Action Plan will be completed and made available to the agency and the Administrator will give a copy to the governing body within 15 days of concluding the meeting.
   
   

8. The administrator allocates resources for implementation of the Performance Improvement program. Resources include, but are not limited to:

·   Training and education programs related to PI

·   Personnel time

·   Information management systems

·   Computer support

Attachment

QAPI Action Plan