Policy Manual sample

MDT Home Health Care Agency, Inc. 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 Written plan of correction is necessary when thresholds are not met Annual Evaluation SCOPE OF PERFORMANCE IMPROVEMENT (PI) ACTIVITIES The mission, vision, and strategic goals guide the agency in development of the scope of performance improvement. Additional PI activities will be prioritized by the agency’s senior management staff. It is a goal of the organization to perform PI activities in interdisciplinary teams whenever possible. (a) Standard: Program scope. (1) The program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) Our HHA will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. (b) Standard: Program data. (1) The program will utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA will use the data collected to: (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. (c) Standard: Program activities . (1) Our HHA’s performance improvement activities must: (i) Focus on high risk, high volume, or problem - prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) 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) Our HHA will take actions aimed at performance improvement, and, after implementing those actions, the HHA will measure our success and track performance to ensure that improvements are sustained. (d) Standard: Performance improvement projects . Our Agency will conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) Our HHA will document the quality improvement projects undertaken, the reasons for conducting Home Health Agency - - Skilled Professional Services D 2