Policy Manual sample

MDT Home Health Care Agency, Inc. these projects, and the measurable progress achieved on these projects. (e) Standard: Executive responsibilities. Our 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 our 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. ESTABLISHING PRIORITIES FOR PERFORMANCE IMPROVEMENT The priorities for performance improvement shall be established collaboratively by the agency’s leadership, composed of senior management staff and the QAPI Committee. The following criteria should be considered when establishing these priorities: High volume events (diagnosis, procedure, process) Agency mission, vision, and commitment Needs and expectations of patients and families, patient care, services Sentinel events Input from physicians and employees, with direct observation of clinical performance Input from external sources (licensing, regulatory agencies, other groups) Resources to make improvements QUALITY STRATEGIES In order to provide a consistent approach to performance improvement throughout the organization, the agency has adopted the Focus-PDCA model. Focus-PDCA is a step-by-step, systematic approach that guides teams in process improvement: Find a process to improve Organize a team that knows the process Clarify current knowledge of the process Understand the causes of process variation Select the proves improvement Plan the improvement and continue data collection Implement the improvement, data collection, and analysis Verify the results and the lessons learned from the team effort Act to standardize the improvement and continue to improve the process IDENTIFIED CUSTOMERS Home Health Agency - - Skilled Professional Services D 3