Policy Manual sample

MDT Home Health Care Agency, Inc. FRAMEWORK FOR IMPROVING ORGANIZATIONAL PERFORMANCE Education The leadership of the agency will be educated in the mechanisms of performance improvement. Quality Improvement (QI) staff will organize performance improvement education programs at regular intervals as well as on an “as needed” basis. This education will be extended from leadership to staff throughout the agency. Staff will be oriented to application of performance improvement theory (Focus-PDCA). Ongoing education will serve to reinforce this training. Methods of education will include, but not be limited to, the following: A. Literature distributed to staff B. On-site conferences/classes/in-service C. Seminars, conferences, workshops, or other meeting devoted to providing performance improvement education D. New employee orientation ORGANIZATION PERFORMANCE IMPROVEMENT ACTIVITIES All process improvement activities carried out within the organization should be performed as described in this plan and, as appropriate, be performed in an interdisciplinary team setting utilizing the elements of process design, performance measurement, aggregation and analysis, and performance improvement as described below: Process Design Senior management staff serves as an ongoing forum in which new processes and services identified for improvement are presented and evaluated. As a part of this review process, the following information is used to design more effective processes, functions, or services: A. Evidence that the proposed design supports the agency mission, vision, and strategic goals, or that the proposed design meets or exceeds stipulated quality control or other requirement and/or standards B. The needs of individuals served, staff, and others C. Up-to-date information (practice guidelines, information from relevant literature, clinical standards, etc.) D. Sound business practice E. The use of information available from other agencies to help reduce the occurrence of sentinel events and other unusual occurrences F. The results of performance improvement activities G. The organization incorporates information related to these elements – when available and relevant-in-the design or redesign processes, function, or services Performance Measurement (Data Collection) Monitoring the performance through data collection (performance measurement) is the foundation of all performance improvement activities. Because of limited resources, performance measures cannot be collected for everything. Leaders determine the important processes for improvement based on Home Health Agency - - Skilled Professional Services D 5