Policy Manual sample

MDT Home Health Care Agency, Inc. agency mission, available resources, functions, as well as concerns of the individuals served, their families, payers, and other customers. Data collection is used to accomplish the following: Establish a performance baseline Assess the dimensions of performance relevant to functions, processes, and Outcomes Measure the level of performance and stability of important existing processes (identify variations) Identify areas for possible improvement in existing processes Determine whether process changes made actually improve outcomes Data to monitor performance may be collected from the following sources: a. Performance measures related to accreditation and other regulatory surveys b. Risk management c. Utilization review d. Quality control, including safety issues e. Staff surveys and questionnaires f. Outcomes of processes or services g. Performance measures from acceptable databases patient demographics h. Diagnoses Financial data i. Infection control surveillance and reporting j. Published research data The following requirements are collected: Patient, Employee and physician satisfaction questionnaires Moments of processed including the following: 1. Adverse drug reactions and medication error reports 2. Care or services provided to a high-risk patient 3. Summary or incident reports and complaint log 4. Care or services provided to high-risk populations Data will also be collected to accomplish the following: a.Monitor performance of targeted areas, such as process stability, risk, b.Sentinel events, and events that require root cause analysis c.Monitor improvement in performance for changed/redesigned processes d.Measure the performance of processes related to function identified by agency leadership as priorities It is a goal of the agency to create an environment in which error reporting is free of the threat of retribution. The detail and frequency of data collection should be appropriate for monitoring improvement in performance. Aggregation and Analysis Home Health Agency - - Skilled Professional Services D 6