Policy Manual sample

MDT Home Health Care Agency, Inc. c. Staff meetings and committee meetings d. Senior management is responsible for systematic follow-up and implementation of operational changes pursuant to performance improvement activities. Participation and Training A. Each employee shall participate in performance improvement activities as requested. Employees unable to perform their responsibilities in performance improvement activities because of a lack of knowledge of PI methods and approaches shall be educated as appropriate. B. Performance improvement knowledge and skills education needs of the Board of Directors, management, and other personnel shall be continually assessed and additional education provided as needed C. Team leaders will be trained in the principles and tools of the Focus-PDCA model, including practical application. Employees will be introduced to the performance improvement plan and the principles of performance improvement during new-hire orientation, staff meetings, and applicable educational meetings/inservices. Annual Appraisal The Quality Improvement staff, in conjunction with senior management (Directors, Administrator, Director of Nursing, Clinical Manager), develops an annual appraisal of the agency performance improvement program. The appraisal should contain information regarding significant opportunities to improve care identified through the performance improvement process and the effectiveness of actions taken. The annual appraisal should discuss the strength and weaknesses (refer to Strategic Plan) of the existing program, the degree of overall integration and coordination, and recommendations for program improvement. The QI and senior management staff will perform an annual self-assessment to review its progress and reestablish strategic goals for the following year. An annual report will be submitted to the QAPI Committee and Board of Directors. Actions taken when negative patient outcomes are directly related to the employee’s performance: A new refresh in-service will be completed in the identified areas of weakness, or poor performance, if applicable a joint supervisory visit will be performed with the staff with deficiency to verify that problems were solved, and re-evaluation of their duties outcomes will be completed within 6 months to continue monitoring outcomes of care until satisfactory outcomes is reached. Home Health Agency - - Skilled Professional Services D 8