QAPI Program Utilization_Manual

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 Transforming the collected data into information allows the agency to draw conclusions about its process performance or the nature of the outcome. A. Aggregation of data at determined intervals enables the agency to evaluate a particular process’s stability or a particular outcome’s predictability in relation to performance expectations B. The analysis phase for any specific process can include any or all of the following elements: a. Review of internal data related to the agency’s processes and outcome measure over time b. Comparison of its performance with other home health agencies c. The use of external sources of information (literature, practice parameters performance measures, standards and reference databases, etc.) Intensive analysis is initiated when comparisons indicate negative trends or performance slightly below expectations. These include the following: a. Important single events, patterns, or trends that vary significantly and undesirably from those expected b. Performance that varies significantly and undesirably from recognized Standards c. A sentinel event occurs (root cause analysis) d. All significant adverse drug reactions and medication errors Performance Improvement A. Elements of organizational performance improvement may include the following: a. Improving existing processes b. Redesigning an existing process c. Designing an essentially new process d. Reducing variation or eliminating undesirable variation in processes or outcomes B. The team involved in an improvement activity will use the Focus-PDCA model Reporting and Coordination · The results of performance improvement activities are used to study and improve processes that affect patient outcomes and , when relevant to the performance of an individual, are used as a component of the evaluation of individual capabilities. Information will be communicated as necessary to achieve these goals. · The conclusions, recommendations, actions, and results of the actions taken shall be documented and reported through established channels as follows: a. The Quality Improvement staff reports to the management staff and the Board of Directors. b. The QAPI committee reports to the Board of Directors c. The work of all teams and the senior management staff are documented using agency standard minutes format and reporting forms · Once the performance improvement results have been evaluated and approved by senior management, the Clinical Mangers, and the Board, the results shall be shared with others in the organization through any of the following: a. Management meetings b. Story boards or agency newsletters 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. 5