QAPI Program Utilization_Manual

ACTION PLAN MONITORING PURPOSE: To assess the effectiveness of process modifications on outcomes. POLICY: Data are collected and analyzed at a predetermined frequency to evaluate the effectiveness of the implemented changes and to ensure that improvement is sustained. Our Agency will initiate an evaluation when undesirable performance is suspected or known as evidenced by comparisons that show that: Important single events, levels of performance, patterns or trends vary significantly (±5%) and undesirably from those expected Performance varies significantly and undesirably from that of other organizations Performance varies significantly and undesirably from recognized industry standards PROCEDURE: Corrective action plan is monitored on an ongoing basis after it has been implemented according to policy and procedure "corrective actions". Implemented corrective action is monitored on an ongoing basis to assess actual or potential effectiveness of problem resolution. Monitored corrective action that is determined to be actually or potentially ineffective in problem resolution is modified or discontinued in a timely manner, as appropriate. Revised corrective action is monitored on an ongoing basis to assess actual or potential effectiveness of problem resolution. Implemented corrective action is monitored and appropriately discontinued/revised as often as necessary, in a timely manner to improve process outcomes. Monitoring information is documented, aggregated, analyzed and displayed in a manner that maintains the confidentiality of information according to Agency policy and procedure while simultaneously providing valuable information to individuals, departments or committees as appropriate. 85