QAPI Program Utilization_Manual

PERFORMANCE IMPROVEMENT MONITORING AND EVALUATION PLAN Department: Home Health Scope: Provide skilled services to patients requiring care and treatment of their disease processes, including instruction, monitoring, assessment and evaluation of their response to treatment modalities, in their place of residence. Date: Responsibility: Case Manager, Nurse Clinician, Physical, Occupation and Speech Therapists, Nurse Executive, Clinical Supervisors, PI Committee Priority Focus Area Performance Measures/Outcomes Related Functions Benchmark Goal Data Collection (Methodology) Integration and Collaboration Assessment and Care/Service Management of Patient with CHF: - Assessment of diuresing as evidenced by weight documentation on each nursing visit - Assessment of response to diuretic medications by documented review of lab work and communication with physician - Adequate assessment of lung sounds and edema with documentation, and any change reported to physician Management of Information Provision of Care, Treatment and Service 90% Data will be collected from the office patient record on a weekly basis by a member of the PI Department/ Committee/Case Manager/Clinical Supervisor. Data will be aggregated, reviewed and reported on a monthly basis to the organization’s PI Committee, the Nurse Administrator/ Director of Patient Care Services/ Management Committee. Aggregate reports will be submitted to the Board of Directors and Professional Advisory Committee on a quarterly basis and summarized annually. Nursing Staff (Employee and Contract) and Nursing Managers Referring Physician Medical Director 86