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 (continued) Pain Management: - All patients are assessed for the presence of pain on admission to the organization according to an objective pain scale - All patients with diagnoses that have the potential for causing pain will have their pain level assessed and documented according to an objective pain scale during each skilled visit - Effectiveness of pain medication, if used by the patient, will be assessed and documented during each skilled visit - Effectiveness of pain management techniques will be assessed and documented during each skilled visit - Documented communication with patient’s physician and other team members providing care/service when change in patient’s pain level/response to medications/other pain management techniques Ethics, Rights and Responsibilities Provision of Care, Treatment and Service Medication Management Management of Information 100% Data will be collected from the office patient record within five (5) days of the Start of Care visit by the Case Manager/Clinical Supervisor and on a weekly basis thereafter while the patient remains on service 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, 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. Clinical Staff (SN, PT, ST, OT) and Managers Referring Physician Risk Management Medical Director 88