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) Provision of Care, Treatment and Service Management of Information Medication Management Surveillance, Prevention and Control of Infection 100% Data will be collected from in-office patient charts upon receipt of Start of Care information and weekly thereafter and from direct observation during supervisory visits by the Case Manager/Clinical Supervisor. Data will be reviewed and reported to the Director of Patient Care Services/ Management/PI Committee on a monthly basis. Quarterly reports and annual summaries of the aggregated data will be submitted to the Board of Directors and Professional Advisory Committee. Nursing Staff (Employees and Contract) and Nursing Management Medical Director Referring Physician Management of Patients with Open Wounds - Open wounds are assessed and measured during admission and each subsequent skilled nursing visit - Open wounds are photographed when improvement/deterioration as professional expertise - Wound care management coincides with physician orders - Aseptic/clean technique/ Standard Precautions followed during wound care procedure - Documented patient/caregiver/ significant understanding of wound care management 89