QAPI Program Utilization_Manual

Annual Appraisal The Quality Improvement staff, in conjunction with senior management (Directors, Administrator, Director of Nursing, Clinical Manager), develops an annual appraisal of the agency performance improvement program. The appraisal should contain information regarding significant opportunities to improve care identified through the performance improvement process and the effectiveness of actions taken. The annual appraisal should discuss the strength and weaknesses (refer to Strategic Plan) of the existing program, the degree of overall integration and coordination, and recommendations for program improvement. The QI and senior management staff will perform an annual self-assessment to review its progress and reestablish strategic goals for the following year. An annual report will be submitted to the QAPI Committee and Board of Directors. Actions taken when negative patient outcomes are directly related to the employee’s performance: A new refresh in-service will be completed in the identified areas of weakness, or poor performance, if applicable a joint supervisory visit will be performed with the staff with deficiency to verify that problems were solved, and re-evaluation of their duties outcomes will be completed within 6 months to continue monitoring outcomes of care until satisfactory outcomes is reached. 6