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 Patient Safety - Basic home safety assessment is conducted and documented at the time of the initial visit - Fall assessment is conducted and documented on every patient during each skilled visit - Documented patient/caregiver/ significant other level of understanding of fall prevention precautions Environmental Safety and Equipment Management Management of Information Medication Management Provision of Care, Treatment and Service 100% Data will be collected from the in-office patient record and direct observation by the Risk Manager/ Clinical Supervisor on a monthly basis. Data will be aggregated, reviewed and reported to the Director of Patient Care Services/Management Committee on a monthly basis and to the Board of Directors and Professional Advisory Committee on a quarterly basis and summarized annually. Clinical Personnel (Employee and Contract SN, PT, OT, ST) and Managers Risk Management Medical Director 91