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 Infection Control - CDC hand hygiene guidelines will be adhered to by all staff - All clinical staff will have alcohol-based handwashing solution available during each patient visit - Personal protective equipment will be used appropriately by all staff - Standard Precautions will be adhered to by all home care staff Leadership Provision of Care, Treatment and Service Surveillance, Prevention and Control of Infection 100% Data will be collected from patient and staff infection reports and unusual occurrence reports by the Risk Manager, and from direct observation during patient visits by the Case Manager/Clinical Supervisor on a monthly basis. Data will be aggregated, reviewed and reported to the Management Committee on a quarterly basis. All Clinical Staff (Employee and Contract) and Managers Risk Management Medical Director Referring Physician Management of Information - Personal health information is protected during home visits - Home chart information is returned to the Agency office upon patient discharge and destroyed appropriately - Every entry into the patient record is dated and signed with the staff member’s full name and professional designation - Computers are turned off when not in use Ethics, Rights and Responsibilities Leadership Management of Information Provision of Care, Treatment and Service 100% Data is collected by direct observation during home visits on a monthly basis and from in office patient records on an ongoing basis by the Case Manager/Clinical Supervisor. Data will be aggregated, reviewed and reported to the Director of Patient Care Services/Management/PI Committee on a monthly basis. All Clinical Staff (Employees and Contract) and Managers 94