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 Orientation and Training - All home care staff complete a structured orientation program prior to providing care, treatment and/or services - Competency evaluations are completed for all home care staff at time of hire, within 90 days of hire and annually - Staff training is provided and competency assessed whenever job responsibilities/ duties change Leadership Management of Human Resources 100% Data will be collected from personnel records on an ongoing basis by a member of the Human Resources Department. Data will be aggregated, reviewed and reported to the Director of Patient Care Services/Management Committee on a monthly basis. Human Resources Clinical Staff and Managers Contractors - Annual education plan includes at least the following topics:  Fire Safety  Infection Control Measures  Ethics  Performance improvement  Body Mechanics and Transfer Safety  Basic Home Safety Measures  Patient Safety Environmental Safety and Equipment Management Leadership Management of Human Resources Provision of Care, Treatment and Service 90% Data will be collected from Personnel/Education Records by a member of the PI Department/ Committee every six (6) months. Data will be aggregated, reviewed and reported to the Director of Patient Care Services/Management Committee biannually. All Clinical Staff (Employees and Contract) and Managers Contractors 95