QAPI Program Utilization_Manual

QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Aspect In-service required, Agency’s Education-Orientation Program Indicator The Agency’s staff education goals are maintained • Orientation Schedule are displayed in Agency’s Board • The Material for internal in-service are reviewed, approved by DON or Education Coordinator • The Education attestation are filed in each staff receiving training • The assistance to each in-service are stored in the Agency’s Orientation binder • The mandatory 12 hours of continue education for field staff are annually collected, and filed in each staff chart. Threshold 100 % of staff Sample Compliance with a minimum of annual mandatories in-services including: Infection Control, Handwashing, Nursing Bag, TB Precautions, Biomedical Waste, Emergency Management, Medical Device, Ethical Issue. Methodology Review of staff charts by the Director of Nursing, Clinical Manager , EducationCoordinator or designee Responsibility Results will be submitted to the Director of Nursing, Clinical Manager or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-up. Re-evaluation: next quarter Plan if finding fail to meet acceptable standards: In-service to staff 127