QAPI Program Utilization_Manual

QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Aspect Annual Performance Evaluation Indicator The field staff demonstrate competency in all job functions as measured by the results of their annual performance evaluation. 1. Personnel files shall be reviewed to determine whether a performance evaluation has been performed. 2. The performance evaluation is conducted at three months and yearly thereafter. 3. Competency evaluations are performed as indicated. Threshold 95% Sample Random a minimum of 10% of referrals Methodology Review of charts by the Director of Nursing, Clinical Manager 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: annually Plan if finding fail to meet acceptable standards: In-service to staff 128