QAPI Program Utilization_Manual

CLINICAL RECORD AUDIT RESULTS AND TREND Clinical audit is about measuring the quality of care we provide against relevant standards. If we are failing to meet these standards, the audit should help us understand the factors that are causing us to fail, so that we can set priorities and make improvements. Instructions: Auditing forms part of a cycle of activities: Selecting standards (setting our own or adopting existing standards or guidelines), Doing the audit (or analyzing the results of ongoing monitoring) and identifying where we are failing to meet standards, Identifying the factors causing us to fail, setting priorities, and taking actions to improve what we do. Checking whether we have improved (by doing a full re-audit or by monitoring one or two indicators, for example, visual outcome or patient numbers) and finding other solutions if we have not improved. If we have improved, repeating the cycle to identify and address the next set of problems or to measure ourselves against a new set of standards. Every time an audit cycle is completed, there should be further improvement in patient care. Clinical Audit results: Quarter: ___________________ Year: _______________ STANDARD Analyzing the results Ongoing Monitoring Fail reason, Priorities Action taking to improving Results of audition Trends/Outcomes Assessment on time/Quality Plan of Care compliance for all disciplines (Nursing, Therapy, Aides) Safety issues, Fall prevention Infection Control/Handwashing Disease / Pain Management Patient response to instructions, teaching Diabetes Management Agency Clinical Records State/Federal/Accreditation standards compliance Discharge Planning Patient complaints, feedback, follow up care referrals Director of Nursing, Clinical Manager signature/Date: _____________________________________________ Discussed in Clinical Record Review Committee on: __________________ Discussed in the BD meeting on: ___________________ 143