QAPI Program Utilization_Manual

ANNUAL PERFORMANCE IMPROVEMENT ( QA PI) REPORT Year: ___________ 9 Data collected as Part of the QI/PI activities including Services, Assessment, Outcomes monitoring, surveys, audits reports, etc during the year analyzed. _____________________________________________________________________________________ _____________________________________________________________________________________ Explain the effectiveness of our PI program: _________________________________________________ 9 Gather data needed for performing the analysis 9 all of our staff received a performance evaluation annually 9 the number of employees involved in PI program, receive a full year Orientation/Training to improve our services/care ___________________________________________________________________________________ 9 Effectiveness, quality and appropriateness of care/services provided to the patients, according Agency’s QA program, Accreditation standard ___________________________________________________________________________ ______________________________________________________________________________________________ 9 Care/service areas and community served, including cultural diverse population _____________________________ ________________________________________________________ 9 all staff trained in cultural diverse population 9 Any service provided under contractual arrangements (explain) __________________________________________ the effectiveness was analyzed, and follow our QA/PI program ____________________________________________ ______________________________________________________________________________________________ 9 Personnel utilization, staff recruitment as needed, ongoing activities ______________________________________ ______________________________________________________________________________________________ 9 Annually review of Policy and Procedures, update as needed following new State, Federal regulation and Accreditation Standards. Last revision: ________________________ 9 Revision of the Agency Forms as needed, including the Adequate documentation under new requirements in all of our services including 9 Nursing 9 Therapy 9 Aides 9 Social Services 9 Summary of all PI Activities, data collection, findings and corrective actions ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 9 Agency Annual Evaluation done on time, approved by Board of Director 9 Submitted to BD Report submitted by: _________________________________________ Director of Nursing, Clinical Manager Date: ______________________ 146