QAPI Program Utilization_Manual

PLAN FOR IMPROVING AGENCY PERFORMANCE PERFORMANCE IMPROVEMENT PLAN (QAPI) POLICY: The agency, through the governing body (Board of Directors) and the Administrator, is accountable to the community for the adequacy and quality of all its services and products. Accountability is ensured through implementation of an effective Performance Improvement (QAPI) Plan, which encourages improvement governance, managerial, clinical, and support functions. The agency’s Performance Improvement (QAPI) Plan is an overall annual plan that focuses on methods to attain patient outcomes of the highest quality and meet or exceed patient expectations. The Performance Improvement (QAPI) Plan provides a collaborative, planned, systematic, agency-wide approach to designing, measuring, assessing, and improving process performance. It outlines the philosophy, principles, organizational structures, priorities, and approach used in fulfilling the agency’s purpose. The plan includes the following basic elements: · A general description of the agency service area, focus and scope of service provided · The agency mission statement · The agency vision statement · Agency strategic plans and goals PURPOSE: To design and implement a systematic multidisciplinary approach to improvement of patient and agency outcomes. Our Agency will develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven QAPI program. Our governing body will ensure that the program reflects the complexity of our organization and services; involves all Agency services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. The methods used by our Agency for self-assessment include a review of current documentation (e.g., review of clinical records, incident reports, complaints, patient satisfaction surveys, etc.); patient care, direct observation of clinical performance, operating systems and interviews with patients and/or personnel. The information gathered by the organization is based on criteria and/or measures generated by personnel. This data reflects best practice patterns, personnel performance, and patient outcomes. Ongoing means that there is a continuous and periodic collection and assessment of data. Assessment of such data enables identification of potential problems and indicates when additional data is needed. The following elements are considered within the Performance Improvement Plan activities: Program objectives Current documentation (e.g., review of clinical records, incident reports, complaints, patient satisfaction surveys, etc.) Patient care Direct observation of clinical performance Operating systems Interviews with patients and/or personnel All patient care disciplines Description of how the program will be administered and coordinated Methodology for monitoring and evaluating the quality of care Priorities for resolution of problems Monitoring to determine effectiveness of the action Oversight and responsibility for reports to the governing body Documentation of the review of its own program Written plan of correction is necessary when thresholds are not met Annual QAPI Evaluation SCOPE OF PERFORMANCE IMPROVEMENT (PI) ACTIVITIES The mission, vision, and strategic goals guide the agency in development of the scope of performance improvement. Additional PI activities will be prioritized by the agency’s senior management staff. It is a goal of the organization to perform PI activities in interdisciplinary teams whenever possible. 1