QAPI Program Utilization_Manual

QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN (QAPI) POLICY: The plan for improvement of organizational performance is derived from the agency philosophy and mission/ purpose, goals and objectives, and plans. SENIOR MANAGEMENT STAFF The Administrator and the DON, Clinical Manager have the responsibility, as delegated by the Board of Directors, for the quality and value of services. The President and Senior Management Staff shall oversee the development and implementation of the performance improvement activities. This leadership team shall be responsible for the following activities: · Ensuring that important internal processes and activities throughout the organization are continuously and systematically measured, assessed, and improved · Establishing priorities for performance improvement projects based on the agency’s mission, vision, and strategic goals · Allocating resources for assessing and improving the organization’s governance, including managerial, clinical, and supportive services · Ensuring that quality review activities are consistent with accreditation, state, federal, and regulatory agency requirements · Modifying the plan for improving the provision of patient care. · Client outcome monitoring is conducted through a structured process · Adverse event reports are reviewed and potential or actual problem areas are targeted for correction or improvement. BOARD OF DIRECTORS The Board of Directors has the ultimate authority and responsibility for ensuring the provision of optimal care and organization-wide performance. The Board of Directors shall facilitate performance improvement through the following responsibilities: Establishing the strategic direction of the agency Requiring reports and mechanisms for monitoring and evaluating the quality of patient care services Providing resources and support systems for performance improvement (QAPI) functions related to patient care services and safety Requiring mechanisms to ensure that all patients with the same health problems are receiving comparable levels of care Reviewing information needed to educate the Board members of their responsibility for quality patient care Evaluating and approving the performance improvement plan and the plan for the provision of patient care on an annual basis. The Board of Directors receives reports from Manager of QAPI regarding concerns and issues. QUALITY IMPROVEMENT STAFF Quality Improvement (QAPI) Staff shall be responsible for supporting the agency’s implementation of performance improvement principles, strategies, priorities, approach, and methodologies. The Quality Improvement (QAPI) Staff will assist in the following activities: · Providing guidance/education to the patient care staff and other services or teams in the design, measurement, assessment, and improvement of processes under study · Facilitating and coordinating the reporting of interdisciplinary teams · Ensuring that important internal processes and activities throughout the organization are continuously and systematically measured, assessed, and improved · Providing guidance in establishing priorities for performance improvement (QAPI) projects 58