QAPI Program Utilization_Manual

based on the agency’s mission, vision, and strategic goals · Coaching/facilitating/recording the proposals of the performance improvement teams · Coordinating survey preparations · Coordinating and reporting patient/referral source satisfaction indicators. Purpose The primary purpose of this Agency's Quality Assessment/Performance Improvement Plan(QAPI) is the ongoing monitoring and evaluation of the appropriateness of patient care, The QAPI Plan's goal is to consistently strive to improve the Agency's provision of care in accordance with patients' needs and professional and regulatory standards. The Quality Assurance/Performance Improvement Plan (QAPI) allows identified problems to be solved in an orderly and constructive manner and provides for measures to address identified opportunities for improvement. Procedure The QAPI Plan involves medical record review criteria and also incorporates certain QAPI activities that focus on areas with significant impact on the quality care for the Agency. These may include the Infection Control Log, as well as indicators developed as a result of significant trends or problem areas identified through record reviews. Reports from these areas will be evaluated to determined trends, patterns, and/or problems. The Agency QAPI Committee will make the recommendations necessary to resolve identified problems, must meet quarterly. Responsibility Responsibility for setting up review activity and the monitoring and evaluation relating to quality and appropriateness rest with the Administrator, DON, Clinical Manager, RN Supervisor, QAPI Coordinator, Medical Director, and other appropriate Agency staff. Scope of Care and Service This agency offers services 24 hours a day to patients of all ages. Ranges of services provided include: · Skilled Nursing · Home Infusion Therapy, High Tech Services · Home Health Aide Services · Physical Therapy · Occupational Therapy · Speech Therapy · Medical Social Worker Services are provided during the business hours of 9:00 am to 5:00 PM., Monday through Friday, with services provided during the weekend as indicated by patient needs. The Agency has an on-call system enabling a nurse to answer patient/family questions after hours and make scheduled and unscheduled visits as necessary. Important Aspect of Care The important aspects of care can be identified as high-risk, high-volume, or problem prone. These are aspects of care that occur frequently or affect large number's of patients; place patients at risk of serious consequences, or deprive them of substantial benefit if the care is not provided, provided incorrectly, or is provided when not indicated, or has tended to produce problems for staff and patients. Examples of Data Collection Form An indicator is a measure variable relating to the structure, process, or outcome of cam. It should 59