QAPI Program Utilization_Manual

be well defined for ease and reliability of data collection. Indicators are often standards of care or practice that include objective clinical criteria established by authoritative sources and consensus. Establish Threshold for Evaluation To conclude that there is an actual problem requires intensive evaluation of the care provided. 1. Threshold is the pre-established point or level in the accumulated date (expressed in percentage), which initiates more intensive evaluation to determine if an actual problem exists. 2. As data is collected for each indicator it will direct attention to the areas in which a problem or opportunity to improve care exists. Collection and Organization of Data Data sources for monitoring and evaluation include: · Patient records · Laboratory reports · Incident/Occurrence reports · Committee meeting minutes/reports · Infection control reports · Grievance logs · Patient satisfaction surveys · Departmental logs Quality Appraisal data is collected on a monthly basis and reported to the Home Health QAPI Committee monthly and the Board of Directors quarterly. A 10% sampling of all clinical records will be reviewed monthly. Aspects of care selected for further monitoring and evaluations will be listed on a calendar according to frequency and assigned dates on which data is to be organized and compared to thresholds. Adverse Event Outcome Reports 1. The agency will incorporate the adverse event outcome reports into the agency's overall quality monitoring program. 2. The agency will have access to the adverse outcome reports. 3. The agency will investigate adverse outcomes quarterly to improve patient outcomes. 4. Corrective actions will be implemented when problems in care provision are identified. Evaluation of Care When data is selected for evaluation, staff members qualified in the particular area evaluate findings to determined the problem and evaluate opportunities to improve care. This evaluation may include analysis of patterns or trends in patient care that relate to specific therapies, skills or segments of the patient population. Action to Solve Identified Problems If the evaluation identified a problem or opportunity for improvement the QAPI Committee develops what corrective action is necessary, The QAPI Committee develops what corrective action is necessary and who or what is expected to change. The QAPI Committee monitors implementation of corrective action in view of the problem's cause, scope, and what is expected to occur. Assessment of Actions The results of continual monitoring and evaluation are documented to provide a record of the efficiency of the actions taken. If the quality and appropriateness of care in a specific area does not improve, then the problem, its cause and the action taken to solve it is assessed. New action is then taken, and once again, the effectiveness of the actions taken is assessed. Communication Monitoring and evaluating information is communicated to the QAPI Committee and departments through the established channels. Relevant findings from all monitoring activities are included in 60