QAPI Program Utilization_Manual

(a) Standard: Program scope. (1) The program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) Our HHA will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. (b) Standard: Program data. (1) The program will utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA will use the data collected to: (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. (c) Standard: Program activities . (1) Our HHA’s performance improvement activities must: (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. (2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. (3) Our HHA will take actions aimed at performance improvement, and, after implementing those actions, the HHA will measure our success and track performance to ensure that improvements are sustained. (d) Standard: Performance improvement projects . Our Agency will conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) Our HHA will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. (e) Standard: Executive responsibilities. Our governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That our Agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. ESTABLISHING PRIORITIES FOR PERFORMANCE IMPROVEMENT The priorities for performance improvement shall be established collaboratively by the agency’s leadership, composed of senior management staff and the QAPI Committee. The following criteria should be considered when establishing these priorities: High volume events (diagnosis, procedure, process) Agency mission, vision, and commitment Needs and expectations of patients and families, patient care, services Sentinel events Input from physicians and employees, with direct observation of clinical performance Input from external sources (licensing, regulatory agencies, other groups) Resources to make improvements QUALITY STRATEGIES In order to provide a consistent approach to performance improvement throughout the organization, the agency has adopted the Focus-PDCA model. Focus-PDCA is a step-by-step, systematic approach that guides teams in process improvement: Find a process to improve Organize a team that knows the process Clarify current knowledge of the process Understand the causes of process variation 2