QAPI Program Utilization_Manual

Select the proves improvement Plan the improvement and continue data collection Implement the improvement, data collection, and analysis Verify the results and the lessons learned from the team effort Act to standardize the improvement and continue to improve the process IDENTIFIED CUSTOMERS The agency’s primary external customers are patients and their families, referring physicians, community residents, other health care providers, managed care companies, and third-party payers. Internal customers include the Board of Directors, administration, management, and employees. IMPORTANT AGENCY-WIDE FUNCTIONS/DIMENSIONS OF PERFORMANCE The agency has identified the following organization-wide functions as key to the delivery of patient care services and patient outcomes: Patient-Focused Functions Patient Rights and Responsibilities and Organizational Ethics Assessment of Patients Care of Patients Patient and Family Education Continuum of Care, Staff interventions, direct observation of clinical performance Organizational Functions Improving Organizational Performance Leadership Management of Environment of Care Management of Human Resources Management of Information Surveillance, Prevention, and Control of Infection The agency functions shall be measured and assessed in terms of the appropriate dimension of performance. Processes involved may include those related to governance, management, clinical, and/or support activities. Performance dimensions include the following: 1. Efficacy – The degree to which care of the patient has been shown to accomplish desired or projected outcome(s). 2. Appropriateness – The degree to which the care is relevant to the patient’s clinical needs 3. Availability – The degree to which appropriate care is available to meet the patient’s needs 4. Timeliness – The degree to which care is provided to the patient at the most necessary or beneficial time 5. Effectiveness – The degree to which care is provided in the correct manner, given current state of knowledge, to achieve the desired or projected outcomes, direct observation of clinical performance 6. Continuity – The degree to which care is coordinated and consistent among providers or organizations over time 7. Safety – The degree to which interventions and environmental risks are minimized for the patient and others, including the health care provider 8. Efficiency – The relationship between outcomes (results of care) and the resources used to deliver patient care 9. Respect and Caring – The degree to which the patient or designee is involved in his or her own care decisions, and the degree to which those providing services are sensitive and respectful of the patient’s needs, expectations, and individual preferences FRAMEWORK FOR IMPROVING ORGANIZATIONAL PERFORMANCE Education The leadership of the agency will be educated in the mechanisms of performance improvement. Quality Improvement (QI) staff will organize performance improvement education programs at regular intervals as well as on an “as needed” basis. This education will be extended from leadership to staff throughout the agency. Staff will be oriented to application of performance improvement theory (Focus-PDCA). Ongoing education will serve to reinforce this training. Methods of education will include, but not be limited to, the following: A. Literature distributed to staff B. On-site conferences/classes/in-service 3