QAPI Program Utilization_Manual

C. Seminars, conferences, workshops, or other meeting devoted to providing performance improvement education D. New employee orientation ORGANIZATION PERFORMANCE IMPROVEMENT ACTIVITIES All process improvement activities carried out within the organization should be performed as described in this plan and, as appropriate, be performed in an interdisciplinary team setting utilizing the elements of process design, performance measurement, aggregation and analysis, and performance improvement as described below: Process Design Senior management staff serves as an ongoing forum in which new processes and services identified for improvement are presented and evaluated. As a part of this review process, the following information is used to design more effective processes, functions, or services: A. Evidence that the proposed design supports the agency mission, vision, and strategic goals, or that the proposed design meets or exceeds stipulated quality control or other requirement and/or standards B. The needs of individuals served, staff, and others C. Up-to-date information (practice guidelines, information from relevant literature, clinical standards, etc.) D. Sound business practice E. The use of information available from other agencies to help reduce the occurrence of sentinel events and other unusual occurrences F. The results of performance improvement activities G. The organization incorporates information related to these elements – when available and relevant-in-the design or redesign processes, function, or services Performance Measurement (Data Collection) Monitoring the performance through data collection (performance measurement) is the foundation of all performance improvement activities. Because of limited resources, performance measures cannot be collected for everything. Leaders determine the important processes for improvement based on agency mission, available resources, functions, as well as concerns of the individuals served, their families, payers, and other customers. Data collection is used to accomplish the following: Establish a performance baseline Assess the dimensions of performance relevant to functions, processes, and Outcomes Measure the level of performance and stability of important existing processes (identify variations) Identify areas for possible improvement in existing processes Determine whether process changes made actually improve outcomes Data to monitor performance may be collected from the following sources: a. Performance measures related to accreditation and other regulatory surveys b. Risk management c. Utilization review d. Quality control, including safety issues e. Staff surveys and questionnaires f. Outcomes of processes or services g. Performance measures from acceptable databases patient demographics h. Diagnoses Financial data i. Infection control surveillance and reporting j. Published research data The following requirements are collected: Patient, Employee and physician satisfaction questionnaires Moments of processed including the following: 1. Adverse drug reactions and medication error reports 2. Care or services provided to a high-risk patient 3. Summary or incident reports and complaint log 4. Care or services provided to high-risk populations Data will also be collected to accomplish the following: a.Monitor performance of targeted areas, such as process stability, risk, b.Sentinel events, and events that require root cause analysis 4