QAPI Program Utilization_Manual

PERFORMANCE MEASUREMENT POLICY: Measurement of process outcomes facilitates improvement in the quality of patient care. The Agency selects and utilizes a performance measurement system that meets the Accreditation Organization's requirements for inclusion in the accreditation process and simultaneously best promotes attainment of the Agency's strategic measurement goals. Performance measures are selected based on their impact on patient/client care, services offered, clinical practice, fiscal accountability and cost effectiveness. Areas targeted for improvement include, but are not limited to, those that are high-cost, high-risk, high- volume and problem-prone. Additionally, these areas offer genuine opportunities to improve the quality of care. PROCEDURE:  The Agency identifies a minimum of four (4) or six (6) clinical and/or perception of care measures to monitor and evaluate. Note: The number of measures chosen is dependent on the Agency's average annual census. With an average annual census of 120 or more patients are required to choose a minimum of six (6) measures by 12/31; with an average annual census of less than 120 patients are required to have chosen four (4) measures by 12/31.  Data is collected and evaluated to ensure that the selected measures fulfill the criteria of high-volume, high-risk, high-cost and/or problem-prone.  Data is collected to measure performance of each of the following potentially high-risk processes: Medication management Blood and blood product use, as appropriate Multiple internal/external data sources are organized to monitor and assess home health services for quality of healthcare. Internal data sources include, but are not limited to, the following: Patient clinical records  Patient accident/incident reports  Medication error reports, including reports of near misses  Infection control reports  Patient perception of care/satisfaction questionnaires  Patient letters and/or comments regarding services  Staff competency assessments  Cost benefit analysis  Performance improvement activity form 79