QAPI Program Utilization_Manual

Appropriate and valid study methods include but are not limited to the following: Audits Patient admission interviews Submitted patient concerns Patient survey forms Staff survey forms Community analysis survey forms Individual patient and staff interviews by telephone and in person Patient discharge/transfer interviews Group interviews Home Health Agency staff exit interviews Home Health Agency staff discipline meetings Patient/family case conferences Direct/indirect observations Patient education surveys Data regarding the effectiveness, i.e., the ability to achieve positive outcomes, of the action plans is collected, compiled and analyzed on a monthly basis. Samples are of sufficient size to provide an adequate representation of the areas/issues being studied. Monitored corrective actions are evaluated for actual or potential effectiveness in improvement in the delivery of healthcare. Confidentiality of client information will be maintained in a manner that is consistent with applicable Agency policies and procedures to preserve any confidentiality or privilege of information established by applicable laws. The data is displayed graphically within the Agency and is analyzed by the Performance Improvement Committee at least on a quarterly basis to ensure that targeted outcomes are being achieved. Statistically valid (  0.10) variances are analyzed immediately upon detection to facilitate improvement of processes, structure or outcomes. Performance measurement data is submitted to the Board of Directors for review and evaluation at least annually and more often if necessary. 81