Performance Improvement Program
The agency's Performance Improvement Program is composed of:
- The Professional Advisory/Quality Improvement Program (Mandated by NYSDOH)
- Patient Satisfaction Survey
- Additional Components/Activities
The goal of the agency is to provide safe, high quality and effective home care services to patients of all ages. A quality assurance process contributes to me provision of continually improving services.
Quality improvement is the responsibility of all staff. At every level, at all times. Supervisory personnel alone cannot ensure quality of care and services. Such quality must be apart of each individual's approach to his/her daily responsibilities.
QUALITY IMPROVEMENT COMMITTEE
The Mission of the agency is to provide safe, high quality and effective home care services to patients of all ages. A quality improvement process will contribute to the provision of continually improving services.
AGENCY SCOPE OF SERVICES
Services include the provision of nursing and paraprofessional services along with appropriate patient/caregiver instructions.
Requests for services are accepted by the Supervising Nurse and provided by qualified agency staff.
SCOPE OF QUALITY IMPROVEMENT PROCESS:
The Quality Improvement Program is a coordinated, multi disciplinary, integrated assessment and improvement process contributed to by ail levels of staff representing the various services and care provided. Results of Quality Improvement activities will be utilized to improve patient care, develop policy and procedure, staff development and serve as a source of planning data for agency development.
QUALITY IMPROVEMENT PROGRAM OBJECTIVES
- Assess and improve patient care.
- Assess and improve patient satisfaction.
- Monitor provision of Care in order to identify: critical areas in need of improvement, staff training needs, policies and/or procedures in need of development or revision.
The Quality Improvement Committee is responsible to:
- Establish and oversee the standards of care.
- Analyze and evaluate the quality or patient care provided by the staff as documented in the patient's record.
All patient and employee documentation and communication regarding quality improvement activities will be kept confidential. Patient names will not appear on QI forms, patient numbers will be used. All QI forms and reports will be kept in a secure place within the administrative office.
- Membership The governing authority shall appoint members on a rotating basis for two year terms with reappointment to consecutive terms an option. As an exception to the two year appointment, staff members representing various services may be rotated in order to expose them to the process and gain input from a number of staff.
The Committee shall consist of a minimum of one person representing the following categories:
- Practicing Medical Doctor;
- Registered Professional Nurse(s);
- Representatives of all categories of staff (i.e. Aide, Coordinator, Therapist)
- Administrator and
- Director of Patient Services/designate from a certified, long term home health or hospice agency which contracts with or refers the to the Agency for service.
- Specialists in areas of concern (i.e. Pharmacologist, Infection Control).
- Schedule The Administrator shall be responsible to schedule and call the four meetings in accordance with agency policy and shall notify members of me meetings and document activities/minutes of the committee in accordance with agency policy.
- Responsibilities, Components, and Reporting
- Meet at least four times a year.
- Review all agency policies related to the delivery of health care services and recommend changes in such policies to the governing authority for adoption as needed but at least annually. Review and recommend action to GA on any policy changes or additions.
- Conduct Patient Satisfaction Surveys.
- Assist in maintaining liaison between the agency and other health care providers.
- Conduct a clinical record review of the safety, adequacy, type and quality of services provided; Review all cases with patient grievances filed since the previous meeting; Recommend follow-up on issues arising from the record review and assess the response at the next meeting;
- Submit a written summary, following each meeting and annually, of committee findings and recommendations to the governing authority for review and action.
- Review the QI Plan annually and revise as indicated.
- Clinical Record Review
- The procedure for selecting records for review include:
- Randomly select records of patients currently receiving services and records of patients discharged within the prior three months. A total of 4 Active and 1 Discharge record of direct patients is to be reviewed at each meeting. As the census increases amaximum of 10% of cases are to be reviewed each year.
- All records of patients who have filed a grievance/complaint during the previous three months; and
- Other records submitted by staff for special review
- Specific Record Review Forms are to be used for the review process which is conducted by the committee at the meeting.
- Monitoring and Evaluation
- Process and Goals: The quality and appropriateness of care is systematically monitored and evaluated. The goal of these activities is to prevent undesirable change in quality, to identify methods to improve patient care and to maintain agency function.
- Evaluation of Services: the Administrator will analyze data on a regular basis, at least four times a year. Corrective actions for identified problems will be implemented.
- Other Activities "Which Identify Potential Areas for improvement:
- Suggestions from staff;
- Patient satisfaction survey summary;
- Complaints from patients, families, physicians or other , agencies.
- Incident Reports
- Monitoring and Evaluation
- Corrective Action - Implementation of corrective action is the primary responsibility of the management staff and the Board of Directors. Tins process includes:
- The Administrator or designate compiles and reviews problems.
- Results and/or problems identified are discussed as applicable.
- Decision is made whether there is a problem, whether further investigation is required, or if corrective action is required.
- Further investigation or corrective action is taken.
- The Administrator reviews corrective action within a month after corrective action is implemented to evaluate its effectiveness.
- The procedure for selecting records for review include:
- Documentation Minutes of meetings which are maintained on file at the agency shall include:
- Date, length, time and location of meeting.
- Members in attendance, excused or absent.
- Number and type of records reviewed.
- Summary of findings.
- Actions recommended.
- Report on follow up of recommendations from previous meetmg(s).
- Policies and procedures reviewed/revised and recommendations made to the Governing Authority.
PATIENT SATISFACTION SURVEY
To monitor and evaluate on an ongoing basis patient's satisfaction level with the availability, knowledge, skills and services provided by agency staff.
- Staff encourage the patient to complete the Patient Satisfaction Survey form.
- The Administrator/designate will send a Patient Satisfaction Survey form to each patient upon discharge from services and/or semi-annually for those patients remaining on service for an indefinite period of time.
- Completed Patient Satisfaction Surveys will be aggregated and analyzed. The results are presented to the QI committee for discussion at each meeting.
- The survey forms are reviewed with staff on an ongoing basis for immediate reviewand/or response to individual patient situations.
ADDITIONAL QUALITY IMPROVEMENT COMPONENTS/ACTIVITIES
To identify supportive activities which, in conjunction with those carried out by the QI Committee, contribute to the quality of services provided and integrate all agency operations for performance improvement.
- Role of Governing Authority
- Contract Requirements and Monitoring
- Fiscal Policies
- Grievance/Complaint Procedure
- Occurrence Reporting
- Patient Rights
- Patient Self Determination
- Service Policies
- Admission and Discharge Policies
- Supervision: Periodic on-site supervision visits
- Patient Care Procedures
- Medical Relations Policies
- Home Care Record Documentation Policies and System
- Infection Control Policies & Practices
- Emergency Planning and Education
- Human Resource/Personnel Practices
- Licensure/Certifi cation Verification
- Employment Verification
- Health Status Verification
- Employee Orientation and Education
- Competency Evaluations
- Defined Job Descriptions
- Confidentiality Policies
- NYS Licensure Regulation