Continuous Quality Improvement (CQI) Plan Policy Number:

Transcription

1 Continuous Quality Improvement (CQI) Plan Policy Number: Effective Date: 07/23/2009 Reviewed/Revised Dates: 04/02/2010, 09/29/2011, 09/27/2012, 09/26/2013, 01/29/2015, 4/16/16 1. PURPOSE: PATHS Continuous Quality Improvement (CQI) system, in keeping with the organization s mission, strategic plan, and health care plan, provides for methods and tools to continuously assess and prioritize quality improvement initiatives to assure that the organization addresses the goals set forth in the organizational strategic plan, meets set requirements (both imposed by other organizations and those set internally), demonstrates prudent management of resources, including staff, and emphasizes optimal outcomes for patients. The ultimate goal for PATHS CQI plan is to cultivate a work environment encouraging a genuine effort to provide the highest quality of services to the communities in which we provide care. It is the responsibility of the organization to support and facilitate each person s efforts to continuously improve the quality of care and service that PATHS provides. Each staff member is obligated to provide the highest quality of care to patients served by PATHS. However, the governing board of PATHS is ultimately responsible for ensuring that the CQI plan is carried out effectively by holding accountable each person involved in the process and by reviewing the CQI reports presented at scheduled meetings and as needed. 2. PERSONNEL: All staff throughout PATHS and its associated programs. 3. PROCEDURE: A. General: PATHS CQI System is designed to encourage data-driven quality improvement initiatives with the following key components: I. Attention to ongoing monitors that regulate quality control, safety and state competency; II. Measurement and assessment of problem prone areas (including high risk and high volume procedures); III. Prioritizing quality improvement efforts; IV. Evaluation of care provided as evidenced by EMR documentation, and CQI Plan Page 1 of 17

2 V. The design of new systems and services, as necessary. B. PDSA: All quality improvement initiatives will involve four steps using the PDSA method: Plan, Do, Study, Act. This method provides a safe, systematic approach toward leading change that allows for work-plans to change and adapt until the desired outcome is achieved, which happens prior to a gradual spread of the work-flow or process across an entire patient population. All activities will be tracked and documented throughout the improvement process using a Quality Improvement Initiative Report (See Appendix A). More information about effectively managing PDSA cycles can be found at: y_and_service_improvement_tools/plan_do_study_act.html#sthash.raam Z1l6.dpuf C. PRIORITIZATION: In keeping health care costs down while addressing quality improvement, it is important to prioritize quality improvement initiatives. PATHS CQI Plan addresses the following priorities: I. Patient, family and staff safety; II. Patient satisfaction; III. High risk, high volume procedures and/or activities; IV. Problem-prone areas; and V. Cost containment. D. ONGOING QUALITY CONTROL MEASURES: I. In order to facilitate efficient ongoing management of quality improvement initiatives, PATHS CQI Plan emphasizes the following ongoing, organization-wide, mandatory quality control monitors: a. Clinical measures; b. Outcome measures; c. Organizational performance measures; d. Clinical coordination; and e. Quality care coordination. II. PATHS has developed a schedule of quality measures that will enable PATHS to both observe that quality is maintained and identify areas needing improvement (See Appendix B). The list of monitors will be reviewed at least once annually, but more often as PATHS operational need dictates. More detailed audits in CQI Plan Page 2 of 17

3 these areas can be triggered on a case-by-case basis when a problem is identified. Any audits in these areas will be reported to PATHS Clinical Director, Chief Medical Officer, Chief Operations Officer and/or Chief Executive Officer, as well as the CQI Committee as needed. III. All staff members are encouraged to identify areas needing improvement. Once a problem is identified, the staff member should bring the problem to the attention of his or her supervisor. The supervisor should then collect information to determine if the problem is an isolated incident or a trend. If the incident is determined to be isolated, the supervisor will document it on the incident report, take corrective action and file it appropriately. If the incident occurs again it will be determined to be a trend. Data supporting the need for improvement is crucial to initiating an improvement project. This initial data is used to support the need for improvement and will be used for later comparison to determine if the plan for improvement worked. After identifying the area needing improvement and collecting the data to support the need for change, a Quality Initiative Report Form is generated (see Appendix A). The initiative is then reported to the CQI Committee, with quarterly updates, until the initiative is complete. 4. COMMITTEE STRUCTURE: A. Key senior management team members make up the committee, which must include: I. Chief Executive Officer (CEO); II. Clinical Director III. Chief Operating Officer (COO); IV. Chief Financial Officer (CFO); V. Program Directors; VI. Program Managers; and VII. Representative from Board of Directors. B. Other members may be added, or invited to attend, as required in order to ensure committee effectiveness. C. Generally, the committee will be guided by the following: I. Meetings will occur at least quarterly; II. Minutes must be recorded; III. A schedule of quality control monitors must be developed; CQI Plan Page 3 of 17

4 IV. Patient data from all clinical areas to include; Medical, Dental and Behavioral Health Services, is extracted from PATHS EMR and presented on all control measures; V. Quality Improvement Initiative Reports are submitted and reviewed on all improvement initiatives; and VI. A summary of all activities and data on all control monitors will be submitted to PATHS Board of Directors for review. 5. QUALITY CARE COORDINATION: A. PATHS Clinical Director, with support from the Senior Management Team (department leads) is responsible for overseeing clinical quality improvement. Primarily, it is his/her responsibility to act as a liaison to help each other in improving care organization wide. The Chief Medical Officer and Chief Operating Officer are resources for dealing with quality issues and educating staff in how to help improve quality of care and services. B. The COO and CFO are responsible for overseeing quality improvement in fiscal and patient registration areas. C. The Clinical Director, CMO and COO are responsible for overseeing quality improvement as it relates to patient care. D. Early identification of trends that may indicate a weakness in striving for continuous clinical quality improvement will prevent safety issues and promote optimal patient outcomes. E. The Chief Medical Officer and Clinical Director are responsible for facilitating cohesiveness among all providers. This is accomplished through activities that review the care provided in order to ensure the practice of evidenced based medicine and that progress toward outcome measures goals, established by regulatory agencies, are being made. One such avenue is peer review by all providers and mid level providers of the clinical chart audit findings from the Quality Control Monitors. (See PATHS Policy # : Peer Review). F. Privileging and Credentialing processes are led by the Director of Human Resources according to PATHS Policy #: : Appointment, Credentialing and Privileging of Licensed Health Care Providers. 6. PLAN REVIEW/REVISION: This plan will be reviewed at least once annually by PATHS Board of Directors, and revised as necessary CQI Plan Page 4 of 17

5 7. SIGNATURES: Board Chair Chief Executive Officer Chief Medical Officer/Medical Director Chief Operations Officer Clinical Director / / Date / / Date / / Date / / Date / / Date CQI Plan Page 5 of 17

6 APPENDIX A: Quality Improvement Initiative Report This form is to be used to report initiation of progress on improvement projects. Attach additional sheets as necessary. 1. Opportunity to improve (describe): 2. Priority Rationale (check all that apply): High Risk High Volume Problem-prone Cost Satisfaction 3. Dimension of Performance Addressed (check all that apply) Efficacy Timeless Safety Appropriateness Effectiveness Efficiency Availability Continuity Respect/Caring Other: 4. Leader (Name): 5. Departments Included (check all that apply): Medical CHAAP MEDAssist Behavioral Health Finance Dental Pharmacy Billing IT Human Resources AHEC Outreach & Enrollment Other: 6. Date need for improvement was identified: / / 7. Need for improvement identified by (Name): 8. How was the need for improvement identified? (Control Monitor Review, Chart review, Survey, Audit, Site Visit, etc): Page 6 of 17

7 9. Measurement data utilized : 10. Suggested plan for improvement: Leader Signature: Date: / / STOP HERE! Submit completed form to CQI Committee for review. If the project is approved, be prepared to do the following, and provide updates on a quarterly basis: 1. Establish and describe a plan for improvement (include action steps, timeline and projected use of financial and human resources). 2. Provide evidence of measurable improvement. 3. Provide a plan to evaluate for continued improvement. Summary of Outcome: SUBMIT COMPLETED REPORT TO THE CQI COMMITTEE. Leader s Signature: Date Completed: / / Date Reviewed by CQI Committee: / / CQI Committee Chairperson s Signature: Page 7 of 17

8 APPENDIX B: Quality Monitors Line # 1 ORGANIZATIONAL WIDE MEASURES 1.A. 1.A.i. 1.A.ii. 1.A.iii. 1.A.iv. 1.A.v. 1.A.vi. 1.A.vii. 1.A.viii. 1.A.ix. 1.A.x. 1.A.xi. 1.B. Staff Competencies by Department (Human Resources) Department 1. Administration 2. CHAAP 3. Finance/Billing 4. MEDAssist 5. Patient Navigators 6. Patient Service Representatives 7. Providers 8. Clinical Support 9. Pharmacy 10. Dental 11. Behavioral Health Monthly Fire Extinguisher Check (OSHA) 1.B.i. 1.B.ii. 1. # Extinguishers Inspected 2. # Times each Extinguisher Inspected 1.C. Annual Professional Inspection of Fire Extinguishers (OSHA) 1.C.i. 1.C.ii. 1.C.iii. 1.C.iv. 1.D. 1.D.i. 1.D.ii. 1. Boydton 2. Chatham 3. Danville 4. Martinsville Employee OSHA Training (OSHA) 1. # New Hires via Film & Quiz 2. Annual Employee Training via eleap 1.E. Work-Related Injury Reports (Forms 301 or 300) (OSHA) 1.E.i. 1.F. # Forms Completed Incident Reports Page 8 of 17

9 1.F.i. 1.F.ii. 1.F.iii. 1. Safety/Risk Management 2. HIPAA/Security 3. Compliance 1.G. Annual Fire Drills (OSHA/Emergency Preparedness) 1.G.i. 1.G.ii. 1.G.iii. 1.G.iv. 1. Boydton 2. Chatham 3. Danville 4. Martinsville 1.H. Bi-Annual General Hazard/Environmental Safety Surveillance Surveys (OSHA/Emergency Preparedness) 1.H.i. 1.H.ii. 1.H.iii. 1.H.iv. 1. Boydton 2. Chatham 3. Danville 4. Martinsville 1.I. Blood Borne Pathogen Risk Assessment (OSHA) 1.I.i. 1.I.ii. 1.I.iii. 1.I.iv. 1.I.v. 1.I.vi. 1. Actual # Staff Assessed 2. Actual # Staff Found to be At Risk 3. Actual # Staff Needing Hep B Immunization 4. Actual # Staff Received Hep B Immunization 5. Actual # Staff Needing Blood Borne Pathogen Risk Training 6. Actual # Staff Trained on Blood Borne Pathogen Safety 1.J. Material Safety Data Sheet (MSDS) Manual Updates 1.J.i. 1.J.ii. 1.J.iii. 1.J.iv. 1. Boydton 2. Chatham 3. Danville 4. Martinsville 1.K. Annual Evaluation of Safer Sharps (Needles, etc.) (OSHA) 1.K.i. 1.K.ii. 1.K.iii. 1.K.iv. 1. Boydton 2. Chatham 3. Danville 4. Martinsville 1.L. Employee Tuberculosis (TB) Risk Assessments (OSHA) 1.L.i. 1.L.ii. 1. Actual # Staff Assessed 2. Actual # Staff Found to be At Risk Page 9 of 17

10 1.L.iii. 1.L.iv. 1.M. 3. Actual # Staff Needing TB Immunization 4. Actual # Staff Received TB Immunization Coding Audits (Compliance/Risk Management) 1.M.i. 1.M.ii. 1.M.iii. 1.M.iv. 1.M.v. 1.M.vi. 1.M.vii. 1. Actual # Charts Audited 2. Actual # Charts Needing Coding Improvement 3. Actual % Charts Needing Coding Improvement 4. Actual # Charts Undercoded 5. Actual % Charts Undercoded 6. Actual # Charts Overcoded 7. Actual % Charts Overcoded 1.N. New Hires by Department & Location 1.N.i. 1.N.ii. 1.N.iii. 1.N.iv. 1.N.v. 1.N.vi. 1.N.vii. 1.N.viii. 1.N.ix. 1.N.x. 1.N.xi. 1.N.xii. 1.N.xiii. 1.N.ixv. 1.N.xv. 1.N.xvi. 1.N.xvii. 1.N.xviii. 1.N.ixx. 1.N.xx. 1.N.xxi. 1.N.xxii. 1.N.xxiii. 1.N.ixxv. 1.N.xxv. 1.N.xxvi. 1.N.xxvii. 1.N.xxviii. 1.N.ixxx. 1.N.xxx. 1.N.xxxi. 1. Administration 2. CHAAP 3. Finance/Billing 4. MEDAssist 5. Pt Nav/Outreach - Boyd 6. Pt Nav/Outreach - Chat 7. Pt Nav/Outreach - Dan 8. Pt Nav/Outreach - Mart 9. Med Front Desk - Boyd 10. Med Front Desk - Chat 11. Med Front Desk - Dan 12. Med Front Desk - Mart 13. Med Provider - Boyd 14. Med Provider - Chat 15. Med Provider - Dan 16. Med Provider - Mart 17. Nursing - Boyd 18. Nursing - Chat 19. Nursing - Dan 20. Nursing - Mart 21. Pharmacy 22. Dent Ft Desk - Boyd 23. Dent Ft Desk - Dan 24. Dent Assist - Boyd 25. Dent Assist - Dan 26. Dent Provider - Boyd 27. Dent Provider - Dan 28. Behav Health - Boyd 29. Behav Health - Chat 30. Behav Health - Dan 31. Behav Health - Mart Page 10 of 17

11 2 FINANCIAL MEASURES (By Quarterly Average) 2.A. 2.B. 2.C. 1. Actual # Days Cash-on-Hand (Goal: >/= 60) 2. Actual Current Ratio (Goal: >/= 1:1) Actual Payor Mix (% Uninsured) (Goal: </= 31%) 3 CLINICAL MEASURES (Medical) Measure Goal Blood Pressure 90% Measurement Blood Pressure 90% Measurement (CVD) Blood Pressure 90% Measurement (DM) Blood Pressure Control 57% Blood Pressure Control 50% (CVD) Blood Pressure Control 40% (DM) BMI Measurement 90% BMI Measurement Age 90% 2-17 BMI Measurement Age 90% 18+ BMI Underweight Age 2-17 BMI Healthy Weight Age 2-17 BMI Overweight Age 2-17 BMI Obese Age 2-17 BMI Age 18+ BMI >30 Age % HbA1C Measurement 71% HbA1C Good Control 53% (<7) HbA1C Poor Control 16% (>9) LDL Measurement LDL Control <100 ASA Antithrombotic Use UDS Tobacco (Extended) UDS Tobacco (Standard) UDS IVD & ASA/Anti- Thrombotic Therapy UDS Adult BMI Screen/Follow-Up UDS Pediatric BMI <Current Year> <Prev Yr1> <Prev Yr2> <<Qtr>> YTD # % # % # % # % Page 11 of 17

12 Assessment & Counseling UDS Colorectal Cancer 71% Screen * UDS A1c <7% UDS A1c 7<=8% UDS A1c 8<=9% UDS A1 >9% or no test 16% * UDS BP in Control * 61% UDS Cervical Cancer 93% Screen* UDS Childhood 80% Immunization * *=HP202 Goal Page 12 of 17

13 4. OTHER INDICATORS 4.A. 4.A.i. 4.A.ii. 4.A.iii. 4.A.iv. 4.A.v. 4.A.vi. 4.A.viii. 4.B. 4.B.i. 4.B.ii. 4.B.iii. 4.B.iv. 4.B.v. 4.B.vi. 4.B.vii. 4.B.viii. MEDAssist Program Actual % Telephone Calls from Patients Documented Appropriately Actual % Patient Medication Formularies Updated between The Pharmacy Connection (TPC) (MEDAssist s Computer System) and eclinicalworks (Electronic Medical Record System) Patient Satisfaction: Actual # Written Patient Complaints Patient Satisfaction Surveys, Actual # Overall Rating Great (Score: %) Patient Satisfaction Surveys, Actual # Overall Rating Good (Score: 61-80%) Patient Satisfaction Surveys, Actual # Overall Rating OK (Score: 41-60%) Patient Satisfaction Surveys, Actual # Overall Rating Poor (Score: 0-20%) CHAAP Program 1. Actual % of Verified HIV Status in Active Patient Records 2. Actual % of Verified Income in Active Patient Records 3. Actual % of Records having All Release Forms signed within Last Year 4. Actual % of Records containing Updated Lab (CD4 and Viral Load) Values from Last 6 Months 5. Actual % of Records Containing Current Individualized Service Plans (Updated in the last 6 Months) 6. Actual # of Patients who Did Not Complete Screening Process Due to Lack of Ability to Provide Proper Documentation 7. Actual # Patients who Returned to Care 8. Actual # Patients Discharged Due to Compliance Issues Page 13 of 17

14 4.B.ix. 4.B.x. 4.B.xi. 4.B.xii. 4.B.xiii. 4.B.ixv. 4.B.xv. 4.B.xv. 4.B.xvi. 4.B.xvii. 4.C. 4.C.i. 4.C.ii. 4.C.iii. 4.C.iv. 4.C.v. 4.C.vi. 4.C.vii. 4.D. 4.D.i. 4.D.ii. 4.D.iii. 4.D.iv. 4.D.v. 9. Patient Satisfaction: Actual # Written Patient Complaints 10. Actual # Patients Tested using Rapid Test 11. Actual # Patients Tested using Rapid Test - Boydton 12. Actual # Patients Tested using Rapid Test - Chatham 13. Actual # Patients Tested using Rapid Test - Danville 14. Actual # Patients Tested using Rapid Test - Martinsville 15. Actual # Patients who Refused Results Actual # Patients who Requested Results Actual # Patients who were Tested and Screened Reactive, Requiring Additional Testing Actual # Patients were Tested, Screened Reactive, and Received Additional Testing Pharmacy 1. Actual # Scripts that Could Not Be Filled Same Day Due to Lack of Inventory 2. Actual # Scripts Not Picked Up and Returned to Inventory 3. Total # Scripts Filled 4. Actual # Refrigerator Temperature Readings Outside Normal Range (36-46*F) 5. Actual # New Patients 6. Actual # Daily IVR Call Out Failures due to Data Entry Error 7. Actual # Daily Fax Failures Medical Centers Patient Satisfaction Survey Average Score (Range 1.0 Poor 3.0 Good): Boydton Patient Satisfaction Survey Average Score (Range 1.0 Poor 3.0 Good): Chatham Patient Satisfaction Survey Average Score (Range 1.0 Poor 3.0 Good): Danville Patient Satisfaction Survey Average Score (Range 1.0 Poor 3.0 Good): Martinsville Actual # Written Patient Complaints Page 14 of 17

15 4.D.vi. 4.D.vii. 3.K.viii. 4.E. 4.E.i. Actual # Sentinel Events Actual # Events Resulting in Potential Adverse Outcome Actual # Patient Records reviewed during Peer Review Process AHEC Program Health Profession Students Participating in Community Based Training: Actual # Interested in Working in Primary Care Setting Page 15 of 17

16 4.E.ii. 4.E.iii. 4.E.iv. 4.E.v. 4.F. 4.F.i. 4.F.ii. 4.F.iii. 4.F.iv. 4.F.v. Health Profession Students Participating in Community Based Training: Actual # Interested in Working in Rural Setting Health Profession Students Participating in Community Based Training: Actual # Interested in Working with Medically Underserved Populations Health Profession Students Participating in Community Based Training: Actual # Interested in Working in Southside Virginia Actual # New Entries in Local Health Professional Recruitment Database Information Technology Actual # Help Desk Calls regarding Hardware Failure Actual # Help Desk Calls regarding Software Failure Actual # Help Desk Calls regarding User Error Actual # PC Failures as the result of Non-approved Software Actual # Workstation Audits Completed 5. CLINICAL MEASURES (Dental) 5.A. 5.B. 5.C. 5.C.i. 5.C.ii. Actual % Total Dental Patients Caries Free (Does not have cavities) Actual % Total Dental Patients Who Had At Least 1 Dental Visit in the Last 12 months Actual % Total Dental Patients who Received a Comprehensive or Periodic Recall Oral Exam, for Whom Phase 1 Treatment Plan is Documented (330 Grant Financial Performance Measure) Actual # Dental Patients who received Comprehensive or Periodic Recall Oral Exam Actual # Dental Patients who received Comprehensive or Periodic Recall Oral Exam for whom Phase 1 Treatment plan is documented Page 16 of 17

17 5.D. 5.E. 5.F. 5.G. 5.H. Actual % of All Dental Patients for Whom Phase 1 Treatment Plan is Completed within 12 Months Actual % of Children, Ages 12 to 72 Months, with 1 or More Fluoride Varnish Application Documented Actual % of Children, Ages 6 21 Years Old, who Received at Least 1 Sealant Treatment Actual % of Dental Patients Who Received Oral Health Education at Least Once in the Last 12 Months Actual % of Dental Patients Who had a Periodontal Screening/Examination in the Last 12 Months Page 17 of 17