Improving Quality and Improving Quality and Reducing RisksReducing Risks

Positive and Positive and Powerful Quality Powerful Quality AssessmentAssessment

2

LearningLearning Objectives Objectives LearningLearning Objectives Objectives

1.1. Basic Elements of a QA/Compliance ProcessBasic Elements of a QA/Compliance Process

2.2. Data Collection – Who, What, How, When & WhereData Collection – Who, What, How, When & Where

3.3. Data Usage – ReportsData Usage – Reports

4.4. Planning – Setting PrioritiesPlanning – Setting Priorities

5.5. Taking ActionTaking Action

6.6. Tracking Over TimeTracking Over Time

3

Objective 1:Objective 1: Basic Elements of a QA/Compliance ProcessBasic Elements of a QA/Compliance Process

Standalone or Existing CommitteeStandalone or Existing Committee

Employee or Contracted IndividualEmployee or Contracted Individual

Choose What to Monitor – Regulators and Choose What to Monitor – Regulators and Internal NeedsInternal Needs

Identify Organizational Risks*Identify Organizational Risks*

4

CrisisCrisis

Special Treatment Procedures Special Treatment Procedures

Medication UseMedication Use

Safe EnvironmentSafe Environment

RecoupmentRecoupment

Maintaining External AccreditationMaintaining External Accreditation

Objective 1:Objective 1: Organizational Risk ExamplesOrganizational Risk Examples

5

Objective 2: Objective 2: Data Collection – Who, What & WhenData Collection – Who, What & When

A Quality Assessment (QA) Calendar* includes: A Quality Assessment (QA) Calendar* includes:

TopicsTopics

Frequency Frequency

Individuals responsible for reporting Individuals responsible for reporting

6

Objective 2: Objective 2: QA Calendar ExampleQA Calendar Example

PERFORMANCE IMPROVEMENT (PI) CALENDAR

7

Objective 2: Objective 2: QA Calendar BenefitsQA Calendar Benefits

Acts as a checklist to ensure ongoing monitoring Acts as a checklist to ensure ongoing monitoring activities are not “lost in the process.” activities are not “lost in the process.”

Helps ensure monitoring activities are conducted Helps ensure monitoring activities are conducted at required timeframes.at required timeframes.

Prompts Annual Review of Organizational Prompts Annual Review of Organizational Processes.Processes.

1.1. Develop Question Sets for each topic*Develop Question Sets for each topic*

2.2. Assign individuals to conduct audits Assign individuals to conduct audits

3.3. Train individuals on the auditing and reporting Train individuals on the auditing and reporting

processprocess

8

Objective 2: Objective 2: Data Collection – HowData Collection – How

9

Should encompass standards/regulations.Should encompass standards/regulations.

Should Should combinecombine questions from applicable standards/regulations questions from applicable standards/regulations for efficiency.for efficiency.

May be created from forms…if forms are developed based on May be created from forms…if forms are developed based on compliance with standards/regulations. compliance with standards/regulations.

May be used for May be used for multiplemultiple activities including peer review, activities including peer review, clinical clinical supervision, ongoing competency, corrective action supervision, ongoing competency, corrective action plans and plans and job performance evaluations. job performance evaluations.

Objective 2: Objective 2: Question Sets for Auditing

Purposes

Objective 2: Objective 2: Data Collection – WhereData Collection – Where

ORGANIZATION-WIDEORGANIZATION-WIDE

10

11

Reports for all Question Sets should: Reports for all Question Sets should:

Identify individual, departmental and organization-wide Identify individual, departmental and organization-wide compliance.compliance.

Show areas of substantial compliance.Show areas of substantial compliance.

Identify areas needing improvement.Identify areas needing improvement.

Track improvements and compliance over-time.Track improvements and compliance over-time.

Be formatted for use by the governing board, executive team, Be formatted for use by the governing board, executive team, management, departments and individuals. management, departments and individuals.

Objective 3:Objective 3:Data Usage - Reports Data Usage - Reports

Results from reports will drive the Planning – Setting Priority activities. Results from reports will drive the Planning – Setting Priority activities.

Setting priorities for improvement is a critical step in the quality Setting priorities for improvement is a critical step in the quality assessment/compliance process. assessment/compliance process.

Priorities should include: Priorities should include: Frequent Activities Frequent Activities Likely to be DifficultLikely to be Difficult High Risk ProcessesHigh Risk Processes

Objective 4:Objective 4: Planning - Setting PrioritiesPlanning - Setting Priorities

12

13

Objective 4:Objective 4:Planning – Setting PrioritiesPlanning – Setting Priorities

Analyzing Data:Analyzing Data:

• Comparing Data – historical patterns; desired performance targets; specifications, etc.

• Determine where performance can be improved…the problems.

• Determine the root cause of the problem…pull the roots…don’t just cut the weed.

• Using tools such as cause-and-effect (fish boning) diagrams for brainstorming problems is an effective way to analyze potential causes of a problem.

14

Fix It!Fix It!

Corrective Actions may include:Corrective Actions may include: EducationEducation Process changesProcess changes Policy and Procedure changes Policy and Procedure changes CommunicationCommunication

Objective 5:Objective 5: Take ActionTake Action

Check for effectiveness of actions taken.Check for effectiveness of actions taken.

Conduct ongoing monitoring of priority activities and Conduct ongoing monitoring of priority activities and other areas required by external agencies.other areas required by external agencies.

Prepare reports that are easy to read and analyze.Prepare reports that are easy to read and analyze.

Enjoy the evidence of improved compliance overtime!Enjoy the evidence of improved compliance overtime!

15

Objective 6: Objective 6: Tracking Over TimeTracking Over Time

See Handout Examples:See Handout Examples:

Individual ReportIndividual ReportQuestion Set Detailed Report Over TimeQuestion Set Detailed Report Over Time

Summary Report Summary Report

16

Sample ReportsSample Reports