QUALITY IMPROVEMENT PROGRAM Week Four – Reporting Requirements

Do your QI reports include all required components? Have you involved your organization’s Board of Directors and/or leadership in your Quality Improvement Program?

Corresponding Standards

FS 2 – Financial Management Review QM 1 – Quality/Performance Improvement Program QM 2 – Adverse/Sentinel Events

QM 3 – Reporting Requirements PS 4 – Client/Caregiver Education and Training PS 5 – After Hours PS 8 – Grievances and Complaints

Complete / Indicator / Corresponding HQAA Standard / Findings / Action/Outcomes
Review your organization’s QI/PI Reports from the current and previous year.
ü  Do the quarterly reports include information gathered from the Medicare required performance measures listed below?
·  Patient/client satisfaction/complaints regarding products and services (Outcomes measurement #1) / QM 1
PS 8
·  Achieving financial performance targets: (Outcomes measurement #2) / QM 1
FS 2
§  Frequency of billing and coding errors
§  Percentage of collections
·  Business activities, functions or services such as staff performance, service issues or information exchanges. You may consider selecting one or more activities or functions to monitor each quarter. (Outcomes measurement #3) / QM 1
PS 4
·  Timeliness of response to customers regarding problems, issues, or concerns (Outcomes measurement #4) / QM 1
PS 5
·  Adverse events (Outcomes measurement #5) / QM 1
QM 2
ü  Do your quarterly reports include noted successes and recommendations for improvement? / QM 1
QM 3
·  When improvements are indicated, are they implemented, monitored, analyzed and sustained in subsequent quarters? / QM 1
QM 3
Are QI/PI reports presented to your organization’s leaders each quarter? / QM 3
Have you created a summary analysis for the year and have you presented that report to your organization’s leaders annually? / QM 3
ü  Have you used the results of this data collection to make adjustments to programs or services to improve the outcomes of the performance measures that have been monitored? / QM 3

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