Quality Assessment and Performance Improvement Plan

Name of ______Hospital 2007

Structure and Accountability

The Board of Trustees (“Board”) retains overall responsibility and accountability for the quality of patient care, including the safety of patients, staff and visitors and the appropriate utilization of resources.

The Board holds ______HospitalMedical and Dental Staff (“Medical Staff”) accountable for the quality of patient care.

The Board also established the ______HospitalQuality Council (“Quality Council”) to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

Functions

Board of Trustees

The Board receives reports from the Medical Staff and Quality Council. The board shall act as appropriate on the recommendations of these bodies and assure that efforts undertaken are effective and appropriately prioritized. Reports on the analysis and actions taken regarding the various quality and utilization functions shall be received and acted upon according to the routine reporting schedule included in this plan. (Variations in the timing of reports described in this and other reporting schedules are allowed as long as appropriate oversight of all of these functions is maintained.)

The Board remains responsible for establishing clear expectations for safety; allocating adequate resources for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients; and enhancing the efficiency and quality of care through an appropriate number of performance improvement projects.

The Board approves the QAPI program, including the indicators used to measure performance.

Medical Staff

The Medical Staff, in accordance with currently approved medical staff bylaws, shall be accountable for the quality of patient care. They shall receive reports from and assure the appropriate functioning of the Medical Staff committees.

Quality Council

The Quality Council shall consist of the Chief Executive Officer, representatives of the Medical Staff and other key hospital leaders. It shall hold primary responsibility for the functioning of the quality assessment and performance improvement program. It shall receive reports from and analyze the activities of the various Medical Staff and hospital committees with primary responsibility for the various aspects of quality monitoring. The Quality Council shall have primary responsibility for the following functions:

  1. Health Outcomes: The Quality Council shall assure that there is measurable improvement in indicators with a demonstrated link to improved health outcomes. Such indicators include but are not limited to measures reported to the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and information submitted to or received from the hospital’s Quality Improvement Organization.
  2. Medical Error Reduction:
  3. The Quality Council shall assure that there is measurable improvement in indicators with a demonstrated link to the reduction of medical errors.
  4. The Quality Council shall assure that the system for the identification of medical errors within the institution is effective.
  5. The Quality Council shall oversee the analysis of medical errors and near misses within the institution to assure that their root cause is identified, andappropriate preventive actions and mechanisms (including feedback and learning throughout the hospital) are implemented.
  6. The Quality Council shall review the experiences of other institutions as they become apparent in the literature and other sources and assure that measures shown to be effective in reducing medical errors are implemented within the organization.
  7. Quality Indicators:
  8. The Quality Council shall oversee measurement, and shall analyze and track quality indicators, including adverse patient events and other aspects of performance. These indicators shall focus on the functions listed in the attached monitoring schedule and shall measure the effectiveness and safety of services and quality of care.
  9. The Quality Council shall approve the specific indicators used for these purposes along with the frequency and detail of data collection. However, individual departments and services may, at their discretion, measure other aspects of performance without the prior approval of the Quality Council.
  10. The Board shall ratify the indicators and the frequency and detail of data collection used by the program.
  11. Patient Safety: The Quality Council shall provides a systematic and coordinated approach to the maintenance and improvement of patient safety through the establishment of mechanisms that support effective responses to actual occurrences; ongoing proactive reduction in medical/health care errors; and integration of patient safety priorities into the new design and redesign of all relevant organization processes, functions and services as identified in the Quality Indicators and Health Care Outcomes.
  12. Prioritization: The Quality Council shall prioritize performance improvement activities to assure that they are focused onhigh-risk, high-volume, or problem-prone areas. It shall focus on issues of known frequency, prevalence or severity and shall give precedence to issues that affect health outcomes, quality of care and patient safety.
  13. Improvement: The Quality Council shall use the analysis of the data to identify opportunities for improvement and changes that will lead to improvement. The Quality Council must also oversee implementation of actions aimed at improving performance.
  14. Follow-up: The Quality Council shall assure that steps taken to improve performance and enhance safety are appropriately implemented, measured, and tracked to determine that the steps have achieved and sustained the intended effect.
  15. Performance Improvement Projects: The Quality Council shall oversee performance improvement projects, the number and scope of which shall be proportional to the scope and complexity of the hospital’s services and operations. The Quality Council must also ensure there is documentation of what quality improvement projects are being conducted, the reasons for conducting those projects, and the measurable progress achieved on the projects.

Methodology:

  • The Plan, Do, Check, Act (PDCA) methodology is utilized to plan, design, measure, assess and improve functions and processes related to patient care and safety throughout the organization.
  • Plan:

Objective and statistically valid performance measures are identified for monitoring and assessing processes and outcomes of care including those affecting a large percentage of patients, and/or place patients at serious risk if not performed well, or performed when not indicated, or not performed when indicated; and/or have been or likely to be problem prone.

Performance measures are based on current knowledge and clinical experience and are structured to represent cross-departmental, interdisciplinary processes, as appropriate.

  • Do:

Data is collected to determine:

Whether design specifications for new processes were met

The level of performance and stability of existing processes

Priorities for possible improvement of existing processes

  • Check:

Assess care when benchmarks or thresholds are reached in order to identify opportunities to improve performance or resolve problem areas

  • Act:

Take actions to correct identified problem areas or improve performance

Evaluate the effectiveness of the actions taken and document the improvement in care

Communicate the results of the monitoring, assessment and evaluation process to relevant individuals, departments or services

Program Evaluation:

To assure that the appropriate approach to planning processes of improvement; setting priorities for improvement; assessing performance systematically; implementing improvement activities on the basis of assessment; and maintaining achieved improvements, the organizational quality assessment performance improvement program is evaluated for effectiveness at least annually and revised as necessary. Effectiveness evaluation will be conducted at the Quality Council level, communicated to the Medical Executive Committee for input and forwarded to the Board of Trustees for review and analysis

Components of the Quality Assessment and Performance Improvement Program:

QAPI Program Plan – outlined above

QAPI Indicators – Attachment A

Reporting Schedule(s) – Attachment B

Departmental Breakdown – Attachment C

Reporting Structure Flow Diagram – Attachment D