PIN CAH CMS Standards Review
Conference Call Notes
Call: Dec 30, 2009
Tag C 336 Quality Assurance
- Use a reporting calendar to ensure all depts. Reports; rotate depts. monthly; clinical & non-clinical
- All depts. develop a PI plan; including independent contractors and contracted pharmacy
- Crow/Cheyenne: include measures that affect their IHS funding
- The Quality committee meets the same day and time each month so all expect it; every dept head and administration report on their project each month; a Board member attends their quality meeting
Contracted Services Included
- Lab and xray contractors report once a quarter; each work on a quality project which is evaluated quarterly
- All contracts are reviewed in Dec; business office prompts each dept to evaluate the contracts they hold
- Make a personal call to the CEO of each company that holds a contract for any clinical service with the facility medical director- discuss any issues, quality of services, etc; facility conducts internal case review, intentionally selecting cases that have utilized diagnostic imaging services and ED trauma cases
Ongoing Monitoring and Data Collection
- Nursing staff collects data once a month; rotate shifts that do the data collection monthly; have risk management software to enter incident reports and review reports/trends monthly
- Conduct ongoing/regular medical records and peer reviews with med staff; note any ‘red flags’, when care appears to be outside of expected standards or procedures; discuss and make recommendations for changes
- Use national patient safety goals to help select cases for review
Priorities for Case Review and/or Measure Selection
- “High risk, high volume, problem-prone” processes; quality coord meets one on one with departments each year to select/define measures; format into a reporting “scorecard” for that department
- Crow/Cheyenne also looks at what other IHS facilities are measuring, and receive direction from the national level; look for undesirable patterns or trends during the ongoing review to identify ops for improvement
- Each dept team develops their own measures, based on the Studer pillars and specific dept goals related to the org strategic plan; proposed measures are reviewed with the manager’s next higher up, as well as the Quality Director to finalize
- Measures driven by the org’s strategic plan and goals which are related to the Studer pillars; use a 5-star rating system to identify measures for LTC
Tag C 336 Quality Assurance, cont
Obtaining Benchmarks
- Obtain peer group benchmarks from PIN reports to help identify opportunities for improvement
- Each dept identifies issues from regulatory surveys, their dept dashboard reports, and/or PIN Clinical Improvement study reports; benchmarks are obtained from peers and are dept-specific; also performance trends and the org’s strategic plan/objectives
- Benchmark issues: primarily for medication errors, as there continues to be no national consensus; all they can do is benchmark internally
Problem Identification, prevention and data analysis
- Data Analysis: pull most of the data fro medical records; good software and e-MR help
o Calculate rates, percentages, use Excel for calculations and graphing
- Problem prevention:
o Conduct one FMEA of a high risk process each year; takes about 6 months to complete the FMEA; PI Coord facilitates the FMEA process; all stakeholders, including MS, are required to participate as appropriate to the FMEA
o Conduct an RCA using a simple form when problems identified, to decrease likelihood it will be repeated
Documentation of Corrective Action when a problem has been identified
- - the dept manager makes a written report to the quality coordinator and reports the problem at the QA meeting; the dept monitors the effectiveness of the correction through data collection; reports back at a subsequent QA meeting regarding effectiveness; the data collected and initial and follow up reports all become part of the minutes of the QA meeting
- Use the same process as above, but the initial and follow up reports might initially be presented at another org meeting, like Safety or Infection Control committee meetings; those committees provide monthly reports to the quality committee, which become part of the quality committee’s minutes
- Use a formal 90-day corrective action plan which is standardized throughout the facility; if the plan will take more than 90 days to implement, a report is provided by the process owner to the quality committee no less than every 90 days.
Tag C 337 All Patient Care Services and other Services Affecting Patient Health/Safety included
Patient Care Services
- review 10% of all mid-level cases; also review physician cases; performance data is collected from reviews to use in reappointment decisions; all review information is provided to the Board
Tag C 337, cont
- told by a surveyor that the performance of contracted nursing staff and biomedical services staff have to be reviewed; review the care provided by contracted nursing staff through case review; set up a tickler system to prompt review of contracted staff; reviews generate a QA report
- use the CAH Periodic (Annual) eval to do this; report goes to Board
Tag C 338 Nosocomial infections and medication therapy are evaluated
- Nosocomial infections: data is collected monthly and included in the org’s monthly dashboard report to the medical staff and Board
- The Pharmacy services are contracted; the contract pharmacist reviews medication therapy monthly and meets with a member of the medical staff to discuss findings
- Have a Pharmacy and Therapeutics (P & T) committee that meets monthly; they generate a report to the medical staff’s Medicine Committee; the Medicine Committee makes a summary report to the full medical staff; the medical staff representative on the Board gives a report to the Board
Tag C 339 Quality and appropriateness of diagnosis and treatment furnished by mid-levels is evaluated by a physician member of the CAH staff
- Each mid-level meets quarterly with their physician supervisor to discuss findings of reviews
- For certified nurse mid-wives: all nurse practitioners, including midwives, are considered ‘mid-levels’
Tag C 340 Quality and appropriateness of diagnosis & treatment furnished by physicans evaluated
- Conduct external peer review as well as internal review pulling random medical records for each physician member of the medical staff
- Includes locums and contract medical staff
- Sources for external review: Monida, the QIO and data submitted to the PIN as part of the clinical improvement studies
Tag C 341 Consider findings of the evaluations, including any findings or recommendations of the QIO, and takes corrective action if necessary
- Use a standard tool to identify opportunities for improvement identified through the evaluations and corrective actions implemented
Tag C 342 The CAH takes appropriate remedial action to address deficiencies found through the QA program
- Document actions taken in the minutes of medical staff meetings
Tag C 343 The CAH takes appropriate remedial action to address deficiencies found through the QA program
- Use a standardized form for each corrective action being implemented; completed form is presented at QA committee meeting and becomes part of the meeting minutes
Next Call: Wed, Jan 27, at 2:00 pm
Beginning with Tags C 344 & C 345: Organ, Tissue and Eye Procurement
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