Tag C 330 COP: Periodic Evaluation s1

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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