Question

Scenario: You have just been hired as the HIM Quality Coordinator. This is a new position in the HIM Department. Your job tasks read as follows:

Develop and implement the HIM Department Quality Plan

Develop data collection, data analysis, and data presentation tools for use in the quality plan

Report findings to the HIM director and medical staff director and administration, as well as medical staff committees, as appropriate

Other duties are as assigned.

The facility is a 338-bed hospital with active ER and outpatient services. There are 45 employees in the HIM Department. About 75% of the medical record is electronic. Those documents are not printed out. The remaining 25% of the record is paper and is scanned into the system by the HIM Department. These documents are scheduled for destruction in 60 days from scanning.

The former director of HIM was successful in working with administration to get the EHR and imaging in place and to get approval to destroy the paper records. However, she failed at managing the day-to-day operations of the department. Now the department has quality issues in the HIM functions. The former director also did a great job preparing the medical staff for the EHR, and the transition went smoothly; however, many physicians and other users are frustrated by the quality issues. Administration is also becoming concerned with the high billing hold report. The director’s position was vacant for 5 months before the new director started work. She has only been here a month.

Today is your first day. The HIM director has her instructions from administration and the medical staff. She has passed these instructions on to you. Your instructions boil down to 2 words—FIX IT. While the director will be actively involved in this clean-up, she cannot do it by herself with the other demands on her time. This is why she requested your position. It is almost unheard of for a new position to be approved in the middle of the fiscal year. Adding the extra position shows how serious administration is about getting the problems solved. The problems are as follows:

1. Scanning: There is a 2-month backlog in scanning the paper records and the quality of the scanning has the following problems: (1) Sometimes pages are fed 2 at a time, and the backs of pages are not always scanned, (2) This requires 100% audit, which is 3 months behind, (3) The staff members conducting the quality audits do not catch all of the errors.

2. Billing: The billing hold report is over $2,000,000.00 and Administration wants the billing hold report held at $500,000.00.

3. Coding: Coding is two weeks behind. There are three vacancies in the coding area and one of your coders is a new graduate of the local HIT program and is slower than the experienced coders. The last coding audit conducted by corporate showed an 80% coding accuracy report.

4. Release of Information: The release of information area is 2 days behind. The release of information area has received repeated complaints that the wrong information is being sent. The errors include: (1) Not everything requested was released, (2) Wrong admissions are being released, (3) Information on wrong patients is being released, (4) Wrong documents are being released.

5. Transcription: An outsourcing company is used, since the hospital had trouble recruiting and retaining qualified transcriptionists. Although the transcription is current, the quality of the work is inconsistent. Most of the reports are perfect, but a significant number of reports are totally inaccurate due to: (1) Multiple typographical errors, (2) Abbreviations that are not spelled out, (3) Poor grammar, (4) Wrong medications with names similar to the right medications.

Your assignment for this project is to develop a plan to solve the problems identified above and to prevent them and other problems from occurring in the future. Your plan should include AT LEAST the following:

Who should be involved

What reporting mechanism you should have

Who you should report to

What accuracy rates you expect

What you will do to solve problems (training, outsourcing, new policies, etc.)

What will be monitored

Frequency of monitoring

Frequency of reporting

What investigations you will do

How you will build quality into your process

How you will prioritize problems to be addressed

Forms - what forms would be needed?

Answer 1

Develop and implement the HIM Department Quality Plan

Improvement work invariably involves work across multiple systems and disciplines within a practice. The quality improvement (QI) team or committee (QIC) is the group of individuals within a practice charged with carrying out improvement efforts. The team may report to the organization’s chief executive officer. To be effective, the team should include individuals representing all areas of the practice that will be affected by the proposed improvement, as well as patient representatives.

The QI team meets regularly to review performance data, identify areas in need of improvement, and carry out and monitor improvement efforts. For these activities, the teams will use a variety of QI approaches and tools, including the Model for Improvement (MFI), Plan Do Study Act (PDSA) cycles, workflow mapping, assessments, audit and feedback, benchmarking, and best practices research.

The team should have a clearly identified “champion” who is committed to the ideal and process of continuous improvement. This individual should be interested in building capacity in the practice for ongoing improvement and implementing effective “processes” that will enable improvement. Such processes may include gathering and reflecting on data, seeking out best practices, and engaging voices and perspectives of individuals involved in all aspects of the process/activity under scrutiny. The role of the QI team champion is to ensure that the team functions effectively and fulfills its charter for the organization.

Who Should Be on a Quality Improvement Team?

The Institute for Healthcare Improvement (IHI) recommends that every team include at least one member who has the following rolesⁱ:

• Clinical leadership. This individual has the authority to test and implement a change and to problem solve issues that arise in this process. This individual understands how the changes will affect the clinical care process and the impact these changes may have on other parts of the organization.
• Technical expertise. This individual has deep knowledge of the process or area in question. A team may need several forms of technical expertise, including technical expertise in QI processes, health information technology systems needed to support the proposed change, and specifics of the area of care affected. For example, a team implementing an intensive care management clinic for people with poorly controlled diabetes might need technical expertise in change management, the clinic’s electronic health record, and the patient treatment protocols that will be used.
• Day-to-day leadership. This individual is the lead for the QI team and ensures completion of the team’s tasks, such as data collection, analysis, and change implementation. This person must work well and closely with the other members of the team and understand the full impact of the team’s activities on other parts of the organization as well as the area they are targeting.
• Project sponsorship. This individual has executive authority and serves as the link to the QI team and the organization’s senior management. Although this individual does not participate on a daily basis with the team, he or she may join periodically and stays apprised of its progress. When needed, this member can assist the team in obtaining resources and overcoming barriers encountered when implementing improvements.

The optimal size of a QI team is between five and eight individuals, although this may vary by practice. The most important requirement is not size, but diversity of the participants. It is important that the team include a diverse group of individuals who have different roles and perspectives on the patient care or other processes under consideration. This group should include whenever possible input from the “end user” of health care, the patient.

Potential members of a QI team might be:

• Chief executive officer.
• Medical directors.
• Physicians.
• Nursing staff.
• Physician assistants.
• Medical assistants.
• Patient representatives.
• Operations manager/director.
• Health educators.
• Community health workers.
• Peer mentors.
• Patients.
• Community representatives.
• Directors of clinical services.
• Practice managers.
• Medical records staff.
• Receptionists.
• Lab technicians.
• Pharmacy or dispensary staff.
• Case managers.
• Physical plant operations.
• Billing department staff.
• Finance director.

i Adapted from the Institute for Healthcare Improvement. Science of Improvement: Forming the Team. Available at: http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx .

Creating a Quality Improvement Plan With a Practice

One of the first tasks to complete with the QI team is to identify goals for the improvement work and associated performance metrics. It is useful to have preliminary performance data available to use in setting improvement goals whenever possible. Goals are fluid and will likely change during your work with the practice as more information is gathered on practice performance and functioning and as the team achieves preliminary goals and is ready to move on to new ones.

Using Key Driver Models To Focus Quality Improvement Plans

Key driver models are roadmaps to particular outcomes that help focus the work of a facilitation program, as well as the work of individual facilitators and facilitation teams at the practice level. Key drivers define the pathway to a desired transformation. Key driver models graphically display the strategies and activities needed to achieve goals and aims of the practice improvement effort

Facilitation programs typically use two levels of key driver models:

• One at the programmatic level that outlines the facilitation program’s overarching goals and underlying model for change, and
• One at the practice level, which tailors the programmatic model to the needs and priorities of individual practices.

Program-level and practice-level key driver models include:

• Desired outcomes for the practice improvement effort,
• Big changes or “key drivers” that are most likely to accomplish these goals, and
• Specific changes or action items that must occur to produce the desired big changes.

Example of a Key Driver Model

This key driver model was developed for the Improving Performance in Practice Initiative funded by the Robert Wood Johnson Foundation and provided by Dr. Darren DeWalt.

The far left column shows specific QI goals. The middle column contains the organizational and care processes thought to improve care and patient outcomes. These key drivers function as a menu from which practices can choose the approaches they will use to achieve their goals. The far right column contains the “change concepts” or action items/steps to implement a particular key driver.

Designing a Key Driver Model With a Practice

You should work with the practice to develop a practice-level key driver model that links to the outcomes identified by the practice and targeted by the facilitation intervention. The practice’s QI plan should be based on the practice-level key driver model to reflect the change concepts included in the model. If your program has a predefined key driver model for the intervention, you should review the prescribed model with the practice’s QI team and work with them to identify the drivers and change concepts they want to implement first, second, and third. You should also ask the practice to identify what other items not currently represented on the key driver model they are interested in changing, and make these additions accordingly.

A first step in developing a key driver model is to choose goals that are clearly defined. Goals and outcomes should be SMART:

• Specific,
• Measurable,
• Attainable/Achievable,
• Relevant, and
• Time bound

When defining its change goals, the practice should include numeric targets. Distinguish between goals that will be accomplished during the period you are facilitating (if it’s time limited) and longer term goals. They should be based on the results of the practice assessment and focus on the areas needing improvement.

Creating a Quality Improvement Plan

A QI plan should provide guidance to the practice on who is to participate on the QI team, how often it is to meet, and what its goals and key activities are. In addition, the plan should lay out the process that will be used to drive improvement in the practice, such as the MFI and PDSA cycles, how these are to be documented, and the way current and ongoing status is going to be monitored using data. A good QI plan includes among other things:

• A statement of the quality vision.
• A description of the program structure.
• A membership for the QI team or committee that is diverse.
• A meeting schedule.
• A defined process for how QI will be conducted.
• A list of improvement goals or priorities that are specific, measurable, achievable, relevant, and time bound.
• A plan for how both the plan and the goals will be evaluated.
• A plan for how performance data will be acquired and reported.

An important role you can play as a practice facilitator will be to assist practices in developing a plan or to review the plan they already have.

Monitoring Progress on the Quality Improvement Plan

With new QI teams, another role you can play is to help the team develop systems that will allow them to track progress toward their improvement goals and monitor their performance on key quality indicators. To do this, you will need to work with practice leadership and staff to set up data systems that can produce practice performance reports on key quality metrics on a monthly or quarterly basis. As much as possible, you should assist the practice to automate the development of these reports so that the burden on staff is minimized or to design the data collection process so staff can carry it out in addition to their existing duties. An elegant system that cannot be sustained is no better than having no system at all.

You will need to work with the QI team to develop a standard template for the performance report and identify the time period for reporting. You will also need to assist them in identifying the staff needed to prepare the reports and the time they will need to accomplish this task. In addition, you will need to work with the team to revise staff job descriptions to include this task, as well as their performance evaluation. You will also need to help them train staff on these tasks.

A QI dashboard or data wall can be a useful tool for QI teams to help them track progress toward key improvement goals. QI dashboards or data walls are one- to three-page summary reports that provide a graphic summary of progress toward key process and outcome metrics. Often they include a “stoplight” system of red, yellow, and green color coding to signal that an activity or performance metric is on track, partially off track, or having serious problems. It can be helpful to include a dashboard of progress toward the elements of the key driver model if one was included as part of the QI plan. In addition, it can be useful to include copies of any PDSA cycles that are underway or completed with the dashboard to enable the QI team to easily review its progress.

The report will create a written record of the team’s progress and help increase ownership and accountability in the QI team and practice for follow-through on improvement work. It also can help you identify QI teams that have hit a roadblock and may need some additional assistance from an expert consultant or a facilitator with a different set of skills. You can add this expertise to your facilitation team if it is needed.

Develop data collection, data analysis, and data presentation tools for use in the quality plan

I. INTRODUCTION

PURPOSE:

Quality Assessment, Performance Improvement, and Patient Safety Plan

The purpose of the Quality Assessment, Performance Improvement (QAPI) and Patient Safety Plan is to provide a formal mechanism by which the Medical Center utilizes objective measures to monitor and evaluate the quality of services provided to patients.

Quality is defined broadly to include care that is safe, effective, patient-centered, timely, efficient, and equitable. The plan facilitates a multidisciplinary, systematic performance improvement approach to identify and pursue improved patient outcomes and reduce the risks associated with patient safety in a manner that aligns with the mission

MISSION:

The mission is to improve the human condition by providing patient-centered, quality care in a way that facilitates the achievement of INSTITUTION .

OBJECTIVES:

Objectives of Patient Safety Plan are :

• Maintain and grow a comprehensive QAPI infrastructure, i.e., human capital, data collection, analysis, process improvement, outcome assessment, software, education and training.

• Create a robust performance improvement culture focused on high reliability measures that enhance quality and safety throughout the organization.

• Integrate quality, safety, and service into performance improvement opportunities, implementing actions, and evaluating results based on the goals of providing care that is safe, effective, patient-centered, timely, efficient, and equitable.

• Encourage an environment that supports safety, encourages non-punitive reporting, addresses maintenance and improvement in patient safety issues in every department throughout the facility, and establishes mechanisms for the disclosure of information related to errors..

• Focus and coordinate the organization-wide performance improvement, patient safety, and patient experience initiatives based on sound metrics, state of the art analysis, and contemporary improvement methods.

• Communicate, report, and document quality, patient safety, and patient experience activities to professional staff, administration, and appropriate governing members.

• Maximize effective organizational and clinical decision making.

• Promote teamwork and group responsibility in identifying and implementing opportunities for improvement.

• Utilize tools and approaches that capitalize on knowledge regarding holistic approaches to improving quality and safety systems, including those developed outside of health care.

2. STRUCTURE AND LEADERSHIP

The leaders work to improve quality by setting priorities, modeling core values, promoting a learning atmosphere, acting on recommendations, and allocating resources for improvement. They are supported by committees and work groups where the components of the program are defined, implemented, refined, and monitored. These groups are structured around six key dimensions of care delivery.

The quality domains include effective, timely, appropriate, safe, efficient, and patient-centered care. These groups are comprised of attending physicians, resident physicians, staff, and management and are represented via a reporting process to the Quality and Patient Safety Council, which acts as the "oversight committee" for QAPI and patient safety reporting. The Quality and Patient Safety Council reports to the Medical Staff Executive Committee, which in turn reports to the Clinical Affairs Committee of the Board of Trustees.

3. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROCESS Prioritization of Areas for Measurement

The process for identifying priorities for measurement requires input and discussion with senior leadership, departments, and services from all areas. Priorities are identified based on leadership objectives, regulatory requirements, opportunities identified in external benchmark projects, opportunities identified through analysis of patient safety event reports and opportunities identified through sentinel events, standard of care findings or "Sentinel Event Alerts." These objectives or topics are then displayed in a matrix to better understand which areas of importance and relevance they cross (high risk, high volume, problem prone, mission, internal and external customer satisfaction, clinical outcome, safety, and regulatory).

Developing Measure Specifications

Work groups or committees define the metrics (indicators, goals, and benchmarks) for each topic. Representatives from all involved services collaboratively develop quality performance measure specifications based on the opportunities identified to be studied. Team members are identified with the help of clinical and administrative leadership. Work groups develop written measurement specifications, along with data abstraction tools when necessary.

Gathering Data

Data is then gathered on a pre-determined timeframe (weekly, monthly, and quarterly). Regular reporting of data requires continued attention from teams. A designated person will be assigned and held accountable for gathering data and having the information available when due. Sampling sizes are determined based on recognized, statistically significant sample sizes of: <30/month - 100%; 3 1-100/month - 30; IO 1-500/month - 50; and >500/month - 70 Real time data are collected as possible.

Analyzing and Reporting Data

The work groups discuss data analysis and determine what initiatives must be implemented to attain the desired outcome. Analyses usually involves multiple iterations to examine different aspects of the quality issue. Whenever possible and appropriate, statistical control methods, trending, and/or comparison with published benchmarks are used to analyze quality and safety measures. Implementation of Actions and Dissemination of Information Implementation begins and re-measurement occurs with refinement in actions if the desired outcome is not achieved or the outcome is not maintained. Communication of quality and safety information is the responsibility of clinical and administrative leadership. This information is reported by the Quality Management Department, and throughout the organization, using the Performance Improvement Quarterly report and/or other acceptable formats. Annually or more frequent as necessary, the performance is presented at the Quality and Patient Safety Council, with minutes from the Quality & Patient Safety Council presented to the Medical Executive Committee.

IV. QAPI MODEL

The quality assessment and performance improvement model developed internally is the ''Plan, Measure, Analyze, Act, and Review Quality Cycle. This cyclical model incorporates defining the opportunity, identifying the objective, collecting and measuring the data, analyzing performance while comparing with objectives, determining action steps and initiatives as appropriate based on performance, educating and re-measuring.

V. CONTENT/SCOPE OF ACTIVITIES

The objectives become the essence of the QAPl activities organization-wide. The FY 2018 QAPI areas of focus include: Improve Patient Safety, Quality, & Service

• Maintain Standardized Infection Rate (SIR) below threshold, while continuously striving to eliminate hospital acquired infections related to: o Catheter related Blood Stream Infections o Catheter related urinary tract infections o Surgical site infections for Colon and Hysterectomy surgeries o Clostridium Difficile infections

• Decrease the number of Patient safety indicator events related to post op VTE, sepsis, and pressure ulcers by 5%.

• Monitor trends in patient safety events through Patient Safety Net and implement actions to reduce harm

• Implement and monitor processes associated with pain management, including safe opiod prescribing . Improve Patient Experience

• Improve 5 percentile points on Press Ganey, rating of hospital for Inpatient satisfaction survey. Improve Resource Utilization

• Reduce readmissions by 2% 3 Monitor external regulatory compliance indicators • Core Measures ( ED , Flu Immunizations, DVT, Stroke and Sepsis) • Restraints • Adverse Drug Reactions

• Blood Utilization (Transfusion Reactions)

• Pain •

Radiology CT indicators

• Resuscitation

• Organ conversion rates

• Operative/Invasive procedures

• Occurrence/Sentinel/Never Event report trends

• Sedation Analgesia

• Seclusion

• Suicide risk

• Behavioral Management and Treatment

• Mortality and Autopsy

• Hazard Management

• Operative Diagnosis Concurrence

• National Patient Safety Goals

• Patient flow/throughput

MEDICAL STAFF COMMITTEE QAPI PROCESS Blood and Laboratory Utilization Committee (BUC) - The goal of the BUC is to ensure the safe, effective, and efficient use of blood products and appropriate use of the lab, i.e., blood draws. Blood usage is monitored ongoingly utilizing data that is reviewed and analyzed quarterly by the committee. Clinically valid criteria and indicators used in screening and in the more intensive evaluation of any identified or suspected concerns in blood usage. Blood usage measurement will include key process indicators related to ordering, preparation, handling and dispensing, blood administration, and transfusion outcomes. The committee reports findings of their QAPI program to the Quality & Patient Safety Committee on an annual basis. Cancer Committee -The Cancer Committee is responsible for the oversight of care and treatment provided in the hospital to patients with cancer. The committee monitors and evaluates patient care, either directly or by interaction with, and review of data from other committees. Cancer Conference presentations occur monthly, which includes all major cancer sites treated at this hospital. The Cancer Committee plans and conducts a minimum of two outcome tudies annually. The Cancer Committee will provide summaries of their QAPI plan to the Quality & Patient Safety Council on an annual basis.

Infection Control Committee –

The Infection Control Committee meets no less than quarterly to review and evaluate the hospital-wide infection control activities. The committee approves and evaluates the type and scope of surveillance activities based on problem prone areas, targeted indicators, or house wide surveillance initiatives. Quality data presented at the infection control meetings includes surgical site infections, central line infections, ventilator associated pneumonias, and catheter related urinary tract infections. The Infection Control Committee reports the annual summary to the Quality and Patient Safety Council .The committee oversees the implementation of the antimicrobial stewardship program.

Medical Records Committee –

The Medical Records Committee ensures the timely completion and accuracy of the medical record. The committee optimizes the use of the electronic medical record. The committee monitors 4 regulatory requirements for completion of required documentation. This list may include, H&P, post operative notes, nursing assessments, etc. The Medical Records Committee reports annually to the Quality and Patient Safety Council.

Medical Staff Executive Committee –

The Medical Staff Executive Committee is delegated the primary authority over activities related to quality assessment and performance improvement of the professional services provided by individuals with clinical privileges. The Executive Committee meets monthly and receives and acts upon reports and recommendations from medical staff committees.

Operating Room Services Committee –

The Operating Room Committee is responsible for monitoring the quality of the care provided to surgical patients. The committee reviews all adverse events and mortalities that occur in the OR. In addition, the committee develops an annual QAPI program consistent with the goals of the organization and reports annually to the Quality and Patient Safety Committee.

Pharmacy & Therapeutics Committee –

The Pharmacy & Therapeutics Committee oversees the quality assessment and performance improvement related to the selection, ordering and transcribing, preparing and dispensing, administering, and monitoring of medications throughout the organization. The committee works closely with nursing, Infection Control, and other medical staff departments in developing policies and QAPI monitoring. Pharmacy is responsible for tracking and monitoring medication errors and adverse events and reporting findings to the Quality & Patient Safety Committee. In addition, they maintain and make recommendations to the drug formulary.

Procedural Case Review Committee –

This committee is responsible for the review of operative and other highrisk procedures for appropriateness based on surgical specimen removal. In addition, the committee reviews all adverse events, mortalities, and autopsies related to unexpected outcomes or adverse events occurring in surgical procedures. The committee selects high-risk patient populations based on identified problem prone or high-risk procedures. The committee meets quarterly or more often as needed and reports annually to the Quality & Patient Safety Committee

Trauma Committee –

The Trauma Committee is responsible for the oversight for the quality of care provided to the Trauma patients. The Committee tracks and monitors quality indicators based on the identified QAPI trauma program. The committee reports annually to the Quality & Patient Safety Committee

HOSPITAL AND/OR SUPPORT SERVICES

The quality and appropriateness of patient care is monitored and evaluated in all important aspects of care, key processes, and in the clinical departments and support services. Each department/service is responsible for establishing specific quality improvement indicators which reflect the hospital-wide plan and prioritizes aspects of care to be studied. Each department/service identifies and participates in the analysis of issues/concerns impacting system processes and functions which affect patient care, experience, and safety. The following hospital department/support services maintain quality reports in their departments while reporting annually to the Quality & Patient Safety Council. Finally, each department/service submits to the annual evaluation of the hospital QAPI program. The following list provides the depa1tment/services along with the responsible parties. Ambulatory services - Allen Seifert Anesthesia Services - Clinical Service Chief Behavioral Health - Clinical Service Chief, Director Behavioral Health, Nurse Manager Cardiac Catheterization Laboratory- Director of Cardiac Services and Medical Director of the Cath Lab Cardiac Rehabilitation Program - Director of Cardiac Rehabilitation Dietary Services - Director of Food & Nutrition and Clinical Nutrition Manager Endoscopy - Medical Director, Nurse Manager Laboratory Services - Clinical Service Chief and Director of Laboratory Services Nursing Services - Chief Nursing Officer Pharmacy - Director of Pharmacy 5 Radiation Therapy - Medical Director of Radiation Therapy Radiology - Clinical Service Chief and Director of Radiology Resource Utilization - Director of Outcomes Management Respiratory Care - Director of Respiratory Care Transplant Service - Medical Director Transplant, Administrator Transplant Services

UNUSUAL CHANGES OR EVENTS

The Quality and Patient Safety Plan is flexible to accommodate significant services changes, structure changes, unusual events or other similar elements. Objectives and topics can be introduced at any time to be prioritized and included in the scope of the Quality and Patient Safety Plan.

SAFETY

The patient safety program is integrated with all quality assessment and performance improvement activities. It encompasses risk assessment and avoidance tactics such as conducting a "Failure Mode Effect Analysis" (FMEA). FMEA is a proactive risk assessment which examines a process in detail including sequencing of events, assessing actual and potential risk, failure, or points of vulnerability and through a logical process, prioritizes areas for improvement based on the actual or potential impact on patient care.

Implementation of processes in the care of Inpatient Detox patients. The safety program proactively institutes action plans based on findings from the "Sentinel Event Alert" which are provided periodically by the Joint Commission. Use of this resource for initiatives is another proactive approach to patient safety. All patient safety events in the safety program track and trend or initiate activities that address process, system, protocol, or equipment events. This includes near miss occurrences and unsafe conditions, as well as findings from adverse events. As the entire organization reports patient safety events, this component integrates all departments into the safety program. Additionally, all developments from Root Cause Analysis activities, including those from Sentinel Events, are implemented and monitored through the safety program. The Quality and Patient Safety Program is also engaged in the following patient safety initiatives which will continue over the next few years: • Implementation of a new inpatient Electronic Medical Record; • Dissemination of trended information from Patient Safety net.

6. OVERSIGHT AND SHARING OF INFORMATION As part of the oversight process, the quality assessment performance improvement information flows from the departmental/service work groups and committees to the Quality and Patient Safety Council. Minutes from the Quality and Patient Safety Council are submitted to the Medical Staff Executive Committee and reports are given to the Clinical Affairs Committee of the Board of Trustees. Through this process, an annual review of the entire QAPI and Patient Safety Plan content and results occurs. The various duties of these oversight committees are further defined below:

1. The Board of Trustees establishes, maintains, supports, and exercises oversight of the quality monitoring and performance improvement function & fulfills its responsibilities related to the quality assessment, performance improvement, and safety functions through 6 the specific activities and interactions of its Clinical Affairs Committee with the Hospital Senior Leadership Teams (SL T) and with the medical executive committee of the medical staff.

2. The Clinical Affairs Committee of the Board of Trustees reviews and provides feedback related to the Quality Report submitted to the committee and the Board of Trustees. The Clinical Affairs Committee approves the annual QAPI plan and annual reappraisal. They are also responsible for making recommendations to enhance the QAPI and patient safety program and initiatives.

3. The Executive Committee of the Medical Staff provides oversight for reporting quality initiatives from the medical staff committees and hospital initiatives. Additionally, as a mechanism to share performance improvement activities with institution staff and visitors, the following activities also take place: • Departmental in-services on special quality performance improvement topics; • Lectures and presentations to students, residents, staff and faculty; • Reports of clinical data distributed to the Clinical Affairs Committee of the Board of Trustees, Executive Committee of the Medical Staff, members of management and leadership teams and the Senior Leadership Team; • Display of Quality Data on individual units.

VII. RESOURCES

The Quality Management Department supports and facilitates ongoing organizational quality assessment, performance improvement, and patient safety activities. Resources within the Quality Management Department assist hospital staff and physicians with data, retrieval of data, development, and coordination of quality performance improvement activities, and analysis of data to support and evaluate quality performance improvement efforts.

The primary functions of this department include:

• Promoting patient safety through evidence-based clinical programs and initiatives;
• Monitoring regulatory standards compliance data; Clinical data management and analysis;
• Collaboration with Service Excellence Department on the integration of patient experience in all process improvement initiatives;
• Quality improvement training and education;
• Preparation of QAPI reports;
• Coordination of internal and external databases that are used for QAPl projects or quality data analysis;
• Dissemination of patient safety event reports to departments,
• Qua I ity and Patient Safety Counci I, and other key groups in the organization;
• Patient safety event, sentinel event, and never event report tracking and analysis;
• Coordination of root cause analysis for sentinel events and other occurrences requiring intense analysis;
• Coordination of Action Plans related to sentinel events or failure mode effect analysis (FMEA) projects;
• Quality performance improvement project for issues found in patient safety event reports;
• Process or procedure modifications related to findings from patient safety event trends and/or FMEA projects.

VIII. SUMMARY

The Quality Assessment, Performance Improvement, and Patient Safety Plan provides the framework for organization to implement quality assessment, performance improvement, and safety activities. These activities improve patient outcomes, patient experience, and patient safety in a comprehensive, methodical, and systematic manner and compliment the Hospital Plan for the Provision of Collaborative Patient Care Services.