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QUALITY IMPROVEMENT
PROGRAM
PURPOSE: To demonstrate a commitment to providing quality patient care within the scope of available resources and the goals of this facility. GOALS: The goal of the Quality Improvement (QI) Program is to monitor the appropriateness and quality of patient care. Monitoring will be accomplished by activities that: 1. Are planned, systematic, and ongoing 2. Are comprehensive 3. Are based on objective criteria that reflect current medical knowledge and clinical experiences 4. Are accomplished by the routine collection and periodic evaluation of data 5. Result in appropriate actions to resolve identified problems 6. Are updated to assure sustained improvements in care and performance 7. Are coordinated in such a way that the information derived is shared among the appropriate staff of this facility
SCOPE: The scope of the QI Program is comprehensive and problem oriented. It includes all departments and services within Health for Life. The topics to be reviewed are: 1. The quality and appropriateness of client teaching procedures 2. The quality, content, and timeliness of repairs and/or replacements of medical equipment 3. Client/staff complaints 4. Patient satisfaction
QI unit is be responsible for identifying the important aspects of the patient care provided, for indicating quality and appropriateness of the important aspects of care, and for the establishment of thresholds that will be used to evaluate the indicators. All personnel are expected to participate in the QI activities.
AUTHORITY AND RESPONSIBILITY Governing Body a. The governing body shall have the responsibility of assuring the public of the goal of optimal quality of all care delivered within Health for Life. b. The governing body shall make the commitment to provide the financial support necessary for Health for Life in order to provide services that are required (e.g., resources, equipment and personnel). c. The governing body will receive reports from the appropriate parties according to the organizational plan on the findings of the Quality Improvement (QI) activities. The governing body will respond definitively, if necessary, to fulfill their responsibility of adherence to the QI program. d. The governing body delegates the authority and accountability for the QI program. e. The governing body stipulates that all departments within Health for Life will work together in a cooperative manner to create and maintain an effective program. f. The governing body stipulates that the Safety/Infection Control Unit and Quality Improvement Coordinator and Committee will create a unified program of Quality Improvement. g. The President of Health for Life shall represent the governing body.
RESPONSIBILITIES A. The Quality improvement Committee shall be combined with the Safety unit and the Infection Control unit to form the Safety/Infection Control/Quality Improvement Committee. The President of Health for Life shall appoint the members of QI committee to review QI activities. The committee will consist of at least three members. The President, on an annual basis, will review committee membership and the program coordinator position. B. The committee shall meet quarterly. The duties of the committee are: A. To identify and coordinate all QI activities B. To conduct routine appraisals of QI unit and to make recommendations regarding QI activities C. To promote and assist, where needed, in developing standards of care within QI unit D. To evaluate and coordinate the reports of QI units E. To identify problems and set priorities for their resolution, if needed F. To insure that all available data sources are utilized in implementing the QI program G. To insure the appropriate utilization of all available methods of studying, assessing, and resolving perceived problems, both within the SICQI Committee and within the individual QI units H. To reappraise the QI plan at least annually for Unity of organization and function Comprehensiveness Effectiveness in solving problems
EVALUATION OF THE QI PROGRAM The President of Health for Life evaluates the program at least annually and direct the committee and its Coordinator as to components that need to be instituted, altered or deleted.
CONFIDENTIALITY Confidentiality of the QI activity records will be honored. All reports and communications regarding QI activities will be filed in the Coordinator’s office. These records will only be available to the Director, the QI committee, and any other persons authorized by the President of Health for Life.
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