1. Quality Improvement and Quality Assurance, Additional Information, and Professional Liability Christopher Gibbs, JD, MPH, LHCRM LCDR Shayna Wilborn, RN, BSN

2. EHB Demo with Sarah Florer begins…. 2

3. Understanding Quality Improvement (QI) and Quality Assurance (QA) QI and QA are often confused as the same process. Terms used interchangeably but not the same. QA is focused on observations only and one-time opportunities. QI is continuous process documenting improvement. Both based on standards for performance. Both important to organization. Both focus on quality services to patients. 3

4. Definition of Quality Assurance QA requires: Planned systematic activities implemented in quality system. Quality requirements for product or service fulfilled. Activities typically based on standards of practice. Can help identify problem but no solution. Compliance with standards goal. 4

5. Definition of Quality Improvement QI is a continuous ongoing process designed to improve patient outcomes, services, or processes. Focus is ongoing rather than one time review. Team is multidisciplinary with representatives from all departments. Focus on process or service not individual. Proactive rather than reactive. 5

6. QI/QA Committee Meeting Minutes FTCA weighs minutes very heavily. The QI/QA minutes should: Provide enough information for reviewer to verify successful implementation of the QI program; Provide written documentation of QI activities; Include information on monitoring activities for measures listed in QI plan; Document multidisciplinary team by name and title during attendance; Report on QI activities conducted during meeting interval; and Document the use of data to measure objectives of QI plan and track improvement activities. 6

7. Sample QI Meeting Minutes Include: Attendees Agenda items Discussion topics Recommendations Action items Clearly label with consistent titles Provide sufficient detail 7

8. Conducting the QI Meeting Agenda should always be set: Review QI data/progress toward goals. Analyze trends and identify problem areas. Brainstorm for improvement strategies. Develop improvement plans. Develop, revise, and implement QI plans. Document meeting minutes and keep on file. 8

9. QI/QA Reports to Board QI/QA information reported at least 6 times. Board meeting minutes reflect: QI committee findings and activities: Short summary of QI projects conducted by staff. Objectives, data, improvement goals. Board review of QI plan on a regular basis Board (or designee) is also responsible for reviewing and approving credentialing/privileges of all medical providers. 9

10. Submission of Information for FTCA Submit QI plan as developed by organization with appropriate signatures and approval. Must also indicate board review during last three years. Meeting minutes: Six months of QI meeting minutes. Six months of Board meeting minutes with reports from QI program. Multiple site minutes. 10

11. Professional Liability 11

12. Information Submitted Brief description of current and previous malpractice claims: Malpractice history submissions within the past 5 years. Claims review process. Recognition and Accreditation Section Check the appropriate boxes that correspond to any accreditation or recognition levels that are applicable to your health center.

13. Professional Liability History Possible litigation requires preservation of any documents related to claim. Summary of each allegation filed within the last five years and what has been done to alleviate future occurrences: Name of provider(s) involved Area of practice/specialty Date of occurrence Summary of allegations Status/outcome of claim Summary of health center internal analysis and steps taken to prevent future occurrences (Do not include this analysis if the case has not been resolved, but please note that the case has not been resolved.)

14. Claims Review Process Describe process in place for reviewing malpractice claims. Connect the process to the appropriate risk management or quality improvement committees for the development of programs designed to reduce future occurrences. Do not include specific information about each individual claim.

15. Recognition and Accreditation Includes Patient Centered Medical Home recognition and The Joint Commission accreditation. Does not require submission of documentation of accreditation or recognition. Centers should maintain documentation in case of FTCA site visit in future.

16. Accreditation/Recognition Resources The Joint Commission ambulatory care accreditation: http://www.jointcommission.org/accreditation/bureau_of_prima ry_health_care.aspx http://www.jointcommission.org/accreditation/bureau_of_prima ry_health_care.aspx Accreditation Association for Ambulatory Health Care: http://www.aaahc.org http://www.aaahc.org National Committee for Quality Assurance Patient Centered Medical Home Accreditation: http://www.ncqa.org.http://www.ncqa.org “Resource Page: Patient-Centered Medical Home” on the Clinical Risk Management website: https://www.ecri.org.https://www.ecri.org

17. Q&A begins….. 17

18. Quality Improvement and Quality Assurance, Additional Information, and Professional Liability Christopher Gibbs, JD, MPH, LHCRM LCDR Shayna Wilborn, RN, BSN