1. Federal Tort Claim Act Medical Malpractice Program CY 2014 Application Technical Assistance February 26, Christopher Gibbs, JD, MPH Sharon Zang, PhD, RN, LPC Amelia Broussard, PhD, RN, MPH Office of Quality and Data Health Resources and Services Administration

2. Overview This presentation is meant to give a general overview of the 2014 application and highlight notable information that will be helpful while filling out this year’s application
Day One:
Day Two:
Application logistics
Application sections
Credentialing/Privileging
Risk Management
Additional Information
QI/QA
Available Resources

3. Review Process
Completeness and Accuracy (CA) Reviewer
Are you missing something?
FTCA Reviewer
Let us look at the substance
Program Quality Check (PQC) Reviewer
We love to review

4. Types of Applications
There are two types of applications for FTCA coverage:
EHB System will be opened to receive applications on , 2013
INITIAL DEEMING APPLICATION
May be submitted at any time during the year when the EHB system is open to receive applications.
Will be acted upon by HRSA within 30 days after receipt of a completed application
ANNUAL REDEEMING APPLICATION
All currently deemed health centers must file a renewal deeming application to be deemed for CY This year’s deadline: TBA

5. Electronic Handbook Reminders
If you have trouble logging in, please contact the HRSA helpdesk at or by at
Old applications in the FTCA folder
A full application must be attached for each subrecipient seeking FTCA coverage
You must submit application for it to be reviewed
Not changeable once submitted
10 business days to revise if sent back

6. 2014 Requirements
A complete initial or redeeming application must include:
An Application Form completed in EHB
Referral, hospitalization, and diagnostic tracking policies and procedures
An approved Quality Improvement/Quality Assurance Plan, including governing board signature and approval date
Two Methods to demonstrate Board approval
QI/QA Plan + Page with Board of Directors Signature
QI/QA Plan + Signed Board Minutes showing QI/QA plan was approve

7. 2014 Requirements
Minutes from past 6 QI/QA committee minutes within the last year. Remove patient names and other identifiers
Minutes from any six Board meetings that reflect Board approval of QI/QA activities. Remove all information not related to QI/QA activity
Summary of professional liability history for cases filed or closed within the last 5 years, if applicable
Name of provider(s) involved
Area of practice/Specialty
Date of Occurrence
Summary of allegations
Status and outcome of claim

8. 2014 Requirements
Credentialing list (in an excel spreadsheet) of all licensed and/or certified health care personnel employed and/or contracted by the health center, with the following information:
Name & Professional Designation (e.g., MD/DO, RN, CNM, DDS)
Title/Position
Specialty
Employment Status (full-time employee, part-time employee, contractor, volunteer)
Date of Hire
Current Credentialing Date
Next Expected Credentialing Date

9. 2014 Requirements
Board-approved Credentialing and Privileging (C&P) policies
Must be signed and dated by the Board
(C&P) Plan + Page with Board of Directors Signature OR
(C&P) Plan + Signed Board Minutes showing C&P plan was approved
Explanation of any “NO” responses
Deeming applications for any sub-recipients (as documented on the organization’s most recent approved scope from FORM 5B - see “sub-recipient submission instructions.”)

10. Section One: Risk Management
I want welcome participants for today’s deeming technical assistance video conference. I want to thank all of you for taking time away from your busy day to watch today’s presentations. Our goal is to have all health centers successfully complete their deeming application, so they can benefit from the cost saving benefit of federal malpractice. As with any malpractice insurance there are requirements to receive coverage. I going to cover Risk Management requirements for FTCA coverage.

11. Overview of Risk Management

12. Risk Management Definition
The identification, analysis, assessment, control, and avoidance, minimization, or elimination of unacceptable risks.
The identification, assessment, and prioritization of risks followed by coordinated and economical application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events or to maximize the realization of opportunities (Hubbard, 2009).
Hubbard, Douglas (2009). The Failure of Risk Management: Why It's Broken and How to Fix It. John Wiley & Sons. p. 46.
Lets begin with the definition of Risk Management.

13. Risk Management Strategies
Proactive is looking forward, assessing the functions and activities of the organization, planning for risks inherent in the organizational system, minimizing or eliminating those risks.
An example would be a risk management plan that protects electronic organizational and patient information by having a generator, redundancy and backed up information, etc..
Reactive is responding in a coordinated way to unexpected occurrences in a thoughtful, logical manner that minimizes loss and risk.
An example would be responding when the server crashes and patient records are not accessible to providers.
Comment #1: Both strategies are recommended to ensure risk is managed. Proactive strategies ensure routine and frequent monitoring/auditing. That way problems and opportunities for improvement are found and early corrective actions can occur.

14. Implementation
Implementation is the realization / fulfillment and execution of a policy.
Comment #1: Through the deeming application, policies are requested and the corporate documents reveal if the organization has implemented policy. Documentation of activities needs to occur.

15. Example of an Adverse Event
Medications errors are often the cause of Adverse Patient Events, clinical risk management policies help prevent harm to patients by ensuring these types of errors are prevented.
An example of an adverse medication error would be a provider prescribing an in-office injectable medication such as a Depo-Provera shot and the wrong injectable, such as the flu shot was given instead. Four months later, the patient was pregnant.

16. Aspects of a Risk Management Plan
Governing Board has a commitment to safety and quality;
The plan is based on healthcare national standards and regulatory/program requirements;
The plan is customized to fit the organization’s, sites, services, size, and patient population;
There is a clear mission statement with goals, objectives, activities, timelines, and defined staff responsibilities;
The plan is reviewed and updated periodically;
There is active and on-going monitoring/auditing, problem identification, data collection, corrective actions, documentation and reporting to the committee and the Board of Directors.
The health center engages all staff in risk management.
Comment #1: BOD commitment is demonstrated in bylaw statements, committee formation, committee duties and participation in committee as documented by meeting minutes.
Comment #2: ECRI has gathered standards as applied to CHC (330 program requirements and FCTA requirements); additionally accreditation bodies have standards- please be mindful, while there is overlap between 330 requirements, FTCA and accreditation bodies. There is also diversion.
Comment #3: Templates need to be reviewed and customized to fit the specific organization, then implemented as seen in organizational documentations.

17. Risk Management
Governance Corporate/regulatory/grant compliance organizational policies and procedures, oversight duties are fulfilled, BOD training, BOD document retention (i.e. is the governing board fulfilling their requirements?).
Administrative Implementation of organizational policies and procedures, ensures the processes within policies and procedures are implemented and are occurring as demonstrated through documentation, claims management, legal and contracts, insurance (e.g. property, D&O, gap, etc.), marketing /advertising/public relations, operations are regulatory/grant requirements, and is meeting goals set forth by the BOD.
Business/Finance Policies and procedures, billing, contracts, corporate/regulatory and grant compliance, procurement of assets, internal and external auditing, reporting, document retention, internal auditing processes are occurring.
The organization purpose creates interdependent units that must function together to achieve the goal.

18. Risk Management - Continued
Environment: Buildings and grounds, equipment, materials, disaster preparation and management, safety/security, event/incident/accident reporting and investigation.
Human resources: HR policies and procedures, compliance with employment regulatory requirements, job descriptions, employee handbooks, employment contracts, employee credentialing, employee orientation, employee health, on-going employee training and development, document security and retention.
Information technology: Privacy and security, vendor contracts, HIPPA,HITECH, information exchanges, patient portals, disaster and recovery plans, IT system redundancy plans.
Clinical: Credentialing of providers, quality/performance assessment and improvement, standard of care (clinical protocols), environmental and employee safety, infection control, patient tracking and follow-up, patient communications, patient and family education, patient satisfaction, pharmaceuticals and therapeutics, behavioral health and social service programs, volunteers.

19. Examples of areas of focus for Risk Management
Buildings and grounds • Safety and security • Equipment management • Claims management • Contracts and Procurement • Corporate/regulatory/grant compliance • Marketing/advertising/public relations • Disaster preparation and management • Event/ incident/accident reporting and investigation • Finance/ billing • Human resources compliance • Employee health • Staff training/education • Credentialing of providers • Clinical protocols • Infection control • Information technology • Patient tracking and follow-up • Patient communications • Patient and family education • Patient satisfaction • Pharmaceuticals and therapeutics • Product/materials management • Quality/performance assessment and improvement • Behavioral Health and social service programs • OB services • Pain management • Staff training/education
As you can see through the listed examples, Risk assessment and management covers all aspects of health center operations.

20. Implementation and Organizational Documentation
Within the organizational policies there are closed loop processes in place. Documentation of an active RM program:
Policies are present and approved by the governing Board of Directors
RM processes are implemented
Board of Directors and employee training programs are present
Data is being collected
Committees are reviewing data
Potential and existing risks are being identified
Solutions are explored and applied
On-going monitoring occurs
Reports are presented to the Board for oversight and governance

21. Deeming Application Questions

22. Review of Risk Management Systems
Deeming Application
Review of Risk Management Systems
The organization conducts periodic assessments to identify, prevent and monitor medical malpractice risk.
Comment #1: Specific to deeming, health centers must perform clinical risk management assessments. Documents attached in the FTCA application (e.g. QA/QI committee minutes) should demonstrate implementation.

23. Clinical Risk Management Assessments
Risk Management work plan (QA/QI)
Review of policies and procedures
Peer Review and chart audits
Scope of grant & privileging
Clinical outcome measures
Event/incident monitoring
Supervisory Agreements
Patient complaints
Adverse outcomes
Claims review

24. Benefits of Peer Review
Using peer review as a way to educate individual physicians as well as the staff in general means that it's integrated into the health center’s overall health performance goals and QA/QI processes.
Educational peer review, for both the provider and the health center, is a tool for identifying, tracking, and resolving suboptimal or inappropriate clinical performance and medical errors in their early stages.
This improves patient safety and overall quality of care.
Comment:

25. Peer Review continued
A closed loop peer review process which evaluates if the provider is delivering quality care per organizational protocols.
There are defined processes for addressing issues identified. Peer review processes address: who, what, where, when and how (e.g. who will review charts, how many per month, how will charts be reviewed and what will happen with reviews).
The procedures need to clearly define what remediation actions will occur given peer review findings. For example level 1, 2, 3, 4 findings would correlate to specific responses.
Peer reviews are retained and used for re-credentialing.
Higher risk practices such as obstetrics and pain management need more rigorous monitoring standards and frequency.

26. Deeming Question # 2
Identify and describe the policies/procedures that are implemented related to how PAs, NPs and support staff such as RNs, LPNs, and MAs are supervised. This description should also include whether there are supervisory agreements for PAs and collaborative agreements for NPs.
The organizational chart reflects appropriate lines of authority and supervision.
The supervision policies are implemented regarding supervision of staff (i.e. physicians, dentist, mid-level providers, nursing and MA,).
Policies are inclusive of support personnel, laboratory technicians; behavioral health and social workers; registered nurses; dental hygienists; dieticians; physicians’ assistants; medical residents.
There are well developed job descriptions with scope of practices, specific employee orientation and training, and review of competency and skill for all staff
Policies are consistent with state law on supervisory and collaborative agreements
Comment #1 : Identify and describe the policies/procedures that are implemented related to the appropriate supervision of PAs, NPs and support staff such as RNs, LPNs, and MAs are supervised. This description should also include whether there are supervisory agreements for PAs and collaborative agreements for NPs.

27. Supervision of clinical and non clinical staff continued
Personnel manual/employee handbook
Clearly defined job descriptions with definition of employee scope
Nursing Policies and Procedures
Front Desk Policies and Procedures
Administrative Policies and Procedures
*policies and procedures need review and updating as operations (e.g. sites and services) change. Employees job descriptions reviewed, training and competency skills evaluated.
BOD approves policy, job descriptions, health center scope, and privileges providers.

28. Question # 3A and 3B
3A. There are medical record policies and procedures that address the following:
Privacy (HIPAA) – YES or NO
Completeness of documentation – YES or NO
Archiving Procedures – YES or NO
3B. Medical records are periodically reviewed to determine quality, completeness, and legibility

29. Medical Records
Privacy updates as the electronic health record is updated/changed – such as going live with patient portals. Completeness of documentation, timeliness of documentation, coding of encounters.
HIPAA - all staff must be trained and expected to maintain the privacy, confidentiality, integrity, and security of protected health information.
Completeness of documents is inclusive of patient demographic information, income verification, current medications, allergies, current and past health conditions, patient assessments, standard of care treatments, performance measures (UDS), referrals and testing.
Policies should define what information is included in medical records, and archiving procedures. Health centers need to check state statutes, administrative codes, or state medical boards.
In addition to peer reviews, scheduled and on-going chart auditing needs to occur. This gives the organization the opportunity to explore the entire patient record for the above items.
Comment: Many electronic health records can generate universal and specific reports to audit/monitor these items.

30. Questions # 4
There are policies/procedures that address the following:
Triage – YES or NO
Walk-in Patients – YES or NO
Telephone Triage – YES or NO
No Show Appointments – YES or NO
Comment # 1: Many health centers have numerous experiences with patients arriving to the health center with urgent or emergent conditions. Timely responses are required. Having proactive strategies (more than one “what if” scenario) and training prepares staff to react with appropriate actions. When events occur that don’t go well, it is a opportunity to explore aspects of the event to and develop corrective actions.

31. Triage
Since health centers care for vulnerable populations with poor access to health care, patients often arrive on-site very ill - sometimes with an appointment, sometimes without an appointment. Triage assessments are essential in delivering needed medical treatment(s) within an appropriate time frame.
Patients calling for appointments may need phone triage to assess the acuity of their condition.
Good triage allows a patient’s conditions to be quickly assessed in order to render timely and appropriate medical care. Delays in assessing and treating patient conditions can lead to increased symptoms, increased hospitalizations/ED visits, poor patient outcomes and increased malpractice claims.

32. Triage Policy
Triage policies include who, what, when and how to respond.
Depending on the type of practice, (e.g. family practice, OB, pediatrics, etc.) standard of care for different patient conditions/ compliant warrants different triage responses.
Staff roles and responsibilities are clearly identified.
Staff are trained in their duties and responsibilities.
Triage events are part of the QA/QI processes.

33. No Show “No-Show” risks are:
Possible negative health consequences for patients
Liability risk
Reduced accessibility
Lost revenue
Patients need to be informed of health center policies and procedures for missed appointments; follow-up for missed appointments should be documented in patient records and depending on the health center’s target population (e.g. homeless population), reasonable accommodations for missed appointments needs to be considered.
Tracking and monitoring no show appointments helps the health center explore the causes (i.e. internal and external), and patient utilization patterns.
Proactive strategies are: reminder phone calls, text and/or s. Case management can help determine barriers to care. Having locations and hours of operation that meet the target population needs. Having transportation agreements. Having open access and/or blended patient schedules helps reduce patient no show frequency.
Assessing patient need (per site) helps the BOD of directors to adapt operations appropriately.

34. Question # 5
There are clinical protocols that define appropriate treatment and diagnostic procedures for selected medical conditions.
Clinical protocols for frequent conditions (i.e. diabetes, hypertension, pain management, prenatal care, etc.).
Protocols need to be based on standard of care for that type of practice.
Protocols need to be updated periodically.
Providers and clinical staff need orientation and training regarding their role of standard of care.
Clinical procedures done at the health center are clearly defined, staff is qualified to perform the procedures.
Peer reviews are conducted based on clinical protocols.

35. Question # 6
There is a tracking system for patients who require follow-up of referrals, hospitalization, diagnostics (i.e. x-ray, lab results)
Referral tracking – YES or NO
Hospitalization tracking – YES or NO
Diagnostic tracking ( x-ray, labs) – YES or NO
ATTACHMENT A - Please upload the health center’s clinical policies and procedures for only the items listed in question 6.

36. Referral Tracking Does referral policy ensure referrals are:
tracked, by whom, how often and within a specific time frame
referring providers are contacted for patient information
patients are reminded of the importance of making referral and are called to be reminded of the referral appointment
referring providers notify health center if patient ‘No shows” for the referral
patients are contacted if they do not make their appointments
all patient referrals are documented
all calls and contacts are documented
the health center uses their EHR to assist with tracking referrals (reports are generated daily/weekly/monthly)
Referral tracking monitoring is part of QA/QI processes
Health center staff need to document within the patient record each step of the referral processes.

37. Referral Tracking
Is there a tracking log with patient identifier, test date, ordering provider, list of tests, reviewed results, follow-up recommendations and communications with the patient.
Policies and documentation need to reflect a closed looped process.
With the recent volume of organizations transitioning to an EHR, it is important to keep tracking systems intact.
Failure of follow up systems may lead to claims associated with failure to diagnose or delay in diagnosis.

38. Why is hospital tracking important?
The over arching goal is to deliver health care services early/timely/consistently so that hospitalizations and/or ED visits are less. When a patient is hospitalized once released, the goal is to maintain and improve their health status.
Being discharged from the hospital can be dangerous
20% of patients experience adverse events within 3 weeks of discharge
Nearly three-quarters of which could have been prevented
Adverse drug events are the most common post discharge complication nearly 40% of patients are discharged with pending test results and recommended further diagnostic testing
*Source:

39. Hospital Tracking Does the hospital tracking policy ensure:
Staff members have identified roles and responsibilities including after-hours, holiday and weekend coverage.
Staff are trained to complete these duties.
Ensure the hospital tracking log identifies patient information and follow-up documentation.
Update health center contact information annually and if the information changes with area hospitals.
Identify key hospital staff that will ensure notification and documentation is forwarded to the health center.
Educate patients to identify themselves as health center patients if hospitalized or visit the ED.
Tracking, auditing and reporting performance compared to goals.

40. Strategies to Improve Tracking Hospitalizations/ ED
If you haven’t received any hospitalization or ED notices, call the most frequented hospitals to ensure there isn’t a system failure/issue.
Ensure patients carry health center business card.
Educate patients to contact the health center when or if they have a hospitalization and/or visited a ED.
Ask the patient at time of all visits if they have been hospitalized or visited a ED.
Check the fax machine ( s) frequently .
Set up an open access or blended patient appointments for same day.

41. Diagnostic Testing
Why is this important? Missed or delayed diagnoses (particularly cancer diagnoses) are a prominent reason for malpractice claims.
The organization must identify normal, abnormal and critical lab values.
Health center staff must know policies and procedures for abnormal and critical lab results and individual’s identified role.
Provider notification of all labs, needs to include EHR if appropriate.
Policies and procedures need to describe how often are labs reviewed, what happens when the ordering provider is not on-site.
Immediate patient notification of all CRITICAL test results. In some areas these are known as “Panic” values.
Procedures need to include after hours, weekend and holiday responses to abnormal lab values.
Patient records need to include documentation and treatments rendered.
Comments: Examples range from the negative rapid strep, but positive strep culture to a positive pap test result.

42. Diagnostic Testing continued
Documentation of notification [date/time/person spoken with] and follow up recommendations including come to the health center or go to the emergency room.
What happens if the patient can’t be reached.
DO NOT leave critical or abnormal lab results on voic or text or . Have alternative patient contact information. Verify patient information at each contact with the patient (phone and/or appointment).
In some cases law enforcement offices can be called for “sick visit”.
The diagnostic tracking log is complete and up to date, the tracking information is part of the patient record.
Example: What happens when the patient’s HbA1C comes back at 650…or higher and the patient is not on-site? What happens when that MRI indicates a major health problem?

43. Risk Management Questions

44. Section Two: Quality Improvement/ Quality Assurance

45. Understanding Quality Improvement & Quality Assurance
Quality Assurance and Quality Improvement are often confused as same process
Terms used interchangeably but not the same
One is focused on observations only and represent a one time opportunity
Other is continuous process documenting improvement
Both based on standards for performance
Both important to organization
Both focus on quality services to patients

46. Definition of Quality Assurance
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 not solution oriented
Compliance with standards or goal
Public health departments, JACHO, or other groups such as licensing groups
Examples include annual infection control and safety training for staff
Review of sample medications to assure current expiration date

47. Definition of Quality Improvement
QI is continuous ongoing process designed to improve patient outcomes, services or process
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
Focus is more often on process
Does not single out individuals but looks at methods of providing services
Involves whole organization in development of activities

48. Goals of Quality Improvement
Goals of QI
Goals of Quality Improvement
Understand process
Reduce & eliminate errors
Improve efficiency
Improve communication
Requires measurement
Focuses on outcomes

49. Core Concepts of Quality Improvement
Exceed expectations of patients or clients
Process usually problem not people
Does not seek to blame but to improve process
Most effective when part of everyday work
Focus on everything, you can not focus on anything
QI based on achieving success through measuring specific outcomes that are related to patient care or financial stability
This also includes patient satisfaction, if patients are satisfied with care, then organization will continue to improve finances, etc.
Quality Assurance often focuses on individuals in a certain discipline rather than the process
Focusing on process reduces staff resistance and finger pointing which can be non-productive
Focus attention on one small part of the process rather than massive overhauls that may not be necessary

50. Goals of QI Plan QI plan integrates all departments in activities
One QI plan for organization
Minutes document QI activities
Plan should have certain components outlining process of committee
Expectation is that one QI committee will be established for the organization. This committee will be responsible for all QI activities. There should not be individual departmental QI committees but one that deals with all QI concerns
Minutes should include information on all QI projects conducted during the month with information on status of project. More to come on this topic
Plan should have a strong outline of how the committee functions and information is reported to the organization as a whole and to the Board of Directors.

51. Quality Improvement Plan Components
Statement of Purpose or Intent of Plan
Scope of Plan
Administrative Responsibility
Risk Management Systems (may be separate plan)
Role of Peer Review in QI
Committee Composition
Committee Accountability
Methods for conducting QI activities
Tracking of QI Activities
Approval and Review
Details for each of these areas will be discussed separately
Each area must be addressed in a successful QI plan
Plan must be approved by Board of Directors within the last three years to be acceptable. A signature page with appropriate signatures from Board and CEO and dates signed must be included as part of the QI plan
Plan does not have to 20 pages as long as all of the required information is in place

52. Statement of Purpose Plan includes statement of purpose or intent
Example
The purpose of the Quality Improvement Program is to support improved health care delivery and outcomes for the patient population receiving care. Objective is to promote continuous Quality Improvement within the organization and support the objectives and scope of Quality Improvement Program.
The main idea is to indicate the overall function of the QI plan and program and its role within the organization.
This statement indicates that the organization supports improved patient care and the QI program in designing projects to improve that care.
It also focuses on outcomes for patient care

53. Scope of Plan Scope refers to what QI committee will do
Includes monitoring of select measures, evaluation of performance and improvement in organizational performance
Discusses which activities are applicable to QI
Includes risk management tracking as reported to QI, results of peer review and measures to be followed during year
Areas of consideration include medical/clinical, operational/administrative, governance and finance
Resources available in notes section
In the scope, the QI committee defines what they will be monitoring on a general scale.
It also indicates what type of measures will be monitored during the course of the year. These should include at a minimum the HRSA clinical measures and financial measures as reported in the most recent grant application.
Other areas that may be included relate to administrative processes such as personnel policies/procedures
QI committee may be responsible for development, implementation and monitoring of practice guidelines or new policies/procedures
HRSA PAL :
National Quality Forum Performance Measures:
AMA Physician Consortium for Performance Improvement™:
AAFP Performance Measurement and Pay-for-Performance:

54. Administrative Responsibility
Health center identifies by title individual with overall responsibility for QI program
Approval requirements are stated (who must approve plan)
Individual consulted in development of QI/QA Plan and activities
Identification of who will receive information about decisions and activities of QI/QA program
This includes all QI/QA activities and projects conducted to improve organizational performance. This is typically the Board of Directors who in turn delegate this authority to the CEO and CMO for implementation
HRSA has an expectation that the authority for the QI/QA program will be delegated to the CMO who in turn may delegate day to day operation to a QI coordinator
Who give approval for the implementation of the QI program at the organizational level
This may include a QI coordinator who actually does most of the monitoring and runs the QI meetings with the approval of the CMO
Typically, there is some provision of reporting to the Board of Directors on a regular basis.

55. Risk Management Systems
Health center identifies the following:
Policies/procedures regarding appropriate supervision of clinical and non-clinical staff
Policies/procedures to identify and document system process or breakdown
Policies/procedures for addressing and investigating medical malpractice claims
Resources available in Notes section of slides
Straight forward statement that defines who supervises who and under what circumstance
Must know/comply with state regulations
A procedure should be in place to track certain indicators defined by the organization that would indicate a system breakdown. This may be something like a patient complaint, incident that occurred during the course of patient care, lack of patient care services that were identified by the staff
Investigation of medical malpractice claims is a very important part of risk management. A process must be in place and described within the QI plan. Results of the investigation may be reported to the QI committee if it is related to patient outcomes and processes that could have avoided potential claims
(ECRI Risk Management Website)
Event Reporting Toolkit:
Patient Satisfaction Questionnaire:
Safety Attitudes Questionnaire:
AHRQ Medical Office Survey on Patient Safety Culture:

56. Role of Peer Review
Peer review is process of all providers reviewing a peer’s medical records
Specific time frame for review is defined (i.e. quarterly, monthly, bi-monthly)
Results of peer review should be communicated in aggregate form to QI committee for possible QI projects to improve patient care
Review should consist of two parts
Medical care review
Review for completion and documentation
Resources in Notes section
Peer review is often overlooked in QI programs
All medical providers should participate, including physicians, nurse practitioners and physician assistants
Should be done at least quarterly to assure continuous monitoring
Based on practice guidelines for most common diagnosis and clinical measures
Review for completion and documentation assures that patient care information is being documented in the correct location to improve access to data in EMR
NCCHCA Healthcare Plan Chart Audit Tool:
Physician Practice Risk Management Self-Assessment Questionnaire:

57. Committee Composition
Establishes QI committee
Membership is defined
Multidisciplinary membership
Committee chairperson & vice chair person identified
Committee must have defined meeting frequency. Meeting 6 times per year strongly encouraged*
Agendas and minutes for committee meetings maintained
* Application requires 6 sets of minutes within past year.
QI committee membership is defined by position rather than individual
Includes representatives from all departments including finance, personnel, front desk, administration, clinical providers, dental providers, behavioral health providers and clinical and dental support staff
Generally, chair is CMO and vice chair is a QI coordinator

58. QI Committee Accountability
Short statement that defines accountability of QI committee
Defines frequency of reports to Board of Directors
Defines time frame for updating QI plan and schedule

59. QI Committee for Multiple Sites
Still one QI committee for organization
Site QI committees may be established and described in overall QI plan
Site QI plans must mirror overall plan and report on a regular basis to overall QI committee
Main QI plan sets agenda for organization
Additional QI projects may be done at satellites based on center needs in addition to main QI program
Reporting from each site is very important in the overall QI committee
QI committees at individual sites must confirm to the multidisciplinary composition indicated in previous slide
Individual site QI programs must mirror overall QI plan
Each site should have the same QI activities that are determined by results of monitoring of clinical and financial measures of the overall QI committee. If that site has better performance on selected measure, they could assist other sites in improving by implementing their process
Individual sites may also conduct extra QI projects that are pertinent to their special situation and/or population
Needs to be reported during main QI meetings for documentation

60. Methods for QI Activities
QI plan should include methods used to conduct QI projects
Includes process for collecting data and sources
Allocation of resources defined
Process most common: Improvement Model and use of PDSA Cycle
Schedule of activities for monitoring measures
Defines QI activities based on subcommittees
Data information should identify source and frequency of when data is collected.
PDAS: Plan, Do Study, Act Process
Schedule defines how often each measure is monitored and what is done with the results.
Information must be reported in minutes of meetings as part of documentation of QI project activities
Defines structure of subcommittees and their responsibilities

61. Tracking of QI Activities
Defines reports to be given by subcommittees to overall organizational QI committee
QI activities reported by subcommittees to overall QI committee
Report baseline on project, interventions attempted, results of interventions and continued monitoring
Committee members track measures over time for QI activity impact
During QI committee meetings, subcommittees should report on the current status of their QI projects. This would include information about the initial performance or baseline performance on the measure chosen for improvement, any interventions or activities done to improve the performance and results of the interventions (PDSA process). If successful, what monitoring is recommended to assure continued improvement would also be part of the report

62. Approval and Review Identifies individuals who must approve QI plan
Signature page in place with dates
Appropriate signatures in place on review page
Frequency of review and updates for individuals who are responsible for approval
The Board of Directors must approve the QI plan within at least three years of implementation
Review of the plan is generally done annually with and updated approval page with appropriate signatures
The Board of Directors determines who will review the plan and the frequency during which this will take place

63. QI/QA Committee Meeting Minutes
Committee minutes are important and key to confirm implementation of QI/QA plan
Should be enough information for reviewer to verify successful implementation of QI program
Provide written documentation of QI activities
Must include information on monitoring activities for measures listed in QI plan
Must document multidisciplinary team by name and title during attendance
Must report on QI activities conducted during meeting interval
Data used to measure objectives of QI plan and track improvement activities
QI meeting minutes provide the written documentation of the implementation of the QI plan for the organization
Minutes should include reports from Risk management and peer review as appropriate
Minutes should also include information on monitoring of all measures listed in QI plan
Subcommittee reports must include and document in the minutes results of all QI activities. This would include baseline on individual QI measures, interventions and results of interventions with expected outcomes through monitoring
Make sure that data is recorded in the minutes and not on attachments that are not submitted.

64. Sample QI Meeting Minutes
Include:
Attendees
Agenda items
Discussion topics
Recommendations
Action items
Clearly label with
consistent titles
Provide sufficient detail
All information should be presented in an professional, objective manner. Act as if this information could be discoverable – i.e. notes in charts, meeting minutes, etc.

65. 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
This is done by reviewing data to determine poor performance on outcomes measures or financial measures
Need at least three months or three measurement periods to determine trends
Use PDSA process or similar process for developing plans or use process outlined in QI plan

66. QI/QA Reports to Board QI/QA information reported at least 6 times
Board meeting minutes reflect:
QI committee findings and activities
Objectives, data, improvement goals
Board review of QI plan on a regular basis (usually annually)
Board meeting minutes must include the same information presented by the subcommittees to the overall QI committee
This includes baseline performance on selected measure, interventions designed and implemented and results of interventions
Data should be included on a regular basis detailing performance on measures included in the QI plan

67. 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:
6 months of QI meeting minutes
6 months of Board meeting minutes with reports from QI program
Multiple site minutes
If there are multiple sites, the organization is expected to have one overall QI committee that receives and records reports from the other sites. These are the minutes which should be submitted to FTCA
Minutes must give details that indicate that the individual site QI committees are functioning in the same manner depicted in the QI plan for the organization. Information on QI activities must be included. This is the only way that organization can document their active QI program

68. Questions for Day One

69. Part 2 Tomorrow, February 21, 2013 At 1:30pm EST