1. Improving Quality and Reducing Risks Positive and Powerful Quality Assessment

2. 2 Learning Objectives Learning Objectives 1. Basic Elements of a QA/Compliance Process 2. Data Collection – Who, What, How, When & Where 3. Data Usage – Reports 4. Planning – Setting Priorities 5. Taking Action 6. Tracking Over Time

3. 3 Objective 1: Basic Elements of a QA/Compliance Process Standalone or Existing Committee Employee or Contracted Individual Choose What to Monitor – Regulators and Internal Needs Identify Organizational Risks*

4. 4 Crisis Special Treatment Procedures Medication Use Safe Environment Recoupment Maintaining External Accreditation Objective 1: Organizational Risk Examples

5. 5 Objective 2: Objective 2: Data Collection – Who, What & When A Quality Assessment (QA) Calendar* includes: Topics Topics Frequency Frequency Individuals responsible for reporting Individuals responsible for reporting

6. 6 Objective 2: Objective 2: QA Calendar Example PERFORMANCE IMPROVEMENT (PI) CALENDAR

7. 7 Objective 2: Objective 2: QA Calendar Benefits Acts as a checklist to ensure ongoing monitoring activities are not “lost in the process.” Helps ensure monitoring activities are conducted at required timeframes. Prompts Annual Review of Organizational Processes.

8. 1. Develop Question Sets for each topic* 2. Assign individuals to conduct audits 3. Train individuals on the auditing and reporting process 8 Objective 2: Objective 2: Data Collection – How

9. 9 Should encompass standards/regulations. Should encompass standards/regulations. Should combine questions from applicable standards/regulations for efficiency. Should combine questions from applicable standards/regulations for efficiency. May be created from forms…if forms are developed based on compliance with standards/regulations. May be created from forms…if forms are developed based on compliance with standards/regulations. May be used for multiple activities including peer review, clinical supervision, ongoing competency, corrective action plans and job performance evaluations. May be used for multiple activities including peer review, clinical supervision, ongoing competency, corrective action plans and job performance evaluations. Objective 2: Question Sets for Auditing Purposes

10. Objective 2: Data Collection – Where ORGANIZATION-WIDE 10

11. 11 Reports for all Question Sets should: Identify individual, departmental and organization-wide compliance. Identify individual, departmental and organization-wide compliance. Show areas of substantial compliance. Show areas of substantial compliance. Identify areas needing improvement. Identify areas needing improvement. Track improvements and compliance over-time. Track improvements and compliance over-time. Be formatted for use by the governing board, executive team, management, departments and individuals. Be formatted for use by the governing board, executive team, management, departments and individuals. Objective 3: Data Usage - Reports

12. Results from reports will drive the Planning – Setting Priority activities. Setting priorities for improvement is a critical step in the quality assessment/compliance process. Priorities should include: Frequent Activities Frequent Activities Likely to be Difficult Likely to be Difficult High Risk Processes High Risk Processes Objective 4: Planning - Setting Priorities 12

13. 13 Objective 4: Planning – Setting Priorities Analyzing Data: Comparing Data – historical patterns; desired performance targets; specifications, etc. Determine where performance can be improved…the problems. Determine the root cause of the problem…pull the roots…don’t just cut the weed. Using tools such as cause-and-effect (fish boning) diagrams for brainstorming problems is an effective way to analyze potential causes of a problem.

14. 14 Fix It! Corrective Actions may include: Education Education Process changes Process changes Policy and Procedure changes Policy and Procedure changes Communication Communication Objective 5: Take Action

15. Check for effectiveness of actions taken. Conduct ongoing monitoring of priority activities and other areas required by external agencies. other areas required by external agencies. Prepare reports that are easy to read and analyze. Enjoy the evidence of improved compliance overtime! 15 Objective 6: Tracking Over Time

16. See Handout Examples: Individual Report Question Set Detailed Report Over Time Summary Report 16 Sample Reports