PERFORMANCE IMPROVEMENT COORDINATOR: Quality Compliance Director or Quality Assurance Coordinator
PERFORMANCE IMPROVEMENT COMMITTEE:
- The PI Committee consists of department heads who review PI reports monthly. PI reports then go quarterly to the Governing Board.
- The Performance Improvement Committee meets monthly. Each indicator is reviewed individually to assure that compliance measures are being followed.
- The committee pays particular attention to patterns and trends which may be prevalent. When identified, adjustments to systematic process and protocols will be recommended and implemented to prevent the probability of future occurrences.
- Committee recommendations are communicated to appropriate supervisors who develop action steps to share with staff and implement improvements in the care environment. Staff is informed of PI activities by their Department Heads during monthly meetings.
PI INDICATORS COLLECTED:
- Patient Satisfaction
- Patient Grievance and Suggestions
- Staff Competency
- Medication Error Rate
- Pharmacy Dispensing Errors
- Nosocomial Infection Rate
- Reportable Diseases
- Employee Exposures
- Risk Management
- Incident Reports
- Patient and Staff Safety Questionnaires
- Clinical Contracts Performance
- Environment of Care Performance Standards
- Employee/Staff Suggestions for Improvement
- Employee Satisfaction
- Kitchen Sanitation
- Utilization Review: Denials, Readmits in 30 Days
- Against Medical/Staff Advice Rate
IMPORTANCE OF PERFORMANCE IMPROVEMENT AND QUALITY COMPLIANCE:
The Palm Beach Institute is a Joint Commission Accredited Organization.
WHAT IS THE JOINT COMMISSION?
- An independent, not-for-profit organization that accredits and certifies more than 20,500 health care organizations and programs in the United States.
- Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
- To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization undergoes an on-site survey by a Joint Commission survey team at least every three years
Death, suicide (in or w/I 72hrs lost d/c), rape, abduction of patient, death/permanent loss of function due to facility acquired infection, event causing permanent loss of function, elopement with death or loss of function. A root cause analysis is done by a team of staff who has knowledge of the event within 45 days. Action plan to correct root cause is implemented. JCAHO is not notified.
The Clinical and Executive Director will review with the Quality and Compliance Director all incidents, as needed. The Clinical Director and/or Executive Director will provide comments regarding the cause of the incident, appropriateness of staff response, or noted action step recommendations. The Quality and Compliance Director reports the incident to the PI Committee.
ROOT CAUSE ANALYSIS:
RCA is done to identify the root causes of a problem or event.
Why something happened. A Root Cause Analysis Form from JCAHO should be used to document a RCA or a “Near Miss”
FAILURE MODE EFFECTS ANALYSIS:
FMEA is done to identify how to keep something from happening. A flow chart of the process is done and each step is reviewed to identify any failure modes. Actions to keep the failure from occurring are implemented.
PATIENT/STAFF SUGGESTIONS FOR IMPROVEMENT:
Suggestion boxes are kept in the Dining Room for staff suggestions on Performance Improvement and Safety. Patients can use Grievance forms and submit these to staff on duty, their therapist or other staff they trust. These go to the Executive Director and once addressed, submitted to the Quality Compliance Coordinator for reporting to the monthly PI Committee meeting.
The group of staff who know about the process being reviewed. They meet to identify ways to improve the process.
PLEASE CLICK ON NURSING COMPLIANCE FORMS BELOW IN THE LESSON TOPICS BOX.
READ THROUGH THE FORMS AND THEN CLICK ON MARK COMPLETE.
YOU WILL BE TAKEN BACK TO THE PERFORMANCE IMPROVEMENT LESSON TO COMPLETE THE QUIZ FOR THIS PORTION OF THE ORIENTATION.