Quality Management (QAPI)

Purpose: 

Recover Care has a comprehensive Quality Management program that is based on collecting data across multiple domains and evaluating opportunities for improvement in client outcomes and/or practice, process or system breakdown. There will be a Quality Management plan in place at all times. The Administrator will oversee and ensure implementation of a quality management process that is effective, data driven, involves all services and takes actions that addresses the agencies performance. This work will be retained for at least two years. 

Regulation: 144A.479(3)
Policy: RC-A14

Measurement:

  1. There will be a QAPI in place, at all times. It will be regularly updated and modified to meet the current needs.

Process:

  1. Each identified area for improvement must contain a baseline measurement and a goal
  2. The program must be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.
  3. At a minimum, the following domains are reviewed to monitor the effectiveness and safety of services and quality of care, identify opportunities for improvement, gauge effectiveness of Quality Management plan interventions. Review of domains and plans must be documented on the  QAPI Form Template
    1. Incidents
    2. Grievances
    3. Client Chart Audits
    4. Employee Personnel Records
    5. Infection Control
  4. The Quality Management program will focus on the following:
    1. High risk, high volume, or problem-prone areas;
    2. Consider incidence, prevalence, and severity of problems in those areas; and
    3. Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.
  5. The Administrator will ensure that the program measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the agency to assess processes of care, services and operations, causes of adverse events and implementation of preventive actions.
  6. All Quality Management plans will be monitored and analyzed quarterly, at a minimum

Executive Leadership Team: 

  1. The Executive Leadership Team is responsible for ensuring the following:
    1. That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained;
    2. That the SITE-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness;
    3. That clear expectations for patient safety are established, implemented, and maintained; and
    4. That any findings of fraud or waste are appropriately addressed.