Performance Improvement Review

• Quality management structure, process and outcomes
• Quality/patient safety/performance improvement/ risk/credentialing integration
• Current structure and functions, roles and responsibilities
• The flow of information through the quality process to identify gaps that may exist
• Communication and teamwork within the department and the organization
• Quality management goals/strategic plan/ execution and outcomes
• Performance improvement tools/methods
• Leadership and direction
• Staff skill mix and deliverables
• Job descriptions and evaluations
• Accountability of QI department staff and clinical leaders for outcomes
• Medical staff peer review and outcomes
• Orientation and education—hospital staff and leadership
• Publically reported quality measures: performance and initiatives
• CMS hospital quality initiative participation and never events process
• Department and interdepartmental performance improvement projects
• RCA and FMEA—outcomes

Pay for Performance Compliance

• Interviews to understand the core measure process
• Document review to understand the process
• All documents, plans, forms, audit tools that define the hospital process in regards to core measure compliance, documentation of, and auditing/abstracting process
  • Prior regulatory or other survey reviews in past 2 years related to core measures
  • Data abstraction verification and organizational planning to improve compliance rates
  • Discharge planning procedure
• Medical record review
  • Two days by two consultants reviewing medical records – the goal is to review 90 medical records

Strategic Planning

• Strategic planning
  • Facilitator approach for leadership planning
  • Identify the top risks and priorities at each facility
  • Complete a SWOT related to quality functions
  • Complete goals and objectives for the risks/ needs identified along with treatment methods
  • Develop a master plan and opportunity grid
• Coaching
  • Customized to the need of the organization and the leader
  • Focused for the new leader in RM, PS or QI
  • Focused on advancing the skills and execution ability of an existing leader

FMEA

• Facilitating and training the staff
  • The steps for a FMEA
  • Select a high risk process
  • Identify a FMEA Team
  • Identify information needed
  • Process mapping
  • Conduct a hazard analysis
  • Prioritize failure modes for action based on criticality score
  • Redesign process and/or underlying systems to minimize risk
  • Test the redesigned process
  • Monitor the effectiveness of the redesigned process
  • Maintain the effectiveness of the redesigned process over time

RCA

• Facilitator plan to assist staff in conducting an RCA or in evaluating effectiveness of current process
• Review PI plan in relation to RCA
• Review the list of all RCA’s conducted in the past 24 months and select four to conduct an intensive review
• Interview participants and leaders in the process
• Review performance improvement documents related to the issue, the follow up, actions and evaluation
• Review peer review process and outcomes if related to the RCA issue
• Review of occurrences related to the issue – prior to the issue and following the RCA actions