Healthcare Performance Improvement: Plans, Policies & Procedures
Contents List
Introduction
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Disease management
¨
Clinical Guidelines
¨
DM in behavioral healthcare
¨
Patient satisfaction
Performance
improvement – quality in action
Definition
Principles
for performance measures in healthcare
Competency assessment strategy and tools
Plans
¨ Quality Improvement Plan – generic example (New 9-07)
à Practitioner Evaluation Process
à Case reviews
à Corrective Action Matrix
à Quality Improvement Program
à Quality Improvement Outreach
à Confidentiality Statement
à Quality Committee Confidentiality Agreement
à Conflict of Interest Declaration
à Joint Commission Quality and Safety Reports
¨
University Performance Improvement Plan - examples
¨
¨
Academic Medical Center Quality Improvement &
Patient Safety Committee functions/programs
¨
Hospital (Community) Performance Improvement Plan,
Policy & Procedure - example
Programs
¨
Annual Distinquished Quality Award
¨
Pay for Performance
v
Evaluating change
v
Family Practice model (
v
‘Bridges to Excellence’
v
Commonwealth Fund Opinion Leader Survey
v
Supporting Pay for Performance Programs - example
v
Requirements for physician buy-in
v
Audit form resource
v
CPOE
v
Group visits
Quality
fundamentals
¨
CQI obstacle busting
¨
Electronic medical records (EMR)
¨
Patient satisfaction – example questionnaire for
medical group practice
¨
Quality measures
¨
Reminders
¨
Preventive health care interventions for high risk
populations
¨
Clinical performance measures - CAD
¨
Presurgical screening tools
¨ Followup tracking tools – pap smears, mammograms
¨ Breast and colon cancer care quality measures
¨ Prolonged LOS related to medical injuries
¨
Unplanned readmissions
Case or Care
Management
Clinical
performance measures for ambulatory care (table)
Hand-offs - SBAR, Checklists, Resources
Quality
improvement tool kit - links
Sentinel
event reports – P & P
Quality notes
Provider profiles – P & P
Case mix
adjustment for provider profiles
Feedback
Steps
to improve productivity, resource management, physician/patient satisfaction
Ambulatory visit data
Resources
Ethics manual
- link
Medicare
“Pay for Performance” Initiatives
Provider
profiles: example indicators for tracking & trending data
QI/UM
Clinical Indicators/Performance Goals
Hospital/SNF
QA Screens
Surgical
Quality Indicators
Prevention
Quality Indicators, AHRQ
Staff quality
certification - resource
Survey
sampling error – statistical estimates (table)
Quality
Indicators – hospital-related
Respiratory
Care Services – QI Indicators
Readmissions
v
Readmission rate - examples
v
Readmission tracking tool
v
Readmission notes
National
Patient Safety Goals
Hospital
Dashboard Report
Health System
Performance Report
Staff
Performance Evaluation (generic)
Regional
Utilization Manager – Job description and performance evaluation
Performance
Improvement Counseling – P & P (
Case Mix Adjustment/Severity of Illness Measures
Addenda
Glossary
Quality
quotes
References
– listed by topic
Thoughts for
the unwary
Web links