td GUTHRIE County HosprraL ADMINISTRATIVE EFFECTIVE DATE: 10/04 SUBJECT: CONTINUOUS QUALITY REVIEWED: 9/10 IMPROVEMENT (CQ) PHILOSOPHY Guthrie County Hospital shall demonstrate a consistent endeavor to deliver patient care that is optimal within our available resources and consistent with achievable well-defined goals. This shall be achieved through a Continuous Quality Improvement (CQl) program and the application of all-house concurrent quality reviews. GOALS The CQI program shall be hospital-wide, comprehensive and integrated, The problem and process focused on approach will be used for review and evaluation of patient care and clinical performance with the ultimate goal of this program being improvement in patient care and clinical performance. The goals and objectives of the CQI program shall be realistic, measurable, related to all areas of hospital practice and cover both process and outcome activities. The CQI program shall be cost effective and efficient and will be conducted within a minimum of effort, time and cost and will avoid unnecessary duplication of resources. The CQI program will be flexible, that is, the program will permit innovation, enable departments/individuals, and permit variation in assessment approaches. AUTHORITY The Board of Trustees shall delegate to the Chief Executive Officer (CEO), as its direct representative, the responsibility for the CQI program, and for assuring the Trustees that the quality of patient care is the highest achievable by the demonstrating performance which is consistent with the pre-established standards. The CEO shall, in tum, delegate the CQI function to the CQ! committee that will utilize individuals from all hospital departments, services, and other areas directly or indirectly involved with patient care. DUTIES OF THE CONTINUOUS QUALITY IMPROVEMENT COMMITTEE, To identify and appraise all present hospital activities concemed with quality of services. To recommend additional activities and modification of existing activities as needed, as well as a combination of activities, if possible. To promote and to assist where needed, in development of standards of care for all CQI activities, with particular reference to existing rules and regulations of the professional staffs To receive, evaluate and coordinate reports of alt CQI activities. To share information between activities, in order to prevent duplication of efforts.To identify problems and evaluate processes, both by department and hospita-wide, and to set priority for their investigation and resolution. 1. Priority will be given to those problems, which may adversely affect patient care, 2, Efforts will remain within budgetary restrictions as suggested by the Board of Trustees. To assess problems and processes objectively for causes, extent, previous remedial action and the attribution of responsibility for the existence of the problem, if possible, and for its resolution To recommend corrective action and monitor the problem to resolution To report, at least quarterly, to the Medical Staff and the Board of Trustees The CQ! committee shall consist of the CQI coordinator and appointed members by the CEO. These members will have the authority to carry out the CQI process and will meet monthly to review alll current CQI processes, identify and prioritize CQI efforts, and receive reports from all managers once per quarter as scheduled by the CQI coordinator. To assure that all Medicare and Medicaid CQI requirements are met This activity shall include: 1. All problems identified and awaiting assessment. 2. All problems awaiting corrective action. 3. All problems awaiting demonstrated resolution. 4. All problems resolved during the reporting period. To reappraise the program annually for: Unity of the CQI organization-integration 2 Unity of the CQ function-coordination. 3. Application of the CQ! to all departments, services, and practitioners- comprehensiveness. 4. Effective prioritization of problems. PROCEDURES The CQI coordinator shall preside at all meeting of the CQ! committee and serve as the CQI coordinator. During times of absence, the Chief Nursing Officer (CNO) or designee will chair the meeting. The CQ! coordinator and committee member shall act for the committee in intervals between meetings, and receive reports of review and evaluation of all patient care areas, hospital and medical staff committees and any other activities related to the quality of care within the hospital The CQI coordinator shall keep accurate and complete records of all deliberation and actions.The committee shall assess problems, which are referred to the CQl committee by any of the management activities, or perceived by the CQ! committee from a study of reports or communications. Each potential problem shall document these items: Identify the problem or process that is being reviewed. Assignment of responsibility for analysis. Documentation of the PDSA form. Appropriate measurements associated with the PDSA evaluation. Actions taken and approved by the CQI committee or a delegate from the committee. ga ReVea The CQl agenda of each committee meeting shall include the following as applicable: 1. Attendance documentation. 2. Old or unfinished business. a. Review of identified problems awaiting analysis, actions, or follow-up and reports of activity regarding these problems. b. Recommendation on action or follow-up. 3. New Business a. Reporting by scheduled department manager b. Identification of any specific problems. c. Assignment of priority, if needed. 4, Analysis of any problem or processes and assign responsibility for analysis. 5, Recommendations and any remaining discussion, as needed. ORGANIZATION’S AUTHORITY AND RESPONSIBILITY OF THE CQ! COMMITTEE 1. Organization and membership of the CQ! committee; ‘a. The CQI committee is a multidisciplinary group composed of the CNO, CQl coordinator and appointed members by the CQI coordinator. b. The CQI committee shall receive quarterly reports from all department or program managers as scheduled by the CQI coordinator. The CQI committee shall have the authority to appoint additional participation from hospital employees as needed. ©. The CQl committee will meet the first Thursday of the month at 11:00 am to receive manager's reports, unless previously rescheduled due to a conflict. d, The CQI committee will hold additional meetings as needed e. The CQI coordinator will assure that the CQI committee functions and activities are carried out properly and in a timely fashion. In the event of the coordinator's absence, reports will be presented by the coordinator's designee. f. The CQl committee will report CQl findings monthly to the Medical Staff and Board of Trustees. REPORTING TO GOVERNING BODIES The CQI committee shall report all activity to both the Board of Trustees and the Medical Staff. 1. Activity will be reported monthly to these entities at their regular meeting times. 2. Activity will be reported: a. Through a representative of the CQl committee present at these meetings.b. Verbally, using either the complete Cl committee meeting minutes that detall the activity of the committee and department reports or capies of department reports. Member so the respective governing bodies will have opportunity to ask for clarification on any report or process. Members of the respective governing bodies have full access to any CQI document, policy, report, or committee member to gain full knowledge of any CQ! matter. After activity is reported to these governing bodies, they will have the opportunity to comment on any CQI matter, including, but not limited to, reports, policies, process, procedure, and committee functions. The Board of Trustees has full power over CQI functions and may delegate that responsibility to the CQI committee or other entities as determined by the Board of Trustees. AUTHORITY OF THE CONTINUOUS QUALITY IMPROVEMENT COMMITTEE The CQI committee shall have the authority to investigate problems and to direct responsible parties to implement action. 1. 2. 3. 6. 7. When action has been implemented, the CQl committee may report directly to the Medical Staff for further action. When action has been implemented, but the problem not resolved, the CQl committee directs responsible parties to Implement additional action. If repeated CQ! committee follow-up indicates that action has not been implemented despite direct referral to any or all of the parties indicated above, and if the problem significantly influences the quality of hospital services and/or hospital liability, the CQl committee may report diractly to the governing body. The CQI committee requests quarterly reports on CQI processes from department managers as scheduled by the CQl coordinator, with the exception not Speech Therapy and nuclear medicine/MRI. The CQI committee shall have the authority to review any claims against Guthrie ‘County Hospital. The CQI committee shall have the authority to direct the Medical Staff and other pationt care departments and committees to complete studies on specified topics. The CQI committee shall report quarterly to the governing body. RESPONSIBILITIES OF THE CQI COMMITTEE Request quarterly reports on CQ! problems or process reviews from department or program managers and any other hospital employees or committees addressing CI concems, with the ‘exception of speech therapy and nuclear medicine/MRI 1. 2. Reports from hospital services shall include measurement data as provided by the PDSA report form completed by department managers or employees. Reports from services that are contracted by the hospital shall include measurement data. These reports shall include a remedial action plan if the service indicator data suggests that there is @ need for further investigation. The CQI committee shall review the PDSA report form, request follow-up data and action implementation, and intercede in problem resolution when necessary.Review department PDSA report form, problems, processes encountered by department, including, but not limited to: chart review, incident reports, and other department documentation. Review actions taken by department managers to correct problems or streamline processes. Recommend and implement action when problems are validated, Assure that findings are disseminated to appropriate individuals and departments. Assign individuals to participate in follow-up studies, as appropriate. Work closely with Utilization Review, Infection Control, Tissue and Transfusion, Pharmacy and Therapeutics, and Safety Committee on CQI matters. Collect and report follow-up data. Maintain appropriate files on CQ! activity. Health Information Services will serve in the capacity of making all requested patient records available for CQI activities as well as serving in an advisory capacity when requested, DEFINITIONS The following definitions of terms used in this plan are provided to assist in plan implementation: 1. Continuous Quality Improvement Plan: A plan that demonstrates, by appropriate documentation through the use of the PDSA form, the continuous improvement and process documentation. 2. Continuous Quality Improvement Coordinator: A non-physician with education and/or experience, logical thinking and ability necessary to perform non physician activities of a Continuous Quality Improvement Plan. 3. Monitor: Technique of measurement developed to provide critical information about the quality of care provided to all patients and to determine priorities of further investigation; to watch, observe and check. 4, PDSA: The acronym for a theoretical quality model for improvement, Plan the improvement, do the improvement, study the results, and act to hold the gains and continue to improve. APPROVAL This plan has been reviewed, approved and adopted as attested to by the signatures below: Leu Sahige i 0910 Chairman, Board of Yrustees Date ty Ne 10 [Le Chief Executive Officer Date