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This video will be covering the Quality Improvement/Quality Assurance Plan: Supplemental Information and
ECRI Institute Resources.
On this slide youíll see a screen shot of the Clinical Risk Management membersí website
that contains guidance articles, sample policies and tools, toolkits, courses for continuing
medical education credit, self-assessment questionnaires, and other resources you can
download and use in your health centers and free clinics. Clinical risk management resources
are made available by ECRI to you for free on behalf of HRSA. Throughout this instructional
video, weíre going to be discussing some best practices that will assist you with preparing
the required materials for the quality improvement portion of the FTCA deeming application, but
weíre also going to be referring you to resources that are available on the Clinical Risk Management
website that can help you. These sample policies and resources are not required, but rather
information that you can review and utilize if you feel it is a good practice that should
be implemented in your health center. If you are using the policies and resources mentioned
in video, you need to make sure that your health center is actually implementing them
and that the resources used are tailored and appropriate for your health center.
Before you fill out the application, youíll need to make sure you have copies of your
quality improvement/quality assurance plan with board approval during the past three
years, the minutes from any six quality improvement committee meetings that took place between
June 1, 2011 and the submission date of the application, minutes from any six board meetings
evidencing oversight of quality improvement activities that took place between June 1,
2011 and the submission date of the application, because you will need to attach these documents
to the application. It is new for the 2013 calendar year application that your quality
committee minutes and board minutes should be between June 1, 2011 and the submission
date of the applicationóif you do not have six meeting minutes during that time period,
attach the minutes that you do have and include an explanation for why you do not have six
minutes. You may also want to have a copy of HRSAís most recent program assistance
letter on calendar year 2013 requirements for FTCA medical malpractice coverage to make
sure youíre meeting all requirements; this document is available on the HRSA Bureau of
Primary Health Care website.
These next few slides outline the questions youíll need to complete for this portion
of the application. For the first part of the application, you will need to upload all
of these documents listed on this slide. This is important: you must have proof that the
quality improvement plan was reviewed and signed by the board within the past three
years. If the plan has not been reviewed by the board within the past three years or you
do not have proof that it was, the application will be returned to you without further review.
One thing that is different for this year is that if you do not have the signature of
the board and date on the actual plan, you can submit board minutes in addition to the
plan that clearly state that the board approved the plan and include the board signature and
date. In addition, if possible, please combine the six quality improvement minutes into one
document and the six board minutes into a second document to expedite the process. You
may black out any patient identifying information in the quality improvement minutes as well
as any information in the board minutes that does not relate to quality improvementóyou
can do this by using a black marker to black out this information on hard copies and then
scanning those copies onto your computer. For the boardís signature, you should also
use the hard copy of the quality improvement plan with the actual signature on it and then
scan that document to the computer and attach that document to make sure that the board
signature is on the actual document.
As an example of how to include the signature and date of the board on your quality improvement
plan or minutes, see this slide. Again, you should take a hard copy of your policy with
the actual signature, scan it to your computer, and then attach that document to make sure
the actual signature appears on the document. The first image on this slide represents what
the signature on the policy should look like. Your policy should not have any blank dates
or signature lines and should not have the typed signature of the board of directors;
the last two images on this slide with the x through them represent what you should not
do.
For question two, youíll need to specify the date that the quality improvement plan
was approved by the board. Again that date should be within the past three years and
should match the approval date in your quality improvement plan or board minutes. For most
of these questions, youíre also going to need to note the pages in the quality improvement
plan where the information appears, so make sure you have the plan in front of you as
youíre completing the questions. For example, for question three, you must describe the
process for assessing clinical quality and risk issues on a continuous basis and also
note what pages of the quality improvement plan include this information. The application
will not be reviewed and it will be returned to you if you do not include both the description
and the page numbers in your response.
Question four relates to questions on the quality improvement committee. Weíre going
to spend the remainder of this video providing some basic information on quality improvement
processes and the structure of the quality improvement committees to help you prepare
for completing the FTCA deeming application.
All health center departments and services should be involved in quality improvement,
particularly risk management since quality improvement goes hand in hand with risk management.
Some areas that may be addressed in the quality improvement plan are listed on the slide.
Throughout this presentation weíll refer to some sample plans and other resources that
can help you in your efforts to develop a quality improvement plan; however, you should
develop your own plan based on the structure and needs of your health center.
Selection of quality measures is important for assessing an organizationís overall performance,
evaluating executive performance, and comparing performance to benchmarks. Health centers
can use established quality measures to set quality and performance goals for their organization
and patient populations, and then assess their progress against these established goals.
HRSA outlines quality measures for section 330 health centers, and health centers provide
data on their performance in these areas to HRSA through the uniform data system; more
information appears in HRSA program assistance letters, and a link one of these documents
is on the next slide. Other methods for assessing quality or identifying areas for improvement
include distributing patient satisfaction surveys to determine the patientís perspective
on what areas might need improvement, looking at general health center data such as demographics
of patients, frequency of missed appointments, and patient flow issues, and distributing
employee surveys or encouraging employees to report any quality-related issues or safety
concerns. Continuous feedback should be provided to the employees to let them know what strategies
were implemented to address the concerns. These are just a few of the methods health
centers can use to assess quality. Health centers should determine which methods work
best for their particular facility.
For the third part of question four, youíll need to list the tools that you use to systematically
collect and analyze data. This slide lists some published performance measures that health
centers can use to collect data on performance and track progress toward goals. The HRSA
program assistance letter outlines HRSA performance measures for section 330 health centers and
free clinics. Some other examples of performance measures from the National Quality Forum and
the American Medical Association are provided, as well as a webpage from the American Academy
of Family Physicians that provides strategies and tips for collecting data on quality measures.
Links to additional resources available from ECRI Instituteís Clinical Risk Management
website and other sources, such as patient satisfaction questionnaires, employee questionnaires,
and self-assessment tools, are available on this slide.
One way to make sure quality data is continually being collected is to educate providers to
document all necessary information relating to quality measures being used. Checklists
or standardized forms that providers complete during or after patient care activities can
help prompt the provider to document necessary information. Data should be compiled and entered
into an electronic database on a continuous basis, and the health center should designate
a staff member, such as a quality improvement coordinator, to analyze and trend the data
on a regular basis, such as monthly or quarterly. This data should be provided to the quality
improvement committee to evaluate during regular quality improvement meetings, and ultimately
compiled in a report to present to the board. Health centers can use benchmarksósuch as
data reported by other similar health centers or their own previous dataóto compare their
results to other centers or their own progress over time and identify areas that need improvement.
Developing a quality improvement plan and program is not a one-time thing. Quality improvement
activities need to be monitored on a regular basis, with problems identified and strategies
for improvement implemented. Getting staff input on improvement strategies and providing
frequent feedback to staff on progress toward meeting goals keeps staff in the loop and
keeps everyone focused on improving quality. Providing incentives to employees has been
shown to help improve efforts.
The purpose of the quality improvement committee is to oversee the quality improvement plan
and develop and monitor quality improvement activities throughout the health center. The
committee should designate a chair such as a quality improvement coordinator or medical
director who will lead the meetings. All departments and levels of staff should be represented
on the committee to gain various perspectives. Many quality committees include permanent
members and rotating members who, for example, serve one- to two-year terms to keep a fresh
perspective; however, when youíre organizing the committee youíll want to make sure you
donít have a situation where the majority of members rotate out at the same time. You
should also plan to meet as often as possible; on a monthly basis is recommended.
Agendas for quality improvement committee meetings may include the items listed on this
slide. The quality improvement committee is responsible for developing, revising, and
implementing quality improvement plans with input from other staff as necessary and the
committee may want to designate one meeting per year to take a close look at the plan
and propose revisions.
As we mentioned earlier, youíll need to six quality improvement meeting minutes that took
place between June 1, 2011 and the submission date of the application as part of the FTCA
deeming application, so make sure you sufficiently document what was discussed during these meetings
and keep these minutes on file. Make sure your minutes include all necessary information
and detail and are clearly labeled with consistent titles. A sample template appears on the slide.
The board and executive staff is ultimately responsible for the quality of care provided
by a health center or organization and should be kept up to date on quality improvement
data, initiatives, and results. The board should vote and take action on quality issues;
provide guidance, oversight and approval of activities; approve health center policies;
and approve and make decisions on credentialing and privileging of providers. The quality
improvement committee should prepare reports that will be provided to the board on a regular
basis, such as quarterly, and include graphs, tables, or other visuals highlighting the
health centerís progress toward goals or results related to quality measures, areas
identified for improvement, and corrective action plans or other initiatives.
As we mentioned before, you have free access to the resources available on the Clinical
Risk Management website provided on behalf of HRSA. One resource that will be of interest
to you related to quality improvement is the Quality Improvement Resource Page. This page
includes links to numerous resources, such as sample quality improvement plans, toolkits,
staff training programs, guidance articles, and other information.
In order to access the Clinical Risk Management website, go to the address listed on the slide,
www.ecri.org/clinical_rm_program. Youíll need to log in with your username and password;
you can see the red circle on the slide where you enter your log in information. If you
donít yet have a username and password, please contact ECRI at the contact information listed
on the slide and weíll get you set up. In addition, if you need any help finding the
resources referred to during this presentation or any other resources, please contact us.
Weíll conclude with some frequently asked questions submitted by grantees on the quality
improvement section of the application. The first question is, if a health center has
multiple quality improvement committees, which minutes should be submitted? And the answer
to this question is that the health center should have one primary quality improvement
committee that is responsible for reporting quality improvement activities and findings
to the governing board and coordinating the efforts of all quality improvement subcommittees.
The meeting minutes from that primary committee should be reported, because it should provide
an overview of the activities within each quality improvement subcommittee.
The next question: can the board and quality improvement committee minutes be blacked out
or copied and pasted? The answer is that it is acceptable to redact the minutes by using
a black marker. The documents can then be scanned and uploaded into the electronic handbook.
Finally, what if the health center does not have six sets of meeting minutes that occurred
on or after June 1, 2011 and by the submission date of the application? The health center
should provide all minutes from meetings that took place between June 1, 2011 and the submission
date of the application. The application must provide an explanation if less than six sets
of minutes are provided.
If you have any questions on the deeming or application process, please contact HRSA at
the contact information listed on this slide.
[End of audio]