Policy AD-CQI Continuous Quality Improvement (CQI) Plan 2022-12-20

Purpose

The mission of Westside Family Healthcare (Westside) is to improve the health of our communities by providing equal access to quality health care, regardless of ability to pay. To help achieve this mission, Westside has created the Quality Improvement Committee (QIC) of the Board, which is guided by the Continuous Quality Improvement Plan.

The purpose of the Continuous Quality Improvement (CQI) Plan is to maintain and enhance the quality of health care provided to the patients of Westside and to identify and address opportunities for improvement.  The CQI Plan provides the mechanism for formalized interaction between health center staff, committees, and Board members, giving the opportunity for organization-wide input into decision-making and problem solving in the quality improvement process.

The CQI Plan also meets requirements contained in the Quality Improvement / Quality Assurance and FTCA Deeming chapters of the HRSA Health Center Program Compliance Manual as well as relevant Leadership and Performance Improvement standards of The Joint Commission.

Policy

The Westside Board of Directors, Quality Improvement Committee (QIC), leadership, and staff perform their defined responsibilities and work collaboratively with one another and across the organization to support and promote the provision of high-quality services through continuous assessments and performance improvement activities, following the structure and procedures outlined below.

Scope

Board of Directors, Quality Improvement Committee (QIC), leadership, and staff.

Definitions

PDSA – PDSA, or Plan-Do-Study-Act, is an iterative, four-stage problem-solving model used for improving a process or carrying out change. Going through the prescribed four steps guides the thinking process into breaking down the task into steps and then evaluating the outcome, improving on it, and testing again.

Procedures

Principles of the Continuous Quality Improvement (CQI) Plan

• 1. The CQI Plan establishes a framework for organizational improvement.
  2. Continuous quality improvement activities are organization-wide.
  3. The CQI Plan focuses on the quality of patient care, safety of the patient, and environment of care.
  4. The CQI Plan is kept simple and systematic.
  5. The CQI Plan helps to identify and support compliance with the requirements of accreditation and governmental agencies.
  6. Continuous quality improvement information may be used in the strategic planning process.
  7. Monitoring of quality is ongoing.
  8. Confidentiality of continuous quality improvement data is a priority.
  9. The CQI Plan is evaluated at least every two (2) years or as needed.

Organization and Responsibility

• 1. The responsibility for the Continuous Quality Improvement (CQI) Plan is divided among the Westside leadership and staff, the Quality Improvement Committee (QIC), and the Board of Westside Family Healthcare.  This approach facilitates a collaborative, interdisciplinary, organization-wide approach.  
  2. Board of Directors (Board)
     1. The Responsibilities of the Board of Directors are:
        1. To give final approval for the CQI Plan at least every 2 years or more frequently as indicated.
        2. To approve and offer guidance for quality and performance improvement activities, as needed.
  3. Quality Improvement Committee (QIC)
     1. The Quality Improvement Committee (QIC) is a standing committee of the Board of Directors and consists of:
        1. at least one Board member who serves as Chair of the committee and as the voice of the committee to the Board;
        2. volunteers, who may be medical professionals and/or representatives of the community served; and
        3. designated Westside leadership and staff.
     2. The mission of the QIC is to maintain and enhance the safety and quality of care and services provided to Westside’s patients through an integrated process of continual assessment of the organization’s performance.
     3. The QIC holds its meetings every other month.  Following each meeting, the Chair provides a summary report of topics discussed to the Board of Directors.
        1. Focus areas reviewed and presentations provided at the QIC meetings are summarized in Attachment C: QIC Meeting Focus Topics.
     4. The responsibility of the QIC is to oversee the quality of care provided by Westside by reviewing and providing guidance on:
        1. compliance with the requirements of HRSA Bureau of Primary Health Care and The Joint Commission;
        2. evaluation of the needs of the patient community;
        3. clinical policies and program planning;
        4. clinical program updates; and
        5. clinical performance measures.
     5. The QIC, in conjunction with the full Board, aims to ensure that performance improvement activities are planned, systematic, and organization-wide.  
     6. The QIC reviews and approves the Continuous Quality Improvement Plan every two years or as needed.
  4. Chief Executive Officer (CEO) and Chief Medical Officer (CMO)
     1. The responsibilities of the CEO and CMO are to:
        1. Participate in performance improvement meetings and efforts, as appropriate;
        2. Oversee the strategic plan with respect to performance improvement needs and activities;
        3. Set priorities for performance improvement activities and data collection;
        4. Set performance expectations (goals);
        5. Assign staff to carry out tasks; and
        6. Report to the Quality Improvement Committee, the Board of Directors, and staff on performance improvement issues.
  5. Associate Medical Director of Population Health and Quality (AMDPHQ) & Director of Quality Improvement (DQI)
     1. The responsibilities of the AMDPHQ and DQI are to:
        1. Develop the Continuous Quality Improvement Plan;
        2. Oversee and conduct the day-to-day implementation of performance improvement, in collaboration with other leadership.
        3. Assess performance improvement data.
        4. Determine what changes will lead to performance improvements.
  6. Clinical and Administrative Staff
     1. The responsibilities of the Clinical and Administrative Staff are to:
        1. Identify areas of needed performance improvement.
        2. Conduct performance improvement activities (data collection, assessment, improvement), as appropriate.
  7. The oversight of quality improvement (QI) activities at Westside is illustrated in Attachment B: Quality Improvement Oversight.

Quality Improvement Activities

• 1. Westside conducts a range of quality improvement-related activities across the organization, including the following, as required by HRSA and/or TJC:
     1. Quality and Utilization of Health Center Services
        1. Primary Responsibility:
           1. Associate Medical Director of Population Health and Quality (AMDPHQ)
           2. Director of Quality Improvement (DQI)
           3. Director of Clinical Operations (DCO)
           4. Director and/or Manager of Dental Operations (DDO)
           5. Director of Site Operations (DSO)
        2. Activities:
           1. Conducting collaborative QI assessments and performance improvement activities
           2. Identifying social determinants of health to prioritize and provide targeted countermeasures for specific populations to increase overall patient population health
           3. Establishing evidence-based clinical guidelines, standards of care, and standards of practice
           4. Reviewing and updating QIC plan and procedures, as needed.
     2. Quality and Safety Incidents, including Adverse Events
        1. Quality and Safety Learning Reports – submission and response – are the responsibility of all Westside staff, as appropriate for the incident.
        2. Primary responsibility for oversight:
           1. Chief Medical Officer (CMO) and Director of Quality Improvement (DQI)
           2. Chief Operating Officer (COO)/Safety Officer/Risk Manager and Director of Site Operations (DSO)
           3. Committees, as appropriate (Culture of Safety Committee, Infection Prevention and Control (IPC) Committee, Pharmacy and Therapeutics (P&T) Committee).
        3. Relevant Policies and Procedures:
           1. Quality and Safety Learning Reports
           2. AD-105 Reporting of Adverse Events and Near Misses (Incidents)
           3. PC-520 Sentinel Event
     3. Patient Experience
        1. Primary Responsibility:
           1. Chief Operating Officer (COO)
           2. Director of Site Operations (DSO)
        2. Relevant Policies and Procedures
           1. Patient satisfaction survey methodology
     4. Patient Grievances
        1. Primary Responsibility:
           1. Chief Operating Officer (COO)
           2. Director of Site Operations (DSO)
        2. Relevant Policies and Procedures:
           1. AD-620 Patient Complaint Resolution Process & Accompanying Form
           2. AD-630 Patient Discrimination Complaints

Performance Improvement Process

• 1. When undertaking quality improvement activities, the Westside Board, QIC, and leadership recognize and utilize five key systems, as identified by the TJC, that influence the effective performance of an organization.
     1. The five key systems for influencing and improving organizational performance are:
        1. Using data
        2. Planning  
        3. Communicating  
        4. Changing performance
        5. Staffing
  2. Westside uses the Plan-Do-Study-Act (PDSA) methodology for its performance improvement efforts, whether designing a new service or process or improving upon an existing one.  
     1. The PDSA methodology is composed of the following steps:
        1. PLAN what to improve and how to do so;
        2. DO what was planned;
        3. STUDY the results of the improvement effort; and
        4. ACT on what was learned. If the plan worked, keep it.  If not, repeat the cycle.
  3. PLAN (Design)
     1. Performance improvement needs are identified through such means as: analysis of daily operations, evaluation of performance improvement measures, monitoring and audits, ongoing review of the strategic plan, and other approaches.
     2. Data collected by the organization is utilized by the leaders to identify and prioritize improvement opportunities.
     3. As performance improvement needs are identified, the Chief Executive Officer, Chief Medical Officer, and Chief Operating Officer prioritize these needs as follows:
        1. High volume, high risk, or high patient impact needs are given priority.
        2. In prioritization, resources (financial, personnel, time, etc.) needed and resources available are considered.
     4. Westside plans improvements to existing services or processes and the addition of new services or processes by:
        1. Describing a need consistent with the mission, operational objectives and strategic goals
        2. Developing changes in established processes that address the identified need and incorporate the results of applicable past performance improvement efforts (PI.2)
        3. Setting measurable performance expectations
        4. Establishing timelines
        5. Determining what data to collect, what performance measures to use to collect the data, and how often to collect it
        6. Determining who will be responsible to implement specific tasks
  4. DO – Once Westside has adequately planned for improvement, Westside:
     1. Takes action on improvement priorities through the implementation of the planned performance improvement processes, and
     2. Collects data on the improvement processes utilizing an appropriate tool from a range of options, including those recommended by ECRI Institute and the Institute for Healthcare Improvement (IHI).
  5. STUDY (Assess) – Data collected is compiled and analyzed.
     1. Data is analyzed to assess performance, patterns, trends, and variations. The data is compared with internal and external sources, when available.
     2. The results of the data analysis are used to evaluate the implementation of the change and whether the actions taken result in performance improvements, as intended.
  6. ACT – Once the data is studied, the QI team, in collaboration with leadership and other teams impacted by the changes, determines which new processes will be implemented permanently.
     1. Results are reported to the staff, Quality Improvement Committee, and/or the Board of Directors, as appropriate.
     2. New processes that improve performance are put into place and maintained.
     3. In the event that the performance improvement processes do not achieve or sustain the desired outcome, alternative measures to improve the targeted process are identified.
     4. After review of the outcome of the performance improvement activity, the Quality Improvement Committee and the Board of Directors may make recommendations for additional performance improvement efforts, or may approve the recommendations presented by the QI team or the Executive and Chief Medical Officers.

Development and Implementation of QIC Policies and Procedures

• 1. Relevant QI policies and procedures are presented to the Quality Improvement Committee followed by the Board of Directors for review, recommendations, and approval.
     1. Attachment D: Policies Approved by the QIC lists the policies that are brought to the QIC for review and approval, before being sent to the full Board for final approval and signature by the Board Chair.
  2. These policies and procedures are then implemented after presentation and education to staff by department meetings, emails, or All Sites Meetings.

References

1. Health Resources and Services Administration (HRSA)
   1. HRSA Health Center Program Compliance Manual, August 2018
      1. Chapter 10: Quality Improvement / Quality Assurance (https://bphc.hrsa.gov/compliance/compliance-manual/chapter10)
      2. Chapter 21: Federal Tort Claims Act (FTCA) Deeming Requirements (https://bphc.hrsa.gov/compliance/compliance-manual/chapter21)
   2. HRSA Health Center Program Site Visit Protocol, May 26, 2022 (https://bphc.hrsa.gov/sites/default/files/bphc/compliance/site-visit-protocol.pdf)
      1. Quality Improvement/Assurance chapter
      2. FTCA Deeming Requirements chapter
2. The Joint Commission (TJC)
   1. Leadership (LD) chapter of the TJC Comprehensive Accreditation Manual for Ambulatory Care (CAMAC), July 1, 2022.
      1. LD.01.03.01 – Governance is ultimately accountable for the safety and quality of care, treatment, or services.
      2. LD.02.01.01 – The mission, vision, and goals of the organization support the safety and quality of care, treatment, or services.
      3. LD.02.03.01 – Leaders regularly communicate with each other on issues of safety and quality.
      4. LD.03.01.01 – Leaders create and maintain a culture of safety and quality throughout the organization.
      5. LD.03.02.01 – The organization uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
      6. LD.03.03.01 – Leaders use organization-wide planning to establish structures and processes that focus on safety and quality.
      7. LD.03.04.01 – The organization communicates information related to safety and quality to those who need it, including staff, licensed independent practitioners, patients, families, and external interested parties.
      8. LD.03.05.01 – Leaders manage change to improve the performance of the organization.
      9. LD.03.06.01 – Those who work in the organization are focused on improving safety and quality.
      10. LD.03.07.01 – Leaders establish priorities for performance improvement. (Refer to the "Performance Improvement" [PI] chapter.)
      11. LD.03.08.01 – New or modified services or processes are well designed.
      12. LD.03.09.01 – The organization has an organization-wide, integrated patient safety program.
      13. LD.03.10.01 – The organization uses clinical practice guidelines to design or to improve processes that evaluate and treat specific diagnoses, conditions, or symptoms.
   2. Performance Improvement (PI) chapter of the TJC Comprehensive Accreditation Manual for Ambulatory Care (CAMAC), July 1, 2022.
      1. PI.01.01.01 – The organization collects data to monitor its performance.
      2. PI.02.01.01 – The organization has a performance improvement plan.
      3. PI.03.01.01 – The organization compiles and analyzes data.
      4. PI.04.01.01 – The organization improves performance.

ECRI Institute

• 1. Quality Improvement / Quality Assurance Resource Collection (https://www.ecri.org/components/HRSA/Pages/ResourceCollection_QualityImprovementQualityAssurance.aspx)

Institute for Healthcare Improvement (IHI)

• 1. Quality Improvement Essentials Toolkit (http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx)
     1. Plan Do Study Act (PDSA) Worksheet (https://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx)

ATTACHMENT A:

SIGNATURES OF APPROVAL

The Continuous Quality Improvement Plan has been reviewed and approved by administration, medical staff, and the Board of Directors as attested by the signatures below.

___________________________________________________________ _______________

Chief Executive Officer (CEO) Date

___________________________________________________________ _______________

Chief Medical Officer (CMO) Date

________________________________________ _______________

Chair, Quality Improvement Committee (QIC) Date

____________________________________________________________ _______________

Chair, Board of Directors Date

ATTACHMENT B:

QUALITY IMPROVEMENT OVERSIGHT

ATTACHMENT C: QIC MEETING FOCUS TOPICS*

* This table shows the standard presentations provided to the QIC each year and the usual month (which may change, if needed). Other quality-related topics are also added to each QIC meeting, as appropriate. Policies requiring QIC approval (as listed on Attachment D) are brought to the QIC based on their renewal dates.

ATTACHMENT D:

POLICIES APPROVED BY THE QIC

Note: All policies approved by the QIC are also sent to the Full Board

for final approval and signature by the Board Chair.