Developing a Compliant QI/QA Program of Excellence

Developing a Compliant QI/QA Program of Excellence

Kyle Vath, BSN, MHA, RNMPCA 2018 Spring Clinical Conference

April 17, 2018

Goals

• Attendees will leave the presentation ready to:• Take practical steps to move their QI Program to the next level of compliance

and excellence.• Review their health center’s QI Plan, QI Work Plan, QI Committee meeting

minutes, risk management programs, peer review and credentialing and privileging processes for compliance and excellence.

• Communicate important (and required) information to the health center’s Board of Directors and leadership.

Objectives

• Describe a framework for compliance and excellence • Explain the key elements required in the creation of QI Plans, QI

Work Plans, QI Committees, compliant meeting minutes, risk management programs, peer review and credentialing and privileging

• Define information to be relayed to the health center’s Board of Directors and leadership.

• Provide practical, customizable tools that will be emailed to attendees after the presentation (As noted with the icon).

FQHC Hierarchy

Regulatory Compliance

Mission & Vision

Goals & Objectives

Systems

Key Leaders

Action!

FQHC Hierarchy

Regulatory Compliance

FQHC Hierarchy

Regulatory Compliance

Mission & Vision

Goals & Objectives

Systems

Key Leaders

Action!

Key Areas of Compliance (Related to QI)

• Required and Additional Services (Ch. 4)• Clinical Staffing (Ch. 5)• Accessible Hours & Locations (Ch. 6)• Coverage for Medical Emergencies During/After Hours (Ch. 7)• Continuity of Care & Hospital Admitting (Ch. 8)• QI/QA (Ch. 10)• FTCA (Ch. 21)• Performance Analysis

A Framework of Compliance

Tools of the Trade

• HRSA Health Center Compliance Manual• HRSA Health Center Program Site Visit Protocol• QI Plan• QI Work Plan• QI Committee Meeting Minutes• Risk Management Assessment• Credentialing and Privileging Log/Checklists• Incident Reporting Documents• Peer Review Documents

https://bphc.hrsa.gov/programrequirements/compliancemanual/introduction.html

https://bphc.hrsa.gov/programrequirements/svprotocol.html

Program Requirements

HRSA Theme•Provide as many patients as possible access to the highest quality care while being good stewards of the government’s resources.

Required and Additional Services (Ch. 4)

• Key QI Team Responsibilities• Ensure programs align with scope on Form 5A (Together with MOUs)

Required and Additional Services (Ch. 4)

Required and Additional Services (Ch. 4)

• Key QI Team Responsibilities• Ensure programs align with scope on Form 5A (Together with MOUs)• Ensure referral processes in place (making, management, tracking)• Ensure interpretation and/or appropriately-translated documents in place for

all areas in scope• Provide cultural competency training to staff and ensure able to demonstrate

culturally-competent care.

Clinical Staffing (Ch. 5)

• Key QI Team Responsibilities• Ensure clinical staffing enables CHC to carry out scope on Form 5A

Clinical Staffing (Ch. 5)

Clinical Staffing (Ch. 5)

• Key QI Team Responsibilities• Ensure clinical staffing enables CHC to carry out scope on Form 5A• Ensure that the clinical staffing mix and number is responsive to the size,

demographics and needs (access, language, etc.) of its patient population.

Clinical Staffing (Ch. 5)

Clinical Staffing (Ch. 5)

• Key QI Team Responsibilities• Ensure clinical staffing enables CHC to carry out scope on Form 5A• Ensure that the clinical staffing mix and number is responsive to the size,

demographics and needs (access, language, etc.) of its patient population.• Ensure health center credentialing procedures require proper identification,

verification of education and training, queries through NPDB, DEA registration, BLS training, upon hire or recurring/ongoing procedures.

• Ensure CHC procedures address initial granting and renewal of privileges and evaluate upon hire (and recurring) fitness for duty, immunization/communicable disease, clinical competence, and has a process for modifying or removing privileges based on assessments.

Clinical Staffing (Ch. 5)

• Key QI Team Responsibilities (cont.)• Maintain up-to-date documentation of licensure, credentialing, and privileging

of all clinical staff.• Ensure contracts for contracted (Form 5A, Column II) and referral (Column III)

services require that the organizations appropriately credential and privilege their providers.

Clinical Staffing (Ch. 5)

Accessible Hours & Locations (Ch. 6)

• Key QI Team Responsibilities (cont.)• Ensure that the CHC takes into consideration access barriers, distance for

patients, etc. when determining health center sites.

Accessible Hours & Locations (Ch. 6)

Accessible Hours & Locations (Ch. 6)

• Key QI Team Responsibilities (cont.)• Ensure that the CHC takes into consideration access barriers, distance for

patients, etc. when determining health center sites.• Ensure that the CHC takes into consideration patient needs when setting

hours of operation.• Ensure that Form 5B is up-to-date with sites/programs in operation.

Coverage for Med. Emergencies (Ch. 7)

• Key QI Team Responsibilities• Ensure that documentation is maintained indicating at least one staff member

(trained in basic life support) is onsite at every HRSA-approved service delivery site whenever the site is open.

• Maintain operating procedures for responding to patient medical emergencies during regular hours and after normal business hours.

• Be prepared to give examples of how staff followed those procedures in responding to medical emergencies.

• Maintain information that is provided to all patients at all sites on how to access after-hours care (that has addressed barriers of language or literacy).

Coverage for Med. Emergencies (Ch. 7)

• Key QI Team Responsibilities (cont.)• Maintain an after-hours call program that:

• Connects patients to an individual with the qualification and training necessary to exercise professional judgment to address an after-hours call;

• Is able to refer patients to a covering licensed independent practitioner for further consultation and to locations such as emergency rooms or urgent care facilities for further assessment or immediate care, and;

• Maintains provisions for calls received from patients with LEP.• Maintain documentation of after-hours calls in the patient record.• Ensure staff are providing necessary follow-up based on the nature of the

after-hours calls.

Continuity of Care & Hosp. Admit. (Ch. 8)

• Key QI Team Responsibilities• Maintain hospital admitting privileges for health center providers and/or formal

agreements with non-health center providers that address hospital admissions.

• Maintain internal operating procedures and/or arrangements with non-health center providers that address how the health center will obtain or receive patient/hospital visit-related info and record info in the EHR, as well as details on follow-up by the health center staff?

• Ensure staff are documenting medical info related to the hospital or ED visit (discharge follow-up, lab, radiology, other results) and follow-up actions.

QI/QA (Ch. 10)

• Key QI Team Responsibilities• Maintain a QI/QA program that addresses the quality and utilization of health

center services, patient satisfaction and patient grievance processes, patient safety and adverse events.

• Designate an individual to oversee the QI/QA program.

QI/QA (Ch. 10)

• Key QI Team Responsibilities• The QI/QA program overseer should ensure the implementation of the QI/QA

procedures, that QI/QA assessments are conducted, monitor QI/QA outcomes, and update QI/QA operating procedures as needed.

• Maintain operating procedures that address the adherence to current, applicable evidence-based clinical guidelines and standards of care/practice, outline a process for staff to follow for identifying, analyzing, and addressing overall patient safety (including adverse events), outline a process for follow-up actions related to adverse events, maintain a process for assessing patient satisfaction, resolving patient grievances, and completing QI/QA assessments [peer review] at least quarterly.

QI/QA (Ch. 10)

• Key QI Team Responsibilities (cont.)• Share reports on QI/QA, including data on patient satisfaction and safety with

key management staff and the governing board (>6x/yr – FTCA only).• Ensure QI/QA assessments are conducted by physicians or other LIPs and

are based on data systematically collected from patient records.• Ensure assessments demonstrate that the health center is tracking and

addressing issues related to the quality and safety of care.

QI/QA (Ch. 10)

• Key QI Team Responsibilities (cont.)• Maintain an individual health record for each patient that is in a structured

format and easily retrievable.• Maintain a process for ensuring that the format and content of health records

are consistent with applicable federal and state laws and requirements (Certified EHR).

• Ensure there are health center procedures that address current federal and state requirements related to confidentiality, privacy and security of protected health info (PHI) including safeguards against loss, destruction, or unauthorized use.

• Ensure staff are trained in confidentiality, privacy, and security.

FTCA (Ch. 21)

• Key QI Team Responsibilities• Assign an individual to oversee and coordinate the CHC’s risk management

activities.• Ensure that the risk management P/Ps apply to all services and sites in the

CHC’s scope of project.• Maintain a system for identifying and mitigating areas/activities of highest patient

safety risk.• Document, analyze, and address clinically-related complaints and “near misses”

reported by CHC employees, patients, and other individuals.• Complete risk management assessments at least quarterly.• Report on the status of risk management activities and progress in meeting risk

management goals to the Board and key management staff at least annually.

FTCA (Ch. 21)

• Key QI Team Responsibilities (cont.)• Implement follow-up actions based on risk management assessments and

reports to the Board and key management staff.• Include in the training plan risk management training for relevant clinical staff

on OB procedures, infection control, and HIPAA medical record confidentiality requirements.

• Track the progress of staff completion of training (in accordance with the annual risk management training plan).

FTCA (Ch. 21)

• Key QI Team Responsibilities (cont.)• Assign an individual who is responsible for management and processing of the

CHC’s claims-related activities (and who serves as claims point of contact).• Ensure appropriate staff can describe how the CHC manages health or health-

related claims.• Ensure there are claims processes that require the preservation of claims-related

documentation and promptly communicating with HHS, Office of General Counsel, General Law Division, regarding any actual or potential claim or complaint.

• Ensure the CHC informs patients (in plain language) that it is FTCA-deemed on websites, promotional materials, and/or visibly posted.

• If there are claims made, ensure there are interventions implemented to mitigate risk of such claims in the future.

340B Pharmacy

• Key QI Team Responsibilities• Ensure patients receiving 340B drugs is a patient, the prescribing provider is

associated with the CHC, duplicate discounts are prevented, and provides oversight via audit or other mechanism.

• Maintain written contract between CHC and contract pharmacy(ies)

Performance Analysis

• Key QI Team Responsibilities• Review UDS Clinical Measure trends• List Contributing Factors (Push trend in desired direction)• List Restricting Factors (Barriers to improved performance)• Perform RCA2 on Restricting Factors

Performance Analysis

• Root Cause Analysis & Action (RCA2)• Strong commitment to model• Create/operationalize a Safety Assessment Policy• Devote a team to the process• Create a flow diagram/Interview involved parties• Complete a Cause & Effect Diagram• Develop Causation Statements• Identify solutions and actions• Plan, implement, evaluate, adjust (PDSA)• Communicate to stakeholders

SOURCE: http://www.npsf.org/?page=rca2

Tools of the Trade

• QI Plan• QI Work Plan• QI Committee Meeting Minutes• Risk Management Assessment• Credentialing and Privileging Log/Checklists• Incident Reporting Documents• Peer Review Documents

Tools of the Trade

• QI Plan• Key requirements• Access to the document

Tools of the Trade

• QI Work Plan• Brings the QI Plan to life!• Visible and actionable• Spread the workload

Tools of the Trade

• Risk Management Assessment, Training Plan, Annual Report• Specifications in Site Visit Protocol• Team effort• Hidden risks

Tools of the Trade

• Credentialing and Privileging Log/Checklists• Checklist on Site Visit Protocol website

• Credentialing Activity• Verification of identity• Verification of current licensure, registration, or certification• Verification of education and training• National Practitioner Databank (NPDB) Query• Verification of DEA registration• Verification of basic life support training

• Privileging Activity• Verification of fitness for duty• Verification of immunization and communicable disease status• Verification of current clinical competence

Tools of the Trade

• Incident Reporting Documents• Documents, analyzes, and addresses clinically-related complaints and

“near misses”

Tools of the Trade

• Peer Review Documents• Used in renewal of privileges• Quarterly• Systematic data• Assess adherence to current evidence-based clinical guidelines,

standards of care/practice• Identification of any patient safety and adverse events (and follow-up)• Cover all areas under scope• Signed off by/supervised physician or LIP

IHI: 5 Practical Strategies for Managing Successful QI Projects (July, 2016)

• Frontload the work• Focus on learning, not perfection• Make it easy• Build a big tent• Have an end date

SOURCE: http://www.ihi.org/communities/blogs/_layouts/15/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=279

Communication to Board and Key Leaders

• Who do you communicate to?• What do you communicate?• When/how often do you communicate?• How do you communicate?

Communication to Board and Key Leaders

FQHC Hierarchy

Regulatory Compliance

Mission & Vision

Goals & Objectives

Systems

Key Leaders

Action!

Tools & Resources

• Please sign-up on my website at www.RegLantern.comAFTER the conference to receive electronic copies of tools shared in the presentation.

• Scan QR Code with your smart phone to be taken directly to the page!

• Also, please follow my Blog (also on my website) for periodic tips and tricks!