Quality Improvement/Quality Assurance Plan: Supplemental Information and

ECRI Institute Resources

HRSA Clinical Risk Management Resources Homepage

Before You Fill Out the Application…

• Have the following items with you: Quality Improvement/Quality Assurance Plan (with board signature

and approval within past 3 years OR have board minutes with proof of approval within past 3 years)

Minutes from any six QI/QA 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 QI/QA activities that took place between June 1, 2011 and the submission date of the application.

HRSA Program Assistance Letter (PAL) 2012-02: Calendar Year 2013 Requirements for Federal Tort Claims Act (FTCA) Medical Malpractice Coverage for Health Centers (access at http://www.bphc.hrsa.gov/policiesregulations/policies/pal201202.html)

Components of Application

• Applicants must attach the following documents: 1a. QI/QA plan with proof of board approval within past 3 years. Proof of approval can be indicated by signature on the plan or by submitting board minutes. 1b. Minutes from any six QI/QA committee meetings that took place between June 1, 2011 and the submission date of the application (combined in one document if possible). 1c. Minutes from any six board meetings evidencing oversight of QI/QA activities that took place between June 1, 2011 and the submission date of the application (combined in one document if possible).

Quality Improvement Policy

• Correct attachments: Sign the hard copy of the policy, scan the policy to a computer, and attach the scanned copy

• Incorrect attachments: Do NOT attach applications with blank signature lines or with typed signatures

Components of Application (cont.)

• Applicants must complete the following questions:2. Select the date the QI/QA was approved by the board.3. QI/QA process questions: 3a. Describe process for assessing clinical quality and risk issues on a continuous basis. 3b. Describe how you identify potential problems and prevent adverse occurrences.3c. List tools used to systematically collect and analyze data.3d. Describe how you identify and document a system or process breakdown.3e. Discuss how strategies for improvement are implemented, continually monitored, and measured.

Components of Application (cont.)

• Applicants must complete the following questions:4. QI/QA committee questions:4a. Describe the structure of the QI/QA committee.4b. Discuss how often the board receives reports from the QI/QA committee on the plan and progress.4c. Describe the process for implementing policies and procedures, such as credentialing, risk management, and clinical and operational policies.4d. Describe how recommendations from the QI/QA committee are presented and approved by the board.

1. QI/QA Plan

• Structure and purpose of QI/QA committee• Clinical, financial, or administrative areas addressed in

quality improvement activities (e.g., continuity of care, disease management, credentialing, patient/staff education, patient satisfaction)

• Assessments/identification of risk areas• Improvement plans• Data collection • Monitoring progress and improvements• Communicating results to the board• Communicating results to staff members

3. QI/QA Processes: Assessing Quality and Risk Issues

• Quality measuresPercentage of patients age 50 to 75 with appropriate

colorectal cancer screeningPercentage of pediatric patients who receive

recommended immunizations • Patient satisfaction surveys• Health center data

Demographic data, missed appointments, patient flow data/wait times in waiting room

• Employee reports/surveysEmployees should be encouraged to report quality

concerns

3. QI/QA Processes: Tools

• Quality Measures: HRSA PAL 2012-01: http://

bphc.hrsa.gov/policiesregulations/policies/pal201201.html. National Quality Forum Performance Measures: http://

www.qualityforum.org/Measures_List.aspx. AMA Physician Consortium for Performance Improvement™: http://

www.ama-assn.org/ama/pub/physician-resources/physician-consortium-performance-improvement/pcpi-measures.page.

• Tips for Collecting Data on Quality Measures: AAFP Performance Measurement and Pay-for-Performance: http://

www.aafp.org/online/en/home/practicemgt/quality/qitools/perfmeasure.html.

3. QI/QA Processes: Tools

• ECRI Institute Clinical Risk Management Resources: Event Reporting Toolkit:

https://members2.ecri.org/Components/HRSA/Pages/EventReportToolkit.aspx.

Patient Satisfaction Questionnaire: https://members2.ecri.org/Components/HRSA/Pages/PSRMPol2.aspx.

Physician Practice Risk Management Self-Assessment Questionnaire: https://members2.ecri.org/Components/HRSA/Pages/SAQ2.aspx.

Safety Attitudes Questionnaire: https://members2.ecri.org/Components/HRSA/Pages/PSRMPol1.aspx.

• Other Resources AHRQ Medical Office Survey on Patient Safety Culture:

http://www.ahrq.gov/qual/patientsafetyculture/mosurvindex.htm. NCCHCA Healthcare Plan Chart Audit Tool:

http://ncchca.affiniscape.com/associations/11930/files/Copy%20of%20bphc_data_entry_tool.xls.

3. QI/QA Processes: Data Collection

• Make sure practitioners routinely document needed information (e.g., information related to quality measures)

• Consider using checklists or standardized forms during patient care activities to document quality information

• Use electronic information systems to track and trend data; plot data over time to identify trends and progress

• Designate a staff member to compile trended data for analysis during QI/QA committee meetings

• Compare data to benchmarks to determine what areas need improvement

• Prepare quality reports highlighting data on a regular basis (i.e., quarterly) to present to the board

3. QI/QA Processes: Monitoring/Improvement

• Review quality improvement activities regularly and revise processes when necessary

• Use quality improvement data to identify areas for improvement and develop strategies or initiatives to address these areas (e.g., education campaign, policy and procedure changes)

• Involve staff members in improvement strategies; solicit input and ideas

• Communicate progress toward goals and improvements made to providers and staff

• Consider providing incentives to employees for meeting goals

4. QI/QA Committee: Structure

• The QI/QA committee oversees the QI/QA plan• Designate a chair (e.g., quality improvement coordinator,

medical director) and vice-chair • QI/QA committee should be a multidisciplinary team

including administration, providers, and frontline staff (e.g., executive director, nursing director, physicians, nurses, administrative assistants, dentists, pharmacists)

• Members of the committee may be permanent or rotating (e.g., one-year term, two-year term) with some staff members invited to participate temporarily (e.g., dentist invited to participate during dental QI initiative)

• The committee should meet on a regular basis (e.g., monthly)

QI/QA Committee Meetings

• Agenda Reviewing QI data/progress toward goalsAnalyzing trends and identifying problem areasBrainstorming strategies for improvementDeveloping improvement plans

• Develop, revise, and implement QI plans • Document meeting minutes and keep on file

QI/QA Committee Meeting Minutes

• Include:AttendeesAgenda itemsDiscussion topicsRecommendationsAction items

• Clearly label with consistent titles• Provide sufficient detail

4. QI/QA Committee: Reporting to the Board

• Board responsible for quality of careVote and take action on quality issuesProvide guidance, oversight, approval of activitiesReview and approve policies (e.g., credentialing and

privileging policies, quality improvement plans) Review and approve credentialing/privileging information

• Prepare regular (i.e., quarterly) quality reports for the boardPrepare reports in a format that is easy to understand,

such as by using graphs or tables• Designate a member of the committee (e.g., chair, vice

chair) to present to the board on results, quality improvement activities, and recommendations

Quality Improvement Resource Page

• Sample QI/QA plans• QI/QA tools/toolkits• Training programs• Online courses• Guidance articles• Self-assessmentquestionnaires• Archived webinars/ audio conferences

Clinical Risk Management Websitehttp://www.ecri.org/Clinical_RM_Program

• Go to: http://www.ecri.org/clinical_rm_program • Enter username and password under “Member Login” • Don’t have a username and password? Contact us:

Clinical_rm_program@ecri.org (610) 825-6000 x5200

Quality Improvement/Quality Assurance FAQs

Q: If a health center has multiple QI/QA committees, which minutes should be submitted?A: The health center should have one primary QI/QA committee that is responsible for reporting QI/QA activities and findings to the governing board and coordinating the efforts of all QI/QA subcommittees. The meeting minutes from that primary committee should be reported, because it should provide an overview of the activities within each QI/QA subcommittee.

Quality Improvement/Quality Assurance FAQs

Q: Can the board and QI/QA committee minutes be blacked out or copied and pasted?A: It is acceptable to redact the minutes by using a black marker. The documents can then be scanned and uploaded into the EHB.

Q: 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? A: 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.

Questions on Deeming/Application Process?

• Contact BPHC helpline at 1-877-974-BPHC (877-974-2742) or BPHChelpline@hrsa.gov9:00AM to 5:30PM (ET)

• FTCA website: http://www.bphc.hrsa.gov/ftca • For EHB technical support (e.g., registration, username

and password), contact HRSA Call Center at 1-877-464-4772 or CallCenter@hrsa.gov. Monday-Friday (except federal holidays) 9:00AM to

5:30PM (ET)