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Section D: QUALITY ASSURANCE


D.1 CONTINUOUS QUALITY IMPROVEMENT (CQI):

CLINICAL QUALITY
PURPOSE

The purpose of this CQI plan is to continuously improve the quality of care provided to patients by members of the Dental Department. This will be accomplished thought the efforts of the Dental Staff both inter- and intra- departmentally within [facility].
PROCEDURE

Describe CQI plan including all activities, indicators, data collection, frequency of activities and reporting.
For assistance with developing a CQI plan in an Indian Health Service/Tribal/Urban facility, contact your Dental Support Center or Area Dental Officer.
Responsibility

The individual responsible for the quality assurance and improvement activities of the Dental Department is [appropriate individual]. The [individual] may delegate this responsibility to other members of the dental staff. It shall also be the responsibility of the dental QA/QI Coordinator to coordinate interdepartmental activities with the CQI programs of those departments so as to provide for quality improvement throughout the facility.
Indicators

The dental staff as a group will develop a set of indicators of quality of care for each of the important aspects of care being monitored. Each indicator will be objective, measurable, and based on current knowledge and clinical experience. Indicators must be easily replicated in order to track improvement. Each indicator will specify a patient care activity, event, or outcome that is to be monitored and evaluated to determine if patient care conforms to current standards.

Modifying Indicators

Indictors will be reviewed regularly. Indicators that are consistently met may be considered to be removed and other issues examined.



Sentinel Events

Additionally, certain unpredictable occurrences in the dental clinic (usually small in number but with very high morbidity or mortality) are of such importance that all such occurrences must be carefully examined, even though objective criteria cannot be formulated in advance for them. Examples of such sentinel events would include:



  • Deaths in the dental clinic

  • Allergic reactions/anaphylactic reactions to medications.

  • Formal complaints or lawsuits.

In addition to other processes set into motion by such events, dentists review each sentinel event and a Quality Improvement Activities Summary submitted to the QA/QI Coordinator for the facility to be reviewed by the QA/QI Committee.
Threshold for Evaluation
Each indicator in focused studies will have thresholds established based on QA documents, national averages, recommendations of appropriate experts, and other generally accepted sources. Comparison of the gathered data for each indicator with the appropriate threshold will then determine if further evaluation is indicated. Due to the high potential for morbidity or mortality, all sentinel events will be reviewed. All indicators appended to this plan will have the threshold and its source indicated.
Collection and Organization of Data

Routine collection of information in the Dental Department concerning important aspects of patient care will be made utilizing [identify routine reports such as Service Minutes, RVUs, equipment maintenance, others] [identify sources such as medical and dental records, monthly computer printouts, appointment logs, recall files, RPMS, environmental health reports, maintenance records, patient satisfaction surveys, etc]. The data source for each indicator is identified with the indicator, as is the frequency of collection and the responsibility for collection and analysis of the data.
Evaluation of Data

Once data have been collected and organized, they are evaluated to determine whether there is a problem and/or opportunity for care improvement. Evaluation of the data will determine if thresholds have been exceeded or if trends have been established.

Other forms of feedback besides exceeded thresholds, such as staff or patient reports or suggestions, bench marking with similar facilities in the Area, important single events, etc., can also be used to identify other opportunities to improve care.


Corrective Actions

If the evaluation identifies a problem, department staff should determine what action is necessary to solve the problem. A plan of corrective action identifies who or what is expected to change; who is responsible for implementing action; what action is appropriate in view of the problem's cause, scope, and severity; and when change is expected to occur. Emphasis will be placed on focusing actions on processes of care rather than of individuals. If a needed action exceeds the department's authority, recommendations are forwarded to the Facility QA/QI Committee.

To be effective, corrective action must be appropriate for the problem's cause. Three common causes of problems are:



  • Insufficient knowledge, skills or attitudes

  • Defects in the system;

  • Deficient behavior or performance.

After an appropriate time has elapsed since a corrective action has been taken, reevaluation must occur to see if the corrective action was successful. This assessment of action and documentation will be used to show sustained (trend analysis) improvement in the quality of patient care.


Communication of Results to the Staff

It is essential that monitoring and evaluation information be communicated to the necessary individuals and departments throughout the community. Such interaction of information will begin with dental department staff meetings. Minutes of these meetings will be kept, and reports will be forwarded to the [appropriate individual] and medical staff according to the bylaws and rules and regulations of the medical/dental staff. Integrating quality improvement information contributes to the detection of trends, performance patterns, or potential problems that affect more than one clinic or department of the facility. It also allows the information gathered to be used in granting and reassessing privileges and in conducting other performance evaluations such as employee performance standards.


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