QI, PI, QA – Making Sense of Alphabet Soup (Part 4)

In this last section of our four-part series entitled QI, PI, QA – Making Sense of Alphabet Soup, we will discuss the last very important component of the QI process: documentation.  We all know that in health care, if it isn’t documented, it didn’t happen.  The same is true in QI.  Your documentation doesn’t need to be fancy; it just has to reflect what occurred.  Here is an example:

On 4-3-12, Sally (Admin), Henry (DON), Rosario (QI Manager) and Mavis (RPT) discussed the results of the QI audit on supervisory visits.  Of the three charts reviewed, only one showed timely supervisory visits; the majority of the missed visits were for LPN supervision, which is the responsibility of Henry (DON).  The team reviewed the agency policy and confirmed that the guidelines are clear.  They checked training documents and noted that all supervisors were trained on the supervisory visit schedule.  In addition, the agency’s tracking system is being used and timely reminders to the clinical professionals were documented by Maria, the Administrative Assistant.  Henry stated that with the new baby, he and his wife don’t get much sleep these days.  He is having difficulty with time management and organization.  Mavis (RPT) stated that she got her days mixed up and was one day late in performing the supervisory visit on her PTA. The team discussed some solutions:  temporarily assigning nursing supervisory visits to another RN; having Maria issue another reminder on the morning of the scheduled supervisory visit; having Maria confirming that the supervisory visit was conducted on the same day, and alerting Sally (Admin) immediately of any problem.  The group selected all the alternative solutions and agreed to a weekly monitoring schedule for the next two months.

Organization of QI records is paramount to tracking your progress and meeting a surveyor’s inquiry.  A QI calendar of activities for the year keeps you on track and provides a scheduling system so audits aren’t due at one time.  Here is an example that shows part of the year: (click here).

It’s a good idea to keep your QI materials in one or several binders, depending on your program.  For example, we advise clients to create a Patient Records Audit binder for each calendar year.  Because this particular client performs these reviews every 60 days, six tabs for the year will help organize their audits.  Under the January tab, we suggested they keep the individual audit forms and a summary of the results.  Any Corrective Action Plans for the Patient Records Audit can be filed in the same binder.

We hope this blog series has been helpful in minimizing your dread of QI activities.  Even though it is mandatory for Medicare providers, monitoring quality ensures that you can back up your claim of quality patient care by studying critical areas and harnessing the diversity and knowledge of your team to drive the improvement process.

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