Quality Improvement Committee Plan



Quality Improvement Committee Plan

2010-2013

Mission: To direct an active organized program of quality improvement at Student Health Services.

Objectives:

1. Annually coordinate and evaluate benchmark indicators with a minimum of one other institution.

Use national clinical guidelines to develop patient outcome indicators.

Evaluation Methods:

• Results from the National College Health Assessment survey through the American College Health Association may be used to identify potential indicators for study.

• At least one standard clinical benchmark will be evaluated and compared to national standards.

• Some SHS QI clinical studies will be ongoing through peer review or other means to measure change, show capacity to sustain improvements, and to reflect performance of SHS providers.

Implementation

• The QI Committee will identify areas for potential study based on the National College Health Assessment survey. Spring 2010 and 2012

• Participate in national ACHA Pap Smear Study. Review results and make recommendations for follow up on an annual basis.

• The QI Committee will choose at least one clinical benchmark to be evaluated by the appropriate department.

• Participate in ACHA clinical benchmark projects.

2. Comply with guidelines set forth by AAAHC.

Evaluation Methods:

• Fall 2013 - AAAHC conducts a site visitation to SHS to review compliance of the AAAHC Standards. Success is determined by passing the accreditation review in the area of Quality Management and Improvement.

Implementation:

• The Quality Management and Improvement chapter of AAAHC will be reviewed at the beginning of each academic year to ensure compliance of standards and readiness for survey.

3. Ensure that a minimum of three (3) quality improvement studies are conducted per year.

Evaluation Methods:

• Quality Improvement studies will be performed by individual departments. The QI committee will make recommendations and coordinate the QI activities.

Implementation:

• The QI Committee will coordinate and assist in identifying potential issues to be evaluated. The following sources will be utilized:

▪ Peer Review – Clinical and nursing departments may identify and conduct potential studies through peer review.

▪ Incident Reports – The Leadership Team reviews SHS incident reports and will bring any quality concerns to the QI committee for recommendations.

▪ Issues identified by the SHS Health and Safety Committee

▪ SHS Surveys – The Leadership Team reviews both the internal and external SHS surveys (alternating years) and will bring potential QI studies to the committee.

▪ Individual Departments – Department managers will facilitate studies in their departments as appropriate. Sources for studies may include: direct observation, overutilization and underutilization. The SHS lab performs QI studies as directed through their accrediting body.

▪ Clinical studies may also be identified through unacceptable or unexpected outcomes of care, clinical practice patterns of health care practitioners, direct observation, staff concerns, or prevalent diseases. The Associate Director, Clinical Services will maintain a folder on the SHS Share (S) Drive of relevant clinical health concerns that have been identified through emails, notices from Benton County Health Dept., and/or other sources. The QI committee will help facilitate clinical studies as needed.

▪ Review of key quality of care indicators in comparison with other similar organizations and national standards.

Quality Improvement Study Reporting:

1. QI study results will be documented by the department performing the study, and reported to the QI committee using the six parameters delineated in the QI Report Tool.

2. The QI committee will maintain a record of results via the QI Report Tool of all QI studies performed, and will report annually to the Leadership Team.

Decisions and Recommendations

▪ The QI Committee will facilitate the incorporation of QI findings through clinician, nursing and other departmental meetings, and CME programs.

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