Making a difference in the lives we touch through quality ...



3522345-92212000Making a difference in the lives we touch through quality assurance and performance improvement.0433MISSION STATEMENT: (Print and save on template)00MISSION STATEMENT: (Print and save on template)1124995DATE OF MEETING:00DATE OF MEETING:ATTENDING (List name and title; save on template)YESNOmedical directoradministratordirector of nursingqaa coordinatorenvironmental servicespharmacyrd/dmsocial servicesactivitieshuman resourcesboard member(insert action plan table from previous meeting)QUALITY OF LIFE/QUALITY OF CAREITEMSYSTEM CHAMPIONREPORTACTIONPIPQuality Measures:Quality measures > 75% and identify trends/causes.ALLFacility Focus:Antipsychotic reductionAdvancing excellenceActivitiesCall lightsEnhancing resident centered careAdvanced care planningOtherDONSSRD/DMACTALLALLInfection Control:Resident infection rateStaff infection rateTrends by location and organismICNMock Survey:Benchmark set/metALLState Survey/Nursing Home Compare:FindsBarriersSurvey readinessBenchmarks set/metStar ratingALLEMR:Totally rolled out?AccurateReports being utilizedCase mixALLCare Transitions Rehospitalization/Discharges:30 day discharge benchmark and resultsFollow up on residents discharged homeDONSSPilot Projects:Interact 3OthersALLITEMSYSTEM CHAMPIONREPORTACTIONPIPPolicies:Current ones updatedNew ones implementedDONSecured Unit:New programsIssues that need attentionDONPharmacist Report:Physician response to recommendationsTracking and trending of medicationPHARMRecruitment and Retention:Turnover rate by departmentEfforts to recruit and retainTrends of exit interviewsHRStaff Satisfaction:Progression of top two areas identified in staff surveyALLOrientation/Training:# of new people starting per departmentALLIncident Reports/Safety:Trends and trackingFalls benchmark/trendsReportable to the StateWork comp trendsResident Council:Recommendation from CouncilConcern Forms:Tracking/trending of staff and family issues24-48 hour follow-up done?SSFamily/Resident Survey:Progression of top two areas identifiedADMDaily Rounding:Items/areas identifiedADMDONOther:ACTION PLANGOALACTIONPROCESS CHAMPIONTARGET DATECOMPLETION DATE22631408115300This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SD-C7-13-XXX.00This material was prepared by SDFMC, the Medicare Quality Improvement Organization for South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SD-C7-13-XXX.-72390105410This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.00This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ................
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