Sample Quality Improvement Policy



Sample Quality Improvement Policy

LHD NAME & LOGO

POLICY NAME: Quality Improvement (QI)

POLICY NUMBER:

EFFECTIVE DATE:

LAST REVISED:

APPROVED BY:

DATE:

Policy Purpose: To promote a culture of quality within the local health department that includes an organization-wide management and staff philosophy of continuous quality improvement (QI) in programs, service delivery and population health outcomes.

Policy: The XXXXXX County health department will objectively, systematically, and continuously assess, assure, monitor, evaluate, and improve the quality of processes, activities, programs, and services provided to community residents. This requires establishing agency-wide and/or specific program goals, objectives and measures (performance indicators) and includes training staff in QI methods and tools. To execute this policy, the health department will establish and implement an agency-wide annual QI Plan. Components of the plan will include, but not be limited to:

1) Designation of a Quality Improvement Coordinator and/or a QI Committee

2) Roles and responsibilities of leadership, management, and staff

3) Quality improvement activities, projects, measures, resources, and timelines

4) Methods to evaluate processes, programs, and services to identify opportunities for improvement

5) Provisions for the use of customer satisfaction data and feedback

6) Use of the Plan-Do-Study-Act or other recognized QI method to address evaluation results and customer recommendations

7) Methods to mobilize both data and team knowledge to improve decision making

8) Provisions for training staff in QI methods

The QI Plan will be presented to the Board of Health or Commission for review and approval on an annual [or other specified time-period] basis. At the end of the calendar or fiscal year in which the plan is implemented, the health department leadership/management team will review the quality improvement activities conducted during the year, including the targeted process or program outcomes, the performance indicators (measures) utilized, the findings, data aggregation, assessment, and the QI initiatives taken in response to the findings. These documents will also be reviewed by the health officer and medical director or his/her designees.

Page 02 Sample QI Policy

QI Definitions for Public Health: For purposes of executing this policy within the local health department, the following nationally accepted public health definitions will be used.

Quality: In public health terms, quality is the degree to which policies, programs, services and research for the population increase desired health outcomes and conditions in which the population can be healthy (Public Health Quality Forum, US Department of Health & Human Services).

Quality Assurance (QA): Assurance of quality is the planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled (American Society for Quality (ASQ)). Quality Assurance may also be defined as a retrospective review of processes, programs, and services. It provides for the systematic monitoring and evaluation of the various aspects of a project or service to ensure that standards of quality are being met. QA is frequently used to guarantee quality.

Quality Improvement (QI): Use of a deliberate and defined improvement process, such as Plan-Do-Study-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community (Accreditation Coalition 2009, Public Health Foundation, et.al.). QI is frequently used to raise quality.

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