Quality Assurance/Risk Management Information Page

Maintaining and improving the quality of our services to our clients is an on-going process. This site will be helpful to supervisors and staff in keeping quality in the forefront. This site will offer tools, information and references designed to support you in your efforts to provide quality services. Please feel free to email me with suggestions, articles or references you think will be helpful to other staff, supervisors and managers throughout the Company. Think win-win!!

These are the Company Quality Assurance indicators for the year 2008 and 2009.

1) Incident Reporting

Value: Occurrence Reports and reporting of critical incidents include required timelines for notification and submission of documentation to the QA Department and to contractors and state officials. This ensures efficient and effective identification, investigation and resolution of risk management situations.

Indicator: Time and date of incidents compared to time and date report was received by QA Department.

Indicator: Report is fully completed with names, dates, and type of occurrence and clear description of incident and follow-up.

Data Source: QA Department Occurrence Report database.

2) Safety

Value: Managing a safe environment and promoting safety awareness minimizes risk of injury for staff, clients and visitors.

Indicator: Number of reported injuries to clients or staff due to physical plant safety hazards, accidental injuries and automobile accidents attributed to staff error.

Data source: QA Department Occurrence Report database.

3) Documentation

Value: Proper and timely documentation validates proper clinical care of our clients, and protects both staff and clients by recording the services and treatment provided. Treatment goals that are observable, measurable and agreed upon by the client drive the treatment process and create a clear plan of action for both staff and clients.

Indicator: Number of timely and complete care plans, progress summaries, and contact notes compared to the number of total charts reviewed during chart reviews by the QA Department and or program management.

Indicator: Number of care plans that are signed by the client and appropriate staff compared to the number of care plans reviewed.

Indicator: Number of care plans containing goals that are observable and measurable compared to the number of care plans reviewed.

Data Source: Internal/program chart review summaries.

4) Credentialing

Value: Proper credentialing during the hiring process ensures that employees are qualified for the positions for which they are hired.

Indicator: Number of new hires that submit proper documentation of their credentials and receive a review of credentials by the hiring supervisor.

Data Source: Verification of Credentials form submitted to HR Department.

5) Training

Value: Proper training ensures that employees are aware of policies and procedures designed to guide them in providing quality care to the clients assigned to them. Proper training ensures that employees are qualified to perform the tasks expected of them. Complying with mandated training manages risk to the Company and ensures continued employment for the employee.

Indicator: Number of employees receiving required training within designated timelines compared to all employees requiring the same training.

Data Source: Monthly training reports/ review of training records.