Quality Management process #21600

Quality Management process #21600 1. The licensee shall have an ongoing collaborative process within the organization that identifies issues affecting patient care. 2. These issues should address the effectiveness and efficiency of the organization, its support systems, as well as that of individuals within the organization. 3. When an issue is identified, a method of information gathering shall be developed. This shall include outcome studies, chart review, case discussion, or other methodology. 4. Findings, conclusions, recommendations, and actions shall be made and recorded. Follow-up, if necessary, shall be determined, recorded, and performed. 5. Training and education needs, individual performance evaluations, equipment or resource acquisition, safety, and risk management issues all shall be integrated with the CQI Performance Improvement process. 6. The QM program has written objective evidence of actions taken in problem areas and the evaluation of the effectiveness of that action. 7. The QM program must be integrated and include activities related to patient care, communications and all aspects of transport operations and equipment maintenance pertinent to the service’s mission statement. 8. QM plan should include the following components: a. Responsibility/assignment of accountability. b. Scope of care. c. Quality metrics that are identified, measured and compared to metrics/outcomes of evidence based standards. d. Indicators. e. Thresholds for evaluation, which are appropriate to the individual service. f. Methodology – the QI process and QI tools utilized; and g. Evaluation of the improvement process.