Quality Assurance

Quality Assurance 1. The hospice shall conduct an ongoing, comprehensive integrated self-assessment quality improvement process (inclusive of inpatient care, home care and respite care) which evaluates not only the quality of care provided, but also the appropriateness care/services provided and evaluations of such services. Findings shall be documented and used by the hospice to correct identified problems and to revise hospice policies. 2. The hospice shall have written plans, policies and procedures addressing quality assurance. 3. The hospice shall designate, in writing, an individual responsible for the coordination of the quality improvement program. 4. The hospice shall conduct quality improvement meetings quarterly, at a minimum. 5. The Hospice’s written plan for continually assessing and improving all aspects of operations must include: a. Goals and objectives; b. A system to ensure systematic, objective quarterly reports. Documentation must be maintained to reflect that such reports were reviewed with the IDT, the Medical Director, the Governing Body and distributed to appropriate areas; c. The method for evaluating the quality and the appropriateness of care; d. A method for resolving identified problems; and e. Application to improving the quality of patient care. 6. Quality assessment and improvement activities are based on the systematic collection, review, and evaluation of data which, at a minimum, includes: a. Services provided by professional and volunteer staff; b. Outcome audits of patient charts; c. Reports from staff, volunteers, and clients about services; d. Concerns or suggestion for improvement in services; e. Organizational review of the hospice program; f. Patient/family evaluations of care; and g. High-risk, high-volume and problem-prone activities. 7. The quality improvement plan must be reviewed at least annually and revised as appropriate. 8. When problems are identified in the provision of hospice care, there shall be evidence of corrective actions, including ongoing monitoring, revisions of policies and procedures, educational intervention and changes in the provision of services. 9. The effectiveness of actions taken to improve services or correct identified problems must be evaluated/documented.