5001 - Performance Improvement Program - Performance Improvement Plan

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					    SUBJECT:       PERFORMANCE IMPROVEMENT PROGRAM/                    REFERENCE #5001
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The purpose of Sovereign Health of California’s Performance Improvement Plan is to ensure that
administration, medical staff and professional service staff demonstrate a consistent endeavor to
deliver safe, effective, optimal patient care and services in an environment of minimal risk.


      The primary goals of Sovereign Health of California’s Performance Improvement Plan are
       to continually and systematically plan, design, measure, assess and improve performance
       of critical focus areas, improve healthcare outcomes and reduce and prevent
       medical/health care errors. To achieve these goals, the plan strives to:

              Incorporate quality planning throughout the organization.

              Provide a systematic mechanism for the facility's appropriate individuals,
               departments and professions to function collaboratively in their efforts toward
               performance improvement, providing feedback and learning throughout the

              Provide for a program that assures the facility designs processes (with special
               emphasis on design of new or revisions in established services) well and
               systematically measures, assesses and improves its performance to achieve
               optimal patient health outcomes in a collaborative, cross-departmental,
               interdisciplinary approach. These processes include mechanisms to assess the
               needs and expectations of the patients and their families, staff and others. Process
               design contains the following focus elements:

                    Consistency with the organization's mission, vision, values, goals and
                     objectives and plans; assess, assure and manage the quality and
                     appropriateness of care and/or services provided

                    Ensuring that delivery of patient care is made at the appropriate level by
                     program personnel who are trained and qualified to meet the care needs of
                     the patient

                    Meets the needs of individuals served, staff and others

                    Use of clinically sound and current data sources (for instance, use of practice
                     guidelines, information from relevant literature and clinical standards)
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                 Is based upon sound business practices

                 Incorporates available information from internal sources and other
                  organizations about the occurrence of medical errors and sentinel events to
                  reduce the risk of similar events in this institution

                 Utilize standards to measure/quantify care practices and appropriate patient

                 Utilizes the results of performance improvement, patient safety and risk
                  reduction activities

                 Develop effective systems for problem identification, tracking, resolution,
                  documentation and communication of performance improvement findings

                 Encourage administrative participation in performance improvement findings

                 Ensure that all JCAHO and other regulatory agencies’ performance
                  improvement requirements are met

          The organization incorporates information related to these elements, when available
           and relevant, in the design or redesign of processes, functions or services.

          Assure that the improvement process is organization wide, monitoring, assessing
           and evaluating the quality and appropriateness of patient care, patient safety
           practices and clinical performance to resolve identified problems and improve
           performance. Appropriate reporting of information to the administration to provide
           the leaders with the information they need in fulfilling their responsibility for the
           quality of patient care and safety is a required mandate of this plan.

          Necessary information is to be communicated among department/services when
           problems or opportunities to improve patient care and patient safety practices
           involve more than one department/service.

          The status of identified problems and action plans is tracked to assure improvement
           or problem resolution.

          Information from services and the findings of discrete performance improvement
           activities and adverse patient events are used to detect trends, patterns of
           performance or potential problems that affect more than one (1) service.
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              The objectives, scope, organization and mechanisms for overseeing the
               effectiveness of monitoring, assessing, evaluation and problem-solving activities in
               the performance improvement program are evaluated annually and revised as

              Treatment and services affecting the health and safety of patients are identified.
               Included are those that occur frequently or affect large numbers of patients; place
               patients at risk of serious consequences or deprivation of substantial benefit if care
               is not provided correctly or not provided when indicated; or care provided is not
               indicated, or those tending to produce problems for patients, their families or staff.

      Assessment of the performance of the following patient care and organizational functions
       are included:

              Ethics, Rights and Responsibilities

              Provision of Care, Treatment and Services

              Medication Management

              Surveillance, Prevention and Control of Infection

              Improving Organization Performance

              Leadership

              Management of the Environment of Care

              Management of Human Resources

              Management of Information


      Sovereign Health of California’s Program will be staffed with an interdisciplinary team
       consisting of Program Director, Medical Director, psychiatrists, LCSWs, MFTs and other
       licensed staff.

      All staff will participate in ensuring that the quality and appropriateness of patient care and
       services delivered will meet those standards set forth by regulatory agencies.
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      Reports of intermittent monitoring of specific problems as they arise and are identified will
       be submitted to the Program Director.

      Monitors will be measurable, objective and reflect all aspects of service. The Program
       Director will compile the data and submit a report to the Performance Improvement
       Committee and to the appropriate medical staff committee.

      The Program Director, along with the Medical Director will continually monitor, evaluate,
       and re-monitor outcomes and initiate corrective action(s) as needed.

      The Program Director will attend designated medical staff committee meetings and
       performance improvement meetings and report findings to the organization.


      Assures that optimal and appropriate outpatient care is provided in a safe, conservative,
       clean and therapeutic environment.

      Coordinates all patient care monitoring functions, emphasizing compliance with
       professional standards, program planning, risk management and cost-effectiveness.

      Assures that all practitioners providing service fulfill their professional obligations in
       accordance with applicable local, state and federal laws, as well as with standards of Joint
       Commission of Accreditation of Healthcare Organizations.

      Systematically evaluates all components of treatment plans utilizing process criteria that
       are objective and timely.

      Assures that quality and content of the medical record is consistently maintained.

      Ensures that problems and opportunities to improve patient care are identified through a
       variety of ongoing data collection activities, with prioritization of those issues, which directly
       bear on the quality of care delivery services.

      Establishes mechanisms for monitoring corrective actions, for problem resolution.
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      Establishes process mechanisms for evaluating and revising the scope of services,
       organizational goals and objectives, at least annually, enhancing effectiveness.

      Ensures that performance improvement activities are integrated and coordinated within the
       program, facility and organization, in order to minimize unnecessary process duplication
       and to promote performance and efficiency.

      Communicates the objectives, goals, mechanisms, and results of performance
       improvement process activities to the administration and staff of the program.


The primary purpose is to improve care delivery and to resolve identified process delivery


      Criteria and pre-determined standards of performance against which indicators are
       measured. These statements may include:

              Simple element of care

              A specific time interval for performance

              An established level of expected compliance

      Indicators are measurable components of patient care that can be evaluated to determine
       the levels of quality of patient care and services provided.

      Indicators and criteria have been developed through departmental review conferences
       using the following data and reference:

              Current Joint Commission Accreditation Manual for Behavioral Health Care

              State regulations

              CMS guidelines

              Partial Hospitalization Standards and Guidelines, American Association of Partial
                   PERFORMANCE IMPROVEMENT PLAN                          PAGE: 6
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