Quality Improvement Program

Statement of Purpose

The purpose of this Quality Improvement Program is to outline a plan by which the care and services provided will be continuously and systematically monitored and evaluated for quality, appropriateness, availability, accessibility and continuity with the ultimate goal of ensuring quality patient care while enhancing efficiency. The scope of the plan is comprehensive, including monitors of both the quality of medical care and customer service.

Mission Statement:

Excellence in patient care, education, research, and the generation of new knowledge including the understanding of disease, technology, and therapy.

Organizational Structure

The Quality Improvement Program will be overseen by a steering committee (Quality Improvement Advisory Committee) consisting of department chairperson and administrators. This committee will provide the Quality Improvement Committee (QIC) with direction, review results, and ensure recommended changes are implemented.

The QIC will be ultimately responsible for the implementation and maintenance of the plan. The participants on this committee will represent a cross-section of the different department responsibilities. Committee membership should include representation form the following areas:

• Attending Physician
• Physics
• Therapist
• Administrator
• Dosimetry
• Nursing
• Engineer
• 3rd year resident
• Radiation Safety

This committee will be directly involved in assigning tasks and, most likely, will be involved in performing some of these tasks

Meetings

The Quality Improvement Advisory Committee will meet regularly to review all quarterly reports, assess the productivity and effectiveness of the Quality Improvement Committee, and provide direction to the QIC. The QIC will meet at least every other month to recommend policy decisions, review and evaluate the results of the quality improvement activities, institute needed actions, and ensure follow-up, as appropriate.

Minutes

Minutes reflecting the decisions, actions, and recommendations are recorded at each meeting. The format includes a description of each issue discussed, the committee's recommendations, and any actions to be taken in follow-up. The minutes will be distributed to members of the committee and attending physicians. The minutes will also be posted in the department for review by all staff members.

Goals and Objectives

This Quality Improvement Program is necessary and critical to the success of the department. It is designed to address the following goals and objectives:

1. To produce, institute and promote a Quality Improvement Program that will be structured, continuous, consistent, and most importantly, widely accepted throughout the department.
2. This program must be structured in such a way as to be able to identify and correct weaknesses and deficiencies and make improvements that have an effect on the quality of care and services and are consistent with the University Hospital mission and values.
3. To develop, implement, and continuously update standards by which the quality of the department can be measured and appraised.
4. To develop and implement monitors which will measure and document improvement in performance and efficiency, as well as, the appropriateness of care.
5. To monitor compliance with all internal and external quality of care standards.
6. To create an atmosphere which provides the opportunity for all patients, department staff, and all others we come in contact with to report deficiencies and emerging problems, as well as, efficiencies to the Quality Improvement Committee.
7. To set up a reporting structure through which goals can be prioritized, work can be assigned, and goals can be achieved.
8. To evaluate the effectiveness of the Quality Improvement Program and report the results.

Quality of Care Standards:

The Oncology Services’ quality of care standards have been developed so as to be in compliance with the quality of standards set by:

• American College of Radiology
• NYS Department of Health
• ARRT
• University Hospital Standards
• JCAHO
• American College of Surgeons

In order to meet these high standards, quality improvement monitoring will be conducted according to their recommendations. In addition, quality improvement monitoring will be conducted in order to fulfill our goals.

Quality Improvement Activities

The following Quality Improvement Activities are performed on an ongoing basis to ensure patient and customer satisfaction, as well as, clinical and staff efficiency and effectiveness. All survey results will be shared with the participants.

1. Clinical Monitoring
Clinical Standards have been set and will be monitored on a continuous basis. Areas such as length of stay, the availability of a physician, patient wait times, patient events, and informed consent are reviewed.
2. Medical Record Audits
There will be ongoing audits of department medical records for all attending physicians. The reviews are designed to address the quality, access, and continuity of care. Content and completeness of each record is also part of the review process.
3. Utilization Management
The utilization management functions will consist of a series of analyses on utilization statistics by diagnosis and attending physician. Appropriate billing procedures will be reviewed for accuracy and completeness.
4. Complaints
All complaints received will be reviewed by the QIC. Appropriate action will be suggested and implemented when necessary. The volume, outcomes, and any trends will be further reviewed and corrected. Source of the complaints will come from customer satisfaction questionnaires completed by patients and any others who come in contact with the department.
5. Credentialing/Recredentialing
The credentialing and recredentialing policies explicitly define the attending physicians who are subject to these policies, as well as, the criteria required to reach a decision. The criteria are designed to assess the physician's ability to deliver care. They include licensure, relevant training and/or experience, board certification or eligible, and disclosure of any health issue that may impact care. There are also credentialing requirements for other staff.
6. Equipment Monitoring
All patient care equipment will be continuously monitored, inspected, tested and calibrated.
7. Staff Education
All staff need continuous training whether it be for orientation of new staff, licensure, new procedures, or new equipment. Monitors will be instituted to ensure all training is kept current.

Evaluation and Follow-up

The Quality Improvement Program will be reviewed on a annual basis in conjunction with a report from the QIC to the QIAC summarizing all activity. At year-end, an annual report will be produced to identify progress made in improving quality, the process, action, and result.