Mgh Family Health Center

MGH FAMILY HEALTH CENTER

d.b.a.

MUSKEGON FAMILY CARE

PERFORMANCE IMPROVEMENT

PLAN

Revised December, 2007

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Melba White Newsome, QA Committee Chair

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MUSKEGON FAMILY CARE – PERFORMANCE IMPROVEMENT PLAN October 2006

Statement of the Board and Administration

In accordance with the bylaws of the MGH Family Health Center d.b.a. Muskegon Family Care, a process shall be established that maintains and supports Performance Improvement across the organization. In keeping with Muskegon Family Care’s Mission and Values, the Quality Assurance Committee of the Board of Directors shall design a process for improvement of organizational performance with measures of competency that demonstrate progressive improvement and are reported regularly. This plan is intended to serve as a guideline and to support our employees as they improve the services they offer our patients, through their work individually and collectively.

MISSION

The mission of the Muskegon Family Care is to promote the physical, emotional and spiritual health of families through our healthcare and other supportive services.

Muskegon Family Care Structure and Scope of Services

Muskegon Family Care is a community-based organization with two medical clinic sites, dental clinic site, family planning site, pharmacy and outreach programs such as a Maternal and Infant Health program. A full range of ambulatory primary care health services are provided at both medical clinic sites. Prenatal services are provided at both clinic sites, with obstetrical deliveries at Mercy General Health Partners Special Delivery Birth Center. Home-based Maternal and Infant Health services are provided to patients of the clinics, as well as patients of other physician offices. General dentistry services are provided at the dental clinic site. Title X Family Planning services are provided at the Family Planning site. As a federally qualified health center, services are geared to the medically under-served population, and special programs may be established which reduce barriers to accessing care for this population.

Current medical staff providers consist of board-certified (and/or board-eligible) family practice physicians, mid-level providers, social workers, RNs, family practice interns, residents and students and assorted support staff. The dental staff consists of licensed dentist and hygienists and support staff. The medical staff is affiliated with, and credentialed by the Westshore Health Network and Mercy General Health Partners. Muskegon Family Care offers clinic sites for the Mercy General Health Partners family practice residency program. The residency program is certified through the American Osteopathic Association and is affiliated with the Michigan State University College of Osteopathic Medicine.

MUSKEGON FAMILY CARE VALUES: C.A.R.E.S.

CARING: Balancing touch and technology. Maintaining a spirit of compassion and empathy.

ACCESS: Ensuring access to quality healthcare for all. Implementing innovative ways to remove barriers of the under-served to accessing healthcare.

RESPECT: Fostering mutual respect. Promoting solutions through teamwork, with our patients and each other. Empowering those closest to the work to improve quality.

EDUCATION: Fostering a climate that supports a learning organization. Advancing the knowledge of our patients and professions through education and research.

SUCCESS: Supporting patients and staff in their efforts to attain a joyful, happy life. Recognizing and enhancing the joy in our work. Encouraging therapeutic use of humor.

STRUCTURE AND SCOPE OF MUSKEGON FAMILY CARE’S PERFORMANCE IMPROVEMENT PLAN

MISSION: The mission of the Performance Improvement Plan is to design, implement, monitor, and/or enhance the processes we use to improve the health of families through the services we offer.

OBJECTIVES:

·  To fulfill regulatory, statutory and accreditation requirements related to organizational excellence

·  To reduce variability of key processes throughout the organization while making improvements where possible

·  To establish program priorities that are evidence-based outcome-oriented

·  To establish an organizational climate that displays and fosters customer-focused behaviors

·  To provide education and training to reinforce performance improvement principles and practices

·  To identify key processes throughout the organization that can be improved and initiate those improvements

·  To include input from the community, patients, family members, physicians, employees and all other service users

·  To measure outcomes of patient care against professional standards

DEFINITION OF QUALITY: Meeting or exceeding the customers’ expectations; fulfilling our mission through living out our values.

The dimensions of quality are:

Doing the right thing:

Efficacy, appropriateness

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Doing the right thing well:

Availability, timeliness, effectiveness, continuity, safety, efficiency, utilization, education, accessibility, respect and caring

COMPONENTS OF THE PERFORMANCE IMPROVEMENT PLAN

There are essentially five components or building blocks of the Performance Improvement Plan at Muskegon Family Care; these are: Quality Improvement Teams, Continuous Monitoring Activities, Department Performance Improvement Activities, Critical Incident Review, and Quality in Daily Work.

QUALITY IMPROVEMENT TEAMS

These activities usually take place within the context of time-limited, cross-functional, interdisciplinary teams, which are chartered by the Quality Assurance Committee in consultation with the Administrative team, to assess and develop strategies to improve existing processes that affect two or more areas of the organization. Recommendations for performance improvement projects are gathered from employees, managers, physicians, patients, and community and outside reviewing organizations.

CONTINUOUS MONITORING ACTIVITIES

This includes the ongoing monitoring of key quality indicators such as immunization rates, patient satisfaction, infection control, clinical performance and peer review, and other indicators as determined by the Quality Assurance Committee of the Board of Directors. These activities are ongoing throughout the organization and are generally carried out by the organization’s professional and administrative staff, and reported on a regular basis to the Quality Assurance Committee.

DEPARTMENT PERFORMANCE IMPROVEMENT ACTIVITIES

These activities take place within the context of a department-specific team which focuses on operational performance improvement and patient or service flow issues within a clinical or non-clinical department. The appropriate department manager approves a team, and reports of activities and progress are made to the Quality Assurance Committee on a regular basis.

CRITICAL INCIDENT REVIEW

Critical Incidents are reviewed in order to identify contributing variances in routine processes, as well as changes that may be needed to prevent reoccurrence of the incident. A multi-disciplinary team is convened that has current knowledge of the incident and the process(es) involved. Together they evaluate the processes for opportunities to improve and develop an action plan to implement changes. The same team meets a short time later to reevaluate the effectiveness of the changes. A Critical Incident Peer Review may occur following the critical incident process review and upon recommendation of the Critical Incident Review team. The Critical Incident Peer Review will focus on analyzing provider factors that contributed to the incident and determine a provider performance improvement plan which could include: limitation / revocation of privileges, additional education, training and supervision, and/or medical or behavioral health assessment and treatment. Critical Incident Peer Review findings are communicated to Human Resources, which becomes responsible for carrying out and monitoring completion of the plan (note: any recommendations to limit or revoke privileges will be enacted within 1 business day following the determination).

QUALITY IN DAILY WORK

Department staff, with management oversight and approval, continually initiates changes in processes in order to reduce variations and alleviate obvious problems.

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PRINCIPLES OF PERFORMANCE IMPROVEMENT

Muskegon Family Care is committed to continuously improving the quality of patient care and services. This commitment is evidenced throughout the organization, appearing in strategic planning, resource allocation, role definitions, record systems, performance evaluations and the organization’s role in the community.

This plan incorporates techniques that foster continuous improvement in performance and quality and is constructed around several principles:

·  Performance improvement cannot succeed without the commitment and involvement of the organization’s leaders.

·  All work involves the execution of processes. The processes of delivering healthcare are carried out within and between the departments and services. These processes can be defined and continuously improved. Performance improvement is process improvement with measurable outcomes.

·  Processes exist to produce services that provide a benefit or meet the needs of internal and external customers. Therefore, the customer is the focus of the performance improvement efforts.

·  Fundamental to performance improvement is the commitment to using data, statistical tools and a logical process to build knowledge and make decisions.

·  The people that work in a process are the ultimate source of knowledge about how to improve it. Every employee is responsible for performance improvement. Performance improvement is achieved by focusing on processes and outcomes.

·  The quality of care is improved through collaborative efforts between all of the partners in the organization. Assessing and improving governance, administrative, managerial, clinical and support processes do this.

·  Understanding and reducing the variability of processes is one of the keys to improving performance.

Muskegon Family Care measures and assesses its clinical and non-clinical performance by comparing its own performance over time, using threshold values, statistical methods and tools and trended data. It also compares its performance against internal and external frames of reference, which include:

·  Professional practice guidelines (developed internally or externally)

·  Use of reference databases

·  Benchmarking with peers

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·  Legal, regulatory and accreditation requirements and standards

·  Qualified Health Plan reviews

RESPONSIBILITY OF LEADERS

The leaders of Muskegon Family Care are accountable for implementing this Performance Improvement Plan including: setting expectations, developing plans, and implementing procedures to assess and improve the performance of the organization’s governance, management, clinical and support processes. The leaders are also accountable for organizing educational efforts for all staff. Muskegon Family Care leaders include:

·  Board of Directors

·  Quality Assurance Committee of the Board of Directors

·  Executive Director

·  Medical Director/ Residency Director

·  Quality Assurance Coordinator

·  Compliance Officer

·  Risk Manager

·  Department Managers

Roles and Responsibilities

Board of Directors, including Quality Assurance Committee

·  Assures the Performance Improvement Plan is consistent with the organization’s mission, values and strategic plan

·  Authorizes administration and medical staff to implement their respective functions in performance improvement as specified in this plan

·  Assesses overall effectiveness of performance improvement activities. Set priorities for performance improvement activities annually through performance improvement plan

·  Allocates adequate resources for assessment and improvement of key processes through assignment of personnel to participate in performance improvement activities, and provision of adequate information services and data management systems to facilitate collection and analysis of data

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·  Assures provision of training and education of all leaders and subsequently their staff, on the processes that contribute to improved patient outcomes

·  Charters quality improvement teams within the organization to work on selected processes for improvement

Executive Director

·  Assures that all departments support and participate in the Performance Improvement Plan

·  Assesses effectiveness of departmental actions for improvement activities

·  Ensures that implementation of the plan is consistent with standards, regulations, and organizational priorities

·  Provides resources necessary to assure success of performance improvement initiatives and routine monitoring activities

·  Evaluates and recommends changes to the Performance Improvement Plan as the structure and needs of the organization change

Medical Director and Residency Director:

·  Monitors and evaluates the quality of clinical care provided by Muskegon Family Care using performance measures and external references to identify areas for intensive assessment and performance improvement

·  Participates in the identification of the important aspects of care in each clinical department and development of criteria and indicators for the purpose of monitoring and evaluating performance and outcomes

·  Conducts peer review activities

·  Establishes clinical practice guidelines based on best practice

·  Takes a leadership role in improving clinical processes that involve patient care

·  Identifies and acts independently and/or collaboratively on performance improvement opportunities relating to medical staff issues

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Quality Assurance Coordinator

·  Participates in the development of the organizational Performance Improvement Plan

·  Collects data on all organizational activities related to quality improvement and report findings to the Management Team

·  Participates in the development of organizational policies related to quality improvement

·  Develops and implement educational strategies to support the organization’s performance improvement efforts

·  Facilitates coordination and communication of quality improvement activities throughout the organization

Compliance Officer

·  Assures compliance with regulatory, statutory and accreditation requirements especially as related to billing and coding regulations.

·  Establishes auditing processes

·  Does a periodic compliancy audits and reports finding to the QA Committee

Risk Manager

·  Evaluates areas of risk within Muskegon Family Care

·  Ensures compliance with all policies, procedures and processes governing risk management

·  Determines and implements an action plan to eliminate, reduce or avoid areas of organizational risk

·  Provides risk management training to all Muskegon Family Care staff

·  Assures all incidents are investigated promptly and that appropriate follow up action is taken

·  Determines when outside legal advice is advised and coordinates providing the required information to the law firm

·  Reports all lawsuits to FTCA

·  Provides annual risk management summary reports to the Management Team and Board of Directors

Management Team:

·  Trains employees in performance improvement principles and techniques

·  Responds to performance improvement suggestions made by employees and other customers

·  Encourages employees to participate in performance improvement activities and groups

·  Incorporates CQI techniques in day-to-day management of departments

·  Reports departmental activities to the Quality Assurance Committee

·  Initiates performance improvement activities that have measurable patient care and service outcomes

·  Conducts departmental performance improvement projects

·  Monitors departmental indicators and quality control

·  Reviews the results, effectiveness and structure of the Performance Improvement Plan on an annual basis and recommends necessary changes to the Quality Assurance Committee of the Board of Directors