Outline:
Section 1: Introduction

About This Course

Learning Objectives

Section 2: Elements of a Quality Improvement Program

The Phone Message

What Is Quality?

QI Principles

QI Program Infrastructure

QI Coordinator

QI Committee

QI Project Teams

Data Collection

Data Reporting

Review

Summary

Section 3: The Quality Improvement Process

The Role of Leadership

QI Models

Core Components

The Model for Improvement

Setting Aims

Establishing Measures

Select Change Strategy

PDSA

Review

Summary

Section 4: Quality Improvement Strategies

Be Both Proactive and Reactive

Proactive QI Strategies

Audits

Peer Review

Peer Review Audit Types

Potential Concerns

Developing Audit Questions

Using Your Peer Review Data

Incorporating HRSA Performance Measures

Patient Satisfaction Program

Patient Satisfaction Surveys

Review

Summary

Section 5: Reactive Strategies

Documenting Complaints and Incidents

Tracking Complaints and Incidents

Complaint Types

Responding to Incidents

Types of Incidents

What Is a Sentinel Event?

Regina’s Collapse

Incidents vs. Sentinel Events

Root Cause Analysis

Remember Regina?

Review

Summary

Section 6: Conclusion

Summary

Course Contributors

Resources

References

Congratulations!

Jennifer Moore, RN-BC, CDP, WCC started working in the senior care industry in 2000. She is a certified Gerontological Nurse, a Certified Dementia Practitioner, and Wound Care Certified. She has held positions including MDS Coordinator, Director of Nursing, Medicare Nurse Coordinator, Nurse Consultant, Area Manager, and Director of Quality Assurance. Her overall responsibility within each of these positions was to ensure residents received the highest quality of care. This included active participation in quality improvement initiatives, review of clinical records to identify areas of weakness, corroboration with the medical director to institute policies and procedures for resident care, and staff education/training. Additionally, she was responsible for maintaining an effective compliance program under a Quality of Care Corporate Integrity Agreement with the Office of Inspector General for a period of five years. She currently serves as the Director of Curriculum Design & Research for Relias. Within this position, her responsibility is to oversee the development of online training modules across the healthcare continuum. She has served as the subject matter expert for courses on re-hospitalization, clinical skill reviews, leadership, management, and various OSHA and regulatory compliance topics. In addition, she has presented at various state conferences on mandatory compliance, quality assessment and assurance (QA&A), and quality assurance and performance improvement (QAPI).  Disclosure: Jennifer Moore, RN-BC, CDP, WCC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

Nellie Galindo received her Masters of Social Work and Masters of Science in Public Health from the University of North Carolina at Chapel Hill. She has worked with individuals with disabilities in several different settings, including working as a direct service provider for individuals with mental illness and leading a youth program for young adults with disabilities. She has facilitated and created trainings for individuals with intellectual and developmental disabilities in the areas of self-advocacy, healthy relationships, sexual health education, and violence and abuse prevention. Mrs. Galindo has worked in state government assisting individuals with disabilities obtain accessible health information in their communities, as well as utilizing the Americans with Disabilities Act to ensure equal access to healthcare services. Disclosure: Nellie Galindo, MSW, MSPH has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

Katy Kunst received her Bachelor of Arts in Psychology from the University of North Carolina at Chapel Hill, and her Master of Business Administration from Elon University. She has 12 years of experience in human services roles, including direct care, program director, and training facilitator. Across those roles, she held responsibility for ensuring quality services, as well as monitoring and managing data. She has created and facilitated training on topics including non-violent crisis interventions, person-centered planning, cultural competence, quality service delivery, regulatory compliance, and a variety of topics related to intellectual and developmental disability services. Disclosure: Katy Kunst, MBA, QIDP has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.