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Quality Improvement Assessment and OUT REACH Cathy Alderman and Heather Beck speaking about SWEEPS

June 9, 2016

Quality Improvement Assessment  Work Plan    18 page plan  – measures for grants and funding sources  ESPRIT education referral to treatment  people screened for behavioral health and mental health and medical cross section

 

they’re measuring long term hazardous behaviors like smoking alcohol coronary artery disease lipid  Ischemic Vascular disease  aspirin,  colorectal cancer screening,  HIV  Linkage to care,  depression screening, dental sealants,  hypertension,  diabetes poor control,   suicide?  trauma,  life events screening,  trauma care,  impact of trauma,  collecting data,  HYGIENE   basic living skills  

 OUT REACH  and Education and Advocacy  –  Cathy Alderman and Heather Beck  and Sherry ADAMS  speaking about SWEEPS

 

CCH  Program Committee with the Board of Directors  –  

 

Universal Data Set   Clinical Measures:  

 

Board members who are attending is growing

 

Komal Vaidya, SANA HAMELIN,  Charles, Darryl, Virginia, 

 

“elaynegallagher@gmail.com” <elaynegallagher@gmail.com>,
Barbara Davis <bhdavis19@gmail.com>,
Charlie Savage <cfsavage1@gmail.com>,
Chris Taravella <ctaravella@montgomerylittle.com>,
Evan Abbott <eabbott@msec.org>,
Jay Brown <jbrown@law.du.edu>,
Judy Glazner <jglazner@gmail.com>,
Keith Smith <kcs@ssslawyers.com>,
Komal Vaidya <komalpvaidya@gmail.com>,
LaRay Kraeplin <lkraeplin@yahoo.com>,
Leanne Wheeler <leanne@wheeleradvisorygroup.org>,
Randle Loeb <randleloeb@gmail.com>,
Sana Hamelin <sanahamelin@gmail.com>,
Toren Mushovic <tmushovic@hotmail.com>,
Virginia Berkeley <vkberkeley@gmail.com>,
Jack Patten <jack.patten@state.co.us>

 

Projects to assist in Transition from Homelessness  Kate Dill  outcomes  PATH

 

reports on the outcomes  for the real time

 

disease registry  delegate agency  access to primary care  struggling to meet outcomes

 

DLA 20  functional assessment tool case management

 

important outcomes:  Housing  HEALTHCARE  Housing quality of life feeling of sense of community  hard ship

 

reasons and need for this information is important for policy changes

 

people with children     parenting  skills  assessment

 

infinite number of opportunities for families always filled as fast as possible

 

Coordinated INTAKE ASSESSMENT  prioritized   for most in need

 

reducing trauma of children and outcome of the transition from foster care to being housed and stable

 

sherry  working poor   people who cannot find a place or because of eviction

 

GAPS  ANALYSIS  in housing people in assessment tool  housing opportunities  just on the edge will figure this out  this is as traumatizing as their past history generation

 

Immigration Customs Enforcement  ICE  certain ethnic minorities believe that they have to care for themselves within the culture.

 

resources that exist for people in marginal situations  in human services  instead of being responsive in a punitive  way

 

often they do not have stability and they are finding it difficult age range.

 

SWEEPING  DOWNTOWN AND ENVIRONS  –     Heather and Sherry

 

Alderman:   March 8  Denver Police  broke up the encampment  out reach workers went out to inform people and offer

 

March 9  Resurrection Village  property  –  required to offer policies and procedures

 

Mayor was not present  met later with the Commission and PJ poked the Mayor

 

other activities that are important

 

COST OF ENCAMPMENTS  Professor at Denver University

 

nomad encampments  coming through to stay here to do drugs

 

Darryl is asking specific questions about who is impacted.

 

WESTWORD is writing about all of this increase in contacts

 

number of contacts has increased dramatically not arresting anyone not issuing formal citations

 

belief in the community  I want to say that there have been very few arrests

 

people are not sleeping for days and having stress and trauma  tension with the city of DENVER

 

achieving goals moving people along  getting these people into services shelters do not work for everyone temporary sheltering

 

they are not looking for temporary places to stay here in DENVER

 

enforcing these bans and services  it is difficult to contact them  they are wandering right in front of cyclists  public relations issue

why is CCH not doing something to curtail this  influx of people when it is warmer

 

out reach them let them know how to get support do not want help  DENVER is their new home  not willingly go into the Rescue Mission of the St Francis Center or the Library  and they are doing light touches to make it possible to care for these people  there is not enough housing

 

not enough benefits no agency in the city because the resources are not there and there is a RIGHT TO REST 

 

NUMBER OF STREET CHECKS WILL GO ON AND ON

 

 

 

 

 

CITY COUNCIL moving separately  major advisors: EVAN DRYER  met with him  city government

 

ALBUS BROOKS   and Bennie Milliner consult with the Mayor

 

gang activity dangerous something needed to happen  emotional  cannot be a human being here  you have to go somewhere else

 

take care of everyone regardless what their circumstances

 

SHERRY was threatened a number of times  had to change her strategies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Colorado Coalition for the Homeless

 

Integrated Health Services
Quality Assurance Program

 

Colorado Coalition for the Homeless (CCH): Background & Unique Characteristics……… 1

Definition of Homeless………….………….………….………….………….………….….. 2

Quality Assurance Plan: Purpose and Goals ………….………….………….………….…… 2

Quality Assurance Plan Oversight & Organizational Structure………….………….………. 3

Employee Orientation………….………….………….………….………….………….……. 9

Health Records………….………….………….………….………….………….…………… 10

Sources of Data available to the QMOC………….………….………….………….……….. 12

Credentialing/Privileging Review Procedures………….………….………….…………….. 12

Consumer Satisfaction………….………….………….………….………….………….…… 13

 

Appendices

  1. Principles of Practice
  2. Annual Quality Improvement Work Plan
  3. CCH Policies and Procedures
  4. Supervision Policy and Procedure
  5. Risk Management Plan
  6. Infection Control Policies
  7. Archiving and Destruction of Paper Charts
  8. Credentialing and Privileging Policy and Procedure
  9. CCH Customer Satisfaction Survey
  10. RPCM Resident Satisfaction Survey

 

The Colorado Coalition for the Homeless

 

Integrated Health Services
Quality Assurance Program

 

A. Colorado Coalition for the Homeless (CCH): Background & Unique Characteristics

Colorado Coalition for the Homeless (CCH) is a 501(c)(3) non profit agency that provides housing and integrated health care to individuals and families who are homeless in Colorado.  CCH health programs were established in 1985 through a grant from the Robert Wood Johnson Foundation and Pew Charitable Trust. The first Healthcare for the Homeless grant from the Federal Bureau of Primary Health Care was awarded in 1987. CCH practices a multi-disciplinary approach to delivering care that combines aggressive street outreach with integrated systems of primary care, mental health and substance abuse services, case management, patient/participant advocacy, and linkages to services such as housing, benefits, and other critical supports. CCH continually seeks ways to create new approaches to deliver comprehensive care, unite providers through collaboration, and decrease fragmentation of services.

The comprehensive range of health services provided without charge to the consumer is described in more detail in the CCH Principles of Practice (Appendix A).

CCH Mission

The mission of CCH is to work collaboratively toward the prevention of homelessness and the creation of lasting solutions for homeless and at-risk families, children and individuals throughout Colorado. CCH advocates for and provides a continuum of housing and a variety of services to improve the health, well-being and stability of those it serves.

CCH Philosophy of Service

We believe all people have the right to adequate housing and healthcare. We work to remove the barriers that restrict access to these rights. Society benefits when adequate housing and healthcare are available to everyone.

We create lasting solutions to homelessness by:

  1. Honoring the inherent dignity of those we serve, affirming their capabilities and fostering their hope that a better life is possible;
  2. Building strong, caring communities through the integration of housing, healthcare and supportive services;

   

  1. Advocating for social equity and challenging the status quo on behalf of the individuals and families we serve;
  2. Achieving excellence through continuous quality assurance, innovation and professional development; and
  3. Using resources judiciously and effectively.
  1. Definition of Homeless

For the purposes of HRSA-funded services, a homeless individual is defined in section 330(h)(4)(A) of the Bureau of Primary Health Care as:

“An individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility (e.g. shelters or psychiatric hospitals) that provides temporary living accommodations, and an individual who is a resident in transitional housing.”

C. Quality Assurance Plan (QAP): Purpose and Goals

The purpose of the Quality Assurance Plan (QAP) is to set forth a coordinated approach to addressing quality assessment and improvement of processes for all health services. Quality assurance activities include instituting programs to ensure the highest quality of care for patient/participants, identifying deficiencies, implementing corrective action(s) to improve performance, and monitoring the corrective actions to ensure that quality of care has been enhanced.

The QAP provides a systematic, organization-wide process for planning, measuring, assessing, and improving performance to:

  1. Ensure the provision of care that is safe, effective, client-centered, timely, and equitable regardless of race, age, gender, disability, values, or lifestyle.
    1. CCH is committed to delivering services, making employment-related decisions, selecting volunteers and selecting vendors without regard to age over 40, race, sex, color, religion, creed, national origin, ancestry, disability, genetic information, marital status, sexual orientation, gender expression, military status or any other applicable status protected by law.
    2. CCH is further committed to employing only individuals legally authorized to work in the United States. As a condition of employment, new employees must properly complete the first section of the Citizenship and Immigration Services Form I-9 before the end of their third day of employment. CCH will make reasonable accommodations for qualified individuals with known disabilities and employees whose work requirements interfere with a religious belief unless doing so would result in an undue hardship to CCH or present a direct threat. Employees needing such an accommodation must contact their supervisor or HR as soon as the accommodation is required.
  2. Improve evidence-based interventions and performance measures over time.

  3. Continuously and systematically improve performance of department-wide functions and processes relative to patient/participant care and services.
  4. Support the continued development of effective patient/participant and direct service practices.

  5. Facilitate patient/participant empowerment.
  6. Expand collaboration and coordination with all community resources to meet the complex needs of the homeless.
  1. Quality Assurance Plan Oversight & Organizational Structure

The locus of responsibility for quality improvement/assurance is established through an interdisciplinary Quality Management Oversight Committee (QMOC) with five subcommittees that include representatives from clinical and management staff. The QMOC consists of CCH leaders who are accountable, responsible, and answerable for planning, directing, coordinating and improving healthcare and support services. This leadership group develops the QAP, reviews reports of the five subcommittees, is responsible for the implementation of the Annual Quality Improvement Work Plan (Appendix B) and meets at least quarterly. Results of quality improvement/assurance activities are reported to the clinical and management staff, as well as to the President and the CCH Board of Directors. The CCH Consumer Advisory Board participates in specific projects as appropriate.

Composition of the Quality Management Oversight Committee is as follows:

  • Vice President of Quality Assurance
  • Medical Director of Integrated Health

  • Psychiatric Director
  • Chief Administrative Officer
  • Chief Program Officer
  • Vice President of Residential Services and Operations
  • Director of Family Support Services
  • Director of Housing First and ACT
  • Director of Human Resources
  • Director of Integrated Health Services
  • Director of Outreach and Engagement Services
  • Director of Residential Services
  • Others as Designated

 

Roles of the Directors of Medical and Psychiatric Services:

The Medical and Psychiatric Directors are integral participants in the quality improvement/assurance process for the clinical services under their purview. Their responsibilities include:

  • Provide leadership for all clinicians and practitioners, whether employees or volunteers
  • Identify areas for improvement in the provision of clinical services
  • Review staff qualifications and competencies according to CCH’s Credentialing and Privileging Policies and Procedures
  • Oversee a formal peer review process based on systematic collection and evaluation of patient/participant records
  • Consider Peer Review results during annual performance reviews, when indicated. (Performance Improvement Plans, if necessary, will follow CCH Performance Management protocol)
  • Participate in the development, review and approval clinical standards of care
  • Participate in the development and selection of health outcome measures for the Annual QI Work Plan (Appendix B), review outcomes, and identify areas of improvement.

 

Role of the Vice President of Quality Assurance:

The Vice President of Quality Assurance performs the oversight role described in Bureau of Primary Health Care documentation as “Clinical Director”. He or she has the primary responsibility for carrying out the Quality Assurance Program in collaboration with the Directors of Medical, Psychiatry,  and Integrated Health Services. Responsibilities of this position include:

  • Review the QAP annually to see if changes are necessary
  • Update/revise QAP at least once every three years
  • Coordinate and facilitate the QMOC meetings, keeping a record of minutes
  • Assist Clinical and Program Directors/Managers in identifying relevant outcomes to track
  • Review data quality reports for programs that use the Homeless Management Information System (HMIS)
  • Review data quality reports for programs that use electronic health records (EHR)
  • Facilitate the collection of occurrence reports, analyzing data for potential trends or patterns to inform quality improvement and risk management
  • Assist in coordinating data collection for qualitative and quantitative analysis
  • Work with Program Directors and Managers to assess levels of staff proficiency with HMIS and EHR
  • Facilitate the collection and quarterly reporting of clinical and management measures in the Annual QI Work Plan (Appendix B)
  • Oversee and direct the implementation of annual continuous quality improvement studies
  • Report evaluation and quality improvement/assurance results to the CCH Board of Directors
  • Analyze and interpret results from annual consumer satisfaction survey administrations

Role of the CCH Board of Directors:

Responsibilities of the BOD include:

  • Review and approve the Quality Assurance Plan
  • Review and approve the Credentialing and Privileging of clinical staff members per the credentialing and privileging policy
  • Provide input relative to customer satisfaction and access to health services, quality of clinical care, quality of the work force and work environment, cost and productivity, and health status outcomes
  • Approve major CCH policies and procedures for the effective delivery of high quality health services
  • The Program Committee of the Board is responsible for receiving quality information/reports relative to patient/participant services and reporting to the full BOD
  • Meet at least quarterly to perform these functions

Role of the Quality Management Oversight Committee (QMOC):

This leadership group serves as a locus of responsibility for the Quality Assurance Program. The QMOC is responsible for ensuring the highest quality of care, identifying deficiencies, implementing corrective action(s) to improve performance, and monitoring the corrective actions to ensure quality of care has been enhanced. The QMOC reviews and approves reports from five subcommittees: 1) Peer Review, 2) Risk Management, 3) Quality Improvement, 4) Workforce Development, and 5) Policy and Procedure. The QMOC responsibilities include:

  • Refers reports needing additional evaluation or clarification back to the appropriate subcommittee or manager/director
  • Identifies areas for continuous quality improvement intervention and develops appropriate plans for resolution and follow up on potential and actual problems
  • Reviews and updates policies and procedures (See Appendix C)
  • Reviews updates from organization-wide initiatives such as the implementation of Trauma Informed Care and the work of the Cultural Competency Council
  • Proactively identifies and plans for potential and actual risk in terms of compliance, facilities, staff, patient/participants, financial, clinical, and organizational well-being (See Risk Management Plan, Appendix E).
  • Approves  an annual quality improvement work-plan with clinical and management measures that are monitored on a quarterly basis
  • Meets at least quarterly
  • Keeps minutes that describe activities

Sample Agenda for the Quality Management Oversight Committee:

  • Subcommittee Reports
  • Electronic Information Systems
  • Complaints and Grievances
  • Review and recommend changes of policies and procedures (see Appendix C)
  • Review and recommend practice standards
  • Review and recommend practice guidelines
  • Recommend actions

Role of the QMOC Subcommittees:

The QMOC subcommittees are comprised of interdisciplinary clinical and management staff. The role of the subcommittees is to provide a systematic, coordinated review of patient/participant satisfaction and access, quality of clinical care, quality of the work force and work environment, cost and productivity, health status outcomes, risk assessments, and policies and procedures. It is recognized that some quality improvement/assurance activities may be relevant to more than one subcommittee.

Peer Review Subcommittee

Peer Review is defined as a periodic internal review that occurs among clinical providers to evaluate the appropriateness and quality of clinical services that are provided.  The Peer Review Subcommittee assures regular performance of peer review activities and reports aggregate results from that data to QMOC. Clinician specific and targeted feedback is critical to the integrity and fulfillment of this process. The Director of Integrated Health Services (or his/her designee) oversees the Peer Review Subcommittee, which is comprised of the Vice President of Quality Assurance, Medical Director of Integrated Health, Psychiatric Director, Director of Dental Services, Director of Family Support Services, Director of Housing First and ACT, Director of Residential Services, or their designees. Responsibilities of the Peer Review Subcommittee include:

  • Review and approve proposed specific areas of focus or processes to evaluate based on department or clinician needs
  • Decide the format for evaluation (chart audit, review, other)
  • Determine parameters for review and analysis
  • Formulate process and documentation for individual feedback for clinician
  • Discuss specific results and give feedback
  • Ensure that the process occurs quarterly (baseline and follow up review as needed)
  • Consider peer review data as part of determining future quality improvement activities or to support privileging criteria

NOTE:   All peer review documents presented to QMOC will protect clinician identity. Individual peer review information will remain confidential.

Feedback from the Peer Review Subcommittee is documented by meeting minutes. These notes include attendance, and a report on current peer review activities as well as any recommendations for further discussion, review, or necessary action. Results and feedback are provided to individual clinicians during regular supervision (see Appendix D for Psychotherapy/Counseling Supervision Policy and Procedure). Individual Provider Results Forms are submitted to Human Resources for inclusion in Credentialing Files. Aggregate data on peer review is presented at monthly provider meetings and submitted quarterly to the Vice President of Quality Assurance.

Peer review results and quality improvement activities are also presented annually to the Program Committee of the Board of Directors.

Risk Management Subcommittee

The risk management subcommittee, comprised of staff volunteers representing disciplines across the organization, will monitor and assess regulatory compliance, information and risk management systems to proactively identify, and plan for potential and actual risk. This is done through review of information/data from a variety of sources, which include occurrence reports, state and federal regulatory compliance (OSHA, HIPAA, BPHC, FTCA, CMS, HCPF, etc.), emergency management drills, chart audits, patient/participant billing, SSHC Safety Committee reports, and other potential areas of liability. The Safety/Emergency Officer(s) will review safety/emergency preparedness activities and reports and will present findings at each meeting (See Appendix E for the Risk Management Plan).

Quality Improvement Subcommittee

The Quality Improvement Subcommittee is comprised of the Chief Program Officer, Vice President of Quality Assurance, Director of Integrated Health Services, Director of Housing First and ACT, Director of Family Support Services, Director of Residential Services, and the Medical Director and Psychiatric Director, or their designees. The Quality Improvement subcommittee will monitor and assess the quality of services, patient/participant satisfaction and outcomes, clinical systems and processes. This is done through review of information/data from a variety of sources, including Occurrence Reports, EHR data quality and summary reports, HMIS data quality and summary reports, satisfaction survey reports, domain-specific outcome assessments (e.g. Patient Health Questionnaire-9 item scale, HRSA Quality of Care Indicators, etc.), and consumer feedback. The committee follows a monthly calendar for data review. The outcomes in the annual Quality Improvement Work Plan are reviewed and discussed quarterly. When areas of improvement are identified, the Quality Improvement Subcommittee reviews processes, procedures, and findings of program specific quality improvement projects and activities.

The Quality Improvement Subcommittee will monitor access to care, patient/participant rights information, and patient/participant complaints and report findings. The Nurse Manager and Regulatory Specialist will monitor infection control practices and report significant findings (See Appendix F for Infection Control Manual).

The Quality Improvement Subcommittee is also responsible for evaluating and approving or rejecting all proposals to conduct research within CCH.

Workforce Development Subcommittee

Workforce Development Subcommittee assesses the quality of workforce management and development activities in order to meet recruitment and retention goals. The subcommittee is comprised of staff volunteers representing disciplines across the organization.  The Workforce Development Subcommittee will obtain and analyze data from a variety of sources including staff surveys, exit interviews, compensation data and workforce statistics. Specific areas of focus include recruitment and selection, staff training and development, performance management, compensation, employee benefits, and diversity and inclusiveness.

Policy and Procedure Subcommittee

The Policy and Procedure Subcommittee is an interdisciplinary team with representation across the organization. The Subcommittee reviews new policies and procedures for consistency and accuracy and presents policies and procedures for approval at the QMOC. All established policies are reviewed on a regular basis for necessary updates. The Policy and Procedure Coordinator ensures all documents are signed and stored in the online Manual.

Sample QMOC Subcommittee Agenda:

  • Membership (those in attendance)
  • Areas of Responsibilities
  • Reporting/Documents to be Reviewed
  • Reporting/Documents/Presentations to be Generated

E. Employee Orientation

The Medical, Psychiatric, Dental and Program Directors ensure the clinical orientation of new providers, which will include clinical supervision, principles of practice, policies and procedures, clinical guidelines and standards of care, reportable events, peer review, credentialing and re-credentialing protocols, overview of patient/participant rights and health record standards of care, and participation in quality improvement activities.

The Director of Human Resources (or his/her qualified designee) is responsible for providing an initial organizational orientation on the first day of employment. This orientation covers the CCH Mission and Philosophy of Service, personnel policies and guidelines (including policies concerning patient/participant confidentiality, conflicts of interest, drug-free workplace and ethical conduct), the CCH organizational structure and employee benefits. HIPAA training regarding the protection of health information is coordinated by the HIPAA Privacy Officer for all employees during orientation. A more in depth training is provided for clinical staff members and volunteers prior to the new employee’s access to the Electronic Health Record. Each Department/Program Manager is responsible for orienting of all new employees to the workplace and job duties/responsibilities, and providing each with a current position description. Additionally, mandatory and optional trainings are provided to employees through the Staff, Training, Education, and Performance (STEP) Program. New employees are required to attend a cultural competency workshop, non-violent crisis intervention training, and trauma informed care training.

F. Health Records

In 2011, CCH implemented NextGen Electronic Health Record (EHR). The Electronic Health Record contains all the components of the previously paper medical record in an electronic format.  

An electronic chart is maintained for every patient/participant receiving medical care, mental health and/or substance treatment services, and enabling services. Electronic health records contain the following patient/participant information:

  • Name, Date of Birth, and Gender
  • All levels and management of care, including initial exam and all medical and psychiatric diagnoses
  • Current medications and problems identified
  • All allergies and adverse reactions (prominently flagged and displayed)
  • A history of x-ray and labs ordered and results
  • Documentation of immunization against preventable and communicable diseases
  • All specialty referrals and reports
  • Follow-up on missed appointments and abnormal findings
  • Plans of action consistent with findings and diagnosis
  • A review of ER visits and inpatient hospitalizations, if applicable and available at the time of the visit
  • Valid Patient/Participant registration forms
  • Patient/participant consent to treatment
  • Notice of privacy rights
  • Informed consent for special procedures
  • Valid patient/participant authorization to send or receive protected health information, if applicable
  • Electronic entries are time stamped with date and time

 

Patients/participants can access their health information through the Patient Website. The Patient Website is a portal that allows patients/participants to request appointments, email their providers, view lab results and medications, request medication refills, and request copies of their medical record.

CCH also participates in the regional Health Information Exchange through the Colorado Regional Health Information Organization (CORHIO) which provides access to electronic health information from other area providers and hospitals.

The ultimate goal of the CCH EHR System is to create a comprehensive health record to enhance the quality of care provided through improved documentation and communication, and to improve patient/participant safety and increase efficiency. A multidisciplinary team, oversees the utilization of the EHR. The following ongoing operations of the EHR are monitored by QMOC:

  • System updates
  • Change control (via the EHR Core Team)
  • Adherence to EHR policies and procedures

Because CCH offers a myriad of services beyond medical, some health records (e.g. behavioral health and substance treatment) may exist in paper or other formats.

Confidentiality of Protected Health Information

Access to health records is permitted only on a “need to know” basis to those clinical/program staff members who are part of the team providing services to the individual. Such information contained in the health record may be accessed only for treatment/services, billing, and operations. The HIPAA Privacy Officer is responsible for ensuring compliance with all local, state, and federal regulations governing the protection of protected health information.

Maintenance of the Health Record:

  • All production Electronic Protected Health Information (eHPI) is stored on servers on the LAN located in the locked IT server room.  The building has a security alarm system which is constantly monitored.  Access to the building is controlled by the use of keys and security codes for the alarm system.  Supervision of those systems is provided by the security department. 
  • An electronic chart is created for each patient/participant, identified by a medical record number, in which all information is linked and easily retrievable to any system user with appropriate access to the system.
  • Archived paper health records are stored in a secure location not accessible to unauthorized individuals. (See Appendix G for the policy regarding the retention, archiving, and destruction of paper charts).

HIPAA Privacy and Security Compliance and Electronic Protected Health Information (ePHI):

  • Security Policies and Procedures are established for the Electronic Health Record in accordance with HIPAA Security Provisions and the HITECH Act which includes policies for all sections:  Administrative Safeguards, Physical Safeguards, Technical Safeguards, and Policies and Procedures Documentation Requirements.
  • ePHI will be protected in accordance to all HIPAA and Security Guidelines.
  • HIPAA Privacy and Security Manuals are available to workforce members electronically via CCH’s Intranet.
  • Training and compliance on HIPAA Privacy and Security Guidelines is required of all workforce members and Business Associates.
  1. Sources of Data available to the QMOC

 

  • Bureau of Primary Health Care Uniform Data System (UDS)
  • Health Services and Resources Administration (HRSA) and other mandated grant reports
  • Customer and Resident Satisfaction Surveys
  • Consumer Outcome Scales (such as Daily Living Activities-20 Functional Assessments and Patient Health Questionnaire)
  • Occurrences/Critical Incident Reports
  • Clinician Credentialing Review
  • Peer Review Summary
  • Quality Improvement Activities and Reports
  • Reports from HMIS and EHR, such as data quality reports
  • Chart Audits
  • Meaningful Use reports
  • Annual Performance Reports
  • Patient/participant/Staff Complaints and Grievances
  • Annual Quality Improvement Work Plan Metrics
  • External Benchmarks
  • Employee Turnover Report
  • Employee Satisfaction Surveys
  • Cultural Competency Council Reports
  • Trauma Informed Care Advisory Committee Reports
  • Practice Management System Reports
  • Emergency Management Reports
  • Stout Street Health Center Safety Committee Report
  • Evidence-based practice outcomes reports
  • External Consultant reports
  • Subcommittee reports

 

 

 

 

 

 

 

 

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