Quality Improvement & Patient Safety Policy

Policy Owner: Associate Dean for Patient Care & Clinic Services

Policy Contact: Quality & Compliance Officer

POLICY STATEMENT

The Associate Dean for Clinical Affairs shall ensure that there are regular reviews of dental charts and professional services monitoring compliance with current policies, procedures, and recognized guidelines of care, and shall ensure that there are reviews of all patient grievances, incident reports, and other documents as necessary or desired which pertain to problem identification. It shall be the responsibility of the Associate Dean for Clinical Affairs to ensure that all quality assurance activities are documented including, but not limited to, the findings, recommendations, and actions taken to resolve identified problems. Additionally, there shall be participation in the program by the administrative staff and health care professionals, representing each professional activity at the UMSOD through membership on the QI/PS Committee. The membership of the QI/PS Committee is defined in the Quality Improvement Plan. The outcome of quality assurance reviews shall be used for the revision or development of institutional policies and in granting or renewing faculty, staff, or student privileges, as appropriate.

1. Specific Components/Tasks of the Program and their Resources

Quality Improvement monitoring will include evaluation of the following:

•  Appropriateness of care and services provided to our patients including, but not limited to:
  • Quality and appropriateness of diagnostic and therapeutic procedures and prescription of medications.
  • Quality of patient access to services at the UMSOD clinics.
  • Quality of patient/provider communications.
  • Patient level of satisfaction with our services.
  • Appropriateness of outcomes of the services provided.
  • Quality, content, and completeness of patient records.
  • Performance of administrative and clinical staff.
  • Utilization and cost analysis of services.
  • Safety of equipment and the environment.

• Resources that will be utilized to perform the above evaluation may include, but are not limited to the following:
  •  Documentation monitors
  • Clinical monitors
  • Patient surveys
  • Patient complaints
  • Incident reports
  • Safety reports

2. Mechanism for Overseeing the Effectiveness of Monitoring and Problem- Solving Activities

The QI/PS program shall be the instrument for overseeing the effectiveness of monitoring and corrective action activities. This program shall be evaluated by the Quality Assurance Committee on an ongoing basis. At least annually, the Program shall be evaluated by the QI/PS Committee to ensure that the collective effort is comprehensive, shows minimal duplication of effort, is cost effective, and impacts

positively on direct and indirect patient care. Recommendations for revisions and changes shall be made with input from appropriate services/professional disciplines, as appropriate.

The Institutional Effectiveness Committee (IEC) of the SOD receives annual data on the quality of services at the SOD. This data is presented to the IEC by the Associate Dean for Clinical Affairs.

3. Appropriateness of Care

The establishment of review criteria for monitoring and assessing treatment is done in accordance with, but not limited to, the following:

• Guidelines of care developed or suggested by qualified consultants or professional organizations.
• The expertise of faculty/professional clinical and administrative staff.
• Current scientific/business literature.
• UMSOD policies and procedures.
• Guidelines promulgated by accrediting agencies, regulatory agencies, and third-party payers.

4. Monitoring Sample Size and Frequency of Data Collection

There are no standard rules for setting specifications for the frequency of data collection or sample size. However, there are a few general principles that should be followed by reviewers:

• Monitoring should be limited to the number of cases/occurrences that will provide information from which to draw meaningful conclusions. Where possible, data collection should be automated and processes put into place to receive and analyze quality data in the least resource intensive manner.
• Some monitors may involve evaluation of a service, condition, or situation that is performed or occurs so frequently that collecting data on all cases/occurrences for one or two weeks will be sufficient.
• Some monitors may involve review of a service, condition, or situation that occurs so infrequently that data collection will have to involve all cases for a specified period of time or until a specific number of cases have accumulated.
• Some monitors involve a high volume of services or conditions so that evaluators may choose a representative sample to review over a specified period of time.
• For monitors that attempt to evaluate patient management issues, sampling may be taken from different departments, sessions, or days of the week.

5. Data to be Displayed on Summary Reports

Selected indicators will be chosen in accordance with professional guidelines of care (when applicable). The frequency with which data should be summarized depends on the amount of data that is gathered during the time period in question. Large numbers of cases or situations should be summarized more frequently than small numbers. Indicators include:

• The quota for the specific discipline reviewed.
• The number of cases or situations reviewed.
• The number and percent of non-compliant occurrences in each category.
• Other demographic and/or clinical variables in the monitoring sample (when applicable).
•  Aggregates by individual, department or institution (when applicable).
• Critical monitors are highlighted.

REASON FOR POLICY

The University of Minnesota School of Dentistry (UMSOD) Quality Improvement/Patient Safety (QI/PS) policy has been established to monitor and assess the quality and appropriateness of patient care and clinical performance on an ongoing basis. The objectives of the QI/PS program are to:

1. Routinely ensure continuous improvement and/or maintenance of the quality of care provided to our patients consistent with recognized professional and scientific guidelines of care and consumer expectations.
2. Educate our students, residents, staff, and faculty in the pursuit of continuous improvement of care and provide experience in quality of care assessment.
3. Encourage interaction regarding QI/PS among students, residents, faculty, and Staff.
4. Constantly modify our clinical and administrative delivery systems through assessment of short- and long-term outcomes and periodically assess the results of such corrective actions.

PROCEDURES

Divisional QI/PS

1. Division Heads should analyze the data collection requirements and assign responsibility to the reviewer(s) who can collect the data most easily and/or most effectively.
2. On a quarterly basis, completed monitors will be submitted to the Associate Quality and Compliance Officer for data entry. The Officer will present initial summary reports to the Division Chair for review.
3. The Quality and Compliance Officer will publish a Quality Assurance Reporting Schedule on an annual basis. Any matters requiring more immediate attention by the Quality Assurance Committee may be brought to the next meeting of that Committee. Selected data may be provided as requested to the other standing committees and/or Division Heads for reappointment and performance appraisal activities.

Compliance and Corrective Action

Compliance Rate

For each critical documentation indicator, the Quality Assurance Committee must specify the desired level of achievement against which summary data will be compared. A level of 100% compliance is desired for each category. However, thresholds may deviate from the 100% level for certain categories with appropriate rationale for such deviation.

Corrective Action

Responsibility for recommending resolutions to problems identified by the monitoring effort lies with the Division Head. The implementation of the corrective action may fall to the QI/PS Committee or an otherwise named oversight group; those who have conducted the reviews will, however, be expected to supply suggestions for remedial actions.

It is imperative that the Division Head inspires positive, helpful responses to suggestions. Recommendations for action need to be offered to all staff in a non-confrontational manner.

The outcomes of certain monitoring efforts may result in operational changes that can involve either individual practitioners or the entire UMSOD. As recommendations for specific actions are formulated, reviewers should be careful to distinguish concerns that are incidental from those that are chronic; problems based on patient care from those that are strictly economic; instances in which the UMSOD’s written policy/procedures have been violated from those in which the adequacy of the procedures themselves are Questioned.

The UMSOD must not rely on informal means of problem resolutions, but rather, those mechanisms set forth in policies and procedures that are kept current and relevant to UMSOD operations. The nature of problem resolution is not a punitive endeavor. It should focus on the productive use of the information discovered through the evaluation process. Staff education, changes in policies and procedures, counseling, and supervision are valid responses to the identification of problems in the provision of patient care, especially in an educational setting such as ours. This does not preclude the implementation of serious measures such as suspension or termination of clinical privileges; however, these measures will only be taken when the seriousness of the breach in policy demands such action.

FORMS/INSTRUCTIONS

There are no forms associated with this policy.

APPENDICES

There are no appendices associated with this guideline.

FREQUENTLY ASKED QUESTIONS

There is no FAQ associated with this policy.

DEFINITIONS

There are no definitions associated with this policy.

RESPONSIBILITIES

There are no responsibilities associated with this policy. 

RELATED INFORMATION

There is no related information associated with this policy. 

HISTORY

ADDITIONAL CONTACTS