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3/31/2009 Survey Tag 0712 Detail for:
Tuesday, March 31, 2020 3:03 AM

Survey Date: 3/31/2009

Regulation Number:0712

Regulation Title: MD RESP-QAPI PROGRAM

Regulation Description: Medical director responsibilities include, but are not limited to, the following: (a) Quality assessment and performance improvement program.

Surveyor Findings:

Based on review of the QAPI (Quality Assessment and Performance Improvement) program, the facility failed to ensure the medical director was assigned operational responsibility for the QAPI program. This failure created the potential to affect all the patient health outcomes in the facility.

The findings were:

The QAPI program was reviewed on 3/30/09. There was no evidence the medical director was providing guidance in the development of the specific quality indicators that must be implemented in the QAPI program. Furthermore, the operational responsibility included educating and encouraging the facility and medical staff regarding the objectives, assessment of the effectiveness of the plan and communication with the governing body regarding the needs that were identified. There was no oversight of implementation of the facility's trends, analysis, plans or timetables.

In summary, oversight by the medical director in developing a viable QAPI program for the facility was not evident.

Facility Plan of Correction:

How the facility CORRECT the deficient practice?

The Medical Director for the Kidney Center is responsible for chairing the Quality Assurance and Performance Improvement (QA/PI) Committee for the Kidney Center which includes an interdisciplinary team consisting of other physicians as indicated, the Clinic Manager (RN), a masters-prepared social worker, a registered dietician, a Quality Improvement specialist, and other members of the Kidney Center, as applicable.

How will the facility IDENTIFY areas of deficient practice?

The Kidney Center QA/PI Committee is responsible for reviewing on a monthly basis the quality indicators as outlined in the Measures Assessment Tool (MAT) on a per patient basis and as an aggregate for the center; these indicators will be displayed on a scorecard that was developed in conjunction with the Medical Director, the Clinical Manager and members of the Quality and Patient Safety Department.

What will the facility do to PREVENT the same deficiency from recurring?

The TCH Chief Medical Officer, to whom the Kidney Center Medical Director reports, and the TCH Chief Quality Officer who oversees the system wide quality program will assure continuous leadership by the Medical Director and reporting of data..

How will the facility MONITOR the implementation of the plan of correction to ensure the problem remains corrected?

These quality indicators will be reviewed MONTHLY. Additionally, bi-annually, the Medical Director for the Kidney Center will present the quality indicators as illustrated on the Kidney Center Scorecard to the Clinical Effectiveness and Improvement Committee, a multi-disciplinary hospital-wide quality improvement committee that is primarily focused on patient outcomes. The QAPI committee met preliminarily on April 20, 2009 and will have its first scheduled meeting during the month of May 2009.


Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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