NATIONAL ASSOCIATION OF OCCUPATIONAL HEALTH PROFESSIONALS

SAMPLEQUALITY ASSURANCE MANUALPREPARED BY DONNA LEE GARDNER, SENIOR CONSULTANT FOR NAOHP/RYAN ASSOCIATES OCCUPATIONAL HEALTH SERVICES

SAMPLE QUALITY ASSURANCE MANUAL

TABLE OF CONTENTS

Introduction 3

Quality Improvement Plan 7

Performance Standards 9

Satisfaction Surveys 13

Treatment Standards & Outcomes 16

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1. Introduction

What is Quality Improvement?

Quality improvement (QI) is an explicit, evidence-based process for evaluating and improving processes and systems. Quality improvement requires: 1) careful planning, 2) the identification of appropriate personnel to execute and monitor the quality improvement plan and 3) ongoing education for health care professionals and client companies on the plan and its projected outcomes. Because of their diversity, occupational health programs require an integrated quality improvement framework that recognizes contributing products and services and the linkages necessary for enhanced efficiency and effectiveness. The framework defines the various components of a quality program and incorporates them in an action plan to simplify implementation. Productivity and Profitability

Health care professionals must embrace the concepts of productivity and profitability to ensure the survival of occupational health programs in an increasingly competitive environment. Productivity requires a careful review of the infrastructure of a program. For example, are staffing ratios in keeping with anticipated daily activities? Is there a process in place to monitor actual staff ratios to projected patient volumes? Have time and productivity surveys been conducted to identify how long it takes to accomplish certain tasks? The development of a process for measuring productivity provides the foundation for improvements in processes, which in turn ensure greater profitability. Appropriate staffing ratios and competent personnel are necessary for an organization to achieve quality care and a reasonable allocation of resources. JCAHO uses a similar approach by setting standards for processes and functions rather than actual practice. Competition and Market Share

The second step to quality improvement is the identification of organizational and programmatic goals. The service delivery model should be in keeping with the parent organization’s mission. For a program to be profitable, it must also be in tune with marketplace expectations and demands. For example, a thorough understanding of the market makes it possible to project patient volumes and demand for services, which are directly correlated with a program’s anticipated revenue, staff complement, salaries and benefits, and associated

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operational expenses. A sample market assessment tool is included in Chapter 7. It is important to differentiate an organization’s program from others in the marketplace to maintain a competitive edge and demonstrate why clients should use your service rather than another. Quality monitoring provides the objective data to validate interventions, staff competencies and the program’s ability to provide services in a cost-conscious manner. Regulatory Factors

A third step in the quality improvement process is alignment with the regulatory environment. For example, health care organizations are required to demonstrate that the environment in which they function is in compliance with standards established by Departments of Public Health, the Occupational Safety and Health Administration (OSHA), JCAHO and laboratory certification groups, among others. In an effort to standardize the delivery of care among programs, these regulatory agencies have established indicators and compliance standards. Failure to meet standard results in a loss of credibility in the marketplace, and consequently a loss of revenue. It is also incumbent upon occupational health professionals to be knowledgeable about regulations affecting their employer clients. OSHA, Department of Transportation regulations, and federal laws such as the Americans with Disabilities Act and the Family and Medical Leave Act all come into play. In addition, state workers’ compensation laws, and accepted regional and local practices, also must be taken into consideration as part of an overall quality improvement program. As employers become more sophisticated in their selection of health care providers, so do their expectations in terms of outcomes and the health care organization’s ability to demonstrate how it can make a difference for the employer. Without an outcomes-orientation, programs are likely to be at a marked disadvantage. Positive outcomes can be used as leverage in a competitive environment. A carefully planned and well-executed quality improvement program is an essential part of that process.

JCAHO and ACOEM have a standard for quality management:

JCAHO: “The organization has a planned, systematic, organization-wide approach to process design and performance measurement, assessment, and improvement. The organization collects data on important processes or outcomes related to patient care and organization functions. Processes for which data are continually

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collected are prioritized and include those processes that are high volume, high risk, or problem prone. The organization initiates intensive assessment when statistical analysis detects undesirable variation in performance. Improvements are acted upon based on established priorities. Prioritizing takes into account the organization’s mission and priorities; effects on patient health outcomes and satisfaction; and resources required for making improvement. When implementation actions are pilot tested and found ineffective, they are modified.” Source: Joint Commission 1996 Comprehensive Accreditation Manual for Health Care Networks.

ACOEM: “An occupational medicine clinic provides high-quality occupational health services, monitors the quality of these services and seeks to improve these services. The clinic should have an established, effective process which:

• identifies and monitors key quality indicators for each of the major services provided; monitors satisfaction of those being served including patients, employees and clients; corrects deficiencies and problems identified;

• have an established process to improve quality which is

comprehensive in identifying areas for improvement including clinical, administrative, and cost-effectiveness;

• has participation by professional and administrative staff in

program development and implementation;

• relies on peer review for evaluation of results; and results in demonstrable, sustained improvements.”

Source: ACOEM Guidelines for Occupational Health Clinics: Operations and Medical Services.

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2. Company Care Quality Improvement Plan

1. Performance Staff Orientation a. Competencies reviewed annually

2. Satisfaction Surveys

a. All patients are given a survey on the way out of the clinic b. Top fifty employer client companies are mailed an employer satisfaction survey annually

3. Equipment

a. Quality control monitoring

4. Treatment Standards a. Monitor 10% of volume for lacerations (hand/finger), back, and ankle injuries

1) Utilize ACOEM 2) Utilize chart monitors 10% of charts will be reviewed by the clinical supervisor. All charts that are reviewed and are determined to not have met the standards are sent to Dr. John Kirkwood for review. Dr. John Kirkwood will provide the Area Practice Manager explanations of non compliance with the standards.

QUALITY INDICATORS FOR ORGANIZATIONAL/PROCESS IMPROVEMENT:

1) Development of a Center-wide marketing plan. To include all services provided, hours of operation and providers available.

2) Standardize medical record process ; to include chart review process, formatting, and the paperless Medical Record system (SYSTOC).

3) Standardize Billing Process; from registration to charge posting. 4) Establish staff productivity monitors with a compliance to standard target of

85%. 5) Establish financial outcome target to monitor compliance to projected

volumes, revenues and expenses.

II. SPECIFIC PROFESSIONAL PERFORMANCE STANDARDS/IMPROVEMENTS:

Annual performance checklists will be evaluated on each employee by their immediate supervisor or manager. This will be completed at the time or in conjunction with the Human Resources Performance Appraisal. General results will be reported to the CQI Team as needed and at least quarterly. Trends in

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performance will be reported and action taken as necessary. Action may include in-service training Center-wide to individual counseling sessions.

III. QUALITY IMPROVEMENT OUTCOME STUDIES:

1. Patient Satisfaction review will be completed quarterly.

2. Chart review/audit criteria (documentation similar to template of treatment outcomes) will be monitored quarterly.

3. Client company satisfaction will be completed annually.

4. Providers will formulate Standards of Care for a variety of conditions and diagnoses (Standard of Care and ACOEM).

5. Laboratory quality control study showing a correlation of on-site

testing with labs run correlated to specific laboratory controls; comparing the results against each other. A percentage of results will be compared twice per year.

6. Establish a Continued Quality Improvement Team

a. All outcomes are reported to the Continued Quality Improvement Team.

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3. Performance Standards

Professional Performance Standards and Improvements:

Annual performance checklists and quarterly criteria will be evaluated on each employee by their immediate supervisor or manager. General results will be reported to OHS as needed and at least quarterly.

Clinicians Competency Skill checklist complies with the clinical standards identified by the OHS process; additional disciplines will comply within their realm of expertise. Trends in performance will be reported and action taken as necessary by the immediate supervisor. Action may include in-service training Program-wide to individual sessions.

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Incentive Plan:

Bonus: Occupational Medicine Supervisor $50.00 – Experience 15% Occupational Medicine Growth in Volume. $50.00 – Retention of Occupational Medicine Clients (expectation – 95%

retention). The clients are defined quarterly. $25.00 – Patient/client surveys (expectation – 4 or 5)

Bonus: All others (front desk, nursing) $50.00 – 0% error ratio for client (checked by supervisor) $25.00 – Experience 30% Occupational Medicine Growth Volume. $25.00 – Patient/Client Satisfaction Surveys (expectation – 4 or 5)

Calculated on a monthly basis. Paid out on a quarterly basis.

Bonus: Marketer 1% of net revenue calculated and paid out monthly

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Competencies requirements: (Effective: 12/07)

COMPETENCY MA X-ray Tech Patient Care

Tech Billing Clerk Receptionist

Audiogram X X X

Billing Accuracy X X

Billing Denials X X

Blood Pressure Check (manual)

X X X

Blood Pressure Check (Dinamap)

X X X

Breath Alcohol X X

Chart Assembly X X X X X

Chart Hold X X X X X

Data Entry X X X X X

DS – Collecting X X X

DS – Resulting X X X

DS – Shipping X X X

Filing Dictation X X X

Foreign Body in Eye Assistance

X X X

Glucometer X X

Handwashing X X X X X

Injections X

Laceration Repair Assist

X X X

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Medications X X

Morgan Lens X X X

Phlebotomy X X X

Random Draws X X X

Record Release X X

Resting EKG X X X

Saliva Alcohol X X X

Scheduling Appointments

X X X X X

Spirometry X X

Sterilization of Instruments

X X

Telephones X X X X X

U/A Dip X X X

Vision Testing X X X

Vital Signs X X X

X-rays (receiving at front desk)

X X X X X

X-rays (filming and developing)

X

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4. Satisfaction Surveys

Patient Satisfaction survey will be completed after every encounter. Standard HCA comments cards are utilized. Client Satisfaction

Employer Survey

Please rate by checking the number that most agrees with the following: (5=Excellent; 1 =Unsatisfactory)

5

4

3

2

1

N/A

1. How would you rate your overall experience with the Occupational Health Program?

2. Please rate the care your employees receive:

Medical Therapy

3. Communication with staff: Reception (appointments, info.) Physician Therapy Comments:

4. Service attitude of staff. If exceptional, in what area?

5. Is there a staff member(s) who has been particularly helpful? If so, who?

6. Timeliness in which your employees are seen?

7. Knowledgeable Staff: Medical Assistants Physicians Therapists

8. Paperwork clear and timely

9. Work Restrictions (specific and applicable)

Other Comments or Suggestions for Improvements: Are there other services or programs you are interested in?

Would you like to discuss your comments? If so, please provide your name and telephone number. All survey information is confidential. Name Telephone

Thank You!

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5. Treatment Standards and Outcomes

The Medical Director and clinical have formulated Standards of Care for a variety of conditions and diagnoses and establish indicators to evaluate outcomes for each standard implemented. Internally, provider quality indicators are directly related to established performance standards and patient outcomes. refer to Figure 4 for a sample of laceration management.

Diagnosis Code

Description

883 Open wound of finger 724.2 Lumbago 847.2 Sprain of Lumbar

845 Sprain of Ankle 847 Sprain of Neck

930.9 Foreign body in eye 840.8 Sprain of Shoulder

924.11 Contusion of Knee 923.11 Contusion of elbow 844.9 Sprain of Knee

816 Fx Phalanx 882 Open Wound of Hand

722.1 Lumbar Disc Displacement 846 Sprain of Lumbosacral

847.1 Sprain of Thoracic 842 Sprain of Wrist

840.4 Sprain Rotator Cuff 372.3 Conjuntivitis 918.1 Superficicial injury to cornea

719.46 Joint Pain - Leg 25 2nd degree burn

729.5 Pain in Limb 923.2 Contusion of Hand 923.3 Contusion of Finger

923.21 Contusion of Wrist

TOP THREE DIAGNOSES TO MONITOR: 1) Lacerations 2) Low Back Pain 3) Ankle

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Injury Management Standard for the Management of Lacerations

Purpose: To provide direction for the development of an evaluation and treatment plan for patients who present with lacerations.

Definition: Lacerations are simply a cut through the skin. Superficial lacerations do

not require suturing, but deeper injuries through the dermis into the subcutaneous fat cause gaping of the wound edges and require surgical repair to minimize scarring, prevent infection, and hasten healing.

The following conditions will require either physician consultation or immediate referral:

! Any deep laceration or puncture wound over vital structures, or which

compromise function, should be stabilized and sent to the Emergency Room.

! High-velocity injuries (such as with a nail gun) should be x-rayed to rule

out bone involvement. If bone injury is present, refer to orthopedics.

Procedure:

! Refer any tendon or deep involvement to surgery (or orthopedics for hand injury)

The Physician/Physician Extender will initiate the patient evaluation and document on the state’s workers' compensation initial medical report form the following:

Chief complaint Diagnostic testing History of present illness* Treatment plan Past medical history Referrals, if appropriate Occupational history related to CC Medications, if appropriate Clinical assessment and findings Prognosis

* HPI should determine the mechanism and age of injury in detail. Be alert for self- inflicted injury, battered states, psychiatric disease, and drug and alcohol usage.

Determine tetanus immunization status. List current medications (especially anticoagulants) and any medication allergies.

Clinical Assessment

Evaluate the patient's general condition, focusing on airway, neurological function, and circulation. Shear lacerations are caused by sharp objects and cause very little injury to the surrounding tissues. Tension lacerations are caused by skin striking a flat surface and ripping, which causes ragged edges. Compression lacerations occur over bony parts of the body when it strikes a blunt surface (e.g., a skull striking pavement). Combination lacerations have multiple characteristics of shear, tension, and compression injuries. Determine depth of wound and any loss of function. The deeper

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the wound the more likely function will be impaired. Determine whether tendons and nerves distal to the injury are intact.

Management:

Administer Tetanus prophylaxis as necessary. If the wound is less than 12 hours old it usually can be closed safely. Wounds more than 12 hours old should be cleansed, irrigated, and dressed with sterile dressing. Arrangements can be made for delayed primary closure in 48 hours. If a previously closed wound is infected, it should be opened by suture removal and cultured. Appropriate antibiotics should be initiated:

First-line antibiotic could be Cephalexin (Keflex) 250-500 mg q.i.d. x 7-l0 d In case of penicillin allergy, use erythromycin 250-500 mg q.i.d. x 7-l0 d

Obtain homeostasis with direct pressure. Anesthetize the wound by local infiltration with Lidocaine with epinephrine, or perform digital block with Lidocaine without epinephrine. Never use epinephrine on fingers, toes, penis, nose, or ears.

Cleanse the wound with mild soap and water. Soaking is almost never appropriate. Irrigation with 500-1,000 ml sterile normal saline is very effective in diluting contaminants and removing debris from a wound. Forceps can be used to remove particles. Devitalized tissue should be sharply debrided, including ragged skin edges.

Using sterile technique, prep the surrounding skin with 1% povidone iodine solution. Drape and suture with 4-0 or 5-0 nylon for trunk, scalp, and extremity wounds; use 5-0, or preferably, 6-0 nylon for facial and hand wounds. When using simple interrupted cuticular sutures, remember to enter the skin at a 90 degree angle as far away from the laceration edge as the laceration is deep (usually the skin thickness or more). After closure, cleanse away povidone solution with sterile water or saline. Apply sterile dressing. Minimize range of motion over joints as appropriate.

Communication with employer

• Notify the employer of work restrictions to initiate the return-to-work

process and facilitate temporary alternate work assignments.

• Notify employer of referrals with other physicians, return for follow-up appointments and, if appropriate, future diagnostic testing. The employer should be advised of future case management contact for patient status updates.

Patient Education

Give patient wound care instructions and review reportable signs and symptoms of infection. Instruct the patient to have sutures removed:

• On face: 4-5 days. • On scalp: 5-7 days. • On arms, legs, hands, back, shoulders: 7-10 days.

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Outcome

• Over extensor surfaces: 14 or more days. • Care Manager to call patient to discuss wound status per protocol. • Care Manager to remove sutures at the worksite when possible.

• Return to temporary alternative work day 1 with specific instructions to

protect the affected body part during job tasks. • No lost work time. • Total number of visits not to exceed two.

Indicators for this Standard

1. Documentation in the HPI of the mechanism and age of injury in detail. Compliance Standard is 98%.

2. Documentation of tetanus immunization status. Compliance Standard is 100%

3. Documentation of current medications (especially anticoagulants) and medication allergies.

Compliance Standard is 100% 4. Documentation of employer notification of work restrictions.

Compliance Standard is 100% 5. Documentation of Care Manager follow-up to call patient and discuss wound status

per protocol. Compliance Standard is 99%

6. The standard for documentation for the initial evaluation of patients with a diagnosis of open would of the hand/finger shall include the cause of the injury.

Compliance Standard is 100% 7. Documentation of the ROM of the hand/affected finger

Compliance Standard is 99% 8. Documentation of the severity of the wound

Compliance Standard is 100% 9. Documentation of the cleanliness of the wound

Compliance Standard is 100% 10. Description of the dressing applied

Compliance Standard is 100% 11. The following conditions need careful monitoring and referral: Any deep laceration

or puncture wound over vital structure, or which compromise function, should be stabilized and sent to the Emergency Department. High-velocity injuries (such as with a nail gun) should be x-rayed to rule out bone involvement. If bone injury is present, refer to Orthopedics. Refer any tendon or deep involvement to Surgeon (or Orthopedics for hand injury). Refer any nerve injury to Surgeon or Hand Specialist.

Compliance Standard is 100% 12. Documentation of the RTW process and employer notification.

Compliance Standard is 100%