CHAP Compliance - Risk Management/Performance Improvement
CHAP & Medicare require that “The group of professional personnel meets frequently to advise the agency on professional issues, to participate in the evaluation of the agency’s program...” Using the MyHomecareBiz Incident Reporting System to document all incidences and then taking effort to mitigate the incident (change in policy, employee training etc) and evaluating the effectiveness of the effort (as evidenced by same statistics after policy change, training etc.) is an effective Performance Improvement Program and meets the criteria required by Medicare, JCAHO, CHAP and ACHC.
What is Performance Improvement (PI)
Your Performance Improvement Program is based on identifying and correcting problems. Problems in patient care are reported as “incidences”. When all incidences are reported and documented, employee training needs and/or policy and procedure changes are identified. The cycle of
1. data collection >
2. policy and procedure change, employee training >
3. incident occurrence after training, policy changes
...becomes the cycle of an ongoing and effective Performance Improvement Program. The MyHomecareBiz Incident Reporting System enables you to run reports that show trends in problems with patient care.
Plan on answering the following questions from an accreditation or regulatory surveyor regarding PI...
- How are hazardous wastes, such as sharps containers, handled at your office site? What is the process for removal and disposal of such waste?
- Storage and handling of hazardous wastes, if any, such as sharps containers
- Describe your organization's process for surveillance, identification, and reporting of infections. What do you consider reportable infections? Who is responsible for collecting and analyzing these data?
- What is a reportable accident or incident and what is the process?
- What is the Agency's safety and security plan for employees during and after Agency hours and in the patient's home?
Plan on the following documentation review from an accreditation or regulatory surveyor regarding PI...
- An incident-reporting system, including defined, specific criteria for the type(s) of accidents, injuries, and safety hazards to be reported; actual reports and documented investigations of accidents, injuries, and safety hazards
- Maintenance of fire detection and extinguishment equipment
- Definition of the scope and content of the infection control program
- Evidence of implementation of the infection-control program, including: data collection, aggregation and analysis of data, external reports
- Identification of the types of data to be collected as part of the infection-control program