Home Health Blogger

Home Health Software: How good is your 'Quality Assurance' Program?

Posted by Melissa Cott on Sep 29, 2014

Does your 'Performance Improvement' program REALLY work?

Medicare requires that “The group of professional personnel meets frequently to advise the agency on professional issues, to participate in the evaluation of the agency’s program14-09-29-Performance-Improvement...” Your home health software should have an Incident Reporting System to document all incidences.  Then you should be demonstrating efforts to mitigate the incident (change in policy, employee training etc) and evaluate the effectiveness of the effort (as evidenced by same statistics after policy change, training etc.).  Collecting, studying and implementing changes to policies and procedures 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. did changes work?

...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.

Here's a good example of Performance Improvement in action...

Data collection

  • After hiring a new employee, Agency XYZ orients the new employee to the agency's incident reporting system.  The agency's policies and procedures clearly define what constitutes an incident, and how and when to report incidences.  One of the reportable incident types is 'patient falls', i.e. the employee must document the occurrance of a patient fall on the agency's Incident Form.
  • Over a given period, the agency receives six (14) incidences which relate to patient falls.
  • When the Professional Advisory Committee (PAC) meets, they discuss the occurrance of the patient falls.  From the documentation on the incident reports, the group determines that patients/caregiver need more teaching on basic home safety.

Policy and Procedure Change, Employee Training

  • The agency develops a new home safety training sheet for patients/caregivers and instructs all direct caregivers to reinforce the safety training tips at each visit.

Did Changes Work?

  • Over the next reporting period, the agency receives six (6) incidences related to patient falls.  Although there is a decrease in patient falls, the PAC determines that certain patients, those with mobility deficits, still have an increased incidence of falls. 
  • The group determines that patients with mobility deficits should have a physical therapy evaluation.


The cycle of data collection, policy changes and re-evaluation never ends.

Performance improvement never 'ends'.  You should always be collecting data, and then refining your policies and procedures.

Examples of events that should be reported and monitored as incidences

  • direct exposure to patient body fluid including needlestick(s)
  • equipment maintenance and/or operational problems
  • error(s) in medication administration, dosage, route, frequency
  • error(s) in treatment
  • errors in documentation/reporting
  • failure of patient education material
  • fire or utility hazard
  • hazardous waste management violation
  • inadequate Agency and/or community resources
  • inadequate supplies
  • missing medical records
  • patient or employee injury during care
  • scheduling error(s)
  • significant side effect(s) associated with medication
  • significant side effect(s) associated with treatment
  • violation of patient confidentiality, privacy, or security
  • workplace safety violation


MyHomecareBiz provides daily Best Practice training classes for our users, including training and support for implementation and Performance Improvement.

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