Quality Assurance and Patient Safety
Quality Compliance Department
Swope Health Services demonstrates its commitment to providing the highest quality of care to patients through the implementation of its Quality Department. The quality compliance department is a distinct unit within SHS with primary responsibilities in four key areas: patient safety, risk management, quality assurance and regulatory affairs.
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Services Provided
- Facilitation of Performance Improvement Committee
- Implementation of Patient Safety program including:
- Incident Reporting
- Root Cause Analysis
- Failure Mode and Effects Analysis
- National Patient Safety Goals
- Education and Awareness
- Coordination of quality and performance improvement initiatives
- Quality Reviews or Morbidity and Mortality reviews
- Quality indicator monitoring, benchmarking and reporting to regulatory entities
- Coordination of Joint Commission and other regulatory compliance
- Management of Infection Control Processes
- Clinical data analysis
- Technical support and education on quality and patient safety issues
- Policy and Procedure development and oversight
- Risk assessment
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Clinical Quality
The Bureau of Primary Healthcare, the Federal Administrator of Health Care Programs for Health Resources and Services Administration (HRSA), has developed a partnership with the Joint Commission that encourages Federally Qualified Health Centers (FQHCs) to align themselves with Joint Commission standards of care and administration. They have established standardized measures of quality in select patient populations including diabetes, asthma and cardiovascular disease.
Click here to see the data on clinical outcomes for Federally Qualified Health Centers.
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Performance Improvement
The Swope Health Services Performance Improvement process utilizes an interdisciplinary approach with a patient safety, customer-service focus. Emphasis is on process and system improvements with the initiation of action when an opportunity for improvement is identified. An integrated approach is used to improve outcomes and sustain achievements.
As we go about creating change in our organization, there are a few questions that naturally arise:
- How will you know which changes worked and which did not?
- How will you know which changes resulted in an improvement?
- Which change(s) is the most important and resulted in the most significant improvement?
Therefore, it is essential that we establish a system that permits us to answer these questions.
Swope Health Services has adopted the Plan-Do-Check-Act (PDCA) model for Performance Improvement initiatives. This model provides a consistent problem solving approach for all Performance Improvement activities. Only when effective quality planning, process design, performance measurement, and performance improvement activities are integrated does the organization’s performance improvement initiative become integrated into the organization’s culture.
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