Agenda - 03-13-2007-9c - Laserfiche WebLink

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43 The Quality Improvement/Provider Relations Department, in collaboration with the AQMC, fulfills the following quality management functions, which are included in the ME's Quality Management Plan: Oversees a comprehensive qualitative monitoring system that incorporates any or all of the following: • data from consumer satisfaction surveys. • reports related to accreditation and/or licensure and applicable self-reporting requirements. • reports related to service access and timeliness of treatment. • reports from external reviews by agencies responsible for system oversight. • results of monitorings, including local, CAP, ar%tl~,=,endorsement site visits. • feedback from consumers and families"'related to participation in treatment planning. _ ~~ • issues identified through community collaboration and needs assessments. • issues related to best practice standards and other, applicable standards of clinical practice • review of personal and aggregate outcomes' <.to guide recommendations for clinical decision-making and policy development. `'°~`'~' ., • identification, documentation, reporting and investigation' of individual incidents and complaints as well as any identified aggregate trends. Additionally, the Quality Management Department is~ responsible to: • Oversee/monitor risk management function to include review of .incidents, complaints and appeals, use of restrictive interventions, and any changes or events ...which could have an impact on continued service provision, and the repai=fing.of such events to appropriate authorities. • Oversee the review, revision, and distribution of applicable policy ~ and /procedures. ~'~ Monitor the implementation of a client rights program that ensures the health, safety'and welfare';of~ all persons served, protects the rights of consumers, and maximizes,the opportunity for stakeholder input and timely response to individual complaints,~'and/or,,appeals. • Facilitate \and°>er'isure CFAC involvement in the LME's quality improvement process. ~,.'~~ • Monitor the implementation of a utilization review system that ensures continuity of care, establishment of best practice guidelines, equitable distribution of funding, and an effective and efficient use of available resources. Incident Review and Reporting The Client Rights Coordinator manages the LME's Incident Reporting and Review function. This staff member is responsible for reviewing all reported incidents and 43