Appendix C - HSWLSCTD 2018-013_QIFG.pdf

DISTRIBUTION – SDL No. 168 a b c d e f g h i j k l m n o p q r s t u v w x y z

A B C D E F G H

NON-STANDARD DISTRIBUTION:

Commanding Officer United States Coast Guard Health, Safety, and Work-Life Service Center

300 E. Main Street Suite 1000 Norfolk, Va. 23510-9109 Staff Symbol: (h) Phone: (757) 628-4787

HSWLSCTD 2018-013

HEALTH, SAFETY AND WORK-LIFE SERVICE CENTER TECHNICAL DIRECTIVE 2018-013

Subj: QUALITY IMPROVEMENT FOCUS GROUP (QIFG)

Ref: (a) Coast Guard Medical Manual, COMDTINST M6000.1 (series)

1. PURPOSE. This Technical Directive (TD) issued by the Health, Safety, and Work-Life Service Center (HSWL SC) addresses the roles and responsibilities, procedures, and guidelines for the Quality Improvement Focus Group (QIFG).

2. ACTION. This TD applies to all the HSWL SC organizational elements at all types of Coast Guard (CG) units. HSWL SC retains the authority to provide technical direction over all HSWL SC organizational elements. This TD is used to clarify policy that falls under the responsibilities and authorities of the HSWL SC. Internet release is authorized.

3. DIRECTIVES AFFECTED. Quality Improvement Implementation Guides 17 and 42 are cancelled.

4. BACKGROUND. Ref (a) requires CG medical clinics with medical and dental officers assigned to establish a QIFG to discuss and monitor the quality of health care provided at each clinic within the region and coordinate activities required to ensure quality improvement. The clinic QIFG will meet quarterly. Regional Managers (RM) will convene a Regional Practice QIFG once a year with all the RP clinics.

a. The provisions of this TD are intended to ensure all QIFGs are completed and documented with established protocols identified through an organized and effective manner.

b. The QIFG at the local level shall consist of all clinic staff to a maximum of 15 members, depending on unit size, including both enlisted members and officers who broadly represent the health care services provided at that unit. The QIFG quorum is composed of but not limited to a medical officer, dental officer, health services administrator (HSA), and department

12 December 2018

HSWLSCTD 2018-013

representatives from pharmacy, x-ray, laboratory, etc. The Chairperson will be the Health Services QI Coordinator.

c. Regional Practice QIFG meetings will be facilitated by the RM or designee and minutes will be forwarded/uploaded to the HSWL SC QI Share Point Site on the CG Portal. Attendance should include Regional Practice leadership and each clinic Health Services QI Coordinator, Senior Health Service Officer (SHSO), and HSA. (Enclosures 1-3).

5. DISCLAIMER. This guidance is not a substitute for applicable legal guidance, nor is it itself a rule.

It is intended to provide operational guidance for CG personnel and is not intended to nor does it impose legally-binding requirements on any party outside the CG.

6. MAJOR CHANGES. None.

7. ENVIRONMENTAL ASPECT AND IMPACT CONSIDERATIONS.

a. The development of this TD and the general policies contained within it have been thoroughly reviewed by the originating office in conjunction with the Office of Environmental Management, and are categorically excluded (CE) under current USCG CE #33 from further environmental analysis, in accordance with Section 2.B.2 and Figure 2-1 of the National Environmental Policy Act Implementing Procedures and Policy for Considering Environmental Impacts, COMDTINST M16475.1 (series).

b. This TD will not have any of the following: significant cumulative impacts on the human environment; substantial controversy or substantial change to existing environmental conditions;

or inconsistencies with any Federal, State, or local laws or administrative determinations relating to the environment. All future specific actions resulting from the general policies in this TD must be individually evaluated for compliance with the National Environmental Policy Act (NEPA), Council on Environmental Policy NEPA Regulations at 40 CFR Parts 1500-1508, DHS and CG NEPA policy, and compliance with all other environmental mandates.

8. DISTRIBUTION. No paper distribution will be made of this TD. An electronic version will be located on the CGPortal: https://cgportal2.uscg.mil/units/hswlsc/SitePages/Unit%20Directives.aspx.

9. PROCEDURE. See Enclosures.

10. RECORDS MANAGEMENT CONSIDERATIONS. This TD has been thoroughly reviewed during the directives clearance process and it has been determined there are no further records scheduling requirements, in accordance with Federal Records Act, 44 U.S.C. 3101 et seq., National Archives and Records Administration (NARA) requirements, and the Information and Life Cycle Management Manual, COMDTINST M5212.12 (series). This policy does not have any significant or substantial changes to existing records management requirements.

11. FORMS/REPORTS. None

HSWLSCTD 2018-013

12. REQUEST FOR CHANGES. Recommendations for improvements to this TD are encouraged and should be submitted to HSWL SC (om); 300 East Main Street; Suite 1000; Norfolk, VA 23510- 9109.

A. E. KOVAC /s/ Captain, U.S. Coast Guard Coast Guard Health Safety and Work-Life Service Center

Encl: (1) Quality Improvement Focus Group Standard Operating Procedure (SOP)

(2) QIFG Minutes Recommended Format

(3) QA Calendar Recommended Format

Enclosure (1) to HSWLSCTD 2018-013

Quality Improvement Focus Group (QIFG)

I. Introduction.

The QIFG oversees all Quality Improvement (QI) activities and ensures that an effective health services QI program is operational at the unit and region. If desired, the QIFG at small units may operate as a “Committee of the Whole” of all staff members. It is still required that the small units still participate as part of the Regional Practice.

II. Roles and Responsibilities.

A. Health, Safety and Work-Life Service Center (HSWL SC).

1. Review QIFG TD annually and update as needed.

2. Review QIFG minutes regularly to identify trends, assess needs across the CG health services system, and develop solutions to resolve issues.

B. Health Services QI Coordinator.

1. Health Services Administrators (HSAs) are required to appoint in writing a Health Services Quality Improvement Coordinator (HSQIC). Responsibility of the HSQIC includes:

a. Implementing the local health care QI program,

b. Identifying and coordinating resolution of health care QI problems,

c. Reporting, evaluating, and monitoring of Patient Event Reporting Template

(PERT),

d. Designing and implementing Quality Improvement Studies (QISs).

2. Qualifications will include:

a. Each assigned individual will undergo initial training on Joint Knowledge Online (JKO) to ensure that they have base line knowledge of QI activities.

b. Previous experience as a QI Coordinator or Assistant QI Coordinator recommended, but it is not required.

c. Annual training required through the external accreditation webinars held annually as part of the CG contract for health care facility accreditation.

3. Training Requirements.

a. Initial training.

i. On Joint Knowledge Online (JKO). Course recommendations will be posted on the HSWL SC QI Coordinator Share Point site:

https://cg.portal.uscg.mil/units/hswlsc/hswl-service-center-quality-improvement-site/Quality%20Coordinator%20Site/Forms/AllItems.aspx

ii. Self-Paced training on the HSWL SC QI Coordinator Share Point site.

b. Annual (by contracted External Accreditation Agency).

i. Webinars (three held annually on various topics during contract year from April to April).

ii. Face to Face (held if funding allows). If a face to face annual training is arranged, webinars will not be held and the substitution will be disseminated as an appropriate substitute by the Contracting Officers Representative (COR) of the External Accreditation contract.

c. Optional training on JKO or other platforms as defined by the HSWL SC.

4. Directs activities of the Health Services QIFG locally by drafting the agenda, scheduling and chairing the meetings.

5. Attends and participates in the regional QIFG meeting.

6. Appoints health services staff members to serve on the local Health Services QIFG.

7. Forwards/uploads copies of the local QIFG meeting minutes to the HSWL SC QI Share Point Site under the appropriate clinic and/or regional practice. See Enclosure (2) for the proper format.

8. Develops and promulgates an annual Quality Assurance (QA) Calendar (Enclosure 3) which sets the agenda for all activities at the unit, including among other activities QIFG meetings and all QISs. See Enclosure (3) for a calendar example.

9. Responsible for training clinic staff regarding quality issues, the Healthcare Process Assessment Program (HPAP) & the currently contracted external accreditation agency standards and guidelines.

10. Acts as an advisor to the Senior Health Services Officer (SHSO) in coordination with the HSA.

11. Ensures all required health services committee meetings are held according to the provisions of Ref (a), HSWL SC standard operating procedures and operational guides, and local instructions.

C. QIFG Members.

1. Encourage reporting of QI/ QA issues by fostering a non-punitive learning environment which will engender a proactive versus reactive stance in identifying and resolving quality of healthcare delivery issues. The SHSO may delegate investigating and resolving a particular QI problem to the staff member responsible for the clinical area where the problem has been identified (e.g. Laboratory, Patient Reception).

2. Use existing CG and external accreditation standards, PERT submissions, HSWL SC self-assessment checklists, and QIS to review and evaluate the quality of services delivered.

3. Perform systematic, documented reviews of health records for compliance and adherence to CG Medical Manual, currently contracted external accreditation agency standards and HSWL SC standard operating procedures, health and safety support program guides, self-assessment checklists, and Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements.

4. Solicit and monitor patient perceptions and satisfaction by surveys and questionnaires.

Reports negative trends and potential solutions to the HSWL SC as a part of the QIFG meeting minutes. Reports positive trends with ways to replicate such results as well.

5. Assist in obtaining and maintaining standards compliance necessary to achieve external accreditation with the contracted external accreditation agency.

6. Provide guidance to QIS investigators and other members of the staff involved in implementing QISs. On-going QISs are discussed in QIFG meetings and documented in their minutes.

D. Documentation.

1. QIFG meeting minutes are electronically forwarded to committee members for approval within two weeks from the date of the meeting. See Enclosure (2) for the meeting minutes format.

2. Approved meeting minutes both local and regional, shall be signed and retained for 5 years in the HSWL SC QI Share Point Site folder:

https://cg.portal.uscg.mil/units/hswlsc/hswl-service-center-quality-improvement-site/Home/Forms/AllItems.aspx

3. The QA Calendar can be modified to suit the capabilities of your clinic (i.e. remove spore monitoring if you do not have sterilization at your site). The QA Calendar is to track the clinic’s scheduled QI/QA activities. See Enclosure (3) for a sample calendar.

https://cg.portal.uscg.mil/units/hswlsc/hswl-service-center-quality-improvement-site/Home/Forms/AllItems.aspx https://cg.portal.uscg.mil/units/hswlsc/hswl-service-center-quality-improvement-site/Home/Forms/AllItems.aspx

4. The QA Calendar should be retained for 5 years in the HSWL SC QI Share Point Site folder: https://cg.portal.uscg.mil/units/hswlsc/hswl-service-center-quality-improvement-site/Home/Forms/AllItems.aspx

E. Frequency.

The clinic QIFG will meet quarterly. Regional Practice Managers will convene a Regional Practice QIFG once a year to identify common issues and best practices.

https://cg.portal.uscg.mil/units/hswlsc/hswl-service-center-quality-improvement-site/Home/Forms/AllItems.aspx https://cg.portal.uscg.mil/units/hswlsc/hswl-service-center-quality-improvement-site/Home/Forms/AllItems.aspx

Enclosure (2) to HSWLSCTD 2018-013

Commanding Officer U.S. Coast Guard Health, Safety & Work-Life Service Center

300 East Main Street, Suite 1000 Norfolk, VA 23510-9109 Staff Symbol: om Phone: (757) 628-4924 Fax: (757) 628-4337

03 March 2017

MEMORANDUM

From: Recorder

To: Regional Practice Manager (rpdxx)

Thru: (1) (2)

Subj: 1ST QUARTER FY18 REGIONAL QUALITY IMPROVEMENT FOCUS GROUP

(RQIFG) MEETING MINUTES

Ref: (a) Coast Guard Medical Manual, COMDTINST M6000.1F, Chapter 13

1. The RQIFG meeting convened 12 October 2018, 1330 hours.

2. Attendance. [ List by Clinic]

3. Review and acceptance of previous minutes.

4. Old Business.

a. Clinic/Department.

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

5. New Business.

a. Clinic/Department.

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

6. Recurring Business.

a. Quality Improvement Studies.

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

b. Quality Improvement Initiatives.

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

c. Patient Safety Issues/PERT Submission(s).

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

d. Patient Satisfaction Issues and Surveys.

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

e. Training.

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

7. Other Business.

(1) Item.

(a) Discussion.

(b) Action/Follow-Up.

(c) Open/Closed.

8. Adjournment Time.

9. Next Meeting.

Copy: RQIFG Attendees without attachments CGPORTAL Regional Practice QIFG folder

Enclosure (3) to HSWLSCTD 2018-013

FYXX QUALITY ASSURANCE CALENDAR - CLINIC NAME

P.O.C. (Name) MONTHLY ITEMS (place a check once completed for the month) OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

HEALTH RECORD REVIEW

DENTAL RECORD REVIEW

DENTAL RADIATION QUALITY CONTROL (QC)

MEDICAL RADIATION QC

SPORE MONITORING

MEDICAL LABORATORY QC

URGENT CARE INVENTORY

CONTROLLED SUBSTANCE INVENTORY

EXPIRED PRESCRIPTIONS

PHYSICIAN ASSISTANT CHART REVIEW

HEALTH SERVICES TECHNICIAN (HS) CHART

REVIEW / DESIGNATED SUPERVISING

MEDICAL OFFICER (DMOA)

IN-SERVICE TRAINING

QUARTERLY ITEMS (place the date once completed for the quarter) OCT - DEC JAN - MAR APR - JUN JUL - SEP

QUALITY IMPROVEMENT FOCUS GROUP MEETING (QIFG)

QUALITY IMPROVEMENT STUDIES (QIS)

DMOA RECORD REVIEW

PHARMACY AND THERAPEUTICS (P & T) MEETING

PATIENT ADVISORY COMMITTEE (PAC) MEETING

SEMI-ANNUAL ITEMS (place the date once completed with POC) OCT – MAR APR – SEP

MEDICAL EMERGENCY DRILL – MEDICAL SIDE

MEDICAL EMERGENCY DRILL – DENTAL SIDE

HEP B UPDATE, CLINIC PERSONNEL

PREVENTIVE MAINTENANCE LOG

ANNUAL ITEMS (place the date once completed with POC) OCT - SEP

HEALTH RECORD REVIEW TRAINING

SUICIDE THREAT TRAINING

FAMILY VIOLENCE TRAINING

MEDICAL PEER REVIEW COMPLETED

DENTAL PEER REVIEW COMPLETED

Enclosure (3) to HSWLSCTD 2018-013

SEXUAL ASSAULT MANAGEMENT TRAINING

MEDICAL EMERGENCY TRAINING

INFECTIOUS WASTE MGMT. TRAINING

SHARP INSTRUMENT PROTOCOL TRAINING

I.V. THERAPY TRAINING

PATIENT SENSITIVE/CONFIDENTIAL (HIPAA) TRAINING

HEALTH RECORD CUSTODY TRAINING

OSHA / SAFETY DATA SHEET (SDS) TRAINING

CPR TRAINING

RADIATION HAZARD FAMILIARIZATION

EQUIPMENT GROUND FAULT TESTING

PATIENT SATISFACTION SURVEY

SOP ANNUAL REVIEW, QIFG

SOP INDIVIDUAL READ, CLINIC PERSONNEL

C-SPINE / PATIENT TRANSPORT EQUIPMENT TRAINING

INFECTION CONTROL POLICY TRAINING