Quality
Does the service and care delivery of the organization reflect person-centered care resulting in enhanced participant outcomes and quality of life?
Community Person-Centered Care
4.1 – How does the organization align participant goals of care with care delivery?
4.2 – How does the organization evaluate the effectiveness of its care planning processes?
Quality Improvement
4.3 – How does the organization develop, implement, and leverage a data management and analysis system that promotes continuous quality improvement and a culture of quality?
4.4 – How does the organization engage stakeholders in quality improvement program activities and inform them of program results?
4.5 – How does the organization leverage a performance evaluation process inclusive of performance measurement and benchmarking to inform on performance improvement priorities?
Regulatory and Accreditation
4.6 – How does the organization communicate compliance program expectations to all staff and contractors to promote a culture of compliance?
4.7 – How does the organization leverage external accreditation, certification and other recognition programs to enhance its quality of care and services?
Participant Engagement and Satisfaction
4.8 – How does the organization solicit feedback from participants and leverage related data to improve care and services?
Clinical Effectiveness
4.9 – How does the organization ensure clinical practices and care delivery are current and evidence-based?
4.10 – How does the organization evaluate the effectiveness of care delivery?
Culture of Safety
4.11 – How does the organization implement a fair and just culture to improve patient safety and promote a culture of safety?
4.12 – How does the organization assess and respond to actual and potential adverse events?
PERFORMANCE MEASURES
- Participant Satisfaction (Engagement and Satisfaction)
- Percent of Care Plans with Documented Person-Centered Goals (Person-Centered/What Matters Most)*
- Days Living in the Community (Quality of Life)
- Fall Rate (Mobility/Outcomes)*
- Percent of Participants with Active Use of One or More Medications on Target List (Medication/Process)*
- Percent of Participants Immunized (Service Delivery/Process)
- Acute Hospitalization Rate Per 1,000 (Outcome)
- Rate of Emergency Department Visits Per 1,000 (Outcome)*
- Percentage of Participants Screened for Dementia (Mentation/Process)*