CARE AMBULANCE SERVICES, INC. (2)

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5. Receive reports from Quality Sub -Committee, if any, 6. Discuss changes needed to indicators. 7. Recommend the chartering of Quality Sub -Committee, if any. 8. Provide Input to the Ql Committee from the Strategic Plan. 9. Summarize action items identified at this meeting. 10. Recommend trainingleducational needs. 11. Evaluation of the meeting. Section IV, Action to Improve A. (Ince a need for improvement in performance has been identified by the TAG, Care Ambulance Service will be utilizing the FOCUS-PDSA model for performance improvement. FOCUS-PDSA involves the following steps: 1. Find a process to improve — the TAG will identify improvement needs. 2. Organize a team that knows the process — the QI Committee will form QI Sub -Committees) as needed and review process documents. 3. Clarify current knowledge of the process — review indicator trends relevant to the process, collect other Information 4. Understand causes of process variation utilizing tools such as fishbone diagrams, Pareto analyses, etc. 5. Select process improvement to reduce or eliminate cause(s). 6. Plan — State objective of the test, make predictions, Develop pian to carry out the test (who, what where, when) 7. Do - Carry out the test, document problems and unexpected observations, begin analysis of the data 8. Study - Complete the analysis of the data, compare the test data to predictions, and summarize what was learned 9. Act - What changes are to be institutionalized? What will be the objective of the next cycle? What, if any, re-education or training Is needed to effect the changes? Once a Performance Improvement Plan has been implemented, the results of the improvement plan will be measured. Changes to the system will be standardized and/or integrated. A plan for monitoring future activities will be established. B. During its Bi -Annual or other meetings, the QI Committee will identify indicators that signal a need for improvement and make recommendations for chartering a QI Sub - Committee, if needed. The QI Committee will select members and charter the Task Force with a specific objective for improvement. Each Task Force will use the FOCUS-PDSA model to conduct improvement planning and prepare recommendations or a report for review by the QI Committee. The QI Committee will modify or accept and implement recommendations of the QI Sub -Committee and prepare the report for distribution to the TAG. The QI Committee will also disband the Quality Task Force at the appropriate time. Notify the Departments and Employees Manager of CWQI will put together a department task force to plan and implement the indicator under review. If the indicator is a clinician documentation improvement issue, 12