Health Plan, Inc.

Quality Improvement Policy & Procedure Subject: QI Program Description Line of

Business (check all that apply) Effective Date: x Commercial: FI x; SF x; Review Date: x Medicaid Next
Review Date: x Medicare Document Number: Page: 1 of 2

I. SCOPE:

Health Plan will maintain a written Quality Improvement Program Description which outlines the QI
program structure and content, encompassing relevant aspects of health care delivery and service
provided to members through Health Plan and its affiliated health personnel.

II. POLICY:

The purpose of the Quality Improvement Program is to promote accountability for the quality of health
care delivery and service. This is accomplished through a systematic approach of assessing, defining
interventions, implementing, and evaluating effectiveness of interventions with the goal of continuous
improvement of clinical care and service. The Quality Improvement Program is supported by a
committee structure that establishes accountability to the Board of Directors of Health Plan Inc. and
allows for information flow to and from the Board and affiliated health plan personnel.

III. PROCEDURE:

A. The QI Program description is developed by the Health Plan Quality Improvement workgroup in
collaboration with the Medical Director. The program description includes the following:

Scope Goals and Objectives, including integration of public health goals Role, structure and function of
all involved committees Quality of care and service activities Delegated activities Staffing/resources
which support the program Confidentiality

B. The program description is approved by the QI/UM Committee, Quality Council, Plan Oversight
Committee, and the Board of Directors on an annual basis.

C. The program description is evaluated by the QI/UM Committee, Quality Council, Plan Oversight
Committee and Board of Directors annually and updated as necessary.

D. The members of the Quality Council are responsible for ensuring the dissemination of the QI Program
Description to appropriate plan staff within their respective service area.

Policy Title: Continuous Quality Improvement Policy and Procedures Last Reviewed: 2/2015

SECTION 1.0 POLICY STATEMENT, PURPOSE and SCOPE

Sec. 1.1 Policy statement

Tarrant County Public Health is committed to continuously improving all aspects of its operations by
systematically evaluating the quality of the programs and processes to deliver high quality services to
the communities we serve.

Sec. 1.2 Purpose

Continuous Quality Improvement (CQI) in public health is the use of a deliberate and defined
improvement process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to
community needs and improving population health.

It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency,
effectiveness, performance, accountability, outcomes, and other indicators of quality in services or
processes which achieve equity and improve the health of the community.

Tarrant County Public Health (TCPH) CQI initiatives consist of two parts; the overall policy and the CQI
plan. The policy states the importance of continuously improving quality in services and the way TCPH
conducts processes. The implementation plan contains the procedures or basic guide on how TCPH will
manage, deploy, and review quality throughout the organization. The main focus is on how TCPH will
work through the process of quality improvement at an overall department wide level as well as specific
program levels.

Sec. 1.3 Scope and Periodicity

The Performance Management (PM)\ CQI Core Team is tasked with developing the annual CQI plan,
with guidance from the Leadership Team (LT). They will also assist in implementing CQI methodology
throughout the organization. The PM\CQI Core Team will oversee all aspects of the Performance
Management System (PMS) and establish the specific processes, schedules and reporting methods that
govern the creation and usage of the CQI plan.

All CQI committee members are responsible for conducting quality improvement activities. The CQI Plan
is a guidance document that informs everyone in the organization as to the direction, timeline, activities,
and importance of quality and quality improvement in the organization. The CQI Plan is a living
document and needs to be revised on a yearly basis to reflect accomplishments, lessons learned, and
changing organizational priorities.

This policy is to be reviewed annually by the PM\CQI Core Team with subsequent

Policy #: 2-20-2015-QUAL-OO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/2015

review (prior to submission for approval) by the Leadership Team. Once approved, this policy
supersedes any/all previous versions. However, the most recently approved version remains in effect, in
spite of declared periodicity, until a new version is approved by the Public Health Director.

SECTION 2.0 QUALITY IMPROVEMENT PROCEDURES

Sec. 2.1 CQI Leadership and Committee

CQI identifies and reduces risk to TCPH and clients; evaluates performance; measures progress towards
goals; improves client outcome; and is required by funding agencies. In order to incorporate CQI into the
structure of TCPH, it is important that an environment exists that enables the initiation, growth, and
continuity of quality activities.

Sec. 2.1.1 CQI Leadership

The key to the success of the CQI process is leadership. CQI requires top management to be actively
involved to ensure oversight, coordination, delegation of roles and responsibilities, and accountability.

1. The Director charges the CQI Committee, at the beginning of the year, with carrying out the purpose
and scope of CQI projects at TCPH.

2. The Leadership Team will review, evaluate and approve the CQI plan annually.

3. The Leadership Team will support and guide implementation of quality improvement activities.

4. The Leadership Team will schedule the CQI Chair to report quarterly at one of the Leadership
meetings.

5. The Director will share quality improvement activities with the Commissioner's Court at least once per
year as a means of reporting and seeking input into ongoing quality management initiatives.

6. The Director, Medical Director, Associate Directors, and Division/Program Managers will attend and
participate in the final CQI meeting in November and any other meetings when available.

Policy#: 2-20-2015-QUAL-OO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/2015

TCPH Leadership Team

Director Medical Director

Associate Director for

Associate Director for Community

Environmental Health and Disease Control

Health Promotion

Associate Director for Prevention

Business Manager

and Public Health Planning

Sec. 2.1.2 CQI Committee and Rotation

The CQI committee is responsible for conducting quality improvement activities and for promoting,
training, challenging and empowering TCPH employees to participate in the CQI process.

1. The CQI Committee will consist of approximately 20 members, representing all division and program
areas and a cross-section of each level of the organizational chart, including administration, division
managers, program managers and program staff.

2. Members will serve on the CQI Committee a minimum of two years, acknowledging that in some
cases, the primary staff for a program maybe one or two employees who work directly with the program
area; if for some reason the CQI Committee member cannot attend the meetings an alternate should be
identified by their manager and/or supervisor.

3. Ad hoc members (representing Compliance Officer, Public Information, Health Equity, Workforce
Development, and the Delivery System Reform Incentive Payment (DSRIP) will engage in CQI activities
on an as-needed basis.

4. The CQI Committee meets bimonthly (every other month) and consists of at least one representative
from every division/program.

Policy#: 2-20-2015-QUAL-OO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/2015

Continuous Quality Improvement Committee Officers and Members

Chairperson Health Informatics

Co-Chairperson HIV Administration

Laboratory

Leadership Representative

Planning and Policy

Adult Health Services Preventive Medical Clinic Customer Services I Fiscal Public Health Preparedness
Services Chronic Disease Prevention Travel Health

Community Health Promotion (Immunizations, Nurse Family Tuberculosis Control Partnership, and
BCCCP)

Environmental Health Women Infants and Children Epidemiology Ad-Hoc Members

Policy#: 2-20-2015-QUAL-OO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/201 5

Sec. 2.2 Roles and Responsibilities

Sec. 2.2.1. TCPH Leadership Roles and Responsibilities

TCPH Leadership Roles and Responsibilities

Provide leadership for the department CQI vision, mission, strategic plan and direction.

Within available funding, assure all the staff has access to resources to carry out CQI projects and
training.

Advocate for a culture of CQI, as well as including quality in messages and presentations to staff, internal
and external partners.
Promote a CQI environment (learning environment) for the department.

Apply CQI principles and tools to daily work.

Participate in ongoing CQI training.

Policy#: 2-20-2015-QUAL-GO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/2015

Sec. 2.2.2 Division/Program Managers Roles and Responsibilities

Division/Program Managers Roles and Responsibilities 1. Facilitate the implementation of CQI activities
at the Division level.

2. Identify a staff member and alternate to serve on the CQI Committee.

3. Support CQI representatives in their work with CQI activities.

4. Document CQI efforts.

5. Provide feedback to shape annual CQI Plan.

6. Participate in CQI project activities as requested or as required.

7. Facilitate the development of CQI projects.

8. Provide the CQI Committee with opportunities to share quality improvement efforts.

9. Apply quality improvement principles and tools to daily work.

10. Communicate regularly with Director and CQI Committee to share successes and lessons learned.

11. Participate in the development of CQI projects.

12. Participate in ongoing CQI training.

Policy#: 2-20-2015-QUAL-OO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/2015

Sec. 2.2.3 CQI Co-Chairpersons Roles and Responsibilities

CQI Chair and Co-Chairs Roles and Responsibilities

The Chair and Co-Chair will be selected for a two-year term with a staggered rotation. At least one
member in the leadership roles (Chair or Co-Chair) must work in an area that services clients.

Coordinate, support, guide and define the overall continuous quality improvement program department
wide.

Develop and manage all aspects of the annual quality improvement plan with input from CQI Committee
and Leadership.
Assist CQI Committee in addressing problems encountered by project teams.

Provide quarterly briefing updates to Director.

Facilitate CQI meetings.

Integrate continuous quality improvement principles in TCPH policies/protocols (e.g. hiring;

performance review; documentation).

Assist continuous quality improvement projects at Director, Division and Proqram level. Document all
continuous quality improvement related activities.

Ensure communication of continuous quality improvement project results.

Ensure continuous Quality Improvement Plan meets accreditation requirements.

Implement other strategies to develop culture of continuous quality improvement. Apply quality
improvement principles and tools to daily work.

Facilitate the development of ongoing staff training through the formation and chairing of a training
sub-committee made up of CQI members.

Policy#: 2-20-2015-QUAL-OO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/2015

Sec. 2.2.4. PM\CQI Core Team

The PM\CQI Core Team will consist of seven members: Performance Management Chair, CQI Chair, CQI
Co-Chair, Administrative support staff, and three current CQI Committee members. The selection of CQI
Committee members to serve on the CQI Core Group is selected at the discretion of the CQI Chair and
Co-Chair. Tenure will be a minimum of one year.

CQI Core Team Roles and Responsibilities

Review & revise the PM plan, CQI Plan & CQI Policy and project documentation

at least annually or as needed.

Develop and provide annual CQI training for the department as per accreditation.

Coordinate CQI bi-monthly meetings.

Provide guidance and support for all CQI projects.

Review and monitor all project documentation and training requirements.

Coordinate CQI Health Quality Week activities.

Develop and submit the Year end PM/CQI Summary Report to LT.

Sec. 2.2.5. CQI Committee Members

The CQI Committee will guide and evaluate quality improvement efforts. Each program/division is
responsible for having two representatives to serve on the CQI Committee. CQI Committee members
will make every effort to come to consensus on issues requiring a decision. However, if consensus
cannot lbe reached, decisions will be made by majority vote. The CQI Committee is responsible for
carrying out quality improvement efforts at TCPH. Members should expect to carry out the following
roles and responsibilities.

Policy #: 2-20-2015-QUAL-GO Policy Title: Continuous Quality Improvement Policy and Procedures Last
Reviewed: 2/2015

CQI Member's Roles and Responsibilities

Provide CQI expertise and guidance for project teams.

Serve a two-year term based on a calendar year.

Participate and facilitate continuous ongoing staff training, including department wide meetinos and
division/prooram staff meetinos. Attend regular bi-monthly meetings.

Prepare to meet local health department accreditation standards related to CQI.

Sec. 2.2.6 TCPH Staff Roles and Responsibilities

All TCPH Staff/ Employees Roles and Responsibilities

Participate in ongoing CQI activities.

Apply CQI principles/ tools to daily work.

Program managers will work with staff to identify program areas for improvement and suggest
improvement actions to address identified projects.

Participate in ongoing staff training.

Title of Policy and Procedures: Continuous Quality Improvement (CQI) Policy

Policy Number: 2-20-2015-QUAL-OO

Number of Attachments: Q

Area(s) and Employees: Department Wide

APPROVAL

This Tarrant County Public Health Policy and Procedures document has been reviewed and
Cordova Community Medical Center Continuous Quality Improvement Plan

Cordova Community Medical Center is dedicated to providing quality healthcare consistent with the
hospital mission. Our goal is to provide delivery of services that are: Safe, effective, patient- centered,
efficient and equitable.

To achieve this goal, all employees of our hospital will participate in ongoing quality improvement
efforts.

The QI Plan outlines the goals and strategies for ensuring patient safety, delivering optimal care, and
achieving high patient satisfaction.

Authority:

The Health Services Board of CCMC is ultimately responsible for ensuring high quality care is provided to
our patients. The Board delegates the responsibility for implementing this plan to the
CEO/Administrator. The CEO/Administrator is responsible to delegate quality management efforts for
the entire facility to all staff through the quality management committee.

Quality Management Committee:

The Quality Management Committee consists of the following individuals: The CEO, Chief of
Staff/designee, Department Managers as well as the CFO.

The members of the QMC are responsible for:

Ensuring that the review functions for each department and sub-committee are completed
Prioritizing issues referred to the QMC for review Ensuring that data obtained through QI activities are
analyzed, recommendations made, and appropriate follow up of problem resolution is done.

The QMC is further broken down in to sub-committees that will meet quarterly or more often as
necessary.
The sub-committees are responsible for policy and procedure review and development as well as
utilization review activities.

1. Fire/Safety/Disaster: This committee shall include but is not limited to representatives from
Environmental Services/Maintenance, Nursing and Administration. This committee is responsible for
providing and maintaining a safe work and care environment and maintaining a disaster plan and
provide training.

2. Infection Control/Employee Health: This committee is required to meet on a quarterly basis and shall
include but is not limited to the Infection Control Coordinator, the Director of Nursing

or designee, the Employee Health Nurse, a Medical Provider a representative from Laboratory,
Environmental Services/Maintenance, Dietary and Administration. This committee is responsible for
staff training and monitoring the infection control system facility wide.

3. Medical Staff: This group includes all members of the medical staff, the Director of Nursing, the HIM
Director, and the Administrator. This group is responsible for ensuring the quality of patient care
through monitoring and evaluating performance and outcomes, in accordance with established medical
staff bylaws and rules and regulations.

4. Pharmacy and Therapeutics: This consists of all members of the Medical Staff, the Administrator, the
Director of Nursing, the Consulting Pharmacist, and the Pharmacy Technician. This committee is
responsible for formulary revision and maintenance, reporting of adverse drug reactions and evaluation
of proper medication usage.

5. Utilization Review: At this time, the QMC is responsible for UR until further notice.

6. Management Information: At this time, the QMC is responsible for MI until further notice.

7. Corporate Compliance: The Compliance Coordinator oversees compliance with the Code of Conduct
and serves as the contact person for any reporting matters that suggest violations of compliance
policies, regulations, or statutes. The Coordinator assesses CCMC’s policies and procedures that address
areas of compliance and ensures CCMC employees understand those policies and the Code of Conduct
through a regular training program. The Compliance Coordinator reports to the Quality Management
Committee on a quarterly basis or more often if necessary.

Quality Improvement Processes and Methodology:

The continuous Quality Improvement plan is a framework for the organized, ongoing and systematic
measurement, assessment and performance improvement activities. The components of this plan
include a quick-fix process that will be used for problems that do not need a comprehensive approach to
problem solving and solution implementation.

Quality improvement teams may be necessary to look at particular issues to identify opportunities to
improve processes and outcomes.

QMC report provides summary data prepared for the board through the CEO/Administrator on a
quarterly basis.

The quality improvement methodology we will use is: PACE

Plan: Opportunity for Improvement. What is the planned Improvement?

Act: What did you do to improve the process? Check: What did you learn? Were improvements
realized?

Enhance: What are the next steps to further improve the process?

Department and Staff Responsibility:

Every department within Cordova Community Medical Center is responsible for implementing quality
improvement activities. All quality improvement initiatives must be conducted as a part of the hospital
wide QMC activities. Each department manager is responsible for identifying quality indicators,
collecting and analyzing data, developing and implementing changes to improve service delivery,
identifying educational needs and ensuring that staff education for quality improvement takes place and
monitoring to assure that improvement is made and sustained. Each department will monitor utilization
of their department’s services and will report utilization review activities to the QMC. The ultimate goal
is to improve the quality of care that is routinely provided to the patients and residents of CCMC.

Network Hospital Responsibility:

Our Hospital is a member of ASHSNA and Alaska Regional Hospital is our network hospital. They are
available to CCMC as needed in our quality improvement activities.

Confidentiality:
The interviews, reports, statements, other data, proceedings and records of the Quality Improvement
Committee shall be privileged and confidential and shall not be subject to discovery either by subpoena
or other means of legal compulsion for release to any person or entity for any reason, including use in
any judicial or administrative proceeding.

No member, consultant, advisor or person supplying information to the Quality Improvement

Committee or sub-committee(s) shall disclose information concerning matters submitted to, consider