Clinical Quality Systems Review. The QRO shall perform a Clinical Quality Systems Review to assess the effectiveness, reliability, and thoroughness of Parkland’s quality management infrastructure and systems throughout Parkland. The QRO shall assess Parkland’s efforts to achieve compliance with its Clinical Quality Policies and Procedures described in Section III.B.2.b-c, the Medicare Conditions of Participation, and other standards designed to ensure that the delivery of patient care items or services at Parkland meet professionally recognized standards of health care and are reasonable and appropriate to the needs of Federal health care program beneficiaries. The Clinical Quality Systems Review will be undertaken at all relevant levels of the organization. The QRO shall assess, among other things, the effectiveness, reliability, and thoroughness of the following: 1. Parkland’s quality management infrastructure, including but not limited to an assessment of: a. Parkland’s Quality of Care Dashboard required under section III.A.4.b. of this CIA; b. The accuracy of Parkland’s internal reports, data, and assessments required by the Clinical Quality Policies and Procedures; c. Xxxxxxxx’s ability to analyze outcome measures and other data; d. The extent to which reviews under Parkland’s Quality, Safety, and Performance Improvement Program and other reviews are occurring to identify and address quality management issues at Parkland; e. Parkland’s compliance with the Clinical Quality Training requirements, Clinical Quality Policies and Procedures, and performance standards of Section III.B.2.b–c & III.C.3 of the CIA; f. The extent to which Parkland’s Clinical Quality Training program is effective, thorough, and competency-based; g. The extent to which Parkland’s communication systems are effective and results of decisions are transmitted to the proper individuals in a timely fashion. 2. Xxxxxxxx’s response to quality of care issues, which shall include an assessment of: a. Xxxxxxxx’s ability to identify the problem; b. Xxxxxxxx’s ability to determine the scope of the problem (e.g., systemic or isolated); c. Xxxxxxxx’s ability to conduct a root cause analysis; d. Xxxxxxxx’s ability to create a corrective action plan to respond to the problem; e. Xxxxxxxx’s ability to execute the corrective action plan; f. Parkland’s ability to operate in a timely and effective manner; and g. Parkland’s ability to monitor and evaluate whether the assessment, corrective action plan, and execution of that plan were effective, reliable, thorough, and maintained. 3. Parkland’s proactive steps to ensure that each patient receives care in accordance with: a. professionally recognized standards of health care; b. the Conditions for Participation for Hospitals, 42 CFR Part 485; c. State and local statutes, regulations, and other directives or guidelines; d. the Policies and Procedures adopted by Parkland, including those implemented under Section III.B.2.b-c of this CIA; and e. professionally recognized standards of clinical staffing. 4. Parkland’s identification and response to Reportable Quality Events, as required by Section B of this Appendix D.
Appears in 2 contracts
Samples: Corporate Integrity Agreement, Corporate Integrity Agreement
Clinical Quality Systems Review. The QRO shall perform a Clinical Quality Systems Review to assess the effectiveness, reliability, and thoroughness of ParklandProvidence’s quality management infrastructure and systems throughout ParklandProvidence. The QRO shall assess ParklandProvidence’s efforts to achieve compliance with its Clinical Quality Policies and Procedures described in Section III.B.2.b-cIII.B, the Medicare Conditions of Participation, and other standards designed to ensure that the delivery of patient care items or services at Parkland Providence meet professionally recognized standards of health care and patient safety, and are reasonable and appropriate to the needs of Federal health care program beneficiaries. The Clinical Quality Systems Review will be undertaken at all relevant levels of the organization. The QRO shall assess, among other things, the effectiveness, reliability, and thoroughness of the following:
1. ParklandProvidence’s quality management infrastructure, including but not limited to an assessment of:
a. Parkland’s Quality of Care Dashboard required under section III.A.4.b. of this CIA;
b. The accuracy of ParklandProvidence’s internal reports, data, and assessments required by the Clinical Quality Policies and Procedures;
c. Xxxxxxxxb. Providence’s ability to analyze outcome measures and other data;
d. c. The extent to which reviews under ParklandProvidence’s Quality, Safety, Quality of Care and Performance Improvement Patient Safety Program and other reviews are occurring to identify and address quality management issues at ParklandProvidence;
e. Parklandd. Providence’s compliance with the Clinical Quality Training requirements, Clinical Quality Policies and Procedures, and performance standards of Section III.B.2.b–c & III.C.3 Section III.B of the CIA;
f. e. The extent to which ParklandProvidence’s Clinical Quality Training program is effective, thorough, and competency-based;based;
g. f. The extent to which ParklandProvidence’s communication systems are effective and results of decisions are transmitted to the proper individuals in a timely fashion.fashion;
g. The extent to which Providence has implemented an effective Quality of Care and Patient Safety Program as required under Section III.A.5 of this CIA
h. The extent to which Providence’s credentialing and privileging process is effective and thorough;
i. The extent to which Providence monitors practitioners with current privileges by the review of clinical practice patterns, ongoing case review, proctoring, and discussion with other individuals involved in the care of patients; and
j. Providence’s implementation and monitoring of medical staff peer review.
2. XxxxxxxxProvidence’s response to quality of care issues, which shall include an assessment of:
a. XxxxxxxxProvidence’s ability to identify the problem;problem;
b. XxxxxxxxProvidence’s ability to determine the scope of the problem (e.g., systemic or isolated);isolated);
c. XxxxxxxxProvidence’s ability to conduct a root cause analysis;analysis;
d. XxxxxxxxProvidence’s ability to create a corrective action plan to respond to the problem;problem;
e. XxxxxxxxXxxxxxxxxx’s ability to execute the corrective action plan;
f. ParklandProvidence’s ability to operate in a timely and effective manner; and
g. ParklandProvidence’s ability to monitor and evaluate whether the assessment, corrective action plan, and execution of that plan were effective, reliable, thorough, and maintained.
3. ParklandProvidence’s proactive steps to ensure that each patient receives care in accordance with:
a. professionally recognized standards of health care;care and patient safety;
b. the Conditions for Participation for Hospitals, 42 CFR Part 485;
c. State and local statutes, regulations, and other directives or guidelines;; and
d. c. the Policies and Procedures adopted by ParklandProvidence, including those implemented under Section III.B.2.b-c III.B of this CIA; and
e. professionally recognized standards of clinical staffing.
4. Parkland’s identification and response to Reportable Quality Events, as required by Section B of this Appendix D.CIA.
Appears in 1 contract
Samples: Corporate Integrity Agreement
Clinical Quality Systems Review. The QRO shall perform a Clinical Quality Systems Review to assess the effectiveness, reliability, and thoroughness of Parkland’s quality management infrastructure and systems throughout Parkland. The QRO shall assess Parkland’s efforts to achieve compliance with its Clinical Quality Policies and Procedures described in Section III.B.2.b-c, the Medicare Conditions of Participation, and other standards designed to ensure that the delivery of patient care items or services at Parkland meet professionally recognized standards of health care and are reasonable and appropriate to the needs of Federal health care program beneficiaries. The Clinical Quality Systems Review will be undertaken at all relevant levels of the organization. The QRO shall assess, among other things, the effectiveness, reliability, and thoroughness of the following:
1. Parkland’s quality management infrastructure, including but not limited to an assessment of:
a. Parkland’s Quality of Care Dashboard required under section III.A.4.b. of this CIA;
b. The accuracy of Parkland’s internal reports, data, and assessments required by the Clinical Quality Policies and Procedures;
c. Xxxxxxxx’s ability to analyze outcome measures and other data;
d. The extent to which reviews under Parkland’s Quality, Safety, and Performance Improvement Program and other reviews are occurring to identify and address quality management issues at Parkland;
e. Parkland’s compliance with the Clinical Quality Training requirements, Clinical Quality Policies and Procedures, and performance standards of Section III.B.2.b–c & III.C.3 of the CIA;
f. The extent to which Parkland’s Clinical Quality Training program is effective, thorough, and competency-based;
g. The extent to which Parkland’s communication systems are effective and results of decisions are transmitted to the proper individuals in a timely fashion.
2. XxxxxxxxParkland’s response to quality of care issues, which shall include an assessment of:
a. XxxxxxxxParkland’s ability to identify the problem;
b. Xxxxxxxx’s ability to determine the scope of the problem (e.g., systemic or isolated);
c. XxxxxxxxParkland’s ability to conduct a root cause analysis;
d. XxxxxxxxParkland’s ability to create a corrective action plan to respond to the problem;
e. Xxxxxxxx’s ability to execute the corrective action plan;
f. Parkland’s ability to operate in a timely and effective manner; and
g. Parkland’s ability to monitor and evaluate whether the assessment, corrective action plan, and execution of that plan were effective, reliable, thorough, and maintained.
3. Parkland’s proactive steps to ensure that each patient receives care in accordance with:
a. professionally recognized standards of health care;
b. the Conditions for Participation for Hospitals, 42 CFR Part 485;
c. State and local statutes, regulations, and other directives or guidelines;
d. the Policies and Procedures adopted by Parkland, including those implemented under Section III.B.2.b-c of this CIA; and
e. professionally recognized standards of clinical staffing.
4. Parkland’s identification and response to Reportable Quality Events, as required by Section B of this Appendix D.
Appears in 1 contract
Samples: Corporate Integrity Agreement
