West Valley Medical Center - November 01, 2016
by Ron Folwell
Ron Folwell

Ron Folwell
Director of Quality

Quality Assessment/Performance Improvement (QAPI)

Here at West Valley, we're always monitoring and evaluating our processes to improve outcomes. Quality Assessment/Performance Improvement (QAPI) is not only a condition of CMS participation, but it's an opportunity for all hospital departments to reflect on their daily operations and make continuous evidence-based, data-driven improvements.

QAPI Requirements

  1. The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.
  2. The hospital's governing body must ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors.

QAPI Program Scope

  1. The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors.
  2. The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.
  3. The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital's Quality Improvement Organization (QIO).
  4. The hospital must use the data collected to monitor the effectiveness and safety of services and quality of care.
  5. The frequency and detail of data collection must be specified by the hospital's governing body.

The QAPI Plan Identifies:

  1. The goal of the quality assurance program is to identify and reduce medical errors and improve health outcomes.
  2. The quality indicators, including adverse patient events, that will be measured, analyzed, and tracked on an ongoing basis.
  3. The performance indicators and data collection activities for:
    1. Every department and service
    2. Every contracted service
  4. Frequency and detail of data collection activities.
  5. Methods to monitor the effectiveness and safety of services and quality of care
  6. The plan to use data collected to monitor the effectiveness and safety of services.
  7. Strategies to be used to identify opportunities for improvement and changes.
  8. Approval of the annual Quality Plan by the governing body.

West Valley QAPI Projects

Masking Required as of Nov. 1 – Sari Folwell, Employee Health

The CDC recommends the influenza vaccine for all healthcare workers in order to prevent infection from and transmission of influenza and its complications, including death, to patients and coworkers. Documentation of flu vaccine was due by October 31, 2016. If you declined the vaccine, please be advised that West Valley policy will require you to wear a mask at all times during flu season in the facility, with the exception of the cafeteria and bathrooms. Masking began November 1, 2016 at 7:00 a.m. If you have not received your flu vaccine and would like to do so, please contact Sari Folwell in Employee Health at (208) 455-3770.

Emergency Care Update – HCA Mountain Division

Have you ever wondered why we transparently report our average ER wait times on billboards, our hospital website and via text message?

The short answer: we focus on putting patients first — and we hold ourselves accountable to that goal. Those wait-time clocks and the critical, behind-the-scenes work in our ERs demonstrate our commitment to consistently do what it takes to deliver exceptional emergency medicine care, as quickly as possible.

Physician Update

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