Quality Assessment Services
The Sibery Group’s approach to quality is a comprehensive and holistic one, including clinical processes and outcomes (effectiveness), as well as appropriate resource utilization (efficiency). We are able to determine the level of “quality maturity” of an organization and tailor an approach based on its needs and vision. With increased scrutiny of healthcare organizations and public availability of quality and financial information, we believe that an institution’s focus on quality will place it at a competitive advantage by:
providing unsurpassed clinical care at lower cost, particularly as healthcare purchasers and consumers are becoming
increasingly aware of the value they receive for their healthcare dollar. (Value = Quality/Cost), and
creating the opportunity for success with regulatory and accreditation authorities by "always being ready."
Our method of quality assessment is one of optimizing value through an interactive approach with the team already in place, working to design or redesign processes and infrastructure, including:
- Identifying performance improvement (PI) opportunities
- Prioritizing PI opportunities
- Developing PI projects
- Implementing PI projects
- Converting data to action
- Creating measurable and sustainable improvement
Our assessment process includes pre-visit and onsite document reviews, interviews and observations. A typical visit might consist of the following activities:
Pre-Visit Document Review
- Organizational Strategic Plan
- Organizational Chart
- Quality/Performance Improvement, Patient Safety and Risk Management Plans
- Examples of PI projects or studies
- Patient satisfaction survey instruments and patient satisfaction data from the last two years
- Job descriptions for Director, Manager or Coordinator of Quality, Patient Safety, Risk Management and Patient Relations
(or equivalent) - The results from any accreditation or regulatory surveys for the last three years
- Any quality/performance improvement newsletters, educational program agendas or promotional material from the last year (including PPR’s and any Corrective Action Plans)
- The Top 25 DRG’s (by volume)
- Four quarters of Core Measure data
- Staffing data (including staffing matrix and #’s of RN’s, LPN’s and CNA’s for the last year)
- Staffing Effectiveness Indicators and data
- Unit Specific Assessments (Micro-systems)
- Medical staff bylaws and rules & regulations
- Employee satisfaction data
On-Site Document Review
- Minutes from the Quality Committee, Medical Executive and Medical Staff Committees and Board of Directors from the last year
- The Annual Report for Quality/ Performance Improvement and Risk Management for the last two years
- Any quality/performance improvement project results, PDCA results, HFMEA or RCA results from the last year
- Evidence of systematic training in quality assurance/performance improvement given to the staff over the last year
(including new employee orientation) - Access to open and closed medical records
- Policies and procedures manuals
On-Site Interviews
- Administration
- Medical Staff Leadership and Quality/Risk Management Staff
- Nursing Leadership
- Front Line Staff and Physicians
- Infection Control Staff
- Medical Staff Administration (credentialing, privileging, peer review)
On-Site Observations
- Performance of tracers and focused assessment of patient care units, including rounding