QUALITY ASSESSMENT AND IMPROVEMENT COMMITTEE

 

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to establish manuals of policies and procedures for providing services.  Procedures shall permit the organization of committees, as needed, to ensure compliance with the New Jersey Standards for Licensure of Long Term Care Facilities, and with applicable Federal and New Jersey State Administrative Codes, related laws, regulatory and licensing standards.

PURPOSE.

This policy and procedure shall ensure that each VMH establishes and maintains a Quality Assessment and Improvement Committee that shall identify problems in the care and services provided to the residents, shall audit the medical records, shall monitor the performance of each service, and monitor trends in various areas.

PROCEDURE.

  1. New Jersey Veterans Memorial Homes’ Quality Assessment (QA) and Improvement Committee

    2.  

    1. The New Jersey Veterans Memorial Homes shall establish and maintain an interdisciplinary Quality Assessment and Improvement Committee charged with monitoring all facility services for the purpose of achieving and maintaining the highest quality of practical physical, mental, and psychosocial well being of the residing population of residents, in accordance with the comprehensive assessment and the plan of care. 
    2. The QA Committee shall also administer the implementation of a Utilization Review Committee to ensure the appropriate and efficient utilization of facility services, auditing the documented care of residents at designated intervals.

  2. The Quality Assessment and Improvement Committee and Utilization Review Committee

    3.  membership shall be representative of the following services:

    1. Quality Improvement Coordinator (Chairperson)
    2. Administrative Departments (TBD by Chair)
    3. Clinical Service Departments (TBD by Chair)
    4. Support Service Departments (TBD by Chair)
    5. Other staff as necessary

     

  3. The QA Committee membership will serve as a functional group, designating individuals charged with implementing a continuous program for monitoring services, identifying problem areas, data collection, compiling reports of findings, and pursuing corrective actions to address identified problems with care and services.

     
  4. The QA Committee shall function as an advisory group, which serves as the organizational line of communication between departments and administration with respect to facility services for the purpose of assuring compliance with Federal and State regulatory and licensing requirements, ensuring the appropriate and efficient utilization of facility services, and for facilitating improvement in services.

  5. The QA Committee shall also lead any Root Cause Analysis (RCA) interdisciplinary teams to identify the basic and contributing causal factors that underlie variations in performance associated with Sentinel Events. The Root Cause Analysis is a specific type of focused review that identifies changes that could be made in systems and processes through either redesign or development of new processes or systems that would improve performance and reduce the risk of Sentinel Events.

  6. The Quality Assessment and Improvement Committee shall meet at least quarterly, in accordance with applicable Federal and State rules, regulations, and standards, for the purpose of administering a quality assessment and improvement program, and for the periodic assessment of the appropriate and efficient utilization of facility services at designated intervals.

    7.  

  7. Minutes of each of these meetings will be kept, and copies of the meeting minutes will be forwarded to the Director, Division of Veterans Healthcare Services/designee, for review.

 

Revised:   July 2005
Revised:   July 2007
Revised:   July 2009

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