Tracking a Sample QI/QA Initiative
To assist health centers and free clinics with quality improvement (QI)/quality assurance (QA) activities, this tool
follows QI/QA initiatives over the course of several months of study. In exploring this sample, users will be able
to see how to utilize a tool such as “Plan, Do, Study, Act” (PDSA) cycles and understand how UDS measures,
patient satisfaction surveys, and data collection can be documented and tracked. This sample utilizes one style of
formatting for the agenda and minutes. You can find these templates and others in the Quality Assurance/Quality
Improvement Toolkit on the Clinical Risk Management Program website.
This sample tool is intended as guidance to be adopted or adapted consistent with the internal needs of your
organization. This tool is not to be viewed as required by ECRI Institute or HRSA.
Contents
QI/QA Committee Meeting January 8, 2013, Agenda ...............................................................................................2
2013 Quality Initiative: Managing Test Results .........................................................................................................3
Handout: PDSA Schematic for Testing Changes .......................................................................................................5
QI/QA Committee Meeting Minutes ..........................................................................................................................7
QI/QA Committee Meeting February 12, 2013, Agenda .........................................................................................11
QI/QA Committee Meeting Minutes ........................................................................................................................12
Health Center Checklist/Audit Tool: Managing Test Results ..................................................................................16
Confidential Patient Record Documentation Audit Tool: Managing Test Results (Completed) .............................17
Confidential Patient Record Documentation Audit Tool: Managing Test Results (Blank) .....................................19
QI/QA Committee Meeting March 12, 2013, Agenda .............................................................................................21
QI/QA Committee Meeting Minutes ........................................................................................................................23
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Sample
QI/QA Committee Meeting
January 8, 2013, Agenda
QA/QI Committee
Date: Tuesday, January 8, 2013
Meeting Location: Third floor conference room, 11:30 AM-12:30 PM (or longer, if needed)
Anticipated Attendance: Dr. Jim Smith, Chief Medical Officer, Chair; Kathy Smith, Director of Quality, Vice Chair; Dave
Garcia, FNP-BC, Nurse Practitioner; Dr. Ralph Valdez, Staff Physician; Ken Mills PA-C, Physicians’ Assistant; Janet Hill,
Office Manager; Mia Teste, Risk Manager; Joseph Williams, Pharm.D., On-site Pharmacist
Excused: H. Barry, RN, Nurse Manager
Following a call to order, introductions and approval of minutes, the items below will be discussed:
Agenda
Agenda Item
Presenter(s)
1. Update on Quality Initiatives for
2013
K. Smith, Director of
Quality
2. Patient Satisfaction Surveys
Using patient satisfaction as part
of 2013 quality initiatives
K. Smith, Director of
Quality
a. recent complaints with
scheduling appointments
3. Update on final 2012 Quality
Initiatives and those that require
further inclusion into 2013 plan
Handouts
10 minutes
Recent Patient Satisfaction
Report
Dr. J. Smith, CMO
and Chair, and K.
Smith, Director of
Quality
4. 2013 Quality Initiative-Managing
Test Results
K. Smith, Director of
Quality; M. Teste,
Risk Manager
5. Wrap Up and Next Steps/Adjourn
Dr. J Smith, CMO
and Chair
Time
20 minutes
10 minutes
2013 Quality InitiativeManaging Test Results
15 minutes
5 minutes
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Sample
2013 Quality Initiative:
Managing Test Results
Initiative:
Improve the flow and management of ordering, tracking, and reporting test results to ensure provider and patient receive
timely and accurate information.
Measurement: Patient record review using checklist/audit forms titled “Managing Test Results.”
Goal: 100% of patients will be notified timely and accurately of test results as defined by Center’s policy.
Target for 2013: 95% of all patient records reviewed will demonstrate timely and accurate test result reporting to the patient,
with the goal of getting to 100% by the third quarter of 2014. Currently, 50% of 10 patient records reviewed demonstrated
timely and accurate test result reporting.
Background
Timely and accurate communications of diagnostic tests are imperative to providers and patients in the delivery of quality care.
Delay or inaccuracy in reporting test results to patients may engender a series of adverse events including the omission of
care, postponed treatment, and patient harm. Failure to effectively manage test results may also be a root cause for frequent
and serious claims and lawsuits.
In November and December 2012, ABC Health Center received 10 calls from patients inquiring about their test results.
Review of these 10 patient records revealed either delay in communications or inaccuracies in information of test results for
five patients (50%). Additionally, four patients had abnormal results and no providers documented follow-up calls or patient
visits regarding these results.
The Center, through its Quality Management Committee (QMC, aka QA/QI Program) organized an action plan using the
PDSA model through a subcommittee of one physician provider, one Center RN, and one nurse practitioner. The following
plan was developed and implemented.
Action Using Plan, Do, Study, Act (PDSA) Cycle (see handout “PDSA Schematic for Testing Changes”)
Plan: Opportunity for improvement was recognized through tracking patient calls about test results and subsequent record
review of those patient charts. QMC subcommittee was formed and action plan initiated.
Do:
 Review and revise existing Center policy and procedure for “Managing Test Results”
 Develop audit forms/tools using Center Policy/Procedure for “Managing Test Results”
 Conduct monthly audits of patient records for 25% of patients listed on test tracking log
Study:
 Track and trend results of record audits for patterns
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Act:






Develop plan for change as indicated based on analysis of audit results
Actions may include:
Educate providers on follow-up communications and documentation
Revise process for maintaining test log
Develop routine audit plan where all providers review a percent of patient records each month
Develop procedure for monitoring patient notification process
Other
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Sample
Handout: PDSA Schematic for Testing Changes
Questions to Ask:



What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Source: Associates for Process Improvement. Available from Internet: http://www.apiweb.org/API_home_page.htm.
Page 5 of 27
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Sample
QI/QA Committee Meeting Minutes
QA/QI Committee
Date: Tuesday, January 8, 2013
Meeting Location: Third floor conference room, 11:30 AM-12:30 PM (or longer, if needed)
Attendance: Dr. Jim Smith, Chief Medical Officer, Chair; Kathy Smith, Director of Quality, Vice Chair; Dave Garcia, FNP-BC,
Nurse Practitioner; Dr. Ralph Valdez, Staff Physician; Ken Mills PA-C, Physicians’ Assistant; Janet Hill, Office Manager; Mia
Teste; Risk Manager; Joseph Williams, Pharm.D.; On-site Pharmacist
Excused: H. Barry, RN, Nurse Manager
Absent:
Minutes
Agenda Item
Discussion/Recommendations
Actions Taken
Call to Order
and
Introductions
Dr. Smith, CMO and Chair, called
N/A
the meeting to order and welcomed
J. Hill, office manager and new
committee member. H. Barry is
excused due to a planned vacation.
Review and
Approval of
Minutes
Dr. Smith, CMO and Chair called
for a review of the minutes of the
December 11, 2012 meeting. No
changes were noted.
Responsible
Person
Follow-up
J. Hill, Office
Manager/ Dr. Smith,
CMO
Feb 12, 2013
Approval of
minutes
Recommendations: Approve
minutes
Update on
2013 Quality
Initiatives
Patient Satisfaction Surveys: K.
Smith, Director of Quality,
discussed continuing to use patient
satisfaction as part of 2013 quality
initiatives. She reported that
throughout 2012 friendliness of the
staff scored in the 97 percentile
and waiting in the exam room was
in the 96 percentile. In the fourth
Plan: identified that
scheduling wait
times are an issue.
Do: added
additional
appointment slots
with D. Garcia,
Nurse Practitioner
Feb 12, 2013
(follow at next
meeting)
Page 7 of 27
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Agenda Item
Discussion/Recommendations
Actions Taken
quarter of 2012 there were seven
complaints and low scores (70) out
of 25 surveys (28%) about wait
times for scheduling appointments.
This was reflected in answers to
the question, “Could you get an
appointment as soon as you
wanted?”
and K. Mills,
Physician Assistant
Beginning Nov 19,
2012 and
beginning on Dec.
17, 2012
Dr. Smith, CMO reviewed the UDS
information for staffing and
utilization and determined that
based on patient demographics
changes were needed in the hours
for staff availability. To address this
we added new appointment times
with D. Garcia, Nurse Practitioner
and K. Mills, Physician Assistant in
November and December.
However, as of the end of
December there were still patient
complaints. We will continue to
look at trends in patient volumes
and compare this with staffing.
Responsible
Person
Follow-up
Evaluation in
January 2013;
will look at
results during
Feb 12, 2013
meeting
Study: Will assess
peak visit times,
evaluate staffing,
and monitor
complaints
K. Smith, Director of
Quality
Monthly
reports
K. Smith, Director of
Quality
Quarterly
reports
Act: Establish this
as a new quality
initiative for 2013.
Additional PDSA
cycles may help
identify the root
causes for
persistent patient
complaints.
Recommendations: set this as a
2013 quality goal and continue to
monitor as a quality initiative.
Monitor changes in patient visit
volumes.
Update on final
2012 Quality
Initiatives and
those that
require further
inclusion into
2013
K. Smith, Director of Quality,
reviewed goals from 2012 Quality
Initiatives including complete chart
documentation of blood pressures
and updated medication lists.
Improvements occurred throughout
2012 and will monitor quarterly in
2013
Act: Continue to
monitor charting of
blood pressures
and updated
medication lists as
part of 2013 Quality
Initiatives.
Report Quarterly
Recommendations: quarterly
monitoring of recorded blood
pressures and updated medication
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Agenda Item
Discussion/Recommendations
Actions Taken
Responsible
Person
Plan: Will begin
utilizing PDSA to
evaluate the
process of
Managing Test
Results.
K. Smith, Director of
Quality/ M. Teste,
Risk Manager/ K.
Mills, Physician
Assistant
Follow-up
lists.
2013 Quality
InitiativeManaging Test
Results
The committee discussed the 2013
Quality Initiative-Managing Test
Results.
K. Smith, Director of Quality noted
that there have been patient
complaints about a delay in
receiving their test results.
1. In November and December of
2012, the health center received 10
calls from patients inquiring about
their test results.
2. A record review demonstrated
four patients with abnormal results
during that same time frame.
These patients did not have
documented calls or follow-up
appointments.
The committee reviewed the
attached Managing Test Results
plan.
K. Smith, Director of Quality
discussed various tools for
assessing this quality initiative
including the PDSA (Plan, Do,
Study, Act) tool.
K. Smith, Director of Quality then
reviewed the steps of the tool with
the committee and determined that
this was an appropriate tool to
apply to this initiative.
Do: Review of
policy and
procedures;
develop audit form
Study: review of 25
charts per month
for documented
calls or
communication of
lab results and
what actions were
taken in follow-up
on abnormal test
results.
Act: Complete
review of policies
and procedures
and development
of audit form.
Provide results of
initial review of 25
charts as a
baseline.
K. Smith, Director of
Quality/ M. Teste,
Risk Manager/ K.
Mills, Physician
Assistant
Begin Policy
and
Procedure
Review by
Jan 30, 2013
Develop Audit
form by Feb
2, 2013
Report on
initial review
of 25 charts to
committee at
the next
meeting.
Recommendations: Begin utilizing
PDSA tool to evaluate the process
of managing test results.
Determine the appropriate areas
for review and begin to monitor.
Page 9 of 27
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Agenda Item
Discussion/Recommendations
Actions Taken
Responsible
Person
Follow-up
The plan will be re-evaluated
periodically with monthly updates
to the committee.
Adjourn
The meeting was adjourned at
12:45
Next meeting:
Feb. 12, 2013
 Previous Minutes approved _______________________________________________ __/__/____
(Signature of committee chair)
(Date)
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and
nonmember institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials.
Healthcare laws, standards, and requirements change at a rapid pace, and thus, the sample policies may not meet current requirements.
ECRI Institute urges all members to consult with their legal counsel regarding the adequacy of policies, procedures, and forms.
Page 10 of 27
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Sample
QI/QA Committee Meeting
February 12, 2013, Agenda
QA/QI Committee
Date: Tuesday, February 12, 2013
Meeting Location: Third floor conference room, 11:30 AM-12:30 PM (or longer, if needed)
Anticipated Attendance: Dr. Jim Smith, Chief Medical Officer, Chair; Kathy Smith, Director of Quality, Vice Chair; Dave
Garcia, FNP-BC, Nurse Practitioner; Ken Mills PA-C, Physicians’ Assistant, Janet Hill, Office Manager; H. Barry, RN, Nurse
Manager; Mia Teste, Risk Manager; Joseph Williams, Pharm.D.; On-site Pharmacist
Excused: Dr. Ralph Valdez, Staff Physician
Following a call to order, introductions and approval of minutes, the items below will be discussed:
Agenda
Agenda Item
Presenter(s)
Handouts
Time
1. Update on Quality Initiative
for 2013-Managing Test
Results and on staffing
K. Smith, Director of Quality
15 minutes
2. Patient Satisfaction Follow up on complaints
about scheduling
appointments
K. Smith, Director of
Quality/J. Hill, Office
Manager
20 minutes
3. Follow up- reporting lab
results to patients
a. Address specific
complaints
b. Evaluate other factors
contributing
4. Wrap Up and Next Steps
/Adjourn
K. Smith, Director of Quality,
M. Teste, Risk Manager, K.
Mills, Physicians’ Assistant
Checklist for Managing Test
Results
20 minutes
Patient Record
Documentation Audit Tool
Dr. J Smith, CMO and Chair
5 minutes
Page 11 of 27
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Sample
QI/QA Committee Meeting Minutes
QA/QI Committee
Date: Tuesday, February 12, 2013
Meeting Location: Third floor conference room, 11:30 AM-12:30 PM (or longer, if needed)
Attendance: Dr. Jim Smith, Chief Medical Officer, Chair; Kathy Smith, Director of Quality, Vice Chair; Dave Garcia, FNP-BC,
Nurse Practitoner; Dr. Ralph Valdez, Staff Physician; Janet Hill, Office Manager; Mia Teste, Risk Manager; Joseph Williams,
Pharm.D.; On-site Pharmacist; Mary Kaplan, LCSW, Social Worker
Excused: H. Barry, RN, Nurse Manager
Absent: K. Mills, PA-C
Minutes
Agenda Item
Discussion/Recommendations Actions Taken
Call to Order
and
Introductions
Dr. Smith, CMO and Chair,
called the meeting to order.
N/A
Review and
Approval of
Minutes
Dr. Smith, CMO and Chair,
asked for
additions/deletions/corrections
to the minutes from January 8,
2013. No additions/deletions or
corrections.
Approval of Minutes
Responsible Person
Follow-up
N/A
Recommendation: approval of
minutes.
Update on
Quality
Initiative
regarding
staffing and for
2013Managing Test
Results
K. Smith, Director of Quality,
reported that there were no
complaints about staffing this
month with a satisfaction score
of 95% when examining
responses to the question
regarding the ability to get an
appointment as soon as they
wanted. We will continue to
monitor this question in our
Plan: Use of Record
Documentation Audit
Tool (attached) to
review ten (10)
charts per month.
K. Smith, Director of
Quality, M. Teste, Risk
Manager
March 12, 2013
Do: Chart review
with report back to
the committee in
March. Determine if
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Agenda Item
Discussion/Recommendations Actions Taken
Patient Satisfaction Survey and
compare it to the National
Averages.
As far as staffing levels and
visits, patient visits were steady
compared to January and
slightly decreased in comparison
to November (-4%) and
December (-2%).
K. Smith, Director of Quality and
M. Teste, Risk Manager,
recognized a need for a
subcommittee to review the
policy, procedure and practice
for Managing Test Results.
Review was assigned to M.
Teste, Dr. Rad (Family Medicine
Chair), and K. Smith, Director of
Quality. An audit form was
created based on the updated
policies and procedures for the
imitative Managing Test Results.
The initial 25 charts were
reviewed and documentation
issues were identified.
Responsible Person
Follow-up
Record
Documentation Audit
Tool is successfully
evaluating the issue.
Action: report the
results of the chart
review and
evaluation of the
chart review tool at
the next committee
meeting.
K. Smith, Director of
Quality, M. Teste, Risk
Manager
Act: Will continue to
monitor patient
satisfaction with
ease of scheduling
appointments and
report monthly.
K. Smith, Director of
Quality
Recommendation: Utilize
Record Documentation Audit
Tool to review ten (10) charts
per month.
Patient
Satisfaction Follow up on
complaints
about
scheduling
appointments
Dr. Smith, CMO and Chair, has
evaluated staffing levels during
peak patient visit times and
added additional time slots.
Mary Kaplan, Social Worker,
has evaluated staffing levels for
behavioral health patients and
noted that the levels are
sufficient. J. Hill, Office
Manager, reports that there
have been few complaints
Monthly reports
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Agenda Item
Discussion/Recommendations Actions Taken
Responsible Person
Follow-up
M. Teste, Risk Manager;
Dr. Smith, CMO
March 12, 2013
relating to scheduling.
Recommendation: continue to
monitor complaints and report to
K. Smith, Director of Quality and
Dr. Smith, CMO.
Follow upreporting lab
results to
patients
M. Teste, Risk Manager
identified a problem with
receiving timely results from the
lab.
Plan: ensure that the
lab returns results of
outstanding tests in
a timely manner.
Address
specific
complaints
Recommendation: follow with
lab regarding receipt of
anticipated lab results and
obtain specific information from
lab about turn-around times for
study results for individual tests.
Do: Establish a
routine follow-up
schedule to obtain
lab results if not
received according
to lab guidelines for
test turn-around.
Evaluate other
factors
contributing
Study: Assess
whether lab results
are returned
according to the
follow-up schedule.
Act: Evaluate test
and result logs for
timely results daily
and report summary
to M. Teste weekly of
any irregularities
experienced and the
actions taken.
Adjournment
The meeting was adjourned at
1:00 PM
Next meeting: March
12, 2013
 Previous Minutes approved _______________________________________________ __/__/____
(Date)
(Signature of committee chair)
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and
nonmember institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials.
Page 14 of 27
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Healthcare laws, standards, and requirements change at a rapid pace, and thus, the sample policies may not meet current requirements.
ECRI Institute urges all members to consult with their legal counsel regarding the adequacy of policies, procedures, and forms.
Page 15 of 27
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Health Center Checklist/Audit Tool:
Managing Test Results
A. Center has a written policy for tracking, ordering and managing test results.
Includes definitions for test results, normal, abnormal, critical and or emergent
Clarifies responsibilities of the providers and the staff
Includes time frames for reporting normal test results, abnormal, critical or emergent
Includes procedures for monitoring patient records for serial testing/preventative care
Includes key components below (# 1-4)
Y/N
1. Orders
Written order for diagnostic tests are dated, timed, legible, clear, and signed by provider
2. Waiting for and Receiving Test Results
A system is in place to ensure daily review of patient record and log for outstanding results
A manual or electronic test order log is used
o The test log includes: date ordered; date specimen sent; patient name and identifier; test name;
expected date of return; status of test: stat, routine, serial and; date, time or results received
A system is in place to indicate results of returned tests such as a highlight or color filled section
Center utilizes telephone software, internet based system or electronic medical record system
3. Reviewing test results
Ordering provider reviews and signs results prior to filing in patient’s paper or electronic record
If electronic record used, only the ordering provider is the authorized user
Results are timely reviewed by ordering provider (per policy timeframe)
Referral of test results to designated provider if ordering provider unavailable
Results timely reviewed by designated provider if ordering provider unavailable
Critical/emergent telephone results are reported immediately to the ordering provider or designate
provider
o Telephone results documented in patient record include: Date and time received; name and
location of caller; test name; test value and date time provider (name) notified
Telephone receiver reads back information and signs note with full name and title
4. Notifying patients
Documentation in record confirms patient notified of test results
o If results are routine or normal, documentation of notification includes: date; time; mode of
communication and; name/title of person making the notification
If Center leaves message that test results are in, the patient record contains previously signed consent
Abnormal results given to patient in person and documentation reflects visit/discussion of results
Attempts to reach patient and mode are documented in the chart (telephone, postcard, certified letter)
Provider documents recommendations made to patient for treatment or additional testing
Provider documents potential consequences of failing to obtain treatment or additional testing
Provider documents discussion and patient’s response
Page 16 of 27
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Sample
Confidential Patient Record Documentation Audit
Tool:
Managing Test Results (Completed)
Patient Identifier: MR # 12345
Provider: D. Garcia FNP-BC
Documentation in Patient Record
Yes
Orders/Results
Written order for diagnostic test(s) is: dated, timed, legible,
clear, and signed by provider
Test result sheet(s) located in patient record and timely (per
policy) received and signed/acknowledged by provider
If results are routine or normal, documentation of patient
notification includes: date; time; mode of communication;
name/title of person making the notification
Telephone results documented in patient record include: date
and time received; name and location of caller; test name; test
value; time provider (name) notified; note signed with full name
and title of person taking call
Abnormal, critical or emergent results
All attempts to reach patient are documented in the chart with
date; time; mode, and person making notification
If Center leaves message that test results are in, the patient
record contains previously signed consent
Abnormal results provided timely (per policy) in person and
documentation reflects discussion
If certified letter sent to patient regarding attempt to reach
patient, copy of letter and return receipt is placed in record
Provider documentation includes recommendations made to
patient for office visit, treatment or additional testing
Provider documentation includes potential consequences of
failing to visit, obtain treatment or additional testing
Provider documentation includes discussion and patient’s
response
No NA*
Comments
No
Order not timed; all
other yes
No
Missing mode of
communication; all
other yes
Missing name,
location of caller and
provider notification
all other yes
Yes
No
Yes
Patient response first
call; agreed to visit
Yes
Yes
NA
Yes
Yes
Yes
*NA means not applicable OR Unknown
Notes:
Page 17 of 27
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All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and
nonmember institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials.
Healthcare laws, standards, and requirements change at a rapid pace, and thus, the sample policies may not meet current requirements.
ECRI Institute urges all members to consult with their legal counsel regarding the adequacy of policies, procedure and forms.
Page 18 of 27
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Sample
Confidential Patient Record Documentation Audit
Tool:
Managing Test Results (Blank)
Patient Identifier: ____________________________Provider: _____________________
Documentation in Patient Record
Yes
No NA*
Comments
Orders/Results
Written order for diagnostic test(s) is: dated, timed, legible,
clear, and signed by provider
Test result sheet(s) located in patient record and timely (per
policy) received and signed/acknowledged by provider
If results are routine or normal, documentation of patient
notification includes: date; time; mode of communication;
name/title of person making the notification
Telephone results documented in patient record include: date
and time received; name and location of caller; test name; test
value; time provider (name) notified; note signed with full name
and title of person taking call
Abnormal, critical or emergent results
All attempts to reach patient are documented in the chart with
date; time; mode, and person making notification
If Center leaves message that test results are in, the patient
record contains previously signed consent
Abnormal results provided timely (per policy) in person and
documentation reflects discussion
If certified letter sent to patient regarding attempt to reach
patient, copy of letter and return receipt is placed in record
Provider documentation includes recommendations made to
patient for office visit, treatment or additional testing
Provider documentation includes potential consequences of
failing to visit, obtain treatment or additional testing
Provider documentation includes discussion and patient’s
response
*NA means not applicable OR Unknown
Notes:
Page 19 of 27
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Copyright ECRI Institute, 2013
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and
nonmember institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials.
Healthcare laws, standards, and requirements change at a rapid pace, and thus, the sample policies may not meet current requirements.
ECRI Institute urges all members to consult with their legal counsel regarding the adequacy of policies, procedure and forms.
Page 20 of 27
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Sample
QI/QA Committee Meeting
March 12, 2013, Agenda
QA/QI Committee
Date: Tuesday, March 12, 2013
Meeting Location: Third floor conference room, 11:30 AM-12:30 PM (or longer, if needed)
Anticipated Attendance: Dr. Jim Smith, Chief Medical Officer, Chair; Kathy Smith, Director of Quality, Vice Chair; Dave
Garcia, FNP-BC, Nurse Practitioner; Dr. Ralph Valdez, Staff Physician; Ken Mills PA-C, Physicians’ Assistant; Janet Hill,
Office Manager; Holly Barry, RN, Nurse Manager; Mia Teste, Risk Manager; Joseph Williams, Pharm.D.; On-site Pharmacist
Excused:
Following a call to order, introductions and approval of minutes, the following items below will be discussed:
Agenda
Agenda Item
Presenter(s)
Handouts
Time
1. First quarterly update: Patient
Satisfaction appointment scheduling
wait time
K. Smith, Director of
Quality
10 minutes
2. Follow up: anticipated receipt of lab
reports/ contacting the lab when no
reports are received
M. Teste , Risk
Manager
10 minutes
3. Discussion of critical, abnormal and
normal test results
Dr. J. Smith , CMO
and Chair
Review Policy and
Procedure for
communicating lab results
20 minutes
4. Use of the various methods of
contacting patients with test results
K. Smith, Director of
Quality M. Teste,
Risk Manager and
Dr. J.Smith, CMO
and Chair
Review Policy and
Procedure regarding Patient
Contacts
15 minutes
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5. Wrap Up and Next Steps /Adjourn
Dr. J Smith, CMO
and Chair
5 minutes
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Sample
QI/QA Committee Meeting Minutes
QA/QI Committee
Date: Tuesday, March 12, 2013
Meeting Location: Third floor conference room, 11:30 AM-12:30 PM (or longer, if needed)
Anticipated Attendance: Dr. Jim Smith, Chief Medical Officer, Chair; Kathy Smith, Director of Quality, Vice Chair; Dave
Garcia, FNP-BC, Nurse Practitioner; Dr. Ralph Valdez, Staff Physician; Ken Mills PA-C, Physicians’ Assistant; Janet Hill,
Office Manager; Holly Barry, RN, Nurse Manager; Mia Teste, Risk Manager; Joseph Williams, Pharm.D.; On-site Pharmacist;
Dr. Linda Thomas, Dentist
Excused:
Absent:
Minutes
Agenda Item
Discussion/Recommendations Actions Taken
Responsible Person
Follow-up
Call to Order
and
Introductions
Dr. Smith, CMO and Chair,
called the meeting to order.
N/A
Review and
Approval of
Minutes
Dr. Smith, CMO and Chair
asked for a review of the
minutes from the February 12,
2013 meeting. There were no
additions or deletions
Minutes Approved
N/A
Plan: Audit Patient K. Smith, Director of
Satisfaction
Quality
Survey monthly to
evaluate
appointment
scheduling wait
time.
Provide continued
quarterly updates
Recommendation: approve
minutes.
First quarterly
appointment
scheduling
wait time
update
K. Smith, Director of Quality,
presented information regarding
patient satisfaction surveys with
appointment-scheduling wait
time. Patient satisfaction
numbers have increased to 89%
in response to the question –
getting an appointment as soon
as you wanted. K. Smith,
Director of Quality, reported that
Study: Patient
Satisfaction
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Agenda Item
Follow up on
anticipated
receipt of lab
reports/
contacting the
lab when no
reports are
received
Discussion/Recommendations Actions Taken
one survey out of the 30 (3%)
received this quarter reflected a
specific complaint regarding
appointment waiting time, and
this complaint was related to
dental appointments. Dr.
Thomas, Dentist, was brought in
to the initiative to evaluate
waiting times for dental
appointments.
Surveys.
M. Teste, Risk Manager, reports
that the lab has provided a list of
when the results of specific lab
tests can be anticipated. This
has helped a great deal. As the
result, M. Teste, Risk Manager,
and Dr. Smith, CMO and Chair,
are in the process of revising the
test log so that any results that
are not received in a timely
fashion from the lab can be
identified and the lab can be
called regarding these results.
Plan: Revise the
process for
maintaining the
test log.
Recommendation: complete
revision of test log and audit the
log weekly with monthly reports
to the committee.
Discussion of
critical,
abnormal and
normal test
The quality plan to Manage Test
Results identified issues with
how critical, abnormal and
normal test results were
reported to patients after
Responsible Person
Follow-up
M. Teste, Risk Manager,
Dr. Smith, CMO and
Chair
April 9, 2013 for
revision of the test log;
M. Teste, Risk Manager,
K. Mills, Physicians’
Assistant, Dr. Jones,
Family Medicine
Report on monthly
review of charts at the
next committee
meeting
Act: continue to
review patient
satisfaction
surveys regarding
appoint
scheduling wait
time with quarterly
updates to the
committee. Dr.
Thomas, Dentist,
will evaluate
waiting times for
patient dental
appointments
Report monthly on
audit reports.
Do: Complete
audits of the
results received
and whether the
lab was contacted
when results were
not received in the
anticipated time
frame.
Study: evaluate
data from the
weekly audits.
There were 100
patients on the
log.
Plan: Re-evaluate
how critical,
abnormal and
normal test results
are handled and
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Agenda Item
Discussion/Recommendations Actions Taken
results
receiving calls about missing
test results in November and
December. This has not been
satisfactorily addressed.
Discuss the use of the
Checklist/Audit Tool for
Managing Test Results with a
focus on how critical, abnormal
and normal test results are
handled. Discuss the need to
review the policies and
procedures for handling tests
results with all providers. K.
Smith, Director of Quality,
suggested a schedule of
education sessions on this topic.
Discuss communication issues.
K. Smith, Director of Quality,
reported that in her initial
analysis of 25 charts, all orders
in those charts were dated,
timed and signed (100%
compliance). There were 10
charts with abnormal lab results.
And, five of those10 charts
(20%) lacked provider
documentation or the absence
of recommendations to patients
for follow-up on abnormal
results.
Recommendation: Develop a
PDSA process for reporting test
results and following-up with
patients. Establish improving
communications and follow-up
with patients of as a new quality
initiative for 2013.
communicated.
Do: Conduct
provider education
regarding
expectations for
handling test
results and their
follow-up with
patients. Focus on
communication,
reporting and
privacy.
Study: Continue to
review 25 charts
per month for
tests ordered,
results received,
patient notified,
patient seen or
other action taken
following
abnormal results.
Responsible Person
Follow-up
Provider Education to
begin in by May 1 and
completed by Sept.
30. Focus on
Communication,
Reporting, and
Privacy
Tracking tool draft due
by April meeting for
committee review with
the goal of
implementing the
tracking system by
September 2013.
Act: develop a
system to track
communication of
abnormal test
results including
sending certified
letters when other
forms of contact
have failed with a
goal of less than
1% lacking
recommendations.
Will follow up by
the end of the
third quarter
(September 30,
2013).
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Agenda Item
Discussion/Recommendations Actions Taken
Responsible Person
Follow-up
Use of the
various
methods of
contacting
patients with
test results
K. Smith, Director of Quality,
noted that patients often request
specific methods of
communication regarding lab
results including: telephone
calls, email notification or that
messages be left on a voice
mail. This information is
recorded in their chart, however,
providers are not always
providing the information as
requested. J. Hill, Office
Manager, suggested that we
develop a procedure for
checking on this preferred
method of communication.
K. Smith, Director of
Quality, J. Hill, Office
Manager, H. Barry,
Nurse Manager
First report due by
April 9, 2013
K. Smith, Director of Quality,
suggested monitoring the patient
notification process to include
documentation of patient
notification, whether that
notification was acknowledged,
and what attempts were made if
it was not possible to contact the
patient by conducting a monthly
chart review.
K. Smith, Director of Quality,
reported that out of the 25 charts
that were initially reviewed after
identifying this area as being
problematic that there were five
charts with abnormal test results
where patients were called
once, no answer was received
and there was no follow up call
or communication.
Plan: Develop
procedure for
monitoring the
patient notification
process.
Do: Provide
education
sessions focusing
on documentation
of test results and
communication
with patients.
Study: Review of
25 charts per
month for
compliance with
patient
notification. The
goal is for 100%
notification.
Education sessions to
begin by June 30,
2013.
Monthly Chart Review
to continue each
month throughout
2013.
Act: Conduct
provider education
regarding patient
notification,
documentation
and follow-up
care. May decide
to include these in
the above
education
process.
June 30, 2013
Recommendation: Evaluate the
methods of notifying patients
and checking these methods
against patient preferences.
Develop a procedure for
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Agenda Item
Discussion/Recommendations Actions Taken
Responsible Person
Follow-up
monitoring the patient
notification process.
Adjourn
The meeting was adjourned at
12:55 PM.
Next Meeting April 9,
2013
 Previous Minutes approved _______________________________________________ __/__/____
(Signature of committee chair)
(Date)
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and
nonmember institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials.
Healthcare laws, standards, and requirements change at a rapid pace, and thus, the sample policies may not meet current requirements.
ECRI Institute urges all members to consult with their legal counsel regarding the adequacy of policies, procedures, and forms.
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