Steps for creating an effective quality assurance program for senior living facilities

Editor’s note: This post is an excerpt taken from HCPro’s upcoming title, Disaster Planning, Environmental Safety, and OSHA Compliance: A Toolkit for the Senior Living Community by Karen T. Stratoti, RN, BSN, LNHA, CALA. This resource is a cost-effective solution to improve safety and satisfaction in your facility, including staff training activities, sample policies and procedures for infection control, and self-audit checklists to ensure a quality environment. Pre-order your copy today!

When implementing a QA program, in many cases, the administrator is the person to create an environment that includes input from all community members and staff. Typically, the facility’s governing board has already established a statement of organizational ethics in recognition of the facility’s responsibilities to residents, staff, and the community they serve.

Quality improvement projects are best conducted by teams of staff who have direct knowledge of the problem or the system to be evaluated. Team members should include staff who are affected by the project. Using interdisciplinary members of a team can be advantageous.

Step #1: Establish a committee

The administrator/executive director is responsible for establishing a QA committee. The purpose of this committee is to ensure that the facility provides a high level of quality care to the residents.

The procedure while conducting this type of committee involves four key elements:

  • The facility will have a committee that is composed of at least the director of wellness (e.g., nursing), a physician, and at least three other facility staff members
  • The committee will meet at least quarterly (although many meet monthly)
  • The committee will identify issues and concerns related to quality deficiencies and will develop plans of action to correct them
  • The committee will identify areas of improvement and develop plans of action

Step #2: Identify areas to be assessed

The first step in the problem identification and solving process is to identify the area to be assessed. These areas can range from resident satisfaction with pharmacy services, to staff turnover or food and beverage options. After identifying each problem, the next step includes measuring the communities’ performance against the standards.

Step #3: Root cause analysis

Exploration is the next step in this problem-solving process. This step creates a significant learning opportunity for participants. Successful problem-solving occurs when the staff is able to identify the most focused reason for the problem being brought forth to solve, otherwise known as a root cause analysis.

Step #4: Setting goals

The community’s goals should match the standard. Each goal needs to:

  • Be realistic
  • Include a time frame to be achieved
  • List the person responsible for achieving the goal
  • Have a date for staff to reevaluate the situation

Step #5: Develop a plan

After all of the above is completed, a plan needs to be developed. The plan should address the reason that caused the problem (which should have been determined in step #3: root cause analysis). A realistic action plan needs to be developed that accomplishes the following:

  • Analyzes results and identifies problems
  • Sets standards that need to be evaluated
  • Helps employees do their jobs better
  • Empowers employees by involving them in problem-solving and decision-making
  • Allows everyone in the organization to work together
  • Develops a spirit of loyalty
  • Assists staff in understanding the organization’s vision and values
  • Emphasizes cooperation and collaboration with all departments

This is a never-ending project as residents’ and staff members’ needs change continually and need to be addressed in a timely way as changes occur.

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