Quality Assurance for Activity Programs

1. Introduction

Ever since we started providing health care to others, we have been interested in improving the results. The process has become more formalized over time. Today it is called by various names including quality assurance, quality improvement, total quality improvement and improving organizational performance. When the process works well, it helps you identify how good your work is without making your work harder.

Today, quality assurance is the process of identifying problems, determining the worst problem, figuring out how to fix it and making sure that the problem does not return. To work as an activity professional today you need to know how to set up a quality assurance program, how to identify problems, how to correct them and how to monitor your progress.

You may ask, Why do I need to create more paper work when I know what is wrong? The answer is because the law says so and because managed care companies want to be sure that they are getting the most for their money. These days knowledge of quality assurance techniques is just as important as knowledge of the disease process, physiology, anatomy and the therapeutic process itself.

One federal law that requires quality assurance is the Omnibus Budget Reconciliation Act of 1990 or OBRA. It requires that facilities know how well they are meeting the needs of their residents. Facilities must have a quality assurance program in place, along with a committee to identify areas that needed improvement. The law also requires a facility to design ways to improve the delivery of services and to follow-through with the changes. While the law allows the activity professional to be one of the committee members, up to now they were seldom chosen.

On July 1, 1995, the OBRA regulations were updated. There were many changes made to the original interpretation but the most significant changes were in the survey process and how the regulations are enforced. One change made it easier to identify the severity of violations. (A violation occurs when a service or piece of equipment is below standards and, therefore, potentially harmful to the resident.) The authors of the newly changed regulations realized that not all violations were an equal threat to the resident’s health. To help staff make decisions about which problems to address first and to help surveyors provide consistent surveys from one facility to the next, a grid was developed. This grid helps identify an incident’s severity and scope. (Scope looks at how often it occurred and how many people it affected.)

The grid also includes the penalties that may be applied by the survey team to assure Substantial Compliance. (Substantial compliance is the term used to indicate that a facility is meeting the minimum expectations for providing quality services.)

A facility is expected to provide services that meet each resident’s physical, social, emotional and psychological needs. However, in reality, errors happen, residents’ needs are missed or not addressed, staff call in sick and other problems arise. Even the best facility has difficulty providing quality services all of the time. Because of this, each facility must have an ongoing program to identify problems, determine needed changes, make those changes and monitor the results. For such a system to work, everyone must be involved at some level.

The basic idea behind a good quality assurance program is that each department is always evaluating its services and determining areas of possible weakness. The program involves all staff members and holds each of them responsible for follow-through. This constant review is referred to as a Continuous Quality Improvement or Total Quality Improvement.

The activity professional is responsible for paying attention to his/her activity program, running his/her department and understanding the specific federal and state requirements that apply to both. For facilities that voluntarily agree to follow standards outlined by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) or the Commission for the Accreditation of Rehabilitation Facilities (CARF), the activity professional must also meet the additional requirements of those organizations.

Even the best run department will have at least one area of service that could be improved. Under quality assurance requirements, the activity professional must identify the most pressing problem, have a plan to correct the problem and have documentation that progress was checked at least once every quarter. If the problem is not being corrected fast enough, the activity professional must modify the plan.

Some departments may find that they have more then one problem that is significant enough to have them out of substantial compliance (or to fail survey). An example is having late quarterly updates and having staff who forget to wash their hands between sessions (infection control). In this case, the activity professional will be tracking the progress of two plans of continuous quality improvement.

The rest of this book will help you understand the terms used when talking about quality assurance; outline the basic, minimum actions you must take to meet standards; and provide you with some of the basic policies, procedures and forms you will need to implement a continuous quality improvement program. While many of the examples in this book are from long term care settings, the information can be used in any health care setting: pediatrics, rehabilitation,