Native Village of Eyak -- Ilanka Community Health Center

Quality Improvement Plan and Program

Mission

Providing personalized quality health care for the entire community.

ICHC offers primary health, urgent and long term care. Our professional staff consists of a
Medical Director, Mid-level Practitioners with a compliment of support staff.

Purpose

Native Village of Eyak -- Ilanka Community Health Center (ICHC) recognizes the Continuous
Quality Improvement (CQI) Plan and Program as a critical element in the success of ICHC. The
purpose of CQI is to monitor and evaluate standards of health care delivery. The CQI Plan
provides mechanisms and oversight to assure accountability for quality patient care and
services provided through an integrated program of quality improvement strategies, studies,
monitoring, audits, and education. The CQI program promotes the effective and efficient
utilization of health care resources, to seek and offer services and programs to meet the
community health care needs.

In order to achieve this purpose, the CQI plan will provide guidelines for documenting quality,
identifying problems, correcting deficiencies and making improvements in the delivery of health
care. ICHC’s CQI Plan supports our mission and is a means of meeting our organizational
commitment to continuously improve quality of care and services.

Scope of Services

The ICHC offers primary health and for individuals and families of all ages. Our professional
staff consists of a Medical Director, Nurse, Mid-level Providers (nurse practitioners, physician
assistants) with a full complement of support staff.

Goals

The goal of the ICHC CQI Plan is to provide continuous and incremental performance
improvement toward the delivery of quality health care that is efficient, cost effective, and
consistent with the mission of ICHC.

It is our goal to ensure access to care for all persons in Cordova, maintain a quality workforce,
provide a safe and positive work environment, and to evaluate and recommend solutions that
affect the viability and productivity of the ICHC.

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Objectives

1. Quality of Care and Health Improvement – Implement a system to assess document

and report performance and improvement in clinical care by:

Strategies

A. Quality of Workforce and Work Environment – Develop and maintain a workforce

and work environment to ensure quality service delivery.
B. Compensation – Ensure quality patient services by providing competitive salaries and
benefits to ICHC staff based on annual review of job descriptions, salary range, and
benefit.
C. UDS Reporting – Implement a practice management system to address UDS reporting
requirements and evaluate results annually to determine quality improvement
opportunities. Utilize the EMR to obtain A1C, BP, immunizations, prenatal, pap
smears and other health disparities as required.
D. Patient Surveys – Conduct patient surveys to provide feedback on topics such as
satisfaction, quality of care, barriers to access care. Clinic patients will receive 2
surveys ER/Outpatient will receive surveys the 2nd month each quarter.
E. Peer Review – Conduct a peer review to monitor standards of care.
F. Incident Reporting – Ensure incident reporting system addresses risk management
issues, safety of adverse events addressed, confidentiality, security, interpersonal
communications and other related issues for the purpose of reducing such events.
G. Health Improvement – Ensure clinical guidelines based on health care industry
standards guide clinical care to patients. Evaluate any health related topics.
H. Training – Ensure training needs provide opportunities, including continuing education
ensuring staff is current in their areas of expertise, certification and licensures.
I. Credentialing and Privileging – Verify and approve professional credentials and grant
clinical privileges established for ICHC.
J. Performance – Ensure regular employee performance evaluations.
K. Work Environment – Conduct regular work environment/systems evaluations to
maintain optimal work performance.
L. Safety – Oversight responsibility for safety programs within the medical center.
Review safety issues and address them in a timely fashion.

2. Access to Care – Identify barriers to care and develop and implement strategies to
overcome barriers to care for ICHC’s targeted population.

Strategies

A. Outreach – Utilize patient surveys and appropriate feedback to identify and

develop recommendations to overcome specific barriers to include facilities,
financial, cultural, language and medical transportation.
B. Facilities – Evaluate and identify barriers to access to include facility design and
configuration, equipment, furnishings and other elements of ICHC.
C. Financial – Evaluate and make recommendations as to financial policies,
discounts, payment plans, collections processes and office management systems.
D. Culture and Language – Identify cultural and language characteristics of the
population, identify barriers and implement specific approaches to reduce these

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 barriers. Provide staff training in cultural awareness specific to the cultures.
Maintain a list of options for interpreters who can assist patients.

3. Financial Viability and Productivity – To develop and implement financially viable

and productive programs that result in a strong organization and high quality service.

Strategies

A. Cost – Identify and monitor the costs of providing services. Establish charges for
services utilizing available resources to include local provider prices, reimbursement
rates and relative value unit analysis as appropriate for maturity of organization.
B. Reimbursement – Evaluate and monitor coding and billing systems and identify
strategies to assure appropriate charges and reimbursement for services.
C. Productivity – Evaluate, monitor and identify strategies to improve staff productivity
by recommending systems, equipment, programs, processes, policies, procedures
and/or training to reduce redundancy, streamline work to maintain or improve the
quality of care to patients by maintaining safe and efficient work environment.

Authority/Responsibility

Native Village of Eyak Tribal Council

The Tribal Council is ultimately responsible for the continuous quality improvement and
process. The Administrator is responsible for the ICHC staff to coordinate the activities of the
Continuous Quality Improvement Team (CQI Team) and development and implementation of
the CQI Plan and Program after adoption by the Ilanka Community Wellness Advisory
Committee and the Native Village of Eyak Tribal Council.

Administrator

The Administrator or designee has an active role in the CQI process but may delegate the
management and implementation to the Medical Director or designee. The Administrator or
designee has the overall authority and responsibility for the CQI Program. The Administrator is
responsible for regular reports to the Tribal Council and the Ilanka Community Wellness
Advisory Committee concerning Continuous Quality Improvements delineating opportunities to
improve care/services, actions taken and improvements resulting from monitoring and
evaluation activities.

Quality Management Committee

The CQI TEAM has been established to develop, implement, monitor and evaluate aspects of
the CQI Plan. The team includes the Administrator or designee, Medical Director, Office
Manager, Billing Specialist, RN, and any others as assigned. The specific duties of the team
include:

1. Meetings – The committee convenes at regularly scheduled meetings on at least a

quarterly basis, or more frequently if deemed necessary.

2. Minutes – Prepare and keep an accessible file of minutes of each CQI Meeting.
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3. Findings – The findings of the CQI Team shall be routinely reported to the Administrator,
Tribal Council, ICWAC, and staff.

4. Recommendations – Based on findings and analysis, the CQI Team shall make
recommendations to the Health Center Director. The Health Center Director shall make
recommendations to the ICWAC, and Tribal Council for the revision of the CQI Plan. .

Quorum
A quorum consisting of either four voting members or 50% of the voting members, whichever is
less, but at no time without the Medical Director, must be present for the committee to conduct
business.

The Medical Director or designee is responsible for notifying committee members about the
meeting schedules. Whenever possible, an agenda and any necessary reading materials will
be provided to participants in advance to prepare for discussion.

Authority
The CQI Team has the authority to formally recommend policies, procedures, and protocols
that promote the improvement of health care services for patients and/or plan members. The
Tribal Council and ICWAC have the full authority to adopt the CQI TEAM recommendations.

Functions
1. The CQI Team is responsible for developing and maintaining the Quality Improvement
Plan, annual Quality Work Plan and annual CQIP Evaluation.

2. The CQI Team is responsible for the selection of routine monitoring and evaluation topics
and special studies that are relevant to the demographic and epidemiological
characteristics as well as having a potential impact on the patient population served, as
well as the evaluation of resources utilized. These monitors must include but are not
limited to:

Provider access, availability, timeliness Patient Satisfaction Provider Satisfaction

Standards of care Utilization of services Sentinel events/adverse outcomes Medical
records for content, completeness and quality of entries, Regulatory Compliance Safety
and Infection Control Patient complaints/grievances Site visit audits Medication use
Preventive Health Measures Credentialing

3. The CQI Team assures the information and findings of quality management activities are
used to detect trends, patterns of performance or potential problems and to develop and
implement corrective action plans. It assures necessary information is communicated to
appropriate individuals, departments, providers or services where problems or
opportunities to improve patient care are identified.

4. The CQI Team is responsible for the development and approval of clinical guidelines are
based on scientific evidence, with quality indicators to monitor provider performance, and
methods to communicate guidelines as well as individual and group performance to
providers. These guidelines include, but are not limited to, standards instituted and
approved by the: American Academy of Family Physicians American Board of Internal
Medicine American Academy of Pediatrics American College of Obstetricians and

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 Gynecologists Alaska’s Child Health and Disability Prevention Program Health Employer
Data and Information Set (HEDIS) Federal Outcome Measurements United States
Preventive Health Task Force

5. The CQI Team is responsible for the review, necessary research and response when a
grievance is filed. After analyzing findings pertinent to grievances, the Committee takes
action as appropriate.

6. To keep personnel informed of decisions made regarding the overall CQIP.

7. Utilizing a standardized format, report findings and recommendations of quality

improvement activities at least quarterly to the Administrator who reports findings to the
Tribal Council and ICWAC including conclusions and recommendations for action and
follow-up on identified opportunities to improve care and problems.

8. The Administrator reviews the scope, objectives, organization and effectiveness of the
CQI Team at least annually and reports to the Tribal Council and ICWAC.

9. The CQI Team reviews for approval any and all requests for conducting research
activities having access to patients or patient confidential information.

10. The CQI Team reviews periodically all existing policies, practices, and procedures
relative to patient care and recommends appropriate or necessary changes.

MEETING MINUTES AND RECORDS

Records are maintained at every level of the CQIP program. Minutes include the name of the
committee, date, time of meeting, list of members present, absent and/or excused, and the
names and titles of guests, if applicable. Any and all minutes need to reflect conclusions of
monitoring and evaluation activities, recommendations, actions, and effectiveness of actions
taken, including rationale, the status of any activities in progress, and a description of the
discussion involving recommended studies and corrective action plans.

A standardized agenda and minute’s format, including reference material attachments, are
used for each meeting. Unresolved agenda items will be successively carried forward meeting
to meeting until resolved. The minutes will reflect review and approval by the CQI TEAM.

All agendas, minutes, reports and documents presented to the Quality Management
Committee are marked as “Prepared for the Quality Management Committee.” Locked minutes
are stored on the shared drive and posted within 2 days of the meeting. Passwords to the
locked minutes are kept by Administrator or designee and the Medical Director.

COORDINATION OF FUNCTION

All areas of patient care will participate in the relevant identification of important aspects of care
and the identification of indicators to monitor the quality of the identified important aspects of
care. Necessary information will be communicated amongst appropriate staff when
opportunities to improve or problems involve more than one area.

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SAFETY AND RISK MANAGEMENT

The CQI Team assures there is a program that addresses the duties and responsibilities for
Safety and Risk Management. This includes but is not limited to:
A. Evaluating adverse events and identify areas for improvement to reduce the severity and
frequency of such occurrences;

B. The development of policies and procedures outlining the mechanisms of risk

identification, evaluation, tracking and corrective action;

C. Assures the facility has the necessary personnel, equipment, and procedures to handle
medical and other emergencies that may arise in connection with services sought or
provided;

D. Provides periodic instruction to all personnel in the proper use of safety, emergency and
fire-extinguishing equipment;

E. Provides a comprehensive emergency plan to address internal and external

emergencies, including evacuation and drill procedures;

F. Assures appropriate personnel are trained in cardiopulmonary resuscitation (CPR) and

the uses of cardiac emergency equipment are present in the facility during hours of
operation;

G. Assures provisions are made to reasonably accommodate handicapped individuals;

H. Assures the facilities are clean and properly maintained;

I. Assures a system exists for proper identification, management, handling, transport,

treatment and disposal of hazardous materials and wastes and in compliance with waste
enforcement agencies;

J. Assures appropriate emergency and other equipment and supplies are maintained,
periodically tested and readily accessible;

K. Assures compliance with AK-OSHA laws regarding an effective injury prevention

program. The program must be in writing and must identify, evaluated and correct
workplace hazards.

UTILIZATION REVIEW

The utilization review process addresses under-utilization, over-utilization and inefficient

scheduling of resources to assure effective utilization of health care services for all patients
while maintaining a cost-effective optimal level of care.

PHARMACY AND THERAPEUTICS

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The functions of Pharmacy & Therapeutics (P&T) will be performed by a committee of all
physicians practicing at ICHC who will recommend policy all matters related to the use of
drugs.

PATIENT RIGHTS, SATISFACTION, COMPLAINTS AND GRIEVANCES

Complaints and Grievances. There is a system for the receipt and timely management of
patient/member/provider complaints or formal grievances and appeals. Periodic aggregation
and analysis of complaint and grievance data is utilized to improve the quality of services and
care. See Policies and Procedures on Patient Complaints/Grievances.

Patient Rights. There is a process of formulating procedures which outline patient rights and
responsibilities. The CQI Team is responsible for assuring that patient rights are evaluated and
revised on an annual basis.

These include policies that require:

Patients are treated with respect, consideration, and dignity;

Patients are provided appropriate privacy during interviews, examination, treatment

and consultation;

Patients are provided to the degree known, complete information concerning their
diagnosis, treatment and prognosis. When it is medically inadvisable to give such
information to a patient, the information is provided to a person designated by the
patient or to a legally authorized person;

Patients are given the opportunity to participate in decisions involving their health
care, except when such participation is contraindicated for medical reasons.

ACCESS TO CARE

The CQI Team establishes written time frame standards for access that include preventive care
appointments; routine, long term care, urgent and emergency care; after hours care; telephone
appointment responsiveness; and patient service telephone responsiveness.

MEDICAL RECORDS

The CQI Team is responsible for:

A. The quality and timeliness of the documentation.

B. The completeness of the documentation.

C. Establishing policies and procedures according to regulations pertaining to clinical

records including completion, forms and formats, filing, indexing, storage, destruction,
availability and methods of procedure enforcement.

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D. Maintaining confidentiality of records and patient identifiable information in accordance
with applicable laws and regulations.

E. Establishing policies for EMR, changes to system and correction of system.

F. Monitoring staff compliance with policies and procedures pertaining to medical records.

INFECTION CONTROL

The CQI Team is responsible for assuring there is a process in place to address the duties and
responsibilities of infection control. These duties include but are not limited to the following:

A. Establishing a program for identifying and preventing infections, and maintaining a

sanitary environment as established by laws and regulations governing infection control
in health care facilities;

B. Devising and implementing procedures to minimize sources and transmission of

infection, including adequate surveillance techniques;

C. Recording, evaluating, reporting and acting on reported incidents of infection exposure;

D. Adequate reporting of infectious disease processes to the appropriate government and

regulatory agencies;

E. Providing a system to monitor compliance with policies and procedures related to

infection control;

F. Establishes an ongoing education program for employees, patients and visitors regarding
infection control and general safety procedures. The Committee assures the appropriate
infection control policies and procedures are implemented and hold Medical Director
accountable for the day-to-day responsibilities of infection control.

CONTINUING EDUCATION PROGRAM

The CQI Team establishes and has oversight for assuring adequate continued education for
professionals and staff. This may include but is not limited to:

A. Convenient access to library services, internet and professional resources that include
materials pertinent to the clinical, educational, administrative, and research services
offered by the organization.

B. Adequate orientation and training to familiarize all personnel with the organization’s
policies, procedures and facilities.

C. Encourage participation in seminars, workshops, and other educational activities within

budgetary allowance.

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D. Monitor evidence of participation in relevant external education programs when
attendance at educational activities is required of processional personnel.

E. Monitor continued maintenance of licensure and/or certification of professional

personnel.

HEALTH EDUCATION

The CQI Team assures the implementation of a comprehensive health education program that
is provided in the languages of the population served.

TRACKING ABNORMAL RESULTS

The CQI Team assures that there are written policies and procedures regarding abnormal test
results that include a physician notification system, patient notification system and medical
record documentation.

PEER REVIEW

ICHC’s standards of professional practice include a planned, systematic, and comprehensive

monitoring process to review and evaluate and improve the quality and effectiveness of service
and care provided by the professional staff of the organization. All aspects of provider service
and care will be considered for review. Selection for study most often will focus on common
problems and issues where improvement will have significant impact on quality improvement.

CREDENTIALING

The Health Care Quality Improvement Act of 1986 outlines the responsibilities for appointment
procedures. The act’s purpose is to improve the quality of medical care both by providing
limited immunity from liability to those who participate in or supply information in conjunction
with peer review activities and by requiring adverse medical staff decisions to be reported to a
central information bank.

The CQI Team is responsible for assuring the implementation of a system that investigates,
verifies, and considers each application for appointment or reappointment of the employed and
contracted clinicians. The criteria for consideration of all applications are defined in the
Credentialing Plan.

CLINICAL GUIDELINES

The CQI Team is accountable for adopting and implementing practice guidelines or explicit
criteria based on reasonable scientific evidence. These guidelines will be reviewed on an
ongoing basis and updated or revised as necessary then or in the interim if new information
becomes available. Physicians are involved in the adoption or development of the clinical
practice guidelines. Physician and other provider performance will be assessed using
indicators based on these guidelines and standards of care. Clinical guidelines topics will focus
on high volume or high-risk services and procedures.

AUDITS AND SURVEYS

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The CQI Team will conduct audits and surveys deemed necessary by the Committee. The
findings along with recommendations are also presented to the Administrator and the Tribal
Council and ICWAC. Desirable characteristics of the criteria are that the data is relevant,
understandable, measurable and able to alter patterns or change is achievable.

SENTINEL EVENTS

The CQI Team is responsible for assuring the establishment of a process to detect and
evaluate sentinel events, which should call attention to problems for which earlier intervention
might have avoided adverse outcomes. These are reported and reviewed individually to the
CQI Team for investigation and corrective action.

QUALITY MANAGEMENT PROCESS

The CQI Team has the authority to review all quality improvement activities. This committee
functions in an oversight capacity. It’s responsible for ensuring that all quality improvement
activities are continuous and effective in improving performance and ambulatory health care
and dental service delivery.

Important Aspects of Care and Service

A. Quality improvement current and retrospective reviews will be completed using quality
monitors and audits for high volume, high risk, high cost, acute and chronic conditions.
The demographic and epidemiological characteristics of the patients served are used in
the selection of important aspects of care for routine monitoring, evaluation and special
study.

B. These aspects of care will also include those established and required by the various
contracts and licensing requirements currently held by the health center.

C. Problems and/or findings of quality review or monitoring reports will be used. Each will be
tracked to assure improvement or resolution.

D. Incident reports are tracked and trended and the information is presented at the CQI
Team meeting. These include pharmacy reports of adverse reaction.

E. Other important aspects include: Evaluation of Clinical Performance Patient Satisfaction

Access and Availability of Services Continuity of Care (Includes Health Education and
Health Maintenance/Preventive Health Clinical Records Maintenance Patient
Compliance Appropriateness of Services (To Include Utilization of Resources,
Emergency Services, etc.) Cost and Effectiveness of Services Support Staff Performance
Environmental Safety and Infection Control.

Monitoring and Evaluation

A. Monitoring and Evaluation is conducted over time for all types of services provided.
Performance goals and/or benchmarks are established for each indicator selected to
measure, analyze and track quality improvement. For use in the monitoring and evaluation

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 process are developed by the CQI Team using current published literature and standards
as well as the opinion of recognized experts in the field of study.

The frequency for evaluation of the data depends on the frequency, significance and
extent needed to demonstrate the indicator is problem free. Evaluations can also be
prompted by important single clinical events and patterns in care outcomes that are a
significant variance with predetermined outcome criteria. The CQI Team will then fully
evaluate the concern by objective and/or quantitative methods to define the specific
problem. The CQI Team members are responsible for analyzing the process or problem
identified.

Tools and techniques for analysis include but are not limited to the following:

Tools Techniques

Flowcharts Brainstorming Histogram Story boarding Data Collection Sheet Silent Idea
Generation Control Chart On-site Observation Scatter Diagram Interview Pareto Chart Focus
Group Run Chart Cause & Effect Diagram

The CQI Team proceeds to implement a problem solving action based upon its findings and the
objective parameters previously measured. Action taken on identified opportunities to improve
care/service, problems and sentinel events is prioritized according to its impact in terms of
urgency and severity. Preliminary investigation of all issues identified is conducted in order to
prioritize and to prevent further action on items that are identified as non-problems.

After adequate time has been permitted for the problem resolution, a re-evaluation is
performed using the same quantitative measures. The CQI Team bases the re-evaluation time
frame (one month, three months, six months, etc.) on the severity of the problem.
Documentation includes:

1 Definition of the area identified to improve care and service.

2 Results of evaluations are used to improve clinical care and services.

3 Problem definition and recommended action.

4 Implementation of improvement process.

5 Results of action implemented.

6 Follow-up on identified issues, to ensure actions for improvement have been effective.

7 Data collected to monitor provider performance is also evaluated. Such evaluations are
done on an annual or as-needed basis when there is a desire to improve the overall
performance. Appropriate clinicians will participate in the evaluation of clinical
performance.

Communication

Recognizing that quality improvement is a continuous process, the findings and information will
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be communicated to all areas of service as appropriate. Communication includes but is not
limited to:

• Evaluation of Findings
• Conclusions
• Recommendations
• Actions to Improve Care
• Continued Monitoring
• Follow-Up (including date, responsibility, and summary)
• Effectiveness of Actions
• Communication of Findings

Employees are provided with training and education to keep them informed of their role in
continually improving the quality of care and services and to strive to exceed minimal
requirements and the importance of communication or results and/or identifying problems.

ANNUAL EVALUATION

Based in part upon the annual appraisal report prepared by the Medical Director, the CQI Team
will conduct a review of the Quality Improvement Plan. The evaluation of the plan’s
effectiveness will be documented. This report will include review of the goals for the previous
year and the status of such goals.

The CQI Team will then begin to prioritize goals for the coming year. The goals will be
presented to the Tribal Council and ICWAC for review and approval as an annual work plan.

CONFIDENTIALITY

The Health Care Quality Improvement Act of 1986 was enacted to provide a mechanism to
improve the quality of medical care. The act provides immunity from liability for damages with
respect to actions taken in the course of such review. Business and Professions code 805-809
and Evidence code 1157 stipulate the process for granting immunity from discovery to records
and proceedings of quality improvement and peer review activities.

Every member of the CQI Team should participate in the discussions. However, Confidentiality
Statements are to be signed by all physicians, support personnel, and guests attending CQI
TEAM meetings. The statement will include elements that provide for confidentiality of all
information shared. The confidentiality agreement shall be maintained in the provider file,
employee file or guest file as appropriate. These statements shall be renewed annually. All
peer review records and proceedings will be confidential.

Because of the goals and objectives of the Quality Improvement Plan, oftentimes, confidential
as well as sensitive information may be discussed during the CQI Team meeting. Therefore, it
is understood by all participants that any information and parties discussed and/or under
investigation as well as the CQI Team any and all documentation, which is an integral part of
such a program, is confidential. As a result, this information is maintained in a manner that will

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preserve its character as not discoverable or admissible in a court of law as provided by state
law.

Records shall be respected by participants and maintain strict confidentiality and policies
pertaining to confidentiality shall be enforced.

Copies of all minutes, reports, data, medical records and other documents used in quality
and/or utilization review are maintained in a manner that will ensure confidentiality of the
patient and providers involved in each case.

All quality management and improvement discussion items will be de-identified, particularly in
committee and the minutes.

All health care practitioners’ names should be coded so that discussion can take place without
anyone identifying whom the discussion is about. The Administrator will keep the key to these
codes in a locked area. Each physician should be aware of his or her own individual code, but
should not know any other code.

Access to these records is restricted to the selected administrative personnel as deemed

necessary (i.e., Administrator, Legal Counsel, Tribal Council and ICWAC). All sensitive
information, medical records and CQI Team are maintained in locked files.

Quality Management Committee reports, minutes, audit results and other quality assessment
and improvement documentation are only distributed for review to the Administrator and Tribal
Council and ICWAC.

PROTECTION FROM DISCLOSURE

Records and findings are confidential and used by CQI Team members in the exercise of the
functions of the council and committee. Records of these committees are not public records
and not subject to court subpoena.

CONFLICT OF INTEREST

No individual may participate in the review, evaluation or final disposition of any case in which
he/she has been professionally involved or where judgment may be compromised.

APPROVALS

______________________________ _________________
ICHC Administrator Date

_____________________________ _________________
Tribal Council President Date

_____________________________ _________________
ICWAC President Date

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 Continuous Quality Improvement Plan

Objective Strategy Schedule

CQI Meeting Administrator, Medical January, April, July, October
Director, Support Staff
1. Quality of Care a. Annually – October, and
a. Patient Surveys
and Health Ongoing
Improvement b. Peer Review b. Quarterly – February, May,
August, November
c. UDS a. February--March
d. Incident Reporting d. Ongoing – Reviewed at each
meeting
e. Health Improvement e. Ongoing – Medical Director
and Providers will develop at the
Provider Meetings – to be
reviewed quarterly at CQI Team
Meeting.
f. Quarterly focus audit for
healthcare or service topic.
2. Quality of a. Compensation a. August
Workforce and b. Training b. Ongoing
Work Environment c. Credentialing and
c. Upon hiring and bi-annually
Privileging
d. Performance d. October
e. Work Environment e. Ongoing
f. Safety f. Ongoing
3. Access to Care a. Surveys a. Bi-annual – April, October
b. Facilities b. Ongoing
c. Financial c. Periodic
d. Culture and Language • d. Ongoing
Interpreter List Begin June 2010 –
Training Begin June 2010 and
periodically
e. Outreach e. Ongoing
4. Financial Viability a. Cost • Monitor Costs •
and Productivity Charges • Monthly • March
b. Reimbursement b. Periodic
c. Productivity c. Ongoing

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 Agenda Items for Scheduled Meetings January

1. Quality of Care and Health Improvement

Patient Surveys from October

Peer Review from November
Incident Reports
Health Improvement – Clinical Guidelines and Focus Audit

2. Quality of Workforce and Work Environment

Training
Credentialing and Privileging
Performance
Work Environment
Safety

3. Access to Care

Surveys
Facilities
Financial
Culture and Language
Outreach

4. Financial Viability and Productivity

Costs --Monitoring
Reimbursement
Productivity Any necessary business

Agenda Items for Scheduled Meetings April

1. Quality of Care and Health Improvement

Peer Review from February

UDS Report
Incident Reports
Health Improvement – Clinical guidelines and Focus Audit

2. Quality of Workforce and Work Environment

Training
Credentialing and Privileging
Work Environment
Safety

3. Access to Care

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 Facilities
Financial
Culture and Language
Outreach

4. Financial Viability and Productivity

Costs – Monitor Costs and Charges

Reimbursement
Productivity

5. Any necessary business

Agenda Items for Scheduled Meetings July

1. Quality of Care and Health Improvement

Peer Review from May

Health Improvement – Clinical Guidelines and Focus Audit

2. Quality of Workforce and Work Environment

Training
Credentialing and Privileging
Work Environment
Safety

3. Access to Care

Patient Surveys from April

Facilities
Financial
Culture and Language

4. Financial Viability and Productivity

Costs – Monitor Costs

Reimbursement
Productivity

5. Any necessary business

Agenda Items for Scheduled Meetings October

1. Quality of Care and Health Improvement

Peer Review from August

Incident Reports
Health Improvement – Clinical Guidelines and Focus Audit

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2. Quality of Workforce and Work Environment
Compensation
Training
Credentialing and Privileging
Safety

3. Access to Care
Facilities
Financial
Culture and Language
Outreach

4. Financial Viability and Productivity

Costs – Monitor Costs

Reimbursement
Productivity

6. Any necessary business

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___________________________________ __________________

Robert Henrich, NVE Tribal Council President Date

__________________________________ __________________

Keren L. Kelley, Health Director Date

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