2019 QIA Sustainability Plan

* 1. Quality Improvement Activity

Please check the Quality Improvement Activity your facility participated in this year. *If your facility participated in more than one QIA, check only ONE improvement activity per submission of the Sustainability Plan. The QIA Sustainability Plan needs to be completed for each separate QIA your facility participated in.

Transplant

Hospiltalization

Infection Detection: Blood Stream Infection

Long Term Catheter

Home Referrals

2. Facility Name*

Please select your facility from the dropdown list, if you do not see your facility on the list use the " Not listed" option in the drop down.

Select

If your facility is not listed above, please write in the CCN and full facility name below.

3. Enter your first and last name*

4. Enter your email address*

5. What is your title? (i.e. Facility Administrator, Clinic Manager, etc.)*

Select

6. Does this facility/organization have a Regional Manager, Director of Operations, or other Corporate Leader?*

Yes

No (if "No", go to question #9)

Don't know

7. If yes to question 6, what is this person's first and last name?

8. Email address for the Regional Manager, Director of Operations, or other Corporate Leader

9. Standardization:

In order for this to become the culture, standard, or usual business in your facility, please provide specific examples of how you will hardwire and prioritize these processes into your current system.

Standardization Example*

(For example: Do you have a policy and procedure, algorithm, checklist, or best practice for these processes and how will you prioritize these interventions into daily work?)

10. Utilization:

How will you utilize frontline staff and corporate leadership to implement these changes?

Utilization Example*

(For example: How could your corporate leadership be instrumental in assisting you at the clinic level to maintain gains and positive outcomes from the quality improvement activities that you have participated in?)

11. Share:

How will these new changes, or changes to existing processes, be communicated with existing staff, new staff, PRN staff, patients, and family members? How will feedback be obtained and addressed from each group?

Share Example*

(For example: Do you have a communication plan?)

12. Transparency:

How can you and/or management make these changes transparent to support and foster a culture of trust between management, staff, and patients?

Transparency Example*

13. Accountability:

How will you build accountability and escalation steps into this sustainability plan to alert you when problems arise that will keep you from sustaining performance and meeting goals?

Accountability Example*

14. Intergration:

How will these processes be integrated into daily work and how will you align them with organizational or departmental goals?

Intergration Example*

Never Go Back

(For example: Identify the most effective tools or interventions from this QIA that will be used to maintain the gains. How will you visually display progress sustained (i.e. an explanatory chart posted on staff and/or patient bulletin board)? What role will the staff, patients, and corporate leaders have in supporting these interventions?)

Never Go Back Example*

If you Disagree or Strongly Disagree comment

DO NOT EMAIL ANY PATIENT-SPECIFIC INFORMATION (NAME, DATE OF BIRTH, SOCIAL SECURITY NUMBER, ETC.) TO THE NETWORK 14 OFFICE.

STEP 1: Complete this survey within 10 business days of receipt. STEP 2: Before submitting this survey, check the box at the bottom of the form and enter your email. Right click mouse to print this Sustainability Plan and keep a copy at the facility. Then click on the Submit button. STEP 3: Obtain the signature and approval on the printed Sustainability Plan of one of the following: Regional Manager, Director of Operations, or other Corporate Leader. STEP 4: Upload your signed Sustainability Plan to the Network. STEP 5: Complete this process for EACH QIA your facility participated in ONLY at the time it is requested by the QIA project lead. STEP 6: Lastly, IMPLEMENT your plan and incorporate progress and results in monthly QAPI meetings. You will have TEN business days from receipt of this survey to complete your sustainability plan. Regional Manager, Director of Operations, or other Corporate Leader (Signature): ______________________________________________

Regional Manager, Director of Operations, or other Corporate Leader (Print Name):*

Date Sustanability Plan Approved*

Verification*

Did you check the "Send me a copy of my responses" checkbox, before clicking on the Submit Sustainability Plan button?

Yes

No

Send me a copy of my responses