Asthma
|
Problem/Need
Statement:
The percentage of patients who have been screened for asthma and demonstrate
compliance with their condition is low which increases their risk of
mortality and morbidity. This is a
major problem for the underserved who may not know that they are at
risk. Early detection and management
will decrease complications from the life-long disease. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Increase
the number of patients receiving testing and early intervention in the
management of asthma. A.1.
All patients will be screened at first visit for asthma. A.2.
Asthmatic patients and/or their family members will be educated about asthma
intervention and self-management. |
A.1.
Screen all new patients for family history and symptoms of asthma. A.2.(a)
Provide patient and family educational material. (Education, intervention,
and self-management to be included in each patient encounter.) Instruct patient regarding self monitoring
with peak flow meter, and provide meters as needed. A.2.(b)
Refer asthmatic patients to asthma clinic when appropriate. |
A.1.
By 6/05, 100% of new patients will have been screened for history and
symptoms of asthma. A.2.(a)
By 6/05, asthma education and interventions for management will be included
at each encounter for asthmatic patients. A.2.(b)
By 6/05, an efficient method of tracking patients who actually attend asthma
clinic will be instituted. |
A.1.
Medical Records, QA/QI A.2.(a)
Medical Records, QA/QI A.2.(b)
Medical Records, QA/QI |
A.1.
Clinical Staff A.2.(a)
Clinical Staff A.2.(b)
Medical Director, Clinical Committee, QA/QI Team |
A.1.
5-Year Strategic Plan, Appendix A (1) A.2.(a)
5-Year Strategic Plan, Appendix A (1) A.2.(b)
5-Year Strategic Plan, Appendix A (1) |
|
B.
2006-2007 Goal: Evaluate
effectiveness of asthma treatment and education |
B.
Track progress of random sampling of asthmatic patients |
B.
By 6/06, an evaluation of the effectiveness of the asthma treatment and
education program will be completed. |
B.
Medical Records, QA/QI |
B.
Medical Director, Clinical Committee |
B.
5-Year Strategic Plan, Appendix A (1) |
|
C.2007-2010
Goal: Continue
to expand service as patient need dictates |
C.
Track patient asthma demographics and assess need for additional equipment
and/or staff |
C.
By 12/09, MCCHC will have sufficient equipment and staff to adequately
provide quality intervention and management skills to its asthmatic patients. |
C.
Medical Records, QA/QI |
C.
Medical Director, Clinical Committee, QA/QI Team |
C.
5-Year Strategic Plan, Appendix A (1) |
Behavioral
Health
|
Problem/Need
Statement: Patients
of MCCHC do not have sufficient access to behavioral health care, due to a
lack of providers and barriers of location, transportation, and
scheduling. Approximately 40% of MCCHC
patients need addictive services. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Increase
access to behavioral health services A.1.
Enhance behavioral health referral system A.2.
Request mental health HPSA designation |
A.1.(a)
Seek additional mental health agencies for referral sources. A.2.(b)
Develop MOU’s with above agencies for the provision of behavioral health
services to MCCHC patients. A.2.
Work with IN Bureau of Primary Health Care to achieve this designation |
A.1.(a)
By 4/05, MCCHC will locate at least one additional referral source for
behavioral health issues. A.1.(b)
By 6/05, MOU’s for the above will be completed. A.2.
By 6/05, MCCHC will have obtained a mental health HPSA designation. |
A.1.(a)
Medical Records, QA/QI A.1.(b)
MOU Binder, QA/QI A.2. HRSA Documentation, QA/QI |
A.1.(a)
CEO, Medical Director A.1.(b)
CEO A.2. Administration/ IN Primary Care Association
staff |
A.1.(a)
5-Year Strategic Plan, Appendix A (7) A.1.(b)
5-Year Strategic Plan, Appendix A (7) A.2.
HRSA/Mental Health designation Protocols |
|
B.
2006-2007 Goal: Add
in-house behavioral providers to the MCCHC staff |
B.1.
Employ clinical social worker and case manager B.2.
Employ psychiatrist |
B.1.
By 9/06, a clinical social worker/psychiatric professional and a case manager
will be staffed on site. B.2.
By 12/06, a psychiatrist will be on staff. |
B.
Personnel Files, QA/QI |
B.
CEO, HR Director, and Medical Director |
B.
5-Year Strategic Plan, Appendix A (7) |
|
C.2007-2010
Goal: Enhance
and expand service as patient need dictates |
C.
Track patient usage and needs, and add staff accordingly |
C.
By 12/09, MCCHC will have sufficient behavioral staff to adequately provide
quality behavioral care to its patients. |
C.
Patient records and Personnel Files, QA/QI |
C.
HR Department & QA/QI Team and staff |
C.
QA/QI Protocols |
Breast
and Cervical
|
Problem/Need
Statement: The number of women aged 40 and older who
have ever had a breast exam/mammogram and pap smear, and the number of women
aged 50 and over who have had a breast exam/mammogram and pap smear within
the past 2 years is low. Low numbers
of screening exams are correlated with higher numbers of undetected breast
cancer and cervical cancer. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Increase
the detection of cancer of the breast and cervix in the older female, and
awareness in all ages and races. A.1.
Provide clinical breast and cervical exams to female patients over the age of
40. A.2.
Educate women receiving health care at MCCHC regarding self breast
examination. |
A.1.
Offer every woman, emphasizing those over 40, an appointment for a full
physical exam to include a breast and pelvic exam. A.2.
Provide educational materials about the importance of early detection of
breast and cervical cancer, and about how to conduct a self- breast exam. |
A.1.
By 3/06, MCCHC will have provided clinical breast and cervical exams to 75%
of its female patients over the age of 40. A.2. By 3/06, MCCHC will have provided education
regarding self-breast examination to 75% of its female patients over 40. |
A.1.
Medical Records, QA/QI A.2.
Medical Records, QA/QI |
A.1.
Medical Director, Clinical Staff A.2.
Medical Director, Clinical Staff |
A.1.
ISDH/BCCP (Breast and Cervical Cancer Program) A.2.
Published information and video tapes. |
|
B.
2006-2007 Goal: Expand
breast and cervical program with needed staff/equipment |
B.
Evaluate the need for diagnostic equipment and additional staff, and
implement according to QA/QI. |
B.
By 3/07, MCCHC will have added an OB/GYN practitioner and some diagnostic
equipment. |
B.
Medical Records, QA/QI |
B.
Medical Director, HR Director, and QA/QI Team |
B.
5-Year Strategic Plan, Appendix A (1,2) |
|
C.2007-2010
Goal: Enhance
QA/QI and continue to expand program as patient needs dictate |
C.
Track medical records for trending patterns, and implement program according
to trends and needs. |
C.
By 12/09, MCCHC will have sufficient appropriate staff and equipment to
adequately provide breast and cervical care to its female patients. |
C.
Medical Records, QA/QI |
C.
Medical Director, HR, and QA/QI Team |
C.
5-Year Strategic Plan, Appendix A (1,2) |
CHAP
|
Problem/Need
Statement:
68% of the students in |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Create
greater access to quality health care for children. A.1.
Determine health risks in children before school begins in the fall. A.2.(a)
Provide physicals, immunizations, health screenings, and health education to
children. A.2.(b)
Refer children to appropriate medical services. |
A.1.
During the months of 1/05 – 7/05, the CHAP Planning Committee will meet at
least 4 times to plan CHAP. A.2.(a)
Collaborate with Physicals Immunizations Health screenings Health education. A.2.(b)
Evaluate screening results and make appropriate referrals. |
A.1.
CHAP will have adequate providers scheduled to complete physicals and health
screenings. A.2.(a)
By 8/15/05, 500 students will have received back-to-school physicals,
immunizations, and health screenings. A.2.(b)
By 9/05, children needing referrals indicated at CHAP will have been referred
to appropriate medical services. |
A.1.
CHAP Planning Minutes, QA/QI A.2.(a)
CHAP Outcomes Report, QA/QI A.2.(b)
CHAP Outcomes Report, QA/QI |
A.1.
CHAP Coordinator, Social Services Department A.2.(a)
CHAP Coordinator, Clinical Staff A.2.(b) Clinical Staff, CHAP Coordinator |
A.1.&2.
Project CHAP was a pilot project in 2001, and has been successful for the
past 4 years. |
|
B.
2006-2007 Goal: Continue
to enhance and expand CHAP, as needed. |
B.
Offer CHAP in August of 2006 in collaboration with the school system. |
B.
By 8/15/06 |
B.
CHAP Coordinator Reports, CHAP Outcomes Reports, QA/QI |
B.
CHAP Coordinator, Clinical Committee, Clinical Staff |
B.
CHAP will be continued as long as the community needs it, and MCCHC is able
to offer it. |
|
C.2007-2010
Goal: Enhance
QA/QI and continue to offer CHAP. |
C.
Continue to collaborate with the school system and its nurses to offer needed
services. |
C.
Each year, |
C.
CHAP Coordinator Reports, CHAP Outcomes Reports, QA/QI |
C.
CHAP Coordinator, Clinical Committee, Clinical Staff |
C.
CHAP will be continued as long as the community needs it, and MCCHC is able
to offer it. |
Dental
Care
|
Problem/Need
Statement:
|
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Evaluate
current program to determine capacity for expansion. A.1.
Set hours of operation for greatest benefit A.2.Provide
adequate staffing B.
Expand to a 3-operatory facility in Elwood and add services of a part-time
dentist. C.
Enhance School Dental Program |
A.1.
Evaluate hours of operation and determine feasibility of expansion into evening
and/or weekend. A.2.(a)
Evaluate current staffing and determine needs. A.2.(b)
Establish MOU contracts with oral hygienists and explore access to pediatric
dentistry. B.
Add 3-operatory dental clinic to Elwood interim facility, and explore
services of a part-time dentist. C.
Provide dental services to 3 targeted schools. |
A.1. By 6/05, MCCHC’s dental program will be in
operation during the hours deemed most beneficial to both patients and staff. A.2.(a)
By 6/05, MCCHC will be operating its 3-operatory dental clinic with adequate
staffing for patient needs. A.2.(b)
By 6/05, MOU contracts will be in place with oral hygienists and access to
pediatric dentistry will be available. B.
By 3/06, a 3-operatory dental clinic will be in operation in Elwood, and a
part-time dentist will be on staff. C.
By 5/06, dental services will have been provided to the 3 targeted |
A.1.
Dental Records, Adminstrative Records, QA/QI A.2.(a)
Dental Records, Administrative Records, QA/QI A.2.(b)
MOU binder, Administrative Records, QA/QI B.
Administrative Records, QA/QI C.
Dental Records, QA/QI, Healthy People 2010 objectives |
A.1.
Dental Director, CEO, QA/QI Team A.2.(a)
Dental Director, CEO, HR, QA/QI Team A.2.(b)
CEO, Dental Director B.
CEO, Dental Director, QA/QI C.
Dental Director, CEO, QA/QI Team |
A.1.
5-Year Strategic Plan (13,14) A.2.(a)
5-Year Strategic Plan (13,14) A.2.(b)
5-Year Strategic Plan (13,14) B.
5-Year Strategic Plan (13,14) C.
Healthy People 2010 |
|
D.
2006-2007 Goal: Re-locate
and expand dental program |
D.1.
Relocate to new building and expand to 8-operatory with capability of
expansion to 12. D.2.
Employ pediatric dentist D.3.
Add in-house operatory for complicated procedures. |
D.1.
By 3/07, MCCHC’s dental clinic will be relocated and expanded to 8
operatories. D.2.
By 3/07, a pediatric dentist will be staffed on site. D.3.
By 3/07, an in-house operatory for complicated procedures will be
established. |
D.1.
New location, Administrative Records, QA/QI D.2.
Dental Records, QA/QI D.3.
Dental Records, QA/QI |
D.1.Board
of Directors, CEO, Dental Director, QA/QI D.2.
CEO, HR, QA/QI D.3.
Dental Director, CEO, QA/QI |
D.1.
5-Year Strategic Plan, Appendix A (9) D.2.
5-Year Strategic Plan, Appendix A (1) D.3.
5-Year Strategic Plan, Appendix A (1) |
Diabetes
|
Problem/Need
Statement:
|
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Increase
the number of patients receiving testing and early intervention in management
of diabetes. A.1.
Identify patients with diabetes. A.2.
Initiate treatment plan guidelines for diabetic patients. A.3.
Educate diabetic patients regarding self-management of diabetes. |
A.1.
Screen all patients at first visit for family history and signs and symptoms
suggestive of diabetes. A.2.
Set treatment plan with each diagnosed patient determining diet, medications,
and glucose monitoring. Provide meters as needed. A.3.
Provide verbal and written education about diabetes self-management. Refer to
in-house diabetic nutrition classes. |
A.1.
All MCCHC patients will be screened for diabetes. A.2.
By 6/05, 75% of MCCHC’s diabetic patients will be adhering to their treatment
plans. A.3.
All of MCCHC’s diabetic patients will be given appropriate education for
self-management of diabetes. |
A.1.
Medical Records, QA/QI A.2.
Medical Records, QA/QI A.3.
Medical Records, QA/QI |
A.1.
Medical Director, Clinical Staff A.2.
Medical Director, Clinical Staff A.3.
Medical Director, Clinical Staff, Nutritionist |
A.1.
5-Year Strategic Plan, Appendix A (3) A.2.
5-Year Strategic Plan, Appendix A (3) A.3.
5-Year Strategic Plan, Appendix A (3) |
|
B.
2006-2007 Goal: Evaluate
effectiveness of patient treatment plans, and revise strategies accordingly. |
B.
Utilize random sampling to evaluate the compliance and success rate of
patient treatment plans. Change
treatment plan strategy as indicated. |
B.
By 6/06, an evaluation of MCCHC’s diabetic treatment strategies will be
completed, and suggested revisions brought before the Clinical Committee. |
B.
Medical Records, QA/QI |
B.
Medical Director, Clinical Committee, QA/QI Team |
B.
5-Year Strategic Plan, Appendix A (3) |
|
C.2007-2010
Goal: Enhance
QA/QI and expand service as patient needs dictate. |
C.
Track medical records for trending patterns, and implement program according
to trends and needs. |
C.
By 12/09, MCCHC will have established a record of providing adequate health
care and self-management education to its diabetic patients. |
C.
Medical Records, QA/QI |
C.
Medical Director, Clinical Staff, Clinical Committee, QA/QI Team |
C.
5-Year Strategic Plan, Appendix A (3) |
Hypertension
|
Problem/Need
Statement:
|
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Decrease
the incidence of deaths due to stroke and heart disease in A.1.
Provide blood pressure screening to all patients A.2.
Provide education regarding management of blood pressure and interventions
for high blood pressure |
A.1.
Screen all patients over the age of three for hypertension. A.2.
Provide education materials to patients with elevated blood pressure and
stress the importance of follow-up care. |
A.1.
All patients with elevated blood pressure will be identified, on an on-going
basis. A.2.
75% of patients with elevated blood pressure will return for a second visit,
50% will return for a third visit, and 25% will return for a fourth visit. |
A.1.
Medical Records, QA/QI A.2.
Medical Records, QA/QI |
A.1.
Medical Director, Clinical Staff A.2.
Medical Director, Clinical Staff |
A.1.
5-Year Strategic Plan, Appendix A (3) A.2.
5-Year Strategic Plan, Appendix A (3) |
|
B.
2006-2007 Goal: Evaluate
management of blood pressure in patients with history of elevated blood
pressure |
B.
Review charts of a random sampling of patients with high blood pressure to
determine the history of treatment and management of blood pressure. |
B.
By 12/06, evaluation will be done and assessment of the success of current
procedures will be completed. |
B.
Medical Records, written assessment, QA/QI |
B.
Medical Director, Clinical Committee |
B.
5-Year Strategic Plan, Appendix A (3) |
|
C.2007-2010
Goal: Enhance
QA/QI based on findings of evaluation and assessment. Continue to expand services as patient need
dictates. |
C.
Implement any changes or additions indicated by QA/QI. |
C.
By 12/2009, MCCHC will provide adequate, quality health care for patients
having an elevated blood pressure. |
C.
Medical Records, QA/QI |
C.
Medical Director, Clinical Staff, QA/QI |
C.
5-Year Strategic Plan, Appendix A (3) |
Immunizations
|
Problem/Need
Statement: The
number of patients aged 65 and over who received influenza and pneumococcal
immunizations is low which increases their risk of morbidity and mortality. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: To
decrease the incidence of deaths due to influenza and pneumonia in those over
65 years of age. |
A. Offer influenza and pneumococcal vaccine to all geriatric patients who qualify. . |
A.
By 2/06, MCCHC geriatric patients will be immunized against influenza and
pneumonia. |
A.
Medical Records, QA/QI |
A.
Medical Director |
A.
5-Year Strategic Plan, Appendix A (1) |
|
Problem/Need Statement: Children
under two years of age, especially Hispanic population, are under immunized
in |
|||||
|
B.2005-2006
Goal: Decrease
the incidence of childhood diseases that can be prevented by early
immunization. B.1.
Increase the number of children receiving immunizations. B.2.
Increase the number of two-year olds up to date with their immunizations. |
B.1.
Provide educational materials about immunizations, in English and
Spanish. Ask patients about young
children at home. B.2.
Track immunizations currently in progress and notify parents when
appointments are missed through phone calls and mail. |
B.1.
By 6/05, MCCHC will increase the number of minority children who receive
immunizations by 35%. B.2.
By 6/05, MCCHC will increase the number of two-year olds up to date with
their immunizations by 95%. |
B.1.
Medical Records, QA/QI B.2.
Medical Records, QA/QI |
B.1.
Medical Director, Clinical Staff B.2.
Medical Director, Clinical Staff |
B.1.
5-Year Strategic Plan, Appendix A (1) B.2.
5-Year Strategic Plan, Appendix A (1) |
|
C.
2006-2007 Goal: (for
both age groups) Evaluate
and enhance immunization programs according to QA/QI standards. |
C.
Evaluate immunization tracking methods and enhance provision of services. |
C.
By 6/06, an evaluation of the immunization programs will be completed. |
C.
Medical Records, QA/QI |
C.
Clinical Committee, Medical Director |
C.
5-Year Strategic Plan, Appendix A (1) |
|
D.
2007 – 2010 Continue
to enhance program according to QA/QI standards. |
D.
Follow QA/QI Team recommendations for enhancement. |
D.
By 12/09, MCCHC will have adequate immunization programs for its geriatric
and pediatric patients. |
D.
Medical Records, QA/QI |
D.
Clinical Committee, Medical Director, QA/QI Team |
D.
5-Year
Strategic Plan, Appendix A (1) |
Pharmaceutical
Services
|
Problem/Need
Statement:
Many of the people serviced by MCCHC do not have the financial resources
needed for the medicines necessary for the needed medical management of their
health problems. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Decrease
the number of clinic patients who develop adverse sequel from lack of
necessary medication A.1.
Provide access to Patient Assistance Programs offered by pharmaceutical
companies A.2.
Provide access to a complete formulary of prescription drugs at minimal cost
to patients |
A.1.
Enroll eligible patients into appropriate Patient Assistance Programs A.2.(a)Implement
340 B pharmacy purchasing program A.2.(b)
Employ pharmacist &/or pharmacy tech |
A.1.
By 3/06, 75% of interested eligible patients will be enrolled in Patient
Assistance Programs. A.2.(a)
By 6/05, the 340B program will be implemented at MCCHC. A.2.(b)
By 6/05, a pharmacist or pharmacy tech will be staffed on site |
A.1.
Medical Records, Patient Assistance Record, QA/QI A.2.(a)
Administrative Records, QA/QI A.2.(b)
Medical Records, QA/QI |
A.1.
Enabling Services Coordinator A.2.(a)
CEO/ Administration A.2.(b)
CEO and HR |
A.1.
Social Services Protocols A.2.(a)
5-Year Strategic Plan, Appendix A (6) A.2.(b)
5-Year Strategic Plan, Appendix A (6) |
|
B.
2006-2007 Goal: Evaluate
and enhance 340 B program |
B.1. Evaluate QA/QI after one year of
implementation B.2. Enhance program by incorporating needed
additions or changes as indicated by QA/QI Team |
B.1.
By 7/06 a one-year evaluation of the 340 B pharmacy services will be
completed. B.2
By 3/07, indicated changes and/or additions will be incorporated. |
B.1.
QA/QI evaluation B.2.
QA/QI Records |
B.1.QA/QI
Team B.2.
QA/QI Team and staff |
B.
5-Year Strategic Plan, Appendix A (6) B.2.
5-Year Strategic Plan, Appendix A (6) |
|
C.2007-2010
Goal: Continue
to expand service as patient need dictates |
C.
Track patient usage and needs, and add staff and formulary accordingly |
C.
By 12/09, MCCHC will have sufficient pharmaceutical and enabling staff, and a
broad enough formulary to adequately provide quality pharmaceutical access to
its patients. |
C.
Pharmacy Records, Medical Records, QA/QI |
C.
Pharmacy Department, QA/QI Team |
C.
5-Year Strategic Plan, Appendix A (6) |
Prenatal
|
Problem/Need
Statement:
|
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Reduce
infant mortality rates in ethnic and minority populations. A.1.
Determine MCCHC’s “high risk” prenatal patients by health indicators. A.2.
Refer “high risk” patients to care coordination. A.3.
Refer “high risk” patients to OB/GYN specialists. |
A.1.
Providers utilize risk assessment tool in determining patient risk status. A.2.
Care coordination will determine what medical and social services need to be
linked to reduce risk factors. A.3.
Assess potential for providing services at MCCHC and refer those presenting
needs beyond its scope of service to specialists. |
A.1.
Pregnancy outcomes will be improved with early detection of risk factors, on
an on-going basis. A.2.
Linkages to needed services will improve pregnancy outcomes, on an on-going
basis. A.3.
“High risk” prenatal patients will receive quality care even when it is
beyond the scope of MCCHC’s service. |
A.1.
Medical Records, QA/QI A.2.
Care Coordination Files, QA/QI A.3.
Medical Records, QA/QI |
A.1. Medical Director, Prenatal providers A.2.
Prenatal Care Coordinator A.3.
Medical Director, Prenatal Providers |
A.1.
5-Year Strategic Plan, Appendix A (1,2) A.2.
Prenatal Care Coordination Manual A.3.
5-Year Strategic Plan, Appendix A (1,2) |
|
B.
2006-2007 Goal: Enhance
prenatal program according to Strategic Plan. |
B.
Employ OB/GYN physician. |
B.
By 6/06, an OB/GYN physician will be staffed on site. |
B.
Medical Records, QA/QI |
B.
CEO, HR Department |
B.
5-Year Strategic Plan, Appendix A (2) |
|
C.2007-2010
Goal: Enhance
QA/QI and expand program as patient need indicates. |
C.
Follow strategic plan for expanding program to meet the needs of the prenatal
patients. |
C.
By 12/09, MCCHC will be staffed with appropriate providers and will have
appropriate equipment to provide sufficient prenatal care. |
C.
Medical Records, QA/QI |
C.
CEO, Clinical Committee, Board of Directors, Medical Director, QA/QI Team |
C.
5-Year Strategic Plan, Appendix A (1,2) |
Prostate
|
Problem/Need
Statement: The number of men who have been screened
for prostate cancer by digital rectal exam and prostate specific antigen test
is low. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Increase
the detection of prostate cancer and decrease the incidence of death from
prostate cancer. A.1.
Make screening tests available to male patients over the age of 50. A.2.
Educate male patients about prostate cancer and early detection. |
A.1. Offer full exam with digital rectal exam
and prostate specific antigen blood test to all male patients over the age of
50. A.2. Provide educational materials and displays
about prostate cancer and early detection. |
A.1.
By 3/06, 75% of MCCHC’s male patients over 50 will have been screened for
prostate cancer. A.2.
By 3/06, 100% of MCCHC’s male patients over 50 will have been offered
education regarding prostate cancer. |
A.1. Medical Records, QA/QI A.2.
Medical Records, QA/QI |
A.1.
Medical Director, Clinical Staff A.2.
Medical Director, Clinical Staff |
A.1. 5-Year Strategic Plan, Appendix A (3) A.2. 5-Year Strategic Plan, Appendix A (3) |
|
B.
2006-2007 Goal: Enhance
QA/QI in early detection of prostate cancer. |
B.
Evaluate current testing procedures in light of new research, and adjust
accordingly. |
B.
By 3/07, MCCHC will have knowledge of any new research data about prostate
cancer, and will be using latest technology testing. |
B.
Medical Records, QA/QI |
B.
Medical Director, Administration, QA/QI Team |
B.
5-Year Strategic Plan, Appendix A (1) |
|
C.2007-2010
Goal: Continue
to expand service as patient needs dictate and continue to enhance QA/QI. |
C.
Evaluate program, its effectiveness, and total patients served, and adjust
accordingly. |
C.
By 12/09, MCCHC will have sufficient staff and equipment to adequately detect
and treat prostate cancer in its male patients. |
C.
Medical Records, QA/QI |
C.
Medical Director, QA/QI Team |
C.
5-Year Strategic Plan, Appendix A (1) |
Social
Services
|
Problem/Need
Statement: MCCHC patients have multiple social
problems that influence health such as lack of finances, housing, abuse in
personal relationships, crime, mental illness, substance abuse, poor reading
skills, unemployment, etc. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Increase
support services to patients A.1.
85% of patients referred to Social Service will receive appropriate services. A.2.
Number of patients enrolled in safety-net programs will be increased by 10%. |
A.1.(a)
Assess strengths and needs of patients referred for social services A.1.(b)
Develop care plans and link clients to appropriate services A.2.
Assess sliding fee patients for eligibility for safety-net programs and make
appropriate referrals |
A.1.(a)
By 12/05, 85% of patients referred to Social Services will have been assessed
for needs. A.1.(b)
By 3/06, 85% of patients referred to Social Services will have a care plan
and will be linked to appropriate services. A.2.
By 3/06, the number of patients enrolled in safety-net programs will be
increased by 10%. |
A.1.(a)
Case Management Files, QA/QI A.1.(b)
Case Management Files, QA/QI A.2.
MCCHC Demographic Files, QA/QI |
A.1.(a)
Social Services Department A.1.(b)
Social Services Department A.2.
Enabling Services Coordinator |
A.1.(a)
Social Services Protocols A.1.(b)
Social Services Protocols A.2.
Safety-net programs enrollment criteria |
|
B.
2006-2007 Goal: Enhance
QA/QI in Social Service Department |
B.
Utilize Patient Satisfaction Survey to assess patients’ perception of
departmental quality |
B.
By 12/06, 80% of patients utilizing Social Services will have completed a
Patient Satisfaction Survey. |
B.
QA/QI Files |
B.
Social Services Department and QA/QI Team |
B.
QA/QI Protocols |
|
C.2007-2010
Goal: Continue
to expand service as patient needs dictate and continue to enhance QA/QI |
C.
Track patient usage and needs, and add staff accordingly |
C.
By 12/09, MCCHC will have sufficient Social Services staff to adequately
provide quality enabling services to its patients |
C.
Case Management Files, QA/QI Files, Personnel Records |
C.
Social Services Department, HR Department, and QA/QI Team and staff |
C.
Social Services Protocols & QA/QI Protocols |
Visual
Services
|
Problem/Need
Statement: MCCHC patients have multiple social
problems that influence health such as lack of finances, housing, abuse in
personal relationships, crime, mental illness, substance abuse, poor reading
skills, unemployment, etc. |
|||||
Goals/Objectives |
Key Action Steps |
Expected Outcomes |
Data,
Evaluation & Measurement |
Person/Area
Responsible |
Comments |
|
A.
2005-2006 Goal: Increase
support services to patients A.1.
85% of patients referred to Social Service will receive appropriate services. A.2.
Number of patients enrolled in safety-net programs will be increased by 10%. |
A.1.(a)
Assess strengths and needs of patients referred for social services A.1.(b)
Develop care plans and link clients to appropriate services A.2.
Assess sliding fee patients for eligibility for safety-net programs and make
appropriate referrals |
A.1.(a)
By 12/05, 85% of patients referred to Social Services will have been assessed
for needs. A.1.(b)
By 3/06, 85% of patients referred to Social Services will have a care plan
and will be linked to appropriate services. A.2.
By 3/06, the number of patients enrolled in safety-net programs will be
increased by 10%. |
A.1.(a)
Case Management Files, QA/QI A.1.(b)
Case Management Files, QA/QI A.2.
MCCHC Demographic Files, QA/QI |
A.1.(a)
Social Services Department A.1.(b)
Social Services Department A.2.
Enabling Services Coordinator |
A.1.(a)
Social Services Protocols A.1.(b)
Social Services Protocols A.2.
Safety-net programs enrollment criteria |
|
B.
2006-2007 Goal: Enhance
QA/QI in Social Service Department |
B.
Utilize Patient Satisfaction Survey to assess patients’ perception of
departmental quality |
B.
By 12/06, 80% of patients utilizing Social Services will have completed a
Patient Satisfaction Survey. |
B.
QA/QI Files |
B.
Social Services Department and QA/QI Team |
B.
QA/QI Protocols |
|
C.2007-2010
Goal: Continue
to expand service as patient needs dictate and continue to enhance QA/QI |
C.
Track patient usage and needs, and add staff accordingly |
C.
By 12/09, MCCHC will have sufficient Social Services staff to adequately
provide quality enabling services to its patients |
C.
Case Management Files, QA/QI Files, Personnel Records |
C.
Social Services Department, HR Department, and QA/QI Team and staff |
C.
Social Services Protocols & QA/QI Protocols |