Administered: August – May (annually)
Target Population: CHS staff members and AAAHC Surveyors
Participation Rate: 24 applicable criteria are evaluated/reviewed annually (augmenting the CHS QI Program criteris) to determine the level o fmeeting or exceeding pre-established practice parameters.
A nationally-recognized ambulatory practice (self-evaluation) program that encourages ongoing assessment of multiple criteria on the basis of actual performance versus pre-established goals for the purpose of improving quality.
- Meet or exceed 100 % of the pre-established performance parameters of the CHS hybrid Quality Improvement Program.
The Campus Health Service achieved a 96.4% level of meeting or exceeding pre-established practice parameters.
Changes Made on Basis of Findings
Resulted in substantively supporting the CHS delivery system’s need to prepare for the AAAHC re-accreditation process in November 2005 for December 2005 renewal.
Resulted in demonstrating quality practice parameters are in place and functioning within the CHS (96.4% met or exceed expectation) – reported to Quality Improvement Executive Committee, Management Team and all CHS staff via meeting minute communications.
One example relates to the development and communication of a comprehensive emergency preparedness program for the CHS.