BOP Program Statement 6013.01 § 1

Improvement(QI) system in the health care programs at Bureau

institutions. Quality improvement is a tool Health Service Units

use to measure effectiveness of health care delivery processes

to:

! Evaluate and improve health care delivery systems and

clinical outcomes,

! Identify and reduce errors, and

! Improve overall staff and patient safety.

Quality improvement activities are most effective when they are

planned, systematic, and when all appropriate disciplines and

staff work collaboratively to implement them.

This Program Statement establishes requirements for Quality

Improvement Plans at every Bureau institution, and introduces

Plan, Do, Check, and Act (PDCA) as the accepted quality

improvement methodology. Each institution has unique issues when

identifying specific areas of systemic health care quality that

require oversight and improvement. This Program Statement

outlines the following major components of quality improvement to

be used at Bureau institutions:

a. A written Quality Improvement Plan with outcome based

measures consistent with evidence based guidance provided by the

Medical Director;

b. Patient Rights and Patient Service Surveys;

c. Risk and Error Management and Sentinel Events, including

undesirable patterns or trends of systemic processes or outcomes;

d. Medication usage including assessing the appropriateness

and effectiveness of pain management, and the safe use of

medications;

P6013.01

1/15/2005

Page 2

e. Quality control where indicated such as radiology retakes,

controls on devices such as glucometers;

f. Infection control surveillance;

g. Utilization Review;

h. Mortality Review; and

i. Primary source credential verification and clinical

privileges. (Refer to Program Statement Credentialing,

Privileging, and Practice Agreements)

Monitoring the processes related to delivery of health care is

critical to evaluate adverse patient outcomes or identify

problematic aspects of a health care delivery process. In order

to improve outcomes and reduce risks, these processes will be

monitored continuously, rather than waiting for the end result,

or an adverse outcome, to determine how the deficiency occurred.