ACOE_Self-Study

Records are compared against the protocols published by the University Eye Center. Records are "flagged" whenever an error, omission, or other failure to comply with the Institution's clinical management protocols may adversely affect the outcome of the patient encounter, as follows: • Level Zero: a note to the practitioner. No clarification or correction required, for informational use only. • Level One: minor error(s) or omission(s) in the record without impact on patient care. Requires clarification or correction by the attending doctor. • Level Two: significant error(s) or omission(s) in the record which may affect patient care. Requires clarification or correction by the attending doctor. • Level Three: potentially sight or life-threatening error(s) or omissions. Requires immediate attention by the attending doctor. In addition to reviewing faculty, the QA team also evaluates clinical indicators and works on specific projects requested by the chief medical officer. The clinical care indicators represent conditions of high risk, high prevalence or both. Faculty members are informed of their flagged charts. Level 2 and level 3 flags are immediately brought to the attention of the Chief Medical Officer. The chief of the particular service where the patient was seen is then informed. The chair of the QA team is notified when the issue has been resolved. Detailed QA reports are provided to the chief of staff/director of professional services and Clinic Council quarterly. Service chiefs share the information with their faculty at the next scheduled service faculty and staff meeting. Patient Surveys Patient’s satisfaction surveys, which can be completed anonymously, are available on all clinic floors as well as on the UEC website. These forms are submitted to the UEC’s Director or Clinical Operations and processed as described in section C-9 of the UEC Policy and Procedure Manual ( Appendix VIII-6 ) . An example of patient satisfaction survey results can be found in Appendix VIII-10 . Information gathered though these surveys was utilized to restructure administrative processes at our reception desks where patients are checked-in and modifications were made to our existing protocols in our call center to better serve patients. Business Integrity Program The Compliance Program for the UEC is reviewed annually by the Compliance and Business Integrity (CBI) Officer and senior administrative staff (C-7 of the UEC Policy and Procedure Manual ; Appendix VIII-6 ). As part of this process, the policies and procedures relating to compliance and business integrity are reviewed along with the Office of the Medicaid Inspector General (OMIG) Annual Work Plan and any associated documents. All employees are required to take an on-line course on related topics and pass a quiz as part of our ongoing training program. The quiz includes examples of relevant scenarios to test the knowledge of individuals and their understanding of their responsibilities as part of the monitoring activities to detect potential compliance-related issues.

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