NW2 2019 Vocational Rehabilitation
Quality Improvement Activity (QIA)
Key Facility Staff and RCA Outcomes Report

QIA KEY Staff, RCA Outcomes and PDSA Plan

Please complete key staff contact information and report high level RCA processes, and PDSA planning via the form below by February 6, 2019.

Key staff will be the primary contacts for this QIA:

Project Lead will be the person responsible for launching interventions and reporting to the Network.
CROWNWeb Lead is the person responsible for entering/reviewing facility data (QIA measures and re-measures are based on CROWNWeb data)
QAPI Lead is the person who reports QIA goals, RCA and PDSA measures for staff discussion.

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* 1. Please select your facility from the dropdown list below; facility name, CMS Certification Number (CCN - 33-XXXX), and city/town have been included.

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* 2. Vocational Rehabilitation QIA Facility Lead

Vocational Rehabilitation QIA Lead Name

Vocational Rehabilitation QIA Lead Title

Vocational Rehabilitation QIA Lead e-mail

Vocational Rehabilitation QIA Lead Phone Number

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* 3. QAPI Lead

QAPI Lead Name

QAPI Lead Title

QAPI Lead e-mail

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* 4. CROWNWeb Lead

CROWNWeb Lead Name

CROWNWeb Lead Title

CROWNWeb Lead e-mail

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* 5. Is there anyone that you would like copied on reports/correspondence about the Vocational Rehabilitation QIA? If yes, please list:

Name

Title/Role

e-mail address

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* 6. Comments or Questions about this QIA?

Root Cause Analysis Outcomes (from CMS/Network Worksheet)

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* 7. RCA Information

Date RCA Completed

RCA Method ( (e.g., Current Reality Tree, Failure Mode and Effects Analysis, Fault Tree Analysis, Fishbone Diagram, Five Whys Analysis, Pareto Analysis, )

Names of Facility Staff Involved in RCA

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* 8. RCA Outcomes (Top Three Underlying Issues/Barriers)

Barrier #1

Barrier #2

Barrier #3

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* 9. Initial PDSA Plan (Plan, Do, Study, Act)

Plan: What are you trying to accomplish?

Plan: Data needed (to set goal for QIA/QAPI)

Do: What - What will intervention implementation (to overcome barriers) entail?

Do: When - When will implementation of the intervention begin?

Do: Who -Who is the facility staff member that is responsible for overseeing the PSDA process

Study: (data) Self reported VR rates (do your January numbers match the NW Baseline provided?)

Act: What changes can be made that will result in improvement (name initial Intervention)?

Intervention Start Date

Thank you for completing the QIA Key Facility Staff Contact Collection, RCA and PDSA report for your facility.

We appreciate your time and effort.

Please click on "DONE" to submit your responses to the Network

Quality Improvement Team

IPRO ESRD Network of New York

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