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Policy 726Santa Ana Police Department Custody Manual Copyright Lexipol, LLC 2024/02/21, All Rights Reserved. Published with permission by Santa Ana Police Department***DRAFT*** Continuous Quality Improvement - 1Continuous Quality Improvement 726.1 PURPOSE AND SCOPE The purpose of this policy is to establish a Continuous Quality Improvement (CQI) process of health care review in an effort to identify improvement needs in policies, processes or staff actions, and to develop and implement better health care strategies to improve the processes and outcomes of the health care services delivered at this facility. 726.2 POLICY It is the policy of this department that an internal review and CQI process for incarcerated person health care delivery and outcomes is developed and maintained, measurable goals and objectives are established and reviewed annually, and that the process itself is periodically reviewed and updated as needed. The process should be supervised by the Responsible Physician. The data evaluated should result in more effective access to services, an improved quality of care, and a better utilization of resources. 726.3 CQI TECHNIQUES AND MONITORING The CQI process may be applied to any aspect of health care delivery and health service outcomes, including, but not limited to, monitoring and reviewing the following: •Quality of the medical charts, by the Responsible Physician or the authorized designee •Investigations of complaints and grievances •Corrective action plans and plan outcomes •Deaths in custody, suicide attempts, sentinel events, and incident and management of serious communicable disease outbreaks •Plans for employee education and training, using investigation findings •Records of internal review activities •Quarterly reports to the Responsible Physician and Jail Administrator •Legal requirements for confidentiality of medical records •Condition and effectiveness of the care environment •Adequacy and quality of supplies and equipment •Quality of care provided to individual patients •Accuracy and efficiency of pharmacy services and medication administration •Ease of access to care •Risk minimization tactics •Data describing the types, quality and quantity of care provided •Accreditation compliance Santa Ana Police Department Custody Manual Continuous Quality Improvement Copyright Lexipol, LLC 2024/02/21, All Rights Reserved. Published with permission by Santa Ana Police Department***DRAFT*** Continuous Quality Improvement - 2726.4 CQI COMMITTEE MEETINGS The jail CQI committee should meet quarterly under the direction of both the committee chair and the Responsible Physician. The CQI meetings may be conducted at the same time as quarterly administrative meetings, but CQI minutes must be produced and maintained separately from any other minutes. The CQI minutes are not subject to disclosure outside of the CQI program, including requests from local, regional and national entities. Other interested parties with a need to know are only entitled to the disclosure of information that includes: (a)Problems that may have been identified. (b)Solutions that have been agreed upon. (c)Persons responsible for implementing the corrective action. (d)The time frame for implementing the corrective actions.