5.14. Evaluation of Quality

Each SCI Service must undertake service-level QI activities that monitor critical aspects of care and provide an on-going and continuous evaluation of the program. A SCI-QI committee is to meet at least quarterly to:

Identify important aspects of care, and monitor areas of service delivery identified as high-risk, high-volume (such as preventive health maintenance program), or problem-prone.
Address patient access to care, patient satisfaction, patient outcomes, and risk management.
Define the systematic plan used for collecting and analyzing data, taking corrective action, and reporting results.
Ensure SCI HC staff are actively participating in the SCI Service QI Program. NOTE: The quality improvement plan is to comply with VHA Central Office and accrediting organizations' criteria, and be evaluated on an annual basis. The results need to be reported at SCI staff meetings and to the medical center quality management program.

All clinical staff must be appropriately credentialed and privileged through medical center and VA approved procedures. All privileges requested by potential or incumbent SCI clinicians must be routed through the Chief, SCI Service, for review, concurrence, and/or recommendations. The Chief, SCI Service, uses the information collected through quality management activities for reviewing and/or revising staff clinical privileges as governed by appropriate public law and VA regulations.
Accreditation must be maintained with the Commission on Accreditation of Rehabilitation Facilities (CARF) and TJC for acute care beds. NOTE: Other accreditation standards are applicable to designated long-term care SCI beds.
Each SCI Service must follow and respond to VA established QI initiatives.

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