In 2018, Virginia Garcia began internal site visits known as ‘C-Qual’ (Compliance and Quality Assurance). Visits are considered an “everybody teach, everybody learn” opportunity, with findings shared with site leaders and senior leaders across the organization. The goal is to improve patient care & safety and ensure compliance with program requirements across our 20 community-based patient care locations. Multiple systems changes and successes have resulted from this twice-a-year internal site visit program.
Tool: Continuous survey readiness activities through structured, repeating, internal site visits that cross multiple healthcare service lines (medical, dental, pharmacy)
Problem: Inconsistent processes across clinic sites for programs with compliance requirements leading to underperformance during state site visits, staff confusion, and risk to patient safety
Tool Selection: Creating an interdisciplinary, ongoing, internal site visit process allowed our organization to measure current state of practice across over 20 patient care locations, provide education on program requirements, identify areas of common concern across locations that needed centralized resources, and provide on-going check-points for leaders to see progress over time
Usage: C-Qual site visits include multiple staff and leaders to review multiple programs in a short site visit. The team includes 6 to 8 ‘site visitors’ who each review a different clinical program or area of compliance during a 1-hour visit with 30-minute report-out to site leaders
Results: For each C-Qual visit, the team of reviewers document their findings and suggestions, and report to site leadership teams before leaving the clinic. Over the last 5 years we have observed multiple improvements in our clinical program compliance, greater readiness for external audits, and implementation of organization-wide process improvements
