Policy: 123

Quality Assurance / Risk Management Program


The MDCBDSN recognizes that every organization, no matter how well run, inherently possesses exposure to risk. It also recognizes that management of risk factors requires a broad-based, coordinated managerial approach in order to mitigate any possible loss.

MDCBDSN Risk Management Program:

The QA/RM Program of the MDCBDSN shall include:

  • A QA/RM Coordinator.
  • Establishment of a QA/RM Committee.
  • A written plan aimed at reducing risk to consumers and staff.
  • RM Training and Education.
  • A system of collecting, analyzing and acting on risk data.
  • Correlating safety committee activities with the QA/RM committee.

The QA/RM Committee will be chaired by the QA/RM Coordinator. Membership will include a representative from each area and service department of the agency including nursing. Committee membership shall include a representative from the Human Rights Committee. Other staff expertise such as the agency nurse, maintenance, Safety Committee Chairman, etc may be asked to serve as resources on an "as needed basis". A representative from the Consumer Advocacy Group may be invited as needed. The QA/RM Committee shall meet on a monthly basis; alternating sites from Dillon one month to Marion the next. Minutes shall be taken at all QA/RM Committee Meetings.

The QA/RM will focus on areas that present the greatest amount of risk to people service by MDCBDSN. This would include reviews of abuse, neglect and exploitation, critical incidents, medication errors, deaths, use of physical restraints, property damage, consumer and/or staff injuries resulting from accidents etc.

The QA/RM will analyze data for trends and identify problem area and will make recommendations for improvement to the Executive Director. This analysis and feedback loop will not take the place of normal supervisory review which should occur as part of good management practice.

A database will be kept of all alleged abuse incidents and critical incidents.

Recommendations from the QA/RM will be made to the Executive Director who will then review and make necessary changes in procedure and if necessary policy change with board approval.

Changes in procedure will be made known to all staff through regular monthly meetings with supervisors and training will make changes in their training curriculum to ensure new staff get the latest procedures.

Tools of QA/RM:

In order for an agency's QA/RM program to be effective the following "tools" need to be available.

Information — knowledge, expertise and commitment of employees; sound practices and procedures; incident reporting systems, computerized databases, correction and feedback loops.

Administrative Supports — agency organization; well-developed infrastructure; committees of reference; systems of communication decision making and follow-up; agency mission, vision and values.

Training Programs — pre-service training; on-the-job training; specialty training in consumer rights, behavioral support, critical incident and abuse training, Med-tech training, driver safety, etc.

Quality Enhancement programs — consumer satisfaction surveys, personal outcomes, continuous quality improvements, etc.


The purpose of this directive is to establish a QA/RM Program which is intended to eliminate, reduce and or control the MDCBDSN's exposure to risk, loss and injury. This Policy also establishes the QA/RM Committee.

Effective Date:
April 6, 2006