In concert with the philosophy and mission of
the American Academy of Micropigmentation and its practitioner members,
specifically-board certified Fellows, and Certified Diplomats, we
believe that:
-Quality review in micropigmentation is a planned,
purposeful, integrated, and coordinated activity used to assess,
monitor, and continuously improve care provided to clients.
-Providing quality micropigmentation care to patients
is the prerogative and obligation of practitioners.
-Self regulation and peer review relative to quality
of care is a major component of autonomous micropigmentation practice.
-Practitioners are accountable for responsible
performance in the conduct of their professional duties.
-Quality review activities undertaken by practitioners
address the efficiency and cost of care as well as the effectiveness
of care.
-Quality improvement in micropigmentation is best
facilitated through a system of review in which practitioners support,
evaluate, and counsel each other in the performance of professional
duties.
Purpose
Quality review involves participation of all members
of the Academy and other disciplines in an ongoing program to develop
standards, monitor, evaluate, and improve micropigmentation practice
and patient care. The process employed is consistent with the JCAHO
Ten Step Model. The process systematically evaluates the degree
of compliance and/or improvement in micropigmentation.
The micropigmentation Quality Review program will
provide direction for the development and implementation of change
toward improved quality of care and efficient use of Academy resources.
An organized and comprehensive quality assessment/improvement
program is the Academy's response to various social, economic, and
legal pressures. The program includes the assessment of quality
utilization review, and risk management components and, to be effective,
is linked with the performance appraisal.
Goals and Objectives
To define practitioners practice through standards
development in terms of systems operation, member performance and
patient care.
To improve systems function, member performance
and patient care and substantiate degree of compliance with internal/
external standards and regulations.
To establish and maintain an objective systematic
approach to monitor the effectiveness of micropigmentation care.
The JCAHO Ten Step Model and the Smith Marker QA Model will be the
basis for this work.
To facilitate collaboration and interdisciplinary
team approach in the quality assessment and improvement process.
To promote judicious allocation of human and material
resources.
To establish and maintain a documentation mechanism
which will reflect continuous quality improvement efforts and/or
the pursuit of opportunities to improve the micropigmentation care.
The quality review manual and quarterly/annual reports will do this.
Responsibility
The Board of Directors of the Academy has the
ultimate authority for establishing, implementing, and evaluating
a coordinated, integrated, effective, and ongoing program to monitor,
evaluate, and improve the quality of micropigmentation delivered
to patients. This responsibility is delegated to the micropigmentation
management team: micropigmentation quality review coordinator and
the micropigmentation quality review committee.
The micropigmentation management team participates
in developing the quality review plan, standards development, compliance
monitoring, and committee function. The micropigmentation management
team uses the results of quality review activities to improve systems
function and steadily improve the quality of patient care.
The Micropigmentation Quality Review Committee
is established to direct monitoring of micropigmentation practice
and patient care, integrate unit based activities, and link quality
review activities to the Board of Directors of the Academy. The
membership of the committee is designed to represent a cross-section
of various services and leadership levels in the Academy.
Functions of the Micropigmentation Quality
Review Committee include, but are not limited to the following:
- Coordinate, standardize, and integrate micropigmentation
activities.
- Establish centralized monitoring and evaluation
activities.
- Provide a common data base for detaching trends,
patterns, and opportunity for improvement of care of the micropigmentation
patient.
- Initiate and/or recommend action improvement
for unresolved quality issues.
- Evaluate the effectiveness of the corrective
action plans in achieving the desired outcomes.
- Seek and recommend creative and realistic resolutions
to recurrent quality care issues.
- Share effective corrective action plans to foster
resolution strategies.
- Review and recommend corrective actions for
citations by surveying and accrediting agencies.
- Review significant findings of other quality
review committees and disciplines that may have implications for
micropigmentation.
- Review significant direct and indirect data
sources that have implications for micropigmentation and formulate
action improvement plans.
- Provide ongoing and annual review/evaluation
of the effectiveness of the micropigmentation quality review plan.
The Micropigmentation Quality Review Coordinator
is a member of the Board of Directors of the AAM. Role and responsibilities
include, but are not limited to the following:
- Chairs the Micropigmentation Quality Review
Committee and prepares an agenda for meeting.
- Develops the division wide quality review plan
- Acts as a key educator, resource, and spokesperson
for the micropigmentation quality review program, encouraging division
wide participation in quality improvement.
- Tracks quality related data and information
- Participates in clinical education Academy programs,
data collection and prepares data displays.
- Serves as a micropigmentation liaison with Academy
wide committees and departments.
- Documents and reports quality issues and improvement
activities to Academy wide committees and/or departments.
- Periodically evaluates the micropigmentation
quality review program to be sure it is in line with program plan
and goals; makes or recommends needed improvements.
- Develops systems for filing quality review data
and ensuring confidentiality whenever appropriate.
- Prepares reports of activities-copy forwarded
to the President of the AAM
Program Scope
The micropigmentation quality assessment/ improvement
program relates to all services within the American Academy of Micropigmentation,
members directly and indirectly involved with the delivery of micropigmentation
care.
Mechanisms
Quality review is a combination of centralized
and decentralized activities. Centralized activities are those that
are carried out by the Micropigmentation Quality Review Committee
and the Micropigmentation Quality Review Coordinator, are universal
across the Academy, and facilitate a common data base of monitoring
for improvement throughout the Academy. Decentralized activities
are those carried out by the practitioners and members on an individual
basis.
Centralized activities are designed to assess
systems operation, member competency, and patient care across the
Academy. These activities include, but are not limited to the following:
monitoring and evaluating data of clinical routines, safety, comfort,
infection control, risk management data, utilization review, patient
satisfaction, complications of the patient population, mortality,
documentation, continuing education and credentialing. Specific
quality indicators are selected by the Micropigmentation Quality
Review Committee with input from the Board of Directors
The micropigmentation quality review coordinator
and quality review committee participate in specific quality review
activities, select important aspects of care and indicators based
on major patient population and scope of services provided. The
micropigmentation quality review coordinator participates in and
coordinates quality activities with emphasis on outcomes.
Integration/ Communication
The micropigmentation quality review coordinator
makes at least annual assessments in review quality assessment data.
This facilitates integration of quality assessment activities of
the Academy in terms of spotting trends and compliance to clinical
standards.
The Micropigmentation Quality Review Committee
meets at least annually. These meetings facilitate communication
of quality review activities, results, joint decision making, and
team approach in the overall quality improvement process.
The Quality Review Plan serves as a base for defining
all activities carried out in the Academy.
The micropigmentation quality review coordinator
communicates with the Director of Nursing of the Academy on a regular
basis to discuss quality improvement activities and the need for
management intervention. The micropigmentation quality review coordinator
attends micropigmentation quality review committee meetings to contribute
quality review information, seek direction for the committee and
share current information in regards to the quality improvement
process.
Micropigmentation quality review activities are
integrated with other Academy programs.
Documentation/ Record Retention
A quality review manual will be maintained in
the Academy office by the micropigmentation quality review coordinator.
The contents of the manual will be organized to document implementation
of the Quality Review Plan and effectiveness of the quality improvement
process.
Quality review activity reports and minutes will
be kept permanently. Completed data retrieval sheets and worksheets
will be destroyed when year end reports are made.
Role In Risk Management
Quality review activities are one component of
the Risk Management Program. The micropigmentation quality review
coordinator will review all reported occurrences and discuss high
risk issues with the Risk Manager.
Confidentiality
Quality review data and reports will only accessible
to those participating in the Quality Review Program and those agencies
responsible for ascertaining the existence of an ongoing and effective
quality improvement program.
Evaluation of Quality Review Program
The objectives, scope, organization, and effectiveness
of the Quality Review Program will be evaluated at least annually
and updated for the next budgetary period. Emphasis will be placed
on aspects of care monitored and evaluated, problems identified,
success of problem resolution, customer and supplier satisfaction,
and improvement in patient care. Efficiency and cost effectiveness
will also be evaluated. The micropigmentation quality review coordinator
will summarize program evaluation reports and prepare an annual
report. The last annual report shall be combined with the annual
evaluation and submitted to the Board.
Quality Assessment Standards Development
The Micropigmentation Quality Assessment/ Improvement
Program includes, but is not limited to the following components
and activities:
1. Professional Standards Development
Standards of care, standards of practice, policies,
procedures , and protocols are reviewed at least annually and approved
by member and other appropriate persons.
2. Staff Competency/ Credentials
Annual licensure validation
Maintenance of board certification records and
exams
Annual review/ update of skills and special procedure
lists
Maintenance of special procedure approvals by
the Board of Examiners
3. Continuing Education
Planned, structured, and individualized orientation
program for all new members.
Attendance at Academy seminars and workshops
in Micropigmentation.
4. Performance Appraisal
Ongoing consultation/ counseling for continuous
improvement.
Quality review findings are utilized.
5. Monitoring
Designed to evaluate structure, process, and
outcome indicators in a systematic and ongoing manner.
Concurrent and retrospective monitoring to determine
degree of compliance to Academy standards.
Monitoring will be planned and spontaneous.
6. Active Problem Identification
Maintenance of problem log to document and track
problems and resolution effectiveness.
7. Utilization Review
Annual review of statistical data for into budgeting/
staffing decisions of Academy.
8. Basic Risk Management
Monitoring and trending of all unusual occurrences.
Quality control checks are documented.
Ongoing review of safety standards.
Participation in institutional planning.
9. Communication Tools
Annual scheduled micropigmentation review meeting
to be held with the annual Academy meeting to discuss quality issues
and pursue opportunities for improvement in a collaboration manner.
QUALITY ASSESSMENT/ IMPROVEMENT PROGRAM
Members of the Quality Review Committee
Qualifications
1. Practitioner appointed by the micropigmentation
quality review coordinator with approval by the Board.
2. Must have at least two years of clinical experience
in micropigmentation
3. Demonstrates knowledge of and commitment to
Academy philosophy and mission.
4. Demonstrates commitment to continuous quality
improvement in the delivery of patient care.
Responsibilities
1. Accountable to the micropigmentation quality
review coordinator
2. Serves as a member of the Micropigmentation
Quality review Committee for at least two years.
3. Assists in the planning and execution of specific
quality improvement activities.
4. Communicates patient care related issues and
improvement action to the Micropigmentation Quality Review Committee.
5. Documents and reports quality review activities
to the micropigmentation quality review coordinator.
6. Assists the quality review coordinator in maintaining
a quality review manual that reflects quality improvement activities.
7. Assists the micropigmentation quality review
coordinator to incorporate review findings and improvement action.
8. Participates in the ongoing evaluation of the
quality improvement program.
Quality Assessment/ Improvement Manual to Document
Quality Improvement Efforts
The following is an outlining format for setting
up a Quality Assessment Improvement Manual for the American Academy
of Micropigmentation. Create major tabs for the topical headings
and different colored tabs for the sub-entries.
The Quality Assessment/ Improvement Manual should
sit along side the Standards Manual , Policy/ Procedure Manual Equipment
Manual and Committee Minutes Manual.
Allow information to accumulate for the annual
report. Annual reports are kept permanently. Worksheets may be destroyed
when annual reports are completed.
Content Outline
I. Academy/ Micropigmentation Philosophy/ Mission
Statement
II. Academy Quality Review Plan
III. Micropigmentation Quality Review Plan
IV. Committee Quality Review Plan
A. Data collection Calendar
B. Data collection Tools
V. Risk Management
A. Quality Control
B. Unusual Occurrences/ Incidents
VI. Utilization Review
A. Academy Reports
B. Budget Review
VII. Credentials/ Competency
A. Licensure Update
B. Competency Skills
C. Board Certification of Academy Members
D. Special Procedures Approval
VIII. Continuing Education
A. Mandatory Requirements
B. Continuing Education records for Academy members
IX. Performance Appraisal
A. Other Professional Society or Academy
B. Other professional educators or experts
X. Communications
A. Communications Log
B. Quality Issue Correspondences
Sterilization Procedures
1. Autoclaves are cleaned daily.
2. all instruments shall be double-wrapped.
3. Indicator tape is placed inside each package.
4. Labels on package include sterilizing date
and expiration date as well as contents.
5. Charts are kept on sterilizing time.
6. Autoclaves are tested daily with live spoars
and records are kept
7. All instruments from each case are opened,
washed and sterilized in washer/ sterilizer, wrapped and re- sterilized.
ENGINEERING RECOMMENDATIONS
1. Relative humidity should be between 50-60%.
2. Temperature should be between 70 and 72 degrees.
3. Air inflow should enter at a height not less
than 7 feet and be removed through vents near the floor.
4. Filters should be meet standards and be serviced
accordingly to manufacturer's standards.
