The final step is to monitor, evaluate, and improve the effectiveness of the risk mitigation actions that are documented in the QCP. As with the other steps in the IQCP process, this step should also be a team effort. This step should never become static. Implementations should be monitored accurately, appropriately, and improved as the on-going evaluation indicates. The QCP should be formally reviewed at a defined frequency (eg, annually). Frequency of review may be dictated by compliance and accreditation agencies.
If a failure does occur, the QCP should be evaluated to determine why the potential failure was not discovered before it occurred, whether the risk to patients is still acceptable, and whether changes need to be made to the QCP.
Failures (errors) can be detected through a variety of sources including:
- Internal staff
- Internally-performed audit
- External sources
Internal staff may detect errors during the performance of daily work and report these errors; supervisors may detect errors through record review, including review of quality control records and maintenance records.
Periodic internal audits of the total testing process may also indicate weaknesses that could lead to failures.
Proficiency testing results may indicate a problem that could lead to a patient-related failure. Complaints from external sources are a means of detecting failure events. These sources may be clinical staff, physicians, other hospital employees, outreach facility personnel, patients, or patient family members.