Quality Improvement Plan Page 10
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
Quality Indicators
Indicators are developed to measure and monitor the performance and stability of
processes used in delivering patient care services and the associated outcomes.
Indicators measure both processes and outcomes in an objective fashion, based on
current knowledge and clinical experience, and may include clinical standards or other
applicable professional guidelines. Special attention shall be given to the development
of indicators for those processes and/or outcomes which are high risk, high volume,
tend to be problem prone, and/or offer opportunities for improvement. The goal of
indicator development, data collection and analysis is to quantify the level of
performance and stability of processes, to identify areas for performance improvement
and to determine if performance improvement initiatives have met their goals.
Quality indicators are established with a hospital-wide (Family of Measures) view, as
well as at each performance improvement council, service-line and department level.
Panels of indicators are developed at various levels throughout the organization that
contain measures of the quality of patient care, the efficiency and effectiveness of the
processes used to provide that care and the level of customer service provided
internally and/or externally to our customers. Using a panel of indicators to measure
these three important dimensions of the delivery system provides a mechanism to
gauge the effect improvement efforts in one dimension have on the other two.
In support of the above, the Family of Measures (FOMs) (Appendix A) provide the
governing Board, Senior Management, Directors, Managers/Supervisors, Staff, the
Medical Staff Executive Committee, the Patient Care Improvement Council, and all
performance improvement councils an effective, high level view of the overall
performance of the Hospital:
See Appendix A for a complete listing of the Family of Measures.
Data Sources
Data used in the assessment of organizational performance and the quality of care is
collected from several sources, including generic occurrence screening, patient events
and internal occurrence reports, safety program review, the risk management program,
Council minutes, patient/family surveys or the complaint log, employee input,
departmental logs, medical records, hospital information systems, financial data/DRG
reports, customer service activities, internal databases, and external monitoring
reports.
Assessment
Crouse Hospital uses statistically valid, aggregated data to determine causes of process
and outcome variation. The assessment of process and outcomes data may include
comparing performance to available reference databases, to clinical practice guidelines
or practice parameters, to the performance of similar organizations and benchmarks,
to the stated objectives of performance for that process, to the expectations of our
patients, staff or physicians, to our own performance over time, or to the accreditation
or regulatory standards promulgated by oversight agencies. The assessment process is
used to identify and prioritize opportunities for improvement. Patterns, trends and
opportunities for improvement are identified at both the organizational and at the
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