Quality Improvement Plan Page 11
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
department or service level. Data collected through the QI program is analyzed,
presented,
prioritized
and
acted
upon
at
several
multi
disciplinary
and
interdepartmental forums.
Setting Improvement Opportunities
•
The impact on patient safety, care and outcomes
•
The impact on customer satisfaction
•
The scope and extent of the process in question
•
Its relevance to the hospital’s mission and strategic plan
•
High risk, problem prone process, or one where variation has historically been a
problem
•
The extent to which the process improvement is a requirement of regulatory or
oversight bodies
•
Available resources
When the monitoring and statistical analysis of quality indicators reveal that there is
an opportunity for process improvement, the decision to act will depend on:Each
operational service and coordinating performance improvement council identifies and
defines the appropriate performance improvement opportunities within their purview.
The Patient Care Improvement Council approves the annual performance improvement
goals for the prospective PI councils.
The annual Quality Improvement Summit (also referred to as Annual Management
Review) will provide direction and prioritization for high level improvement initiatives.
The hospital will continue to focus attention on collaboration with outside agencies to
improve the overall delivery of care to all patients. There will also be efforts paid in
prioritizing opportunities for improved performance through the examination of
relationship between patient demographics, length of stay, and costs in relation to
complications. We will continue to examine ways to decrease unplanned readmissions
and preventable hospital acquired conditions and complications.
Continued attention will be paid to performance indicators through third party payers
and the overall reduction of “never events”.
Performance Improvement Model: PDSA
When opportunities for improvement are identified through data collection and
analysis, and are subsequently prioritized for action, the PDSA methodology is used to
make the improvement. This approach includes the following steps:
Plan an intervention that responds to the analysis of the data
Do a pilot of the intervention
Study the effectiveness of the pilot
Act on the results of the intervention and repeat the PDSA cycle as necessary
•
Members from all organizational levels integrate their knowledge and expertise
in a collaborative environment.
•
Members of one department/service learn how their processes affect other
departments or services.
10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business