Quality Improvement Plan Page 6
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
Crouse uses an approach to improving clinical and service quality that includes five
key processes: definition, measurement, analysis , improvement and control. Important
patient care and service processes and outcomes are measured through the use of
quality indicators and data collection techniques. Analysis of the collected data is
accomplished through statistically valid techniques to determine levels of performance
and quantify variation in processes and outcomes. Where there is an identified
opportunity for improvement, the decision to act will depend upon a prioritization
process that considers factors such as the impact on patient care and outcomes,
customer satisfaction, relevance to the mission and strategic plan, and the extent to
which the improvement is required by oversight or regulatory entities. When an
opportunity for improvement is prioritized for action, the PDSA methodology is
employed to make the improvement. Within PDSA is the six sigma DMAIC model; a set
of tools outlined in five chronological phases: Define, Measure, Analyze, Improve and
Control. In addition to the PDSA and DMAIC approach, lean healthcare principles will
be applied throughout the process redesign.
The performance improvement council infra-structure supports Crouse’s commitment
to quality and the core values of clinical excellence, service excellence and teamwork.
The committees and councils within the structure are multidisciplinary and include
representatives from the medical staff, the hospital staff. There are four types of quality
improvement councils:
•
The Oversight council is responsible for the establishment and implementation
of the overall Quality Improvement Plan.
•
Coordinating council is responsible for supporting the functional and service
line Councils through leadership, barrier removal, prioritization and allocation
of resources.
•
Peer review committees exist to review individual cases that require a
determination pertaining to the standard of care delivered.
•
The functional and service line performance improvement councils
measure, assess and improve the quality of care and delivery of services
throughout the organization.
•
The Clinical Advisory Group is a team of physicians, nursing professionals, and
quality experts that advises the Hospital leadership and the QI teams. They
serve as a think tank, as well as a way in which physician engagement can be
nurtured through physician leadership.
Results of process or quality improvement initiatives are communicated as appropriate
throughout the organization in an effort to share ideas, gain understanding of relevant
processes, encourage collaboration, instill CQI into the organizational culture and to
stimulate creative and innovative improvement initiatives. The staff is encouraged to
participate by offering improvement suggestions formally or informally and through
participation on teams and Councils.
The objectives, scope, organization and effectiveness of the Quality Improvement
Program are evaluated annually and revised as necessary.
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