Benchmark Assignment: Performance Management Plan Proposal

Benchmark Assignment – Performance Management Plan Proposal

Grand Canyon University: HLT313V

Benchmark Assignment – Performance Management Plan Proposal

Given the complicated nature of outcomes improvement and the numerous requirements for building and maintaining an effective, continuous quality improvement program with sustained outcomes, it’s no surprise health systems feel overwhelmed. Performance management is a process for setting goals within your organization and checking regularly the progress toward achieving the goals that were set (HRSA, 2019). All of the goals are monitored to make sure they are effective and efficient. “The overall goal of performance management is to ensure that an organization and its departments are optimally working efficiently together to achieve the results that are hopeful by the organization”(HRSA, 2019).

Performance Plan

Quality improvement can’t happen without a constant measurement and evaluation of process”. “Although it is possible to implement the quality improvement cycle once; simple cycle improvement isn’t quality improvement in the purest sense; it eliminates the critical “study” step in the “plan, do, study, and act” sequence; this step is very critical for successful quality improvements” (Outcomes, 2019).

Organizational Goals

The mission of Baylor College of medicine is to provide quality health care which recognizes the human worth and dignity of all people, and to make our programs and services available to everyone without restriction. We want to create a healing environment where providers, allied health care professionals and staff work together as a team to provide the best personalized care. We want to be a leader in advocating high quality health care services and programs that develop resources to help the primary health care needs of the population in the area. Being consistent with our mission; our goal is to provide care that is safe; avoiding injuries to patients from the care that is intended to help them: Effectiveness – providing services based on scientific knowledge to those who would benefit and also trying to avoid providing it to patients who would not likely benefit from it. Being patient centered – providing care that is respectful, putting the patients’ needs before anything, being responsive to patients concerns and needs. Making sure they opinions are valued and worth. Making sure we are being timely by reducing wait times and any harmful delays. Being efficient by avoiding meaningless waste, this is including excess equipment, supplies and electricity. The biggest goal is making sure we are equitable; providing the best high quality care no matter what the patients’ gender, ethnicity, geographical location or socioeconomic status is.

The Baylor College of Medicine (BCM) has a guiding principle to provide value based care with a focus on quality, safety and patient satisfaction. In fact, patient satisfaction has gained notoriety as a very important metric according to Centers for Medicaid and Medicare Services and in the near future reimbursement will be linked to this metric (which is coming this October 2019) as measured by HCAPS and Press Ganey surveys. Increase the rate of oral glucose tolerance testing (OGTT) in adults with Cystic Fibrosis ages 18 and older without cystic fibrosis‐related diabetes (CFRD) from 25% to 75%.

Summary of Relevant Performance Measures

We examined our practices and identified significant barriers to oral glucose tolerance testing including failure of providers to order testing, reluctance of families to have child undergo multiple blood draws and inconvenience of going to an outside lab for testing. To overcome these issues, we pre‐identified patients needing an oral glucose tolerance testing and offered this test during a clinic visit. A list of eligible patients was created using the cystic fibrosis related diabetes and EPIC reporting workbench. As part of their annual review, patients were scheduled for an early morning appointment and asked to arrive fasting. The Cystic Fibrosis nurse coordinator called the families during the week prior to the visit to remind them. On arrival to clinic, fasting status was verified, a finger stick was done for fasting blood sugar (FBS) using a One Touch Verio IQ glucometer. An appropriate dose of 1.75mg/kg (max of 75gm) of an Oral Glucose Tolerance Drink was given based on the patient’s weight. The clinic visit was conducted. At the 2 hour mark, annual labs, including blood glucose, were obtained in the clinic phlebotomy station. The Cystic Fibrosis Foundation criteria (2 hr > 200, FBG > 126) were used to diagnose Cystic Fibrosis Related Diabetes. At the conclusion of the project, a survey assessing satisfaction with this process was delivered to patients via email.

Performance Baseline

Once a performance measure is chosen; we will collect the baseline data for each measure” (white, 2012). “The baseline data is a snap shot of the performance of the process or outcome that is considered within the normal or average over a time period that reflects the existing system” (CMSS, 2019). Being able to determine the baseline would involve calculating our measure. As we assess where we were at the start of the process we will often find that our data reflects a lower than desired performance.

Performance Evaluation

Our Performance Quality Improvement plan will be evaluated on an annual basis for the effectiveness in achieving the goals we have set are being completed with the highest quality of care. We will continue to monitor the improvement on wait times as the clinic grows and expands. A summary of activities, improvement made, care delivery processes that were modified, any current projects that are in active process and recommendations for changes to this plan.

Definition of Success


Of the 135 patients eligible for oral glucose tolerance test at the start of the project, 116 adults (86%) completed the Oral Glucose Tolerance Testing by the end of 2018. Testing was performed on 100 adults in clinic. Two adults were completed at their primary care provider. An additional 7 had testing done at a local laboratory, usually because they lived at too great a distance for an early appointment or they preferred an afternoon appointment. In six instances, oral glucose tolerance testing was performed at the end of a hospitalization. Of those tested, six met the criteria for Cystic Fibrosis Related Diabetes and an additional five adults were diagnosed with impaired glucose tolerance. All tested in clinic were verbally appreciative to staff of the ability to combine the oral glucose tolerance testing was with their clinic visit. Few families completed the online evaluation survey. However, all respondents rated their experience as “Excellent” and preferred oral glucose tolerance testing in clinic compared with going to an outside laboratory.


Oral Glucose Tolerance Testing performed in clinic improved adherence to the Cystic Fibrosis Foundation recommendations for Cystic Fibrosis Related Diabetes screening. The procedure was easily incorporated into the annual review process. It was well received by patients and families. The next step we are planning is completing is having our patients due a non-fasting two hour glucose tolerance test. Cystic Fibrosis patients who have diabetes are not like patients who don’t have cystic fibrosis and have diabetes. So completing a non-fasting two hour glucose test will not give false results. We will continue to monitor our completion for oral glucose tolerance testing and hopefully achieve 100 percent compliant even as the center grows.References

CMSS. (n.d.). Council of Medical Specialty Societies. Retrieved August 11, 2019, from

Duquette, C.E. (2012). Leadership and Management. Q Solutions: Essential Resources for the Healthcare Quality Professional, (3rd ed.). National Association for Healthcare Quality: Glenview, IL.

HRSA. (n.d.). Performance Measurement & Quality Improvement. Retrieved August 11, 2019, from

Outcomes Improvement: Five Essentials. (2019, May 01). Retrieved August 11, 2019, from

White, S.V. (2012). Quality and Performance Improvement. Q Solutions: Essential Resources for the Healthcare Quality Professional, (3rd ed.). National Association for Healthcare Quality: Glenview, IL.