Benchmark Assignment: Quality Improvement Performance Plan
Grand Canyon University
Benchmark Assignment: Quality Improvement Performance Plan
Quality Improvement Organizational Program Goals
Health care organizations are constantly changing, and they depend on the ability to successfully manage change in this complex health care industry. Implementing an effective quality improvement (QI) program provides benefits that impact a health care’s organization in improving patient quality of care and patient safety. To develop and improve processes that form the framework of an organizations level of performance, (QI) is an essential key factor that integrates knowledge, structures, processes and outcomes with-in the health care organization. According to Health Resources and Services Administration (HRSA, 2011), “quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups” (HRSA, p.1). QI performance programs can vary from organization to organization, however the key principles that factor into the plans resources such as technology, people and information or problem are processed by what is done such as achieving a goal, that provides a result in improving quality of care and a quality improvement initiative. QI focus’s meeting the expectations and needs of patients, practicing with a team approach and utilizing data collections in both qualitative and quantitative methods. The goals of a QI program include effective leadership, improved patient quality of care and outcomes, utilizing evidenced based best practices, implementing a systemic data system to manage performance improvement and a team approach with clear understanding from health care clinicians and staff of QI processes in compliance with regulatory and accreditation requirements.
Quality Improvement Organizational Objectives
An organizations mission includes quality health care that is dependent on QI fundamentals and principals. A Quality Improvement Program (QIP) equips an organization with the fundamentals needed to provide continuous improvements that enhance and better serve the organization. The following objectives will support the QIP:
Effective Leadership – The Quality Improvement Committee (QIC) are responsible for the strategic planning in managing a QIP program. The QIC implements policy decisions, planning, designing, analyzing, coordinating and evaluating. The QIC incorporates practitioner participation through the QIP and supports other various committees and sub-committees.
Improved Patient Quality of Care – The QIC identifies trends and significant improvements in care and service. Implementation of QI activities that address patient quality of care, patient safety and quality of service.
Evidence Based Best Practices– Implementing clinical practice that includes evidence based best practices guidelines. Incorporating structure, process and outcome that involve multidisciplinary teams and individual physicians.
Staff Quality Improvement – Development of team spirit by utilizing a team approach method collaborating individuals in their knowledge, skills, diversity, perspectives and viewpoints. Educate staff with tools, resources and guidance to promote strategies in providing high, effective quality of care for patients. Staff adherence in accordance with compliance of regulatory and accreditation to ensure the structure in the delivery of high quality of care.
Data Systems Approach – Implementing an enterprise data warehouse (EDW) with aggregated data that is stored in one location with availability to interdisciplinary teams. Integrate other data collection systems such as Healthcare Effectiveness Data and Information Set (HEDIS) to collect specific information including practitioner, provider and population based. Health outcomes surveys, case management and disease management data bases, medical records, appeals data and analysis to determine appropriate interventions.
Measuring Performance Summary
Quality measurement that proves to be effective for a performance summary starts with a base that consists of clinical research that relates to a specific process, structure or better outcomes in patient care. Utilizing quality measure initiatives provides improvement performances in quality health care. Health care organizations must be able to identify and support a reduction in cutting health care costs, improving quality of care and monitoring and or addressing the sources. Applying the goals in a quality assurance process that meets the performance management plan will ensure a successful organization. The development of these measures begin with leadership to develop quality measures, patient quality of care that includes complex data sources, evidence base that is provided by different groups that validates a quality measure and evaluate the staff perception on quality of health care to develop better outcomes such as adopting the Continuous Quality Improvement (CQI) process, “CQI has been used as a means to develop clinical practice and is based on the principle that there is an opportunity for improvement in every process and on every occasion ((Hughes, 2008, Chapter 44).
Performance Measurement Baseline
The performance measurement baseline (PMB) core includes implementing strategies, ensuring capabilities, prioritizing problems that create solutions, identifying reoccurring situations and delivering solutions. The HRSA states that “since accountability for performance has become increasingly critical in health care, it is necessary for an organization to understand the key drivers behind its performance and demonstrate the results of its work” (HRSA, 2011). To determine if an organizations current performance plan is successful, it is important to utilize a PMB. Creating a PMB enables an organization to measure performance and differentiate between an illusion and reality of a situation. The establishment of a PMB baseline allows an organization to assess the need for improvements, effective decision making, human factors input, quality improvements performance and quantify changes that are applicable to the need in improvements. Leaderships ability to monitor performance from managers, clinical staff, administrative services and improve there with in is enhanced by a PMB. Other purposes to create a PMB is evidence-based care utilized to demonstrate the effectiveness by quantifying performance measurements that is used by clinicians and regulatory, accrediting organizations provide credibility and funding to the organization.
As part of an organizational performance evaluation, quality of care that is provided by providers or clinicians that represent a health care organization utilize methods such as outcome, balance and process measures. This performance plan will implement process measures that provide evidence based best practices that may lead to a negative or positive outcome. A delay in discharge would be on the negative side that would call for improvement efforts to be administered. The Council of Medical Specialty Societies (CMSS, 2014, p. 12), states “Ideally, measures are based on evidence where there is the highest quality with sufficient numbers of studies to support the focus and little to no disagreement” (CMSS, 2014). Measurements in improving quality of care and lowering health care costs enables health care organizations the ability to reduce inappropriate variation in care by utilizing process metrics. Process metrics rely on advanced technology for analytics such as an EDW that distribute data properly from a single source that collaborate patient information on it process measures including balance and outcomes. According to HRSA, “process measure quantifies a health care service provided to, on behalf of, or by a patient, that is based on scientific evidence of efficacy or effectiveness and/or it quantifies a specific system; e.g., to get a test done or a service performed” (HRSA, 2011).
Defining Performance Organizational Success
The hallmark of a successful organization depends on a high-quality performance management plan that ensures that goals are being met in the highest possible effective and an efficient manner. This organization will uphold its success by providing high effective quality of care and patient safety with better outcomes. The continuation of measuring performance that support the processes by utilizing the data to implement improvements will increase the level of performance and make it successful. Quality improvement (QI) success includes safety, effectiveness, patient-centered care, time, efficiency and equability in an organization. Achieving goals, creating balance, effective communication, implementing data, and utilizing evidence based best practices all work hand and hand towards a successful, executable performance management plan.
Acreditas Global. (2017). How Does Accreditation Contribute to Improved and Higher Quality Care? Retrieved from http://acreditasglobal.org/higherqualitycare/
Banerjee, A., Stanton, E., Lemer, C., & Marshall, M. (2012). What can quality improvement learn from evidence-based medicine? J R Soc Med., 105(2), 55-59. https://doi.org/10.1258/jrsm.2011.110176
Council of Medical Specialty Societies. (2014). The Measurement of Health Care Performance. Retrieved from https://cmss.org/wp-content/uploads/2015/07/CMSS-Quality-Primer-layout.final_.pdf
Hughes, R. G. (2008). Tools and Strategies for Quality Improvement and Patient Safety. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2682/
Schwartz, M., Landis, S., & Rowe, J. E. (1999). A Team Approach to Quality Improvement. Fam Pract Manag., 4(4), 25-30. Retrieved from https://www.aafp.org/fpm/1999/0400/p25.html
U. S. Department of Health and Human Services Health Resources and Services Administration. (2011). Quality Improvement. Retrieved from https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf