Performance Improvement Plan for a Public Health Organization

Performance Improvement Plan

IHP 604

Final Project


Purpose and Quality Statement

The overall review of a quality plan is a set of goals to help achieve exceptional standards in a healthcare organization. The purpose of developing, implementing, and evaluating a quality plan is to define these activities that will deliver care while focusing on achieving consumer quality expectations. Another reason for the importance of a quality plans is to enhance the safety, efficiency and effectiveness in all areas arranging from clinical and non-clinical entities in healthcare. Quality plans are the bases for quality standards and both work together to determine what work best for the organization. Quality plans consist of peer reviews, checklist execution by using various quality guides like templates, standards, checklists. Quality measures are used to test continuous improvement of the quality plan (Blum, 2011). Implementing a good quality plan can help an organization obtain and continuously keep accreditation status. Accreditation is recognition from various credentialing organizations that a healthcare organization must meet the standards for approval to achieve. Accreditation shows that an organization when above and beyond promoting good safety practices and it creates more public awareness. Many government program example Medicaid and Medicare give funding for health organizations that participate in accreditation one of them being the Joint Commission.

The healthcare organization that I chose to review is a clinical setting (infectious disease) within a hospital base healthcare system (hospital has specialty clinics). This organization is very committed to patient safety and quality by being the nation’s most widely accredited health systems for patient safety and quality care. Health System mission is to create and deliver high quality hospital, physician and other healthcare related services that improve the health and well-being of the individuals and communities we serve (Wellstar, 2017). From infection prevention to Safety First programs this healthcare organization has been and will continually be committed to the safety patient and quality of health given.

Health System has a variety of community stakeholders and partnering groups. The chart below illustrates the stakeholders in their position in the performance improvement process.

Stakeholders Interest in Performance Improvement
Georgia Health policy Center Research for hospitals and health systems and correlates with the Joint Commission.
Staff of the Safety Health Program Educate all staff on the importance of safety care by using strategies like:Employing patient handling equipment to prevent and reduce team member injuries due to patient transfers, repositioning and lifting•Developing valuable clinical experience using the first Advanced Patient Simulation Center in a non-academic health system in Georgia•Preventing treatment and medication errors using electronic medical records, computerized order entry, medication bar coding and Smart Pumps•Adopting best practices and high-reliability concepts from nuclear engineering, aviation and manufacturing industries to decrease errors and streamline processes
Nursing Leadership Manages and educate nurses in the hospital on safety and provide quality care towards patients.
Patients Look at feedback from surveys about their visit

Quality Statement

To honor the best strategies for patient safety and quality of care the Quality Improvement Committee is committed to defining goals and objectives for the organization to accomplish each year during evaluation. These goals include training of clinical and administrative staff. Training will reflect continuous quality improvement principles and specific quality improvement initiatives to maintain the integrity and high standard of our health care system.

Status of Quality Tools and Standards

According to the recent accreditation survey reports Health System is recognized by state, regional and national level. This healthcare organization receives accolades from many national organizations that set healthcare standards and monitor performance. Uses EPIC as their health information system. The EPIC system allows clinics to provide the best acute and best ambulatory EMR for physician productivity and effectiveness also predictive analytics and rooted decision support tools to support clinical practice which leads to better outcomes. On the patient spectrum which helps the clinic even more EPIC provides personal and family health information via My Chart for patients. Patients are able to message their doctors, attend e-visits, complete questionnaires, schedule appointments, and be more involved in managing their health. EPIC is in compliance with the healthcare reform and regulatory compliance including HIPAA and HITECH. According to EPIC this software meets all regulation from the government and state providing the highest meaningful use coverage. (EPIC, 2017)

(Epic, 2017)

Meaningful use has a big impact on the Health System. The EPIC system is widely use across the whole health system by each department. With a health information system that is design with Meaningful Use in mind along with state and national rules and regulations (HIPAA and HITECH) allows for to focus on strategic programs that goes even further to protect the safety and health of their patients.

Measure and Benchmarks

To begin improvement of quality, organizations first create and study performance and improvement data. Collecting data and using method tool will track and demonstrate if new improvement strategies are working. The reason for quality measurement and benchmarks is to set good performance, which will in returned reflect a good quality in the organization. Comparing health organization performance along with the national benchmarks encourages better performances (HHS, 2017). Below is an outline of how current performance improvement data and initiatives are tracked by the Infectious Disease office within Health System and benchmark tables comparing Health System to other healthcare facilities within the same area.

Figure 1Outline of performance improvement data for Infectious Disease Clinic

Measurements Steps of Data Management Description and used of tool for data collection
Collecting: It is important for a healthcare organization to organize their systems were data is collected the same way each time. Collecting data the same ensures accurate and credible data for quality improvement. A successful way of collecting data includes: framework, techniques, tools, steps and a detailed documented plan that shows a collection plan for each measure. *Identify what is going to be measured.*Details on exclusion and inclusion including denominator and numerator.*Set parameters *Identify who collects what data*Calendar of progress Simple Data Collection*Ensures data collected is reliable without unnecessary cost. Reference Institute for Healthcare Improvement (IHI) Boston, Massachusetts.
Tracking: Calculating each measure overtime and deciding the right time for monitoring. Run charts: Show trends in data over time. Easy to interpret, and provide visual of how a process is performing.Control Charts: helps with understanding if the variation in data is beyond expectations. Worksheet for Tracking Performance Results* Tracks performance results over several evaluation periodsReference e_results.html
Analyzing: Review of performance data use to determine if data meets the anticipated quality level. Also used to outline a performance plan. Used along with interpretation of data to review organization’s performance and learn from it.  
Interpreting: Assessing the meaning or determining the significance of implications, and conclusions of data collected. Identify gaps, improve activities, and plan for improvement. that’s received  
Acting: An organization analysis and interpretation of the data results initiates its following actions on performance. *Ensure data systems are reliable*Re-evaluate potential causes of system problems*Re-evaluate changes made for improvement*Remove any barriers that are still present*Spread the improvement Plan-Do-Study-Act (PDSA)* PDSA is a cycle is essential to rapid-cycle change methodology with emphasis on the study part of the cycle.

Figure 2 Benchmark Data various hospitals in the same area

Measurement National Benchmark HEALTH SYSTEM677 CHURCH STREET MARIETTA, GA 30060(770) 793-5000 Grady memorial Hospital80 JESSE HILL, JR DRIVE SE ATLANTA, GA 30303(404) 616-4252 EMORY UNIVERSITY HOSPITAL1364 CLIFTON ROAD, NE ATLANTA, GA 30322(404) 686-8500
Patient Experience(Would you recommend this hospital to a friend or family member?) 72% 72% 71% 86%
Complications from Clostridium difficile (C.diff.) No Different than National Benchmark Better than the National Benchmark Worse than the National Benchmark  
Deaths among patients with serious treatable complications after surgery No Different than the National Rate No Different than the National Rate Better than the National Rate 136.4820 per 1,000 patient discharges
Rate of readmission for stroke patients No Different than the National Rate No Different than the National Rate No Different than the National Rate 2012.2%

The metrics used to determine the status of the Infectious Disease office and how it is in compliance with accreditation standards is through The Joint Commission. As I stated in my Joint Commission Paper, Accreditation is a process of review that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by a recognized accreditation organization (Barabas, 2009). The National Patient Goals were established to help accredited organizations address specific areas of concern in regard to patient safety (The Joint Commission, 2017). The National Patient Safety Goals is abundance of specific missions that accredited organizations is required to do in order to prevent medical errors (The Joint Commission, 2017).

National standards of care and treatment are presentenced by steps of core measures, which are a determining factor for reimbursement. Creating and implementing core measures leads to a decrease in clinic problems. As stated in my comparative data bar graph activity, benchmark values are great methods for implementing best practices. A Hospital Value-Base Reimbursement is a system that ties in Medicare/Medicaid and The Joint Commission that rewards physicians for the quality of care provided to patients by giving substantial incentive payments. The Hospital Value Base program adjusts payments to hospitals under the Inpatient Prospective Payment System, based on the quality of care the hospital gives ( Meeting national quality benchmarks on value based reimbursements ensures that the infectious disease office along with Health System is providing and delivering the highest quality of care. When an organization is meeting benchmark goals it helps the organization keep track of their levels of service from core measures and surveys that are pertain from The Joint Commission. If did not meet benchmark then they will be subject to not receiving money from the government for their Medicare and Medicaid services this can lead to a lost in finical aid.

Process Improvements

I have come up with three recommendations that can help improve those statues of which are: Care Coordination in the Emergency Room, implementation of Epic in new acquired hospitals, and Magnet accreditation for nurses. Emergency room coordination project initiatives will consist of refresh data analysis finalizing initiatives & reporting metrics; develop work plans, team characters and workgroups; complete design sessions; implement clinical operations (CO) management; and conduct training and knowledge transfer. Implementation of Epic in new acquired hospitals project initiative consist of vendor selection, planning, work development, upgrades, training staff, initial go live date, onsite support. Last recommendation is Magnet accreditation for nurses includes the project initiatives of compliance certification, off site review, quality enhance plan, onsite peer review, and review by Magnet. The recommend goals for WellStar will ensure success in implementing new ideas to serves better healthcare for the community.

A new technology that I feel that will help with patient safety is Computerized Physician Order Entry (CPOE) . Communication between the staff and physician on patient care can be difficult at times to understand fully which can lead to error. Studies have shown 90% of medical errors are from the ordering or transcribing stage. Entering medication orders or instructions electronically instead of the use of paper chart have the ability to prevent errors, which is what the CPOE system is used for. CPOE not only increase safety, but efficiency too. (Calmen, 2015)

Constructing interdisciplinary collaboration can be successful in engaging both stakeholders and community to ensure a quality program among the health organization. Collaboration between healthcare professionals including leadership, coordination and communication work well because each entity can share different ideas, but feel equal this will produce great quality and safety strategies.

A policy change to solve patient safety and quality issues is the amount to credit the staff needed for their continuing education. An example is nursing: If there is an occasional system failure than nurses will still need to know how to perform without technology. A six month or one year training course should be taken by nurse to test their skills or refresh them on what to do during power outages. Stakeholders will need to collaborate with will be board of nurses, department overhead, and nurses.

Evaluation and Reporting

Infectious disease office sees many ill patients who are week and wheelchair bond.

Falls are the leading cause of non-fatal and fatal injuries for the older generation in America. Falls usually occur in hospice settings. People with advanced illness are more vulnerable to fall due to weakness. Evidence based programs can help reduced falls substantially. Below on figure 3 shows Plan-Do-Study-Act of fall prevent program implantation.

Cycle Step List of Activities Start Date Completion Date
Plan Study the data of falls from the nursing home. Put together a team with staff included to learn what is not working. Brainstorm solutions of fixing the problem. Ideas generated from brainstorming should be organized into a matrix. As soon as data is collected on the numbers of fall incidents occurred in the nursing home is reported. Feb 10, 2018 Coming up with a Plan. 1 month March 10, 2018
Do Ideas from the planning phase are put into place. Camera monitors will be excellent ideas for staff to see if patient are out of bed walking around. Bed alarms are also good for nurses to know if patients need to go to the restroom. A week after communicating and educating all staff of new plan being implemented. March 26, 2018 Continuously, unless plan does not work or show major down fall Sep 30, 2018
Study/Check Reviewing the outcome of implemented changes. This dictates if the plan is working in favor. Measurements for falls include the prevalence of falls per and severity before and after implementation. Once changing of the plan is in action reviewing and checking the new plan goes into effect.March 26, 2018 Continuously, unless plan does not work or show major down fall the plan step must be revisit. Sep 30, 2018
Act Is it working or not and what to do? Once strategies are implemented and review of them is complete. Data is then created to provide best possible outcomes of continuation or discontinuation. This is when the strategy team has to decide if they fully want to implement the change or create or update something else or something new. After a couple of months collecting dataOct 1, 2018 If data shows improvement to a significant level than the implantation of the plan is completed on periodic reviews should be done. But…..If the plan was not successful then more brainstorming and planning should occur to start this process over again.Until….

Figure 3 PDSA

Figure 4 Timeline for evaluation of performance improvement activities

Goal # Activity Checkpoint Date Type of Follow-up(memo/call/meeting) Progress Expected Notes

Above is a timeline evaluation table to show performance improvement activities. This table helps when creating goals, implementing strategies, view check dates, and more in the process of creating, implementing, and evaluating different strategies and methods within the organization.

When measuring the success of a new technology there are some important steps to follow. First there need to be clear understanding of the problem. Next is research of technology and learning the difference between what will suite the organization best. The system chosen needs to meets clinical needs and be affordable. Planning should take effect with implementation strategies and create strategies around the infrastructure of the new technology ensure a smooth transition. Training staff should include having the ability to practice with as close as working the real environment. Creating simulation training will help staff become comfortable and educated with new equipment on a greater level. Evaluation of the new technology is important in seeing if the system is helping the practice or not. During the evaluation process is the time to form new ideas that can help aid and increase quality and productivity.

When changing occurs it must be reported to The Joint Commission. Since there is an implementation of a new system then the organization have 30 days to notify and report the change. The Joint Commission will usually extend accreditation until determination of the change is major enough to warrant a special extension survey (The Joint Commission).

To reach a level of good standing on quality, safety, efficiency, and core measures it important for a health organization to collect, track, analyze, and interpret data to create strategies that can lead the organization to success and exceptional care given to patients. A quality improvement project helps in communication of leadership and communication create strategic plans to help build and sustained any healthcare organization.


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