Completing Yo r Q alit Completing Your Quality Improvement Plan

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Seasonal Variation• Some indicators fluctuate during the year• E.g. Busy ED at Christmas, flu season, March break• Options for dealing with seasonal variation:– Ensure same‐quarter comparisons• Eg E.g. Compare 2010‐1111 Q4 with 2011‐1212 Q4; do notcompare 2010‐11 Q3 to 2011‐12 Q4– Use four‐quarter or 12‐month rolling gaeages averages• E.g. ok to compare Dec09‐Nov10 to Apr11‐Mar1212
Example:• Foxden Regional Hospital wants to reduce inpatientfalls. It is very worried about falls withinjury, but that number is rather low (10 peryear). There are about 80 falls per year. Itbelieves it can reduce falls by 30%.• Which h measure should ldit use, and would it beable to detect this degree of change?13
Page 1: Completing Your QualityImprovement
Page 4 and 5: What are Required Indicators?• Fo
Page 6 and 7: Statistical Variation in Measures
Page 8 and 9: Rare EventsIf you had a bad eventTh
Page 10 and 11: Patient Experience SurveyThis comin
Page 14 and 15: Rare EventsIf you had a bad eventTh
Page 16 and 17: Ideas for Improvement:Change Sectio
Page 18 and 19: Example• Our plan: improving the
Page 20 and 21: Template: Line‐by‐Line StyleImp
Page 22 and 23: “Improvement Initiative”• Opt
Page 24 and 25: Falls• Hospitals tracking falls i
Page 26 and 27: VAP, CLI- Follow BundlesVAP:• Hea
Page 28 and 29: • Special considerations:C Diffic
Page 30 and 31: ALC, ED waits, Readmissions• Thre
Page 32 and 33: HSMR• Possible goals: reduction 5
Page 34 and 35: Patient Experience ‐ Data• Curr
Page 36 and 37: Setting Performance Goals and Targe
Page 38 and 39: Part A- Overview• Provide plain l
Page 40 and 41: Part A ‐What the organization wil
Page 42 and 43: Part A ‐ Ideas for ImprovementFro
Page 44 and 45: How the plan aligns with the other

Completing Yo r Q alit Completing Your Quality Improvement Plan

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