Completing Yo r Q alit Completing Your Quality Improvement Plan

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Rare EventsIf you had a bad eventThe number of bad events would havethat occurred thefollowing number oftimes last year...to drop to this level in the coming yearbefore you could say you've made astatistically significant drop% Drop5 0 100%10 3 70%25 13 48%50 32 36%75 53 29%100 74 26%200 163 19%Assumes Poisson distribution of rare events.14
Example ‐ Answer• Foxden is better off using # of in‐patient fallsfor its plan• 30% improvement represents significantchange• Foxden can still choose to monitor falls fll with ihinjury (especially over long‐term)15
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 12 and 13: Seasonal Variation• Some indicato
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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