Completing Yo r Q alit Completing Your Quality Improvement Plan

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Template: Line‐by‐Line StyleImprovementInitiativeCurrentperf.Perf.goal PriorityRecommend tofi friends, family? 70% 73% 2ImprovementinitiativeOverall paininitiativepaindocumentationfor all med / surgptsMethods and results trackingTarget2011/12% who said staff did everythingthey could to control pain 75%chart audit of med/surg patients:% with daily visual analogue painscale documented 90%TargetjustificationAim to bebetter thanaverageRecognizedbest practice% who saidstaff dideverything theycould to controlpain 70% 75% 1chart audit of palliative/selectedPt controlled surgery patients: % documentedanalgesia for to be in pain and did not get PCApalliative, selected and no documentedRecognizedsurgery patients contraindication
Template: Cascade StyleImprovementInitiativeWould yourecommendthis hospitalto yourfriends andfamily?Current Perf. ImprovementTarget Targetperf.goal Priorityinitiative Methods and results tracking2011/12justification70% 73% 1 Pain controlPicker survey: increase % who Aim to besaid we did everything webetter thancould to control pain from 70% 75% averagechart audit of med/surgpatients: % with daily visualanalogue pain scaledocumented 90%Recognizedbest practicechart audit of palliative,selected surg patients: %documented to be in pain anddid not get pt‐controlledanalgesia and no documentedcontraindication
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 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 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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