Completing Yo r Q alit Completing Your Quality Improvement Plan
Completing Yo r Q alit Completing Your Quality Improvement Plan Completing Yo r Q alit Completing Your Quality Improvement Plan
Part A ‐ Ideas for ImprovementFrom April 2011 to March 2012, we will:• Continue to monitor adherence to practice guidelines for ventilatorassociatedpneumonia and central line infection.• Use physician champions to promote hand hygiene among staff.Encourage patients to ask staff if they’ve washed their hands yet. Monitorcompliance monthly and post results on each ward.• Update our clinical information system so that we can track compliance on25 key clinical best practices for heart attack, sepsis and VTE prophylaxisand feed information on individual physician performance back tophysicians.• Enhance the medication reconciliation process and ensure all patientsleave knowing, for each drug, the dosage, purpose, and changes made tomedications while in hospital.42
Ideas for Improvement cont.From April 2011 to March 2012, we will:• Enhance the medication reconciliation process and ensure all patientsleave knowing, for each drug, the dosage, purpose, and changes made tomedications while in hospital.• Use database‐driven discharge summaries to eliminate delays in sendingout discharge summaries.• Implement LEAN to reduce turn‐around times for lab and diagnosticimaging• Update our bed tracking system in the ED and hospital to ensure beds aremade available as soon as possible after they are vacated• Train 10 additional staff on LEAN process improvement at the green‐beltlevel43
- 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 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 44 and 45: How the plan aligns with the other
Ideas for <strong>Improvement</strong> cont.From April 2011 to March 2012, we will:• Enhance the medication reconciliation process and ensure all patientsleave knowing, for each drug, the dosage, purpose, and changes made tomedications while in hospital.• Use database‐driven discharge summaries to eliminate delays in sendingout discharge summaries.• Implement LEAN to reduce turn‐around times for lab and diagnosticimaging• Update our bed tracking system in the ED and hospital to ensure beds aremade available as soon as possible after they are vacated• Train 10 additional staff on LEAN process improvement at the green‐beltlevel43
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