Completing Yo r Q alit Completing Your Quality Improvement Plan

More documents

Recommendations

Info

What are Required Indicators?• For acute care hospitals:• At least one of: C Diff, VAP, hand hygiene, CLI, new ulcers in CCC, falls in CCC,• HSMR (if large enough to publicly report on it)• Readmissions• ALC• Total margin• ED wait times (either admitted pts or complex pts)– For urgent care centres, include if publicly reporting wait times• % who would definitely recommend to others– Specify if for hospital or ED• No obligation to set any of the above at priority 1• Indicators to be tied idto exec compensation are not specified inlegislation—hospitals to make this determination• If area already optimized (e.g. VAP=0), consider setting goal tomaintain at that level4
What Are Required Indicators?• For mental health hospitals:– Safety –not required to include any of the coresafety indicators in the template• please include other safety indicator that is relevant toyour organization– Not required to include HSMR– Do not include ED waits if no ED• please include other access indicator5
Page 1: Completing Your QualityImprovement
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 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

Create successful ePaper yourself

Delete template?

Save as template?