Quality Improvement Plan I

Since the Institute of Medicine’s widespread reports, To Err Is Human (2000) and Crossing the Quality Chasm (2001), revealed widespread incidence of medical errors in U. S. hospitals, there has been a great deal of effort to measure and improve the quality of hospital care. Progressive input has been made in establishing quality indicators and risk adjustment components to compare quality across organizations, and in analyzing processes and cultures in high-performing hospitals. There is a vast amount of knowledge to learn about the infrastructure of hospital performance.

Health care organizations performance measures may include which hospitals are improving (or deteriorating) over time, and how they accomplish and provide for that improvement. This paper will seek to develop a quality improvement plan for St. Joseph Medical Center, the difference between performance measurement and quality improvement, examine quality indicators, and explain stakeholder feedback is used in the quality improvement process. St. Joseph Medical Center has provided healthcare to the Kansas City metropolitan area since 1874. According to St.

Joseph Medical Center (2013), “It is a joint accredited, 310-bed hospital offering a full array of acute care, outpatient and extended care services with a reputation for quality care and compassionate service” (para. 1). The hospital is committed in providing exceptional quality care and has earned the Magnet Nursing Designation from the American Nurses Credentialing Center, the nation’s leading credentialing organization. This accomplishment is one of the highest achievements a hospital can receive in professional nursing. Research has shown there are clear benefits to patients in Magnet hospitals.

They have fewer complications, shorter hospital stays, higher patient safety, and higher patient and employee satisfaction scores. * St. Joseph Medical Center Mission: Carondelet Health consists of Catholic organizations dedicated to the healing ministry of Jesus Christ. Our commitment to human dignity compels us to provide compassionate, quality health care for body, mind and spirit, with a special concern for the poor. We are responsible stewards serving the needs of all people from conception to death. We are united in this mission. * St Joseph Medical Center’s Vision:

Our mission inspires us to be a united community where we exceed the expectations of every individual with every interaction through unwavering advocacy. * St. Joseph Medical Center’s Values: Integrity – Compassion – Unity For issues related to moral and ethical nature requiring guidance, Carondelet Health facilities use The Ethical and Religious Directives, published by the United States Conference of Catholic Bishops. The hospital’s primary goals are focused on their commitment to implement the best care possible to consumers in the Kansas City metropolitan area.

St. Joseph Medical Center does this by voluntarily reporting Quality Measures to the Centers for Medicare and Medicaid Services (CMS) and the Missouri Hospital Association (MHA). According to St Joseph Medical Center (2013), “Through research, doctors and other scientists have institute best practice guidelines and continue to refine national guidelines for recommended care of patients with heart attacks, heart failure, and pneumonia, which may include giving needed medicine, treatments or tests at the appropriate time” (para. ).

Consumers can engage into a significant number of roles in health care to improve quality and reduce costs. The first action consumers will take will be informed choosers of care. Higher quality health care will be within the reach of consumers who learn to use comparative performance data to select high-performing providers, hospitals, nursing homes, and health plans for themselves and their family members (Marshall , Shekelle, Leatherman, & Brook, 2000). These types of consumers actually stimulate the providers to enhance their performance. St. Joseph Medical Center reports the results of their performance for heart attack, heart failure and pneumonia as part of a national report.

This information provides the consumer the ability to compare the quality of care provided at St. Joseph to other hospitals in the area. The data is available on the CMS Website http://www. hospitalcompare. hhs. gov and the consumer/patient can compare the hospital to others in the area. The hospital also participates in a Hospital Quality Demonstration Project with CMS and Premier Inc. This project includes coronary artery bypass graft (CABG) surgery and total hip/total knee surgery.

These graphs compare St. Joseph Medical Center to other hospitals participating in this project around the nation for hip/knee and CABG surgeries. Performance measurement enables quality improvement through the measurement of performance based upon quality indicators. Therefore, performance measurements can lead to quality monitoring and ultimately quality improvements and the two are dependent upon each other. External indicators involve using comparative data between organizations to examine performance and identify improvements that have proven to be successful in other organizations.

Comparative data are available from national organizations, such as AHRQ’s annual National Health Care Quality Report1 and National Healthcare Disparities Report, as well as several proprietary benchmarking companies or groups (e. g. , the American Nurses Association’s National Database of Nursing Quality Indicators). Today, hospitals are trying to enhance their connection with stakeholders in a number of ways. Hospitals typically conduct periodic opinion surveys of internal stakeholders, such as employees and physicians, and regularly seek feedback from patients on their satisfaction with the care and service they experience.

However, leading hospitals also are reaching into the community and conducting stakeholder assessments to better understand broader needs and concerns and how well the hospital is meeting them. These assessments, which usually involve surveys or interviews with stakeholder groups, help the hospital understand and prioritize what key stakeholders most want and need. Hospital boards play a key role in helping their hospitals understand key stakeholders and focusing action to meet their needs through development of mission, vision, and values statements and obtaining and using stakeholder feedback in managing risk and setting strategy.

In conclusion, Progressive input has been made in establishing quality indicators and risk adjustment components to compare quality across organizations, and examining processes and cultures in high-performing hospitals. Key stakeholder needs are typically addressed in an organization’s mission, vision, and values statements. These statements address the health care organization’s purpose today, what it wants to become in the future, and the values that shape its culture and focus its performance.

According to Varkey, Pellar, & Resar (2007), “whether improvement efforts (1) lead to change in the primary end point in the desired direction, (2) contribute to unintended results in different parts of the system, and (3) require additional efforts to bring a process back into acceptable ranges” (p. 783). The rationale for measuring quality improvement is the idea that good performance reflects good-quality practice, and that comparing performance among providers and health care organizations will promote a higher quality of performance. References Institute of Medicine. (2001).

Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press. Institute of Medicine. (2000). To Err Is Human: Building a Safer Health System. Washington, D. C. : National Academies Press. Marshall, M. , Shekelle, p. , Leatherman, S. , & Brook. , R. (2000). The public release of performance data: what do we expect to gain? A review of the evidence. JAMA, 283, 1866-1874. St. Joseph Medical Center. (2013). Retrieved from www. St. Josephkc. com on 03/25/2013. Varkey, P. , Peller, K. , and Resar, R. (2007). Basics of quality improvement in health care. Mayo Clin Proc. 82(6):735-9.

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