5.Quality Improvement Plan and strategic plan.pdf

Quality Improvement Plan

1. Planning
Quality ImprovementPlanning (QIP)

2. What isPlanning?
Typesof Plans
Strategic Planning
QualityImprovementPlanning
◦
◦
◦
Definition
Methodstodevelopa QIP
LinkingtheQIPwithstrategicplanning
GroupCase
Outline
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3. InanyHealthcareOrganization(HCO),planningisacoreand
essential
business
etc...All
activity,andmanytypesofplansexistsuchas
plans,marketingplans,openinganewfacilityplan,
of themareinvolvedin:
◦Choosinganddescribingtasksthatmustbeperformed
attainorganizationalgoalsand/or objectives
to
◦Outlininghow thetasks mustbeperformed,and
◦Indicatingwhentheyshould beperformed.
Planning:anOverview
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4. Strategic Planning
•Strategy:outlinesthebasicsteps/tactics
managementplanstotaketoreacha
goal/objective.
StrategicPlanning:•
–Ismethodicalandstructuredprocess
wherebyanorganization:
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5. Strategic Planning
define
mission
allocate
resources
identify
directions
Strategic
Planning
assign
accountabi
lities
develop
unified
approach
prioritize
long and
short term
goals
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6. •Strategicplanninghelpstheorgdevelopanactionoriented
approach andidentify thepiecesneededtobuilda
successfulorg operation.
•Remember to:
–Involvestaffat everylevel
–Beflexibleindevelopingaplanbycirculatingdraftsandallowing
peopleto providefeedback
–Ensurethateveryoneknowstheirresponsibility
Strategic Planning Benefits
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7. •OrganizationStrategicPlanning:itiswideplanthatmight
notcover butaffects allaspects of an organization.
•DepartmentPlan:itisaspecificplanfordepartments.It
couldbedevelopedwithgeneralandspecificobjectives;
however, itMUSTalignwiththe organizationplan.
StrategicPlanning
OrganizationVs.Department
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8. QIPandStrategicPlanning:
Characteristics:
◦Toknowandidentifywhatthe
his/herexpectationsare.
customerwantsandwhat
◦Todevelopand/orreviewofthemission,visionandvalues
oftheHCO;asitwillactastheframeworkandthe
pathwayfor theinstitutionto
and vision
followuptoattainitsmission
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9. ConductingEnvironmentalAnalysis:
External
Internal
Why:topinpointoutthefactorsthatwould
significantlyaffectthe
patient
organizational
expectationsoperations,suchas:
aboutthequalityofservices,andthe
technology
enhancethe
advancements
qualityofcare.
thatmight
Strategic PlanningSteps
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10. SWOTAnalysis
•
•
•
•
Strength
Weaknesses
Opportunities
Threats

11. •Thestrategiccommitmentplanningisa
methodicalandstructuredprocesswhereby
anorganizationhastoimplementthe
followingsteps:
StrategicPlanningSteps:
CommitmentPlan
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12. Strategic Planning Steps:
Commitment Plan
•Definethemission:amissioniswhat
existstodo,givenaparticulargroupof
It answersthe followingquestions:
–WhatistheHCOpurpose?
theorganization
customerneeds.
–InwhatactivitiestheHCOwillwebeengagedandwhatkind
ofservices it willofferin orderto accomplishthatpurpose?
–WhataretheHCObasicvaluesandsharedbeliefs?
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13. Strategic PlanningSteps:
Commitment Plan
•Characteristics ofaMission:
–Acontinuingguide:your missionisacontinuingguide
forthe actionsthat youtake
–Abasisforselfaudit:itforcesyoutore-thinkeach
vitalfactortowhichyourhavecommittedyour
resources
–Integratedeffort:every
inyourmission
oneinyourorgcansubscribe
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14. •Definethevision:avisioniswhat themanagers,
employees,physiciansandpatientsandotherinterested
partieswanttheHCOtobewhenitaccomplishesits
mission. Itisahopeforthefuture.Itshouldbebrief,
tied
and
toindividualmotivation,stretchingbutachievable
it canbeinferredfromthemissionstatement.
StrategicPlanningSteps:
CommitmentPlan
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15. StrategicPlanningSteps:
Commitment Plan
•Define the values:theseareprinciplesthatguidedecision
making andarehelddear
–innovation,
–integrity,
–teamworkand
–nosmokingpolicies
bymembersoftheorganization.Ex:
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16. StrategicPlanningSteps:
CommitmentPlan
Prioritizelong&shorttermgoals&objectives:thestrategic
goalsshouldhave intheiressencethetargetofimproving
performanceoftheorganizationoperationsandmeetcustomer
expectations.The Goals :
◦Are ends oran outcomethatone hopes toattain.
◦Aremostofthetimegeneral,on
technical
theHospitalLevelandnot
highlyaffiliatedto andspecificdepartment
operations.
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17. StrategicPlanningSteps:
Commitment Plan
•Theobjectives:are thetargets towards whichthe
managementsystemisdirectedandistryingtoachieve.
Theyflowfromthe organization’spurposeormission
•Tendtobemorespecificandmorerelatedtodepartment
orunitoperationsandmanagementprocesses.Also,they
shouldbemeasurable,attainable,andrealisticandhave
timelines.ThisisknownastheS.M.A.R.Tapproach.
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18. StrategicPlanningFinal Steps:
CommitmentPlan
•Assignaccountabilities: theHCOshouldassign
responsibilitiestooverseetheproperimplementation
ofthestrategicplananditsstatedgoals.
•Allocateresources:theHCOshouldensurethatall
neededresourcessuchas:time,manpower,money,
equipment,educationand training,etcareall
securedinordertofulfillthestrategicplan.
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19. •AQIP isan organizationwidecoordinatedapproachto:
–definingareasof problemsand
–establishing mechanisms and actions to improve such
areaswith theavailableresources.
•Itdealscompletelywithalltheeffortsandresources
usedto achieveobjectivesthataredirectlyand
andindirectlyaffectingthepatient(customer)care
satisfaction
QIPDefinition
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20. •“Coordinatedandcomprehensiveprocesstomonitor
andimprovepatientsafetyandtheperformanceofall
care
shall
and
be
servicesprovided.Itsgoalsandpurpose
tostrive,withinavailableresources,for
optimumoutcomeswithcontinuousimprovements
thatareconsistentlyrepresentativeofahighstandard
ofpractice inthecommunity,minimizeriskto
patientsandorganizationandare cost-effective”
Jointcommission
QIP:anotherdefinition
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21. QIP: benefits
•Meetingthe patient satisfaction and expectations
•Improvingservicesin termsof quality
•Improvingtheimagetocustomers,suppliersand
competitions.
•Implementing the accreditationrequirements
•Institutingconcreterecordsanddocumentationfor
followuponimprovementprojectsandasevidenceto
the improvementprocesses.
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22. QIP: Methodsto develop
•ThecoreofaQIPistoimprovedefectedareasinan
organization againstasetreferenceorcustomer
expectations.Forexamplethrough:
–Theidentificationof areasthatneedimprovement
–QIPandstrategicplanning
•Allofthesemechanismswillresultinthesame
outcomewhichis the improvementof the HCO.
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23. QIP: IdentificationofAreasthatNeed
Improvement
•Anyorganizationwillface alotofchallenges
duringitsoperationlife.Butthebiggestchallenge
istoidentifytheproblemsandtryto
process.
solvethemin
asystematicandstructured
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24. STEPSFOR IMPROVEMENT
•Establish acommitteethatis responsiblefor
improvementprocess
the
•Start theassessmentandmeasurementphase
•Analyzedata
•Plan forimprovement(QIP)
•Evaluate
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25. AreasforImprovementIdentification
Method
•
•
•
Establishadecisionunit (mechanism) (SteeringCommittee)
Identifyarea forimprovement usea QIT
Implement relevantcorrectiveactionsand preventiveactions
Areasfor
Improvement
•
•
•
StateRationale
Collectdata:establishthe necessarysystemand methods
Set the goal ofimprovement
Measurement
&Assessment
•Analyzedata and
information
transformitintouseful
Analysis of
Data
•
•
Establisha QIP
Evaluate yourplan
Planfor
Improvement
& Evaluate
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26. QIP Objectives
Currentapproach: C-Smarter
Challenging
Specific
Measurable
Attainable
Realistic
Time bound
Evaluated
Reviewed
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27. DataCollectionandPerformance
Indicators
•Data:acollectionofun-interpreted materials,facts,
observations,statistics,figures,numbersorrecordsthatare
usedtoformulateinformationnecessarytocontroland/or
assessanoperation,aprocessandaprocedureforaspecific
action
TypesofData:datacanberelatedtooperational,financial,
utilization,humanresources,qualitymanagement,customer
satisfaction,clinicalandother.
•
•Confidentiality:Restriction ofaccessto data and
informationtoindividualswhohaveaneed,areason,and
permission ofsuchaccess.
Data security:the protectionof datafrom•
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28. Data
•
•
and PI examples:
Patientdemographics
HospitalUtilization:
–OccupancyRate
–AverageLengthofStay
–BedTurnoverRate
Quality:•
–
–
–
–
–
–
–
–
–
–
–
PatientSatisfaction
Medicationerrors
Pressureulcers
Patientfalls
Waitingtimebeforeattendingto apatient
Numberoflostx-rays
Numberofexpiredreagents
%oflostspecimensinlaboratories
Numberofpatientsreadmittedwithin24-48hourstotheER
C-sectionrate
Transfusionreactions
–Infectionrate
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29. Data &
Complaints
Information
Areasfor
Improvement
HowtoGetYourObjective?
Indicator
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30. Plan for Improvement
•Definespecificallytheobjectivesthatneedtobereached.
Theobjectivesshouldfollow the S.M.A.R.Tapproach
•Statethe rationalfor improvements
•Setthe actionplanforreachingtheobjectives
•Assignresponsibilitiesandassign
steps
stafftofulfilltheaction
•Settimelinestoachievingeachstepintheprocessof
fulfillingthe objective
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31. QIP, example
QIP
Action
Steps/
Mechanism
Key
Performance
Indicators
Timelines/
Deadlines
ObjectiveRationale Responsible
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32. QIP Detailed
ObjectiveRationale KPI
Howto
assess
yourobj
SMART Why
Ex Ex Ex
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33. QIP Detailed,cont’d
How
Thesteps
neededto
Responsible
Whois
responsiblefor
eachstep
Time
Whenforeach
step
reachyourObj
Ex Ex Ex
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34. LinkingtheQIP with theStrategicPlan:
OrgGoalsDept
Obj
Rationale KeyPerformance
Indicator
(Outcome
Indicator)
Steps KeySteps
Indicator
(Process
Indicator)
ResponsibleTimeline
Hospital
Strategic
Plan
Why you’re
choosing
thisobj
Yourobjective Mechanism
toreach
your
objective
Whois
responsible
forthe
implementatio
neachstepin
the
mechanism
Whenisit
goingto
finish?For
eachstep
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