I. Create aQI plan on patient safety and oganize the plan as you would present it to the organization’s board of directors for approval.

A. Introduce the organization and state its mission. Describe the types of services the organization provides.

BDescribe what goals the organization has to meet its mission. These are principles that shape how the organization views and achieves quality. Examples may involve the concepts of safety, effectiveness, timeliness, and patient centeredness.

C.  Describe what departments, programs, and activities are affected by the plan and why they are involved in its implementation.

D.  Describe the type of performance data to be collected and why that data is focused on. Describe why each data collection and display tool was selected for the QI plan.

E. Describe the methodology and processes used to implement the plan. This must explain why each methodology and process are in the plan and why they were chosen.

F.Describe what the organization will use as a standard to compare performance. This section must be one paragraph. This may be through a number of methods such as a comparative database or a competing organization’s annual report.

D. Describe the authority structure of the plan’s implementation. This must describe who is responsible for implementing the plan. Include a description of each role involved in the plan.

·         Board of directors

·         Executive leadership

·         Quality improvement committee

·         Medical staff

·         Middle management

·         Department staff

E. Identify who the performance activity outcomes are communicated to and who does the communicating. This describes who is responsible for overseeing data collection and preparing data reports.

F.  Describe how staff will be educated regarding the plan. This covers how each staff member will be initially oriented to the plan and each employee fits into the plan based on job responsibilities. This section must be approximately one to two paragraphs.

G.  Describe what elements of the plan are annually evaluated for improvement. This section must be approximately one paragraph.

In the QI Plan Template, complete the following:

• Evaluate various data collection and display tools used in performance measurement.
• Evaluate tools used to measure and report data.
• Analyze various improvement methodologies for integrating quality improvement strategies into performance measurements.
• Analyze the impact of information technology applications on performance measures.
• Analyze the use of internal and external benchmarking and milestones in managing the utilization of quality indicators.
• Evaluate criteria and tasks for developing quality improvement plans.
• Analyze how performance and quality measures are aligned to the organizations mission, vision, strategic and operational plans.
• Evaluate strategies for meeting regulatory and accreditation standards within health care organizations.
• Evaluate measures used to monitor and revise quality program implementation.
• Evaluate barriers that can interfere with the implementation of quality measures.
• Evaluate strategies to ensure successful implementation of quality measures.

II

Evaluate the current state of QI at the organization, its organizational and operational QI structure, authority, mission, methodology, and tools used.

• Recommend how the organization will achieve its objectives over the long term.
• Evaluate challenges that may impact the future of health care quality improvement.
• Evaluate effect of health care quality improvement on operational and financial performance. 

   

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