Write a 500- to 750-word paper in which you answer the following questions: • What types of care or service does your chosen organization focus on? What is its mission? What QI goals does Baptist Memorial Hospital have in place? • What is the role of consumers–patient, family, and friends–in Baptist Memorial Hospital QI process? What external quality indicators are available to consumers regarding that organization?

Describe at least three indicators in detail. How do consumers use these indicators as part of the QI process? • For your organization, how is or can stakeholder–patient, managers, administrators, clinicians, health insurers, regulatory agencies, and so forth–feedback be used in the QI process? If you do not know how it is used, indicate how it can be used. Cite at least three sources to support your information. Combine all four parts of the QI plan into one document, making sure to include instructor and Learning Team feedback. Organize the plan as you would present it to the organization’s board of directors for approval. Use the QI Plan Template as a guide.

Quality Improvement Plan Template

In this course, you develop an organizational quality improvement (QI) plan for a health care organization of your choice. Organize the plan as you would present it to the organization’s board of directors for approval. Use the following outline as a guide when developing your plan.

Executive Summary: A one-page overview of the plan

Introduction/Purpose: Introduce the organization and state its mission. Describe the types of services the organization provides. This section must be approximately half a page.

Goals/Objectives: Describe 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. This section must be approximately half a page.

Scope/Description/QI Activities: Describe what departments, programs, and activities are affected by the plan and why they are involved in its implementation. This section must be approximately half a page.

Data Collection Tools: 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. This section must range from half a page to a full page.

QI Processes and Methodology: 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. This section must range from half a page to a full page.

Comparative Databases, Benchmarks, and Professional Practice Standards: 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.

Authority/Structure/Organization: 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. This section must be approximately half a page:

• Board of directors • Executive leadership • Quality improvement committee • Medical staff • Middle management • Department staff

Communication: 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. This section must be approximately one paragraph.

Education: 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.

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

QI Plan Part One Organizations are faced with challenging obstacles of functionality where improvement plans within the organization is outdated. Some of the challenges include technological advancements have taken great shape compared to the previous century. It has become an essential attribute that an organization meets the needs of society and the improvement plan must be cost effective. In this discussion we have taken the effort to discuss “Baptist Memorial Hospital Memphis” which is considered as one of the top social and economical medical facilities headquartered in Memphis, Tennessee.

“Six Sigma, originally designed as a business strategy, involves improving, designing, and monitoring process to minimize or eliminate waste while optimizing satisfaction and increasing financial stability” (McGraw Hill, 2000). Baptist Memorial Hospital implements this strategy to improve the organization’s plan by identifying the potential areas of improvement. Areas of Potential Improvement To identify potential areas for improvement organization should have a proactive analysis to determine performance shortcomings. The analysis can be used to diagnose the cause and effect to identify the cause to obtain a technique suitable the resolve the issue.

Based on the outcome of the analysis the organization can then evaluate and decide what area(s) need to be addressed to achieve organizational goals. The potential improvement areas include: • A customer analytics should be implemented to provide insight to understanding the needs of customers served within the community. • Statistical analysis of data to reduce error reduction to continually improve to ensure safety of patients. • Conceiving and implementing enterprise cost management systems for better performance.

Objective indicators of performance determine how effective an improvement plan is no matter if the performance is improving or worsening. To analyze improvement rate, the organization has to start a survey program which will ensure that each patient provides feedback. There should be a team to analyze that how far the initiatives made by the hospital group to full fill the needs of the patients. Additionally the performance of each device must be monitored on a regular basis so that it will be quite easy to understand the efficiency of the hospital.

Along with the activities the employees should be evaluated to identify whether they are providing good service delivery. The current strategy of Baptist Memorial Hospital has supported well enough to draw the attraction of the consumers in a competitive market. Even after that it is quite necessary to implement certain tools to look after certain performance so that it will be easy to add new plans. The performance information measurement tools include a logic model, balanced scorecard,

and performance dashboard. A logic model is a visual map that displays a strategy of activities in an organization that will bring change in efforts to move in a better direction. In doing so, an organization can identify the challenging factors and take the necessary actions to overcome them. The next step would be to set up a good environment for the employees, as well as consumers. The logic model has many names such as a mental model, model of change, and blueprint of change. The goal of this technique allows the organization to spot a potential problem before the effects get out of hand.

Another method used to achieve the organizational goal is the balanced scorecard which offers the vision, strategies, tactical activities, and metrics. Baptist Memorial Hospital focus on a QI plan to ensure the organization benefited in areas of profiting, customer satisfaction and performance. This method is similar to the logic method because the methods is visual and consist of a strategy map and linked to measuring operating cost, and investment returns to maximize profits for future productivity.

This method focuses on customer satisfaction as the logic method, but the balanced scorecard is different because it offers more benefits. This tool can guide the overall process of the health care, as a result it will be easy to keep track among all the activities. Performance dashboard is a tool that is used to measure the efficiency of the organization’s operation and performance indicators. This tool accumulates necessary information to map the performance criteria so that it will be easy for an organization to keep track of all necessary information. The data is displayed by using pie charts, run charts, and bar graphs. Dashboards monitor time limited priorities and are monitored by team members regularly.

Among all the performance improvement tools, logic model is considered as one of the important tools since it creates relational strategy for the organization to retain the consumers for a long time. At the same time, Balanced Scored model also plays a vital role, as it will provide a path to strengthen the business strategy. The Balanced Scored model will provide an option to analyze the current market and make necessary statements that will help to develop strong business model. However, all the tools exhibit similar kinds of behaviour to develop a business strategy for the Baptist Memorial Hospital, and also each tool provides analysis about the current business process and motivates to implement new steps so that the organization can be benefitted well.

Tools to Measure and Display Data There are many methods that can be used to identify quality of the service that is provided by the Baptist Memorial Hospital to analyze processes that will provide quantitative data. The QI tools include run chart, control chart, histogram and scatter diagram. Another method used is a run chart which displays performances over time in sequential order. This method allows the organization to visually detect signals of causes to understand variation within the process.

A center line is drawn to test the data for identifying upward and downward trend that from the real data. Another method is a control chart that has upper and lower lines and a center line to control data within the lines of the data to monitor to control the process. The information is monitored to determine if the process is or is not stable. This method is similar to the run chart, but the control chart can control statistical limits. Adjustments can be made to add more variation to the process. When information about frequency distribution need to be graphically displayed within the organization histogram are used. It helps analyze data and defines a right way to distribute the data across various departments.

Strengths and Weakness of Data Tools As far as run chart is concerned, it is much helpful to arrange the data in the right way so that it will be easy to avoid the data integrity. These strengths will boost up the performance level at every stage of the business line. At the same time, it does not provide a stabilized solution for maintaining the variation level; as a result it will not be effective in case of error elimination. The control chart is helpful to maintain the upper as well as lower level limits to capture the variation limit and in that case it is easy for an organization to look after the error. These are strengths of the control chart, but sometimes the control chart does not provide actual variation beyond the fixed point. In that case,

this is considered as one of the weaknesses of the tool. Histogram’s main strength is the graphical display which will ensure a fixed variation and it will be helpful for the organization to track the actual performance. Sometimes the graph level does not reflect the actual data and in that case the process is quite complicated due to this it is considered as one of the major weakness. When we look the nature of such tools from a performance point it is quite easy to say that, all these tools will helpful to maintain the proper business line for health care organizations.

These tools will also set a standard so that it will have a direct impact on the performance. Conclusion In conclusion, it is essential for organizations to understand if the quality improvement plan is effective. Baptist Memorial Hospital strives to focus on the needs of the customer, productivity, and profiting to continuously improve. The success of the organization relies on a quality improvement plan. The methods discussed in this paper shows how the organization continues being one of the leading organizations in these improvement area

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