Quality Improvement Plan

1. Planning
Quality Improvement Planning (QIP)

2. What is Planning?
Types of Plans
Strategic Planning
Quality Improvement Planning
◦
◦
◦
Definition
Methods to develop a QIP
Linking the QIP with strategic planning
Group Case
Outline
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3.  In any Healthcare Organization (HCO), planning is a core and
essential
business
etc... All
activity, and many types of plans exist such as
plans, marketing plans, opening a new facility plan,
of them are involved in:
◦ Choosing and describing tasks that must be performed
attain organizational goals and/or objectives
to
◦ Outlining how the tasks must be performed, and
◦ Indicating when they should be performed.
Planning: an Overview
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4. Strategic Planning
• Strategy: outlines the basic steps/tactics
management plans to take to reach a
goal/objective.
Strategic Planning:
•
– Is methodical and structured process
whereby an organization:
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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. • Strategic planning helps the org develop an action oriented
approach and identify the pieces needed to build a
successful org operation.
• Remember to:
– Involve staff at every level
– Be flexible in developing a plan by circulating drafts and allowing
people to provide feedback
– Ensure that everyone knows their responsibility
Strategic Planning Benefits
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7. • Organization Strategic Planning: it is wide plan that might
not cover but affects all aspects of an organization.
• Department Plan: it is a specific plan for departments. It
could be developed with general and specific objectives;
however, it MUST align with the organization plan.
Strategic Planning
Organization Vs. Department
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8. QIP and Strategic Planning:
 Characteristics:
◦ To know and identify what the
his/her expectations are.
customer wants and what
◦ To develop and/or review of the mission, vision and values
of the HCO; as it will act as the frame work and the
pathway for the institution to
and vision
follow up to attain its mission
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9. Conducting Environmental Analysis:
 External
 Internal
Why: to pinpoint out the factors that would
significantly affect the
patient
organizational
expectations
operations, such as:
about the quality of services, and the
technology
enhance the
advancements
quality of care.
that might
Strategic Planning Steps
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10. SWOT Analysis
•
•
•
•
Strength
Weaknesses
Opportunities
Threats

11. • The strategic commitment planning is a
methodical and structured process whereby
an organization has to implement the
following steps:
Strategic Planning Steps:
Commitment Plan
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12. Strategic Planning Steps:
Commitment Plan
• Define the mission: a mission is what
exists to do, given a particular group of
It answers the following questions:
– What is the HCO purpose?
the organization
customer needs.
– In what activities the HCO will we be engaged and what kind
of services it will offer in order to accomplish that purpose?
– What are the HCO basic values and shared beliefs?
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13. Strategic Planning Steps:
Commitment Plan
• Characteristics of a Mission:
– A continuing guide: your mission is a continuing guide
for the actions that you take
– A basis for self audit: it forces you to re-think each
vital factor to which your have committed your
resources
– Integrated effort: every
in your mission
one in your org can subscribe
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14. • Define the vision: a vision is what the managers,
employees, physicians and patients and other interested
parties want the HCO to be when it accomplishes its
mission. It is a hope for the future. It should be brief,
tied
and
to individual motivation, stretching but achievable
it can be inferred from the mission statement.
Strategic Planning Steps:
Commitment Plan
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15. Strategic Planning Steps:
Commitment Plan
• Define the values: these are principles that guide decision
making and are held dear
– innovation,
– integrity,
– teamwork and
– no smoking policies
by members of the organization. Ex:
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16. Strategic Planning Steps:
Commitment Plan
 Prioritize long & short term goals & objectives: the strategic
goals should have in their essence the target of improving
performance of the organization operations and meet customer
expectations. The Goals :
◦ Are ends or an outcome that one hopes to attain.
◦ Are most of the time general, on
technical
the Hospital Level and not
highly affiliated to and specific department
operations.
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17. Strategic Planning Steps:
Commitment Plan
• The objectives: are the targets towards which the
management system is directed and is trying to achieve.
They flow from the organization’s purpose or mission
• Tend to be more specific and more related to department
or unit operations and management processes. Also, they
should be measurable, attainable, and realistic and have
timelines. This is known as the S.M.A.R.T approach.
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18. Strategic Planning Final Steps:
Commitment Plan
• Assign accountabilities: the HCO should assign
responsibilities to oversee the proper implementation
of the strategic plan and its stated goals.
• Allocate resources: the HCO should ensure that all
needed resources such as: time, manpower, money,
equipment, education and training, etc are all
secured in order to fulfill the strategic plan.
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19. • A QIP is an organization wide coordinated approach to:
– defining areas of problems and
– establishing mechanisms and actions to improve such
areas with the available resources.
• It deals completely with all the efforts and resources
used to achieve objectives that are directly and
and
indirectly affecting the patient (customer) care
satisfaction
QIP Definition
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20. • “Coordinated and comprehensive process to monitor
and improve patient safety and the performance of all
care
shall
and
be
services provided. Its goals and purpose
to strive, within available resources, for
optimum outcomes with continuous improvements
that are consistently representative of a high standard
of practice in the community, minimize risk to
patients and organization and are cost-effective”
Joint commission
QIP: another definition
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21. QIP: benefits
• Meeting the patient satisfaction and expectations
• Improving services in terms of quality
• Improving the image to customers, suppliers and
competitions.
• Implementing the accreditation requirements
• Instituting concrete records and documentation for
follow up on improvement projects and as evidence to
the improvement processes.
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22. QIP: Methods to develop
• The core of a QIP is to improve defected areas in an
organization against a set reference or customer
expectations. For example through:
– The identification of areas that need improvement
– QIP and strategic planning
• All of these mechanisms will result in the same
outcome which is the improvement of the HCO.
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23. QIP: Identification of Areas that Need
Improvement
• Any organization will face a lot of challenges
during its operation life. But the biggest challenge
is to identify the problems and try to
process.
solve them in
a systematic and structured
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24. STEPS FOR IMPROVEMENT
• Establish a committee that is responsible for
improvement process
the
• Start the assessment and measurement phase
• Analyze data
• Plan for improvement (QIP)
• Evaluate
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25. Areas for Improvement Identification
Method
•
•
•
Establish a decision unit (mechanism) (Steering Committee)
Identify area for improvement use a QIT
Implement relevant corrective actions and preventive actions
Areas for
Improvement
•
•
•
State Rationale
Collect data: establish the necessary system and methods
Set the goal of improvement
Measurement
&Assessment
• Analyze data and
information
transform it into useful
Analysis of
Data
•
•
Establish a QIP
Evaluate your plan
Plan for
Improvement
& Evaluate
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26. QIP Objectives
Current approach: C-Smarter
Challenging
Specific
Measurable
Attainable
Realistic
Time bound
Evaluated
Reviewed 26

27. Data Collection and Performance
Indicators
• Data: a collection of un-interpreted materials, facts,
observations, statistics, figures, numbers or records that are
used to formulate information necessary to control and/or
assess an operation, a process and a procedure for a specific
action
Types of Data: data can be related to operational, financial,
utilization, human resources, quality management, customer
satisfaction, clinical and other.
•
• Confidentiality: Restriction of access to data and
information to individuals who have a need, a reason, and
permission of such access.
Data security: the protection of data from
•
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28. Data
•
•
and PI examples:
Patient demographics
Hospital Utilization:
– Occupancy Rate
– Average Length of Stay
– Bed Turnover Rate
Quality:
•
–
–
–
–
–
–
–
–
–
–
–
Patient Satisfaction
Medication errors
Pressure ulcers
Patient falls
Waiting time before attending to a patient
Number of lost x-rays
Number of expired reagents
% of lost specimens in laboratories
Number of patients readmitted within 24-48 hours to the ER
C-section rate
Transfusion reactions
– Infection rate
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29. Data &
Complaints Information
Areas for
Improvement
How to Get Your Objective?
Indicator
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30. Plan for Improvement
• Define specifically the objectives that need to be reached.
The objectives should follow the S.M.A.R.T approach
• State the rational for improvements
• Set the action plan for reaching the objectives
• Assign responsibilities and assign
steps
staff to fulfill the action
• Set timelines to achieving each step in the process of
fulfilling the objective
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31. QIP, example
QIP
Action
Steps/
Mechanism
Key
Performance
Indicators
Time lines/
Deadlines
Objective Rationale Responsible
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32. QIP Detailed
Objective Rationale KPI
How to
assess
your obj
SMART Why
Ex Ex Ex
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33. QIP Detailed, cont’d
How
The steps
needed to
Responsible
Who is
responsible for
each step
Time
When for each
step
reach your Obj
Ex Ex Ex
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34. Linking the QIP with the Strategic Plan:
Org Goals Dept
Obj
Rationale Key Performance
Indicator
(Outcome
Indicator)
Steps Key Steps
Indicator
(Process
Indicator)
Responsible Timeline
Hospital
Strategic
Plan
Why you’re
choosing
this obj
Y
our objective Mechanism
to reach
your
objective
Who is
responsible
for the
implementatio
n each step in
the
mechanism
When is it
going to
finish? For
each step
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