Section 3: Quality Measurement and Assessment

Pneumonia 30 day readmission is the quality improvement issue

Think about the quality improvement issue that you are addressing and the associated plan that you are developing. Consider the following:

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· What is the overall purpose, or aim, of doing this work?

· What would you hope to achieve for the organization by undertaking this project? What are the objectives of this initiative?

· What value would this work add to the organization?

· How would this work improve practice and create outcomes with impact?

Consider how addressing this quality improvement issue would align with the organization’s mission, vision, values, and strategic goals and objectives. How does it relate to regulatory issues, and other matters that are significant for the organization? If you notice a misalignment, use this as an opportunity to refine your focus.

With this in mind, continue to hone your development of this Assignment, integrating the concepts addressed here into Section 3.

To complete:

Write a 3- to 5-page paper that includes:

· An introduction to your quality improvement plan, including the overarching aim of this initiative and an explanation of how it aligns with the mission, vision, values, and strategic goals and objectives of the organization, as well as regulatory issues and other matters that are significant for the organization

· An overview of the current situation with regard to this quality improvement issue in the organization

· A description of measures and indicators

· A presentation on data related to this issue, including:

· Actual historical and current data and/or a description of the methods that you would use to collect and analyze the data

· Methods for collecting and analyzing data in the future, including when you would do this

· A description of realistic, evidence-based targets

Be sure to cite evidence from the literature to justify your selection of the measures and indicators, as well as the performance targets. 

Section 4: Quality Improvement Strategies

Through your work on Section 3 of the Course Project, you have examined the gap between current performance and evidence-based targets and considered how addressing this gap relates to organizational priorities and large-scale aims for quality improvement.

In this section of the Course Project, you begin to think about quality improvement strategies that could help to bridge this gap. As noted in the Sadeghi, Barzi, Mikhail, and Shabot text, this is referred to as performance-driven planning.

Since the publication of the Institute of Medicine’s report “Crossing the Quality Chasm,” a good deal of attention has been paid to the need to examine processes that contribute to outcomes (Ernst, Wooldridge, Conway, Dressman, Weiland, Tucker, and Seid). As the USAID has noted, interventions “will not create the desired outcome to improve the quality of care unless the overall process of care delivery is also improved.” Therefore, attention to process redesign is a central aspect of cultivating strategies for improvement.

To prepare:

· Refer to the modified Donabedian model (access, structure, process, outcome, and patient experience) presented in Chapter 9 of the Sadeghi, Barzi, Mikhail, and Shabot text.

· Recall the performance targets that you identified for Section 3 (in Week 6). What does the recommendation that performance-driven planning should “begin with the end in mind” suggest given your established goals?

· Review the information presented in Chapter 9 of the Sadeghi, Barzi, Mikhail, and Shabot text, and think about how you would assess the organization’s strengths and weaknesses related to the performance gaps you identified in Section 3 (Week 6).

· Based on the above, start to think of specific evidence-based strategies that could be implemented to close/minimize the performance gaps you have identified. Consider both interventions (what) and processes (how). Focus on strategies that are supported by the latest research and could create systems-level change. These may be tentative for now, but be sure to identify at least one that specifically lends itself to a change in process (i.e., practice, protocol, pathway, activity).

Throughout this course you have been considering the relationship between structure, process, and outcomes as it relates to health care quality. Looking at outcomes, alone, may not tell the “whole story.” For instance, if you are concerned with improving fall rates, evaluating the process—related activities or practices—can help you identify factors that contribute to outcomes and develop strategies for improving them.

For this section of your Course Project, you create a process map to examine a current process related to your quality improvement issue. You will use the results of the process mapping to redesign a process to help minimize or close the performance gap(s). As you proceed, keep in mind the importance of maintaining a patient-centered focus so the patient experience is not negatively affected by any changes in process.

To prepare:

· Review the instructions provided in the Learning Resources for creating a process map.

· With your quality improvement issue in mind, as well as the other work you have completed on your Course Project thus far, think about how creating a process map could help you to better understand your quality improvement issue and redesign an associated process.

· Create a process map using Microsoft Word or PowerPoint.

· Refine the strategies for promoting systems-level change to minimize or close the performance gap(s) that you began to think about in Week 7. As part of this, identify a way to redesign at least one process based on your analysis of the process map that you have created.

To complete:

· Write a 2- to 3-page paper in which you describe quality improvement strategies that you selected related to your quality improvement issue.

· Finalize your process map, which will be submitted along with the paper.

Process map help

https://www.isixsigma.com/tools-templates/process-mapping/practical-guide-creating-better-looking-process-maps/

Provides detailed description of how to create a process map

http://www.miltonkeynesccg.nhs.uk/resources/uploads/files/NHS%20III%20Handbook%20serviceimprove.pdf
 
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