Organizational Quality Improvement Plan Part 1
HCS/588
June 3, 2013

Organizational Quality Improvement Plan Since the Institute of Medicine’s report “To Err is to Human” enacted in 2000, effort has been made to improve the quality of health care. To implement correctly a quality improvement plan (QIP) the perception of the organization culture and the stakeholder’s culture need to be explored (Centers for Medicare & Medicaid Services, 2013). Quality improvement plan improves quality and efficiency of services to the highest levels rendered. In the United States, for example, consumers have the right to choose, bargain, and express their dissatisfaction or concerns about a product or service. The economy is based on consumerism and the opinion of the consumer is valuable. In the health care arena, consumers have the right to choose the right providers when they looking for medical attention. They have the option to choose the one that can accommodates their needs. This also can create competition in an open market. Competition is very good because it helps competitors to improve the quality of their goods and services. In this paper, a quality improvement plan will be developed for Mary Washington Hospital, the difference between performance measurement and quality improvement will be addressed along with the organization mission and goals. The role of the stakeholders, and which external quality indicators are available will also be discussed in this paper. Differences between Performance Management and Quality Improvement
Performance management is a method intended to help accomplish an organization’s mission and goals by improving effectiveness, empowering employees, and simplifying the decision-making process (Center of Disease Control and Prevention, 2011).
Quality improvement (QI) is a process that continuously moving forward in an effort to achieve measurable improvements in the efficacy, productiveness, performance, accountability, outcomes and other indicators of quality services which improve health of the community (Riley et al, 2010). QI focuses on being proactive in preventing errors, responding to near misses, or developing a plan in which safety is a major component of the plan. Hence, in case of medical errors, QI identifies the changes that need to be implemented for improvement. Performance management enables quality improvement and provides information of whether or not quality of care/services is improving (Center of Disease Control and Prevention, 2011).
Chosen Organization-MW Hospital MW Hospital is part of an independent corporation and has been in existence for over 100 years. This organization is a 437-bed, full-service hospital offering advanced services usually found in major cities such as such as trauma care, neurosurgery, advanced cancer care, stroke care, to name a few. MWH met the highest national standards in health care. In September 2009, MWH received the Magnet award for excellence in nursing services from the American Nurses Association (ANA). MWH is among the 15 Virginia hospitals that have attained the status. The Magnet Recognition Program addressed the professional work environment that required facilities to comply to its model components such as the transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation, and improvement, and empirical quality results (ANCC, 2008). Research shows patients admitted to Magnet hospitals receive better care, they have fewer complication, shorter hospital stays, and improved patient and staff satisfaction scores.
Mission Statement MW Hospital mission is clear. MW hospital exists to improve the health status of all the people within its service area. As a non-profit corporation, the hospital invests its profits back into the organization by investing in new technology to enhance patient safety, by developing new services and by investing in hiring new employees. The result is an ongoing improvement in the scope and quality of care that the hospital is able to provide to the community MW hospital is committed to the ongoing improvement of the quality of care of its clients. The organization continues to make great effort to make sure that: * The treatment that the consumers receive includes evidence-based, effective practice. * The treatment and services are appropriate to the patient’s need and is available when needed * Consumers feel safe and errors are reduced to a minimum * Consumers need are respected * Consumers have the opportunity to participate in their own care, treatment, and decision * Treatment and services are provided in a timely manner and with care and sensitivity
MW hospital approach to quality improvement is based on the focus of its consumers (internal and external) and thrives to meet or exceed needs and expectation , its employee empowerment, statistical tools, leadership improvement, and continuous improvement.
MW Campus includes four Intensive Care Units, an Emergency Department with 50 treatment areas, and four medical specialty care units. Patients and their families are the primary focus, and the way in which care is delivered reflects the passion for what healthcare professionals do every day. MW hospital is the only stroke center in the area and the nurses working on the stroke unit must be certified so they can provide standardized evidence-based care to stroke patients. Nurses on this unit care for an average of 50 stroke patients each month. The estimated length of stay for patients diagnosed with stroke is 4 days. Many of these patients are discharged without the appropriate follow-up care. Caring for stroke patients require nurses to have a keen sense of assessment and critical thinking skills to determine the level of care to be provided.
Role of the Consumer/Nursing staff In order to improve continually, an organization must understand that it is a system on interdependent parts, all with the same mission and to meet the needs and exceed the expectations of the patients. Achieving Stroke certification is important to MW Hospital because of the need to acknowledge the hospital as a magnet for excellence by creating a work environment that recognizes, rewards, and promotes professional nursing and supports all disciplines in providing quality patient care.
External Quality Indicators The hospital uses several external quality indicators to assist and maintain quality improvement plans. MW hospital must meet standards and requirements set aside by the Joint Commission on Accreditation of Healthcare Organization (JCAHO) for it to be certified and accredited. The Joint Commission guidelines, identifies five elements of stroke education that must be received by patients and /or their caregivers. These elements are, personal risk factors, warning signs of stroke, dial 911; goal hospital within one hour onset, follow up after discharge, and medication reviewed. Educating patients on the risk factors provides them with the information that assists in reducing their personal risk factors for a repeat stroke and can also assist patients in taking more responsibility in living healthy lives. Educating patients on risk factors for stroke is an ongoing issues because nurses fail to do that. Ninety five percent of the nurses on the stroke unit are Board Certified by the American Stroke Association (ASA) and have completed the National Institute of Health (NIH) Stroke Scale and are able to fully or partially complete the standardized neurological assess utilizing the NIH tool. External quality indicators guide the hospital to make changes and to keep up with the standards of quality services provided.
Consumer’s use of the indicators Stroke is a major neurological disorder in the United States and it affects millions of people and their families. Stroke is the third leading cause of death and the primary cause of adult disability. (American Stroke Association, 2010). The hospital offers services to consumers suffering from stroke and encourages them to take advantage of the services. The stroke center provides consumers and their family with valuable resources on how to recognize the signs and symptoms of a stroke and it is diagnosed and treated.
Quality Improvement Feedback Feedback from the patients after they go home is used to assist with changes that need to be implemented in the unit. Feedback is very important because it will tell how the consumers experience health care and how they feel about their treatment, interaction with the staff. Consumer experience can be negative and positive and that can help the organization in shaping and delivering care.
Conclusion
The hospital needs to provide education and training to the nurses working on the stroke unit so the nurses can provide effective care to their patients and improve job performance. Each nurse also should be held accountable for non-adherence to the organization standards of practice.

References American Association of Colleges of Nursing (AACN) (2008). The essentials of Baccalaureate education for professional nursing practice. Washington, DC
Center for Medicare and Medicaid Services. (2013). Quality improvement organizations - Centers for Medicare.... Retrieved from http://www.cms.gov > Medicare > Quality Improvement Organizations
Center of Disease Control and Prevention. (2011). Definitions and concepts - performance management and quality. Retrieved from http://www.cdc.gov/stltpublichealth/performance/Definitions.html
American Stroke Association (2010). Heart disease and stroke statistic. American Heart Association Journal. Retrieved from http://circ.ahajournals.org
Riley, W., Moran, J., Corso, L., Beitsch, L., Bialek, R. & Cofsky A. (2010). Defining quality Improvement in Public Health. Journal of Public Health Management & Practice. 16 (1) 5-7