Analyze how this healthcare organization’s mission is correlated with its quality philosophy.
Assess the role of quality within value-based reimbursement in this particular healthcare organization.
How is leadership involved in the dissemination and application of quality data at this healthcare organization?
II. Quality Infrastructure
Part of any performance improvement (PI) or quality plan is the description of the quality infrastructure or organizational foundation and also of the delineation of how quality information is disseminated throughout the healthcare:
Provide brief details about the organization’s information management system, including what type of system is used and patient records management.
What phases of meaningful use have been implemented to date?
Outline how performance improvement data and initiatives are tracked through the organization, starting at the department level. Consider using a visual aid to depict this.
Discuss leadership strategies that ensure stakeholder and community input into the quality program.
Discuss how the infrastructure of this healthcare organization supports data abstraction to support pay-for-performance (P4P) reporting requirements for the Centers for Medicare & Medicaid Services (CMS) and other insurance providers.
III. Process for Evaluation and Dissemination
Delineation of key metrics is an essential component of a PI or quality plan. In this milestone, you will discuss and delineate certain required metrics for the healthcare organization. In discussing these metrics, you will learn what quality elements are being measured by them as well as their vital role to the healthcare organization and patient safety and quality:
Describe the various stakeholder groups involved in the performance improvement process (e.g., nursing leadership, departmental directors, etc.). Consider using an organizational chart to depict these stakeholders.
How does leadership in various departments promote involvement in performance improvement?
Evaluate the frequency of performance improvement initiatives and timeline for submission of data.
Describe the processes for collecting, interpreting, and presenting data within the organization.
Define the metrics required for the hospital value-based purchasing program through CMS and provide the rationale for inclusion of these outcome and process-of-care measures.
IV. Define the following metrics for their use in the quality plan, including how they meet accreditation or quality requirements and how their use influences delivery of ethical care in the healthcare organization. Consider including a current example of each of these metrics:
Core measures included in the quality plan
Inpatient and outpatient scores (HCAHPS)
NDNQI included in the quality plan
Serious reportable events related to the quality plan
. CAUTI, CLABSI, and surgical site infections (infection prevention)
Reporting of blood usage
Culture of safety scores
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