Scenario: You have just been h

Develop and implement the HIM Department Quality Plan

Improvement work invariably involves work across multiplesystems and disciplines within a practice. The quality improvement(QI) team or committee (QIC) is the group of individuals within apractice charged with carrying out improvement efforts. The teammay report to the organization’s chief executive officer. To beeffective, the team should include individuals representing allareas of the practice that will be affected by the proposedimprovement, as well as patient representatives.

The QI team meets regularly to review performance data, identifyareas in need of improvement, and carry out and monitor improvementefforts. For these activities, the teams will use a variety of QIapproaches and tools, including the Model for Improvement (MFI),Plan Do Study Act (PDSA) cycles, workflow mapping, assessments,audit and feedback, benchmarking, and best practices research.

The team should have a clearly identified “champion” who iscommitted to the ideal and process of continuous improvement. Thisindividual should be interested in building capacity in thepractice for ongoing improvement and implementing effective“processes” that will enable improvement. Such processes mayinclude gathering and reflecting on data, seeking out bestpractices, and engaging voices and perspectives of individualsinvolved in all aspects of the process/activity under scrutiny. Therole of the QI team champion is to ensure that the team functionseffectively and fulfills its charter for the organization.

Who Should Be on a Quality Improvement Team?

The Institute for Healthcare Improvement (IHI) recommends thatevery team include at least one member who has the followingrolesⁱ:

• Clinical leadership. This individual has theauthority to test and implement a change and to problem solveissues that arise in this process. This individual understands howthe changes will affect the clinical care process and the impactthese changes may have on other parts of the organization.
• Technical expertise. This individual has deepknowledge of the process or area in question. A team may needseveral forms of technical expertise, including technical expertisein QI processes, health information technology systems needed tosupport the proposed change, and specifics of the area of careaffected. For example, a team implementing an intensive caremanagement clinic for people with poorly controlled diabetes mightneed technical expertise in change management, the clinic’selectronic health record, and the patient treatment protocols thatwill be used.
• Day-to-day leadership. This individual is thelead for the QI team and ensures completion of the team’s tasks,such as data collection, analysis, and change implementation. Thisperson must work well and closely with the other members of theteam and understand the full impact of the team’s activities onother parts of the organization as well as the area they aretargeting.
• Project sponsorship. This individual hasexecutive authority and serves as the link to the QI team and theorganization’s senior management. Although this individual does notparticipate on a daily basis with the team, he or she may joinperiodically and stays apprised of its progress. When needed, thismember can assist the team in obtaining resources and overcomingbarriers encountered when implementing improvements.

The optimal size of a QI team is between five and eightindividuals, although this may vary by practice. The most importantrequirement is not size, but diversity of the participants. It isimportant that the team include a diverse group of individuals whohave different roles and perspectives on the patient care or otherprocesses under consideration. This group should include wheneverpossible input from the “end user” of health care, the patient.

Potential members of a QI team might be:

• Chief executive officer.
• Medical directors.
• Physicians.
• Nursing staff.
• Physician assistants.
• Medical assistants.
• Patient representatives.
• Operations manager/director.
• Health educators.
• Community health workers.
• Peer mentors.
• Patients.
• Community representatives.
• Directors of clinical services.
• Practice managers.
• Medical records staff.
• Receptionists.
• Lab technicians.
• Pharmacy or dispensary staff.
• Case managers.
• Physical plant operations.
• Billing department staff.
• Finance director.

i Adapted from the Institute for Healthcare Improvement. Scienceof Improvement: Forming the Team. Available at:http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx.

Creating a Quality Improvement Plan With a Practice

One of the first tasks to complete with the QI team is toidentify goals for the improvement work and associated performancemetrics. It is useful to have preliminary performance dataavailable to use in setting improvement goals whenever possible.Goals are fluid and will likely change during your work with thepractice as more information is gathered on practice performanceand functioning and as the team achieves preliminary goals and isready to move on to new ones.

Using Key Driver Models To Focus Quality Improvement Plans

Key driver models are roadmaps to particular outcomes that helpfocus the work of a facilitation program, as well as the work ofindividual facilitators and facilitation teams at the practicelevel. Key drivers define the pathway to a desired transformation.Key driver models graphically display the strategies and activitiesneeded to achieve goals and aims of the practice improvementeffort

Facilitation programs typically use two levels of key drivermodels:

• One at the programmatic level that outlines the facilitationprogram’s overarching goals and underlying model for change,and
• One at the practice level, which tailors the programmatic modelto the needs and priorities of individual practices.

Program-level and practice-level key driver models include:

• Desired outcomes for the practice improvementeffort,
• Big changes or “key drivers” that are mostlikely to accomplish these goals, and
• Specific changes or action items that mustoccur to produce the desired big changes.

Example of a Key Driver Model

This key driver model was developed for the ImprovingPerformance in Practice Initiative funded by the Robert WoodJohnson Foundation and provided by Dr. Darren DeWalt.

The far left column shows specific QI goals. The middle columncontains the organizational and care processes thought to improvecare and patient outcomes. These key drivers function as a menufrom which practices can choose the approaches they will use toachieve their goals. The far right column contains the “changeconcepts” or action items/steps to implement a particular keydriver.

Designing a Key Driver Model With a Practice

You should work with the practice to develop a practice-levelkey driver model that links to the outcomes identified by thepractice and targeted by the facilitation intervention. Thepractice’s QI plan should be based on the practice-level key drivermodel to reflect the change concepts included in the model. If yourprogram has a predefined key driver model for the intervention, youshould review the prescribed model with the practice’s QI team andwork with them to identify the drivers and change concepts theywant to implement first, second, and third. You should also ask thepractice to identify what other items not currently represented onthe key driver model they are interested in changing, and makethese additions accordingly.

A first step in developing a key driver model is to choose goalsthat are clearly defined. Goals and outcomes should be SMART:

• Specific,
• Measurable,
• Attainable/Achievable,
• Relevant, and
• Time bound

When defining its change goals, the practice should includenumeric targets. Distinguish between goals that will beaccomplished during the period you are facilitating (if it’s timelimited) and longer term goals. They should be based on the resultsof the practice assessment and focus on the areas needingimprovement.

Creating a Quality Improvement Plan

A QI plan should provide guidance to the practice on who is toparticipate on the QI team, how often it is to meet, and what itsgoals and key activities are. In addition, the plan should lay outthe process that will be used to drive improvement in the practice,such as the MFI and PDSA cycles, how these are to be documented,and the way current and ongoing status is going to be monitoredusing data. A good QI plan includes among other things:

• A statement of the quality vision.
• A description of the program structure.
• A membership for the QI team or committee that is diverse.
• A meeting schedule.
• A defined process for how QI will be conducted.
• A list of improvement goals or priorities that are specific,measurable, achievable, relevant, and time bound.
• A plan for how both the plan and the goals will beevaluated.
• A plan for how performance data will be acquired andreported.

An important role you can play as a practice facilitator will beto assist practices in developing a plan or to review the plan theyalready have.

Monitoring Progress on the Quality Improvement Plan

With new QI teams, another role you can play is to help the teamdevelop systems that will allow them to track progress toward theirimprovement goals and monitor their performance on key qualityindicators. To do this, you will need to work with practiceleadership and staff to set up data systems that can producepractice performance reports on key quality metrics on a monthly orquarterly basis. As much as possible, you should assist thepractice to automate the development of these reports so that theburden on staff is minimized or to design the data collectionprocess so staff can carry it out in addition to their existingduties. An elegant system that cannot be sustained is no betterthan having no system at all.

You will need to work with the QI team to develop a standardtemplate for the performance report and identify the time periodfor reporting. You will also need to assist them in identifying thestaff needed to prepare the reports and the time they will need toaccomplish this task. In addition, you will need to work with theteam to revise staff job descriptions to include this task, as wellas their performance evaluation. You will also need to help themtrain staff on these tasks.

A QI dashboard or data wall can be a useful tool for QI teams tohelp them track progress toward key improvement goals. QIdashboards or data walls are one- to three-page summary reportsthat provide a graphic summary of progress toward key process andoutcome metrics. Often they include a “stoplight” system of red,yellow, and green color coding to signal that an activity orperformance metric is on track, partially off track, or havingserious problems. It can be helpful to include a dashboard ofprogress toward the elements of the key driver model if one wasincluded as part of the QI plan. In addition, it can be useful toinclude copies of any PDSA cycles that are underway or completedwith the dashboard to enable the QI team to easily review itsprogress.

The report will create a written record of the team’s progressand help increase ownership and accountability in the QI team andpractice for follow-through on improvement work. It also can helpyou identify QI teams that have hit a roadblock and may need someadditional assistance from an expert consultant or a facilitatorwith a different set of skills. You can add this expertise to yourfacilitation team if it is needed.

Develop data collection, data analysis, and data presentationtools for use in the quality plan

I. INTRODUCTION

PURPOSE:

Quality Assessment, Performance Improvement, and Patient SafetyPlan

The purpose of the Quality Assessment, Performance Improvement(QAPI) and Patient Safety Plan is to provide a formal mechanism bywhich the Medical Center utilizes objective measures to monitor andevaluate the quality of services provided to patients.

Quality is defined broadly to include care that is safe,effective, patient-centered, timely, efficient, and equitable. Theplan facilitates a multidisciplinary, systematic performanceimprovement approach to identify and pursue improved patientoutcomes and reduce the risks associated with patient safety in amanner that aligns with the mission

MISSION:

The mission is to improve the human condition by providingpatient-centered, quality care in a way that facilitates theachievement of INSTITUTION .

OBJECTIVES:

Objectives of Patient Safety Plan are :

• Maintain and grow a comprehensive QAPI infrastructure, i.e.,human capital, data collection, analysis, process improvement,outcome assessment, software, education and training.

• Create a robust performance improvement culture focused onhigh reliability measures that enhance quality and safetythroughout the organization.

• Integrate quality, safety, and service into performanceimprovement opportunities, implementing actions, and evaluatingresults based on the goals of providing care that is safe,effective, patient-centered, timely, efficient, and equitable.

• Encourage an environment that supports safety, encouragesnon-punitive reporting, addresses maintenance and improvement inpatient safety issues in every department throughout the facility,and establishes mechanisms for the disclosure of informationrelated to errors..

• Focus and coordinate the organization-wide performanceimprovement, patient safety, and patient experience initiativesbased on sound metrics, state of the art analysis, and contemporaryimprovement methods.

• Communicate, report, and document quality, patient safety, andpatient experience activities to professional staff,administration, and appropriate governing members.

• Maximize effective organizational and clinical decisionmaking.

• Promote teamwork and group responsibility in identifying andimplementing opportunities for improvement.

• Utilize tools and approaches that capitalize on knowledgeregarding holistic approaches to improving quality and safetysystems, including those developed outside of health care.

2. STRUCTURE AND LEADERSHIP

The leaders work to improve quality by setting priorities,modeling core values, promoting a learning atmosphere, acting onrecommendations, and allocating resources for improvement. They aresupported by committees and work groups where the components of theprogram are defined, implemented, refined, and monitored. Thesegroups are structured around six key dimensions of caredelivery.

The quality domains include effective, timely, appropriate,safe, efficient, and patient-centered care. These groups arecomprised of attending physicians, resident physicians, staff, andmanagement and are represented via a reporting process to theQuality and Patient Safety Council, which acts as the “oversightcommittee” for QAPI and patient safety reporting. The Quality andPatient Safety Council reports to the Medical Staff ExecutiveCommittee, which in turn reports to the Clinical Affairs Committeeof the Board of Trustees.

3. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROCESSPrioritization of Areas for Measurement

The process for identifying priorities for measurement requiresinput and discussion with senior leadership, departments, andservices from all areas. Priorities are identified based onleadership objectives, regulatory requirements, opportunitiesidentified in external benchmark projects, opportunities identifiedthrough analysis of patient safety event reports and opportunitiesidentified through sentinel events, standard of care findings or”Sentinel Event Alerts.” These objectives or topics are thendisplayed in a matrix to better understand which areas ofimportance and relevance they cross (high risk, high volume,problem prone, mission, internal and external customersatisfaction, clinical outcome, safety, and regulatory).

Developing Measure Specifications

Work groups or committees define the metrics (indicators, goals,and benchmarks) for each topic. Representatives from all involvedservices collaboratively develop quality performance measurespecifications based on the opportunities identified to be studied.Team members are identified with the help of clinical andadministrative leadership. Work groups develop written measurementspecifications, along with data abstraction tools whennecessary.

Gathering Data

Data is then gathered on a pre-determined timeframe (weekly,monthly, and quarterly). Regular reporting of data requirescontinued attention from teams. A designated person will beassigned and held accountable for gathering data and having theinformation available when due. Sampling sizes are determined basedon recognized, statistically significant sample sizes of:<30/month – 100%; 3 1-100/month – 30; IO 1-500/month – 50; and>500/month – 70 Real time data are collected as possible.

Analyzing and Reporting Data

The work groups discuss data analysis and determine whatinitiatives must be implemented to attain the desired outcome.Analyses usually involves multiple iterations to examine differentaspects of the quality issue. Whenever possible and appropriate,statistical control methods, trending, and/or comparison withpublished benchmarks are used to analyze quality and safetymeasures. Implementation of Actions and Dissemination ofInformation Implementation begins and re-measurement occurs withrefinement in actions if the desired outcome is not achieved or theoutcome is not maintained. Communication of quality and safetyinformation is the responsibility of clinical and administrativeleadership. This information is reported by the Quality ManagementDepartment, and throughout the organization, using the PerformanceImprovement Quarterly report and/or other acceptable formats.Annually or more frequent as necessary, the performance ispresented at the Quality and Patient Safety Council, with minutesfrom the Quality & Patient Safety Council presented to theMedical Executive Committee.

IV. QAPI MODEL

The quality assessment and performance improvement modeldeveloped internally is the ”Plan, Measure, Analyze, Act, andReview Quality Cycle. This cyclical model incorporates defining theopportunity, identifying the objective, collecting and measuringthe data, analyzing performance while comparing with objectives,determining action steps and initiatives as appropriate based onperformance, educating and re-measuring.

V. CONTENT/SCOPE OF ACTIVITIES

The objectives become the essence of the QAPl activitiesorganization-wide. The FY 2018 QAPI areas of focus include: ImprovePatient Safety, Quality, & Service

• Maintain Standardized Infection Rate (SIR) below threshold,while continuously striving to eliminate hospital acquiredinfections related to: o Catheter related Blood Stream Infections oCatheter related urinary tract infections o Surgical siteinfections for Colon and Hysterectomy surgeries o ClostridiumDifficile infections

• Decrease the number of Patient safety indicator events relatedto post op VTE, sepsis, and pressure ulcers by 5%.

• Monitor trends in patient safety events through Patient SafetyNet and implement actions to reduce harm

• Implement and monitor processes associated with painmanagement, including safe opiod prescribing . Improve PatientExperience

• Improve 5 percentile points on Press Ganey, rating of hospitalfor Inpatient satisfaction survey. Improve Resource Utilization

• Reduce readmissions by 2% 3 Monitor external regulatorycompliance indicators • Core Measures ( ED , Flu Immunizations,DVT, Stroke and Sepsis) • Restraints • Adverse Drug Reactions

• Blood Utilization (Transfusion Reactions)

• Pain •

Radiology CT indicators

• Resuscitation

• Organ conversion rates

• Operative/Invasive procedures

• Occurrence/Sentinel/Never Event report trends

• Sedation Analgesia

• Seclusion

• Suicide risk

• Behavioral Management and Treatment

• Mortality and Autopsy

• Hazard Management

• Operative Diagnosis Concurrence

• National Patient Safety Goals

• Patient flow/throughput

MEDICAL STAFF COMMITTEE QAPI PROCESS Blood and LaboratoryUtilization Committee (BUC) – The goal of the BUC is to ensure thesafe, effective, and efficient use of blood products andappropriate use of the lab, i.e., blood draws. Blood usage ismonitored ongoingly utilizing data that is reviewed and analyzedquarterly by the committee. Clinically valid criteria andindicators used in screening and in the more intensive evaluationof any identified or suspected concerns in blood usage. Blood usagemeasurement will include key process indicators related toordering, preparation, handling and dispensing, bloodadministration, and transfusion outcomes. The committee reportsfindings of their QAPI program to the Quality & Patient SafetyCommittee on an annual basis. Cancer Committee -The CancerCommittee is responsible for the oversight of care and treatmentprovided in the hospital to patients with cancer. The committeemonitors and evaluates patient care, either directly or byinteraction with, and review of data from other committees. CancerConference presentations occur monthly, which includes all majorcancer sites treated at this hospital. The Cancer Committee plansand conducts a minimum of two outcome tudies annually. The CancerCommittee will provide summaries of their QAPI plan to the Quality& Patient Safety Council on an annual basis.

Infection Control Committee –

The Infection Control Committee meets no less than quarterly toreview and evaluate the hospital-wide infection control activities.The committee approves and evaluates the type and scope ofsurveillance activities based on problem prone areas, targetedindicators, or house wide surveillance initiatives. Quality datapresented at the infection control meetings includes surgical siteinfections, central line infections, ventilator associatedpneumonias, and catheter related urinary tract infections. TheInfection Control Committee reports the annual summary to theQuality and Patient Safety Council .The committee oversees theimplementation of the antimicrobial stewardship program.

Medical Records Committee –

The Medical Records Committee ensures the timely completion andaccuracy of the medical record. The committee optimizes the use ofthe electronic medical record. The committee monitors 4 regulatoryrequirements for completion of required documentation. This listmay include, H&P, post operative notes, nursing assessments,etc. The Medical Records Committee reports annually to the Qualityand Patient Safety Council.

Medical Staff Executive Committee –

The Medical Staff Executive Committee is delegated the primaryauthority over activities related to quality assessment andperformance improvement of the professional services provided byindividuals with clinical privileges. The Executive Committee meetsmonthly and receives and acts upon reports and recommendations frommedical staff committees.

Operating Room Services Committee –

The Operating Room Committee is responsible for monitoring thequality of the care provided to surgical patients. The committeereviews all adverse events and mortalities that occur in the OR. Inaddition, the committee develops an annual QAPI program consistentwith the goals of the organization and reports annually to theQuality and Patient Safety Committee.

Pharmacy & Therapeutics Committee –

The Pharmacy & Therapeutics Committee oversees the qualityassessment and performance improvement related to the selection,ordering and transcribing, preparing and dispensing, administering,and monitoring of medications throughout the organization. Thecommittee works closely with nursing, Infection Control, and othermedical staff departments in developing policies and QAPImonitoring. Pharmacy is responsible for tracking and monitoringmedication errors and adverse events and reporting findings to theQuality & Patient Safety Committee. In addition, they maintainand make recommendations to the drug formulary.

Procedural Case Review Committee –

This committee is responsible for the review of operative andother highrisk procedures for appropriateness based on surgicalspecimen removal. In addition, the committee reviews all adverseevents, mortalities, and autopsies related to unexpected outcomesor adverse events occurring in surgical procedures. The committeeselects high-risk patient populations based on identified problemprone or high-risk procedures. The committee meets quarterly ormore often as needed and reports annually to the Quality &Patient Safety Committee

Trauma Committee –

The Trauma Committee is responsible for the oversight for thequality of care provided to the Trauma patients. The Committeetracks and monitors quality indicators based on the identified QAPItrauma program. The committee reports annually to the Quality &Patient Safety Committee

HOSPITAL AND/OR SUPPORT SERVICES

The quality and appropriateness of patient care is monitored andevaluated in all important aspects of care, key processes, and inthe clinical departments and support services. Eachdepartment/service is responsible for establishing specific qualityimprovement indicators which reflect the hospital-wide plan andprioritizes aspects of care to be studied. Each department/serviceidentifies and participates in the analysis of issues/concernsimpacting system processes and functions which affect patient care,experience, and safety. The following hospital department/supportservices maintain quality reports in their departments whilereporting annually to the Quality & Patient Safety Council.Finally, each department/service submits to the annual evaluationof the hospital QAPI program. The following list provides thedepa1tment/services along with the responsible parties. Ambulatoryservices – Allen Seifert Anesthesia Services – Clinical ServiceChief Behavioral Health – Clinical Service Chief, DirectorBehavioral Health, Nurse Manager Cardiac CatheterizationLaboratory- Director of Cardiac Services and Medical Director ofthe Cath Lab Cardiac Rehabilitation Program – Director of CardiacRehabilitation Dietary Services – Director of Food & Nutritionand Clinical Nutrition Manager Endoscopy – Medical Director, NurseManager Laboratory Services – Clinical Service Chief and Directorof Laboratory Services Nursing Services – Chief Nursing OfficerPharmacy – Director of Pharmacy 5 Radiation Therapy – MedicalDirector of Radiation Therapy Radiology – Clinical Service Chiefand Director of Radiology Resource Utilization – Director ofOutcomes Management Respiratory Care – Director of Respiratory CareTransplant Service – Medical Director Transplant, AdministratorTransplant Services

UNUSUAL CHANGES OR EVENTS

The Quality and Patient Safety Plan is flexible to accommodatesignificant services changes, structure changes, unusual events orother similar elements. Objectives and topics can be introduced atany time to be prioritized and included in the scope of the Qualityand Patient Safety Plan.

SAFETY

The patient safety program is integrated with all qualityassessment and performance improvement activities. It encompassesrisk assessment and avoidance tactics such as conducting a “FailureMode Effect Analysis” (FMEA). FMEA is a proactive risk assessmentwhich examines a process in detail including sequencing of events,assessing actual and potential risk, failure, or points ofvulnerability and through a logical process, prioritizes areas forimprovement based on the actual or potential impact on patientcare.

Implementation of processes in the care of Inpatient Detoxpatients. The safety program proactively institutes action plansbased on findings from the “Sentinel Event Alert” which areprovided periodically by the Joint Commission. Use of this resourcefor initiatives is another proactive approach to patient safety.All patient safety events in the safety program track and trend orinitiate activities that address process, system, protocol, orequipment events. This includes near miss occurrences and unsafeconditions, as well as findings from adverse events. As the entireorganization reports patient safety events, this componentintegrates all departments into the safety program. Additionally,all developments from Root Cause Analysis activities, includingthose from Sentinel Events, are implemented and monitored throughthe safety program. The Quality and Patient Safety Program is alsoengaged in the following patient safety initiatives which willcontinue over the next few years: • Implementation of a newinpatient Electronic Medical Record; • Dissemination of trendedinformation from Patient Safety net.

6. OVERSIGHT AND SHARING OF INFORMATION As part of the oversightprocess, the quality assessment performance improvement informationflows from the departmental/service work groups and committees tothe Quality and Patient Safety Council. Minutes from the Qualityand Patient Safety Council are submitted to the Medical StaffExecutive Committee and reports are given to the Clinical AffairsCommittee of the Board of Trustees. Through this process, an annualreview of the entire QAPI and Patient Safety Plan content andresults occurs. The various duties of these oversight committeesare further defined below:

1. The Board of Trustees establishes, maintains, supports, andexercises oversight of the quality monitoring and performanceimprovement function & fulfills its responsibilities related tothe quality assessment, performance improvement, and safetyfunctions through 6 the specific activities and interactions of itsClinical Affairs Committee with the Hospital Senior LeadershipTeams (SL T) and with the medical executive committee of themedical staff.

2. The Clinical Affairs Committee of the Board of Trusteesreviews and provides feedback related to the Quality Reportsubmitted to the committee and the Board of Trustees. The ClinicalAffairs Committee approves the annual QAPI plan and annualreappraisal. They are also responsible for making recommendationsto enhance the QAPI and patient safety program and initiatives.

3. The Executive Committee of the Medical Staff providesoversight for reporting quality initiatives from the medical staffcommittees and hospital initiatives. Additionally, as a mechanismto share performance improvement activities with institution staffand visitors, the following activities also take place: •Departmental in-services on special quality performance improvementtopics; • Lectures and presentations to students, residents, staffand faculty; • Reports of clinical data distributed to the ClinicalAffairs Committee of the Board of Trustees, Executive Committee ofthe Medical Staff, members of management and leadership teams andthe Senior Leadership Team; • Display of Quality Data on individualunits.

VII. RESOURCES

The Quality Management Department supports and facilitatesongoing organizational quality assessment, performance improvement,and patient safety activities. Resources within the QualityManagement Department assist hospital staff and physicians withdata, retrieval of data, development, and coordination of qualityperformance improvement activities, and analysis of data to supportand evaluate quality performance improvement efforts.

The primary functions of thisdepartment include:

• Promoting patient safety through evidence-based clinicalprograms and initiatives;
• Monitoring regulatory standards compliance data; Clinical datamanagement and analysis;
• Collaboration with Service Excellence Department on theintegration of patient experience in all process improvementinitiatives;
• Quality improvement training and education;
• Preparation of QAPI reports;
• Coordination of internal and external databases that are usedfor QAPl projects or quality data analysis;
• Dissemination of patient safety event reports todepartments,
• Qua I ity and Patient Safety Counci I, and other key groups inthe organization;
• Patient safety event, sentinel event, and never event reporttracking and analysis;
• Coordination of root cause analysis for sentinel events andother occurrences requiring intense analysis;
• Coordination of Action Plans related to sentinel events orfailure mode effect analysis (FMEA) projects;
• Quality performance improvement project for issues found inpatient safety event reports;
• Process or procedure modifications related to findings frompatient safety event trends and/or FMEA projects.

VIII. SUMMARY

The Quality Assessment, PerformanceImprovement, and Patient Safety Plan provides the framework fororganization to implement quality assessment, performanceimprovement, and safety activities. These activities improvepatient outcomes, patient experience, and patient safety in acomprehensive, methodical, and systematic manner and compliment theHospital Plan for the Provision of Collaborative Patient CareServices.