Managing a Quality Improvement Initiative

1. As the Quality Improvement Manager, you have learned that there may be an increase in the number of patients with a nosocomial infection. The hospital would like to stay below 2% for nosocomial infection rates.

The Chief Medical Officer (CMO) has provided you with the data tables below:

The CMO would like you to use this data to do the following:

A. Compute the monthly nosocomial infection rates and provide 2 bar graphs depicting the infection rate for each month for the past 2 years.

o Compute the infection ratesand include them in the table below for each year.

o Complete the graphs in Excel and copy and paste your bargraphs below.

B. Provide an analysis of the bar graphs you created (pasted above) and indicate data trends. What is your analysis of the graphs for both years? How is the data trending? Are the infection rates below 2%?

2. Now that you have determined that a quality improvement initiative exists with the nosocomial infection rate, what hospital employees would you pull together to form a Performance Improvement (PI) Team? Explain why you chose each employee.

3. The quality improvement initiative has been underway for a few weeks. However, two of your PI Team members have not been getting along and it is affecting the entire group. As the PI Team Leader, how would you address the two PI Team members and encourage them to work together?