QAPI Goal Setting Worksheet

Directions:

Goal setting is important for any measurement related to performance improvement. This worksheet is intended to help QAPI teams establish appropriate goals for individual measures and also for performance improvement projects.

Goals should be clearly stated and describe what the organization or team intends to accomplish. Use this worksheet to establish a goal by following the SMART formula outlined below.

Note that setting a goal does notinvolve describing what steps will be taken to achieve the goal.

[Example: We will increase the number of long-term residents with a vaccination against both influenza and pneumococcal diseasedocumented in their medical record from 61 percent to 90 percent by December 31, 2017.]

1. Describe the business problem to be solved (Use the SMART formula below to develop a goal)

A. SPECIFIC

Describe the goal in terms of 3 ‘W' questions:

• What do we want to accomplish?

• Who will be involved/affected (what staff, what residents, others)?

• Where will it take place?

B. MEASURABLE

Describe how you will know if the goal is reached:

• What is the measure you will use?

• What is the current data figure (i.e., count, percent, rate) for that measure?

• What do you want to increase/decrease that number to?

C. ATTAINABLE

Defend the rationale for setting the goal measure above:

• Did you base the measure or figure you want to attain on a particular best practice/average score/ benchmark?

• Is the goal measure set too low that it is not challenging enough?

• Does the goal measure require a stretch without being too unreasonable?

D. RELEVANT

Briefly describe how the goal will address the business problem stated above.

E. TIME-BOUND

Define the timeline for achieving the goal:

• What is the target date for achieving this goal?

• Write a goal statement, based on the SMART elements above. The goal should be descriptive, yet concise enough that it can be easily communicated and remembered. Use the example at the beginning for a reference on statement format and information.

Discussion

A. Note how your selected nursing facility rates in each of the following quality measurement categories:

a. Health Inspections: Above Average

b. Staffing: Above Average

c. Quality Measures: Above Average

1. Explore the website further and review the data for each measurement category. Then answer the following

1. Which of these performance measures do you believe is most important to potential customers of healthcare services? Why?

I chose BOWLING GREEN NURSING AND REHABILITATION CENTER because one of my mother's friend been there and when I asked her she said they have the best service for the caregivers and their safety is better than the others that she has visited before. I totally believe that the most important performance measures for the customers of healthcare is the Staffing.

Staffing is the major concern because they have the most impact on the patient. Staffing they always have to be with the patients and take care of them because the patient will feel save and comfort if the get the best quality of care from the staff.

1. Which performance measure is least important to the consumers? Why?

I think the least important performance fro the consumers is the Health Inspections because if the facility provides the best environment for the patient then they won't need heath inspections at all.

1. Should consumers use this website as part of their process to select a nursing facility? Why or why not?

Absolutely Yes, sometimes patient does not have more information about a certain facility that they are looking for, but not internet made it so much easier fro the patient to search and found the facility's website and read about it. So yes, it's very important for each facility to have their own website and put all the information that the patient need to know about.

1. What other factors, data, information or methods should a consumer seek out and utilize when choosing a nursing facility?

There are a lot of ways to do when choosing a nursing facility but if I was looking for a nursing facility I will look fir a reference or a friend that I trust and who is been there and ask about their service. I also will look for the location of the facility because there are not safe location where the facility is located at, so it's very important to checkout the location before.

1. If you have visited this nursing facility, do you agree with the ratings it has received by CMS?

I have not been there at all, but I agreed after I asked my mother's friend about it and I heard good thinks about it.