Quality plans are used by healthcare facilities to provide frameworks for collaboratively planned, systematic, and organization-wide approaches to improvement.

These quality plans are always kept on-site, updated yearly, and reviewed by surveyors and accreditors. For your final project, you will develop a healthcare organization quality plan. This will assist you in synthesizing your prior knowledge of performance improvement.

This will also help you to see how quality performance encompasses all stakeholders and departments in the healthcare organization. This assessment addresses the following course outcomes:

Incorporate regulatory requirements and accreditation standards into quality planning

Evaluate appropriate methods of healthcare data collection, interpretation, and presentation for informing decision making

Prioritize performance improvement initiatives and data collection needs in healthcare organizations through evaluation of organizational quality programs

Synthesize changes in healthcare reimbursement for their influences on the healthcare organization's ability to provide quality and safe patient care

Evaluate requirements of current quality and safety initiatives for how they influence delivery of ethical care in healthcare organizations

Assess leadership strategies that promote interdisciplinary collaborative care within healthcare organizations Prompt In this assignment, you will be developing a quality plan-also known as a performance improvement plan-for a healthcare organization.

This plan may be developed for an acute care facility, a day surgery facility, an ambulatory care organization, a clinic setting, a long-term care facility, or some other type of healthcare organization with which you may be familiar, given your own professional healthcare work experience. In addressing the critical elements for this assignment, all APA formatting and citation requirements apply.

Furthermore, as this is a scholarly initiative, you must use peer-reviewed or evidence-based sources for this assignment. Data may be derived from public healthcare databases, or you may use data from your own healthcare organization. Specifically, the following critical elements must be addressed:

I. Quality Statement

A. Craft your healthcare organization's quality philosophy by discussing the National Quality Strategy priorities and their application to the overall organizational quality plan.

B. Analyze how this healthcare organization's mission is correlated with its quality philosophy.

C. Assess the role of quality within value-based reimbursement in this particular healthcare organization.

D. How is leadership involved in the dissemination and application of quality data at this healthcare organization?

II. Quality Infrastructure

A. Provide brief details about the organization's information management system, including what type of system is used and patient records management.

B. What phases of meaningful use have been implemented to date?

C. 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.

D. Discuss leadership strategies that ensure stakeholder and community input into the quality program.

E. 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

A. 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.

B. How does leadership in various departments promote involvement in performance improvement?

C. Evaluate the frequency of performance improvement initiatives and timeline for submission of data.

D. Describe the processes for collecting, interpreting, and presenting data within the organization.

E. 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. A. Core measures included in the quality plan

B. Inpatient and outpatient scores (HCAHPS)

C. NDNQI included in the quality plan D. Serious reportable events related to the quality plan

E. CAUTI, CLABSI, and surgical site infections (infection prevention)

F. Reporting of blood usage

G. Culture of safety scores

V. Accreditation Compliance

A. Describe the current status of accreditation (i.e., Joint Commission, CMS). Consider including logical reasoning on why this healthcare organization has attained this current status of accreditation.

B. From the most recent accreditation survey, describe the areas needing improvement that were identified.

VI. Evaluate and Prioritize Performance Improvement

A. Justify the timeline for evaluation of performance improvement activities. Consider using a visual aid.

B. Delineate the role of the Quality Improvement Council.

C. What is the Plan, Do, Study, Act (PDSA) process for incorporating necessary changes in standards and practice pursuant to performance improvement data?