Quality Infrastructure and Process for Evaluation and Dissemination

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:


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

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


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


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

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.

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

You will have the opportunity to analyze the accreditation status of the chosen healthcare organization and consider what factors

influenced the accreditation status. Further, it is important to consider the areas that require improvement following an accreditation or regulatory survey. Also,

in a healthcare organization, a vital aspect tied with accreditation is the timeframe for evaluation of performance improvement initiatives. Usually, the quality

improvement committee or council oversees these activities, and so the final part of the quality plan addresses the role of the quality council and the PDSA

process, which is often used for incorporating necessary PI changes in standards and practice such as may occur following an accreditation or survey inspection.

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?

Quality Infrastructure


Information management forms an important part of any healthcare organization that wishes to identify and solve problems (Joshi et al., 2014). In fact, the health professionals recognize that care provision activities depend largely on the availability of information. With the increased use of computers, many healthcare organizations have become information intensive. Consequently, the health professionals recognize that the practice of care provision cannot be segregated from the management of information systems.

Accordingly, health care organizations use the financial and clinical health systems and computer simulation information systems. Beautmont (2011) notes that the financial systems are used to tag the various items utilized by the patients with their prices. Additionally, the organization uses the financial and clinical information systems in invoicing and making follow-ups for non-payments. Also, the computer simulation systems are used within the organization to solve specific problems such as the costs of treating depression. Epidemiological studies within the organization such as the effects of smoking on populations and the cost benefits of influenza virus also utilize the computer simulation systems.

The healthcare organization uses the electronic health records in keeping the accounts of the patients. The staff in various departments have been trained on electronic data entry and health information exchange. The electronic record keeping is preferred to the other methods because of the range of benefits it has such as improved clinical quality, reduced medical errors, cost reduction, and increased financial and operational benefits.

Meaningful Use

In healthcare, meaningful use refers to the utilization of the electronic health records systems to improve quality, uphold the privacy and security of patient data, improve care coordination, and reduce healthcare disparities (Menachemi & Collum, 2011). The organization has implemented three stages of meaningful use including data capture and sharing, advanced clinical processes, and improved outcomes. The first step involves the capturing of data from the patients and using the information to engage patients and their families in their care. The second stage includes engaging the staff in rigorous health information exchange across the departments while the third one involves decision making processes in the organization.

Performance Improvement

Central to the success of the organization is the development and adequate monitoring of performance. The organization uses several indicators to track performance data and initiatives. These indicators include client persistence in receiving treatment, client attendance rates, the success of transfer to both inpatient and outpatient treatment as well as their satisfaction. By measuring these performance indicators regularly, the organization is capable of determining whether the initiatives carried out have improved the performance indicators.

Additionally, the organization uses a visual aid in data analysis and interpretation, thus giving meaning to the data gathered. Moreover, the visual aid helps in determining the importance and consequences of the findings. The organization makes use of various kinds of visual aid to track data performance in all its departments. Among the tools used are run charts, control charts, and dashboard reports. The use of visual aid helps the organization in conveying various kinds of information in ways that are easy to understand.

Leadership Strategies One of the leadership strategies that ensures stakeholder and community participation in the healthcare quality program is the ability to show respect for the opinions of others. The organization recognizes that respecting the views of people within the community regardless of their social and economic differences helps in enabling them to appreciate the program. As a result, it earns the interest of stakeholders and the community as a whole. Secondly, the organization believes in teamwork as a way of enabling it to reach higher performance levels. As a rule, the organization engages in shared leadership in which power is vested in the hands of those with expertise at any given moment. Consequently, all the employees are capable of fitting into the program. In mobilizing the local community to support the program, the organization engages in capacity building initiatives…

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