Proposal for a Reporting System for Quality Improvement in Healthcare

Indicator Identification

Instructions:

You have been selected to represent the Performance Management Committee of your organization. Your committee has responsibility for the oversight of quality improvement, patient safety, risk, and utilization management activities for the organization.

 

You have been tasked by your organization’s senior administration and Board of Governors to develop and present a proposal for a reporting system that would encompass the following elements. The suggested length is 1,200 to 2,000 words, excluding the title page, references, and any appendices you include. The document should be double-spaced. 

 

1. Introduction: The introduction is engaging, states the background, document purpose, and previews the structure of the paper.  

 

2. Indicator Identification: Document a total of 3 indicators to provide a balanced overview of the organization’s performance. The three indicators should be selected from the following areas of quality management. Choose no more than one indicator from each of the areas.

o Quality of patient care;
o Utilization of resources;
o Patient safety concerns; or
o Risk indicators.

 

3. Indicator Description and Rationale: For each indicator, provide the following information:
o A description and rationale for the indicator; and
o The recommended format (example) for graphical and tabular analysis. 

 

Note: Make sure to refer to the Performance Indicator section of your Learning Guide for information on indicators. Graphical and tabular analysis refers to what sort of charts or tables you would create to visualise the information. If you need additional information on types of tables and charts, refer to Sayles’ Health information management technology: An applied approach, (6th ed.), in the section on Presentation of Statistical Data (pp. 392-403).

 

4. Safety Improvement Tool: Provide a recommendation and brief description of a tool that can improve either patient safety or the safety of the environment for staff. Include commentary on the advantages of that tool in supporting safety improvement.  

 

5. Role of the HIM Professional: Provide a rationale for the integral involvement of the HIM professional in the activities of the Performance Management Committee.

 

6. Conclusion: Include a concluding paragraph that unifies the paper and contains an engaging and interesting point about the subject.

 

Review the grading rubric provided below for further details of the requirements of the paper and how marks will be assigned.

 

Learning Outcomes

Upon successful completion of the course, the student will be able to demonstrate the following. Square bracketed codes following the learning outcome indicate the relationship to the CHIMA LOHIM document.

Indicator Description and Rationale

1. Identify national agencies involved in health and health information related fields (i.e. accreditation, patient safety). [B.6]
2. Recognize current health care issues and trends (e.g. quality management). [B10]
3. Describe clinical indicators and their role in monitoring health care quality. [C.1.3.1.11]
4. Describe risk management program concepts. [C.1.3.12; C.1.4.14; E.17]
5. Recommend appropriate graphical and tabular presentation of health care data and services. [C.2.4.6]

6. Select an impact analysis. [C.2.4.7]
7. Recommend appropriate methods for assessing and improving the quality of care and services. [C.2.4.7]
8. Identify performance indicators, standards, and benchmarks. [C.2.4.12; E.4]
9. Discuss the relationship between outcome measurement and quality management initiatives. [C.2.4.13]
10. Describe process mapping, including workflow analysis techniques. [D.14]
11. Describe quality management practices and the steps required to introduce and maintain those practices. [E.13]
12. Describe workflow analysis techniques. [E.14]
13. Discuss the role of the HIM professional within the Canadian health care system at all levels of care. [F.3]
14. Demonstrate the HIM professional as a valuable contributor to the health care team. [F.7]

 

Who Is Involved in Quality?

 

Those involved in quality are known as stakeholders and should include all groups or individuals that are affected or who might be affected by the organization’s products, services, actions, or success. Of primary importance in healthcare are the customers who are those who use the services or products. Customers are often divided into external and internal customers. External customers include individuals or groups from outside the organization, such as patients, families, clients, and communities. Internal customers are those within the organization such as healthcare providers. Other stakeholders include “insurers or other third-party payers, employers, health care providers, patient advocacy groups, Departments of Health, staff, partners, governing boards, investors, charitable contributors, suppliers, taxpayers, policymakers, and local and professional communities” (National Institute of Standards and Technology, 2011, pg. 63).

 

• What tools are used in your health care workplace or practicum setting to measure and monitor performance?
• Consider what quality methodology might be in place for the whole organization. How does it apply to health information management functions? 

• Information is frequently derived from coded data. How do you think this information might be used in the utilization review process mentioned above?

 

Outcomes Management

The outcomes of an effective utilization management program should be:
• medically necessary admissions;
• appropriate lengths of stay; and
• optimal resource utilization.

A health care facility must render quality care while improving efficiency, decreasing costs, and responding effectively to marketplace pressures. Donabedian’s Model of Structure, Process, and Outcomes (see Abrams & Gibson, 2013, p. 312) is a widely used model for outcomes management. The model poses the five questions related to utilization review:

1. What interventions occur in the facility?
2. How appropriate are these interventions?
3. What is the quality of these interventions?
4. What is the outcome or impact on quality of life of these interventions?
5. What is the cost of these interventions? 

 

• Does Accreditation Canada recognize your organization or practicum site?
• Is the award (certificate) on public display? Where?
• What accreditation activities may be occurring at your organization or practicum site at this point?
• How are the HIM professionals or health information department involved in the process? 

• What is the benefit to an organization to have credentialed HIM professionals as members of the health care team?  

• Within your organization or practicum setting, what roles might HIM professionals play in identifying, analyzing, controlling, and evaluating risk(s)?  

 

Discussion Assignment

Return to Brightspace and click on the Discussion Question. You will be required to make an initial post with your answers to the case study questions, and then respond to two of your classmates’ posts. This discussion is worth 10% of your mark.

 

Answer the following questions in your initial discussion post:
1. Describe at least three causal factors that contribute to the wrong site surgery.
2. Who would you include in activities to perform a Root Cause Analysis?
3. Using Root Cause Analysis, document what you consider to be the most significant cause of this event. Explain why you selected this cause.
4. Following the Root Cause Analysis, what should the next steps be for the hospital?
5. What other tools or processes might be used in the investigation of, or response to, this issue? 

 

• What performance standards are in your health care workplace or practicum setting?
• Consider what might be in place for the whole organization, and specifically in the area of health information management functions. 

• What role do HIM professionals play in performance assessment in your organization or practicum setting?