Quality Improvement Plan for Healthcare Clinic

Abstract

Currently in The United States, there is call for healthcare reform. This calls for exploration within the system itself to not only control costs, but improve the health of communities overall. Improving quality and access while reducing costs is not just achievable, but instead, a national imperative that needs to be revamped. Through this reform comes greater collaboration from providers to give and create a cohesive care experience, promotion of wellness and prevention through improved care delivery and lastly, be rewarded for quality outcomes that will suppress costs (Burwell, 2016, para. 2). As a patient, the term healthcare should encompass access to quality care, having a provider who actively listens, provides the best possible treatment and understands your health issues. Consistent delivery of quality healthcare is central to delivering sustained performance as well as improving continuity of care. In the end, care and support is something that nearly everyone will experience at some point in their lives therefore; it is important to have a system in place that can keep up with the demands of a growing ageing population

Purpose and Quality Statement

Implementing a quality plan creates a culture of quality where growth can be managed, and business can be marketed more effectively. In healthcare, this culture will encompass patient safety, improvements in the quality of services and most importantly, patient satisfaction. With the help of clinical experts, providers and employees; a quality improvement template will be designed to access and analyze data to help identify and implement quality improvements. Knowing that improved patient outcomes is what it is all about; makes it easier to address and satisfy the appropriate benchmarks. The takeaways should answer whether or not the plan met and/or exceeded the objectives set forth. Accreditation standards in relation to driving an organization’s patient safety and quality initiatives, serves as an important means of improving organizational performance and clinical practice. Standards enable all organizations no matter the size, “to embed practical and effective quality improvement and patient safety initiatives into their daily operation” (Greenfield et al., 2012). The need to instill a culture of continuous quality improvement whilst promoting professional training; is the only way to improve patient safety and quality measures.

Based out of Rochester, MN, Mayo Clinic is one of the most recognized medical centers in the nation for providing high-quality patient care. Defined by teamwork along with a group of experts, their model of care focuses on one patient at a time. Given their history of innovation in health care delivery, their mission continues to inspire hope through education and research, contribute to health and well-being by providing the best care to every patient through integrated clinical practice. As far as patient safety and quality goes, the clinic evaluates those measures by looking at outcomes (readmission rates, mortality ratio), processes (specific process steps which have been identified to provide timely and effective care) and quality rankings (patient and outside agency perspectives about the care provided) (“Quality and”, n.d.).

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Stakeholders in healthcare are defined as “persons or groups that have a vested interest in a clinical decision and the evidence that supports that decision” (“Getting involved”, 2014, para. 3). They hold the power to repair current issues, have continuous dialogue to build and guide goals that can direct and develop national health policies. Stakeholders are committed to the one mutual goal of improving the quality of health care. The goal is achieved through getting the right care at the right time for the right reasons and obtaining increased access to health care for all.  The stakeholder groups that have a vested interest in the performance-improvement process include: policy makers, government officials, board members and legislators. They can be seen as representatives who are open-minded, put forth the effort to listen, stay connected whilst ensuring that everyone’s interests are effectively represented. Furthermore, they help set overall organizational agenda while providing guidance and support.

Status of Quality Tools and Standards

The current status of accreditation is to continue on with aiming to inspire organizations to improve their services, care and treatment. It should be utilized as a tool to not only improve the quality of healthcare services, but as an educational service to measure performance levels and come up with customized solutions. In relation to ensuring patient safety, accreditation equips organizations with “state-of-the-art performance-improvement strategies to continuously improve the safety and quality of care” (“The value”, n.d.). The overall consensus is that accreditation will improve the process and structure of care, clinical outcomes and most importantly, a framework centered on the culture of high performance.

Healthcare information systems (HIM) encompasses various components to manage, capture, store and or transmit information related to the health of individuals or the activities of an organization that work within the health sector (“4 types”, 2017). Organizations must select and implement information technology that not only provides high-quality healthcare, but can also reduce costs. The system should be designed to assist healthcare providers with managing patient information and daily tasks through efficient data management and fast data retrieval. Given the extensive effect of new technologies in organizations, there is a growing need to assess the quality of these services regularly, especially for improving healthcare services and measuring success.

“Most health care providers must follow the Health Insurance Portability and Accountability Act (HIPAA), a federal privacy law that sets a baseline of protection for certain individually identifiable health information” (“Health information”, n.d.). Reliable and effective policies and procedures set the foundation for providing the best level of care, promote compliance with accreditation requirements and regulations, standardize practices and most importantly; reduce practice variability that can result in patient harm and substandard care. Additionally, a good healthcare policy helps ensure that information is contained within hospital guidelines and only accessible to authorized parties. This assures privacy of personal information, protects patients and staff in the sense that medical information is presented using standardized means. Adhering to the appropriate policies and regulations to meet the needs for accreditation and compliance; sets better processes for patient and staff safety, and greater consistency of care. Furthermore, it avoids penalties, prevents violations and other potential liabilities.

Meaningful use aims to maintain privacy and security of patient health information, engage patients and family, reduce health disparities, improve care coordination, population, public health, quality, safety and efficiency (“Meaningful use”, n.d.). This infrastructure promotes the widespread adoption of electronic health records systems that ultimately improves the efficiency, quality and safety of patient care. In conjunction with the Office of the National Coordinator for Health IT (ONC), the program is run by the Centers for Medicare & Medicaid Services (CMS) to provide incentive payments to eligible providers who successfully demonstrate “meaningful use” of certified technology. Providers have to meet a certain threshold that consists of improved outcomes, advanced clinical processes, data capturing and sharing to show that patient safety practices are being utilized the right way to protect patients from any type of preventable harm that can be associated with health care services.

Measures and Benchmarks

Performance-improvement data enables organizations to identify then implement opportunities for improvements to their delivery systems and monitor progress as changes are applied. By managing this data, they are able to get a better understanding of how outcomes are achieved. For example, costs and revenues associated with patient care and patient satisfaction. Mayo clinic’s initiatives and improvement data are tracked through “safety record of the institution, compliance with evidence-based processes known to enhance care and outcomes achieved such as mortality rates and surgical infections” (“Quality and”, n.d.). From the department level, it starts with the totality of a patient’s experience. For example, ensuring all patient information and test results are readily available when needed, treating patients with respect and kindness and conducting patient surveys that rate experiences with various aspects of hospital care.

Benchmarking data involves collecting data over time to boost performance, improve quality and most importantly, meet expectations of payers, patients and regulators. Not to mention, it also helps organizations focus on a particular area of improvement. “By including 40 diagnoses and procedures selected for their high cost per case, large variations in cost and utilization, and frequency of claims occurrence— Mayo Clinic was provided the opportunity for focused comparisons” (Wood, 1992). When you are able to identify where your performance is not as good as others, you are provided with the necessary information needed to help you decide what to target and how to set what would be a reasonable goal for improvement. Acting on these results determine best practices that lead to superior performance when utilized and adapted in the right way.

Mayo Clinic measures quality not simply by licensure and accreditation, but also by how they continuously improve all processes and services to support patient care. They are committed to policies and procedures necessary to promote regulatory compliance, workplace safety and high-quality patient care. Under the HIPAA rule, entities cannot disclose information without the proper authorization as a violation of this constitutes a breach of privacy that can be subjected to civil or criminal consequences.

Reimbursement data is used to identify patient safety and quality issues through an integrated system that pinpoints, monitors and acts upon the performance opportunities revealed through advanced analytics. Providers can understand and identify how and when their health care decisions impact profitability, cost and care quality. Examples of patient safety and quality issues include: wrong treatment/medication, wrong diagnosis and HAIs (hospital acquired infections). Patient safety extends beyond patient welfare to increasingly impacting an organizations bottom line therefore; insights into risks for patient harm and appropriate intervention protocols have to be developed.

In relation to accreditation status, reimbursement data is useful in this instance to ensure that if organizations want to continue to provide care, then minimum standards should be met. The best procedures and programs should be used to monitor success or failure, hold providers accountable for achieving quality targets and evaluate changes for effectiveness. Reimbursement policies on patient safety and quality issues align methods, resources and strategies to minimize inconsistencies to further enhance the effectiveness of approaches to quality improvement. The widespread adoption of such practices will aid in “decreased provider’s collection burden and cost, value-based payment and purchasing and consumer decision-making” (“Core measures, 2017).

Dissemination and application of quality data at Mayo clinic can only be done with effective leadership. Effective leaders are multi-faceted, able to influence the attitudes and behaviors of others and most importantly, lead by working together to nurture a shared culture where everyone involved continuously delivers compassionate, high quality and improved patient care. Great leadership is the only way to set the course for a resolution that acknowledges concerns for all parties; while still putting patients at the forefront. A leader who effectively evaluates the performance of their employees can easily measure success and make the necessary adjustments required to succeed.

Process Improvements

 Recommendations for Mayo Clinic include market power within the healthcare industry to give providers a push towards greater coordination of care and consumer welfare. This will open the door to lower costs, creates rules and regulations to help make health care market forces work better to produce the best outcomes patients desire. The clinic will reap the benefits of improved care delivery and empowered consumers. Consistent delivery of quality healthcare will be central to improving continuity of care and delivering sustained performance thus; the need to have a system that incorporates a framework of best practices.

Three goals that Mayo clinic should set their focus on is communication, technology issues and quality improvement. Any communication no matter the field will require a great deal of teamwork, collaboration and employee engagement. It will also ensure that the changes are implemented consistently and quickly across the board. Technology can only improve and aid our lives in such a way that the yielded results are amazing achievements. To maintain such results, encryption methods should be provided to maintain security and make it impossible for unauthorized users to access the data. In addition, provide authentication mechanisms such as passwords or codes to improve data security measures and have an IT team on site ready and available to fix issues before providers and or staff members are impacted. When dealing with quality improvement, priority should be placed on measuring and obtaining performance feedback in order to continuously learn and improve. Meetings should be held regularly to ensure that both the processes and procedures support intended outcome and communicate results. For example, if the project is successful, it should be acknowledged and celebrated.

 A new technology that could improve patient safety is the implementation of data integrity in terms of safety checks to reduce errors and improve monitoring. Duplicate patient records for example are a common problem that can result in harm when clinicians lack complete information on their patients. To avoid any type of mishap when dealing with patient identification, it is recommended to use at least two identifiers such as the date of birth or name to ensure correct identification. Having a unique safety identifier makes it easier to accurately match health records so that providers and hospitals are better able to efficiently and safely exchange information. A policy change that will solve patient safety and quality issues would be to implement and enforce identification alerts to decrease the risk of wrong-patient orders being entered into the system, reporting requirements to ensure that clinical staff feels comfortable enough to report quality issues and monthly multidisciplinary team safety meetings.

Leadership strategies required for stakeholder engagement should include applicable knowledge and skills, needed to accomplish both the vision and mission that directly aligns with culture and direction of the organization. Involve stakeholders who are able to garner support, offer fresh insight and strategies needed to address health needs. And although different strategies and techniques are necessary for different audiences; the message being delivered from the stakeholders should remain the same. Collaboration is key when given the responsibility of services that influence people’s health; as it has a direct role in identifying those needs and intervening early enough to address them.

Evaluation and Reporting

Cycle Step

List of Activities

Start Date

Completion Date

Plan

Start with a committed workforce that is engaged, ready, productive and resilient

Coordinate data collection, analysis, and reporting to better understand its need

11/30/18

11/30/18

12/30/18

12/13/18

Do

Define key performance indicators to include what tools and methods will be utilized to evaluate, measure and monitor

Assign people who will be in charge of performing the monitoring and measuring

11/30/18

11/30/18

12/30/18

11/30/18

Study/Check

Identify strengths and weaknesses and where improvements can be made

Qualitative research brought forth to the stakeholders to explain reasons behind various patterns

11/30/18

11/30/18

1/13/19

1/13/19

Act

Share results and welcome input on how to further improve performance

Are the selected performance indicators and goals are still relevant? If so, was there any impact? Why or why not?

11/30/18

11/30/18

12/7/18

12/30/18

To measure the successful implementation of new technology, there has to be a tracking method in place that communicates results to the entire organization throughout. Managers should be made in charge of progress tracking to mark specific points along the way. Keep employees engaged and up-to-date on what’s happening because ultimately, they will be using the product the most. Develop a learning culture with a good training platform that will highlight the value of said new technology. Maintain momentum from start to finish, monitor ongoing usage after the implementation phase to ensure continued progress and efficiency. For accreditation reporting, managing data within the organization will maintain compliance. This helps organizations grow, achieve goals, prevent disasters, failures and manage risks. It also places them in a unique position to organize and strengthen patient safety efforts, maintain integrated care as well as performance excellence.

References

4 types of healthcare information systems. (2017, January 3). Retrieved November 29, 2018, from https://www.healthcarefirst.com/blog/4-types-healthcare-information-systems/

About Mayo Clinic – Quality and mayo clinic. (n.d.). Retrieved November 30, 2018, from https://www.mayoclinic.org/about-mayo-clinic/mission-values

Burwell, S. (2016, December 12). Building a system that works: The future of health care.  Retrieved November 30, 2018, from http://www.healthaffairs.org/do/10.1377/hblog20161212.057877/full/

Chapter 3: Getting involved in the research process. Content last reviewed February 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/stakeholderguide/chapter3.html

Core measures. (2017, July 28). Retrieved November 30, 2018, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Core-Measures.html

Greenfield, D., Pawsey, M., Hinchcliff, R., Moldovan, M., & Braithwaite, J. (2012). The standard of healthcare accreditation standards: A review of empirical research underpinning their development and impact. BMC health services research, 12, 329. doi:10.1186/1472-6963-12-329

Health information privacy law and policy. (n.d.). Retrieved November 29, 2018, from https://www.healthit.gov/topic/health-information-privacy-law-and-policy

Meaningful use. (n.d.). Retrieved November 29, 2018, from https://www.healthit.gov/topic/federal-incentive-programs/meaningful-use

The value of accreditation & certification. (n.d.). Retrieved October 11, 2018, from https://www.qualitycheck.org/the-value-of-accreditation-certification/

Wood, L. W. (1992, January). Benchmarks and business. In Mayo Clinic Proceedings (Vol. 67, No. 1, pp. 92-94). Elsevier.