A Quality Improvement Plan For a Hospital Organization


Continuous quality control in health care is evident in different contexts. It has been given different terms such as total quality management or Continuous Quality Improvement (TQM) (Roth 1998, p.3). Continuous Quality Improvement (CQI) engages personnel in planning and executing continuous flow of improvements with the objective of enhancing the quality of health care to enable it meet the expectations of the clients. Normally, CQI and TQM are often used interchangeably (Roth 1998, p.3). On the one hand, TQM refers to an industry- based program. On the other hand, CQI is used in reference to programs designed for clinical setting. Its use covers quality improvement efforts and philosophies (Roth 1998, p.3). Characteristics of quality improvement include provision of link to organization’s strategic plan; its quality council comprises top leadership who have received training in the subject matter. It has mechanisms for coming up with improvement opportunities, formation of process improvement teams, integration of process analysis and design in the staff support, and staff participation in process improvement due to availability of personnel policies that motive and support staff (Roth 1998, p.3). From the point of view of both TQM and CQI, quality improvement is an approach and set of activities used to improve performance in an institution’s localized improvement efforts, organizational learning, process reengineering, and evidence based medicine and management (Roth 1998, p.3). Organizational learning can only take place when localized improvement is documented and its results in policy development and procedures implemented. This research paper seeks to develop a continuous quality improvement plan for a hospital organization.

Hospital model quality improvement plan


Hospitals always endeavor to provide quality health care that recognizes humanity and people’s dignity, and make programs and services accessible to all without restrictions. Hospitals aim to create an environment where physicians and allied health workers provide personalized health care to patients (Juran 1989). They also endeavor to become pioneers in the provision of high quality health care program provision and marshalling of resources to satisfy primary health care needs of patients within the vicinity of the hospitals service area. Moreover, a hospital looks forward to observing ethics in their operations without jeopardizing patients care needs (Juran 1989). Hospitals would wish to provide care that guarantees safety of the patients, provide services informed by scientific knowledge and refraining from service provision to those who are unlikely to benefit from them. The medical care providers should be patient –centered. In addition, the care provided should be timely hence reduce waits and delays that may be potentially dangerous. In addition, the care should be efficient to avoid waste of equipment, supplies, and energy. Lastly, care offered ought to be the same. Therefore, there should be no biasness in ethnicity, gender, socioeconomic status or geographical location a (Juran 1989). To achieve the above goals, the hospital wants to undertake systematic quality improvement efforts that will focus on direct patient care delivery process and support processes that encourage optimal patients outcome and up to date business practices.

Hospitals board of directors has the mundane duty to ensure that high quality care is provided to their patients (Ryan 1993, p.45). Responsibility for implementing plan to the medical staff is delegated by the board through the hospitals medical staff, the utilization management committee, or quality improvement committee to the hospital leadership team.

All employees have the responsibility to help in delivery of high quality care. All employees are therefore entitled to participate in quality improvement program. These activities have to be done in quality improvement program: medication therapy, direct and indirect patient care services that have bearing on patient health and safety, hospital payment monitoring program, hospital acquired infections, hospital satisfaction surveys, blood usage and surgical case reviews, and review of medical records (Ryan 1993, p.44).

Quality improvement community should comprise the CEO, chief staff, nursing director, quality improvement manager, pharmacist, nurse in charge of infection control, utilization management manager, and some representation from board of director’s office (Ryan 1993, p.45). Members of quality improvement committee should ensure the outlined review functions are completed. In addition, they should also prioritize review issues referred to quality improvement committee, ensure that data obtained from quality improvement activities are analyzed, recommendations made, and problem resolution follow up is done, incorporate internal and external sources of data benchmarking, through utilization of clinical outcome measurement system and project in a box data, identify other sources like JCAHO’s 2003 National Patient Safety Goals and integrate them in hospitals quality improvement initiatives, report in process findings, studies, recommendations, and trends to governing board yearly, identify educational needs and ensure that staff education for quality improvement is done, appoint subcommittees to work on specific issues, and availing of necessary resources (Ryan 1993, p.45).

Responsibility of medical staff: the medical staff is involved in surgical, blood, medical record, and mortality review. They also do infection control, therapeutic and pharmacy review, mortality review, and utilization management with a view to improving quality of care.

Responsibility of department staff: every department responsibility is quality improvement activities implementation. Quality improvement initiatives should have a wider perspective of quality improvement committee activities. Each department should identify quality indicators, collect and analyze data, develop and implement changes to improve service delivery, and monitor and assure that improvements are made and sustained (Fuller 1993, p.2).

Confidentiality: information created by quality improvement plan is protected by Nrb.Res.Saf. Section 81-2047 to 72-2049. Quality improvement committee records are confidential and cannot be revealed even under form of legal compulsion. No member that gives information to this community should divulge information to any other source. In this case, an infringement may lead to disciplinary action (Fuller 1993, p.1).

Best practices: process incorporation will be considered in the perspective of comparative databases.

QI Process methodology: this should include quick fix process, quality assessment activities, quality improvement teams, dashboard report, and comparative databases.

Communication: QI committee is the central clearing house for quality data. They should track trend and aggregate data from sources to be used in making a report (Jun, Peterson and Zsidisin 1998, p.82).

Education: staff should be provided with information pertaining to QI plan.

Annual evaluation: QI plan should be evaluated annually to guarantee effectiveness in achieving the set goals. Activities done, improvements made, delivery processes delivered, and intended changes to QI plan are also compiled.

Reference List

Fuller, F. T. (1993). Strategies for implementing continuous improvement. TQM Rehab, 1 (3), 1-7.

Jun, M., Peterson, R. T., & Zsidisin, G. A. (1998). The identification and measurement of quality dimensions in health care: Focus group interview results. Health Care Management Review, 23 (4), 81-96.

Juran, J. M. (1989). Juran on leadership for quality: An executive Hand book. New York: Free Press.

Roth, C. R. (1998). Surviving with the principles of quality improvement. ASHA Quality Improvement Study Section Newsletter 3(2), 1-4.

Ryan, S. M. J. (1993). The future is continuous quality improvement. Quality Management in Health Care, 1(3), 42-48.

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