A hospital’s performance improvement activities as opportunities for improvement

In three previous posts, I brought to you how aggregate data are an important part of the hospital’s performance improvement activities. In particular, the three posts were about aggregate data from risk management, utility system management, infection prevention and control, and utilisation review and how they can help the hospital understand its current performance and identify opportunities for improvement.

The posts were:

(i)                  JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” ;

(ii)                JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” ;

and

(iii)             JCI Standard MCI.20.1, ME 1 (Part 3) – utility system management and utilisation review, in “The organization has a process to aggregate data in response to identified user needs.”

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In this review of those 3 posts, I like to emphasise that a hospital chooses which clinical and managerial processes and outcomes are most important to monitor based on its mission patient needs and services provided. The hospital’s leaders must identify key measures (indicators) to monitor the hospitals’s clinical and managerial structures, processes and outcomes.

A required clinical monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of infection control, surveillance and reporting. For managerial monitoring, a required managerial monitoring which includes structure, process or outcomes data selected by the leaders is on aspects of risk management and utilisation review/management.

The hospital collects and analyses aggregate data from clinical monitoring and managerial monitoring to support patient care and organisation management. Aggregate data provides a profile of the hospital over time and allows the comparison of the hospitals’s performance with other hospitals.

To measure the hospital’s performance improvement activities, hospitals usually prepare a master plan to reduce evident risks in the environment or individual plans which incorporates a comprehensive program and plan inclusive of :

1. a program and plan to reduce the risk of health care-associated infections in patients, health care workers and visitors
2. a program and plan that includes utility systems – electric, water and other utility systems,  maintained to minimise risk of failure

There is also a written plan for an organisation-wide quality improvement and patient safety program that includes clinical and managerial processes for risk management, utility system management, infection prevention and control, and utilisation review.

References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA