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Quality Improvement Plan

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For health care organizations quality data collection is an essential tool used for data collection. The information produced from the data assists the health care organization in other functions such as effective ways to manage and perform decision making for the organization, this includes the strategic planning process. Quality improvement is the method of assessing processes and provides the information necessary to improve services. All of this together allows the health care organization to become a high producing system of quality health care. This paper will address how the Bon Secours Health System used in the quality improvement plan part 1, and by using these methods it will increase their capacity to create a successful system of quality care.

Bon Secours has the ability to improve the organization, using data required to examine performance areas for improvement. Tools that measure and reveal quality improvement data provide performance information and allows for comparison of these tools. The tools used will be analyzed and compared, and provide how beneficial these tools are to the health care organization.

Areas for Possible Improvement for the Organization
Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups (“Quality improvement,” 2011). At the Bon Secours Health System in Hampton Roads, Virginia, the organization has identified potential areas of needed improvement. Each area identified as needing improvement will potentially have a financial consideration and will increase patient satisfaction. Staff, internal systems and functions will also be touched by the quality improvement process.

Bon Secours, a member of the Premier alliance, is the largest health care system participating in the Hospital Quality Incentive program. Bon Secours is using six of the nine quality improvement (QI) strategies outlined in AHRQ’s Evidence Report, Closing the Quality Gap, as the template for its “Quality First” initiative (“Bon secours health,” 2005). Bon Secours through its Quality Improvement process saved the health system more than 1.1 million by standardizing care of heart bypass and cardiac valve replacement surgeries. Heart surgeons helped create new blood transfusion guidelines across the system that reduced transfusions in heart surgery patients from 66% to 42% and the average amount of blood transfused dropped by nearly two-thirds. In addition the complication rate went down and the length of time people spend in the hospital also went down (Getting ready for, 2012). Data Needed to Monitor Improvement in Performance Areas

Required data is collected and monitored for quality improvement performance areas. Data collected involves heart bypass and cardiac valve replacement, this also includes the need for transfusions and blood loss during surgery. This data can be utilized to decrease recovery time and a decrease in days spent in the hospital and improved health due to a decrease in blood loss. Staff in discharge instructions can increase the patient’s compliance with medications and needed follow up with physicians.

For Bon Secours Health System to improve their performance in these areas, use methods of data collection needed by the organization to authenticate the improvements. The Plan, Do, Study, Act Cycle (PDSA) is a tool used in most healthcare organization to focus on areas need in improvement (Ashworth & Kordowicz, 2010). Methods like PDSA utilizes questions that consist of, what change will result, how with the organization know that the improvement process created the change desired and does the change results in the desired outcome. These types of tools can establish the path of the improvement utilizing the information from the data. For the patient it will increase their satisfaction with their providers and the facility. Data Tools and Information Collected

Data collected is the most effective way to provide needed information utilized in the quality improvement processes. The desired results from the data collected is to improve quality services at while containing the costs associated with providing a service and to improve the patients desire for quality care. For heart surgery the data collected is to see trends that allow those reviewing the data to develop solutions that improves the outcome for the patient and decreases the costs for the organization.

Each system use can undergo an audit review allowing analysis of all aspects of the organization, including how the service(s) are improving the patient’s outcome. It is important that the staff of the organization are engaged in the process of quality improvement and that their function plays a vital role in the success of the process. This type of data can also provide information when audited on patients having post-surgical pain and reviewing the data of satisfied patients and provide a window into how to better control all surgical patients with successful pain control. Compare and Contrast Data Collection Tools

Each tool utilized in the data collection process is different, they each serve different functions. The patient satisfaction survey is utilized to evaluate the outcome of a patients care provided by the organization. In comparison to other tools reviewed above, a survey is relatively inexpensive to perform but provide valuable data that provides the organization with weaknesses in their processes. This also offers the organization to provide the opportunity to make timely changes to their systems.

Benchmarking for clinical performance measurement involves collecting and reporting data on practices’ clinical processes and outcomes. Measuring clinical performance can create buy-in for improvement work in the practice and enables the practice to track their improvements over time. This information should also be used to identify and prioritize improvement goals and to track progress toward those goals. In addition, these data should be used to monitor maintenance of changes already made (“Module 7. measuring,” 2013). Benchmarking can also be utilized to do a comparison between other health care organizations, provide areas where training could improve staff functions. How Tools are Helpful for a Health Care Organization

Data collected provides the health care organization, providers, administrators and the patients with valuable information. Tools assist the organization by measuring the performance data that provide the information to improve the patient experience and improve their care. These tools engage the organization in self-evaluation on an ongoing basis. These tools also provide and effective method of containing costs and provides the means to meet the regulatory requirements to improve quality care. Tools allow organizations to provide a comparison to other organization and seeing how they are different or similar. These tools allow the organization to remain strong and provide endurance for the future. Conclusion

Quality Improvement is here to stay and health care organizations need to find the right tools to meet their goals to reach superior quality. Patients, stakeholders and other regulatory agencies demand that health care organizations be held responsible for improving the care they provide to their patients. Bon Secours is taking the steps to meet these needs and have been successful at meeting their goals, they must continue to monitor their data for potential problems and use the tools to continue to improve surgical and blood loss quality measures.

US Department of Health and Human Services, Health Resources and Services Administration. (2011). Quality improvement. Retrieved from website: http://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf. Getting ready for healthcare reform: Annual report to the community. (2013, August ). Bon Secours Health System. Retrieved from http://hso.bonsecours.com/2012-annual-report/files/inc/4a6a937462.pdf. Ashworth, M., & Kordowicz, M. (2010). Quality and outcomes framework: smoke and mirrors?. Quality Primary Care, 18(2), 127-131. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20529474. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2013). Module 7. Measuring and benchmarking clinical performance (13-0046-EF). Retrieved from website:

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