CQI

() Hospital Accreditation (HA)-HA --

AssessmentPlanningImplementationEvaluationEntryDischargeCare & RiskCommunicationContinuity & D/C plan Team workHRDEnvironment & EquipmentCustomer Complaint ReviewAdverse Event/Risk Management SystemCompetency Management SystemInfection ControlDrug Management SystemResource Management / Utilization ReviewKPI Review HolisticEmpowermentLifestylePrevention

/Evidence-based PracticeHolistic CareMultidisciplinary TeamBenchmarkingRoot cause Analysis from IncidenceBedside/Medical Record ReviewKPI MonitoringCreativity & Innovation

/(Learn During)After Action Review(Learn After) Evaluation-Achievement-Strength/weakness-KPI Monitoring-Evaluation research(Learn Before)Knowledge SharingPeer Assist

Plan/DesignDoStudy/LearningAct/Improve/ (Core Values & Concepts) Root cause3C-PDSA vs Clinical Tracer of Quality

/

Core Values & Concepts

/ Core Values & Concepts

(Structural indicators)- - -

(Process indicators) - (Activity) - (Time) - - -

(Process indicators) /

Palmer, Int J Quality Healthcare, 1998

(Outcome indicators)- Disease-specific / General health status - Goal achievement - Adverse outcomes (Morbidity/Mortality) - (Satisfaction)- -

(Outcome indicators) Palmer, Int J Quality Healthcare, 1998

(Disease-Specific Outcome Indicators),

Quality of Patient Care Balance (level)

Lag and Lead MeasuresLAGOutcome/LEAD Process/ CPG/caremap

(tracer) /

HA HA

1 1

PDSA ( Design-Action-Learning-Improvement) PDSA # who achieved pain control over # being treated for pain symptoms

# with improved signs of depression over those being treated for depression

Can also measure mortality and morbidity# deaths in infants under 1 year over total births # of children under 5 who develop measles over the # of children under 5 years# new cancer cases over total population