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Quality Improvement: Do you have the tools you need?

Fortunately, We Provide 5 Tips to Help

march 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

 There is no shortage of quality metrics that require monitoring in healthcare. Developing and maintaining a top-notch quality program is no small task. It is also a very necessary one. It is important to remember that having a good quality plan and program in place equates to improved patient outcomes, patient satisfaction, employee satisfaction, improved efficiency, engaged leadership, and increased revenue. Here are a 5 key topics/tips to help improve your organization’s Quality Program and reap the benefits of what having a good plan and program in place can do: 


  • Plan: Establish or review your organization’s approved plan and program. Does your current program address safe culture, chart review, surveillance, education, risk assessments, communication, benchmarks and reporting? If not, now is a good time to correct this. Keep in mind that this should be done no less than annually. The purpose of an annual review is to determine what worked well and what could be improved.


  • Oversight: It is not always easy in healthcare today to retrain or recruit experienced healthcare professionals. Practical planning is always a good strategy. Be sure that team members who oversee your quality program are educated and stay current on updates and trends. It is important for them to be knowledgeable of evidence-based practices, quality measures, gathering/review data, conducting a root cause analysis and reporting all findings to the facility’s governing body, local, state and federal agencies as appropriate.


  • Change Management: It is important to consider that having a successful quality improvement program is NOT the role and responsibility of the Quality Manager or Director alone.  Education and planning are essential elements of change management. A facility-wide approach is necessary in order for any quality program to be successful. Empower you team members with the tools that they need to impact change and improve the quality of care provided.

 

{continues after in-line diagram courtesy of CMS.gov}

Social Media Healthcare Facility Fail

 Review:  While a top-notch quality plan requires a proactive approach, it is critical to conduct time sensitive reviews when an adverse event occurs. One of the easiest diagrams to use when conducting a root cause analysis (RCA) is the fishbone diagram. CMS released a revised document on how to use the fishbone tool diagram.  Another tool that may be used is failure mode and effects analysis (FMEA). The RCA should be done as close to the time of the event as possible. This will help with recall of the actual events that occurred. It is important to emphasize that the review is non-punitive, and the purpose is to gather information that will be used to identify areas where process improvements may be necessary.

Reporting:  Be sure to report metrics, outcomes, successes and failures in a timely manner. Delays in reporting can lead to repeat occurrences of adverse outcomes, negative impact on employee morale and a decrease in revenue. It is also important to keep in mind that your outcomes may also become public information. Specifically, if you are a CMS provider, have you looked at your facility’s data lately? Check out Medicare.gov’s Quality of Care search  or The Agency for Healthcare Research and Quality’s (AHRQ) toolkit.

 
Worth the review, Harvard Business School published five key steps for implementing change management. Before any healthcare organization can have a successful Quality Program, there may be some underlying changes that must occur first.


HCE is Here to Help

Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.


Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state-of-the-art project or renovating an existing structure. Be sure to visit Our Website to see a full list of the services that we provide.
Contact us today at +1 (800) 813-7117 for a free initial consultation.


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References:

https://www.medicare.gov/care-compare/?providerType=Hospital&redirect=true

https://www.ahrq.gov/evidencenow/tools/keydrivers/implement-qi.html

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf

https://asq.org/quality-resources/fmea

https://online.hbs.edu/blog/post/change-management-process

Healthcare Consulting Experts LLC

NSHN and OSHA Reporting: Prepared to Meet the Deadline?

February 10, 2025
It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1 st , then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key. It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added. If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1 st , 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example. Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type: Instructions for Completing Annual Hospital Survey Instructions for Completing LTAC Annual Survey Instructions for Completing IRF Annual Survey OSHA requires the following facilities to complete an annual occupational injury and Illness Report: Ambulatory Health Care Servies General Medical and Surgical Hospitals Psychiatric and Substance Abuse Hospitals Specialty Hospitals Skilled Nursing Facilities For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements . Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide . Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported. Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting . Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges. Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing support services, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry. Be sure to browse Our Website for a full list of services we provide. Contact us today at +1 (800) 813-7117 to schedule a free consultation. References: https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB https://www.osha.gov/sites/default/files/ita_user_guide.pdf https://www.osha.gov/sites/default/files/osha_rktutorial.pdf
A hospital room with a bed and a lot of medical equipment.

National Patient Safety Goals: A Glimpse At 2025

January 13, 2025
In 2002 The Joint Commission (TJC) first established the National Patient Safety Goals (NPSG) Program. In 2003, TJC rolled out the first set of NPSG’s. Each year, TJC prioritizes patient safety goals for various healthcare programs.
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Radiologic Services: Refresher for Hospitals on CMS Conditions of Participation

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When it comes to delivering radiologic and diagnostic services under The Centers for Medicare & Medicaid Services Conditions of Participation, hospitals need to have policies, procedures and safe practices in place that are centered around delivery of patient services, safety of patients and personnel, qualifications of personnel and record keeping practices.
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