This unit is oriented toward internal organizational success. The chapters in this section investigate how data helps determine and drive an organization’s success. This success may have many different types of internal drivers. Internal drivers may be people, departments, processes, or the actual measures. Internal drivers are found within all health care organizations. This week, you will think about internal drivers within health care organizations that are most familiar to you. From the foundational piece of the first four units, this unit includes readings that discuss ongoing processes for performance improvement (PI). PI is a term that may be used synonymously with quality management. However, PI seems to be a higher-level skill or process that takes hold when an organization is truly focused on measuring quality.

Use the Measuring Health Care Quality text to read the following:

• • Chapter 7, “Integrating Data for Operational Success,” pages 135–156. This chapter builds on previous chapters that identified health care quality measures and discussed who is responsible for determining, measuring, and reporting on measures. This chapter looks at how quality measures and data are integrated to improve an organization’s success. Data helps drive success. How an organization chooses its measures and then how it integrates the findings help push forward evidence-based care, evidence-based measures, and improved patient quality.
  • Chapter 8, “Internal Drivers of Quality,” pages 157–175. Different people and processes in each organization help drive quality. This chapter provides concrete discussions on the internal drivers found in most organizations.
  • Chapter 9, “Using Data for Performance Improvement, ” pages 176–195. Performance improvement denotes a highly skilled organization working on continuing quality improvements. This chapter investigates data-driven performance improvement. It is interesting to note how quantifiable health care quality has become.

1. Using the FMEA Tool – use the Institute for Healthcare Improvement web site to answer the following question. Your post need to be 250- to 300-word overview of your chosen FMEA report from the IHI Web site. Describe the facility, the process that this facility chose to work on, and the outcomes found. Suggest any other improvements this facility might consider as it builds on this success. Do you see value for organizations to publicly report their own quality initiatives to the IHI? Who would need to approve such submissions from a facility?

Visit the Web site of the Institute for Healthcare Improvement (IHI), which provides a forum for health care organizations to share their FMEA success stories. There are at least 22 different categories included in this database. Peruse a wide variety of reports. Choose one FMEA success story.

2. Emergency Department Case- Your post need to be 250- to 300-words. discuss what your plan of action will be. What should you do with this data? How will you turn this situation around? Create a short outline of your steps. Who will you involve in this plan?

You are the CEO for a hospital that constantly experiences overcrowding in the Emergency Department (ED). Your facility struggles with appropriate staffing and is currently providing uncompensated care to as many as 20% of all patients who come to the ED. Your current data-gathering efforts point out a problem with treating those who come to the ED with pneumonia. Current Centers for Medicare and Medicaid (CMS) guidelines and The Joint Commission (TJC) standards both require that patients with pneumonia receive antibiotics within four hours of admission to the ED. Your facility’s current data demonstrates an average of six hours. You are out of compliance. Continued noncompliance will result in negative financial outcomes.

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