Quality Improvement Plan Final

The journey of quality improvement is a responsibility of all those involved in patient care. At The Women’s Hospital (TWH) at Saint Joseph East (SJE) it was decided that a change in culture would be needed and focus was directed on decreasing the length of stay (LOS) for maternity patients. Quality process improvement is a formal approach to the analysis of performance and systematic efforts through a team approach to improve the outcomes for patients and staff (Spath, 2013).

The Women’s Hospital at SJE is a state-of-the-art free standing facility that provides exclusive care for the women of central and eastern Kentucky.

Services include both high and low risk maternity care, a level three neonatal intensive care nursery, cardiology and rheumatology services, all exclusively specialized and conveniently under one roof for women. The mission of TWH is shared by the larger market based organization of Catholic Health Initiatives (CHI).

As part of the mission statement of CHI and TWH the goal is to “…create healthier communities”, this is done through culture changing quality improvement processes such as decreasing the LOS (Catholic Health Initiatives [CHI], 2014, para.

1). The Women’s Hospital welcomes the chance to collaborate with SJE and other hospitals within CHI to offer quality improvement data while supporting the mission of the organization.

Health care is a business just like any other, with customers that have a choice where to obtain services. The customer is just beginning to become an integral part in the quality improvement process for health care.

At TWH the role the patient and family plays will help to shape a culture of improved safety and quality of care. Patients and families are engaged in the quality improvement process through patient surveys, bedside reporting, and direct observation through patient rounding by nursing management. The organization of TWH practices transparency and public methodology.

Quality results are reported and available through websites supported by agencies such The Center for Medicare and Medicaid Services, The Joint Commission and the Kentucky Hospital Engagement Network. To assist the consumer in partnering with TWH in quality improvement the websites for TWH offer links to resources to navigate the websites that provide the reported quality data.

The organization has both internal and external accountability to quality indicators. External quality indicators are used by government agencies, third party payers and consumers to define a quality hospital stay (Kelly, 2011). The external indicators relevant to consumers for TWH include; overall patient satisfaction with hospital stay, infection rates for surgeries and patient satisfaction with nursing care. Knowing patient satisfaction with an organization, for those that are seeking similar services will allow a consumer to know if they will be able to have the desired experience at TWH.

When infection rates are reported to external agencies it allows consumers to make informed decisions as to the safety of the care provided by TWH and speaks to the transparency of the quality improvement programs. Lastly, since everyone in the hospital will have contact with a nurse, the reporting of patient satisfaction with nursing care will promote the compassionate nursing culture of care available at TWH. Monitoring and reporting quality indicators externally allows the organization to know if the customer’s interests are being properly served.

The Women’s Hospital at SJE takes a proactive approach to quality improvement. This approach means including all stakeholder involved in patient care; patients, managers, administration, medical staff, health insurers, accrediting agencies, and the mission team. In addition to patient surveys and manager rounding, TWH has a quarterly community group that meets to listen to the needs of its members.

This multidisciplinary team is comprised of executive team associates, nursing staff, medical staff, former patients, commercial insurance representatives and is open to anyone interested in the community. Information learned in these meetings is then taken back the perinatal quality committee and serves as direction for future efforts of quality improvement initiatives. Jointly working to improve the quality of care will create an environment of trust between TWH and the community served.

In conclusion, the responsibility of quality improvement is shared by all members of the health care team and includes the patient. Importance and relevance of quality indicators is influenced by internal and external factors. At The Women’s Hospital, efforts are made to incorporate the role of the consumer in improving the quality of care delivered and through collaboration achieve optimal outcomes for both patient and caregiver.