PI - Improving Organizational Performance

PI001O Guidelines for Documenting Performance Improvement Activities
Related Documents:  Forms used for documenting PI Activities
Facility Type: Acute Care - 135 Beds
Last Joint Commission Survey: November 1995
Comments:   Documents used to collect and submit the Performance Improvement activities for departments or teams.  To decrease duplicate efforts, the data previously included in the department or team plan for PI was incorporated into the the reporting form.  The facility uses the PDCA method.  The content of the guidelines is updated annually to also serve as an educational tool for department managers and team leaders.
Downloadable or Viewable Documents:
Department/Team Mission Vision PI001Fa.pdf
Department/Team Scope of Care PI001Fb.pdf
Performance Improvement Plan and Findings PI001Fc.pdf
Department/Team Annual Evaluation PI001Fd.pdf
Download all of the above forms in Word 97 format zipped in a self extracting file:  PI001F.exe
 

GUIDELINES FOR DOCUMENTING

PERFORMANCE IMPROVEMENT ACTIVITIES

I. GENERAL GUIDELINES

A. ONE YEAR PLAN

A one-year plan outlining your projected Performance Improvement Activities should be submitted to the QA Department each year with the report for the first quarter of the year, which is due on April 15. Please note that the Plan has now been incorporated into the reporting form.

B. QUARTERLY REPORT

Each team and department should submit a quarterly report to the QA Department. The report should aggregate and analyze the data collected for each performance measure for that time period. The quarterly reports must be received in the QA Department by the 15th of the month following the end of the quarter, as follows:

  • April 15 (January - March Report due)

  • July 15 (April - June Report due)

  • October 15 (July - September Report due)

  • January 15 (October - December Report due)

    1. If the report is to be delayed for any reason, the QA Department must be notified, preferably in writing, of the reason for the delay, and the expected date of completion.

    2. The quarterly reports must be submitted on designated forms to provide a consistent format. There are no exceptions.

    3. Special requests for reporting more frequently than quarterly may be made by the Utilization Review/Quality Assurance/Risk Management Committee. In addition, you may be requested to attend the Utilization Review/Quality Assurance/Risk Management Committee meeting to present your report.

    4. The component to be submitted quarterly is the form titled "Performance Improvement Report – Part One: Performance Measurement Plan and Findings" and "Performance Improvement Report – Part Two: Analysis and Plan for Improvement."

    If you also collect performance measures on the "Additional Performance Improvement Measurements", that should also be submitted with the quarterly report.

    5. Organizational Planning Statistics

    If you choose to collect statistical information for your department or team, it can be recorded on the form called "Additional Performance Improvement Measurements."

    6. Collection of data on a minimum of two (2) performance measures is required.

    The two performance measures, when possible, should relate to the Priority Functions determined by the Performance Improvement Task Force.

    For 1998, the priority areas are as follows:

    a) Patient and family education (Continued from 1997)

    b) Patient restraint/seclusion (Continued from 1997)

    Please note that the Joint Commission on Accreditation of Healthcare Organizations requires data collection, measurement, and assessment for restraint and seclusion for all units, all shifts, and all purposes.

    7. Submit one report form for each indicator that is being monitored.

    8. If you change your Performance Improvement Plan, please make the changes directly on the Performance Improvement Report – Part One: Performance Measurement Plan and Findings when your report is submitted. The findings from ongoing measurement will be updated on this form with each reporting period.

    9. Only two performance measures will be included on the final report to the Board of Directors. If you submit more than two performance measures, please indicate which performance measures you want to have included on the report by checking the appropriate box (Yes or No for Board of Directors) on the "Performance Improvement Report – Part One: Performance Measurement and Plan" form.

    10. No more than 5 indicators should be submitted on the Performance Improvement Report form, however any additional indicators can be recorded on the form called Additional Performance Improvement Measures.

    11. Important Processes or Outcomes Requiring Data Collection Or Assessment by Joint Commission on Accreditation of Healthcare Organizations

    The Comprehensive Accreditation Manual for Hospitals (The JCAHO Standards) specifically indicates processes and outcomes that require data collection and assessment. They are listed in the Improving Organizational Performance standards (PI.3.2 – 4.6) If the standards apply to your area, you must collect the appropriate data. A list of these processes and outcomes is attached.

    The "Additional Performance Measures" form can be used to document this data. Please note, however that for those that require analysis, the data must be submitted on the Performance Improvement Report forms to include the written analysis of the data.

C. ANNUAL APPRAISAL

An Annual Appraisal should be performed at the end of each calendar year

The Appraisal should be submitted with the April 15 Quarterly Report

The Annual Appraisal form included in these Performance Improvement Guidelines should be used for the Annual Appraisal, unless otherwise indicated by the QA Department.

III. DOCUMENTING PERFORMANCE IMPROVEMENT ACTIVITIES

A. MISSION AND VISION

The Mission Statement and Vision Statement for each department or team should be reviewed by the department or team members annually during the evaluation process, and revised as needed. The revised Mission or Vision Statement should be submitted annually with the Performance Improvement Plan, utilizing the Department Mission and Vision Statement Form.

B. SCOPE OF CARE

1. Responsibility

Each department director and team leader is responsible for the Performance Improvement activities in his/her department or team. These Performance Improvement functions may be delegated to others.

2. Delineate Scope of Care

Scope of care should define the types of services provided, types of patients served, identify the types of care providers, sites where care is provided, conditions and major diagnoses treated, and times care is provided.

Each department/team must utilize the Scope of Care Form to define the scope of care/service provided by the department/team, and to document the assignment of responsibility for identifying indicators, collecting data, evaluating care and taking actions to improve care

This form should be reviewed and revised annually and submitted to the QA Department with the first quarter report submitted in April each year.

C. PERFORMANCE IMPROVEMENT PLAN DEVELOPMENT

Each department must develop a Performance Improvement Plan, which projects performance measurement activities that are planned for the year.

The plan can be changed at any time throughout the year with submission of a revised plan.

When the establishing the plan, consideration should be given to the inclusion of performance measures for those functions that have been established by the Joint Commission Task Force and Hospital Leaders, as priority areas.

The Performance Improvement Plan MUST include those measures that are required by the Joint Commission. (See attached IMPORTANT PROCESSES OR OUTCOMES REQUIRING DATA COLLECTION OR ASSESSMENT)

Note that if you are involved in performance measurement activities at the team level, and data collected by that team directly reflects activities of your department, those activities can account for your departmental Performance Improvement activities. The Quality Assurance Department must be notified of your participation in the team Performance Improvement process.

COMPONENTS OF THE PERFORMANCE IMPROVEMENT REPORT

All information regarding each performance measure will be documented on this report form. This form incorporates the plan for measurement and assessment, and the findings of those activities.

Each quarter, the new information will be added to this form. Therefore, please keep a copy for your department records so that you can continue your documentation on this form.

Only two (2) performance measures will be included on the report to the Board of Directors. Please check the box labeled ‘Board of Directors’ to indicate the performance measure you have chosen to be included on the report. If the boxes are not checked, the Quality Assurance Department will select the performance measures to be included.

If you are involved in performance measurement activities at the team level, and data is being collected by that team that directly reflects activities of your department, those activities will account for your departmental Performance Improvement activities and you must maintain a copy of those Performance Improvement records in your department.

Each department manager and team leader will be required to attend the Utilization Review/Quality Assurance/Risk Management Committee and present the Performance Improvement report for his or her department. A copy of the reporting schedule is attached. Updates will be distributed periodically as needed. If you cannot attend the meeting, please make plans for another representative familiar with the Performance Improvement for your department to attend and report the information.


Performance Improvement Report –
Part One: Performance Measurement Plan and Findings

Measurement Plan

1. Department or Team Name

Check the applicable box for department or team

Indicate the department or name of the team reporting

2. Other Department/s Involved

Indicate any other departments that are involved in this Performance Improvement activity, or N/A of not applicable

3. Year

Indicate the calendar year for Performance Improvement activities

4. Submitted by

Indicate who is preparing the report

5. Date Initiated

Indicate the month and year that the data collection for this indicator began

6. Date Discontinued

When Performance Improvement activities have been discontinued due to improvement or re-prioritization of your Performance Improvement activities, indicate the date that the data collection for this indicator was discontinued

7. PI Measure #

Each performance measure should be assigned a number. The number assigned should be entered here.

8. Submit to Board of Directors

Two performance measures from each department or team will be included in the report to the Board of Directors. Please choose the performance measures you would like to have included on the report to the Board of Directors by checking the appropriate (yes or no) box. When possible, the performance measures selected should reflect the priority functions.

If more than two measures at submitted and indication has not been made regarding which measures to include, the Quality Assurance Department will chose the indicators to submit.

Measurements required by Joint Commission will automatically be included in the report.

9. Function

The applicable function should be noted for each performance measure

See the Joint Commission Standards, or the reference attached for a listing of the Important Hospital Wide Functions

10. Type of Measurement

Indicate whether the performance measure focuses on the process or outcome

Process – A goal-directed, interrelated series of actions, events, mechanisms, or steps

Outcome – The result of the performance (or nonperformance) of a function or process/es

11. Dimension of Performance

Indicate the Dimension of Performance that is the focus of the measurement

See the Joint Commission Standards, or the reference attached for Dimensions of Performance

12. Method of Collection

Indicate how the data will be collected.

A data collection methodology should be chosen and established. The methodology should consider the following:

Who will collect the data

Data sources that will be utilized

Whether the collection will be concurrent or retrospective

How often the data will be organized and compared to a threshold or benchmark

13. Sample Size

Indicate the Sample Size

The sample size to be reviewed should reflect the volume of cases involved. When the volume is very low, a sample many not be adequate to reflect a true picture.

Guidelines for Sample Size

*If the average number of cases per quarter is more than 600, at least 5% of the cases are reviewed

*If the average number of cases per quarter is less than 600, at least 30 cases are reviewed

14. Age Specific

Indicate whether or not the performance measurement requires age specific consideration

*Age specific categories include Infants, Children, Adolescents, Adult, and Geriatric

15. Frequency of Assessment of Data

While the process of data collection is ongoing, the frequency of assessing the data may vary for each performance measure. The frequency of assessment should be related to the frequency of the event or activity, the significance of the event or activity, and the extent to which problem areas are identified.

While some measurements can routinely be assessed quarterly, others may require assessment of the data more frequently, especially when problems have been identified that need more intensive investigation.

In determining how often to collect and assess the data for a given performance measure, consideration should be given to the following:

Volume of patients that will be affected

Element of risk to the patient

Frequency that the aspect of care is performed

Extent of previously identified problems in a particular area

When a problem is identified, the frequency of measurement may need to be increased, or focused review may be necessary.

16. Rationale For Choice Of Performance Measure

Indicate the rationale for choosing this indicator for performance measurement efforts.

The rationale is the evidence or reason that a performance measure is important or useful to measure (how the process or outcome measured affects patient outcomes).

A rationale could indicate that the performance measure is of a high-risk nature, high-volume, and/or problem-prone processes. Performance measurement could also be needed to design or assess new processes, assess the dimensions of performance relevant to functions, processes and outcomes, measure the level of performance and stability of important processes, identify areas for possible improvement of existing processes, determine whether changes have improved the processes, or because it is an organization-wide priority improvement effort.

17. Goal or Anticipated Outcome

Indicate the expected goal or outcome desired for this performance measure. The goal or outcome might be the expected standard of care as it relates to the chosen performance measure.

Outcome - The result of the performance of a function or process/es

Data Aggregation Findings

18. Performance Measure

Document the performance measure that will be used

19. Performance Measure Source

Note the source on which the performance is based (i.e., hospital or departmental policy, standard of care, etc.)

20. Numerator

The upper portion of a fraction used to calculate a rate, proportion, or ratio; the population, or number of patients for whom a specified event occurs

Example: Number of patients developing a surgical wound infection

The data should be aggregated quarterly and the numerator for the performance measure for the quarter documented under the designated column.

21. Denominator

The lower portion of a fraction used to calculate a rate, proportion, or ratio; the population or number of patients (i.e., universe) at risk in the calculation (or who have the specified procedure or condition)

Example: Number of patients having a surgical procedure

The data should be aggregated quarterly and the denominator for the performance measure for the quarter documented under the designated column.

22. Benchmark or Threshold

Indicate the threshold or benchmark that will be utilized in assessing the data collected for this indicator.

Benchmarks or thresholds can be used to assess performance. Utilizing thresholds or benchmarks, conclusions can be can be drawn by analyzing the data collected and comparing the findings to pre-established criteria, a single sentinel event, or control limits.

Assessing performance can be done using various frames of reference, including the following:

Internal comparisons over time

Comparison of up-to-date sources of information, such as accreditation standards, practice guidelines, or practice parameters

Comparison with similar processes and outcomes in other like facilities, including the use of reference databases

Consideration of legal and regulatory requirements

A means of assessment comparison should be chosen for each performance measure and should be established by means of a threshold range or benchmark, which can be documented as a numerator/denominator ,or rate, with a positive numerical value when possible.

23. Benchmark or Threshold Source

Indicate the reference used to establish the Benchmark or Threshold (see above Benchmark or Threshold)

24. Rate

Using the numerator and denominator established for your performance measurement, calculate the rate or each quarter, when possible in a positive value.

25. Total/Average

At the end of the calendar year, enter the total or average for the year, whichever is applicable.

Analysis and Plan for Improvement

Note: The remainder of this report form only needs to be completed when a problem, or opportunity for improvement is identified.

26. Date

Upon analysis of the data, when an a problem or opportunity for improvement has been identified, enter the date of the analysis report

27. Summary Of Problem/s Identified Or Opportunity For Improvement

An analysis is conducted to determine if the level of performance is acceptable, or if improvement is need. The summary of the problem or opportunity for improvement is documented here.

In making the assessment, as noted above under Benchmarks or Thresholds, actual findings should be compared to the benchmark or threshold. After the comparison is made, if findings are not within the expected range, the assessment process should continue to determine the cause, decide what needs to be done, and develop a plan for achieving that goal.

28. Plan of Action

The plan of action is based on the assessment of the data.

Document the plan that you have developed to achieve your expected outcome. If you are in a second cycle (or measurement period) of the improvement process, (you have previously initiated a plan that has not resulted in improvement) document the new plan or revisions to the previous plan that will be initiated.

If the goal of a plan was not achieved, continue each cycle of the process on the same report form, entering the current date and modification to the plan in this column.

29. Individual Responsible for Action/s

Indicate who is responsible for carrying out each part of the action plan.

30. Date and Description of Implementation of Action

Indicate the date, and the action that was taken with each cycle of the process in this column.

31. Evaluation of Implemented Plan

Evaluate the effectiveness of the action/s taken, and document whether or not improvement has occurred.

If the action/s taken were not effective in achieving the expected results, modify the plan and document the new plan of action in the Plan of Action column.

Repeat this Plan-Do-Check-Act cycle through subsequent cycles or measurement periods, until the necessary results are achieved.

D. Additional Performance Improvement Measures

Performance Improvement Measures should be limited to 5 indicators. However, if your department collects organizational planning statistics, quality control data, measurement of functions required by the Joint Commission, or additional Performance Measurement data, it can be recorded on this form.

No documented analysis is required for these measures.

If a performance measure provides an opportunity for improvement or you detect or suspect significant undesirable variation, you must promptly initiate intensive assessment to bring the performance to a desired level. In these instances, a review of the overall department Performance Improvement activities should be done to re-prioritize your performance improvement efforts.

E. GUIDELINES FOR COMPLETING TEAM GOALS

1. Performance Improvement Team

Indicate the team name

2. Date Team Formed

Indicate the date that the team was originally formed

3. Completion Date

If the team was formed for a temporary project, enter the date the project was completed; otherwise leave this area blank

4. Team Type

Check the box for the appropriate team type

Chartered Team – An ongoing team approved and overseen by the Performance Improvement Task Force

Unchartered Team – A team that comes together on the initiative of its members to improve a specific process or problem area

Special Project Team – A team assigned a special project by the performance improvement task force or by a chartered team

5. Team Leader

Indicate who is assigned responsibility of Team Leader.

The Team Leader is responsible for coordinating team efforts, developing team meeting agendas, providing guidance to the team members, assigning team functions as appropriate, such as record keeping and time keeping, scheduling meetings as needed, (at least quarterly), collecting and maintaining all policies, procedures and minutes of the team, reviewing and approving policies and procedures that the team is responsible for and determining and obtaining approval from the necessary individuals, committees or teams, initiating and maintaining a record of and reporting all performance improvement activities of the as outlined by the Performance Improvement Plan. (Responsibilities can be assigned to other team members.)

6. Facilitator

Indicate what individual is assigned the responsibility of maintaining the focus of the team during team meetings

7. Recorder

Indicate which team member is assigned the responsibility of recording the meeting minutes for each meeting.

It is recommended that one individual assume the responsibility or be assigned the responsibility for a time period (for example one year or six months) rather than random assignment to provide continuity. In the event that the recorder cannot attend the meeting, a temporary recorder should be assigned the responsibility for documenting the minutes for that particular meeting at the beginning of the meeting.

8. Time Keeper

Indicate which team member is assigned the responsibility of TimeKeeper.

The timekeeper should be assigned the responsibility on a permanent basis, or for a particular time period. Meetings should be scheduled for now longer than a one hour time period. Every effort should be made to start the meeting on time in consideration of busy schedules of all team members. The TimeKeeper should announce to the team when a 30 minutes remain, when 15 minutes remain, and when 5 minutes remain. When complete agendas are developed, the time announcements help to set the pace for the meeting so that all agenda items can be covered in the time frame.

9. Team Reports To

Indicate the reporting chain of the team.

All teams report progress and activities to the Performance Improvement Task Force.

Teams that have been established as an ad hoc team report their findings to the team established to oversee that function. (For example, the IM.3 Team is an ad hoc team to the Information Management Team, and therefore reports to the Team Leader of the Information Management Team. The Information Management Team Leader is then responsible to report the activities of the IM.3 ad hoc team, through the established channels.)

10. Team Members

List all members of the team.

When possible, teams should be limited to seven members. Members should be representative of the disciplines involved in the process or function. Department Managers should be contacted and approve the addition of a staff member from that area before any new or additional team members are assigned.

11. Team Mission

Indicate the mission statement of the team.

A mission statement should be developed for each team by the team members. The mission statement should be modeled after the hospital’s mission statement and reflect the activities of the team. The mission statement should be reviewed each year making any necessary changes.

12. Projected Goals For This Year

List the goals for the team for the coming year.

During the annual evaluation process, any changes in regulatory standards should be reviewed and considered in determining items that need to be accomplished for the year. Priorities should be established based on the hospital-wide priorities.

13. Date Met

Indicate the date that the goal was met.

The team updates the list of goals and accomplishments on an ongoing basis.

14. Special Considerations

A note should be made of any special considerations of the team (for example, if efforts in a particular area need to be coordinated with another team or committee).


DIMENSIONS OF PERFORMANCE

I. DOING THE RIGHT THING

Efficacy

The efficacy of the procedure or treatment in relation to the patient’s condition

The degree to which the care of the individual has been shown to accomplish the desired or projected outcome(s)

*The efficacy of a particular treatment should be supported by scientific literature and research. Efficacy can be determined by measuring various outcomes of care.

Appropriateness

The appropriateness of a specific test, procedure, or service to meet the patient’s needs

The degree to which the care and services provided are relevant to the individual’s clinical needs, given the current state of knowledge

*Appropriateness pertains to the choices that practitioners make, whether those choices be medication therapies, diagnostic tests, noninvasive procedures, or invasive procedures. Even if performed well, an inappropriate type of care may harm and will not help the patient.

II. DOING THE RIGHT THING WELL

Availability

The availability of a needed test, procedure, treatment, or service t the patient who needs it

The degree to which appropriate care is available to meet the individual’s needs

*Appropriate choices of treatment that are potentially efficacious for patients are futile unless they are actually available to patients. Thus an organization needs to ensure that its services meet community needs and that they be rendered in such way and at such times that the community served can access those services.

Timeliness

The timeliness with which a needed test, procedure, treatment, or service is provided to the patient

The degree to which the care is provided to the individual at the most beneficial or necessary time

*Timeliness pertains to the process of care and can certainly affect the outcome of care. In health care, timing is crucial for everything from initial assessment to pre-surgical antibiotic administration to patient education.

Effectiveness

The effectiveness with which tests, procedures, treatments, and services are provided

The degree to which the care is provided in the correct manner, given the current state of knowledge, to achieve the desired or projected outcome(s) for the individual

*This dimension of performance also addresses how care is provided and suggests that an effective process of care increases the chance of a desirable or expected outcome. Currently, more hospitals are attempting to standardize care by using such tools as practice guidelines and standards to help ensure that care reflects the current state of the art.

Continuity

The continuity of the services provided to the patient with respect to other services, practitioners, and providers, and over time

The degree to which the are for the patient is coordinated among practitioners, among organizations, and over time

*Continuity of care has entered the spotlight with the proliferation of vertically integrated delivery systems. A hallmark of a truly integrated system is its continuity of care—its ability to effectively guide a patient from acute care to skilled nursing care, or example, or from skilled nursing care to home care. Continuity within an organization is equally important for good outcomes. Continuity requires effective communication and planning, or example, discharge planning that begins early in the care process.

Safety

The safety of the patient (and others) to whom the services are provided

The degree to which the risk of an intervention (for example, use of a drug or a procedure) and risk in the care environment are reduced for a patient and others, including the health care practitioners

*Safety management is not an isolated function. Rather, it permeates the activities in an organization, from managing risk for patients and practitioners to effectively maintaining equipment, implementing appropriate fire safety procedures, and monitoring and controlling infection.

Efficiency

The efficiency with which services are provided

The relationship between the outcomes (results of care) and the resources used to deliver patient care

*In an era of cost management, efficiency is the dimension of care that may be receiving the most attention today. Efficiency should not necessarily be viewed as unfavorable to good patient outcomes. For example, regarding turnaround times of laboratory tests, increasing efficiency in ordering and performing tests, thereby potentially improving a patient’s chance for a good outcome. In addition, the enhanced understanding of patient care processes, the increased cooperation among caregivers, and improved practices that arise from multidisciplinary improvement efforts can improve efficiency while improving efficacy and effectiveness.

Respect and Caring

The respect and caring with which services are provided

The degree to which those providing services do so with sensitivity and respect for the individual’s needs, expectations, and individual differences, and the degree to which the individual or a designee is involved in his or her own care decisions

*When seeking to improve the performance of clinical processes, the focus may be set on a dimension of performance such as efficacy before any attempt is made to improve the degree of respect and caring. However, patients treated with respect and caring may be more likely to participate effectively in their care, for example, to carry out their medication regimens. In addition, patients have the right to be treated with respect and caring, which makes this dimension of performance a high priority for improvement. Since patients have choices about who will provide their care, patient satisfaction, enhanced by respect and caring , will be key to any organization’s success.

_____________________________

References:

Comprehensive Accreditation manual for Hospitals: The Official Handbook, Joint Commission on Accreditation for Healthcare Organizations, August 1997 Update, p. PI-4.

*An Integrated Approach to Medical Staff Performance Improvement, Second Edition, Joint Commission on Accreditation of Healthcare Organizations, 1996, pp. 5-7.


PI002F Forms for Review of Operative, Invasive and Noninvasive Procedure Measures (Previously Known as 'Surgical Case Review')
Related Documents:  Forms used for data collection of performance measures - PI.3.2.1
Facility Type: Pediatric Cancer
Last Joint Commission Survey: October 1997
Downloadable or Viewable Documents:
Surgical Case Review Data Collection Sheet - General PI002Fa.pdf
Anesthesia Case Review Data Collection Sheet PI002Fb.pdf
Vascular Access Devices Surgical Case Review Data Collection Sheet  PI002Fc.pdf
Download all of the above forms in Word 97 format zipped in a self extracting file:  PI002F.exe

PI003F Performance Improvement Report Sample
Related Documents:  None
Facility Type: Submitted by Connie Tohar for HealthCare Consulting Associates, LLC
Last Joint Commission Survey: Not Applicable
Comments: Measures that are included in the report can vary depending upon the organization's needs and PI activities.  The categories and sub-categories, however, are pretty much right out of the JCAHO standards.
Downloadable or Viewable Documents: 
Performance Improvement Report PI003F.pdf
Download the above form in Excel 97 format zipped in a self extracting file:  PI003F.exe

PI004F Patient Survey Questionnaire
Related Documents:  None
Facility Type: Acute Care
Last Joint Commission Survey: November 1995
Comments: Surveys were developed with the input of applicable disciplines
Downloadable or Viewable Documents: 
Patient Survey Questionnaire for Inpatients:  PI004Fa.pdf
Patient Survey Questionnaire for Outpatients:  PI004Fb.pdf

PI005F Performance Improvement Case Review Worksheet
Related Documents:  None
Facility Type: Acute Care
Last Joint Commission Survey: November 1998
Comments:
Downloadable or Viewable Documents: 
Performance Improvement Case Review Worksheet:  PI005F.pdf
Downloadable in Word 95 File Format:  PI005F.exe

PI006F Performance Improvement Mortality Case Review Worksheet
Related Documents:  None
Facility Type: Acute Care
Last Joint Commission Survey: November 1998
Comments:
Downloadable or Viewable Documents: 
Performance Improvement Mortality Case Review Worksheet:  PI006F.pdf
Downloadable in Word 95 File Format:  PI006F.exe

PI007O Sample Board Report
Coordination of Hospital-Wide Data
Related Documents:  None
Facility Type:  Acute Care Acute Care
Last Joint Commission Survey: November 1998
Comments:  The information noted here shows two features based on hospital-wide data that has had some measures (required hospital-wide functions) entered into an Excel spreadsheet, and Team and Department Performance Measures entered into an Access Database.  Reports can be generated for reporting to the Board of Directors, or to the hospital steering committee and/or team leaders.

This is an example of how hospital-wide data is integrated in a facility using a 'Key Function' team approach.  A list of all Performance Measures is able to be generated by 'Key Function', whether collected by a team or department or committee.  The listing of performance measures is then able to be sorted by 'Key Funciton' and distributed to the Team Leaders of the 'Key Function' teams, to be reviewed and determine if further efforts at coordinating the Performance Measures into the Team is necessary.

Reports listing the performance measures can be generated in any manner once the data has been entered into the database.  It can be generated by department/team or by function. 

PI Board Report sample noted here is composed of 2 parts.   The hospital-wide functions are entered into the Excel spreadsheet.  The performance measures established by each department or team is entered into Access database for tracking and reporting progress of improvement.  The documents provided show examples of both.  These examples provide quarterly reporting to the Board of Directors.  Graphs can be be quickly developed from the Excel spreadsheet data.   The department and team performance measurement data is 'cycled' to the Board of Directors so that the Board is not overwhelmed with all departments and teams reporting each quarter.  In addition, each team or department chooses only two performance measures that they feel are most pertinent, to be reported to the Board of Directors.

Downloadable or Viewable Documents
Sample Board Reports
1)  Sample PI Measures Sorted by Key Function (Viewable online or downloadable in Adobe Acrobat Reader Format):  PI007Oa.pdf    (Please note, the viewing quality is somewhat distorted due to small fonts in the form, however, zooming in once opened in Adobe Acrobat Reader will make the document legible.)

2)  Sample Board Report of Hospital-wide Required Functions (Downloadable in Excel File Format):  PI007Ob.exe or Viewable online or downloadable in Adobe Acrobat Reader Format:  PI007Ob.pdf   (Please note, the viewing quality is somewhat distorted due to small fonts in the form, however, zooming in once opened in Adobe Acrobat Reader will make the document legible.)

3)  Sample Board Report of Teams and Departments in Access Format (Viewable online or downloadable in Adobe Acrobat Reader Format): PI007Oc.pdf  (Please note, the viewing quality is somewhat distorted due to small fonts in the form, however, zooming in once opened in Adobe Acrobat Reader will make the document legible.)


PI008O Performance Measurements and Assessments Required by JCAHO
Related Documents:  None
Facility Type: Acute Care 139 beds
Last Joint Commission Survey: November 1998
Comments: List of measurements and assessments required by JCAHO
Downloadable or Viewable Documents: 
Downloadable in Word 97 File Format:  PI008O.exe

IMPORTANT PROCESSES OR OUTCOMES REQUIRING DATA COLLECTION OR ASSESSMENT

PROCESSES REQUIRING MEASUREMENT (DATA COLLECTION)

Measurement: The systematic process of data collection, repeated over time or at a single point in time

PI.3.2.1 Operative, Other Invasive, And Noninvasive Procedures That Place Patients At Risk

Selection of the appropriate procedure
Patient preparation for the procedure
Performance of the procedure and patient monitoring
Post procedure care
Post procedure patient education

PI.3.2.2 Processes Related To Medication Use (Not necessarily at the same time)

Prescribing and ordering
Preparing and dispensing
Administration
Monitoring effects on patients

PI.3.2.3 Processes Related To The Use OF Blood and Blood Components

Ordering
Distributing, handling, and dispensing
Administering
Monitoring blood and blood component effects on patients

PI.3.2.4 Appropriateness Of Admissions And Hospital Stays (Utilization Management Activities)

PI.3.2.5 Needs, Expectations And Satisfaction Of Patients
(Same items as listed under PI.3.2.6)

PI.3.2.6 Staff Views Regarding Performance And Improvement Opportunities

Needs and expectations
Satisfaction with how well hospital meets their needs and expectations
Perceptions of how the hospital could improve
Perceptions of how well the hospital performs relative to dimensions of performance

PI.3.2.7 Appropriateness Of Behavior- Management Procedures

PI.3.3 Autopsies results

PI.3.3.2 Risk Management Activities

PI.3.3.3 Quality Control Activities

Clinical laboratory
Diagnostic radiology
Dietetic
Nuclear medicine
Radiation oncology
Equipment used in administering medication
Pharmaceutical equipment used to prepare medications

FUNCTIONS REQUIRING ASSESSMENT OF COLLECTED DATA

Assessment: To transform data into information by analyzing data

PI.4.5.1 ALL major discrepancies or patterns of discrepancies, between preoperative and postoperative (including pathologic) diagnoses, including those identified during the pathologic review of specimens removed using surgical or invasive procedures.

PI.4.5.2 Adverse events or patterns of adverse events during anesthesia

PI.4.5.3 All confirmed transfusion reactions

PI.4.5.4 All significant adverse drug reactions

PI.4.6 Processes and outcomes related to behavior management procedures (PI.3.2.7)

Behavior management: The use of basic learning techniques, such as conditioning, biofeedback, reinforcement, or aversion therapy, to manage and improve human behavior

IC.6 Rates or trends of epidemiologically significant infections

TX.7.1.2 Use of Restraint and Seclusion (ALL UNITS, ALL SHIFTS, ALL PURPOSES)

EC. (Environment of Care) requires that data be collected relative to safety, emergency preparedness, life safety, hazmats, security, utility systems, and medical equipment.


PI009O Performance Improvement Plan
Related Documents:  None
Facility Type: Acute Care 139 beds
Last Joint Commission Survey: November 1998
Comments: Due to the size of the document, it is it is viewable online in Adobe Acrobat Reader format only by clicking on the PI009O link below.  It can also be downloaded in the Word 97 file format. 
Downloadable or Viewable Documents: 
Performance Improvement Plan:  PI009O.pdf
Downloadable in Word 97 File Format:  PI009O.exe

PI010O Blood Trending Form and Sample Report
Related Documents: None
Facility Type: Acute Care - 206 Beds
Last JCAHO Survey: May 1998
Comments: The trendiing occurs over a rolling year
Downloadable or Viewable Documents: 
Blood Trending Form Viewable online and Downloadable in Adobe Acrobat Reader Format:  
PI010Oa.pdf
Blood Trending Sample Report Viewable online and Downloadable in Adobe Acrobat Reader FormatPI010Ob.pdf
Blood Trending Form and Sample Report Downloadable in a self-extracting executable file in Word95 format: PI010O.exe

INDICATOR TRENDING FORM

DEPARTMENT: Blood Usage Team YEAR 1997-1998

.

QUARTER 3 1997
FFP

QUARTER 4 1997
Cryo

QUARTER 1
1998
PRBC

QUARTER 2
1998
Platelets

QUARTER 3
1998
FFP

ASPECT OF CARE-----INDICATOR

#

%

#

%

# %

#

%

#

%

Aspect of Care
Ordering
Blood or Blood Component was ordered appropriately according to approved Medical Staff Criteria as evidenced by documentation in the Medical Record.

30/30

100%

30/30

100%

25/30

83%

30/30

100%

30/30

100%

Aspect of Care
Handling, Preparing, and Dispensing
Stat unit of blood or blood component was handled, prepared, and dispensed to the Nursing Unit within 60 minutes of the receipt of the crossmatch specimen in Transfusion Services as evidenced by documentation in the Medical Record and Transfusion Services Daily Work Logs.

9/9

100%

2/2

100%

8/10

80%

8/9

89%

10/10

100%

Stat unit of blood or blood component was obtained from Transfusion Services within thirty minutes of notification that the unit was ready for dispensing as evidenced by documentation in the Transfusion Services’ log.

6/9

67%

1/2

50%

7/10

70%

7/9

78%

8/10

80%

Aspect of Care
Administration
Blood or Blood Component administration was begun within 30 minutes of release from Transfusion Services as evidenced by documentation in the Medical Record.

29/30

97%

30/30

100%

30/30

100%

30/30

100%

30/30

100%

Blood or Blood Component was administered safely according to Hospital Policy guidelines as evidenced by documentation in the Medical Record of: . . . . . . . . . .
1. Two registered nurse signatures witnessing the correct identification number on the Blood or Blood Component bag. 30/30 100% 30/30 100% 30/30 100% 30/30 100% 30/30 100%
2. The start time and completion time of the transfusion are noted. 30/30 100% 30/30 100% 30/30 100% 30/30 100% 30/30 100%
3. Patient Blood Pressure and Temperature are recorded at the start of the transfusion.

30/30

100%

30/30

100%

30/30

100%

30/30

100%

30/30

100%

Aspect of Care
Effect on the Patient
The effect of the Blood or blood component on the patient was noted by the Healthcare team as evidenced by documentation in the Medical Record of: . . . . . . . . . .
1. Transfusionist completes transfusion reaction section of the Transfusion Form.

29/30

97% 29/30 97% 30/30 100% 29/30 97% 27/30 90%
2. Post transfusion Lab studies are ordered and noted by the physician.

30/30

100%

30/30

100%

30/30

100%

28/28

100%

30/30

100%

*patient expired prior to completion of post transfusion lab studies.

SAMPLE REPORT
BLOOD USAGE STUDY - Platelets
Date of Report: July 8, 1998

Findings:

  • Patient Population: 30 Patients (Some patients received multiple units and/or multiple transfusions. In this study, "number of patients" refers to number of transfusions reviewed.)
  • Time Frame: Second Quarter 1998
  • Data Sources: Open and Closed Medical Records, Transfusion Services Logs
  • Resources: Hospital Policies regarding Transfusion of Blood or Blood Components, Transfusion Services Policies and Procedures relating to Platelet Handling, Distribution and Dispensing, Medical Staff Criteria for Appropriate Indications for the Ordering of Platelets.
  • Criteria: High Risk
  • Dimensions of Performance: Appropriateness, Availability, Continuity, Effectiveness, Timeliness, Competency and Safety.
  • Indicators:
Aspect of Care: Ordering

#

%

Blood or Blood Component was ordered appropriately according to approved Medical Staff Criteria as evidenced by documentation in the Medical Record.

30/30

100%

Aspect of Care: Handling, Preparing, and Dispensing
Stat unit of Blood or Blood Component was handled, prepared, and dispensed to the Nursing Unit within 60 minutes of the receipt of the crossmatch specimen in Transfusion Services as evidenced by documentation in the Medical Record and Transfusion Services Daily Work Logs.

8/9

89%

Stat unit for blood or blood component was obtained from Transfusion Services within thirty minutes of notification that the unit was ready for dispensing as evidenced by documentation in the Transfusion Services’ log

7/9

78%

Aspect of Care: Administration
Blood or Blood Component administration was begun within 30 minutes of release from Transfusion Services as evidenced by documentation in the Medical Record.

30/30

100%

Blood or Blood Component was administered safely according to Hospital Policy guidelines as evidenced by documentation in the Medical Record of: . .

1. Two registered nurse signatures witnessing the correct identification number on the Blood or Blood Component bag.

30/30 100%

2. The start time and completion time of the transfusion are noted.

30/30

100%

3. Patient Blood Pressure and Temperature are recorded at the start of the transfusion.

30/30

100%

Aspect of Care: Effect on the Patient
The effect of the Blood or blood component on the patient was noted by the Healthcare team as evidenced by documentation in the Medical Record of: . .

1. Transfusionist completes transfusion reaction section of the Transfusion Form.

29/30 97%

2. Post transfusion Lab studies are ordered and noted by the physician.

28/28*

100%

*Two (2) patients expired prior to completion of post transfusion lab studies.

Conclusions:

  • The review of the indicators for platelets demonstrates an area of concern related to the dispensing of blood or blood components. The Blood Bank did not dispense the unit of platelets within 60 minutes for 1 of the 9 stat transfusions. This is related to the fact that platelets are very expensive and the hospital does not keep them in stock. The process to obtain platelets is to have the courier (if he is at the hospital) go to the Blood Center to pick up the units, or to have the Blood Center deliver the units (when the courier is not available). When the courier is available, the process can be completed in less than or close to one hour. It often takes longer when The Blood Center has to deliver the units. This is markedly improved from platelet review in 1997.
  • Twice nursing did not pick up the stat units within 30 minutes of notification that the unit was ready. This indictor has shown steady improvement over the past year. Rising from 43% during platelet review in 1997. The two cases have been referred to the appropriate clinical coordinators for review and staff education.
  • Documentation of the administration and the effect of the transfusion demonstrates continued improvement.

Recommendations/Actions:

  • The indicators will continue to be used to measure the process of transfusion of blood or blood components during the current year. This data will be trended to identify further areas of concern within the process.
  • The process for obtaining units should not be changed because the cost of keeping the units is too high and the usage requirements fluctuate with too much variance to allow for consistent stocking levels.
  • The results of this study will be shared with the Nursing, Blood Bank, and Medical Staff to allow these disciplines the opportunity to assess the process of transfusion of blood or blood components within their own Departments.
  • The minutes of the Transfusion Committee will be utilized as the communication tool by being forwarded to the Medical Executive Committee, Nursing Quality Improvement Coordinator, and the Quality Management Department.

PI011F Reappraisal of Quality Management Process Form
Related Documents: None
Facility Type: .
Last JCAHO Survey: .
Comments: .
Because it is difficult to convert some forms to a format suitable for viewing in this format, the form is viewable or downloadable in the file formats listed below.

Downloadable or Viewable Documents: 
Quality Management Reappraisal Form Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI011F.pdf
Quality Management Reappraisal Form Downloadable in a self-extracting executable file in Word95 format: PI011F.exe


PI012P PERFORMANCE IMPROVEMENT/QUALITY ASSESSMENT PLAN SENTINEL EVENTS POLICY
Related Documents: None
Facility Type: Acute Care 81 Beds
Last JCAHO Survey: January 1999
Comments: .
Because of the length of this document, it is viewable or downloadable in the file formats listed below.

Downloadable or Viewable Documents: 
Performance Improvement/Quality Assessment Plan Sentinel Events Policy Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI012P.pdf
Performance Improvement/Quality Assessment Plan Sentinel Events Policy Downloadable in a self-extracting executable file in Word95 format: PI012P.exe


PI013O JCAHO Standards Scoring Spreadsheet
Related Documents: None
Facility Type: .
Last JCAHO Survey: .
Comments: A personally developed Excel spreadsheet template that can help score mock surveys.  Developed and shared by a listserv member.
Because of the file format of this document, it is downloadable in the file formats listed below.

Downloadable or Viewable Documents: 
Scoring Spread Sheet (Excel file format) and Scoring Instructions (Word 95/6.0 format) can be downloaded in a self extracting file:   PI013O.exe
For Windows, right click on the above download file and choose "Save Link As..." and save the file to your directory of choice.  Once downloaded, double-click on the downloaded file to extract the two files for the scoring spreadsheet and the instructions.


PI014F Mock Survey Tool
Related Documents: None
Facility Type: .
Last JCAHO Survey: .
Comments:   Generic mock survey tool to be used for evaluating readiness of departments.  It is more appropriate for in-patient units, but has been used it for 20+ departments totally, including areas like cardiac rehab, laboratory services, etc.
Because it is difficult to convert some forms to a format suitable for viewing in this format, the form is viewable or downloadable in the file formats listed below.

Downloadable or Viewable Documents: 
Mock Survey Tool is Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI014F.pdf
Mock Survey Tool Downloadable in a self-extracting executable file in Word95 format: PI014F.exe


PI015F Peer Review Form
Related Documents: None
Facility Type: .
Last JCAHO Survey: .
Comments:   Utilizes CRAE format for peer review. 

Instructions for using the form:

CONCLUSIONS is where our RN reviewer records the main reason for the chart being reviewed. 

RECOMMENDATIONS is where the MD records his review of the chart.

ACTION is where it is recorded if the charts needs to go to Committee, or if a letter needs to be written to the MD, or whatever action the doc doing the review recommends.

EVALUATION is where the comments from Committee are recorded (if the chart goes to committee).

Downloadable or Viewable Documents: 
The Peer Review Form is Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI015.pdf
You can view the file if you Adobe Acrobat Reader installed by simply clicking on the link, or you can download it by right clicking and specifying the directory on your computer where you want the file to be downloaded. Please see information on the About this Site page to download Adobe Acrobat Reader.

The Peer Review Form is Downloadable in a self-extracting executable file in Word95 format: PI015F.exe
For Windows, right click on the above download file and choose "Save Link As..." and save the file to your directory of choice.  Once downloaded, double-click on the downloaded file to extract the two files for the scoring spreadsheet and the instructions.

Your Hospital
Quality Management Department

Peer Case Review

Account #___________________

Attribution #_________________

 CONCLUSIONS:

 

 RECOMMENDATIONS:

 

 ACTION:

 

 EVALUATION:

 

  

REFERRED TO COMMITTEE: YES_____ NO _____

SIGNATURE _________________________________

 

PI016F PI Report
Facility Type: .
Last JCAHO Survey: .
Comments:   In an attempt to streamline, standardize and simplify the reporting of departmental and team PI activities, this for was developed.  Our managers/team leaders seem to like it and it does meet our needs.   The next challenge is to transition it to an Access database which would greatly improve the ability to aggregate and produce organizational reports.
Because it is difficult to convert some forms to a format suitable for viewing in this format, the form is viewable or downloadable in the file formats listed below.

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI016F.pdf
Downloadable in a self-extracting executable file in Word95 format: PI016F.exe

 

PI017P Occurrence Report Policy
Facility Type: Acute Care
Last JCAHO Survey: .
Comments:   

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI017P.pdf  Click on the file to view; right-click on the file to download
Downloadable in a self-extracting executable file in Word95 format: PI017P.exe

 

PI018F CPR Data Collection Form
Facility Type: Acute Care 247 beds
Last JCAHO Survey: January 1998
Comments:  This is a Data Collection Tool we developed for the collection of in-house resuscitation information from the AHA/Utstein-style recommendations.

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI018F.pdf  Click on the file to view; right-click on the file to download
Downloadable in a self-extracting executable file in Word95 format: PI018F.exe

 

PI019O Peer Review Process
Facility Type: Not submitted
Last JCAHO Survey: Not submitted
Comments:  None 

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI019O.pdf  Click on the file to view; right-click on the file to download
Downloadable in a self-extracting executable file in Word97 format: PI019O.exe

 

PI020F Prioritization Tool
Facility Type: Not submitted
Last JCAHO Survey: Not submitted
Comments:  None 

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI020F.pdf  Click on the file to view; right-click on the file to download. 

 

PI021F Root Cause Analysis Form
Facility Type: Not submitted
Last JCAHO Survey: Not submitted
Comments:  A JCAHO approved form 

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI021F.pdf  Click on the file to view; right-click on the file to download.
Downloadable in a self-extracting executable file in Word97 format: PI021F.exe

 

PI022F Variance Report Survey
Facility Type: Not submitted
Last JCAHO Survey: Not submitted
Comments:  A JCAHO approved form 

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI022F.pdf  Click on the file to view; right-click on the file to download.
Downloadable in a self-extracting executable file in Word97 format: PI022F.exe

PI023F Prioritization of PI Projects Tool
Facility Type: Not submitted
Last JCAHO Survey: Not submitted
Comments:  None submitted

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:   PI023F.pdf  Click on the file to view; right-click on the file to download.
Downloadable in a self-extracting executable file in Word format: PI023F.exe

PI024F Patient Safety Form
Facility Type: Acute Care - 54 bed facility
Last JCAHO Survey: May 2001
Comments:  The forms are two sided.   They are used in addition to the regular occurrence forms, for issues that just don't seem to fit in on the Occurrence Report.   Anyone can write one up and get it to me.   It can be anonymous.   They are investigated through Risk Management or Safety Officer depending on the issue.

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:  
Click on the file to view; right-click on the file to download.
Informal Quality/Risk Concern Report Form PI024Fa.pdf 
Safety Concern/Suggestion Report Form PI024Fb.pdf
Downloadable in a self-extracting executable file in Word format: PI024Fa and b.exe

 

PI025F Clinical Alarm List - NPSG #6

Downloadable or Viewable Documents: 
Viewable online and Downloadable in Adobe Acrobat Reader Format:  
Click on the file to view; right-click on the file to download.
Clinical Alarm List PI025Ff.pdf 
Downloadable in a self-extracting executable file in Word format: PI025f.doc

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