Review the following lectures:

Performance Improvement for Quality Care (Performance Improvement for Quality Care
Leaders and managers in healthcare strive to provide the best care possible for the population they serve. In order to do so, appropriate data must be collected, analyzed, and then used to improve operations where necessary. There is a process known as performance improvement (PI), which includes establishment of quality indicators for assessment and monitoring. There are several important steps to PI that will be discussed during the week. PI processes should be in place for high-risk, high-volume, and problem-prone areas of an organization or a community.

In order for leaders and managers to pinpoint what to focus on, assessments must be conducted and a team of diversified people must assist the managers in developing quality indicators; these are specific processes in need of continuous data collection, analysis, monitoring, and measurement of effectiveness. Our textbook gives many examples of quality indicators. Some indicators require focus per accrediting bodies, such as medication error rates, surgical infection rates, and number of patient falls.

In order to collect data, surveillance tools must be used. Surveillance can be conducted in several ways:

Routinely, as with generalized hospital-wide surveillance on a monthly basis
Periodically (every few months, for example)
When needed, the review of prevalent issues that have occurred during a specified time frame
Targeted surveillance (as with a sudden problem with newborns with infections)
Outbreak surveillance
Surveillance tools include surveys, checklists, charts, graphs, and many other risk-specific tools for specific departments or other areas in the healthcare services field.

Use of graphs and charts assists managers and leaders in analyzing the data collected. Thresholds must be established, and if not met, action plans must be made and implemented to improve processes and quality of care. Continuous monitoring is imperative.

Benchmarking is an important part of the PI process and one that should always be in place when monitoring quality indicators. It is important for leaders to know how well their organization is performing. The data collected through PI can be used to compare an organization’s performance to that of peers and to national data, when available. This is called benchmarking.

Healthcare Tools

Quality healthcare is a goal of every healthcare organization in the United States. Without quality care, organizations would not survive long term. Healthcare leaders and managers strive to maintain and improve the quality of care that is provided by their respective organizations. These individuals use various tools to assist them in collecting, comparing, and analyzing healthcare data for the purpose of improving care. Below you will find links to two examples of these tools. Tools can be revised to fit specific needs since each organization might provide different services to different segments of the population.)



Total Quality Management(Total Quality Management
Total quality management (TQM), also known as quality improvement (QI), is a process that leaders and managers in healthcare use to ensure quality of care. TQM focuses on processes in place instead of individuals when quality care is not at a desired level. Part of the TQM process is a plan, do, study, act (PDSA) cycle. Managers and leaders meet periodically to brainstorm ideas on how to promote the best service to the population they serve. Brainstorming leads to the creation of specific graphs and charts, known as fishbone diagrams and flow charts, among others discussed in Chapter 5, Quality of Care Management, of our textbook. These diagrams and charts are designed to help identify process failures that lead to errors or undesired outcomes.

Other types of formal processes used in healthcare organizations to improve processes and quality are failure mode and effects analysis (FMEA) and root cause analysis (RCA). FMEA is a structured process that helps leaders and managers map out processes prior to implementation of new procedures. If leaders can pinpoint a possible entry for errors or risk in quality care, the process can be fixed prior to implementation; this is ideal. RCA, on the other hand, is a process that is put into place after errors or undesired outcomes occur. The intention of RCA is to dig deep into the cause of the error and then develop plans to prevent future errors. Then, data will be collected, analyzed, and monitored to assure plans result in desired outcomes.

PDSA Model

Total Quality Management (TQM) procedures are in place in healthcare organizations and are followed to ensure that quality care is being provided. TQM includes not only quality for patients but also quality for employees, physicians, visitors, and any other customer of the organization. Below you will find a Plan, Do, Study, Act (PDSA) chart describing a particular type of model used by some TQM managers.

Review the tabs to know more about the PSDA model.

There are many organizations from which best practices can be obtained and guidelines to prevent errors can be followed. The Agency for Healthcare Research and Quality (AHRQ), the Leapfrog Group, the Centers for Medicare & Medicaid Services (CMS), the Joint Commission (TJC), the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the National Patient Safety Foundation (NPSF), and many other service-specific, reputable groups are organized to make healthcare safer for populations.)

Discussion Questions:
Before beginning work on this discussion forum, please review the link “Doing Discussion Questions Right” and any specific instructions for this topic.

Before the end of the week, begin commenting on at least two of your classmates’ responses. You can ask technical questions or respond generally to the overall experience. Be objective, clear, and concise. Always use constructive language, even in criticism, to work toward the goal of positive progress. Submit your responses in the Discussion Area.

As we have learned this week from our lectures and required textbook reading, leaders and managers in healthcare must work diligently and continuously to assess the health and needs of the populations they serve. Total quality management (TQM) is a process that is used to analyze the available relevant data, plan for improvements where necessary, implement plans, and monitor the plans for effectiveness through formal processes adopted.

After thorough research of credible sources from the South University Library and the Internet, please answer the following questions:

Why do the Centers for Medicare & Medicaid Services (CMS) believe that prevention of inpatient admissions will improve the quality of care in populations served by hospitals?
What specific age group and diagnoses does the CMS monitor for readmissions?
Does research tell us that so far prevention of readmissions has improved the quality of care for patients?
How has hospital reimbursement been affected by the readmission standard mandated by the CMS?
What recommendations (best practices) to decrease hospital readmissions have been suggested by experts in the healthcare field?


Sample Answer

Sample Answer

Performance Improvement for Quality Care in Healthcare


Leaders and managers in healthcare play a crucial role in ensuring the delivery of high-quality care to the population they serve. A key aspect of this is performance improvement (PI), where data is collected, analyzed, and utilized to enhance operations and service quality. In the healthcare sector, establishing quality indicators, conducting assessments, and implementing monitoring processes are vital steps in the PI journey.

Thesis Statement

Performance improvement processes, surveillance tools, benchmarking, and total quality management are essential components that healthcare leaders and managers must utilize to drive continuous enhancements in care quality and operational efficiency.

Performance Improvement Processes

Performance improvement in healthcare involves setting up quality indicators that guide assessment and monitoring efforts. By collecting data through surveillance tools such as surveys and checklists, managers can identify areas for improvement. Benchmarking against peers and national data allows organizations to gauge their performance levels accurately.

Surveillance Tools and Data Analysis

Surveillance tools like charts and graphs aid in analyzing data collected, enabling leaders to establish thresholds for quality indicators. Continuous monitoring ensures that action plans are promptly implemented to address any deviations from set benchmarks.

Total Quality Management (TQM) Approach

Total Quality Management (TQM) focuses on process improvement rather than individual accountability. Through tools like fishbone diagrams, flow charts, failure mode and effects analysis (FMEA), and root cause analysis (RCA), healthcare organizations can identify process failures, prevent errors, and enhance service quality.

Discussion Questions

1. Centers for Medicare & Medicaid Services (CMS) Perspective: CMS believes that preventing inpatient admissions enhances care quality by reducing unnecessary healthcare utilization and improving patient outcomes.

2. Specific Monitoring by CMS: CMS monitors specific age groups and diagnoses for readmissions to track trends and ensure targeted interventions for high-risk populations.

3. Impact on Quality of Care: Research indicates that prevention of readmissions has led to improved care quality by minimizing complications, enhancing care coordination, and optimizing patient outcomes.

4. Hospital Reimbursement: CMS’s readmission standard has influenced hospital reimbursement by incentivizing care providers to focus on delivering effective treatment and reducing avoidable readmissions.

5. Recommendations to Decrease Readmissions: Experts recommend strategies such as care coordination, patient education, transitional care programs, and follow-up support to reduce hospital readmissions effectively.


In conclusion, the integration of performance improvement processes, surveillance tools, TQM principles, and adherence to CMS guidelines are essential for healthcare leaders and managers to elevate care quality, optimize patient outcomes, and drive operational excellence in healthcare organizations. By embracing best practices and continuous improvement initiatives, healthcare providers can ensure sustainable delivery of high-quality care to the populations they serve.

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