The final project for this course is the creation of a quality plan—also known as a performance improvement plan—for a healthcare organization. You may develop this plan for an acute-care facility, a same-day surgery facility, an ambulatory care organization, a clinic setting, a long-term care facility, or some other type of healthcare organization you may be familiar with given your own professional healthcare work experience. In addressing the critical elements for this assignment, all APA formatting and citation requirements apply. Further, as this is a scholarly initiative, you must use peer-reviewed or evidence-based sources for this assignment. Data may be derived from public healthcare databases, or you may use data from your own healthcare organization. The final product represents an authentic demonstration of competency because quality plans are used as tools by healthcare facilities to provide frameworks for collaboratively planned, systematic, and organization-wide approaches to improvement. These quality plans are always kept on-site, updated yearly, and reviewed by surveyors and accreditors.

The following critical elements must be addressed: 

I. Purpose and Quality Statement: In this section, you will define patient safety and the purpose of a quality plan.
A. Explain the purpose of implementing a quality plan. In your explanation, consider how accreditation standards drive an organization’s patient safety and quality initiatives. 

B. Determine the healthcare organization’s commitment to patient safety and quality. Consider the mission statement and policies of the organization to guide your answer. 

C. Describe the various stakeholder groups that have a vested interest in the performance-improvement process (e.g., nursing leadership, departmental directors). Consider utilizing an organizational chart to depict these stakeholders. 

D. Develop a quality statement that outlines the objectives of the quality plan. 

 II.  Status of Quality Tools and Standards: In this section, you will review the status of the information management system and accreditation. 

 1.  Describe the current status of accreditation based on recent accreditation survey reports. 

 2.  Analyze the current information management systems and patient care technologies for their ability to collect data used to report quality measures and accreditation requirements. Are these systems and technologies adhering to the appropriate policies and regulations to meet the needs for accreditation and compliance? 

 3.  Explain the impact of meaningful-use implementation at the organization as it pertains to patient safety and quality. 

 III.  Measures and Benchmarks: In this section, you will identify and evaluate the metrics that can be used to measure quality and patient safety at your organization. 

 1.  Outline how current performance-improvement data and initiatives are tracked through the organization, starting at the department level. Consider using a visual aid to depict this through specific types of data. 

 2.  Compare how the organization is doing in key safety measures using appropriate benchmark data. 

 3.  Analyze the metrics to determine if the healthcare organization demonstrates compliance for accreditation standards. 

 4.  Explain how reimbursement data is used to identify patient safety and quality issues. Consider the role of core measures in your response. 

 5.  Explain the impact of reimbursement data on the accreditation status. 

 6.  Describe the impact of reimbursement policies on patient safety and quality initiatives. 

 7.  Discuss how leadership is involved in the dissemination and application of quality data at this healthcare organization. 

 IV.  Process Improvements: In this section, you will develop specific actions to address your analysis of key patient safety and quality metrics. 

 1.  Summarize recommendations based on the analysis of the current organization. 

 2.  Develop goals based on the evaluation of the current organization quality measurements and improvement needs. 

 3.  Recommend new technology that could improve one of the patient safety or quality concerns identified in Sections II and III. Explain your recommendation. 

 4.  Describe leadership strategies that are needed to ensure stakeholder and community input into the quality program. 

 5.  Recommend a policy change to solve the patient safety and quality issues identified. Consider what stakeholders you would need to collaborate with to execute the policy changes. 

 V.  Evaluation and Reporting: In the last section, you will develop a timeline and make recommendations for evaluating and reporting key measures of success to stakeholders and accrediting bodies. 

A.  Create an evaluation plan using principles from Plan-Do-Study-Act (PDSA). Include a project timeline in your plan. 

B.  Justify a timeline for evaluation of performance-improvement activities. Consider using a visual aid. 

C.  Explain how to measure the successful implementation of the new technology suggested in the Process Improvements section. 

D.  Describe the changes to the processes for managing data within the organization for accreditation reporting. 

Guidelines for Submission: Your quality plan should be 10 to 12 pages in length (plus a cover page and references) and written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margins. Include at least five references cited in APA format.