Quality Improvement Plan: John H. Stroger, Jr. Hospital of Cook County
[Institution Title]
Abstract
This paper present a Quality Improvement Plan for John H. Stroger, Jr. Hospital of Cook County. Specifically, the focus of the QI plan relates to advocating injury prevention programs as well rendering superior quality patient care, the quality improvement plan shall concentrate on this aspect of health care. The said plan is directed towards the patient service, My Cook County Health, and clinical service pertaining to the Psychiatry Department. The two areas were selected because of the direct correlation of the following departments and areas of concern to injury prevention programs and superior quality patient care emanated by securing the privacy and integrity of patient’s electronic medical record. The QI plan implored the use of flowcharting and cause analysis as data collection tools. These tools ability to gather all the pertinent details of the issues presented under the areas it was used was a major reason they were introduced. The proposed quality improvement plan will be evaluated by the feedback generated and collated from patients as well as the number of incidents and cases forwarded.
Keywords: Quality Improvement Plan, John H. Stroger, Jr. Hospital of Cook County flowcharting, root cause analysis
Introduction
Formerly cook County Hospital, the John H. Stroger, Jr. Hospital of Cook County service a total of 5 million residents of Cook County. The hospital can provide primary, specialty and tertiary services among the residents of the county. The organization envisions itself as being a leader in providing quality health care services. Specific to its mission statement is to embrace a system that would create a high-performing Supply Chain Management Procurement function by strategically sourcing quality goods and services across all major spend categories, effectively managing supplier relationships and realizing contracted performance and cost savings throughout the health system (John H. Stroger, Jr. Hospital of Cook County, 2014). Cook County Hospital eleven (11) distinct type of medical services namely: (a) anesthesiology and pain management, (b) burn and trauma unit, (c) emergency medicine, (d) family and community medicine, (e) language, speech and hearing, occupational and physical therapy, (f) medicine, obstetrics and gynecology, (g) pathology, (h) pediatrics, (i) Psychiatry, (j) surgery, (k) radiology and imaging (John H. Stroger, Jr. Hospital of Cook County, 2014). On the other hand, there are also nine (9) patient services offered by Cook County Hospital. Among these includes: (a) My Cook County Health, (b) pharmacy, (c) blood bank, (d) physicians, (e) access to services, (f) patient’s rights and responsibilities, (g) medical records, and (h) financial assistance and billing . In lieu with all these information, this paper aims to create an organization quality improvement plan for John H. Stroger, Jr. Hospital of Cook County particularly relating to the concepts of safety and patient-centeredness.
As specified under the goals and objectives of Cook County Health and Hospital System, it is the organization’s desire to render the highest quality of care for the resident of the Cook County community. This is accomplished by advocating injury prevention programs as well rendering superior quality patient care. The goal of the entire medical team and the health care delivery system at Cook County are to facilitate for their patient’s restore productivity continuously to dominate the medical education, trauma, emergency service and research. This goal is shaped by organization’s earnest and passionate desire to render the appropriate medical service needed by the community that only a dedicated team can provide.
Scope, Description and Quality Improvement Activities
Since the goal of the organization is centered on advocating injury prevention programs as well as rendering superior quality patient care, the quality improvement plan shall concentrate on this aspect of health care. Two services that will be the focal point of the improvement plan relates patient services referring to My Cook County Health and clinical service pertaining to the Psychiatry Department. The psychiatry department is incorporated into the quality improvement plan because it is one department constantly identified as a high-risk area where patient abuse and patient injury are frequently associated (Krüger, 2010). On the other hand, My Cook County Health has been selected because of its capacity to secure the online medical records bearing patients’ medical records. Both areas had been selected because of its clear connection to patient’s safety and wellness. The Psychiatry department refers to the physical safety and the wellness aspect mentioned in the quality improvement plan, while the My Cook County Health is particularly referring to safety of patient’s medical records from possible access thereby invading their security and privacy (Bleich & Slack, 2010).
Data Collection Tools
There are two specific tools proposed to be utilized for this particular quality improvement plan. The first tool is the Quality of Care Indicator Condition under the guise of Quality Care pertaining to processing specified as a Role Evaluation Tool. This particular tool is very useful in the review of the Psychiatry Department. This warrants the evaluation of all the factors that could significantly affect the optimal health care service provided to patients. Particularly this makes use of the cause analysis tool. This tool would take into consideration the issues encountered within the psychiatry department which has significantly affected the quality of care provided to psychiatric patients. It will also trace the origin of the problem taking note of the condition, the participants the causes and the effects of actions encountered during the health care delivery process. Similarly, this would help prevent any incidents of abuse from further occurring. If the risk of injury has significantly been caused by environment factors like railings, abilities, and other tangible objects then this risk should be replaced to prevent it from causing further harm.
On the other hand, in relation to privacy the best presented tool for this activity relates to the use of flow charts. Flowcharting implores the use of the diagram where graphic symbols are introduced to represent the nature and movement of the phases in the process. This tool is mainly convenient in the early stages of a plan to assist the team comprehend and appreciate how the process currently works. The “as-is” flow chart could be associated to how the progression is envisioned and planned to work. Towards the completion of the project, the team may necessarily be required to then re-plot the altered process to demonstration how the modified process should happen or transpire. The advantages of employing the use of a flow chart are that it: (1) it promotes understanding, (2) it is a potential tool for training employees, and (3) clear identification and presentation of the problem areas. While the My Cook County Health is no longer in its pilot stage, there are areas that might necessarily be modified. For example, it is usually accessible even using unsecured portals that might compromise the security protocols of the electronic medical records.
QI Processes and Methodology
Since the objective of a quality improvement plan is to advocate injury prevention programs as well as rendering superior quality patient care, the plan is to accomplish this through three effective programs and activities. These would include (a) employee empowerment, (b) leadership involvement and (c) data informed practices.
- Employee Empowerment would involve subjecting all employees particularly those working under the Psychiatry Department and the My Cook County Health section to a refresher training that would center on the protocols of preventing the risk of fall, abuse and maltreatment on patients under the Psychiatric Department. At the same time, educating every personnel on rendering the appropriate technique on the transfer, storage and processing of electronic medical records to avoid risks associated with privacy and confidentiality.
- Leadership Involvement would require strong leadership, a directed vision and support for activities under the quality improvement program. By getting the leaders to be involved in the activities specified under the plan, it will ensure that all activities and programs are under the guise of the organization’s strategic plan and mission.
- Data informed practices are sourced from the key stakeholders of the hospital. This would necessarily have to include patients and their support group to be involved and give the necessary feedbacks about the services they received from the hospital and the staff. This is also an avenue by which the quality improvement team can strictly monitor the progress of the QI plan.
Comparative Databases, Benchmarks, and Professional Practice Standards
Monitor and track the progress of the quality improvement plan, performance measurements shall be utilized. This would ensure the periodic assessment of results as produced by the program. This would necessarily involve identifying the process, system as well as the outcomes that are necessary to the processing of the service delivery system. It is endorsed to be conducted periodically to monitor and document the areas of concern and establish the consistency of the results and methods as indicated by their performance. The performance measurement is aimed at assessing the stability of process and outcomes as desirable or otherwise. It will also identify the problems as well as the opportunities of the adapted practices. This would have to be in accordant to the National Institute of Mental Health being the professional organization that lays the standards for all Psychiatric facilities in the United States.
Authority/Structure/Organization
There are two authorities responsible for plan implementation. These authorities include Quality Improvement Committee and the John H. Stroger, Jr. Hospital of Cook County Board of Directors. They will be tasked at monitoring and ensuring that the QI plan is implemented.
- Quality Improvement Committee
The Committee shall be spearheaded by a Chairperson who is responsible for the developing and approving the activities and programs drafted for inclusion to the quality improvement plan. In addition, it will also require the Committee to create measurable objectives according to the priorities of John H. Stroger, Jr. Hospital of Cook County.
- John H. Stroger, Jr. Hospital of Cook County Board of Directors
The Board of Director of the John H. Stroger, Jr. Hospital of Cook County will provide the necessary leadership for the Quality Improvement process. This group will support and guide the implementation of the activities and programs specified under the submitted and approved Quality Improvement Plan.
Communication
The Committee will convene every month to monitor and track the progress of the Quality Improvement Plan. Minutes will be created taking into account the attendees, the topics, the progress and the amendments that were proposed during the meeting. This will be formalized to a memo which will be submitted to every member of the Board of Directors and posted in every bulletin board in every department and offices of the John H. Stroger, Jr. Hospital of Cook County.
Education
The staff working in the two specified department and section shall be called for an intensive training which will highly the re-institutionalization of the standards and protocol for their respective department. It will also highlight the inclusive duties and responsibilities of the nurses and aides that are assigned in these particular areas. The training shall be composing of lecture, discussion, hands-on activities, case study analysis and evaluation and assessment. The activities were selected because it will help enhance and support the staff’s existing knowledge on what is needed in their respective positions.
Annual Evaluation
An annual evaluation is conducted to assess the aspect of the Quality Improvement Plan that requires amendment or elimination. This would include sections referring the objectives that had been successfully accomplished. This is to give way to new areas of concern that needs attention and prioritization. Amendments would also be necessary for aspects referring to process and methodologies as well as activities that has been proven ineffective. These will necessarily have to be replaced with new provisions more appropriate as agreed during one of the meetings.
References
Bleich, H. L., & Slack, W. V. (2010). Reflections on electronic medical records: When doctors will use them and when they will not. International Journal of Medical Informatics, 1-4.
John H. Stroger, Jr. Hospital of Cook County. (2014, November 24). About Us: John H. Stroger, Jr. Hospital of Cook County. Retrieved from John H. Stroger, Jr. Hospital of Cook County Website: http://www.cookcountyhhs.org/about-cchhs/doing-business-with-cchhs/
John H. Stroger, Jr. Hospital of Cook County. (2014, November 24). Cook County Health & Hospitals System Clinical Services. Retrieved from John H. Stroger, Jr. Hospital of Cook County Website: http://www.cookcountyhhs.org/medical-clinicalservices/
John H. Stroger, Jr. Hospital of Cook County. (2014, November 24). Patient Services. Retrieved from John H. Stroger, Jr. Hospital of Cook County Website: http://www.cookcountyhhs.org/patient-services/
Krüger, C. (2010). Risk factors for violence among long-term psychiatric in-patients: a comparison between violent and non-violent patients. African Journal of Psychiatry, 366-375.
