| Section |
Action Steps |
Tool That Supports
Action |
Audiences |
Lead Role |
Section A |
Determining
Readiness To Change |
A.1. |
Getting To Know the PSIs/IQIs. |
Tool A.1a. Fact Sheet on Inpatient Quality
Indicators (IQI)
(PDF File, 225 KB [Plugin Software Help]; Word® File, 30 KB [Plugin Software Help])
Tool A.1b. Fact Sheet on Patient Safety
Indicators (PSI)
(PDF File, 270 KB [Plugin Software Help]; Word® File, 35 KB [Plugin Software Help]) |
All Hospital Board and Staff Members |
Senior Staff and Quality Leaders |
A.2. |
Help Board members and relevant staff
understand the importance and financial and clinical implications of the AHRQ
Quality Indicators. (The "notes" view in PowerPoint® has additional
instructions for using this tool.) |
Tool A.2. Board/Staff PowerPoint® Presentations
on the Quality Indicators
(PDF File, 1.2 MB [Plugin Software Help]; PowerPoint® File, 270 KB [ (Plugin Software Help).]; Word® File, 130 KB [Plugin Software Help]) |
Board Members, Senior Management Staff,
Quality Staff |
Quality Leaders |
A.3. |
Assess your hospital's organizational
infrastructure and its readiness to support effective implementation efforts. |
Tool A.3. Getting Ready for Change
Self-Assessment
(PDF File, 340 KB [Plugin Software Help]; Word® File, 55 KB [Plugin Software Help]) |
Senior Management Staff and Quality Leaders |
Senior Staff and Quality Leaders |
Section B |
Applying
QIs to the Hospital Data |
B.1. |
Perform the QI calculations using the AHRQ
4.1 software. |
Tool B.1. Applying the AHRQ Quality Indicators
to Hospital Data
(PDF File, 500 KB [Plugin Software Help]; Word® File, 75 KB [Plugin Software Help]) |
Quality and Safety Leaders, Data Analysts,
Statisticians, and Programmers |
Quality Leaders, Data Analysts |
B.2. |
Review this example of the output from the
AHRQ QI 4.1 software. |
Tool B.2a. IQI and PSI Rates Generated by
the AHRQ SAS Programs
(PDF File, 835 KB [Plugin Software Help]; Word® File, 75 KB [Plugin Software Help])
Tool B.2b. IQI and PSI Rates Generated by
the AHRQ Windows QI Software
(PDF File, 410 KB [Plugin Software Help]; Word® File, 55 KB [Plugin Software Help]) |
Data Analysts or Programmers calculating
rates; Quality Leaders |
Data Analysts, with Quality Leaders |
B.3. |
Use this PowerPoint® to understand and
review the AHRQ QI data, trends, and rates. |
Tool B.3a. Excel® Worksheets for Charts on Data, Trends, and Rates To Populate the PowerPoint® Presentation
(PDF File, 180 KB [Plugin Software Help]; Excel® File, 90 KB [Plugin Software Help])
Tool B.3a. Instructions
(PDF File, 110 KB [Plugin Software Help]; Word® File, 20 KB [Plugin Software Help])
Tool B.3b. PowerPoint® Presentation: The AHRQ
Quality Indicators, Results, and Discussion of Data Analysis
(PDF File, 380 KB [Plugin Software Help]; PowerPoint® File, 300 KB [ (Plugin Software Help).]; Word® File, 50 KB [Plugin Software Help]) |
Quality Leaders, Senior Leaders, Analysts |
Quality Leaders |
B.4 |
Understand documentation and coding issues
that affect PSI and IQI rates. |
Tool B.4. Documentation and Coding for
Patient Safety Indicators
(PDF File, 675 KB [Plugin Software Help]; Word® File, 80 KB [Plugin Software Help]) |
Providers, Clinical Documentation
Specialists, Coders, Quality Leaders |
Quality Leaders |
B.5 |
Analyze the hospital's performance on the QIs
by assessing trends in rates and using benchmark comparisons. |
Tool B.5 Assessing Indicator Rates Using
Trends and Benchmarks
(PDF File, 245 KB [Plugin Software Help]; Word® File, 35 KB [Plugin Software Help]) |
Quality and Safety Staff, Senior Leaders,
Hospital Board, Analysts |
Quality Leaders |
Section C |
Identifying
Priorities for Quality Improvement |
C.1. |
Determine direction of organizational focus
and decisions about which QIs should be addressed. |
Tool C.1. Prioritization Matrix
(PDF File, 840 KB [Plugin Software Help] ; Excel® File, 25 KB [Plugin Software Help])
Tool C.1. Instructions
(PDF File, 100 KB [Plugin Software Help]; Word® File, 25W KB [Plugin Software Help])
|
Senior Leaders and Quality Staff |
Senior Leaders and Quality Staff |
C.2. |
Review this example of a completed
prioritization matrix. |
Tool C.2. Prioritization Matrix Example
(PDF File, 525 KB [Plugin Software Help]; Excel® File, 200 KB [Plugin Software Help]) |
Senior Leaders and Quality Staff |
Senior Leaders and Quality Staff |
Section D |
Implementing
Improvements |
D.1. |
Evaluate current systems in place,
modifications to existing protocols and electronic order sets, and
development of new systems and processes of care. |
Tool D.1. Improvement Methods Overview
(PDF File, 200 KB [Plugin Software Help]; Word® File, 30 KB [Plugin Software Help]) |
Multidisciplinary improvement team |
Quality Leaders |
D.2. |
Define the implementation team and its
goals. |
Tool D.2. Project Charter
(PDF File, 210 KB [Plugin Software Help]; Word® File, 35 KB [Plugin Software Help]) |
Multidisciplinary improvement team |
Quality Leaders |
D.3. |
Understand actions taken by other hospitals
to help improve performance on the QIs. |
Tool D.3. Examples of Effective PSI
Improvement Strategies
(PDF File, 155 KB [Plugin Software Help]; Word® File, 40 KB [Plugin Software Help]) |
Multidisciplinary improvement team |
Quality Leaders |
D.4. |
Identify existing best practices that may
help in assessing options for action. |
Tool D.4. Selected Best Practices and
Suggestions for Improvements (for 8 PSIs):
- PSI 7: Central Venous Catheter (CVC)-Related Bloodstream Infections (BSIs)
(PDF File, 480 KB [Plugin Software Help]; Word® File, 70 KB [Plugin Software Help]).
- PSI 12: Postoperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT)
(PDF File, 510 KB [Plugin Software Help]; Word® File, 65 KB [Plugin Software Help]).
- PSI 3: Pressure Ulcer
(PDF File, 600 KB [Plugin Software Help]; Word® File, 70 KB [Plugin Software Help]).
- PSI 5: Foreign Body Left in During Procedure
(PDF File, 600 KB [Plugin Software Help]; Word® File, 65 KB [Plugin Software Help]).
- PSI 6: Iatrogenic Pneumothorax
(PDF File, 560 KB [Plugin Software Help]; Word® File, 65 KB [Plugin Software Help]).
- PSI 8: Postoperative Hip Fracture
(PDF File, 575 KB [Plugin Software Help]; Word® File, 60 KB [Plugin Software Help]).
- PSI 9: Postoperative Hemorrhage or Hematoma
(PDF File, 450 KB [Plugin Software Help]; Word® File, 60 KB [Plugin Software Help]).
- PSI 10: Postoperative Physiologic and Metabolic Derangement
(PDF File, 450 KB [Plugin Software Help]; Word® File, 60 KB [Plugin Software Help])
|
Multidisciplinary improvement team |
Quality Leaders |
D.5. |
Understand the extent to which current
practices align with best practices. |
Tool D.5. Gap Analysis
(PDF File, 140 KB [Plugin Software Help]; Word® File, X KB [Plugin Software Help]) |
Multidisciplinary improvement team |
Quality Leaders |
D.6. |
Assign team responsibilities and set
timeline. |
Tool D.6. Implementation Plan
(PDF File, 170 KB [Plugin Software Help]; Word® File, 40 KB [Plugin Software Help]) |
Multidisciplinary improvement team |
Quality Leaders |
D.7. |
Measure progress in improving work and clinical
care processes. |
Tool D.7. Implementation Measurement
(PDF File, 195 KB [Plugin Software Help]; Word® File, 50 KB [Plugin Software Help]) |
Multidisciplinary improvement team |
Quality Leaders |
D.8. |
Understand what worked in the
implementation process and what needs improvement. |
Tool D.8. Project Evaluation and
Debriefing
(PDF File, 225 KB [Plugin Software Help]; Word® File, 35 KB [Plugin Software Help]) |
Multidisciplinary improvement team |
Quality Leaders |
Section E |
Monitoring
Progress for Sustainable Improvement |
E.1. |
Conduct an ongoing, standardized process
for reporting trends in the measures developed and acting upon issues
identified by those trends. |
Tool E.1. Monitoring Progress for
Sustainable Improvement
(PDF File, 200 KB [Plugin Software Help]; Word® File, 40 KB [Plugin Software Help]) |
Quality Staff |
Quality Leaders |
Section F |
Analyze
Return on Investment |
F.1. |
Estimate the return on investment from the
interventions implemented to improve performance on the QIs. |
Tool F.1. Return on Investment Estimation
(PDF File, 650 KB [Plugin Software Help]; Word® File, 120 KB [Plugin Software Help]) |
Senior Leaders, including the Chief
Financial Officer |
|
Section G |
Using
Other Resources |
G.1. |
Obtain further guidance for
conducting effective quality improvements. |
Tool G.1. Available
Comprehensive Quality Improvement Guides
(PDF File, 140 KB [Plugin Software Help]; Word® File, 30 KB [Plugin Software Help]) |
Quality Staff and Improvement Team |
Quality Leaders |
G.2. |
Identify specific analytic or action
tools to use in improvement processes. |
Tool G.2. Specific Tools To Support Change
(PDF File, 710 KB [Plugin Software Help]; Word® File, 60 KB [Plugin Software Help]) |
Quality Staff and Improvement Team |
Quality Leaders |
G.3. |
Review this case study for an example of
how one hospital used the toolkit. |
Tool G.3. Case Study of PSI Improvement
Implementation
(PDF File, 300 KB [Plugin Software Help]; Word® File, 30 KB [Plugin Software Help]) |
Senior Leaders, Quality Staff, Improvement Team |
Quality Leaders |
540 Gaither Road Rockville, MD 20850 