PERFORMANCE
IMPROVEMENT
Performance Improvement (PI)
• Guided by the Mission, Vision, and Goals of the
Organization
• Responsibility of Everyone
• Data collection provides the foundation of
Performance Improvement
• Analysis of data identifies opportunities for
improvement
• Actions create change for improvement
• Review and Re-measure to sustain improvements
Goals of Performance Improvement
• Improve processes
• Improve teamwork
• Improve systems
• Improve outcomes
Benefits of Performance Improvement
• Patients and families
• You and your co-workers
• UTMC
• Community
Performance Improvement Model
ü Determine an action that will
ü Collect measurement data
impact the trend in the desired
ü Display data over time on a “run
direction
chart”
ü Plan for actions to be executed
ü Comparative data displayed
appropriately
simultaneously
ü Communicate, initiate
ü Conduct quantitative analysis
v
How much – which direction?
v
How does this compare to
benchmark?
v
Is the process in control or is
variation excessive?
ü Conduct qualitative analysis
v
Why is this happening?
v
What are contributing factors?
v
What does this mean?
M
e
as
ure
3/8/2006 tm
Analyze
Act
ü Define opportunities
ü Determine what is to be
accomplished
ü Identify performance indicators,
how they will be obtained, how
frequently they will be measured,
what comparison values will be
used
ü Identify responsible parties
n
la
ü Did actions produce desired
results?
ü Why or why not?
ü Are additional actions
necessary?
ü Is the “right” thing being
measured?
ü What has been learned?
ü Continue the cycle; modify
based on findings
P
R
ev
ie
w
PMAAR
Performance Improvement Cycle
Examples of PI Initiatives
• Increase compliance with Core Measures
• Improve flow of patients in organization
• Improve patient safety by reducing patient falls
• Monitor Infection Control measures to decrease
infections
• Improve access to care for ambulatory patients
• Increase patient satisfaction and patient
experience
Example of Graphical Data Display
Example Graph
400
300
200
Change
Implemented
100
0
Jan
Feb
M ar
Apr
M ay
Jun
The Joint Commission
• The nation’s predominant standards-setting
and accrediting body in health care
• Is recognized nationwide as a symbol of
quality that reflects an organization’s
commitment to meeting certain
performance standards
• To earn and maintain The Gold Seal of
Approval™, an organization must undergo
an on-site survey at least every three years
Quality Management
• Provides resources to individuals and
groups to identify, implement and evaluate
quality and performance initiatives
• Includes Performance Improvement
Coordinators, Data Coordinators, and
Data Techs
• Provides education about quality and
performance improvement