How to Write a Hospital Performance Improvement Plan

Hospital staff work together to achieve quality improvement.

Most hospitals maintain a quality department that oversees general hospital operational and clinical performance. Quality managers complete audits of the hospital and create performance improvement plans in collaboration with department leadership and members of quality committees. As a result, this facilitates a continuous process of reviews and action plans that ultimately show the hospital can meet stringent accreditation standards. Documenting these audits and plans is essential to showing measurable improvement.

Instructions

1. Review the standards from accrediting bodies such as the Joint Commission and URAC. This information is available for purchase from each organization. These organizations set the bar for health care operations. Review the quality goals of your hospital and the purpose of creating a performance improvement plan.

2. Complete audits of your hospital against accrediting body standards and state and federal regulations. Ask department leadership their opinions on performance and needed improvements. Additionally, review results of your hospital's clinical indicators to determine hospital performance and identify where performance improvement is needed.

3. Document the findings of your audits and share with a quality committee to determine areas that need improvement. Create action plans and interventions for each deficient area and share them with the management of those areas. Prioritize the areas of improvement by what's most lacking, what effects quality of care or delivery of patient services and what is causing the most strife within the hospital.

4. Create a document for your performance improvement plan. You may want to use Excel to create a grid for this documentation. List the deficient areas and categorize tasks under each area with the responsible party and due date for each. For example, under policies and procedures, update the complaint policy to include formal tracking mechanism and allocate this to a person with a due date.

5. Assign this project to a Quality Manager to oversee. Although many individuals throughout the hospital will assist in enhancing the hospital's performance to improve the deficient areas as outlined on the performance plan, you want to have one person responsible for the overall project who can monitor the individuals' tasks.

6. Create a formal report that includes an executive summary, goals of the performance improvement plan, summary of initial findings, action plans, interventions and outcomes of the associated tasks with the action plans.

References

• New York State Office of Mental Health: Quality Improvement Plan Template
• The American Health Quality Association: Study Documents Progress in QIO Hospital Work
• The Healthcare Management Council, Inc: Hospital Performance Improvement FAQ
• The Joint Commission: Interested in Hospital Accreditation?
• URAC: General Questions About URAC Accreditation

Resources

• The Joint Commission
• The American Health Quality Association