Regulatory requirements and accreditation standards

IHP 604 Final Project Guidelines and Rubric

 

Overview

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 project is divided into two milestone journals, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Four and Seven. In these journal assignments, you will reflect on the progress you have made on your project thus far and ask any clarifying questions that will assist you as you progress on your project. These assignments will also provide you with the opportunity to submit drafts of your project so that you can receive feedback on them from your instructor. In addition, there are several short papers that you will complete throughout the course which will help you to understand course concepts, as well as activities that will allow you to practice working with data. All of these concepts should be incorporated into the final project. The final product will be submitted in Module Nine.

 

In this assignment, you will demonstrate your mastery of the following course outcomes:

 

• Determine the impact of regulatory requirements and accreditation standards on quality planning for improving patient care
• Assess information management systems and patient-care technologies for their ability to promote care coordination and improve patient safety
• Recommend performance-improvement initiatives using quality program requirements and quality data metrics
• Analyze healthcare reimbursement policies for the impact on patient safety and quality initiatives
• Recommend leadership strategies that promote interdisciplinary collaborative care within healthcare organizations in the healthcare ecosystem

 

Prompt

Specifically, the following critical elements must be addressed:

 

1. Purpose and Quality Statement: In this section, you will define patient safety and the purpose of a quality plan.
   1. Explain the purpose of implementing a quality plan. In your explanation, consider how accreditation standards drive an organization’s patient safety and quality initiatives.
   2. Determine the healthcare organization’s commitment to patient safety and quality. Consider the mission statement and policies of the organization to guide your answer.
   3. 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.  Develop a quality statement that outlines the objectives of the quality plan.  

 

1. Status of Quality Tools and Standards: In this section, you will review the status of the information management system and accreditation. A. Describe the current status of accreditation based on recent accreditation survey reports.
   1. 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?
   2. Explain the impact of meaningful-use implementation at the organization as it pertains to patient safety and quality.

 

• 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.

1. Compare how the organization is doing in key safety measures using appropriate benchmark data.
2. Analyze the metrics to determine if the healthcare organization demonstrates compliance for accreditation standards.
3. Explain how reimbursement data is used to identify patient safety and quality issues. Consider the role of core measures in your response.
4. Explain the impact of reimbursement data on the accreditation status.
5. Describe the impact of reimbursement policies on patient safety and quality initiatives.
6. Discuss how leadership is involved in the dissemination and application of quality data at this healthcare organization.

 

1. Process Improvements: In this section, you will develop specific actions to address your analysis of key patient safety and quality metrics. A. Summarize recommendations based on the analysis of the current organization.
   1. Develop goals based on the evaluation of the current organization quality measurements and improvement needs.
   2. Recommend new technology that could improve one of the patient safety or quality concerns identified in Sections II and III. Explain your recommendation.
   3. Describe leadership strategies that are needed to ensure stakeholder and community input into the quality program.
   4. 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.

 

1. 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.
   1. Create an evaluation plan using principles from Plan-Do-Study-Act (PDSA). Include a project timeline in your plan.
   2. Justify a timeline for evaluation of performance-improvement activities. Consider using a visual aid.
   3. Explain how to measure the successful implementation of the new technology suggested in the Process Improvements section.
   4. Describe the changes to the processes for managing data within the organization for accreditation

 

Milestones

Milestone One: Check-in Journal

In Module Four, you will submit a check-in journal assignment. The journal assignment should include a reflection of the status of your final project. You also have the opportunity to submit a draft of the Purpose and Quality Statement and Status of Quality Tools and Standards sections of your final project to your instructor for review and feedback. This milestone will be graded with the Milestone One Rubric.  

 

Milestone Two: Check-in Journal

In Module Seven, you will submit a check-in journal assignment. The journal assignment should include a reflection of the status of your final project. You also have the opportunity to submit a draft of the Measures and Benchmarks, Process Improvements, and Evaluation and Reporting sections of your final project to your instructor for review and feedback. This milestone will be graded with the Milestone Two Rubric.

 

Final Submission: Quality Plan

In Module Nine, you will submit your final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the course. This submission will be graded with the Final Project Rubric.

 

Final Project Rubric

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.

 

Critical Elements	Exemplary (100%)	Proficient (85%)	Needs Improvement (55%)	Not Evident (0%)	Value
Purpose and Quality Statement: Purpose	Meets “Proficient”  criteria and explanation demonstrates an advanced understanding of the purpose of implementing a quality plan and the role of accreditation	Explains the purpose of implementing a quality plan using accreditation standards to support the response	Explains the purpose of implementing a quality plan but explanation is unclear or does not address accreditation standards in the response	Does not explain the purpose of implementing a quality plan	6.4
Purpose and Quality Statement: Commitment	Meets “Proficient”  criteria and includes exceptional detail to support determination	Determines the healthcare organization’s commitment to patient safety and quality	Determines the healthcare organization’s commitment to patient safety and quality but contains gaps in detail or is unclear	Does not determine the healthcare organization’s commitment to patient safety and quality	6.4

 

Critical Elements	Exemplary (100%)	Proficient (85%)	Needs Improvement (55%)	Not Evident (0%)	Value
Purpose and Quality Statement: Stakeholder Groups	Meets “Proficient”  criteria and illustrates a sophisticated understanding of the various stakeholder roles impacted by the process	Describes the various stakeholder groups that have a vested interest in the performance-improvement process	Describes the various stakeholder groups that have a vested interest in the performance-improvement process, but response is cursory or is missing key stakeholders	Does not describe the various stakeholder groups that have a vested interest in the performance-improvement process	4.8
Purpose and Quality Statement: Quality Statement	Meets “Proficient”  criteria and demonstrates a sophisticated understanding of the objectives needed to implement a quality plan	Develops a quality statement that outlines the objectives of the quality plan	Develops a quality statement that outlines the objectives of the quality plan, but plan is cursory or illogical	Does not develop a quality statement that outlines the objectives of the quality plan	2.74
Status of Quality Tools and Standards: Status of Accreditation	Meets “Proficient”  criteria and demonstrates a thorough understanding of accreditation survey results	Describes the current status of accreditation based on recent accreditation survey results	Describes the current status of accreditation, but explanation is cursory or illogical or is not supported by accreditation survey results	Does not describe the current status of accreditation based on recent accreditation survey results	6.4
Status of Quality Tools and Standards: Information Management Systems	Meets “Proficient”  criteria and demonstrates a sophisticated understanding of the information management systems and patient care technologies	Analyzes the current information management systems and patient care technologies for their ability to collect data for reporting quality measures and accreditation requirements	Analyzes the information management systems and patient care technologies, but analysis is cursory or unclear or contains inaccuracies	Does not analyze the information management systems and patient care technologies	3.2
Status of Quality Tools and Standards: Meaningful Use	Meets “Proficient”  criteria and includes exceptional detail	Explains the impact of meaningful-use implementation at the organization as it pertains to patient safety and quality initiatives	Explains the impact of meaningful-use implementation at the organization, but explanation is cursory or unclear or contains inaccuracies	Does not explain the impact of meaningful-use implementation at the organization as it pertains to patient safety and quality initiatives	3.2
Measures and Benchmarks: Performance- Improvement Data	Meets “Proficient”  criteria and outline is exceptionally thorough and detailed	Outlines how current performance-improvement data and initiatives are tracked through the organization	Outlines how current performance-improvement data and initiatives are tracked through the organization, but outline is cursory, illogical, or missing components	Does not outline how current performance-improvement data and initiatives are tracked through the organization	3.2

 

Critical Elements	Exemplary (100%)	Proficient (85%)	Needs Improvement (55%)	Not Evident (0%)	Value
Measures and Benchmarks: Benchmark Data	Meets “Proficient”  criteria and comparison is exceptionally thorough	Compares how the healthcare organization is doing in key safety measures using appropriate benchmark data	Compares how the healthcare organization is doing in key safety measures using appropriate benchmark data, but comparison is cursory or unclear or contains inaccuracies	Does not compare how the healthcare organization is doing in key safety measures using appropriate benchmark data	2.74
Measures and Benchmarks: Compliance	Meets “Proficient”  criteria and provides sophisticated analysis of the metrics, demonstrating deep insight into compliance for accreditation standards	Analyzes the metrics to determine if the healthcare organization demonstrates compliance for accreditation standards	Analyzes the metrics to determine if the healthcare organization demonstrates compliance for accreditation standards, but response is cursory or illogical or lacks justification	Does not analyze the metrics to determine if the healthcare organization demonstrates compliance for accreditation standards	2.74
Measures and Benchmarks: Patient Safety and Quality Issues	Meets “Proficient”  criteria and makes cogent connections between reimbursement data and patient safety and quality issues	Explains how reimbursement data is used to identify patient safety and quality issues	Explains how reimbursement data is used to identify patient safety and quality issues, but explanation is cursory or illogical	Does not explain how reimbursement data is used to identify patient safety and quality issues	6.4
Measures and Benchmarks: Impact of Reimbursement Data	Meets “Proficient”  criteria and makes cogent connections between reimbursement data and accreditation status	Explains the impact of reimbursement data on the accreditation status	Explains the impact of reimbursement data on the accreditation status, but explanation is cursory or illogical	Does not explain the impact of reimbursement data on the accreditation status	6.4
Measures and Benchmarks: Policies	Meets “Proficient”  criteria and provides keen insight into the impact of reimbursement policies on patient safety and quality initiatives	Describes the impact of reimbursement policies on patient safety and quality initiatives	Describes the impact of reimbursement policies on patient safety and quality initiatives, but response is cursory or illogical	Does not describe the impact of reimbursement policies on patient safety and quality initiatives	6.4
Measures and Benchmarks: Leadership	Meets “Proficient”  criteria and includes exceptional detail	Describes the role of leadership in the dissemination and application of quality data	Describes the role of leadership in the dissemination and application of quality data, but description is cursory, contains inaccuracies, or lacks justification	Does not describe how leadership is involved in the dissemination and application of quality data at this healthcare organization	4.8

 

Critical Elements	Exemplary (100%)	Proficient (85%)	Needs Improvement (55%)	Not Evident (0%)	Value
Process Improvements: Recommendations	Meets “Proficient”  criteria and recommendations demonstrate a sophisticated analysis of current organization	Summarizes recommendations based on the analysis of the current organization	Summarizes recommendations based on the analysis of the current organization, but recommendations are unclear or illogical or lack justification	Does not summarize recommendations based on the analysis of the current organization	2.74
Process Improvements: Goals	Meets “Proficient”  criteria and demonstrates a sophisticated understanding of the goals needed to improve current quality measures	Develops goals that address the current organization’s quality measurements and improvement needs	Develops goals, but goals are cursory or do not address current organization’s quality measurements and improvement needs	Does not develop goals based on the evaluation of the current organization’s  quality measurements and improvement needs	2.74
Process   Improvements: New Technology	Meets “Proficient”  criteria and includes exceptional detail	Recommends a new technology that addresses one of the patient safety or quality concerns with a clear explanation	Recommends a new technology, but recommendation does not address the issues or explanation is unclear	Does not recommend new technology that could improve one of the patient safety or quality concerns	3.2
Process Improvements: Leadership Strategies	Meets “Proficient”  criteria and demonstrates a sophisticated understanding of leadership strategies	Describes leadership strategies that are needed to ensure stakeholder and community input into the quality program	Describes leadership strategies that are needed to ensure stakeholder and community input into the quality program, but description is cursory or strategies lack justification	Does not describe leadership strategies that are needed to ensure stakeholder and community input into the quality program	4.8
Process Improvements: Policy Changes	Meets “Proficient”  criteria and recommendation comprehensively addresses the issues and demonstrates keen insight	Recommends a policy change that addresses the patient safety and quality issues	Recommends a policy change that addresses the patient safety and quality issues, but recommendation is cursory or illogical or does not include rationale	Does not recommend a policy change that addresses the patient safety and quality issues	4.8
Evaluation and Reporting: Plan, Do, Study, Act (PSDA)	Meets “Proficient”  criteria and plan includes exceptional detail and demonstrates keen understanding of the PDSA model	Creates an evaluation plan using principles from the PDSA model	Creates an evaluation plan using principles from the PDSA model, but plan is missing principles from the model or plan is cursory or illogical	Does not create an evaluation plan using principles from the PDSA model	2.74
Evaluation and Reporting: Timeline	Meets “Proficient”  criteria and includes exceptional detail in explaining the rationale for timeline	Justifies a timeline for evaluation of performanceimprovement through explanation of activities	Justifies a timeline for evaluation of performanceimprovement but with gaps in detail or missing key activities	Does not justify a timeline for evaluation of performanceimprovement activities	2.74
Critical Elements	Exemplary (100%)	Proficient (85%)	Needs Improvement (55%)	Not Evident (0%)	Value
Evaluation and Reporting: New Technology	Meets “Proficient”  criteria and response demonstrates insightful awareness of how to measure the success of the new technology	Explains how to measure the successful implementation of the new technology suggested in the Process Improvements section	Explains plans to measure the successful implementation of the new technology suggested in the Process Improvements section, but explanation is cursory or contains missing key components	Does not explain how to measure the successful implementation of the new technology suggested in the Process Improvements section	3.2
Evaluation and Reporting: Accreditation	Meets “Proficient”  criteria and includes exceptional detail in describing the changes to the process	Describes the changes to the processes for managing data within the organization for accreditation reporting	Describes the changes to the processes for managing data within the organization, but description lacks detail or is unclear	Does not describe the changes to the processes for managing data within the organization for accreditation reporting	3.2
Articulation of Response	Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format	Submission has no major errors related to citations, grammar, spelling, syntax, or organization	Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas	Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas	4.02
				Total	100%

 

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