1. Under ‘Quality’, select one data element from one of the following categories: “Timely & Effective Care”, “Complications and Deaths”, “Unplanned Hospital Visits”, “Psychiatric Unit Services”, or “Payment and Value of Care” for the hospital you selected. zip code 750802. Compare your data element to the state and national averages and create at least 1 appropriate graph or table (dependent on the data elements you select) for this data in Excel. Save the table or graph and upload it to your discussion response.3 Is your chosen hospital better, worse, or the same as the state or national averages for the data element you analyzed? Discuss how your hospital compares. 4. Investigate other information on the Medicare.gov site about your data element and try to determine what action your hospital needs to take to correct or improve the reported data to be better or equal to the state or national averages. Click on the links entitled, ‘Find out why these measures are important’, ‘Get more information about the data’, ‘Get current data collection period’, and ‘Watch a video to learn more about _____’. Discuss your findings. 5. Create a Performance Improvement Plan (PIP) for a measure you found that is performing poorly at your hospital choice. Use the Performance Improvement Plan Template – EXAMPLE document attached as an example to compare for your information
Performance Improvement Plan (PIP)
Discussion #6: Researching Customer Satisfaction
Go to this website: https://www.medicare.gov/hospitalcompare/search.htmlLinks to an external site. and initiate a search on Medicare.gov. Enter your local zip code and select the data for a hospital of your choice.
1. Under ‘Quality’, select one data element from one of the following categories: “Timely &.Effective Care”, “Complications and Deaths”, “Unplanned Hospital Visits”, “Psychiatric Unit
Services”, or “Payment and Value of Care” for the hospital you selected.
2. Compare your data element to the state and national averages and create at least 1
appropriate graph or table (dependent on the data elements you select) for this data in
Excel. Save the table or graph and upload it to your discussion response.
3. Is your chosen hospital better, worse, or the same as the state or national averages for the
data element you analyzed? Discuss how your hospital compares.
4. Investigate other information on the Medicare.gov site about your data element and try to
determine what action your hospital needs to take to correct or improve the reported data
to be better or equal to the state or national averages. Click on the links entitled, ‘Find out
why these measures are important’, ‘Get more information about the data’, ‘Get current
data collection period’, and ‘Watch a video to learn more about _____’. Discuss your findings.
5. Create a Performance Improvement Plan (PIP) for a measure you found that is performing
poorly at your hospital choice. Use the Performance Improvement Plan Template EXAMPLE document attached as an example to compare for your information
1
Performance Improvement Plan (PIP)
To: Alejandro Arroliga, Chief Medical Officer
From: Cynthia Morgan, Chief Nursing Officer
Date: 11/29/2021
Regarding: Performance Improvement Plan for Catheter-Associated Urinary Tract Infections in ICUs
and affected wards.
Purpose of the PIP:
The purpose of this Performance Improvement Plan (PIP) is to improve infections related to CatheterAssociated Urinary Tract Infections (CAUTI) in the ICU and select wards at Baylor Scott & White
Medical Center Plano. Our goal is to minimize the number of infections, and improve the benchmark
through observations, and review of current processes and procedures.
Performance Areas of Concern (Problem Statement):
Compared to other facilities of similar size, Baylors CAUTIs rating is higher than the national
benchmark of 1.000.
Observations and Data to Support the Problem:
1. Data from Medicare.gov reflects a 1.419% rating compared to the national benchmark of 1.000. A
similar facility, Texas Health Plano, has a rating of 0.000. (Medicare.gov)
2. Baylor has implemented the following measures to prevent infections (Infection Control):
o Wash hands
o Wear gloves and gowns
o Use disposable equipment
o Ensure equipment is clean
o Wipe surfaces
o Follow best practices for isolation
Step 1 – Identify Improvement Goals:
1. Improve patient experience from current benchmark to better than national benchmark. This goal
will be accomplished by 12/31/2022.
2. Goal will be measured by testing necessary patients between 2/1/2022 and 12/31/2022. This
includes patients in ICU and select wards.
Step 2 Action Plan:
Goal
#
1
Goal
How to Accomplish
Start Date
End Date
Assigned To
Improve Patient
Experience for
CAUTIs
01/01/2022
01/15/2022
Determine if
project is
warranted
Define overall
objective
2
Nursing Directors
Medical Directors
Quality
Improvement
Staff
Performance Improvement Plan (PIP)
2
Plan the Process
3
Begin execution
Select team
Create vision and
mission
statement
1/16/2022
Determine
process and
design (including
testing and
tracking)
Create timeline
Discuss test
methods
(identify group
to be tested)
Review current
data set (group
impacted by
infection)
Define training
Review current
processes and
procedures
Review HospitalAcquired
Condition (HAC)
Reduction
Program
Measures
Review data for
comparable
facilities
Determine cost
1/31/2022
2/1/2022
8/1/2022
Distribute plan
to group
Restate
goal/objective
Implement new
process on
random sample
of patients
Train
appropriate staff
3
Regulatory
Compliance
Officer
CEO-Leadership
Administrative
Assistant
Nursing Directors
Medical Directors
Quality
Improvement
Staff
Regulatory
Compliance
Officer
Quality
Improvement
Staff
Administrative
Assistant
Nursing Directors
Medical Directors
Nurses/Providers
Quality
Improvement
Staff
Nursing Staff
Medical Staff
Regulatory
Compliance
Officer
Performance Improvement Plan (PIP)
4
Monitor process
Ensure that
timeline is being
followed
Measure
effectiveness of
plan; revise plan
if necessary
Certify plan is on 8/2/2022
track
Make
amendments to
plan, if necessary
Perform
corrective
actions
10/30/2022
5
Close
performance
improvement
plan initiative
Ensure that new
process is
incorporated in
organizations
operations
Continue to
monitor
11/1/2022
12/31/2022
4
Quality
Improvement
Staff
CEO-Leadership
Nursing Directors
Medical Directors
Nurses/Providers
Quality
Improvement
Staff
Nursing Staff
Medical Staff
Regulatory
Compliance
Officer
Quality
Improvement
Staff
Administrative
Assistant
Nursing Directors
Medical Directors
Quality
Improvement
Staff
Regulatory
Compliance
Officer
CEO-Leadership
Administrative
Assistant
Performance Improvement Plan (PIP)
Step 3 Resources:
Listed below are recommended resources to complete the improvement activities:
Resource
Administrative Assistant
Nursing Director
Role
Survey development/deployment. Record notes/minutes.
Monitor outcomes/develop staff/oversee patient satisfaction. Provide
expertise for current processes.
Medical Director
Monitor outcomes/develop staff/practice changes. Offer scientific
knowledge.
Care Coordinators
Engage patients for follow-up
Quality Improvement Staff
Define project, guide performance improvement, develop data, monitor
change
Nursing Staff
Implement changes/improvement
Medical Staff
Implement changes/improvement
Chief Executive Officer (CEO) Leadership; is kept abreast of project and outcome.
Regulatory Compliance
Another resource for data
Officer – Health Information
Services
Step 4 Expectations:
The following performance standards must be improved to demonstrate progress towards achieving
each improvement goal:
1. Minimize the number of infections and improve benchmark from 1.419 to 0.000 by 12/31/2022.
2. Survey 100% of all necessary patients that enter the ICU and selected wards between 2/1/2022
through 10/30/2022.
3. Team collaboration and commitment to the project.
4. Define the problem.
5. Analyze the root cause.
6. Implementation of a monthly staff education and training program conducted by the Director of
Nursing from 2/1/2022 through 10/30/2022 to include:
o Determine when catherization is appropriate/necessary.
o Selection of catheters and sites.
o Proper techniques for insertion (including staff hygiene; patient cleansing; aseptic
technique and sterile equipment; securing catheters; and know appropriate intervals).
o Proper techniques for maintenance 100% of the time (including maintain unobstructed
urine flow; use of standard precautions e.g. gloves, gowns and mask; change drainage bags at routine intervals; consider the materials being used; and specimen collection).
o Implement a quality improvement strategy to enhance the appropriate use.
o Skin preparation.
5
Performance Improvement Plan (PIP)
o Monitor the progress.
o 80% passing score on CE courses/exams.
7. Measurable progress.
8. Ensure that PIP team meets deliverables with adherence to timelines outlined in Plan.
9. A final documented process.
Acknowledgements:
PIP Proposer: _Cynthia Morgan, Chief Nursing Officer_________
Date: _11_/__5__/__2021__
Medical Director: ___Alejandro Arroliga_________________________
Date: _11_/__6__/__2021__
X__I accept this Performance Improvement Plan as written
___I accept this Performance Improvement Plan with changes (to follow) by _____/______/_______
Nursing Director: ___Janice Walker______________________________
Date: __11__/__6___/_2021_
X___I accept this Performance Improvement Plan as written
___I accept this Performance Improvement Plan with changes (to follow) by _____/______/_______
Chief Quality Officer: ___Brett Stauffer____________________________________ Date: _11__/__6__/__2021_
X___I accept this Performance Improvement Plan as written
___I accept this Performance Improvement Plan with changes (to follow) by _____/______/_______
Chief Executive Officer: __Jim Hinton____________________________________ Date: _11___/_6___/_2021_
X___I accept this Performance Improvement Plan as written
___I accept this Performance Improvement Plan with changes (to follow) by _____/______/_______
6
