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When Joint Commission representatives arrive for an unannounced five-day survey at any point between now and August, they will expect staff members to be aware of the four areas identified as top hospitalwide priorities for performance improvement

Understanding the performance improvement process

06/Apr/2012

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Last month, four areas – medication reconciliation, universal protocol, infection prevention and care redesign/the Innovation Units – were identified as top hospitalwide priorities for performance improvement. When Joint Commission representatives arrive for an unannounced five-day survey at any point between now and August, they will expect staff members to be aware of these four priorities and to understand their personal role in all performance improvement efforts at the hospital.

“All MGH employees are involved in performance improvement – a term we use to 
describe the process of improving care by measuring 
performance and then using our findings 
to implement change,” says John Belknap, 
director of Corporate Compliance.

Information about performance improvement efforts flows back and forth through quality and safety groups at every level of the hospital (see chart at right). Each clinical department has a quality assurance chairperson as well a quality and safety committee. These departmental resources share quality- and safety-related information with two interdisciplinary groups: the Quality and Patient Safety Committee, made up of all the quality assurance chairpersons, and the Quality Oversight Committee, which comprises leadership from various MGH departments, who 
review high-priority projects throughout the year. 
These committees report to the MGH/MGPO Boards Subcommittee on Quality, a group that 
includes trustees and quality and safety leadership. The subcommittee in turn shares key information 
with the MGH/MGPO Boards of Trustees.

“Regardless of the focus of a particular performance improvement project, each one is implemented in the same format: plan, do, check and act, or PDCA,” says Belknap. “Everyone can probably think of an example of how they or their department have used this method – or perhaps a similar version – 
to successfully implement change.”

Planning is the stage at which an 
opportunity for improvement is identified, current performance is measured and an improvement plan is developed; doing is when 
the plan is implemented; checking is the measurement 
of whether or not the plan worked; and acting 
means the plan is modified if need be, standardized 
and then monitored to sustain the improvement.

For more information about performance improvement and other important quality and safety topics, access http://intranet.massgeneral.org/excellenceeveryday.


Read more articles from the 04/06/12 Hotline issue.

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