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Quality Improvement Plan

Executive Summary

The Quality Management (QI) and Improvement Plan of Angel’s Regional Health Center will be developed to demonstrate that the consistent and gradual efforts and focused goals to deliver optimal care to patients having different ailments and from different cultural backgrounds without prejudice, discrimination or favor. The health center has a focus to enhance internal interaction of staff and the patients in the different wards. The management and the physicians will also integrate the quality management improvement plan in their daily rounds attending to patient needs in a continuous, systematic and coordinated approach that will be geared towards improving the performance of the health center mechanisms and processes that addresses Angel’s Health Center values. Patient care is a collaborative and coordinated effort and this will require calculated and organized approaches that will improve the overall performance of the health center through the various disciplines and departments. These factions will be involved in the processes, plans and mechanisms in the improvement performance activities. This program will be developed to monitor all aspects of patient care with approval and support for the Medical Staff involved in these activities. Optimal patient safety and care is the top priority of Angel’s Health Center which strives to gradually facilitate and improve patients’ positive outcome with the availability and access to health care services to every segment of the population. The health center will continuously push efforts to enhance optimal and inclusive primary health care services.

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The mission of the health care centre is to provide quality health service to all its patients who take into consideration the innate human life dignity and worth of all people irrespective of their race, gender or affiliations, and to avail the center’s services and programs without any restrictions. The center strives to create a conducive healing environment where allied professionals, physicians and staff work together as a team to give personalized and interactive care. It also aims to lead in advocating quality health care programs with high standards and develop resources that satisfy the basic health care needs of people, that is, communities and families, within the service area. Angel’s Health Center also seeks to operate in a fiscal and ethical manner being responsible without putting patient care needs at unnecessary risk (Jones, 1997).


The goals of the health center include:


provision of ongoing and organized processes that review proper and


patient care services;

in delivering optimal patient care to patients using the available



health center will also cater and provide special assistance to people,



the homeless, HIV positive patients, substance abuse addicts, and

the mentally ill.



ensure that that the facility operates in optimal clinical performance in the

patient care given and simultaneously complying with mandated

requirements in the health

care facility.

The objectives will include assessing and identifying indirect and direct problems that may be barriers to efficient delivery of patient care. Necessary plans will be developed and implemented to address various problems and issues in the facilities, with monitoring indicators developed based on Angel’s Health Center standards. Consistent with the health center’s mission safety in

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handling patients, healthcare effectiveness, patient centered focus, better utilization of time to avoid delays, equitability concept to health care provision and overall efficiency will be integrated in the health facility.


To achieve its goals and objectives, the health center staff will participate in the activities that improve quality at the facility through the quality improvement efforts and delivering high quality care. The activities will entail the following: risk management activities, the staff/patient/physician satisfaction surveys, direct and indirect patient care services that affect their health and safety, professional staff credentialing, medication therapy, mortality and morbidity reviews, nosocomial infections and medical records review. This scope will be integrated into the continuous quality improvement plan that will evaluate priorities in the health care plan that will be defined and documented. The health center will also have to develop programs that will overlook the patient enhancements or improvements while under care. The quality improvement activities will also take into consideration patient satisfaction in utilization management (Henderson, 2001).

Data Collection Tools

The performance data to be collected will be based on the medical records, professional credentials, and the patient, physician and staff satisfaction surveys. This performance data will be assessed and evaluated to give or indicate the performance level of the health centre in relation on how it handles its patients through equitability and efficiency. Potential delays in admitting, checking out and attending to patients will be factored in the quality improvement tool. The coordination and collaboration between the different departments in the health center facility is crucial to the performance of the entire organization (Daley, 1997). The perceptions carried by patients due to facilities and resources in catering for their needs, patient centered focus, attitude of staff and physicians will ultimately translate to quality and performance aspects that patients go with that inevitably affect the performance of the health facility.

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Processes and Methodology

The Quality Improvement plan will be used for the organization, systematic and gradual measurements to assess the performance of the improvement activities. The following components can be included in the plan processes: Quality assessment activities towards utilization management, medication therapy, staff or patient satisfaction surveys and medical reviews will be used to assure standards are attained and maintained; Quality improvement teams through the intra or inter-departments will identify issues and opportunities to improve processes outcomes.; Comparative databases or outside sources such as professional practice standards will be used in comparison to processes and outcomes and identify areas requiring focus in quality improvement efforts; and dashboard reports that will provide summaries to data for selected indicators. The methodology can use the PDSA plan improvement that identifies improvement opportunities in the health care facility’s objectives. This will entail Plan, Do, Study and Acting to improve the processes (Buckle, 1997).

Comparative Databases, Benchmarks, and Professional Practice Standards

The health care center will employ comparative databases to integrate continuous process assessments, best practices and standards with similar organizations that will lead to improvement actions as necessary.


The Board of Directors at the healthcare center will be ultimately responsible for quality care of patients and assuring performance. The Board will delegate responsibility for the Quality Improvement plan to the medical staff through the Quality Improvement Committee, Management Committee and the health center’s Leadership Team. The chairperson of the Quality Improvement plan will report directly to the Executive Director or Board of Directors and responsible for monitoring corrective action plans, monitoring for compliance, updating procedures, policies and protocols, and program implementation. The coordinator will report to the chairperson who will undertake data collection and audit activities. The committee members will constitute of the different departments in the health facility. The larger members will include

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the department staff undertaking various responsibilities such as the medical records and laboratory staff.


The Quality Improvement Committee will provide functions for tracking aggregate quality information and data oversight collected throughout the health center to prepare reports that will govern medical and board staff (Young, 1998).


Angel’s Health Center staff will be given the authority and responsibility to participate in the center’s Quality Improvement Plan. To accomplish this, education will be provided concerning QI plan during initial orientation, how they fit in the plan based on their specific job responsibilities.

Annual Evaluation

The QI plan will be assessed annually to monitor effectiveness of the goal objectives in assuring proper quality health care to the center’s patients. Summary of activities, recommendations and progress will be integrated into the QI plan.

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Buckle, J. M. & Horn, S. D. (1997). Clinical Practice Improvement Methodology: Implementation and Evaluation. Faulkner & Gray, Inc. New York.

Daley, J. (1997). The role of coordination. Health Care Management Review.

Henderson, W. G. (2001). National Surgical Quality Improvement Program. Annals of Surgery.

Horn, S. D. (1999). Provision of Outcomes Data. Society of Critical Care Medicine.

Jones, R. S. (1997). The future is now. Journal of the American College of Surgeons.

Young, G. J. (1998). Patterns of coordination and clinical outcomes: a study of surgical services.

Health Services Research.

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