Organizational Quality Improvement Plan

Executive Summary
Health care is an imperative service that touches the lives of millions of Americans on a daily basis at considerable and susceptible times from birth to death. In recent decades, knowledge and skills, pharmaceuticals, and proficiency have significantly enhanced how care is delivered and the projection for recovery. American markets for innovation in pharmaceuticals and medical devices are the best in the world. The miracles of recent medicine have become more or less routine. The healthcare that is provided within the United States is the best in the world.

Despite these amazing achievements, the cost, quality, and convenience of American health care have become major governmental and procedure issues. Health care quality varies extensively, even after calculating for cost, source of payment, and patient preferences. A lot of Americans find themselves without health insurance coverage at some point during any given year. The expenses of providing uncompensated care are a large burden for many health care providers, other Americans, and tax payers.

Hospitals across the Country are always searching for ways to improve their quality of care and promote effective quality improvement strategies. The findings of this quality improvement plan will offer guidance and steps for Memorial Healthcare System move in the right direction. To promote greater use of practices and policies that enhance quality in their facilities, this plan identifies and describes the key ingredients to the success of their organization.
This plan examines the issues that are made with dispensing medication to patients. Imperfections in the health care system have impeded the competition from reaching its full potential. This plan will discuss the current procedures that are in place for dispensing medication to the patients, what can be done to improve this issue and how it can increase the patients care and satisfaction.

Memorial Healthcare System has been servicing the South Florida residents for the past 55 years. It is the fifth-largest public healthcare system in the nation and is highly regarded for its exceptional patient and family centered care ( Their organization has been recognized as a national leader in quality care. They have several facilities located in Broward County that offers extensive and diverse services that include Memorial Cardiac and Vascular Institute, Memorial Cancer Institute and Memorial Neuroscience Center ( The organization also provides a comprehensive array of pediatric services and is the leading children’s hospital (Joe DiMaggio Children’s Hospital) in Broward and Palm Beach Counties ( Their mission statement provides safe, quality, cost-effective, patient and family centered care, regardless of one’s ability to pay, with the goal of improving the health of the community it serves ( The organization’s vision is to improve the health of the community by becoming a world-class model of safety, quality, serve and efficiency (

Memorial Healthcare System is dedicated to surpassing customer expectations by applying a Patient First philosophy to all aspects of its operations. Every decision is based on the best interest of patients and their families. Through excellence in safety, quality and service, they strive to ensure that their patients and families receive the care, information, access, collaboration and support they need ( They are committed to treating their patients and families with compassion, dignity and respect. With this commitment they are dedicated to improving the health, well-being and, most of all, quality of life to all of their patients.

The organizations value’s are focused on improving their patients care one step at a time and by providing extraordinary patient care. All employees who work with Memorial Healthcare System is responsible for helping provide superior patient care. They have set high standards and consistently challenge them to provide the highest levels of safety, quality and service at all times (

Scope/Description/QI Activities
To continue achieving the goal of providing high quality of care to all patients, Memorial Healthcare Systems believes that all of their employees need to be part of the quality improvement plan to reduce/eliminate the errors currently being found when dispensing medication to their patients. All of their employees will be given a Quality Improvement Program that will describe their responsibilities. The Quality Improvement Program will include a number of activities which include:
• Seminars on all patient services that affect patient health and safety
• Medication therapy and medication error prevention
• Patient, staff and physician surveys
• National Patient Safety Goals
• Medical Record Reviews

The organization will have a Quality Improvement Committee that will oversee the implementation of this quality improvement plan. The committee will consist of the CEO, the Chief of Staff, the Director of Nursing, the QI Manager, the head Pharmacist from each facility, Infection Control nurse, Utilization Manager, a representative from the organization’s Board of Directors, one physician and one nurse from each of the following departments:
• Bariatric/Weight-Loss Surgery
• Behavioral Health Center
• Cancer Institute
• Cardiac & Vascular Institute
• Diabetes Centers
• Family Birthplace
• Fitness & Rehabilitation Centers
• Geriatric Care Program
• Home Health Services
• Lymphedema Program
• Neuroscience Center
• Outpatient Services
• Pediatrics
• Pediatric Cancer
• Pediatric Cardiac Center
• Pediatric Cleft & Craniofacial Center
• Pediatric Cystic Fibrosis and Pulmonary Center
• Pediatric Endocrinology
• Pediatric Neonatal ICU
• Pediatric Neuroscience
• Pediatric Nephrology and Hypertension
• Pediatric Orthopedics
• Robotic Institute
• Sickle Cell
• Sleep Study Program
• Spine Center
• Women’s Services (
The members of this Quality Improvement Committee will have many responsibilities which will consist of:
• Assuring that the functions of this plan are completed
• Prioritizing issues referred to them for review
• Ensuring that the data that they receive are analyzed, recommendations made, and follow up is completed
• Incorporating internal and external sources of benchmarking data utilizing (COMS) Clinical Outcome Measurement System, and JACHO’s National Patient Safety Goals.
• Identifying any other resources they see fit for the incorporation into the organizations overall quality improvement efforts.
• Reporting on findings, studies, recommendations, and trends to the Governing Board quarterly and annually; reporting to the QI Committee and Medical Staff monthly; and reporting all of the employees when appropriate.
• Identifying any educational needs and assuring that staff education for quality takes place.
• Appointing sub committees or teams to work on specific issues as necessary
• Coordinating activities for all of the employees within the Memorial Healthcare System (

Data Collection Tools
The ability to develop, test, and implement changes is essential for any individual, group, or organization that wants to continuously improve ( Memorial Healthcare System will use flowcharts to draw a picture of the processes they currently have for their medication dispensing and for their patient medical documentation. By using a detailed flowchart it will allow the organization to identify rework loops and complexity in a process. Using a flowchart will help them to identify and clarify any complex processes they might have, identify steps that do not add value to the internal or external customer, including: delays; needless storage and transportation; unnecessary work, duplication, and added expense; breakdowns in communication ( It will also provide team members a shared understanding of the process and use this knowledge to collect data, identify problems, focus discussions and identify resources ( Using the flowchart will also provide the basics needed to creating their new processes that need to be put in place.

The organization will also use the cause and effect diagram to help them with displaying the possible causes as to why their current system isn’t working. It will show possible problems within each step of their current process. By using this tool, Memorial Healthcare System will be able to graphically display the relationship between the causes to the effect and to each other. They will be able to see how each problem is linked to each other and identify areas that need to be improved.

Another tool that will be used is the Pareto Diagram. This diagram is a type of bar chart in which the various factors that contribute to an overall effect are arranged in order according to the magnitude of their effect ( By using this tool Memorial Healthcare System can visualize the different areas within each of their QI initiatives that will have the greatest impact on their success. It will allow the organization to focus on the different parts of each initiative that needs the most attention and the rationale for focusing on these areas.

QI Processes and Methodology
Customer-Inspired Quality (CIQ) is the methodology that will be used to focus on this organizations performance improvement area. It is best suited for success in the healthcare industry because it defines all patient care and administrative processes and it is hospital/service organization friendly and understandable by all stakeholders which encourages a broad cross section of staff input and involvement. It’s administrative and quality measures are implemented to monitor work process changes, and, takes quality methods used in manufacturing and adapts them into the healthcare industry that can provide successful short and long-term improvements in quality, safety, and customer satisfaction (Moyer, H., New, W., Shaw, J.G., 2004).

Memorial Healthcare Systems will use Electronic health records known as EHR which can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures (Carter, J.H., 2004). This software can provide automatic drug-drug/drug-food interaction checks and allergy checks, standard drug dosages and patient education information. Alerts can remind clinicians of intervals for preventive care and track referrals and test results. This software has demonstrated benefits during the process of treating patients.

The staff will electronically document the medications being given to the patients by using the Barcode Technology, ( Before delivering each medication, the medication’s bar code and patient’s identification bracelet are both scanned. Computerizing this process alerts healthcare providers to possible drug allergies and potential risks, and helps to ensure what is known in the healthcare industry as “The Five Rights of Medication Administration (” These rights include the right patient, right drug, right dose, right route of administration and right frequency (

The organization will also use Computerized Physician Order Entry (CPOE). This can reduce total medication error rates by 80% and adverse errors by 55% (Bates, D.W. MD, et al. 1998). Computerized Physician Order Entry (CPOE) allows physicians to enter orders for treatment, tests and consultations directly into computer software that captures and transmits the information. This helps prevent medical errors that occur from verbal or handwritten orders that are inaccurate or hard to read. Successful use of CPOE leads to safer, more efficient, higher-quality care.

Comparative Databases, Benchmarks, and Professional Practice Standards
Memorial Healthcare will use comparative databases to integrate a process for constant evaluation with similar organizations, values and best practices. Constantly implementing leading-edge initiatives will assist the organization with providing the best care to their patients. It is extremely important that the organization continues to benchmark local hospitals and facilities within the Broward and Palm Beach Counties of Florida so that they will be able to continue being one of the nation’s best medical facilities.

The Governing Board of Memorial Healthcare System maintains ultimate authority and responsibility for the quality of care received by their patients and will oversee the development and implementation of this QI plan. The CEO is employed directly under the Governing Board and will be in charge of ensuring that the QI plan maintains a meaningful and effective quality improvement program. The Medical Director in conjunction with the Quality Improvement Committee will be responsible for the direction and management of all the QI activities. The Medical Director will report directly to the Governing Board on any medical issues and to the CEO for any administrative issues. The Quality Improvement Committee’s main function will be to oversee the medical and operational systems as they affect the patients and the employees.
Every department within the Memorial Healthcare System will be responsible for ensuring that all quality improvement activities are taken place with every employee. All of the quality improvement initiatives must be conducted as a part of the organizations Quality Improvement Committee activities ( Every manager within each department will be responsible for identifying quality indicators, collecting and analyzing data, developing and implementing the changes to improve the care that is being provided to the patients when medication is dispensed. This will also include monitoring their employees to ensure that improvement is made and sustained.

The Quality Improvement Committee provides oversight and functions as the central clearing house for the quality data and information collected throughout the Memorial Healthcare System. This committee will track, trend, and aggregate the data received, create reports and communicate the findings to the Governing Board. The Governing Board will then communicate the findings to all of the appropriate staff members.

The entire staff population within the Memorial Healthcare System will be responsible for attending all activities implemented for the quality improvement plan. Each employee will receive education regarding this plan during an initial orientation and on an annually basis thereafter. Any new developments or changes that might arise, each employee will receive updated documents for educational purposes. The material received will include a description of the QI plan and how their ownership fits into the plan depending on their job responsibilities.

Annual Evaluation
This Quality Improvement Plan will be evaluated on an annual basis for effectiveness in achieving the organizations goal of assuring that the best quality of care is being provided to all of their patients. A summary of all activities taken place, improvements that are made, the modification of care delivered, projects that are in process, and any change recommendations for this QI plan will be compiled and forwarded to the board for action to be taken.

Bates, D.W. MD, et al. (1998). “Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors”. JAMA 280: 1311-1316. doi:10.001/jama.280.15.1311. Retrieved on December 20, 2009 from
Memorial Healthcare System Services (2009). About Us. Retrieved online on December 20, 2009 from
Memorial Healthcare System Services (2009). Commitment to Patients First. Retrieved online on December 20, 2009 from
Memorial Healthcare System Services (2009). Our Mission, Our Vision. Retrieved online on December 20, 2009 from
Model Quality Improvement Plan (2009). Retrieved online on December 20, 2009 from
Moyers, H., New,W., Shaw, J.G (2004). Choosing a Quality/Performance Improvement Methodology. Shaw Resources. Retrieved on December 7, 2009 from
The Institute for Healthcare Improvement. (2009). Tools. Retrieved online on December 20, 2009 from
Strategic Technologies Inc. (2004). Improvement Approaches – Comparison Table. Retrieved on December 20, 2009 from