Module 3 – Assignment

Organization’s Quality Program Goals and Objectives

Today, health care organizations are facing a series of problems as they try to keep up with the ever-evolving healthcare industry and to satisfy the ever-progressively aware and demanding user. Health care organizations’ quality programs and objectives provide a guideline for health care providers to simultaneously deliver high quality, improve the health status of patients, and reduce the cost of health care among others. At Los Angeles Community Hospital, the organization has various quality program goals and objectives. Firstly, the hospital seeks to provide high quality, cost effective clinical services and demonstrate the outcomes of services through a system of data collection, aggregation, and analysis. Secondly, the hospital seeks to achieve performance improvement goals in a systematic manner by collaborating with physicians, employees, contracted services, and hospital leadership. The third quality program goals and objective is providing a mechanism to assure that all patients receive the same level of care. Fourthly, the organization seeks to provide a culture that promotes risk reduction strategies to prevent adverse outcomes in patients. The other quality program goal and objective involves reinforcing the process for intensive analysis using root cause analysis or Failure Mode Effects and Analysis (FMEA). Along with that the organization seeks to ensure compliance with licensing and accreditation, promote service excellence through education and training, and provide a mechanism to monitor the effectiveness and safety of services, care, and treatment.

Organization’s Quality Management Structure

Despite years of quality and safety improvement initiatives, health care organizations still experience frequent reports of medical errors, ineffective implementation of evidence-based practice, disparities in care delivery, and wasted resources amidst high health care costs among others (Singer, Benzer, & Hamdan, 2015). Within the health care settings, a quality management structure is critical. Consistently, at Los Angeles Community Hospital, performance improvement involves a systematic hospital approach to quality and safety that covers each of the following elements: development, implementing, maintaining, effectiveness ongoing, facility wide, contract services, improved outcomes and reduction of medical errors. The quality management council consists of a physician leader, the director of quality, administrative executive, and directors from all departments within the hospital. The quality management consists of a director, coordinator, analyst, and administrative assistant.

Selection, Management, and Monitoring of Quality Improvement Projects

At Los Angeles Community Hospital, the department manager is responsible for developing department specific performance indicators that take into consideration issues such as high-risk, high volume, or problem prone areas. The performance indicators are expected to serve as a guide to improve care and services delivered within specific nursing units. The departments are responsible for involving their staff in the collection of date, educating, and informing them of findings/ results. Additionally, the department’s manager is responsible for holding staff accountable to ensure the success of the performance indicator program such as ensuring patient safety and error reduction. Notably, when an indicator is selected, it is presented to the Quality Council for Approval and later sent to the MEC and GB.

Quality Improvement In-service programs

In the United States, health care organizations are regulated by state and federal standards, which define among other things requirements for quality. According to Huber (2014), quality improvement programs represent overarching organizational strategies that ensure employees are accountable and incorporation of EBP quality indicators to improve continuously care. Los Angeles Community Hospital has mini in-services related to quality programs and accreditation at each Quality Council. The hospital also has printed information of the mini in-service. Additional information can be obtained from California Hospital Association of Southern California, ECRI, and HSAG among others.

Quality Methodology and Quality Tools/ Techniques being Utilized

Ideally, on quality methodology and quality tools/ techniques being utilized, Los Angeles Community Hospital uses the Joint Commission Performance Improvement Chapter. The performance indicator is divided into 4-quarters with analysis and action/ follow-up that has been effective.

Communicating QI Activities and Processes to Staff

Nurses play a critical role in the prevention and early recognition of adverse events and possible complications (Zrelak, Utter, Sadeghi, Cuny, Baron, & Romano, 2012). Communicating quality improvement activities and processes to nurse is becoming increasingly important and critical to successful implementation of quality improvement activities and processes. Unfortunately, as Cooper, Gray, Willson, Lines, McCannon, and McHardy (2015) elaborate communication strategies are not formally incorporated in QI frameworks. Los Angeles uses poster campaigns and presentations to engage its principal audience. The use of presentations help explain detail the QI initiative, while the poster campaigns are designed and placed at strategic locations to act as reminders to staff.

Evaluating the Effectiveness of QI Activities

When a PI initiative is closed as the goal was maintained for more than 4 months the Quality Council request for the PI initiative to be rechecked to ensure compliance is still being met at the 6 month and 12 month marks. This is done to ensure we are maintaining goal.

Examples of QI Initiatives that have been Effective in the Organization

At Los Angeles Community Hospital, there are some examples of QI initiatives that have been effective in the organization. For instance, a PI project was done by nursing on proper assessment. Nurses were having difficulty with the EHR and doing complete assessments. The nursing director of the unit with the involvement of the charge nurses started a PI project. Individual education was done with the nursing team members on assessment, nurses were evaluated to ensure appropriate assessment, and interventions were done. At the beginning of this project, the score was below 50%. The % currently is at 100%. Registry nurses were educated to the assessment sheet used and the expectations of the hospital. All new hires nurses were educated on what was expected of them regarding assessments. The PI initiative involved blood glucose levels were documented. At the beginning of this initiative blood glucose were not being in the same area of the EHR or the abbreviation of WNL was being used or the results were not documented. The baseline was at 50%. Education and one on one education was done. Charge nurses were asked to help in education of the staff within their unit. The % rate is now at 100%


Cooper, A., Gray, J., Willson, A., Lines, C., McCannon, J., & McHardy, K. (2015). Exploring the role of communications in quality improvement: A case study of the 1000 Lives Campaign in NHS Wales. Journal of Communication in Healthcare, 8(1), 76-84.

Huber, D. (2014). Leadership & nursing care management. St. Louis: Saunders/Elsevier.

Singer, S. J., Benzer, J. K., Hamdan, S. U. (2015). Improving health care quality and safety: The role of collective learning. Journal of Healthcare Leadership, 7, 91-107.

Zrelak, P. A., Utter, G. H., Sadeghi, B., Cuny, J., Baron, R., & Romano, P. S. (2012). Using the Agency for Healthcare Research and Quality Patient Safety Indicators for Targeting Nursing Quality Improvement. Journal of Nursing Care Quality, 27(2), 99-108.

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