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Step 1: Quality as Culture
Embed quality improvement into culture and management systems so it guides operational decisions and resource allocation.
Goal: Integrate improvement targets into leadership priorities, management systems, and frontline workflows.
Map enterprise key performance indicators (KPIs) to public scorecards and assign KPI owners.
Link incentives, budgets, and staffing to progress on priority measures.
Embed scorecard targets into leader standard work.
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Step 2: Understand Ratings Methodologies and Prioritize Measures
Understand how each rating system calculates results and how these factors influence your composite score and comparison to peers.
Goal: Prioritize CMS Stars metrics that are included in multiple rating systems. This provides the strongest foundation for scalable improvement across scorecards.
Create an alignment map for CMS, Leapfrog, US News, and other scorecards.
Build analytics to track performance by metric and forecast future scorecard performance.
Narrow your focus to the 25 to 30 metrics with the highest impact. Establish clear improvement targets based on what other hospitals have achieved.
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Step 3: Engage Clinical Leadership
Enlist physicians and nurses as co-owners of quality and safety improvement efforts to engage them and ensure that clinical insights drive priorities and solutions.
Goal: Share prioritized list of metrics with clinical leaders, design action plans, and establish physician-led teams across key domains.
Set expectations for how clinical leaders will drive improvement.
Include clinical leaders in scorecard review activities.
Create rapid feedback loops for timely course corrections.
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Step 4: Action Plans and Governance
Sustain improvements by embedding action plans into daily operations and utilizing high reliability organization (HRO) practices, strengthening governance and reinforcing expectations for consistent execution.
Goal: Create a robust, highly reliable system to consistently turn action plans into sustainable results.
Translate action plan elements into standard work.
Use the insights gained through the quarterly reviews to reinforce team-member accountability and strengthen quality governance.
Review results quarterly. Use current performance to guide ongoing improvement efforts.
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