quality measure
Quality Improvement
A B C D E F G H
1 Hospital Name Measure Name Measure ID Measure Start Date Measure End Date National Benchmark Score Footnote
2 ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 1/1/2015 9/30/2015 2.548 3.555
3 ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2015 9/30/2015 3.422 3.422
4 ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2015 9/30/2015 1.231 0.466
5 ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2015 9/30/2015 2.703 4.608
6
7 ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 1/1/2014 12/31/2014 2.319 2.487
8 ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2014 12/31/2014 3.063 3.063
9 ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2014 12/31/2014 1.089 0.567
10 ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2014 12/31/2014 2.512 3.697
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12 ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 3/1/2013 11/30/2013 2.219 2.219
13 ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 3/1/2013 11/30/2013 3.128 3.062
14 ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 3/1/2013 11/30/2013 Not available Not available 4 – Data suppressed by CMS for one or more quarters.
15 ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 3/1/2013 11/30/2013 2.094 2.094
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18 ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2012 12/31/2012 2.089 2.203
19 ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2012 12/31/2012 0.827 0.827
20 ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2012 12/31/2012 2.132 2.132
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22 ABC Health Surgical Site Infection from colon surgery (SSI: Colon) HAI_3_SIR 1/1/2011 12/31/2011 2.234 0.273
23 ABC Health Central line-associated blood stream infections (CLABSI) HAI_1_SIR 1/1/2011 12/31/2011 2.234 2.845
24 ABC Health Catheter-Associated Urinary Tract Infections (CAUTI) HAI_2_SIR 1/1/2011 12/31/2011 1.879 2.814
25 ABC Health Surgical Site Infection from abdominal hysterectomy (SSI: Hysterectomy) HAI_4_SIR 1/1/2011 12/31/2011 2.133 1.148
The purpose of this assignment is to examine health care data on hospital-associated infections and determine the best methods for presenting the data to stakeholders. Use the scenario below and the “Hospital Associated Infections Data” Excel spreadsheet to complete the assignment.
Scenario
You have been tasked with displaying Centers for Medicare and Medicaid Services (CMS) hospital quality measures data for a 5-year period on four quality measures at your site. After examining the data, identify trends and determine the best way to present the actionable information to stakeholders.
Assignment
Create a 12-15-slide PowerPoint (not including title and reference slides) presenting the data to the stakeholders. Address the following in your PowerPoint:
1. What conclusions can be drawn for each quality measure over the 5-year period?
2. What trends do you see for each quality measure over the 5-year period?
3. When comparing each quality measure, is the quality measure better than, worse than, or no different from the national benchmark over time?
4. Based on your examination of the data, which of the quality measures should you prioritize and why?
6. Explain how you would monitor the metric and use collected data for improvement.
Include a title slide, references slide, and comprehensive speaker notes.
Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.
Use a minimum of two peer-reviewed, scholarly sources as evidence.
Use this rubric
1Target
Conclusions that can be drawn for each quality measure over the 5-year period are appropriate. The conclusions are supported by the data.
2 )Trend
A description of the trends that can be seen in the data is present. The trends discussed are accurate.
3) Quality Measure and National Benchmarks
A comparison of each quality measure to the national benchmark is present and all comparisons are accurate.
4) Prioritization of the quality measures is present and is appropriate based on the data.
5 )A quality improvement metric is present and thorough. The metric is appropriate for the quality measure.
6) An explanation of how to monitor the metric and related measures to improve care processes, outcomes, and the patient experience is present and thorough.
The content is written clearly and concisely. Ideas universally progress and relate to each other. The project includes motivating questions and advanced organizers. The project gives the audience a clear sense of the main idea
