Vol. XIII, No. 4Archive > April, 2012
Letters & E-Mails
Demonstrate Your QI Activities
Re: "6 Tips for a Stress-Free Accreditation Survey" (February, page 29). Quality improvement begins with identifying indicators that have meaning for your facility. Those with clinical significance should have priority over such secondary ones as follow-up phone calls made and patient satisfaction responses. Once you've established quality indicators, show the data that they generate. View this data in terms of occurrence, with the cases looked at being the denominator and the occurrences, either negative or positive, the numerator. Provide examples of your center's tracking, trending and use of this information to improve clinical outcomes and patient safety. Show how the data will prevent negative outcomes in the future. Expect that in many cases the numerators will be zero. If so, suspend continued use of that particular indicator, but have a plan to return to it on a periodic basis at some future time. Such "zero results" serve to provide examples that QAPI (quality assessment and performance improvement) is being conducted in an ongoing manner and in essence you're looking at what you're doing to keep patients safe and ensure positive clinical outcomes. Above all, be able to describe your facility's efforts to assess and improve the quality of what your facility is doing and demonstrate that this activity, conducted, is used to improve patient care and safety.
Albert B. Kapstrom, MD Obstetrics & Gynecology
Los Angeles, Calif.
akapstro@cdph.ca.gov
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