Quality and Performance Management

Quality and Performance Management

RYT Task 1  

The areas of focus for quality improvement in the scenario include: First, bringing patients down for therapies on time from the nurses’ station. Of late, patients are not being brought down on time for therapies. The transporter usually goes to bring the patients but it ends up waiting or coming back to the department. As a result, the therapists sometimes even run down to the nurses’ station just to see what is going on. Secondly, nurses are short-staffed and overworked, hence the nurses are not able to get the patients up on time and their reason is that they are short-staffed and overworked. It is notable that when the therapists get the patients late, they cannot give full treatment since they have to be seen by all therapists. This problem happens all the time now and even one family member said that she would take her husband to another rehab if he is not given better care.

A model for the process is Plan, Do, Study, Act (PDSA) cycle model. Plan: The objective is specified, questions and prediction are made, and plan is made to carry out the cycle. The who/what/where/when is clarified. A change is planned. DO: the plan is carried out, and unexpected observations and problems are documented, and data analysis is started. Study: the results are looked at, what was discovered? The analysis of the data is completed, data is compared to predictions, and what was learned is summarized. Act: what changes are to be made? Next cycle? The actions that should be taken to improve (Department of Health and Human Services, 2014). The types of data needed for objective information include data about the time that the patients are brought down from the nurses’ station for therapies, and data regarding the number of nurses, their functions and whether or not they are short-staffed and overworked.

I would gather the data by looking at hospital records and documents pertaining to the times that patients are brought down for therapies to determine if therapists always get the patients late, and the number and functions of nurses to determine if the nurses are short-staffed and overworked. Team members who would contribute to the team include: Karen, Betsy, Ellie and Lauren. In regards to their professional roles, Karen is a physical therapist; Ellie is the rehab supervisor; Lauren is an associate’s degree in business office management and certified coding professional credentials; and Betsy is Lauren’s supervisor.       

The team members’ participation would benefit the project because of the following: the team members would be able to undertake problems that are more intricate than they could individually; the team would be able to assign responsibilities and roles; and the team would pool skills and knowledge. In addition, the members would share diverse perspectives; they would hold one another responsible. Moreover, members would be able to come up with new methods to resolve differences. To facilitate the project success, there are a number of qualities needed by the team. These include: (i) Respect: Regardless of the number of members in the team, their ages, or professional roles they carry, what basically matters that they all respect one another for whatever they are, or they are not. Every team member deserves respect of each other. (ii) Value: each member of the team has to value the work given to him or her. No one should complain that the task assigned to him/her is not that significant. An individual disrespecting the task given to him/her could lead to low performance levels, which would undermine the effort of the team (Schmidt, 2011). (iii) Coordination: it is noteworthy that right coordination is imperative to teamwork since it is not the matter of one individual representing the team, but everyone. (iv) Time management: it is of essence for the members of the team to learn how to manage time. The team should do everything in the right time and deliver the right work at the right time. I would communicate my ideas for quality improvement project to organizational leaders simply by calling for a meeting with all the leaders of the organization and then communicate my ideas with them in that meeting face-to-face. In case they are unavailable to attend the meeting, I would use email and/or telephone to communicate to them (Cleland & Ireland, 2013). What is needed to proceed with a quality improvement project top change this situation is cooperation from the team members, and authorization or approval from the leaders of the organization.

RYT Task 2

The interviewee’s Name: Donna Wilson; Title: Director of quality improvement; Healthcare organization: Beth Israel Medical Center New York, N. Y; Length of time with the organization: 4 years and 3 months. The role of health information management (HIM) professionals in leading quality improvement projects/programs in the organization of the interviewee is: HIM professionals effectively manage patient information as well as healthcare data that is required in delivering quality treatment and care to members of the public. They also play a vital role in regards to successfully executing electronic health records (EHR) and ensuring that patients, providers and the organization have access to the correct health information wherever and whenever it is required whilst maintaining the highest data security, confidentiality and integrity standards. The HIM expert also plays an essential role by gathering the data that other members of the healthcare team should have so as to do their tasks effectively.

The requirements created by The Joint Commission (TJC) influence quality improvement projects/programs in the interviewee’s organization greatly. The Joint Commission, in essence, aims to improve the safety of care offered to patients in healthcare organizations. The TJC requirements focus on the healthcare organization’s performance level in main functional areas for instance patient treatment, patient rights, infection control, as well as medication safety. TJC standards center on placing anticipations for a hospital’s actual performance and for evaluating its capability of providing high-quality and safe care (The Joint Commission, 2014). As such, the interviewee’s organization must conform to the TJC standards/standards of high-quality, safe care. The organization of the interviewee measures the success of quality improvement projects in the following way. First, they assess to see if it the projects were completed on the specified time frame. Secondly, they assess the project to see whether it delivers benefits to the organization. The interviewee manages stress during quality improvement projects through: seeking support from other employees; eliminating interruptions such as phone calls and emails during the quality improvement projects; identifying self-imposed stress; prioritizing his priorities; being his own best critic; and eating right and sleeping well. I can apply what I leaned in the interview for my own professional growth since I learnt that making mistakes as HIM supervisor could actually lead to professional growth. This is primarily because I will learn from the mistakes and never repeat them again in future, and this way, I would be a better HIM supervisor.

RYT Task 3

Diagram of the internal processes that need attention in the process

Applicable standards from external agencies would require the delivery of patient care to be examined and changed. Joint Commission standards as well as Centers for Medicare and Medicaid Services would require the organization to deliver high-quality and safe services to the patients. With improved communication with customers, one will be able to understand what they need and want, and this will help to deal with customers who are unhappy. Improved communication would also result in improved customer service (Hallet, 2013). This would partially help to resolve the current problems. Customer satisfaction should be a consideration in attending to these processes primarily because it is vital to have customers to be happy with the services provided by the organization. Gaining customer satisfaction is also important since if customers are satisfied, they are likely to be loyal and use the organization’s services repeatedly in future.

Coding productivity guidelines can be evaluated by appraising how effective they have been, whether they have met their intended purpose, and how they have benefited the organization. In the scenario, benchmarking could be used for supportive documentation to show quality improvement by using by identifying a point of comparison against which quality could be measured. In this scenario, the organization can use the set quality standards as benchmarks. The human resources problems that need immediate attention include: human resource being short-staffed, overworked employees, and workers lack motivation to work.

I would initiate a training program for new staff members by doing the following: (i) identifying the training needs; (ii) involving the new employees in training decisions; (iii) developing a training plan; and (iv) assessing the training. In essence, the training program would be available for new workers on the very first day that they begin working in the organization. I would promote professional development for existing staff members through: (i) Cross-training work assignments and on-the-job training: On-the-job training is understood as an effective and conventional technique used to encourage professional development at the workplace. Cross-training will engage the workers and show them that I value their work enough to offer them other opportunities. (ii) Access to resources: the employees would be offered opportunities for professional development using various resources. An online video library or DVD for training tutorials and materials would be availed. Guest speakers on current issues and new developments in their fields would be hosted. Staff would also be helped to access other resource materials they need to advance their career and professional development (Cleland & Ireland, 2013). (iii) Coaching and development: a customized development plan would be created with every staff member to support professional development for the period of performance planning (Harbour, 2011).

In this situation, staff morale can be immediately improved by appreciating them and what they are doing for the organization encouraging communication between the employees and the administration; having fun; and offering bonuses such as financial incentives. The data that must be gathered for this project include data on time that the patients leave the nurses’ station; the time that patients are brought down for therapies; duration of each therapy; the number of nurses in the organization; the tasks carried out by nurses on the patients; and the treatments the therapists give the patients whenever they are brought in late (Schmidt, 2011). The gathered data would be used for benchmarking purposes by comparing it against the set standards. The data would be compared against the identified best practice in the industry. I would implement the project by: (i) monitoring it; (ii) assigning roles and responsibilities to individuals who would oversee the success of the project; (iii) providing the necessary training to individuals involved in the project implementation. I would keep the staff on a project timeline by setting key milestones with specified dates which would have to be attained (Harbour, 2011). The indicators for quality to be used in monitoring the project are: the success of the project; if it has attained the intended purpose; if it was conducted within the specified time frame; and if it was within budget. I would evaluate the success of the project by: assessing whether the defined objective is met; whether it was completed on time; and how the organization benefits from it.


Cleland, D., & Ireland, L. (2013). Project Management: Strategic Design and Implementation. Crescent City, CA: Prentice Hall.

Department of Health and Human Services. (2014). What is Quality Improvement?

Hallet, T. (2013). Dealing with Unhappy Customers. Boston, MA: CRC Press.

Harbour, S. (2011). Ways to Support Professional Development in the Workplace. Cleveland, OH: Penguin Publishers/

Schmidt, T. (2011). Strategic Project Management. Madison, WI: McGraw-Hill

The Joint Commission. (2014). The Joint Commission: Inspiring Health care Excellence. Retrieved from www.jointcommission.org