Hospital Quality Management Effectiveness Self Assessment

This self administered assessment posesaccreditation, we are survery ready every day.
statements regarding specific attributes that I______ We routinely provide quality
have determined to be critical quality markers. Itperformance information to our Board, our
is designed to help you move beyond a "gut feel"employees and Physicians, and to the community.
to see how your organization stacks up against a______ Our employees and physicians believe
variety of critical dimensions of quality. Hopefullywe have effective and efficient clinical care
you will learn something that challenges yourprocesses.
assumptions about what it will take for your______ Our care processes are based on
organization to establish a true environment ofcurrent medical best practice evidence
quality and patient safety.______ Our We have the organizational skill and
For each of the following statements, scorecapacity to develop and implement effective
yourself as follows based on your reaction to thequality performance improvement initiatives.
statement:______ Our approach to quality assurance
- 4 points: Strongly Agreeincorporates concurrent intervention techniques.
- 3 Points: Agree______ We have tools and technologies that
- 2 Points: Disagreeenhance our caregivers' ability to provide quality
- 1 point: Strongly Disagree.care at the point of care.
After recording your reaction to all 15______ We have a culture of safety that is
statements, add up your total and refer to theunderstood and embraced by all employees.
evaluation at the bottom of the form.______ Our Physicians understand and are
______ The ability to provide demonstrably highaligned with our Quality Management strategy.
quality patient care is a key element of our_______ TOTAL SCORE
Strategic Plan.54 - 60 Top Performer. Your organization
______ We have a strong imperative forunderstands the core elements of Quality
quality improvement in our organization, driven byManagement and is well positioned to remain a
our Executive Leadership.leading quality provider in your market. Quality is
______ We have effectively defined whatinherent in your culture and you are continuously
constitutes quality, and have developed a robustimproving your performance. What to do next?
set of objective measures to monitor it on aConsider developing a Quality Innovation or
routine periodic basis.Accelerated Quality Implementation program to
______ We have an aggressive set of qualityinfuse a fresh new level of effectiveness into
performance goals.your quality management organization.
______ Our quality measures include48 - 54 Aspiring Performer. You are a solid quality
consideration of care processes, outcomes andprovider, but the competition is not far behind.
resource utilization.What to do next? Assess how your organization
______ We periodically benchmark our qualityrates against each of the five Critical Quality
performance against other organizations and findMarkers to clearly define your organizations
that our performance is similar to Topstrengths and weaknesses, and develop your
Performers.Blueprint for Strategic Quality Management
______ With regard to Joint CommissionSuccess.