Principles regarding the design of improvement activities by the CEQS

The implementation of quality improvement and patient safety initiative will utilize the following key elements:

1.    The design is based on the UK’s mission, vision, and strategic imperatives.

2.    The needs and expectations of patients, staff, and others, and the effect of the design on patients and care delivery.

3.    Research of current literature and practice guidelines are reviewed for successful or best practice(s).

4.    Design is consistent with sound business practices.

5.    Baseline performance expectations are utilized to guide measurement and assessment activities.

Monitoring and evaluation standards are department, and division focused. Processes which are high volume, problem prone, high risk, and high cost are measured on an ongoing basis using the four step JCAHO Cycle for Improving Organizational Performance, Design, Measure, Assess, and Improve.

CEQS projects are developed to measure, assess, improve, and maintain process improvements and compare UK’s performance with other “like” facilities to identify variations or “failure modes.” Comparative data is used from the UHC, NACHRI, LHCR, or current/past department performance. Each activity monitored has an established performance level or threshold to measure expected performance. A strategy for maintaining the effectiveness of the redesigned process over time is also implemented.