Course project: abc health center quality management plan

Course Project: ABC Health Center Quality Management Plan


            ABC Health Center is dedicated to the health status of all patients.  Quality of care is a direct link to the dedication of our administrative, clinical, managers, and ancillary team.  The organization’s mission, vision and core values guides the process of quality through design, implementation and improving.  The mission for the center is “Health Care for All”.

            The Quality Management (QM) Program allows ABC to improve the health for our patients and to strive for excellence in our processes.  The scope of the QM with the healthcare team includes activities that have direct or indirect influence on care delivered to ABC Health Center patients.  Primary care, dental, family planning, chiropractic, behavioral health, and optometry have specialized clinical professionals as well as patient care programs (Benson, 2003).

            The Board of Director’s is ultimately accountable for the quality of care that is provided at ABC Health Center.  The board hold the CEO accountable for the efficient and effective functioning of the organizations to include the Quality Management Program.  Included in the center management is the Director of Quality, who reports to the CEO on the overall operational responsibilities of the QM program.  The Medical Director is responsible for the performance and the improvement of the provider’s and recommends credentialing requirements to the governing board to lessen the malpractice claims (Benson, 2003).

            The Governing Board, Board Quality Management Committee, and Corporate Quality Committee (CQC) are assigned to oversee the quality and assessment.  The CQC reports to the Board Quality Management Committee.  All departments through ongoing operations integrate the QM program.  The coordination and integration of QM activities is in accordance to the Joint Commission of Accreditation (Benson, 2003).

            ABC Health Center coincides with JCAHO’s ambulatory care accreditation standard manual.  The organizational improvement model has been built into the QM program.  The program is systemic, and collaborative.  The process design is patient-focused.  Data is related to processes, performance, outcomes, decisions, and patient and or staff satisfaction.  External and internal benchmarks are used to assess the appropriateness of the QM.  All HIPPA requirements will be followed to ensure patient/staff confidentiality (Benson, 2013).

Components of Quality Management

            The quality assessment involves the indicator selection, measurement, the indicator assessment, reporting and tracking.  Quality improvement enables the organization to prioritize improvement activities. ABC Health Center has identified the PLAN-DO-Check-Act (PDCA) Cycle for resolving problems.  The CQC will monitor teams involved in improvement activities.  The health center encourages all departments and staff to take opportunities to pilot the improvement to evaluate the effectiveness of the change.  There must be an established target date for the conclusion of the plan.  If the pilot has been a success then the plan can be incorporated into the policies and procedures (Benson, 2013).

            Provider performance evaluation and improvement is based on clinical guidelines, peer review, clinical audits, provider performance improvement activity, and the integration with organization wide QM program. These specific activities apply to the licensed practitioner as defined by JCAHO.  The Medical Director is responsible for improved activities to be integrated in the overall program (Benson, 2013).


Additional Components

            ABC Health Center Utilization Management program is in accordance with the clinical practices as well as the guidelines and standards of local, state, and Federal regulators.  Credentialing and Privileges process ensures that providers have the appropriate qualifications to provide services and care.  The provider needs to be checked for any sanctions by any State or CMS agency.  The area of risk management has the following components: incident reports; infection control; lab quality; and patient safety.  The patient’s health records needs to maintain at a high standard of excellence.  They will be current, detailed, and secure.  The records will be evaluated for completeness and accuracy (Benson, 2003).

Assessment of the Environment

            ABC Health Center uses the safety Attitudes Questionnaire (SAQ) to show the need for performance improvement.  This methodological approach uncovers pertinent information into how the clinicians and staff see the climate/culture of the work environment so that improvement measures can be implemented (Leonard et al, 2004).

            The culture of safety is the foundation of quality of health care.  This system requires prevention of errors, learning from errors, and the understanding that the healthcare center has a culture of safety.  There needs to be an alignment of all components such as work processes and organizational policies and procedures.  There are certain factors for the SAQ.  The first is teamwork, which can also include dealing with medical errors, job satisfaction, communication and overall safety of the organization.  Another is safety climate, which deals with areas of improvement.  Management, discipline and training indicate that the organization should review the policies and procedures to ensure all the employees are being adequately trained and any difficulty with staff are dealt with appropriately.  Morale is a very important component of the culture.  The last is excessive workload, which causes fatigue, problems with work performance and safety issues.  The WHO has recognized that there is a common concern in amongst healthcare professions of the heavy workloads (“Institute for Quality”, 2014).

Sources of Information and Evaluated Information

Joint Commission

FTCA Guidelines

BPHC Health Disparities Collaborative

SWOT Analysis


Exceptional Medical Staff

Strong commitment to the mission of the ABC Health Center

Excellent primary care facilities

Outstanding Healthcare


Lack of sufficient resources

Lack of primary care network

Shortage of experienced staff and increase turnaround


Growing population in the community of Bakersfield

Increased new business initiatives available to ABC Health Center

Increased Healthcare Program within the community




Reduced funding of the government

Competition of specialist in the area

Competition with other healthcare networks (Harrison, 2010).


Plan for Improvement of Shortage of Experienced Staff

            The growing demand for health care services requires strategies to address the issue of nursing/staff shortage. Some school districts are reaching out to the high school students and early college students to promote careers in the health field.  ABC Health Center has created an intern program to bridge with the education component.  The benefits are that the organization can have the student trained specifically for our clinic and be able to transfer after graduation into job placement with ABC.  The state is offering grants for the blending of programs to take place. (“Strategies to Address”, 2008).

            Many states are trying to find ways to accelerate health care training programs to individuals that have lost their jobs in other fields.  An example would be with a male factory worker that has been laid off that can join the healthcare field with funding and support. In addition, competitive salaries are required to have a quality worker stay at the organization even with the demands of the job (“Strategies to Address”, 2008).

            Low job satisfaction has been a factor in retaining staff that are qualified and have excellent experience.  Lack of connection of the mission can make staff have low morale with the organization. It requires financial gain, training, and advancement goals to have staff strive for the best to have the commitment of their goals in their profession (“Strategies to Address”, 2008).

Interviews of the SAQ

            Interviews were done by the Quality Management Team to gather data on causes for the increase staff turnover.  Main concepts were highlighted and gathered to analyze and improve the situation. These are a few of the responses gathered in the report. The staff voluntarily revealed their names.

Susie MA (personal communication, November 10, 2014) stated when my workload becomes more than I can handle, my performance is impaired.

Sally MA (personal communication November 10, 2014) stated In the Health Center it is difficult to speak up if there is a problem with a patient.

Mary MA (personal communication November 10, 2014) stated I feel I carry most of the work load, while I see other co-workers chit chatting.

Joe MA (personal communication November 10, 2014) stated I don’t feel I had the same training as the other MA’s I work with. I was trained at the other clinic by another senior MA.

Root Cause Analysis

ABC Health Center’s management team has been concerned due to the increase in turnover rates of staff at the clinical level.  The majority is with nursing but there has also been an increase in front office and providers.  Management realized the importance of using an effective tool to understand the what, how and why this is happening in the recent year.  The management team decided to use root cause analysis (RCA) to determine why the failure occurred.  The RCA model focuses on prevention and not on blame.  It also focuses on a system and assumes the event is caused by a system failure (Rooney & Vanden Heuvel, 2004).

            ABC Health Center developed a guide to better understand possible areas and questions that can find the possible factors involved in the area of concern.  This included: communication; environment; equipment; barriers; rules; policies and procedures; and fatigue/scheduling.  Each area needs to be specific, concrete, and understood. The recommendations need to be able to adapt to real work situations.  The roles and responsibilities of all involved need to be defined and have a set timeframe for application (“Patient Safety”, 2012).

            Improvements are needed in patient safety and quality of care.  This is also happening simultaneously when providers and staff are being pressured into doing more for less.  Providers are expected to see more patients with fewer qualified nurses and other staff.  This coincides with declining reimbursements and increasing operating costs. The burden on the system has a significant impact on patient safety.  Other issues are related to complex regulatory and legal frameworks that healthcare personnel need to operate in (“Patient Safety”, 2007).

            ABC Health Center has developed a diagram of the clinical workflow process to begin to understand the reasons for the continual overturn of staff in the clinic.  Many of the areas have bottleneck effect that has made it difficult for staff to accomplish the necessary workload.

SEE APPENDIX A Workflow Process

            Data collection was gathered to establish the reasons for a high turnover within the clinic.  Questionnaires were presented to the staff monthly and exit interviews were documented to have the most accurate information to understand the reason for turnover.

SEE APPENDIX B Casual Factor Chart


SEE APPENDIX D Root Cause Summary Table

Balanced Scorecard

            ABC Health Center conducted an initial assessment of turnover in the clinic. Concentrating on four domains: lack of experience; insufficient training; poor communication with management; and lack of recognition.  The scorecard was presented in a way to easily understand the concepts. Target levels were set from the committees that focused on national standards.

The four perspectives of the organization with the measures was created in a simplified version of the Balanced Scorecard. The management continued to develop the scorecard by linking the strategy with the measures in future plans.

Balanced Scorecard

Financial– profit, revenues and cost   Measure- specific billing rates total cost unit cost increase volume

Customer– satisfaction, retention, loyalty Measure- customer satisfaction on time delivery

Operations (Internal) – quality, customer satisfaction, patient centered Measure- innovative business practices

Employee (Growth and Learning) – satisfaction, increase training, education, retention and knowledge management Measure-  staff development assignments staff satisfaction number of staff with license/certificates climate for

The linkage between the perspectives and measures were defined.  Once the scorecard was implemented many staff were responding positively to the attention and change of the system.  Staff began to have additional training, improved communication between management, reward system through incentives, and increase respect from upper management due to the advancement of skill of staff and positive attitudes.

Shewhart Cycle

            The ABC Health Center is very concerned with staff turnover and has previously performed analysis of the root cause.  The center is now going to use the Shewhart cycle to improve work environment and staff satisfaction.  ABC Health Center’s focus is to reduce the number of employees that want to leave due to preventable circumstances.  The Quality Improvement (QI) team began to brainstorm to find areas of the clinic that caused poor work satisfaction.  The team also developed methods that can be quick and efficient, as well as minimal resources and money.

            The team realized that goals needed to be set that are specific to staff turnover.  The goals need to be measureable, realistic and attainable.  By establishing a timeframe limits the potential for process paralysis.  The last part of the plan is to define what is happening in the process to understand the issues.  The team interviewed employees, asked patients point of view, developed a flow chart to look for variations and fine tune the process (“Quality Improvement”, 2014).

SEE APPENDIX E Basic Flow Chart

            The team continued to brainstorm. The QI team focused on the three steps of quality management, Do-Check and Act.


            The QI team began with a small group of medical assistants to pilot the process.  The MA’s were interviewed on what type of training and empowerment was needed for job satisfaction.  The results showed that the lack of consistency of job requirements and variance of implementation of training were causing conflict amongst the MA’s.

            By setting a standardized skill sheet to train new hires, reward MA’s for effective job performance, and improve teaching/training of MA’s there has been positive outcomes with MA’s job satisfaction.  It has also improved the outcomes of quality healthcare delivery and patient satisfaction.



            The QI team recommended to adopt the change since it resulted in positive improvements.  Next, a spread team was created, that included an executive leader, supervisor, representatives from the pilot and clinic setting, additional IT staff and axillary staff.  The team evaluated lessons that have been learned from the pilot and clinic setting, additional IT staff and axillary staff.  The team evaluated lessons that have been learned from the pilot. The team was aware of the importance not to return to the old ways.  They assigned a person to have the responsibility of reviewing the data and process on a continual basis. The data was presented on a chart for all staff to see the results and displayed in a common place. The changes were put into all the protocols necessary to establish permanent change.


            After six months of implementation, there was additional tweaking, to accomplish even more perfection to the system (“Quality Improvement”, 2014). Since the change from six months ago only one MA had left the clinic.  On the exit interview, she stated it was due to family situations and not the clinic. She added that she would love to return if her situation changes.

            Employee satisfaction is so important in today’s healthcare setting.  The patient satisfaction is the ultimate end result.  If the staff are happy, which reflects if their daily tasks, patients want to return to the clinic.  This has a trickle effect on production and profit.  The minimal cost of the change, the limited time it required to create the change, and the positive outcome was a win situation for all parties.  The main outcome is with patient satisfaction. Patients notice any subtle changes in their environment.  The clinic can continue to find avenues that can improve staff satisfaction and improvement of quality.



Benson, D., (2003).  Quality Management Plan.  National Association of Community Health

Centers, Inc.  Retrieved from


Harrison, J. (2010).  Strategic Planning and SWOT Analysis.  Essential of Strategic Planning in

 Healthcare.  Retrieved from http://


Institute for Quality Improvement (2014).  Safety Attitudes in Primary Care Setting.  Retrieved

 from https://www.aahc.accrediationassoc_for-ambulatoryhealthcare.pdf.


Leonard, M., Frankel, A., Simmonds, T., Vega, K. (2004).  Achieving Safe and Reliabl

 Healthcare.  Foundation of the American College of Healthcare Executives.


Patient Safety:  Conducting a Root Cause Analysis of Adverse Events (2007).  Massachusett

Medical Society.  Retrieved form



Patient Safety (2012).  World Health Organization.  Retrieved fro


Rooney, J., Vanden Heuvel, L. (2004).  Root Cause Analysis for Beginners.  Quality Progress

  Retrieved from


Quality Improvement and PDSA Cycle Self-learning Packet. (2014). Quality Insight.  Th

Center of Medicare and Medicaid Services.  Retrieved from


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Appendix A

Workflow Process


Patient Leaves totclinic to cvheckout

Patient Checks In

Secretary Enters PT Into Next GEN

Secretary Takes Chart To Nurse






















Appendix B

Casual Factor Chart























Appendix C

Root Cause Map

Initiate Turnover Reduction

Update job standards and competencies







Root Cause 1: Team is understaffed

Supporting Data: A 5% reduction in workforce since last quarter, 20% increase in turnover in last year

Performance Gap:

ABC Health Center unable to meet staffing needs

Desires Outcome:

A 10% increase in retention in next quarter to meet goal


















Appendix D

Root Cause Summary Table

Causal Factor

Lack of Experience

Paths Through Root Cause Map

Personnel difficulty

Administrative/mangement systems

Policies less than adequate


Screen out candidates based on job fit

Insufficient Training

Lack of role clarity

Low control over job performance


Review training methods and evaluate on a regular basis for deficiencies in skills

Poor communication with management

Open discussion regarding critical issues

Establish times for regular meetings and visits at the clinic setting

Not receiving recognition for quality worked performed

Upper mangement to improve relationships by respecting staff members.

Reward quality and safe work practices with monetary funds and advancement



(Hunt, 2009).



Appendix E

Basic Flow Chart


Employee Satisfaction and Competence

Training and Empowerment of Employees

Skill Hand-out Assign Trainers

Superior Health Care Delivery

Patient Satisfaction Increase profit

Staff Retention























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