Risk management uses certain documents to track incidents. It will help you to become familiar with the kind of information that goes into these documents.
Create and fill in a quality improvement chart for the high-risk area topic Surgery
1 Design a chart to show the indicators, their measurements, and the expected and actual performance. Use the template to design your chart. Further, use 5 out of the 10 standards listed. See below to review the template.
2 Select one of the fictional incidents. Describe the incident under Status.
3 For this incident, complete the Compliance section using fictitious data. The tracking of the indicators should correspond to the incident. That is, some failure of compliance may have led to the incident.
4 Develop a plan of correction to address the incident. Write a brief description under Plan of Correction.
Use the matrix below to design your quality improvement chart. Show all the indicators you selected in the chart.
Quality Improvement Activity Schedule
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Standards
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Severity of Risk
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Performance Indicator
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Level of Performance / Threshold
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Compliance in Percent
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Status
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Plan of Correction
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Qtr 1
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Qtr 2
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Qtr 3
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Qtr 4
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Under standards, you may include areas such as the following:
IC: Surveillance, Prevention, and Control of Infection HR: Management of Human Resources
EC: Management of the Environment of Care IM: Management of Information
MM: Medication Management LD: Leadership
NPSG: National Patient Safety Goals PI: Improving Organizational Performance
PC: Provision of Care, Treatment, and Services RI: Ethics, Rights, and Responsibilities
Severity of risk may be designated as follows:
H: High risk M/H: Medium/high risk M: Medium risk L: Low risk
Compliance (in percent) may be entered on a monthly, quarterly, bi-annual, or annual schedule. The matrix here shows quarterly compliance schedule. Adjust it as necessary.