14 Apr 2022


Accreditation and Quality Improvement Plans

Format: APA

Academic level: Master’s

Paper type: Research Paper

Words: 2100

Pages: 7

Downloads: 0

Goals and Objectives


The main goal is to urgently, permanently, and systematically stem the overall plunge of the hospital and further create and maintain a sustainable improvement phase culminating in reasonable levels of success in all sections of the hospital.

Measurable Goals

The immediate measurable goal is to improve the HEDIS and ORYX metric measurements above industry minimums. The second is to improve patient satisfaction to a point that the hospital income will considerably improve. The long term measurable goal is to match the highest HEDIS and ORYX metric measurements in the state as well as achieve healthy profit making status.

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The initial objective is to establish a hospital salvage team to oversee the critical quality improvement exercise. The team will conduct an investigation, audit, and make inventory to establish the cause and extent of the problems. Contemporaneously, the team will find out the reason for the poor HEDIS and ORYX metric measurements and immediately commence improvement stratagems. Finally, the issues regarding patient satisfaction that do not fall under the ambit of HEDIS and ORYX will be resolved. 

Overview of HEDIS and ORYX measures

Overview of HEDIS

Healthcare Effectiveness Data and Information Set (HEDIS) is a tool utilized by an overwhelming majority of hospitals to gauge their performance in the areas critical to proper healthcare service provision (NCQA, 2014). It is a form of audit on the clinical efficacy of a hospital using data collected through the administrative or hybrid format. The data used spans a considerable duration, approximately one year but may vary according to National Committee for Quality Assurance (NCQA) directives (NCQA, 2014). It was initially developed in 1991 as "HMO Employer Data and Information Set" as version 1.0 and has been continuously varied and improved (Stone et al., 2015). Currently, HEDIS consists of 81 measures cutting across 5 fundamental domains of care pertaining to the particular health institution (NCQA, 2014). Due to its meticulous and highly particularized nature, HEDIS is reasonable, accurate, and reliable.

Importance of HEDIS

Albeit HEDIS measurements are used for a variety of undertakings including accreditation, the system was initially created to assist healthcare consumers make informed decision about which institution to get medical attention from. HEDIS is specifically designed to reduce all healthcare institution into an equal set of parameters for ease of comparison by lay consumers. Further, HEDIS undergoes rigorous audit by audit firms approved by the NCQA (NCQA, 2014). This ensures that the publicized HEDIS measurements are accurate and reliable enough for public consumption (Stone et al., 2015). 

Improvement of HEDIS Metric measurements

Unlike the more amorphous patient satisfaction indices, HEDIS is about results and the way they are recorded and propagated over a long period. The hospital, therefore, needs to improve performance, the way the good performance is recorded and also the way that performance is propagated mostly in written forms through insurance claims among other ways. The hospital salvage team coordinating with management and professional staff must therefore join together, evaluate, and improve results emanating from service delivery. The administration should then improve the recording and propagation procedures at the hospital.

Overview of ORYX

The Joint Commission’s ORYX initiative is a tool used to incorporate performance into the process of accrediting healthcare institutions. To facilitate this inclusion, it was important to reduce performance into a quantifiable measure, a feat that was achieved through the creation of the patented tool ORYX (The Joint Commission, 2015). As ORYX is a performance measurement, it is specific in nature and compares health institutions with their peers as opposed to the HEDIS tool that lumps all institution together into one cluster. As ORYX is patented, the healthcare institution’s data is processed through a vendor who also submits the data to the Joint commission (The Joint Commission, 2015).

According to the Joint Commission, every institution is expected to come up with a minimum of 6 core areas of clinical service provision and provide quarterly data regarding the same to the Joint Commission. As a rule, the data should be submitted within 4 months of the end of that calendar quarter. The six sets of core measures will be determined by the nature of clinical services provided by the particular health institution hence the peer nature of ORYX. The measures provided by a community hospital in a gang invested neighborhood for instance, will definitely vary from that given by an acute care institution or a specialized care institution that deals with neurosurgery (The Joint Commission, 2015). 

As ORYX is peer related, special consideration is given to some specific organizations due either to their nature or the nature of services they provide. Small hospitals with less than 10 inpatients albeit still supposed to maintain ORYX standards are exempted from quarterly submission of data except by choice. Critical Access Hospitals are allowed to reduce the core measures from 6 to 4. Further, accredited freestanding children’s hospitals, long term acute care hospitals (LTACHs), and inpatient rehabilitation facilities (IRFs) are allowed the option of using the Performance Improvement (PI) standards thus excepting them from the ORYX program (The Joint Commission, 2015). The freestanding psychiatric hospitals are limited to one core measure, to wit hospital-based inpatient psychiatric services (HBIPS) with all the other core measures being optional (The Joint Commission, 2015). 

Importance of ORYX

The core function of ORYX is to provide the Joint Commission with data to use in incorporating clinical performance outcomes of health institution into the accreditation process. This is vital because healthcare is an area of service provision to the end consumer. No matter how great the healthcare institution is in all other areas including facilities, equipment, and human resource management, ORYX is driven towards better service provision to the customers. It is, therefore, very important to measure whether the totality of all the other parameters is improving service delivery in a healthcare institution (The Joint Commission, 2015). As a secondary function, ORYX data is used by healthcare institutions to rate and improve their services. Once again, the investments made by healthcare institution is geared towards better services, hence ORYX provides an accurate means to assess if this is being achieved. Therefore, over and above getting accredited, ORYX will enable the healthcare institution to better focus on its core objective by improving the services given to customers.

Improvement of ORYX Metric measurements

Being an acute care institution, the hospital does not qualify for any of the exemptions in ORYX. The first step is to carefully pick the six best areas in the hospital and match them with six core measure of ORYX. The second step is to put in place ways and means to permanently improve service delivery in these core areas as well as ensure proper and accurate recording of all the results emanating from the now better service provision. It is these better results that will ensure a continued rise in the ORYX metric measurements in the care institution.

Pecuniary importance of patient satisfaction

The fundamental objective of any healthcare institution is the provision of the best possible healthcare services to its customers, whether patients or otherwise. Over and above the official, structured, and well-designed means, modes, and tools of measuring the efficacy of service provision in the healthcare industry, the most relevant to the intuition’s finances is patient satisfaction (Health Catalyst, 2016). According to Prakash (2010), patient satisfaction is a proxy and amorphous yet a critical measuring tool. Its main components are clinical outcomes after treatment and patient retention on the positive side and malpractice or negligence claims on the other (Prakash, 2010).

America for instance, is an extremely capitalist driven economy where healthcare institutions survive through finances from client charges either paid directly or through healthcare insurance programs. Even those hospitals that seek government financial assistance or donor funding still depend on the number of patients being handled and the nature of publicity prevalent regarding the particular institution (Mehta, 2015). Patient satisfaction, therefore, becomes core for the financial health of any institution in the healthcare sector (Health Catalyst, 2016).

Capitalism in the healthcare sector has often brought to fore the massive power of law courts towards all consumer based services through lawsuits. The frequency of malpractice related lawsuits and the tendency of juries to award massive damages in these lawsuits are a major problem to healthcare institution (Mehta, 2015). This increases the value of patient satisfaction in healthcare institutions as a few unsatisfied patients can cause critical damage to the finances of a healthcare institution (Health Catalyst, 2016).

Ways of improving patient satisfaction in the hospital

Patients are first human beings then invalids, patient satisfaction strategies must, therefore, appeal to both aspects of the patient; the treatment of the illness and the proper treatment of the human being. Improving clinical attention at the hospital will begin through the evaluation and upgrading of the administrative elements (Mehta, 2015). The doctor to patient ratio as well as the nurse to patient ratio is an important administrative factor that has to be adhered to. The second administrative obligation is the provision of the necessary tools, equipment and implements necessary for quality healthcare delivery. 

Thirdly, the doctors and nurses as well as all other medical personnel handling the patients must strictly adhere to their respective professional codes of conduct. The support staff must also carry out all their obligations diligently and according to well set and articulated laid down procedures. Finally, the hospital’s human resource department should adapt a staff management regimen that ensures a conducive working environment for all staff, so that management issues do not interfere with service delivery to the patients (Mehta, 2015). 

Over and above the core clinical services, customer satisfaction also requires an appeal to the basic human elements of the patients. Health Catalyst (2016), gives a collection of ideas, experiences, and research conducted in the amorphous arena of patient satisfaction and gives several important insights. One of the key stratagems to be implemented in achieving patient satisfaction is learning to treat a patient in the same way that the hospitality industry treats their customers. There must be courtesy, proper communication and even a little pampering of the patient over and above proper clinical care (Health Catalyst, 2016). 

Pricing is another critical area that needs to be handled and improved. This however, does not refer to undercharging for services but rather the provision of value for the services so charged (Mehta, 2015). This also calls for proper communication regarding medical costs prior to the services being administered subject to practicability. Finally, other than the professional clinical and non-clinical attention, there is the invaluable human element of caring, emotional support, and compassion that enables patients to feel that they are not just being treated but also taken care of (Health Catalyst, 2016). Whereas there are no guarantees that patient satisfaction can be fully achieved, a conscious effort towards incorporating all the above will definitely reduce patient dissatisfaction and its adverse consequences. 

Communication approaches for change management among clinicians and non-clinicians throughout the organization

The envisaged change will have to be a team effort for it to succeed, over and above the hospital salvage team to be organized. It is, therefore, crucial for the entire human resource corps of the hospital to both be included in the changes being made and also support the general notion of change. The communication approaches implemented must be well structured, organized and capable of being well received. Change is always difficult to implement, proper communication approaches can however, make it easier (Collyer, 2013). 

The first critical approach is the use of the right person or medium for communication. Sensitive information has a better chance of getting well received if communicated by the right person or medium with the vice versa being equally true. If for instance, a member of the support staff is sent to make a vital communication to members of the medical team, even a good message might receive a negative response (Collyer, 2013). Further, information meant for specific individuals should not be communicated in general forums such as notice boards, a personalized approach should be adopted (Collyer, 2013).

The second approach is to continuously satisfy the desire by the members of staff to know why the change is being undertaken so that they are not left behind. The third is drawing the team into the change regiment by answering the fabled "What's in it for me (WIIFM)?” question which is obvious in the capitalist society (Collyer, 2013). Another key approach is delegation. This involves communicating to the respective leaders of workers’ teams such as doctors, nurses or janitor and having these trusted leaders communicate the sensitive elements to the respective staff members (Collyer, 2013). Finally, communication is a two way system; there should always be avenues for the team members to communicate back without being victimized. Constant evaluation should also be undertaken on the communication strategies to ensure efficacy (Collyer, 2013).

Quality improvement and evaluation method(s) for the plan

To achieve the goals and objectives outlined above in a measurable manner for the purposes of evaluation, the entire process of running the hospital will be reduced to three main parts as shown in the diagram above. All the materials, equipment, and staff members necessary to achieve the required changes fall under the ambit of resources. All the processes involved in the service provision at the hospital from the clinical, support to subsidiary activities will fall under the processes ambit. Finally, end results of all the efforts emanating from the resources and the processes so input will fall under the outcomes ambit (HRSA, 2016). This simple and easily verifiable system of quality improvement and evaluation shall be utilized in the entire process of change. It will be effective from the initial investigation to assess what needs to be done, through the implementation of the improvement regimens, and finally to the continued evaluation and improvement of the hospital’s operational procedures.


Collyer, S. L. (2013). Managing dynamism in projects: A theory-building study of approaches used in practice. PhD Thesis, UQ Business School. The University of Queensland

Health Catalyst. (2016).  How to integrate patient satisfaction data to deliver quality healthcare and improve operational efficiency . Retrieved from <https://www.healthcatalyst.com/success_stories/integrate-patient-satisfaction-data/> 

HRSA. (2016).  Quality improvement. Retrieved from <http://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/> 

Mehta, S. J. (2015). Patient satisfaction reporting and its implications for patient care. AMA Journal of Ethics, 17 (7), 616-621. doi:10.1001/journalofethics.2015.17.7.ecas3-1507 

NCQA. (2014).  HEDIS & quality measurement . Retrieved from <http://www.ncqa.org/hedis-quality-measurement/> 

Prakash, B. (2010). Patient satisfaction.  Journal of Cutaneous and Aesthetic Surgery, 3 (3) 151–155. doi: 10.4103/0974-2077.74491

Stone, N. J., Robinson, J., Lichtenstein, A. H., Merz, C. B., Lloyd-Jones, D. M., Blum, C. B. & Eckel, R. H. (2015). Proposed New Measure for HEDIS® 2016: Statin Therapy for Patients With Cardiovascular Disease . Circulation, 119 (23), 3028-3035. 

The Joint Commission. (2015).  General ORYX* requirements for hospitals . Retrieved from  <https://www.jointcommission.org/general_oryx_requirements_for_hospitals/> 

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