Part IV: Design a Chart for the Topic Surgery

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.

This week, you will 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 you created last week. 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.

Part IV: Design a Chart

Use the matrix below to design your quality improvement chart. Show all the indicators you selected in the chart.

Quality Improvement Activity Schedule

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.