Reference no: EM131355401

Managing a Quality Improvement Initiative

1. As the Quality Improvement Manager, you have learned that there may be an increase in the number of patients with a nosocomial infection. The hospital would like to stay below 2% for nosocomial infection rates.

The Chief Medical Officer (CMO) has provided you with the data tables below:

Year 1	Jan	Feb	Mar	Apr	May	June	July	Aug	Sept	Oct	Nov	Dec
Infections	19	32	10	3	5	19	21	12	3	7	10	22
Discharges	345	350	333	310	347	362	301	297	303	288	290	365

Year 2	Jan	Feb	Mar	Apr	May	June	July	Aug	Sept	Oct	Nov	Dec
Infections	12	10	5	9	17	21	2	11	8	3	7	10
Discharges	361	245	259	232	323	345	321	301	299	233	300	288

The CMO would like you to use this data to do the following:

A. Compute the monthly nosocomial infection rates and provide 2 bar graphs depicting the infection rate for each month for the past 2 years.

o Compute the infection ratesand include them in the table below for each year.

Years

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

Year 1

Year 2

o Complete the graphs in Excel and copy and paste your bargraphs below.

B. Provide an analysis of the bar graphs you created (pasted above) and indicate data trends. What is your analysis of the graphs for both years? How is the data trending? Are the infection rates below 2%?

2. Now that you have determined that a quality improvement initiative exists with the nosocomial infection rate, what hospital employees would you pull together to form a Performance Improvement (PI) Team? Explain why you chose each employee.

3. The quality improvement initiative has been underway for a few weeks. However, two of your PI Team members have not been getting along and it is affecting the entire group. As the PI Team Leader, how would you address the two PI Team members and encourage them to work together?