DOMAIN 9: Quality Improvement

Measure 9.1.1:

(All) Staff at all organizational levels engaged in establishing and/or updating a performance management system

HAI/AR Programs are expected to develop metrics and processes for ongoing performance improvement. HAI/AR Program staff should be aware of how program specific performance improvement strategies may contribute to an overall performance management system.

Context: HDs must document engagement of staff at all levels in determining the nature of a performance management system (PMS) for the dept./program/division.

Opportunity: This supports the need for the inclusion of HAI coordinators, HAI program staff, and HAI program activities in these efforts. HAI staff may have an opportunity to participate on such committees or teams.

Measure 9.1.3:

(All) Implemented Performance Management System

HAI/AR Programs may develop their own goals, objectives and targets for demonstrating performance improvement that may include but not be limited to the addition of National measures and benchmarks for HAI/AR infections and antibiotic stewardship programs. HAI/AR Program staff should be aware of how program-specific performance improvement strategies may contribute to an overall performance management system.

Context: HDs must provide documentation of HD team, committee, etc. that is responsible for implementation of a PMS. HDs must provide 2 examples of the implementation of the PMS in monitoring and evaluating achievement of goals and objectives. HDs must also demonstrate that performance monitoring is accomplished for the objectives identified, using any of a variety of means of measuring progress (e.g. run charts, etc.). Results must be analyzed and be able to show that performance improvement occurred.

Opportunity: HAI/AR Programs may be one programmatic area to provide such documentation with the strong emphasis on performance across all activities and sub-activities.

Measure 9.1.5:

(All) Opportunities provided to staff for involvement in the department’s performance management

HAI/AR Programs are expected to develop metrics and processes for ongoing performance improvement. HAI/AR Program staff should be aware of how program-specific performance improvement strategies may contribute to an overall performance management system and can be engaged in the planning and process through interactions with key HD staff or leaders.

Context: HDs should include staff from across the agency in performance management efforts, particularly those who will be working on performance measure monitoring and analysis. .

Opportunity: HAI/AR staff should be involved in, or at least aware of, HD-wide performance management activities.

Measure 9.2.1:

(All) Established quality improvement program based on organizational policies and direction

Jurisdictions conduct a variety of performance improvement and program improvement activities including but not limited to coordination with internal HD programs. HAI/AR Programs and public health laboratories are expected to develop process and impact evaluations and work towards ongoing quality improvement efforts.

Context: HDs must establish an agency Quality Improvement (QI) Plan.

Opportunity: While the agency-wide plan will likely be produced from QI staff, HAI/AR staff should be aware of or involved in the quality improvement efforts occurring across the HD.