Summerlin Hospital: Quality Improvement Project

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SUMMERLIN HOSPITAL
Introduction
Summerlin Hospital: Background
The Summerlin hospital and Medical center in Las Vegas, is one of the 25 largest nonprofit hospitals in the United States. The hospital has 454 beds with private rooms and sits on a 40-acre campus, with 1,500 employees with 1,600 physicians on staff. The hospital has been providing quality healthcare to the residents of Summerlin and the Las Vegas area since 1997. The hospital is one of the most comprehensive healthcare facilities in southern Nevada (Summerlin Hospital, 2017). The Institute of Medicine(IOM) defines quality as: "...the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." (AACN, 2016). The core dimensions of quality are identified as care that is: safe; timely; effective; efficient; equitable; and patient-centered (AACN, 2016).

Data Metrics and Dashboards
To hospitals such as Summerlin, metrics are like headlights: they allow a vision of what's ahead. Metrics and dashboards together can translate the hospital's vision into focused strategies and key performance indicators, allowing the facilitation of the hospital's strategic goals with the operational metrics and can provide feedback at each level of the hospital so that decisions can be made and business objectives and goals can be met (Kollengode, 2009). There are many key aspects to building a good dashboard. These include, but are not limited to:
1. Accessibility. A dashboard should be easily accessible and user-friendly.
2. Reliable data. It is imperative that users have reliable, trustworthy data-If this is not the case, they will not use it.
3. Relevant data. A good dashboard should also contain the factors users need. If the dashboard can report on 50 metrics, but the user can only use or only needs five, the extra 45 metrics is simply creating clutter.
4. Timely Data. A dashboard needs to contain real-time data so users can address challenges promptly.
5. Include trends and/or benchmarks. Trends and benchmarks help users track where they've been and where they are going. Trending data also helps so they can see if their efforts are making a difference. This keeps them engaged and motivated (Klas, 2017).

Laws, Regulations, Policies, And Procedures That May Affect the Quality Improvement Project
Policies and Procedures
Formalized, written policies and procedures exist for several reasons, and can help hospitals such as Summerlin, fulfill several QIs which include but are not limited to:
• Ensuring and facilitation of employees' adherence of the hospital's values, mission, vision and core values, and promise to its patients and their families;
• Helps to promote and ensure compliance with State and National regulations, statutes, and accreditation requirements such as HIPAA, and CMS Conditions of Participation, and others;
• Policies and Procedures also help to reduce practice variation and encourage consistency;
• Helps to allow for the standardization of practices across multiple entities within the hospital system;
• Serves as a valuable resource for especially personnel as well as other staff members and;
• Increases patient safety, by reducing human errors-and the reliance on memory which often lead to major medical errors and oversights (AACN, 2016).
Laws and Regulations
Hospitals' scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey are now more than ever, increasingly important for hospitals such as Summerlin to maintain market share and avoid losing reimbursement (AACN, 2016). Especially under the value-based purchasing program, hospitals such as Summerlin, can be financially penalized for low HCAHPS scores. On the other hand, knowing this should motivate the hospital to develop better quality outcomes.

The HCAHPS Patient Survey
The survey instrument and data collection methodology for measuring patient's perceptions regarding their hospital experience, is the HCAHPS Patient Survey, also known as the CAHPS® Hospital Survey or Hospital CAHPS, and is usually administered randomly to a sample of patients upon discharge. The instrument contains 21 ...