Final Report Template
Create a final report in response to the “Voice of the Community” (VOC) report found in the
course using this template.
Part 1:
Process Control Plan
Create a process control plan by doing the following:
A. Measures, Key Indicators, and Thresholds for Response
Describe your measures, key indicators, and thresholds for potential response:
1. Define measures or key indicators that will be used to track improvement project
progress.
2. Identify the threshold for the measures of key indicators that will signal a need for a
potential response plan.
1. Timely care for patients receiving assistance at
Shelbyville Medical Center. Improved patient
bedding/admitting/call light answer wait times by 20-25%
decrease over two quarters once in place.
2. Patients will receive improved communication from
physicians, providers, and staff during their stay.
Measures or Key 100% of physicians/providers will attend an in-service within
Indicators four months. Improved communication via providers in the
ED by 50-60% in eight months.
3. Patients receive an improved understanding of their
diagnosis, care process, and discharge instructions,
including treatment following discharge. 90-95% of ED
patients will be contacted the day following discharge by ED
nursing staff. Discharge instructions repeated.
Thresholds for 1. Timely care for patients receiving assistance at
measures or key Shelbyville Medical Center. Improved patient
indicators bedding/admitting/call light answer wait times by 15-20%
will be acceptable, but 10-15% improvement will not be, and
we will need to reevaluate our process and the need for a
response plan.
2. Patients will receive improved communication from
physicians, providers, and staff during their stay. 80-
100% attendance by providers to the in-service will be
acceptable, but anything less than 80% will signal a need for
a response plan. Improved communication via providers in
the ED, as demonstrated by the Voice of the Customer
Report, will be acceptable if enhanced by 40-50%. However,
anything less than a 40% increase from the baseline set at
the beginning of the project will signal a need for a potential
response plan.
3. Patients receive an improved understanding of their
diagnosis, care process, and discharge instructions,
including treatment following discharge. 85-90% of ED
Confidential and Proprietary Information. © Western Governors University. All Rights Reserved.
, patients being contacted the day following discharge will be
acceptable, but anything less than 85% will be a signal that
there is a need for a potential response plan.
3. Explain your potential response plan if a key indicator fails to meet the target
threshold standards established in parts A1 and A2.
The number one priority of a potential response plan is consistency in data gathering,
evaluating, and comparing to the goals or thresholds set. By doing this, the ability to
capture real-time information about where and when we falling short will be easily
spotted. This will assist in answering why we are not meeting the threshold and if
something has changed in the process, with the data being gathered, if it is due to new
(untrained) staff, community factors, or other factors. Once an understanding of why we
are not meeting the threshold has been discovered, a response plan can be developed
that coordinates with the findings. For instance, if we are dropping due to the presence of
many new staff, training and reeducation would be part of the response plan. If the
system for gathering wait times or bedding times has gone down, IT would need to be
involved in evaluating an option to fix it, or possibly new systems would need to be
purchased. The response plan must fit the findings of why we need to meet the threshold.
B. Recipients of Report Results
Identify five individuals who will receive the reports of the results of the quality
improvement project, including their professional title, department, and service:
Professional Title Department Service
Shelbyville Medical Center As the CQI project manager,
CQI Project Manager/COO Administration Team this person oversees the
project and the entire
operation. This individual
will collect, evaluate, and
enter data into overall
project reports.
Shelbyville Medical Center The ED nurse manager
ED Nurse Manager Emergency Department oversees all nursing staff
working in the ED. This
individual sets systems and
nursing care in the ED and
will need to see the reports
to evaluate these systems.
Shelbyville Medical Center The Chief Nursing Officer
Chief Nursing Officer Administration Team (CNO) is the administrative
person responsible for
nursing at Shelbyville
Medical Center. This
individual will need to
receive reports with a vision
of how the numbers and
data affect the rest of the
facility and how the facility
can assist with the data
through system changes.
Shelbyville Medical Center The Quality Director is on
Quality Director Administration Team the administrative team.
Confidential and Proprietary Information. © Western Governors University. All Rights Reserved.
Create a final report in response to the “Voice of the Community” (VOC) report found in the
course using this template.
Part 1:
Process Control Plan
Create a process control plan by doing the following:
A. Measures, Key Indicators, and Thresholds for Response
Describe your measures, key indicators, and thresholds for potential response:
1. Define measures or key indicators that will be used to track improvement project
progress.
2. Identify the threshold for the measures of key indicators that will signal a need for a
potential response plan.
1. Timely care for patients receiving assistance at
Shelbyville Medical Center. Improved patient
bedding/admitting/call light answer wait times by 20-25%
decrease over two quarters once in place.
2. Patients will receive improved communication from
physicians, providers, and staff during their stay.
Measures or Key 100% of physicians/providers will attend an in-service within
Indicators four months. Improved communication via providers in the
ED by 50-60% in eight months.
3. Patients receive an improved understanding of their
diagnosis, care process, and discharge instructions,
including treatment following discharge. 90-95% of ED
patients will be contacted the day following discharge by ED
nursing staff. Discharge instructions repeated.
Thresholds for 1. Timely care for patients receiving assistance at
measures or key Shelbyville Medical Center. Improved patient
indicators bedding/admitting/call light answer wait times by 15-20%
will be acceptable, but 10-15% improvement will not be, and
we will need to reevaluate our process and the need for a
response plan.
2. Patients will receive improved communication from
physicians, providers, and staff during their stay. 80-
100% attendance by providers to the in-service will be
acceptable, but anything less than 80% will signal a need for
a response plan. Improved communication via providers in
the ED, as demonstrated by the Voice of the Customer
Report, will be acceptable if enhanced by 40-50%. However,
anything less than a 40% increase from the baseline set at
the beginning of the project will signal a need for a potential
response plan.
3. Patients receive an improved understanding of their
diagnosis, care process, and discharge instructions,
including treatment following discharge. 85-90% of ED
Confidential and Proprietary Information. © Western Governors University. All Rights Reserved.
, patients being contacted the day following discharge will be
acceptable, but anything less than 85% will be a signal that
there is a need for a potential response plan.
3. Explain your potential response plan if a key indicator fails to meet the target
threshold standards established in parts A1 and A2.
The number one priority of a potential response plan is consistency in data gathering,
evaluating, and comparing to the goals or thresholds set. By doing this, the ability to
capture real-time information about where and when we falling short will be easily
spotted. This will assist in answering why we are not meeting the threshold and if
something has changed in the process, with the data being gathered, if it is due to new
(untrained) staff, community factors, or other factors. Once an understanding of why we
are not meeting the threshold has been discovered, a response plan can be developed
that coordinates with the findings. For instance, if we are dropping due to the presence of
many new staff, training and reeducation would be part of the response plan. If the
system for gathering wait times or bedding times has gone down, IT would need to be
involved in evaluating an option to fix it, or possibly new systems would need to be
purchased. The response plan must fit the findings of why we need to meet the threshold.
B. Recipients of Report Results
Identify five individuals who will receive the reports of the results of the quality
improvement project, including their professional title, department, and service:
Professional Title Department Service
Shelbyville Medical Center As the CQI project manager,
CQI Project Manager/COO Administration Team this person oversees the
project and the entire
operation. This individual
will collect, evaluate, and
enter data into overall
project reports.
Shelbyville Medical Center The ED nurse manager
ED Nurse Manager Emergency Department oversees all nursing staff
working in the ED. This
individual sets systems and
nursing care in the ED and
will need to see the reports
to evaluate these systems.
Shelbyville Medical Center The Chief Nursing Officer
Chief Nursing Officer Administration Team (CNO) is the administrative
person responsible for
nursing at Shelbyville
Medical Center. This
individual will need to
receive reports with a vision
of how the numbers and
data affect the rest of the
facility and how the facility
can assist with the data
through system changes.
Shelbyville Medical Center The Quality Director is on
Quality Director Administration Team the administrative team.
Confidential and Proprietary Information. © Western Governors University. All Rights Reserved.
