Managing a Quality Improvement Initiative

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:

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

Complete the graphs in Excel and copy and paste your bar graphs below.

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?

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