The Plan-Do-Study-Act has been a long-standing favorite quality improvement process inhealthcare. Perhaps the most important and time intensive step in the PDSA cycle is the Plan phase. Implementation (Do) follows directly from the plan and the Study-Act phases are the culmination of the implementation.

Sarah is a quality improvement professional with Baptist Memorial Hospital (BMH). Sarah has been asked to demonstrate or explain status report for an executive committee regarding a quality improvement initiative focused on preventing hospital acquired conditions (HACs) for her large Medicare patient population. Specifically, Sarah has been asked to target the issue of catheter-associated urinary tract infections (CAUTI).The executive committee is concerned about the financial penalties imposed by Medicare whenHACsoccur as well as the patient safety and quality of care aspects of such events. Sarah's hospital employs the PDSA model for quality improvement and has been asked to specifically address the Plan phase of the HAC initiative. Sarah's report must include the following:

• A rationale for the initiative (i.e., why are we working to reduceHACsfor our Medicare patients?).
• A rationale for where to focus her efforts (i.e., why is CAUTI being targeted?).
• A description of the measure and its development (i.e., where did the measure come from and how was it developed?).
• A critique of the costs and benefits of using a clinical practice guideline (i.e., why use an existing guideline? Why not develop our own?).
• A description of the intended scope of implementation (i.e., will the initiative be implemented on a particular unit(s) or throughout the entire facility?).
• A rationale for the intended scope of implementation (i.e., why a particular unit(s) or why the entire facility?).

Sarah has asked her assistant to provide some background information and she has given her the following:

1. Hospital Compare results:BMH versusMethodist Healthcare Methodist Hospital-itsprimary competitor(the HAC results are found under the Complications tab).
2. Aclinical practice guidelinecontaining steps to prevent CAUTI.

Sarah's report should be brief (no more than seven hundred words) and address each of the required topics. Additionally, Mary should make mention of the Do-Study-Act phases of the cycle by describing the purpose of each phase and what each is intended to accomplish (this can be done in one or two short paragraphs).

References

1. U.S. Department of Health & Human Services (n.d.).Hospital compare results for Baptist Memorial Hospital and Methodist Hospital.
2. Center for Disease Control and Preventions - Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html. Retrieved from:https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html
3. Aclinical practice guidelinecontaining steps to prevent CAUTI. https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
4. Hospital Compare results:BMH versusMethodist Healthcare Methodist Hospital-itsprimary competitor(the HAC results are found under the Complications tab). https://www.medicare.gov/care-compare/compare?providerType=Hospital&providerIds=440048,440049&city=Memphis&state=TN&zipcode=38120