Hospital Quality Management Effectiveness Self Assessment

May 25 09:31 2008 Scott Hodson Print This Article

If you are responsible for Hospital or Health System Quality, try this quality management self assessment to see how you stack up against industry top performers.

This self administered assessnent poses statements regarding specific attributes within areas that Maverick Healthcare Consultants has determined to be critical “quality markers.” It is designed to help you move beyond a "gut feel" to see how your organization stacks up against a variety of critical dimensions of quality.   Hopefully  you will learn something that challenges your assumptions about what it will take for your organization to establish a true environment of quality and patient safety.

For each of the following statements,Guest Posting score yourself as follows based on your reaction to the statement:

  • 4 points: Strongly Agree
  • 3 Points: Agree
  • 2 Points: Disagree
  • 1 point: Strongly Disagree.

After recording your reaction to all 15 statements, add up your total and refer to the evaluation at the bottom of the form.

______  The ability to provide demonstrably high quality patient care is a key element of  our Strategic Plan.

______   We have a strong imperative for quality improvement in our organization, driven by our Executive Leadership.

______   We have effectively defined what constitutes “quality,” and have developed a robust set of objective measures to monitor it on a routine periodic basis.

______   We have an aggressive set of quality performance goals.

______   Our quality measures include consideration of care processes, outcomes and resource utilization.

______   We periodically benchmark our quality performance against other organizations and find that our performance is similar to "Top Performers."

______   With regard to Joint Commission accreditation, we are "survery ready every day."

______   We routinely provide quality performance information to our Board, our employees and Physicians, and to the community.

______   Our employees and physicians believe we have effective and efficient clinical care processes.

______   Our care processes are based on current medical “best practice” evidence

______   Our We have the organizational skill and capacity to develop and implement effective quality performance improvement initiatives.

______   Our approach to quality assurance incorporates “concurrent intervention” techniques.

______   We have tools and technologies that enhance our caregivers’ ability to provide quality care at the point of care.

______   We have a “culture of safety” that is understood and embraced by all employees.

______   Our Physicians understand and are aligned with our Quality Management strategy.

_______  TOTAL SCORE

54 - 60   Top Performer. Your organization understands the core elements of Quality Management and is well positioned to remain a leading quality provider in your market.  Quality is inherent in your culture and you are continuously improving your performance.  What to do next?  Consider developing a Quality Innovation or Accelerated Quality Implementation program to infuse a fresh new level of effectiveness into your quality management organization.

48 – 54   Aspiring Performer. You are a solid quality provider, but the competition is not far behind.  What to do next?   Assess how your organization rates against each of the five Critical Quality Markers to clearly define your organizations strengths and weaknesses, and develop your  Blueprint for Strategic Quality Management Success.

< 48       Challenged Performer. While you recognize that quality is important, your organization’s culture, processes and infrastructure do not support effective quality management. Quality performance is mixed, and significant improvements are elusive.  What to do next?   Consider developing a comprehensive Quality Management Strategy to create a tailored program that will transform your organization’s quality and patient safety culture and capabilities.

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About Article Author

Scott Hodson
Scott Hodson

Scott Hodson and Rick Smith are Principals in Maverick Healthcare Consulting. 

Visit their Hospital Quality Improvement website at

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