Health Care Evaluation Plan

Evaluation is a critical part of quality improvement processes because it allows healthcare practitioners to identify gaps in quality management (Hickey & Brosnan, 2017). This paper reviews the methods for evaluating quality improvement initiatives, possible metrics for integrating quality indicators, tools for data presentation, and techniques for achieving an integrated view of performance in Johns Hopkins Hospital’s use of electronic health records as a quality management issue.

Methods for Evaluating Quality Improvement Initiatives

Two evaluation tools could be used to assess quality improvement processes at Johns Hopkins Hospital – process evaluation and focused audit studies. Process evaluation works by investigating an organization’s quality improvement initiatives by reviewing whether its process variables achieve their intended objectives (CDC, 2018), while focused audit studies evaluate improvements in a particular area of quality management.

Focused evaluations could be used to assess quality improvement initiatives at Johns Hopkins Hospital using randomized control trials, which examine how the organization uses EHR to improve quality processes in different health facilities. Here, sample findings could be used to deduce the success of the quality implementation processes in the wider organization. The financial implications of employing this technique in the organization are subject to the scope of the evaluation tool. In this regard, it could be expensive to employ the assessment technique because different organizational processes have to be evaluated, relative to how well they contribute to the accomplishments of their intended goals.

Alternatively, focused audit studies evaluate improvements in a particular area of quality management. As Sadeghi, Barzi, Mikhail, and Shabot (2013) posit, this technique highlights observation as an integral part of the quality improvement process, but with a special emphasis on how change management processes could affect organizational systems. Focused audit studies are relatively cheap to administer compared to process evaluations because they have a smaller focus on the review. Therefore, it is cheaper for Johns Hopkins Hospital to administer it when conducting a focused review of quality assessment (Sadeghi et al., 2013).

Metrics for Integrating Quality Indicators

The key quality indicators for Johns Hopkins Hospital are patients’ experiences, infection prevention, core measures, surgical volumes, the quality of care ratings, and pediatrics (Johns Hopkins Medicine, 2018). New indicators that may comprehensively assess its quality management initiatives are compliance with regulatory requirements, staffing effectiveness, and productivity. These two sets of quality indicators could be merged using the integrated logic care model.

The framework has four components of integration, which are enablers of integration, components of integrated care, outcomes of the quality improvement initiatives, and their impact on the care delivery process (Social Care Institute for Excellence, 2018). These four tenets help to provide a clearer picture of high-quality care at Johns Hopkins Hospital. Similarly, by integrating quality indicators, it is possible for healthcare practitioners to understand measurable indices of quality performance and their effects on the quality improvement process.

Data Presentation

Data presentation is a critical part of quality evaluation processes because it helps nurse managers to understand patterns or themes that characterize quality management processes. Graphs, surveys, and chart reviews are important statistical analysis tools that could be used to quantify quality improvement initiatives of Johns Hopkins Hospital. These techniques are proposed by Hickey and Brosnan (2017) as reliable assessment tools for examining quality management initiatives in the healthcare sector.

How to Achieve an Integrated View of Performance

According to Hickey and Brosnan (2017), the interest in integrated reporting among different stakeholders in the health sector has increased because of its immense benefits to health practitioners and patients alike.

The balanced scorecard technique could help to achieve an integrated view of performance for Johns Hopkins Hospital because it integrates the hospital’s operating plan strategy, quality deliverables, performance indicators, and organizational dynamics in a larger framework of performance analysis (Kaplan & Norton, 1992; Balanced Scorecard Institute, 2012). From this structure, it is possible to link the organization’s financial and quality performance because a consensus on deliverables can be easily obtained, relative to how well the deliverables align with the organization’s quality management goals. In this regard, it is possible to gain a broad understanding of the processes and impact of quality management initiatives on the organization.

Quality Improvement Action Plan

The quality improvement plan for Johns Hopkins Hospital (highlighted below) is adapted from the recommendations of Stratis Health (2018) for developing action plans in healthcare facilities. It has four key objectives: improvement of patients’ satisfaction levels, increase in service volumes, improvements in patients’ safety standards, and maintenance of proper financial health. The milestones that are expected to be achieved from this action plan include:

  1. To ensure Johns Hopkins Hospital provides quality, satisfactory, and safe healthcare services to patients
  2. To integrate evidence-based practices in the improvement of quality standards in the organization
  3. To improve the quality of life-work balance for healthcare staff in the organization
  4. To provide quality health care services in a financially prudent manner

The action plan appears below.

Objectives Process Steps Responsible Person Date/Timeline
Patient Satisfaction
  • Conduct a survey on quality expectations among hospital staff
  • Tabulate data daily and present the same to management
  • Management visits patients weekly to identify their needs and assess how they are being met
  • Develop the patients’ declaration of values
  • Publish monthly articles on the local listings
  • Participate in community meetings in multiple locations where the hospital serves
  • Involve patients in the formulation/revision of patients’ declaration of values
Senior nurse manager Start November 2018 and end in June 2019
Increase Service volumes
  • Review triage levels
  • Develop clinical pathways for frequent visits
  • Encourage patients to see their family healthcare service providers
  • Monitor the number of patients seeking care as per different triage level requirements
  • Review daily surgery data
  • Monitor the alternative level of care (ALC) data monthly
  • Seek partnerships with stakeholders to decrease ALC pressures
  • Early identification of patients’ at risk
  • Educate staff and physicians
  • Discharge planning policies
  • Discharge flow maps which may show appointments, tests, and follow-ups
  • Review and adopt checklists for discharging patients
Patient care committee 4-6 Months
Improve Patients’ Safety Standards (medication errors, patient falls, hospital-acquired infections, and sentinel events)
  • Review medication improvement policies and procedures
  • Implement medication reconciliation procedures
  • Introduce tools for risk assessment of patient falls
  • Design a client safety plan that addresses sentinel events and protects whistleblower
  • Implement hand hygiene programs throughout the hospital
  • Results of the hospital’s care plan should be shared on the hospital and ministry’s website
Patient care committee Ongoing
Improving Financial Health (Appropriate resource utilization, the ability to meet financial obligations, and reporting compliance)
  • Review financial commitments weekly to establish a balance
  • Educate coordinators and staff about MIS coding and the importance of complying with audit requirements
  • Develop a schedule for monitoring and evaluating financial reports when they are due
  • Review internal resources to make sure efficiencies are maximized when meeting financial objectives
Senior managers 6-12 months
Improve organizational health (staff satisfaction and reduction of employee turnover)
  • Conduct monthly meetings that will involve interdepartmental discussions, the CEO, and coordinators to address any issues that the staff may have regarding quality improvement processes
  • Introduce an open-door policy where employees can gain access to senior administrators
  • Integrate staff in the hospitals’ decision-making organ
  • Support staff education and training, relative to quality management initiatives
  • Promote inter-departmental collaboration
  • Report incident statistics
  • Review hiring processes during interviews and reference check all new hires
Human Resource Manager 6-12 months


Based on the requirements of the above-mentioned action plan, Johns Hopkin’s chief executive officer (CEO) should assume the task of monitoring the effectiveness of the action plan. This role is appropriate for the CEO because of the immense powers that the office has within the larger hospital’s administrative structure. Furthermore, from an administrative point of view, the CEO has influence over different departmental processes and can provide an effective oversight role in this regard.

Lastly, the timeline for planning, implementing and evaluating the key tenets of the quality improvement plan was developed after evaluating associated tasks, the number of stakeholders involved, and the effects of the tasks on the organization’s processes. These considerations played a key role in developing specific timelines for the quality assessment processes. Therefore, relative to the quality improvement objectives of Johns Hopkins Hospital, the aforementioned action plan could help it to fulfill the organization’s mission, which is to provide patient-centered care (Johns Hopkins Medicine, 2018).


Balanced Scorecard Institute. (2012). What is the balanced scorecard? Web.

CDC. (2018). Types of evaluation. Web.

Hickey, J. V., & Brosnan, C. A. (2017). Evaluation of health care quality in for DNPs (2nd ed.). New York, NY: Springer Publishing Company.

Johns Hopkins Medicine. (2018). Johns Hopkins medicine strategic plan. Web.

Kaplan, R. S., & Norton, D. P. (1992). The balanced scorecard – Measures that drive performance (reprint #92105). Harvard Business Review, 70(1), 71-79.

Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. M. (2013). Integrating quality and strategy in healthcare organizations. Burlington, MA: Jones & Bartlett Publishers.

Social Care Institute for Excellence. (2018). Metrics for integrated care: What should we measure to know that care is improving? Web.

Stratis Health. (2018). Quality improvement toolkit for emergency department transfer communication measures. Web.