Whether you’re a large hospital with multiple service lines or a small rural facility serving a tight-knit community, your quality department plays a crucial role in delivering safe, efficient, and patient-centered care. Each year, it’s essential to step back and ask: *How did we, as an organization, perform overall? Did we hit our key performance indicators (KPIs)? Did our quality improvement initiatives make a measurable impact? Are we staying aligned with the latest industry standards and regulatory expectations?
An annual review isn’t just a formality—it’s an opportunity to reflect, learn, and improve. As you kick off your evaluation for the prior year, use the following checklist to determine whether your quality department might be in need of a refresh or a complete revamp. Whether it’s revising outdated processes, investing in staff training, or streamlining data collection and reporting, a proactive approach will help ensure your hospital—large or small—continues to provide exceptional care while meeting critical benchmarks.
Evaluating your quality department isn’t just about checking boxes – it’s about ensuring your hospital is equipped to deliver the best care possible. Whether you’re in a large urban hospital or a small rural facility, thoughtful evaluation and strategic changes can make 2025 a year of growth, learning, and – most importantly – excellence in healthcare.
Define/Redefine the Department’s Mission & Vision - Does the quality dept and hospital depts align with the overall mission, strategic goals and objectives?
Identify Key Performance Indicators (KPIs) - Are you able to measure the dept(s) effectiveness and impact on patient care?
Evaluate Technology & Software - Are there any more modern quality management systems and analytic tools available? Improve the dashboard and data capture for each department?
Provide Training & Education - Ensure all staff have skills and knowledge of quality and understand the ‘why’ we do what we do? Does quality staff provide education to each department?
Policy & Procedures Are Up-to-Date - Any P&P need revisited related to quality?
Data Collection Is Streamlined - Any method to enhance automation vs manual data collection? Dept. staff understand the data collection and results?
Evaluate Analytical Capabilities - Can you enhance the use of predictive analytics? Does data visualization allow for informed decision-making? Does your data tell a story?
Enforce Data-Driven Quality Improvement Strategies - Does the data identify areas of opportunity? Data tracks flow of improvement process? If a dept is at 100% from start of measure, is this the right measure?
Promote a Culture of Transparency & Accountability - Consider adopting the Just Culture methodology. Encourage open communication and reporting of near misses and adverse events.
Frontline Staff Engagement - Are frontline staff engaged in department quality improvement measures? Are frontline staff aware of overall hospital quality efforts? Empower staff to identify and implement improvements.
Recognition & Reward - Celebrate successes, even the small ones! Reinforce a culture of excellence.
Foster Partnerships with Clinical Departments - Look at ways to collaborate on quality improvement initiatives. Share best practices and replicable improvements.
Patients & Family Engagement - Incorporate patient feedback and perspectives into quality improvement… survey analysis? What data are you gathering from rounding?
Develop Relationships with External Organizations - Sharing best practices with peers, state and regional conferences, engaging with other healthcare organizations.
Stay Up-to-Date on Regulatory Requirements - What regulatory bodies are in your organization? TJC, DNV, other? How are you ensuring up-to-date information? Is it being shared?
Regular Internal Audits - Identify areas for improvement or change from regulatory bodies, ensure compliance is occurring. Have any internal audits identified new quality metrics?
Dr. Angie Schierer is an accomplished C-suite executive consultant specializing in rural healthcare administration. With a robust background in operations, quality, process improvement, and team development, she thrives on tackling new challenges and leading diverse teams through transformational growth and innovative thinking.
Ready to put Angie and our team to work for you? Contact us today to get started!