ABSTRACT

By Phase 3 of the STEEEP (safe, timely, effective, efficient, equitable, and patient centered) Quality Journey, the Operationalizing Phase (Figure 3.1), all senior-level organizational leaders will be involved in driving the organization to a culture of continuous quality improvement (QI). These leaders will formally have committed to, launched, and laid a solid foundation for the QI program. Now, they will refine the program, frequently reminding themselves and others that QI is not an end point but a journey as well as “the way we do business.” After having driven significant improvements in STEEEP care during Phases 1 and 2, leaders need to ensure that the organization does not begin to take these improvements for granted. To attain the aims of Phase 3 and position the organization to migrate to Phase 4, leaders should focus on the following goals:

• Establishment of a culture of QI throughout the organization • Improved transparency of quality, patient safety, and patient experience data • Quantitative goal setting based on historical performance and statistical modeling and

prediction • Shared governance to engage all staff in delivering STEEEP care • Development of a formalized organizational structure for patient safety and patient

experience • Enhancement of data collection, measurement, and reporting capacities • Building of a regional reputation for delivering STEEEP health care • Strong patient and family involvement in the QI program

As the Operationalizing Phase of the STEEEP Quality Journey commences, all board and senior-level administrative leaders should be directly involved in driving the organization to

a culture of continuous QI. The organizational structure for leading the QI program in this phase will include, but is not necessarily limited to, the following:

• Board members • Chief executive officer (CEO) • Chief operating officer • Chief medical officer • Chief nursing officer • Chief financial officer • Clinical service line chairs • Leaders from support functions (e.g., human resources, information technology) • Patient and family leaders to support and drive the culture of continuous QI

Organizational leaders will be required to collaborate to provide funding and support for the QI program to launch the organization to Phase 4 of the STEEEP Quality Journey, when a culture of QI will be embraced and advanced by employees at all levels.