Program Improvement (PI) at

Self Regional Healthcare

Emily Hulse
Marywood University MS/DI Program
What is PI?

● A way to continuously improve health care for the public

● Able to address health care trends and their outcomes
● An evolution from quality assurance to performance improvement
● Provides a testimony to the importance of our profession
● Can help justify programs, products, and services
FADE Model of Quality Improvement

Focus → Define and verify the processes to be improved

Analyze → Collect and analyze data to identify root causes and point toward
solutions

Develop → Action plans for improvement

Execute → Implement action plans and evaluate their success

PDSA Model of Quality Improvement

Plan → A change in how something works

Do → Carry out the plan

Study → Find the results, analyze them

Act → Decide what actions should be taken as a result

PI at

● Clinical dietitians typically use the FADE model

● Dietitians choose 5+ patients weekly to perform PI on
● Dietitians complete PI form developed specifically for continuous
improvement
● Manager analyzes data and develops changes
● Clinical dietitians complete changes and monitor that progress using
continuous PI forms
PI Form
Results of PI Study

● Intern → Difficulty supporting diet order w data, but provided timely follow-ups
● RD1 → Data unavailable
● RD2 → Often able to follow up with patients in a timely manner, but on occasion did not provide goals or
interventions
● RD3 → Provided data and goals for diet order, but saw a moderate nutritional risk patient in 6 days (goal of 4)
● RD4 → Many of this RD’s patients were discharged before being able to follow up, some areas of PI form were
not properly reported
Impact of Results on SRH

● Indicates some clinical dietitians understand the importance of PI more

than others
● All RDs understand differences between high, moderate, and low
nutritional risk patients
● All RDs did stay up-to-date on weekly submission of PI forms
● Shows areas of improvement: filling out form in full, seeing follow ups in a
timely manner, and prioritizing caseload based on nutritional risk
Conclusion

● Performance improvement allows services, products, and programs to

continue receiving funds and impacting patients
● SRH values PI to create best outcomes for patients and staff
● Results indicate need to continue timely follow ups, completion of full PI
form, and prioritizing caseload based on nutritional risk
● PI will continue to transform the care provided by clinical dietitians at SRH
References

Marywood University provided overview of performance improvement

All data provided by Self Regional Healthcare