Building Your Professional Toolkit: The Hospital Quality Director Series
Building a Hospital Quality Program, Part 1
Hello there, fellow quality champions! If you're reading this, you're likely responsible for one of healthcare's most challenging yet rewarding roles: building and maintaining a hospital quality program that meets or exceeds regulatory and accreditation requirements while genuinely improving patient care.
As a hospital quality director, you're not just checking boxes for surveyors—you're creating systems that save lives, improve outcomes, and transform organizational culture. It's a tall order, and sometimes it can feel overwhelming. But you're not alone on this journey.
In this series, we'll walk through the step-by-step process of building a robust hospital quality program that will not only satisfy regulatory bodies like CMS, licensing and accreditation bodies like state health departments and The Joint Commission but will also drive meaningful improvements in patient care. This series will share practical tips, downloadable resources, and real-world strategies to help you succeed in your role as a hospital quality director.
Understanding the Regulatory and Accreditation Landscape
Before we dive into building your quality program, let's make sure we understand the regulatory framework we're operating within.
The Foundation: CMS Conditions of Participation
The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) form the regulatory backbone of any hospital quality program. (Visit the posts in this series focused on preparing for accreditation surveys for more detailed information.) These federal requirements establish the minimum health and safety standards that hospitals must meet to participate in Medicare and Medicaid programs.
The CoPs include specific requirements for:
Quality Assessment and Performance Improvement (QAPI)
Medical staff
Nursing services
Pharmaceutical services
Infection control
Patient rights
Emergency services
Medical record services
Physical environment
And many other areas
Accrediting Organizations
While meeting CMS requirements is mandatory, most hospitals also pursue accreditation through one of these approved organizations, or other approved organizations not listed:
The Joint Commission (TJC): The largest and oldest healthcare accrediting body, known for its comprehensive standards and "gold seal" of approval.
Det Norske Veritas (DNV): Offers the National Integrated Accreditation for Healthcare Organizations (NIAHO®) program, which uniquely integrates ISO 9001 quality management principles into its accreditation process.
Healthcare Facilities Accreditation Program (HFAP): Focuses on patient-centered processes through comprehensive surveys.
Center for Improvement in Healthcare Quality (CIHQ): The newest CMS-approved accrediting agency (since 2011).
When your hospital is accredited by one of these organizations, you receive "deemed status," which means you're considered to meet or exceed the Medicare CoP standards without requiring separate CMS certification. One of the requirements for meeting the CMS Conditions of Participation as well as for accreditation requirements, is the establishment of a quality program. Let’s dive into how to build a robust program for your hospital.
Step 1: Establish Your Quality Program Structure
Let's start building! The first step is creating a well-defined structure for your quality program.
Leadership Commitment
Quality improvement cannot succeed without visible, active leadership commitment. Work with your C-suite to:
Develop a clear vision statement for quality in your organization
Secure adequate resources (budget, staff, technology)
Establish quality as a standing agenda item in board and leadership meetings
Create accountability mechanisms for quality metrics at all levels
Quality Department Organization
Your quality department should include professionals with expertise in:
Quality improvement methodologies
Data collection and analysis
Regulatory and accreditation requirements
Risk management
Patient safety
Infection prevention
Depending on your hospital's size, these roles might be combined or expanded. Create clear job descriptions that outline each team member's responsibilities.
Committee Structure
A well-functioning committee structure is essential for your quality program. No matter which structure works best for your hospital’s individual circumstances, remember that the Governing Board of Trustees/Directors carries the burden of the ultimate oversight for quality and safety at a hospital. Your structure MUST support regularly occurring reports to the Board to assist the members to meet that requirement with enough information to provide adequate oversight. Consider this model:
Board Quality Committee: Provides governance oversight of quality and safety activities
Membership: Board members, CEO, CMO, CNO, Quality Director
Frequency: Quarterly
Focus: Strategic direction, accountability, resource allocation
Quality Council/Executive Quality Committee: Oversees organization-wide quality initiatives
Membership: CEO, CMO, CNO, Department Chiefs, Quality Director
Frequency: Monthly
Focus: Performance data review, priority-setting, resource allocation
Department/Service Line Quality Committees: Focus on specialty-specific quality issues
Membership: Department leadership, physicians, nurses, quality staff
Frequency: Monthly
Focus: Department-specific metrics, improvement projects
Performance Improvement Teams: Address specific improvement opportunities
Membership: Front-line staff, subject matter experts, quality representative
Frequency: As needed (often weekly during active projects)
Focus: Rapid-cycle improvement on specific issues
QAPI Plan Development
Your Quality Assessment and Performance Improvement (QAPI) plan serves as the roadmap for your quality program. CMS requires hospitals to "develop, implement, and maintain an effective, comprehensive, data-driven QAPI program."
A comprehensive QAPI plan should include:
Purpose and Goals: Define what you aim to achieve with your quality program
Scope: Outline which services and departments are covered
Organizational Structure: Document your committee structure and reporting relationships
Roles and Responsibilities: Define who does what in your quality program
Data Collection Strategy: Outline what metrics you'll track and how
Performance Improvement Methodology: Specify your approach (PDSA, Six Sigma, Lean, etc.)
Annual Evaluation Process: Describe how you'll assess the effectiveness of your QAPI program
RESOURCE ALERT! Download a CMS QAPI Plan Template to get started quickly with your hospital's customized plan.
Step 2: Identify and Define Your Key Performance Indicators (KPIs)
Once you have your structure in place, you need to determine what you'll measure. Effective quality programs are data-driven, focused on carefully selected metrics that reflect organizational priorities.
Categories of Quality Metrics
Consider organizing your metrics into these categories:
Patient Safety Metrics
Healthcare-associated infections (HAIs)
Falls with injury
Medication errors
Pressure injuries
Wrong-site surgeries and never events
Handoff communication effectiveness
Clinical Outcome Metrics
Mortality rates
Readmission rates
Complication rates
Length of stay (risk-adjusted)
Disease-specific outcomes (e.g., surgical site infections, sepsis bundle compliance)
Operational Efficiency Metrics
ED throughput times
Door-to-doctor times
Discharge timeliness
Operating room turnover
Bed utilization rates
Patient Experience Metrics
HCAHPS scores
Complaints and grievances
Patient satisfaction surveys
Wait times
Call bell response times
Workforce Metrics
Staff turnover and vacancy rates
Employee engagement scores
Professional development completion rates
Safety culture survey results
Staff injury rates
Selecting the Right Metrics for Your Hospital
Don't try to measure everything! Select metrics that:
Align with your strategic priorities
Address known areas of risk or concern
Include required regulatory and accreditation measures
Cover all dimensions of quality (safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity)
Are actionable (you can influence the results)
Start with about 15-20 high-priority organizational metrics, with additional department-specific measures as needed.
RESOURCE ALERT! Download a KPI Selection Worksheet example from AHRQ to help identify the most important metrics for your organization.
Step 3: Implement Data Collection and Reporting Systems
With your metrics selected, you need reliable systems to collect, analyze, and report the data.
Data Collection Methods
Consider these approaches:
Electronic health record (EHR) reports
Chart abstraction
Direct observation
Patient surveys
Administrative data
Incident reporting systems
Safety culture surveys
Building Your Dashboards
Effective dashboards make data accessible and actionable. Create dashboards that:
Display trends over time
Compare performance to benchmarks
Use visual cues (colors, symbols) to highlight areas of concern
Allow drill-down to more detailed data
Are customized for different audiences (board, leadership, departments, front-line staff)
Reporting Cadence
Establish a regular rhythm for reviewing quality data:
Daily safety huddles for real-time safety issues
Weekly leadership reviews of critical metrics
Monthly department and committee reviews
Quarterly board and organizational performance reviews
Annual comprehensive program evaluation
RESOURCE ALERT! Download a Quality Dashboard Template from IHI from the Institute for Healthcare Improvement's Quality Improvement Essentials Toolkit.
Once you have settled on your committee structure, developed a solid QAPI plan, decided on metrics to measure and a reporting cadence, it is time to get to work on the actual improvement part of the QAPI activities. Join us in Part 2 to learn more about that!