The following is a guest article by Michelle Hilburn, MSN, RN, CPHQ, CPPS, Associate Vice President of Quality Compliance and Standards at Vastian

Despite healthcare’s growing focus on patient safety and Quality outcomes, many hospitals still rely on outdated methods for managing risks and performance improvement. Handwritten logs, spreadsheets, and email chains continue to be key components when developing and driving action plans. But these standalone systems are generating more problems than solutions, and they are proving to be significant barriers to improving performance.

The fact that many hospitals still use legacy systems when the penalties for hospital-acquired conditions and patient harm events are so severe is alarming. For starters, patient outcomes are at stake, which should be enough motivation to abandon pen and paper in favor of a digital solution. Poor outcomes not only jeopardize patients but can also endanger a hospital’s financial performance and sustainability. Studies have shown that hospital-acquired infections (HAIs) cost approximately $25,000 in unreimbursed costs per case, and penalties under the Hospital-Acquired Condition Reduction Program (HACRP) are averaging $329,000 annually. Beyond these financial metrics, hospitals also risk their reputations when patient volumes, payer negotiations, and public trust are hanging in the balance based on demonstrated safety and Quality excellence.

With reputation, money, and patient well-being on the line, it is time to move beyond manually executed action plans and embrace technology that not only tracks work but drives real and sustained change.

The Weaknesses of Traditional Action Plans

It was Canadian-American psychotherapist Nathaniel Branden who once said, “A goal without an action plan is a daydream.” That fantasy can quickly turn into a nightmare if any of these circumstances are present:

• Fragmented Processes – Quality improvement efforts often live in multiple silos across departments. When corrective actions, audits, and performance data are managed separately, it leads to duplicated work, inconsistent documentation, and missed opportunities for improving outcomes and education. Leaders who lack a hospital-wide view of performance improvement efforts will find it difficult to implement or measure change effectively.
• Manual Inefficiencies – According to recent research conducted by Vastian, hospitals lose an estimated 19 million hours annually due to the lack of automation in Quality initiatives. Those hours represent valuable time spent on repetitive data entry, chasing email follow-ups, aggregating data, and creating reports. That time could, and should, otherwise be invested in proactive risk management and performance improvement activities.
• Tracking Limitations and Accountability Gaps – Manual systems introduce a high risk of human error. A single missed status update or delayed escalation can derail an entire improvement plan. Without a digital audit trail, tasks and responsibilities often get lost in the shuffle, making it hard to hold individuals accountable or advance a plan through to completion.

Why This Matters More Than Ever

Simply put, everything in healthcare is tied to improving outcomes and sustaining high reliability. The regulatory environment is more demanding than ever, with CMS Star ratings, Value-Based Purchasing performance thresholds, and Hospital-Acquired Condition penalties directly impacting a health system’s bottom line. Public performance grades from organizations like The Leapfrog Group influence patient choice and negotiating power with payers. Economic and political uncertainties have healthcare leaders scrambling to understand what’s allowed, what’s not, and what the new penalties for missteps are.

With financial, reputational, and political stakes rising, hospitals can no longer afford to simply check the box when it comes to patient safety, risk mitigation, and Quality improvement. Effective risk assessment and avoidance strategies require systems that bridge planning, execution, and long-term monitoring without the disruption and inherent challenges linked to legacy systems.

How Technology Can Radically Transform Hospital Action Planning

Since traditional action plans have reached their limits, Quality leaders must rethink their approach. Leveraging modern digital technology for performance improvement provides many benefits, including:

• Automation – Automated workflows replace hours of manual follow-up with real-time task assignment, monitoring, and escalation. When an action plan stalls or a deadline is missed, the system instantly alerts relevant stakeholders, ensuring corrective steps are taken without delay. This saves time and keeps momentum moving in a positive direction to ensure improvement.

• Data-Driven Insights – Digital solutions also allow hospitals to link historical performance data with current action plans. Leaders recognize what interventions worked before and which did not, enabling evidence-based decision-making. Data visualization and analytics highlight trends, systemic risks, and areas requiring focused attention.

• Integration – Today’s Quality management solutions unify all parts of an action plan into one system, keeping everyone on the same page with a single source of truth. By consolidating compliance tracking, corrective actions, KPI monitoring, and even incident reporting, hospitals have greater visibility into risks and performance. 

The Path Forward: Making Action Plans Actually Work

To move from “checking a box” to achieving real, sustained improvement, hospitals must shift from legacy methods to digitally enabled strategies. Quality and Risk leaders should look for technology that streamlines processes, centralizes accountability, leverages analytics, and enhances transparency. 

The result is more than just adopting new tools. It will also ignite a cultural transformation in how hospitals approach patient safety and performance improvement. Hospitals that embrace digital action planning will position themselves to meet evolving regulatory demands, strengthen patient trust, and, most importantly, deliver safer, more effective care.

About Michelle Hilburn

Michelle Hilburn, MSN, RN, CPHQ, CPPS, is the current Assistant Vice President of Quality, Compliance & Standards at Vastian, a leading provider of quality management software for hospitals and laboratories. With 29 years in healthcare, including 18 years leading Quality, Risk, Infection Prevention & Regulatory Compliance, as Director, System Director, and VP, she has spent her career championing patient safety. In her current role, Michelle provides strategic and operational insight into the development of Vastian’s Quality management software products and solutions. She represents Vastian as a member of the Leapfrog Partners Advisory Committee.