Quality Management

1. Quality Management

2. Objectives

3. Topics

4. Quality & Patient Safety • Our Responsibilities • Quality & Clinical Effectiveness • Patient Safety • Risk Management • Patient Relations • Infection Control • Accreditation

5. Quality Management John Muir Health Board Medical Executive Committee Safety & Performance Improvement Committee Administrative Staff Quality Management Department

6. Quality/Clinical EffectivenessQM Nurses Core Measures CHART process measures Death reviews Sepsis reviews NSQIP Blood reviews Universal Protocol reviews Medical staff peer review Medical staff department support Medical staff committee support PI priority measures 6

7. 2010 Performance Improvement (PI) Priorities* Fall Prevention Pressure Ulcer Prevention Sepsis Management Hand Hygiene Deep-Vein thrombosis (DVT)/Venous Thromboembolism (VTE) Informed Consent Pain Management *Priorities are approved by the Performance Improvement Committee (PIC) 7

8. Analytics Measuring and Reporting Regulatory Data (e.g., Core Measures, Mortality, Hospital Acquired Conditions, Never Events)  Service Line Support (primarily Cardiac but will grow in 2010) On-going Physician Performance Evaluation (OPPE):  Support the Medical Staff Office with data for Physician reappointments Maintain & support Midas QM database Vision: Provide the RIGHT information, to the RIGHT decision maker, in the RIGHT format, at the RIGHT time to support the RIGHT decision 8

9. Patient Relations Patient Relations & QI Coordinators Patient Satisfaction Patient Complaints & Grievances Culture of Caring program Patient Rights oversight Performance improvement projects (Management of disruptive behavior, Senior Leadership Rounding, Patient Interviews, etc.) 9

10. Patient Relations: Concerns / Grievances Patients have a right to present their concerns/complaints, free of interference & discrimination Patients are encouraged to voice concerns to the staff, the California Department of Public Health, or the Joint Commission. Employees have a responsibility to address concerns/grievances in a timely manner (7 days for grievance) Employees are to report all concerns/grievances to Patient Relations Employees are also encouraged to voice their concerns to leadership, quality, CDPH or Joint Commission 10

11. Patient Relations: RDE entry

12. Patient Safety Risk Managers Patient Safety Alert/RDE monitoring Claims management Root Cause Analyses Pro-active risk assessments (FMEA) National Patient Safety Goal Compliance Patient Safety Leadership Team (PSLT) Performance Improvement projects Policy Oversight Culture of Safety Survey for Employee’s 12

13. Patient Safety: Legal Issues Subpoenas: Employees do not accept subpoenas. Send the process server to the Risk Manager or Human Resources Phone Calls:Refer phone inquiries to Public Relations or the Administrative Coordinator on duty Legal Assistance:Employees will be provided legal advice and assistance in any case involving John Muir Health 13

14. Patient Safety: Incident Reporting • Submit a PSA / RDE any time there is: • A patient or visitor injury of any kind • A great catch / near-miss / harmless hit • A medication error or adverse reaction • Behavior issues (staff, physicians, or patients) • Don’t use PSA / RDEs for: • Employee injuries (use the appropriate form) • General complaints about your job • These are confidential – do not mention the incident report in the patient’s chart

15. Patient Safety: RDE risk

16. National Patient Safety Goals Patient identification Communication Medication Safety Health Care Associated Infections Medication Reconciliation Preventing Harm from Falls Patients’ Active Involvement in Care Suicide Risk Assessment Universal Protocol 16

17. Licensing & Accreditation Accreditation organizations include CDPH, CMS, NCQA, TJC Coordinate survey readiness activities Lead monthly CALS committee Maintain Joint Commission Command Center website Coordinate survey activities (CDPH, CMS, NCQA, TJC) Manage submission of corrective action plans and evidence of standards compliance Manage & maintain license with regulatory agencies 17

18. Licensing & Accreditation: Intranet

19. Quality & Patient Safety Intranet Site: For More Info…

20. “The definition of insanity is doing the same thing over and over again expecting different results” Albert Einstein Continuous Improvement 20

21. Key Points

22. Quality & Patient Safety