Quality Corner

February Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff

• Physician Leadership Projects
  • Thirty percent of the 26 physician leadership trainees are doing academic projects, while the other 70 per cent are completing hospital-related projects in such areas as marketing or business plans, quality projects or development of new services.
  • The program is rated a success and has been approved to be repeated next year.
• FMEA [Failure Mode and Effects Analysis] on PCA [Patient Controlled Analgesia] Pumps
  • The multidisciplinary team achieved a dramatic improvement in the ability to ensure safe administration of patient controlled analgesia.
  • Sources of potential errors have been removed.
• Cardiac Services Quality Report included discussions of:
  • QI Initiatives
    • Reduce mean ICU length of stay
    • Reduce extubation time
    • Reduce incidents of delirium, Afib and complications
  • Continue to monitor CT surgery complication types – focusing on:
    • Mediastinities infection rate
    • Sternal wound infections
    • Surgical site infections
    • Pressure ulcers
• H-CAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems]
  • To avoid cuts in Medicare reimbursement, hospitals will need to participate in this public-private initiative, which was created to uniformly measure and publicly report patients’ perspectives of their inpatient care.
  • *Standardized surveys of patients’ experiences with ambulatory and inpatient care are being developed by the program. Results are expected to be released this summer.
• Medication Reconciliation
  • An extensive education and promotion program is under way to remind physicians of the patient safety need to verify and ensure prescription drug verification and compliance.
  • An RN has been assigned to review charts and to contact physicians to ensure that Medication Reconciliation checklists are completed.
• Communications
  • All members of the health care team have a duty to advocate for the patient through the organizational chain of command whenever they are concerned that a patient’s condition is not being adequately addressed, or they have concerns about decisions being made in the care of the patient.
  • Clinical and administrative lines of authority are established to ensure effective conflict resolution in patient care situations. The chain of command should follow:
    • 1. Immediate supervisor
    • 2. If unresolved, the individual should speak to the supervisor’s manager, and from there, up the chain of command as necessary.
    • 3. The final authority on the chain of command is the Chief of Staff or his/her designee.
  • SHC has a draft policy on Chain of Command that needs to be finalized before implementation.
  • All medical staff members are asked to remind house staff members of the importance to rapidly move up the chain-of-command to senior residents, fellows and attending physicians whenever there is uncertainty about a patient’s condition or management.