Quality Corner
August and September Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee [QIPSC],
chaired by Joseph Hopkins, associate chief of staff
JCAHO - Periodic Performance Review (Conducted July 24-28)
• Best practices/excellent performance:
- Medical Education in clinics
- Medication Reconciliation
- Psychiatry service
- Dialysis
- Kitchen
- OR region
- Others
• System and practice improvements:
- Data aggregation and analysis
- Comparable care and consistent policies/procedures
- Physician quality profiles
- Hand hygiene (see related article)
- OR “time out”
TB testing and communicable disease screening is required by Title 22 of all physicians on the medical staff. A comprehensive implementation plan will be rolled out in mid-October.
Annual Infection Control [IC] Plan for 2006
• IC Department complimented by JCAHO surveyors for its work and data analysis
• Services provided by IC
- Consultation
- Education
- Policies and procedures
- Surveillance (including data for infection control rates in selected units)
- Cluster investigations (such as chicken pox investigations and follow-up)
- Performance improvement projects
- Continuous readiness
• Risk Assessment Grid in line with JCAHO standards, including evaluation and action plan for pandemic preparedness
• Education plan for SHC staff on policies and procedures
Overall marked improvement with DVT prophylaxis reported by OR Medical Director Richard I. Whyte
Visiting Observers Policy
• Applies to individuals who want to observe a procedure at SHC or LPCH or affiliates
• Intended to help ensure that SHC/LPCH policies are followed and that protected health information is used and/or disclosed appropriately
• Faculty and community physicians must accompany visitor observers whom they bring into the facility
Kidney/liver transplants - presented by multi-organ transplant faculty member Waldo Concepcion
• Performance Improvement effort has resulted in statistically significant improvements in clinical outcomes.
• Key components of success
- Passionate commitment to excellence
- Standardization of processes
- Close supervision of trainees
- Use of data to identify opportunities and monitor improvement
- Specialized, interdisciplinary teams
Core Measures - Pneumonia and Heart Measures teams formed
• Both multidisciplinary teams to develop a concrete and sustainable process for achieving best practice performance
• Teams will be led by physician champions and the assistant director of QIPSD, Kerin Bashaw
Strategic Use of Data Task Force
• Small group will evaluate the use of aggregated clinical data and processes for analysis
• Task force will recommend the fiscal year ’07 process improvement priorities and ongoing metrics to ensure that identified goals, including ’07 strategic goals, are aligned and then met
• Reporting templates and mechanisms will work toward consistency and use of statistically relevant analysis
