HABERSHAM MEDICAL CENTERHABERSHAM MEDICAL CENTER

Quality Leadership to Quality Leadership to Improve Improve

ORGANIZATIONAL ORGANIZATIONAL PERFORMANCEPERFORMANCE

20122012

Habersham Medical CenterHabersham Medical Center

HOSPITAL AUTHORITY has the final ultimate responsibility for the qualityand safety of patient care.

GOAL:GOAL: design processes well, to design processes well, to identify, prioritize, and identify, prioritize, and

systematically monitorsystematically monitor to to improve patient outcomesimprove patient outcomes

Authority By-Laws to create a Authority By-Laws to create a Quality CommitteeQuality Committee

Challenge: Integrating the current quality program

into the new structure Design meaningful information for

Committee members Meet the requirements of the Hospital

Authority

By-laws

Quality Committees will:Quality Committees will:

Have different levels of authority QCC will be subject to QLSC and MEC

Conduct business under the state statute of “Peer Review” protection: Statute O.C.G.A. 31-7-131.

Receive metrics, reports and dashboards

Medical Peer ReviewMedical Peer Review

Immediate resolution of unusual or urgent events or a trended practitioner related trend requires another system of review including peer review if necessary.

Peer Review (Nurse, Physician, other healthcare providers) is utilized for determining actions to be taken in response to events and/or trends in a timely manner.

1. Actively reporting errors, near misses/close calls, and hazardous conditions when recognized.

2. Participating in disclosure of unanticipated outcomes, working with the leadership, and following hospital policy on process for unanticipated outcomes.

3. Comprehending and adhering to policies and procedures addressing patient safety.

Medical StaffMedical Staff

Patient SafetyPatient Safety

HMC integrated several Committees that address the safety of our patients, visitors, staff, and Medical Staff:

QLSC , QCC, PCSC, MEC/QI

EOC/Safety CommitteeEOC/Safety Committee Medical Equipment Management Hazardous Waste Management Fire Safety Management Disaster Preparedness Infection Prevention/Infection Control Risk

Assessment Workman Compensation Reports Accident Prevention Recalls Security Management Utilities Management Plan

Patient Care Safety CouncilPatient Care Safety Council(PCSC)(PCSC)

Product Review MEC and QLSC Summaries Regulatory Compliance Patient Safety and Alerts Quality Indicators Departmental Chart Reviews QCC Chartered Team Reports

Clinical Steering CommitteeClinical Steering Committee

Restraint Falls Medication Management

Medication Error Report Medication Reconciliation

Blood Utilization National Patient Safety Goals

Patient Care Treatment Services Patient Care Treatment Services (PCTS)(PCTS)

Medical Records Compliance Information Management Pharmacy and Therapeutic Forms Patient Care Policies and Procedures

Medical Executive Committee Medical Executive Committee (MEC)(MEC)

Lateral to QCC in organizational chart

Medical QI Review

Final Patient Care approval for forms/policies/& procedures

Credential and Privileging

Hospital Authority By-LawsHospital Authority By-Laws

“Medical Review Committee”

“Evaluate and improve the quality of health care rendered, to determine that health care services were professionally indicated, performed in compliance with the applicable standard of care and the cost of health care rendered, PI efforts, patient and peer evaluations of health care services rendered and costs of such care.”

Quality Care Committee Quality Care Committee (QCC)(QCC)

Lateral to MEC in organizational chart Quality indicators upcoming for public

reporting Departmental Reviews Charter Team Review Mortality Review (overall) Patient Satisfaction concurrent review Blood Utilization Current Core Measure Data

Quality Care Committee Quality Care Committee (QCC) (QCC)

Management has developed an approach to restructure information for Medical Review, Public Reporting and Cost Analysis for the Authority Committee.

This committee will be named:“Quality Leadership Steering

Committee”=QLSC

Committee will continue to monitor patient outcomes and internal processes that contribute to quality, patient satisfaction and high risk problem prone patient care processes.

This working committee will be named:“Quality Care Committee”= QCC

Quality Leadership Steering Quality Leadership Steering CommitteeCommittee(QLSC)(QLSC)

Membership: Physician members of Hospital

Authority One non-physician member of HA Chief of Medical Staff Chair of QCC Hospital staff: CEO, SVP Pt. Care, and

VP of Quality

Authority of Quality Leadership Authority of Quality Leadership Steering Committee (QLSC)Steering Committee (QLSC)

All Public Reports Patient Satisfaction Mortality Rate (AMI-HF-PN) Hospital Acquired Conditions Readmission Rates (AMI-HF-PN) Medical Staff Performance Price Transparency Report QCC Activity Reports

Authority of HMCAuthority of HMC

Authority of QualityAuthority of Finance

Medical Executive Committee

(MEC)

Quality Care Committee

(QCC)

Patient Care Treatment Services

(PCTS)

Administrative Team

Patient Care Safety Council

(PCSC)

Clinical Steering Committee Environment of Care Committee

(EOC/Safety)

Flow of information to the Flow of information to the bedside…bedside…

After information is approved and passed through the chain of command: Medical Staff

Power point review of committee minutes are reviewed every other month.

Patient Care Safety Council Information taken to staff meetings

from the PCSC minutes.

AccountabilityAccountability

Performance Measures Medical Staff

Provider information sent to MEC and points are appointed, as appropriate.

Clinical StaffClinician information sent to

Clinical Peer Review and points are appointed, as appropriate.

Education provided, as identifiedDiscipline action taken for

identified trending

Questions ??