MEETING MANAGEMENT-

BEST PRACTICES

Reorganizing the Medical Staff & Meeting Management

Improvement

STRUCTURE IS THE BACKBONE OF SUSTAINABILITY

LEAN TENANTS AND PRINCIPALS Janet McClain, RN, MSN, CPHQ, CHC

Quality/Compliance Officer

West Park Hospital

707 Sheridan Ave.

Cody, WY 82414

(307) 578-2219

jmcclain1@wphcody.org

Cindy RohdeMedical Staff Coordinator

West Park Hospital

707 Sheridan Ave.

Cody, WY 82414

(307) 578-2219

Crohde@wphcody.org

OBJECTIVES: LEAN TENANTS/PRINCIPALS

Give examples of measureable

improvement goals

Evaluate the environment

according to the key principles of Lean

Describe the key concepts of performance improvement

WHAT IS LEAN?

“The endless transformation of waste into value from the customer’s perspective.”

It is a System Thinking Concept.

Adapted from James Womack, Juran Institute

KEY PRINCIPLES OF LEAN THINKING

Specify Value in the eyes of the customer.

Identify & eliminate anything that does not add customer value (eliminate waste)

Promote flow – eliminate batching and variation

Make Value flow without

interruptions.

Focus on processes that deliver customer value

All activities (within the Value Stream) are categorized as adding value or creating waste

Identify the Value Stream

for each product.

Let customers pull Value.

Pursue Perfection.

Guiding Principles for Achieving Results

LEAN THINKING

Key Principles

Focus on processes that deliver value

Identify & eliminate anything that does not add value (waste)

What Lean Is Not About…

Making people work harder

Short-cutting value-added processes

Cutting staff!

FLOW

In order to accurately capture the flow:

You must see the flows with your eyes today

You cannot rely on what you’ve heard or seen in the past

Penny Game

Institute for Healthcare Improvement

“Changing the people, or pushing them to “try harder” or “do better” will not result in improved performance.

If we want a new level of performance, we must get a new system.”

MUST TRY HARDER

LEAN HEALTHCARE:

Sustaining the Practice through Structure

OBJECTIVES: LEAN HEALTHCARE

Understand Sustainability and learn how to achieve it

Learn how to develop an effective, proven Quality Improvement Structure

Learn how to prioritize improvement opportunities in your organization

Learn how to integrate Lean with other existing Performance Improvement

methods

SUSTAINABILITY IN ACTION Set and share goals on a regular basis.

This means more than once. Keep them alive!

Communicate, communicate, and communicate!  People need to constantly be reminded of goals and action

plans so that they sink in over time.

Review goals regularly.  Share results.  Enjoy accomplishments but use them to spur greater

progress. Review progress in order to stay on track.

Establish accountability that is truly accountable.  A powerful action plan asks Who, What and When  and

describes the desired outcome.

P&T / Med UtilizationBlood UtilizationMedical Record /

Clinical PertinenceInfection ControlCase ManagementResource

ManagementQIO IssuesRAC /MAC / MIC /

ZPIC

Life Safety / SafetyHazardous MaterialsEquipment / Utilities MgtSecurity / Emergency prepStaff / Visitor IncidentMedication ErrorsIncident Reports / Pt FallsProcedure VariancesAMA’sSentinel Events / FMEAPatient Safety P&P’s

Can only be appointed by Quality Improvement Committee

QIC will create multidisciplinary teams based on priority opportunities

Utilization Review /

Management

EOC / Safety Committee

Quality Improvement

Teams

Op

era

tion

al

Com

mit

tees

Ph

ysic

ian

C

om

mit

tees

Mortality Review / Autopsy

Invasive Procedure Peer Review

Radiology Peer Review

ER Peer ReviewSentinel EventsICD, P&P

Mortality Review / Autopsy

Operative & Invasive Procedure Review

Anesthesia Peer Review

Pathology Peer Review

Sentinel EventsTissue Review

General Medical Staff Committees:

Bylaws Credentialing

Medical Care Review

Surgical Care Review

Op

era

tion

al

Overs

igh

t

Quality Improvement Committee(hospital wide

committee)

Chief or Vice Chief of StaffCEO, CFO, CNOVP or Director of Quality2 other PhysiciansChairs of other committees

Board of Trustees

Medical Executive Committee

Ethics

Execu

tive

Lead

ers

hi

p

Overs

igh

t

QUALITY LEADERSHIP MODEL

Quality Improvement Committee

(hospital wide committee)

Op

era

tion

al

Overs

igh

t

Chief or Vice Chief of StaffCEO, CFO, CNOVP or Director of Quality2 other PhysiciansChairs of other committees

THE QUALITY LEADERSHIP MODEL UTILIZES THE BOARD OF TRUSTEES AND PHYSICIANS’ LEADERSHIP

QUALITY IMPROVEMENT COMMITTEE Membership should consist of:

Small hospitals – at least 2-3 physicians

Medium hospitals – 5-7 physicians

Large hospitals – 5-10 physicians

If Medical Staff will allow, the CEO, CFO, CNO, and Director of Quality should be voting members.

If voting membership is not allowed, they should attend all meetings

QUALITY IMPROVEMENT COMMITTEE Why CFO? If program functions as

designed, a lot of financial issues will have QI teams appointed or will be part of a QI team

Should meet monthly

There is no need for another hospital QI Committee. Joint Commission requires one hospital-wide committee that is responsible for medical staff and hospital quality issues. CMS and States are less specific as long as required functions are performed.

USE LEAN AS YOUR PERFORMANCE IMPROVEMENT METHODOLOGY

Use program to solve majority of problems identified, not just ones that someone feels should have a QI Team appointed.

QI Teams should not be established for any problem that has not been through problem referral, prioritization, and QIC appointment.

QIC FOCUSES ALL PERFORMANCE IMPROVEMENT WORK WITHIN THE HOSPITAL QIC is responsible for appointing all QI

Teams, appointing team leaders, identifying type of team members needed, and holding teams accountable for timely completion of required tasks.

All recommended actions must be submitted to QIC for approval and implementation

MEDICAL STAFF MEMBERSHIP ON THE QUALITY IMPROVEMENT COMMITTEE Some hospitals have included the

Chairpersons of standing committees on QIC to ensure good communication between the committees, but they should only be a part of the membership, not the entire committee, or due process rights could again be questioned.

All QI information must come through QIC before it goes to MEC – including all process issues during peer review. Having a separate peer review committee is unnecessary if this structure is utilized correctly.

MEDICAL STAFF MEMBERSHIP ON THE QUALITY IMPROVEMENT COMMITTEE If Medical Staff is departmentalized, QIC

physician membership should NOT be medical staff department chiefs because they sit on MEC.

Hospital should avoid MEC members serving on QIC if at all possible.

To assure due process is provided to LIPs and physicians, the same physicians should not be rendering decisions of appropriate quality at all levels. Use as many different physicians as possible.

P&T / Med UtilizationBlood UtilizationMedical Record /

Clinical PertinenceInfection ControlCase ManagementResource

ManagementQIO IssuesRAC /MAC / MIC /

ZPIC

Life Safety / SafetyHazardous MaterialsEquipment / Utilities MgtSecurity / Emergency prepStaff / Visitor IncidentMedication ErrorsIncident Reports / Pt FallsProcedure VariancesAMA’sSentinel Events / FMEAPatient Safety P&P’s

Can only be appointed by Quality Improvement Committee

QIC will create multidisciplinary teams based on priority opportunities

Utilization Review /

Management

EOC / Safety Committee

Quality Improvement

Teams

Op

era

tion

al

Com

mit

tees

Ph

ysic

ian

C

om

mit

tees

Mortality Review / Autopsy

Invasive Procedure Peer Review

Radiology Peer Review

ER Peer ReviewSentinel EventsICD, P&P

Mortality Review / Autopsy

Operative & Invasive Procedure Review

Anesthesia Peer Review

Pathology Peer Review

Sentinel EventsTissue Review

General Medical Staff Committees:

Bylaws Credentialing

Medical Care Review

Surgical Care Review

Op

era

tion

al

Overs

igh

t

Quality Improvement Committee(hospital wide

committee)

Chief or Vice Chief of StaffCEO, CFO, CNOVP or Director of Quality2 other PhysiciansChairs of other committees

Board of Trustees

Medical Executive Committee

Ethics

Execu

tive

Lead

ers

hi

p

Overs

igh

t

QUALITY LEADERSHIP MODEL

Based on our culture WPH chose

different models.

WPH COMMITTEE ORGANIZATIONAL CHART

EOC Committee

•Life Safety / Safety•Hazardous Materials•Equipment / Utilities Mgmt•Security•Emergency Prep•P&P’s

Accreditation Readiness Committee

•CMS / Joint Commission•LTCC•CMC / Behavioral Health•Home Health / Hospice•Lab

PI / Patient Safety Committee

•Operational Clinical Dept PI•Operational Non-Clinical Dept PI•RCA’s•Unusual Events•Medication Errors•Patient Falls•Safety Award Program

•Highlights of Minutes:•LTCC/Home Health/Hospice PI Cmt•Falls Cmt•EOC Cmt

Quality Improvement

Teams

• Can only be appointed by Quality Improvement Council

• QIC will create multidisciplinary teams based on priority opportunities

• LEAN Projects

Quality Improvement Council

BEFORE REORGANIZATION MSS RESPONSIBLE FOR…

56 Medical Staff members

16 Medical Staff Committee

Monthly General Staff Meetings

Averaged 2-3 meetings per week or 10-13 meetings per month depending on schedule

HOW WE DID THIS…. IT WASN’T EASY!

Lean Training w/ Management QI/MSS meets to begin process QI meets with Administration CEO/QI/MSS meets w/

Consultant QI/MSS meets w/CoS; V-CoS;

current QI or PIT Chair We propose changes to MEC Meet with all Committee Chairs

(This did not go well!!!)

QI/MSS meets w/ MEC (again) QI/MSS meets w/ all Committee

Chairs (again) w/ consultant QI proposes changes to Board

of Trustees

QI/MSS meets with MEC (3rd time is the charm!!!) to finalize

QI/MSS meets with Medical Staff for input

APPROVED BY MEC – YAHOO!!!! APPROVED BY Medical Staff – WAHOO!!! MEC begins assigning membership to

committees QI/MSS presents to Management Team

Implementation BEGINS!!!!!

DON’T EVER GIVE UP!!

AFTER REORGANIZATION (7/2014)WHAT WE DID…. Hired Trauma Coordinator / Moved Trauma

Committee out of MSS Combined Medicine & Psych/Detox Eliminated Infection Control Committee

(Functions moved into Surgery/Anesthesia & Medicine)

Blood Utilization reports moved to Surgery/ Anesthesia

Decreased # of General Medical Staff meetings

Bylaws Committee meets as needed Total 10 Committee’s

WPH Medical Staff Committee

Organization

WPH Board

Medical Executive Committee

Quality Improvement Council

Co-Chairs Vice COS & CEOCFO,CCO

Quality DirectorBoard Member

Medical Staff Committee ChairsSurgery/Anesthesia

MedicineOB/Peds

Emergency Medicine

Medical Staff Committees

Medicine (combines)Med/CCU

Psych/Detox(Infection Control becomes

agenda item)

Surgery/Anesthesia(combines) AnesthesiaSurg/Anes

(Infection Control & Blood Util will be agenda items)

OB/Pediatrics

Emergency Med

General Medical StaffMeets Every Other Month

Medical Staff Committees

BylawsCredentialing

EHRTrauma

UR/CM-Medical Records

P&T / Med Utilization

Med Staff Function

Credentialing

Quality Oversight

Each of 4 Medical Staff Committee Meetings:

Medical Staff PIMinutes

P&P’s

Executive Session:Peer Review

OTHER LEAN CONCEPTS ADOPTED BY MSS

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MEETING MANAGEMENTDo you know how much time you

spend in meeting preparation?

I thought I did…..boy was I wrong!

LEAN - Track every step and how much time it takes.

<See Meeting Tracking Tool>

BEFORE REORGANIZATION

Date Name of Meeting*Pre-Prep

Time*Meeting Day

Time*Post Meeting

F/U*Total Min Total Hours

Total Hrs per Week

March

3/18/14 General Medical Staff 38 233 94 365 6

3/20/14 EHR Committee 10 90 73 173 2.8 8.8

3/25/14 Credentials Committee 74 99 37 210 3.5

3/25/14 Psych/Detox 49 100 20 169 2.8

3/26/14 Anesthesia 35 167 58 260 4.3 10.6

April

4/8/2014 P & T Committee 17 121 49 187 3.1

4/11/2014 MEC 65 235 113 413 6.8 9.9

4/17/2014 EHR Committee 42 105 54 201 3.35

4/18/2014 Emergency Medicine 44 126 56 226 3.8 7.15

4/22/2014 Credentials 82 172 48 302 5

4/23/2014 Anesthesia Committee 42 90 52 184 3.65

4/23/2014 Surgery Committee 57 125 61 243 4.5 13.15

*Time measured in minutes

NEW PROCESSES IMPLEMENTED

$$ Spent in the Beginning

Saves You Time in the End

Purchased Color printer for MSS Projector 2nd Lap Top

Paper light process implemented Decreased copy time Only copy agenda’s,

pertinent documents

Meeting Management Consent agenda Adhere to Roberts

Rules of Order

Email Meeting Notifications and Attachments – 1 week prior

THANK

YOU!!

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Thank You!