UHC MD / APP Profile Form (Example) - LSU Health Shreveport

1

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER – SHREVEPORT

(HOSPITAL WIDE)

PERFORMANCE IMPROVEMENT AND PATIENT SAFETY PLAN

2013

Leisa Oglesby, BSRN, MBA, CPHQ Date Executive Director of Medical Services Kevin Sittig, MD Date Senior Associate Dean for Clinical Affairs/ Chief Medical Officer Joseph Miciotto Date (Board Approval) Hospital Administrator The information, data and reports used in the Medical Staff and Resident Peer Review Process may only be provided to the following for review: The attribution physician, the Department Chairperson of the attribution physician, the Medical Director and, in cases involving litigation, Legal Affairs

2

Table of Contents Performance Improvement and Patient Safety

Performance Improvement Plan

I. Introduction 3

II. Performance Improvement & Patient Safety Goals 5

III. Design 6

IV. Measure 6

V. Assess 7

VI. Improve 18 VII. ATTACHMENTS:

A. 2012 PI Communication Process Attachment A B. LSUHSC-S PI Reporting Process Attachment B C. LSUHSC-S Performance Improvement Cycle Attachment C D. 2012 Hospital Wide Generic Indicators Attachment D E. Medical Staff, Resident & APP Peer Review Process Attachment E F. Medical Staff, Resident & APP Appeal Process Attachment F G. MD/ APP Profile Form Attachment G H. FPPE Process Attachment H I. OPPE Process Attachment I J. Physicians Profile Report Attachment J K. Adjunctive Staff OPPE Process Attachment K L. Adjunctive Staff FPPE Process Attachment L M. Electronic Health Record (EHR) Meaningful Use Measures

(Stage One Measures) Attachment M N. 2013Variance Process Attachment N

3

PERFORMANCE IMPROVEMENT & PATIENT SAFETY PLAN

INTRODUCTION

The Performance Improvement and Patient Safety Plan is a description of the organizational, multidisciplinary, and systematic performance improvement function designed to support the Mission, Values, and Philosophy of the University Health Sciences Center. The Performance Improvement Communication Process may be found in (Attachment A). The intent of the Performance Improvement and Patient Safety Plan is to identify the facility’s systematic approach to improving and sustaining its performance through the prioritization, design, implementation, monitoring, and analysis of performance improvement initiatives. Moreover, the Performance Improvement and Safety Plan is an ongoing program that demonstrates measurable improvement in indicators for which there is evidence that they will improve patient outcomes, and identify and reduce medical errors. All Performance Improvement and Patient Safety activities / processes are depicted in (Attachment B). In accordance with the 2012 Joint Commission (TJC) Standards, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (COPs) and the vision of the facility established expectations include but are not limited to:

1. Providing a safe environment for patients, visitors, and staff. 2. Performing patient care services in a timely and efficient manner. 3. Participation of all staff in Performance Improvement activities.

The Performance Improvement and Patient Safety Plan, with total support of Leadership, will utilize internal and external reference databases in an ongoing effort to design, measure, assess, and improve the organization (Attachment C). The needs, opinions, and perceptions of safety risks to patients, visitors, and staff as well as suggestions for improvements are also incorporated into the plan. The organization’s approach to Performance Improvement and Patient Safety is guided by, but not limited to, the following Joint Commission standards:

PI.01.01.01 The hospital collects data to monitor its performance. PI.02.01.01 The hospital compiles and analyzes data. PI.02.01.03 The hospital improves its performance on ORYX accountability measures. PI.03.01.01 The hospital improves performance on an ongoing basis. LD 01.03.01 The governing body is ultimately accountable for the safety and quality of

care, treatment and services. LD.02.01.01 The mission, vision, and goals of the hospital support the safety and

quality of care, treatment, and services. LD 02.02.01 The governing body, senior managers and leaders of the organized

medical staff address any conflict of interest involving leaders that affect or could affect the safety or quality of care, treatment and services.

4

LD 02.03.01 The governing body, senior managers and leaders of the organized medical staff regularly communicate with each other on issues of safety and quality.

LD 02.04.01 The hospital manages conflict between leadership groups to protect the

quality and safety of care. LD 03.01.01 Leaders create and maintain a culture of safety and quality throughout the

hospital. LD 03.02.01 The hospital uses data and information to guide decisions and to

understand variation in the performance of processes supporting safety and quality.

LD 03.03.01 Leaders use hospital-wide planning to establish structures and processes that focus on safety and quality.

LD 03.04.01 The hospital communicates information related to safety and quality to

those who need it, including staff, licensed independent practitioners, patients, families, and external interested parties.

LD.03.05.01 Leaders implement changes in existing processes to improve the

performance of the hospital. LD 03.06.01 Those who work in the hospital are focused on improving safety and

quality. LD.04.01.07 The hospital has policies and procedures that guide and support patient

care, treatment, and services. LD 04.01.11 The hospital makes space and equipment available as needed for the

provision of care, treatment, and services. LD 04.02.01 The leaders address any conflict of interest involving licensed independent

practitioners and/or staff that affects or has the potential to affect the safety or quality of care, treatment, and services.

LD 04.03.01 The hospital provides services that meet patient needs. LD 04.03.07 Patients with comparable needs receive the same standard of care,

treatment, and services throughout the hospital. LD 04.03.09 Care, treatment, and services provided through contractual agreement are

provided safely and effectively. LD 04.03.11 The hospital manages the flow of patients throughout the hospital. LD.04.04.01 Leaders establish priorities for performance improvement.

5

LD 04.04.03 New or modified services or processes are well designed. LD.04.04.05 The hospital has an organization-wide, integrated patient safety program

within its performance improvement activities.

LD.04.04.07 The hospital considers clinical practice guidelines when designing or improving processes.

Performance Improvement & Patient Safety Goals

The hospital’s approach to performance improvement is continuously assessed and revised to meet the goal of ensuring that patient outcomes are continually improved and safe patient care is provided. Examples of information utilized to achieve this goal include: variance related data such as medication errors and falls; infection control surveillance; sentinel event alerts; and TJC/CMS Quality Measure data, as well as, patient satisfaction reports. Staffing effectiveness data focusing on patient complaints, patient falls, staff turnover and employee injuries is also addressed. The hospital recognizes that to be effective in improving patient safety there must be an integrated and coordinated approach to reducing errors. To such an end, Louisiana State University Health Sciences Center has a Performance Improvement/Patient Safety list of goals that include, but are not limited to the following high risk, high volume, high cost, and potentially increased patient safety risk priorities:

1. Achievement of a Patient Safety conscious environment integrated throughout the

facility. 2. Improve the reporting of medical errors by establishing a policy focusing on

corrective actions through staff education for those reporting their errors, rather than punitive or disciplinary actions.

3. Implementation of a confidential online Variance/Sentinel Event reporting process that identifies a safety risk index to analyze harm score distribution for reported incidences.

4. Monitoring of hospital-wide indicators in comparison to their thresholds. 5. Reducing the number of medication errors. 6. Monitoring completion of informed consent. 7. Reducing the number of falls. 8. Decreasing staff turnover rates and retention of qualified staff by monitoring

staffing effectiveness. 9. Develop a process to address right site surgery.

10. Monitoring of patient safety indicators related to an area’s specific “Scope of Service.”

11. Identifying an area for improvement and completing a Failure Mode, Effects Analysis.

12. Monitoring and improving areas identified through Patient Satisfaction.

6

DESIGN In order to design or redesign effective processes, functions or services, the following key elements are considered when relevant and available:

1. The process design is based on the organization’s mission, vision and strategic imperatives.

2. Consideration is given to the needs and expectations of patients, staff, and others, as well as, the direct effect or criticality of the design on patients.

3. Research of current literature and practice guidelines are reviewed for successful or best practice(s).

4. Design is consistent with sound business practices. 5. Baseline performance expectations are utilized to guide measurement and

assessment activities. Performance monitoring and evaluation standards are department, division, service line and/or population focused. Certain processes are measured on an ongoing basis both in response to occurrences and proactively. Selected processes which are high volume, problem prone, high risk, and high cost are measured on an ongoing basis using the four step TJC Cycle for Improving Organizational Performance, Design, Measure, Assess, and Improve. Performance Improvement projects that are designed or redesigned to monitor expected performance within the hospital are developed to measure, assess, improve and maintain process improvements. Performance levels may be established through comparison performance with other “like” facilities to identify variations or “failure modes.” Comparative data is used from the UHC, NACHRI, LHCR, or current/past department performance. Each activity monitored has an established performance level or threshold to measure expected performance. A strategy for maintaining the effectiveness of the redesigned process over time is also implemented.

MEASURE Data collection is the basis of all Performance Improvement activities and provides a means of measuring performance through which informed decisions can be made.

1. Program data is collected for a comprehensive set of performance measures based on the priorities established by the leaders of the organization in order to: a. Establish a baseline when a process is implemented or redesigned. b. Describe process performance or stability. c. Describe the dimensions of performance or stability. d. Describe the dimensions of performance relevant to functions, processes, and outcomes. e. Identify areas for improvement including the effect on patients. f. Determine whether changes in a process have met objectives g. Implement a strategy for maintaining the effectiveness of the redesigned process over time.

2. Data is collected as a part of continuing measurement, in addition to data collected for priority issues.

3. Data collected considers measures of processes and outcomes. 4. Data collection includes at least the following processes or outcomes:

7

a. Operative and other invasive and noninvasive procedures that place patients at risk b.Processes related to medication usage/errors c. Processes related to the use of blood and blood components d. Needs, expectations, safety, and satisfaction of patients e. Quality Control Activities

1. Clinical and Support Departments 2. Medical Staff Departments 3. Medical Staff Committees 4. Variance Reporting 5. Patient Satisfaction 6. Patient Complaints

ASSESS Program activities involve the assessment process, which includes the necessary discipline of departments to draw conclusions about the need for more intensive measurement. A systematic process is used to assess collected data in order to determine whether specifications for newly designed processes were met and the level of performance and stability of important existing processes. Priorities for possible improvements or redesign of existing processes, actions taken to improve the performance improvement processes and whether changes in the processes resulted in improvement are also assessed. Collected data is reported monthly and analyzed quarterly. Findings are documented and are forwarded through the performance improvement communication structure. Quarterly reports are compiled through the Quality Management Department and reviewed by the Quality Leadership Team. Quarterly reports would include the following:

• Variance Report – LSUHSC will utilize online variance reporting (Attachment N) to identify events or occurrences requiring rapid problem solving. Variances are forwarded to the Quality Management Department for investigation. Variances, including patient safety issues, are forwarded to the Safety Department for prompt investigation, reporting to external agencies in accordance with law and regulation, resolution, tracking and trending. Any employee or physician who witnesses an unusual or unexpected event, which has the potential to result in an undesirable outcome for the patient, may initiate variance reports. Risk reduction and appropriate problem solving will be documented, tracked and trended. A Harm Score Distribution is used to assess the degree of risk. Certain serious outcomes will be reported to the State of Louisiana and other regulatory agencies as required. Monthly and Quarterly results are reported to the Quality Leadership Team and action taken as appropriate.

• Patient Satisfaction – Patient Satisfaction surveys are utilized to evaluate the needs

and expectations of patients including safety needs. AVATAR coordinates and submits the Inpatient Satisfaction Survey results to CMS to ensure compliance with the HCAHPS requirements and these survey results are reported quarterly to the Quality Leadership Team for follow up internally. The Quality Management Department works in concert with the Ambulatory Care Division to compile and

8

submit Outpatient Satisfaction Survey results. The Quality Leadership Team and Clinical Board review a summary of the findings quarterly. When opportunities for improvement are identified, pertinent information is forwarded to the appropriate department or individual for review, evaluation, and action as necessary.

• Patient Complaints – The Patient Relations Department is a resource to patients

and families in helping address unmet needs or complaints that have not been resolved through front-line efforts. Patient Issues Committee facilitates the patient grievance process. The activities provide resolution to enhance the patient’s experience.

• Sentinel Event - Sentinel events are one source of identification of opportunities

for improvement. LSUHSC has adopted The Joint Commission’s (TJC) definition of a sentinel event, which states, “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof,” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. The terms “sentinel events” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events. Events may include unanticipated death or major permanent loss of function, an infant abduction, an infant discharged to the wrong family, rape by another patient or staff, hemolytic transfusion reaction, surgery on the wrong patient or wrong body part, equipment malfunction resulting in paralysis or loss of life, medication error resulting in death or near death, nosocomial infection resulting in unanticipated death or major permanent loss of function, or suicide of an inpatient. Root Cause Analysis (RCA) is a process for identifying the basic or causal factors that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individual performance. A standardized format developed by the TJC called a RCA, Root Cause Analysis, has been adopted to investigate all sentinel events. An “adverse outcome that is directly related to the natural course of the patient’s illness or underlying condition, except for suicide in the hospital, or any “Near Miss” in which a recipient of care was not actually or permanently affected is not considered a reportable sentinel event.”

• Near Miss –A near miss represents an opportunity to proactively identify and

implement a risk- reduction strategy and action plan that includes measurement of the effectiveness of process and system improvements to reduce risk. LSUHSC has adopted the Joint Commission’s definition of a near miss, which states, “any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome. Such a near miss falls within the scope of a definition of a sentinel event, but outside the scope of those sentinel events that are subject to review by The Joint Commission under its Sentinel Event Policy.”

9

• TJC / CMS Quality Measures - LSUHSC participates in the UHC Clinical Database for monitoring and reporting of TJC/CMS Quality Measures. TJC / CMS Quality Measures were designed to permit more rigorous comparisons using standardized, evidenced based measures to identify performance outcomes. The Core Measures have been added to the list of hospital-wide indicators for the Medical Staff and Resident Peer Review Process The following is a list of the inpatient and outpatient core measures and their related indicators for 2013:

• INPATIENT and OUTPATIENT CORE MEASURES:

INPATIENT Core Measure GROUP

INDICATORS

AMI ACUTE MYOCARDIAL INFARCTION

AMI-01 ASA at arrival or contraindication documented

AMI-02 ASA prescribed at discharge or contraindication documented

AMI-03 ACEI or ARB for LVSD prescribed at discharge or contraindication documented

AMI-05 Beta Blocker prescribed at discharge or contraindication documented

AMI-07 Fibrinolytic therapy received within 30 minutes of hospital arrival

AMI-08 PCI received within 90 minutes of hospital arrival

AMI-10 Statin prescribed at discharge PN PNEUMONIA

PN-03a Blood cultures performed within 24 hrs prior to / or 24 hrs after hospital arrival

PN-03b Blood cultures performed in ED prior to initial antibiotic received

PN-06a Initial antibiotic selection for CAP in Immunocompetent patient (ICU)

PN-06b Initial antibiotic selection for CAP in Immunocompetent patient (Non-ICU) CHF CONGESTIVE HEART FAILURE

CHF-01 Written discharge instructions for CHF include: Level of activity, diet, medications, follow-up appointment, weight monitoring, and worsening of symptoms – documented that educational material given to pt.

CHF-02 Documentation of LVS function evaluated before arrival, during hospitalization or planned after discharge

CHF-03 Documentation of ACEI and/or ARB prescribed at discharge for patient with LVSC (LVEF,40%) or contraindication documented for BOTH ACEI and ARB

10

• INPATIENT and OUTPATIENT CORE MEASURES (continued):

INPATIENT Core Measure GROUP INDICATORS

ED ED -THROUGHPUT

ED-01 Median Time from ED arrival to ED Departure for Admitted ED Patients

ED-02 Admit Decision Time to ED Departure Time for Admitted Patients

IMM GLOBAL IMMUNIZATION MEASURE SET

IMM 1b Pneumococcal Immunization- Age 65 and older

IMM 1c Pneumococcal Immunization- High Risk Populations (Age 6 through 64 years)

IMM 2 Influenza Immunization SCIP SURGICAL CARE IMPROVEMENT PROJECT

SCIP INF-1 Prophylactic antibiotic received within 1 hour prior to surgical incision

SCIP INF-2 Prophylactic antibiotic selection for surgical patients

SCIP INF-3 Prophylaxis antibiotics discontinued within 24 hours after anesthesia end time

SCIP INF-4 Cardiac surgery patients with controlled 6 a.m. post-operative serum glucose

SCIP INF-6 Surgery patients with appropriate hair removal

SCIP INF-9 Urinary catheter removed on post-op Day 1 or post-op Day 2 with day of surgery being day zero

SCIP INF-10 Surgery patients with peri-operative temperature management

SCIP Card-2 Surgery patients on Beta Blocker Therapy prior to arrival who received a beta blocker during the peri-operative period

SCIP VTE-1 Surgery patients with recommended venous thromboembolism prophylaxis ordered

SCIP VTE-2 Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

HBIPS HOSPITAL-BASED INPATIENT PSYCHIATRIC SERVICES

HBIPS-1 Admission screening for violence risk, substance abuse, psychological trauma history and patient strengths completed

HBIPS-2 Hours of physical restraint use

HBIPS-3 Hours of seclusion use

HBIPS-4 Patients discharged on multiple antipsychotic medications

HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification

HBIPS-6 Post discharge continuing care plan created

HBIPS-7 Post discharge continuing care plan transmitted to next level of care provider upon discharge

11

• INPATIENT and OUTPATIENT CORE MEASURES (continued):

INPATIENT Core Measure GROUP

INDICATORS

STK STROKE

STK-1 Venous Thromboembolism (VTE) Prophylaxis

STK-2 Discharged on Antithrombotic Therapy

STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK-4 Thrombolytic Therapy

STK-5 Antithrombotic Therapy by End of Hospital Day 2

STK-6 Discharged on Statin Medication

STK-8 Stroke Education

STK-10 Assessed for Rehabilitation

VTE VENOUS THROMBOEMBOLISM

VTE-1 Venous Thromboembolism Prophylaxis

VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis

VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy

VTE-4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol

VTE-5 Venous Thromboembolism Discharge Instructions

VTE-6 Incidence of Potentially-Preventable Venous Thromboembolism

OUTPATIENT Core

Measure GROUP

INDICATORS

SCIP SURGICAL CARE IMPROVEMENT PROJECT

OP-6 Timing of Antibiotic Prophylaxis (Prophylactic ABX initiated within 1 Hr. prior to Surgical Incision)

OP-7 Antibiotic Selection

ED ED -THROUGHPUT

OP-18 Median time from ED arrival to ED departure for discharged ED patients

OP-19 Transition record with specified elements received by discharged patients

OP-20 Door to Diagnostic Evaluation by a Qualified Medical Personnel

PM PAIN MANAGEMENT

OP-21 Median Time to Pain Management for Long Bone Fracture

STROKE STROKE

OP-23 Head CT/MRI scan results for Acute Ischemic Stroke or Hemorrhagic Stroke patients who received head CT/MRI scan interpretation within 45 minutes of ED arrival

12

• Hospital-Acquired Conditions - Foreign object retained after surgery - Air Embolism - Blood incompatibility

- Stage III and IV pressure ulcers - Falls and Trauma

Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Other Injuries

- Manifestations of poor glycemic control Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity

- Catheter-associated urinary tract infection (UTI) - Vascular catheter-associated infection - Surgical site infection following:

o Coronary Artery Bypass Graft (CABG) – Mediastinitis o Bariatric Surgery for Obesity

Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery

o Certain Orthopedic Procedures Spine Neck Shoulder Elbow

o Following Cardiac Implantable Electronic Device (CIED) - Deep vein thrombosis (DVT)/Pulmonary embolism (PE) following:

o Certain Orthopedic Procedures Total Knee Replacement Hip Replacement

- Iatrogenic Pneumothorax with Venous Catheterization Any performance measure outlier is investigated to determine reasons expected performance was not achieved. The Quality Management Department identifies outlier cases and determines which departments need to improve performance.

o Central Line Associated Bloodstream Infections (CLABSI), as defined by the Centers for Disease Control and Prevention (CDC) - The tracking and reporting of Central Line Associated Bloodstream Infections (CLABSI) as defined by the CDC and to meet the requirements of the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program will be managed by the Infection Control Department. The annual Infection Control Plan will specify the frequency of reporting in detail.

13

• Pelican / EPIC reports - The transition over to the Electronic Health Record (EHR) that began in November 2011 continues to evolve. The previously utilized Patient Safety Report (Quality Performance Report) will now be replaced by reports accessed by the departments via the Reporting module from within the EPIC systems. An example of one of the Reporting modules is the WILLOW module; which is utilized by the Pharmacy Department to capture and report various Medication Administration functions for the hospital. Reports are being developed to track various patient safety areas of concern within the hospital based on EHR attestation requirements, as well as Meaningful Use requirements (see also attachment M). The new EPIC reports shall be accessed by individual departments and scheduled for reporting (daily, weekly, monthly, quarterly, etc.) to hospital administration as deemed appropriate based on data content. Areas of concern include:

Eligible Professional (EP) Measures: EP Core Objectives

• CPOE Drug-Drug and Drug-allergy checks Up-to-Date Problem list Maintain Medication List Maintain Medication Allergy List Record Demographics (language, gender, race, ethnicity, date of birth) Record and chart vital signs (height, weight, blood pressure, BMI, growth charts (2-20 y/o) including BMI Record smoking status for patients >/= 13 y/o Clinical Decision Support After Visit Summary E-Prescribing Report ambulatory quality measures to CMS Electronic Copy of Health Information Exchange Key Clinical Information Electronically Protect Electronic Health Information

EP Menu Objectives Drug formulary check Patient education Medication Reconciliation Summary of Care Incorporate clinical lab-test results Generate list of patients by specific conditions Electronic access for patients Submit data to immunization registries

EP Quality Measures

Core Set Tobacco Use Assessed and Cessation Intervention documented BMI Documented and Follow (>/= 18 y/o) Patients >/= 18 y/o have Blood pressure documented Alternate Core set Patients >/= 50 y/o receive Influenza Immunization Childhood Immunization Status BMI Documented (2-18 y/o) Additional Set Controlling High Blood Pressure

14

Preventative Care and Screening: Advising Smokers to Quit Breast Cancer Screening Chlamydia Screening for Women Pneumonia Vaccination Status for Older Adults Prenatal Screening for HIV

LSUHSC-S Eligible Professionals will be following 12 Quality Measures (3 Core set, 3 Alternate Core set, & 6 Additional Measures)

Eligible Hospital (EH) Measures: EH Core Objectives

Comprehensive Physician Order Entry (CPOE) Drug to Drug and Drug Allergy Checks Maintain up-to-date problem list Maintain an active medication list Maintain medication allergy list Record demographics (language, gender, race, ethnicity, date of birth, date/preliminary cause of death) Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth charts for children

</= 2 years of age with BMI) Record Smoking status for patients >/= 13 years of age Clinical decision support Provide patients with an electronic copy of their discharge instructions at the time of discharge Report hospital quality measures to CMS Provide patients an electronic copy of their health information Capability to exchange key clinical information among providers of care electronically Protect electronic health information created or maintained by the certified EHR

EH Menu Objectives Implement Drug-Formulary Checks Record Advance Directives for patients >/= 65 years of age Summary of Care provided to accepting provider Generate list of patients by specific conditions to use for quality improvement Use certified EHR technology to identify patient-specific education resources Medication Reconciliation on patients transferred from another facility Incorporate clinical lab-test results Capability to submit electronic date to Immunization Registries

EH Quality Measures Emergency Department median time of arrival to departure, Emergency Department median time of admit decision to departure, Ischemic stroke patients prescribed antithrombotic at discharge Ischemic stroke patients with atrial fibrillation/flutter prescribed anticoagulation therapy at discharge Acute Ischemic Stroke patients receive tPA within 2 hours Ischemic Stroke patient administered antithrombotic therapy by the end of hospital day 2 Ischemic Stroke patients with LDL > 100 on lipid lowering medication prior to arrival are prescribed statin

at discharge Ischemic or hemorrhagic stroke patients or caregivers given educational materials during hospital stay Ischemic or hemorrhagic stroke patients assessed for rehabilitation services VTE prophylaxis within 24 hours of arrival ICU VTE prophylaxis Anticoagulation overlap therapy Platelet monitoring on unfractionated heparin VTE discharge instructions Incidence of potentially preventable VTE

15

• Cooperative Forums – LSUHSC-S participates in the Louisiana Health Care Review (LHCR) Cooperative forums to benchmark our results with other Louisiana facilities.

• Departmental Performance Improvement Report – The following departments

participate in ongoing Performance Improvement activities using The Joint Commission “Cycle for Improving Performance”, Design, Measure, Assess, and Improve. The departments/clinics/units include: Admitting, Biomedical Engineering, Bone Marrow Unit, Cancer Registry, Cardiopulmonary Dept., Central Medical Supply, Clinical / Anatomic Pathology Lab, Clinical Neurophysiology, Echo Lab, Environmental Services, Heart Cath Lab, Hospital Telecommunications, Infection Control, Laundry & Linen, Medical Education, Medical Records, Medical Staff, Nursing: ACD / OTPT Care Clinics, Ophthalmology (Eye) clinic, Nursing: ECC / Emergency services, Nursing: FWCC, Nursing: PCS/ INPT Care depts., Nutritional Services, Patient Relations, Perfusion Services, Pharmacy, Physical Plant, Public Safety (UPD), Quality Management, Radiology, Rehabilitation Services, Social Services, Special Hematology Lab, Trauma Registry, All departments participate in ongoing monitoring and evaluation using the TJC, “Cycle for Improving Performance”. Quarterly the Quality Leadership Team reviews results and work with Department Directors regarding their performances. Performance Improvement activities are reported to the Clinical Board through the Quality Leadership Team.

• University HealthSystem Consortium (UHC) Cooperative Studies – LSUHSC

participates in cooperative studies coordinated by UHC. The clinical benchmarking/process improvement projects collect and use data to develop best practices and reduce cost, increase efficiency, and improve the quality and safety of patient care. Cooperative Studies for 2012 include, but are not limited to:

• Rapid Rescue Response • Catheter Associated Urinary Tract Infections (CAUTI) Project through

cooperation with UHC’s Health Engagement Network (HEN)

• Quality Improvement Committee– Establishes hospital-wide indicators (Attachment D) and oversees the Medical Staff and Resident Peer Review process to ensure consistency and optimal patient care including patient safety. Peer Review results are monitored and tracked and level 3’s and 4’s are reported to the Credentials Committee monthly. In addition, physician profiles are used at the time of reappointment to support physician performance for reappointment to the medical staff. Recommendations are made to the Clinical Board for approval to improve patient outcomes.

• Clinical Board– Monitors and approves the clinical operations of the hospital

including Medical Staff appointment and re-appointment, approval of adjunctive staff and Medical Staff Credentialing, Hospital Policies and other issues impacting greater than one department.

16

• Medical Staff –Each Medical Staff Department participates in the hospital’s peer review process (Attachment E), as well as, the Clinical Appeals Process (Attachment F). The Medical Staff Department Chairperson approves aspects of care to be monitored, based on high volume, high risk, high cost, or problem prone procedures/diagnoses. Each month the designated Department Peer Reviewer receives cases and renders a preliminary disposition. The cases are reviewed and returned to Quality Management for tracking and trending. Cases that are rendered a preliminary disposition of Level One, Clinical Practice/Treatment within National Standard of Care, require no further review. Cases that have a preliminary disposition of two, Questionable Clinical Practice/Treatment not Clearly within National Standard of Care, are referred to the Medical Staff Department Quality Council for review and a final level of disposition is rendered. Final dispositions may include:

• Level 1 - Clinical Practice/Treatment within National Standard of Care. (No

further review necessary). • Level 2a- Questionable Clinical Practice/Treatment Not Clearly Within National

Standard of Care reflecting a Documentation Issue . • Level 2b - Questionable Clinical Practice/Treatment Not Clearly Within National

Standard of Care reflecting a Clinical Concern/Issue. • Level 3 - Clinical Practice/Treatment does not meet National Standards of

Care and has a low probability of causing patient harm. • Level 4 - Clinical Practice/Treatment does not meet National Standards of Care and

has a high probability of causing patient harm.

Monthly and Quarterly Department Chairpersons receive departmental performance summaries. Resident Program Chairpersons receive quarterly resident performance summaries. All mortality reviews are discussed and documented in the department’s monthly meeting. Monthly meeting minutes are kept in each department and a copy forwarded to the Quality Management Department.

Each Medical Staff Department participates in: Focused Professional Practice Evaluation (FPPE): A process (Attachment H) in which the organization evaluates the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization. FPPE is a time –limited period during which the organization evaluates and determines the practitioner’s professional performance. Focused Professional Practice Evaluations (FPPEs) will be completed on all new physicians. For each physician, a minimum of 3 cases will be reviewed for each privileged category (privilege group) requested within the first year of practice. For all adjunctive staff members, (CRNA, PA, FNP, CNM, CNS, NP, NNP, PNP, PhD, and LPC) a focused evaluation will be completed on the ACGME six competencies, which include the following: Patient Care, Medical Knowledge, Practice Based, Interpersonal and Communication Skills, Professionalism, and Systems Based Practice. For an overview of this process for adjunctive staff, see Attachment L.

17

The organized medical staff does the following:

Evaluates practitioners without current performance documentation at the organization. Evaluates practitioners in response to concerns regarding the provision of

safe, high quality patient care. Develops criteria for extending the evaluation period. Communicates to the appropriate parties the evaluation results and

recommendations based on results. Implements changes to improve performance.

At time of initial appointment, the department Chairperson will identify the specific cases to be reviewed for evaluation of permanent status; also individual privileges will be decided by the department Chairperson for each applicant based upon the privileges requested at time of initial application. The Joint Commission standards MS. 08.01.01: The organized Medical Staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

In addition, each Medical Staff Department also participates in: Ongoing Professional Practice Evaluation (OPPE): The OPPE process (Attachment I) allows the organization to identify/monitor the individual professional practice trends that impact on quality of care and patient safety.

For new procedures and new equipment, 100% chart review is completed. Additionally, physicians are monitored by two separate OPPE processes:

1. For each physician that comes up for reappointment monthly, 40 charts are reviewed, based on the previous 24 month time period. This information is then presented to the Department Chairperson and Credentials Committee to be used in the decision for reappointment.

2. On a quarterly basis, a physician profile report (See Attachment J) is generated that identifies a detailed listing of cases by physician. In addition, each Department Chairperson and each Program Director receives the results of cases entering peer review for specific indicators. (See complete list of indicators in attachment D)

3. Items #1 & #2 above will also apply to all adjunctive staff. Please see Attachment ‘K’ for an overview of this process for the adjunctive staff members.

The Joint Commission standard MS.08.01.03: Ongoing Professional Practice Evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s) or to revoke an existing privilege prior to or at the time of renewal. Attachment G’ is an example of the OPPE form (UHC MD/ APP Profile Form) which is used to report the results of a physician’s performance for a 24 month period. The results are used by the Department Chairperson and the Credentials

18

Committee to evaluate the performance of the individual practitioner based on privileges granted.

• Medical Staff Committees – The Medical Staff Committee chairpersons are

responsible for assessing the Performance Improvement activities related to their assigned committees and recommending policy and operational changes based on analysis of committee related data. Each of the Medical Staff committees submits a monthly report to the Clinical Board. The Medical Staff committees include:

• Operative, and Other Invasive Procedure Review Committee • Antibiotic Review Committee • Cancer Committee • Blood Utilization Review Committee • Pharmacy and Therapeutics Committee • Infection Control Committee • Utilization Review Committee • Medical Records Committee • Credentials Committee • Graduate Medical Education Committee • Trauma Committee • Special Care Committee • Quality Improvement Committee

When data analysis identifies a problem or trend, proactive risk reduction activities or a corrective action plan will be developed and implemented by the Department Head. These actions may include:

1. System Changes – Changes in communication channels, changes in organizational

structure, adjustments in staffing and changes in equipment or chart forms. 2. Knowledge Enhancement – In-service education, continuing education and

circulating informational material.

3. Intensive Reviews/Focus Studies – When a medical/health care system error-related occurrence is identified; proactive risk assessment activities are implemented including intensive review and/or a focused study. A data collection tool is developed to address processes, functions, and services that can be designed or redesigned to prevent trends that may have contributed to the problem. Once all charts are reviewed, a summary report is compiled to report conclusions.

4. Root Cause Analysis – When a medical/health care error is classified by

Administration as a Near Miss or Sentinel Event, the recommended Root Cause Analysis format by TJC is used to detect the underlying causes of the variation. Upon approval by administration, the outlined action plan is implemented.

5. Failure Mode Effects Analysis – In accordance with TJC published information

regarding the most frequently occurring types of sentinel events and patient safety risk factors, at least one high-risk process is selected annually for proactive risk assessment.

19

6. Behavior Changes – Informal or formal counseling, consulting, changes in

assignments, and disciplinary action.

7. Policy Revisions – Policies are developed or revised for significant organizational issues that are interdepartmental or mandated to be hospital-wide by accreditation agencies or state/federal legislation. Any potential policy revisions are presented to the Policy Committee to identify the appropriate entity for development, and ensure that input is obtained and incorporated into a final policy statement. Once completed, the committee will submit the policy to the Hospital Administrator for approval, who will then forward it to the Clinical Board for final approval.

8. Multidisciplinary Process Teams – Teams are formed as needed and over site is

provided by the Quality Leadership Team to investigate and make recommendations when organization-wide performance becomes unacceptable or when a process has been identified to be proactively redesigned. The process team presents the recommendations to the Quality Leadership Team for approval.

9. Operational Changes – Any activity that may need to be performed differently in

order to expedite a process or improve overall patient care will be examined and changed if appropriate.

The assessment process includes the use of statistical process control techniques/tools as appropriate. When assessment of data indicates a variation in performance or potential risk to patient safety, more intensive measurements and analysis will be conducted, and in addition, the department/service or team will reassess its performance measure. When a performance measurement does not reach the predetermined optimal threshold, or if it is attained but further evaluation indicates that performance is not acceptable, the Performance Improvement process should continue. If the level of performance shows no improvement for the time frame established by the identified department/service or team plan, an intensive evaluation should be conducted with input from the Quality Leadership Team, or Director regarding the need for continued measurement and additional corrective action.

When any process remains stable or minimal variation is demonstrated in overall performance after two quarters of data collection, the performance measure should be re-evaluated to determine the need to continue measurement, and re-prioritization of performance measurements should occur.

IMPROVE

When opportunities for improving performance are identified, a proactive systematic approach is used to redesign the involved process, or to design a new process. The leadership, through the Quality Leadership Team will establish hospital-wide priorities and provide adequate resources to be effective.

20

1. When a department or service identifies an opportunity for improvement, the department/service will determine if other disciplines or departments will have an impact on the design/redesign of the process. If other disciplines or departments are involved, the opportunity for improvement will be referred to an appointed team.

2. The assigned team/department will establish priorities for improvement based on the

guidelines established in this plan. When necessary, the Quality Leadership Team will assist the team or department/service in establishing priorities.

The Performance Improvement and Patient Safety Plan will be reviewed, evaluated, and revised as necessary to incorporate the most current TJC/CMS standards. A summary of evaluation results will be presented to the Clinical Board. The annual review will assess, at least, the objectives, scope, organization effectiveness and appropriateness of the program. The plan will be modified as needed based on the results of the annual evaluation. Individual committees and departments will review, evaluate and revise their performance improvement activities and plans annually as part of the organization-wide review.

21

Attachment A PERFORMANCE IMPROVEMENT

COMMUNICATION PROCESS

(2013)

Graduate Medical Education Committee

Credentials Committee

Clinical Board

Quality Improvement Committee Quality Leadership

Team

Medical Directors

Hospital Clinical and Support Department Reports Clinical Departments Nursing PI (Inpatient and Outpatient) Support Departments

Clinical/Risk Management Variance Reporting Requested Reviews Mortality Reviews Patient Complaints Patient Safety report

Other Related Performance Activities TJC Core Measures Benchmarking Studies FMEA

Functional Medical Staff/Hospital Committees Antibiotic Blood Utilization Review Cancer Infection Control Medical Records Operative, Other Invasive and Non-Invasive Procedure Review (Surgical Case) Pharmacy Therapeutics Special Care Trauma Utilization Review

Medical Staff Department PEER Review Hospital (Generic Indicators) Department Indicators Department Focus Study

Medical Staff Department Chairperson

PI Communication Process 2013

22

• STUDYING PHASE: • What are the Improvement

Priorities?

• ACTING PHASE: • Implementing

Improvements/ Innovations to correct Identified Process Issues

• DOING PHASE: • Utilize sources for

Performance Measurement: • Internal Database:

Variance Database /Reports • •Comparative

Information: External databases

• (UHC, AVATAR)

• PLANNING PHASE: • What are Objectives ? • What is Function or

Process for improvement?

STEP 1: Design (PLANNING)

STEP 2: Measure (DOING)

STEP 3: Assess (STUDYING)

STEP 4: Improve (ACTING)

Attachment B

Clinical Board

Hospital Clinical and Support Departments

Quality Improvement Committee

Medical Staff Department Peer Review

Functional Medical Staff Committees

Quality Leadership Team

Core Measures

Clinical & Support Departments Biomedical Engineering Patient Admitting Echo Dept. Patient Relations / Volunteer

Services Cardiopulmonary Services Dept.

Pharmacy

Physical Plant Anatom / Clinical Path. Lab Physical Rehabilitation Services Clinical Neurophysiology Lab Public Safety / UPD CMS - Central Med. Supply Quality Management Environmental Services Radiology Cardiac Cath Lab Bone Marrow Unit Hospital Telecommunications Trauma Registry Infection Control Cancer Registry Laundry and Linen Service Perfusion Services HIM - Medical Records Social Services Nutritional Services Hem/Onc- Spec. Hem. Lab PCS -Patient Care Services (Nursing)

ER- Emergency services Dept. ACD- Ambulatory Care Clinics FWCC- Feist-Weiler Cancer Center

EYE CLINIC Hospital Med. Education Hospital Med. Staff

Medical Staff Departments: Anesthesiology Emergency Medicine Family Medicine Medicine Neurology Neurosurgery OB/GYN Ophthalmology Oral Surgery Orthopedics Otolaryngology Pathology Pediatrics Psychiatry Radiology Surgery Urology

Committees: Antibiotic Blood Utilization Review Cancer Infection Control Medical Records Operative and Other Invasive Procedure Review Pharmacy & Therapeutics Special Care Committee Trauma Committee Utilization Review

PROCESS USED FOR IMPROVEMENT

“TJC" Cycle for Improving

Performance”

1. Design 2. Measure 3. Assess 4. Improve

Developed 1/97 Reviewed/Revised 1/98, 1/99, 7/99, 11/00, 12/00, 12/01, 12/02, 9/03, 12/03, 1/04, 10/05, 10/06, 10/07, 10/08,10/09, 12/10, 11/12

Other Hospital Committees: Endoscopy Environment of Care Forms Laser Material Evaluation Radiation Safety Respiratory Therapy Safety

LSUHSC-S UNIVERSITY HOSPITAL Performance Improvement Reporting Process

Credentials Committee

Graduate Medical

Education Committee

23

Attachment C LSU Health Sciences Center at Shreveport

Performance Improvement

Cycle

Quality Management Receives and Tracks

Variations Analyzed

Action Taken

Variance Report Patient Satisfaction Patient Complaints ORYX Data Performance Report Card LHCR Cooperative Studies Departmental PI Report

System Changes Knowledge Enhancement Intensive Review Behavior Changes Policy Revisions

Variance Report Patient Satisfaction Patient Complaints

National Association

Continue to Monitor Performance, Re-

Evaluate

Actions Taken to Improve Performance

as Appropriate

Identified Problems Analyzed, Plan of Action Developed

Reports & Actions Taken to Improve Performance are sent to Clinical Board, Medical Staff Departments, & Medical Staff Committees

Quarterly Reports

Compiled and Reviewed by Quality

Leadership Team

Reports Compiled Monthly of

Performance

Ongoing Monitoring

Implemented

Scope of Service/Plan for Provision of

Review/Revise Care High Volume Problem Prone High

Risk Cost

Indicators Selected

Level of Performance Identified

(Threshold)

Assess

Improve Design

Measure

Start

24

(Pg 1 of 3)

Indicator Threshold Indicator Threshold

Inpatient/Outpatient Generic Indicators Hospital-Acquired Conditions Indicators * Per CMS 10/12

Appropriate care rendered. 100% Foreign Object retained after surgery. 100% Mortality review completed and documentation of autopsy offered on cases that meet criteria. 100% Air Embolism. 100%

No admit for adverse reaction to OP management. 100% Blood Incompatibility. 100% No re-admit within 31 days. 100% Stage III and IV pressure ulcers 100% No unplanned transfer from general to special care unit. 100% Falls and Trauma (Fractures, Dislocations, Intracranial Injuries, Crushing Injuries,

Burns, other injuries). 100%

No coded complications occurring during or following procedure performed. 100%

Manifestations of poor glycemic control (Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, and Secondary Diabetes with Hyperosmolarity).

100%

All abnormal lab/x-rays/tests addressed by physician. 100% Catheter-associated urinary tract infection (UTI). 100% Legal Review completed. 100% Vascular catheter-associated infection. 100%

Code management measures appropriate. 100% Manifestations of Poor Glycemic Control (Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity)

100%

All operative /invasive procedures are performed with no returns to the OR. 100% Surgical site infection , Mediastinitis, following Coronary Artery Bypass

Graft (CABG) 100%

No unscheduled return to clinic within 48 hours with the same complaint. 100% Surgical site infection following Certain Orthopedic Procedures (Spine,

Neck, Shoulder, Elbow). 100%

All documentation/forms completed. 100% Surgical site infection following Bariatric Surgery for Obesity (Laparoscopic Gastric Bypass, Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery).

100%

Appropriate restraint/seclusion documentation. 100% Surgical site infection following cardiac Implantable Electronic Device (CIED)

100%

AVATAR Requested Review. 100% Deep vein thrombosis (DVT), Pulmonary embolism (PE) following Certain Orthopedic Procedures (Total Knee Replacement, Hip Replacement).

100%

All medication orders are appropriate/accurate. 100% Iatrogenic Pneumothorax with Venous Catheterization 100% History and Physicals updated within 24 hours of admission. 100% INTENTIONALLY LEFT BLANK ****

Attachment D

Louisiana State University Health Sciences Center – Shreveport 2013 Hospital-wide Generic Indicators

Medical Staff and Resident Peer Review Thresholds as determined by TJC 1st Q 2012 National Average

25

(Pg 2 of 3)

Indicator Threshold Indicator Threshold Acute Myocardial Infarction Indicators (AMI) AMI-1: Aspirin at arrival. 98% INTENTIONALLY LEFT BLANK **** AMI-2: Aspirin prescribed at discharge. 98% INTENTIONALLY LEFT BLANK **** AMI-3: ACEI or ARB for LVSD. 97% INTENTIONALLY LEFT BLANK **** AMI-5: Beta blocker prescribed at discharge. 98% INTENTIONALLY LEFT BLANK **** AMI-7: Fibrinolytic therapy received within 30 minutes of arrival N/A INTENTIONALLY LEFT BLANK **** AMI-8: PCI received within 90 minutes of arrival 93% Surgical Care Improvement Project (SCIP) AMI-10: Statin Prescribed at Discharge 95% SCIP-Inf-1(Overall rate): Prophylactic antibiotic received within 1 hour prior to incision. 98%

INTENTIONALLY LEFT BLANK **** SCIP-Inf-2: Prophylactic antibiotic selection for surgical patients 98%

AMI – (Continuous Measures) SCIP-Inf-3: Prophylactic antibiotic discontinued within 24 hrs. after Anesthesia end time. (48 hrs. for cardiac pts) 97%

Time to Percutaneous Coronary Intervention 42 Min SCIP-Inf-4: Cardiac surgery patients with controlled 6 AM post-op serum glucose. (POD1 and POD2) 96%

Time to Fibrinolysis. 65 Min SCIP-Inf-6: Surgery patient with appropriate hair removal. 99.8%

Heart Failure Indicators (HF) SCIP-Inf-9: Urinary catheter removed on (POD1) or (POD2) with day of surgery being day zero (0). 94%

HF-1: Discharge instructions. 92% SCIP-Inf-10: Surgery patients with perioperative temperature management. 99.6% HF-2: Evaluation of LVS function. 99% SCIP-Card-2: Surgery patients on beta blocker prior to arrival who received a beta blocker during

the perioperative period. 94%

HF-3: ACEI or ARB for LVSD. 96% SCIP-VTE-1: Surgery patient with recommended venous thrombo embolism (VTE) prophylaxis ordered. 97%

INTENTIONALLY LEFT BLANK **** SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hrs after surgery. 97%

Pneumonia Indicators (PN) Outpatient AMI and Chest Pain

PN-3a: Blood culture within 24 hours of arrival for patients transferred/admitted to ICU. 98% OP-1: Median time to fibrinolysis 33.8 minutes

(UHC Median – TJC method) PN-3b: Blood cultures in the ED prior to antibiotics. 97% OP-2: Fibrinolytic therapy received within 30 minutes 50.7%

(TJC Nat. Average) PN-6a: Antibiotic selection for CAP in immunocompetent ICU patient. 90% OP-3: Median time to transfer to another facility for acute coronary intervention 63.0 minutes

(UHC Median - TJC method) PN-6b: Antibiotic selection for CAP in immunocompetent non-ICU patient. 96% OP-4: Aspirin at arrival 95.2%

(TJC Nat. Average)

96% OP-5: Median time to ECG 6.1 minutes (AMI)

7.8 minutes (CP) (UHC Median - TJC method)

INTENTIONALLY LEFT BLANK **** Outpatient Surgical INTENTIONALLY LEFT BLANK **** OP-6: Antibiotic timing 95% INTENTIONALLY LEFT BLANK **** OP-7: Antibiotic selection 96% INTENTIONALLY LEFT BLANK **** INTENTIONALLY LEFT BLANK **** INTENTIONALLY LEFT BLANK **** INTENTIONALLY LEFT BLANK ****



26

(Pg 3 of 3)

Indicator Threshold Indicator Threshold The following NEW Measure Sets indicators went into effect with discharges of Jan. 01, 2012

Global Emergency Department (ED) Inpatient Measure set OUTPATIENT Measure Sets * These are in addition to the OP Measures: (AMI, CP, and Surgical) listed on previous page.

ED-1a: Median Time from ED arrival to ED Departure for admitted ED patients (Overall Rate)

283.6 min. (TJC Target)

OP-18 [ED] Median Time from ED Arrival to ED Departure for Discharged ED Patients 191.6 min. (UHC Avr. –TJC

Method) ED-2a: Admit Decision Time to ED Departure Time for Admitted Patients (Overall Rate)

114.6 minutes

(TJC Target)

OP-19 [ED] Transition Record with Specified Elements Received by Discharged Patients 0.9%

(TJC Nat. Avr.)

Global Immunization (IMM) Measure Set OP-20 [ED] Door to Diagnostic Evaluation by a Qualified Medical Professional 46.2 min. (TJC Target)

IMM-1a: Pneumococcal Immunization (Overall Rate) 86% (TJC Nat. Avr.)

OP- 21[PAIN MANAGEMENT] Median Time to Pain Management for Long Bone Fracture

73.0 min. (TJC Target)

IMM-2a: Influenza Immunization (Overall Rate) 82% (TJC Nat. Avr.)

OP-22[ ED]- Left without being Seen Reported via Qnet

INTENTIONALLY LEFT BLANK ****

OP-23 [STROKE] ED- Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT Scan Interpretation Within 45 Minutes of Arrival

36.6 min. (UHC avr.-TJC

Method) INTENTIONALLY LEFT BLANK **** INTENTIONALLY LEFT BLANK ****

HBIPS (Psych) Measure set To go into effect Jan. o1, 2013 STROKE (STRK) Measure set To go into effect

Jan. o1, 2013 HBIPS-2 Hours of Physical Restraint Use TBA STK-1 Venous Thromboembolism (VTE) Prophylaxis for patients with ischemic or

hemorrhagic stroke TBA

HBIPS-3 Hours of Seclusion Use TBA STK-2 Ischemic stroke patients discharged on antithrombotic therapy TBA HBIPS-4 Patients Discharged on Multiple Antipsychotic Medications TBA STK-3 Anticoagulation therapy for atrial fibrillation/flutter TBA HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

TBA STK-4 Thrombolytic Therapy for Acute Ischemic Stroke patients TBA

HBIPS-6 Post Discharge Continuing Care Plan Created TBA STK-5 Antithrombotic therapy by the end of hospital day two TBA HBIPS-7 Post Discharge Continuing Care Plan Transmitted to Next Level of Care provider upon Discharge

TBA STK-6 Discharged on Statin Medication TBA

INTENTIONALLY LEFT BLANK **** STK-8 Stroke Education TBA INTENTIONALLY LEFT BLANK **** STK-10 Assessed for Rehabilitation Services TBA

Venous Thromboembolism (VTE) Measure set To go into effect Jan. o1, 2013 Venous Thromboembolism (VTE) Measure set (continued from left of page) To go into effect

Jan. o1, 2013 VTE-1 Venous Thromboembolism Prophylaxis TBA VTE-4 Venous Thromboembolism patients receiving unfractionated heparin with

dosages/platelet count monitoring by protocol TBA

VTE-2 Intensive Care Unit (ICU) Venous thromboembolism Prophylaxis TBA VTE-5 Venous Thromboembolism Discharge Instructions TBA VTE-3 Venous Thromboembolism patients with anticoagulation overlap therapy

TBA VTE-6 Incidence of Potentially Preventable Venous Thromboembolism TBA



27

LSU Health Sciences Center at Shreveport • Medical Staff, Resident & Advanced Practice Professional

(APP) Performance Improvement Developed by Leisa Oglesby, RN, BSN, MBA, CPHQ

Attachment E

Developed 1/97. Reviewed/Revised 1/98, 1/99, 12/99, 12/00, 12/01, 12/02, 9/03, 12/04, 8/05, 10/06, 12/07, 12/08, 12/09, 05/10, 12/10, 11/11

Medical Staff, Resident and Advanced Practice Professional

Peer Review Pathway

Decision Input Output

Annual Physician Performance Profile submitted to Department Chairperson for reappointment

Dept. Quality Council (Faculty, Residents, & APP) reviews, renders Level of Disposition, and recommends action:

• Dept. Policy Change • Hospital Operations Change • Change Screen Criteria • Educational Dept. Mtg. • Disciplinary Action • Standard of Care Change • May Request Outside Review • Other

Episodic/re-delineation of Privileges Quarterly Report of

Resident’s /MD’s / APP’s profile to Chairperson and Program Director

Attribution Physician and Resident and APP notified of Final Disposition** (Attribution M.D. may request the case enter the appeals process). See Medical Staff, Resident, an APP Clinical Appeals Process.

**Final Levels of Disposition 1. Clinical practice/treatment within National Standard of Care. (No

further review necessary) 2a. Questionable Clinical Practice/Treatment Not Clearly Within National Standard of Care reflecting a Documentation Issue 2b. Questionable Clinical Practice/Treatment Not Clearly Within National Standard of Care reflecting a Clinical Concern/Issue 3. Clinical practice/treatment does not meet national Standard of Care

and has a low probability of causing patient harm. 4. Clinical practice/treatment does not meet National Standard of Care

and has a high probability of causing patient harm.

Quality Improvement Committee (Reviews all cases for appropriateness and consistency of reviews)

Medical Staff Dept. Chairperson renders and applies appropriate actions:

• Verbal Counseling • Letter of Reprimand • Proctoring • Formal Retraining • Department Censure • Medical Staff Censure

Reappointment

Monthly and Quarterly 3’s and 4’s reported to the Credentials Committee for review and appropriate action. Examples: • Loss of Privileges • Suspension for a period of time • Termination

*Medical Staff Departments: Anesthesiology OB/GYN Pediatrics EMS Ophthalmology Psychiatry Family Medicine Oral Surgery Radiology Medicine Orthopedics Surgery Neurology Otolaryngology Urology Neurosurgery Pathology

Clinical Board

Attribution Physician/Resident /APP Input

Medical Staff Departments* establish Specific Indicators QI Committee /Clinical

Board establish Hospital Wide Indictors

Clinical regulatory Compliance Issues

Functional Medical Staff Committee Referrals: BURC, Infection Control, Medical Records, Trauma, Cancer, O&OINPRC, P&T, Utilization Review

Variance Reporting

Requested Reviews

Mortality Reviews

Variation Identified

Medical Staff Department Peer Reviewer/APP Peer Reviewer renders preliminary decision: 1. No action necessary. 2. Refer to Department

Quality Council for review and disposition.

28

LSU Health Sciences Center at Shreveport • Medical Staff, Resident & Advanced Practice Professional (APP)

Clinical Appeal Process

Developed 1998. Reviewed/Revised 1/99, 12/99, 12/00, 12/01, 12/02, 12/03, 10/04, 12/04, 8/05, 10/06, 12/07, 12/08, 12/09, 05/10, 12/10.11/11

M.D. / APP notified

(May initiate appeals process)

Quality Council

(2,3,4)

Attribution Physician / APP comments

requested

Peer Reviewer Initial Disposition

LSU Health Sciences Center at Shreveport

Medical Staff, Resident & APP Peer Review

“Clinical Appeals Process” “Clinical Appeals Process” addresses the clinical performance of the Medical Staff

(Attribution Physician/APP) and the final disposition of the Medical Staff Department of the Quality Council.

Attribution M.D./ APP requests review of Clinical Performance to the Medical Staff Department Quality Council . (If attribution M.D. is Department Chairperson, request for appeal to Quality Improvement Committee)

Attribution M.D. / APP presents written comments/supporting documents regarding the case to the Quality Council.

Quality Management notifies M.D. / APP and Department Chairperson. Appeal Documentation is placed in M.D./ APP profile in Quality Management

Attribution M.D. / APP may request formal appeal of disciplinary action.

Attribution M.D. /APP follows the Appeal Process described in the Medical Staff Bylaws, Rules & Regulations.

If present for additional comments, attribution M.D. / APP leaves.

Quality Council revises or supports the level of disposition rendered.

Quality Council revises the level of disposition.

Quality Management notifies M.D. / APP and Department Chairperson. Appeal documentation is placed in M.D. /APP’s profile in Quality Management.

Quality Council supports the level of disposition.

Attribution M.D. / APP requests appeal in writing to the Quality Improvement Committee.

Quality Improvement Committee renders a decision.

Quality Improvement Committee performs Clinical review of the case. (No M.D. /APP name, no Department is discussed)

1. Quality Improvement Committee requests the Department Quality Council revise the level of disposition.

OR 2. Quality Improvement Committee supports

disposition by the Department Quality Council. (Appeal of disposition assignment complete.)

Written Appeal of Disposition Completed by

Medical Staff.

Attachment F

29

PHYSICIAN / APP ID #: _XX9090XX__

UHC MD / APP Profile Form (Example) 2013 UHC MD / APP Profile Form (Example) 2013 Attachment G

30

UHC MD / APP Profile Form (Example) 2013

31

UHC MD / APP Profile Form (Example) 2013

32

UHC MD / APP Profile Form (Example) 2013 UHC MD / APP Profile Form (Example) 2013

33

34

Rev. 12/12

Attachment H

Approved

Medical Staff Office (MSO) receives signed Letter of Offer and Pre-Application from Human Resources

Data Verified with Primary Source: Medical School, Internship, Residency, Fellowship, Hospital Affiliations, Medical License, State CDS, Federal DEA, Board Certification, and AMA Profile* (Except on International Medical Graduates and LSUHSC graduates). ECFMG Primary Verification completed on International Medical Graduates. Verification of VISA status completed on International Medical Graduates through Legal Affairs Office and Human Resources. Data Collected From Primary Source: Peer References (2), Program Chair Evaluations, Data Bank Report, and Medicare/Medicaid Sanctions (OIG and EPLS). Medicare Part B Opt Out verification will be provided by the Managed Care representative and added to the completed credentialing file. Primary source verifications are obtained directly from Educational institutions attended, hospitals where privileges were held (past and present), State Boards of Medical Examiners (for licensure). Competency is verified with applicant’s educational program chairs and peer references.

(MSO) Mails: Cover letter, Application, Request for delineations, Medicare/Medicaid Attestation Form, and the Medical Staff Bylaws to the applicant.

Physician/Adjunctive Staff completes and returns all forms to the MSO for processing. The applicant is responsible for completing all forms.

MSO verifies pre-app. to ensure core requirements are met. If YES, precede with application process. If NO, Notify Department Chairperson that candidate does not meet membership requirements.

Upon receipt of completed application, MSO begins data collection/Primary Source Verification Process.

Utilizing the Privilege List by Provider form pulled from MDSTAFF; the Clinical Chief completes substantive review, recommends membership category, and clinical privileges with or without modifications.

Credentials Committee reviews and approves the applicant for recommendation to the Clinical Board.

Credentials Chair presents all applicants to the Clinical Board the same month that Credentials meets.

Applicants approved at the next Clinical Board Meeting. Applicants not approved require prompt written notification.

MSO generates letter RE: Board approval signed by CEO and sent to applicant with copy of approved clinical privileges.

MSO assigns Hospital ID number and notifies the appropriate departments.

LSUHSC Medical Staff Initial Application Process (FPPE)

NO Application returned to the Department and Chair of the Clinical Board notified. The applicant may appeal.

YES Applicants are a Provisional Status for one year at which time a proctor report is completed by Dept. Chair to assign membership status. All members are reappointed every two years based on the date of initial appointment and must be evaluated on six competencies based on Dept as outlined in the FPPE process.

Letter of offer withdrawn by the Department and MSO is notified.

Not Approved

Applicants not approved are notified by the Dean /designee. The applicant may then request an appeal.

35

Attachment I

Rev. 12/12

Medical Staff Office (MSO) sends notice at least 120 days prior to the reappointment date to the Clinical Chief to review and approve.

(MSO) Mails: Cover letter, provider profile application, including, current delineated clinical privileges on file, sanct Medical Staff Office (MSO) sends notice at least 120 days prior to the reappointment date to the Clinical Chief to review and approve. i hi d

Physician completes and returns forms or documents required to the MSO at least 60 days or 2 months prior to the expiration date of the current appointment period.

MSO receives Notice from Department Chairperson YES to approve NO not to approve. Approved applicants are mailed a reappointment application. Applicants not approved are sent a letter stating the Department did not approve the applicant for reappointment.

Upon receipt of a completed application the MSO begins data verification. All incomplete applications are returned to the applicant for completion.

MSO verifies data for reappointment: Medical License, State CDS, Federal DEA and Board Certification, National Practitioner’s Data Bank, Medicare/Medicaid Sanctions, and hospital affiliations for the previous two (2) years. MSO completes physician specific aggregate data including, quality profiles, infection control rates, committee attendance, medical records statistics, and patient complaints.

Utilizing UHC and MDSTAFF / APP Profile form; the MSO forwards compiled data to the Clinical Chief for completion of the substantive review (Attachment Q), membership category, and clinical privileges with or without modifications. Each physician must be evaluated on six competencies which are specified by the individual department chairs as outlined in the OPPE process. After approval by the Clinical Chief, the applicant must be approved by the Departmental Education Committee (2 signatures). Medicare Part B Opt Out verification will be provided by the Managed Care representative and added to the completed credentialing file.

Credentials Committee reviews and approves the applicant for recommendation to the Clinical Board.

Credentials Chair presents all applicants to the Clinical Board the same month that Credentials Committee meets.

Applicants approved at the next Clinical Board Meeting. Applicants not approved require prompt written notification by the Dean/designee. The applicant may request an appeal.

MSO generates letter RE: Board approval signed by the CEO and sent to the applicant with a copy of the approved privileges.

LSUHSC Medical Staff Reappointment Application Process (OPPE)

Application returned to the Department and follow up is completed as applicable.

No

Yes

36

Physician Profile (Example) Review Dates From 02/01/2009 To 01/31/2012

LSU Health Sciences Center Provider: Doe, Smith Z. All Review Reasons

_______Review_______ MD ID / Name Dept Acct# Var CCC Out Comp Indicator Outcome XX9090XX – Doe, Smith Z. Inpatient

Physician Review 1055495XXX Y N 1 Y 1000 Appropriateness of care rendered

1010 Legal review completed Inpatient

Physician Review 1060195XXX N N 1 Y 1000 Appropriateness of care rendered

1001 Mortality review completed and documentation of autopsy offered which meet criteria

1018 All medication orders are appropriate/accurate 1019 H&P updated within 24 hours of admission 500 106019XXX N N 1 Y Completed post-op note No surgery cancelled after the patient is in the Operating

Room/Surgeries canceled must have documented medical reason.

Inpatient Physician Review

106028XXX N N 1 Y 1000 Appropriateness of care rendered

1018 All medication orders are appropriate/accurate 1019 H&P updated within 24 hours of admission 500 10602XXXX N N 1 Y Completed post-op note No surgery cancelled after the patient is in the Operating



10602XXX N N 1 Y 1000 Appropriateness of care rendered

1018 All medication orders are appropriate/accurate 1019 H&P updated within 24 hours of admission 500 106028XXXX N N 1 Y Completed post-op note No surgery cancelled after the patient is in the Operating


CANCER 106070XXX Y N 1 Y AJCC Staging Documented Blood Consent Completed for Blood/Blood Products Administered Case Summary Complete Case Summary Present Consent and Procedure Performed Agree Consent Obtained Consults Identified and Ordered in a Timely Manner Diagnosis and Treatment Consistent with Needs Diagnosis and Treatment Consistent with Practice Guidelines Nursing Assessment Incomplete Referrals Documented CANCER 106087XX Y N 1 Y AJCC Staging Documented Blood Consent Completed for Blood/Blood Products Administered Case Summary Complete Case Summary Present Consent and Procedure Performed Agree Consent Obtained

Consults Identified and Ordered in a Timely Manner Diagnosis and Treatment Consistent with Needs

Attachment J

37

Physician Profile (Example) Review Dates From 02/01/2009 To 01/31/2012

Provider: Doe, Smith Z. All Review Reasons

_______Review_______ MD ID / Name Dept Acct# Var CCC Out Comp Indicator Outcome Inpatient

Physician Review 1067782XXX Y Y 2 Y 1018 All medication orders are appropriate/accurate Not Met


10692XX N N 1 Y 1013 All documentation/forms completed Indicator Met


10693XXXX N N 1 Y 1013 All documentation/forms completed Indicator Met




107063XXX N N 1 Y 1013 All documentation/forms completed Indicator Met


10725XXX N N 1 Y 1013 All documentation/forms completed Met




10726XXXXX N N 1 Y 1013 All documentation/forms completed Met


1072XXXX N N 1 Y 1013 All documentation/forms completed Met


107273XX N N 1 Y 1013 All documentation/forms completed Met


10727XXXX N N 1 Y 1013 All documentation/forms completed Met




10727XXX N N 1 Y 1013 All documentation/forms completed Indicator Met



















38

Attachment K

Medical Staff Office (MSO) sends notice at least 120 days prior to the reappointment date to the Clinical Chief to review and approve.

(MSO) Mails: Cover letter, provider profile application, including, current delineated clinical privileges on file, sanction history, and acknowledgement statement for signature for the reappointment period.

AHP completes and returns forms or documents required to the MSO at least 60 days or 2 months prior to the expiration date of the current appointment period.

MSO receives Notice from Department Chairperson YES to approve NO not to approve. Approved applicants are mailed a reappointment application. Applicants not approved are sent a letter stating the Department did not approve the applicant for reappointment.

Upon receipt of a completed application the MSO begins data verification. All incomplete applications are returned to the applicant for completion.

MSO verifies data for reappointment: Current License, National Practitioner’s Data Bank, Medicare/Medicaid Sanctions, and hospital affiliations for the previous two (2) years.

Utilizing the UHC and MDSTAFF / APP Profile form; MSO forwards compiled data to the Clinical Chief for completion of the substantive review (Attachment R), membership category, and clinical privileges with or without modifications. Each AHP must be evaluated on six competencies which are specified by the individual department chairs as outlined in the OPPE process. After approval by the Clinical Chief, the applicant must be approved by the Departmental Education Committee (2 signatures).

Credentials Committee reviews and approves the applicant for recommendation to the

Credentials Chair presents all applicants to the Clinical Board the same month that Credentials Committee meets.

Applicants approved at the next Clinical Board Meeting. Applicants not approved require prompt written notification by the Dean/designee. The applicant may request an appeal.

MSO generates letter RE: Board approval signed by the CEO and sent to the applicant with a copy of the approved privileges.

LSUHSC Adjunctive Staff Reappointment Application Process (OPPE)

Application returned to the Department and follow up is completed as applicable.

No

Yes

Rev. 12/12

39

Attachment L

Rev. 12/12

Medical Staff Office (MSO) receives signed Letter of Offer from Human Resources.

(MSO) Mails: Cover letter, Application, Request for delineations (CRNA only), Medicare and Medicaid Attestation Form, Medical Staff Bylaws.

Adjunctive Staff completes and returns all forms to the MSO. Job Descriptions are required for Nurse Practitioners and Physician Assistants. Physician Assistants must submit a letter received from LSBME, which indicates their Supervising Physician.

Upon receipt of completed application, MSO begins data collection/Primary Source Verification Process. MSO sends the applicant pharmacy cards. Incomplete applications are returned to applicant for completion.

Data Verified with Primary Source: Professional School, Hospital Affiliations, and Professional License. Data Collected From Primary Source: Peer References (2), Program Chair Evaluations, Data Bank Report, and Medicare/Medicaid Sanctions. Primary source verifications are obtained directly from Educational institutions attended, hospitals where privileges or positions were held (past and present), State Boards of Medical Examiners (for licensure) or Nursing Boards. Competency is verified with peer references.

Application Complete

Utilizing the Privilege List by Provider form pulled from MDSTAFF; Clinical Division Chief completes substantive review (Attachment M), recommends membership, and clinical privileges with or without modifications (CRNA only).

Credentials Committee reviews application and clinical privileges (CRNA only) or Job Descriptions with or without modifications.

Credentials Chair presents application to Clinical Board same month that Credentials meets.

Clinical Board approves the application the following month.

MSO generates letter RE: Board approval signed by CEO and sent to applicant with copy of approved clinical privileges and/or appointment to the Adjunctive Staff.

MSO assigns Hosptial ID number and notifies the appropriate departments.

NO Return to Department YES

Applicants are a Provisional Status for one year at which time a proctor report is completed, as outlined in the FPPE process, by Dept. Chair to assign membership status. All members are reappointed every two years based on the date of initial appointment and must be evaluated on six competencies based on Dept.

LSUHSC Adjunctive Staff Initial Application Process (FPPE)

40

Meaningful Use Eligible Professional Measures

Core Objectives

• CPOE Drug-Drug and Drug-allergy checks Up-to-Date Problem list Maintain Medication List Maintain Medication Allergy List Record Demographics (language, gender, race, ethnicity, date of birth) Record and chart vital signs (height, weight, blood pressure, BMI, growth charts (2-20 y/o) including BMI Record smoking status for patients >/= 13 y/o Clinical Decision Support After Visit Summary E-Prescribing Report ambulatory quality measures to CMS Electronic Copy of Health Information Exchange Key Clinical Information Electronically Protect Electronic Health Information

Menu Objectives Drug formulary check Patient education Medication Reconciliation Summary of Care Incorporate clinical lab-test results Generate list of patients by specific conditions Electronic access for patients Submit data to immunization registries

Quality Measures Core Set Tobacco Use Assessed and Cessation Intervention documented BMI Documented and Follow (>/= 18 y/o) Patients >/= 18 y/o have Blood pressure documented Alternate Core set Patients >/= 50 y/o receive Influenza Immunization Childhood Immunization Status BMI Documented (2-18 y/o) Additional Set Controlling High Blood Pressure Preventative Care and Screening: Advising Smokers to Quit Breast Cancer Screening Chlamydia Screening for Women Pneumonia Vaccination Status for Older Adults Prenatal Screening for HIV

LSUHSC-S Eligible Professionals will be following 12 Quality Measures (3 Core set, 3 Alternate Core set, & 6 Additional Measures)

10-4-11

Attachment M

41

Meaningful Use Eligible Hospital Measures

Core Objectives

Comprehensive Physician Order Entry (CPOE) Drug to Drug and Drug Allergy Checks Maintain up-to-date problem list Maintain an active medication list Maintain medication allergy list Record demographics (language, gender, race, ethnicity, date of birth, date/preliminary cause of death) Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth charts for children </=

2 years of age with BMI) Record Smoking status for patients >/= 13 years of age Clinical decision support Provide patients with an electronic copy of their discharge instructions at the time of discharge Report hospital quality measures to CMS Provide patients an electronic copy of their health information Capability to exchange key clinical information among providers of care electronically Protect electronic health information created or maintained by the certified EHR

Menu Objectives

Implement Drug-Formulary Checks Record Advance Directives for patients >/= 65 years of age Summary of Care provided to accepting provider Generate list of patients by specific conditions to use for quality improvement Use certified EHR technology to identify patient-specific education resources Medication Reconciliation on patients transferred from another facility Incorporate clinical lab-test results Capability to submit electronic date to Immunization Registries

Quality Measures

Emergency Department median time of arrival to departure, Emergency Department median time of admit decision to departure, Ischemic stroke patients prescribed antithrombotic at discharge Ischemic stroke patients with atrial fibrillation/flutter prescribed anticoagulation therapy at discharge Acute Ischemic Stroke patients receive tPA within 2 hours Ischemic Stroke patient administered antithrombotic therapy by the end of hospital day 2 Ischemic Stroke patients with LDL > 100 on lipid lowering medication prior to arrival are prescribed statin

at discharge Ischemic or hemorrhagic stroke patients or caregivers given educational materials during hospital stay Ischemic or hemorrhagic stroke patients assessed for rehabilitation services VTE prophylaxis within 24 hours of arrival ICU VTE prophylaxis Anticoagulation overlap therapy Platelet monitoring on unfractionated heparin VTE discharge instructions Incidence of potentially preventable VTE

42

Case closed, Tracked and trended.

Variance Process 2013

Rev. 02/12

Variance submitted to Quality Management.

No. Yes.

Investigation completed and warrants follow up

Quality patient care identified and referred to appropriate Department

Quality Council for disposition.

Variance closed. Investigation performed, which may include request for comments by staff.

Does the Variance warrant further investigation/comments from the Attribution

Physician/Nursing/Supporting Depts?

Issue identified and chart reviewed in EPIC by Assistant

Director of QM.

Yes

Department Quality Council renders disposition.

No

Case closed, tracked and trended Quarterly Report to Chairs/Program Directors.

Quarterly Report to Chairs/Program Directors/Unit

Managers

Attachment N

Documents

UHC MD / APP Profile Form (Example) - LSU Health Shreveport