C4QI Survey Monkey Results

Hospital Quality Committee Structure – C4QI Hospital Survey Results

April 2014

Ali Casiere

The Ohio State University Comprehensive Cancer Center –

Arthur G. James Cancer Hospital and Richard J. Solove Research Institute

2

Who Participated

MD Anderson Yale Duke Memorial Sloan-

Kettering Dartmouth

Siteman Dana-Farber Karmanos Roswell Park H. Lee Moffitt

• We surveyed the 17 other C4QI hospitals and we had 10 of those hospitals respond to the survey.

• This survey was sent out on March 18, 2014



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Scope of Each Organization’s Committee

**Yale and Duke are the two hospitals that have separate committees for Quality and Safety.

16.67%

16.67%

66.67%

**Quality (2)

**Safety (2)

Both Quality and Safety (8)



4

Current Committee Membership Size

MSK

Roswell

Par

k

Sitem

an

MD A

nder

son

Karm

anos

Duke

Dartm

outh

Dana-

Farbe

r

Mof

fitt

Yale0

10

20

30

40

50

60

# of Committee Members

**Yale does not have a centralized committee



5

Committee Meeting Frequency

Monthly 8 Times Per Year

Bi-Monthly Quarterly Bi-Annually0

1

2

3

4

5

6 Roswell Park, Dart-mouth, MSK, Yale, MD

Anderson

Karmanos

Siteman and Moffitt

Dana-Farber Duke

Committee Meeting FrequencyCommittee Meeting Frequency



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Meeting Time and Duration

Dana-Farber

7AM-8AM

Siteman

7AM-8AM

MSK

8AM-9:30AM

Dartmouth

9AM-11AM

Duke MD Anderson

Yale

Moffitt

Roswell Park

Karmanos

9AM-10AM 11AM-12:30PM 1-1.5 hours mid-day 4PM-5PM

4PM-5:30PM 1 hour any time



7

Does Meeting Agenda Include Both Inpatient and Outpatient?

**The way the survey monkey was set up there was the option to click all three and options of “Inpatient”, “Outpatient”, and “Both” which is why this data is skewed.

8.33%

8.33%

83.33%

Inpatient (1)Outpatient (2)Both (10)



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Standing Agenda ItemsHospital Standing Agenda Items

MD Anderson Reported Incidences, Patient safety Reports, Pharmacy, OR, Infectious Disease Specific Reports.

Yale --

Duke Updates on Quality Projects and Strategy

Memorial Sloan-Kettering

Review of department QA committee meeting minutes. Also, any completed RCAs, status update of action items from previous RCAs. Each Department QA Committee chair presents once per year on how his/her department is using data to drive improvement.

Dartmouth Dashboard Review, Status Updates, Program Evaluation

Siteman Subcommittee Reports, Cancer Registry Reports

Dana-Farber Joint Commission Requirements spread out throughout the year.

Karmanos Root Cause Analysis Update, Core Measures Data, JC Readiness Updates

Roswell Park Department Reports, Areas of Focus, Occurrence Complaints Institute scorecard, Patient Safety scorecard, Patient Satisfaction Scores

Moffitt Ethics, Grievances, Risk, Quality and Safety, Credentials



9

Leaders and Facilitators of MeetingsHospital Leader/Chair FacilitatorMD Anderson VP of Performance Improvement Director of Patient Safety

Yale Several different people Several different people

Duke VP and Associate Dean -

Memorial Sloan-Kettering Appointed Chair of Committee (Physician) Appointed Chair of Committee (Physician)

Dartmouth Chief Safety Officer (Physician) and CNO/VP Clinical Operations

Chief Safety Officer (Physician) and CNO/VP Clinical Operations

Siteman Physicians Physicians

Dana-Farber CQO and CNO/VP Quality and Patient Safety CQO and CNO/VP Quality and Patient Safety

Karmanos VP Medical Affairs Clinical Improvement Specialist (Quality)

Roswell Park CMO and VP Quality CMO and VP Quality

Moffitt CMO Director of Quality and Safety



10

Disciplines of Membership

11%

11%

9%

3%

11%

5%2%7%

6%

2%

3%

7%

10%

6%6%

Physicians (10)

Nursing (10)

Pharmacy (8)

Clinical Research (3)

Quality (10)

Tumor Registry (4)

Clinical Nutrition (2)

Diagnostics (6)

Rehab (5)

Pastoral Care (2)

IT (3)

Clinical Informatics (6)

Risk/Legal (9)

Patient/Family Advisor (5)

Other (5)



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“All Other” Responses for Disciplines of Membership

Hospital Other Disciplines

Memorial Sloan-Kettering Hospital Administration, President’s Office, Patient Relations, Ambulatory Care Network, GME, Patient Safety, QA Committee Chairs for BMT, Lab Medicine, Medicine, Neurology, Nursing, Pathology,, Pediatrics, Pharmacy, Psychiatry, Radiology, Surgery

Siteman Hospice, Palliative Care, American Cancer Society

Dana-Farber Trustees

Karmanos Medical Records

Roswell Park 5 Governance Board Members

Moffitt Hospital Board Members, Hospital Administration (President and SVP)



12

Reporting Structure of Quality Committee

Hospital Who They Report To

MD Anderson President

Yale Safety/Quality Nurse for each service line; central performance management group for the system

Duke Includes leadership to the highest level

Memorial Sloan-Kettering Medical Board Board of Trustees

Dartmouth Quality Subcommittee of the Board of Trustees

Siteman Medical Executive Committee

Dana-Farber Chief Quality Officer Board of Trustees

Karmanos HPIC (Hospital Performance Improvement Committee)

Roswell Park CEO and Medical Staff Executive Committee

Moffitt Subcommittee of Hospital Board



13

Quality Committee Sub-Committees Hospital Subgroup/Sub-Committee

MD Anderson --

Yale --

DukeStarting a quarterly sub-group

Memorial Sloan-Kettering Steering committee- Reviews department QA committee meeting minutes and finalized presentation agenda

Dartmouth Safety Sub-Committee- Help from several Quality and Measurement support departments

Siteman •QI Committee•Palliative/Supportive Care Sub-Committee•Education Subcommittee

Dana-Farber •Satellite Quality Committee (oversees offsite locations)•Infection Control Sub-Committee

Karmanos --

Roswell Park •Patient Safety

Moffitt •Credentials, Risk, Ethics, Joint Commission, Grievance, Ancillary, Support Improvement Committees



14

How Information is Communicated “Up” Within the Organization

Hospital How Information is Communicated “Up”

MD Anderson Report given to leadership

Yale Emailed, representatives relay information to different committees, and service lines

Duke Highest leadership is already part of this committee


Quarterly Board of Managers reports

Dartmouth Officers and other leaders are on the committee

Siteman Minutes are shared at department meetings and sent monthly to MEC; Report annually to Hospital Safety & Quality Council

Dana-Farber CQO and Trustees sit on the committee and are actively involved

Karmanos HPIC minutes/presentations are communicated to KCC Board Quality Committee (sub-committee of Board of Trustees)

Roswell Park Minutes are sent to CEO and MSEC. Department Representatives are responsible for communicating with constituents.

Moffitt Directly to the HBOD



15

How Information is Communicated “Down” Within the Organization

Hospital How Information is Communicated “Down”

MD Anderson Online, Executive Committee of Medical Staff

Yale Through management and education

Duke --

Memorial Sloan-Kettering --

Dartmouth Working on an open forum with voting members and others who can attend for information purposes

Siteman Staff meetings and minutes distribution

Dana-Farber Quality, Nursing, and clinical leadership

Karmanos VPs, Directors, and managers attend HPIC and are responsible for reporting back to their departments

Roswell Park Department Representatives are responsible for communicating with constituents

Moffitt Monthly Management Update



16

Does your Quality Committee have an annual Goal Setting Determination/Process?

Hospital No Yes

MD Anderson - Drive from top down and from bottom up

Yale - Based on patient safety & quality, employer of choice, provider of choice, fiscal

Duke

Memorial Sloan-Kettering - QCI Steering Committee and chair of HQAC presents annual goals to the group

Dartmouth

Siteman -Review scorecard from fall and propose areas that need improvement. Review organization strategic plan. Goals determined by QI Committee and then discussed by Cancer Committee and then voted on.

Dana-Farber - Strategic goals are discussed at the end of FY and the quality goals are created. Goals are aligned and includes NPSG’s in the process.

Karmanos

Roswell Park -“Areas of focus” are determined in November. VP of Quality makes recommendations and those are voted on in January.

Moffitt - Annually review and select goals and targets for FY.

70%

30%

YesNo



17

Are Service-Line or Disease-Line Reports Shared at this Committee?

Hospital No Yes

MD Anderson

Yale - Some are Service-Line based, some have representatives from each service line

Duke - If they have relevant projects


Dartmouth

Siteman -Scorecard broken into service lines, reviewed monthly at both Cancer and QI Committee. Program specific scorecards are reported once annually to the committee.

Dana-Farber - Institutional dashboard that high-lights 40+ departments across the institute. If there is poor performance anywhere, that department has to present their action plan.

Karmanos

Roswell Park - Medical, surgical, and diagnostic plans report to the committee at least twice a year

Moffitt

80%

20%

YesNo



18

Are Monthly/Quarterly Scorecards Regularly Shared?

80%

20%

Yes (8)

**No (2)

**Yale and Duke are the two hospitals that do not regularly share their scorecards



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Feedback/Next Steps

Does anything stand out to you? Linda will be sharing this information with Carol

Colussi and Kris Kipp next week

Health & Medicine

C4QI Survey Monkey Results