Department of Quality and Patient Safety

UMass Memorial Healthcare

PresidentW. Ettinger, MD

Chief MedicalOfficer

S.Tosi, MD

Chief NursingOfficer

N. Kruger, DNSc,RN

Chief QualityOfficer

R. Klugman, MD

Senior VicePresident

V. Diamond, MPA

Hospital Epidemiologistand Infection Control

R. Ellison, MD

Physician QualityOfficers (8)

Director ofNetwork QualityE. Westrick, MD

Sr. Director ofQuality & Safety

TBD

Director of PatientExperience

R. Johnson, MBA

Director of QI/PIC. Brazauskas,

RN

Director ofClinical Decision

SupportJ. Paster, RN

RiskManagement

P. Hughes

PatientRepresentatives

S. Tarrant

CaseManagementC. Sullivan

Director of PatientSafety

E. Felkel-Brennan

Home HealthM. Stone

Medical StaffServices

M. Podesta

Rev. 3/5/07

Senior Vice PresidentV. Diamond, MPA

Sr. Director of Quality &SafetyTBD

ExecutiveSecretary

K. Catalina

Director of QI/PIC. Brazauskas,

RN

Dir Patient Exp.R. Johnson, MBA

Director ofClinical Decision

SupportJ. Paster, RN

Patient & FamilyAdvisory Council

Office of Quality & Patient Safety

Manager ofRegulatory

TBD

Mgr. of ClinicalDecision Support

D. Vogel

Senior Decision SupportSpecialist

Decision Support Specialist

Database Administrator (CTSurgery) / Organ Transplant

Data Abstractor/Reporter

Quality ProjectManagers

(Continuous)

Quality ProjectManagers(Focused)

Executive SecretaryTBD

Dir. Patient SafetyE. Felkel-Brennan,

RN, MSN

Project CoordinatorPatient Safety & Reg.K. Marc

3rd Party PayorCoodinatorTBD

Heart & Vascular Services C. MorleyCancer Services J. TrottierMusculoskeletal Services C. BrazauskasSurgical Services TBDBehavioral Health V. Gaw

Rev. 3/5/07

Chief Quality OfficerR. Klugman, MD

HospitalEpidemiologist &Infection ControlR. Ellison, MD

Physician QualityOfficers

Vice PresidentMedical Mgmt.

E. Westrick, MD

M. Aronson, MD

M. Gitkind, MD

M. Manno, MD

M. Hudlin, MD

R. Luckman, MDE. Smith, MD

S. Viswanathan, MD

K. Walsh, MD

•Patient Safety Programs are essentially diagnostic•Their purpose is to:•Improve the culture of Safety. •Non-punitively identify concerns and

problems •Focus on teamwork •Offer evidence based design principles •Create an awareness of the

vulnerabilities in systems •Upgrade processes to reduce

likelihood of recurrence of problems•Support patient safety research

•QI processes are intended to:•Help the sharp end staff (patient level healthcare workers) and the blunt end staff (managers and administration) work together to take effective action once a problem or opportunity for improvement has been identified.

•Risk Management contributes to patient safety through retrospective analysis of events. •It’s purpose is to:•Protect the assets of the organization•Identify and mitigate risk though audits, which can;•Prevent future adverse events•Educate about risk which can facilitate;•Recommending prospective

interventions, grounded in safety science

•‘Patient safety requires great humility. It requires a shift from the concept of autonomous operators to that of team members. This shift is challenging but represents an opportunity for intellectual challenge and learning.’

IOM 6 Aims•Safe

•Effective

•Patient Centered

•Efficient

•Timely

•Equitable

The Platform

The six interventions from the 100,000 Lives Campaign:

• Deploy Rapid Response Teams…at the first sign of patient decline• Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart

attack • Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation• Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps• Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time • Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically

grounded steps

New interventions targeted at harm:

• Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention• Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection…by reliably implementing

scientifically proven infection control practices• Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics,

and insulin• Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by the

Surgical Care Improvement Project (SCIP) • Deliver Reliable, Evidence-Based Care for Congestive Heart Failure…to reduce readmissions • Get Boards on Board….Defining and spreading the best-known leveraged processes for hospital Boards of

Directors, so that they can become far more effective in accelerating organizational progress toward safe care

IHI

Pay for Performance Today and Tomorrow

–Claims Based–Outcome Based–Prevention–Disease Management–Efficiency

•Pharmacy•EMR•Radiology/Expensive tests•Admin. simplification

Achieving Quality – Medical Staff (MS) Elements of Performance

Qualifications, Roles, & Responsibilities of Dept. Chair (MS.1.20 EP 8.)

• All clinically/administratively related activities of the department• Continuing surveillance of the performance of all individuals with

clinical privileges.–Recommending to the staff the criteria for clinical privileges–Recommending clinical privileges for each member of the department

• Maintaining ongoing quality control activities• Continuing assessment and improvement of the quality of care,

treatment and services.• Continuing education of all persons in the department

Physician role in management & coordination of patient care, treatment, & services (MS. 2.20.)

• MS provides leadership in

–Patient safety

–Teamwork

–Speaking up

–Analyzing and improving patient satisfaction

• MS specifies minimum content of H&P

–Monitors quality of H&Ps

•Performs H&P

–Defines scope of H&P for non-inpatient services

• Consultation is obtained for the circumstances defined by the medical staff

–E.g, ASA 4 - consult anesthesia

Achieving Quality – Medical Staff (MS) Elements of Performance

UMass Memorial Medical Center Mission

UMass Memorial Medical Center is committed to improving the health of the people of Central New England through excellence in clinical care, service, teaching and research.

• Cornerstones

–Deliver high quality, safe care- Assuring appropriate skills and knowledge of staff, using standardized, evidence based processes of care, creating safe environment

–Create an excellent experience for patients- Approaching pts and families with courtesy and compassion, meeting personal needs for information and involvement, following processes for referrals and transfers, creating a warm and comfortable environment

–Manage resources- Enhancing revenue, controlling expenses and maximizing return on assets

–Engage staff in the work- Approaching employees with respect, listening to concerns, clarifying expectations, involving staff in solutions

6 Principles of MD Competence

•Patient care• Competence• Compassion• Honesty• Confidentiality• Quality• MD-Patient Relationship

»Access»Resource Use»Med record integrity

•Medical / Clinical knowledge• Life-long learning• Maintain Skills• Use of science•Practice based learning and improvement• Evidence based medicine

»Improvement using scientific method »…to evaluate and improve practice»Guidelines and protocols»Scheduling»EMR

•Interpersonal and communication skills• With patients• Families

»Colleagues

•Professionalism• Patient Welfare

»Patient’s interests first, ahead of market forces, admin. needs, societal pressures

•• Patient Autonomy• Informed decisions• Empowerment•• Social Justice• Fair distrib. of resources• Fight discrimination• Conflicts of Interest• Teaching• Service• Research•System based practice• Understanding of how he/she fit into

systems of care• Understanding of systems of care,

practices, groups, healthcare systems, payors, government

»Participate in improving these systems

•

Examples - Ongoing Professional Practice EvaluationLeading the Way

• Respect • Attendance at PI meetings• Participation in Chart Reviews• Compliance with NPSGs• Site marking • Time out• Timely response to critical values• Use of unapproved abbreviations • Review of operative/other clinical procedures that place patients at risks • Pattern of blood and drug usage• Requests for tests and procedures• LOS patterns• M&M data• Use of consultants

Achieving Quality – Ongoing Professional Practice Evaluation (MS.4.40)