Key Accrediting Agencies Agency Full Name Next Visit / Visit Frequency JCAHO CMS Joint Commission for the Accreditation of Healthcare Organizations Center for Medicare and Medicaid Services March 2005 & then unannounced every 3 years & as randomly selected As needed for patient complaint follow-up & JCAHO validation DFS As needed for patient complaint follow-up & JCAHO validation
Physician Role with JCAHO and CMS surveys §Be familiar with and practice to the standards related to their areas of expertise (i.e. infection control, sedation/analgesia, tissue…) and comply with National Patient Safety Goals §Member of the Department or unit-level care team §Participates in survey as requested §Works with JCAHO/CMS teams working for ongoing enhancement and compliance
National Patient Safety Goals 1. Improve the accuracy of patient identification. a. use at least two patient identifiers (neither to be the patient's room number) whenever taking blood samples or administering medications or blood products. b. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using activenot passivecommunication techniques. 2. Improve the effectiveness of communication among caregivers. a. Implement a process for taking verbal or telephone orders that require a verification "read-back" of the complete order by the person receiving the order. b Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use. 3. Improve the safety of using high-alert medications. a. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. b. Standardize and limit the number of drug concentrations available in the organization. 4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery. a. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. b. Implement a process to mark the surgical site and involve the patient in the marking process. 5. Improve the safety of using infusion pumps. a. Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization. 6. Improve the effectiveness of clinical alarm systems. a. Implement regular preventive maintenance and testing of alarm systems. b. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
IMPACT CARE A Performance Measurement and Improvement System: Organization wide and Department & Unit-Level
Definition of Quality The UNC Health Care system embraces the philosophy of continuous quality improvement. The IMPACT CARE concept defines quality as "meeting or exceeding the needs of our customers." Therefore, a product or service is viewed to be quality only if it meets (or exceeds) customer's needs or expectations.
IMPACT CARE IMPACTCAREIMPACTCARE IDENTIFY MONITOR PRIORITIZE ACTION PLAN CHECK TRANSFORM CUSTOMER SATISFACTION ACHIEVED OUTCOMES REDUCED COST EMPLOYEE OWNERSHIP Monitor Report Hospital Report Board Report FOR Key customers, scope of care or services, key activities, corporate goals, quality improvement goals, cost, satisfaction, survey results, and other indicators Indicators as above Identify opportunities for Improvement; prioritize based on impact on service, outcome, cost; set goals Implement (AIDE teams, etc.) Re-monitor, analyze data Institutionalize or generalize
IMPACT CARE REPORT Team Name: 7 NorthDate:
IMPACT CARE Control charts
Continuous Monitoring of Customer Satisfaction Press Ganey reports Surveys all inpatient discharges and sample of outpatients Data distributed quarterly Departmental/clinic independent surveys One Question satisfaction surveys
Interdisciplinary Approaches to Rapid Cycle Improvement §AIDE Teams (improve systems) l Assess l Identify Root Causes l Develop a Plan l Evaluate §CPITs (improve clinical processes) l Clinical Process Improvement Teams
Interdisciplinary Approaches to Rapid Cycle Improvement AIDE Teams (Improve Systems) Clinical Process Improvement Teams CPITs (improve clinical processes) Bed Management Supplies Availability Results Turn Around Time Emergency Department Wait Time Pediatric Asthma Non-ST-segment elevation Acute Coronary Syndrome (NSTE ACS) Stroke Diabetes Management
AIDE Team Clinical Process Improvement Team (CPIT) Focuses on systems problem, i.e.admitting process, turnaround time, etc Focuses on one problem Usually meetings of full team Most work done at meetings Does not always have physician members Recommendations are implemented by the hospital Staff leader Interdisciplinary Needs prior approval of the CQI Council Focuses on a DRG or procedure Focuses on more than one problem at a time (variations in practice) Three meetings of full team Most work done behind the scenes Heavy on physician team members Recommendations are voluntary (not rules) Physician leader Interdisciplinary Needs prior approval of the Clinical Management Committee
The AIDE Process PhaseOutcome of PhasePI Tools A ssess the Situation I dentify Root Causes D evelop a Plan E valuate Measurable problem statement, During the past six months an audit of patient records showed total undercharges of $220,951 for urokinase. This represents an 88% error rate Data-verified root causes of the problem Action plan implemented An indicator related to the problem statement, looking for improvement. Determine if follow-up actions are needed. Process flow diagram, control charts, brainstorming, multi- voting, selection matrix, pareto checksheets, other. Cause-effect diagram, pareto, graphs, selection matrix, other. Action plan, cost-benefit, force-field, selection matrix, other. Graphs, pareto, control chart, etc.
Goals of Clinical Process Improvement Team (CPIT) §Improve the quality of care for a specific patient population §Decrease over-utilization (or underutilization) of resources and services §Decrease variation in physician clinical practice patterns
UNIVERSITY OF NORTH CAROLINA HOSPITALS & CLINICS OPERATING GOALS AND ASSUMPTIONS (Excludes Rex Healthcare) Fiscal Year The following operating goals and assumptions were developed by the UNC Health Care Systems* CQI Council in response to patient care needs, environmental and regulatory assessments, and financial expectations: Strategic Quality Goals: SERVICE Inpatient Demonstrate organization-wide improvement in the top three problematic areas identified on the 2002 Employee Opinion Survey (communication, employee involvement in decision-making, leadership). Make medical staff and internal customer (departmental) satisfaction measurable. Continue to improve overall inpatient satisfaction. Fully utilize the Clinical Decision Unit. Reduce observation status discharge delays across services. Reduce billing complaints. Continue facility renovations and improvements. Outpatient Demonstrate organization-wide improvement in the top three problematic areas identified on the 2002 Employee Opinion Survey (communication, employee involvement in decision-making, leadership). Continue to improve overall outpatient satisfaction. Improve staff courteousness. Reduce billing complaints. Answer telephones within four rings. Provide live operator option in all voice response systems. Decrease wait time before going to exam room. Decrease wait time in exam room. Improve exam room utilization. Reduce no show rate. Reduce cancellation rate. Reduce reschedule rate. Improve access to care (availability of first appointment). Improve identification of care providers by patients and their families
Strategic Quality Goals: OUTCOME Inpatient Successfully implement Computerized Provider Order Entry. Reduce the number of Severity Level 3 and above medication errors for the top three drugs that are leading to patient harm or have the potential for patient harm (insulin, heparin, and narcotics). Implement patient safety focused Executive WalkRounds and Safety Huddles. Prevent medication reconciliation errors upon admission. Develop and begin implementation of a new interdisciplinary care delivery model designed to maintain high quality patient care in anticipation of reduced availability of resident hours and professional care staff. Decrease average LOS for all patients, without increasing readmission rate. Be able to show measurable improvement in IMPACT CARE plans. Continue AIDE team education of managers. Outpatient Provide evidence of continuity and coordination of care across the care spectrum. Be able to show measurable improvement in IMPACT CARE plans. Continue AIDE team education of managers. Deliver prevention and specialty care according to best practice guidelines. Address patients' primary concerns. Improve the medication record. Strategic Quality Goals: COST Inpatient Obtain accurate insurance information. Reduce reimbursement denials. Reduce the costs associated with paid FTE's obtained through contracted services. Outpatient Reduce volume/amount of noncompliance with Local Medical Review Policies (LMRP). Manage authorization denials for completed ancillary services to prevent account write-offs. Improve cash collection. Decrease charge lag time.