Medical Staff CQI

1
Medical Staff CQI

• Memorial Hospital
• Chester, Illinois
• 3/26/09

2
Medical Staff Performance Improvement Process

• Variety of Indicators which involve all Medical
  Staff
• Active Staff
• ER Physicians
• Radiologist
• Consultants
• Source of indicators
• Best practice Guidelines (HQA, HOP QDRP, etc. )
• COP/JC Standards (V.O., Timely H P, H P
  Update)
• National Patient Safety Goal Compliance
• Physician approved protocols
• Data collected by various disciplines throughout
  the hospital for example
• Blood Utilization (Lab)
• Clinical indicators (OR, ER)
• Core Measures PI director
• Incident Reports Safety Director
• Medical Record Review HIM director
• Utilization Review UR Mgr.

3
Process continued

• The overall results of the indicators are then
  reported to
• PI committee,
• Environment of Care Committee.
• From these two committees, the overall results
  are then forwarded to the Medical Staff Committee
  of the Whole.

4
Peer Review Process

• Any indicators that result in variation are
  referred initially to the Physician Advisor,
• Examples
• Blood Utilization Lab Advisor
• IP Core Measures Chief of Staff
• Trauma Indicators (ER) ER Physician Director
• Vancomycin Infection Control Advisor.
• Physician Advisor determines if further review is
  warranted by the Peer Review Committee.
• If further review warranted
• Sent on to Quarterly Peer Review Committee
  Meeting.
• Peer Review committee takes further action as
  warranted
• Continuing education, monitoring, focused
  practice evaluation.
• Form to track record as it moves through this
  process

5
MEMORIAL HOSPITAL CHESTER, ILLINOIS PHYSICIAN
REVIEW FORM Patient Name DOB M Date of
Admission/Occurrence Physician
Involved Committee Recommending the
Review

PHYSICIAN REVIEW Date reviewed


Physician Reviewer
Recommend for Peer Review Committee?
_________________Yes
_________________No Comments


PEER REVIEW COMMITTEE Date Reviewed by
Committee Comments/Recommendations Chief of
Staff____________________________________________
______________________________________________



Signature
Date

FOLLOW
UP Supporting documentation of follow up actions,
activity, monitoring, education, or other
relevent information may be attached
as indicated. Chief of Staff___________________
__________________________________________________
__________________


Signature

Date PRIVILEGED CONFIDENTIAL All information
provided on this form, including any appended
materials, is Privileged Confidential, to be
used solely in the course of internal control and
for the purposes of reducing morbidity and
mortality and improving the quality of patient
care, as provided in the Illinois Medical Studies
Act 735 ILCS 5/8-2101.
6
Indicators

• Core Measures
• IP
• AMI, CHF, Pneumonia, SCIP
• OP
• Chest Pain, AMI, Out Patient Surgery.
• Tissue Review
• Normal tissue, too little tissue, clear margins,
  etc.
• Blood utilization
• Hgb below 8.2 Platelets, FFP, etc
• Documentation of informed consent, written orders
• Incident Reports
• Physician complaints.
• Sentinel Event.

7
Indicators continued

• Medication Usage
• Significant clinical interventions
• Anticoagulation Protocol
• Vancomycin Usage
• Infection Control
• HAI
• Vancomycin Usage
• Medical Record Review
• Dating, timing, signing Verbal and Telephone
  orders
• Prohibited abbreviations
• Delinquent Records
• H Ps Update to H P
• Complete/Timely Operative Report/Operative note
• Timely consultant dictation

8
Indicators

• ER Physician Indicators
• Trauma Indicators
• Chest pain / AMI
• Timeliness of Thrombolytics,
• X-ray interpretation
• ER Management / Documentation issues
• Utilization Management
• LOS
• Readmissions
• Admission/Continued stay criteria not met.
• Denials
• RAC Audits ??
• Mortality/Morbidity Review

9
Indicators Continued

• Surgical and other invasive procedures
• Timely H P update
• Universal Protocol
• Informed consent
• Pre-op / Post-op discrepancies including path
  diagnosis
• Conscious Sedation Outcomes
• Deaths in OR/PACU
• Repairs, lacerations, Perforations, Tears
• Anesthesia indicators
• Retained foreign body
• Returns to OR in 24 hours.

10
Hospital Quality Alliance Memorial Hospital
Ref Joint Commissions Medical Staff Standards.
Sponsored by Illinois Hospital Association.
11
Hospital Quality Alliance Memorial Hospital
Ref Joint Commissions Medical Staff Standards.
Sponsored by Illinois Hospital Association.
12
Credentialing

• Summary of all indicators is compiled for each
  physician.
• Summary attached to Medical Staff Re-application.
• Reviewed by Medical Staff when physician is
  recredentialed.
• See Summary Form

13
PHYSICIAN SUMMARY MEMORIAL HOSPITAL, CHESTER,
IL PHYSICIAN __________________________________
__
Year_________________________



YEAR TO DATE
PATIENT CARE ACTIVITIES
Admissions Discharges
Observation Patients
Procedures Deaths Del
Charts
ALOS
HOSPITAL
QUALITY ALLIANCE Congestive Heart
Failure..........................................
..................................................
..........................................100
Discharge Instructions.....................
..................................................
..................................................
...............90 LVF
Assessment ......................................
..................................................
..................................................
.....100
Smoking Cessation..........
..................................................
..................................................
...............................100

Pneumonia Antibiotics within 4 hours
of arrival.......................................
..................................................
..........................90
Appropriate Selection of Antibiotics
..................................................
..................................................
............100
Blood Culture prior to Antibiotics
..................................................
..................................................
................100
Influenza Vaccine
--------------------------------------------------
--------------------------------------------------
-------80
Pneumonia Vaccine
--------------------------------------------------
--------------------------------------------------
----100 Oxygenation Assessment

Adult Smoking
Prot
Ordered
Acute Myocardial
Infarction Aspirin on Arrival

Aspirin at Discharge
Beta Blocker on
Arrival Beta Blocker at Discharge
PATHOLOGY REVIEW Tissue
Adequate.........................................
..................................................
..................................................
........96 Biopsy Justified.............
..................................................
..................................................
...................................... 4
14
MEDICATION REVIEW of Medication
Interventions.....................................
..................................................
...............................................0
Appropriate Use of Vancomycin................
..................................................
..................................................
.......100 BLOOD/BLOOD COMPONENT REVIEW
Approved Indicator Met for Transfusion...........
..................................................
.................................................
Reviewed by Pathologist and Approved
..................................................
..................................................
......... Written Order for Blood
Transfusion......................................
..................................................
........................... Documentation of
Informed Consent.................................
..................................................
................................ CLINICAL
PERTINENCE Timely H P....................
..................................................
..................................................
............................. Operative
Report Dictated Day of Surgery
..................................................
..................................................
.... Operative Note Written Immediately post
op ..............................................
..................................................
... Timely Clinical Resumes
..................................................
..................................................
............................... Timely
Surgical HP.....................................
..................................................
.................................................
PHYSICIAN ADVISOR REVIEW Reason for review
Outcome - Refer to Peer Review Committee? PEER
REVIEW COMMITTEE Reason for Review
MEETINGS - ATTENDED Medical Staff
Meeting Committee of the Whole
..................................................
..................................................
Medical Conference Peer Review
..................................................
..................................................
.................... Special Committees
Mortality Morbidity