QUALITY

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QUALITY

• Liz Walliser, RN, MS, CPHQ
• Director Quality
• Office located on 6th floor

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Role of Quality Department

• To support physicians to provide best practice
• Peer Review
• Review of Quality Indicators
• Ensure compliance with regulatory requirements
  (Medicare, Joint Commission)
• Provide data/feedback to physicians (LOS)
• Provide information on upcoming changes

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Peer Review

• Peer Review-centralized except for specialty
  practice (ED, Psych, Rad, Path)
• MSQC-Medical Staff Quality Committee
• Multidisciplinary
• Group consensus
• Rating system and results entered to report card
• Physicians notified of all reviews and outcomes

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Physician Report Card

• Required by Joint Commission
• Ongoing, continual evaluation of practice
• Indicators by Specialty
• Patient Care
• Medical/Clinical Knowledge
• Practice Based Learning Improvement
• Interpersonal Communication Skills
• Professionalism
• System Based Practice

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Focused Professional Review

• Required by Joint Commission
• Organization evaluates the privilege-specific
  competence of the practitioner who does not have
  documented evidence of competently performing the
  requested privilege at the organization (can also
  applied when there is a concern)

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Core Measures

• Acute MI
• Congestive Heart Failure
• Pneumonia
• Surgical Care
• Pregnancy
• Psychiatric

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Core Measures

• Acute MI
• Door to balloon lt90 minutes
• Heart Failure
• Evaluation of LV function (ECHO, nuc med, cath or
  normal, mod, severe in progress notes) and
  document
• If LV impaired-ACEI/ARB prescribed on DC
• Beta blocker prescribed on DC

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Core Measures

• Pneumonia
• Use Order Set to ensure right antibiotic
• Pt is screened and vaccination given unless
  physician orders not to
• Surgical Care
• Antibiotic w/i one hour of incision
• Antibiotic must be DCd by 24 hours (except CABG)
• Use the right antibiotic
• Normothermia intra-op
• Glucose control post-op
• VTE prophylaxis

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Core Measures

• Pregnancy
• Prevent 3rd/4th degree lacerations
• Minimize VBAC
• Psychiatric
• Reduce of antipsychotic meds prescribed at
  discharge
• Discharge follow-up (referrals, meds, reason for
  hospitalization)