JULY
2004
Volume 28 •
No. 7
Kelly DeMaria, director of SHC's Quality Improvement and Patient Safety Department, believes nurturing quality ensures licensure success.
Death Certificates must be reviewed, signed promptly
Daylong seminar helps professionals support families facing a death
SHC offers media relations services to physicians
Wachter
talk available for viewing on
DVD/VHS
Quality and Patient Safety efforts transcend site visits
Contact Compliance if Lumetra or other official agency contacts you
Quality
and patient safety efforts transcend site visits
Preparations for licensure site visits never stop for Kelly DeMaria, who became director of SHC's Quality Improvement and Patient Safety Department in January.
DeMaria said that she and her staff of experienced clinical nurses and research analysts can never disregard the need to help prepare the hospital and its medical staff for licensure reviews. "But realistically, we wouldn't be able to enlist the support of our clinical colleagues if we were asking them to perform tasks that didn't also contribute to the organization's clinical mission.
"Certainly we have to perform some tasks which are license and inspection specific, but fortunately the JCAHO and other regulatory organizations are now more aligned than ever before with the realities of good patient care," she said.
DeMaria, who holds a master's degree in nursing, worked in a similar quality assurance position at Saint Mary's Regional Medical Center in Reno before coming to Stanford. She has more than 20 years experience in management and clinical care, primarily in high intensity environments, including critical care and emergency services.
DeMaria, like most of her medical and hospital staff colleagues, is pleased with the results of the most recent JCAHO survey in April.
"We had 30 to 40 medical staff members directly involved, and it was really heartening for me as a newcomer to Stanford to see the pride and the expertise that the physicians and clinical staff offered to the surveyors," she said.
Now she is looking ahead to as-yet unscheduled but possibly imminent surveys by the regulators from the California Department of Health Services (DHS).
"But everything really aligns in 2006 when all Joint Commission surveys will be conducted unannounced. We will have moved from 'survey readiness' to the more constructive mode of 'continuous compliance'. We really will have to be ready at all times," she said.
DeMaria said she is discovering that one of the most potent tools SHC now uses to ensure quality and safety is the physician-driven Quality Improvement Patient Safety Committee, chaired by Associate Chief of Staff Joe Hopkins, and supported by DeMaria and her staff. [See Quality Corner in the Medical Staff Update each month for current highlights].
"This newly structured committee was re-focused last year as a truly physician-driven organization. As hospital staff, we can make its job easier by providing administrative and structural support, but ultimately physicians are responsible for quality initiatives and patient safety in this hospital," DeMaria said.
Working in a teaching hospital is satisfying, "because the analytical emphasis is built around using scientific evidence to achieve results," she said.
"If you achieve standards of best practices, you align yourself with what the survey groups are now requiring," she said. "The standards are developed based on research and established standards of care and experiences from other accredited organizations which are respected by the physician scientists on our medical staff."
DeMaria said one of the more complicated tasks facing the hospital and medical staff is the need to apply National Patient Safety Goals in a huge, diverse medical center. Procedures and protocols, including clinical pathways, have to be consistent across a wide spectrum of services, ranging from research oriented invasive procedures to outpatient clinics.
"We've streamlined our standards, we're currently fine-tuning our documentation, but we don't have all the answers," she said. "This is always a work in progress."
For example, implementing the JCAHO goal of eliminating wrong site procedures requires parallel but somewhat different protocols in various settings, ranging from the operating rooms to the outpatient clinics.
"You can't fix problems by simply adding new rules when something goes wrong. Eventually you create inconsistencies, complications and ultimately confusion. This sets the institution up for error. You have to look at what you're doing across the whole institutional spectrum, and that requires a great deal of collaboration. Fortunately, we have leadership in the medical staff that understands the broad picture and can help all of us develop protocols and pathways which are consistent with both rules and quality patient care," DeMaria said.
"We can and have also influenced the JCAHO in terms of setting standards," she said. For example, SHC leadership pointed out to the JCAHO that an initiative to require barcodes to manage patient information would put an undue burden on smaller hospitals.
DeMaria said some of the key preparations for future surveys - and improved patient safety - are already in place. She said "mock tracers," or detailed, real-time patient reviews are conducted on units approximately weekly - a carryover from preparations made for the April JCAHO visit.
This year, SHC is hoping to become one of the first Academic Medical Centers certified as a Primary Stroke Center. The Quality Improvement and Patient Safety Department is working with the Stroke Center and numerous other hospital departments, DeMaria said, to ensure that Stanford achieves this important recognition.
