JULY
2005 • Volume
29 • No. 7
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June
Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee,
chaired by Joseph Hopkins, associate chief of staff
Physician
Guide
The QIPSD [Quality Improvement Patient Safety Department] has collaborated
with key physicians to publish a "Physician Guide" on quality
and safety initiatives, including the key regulatory requirements affecting
physicians.
Leapfrog Group -
slated to publish hospital scores on-line by mid-July. Leapfrog
is a voluntary program driven by 170 corporate and organizational purchasers
of health care to alert America's health industry that "big leaps"
in health care safety, quality and customer value will be recognized
and rewarded
SHC
meets the CPOE [Computerized Physician Order Entry] Leap
HSHC
is working toward compliance in the Evidence Based Referral Leap
The
"closed" ICU model definition Leap is in progress
Cancer
Center Committee
-
Quality
improvement studies for cancer have been approved:
-
Chemotherapy administration
-
Colo-rectal oncology interdisciplinary sequential visits
- Cancer Center Telephone Access Center
-
Non-emergent healthcare communication facilitated through
Relay Health's secure website
-
Cancer Center shuttle transportation
-
Video of treatment options for localized prostate cancer
-
New patient DVD
- Vocera
The
committee is preparing for accreditation by the American College of
Surgeons. Mock surveys will occur during July and August to prepare
for a pre-survey scheduled Sept. 12.
PCA and FMEA
- Nurse Management is scheduled in September to publish an article on
the PCA [patient controlled anesthesia] FMEA [failure modes and effects
analysis]. The recently completed analysis resulted in the purchase
of new Alaris PCA pumps and training for clinical staff.
Process and Quality Improvement Projects - A comprehensive document
listing, prioritizing and structuring all quality and process improvement
projects for fiscal years '05 and '06 has been prepared.
Mortality and Length of Stay - A
multi-year project to improve outpatient clinic service, including waiting
times for patients
Observed
and expected mortality remain similar and average length of stay observed
and expected remain consistent based on data changes the University
Healthsystem Consortium [UHC] has made using the All Patient Refined
[APR] diagnostic related group [DRG] model.
National Patient Safety Goals - New auditing process
established:
Minimum acceptable level of compliance is 95
percent
An action plan is required when any goal component measures less
than 95 percent for two consecutive months
A goal that achieves 100 percent for three months may revert
to quarterly reporting
