Industry Interactions Pollcy
--Revisions of draft policy to be reviewed in June by QIPSC (See related comments by Medical School Dean Philip A. Pizzo)

• Would establish guidelines for interactions with industry representatives

• Applies to medical staff (faculty and community), staff, students and trainees of the SOM, SHC and LPCH

• Intended to ensure that all interactions with industry are ethical and avoid conflicts of interest that could endanger:

Patient safety
Data integrity
Integrity of education and training programs
Reputation of either a faculty member or institution

• Draft changes to be considered for June review include:

Operational issues
Inclusion of additional hospital staff, i.e. nurse practitioners, physician assistants, etc.
Clarification of community physician applicability

National Patient Safety Goals
--Actions required for NPSG compliance will be principal discussion item for June QIPSC meeting

• Compliance must be 100 percent in all areas to meet JCAHO requirements and to improve clinical outcomes

• Report format will change to reflect action-oriented reporting process

• 2006 goals:

Improve accuracy of patient identification
Effective communication among caregivers
Safe use of medications
Universal protocol: eliminate wrong site, wrong patient, wrong procedure surgery
Reduce the risk of health care associated infections
Accurately and completely reconcile medications across the continuum of care
Reduce the risk of patient harm resulting from falls

Peer Review Process Analysis

• QIPSC approved a process that will include:

QIPSD oversight to ensure consistency and integrity of process
Identification of system-process issues
Assigning quality managers to each service
Routine meetings to review data and cases
Service specific indicators
Use of aggregated data

• New process will launch first in medicine and anesthesia departments
• Peer Review process improvement is focused on:

Physician reviewer workload
Consistency of data reported throughout departments to improve clinical outcomes
Evidence-based medicine
Non-punitive environment

• QIPSD & CIC will provide oversight to Peer Review Process
• Quality Managers will be assigned to Quality Improvement MD on each service level to:

Review data
Perform data analysis
Manage/review QI indicators

Orthopedic Service Report
--Current year goals:

• Improve service excellence
• Outcomes analysis and reporting
• Robust QI Program at North Campus
• Development of service line dashboard
• Specialists recruitment

Sentinel Event Policy
--Amended to reflect new item added by JCAHO: unintended retention of a foreign object in a patient after surgery or other procedure

Informed consent Policy Change (SHC only)
--Remove arterial line insertions and central line insertions from list of procedures requiring informed consent

Autopsy Consent Form

• Format and process are being reviewed
• Risk management will present possible edits to QIPSC in July
• Concerns about the form and usage are:

Inconsistent use
Specific wording about retention of organs