QUALITYQUALITY

Liz Walliser, RN, MS, CPHQLiz Walliser, RN, MS, CPHQDirector QualityDirector Quality

Office located on 6Office located on 6thth floor floor

Role of Quality DepartmentRole of Quality Department

To support physicians to provide best To support physicians to provide best practicepractice

Peer ReviewPeer Review Review of Quality IndicatorsReview of Quality Indicators Ensure compliance with regulatory Ensure compliance with regulatory

requirements requirements (Medicare, Joint Commission)(Medicare, Joint Commission) Provide data/feedback to physicians Provide data/feedback to physicians (LOS)(LOS) Provide information on upcoming changesProvide information on upcoming changes

Peer ReviewPeer Review

Peer Review-centralized except for Peer Review-centralized except for specialty practice (ED, Psych, Rad, Path)specialty practice (ED, Psych, Rad, Path)

MSQC-Medical Staff Quality Committee MSQC-Medical Staff Quality Committee MultidisciplinaryMultidisciplinary Group consensusGroup consensus

Rating system and results entered to Rating system and results entered to report cardreport card

Physicians notified of all reviews and Physicians notified of all reviews and outcomesoutcomes

Physician Report CardPhysician Report Card

Required by Joint CommissionRequired by Joint Commission Ongoing, continual evaluation of practiceOngoing, continual evaluation of practice Indicators by SpecialtyIndicators by Specialty

Patient CarePatient Care Medical/Clinical KnowledgeMedical/Clinical Knowledge Practice Based Learning & ImprovementPractice Based Learning & Improvement Interpersonal & Communication SkillsInterpersonal & Communication Skills ProfessionalismProfessionalism System Based PracticeSystem Based Practice

Focused Professional ReviewFocused Professional Review

Required by Joint CommissionRequired by Joint Commission Organization evaluates the privilege-Organization evaluates the privilege-

specific competence of the practitioner specific competence of the practitioner who does not have documented evidence who does not have documented evidence of competently performing the requested of competently performing the requested privilege at the organization privilege at the organization (can also (can also applied when there is a concern)applied when there is a concern)

Core MeasuresCore Measures

Acute MIAcute MI Congestive Heart FailureCongestive Heart Failure PneumoniaPneumonia Surgical CareSurgical Care PregnancyPregnancy PsychiatricPsychiatric

Core MeasuresCore Measures

Acute MIAcute MI Door to balloon <90 minutesDoor to balloon <90 minutes

Heart FailureHeart Failure Evaluation of LV function (ECHO, nuc med, Evaluation of LV function (ECHO, nuc med,

cath or normal, mod, severe in progress cath or normal, mod, severe in progress notes) and documentnotes) and document

If LV impaired-ACEI/ARB prescribed on DCIf LV impaired-ACEI/ARB prescribed on DC Beta blocker prescribed on DCBeta blocker prescribed on DC

Core MeasuresCore Measures PneumoniaPneumonia

Use Order Set to ensure right antibioticUse Order Set to ensure right antibiotic Pt is screened and vaccination given unless physician Pt is screened and vaccination given unless physician

orders not toorders not to

Surgical CareSurgical Care Antibiotic w/i one hour of incisionAntibiotic w/i one hour of incision Antibiotic must be DC’d by 24 hours (except CABG)Antibiotic must be DC’d by 24 hours (except CABG) Use the right antibioticUse the right antibiotic Normothermia intra-opNormothermia intra-op Glucose control post-opGlucose control post-op VTE prophylaxisVTE prophylaxis

Core MeasuresCore Measures

PregnancyPregnancy Prevent 3Prevent 3rdrd/4/4thth degree lacerations degree lacerations Minimize VBACMinimize VBAC

PsychiatricPsychiatric Reduce # of antipsychotic meds prescribed at Reduce # of antipsychotic meds prescribed at

dischargedischarge Discharge follow-up (referrals, meds, reason Discharge follow-up (referrals, meds, reason

for hospitalization)for hospitalization)