1. At Stony Brook Medicine
Continuous Quality Improvement
Continuous Quality Improvement
At Stony Brook Medicine

2. Continuous Quality Improvement (CQI)
A journey to satisfy the needs and exceed the expectations of our customers
A means of performance improvement
Is Aligned with our Mission to deliver world class, compassionate care, advance our understanding of health and disease and to educate healthcare professionals
Stony Brook University Hospital is on a continuous journey to improve the care it renders to it’s community. 2

3. What does CQI Encompass?
Patient Care
Patient Safety
Employee Satisfaction
Administrative & Operational function
Regulatory Requirements
Employee Safety
Patient Satisfaction
What does CQI Encompass?
In addition to our current customers, as we move into the future models of care we will be growing our relationships with community partners as well. 3

4. CQI Principles All work is part of a process
Quality is achieved through people
Decision making is done with facts
Our patients and customers are our first priority
Quality requires continuous improvement
CQI focuses on the process not the person
Stakeholders
Best practice
Patient centered 4

5. Find a process to improve
Administration, Program of Distinction (POD) Groups, other Committees charter a CQI team
Criteria used to prioritize opportunities for improvement
High Risk
High Cost
High Volume
Problem Prone
Patient Safety related
Our information flows top down and bottom up with multiple opportunities for stakeholders as well as leaders to identify and prioritize improvement opportunities. 5

6. Robust Performance Improvement
Tools of the Quality Trade
FOCUS PDCA
Lean Methodology
Six Sigma Analytics
Proactive FMEA
RCA Reviews
Robust Performance Improvement
The synergy of all of these strategies lead us to a very robust PI program 6

7. Methodology for Improving a ProcessU S
Find a process to improve Organize a team that knows the process Clarify current knowledge of the process Understand causes of process variation Select the process improvement
FOCUS PDCA is our performance improvement methodology.
All of our initiatives are data driven and evidence based. 7

8. How does FOCUS PDCA help us to adhere to the Simple Rules of Work?
Patients First
Prevent Failure (a breakdown in operations or functions)
Use World Class Processes
Redesign the Process to meet the best standard of care without compromise to the patient
Encourage Growth in Knowledge
Use Resources Wisely 8

9. Sentinel Event Root Cause Analysis
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
Examples include: Suicide - Rape - Loss of limb – Elopement - Death
Root Cause Analysis
A process for identifying the contributing factors that underlie variations in performance; includes the occurrences of the sentinel events, adverse event or close calls.
Process that features interdisciplinary involvement of those closest to and/or most knowledgeable the situation to find out:
What happened?
Why did it happen?
How can we prevent it?
How do we know we made a difference?
We also may utilize various Performance Improvement tools and risk reduction approaches such as RCAs and FMEAs. Our organization is focused on accomplishing more internal RCAs this year for example. 9

10. Joint Commission Requirement
Failure Mode and Effects Analysis (FMEA)
Proactive risk assessment
A team based, systematic, and proactive approach for identifying the ways a process or design can fail, why it might fail, and how it can be made safer.
Joint Commission Requirement
What performance improvement initiative has our department implemented recently?
Hint: It MUST be supported by trended data 10

11. Core Measures of Excellence
Core Measures of Excellence are a variety of evidence-based, scientifically-researched standards of care which have generally been shown to result in improved clinical outcomes for patients
CMS (the Center for Medicare & Medicaid Services) established the Core Measures in 2000 and began publicly reporting data in This program is designed to address clinical care, person and caregiver-centered experiences and outcomes, safety, efficiency and cost reduction, care coordination and Community / population health.
CMS ties some parts of reimbursement to reporting the data; in the future reimbursement will be tied to how well we do in delivering the elements of care (Value-Based Purchasing) 11

12. Core Measures of Excellence
Children’s Asthma: specific medication use
Venous Thromboembolism (VTE): prophylaxis use, therapy and education
Stroke, Acute Myocardial Infarction & Heart Failure: medications prescribed upon admission and discharge
Emergency Department : departure/admit times, pain management
Sepsis: lactate ordering, blood culture collection, timely antibiotics, and fluid resuscitation with hemodynamic monitoring
Endoscopy Previous & Future Care: appropriate documentation of previous and follow-up interval care
Imaging Efficiency: MRI for Lumbar spine; mammography follow up, use of contrast material
Hospital Based Inpatient Psychiatric Services (HBIPS) & Substance Screening
Catheter Associated Urinary Tract Infection (CAUTI)
30-Day Risk adjusted readmissions 12

13. Examples of CQI projects
Decreasing Sepsis Mortality
Decreasing Surgical Site Infections
Post-operative glycemic control in our CTICU population
Improving patient throughput for ED Admissions
Preventing Central Line and Catheter Associated Urinary Tract Infections
Specimen mislabeling FMEA
Core measure compliance: AMI, HF, Stroke, VTE, Psychiatry e-documentation
Avoiding Readmissions within 30 days
Enhancing Cardiac Arrest and Post Cardiac Arrest Care
Timely referrals and effective requests for organ donation (LONY)
Ongoing Professional Practice Evaluation (OPPE)
Asthma Action Plan use on our inpatient pediatric units 13

14. Decreasing Severe Sepsis/Shock Mortality
Over a 20% decrease in annual mortality rates contributing to a shorter LOS and overall cost savings. 14

15. How to contact the CQI Department
Continuous Quality Improvement
How to contact the CQI Department
If you have any questions or ideas for a potential CQI project in your department, please call us at
(631)
Or enter a request
(Performance Improvement Requests)
via the
Intranet under the My Requests section
2016 15