1. QUALITY Liz Walliser, RN, MS, CPHQ Director Quality Office located on 6 th floor

2. Role of Quality Department To support physicians to provide best practice To support physicians to provide best practice Peer Review Peer Review Review of Quality Indicators Review of Quality Indicators Ensure compliance with regulatory requirements (Medicare, Joint Commission) Ensure compliance with regulatory requirements (Medicare, Joint Commission) Provide data/feedback to physicians (LOS) Provide data/feedback to physicians (LOS) Provide information on upcoming changes Provide information on upcoming changes

3. Peer Review Peer Review-centralized except for specialty practice (ED, Psych, Rad, Path) Peer Review-centralized except for specialty practice (ED, Psych, Rad, Path) MSQC-Medical Staff Quality Committee MSQC-Medical Staff Quality Committee Multidisciplinary Multidisciplinary Group consensus Group consensus Rating system and results entered to report card Rating system and results entered to report card Physicians notified of all reviews and outcomes Physicians notified of all reviews and outcomes

4. Physician Report Card Required by Joint Commission Required by Joint Commission Ongoing, continual evaluation of practice Ongoing, continual evaluation of practice Indicators by Specialty Indicators by Specialty Patient Care Patient Care Medical/Clinical Knowledge Medical/Clinical Knowledge Practice Based Learning & Improvement Practice Based Learning & Improvement Interpersonal & Communication Skills Interpersonal & Communication Skills Professionalism Professionalism System Based Practice System Based Practice

5. Focused Professional Review Required by Joint Commission Required by Joint Commission Organization evaluates the privilege- specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization (can also applied when there is a concern) Organization evaluates the privilege- specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization (can also applied when there is a concern)

6. Core Measures Acute MI Acute MI Congestive Heart Failure Congestive Heart Failure Pneumonia Pneumonia Surgical Care Surgical Care Pregnancy Pregnancy Psychiatric Psychiatric

7. Core Measures Acute MI Acute MI Door to balloon <90 minutes Door to balloon <90 minutes Heart Failure Heart Failure Evaluation of LV function (ECHO, nuc med, cath or normal, mod, severe in progress notes) and document Evaluation of LV function (ECHO, nuc med, cath or normal, mod, severe in progress notes) and document If LV impaired-ACEI/ARB prescribed on DC If LV impaired-ACEI/ARB prescribed on DC Beta blocker prescribed on DC Beta blocker prescribed on DC

8. Core Measures Pneumonia Pneumonia Use Order Set to ensure right antibiotic Use Order Set to ensure right antibiotic Pt is screened and vaccination given unless physician orders not to Pt is screened and vaccination given unless physician orders not to Surgical Care Surgical Care Antibiotic w/i one hour of incision Antibiotic 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 antibiotic Use the right antibiotic Normothermia intra-op Normothermia intra-op Glucose control post-op Glucose control post-op VTE prophylaxis VTE prophylaxis

9. Core Measures Pregnancy Pregnancy Prevent 3 rd /4 th degree lacerations Prevent 3 rd /4 th degree lacerations Minimize VBAC Minimize VBAC Psychiatric Psychiatric Reduce # of antipsychotic meds prescribed at discharge Reduce # of antipsychotic meds prescribed at discharge Discharge follow-up (referrals, meds, reason for hospitalization) Discharge follow-up (referrals, meds, reason for hospitalization)