1. Department of Quality and Patient Safety UMass Memorial Healthcare

4. Patient Safety Programs are essentially diagnostic Their purpose is to: Improve the culture of Safety. Non-punitively identify concerns and problems Focus on teamwork Offer evidence based design principles Create an awareness of the vulnerabilities in systems Upgrade processes to reduce likelihood of recurrence of problems Support patient safety research QI processes are intended to: Help the sharp end staff (patient level healthcare workers) and the blunt end staff (managers and administration) work together to take effective action once a problem or opportunity for improvement has been identified. Risk Management contributes to patient safety through retrospective analysis of events. It’s purpose is to: Protect the assets of the organization Identify and mitigate risk though audits, which can; Prevent future adverse events Educate about risk which can facilitate; Recommending prospective interventions, grounded in safety science ‘Patient safety requires great humility. It requires a shift from the concept of autonomous operators to that of team members. This shift is challenging but represents an opportunity for intellectual challenge and learning.’

5. IOM 6 Aims Safe Effective Patient Centered Efficient Timely Equitable

6. The Platform The six interventions from the 100,000 Lives Campaign: Deploy Rapid Response Teams…at the first sign of patient decline Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps New interventions targeted at harm: Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection…by reliably implementing scientifically proven infection control practices Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by the Surgical Care Improvement Project (SCIP) Deliver Reliable, Evidence-Based Care for Congestive Heart Failure…to reduce readmissions Get Boards on Board….Defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care IHI

7. Pay for Performance Today and Tomorrow –Claims Based –Outcome Based –Prevention –Disease Management –Efficiency Pharmacy EMR Radiology/Expensive tests Admin. simplification

8. Achieving Quality – Medical Staff (MS) Elements of Performance Qualifications, Roles, & Responsibilities of Dept. Chair (MS.1.20 EP 8.) All clinically/administratively related activities of the department Continuing surveillance of the performance of all individuals with clinical privileges. –Recommending to the staff the criteria for clinical privileges –Recommending clinical privileges for each member of the department Maintaining ongoing quality control activities Continuing assessment and improvement of the quality of care, treatment and services. Continuing education of all persons in the department

9. Physician role in management & coordination of patient care, treatment, & services (MS. 2.20.) MS provides leadership in –Patient safety –Teamwork –Speaking up –Analyzing and improving patient satisfaction MS specifies minimum content of H&P –Monitors quality of H&Ps Performs H&P –Defines scope of H&P for non-inpatient services Consultation is obtained for the circumstances defined by the medical staff –E.g, ASA 4 - consult anesthesia Achieving Quality – Medical Staff (MS) Elements of Performance

10. UMass Memorial Medical Center Mission UMass Memorial Medical Center is committed to improving the health of the people of Central New England through excellence in clinical care, service, teaching and research. Cornerstones –Deliver high quality, safe care- Assuring appropriate skills and knowledge of staff, using standardized, evidence based processes of care, creating safe environment –Create an excellent experience for patients- Approaching pts and families with courtesy and compassion, meeting personal needs for information and involvement, following processes for referrals and transfers, creating a warm and comfortable environment –Manage resources- Enhancing revenue, controlling expenses and maximizing return on assets –Engage staff in the work- Approaching employees with respect, listening to concerns, clarifying expectations, involving staff in solutions

11. 6 Principles of MD Competence Patient care Competence Compassion Honesty Confidentiality Quality MD-Patient Relationship »Access »Resource Use »Med record integrity Medical / Clinical knowledge Life-long learning Maintain Skills Use of science Practice based learning and improvement Evidence based medicine »Improvement using scientific method »…to evaluate and improve practice »Guidelines and protocols »Scheduling »EMR Interpersonal and communication skills With patients Families »Colleagues Professionalism Patient Welfare »Patient’s interests first, ahead of market forces, admin. needs, societal pressures Patient Autonomy Informed decisions Empowerment Social Justice Fair distrib. of resources Fight discrimination Conflicts of Interest Teaching Service Research System based practice Understanding of how he/she fit into systems of care Understanding of systems of care, practices, groups, healthcare systems, payors, government »Participate in improving these systems

12. Examples - Ongoing Professional Practice Evaluation Leading the Way Respect Attendance at PI meetings Participation in Chart Reviews Compliance with NPSGs Site marking Time out Timely response to critical values Use of unapproved abbreviations Review of operative/other clinical procedures that place patients at risks Pattern of blood and drug usage Requests for tests and procedures LOS patterns M&M data Use of consultants Achieving Quality – Ongoing Professional Practice Evaluation (MS.4.40)