C4QI Survey Monkey Results

  • 75 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
75
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
5
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Hospital Quality Committee Structure – C4QI Hospital Survey Results April 2014 Ali Casiere
  • 2. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Who Participated  MD Anderson  Yale  Duke  Memorial Sloan-Kettering  Dartmouth  Siteman  Dana-Farber  Karmanos  Roswell Park  H. Lee Moffitt 2 • We surveyed the 17 other C4QI hospitals and we had 10 of those hospitals respond to the survey. • This survey was sent out on March 18, 2014
  • 3. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Scope of Each Organization’s Committee 3 **Yale and Duke are the two hospitals that have separate committees for Quality and Safety. 16.67% 16.67% 66.67% **Quality (2) **Safety (2) Both Quality and Safety (8)
  • 4. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Current Committee Membership Size 0 10 20 30 40 50 60 # of Committee Members 4 **Yale does not have a centralized committee
  • 5. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Committee Meeting Frequency 5 Roswell Park, Dartmouth, MSK, Y ale, MD Anderson Karmanos Siteman and Moffitt Dana-Farber Duke 0 1 2 3 4 5 6 Monthly 8 Times Per Year Bi-Monthly Quarterly Bi-Annually Committee Meeting Frequency Committee Meeting Frequency
  • 6. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Meeting Time and Duration 6 Dana-Farber 7AM-8AM Siteman 7AM-8AM MSK 8AM-9:30AM Dartmouth 9AM-11AM Duke MD Anderson Yale Moffitt Roswell Park Karmanos 9AM-10AM 11AM-12:30PM 1-1.5 hours mid-day 4PM-5PM 4PM-5:30PM 1 hour any time
  • 7. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Does Meeting Agenda Include Both Inpatient and Outpatient? 7 **The way the survey monkey was set up there was the option to click all three and options of “Inpatient”, “Outpatient”, and “Both” which is why this data is skewed. 8.33% 8.33% 83.33% Inpatient (1) Outpatient (2) Both (10)
  • 8. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Standing Agenda Items Hospital Standing Agenda Items MD Anderson Reported Incidences, Patient safety Reports, Pharmacy, OR, Infectious Disease Specific Reports. Yale -- Duke Updates on Quality Projects and Strategy Memorial Sloan- Kettering Review of department QA committee meeting minutes. Also, any completed RCAs, status update of action items from previous RCAs. Each Department QA Committee chair presents once per year on how his/her department is using data to drive improvement. Dartmouth Dashboard Review, Status Updates, Program Evaluation Siteman Subcommittee Reports, Cancer Registry Reports Dana-Farber Joint Commission Requirements spread out throughout the year. Karmanos Root Cause Analysis Update, Core Measures Data, JC Readiness Updates Roswell Park Department Reports, Areas of Focus, Occurrence Complaints Institute scorecard, Patient Safety scorecard, Patient Satisfaction Scores Moffitt Ethics, Grievances, Risk, Quality and Safety, Credentials 8
  • 9. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Leaders and Facilitators of Meetings Hospital Leader/Chair Facilitator MD Anderson VP of Performance Improvement Director of Patient Safety Yale Several different people Several different people Duke VP and Associate Dean - Memorial Sloan-Kettering Appointed Chair of Committee (Physician) Appointed Chair of Committee (Physician) Dartmouth Chief Safety Officer (Physician) and CNO/VP Clinical Operations Chief Safety Officer (Physician) and CNO/VP Clinical Operations Siteman Physicians Physicians Dana-Farber CQO and CNO/VP Quality and Patient Safety CQO and CNO/VP Quality and Patient Safety Karmanos VP Medical Affairs Clinical Improvement Specialist (Quality) Roswell Park CMO and VP Quality CMO and VP Quality Moffitt CMO Director of Quality and Safety 9
  • 10. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Disciplines of Membership 10 11% 11% 9% 4% 11% 5%2% 7% 6% 2% 3% 7% 10% 6% 6% Physicians (10) Nursing (10) Pharmacy (8) Clinical Research (3) Quality (10) Tumor Registry (4) Clinical Nutrition (2) Diagnostics (6) Rehab (5) Pastoral Care (2) IT (3) Clinical Informatics (6) Risk/Legal (9) Patient/Family Advisor (5) Other (5)
  • 11. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute “All Other” Responses for Disciplines of Membership Hospital Other Disciplines Memorial Sloan-Kettering Hospital Administration, President’s Office, Patient Relations, Ambulatory Care Network, GME, Patient Safety, QA Committee Chairs for BMT, Lab Medicine, Medicine, Neurology, Nursing, Pathology,, Pedia trics, Pharmacy, Psychiatry, Radiology, Surgery Siteman Hospice, Palliative Care, American Cancer Society Dana-Farber Trustees Karmanos Medical Records Roswell Park 5 Governance Board Members Moffitt Hospital Board Members, Hospital Administration (President and SVP) 11
  • 12. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Reporting Structure of Quality Committee Hospital Who They Report To MD Anderson President Yale Safety/Quality Nurse for each service line; central performance management group for the system Duke Includes leadership to the highest level Memorial Sloan-Kettering Medical Board  Board of Trustees Dartmouth Quality Subcommittee of the Board of Trustees Siteman Medical Executive Committee Dana-Farber Chief Quality Officer  Board of Trustees Karmanos HPIC (Hospital Performance Improvement Committee) Roswell Park CEO and Medical Staff Executive Committee Moffitt Subcommittee of Hospital Board 12
  • 13. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Quality Committee Sub-Committees Hospital Subgroup/Sub-Committee MD Anderson -- Yale -- Duke Starting a quarterly sub-group Memorial Sloan-Kettering Steering committee- Reviews department QA committee meeting minutes and finalized presentation agenda Dartmouth Safety Sub-Committee- Help from several Quality and Measurement support departments Siteman •QI Committee •Palliative/Supportive Care Sub-Committee •Education Subcommittee Dana-Farber •Satellite Quality Committee (oversees offsite locations) •Infection Control Sub-Committee Karmanos -- Roswell Park •Patient Safety Moffitt •Credentials, Risk, Ethics, Joint Commission, Grievance, Ancillary, Support Improvement Committees 13
  • 14. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute How Information is Communicated “Up” Within the Organization Hospital How Information is Communicated “Up” MD Anderson Report given to leadership Yale Emailed, representatives relay information to different committees, and service lines Duke Highest leadership is already part of this committee Memorial Sloan- Kettering Quarterly Board of Managers reports Dartmouth Officers and other leaders are on the committee Siteman Minutes are shared at department meetings and sent monthly to MEC; Report annually to Hospital Safety & Quality Council Dana-Farber CQO and Trustees sit on the committee and are actively involved Karmanos HPIC minutes/presentations are communicated to KCC Board Quality Committee (sub-committee of Board of Trustees) Roswell Park Minutes are sent to CEO and MSEC. Department Representatives are responsible for communicating with constituents. Moffitt Directly to the HBOD 14
  • 15. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute How Information is Communicated “Down” Within the Organization Hospital How Information is Communicated “Down” MD Anderson Online, Executive Committee of Medical Staff Yale Through management and education Duke -- Memorial Sloan-Kettering -- Dartmouth Working on an open forum with voting members and others who can attend for information purposes Siteman Staff meetings and minutes distribution Dana-Farber Quality, Nursing, and clinical leadership Karmanos VPs, Directors, and managers attend HPIC and are responsible for reporting back to their departments Roswell Park Department Representatives are responsible for communicating with constituents Moffitt Monthly Management Update 15
  • 16. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Does your Quality Committee have an annual Goal Setting Determination/Process? Hospital No Yes MD Anderson - Drive from top down and from bottom up Yale - Based on patient safety & quality, employer of choice, provider of choice, fiscal Duke  Memorial Sloan-Kettering - QCI Steering Committee and chair of HQAC presents annual goals to the group Dartmouth  Siteman -Review scorecard from fall and propose areas that need improvement. Review organization strategic plan. Goals determined by QI Committee and then discussed by Cancer Committee and then voted on. Dana-Farber - Strategic goals are discussed at the end of FY and the quality goals are created. Goals are aligned and includes NPSG’s in the process. Karmanos  Roswell Park -“Areas of focus” are determined in November. VP of Quality makes recommendations and those are voted on in January. Moffitt  - Annually review and select goals and targets for FY. 16 70% 30% Yes No
  • 17. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Are Service-Line or Disease-Line Reports Shared at this Committee? Hospital No Yes MD Anderson  Yale - Some are Service-Line based, some have representatives from each service line Duke - If they have relevant projects Memorial Sloan- Kettering  Dartmouth  Siteman -Scorecard broken into service lines, reviewed monthly at both Cancer and QI Committee. Program specific scorecards are reported once annually to the committee. Dana-Farber - Institutional dashboard that high-lights 40+ departments across the institute. If there is poor performance anywhere, that department has to present their action plan. Karmanos  Roswell Park - Medical, surgical, and diagnostic plans report to the committee at least twice a year Moffitt  17 80% 20% Yes No
  • 18. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Are Monthly/Quarterly Scorecards Regularly Shared? 80% 20% Yes (8) **No (2) 18 **Yale and Duke are the two hospitals that do not regularly share their scorecards
  • 19. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute 19
  • 20. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Feedback/Next Steps  Does anything stand out to you?  Linda will be sharing this information with Carol Colussi and Kris Kipp next week 20