ORGANIZATIONAL QUALITY MANAGEMENT PLAN



VA NORTHERN INDIANA HEALTH CARE SYSTEMApril 16, 2010 POLICY NO. 00Q-04-10ORGANIZATIONAL QUALITY MANAGEMENT PLANPURPOSE: The purpose of this policy is to outline the processes that support Quality Management to enhance the delivery of patient care and services provided at the VA Northern Indiana Health Care System (VANIHCS).POLICY: The policy of VANIHCS is to consistently monitor and evaluate performance through data collection, aggregation, trending and analysis to identify areas for improvement that will enhance performance, patient safety, outcomes of care/treatment/services, and reduce risks and recurrence through non-punitive process analysis. The Health Care System receives guidance and performance expectations through a variety of mandates and regulations. They include, but are not limited to the following.Veterans Health Administration (VHA) Program Mandates.VHA Performance Measures/Clinical Practice Guidelines and ORYX/Core Measures.The VHA’s Mission, Vision, Core Values and Domains of Value as described in IL 10-2005-008.VHA Patient Safety Improvement Handbook 1050.01 which provides guidance for Root Cause Analysis (RCA) and proactive risk assessment in the form of Healthcare Failure Mode & Effect Analysis (HFMEA).Occupational Safety and Health Administration (OSHA).The Joint Commission Accreditation StandardsCollege of American Pathologists (CAP).Other accreditation oversight bodies.PROCEDURES:VHA and Joint Commission require that the following are consistently monitored and performance improvement initiatives are implemented:Performance Measures/Clinical Practice Guidelines and ORYX/Core Measures are utilized to decrease variation among practitioners and across care settings, while improving patient outcomes. VHA Performance Measures and Clinical Practice Guidelines are mandatory and are assigned to leads by the Health Care System Director, upon recommendation by the Quality Manager. Primary data collection occurs through the External Peer Review Process. Data is reviewed and outliers are further analyzed. The Performance Measure Dashboard reflects data on an ongoing basis and is reviewed by PMB on a monthly basis. Additionally, clinical performance measures are reviewed and analyzed by the Chief of Staff through Medical Staff and/or the Clinical Executive Board (CEB). Those indicators not meeting expected performance will require further analysis and action plans for improvement will be reported monthly to the PMB by the assigned Lead.Patient Satisfaction – The Patient Satisfaction Committee and its members are assigned as leads for the satisfaction related metrics i.e. Outpatient Satisfaction, Inpatient Satisfaction and the question specific measures for the CAHPS Survey. The committee reviews ongoing reports and integrates them into organizational performance improvement through review and analysis at the QLC and PMB. The committee reviews and critically analyzes patient complaints to determine patterns or trends and compares these results with satisfaction survey results to see if there is any correlation. Areas for improvement are then identified and action plans are developed, implemented and monitored for effectiveness.Employee Satisfaction – Surveys through VHA or facility-level employee needs assessment is reviewed and analyzed by Leadership at the Quality Leadership Council. Areas for improvement are reflected within the survey outcomes and the Director assigns improvement action to appropriate staff, as identified. Oftentimes, direction on improvement efforts will be assigned by the Veterans Integrated Service Network (VISN) 11 Network Director, at which time the Health Care System Director will seek the appropriate lead for the facility.Medication Management is assessed through a variety of indicators. The Medication Management Continual Readiness Team continually monitors compliance with multiple Joint Commission and OIG Standards by conducting medication system tracers and trending and analyzing data and implementing Performance Improvement approaches to increase compliance. The Medication Management Continual Readiness Team provides assessment and outcomes to the Pharmacy and Therapeutics Committee, the Nurse Executive Advisory Board, and other committees and services as indicated. Primary oversight of Continual Readiness Team activity is provided by the Quality Leadership Council.Blood and Blood Product Use is the responsibility of Pathology and Laboratory Medicine Service through the CEB. Reports of adverse outcomes and other criteria-based requirements are reported to the CEB.Restraint Use is monitored on an ongoing basis by Quality Management and is reported on a quarterly basis. Quarterly report findings will be appropriately communicated to the Provision of Care Continual Readiness Teams as well as unit nurse managers and clinical providers as identified for service-level process improvement. Data related to restraint use is reported to the Medical Staff/CEB and the Nurse Executive Advisory Board. Seclusion Use – This Health Care System does not participate in any form of seclusion.Behavior Management and Treatment is monitored through the Mental Health Executive Committee. Mental Health specific and program specific performance measures and monitors are reviewed and improvement opportunities identified. These measures/monitors include, MHICM, Day Treatment and Substance Abuse program measures as well as Mental Health access measures.Operative and Invasive Procedures are monitored monthly through clinical pertinence record reviews and a Procedural Case Review Report that is submitted to multiple clinical oversight committees, with primary reporting to the CEB. Improvement opportunities that are identified are the primary responsibility of the Surgical Services and Anesthesia Committee.Resuscitation and its outcomes is monitored through Code Blue critiques that are tracked, trended, and analyzed by the Critical Care Committee and reported to the CEB. Negative trends, barriers to the code blue process, and other factors are analyzed with opportunities for improvement being recognized, documented, and acted upon.The following activity outcomes identified are integrated into PI initiatives. Data are systematically aggregated and analyzed utilizing spreadsheets, display graphs, and statistical process control charts for each of the monitoring and evaluation activities listed below:Risk Management – Risk Management activities include, but are not limited to, peer review program, tort claims, investigations, occurrence screening, infection control, credentialing and privileging, informed consent, utilization review, ongoing hazard surveillance, environment of care rounds, pro-active risk assessment through HFMEA, environmental safety risk assessments, patient incident reporting, and reporting of close calls involving patient care. Each area of risk management that identifies an area for improvement is appropriately integrated into initiatives within the defined service or program. They are reported, analyzed, and documented through a variety of committees.Utilization Management (UM) – The Utilization Management Program is the primary responsibility of the Utilization Management Coordinator who reports to the Quality Manager. The UM Coordinator refers to VHA direction and VISN 11 guidance for the monitoring and evaluation of continual utilization management activities. Data is tracked, trended, reported, and analyzed at the Utilization Management Committee. Areas for improvement are identified, documented, and PI approach implemented when indicated.Quality Control activities are widespread and mostly owned and analyzed at the Service-level through environmental assessments and spot-checking of quality control logs. Improvements are implemented at the Service-level, unless trends across the facility are recognized through monitoring and evaluation at which time the appropriate Committee or Service would need to direct performance improvement efforts.Infection Control Surveillance and reporting is the responsibility of the Infection Control Nurse who reports to the Associate Director of Patient Care Services. The Infection Control Committee is responsible for the ongoing evaluation of infection control data and organizational improvement. The Health Care System follows an Infection Control Plan that is outlined in policy.Autopsy data is integrated into the morbidity/mortality reviews for the medical center, which are submitted to CEB on a quarterly an/Tissue Procurement - Organ procurement effectiveness is monitored by the conversion rate data (conversion rate is defined as the number of actual organ donors over the number of eligible donors). Each patient death is reported to the Indiana Organ Procurement Organization (IOPO) within the extent permitted by applicable laws and regulations to determine whether the patient is a suitable potential donor. Data is monitored through death reviews conducted in Quality Management.Pain management – The Pain Management Committee, who reports to CEB, is responsible for oversight of tracking, trending and analysis of quality indicators to monitor the effectiveness of interventions, completeness of assessment and appropriateness of interventions (including the patients’ perception of pain management).Staffing effectiveness defines the process utilized to help the VA determine and continuously improve effectiveness of their nurse staffing through an objective evidence-based approach. Clinical and human resource indicators assist nursing management in identifying data outliers that may constitute casual relationships between clinic al outcomes and adequate staffing and/or other human resource factors. Data is collected at the service level (Acute Care and Community Living Center) and reported to Extended Care and Rehabilitation Committee and Resource Management Board (RMB).Medical record review – VANIHCS Policy No. 11-62, Health Information Management, defines the methods and oversight of ongoing monthly medical record reviews for the purpose of monitoring and evaluation of documentation requirements in all care settings.Patient flow – managing the flow of patients through their care is essential to ensure care is safe, timely, and results in positive patient outcomes. Assessment and management of patient flow can improve resource utilization and reduce the risk of negative outcomes related to delays in the delivery of care, treatment, and services. The patient flow plan is outlined in Appendix D.Fall Reduction – The Health Care System evaluates the effectiveness of all fall reduction activities including assessment, interventions, and education. Data on number of falls and number and severity of fall related injuries is collected and analyzed and reported quarterly to leadership through the Patient Care Safety Board (PCSB).Change in Patient Condition – The hospital collects data on the effectiveness of its response to change or deterioration in a patient’s condition. Rapid Response Team Critiques (Medical and Behavioral) data will be collected and analyzed and reported to the appropriate oversight committee.Data analysis is mandatory for the following:All transfusion reactions are reported to the CEB.All serious adverse drug events are analyzed by Pharmacy Service and reported to the Pharmacy and Therapeutics.All medication errors are analyzed through individual RCA or Aggregate RCA.All major discrepancies between preoperative and postoperative (including pathologic) diagnoses are analyzed through the Procedural Case Review process.Adverse events or patterns of adverse events during moderate sedation and anesthesia use are analyzed through the Procedural Case Review process.Hazardous conditions are monitored through environmental rounds, hazard surveillance, employee reporting, employee and patient incident reports, etc. and are analyzed through the Environment of Care Board.Sentinel Events for the Health Care System are immediately analyzed and the process for conducting an RCA for further analysis and recommendations for improvement are outlined in VANIHCS Policy No, 00Q-07, Patient Safety Program. Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events:Outcomes of data analysis that result in recommendations for improvement that are submitted to appropriate Service Chiefs, Program Leads, Management, etc.Root Cause Analysis teams are chartered by Leadership and recommendations for improvement are reviewed and approved by Leadership and issued to responsible staff throughout the hospital.Any enhancement to processes or the design of new processes is closely evaluated through implementation monitoring and evaluation. Monitoring continues as long as needed to ensure sustained improvement.When planned improvements fail to reflect improvements, the teams may be re-convened to further the analysis and PI recommendations.A pro-active analysis for identifying and reducing unanticipated adverse events and safety risks is the HFMEA process. Annually, an HFMEA is conducted, for each accredited care setting as required by Joint Commission Standards for applicable care settings. The HFMEA is completed using tools and established assessment methods to identify risks and barriers to the process, as outlined in VANIHCS Policy Memorandum No. 00Q-07-10, Patient Safety Program. The continual assessment of Joint Commission Standards is conducted through the work of the Continual Readiness Teams and other staff assigned specific oversight and management of processes that support continual compliance. Policy 00Q-09, Continual Readiness Compliance Teams describes the responsibility and initiatives relevant to Joint Commission standards.PERFORMANCE MANAGEMENT APPROACH/TOOLS:PI Activity Levels – PI activities are based on low, moderate, and high risk process determinations:Low risk processes are those which demonstrate relatively stable performance trends. A Level I PI approach is used and consists of data collection, measurement, trending and analysis. Findings will be reviewed by the appropriate manager at designated intervals. Opportunities to improve will be primarily addressed through direct management intervention. An example of Level I measurement is Number of Outpatient Visits.Moderate risk processes are those which demonstrate a moderate level of deviation from established thresholds, performance goals, or standards of practice. A Level II M&E approach (use of appropriate PI Tools and approaches, i.e. fishbone, brainstorming list, etc) is used to improve outcomes in this category. Trend reports, run charts, or statistical control charts are used to display outcomes. Findings are collaboratively analyzed at the assigned CR Team or oversight committee level, with improvement actions piloted. Actions are formalized in process, policy, or procedure when sustained improvement is demonstrated.High risk processes include those which demonstrate significant deviation from established thresholds/performance goals/standards of practice, performance trends demonstrate that the process is statistically out of control, or the current process has a real/potential major negative impact on patient safety, care delivery, access, efficiency, or satisfaction. For improvement initiatives in this category, a formal PI approach is used. The formal performance improvement approach utilized at this Health Care System is the TAMMCS Project Improvement Framework listed in Attachment A. It is an alternative to the Plan, Do, Check, Act (PDCA) PI approach. Often times, work groups and task groups are established to analyze and improve processes – all of which utilize PI tools and methods described in the Attachments A-C.Data Collection and Analysis:Data will be collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement and sustain improvement. Joint Commission recommended sample sizes are suggested when data is gathered for PI purposes (see grid below).Population SizeSample SizeIf the population size is less than 30 cases100%31 up to 100 cases30 cases101 up to 500 cases50 casesData will be systematically aggregated and analyzed on an ongoing basis. Appropriate statistical techniques (run charts, control charts, histograms, pareto charts, cause and effect or fishbone diagrams) will be used to analyze and share this data. The analysis is most effective when it incorporates four comparisons:With selfWith other comparable organizationsWith standardsWith best practicesMonitoring and evaluation (M&E) of data is ongoing and meets the reporting timeframes as identified by the oversight body.Data is trended and analyzed by appropriate oversight body. Reporting is elevated to committees, boards, etc., as assigned for further evaluation and assignment of actions/resolution appropriately communicated.Benchmarking and comparative data analysis is utilized especially with Performance Measures/Clinical Practice Guidelines against other VISN 11 VA facilities.Education related to Performance Improvement takes many forms. Just-in-Time training is given to staff as they are newly introduced to a PI/Patient Safety project team or workgroup. Periodically, a “Joint Commission Fair” is held for all employees. PI/Patient Safety are priority educational topics. All new employees are educated at the time of hire during new employee orientation on the PI process as well. Compliance with mandated data collection methodology and/or reporting formats/graphics is to be one source of assessment data for determining individual, targeted, or organizational educational learning needs.Confidentiality of documentation related to PI activities will be maintained in accordance with the provisions of 38 USC 5705 and its implementing regulations.RESPONSIBILITIES:Quality Manager (QM): The QM is responsible for:As the designee of the Director, providing direction and oversight for the organizational performance improvement efforts. The QM communicates mandates, implementation requirements, and process improvement initiatives to assigned oversight teams or committees. Recommending to the Director for final approval, the assigning of Performance Measures and Clinical Practice Guidelines Leads; members for CR-Teams; members for Root Cause Analysis (RCA) Teams; members for Healthcare Failure Mode and Effects Analysis (HFMEA) Teams; and approves external reviews for Joint Commission Readiness, OSHA, Office of Inspector General (OIG), and other program reviews as mandated by VHA. Providing coordination and facilitation for the ongoing assessment and improvement activities in support of VHA, Office of Inspector General (OIG) and Joint Commission-related processes. Providing ongoing education and consultation with performance improvement methods and tools, assist in the development of data tracking and data display, and monitor processes through review of data, local policy memorandums, and other activities. Attending the Quality Leadership Council and other oversight committees for continuity and communication across the organization. Facilitating formal performance improvement activities, including; Plan Do Check Act (PDCA) Teams, Deep Dive Teams, and informal PI Workgroups.Chief of Staff, Associate Director for Patient Care Services, Associate Directors for Operation. The Chief of Staff, Associate Director for Patient Care Services, and the Associate Directors for Operation are responsible for the performance measures and clinical practice guidelines, as assigned. They are responsible for providing primary oversight for the activities of data collection, trending, aggregation and analysis, and process improvement to meet established targets. Additionally, the members of the Executive Leadership Team (ELT) are responsible for attending Continual Readiness Teams that have been established to review Joint Commission, VHA and Office of the Inspector General (OIG) standards across care settings. Continual Readiness Teams (CR-Team)/Leads. Continual Readiness Team Leads are responsible for providing primary direction (with the assistance of Quality Management facilitators) in the continual assessment of Joint Commission, VHA and OIG Standards. They are also responsible for providing direction in scoring of elements of performance, development and tracking of action plans for non-compliant standards, and performance improvement to reach satisfactory compliance. With the assistance of Quality Management Staff, Joint Commission standards are scored and updated using a Joint Commission-approved and procured software program, Accreditation Manager Plus (AMP). VHA and OIG standards are scored with OIG and System-wide Ongoing Assessment Review Strategies (SOARS) Assessment Guides located on the SOARS SharePoint sitePatient Safety Managers. The Patient Safety Managers are responsible for providing coordination and facilitation for all patient safety activities including Root Cause Analysis, HFMEA, and other workgroups for the purpose of improving patient safety. Patient Safety Managers ensure that components of the Quality Management System and Patient Safety Improvement Program are integrated. They are also responsible for implementing a coordinated patient safety improvement program at the facility level that is based on guidance and tools from the National Center for Patient Safety, and which meets the needs and priorities identified by the Director. These include addressing and monitoring important standards, requirements, and recommendations promulgated by the Joint Commission and other organizations working to improve patient safety.Service Chiefs/Program Leads. Service Chiefs/Program Leads are responsible for assigned performance measures, Clinical Practice Guidelines, and other VHA, OIG, and Joint Commission-related indicators for primary oversight of data collection, monitoring and evaluation, analysis, and the identification of opportunities for improvement. Service-level performance improvement indicators will be aligned and coordinated with the Organizational Quality Management Plan. Service Chiefs/Program Leads are responsible for recommending formal Performance Improvement (PI) approaches when indicated – through the appropriate oversight body. Additionally, they are responsible for the identification of areas for improvement within their own departments and will apply PI tools and methods to reflect Service-Level improvements. Service Chiefs/Program Leads are expected to engage front-line staff in service-level improvements and communicate on an ongoing basis the service-level mittee Chairpersons. Committee Chairpersons are responsible for integrating performance improvement into the activity of the Committee when data collection and analysis results in the need for improvement in their oversight areas.All Employees. All employees are responsible for participating in Service-level and Organizational Performance Improvement as identified. Front-line staff participates in PI Teams; formal and informal Performance Improvement Work/Task groups; RCA’s; and HFMEA’s.PROGRAM GOALS: The following goals have been established for the FY 2010 Performance Improvement Plan:The organizational PI focus shall be on the improved coordination, communication, and integration of patient care and service delivery as measured by VHA and Joint Commission requirements.Meet or exceed targets for VISN and VHA Mandated Performance Measures, ORYX/Core Measures and other assigned indicators.Engage staff in Continual Survey Readiness to achieve improvement and compliance with VHA, OIG and Joint Commission Standards through the thorough assessment/reassessment of elements of performance by Continual Readiness Teams and Program Leads utilizing many methods of evaluation and improvement when indicated.Engage the appropriate stakeholders in monitoring and evaluation and performance improvement of contracted services, patient care activities, and other organizational planning.REFERENCES:Joint Commission Comprehensive Accreditation Manual for Hospitals, Behavioral Health, Long-Term Care, and Home Care.VHA IL 10-2005-008, dated May 9, 2005VHA National Patient Safety Improvement Handbook, 1050.01VANIHCS Policy 00Q-07, Patient Safety ProgramVANIHCS Policy 00Q-09, Continual Readiness Compliance Teams VANIHCS Policy 11-62, Health Information ManagementVANIHCS Policy 11-24, Human Research Protection PlanVANIHCS Policy 117EX-12-03, Community Nursing Home Care ProgramVANIHCS Policy PCS-04, Infection Surveillance, Prevention And Control Program38 USC 5705 M-2, Part 1, Chapter 25RESCISSION: VANIHCS Policy No. 00Q-04, dated February 6, 2006.RESCISSION DATE: September 2010 (This is an annual policy review).FOLLOW-UP RESPONSIBILITY: Quality Manager. KIMBERLY L. RADANT, MS, RNActing DirectorAttachments:TAMMCS PROJECT FRAMEWORK(Alternative to PDCA)STEP 1TEAMSELECT A TEAM?Front Line?Management Supported?Identify Process OwnerSTEP 2.AIMIDENTIFY THE GOAL?Develop a plan?5 Questions: Who, What, Where, When, How?Develop a Team Charter STEP 3.MAPUSE LEAN TOOLS?Process input & output?Value Stream the processSTEP 4MEASUREDATA MEASUREMENT?Establish measurement standard?Compare current data and gap?Use graphs to display dataSTEP 5.CHANGE IMPLEMENT?Pilot test a solution?Compare data before and after?Use graphs to display dataSTEP 6.SUSTAIN (&SPREAD)FORMALIZE IN POLICY/PROCEDURE?Implement a formal change in the process and put into operation across all care settings.?Implement monitoring & evaluation to demonstrate sustained improvement. ?Hardwire into the organizationPDCA CYCLESTEP 1PLANSELECT A PROCESS?Identify the problem by reviewing current data.?Utilize design standards/PI Design Form ?Develop a Team Charter WHY WAS THIS SELECTED?What is the scope of the problem??What process do we want to improve??Who should be involved?LOOK AT THE CURRENT SITUATION (DATA)?Implement data collection tool(s)?Flow chart the process?Brainstorm barrier (fishbone diagram)?Display data on graph?Analyze the data?What are the possible “root causes”??What are the actual “root causes”??How often does it happen?STEP 2.DODEVELOP SOLUTIONS?Brainstorm all possible solutions?Develop a plan/the ideal situationIMPLEMENT?Pilot test a solutionSTEP 3.CHECKREVIEW RESULTS?Evaluate results of pilot?Compare data before and after?Use graphs to display dataSTEP 4ACTFORMALIZE IN POLICY/PROCEDURE?Implement a formal change in the process and put into operation across all care settings.?Implement monitoring & evaluation to demonstrate sustained improvement. ?Prepare a brief PowerPoint presentation and team presents to the chartering group.?Share results/rejoice/celebrate!?If not successful, re-enter PDCA cycle and try again473773513741400073723511988800018802351746250085153516510000760095242443000176593536601400036175952631440003823335288925001537335802640ACT: Act by adopting, adjusting or abandoning the change.00ACT: Act by adopting, adjusting or abandoning the change.15373352031365CHECK:Check the results and lessons learned. 00CHECK:Check the results and lessons learned. 29089352031365DO:Do the improvement, data collection and analysis.00DO:Do the improvement, data collection and analysis.2908935802640PLAN:Plan the process improvement.00PLAN:Plan the process improvement.98869519253200026803352794000085153527940000Deep DiveThis method is meant to be used for rapid process improvement. Normally a team will meet 4-8 hours continuously to complete the process.Identify/Describe each:Issue:Areas of Focus:Approach:Findings:Develop report/Action Plan:Action for Improvement (what):Who:When:Lessons Learned:Patient Flow PlanManaging the flow of patients through their care is essential to ensure care is safe, timely, and results in positive quality outcomes. Access to routine and specialty care is a critical issue in today’s healthcare arena. Improved assessment and management of patient flow can help ensure the wise utilization of limited resources, and thereby reduce the risk to patients of negative outcomes from delays in the delivery of care, treatment, and services. As we continually improve care delivery, it is essential to understand the flow of the patient from time of arrival to discharge to the next care setting. Impact on patient safety must be considered and barriers mitigated. Leadership and Medical Staff, as well as supporting departments, work together to share accountability and develop processes that support efficiency and the Veteran’s need for timely care. Supporting processes must be understood, measured, and improved. Appropriate measures must be implemented to track the effectiveness of improvement actions, and to determine when process changes are indicated. Many Priority Focus Areas come into play when designing optimum flow. These can include Communication, Physical Environment, Infection Control, Equipment Management, and Patient Safety. While there are many components to effective patient flow, primary approaches used by VA Northern Indiana Health Care System (VANIHCS) are summarized below.Advanced Access: A formal Systems Redesign Committee is in place, which incorporates the Advanced Clinical Access principles outlined in the Integrated Healthcare Improvement (IHI) initiative. Goals are to reduce backlogs and delays in patient care, and to serve the Veteran in a timelier manner. Targets are established (e.g. Primary Care wait time for new patients < 14 days) and tracked. Special emphasis is placed on problem areas such as Missed Opportunities (No-shows and cancellations). Outcome measures related to patient access and supporting processes are reviewed monthly by the Quality Leadership Council. Champions are designated for process improvements, and action plans and status toward goals are presented to Leadership. Strategic planning is conducted at the VISN, National, and facility levels. PDCA Teams and PI Workgroups focus on systems analysis and improvements to flow, efficiency, quality, and safety of care delivered. Many Performance Measures require an intensive understanding of primary and supporting processes, with an emphasis on prevention of delays and backlogs. Continual Readiness Teams are in place to analyze compliance with standards, to include all standards supporting Patient Flow.The facility Emergency Management Plan defines actions to be taken in emergent situations, such as disaster, utilities interruptions, acts of terrorism, etc. A diversion criterion has been established, and this facility works closely with the community emergency response agencies to coordinate the care and flow of patients in critical situations. Bed availability is closely monitored, and reported to local leadership as well as VISN staff. We have contingency plans in place for a Department of Defense influx of injured active duty staff. Local hospitals support the influx of our patients as we support military needs. Influx of patients is also addressed in VANIHCS Policy 11-33, Bioterrorism Infection Control. The plan for the management of an influx of patients is outlined in the policy, and monitored by the Emergency Operating Center, which is headed by the Medical Center Director who acts as Incident Commander. Influx plans take into consideration the recommendations of the Center for Disease Control, and the National Strategies for Pandemics and Disasters Toolkit provided by VHA.A nationally approved criterion is used to guide Utilization Management activities, to include admission and continued stay appropriateness. Data is collected to identify opportunities to improve patient flow, and the movement of the patient thru the healthcare system is facilitated by the UM Nurse. Data collected and reported includes the diversion of patients in non-emergent situations. Data is analyzed, and opportunities for improvement are identified by the Utilization Management Committee. Bed availability and appropriateness of the setting of the delivery of care are primary focuses of daily UM activity. Medical Administration Service is responsible for reporting Bed Availability and has responsibility for monitoring the patient flow and continuity of care related to fee basis care, which ultimately impacts financial resources. Facilities Management staff perform space and utilization studies, and the Infection Control nurse conducts pre-construction assessments to ensure the safe flow of patients and staff in areas under construction. Formal Environmental Rounds are conducted, and facility leadership participates on a routine basis. Departmental managers also conduct environmental rounds in their designated areas. Data related to findings is analyzed by the Environment of Care Board, which is chaired by the Associate Director for Operations - Marion. Environment of Care Management plans outline processes for routine and emergent support. Continual Readiness teams also conduct environmental audits as the care of the patient is traced to ensure compliance with Joint Commission standards. An Annual Workplace Evaluation, which focuses on the physical environment, is conducted by outside auditors. Patient Safety is of highest priority in this organization. Information related to patient flow, backlogs and delays, environmental or other issues that decrease safety or efficiency are acted on through RCAs, HFMEAs, close call or incident reporting, and associated follow-up activities.Patient flow concerns are also identified through the Patient Representative Program, as well as SHEP (Shared Healthcare Experience of Patients) feedback data, and referred appropriately. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download