1 / 9

QUALITY

QUALITY. Liz Walliser, RN, MS, CPHQ Director Quality Office located on 6 th floor. Role of Quality Department. To support physicians to provide best practice Peer Review Review of Quality Indicators Ensure compliance with regulatory requirements (Medicare, Joint Commission)

cosmo
Download Presentation

QUALITY

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

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

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

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

  5. Focused Professional Review • 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)

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

  7. Core Measures • Acute MI • Door to balloon <90 minutes • Heart Failure • 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 • Beta blocker prescribed on DC

  8. Core Measures • Pneumonia • Use Order Set to ensure right antibiotic • Pt is screened and vaccination given unless physician orders not to • Surgical Care • Antibiotic w/i one hour of incision • Antibiotic must be DC’d by 24 hours (except CABG) • Use the right antibiotic • Normothermia intra-op • Glucose control post-op • VTE prophylaxis

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

More Related