Community Hospital of the West is a 350-bed tertiary medical center with an inpatient and outpatient continuum of care that provides medical and surgical services to a community of approximately 250,000. The facility’s scope of services includes cardiology, orthopedics, obstetrics/gynecology, oncology, and psychiatry. The Community Hospital of the West board of directors is committed to continually improving the delivery and effectiveness of the care and services provided and proactively monitoring and assessing care delivery, patient safety, and the satisfaction of its customers. The board supports an environment that encourages the identification of improvement opportunities from all sources throughout the organization and community and the provision of care and service that is reflective of the organization’s mission and vision.
Community Hospital of the West is the preeminent regionally integrated healthcare delivery system in the Intermountain West dedicated to providing compassionate, quality, high-value healthcare services to the residents of our communities.
To provide leadership in patient-centered care, built on a foundation of knowledge, innovation, and human values.
Performance Improvement Approach and Model
An interdisciplinary, continuous, performance improvement approach is recognized across our continuum of care and service areas utilizing a Plan-Do-Check-Act (PDCA) model. Patient care and safety, and all other important organizational functions, are continually monitored, analyzed, and improved.
Organizational Performance Improvement Structure and Expectations
The leaders of Community Hospital of the West (the board of directors, the medical staff officers, and the senior hospital administrators) are committed to the integration of performance improvement activities. All staff is educated in the principles of performance improvement and participate in identifying opportunities for improvement, data collection and reporting activities, performance improvement team activities, and ongoing education. The board of directors has overall responsibility for ensuring the quality of care and services provided to the community. The board has delegated implementation responsibility for the organization-wide continuous performance improvement activities to the Performance Improvement and Patient Safety Council.
Performance Improvement and Patient Safety Council
The Performance Improvement and Patient Safety Council is an interdisciplinary senior-leadership committee that provides oversight and direction for the design and implementation of the organization-wide, continuous performance improvement and patient safety program. The council annually reviews outcome data and survey information as part of its strategic planning and prioritization processes. The council reports monthly to the medical executive committee and quarterly to the board of directors any adverse outcomes, significant process variations, and actions are taken to improve care and address patient safety issues, both proactively and reactively. Standing committees of the medical staff, clinical and department discipline meetings, and this council are responsible for managing and improving patient care and safety issues within their particular high-risk areas. Prioritized measures that include high-risk and problem-prone areas identified throughout the organization are trended, analyzed, and reported to the council by assigned committees/staff on a pre-established schedule. The performance improvement department coordinates the implementation of the performance improvement and patient safety plan. The department provides organization-wide support in the design of data collection tools, data display, statistical analysis, benchmark data research, and the preparation of council reports. The council is responsible for receiving findings and acting on recommendations from the board, all committees, departments, performance improvement teams, customer survey data, sentinel events, near misses, and other identified trends in areas such as risk management and infection control. The council also is responsible for the design of the organization-wide staff development program related to continuous performance improvement and patient safety, and for the assessment and assignment of an annual proactive risk reduction activity. At least annually, the council reviews the activities of the performance improvement program and makes recommendations for the continuous improvement of the performance improvement and patient safety plan to the board of directors. The council membership is composed of a physician chairperson, the chief executive officer, medical director, clinical and administrative service directors, performance improvement team members, and other invited staff and guests as appropriate. The council meets at least every other month and as needs indicate.
Standing Committees of the Medical Staff
All standing committees of the medical staff are chaired by a physician with representation, as appropriate, from hospital leadership, department directors, and frontline staff. Reports are submitted to the Performance Improvement and Patient Safety Council, which in turn forwards critical events and findings to the executive committee and to the board of directors. Communication throughout the organization among the board, committees, councils, hospital departments, medical staff, employed and contract staff, and its patients/families is open and flows in all directions, as appropriate and as allowed by regulations.
Medical Executive Committee
An elected official from the medical staff, medical staff committee chairs, medical director, chief executive officer, clinical service director, compliance officer, and the chief financial officer are standing members of this committee. This committee meets monthly and coordinates the business of the medical staff (recommending changes to their bylaws, rules, and regulations, reviewing appointment and reappointment recommendations, and election of officers) and the integration of patient care and hospital support services. Significant performance improvement and patient safety-related issues forwarded from the Performance Improvement and Patient Safety Council are reviewed, discussed, acted upon, and forwarded to the board and, as appropriate, to other departments, committees, and staff.
Medical Staff and Specialty Department Meetings
Each clinical staff specialty department meets at least quarterly to review and discuss performance improvement activities, staff development issues, and other related planning and directing activities. The medical staff at large meets at least annually for the election of officers, bylaws review, and general staff education.
This committee is responsible for serving as a resource regarding medical/ethical issues that surface for patients, their families, and the organization’s clinical care providers.
This committee is responsible for the design and implementation of the organization’s credentialing process and includes reviewing applications for appointment and reappointment, defining privilege delineation criteria, and evaluating physical health issues. Recommendations on all credentialing-related issues are reported to the executive committee and forwarded to the board of directors for final approval.
Utilization and Documentation Standards Committee
This committee is responsible for the review of findings from the monitoring activities on patient-specific data and information, timeliness of clinical record entries, and appropriateness of admissions and continued stays. Significant findings and recommendations are reported to the Performance Improvement and Patient Safety Council, the executive committee, provider quality profiles, other committees, and departments and individuals, as appropriate.
Pharmacy and Therapeutics Committee
This committee is responsible for formulary review and development, policy setting, procedure development, medication-related safety education, and monitoring the safety and efficacy of medication use throughout the organization. Medication monitoring includes a systematic, ongoing process of reviewing prescribing/ordering, procurement and storage, preparation and dispensing administration, and adverse drug reactions. This committee performs data collection, analysis of aggregate data for patterns and trends, recommendations for process/system changes, and reporting of significant findings and actions to the Performance Improvement and Patient Safety Council.
Environmental Safety Committee
This committee is responsible for planning and directing environmental services within all environments of care. It also is responsible for educating staff on environmental safety issues and performance monitoring, data analysis, and continuous improvement efforts. This committee meets monthly and reports data collection, analysis, and improvement initiatives to the Performance Improvement and Patient Safety Council at least quarterly. The committee submits an environmental safety report identifying and reviewing improvement goals to the board of directors annually. Committee representation includes individuals from the hospital and medical staff leaders, engineering and maintenance, housekeeping, central processing, security, and employee health.
Strategic Planning Process
The strategic planning process occurs annually prior to the start of the fiscal year and coincides with organization-wide plan/program reviews and the budgeting process. Performance improvement and patient safety program review is initiated by the council using findings from the leaders’ strategic goals, the council’s self-assessment, and staff survey data on the program’s effectiveness. Additional information, such as aggregate outcome data from performance measures, the effectiveness of corrective actions implemented as a result of process variations and adverse outcomes, input from customer surveys, status on past year’s goals, findings, and actions from the annual proactive risk assessment/reduction activity, and regulatory and hospital process changes, are all reviewed and considered in the planning process and in the prioritization of performance initiatives and measures for the upcoming year.
Criteria for Prioritization of Improvement Goals, Performance Measures, and Data Collection
- • Does the improvement opportunity/measure support the organization’s mission, the scope of care, and service provided and/or population(s) served?
- • Is the performance measure a required regulatory measure, and does it provide performance information on an important function?
- • Does the opportunity improve patient safety?
- • Does the opportunity relate to an event that resulted in a sentinel event or near-miss?
- • Does the opportunity reflect patient feedback on needs or expectations?
- • What degree of adverse impact on patient care can be expected if the improvement opportunity remains unresolved?
- • Does the opportunity reflect a high-volume, problem-prone, or high-risk process?
- • Are resources available to conduct the improvement process?
- • Does the opportunity involve changing regulatory requirements?
This organization collects data on key systems, processes, and outcomes to monitor its performance. Data collection is prioritized based on this organization’s mission, the scope of care, services provided, and populations served. Data collection is systematic and may be used to establish a performance baseline, describe process performance stability, identify areas for more focused data collection, and/or determine if improvement has been sustained. Available benchmark information for established performance measures is drawn from internal and external databases. Data collection, responsibilities, and reporting schedules are defined in an appendix to this plan. Data that are collected to monitor performance include the following:
- Performance measures related to accreditation requirements (Core measures or ORYX)
- Patient safety issues, including the following error-prone areas: medication events, falls, blood events, procedure/treatment/surgical events, behavioral events, equipment events, and laboratory events
- High-risk processes that may have the potential to result in a sentinel event, including operative or other invasive procedures that place patients at risk, medication management, restraint use, seclusion use, blood and blood product use, and outcomes related to resuscitation
- Relevant clinical practice guidelines
- Adverse drug events (ADEs)
- Needs, safety concerns, expectations, and satisfaction of patients and their families
- Failed processes related to The Joint Commission’s National Patient Safety Goals
- Utilization management activities
- The performance of new and modified processes
- Quality control activities in the clinical laboratory, diagnostic radiology, nutritional services, nuclear medicine, radiation oncology, and pharmacy
- Infection control surveillance and reporting
- Medical record documentation for quality of care and timeliness
- Risk management information, including sentinel events, near misses, complaints, findings from inspections by regulatory agencies, and compensable events
- Environmental safety
- Efficacy of services provided through contract or written agreement
- The appropriateness and effectiveness of pain management
- Appropriateness of behavior management procedures
- Autopsy results, when performed
- Customer demographics and diagnoses
- Financial data
- Staff opinions and needs
- Measures established when performance improvement and patient safety teams are chartered to design/redesign a process
- Other measures that may warrant targeted study
Measurement Process and Tools
When clinical conditions or systems are evaluated, measurement includes the following components:
- • Design and assessment of new processes
- • Assessment of data from customer satisfaction surveys, financial analysis, clinical outcomes of care, and functional outcomes of care
- • Development of indicators of care or service that are measurable and focus on processes or outcomes
- • Utilization of benchmarks or thresholds for performance
- • Identification of data sources
- • Development of a method of data collection and organization of data measures
- • Measurement of the level of performance and stability of important existing processes
- • Aggregation and trending of data
- • Use of established clinical practice guidelines as a framework for standards of care and practice, when applicable
- • Evaluation of individual cases that have potential or actual risk to the patient (adverse event/sentinel event review)
Benchmarks/thresholds are based on current professional literature, national standards, clinical practice guidelines, or internal benchmarks for improvement. Thresholds are derived from retrospective data relative to previous measurements within the organization or from comparable organization data. A benchmark is a quantitative goal embraced by the organization and is reflective of best practices within the internal and/or external environment. These goals serve as a mechanism for the acceleration of performance curves through the process of continuous improvement.
Data Sources and Sampling
Data sources include medical records, encounter data, satisfaction surveys, complaint information, internal clinical databases (for example, information from the order-entry system, diagnosis and procedural coding system, departmental logs, observation, surveys, and interviews). Sampling methodology shall be relevant to the performance measures or study being conducted. For general review studies, a sample size of 5 percent or 30 cases, whichever is greater, may be utilized. When the statistical significance of a study is critical, a scientific methodology is recommended. Control charts are used to measure key indicators on an ongoing basis to assist in determining sustained improvement(s). Statistical process control methods are utilized to identify whether an indicator is in control.
Aggregation and Analysis of Performance Data
The results of systematic, ongoing measures are aggregated and analyzed to identify trends, variances, and opportunities to improve patient care and safety. Data analysis should answer the following questions:
- What is our current level of performance?
- How stable are current processes?
- Do any steps in the process have undesirable variation(s)?
- Have strategies to stabilize or improve performance been effective?
- Are there areas that could be improved?
- What should the improvement priorities be?
- Was there sustained improvement in the processes that were changed?
Trended data are reviewed when:
Trended performance measures significantly and undesirably vary from those of other organizations, requiring a more detailed review.
- Trended performance measures significantly and undesirably vary from recognized standards, benchmarks, or statistical process controls.
- The occurrence of an event is questionable or too infrequent to make judgments about patterns in care or to analyze statistical significance.
Near miss is defined as an opportunity to improve patient safety-related practices based on a condition or incident with the potential for more serious consequences. A root-cause analysis may be performed when a near miss occurs.
A reportable event is defined as an unintended act, either of omission or commission or an act that does not achieve its intended outcome. An incident report is completed by staff and forwarded to the Performance Improvement and Patient Safety Council. Reportable events are trended quarterly. These events are reviewed by their respective committees and/or service area directors and recommendations for corrective actions are reported to the Performance Improvement and Patient Safety Council.
A Sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. A root-cause analysis is performed when a sentinel event occurs. All Sentinel Event Alert publications from The Joint Commission will be reviewed for relevance to our organization.
Intensive review of an incident requires the review of medical records or other data elements to determine if process problems exist and if an ongoing performance measure should be established to monitor process stability. An intensive review is undertaken when:
- • A significant adverse drug reaction or medication error occurs
- • An external regulatory agency requests the review
- • The Performance Improvement and Patient Safety Council requests the review
- • An organization is performing proactive risk-reduction activities
Root-cause analysis is conducted when a significant negative deviation from expected outcomes occurs or when a near miss occurs and further study is recommended by the council.
Peer Review Process
Cases are referred to peer review when they meet criteria as defined in the medical staff peer review plan. Findings are referred to appropriate committees for review and action, as warranted, and to individual physician practice profiles and are reviewed as part of the reappointment process.