Quality Safety Service Priorities Disclosures Faculty have nothing

Quality, Safety & Service Priorities

Disclosures Faculty have nothing to disclose. Date 2

VCUHS Quality, Safety, Service (QSS) Program Continuous Quality Improvement Philosophy: Quality Improvement is not a program, rather is a leadership approach … and is part of the culture at VCUHS. “Chronically dissatisfied” – John Duval, CEO

Why Establish QSS Improvement Priorities? • Not all improvements are equally important • Organizations have limited resources • Prioritization schema ensures alignment and provides a direction • Alignment with organizational strategy • Enhance operations • Better meet customer needs, improve customer satisfaction • Improve finances/market share 4

Quality, Safety, Service Priorities Approved by the Quality Executive Council ■ Priorities are established based on assessment of many inputs: • • • ■ internal and external data and information input from frontline to Board benchmarking and studying best practices safety events, staff perceptions, patient perceptions external/public data, report cards, and other inputs Proposed Priorities are assessed using STEEEP framework: • Safe-Timely-Effective-Efficient-Equitable-Patient Centered Care Date 5

QSS PRIORITY SETTING INPUTS • • • Serious Safety Events (trends in the causes of events) Daily Safety Check-In Front line input: • • • Customer/patient input: • • • Patient satisfaction survey, patient complaints “Defect surfacing” Exercises: Patient Family Advisory Council National quality measure & Value-based payment programs • • • Safety Intelligence Reports “Defect Surfacing” Exercises: Safety Coaches, Chief Residents Publicly reported metrics Financial impacts Emerging evidence/changes in standards of care Regulatory requirements Quality STEEEP dashboard (key metrics) Other dashboard, metrics, comparative data

IMPROVEMENT PRIORITY-SETTING PROCESS Input gathering, Data review Defect surfacing – multiple groups Multiple discussions Research/ further info gathering “Short list” to QEC: narrowed/ expanded QEC discussion, multi-voting QEC consensus decision (or vote) Board Vote

Quality Governance and Leadership VCU Health System Board Quality, Safety, Service Committee of VCUHS Board Medical Executive Committee QSS Priority Teams Process Improvement Committees Quality Executive Council Safety Council Pt/Family Advisory Council Program Centers of Excellence Committees Operations Council Regulatory Oversight Department/Program Quality Committees/ Councils 8

FY 2017 Quality, Safety, Service Priorities Approved by the Quality Executive Council FY 2017 Recommended Priorities New New Provider Consult Process Safe, Timely, Effective Advanced Care Planning Effective, Patient Centered Readmissions Safe, Effective, Efficient, Patient Centered Hospital & ED Throughput Timely, Efficient, Patient Centered Communication with Patients/Families Safe, Timely, Efficient, Equitable, Patient Centered Pain Management & Substance Abuse Safe, Effective, Timely, Patient Centered Hospital Associated Infections Safe, Effective, Patient Centered -- C difficile Handoffs -- Medical Teams -- Nursing Bedside Shift Handoff New Domains of Quality Safe, Effective, Patient Centered Science of Improvement All STEEEP domains Sepsis Safe, Timely, Effective Test Results Management Safe, Timely, Effective Access to Care Timely, Efficient, Equitable 9