The Program - Hospital Quality

Much the same way collegiate athletics structure, measure, and define their respective programs, hospital quality professionals can benefit by following a similar approach.

For example, a typical college football program consists of standard domains of work and accountability. The program continuously strives to improve the areas of work and levels of effectiveness so that it may achieve a comprehensive, robust and sustainable product; that is not personnel dependent. The program measures its success via outcome measures such as: graduation rate within 4 years, transfer rate, NCAA violations incurred, conference titles, and overall winning percentage, to name a few.

- Coaching
- Recruiting & Retention
- Scheduling
- Academic Counseling
- Housing
- Conditioning and Weight Lifting
- Athletic Facility Management
- Alumni Relations
- Transportation
- Media & Communications
- Contracts & Apparel
- Graduation Rate - outcome measure
- Winning Percentage - outcome measure

Yet, a program doesn't truly exist (nor does it reach levels of sustained success) until all domains of work, expectations, and accountability are connected and aligned to one central mission. The mission must be transparent and embraced throughout. Until such a time, the program more accurately resembles beads on a table without a string. Of course, depending on the levelness and frictional surface of the table, the beads could roll and drop to the floor.

You may recall in my previous postings the acronym STEEPE: Safety, Timeliness, Effectiveness, Efficiency, Patient-Centered, and Equity.

The Program - Hospital Quality
Mission: Continuous Improvement for the betterment of the patient
Domains of Work (in no particular order):

• Joint Commission/State Accreditation (continual readiness) -- STEEPE
• Core Measures -- Effectiveness, Timeliness
• Hospital Outpatient Measures - Effectiveness, Timeliness
• Never Event Reporting -- Safety Hospital Outpatient Program -- Effectiveness, Timeliness
• Patient Satisfaction (HCAHPS & Press Ganey) -- Patient Centered
• Hand Hygiene -- Effectiveness, Safety
• Hospital Acquired Infections (SSI, UTI, VAP, CLBSI, Sepsis) -- Safety, Effectiveness
• Near Miss Reporting (Medication Administration) - - Safety, Effectiveness, Efficiency
• Patient Falls -- Safety
• Medication Reconciliation -- Safety, Efficiency
• Never Event Reporting -- Safety
• OR Quality (Surgical Checklist, On-Time Starts, Turnaround Time) -- Safety, Efficiency, Effectiveness
• Percentage of Patients Leaving AMA -- Equity
• Average Wait Time in ED -- Timeliness, Efficiency, Patient Centered
• Medical Staff Quality (OPPE, % Medical Case Reviews Deemed Appropriate, Medical Record Delinquencies equal or greater than 30days) -- Equity
• Risk-Adjusted Mortality (O/E ratio) -- outcome measure
• Readmissions (15 day, 30 day) -- outcome measure
• Scorecard/Dashboard reporting -- competency measure
• Regular Reporting to the Board of Directors --competency measure

The healthcare quality professional must be relentless and connect these beads to a centralized string.

Does your hospital have a Quality Program?