Medical Staff CQI

1. Medical Staff CQI Memorial Hospital Chester, Illinois 3/26/09

2. Medical Staff Performance Improvement Process: Variety of Indicators which involve all Medical Staff: Active Staff ER Physicians Radiologist Consultants Source of indicators: Best practice Guidelines: (HQA, HOP QDRP, etc. ) COP/JC Standards (V.O., Timely H &P, H & P Update) National Patient Safety Goal Compliance Physician approved protocols Data collected by various disciplines throughout the hospital; for example: Blood Utilization (Lab) Clinical indicators (OR, ER) Core Measures: PI director Incident Reports: Safety Director Medical Record Review: HIM director Utilization Review: UR Mgr.

3. Process continued: The overall results of the indicators are then reported to: PI committee, Environment of Care Committee. From these two committees, the overall results are then forwarded to the Medical Staff Committee of the Whole.

4. Peer Review Process: Any indicators that result in variation are referred initially to the Physician Advisor, Examples: Blood Utilization: Lab Advisor IP Core Measures: Chief of Staff Trauma Indicators (ER): ER Physician Director Vancomycin: Infection Control Advisor. Physician Advisor determines if further review is warranted by the Peer Review Committee. If further review warranted: Sent on to Quarterly Peer Review Committee Meeting. Peer Review committee takes further action as warranted: Continuing education, monitoring, focused practice evaluation. Form to track record as it moves through this process

6. Indicators: Core Measures: IP: AMI, CHF, Pneumonia, SCIP OP Chest Pain, AMI, Out Patient Surgery. Tissue Review: Normal tissue, too little tissue, clear margins, etc. Blood utilization: Hgb below 8.2; Platelets, FFP, etc Documentation of informed consent, written orders Incident Reports Physician complaints. Sentinel Event.

7. Indicators: continued Medication Usage: Significant clinical interventions Anticoagulation Protocol Vancomycin Usage Infection Control HAI Vancomycin Usage Medical Record Review Dating, timing, signing Verbal and Telephone orders Prohibited abbreviations Delinquent Records H & P�s; Update to H & P Complete/Timely Operative Report/Operative note Timely consultant dictation

8. Indicators: ER Physician Indicators: Trauma Indicators Chest pain / AMI Timeliness of Thrombolytics, X-ray interpretation ER Management / Documentation issues Utilization Management LOS Readmissions Admission/Continued stay criteria not met. Denials RAC Audits ?? Mortality/Morbidity Review

9. Indicators: Continued Surgical and other invasive procedures: Timely H & P; update Universal Protocol Informed consent Pre-op / Post-op discrepancies including path diagnosis Conscious Sedation Outcomes Deaths in OR/PACU Repairs, lacerations, Perforations, Tears Anesthesia indicators Retained foreign body Returns to OR in 24 hours.

12. Credentialing: Summary of all indicators is compiled for each physician. Summary attached to Medical Staff Re-application. Reviewed by Medical Staff when physician is recredentialed. See Summary Form