|
UK HealthCare Quality Initiatives
UK HealthCare is committed to providing the highest-quality and safest patient
care possible. The quality process is crucial for health care leaders to improve
outcomes and adapt to change as well as to deliver cost-effective and high-quality
patient
care. Regulators, payers, and patients will continue to demand performance-based
data that documents compliance with quality standards and benchmarks.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
defines performance measurement in health care as representing what
is done and how well
it is done. The goal is to accurately understand the basis for current
performance so that better results can be achieved through focused improvement
actions.
Quality ensures that the organization designs processes well and systematically
monitors,
analyzes, and improves its performance to improve patient outcomes (JCAHO,
2002).
Plan for
Improving
Organization Performance
Hospital Leaders
The Hospital Director, Associate/Assistant Hospital Directors, Service
Directors, managers, and supervisors provide ongoing evaluation of
the quality of care
and services provided by the Hospital. Hospital administrators are
assigned liaison
responsibilities with medical staff departments and services.
Medical Staff Leaders
The Chief Medical Officer serves as the chief administrative officer
of the medical staff. The Chief of Staff serves in the absence of
the Dean
as Chair
of the Medical
Staff Executive Committee. The Medical Staff Executive Committee
meets monthly to receive and act on reports and recommendations from
medical
staff committees,
clinical departments, and assigned activity groups. The Committee
is comprised of department chairs and Hospital administrative representatives.
Operations, Quality, and Safety Council
The Operations, Quality, and Safety Council is responsible for administering
an effective, integrated, organization-wide performance improvement
program. The Council is comprised of Hospital and Medical Staff leaders,
including
the Hospital Director, Hospital Administrators and Service Directors,
the Chief
Medical Officer, and other medical staff leaders.
The Council provides oversight to four sub-groups.
- Organization Performance Council: Analyzes reports and
makes recommendations for improving organization performance; recommends
resources in
support of organization priorities.
- Accreditation Management Team: Assesses compliance with
external regulatory, accrediting, and licensing requirements; initiates
activity to
address deficiencies; and coordinates surveys by external agencies.
- Training Council: Addresses staffing effectiveness, staff
competence, and staff learning needs.
- Patient Safety Committee: Addresses activities to reduce
medical and healthcare errors and improve patient safety.
The Operations, Quality, and Safety Council establishes priorities
for organization improvement based on external regulatory, accrediting,
and licensing requirements;
critical success factors; results of hospital and medical staff
oversight of quality of care and services; and payer expectations.
Initiatives
focus high
volume, high risk, problem-prone, or high-cost activities and
on one or more dimensions of performance, including the choice of treatment,
procedures,
or services (efficacy and appropriateness) as well as the performance
of
treatment,
procedures, or services (availability, timeliness, effectiveness,
continuity, safety, efficiency, and respect and caring).
The Operations, Quality, and Safety Council (OQSC) receives annual
reports on performance improvement, patient safety, staffing
effectiveness, staff
competency, staff learning needs, and standards compliance. The
Council reviews selected
reports from sub-groups and other groups on a periodic basis.
An annual report is provided to the Hospital Board of Directors.
|