Background:
Building on the development of order sets and their monitoring, our organization crafted a dashboard to track 25 key quality indicators for the entire organization, with more than half linked to diagnoses managed by the Department of Hospital Medicine. Building on past achievements, the hospitalist group is at the forefront of the movement for improved measurement of quality.
Purpose:
The purpose of our innovative approach to accountability for metrics is to provide integrated oversight, visible accountability, and consistent communication, bridging individual departments through the assignment of members of the Center for Quality Excellence (CQE) to clinical departments. Our purpose is to improve at least 30% in all targeted metrics, or place in the 90th percentile for each benchmark.
Description:
We centralized the data within the CQE and provided standard definitions and measurements of goals that are used by all departments. We developed a Clinical Excellence Committee that will oversee the quality initiatives of all 3 regions of the organization. Its purpose is to provide leadership, structure and resources to systematize the approach to quality improvement within the organization; it will report directly to the Board of Directors.
We centralized the data within the CQE and provided standard definitions and measures of goals.
While department chairmen and administrative directors remain accountable for reaching their specific targets, they will be assisted and encouraged by the CQE staff.
By the next SHM Forum, we anticipate having results that will demonstrate improvement in at least 90% of the clinical quality indicators, based on the breadth of the support that will be brought to bear to improve quality at our institution. The hospitalist group is key in promoting the use of best practice order sets that reduce variance and improve adherence to quality.
Summary of Results:
We have already demonstrated in prior years that real time feedback to physicians on their use of order sets improves compliance. The Chair of the Department of Hospital Medicine monitors use of the order sets by the hospitalists and provides mentorship in coding and documentation. The Dashboard will provide a barometer for the hospitalists as well as all other departments in the organization to assess how well we are achieving our quality goals.
Author Disclosure Block:
D.H. Lee, None; S.B. Deitelzweig, None; P.F. McDonald, None; S.M. Rodriguez, None; M.W. Milner, None.