HABERSHAM MEDICAL CENTER

1. HABERSHAM MEDICAL CENTER Quality Leadership to Improve ORGANIZATIONAL PERFORMANCE 2012

2. Habersham Medical Center HOSPITAL AUTHORITY has the final ultimate responsibility for the quality and safety of patient care. GOAL:design processes well, to identify, prioritize, and systematically monitorto improve patient outcomes

3. Authority By-Laws to create a Quality Committee Challenge: Integrating the current quality program into the new structure Design meaningful information for Committee members Meet the requirements of the Hospital Authority By-laws

4. Quality Committees will: • Have different levels of authority • QCC will be subject to QLSC and MEC • Conduct business under the state statute of “Peer Review” protection: • Statute O.C.G.A. 31-7-131. • Receive metrics, reports and dashboards

5. Medical Peer Review Immediate resolution of unusual or urgent events or a trended practitioner related trend requires another system of review including peer review if necessary. Peer Review (Nurse, Physician, other healthcare providers) is utilized for determining actions to be taken in response to events and/or trends in a timely manner.

6. 1. Actively reporting errors, near misses/close calls, and hazardous conditions when recognized. 2. Participating in disclosure of unanticipated outcomes, working with the leadership, and following hospital policy on process for unanticipated outcomes. 3. Comprehending and adhering to policies and procedures addressing patient safety. Medical Staff

7. Patient Safety • HMC integrated several Committees that address the safety of our patients, visitors, staff, and Medical Staff: QLSC , QCC, PCSC, MEC/QI

8. EOC/Safety Committee • Medical Equipment Management • Hazardous Waste Management • Fire Safety Management • Disaster Preparedness • Infection Prevention/Infection Control Risk Assessment • Workman Compensation Reports • Accident Prevention • Recalls • Security Management • Utilities Management Plan

9. Patient Care Safety Council(PCSC) • Product Review • MEC and QLSC Summaries • Regulatory Compliance • Patient Safety and Alerts • Quality Indicators • Departmental Chart Reviews • QCC Chartered Team Reports

10. Clinical Steering Committee • Restraint • Falls • Medication Management • Medication Error Report • Medication Reconciliation • Blood Utilization • National Patient Safety Goals

11. Patient Care Treatment Services (PCTS) • Medical Records Compliance • Information Management • Pharmacy and Therapeutic • Forms • Patient Care Policies and Procedures

12. Medical Executive Committee (MEC) • Lateral to QCC in organizational chart • Medical QI Review • Final Patient Care approval for forms/policies/& procedures • Credential and Privileging

13. Hospital Authority By-Laws • “Medical Review Committee” • “Evaluate and improve the quality of health care rendered, to determine that health care services were professionally indicated, performed in compliance with the applicable standard of care and the cost of health care rendered, PI efforts, patient and peer evaluations of health care services rendered and costs of such care.”

14. Quality Care Committee (QCC) • Lateral to MEC in organizational chart • Quality indicators upcoming for public reporting • Departmental Reviews • Charter Team Review • Mortality Review (overall) • Patient Satisfaction concurrent review • Blood Utilization • Current Core Measure Data

15. Quality Care Committee (QCC) Management has developed an approach to restructure information for Medical Review, Public Reporting and Cost Analysis for the Authority Committee. This committee will be named: “Quality Leadership Steering Committee”=QLSC Committee will continue to monitor patient outcomes and internal processes that contribute to quality, patient satisfaction and high risk problem prone patient care processes. This working committee will be named: “Quality Care Committee”= QCC

16. Quality Leadership Steering Committee(QLSC) Membership: • Physician members of Hospital Authority • One non-physician member of HA • Chief of Medical Staff • Chair of QCC • Hospital staff: CEO, SVP Pt. Care, and VP of Quality

17. Authority of Quality Leadership Steering Committee (QLSC) • All Public Reports • Patient Satisfaction • Mortality Rate (AMI-HF-PN) • Hospital Acquired Conditions • Readmission Rates (AMI-HF-PN) • Medical Staff Performance • Price Transparency Report • QCC Activity Reports

18. Authority of HMC Authority of Finance Authority of Quality Medical Executive Committee (MEC) Quality Care Committee (QCC) Administrative Team Patient Care Treatment Services (PCTS) Patient Care Safety Council (PCSC) Clinical Steering Committee Environment of Care Committee (EOC/Safety)

19. Flow of information to the bedside… • After information is approved and passed through the chain of command: • Medical Staff • Power point review of committee minutes are reviewed every other month. • Patient Care Safety Council • Information taken to staff meetings from the PCSC minutes.

20. Accountability • Performance Measures • Medical Staff • Provider information sent to MEC and points are appointed, as appropriate. • Clinical Staff • Clinician information sent to Clinical Peer Review and points are appointed, as appropriate. • Education provided, as identified • Discipline action taken for identified trending

21. Questions ??