Quality and Performance Improvement

Quality/Performance Indicators

Performance indicators, developed with input from appropriate medical staff departments and services and approved by the medical executive committee (MEC), are used in the monitoring process on an ongoing basis to provide feedback for continuous improvement purposes.

Feedback may be ongoing as reflected in the Ongoing Professional Practice Evaluation (OPPE), or more specific as reflected in the Focused Professional Practice Evaluation (FPPE), and is used in an attempt to validate competency on all physicians.

Quality Performance Improvement Reports are distributed to services and departments bi-annually. Physician Performance Feedback Reports are distributed to individual physicians on an annual basis. The purpose of these reports are to set clear expectations of physician performance for all competency categories; to create a medical staff culture that accepts performance data feedback in the spirit of continuous improvement; to make physicians aware of areas of excellent performance, as well as areas of improvement opportunities; to allow physicians the opportunity to self-improve based on the data provided; and to meet the Joint Commission standards for ongoing professional practice evaluation.

Integrated Quality Assurance/Performance Improvement Program

The board of directors is ultimately responsible for quality and safety in the organization and delegates the responsibility for implementation of the program through administration, the medical staff, the performance assessment committee and quality coordinating council with oversight by the quality assurance/performance improvement committee of the board.

The program is aligned with the hospital’s mission, vision, values and strategic goals.

The purpose of the Integrated Quality Assurance/ Performance Improvement Program is to ensure continuous improvement of health care across hospital functions with the goal to provide care that is:

The program focuses on key functions and processes to provide a systematic, coordinated and continuous approach to improve performance. Departments and disciplines are involved in establishing processes and mechanisms that comprise performance improvement activities.

For more information, please refer to the Reference Manual on Dominet.

Focused Professional Practice Evaluation (FPPE)

FPPE is a process whereby the privilege/procedure specific competence of a physician who does not have documented evidence of competently performing the requested privilege at St. Dominic’s is evaluated. FPPE is a time-limited period during which the medical staff evaluates and determines a physician’s professional performance.

FPPE will be implemented under the following circumstances:

Ongoing Professional Practice Evaluation (OPPE)

OPPE is the continuous evaluation of the physician’s professional performance. It is intended to identify and resolve potential performance issues as soon as possible, as well as foster a more efficient, evidence based privilege renewal process while allowing the organization to identify professional practice trends that may impact the quality of care and patient safety.

Ongoing evaluation information is factored into the decision to maintain an existing privilege, to modify an existing privilege, or to revoke an existing privilege prior to or at the time of reappointment. OPPE results are shared with the physician on a regular basis.

For further information refer to the St. Dominic Hospital Medical Staff Bylaws.

Sentinel Event-Root Cause Analysis

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, not related to the natural course of the patient’s illness or underlying condition. Additional events, such as surgery on the wrong patient or wrong body part, unintended retention of a foreign object, or hemolytic transfusion reaction are also defined as sentinel events.

For any sentinel event that should occur, a Root Cause Analysis (RCA) must be completed. A RCA requires investigation with the team members that were involved to facilitate the development of action plans to address identified process improvement opportunities.

Often events occur that do not meet the sentinel event definition but are considered significant. These events are called Near Misses and like a sentinel event, necessitate thorough analysis and require a RCA.

Following a RCA, an action plan is developed and each plan is evaluated through its established outcome measure. This continual monitoring of outcomes is imperative to patient safety processes.

Joint Commission

The Joint Commission has revised a hospital Accreditation Participation Requirement that prohibits disciplinary action against employees who report health care quality and safety concerns. The revised requirements (APR 17) clarifies that the rule also pertains to physicians and medical staff, meaning accredited hospitals must educate medical and other staff that any concerns about safety or quality may be reported to the Joint Commission without fear of disciplinary action.