CHP Ambulatory Surgery Clinical Integration Quality
Improvement Program
Purpose/Introduction:
The mission of our endoscopy clinical integration program is to provide quality
health care which recognizes the inherent human worth and dignity of all persons,
and to make our programs and services available to all without restriction; to create
a healing environment where physicians, allied health professionals and staff work
together to provide personalized care; to be a leader in advocating high quality
endoscopic programs and developing resources to satisfy the digestive health care
needs of the citizens of our service area; and to operate in an ethically and fiscally
responsible manner without compromising the patient care needs. Consistent with
this mission, our goal is to provide care that is:
Safe – avoiding injuries to patients from the care that is intended to help them;
Effective – providing services based on scientific knowledge to those who would
benefit, and refraining from providing services to those not likely to benefit;
Patient centered – providing care that is respectful of, and responsive to,
individual patient preferences, needs, and values and ensuring that patient values
guide all clinical decisions;
Timely – reducing waits and potentially harmful delays;
Efficient – avoiding waste, including waste of equipment, supplies, ideas and
energy;
Equitable – providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic
status
To achieve this goal, all employees of our integrated ambulatory centers and
hospital based surgical units will participate in ongoing and
systematic quality improvement efforts. Our quality improvement efforts will focus
on direct patient care delivery processes and support processes that promote
optimal patient outcomes and effective business practices. This is accomplished
through peer review, clinical outcomes review, variance analysis, performance
appraisals, and other appropriate quality improvement techniques.
Our Quality Improvement Plan demonstrates our program’s commitment to improve
the quality of care we deliver. The QI Plan outlines the goals and strategies for
ensuring patient safety, delivering optimal care, and achieving high patient
satisfaction. This program is integral to the overall mission of all integrated
ambulatory endoscopy centers and hospital based endoscopy units that are part of
the CHP endoscopy clinical integration program.
The QI Process
All staff members must participate in the quality management and improvement process.
Medical staff will be an integral part of the process and will have representation on the quality
management and improvement committee. The facility’s quality management and
improvement program will use appropriate analysis tools and statistical reporting to evaluate
identified indicators. Reevaluation of quality improvement studies should occur consistently.
The centers or hospitals may use a “FOCUS PDCA” strategy for improving organization
performance:
Find a process to improve
Organize an effort to work on improvement
Clarify current knowledge of the process
Understand process variation and capability
Select a strategy for improvement The cycle that can be used in the ambulatory endoscopy
unit is:
Plan
1. Determine data needed to monitor the improvement in the process
2. Determine measures or indicators for the improvement-monitoring plan
3. During the planning process several issues should be resolved:
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Why is this idea being monitored?
Who will be involved in the process?
What do they need to know to participate in the process?
What are the timetables?
How will the process be implemented?
What are the success factors?
How will the process and the outcomes be measured and assessed?
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Collect and analyze data on improvement in the process
Make improvement changes/actions when indicated and appropriate
Do
This step involves implementing the pilot test and collecting actual performance data
Check
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Establish decision/review points to determine the effectiveness of changes
Assess the effects of improvements
Analyze the improvement results
This step involves analyzing collected data during the process to determine whether the
improvement action was successful in achieving the desired outcome(s). Actual test
performance is compared to desired performance targets and baseline results achieved using
the established process.
Act
The team meets on a regular basis to determine what was learned. Tests or actions are
repeated, if necessary, to ensure improvement. This step involves taking action:
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If the pilot test is not successful, the cycle is repeated. Once the actions have
been shown to be successful, they are made part of the standard operating
procedure
The effectiveness of the action will continue to be measured and assessed to
ensure that improvement is maintained
Report all activities to the governing body
Restudy
All actions implemented will be restudied within a specified period of time to evaluate
effectiveness.
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Study will be reopened as determined by committee
The quality management and improvement process will be a part of orientation
and annual training of employees
Reporting
All quality management and improvement activities will be reported to the governing body.
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The governing body will take appropriate action on the quality management and
improvement activities as necessary
Annual evaluation of the quality management and improvement program should occur to
determine the effectiveness of the program as part of the total surgery center appraisal. A
written report of this evaluation is submitted to the governing body. This report includes:
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Identified opportunities to improve care
Corrective actions taken to resolve issues identified and make improvements
Educational programs related to continuous quality management and improvement
activities
Program changes planned as a result of the annual evaluation (changes in scope,
organization, objectives, etc.).
Physician Quality Achievment and Improvement
As a part of a continued effort to monitor and modify physician behavior to achieve
compliance with best practices, as well as enhance quality and value, physicians’
performance will be formally assessed as follows:
1. All affiliated centers and hospital endoscopy units participate in GIQuIC which is a
national data repository and benchmarking program that tabulates procedural data for
colonoscopies.
2. Data on endorsed quality measures related to the safe, quality performance of all
procedures is continuously aggregated by center and by individual physician.
3. A quarterly quality achievement report (appendix A) will be generated for each
physician performing procedures at any CHP clinically integrated facility. The reports
measure each physician’s performance on procedural process measures as well as
satisfaction survey results and peer review compliance measures.
4. Physicians will be scored individually and will also be compared to national
benchmarks when available and internally by facility.
5. Physician quality achievement reports will be posted on the CHP endoscopy clinical
integration website where they will be available to multiple stakeholders including the
general public, patients, and physicians.
Physician Quality Outlier Protocol
Based on results extracted from a member's quarterly quality performance achievement report,
the following protocol should be followed for those physicians who are outliers in one or more
measures:
1. The physician should be informed by the medical director that the ongoing monitoring of
quality is intrinsic to clinical integration and the goal is to educate all physicians so they can
achieve compliance with all measures.
2. Non-compliant physicians must participate in one of the following three activities:
a. 2 hours of targeted CME activity pertinent to the areas of deficiency. CME can
beaccessed on the clinical integration website under the “Physician Education” subheading.
Sucessful documentation of completion of these activities must be received by the medical
director within 30 days of the request being made.
b.Proctoring - Physicians who are not in compliance with clinical or
documentation measures may request or be proctored at the discretion of the local
medical director. Two procedures over a 30 day period should be proctored by a
physician who is a non-economic competitor of the noncompliant physician (from
another ASC or affiliated hospital)
c. EHR Instruction- Some deficiencies in quality measure compliance may reflect
incomplete knowledge of how to correctly input data using the EMR. Web based training by
the vendor and/or instruction by senior nursing staff, unit "super users", or medical director
should be offered and documented.
d. A summary letter outlining the agreed upon plan should be signed by both the medical
director and the physician and inserted into the physicians credentialing file. This letter
should also include an agreement by the physician to complete the activities within 30 days
of request and to meet in 60 days with the medical director to review progress.
e. Failure to make progress 30 days after completion of the education plan will require an
additional cycle of the above activities and reassessment by the medical director.