Mike Glenn, CEO Jefferson Healthcare Rural Safety What s new, how can Boards lead?
Jefferson Healthcare Who We Are A 25 bed, full service, fully accredited critical access hospital meeting the healthcare needs of 25,000 residents of East Jefferson County; Governed by a 5-member, publicly elected board of commissioners; The owner and operator of 8 primary care clinics and 4 specialty service clinics employing 40 primary and specialty care providers and contracting with 4 specialty care providers; The owner and operator of Jefferson Healthcare Home Health and Hospice Services; A charter affiliate in the Swedish Health Network; The largest employer in Jefferson County, employing 463 FTE s and generating over $48 million in annual payroll; and THE HEALTHCARE SYSTEM OF EAST JEFFERSON COUNTY
Why is Governance Important? Because you set the culture And culture drives behavior
JEFFERSON HEALTHCARE QUALITY MANAGEMENT SYSTEM
Executive Quality Council The Board of Commissioners has the ultimate oversight for Quality and Patient Safety Executive Quality Council consists of: Commissioners Chief Executive Officer Chief Medical Officer Chief Nursing Officer Chief Ancillary Officer Chief Financial Officer Executive Director of Patient Safety & Quality Additional support staff: IT Director, Infection Preventionist, Privacy Officer, Compliance Officer, Medical Staff, Facilities Director, Risk Manager, Patient Advocate
Our structure Executive Quality Council Environment of Care Committee Compliance Committee Medical Executive Committee Clinical Quality Committees Service Excellence Committee Performance Improvement Emergency Management Meaningful Use Peer Review Patient Safety PFAC Departmental PI Projects Infection Control Privacy Sub Sections: (OB, ER, Acute Care, Primary Care) Palliative Care Employee Engagement Access to Care Employee Safety Internal Audit Team Credentials Committee Transitions of Care Provider Engagement Security Utilization Review Quality Teams Quiet at Night Team Hazardous Materials Infection Control
Executive Quality Council Sample Agenda
It starts with a plan The Quality Management System is based on the goals outlined in the Jefferson Healthcare strategic plan Improve the patient experience Improve the care team experience Solidify our financial position Improve the health of our population
It starts with a plan Leadership reviews regular reports on each element of the strategic plan Data Review with Benchmarks Customer Inputs Audit results and corrective action Status of preventive and corrective actions Performance Improvement projects
Leadership commitment Jefferson Healthcare senior leadership demonstrates their commitment to quality by: Ensuring that departments, functions, teams and staff interact to deliver services which meet customer needs, and also provide continual improvement Establishing quality objectives and performance standards Clarification of departments, functions, teams, staff roles and responsibilities with linkages to interested parties Resource Management: provision of resources, human resources, training, education and competencies, infrastructure and work environment
Governance key factors for success Make Patient Safety and Quality Improvement your highest priority Highest v. High Know your numbers, particularly your big dot numbers Allocate necessary resources Look for high profile ways to reinforce your commitment
Key factors for success Make the EQC/your quality committee the most important and influential committee assignment in the organization. The Power Committee Frequent report outs at board meetings Make on the spot resource allocation decisions Invite and invest the CFO c-o-chaired by the CMO/CEO
Key factors for success Cultivate provider interest and enable provider participation Hospitalist CMO Outpatient Providers Compensate them if you must
Key factors for success Celebrate successes and perseverate over near misses Make a big deal out of successes. And a much bigger deal out of near misses. Do 1,000 things right and the local newspaper doesn t notice. Do 1 thing wrong
Key factors for success Things to consider: Seek accreditations Participate in culture of safety surveys Celebrate successes
And finally, Leaders are responsible for everything in an organization, especially what goes wrong. Paul O Neill
Here is what I think we should do. I think we should save 100,000 lives. And I think we should start by June 14, 2006 18 months from today. Some is not a number and soon is not a time. Here s the number: 100,000 Here s the time: June 14, 2006, 9:00 am Don Berwick
COMMENTS & QUESTIONS Mike Glenn, CEO