UPMC ST. MARGARET & UPMC ST. MARGARET HARMAR OUTPATIENT CENTER

UPMC ST. MARGARET & UPMC ST. MARGARET HARMAR OUTPATIENT CENTER Perfrmance Imprvement Plan 2012

UPMC ST MARGARET UPMC ST. MARGARET HARMAR OUTPATIENT CENTER PERFORMANCE IMPROVEMENT PLAN 1. PURPOSE The purpse f this plan is t prvide a framewrk fr prmting perfrmance imprvement at UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center. Perfrmance Imprvement shall entail quality patient care and verall rganizatinal perfrmance and reductin f risks t ur patients. Thrugh the supprt and invlvement f the Bard f Directrs, Medical Staff, Administratin, and UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center persnnel, the culture will prmte an envirnment based n cllabratin and mutual respect, supprt innvatin, excellent data management, perfrmance imprvement, practive risk assessment, and cmmitment t custmer satisfactin and patient safety. The plan is crdinated t participate in the UPMC Health System strategic initiatives and is based n UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center s missin, values, and visin. 2. MISSION STATEMENT The missin f UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center is t prvide the right care, every time, ensuring the highest level f quality care and patient satisfactin. 4. VALUES UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center are guided by the fllwing values: Cmpassin UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center will uphld the highest standards f custmer service by prviding an envirnment that is kind, caring, cmpassinate, and patient centered. Academics UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center will attract the best qualified medical and supprt staff using a multi-disciplinary apprach t patient care in cllabratin with the University f Pittsburgh Medical Center, cmmunity resurces, and patients families, resulting in specialized medical care supprted by evidence based research and educatin. Respect UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center respect the diversity f all individuals regardless f race, religin, and cultural backgrund; we are cmmitted t prviding access t high quality and cst-effective care. Empathy UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center understand and respect the specific needs f each patient and family, which results in an individualized plan f care. Safety UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center prvide the highest quality care t ensure a safe envirnment fr each patient. We are leaders in quality care. We measure, reprt, and mnitr ur quality utcmes and revise prtcls and/r prcedures t imprve the safety and quality f the patients envirnment f care. 3. VISION STATEMENT Fr all patients t have The Ultimate Patient Experience. The key factrs t ur success will be: T develp effective partnerships and gvernance with physicians and thers, based n mutual trust and shared bjectives T invest in ur emplyees thrugh educatin, recgnitin, clear wrk expectatins and effective perfrmance evaluatin 2

T anticipate and respnd t the health care needs and expectatins f the patients in ur cmmunity T prduce bth traditinal and innvative health care services that are cst effective and measurable in utcme. T imprve financial strength thrugh effective resurce management and increased revenue pprtunities 5. DEFINITION OF QUALITY UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center believe that quality is prviding the right care, at the right time, the right way, every time. Quality is the desire f every persn at every level t d it perfectly the first time. It is patient-centered care withut errrs, defects and rewrk. 6. GOALS AND OBJECTIVES The fundamental gal f perfrmance imprvement at UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center is t cntinuusly imprve patient safety and the quality f all patient care and ther services. The Perfrmance Imprvement Prgram will be a systematic, rganizatin-wide prcess fr planning, designing, measuring, assessing, and imprving perfrmance and sustaining achieved imprvement t imprve patient utcmes and ensure patient safety. The apprach t imprving perfrmance, creating a supprtive and nurturing atmsphere and empwering participants will be fstered by the fllwing essential prcesses: Develping a planning mechanism incrprating baseline data frm external and internal surces and input frm rganizatin leaders that will result in perfrmance measurement, analysis, imprvement, and patient safety. Emphasizing design needs assciated with new and existing services, patient care delivery, wrk flws and supprt systems, which will minimize medical errr and increase satisfactin n the part f patient and their families, physicians and staff. Mnitring perfrmance by develping apprpriate measures and cmparing with internal and external benchmarks, thereby identifying trends in care. Analyzing current perfrmance by assessment f data cllected and identifying pprtunities fr imprvement. Fcusing n imprving perfrmance in all f its dimensins and sustaining imprved perfrmance. Prmting cmmunicatin, dialgue and infrmatinal exchange acrss the facility with regard t findings, analyses, cnclusins, recmmendatins, actins and evaluatins pertaining t perfrmance imprvement. Striving t establish cllabrative relatinships with diverse agencies, crpratins and fundatins fr the purpse f prmting the general health and welfare f the cmmunity served. Practively identifying imprvements in patient care prcesses t enhance patient safety. 7. STRATEGIC INITIATIVES Partner with the Bard, Medical Staff, Administrative Leadership t enhance and fster a culture which prmtes patient and emplyee safety, quality, and satisfactin. Imprve clinical, quality, and, safety perfrmance. Enhance cmputer applicatins/technlgy fr staff efficiency and patient safety. Imprve cmmunity health thrugh cmmunity based initiatives. Imprve and sustain prgram gals and bjectives related t P4P Initiatives and VBP. Imprve and sustain Patient Satisfactin scres/targets. Strive fr Magnet Redesignatin Enhance cmmunicatins thrughut the entire rganizatin prviding infrmatin t patients, families, physician, and staff n prgrams and services. Cntinuusly mnitr and implement prcess/prgrams t imprve patient thrughput Enhance clinical practice thrugh research and evidenced based practice. 3

8. ORGANIZATION FRAMEWORK Bard f Directrs The Bards f Directrs f UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center have the ultimate respnsibility fr perfrmance imprvement. T fulfill the cmmitment f perfrmance imprvement, the bards delegate the respnsibility fr develping, implementing, and maintaining perfrmance imprvement activities t administratin, management, medical staff and emplyees. The bards recgnize that perfrmance imprvement is a cntinuus prcess, and will prvide the necessary resurces t carry ut this philsphy. Thrugh the develpment f strategic initiatives, the bards prvide directin fr the rganizatin s imprvement activities. Membership n the Quality Patient Care Cmmittee and reprts frm the Cmmittee prvide the bards with a means f evaluating the rganizatin s effectiveness in imprving quality. Medical Staff Executive Cmmittee The Medical Staff Executive Cmmittee is chaired by the Past President f the Medical Staff, and is cmprised f the chair f each Medical Staff department, physician leaders and Hspital Administrative Staff. This bdy is respnsible fr the medical plicies f UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center, and makes recmmendatins t the Bards, as necessary. The Medical Staff Executive Cmmittee reviews data that impact quality and safety imprvement effrts frm the Quality Patient Care Cmmittee, Safety Cmmittee, Medical Staff Quality Review Cmmittee, the Critical Care Cmmittee, the Pharmacy and Therapeutics Cmmittee, the Infectin Cntrl Cmmittee, the Surgical Review Cmmittee and the Transfusin Cmmittee. Medical Staff Quality Review (MSQR), Critical Care, Pharmacy and Therapeutics (P&T), Infectin Cntrl Cmmittee, Surgical Review Cmmittee, and Transfusin Cmmittee These bdies are standing cmmittees f the Medical Staff. These cmmittees have representatin frm Medical Staff departments, Administratin and clinical departments, and are cncerned with issues, and reprts that impact quality and safety imprvement initiatives related t: Patient care prcesses Quality and apprpriateness and utcmes f care prvided by clinical areas and medical staff Quality Patient Care Cmmittee This is a multi-disciplinary cmmittee chaired by the Directr f Medical Services. It versees the quality imprvement activities f all departments. The cmmittee respnsibilities include the fllwing: T versee the implementatin f and t mnitr beneficial quality initiatives and quality measurements T assess the prvisin f patient care and prmtin f perfrmance imprvement T assess resurce needs fr cntinued quality f patient care and prgrammatic develpment T assure cmpliance with the standards f the Jint Cmmissin and ther regulatry agencies relevant t patient care T review reprts frm ther cmmittees charged with matters f quality f care and patient safety T review published quality reprts and ther natinal data as well as published literature frm lcal and natinal media, jurnals, etc. T prvide a frum fr the discussin f matters f Hspital plicy and practice, especially thse pertaining t patient care, and t prvide fr liaisn amng the Bard, the Medical Staff, and Administratin T keep the Bards f Directrs and the Membership infrmed as t prblems, changes r trends in the healthcare field that culd materially affect the quality f patient care services r peratins f the Hspital The Quality Patient Care Cmmittee shall meet at least quarterly. Minutes f each meeting will be recrded and prvided t the Cmmittee and the Bard. Management Management is respnsible fr nging perfrmance imprvement activities in their service areas as well as supprting system wide multidisciplinary teams. Many f these activities interface with varius departments, medical staff, and the cmmunity. It is critical that the managers fster an envirnment f cllabratin with 4

bth internal and external custmers. Rle f Emplyees The rle f the individual emplyee is critical t the success f a perfrmance imprvement initiative. Quality is everyne s respnsibility. All emplyees must believe that every prcess can be imprved and feel empwered t fix and prevent prblems, as well as cntribute t imprvement effrts. Any emplyee, medical staff member r vlunteer may make a suggestin fr a Perfrmance Imprvement Team. Patient Safety Cmmittee The Patient Safety Cmmittee includes departments and cmpnents f UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center. All areas participate in the prgram thugh the reprting f near misses and actual medical health care events. This cmmittee will recmmend the prcesses chsen fr practive risk assessments based n literature, errrs and near miss events, sentinel event alerts, and the natinal patient safety gals. This cmmittee als versees the prvisin f educatin t emplyees, cntractrs, and vlunteers abut the reprting and reducing f health care errrs. The Patient Safety Cmmittee will facilitate and versee the implementatin f the natinal patient safety gals at UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center. The Patient Safety Cmmittee reprts their actins and recmmendatins t the Quality Patient Care Cmmittee and t the Bard f Directrs. Perfrmance Imprvement Teams Teams are crss-functinal and multidisciplinary in nature. Teams will be priritized based n the strategic initiatives f the rganizatin, with regard t high risk, high vlume and urgency. Perfrmance Imprvement teams reprt their findings and recmmendatins t key stakehlders fr apprval. Perfrmance Imprvement teams establish specific, measurable gals fr identified initiatives. A facilitatr will be assigned when necessary. Framewrk fr Perfrmance Imprvement Activities All teams and imprvement effrts will utilize the FOCUS PDCA methdlgy fr their activities. All teams are educated in this prcess at the time f their kickff and all mangers have received frmalized training in using the FOCUS PDCA mdel. 9. SCOPE OF PERFORMANCE IMPROVEMENT ACTIVITIES The Perfrmance Imprvement Prgram includes the mnitring and evaluatin f the interdisciplinary activities f the medical staff, nursing staff, ancillary clinical staff and supprt services. Perfrmance Imprvement findings are used fr the evaluatin f prviders with clinical privileges (during reappintment, request fr new r additinal privileges and perfrmance evaluatin) and t evaluate the perfrmance f emplyees wh are nt subject t the Medical Staff credentialing prcess. Medical Staff The n-ging perfrmance imprvement prcess f the medical staff includes the services prvided by the fllwing departments: Anesthesilgy Emergency Medicine Family Practice and Pediatrics Medicine Orthpedic Surgery Pathlgy Radilgical and Diagnstic Imaging Surgery Hspital and Outpatient Services The perfrmance imprvement prcesses f Hspital/Outpatient services include all departments/prgram Lines and Prcess Imprvement Initiatives. Quality Cntrl Quality cntrl functins are carried ut in patient and nn-patient care departments where lack f cntrl measures wuld cause a negative impact n patient care (i.e. labratry calibratin instruments, radilgy 5

quality cntrl measurements) Peer Review Prcess Medical Staff activities specifically thse related t Bld Usage, Operative and Invasive prcedures, Mrtality, Unplanned Readmissin, Medicatin Usage, Sentinel Events, Timeliness and pertinence f clinical dcumentatin are mnitred and findings which suggest that issues relating t practitiner perfrmance might exist are subject t the peer review prcess. Peer review prcess is triggered by variatins in perfrmance seen during criteria based reviews cnducted n Medical Staff activities. The findings frm these reviews are then submitted fr further review by peers n relevant cmmittees, r departments and then cmmunicated t the physician fr his/her cmments and finally cmmunicated t the respnsible Medical Staff fficial fr deliberatin, adjustment f cncern levels and reslutin. T further facilitate the peer review prcess, this material is placed in the cnfidential files f the practitiner s that it is readily available t the Department Chairman fr final determinatins and cnsideratin at the time f reappintment. 10. CONFIDENTIALITY All activities set frth in this plan including any infrmatin cllected by any Medical Staff Cmmittee, Administrative Cmmittee r Hspital department in rder t evaluate the quality f patient care is cnsidered a part f the Hspital and Medical Staff Peer Review Prcess and thus, is private and cnfidential. This includes all minutes, reprts, wrksheets and ther recrds, which are t be maintained in physically secure areas. Such materials are t be held in strictest cnfidence and are t be carefully safeguarded against unauthrized disclsure. Cnfidentiality f patient and prvider will be maintained by assigning numbers t thse invlved in crrective/disciplinary actins invlving privileges f a member f the Medical Staff shall be in accrdance with the Medical Staff Bylaws and Bard Plicy n Medical Staff Appintment and Clinical Privileges. 11. IMPROVING ORGANIZATIONAL PERFORMANCE The FOCUS-PDCA methdlgy is the UPMC St. Margaret apprach t rganizatinal perfrmance imprvement. The mdel fr cntinuus imprvement, FOCUS-PDCA, was riginally defined by the Hspital Crpratin f America. It prvides a cmmn language fr interventinal strategies and an rderly sequence fr implementing the cycle f cntinuus imprvement. FOCUS Find a prcess t imprve Organize a team that knws the prcess Clarify current knwledge f the prcess Understand the causes f prcess variatin and impact n cmpatibility Select the change PDCA Plan D Check Act A. FOCUS 1. Find a prcess t imprve priritize based n custmers define the prblem state the aim 2. Organize a team that knw the prcess identify the team members with the fundamental knwledge f the prcess identify senir leaders t supprt the team and remve the barriers t success 6

assign rles and respnsibilities write a missin statement and identify the aims t accmplish knw custmers (expectatins/needs) 3. Clarify current knwledge f the prcess dcument the current prcess review the literature review the practice f thers identify ptential rt causes identify key quality findings t measure develp data retrieval tls measure key quality findings establish baseline data 4. Understand causes f prcess variatins and impact r cmparability measure the results stabilize the prcess identify and reduce the variatin eliminate inapprpriate variatin prepare t cmpare apples t apples 5. Select the change priritize pprtunities t imprve select the imprvement B. PDCA 1. Plan a change aimed at imprvement state the plan/interventin create evidence based recmmendatins frm literature, cnsensus r expertise 2. D implement the change n a small scale; pilt 3. Check check the results analyze the data fr prcess imprvement and custmer service lessns learned 4. Act revise and standardize the changes Incrprating Staff Recmmendatins Staff views and recmmendatins are sught thrugh staff surveys, staff meetings, and with leaders thrugh nminal grup studies. Multidisciplinary teams cnsisting f frnt line staff cnduct prcess imprvement activity. Brainstrming is used t clarify the current prcess and select the prcess(es) t imprve. The teams priritize the prcesses t imprve and develp the actin plan. Changes are made t the imprvement plan based upn the findings, grup discussin and suggestins frm the Perfrmance Imprvement Team. Educatin and Training T facilitate the develpment f peratinal expertise, cmmunicatin skills, knwledge and cmpetency related t Prcess Imprvement fundamentals and safety; educatin and training prgrams are made available and prvided in the frm f: 7

rientatin prgrams fr new staff perfrmance imprvement educatin prgrams and wrkshps fcus prgrams fr managers and leaders Imprving Upn Perfrmance Imprvement As a result f the assessment prcess assciated with the review f indicatr data, evaluatins can be made regarding current levels f perfrmance and whether specific imprvement pprtunities exist which shuld be designated as pririties. The type and cause f variatin are presented by using statistical tls and methd in the reprting frmat. Intense analysis f the data by drilling dwn t arrive at the rt cause f variatins is used t identify changes that need t be implemented. Perfrmance Imprvement Pririties Perfrmance imprvement pririties are determined annually. Pririty cnsideratin is given t: The visin, key strategic planning initiatives Key stakehlder feedback High vlume activities High risk activities r prcesses which place patients at risk if nt perfrmed well, if perfrmed when nt indicated r if nt perfrmed when indicated Prblem prne activities High cst activities Sentinel/near miss events r sentinel event alerts System initiatives High rganizatinal impact Critical steps in a least ne high-risk prcess will be measured and analyzed n an nging basis Patient Safety issues Natinal Patient Safety Gals Because UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center are sensitive t the ever changing needs f the rganizatin, pririties may be changed r re-priritized due t: Identified needs frm data cllectin and analysis Unanticipated adverse ccurrences affecting patients Changing regulatry requirements Significant needs f patients and/r staff Prcesses identified as errr prne r high risk regarding patient safety Criteria t institute a practive risk assessment (i.e., sentinel alerts, infrmatin in prfessinal jurnals) Changes in the envirnment f care Changes in the cmmunity Sustaining Imprvement Once perfrmance imprvement pririties are identified, apprpriate resurces and changes needed in a prcess are implemented either n a pilt basis r acrss the rganizatin. Perfrmance measures are then selected t determine the effectiveness f the change and whether the imprved results are sustained. 12. DESIGNING NEW AND MODIFIED PROCESSES/FUNCTIONS/SERVICES UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center design and mdify prcesses, functins, and services with quality and safety in mind. When designing r mdifying a new prcess the fllwing steps are taken: An expert within the rganizatin is assigned the respnsibility f develping the new prcess. Key individuals, wh will wn the prcess when it is cmpleted, are assigned t a design team led by the expert. The design team develps r mdifies the prcess utilizing infrmatin frm the fllwing cncepts: It is cnsistent with ur missin, visin, values, gals, bjectives and strategic plans 8

It meets the needs f individuals served, staff and thers It is clinically sund and current It is cnsistent with sund business practices It incrprates available infrmatin frm within the rganizatin and frm ther rganizatins abut ptential risks t patients, including the ccurrence f sentinel events, in rder t minimize risks t patients affected by the new r redesigned prcess, functin r service It includes analysis and/r pilt testing t determine whether the prpsed design/redesign is an imprvement It incrprates the results f perfrmance imprvement activities It incrprates the cnsideratin f patient safety issues Perfrmance expectatins are established, measured, and mnitred. These measures may be develped internally r may be selected frm an external system r surce. The measures are selected utilizing the fllwing criteria: They can identify the events it was intended t identify They have a dcumented numeratr and denminatr r descriptin f the ppulatin t which it is applicable They have defined data elements and allwable values They can detect changes in perfrmance ver time They allw fr cmparisn ver time within the rganizatin and between ther entities The data t be cllected is available Results can be reprted in a way this is useful t the rganizatin and ther interested stakehlders 13. PROACTIVE RISK ASSESSMENTS At least ne high-risk prcess will be selected fr risk assessment and hazard analysis. Selectin will in part be based n infrmatin published by The Jint Cmmissin that identifies the mst frequently ccurring types f sentinel event: The prcess is assessed t identify steps that may cause undesirable variatins, r failure mdes Fr each identified failure mde, the pssible effects, including the seriusness f the effects n the patient are identified Ptential risk pints in the prcess will be clsely analyzed including decisin pints and patient s mving frm ne level f care t anther thrugh the cntinuum f care Fr the effects n the patient that are determined t be critical, a rt cause analysis is cnducted t determine why the effect may ccur The prcess will then be redesigned t reduce the risk f these failure mdes ccurring r t prtect the patient frm the effects f the failure mdes The redesigned prcess will be tested and then implemented. Perfrmance measures will be develped t measure the effectiveness f the new prcess Strategies fr maintaining the effectiveness f the redesigned prcess ver time will be implemented Risk assessments are cnducted t practively evaluate the impact f buildings, grunds, equipment, ccupants, and internal physical systems n patient and public safety. Onging hazard surveillance runds including Safety Surveillance Runds, Security Runds, and departmental mnitring are cnducted t prvide a cmprehensive nging surveillance prgram. The Safety Officer and Envirnmental Safety Cmmittee review trends and incidents related t the Safety Management Plan. The Envirnmental Safety Cmmittee prvides guidance t all departments regarding safety issues. These trends and incidents are identified frm incident reprt frms, Safety Surveillance Runds, Security Runds, and department questins. 14. DATA COLLECTION UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center chse prcesses and utcmes t mnitr based n the missin and scpe f care and services prvided and ppulatins served. 9

Data that the rganizatins cnsider fr the purpse f mnitring perfrmance include, but is nt limited t, the fllwing: Natinal Database f Nursing Quality Indicatrs (NDNQI) Perfrmance measures related t accreditatin and ther requirements Risk management Utilizatin management Quality cntrl (i.e., Lab, Radilgy, etc.) Patient, family, and staff pinins, needs, perceptins f risks t patients, and suggestins fr imprving patient safety The effectiveness f pain management Staff willingness t reprt medical/health care errrs Outcmes f prcesses r services Autpsy results Perfrmance measures frm acceptable data bases Custmer demgraphics and diagnses Financial data Infectin cntrl surveillance and reprting Research data Perfrmance data identified within The Jint Cmmissin standards r identified by ther regulatry bdies Needs, expectatins and satisfactin f individuals and rganizatins served, including: Their specific needs and expectatins Their perceptins f hw well the rganizatin meets these needs and expectatins Hw the rganizatin can imprve Hw the rganizatin can imprve patient safety Measurement t determine the effectiveness f ur patient safety gals implementatin prgrams Organ Prcurement The rganizatins als cllect data t mnitr the perfrmance f prcesses that invlve risks r may result in a sentinel event. As apprpriate, perfrmance measures will be identified fr the fllwing prcesses: Medicatin Management Operative and ther prcedures, such as raditherapy, CT scans, MRI, that place patients at risk Use f bld and bld cmpnents Restraint use Care r services prvided t high-risk ppulatins Outcmes related t resuscitatin Staffing effectiveness In additin, the fllwing clinical and administrative data are aggregated and analyzed t supprt patient care and peratins: Pharmacy transactins as required by law and t cntrl and accunt fr all drugs Infrmatin abut hazards and safety practices used t identify safety management issues addressed by the rganizatin Recrds f radi-nuclides and radipharmaceuticals, including the radi-nuclide s identity, the date administered, and dispsal Recrds f required reprting t authrities Perfrmance measures f prcesses and utcmes Summaries f perfrmance imprvement actins and actins t reduce risks t patients 15. AGGREGATION AND ANALYSIS OF DATA UPMC St. Margaret and UPMC St. Margaret Harmar Outpatient Center believe that excellent data management and assessment are essential t an effective perfrmance imprvement initiative. All perfrmance imprvement teams and activities must be data driven and utcme based. The analysis prcess includes cmparing data within ur rganizatin, with ther cmparable rganizatins, with standards, and with best practices. Data are aggregated and analyzed within a time frame apprpriate t the prcess r area f study. Data will als be 10

analyzed t identify system changes that will help t imprve patient safety. Data are analyzed in many ways including: Using apprpriate perfrmance imprvement prblem slving tls Making internal cmparisns f its perfrmance f prcesses and utcmes ver time Cmparing perfrmance data abut its prcesses with infrmatin frm up-t-date surces Cmparing perfrmance data abut its prcesses and utcmes t ther hspitals and reference databases Intensive analysis is cmpleted fr: Levels f perfrmance, patterns r trends that vary significantly and undesirably frm what was expected Perfrmance varies significantly and undesirably frm the perfrmance f ther rganizatins Perfrmance varies significantly and undesirably frm recgnized standards When a sentinel event has ccurred When a variatin has ccurred in the perfrmance f prcesses that affect patient safety Hazardus cnditins which wuld place patients at risk When undesirable variatin ccurs, which may change pririties. The fllwing events will autmatically result in an intense analysis: Cnfirmed transfusin reactins Serius drug events Significant medicatin errrs and Majr discrepancies between pre and pst p diagnses Adverse events related t use f sedatin r anesthesia Staffing Effectiveness Issues Deaths assciated with Hspital Acquired Infectins A Sentinel event 16. PLAN APPROVAL Representatives f Administratin, the Medical Staff, and the Bards f Directrs have apprved this plan. Any amendments t this prgram may be made as needed and shall be apprved by these parties. UPMC ST. MARGARET and UPMC ST. MARGARET HARMAR OUTPATIENT CENTER PERFORMANCE IMPROVEMENT PLAN Apprved by the Quality Patient Care Cmmittee Date: Jhn T. Wisneski, Jr., M.D. Directr f Medical Services Apprved by Administratin Date: Teresa Petrick President & CEO 11

Apprved by UPMC St. Margaret Bard f Directrs Date: Neil Y. VanHrn Chairman Apprved by UPMC St. Margaret Harmar Outpatient Center Bard f Directrs Date: Neil Y. VanHrn Chairman 12