A Mid-Sized Acute Care Hospital
Hospital Quality Improvement Programs are designed with the intention of maintaining patient safety and continuously improving processes and outcomes. However, measurable improvement in processes and outcomes can be hard to demonstrate, especially in the Medical Staff Peer Review function. Hospitals often need external expertise in redesigning their programs to demonstrate results. This was the intention of a General Hospital in the Central Valley when they issued a Request for Proposals. They were looking for a partner to help them evaluate and redesign their overall quality improvement program, with emphasis on the Medical Staff Peer Review process, to foster improvement in quality of care.
The proposal submitted by Lumetra Healthcare Solutions was selected for this year-long project because of our long-standing history assisting California hospitals with quality initiatives and because of the demonstrated experience of our staff in clinical quality program design. This project was structured with the involvement of Medical Staff leaders who identified key areas for focused attention in their clinical departments, and with Directors in the departments of Nursing, Quality Management, and Medical Staff Services. Another key element of this work was to build information in the physicians’ credential files for Professional Practice Evaluation (PPE), important to the Joint Commission Accreditation Process.
Existing “best practices” in the Quality Improvement Program were identified and built upon, new systems for Peer Review were designed to encourage meaningful case discussion, and quality measures were prioritized to create alignment and focus. Lumetra Healthcare Solutions helped this organization streamline systems, make quality review activities meaningful, improve outcomes for the Centers for Medicare and Medicaid Services Core Measures of Quality, and position themselves for excellent Joint Commission performance evaluation.
