36A77620Q0079-0002001.pdf

JAMES A. HALEY VETERANS' HOSPITAL HOSPITAL POLICY

TAMPA, FLORIDA 33612 MEMORANDUM NO. 00-15

AUGUST 2018

ENTERPRISE FRAMEWORK FOR QUALITY, SAFETY, AND VALUE

1. PURPOSE: To establish a policy and procedures to design and implement the deployment of an enterprise-wide, integrated framework for the James A. Haley Veterans’ Hospital and Clinics (JAHVH). To become the most trusted choice for Veterans for high quality, safe, and reliable care. This policy applies system-wide to all organizational elements.

2. POLICY: It is the policy of the JAHVH that an enterprise-wide framework be established for each organizational level that integrates the functions of quality, safety, and high reliability to achieve value for Veterans; recognizes current emerging Veteran needs; is aligned with VHA strategic guidance and resource allocation; and is consistent with VA core values of Integrity, Commitment, Advocacy, Respect, and Excellence.

4. DELEGATION OF AUTHORITY AND RESPONSIBILITY:

a. The Hospital Director is responsible for:

(1) Ensuring that the functions of the Enterprise Framework for Quality, Safety, and Value are in compliance with VHA standards, regulations, and policies, and are integrated under an organizational structure that promotes the exchange and flow of quality information, and guards against organizational silos.

(2) Facilitating an environment in which staff act with integrity to achieve accountability while remaining mindful, proactively risk aware, with processes that are highly reliable, and predictable.

(3) Promote a just culture in which staff can experience the psychological safety necessary to bring issues forward.

(4) Designating an official of appropriate background and skill to provide leadership for an integrated team that ensures thorough and uniform discharge of the key functions of the Enterprise Framework for Quality, Safety and Value in alignment with policies and mandates. This designated official must report to the Hospital Director. This official must function as a liaison for needed collaboration with the Network counterpart.

Designated official is Chief of Quality Management.

(5) Ensuring adequate resources for planning and implementing the facility Enterprise Framework for Quality, Safety and Value.

JAMES A. HALEY VETERANS' HOSPITAL HPM NO. 00-15

TAMPA, FLORIDA 33612 AUGUST 2018

(6) Establishing a standing committee under an enterprise framework to review data, information, and risk intelligence and ensure that key quality, safety, and value functions are discussed and integrated on a regular basis. This committee is comprised of a multidisciplinary group working towards understanding the complex environment that results in adverse events, and loss of value and efficiency. This committee must develop prioritized recommendations to aid facility leadership. Medical facility leadership must charter improvement teams or initiate strategies to make changes to improve outcomes for Veterans. The JAHVH has designated the Quality, Safety Value Board (QSVB) as being this committee with the following functions:

(a) Meet at least quarterly, and as warranted.

(b) Be chaired by the Hospital Director.

(c) Ensure documents generated by the QSVB, including meeting minutes, are produced in the process of conducting systematic health care reviews for the purpose of improving the quality of health care, or the utilization of health care resources in VA health care facilities. Meeting minutes must record attendance and track issues to resolution.

(d) Ensure documents generated as a result of enterprise framework activity generally fall within the class of health care Quality Assurance (QA) review identified as “monitoring and evaluation reviews conducted by facility” in accordance with 38 CFR 17.501(a)(1) and must involve primarily service and program monitoring activity.

(e) Ensure the QA criteria is met, enterprise framework documents are protected as QA documents under 38 U.S.C. 5705, and its implementing regulations at 38 CFR 17.500-511.

(f) Ensure that if facility engages in any other type of QA review that is associated with enterprise framework activity, such as a focused review that requires designation as QA at the outset of the review, the facility needs to follow its standard practice in ensuring that the review is appropriately covered as QA.

(g) Ensure aggregated data collected for the Enterprise Framework for Quality, Safety, and Value functions are analyzed and reviewed at meetings of the QSVB.

b. The Chief of Quality Management is the position-designated official to provide leadership for an integrated team that ensures thorough, and uniform discharge of the key functions of the Enterprise Framework for Quality, Safety, and Value in alignment with policies and mandates. This designated official reports to the Hospital Director.

The Chief of Quality Management functions as the liaison for needed collaboration with the Network counterpart and will ensure the following:

(1) Ensure that components of the enterprise framework for quality, safety, and value and enterprise risk management program and patient safety improvement program are integrated.

(2) Ensure a systematic process is in place for monitoring the facility quality data.

(3) Serve as the quality consultant to the facility leadership, quality improvement teams, and employees.

(4) Serve on QSVB and workgroups where quality data and information are collected, reviewed, aggregated, analyzed, trended and acted upon.

(5) Have unrestricted access to data and information that are relevant to quality improvement, performance measurement, and all other topics associated with key quality management components, which are collected, consolidated, or analyzed at the facility level. Quality and patient safety data must be protected and used only as consistent with 38 U.S.C. 5705, and appropriate agency policies and directives governing confidential data.

c. The Patient Safety Manager (PSM) will:

(1) Ensure that components of the enterprise framework for quality, safety, and value and Patient Safety Improvement Program are integrated.

(2) Implement a coordinated patient safety improvement program at the facility level that is based on guidance and tools from the National Center for Patient Safety (NCPS), and which meets the needs and priorities identified by the Hospital Director. These include addressing important standards, requirements, and recommendations promulgated by The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), and other organizations working to improve patient safety.

(3) Work collaboratively with VISN Patient Safety Officers (PSOs), and those described in the VHA Handbook 1051.01.

d. The Chief of Staff (COS) will:

(1) Ensure that components of the enterprise framework for quality, safety, and value are integrated.

(2) Monitor the quality and safety of clinical medical practice within the facility.

(3) Contribute to effective enterprise quality, safety, and value through clinical leadership.

(4) Participate in facility enterprise quality, safety, and value activities.

(5) Ensure a data driven process for granting, and renewing clinical privileges based on appropriate initial and ongoing evaluations of training, competency, and performance is present at the facility.

(6) Chair the Peer Review Committee.

(7) Ensure medical staff participation on Peer Review activities.

e. The Associate Director for Patient Care Services (ADPCS) will:

(1) Ensure that components of the enterprise framework for quality, safety, and value are integrated.

(2) Monitor the quality and safety of clinical nursing practice and other patient care services within the facility.

(3) Contribute to effective enterprise quality, safety, and value through clinical leadership.

(4) Participate in facility quality, safety, and value activities.

(5) Serve as a member of the Peer Review Committee.

f. The Service Chiefs will:

(1) Integrate components of the quality, safety, and value framework to ensure that services under their supervision support quality care expectations and those applicable to accrediting body standards and VA policies.

(2) Promote effective quality, safety, and value activities by working collaboratively with medical center leadership, quality management staff, risk management, and patient safety staff, to ensure that services under their supervision support quality care expectations and those applicable to accrediting body standards and VA policies.

(3) Develop, in collaboration with the COS, ADPCS, and QM, the Service level collection, analysis, evaluation, trending and follow-up of quality, safety, and value activities. All of which must be approved by the Hospital Director.

(4) Ensure their subordinate staff participates in Patient Safety, Peer Review, and other Quality activities.

(5) Complete pertinent formal tracking using facility-tracking tools.

g. All Employees will:

(1) Report issues affecting the quality, and safety of health care provided to Veterans through the appropriate channels.

(2) In addition to reporting concerns to their supervisor, contact the Quality Manager, Risk Manager, or Patient Safety Manager with any concerns about the quality and safety of patient care.

(3) Contact the Joint Commission or the Office of the Inspector General without fear of reprisal for quality, or patient safety issues of concern at VHA Office of the Medical Inspector (1-800 634-4782), the VA Office of the Inspector General (OIG) (1-800-488- 4244), or The Joint Commission at (complaint@jointcommission.org or by fax to: 630- 792-5636).

h. The QSVB, which meets at least quarterly, will ensure information and key quality components are discussed and data reviewed at its meetings with appropriate documentation in meeting minutes. (See QSVB Committee Charter)

(1) The data collected for key quality management components must be trended, with aggregate data examined for direction and magnitude of change, and reviewed at this meeting.

(2) Use of comparison data and triggering thresholds is encouraged and must be noted on the minutes of the meeting.

i. The Clinical Executive Board (CEB) will:

(1) Ensure that components of the enterprise framework for quality safety and value are integrated.

(2) Oversee the quality and safety of care delivered by its members, who need to be actively involved in the collection, analysis, trending, evaluation, and follow-up of enterprise framework for quality safety and value activities.

(3) Participate in other facility quality, safety, and value activities.

(4) Ensure that a data driven process is in place for granting privileges.

3. DEFINITIONS:

a. Enterprise Risk Management (ERM): Risks are inherent in health care and cannot be totally eliminated. The Enterprise Framework for Quality, Safety, and Value will provide a comprehensive understanding of the factors underlying risk, and improve their management and control. ERM broadly examines multiple-risk categories and anticipates how the likelihood and potential impact of interrelated risks might have implications for the entire healthcare organization. ERM fundamentally recognizes that risks do not occur in isolation, but rather exist synergistically, and when managed proactively, can result in the strategic leveraging of positive opportunity and risk prevention. The goal of ERM is to prioritize and act in a deliberative and measured manner to address the greatest risks to the entire enterprise, whether those risks are regularly found within a medical facility, or had up until now never been considered.

Once the greatest risks are identified and prioritized, the medical facility needs to be able to develop an appropriate, integrated response, including prevention, mitigation, management, and financing the response.

b. Baldrige Framework for Excellence®: The Baldrige Framework for Excellence® is a roadmap to excellence and high reliability through implementation of interrelated concepts and values that serve as the foundation for integrating key business requirements within a results-oriented environment that continually creates a basis for action, feedback, and learning.

c. Quality Assurance Documents: Quality Assurance Documents are defined as documents or parts of documents produced by, or for, the Department of Veterans Affairs (VA) in the process of conducting systematic health care reviews for the purpose of improving the quality of health care and improving the utilization of health care resources, and which are protected by 38 U.S.C. and its implementing regulations.

d. High Reliability Organization (HRO): An HRO is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. The success of HROs is attributed to their determined efforts to act mindfully. Mindfulness is a psychological quality that involves bringing one’s complete attention to the present experience on a moment-to-moment basis. As an individual or as a team member, this means noticing an unexpected event in the making, and taking the needed steps to halt its development. If the event cannot be halted, it is contained. If the event cannot be contained, focus is shifted to resilience and restoration.

e. Just Culture: A just culture learns and improves by openly identifying and examining its own weaknesses. In such a culture, employees feel safe and emotionally comfortable in the work environment. Employees will be able, and expected, to perform at peak capacity. They must also be able to admit weakness, concern, or inability, and to seek assistance when the quality and safety of care may be threatened. Individuals feel as accountable for maintaining this environment as they do for delivering outstanding care. They know that they are accountable for their actions, but will not be blamed for system faults beyond their control. They accept accountability for developing and maintaining an environment that feels psychologically safe.

f. Learning Organization: A learning organization empowers individuals to continually exercise their ability to create desired results. It nurtures new and expansive patterns of thinking in which people are integrated and together continually learn to visualize systems as a “whole.” People in a learning organization are agents, able to act upon the structures and systems of which they are a part. Key tools critical to sustaining learning organizations are: systems thinking, personal mastery, mental models, building shared vision, and team learning.

g. Value: Value is the generation of both population health and increasing levels of patient satisfaction, health literacy, and engagement in seamless, efficient systems throughout a patient centered experience of coordinated care at the lowest per capita cost.

h. Enterprise Framework for Quality, Safety and Value: Enterprise Framework for Quality, Safety and Value require the following four elements for its functionality; they are:

(1) Sustainable Results and Breakthrough Innovations: The Enterprise Framework for Quality, Safety and Value serves as a critical driver to deliver sustainable results and breakthrough innovations for the VA health care system. The framework requires visible and accountable leadership that is clearly focused, and fully engaged in processes serving as the foundation for excellence.

(2) Leadership Responsibility: It is incumbent upon leadership to create and nurture an environment of transparency, and a just culture in which employees are mindful of inherent risks within their surroundings, and are empowered to bring concerns forth to leadership, confident that they will be addressed without fear of reprisal. Organizational leaders must ensure that the functions of the enterprise framework are integrated under an organizational structure that promotes unity of purpose in quality, safety, and value, and guards against organizational silos, while promoting integrated joint management of quality, safety, and value.

(3) Integration and Coordination: The enterprise framework provides a mechanism for integrating and coordinating interrelated activities to achieve optimal patient value. This framework unites the efforts of many experts and organizational functions to best serve Veterans. Unity of purpose toward achieving value needs to be reflected at VA Central Office, Veterans Integrated Service Network (VISN), and the facility level. Staff alignment and reporting structures at the VISN and facility level will be at the discretion of the respective directors.

(4) Key Functions: Organizational leaders must incorporate key functions in their activities to ensure successful implementation of the enterprise framework. The framework includes environmental scanning, strategic planning, and patient-centered design of delivery platforms, a focus on workforce development and learning, and efficient integrated operations. Measurement, analysis, and knowledge management are critical to risk awareness, performance gaps appraisal process improvement, and sustained quality in support of fact-based, knowledge-driven management of operational systems. Key functions include:

NOTE: This includes quality assurance, regulatory compliance, and quality control.

(a) Quality Management Systems and Internal Control

(b) Continuous improvement, redesign, systems engineering, and efficiency management

(c) Patient Safety

(d) Internal and External Reviews

(e) Patient Flow/Utilization Management

(f) Risk Management

NOTE: This includes peer review, tort claim processing, and institutional disclosure monitoring.

(g) Performance measurement and evaluation

(h) Veteran and family engagement, activation, satisfaction and transparency innovations

(i) Credentialing and Privileging

(j) Environment of Care Safety and Engineering

5. PROCEDURES:

a. JAHVH recognizes the imperative to create new models of care to meet the evolving expectations of today’s Veterans. JAHVH has set the goal of serving as the region’s leader in delivering high quality, safe, and reliable care, centered on the Veteran, while promoting population health throughout the coordinated care continuum.

b. JAHVH will foster a culture that acts with integrity to achieve accountability, a culture that is vigilant and mindful, proactively risk aware, highly reliable, predictable, and a culture that seeks to continuously improve. Such a culture allows staff to serve as positive change agents on behalf of Veterans, families, and co-workers.

c. JAHVH culture must employ recognized principles, practices, and behaviors of successful organizations to create an enterprise-wide framework focused on delivering high quality, safe and reliable care centered on the Veteran. High Reliability Organizations, Learning Organizations, Enterprise Risk Management concepts, and the Baldrige Framework for Excellence® represent industry-standard approaches that VHA can utilize to facilitate the implementation of an integrated enterprise-wide program of quality, safety, and value.

d. Lessons from health care and other industries demonstrate that the achievement of high-quality outcomes requires strategic alignment and both horizontal and vertical integration within the organization. Critical to optimal outcomes is an engaged leadership that supports high-functioning teams and ensures an atmosphere of trust in which stakeholders are encouraged and feel the psychological safety to bring their essential concerns to management. Effective leaders assess performance gaps, set priorities, make changes, create a transparent environment, and a just culture that encourages employees to be individually and collectively aware of their responsibilities to ensure successful outcomes.

e. In alignment with VHA, JAHVH is undergoing critical realignment to transform its services to Veterans, and drive implementation of its vision for healthcare excellence and patient-centric, value-driven care. The realignment connects and integrates quality, safety, systems redesign and engineering, risk management, compliance, and consultative functions to support an enterprise framework for high reliability, and a culture of safety, robust information systems, evidence-based practice, and continuous measurement and improvement.

f. Effective leaders in JAHVH must ensure that Veterans are provided with high-quality health care that is safe, effective, patient-centered, timely, efficient, and equitable.

Successful leadership is reflected in accountability structures, attention to early warning signals, and the flow of critical information within the organization. Leadership includes the identification, prioritization, and coordination of improvement, and re-engineering activities to promote value, safety, quality, and efficiency. VHA’s leaders must be visible at all levels throughout the organization.

g. Key components of the JAHVH enterprise framework for quality, safety, and value will include the following:

NOTE: This includes quality assurance, regulatory compliance, and quality control.

(1) Quality Management Systems and Internal Control

(2) Continuous performance improvement, redesign, systems engineering, and efficiency management

(3) Performance measurement and evaluation

(4) Patient safety improvement

(5) Internal and external reviews; including accrediting bodies

(6) Veteran and family engagement, activation, satisfaction and transparency innovations

(7) Internal and external customer perception, satisfaction, and loyalty

(8) Patient Flow which includes Utilization Management

(9) Risk management; including peer reviews and tort claim processing and institutional disclosure monitoring.

(10) Infection prevention and control

(11) Credentialing and privileging

(12) Electronic Health Record (EHR) review

(13) Environment of Care, Safety, and Engineering

h. Enterprise framework for quality, safety, and value will include the activities listed below:

(1) Setting quality management goals based upon population assessment and alignment with the strategic plan.

(2) Collecting, analyzing and trending, data to measure progress towards goals.

(3) Developing and monitoring action plans based upon the analysis.

(4) Communicating goals and engaging employees at all levels in action plans.

(5) Tracking action plans to completion.

i. All requirements for Quality Management documents to be confidential will be maintained as described in Title 38 United States Code (U.S.C.) Section 5705 and its implementing regulations; and Title 38 Code of Federal Regulations.

j. Quality and patient safety data must be protected and used only as consistent with 38 U.S.C. 5705 and appropriate agency policies and directives governing confidential data

6. REFERENCES:

a. VHA Directive 1026, “VHA Enterprise Framework for Quality, Safety, and Value”

b. Title 38 U.S.C. § 5705

c. Title 38 CFR 17.500-17.511, “Confidentiality of Healthcare Quality Assurance Review Records”

d. VHA Handbook 1050.1, “VHA National Patient Safety Improvement Handbook”

e. HPM 11-54, “Patient Safety Improvement/ Adverse Event Reporting”

7. FOLLOW-UP RESPONSIBILITY: The Chief, Quality Management Service (00QM) is responsible for updating this hospital policy memorandum.

8. RESCISSION: Hospital Policy Memorandum No. 11-109 Quality Management System, dated, October 2014.

//s// Joe D. Battle Director

DISTRIBUTION: Electronic Distribution to All Employees