VA244-17-R-1154-003.docx

QUALITY MANAGEMENT SYSTEM

VA Pittsburgh Healthcare System (VAPHS) utilizes a comprehensive structure which supports a culture of quality and patient safety.

II. POLICY

VA Pittsburgh Healthcare System is committed to providing quality health care to eligible Veterans through a Quality Management System that optimizes health care and patient safety processes and outcomes. The System supports VA core mission; recognizes current and emerging veteran needs; and is aligned with VHA strategic guidance, resource allocation, and associated VHA policy.

III. DEFINITIONS

1. Performance measures – patient outcome measures used to evaluate the provision of care for specific diagnoses and/or settings.

1. ORYX data – performance measures evaluated by The Joint Commission.

0. PDCA – performance improvement model used at VAPHS. The Plan-Do-Check-Act (PDCA) Cycle is a checklist of the four stages one must go through to get from “problem-faced” to problem solved.

1. Plan – Identify the Problem – select the problem to be analyzed; clearly define the problem and define a precise problem statement; set a measurable goal for the problem solving effort; and establish a process for coordinating with and gaining approval of leadership.

Analyze the Problem – identify the process that impact the problem and select one; list the steps in the process as it currently exists; identify the potential cause of the problem; collect and analyze data related to the problem.

2. Do – Develop Solutions – establish criteria for selecting a solution; generate potential solutions that will address the root causes of the problem; select a solution; plan the solution.

Implement a Solution – implement the chosen solution on a trial or pilot basis.

1. Data management and analyses – critical factor in any Quality Management Program. It includes, but is not limited to: gathering and critically analyzing data relevant to quality and patient safety, ensuring data is valid and reliable, comparing the data analysis results with established goals or internal or external benchmarks, identifying specific opportunities for improvement, and implementing and evaluating actions until problems are resolved or improvements are achieved.

0. Confidentiality – The requirements for a Quality Management document to be confidential are described in Title 38 United States Code (U.S.C.) Section 5705 and it’s implementing regulations; and Title 38 Code of Federal Regulations (CFR) Sections 17.501 (a), (b), (c), and (g); and is fully outlined in current VHA policy. Quality and patient safety data must be protected and used only as consistent with 38 U.S.C. 5705 and appropriate Department of Veterans Affairs (VA) policies and directives governing confidential data.

IV. PROCEDURE

0. The annual performance measures plan for VA Headquarters along with VISN specific measures represents the key driver in defining the priorities for Healthcare System improvements and will be coordinated with the Strategic Planning process with an emphasis on quality outcomes, improved efficiency and integration. Target performance is established at benchmark levels and is monitored on a regular basis.

1. Data analysis identifies trends, patterns and performance levels which suggest opportunities for improvement. Once a change has been made the change is monitored to make sure the desired improvement is achieved and sustained. When an improvement does not meet expectations, additional changes are made and/or the PDCA cycle starts over.

1. Interdisciplinary committees and continuous readiness teams are established around key medical center functions, Joint Commission accredited programs, performance measures, and other required review body activities.

b. Evaluate performance of the processes, included in the committee responsibility, to comparative databases of other healthcare entities, reference information, and community and/or national standards of practice. Processes selected for in-depth evaluation will be prioritized based on high volume, problem prone, high risk, and high impact on patient outcomes.

1. All Service Lines and/or Programs are encouraged to identify opportunities for improvement within their operations and are empowered to re-design or improve within their scope, utilizing the Plan-Do-Check-Act process. Extensive changes in policy or exceptional resource requirements will be brought to the appropriate board. The domains of cost, access, utilization, quality and satisfaction are to be considered in choosing improvement opportunity. Successful improvement efforts will be prepared in a concise and clear manner and posted for staff and visitors to view in the applicable work area. Bulletin boards for this purpose will be maintained in each patient care and administrative work area.

1. All Performance Improvement Activities which reflect medical center performance are reviewed by the Executive Leadership Board. These include but are not limited to:

1. An annual evaluation completed by the Quality Improvement staff will focus on achievements and accomplishments throughout the medical center within the key components of the Quality Management System which include but are not limited to: performance measures, resident supervision, occurrence screens, peer review, patient safety, internal and external reviews, internal and external customer satisfaction, controlled substance inspection program, and initiatives driven through the utilization of the data warehouse.

1. RESPONSIBILITIES

Medical Center Director is responsible for:

0. Ensuring that components of the quality management plan are integrated.

2. Monitoring the quality and safety of clinical nursing practice within the facility.

3. Contributing to effective quality management through clinical leadership.

4. Participating in medical center quality management activities.

5. Serving as a member of the Peer Review Committee.

1. Quality Management Director is responsible for:

0. Ensuring that components of the Quality Management System and Patient Safety Program are integrated.

0.

1. All employees are responsible for patient safety. Each is encouraged to participate in continuous quality improvement activities. This is accomplished through identifying areas for improvement, sustaining improvement, maintaining and supporting the organization’s mission, vision and strategic goals.

VI. REFERENCES

VHA Directive 2009-043 Quality Management System September 11, 2009 Current Joint Commission Standards Manual

VII. RESCISSIONS

Memorandum PI-003 dated March 22, 2010.

VIII. CONCURRENCES

11, 00S, 001, 002, 05, all Service Line VP’s, AFGE Local 2028 and AFGE Local 3344

IX. EXPIRATION

This memorandum will automatically expire February 21, 2016.

//Signed//

TERRY GERIGK WOLF, FACHE

Director and CEO