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LUHS System-Wide Quality and Patient
Safety Goals
for
Fiscal Year 2007
Goal #1: Prioritize and coordinate
performance improvement across LUHS
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JCAHO ongoing readiness/annual self
evaluation
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Coordinate National Patient Safety
Goals and provide consultation as needed
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AHRQ Quality and
Safety Measures
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Team training
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UHC Benchmarking project
Goal #2:
Facilitate the adoption and creation of "best practice"
throughout LUHS
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National Hospital Quality
Measures: AMI, CHF, Pneumonia
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Surgical Care Improvement
Project
- Surgical Infection Prevention
- VTE
- Ventilator Associated Pneumonia
- Post MI
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Rapid response team
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Outpatient physician
focused QI measures
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Reduce central-line
associated bloodstream infections
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Inpatient Hyperglycemia
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DRG cost management
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Support service
line/departmental QI efforts
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Pain management
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Implement interpreter
services
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Revise patient grievance process
Goal #3: Implement state of the art quality
improvement tools throughout LUHS
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EPIC – inpatient physician and nursing
documentation tools
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Improve Safety Information to LUHS
Board
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HCAHPS Survey
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MIDAS
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Enhance quality improvement and pt
safety education
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Electronic adverse event reporting
system
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Improve RCA/FMEA capability
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Support
Service Excellence/Magis
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Continue to assist Provider Relations
with data to manage HMOI population more effectively
Goal #4: Communicate performance
improvement work within LUHS and externally
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External reporting of quality measures
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Internal reporting regarding patient
safety
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Annual Quality
and Patient Safety Fair
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Presentation /publication of QI
activity
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UHC, NQF, IHI
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Quality and You columns
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CCE
newsletter
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