Over the summer, Community General Hospital began working with FTI Consultants, a national firm, to assist with strategic planning to help us prepare for changes associated with health care reform. We have recently provided the results of FTI’s research to our Board of Directors and to the Medical Executive Committee. Our planning activity will continue this fall.
Among the options presented by our consultant is the development of a collaboration with another hospital, and Crouse Hospital has been identified as our leading potential partner.
Independent of our planning process, Crouse Hospital has worked with its own strategic planning consultant (a national firm called Sg2), and its planning has identified Community General as a potential partner. Consistent with these results, I have held preliminary discussions with Dr. Paul Kronenberg, President & CEO of Crouse Hospital, regarding the potential community benefits of working together.
The fact that Community and Crouse are talking again may seem surprising, given our past, unsuccessful relationship in the Health Alliance of CNY (1999-2002). However, the health care world is different today with new regulatory and financial pressures on hospitals and doctors, and there are important reasons for looking at ways we might work together, as well as important lessons to be learned from our past experience.
The progress each hospital has made since 2002 is noteworthy. For example, HealthGrades has awarded Community its five-star service designation for several years, while Crouse was named “Business of the Year” by the Greater Syracuse Chamber of Commerce and has been the recipient of a “Human Resources Excellence – Employer of Choice Award” from the Central New York Chapter of the Society for Human Resource Management. In addition, both Community and Crouse were named “Top 100” most improved hospitals by Thomson Reuters.
To date, our discussions have been exploratory, and both hospitals will continue with normal business operations. As discussions progress, recommendations will be developed for the Board of Directors, and we will involve physician and clinical leaders.
Community General's physicians, employees, and volunteers are dedicated to advance health care in Central New York that is high quality, safe, compassionate, and cost effective. That has not, and will not, change.
Showing posts with label Thomson 100 Top Hospitals Performance Improvement Leader. Show all posts
Showing posts with label Thomson 100 Top Hospitals Performance Improvement Leader. Show all posts
Thursday, October 22, 2009
Friday, September 28, 2007
Our survey by the Joint Commission
Yesterday the Joint Commission re-accredited Community General Hospital for a full three-year term.
The preliminary award of accreditation was announced at the summation conference for senior management, following a three-day unannounced site visit that involved four surveyors. The re-accreditation is subject to review and finalization by the Joint Commission over the next week.
The review was detailed, and the surveyors identified a number of areas for CGH to make improvements – some of these are requirements for improvement (RFIs) for which we have 45 days to make changes that are acceptable to the Joint Commission. Other changes, called supplemental recommendations, are intended to improve CGH performance even further.
CGH received nine RFIs. Improvements are required in the provision of care, namely better documentation involving pain management and conscious sedation. We need to do better in two national patient safety goals: better medication labeling in the operating room and better measurement of the time frames involving critical test value reporting. Other RFIs involve a change in the Medical Staff’s policy on awarding temporary privileges to physicians in emergency situations and improvement in the signing of verbal orders by physicians. The remaining requirements involve the routine testing of the emergency generator and repairs and safety improvements in the physical plant.
We take the Joint Commission’s RFIs seriously, as we do the supplemental recommendations. We have already begun to make the changes needed.
The surveyors followed a “tracer” methodology. They identified patients at random, reviewed their charts, and traced the progress of their care. They interviewed the patients, spoke with their caregivers, and examined documentation and policies specific to the individual patient and the caregivers. The surveyors visited many areas of the hospital, including off-site departments. Noteworthy were comments they made about CGH employees: “bright,” “very knowledgeable,” “willing to listen,” and “not afraid to explain.” They also challenged us to be more consistent in our processes with comments such as “mandatory,” “not acceptable,” and “inconsistent” to describe areas where we need to improve.
I sincerely appreciate the attention and respect afforded the surveyors by the CGH family, but most of all I thank employees and managers for the preparation, competence, and professionalism they bring to patient care every day.
The surveyors noted with interest our preparations for computerized physician order entry (CPOE), which will be rolled out at CGH next year. They said the introduction of CPOE, electronic medical records and other information technology in the coming years should help improve our processes, further lower the risk of error, and avoid some of the documentation issues that were encountered.
I thank members of the Board of Directors and Medical Staff who participated in the Joint Commission leadership conference: Steve Infanti and Chet Amond, current and past Board chairs; as well as Drs. David Halleran, Thomas Hartzheim, Andrew Merritt, and Howard Weinstein, representing Medical Staff leadership. I appreciate the assistance of Mary Kinneman, interim Chief Nursing Officer, who helped the Nursing Division and the management team improve standards compliance and survey readiness. Dr. Fred Goldberg, new in his role as Chief Medical Officer, was helpful in this survey. Thanks also to Brendan McGrath, interim Vice President – Operations.
I especially acknowledge the staff of the Quality Department, which helps the entire hospital monitor and maintain compliance with our policies and with the Joint Commission standards, particularly Sally Ramsden, Director of Quality and Education, and Wendy Tarby, Director of Performance Improvement.
Last month CGH was honored as one of the Thomson Top 100 Performance Improvement Leaders among the nation’s hospitals. This demonstrated our progress in recent years in reducing mortality, improving patient safety, improving length of stay performance, as well as other measures. Maintaining Joint Commission accreditation is further evidence that Community General Hospital provides quality and safe care for our patients – and that we are committed to making ongoing improvements.
Thank you all, and congratulations.
The preliminary award of accreditation was announced at the summation conference for senior management, following a three-day unannounced site visit that involved four surveyors. The re-accreditation is subject to review and finalization by the Joint Commission over the next week.
The review was detailed, and the surveyors identified a number of areas for CGH to make improvements – some of these are requirements for improvement (RFIs) for which we have 45 days to make changes that are acceptable to the Joint Commission. Other changes, called supplemental recommendations, are intended to improve CGH performance even further.
CGH received nine RFIs. Improvements are required in the provision of care, namely better documentation involving pain management and conscious sedation. We need to do better in two national patient safety goals: better medication labeling in the operating room and better measurement of the time frames involving critical test value reporting. Other RFIs involve a change in the Medical Staff’s policy on awarding temporary privileges to physicians in emergency situations and improvement in the signing of verbal orders by physicians. The remaining requirements involve the routine testing of the emergency generator and repairs and safety improvements in the physical plant.
We take the Joint Commission’s RFIs seriously, as we do the supplemental recommendations. We have already begun to make the changes needed.
The surveyors followed a “tracer” methodology. They identified patients at random, reviewed their charts, and traced the progress of their care. They interviewed the patients, spoke with their caregivers, and examined documentation and policies specific to the individual patient and the caregivers. The surveyors visited many areas of the hospital, including off-site departments. Noteworthy were comments they made about CGH employees: “bright,” “very knowledgeable,” “willing to listen,” and “not afraid to explain.” They also challenged us to be more consistent in our processes with comments such as “mandatory,” “not acceptable,” and “inconsistent” to describe areas where we need to improve.
I sincerely appreciate the attention and respect afforded the surveyors by the CGH family, but most of all I thank employees and managers for the preparation, competence, and professionalism they bring to patient care every day.
The surveyors noted with interest our preparations for computerized physician order entry (CPOE), which will be rolled out at CGH next year. They said the introduction of CPOE, electronic medical records and other information technology in the coming years should help improve our processes, further lower the risk of error, and avoid some of the documentation issues that were encountered.
I thank members of the Board of Directors and Medical Staff who participated in the Joint Commission leadership conference: Steve Infanti and Chet Amond, current and past Board chairs; as well as Drs. David Halleran, Thomas Hartzheim, Andrew Merritt, and Howard Weinstein, representing Medical Staff leadership. I appreciate the assistance of Mary Kinneman, interim Chief Nursing Officer, who helped the Nursing Division and the management team improve standards compliance and survey readiness. Dr. Fred Goldberg, new in his role as Chief Medical Officer, was helpful in this survey. Thanks also to Brendan McGrath, interim Vice President – Operations.
I especially acknowledge the staff of the Quality Department, which helps the entire hospital monitor and maintain compliance with our policies and with the Joint Commission standards, particularly Sally Ramsden, Director of Quality and Education, and Wendy Tarby, Director of Performance Improvement.
Last month CGH was honored as one of the Thomson Top 100 Performance Improvement Leaders among the nation’s hospitals. This demonstrated our progress in recent years in reducing mortality, improving patient safety, improving length of stay performance, as well as other measures. Maintaining Joint Commission accreditation is further evidence that Community General Hospital provides quality and safe care for our patients – and that we are committed to making ongoing improvements.
Thank you all, and congratulations.
Saturday, August 11, 2007
Of quality & board oversight
I recently made a presentation to the hospital’s quality committee that displayed 293 quality and safety measures tracked by Community General Hospital. It was a confusing, hard-to-understand picture of the ongoing surveillance we perform.
A few months ago I sat at a table with hospital CEOs from across the state as we struggled to get our arms around the number of quality measures each of us tracks. How, we asked ourselves, can we use such data more effectively to improve performance at our hospitals?
“We are at our limit in making sense of so many indicators,” said one CEO. Another observed, “We can’t go in a thousand directions. We have to focus on a limited set of meaningful measures.” “We’re struggling too,” added a third.
What is included in our 293 data measures? Data we report to the federal and state governments about heart disease, pneumonia, and infection control. Data we examine internally, including medication problems, falls, and near-misses. Measures we report to insurers in compliance with pay-for-performance contracts. And measures reported about us by outside organizations, such as HealthGrades®, the Niagara Health Quality Coalition, or Thomson Healthcare (formerly Solucient).
A recent article in the Journal of Patient Safety the performance of some 200 hospitals and concluded that “better quality outcomes were associated with hospitals at which the board spends more than 25% of their time on quality issues.” The Institute for Healthcare Improvement (IHI) recently recommended that “[b]oards in all hospitals…[should] spend at least 25% of their meeting time on quality and safety issues.”
A few years back, Community General’s board agenda was rearranged so that reports on quality come before reports on finances. But how much time does the board actually devote to quality issues? I reviewed last year’s board minutes and estimated the time spent on quality issues was about 30%. That was higher than I had thought. But does it mean we are working on the right things? Are we doing enough? I asked such questions of members of the board’s quality committee – and they think we can improve.
Serving on a hospital board is quite a responsibility. As a director, you have the overall responsibility for hospital performance. Section 405.2 of the New York State hospital code holds the governing body responsible for quality performance and for process improvement. The board exercises its responsibility, of course, by hiring management, by assuring proper policies are in place, and by overseeing the hospital’s performance.
In New York, most hospital boards are composed of volunteer representatives who devote their time (and often donate money too) to assure their community has excellent hospital care and services. What education and information do they need to provide quality oversight?
Chaired by board member Dr. David Tyler, the quality committee has held two meetings on this subject, and it will make recommendations to the full board later this year. Management is working with the committee in developing its recommendations. As part of the process, some members of VHA Empire State[1] generously shared with us their own board-level quality reports, and we have learned from them. We will probably borrow ideas from some of these boards, but our work is very much organization-specific. Where should Community General focus its attention in order to make more progress in areas that will best serve patients?
This week Community General was honored for having “one of the fastest and most consistent rates of improvement in the nation” by Thomson Healthcare. It’s reassuring that our improvement has been better-than-average in recent years as we set the stage for the next series of safety and quality initiatives.
[1] Community General Hospital is a member of VHA Empire State is part of VHA, Inc., a health care provider alliance of more than 2,400 not-for-profit health care organizations.
A few months ago I sat at a table with hospital CEOs from across the state as we struggled to get our arms around the number of quality measures each of us tracks. How, we asked ourselves, can we use such data more effectively to improve performance at our hospitals?
“We are at our limit in making sense of so many indicators,” said one CEO. Another observed, “We can’t go in a thousand directions. We have to focus on a limited set of meaningful measures.” “We’re struggling too,” added a third.
What is included in our 293 data measures? Data we report to the federal and state governments about heart disease, pneumonia, and infection control. Data we examine internally, including medication problems, falls, and near-misses. Measures we report to insurers in compliance with pay-for-performance contracts. And measures reported about us by outside organizations, such as HealthGrades®, the Niagara Health Quality Coalition, or Thomson Healthcare (formerly Solucient).
A recent article in the Journal of Patient Safety the performance of some 200 hospitals and concluded that “better quality outcomes were associated with hospitals at which the board spends more than 25% of their time on quality issues.” The Institute for Healthcare Improvement (IHI) recently recommended that “[b]oards in all hospitals…[should] spend at least 25% of their meeting time on quality and safety issues.”
A few years back, Community General’s board agenda was rearranged so that reports on quality come before reports on finances. But how much time does the board actually devote to quality issues? I reviewed last year’s board minutes and estimated the time spent on quality issues was about 30%. That was higher than I had thought. But does it mean we are working on the right things? Are we doing enough? I asked such questions of members of the board’s quality committee – and they think we can improve.
Serving on a hospital board is quite a responsibility. As a director, you have the overall responsibility for hospital performance. Section 405.2 of the New York State hospital code holds the governing body responsible for quality performance and for process improvement. The board exercises its responsibility, of course, by hiring management, by assuring proper policies are in place, and by overseeing the hospital’s performance.
In New York, most hospital boards are composed of volunteer representatives who devote their time (and often donate money too) to assure their community has excellent hospital care and services. What education and information do they need to provide quality oversight?
Chaired by board member Dr. David Tyler, the quality committee has held two meetings on this subject, and it will make recommendations to the full board later this year. Management is working with the committee in developing its recommendations. As part of the process, some members of VHA Empire State[1] generously shared with us their own board-level quality reports, and we have learned from them. We will probably borrow ideas from some of these boards, but our work is very much organization-specific. Where should Community General focus its attention in order to make more progress in areas that will best serve patients?
This week Community General was honored for having “one of the fastest and most consistent rates of improvement in the nation” by Thomson Healthcare. It’s reassuring that our improvement has been better-than-average in recent years as we set the stage for the next series of safety and quality initiatives.
[1] Community General Hospital is a member of VHA Empire State is part of VHA, Inc., a health care provider alliance of more than 2,400 not-for-profit health care organizations.
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