reorganizing the medical staff & meeting management improvement
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MEETING MANAGEMENT-
BEST PRACTICES
Reorganizing the Medical Staff & Meeting Management
Improvement
STRUCTURE IS THE BACKBONE OF SUSTAINABILITY
LEAN TENANTS AND PRINCIPALS Janet McClain, RN, MSN, CPHQ, CHC
Quality/Compliance Officer
West Park Hospital
707 Sheridan Ave.
Cody, WY 82414
(307) 578-2219
jmcclain1@wphcody.org
Cindy RohdeMedical Staff Coordinator
West Park Hospital
707 Sheridan Ave.
Cody, WY 82414
(307) 578-2219
Crohde@wphcody.org
OBJECTIVES: LEAN TENANTS/PRINCIPALS
Give examples of measureable
improvement goals
Evaluate the environment
according to the key principles of Lean
Describe the key concepts of performance improvement
WHAT IS LEAN?
“The endless transformation of waste into value from the customer’s perspective.”
It is a System Thinking Concept.
Adapted from James Womack, Juran Institute
KEY PRINCIPLES OF LEAN THINKING
Specify Value in the eyes of the customer.
Identify & eliminate anything that does not add customer value (eliminate waste)
Promote flow – eliminate batching and variation
Make Value flow without
interruptions.
Focus on processes that deliver customer value
All activities (within the Value Stream) are categorized as adding value or creating waste
Identify the Value Stream
for each product.
Let customers pull Value.
Pursue Perfection.
Guiding Principles for Achieving Results
LEAN THINKING
Key Principles
Focus on processes that deliver value
Identify & eliminate anything that does not add value (waste)
What Lean Is Not About…
Making people work harder
Short-cutting value-added processes
Cutting staff!
FLOW
In order to accurately capture the flow:
You must see the flows with your eyes today
You cannot rely on what you’ve heard or seen in the past
Penny Game
Institute for Healthcare Improvement
“Changing the people, or pushing them to “try harder” or “do better” will not result in improved performance.
If we want a new level of performance, we must get a new system.”
MUST TRY HARDER
LEAN HEALTHCARE:
Sustaining the Practice through Structure
OBJECTIVES: LEAN HEALTHCARE
Understand Sustainability and learn how to achieve it
Learn how to develop an effective, proven Quality Improvement Structure
Learn how to prioritize improvement opportunities in your organization
Learn how to integrate Lean with other existing Performance Improvement
methods
SUSTAINABILITY IN ACTION Set and share goals on a regular basis.
This means more than once. Keep them alive!
Communicate, communicate, and communicate! People need to constantly be reminded of goals and action
plans so that they sink in over time.
Review goals regularly. Share results. Enjoy accomplishments but use them to spur greater
progress. Review progress in order to stay on track.
Establish accountability that is truly accountable. A powerful action plan asks Who, What and When and
describes the desired outcome.
P&T / Med UtilizationBlood UtilizationMedical Record /
Clinical PertinenceInfection ControlCase ManagementResource
ManagementQIO IssuesRAC /MAC / MIC /
ZPIC
Life Safety / SafetyHazardous MaterialsEquipment / Utilities MgtSecurity / Emergency prepStaff / Visitor IncidentMedication ErrorsIncident Reports / Pt FallsProcedure VariancesAMA’sSentinel Events / FMEAPatient Safety P&P’s
Can only be appointed by Quality Improvement Committee
QIC will create multidisciplinary teams based on priority opportunities
Utilization Review /
Management
EOC / Safety Committee
Quality Improvement
Teams
Op
era
tion
al
Com
mit
tees
Ph
ysic
ian
C
om
mit
tees
Mortality Review / Autopsy
Invasive Procedure Peer Review
Radiology Peer Review
ER Peer ReviewSentinel EventsICD, P&P
Mortality Review / Autopsy
Operative & Invasive Procedure Review
Anesthesia Peer Review
Pathology Peer Review
Sentinel EventsTissue Review
General Medical Staff Committees:
Bylaws Credentialing
Medical Care Review
Surgical Care Review
Op
era
tion
al
Overs
igh
t
Quality Improvement Committee(hospital wide
committee)
Chief or Vice Chief of StaffCEO, CFO, CNOVP or Director of Quality2 other PhysiciansChairs of other committees
Board of Trustees
Medical Executive Committee
Ethics
Execu
tive
Lead
ers
hi
p
Overs
igh
t
QUALITY LEADERSHIP MODEL
Quality Improvement Committee
(hospital wide committee)
Op
era
tion
al
Overs
igh
t
Chief or Vice Chief of StaffCEO, CFO, CNOVP or Director of Quality2 other PhysiciansChairs of other committees
THE QUALITY LEADERSHIP MODEL UTILIZES THE BOARD OF TRUSTEES AND PHYSICIANS’ LEADERSHIP
QUALITY IMPROVEMENT COMMITTEE Membership should consist of:
Small hospitals – at least 2-3 physicians
Medium hospitals – 5-7 physicians
Large hospitals – 5-10 physicians
If Medical Staff will allow, the CEO, CFO, CNO, and Director of Quality should be voting members.
If voting membership is not allowed, they should attend all meetings
QUALITY IMPROVEMENT COMMITTEE Why CFO? If program functions as
designed, a lot of financial issues will have QI teams appointed or will be part of a QI team
Should meet monthly
There is no need for another hospital QI Committee. Joint Commission requires one hospital-wide committee that is responsible for medical staff and hospital quality issues. CMS and States are less specific as long as required functions are performed.
USE LEAN AS YOUR PERFORMANCE IMPROVEMENT METHODOLOGY
Use program to solve majority of problems identified, not just ones that someone feels should have a QI Team appointed.
QI Teams should not be established for any problem that has not been through problem referral, prioritization, and QIC appointment.
QIC FOCUSES ALL PERFORMANCE IMPROVEMENT WORK WITHIN THE HOSPITAL QIC is responsible for appointing all QI
Teams, appointing team leaders, identifying type of team members needed, and holding teams accountable for timely completion of required tasks.
All recommended actions must be submitted to QIC for approval and implementation
MEDICAL STAFF MEMBERSHIP ON THE QUALITY IMPROVEMENT COMMITTEE Some hospitals have included the
Chairpersons of standing committees on QIC to ensure good communication between the committees, but they should only be a part of the membership, not the entire committee, or due process rights could again be questioned.
All QI information must come through QIC before it goes to MEC – including all process issues during peer review. Having a separate peer review committee is unnecessary if this structure is utilized correctly.
MEDICAL STAFF MEMBERSHIP ON THE QUALITY IMPROVEMENT COMMITTEE If Medical Staff is departmentalized, QIC
physician membership should NOT be medical staff department chiefs because they sit on MEC.
Hospital should avoid MEC members serving on QIC if at all possible.
To assure due process is provided to LIPs and physicians, the same physicians should not be rendering decisions of appropriate quality at all levels. Use as many different physicians as possible.
P&T / Med UtilizationBlood UtilizationMedical Record /
Clinical PertinenceInfection ControlCase ManagementResource
ManagementQIO IssuesRAC /MAC / MIC /
ZPIC
Life Safety / SafetyHazardous MaterialsEquipment / Utilities MgtSecurity / Emergency prepStaff / Visitor IncidentMedication ErrorsIncident Reports / Pt FallsProcedure VariancesAMA’sSentinel Events / FMEAPatient Safety P&P’s
Can only be appointed by Quality Improvement Committee
QIC will create multidisciplinary teams based on priority opportunities
Utilization Review /
Management
EOC / Safety Committee
Quality Improvement
Teams
Op
era
tion
al
Com
mit
tees
Ph
ysic
ian
C
om
mit
tees
Mortality Review / Autopsy
Invasive Procedure Peer Review
Radiology Peer Review
ER Peer ReviewSentinel EventsICD, P&P
Mortality Review / Autopsy
Operative & Invasive Procedure Review
Anesthesia Peer Review
Pathology Peer Review
Sentinel EventsTissue Review
General Medical Staff Committees:
Bylaws Credentialing
Medical Care Review
Surgical Care Review
Op
era
tion
al
Overs
igh
t
Quality Improvement Committee(hospital wide
committee)
Chief or Vice Chief of StaffCEO, CFO, CNOVP or Director of Quality2 other PhysiciansChairs of other committees
Board of Trustees
Medical Executive Committee
Ethics
Execu
tive
Lead
ers
hi
p
Overs
igh
t
QUALITY LEADERSHIP MODEL
Based on our culture WPH chose
different models.
WPH COMMITTEE ORGANIZATIONAL CHART
EOC Committee
•Life Safety / Safety•Hazardous Materials•Equipment / Utilities Mgmt•Security•Emergency Prep•P&P’s
Accreditation Readiness Committee
•CMS / Joint Commission•LTCC•CMC / Behavioral Health•Home Health / Hospice•Lab
PI / Patient Safety Committee
•Operational Clinical Dept PI•Operational Non-Clinical Dept PI•RCA’s•Unusual Events•Medication Errors•Patient Falls•Safety Award Program
•Highlights of Minutes:•LTCC/Home Health/Hospice PI Cmt•Falls Cmt•EOC Cmt
Quality Improvement
Teams
• Can only be appointed by Quality Improvement Council
• QIC will create multidisciplinary teams based on priority opportunities
• LEAN Projects
Quality Improvement Council
BEFORE REORGANIZATION MSS RESPONSIBLE FOR…
56 Medical Staff members
16 Medical Staff Committee
Monthly General Staff Meetings
Averaged 2-3 meetings per week or 10-13 meetings per month depending on schedule
HOW WE DID THIS…. IT WASN’T EASY!
Lean Training w/ Management QI/MSS meets to begin process QI meets with Administration CEO/QI/MSS meets w/
Consultant QI/MSS meets w/CoS; V-CoS;
current QI or PIT Chair We propose changes to MEC Meet with all Committee Chairs
(This did not go well!!!)
QI/MSS meets w/ MEC (again) QI/MSS meets w/ all Committee
Chairs (again) w/ consultant QI proposes changes to Board
of Trustees
QI/MSS meets with MEC (3rd time is the charm!!!) to finalize
QI/MSS meets with Medical Staff for input
APPROVED BY MEC – YAHOO!!!! APPROVED BY Medical Staff – WAHOO!!! MEC begins assigning membership to
committees QI/MSS presents to Management Team
Implementation BEGINS!!!!!
AFTER REORGANIZATION (7/2014)WHAT WE DID…. Hired Trauma Coordinator / Moved Trauma
Committee out of MSS Combined Medicine & Psych/Detox Eliminated Infection Control Committee
(Functions moved into Surgery/Anesthesia & Medicine)
Blood Utilization reports moved to Surgery/ Anesthesia
Decreased # of General Medical Staff meetings
Bylaws Committee meets as needed Total 10 Committee’s
WPH Medical Staff Committee
Organization
WPH Board
Medical Executive Committee
Quality Improvement Council
Co-Chairs Vice COS & CEOCFO,CCO
Quality DirectorBoard Member
Medical Staff Committee ChairsSurgery/Anesthesia
MedicineOB/Peds
Emergency Medicine
Medical Staff Committees
Medicine (combines)Med/CCU
Psych/Detox(Infection Control becomes
agenda item)
Surgery/Anesthesia(combines) AnesthesiaSurg/Anes
(Infection Control & Blood Util will be agenda items)
OB/Pediatrics
Emergency Med
General Medical StaffMeets Every Other Month
Medical Staff Committees
BylawsCredentialing
EHRTrauma
UR/CM-Medical Records
P&T / Med Utilization
Med Staff Function
Credentialing
Quality Oversight
Each of 4 Medical Staff Committee Meetings:
Medical Staff PIMinutes
P&P’s
Executive Session:Peer Review
OTHER LEAN CONCEPTS ADOPTED BY MSS
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MEETING MANAGEMENTDo you know how much time you
spend in meeting preparation?
I thought I did…..boy was I wrong!
LEAN - Track every step and how much time it takes.
<See Meeting Tracking Tool>
BEFORE REORGANIZATION
Date Name of Meeting*Pre-Prep
Time*Meeting Day
Time*Post Meeting
F/U*Total Min Total Hours
Total Hrs per Week
March
3/18/14 General Medical Staff 38 233 94 365 6
3/20/14 EHR Committee 10 90 73 173 2.8 8.8
3/25/14 Credentials Committee 74 99 37 210 3.5
3/25/14 Psych/Detox 49 100 20 169 2.8
3/26/14 Anesthesia 35 167 58 260 4.3 10.6
April
4/8/2014 P & T Committee 17 121 49 187 3.1
4/11/2014 MEC 65 235 113 413 6.8 9.9
4/17/2014 EHR Committee 42 105 54 201 3.35
4/18/2014 Emergency Medicine 44 126 56 226 3.8 7.15
4/22/2014 Credentials 82 172 48 302 5
4/23/2014 Anesthesia Committee 42 90 52 184 3.65
4/23/2014 Surgery Committee 57 125 61 243 4.5 13.15
*Time measured in minutes
NEW PROCESSES IMPLEMENTED
$$ Spent in the Beginning
Saves You Time in the End
Purchased Color printer for MSS Projector 2nd Lap Top
Paper light process implemented Decreased copy time Only copy agenda’s,
pertinent documents
Meeting Management Consent agenda Adhere to Roberts
Rules of Order
Email Meeting Notifications and Attachments – 1 week prior
THANK
YOU!!
Click icon to add picture
Thank You!
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