OO - Organizational Overview

OO25: A description of the infrastructure, the organizational committees, and decision-making bodies specifically designed to oversee the quality of patient care. (EP33)

Jersey CityMedicalCenter utilizes the Six Sigma approach to quality care. The objectives of this process are to eliminate defects and variation in the quality process. Six Sigma utilizes a set of quality management methods, including the use of statistics, and creates an infrastructure of people within the organization who have been trained as experts on these measures. There are a number of staff members that have been educated on this process at the MedicalCenter and have earned Black and Green belts.

The methodology used in the organization related to the Six Sigma process utilizes the acronym DMAIC which is defined as:

  • D efine the problem, the voice of the customer and project goals
  • M easure the aspects of the current process and collect all relevant data
  • A nalyze the data in order to verify cause-and-effect relationships
  • I mprove or optimize the current process
  • C ontrol the future state process to insure any deviations are corrected

This methodology is utilized on all of the quality projects at the MedicalCenter.

The Quality Management System was recently redesigned at Jersey CityMedicalCenter. The quality process integrates the six (6) Institute of Medicine (IOM) aims for improvement for healthcare. The aims are safe, effective, patient-centered, timely, efficient and equitable. The Senior Vice President of Quality and Safety, Brenda Hall RN, determined that there would be five (5) primary councils. The Councils were renamed and redesigned to coincide with the four (4) hospital pillars (Safety, Quality, Engagement, and Economic Health). The major councils are:

  • Quality Management Steering Council
  • Patient Safety and Clinical Quality Council
  • Engagement/Operational Process Council
  • Strategic Growth Council
  • Business Expense Council

A physician is assigned to Chair each council with senior management functioning as Co-Chairpersons. These councils are truly interdisciplinary and nursing is strongly represented on all levels of each council. Performance Improvement Specialists function as support staff to each council and collect and provide the necessary data. The Performance Improvement Specialists are: Rachele Dalalian and Bonnie Rosenzweig, who are both registered nurses.

Each council is assigned Key Performance Indicators (KPIs) which are designed specifically to measure the performance of a specific committee. The Patient Safety and Clinical Quality Council’s KPIs are as follows:

  • Medication Management
  • Emergency Medicine
  • Critical/Cardiac Care
  • Nursing Care Process (Magnet)
  • Infection Control
  • Core Measures
  • Patient Flow
  • Trauma/Surgery
  • Women/Children’s Health

Key Performance Indicators from the Key Business Expense Council are:

  • Supply Chain
  • Revenue Cycle

Key Performance Indicators from the Engagement/Operational Council are:

  • Work Force Management
  • Customer Focus (Patient, Employee and Physician)
  • Life Safety and Environment of Care
  • Information Management
  • Marketing Communication
  • Incident Reporting (Complaints Management)
  • Ambulatory Care
  • Rehabilitation (PT/OT/ST)
  • Behavioral Health

Key Performance Indicators for Strategic growth include:

  • Increase number of inpatient surgical procedures
  • Increase the number of Cardiac Catheterizations
  • Increase inpatient medical admissions
  • Increase physician referrals
  • Increase obstetric deliveries
  • Increase outpatient radiology volume
  • Increase Foundation support

Report Cards were developed for each council in order to measure progress. The Report Cards depict Goals, Strategies, Objectives and Tactics needed to achieve goals. The Report Cards further portray the person assigned to the measure, the date the measure is to be completed, the current baseline of the measure and the target to be reached. The

Report Cards are color-coded to enable a rapid assessment of progress made. Persons assigned to specific elements/measures are required to report on a monthly basis on progress/impediments to strides made. Action plans to achieve accomplishments are needed when sufficient progress is not being made.

The reporting structure for the Quality Management System incorporates the “feeding” in of information from the Six Sigma teams hospital-wide. There are currently fourteen (14) teams in place that are working on a variety of issues, for example Falls, Sepsis and Perinatal Safety for complete listing review (Appendix 0025-A). Each team reports into the pertinent quality council. The four (4) primary councils report up to the Quality Management Steering Council (QMSC) which receives feedback from the Medical Executive Committee. This Council receives updates of all ongoing process improvement activities, to include recommendations and follow-up, identification of any deficiencies in fulfilling functional standards and regulatory compliance and the provision of remediation plans where appropriate. This Council establishes a Performance Improvement framework and methodology. The Quality Management Steering Council reports into the Quality Assessment and Oversight Committee (QAOC) which reports directly to the Board of Trustees. The QAOC primarily oversees the Performance Improvement Plan implementation and monitors compliance with the plan. See below for reporting structure:

Reporting Structure

The Root Cause Analysis process is a part of the Quality Management System. This process evolves because of an issue which has occurred which may cause or have caused a harmful outcome. This process involves assembling a team of people either directly or indirectly related to the event, and each component of the event is investigated. A sequence of events or timeline is established in order to understand the relationship between contributory factors and root causes in the defined problem. The goal is to identify all the solutions to a problem and to prevent a recurrence at the lowest cost and in the simplest way. This process is spearheaded by the Senior Vice President of Quality and Safety and the Risk Manager. Issues/problems are frequently entered into RL-Solutions, an incident reporting system.

Jersey CityMedicalCenter proactively seeks to identify and reduce risks to the safety of our patients and staff. In doing so, the hospital has organized a multidisciplinary and cross-functional Adverse Event Team. This team serves to respond to and conduct an analysis of all adverse events and near misses. These are negative consequences of care that results in unintended injury or illness which may/may not have been preventable. In conducting an analysis of an event the team is able to draw conclusions about our performance of a process or outcome. The team consists of:

OO25-Table 1

Additional Nursing Staff and Physicians join the team twice a month to discuss and analyze performance that vary substantially from those expected or varies significantly and undesirably from recognized standards of practice. The team internally compares our performance over time (patterns/trends), compares our processes with similar processes in other organizations.

The performance under evaluation may or may not have contributed to an undesirable patient outcome, however, the Adverse Event Team seizes every opportunity to aggregate patient safety related data and information to improve patient safety, professional and organizational performance. Based on their findings, the team makes recommendations for patient safety risk reduction strategies and an action plan for minimizing the recurrence of the adverse event.