Smullens, Stanton N.

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Jefferson Health System Quality Council

Jefferson Digital Commons

Health Policy Newsletter ____________________________________________________________ Volume 13 Number 3    September, 2000                   Article 3 ____________________________________________________________  Jefferson Health System Quality Council  Stanton N. Smullens, MD*  * Jefferson Health System  Copyright ©2000 by the author.  Health Policy Newsletter is a quarterly publication of TJU, JHS and the Office of Health Policy and Clinical Outcomes, 1015 Walnut Street, Suite 115, Philadelphia, PA 19107.  Suggested Citation:Smullens, SN.  Jefferson Health System Quality Council.  Health Policy Newsletter 2000; 13(3): Article 3.  Retrieved [date] from http://jdc.jefferson.edu/hpn/vol13/iss3/3.  Stanton N. Smullens:  JHS Quality Council Health Policy Newsletter Vol. 13, Number 3 (September 2000), Article 3 Jefferson Health System Quality Council __________________________________________  At its initial meeting on December 15, 1997, the Jefferson Health System (JHS) Quality Council discussed its mission to promote a quality agenda among the members of the JHS and to encourage them to maintain high standards of clinical quality and patient service. Additionally, it agreed its role was to coordinate educational efforts in these critical areas. This was and remains the core purpose of the Quality Council. In the two and half years of its existence, the Council has evolved into an active forum for interchange of information between the member organizations. Initially consisting of Thomas Jefferson University Hospital and the Main Line Health System, it expanded in 1998 to include representatives from the Albert Einstein Health Network, Frankford Health Care System and Magee Rehabilitation Hospital. The members are a cross section of the medical and nursing leadership of the JHS with input from the Dean’s office of the Jefferson Medical College. As envisioned by Douglas S. Peters, President and CEO of JHS, the Quality Council reports to the JHS Clinical Affairs and Quality Committee, chaired by Carter Buller, Esq. The Quality Council itself is chaired by Stanton N. Smullens, MD, Chief Medical Office of the JHS. The members of the Council include the Senior Vice Presidents of Medical Affairs of the member networks, medical directors of the quality committees of the member institutions, the medical directors of the risk networks, and heads of nursing. The Dean’s Office is rep resented by Thomas J. Nasca, MD, acting Dean, Jefferson Medical College; and David B. Nash, MD, Associate Dean and Director, Office of Health Policy and Clinical Outcomes.    The Council set as its initial agenda to inventory the quality programs of the member institutions and to develop a JHS Quality Performance Report. To assist in the development of the performance report, a permanent subcommittee of the Council was established consisting of the quality directors and coordinators of the member organizations. The subcommittee is lead by Barbara Turk, RN, MS, Director of Performance Improvement for the JHS.    During the first year the Council met quarterly and reviewed the member quality programs. It began to develop performance indicators for the Performance Report Card planned for release in January 1999. Using the JHS Mission Statement as the JHS definition of quality, categories of indicators were selected. These included clinical outcomes and processes in acute care, nursing care, long-term care and home health. Patient satisfaction indicators in similar areas were also selected. Additionally, efficient use of financial and other resources was examined, and indicators in support of the academic mission reviewed. The process was long and involved because of differing definitions of the same quality indicators, varied systems and approaches to collecting data, and differences in assuring data reliability.  The first Performance Report Card was released in January 1999, and 38 indicators were chosen. Although data are collected quarterly, the report is released semi-annually.  Reports were released in July 1999, January and July 2000.  The Council meetings are now held monthly.    During the same year, under the direction of the Quality Council, an educational program called “Train the Trainer” was developed by Dr. Nash and assisted by Jeffrey L. Lenow, MD, JD, Medical Director of JeffCARE. It was an interactive program exploring the meaning and implementation of evidence-based medicine.  Stanton N. Smullens:  JHS Quality Council Health Policy Newsletter Vol. 13, Number 3 (September 2000), Article 3 To improve exchange of information among the members and share performance improvement techniques, the Quality Council decided to select the same ORYX indicators for all the member institutions. This was begun in January 2000.  It was also decided that the Atlas MediQual System would be used as the intermediary to send the data to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Atlas was chosen since this system’s use is mandated by the state for other reporting and allows risk adjustment of the acute clinical indicators. This risk adjustment was reported in the Performance Report for July 2000. This will also allow the use of “control charts” for data presentation, a technique used by JCAHO.  A second JHS “Train the Trainer” educational program was held in the fall of 1999 and again was an interactive program presented by the Office of Health Policy and Dr. Lenow. The topic was a continuation of the use of evidenced-based medicine as it relates to performance measurement and profiling of individual physicians in their use of established evidenced-based guidelines.  The Council had targeted medication safety for further educational effort when the Institute of Medicine’s report was released to the public in November 1999. It became apparent that patient safety needed to be an integral part of the definition of quality care. An inventory of the safety programs and a separate nationally benchmarked inventory of current medication practices was carried out at member institutions in March 2000. This interest in patient safety led to a JHS sponsored conference on May 5, 2000 entitled Patient Safety Conference: Enhancing Patient Safety by Medical Simulation.Future directions for the Council will encourage sharing of performance improvement activities among the members in all areas of quality including patient safety. These activities will concentrate in performance improvement involving the Core Measures announced recently by JCAHO, particularly where they overlap with the Sixth Scope of Work Indicators released by the Health Care Financing Administration (HCFA[SCS1]). JHS is participating in a system-wide Keystone Peer Review Organization (KePRO) evaluation of these Medicare performance measures that will examine current practices. Work will continue in the area of patient safety and will explore common definitions and reporting procedures among the members. Future educational activities will include topics that relate to improving and measuring the quality of care in the JHS.  For more information contact Barbara Turk at 215-955-5176.  About the Author  Stanton N. Smullens, MD, is Chief Medical Officer of the Jefferson Health System.  

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Jefferson Health System Quality Council

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