II.

JOHNS HOPKINS BAYVIEW MEDICAL CENTER

PERFORMANCE IMPROVEMENT PLAN
Fiscal Year 2015

Introduction

The primary purpose of the organization-wide Performance Improvement

Program at Johns Hopkins Bayview Medical Center (JI-IBMC) is to ensure the
provision of quality patient care by competent individuals in a safe and caring
environment. This responsibility is met through a process of ongoing review of
the care and services provided so that opportunities for improvement can be
easily
identified and appropriate actions aimed at such improvement can be
implemented.

In order to fulfill the Medical Center’s responsibility for providing quality

care
and service in a safe environment, the Johns Hopkins Bayview Medical Center
Board of Trustees, its Medical Staff and Administrative Leaders commit
themselves to the adoption and implementation of the Performance Improvement
Program outlined in this plan.

Mission, Vision, and Values

The leaders of J HBMC shall be responsible for the development of a statement

outlining the Mission, Vision, and Values of the organization. These statements
are communicated to the staff and physicians of the Medical Center at
orientation
programs, through organization—Wide publications and documents, and through
departmental and organizational meetings.

The Performance Improvement Program of Johns Hopkins Bayview Medical

Center receives its direction from the Mission, Vision, and Values.

Our Mission:

Johns Hopkins Bayview Medical Center, a member of Johns Hopkins Medicine,

provides cornpassionate health care that is focused on the uniqueness and
dignity
of each person we serve. We offer this care in an environment that promotes,
embraces, and honors the diversity of our global community. With a rich and
long tradition of medical care, education and research, we are dedicated to
providing and advancing medicine that is respectful and nurturing of the lives
of
those we touch.

Our vision:
The Johns Hopkins Bayview Medical Center will be widely recognized for
innovation and excellence in clinical care, education and research in medicine.

\nIII.

IV.

As a leading academic medical center, we will provide an enriching environment

for our employees and an exceptional healthcare experience for our patients and
their families.

Our core values include:

0 Excellence and Discovery

0 Leadership and Integrity
0 Diversity and Inclusidn

0 Respect and Collegiality

Program Goals and Objectives

The goal of Johns Hopkins Bayview Medical Center’s Performance Improvement

Program is to provide an integrated, collaborative, interdisciplinary approach
to
measuring, assessing, and improving the performance in key measures Within the
organization.

To meet this goal, the Performance Improvement Program will:

- Define an organization—wide model for Performance Improvement.

0 Develop a system for monitoring the quality, the safety and the
appropriateness of care provided to both inpatients and outpatients.

- Identify key performance measures that will be utilized in the review of

medical, clinical and support departments throughout the organization.

0 Establish a format for reviewing the results of monitoring activity for the
purpose of identifying opportunities for improvement.

0 Ensure that appropriate plans of corrective action are developed and

implemented when opportunities for improvement in care and] or service are
identified.

0 Oversee the effectiveness of the plans of corrective action in resolving

identified issues. - '

I Forward clinician specific performance reports to the appropriate

credentialing body for review and consideration at the time of recredentiaiing
and appointment.

- EnstIre that evaluation activities are included in the design of new or the
revision of Current processes.

Performance Improvement Responsibilities

A. Board of Trustees
The Board of Trustees of Johns Hopkins Bayview Medical Center is
responsible for:
1- Ensuring the provision of optimal quality of care by competent staff in
a safe environment.

\npractitioner specific findings shall be considered as part of the re-

credentialing process for medical staff privileges.

invasive and Non-invasive Procedure Review

The plan for procedure review focuses on those elements of clinical care
which have the potential to place the patient at risk. Invasive and many
non-invasive procedures which are part of the diagnostic and treatment
plans are considered for review.

The following aspects of the procedure are monitored as part of this

process:

Indications for the procedure

Preparation of the patient

Performance of the procedure

Post procedure care

Patient education/preparation of the patient for discharge

Complications

Discharge disposition/outcomes

A listing of procedures which will be included in the review shall be

developed and approved by the Clinical Practice Committee on an annual
basis.

W
The primary function of the Transfusion Review process is to monitor
compliance to the standards of practice that have been developed related
to the ordering, distribution, handling, dispensing, and administration of
blood and blood components at Johns Hopkins Bayview Medical Center.
During the coming year, data for the following indicators Wili be
collected, analyzed, reviewed, and reported twice a year to the Clinical
Practice Committee:

I Appropriateness of the transfiision based on pro-«established

indications for the transfusion of:

— Packed red blood cells

— Platelets
— Fresh Frozen Plasma
— Cryoprecipitate

0 Review of ordering practices, including

— Crossrnatch—Transfirsion Ratio
— Blood wastage

0 Review of all transfusion reactions, both hemolytic and non~he1nolytic

- Documentation of the transfusion to include:

— Patient identification procedures

— Patient preparation
— Monitoring of the patient during the transfusion

11

\nG.

— Effects of therapy

Drug Use Review

The Pharmacy and Therapeutics Committee of Johns Hopkins Bayview

Medical Center is responsible for evaluation of drug utilization. On an

annual basis, the committee shall select those drug classes for which a
review is warranted. Selection of the drug classes shall be based upon
criteria, including drugs which are high risk, high cost, high volume, and
problem prene.

The focus of the review shall include:

o Appropriateness of prescribing
o Dispensing
I Administration
0 Monitoring effects of the medication

The Pharmacy and Therapeutics Committee shall also collect and report
data on the following measures:

0 Significant adverse drug reactions

0 Look~alike, sound alike medications

Reports shall be forwarded to the Clinical Practice Committee of the

medical staff on a scheduled basis.

Cardiopulmonary Arrest] Code Review

A multidisciplinary Code Review Committee is responsible for reviewing

all cases Where CPR was initiated outside of an ICU and for taking actions
aimed at improving both resuscitation processes.

The review includes the following measures:

I Response time for code team members

0 Use of ACLS protocols

- Availability of supplies and equipment

- Outcomes

Time from arrest to intubation is less than 5 minutes

The Code Review Committee reports its findings to the Clinical Practice
Committee on a scheduled basis.

Tissue. Review

The Pathology Department is responsible for monitoring any discrepancy

between the preoperative diagnosis and the postoperative diagnosis based
on pathology specimen findings. When patterns or trends are identified,
appropriate actions are taken to address these trends. The Committee
reports its findings twice each year to the Clinical Practice Committee.

12

\nUtilization Review

A Utilization Review Plan is established and implemented Within Johns

Hopkins Bayview Medical Center on an annual basis. The objectives of
that plan are to:

0 Promote efficient use of available health care resources;

I Provide and maintain quality patient care through the analysis,

review and evaluation of clinical practices within the Medical
Center.

The Utilization Management reports to the appropriate Joint Practice

Committee shall focus upon the following issues:

0 Preadmission review
- Admission review and denials

- Continued stay review and denials due to

— Clinical service delays
— Discharge delays
— Authorization issues
— Standards of care issues
c Re-adrnissions to the hOSpital
- ALOS by DRG
0 Cost per case by DRG

Agency for Healthcare Research and 5 Quality Patient Safety Indicators

Johns Hopkins Bayview Medical Center, through a monthly report

available through the Premier Quality Adviser program, reviews data

related to the Patient Safety Indicators of the AHRQ. The report also
provides for the ability to benchmark against national results. The
indicators include the following:
- Complications of anesthesia
Death in low mortality DRGs
Decubitus ulcers
Failure to rescue
Foreign body left during procedures
Iatrogenic pneumothorax
Selected infections due to medical care
Post operative hip fracture
Post operative hemorrhage or hematorna
Post operative physiologic and metabolic derangement
Post operative respiratory failure
Post operative pulmonary emboli or deep vein thrombosis
Post operative sepsis
Post operative wound dehiscence
Accidental puncture or laceration during procedure
Transfusion reaction

C O I O I C I O O O O O O I I

13

\n0 Birth trauma with injury to neonate

0 Obstetric trauma-vaginal delivery with instrument

0 Obstetric trauma-vaginal delivery without instrument

0 Obstetric trauma— Cesarean section

L Service Excellence/ Patient Satisfaction

Johns Hopkins Bayview Medical Center participates in the Press-Ganey
Patient Satisfaction Survey. This program allows the organization to
compare its scores for patient satisfaction with organizations which are
similar in size.

Reports are forwarded to the appropriate Joint Practice Committees, as

well as to the Service Excellence Coordinating Group for review and
action.

M. Infection Control
Johns Hopkins Bayview Medical Center’s Infection Control Committee
focuses on prevention , detection, and analysis of nosocomial infections in
the patient population that we serve. When negative trends are identified,
intensive analysis is completed and a plan of action developed to reduce
the incidence of infections.

The Infection Control Program Director reports on negative trends, plans

of actions, and results of ongoing monitoring to the Quaiity and Patient
Safety Council on a scheduled basis.

N. Safety
An organization-wide Safety Committee has been established to review
environmental safety practices throughout the Medical Center. The Safety
Committee reports on a scheduled basis to the Quality and Patient Safety
Council.

The Bayview Safety Improvement Council (BaSIC) has been established

to review issues specific to patient safety. The Council meets monthly and
reviews event reports that have been identified as resulting in harm to
patients or having the potential to cause such harm. The Chair of this
council shall report menthly—to the Quality and Patient Safety Council.

0. Staffing Effectiveness
One of the key components in providing care in a safe, competent, and

caring manner is the staff providing that care. The Johns Hopkins
Bayview Medical Center works to ensure that there is a sufficient number
of qualified and competent staff to provide that care. The Medical Center

14

\npfl-x

continually evaluates its staffing by reviewing its patient population and

their needs, the number of staff available to meet those needs, the skill mix
of staff assigned, and the availability of support staff to assist direct and
indirect caregivers.

To meet the challenges of providing care with an appropriate level of

experienced staff, Johns Hopkins Bayview Medical Center seeks to
develop a system for monitoring the effectiveness of staffing provided on
inpatient/acute care units within the organization. Key performance
measures will be utilized in the review of staffing effectiveness throughout
the organization.

Failure Mode and Effects Analysis {FMEAQ

On an annual basis, the Medical Center will select at least one high-risk
safety process for pro-active risk assessment. The pro-active risk
assessment will include:

0 Assessment of the process so as to identify the steps in the process

where there is, or may be, undesirable variation and potential risk.

0 Identification of the possible effects of the variation on patients.

0 Conduct a root cause analysis to determine why the undesirable

variation leading to that effect may occur.

0 Redesign the process and/or the underlying systems to minimize the

risk of that undesirable variation and to protect patients from the
effects of that undesirable variation.

0 Test and implement measures of the effectiveness of the redesigned

process.

0 Implement a strategy for maintaining the effectiveness of the

redesigned process over time.

For fiscal year 2015 the F MEA will focus on implementation of the new
EPIC Clinical Information System for inpatients. A team will be
developed to address this issue.

Restraint and Seclusion

The Medical Center has a goal of reducing use of restraint and/or

seclusion when that is possible. The Falls and Restraints Committee_has
been charged with review of patients who have been restrained, and with
developing processes that focus on appropriate assessment and
management of patients who are restrained and/or placed in seclusion
While hospitalized.

Performance Improvement Teams

Hospital staff or physicians who wish to request that a particular project be

given status of a Performance Improvement Team shall forward a request

to the Quality and Patient Safety Council. The Council members shall

15

\nconsider the request and shall prioritize the issue using criteria outlined
earlier in this document.

The Council shall commission mum-disciplinary Performance

Improvement Teams to address organization-wide issues that focus on the
need for improvement in clinical care, service, or specific processes. The
teams shall report their progress in development of a plan of action and on
the effectiveness of that plan to the Council as requested.

Departmental PI Initiatives
Each department within the Johns Hopkins Bayview Medical Center is

responsible for monitoring the quality of care and service provided within
key areas. When opportunities for improvement are identified, plans of
action are developed, implemented and the effectiveness of those plans are
evaluated. Reports of these departmental initiatives are reported to the
appropriate administrative director and Summarized for Council annually.

T Peer Review

When issues which are relevant to an individual practitioner’s

performance are raised or when negative or otherwise unexpected

outcomes are identified, a process for conducting peer review of the case

is implemented. An objective review of the case is conducted to

determine if:

I The occurrence is within the standard of care.

0 The occurrence represents a marginal deviation from the standard of

care; a marginal deviation from the established standard is one which
does not have a long term impact on the outcome of care provided.

0 The occurrence is a major deviation from the standard of care, as

determined by the expert peer reviewer. A major deviation fiom the
standard has a longer term, negative impact on the outcomes of care.

Findings from the Peer Review Process are included as part of the re
credentialing process for members of the medical staff.

Competency Review
Competency of all Medical Center employees will be evaluated on an

annual basis. Criteria for this review are developed jointly by the Human
Resource Department and by managers of the other Medical Center
departments. Individual competency is determined by the immediate
supervisor based on a review of these criteria, on direct observation of the
employee completing work assignments, and on reports from the
employee, other supervisors, and peers. Reports of the competency
review are forwarded to the Board of Trustees on an annual basis.

Special Projects

16

\nW

The leadership of the organization may request that special projects

focusing on a specific issue be addressed during any given period of time.
These issues are identified as being critical to the success of the mission of
this organization.

Hospital Acguired Conditions/Potentially Preventable Conditions

The Medical Center staff shall identify and monitor patients with one of

the following Hospital Acquired Conditions/ Potentially Preventable

Complications not present on admission as defined by Maryland’s Health
Services Cost Review Commission

I I I I I I

l I I I I I I I

In hospital stroke and intracranial hemorrhage

Extreme CNS complications

Acute pulmonary edema and respiratory failure with and

without mechanical ventilation

Hospital acquired pneumonia and other lung infections

Aspiration pneumonia

Pulmonary emboli

Other pulmonary complications

Shock

Congestive Heart Failure

Acute MI

Cardiac arrhythmias and conduction disturbances

Other cardiac complications

Ventricular fibrillation/cardiac arrest

Peripheral vascular complications except venous

thrombosis

Venous thrombosis

Major GI complications with and without transfusion or

significant bleeding

Major liver complications

Other GI complications without transfusion or significant

bleeding

Clostridium difficile infection

Other Genitourinary complications except UTI

Renal failure with and without dialysis

Diabetic Ketoacidosis and coma

Post hemorrhagic and other acute anemia with transfusion

Iii—hospital trauma and fractures

Poisonings except from anesthesia

Poisoning due to anesthesia

Decubitus ulcer any stage

Transfusion incompatibility reaction

Cellulitus

Moderate infections

Septicemia and severe infections

Acute mental health changes

17

\nI Post operative infection and deep wound disruption with

and without procedure

I Reopening surgical site

I Post operative hemorrhage and hematoma with and without

hemorrhage control procedure or 185D procedure

I Accidental puncture/laceration during invasive procedure

I Accidental puncture/laceration during other medical care

I Other surgical complications, moderate

I Post procedure foreign bodies

I Post operative substance reaction and non-OR procedure

for foreign body

I Encephalopathy

I Other complications of medical care

I Iatrogenic pneumothorax

I Mechanical complication of device, implant and graft

I Gastrointestinal ostomy complications

I Inflammation and other complications of devices, implants

or grafts except vascular infection

I Infection, inflammation and clotting complications of

peripheral vascular catheters and infusions

I Infections due to central venous catheters

I Obstetrical hemorrhage without transfusion

I Obstetrical hemorrhage with transfusion

I Medical and Anesthesia Obstetric complications

I Other complications of obstetrical surgical and perineal

wounds

IE Delivery with placental complications

I Post operative respiratory failure with tracheostomy

I Other in hospital adverse events including falls, rape,

assault, suicide

I Urinary tract infection without catheter

I Catheter associated UTI

As cases are identified which are determined to be preventable and not

present on admission, second level reviews shall be requested of peer
physicians or other involved providers. Findings shall be trended,
reported and included as part of the ongoing provider performance
evaluation or staff competency.

X. QUEST
Johns Hopkins Bayview Medical Center participates in Premier’s QUEST
national collaborative. As part of this project, the hospital works with other
facilities across the country to:

0 Reduce mortality with the goal of achieving an observed to expected

ratio of 0.87

18

\nIX.

0 Reduce hospital readmissions, with the goal of achieving less than or

equal to an 8% readmission rate.

0 Improve evidence based care compliance for each of the measures

(Core Measures) to 96%

- Improve patient experience of care (HCAHPS ) to a top box score of

75% or higher for each domain

0 Decrease the incidence of patient ham

0 Decrease the cost of care.

0 Improve the health of the community

Y. Partnership for Patients

Johns Hopkins Bayview Medical Center participates in the Medicare
Partnership for Patients collaborative through the Premier Hospital
Engagement Network. Goals include:

0 To reduce patient harm by 40% compared to baseline 2010.

0 To reduce 30 day readmissions by 20% compared to baseline
2010.

Z. Patient Family Advisory Council

Johns Hopkins Bayview Medical Center implemented a Patient Family
Advisory Council in January, 2014. That council will report a summary of
its initiatives to the Quality and Patient Council twice each year.

Data Collection and Analysis

All performance improvement activities shall be data driven. Processes shall be

established that serve to ensure that data integrity will be maintained at all
times.

Intense analysis, including a study of the causes of any special cause variation
is
initiated when undesirable patterns, trends, or outcomes are identified or when
clinical standards of care are not consistently met.

Appropriate statistical techniques shall be utilized as part of the analysis of

the
data. Control charts with upper and lower control limits shall be included in
the
reports of data analysis as appropriate.

Plans of Corrective Action

When opportunities for improvement are identified, a plan of corrective action

aimed at improvement in performance shall be developed. The plan shall include:

- Measurable goals for improvement

0 Actions that will be taken to achieve the goals that are outlined

l9

\nXII.

XIII.

Actions shall reflect the root cause of the variation that is identified.
Actions may include but are not limited to:
0 Staff education
Changes in policies and/or procedures
Educational letters addressed to specific staff members
Counseling
Cemmunication regarding standards of practice, of care, of behavior,
etc.
- Changes in practice
0 Disciplinary actions as appropriate
0 Persons responsible for implementing the plan of action
0 Targeted dates for achievement of the goals
0 Processes that will be utilized to determine the effectiveness of the plan

Evaluating the Effectiveness of the Plan of Action

After the plan of action has been implemented, a follow-up assessment will be
performed by the Department or Program leaders to determine the effectiveness
of the plan. The assessment will include:
0 Collection of data in areas identified by the plan of action.
0 Statistical analysis of the data to determine if goals have been achieved
and improvement has occurred.

In the event that improvement has not been achieved, the plan of action shall be
reviewed and revised as appropriate.
This evaluation shall be submitted to the Senior Director of Quality and Patient
Safety in writing and reported to the Quality and Patient Safety or to the
Clinical
Practice Committee of the Medical Staff.

Confidentiality

The confidentiality of performance improvement information will be protected by

controlling access to those participating in the Performance Improvement
Program and those responsible for evaluation of the Medical Center’s
performance. All patient and physician identifiable information shall be coded
in

all reports or connnunications.

Communication
In an effort to ensure that there is appropriate communication to all Medical
Center physicians and staff regarding performance improvement initiatives, the

following measures will be implemented:

20

\n4‘ Delegating the authority to design and implement a Performance

Improvement Plan through the president and CEO to the Quality and
Patient Safety'Council.

0 Reviewing and approving the design of the Performance Improvement

Program of Johns Hopkins Bayview Medical Center.

0 Ensuring the provision of adequate resources for monitoring and

evaluating the quality and safetypf care and service provided.

0 Receiving and evaluating reports concerning the performance of the

organization and the effectiveness of organization-wide performance
improvement activities.

Executive Team

The Executive team of Johns Hopkins Bayview Medical Center is

responsible for:

0 Creating a culture that encourages and sustains continuous

measurement, evaluation, and improvement in clinical care, patient
safety and customer service.

0 Selecting a performance improvement model.

0 Establishing and enforcing measurable performance expectations for

employees of the Medical Center.

I Establishing annual management objectives upon which the

performance improvement priorities are established.

0 Allocating resources for performance improvement activities.

- Participating in performance improvement initiatives as appropriate.

Medical Board

The Medical Board of Johns Hopkins Bayview Medical Center is

accountable for the quality and safety of medical care and professional
services provided at this organization. The Board meets on a monthly
basis and is responsible for:

0 Establishing or adopting and enforcing standards of practice for the

provision of quality medical care to patients at Johns Hopkins
Bayview Medical Center

0 Reviewing, evaluating, and acting upon performance data, including

all medical staff performance improvement functions and the
performance of individual practitioners with clinical privileges.

Clinical Practice Committee

A Clinical Practice Committee of the medical staff oversees the medical

staff monitoring and evaluation program. The Clinical Practice
Committee, which reports to the Medical Board, is responsible for
monitoring and acting upon data from:

- Invasive and Non-invasive procedure review

0 Transfusion Review

a Drug Use Review

\n21. Meetings of the Quality and Patient Safety Council shall be open
to all medical center leaders, physicians, and hospital staff.
Announcements of the meetings and the agenda shall be posted on
the hospital’s intranet. Specific issues related to quality of care
and service within the organization shall be disc used in depth at
each meeting. The focus of the meeting will be on planning
organization-wide performance improvement initiatives, sharing
information and ideas, and evaluation of the effectiveness of
specific measures.

b. The Quality Management Office shall maintain a Sharepoint Site

where issues related to quality of care and service can be posted.
Additionally trend reports and bi-monthly reports and dashboards
shall also be available for review by staff and physicians using
their J HED ID and password.

XIV. Program Evaluation

A written evaluation of the Performance improvement Plan shall be developed by
the Senior Director of Quality and Patient Safety at the end of each fiscal year
and
presented to the Medical Board in August of each calendar year and to the Board
of Trustees at their September meeting.

This plan and its effectiveness shall be reviewed annually and revised as
necessary by the Quality Management Department; the revisiOns shall be
presented to the Quality and Patient Safety Council and the Medical Board for
approval.

The Board of Trustees shall be responsible for final review and approval of the
plan.

21

\nThe attached FY15 Performance Improvement Plan for the Johns Hopkins Bayview
Medical Center has been reviewed and approved.

Chet Wyman, MD
Chair, Quality and Patient Safety Council
Approved June 16, 2014
Kostas Lyketsos, MD
Chair, Medical Board
Approved: July 14, 2014

Richard Bennett, MD
President, Johns Hopkins Bayview Medical Center
Approved: July 15, 2014

J ames Drescher
Chairman, Board of Trustees
Approved:

22

\n23

\n1"“-

Clinical Documentation Review

Cardiac Arrest Review

Review of PI initiatives within all Medical Staff Departments

Review of clinical guidelines and protocols

Tissue Review

Autopsy Effectiveness Review

Mortality Review

Core Measures Review

Review of Maryland Hospital Acquired Conditions

Peer Review

Quality and Patient Safety Council

The Quality and Patient Safety Council of Johns Hopkins Bayview
Medical Center reports directly to the Medical Board and is responsible

for:

Establishing an annual Quality Management Plan for the Medical

Center which focuses on continuous improvements in clinical care, of
patient safety and customer service.

Setting priorities for specific performance improvement initiatives that

support the Medical Center’s mission, vision, values and goals for
general operations, patient care services, clinical services, human
resources, and financial and support services at the beginning of each
fiscal year.

Commissioning performance improvement teams to study issues and

to develop plans of action that focus on continuous improvement.
Ensuring that performance improvement activities are collaborative
and interdisciplinary.

Receiving and acting on reports from the Joint Practice Committees

and from various Performance Improvement Teams.

Serving as a conduit for information between the Joint Practice

Committees and other committees of the medical center.
Reviewing and responding to the Performance Report Card outlining
current performance and opportunities for improvement.

Educating members on a variety of topics, including performance

improvement methodologies, data collection and analysis, developing
and implementing plans for improvement and patient safety initiatives.
Providing the Medical Board with monthly updates of improvement
initiatives.

Reporting the progress of initiatives to the Board of Trustees.

Joint Practice Committees

Multidisciplinary Joint Practice Committees have been established in the
following areas:

\n0.00.0000...-

Emergency Medicine
Specialty Hospital
Maternal Child Health
Medicine
Neuroscience
Psychiatry

Surgery

Burn

Trauma

ElderPlus Program
Collaborative Critical Care , \(
Ambulatory Care
Orthopaedic Surgery Oh

The Joint Practice Committees at Johns Hopkins Bayview Medical Center

are responsible for:

.00.

Developing a Performance Improvement Plan that includes specific

quality and safety measures_that will be the Committee’s focus on an
annual basis.

Developing interdisciplinary approaches to care management,

outcomes management, cost management, quality management,
patient safety and patient satisfaction.

Prioritizing performance improvement initiatives within the specific

specialties that they represent.

Collecting and analyzing performance measurement data.

Initiating plans of action to address opportunities for improvement.
Monitoring progress in achieving performance goals.

Reporting progress on a scheduled basis to Quality and Patient Safety

Council.

Evaluating'the effectiveness of the Plan at the end of each fiscal year.

Physicians and Medical Center Staff

The physicians and staff of Johns Hopkins Bayview Medical Center are
responsible for:
Maintaining standards of care, standards of practice, and performance
standards Within their discipline in providing care and service to
patients and their family members.

Forwarding suggestions to appropriate leadership identifying

opportunities for improvement in care and service.

Participating in performance improvement initiatives within their

individual departments and on an organization-Wide basis as requested

\nV.

Model for Performance Improvement

Johns Hopkins Bayview Medical Center has adopted the FOCUS—PDCA model
for all performance improvement activities.

Eind a process to improve

Qrganize a team to study the process

Clarify issues and knowledge
flnderstand variation

Select the improvement

Elan the improvement

Do: Pilot the improvement

Check: Evaluate the pilot

Act: Standardize the improvement

VI. Program Structure

A.

1.

3.

Quality and Patient Safety Council

Meetings: The Quality and Patient Safety Council shall meet on a
monthly basis, at least ten months every year. A reporting
calendar will be developed and maintained.

Chairman:

The Chairman of the Quality and Patient Safety Council shall be

the Chief Medical Officer for Quality and Patient Safety who is
jointly appointed by the President of the Medical Center and the
Chairman of the Medical Board

Membership: , The members of the Quality and Patient Safety

Council shall include the following:
One of the co~chairs from each of the following Joint
Practice Committees.
' Emergency Medicine
Medical Services
Maternal Child Health
Neuroscience
Psychiatry
Surgical Sciences
Burn
Trauma
Elder Plus
Collaborative Critical Care
Ambulatory Care
Specialty Hospital
Orthopaedic Surgery

©WHQM§WPP

10.

12.
13.

\nVII.

a. Medical Center Leadership as follows:

1.
2.
3' .
'3
4

7.
8.
9.

10.
ll.-
12.
13.
14.
15.

President and CEO, ex officio

Executive Vice President/COO

Vice President of Medical Affairs

Vice President, Patient Care Services

Senior_Director, Quality Management and Patient
Safety

Director, Quality and Patient Safety

Senior Director of Care Management

Risk Manager

Director, Pharmacy

Manager, Infection Control

Director, Safety and Environmental Health

Director of Regulatory Affairs

Director of Service Excellence

A member of the Board of Trustees appointed by

the Chairman of the Board,

b. Additional members from throughout Johns Hopkins

Bayview Medical Center may be appointed by the
ChairpeISOn of the Council

(1. Committee support will be provided by the Quality

Management Department staff.

4. Attendance Requirements:
a. Committee members are expected to attend and to actively
participate in the council meetings:

1- Members are expected to attend at least six of the

core membership meetings each year.

2. Failure to attend the meetings as outlined above

may resnlt in removal of membership on the
committee.

b. Meetings will be open to any member of the board of

trustees, physician, or hospital staff.

Establishing Priorities

On an annual basis, the Quality and Patient Safety Council_shall review all
performance measures. Priorities shall be established based on the following

criteria:

0 The measure reflects the mission, vision, values, and goals of

the organization.

0 The measure addresses the annual management objectives

established by the organization.

\no The measure involves key processes for clinical caregpatient

safety and service, including but not limited to those processes
which are high in volume, high in cost, involve high risk to the
patient, or processes in which problems have been identified in
the past.

0 The measure addresses regulatory requirements TJ C, DHMH,

CMS, etc.)

o The measure addresses improvements in the culture of safety

within the organization.

0 The measure addresses service excellence or patient

satisfaction initiatives.

0 The measure reflects community, patient, staff or physician

recommendations for improvement.

I There are appropriate staff and financial resources available to

address the issue.

Based on these criteria, the Performance Improvement Program has

established the following priorities for fiscai year 2015

I Patient Harm

Reduce the incidence of surgical site infections and achieve a

standardized infection ration (SIR) of <=1.00 for Cesarean
Sections, Craniotomies, Larninectomies, Spinal Fusion Surgeries,
Total Hip Replacements and Total knee replacements by end of the
fiscal year.

Reduee the incidence of Centred Line Associated Blood Stream

Infections and achieve a standardized infection ratio (SIR) of less
than or equal to 0.50 in each of the ICUs.

Achieve a standardized infection ratio of less than or equal to 0.75

for catheter associated urinary tract infections in intensive care
units.

Achieve a standardized infection ratio of less than or equal to 1.0

for hospital acquired Clostridium difficile infections

Maintain hand hygiene compliance at greater than 90% using

secret shoppers on inpatient units and the emergency room.

Maintain hand hygiene compliance at greater than 90% in all

outpatient programs and clinics.

Achieve a composite harm score within the QUEST collaborative

of less than 0.25.

Achieve a positive financial balance with the Maryland Hospital

Acquired Conditions program by end of the CY14 as evidenced by
a score of 0.61 or higher.

\nVIII.

0 Readmissions

o DecreaSe ali~cause risk adjusted (HSCRC Calculation) adult

inpatient readmission rate by 6.7% over CY 13 results

0 Achieve an observed to expected ratio for 30 day readmissions at

1.0 or less by the end of the fiscal year.

a Patient Satisfaction

o Achieve at least the top quartile or achieve a three point

improvement from prior year in each of the HCAHPS domains of
care by the end of FY15.

- Evidence Based Care

0 96% aggregate score and 100% of individual measures are at 95%

or above (N 230 per measure annually) for each inpatient core
measwre.

o Outpatient Core measure indicators to achieve 2 national target

compliance for each measure

0 Maintain top performance status for evidence based care in the
QUEST collaborative.

0 Mortality

o Achieve an observed to expected ratio of 0.85 by the end of the

fiscal year.

0 Throughput '

o The Adult ED Boarding Time will be <=4 hours for 75% of

patients.

0 The Median Total ED time (from arrival until hospital admission)

will be less than or equal to 7.00 hours

0 The rate of ED patients who are registered but who leave Without
being seen will be less than or equal to 3%.

Scope of the Program

The Performance Improvement Program of the Johns Hopkins Bayview Medical

Center shall include the following:

A. Core Measures: As is required as a condition for accreditation by The

Joint Commission, Johns Hopkins Bayview Medical Center participates in
the Core Measures Component:

\nB.

Johns Hopkins Bayview Medical Center has selected the following

Performance Measurement System for submission of Core Measures
data:

I Press Ganey’s Quality Performer

Johns Hopkins Bayview Medical Center has selected the following

core measure sets for review during fiscal year 2944—201 5

0 Management of Patients with Community Acquired

Pneumonia

Management of Patients with Congestive Heart Failure

Management of Patients with Acute Myocardial Infarction.
Surgical Care Improvement Project

Children’s Asthma Care

Emergency Department Measures

Global immunization

Management of patients with stroke (STK)

.Preventing venous thromboembolism (VTE)

Perinatal measures as required

Outpatient measures as required

Sentinel Events
A summary of aliroot cause analyses conducted in response to significant
events, including a brief review of the plan of corrective action, shall be
reported to the Quality and Patient Safety Council by the Hospital’s Risk
Manager on a scheduled basis. As part of the plan of action, ongoing
measurement and evaluation shall be conducted and reported in order to
determine the effectiveness of the plan in addressing the root cause of the
issue.

Other Risk Management Issues

A summary review of occurrence reports shall be provided to the

appropriate Joint Practice Committees and to the Quality and Patient

Safety Council on a scheduled basis. Reports shall include the frequency
and severity of medication events, patient falls and patient falls with
injury, and other significant occurrences

Mortalig Review
The Quality Management Department shall conduct a review of 100% of

all deaths occurring each month. Results from this review shall be
reported to the Clinical Practice Committee twice a year. _Furthermore,

10