UCLA HEALTH SYSTEM

PERFORMANCE IMPROVEMENT & PATIENT SAFETY PLAN

FY 2020

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 PURPOSE

The Performance Improvement and Patient Safety Plan is a description of the organizational,
multidisciplinary, and systematic performance improvement function designed to support the
Mission, Values, and Philosophy of the UCLA Health System. The intent of the Performance
Improvement and Patient Safety Plan is to identify the health system’s approach to improving and
sustaining its performance through the prioritization, design, implementation, monitoring, and
analysis of performance improvement initiatives. Moreover, the Performance Improvement and
Safety Plan is an ongoing program that demonstrates measurable improvement in indicators for
which there is evidence that they will improve patient outcomes, and identify and reduce medical
errors. The Performance Improvement and Patient Safety Plan, with total support of Leadership,
will utilize internal and external reference databases in an ongoing effort to design, assess,
measure, and improve the delivery of care process and outcomes. In accordance with the Joint
Commission (TJC) Standards, Centers for Medicare and Medicaid Services (CMS) Conditions of
Participation (COPs), California Department of Health Title XXII and the vision of the facility, the
following expectations regarding healthcare delivery at the UCLA Health System have been
established:

1) Safe – Avoiding injuries to patients from the care that is intended to help them by:
a) Recognizing and acknowledging risks and unanticipated adverse events;
b) Investigating factors that contribute to unanticipated adverse events;
c) Focusing on processes and systems with minimization of individual blame or retribution for
involvement in a medical/healthcare error;

2) Effective – Providing services based on scientific knowledge to all who could benefit and
refraining from providing services to those not likely to benefit by:
a) Reviewing reported risks to identify underlying causes and system changes needed to
reduce the likelihood of recurrence;
b) Initiating actions to reduce these risks and unanticipated adverse events;
c) Reporting internally risk reduction initiatives and their effectiveness;
d) Analyzing selected healthcare services before an adverse event occurs to identify system
redesign that will reduce the likelihood of error;
e) Integrating Performance Improvement and Patient Safety priorities into the new design and
redesign of all relevant organization processes, functions and services;
f) Researching ways to improve patient safety and quality;
g) Conducting systematic planning, analysis and monitoring of performance to improve and
sustain advances of processes and outcomes of patient care through interdisciplinary
teamwork;

3) Patient-centered – Providing care that is respectful of and responsive to individual patient

preferences, needs and values and ensuring that patient values guide all clinical decisions by:
a) Assuring public transparency of information;
b) Meeting and exceeding customer’s needs and expectations;
c) Incorporating the patient’s perspective in developing care delivery processes;

4) Timely – Reducing wait times and delays for both those who receive and provide care by:
a) Monitoring performance improvement priorities continuously.

5) Efficient – Avoiding waste of equipment, supplies, ideas and energy by:

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 a) Implementing evidence based care utilizing standardized order sets, protocols and clinical
pathways;
b) Utilizing UCLA LEAN Methodology when developing and evaluating processes;
c) Assuring the application of PI priorities to medical/healthcare errors and organization
learning;
d) Assuring organizational learning regarding medical/health care errors and the application
of performance improvement principles for resolution;

6) Equitable – Providing care that does not vary in quality because of personal characteristics
such as gender, ethnicity, geographic location and socioeconomic status by:
a) Assuring the highest standard of care is delivered to each patient every time regardless of
personal characteristics

SCOPE AND ACTIVITIES

This plan applies to all inpatient services and sites of care provided at UCLA Health System. The
Performance Improvement and Patient Safety Program include an ongoing assessment, using
internal and external knowledge and experience, to prevent error occurrence and maintain and
improve healthcare safety and quality. The UCLA Health System recognizes that patients, staff,
visitors and other customers have the right to expect the best possible clinical outcomes, a safe
environment and an error free care experience. Therefore, the organization commits to continuous
designing, monitoring performance, analyzing data, improving and sustaining performance while
undertaking a proactive approach to the identification and mitigation of medical errors. The
organization responds quickly, effectively, and appropriately when errors occur. We recognize
that the patient has the right to be informed of the results of treatments or procedures including
whenever those results differ significantly from anticipated results.

Additional program specifics include:

1) All departments within the organization (patient care and non-patient care departments) are
responsible for on-going performance improvement and quality assurance activities. These
efforts are monitored through the organizational leadership structure and key indicators are
reported to the Clinical Excellence/Quality Outcomes Committee.

2) All departments within the organization (patient care and non-patient care departments) are
responsible to report healthcare safety occurrence and potential occurrences. The UCLA
Health System has implemented an electronic event reporting system, available on all UCLA
Health System computers, to report unexpected events and near misses (reference Event
Reports Policy). Summary data from the event reporting system will be aggregated and
presented periodically to the Clinical Excellence and Medical Staff Executive Committees who
will determine further safety (risk reduction) activities as appropriate.

3) Upon identification of a medical/health care actual or , potential care adverse Event will The
Care delivery team

• Perform in accordance to the event management policy.

• An effective Patient Safety Program cannot exist without optimal reporting of

medical/health care errors and occurrences. Therefore, UCLA Health System adopts a
just approach in its management of errors and occurrences. All personnel are required to

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 report suspected and identified medical/health care errors, and should do so without the
fear of reprisal in relationship to their employment. This organization supports the
concept that errors occur due to a breakdown in systems and processes, and will focus
on improving systems and processes. A focus will be placed on remedial actions and
individual development to assist rather than punish staff members.

4) Through review of internal and external data sources (including, but not limited to reports from
evidence based medicine centers, the National Quality Forum, the Agency for Healthcare
Research and Quality and other federal and state organizations, the Joint Commission and
current literature), the Clinical Excellence/Quality Outcomes Committees will select at least
one high-risk safety process for a Failure Mode and Effects Analysis (FMEA) annually.

5) The Performance Improvement and Patient Safety Program includes an assessment of staff
(including medical staff) opinions, as appropriate, regarding perceptions of risks to patients,
the culture of the healthcare environment to facilitate safe practices, and suggestions for
improving patient safety and clinical outcomes through culture of safety surveys.

6) The Performance Improvement and Patient Safety Program includes an ongoing assessment
of patient satisfaction through the use of a comprehensive survey tool that includes all
HCAHPS required elements.

7) Patients, and when appropriate, their families are informed about the outcomes of care,
including unanticipated outcomes, or when the outcomes differ significantly from the
anticipated outcomes, following guidelines outlined in the Disclosure Policy.

8) Staff will educate patients and their families about their role in helping to facilitate the safe
delivery of care. Patient and family safety education interventions are documented in the
patient’s medical record.

9) Staff will receive education and training during their initial orientation and on an ongoing basis
regarding job-related aspects of patient safety, including the need and methods to report and
reduce medical/health care errors. In addition, staff will be educated and trained on the
provision of an interdisciplinary and collaborative approach to patient care.

10) Medical/health care errors and occurrences, including sentinel events, will be reported in
accordance with all state, federal and regulatory body rules, laws and requirements.

11) Leaders will provide feedback to staff when they have identified a safety issue or occurrence.

PERFORMANCE SAFETY PLAN PRIORITIES & GOALS

The hospital’s approach to performance improvement is continuously assessed and revised to

meet the goal of ensuring that patient outcomes are continually improved and safe patient care is
provided. Examples of information utilized to achieve this goal include: variance related data such
as medication errors and falls; infection prevention surveillance; sentinel event alerts; and
TJC/CMS Quality Measure data, as well as, patient satisfaction reports. The criteria used to
prioritize opportunities for improvement include, but are not limited to:

• Patient Safety
• Strategic plan goals/objectives
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 • Mission/vision
• Quality outcomes
• Patient care operations
• Efficiency of care
• Customer satisfaction

The hospital recognizes that to be effective in improving patient safety there must be an integrated
and coordinated approach to reducing errors. While taking into consideration high risk, high
volume, high cost and problem prone processes, the UCLA Health System has established the
following Performance Improvement/Patient Safety goals:

1. Achieve of a Patient Safety conscious environment integrated throughout the facility.

2. Improve the reporting of medical errors by establishing a policy focusing on corrective
actions through staff education for those reporting their errors, rather than punitive or
disciplinary actions.
3. Implement confidential electronic Event Reporting process that includes documentation
of follow-up and reporting processes.
4. Expand the implementation of evidence-based practices.
5. Monitor hospital-wide indicators for established areas of focus.
6. Reduce the number of medication errors.
7. Monitor patient safety indicators related to an area’s specific “Scope of Service.”
8. Conduct a proactive risk assessment utilizing the Failure Mode, Effects Analysis
Methodology.
9. Monitor and improve areas identified through Patient Satisfaction Surveys.
10. Review the governance of medication management and conduct a Failure Mode, Effects
Analysis and assess patient safety and alignment of processes with a culture of safety.

Performance improvement priorities and activities may be reprioritized based on significant

organizational performance findings or changes in regulatory requirements, patient population,
environment of care, and expectations and needs of patients, staff, or the community. Priorities
may be reset by the multidisciplinary hospital quality committee in consultation with Senior
Management and Medical Staff leadership.

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The following Quality Mission Vision and Movers strategy have been developed and implemented:

PERFORMANCE IMPROVEMENT METHODOLOGY

The evaluation, monitoring, and improvement methodologies utilized by the UCLA Health System
are the FOCUS-PDCA and LEAN process improvement tools. The FOCUS-PDCA steps are as
follows:

Find a process to improve

Organize a team that knows the process
Clarify current knowledge of the process
Understand sources of process variation
Select the process improvement

Plan the improvement and continued data collection

Do Improvement, data collection and analysis
Check and study the results
Act to hold the gain and to continue to improve the process
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UCLA also employs tools for process improvement and/or redesign and cause-mapping
incorporate the concepts of statistical process control, Six Sigma, and lean systems thinking to
reduce system variation, delays, and complexity that is detrimental to patient care and safety. The
LEAN tools are available on the Mednet home page under “UCLA Operating System”. The Cause-
mapping resources under Quality Management Services Quality reports.

PLAN

In order to plan and develop effective processes, functions or services, the following key elements
are considered when relevant and available:

1. The process design is based on the organization’s mission, vision and MOVERS
strategic
2. Consideration is given to the needs and expectations of patients, staff, and others, as
well as, the direct effect or criticality of the design on patient care.
3. Research of current literature and practice guidelines are reviewed for successful or
best practice(s).
4. Development is consistent with sound business practices.
5. Baseline performance expectations are utilized to guide measurement and
assessment activities.

Performance monitoring and evaluation standards are department, division, service line and/or
population focused. Certain processes are measured on an ongoing basis both in response to
occurrences and proactively. Selected processes which are high volume, high risk, high cost and
problem prone are measured, analyzed and improved on an ongoing basis.

Performance Improvement projects that are designed or redesigned to monitor expected

performance within the hospital are developed to measure, assess, improve and maintain process
improvements. Performance levels may be established through comparison performance with
other “like” facilities to identify variations or “failure modes.” Comparative data is used from the
UHC, NHSN, CMS or current/past department performance. Each activity monitored has an
established performance level or threshold to measure expected performance. A strategy for
maintaining the effectiveness of the redesigned process over time is also implemented.

DO

Data collection is the basis of all Performance Improvement activities and provides a means of
measuring performance through which informed decisions can be made.

1. Program data is collected for a comprehensive set of performance measures based on the
priorities and frequency established by the leaders of the organization in order to:
a. Establish a baseline when a process is implemented or redesigned.
b. Describe process performance or stability.
c. Describe the dimensions of performance or stability.
d. Describe the dimensions of performance relevant to functions, processes and
outcomes.
e. Identify areas for improvement including the effect on patients.
f. Determine whether changes in a process have met objectives
g. Implement a strategy for maintaining the effectiveness of the redesigned process

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 over time.
2. Data is collected as a part of continuing measurement, in addition to data collected for priority
issues.

CHECK

Program activities involve the assessment process, which includes the necessary disciplines of
departments to draw conclusions about the need for more intensive measurement. A systematic
process is used to assess collected data in order to determine whether specifications for newly
designed processes were met and the level of performance and stability of important existing
processes. Priorities for possible improvements or redesign of existing processes, actions taken
to improve the performance improvement processes and whether changes in the processes
resulted in improvement are also assessed.

Ongoing data collection and PI activities are regularly reported as follows:

• MOVERS Organization, Goals Oversight Team
• PT care units Departments: Clinical Excellence Committee

The assessment process for the Medical Staff is addressed at the time of initial application and
continuously through the Ongoing and Focused Profession Practice Evaluations (refer to Policies
MS119, MS120, and MS120A) and department level PI activities. The Medical Staff Committee
chairpersons are responsible for assessing the Performance Improvement activities related to
their assigned committees and recommending policy and operational changes based on analysis
of committee related data. In addition, each department/service-line presents annually to the
Quality Council regarding achievements and PI activities. Each of the Medical Staff committees
submits a monthly report to the Clinical Board and presents regularly to the Quality Council
integrating their support of and progress with the MOVERS strategy The Medical Staff
committees addressing PI include the following:

 Blood Utilization Review Committee

 Cancer Committee
 Clinical Excellence Committee
 Infection Control Committee
 Pharmacy and Therapeutics Committee
 Trauma Committee
 Surgical and Other Invasive Procedure Review Committee

When data analysis identifies a problem or trend, a corrective action plan will be developed and
implemented. These actions may include:

1. System Changes – Changes in communication channels, changes in organizational

structure, adjustments in staffing and changes in equipment or chart forms.

2. Knowledge Enhancement – In-service education, continuing education and circulating

informational material.

3. Intensive Reviews/Focus Studies – When a medical/health care system error-related

occurrence is identified; proactive risk assessment activities are implemented including
intensive review and/or a focused study. A data collection tool is developed to address

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 processes, functions, and services that can be designed or redesigned to prevent trends
that may have contributed to the problem. Once all charts are reviewed, a summary report
is compiled to report conclusions.

4. Root Cause Analysis – When a medical/health care error is classified as a Sentinel

Event, the recommended Root Cause Analysis format by TJC is used to detect the
underlying causes of the variation. Upon approval by administration, the outlined action
plan is implemented.

5. Causal Analysis – When a medical/health care error is established as a near miss, a

causal analysis is completed to determine the underlying causes of the potential variation,
the outlined action plan is implemented.

6. Failure Mode Effects Analysis – In accordance with TJC published information

regarding the most frequently occurring types of sentinel events and patient safety risk
factors, at least one high-risk process is selected annually for proactive risk assessment.

7. Behavior Changes – Informal or formal counseling, consulting, changes in

assignments, and disciplinary action.

8. Policy Revisions – Policies are developed or revised for significant organizational

issues that are interdepartmental or mandated to be hospital-wide by accreditation
agencies or state/federal legislation. Any potential policy revisions are presented to the
Policy Committee to identify the appropriate entity for development, and ensure that input
is obtained and incorporated into a final policy statement. Once completed, the committee
will submit the policy to the Hospital Administrator for approval, who will then forward it to
the Clinical Board for final approval.

9. Multidisciplinary Process Teams – Teams are formed as needed and over site is
provided by the Quality Leadership Team to investigate and make recommendations when
organization-wide performance becomes unacceptable or when a process has been
identified to be proactively redesigned. The process team presents the recommendations
to the Quality Leadership Team for approval.

10. Operational Changes – Any activity that may need to be performed differently in order
to expedite a process or improve overall patient care will be examined and changed if
appropriate.

The assessment process includes the use of statistical process control techniques/tools as
appropriate. When assessment of data indicates a variation in performance or potential risk to
patient safety, more intensive measurements and analysis will be conducted, and in addition, the
department/service or team will reassess its performance measure.

When a performance measurement does not reach the predetermined optimal threshold, or if it is
attained but further evaluation indicates that performance is not acceptable, the Performance
Improvement process should continue. If the level of performance shows no improvement for the
time frame established by the identified department/service or team plan, an intensive evaluation
should be conducted with input from the Quality Leadership Team, or Director regarding the need
for continued measurement and additional corrective action.

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When any process remains stable or minimal variation is demonstrated in overall performance
after two quarters of data collection, the performance measure should be re-evaluated to
determine the need to continue measurement, and re-prioritization of performance measurements
should occur.

ACT

When opportunities for improving performance are identified, a systematic approach is used to
redesign the involved process, or to design a new process. The leadership, through the Clinical
Excellence/Quality Outcomes Committees, will establish hospital-wide priorities and provide
adequate resources to be effective.

1. When a department or service identifies an opportunity for improvement, the

department/service will determine if other disciplines or departments will have an impact
on the design/redesign of the process. If other disciplines or departments are involved,
the opportunity for improvement will be referred to an appointed team.

2. The assigned team/department will establish priorities for improvement based on the
guidelines established in this plan. When necessary, the Quality Leadership Team will
assist the team or department/service in establishing priorities.

The Performance Improvement and Patient Safety Plan will be reviewed, evaluated, and revised
as necessary to incorporate the most current TJC/CMS/CDPH standards. A summary of
evaluation results will be presented to the Clinical Excellence/Quality Outcomes Committees. The
annual review will assess, at least, the objectives, scope, organization effectiveness and
appropriateness of the program. The plan will be modified as needed based on the results of the
annual evaluation. Individual committees and departments will review, evaluate and revise their
performance improvement activities and plans annually as part of the organization-wide review.

REPORTING STRUCTURE/ACCOUNTABILITY

The executive responsibility for the Performance Improvement and Patient Safety Program Vice
Chancellor, Medical Sciences, acting as the Governing Body for UCLA Ronald Reagan Medical
Center. The Medical Staff Executive Committees the President & CEO, Hospital Systems, and
the Clinical Excellence/Quality Outcomes Committees ensure implementation of an integrated
program throughout the organization.

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 RONALD REAGAN

Vice Chancellor of Health Sciences

(Governing Board)

Medical Staff
President & CEO
Executive Clinical Excellence
Hospital Systems
Committee

Health System Ambulatory Peer Review

Quality Council Committee Committee Med Event
Committee
Infection
Control P&T Committee
QMIC Committee
Med Admin
Critical Care Task Force**
Stroke Program Organization Committee
Goals Oversight
Team
Cancer Surgical & Other
Committee Invasive
Committee
Legend
Operating Room Trauma
Health System Committee Committee

Not Health System Blood & Blood

Derivatives Incident Review Grievance
Committee Committee Committee

Emergency Stroke Program

Care Quality
Committee Committee

Environment of
Care
Committee
Surgical Nursing Quality Subject Matter Oversight
Active Sub Committees Services Outcomes Council Experts
Committee

Infection Nursing Policy Blood Stream Infections Documentation & EHR Magnet
Prevention Oversight CICARE & Nursing
CAUTI Communication Attendance
VAP Call Light Response
Falls Patient Safety Scheduling/Time Off
Surgical Wound Infections Toileting Response
Falls Ethics Uniforms & Dress Code

Nursing Restraints Palliative Care and End of Life Break Relief

Pain
Documentation Pressure Ulcers Organ Tissue Donation
Reassignment/Floating
Clinical Lab Diagnostics Patient Privacy Float Pool & Resource Administrative
Medication Nursing Practice Blood Safety Discharge Teaching Team
Administration Research Patient Classification
Safety Council Medication Events Knowledge Transfer

IV Infiltrates (Peds) Disaster Planning Clinical Competencies

Clinical Practice Peripheral Intravenous Geriatrics Culture Competencies
Skin
Council Sepsis Emergency Carts
Labor Relations
Conscious Sedations Hemodynamic Monitoring
VTE/DVT/Mobility Glucose Management Certifications

Unit Practice Councils

Focusing on Patient Satisfaction & Nurse Sensitive Indicators

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 SANTA MONICA HOSPITAL
Vice Chancellor of Health Sciences
(Governing Board)

Medical Staff Clinical

President & CEO
Executive Excellence
Hospital Systems
Committee Committee

Health System Family Medicine Committee Cardiovascular

Quality Council Includes FM peer review Committee Med Event
Committee

QMC Medicine Committee P&T Committee

Includes Medicine peer review Med Admin
Task Force
ED Committee Infection Prevention
Includes ED peer review
Risk Management
Legend
OB/GYN Committee Committee
Health System Includes OB/Peri peer review
Not Health System Utilization Review
Pediatrics Committee Committee
Includes Peds peer review
Grievance Committee
(Patient Affairs
Surgery Committee Committee)
Includes Surgery peer review
Includes Anesthesia peer review
Includes Ortho peer review

Bioethics Committee

Cancer Committee

Exemplary Professional
Surgical Services Committee
Performance (Nursing)

Nursing Policy Oversight Committee

Clinical Practice Council

Exemplary New Knowledge Structural
Professional Transformational
Innovation and Empowerment
Practice Leadership
Improvements

Falls Committee CNIII Portfolio Nursing Practice

Review Group Research Council
Pain Committee
CNII Portfolio
Subcommittees

Review Group
Skin Care
EPP

Committee

Nurse-sensitive UPC Chairs are

Hospital Acquired Members of TL
Infection Committee

Nursing Pharmacy
Unit Level
Unit Pr actice Cou nci ls
3NW Or tho, 4NW MedS urg, 5NW Ge riatrics, 6NW Pe diatrics, 4MN Medicine, 5MN Inte rmediate Ca re, L&D, Postpartum, NICU, PACU/UPTU, OR, ED
Resource Pool

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MEDICAL STAFF EXECUTIVE COMMITTEE (MSEC)

The Medical Staff, through the Medical Staff Executive Committee, has the responsibility for the
safety and quality of the medical care rendered to UCLA Medical Center patients. The Medical
Staff shares responsibility for the Performance Improvement and Patient Safety Plan with Medical
Center administration, represented by the President & CEO, Hospital Systems. The Medical Staff,
Medical Center Administration and Clinical Excellence Committee share responsibility for
reviewing and evaluating aggregate Performance Improvement data and making
recommendations, when needed, for further action. The Medical Staff shares responsibility with
the UCLA Medical Center Administration for developing and reviewing non-physician professional
staff policies and recommending standards for other UCLA Medical Center staff whose conduct
directly influences the safety and quality of patient care.

The MSEC also requires each medical staff department/service-line to participate in the
Performance Improvement and Patient Safety Program. Each department/service-line identifies
opportunities for improvement through individual case review, data analysis or staff reported
events. These cases are reviewed with a focus on identifying opportunities for system
improvement, clinical education, performance measurement and professional feedback. Process
issues are referred to the appropriate department/committee for resolution. Educational
opportunities are addressed individually or through group entities such as M&M or Grand Rounds.
Professional competency or medical judgment issues are managed through the FPPE or Hospital-
Wide Peer Review Committee. Specific responsibilities and processes are delineated in the
Medical Staff Bylaws, Rules and Regulations and Department Specific PI Plans

CLINICAL EXCELLENCE

The Clinical Excellence Committee, which represents leadership across UCLA Medical Center, is
responsible and accountable for the success of the Medical Center’s Performance Improvement
and Patient Safety activities. The Committee synthesizes and coordinates Performance
Improvement and Patient Safety activities of the Medical Staff and Medical Center. As such, the
UCLA Medical Center and Medical Staff have assigned primary responsibility for developing,
implementing, monitoring, and integrating their Performance Improvement and Patient Safety
activities to the Clinical Excellence Committee. The Committee ensures that activities throughout
the organization are consistent with the priorities established by leadership. The Committee
systematically reviews reports from patient safety and quality related UCLA Medical Center
committees and subcommittees to identify key areas of opportunities. The Committee identifies
specific high volume, high risk, high cost and problem prone aspects of care, instructing the
appropriate committee or committees (as delineated in the Medical Staff Bylaws) to prioritize their
efforts accordingly. Intradepartmental performance improvement activities, when appropriate, are
shared with the Clinical Excellence Committee to assure coordination of efforts. Each year the
UCLA Medical Center leadership proposes specific improvement efforts they believe should be
addressed. Priorities will be communicated to each department and service at the beginning of
the year so that these suggestions may be incorporated into their Performance Improvement and
Patient Safety programs.

The Clinical Excellence Committee provides Performance Improvement and Patient Safety
leadership, including but not limited to:

1. Assuring compliance with national recommendations for patient safety, including the National
Patient Safety Goals.
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2. Overseeing and setting/resetting priorities for the Medical Center’s comprehensive,
interdisciplinary Performance Improvement (PI) program;
3. Development of an environment that encourages and empowers staff to identify and address
issues through the performance improvement process in a collegial, just manner;
4. Empowering subcommittees to identify opportunities, design performance improvement
activities and resolve issues;
5. Monitoring patient safety and quality-related functions;
6. Reviewing reports from subcommittees and making recommendations regarding operational,
safety, and quality of care issues;
7. Overseeing of performance measures that are required by accrediting and licensing agencies
related to patient safety and quality;
8. Assessing resource utilization and providing oversight to the Utilization Review service;
9. Reviewing medical record documentation compliance trends and recommending operational
improvements and actions when appropriate
10. Obtaining input for improvement opportunities from committee’s representatives, department
heads or representatives, administrative reports including incident reports, survey findings from
professional organizations such as the Joint Commission (JC), departmental quality
assessment reports, and continuous hospital-wide trend reports on mortality and readmission;
11. Identifying opportunities for interdisciplinary approaches as needed to efficiently and
efficaciously resolve problems;
12. Chartering performance improvement teams addressing organizational priorities and review
their activities;
13. Referring issues to appropriate performance improvement teams, clinical services,
departments or committees;
14. Facilitating dissemination, discussion and understanding of clinical and management
Performance Improvement and Patient Safety data;
15. Educating Medical Staff and Medical Center employees in Performance Improvement and
Patient Safety principles and processes;
16. Reporting to the MSEC and Medical Center Director’s Senior Advisory Group on significant
issues;
17. Assuring compliance with accreditation standards and regulatory agency requirements (e.g.,
ORYX core measures).
18. Monitoring Sentinel Events, Root Cause Analyses, and Adverse Event Investigation findings
and action plans.
19. Selecting, approving, and reviewing Failure Mode and Effects Analyses performed by the
organization.
20. The Governing Body will receive regular reports regarding Performance Improvement and
Patient Safety activities, including actions to improve patient safety and quality both in
response to actual occurrences and proactively.

INCIDENT REVIEW COMMITTEE (RRMC Only)

The Incident Review Committee, which includes leadership across Ronald Regan UCLA Medical
Center, is responsible for overseeing the effective management of significant actual or near miss
events. The Grievance Committee reports to IRC to ensure patient complaint are evaluated for
system and Processes issues. The Committee reviews these events, assures causal analysis
occurs and solutions are implemented. In addition, the Committee ensures the required reporting
to regulatory agencies and the CMS. The Committee adheres to and promotes the principles of
high reliability organizations and a just culture.

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UCLA Health Quality Measurement and Improvement Committee (QMIC)

The Quality Measurement and Improvement Committee (QMIC) is responsible for measuring and
improving the quality of care within clinical departments and across integrated service lines. QMIC
will encompass a patient-centered, inter-professional and population-based approach to
optimizing clinical outcomes, patient experience, appropriate utilization, and total cost of care. .
The QMIC will foster a collaborative learning and sharing environment for physician quality officers
interested in improvement science and health services research. The Committee will closely align
its efforts with health system goals (ex. MOVERS) and the objectives of advanced payment
models. QMIC will report directly to the UCLA Health System Quality Council and collaborate with
Department Chairs and the Chief Medical and Quality Officer on various clinical quality initiatives.
The members of the QMIC may also serve on relevant committees related to any UCLA Health
accountable care organization or clinically integrated network. The Quality Measurement and
Improvement Committee is composed of the Department and Division Quality Officers appointed
by Clinical Department leadership. The Chairperson shall be nominated by the CMQO, in
collaboration with the Committee, and approved by the UCLA Health Quality Council for a term of
two years. The term is unlimited as pertains to positions held. The Quality Measurement and
Improvement Committee shall meet on a regular basis, at least monthly. The Quality Measurement
and Improvement Committee reports to the UCLA Health System Quality Council. Minutes of its
meetings will be provided in a timely manner to the Quality Council Chair and the CMQO.

UCLA Health Surgical Services Committee

The Surgical Services Committee is responsible for reviewing the surgical activities within UCLA
Health, and making recommendations to the UCLA Health leadership regarding allocation of
resources, development of new surgical facilities, and other forms of infrastructure support. It may
also make recommendation to the Medical Staff organizations of UCLA Health hospitals regarding
initiation or change in Medical Staff policies and procedures relevant to surgical services.
The Surgical Services Committee shall consist of the Chairs of the Departments of Surgery, Head
and Neck, Neurosurgery, Obstetrics and Gynecology, Ophthalmology, Urology, and
Anesthesiology of the David Geffen School of Medicine at UCLA, and the OR medical directors
for UCLA Health surgical suites. Non-voting members include members of UCLA Health
administration, such as the Executive Director for Operative Services, the Health System
President, COO, CMQO, CNO, SMH CAO, Executive Director for Quality and Safety, and the
CMO’s. The term is unlimited as pertains to positions held. The Surgical Services Committee shall
meet on a regular basis, at least monthly. The Surgical Services Committee reports directly to the
Medical Staff Executive Committees of RRMC and SMH and indirectly to the UCLA Health Quality
Council. Minutes of its meetings will be provided in a timely manner to the Board.

SPECIFIC STAFF RESPONSIBILITIES

• All staff from every hospital department are responsible to report patient safety occurrences or
near misses.
• Patients Relations reports on Patient Satisfaction Surveys and staff questionnaires that solicit
information about patient and staff perceptions of risks to patients.
• Hospital Infection Control aggregates and analyzes data related to nosocomial infection,
mucocutaneous exposures, and contact tracing and multi-drug resistant organisms.
• The Safety Officer aggregates and analyzes data related to environment of care surveillance
and risks, including: safety, security, hazardous materials, and fire prevention.

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• Clinical Engineering aggregates, analyzes and reports data related to medical equipment
preventive maintenance, incidents, and risks.
• Human Resources with Employee Health aggregates, analyzes and reports data related to
staff tuberculosis screening and safety related competencies of staff.
• Pharmacy aggregates, analyzes and reports data related to pharmacist interventions,
pharmaceutical inspections, and medication use.
• Risk Management aggregates, analyzes and reports data related to potential risk management
issues.
• Medical Records aggregates, analyzes and reports data related to potential medical record
documentation issues.
• Nursing aggregates, analyzes and reports data related to nurse sensitive indicators such as
hospital acquired pressure ulcers, falls and Unit Practice Council Performance Improvement
activities.

DEPARTMENT-BASED PEER REVIEW OPERATING PLAN AND SCOPE:

FACULTY AND STAFF

1) All staff physicians and faculty physicians with medical privileges at RRMC, SMH, and
NPH shall be assigned to an accountable academic department within the David Geffen
School of Medicine, for the purpose of meeting organizational and departmental objectives
with respect to quality, safety, performance improvement, peer review, regulatory and
accreditation requirements, patient experience, value-based care redesign, and population
health.
2) The QAPI (Quality Assurance and Performance Improvement) program of the accountable
DGSOM Academic Department shall extend to any facility owned and operated by UCLA
Health in which staff physicians and faculty practice, regardless of whether he/she has
medical staff privileges, as outlined in any memorandum of understanding between the
DGSOM and the Health System.
3) Department- and clinical program-based activities and committees designed to improve
patient outcomes shall be considered part of the QAPI program of the Medical Staff
Executive Committee and is privileged and confidential under Evidence Section Code 1157.
4) The academic departments within the David Geffen School of Medicine shall be responsible
for assuring that appropriate peer review activities are conducted for all practicing physicians
that are assigned to their departments, including but not limited to:
a. Case review involving a single discipline or specialty;
b. Case review that is multidisciplinary, interdepartmental, and/or interprofessional;
c. Peer review of individual physicians (ex. FPPE or focused professional practice
evaluation);
d. Data review (ex. OPPE or ongoing professional practice evaluation);
e. Clinical registry review (ex. NSQIP, STS, VQI, CHA reports etc.);
f. Educational case review conferences (ex. morbidity and mortality conferences);
g. Case reviews referred by Health Plans or by external providers (outside clinicians
and health care facilities).
h. Case reviews of patient and family complaints and grievances
5) Triggers for peer review of individual physicians include, but are not limited to:
a. Clinical Care
i. Clinical judgment
ii. Technical skills
iii. Resource utilization
iv. Safety concerns
Page 17 of 31
 v. Patient outcomes
b. Patient and Family Experience
c. Physician Wellness
d. Disruptive Behaviors
e. Professionalism
6) Department-based peer review activities that require urgent escalation, regardless of practice
site and whether or not there is a DGSOM faculty appointment, should be referred to the:
a. Medical Staff Executive Committee (ex. serious concerns with clinical judgement,
technical skills, resource utilization, patient outcomes, safety, supervision of
residents, patient privacy and data security concerns, medical record integrity and
compliance, disruptive behaviors and professionalism)
b. Incident Review Committee (ex. system-related issues, sentinel events, never-
events, state-reportable events, potentially compensable cases)
c. Physician Wellness Committee (ex. evaluation and recommended strategies for
treating, coaching/mentoring, monitoring, and privileging physicians with respect to
disruptive behavior, anger management, mental and physical health issues, and
alcohol and drug dependency)
d. UCLA Health Chief Medical and Quality Officer (ex, immediate escalation for sexual
harassment/assault, discrimination, workplace violence, impairment, and
retaliation).
7) Peer review findings that a) are not readily amenable to corrective action at the department-
level, b) represent an ongoing or potential threat to patient safety, c) are below department
expectations for the reasonable delivery of optimal care, or 3) constitute a serious breach
professional, ethical, legal, and/or regulatory standards, are referred to the Medical Staff
Executive Committee and may result in disciplinary action, or trigger a Fair Hearing Process.
8) It is the expectation of the UCLA Health System that all actual or potential adverse events
will be reported in SOFI (Safe Opportunities for Improvement), and that documentation of
peer review minutes and findings will be kept in an approved and secure HIPPA-compliant
peer review database whenever possible (ex. Quality Management Portal, MIDAS, or RL
Solutions).
9) Disruptive Physician Behaviors entered into the SOFI system should be categorized by the
reporter into one of the following categories: a) comments undermining trust; b) failure to
adhere to safety practices; c) failure to respond to patient care needs; d) lack of concern; e)
failure to communicate; f) intimidating/demeaning behavior; g) sexual harassment/assault, h)
discrimination, i) workplace violence, j) impairment, k) retaliation
10) Clinical Data Registries (including but not limited to those in Appendix D) and Health System
supported clinical databases (ex. SOFI, RL Solutions, MIDAS, Box) shall be considered
privileged and confidential under Evidence ode Section 1157 when used for the purpose of
peer-review and improving clinical quality and safety.
11) A summary report of department-based peer review activities shall be submitted to the
Quarterly Governing Body Meeting by the Medical Staff Executive Committee for review and
discussion.

DEPARTMENT-BASED PEER REVIEW OPERATING PLAN AND SCOPE:

COMMUNITY PHYSICIANS

1) All community physicians with medical staff privileges at RRMC, SMH, and NHP shall
be assigned to an accountable hospital department, as outlined in the medical staff bylaws,
for the purpose of meeting organizational and departmental objectives with respect to

Page 18 of 31
 quality, safety, performance improvement, peer review, regulatory and accreditation
requirements, patient experience, value-based care redesign, and population health.
2) Department- and clinical program-based activities and committees designed to improve
patient outcomes shall be considered part of the QAPI program of the Medical Staff
Executive Committee and is privileged and confidential under Evidence Section Code 1157.
3) The clinical departments within RRMC, SMH, and NPH shall be responsible for assuring that
appropriate peer review activities are conducted for all practicing physicians that are assigned
to their departments, including but not limited to:
a. Case review involving a single discipline or specialty;
b. Case review that is multidisciplinary, interdepartmental, and/or interprofessional;
c. Peer review of individual physicians (ex. FPPE or focused professional practice
evaluation);
d. Data review (ex. OPPE or ongoing professional practice evaluation);
e. Clinical registry review (ex. NSQIP, STS, VQI, CHA reports etc.);
f. Educational case review conferences (ex. morbidity and mortality conferences);
g. Case reviews referred by Health Plans or by external providers (outside clinicians
and health care facilities).
h. Case reviews of patient and family complaints and grievances
4) Triggers for peer review of individual physicians include, but are not limited to:
a. Clinical Care
i. Clinical judgment
ii. Technical skills
iii. Resource utilization
iv. Safety concerns
v. Patient outcomes
b. Patient and Family Experience
c. Physician Wellness
d. Disruptive Behaviors
e. Professionalism
5) Department-based peer review activities that require urgent escalation, regardless of
practice site and whether or not there is a DGSOM faculty appointment, should be referred
to the:
a. Medical Staff Executive Committee (ex. serious concerns with clinical judgement,
technical skills, resource utilization, patient outcomes, safety, supervision of
residents, patient privacy and data security concerns, medical record integrity and
compliance, disruptive behaviors and professionalism)
b. Incident Review Committee (ex. system-related issues, sentinel events, never-
events, state-reportable events, potentially compensable cases)
c. Physician Wellness Committee (ex. evaluation and recommended strategies for
treating, coaching/mentoring, monitoring, and privileging physicians with respect to
disruptive behavior, anger management, mental and physical health issues, and
alcohol and drug dependency)
d. UCLA Health Chief Medical and Quality Officer (ex, immediate escalation for
sexual harassment/assault, discrimination, workplace violence, impairment, and
retaliation).
6) Peer review findings that a) are not readily amenable to corrective action at the department-
level, b) represent an ongoing or potential threat to patient safety, c) are below department
expectations for the reasonable delivery of optimal care, or 3) constitute a serious breach
professional, ethical, legal, and/or regulatory standards, are referred to the Medical Staff
Executive Committee and may result in disciplinary action, or trigger a Fair Hearing Process.

Page 19 of 31
7) It is the expectation of the UCLA Health System that all actual or potential adverse events
will be reported in SOFI (Safe Opportunities for Improvement), and that documentation of
peer review minutes and findings will be kept in an approved and secure HIPPA-compliant
peer review database whenever possible (ex. Quality Management Portal, MIDAS, or RL
Solutions).
8) Disruptive Physician Behaviors entered into the SOFI system should be categorized by the
reporter into one of the following categories: a) comments undermining trust; b) failure to
adhere to safety practices; c) failure to respond to patient care needs; d) lack of concern; e)
failure to communicate; f) intimidating/demeaning behavior; g) sexual harassment/assault, h)
discrimination, i) workplace violence, j) impairment, k) retaliation
9) Clinical Data Registries (including but not limited to those in Appendix D) and Health System
supported clinical databases (ex. SOFI, RL Solutions, MIDAS, Box) shall be considered
privileged and confidential under Evidence ode Section 1157 when used for the purpose of
peer-review and improving clinical quality and safety.
10) A summary report of department-based peer review activities shall be submitted to the
Quarterly Governing Body Meeting by the Medical Staff Executive Committee for review and
discussion.

APPENDIX A - DEFINITIONS

Adverse Event: as defined by DPH (CA Health and Safety Code 1279.1), events that cause the
death or serious disability of patients, personnel or visitors. (See Appendix B for a list of Adverse
Events)

Adverse Event Investigation: Investigation that may lead to a causal analysis of a non-Sentinel
Event based on framework described in the Root Cause Analysis and Adverse Event Policy.

Causal Analysis: A structured or informal approach for identifying the basic or causal factor(s)
that underlie variation in performance, to prevent recurrence of untoward events.

Clinical Service: Clinical service refers to clinical services of the UCLA Medical Center Medical
Staff.

Department: Department refers to departments of the Medical Center (e.g., nursing, pharmacy,
clinical laboratory, hospital epidemiology).

Disclosure: Providing information to the patient or the patient’s family regarding a sentinel event,
or substantive near-miss accident according to the guidelines of the organization’s disclosure
policy.

Error: An unintended act, either of omission or commission, or an act that does not achieve its
intended outcome.

Hazardous Condition: Any set of circumstances (exclusive of the disease or condition for which
the patient is being treated) that significantly increases the likelihood of a serious adverse
outcome.

Page 20 of 31
Incident: An untoward, undesirable, and usually unanticipated event in a health care organization.
Incidents such as patient falls or improper administration of medications are also considered
incidents even if there is no permanent effect on the patient.
Intentional Unsafe Acts: Intentional unsafe acts, as they pertain to patients, are any events that
result from: a criminal or reckless act, a purposefully unsafe act; an act related to alcohol or
substance abuse, impaired provider/staff; or events involving alleged or suspected patient abuse
of any kind. Intentional unsafe acts should be addressed in consultation with Human Resource
Specialists.

Just Culture: Encourages personal accountability, provides a safe place to report errors, and
seeks to learn from mistakes to improve the overall safety of the system.

National Patient Safety Goals: These are evidence based requirements approved by the Joint
Commission’s Board of Commissioners that reflect optimal patient safety practices.

Near Miss: A Near Miss is an event or situation that could have resulted in an accident, injury or
illness, but did not, either by chance or through timely intervention (e.g., surgical or other procedure
almost performed on the wrong patient due to lapses in verification of patient identification but
caught at the last minute by chance). Near Misses are learning opportunities and afford the chance
to develop preventive strategies and actions. Near Misses are evaluated in the same manner as
adverse events that result in actual injury.

Patient Safety Practice: A clearly recognizable process or manner of providing care that has an
evidence base demonstrating that it reduces the likelihood of harm due to systems, processes or
environments of care.

Performance Improvement Practice: A clearly recognizable process or manner of providing

care that has an evidence base demonstrating that it improves outcomes of care.

Personal Accountability: The individual involved in the error (potential or actual) will participate
in reporting the error, determining what went wrong, identifying a solution, participating in
discussions about the error, and taking an active part in improving the system.

Prevention: A future-oriented process that improves performance and productivity; a philosophy

of never-ending improvement.

Punitive or Disciplinary Action: The recording of a reported medical/health care error in an

employee’s permanent file for use during the evaluation process for promotion, salary increases,
or references. The requirement of an individual to undergo continuing education, competency
training or assessment, or an individual educational plan is not a punitive or disciplinary action.

Redesign: Changing a process to create a more effective or safer environment.

Root Cause Analysis: performed for an identified or potential sentinel event as defined by the
JC, is a highly structured process for assessing the basic or root factor(s) that underlie the incident
and identifying opportunities for risk elimination. Analysis focuses on processes and systems, not
individuals.

Sentinel Event: As defined by the JC, an unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb

Page 21 of 31
or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence
would carry a significant chance of a serious adverse outcome. See Appendix B for examples of
Sentinel Events and Appendix C for example of incidents not considered Sentinel Events.

Specific definitions related to medication events (i.e., medication errors, adverse drug events,
adverse drug reactions, and specific medication events) are included in the Medication Events
Policy.

APPENDIX B – ADVERSE EVENT DEFINITIONS

CMS HOSPITAL ACQUIRED CONDITIONS (HAC)

1. Foreign object retained after surgery
2. Air embolism
3. Blood incompatibility
4. Pressure ulcer stage III & IV
5. Falls and trauma
6. Catheter-associated urinary tract infection (UTI)
7. Vascular catheter-associated infection
8. Poor glycemic control
9. Surgical site infection (CABG, Ortho, Bariatric, CIED)
10. Deep vein thrombosis and pulmonary embolism (following total knee and hip)
11. Iatrogenic pneumothorax with venous catheterization

CALIFORNIA DEPARTMENT OF HEALTH ADVERSE EVENTS

Surgical events
1. Wrong body part
2. Wrong patient
3. Wrong procedure
4. Unintentional retention of foreign object
5. Unexpected death during surgery or within 24 hours after anesthesia begins

Product or device events

1. Death/serious disability associated with use of contaminated drug/device/biologic
2. Death/serious disability associated with use/function in ways other than intended
3. Death/serious disability associated with intravascular air embolism, excluding during
certain neurosurgical procedures

Patient protection events

1. Infant discharged to wrong person
2. Death/serious disability associated with patient disappearance for more than four hours
(excluding adults with capacity)
3. Patient suicide or attempted suicide in the facility resulting in death/serious disability

Care management events

1. Death/serious disability associated with a medication error
2. Death/serious disability associated with administration of ABO-incompatible blood or blood
products
3. Maternal death/serious disability associated with labor or delivery in a low-risk pregnancy
(with some exclusions)
4. Death/serious disability related to hypoglycemia, onset in hospital

Page 22 of 31
 5. Death/serious disability associated with failure to identify and treat hyperbilirubinemia in
neonates during first 28 days of life
6. Stage 3, 4 or unstageable ulcer acquired after admission (unless progression to Stage 3
was from a Stage 2 identified at admission)
7. Death/serious disability from spinal manipulation at hospital

Environmental events
1. Death/serious disability associated with an electric shock (excluding planned treatments)
2. Any incident where line designated for oxygen or other gas contains wrong gas or is
contaminated by toxic substance
3. Death/serious disability associated with burn in facility
4. Death associated with fall in facility
5. Death/serious disability associated with restraints/bedrails

Criminal events
1. Care ordered or provided by someone impersonating licensed health care provider
2. Abduction of patient, any age
3. Sexual assault of patient
4. Death or significant injury of patient or staff resulting from physical assault
5. Any adverse event that causes death or serious disability of a patient, personal or visitor.

MEDICAL PROVIDER PREVENTABLE CONDITIONS

OPPCs are defined as:
• Wrong surgical or other invasive procedure performed on a patient
• Surgical or other invasive procedure performed on the wrong body part
• Surgical or other invasive procedure performed on the wrong patient

HCACs are defined as:

• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection (UTI)
• Falls and trauma that result in fractures, dislocations, intracranial injuries, crushing
injuries, burns and electric shock
• Foreign object retained after surgery
• Iatrogenic pneumothorax with venous catheterization
• Manifestations of poor glycemic control
 Diabetic ketoacidosis
 Nonketotic hyperosmolar coma
 Hypoglycemic coma
 Secondary diabetes with ketoacidosis
 Secondary diabetes with hyperosmolarity
• Stage III and IV pressure ulcers
• Surgical site infection following:
 Mediastinitis following coronary artery bypass graft (CABG)
 Bariatric surgery, including laparoscopic gastric bypass, gastroenterostomy, and
laparoscopic gastric restrictive surgery
 Orthopedic procedures for spine, neck, shoulder, and elbow
 Cardiac implantable electronic device (CIED) procedures
• Vascular catheter-associated infection
Page 23 of 31
 • For non-pediatric/obstetric population, deep vein thrombosis (DVT)/pulmonary embolism
(PE) resulting from:
 Total knee replacement
 Hip replacement

Frequently Asked Questions about PPCs can be found on this website:

http://www.dhcs.ca.gov/individuals/Pages/PPCFAQ.aspx

JOINT COMMISSION SENTINEL EVENT DEFINITIONS

• Any patient death, paralysis, coma, or other major permanent loss of function associated
with a medication error.
• A patient commits suicide within 72 hours of being discharged from a hospital setting that
provides staffed around the clock care.
• Any elopement, that is unauthorized departure, of a patient from an around the clock care
setting resulting in a temporally related death (suicide, accidental death, or homicide) or
permanent loss of function.
• Surgery on the wrong side of the patient’s body.
• Any intrapartum (related to the birth process) maternal death.
• Any perinatal death unrelated to a congenital condition in an infant having a birth weight
greater than 2,500 grams.
• A patient is abducted from the hospital where he or she receives care, treatment, or
services.
• Assault, homicide, or other crime resulting in patient death or major permanent loss of
function.
• A patient fall that results in death or major permanent loss of function as a direct result of
the injuries sustained in the fall.
• Hemolytic transfusion reaction involving major blood group incompatibilities.
• A foreign body, such as a sponge or forceps that was left in a patient after surgery.

EXAMPLES OF INCIDENTS NOT CONSIDERED TO BE SENTINEL EVENTS AS DEFINED BY

THE JOINT COMMISSION

• Any “near miss.”

• Full or expected return of limb or bodily function to the same level as prior to the incident
by discharge or within two weeks of the initial loss of said function.
• Any sentinel event that has not affected a recipient of care.
• Medication errors that do not result in death or major permanent loss of function.
• Suicide other than in an around the clock care setting or following elopement from such a
setting.
• A death or loss of function following a discharge “against medical advice (AMA).”
• Unsuccessful suicide attempts unless resulting in major permanent loss of function.
• Minor degrees of hemolysis not caused by a major blood group incompatibility and with no
clinical sequelae.

Page 24 of 31
 APPENDIX C: QUALITY INITIATIVES AND REPORTING FREQUENCY

UCLA Ronald Reagan and Santa Monica Medical Center

Quality Initiatives and Reporting Frequency
FY 2020

Quality Measure Mandatory Publicly RR Process SM Process Reporting

Reported Frequency

INPATIENT QUALITY REPORTING PROGRAM (IQR)

ED Throughput Core Measure Federal Yes QMS Chart QMS Chart Monthly
(ED-1 & ED-2) Abstraction Abstraction

eED-1, eED-2 Federal No eCQM eCQM Annually

Immunization Influenza Core Federal Yes QMS Chart QMS Chart Monthly
Measure Abstraction Abstraction

Stroke GWTG & Federal Yes QMS Chart QMS Chart Monthly
Comprehensive Stroke Abstraction Abstraction
Measures
eStroke- 2,3,5,6 Federal No eCQM eCQM Annually

Venous Thromboembolism Federal Yes QMS Chart QMS Chart Monthly

(VTE-6) Core Measure Abstraction Abstraction

Perinatal Core Measure Federal Yes QMS Chart QMS Chart Monthly
Abstraction Abstraction

AMI, HF, PN, Stroke, COPD Federal Yes Administrative Administrative Monthly
and CABG Mortality Claims Claims
Patient Experience- HCAHPS Federal Yes Survey-PI Teams Pt. Affairs- NRC Monthly
Picker
Pt. Survey
results
AMI, HF, PN, THA/TKA, Federal Yes Chart Abstraction- Chart Monthly
COPD, Stroke, CABG and All Multi-disciplinary Abstraction-
Cause 30 Day Readmission Team Multi-disciplinary
Peer review Team
Peer review
AHRQ Patient Safety Federal Yes Administrative Administrative Monthly
Indicators- Claims, Validation, Claims,
PSI 90 Composite Score- Multi-disciplinary PI Validation, Multi-
(Pressure Ulcer [Stages III and Team disciplinary PI
IV]; Iatrogenic Pneumothorax; Team
Post-op Hip Fracture; Post-op
Hemorrhage or Hematoma;
Post-op Physiologic and
Metabolic Derangement; Post-
op Respiratory Failure; Post-
Page 25 of 31
 Quality Measure Mandatory Publicly RR Process SM Process Reporting
Reported Frequency
op Pulmonary Embolism (PE)
or Deep Vein Thrombosis
(DVT); Post-op Sepsis; Post-
op Wound Dehiscence; and
Accidental Puncture or
Laceration)
AHRQ Patient Safety Federal Yes Administrative Administrative Monthly
Indicators- Claims, Validation, Claims,
PSI 4 (Death Among Surgical Multi-disciplinary PI Validation, Multi-
Inpatients) Team disciplinary PI
Team

Cardiac Surgery Registry Federal Yes Chart Abstraction- N/A Quarterly

QMS/Direct
Difference

Nurse Sensitive Database Federal Yes Chart Abstraction, Chart Quarterly

Prevalence Study- Abstraction,
Nursing Prevalence
Study-Nursing

General Surgery Registry Federal Yes Chart Abstraction- N/A Quarterly

QMS

Safe Surgery Checklist Federal Yes Submitted via Q- Submitted via Q- Annually
Net Net

Patient Safety Culture Federal Yes Submitted via Q- Submitted via Q- Annually
Net Net

Hospital Acquired Catheter Federal Yes Chart Abstraction- Chart Monthly

Associated Urinary Tract NHSN Abstraction-
Infection (CAUTI) CUSP NHSN
Multi-disciplinary
Team
Hospital Acquired Central Line Federal Yes Chart Abstraction- Chart Monthly
Bloodstream Infection (CLABI) NHSN Abstraction-
Multi-disciplinary NHSN
Team Multi-disciplinary
Team
Surgical Site Infection within Federal Yes Chart Abstraction- Chart Monthly
30 Days NHSN Abstraction-
CUSP NHSN
Multi-disciplinary
Team
Hospital Acquired MRSA Federal Yes Chart Abstraction- Chart Monthly
Bacteremia NHSN Abstraction-
NHSN

Page 26 of 31
 Quality Measure Mandatory Publicly RR Process SM Process Reporting
Reported Frequency
Multi-disciplinary
Team

Hospital Acquired Clostridium Federal Yes Chart Abstraction- Chart Monthly

Difficile NHSN Abstraction-
NHSN
Multi-disciplinary
Team
Healthcare Personnel Federal Yes Data entry Data entry Annually
Influenza Vaccine employee health employee health
Medicare Spending per Federal No Administrative Administrative Annually
Beneficiary
OUTPATIENT QUALITY REPORTING (OQR)
ED-3 Throughput Core Federal Yes QMS Chart QMS Chart Monthly
Measure Abstraction Abstraction
ED-Chest Pain/Acute Federal Yes QMS Chart QMS Chart Monthly
Myocardial Infarction Abstraction Abstraction
ED-Stroke Federal QMS Chart QMS Chart Monthly
Abstraction Abstraction

MRI Lumbar Spine for low Federal Yes Administrative Administrative Quarterly
back pain Claims Claims
Mammography Follow-up Federal Yes Administrative Administrative Quarterly
Claims Claims
Abdomen CT with Contrast Federal Yes Administrative Administrative Quarterly
Claims Claims
Thoracic CT with Contrast Federal Yes Administrative Administrative Quarterly
Claims Claims
Cardiac Imaging for Pre-op Federal Yes Administrative Administrative Quarterly
Risk Assessment for Low Risk Claims Claims
Patients
Simultaneous Use of Brain CT Federal Yes Administrative Administrative Quarterly
and Sinus CT Claims Claims
ED-Head CT Scan Results for Federal Yes Administrative Administrative Quarterly
Acute Ischemic or Claims Claims
Hemorrhagic Stroke who
Received Head CT Scan
Interpretation Within 45
minutes of Arrival.

Endoscopy/Polyp Surveillance Federal Chart Chart Quarterly

Appropriate Follow-up Interval Abstraction/QNET Abstraction/QNE
for Normal Colonoscopy in T
Average Risk Patients

Page 27 of 31
 Quality Measure Mandatory Publicly RR Process SM Process Reporting
Reported Frequency
Endoscopy/Polyp Surveillance: Federal Chart Chart Quarterly
Colonoscopy Interval for Abstraction/QNET Abstraction/QNE
Patients with a History T

Tracking Clinical Visits Federal Administrative Administrative Quarterly

Between Visits Claims Claims

ED Left Without Being Seen Federal No QNET QNET Annually

Surgical Safety Checklist Federal QNET QNET Annually

Influenza Vaccination Federal QNET QNET Annually

Coverage among Healthcare
Personnel
Volume data on selected Federal QNET QNET Annually
surgical procedures
VALUE BASED PURCHASING (VBP)
AMI, HF, PN, COPD and Federal Yes Administrative Administrative Monthly
CABG Mortality Claims Claims

Hospital Acquired Infection Federal Yes Surveillance- Surveillance- Monthly

(CLABSI, CAUTI, SSI, MRSA, NHSN NHSN
C.diff)
THA/TKA Complications Federal Yes Administrative Administrative Monthly
Claims Claims

Patient Experience- HCAHPS Federal Yes Survey-PI Teams Pt. Affairs- NRC Monthly
Picker
Pt. Survey
results
Payment-Standardized Federal Yes Administrative Administrative Quarterly
Medicare Spending Per Claims-Data Claims-Data
Beneficiary (MSPB) validation validation

HOSPITAL ACQUIRED CONDITIONS (HAC) REPORTING PROGRAM

AHRQ Patient Safety Federal Yes Administrative Administrative Monthly
Indicators- Claims, Validation, Claims,
PSI 90 Composite Score- Multi-disciplinary PI Validation, Multi-
(Pressure Ulcer [Stages III and Team disciplinary PI
IV]; Iatrogenic Pneumothorax; Team
Central Venous Catheter
Related Bloodstream Infection;
Post-op Hip Fracture; Post-op
Hemorrhage or Hematoma;
Post-op Physiologic and
Metabolic Derangement; Post-
op Respiratory Failure; Post-
op Pulmonary Embolism (PE)
or Deep Vein Thrombosis

Page 28 of 31
 Quality Measure Mandatory Publicly RR Process SM Process Reporting
Reported Frequency
(DVT); Post-op Sepsis; Post-
op Wound Dehiscence; and
Accidental Puncture or
Laceration)
Hospital Acquired Infection Federal Yes Surveillance- Surveillance- Monthly
(CLABSI, CAUTI, SSI, MRSA, NHSN/Administrati NHSN/Administr
C.diff) ve Claims ative Claims
HOSPITAL READMISSIONS REDUCTION PROGRAM (HRRP)
AMI, HF,PN, THA/TKA,COPD, Federal Yes Administrative Administrative Monthly
and CABG readmissions Claims-Data Claims-Data
validation validation

JOINT COMMISSION REQUIRED MEASURES

ED Throughput TJC Yes Abstraction- QMS Abstraction- Monthly
QMS
eED-1; eED-2 TJC No eCQM eCQM Annually

Perinatal TJC Yes Abstraction- QMS Abstraction- Monthly

QMS
eStroke-2,3,5,6 TJC No eCQM eCQM Annually

VTE-6 TJC Yes Abstraction- QMS Abstraction- Monthly

QMS
Immunization TJC Yes Abstraction- QMS Abstraction- Monthly
QMS
PE and DVT (PSI) Federal Administrative Administrative Monthly
Claims Claims-
Validation;
Multi-
Disciplinary
Team
Readmission 30 Day All Federal Yes Administrative Administrative Monthly
Cause Claims Claims-
Validation;
Multi-
Disciplinary
Team
Adverse Drug Event- C- Federal Administrative Administrative Monthly
Difficile due to antibiotic Claims Claims-
exposure Validation;
Multi-
Disciplinary
Team
Adverse Drug Event- Federal Administrative Administrative Monthly
Hemorrhage due to Claims Claims-
anticoagulant exposure Validation;

LEAPFROG

Page 29 of 31
 Quality Measure Mandatory Publicly RR Process SM Process Reporting
Reported Frequency
Computerized Physician Order No Yes Hospital Survey Hospital Survey Annually
Entry
ICU Physician Staffing No Yes Hospital Survey Hospital Survey Annually
Leadership Structures and No Yes Hospital Survey Hospital Survey Annually
Systems
Culture Measurement, Feedback No Yes Hospital Survey Hospital Survey Annually
and Interventions
Teamwork Training and Skill No Yes Hospital Survey Hospital Survey Annually
Building
Identification and Mitigation of No Yes Hospital Survey Hospital Survey Annually
Risks and Hazards
Nursing Workforce No Yes Hospital Survey Hospital Survey Annually
Medication Reconciliation No Yes Hospital Survey Hospital Survey Annually
Hand Hygiene No Yes Hospital Survey Hospital Survey Annually
Care of Ventilated Patient No Yes Hospital Survey Hospital Survey Annually
SCIP Antibiotic Timing Federal Yes CMS Hospital CMS Hospital Monthly
Compare Compare
Concurrent Rounds Concurrent
Rounds
SCIP Antibiotic Selection Federal Yes CMS Hospital Concurrent Monthly
Compare Rounds
Concurrent Rounds Concurrent
Rounds

APPENDIX D: List of Clinical Data Registries

FY 2020

Name of Data Registry Measures Associated with Registry Clinical Department

STS Adult, Congenital & Thoracic 21 NQF measures Cardiac Surgery
CCORP/OSHPD 30 day mortality, DSWI, IMA, usage, stroke Cardiac Surgery
NCDR ICD- RR & SMH CMS mandatory registry for implantable Cardiac Intervention
NCDR PCI RR & SMH STEMI Core Measures Cardiac Intervention
NCDR Action All GWTG Core Measures Cardiac Intervention
NCDR-IMPACT ACHD measures Cardiac Intervention
CMS mandatory registry for valve
NCDR-TVT replacement Cardiac Intervention
Vascular perioperative and one year follow-
VQI up data Vascular Surgery
Acute ischemic stroke and cerebral
NVQI aneurysm Neurology
NSQIP Surgical perioperative and 30 days post-op General Surgery
Pediatric NSQIP Surgical perioperative and 30 days post-op Pediatric Surgery
MBASQIP Bariatric periop and postop General Surgery
Outcome-GWTG Heart Failure JC and GWTG measures Cardiology
Outcome-GWTG AMI JC and GWTG measures Cardiology
Outcome-GWTG Stroke JC and GWTG measures Neurology

Page 30 of 31
Outcome-GWTG Resuscitation Cardiopulmonary arrest Critical Care Committee
Virtual PICU (VPS) Demographics and clinical plus follow-up Pediatric Surgery
CHA Administrative upload only Pediatric
Temporary life supports for pts with
ELSO-ECMO reversible cardiac and respiratory failure Cardiac Intervention
Interagency registry for mechanically
Intermac-VAD assisted circulatory support Cardiac Intervention
LAAO (Left Atrial Appendage Watchman device implantation for atrial
Occlusion Registry fibrillation/stroke prevention Cardiac Intervention
Mandatory donor registry for pts in heart
UNOS-Heart Transplant waiting list Heart/Lung Program
Mandatory donor registry for pts in lung
UNOS-Lung Transplant waiting list Heart/Lung Program
Mandatory donor registry for pts in liver
UNOS-Liver/Intestine Transplant waiting list Liver Program
Mandatory donor registry for pts in
UNOS-Pancreas Transplant pancreas waiting list Pancreas Program
Mandatory donor registry for pts in kidney
UNOS-Kidney Transplant waiting list Kidney Program
Living Donor Paired Exchange NKF-donor registry for living donors Kidney Program
Graft survival rates of heart transplant
SRTR-Heart Transplant Recipients recipients Heart/Lung Program
Graft survival rates of lung transplant
SRTR-Lung Transplant Recipients recipients Heart/Lung Program
SRTR-Liver/Intestines Transplant Graft survival rates of liver transplant
Recipients recipients Liver Program
SRTR-Pancreas Transplant Graft survival rates of pancreas transplant
Recipients recipients Pancreas Program
Graft survival rates of kidney transplant
SRTR-Kidney Transplant Recipients recipients Kidney Program
Cancer cases abstracted & survivor follow-
CCSP - Cancer Surveillance up Oncology
Facilitates the identification of perinatal
NICU-CPQCC improvement targets Pediatric
Reduction of maternal morbidity from
OB CMQCC CPMS (California) hemorrhage Obstetrics

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