Assessments

An important aspect of the role of the CEQS is the assessment process, which assures that the necessary discipline of departments to draw conclusions about the collected measures and the need for more intensive measurement. We will employ a systematic process to assess collected data in order to determine whether specifications for newly designed processes were met. 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.

Collected data is reported weekly and analyzed monthly. Findings are documented and are forwarded through the CEQ communication structure. Quarterly reports are compiled through the PQSPR and reviewed by leadership (need to specify here). Reports include the following:

Variance Report

CEQ will use online variance reporting to identify events or occurrences requiring rapid problem solving. Variances patient safety issues are forwarded to the appropriate discipline or department for investigation and reported to external agencies in accordance with law and regulation, resolution, tracking and trending. Any employee or physician who witnesses an unusual or unexpected event, which has the potential to result in an undesirable outcome for the patient, may initiate variance reports. Risk reduction and appropriate problem solving will be documented, tracked and trended. A Harm Score Distribution is used to assess the degree of risk. Certain serious outcomes will be reported to JACHO and other regulatory agencies as required. Monthly results are reported to Leadership Team and action taken as appropriate.

Patient Satisfaction

Press Ganey patient satisfaction surveys are utilized to evaluate the needs and expectations of patients including safety needs. Leadership reviews a summary of the findings quarterly. When opportunities for improvement are identified, pertinent information is forwarded to the appropriate department or individual for review, evaluation, and action as necessary.