History The Center for Clinical Effectiveness and Patient Safety was developed by Dr. John Heffner (Executive Medical Director 2001-2006) and Rosemary Ellis (Director of Quality 2001-2007) for the purpose of developing partnerships throughout the medical center in order to improve the systems of care for the patients. This Center’s current leader is Dr. Patrick Cawley (Executive Medical Director 2006-present), The Center has two divisions: Quality/Patient Safety and Clinical Effectiveness. Quality/Patient Safety is currently led by Christopher Rees as the Interim Director of Quality/Patient Safety and Mary-Eliese Merrill as the Director of Clinical Effectiveness. The Quality Division includes the following areas: Critical Intervention Management, Joint Commission Coordination, Infection Control, Medical Staff Affairs, Medical Staff Credentialing, Outcomes Management, Patient/Family Liaison Office, Performance Improvement, and Risk Management. The Clinical Effectiveness Division includes the following areas: Diabetes Management Service, Home Health, Medical Social Work, and Nurse Case Management. Mission Facilitate clinical care by focusing on excellence in all aspects of quality health: safe, effective, efficient, patient centered, timely, and equitable. Vision To be a leader of quality and patient safety implementation in South Carolina and the nation Motto Improving health through collaboration Strategic Objectives 2006-2009 (we have focused our strategic objectives in two areas): 1. Quality: The degree to which healthcare increases the likelihood of desired health outcomes and are consistent with current professional knowledge. There are six domains of quality: safe, effective, efficient, patient centered, timely, and equitable. a) Improve mortality index Current focus (March 2008): This objective was adopted as an organization wide goal. Current improvement efforts are focused on each service line developing a multidisciplinary review of every patient death to include not only the clinical issues but the documentation and coding issues as well. Additionally, each service line is encouraged to have data transparency with all its clinicians in order to provoke further quality improvement efforts. Each section of CCEPS is focused on a variety of methods to improve mortality. For example, the Diabetes Management Service is collaborating with the Division of Endocrinology in a Hyperglycemia Improvement Project whose focus is to improve the results of hyperglycemia management across the entire enterprise.
b) Improve system operational efficiency Current focus (March 2008): Current improve efforts in this area are focused on continued development of the new MUSC service line organizational structure. Four service lines became operational on 7/1/07. Eight additional services lines are scheduled to become operational on 7/1/08. Each service line goes through a deliberate planning process beginning with strategic planning and continuing through midlevel design and process planning. An early area of focus this year will be the beginning of a similar planning process for shared services.
Another major effort currently underway is to continue to mature the concept of case management at MUSC.
Finally, the department is broadly supporting the rollout of eCareNet
2. Patient Safety: Prevention and mitigation of harm to patient-centeredness a) Improve culture of safety Current focus (March 2008): The patient safety process is in the middle of an organizational restructuring. The organization has outgrown the original Patient Safety Committee structure. Current planning and implementation is focused on the development of patient safety officers within each service line and shared service. This PSOs will constitute the organization’s new Patient Safety Committee which will be chaired by the Director of Quality and Patient Safety. Additionally, a new outcomes manager position is planned with the major focus being the coordination and development of service line specific patient safety scorecards. Each scorecard will evaluate the service line in the following areas: Regulatory Safety Compliance, Culture of Safety (from physicians, employees, patients, and safety survey), Error Reporting, and Safety Innovation.
b) Develop problem solving skills of leaders Current focus (March 2008): Two education programs have been developed. The first is a small time intensive program in collaboration with the College of Health Professions (CHP). This program is led by the Director of Quality & Patient Safety and include weekly lectures and hands on coaching through a quality improvement project. It teams a hospital leader with a CHP MHA student. The second education program is predominantly focused on those groups going through service line or shared service planning. It focuses on process design, variance analysis, and service level agreement training. The plan is to develop and widen the scope of each of these trainings over the next year to include all hospital leaders that attend the quarterly Leadership Development Initiatives. Each service line leader and departmental leader will undergo a formal leadership evaluation which will result in a action plan for continued leadership development.
Pillar Goals Each CCEPS leader takes in the MUSC Excellence program which consists of quarterly Leadership Development Institutes and an objective evaluation process. The evaluation process is based on the MUSC Excellence metrics framework in the areas of People, Service, Quality, Growth, and Finance. Dr. Cawley's blog
http://c-vapp-mrkt1/medblog/default.aspx Committee Reports (password protected)
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