UNC Provider Orientation

Continuous Quality Improvement

Key Accrediting Agencies

AgencyFull NameNext Visit / Visit FrequencyJCAHOCMSJoint Commission for the Accreditation of Healthcare OrganizationsCenter for Medicare and Medicaid ServicesMarch 2005 & then unannounced every 3 years & as randomly selectedAs needed for patient complaint follow-up & JCAHO validationDFSAs needed for patient complaint follow-up & JCAHO validation

Department of Facility Services, State of North Carolina

Physician Role with JCAHO and CMS surveysBe familiar with and practice to the standards related to their areas of expertise (i.e. infection control, sedation/analgesia, tissue) and comply with National Patient Safety GoalsMember of the Department or unit-level care teamParticipates in survey as requestedWorks with JCAHO/CMS teams working for ongoing enhancement and compliance

National Patient Safety Goals1. Improve the accuracy of patient identification. a. use at least two patient identifiers (neither to be the patient's room number) whenever taking blood samples or administering medications or blood products. b. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure and site, using activenot passivecommunication techniques.2. Improve the effectiveness of communication among caregivers. a. Implement a process for taking verbal or telephone orders that require a verification "read-back" of the complete order by the person receiving the order. b Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.3. Improve the safety of using high-alert medications. a. Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. b. Standardize and limit the number of drug concentrations available in the organization.4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery. a. Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. b. Implement a process to mark the surgical site and involve the patient in the marking process.5. Improve the safety of using infusion pumps. a. Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.6. Improve the effectiveness of clinical alarm systems. a. Implement regular preventive maintenance and testing of alarm systems. b. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.

IMPACT CARE

APerformance Measurement and Improvement System: Organization wide and Department & Unit-Level

Definition of QualityThe UNC Health Care system embraces the philosophy of continuous quality improvement. The IMPACT CARE concept defines quality as "meeting or exceeding the needs of our customers." Therefore, a product or service is viewed to be quality only if it meets (or exceeds) customer's needs or expectations.

IMPACT CAREIMPACT

CARE

IDENTIFYMONITORPRIORITIZEACTION PLANCHECKTRANSFORMCUSTOMER SATISFACTIONACHIEVED OUTCOMESREDUCED COSTEMPLOYEE OWNERSHIPMonitor ReportHospital ReportBoard ReportFORKey customers, scope of care or services, key activities, corporate goals, quality improvement goals, cost, satisfaction, survey results, and other indicatorsIndicators as aboveIdentify opportunities for Improvement; prioritize based on impact on service, outcome, cost; set goalsImplement (AIDE teams, etc.)Re-monitor, analyze dataInstitutionalize or generalize

IMPACT CARE REPORTTeam Name: 7 NorthDate: 2001-2002

]Data

Line ChartControl ChartSTRATEGIC GOALCATEGORYINDICATORGOAL FROM TOJan-01Feb-01Mar-01Apr-01May-01Jun-01Jul-01Aug-01Sep-01Oct-01Nov-01Dec-01

CUSTOMER SATISFACTION

Improve PatientPatient/FamilyOverall Rating of Care Given82.090.080.382.480.582.583.684.084.385.387.187.187.586.1

3SatisfactionPatient/FamilyStaff worked together for you83.684.383.785.285.985.687.687.787.489.490.489.2

(Press Ganey)CleanlinessCleanliness of room82.082.482.383.785.085.685.986.787.388.189.087.8

OUTCOME

1Improve PatientPatientMed Variance Rate (per 100 pt days)0.00.00.04.55.44.53.63.62.72.73.62.71.80.91.8

2OutcomesPatientPatient Falls per month5.06.05.04.04.03.03.04.03.02.01.02.0

COST

Reduce CostsStaffingFTE per adjusted patient day6.26.26.15.95.86.35.85.35.75.55.65.4

VarianceExpenses vs. budget$5,000$1,500$5,210$4,75015%12%10%12%14%9%10%8%12%10%

&C&"Arial,Bold"&16IMPACT CARE REPORT - 7 NORTH

&LConfidential - For internal use only to supportquality/performance improvement. Do not copy.&C&D&RSource: I made it all up!!!!!!!!! Data is not trimmed, stratified or severity adjusted.

]ControlChart

&C&"Arial,Bold"&14IMPACT CARE CONTROL CHARTS FOR 7 NORTH

&LConfidential - For internal use only to supportquality/performance improvement. Do not copy.&C&D&RSource: I Made it all up!!! Data is not trimmed, stratified or severity adjusted.

]ControlChart

02.90769230775.95122264650

4.52.90769230775.95122264650

5.42.90769230775.95122264650

4.52.90769230775.95122264650

3.62.90769230775.95122264650

3.62.90769230775.95122264650

2.72.90769230775.95122264650

2.72.90769230775.95122264650

3.62.90769230775.95122264650

2.72.90769230775.95122264650

1.82.90769230775.95122264650

0.92.90769230775.95122264650

1.8

Staff worked together for you

Mean

UCL

LCL

Outcome - Med Variance Rate (per 100 pt days)

]Buttons

368923.63636363646.50310077430.7696264984

53.63636363646.50310077430.7696264984

63.63636363646.50310077430.7696264984

53.63636363646.50310077430.7696264984

43.63636363646.50310077430.7696264984

43.63636363646.50310077430.7696264984

33.63636363646.50310077430.7696264984

33.63636363646.50310077430.7696264984

43.63636363646.50310077430.7696264984

33.63636363646.50310077430.7696264984

23.63636363646.50310077430.7696264984

13.63636363646.50310077430.7696264984

Staff worked together for you

Mean

UCL

LCL

Outcome - Patient Falls per month

]ControlChartData

3689286.429541021890.959047506581.9000345371

83.594025463986.429541021890.959047506581.9000345371

84.321639127186.429541021890.959047506581.9000345371

83.660257482286.429541021890.959047506581.9000345371

85.151952302286.429541021890.959047506581.9000345371

85.851650641586.429541021890.959047506581.9000345371

85.62305876786.429541021890.959047506581.9000345371

87.628100779686.429541021890.959047506581.9000345371

87.717063061786.429541021890.959047506581.9000345371

87.374472396586.429541021890.959047506581.9000345371

89.438843878886.429541021890.959047506581.9000345371

90.363887339686.429541021890.959047506581.9000345371

Overall Rating of Care Given

Mean

UCL

LCL

Customer Satisfaction - Staff worked together for you

12Jan-01Feb-01Mar-01Apr-01May-01Jun-01Jul-01Aug-01Sep-01Oct-01Nov-01Dec-01

1Mean2.90769230772.92.92.92.92.92.92.92.92.92.92.9

1UCL5.95122264656.06.06.06.06.06.06.06.06.06.06.0

1LCL00.00.00.00.00.00.00.00.00.00.00.0

2Mean3.63636363643.63.63.63.63.63.63.63.63.63.63.6

2UCL6.50310077436.56.56.56.56.56.56.56.56.56.56.5

2LCL0.76962649840.80.80.80.80.80.80.80.80.80.80.8

3Mean86.429541021886.486.486.486.486.486.486.486.486.486.486.4

3UCL90.959047506591.091.091.091.091.091.091.091.091.091.091.0

3LCL81.900034537181.981.981.981.981.981.981.981.981.981.981.9

4Mean84.0

4UCL89.1

4LCL79.0

5Mean86.4

5UCL91.0

5LCL81.9

6Mean85.3

6UCL90.1

6LCL80.4

7Mean

7UCL

7LCL

8Mean

8UCL

8LCL

9Mean

9UCL

9LCL

10Mean

10UCL

10LCL

11Mean

11UCL

11LCL

12Mean

12UCL

12LCL

13Mean

13UCL

13LCL

14Mean

14UCL

14LCL

15Mean

15UCL

15LCL

MBD00047CF3.unknown

MBD053D02D6.unknown

MBD05E55E6C.unknown

MBD01A82E29.unknown

MBD053C2991.unknown

MBD0004991B.unknown

MBD00000064.unknown

MBD000000C8.unknown

IMPACT CARE Control charts

Chart1

4.53.155.75279569970.5472043003

5.43.155.75279569970.5472043003

4.53.155.75279569970.5472043003

3.63.155.75279569970.5472043003

3.63.155.75279569970.5472043003

2.73.155.75279569970.5472043003

2.73.155.75279569970.5472043003

3.63.155.75279569970.5472043003

2.73.155.75279569970.5472043003

1.83.155.75279569970.5472043003

0.93.155.75279569970.5472043003

1.83.155.75279569970.5472043003

86.200410163391.16796289281.2328574345

86.200410163391.16796289281.2328574345

86.200410163391.16796289281.2328574345

86.200410163391.16796289281.2328574345

Indicator

Mean

UCL

LCL

Outcome - Med Variance Rate (per 100 pt days)

Data

Line ChartControl ChartSTRATEGIC GOALCATEGORYINDICATORGOAL FROMTOJan-01Feb-01Mar-01Apr-01May-01Jun-01Jul-01Aug-01Sep-01Oct-01Nov-01Dec-01

Customer Satisfaction

Improve PatientPatient/FamilyOverall Rating of Care Given82.090.080.382.480.582.583.684.084.385.387.187.187.586.1

2SatisfactionPatient/FamilyStaff worked together for you80.590.083.684.383.785.285.985.687.687.787.489.490.489.2

CleanlinessCleanliness of room75.090.082.082.482.383.785.085.685.986.787.388.189.087.8

Outcome

1Improve PatientPatientMed Variance Rate (per 100 pt days)4.51.84.55.44.53.63.62.72.73.62.71.80.91.8

3OutcomesPatientPatient Falls per month5.02.05.06.05.04.04.03.03.04.03.02.01.02.0

Cost

Reduce CostsStaffingFTE per adjusted patient day6.24.96.26.26.15.95.86.35.85.35.75.55.65.4

VarianceSupply variance10%5%10%12%15%12%10%12%14%9%10%8%12%10%

&C&"Arial,Bold"&16IMPACT CARE REPORT - 7 NORTH

&LConfidential - For internal use only to supportquality/performance improvement. Do not copy.&C&D&RSource: I made it all up!!!!!!!!! Data is not trimmed, stratified or severity adjusted.

ControlChart

&C&"Arial,Bold"&14IMPACT CARE CONTROL CHARTS FOR 7 NORTH

&LConfidential - For internal use only to supportquality/performance improvement. Do not copy.&C&D&RSource: I Made it all up!!! Data is not trimmed, stratified or severity adjusted.

ControlChart

4.53.155.75279569970.5472043003

5.43.155.75279569970.5472043003

4.53.155.75279569970.5472043003

3.63.155.75279569970.5472043003

3.63.155.75279569970.5472043003

2.73.155.75279569970.5472043003

2.73.155.75279569970.5472043003

3.63.155.75279569970.5472043003

2.73.155.75279569970.5472043003

1.83.155.75279569970.5472043003

0.93.155.75279569970.5472043003

1.83.155.75279569970.5472043003

86.200410163391.16796289281.2328574345

86.200410163391.16796289281.2328574345

86.200410163391.16796289281.2328574345

86.200410163391.16796289281.2328574345

Indicator

Mean

UCL

LCL

Outcome - Med Variance Rate (per 100 pt days)

Buttons

83.594025463986.66270832991.273664277382.0517523807

84.321639127186.66270832991.273664277382.0517523807

83.660257482286.66270832991.273664277382.0517523807

85.151952302286.66270832991.273664277382.0517523807

85.851650641586.66270832991.273664277382.0517523807

85.62305876786.66270832991.273664277382.0517523807

87.628100779686.66270832991.273664277382.0517523807

87.717063061786.66270832991.273664277382.0517523807

87.374472396586.66270832991.273664277382.0517523807

89.438843878886.66270832991.273664277382.0517523807

90.363887339686.66270832991.273664277382.0517523807

89.22754870886.66270832991.273664277382.0517523807

5.73756.38196360125.0930363988

5.73756.38196360125.0930363988

5.73756.38196360125.0930363988

5.73756.38196360125.0930363988

Indicator

Mean

UCL

LCL

Customer Satisfaction - Staff worked together for you

Sheet1

53.56.39199522190.6080047781

63.56.39199522190.6080047781

53.56.39199522190.6080047781

43.56.39199522190.6080047781

43.56.39199522190.6080047781

33.56.39199522190.6080047781

33.56.39199522190.6080047781

43.56.39199522190.6080047781

33.56.39199522190.6080047781

23.56.39199522190.6080047781

13.56.39199522190.6080047781

23.56.39199522190.6080047781

87.445960752792.323283250782.5686382547

87.445960752792.323283250782.5686382547

87.445960752792.323283250782.5686382547

87.445960752792.323283250782.5686382547

Indicator

Mean

UCL

LCL

Outcome - Patient Falls per month

ControlChartData

OFFSET(Data!$H$3,0,0,1,COUNTA(Data!$H$3:$CE$3))

13ActiveWorkbook.Names.Add Name:="Ind1", RefersTo:="=OFFSET(Data!$H$3,0,0,1,COUNTA(Data!$H$3:$CE$3))

24ActiveWorkbook.Names.Add Name:="Ind2", RefersTo:="=OFFSET(Data!$H$4,0,0,1,COUNTA(Data!$H$4:$CE$4))

35ActiveWorkbook.Names.Add Name:="Ind3", RefersTo:="=OFFSET(Data!$H$5,0,0,1,COUNTA(Data!$H$5:$CE$5))

46ActiveWorkbook.Names.Add Name:="Ind4", RefersTo:="=OFFSET(Data!$H$6,0,0,1,COUNTA(Data!$H$6:$CE$6))

57ActiveWorkbook.Names.Add Name:="Ind5", RefersTo:="=OFFSET(Data!$H$7,0,0,1,COUNTA(Data!$H$7:$CE$7))

68ActiveWorkbook.Names.Add Name:="Ind6", RefersTo:="=OFFSET(Data!$H$8,0,0,1,COUNTA(Data!$H$8:$CE$8))

79ActiveWorkbook.Names.Add Name:="Ind7", RefersTo:="=OFFSET(Data!$H$9,0,0,1,COUNTA(Data!$H$9:$CE$9))

810ActiveWorkbook.Names.Add Name:="Ind8", RefersTo:="=OFFSET(Data!$H$10,0,0,1,COUNTA(Data!$H$10:$CE$10))

911ActiveWorkbook.Names.Add Name:="Ind9", RefersTo:="=OFFSET(Data!$H$11,0,0,1,COUNTA(Data!$H$11:$CE$11))

1012ActiveWorkbook.Names.Add Name:="Ind10", RefersTo:="=OFFSET(Data!$H$12,0,0,1,COUNTA(Data!$H$12:$CE$12))

1113ActiveWorkbook.Names.Add Name:="Ind11", RefersTo:="=OFFSET(Data!$H$13,0,0,1,COUNTA(Data!$H$13:$CE$13))

1214ActiveWorkbook.Names.Add Name:="Ind12", RefersTo:="=OFFSET(Data!$H$14,0,0,1,COUNTA(Data!$H$14:$CE$14))

1315ActiveWorkbook.Names.Add Name:="Ind13", RefersTo:="=OFFSET(Data!$H$15,0,0,1,COUNTA(Data!$H$15:$CE$15))

1416ActiveWorkbook.Names.Add Name:="Ind14", RefersTo:="=OFFSET(Data!$H$16,0,0,1,COUNTA(Data!$H$16:$CE$16))

1517ActiveWorkbook.Names.Add Name:="Ind15", RefersTo:="=OFFSET(Data!$H$17,0,0,1,COUNTA(Data!$H$17:$CE$17))

1618ActiveWorkbook.Names.Add Name:="Ind16", RefersTo:="=OFFSET(Data!$H$18,0,0,1,COUNTA(Data!$H$18:$CE$18))

1719ActiveWorkbook.Names.Add Name:="Ind17", RefersTo:="=OFFSET(Data!$H$19,0,0,1,COUNTA(Data!$H$19:$CE$19))

1820ActiveWorkbook.Names.Add Name:="Ind18", RefersTo:="=OFFSET(Data!$H$20,0,0,1,COUNTA(Data!$H$20:$CE$20))

1921ActiveWorkbook.Names.Add Name:="Ind19", RefersTo:="=OFFSET(Data!$H$21,0,0,1,COUNTA(Data!$H$21:$CE$21))

2022ActiveWorkbook.Names.Add Name:="Ind20", RefersTo:="=OFFSET(Data!$H$22,0,0,1,COUNTA(Data!$H$22:$CE$22))

ActiveWorkbook.Names.Add Name:="Ind1", RefersTo:="=OFFSET(Data!$H$3,0,0,1,COUNTA(Data!$H$3:$CE$3))

ActiveWorkbook.Names.Add Name:="Ind2", RefersTo:="=OFFSET(Data!$H$4,0,0,1,COUNTA(Data!$H$4:$CE$4))

ActiveWorkbook.Names.Add Name:="Ind3", RefersTo:="=OFFSET(Data!$H$5,0,0,1,COUNTA(Data!$H$5:$CE$5))

ActiveWorkbook.Names.Add Name:="Ind4", RefersTo:="=OFFSET(Data!$H$6,0,0,1,COUNTA(Data!$H$6:$CE$6))

ActiveWorkbook.Names.Add Name:="Ind5", RefersTo:="=OFFSET(Data!$H$7,0,0,1,COUNTA(Data!$H$7:$CE$7))

ActiveWorkbook.Names.Add Name:="Ind6", RefersTo:="=OFFSET(Data!$H$8,0,0,1,COUNTA(Data!$H$8:$CE$8))

ActiveWorkbook.Names.Add Name:="Ind7", RefersTo:="=OFFSET(Data!$H$9,0,0,1,COUNTA(Data!$H$9:$CE$9))

ActiveWorkbook.Names.Add Name:="Ind8", RefersTo:="=OFFSET(Data!$H$10,0,0,1,COUNTA(Data!$H$10:$CE$10))

ActiveWorkbook.Names.Add Name:="Ind9", RefersTo:="=OFFSET(Data!$H$11,0,0,1,COUNTA(Data!$H$11:$CE$11))

ActiveWorkbook.Names.Add Name:="Ind10", RefersTo:="=OFFSET(Data!$H$12,0,0,1,COUNTA(Data!$H$12:$CE$12))

ActiveWorkbook.Names.Add Name:="Ind11", RefersTo:="=OFFSET(Data!$H$13,0,0,1,COUNTA(Data!$H$13:$CE$13))

ActiveWorkbook.Names.Add Name:="Ind12", RefersTo:="=OFFSET(Data!$H$14,0,0,1,COUNTA(Data!$H$14:$CE$14))

ActiveWorkbook.Names.Add Name:="Ind13", RefersTo:="=OFFSET(Data!$H$15,0,0,1,COUNTA(Data!$H$15:$CE$15))

ActiveWorkbook.Names.Add Name:="Ind14", RefersTo:="=OFFSET(Data!$H$16,0,0,1,COUNTA(Data!$H$16:$CE$16))

ActiveWorkbook.Names.Add Name:="Ind15", RefersTo:="=OFFSET(Data!$H$17,0,0,1,COUNTA(Data!$H$17:$CE$17))

ActiveWorkbook.Names.Add Name:="Ind16", RefersTo:="=OFFSET(Data!$H$18,0,0,1,COUNTA(Data!$H$18:$CE$18))

ActiveWorkbook.Names.Add Name:="Ind17", RefersTo:="=OFFSET(Data!$H$19,0,0,1,COUNTA(Data!$H$19:$CE$19))

ActiveWorkbook.Names.Add Name:="Ind18", RefersTo:="=OFFSET(Data!$H$20,0,0,1,COUNTA(Data!$H$20:$CE$20))

ActiveWorkbook.Names.Add Name:="Ind19", RefersTo:="=OFFSET(Data!$H$21,0,0,1,COUNTA(Data!$H$21:$CE$21))

ActiveWorkbook.Names.Add Name:="Ind20", RefersTo:="=OFFSET(Data!$H$22,0,0,1,COUNTA(Data!$H$22:$CE$22))

12Jan-01Feb-01Mar-01Apr-01May-01Jun-01Jul-01Aug-01Sep-01Oct-01Nov-01Dec-01

Indicator

1Mean3.153.153.153.153.153.153.153.153.153.153.153.1586.286.200410163386.200410163386.2004101633

1UCL5.75279569975.755.755.755.755.755.755.755.755.755.755.7591.16796289291.16796289291.16796289291.167962892

1LCL0.54720430030.550.550.550.550.550.550.550.550.550.550.5581.232857434581.232857434581.232857434581.2328574345

2Mean86.66270832986.6686.6686.6686.6686.6686.6686.6686.6686.6686.6686.665.73755.73755.73755.7375

2UCL91.273664277391.2791.2791.2791.2791.2791.2791.2791.2791.2791.2791.276.38196360126.38196360126.38196360126.3819636012

2LCL82.051752380782.0582.0582.0582.0582.0582.0582.0582.0582.0582.0582.055.09303639885.09303639885.09303639885.0930363988

3Mean3.53.503.503.503.503.503.503.503.503.503.503.5087.445960752787.445960752787.445960752787.4459607527

3UCL6.39199522196.396.396.396.396.396.396.396.396.396.396.3992.323283250792.323283250792.323283250792.3232832507

3LCL0.60800477810.610.610.610.610.610.610.610.610.610.610.6182.568638254782.568638254782.568638254782.5686382547

4Mean84.2

4UCL89.2

4LCL79.2

5Mean86.7

5UCL91.3

5LCL82.1

6Mean85.5

6UCL90.3

6LCL80.6

7Mean

7UCL

7LCL

8Mean

8UCL

8LCL

9Mean

9UCL

9LCL

10Mean

10UCL

10LCL

11Mean

11UCL

11LCL

12Mean

12UCL

12LCL

13Mean

13UCL

13LCL

14Mean

14UCL

14LCL

15Mean

15UCL

15LCL

MBD00A0A49E.unknown

Continuous Monitoring of Customer SatisfactionPress Ganey reportsSurveys all inpatient discharges and sample of outpatientsData distributed quarterlyDepartmental/clinic independent surveysOne Question satisfaction surveys

Interdisciplinary Approaches to Rapid Cycle ImprovementAIDE Teams (improve systems)AssessIdentify Root CausesDevelop a PlanEvaluateCPITs (improve clinical processes)Clinical Process Improvement Teams

Interdisciplinary Approaches to Rapid Cycle ImprovementAIDE Teams (Improve Systems)Clinical Process Improvement Teams CPITs (improve clinical processes)Bed ManagementSupplies AvailabilityResults Turn Around TimeEmergency Department Wait TimePediatric AsthmaNon-ST-segment elevation Acute Coronary Syndrome (NSTE ACS)

StrokeDiabetes Management

AIDE TeamClinical Process Improvement Team (CPIT)Focuses on systems problem, i.e.admitting process, turnaround time, etcFocuses on one problemUsually 4 - 6 meetings of full teamMost work done at meetingsDoes not always have physician membersRecommendations are implemented by the hospitalStaff leaderInterdisciplinaryNeeds prior approval of the CQI CouncilFocuses on a DRG or procedureFocuses on more than one problem at a time (variations in practice)Three meetings of full teamMost work done behind the scenesHeavy on physician team membersRecommendations are voluntary (not rules)Physician leaderInterdisciplinaryNeeds prior approval of the Clinical Management Committee

The AIDE ProcessPhaseOutcome of PhasePI ToolsAssess the SituationIdentify Root CausesDevelop a PlanEvaluateMeasurable problem statement, During the past six months an audit of patient records showed total undercharges of $220,951 for urokinase. This represents an 88% error rateData-verified root causes of the problem

Action plan implemented

An indicator related to the problem statement, looking for improvement. Determine if follow-up actions are needed.Process flow diagram, control charts, brainstorming, multi-voting, selection matrix, pareto checksheets, other.Cause-effect diagram, pareto, graphs, selection matrix, other.Action plan, cost-benefit, force-field, selection matrix, other.Graphs, pareto, control chart, etc.

Goals of Clinical Process Improvement Team (CPIT)Improve the quality of care for a specific patient population

Decrease over-utilization (or underutilization) of resources and services

Decrease variation in physician clinical practice patterns

UNIVERSITY OF NORTH CAROLINA HOSPITALS & CLINICSOPERATING GOALS AND ASSUMPTIONS (Excludes Rex Healthcare)Fiscal Year 2003-04The following operating goals and assumptions were developed by the UNC Health Care Systems* CQI Council in response to patient care needs, environmental and regulatory assessments, and financial expectations:Strategic Quality Goals: SERVICEInpatient Demonstrate organization-wide improvement in the top three problematic areas identified on the 2002 Employee Opinion Survey (communication, employee involvement in decision-making, leadership). Make medical staff and internal customer (departmental) satisfaction measurable. Continue to improve overall inpatient satisfaction. Fully utilize the Clinical Decision Unit. Reduce observation status discharge delays across services. Reduce billing complaints. Continue facility renovations and improvements.Outpatient Demonstrate organization-wide improvement in the top three problematic areas identified on the 2002 Employee Opinion Survey (communication, employee involvement in decision-making, leadership). Continue to improve overall outpatient satisfaction. Improve staff courteousness. Reduce billing complaints. Answer telephones within four rings. Provide live operator option in all voice response systems. Decrease wait time before going to exam room. Decrease wait time in exam room. Improve exam room utilization. Reduce no show rate. Reduce cancellation rate. Reduce reschedule rate. Improve access to care (availability of first appointment). Improve identification of care providers by patients and their families

Strategic Quality Goals: OUTCOMEInpatient Successfully implement Computerized Provider Order Entry. Reduce the number of Severity Level 3 and above medication errors for the top three drugs that are leading to patient harm or have the potential for patient harm (insulin, heparin, and narcotics). Implement patient safety focused Executive WalkRounds and Safety Huddles. Prevent medication reconciliation errors upon admission. Develop and begin implementation of a new interdisciplinary care delivery model designed to maintain high quality patient care in anticipation of reduced availability of resident hours and professional care staff. Decrease average LOS for all patients, without increasing readmission rate. Be able to show measurable improvement in IMPACT CARE plans. Continue AIDE team education of managers.Outpatient Provide evidence of continuity and coordination of care across the care spectrum. Be able to show measurable improvement in IMPACT CARE plans. Continue AIDE team education of managers. Deliver prevention and specialty care according to best practice guidelines. Address patients' primary concerns. Improve the medication record.Strategic Quality Goals: COSTInpatient Obtain accurate insurance information. Reduce reimbursement denials. Reduce the costs associated with paid FTE's obtained through contracted services.Outpatient Reduce volume/amount of noncompliance with Local Medical Review Policies (LMRP). Manage authorization denials for completed ancillary services to prevent account write-offs. Improve cash collection. Decrease charge lag time.