Overview

From accreditation and regulatory requirements, to patient outcomes and publicly reported data, every action from every individual at JPS should be done so with quality and compassion. In the Quality Division, there are four important departments that are at the heart of JPS. Infection Prevention, to keep our patients and staff safe when providing direct and indirect care. Clinical Risk and Accreditation, that acts proactively to ensure staff is providing the very best evidence based practice and when there is a variance, they look at the process, not the person, to try to prevent this variance from happening again. Performance Excellence, a department dedicated to streamlining processes to improve patient care and advance staff practice with various tools and classes from Lean Six Sigma methodology. And lastly, Clinical Outcomes, that reviews and/or abstracts vital information for various publicly reported programs or accredited registries like HAC Reduction Program, American Joint Replacement Registry, Chest Pain Registry, and Leapfrog. Participating in these various reporting structures shows JPS’s “commitment to transparency and educating their patients about the quality and safety of the care they provide” (Leapfrog, 2020). The goal of this learning plan is to provide education on all this information from the multiple departments that make up the Quality Division to JPS staff and the various affiliated provider groups to ensure all providers are aware of evidence-based best practice and proper infection prevention techniques, to improve patient care utilizing different tools and teaching methods, which ultimately will result inaccurate reporting to various accrediting bodies and registries to show JPS really does provide excellent care to all their patients.

Series Objectives

Upon completion of this activity leaners should be able to:

• Describe what is quality healthcare;
• Identify what departments are within the Quality Division;
• Determine why there are quality measures;
• Describe proper hand hygiene;
• Demonstrate how to report a patient safety event;
• Discuss how quality measures obtain an organization's data for public reporting; and
• Evaluate which measures are published by Centers for Medicaid and Medicare Services (CMS)

Target Audience

The audience for this presentation will include employees, staff and contractors working inside JPS Health Network.