Board of Trustees Orientation to Quality and Patient Safety

Intermountain Healthcare considers Patient Safety to be of paramount importance. As a member of the Board of Trustees, you have a key role in quality and patient safety at your hospital. Boards make a significant difference and assure hospitals achieve best patient care outcomes when they:

  • Set clear objectives to monitor and formally review patient quality performance measurement reports, and utilize data for improvements.
  • Serve in a decision making role for the hospital's medical staff and conduct frequent discussions with medical staff on quality and patient safety strategies.
  • Help maintain quality of care oversight, promote quality and safety education, and assure resources are allocated to improve process.
  • Hold senior leaders accountable for the quality of care within the hospital and ensure compliance with regulatory and accreditation standards.

The Quality Structure

Each facility in the Intermountain system has a hospital and/or regional Quality and Patient Safety Director and an assigned Central Office Quality and Patient Safety Consultant. These individuals work together to ensure compliance with patient safety policies, procedures, standards, and regulations. They use a comprehensive system of continuous readiness to monitor trends, and evaluate and improve quality, safety, and efficiency of patient care throughout the organization. Through system-wide collaboration, Intermountain focuses on patients, families, physicians, and communities.

Quality and Patient Safety Responsibilities

  • Be aware of the connections among regulating bodies and their relationships with healthcare.
  • Monitor national quality and patient safety trends, ongoing changes in Centers for Medicare and Medicaid Services (CMS) regulations and revisions to accreditation standards. Accrediting organizations scrutinize the Board's role in:
    • Performance measures
    • Transparency, escalating public awareness, and community involvement
    • Involvement with senior leadership
    • Accountability for patient safety and quality of care
  • Familiarize yourself with local initiatives that promote patient safety in your facilities.
  • Participate in discussing quality reports from your facilities.
  • Discuss clinical excellence as Intermountain's priority when meeting with staff, public, and surveyors.

Participate in Quality Reports for Your Facility

Value-Based Purchasing is the name for the Centers for Medicare & Medicaid Services (CMS) Pay for Performance program. This program marks a historic change as hospitals will now be compensated financially for the quality of care (not just the quantity of services) they provide to Medicare patients.

To demonstrate success in providing quality of care, every hospital is required to submit specific data to CMS that are then reported to the public for comparison with other hospitals.

There​ are four areas of Value-Based Purchasing measures; new areas will be added each year:

  • Patient experience
  • Clinical Process
  • Outcomes
  • Efficiency

Value Based Purchasing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Value-Based Purchasing will reward individual hospitals for achievement, improvement and consistency on each of the eight HCAHPS areas of focus:

  • Nurse Communication
  • Doctor Communication
  • Responsiveness of staff
  • Medication Communication
  • Pain Management
  • Cleanliness/Quietness
  • Discharge Information

Value Based Purchasing and Clinical Process Measures

  • Acute Myocardial Infarction
  • Heart failure
  • Pneumonia
  • Surgery

Our goal at Intermountain Healthcare is to meet Value-Based Purchasing measures at 100% and continue utilizing best practice processes.

We support reporting, transparency, and sharing this information. Having this information can be helpful to patients as they make decision about their healthcare. Although, Intermountain has been recognized as a leader in high quality and lower costs, we continually strive to be better. In most areas we're doing very well. We still recognize there are always opportunities to improve, because "better" has no limit.

The Joint Commission Accreditation

Many of Intermountain's facilities are accredited by The Joint Commission (TJC). For accredited facilities, TJC conducts periodic surveys to assess compliance with its standards and with CMS regulations.

Board members are encouraged to participate during TJC surveys. A Governing Board representative should be available, if possible, for the opening leadership conference, daily briefings, and the closing conference. Other board members are welcome.

During surveys, The Joint Commission surveyors:

  • Arrive "unannounced", but facilities usually know the approximate time of year the survey is expected.
  • Conduct an opening leadership conference where an agenda for the survey is presented.
  • May review information such as bylaws, rules and regulations, facility goals, organizational charts, and key policies including restraint use, medication use, consents, infection control, etc.
  • Use "Tracer Methodology." This means surveyors follow a selected patient's care process and visit all the settings where the patient received care.
  • Select patients and processes on which to perform tracers based on the facilities' scope of service, publicly reported measures, and previous survey results.
  • Invite senior leaders, key medical staff, and board members to attend daily briefings where observations from the previous day are reviewed.

As a board member, you play a vital role in keeping Intermountain Healthcare's patients safe. We appreciate your important contributions and value our partnership.

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