C4QI Survey Monkey Results

Hospital Quality
Committee Structure –
C4QI Hospital Survey
Results
April 2014
Ali Casiere

The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute
Who Participated
 MD Anderson
 Yale
 Duke
 Memorial Sloan-Kettering
 Dartmouth
 Siteman
 Dana-Farber
 Karmanos
 Roswell Park
 H. Lee Moffitt
2
• We surveyed the 17 other C4QI hospitals and we had 10 of those
hospitals respond to the survey.
• This survey was sent out on March 18, 2014

Research Institute
Scope of Each Organization’s Committee
3
**Yale and Duke are the two hospitals that have separate committees for
Quality and Safety.
16.67%
16.67%
66.67%
**Quality (2)
**Safety (2)
Both Quality and Safety (8)

Research Institute
Current Committee Membership Size
0
10
20
30
40
50
60
# of Committee
Members
4
**Yale does not have a centralized committee

Research Institute
Committee Meeting Frequency
5
Roswell
Park, Dartmouth, MSK, Y
ale, MD Anderson
Karmanos
Siteman and Moffitt
Dana-Farber Duke
0
1
2
3
4
5
6
Monthly 8 Times Per
Year
Bi-Monthly Quarterly Bi-Annually
Committee Meeting Frequency
Committee Meeting
Frequency

Research Institute
Meeting Time and Duration
6
Dana-Farber
7AM-8AM
Siteman
7AM-8AM
MSK
8AM-9:30AM
Dartmouth
9AM-11AM
Duke MD Anderson
Yale
Moffitt
Roswell Park
Karmanos
9AM-10AM 11AM-12:30PM 1-1.5 hours mid-day 4PM-5PM
4PM-5:30PM 1 hour any time

Research Institute
Does Meeting Agenda Include Both
Inpatient and Outpatient?
7
**The way the survey monkey was set up there was the option to click all three and options of
“Inpatient”, “Outpatient”, and “Both” which is why this data is skewed.
8.33%
8.33%
83.33%
Inpatient (1)
Outpatient (2)
Both (10)

Research Institute
Standing Agenda Items
Hospital Standing Agenda Items
MD Anderson Reported Incidences, Patient safety Reports, Pharmacy, OR, Infectious Disease
Specific Reports.
Yale --
Duke Updates on Quality Projects and Strategy
Memorial Sloan-
Kettering
Review of department QA committee meeting minutes. Also, any completed
RCAs, status update of action items from previous RCAs. Each Department QA
Committee chair presents once per year on how his/her department is using data
to drive improvement.
Dartmouth Dashboard Review, Status Updates, Program Evaluation
Siteman Subcommittee Reports, Cancer Registry Reports
Dana-Farber Joint Commission Requirements spread out throughout the year.
Karmanos Root Cause Analysis Update, Core Measures Data, JC Readiness Updates
Roswell Park Department Reports, Areas of Focus, Occurrence Complaints Institute scorecard,
Patient Safety scorecard, Patient Satisfaction Scores
Moffitt Ethics, Grievances, Risk, Quality and Safety, Credentials
8

Research Institute
Leaders and Facilitators of Meetings
Hospital Leader/Chair Facilitator
MD Anderson VP of Performance Improvement Director of Patient Safety
Yale Several different people Several different people
Duke VP and Associate Dean -
Memorial Sloan-Kettering Appointed Chair of Committee (Physician) Appointed Chair of Committee
(Physician)
Dartmouth Chief Safety Officer (Physician) and CNO/VP
Clinical Operations
Chief Safety Officer (Physician) and
CNO/VP Clinical Operations
Siteman Physicians Physicians
Dana-Farber CQO and CNO/VP Quality and Patient Safety CQO and CNO/VP Quality and
Patient Safety
Karmanos VP Medical Affairs Clinical Improvement Specialist
(Quality)
Roswell Park CMO and VP Quality CMO and VP Quality
Moffitt CMO Director of Quality and Safety
9

Research Institute
Disciplines of Membership
10
11%
11%
9%
4%
11%
5%2%
7%
6%
2%
3%
7%
10%
6%
6%
Physicians (10)
Nursing (10)
Pharmacy (8)
Clinical Research (3)
Quality (10)
Tumor Registry (4)
Clinical Nutrition (2)
Diagnostics (6)
Rehab (5)
Pastoral Care (2)
IT (3)
Clinical Informatics (6)
Risk/Legal (9)
Patient/Family Advisor (5)
Other (5)

Research Institute
“All Other” Responses for Disciplines of
Membership
Hospital Other Disciplines
Memorial Sloan-Kettering Hospital Administration, President’s Office, Patient
Relations, Ambulatory Care Network, GME, Patient
Safety, QA Committee Chairs for BMT, Lab
Medicine, Medicine, Neurology, Nursing, Pathology,, Pedia
trics, Pharmacy, Psychiatry, Radiology, Surgery
Siteman Hospice, Palliative Care, American Cancer Society
Dana-Farber Trustees
Karmanos Medical Records
Roswell Park 5 Governance Board Members
Moffitt Hospital Board Members, Hospital Administration
(President and SVP)
11

Research Institute
Reporting Structure of Quality Committee
Hospital Who They Report To
MD Anderson President
Yale Safety/Quality Nurse for each service line; central performance
management group for the system
Duke Includes leadership to the highest level
Memorial Sloan-Kettering Medical Board  Board of Trustees
Dartmouth Quality Subcommittee of the Board of Trustees
Siteman Medical Executive Committee
Dana-Farber Chief Quality Officer  Board of Trustees
Karmanos HPIC (Hospital Performance Improvement Committee)
Roswell Park CEO and Medical Staff Executive Committee
Moffitt Subcommittee of Hospital Board
12

Research Institute
Quality Committee Sub-Committees
Hospital Subgroup/Sub-Committee
MD Anderson --
Yale --
Duke
Starting a quarterly sub-group
Memorial Sloan-Kettering Steering committee- Reviews department QA committee meeting minutes and
finalized presentation agenda
Dartmouth Safety Sub-Committee- Help from several Quality and Measurement support
departments
Siteman •QI Committee
•Palliative/Supportive Care Sub-Committee
•Education Subcommittee
Dana-Farber •Satellite Quality Committee (oversees offsite locations)
•Infection Control Sub-Committee
Karmanos --
Roswell Park •Patient Safety
Moffitt •Credentials, Risk, Ethics, Joint Commission, Grievance, Ancillary, Support
Improvement Committees
13

Research Institute
How Information is Communicated “Up”
Within the Organization
Hospital How Information is Communicated “Up”
MD Anderson Report given to leadership
Yale Emailed, representatives relay information to different committees, and service
lines
Duke Highest leadership is already part of this committee
Memorial Sloan-
Kettering
Quarterly Board of Managers reports
Dartmouth Officers and other leaders are on the committee
Siteman Minutes are shared at department meetings and sent monthly to MEC; Report
annually to Hospital Safety & Quality Council
Dana-Farber CQO and Trustees sit on the committee and are actively involved
Karmanos HPIC minutes/presentations are communicated to KCC Board Quality Committee
(sub-committee of Board of Trustees)
Roswell Park Minutes are sent to CEO and MSEC. Department Representatives are responsible
for communicating with constituents.
Moffitt Directly to the HBOD
14

Research Institute
How Information is Communicated “Down”
Within the Organization
Hospital How Information is Communicated “Down”
MD Anderson Online, Executive Committee of Medical Staff
Yale Through management and education
Duke --
Memorial Sloan-Kettering --
Dartmouth Working on an open forum with voting members and others who can attend for
information purposes
Siteman Staff meetings and minutes distribution
Dana-Farber Quality, Nursing, and clinical leadership
Karmanos VPs, Directors, and managers attend HPIC and are responsible for reporting
back to their departments
Roswell Park Department Representatives are responsible for communicating with
constituents
Moffitt Monthly Management Update
15

Research Institute
Does your Quality Committee have an annual Goal
Setting Determination/Process?
Hospital No Yes
MD Anderson - Drive from top down and from bottom up
Yale - Based on patient safety & quality, employer
of choice, provider of choice, fiscal
Duke 
Memorial Sloan-Kettering - QCI Steering Committee and chair of HQAC
presents annual goals to the group
Dartmouth 
Siteman -Review scorecard from fall and propose
areas that need improvement. Review
organization strategic plan. Goals determined
by QI Committee and then discussed by
Cancer Committee and then voted on.
Dana-Farber - Strategic goals are discussed at the end of
FY and the quality goals are created. Goals are
aligned and includes NPSG’s in the process.
Karmanos 
Roswell Park -“Areas of focus” are determined in
November. VP of Quality makes
recommendations and those are voted on in
January.
Moffitt  - Annually review and select goals and
targets for FY.
16
70%
30%
Yes
No

Research Institute
Are Service-Line or Disease-Line Reports
Shared at this Committee?
Hospital No Yes
MD Anderson 
Yale - Some are Service-Line based, some
have representatives from each service
line
Duke - If they have relevant projects
Memorial Sloan-
Kettering

Dartmouth 
Siteman -Scorecard broken into service lines,
reviewed monthly at both Cancer and QI
Committee. Program specific scorecards
are reported once annually to the
committee.
Dana-Farber - Institutional dashboard that high-lights
40+ departments across the institute. If
there is poor performance anywhere, that
department has to present their action
plan.
Karmanos 
Roswell Park - Medical, surgical, and diagnostic plans
report to the committee at least twice a
year
Moffitt 
17
80%
20%
Yes
No

Research Institute
Are Monthly/Quarterly Scorecards Regularly
Shared?
80%
20%
Yes (8)
**No (2)
18
**Yale and Duke are the two hospitals that do not regularly share their scorecards

Research Institute 19

Research Institute
Feedback/Next Steps
 Does anything stand out to you?
 Linda will be sharing this information with Carol
Colussi and Kris Kipp next week
20

C4QI Survey Monkey Results

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