OO17 A description of the infrastructure, the organizational committees, and the decision-making bodies specifically designed to oversee the quality of patient care.
Infrastructure – BHSF
The oversight for the quality of patient care delivered throughout Baptist Health South Florida (BHSF) begins with the Board of Trustees and continues throughout the organization within the structures depicted on the following chart.
Exhibit OO17a: BHSF Quality and Safety Organizational Chart
The BHSF Board of Trustees has the ultimate responsibility for ensuring the quality and safety of patient care, services, and operational performance of the health system. The Board Committee for Quality and Patient Safety (BCQPS) is a standing committee of the Board of Trustees led by the corporate chief quality officer and includes representatives from BHSF Board of Trustees, entity Board of Trustees, entity medical, hospital and nursing leaders. This committee oversees the quality management improvement and patient safety programs of the health system; supports clinical and operational priorities for improvement; and ensures the application of evidence-based design and practices.
The BHSF Quality and Patient Safety Steering Council (QPSSC) is led by Geri Schimmel RN, MS, LHRM, CPPS (Director of Patient Safety Partnership) and reports its work to the Board Committee on Quality and Patient Safety. QPSSC is a joint committee composed of all chief nursing officers (CNO) and key leaders from the following groups—Performance Improvement Leadership Council; Family Advisory Council; Steering Council—Harmonization in Pediatrics, and Patient-and Family-Centered Care; all patient safety officers; and the chairs of Accelerated Change Teams (ACT). This council has operational responsibilities for all performance improvement and patient safety activities throughout the health system including prioritizing, planning and implementing health system performance improvement (PI) and patient safety activities.
In addition to the QPSSC, BHSF has an AHRQ certified Patient Safety Organization (PSO) named the Baptist Health Patient Safety Partnership. The PSO’s mission and primary activity is to conduct activities that are to improve patient safety and the quality of healthcare delivery. The Homestead Hospital Patient Safety Evaluation System collects, manages, and/or analyzes information (Patient Safety Work Product) for reporting to or by the PSO. The Patient Safety Organization was created to use the patient safety work product of its contracted providers for the purpose of encouraging a culture of safety and of shared learning to prevent patient harm.
In October 2013, the Patient Safety Simulation Lab became a corporate department under Risk Management/Patient Safety and is now named the Baptist Health Patient Safety Simulation Lab (PSSL). The PSSL trains multidisciplinary teams on Crisis Resource Management and is available to all departments throughout the health system.
Corporate Risk Management and Patient Safety department oversees patient safety and risk management programs at the system and entity level. Risk Managers Susan Bunting and Susan Beaulieu, RN, who is also the Patient Safety Officer, are based in Homestead Hospital. They manage day-to-day operations at the risk management office.
PI, Case Management and Medical Staff Director Jill White, RN represents Homestead Hospital in the system-wide. CNO and Vice President Gail Gordon, RN, Beaulieu and White represent Homestead Hospital in the system-wide. Additionally, Gordon represents Homestead Hospital in the Patient Care Leadership Council (PCLC).
Exhibit OO17b: Corporate Risk Management and Patient Safety Organizational Chart
Infrastructure – Homestead Hospital
Homestead Hospital has adopted a planned, systematic, and hospital-wide approach in continuously looking for opportunities to improve delivery of quality patient care. The organization formulates its long-range and annual strategic plan based on the 6 Pillars of Success, namely: People, Service, Quality, Finance, Growth and Community. Accordingly, the Nursing Service Department uses the 6 pillars in developing its annual strategic goals.
The Homestead Hospital Board of Directors provides oversight on patient safety and quality. The Board delegates responsibility for the planning, implementation, and monitoring of performance improvement (PI) activities through the Performance Improvement Steering Council (PISC); PI department; Senior Leadership Group; and the Medical Executive Committee (MEC). Every employee, medical staff member and volunteer plays a vital role for ensuring quality and safe patient care.
White reports directly to the chief executive officer (CEO). In her role, she directs the PI initiatives including national quality measures (NQM), value-based purchasing, medical staff peer review, physician satisfaction, medical staff credentialing, the Joint Commission (TJC) accreditation readiness, and PI teams. On the other hand, CNO Gordon directly oversees hospital-wide patient satisfaction program. Assistant Vice President Ana Cabrera, ARNP, who coordinates National Database of Nursing Quality Indicators (NDNQI) and Nursing Peer Review, and Magnet Project Director Julie David, ARNP report directly to Gordon.
The PI department consists of a supervisor and 8 full-time nurses who monitor all patients (inpatient and ED) for compliance with NQM established by the Center for Medicaid and Medicare Services (CMS) and TJC. They also check for compliance with the National Surgical Quality Improvement Program (NSQIP) among surgical patients. These nurses perform concurrent and retrospective medical record reviews as well as data submission. They work collaboratively with physicians and clinical nurses to ensure that evidenced-based care is delivered.
The PI department is also responsible in coordinating medical staff peer review for quality/resource utilization as well as hospital and medical staff PI initiatives including facilitation support and data analysis. The department has 0.5 data analyst FTE to support this and other functions. The department’s other responsibilities include coordination of accreditation readiness through education, mock tracers and mock surveys. Recently, 3 RN FTE’s were added in this department to support meaningful use (MU) education and compliance as Homestead Hospital continues to move forward with this important initiative.
Homestead Hospital has focused on performance and accountability by leveraging the PI framework and implementing hospital, vice president and manager scorecards. The scorecards align with the strategic objectives and the 6 pillars and provide a great tool to communicate metrics, targets and performance throughout the organization. Senior leaders meet monthly to review progress. The PI department, along with the responsible leader, reviews indicators which are not meeting target and provides assistance, if necessary, through a Data Analysis team and a Solutions team. These teams help promote utilization of PI methodology and tools such as brainstorming, pareto diagrams, flow charts, and control charts.
Homestead Hospital subscribes to the following national databases for benchmarking purposes:
Indicator |
Name of Database |
Nurse-Sensitive Indicators |
National Database for Nursing Quality Indicators (NDNQI) |
Catheter-Associated Blood Stream Infection (CLABSI) |
National Health Safety Network (NHSN) |
Catheter-Associated Urinary |
National Health Safety Network (NHSN) |
National Quality Measures (NQM) |
Care Discovery Advance, Hospital Compare |
Left Without Being Seen |
Centers for Disease Control (CDC) |
Surgical Care |
American College of Surgeon (ACS) National Surgical Quality Improvement Program (NSQIP) |
Patient Safety Culture Hospital Survey |
Agency for Healthcare Research and Quality (AHRQ) |
Patient Satisfaction |
Press Ganey; Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) |
Breast Feeding Rate |
CDC National Survey of Maternity Practices in Infant Nutrition and Care; TJC |
Clinical Benchmarking |
Premier Quality Advisor, Care Discovery Advance, VHA Southeast |
Operational Benchmarking |
Truven Health ActionOI |
RN Satisfaction |
National Database for Nursing Quality Indicators (NDNQI) |
Physician Satisfaction |
HealthStream |
Employee Engagement |
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In October 2012, Press Ganey recognized Homestead Hospital as Top Performer on Key Quality measures by TJC. (OO17 01 Press Ganey Letter). The Consumers Report has also ranked Homestead Hospital as 4th safest hospital in Florida (OO17 02 Consumer Report Hospital Safety Rating 2012) while the Leapfrog group gave a rating of “A” for patient safety in 2013 (OO17 03 Safest Hospital in America).
Organizational Committees
Legend: *Decision-making Bodies
Councils/Committees |
Purpose |
*Board of Directors |
Provides oversight of Homestead Hospital’s patient safety and quality programs |
*Congestive Heart Failure (CHF) Committee |
Aims to decrease costs and utilization; meet requirements of accreditation; improve patient outcomes; interprofessional committee |
*Chest Pain Center Committee |
Seeks to meet requirements of accreditation and improve patient outcomes; interprofessional committee |
*Clinical Practice Council (CPC) |
The shared governance council responsible for defining and approving all issues, products and activities related to quality care and clinical nursing practice; interprofessional council |
*Critical Care Committee |
Evaluates practice, policies, and data specific to critical care; interprofessional committee |
Emergency Management Committee |
Ensures emergency preparedness so that such responsibilities can be carried out in the event of a natural or man made disaster; interprofessional committee |
*Evidence Based Practice Research Council (EBPRC) |
The shared governance council responsible for defining and directing all research and evidence-based activities related to clinical nursing. |
Infection Control Committee |
Addresses safety and PI initiatives in the prevention and control of infections in patients, employees, physicians, students, and visitors |
Medication Safety Committee |
Aims to improve the safe use of medications throughout the healthcare environment. |
Medical Staff Quality Committee (MSQC) |
Coordinates systematic and ongoing review of physician quality indicators and medical staff PI activities. |
*Nurse Governance Council (NGC) |
The shared governance council that oversees the implementation of professional nursing practice throughout the organization |
Nursing Peer Review Council (NPRC) |
Provides timely and objective feedback of the efficacy, effectiveness and appropriateness of care provided by the nursing staff based on professional standards of care |
*Nursing Quality Council (NQC) |
The shared governance council that monitors nursing-sensitive indicators and formulates/implements action plans |
Patient Safety Committee |
Evaluates data and implements action plans related to patient safety; interprofessional committee |
Pharmacy & Therapeutics |
Promotes the appropriate use of high quality, evidence-based and cost-effective pharmaceuticals and ensure compliance with appropriate standards and state and federal regulations |
*PI Steering Council (PISC) |
Provides oversight and coordination of PI initiatives; identifies opportunities for improvement and sets priorities; interprofessional council |
Safety Committee |
Evaluates and resolves environment of care issues across the organization; interprofessional committee |
*Wound Care Committee |
Coordinates data collection for wound prevalence study; evaluates data; and formulates/implements action plan |