Northwestern Memorial Healthcare Quality Plan FY14

Northwestern Memorial Healthcare Quality Plan FY14 Introduction Northwestern Memorial Hospital and Northwestern Lake Forest Hospital share a longstanding commitment to a culture of quality, safety and service. * We are consistently recognized for exceeding national benchmarks, making our health system a destination of choice for quality care. By aspiring to the highest standards for quality and patient satisfaction, we continue to advance our commitment to delivering care that is of the highest quality, is evidence based, and eliminates preventable harm. The Northwestern Memorial Healthcare Quality plan aligns with the Northwestern Medicine 2010 2020 Strategic Plan: Our Northwestern Medicine Vision We aspire to be the destination of choice for people seeking quality healthcare and for those who provide, support and advance that care through leading edge treatments and breakthrough discoveries. Our shared commitment to transform healthcare and to be among the nation s top 10 academic medical centers will be accomplished through innovation and excellence. To accomplish this vision the strategic plan is built upon three integrated goals that serve as the roadmap for the next decade 2010 2020: 1. Deliver exceptional care as evidenced by being among the nation s safest, quality driven healthcare organizations for all patients; becoming a recognized destination for patients with complex conditions; earning a distinguished reputation for advancements in care and highly specialized clinical programs; and creating significant improvement in a health issue of importance to our community. 2. Advance medical science and knowledge by imprinting our research findings and contributions through an increase in top tier peer reviewed publications, increased participation in clinical trials; through innovations that lead to patents and inventions; and increased funding in strategic areas by the National Institutes of Health. 3. Develop people culture and resources to ensure a solid future for our medical center and achievement of our goals through the recruitment and retention of key faculty leaders in strategic areas; perpetuation of Magnet status for nursing excellence; recognized leadership in diversity practices; top 10 reputation ranking for fellowship and residency programs; high placement of graduates matched to top residency programs; sustainable improvement in campus wide productivity; and maintaining superior bond ratings. * This plan will incorporate the newest component of Northwestern Memorial Health Care, the Northwestern Medical Group. During 2013 2014 the plan will be updated to reflect the integration of NMG. 1 rev 10/15/13

The Northwestern Medicine Quality Plan focuses on the first of these goals, to Deliver Exceptional Care, which will be evidenced by: 1. Top decile performance on publicly available quality and patient satisfaction measures 2. Zero preventable severe adverse events 3. The quality plan is designed to align leadership, staff and resources to accomplish these goals. Over time, the plan will be expanded in phases across the continuum of care. The plan also outlines the appropriate protections of quality related information under the Illinois Medical Studies Act. Guiding Principles The Guiding Principles of Northwestern Memorial Health Care (NMHC) Quality Management outline key components that support the provision of care with one standard of quality throughout the healthcare system. (See Appendix I) Scope The plan encompasses patient care and service processes at the Hospitals of Northwestern Memorial Healthcare, including: Medical staff departments and divisions Hospital departments Inpatient, outpatient, long term care, home care, and other services across the continuum of care Full range of adult, pediatric, and neonatology services as relevant to each setting Residency and other training program participants as they participate in patient care Program Summary I. Goals A. Strategic Goals set via Northwestern Strategic Plan, by 2020: 1. Top decile performance on publicly available quality and patient satisfaction measures 2. Zero preventable severe adverse events. B. Annual goals established via annual quality goal planning process (see Appendix II) II. Governance & Accountability A. Board of Directors 1. The Professional Standards Committees (see Appendix) of the Boards of Directors are charged with the approval of the annual quality plan and the continual monitoring of performance against the plan. B. Management The Medical Executive Committee and an executive Quality Management Committee (see Appendix), oversee the execution of the annual planning process (see Appendix), and the The plan will be updated if and when Northwestern Memorial Health Care participates in a federallycertified Patient Safety Organization. 2 rev 10/15/13

achievement of the annual goals (see Appendix). Management will allocate resources as necessary to improve performance utilizing the appropriate committee structure and the process improvement program (see Appendix). The Northwestern Memorial HealthCare (NMHC) Quality Management Committee is an administrative committee charged with developing and implementing a plan to share relevant quality, risk management, and patient safety data and information to best accelerate learning and improvement of medical care and clinical outcomes in NMHC organizations. C. Committees Quality Committees are charged with the advancement of care, ensuring the implementation of evidence based care and the achievement of the best possible outcomes. (see Appendix) 1. Quality Committees Multidisciplinary committees led by medical staff and nursing leadership with front line staff engagement oversee measurement and evaluation of the day to day processes of care to achieve the goals of top decile performance and zero preventable serious adverse events. 2. Functional Committees Multidisciplinary management and staff led committees charged with overseeing care processes which support direct patient care (e.g. pharmacy, laboratory, Clinical Care Evaluation Committee). D. Individuals: The NMHC Quality Program also requires individual behaviors and decision making consistent with the goals of the program. This includes competency and behaviors. The program goal is a just culture which is consistent with a culture of quality and patient safety. The key programs utilized to accomplish these goals are (see Appendix): 1. Medical Staff Peer Review and OPPE Programs 2. Nursing Peer Review Program 3. Advance Practice Nurse Physician Assistant Peer Review Program 4. Organizational Human Resources Performance Management Program 5. Medical Staff Credentialing III. Transparency Core to the NMHC Quality Program is the principle of transparency to patients, families, consumers, the Board of Directors, healthcare staff and medical staff. Transparency includes quality performance (process) metrics, adverse events and clinical outcomes. A. Patient and Consumer Communications 1. All consumers have access to outcomes data and are able to distinguish NMHC as the quality provider of choice. Mechanisms for transparency include the consumer oriented website, internal quality dashboards and a full disclosure policy regarding adverse events (see Appendix). 2. The patient education program incorporates priorities related to patient safety, such as medication information and related materials. 3. Patients are encouraged to provide input, information, questions and concerns about their care. They are entitled to the opportunity to provide fully informed consent. Patients have 3 rev 10/15/13

access to complete information about their care and full participation, by themselves or their surrogates, in decision making. They are entitled to complete communication about all aspects of their care including unexpected outcomes (see policies: Patient Rights and Responsibilities, Complaint and Grievance, Disclosure of Unanticipated Outcomes and Patient Communication). 4. Patients are involved in important aspects of care such as goals of care, patient identification, site/side marking, and escalation for urgent changes in clinical condition. 5. Patient satisfaction with adequate information is one measure of the program. B. Staff Education The staff education program incorporates priorities related to quality and patient safety, such as clinical practice education, staff orientation, incident reporting, etc. All staff receive appropriate orientation and ongoing education as relevant to their job responsibilities. All staff are educated regarding the requirement to report unusual incidents (policy: Unusual Incident Reporting). Management training is provided regarding DMAIC, safe process design, quality measurement and patient safety. C. Staff Communications and Reporting Quality and patient safety communications are provided at all levels of the organization including: 1. Leadership Communications a. Updates on quality and patient safety to management b. Annual report on quality and patient safety c. Quality Committee hot sheets with current highlights 2. Clinician and Staff Communications a. M&M conferences and Good Catch awards b. Safety huddles for front line staff c. Items in communication vehicles such as newsletters d. Posters, reports and presentations at annual Quality Day e. Periodic communications regarding new policies, processes, national issues, regulatory and accreditation developments f. Periodic communications through appropriate departments such as pharmacy, radiology, nursing, surgical services, etc., regarding quality and patient safety improvements in each area. IV. Patient, Consumer, & Community Engagement Patient engagement in quality and safety is achieved at two levels. First, each patient and family should be engaged as partners in the safety and quality of their own care. Each patient (or surrogate decision maker) is educated about important quality and safety aspects of care, is invited to participate in developing the goals and plan of care, and is fully informed if an error or unexpected outcome occurs. There are measures in the plan to evaluate their satisfaction with this relationship. Second, patients and consumers are involved in program development and quality improvement to benefit all patients. This is accomplished through mechanisms such as a Patient Family Advisory Council, including patients and consumers on quality improvement panels and teams, use of focus groups and other mechanisms to gather input, and engagement of patients who have shared their ideas for improvement through complaints and compliments. 4 rev 10/15/13

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Northwestern Memorial Healthcare Quality Plan FY2013 APPENDICES System Appendices I. NMHC Quality Management Guiding Principles Page 6 II. NMHC Annual Quality Planning Process and Goals Pages 7 8 III. NMHC Process Improvement Program Pages 9 IV. NMHC Patient Safety Plan Pages 10 11 Organization Specific Appendices Northwestern Memorial Hospital V. NMH Annual Quality Goals Page 12 13 VI. NMH Functional Overview of Participants Pages 14 24 VII. NMH Ongoing Professional Practice Evaluation & Peer Review Pages 25 29 Northwestern Lake Forest Hospital VIII. NLFH Annual Quality Goals Pages 30 31 IX. NLFH Functional Overview of Participants Pages 32 41 X. NLFH Ongoing Professional Practice Evaluation & Peer Review Pages 42 53 6 rev 10/15/13

APPENDIX I NMHC Quality Management Guiding Principles NMHC is committed to serving our communities with exceptional care that is effective, safe, patientcentered, efficient and equitable. Effective communication and collaboration promote a culture of safety and accountability. All providers within the Northwestern Memorial Health Care System demonstrate a commitment to a common standard of quality by incorporating the following principles: 1. Quality planning aligns with the Northwestern Medicine Strategic Plan to Deliver Exceptional Care and is performed collaboratively among NMHC members. a. Governance includes a board level committee with a common approach to internal and external transparency and accountability, including regulatory and accreditation compliance. b. Goals are established for process and outcome measures to achieve top decile performance, consistent implementation of evidence based care, and the elimination of preventable harm. 2. Common methods of reducing and eliminating adverse events are implemented to include a Senior Executive led committee such as a Clinical Care Evaluation Committee and a clearly defined method for analysis of systemic failures, such as root cause analysis. 3. Common platforms, such as the Enterprise Data Warehouse, exist to establish benchmarks, advance quality measurement, monitoring, and improvement. 4. Performance Improvement includes a formal methodology (such as DMAIC) to achieve and sustain improvement of clinical care processes and operational systems 5. Quality committees are multi disciplinary and interdepartmental, with vigorous collaborative clinician leadership and represent all areas with impacts on care of the patient populations. 6. We are committed to providing quality care that patients and families value. Patients and families are valued members of the health care team and partner with NMHC to assess community needs and the development and evaluation of services implemented to meet those needs. Members of a patient and family committee collectively and individually collaborate in improvement initiatives to inform change from the patient s perspective. 7 rev 10/15/13

Appendix II NMHC Annual Quality Planning Process and Goals I. Inputs The annual quality planning process is designed to align quality goals with the Northwestern Medicine Strategic Plan to Deliver Exceptional Care. An Exceptional Care Dashboard defines annual organizational goals for selected clinical quality measures and provides a tracking tool for monitoring performance against targets and external benchmarks. The goals consider key components of the National Quality and Magnet agendas, value, and input from stakeholders both internal and external to the system including patients and their family members. II. Goal Setting Principles A. Clinical and service processes and outcomes of care are incorporated as metrics of performance within the quality plan. Process measure goals are aimed at top decile performance on all nationally established measures. When no national comparator benchmark exists for a process measures, the goal is to achieve 95% 100% consistent performance for established measures and to close the gap by at least 1/3 for new measures. B. Outcome measure goals target best performance against like populations on nationally established measures. In some instances, multi year plans are established to achieve top decile performance. 8 rev 10/15/13

C. Indicator measures do not include specific goal targets. They are incorporated within the dashboard to highlight select processes and outcomes for continuous monitoring. D. Benchmarks for process measures are set at top decile compared to all healthcare organizations in the nation for nationally established measures and 95% 100% for measures without comparative benchmarks available. The benchmark for outcome measures is obtained from sources such as the University Health Systems Consortium or MIDAS+ database comparing our performance against peers. The National Database for Nursing Quality Improvement provides the benchmark for nursing sensitive measures. E. The organizational dashboard defines annual organizational goals for selected clinical quality measures, whereas committee dashboards define selected clinical quality measures at the program level. NMHC Quality Planning Framework Review & Approve Professional Standards Committees of the Boards Committee Approvals Quality Management (NMH) Quality Monitoring & Standards (NLFH) Medical Executive Review Patient Family Advisory Draft Hospital Dashboard Present Departmental Plans Senior Management Departmental Chairs Measures Review Draft Departmental Plans Literature Review Stakeholder Interviews Risk Profile Generation 4/12 5/12 6/12 7/12 8/12 9/12 10/12 III. 22 Apr May Jun Jul Aug Sep Oct 9 rev 10/15/13

Goals, FY 2014 Domain (Aim to achieve all ) Target Quality Program Initiatives: Update of NM Quality program to include all NM Achieve two NM Care Models/Pathways Design and begin implementation of program to address culture of safety Establish NM methodology to measure, monitor and improve evidence based process of care measures. Mortality UHC Overall Observed/Expected Programmatic Excellence Access & Care Transitions Meet access goals for targeted clinics & meet goal for follow up appts for patients Evidence Based Care Selected measures across system targeted at >= 95% performance Magnet Designation Meet criteria for quality metrics Preventable Severe Harm Readmissions All Payer All Cause Likely To Recommend Achieve Milestones Achieve top decile comparable performance Monitor 95% 90% Achieve Magnet designation Monitor Improve Improve 10 rev 10/15/13

APPENDIX III NMHC Process Improvement Program I. Goal Deliver measurable results which significantly impact the strategic plan. II. III. IV. Approach A. NMHC follows a DMAIC based approach to process improvement. DMAIC (Define, Measure, Analyze, Improve, and Control), the process improvement methodology from Six Sigma, is the roadmap that we follow on every improvement project. Change Management is also a core element of our approach. B. Depending on the nature of the problem to be addressed, project teams apply tools & techniques from Six Sigma, Lean, and Rapid Improvement Workshops. Accountability is assured through formal designation of key roles on each DMAIC initiative: A. Executive Sponsor Provides overall guidance and accountability for the project B. Sponsor Accountable for the timely and successful implementation of the project C. Clinical Sponsor (as required) The Physician champion, responsible for engaging colleagues and assuring successful implementation/acceptance of change D. Process Owner Accountable for the implementation, monitoring (e.g. data measurement), and sustainability of project related improvements E. Improvement Leader DMAIC methodology expert, accountable for managing the project and completing all deliverables in a timely manner F. Project Team Comprised of individuals who possess a profound understanding of the process which is being improved and who will make a significant contribution to the timely and successful completion of the project Training A. Introduction to Process Improvement and DMAIC All members of the management team and many medical leaders and staff take this foundational course. B. Lean Principles and Tools for DMAIC C. Excel for DMAIC D. DMAIC Improvement Leader Training V. Project Selection NMHC employs a structured approach to determine which projects to undertake (based on linkage with strategic plan) and what level of support is required to be successful. VI. Project Oversight Improvement Council, chaired by designated senior leaders, is held bi monthly and provides a forum for accountability and feedback for the project teams. 11 rev 10/15/13

APPENDIX IV NMHC Patient Safety Plan I. Program Goals A. The Patient Safety Plan supports the strategic goal to Deliver Exceptional Care. The patient safety program seeks to ensure that NMHC delivers safe and reliable care and service using the Improvement Principles for quality and patient safety (see above) and: 1. Improve the culture of safety and improve staff awareness of patient safety 2. Improve delivery of high reliability care and eliminate harm by assuring that that serious adverse events or potential events are identified, investigated, and used to develop appropriate improvement plans 3. Engage patients as partners in improving the safety of their own care and in assisting in the improvement of the safety of patient care systems 4. Assure compliance with accreditation requirements and other best practices B. These goals are advanced by surveillance, monitoring and analysis of patient care and information to identify actual or potential adverse events and trends; identification and implementation of opportunities for improvement in patient care systems; and provision of information, feedback, education and other communications. C. NMHC is committed to transparency of information and disclosure (see page 3: Quality Plan Program Summary section III Transparency and section IV Patient Engagement). D. NMHC is committed to pursue best practices from reliable sources such as The Joint Commission, National Quality Forum, Leapfrog Group, Agency for Healthcare Research and Quality, CMS Partnership for Patients, AAMC Best Practices for Better Care consortium, University HealthSystem Consortium, Centers for Disease Control and Prevention, Magnet (American Nurses Credentialing Center), and others. II. III. Scope A. The plan addresses all departments, functions, programs, and staff outlined in the Quality Improvement Plan. Structure and Mechanisms for Coordination: The patient safety plan is an element of the annual QI plan. Patient Safety is overseen as a core element of the quality improvement program by a multidisciplinary Patient Safety Committee, implemented as appropriate at each NMHC entity and outlined in its Quality Plan. See appendices for provider specific structures. 12 rev 10/15/13

A. Important inputs to the development of the patient safety plan and program include: 1. Incident reporting, risk management and Root Cause Analysis data and trends 2. Findings from adverse / near miss events and sentinel events 3. Analysis and direction by the Clinical Care Evaluation Committee 4. Quality committee findings, staff insights and suggestions 5. Patient / family suggestions, complaints, opportunities to improve safety 6. Process and outcome measures associated with high risk processes 7. Staffing patterns and orientation / competence data as relevant 8. Research and surveillance data and trends 9. Operational processes and facility safety recommendations and concerns B. External sources 1. Data from Joint Commission Sentinel Event Alerts, National Patient Safety Goals 2. Opportunities identified by experiences reported at other health care sites 3. Literature regarding external benchmarks, best practices, guidelines C. Establishment of Goals and Priorities The patient safety program, through the Patient Safety Committee, establishes priorities and goals each year. See Appendix I for the current year s high level goals. Patient Safety goals include focus on such areas as: 1. Proactive risk assessment (e.g. failure mode and effects analysis) 2. Processes which have an opportunity for improvement based on analysis 3. Teamwork and a culture of safety. IV. Communicating with Patients About Safety See Quality Plan Program Summary section III Transparency and section IV Patient Engagement V. Patient Safety improvement priorities are identified during the annual Quality planning cycle. VI. Communications and Reporting on Patient Safety: See Quality Plan Program Summary section III Transparency and section IV Patient Engagement 13 rev 10/15/13

APPENDIX V Northwestern Memorial Hospital Annual Quality Goals 2014 The hospital specific annual quality goals are established within the context of the NMHC Quality Goals by the Executive Quality Management Committee (EQMC) and are approved by the Medical Executive Committee. NMH Exceptional Care Dashboard Goals Domain and metric Baseline YTD_June Period Target Diagnose me timely & accurately Baseline Period Target Access and Screening Baseline Period Target Improve access to NMG clinics* (% achieving 3rd next appointment target of 10 days) Goal to be set after Q1 baseline measurement tbd Q4, tbd NMG Mammogram provided per recommended schedule (GIM/former NMFF practice) 80.30% FY, 80.4% NMG Cervical Cancer Screening provided per recommended schedule (GIM/former NMFF practice) 82.40% FY, 82.5% Evidence Based Early Initiation of Treatment Period Target AMI PCI 90 minutes 100% FY, 98% ASA at arrival for AMI 100% FY, 98% HF timely LV function 100% FY, 98% % ESI-2 (potentially life-threatening) patients seen (in bed) within 30 minutes 49.5% FY, 52% Accurate Diagnosis Period Target RadPeer results (% discrepancy in interpretation) n/a FY, 0.25% Timely results Period Target Timely attention to unexpected radiology findings (% cases resolved between 1 month and 7 months) 85% FY, 90% Critical results timely 92.3% FY, 92% Treat Per Evidence Baseline Period Target Evidence based care Inpatient Period Target SCIP measures 93.90% Q4, 95% Stroke measures 94.6% FY, 95% Influenza Immunization 96.7% FY, 95% Pneumococcal Immunization (Overall) 88.0% FY, 90% Hand Hygiene (global, % of units achieving 95%) 28 FY, 27 Falls with injury, rate/1000 days - metric is % units at or better than NDNQI Pressure Ulcers, hospital acquired prevalence - metric is % units at or better than NDNQI 70% FY, 60% 59% FY, 60% 14 rev 10/15/13

Domain and metric Baseline YTD_June Period Target CLABSI ICU SIR, NHSN measure 0.96 FY, 0.99 CAUTI Prevention -% patients on Foley Catheter Protocol 35% Q4, 50% SSI, All cases - NSQIP Odds Ratio 1.11 FY 0.88-1.4 Surgical death/serious morbidity, Elderly - NSQIP 1.15 FY 0.9-1.46 Evidence Based Care Outpatient Period Target SCIP OP - ABX selection & timely administration 93.6% FY, 95% NMG Nephropathy screening or treatment in diabetes (GIM/former NMFF) NMG Pneumococcal vaccination for patients with chronic disease (GIM/former NMFF) 85.4% FY, 85.4% 50.3% FY, 50.4% NMG Fall screening (GIM/former NMFF) 54.9% FY, 54.9% NMG: A1C evaluated (IM & FP) (former NMPG) 97% FY, 95% NMG: High blood pressure evaluated (IM & FP) (former NMPG) 98% FY, 97% NMG Pediatric immunization (former NMPG) 79% FY, 79% Transition My Care Baseline Period Target LOS, % of Long LOS cases 6.19% Q4, 5.88% Readmissions (All Cause, All Payor) 15.05% Q4, 14.3% Medication transitions Period Target Inpatient medication reconciliation at d/c 91% FY, 95% Outpatient home medication documentation 90.2% FY, 95% Discharge Process Period Target Follow-up appointment (inpatient) scheduled rate 53.8% Q4, 56% Follow-up appointment (ED) scheduled rate 11.25% Q4, 11.81% Improve My Health Baseline Period Target Mortality Period Target UHC Mortality O/E 0.75 FY,.83-.65 - Oncology UHC O/E 0.74 FY, 0.74 - Neurosciences UHC O/E 0.69 FY, 0.73 - Cardiovascular UHC O/E 0.76 FY, 0.80 - Ortho MSK UHC O/E 0.38 FY, 0.57 Ambulatory Outcomes Period Target NMG: diabetes management/control (IM & FP) (former NMPG) 76% FY 70% NMG: high blood pressure management/control (IM & FP) (former NMPG) 69% FY 67% Patient Centered Experience Baseline Period Target Likely to Recommend, all NMH 81.3 FY 81.4% 15 rev 10/15/13

APPENDIX VI Northwestern Memorial Hospital Functional Overview of Participants The organizational governance structure for Quality at NMH is as represented below: I. The Board of Directors Is empowered by the Corporate Bylaws of NMH as its governing arm to: A. Delegate to the Professional Standards Committee (and its subcommittees), as its designees, responsibility for overseeing the monitoring and evaluation of the quality of care and services B. Delegate to the medical staff and administration the responsibility for quality patient care and peer review within Northwestern Memorial Healthcare. II. Medical Staff and Interdisciplinary Quality Committees Responsible for Quality Oversight and Improvement. Note: The committee chair or co chair or the full committee may initiate, on behalf of the committee, quality investigations and other activities designed to monitor and improve the quality and safety of medical care, with findings/results to be reported back to the committee. See also: Medical Staff Bylaws and Documents ( Committee Plan ) for details on membership and responsibilities of these committees and individuals A. Chief of Staff Elected by the medical staff and represents the medical staff to administration Appoints Co Chairmen and other members to Interdisciplinary Quality Management Committees B. Medical Executive Committee 16 rev 10/15/13

1. See Medical Staff Bylaws and Committee Plan 2. Accountable to the Board for medical staff Quality Management 3. Designates clinical chairmen 4. Assigns oversight and responsibility of quality management activities to Quality Management Committee C. Executive Quality Management Committee (EQMC) 1. Charged as designee of Board with: 2. Membership includes Operational Vice Presidents, Chief Medical Officer, Chief Nurse Executive, Associate Chief Nurse Executive, Medical Director for Quality, Chair Quality Management Committee, Director of Quality, Manager Clinical Quality, Director of Analytics, Director of Performance Improvement 3. Monitoring and improving healthcare performance in clinical and service outcomes in order to evaluate and improve quality of care and reduce morbidity and mortality. Oversee the Exceptional Care dashboard. 4. Establishment of priorities for performance improvement and patient safety 5. Appointment and oversight of interdepartmental/interdisciplinary teams as indicated to identify opportunities and recommend / implement improvements 6. Referral of quality issues to appropriate management, staff members, and medical staff committees for investigation, recommendation, and resolution 7. Delegated by the Board of Directors as its designee to oversee management of patient grievances/complaints 8. Through the vice presidents who are members, request and receive reports on performance from Healthcare departments and functional committees Reports and coordinates as needed with QMC, Medical Executive Committee, Chief Executive Officer and the Board of Directors D. Medical Quality Executive Committee 1. Charged with reviewing, evaluating and making recommendations concerning the quality of patient care. Composed of officers of the medical staff. E. Northwestern Memorial HealthCare Quality Management Committee (NMHC QMC) 1. Membership includes Chief Medical Officer, Chief Nurse Executive, and Vice President responsible for quality management at each organization Director of quality at each organization Directors/managers/staff in areas such as risk management, patient safety, accreditation/licensure, infection control, case management and other fields, disciplines and departments as relevant to the current agenda and plan Others as appointed by the Chief Executive Officer of NMHC 2. Responsibilities: Develop and implement a plan to share relevant quality, risk management, and patient safety data and information to best accelerate learning and improvement of medical care and clinical outcomes; Share information with each organization regarding routine quality measures, peer review processes and data, process improvement initiatives, risk management and 17 rev 10/15/13

patient safety events, data and improvement, and other initiatives and data pertinent to the measurement, evaluation and improvement of patient care, patient safety, and clinical outcomes F. Quality Management Committee (QMC) See Medical Staff Organizational Documents: Bylaws and Committee Plan 1. Membership includes representatives selected by QMC co chairs from among: co chairs of Interdisciplinary Departmental Quality Committees, and leadership of patient care, clinical quality, and other departments. 2. Manages and oversees the medical staff quality and peer review processes 3. Reports to the Board through Medical Executive Committee, and periodically to the Professional Standards Committee 4. Chaired by Chief Medical Officer and Vice President, Quality or designees 5. Ad hoc committee charged for FY14: OPPE Steering Committee Chaired by Chief of Staff Members: Department Chairmen or delegates, representatives from Clinical Quality and Analytics departments Chartered effective September 2013 for a period of at least one year Meets quarterly, reports back to QMC Focus: review our current OPPE process, establish how departments, department chairs, practitioners and the medical staff office are currently using OPPEs, and determine if changes to metrics, distribution, etc. may increase OPPE value. 6. G. Clinical Care Evaluation Committee (CCEC) Co chaired by the Chief Nurse Executive, Chief Medical Officer, and Vice President for Quality / Chief Quality Officer. Members may include Chief Medical Officer, Chief of Staff, other physician designees, administrative leadership or their designees, medical leadership in quality and patient safety, Risk Management, and Clinical Quality Management. The committee is charged as designee of the Board to: 1. Identify, investigate and communicate sentinel and critical events or areas of potential risk to patient care and safety 2. Promptly direct investigation of such events to identify potential underlying system issues and improvement opportunities, including composing a senior management and/or peer review panel if necessary 3. Oversee implementation of policies on incident reporting and communication of adverse events to ensure that serious adverse events are managed and reported appropriately, and that patients receive full communication about unexpected outcomes and potential harm 4. Identify, direct, monitor, and report on system improvements to reduce risk, improve patient safety and clinical quality 5. Establish subcommittees as needed 6. Trend critical events as appropriate 7. Report periodically to EQMC, QMC, and the Board H. Multidisciplinary Committees, Process Improvement Teams, Nursing and other Department Grand Rounds, and Clinical Path Work Groups Charged by EQMC and/or QMC to: 18 rev 10/15/13

1. Undertake activities to improve patient care, primarily through improvement of systems and processes 2. Provide periodic reports to QMC, EQMC, and other committees as requested, on patterns and trends in patient care, utilization, and service, with recommendations for improvement activities I. Patient Family Advisory Council Charged by EQMC to: 1. Engage the perspectives of patients and families to identify opportunities for improvement and to provide input into the design of plans, programs, processes and facilities to meet the needs of patients and the community 2. Provide periodic reports to QMC, EQMC, and other committees as requested, on the work of the council J. Clinical Department Chairmen See Medical Staff Bylaws 1. Appointed by the Board of Directors on the recommendation of the President 2. Responsible for monitoring and evaluating the quality and safety of patient care provided by clinical department medical staff members in NMH programs on an ongoing basis and reporting such information as requested 3. Assure that department activities are monitored by an appropriate Medical Staff Interdisciplinary Department Quality Committee (see below) 4. Each department chair appoints representatives to an appropriate Medical Staff Interdisciplinary Department Quality Committee (see below) 5. May delegate responsibility for operation of quality activities to a member of the department, but is ex officio member of relevant quality committee and retains responsibility for outcomes K. Interdisciplinary Departmental Quality Committees See Medical Staff Bylaws and Committee Plan The NMH quality committees are interdisciplinary groups of Healthcare staff and physicians that actively engage to improve patient care and advance safe practices. These committees report to the Quality Management Committee and: 1. Meet not less than quarterly and are co chaired by a Department Chairman or Chief of Staff Appointee and a Chief Nurse Executive appointee. 2. Are composed of representatives of the clinical departments and/or multi disciplinary members as appointed by the department chair or Chief of Staff and the Chief Nurse Executive. 3. Develop and implement annual quality plans to achieve goals. 4. Oversee the delivery of safe, reliable and effective evidence based care for all patients in their respective purviews. 5. Provide direction in conducting quality reviews of individual patients care, relevant patient populations and/or Healthcare functions as defined by the quality plan and/or referred from other quality committees. Establish an effective monitoring and evaluation process utilizing benchmarked data and ongoing assessment of processes and outcomes. 6. Review analysis of quality improvement data and collaborate with other committees or initiatives to improve patient outcomes and services improvement. 19 rev 10/15/13

Committees are illustrated below: III. Peer Review Committees A. Medical Staff Peer Review Committees include Surgical, Medical, Obstetrics and Pediatrics and others as they may be established by the clinical department chairman, QMC, etc. The medical staff peer review committees are to review and evaluate selected outcome measures and quality of care, and report to QMC and Medical quality Executive Committee. B. Nursing Staff Peer Review is to review and evaluate nursing practice and report to Nursing Professional Practice Committee. C. Advanced Practice Nurse Physician Assistant Committee reviews and evaluates practice of midlevel providers credentialed and privileged through the medical staff process. IV. Clinical Department Morbidity and Mortality (M&M) Conferences Attended by physicians (house staff, attending) and other staff as identified by the Department Chairman. This committee is charged with performance of a range of responsibilities including: A. Review and monitoring of patient care in order to improve care through physician education and other process improvement activities 20 rev 10/15/13

B. Potential peer review quality issues are referred to the pertinent interdisciplinary quality committee Co Chairman or designated Quality Leader for review at the appropriate Peer Review committee meeting C. Potential system quality issues are referred to the appropriate interdisciplinary quality committees V. Functional and Interdisciplinary Quality Committees (subcommittees of QMC) (See Medical Staff Organizational Documents, Bylaws and individual committee documents for full details on these groups responsibilities and operations). The NMH functional quality committees are interdisciplinary groups of Healthcare staff and physicians that are actively engaged in improving quality and processes related to specific functions or activities. These committees report to the Quality Management Committee. A. Pharmacy and Therapeutics/Drug Usage Committee The Pharmacy and Therapeutics Committee and its subcommittees focus on improving medication safety and use at NMH. These committees are charged with performance of a range of responsibilities including: 1. Developing policies and processes relating to the distribution, handling, use, and administration of drugs and diagnostic testing materials 2. Promoting interdisciplinary approaches to improve control and optimize the safety, efficacy, and economy of medication use 21 rev 10/15/13

3. Monitoring and Evaluating significant adverse drug reactions and medication errors to identify patterns that can guide productive improvement efforts 4. Contributing to national medication safety and adverse drug reaction reporting programs 5. Medication Safety Subcommittee Charged by P&T Committee to evaluate, monitor and improve the quality of medical care relating to the medication process B. Transfusion Committee This committee is charged with performance of a range of responsibilities including: 1. Monitoring and improving processes and policies related to the appropriate use of blood and blood components 2. Evaluation of all confirmed transfusion reactions C. Committee on Infection Control and Prevention This committee is co chaired by a Chief of Staff appointee and a Chief Nurse Executive appointee and charged with performance of a range of responsibilities including: 1. Reviewing infections with regard to their proper management, prevention, and epidemic potential 2. Establish subcommittees and work groups as necessary to design, implement, analyze, and monitor operational change and improvement 3. Multidisciplinary Epidemiological Surveillance Subcommittee a. Charged by the Committee on Infection Control and Prevention to: b. Monitor trends in organisms of epidemiologic significance and make recommendations for prevention and control c. To work collaboratively across disciplines to implement corrective actions plans when trends are identified d. To identify, review and report cases of healthcare associated (nosocomial) infections resulting in death or major permanent loss of function D. Utilization Management Committee (See Utilization Management Plan) This committee is charged with performance of a range of responsibilities including: 1. Collecting and analyzing data and information on events related to the utilization management process 2. Make recommendations for process improvement related to utilization management 3. Working with the clinical departments to improve patient care and support E. Emergency Response Teams Committee This committee is charged with performance of a range of responsibilities including: 1. Oversight, monitoring and process improvement relating to the use of the various clinical emergency response teams and their related activities 2. Developing the emergency response teams structure and processes necessary to provide evidence based care for emergency codes 3. Collecting and analyzing data on events related to emergency response processes and outcomes F. Medical Ethics Committee Charged to: 22 rev 10/15/13

1. Provide consultation regarding the ethical and human values involved in patient care questions 2. Develop educational programs to enhance attention to ethical issues and human values in medical care 3. Develop or contribute to development of policies and procedures to support improved care based on these insights 4. Report to QMC and Medical Executive Committee upon request and may refer issues to clinical chairmen for quality and/or credentialing consideration G. Moderate Sedation Committee Members include Physician and Nurse representatives from each area approved to use moderate sedation, charged to: 1. Develop, approve, monitor Moderate Sedation Policy 2. Assure quality measures are in place to evaluate and improve processes related to safe and effective moderate sedation practice 3. Evaluate adverse events associated with moderate sedation 4. Recommend competency / privileging systems to relevant authorities and approve supporting training and education materials 5. Meet quarterly or more often as needed and report at least annually to QMC H. Nursing Professional Practice Committee Objective is to create a culture of quality within nursing that supports Delivering Exceptional Care by advancing evidence based care and maximizing patient safety through supporting Healthcare wide quality plans/goals. Reports at least annually to Quality Management Committee. Purpose: Oversee nursing practice to ensure safe, high quality, evidence based care Oversee the development & revision of nursing policies and procedures Recommend evidence based practice changes to meet BPE goals Bi annually review the hospital s written staffing plan to ensure ongoing compliance with Staffing by Patient Acuity Legislation Membership: Staff nurse chair, director facilitator, one manager, one APN, staff nurse representatives from each nursing department/division, representative from pharmacy, Quality representative, Infection Control representative, and physician representative ad hoc Subcommittees: Nursing Peer Review Nursing Policy and Procedure Nursing Performance Other subcommittees are formed as needed to review, evaluate and improve patient care. I. Advanced Practice Nurse Physician Assistant Committee The APN PA Committee reviews and renders recommendations regarding credentials files credentialed and privileged through the medical staff process as referred to it by the CNE or Credentials Committee. The committee evaluates requests for new categories of APNs and PAs, or expanded privileges. The committee may review a corrective action as well. The objective is to support exceptional care by advancing evidence based care and maximizing patient safety 23 rev 10/15/13

through supporting Northwestern Memorial Healthcare wide quality plans/goals. Reports at least annually to Quality Management. See also policy NMH MS 01.5012. APN PA Peer review is performed by this committee. o Peer review findings are reported to the relevant QM departmental committee with aggregate findings reported annually to QM Committee. J. Patient Safety Committee The Patient Safety Committee reports to QMC, EQMC, and through them to the Board s Professional Standards Committee, and the NMH Board as outlined in the QI plan. This committee is charged with developing and managing the annual Patient Safety Plan to help achieve the NM strategic goal to deliver care that is safe and without error, including: 1. Monitor NMH performance in patient safety and recommend patient safety metrics and priorities to QMC and EQMC 2. Recommend systems improvement, policies, programs, education, and other resources to improve patient safety 3. Monitor and integrate national developments in patient safety 4. See Appendix IV for more detail 5. Reports to QMC VI. Administration A. The President and CEO of NMH is nominated by the parent/member (NMHC) and then elected by the board of the specific entity. 1. Responsible as designee of Board for the performance improvement program 2. Delegates to the Senior Vice President for Medical Affairs and the Vice President, Quality and Operations, as designees of the Board, oversight responsibility for assisting the medical staff, through the provision of adequate support resources, to implement quality and credentialing programs and to integrate these with administrative performance improvement activities 3. Provide periodic reports to the Professional Standards Committee of the Board of Directors B. Management, Department Quality Committees Management is responsible for establishing an effective Quality Management/Process Improvement (QM/PI) monitoring and evaluation process as described in this Plan in order to deliver superior clinical outcomes and service excellence. As designees of the Board, vice presidents (or delegates) convene a quality committee or committees as appropriate to each area, composed of managers and/or staff, to oversee and monitor the quality of our patient experience and improve outcomes. These committees are charged to: 1. Implement and monitor baseline quality improvement measures focused on important aspects of care 2. Propose and implement process improvement initiatives in focused areas synchronized with annual goals and performance management process (PMP) goals 3. Provide support for QM/PI activities 4. Incorporate QM/PI review findings into the performance evaluation process 5. At request of EQMC, as designee of the Board, document activities and report results C. Senior Vice President for Medical Affairs Appointed by the Board of Directors on the recommendation of the President and CEO of NMH 1. As Board s designee, represents the medical staff to the EQMC 24 rev 10/15/13

2. Co chairs Clinical Care Evaluation Committee (CCEC) 3. Provides for the integration and coordination of medical staff and administrative review activities 4. Makes recommendations to QMC and EQMC regarding compliance with the Quality Plan 5. Provides direction to Medical Staff leadership regarding medical staff program activities 6. Implements education and communication for the house staff and attending staff regarding quality and patient safety 7. Reports to the Chief of Staff on medical staff program activities D. Chief Medical Officer and Medical Director, Quality and Patient Safety Appointed by the Board as a medical administrative leader on the recommendation of the President, NMH 1. Chairs Patient Safety Committee and Medication Safety Subcommittee of P&T Committee 2. Serves on Quality Management Committee 3. Leads quality and patient safety oversight and improvement in conjunction with administrative directors in those areas 4. Reports to MEC and Board Professional Standards Committee periodically E. Risk Management Department Charged with: 1. Collecting information to identify potential areas of risk exposure 2. Review, investigation, and/or facilitation of root cause analyses as needed for identified critical incidents and events at the direction of EQMC and other QM/PI committees as designees of the Board 3. Advising administrative and Medical Staff leadership of RM issues, patterns and trends 4. At request of executive quality committees, as designee of Board, reports to the Senior Vice President and General Counsel F. Vice President, Quality and Operations Appointed by the Board on the recommendation of the President, NMH 1. Chairs Executive Quality Management Committee and co chairs Clinical Care Evaluation Committee 2. Provides for the integration and coordination of medical staff and administrative quality review activities 3. Makes recommendations to QMC and EQMC regarding compliance with the Quality Plan 4. Delivers program compliance reports and activity summaries to the Professional Standards Committee of the Board 5. Oversees activities within division, including functions such as: a. Clinical quality management b. Risk management c. Infection prevention and control program d. Clinical documentation and coding e. Utilization management f. Patient safety g. Patient experience, complaints and grievances h. Care coordination and patient throughput i. Analysis and improvement programs 25 rev 10/15/13

G. Senior Vice President and Chief Nurse Executive Appointed by the Board as a nursing administrative leader on the recommendation of the President, NMH 1. In collaboration with operating vice presidents, oversees activities that relate to the provision of patient care and achievement of the NMH quality plan 2. Chairs the CNE Quality Council which oversees quality management and improvement for patient care. Reports compliance and progress towards goals through the Healthcare and medical staff committee structure. 3. Strategically plans and prioritizes the implementation of initiatives to improve and enhance care delivery and coordination across the continuum 4. Oversees multidisciplinary departments of caregivers to assure alignment of quality and patient safety activities (such as medicine, surgical, psychiatry, and oncology nursing services) 5. Leads strategies to assure that recruitment, retention, education, and staffing practices support the delivery of safe and effective care 6. Recommends Co Chairs for Quality Committees to Chief of Staff for appointments. 26 rev 10/15/13

APPENDIX VII Northwestern Memorial Hospital Ongoing Professional Practice Evaluation, Medical Staff Peer Review, and Focused Professional Practice Evaluation Ongoing professional practice evaluation, medical staff peer review and focused practice evaluation processes enable NMH to identify and address patterns and events in quality of care and patient safety. This plan outlines the process for conducting ongoing professional practice evaluation, the circumstances requiring review of a practitioner s performance and the process for focused evaluation of a practitioner s performance by peers. See also the Medical Staff Organizational Documents for a discussion of the application of professional practice evaluation during the medical staff appointment and privilege delineation process. Professional Practice Evaluation utilizes a six part framework described by The Joint Commission on the basis of work of the Accreditation Council for Graduate Medical Education, including the performance dimensions of: Patient Care (process and outcomes), Medical Clinical Knowledge, Practice Based Learning and Improvement, Interpersonal/Communication Skills, Professionalism and Systems Based Practice. Using this framework, the individual Quality Management Committees are responsible for determining departmental dashboard measures, ongoing professional practice evaluation measures and case identification triggers for peer review. Ongoing professional practice evaluation, peer review, and focused professional practice evaluation processes provide relevant and valuable information about common problems that can be assessed for systematic quality improvement through the Quality Management (QM) Committee structure. I. Ongoing Professional Practice Evaluation A. Physicians on staff at NMH receive an ongoing professional practice evaluation profile on a semi annual basis. The profile includes information regarding individual performance on measures previously identified by the Quality Management (QM) Committees as described above and will be shared with the Chairman of the department or his/her designee. This may include data such as: 1. Review of operative and other clinical procedure(s)* performed and their outcomes 2. Pattern of blood and pharmaceutical usage 3. Requests for tests and procedures 4. Length of stay patterns 5. Morbidity and mortality data 6. Practitioner s use of consultants 7. Other relevant criteria as determined by the organized medical staff B. The information used in the ongoing professional practice evaluation may be acquired through periodic chart review, aggregate data from clinical information systems, direct observation, monitoring of diagnostic and treatment techniques, discussion with other individuals involved in the care of each patient including consulting physicians, assistants at surgery, nursing, and administrative personnel. 27 rev 10/15/13

II. C. The ongoing professional practice evaluation profile will be used as part of the process for reappointment and decisions regarding privileges. Circumstances Requiring Peer Review A. The Clinical Quality Committees review key drivers of risk and negative clinical outcomes to determine triggers for the peer review process. The triggers for peer review may include cases of morbidity and mortality, cases identified with a quality of care indicator, invasive diagnostic procedures for appropriateness, operating room procedures not supported by a diagnostic/pathologic specimen for appropriateness, department specific high volume/high risk areas, major adverse drug reactions, major incidents reported to or by the Risk Management Department, cases identified by Pathology for surgical case review, major transfusion reactions, ordering practices for blood products, patient or staff complaints and grievances, utilization of ancillary services, utilization, results of clinical pertinence reviews, and noncompliance with policies such as those related to medical records, other documentation, patient care procedures, or administrative procedures. B. In the event that a sentinel, never, or adverse event is identified, the Clinical Care Evaluation Committee (see that section of the Plan) will ensure that an appropriate panel is convened for review. This includes at minimum any serious, unexpected event which potentially involves an immediate, serious threat to patient care or safety, was avoidable or potentially avoidable, and/or results in a significant change in the clinical management of the patient s care. III. Medical Peer Review Structure and process A. Three multidisciplinary peer review committees have been established; Medical, Surgical, and Obstetrics and Pediatrics. Members from the Department of Radiology and Emergency Medicine participate on each committee. The chairman for each committee is appointed by the Chief of Staff with concurrence with the Senior Vice President of Medical Affairs. Members of the committees will be appointed by the Chairman of each clinical department represented on the peer review committee. B. Peer Review Committees meet regularly to review cases as identified and referred, using a structured approach approved by the Quality Management Committee, and report their findings to the chairman, as designee of the Board. During case review if a potential quality issue is identified for another peer review committee, the case is referred to that Peer Review Committee Chairman. C. Physician case reviews will be completed by the committees within 90 days of initial review. D. Conclusions are supported by appropriate clinical practice guidelines and literature, when available. E. Decisions of the physician reviewer and committee are recorded in the Clinical Quality Management database. F. Results are reported on the individual physician s ongoing professional practice profile and reviewed at the time of reappointment. 28 rev 10/15/13

G. Results of the peer review process are monitored over time. The Medical Executive Committee reviews a two year report of all serious cases for patterns, trends, and consistency in ranking. Actions taken are monitored as needed. IV. External Peer Review A. The Peer Review committees have the option to recommend to the chairman of the Medical Staff Quality Committee and the Medical Staff Officers that NMH solicit input from an expert panel of internal or external resources, or an external peer review organization, in situations where the committee deems necessary to ensure proper consideration. V. Participation in the Review Process by the Individual whose Performance is being Reviewed A. The Peer Review Committee may request additional information from the attending physician to clarify information in the medical record. This request must be in writing and the attending physician is required to submit a written response to the Peer Review Committee within 10 days of receipt of the request. If no response is received the Quality Leader will contact the physician. The physician has an additional 10 working days to submit a response. B. In the absence of a physician response, the case will be forwarded to the Peer Review Committee for review. C. The attending physician may request a re review of any case. A written request for reconsideration accompanied by all the pertinent information may be sent to the Peer Review Committee Chairman within 30 days. VI. Focused Professional Practice Review A. Each medical staff department establishes a process to confirm the current privilege specific competency of practitioners performance in situations such as: 1. A practitioner who does not have documented evidence of competently performing the requested privileges at NMH 2. Professional practice trends or an issue for an individual with NMH medical staff privileges have been identified that have the potential to impact quality of care and patient safety. B. Each clinical department at NMH develops and clearly defines appropriate department specific methods to assess competency for respective specialty areas. These methods will be consistent with the requirements and standards set forth by the Board of Directors, management and organized medical staff, Federal, State and local law and regulations, and by The Joint Commission (TJC). C. See Medical Staff Department Policy, Focused Professional Practice Review 29 rev 10/15/13

30 rev 10/15/13

VII. Nursing Quality Peer Review A. The Nursing Quality Peer Review Committee reviews and evaluates individual staff nurse practice. Cases are identified by referral from Quality, Patient Safety, Risk Management, Physician Peer Review, and members of the interdisciplinary team including nurses (self or peer). Cases include those with such triggers as missed care, near misses, unanticipated codes, unexpected transfer to ICU, falls resulting in significant patient harm, medication errors, returns to surgery, patient/family complaints, and cases that do not meet core measure expectation, as well as others. B. The Nursing Quality Peer Review Committee is a subcommittee of the Nursing Professional Practice Committee. It is facilitated by the Chair of the Nursing Professional Practice Committee with support from the irector Facilitator and is comprised of one staff nurse representative from each of the Nursing Departmental Shared Leadership Committees; nomination is required with manager approval. Nomination criteria include a minimum of two years of experience as a direct care provider at NMH and annual review as Exceptional Performer. a. Nursing Quality Peer Review meets monthly to review cases as identified and referred using a structured approach approved by the Chief Nurse Executive, and reports their findings to the Chief Nurse Executive. During case review if a potential quality issue is identified for another peer review committee, the case is referred appropriately. b. Conclusions are supported by appropriate clinical practice policies, procedures, guidelines, standards and referenced literature, when available. c. Decisions of the committee are recorded in the Clinical Quality Management database. d. Results are communicated in writing to the individual nurse, manager and director. C. Participation in the Review Process by the Individual whose Performance is being reviewed The Nursing Quality Peer Review Committee may request additional information from the nurse to clarify information in the medical record. This request will be in writing and the nurse is requested to submit a written response within 10 days of receipt of the request. This written communication will be followed by a phone call from the Committee Chair. In the absence of a nurse response, the case will be forwarded to the Nursing Quality Peer Review Committee for review. VIII. Advanced Practice Nurse Physician Assistant Peer Review A. Process is similar to physician and nurse peer review B. See Medical Staff Policy 01.5012 C. See Committee description, above in Functional Committees. 31 rev 10/15/13