leadership matters - hospital quality institute · 2019-07-21 · leadership matters: inspiring....

2017

AN

NU

AL

REP

OR

T

inspiring » engaging » discoveringLEADERSHIP MATTERS

Welcome,

We are pleased to present the fourth annual report from the Hospital Quality

Institute (HQI). This report, titled Leadership Matters, reflects the power of aligned

leadership, as both a noun and a verb. Leadership comes from our boards, our

frontlines, our hospital executives, physicians and providers. It is top down, bottom

up and middle out, through strategy, aligned action, influencing, and partnering.

California hospitals are leading the way to innovate and take excellence to scale.

We crossed into our fifth year of existence in March 2018. Below are the topline

results since the founding in March 2013 to December 2017. Please enjoy this year’s

report of the evidence of improvement in California. Thank you to the HQI Board,

Members Association Leaders, Member Hospitals and Partners, for another

inspiring year.

Respectfully,

Julianne Morath, RN, MS, CPPS David Perrott, MD, DDS

President/CEO Board Chair

23,500Lives Saved

$772,190,000Cost

Saved

TOPLINE RESULTS

$13,895,000 Grants/Contracts

Received71,950Harms

Prevented

20,986 Learners Engaged

LEADERSHIP MATTERS: Inspiring. Engaging. Discovering. » 1

The health care workforce commits to care for others every day as they promote

wellness, rescue, heal and comfort, and restore health. The sources of inspiration

for this work are many – the advances of modern medicine, the diversity and

depth of talent on a clinical team, the reward inherent in a person’s smile, the joy

and meaning of contribution.

INSPIRING PURSUIT OF EXCELLENCE

The hospital cultures that inspire commitment

and excellence are shaped by inspired

leadership — encouraging learning,

providing timely and effective resources, and

establishing the environment that continually

engages the workforce to improve performance. These are the

cultures evidenced by California hospital and health system

leaders that are innovating solutions, including renewed

workforce joy and meaning.

To achieve the quadruple aim, inspiration must be nurtured to

thrive. This responsibility is embraced by exceptional leaders

— leaders who encourage the pursuit of excellence and value

the contributions and aspirations of the workforce. C. Duane

Dauner, who retired this year after 32 years as CEO of the

California Hospital Association, is such a leader. Instrumental

in the founding of HQI, Duane’s vision was to align, inspire

and equip California hospitals to discover new and better

ways to continually learn and improve the care provided for

their communities.

This year, HQI’s Vanguard award, which recognizes

outstanding achievement in the areas of patient safety, quality

improvement and experience, was renamed and dedicated to

inspiring

2 » HQI 2017 ANNUAL REPORT

Duane’s leadership. The C. Duane Dauner Quality Award was

inaugurated at the 2017 HQI

Conference as Julianne Morath,

HQI CEO and President, and Lucian

L. Leape, MD, esteemed founder of

the field of patient safety,

recognized Duane for lifetime

achievement in honor of his

contributions to the safety and

quality of care of Californians.

Respect, Reliability, Resilience: 2017 Annual ConferenceA growing community of healthcare improvers and innovators

came together at the HQI’s Annual Conference to explore

and build out the concepts of respect for people, reliability,

and resilience. From presentations on the complex topics of

high reliability and cutting edge genomics, to the powerful

simplicity of Dr. Lucian Leape’s declaration that “the golden

rule is the most impactful and important strategy for

improving patient safety,” this year’s conference offered

inspiration in many shapes and forms. A poignant drama

involving the many caregivers and first responders that helped

a young man and his family through a medical crisis captured

the joy and meaning inherent in teamwork.

The HQI Annual conference is a rich learning environment

where colleagues and leading experts inspire, and inspire each

other through engagement in learning and improvement,

exploration of tools and methods, and sharing of best

practices. Attendees are immersed in new knowledge and

practical tools and methods designed to reinforce purpose

and inspire meaning in work.

“I think this was the best conference I have ever attended! The speakers were amazing and the entire conference was a just wonderful experience. Thank you for giving me this opportunity!” - Conference attendee

Pictured L to R: Siddhartha Mukherjee, MD; Beverly Malone, PhD, RN, FAAN; “Kyle’s story – The Dramatization” spotlighted the actual team that came together to care for Kyle and his family in Monterey.

HQI supports, recognizes and lifts the

meaningful work done by hospitals by

engaging in collaborative efforts to

achieve harm-free, reliable care and

best outcomes. The annual conference

brings top experts into conversations

to generate new ideas and spread best

practices; and nurture the dedication of

hospital workforces to provide the

best healthcare to Californians.


An engaged workforce is vital to success in patient experience, safety and quality of

care. Effectively connecting with patients and families, performing to the top of one’s

capabilities, working productively on teams, discovering new and better ways –

this is what engagement looks like inside California’s hospitals.

HQI works with its members and partners

to inform, enable, and equip hospitals to

continuously improve by providing programs

and creating collaborations that foster the

teamwork of patient and family engagement.

Improving Patient Engagement and Experience of CareHQI’s Partnership for Patient Experience (P4PEx) assists

California hospitals in efforts to advance patient and family

engagement and experience of care. Tracking and analyzing

related data provides focus for the design and implementation

of collaborative strategies and programs by hospitals. HQI

provides unique insights into the underlying drivers of

HCAHPS data and other indicators of engagement and

experience of care.

California HCAHPS Improvers PlaybookHCAHPS surveys are a means to engage patients in a process

of meaningful feedback to improve responsiveness to patient

need, preference, and experience of care. Response rates are

a challenge for hospitals yet contain information to inform

improvement work. To assist hospitals, HQI developed the

HCAHPS Improvers Playbook containing evidence-based

recommendations for increasing survey response rates, while

implementing best practices in compassion, inclusion, and

environment.

A CULTURE OF COMPASSIONATE CARE

engaging


Journey to a Quiet Night HCAHPS survey data indicate that a steady challenge for

California hospitals is excessive noise, negatively impacting

patient rest and healing. In 2016, HQI launched its Journey

to a Quiet Night Toolkit, containing best practices for noise

reduction, abatement, and maintaining a therapeutic

environment. This year the program was enhanced by the

launch of an interactive mobile app. HIPAA compliant and

accurate to within -/+ 1 decibel, the Quiet NightTM app

rapidly measures the sound floor in any environment and

quantifies opportunities for noise abatement. The app

registers and tracks baseline as well as startle noise and

provides actionable guidance when noise levels are moving to

unacceptable levels. The app is free of charge.

Focus on DisparitiesIdentifying and eliminating disparities in care is central to

providing effective care. Accurate collection of patient’s race,

ethnicity and primary language (REaL) data is a source to

understanding disparities. While the majority of California

hospitals (96%-99%) regularly collect REaL data at the point

of care, fewer than 40% routinely examine measures of care

quality by these variables or use targeted interventions to

reduce identified gaps. As a partner in the CMS-funded

HSAG HIIN, HQI is working with Massachusetts General

Hospital’s Disparities Solutions Center to examine the gaps

in collection of ReAL data, provide assistance to reduce the

gaps, and generate hospital-specific equity reports in the area

of readmissions.

Patient responses to the HCAHPS survey of experience consistently identify

noise at night as a dissatisfier in their hospital stay. Only 51% of patients surveyed

following discharge from a California hospital report that their hospital room was

always quiet at night, compared to 62% of patients nationally. Noise at night is our

greatest challenge to create a healing environment of care.

Hospitals that have successfully improved this dimension of care have used a

few common strategies: informed staff behavior modification, mechanical noise

mitigation, environmental noise mitigation, and real time data to drive changes.

Journey to a Quiet Night

Strategies to Reduce Hospital Noise and Promote Healing

q u i e t n i g h t t o o l k i t

» HQI ADVANCED ANALYTICS provides focus

for programs to improve engagement with

patients and families.

» EXPERTISE IN HUMAN FACTORS ENGINEERING,

coupled with focus on workforce well-being,

ensures that programs are designed to optimize

engagement and support team work.

» HQI’s work in reliability is premised on a

model of GUIDED ENGAGEMENT keeping its

participating hospitals informed, connected

and engaged while implementing practices

from reliability science.

of CA hospitals are

engaged in HQI-sponsored

improvement programs

» 277 HOSPITALS PARTICIPATE in the Hospital

Improvement Innovation Network (HIIN)

» 329 HOSPITALS ARE MEMBERS of CHPSO

» 201 (79.8%) CA MATERNITY HOSPITALS

PARTICIPATE in CMQCC’s Maternal Data Center,

representing 83.4% of all births

» 2,169 downloads of HQI’s QuietNight App

ENGAGEMENT takes many forms in health care »


Focus on Social Determinants of HealthHQI represents the hospital associations as a partner in the

Root Cause Coalition, whose mission is to reverse and end

the systemic root causes of health inequities for individuals

and communities through cross-sector partnerships.

Its work is grounded in four core values: Focusing on

Community Change, Advancing Authentic Collaboration,

Scaling Innovative Solutions, and Engaging and Learning

from Communities. Partnership in this coalition will allow

California hospitals to be at the forefront of developing

and implementing new collaborative strategies to improve

the health and well-being of individuals and communities.

This effort complements, enhances and connects the work

undertaken within regional associations.

Focus on Palliative CareThe Coalition for Compassionate Care of California (CCCC)

is an interdisciplinary partnership of thought-leaders from

healthcare systems and organizations, government agencies,

consumer organizations, and the general public. HQI is a

partner to the Coalition which seeks to expand palliative

care across the care continuum and promote high-quality,

compassionate care for everyone who is seriously ill or nearing

the end of life, driven by patient preferences.

Pictured right: 2017-2018 Guide Team leaders helped prepare SARH for HCRO implementation.

California Hospitals TAKING HCRO FORWARD »

• Conducting a comprehensive and successful

introduction of HCRO Foundations, involving over 230

team leaders and members, to see and understand risk

• Examining risk through prospective mitigation strategies

• Forming and training multidisciplinary HCRO guide

teams, with responsibility for supporting transformation

• Updating policies and procedures, tools, recognition,

and processes to reflect HCRO principles, including

just culture

• Designing and launching training programs for

workforce and medical staff, utilizing Learning

Management System (LMS), a web enabled reverse

classroom method for adult learning

• Aligning and integrating

existing practices, including

huddles, debriefs,

TeamSTEPPS, reporting,

event review and action

within a reliability framework

• Rolling out HCRO

Foundations enterprise wide

in Q4, engaging 2,410

employees and contractors

across the system, with

goal of 100% completion of

Foundations by Q3 2018

Commitment to high reliability performance is part of our

mission to assist California’s hospitals make sustainable

change from within. Guided engagement is provided through

the HealthCare Reliability Organizing (HCRO) initiative,

where communities collaborate to create shared solutions.

GUIDED ENGAGEMENT

San Antonio Regional Hospital, Upland, CA became the first HCRO cohort hospital

to implement an organizing framework for sustainable reliability practices. Major

accomplishments include:

Completion Rate Achieved To Date


Sepsis RoundtableSignificant quality and safety issues require

engagement and collaboration across communities

and delivery system sites. Sepsis is such an issue. It

is the number one reason for mortality in hospitals

and the number one reason for readmission. A

serious and deadly health condition, it impacts

millions of lives annually in the United States at a

cost of $20 billion to the health system. In August

2017, HQI convened the first Sepsis Roundtable

with leaders from across California to examine

recent statewide experience, share lessons learned

and best practices, and discuss strategies to drive

continued improvement across the state. By 2016,

efforts in California hospitals have reduced the

sepsis mortality rate by 30% since 2010. As >90%

of sepsis cases were present on hospital admission,

attention was given to upstream strategies for

awareness, early identification, and treatment in

the community, and downstream post-discharge

strategies to prevent readmission. The proceedings

were distributed state-wide.

5%7%

9%4%7%

12% 14% 13% 14%7%

6%

24.5%

5%

21.9%23.2%

20.5%

17.4%18.6%

16.8%31.5%

82.8%3.2% 3.6% 3.8% 4.4% 4.9%

5.6% 5.9%

BETTER

BETTER

24.5%

21.9%23.2%

20.5%

17.4%18.6%

16.8%

3.2% 3.6% 3.8% 4.4% 4.9%5.6% 5.9%

5%

12% 7% 14% 13% 14% 6%

5%7%

9%7% 4%

31.5%

82.8%

Sepsis Hospitalization and Case Mortality Rates %California: 2010-2016 (Annual)30%

25%

20%

15%

10%

5%

0% 2010 2011 2012 2013 2014 2015 2016

Rate

per

100

(%)

Source: OSHPD Discharge DataSepsis deaths per 100 sepsis cases (%)

Sepsis cases per 100 hospitalizations (%)

Engagement in collaborative learning networks is an

impactful way to advance improvement initiatives.

The Health Services Advisory Group (HSAG) and HQI partnership was awarded one of 16 contracts for

Hospital Improvement Innovation Network (HIIN)

by CMS.

In addition to improvement efforts in readmissions

and 11 areas of harm, the HSAG-HQI HIIN has

significant focus on person and family engagement,

health care disparities and patient safety culture.

The HSAG-HQI HIIN peer learning network has 282

participating hospitals, 277 of which are in California.

All hospitals are engaged in the systematic

identification, use and spread of evidence-based

better practices with technical assistance in

improvement and hospital-specific measured

feedback of progress.

ADVANCING IMPROVEMENT INITIATIVES

• Organizations attending represented 43,000 annual discharges

of sepsis cases.

• 22 subject matter experts and key stakeholders including

3 foundations

• Examined key factors shaping California’s sepsis mortality

reduction over past 3-5 years as well as current sepsis issues

• Consensus of expert opinion to address next steps for

improving incidence and mortality rates

• Identification of opportunities for aligned action


Discovery occurs with humility, curiosity,

inquiry, and rigorous analysis. HQI is driven

to discover and deliberate about the creation

of actionable intelligence to help hospitals

inform their improvement work.

There are collaboratives of member hospitals to promote

and provide opportunities for discovery, and disseminate

innovations in improvement.

States Targeting Reduction in Infections Via Engagement (STRIVE), was a grant received from the CDC, focused on

improving coordination of infection prevention efforts and

enhancing collaboration and alignment among agencies and

organizations to improve infection prevention and control

practices in hospitals. An AHRQ ICU grant focused on

infection prevention in ICUs was awarded with 16

hospitals participating.

79.8% of California maternity hospitals are reporting data

to the California Maternal Quality Care Collaborative Maternal Data Center (CMQCC MDC) representing 83%

of all births in California. The MDC is an online tool that

generates rapid-cycle performance metrics on maternity care

services for hospitals and supports discovery of new and better

ways and quality improvement. HQI is a strategic partner

of CMQCC to support the work in maternal safety. 111

California hospitals are on the State Honor Roll, with NTSV

rates less than the Healthy People 2020 goal of 23.9%

Discovery is an active and iterative process both formal and informal across

the health care system. It drives advances in medicine and technology, new

approaches to care delivery and new understandings of human interactions

necessary for engagement.

INFORMATION AND INFLUENCE

discovering


Promoting Optimal NTSV Delivery Rates (PONDR) Study,

funded by CHCF, examined both best practice (positive

deviance) and events affecting cesarean birth rates in small

community and rural hospitals. The final study report was

released to all 243 CA birthing hospital CEOs and contained

nine significant sets of findings and recommendations.

The report also noted emerging topics for maternity care

improvement including: the practice culture of birthing

centers; the integration of certified nurse midwives; maternal

mental health; maternal opioid and substance addiction; and

outcome disparities.

Reducing Harm from Respiratory Depression in Non-ICU Patients Through Risk Mitigation and Respiratory Monitoring, was updated and published in 2017 through a

grant from Medtronic. Multidisciplinary groups from statewide

member hospitals and health systems met to review current

literature, assess community practice, and provide evidence-

based recommendations and best practices to reduce patient

harm from respiratory depression in a non-ICU environment.

The toolkit is intended for frontline clinicians, as a source for

key guidelines and decision support for risk assessment and

mitigation related to respiratory depression in patients older

than 14 years. The toolkit is intended to be integrated into the

clinical workflow and improvement efforts.

For ease of use, HQI created a dynamic mobile app that allows

fast access to critical algorithms, including frequent updates

and commentary on current and emerging best practices.

The toolkit pdf version and mobile app have been downloaded

thousands of times in and outside the U.S., and used in

curriculum by Respiratory Therapists, clinicians and educators.

HQI2 is a central source for California hospitals to obtain timely, actionable intelligence to

drive quality improvement efforts. It brings together disparate data sources and

integrates them on a single statewide quality improvement platform to facilitate data-

informed decision-making to improve care. Its goal is to help hospitals across California

get more out of their existing data.

The platform provides hospitals and health systems with access to reports and

benchmarking tools using data that is timely, clinically relevant, standardized, and

valuable in advancing care. Hospitals are provided with performance analytics and

reporting, state and national comparisons, consultation and education, including

understanding of publicly reported rankings, grades, and scores.

THE HOSPITAL QUALITY INTELLIGENCE INITIATIVE (HQI2) » Coming Soon

RESPIRATORy STATUS ZONESHQI characterizes a patient’s

respiratory deterioration into three

high-level status zones: Safe, Risk,

and Harm (Figure 9.0). This section

describes each zone and typical, zone-

specific interventions.

Safe Zone: Effective Breathing With adequate patient screening,

assessment, and monitoring, patients

will be more likely to stay in the Safe

Zone preventing respiratory decline

into the Risk and Harm Zones. Safe

Zone interventions include screening

patient for monitoring appropriateness (e.g., STOP BANG

assessment and sedation assessment) and effectiveness including

EtCO2 monitoring based on risk level.

Risk Zone: Respiratory DepressionBedside caregiver knowledge of respiratory depression warning

signs (see Figure 10.0) plus effective monitoring can result in

prompt intervention of a patient in the Risk Zone. Risk Zone

interventions include using a reversal agent, transferring

patient to higher level of care, notifying RRT, and/or adjusting

medications.

Harm Zone: Respiratory ArrestThe Harm Zone is characterized by a patient experiencing acute

respiratory compromise or an adverse event/reaction to opioid

and sedatives. Harm Zone intervention requires calling a Code

and assisting with ventilation and oxygenation.

PATIENT DETERIORATION RESPONSE AlGORITHMFigure 11.0 provides an algorithm for responding to a patient’s

status that has deteriorated.

Intervene7

Figure 9.0: respiratory status Zones

Source: San Diego Patient Safety Council 2014

adverse event, respiratory arrestIntervention:•Code•Intubation•ICU Transfer

respiratory depressionIntervention:•RRT Intervene•Reversal Agent

effective oxygenation & ventilationIntervention:•Effective monitoring for early detection

HARM ZONE

RISK ZONE

SAFE ZONE

Figure 10.0: respiratory depression warning signs

(When Monitoring Patient)

HQI 2017

– abnormal slowness of respiration (<8 or <10 breaths/minute)

– treatment of pain/agitation ineffective (requiring increased medication doses)

– Mental status change or reduced level of consciousness

– oxygen saturation is low– snoring or other noisy respirations– Pasero opioid-induced sedation scale

(Poss) – Hypoxia/Hyperventilation – elevated carbon dioxide level

in the circulating blood– richmond agitation sedation scale (rass)– environmental barriers/alarming

A

T

M

OSP

HE

RE

C A R E P R O C E S S Step 7: Intervene

34 | Reducing Harm from Respiratory Depression in Non-ICU Patients Through Risk Mitigation and Respiratory Monitoring

G U i d e L i N e s o F C a r e t o o L K i t N o v 2 0 1 7

Reducing Harm from Respiratory Depression in Non-ICU PatientsThrough Risk Mitigation and Respiratory Monitoring


“It is helpful to hear what other hospitals are doing and lessons learned. We are a small standalone rural hospital and it is a helpful way to network with other organizations.” - Safe Table attendee

CHPSO is the longest

tenured and largest

Patient Safety

Organization (PSO)

in the country, with a

robust safety event data

base sufficient for prediction, proactive risk mitigation, and

informed system design. A trusted leader in the collection,

analysis, dissemination and archiving of patient safety

information, CHPSO works with its members through a variety

of mechanisms to disseminate information, best practices,

safety alerts and tools for risk mitigation. Focused projects

in 2017 included clinical alarm management safety, industry

transition of small bore connectors and health information

technology risks. Its national leadership and scale positions

CHPSO to communicate safety concerns to manufacturers and

vendors and influence policy. The Executive Director completed

a year-long appointment to advise AHRQ and other federal

agencies on the development and continued implementation

of the national PSO program.

CHPSO received a multi-site, multi-year grant from the

Gordon and Betty Moore Foundation, with The Brigham

and Women’s Hospital, IHI/NPSF, and the University of Utah.

This $2.8 million grant will fund the development and testing

of a tool to improve ambulatory prescribing safety. Activity

and funding will be most significant for HQI and California in

Year 3 of the grant with $890,000 of the total grant dollars.

• 1.6 million safety reports in the CHPSO database

• 435 CHPSO members, including hospitals and healthcare

organizations from Hawaii to Rhode Island

• 2,833 CHPSO newsletter subscribers

• 219 Legal Counsel Discussion Group subscribers

• 20 Safe Tables convened

CHPSO FACTS »


AWARD-WINNING EXEMPLARS LEAD THE WAY

Leadership matters. Effective leadership inspires behavior, sets the tone for a culture

of respect and professionalism, promotes ongoing learning and improvement,

exhibits compassion, and engages everyone in an ongoing quest for habitual

excellence. It is palpable in the halls of an organization and evident in its results.

Such leadership is manifested in the breadth and success of improvement work in

California’s hospitals and health systems.

Winner of the 2017 C. Duane Dauner Quality AwardSanta Clara Valley Medical Center was

named recipient of the 2017 Dauner Quality

Award, for their work entitled Specialty

Care Access Improvement at a Large Safety Net Hospital.

The work reflects an innovative approach to improving

patient experience, timely access to quality specialty referrals,

continuity of care and provider satisfaction. Piloted in 3 clinics,

the program has grown to encompass 18 adult specialties.

More than 3,000 referrals are processed monthly under the

new system, with 90% of patients needing referrals being

scheduled with median wait times of 22 days for routine and

1.6 days for urgent referrals.

Pictured above, Dr. Lucian Leape with Santa Clara Valley Medical Center leaders left to right – Jelili Apalara, Medical Director Specialty Care; Ofelia Hawk, Director, Ambulatory Quality, Education & Standards; Ahmad Kamal, Vice Chair, Medicine & Associate Chief, Gastroenterology

leading


Finalists for the 2017 C. Duane Dauner Quality AwardMammoth Hospital was recognized as a finalist for the 2017

Dauner Quality Award for their transforming initiative,

A Quadruple Aim Approach for Improving Perioperative

Clinical Outcomes, based on caring for the whole person

through engagement, reliable systems design, and living the

mission of patients first.

Cottage Health was recognized as a finalist for the 2017

Dauner Quality Award for its initiative, Turning Up the

HEAT on Harm, a system-wide, intra-disciplinary initiative to

reduce harm through engagement, use of data, and focused

interventions.

The work of Dauner Quality Award recipients was featured

through video presentations filmed on-site and as part of

the conference.

Effective Leadership Produces ResultsCalifornia HIIN hospitals evidenced substantial improvements

in 2017 that included:

• 34% reduction in adverse drug events

• 25% reduction in healthcare-associated infections

• 11% reduction in patient injury falls

• 7% reduction in sepsis mortality

• 19% reduction in surgical site infections

• 5% reduction in pulmonary embolism/deep vein

thrombosis

HQI was named recipient of the prestigious AHA Dick Davidson Quality Milestone Award for Allied Association Leadership. The award is conferred for

demonstrated leadership and innovation in quality

improvement and contributions to national health care

improvement efforts. This honor reflected the ability to

both lead and nurture leadership, evidenced by successful

execution of programs in pursuit of a shared vision for better

and safer healthcare in California.

California Hospitals through HQI were recognized by the

Patient Safety Movement Foundation for their 2017

commitment to eliminate preventable deaths by 2020.

“HQIs strategic vision of a

comprehensive, statewide approach

to quality and safety across California

stood out to the AHA Award

Committee as especially impressive.

So did HQIs strong and collaborative

approach to engage key stakeholders

to achieve this vision. These efforts

enabled the launch of successful

– and more importantly, sustainable and replicable –

initiatives such as reducing NTSV C-section rates. Because

of the significant ongoing contributions HQI has made

in quality and patient safety as a reputable example for

the field, you are an excellent representative for the Dick

Davidson Quality Milestone Award for Allied Association

Leadership.”

- R. Pollack, AHA President

Finalists pictured above, top: Mammoth Hospital; bottom: Santa Barbara Cottage Hospital

Dick Davidson Quality Milestone Award


Agency for Healthcare Research & Quality (AHRQ)

Alliance Working for Antibiotic Resistance Education (AWARE)

American College of Surgeons (ACS)

American Congress of Obstetricians & Gynecologists (ACOG) District 9

American Hospital Association (AHA)

American Organization of Nurse Executives (AONE)

Association for the Advancement of Medical Instrumentation (AAMI)

Association of California Nurse Leaders (ACNL)

Association of periOperative Registered Nurses (AORN)

Association for Professionals in Infection Control & Epidemiology (APIC)

BETA Healthcare Group

Blue Shield of California

California Association of Healthcare Purchasing & Materials Managers (CAHPMM)

California Association for Healthcare Quality (CAHQ)

California Association of Physician Groups (CAPG)

California Association of Public Hospitals/Safety Net Institute (CAPH-SNI)

California Materials Management Group

California Department of Public Health (CDPH)

California Health Care Foundation (CHCF)

Cal Hospital Compare

California Maternal Quality Care Collaborative (CMQCC)

California Quality Collaborative (CQC) of PBGH

Centers for Disease Control & Prevention (CDC/NHSN)

Centers for Medicare & Medicaid Services (CMS)

CHI/Optima Healthcare Insurance Services

Coalition for Compassionate Care of California (CCCC)

Collaborative Alliance for Nursing Outcomes (CALNOC)

Covered California

Disparities Solution Center (DSC) at Massachusetts General Hospital (MGH)

HealthInsight End Stage Renal Disease (ESRD) Alliance

Health Research & Educational Trust (HRET) of the American Hospital Association (AHA)

Health Services Advisory Group (HSAG)

Infectious Disease Association of California (IDAC)

Institute for Healthcare Improvement (IHI)

Institute for Safe Medication Practices (ISMP)

International Organization for Standardization (ISO)

Los Angeles County Department of Public Health (LACDPH)

Lucian Leape Institute (LLI) of the National Patient Safety Foundation (NPSF) of Institute for Health Improvement

March of Dimes

National Database of Nursing Quality Indicators (NDNQI)

National Patient Safety Foundation (NPSF)

National Quality Forum (NQF)

National Surgical Quality Improvement Program/American College of Surgeons (NSQIP/ACS)

Nationwide Alliance of Patient Safety Organizations (NAPSO)

KEY PARTNERSHIPS

Office of the National Coordinator for Health Information Technology (ONC)

Office of Statewide Health Planning & Development (OSHPD)

Pacific Business Group on Health (PBGH)

PartnerHealth

Partnership for Health Information Technology Patient Safety

Partnership HealthPlan of California (PHC)

Patient & Family Centered Care Partners (PFCCpartners)

Patient Safety Movement Foundation (PSMF)

Patient Transformation Networks (PTNs)

Quality Executives Forum Invitational of IHI State Hospital Associations

Safe and Reliable Healthcare

San Diego Health Exchange and ePOLST Registry Workgroup

San Diego Prescription Drug Abuse Task Force (PDATF)

SG Collaborative Solutions

Smart Care California

State Hospital Associations

The Joint Commission (TJC)

The Root Cause Coalition

UC Davis Institute for Population Health Improvement (IPHI)


Dimitrios Alexiou

President/CEO

Hospital Association of San Diego

& Imperial Counties

Glenn Billman, MD

Chief Medical Safety Officer

Rady Children’s Hospital San Diego

Carmela Coyle

President/CEO

California Hospital Association

Anne M Goldfisher, RN, MA, CENP, CPHQ

Regional Executive Director,

Quality & Regulatory Services

Kaiser Permanente

Northern California Region

George W Greene, Esq

President/CEO

Hospital Association of

Southern California

William Isenberg, MD, PhD

Enterprise Vice President, Patient Safety

Sutter Health

2017 BOARD OF DIRECTORS

Michael Langberg, MD, FACP

Senior Vice President for Medical Affairs

& Chief Medical Officer

Cedars-Sinai Health System

Gregory Maynard, MD, MSc, SFHM

Chief Quality Officer

UC Davis Medical Center

HQI BOARD CHAIR David Perrott, MD, DDS

Senior Vice President & Chief

Medical Officer

California Hospital Association

Clinton Purvance, MD

President/CEO

Barton Health

HQI BOARD SECRETARY/TREASURER Arthur A Sponseller President/CEO

Hospital Council of Northern &

Central California

Katie Skelton, RN, MBA, NEA-BC

Vice President, Patient Care Services

Chief Nursing Officer

St. Joseph Hoag Health

Lynn Welling, MD, FACEP

Chief Medical Officer

Sharp Chula Vista Medical Center

PRESIDENT/CEO

Julie Morath, RN, MS, CPPS

President/CEO

Hospital Quality Institute

EX-OFFICIO MEMBER

Philip Robinson, MD

Medical Director

Infection Prevention and

Hospital Epidemiology

Hoag Memorial Hospital Presbyterian

FORMER MEMBERS

James D. Barber; John Calderone, PhD; C. Duane Dauner; Steven Escoboza; Linda Marsh; Nancy Pratt, RN; Gayle Sandhu, MS, FACHE; Melinda Skeath, RN, CNS; James Stein, MD, MSc

AcknowledgmentsWiley Design Communications, Inc.[printer name to be determined]

HQI is a not-for-profit, non-regulatory, non-accrediting, non-governmental body,

created by hospitals to support hospitals in their improvement efforts to safer

care, better care, better health and lower costs. HQI does not require compliance

but rather inspires and empowers hospitals to commit to improvement and build

ownership from within.

HQI Vision: California hospitals will lead the nation in patient safety and quality

performance with high reliability and zero defects in care on behalf of the people and

communities they serve. They will lead through respect for people and a culture of

habitual excellence.

HQI Mission: To advance and accelerate patient safety and quality improvement for

coordinated statewide impact, with aims to achieve zero defects, optimize clinical

effectiveness, and enhance patient and family experience in health care.

Hospital Quality Institute1215 K StreetSuite 800Sacramento, CA 95814916.552.7600www.hqinstitute.org

HQI is a collaboration of the California Hospital Association, Hospital Council of Northern and Central California, Hospital Association of Southern California, and Hospital Association of San Diego and Imperial Counties

leadership matters - hospital quality institute · 2019-07-21 · leadership matters: inspiring....

Documents