Thomas Jefferson UniversitySidney Kimmel Medical College

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Quality, Safety, & Ethics Committee (QSEC)

Mission Statement

The Quality, Safety, and Ethics Committee (QSEC) of the Department of Medical Oncology strives to provide a multidisciplinary approach to improving the care of patients with oncological diseases at the Kimmel Cancer of Thomas Jefferson University/Thomas Jefferson University Hospital. This includes a focus on patient safety, quality of care and ethical decision making. In an effort to provide state of the art care with compassion, respect and dignity at all stages of the disease process, this group will take proactive and reactive measures to recommend improvement in patient care. The measures will include, but not be limited to:

  • Problem focused subcommittees
  • Chart review
  • Morbidity and mortality conferences
  • Process Improvement plans and programs including implementation and monitoring
  • Interface with other committees that cover similar areas

Introduction

Scope

The Medical Oncology Department of the Kimmel Cancer Center of Thomas Jefferson University and Thomas Jefferson University Hospital, is part of an NCI designated comprehensive cancer center and an academic and regional medical center and non-profit organization includes the facilities of:

Committee Chairman
John Wagner, MD

Standing Members
Tiffany Avery, MD
Bettina Berman, RN BS CNOR CPHQ
Avnish Bhatia, MD
Meghan Boyle, CNRP
Barbara Campling, MD
Neha Chawla, MD
Andrew Curran
Carolyn Davis
Anne Delengowski, RN MSN
Jennifer Duff
Joanne Filicko-O'Hara, MD
Caroline Golab, PhD
Ruth Hostler, RN MSN
Lisa Kearns, CRNP
Ronald Myers, PhD
Annette Noll, RN
Madhavan Pillai, MD
Lauren Potor, RN
Michael Ramirez, MD
Deborah Smyth, RN MSN
Rachel Sorokin, MD
Karen Steffen-Albert MSN RN
Andrew Wierzbieniec

Administrative Offices

  • Department Administrative Offices located at 834 Chestnut Street, Suites 311, 314, and 315

In-patient Units

  • Blood and Marrow Transplant Unit located on the 14th floor of the Foerderer Pavilion Building;
  • Inpatient Oncology Unit – 3 West/ North West; Gibbon Building

Out-patient Units

  • The Outpatient Infusion Center located in the 925 Chestnut Street Building , 2nd floor;
  • The Jefferson Hematology/Medical Oncology Associates Outpatient Practice located on the 3rd and 4th floors, 925 Chestnut Street; any other facilities that may be added at a later time

Laboratory

  • The Hematopoietic Progenitor/Stem Cell Processing Laboratory located in the Edison Building, suite 400;
  • Kimmel Cancer Center with administrative offices in the Bluemle Life Science Building

The Medical Oncology Department of the Kimmel Cancer Center at TJUH provides comprehensive care for a variety of tumors. The Kimmel Cancer Center provides a full range of medical, surgical, radiation oncology and hematology services. As a university teaching center, a full array of medical and surgical specialties exist which can provide support, when needed, to the Medical Oncology Department. This Quality Committee has been developed to address the full scope of medical oncology clinical services.

Mission & Values

The Thomas Jefferson University Department of Medical Oncology seeks to balance two major goals in the service of our patients. The first goal is to provide patient-centered state-of-the-art care in the treatment of malignancies. However, as a program within an academic medical center, simply practicing state-of-the-art medicine, by itself, is insufficient. Therefore, our second, interdigitating goal is to help define and advance the state-of-the-art in our field. This second goal is achieved through the appropriate integration of clinical and basic research activities, as well as, clinical education in patient care process.

Our efforts are focused on reducing errors, improving patient safety and ultimately providing state of the art quality of care in a humane and efficient manner regardless of the patients' background the moment the patient first has contact TJU/TJUH to the moment they leave the facility for the last time.

Goals & Objectives

This QSEC operating procedure describes the structures and processes that have been instituted to continuously improve the quality of services provided to our patients. Performance improvement indictors are selected taking into consideration the following priorities established by the Medical Oncology Department Leadership. The priorities are: patient satisfaction; efficient use of resources and time; promoting best practices (adherence to benchmarks, guidelines and regulations); and improving outcomes. The overall goals are to provide a planned, systematic, collaborative, Medical Oncology Department Program-wide approach to designing, implementing, reassessing and improving performance which can also be used at other "levels" such as "hospital-wide". Other objectives include:

  • To ensure a consistent, high level of care to patients;
  • To assess and improve important patient care and Medical Oncology Department activities;
  • To establish priorities for Medical Oncology Department performance improvement activities by focusing on those with the greatest potential effect to Medical Oncology Department functions, processes, and outcomes;
  • To promote an interdisciplinary, collaborative, coordinated and integrated approach to performance improvement within the Department and among all departments;
  • To provide a method of communication of performance improvement activities and outcomes throughout the Department and the TJU/TJUH organization;
  • To promote the appropriate sharing of resources for performance improvement activities within and among departments;
  • To monitor and ensure compliance with policies, standards, regulations and laws of the Thomas Jefferson University Hospital Board of Trustees, Hospital Administration, Medical Staff, the Joint Commission, the Foundation for the Accreditation of Cellular Therapy (FACT), the American Association of Blood Banks (AABB), state and federal governments, and other applicable regulatory bodies.

Outcome Analysis

Responsibilities

The Thomas Jefferson University Hospitals, Inc. Board of Trustees has the ultimate responsibility for clinical and operational performance. The Board of Trustees Quality Committee meets 4-8 times/ year. The Board assures the establishment of mechanisms to measure and improve the performance of the organization. The Board charges the clinical and administrative leaders with the responsibility for measuring and improving performance within the organization on a continuous basis and supports performance improvement through the allocation of resources.

The Department of Medical Oncology Executive Leadership Committee of which the chairperson of the QSEC is a member is ultimately responsible for measuring and improving performance within the Department. This responsibility includes ensuring compliance with all other regulatory standards and this responsibility is handled through the QSEC.

Department clinical and administrative leaders are responsible for establishing a planned, systematic, Department-wide approach to process design, performance measurement, analysis and improvement. These collaborative, interdisciplinary activities may be carried out across the Department or within one or more facets of the Department assuring that care and services are evaluated as close to the work site as possible. In all cases, improvement activities will include those individuals most closely involved with the process/service to assure the results are consistent with and support the unique aspects of the local environment.

The Department participates in performance improvement activities. The QSEC is responsible for:

  • Developing and implementing a performance improvement plan relevant to the functions of the Department and the scope of services it provides. The plan is consistent with the priorities established by the hospital leadership;
  • Identifying and defining criteria and measures to evaluate its performance, systematically collect and analyze data;
  • Integrating its activities into the organization-wide performance improvement program; Initiating projects to improve patient education and ultimately patient care
  • Initiating action plans or recommendations to improve performance from the Medical Center Quality Committee, Clinical Performance Improvement Committee, Patient Safety Committee, Department Process Improvement Teams, etc. or other Department Program performance improvement meetings;
  • Reporting results of performance improvement activities through the established reporting structure at least biannually and to any key area in a timely manner;
  • When appropriate, measures recommended by the Joint Commission or other accrediting and regulatory bodies are reviewed and considered for use in the development of performance measures.

QSEC Subcommittees

The QSEC may be organized into subcommittees which may include individuals from outside the QSEC for the purpose of integrating efforts to continuously assess and improve outcomes. The subcommittees are responsible for developing and implementing a plan to address an identified opportunity for improvement utilizing the "PDMAI" (Plan-Design-Measure-Analyze-Improve) or other type of process. These teams may be within the Department or interdisciplinary in nature. Membership will include representatives from involved areas, including medical, ancillary, administrative, performance improvement and additional staff as appropriate. Reports will be presented to the Department Executive Leadership Council regularly and at the completion of the projects.

Performance Measurement

Data will be systematically collected according to the priorities established by the QSEC or the Department Executive Leadership Council. These ongoing measurement activities include design of new functions and processes, ongoing monitoring of the performance of existing measures, identifying opportunities for Department improvement and monitoring outcomes.

Data Analysis

Results of measurement activities are systematically analyzed to determine whether design specifications for the processes are met; the level of performance; the stability of the current processes; whether the opportunity for improvement exists; and the effectiveness of actions taken to improve and maintain performance.

Representatives from all involved disciplines/departments participate in the review of the results. The analysis incorporates the comparison of results of past performance, other comparable organizations, current standards, external databases, and external experts.

Examples of references and databases, which can be utilized by BMT Program staff in the analysis process and accessed to measure performance, include:

  • External clinical information databases (University Hospital Consortium Clinical Information Database and Premier);
  • Current information resources such as scientific, clinical or management literature, accreditation standards, and practice guidelines or parameters, such as, ASCO, ASH, NCCN, interdepartmental guidelines and AHQRI.
  • Similar processes and outcomes at other facilitates, including thorough use of reference databases such as Atlas, PA Healthcare Cost Containment Council, Pennsylvania Tumor Registry and the Press-Ganey Patient Satisfaction Survey.

Retention Of Information

Performance improvement reports and minutes are retained for at least ten years. Records of medical staff peer review activities and physician profiles will be retained for at least ten years and are kept within the Department of Performance Improvement at TJUH.