HIM410 Introduction to the Health Care System

In 2008, Gwenn McLaughlin, MD, was asked to consider taking on the duties of Chief Quality and Safety Officer for the 254-bed Holtz Children’s Hospital, associated with the University of Miami Miller School of Medicine Medical School and the Jackson Health System. A pediatric intensivist and Professor of Clinical Pediatrics, she had been on the medical school faculty and hospital staff for almost 20 years, since completing her residency and fellowship elsewhere. During that period, she had participated in the clinical governance of the hospital in a number of ways, including the Pharmacy & Therapeutics Committee, the Credentials Committee, the electronic medical record implementation team, and director of quality improvement in the Pediatric Intensive Care Unit. With her husband established in his private medical practice and her children in college, she had recently completed all the course work for an MPH degree locally and was considering her career alternatives.

While she negotiated other terms and conditions of the job to assure continued income and an appropriate balance between clinical and administrative duties, she began to look at the position itself. She was provided the job description shown in Exhibit 6–1. After considerable discussion with the Hospital Chief of Staff and Chief Medical Officer, the job description given in Exhibit 6–2 emerged. It was further refined in 2009 as shown in Exhibit 6–3.

The Holtz Children’s Hospital Chief and Safety Quality Officer will report to the Hospital Chief of Staff and work in coordination with the Hospital Chief Medical Officer to provide leadership for the Hospital’s Quality and Safety Program. Working in partnership with Hospital leadership and medical staff leadership, the Chief Quality and Safety Officer will provide leadership in the development and measurement of the Hospital’s approach to quality/performance improvement and medical safety.

1. Initiate and oversee the development of a comprehensive quality/performance improvement program.

2. In conjunction with the medical staff and Children’s Hospital (CH) leadership, the Chief Quality and Safety Officer will direct and coordinate quality/performance improvement initiatives for the Children’s Hospital.

3. In collaboration with clinical staff and service chiefs, participate in the development, monitoring, reporting, and improvement of activities related to clinical pathways and guidelines.

4. Foster and maintain collaborative relationships with external agencies, purchasers, and stakeholders related to quality/performance initiatives.

5. Chair the CH Quality and Safety Council and work with the council to establish quality/performance improvement priorities.

6. Lead the development of CH policies and procedures related to quality improvement/medical safety and participate as a stakeholder in the crafting of CH policies.

7. Ensure the development of such policies and secure overall Medical Center approval.

8. Monitor activities for and ensure compliance with laws, government regulations, Joint Commission requirements, and CH policies.

9. As directed, implement external and internal audits of Quality and Safety within the Children’s Hospital.

The Holtz Children’s Hospital Chief Quality and Safety Officer reports to the Hospital Chief of Staff and works in coordination with the Hospital Chief Medical Officer to provide leadership for the Hospital quality and safety program. Working in partnership with the Hospital leadership and the medical staff leadership, the Chief Quality and Safety Officer will provide leadership in the development and measurement of the Hospital’s approach to quality/performance improvement and medical safety.

1. Initiate and oversee the development of a comprehensive quality performance improvement program that tracks both established nationally accepted and innovative locally developed quality indicators for the Children’s Hospital.

2. In conjunction with the medical staff and CH leadership, implement patient safety initiatives in accordance with best practices as established by national bodies.

3. Lead the development of CH policies and procedures related to quality improvement/medical safety.

4. In conjunction with the medical staff and CH leadership, create and lead project improvement/process redesign teams to facilitate patient care and flow within the system.

5. In collaboration with medical staff, participate in the development of clinical pathways and guidelines.

6. Supervise the physician and nursing clinical educators in their role to educate the staff regarding best practices, clinical pathways, policies, and procedures.

7. Create monitoring programs to document compliance with best practices, clinical pathways, and hospital policies.

8. Review all incident reports and attend all root cause analyses to determine where there are systems problems that can be addressed.

9. Foster and maintain collaborative relationships with external agencies, purchasers, and stakeholders related to quality/performance initiatives.

10. Chair the CH Quality and Safety Council and work with the council to establish performance improvement priorities.

11. Provide advice and direction for individual quality improvement teams to identify goals and facilitate implementation of the recommendations to achieve those goals.

The Holtz Children’s Hospital Chief Quality and Safety Officer reports to the Hospital Chief Medical Officer and the Service Chief for Pediatrics to provide leadership for the Children’s Hospital quality and safety program. Working in partnership with the Hospital leadership and the medical staff leadership, the Chief Quality and Safety Officer will provide leadership in the development and measurement of the Hospital’s approach to quality/performance improvement and medical safety.