May 26, 1999

TO: Mark Finucane

Director of Health Services

Donald C. Thomas, III, M.D.

Associate Director, Clinical and Medical Affairs

FROM: Roberto Rodriguez

Executive Director/CEO, LAC+USC Healthcare Network

SUBJECT: PROPOSAL FOR THE RESTRUCTURING OF THE QUALITY MANAGEMENT PROGRAM OF DHS AND LAC+USC HEALTHCARE NETWORK.

Attached for your perusal and consideration is a two-part proposal for the restructuring

of the Department=s Quality Management/Improvement Program and that of the

LAC+USC Healthcare Network. This proposal is a result of my assessment of the entire QA process involving both the Department and LAC+USC Network in preparation for the recently completed JCAHO survey, a review of QAVI committee minutes, a review of the LAC+USC Medical Staff By-laws, a review of the reporting and corrective action activities, and a review of County Ordinance Section 2.76.590 as well as Evidence

Code Section 1157.

The intent of this proposal is to shift the current process and its protocols from an

incident-driven approach, to one that is more proactive and comprehensive from both a departmental and facility perspective in that it would allow for:

$ More comprehensive monitoring of clinical trends and activities against

departmental goals and governing body responsibilities delegated to you;

$ Preventive intervention by ensuring that quality of care is provided through measurable standards, criteria and protocols by which actual care can be measured at each facility and consistent with departmental initiatives, rules and regulations;

Mark Finucane

May 26, 1999

Page 2

$ Ensure that facility specific procedures, methods and systems are effective, efficient and consistent with departmental objectives;

$ More integrated process for establishing and monitoring department-wide clinical and associated administrative indicators;

$ Reduction of professional and financial liability by ensuring adherence to quality of care standards and protocols through continuous monitoring;

$ Ensure continuous performance improvement, JCAHO and State survey readiness at all facilities; and

$ Better alignment between the Associate Director for Clinical and Medical Affairs and the facilitates= CEO, Medical Directors, and Presidents of Medical Staff with more direct and frequent interaction.

The proposal calls for the establishment of a DHS Quality Assurance Committee

chaired by Dr. Thomas, with ex-officio members to include (at your discretion) Assistant Director for Operations, Director of Ambulatory Care, and County Counsel (at

Chairman=s discretion) and the Director of Public Health. You may also want to consider

the inclusion of Public Health facilities involved with direct patient care.

Appendix A illustrates the structure and reporting relationship between this committee

and the facilities involved.

Appendix B illustrates the leadership duties and responsibilities of all parties.

Appendix C illustrates what the subject matter is to be reported by each facility and

serve as the standing agenda for each meeting with the DHS Quality Assurance

Committee on a quarterly basis. The current DHS Quality Improvement Program staff

would serve as staff of the committee.

The second part of this proposal calls for the establishment of a Hospital-wide (Center

or Network-wide) Quality of Care Review Committee to replace the current committees

at each facility (and in the case of LAC+USC, pull it out of the Medical Staff structure). These committees would be chaired by the CEO and co-chaired by the Medical

Director.

Appendix D is the LAC+USC Network Quality of Care Review Committee

structure/table of organization.

Mark Finucane

May 26, 1999

Page 3

In the case of LAC+USC ( and other facilities with a similar structure), this change will

call for a revision of the Medical Staff By-laws to dissolve he current QAVI committee.

This would also serve to address one of the concerns of a CMA surveyor which

questioned in independence of the Medical Staff because he viewed the role of the

Chief of Staff - currently an Officer of the medical staff - as compromising the

independence of the body. I agree with this observation and, therefore, propose

changing the role of the Medical Director to Ex-Officio without vote and discontinue his

appointment/election as an officer of the Medical Staff (Executive Secretary).

In addition, I am proposing changing the designation of the facility CEO, CNO and any

other facility senior manager to ex-officio without vote.

Appendix E illustrates the LAC+USC Network Quality Improvement structure,

leadership responsibilities, Committee composition, purpose/authority, and duties and

responsibilities.

Utilizing the most current Quality Improvement appraisals, each facility can revise their

respective program plans to accommodate the new structure and reporting

requirements.

I would also ask to consider forwarding this as a draft document soliciting

comments from the respective CEOs, Medical Directors, and Presidents of Medical

Staff with a 15-day turnaround time. You may also wish to run this by the Rathgar

Group and DHS/QI staff.

I am available to discuss this with both of you and your earliest convenience as I would

like to proceed with the LAC+USC portion of this proposal within the next 30 days.

Please advise.

RR:ajc

Attachment

3: Douglas Bagley

Ronald L. Kaufman, M.D.

Katherine A. Eaves, R.N.

Ramona Hernandez

APPENDIX B

LEADERSHIP

RESPONSIBILITIES

DHS/LA HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX B: LEADERSHIP RESPONSIBILITIES
WHO	RESPONSIBILITY	DUTIES
GOVERNING BODY	Ultimate responsibility and authority for Quality Assurance and PI programs. QA Committee acts on behalf of the Director for oversight of major activities related to QA /I/I, RM, credentialing, safety management, and patient relations, as delegated by the Board Supervisors	o Directs the Director of DHS to establish mechanisms for Quality of Care Review and performance improvement. o Reviews summary of hospital=s findings related to performance improvement; o Ensures that appropriate follow up action including any disciplinary and/or other Corrective actions are taken by the facility; o Reviews corrective actions and monitor plans implemented by the hospital ; o Meets quarterly with key members of the HQCRC to review the quarterly report submitted by each hospital; o Provides a quarterly report to the Board of Directors on the status of the hospital=s performance improvement program.
EXECUTIVE DIRECTOR	To establish a comprehensive and integrated quality review/performance improvement program that is in compliance with applicable federal and state law and the requirements of third-party payers.	o Establish/chair HQCRC which shall issue quarterly reports to the DHS QA Committee; o Review findings of the hospital=s performance improvement, risk management, Credentialing, safety management,. Infection control, and patient relations activities; o Meet quarterly with DHS to present quarterly PI report; o Receive quarterly reports from the MEC, ICC, Safety committee, and Home Health Agency; o Organize, direct, and staff patient care and support services in a manner consistent with the scope of services offered; o Provide a framework for the provision of services that is responsive to community and patient needs. o Assess the needs of patient=s and other users of the hospital=s services; o Define a strategic plan and communicate the plan throughout the organization; o Provide forum for setting priorities for performance improvement; o Allocate resources for assessing and improving the organization=s performance; o Create and maintain information systems and appropriate date management processes; o Assess the effectiveness of performance improvement activities.
MEDICAL DIRECTOR	Provides clinical and administrative direction to the Chiefs of Service, and the medical service training programs; Serves as medical advisor to both the Affiliation and the Executive Director; Oversees the quality/performance improvement, risk management, and physician credentialing activities.	o Evaluate and recommend for appointment or reappointment, the Chiefs of Service to the Executive Director and subsequently to the Credentialing Committee; o Serve as co-chair of the Hospital-Wide Quality of Care Review Committee; o Work with the President of the Medical Staff to ensure Medical Staff compliance with the appropriate directives and guidelines, bylaws, rules and regulations of the hospital, the governing body, and the standards of JCAHO, local, state, and federal agencies. o Serve as an ex-officio member of all Committees of the Medical Board of which he is not a regular member; o Work closely with the President of the Medical Staff on quality of care issues, and report regularly at the Executive Committee meetings of the Medical Board; o Provide leadership for the clinical department/service directors; o Develop appropriate standards for the delivery of patient cars and for professional performance. o Oversee patient care services performed outside of the organization via monitoring and evaluation of the quality of patient care rendered.

DHS/LA HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX B: LEADERSHIP RESPONSIBILITIES
WHO	RESPONSIBILITY	DUTIES
MEDICAL STAFF CHIEFS OF CLINICAL SERVICES	Responsible and accountable for implementation of the department=s Quality of Care and Performance Improvement Program. Responsible for all clinically related activities of the department;	o Coordinate and integrate interdepartmental and intradepartmental services; o Develop and implement policies and procedures that guide and support the Provision of services; o Recommend sufficient: number of qualified and competent persons; space; and other resources to provide care; o Recommend the criteria for clinical privileges in the department to the department; o Recommend clinical privileges for each member of the department; o Continual surveillance of the professional performance of individual who have Delineated clinical privileges; o Orientation and continuing education of all persons in the service; o Maintain he appropriate quality control programs; o Establish and implement a planned and systematic process for monitoring and Evaluation of the quality of patient care for their respective Department as specified in the LAC+USC Medical Staff By-Laws@. o Convene regular meetings at which Performance Quality Improvement activities will be reviewed. o Provide an effective mechanism to monitor and evaluate the quality of patient care and the clinical performance of individuals with delineated clinical privileges. o Identify opportunities to improve patient care outcomes and implement action plans, so that important problems are addressed and resolved. o Review at least the following activities, as part of the Department=s Performance/Quality Improvement Program: Surgical Case Review, Invasive Procedures and Non-Tissue Case Reviews, Drug Use and Evaluation, Blood Utilization and Evaluation, Medical Record Review, Morbidity/Complications, Mortality Review, Medical Malpractice Case Review, Clinical Indicator Review, Incident Review, Infection Control Review, Patient Complaints, Pharmacy and Therapeutics, Utilization Review, and Safety. o Document conclusions, recommendations, action taken and effectiveness of action taken (CRAE) when opportunities for improvement are identified. o Submit timely minutes using the approved minutes format to the Medical Director, the Medical Executive Committee (MS.3.1.7). And the office of Quality Management. o Consider the results of the performance/quality improvement review activities when defining the content of continuing medical education programs and the granting of clinical privileges. o Evaluate the effectiveness of the performance improvement activities at least annually, and submit a written evaluation to the office of Qualaity Management and the Medical Director. Note: When quality of care issues are identified during review activities, a comprehensive chart review should be done. In order to facilitate interdisciplinary and interdepartmental process improvement, identified issues which involve other departments or disciplines should be referred and followed up via the quality improvement mechanism.

DHS/LA HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX B: LEADERSHIP RESPONSIBILITIES
WHO	RESPONSIBILITY	DUTIES
NURSING EXECUTIVE (CNO)	Plan and implement the monitoring and evaluation process for performance improvement in the Department of Nursing and Patient Care Services.	o Participate in and represent the Nursing and Patient Care Services at the Hospital-Wide Quality of Care Review Committee, the Medical Executive Committee, and the Quality of Care Committee. o Determine the qualifications and competence of personnel who provide patient care services and recommends a sufficient number of qualified and competent Personnel, space, and other resources as necessary to provide care/services. o Develop programs to promote recruitment, orientation and continuing education of all departmental personnel. o Oversee the ongoing functioning and activities of the Nursing Service Quality Improvement Committee, and the Nursing and Patient Care Services Quality Improvement Committee. o Implement a planned process for the systematic monitoring and evaluation of the Quality and appropriateness of patient care on an on-going basis. o Assess the cause and scope of unresolved problems. o Monitor effectiveness of corrective action. o Implement recommended disciplinary action. o Ensure integration of Nursing and Patient Care Services with other clinical and support services in the hospital. o Develop and implement recommended changes in policies and procedures that guide and support the provision of servcices. o Receive, review and make recommendations for approvals on research projects in the Department of Nursing and Patient Care Services. o Communicate the results of Performance/Quality Improvement monitoring and evaluation activities to the Clinical Councils quarterly, or more frequently as necessary. o Coordinate and integrate interdepartmental and intradepartmental services, and communicate to other Clinical /Support Services as necessary. o Participate in the hospital admission system to coordinate patient requirements for nursing care with available nursing resources. o Participate in policy decisions affecting patient care services at relevant levels of corporate hierarchy.

DHS/LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX B: LEADERSHIP RESPONSIBILITIES
WHO	RESPONSIBILITY	DUTIES
NON-CLINICAL DEPARTMENT DIRECTORS	Develop and implement a planned, integrated, systematic Performance Improvement Program, consistent with the hospital=s mission and vision.	o Coordinate and integrate interdepartmental and intradepartmental services. o Develop and implement policies and procedures that guide and support the provision of services. o Determine the qualifications and competence of department personnel, and recommend a sufficient number of qualified and competent personnel, space and other resources as necessary to provide care/service. o Provide orientation and continuing education to all department personnel. o Maintain the appropriate quality control program . o Review and approve indicators, reports and minutes. o Convene meetings to discuss the findings of the monitoring, evaluation and Improvement activities. Document conclusions, recommendations, actions and effectiveness of actions. o Submit minutes and/or reports to the Quality Management Department. o Utilize the results of performance/quality assessment activities when defining the content of continuing education programs. o Review and document discussions on relevant issues of hospital monitoring committees and actions taken at departmental meetings. (The review shall include but is not limited to the following monitoring activities: patient complaints, risk management, safety management and infection control.) o Review performance/quality improvement activities annually and submit a written annual evaluation to the Quality Management Department.
COMMITTEE CHAIRPERSON	Conduct meetings at a predetermined frequency which address the purpose(s) of the committee.	o Prepare meeting agenda which encompasses the purpose of the committee. o Ensure closure of open issues. o Chair meeting in an orderly fashion, pursuant to Robert=s rules of order. o Document and approve minutes of each meeting which include issues discussed, status and conclusions regarding problems identified, recommendations for solutions, actions taken (including tracking and trending when necessary), and follow up evaluation of actions taken. o Forward copies of the minutes to the Medical Executive Committee via the Medical Board Office, or Hospital-wide Quality of Care Review Committee via the Quality Management Department, as appropriate. o Maintain the attendance record of each committee member for each meeting. o Conduct an annual evaluation of the committee=s effectiveness.

DHS/LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX B: LEADERSHIP RESPONSIBILITIES
WHO	RESPONSIBILITY	DUTIES
QUALITY MANAGEMENT DEPARTMENT	Provide support to the Performance Improvement Committees and the HQCRC. Assist in the coordination and integration of the hospital Performance/Quality Improvement Program.	o Create a mechanism to receive reports of identified problems or variances and ensure that they are referred to the appropriate department or committee for investigation, corrective action, resolution and follow-up. o Create a mechanism to inform Risk Management and Safety Management of patient care occurrences and findings that may affect patient care and/or exposure the hospital to liability. o Analyze and evaluate past liability experience and risk exposure to predict the risk in patient care, hospital operations, and community image. o Provide ongoing staff education/training to all employees. Provide technical assistance to departments, services and committees for the development of objective standards, criteria, and indicators; o Establish monitoring and analysis protocols; o Document performance/quality improvement review activity which will indicate findings, conclusions, recommendations, actions taken and effectiveness of action taken. o Track significant identified events or problems to ensure that required analysis and recommendations are completed and reported in a timely manner. o Maintain records and reports of all Quality Improvement activity. o Evaluate annually the objectives, scope, organization and effectiveness of the Quality/Performance Improvement program and make recommendations for revision to the Hospital-Wide Quality of Care Review Committee. o Review Performance Improvement and monitoring Committee minutes to ensure the appropriateness for monitoring and evaluation activities. o Assist in the review and revision of the hospital-wide Performance Improvement Plan which should address at least the five elements of performance improvement, i.e., plan, design, measure, assess, improve.
QUALITY MANAGEMENT DEPARTMENT	Provide support to the Performance Improvement Committees and the HQCRC Assist in the coordination and integration of the hospital Performance/Quality Improvement Program.	o Create a mechanism to receive reports of identified problems or variances and ensure that they are referred to the appropriate department or committee for investigation, corrective action, resolution and follow-up. o Create a mechanism to inform Risk Management and Safety Management of patient care occurrences and findings that may affect patient care and./or expose the hospital to liability. o Analyze and evaluate past liability experience and risk exposure to predict the risk in patient care, hospital operations, and community image. o Provide ongoing staff education/training to all employees. o Provide technical assistance to departments, services and committees for the development of objective standards, criteria, and indicators; o Establish monitoring and analysis protocols; o Document performance/quality improvement review activity which will indicate findings, conclusions, recommendations, action taken and effectiveness of action taken. o Track significant identified events or problems to ensure that required analysis and recommendations are completed and reported in a timely manner. o Maintain records and reports of all Quality Improvement activity. o Evaluate annually the objectives, scope, organization and effectiveness of the Quality/Performance Improvement program and make recommendations for revision to the Hospital-Wide Quality of Care Review Committee. o Review Performance Improvement and monitoring Committee minutes to ensure The appropriateness of monitoring and evaluation activities. o Assist in the review and revision of the hospital-wide Performance Improvement Plan which should address at least the five elements of performance improvement, i.e., plan, design, measure, assess, improve.

5.20.99 CONFIDENTIAL APPENDIX C

DRAFT

(For discussion only)

AGENDA

DHS

QUALITY

ASSURANCE

COMMITTEE

Meeting Date:

Time:

Location:

1. CALL TO ORDER

ADOPTION OF MINUTES OF THE QUALITY ASSURANCE COMMITTEE

(Name of Institution) Quarterly Report

II EXECUTIVE SUMMARY

A. Self Assessment of the Status of Quality of Carte - Verbal Presentation by

CEO

III ADMINISTRATIVE ISSUES (Update)

A. Major changes affecting Facility Operations

B. New or Discontinued Affiliations/Training

C. New or Discontinued Residency Programs

D. Addition/Deletion/Reduction of Services, Clinics, and/or Programs

E. Regulatory and Accreditation Agency Surveys

F. Performance Evaluations for All Staff

G. Mandated In-Service Education - Clinical Departments

H. Mandated In-Service Education - Hospital Departments

IV PATIENT RIGHTS/SATISFACTION

A. Patient Rights Issues - Advanced Directives (Inpatient and Outpatient

Services)

B. Patient Relations Activities - Surveys and Complaints

1. Department(s)

2. Category (ies)

V. UTILIZATION MANAGEMENT DATE ( QUARTERLY)

A. Statistics

1. Number of Inpatient Discharges

2. Inpatient Occupancy Rate

3. Number of Deliveries

4. Average Length of Stay (ALOS)

5. Number of Emergency Room Visits

DRAFT

(For Discussion Only)

6. Number of Outpatient Visits (Closed, broken appointments,

appointment time, clinic waiting time)

7. Number of New Registrants

8. Number of New Registrants

9. HMO Enrollment/Disenrollments (By Plan)

a. Number of Enrollees

b. Number of Voluntary Disenrollments

c. Number of Involuntary Disenrollments

10. Reasons for Voluntary Disenrollments

B. Third Party Payor/Managed Care Final Denials Report

1. Administrative Denials

2. Technical Denials

3. Number of Denials by Service (trends and/or greatest number per

quarter)

4. Total Dollars Denied

C. Top Ten Inpatient DRGs and Description

D. Top Ten Ambulatory Care Principal Diagnosis

E. Top Ten Emergency Department Principal Diagnosis

VI. COMPREHENSIVE HEALTH CENTERS ACTIVITIES

A. Number of Clinic Visits (Closed, broken appointments, appointment time

clinic waiting time)

B. Number of Registrants

C. Number of Ambulatory Surgical Procedures (Where applicable)

D. HMO Enrollments/Disenrollments (By Plan)

1. Number of Enrollees

2. Voluntary Disenrollments

3. Involuntary Disenrollments

4. Reasons for Voluntary Disenrollments

E. Third Party payor/Managed Care Final Denials Report

1. Administrative Denials

2. Technical Denials

3. Denials by Clinic

4. Total Dollard Denied

DRAFT

(For Discussion Only)

F. Practice Guidelines/Case Management Activities

G. Top Ten Ambulatory Care Principal Diagnosis

H. Administrative Issues/Update

VII HOSPITAL/NETWORK INFORMATION MANAGEMENT

A. Chart Completion (Hospital and CHCs)

1. Incomplete Medical Records

2. Delinquent Medical Records

3. Delinquent History and Physicals

4. Delinquent Operative Reports (indicated)

VIII. QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT ACTIVITIES

A. Department-Wide Indicator Monitoring Activities (e.g. below)

1. Clinical Pathways (Status and/or Update)

2. Pediatric Asthma Emergency Room Visits/Revisits

3. Adult Asthma Emergency Room Visits/Revisits

4. Psychiatry Re-Admissions

5. Admissions within 30 days of Discharge (by service)

6. Diabetic Admissions

B. 1. 1115 Waiver Activities

2. Access Indicators (targets)

3. Service Indicators (60-minute service)

C. Infection Control Indicators

D. Summary of Performance Improvement Process: Functions Monitoring

1. Continuum of Care

2. Care of Patients

3. Patient Education, etc.

E. List of Performance Improvement Projects Sanctioned by the Hospital

Quality of Care Review Committee

F. Performance Improvement Project Presentation

G. Mortality Review Date

1. Number of Mortalities

2. Number of Autopsies

DRAFT

(For Discussion Only)

H. Major Quality of Care Issues Identified from Mortality Review

IX CERTIFIED HOME HEALTH AGENCY REPORT

A. Patients= Rights Issues (Advance Directives)

B. Home Health Referral Disposition Data

C. Home Health Statistics

1. Admissions

2. Discharges

D. Home Health Utilization Data

1. Visits by Each Discipline

2. Hours Related to Visits

3. Visits Billed to Each Payor

E. Summary of Performance Improvement on Agency Indicators

F. List of Performance Improvement Projects

G. Professional Advisory Committee Minutes

10. RISK MANAGEMENT

A. Reportable Incidents

B. Narrative Summary of Incidents (with corrective actions taken)

C. Settled Case Reports

XI. CREDENTIALING

A. Credentialing and Privileging Activities

B. Reappointments

C. Terminations/Separations

D. Practitioners Reported to Disciplinary Organizations.

DRAFT

(For Discussion Only)

XII. MANAGEMENT OF THE ENVIRONMENT OF CARE

A. Safety management (e.g. TB respirator assessment and fit testing;

Hazardous Materials)

B. Security Management (e.g. Hospital Police Training, employee orientation)

C. Annual In-Service/New Employee Orientation

D. Resistant and Seclusion

E. Customer Relations and Cultural Sensitivity

F. Emergency Preparedness (to include preparedness training)

G. Life Safety Management

H. Medical Equipment

1. Malfunction requiring major repairs versus user errors

2. User Errors

3. Inspection and Preventive Maintenance

4. Major Repairs

I. Other Environmental Considerations (e.g. Patient Smoking)

XIII. QUALITY ASSURANCE AND IMPROVEMENT ACTIVITIES AND MINUTES LOG

XIV. ADDENDUM

XV. ADOPTION OF QUALITY ASSURANCE REPORT

XVI. ADJOURNMENT

APPENDIX E

LEADERSHIP

COMMITTEE

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
HOSPITAL-WIDE QUALITY OF CARE REVIEW COMMITTEE (HQCRC)	MEMBERSHIP: o Executive Director, (Chairperson); o Medical Director, Co-Chairperson; o President of Medical Staff o Deputy Executive Director for Nursing and Patient Care Services; o Chief Financial Officer; o Director of Social Work Services o Chief of Ambulatory Care, (Chairperson, Quality of Care Committee) o Chief of Medicine o Chief of Surgery o Chief of Obstetrics/Gynecology; o Chief of Pediatrics o Chief of Emergency Medicine; o Chief of Psychiatry o Chief Operations Officer (Chairperson, Safety Committee); o Associate Executive Director/Quality Management	PURPOSE: To coordinate and oversee the hospital-wide performance/quality improvement program that integrates all aspects of performance/quality improvement, risk management, safety management, and infection control. AUTHORITY: Full responsibility to follow-up on all actions, and monitor effectiveness of the actions taken by the oversight departments and/or committees. Recommend disciplinary and/or remedial action as may be necessary.	o Oversight of: - The comprehensive hospital-wide Performance/Quality Improvement Program. - Significant performance/quality assessment and improvement and risk management activities to ensure that findings are made available and/or used in the credentialing, appointment/reappointment and performance evaluation process of clinical staff as indicated. - The effectiveness of the hospital-wide Performance/Quality Improvement Program on an annual basis. - Continuing In-service Education activities to ensure that they are carried out as mandated by DHS and State Codes, Rules and Regulations, e.g. (Safety, Quality Assessment and Improvement; Risk Management (QI/RM), incident Reporting, Patients Rights, AIDS, and Infection Control). o Receive reports and/or identified problems from: - Executive Committee of the Medical Board (MEC); - Clinical Councils; - Quality of Care Committee (QCC); - Infection Control Committee (ICC); - Safety Committee; - Home Health Agency; - Performance Management Teams o Refer action plans, as appropriate, back to the appropriate committee or administration for final resolution. o Track implemented plans of correction to ensure successful resolution. o Maintain a log of the receipt of minutes documenting the Performance/Quality Improvement activities of all the departments, services and committees as required by the hospital=s Performance/Quality Improvement Plan.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
MEDICAL EXECUTIVE COMMITTEE MEETING FREQUENCY: Monthly in the interim between full Medical Board meetings. REPORTS TO: Hospital-Wide Quality of Care Committee regarding performance/quality improvement issues. DHS on hospital management matters through the Executive Director.	o Officers of the Medical Board; o Chiefs of Service/Designees; o Two Medical Staff Members at large; o House Staff Member o Ex Officio Members (no vote): - Medical Director; - Executive Director; - Chief Nursing Officer; - Chief Operations Officer; - Affiliation Representative - Associate Executive Director of Quality Management	PURPOSE: To establish appropriate mechanisms to assure continued participation of the Medical Staff in Medical Administrative matters, including Hospital Budget Formulation, Budget Allocation, Facilities Planning and Utilization. AUTHORITY: To represent and to act on behalf of the Medical Staff, subject to such limitations as may be imposed by the Medical Staff By-laws.	o Coordinate the activities and general policies of the various departments. o Receive and act upon Committee and department reports. o Implement policies of the Medical Board. o Provide Liaison between the Medical Staff, the Chief Executive Officer and DHS. o Recommend action to the Chief Executive Officer or a qualified designee on matters of Medical-administrative nature. o Make recommendations on hospital management matters (for example, long range planning) to DHS through the Executive Director (Chief Executive Officer). o Ensure that the Medical Staff complies with and is kept abreast of the accreditation programs and informed of the accreditation status of the hospital. o Provide for the preparation of all meeting programs either directly or through delegation to a program committee or other suitable agent. o Provide for the preparation of meeting programs either directly or through delegation to a program committee or other suitable agent. o Review credentials of all applicants and make recommendations for staff membership, assignments to departments and delineation of clinical privileges. o Review, periodically, all information available regarding the performance and clinical competence of staff members and other practitioners with clinical privileges and, as a result of such reviews, to make recommendations for appointments and renewal or changes in clinical privileges. o Take all reasonable steps to ensure professional ethical conduct and competent clinical performance on the part of all members of the medical staff, including the initiation of and/or participation in medical staff corrective or review measures when warranted, and to report at each meeting of the Medical Board. o Receive appropriate reports from the Hospital Infection Control and Safety Committees.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
CLINICAL COUNCILS Ambulatory Care, Emergency Department Medicine, Obstetrics/Gynecology, Pediatrics Psychiatry, Surgery, and Nursing & Patient Care Services, MEETING FREQUENCY: At least 10 times per year and as needed. REPORTS TO: Hospital wide QCRC monthly.	o Chief of Service (Chairperson); o Quality Improvement (QI) Physician Liaison Representatives from the following disciplines or departments: o Medical Staff (Attending and Resident Physicians) o Nursing o Nutritional Services o Social Work Services o Patient Relations o Respiratory Care o Quality Management o Utilization Management It will be within the purview of the Committee to invite representatives of departments and/or non-clinical services to participate in presentation or discussion of specific topics as required.	PURPOSE: o Designed to coordinate and integrate all departmental performance/quality improvement and risk management activities. o To provide an effective, and efficient mechanisms for the identification of opportunities to improve care; o To ensure the delivery of the highest possible quality of care within the limitations of available resources. AUTHORITY: o Ensure the implementation of a planned and systematic process to monitor and evaluate the quality of patient care provided on an ongoing basis; o Assess the cause and scope of unresolved problem; o Monitor effectiveness of corrective action taken; o Recommend disciplinary and/or remedial actions and/or changes in policies and procedures, if appropriate.	o Coordinate and integrate all departmental performance/quality improvement activities. o Review and approve departmental performance improvement plans, minutes indicators and/or other monitoring activities. o Prioritize problems with patient care and/or hospital wide impact. o Present a verbal report quarterly to the Hospital-wide Quality of Care Review Committee. o Submit minutes to the Hospital-wide Quality of Care Review Committee. o Review and evaluate, at least annually, the effectiveness of the departmental performance/quality improvement program.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
QUALITY OF CARE COMMITTEE MEETING FREQUENCY: At least four (4) times each year or more frequently as need (incidents) dictates. REPORTS TO: There is a direct channel of formal communication to the Executive Director, and to the Medical Board through the Hospital- wide Quality of Care Review Committee, should a matter require immediate action.	o Chief of Service o Executive Director/Designee; o Medical Director o Chief of Medicine; o Chief of Surgery; o Chief of Obsterrics/Gynecology; o Chief of Pediatrics; o Chief of Emergency Medicine; o Director of Nursing/Designee; o Associate Executive Director for Quality Management. o Attorneys (County Council) as appropriate o Committee Staff: Associate Director/Risk Management.	PURPOSE: o To provide a planned and systematic process to monitor and detect trends patterns and potential problems that may affect a patient, department/service and/or professional discipline. o To promote the quality of patient care to reduce liability for the hospital. AUTHORITY: o The committee is guided by the Principles consistent with standards And/or desirable medical practices, It has the authority to use risk management data to recommend specific corrective actions and/or procedures which will lead to improved patient care, and reduction of loss. o The ultimate impact of the Quality of Care Committee emanates from its recommendations.	o To review cases, situations; occurrences and incidents at the hospital from the viewpoint of appropriate corrective action and prevention of future occurrences of a similar nature. o To ensure the implementation of recommendations, policies, procedures and by-laws to protect the interest and welfare of patients and the hospital. o To base deliberations and actions upon actual occurrences and loss prevention issues, and seeks practical methods of promoting the quality and safety of patient\ care by preventing medical malpractice. o To trend occurrences and incidents. o To ensure that root-cause analyses are conducted for sentinel events. o To communicate to individual clinical or non- clinical services as needed. o To recommend corrective action. o To determine methods for prevention of future occurrences. o To suggest monitoring and evaluation studies based upon its recommendations. (Such studies will be fact finding in nature and may lead to further recommendations.)

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
HOME HEALTH AGENCY PROFESSIONAL ADVISORY COMMITTEE MEETINGS FREQUENCY: At least quarterly REPORTS TO: The DHS Quality/Assurance Committee via the Hospital-wide Quality of Care Committee on a quarterly basis	o Chaired by a member of the Medical Board. o Co-Chaired by the Director of Home Care Services. o Representatives from each of the Home Health services; - Medical Staff - Nursing and Patient Care Services - Rehabilitation Medicine - Utilization Management - Social Work Services - Community Representatives o Director/Regulatory Affairs	PURPOSE: o To evaluate the quality of care provided By the Certified Home Health agency. o To maintain optimal patient care within the available resources. o To communicate performance or quality improvement issues as necessary to HQCRC and Medical Board. AUTHORITY: o Authority to evaluate the disposition of assets and the incurring of liabilities on behalf of the agency. o Authority over the adoption and policies regarding the operation of the agency.	o Maintain an on-going review of patient care within the Certified Home Health Agency. o Promote and maintain optimal patient care through analysis, review and evaluation of clinical practices. o Identify problems related to quality care as efficiently as possible, making maximum use of existing patient care review mechanisms and data collection activities with minimum use of additional financial resources and provider time. o Facilitate correction of identified problems. Demonstrate improvement of patient care outcomes. o Maintain standards of care and practice in accordance with regulatory agencies, i.e., DHS, California Department of Health, Joint Commission on Accreditation of Healthcare Organizations and medicare intermediaries, for each of the services offered directly or by contact. o Review policies pertaining to the delivery of the health care and services provided by the agency. o Make recommendations to the governing authority of professional issues including the adequacy and appropriateness of services based on: an assessment of health care resources in the community; patients= needs; available reimbursement mechanisms; and availability of qualified personnel. o Assist the agency in maintaining liaison with other health care providers in the community. o Review a sample of both active and closed clinical records to determine whether established policies are followed in furnishing services directly or under arrangement. o Ensure that an annual evaluation of the agency=s program is conducted.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
BLOOD UTILIZATION AND TRANSFUSION COMMITTEE MEETING FREQUENCY: Quarterly REPORTS TO: The Executive Committee of the Medical Board	o Chaired by a member of the Medical Board. o Membership shall be appointed by the President of the Medical Board o Administrative Representatives will be appointed by the Executive Director.	PURPOSE: o Designed to fulfill the Hospital=s responsibility to oversee the process involved in ordering, distributing, handling and dispensing, administering and monitoring of patient response to the use of blood components. AUTHORITY: o Authority to provide staff leadership for the measurement, assessment, and improvement of processes related to the use of blood and blood components. .	o Review the appropriateness of confirmed transfusions of blood and blood derivatives on a reliable sample. o Perform an intensive evaluation of known or suspected problems in blood utilization based upon valid indicators. o Review transfusion practices including the review of all blood transfusion reactions. o Make at least quarterly reports to the Medical Executive Committee (MEC), concerning: - Number of transfusions, including number and type of components transfused by service. - Number of compatibility tests by service. - Number of units outdated or otherwise discarded by service. - Results of proficiency testing and Inspections of the Blood Bank by governmental or private agencies. - Results of Peer Review o Make recommendations to the MEC concerning transfusion policies and procedures, as well as ordering practices for blood products. o Communicate to the individual clinical services as needed.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
CREDENTIALS COMMITTEE MEETING FREQUENCY: Quarterly or more often if necessary. REPORTS TO: The Executive Committee of the Medical Board	o Chaired by a member of the Medical Board. o Membership shall be appointed by the President of the Medical Board o Administrative Representatives will be appointed by the Executive Director.	PURPOSE: o Designed to fulfill the Network=s responsibility to establish network- specific mechanisms for the appointment of medical staff members and the granting and renewal/revision of clinical privileges. AUTHORITY: o Authority to review credentials of all medical staff members and prepare recommendations to the Executive Director and to the Medical Executive Committee.	o Investigate the credentials of all applicants for appointments/reappointments to the Medical Staff. o Investigate the credentials of the Allied Health Professions Staff applying for employment o Review, once notified, any breach of ethics reported. o Review all information available regarding the professional competence of staff members. o Make recommendations to the Medical l Executive Committee and for the granting of privileges. o Review information available regarding the professional competence of Staff Members. o Make recommendations to the Executive Director and the Medical Board for the appointment and biennial reappointment of the Medical Staff. o Communicate to the individual clinical services as needed.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
DRUG UTILIZATION REVIES COMMITTEE MEETING FREQUENCY: Quarterly REPORTS TO: The Medical Executive Committee at least quarterly.	o Chaired by a member of the Medical Board. o Director of Pharmacy/Designee o Director of Nursing/Designee o Membership shall be appointed by the President of the Medical Board. o Administrative Representatives will be appointed by the Executive Director.	PURPOSE: o To ensure the ongoing evaluation of drug usage to improve the appropriateness of their use. AUTHORITY: o To provide Medical Staff leadership for the measurement, assessment, and improvement of processes related to the use of medications.	o To routinely collect and assess drug usage information in order to identify opportunities to improve and resolve problems in their use. o To evaluate practices regarding: - the prescribing/ordering of drugs and the rationale for their choice. - distribution, handling and dispensing - administration. - monitoring of patient response. o To select drugs to be monitored based upon those most frequently prescribed, high risk, or problem-prone; or as they relate to the care provided for a specific diagnosis, condition or procedure. o To ensure predetermined criteria are used in order to identify cases or groups of cases that require further intensive evaluation. o To utilize the results of monitoring and evaluation to improve processes. o To communicate to the individual clinical services as needed. o To make recommendations, as necessary, to the Medical Executive Committee on all matters pertaining to the use of drugs.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
MEDICAL RECORDS (Health Information Management Committee) MEETING FREQUENCY: At least 10 times per year. REPORTS TO: The Executive Committee.	o Chaired by a member of the Medical Board. o Representatives of the: - Medical Staff - Nursing Service - Medical Record Department, and - Administrative Services. o Membership shall be appointed by the President of the Medical Board. o Administrative representatives shall be appointed by the Executive Director.	PURPOSE: o To oversee the Medical Records Review function of the Medical Staff. o To recommend approval of the format and forms of the Medical Record to the Medical Executive Committee. AUTHORITY: o Authority to provide medical staff leadership for the measurement, assessment, and improvement of processes related to the use efficiency of clinical practice patterns.	o Assess medical records for clinical pertinence. (AClinical Pertinence@ of the Medical record requires that each medical record, or a representative sample of records reflects the diagnosis, results of diagnostic tests, therapy rendered, in-hospital progress of the patient, the condition of the patient at discharge and the plans for follow up care.) o Assessment of the timely completion of medical records. o Ensure proper Acoding@ of the medical record. o Maintain minutes of meetings and submit a copy to the Medical Executive Committee. o Recommend approval of forms which may be included in the medical record. o Track and report information regarding the timely completion of all Medical Records.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
PHARMACY AND THERAPEUTICS COMMITTEE MEETING FREQUENCY: A minimum of (7) seven meetings shall be held per calendar year. REPORTS TO: The Executive Committee of the Medical Board.	o Chaired by a member of the Medical Board. o Membership shall be appointed by the President of the Medical Board. o Administrative Representatives will be appointed by the Executive Director.	PURPOSE: o To serve in a advisory capacity to the Medical Staff and hospital Administration in all matters pertaining to the use of drugs (Including investigational drugs). AUTHORITY: o To recommend the adoption of, or assist in the formulation of, broad professional policies regarding the evaluation, selection, and therapeutic use of drugs in this institution.	o To develop formulary drugs accepted for use in the hospital and provide for its periodic revision. o To minimize duplication of the same basic drug type, drug entity or drug product. o To establish or plan suitable educational programs for the hospital=s professional staff on matters related to drug use. o To study issues related to the distribution and administration of medications, including monitoring and evaluation of medication incidents.. o To review adverse drug reactions occurring In the hospital. o To advise the Pharmacy in the Implementation of effective drug distribution and control procedures. o To review and recommend approval, on a biennial basis, the policies and procedures related to the administration, dispensing and distribution of medications. o To communicate to the individual clinical services as needed. o To evaluate the effectiveness of the Pharmacy and Therapeutics Committee on an annual basis.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
SURGICAL CASE REVIEW COMMITTEE(1) MEETING FREQUENCY: Monthly REPORTS TO: The Executive Committee of the Medical Board	o Chaired by a member of the Medical Board. o Membership shall be appointed by the President of the Medical Board. o Administrative Representatives will be appointed by the Executive Director.	PURPOSE: o To ensure the continuous process of review and evaluation of surgical and other invasive procedures performed by the Medical Staff. AUTHORITY: Authority to ensure review of Surgical and other invasive procedures is conducted as appropriate by those departments/services involved in performing such procedures.	o To ensure the review of operative and other invasive procedures that place patients at risk via the systematic collection of data regarding: - selection of the appropriate procedure; - patient preparation for the Procedure; - performance of the procedure and patient monitoring; - post procedure care; and - post-procedure patient education. o To review categories of procedures through the use of screening criteria to identify single cases of patterns of cases that require more intensive evaluations. o To prioritize procedures for review based upon high volume, high risk, and/or problem prone categories. o To ensure the intensive evaluation of a Single case or group of cases when the review of specimens removed during a surgical or other invasive procedure identifies a major discrepancy, or a pattern of discrepancies, between preoperative and Postoperative (including pathologic) diagnoses. o To maintain written reports of conclusions, recommendations, actions taken (including tracking and trending as necessary), and the effectiveness of actions taken. o To communicate to the individual clinical services as needed.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
UTILIZATION REVIEW COMMITTEE(1) MEETING FREQUENCY: Quarterly REPORTS TO: The Executive Committee of the Medical Board (1) Requires establishment by Medical Board	o Chaired by a member of the Medical Board. o Membership shall be appointed by the President of the Medical Board. o Administrative Representatives will be appointed by the Executive Director.	PURPOSE: o Responsible for overseeing the Utilization Review. AUTHORITY: Authority to ensure that the facility addresses the over-utilization, under utilization, and inefficient scheduling of the hospital=s resources.	o To review the over-utilization, under utilization and/or inefficient scheduling of resources. o To review appropriateness of admission. o To review services ordered and provided. o To review continued stay (length of stay) o To review the admission, discharge and transfer of patients to: - in-patient services - ambulatory services; - special care services, and - post hospital care services. o To review outcomes related to clinical practice guidelines. o To communicate to the individual clinical services as needed.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
INFECTION CONTROL COMMITTEE(1) MEETING FREQUENCY: At least six (6) times per year. REPORTS TO: The Hospital-wide Quality of Care Review Committee.	The chairperson and multidisciplinary membership will be appointed by the Executive Director and the President of the Medical Board. o Section Chief of Infectious Disease o Nurse Manager, Employee Health Services	PURPOSE: o To oversee surveillance, prevention, and Control of infections within the hospital. AUTHORITY: o The committee, or its designee, has the Authority to institute any surveillance Prevention and control measures or Studies where there is reason to believe that any patient or personnel may be in danger, as defined in writing and approved by the hospital administration and medical staff. o The statement of authority is reviewed and authenticated every two years by the Hospital Administration and Medical Staff.	o To review patient infections within the hospital, to determine whether an infection is nosocomial, using approved criteria particularly with regard to their proper Management and their epidemic potential. o To review prevalence and incidence studies, and to make recommendations if appropriate. o To review the results of any antimicrobial susceptibility/resistance trend studies. o To review proposals and protocols and data for all special infection control studies to be conducted throughout the hospital and any subsequent findings. o To approve actions to prevent or control infections based on an evaluation of the surveillance reports of infections and of the infection potential among patients and hospital personnel. o To originate, supervise, review and act upon sample cultures required by the hospital, the agencies or regulations in exceptional situations, e.g., the flooding of sterile areas. o To review compliance with ventilation patterns and air exchange rates for rooms with negative pressure ventilation system. o To evaluate the hospital disposal systems for all liquid and solid wastes. o To review and approve all policies and procedures related to the infection surveillance and prevention and control program. o To communicate to individual clinical or non clinical services as needed. o To evaluate the Infection Control Program on an annual basis.

LAC+USC HEALTHCARE NETWORK

PERFORMANCE/QUALITY IMPROVEMENT PLAN

APPENDIX E: LEADERSHIP RESPONSIBILITIES
COMMITTEE	MEMBERSHIP	PURPOSE; AUTHORITY	RESPONSIBILITIES AND DUTIES
SAFETY MANAGEMENT COMMITTEE MEETING FREQUENCY: At least every two months. REPORTS TO: The Executive Director; The Hospital-wide Quality or Care Review Committee.	o Chief Operations Officer, Chairperson. o Membership shall include representatives from the following Departments: - Senior Physician Member; - Nursing and Patient Care Services; - Director/Safety Management; - Director/Risk Management; - Supervisor of Nursing/Infection Control o Chairpersons of Safety Subcommittees: - Life Safety Sub-committee - Utilities management Safety Sub- Committee; - Equipment Management Safety Sub- Committee; - Disaster Preparedness Sub Committee. o Quality Management (Designee).	PURPOSE: o To analyze identified Safety Management issues. o To develop or approve recommendations for resolving hospital-wide safety issues. AUTHORITY: o To communicate to the Executive Director when conditions exist that pose An immediate threat to the safety of Patients, visitors, and staff or where there is a threat of damage to equipment, facilities or grounds.	o To provide a process for the collection and evaluation of information on hazards and safety practices. o To provide a process for review and monitoring of the effectiveness of the management plans for: - Safety; - Security - Control of Hazardous Materials and Waste - Emergency Preparedness; - Life Safety; - Medical Equipment; and - Utility Systems o To provide a process for review and monitoring of an Accident Prevention Program. o To ensure that hospital-wide education regarding the safety management plans is implemented and documented. o To communicate immediately to the Executive Director when conditions exist that require immediate and/or emergent action. o To prepare quarterly reports on safety related issues for the Quality Assurance Committee of DHS. o To communicate to the individual clinical or non clinical department directors concerning significant safety related issues as needed.