Reference no: EM133658497

Assignment:

Reference: Becker's Hospital Review: March 31,2014 Massachusetts General Hospital: Investing in Structure to Improve Quality Ellie Rizzo

ASSIGNMENT - Mass General Quality Evaluation

Massachusetts General Hospital's name is synonymous with quality, and for good reason. The hospital has put plenty of thought into how best to organize every aspect of its organization to reflect quality, safety and clinical excellence.

When the groundbreaking 1999 Institute of Medicine report, "To Err is Human," appeared, they took it seriously, creating a board of trustees subcommittee focused on quality and patient safety. In addition, the hospital made quality a first priority, setting policies to ensure quality and safety were regularly discussed at board meetings and among the highest leadership of the institution.

Mass General's commitment to quality has gone even further. Since the early 2000s, President Peter Slavin, MD, has started every meeting with the chiefs and executives with information about quality and safety.

In the mid 2000s the hospital staged a retreat for senior managers at Harvard Business School, in which they analyzed quality progress improvement. The results of the retreat included a mission statement with a safety focus, developing credo and boundary statements for MGH employees and establishing the Center for Quality and Safety, and a C-suite level executive to lead it.

As a result of its rigorous quality leadership, Mass General has put in place some remarkable programs, including a quality reporting program complete with quality chairs for each clinical department to ensure safety events are appropriately and quickly addressed. The just culture of the institution has allowed staff to make remarkable progress in trouble areas such as hand hygiene.

The hospital keeps quality consistent through conducting an annual institutional sweep for potential quality issues. After doing an internal audit, talking to affiliates and consulting national sources, the hospital creates a list of the top quality and safety issues. It then re-prioritizes its own projects based on this list.

In the end, the organization believes it all comes down to leadership, structure and communication.

Reference: Becker's Hospital Review: March 31,2014 Massachusetts General Hospital: Investing in Structure to Improve Quality Ellie Rizzo

The assignment is to read the attached article on Massachusetts General Hospital quality structure. Then conduct additional research on effective healthcare quality structures to compare and contrast your research to the Mass General structure and commitment to Quality Improvement.

Find three articles related to facility healthcare quality structure, no older than 2015. The end product will need to be have minimum of the three articles referenced. Your paper will address the following questions, identifying what you see as the best quality structure:

1. What is main role of the Hospital Quality Leader?

2. What credentials and experience in healthcare quality should they possess?

3. Who should they report to in the organization?

4. Who should report to them and what are their jobs and responsibilities?

5. What is the commitment most organizations have to quality & safety and how is that commitment demonstrated?

6. What should the quality and reporting structure be in an organization?

7. What federal, state or local policies affect an organizations quality structure?

8. Do you believe that Mass General's Quality commitment and structure is "best practice"? Why or why not?

Close with a concluding paragraph based on the research comparing those organizations with the Mass General commitment to Quality.

Article:

Massachusetts General Hospital: Investing in Structure to Improve Quality - Monday, March 31st, 2014

Massachusetts General Hospital's name is synonymous with quality, and for good reason. The hospital has put plenty of thought into how best to organize every aspect of its organization to reflect quality, safety and clinical excellence.

When the infamous 1999 Institute of Medicine report, "To Err is Human," appeared, MGH took it seriously, creating a board of trustees subcommittee focused on quality and patient safety. In addition, the hospital made quality a first priority, setting policies to ensure quality and safety were regularly discussed at board meetings and among the highest leadership of the institution.

MGH's commitment to quality goes even further, according Elizabeth Mort, MD, senior vice president of quality and safety and CQO at MGH. Since the early 2000s, President Peter Slavin, MD, has started every meeting with the chiefs and executives with information about quality and safety. "This has persisted so that every single chief understands it is the most important thing in this situation," says Dr. Mort.

In the mid 2000s the hospital staged a retreat for senior managers at Harvard Business School, in which they analyzed quality progress improvement. The results of the retreat included a mission statement with a safety focus, developing credo and boundary statements for MGH employees and establishing the Center for Quality and Safety, and a C-suite level executive to lead it. "We established a new position reporting directly to the MGH president and the CEO of the physicians' organization, the senior vice president for quality and safety, which sent the message that quality and safety is important enough to act upon," says Dr. Mort, who is the second to occupy the position since its inception.

As a result of its rigorous quality leadership, MGH has put in place some remarkable programs, including a quality reporting program complete with quality chairs for each clinical department to ensure safety events are appropriately and quickly addressed. The just culture of the institution has allowed staff to make remarkable progress in trouble areas such as hand hygiene, which is consistently at 90 percent and is an initiative emblematic of MGH's improvement culture, according to Dr. Mort.

MGH keeps quality consistent through conducting an annual institutional sweep for potential quality issues. After doing an internal audit, talking to affiliates and consulting national sources, the hospital creates a list of the top quality and safety issues. It then re-prioritizes its own projects based on this list. The process is one Dr. Mort calls critical for maintaining excellence. In the end, she says, it all comes down to leadership, structure and communication. "You have to invest to get quality," says Dr. Mort, "and this is a good structure for which to do it."