Key Initiatives and Goals

2013 Key Initiatives and Quality Goals

The goal of University Hospitals Institute for Health Care Quality & Innovation is to improve outcomes, create more satisfied patients and better value, all across the University Hospitals system. The institute is developing data-based, patient-focused metrics for every aspect of quality, including clinical care, patient satisfaction, safety, process improvement, research and education, and is dedicating teams of top experts to find the highest-value ways to achieve those goals.

UH is committed to achieving the Institute of Medicine’s six quality aims: safety, patient-centeredness, effectiveness, efficiency, timeliness and equity.

UH Institute for Health Care Quality & Innovation’s key initiatives and goals include the following:


  • Infection prevention
    • Expand the concurrent antibiotic stewardship program system wide
    • Continue and expand Central Line Acquired Bloodstream reduction initiatives in UH Seidman Cancer Center
  • Reduction of preventable complications/harm
    • Reduce hospital-wide all cause readmission rates system-wide by 5 percent
    • Reduce Sickle Cell readmission rate by 15 percent
  • Meet or exceed core measure MIP goal
  • Redesign procedure transport process to improve patient safety
  • Medication Safety
    • Implement four new system medication policies
    • Activate four medication therapeutic substitutions system wide
    • Add standardized EMR pharmacist documentation
    • Perform bedside bar-coding FMEA
    • Achieve 90 percent Alaris drug library use
    • Comprehensive chemotherapy safety


  • Consistent use of Patient Satisfaction Bundle across inpatient settings
  • Continue development of patient satisfaction initiatives
  • Implement PI Process across ambulatory continuum
  • Increase use of navigators and volunteers
  • Complete way-finding project
  • Continue development of patient and family councils (PFAC)
  • Continue emphasis on relationship-based interdisciplinary model of care
  • Develop system wide palliative care program
  • Meet or exceed number of scales above the 55th percentile for the MIP goal


  • Clinical analytics
    • Implement Director of Clinical Informatics position
    • Implement data governance process
    • Implement concurrent core measure monitoring using Allscripts Quality Monitoring tools
    • Explore dashboards/warehouse options
  • Team training and communication
    • Team Stepps (UH MacDonald Women’s Hospital, Adult Med Surg, CMC)
    • VitalSmarts (OR)
    • Healthcare Performance Improvement (RBC)
  • Partnership for Patients
    • Achieve CMS defined goals for chosen measures using either University Health System Consortium or Premier
      • 40 percent reduction of harm measures
      • 20 percent reduction in readmission
  • Electronic Medical Record optimization
    • Develop six new relevant Clinical Effectiveness Teams
      • Anesthesia, orthopedics, cardiology, psychiatry, general surgery, critical care (ICU and step down)
  • Improve physician attestation as measured by attaining Heart Failure certification
  • Improve mortality index system wide to rank in the Consortium/Premier top half


  • Integrate UHCare use into clinical workflow
    • Improve order set utilization by 20 percent
    • Improve admission and discharge medication reconciliation by 20 percent
  • Improve core measure abstraction turnaround time within 30 days of discharge


  • Assure consistent outcomes related to:
    • Time is muscle – Chest Pain Certifications
      • Angioplasty within 90 minutes
      • EKG within 5 minutes
  • Improve selected ED core measures by 10 percent
  • Critical Results
    • Integrate critical results into UHCare


  • Assuring consistent outcomes regardless of race, ethnicity, and socioeconomic class as measured by UHC Quality and Accountability Study
    • Maintain No. 1 ranking for this metric in UHC Q&A Study

Health Care Reform

  • Improve Value Based Purchasing results to realize a positive financial impact for FY 2014
  • Improve 30-day readmission rate for AMI, HF, and PN as measured by readmission reduction program to realize a positive financial impact for FY 2014
  • Implementation of Stage 2 Quality requirements for Meaningful Use
  • Anticipate future impact of healthcare reform on cancer care and reimbursement

Organizational Goals

  • Pursue National Quality Forum Quality Award
  • Develop a Physician Improvement program
  • Develop a Physician Accountability program
  • Develop an Interdisciplinary Professionalism program
  • Complete Quality Institute infrastructure development

Accreditation and Certification Readiness

  • Sustain accreditation programs at all hospitals
  • Create an electronic patient education documentation process
  • Pursue Magnet Journey or Pathway to Excellence designation for all hospitals
  • Continue Quality Oncology Practice Initiative certification readiness process
  • Attain National Accreditation Program for Breast Centers for Comprehensive UH Breast Centers
  • Re-accreditation in American College of Surgeons Commission on Cancer
  • CLIPSS Goal – Increase CLIPSS compliance by 5 percent
  • Implementation of System Wide JC Tracer Process
  • Regulatory
    • Maintain ORYX core measures to “desirable performance”
    • Achieve successful ODH annual surveys

Quality Center Goals

  • Best Place to Work Goals: Improve identified targeted survey statements
  • Implement and standardize a quality orientation program
    • Implement quality orientation manual
    • Determine system applicability to orientation components

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