Medical Staff Pulse is
a Publication of the Chief of Staff
MEC Update on Quality Goals

Meeting Our FY2007 Quality Goals

Cedars-Sinai, led by the medical staff, continues to focus its efforts on meeting its six Medical Staff Quality Goals for fiscal year 2007. Most of the following goals are dictated by outside regulatory agencies while others, such as the appropriate utilization of cardiac stents, have been voluntarily adopted by the Quality Council and the Medical Executive Committee, which work in parallel to assure high quality, safe medical care.

"We have already met some of these goals and are making steady progress towards reaching 100 percent compliance on the remainder," said Paul Silka, M.D., Chief of Staff. "I would like to thank all of the quality goal team leaders (noted below in parentheses) and team members working to ensure we continue to make progress on these goals. This performance reflects hundreds of hours by our physicians and staff, and I am grateful for their dedication to this critical work. The institution's primary Quality Strategic Goal is to reduce mortality. Success with these goals directly impacts this by saving lives."

  1. Identify patients at risk for suicide by improving prospective suicide assessments. Goals met. (Linda Burnes Bolton, Dr.PH., R.N., F.A.A.N. and Mark Rapaport, M.D.)
  2. Prevent Venous Thromboembolism (VTE) in surgical patients through prophylaxis/anti-coagulation therapy. Surgical patients receiving appropriate prophylaxis has increased from 87% to 92% in the last three months. The goal is 100%. (Linda Burnes Bolton, Dr.PH., R.N., F.A.A.N., Jeffrey Deeter, Julian Gold, M.D., Richard Riggs, M.D.)
  3. Surgical Infection Prevention -- three new measures:
    • Clipping instead of shaving surgical sites
    • Cardiac surgery: post-op serum glucose control (Linda Burnes Bolton, Dr.PH., R.N., F.A.A.N., Glenn Braunstein, M.D., Bruce Gewertz, M.D.)
    • Colorectal surgery: immediate post-op normothermia (Bruce Gewertz, M.D., Julian Gold, M.D., Linda Procci, Ph.D.)
  4. Ensure appropriate use of coronary artery stent procedures. Goals met. (Glenn Braunstein, M.D., Linda Procci, Ph.D., and Patricia Kittell)
  5. Surgery patients on beta-blocker therapy prior to admission receive a beta-blocker during the peri-operative period. Significant improvement in the last quarter showed an increase from 52% to 93%. A process for administering perioperative beta-blockers for AM surgery patients was established and as of March 1, 2007, non-compliant admitting MDs are referred to peer review. (Bruce Gewertz, M.D., Julian Gold, M.D., Ronald Wender, M.D., Linda Procci, Ph.D.)
  6. Eliminate retained foreign objects following a procedure. All medical staff members who have been granted clinical privileges in the Departments of Surgery, Obstetrics & Gynecology and Neurosurgery must complete online competency training for the elimination of Retained Foreign Objects prior to June 15, 2007. (Ricardo Azziz, M.D., Keith Black, M.D., Linda Burnes Bolton, Dr.PH., R.N., F.A.A.N., Bruce Gewertz, M.D., Barry Pressman, M.D. and Linda Procci, Ph.D.)

In addition to the medical staff quality goals, departmental performance improvement goals have been set that are specific to departments such as Medicine and Surgery. Examples of these measures include:

  • Assessment of LV (left ventricular) function before or during admission (Steve Khan, M.D.); ASA or Beta Blocker within 24 hours (Bojan Cercek, M.D.)
  • Compliance with administration of prophylactic antibiotics one hour to incision time for the following procedures: cardiac surgery, total hip & knee replacement, hysterectomy (abdominal and vaginal), colon surgery and vascular surgery (William Brien, M.D., Anthony Alter, M.D., Ricardo Azziz, M.D., and Philip Brooks, M.D.)