Avera Health System Quality Plan 2018-2019
The Purpose of Quality
We’re passionate about quality. The best care for you and your family is our continuous, relentless pursuit at Avera Health. We’re dedicated to award-winning health care excellence in the communities we serve. Avera participates in systematic performance improvements that align with the National Strategy for Quality Improvement in Health Care priorities and goals.
The National Quality Strategy pursues three broad aims:
- Better Care: Improve the overall quality by making health care more person-centered, reliable, accessible and safe.
- Healthier People and Healthier Communities: Improve the health of Americans by supporting proven interventions to address behavioral, social and environmental determinants of health and deliver higher-quality care.
- Smarter Spending: Reduce the cost of quality health care for individuals, families, employers, government and communities.
Our Quality Plan Design
We achieve quality by design. We focus on the processes and systems that affect delivery of service and patient outcomes. Our Quality Plan aligns with the mission and vision of Avera, and considers the impact of the organization’s strategic and long-term goals.The Avera Clinical Leaders Forum aligns with the National Quality Strategy as authored by Agency of Health Research and Quality (AHRQ) on behalf of the U.S. Department of Health and Human Services in the following categories:
- Make care safer by reducing harm caused in the delivery of care
- Strengthen person and family engagement as partners in their care
- Promote effective communication and coordination of care
- Promote effective prevention and treatment of chronic disease
- Work with communities to promote best practices of healthy living
- Make care affordable
Governance of Our Quality
Everyone at Avera is responsible for quality. Our leaders strive to develop a system-wide culture that encourages leadership asking for input on quality measures—along finding places for improvement. Each year, we evaluate and revise our Quality Plan as needed.
Tracking Our Quality Efforts
Excellent health care performance is our goal. Avera has data systems in place to monitor the care and services provided.
- We use performance indicators to monitor a wide range of care processes and outcomes
- We review findings against benchmarks and/or targets the system has set for performance
- We track, investigate, and monitor adverse events and implementing action plans to prevent recurrences
Our Quality Plan outlines a process to support sharing of best practices, implementation of current evidence-based practice, and to ensure participation.
- Avera facilities have a facility specific annual quality plan that is in alignment with the Avera Quality Plan. As a part of the plan, all facilities will participate in and report data on Avera initiatives.
- Best Practice Continuum meetings are regularly scheduled for sharing of data and best practices across the various facility types and service lines.
- System strategic initiatives are discussed and prioritized through the Avera Clinical Leaders Forum.
- Avera Clinical Leaders Forum priorities are made actionable through the Core Analytics Team and subsequent performance improvement efforts.
- Aggregate data and opportunities are shared at the Performance Improvement Consumer Satisfaction meeting & Avera Health Board meeting for review and recommendations.
- An annual summary of the effectiveness of the quality program will be sent to the Avera Health Board of Directors at the end of the fiscal year.
Assuring Our Quality and Improving Performance
We want to set the highest standards for patient care. Quality Assurance (QA) is the process of meeting quality standards to comply with regulations. We focus on current patient outcomes with a retrospective view of what happened.
How do we get better? Performance improvement (PI) is a method to introduce process changes to improve the quality of care and service. Avera’s performance improvement is a systematic approach to help refine processes to achieve results you deserve. Focus areas for improvement are selected based on opportunity to improve patient outcomes, care delivery, and overall opportunities for reducing the cost of care and services.
The numbers guide us. Quality Assurance Performance Improvement (QAPI) is a data driven, proactive approach used to identify, analyze and improve existing care processes in order to meet goals and thresholds identified within the strategic plan.
Avera leadership teams have reviewed the National Quality Strategy and Avera’s outcome data to determine focus areas of improvement. The focus areas identified for this quality year are:
- Prevent avoidable readmissions
- Prevent harm related to health care acquired infections; emphasis on hand hygiene
- Prevent opioid related adverse events in the health care setting
- Improve the use of standardized depression screening tools to identify persons at risk for suicidal ideation
We take a close look at challenges and act to improve. We use a systematic approach to address current issues, prevent future events, and continually improve.
Evaluating Quality and Protecting Confidentiality
We’re ready for our report card, and we respect privacy. Evaluation is an important part of successful quality plans. Our evaluation process includes identifying achieved outcomes, gaps in processes and sustainability. Avera committees maintain copies of all minutes, reports, worksheets and other data in a manner to ensure strict confidentiality. Data collected by or generated by the Avera committees are protected by law and treated as confidential.