Bartlett Regional | HouseCalls | Fall 2017

www.bartletthospital.org 5 “I can remember when the quality department was just one person in a little office.” —Quality and Compliance Director Denise Plano Denise Plano, Quality and Compliance Director —Continued on page 6 he’ll look up some various regulations and get back to her. “I see myself as a resource to help interpret regulation when changes to process are considered or needed,” says Overson. “I make sure that rules are understood and that providers have the policy or regulatory tools, because there is more than one way to be compliant.” A changing field “I can remember when the quality department was just one person in a little office,” says Quality and Compliance Director Denise Plano. Seventeen years ago, the Institute of Medicine published “To Err is Human.” The study rocked the international medical scene. It focused on the impact of preventable medical errors that may have led to thousands of deaths. “Then these departments grew like wildfire,” says Plano. “The regulations changed; regulatory people started looking at patient safety.” The Institute of Medicine defines quality as “care that is safe, effective, patient-centered, timely, efficient and equitable.” In fact, the first organized awareness of preventable risks to patient safety goes back at least 100 years, to a standardization program initiated by the American College of Surgeons in 1917. By 2003, CMS and The Joint Commission had created the National Hospital Inpatient Quality Measures to standardize care and improve outcomes. Increased oversight The current intense focus on quality standards and implementation did not occur until 2010, with the Patient Protection and Accountable Care Act. Today, hospitals must submit quality reports to the federal government in order to receive full reimbursement payments from Medicare and Medicaid. Health care institutions that don’t report specific quality data to the government stand to lose a portion of their reimbursement payments. Joint Commission-accredited hospitals, like Bartlett, are also evaluated by Joint Commission surveyors who show up—unannounced—once every three years. “Patient safety is paramount,” announces Plano at a recent packed “lunch and learn” presentation and question-and-answer session on Joint Commission requirements. “Process improvement is a big part of quality.” Plano’s presentation touched on infection prevention, surgical outcomes and staff communication. Quality reporting to regulators can include the rate of admissions, rate of infections and the answers to such questions as “Did the patient get antibiotics for community-acquired pneumonia?”