Week 1 Assignment

MHA 601: Principles of Health Care Administration

January 20, 2015

Texas Health Harris MethodistCleburne is one of the top institutions in the country on
surgical care process-of-care measures. These measures are often referred to as core" or
Surgical Care Improvement Project (SCIP) measures. This case study explains
the core measures which were, developed by the Hospital Quality Alliance. It also details
the benefits achieved by sharing information and tackling problems with other hospitals
within their health system.
Texas Health Harris MethodistCleburne is part of Texas Health Resources,
which is a large, nonprofit health care delivery system that covers north Texas. This
corperation controls 14 hospitals and has an annual revenue of $2.6 billion.

Texas Health Resources plays a vital role in the operations of Texas Health Harris
which has proven to be beneficial. With their aid, Texas Health Harris MethodistCleburne is operating in the top 15th percentile in all four clinical areas of the core
measures. Employee moral and loyalty is recognized as this large corperation hosts an
annual quality conference where the staff is acknowledged by their peers for their efforts
in improving the quality and safety of care. It also participates in projects such as the
Hospital Quality Intensive Program and QUEST, a nationwide quality participation,
overseen by Premier.
The program, QUEST sets standards designed to push hospitals to new levels of
performance. The goal is to save lives, improve care and safely reduce the cost for each
patient's hospitalization by sharing knowledge and information. In order to reach their
goals, Texas Health Resources is currently in the process of implementing a system-wide
electronic health record system.
In early 2006, Texas Health Resources gave Texas Health Harris Methodist-Claburne
permission and the resources to create a new position titled Clinical Outcomes Specialist.
This specialist's job is to focus on the daily management of core measures performance.
The duties include teaching or training new staff about the core measures and their
relationship in improving the quality of patient care, speaking with other quality
improvement staff at monthly staff meetings, and helping with other physician endorsed
activities. The specialist creates regular reports on core measure performance.
Reports are broken down by the physician, department, and hospital levels, then
distributed to nursing leaders, medical staff, and corporate leaders. When a case falls out
of compliance with the company's core measures guidelines, a letter is sent to the
responsible staff member. The Clinical Outcome Specialist also provides one-on-one

coaching to non-compliant physicians and other staff members, and also alerts a manager
if their performance fails to improve after receiving a letter and one-to-one coaching.
Physician performance is also tracked on report cards that are included in their
credentialing file. All of the hospitals physicians are community-based, and all have
admitting privileges. Between the one-on-one coaching, report cards, and admitting
privileges, it helps the Doctor's feel invested in Texas Healths performance improvement
efforts, even though they are not hospital employees.
Texas Health relies largely on their concurrent reviews, the processes of any changes
in patient care, and the use of pre-printed order forms to help improve performance in the
SCIP core measures. To implement any change, it is extremely important to have good
communication and feedback from the staff.
When the SCIP core measures were introduced by the Joint Commission, Texas
Health organized an interdisciplinary SCIP work-group of pharmacists, anesthesiologists,
nurses, and other medical staff to provide recommendations for improving performance
in the administration of antibiotics within one hour before surgery. The discontinued use
of the antibiotics within 24 hours after surgery, and the administration of appropriate
antibiotics. The hospital must rely on chart reviews where everyone must be in
agreement in order to optimize performance and provide ongoing education and
reinforcement to the staff.
Each day, the quality department generates a report outlining which cases meet the
criteria for admittance into the core measures. Nurses review the identified charts to
check for compliance and address or correct any problems that they might find. The
discharge of staff not conforming to the core measures can result.
When these Surgical Care Improvement Strategies are implemented, hospitals within a
health system can turn to each other as partners in quality improvement efforts and
resources to help solve shared problems and learn from one another. Sharing evidence-

based information between physicians has proved beneficial and be more inclined to
accept recommended care practices.
With the practice of SCIP core measures and following the standards set by programs
like Quest. Texas Health Harris Methodist-Claburne has outperformed most other United
States hospitals on all of the surgical care improvement measures, and has proven that
these strategies can be beneficial to any participating health organization. The specialist
creates regular reports on core measure performance.
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References