Quality Management Committee

by Dr. Ali Sarram

The leadership team of the Medical Executive Committee (MEC) has been working tirelessly over the past two years to define the role of the MEC.  We have tried to come up with a structure that is most conducive to fulfilling the primary role of the MEC, which is credentialing, peer review and quality.   Several structures have been proposed over the past two years, and we have heard the concerns of the general medical staff.  With the input from many interested and vested colleagues, we have tried to create a MEC that is lean, nimble, well represented and empowered to meet its primary charter.  Elsewhere in this issue you will find the proposed structure.  A lot of hours and thought has gone into this proposal, and I invite all to familiarize themselves with the proposed structure.  We welcome constructive feedback before this is presented to the general medical staff for a vote.

It has become clear that the current MEC structure does a good job of credentialing and peer review.  It has also become clear that when it comes to quality, our MEC is not properly structured.  There are two intricately interlaced parts to delivery of quality care at the hospital.  The medical staff needs to deliver quality care, and the hospital needs to provide an environment in which the doctors can practice their craft to the best of their ability.  It is clear that when one or the other component does not look at itself critically, the overall outcome is not good.

We live in an environment of increasing transparency.  Our outcomes are public knowledge.  Technology has empowered the consumer (in this case, our patients) to become critical users of medical care.  Core measures and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) are in the public domain, and despite the fact that from the inside, these measures do not appear to really reflect quality of care, from the outside these measures are what our consumers hang their hats on.  For example, when the Medical Center of Aurora has reported infection rates that are higher than our sister hospitals, all of us on the inside know that this is a reflection of higher acuity patients and perhaps better reporting on our part.  From the outside, however, Mr. Jones who needs a knee replacement may look at this information and chose to go elsewhere for his new prosthesis.

It is in the best interest of every one of us to look at our quality outcomes, and to identify ways we can improve the care that we provide to our patients.  The old days of functioning in a vacuum and relying on our personal assertion of greatness are over.  When the inpatient team provides good care, this helps me build my urology practice.  When orthopedics has low infection and DVT rates, this helps me bring my urology patients to this hospital.  When my referring doctors believe that the TMCA provides top quality care, their referrals to my practice will increase!

As the MEC structure gets reorganized, there will be a greater emphasis on quality.  The MEC representatives of the departments and service lines will be asked to play an active role in the Quality Management Committee (QMC).  It is no longer adequate to only look at these measures.  Representatives from these departments will be asked to help the QMC look at our quality outcomes, assess areas for improvement and make recommendations to QMC and MEC to improve the quality of care.  We shall not limit ourselves to measures such as core measures and HCAHPS, but look at ways to improve actual delivery of care to our patients.

I encourage our colleagues on the medical staff to become actively involved and to look at how they can make a difference individually.  If you have any further questions or comments, please contact me at ali.sarram@gmail.com  or call me on my cell phone at 303-720-6254.