Clinical Quality

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Our Quality Program

Evolution towards becoming a High Reliability Organization (HRO)

UMMC has worked with The Joint Commission Center for Transforming Healthcare on our quality journey to progressively improve in the HRO domains of Leadership, Culture and Performance Improvement. The steps taken in the first few years have been:

  • An assessment of UMMC readiness as an HRO by senior leaders which identified four focus areas for improvement.
  • A reassessment conducted 18 months later showed improvement in the focus areas, as well as a realistic assessment of our true status. Work continued on the focus areas and Change Management training was provided for leaders and managers driving performance improvement.

While improving the domains of High Reliability, the UMMC Quality Program has continued to evolve:

  • Standardization of the UMMC quality improvement building blocks outlined in the graphic on the prior page led to:
    • Annual quality scorecard for the health system with focused goals and specific targets.
    • Improvement in patient safety, outcomes, and experience metrics as shown in the Quality Measures
    • Quality data available to all employees with monthly updates on the Clinical Intranet.
    • Quarterly leader reviews evolving from clinical departments to include functional service lines.
    • Quarterly reporting to the governing board, the Mississippi Institutions of Higher Learning Trustees.
  • Monthly Leadership Rounds, when 100-plus UMMC academic, clinical and administrative leaders engage front-line staff on issues affecting quality and debrief on their interactions, improved leadership engagement and visibility.
  • Chasing Zero – Eliminating Harm at UMMC- became a major initiative two years into the HRO journey, and by highlighting patient safety events as learning opportunities this program has contributed to improving the culture of safety.