Performance Standards for Quality of Clinical Service

Introduction

The clinical goals of the Department of Medicine include establishing practices which deliver high quality of care with high patient satisfaction, and establishing effective quality management and utilization management programs. These goals are in concert with Standard 9 (Quality Management) of the Creighton Medical Associations Standards for Clinical Operations. This standard directs that "there is an ongoing quality assessment and improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care and client services, pursue opportunities for improvement and resolve identified problems". The criteria offered under this standard identify the essential elements of process improvement as follows: (1) describing quality objectives, (2) include measures of quality of care and quality of service (including at least one clinical and one administrative measure of care); (3) patient satisfaction surveys are to be included as one of these measures, (4) results from indicators will be analyzed and information used to improve the patient care processes and client services.

Thus it is necessary to identify some initial performance standards for quality of service and quality of patient care and to measure our actual performance against these indicators in order to provide opportunities for improvement. The following are a proposed list of initial performance standards to guide improvements in service and care in the Department of Medicine over the next year.

Quality of Service Performance Standards

1. Responsiveness to patients

• Outpatient Clinics must ensure ready accessibility by telephone to patients.
• Telephone will be answered within 5 rings
• "One call serves all", i.e. no more than one transfer will be needed to provide initial service after contacting the department/ division.
• Interactions with patients must be courteous, responsive and helpful (e.g. "very good" or better ratings for telephone courtesy on satisfaction surveys)
• Physicians must be readily accessible by telephone to patients
• a. telephone calls for urgent problems must be returned within 15 minutes by the physician or their designate;
• b. non-urgent calls must be returned within 4 hours by the physician
• Patients requesting outpatient visits with the physicians must be readily accommodated
• Urgent appointments available within 24 hours
• Routine New patient appointments available within 7 days
• Patients must receive efficient and courteous service in our clinic
• Patients will be seen by a physician within 15 minutes of their appointment (assuming on-time check-in by patient)
• Patients will rate the quality of communication with their physician as "very good" or better.

1. Responsiveness to referring physicians

• Medicine Physician offices must ensure ready access by telephone to referring physicians.
• Telephone will be answered within 5 rings
• "One call serves all", i.e. no more than one transfer will be needed to provide initial service after contacting the department/ division.
• Interactions with referring physicians must be courteous, responsive and helpful (e.g. "very good" or better ratings for telephone courtesy on satisfaction surveys)
• Physicians must be readily accessible to referring physicians by telephone (e.g. telephone calls from referring physicians must be returned by the faculty member within 15 minutes).
• Physicians must rapidly respond to requests for inpatient consults
• Urgent consult requests should receive an initial response within 1 hour
• Non-urgent consult requests should receive an initial response within 24 hours
• All consults performed by medicine residents will be seen by faculty within 24 hours of the consult request
• Communication with referring physicians must be rapid, efficient and helpful.
• Letter must be mailed/ faxed to the referred physician within 48 hours of hospital discharge
• A letter must be mailed or faxed to the referring physician within 48 hours of completion of an ambulatory based consultation.
• Communication with referring physicians must be courteous, responsive and helpful (e.g. rated "very good" or better on referring physician satisfaction surveys).

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Updated September 2006