Seton Physicians Take Innovative Steps to Raise Quality Standards

It is a recognized goal at Seton Healthcare Family to continually strive to improve the quality of patient care. Now, a group of Seton physicians have stepped up to make quality improvement their specific focus and to raise the bar on medical best practices across the Seton network.

The Best Practices Implementation Committee (BPIC) was established so that physicians could assume a leadership role in improving quality in processes and procedures at Seton, says Dr. Frank Mazza, vice president, chief patient safety officer and associate chief medical officer. “The committee’s physician members represent multiple specialties from across the network,” he added. “They’ve taken on the task of reviewing and recommending potential improvements in best practices, to find what works best and to make that the standard for everyone across our network.”

According to Dr. Sam Roberts, director of Emergency Services and BPIC chair, the committee was created as an offshoot of the Network Medical Executive Committee (Network MEC), the internal governing body of Seton physicians. He explained that the seed idea grew out of discussions with Jesus Garza, Seton’s interim president and CEO. Both the physician leaders and Garza felt that Seton’s medical staff and patients could benefit from a more formal system to evaluate and standardize best practices. The challenge, Dr. Roberts says, was that while procedures used across the system may reflect high quality standards, they may vary from facility to another.

Dr. Chad Dieterichs, BPIC vice chairman, president-elect of the Seton Medical Staff, and partner in Capital Anesthesiology Association, says the committee’s goal is to help unify the Seton network and to further facilitate and standardize best practices across the network. “Everyone does great things here,” he said. We simply want those great things to be made the standard across all of Seton’s hospitals. 

“I have a unique advantage as a committee member,” he added. As an anesthesiologist, I work at facilities across the Seton network, work with all disciplines of medicine and have a broad perspective on how BPIC recommendations can help improve efficiencies and unify best practices.”

Which best practices are being given the highest priority? According to Dr. Mazza, BPIC concentrates on areas of high volume and high impact on patient care and safety. The committee uses both a bottom-up and top-down approach to identify areas where they feel current standards could be refined and improved.

“Some ideas come from physicians and nursing staff and make their way up to our committee,” Dr. Mazza said. “Others come from the Network MEC and funnel down. In every case, a change in process must have detailed research to substantiate its value and effectiveness before BPIC considers it.”

Dr. Roberts added, “Each new idea must go through a rigorous review by peers across the network before it becomes a new best practice. BPIC goes a step further by developing refinements in process from within – from the physicians and staff who use these processes each day.”

One example Dr. Roberts noted is the “time out” period before surgeries. In the same way that pilots check all systems before flying a plane, everyone on the surgical team runs through a safety check list to ensure that they’re fully prepared and they understand everything that needs to occur prior to the surgery.

“In other facilities,” Dr. Roberts said, “physicians usually have a limited role in leading efforts to set or control quality standards. BPIC is a novel concept. It empowers our physicians and staff to initiate improvements where they see a need, and it gives them a formal process to follow to get things done.”

Dr. Dieterichs pointed out a second example in which EKG is now used instead of X-rays with peripherally inserted central catheters (or PICC lines). In this process, a slender flexible tube is inserted into a peripheral vein, typically the upper arm, and then advanced until the catheter tip terminates in a large vein usually in the chest. Previously, X-rays were used to determine the optimal positioning of the PICC lines as it was inserted. But developing and analyzing X-rays made the process time-consuming. Under the new procedure endorsed by BPIC, EKG changes are used to visualize the positioning of the PICC line in real-time and expose the patients to less radiation. 

In the year that BPIC has been in place, Dr. Roberts says they’ve seen some significant accomplishments. “Everyone has been cooperative and responsive to our goals. I only expect our impact on raising quality standards to continue as more staff realize the value and importance of this work for patients.” 

Dr. Dieterichs agrees and adds that everyone at Seton wants to ensure that all patients receive the same high level of quality care, no matter which facility they visit. With BPIC, he says, there’s now a formal process for achieving this goal. 

BPIC Committee

• Dr. Sam Roberts: emergency medicine, BPIC chair
• Dr. Chad Dieterichs: anesthesiology; BPIC vice chair; president-elect, Seton Healthcare Family Medical Staff
• Dr. Sujit Iyer: emergency medicine, pediatrics
• Dr. Andrew Reifsnyder: radiology; immediate past president, Seton Healthcare Family Medical Staff 
• Dr. Thomas Traweek, pathology; chief of staff, Seton Medical Center Hays 

The Joint Commission Core Standards for Quality

National quality standards are reviewed by an independent not-for-profit organization called The Joint Commission, which accredits and certifies more than 19,000 health care organizations and programs across the U.S. The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care.

When a medical facility receives Joint Commission certification, it’s like a stamp of approval that tells patients they can trust that this facility meets the commission’s basic standards for quality and safety. To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission team at least every three years.

Benefits of Joint Commission Certification

• Provides an objective, external assessment of clinical excellence. 
• Provides a framework for the structure and management of health care programs and helps maintain a consistently high level of quality.
• Creates an opportunity for clinical staff to develop their skills and knowledge and helps build a more cohesive and loyal team.
• Provides the certified facility a competitive advantage in attracting new patients.
• Strengthens patient and community confidence in an organization’s commitment to providing the highest quality services.