The Department of Medicine Quality Improvement Initiatives

Section-Specific Quality Metrics

Cardiology	General Internal Medicine	Infectious Diseases
Dermatology	Geriatrics	Nephrology
Emergency Medicine	Genetic Medicine	Pulmonary/Critical Care
Endocrinology, Diabetes and Metabolism	Hematology/Oncology	Rheumatology
Gastroenterology

Proposed Quality Measures for the Department of Medicine

Update 10/18/07

Sectional/Departmental/Institutional Level

Volume Indicators:

Number of selected procedures by section (Data Source; Section and Hospital CPT Data)

Mortality Indicators:

Risk-Adjusted (Observed to Expected) Mortality for section-relevant principal diagnosis (Data Source: UCH Clinical Database)

Inpatient Quality Indicator:

Readmission within 30 days for section relevant principal diagnosis (Data Source: UHC Clinical Database)

Ambulatory Quality:

Selected Subspecialty Society QI Measure for Clinical Care process (Data Source: section)
Selected Subspecialty Society QI Measure for Procedural competency/proficiency/ complication (Data Source: section) (for sections with appropriate procedures)
PQRI – Section-wide performance (Data source: UCMC TSI and UCPG data)

Peer review and Care Process Improvement:
MDR process and track record of resulting measurable improvement (Data Source: UCMC DOM Quality Committee and sections)

Physician Level

Volume Indicators:

Number of selected procedures by attending (Data Source; Section and Hospital CPT Data)
Top 10 Ambulatory ICD-9 diagnoses seen in clinic (Hospital CPT Data)
Top 10 Inpatient ICD-9 diagnoses seen on service (Hospital CPT Data)

Medical Record Indicators:
Dictation signing metric (UCMC data)

Ambulatory Quality:
PQRI rates of relevant measures (Data source: UCMC TSI and UCPG data)

QI participation: (defined as attendance at M& M conferences; q 2 yr participation in a departmental PI project, recertification completion of ABIM Performance Improvement Module (PIM)) (Data Source: Sections)

Patient Satisfaction/Complaints:

Scan for patterns by UCMC Credentials Committee (Data Source: TBD)

Section Specific Measure Resources

Cardiology

http://www.accncdr.com/WebNCDR/Common/

http://www.acc.org/qualityandscience/quality/quality.htm

Dermatology

Psoriasis Quality Measures

Emergency Medicine

http://www.aemj.org/cgi/reprint/j.aem.2006.05.020v1.pdf

Endocrine

http://www.nationaldiabetesalliance.org/Final2005Measures.pdf