Patient Safety and Quality Services


JCAHO Core Measures... JCAHO National Patient Safety Goals... Leapfrog... state initiatives... CMS... payers... NSQIP.... It seems that all manner of organizations want to measure your quality. Also, it seems like all manner of other organizations want to help you "achieve quality". As a senior executive or board member of your health system, you know what you need to do - make sure that every element of the organization is tuned to make certain that you are at the top in patient safety measures and at the very top of quality measures. If there was an affordable way to guarantee that your culture, processes, and information systems were aligned to achieve your patient safety and quality measures, as well as report to all of those entities who matter, you would have no second thoughts about doing "it."

Santa Rosa Consulting understands this burden and has a continuum of services that can support your needs. Over twenty years ago external influences pushed health care organizations to develop formalized quality programs and measurements. These programs evolved into continuous quality improvement programs that began to study process and organizational alignment - focusing on the "why" and not the "who". These initiatives changed your organizational culture and in many cases, the way you do business. Today, these same influences are driving organizations to refine and augment quality programs into ones that focus on specific aspects of "how" care is delivered. We understand the requirements of this transition and how it effects your organization as you engage in the evolutionary process of moving quality initiatives toward patient safety activities.

Santa Rosa is keenly aware of and has evaluated the many vendor offerings available that address one or two of the domains of change and how they affect the patient safety initiatives. These domains of change include:

  • People - who carry out the strategic direction or mission
  • Process - defining how work is done and aligning the work with the roles
  • Data - transforming data to acquire information

Our staff at Santa Rosa Consulting have led and directed many quality initiatives and amassed the subject matter expertise to assist our customers through the myriad of vendors that have emerged in the marketplace offering services that focus on patient safety. In many instances these vendors are focused on one, or possibly two, of the domains of change. Santa Rosa can offer you an experienced approach that will assemble your resources, existing vendor relationships, and the available tools into a cohesive and sustainable patient safety program.

Based on our experience we have carved out the key elements for success and have described our services below:

Strategic Planning for Patient Safety and Quality

Healthcare organizations are accustomed to developing strategic plans for fulfilling and honoring their ongoing mission. As part of that process future direction is vetted with key stakeholders. Santa Rosa believes that the creation of a Patient Safety and Quality Strategic Plan should be an integral component of the organization’s strategic direction. Further, Santa Rosa believes that organizations must refine their culture to make patient safety a part of the fabric or the mission.

Santa Rosa can offer Board of Trustee educational services, proctoring and facilitation services, and physician/executive support to its clients to incorporate patient safety more deeply into your organization. Our approach is one that can be prescriptive, but is generally collaborative based on each organization’s challenges, whether geographical, competitive, or financial in nature, are unique to its environment and culture. These facilitation services enable the latest thinking in patient safety trends and activities to be readily accessible and explainable.

Santa Rosa can also help define the current condition of your organization. We can map your current strategic plan to one that can reliably embrace a more pronounced emphasis on Patient Safety and build from the existing quality programs. Our focus for these types of services addresses the effects of variable reimbursement and your continued viability in an age where patients will value the transparency of cost and quality.

Allow us to assist you in your navigation of the myriad of tools to align your strategic initiatives with an accent on patient safety as it builds from your successful quality initiatives.

Assessments for Readiness (A Current State Assessment of Your Patient Safety and Quality Program)

Santa Rosa understands the process of change management and how difficult changing an organizational culture can be. Often one of the most difficult aspects of a program is the lack of adoption by any level in the organization. As such, our experts never assume that the mission or plan has been fully communicated to the staff and our approach is to determine the organization’s position for change. The question must be asked and answered, "Are we ready?"

Santa Rosa can help answer the question by providing a readiness assessment. We have found it absolutely essential. Success is driven by a keen understanding of the starting point for these patient safety programs. Our purpose is to understand the current status of the people, processes, and data, which afford us a glimpse into your organization. This viewpoint will allow us to create a roadmap to achieve the goals your organization is seeking. This assessment is created as a management letter, organized by the significance of items identified, and used to set expectations.

If requested we can estimate the resources and costs required to tactically execute to a given goal or program event based on your direction.

Tactical Plan for Patient Safety

Santa Rosa Consulting has amassed the knowledge and resources to assist its clients with developing tactical plans for its patient safety programs. Our approach begins with seeking alignment in understanding and prioritizing potential patient safety initiatives based on their risk or reward to your organization. Based on our expertise and operational knowledge of health systems, we can help you understand what patient safety activities have yielded the most relevant returns on investment.

Further, we have created an approach that will define an organizational structure to support the execution of tasks for your patient safety initiatives. We incorporate the roles of the staff into the tactical plan and build an educational program to define the reasons for patient safety initiatives and how they relate to your existing quality program. Our experience often indicates that staff are assumed to understand these causal relationships, yet are uncertain of the "how, what, and why."

Once the roles and structure are established, Santa Rosa begins the vetting process with the members of the team and with outside experts to prescriptively build project plans and identify role-based assignments for patient safety events. Blended into this plan are tasks to identify information system constraints, data collection issues, and the detail surrounding how to measure the results. Further Santa Rosa defines how the program will coincide with regulatory compliance issues, report Core Measures, prepare the organization for pay for performance, and anticipate the framework for the effects of transparency.

With this approach Santa Rosa can provide its clients with a foundation for continuous patient safety improvement. Though many new regulations are anticipated, our focus will position your organization to be dynamically responsive and not overly reactive. As more information from JCAHO and CMS becomes available we will include the required activities in our approach and assimilate them into our tactical planning services.

Tactical Assistance

Santa Rosa Consulting can offer your organization assistance with your patient safety and quality program by providing leadership or staff to an existing initiative. Our goal is for you to be successful and we can provide resources to backfill your staff that is focused on patient safety and quality activities. We are adept at building and designing project plans that can leverage your staff, engage them in the management process, and lead the project plan through to fruition. Our objective is that you become self-sufficient in managing the continuing effort of the initial program event and that we could become valuable as a consultative expert, if needed, as your programs expand.

We can offer other critical support in the form of educators, educational plans, organizational change expertise, communication plans, and services that can assist with physician and stakeholder adoption. In each case we are responding to you as our client and the leader of the project. We can tailor our services to you and offer our advice when it is solicited based upon the role we are fulfilling.

Process Improvement

Santa Rosa Consulting and its experts have embraced the concepts of improving processes to reduce redundant, costly, and nonproductive tasks. We have the necessary experience in building a programmatic approach to projects with multiple phases and extreme interdependencies. As such we develop an operating model that enables you to execute the strategic, tactical, and program work plans. Further our operating model approach is oriented by function rather than role, and incorporates management, compliance, and reporting issues. Further respect is given to communications and topics like avoiding the "Never Events" and improving cash flow.

Our overall approach is geared for a high degree of interdependence between each of the value-driven centers of processing and often, with your support, reallocates work and work queues to garner the expected efficiencies.

If desired we can tailor our process improvement approach to focus on a key or specific area of your patient safety and quality organization and improve or re-integrate its processes. We are interested in supporting you wherever we can through our flexible approach. As you implement and confirm success we can guide you through the process.

Aligning Information Systems

Santa Rosa Consulting can also assist its clients with aligning their data collection, capture, and information system set-up with the reporting and information requirements of their patient safety and quality programs. Santa Rosa has the requisite technical, system, healthcare operations and experience to assess, recommend, and effect changes to your systems to facilitate the data capture requirements of your patient safety and quality programs. We are aware that this element of a patient safety program can place a significant burden on information technology staff as the requirements for data feeds and files are numerous. Santa Rosa can decrease your labor costs with these activities through many scenarios, ranging from our resource doing the task on your behalf, to re-engineering the processes for information extraction.

Please allow us to work with your staff to find optimal and more productive solutions.