Quality Improvement

Keeping quality improvement at the forefront

The department of surgery has ramped up its focus on quality improvement over the last several years.

A major part of this effort is the department’s quality committee.

Steven Hughes, M.D., vice chair for quality and the chief of general surgery, leads the quality committee, which meets monthly. The committee includes representatives of each division, with several people representing the division of general surgery — one each for burn, trauma, surgical critical care, gastrointestinal surgery and surgical oncology.

The representatives take information from the committee meetings back to the personnel of their own division or service line, relaying important information about trends, changes to be implemented and progress made.

In addition to issuing periodic reports from the numerous clinical databases, Hughes and the committee also investigate and create patient safety reports on specific cases. These reports go through a peer-review process.

“When we have an unacceptable outcome, we’ll explore it in detail and look at where there are system issues or any opportunity for improvement,” Hughes said. “That’s given to a specific individual based on a specific event.”

The committee also hosts quality-focused lecture sessions for the whole department every six weeks. Twice a year, speakers from outside the department join the surgeons for grand rounds that emphasize quality. One of last year’s guest speakers was Randy Harmatz, M.B.A., chief quality officer for UF Health.

“This year, we’re going to have the new chief of palliative care (Sheri Kittelson, M.D., medical director of the UF Health Palliative Care Program) come and talk to us about the role of early consultation to palliative care and how that plays into a high-quality organization,” Hughes said.