The mission of the Department of
Medicine Morbidity and Mortality Steering Committee (MMSC) is to review the
action items identified during monthly DOM and quarterly interdepartmental DOM
M&M conferences, case conferences and divisional M&Ms. The MMSC will triage
these action items to the appropriate process improvement stakeholder, and
prioritize action items for quality improvement activities for UCHealth and the
DOM. The MMSC will continually foster a
safe and respectful environment for discussion and learning, with a primary
objective of identifying quality and process improvement initiatives that align
with UCHealth and the DOM
The MMSC reports activities and
outcomes to the University of Colorado Hospital Quality Department, the Chair
of the Department of Medicine (DOM), the Vice Chair for Clinical Affairs for
the DOM, the Clinical Chiefs for each Division within the DOM, and the Clinical
Effectiveness and Patient Safety Committee (CEPSC). The MMSC collaborates and aligns hospital
based process improvement initiatives with the CEPSC.
Role of MMSC:
Steering Committee members are not
directly responsible for presenting the M&M cases, or for managing process
improvement activities, but are responsible for providing support and guidance
for those who do and reviewing progress of quality improvement activities derived
from recommendation of the committee. Thus, Steering Committee members will:
Strengthen the culture of safety by
guiding open, collaborative discussions within a multidisciplinary forum.
Determine the scope and breadth of actionable process improvement (PI)
opportunities forwarded to the DOM MMSC from various DOM Division’s
M&M presentations, the QPS team, CEPS teams, or Med QT committee.
Analyze the degree of difficulty,
complexity, cost, risk, and benefit of implementing PI activities to patients
and the system, and utilize key stakeholder input prior to making
recommendations for or against hospital based projects.
Strategically align action items with current and evolving
process improvement projects wherever possible.
Make recommendations in regards to
baseline data, additional metrics and ROI in order to help bolster the argument
for intervention in identified M&M issues by various outside stakeholders.
Collaborate with the DOM QPS team to
forward actionable items to the appropriate CEPS, QI team, or other UCH committee for further review and
implementation of key quality initiatives.
Communicate with the DOM QPS team and
physician learners on progress of M&M driven hospital initiatives via QPS
intranet site. This will provide a continuum of education and subsequent loop
closure for internal QPS tracking of actionable PI outcomes.
The MMSC will meet at least quarterly, and more frequently
if the need arises.
1) The MMSC will have delegated authority to
determine the priority matrix for implementation of quality initiatives
designed to improve systems of care and patient outcomes
2) The MMSC will have two co-chairs representing
the UCHA and SOM as well as representatives from key clinical and
3) The MMSC will have process improvement, quality
improvement and data analyst support from the Medicine pod and the DOM quality
4) The MMSC will have a UCH executive sponsor, Jeff
Glasheen, MD, CQO, and DOM executive sponsor, Rick Albert, MD, Vice Chair for
DOM Clinical Affairs.
5) The sponsors, or assigned delegates, will be responsible
for attending meetings, assisting programs with goal setting, primary review of
the written reports and ad hoc meetings and support.
6) The MMSC will act as a Steering Committee, and will
make recommendations for creation of working groups within the UCH Medical pod
or the DOM quality enterprise at their discretion.
report of M&M driven hospital-based patient safety initiatives and
subsequent progress towards completion
to Chair DOM, Vice Chair for Clinical Affairs, DOM, and Clinical Division
Chiefs, UC Hospital Quality Department, and CEPSC.
Chair: Michael Ho
CMR (2): Amy Yu & Andrew Berry
Ambulatory Care: Elena Lebduska
Division: James Carter
Division: Jessica Kendrick (Renal)
Division: David Saxon (Endocrine)
Division: Swati Patel (GI)
Division: Brian Montague (ID)
Nurse Manager: Kaycee Shiskowsky
(Director is Jenn Zwink)
Nurse Manager: Mark Yoder
(Director is Michelle Feller)
Clinical Quality Specialist, UCH:
Sylvia Park (Director is Sue West)
Clinical Quality Specialist, DOM:
Lindsie Stephan (Director is Sue West)