Quality
At Spectrum Healthcare Partners, the Quality team is committed to enhancing patient care by prioritizing safety, satisfaction, and clinical outcomes. As a physician-owned organization, we hold ourselves to the highest standards of quality. We believe it’s essential to demonstrate our commitment to excellence, not only to our patients, but also to the facilities that contract with us. Collaborating across all divisions, we monitor and continually improve the quality of care we provide, ensuring compliance with national standards. Our Quality Committee, which includes representatives from each specialty division, reports directly to the Spectrum Healthcare Partners Board of Directors, reflecting the importance we place on quality care at every level of our organization.
Key Responsibilities:
- Support to Divisional/Facility QI Committees: Providing administrative and content support to help monitor and improve quality across departments.
- Accreditation & Certification: Ensuring compliance with national standards from organizations like The Joint Commission, American College of Radiology (ACR), and College of American Pathologists (CAP).
- Peer Review Process: Facilitating peer review across all divisions to ensure high standards of care.
- Event Investigations: Investigating events reported in our incident reporting system to enhance patient safety.
- Quality Reporting: Generating monthly, quarterly, and annual quality reports for divisional committees and partner facilities, including Power BI reporting in collaboration with Risk Management.
- Provider Competency & Re-Privileging: Managing Ongoing Professional Practice Evaluations (OPPEs), Focused Practice Evaluations (FPPEs), and distributing physician feedback surveys.
- Trauma & Sedation Programs: Overseeing trauma data and sedation program compliance at MaineHealth.
- Clinical Data Access: Managing access to critical clinical data systems like Epic, Cerner, and PACS.
- Continuous Improvement: Our approach to quality improvement ensures that we are always working towards better outcomes for our patients and enhancing operational efficiency.
Risk Management
The Risk Management team works to identify and manage risks, reduce harm, and ensure a safe environment for patients and staff. We investigate incidents, monitor trends, and provide support to minimize liabilities and improve safety across the organization.
Key Responsibilities:
- Incident Reporting System: Managing and investigating incidents, complaints, and adverse events reported across the organization, including patient feedback from Google Reviews.
- Risk Reviews: Conducting regular risk reviews during Risk Management Rounds to identify and mitigate potential risks.
- Professional Liability Program: Managing malpractice claims, subpoenas, lawsuits, and complaints from licensing boards, while providing legal and risk management support.
- Root Cause Analysis (RCA): Performing in-depth analysis of significant incidents to determine root causes and prevent recurrence.
- Monitoring & Auditing: Regularly auditing policies, incident trends, and safety protocols to ensure compliance.
- Sentinel Event Reporting: Reporting sentinel events to The Joint Commission or state agencies as required.
- Risk Mitigation: Reviewing informed consent processes and addressing potential conflicts of interest to reduce legal risks.
- Policy Management: Collaborating with the Compliance team to manage and ensure the implementation of risk-related policies and procedures
Compliance
The Compliance team ensures adherence to healthcare regulations and industry standards. We provide training, conduct risk assessments, and maintain a robust reporting system to safeguard patient safety and uphold legal and ethical standards throughout the organization.
Key Responsibilities:
- Leadership Oversight: from the Compliance Officer and Operational Compliance Committee.
- Regulatory Compliance: Adhering to key regulations for HIPAA, OSHA, Stark Law, Anti-Kickback Statute, and the False Claims Act.
- Compliance Risk Assessment: Maintaining a comprehensive risk assessment process to identify and mitigate compliance risks.
- Training & Education: Providing Regulatory Compliance Training, Annual Competency Training, and Basic Life Support (BLS) training for eligible providers.
- Reporting Mechanisms: Operating a confidential Compliance Hotline for employees to report suspected violations.
- CME Program: Facilitating Continuing Medical Education (CME) for all QI committees and ensuring compliance with Accreditation Council for Continuing Medical Education (ACCME) accreditation standards.
- Policy Management: Overseeing policies related to conflicts of interest, HIPAA privacy, and other essential protocols.
