NOTICE. May 3, KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer. Cindy Moccio Board Clerk, Executive Assistant to CEO

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1 May 3, 2018 NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Quality Council Committee meeting at 7:00AM on Thursday May 10, 2018, in the Kaweah Delta Medical Center Acequia Wing Executive Office Conference Room {400 W. Mineral King, Visalia}. All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room. The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer Cindy Moccio Board Clerk, Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff West Mineral King Avenue Visalia, CA (559)

2 KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS QUALITY COUNCIL Thursday, May 10, 2018 Kaweah Delta Medical Center Acequia Wing 400 W. Mineral King Avenue, Visalia, CA Executive Conference Room ATTENDING: Board of Directors: Herb Hawkins Committee Chair; Nevin House; Gary Herbst, CEO; Regina Sawyer, RN, VP & CNO; Edward Hirsch, MD, CMO/CQO; Harry Lively, MD, Chief of Staff; Byron Mendenhall, MD, Professional Staff Quality Committee Chair; Monica Manga, MD, Secretary/Treasurer; Dan Boken, MD, Past Chief of Staff; Lori Winston, MD, DIO; Tom Gray, MD, Quality and Patient Safety Medical Director; Sandy Volchko, Director, and Heather Goyer, Recording OPEN MEETING 7:00AM Call to order Herb Hawkins, Committee Chair & Board Member Public / Medical Staff participation Members of the public wishing to address the Committee concerning items not on the agenda and within the subject matter jurisdiction of the Committee may step forward and are requested to identify themselves at this time. Members of the public or the medical staff may comment on agenda items after the item has been discussed by the Committee but before a Committee recommendation is decided. In either case, each speaker will be allowed five minutes. 1. Handoff Communication Quality Focus Team Update- An update on the action items related to handoff communication safety. Sandy Volchko, RN, Director of Quality and Patient Safety 2. Leapfrog Safety Score A review of current performance, components of the score and associated action items. Sandy Volchko, RN, Director of Quality and Patient Safety 3. Quality Transparency Dashboard - A review of a new initiative through Hospital Quality Institute (HQI) and a proposed Quality Transparency Dashboard for the District. Sandy Volchko, RN, Director of Quality and Patient Safety 4. Mission and Purpose Statement Review- A review of the Board Committee Mission and Purpose statement. Edward Hirsch, MD, CMO/CQO; Sandy Volchko, RN, Director of Quality and Patient Safety Adjourn Open Meeting Herb Hawkins, Committee Chair & Board Member In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors committee meeting. Thursday, May 10, 2018 Quality Council Page 1 of 1 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member President Board Member Board Member Secretary/Treasurer

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4 Problem A study released in 2016 estimated that communication failures in U.S. hospitals and medical practices were responsible at least in part for 30 percent of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years. Following the completion of a gap analysis on The Joint Commission s (TJC) Sentinel Event Alert relating to Handoff Communication, KDHCD leadership established a Quality Focus Team (QFT) to evaluate the quality of handoff. TJCs recommends the use of a standardized tool for handoff, KDHCD s new electronic medical record serves as a standardized tool. The initial goal of the QFT is to evaluate the quality of handoff pre and post KD Hub implementation. From this the QFT will be able to determine: a) The impact of KD Hub on the quality of handoff communication b) Determine areas of opportunity post implementation (scope of the teams work post implementation)

5 Collecting A Baseline Measure Pre-KD Hub The QFT will use TJCs TST Tool as a data collection tool (Targeted Solutions Tool). The TST tools are surveys that senders and receivers of handoff complete. The surveys consist of 14 questions, and include custom criteria expected during handoff at KDHCD RN to RN Handoff Scenarios measured: In the same unit (shift to shift handoff) In different departments (patient transfer/transition) Includes med/surg, critical care, mental health, emergency dept, maternal child health Resident Handoffs Measured Handoff within the same program (between Emergency Medicine, Psychiatry and Surgery residents)

6 What is the Quality of our Handoff Pre-KD Hub? KDHCD Handoff Communication (HOC) Defective Rate April 2018 Inpatient to Inpatient HOC Defective Rate (n=272) Reciever Sender HOC defective rate = 60% with one outlier removed KDHCD ED to Inpatient HOC Defective Rate (n=269) Reciever Sender KDHCD Shift to Shift HOC Defective Rate (n=424) Reciever Sender US Baseline Defective Rate* (12/31/2017) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HOC Type Inpatient to inpatient ED to inpatient Shift to shift Top Contributing Factors Inaccurate/incomplete info, pending info, inadequate time, staffing, interruptions Inaccurate/incomplete info, interruptions, repeating information, unable to contact the receiver Inaccurate/incomplete info, pending info, interruptions *US Baseline Defective HOC Rate as of 12/31/17. This comparative group consists of 129 hospitals; 119 of these are full-service, Joint Commission Accredited Hospitals and 3 are Critical Access Hospitals (John T. Cullinan, Black Belt, Director, Application Development and Data Analysis. The Joint Commission Center for Transforming Healthcare. Oakbrook Terrace, Illinois)

7 Next Steps Resident handoff data pending (surgery, psychiatry & emergency medicine) Review baseline data & analysis with stakeholders (May 10, 2018) to determine if there are any low hanging fruit to improve handoff based on comments from staff Post KHD Hub Implementation surveys set to be completed Sept/Oct 2018 Compare analysis pre and post KD Hub to determine and prioritize area(s) for opportunity in handoff

8 Questions?

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10 Leapfrog Safety Grade KDHCD Hospital Safety Score May 2018 = Letter Grade Key: A = >3.133 B= >2.964 C= >2.476 D= >2.047 Time Frame May 2018 Grade October 2017 May 2017 October 2016

11 Components of the Hospital Safety Score Measure Domain Measure Data Date Range Process/Structural Measures (higher is better) Outcome Measures (lower is better) Your Hospital's Score Mean Your Final Weight CPOE Jan % ICU Physician Staffing June % SP 1 - Culture of Safety Leadership Structures and Sys tems June % SP 2 - Culture Measurement, Feedback and intervention June % SP 4 - Risks and Hazards June % SP 9 - Nursing Workforce June % SP 19 - Hand Hygiene June % H-COMP-1 Communication with Nurses 4/1/2016-3/31/ % H-COMP-2 Communication with doctors 4/1/2016-3/31/ % H-COMP-3 Responsiveness of hospital staff 4/1/2016-3/31/ % H-COMP-5 Communication about medicines 4/1/2016-3/31/ % H-COMP-6 - Discharge information 4/1/2016-3/31/ % HAC: Foreign Object Retained 7/1/2014-9/30/ % HAC: Air Embolism 7/1/2014-9/30/ % HAC: Falls and Trauma 7/1/2014-9/30/ % CLABSI 4/1/2016-3/31/ % CAUTI 4/1/2016-3/31/ % SSI: Colon 4/1/2016-3/31/ % MRSA 4/1/2016-3/31/ % C. Di ff 4/1/2016-3/31/ % PSI 3 - Pressure ulcer rates 7/1/2014-7/1/ % PSI 4 - failure to rescue 7/1/2014-7/1/ % PSI 6 - Iatrogenic pneumothorax rate 7/1/2014-7/1/ % PSI 11 - Post op respiratory failure 7/1/2014-7/1/ % PSI 12 - Post op PE/DVT 7/1/2014-7/1/ % PSI 14 - Post op wound dihiscence 7/1/2014-7/1/ % PSI 15 Accidental Puncture/Laceration 7/1/2014-7/1/ %

12 Regional Safety Grades May 2018 Adventist Medical Center Selma = A Adventist Medical Center Hanford = B Sierra View Medical Center = B Community Regional Medical Center = C Clovis Community Medical Center = C Saint Agnes Medical Center = B Kaiser Foundation Hospital Fresno = B

13 Components of the Hospital Safety Score NQF Safe Practices ACTION: Administered & disseminated the Safety Attitudes Questionnaire (SAQ) and set targets and plan for improvements Be proactive to reduce risk ie. Failure Modes Effects Analysis (FMEA)/risk assessments Review and disseminate the connection between adverse events and staffing Continue measuring hand hygiene; act and disseminate performance and targets for improvement

14 Components of the Hospital Safety Score ACTION: Continue to monitor all hospital acquired conditions timely and act to correct INFECTION PREVENTION, INFECTION PREVENTION, INFECTION PREVENTION, measure, disseminate and act on results

15 Questions?

16 Quality Transparency Dashboard Outcome Measures: CLABSI Colon SSI NTSV Sepsis Mortality VTE Medicare Hospital Compare Score % 17.8% 0.0% Measure Period 04/01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/ /01/ /31/2017 Current Score (Jan-Dec 2017) % 13.5% 0.0% California Level % 18.3% 2.0% National Level % 25.0% 2.0% Key Outcome and Process Measures: Total Knee/Hip Complications PSI-90 Stroke Received Thrombotic <3hours Overall Patient Rating (HCHAPS) Hospital Compare Star Rating Medicare Hospital Compare Score % 3 Star Measure Period 04/1/ /31/ /1/ /30/2015 7/1/2016-6/30/2017 As of 4/20/2018 Current Score (Jan-Dec 2017) % (AHA Data) 75.5% California Level N/A N/A 92.6% (AHA Data) 69.0% National Level % (AHA Data) 73.0% Safety Grade: Hospital Spring 2018 Safety Grade: Click Here For Measure Definitions Hospital Comments: Based on surveys submitted voluntarily by hospitals across the country for the purpose of transparency and improvement. The survey assesses hospitals on three key areas: how patients fare, resources used in caring for patients, and leadership and structures that promote patient safety. Participated Programs: Certified Advanced Primary Stroke Center. Joint Commission advanced certification clinically meeting specific requirements, expectations, and focusing on continuous improvement. Participates in American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). ACS NSQIP is the leading nationally validated, risk-adjusted, outcomesbased program to measure and improve the quality of surgical care in the private sector. Participates in National Database of Nursing Quality Registry (NDQI). National nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level. Participates in The Society of Thoracic Surgeons & American College of Cardiology Registry. Monitors patient safety and real-word outcomes related to aortic valve replacement. This hospital has a Maternity Safety Program in place. A maternity safety program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth. This hospital has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach for identification and treatment of an infection and inflammatory response which is present throughout the body. This hospital has a Respiratory Monitoring program in place. Respiratory monitoring provides guidance for assessment of risk of respiratory depression, and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated. Higher is Better Higher is Better Higher is Better

17 Quality Transparency Dashboard Definitions Medicare Hospital Compare Score: Hospital Compare provides information about the quality of care at over 4,000 Medicare-certified hospitals across the country. Hospital Compare was created through the efforts of the center for Medicare & Medicaid Services, in collaboration with organization representing consumers, hospitals, doctors, employers, accrediting organizations, and other federal agencies. Current Score: Based on internal data abstraction and analysis following national standardize definitions. See definitions below. CLABSI - Central line-associated Blood Stream Infection: A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitation: In the calculation of the Standardized Infection Ratio (SIR), the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection. Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors. Colon SSI - Colon Surgical Site Infection: An infection (usually bacteria) that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measured period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitation: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections. However, not all relevant risk factors are included (e.g., trauma, emergency procedures). Hence, the SIRs for hospitals performing more complex procedures or with larger volumes of trauma or emergency procedures may not be adequately adjusted to account for those patient-specific risk factors.

18 NTSV - Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate: The percentage of cesarean (surgical) births among first-time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers. Limitation: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant. Sepsis Mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival. Limitation: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult. VTE - Venous thromboembolism: The measure of patients who develop deep vein clots who had not received potentially preventive treatment. Limitation: Although not adjusted to account for patient-specific risk factors, this rate is helpful in distinguishing a hospital s adherence to the best practice of administration of appropriate VTE prophylaxis to all appropriate patients. Total Knee/Hip Complications: Rate of patients electively admitted for primary total hip and/or knee replacement with a complication. Measured complications include heart attack, pneumonia, sepsis, surgical site bleeding, pulmonary embolism, mortality, joint infection, and wound infection. Limitation: Patient risk factors are not taken into account. Patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a complication. Patient Safety Indicator (PSI) 90: Overall score for serious complications is based on how often adult patients had certain serious, but potentially preventable, complications related to medical or surgical inpatient hospital care. This composite (or summary) measure Patient Safety and Adverse Events Composite is based on the following measures: (PSI 3) Pressure sores (pressure ulcers) (PSI 6) Collapsed lung that results from medical treatment (Iatrogenic pneumothorax) (PSI 8) Broken hip from a fall after surgery (in-hospital fall with hip fracture) (PSI 9) Bleeding or bruising during surgery (perioperative hemorrhage or hematoma) (PSI 10) Kidney and diabetic complications after surgery (postoperative acute kidney injury requiring dialysis) (PSI 11) Respiratory failure after surgery (postoperative respiratory failure) (PSI 12) Blood clots, in the lung or a large vein, after surgery (perioperative pulmonary embolism or deep vein thrombosis) (PSI 13) Blood stream infection after surgery (postoperative sepsis) (PSI 14) A wound that splits open after surgery (postoperative wound dehiscence) (PSI 15) Accidental cuts and tears (unrecognized abdominopelvic accidental puncture or laceration)

19 Stroke Received Thrombolytic<3 Hours: Percent of acute ischemic stroke patients who meet criteria and arrive at the hospital with in 2 hours of last known well time and received clot busting medication within 3 hours of time last known well time. Providing timely evidence base treatment improves patient outcomes. Data is from American Heart Association (AHA), Get With The Guidelines-Stroke Patient Registry. Currently, CMS Hospital Compare does not collect this data. Overall Patient Rating: Hospital Consumer Assessment of Healthcare Providers (HCAHPS): A standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care. The HCAHPS Survey is administered to a random sample of patients continuously throughout the year to gain the patient's perspective of care. Hospital Compare Star Rating: Overall rating summarizes up to 57 quality measures across seven area of quality into a single star rating for each hospital. Hospitals report their data to the Centers for Medicare & Medicaid Services through the Quality Reporting Program. Three star is the most common rating of a 1-5 star rating system.

20 Kaweah Delta Health Care District QUALITY COUNCIL COMMITTEE MISSION AND PURPOSE: The mission of Quality Council is to fulfill the Board of Director s requirement for an organized, documented quality improvement (QI) program by establishing a set of prioritized performance improvement projects and assuring appropriate allocation of resources to maximize QI efforts within the District. MEMBERSHIP: The membership of this committee shall consist of two (2) Board members, the CEO or designate, the CMO, COO, CNO, CIO, the Chief of the Medical Staff, the chair of the Professional Staff Quality Committee (Prostaff), and members of the Medical Staff as designated by the Board. SPECIFIC RESPONSIBILITIES: 1. Review and recommend approval of the annual QI Plan and Patient Safety plans to the Board of Directors. 2. Determine priorities for improvement. 3. Monitor key outcomes related to Quality Focus Team activities. 4. Evaluate clinical quality, patient safety, and patient satisfaction. 5. Monitor and review risk management activities and outcomes. 6. Evaluate the effectiveness of the performance improvement program. 7. Foster commitment and collaboration between the District and Medical Staff for continuous improvement. 8. Reviews all relevant matters related to Quality within the institution, including Performance Improvement, Peer Review, Credentialing/Privileging and Risk Management. GOALS AND OBJECTIVES: Promote an environment focused on patient safety that encourages error identification and development of remedial steps Develop an understanding of important organizational and patient care functions and related processes. Oversee establishment of dimensions defining performance and quality for District based activities. Oversee development of tools and methodologies used for assessing and improving performance. Foster a District-wide commitment to meeting and exceeding the requirements of regulatory, licensing and accrediting agencies. Quality Council Committee Mission & Purpose January 22, 2009 Page 1 of 2

21 Foster a District-wide commitment to excellence in service and practice. Foster a District-wide commitment to collaboration. Foster a District-wide commitment to achieving superior outcomes. Ensure a Failure Mode and Effects Analysis (FMEA) is completed at least every 18 months. Adopted by the Quality Council Committee on April 20, Quality Council Committee Mission & Purpose January 22, 2009 Page 2 of 2