Cochise Regional Hospital Quality, Risk and Safety Policy and Procedure

Transcription

1 Cochise Regional Hospital Quality, Risk and Safety Policy and Procedure INTRODUCTION Cochise Regional Hospital Quality, Risk and Safety Policy and Procedure describes the organizational structure used to measure and improve the quality and safety of patient care and service. Cochise Regional Hospital integrates safety, error prevention, and quality improvement into a single set of processes in order to implement an institution-wide quality and safety management approach to the delivery of high quality health care and to ensure a safe environment for patients, staff, and visitors at all CRH facilities. Quality Improvement, Clinical Safety and Medical Services Management, Risk Management, and Environment of Care Safety Plans are integrated into a single Quality, Risk and Safety Program (CRH Quality, Risk & Safety.Attachments A-E). The Program is approved by both the Medical Staff Committee and the Douglas Community Hospital Board of Directors. The plan is reviewed and evaluated by the Quality, Risk, and Safety Committee annually and/or on an as needed basis. If necessary, revisions are prepared and then submitted for approval to the Medical Staff and Douglas Community Hospital Board of Directors. GOAL Cochise Regional Hospital s Quality, Risk and Safety Program is designed to identify and effectively resolve events and/or concerns that lead to or have the potential to lead to adverse outcomes. The program is designed to monitor current processes to identify opportunities for improvements that lead to a reduction in risks of adverse outcomes of care and to ensure a safe environment for patients, staff, and visitors. Moreover, the plan envisions the implementation of processes that will ensure the practice of medicine at highest standards and according to the best available evidence. OBJECTIVES To ensure an institution-wide governance and leadership commitment to quality and safety as a defining and strategic element of the organization s culture. To utilize education of the entire work force as a means of improving quality, minimizing risk, and ensuring safety.

2 To provide a standardized mechanism for identifying, reporting, and monitoring safety issues throughout the organization. To provide a standardized method for assessing quality and safety in the organization. To provide a mechanism for developing strategies for addressing necessary system/process improvements to ensure the safety of patients, staff, and visitors. To provide a process for reporting quality and safety concerns to appropriate personnel. To ensure that risk reduction strategies are implemented when necessary and follow-up is completed on all safety issues when appropriate. CULTURE Reporting quality of care/safety concerns is seen as an opportunity for improvement in the organization and is highly encouraged. An emphasis is placed on system and process issues. A non-punitive approach to error identification, remediation and prevention will be utilized within the parameters of a reasonable standard of conduct and professional practice. QUALITY, RISK & SAFETY MANAGEMENT PHILOSOPHY Cochise Regional Hospital is committed to continuously improving the quality of patient care, customer satisfaction (service), efficiency, and ensuring a safe environment for patients, staff, and visitors. Quality, Risk, Safety Committee supports the Mission, Vision, Values and strategic goals of the organization. Quality and safety are monitored over time at all levels: organization-wide, departmental, and with staff members. Performance standards are based on internal monitors of current performance, customer expectations, current levels of technology, institutional resources, patient outcomes and nationally accepted levels of care. Key aspects of the Quality, Risk and Safety program include: The entire organization is dedicated to continually improve upon patient outcomes. The core belief of doing the right thing at the right time, every time is held by all. Quality, Risk and safety is perceived in all aspects of CRH s operations by physicians, patients, staff, and visitors.

3 The organization is focused on customer satisfaction through consistently meeting or exceeding the expectations of all. The measurement and surveillance of quality, risk and patient safety will lead to improved patient care. An institution-wide governance and leadership commitment to quality and safety is a defining and strategic element of the organization s culture. A safe environment is provided for all patients, staff, and visitors. DOMAINS OF QUALITY Leadership and Governance of the Quality Process The design and implementation of quality systems shall be based on a commitment from the Board of Directors and Management to keep quality as a strategically defining corporate priority. Education The education of all staff (medical, hospital, and student) on the dimensions of quality shall be central to the organizational culture. Educational efforts shall be continuous, standards/outcome driven, flexible to the varied approaches to clinical problems, and sensitive to the changing nature of medical services. Quality, Safety Surveillance, Error Reporting, and Analysis The quality system shall incorporate a means to identify, report, and analyze both the quantity and the underlying causes of errors in the environment. All errors (even in nonclinical areas) shall be included because system errors anywhere in the hospital environment have the potential to lead to a clinical consequence. Physical Environment The physical environment shall be designed, to the extent achievable, to eliminate preventable error as well as to promote patient and staff safety. Communication Structured, frequent, timely, and accurate communications of quality-related activities to all staff (medical, hospital, and student) is fundamental to changing the organizational culture and to the institution-wide acceptance of the quality system.

4 Professional Practice Standards An organized approach to establishing and monitoring professional practice standards is necessary in a quality organization. Regulatory Compliance Compliance with applicable regulations and standards supports a culture of quality. QUALITY & SAFETY STRUCTURE The primary entities that evaluate the quality of care and safety of the services rendered at Cochise Regional Hospital are Douglas Community Hospital (CHD) Board of Directors, Executive Staff (Director of Operations and Director of Nursing), Medical Staff, and Quality, Risk and Safety Committee (Attachment B - Quality, Risk, Safety Structure Flow Chart). Douglas Community Hospital (CHD) Board of Directors The Board of Directors will adopt priorities for quality and safety related activities in accordance with the Cochise Regional Hospital Quality and Safety Plan. Executive Staff The Executive Staff is responsible for achieving improvements in the corporate culture, assuring a safe environment for CRH patients, staff, and visitors, and improving overall quality of care and services rendered at CRH. The Executive Staff consists of the Director of Operations and the Director of Nursing. Medical Staff & Chief Medical Officer The Medical Staff and the PeoplesChoiceHospital Chief Medical Officer has overall responsibility for the quality of the professional services provided by individuals with clinical privileges and for accounting therefore to the Board of Directors. The Medical Staff participates in and evaluates the effectiveness of patient care monitoring and utilization management activities. The Medical Staff has the responsibility for monitoring, implementing, and evaluating quality improvement and safety within the organization, which is contained in the Cochise Regional Hospital Quality, Risk and Safety Program. The Medical Staff and the Chief Medical Officer participate in the annual evaluation of the overall quality and safety program, which considers its comprehensiveness, integration, effectiveness, and cost efficiency. The Chief Medical Officer and the Chief Compliance Officer at the PeoplesChoiceHospital Corporate level will work closely with the Medical Staff to achieve all of the above. The Medical Staff and the Chief Medical Officer are responsible for evaluating physician proactive and process issues related to patient care as defined in the Medical Staff Bylaws. The Medical Staff delegated by the CHD Board is responsible for the

5 review of sentinel events, adverse occurrences, and medical staff peer review. The Medical Staff is responsible to ensure the completion and evaluation of root cause analysis, development, and implementation of risk reduction strategies, and the measurement of the effectiveness of these action plans. The Medical Staff is also responsible for trending adverse occurrences for review. The Medical Staff reports sentinel event alert information to appropriate individuals and departments throughout CRH in an attempt to take a proactive approach to the prevention of medical errors. The Medical Staff focuses on clinical issues and will refer operational and environmental issues to the Quality, Risk and Safety Committee. The Medical Staff will consider operational and environmental processes when analyzing adverse occurrences, actual or potential. The Medical Staff meets at least quarterly. Action by the Medical Staff is by a majority of the voting members present. The Medical Staff reports to the Board of Directors at least quarterly. Quality, Risk and Safety Committee The Quality, Risk, and Safety Committee is responsible for the Quality, Risk and Safety Plan vested by the Douglas Community Hospital Board of Directors and the Medical Staff to provide a safe environment for patients, staff, and visitors; develop, implement, and continuously refine the institutional Quality and Safety Plan; provide institution-wide education on CRH s quality and safety processes; and recommend priorities regarding quality improvement projects to the CHD Board of Directors. Its purpose is to improve the quality of care delivered to patients by CRH by ensuring departmental accountability for clinical, service, and operational process improvement. The Quality, Risk and Safety Committee is responsible for: Establishing organization-wide patient safety program that uses internal and external knowledge and experience to prevent the occurrence of errors; Establishing clear systems for internal and external reporting of information related to patient care related errors; Ensuring that an ongoing proactive approach for identifying risks to patient safety and reducing patient care related errors is defined and implemented; Setting goals and measuring the effectiveness of actions to improve patient safety and the overall quality of care; Developing and implementing a comprehensive, systemic plan for Quality and Safety based upon the mission and strategic goals of the organization; Recommending the provision of adequate financial and human resources necessary for process improvement; Establishing, monitoring and evaluating Clinical Process Improvement teams; Assigning Quality Improvement Teams on an adhoc origin based upon significant discoveries from data analysis; Defining the methodology for the Quality Improvement process including the use of technology such as Empower Electronic Health Record based systems;

6 Determining quality and safety indicators utilized to measure the effectiveness of the Quality and Safety Program; Reporting to the CHD Board of Directors regarding process of the Quality and Safety Program; and Educating teams in quality improvement methodology. The Quality, Risk and Safety Committee is responsible for annually selecting high risk process for proactive assessment, and ensuring that necessary risk reduction strategies and action plans are developed, implemented, and evaluated when appropriate. The Quality/Risk Committee meets at least quarterly. A quorum is required for action and consists of a simple majority of all of the members. Actions taken are by a majority of all members present at the meeting. When financial decisions are involved, recommendations are made to both the Executive Staff and People s Choice Hospital Corporate layer for approval. The Quality, Risk and Safety Committee is accountable to the CHD Board of Directors through the Executive Staff. Each department reports on quality indicators to the Quality, Risk and Safety Committee at least quarterly. Quality, Risk and Safety Committee coordinates processes within the Environment Surveillance including safety, fire prevention, utilities, hazardous materials and waste, security, emergency and medical equipment management. The Quality, Risk and Safety Committee assesses environmental safety issues and conducts process improvements when indicated. The Quality, Risk and Safety Committee advices the Executive staff regarding environmental safety issues which may necessitate changes to policies and procedures, orientation or education, or expenditure of funds. The Safety Officer attends and reports to the Quality, Risk and Safety Committee. PRIORITIZATION OF IMPROVEMENT ACTIVITIES It is the responsibility of the Quality, Risk and Safety Committee to prioritize process improvement activities for the entire organization. Prioritization is based on high volume, high risk, and problem prone areas. Prioritization is further guided by the strategic goals of the organization. PROACTIVE RISK REDUCTION & MECHANISMS FOR COORDINATION Staff at all levels of the organization is encouraged to report all safety and quality of care concerns. Staff is encouraged to be proactive and report concerns and near misses as well as actual incidents. Such data may be reported via written, electronic, or telephonically to the Quality, Risk and Safety Committee or Executive Staff. Environment of Care data is collected on a regular basis to gain information regarding safety and quality of care issued within the organization. Staff members

7 throughout the organization are encouraged to share information regarding potential or actual patient and staff safety issues. This data is collected and analyzed by the Quality, Risk and Safety Committee. Clinical processes, safety issues, and quality of care concerns are collected and analyzed by the Quality, Risk and Safety Committee and the Medical Staff. The occurrence of clinical and environmental safety concerns, adverse occurrences, and actions taken to improve patient safety are reported to the Medical Staff and Douglas Community Hospital Board of Directors. Please, refer to CRH Risk Management Plan (CRH Risk Management Plan.Attachment C) for a complete description of the CRH Risk Management Plan. COMMUNICATING WITH PATIENTS REGARDING SAFETY Cochise Regional Hospital is committed to full disclosure of medical errors and unanticipated outcomes to patients and their families. CRH encourages patients to take an active role in preventing health care errors by becoming active, involved and informed participants in their healthcare. DATA Data is collected throughout the organization to assess outcomes or determine the performance of a function or process. The majority of data is collected and maintained under the direction of the Quality, Risk and Safety Committee and presented at the Quality, Risk and Safety Committee mettings. The data is utilized to establish baseline information when a process is implemented or redesigned, identify areas of improvement, or evaluate changes in processes or functions. Data is collected and distributed in a manner to assure privacy and confidentiality of patient information in compliance with applicable regulations. The Quality, Risk and Safety Committee identifies the performance measures that are important to monitor patient outcomes, safety, and overall quality of care and services rendered at CRH. The Quality, Risk and Safety Committee sets priorities for measurement based upon the strategic goals of the organization and high risk, problem prone, and high volume populations and/or processes. Ongoing measurement enables the Quality, Risk and Safety Committee to judge the stability of the processes and the predictability of the outcomes. Priority issues are chosen for improvement, and the detail and frequency of the data collected for these issues are appropriate to the activity, population, or process being measured. Once a process is selected for improvement, measurement becomes more detailed and frequent. Data is collected both electronically and manually. Manual data collection is obtained from the patient s medical record. Electronic data is obtained from various databases available to the hospital including the Empower systems. Data retrieval is conducted in a timely fashion concurrent with the needs of the study. Both retrospective

8 and concurrent data collection is performed. Data will be submitted as appropriate for regulatory and compliance requirements. Integrated reliability is enhanced by limited the number of individuals abstracting data manually. QUALITY, SAFETY SURVEILLANCE, ERROR REPORTING AND ANALYSIS The following data is collected and analyzed for the purpose of identifying quality and safety related issues that may warrant follow-up. All data is collected for the purpose of identifying opportunities for improvement. Data is tracked and trended. Process improvement activities are data driven. Quality management initiatives contained in the Cochise Regional Hospital Quality and Safety Plan Incident Reporting that may be done by writing or ing. Health Services Advisory Group (HSAG) Arizona and other organizations Quality Improvement initiatives when applicable Referrals from CRH Risk Management and others Patient Surveys such as HCAHPS One hundred percent (100%) of all detected adverse occurrences are reviewed. Potential Sentinel Events are identified and reported to the Medical Staff for follow-up per CRH s policy. INDENTIFICATION, REPORTING, AND MANAGEMENT OF SENTINEL EVENTS To support CRH s Mission, Vision, and Values, and commitment to providing safe healthcare, CRH identifies, investigates, and analyzes sentinel events as outlined in Attachment C. All potential sentinel events shall be reported to the Director of Operations, who shall report to the Chief of Staff and to the People s Choice Hospital Chief Medical Officer. The Chief of Staff and the People s Choice Hospital Chief Medical Officer determine whether the Medical Staff needs to meet urgently to address the potential sentinel event, or whether the event can be discussed at the next regularly scheduled Medical Staff meeting. The Medical Staff determines whether or not an event is a sentinel event (CRH Sentinel Event. Attachment D). If the occurrence is determined to be a sentinel event, the Medical Staff is responsible for coordinating the completion of a summary of the event, and the correction action plan to the Governing

9 Body for approval. The Medical Staff in conjunction with the Governing Body shall be responsible to assure that all action items on the corrective action plan have been carried out and evaluated to assure positive outcomes. POSSIBLE SOURCES for IDENTIFYING SENTINEL EVENTS & UNEXPECTED ADVERSE OCCURRENCES! ICD 9-10 Coding! Readmissions within 48 (forty-eight) hours to the ER for the same diagnosis! Readmissions within 30 (thirty) days to the Acute Care for the same diagnosis! Incident Reports/Adverse Drug Event Reports! Blood Review! Death Reviews! Risk Management! Pharmacy (P&T Committee)! Infection Prevention! Case Managers! Care Concerns from Insurance Companies! Hospital Staff/Personnel QUALITY IMPROVEMENT PROJECTS AND PROCESSES Quality Improvement/Quality Control indicators and its management is integrated within the Cochise Regional Hospital Quality and Safety Plan. The organization is dedicated to consistently evaluate processes and addressing suboptimal outcomes. Quality improvement projects at Cochise Regional Hospital are categorized as follows: Improving existing processes Creating new processes Quality Improvement efforts at Cochise Regional Hospital will focus on Data mining, compilation and interpretation, Planning, and on the Implementing of action plans. Evaluation of the effects of actions taken to improve patient care, systems or processes will be incorporated into all quality improvement efforts, and will be communicated throughout the institution. A. IMPROVING EXISTING PROCESSES DATA Data mining, compilation, and interpretation will be electronic health record based (Empower systems). Electronic reports will be built to track the data of interest, and will require approval by both Medical Staff and Douglas Community Hospital Board of Directors prior to its implementation. PLAN Evaluation of existing processes will focus on improving processes, reducing variation, eliminating redundancy, and expediting quality and safe

10 patient care. Individuals may identify opportunities for improvement. IMPLEMENT- Following approval of the quality improvement project, the corrective plan of action will be implemented with appropriate follow-up evaluation. EVALUATE Evaluation will consist of collecting data to compare postimplementation data to baseline and benchmarking data; whether the corrective action met anticipated expectations; and, if not, make recommendations for additional action. COMMUNICATE Documentation of results are forwarded to the Quality/Risk /Safety Committee and Executive Staff where necessary revisions or refinement changes may be made. Storyboards, department and/or team meetings and newsletters are avenues used to communicate results of the program throughout the organization. B. CREATING A NEW PROCESS When the organization is presented with a need or opportunity to establish new services, extend product lines, occupy a new facility, or significantly change existing functions or processes, the following methodology is used: DATA Data mining, compilation, and interpretation will be electronic health record based (Empower systems). Electronic reports will be built to track the data of interest, and will require approval by both Medical Staff and Douglas Community Hospital Board of Directors prior to its implementation. PLAN A brief new program plan statement needs to be submitted to the Executive Staff and to the Medical Staff. This statement includes the proposed program objectives and goals; rationale for implementation; identification of those who need to be involved. It states how the proposed program ties into corporate mission, vision, objectives, and how it will improve customer service; and identifies the potential impact on revenue and cost savings for the organization. IMPLEMENT- A pilot project, when applicable, may be initiated to evaluate the detailed plan. Also during this phase, education, and communication is instituted thereby allowing those involved to be informed of their roles. EVALUATE evaluation of the program s goals and objectives shall be periodically performed. Comparative measures against baseline data are used to determine effectiveness of the quality improvement processes. COMMUNICATE Documentation of results are forwarded to the Quality/Risk /Safety Committee and Executive Staff where necessary revisions or refinement

11 changes may be made. Storyboards, department and/or team meetings and newsletters are avenues used to communicate results of the program throughout the organization. QUALITY IMPROVEMENT AND CLINICAL SAFETY MANAGEMENT Clinical Safety Management ensures that patient care activities and outcomes are managed, analyzed, and reported in an attempt to identify opportunities for improvement. All Clinical Safety Management activity is for the purpose of providing high quality of care within a safe environment. Emphasis is placed on system and process issues. A non-punitive approach is obtained within the parameters of a reasonable standard of conduct and professional practice. Clinical Safety Management is the responsibility of the Medical Staff. The Medical Staff reviews professional practices for the purpose of reducing morbidity and mortality and improving the quality of care. The Medical Staff evaluates the quality of patient care and collaborates with other committees, clinical services and sections, and organizational departments. The Medical Staff in collaboration with other organizational entities ensures that CRH s patients are free from injury. When opportunities for improvement are identified, the Medical Staff ensures adequate investigation, analysis, and follow-up when indicated. ENVIRONMENT OF CARE SAFETY MANAGEMENT Environment Surveillance Safety Management ensures a safe physical environment for CRH patients, visitors, and staff. See CRH Environment of care Safety and Management Plan for details (CRH Environment of care Safety and Management Plan. Attachment E). The purpose of the Environment of Care Safety Management plan is to reduce the risk of injury to patients, staff, and visitors by managing, analyzing, and reporting all environmental safety incidents and concerns. Emphasis is placed on system and process issues. A non-punitive approach is obtained within the parameters of a reasonable standard of conduct and professional practice. Environment Safety Management is the responsibility of the Quality, Risk and Safety Committee. Quality, Risk and Safety Committee ensure compliance with safety standards and regulations, enforces current safety practices, provide safety education, monitors the effectiveness of the plan, identifies for improvement, and ensures follow-up when necessary. The Quality, Risk and Safety Committee in collaboration with other organizational entities ensures that CRH s patients, visitors, and staff are free from injury.

12 COMMUNICATION AND EDUCATION LEADERSHIP The leadership including the director of operations and the head of departments of the organization are responsible for educating themselves on organizational improvement and safety issues and for communicating these activities and outcomes to their staff members. Communication vehicles include: Department Head meetings, Quality, Risk and Safety Committee meetings, Departmental staff meetings, internal newsletter, administrative and environmental of care rounds, and . Leaders are responsible for informing their staff of opportunities for Quality Improvement education and opportunities. Leaders set standards for staff member performance based on both technical quality and service quality. STAFF Staff members are responsible for educating themselves on Quality improvement issues in a variety of ways, including: attending training, staff meetings, bulletin boards, and outside educational opportunities. Staff is encouraged to communicate to leadership regarding opportunities for improvement by talking to their supervisor. They are responsible to meet standards for both technical and service quality set for their position and their department. PHYSICIANS - Communication is the responsibility of the entire organization. CRH s Chief of Staff and People s Choice Hospital s Chief Medical Officer are responsible for CRH issues that need to be communicated to physicians. The Quality, Risk and Safety Committee and Executive Staff are responsible for targeted physician communication.

13 Attachment A Cochise Regional Hospital Quality, Risk and Safety Plan Quality improvement Nursing/Pharmacy Services I - Nursing Expertise Initiative/The Buddy Program The objective of this initiative is to provide nursing expertise to oversee the quality of nursing services offered in at Cochise Regional Hospital. The Nursing Expertise Initiative is a 3 Step program as follows: Step 1: The Director of Nursing (DON) and/or someone designated by the DON will perform the RN supervisor function. There is one assigned RN House Supervisor for every shift the DON is not on site. Breakdown of RN House Supervisor Schedule Monday-Friday: Weekends: 08:00-16:30 DON on site 19:00-07:30 RN House Supervisor on-site RN House Supervisor on-site Step 2: Redirection of roles and responsibilities under the RN House Supervisor: RN House Supervisor will document the clinical condition of every patient at the beginning of the shift and at the end of shift. RN House Supervisor will attend supervisory rounds when applicable with the primary RN on each department and document accordingly (Acute Care Floor and Emergency Department). RN House Supervisor will provide his/her expertise as needed based on patient s status and will document accordingly. RN House Supervisor will oversee the need for additional resources such as general nursing supplies, pharmaceuticals, respiratory supplies, and staffing issues. Step 3: Supervision of the Nursing Staff The Buddy System It is a proactive approach to ensure that quality care is delivered in a timely manner and that orders are executed correctly. The RN House Supervisor will oversee the care delivered by the primary RNs in each department (Acute Care Floor and Emergency Dept).

14 Attachment A The RN House Supervisor will perform supervisory rounds to be executed with the primary RN on each department when applicable (Acute Care Floor and Emergency Department). The RN House Supervisor will check the execution of orders that include, but are not limited to, medication administration and the implementations of policies and guidelines that relate to patient care. The Cochise Regional Hospital is implementing important Quality Management Programs. The aim of these programs is to identify retroactively through Electronic Medical Record generated reports and through charts reviews deficiencies in the nursing services and other areas of hospital operations. The Buddy System is a system that allows the RN House Supervisor to proactively prevent deficiencies in the nursing services prior to its occurrence. Supervisor Documentation A) RN House Supervisor Expertise Advice a. Reason for Nursing Expertise Advise b. Outcome c. Follow up, if applicable d. Additional comments B) RN House Supervisor Change of Shift Evaluation A Report called AccuRNSupervisor Notes is generated in the Empower Systems. Note type and Note content is showed in the report among other variables. Moreover, when considering the RN House Supervisor Expertise Advice, the surveyor will be able to group together the reason for the Nursing Expertise Advice, which overtime may facilitate the identification of areas for additional training and teaching. A montly report of the Nursing Expertise Initiative/The Buddy Program will be presented at the Quality Meeting.

15 Attachment A II - Program 1 AccuMED Program REVIEW OF MEDICATION RELATED EVENTS A) Step 1: A report called Pharmacy Untimely Administration of Medication Orders is generated in the Empower Systems. The logic of this report follows the Pharmacy and Therapeutics time frame for medication administration. The objective of this report is to identify instances in which medications are administered on an untimely manner. This will allow the Quality Committee to not only follow trends, but to provide proper continuing education to staff and identify possible system issues that may be preventing proper timely administration of medications as well. B) Step 2: Random review of charts - Nursing Random review of ten (10) charts from acute care floor and ten (10) from the ER a week. Main objective is to look for all other med errors other than untimely administration. The surveyor is supposed to complete in the patient chart the following form: Medication Variance Report. A report called AccuDocument-Medication Variance Report and Adverse Drug Report is generated in the Empower Systems. C) Step 3: Narcotics tracking and Random review of charts - Pharmacy All narcotic orders are tracked daily from point of order to patient intake and to ensure the narcotic log is complete and devoid of discrepancies. The pharmacy technician currently reviews all daily narcotic transactions and compiles a spreadsheet report. The report is then sent to the Pharmacist, and the DON. If there is a drug administered without an order or the documentation varies based on the narcotic log, an incident report is completed and the DON investigates the issue and resolves any concerns within 24 hours. In addition, a random review of ten (10) charts institution wide a month will be performed to also include non-controlled substances, including IV fluids, to ensure proper follow through from ordering to administration is completed. The pharmacist with the assistance of the pharmacy technician and of the DON shall review 10 charts monthly for accuracy of follow through and appropriate documentation including a comparison of physician orders with nursing documentation of medication administration to ensue physician orders are being followed appropriately. Any variances are appropriately documented in the patients chart and a med variance report is completed if necessary. D) Step 4: Voluntarily report of medication related events program by RN RN to complete in the patient chart the following form in the setting of a medication error: Medication Variance Report. A report called AccuDocument-Medication Variance Report and Adverse Drug Report is generated in the Empower Systems. Monthly report of all three Steps of accumed Program should be presented at the Quality Meeting and P&T Meeting. III - Program 2 AccuDOCUMENT ED Program REVIEW OF DOCUMENTATION ACCURACY in the Emergency Department and in the Acute Care Floor

16 Attachment A A) Step 1: AccuDOCUMENT ED I Empower Monthly Report of all Charts missing at least one of the ED RN notes type: Triage Note, Vitals prior to transfer, Transfer Note, and/or Discharge Note. Report name AccuDocument ED Triage Discharge or Transfer Notes Vitals10min MISSING prior to Disposition. II Empower Report to generate a list of patients seen in the ER stratified by the ESI category. Report name AccuDocument ED ESI Category. Random review of ten (10) charts from acute care floor and ten (10) from the ER a week. Surveyor will evaluate if patients are being evaluated as frequent as they should be according to their ESI level, and also if RN documented as frequently as they should according to their ESI level. Surveyor to complete the Cochise Regional Hospital Data Collection Form I. III Documentation of reassessment of the patient complaint and/or clinical status after the administration of IV meds. Random review of ten (10) charts from acute care floor and ten (10) from the ER a week. Surveyor will evaluate if patients are being reevaluated after a complaint is reported and/or after the administration of IV meds, and if appropriate documentation is done. Surveyor to complete the Cochise Regional Hospital Data Collection Form I. B) Step 2: AccuDOCUMENT AC I Empower to generate daily a list of patients in the AC stratified by the acuity category (Report: AccuDocument Acuity AC ). Random review of ten (10) charts from acute care floor and ten (10) from the ER a week. Surveyor will evaluate if patients are being evaluated as frequently as they should be according to their acuity level, and also if RN documented as frequent as they should according to their acuity level. Surveyor to complete the Cochise Regional Hospital Data Collection Form I. II Documentation of reassessment of the patient complaint and/or clinical status after the administration of IV meds. Random review of ten (10) charts from acute care floor and ten (10) from the ER a week. Surveyor will evaluate if patients are being reevaluated after a complaint is reported and/or after the administration of IV meds, and if appropriate documentation is done. Surveyor to complete the Cochise Regional Hospital Data Collection Form I. All 2 steps of the AccuDOCUMENT program to be presented in the monthly Quality meeting. IV - Program 3 AccuORDERS Program RN compliance with implementation of key Policies (Quality indicators review) A) Step 1: Wound Policy Quality indicators* Empower to generate a list of patients who were placed in the following order: Pressure Ulcer Prevention and Wound Care Treatment Guidelines. Name of the report: AccuOrders Wound Policy Quality Indicators. Surveyor to complete the Cochise Regional Hospital Data Collection Form I. Data such as Braden Scale completed and documented? Photography of wound with paper ruler obtained? RN clinical note matches Photography information? (ex: number of wounds, location) etc are followed.

17 Attachment A B) Step 2: Fall Precautions Policy Quality indicators* Empower to generate a list of patients who got the order for Fall Prevention & Risk Assessment Policy : Name of the report: AccuOrders Fall Precaution Policy Quality Indicators. Surveyor to complete the Cochise Regional Hospital Data Collection Form I. Data such as Fall Risk Assessment Form completed? If patient deemed high risk for falls (>34 on the fall assessment form), were the High-risk prevention interventions implemented? Etc are followed. C) Step 3: Restraints Policy Quality indicators Empower report of all charts of those patients that received an order for Restraints. Name of the report: AccuDocument-Restraint Quality Assurance Program. Surveyor to complete the Cochise Regional Hospital Data Collection Form I. Several quality indicators including the presence of a physician order for restraints are followed. D) Step 4: Insulin Sliding scale Quality indicators Empower to generate a list of patients who got the order for all different types of insulin sliding scale. Name of the report: AccuDocument Insulin Sliding Scale and Medication Administration QA Program. Surveyor to complete the Cochise Regional Hospital Data Collection Form I ensuring that an accurate insulin dose was given according to sliding scale ordered? E) Step 5: Wound, Fall, and Acuity Documentation RNs are supposed to complete a form every shift for Wound, Fall, and Acuity level documentation in the Acute Care floor. Empower will generate a report of all charts missing one of these forms/notes. Report Name: AccuOrders-Wound, Fall, Acuity Care Quality Indicators- Acute Care. All 4 steps of this program to be presented in the monthly Quality meeting. V - Program 4 MEDverify Cochise Regional Hospital has a twice a day (close to every 12 hours) remote medication verification system. Empower will generate a monthly report of verification timing in order to evaluate pharmacist compliance with the medication verification system. Name of the report: Pharmacist Medication Verification Log. The MEDverify program data will be presented in both Quality and Pharmacy & Therapeutics meetings. Clinical Safety and Medical Services Management I Program 5 SAFETY A) Adult transfers: Cochise Regional Hospital has a 24/7 Tele-Hospitalist coverage in order to access the appropriateness of all transfers and the clinical stability of the patients being transferred to higher level of care. Empower will generate a monthly report of all

18 Attachment A Tele-Med Transfer Review Note that will track all non-obgyne and non-peds transfers. Name of the report: AccuSafety Transfer Review. B) Pediatric/ObGyne transfers: Cochise Regional Hospital has a 24/7 Emergency room or Family Physician coverage in order to access the appropriateness of all transfers and the clinical stability of the pediatric and/or Obstetric-Gynecologic patients being transferred to higher level of care. Empower will generate a monthly report of all Tele-Med ObGyne Transfer Review Note and Tele-Med Pediatric Transfer Review Note. Name of the report: ObGyne & Peds AccuSafety Transfer Review. C) Global transfers: An additional report called Transfer to Az Hospitals for Medical Surgery Pediatrics and Pregnancy is a global compilation of all patients transferred. The reports Hospital Transfers to NON-Sierra Vista Hospital and Insurance and Hospital Transfers to Sierra Vista and Insurance allow the above mentioned transfer data to be stratified by destination and insurance status. The SAFETY program data will be presented in the Quality and Medical Staff meetings. II Program 6 CORE MEASURES-like reports CRH will follow and report Core Measures-like variables. The following reports will be generated by Empower every month: 1) "CHF Core Measures Report" 2) "Pneumonia Core Measures Report" 3) "VTE Prophylaxis Core Measures Report" 4) "ED Quality Indicators - Time" 5) "ED Quality Indicators Left without being seen" 6) "Vaccination Quality Report" The Program 6 data will be presented in the Quality and Medical Staff meetings. IV Program 7 Infection Surveillance Infection control staff at CRH will track the results of all Cultures performed in both the inpatient and outpatient settings including: Blood culture, Urine culture, Sputum culture, etc. Special attention to Multi Drug Resistant Organisms (MDRO) will be paid. When identified, results of the culture with the name of the MDRO will be placed under Past Medical History in the patient s chart in the Empower Medical Record for early identification in future admissions. Checking the antibiotics prescribed and matching it to the culture results will ensure appropriateness of treatment. An infection control form will be completed in all patient s charts with positive results. A monthly "Infection Surveillance Report" will be generated by Empower. The Program 7 data will be presented in the Quality and Medical Staff meetings.

19 Attachment A V - Program 8 Peer Review The Medical Staff Committee review professional practices performed within CRH facilities for the purpose of reducing morbidity and mortality and improving the quality of care delivered at CRH. The Medical Staff Committee performs the following reviews: 1) Review of Sentinel Events/Significant Adverse Events (CRH Quality, Risk & Safety.Attachment D). In the case of death, a CRH Mortality Review WorkSheet must be completed. 2) Case Review when requested triggered by staff members including the risk manager, patients, and/or family members: A) Variation from Rules (hospital medical staff policies & procedures, regulations and guidelines, etc); B) Reviews of performance including Quality of Medical Care, Medication Errors and Procedural Complications; Either the Chief of staff or the PCH Chief Medical Officer performs a review of the chart. The responsible health care practitioner is asked for input, and has until the following Medical Staff meeting to provide this input. The Medical Staff Committee reviews the peer reviewer s comments and those of the responsible health care provider, and assigns a corrective action to be taken if applicable according to Cochise Regional Hospital Bylaws. If a response is not received, the Medical Staff Committee considers the case a case without a response and a corrective action may to be taken unilaterally. Peer review case will be considered closed if the answer provided by the responsible health care provider is deemed to be satisfactory. A) Further Review and Evaluation of a physician s clinical performance will proceed in accordance with Medical Staff Bylaws, Article VII. B) Confidentiality Peer review documents are confidential. Requests for peer review are delivered in sealed envelopes. Each request for peer review states that the documents may not be shared with any other individual. Completed reviews are collected. Agendas for the Medical Staff Committee meetings are numbered and hand delivered to those members who have indicated they will be attending the meeting. Agendas are collected following the meeting. Anyone unable to attend a meeting for which they have received an agenda must return his/her agenda or call to have it collected. Members of the Medical Staff Committee are made aware of the importance of not discussing these cases with others. Peer review files are secured within the Risk Management Department. All System Issues from Sentinel Events, Sentinel Event Alerts, Serious Adverse Events, and Case Review Events are forwarded to the CRH Board of Directors. 3) Random Charts audits A CRH surveyor will perform a random audit of ten (10) charts a month to evaluate compliance with an acceptable Discharge Summary/Plan (CRH Random Chart Audit Discharge Data form). A report of the charts audit is presented at every Quality Committee Meeting, and is referred to the Medical Staff Committee accordingly. The Program 8 data will be presented in the Quality and Medical Staff meetings.

20 Attachment A VI - Program 9 HCAHPS The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey will allow CRH to collect and report patient satisfaction data on a standardized way. Obviously, the public reporting of this information will enable valid comparisons to be made across all hospitals of similar characteristics to support consumer choice. However, more importantly, the availability of this data will guide CRH to achieve higher levels of consumer satisfaction. The HCAPHS program will start under the National Research Corporation on January 1, The Program 9 data will be presented in the Quality and Medical Staff meetings. Other Services Quality Indicators I Respiratory Quality Indicators A. EKG timing from order to execution Empower generated Report called "Respiratory EKG timing" will provide the time from order to execution for all EKGs performed at CRH. Moreover, a global average of the above data will be available as well. B. ABG after minutes from the time patient was placed on ventilator support (Bipap/CPAP/Mechanical ventilator) Empower generated Report called "Respiratory Ventilatory Support" will compile all the patients that received an order for CPAP/BIPAP/MECHANICAL VENTILATION. A chart review will be done to ensure ABG time frame was achieved. C. Nursing staff should document ventilator support details (Bipap/CPAP/Mechanical ventilator). Empower generated Report called "Respiratory Ventilatory Support" will compile all the patients that received an order for CPAP/BIPAP/MECHANICAL VENTILATION. A chart review will be done to ensure documentation through one of the applicable nursing forms was done: Respiratory BIPAP/CPAP Management Respiratory Ventilator Management II - PT/OT Quality Indicators Empower generated Report called "PT/OT Quality Indicators" will compile all the patients that received an order for Physical Therapy and/or Occupational Therapy Consult. A chart review will be done to ensure that the following documentation was done: A. Vitals (Blood Pressure, Pulse & O2 saturation) to be documented in the beginning and at the end of every treatment session (to assess cardiovascular response to exercise) therapist will need to record both sets of data in the Daily Note.

21 Attachment A B. Therapist to perform a Fall Risk Assessment for all Physical Therapy patients in the inpatient setting. Therapist to complete the Fall Risk Assessment Form Nursing contained in the Empower systems at initial evaluation, and at discharge. III Laboratory Quality Indicators A. Turnaround Times (STAT and Routine) for CMP B. Turnaround Times (STAT and Routine) for Cardiac Profile C. Turnaround Times (STAT and Routine) for CBC D. Turnaround Times (STAT and Routine) for PTT E. Turnaround Times (STAT and Routine) for PT Targets are STAT within 1 hour and Routine within 3 hours. Empower generated Report called "Laboratory Turn around time" will provide above data. IV Radiology Quality indicators A. Radiology Technician X-ray, CT scans, and Ultrasounds Turnaround Time Under the radiology workflow checklist, the radiology technicians are supposed to document among other variables, the Exam Start and End times. The average turn around time will be calculated for every category, and presented at the Quality Meeting. B. Number of Repeats on X-ray Films The number of repeats on X-ray tests will be obtained from CRH s X-ray Processor log ( Reject Log ) monthly. C. Final Report Turnaround times for general and STAT/ER exams EmpowerPACS will generate monthly reports of radiology turn around times (time lapsed between time the films left CRH, and the time report is received by Empower systems). Data for all radiology categories including but not limited to X-ray, CT scans, and Ultrasounds will be reported. V - Dietary: What indicators A. Patient Satisfaction Surveys Target 95% The dietary supervisor applies a patient survey in order to assure quality food service and improve it. The Patient Satisfaction Survey Policy is followed to conduct at least one interview per week (depending on CRH census). The information collected is obtained directly from the patient and/or relative, and it is compiled in the form of percentage average, which is presented to the Quality Committee. B. Inspection of Meal Trays Target 100%

22 Attachment A The dietary supervisor performs 3 meal inspections per month by following the Meal Tray Inspection Policy. The dietary supervisor must ensure trays proceed safely and efficiently. In every inspection, the tray presentation is rated by checking if the appearance is pleasant to the patient, if the temperature is proper when the food is served, and if there are appropriate garnishment in all meals. Proper sanitation, proper portions, and accuracy with the diet card are also followed. The diet card must be correlated with physician recommendations. C. Freezer/Refrigerator Temperature Logs Target 100% Temperature logs are presented in the applicable of the kitchen. For the Walk-in-Fridge & Freezer, the temperature is taken at the time of opening and closing of the kitchen. Freeze: proper temperature (0 to 10 ). Walk-in Fridge/Refrigerators: Proper temperature (35 to 41 ). The temperature in the snack refrigerators in both the acute care and in the emergency department is collected daily. The Other Services Quality Indicators data will be presented in the Quality and Medical Staff meetings. Utilization Quality Indicators The Empower systems will generate monthly a report called "Utilization Report" with the following quality indicators: A) Revisit to the Emergency Department within 72 hours B) Readmission to the Acute Care floor within 30 days after an inpatient admission C) Number of patients transferred to Higher Level of Care after admission to the Acute Care floor. The Utilization Quality Indicators data will be presented in the Quality and Medical Staff meetings. Environment of Care Quality Indicators I - SAFETY REPORT & SAFETY OFFICER REPORT A) Safety Report: Maintenance monthly report to Quality/Risk/Safety Committee of the following topics: Fire Extinguisher monthly check; Monthly Emergency Lights monthly check; Exit Signs monthly check; Fire Sprinkler Maintenance for Wet Systems monthly ; Emergency Generator weekly check; Isolated Electrical Panel in Surgery monthly check quarterly report on Fire Drills quarterly test of Negative Pressure Room; quarterly Sprinkler Inspection; bi-annually Kitchen Hood Inspection; annual Generator Inspection; annual Backflow Test; and annual Riser check. B) Safety Officer Report Utility Systems - incident reports, inspection, testing, and maintenance activities related to critical components of utility systems - Heating, Ventilation & Air Conditioning, Medical Gas System, Medical/Surgical Vacuum Systems, Electrical Safety, and Radiation Safety. Hazardous Material/Medical Waste Management Plan Handling Requirements - Identification and labeling; Handling techniques and precautions; Emergency procedures; and Disposal. Life Safety -Inspection, Testing, and