TOPIC DISCUSSION ACTION Sue Currin and Todd May chaired the meeting. Agenda for today s meeting was presented for review.

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1 Attendance: Excused: Guest(s): Quality Council Minutes November 20, 2012 Sue Currin, Kathy Jung, Rachel Kagan, Tina Lee, Todd May, Anson Moon, Iman Nazeeri-Simmons, Sue Schwartz, Shannon Thyne, Sharon Wicher, Lann Wilder, Troy Williams, David Woods Sue Carlisle, Morgen Elizabethchild, Doug Eckman, Tom Holton, William Huen, Valerie Inouye, Shermineh Jafarieh, Jay Kloo, Elaine Lee, Roland Pickens, Cathryn Thurow Chris Barton, Kerin Bashaw, Akilah Cadet, Jeff Critchfield, Terry Dentoni, Kathryn Fowler, Brandi Frazier, Sarah Garden, Brad Hare, Franco Herrera, Diane Jones, Cheryl Kalson, Jasmeen Karan, Laure Marshall, Mary Mercer, Jessica Morton, Michael Pfeffer, Neil Ponferrada, David Staconis TOPIC DISCUSSION ACTION ADMINISTRATIVE Sue Currin and Todd May chaired the meeting. Agenda for today s meeting was presented for review. Agenda reviewed. POLICIES AND PROCEDURES The Minutes of the October 2012 meeting were presented for approval. The following P&Ps were presented by Cheryl Kalson: Policy Cytotoxic Agents: Authority for Clinical Oversight Changes to Appendix C and D Policy Cytotoxic Agents: Competency and Performance Improvement Minor changes to policy Policy Cytotoxic Agents: Ordering Cytotoxic Therapies Approved list of oncology providers will be maintained in IVAC. For non-hematologic/oncologic services w/o a P&T-approved protocol, the chemotherapy order must now be co-signed by a Hematology/Oncology attending physician. Oral continuous multi-day cytotoxic therapy may be written on one chemo order form. Policy Cytotoxic Agents: Order Transcription and Verification As oral cytotoxic are high-alert meds, policy now includes statement that dose requires 2 independent RN double-checks prior to administration, consistent with Nursing Policy and Procedure Policy Cytotoxic Agents: Preparation, delivery, disposal, and spill management Minor changes Minutes approved. All policies approved. Policy Cytotoxic Agents: Areas of Administration Changes to appendices, including a new appendix D: Extravasation Management. Also, if cytotoxic 1

2 therapy is administered outside of a designated clinical area, approval will now be obtained from the unit charge nurse and the 5A charge nurse to ensure an ONS-trained nurse is available Policy Cytotoxic Agents: Guidelines for Administration More specific directions for peritoneal and oral chemo added. Re oral chemo, since more oral meds are in use, policy updated to more clearly delineate how these are handled. Policy Cytotoxic Agents: Extravasation Management Minor changes Policy : Messenger Services Center No changes Policy : Procedures for Discharge/Readmission of Patients changing level or type of care Major changes to discharges from Psych to Med/Surg regarding the process delineation between Med/Surg and Psych PERFORMANCE MEASURES: EMERGENCY DEPARTMENT Mary Mercer presented the Emergency Department performance measures: Procedural Sedation AIM: Maintain compliance with the performance of a time out and a consent being obtained for both sedation and procedure at 100% through December 31, Consent is measured through chart audits using a Sedation Audit Tool. During 2012, compliance has been maintained at 100%, attributed to features in the EDIS system which allows easy documentation of procedural sedation components. Controlled Substance Override Maintain decreased irreconcilable controlled substance override transactions through This has decreased significantly since 2010, to below 5 instances per month in Pharmacy and nursing are working together to constantly improve process. One-on-one education and follow up med-pass audits are required after each discrepancy. Sepsis AIMS: To maintain screening compliance above 95% for all eligible patients To Increase and maintain lactate draw at 95% by December 2012 To increase bundle compliance to 40% or above by December 2012 Will continue the aim of 100% compliance with procedural sedation consents. Plan for 2013 to build out ED/Pharmacy electronic interface. Plan to increase ED Pharmacist coverage to 24/7 2

3 The bundle compliance has doubled in the last year, from 22% (Nov 2011) to 45% (Sept 2012), and the sepsis mortality rate has decreased from 25% (Jan 2012) to 7.4% (Sept 2012) Initiatives have included: Hospital-wide education and awareness campaign including pocket cards for providers. Individual patient chart reviews with provider follow-up regarding goals and recommendations ED-based education with chart reviews and global recommendation updates to physicians, residents and staff Focus over the year has shifted from fluid bolus ordering, timely antibiotics and lactate administration to increasing the sepsis bundle compliance which includes these three former elements. The Sepsis team will develop a sepsis order set to trigger fluid and antibiotic administration. Additional Aims added for 2013 to improve compliance of: Appropriate antibiotics Fluid Delivery Overall bundle compliance at 75% ED Flow AIMS To reduce ED length of stay (LOS) for admitted patients to <8 hours by December 31, To reduce ED LOS for non-admitted patients to <4 hours by December 31, To decrease 2012 average Left Without Being Seen (LWBS) and Left Without Being Triaged (LWBT) rate to <8% by December Length of Stay (LOS) has decreased steadily over this past year for both admitted and non-admitted patients, due to focused initiatives to reduce LOS in the ED. LOS is consistently under 10 hours for admitted patients since February 2012 and consistently under 5 hours for non-admitted patients. There has not been an increase in ED encounters as a result yet. Initiatives to address flow include: -ED providers (including residents) will be given more information semi-annually on their own performance in reducing patient LOS. -Rapid Rooming/Triage pilot in June 2012 no change in LOS or LWBS, however the pilot identified better triage processes to more efficiently medically screen patients and provided a rationale for staffing a third RN at Triage. -Flow data is incorporated into ED dashboard -Consultant policies changed with lowered timeframes for responding to consult requests. -A Consult tracking pilot program started fall Point of Care urine pregnancy testing initiated in ED Flow metrics will be tracked related to the new Clinical Decision Unit opening in late November. Service Excellence AIMS: Align patient and staff experience initiatives in ED to hospital-wide initiatives -According to HCAHPS Patient Satisfaction results, as of Q1 2012, 42% of patients felt their ED care was organized and 49% of patients felt they d received enough information about their condition 3

4 and treatment (both of these results are above the UHC average) -ED Service Excellence Committee was formed, comprised of physicians, nurses, MEAs and residents. The committee translated Monthly Standards around three modalities of staff behavior: Situational awareness, acknowledge waits, acknowledge others. These standards are disseminated through resident newsletter, faculty meetings and at twice daily talking points - Staff Experience Staff Satisfaction Survey administered bi-annually to nurses. Service Excellence committee is going to track 7 most meaningful results and focus improvement efforts there. Some of these areas are: opportunities to learn and grow, work expectations, recognition and praise, learning opportunities, alignment to the hospital s Strategic Plan. Through this committee s work the ED hopes to increase HCAHPS patient satisfaction scores to 60% by July 2014 Physician training on Service Excellence scheduled for March Violence in the ED AIM: To improve staff and patient safety in all areas of the ED and to lower incidences of violent or threatening behavior throughout the ED -In Q3 2012, there were 26 reported incidents of aggressive behavior in the ED, 17 of which were in Zone 1. The following actions are being taken to address this spike in incidents: Improved partnership with PES physicians regarding consultation times and holds Incorporation of situational awareness into service excellence plans Regular communication with physician and nursing staff about early medication and deescalation techniques Continued collaboration and communication between ED staff, ED RN/MD Leadership and SFSD Leadership. Quality Council members requested that ED leadership involve the hospital s Violence Prevention Task Force to assist with addressing this issue. PERFORMANCE MEASURES: MED/SURG NURSING Franco Herrera presented on Med/Surg Nursing performance measures: Falls Aim: Decrease falls and falls related injury rates by 10% by December Unintentional adult patient falls on medical and surgical units, calculated from Unusual Occurrence and census data have seen a 22% sustained reduction observed in 2011-YTD in comparison to PCA surveillance and assistance to patients deemed at high risk -New clinical lead (Sasha Cuttler) assigned for falls initiative in June Quality Council requested more specific falls prevention data: In the future: Test and implement chair alarms. Use standardized dashboard for Falls across MS units. Falls task force to focus efforts on units that have higher incidence of falls, and repeat fallers. Additional data will be compiled. 4

5 Track falls by age and type of patient How many falls occur when patients are under observation? For observed patients who fell: Falls Assessment Post Fall Review UO investigation Hospital Acquired Pressure Ulcers (HAPUs) FY : total of 17 HAPUs were reported to the State. Med Surg FY goal is to reduce reportable HAPUs by 50% or 8 total. Increased incidence of reportable HAPUs may be due in part to increased recognition with more intensive surveillance by new CNS. HAPU prevention includes: Daily rounding to identify at risk patients and community acquired pressure ulcers by CNS Leading team of wound-certified staff RNs who champion new initiatives, assist with data collection, and serve as unit resources 2 full-day continuing education classes in wound care and HAPU prevention for staff New skin care products introduced Follow up: Improve accuracy of RN skin assessment and documentation of SKIN bundle (Surface, Keep Moving, Improve Moisture Mgt, Nutrition & Fluids) through education and immediate feedback. Continue effort to standardized approach to wound care between services. Increase collaboration with surgical services and OR for HAPU prevention. Capitalize on learnings from NAPH collaborative and from Laguna Honda Hospital and Health-at-Home wound care. In future reports, include status of HAPUs at discharge Patient Experience AIM: Improve the following HCAHPS Composites by 15% by Dec 2013: Communication about medicine (to 69%) Room quiet at night (to 46%) Med/Surg top box patient experience results in Q2 and Q3 2012: Communication about medicine positive score has decreased from 68% to 48%, and Quiet Room at night positive score has decreased from 40% to 37% -Med Surg Annual Update emphasized the need to explain the term side effect during medication teachings at the bedside. Continue to coordinate efforts with the Service Excellence Committee. 5

6 Standardized medication Information sheet available on computer workstations, including most common medications and their side effects, as well as a list of hospital-approved resources on medications and side effects. -Unit 4D s SILENT campaign (Shhhh in the hallway, It's nighttime, Low TV volume, Earplugs can be offered, No loud voices, Turn down nursing station phone ringers) to reduce noise at night is currently being rolled out to other MS units. PERFORMANCE MEASURES: POSITIVE HEALTH PROGRAM Diane Jones and Brad Hare presented on primary care s Positive Health Program: Antiretroviral treatment (ART) AIM: To have 80% of treatment patients in clinic on antiretroviral therapy with at least 75% with an undetectable viral load. -In the last year, ARVs were prescribed to 91.7% and 82.4% of those have undetectable viral loads. This is significant rate of virologic suppression considering the mental health, housing and substance use challenges as well as the heavy prior ARV treatment of the PHP patient population in general. -The percentage of patients on antiretroviral therapy (ARTs) increased from 80.7% (Dec 2009) to 90.2% (June 2012). The increases in the total percentage of patients with undetectable viral loads also increased from 79.1% (Dec 2009) to 82.3% (June 2012), though not as dramatic. - Initiation of ART now includes inpatients, not just outpatients, thanks to collaborative efforts with SFGH s Social Work team. Success in this initiative can be attributed to multiple factors: Integration of patient care into HIV research Consistent messaging of treatment goals by all members of a multi-disciplinary team including front desk, pharmacy and providers. A 2010 policy promoting ARV therapy for all patients Community support and buy-in Establishment of the FAST team, providing inpatient to outpatient linkage. Cervical Cancer Screening AIM: Increase percentage of annual Cervical Pap Screenings by at least 10% (5% January-June and 5% July-December) in women receiving funding/services from the Ryan White part D program. -In 2009 PHP s cervical cancer screening rates for were 49%. This prompted a QI initiative to increase the cervical cancer screening rates among Ward 86 patients. One of the objectives was to increase screening rates among a specific cohort of women. The objective for this cohort is to increase percentage of annual Cervical Pap Screenings by at least 10% (5% January-June and 5% July- December). - As a result of PHP s continued effort with regard to women s health, among PHP women Quality Council commended PHP on outstanding work on ART, suggesting that they could serve as a model for other chronic disease management. Currently PHP staff participate on multiple DPH committees to offer input and spread expertise. - In the future, PHP will continue to focus education efforts regarding the importance of cervical pap smears to ALL female patients seen on Ward 86 particularly those that are not regularly seen during Women s Clinic 6

7 participants in the SF Health Plan, 76.6% received the recommended cervical cancer screening last year. This is at the 90 th percentile among Medicaid programs nationally.. UPDATE: JUST CULTURE Jeff Critchfield gave an update on the Fair and Just Culture program: An overview of Fair and Just culture has been presented to over 650 staff throughout SFGH. Jeff reviewed key questions from the AHRQ Culture of Safety Survey results for 2012 that reflected an increase over 2011 results in positive responses to questions about staff comfort with reporting errors. Moving forward, the program will focus on: Expanding introduction work to new settings like SFGH Environmental services, community clinics, and Laguna Honda Hospital. Work with Human Resources to align policies with Fair and Just Culture Principles Establish a deeper dive curriculum for leaders to apply these principles ( Spring 2013) UPDATE: PATIENT EXPERIENCE DATA UPDATE: INTEGRATED DELIVERY SYSTEM (IDS) QUALITY MEASURES Sue Schwartz gave an update on inpatient (HCAHPS) and outpatient (CG-CAHPS) patient experience data results: Results: Overall rating HCAHPS and CG-CAHPS scores have decreased over Overall scores are based on positive patient responses about their general experience at the hospital or in rating their outpatient provider. Responses most highly correlated with these general experience scores are communication with nurses and being treated with respect by both doctors and physicians. Regular reporting of patient survey data is available to all managers through QM staff or direct access from the NRC Picker website. Sue Schwartz presented the proposed set of common quality measures from the IDS Quality & Utilization Implementation Group: Clinical Quality measures: diabetes management, smoking cessation, asthma, hypertension, recorded BMI. -suggested add to clinical quality measures: treatment of patients with high BMI, cancer screening, up to date medication list. Next steps: Review of patient experience data by Service Excellence Committee. Develop and publish patient experience dashboard. Increase inpatient sample size (completed) Sue will schedule Tomas Aragon and the IDS Quality & Utilization Implementation workgroup chairs to Quality Council in January 2013 for additional discussion. 7

8 Efficiency measures: time to clinic appointment, time to Laguna Honda bed for SFGH patients, time to placement in community from Laguna Honda - suggested add to efficiency measures: cost of keeping patients at the inappropriate level of care Patient Experience measures: overall rating of care, satisfaction with communication, patients treated with respect Staff Experience measures: Gallup 12 with crosswalk to Laguna Honda Staff Survey These measures will be finalized and customized as applicable to each program, and their feasibility will be tested. Council members requested more discussion about selecting appropriate DPH wide quality and utilization measures. ANNOUCEMENTS NEXT MEETING No Announcements December 18, 2012, 10am to Noon, 2A6 8