Accreditation, Risk Management & Patient Safety Report

Transcription

1 MAY 2018 Accreditation, Risk Management & Patient Safety Report QPSC Smith, Adrian, Director ALAMEDA HEALTH SYSTEM

2 April 26, 2018 Accreditation Summary System Wide Joint Commission Accreditation We have Received our Accreditation Status Letter and Certificates Joint Commission were onsite for a two day Validation Survey to follow up on last years full Accreditation Survey. There were two surveyors, a Registered Nurse / Administrator and a Life Safety Specialist. The RN Surveyor was focused on the clinical and administrative part of the survey and found no deficiencies! She commented upon how this reflected the hard work and dedication that staff and leadership displayed. She gave feedback on the following items; OPPE - she described this as a sophisticated an outstanding example of the process Tissue Program in Ambulatory - She described this as a very rigorous process, that although labor intensive was a huge improvement for us. C-SSRS - she observed that we were going above and beyond with this and again that this was a dramatic improvement, she did recommend that we review the process but only to reduce redundancy. Human Resources - sole source verification was exemplary - her only comment was that our process is labor intensive, but effective. The Life Safety Surveyor reviewed the Environment of Care and Life Safety chapters, most of the deficiencies noted on our previous survey were cleared. In this area we did receive three repeat deficiencies and two new deficiencies. We have opportunities in the following areas at Highland; REPEAT minor issues with Electrical Panels that were corrected during the survey REPEAT Penetrations in the floor of a Telecom Closet that were not appropriately caulked, this was corrected during the survey NEW Use of multi plug strips in the OR NEW Missing Ceiling Tile in an Electrical Closet this was corrected during the survey and the following opportunity at John George; REPEAT Ligature Risks in the physical environment The Ligature Risks at JGPH would under normal circumstances be cited at Conditional status, however the surveyors felt that the amount of work that had been done already to correct the originally cited risks, the rigorous and well documented risk assessments of the areas and the plan that is in place to both mitigate these risks and correct them. Robert was impressed by the thorough nature of our risk assessment and none of his observations had not already been identified by us led them to downgrade the citation to a standard finding. At the time of drafting this report AHS is waiting for the final report to be reviewed by the Central Office at The Joint Commission, and there is a risk of the Ligature Risk finding being changed to a Conditional finding. A verbal update will be provided at the meeting

3 State and Federal Regulatory Issues Accreditation, Risk Regulatory Visits Since the last meeting we have received a further 7 visits, with a total of 41 visits from CDPH/CMS to date this Calendar Year. Many have resulted in no deficiencies 23 were found to have no deficiencies 11 we expect, or have received 2567 (statement of deficiency) 7 are still open cases CMS Visit for Elopement at JGPH On receipt of the findings from CDPH the CMS office reviewed the findings and added some additional findings to the CMS 2567 (Statement of Deficiencies) from the Conditions of Participation; Governing Body This kind of finding is typically issued when an Immediate Jeopardy is observed, and is focused on having leadership oversight of the corrective actions Quality And Performance Improvement (QAPI) CMS took the two elopements that occurred at John George recently into account and have set an expectation for AHS to have corrective actions implemented in a systemic fashion CMS Re-Validation Visit for Elopement at JGPH (May 16-17, 2018) CMS has found that in response to the Focused Survey Revisit, John George, Highland and Fairmont are in substantial compliance. No deficiencies will be sited in the 2567 we receive form CMS.

4 Risk Management Summary ACUTE SBU Dashboard through March 2018 SYSTEM DATA Overall reporting volumes are stable. The median days to close have decreased dramatically, and is nearly at target of 10 days. The primary risks in the last three reporting months are Medication Events, Test/Treatment (Clinical) issues and Staff/Provider Clinical Practice/Behavior, consistent with prior months reports. The incidence of harm is low. The volume of Patient Complaints and Grievances is stable, Patient Relations event reported, also consistent with prior reports. Trend

5 ALAMEDA HOSPITAL The only deviation from the system trends and analysis is that Safety & Security is the third most prevalent type, this is consistent with prior reports. Alameda Hospital also has a very high volume of events reported as a Near Miss or Good Catch HIGHLAND HOSPITAL The only deviation from the system trends and analysis is that Patient Behavior is the third most prevalent type, this is consistent with from prior reports

6 SAN LEANDRO HOSPITAL San Leandro does not have Medication Events as one of the top three, but instead has Treatment/Test (Clinical), Safety and Security and Skin issues, this is consistent with prior reports. San Leandro Hospital s largest volume of reports fall into the Near Miss or Good Catch significance.