Present: Chairman Ada Mary Gugenheim and Directors Mary Driscoll, RN, MPH and Layla P. Suleiman Gonzalez, PhD, JD (3)

Transcription

1 Minutes of the meeting of the Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System held Friday, February 17, 2017 at the hour of 10:00 A.M. at 1900 W. Polk Street, in the Second Floor Conference Room, Chicago, Illinois. I. Attendance/Call to Order Chairman Gugenheim called the meeting to order. Present: Chairman Ada Mary Gugenheim and Directors Mary Driscoll, RN, MPH and Layla P. Suleiman Gonzalez, PhD, JD (3) Absent: None (0) Board Chairman Hammock (ex-officio) and Directors Emilie N. Junge and Mary B. Richardson-Lowry Patrick T. Driscoll, Jr. (non-director Member) Additional attendees and/or presenters were: Claudia Fegan, MD Executive Medical Director/Medical Director-Stroger Jeff McCutchan Interim General Counsel Deborah Santana Secretary to the Board John Jay Shannon, MD Chief Executive Officer Agnes Therady Executive Director of Nursing Ozuru Ukoha, MD John H. Stroger, Jr. Hospital of Cook County II. Public Speakers Chairman Gugenheim asked the Secretary to call upon the registered public speakers. The Secretary responded that there were none present. III. Report from Chief Quality Officer A. Regulatory and Accreditation Updates B. Metrics (Attachment #1) Dr. John Jay Shannon, Chief Executive Officer, presented the metrics for the Committee s information. He provided information on some upcoming topics that will be addressed. There will be an update on the status of the operating room process improvements. In March or April, an updated presentation will be provided on the specific HEDIS measures, as a part of requirements by the State, and in particular around Ambulatory Services. Additionally, he will discuss the possibility with staff of doing an analysis on emergency room visits sometime in the upcoming months. Dr. Shannon stated that three representatives of HPI were present - Tammy Strong, Rob Douglas and David Varnes. HPI is a subsidiary of Press Ganey. They have been engaged to work with the organization specifically around safety and reliability. They will be starting that process with a review of safety events, safety reporting and culture of safety in the organization. Concurrent with that, they will be doing a detailed qualitative assessment, and speaking with operational leaders and clinicians across the System. They will then come to an assessment that will ultimately lead to a prescription, if you will, for how the organization can improve. At least part of that prescription will include two (2) tiers of training - one (1) tier will be focused on managers and clinical leaders (approximately individuals) on reliable processes in healthcare, and the secondary part of training will include training-the-trainers, so the System will ultimately have all of its employees exposed to the principles of highly reliable processes in healthcare. In particular, he is looking forward to the end of the first phase; he noted that an analysis of their findings will be shared with the Board. Page 1 of 50

2 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, February 17, 2017 Page 2 IV. Report/Informational Item A. Report on Nursing (Attachment #2) Agnes Therady, Executive Director of Nursing, reviewed the Report on Nursing, which included information on the following subjects: Impact 2020: Nursing s Role in the Strategic Plan and Major Nursing Strategies National Database of Nursing Quality Indicators (NDNQI) - Nurse Sensitive Measures in NDNQI - NDNQI Timeline at CCHHS - Partnership with Business Intelligence Registered Nurse (RN) Education Indicators Third Quarter CY2016 Patient Experience Nurse-Sensitive Clinical Indicators Third Quarter CY2016 The Committee discussed the information on slide 5, regarding the grant-related partnership with Morton College and Loyola University to increase diversity in the workforce by implementing a multi-component training program that will create a pipeline of Hispanic/Latino nurses. Director Suleiman Gonzalez stated that there are also high schools in the community that concentrate on medical professions; depending on how the conversation continues, she would be happy to broker that conversation, so potentially a pipeline can be created from the high school to the college or university. Chairman Gugenheim recommended that the administration pursue potential opportunities of private sector funding for this purpose, as well. Director Richardson-Lowry inquired regarding the academy; she asked whether certification/affiliation is involved - a linkage to Loyola, for example, where the nurses can walk away with some additional benefits for learning opportunities. Ms. Therady responded that the administration has applied for continuing education units through the Ohio State Nurses Association. With regard to the NDNQI, Board Chairman Hammock inquired regarding the comparison groups; when comparing academic institutions, is it known which hospitals are in that group? Ms. Therady responded that she will follow-up on that question and see if that data is available. Board Chairman Hammock stated that, later in the year, it would be helpful if the Committee receives a similar presentation on nurse-sensitive clinical indicators after the Clairvia database, which went live in November 2016, has stabilized. V. Action Items A. Approve reappointments of Stroger Hospital Department Chair(s) and Division Chair(s) (Attachment #3) Dr. Claudia Fegan, Executive Medical Director/Medical Director-Stroger, presented the Stroger Hospital Division Chair reappointment for the Committee s consideration. Director Suleiman Gonzalez, seconded by Director Driscoll, moved to approve the proposed Stroger Hospital Division Chair reappointment. THE MOTION CARRIED UNANIMOUSLY. Page 2 of 50

3 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, February 17, 2017 Page 3 V. Action Items (continued) B. Executive Medical Staff (EMS) Committees of Provident Hospital of Cook County and John H. Stroger, Jr. Hospital of Cook County i. Receive reports from EMS Presidents Dr. Ozuru Ukoha, President of the EMS of Stroger Hospital, presented his report. He stated that this is his last time reporting to this Committee as EMS President; his term is ending and a new President, Dr. Trevor Lewis, has been elected. The Committee thanked Dr. Ukoha for his efforts and hard work in serving as President of the EMS for two (2) terms. ii. Approve Medical Staff Appointments/Re-appointments/Changes (Attachment #4) Director Suleiman Gonzalez, seconded by Director Driscoll, moved to approve the Medical Staff Appointments/Re-appointments/Changes for John H. Stroger, Jr. Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the Medical Staff Appointments/Re-appointments/Changes for Provident Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. C. Minutes of the Quality and Patient Safety Committee Meeting, January 20, 2017 Director Driscoll, seconded by Director Suleiman Gonzalez, moved to accept the Minutes of the Quality and Patient Safety Committee Meeting of January 20, THE MOTION CARRIED UNANIMOUSLY. D. Any items listed under Sections V and VI VI. Closed Meeting Items A. Medical Staff Appointments/Re-appointments/Changes B. Litigation Matter(s) Director Driscoll, seconded by Director Suleiman Gonzalez, moved to recess the open meeting and convene into a closed meeting, pursuant to the following exceptions to the Illinois Open Meetings Act: 5 ILCS 120/2(c)(1), regarding the appointment, employment, compensation, discipline, performance, or dismissal of specific employees of the public body or legal counsel for the public body, including hearing testimony on a complaint lodged against an employee of the public body or against legal counsel for the public body to determine its validity, 5 ILCS 120/2(c)(11), regarding litigation, when an action against, affecting or on behalf of the particular body has been filed and is pending before a court or administrative tribunal, or when the public body finds that an action is probable or imminent, in which case the basis for the finding shall be recorded and entered into the minutes of the closed meeting, and 5 ILCS 120/2(c)(17), regarding the recruitment, credentialing, discipline or formal peer review of physicians or other health care Page 3 of 50

4 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, February 17, 2017 Page 4 VI. Closed Meeting Items (continued) professionals, or for the discussion of matters protected under the federal Patient Safety and Quality Improvement Act of 2005, and the regulations promulgated thereunder, including 42 C.F.R. Part 3 (73 FR 70732), or the federal Health Insurance Portability and Accountability Act of 1996, and the regulations promulgated thereunder, including 45 C.F.R. Parts 160, 162, and 164, by a hospital, or other institution providing medical care, that is operated by the public body. On the motion to recess the open meeting and convene into a closed meeting, a roll call was taken, the votes of yeas and nays being as follows: Yeas: Chairman Gugenheim and Directors Driscoll and Suleiman Gonzalez (3) Nays: None (0) Absent: None (0) THE MOTION CARRIED UNANIMOUSLY and the Committee recessed into a closed meeting. Chairman Gugenheim declared that the closed meeting was adjourned. The Committee reconvened into the open meeting. VII. Adjourn As the agenda was exhausted, Chairman Gugenheim declared the meeting ADJOURNED. Respectfully submitted, Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System XXXXXXXXXXXXXXXXXXXXXX Ada Mary Gugenheim, Chairman Attest: XXXXXXXXXXXXXXXXXXXXXX Deborah Santana, Secretary Page 4 of 50

5 Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting February 17, 2017 ATTACHMENT #1 Page 5 of 50

6 COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Dashboard Overview 17 February 2017 Krishna Das, MD, Chief Quality Officer 1 Page 6 of 50 CCHHS Board QPS Committee

7 Quality Stroger Page 7 of 50 2 CCHHS Board QPS Committee

8 Quality Provident Page 8 of 50 3 CCHHS Board QPS Committee

9 Safety Stroger Page 9 of 50 4 CCHHS Board QPS Committee

10 Patient Experience Stroger Page 10 of 50 5 CCHHS Board QPS Committee

11 Patient Experience Provident Page 11 of 50 6 CCHHS Board QPS Committee

12 ACHN Page 12 of 50 7 CCHHS Board QPS Committee

13 Board Quality Dashboard Page 13 of 50 8 CCHHS Board QPS Committee

14 Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting February 17, 2017 ATTACHMENT #2 Page 14 of 50

15 COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Nursing Quality Report Agnes Therady, RN Executive Director of Nursing February 17, 2017 Page 15 of 50

16 Impact 2020: Nursing s Role in the Strategic Plan. Nursing... 2 Page 16 of 50 Nursing QPS Presentation

17 Impact 2020: Major Nursing Strategies Pursue Magnet status Develop a system-wide professional practice model Leverage information technology initiatives Pursue academic partnerships with colleges of nursing Establish nursing leadership academy for managers Participate in the National Database of Nursing Quality Indicators (NDNQI) for quality national benchmarks 3 Page 17 of 50 Nursing QPS Presentation

18 . IMPACT 2020 Tactic: Pursue Magnet Status and adopt standard metrics. Develop a System-wide professional practice model for the delivery of high-quality, safe, patient-centered, evidence-based nursing care. Leverage information technology initiatives such as Clairvia Progress to date: Adopted NDNQI measures reported two quarters of data (Qtr 3 and Qtr 4, 2016) Literature search and benchmarking of Professional Practice Models; Results presented to Nursing Executive Team Clairviawent live on November 14, Now creating reports 4 Page 18 of 50 Nursing QPS Presentation

19 IMPACT 2020 Tactic: Pursue academic partnership with one college of nursing to foster and grow nursing research at CCHHS Progress to date: Meeting with Deans of nursing colleges on February 22, 2017 to create new expectations for our academic affiliations and to foster unique relationships to better meet the evidence based practice needs of CCHHS Partnership with Morton College and Loyola University to increase diversity in the workforce by implementing a multi-component training program that will create a pipeline of Hispanic/Latino nurses 5 Page 19 of 50 Nursing QPS Presentation

20 IMPACT Tactic: Benchmark nurse-driven quality indicators to regional and national standards Invest in continuous learning and development including training around domain specific best practices for management Progress to date: Adopted NDNQI measures reported two quarters of data (Qtr 3 and Qtr 4, 2016); Creating unitbased scorecards and action plans Completed 50% of nursing leadership academy curriculum. Slated for completion by October Page 20 of 50 Nursing QPS Presentation

21 National Database of Nursing Quality Indicators (NDNQI) Created to aid the Registered Nurse in patient safety and quality improvement efforts by providing research-based national comparative data on nursing care and the relationship to patient outcomes. Uses data definitions from NQF, CDC and NHSN. Includes a Nurse satisfaction survey to provide insight into the work environment Benchmarks are made to like-hospitals and like-units 2,000 hospitals in the database (and 98% of Magnet Hospitals) 7 Page 21 of 50 Nursing QPS Presentation

22 Nurse Sensitive Measures in NDNQI NDNQI defines nursing sensitive measures as measures that are strongly influenced by the care that nurses provide or directly measure nursing as reflected by the structure, process and outcomes of nursing care. STRUCTURE PROCESS OUTCOMES Voluntary Nurse Turnover Restraint Prevalence Patient Falls & Falls w/injury Nursing Care Hours/Minutes Discharge Care Coordination Pressure Ulcer Prevalence Patient Days/Volume Pediatric Pain AIR Cycle CAUTI RN Education Level CLABSI RN Specialty Certification VAP/VAE Staffing Indicators Hospital Readmission Rates Pediatric PIV Infiltration Nursing Satisfaction Nursing Satisfaction Nursing Satisfaction 8 Page 22 of 50 Nursing QPS Presentation

23 NDNQI Timeline at CCHHS Unit enrollment, data definitions and processes 6/ /2016 1/2017 First results reported from NDNQI with benchmarks Ongoing monitoring and improvements Submit clinical data for 3 rd Quarter (July September) 11/2016 2/2017 Share results with Board, leadership and staff. Create action plans based on the results 9 Page 23 of 50 Nursing QPS Presentation

24 Partnership with Business Intelligence 10 BI has partnered with nursing to create a database for NDNQI RN information such as: Degrees Board Certifications Languages Spoken Turnover Page 24 of 50 Nursing QPS Presentation

25 RN Education Indicators Third Quarter CY 2016 Page 25 of 50

26 RN Education Level Stroger Hospital Aggregate Percent of Direct Care RNs with BSN or higher. Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 78. Positive value is goal. 2% Stroger Hospital Direct Care RNs with BSN 2% 1% 1% 0% -1% 0.26% Stroger 0.92% 0.45% -0.10% -0.46% -1% CCHHS 10th percentile Page 25th 26 of 50 Mean (average) 75th Nursing QPS Presentation 12

27 RN Education Level ACHN Clinics Percent of Direct Care RNs with BSN, MSN or PhD. Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= % ACHN Clinics Direct Care RNs with BSN, MSN or PhD 100% 90% 80% 70% 60% 62.04% 50% 40% 30% 20% 10% 0% 73.33% Antepartum Testing Unit 16.67% Oak Forest Health Center Specialty Care Center % Oak Forest Primary Care 66.67% Robbins Health and Cottage Grove Health Center 14.29% South Region and Austin 26.67% West and North Region 53.13% Stroger Specialty Clinics 73.68% Fantus General Medicine Clinic 21.05% Fantus Adult Medical Specialties 77.78% Public Health Department 43.06% 50.00% 0.00% CORE Center 13 CCHHS 10th Page 25th27 of 50 Mean (average) 75th Nursing QPS Presentation

28 Patient Experience Communication with Nurses Page 28 of 50

29 Patient Experience: Communication with Nurses 100 Top Box (%) Target 86% Top Box 90 th %ile Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q Description Composite of 3 Questions (how often did ): Nurses treat with courtesy, respect Nurses listen carefully to you Nurses explain in way you could understand Goal = 86% (90 th percentile) Opportunity Represents largest part of CCHHS workforce (1,800) May be primary source of patient perception Action Plan Training management for nurse engagement 2/15/2017 New hires attending customer service training during orientation and practice hourly rounding Accelerate pace and scale of customer service training for current nurses: 16 nurses to be customer service trainers Currently training 60 nurses/month. Will increase as open positions are filled and more trainers are available 15 Page 29 of 50 Nursing QPS Presentation

30 Nurse Sensitive Clinical Indicators Third Quarter CY 2016 Hospital Based & Selected Ambulatory Measures Page 30 of 50

31 Patient Falls Per 1,000 Patient Days Stroger Hospital Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 176. Zero or negative value is goal. CCHHS Aggregate 0.6 Total Patient Falls Per 1,000 Patient Days CCHHS CCHHS 10th 25th Mean (average) 75th Page 31 of 50 Nursing QPS Presentation

32 Falls with Injury per 1,000 Patient Days Stroger Hospital Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 176. Zero or negative value is goal. Stroger Hospital Injury Falls Per 1,000 Patient Days CCHHS CCHHS 10th 25th Page 32 of 50 Mean (average) 75th Nursing QPS Presentation

33 Patient Falls per 1,000 Patient Visits ER & Ambulatory Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 86. Zero or negative value is goal. CCHHS 0.6 Total Patient Falls Per 1,000 Patient Visits CCHHS 10th 25th Mean (average) 75th Page 33 of 50 Nursing QPS Presentation

34 Falls with Injury per 1,000 Patient Visits ER & Ambulatory Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 86. Zero or negative value is goal. CCHHS Injury Falls Per 1,000 Patient Visits CCHHS 10th 25th Page 34 of 50 Mean (average) 75th Nursing QPS Presentation

35 Hospital Acquired Pressure Ulcers Stroger Hospital point prevalence Percent of Surveyed Patients with Hospital Acquired Pressure Ulcers. Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= Stroger Hospital Percent of Surveyed Patients with HAPU 0.08 CCHHS 10th 25th Mean (average) 75th ACTION PLAN TARGET STATUS PLAN HOSPITAL ACQUIRED PRESSURE ULCERS SKIN CHECK EDUCATION PROGRAM CONSISTENCY IN CARE PROGRAM TO AUDIT USE OF EVIDENCE BASED PRESSURE INJURY PREVENTION PEER COACHING FROM SKIN CHAMPIONS EVIDENCE-BASED PREVENTION PRODUCTS Page FILL 35 WOUND of 50 CARE NURSE POSITIONS AND INCREASE FOCUS ON PREVENTION IN ADDITION TO TREATMENT Nursing QPS Presentation

36 22 Physical Restraints Point Prevalence Stroger Hospital Percent of Patients with Physical Restraints (Limb and/or Vest). Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 153. Zero or negative value is goal Percent of Patients with Physical Restraints (Limb and/or Vest) 0.29 CCHHS 10th 25th Mean (average) 75th ACTION PLAN TARGET STATUS PLAN PHYSICAL RESTRAINT USE 0.07% 0.29% DEFINE LOW TO MODERATE PROBABILITY OF PATIENTS TERMINATING THEIR DEVICES AND WHOSE HARM IS LIKELY TO BE LOW TO MODERATE WITHOUT A PHYSICAL RESTRAINT. RESTRAINT ROUNDS UTILIZING DEFINITIONS TO REDUCE Page 36 of 50 RESTRAINT USE Nursing QPS Presentation

37 Percent of Peripheral IV Sites with Infiltration (Pediatric In-Patients) Percent of Peripheral IV Sites with Infiltrations. Comparison is made between Stroger Hospital and Teaching Hospitals in the database: Teaching Hospital s N= 62. Zero or negative value is goal. Stroger Hospital Percent of PIV Sites with Infiltrations Stroger CCHHS 10th 25th Mean (average) 75th Page 37 of 50 Nursing QPS Presentation

38 CLABSI per 1000 Central Line Days Stroger Hospital Central Line Associated Blood Stream Infections per 1000 Central Line Days. Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 123. Zero or negative value is goal. Stroger Hospital 0.6 CLABSI per 1000 Central Line Days CCHHS 10th 25th Page 38 of 50 Mean (average) 75th Nursing QPS Presentation

39 CAUTI per 1000 Catheter Days Stroger Hospital Catheter Associated Urinary Tract Infections per 1000 Catheter Days. Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 121. Zero or negative value is goal. CAUTI per 1000 Catheter Days CCHHS 10th 25th Mean (average) 75th 25 ACTION PLAN TARGET STATUS PLAN CATHETER ASSOCIATED URINARY TRACT INFECTIONS DAILY CATHETER ROUNDS FOR ASSESSMENT FOR PRESENCE AND NEED FOR INDWELLING CATHETER USE OF ALTERNATIVE URINE-COLLECTION METHODS AHRQ CAUTI EDUCATION 4 MODULES IN ICU Page 39 of 50 OBSERVATIONS OF CATHETER INSERTION Nursing QPS Presentation

40 26 VAE per 1000 Ventilator Days Stroger Hospital Ventilator-Associated Events per 1000 Ventilator Days. Comparison is made between CCHHS and Teaching Hospitals in the database: Teaching Hospital s N= 50. Zero or negative value is goal. Stroger Hospital 0.6 VAE per 1000 Ventilator Days ACTION PLAN TARGET STATUS PLAN VENTILATOR ASSOCIATED EVENTS 0.44 CCHHS 10th 25th Mean (average) 75th ADOPT AHRQ 2017 TOOLKIT FOR VAE REDUCTION INITIATE CUSP IMPLEMENTATION BY INTER- PROFESSIONAL CRITICAL CARE TEAM Page DAILY 40 /WEEKLY of 50 MONITOR, REPORT AND RESET ACTION PLAN BASED ON RESULTS Nursing QPS Presentation

41 Sample Quality Unit Based Scorecard Trauma ICU Strategic Plan Focus Area High Quality Care Objectives EXPLOIT RELEVANT SOURCES FOR MONITORING QUALITY, COST, UTILIZATION AND PATIENT OUTCOMES Tactic Measures Targets Status Initiatives Benchmark nursedriven quality indicators to regional and national standards FALLS WITH INJURY PER 1,000 PATIENT DAYS - NDNQI HOSPITAL ACQUIRED PRESSURE ULCERS- NDNQI MET SAMPLE: CONTINUE TO DEVELOP INDIVIDUALIZED CARE PLANS BASED ON TYPE OF RISK OF FALLS CONTINUE WITH PURPOSEFUL HOURLY ROUNDING 6.45% 25% - Not Met SAMPLE: SKIN CHECK EDUCATION PROGRAM 2/2017 CONSISTENCY IN CARE PROGRAM TO AUDIT USE OF EVIDENCE BASED PRESSURE INJURY PREVENTION PHYSICAL RESTRAINTS 16.79% 75% - Not Met SAMPLE: DETERMINE DEFINITIONS FOR LOW TO MODERATE PROBABILITY OF PATIENTS TERMINATING THEIR DEVICES AND WHOSE HARM IS LIKELY TO BE LOW TO MODERATE WITHOUT PHYSICAL RESTRAINT INCLUDE RESTRAINT ROUNDS DURING MULTIDISCIPLINARY ROUNDS TO ASSESS NEED FOR RESTRAINTS UTILIZING DEFINITIONS 27 CATHETER ASSOCIATED URINARY TRACT INFECTIONS Page 41 of % 7.2% - Not Met SAMPLE: PROVIDE EDUCATION ON THE CAUTI BUNDLE INCLUDING INSERTION TECHNIQUE AUDIT PATIENTS WITH URINARY CATHETERS DAILY AND ASSESS FOR PROMPT REMOVAL Nursing QPS Presentation

42 Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting February 17, 2017 ATTACHMENT #3 Page 42 of 50

43 Page 43 of 50

44 Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting February 17, 2017 ATTACHMENT #4 Page 44 of 50

45 Page 45 of 50

46 Page 46 of 50

47 Page 47 of 50

48 Page 48 of 50

49 Page 49 of 50

50 Page 50 of 50