Clinical Quality and Professional Affairs Committee June 19, 2017 3:00PM ProVidence Suite
AGENDA University Medical Center of Southern Nevada UMC GOVERNING BOARD CLINICAL QUALITY AND PROFESSIONAL AFFAIRS COMMITTEE June 19, 2017 3:00 p.m. 800 Hope Place, Las Vegas, Nevada UMC Trauma Building, ProVidence Suite (5 th Floor) Notice is hereby given that a meeting of the UMC Governing Board Clinical Quality and Professional Affairs Committee has been called and will be held at the time and location indicated above, to consider the following matters: This meeting has been properly noticed and posted in the following locations: University Medical Center CC Government Center Third Street Building Regional Justice Ctr 1800 W. Charleston Blvd. 500 S. Grand Central Pkwy. 309 S. Third St. 200 Lewis Ave., 1 st Fl. Las Vegas, NV Las Vegas, NV Las Vegas, NV Las Vegas, NV (Principal Office) City of Las Vegas City of Henderson 400 Stewart Ave. 240 Water St. Las Vegas, NV Henderson, NV The main agenda is available on University Medical Center of Southern Nevada s website http://www.umcsn.com, For copies of agenda items and supporting back-up materials, please contact Terra Lovelin, Board Secretary, at (702) 765-7949. The Clinical Quality and Professional Affairs Committee may combine two or more agenda items for consideration. Items on the agenda may be taken out of order. The Clinical Quality and Professional Affairs Committee may remove an item from the agenda or delay discussion relating to an item at any time. Consent Agenda - All matters in this sub-category are considered by the Clinical Quality and Professional Affairs Committee to be routine and may be acted upon in one motion. Most agenda items are phrased for a positive action. However, the Clinical Quality and Professional Affairs Committee may take other actions such as hold, table, amend, etc. Consent Agenda items are routine and can be taken in one motion unless a Committee member requests that an item be taken separately. For all items left on the Consent Agenda, the action taken will be staff's recommendation as indicated on the item. Items taken separately from the Consent Agenda by Committee members at the meeting will be heard in order. SECTION 1. OPENING CEREMONIES 1. Public Comment CALL TO ORDER PUBLIC COMMENT. This is a period devoted to comments by the general public about items on this agenda. If you wish to speak to the Committee about items within its jurisdiction but not appearing on this agenda, you must wait until the Comments by the General Public period listed at the end of this agenda. Comments will be limited to three minutes. Please step up to the speaker's podium, clearly state your name and address and please spell your last name for the record. If any member of the Committee wishes to extend the length of a presentation, this will be done by the Chair or the Committee by majority vote. 1 Page 2 of 12
2. Approval of minutes of the regular meeting of the UMC Clinical Quality and Professional Affairs Committee meeting on April 10, 2017. (For possible action) 3. Approval of Agenda. (For possible action) SECTION 2. BUSINESS ITEMS 4. Receive a presentation on Palliative care (For possible action) 5. Receive a report on current HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, reviewing trended data as well as benchmarks and initiatives for improvement. (For possible action) 6. Receive an update on ICARE4U. (For possible action) 7. Receive an update on Value Base Purchasing (For possible action) 8. Approve and recommend approval by the Governing Board and Board of Hospital Trustees, the amended Medical and Dental Staff Bylaws of University Medical Center of Southern Nevada; as accepted and voted on by the Medical Executive Committee and General Medical Staff on April 25, 2017. (For possible action) 9. Identify emerging issues to be addressed by staff or by the Clinical Quality and Professional Affairs Committee at future meetings; and direct staff accordingly. COMMENTS BY THE GENERAL PUBLIC A period devoted to comments by the general public about matters relevant to the Committee s jurisdiction will be held. No action may be taken on a matter not listed on the posted agenda. Comments will be limited to three minutes. Please step up to the speaker s podium, clearly state your name and address and please spell your last name for the record. All comments by speakers should be relevant to the Committee s action and jurisdiction. UMC ADMINISTRATION KEEPS THE OFFICIAL RECORD OF ALL PROCEEDINGS OF UMC GOVERNING BOARD CLINICAL QUALITY AND PROFESSIONAL AFFAIRS COMMITTEE. IN ORDER TO MAINTAIN A COMPLETE AND ACCURATE RECORD OF ALL PROCEEDINGS, ANY PHOTOGRAPH, MAP, CHART, OR ANY OTHER DOCUMENT USED IN ANY PRESENTATION TO THE BOARD SHOULD BE SUBMITTED TO UMC ADMINISTRATION. IF MATERIALS ARE TO BE DISTRIBUTED TO THE COMMITTEE, PLEASE PROVIDE SUFFICIENT COPIES FOR DISTRIBUTION TO UMC ADMINISTRATION AND COUNTY COUNSEL. THE COMMITTEE MEETING ROOM IS ACCESSIBLE TO INDIVIDUALS WITH DISABILITIES. WITH TWENTY-FOUR (24) HOUR ADVANCE REQUEST, A SIGN LANGUAGE INTERPRETER MAY BE MADE AVAILABLE (PHONE: 765-7949). 2 Page 3 of 12
University Medical Center of Southern Nevada UMC Governing Board Clinical Quality and Professional Affairs April 10, 2017 UMC ProVidence Conference Room Trauma Building, 5 th Floor 800 Hope Place Las Vegas, Clark County, Nevada April 10, 2017 3:00 p.m. The University Medical Center Governing Board Clinical Quality and Professional Affairs Committee met in the ProVidence Conference Room, Trauma Building, 5 th floor, Las Vegas, Clark County, Nevada, on Monday, April 10, 2017 at the hour of 3:00 p.m. The meeting was called to order at the hour of 3:00p.m. by Chair Dr. Donald Mackay and the following members were present, which constituted a quorum of the members thereof: CALL TO ORDER Board Members: Present: Donald Mackay, M.D. Renee Franklin (via phone) Laura Lopez-Hobbs Mike Saltman Absent: Also Present: Tony Marinello, Chief Operating Officer Jeff Ellis, Governing Board Member Haley Hammond, Director of Patient Experience Jennifer Gaca, Associate Administrator, Director of Clinical Safety and PI Terra Lovelin, Administrative Assistant/Board Secretary SECTION 1. OPENING CEREMONIES ITEM NO. 1 PUBLIC COMMENT Chair Dr. Mackay asked if there were any persons present in the audience wishing to be heard on any item on this agenda. Speaker(s): None ITEM NO. 2 Approval of minutes of the regular meeting of the UMC Governing Board Clinical Quality and Professional Affairs Committee meeting on February 13, 2017. (For possible action) FINAL ACTION: A motion was made by Member Saltman that the minutes be approved as recommended. Motion carried by unanimous vote. Page 4 of 12
UMC Governing Board Clinical Quality and Professional Affairs April 10, 2017 Page 2 of 6 ITEM NO. 3 Approval of Agenda (For possible action) FINAL ACTION: A motion was made by Member Lopez that the agenda be approved as recommended. Motion carried by unanimous vote. SECTION 2. BUSINESS ITEMS ITEM NO. 4 Receive a report on current HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, reviewing trended data as well as benchmarks and initiatives for improvement. (For possible action) DOCUMENT(S) SUBMITTED: - Slide DISCUSSION: Haley Hammond, explained the handout that shows a more accurate picture of our initiatives and scores with a year s data trended. Most of the categories are showing a large improvement from the past years. Tony Marinello, Chief Operating Officer added that we have received 200 surveys from discharged patients and are hoping for more as to depict more accurate data. ITEM NO. 5 Receive an update on ICARE4U. (For possible action) DOCUMENT(S) SUBMITTED: - None submitted DISCUSSION: Haley Hammond, Director of Patient Experience announced that over 1000 employees have attended the ICARE4U refresh. There have been great discussions on what is working and improvements that have been made. Ms. Hammond and her team are working on refreshing physicians and will be going out to the ambulatory clinics to conduct the refreshers on site. Member Lopez-Hobbs asked if employees are tested on ICARE4U and Ms. Hammond replied that they are given a quiz and rewarded with Starbucks drinks and UMC cafeteria dollars. Member Franklin suggested looking at how the team can drive the ICARE behaviors and then measure them. FINAL ACTION: None taken. Page 5 of 12
UMC Governing Board Clinical Quality and Professional Affairs April 10, 2017 Page 3 of 6 ITEM NO. 6 Discuss and establish goals for CEO performance; and direct staff accordingly. (For possible action) DOCUMENT(S) SUBMITTED: - Schedule B DISCUSSION: Dr. Mackay commented that the Chair of the HR Committee, Jeff Ellis, would like each committees goals for the CEO, sent to him before the next HR meeting on May 16. Member Ellis commented that if UMC does not hit a financial goal, no other goals matter because there will be no money to be paid out. The Clinical Quality metrics are not defined enough so he suggested listing 5 or 6 quality metrics and then measuring each one. The committee needs to figure out the goal on how to increase the metrics each year. He also suggested that the clinical objectives should be comprised of the individual HCAHPS measurements and the measurement period should be calendar year 2016. Dr. Mackay suggested that perhaps Clinical Quality objectives could make up 25% of the total percentage of all the committees. Member Lopez-Hobbs asked that Mason come back to the committee with his goals and she also agrees with the 25% suggestion. Member Ellis asked staff to get together with Dr. Mackay to come up some measurements. Member Franklin suggested that when staff comes back with the goals to make sure the data is reliable in order to measure the goals correctly. FINAL ACTION: Dr. Mackay will meet with staff to come up with measurable goals for the CEO. ITEM NO. 7 Receive a report on the 2016 Annual Evaluation of the Quality program and the 2017 Quality Plan. (For possible action) DOCUMENT(S) SUBMITTED: - 2016 Quality Plan Evaluation DISCUSSION: Jenny Gaca, Associate Administrator, Clinical Quality and Performance Improvement, presented the evaluation of the Quality program. The purpose of the program is to evaluate the quality of care provided at the organization and then implement actions to improve that care. Some of the accomplishments for 2016: -Score of C from F with Leapfrog -Improvements with the State Board of Nursing and State Board of Medicine Page 6 of 12
UMC Governing Board Clinical Quality and Professional Affairs April 10, 2017 Page 4 of 6 -Implementation of quality reporting schedule -Peer review -Performance improvement projects underway -Coordination of regulatory visits and responses -Sepsis mortality index improvement, able to decrease our target Dr. Mackay asked how we compared to community hospitals and Ms. Gaca said that we can t compare to the Las Vegas community because they do not participate in Vizient. 2017 Quality Plan: -Data collection -Medical staff peer review -Bench marking -Compliance with other external agencies -Coordination of Quality committee Priorities for 2017: -Hospital acquired conditions and data collection Member Lopez-Hobbs asked when she would start seeing the data collection reports for the measures and then the improvements that have been made. Ms. Gaca replied that Epic will be up and running in November so hopefully by the second quarter of next year, she will be able to show before and after statistics. FINAL ACTION: None taken ITEM NO. 8 Receive a report on the 2016 Annual Evaluation of the Infection Control program and the 2017 Infection Control plan. (For possible action) DOCUMENT(S) SUBMITTED: - PowerPoint presentation DISCUSSION: 2016 Accomplishments include: -Improved hand hygiene, 41% increase -21% decrease in CLABSI -35% decrease in MERSA rate -Sustained compliance with education of patients and families regarding isolation -100% compliance with annual TB and FIT testing -Being recognized with the Silver Syringe award for above 90% compliance for employee vaccination rate 2017 Annual Infection Control Plan Purpose: The Infection Prevention Manager and Infectious Disease Medical Director have over site of the program. Page 7 of 12
UMC Governing Board Clinical Quality and Professional Affairs April 10, 2017 Page 5 of 6 Another requirement is to perform a risk assessment every year. What we have in terms of risks and priorities are: -Bio-terrorism for infectious disease -Building infrastructure -Environmental cleaning -Transmissions of pathogens related to PPE -Procedures -Hand Hygiene -Multi drug resistance organisms -Employee Health (making sure TB tests and FIT tests are done for all employees) FINAL ACTION: A motion was made by member Ellis to approve and make a recommendation to the Governing Board to approve the 2017 Infection Control Plan and Quality Plan. Motion carried by unanimous vote. ITEM NO. 9 Receive a report on hospital grievances. (For possible action) DOCUMENT(S) SUBMITTED: - Grievance Report DISCUSSION: Ms. Gaca updated the committee on the hospital grievance process. The process had been completely re-designed and all grievances have to go through Patient Experience and they are answered with one coordinated response. Ms. Cohen and Mr. VanHouweling look at each response letter before they go out to the patient. During the first quarter of 2017, UMC took in 36 grievances. CMS requires an initial response within seven days and Ms. Gaca, Ms. Cohen and their teams are responding within two days. The top units with grievances have been the ED and the outpatient clinics; most are tied to financial grievances. Ms. Gaca is hoping that the software she needs is going to be approved and purchased soon as this will help with tracking and resolving grievances. A discussion ensued regarding Patient Pal and phone calls not being made. Ms. Gaca and her team will look into this as all in-patients should be called upon discharge. FINAL ACTION: None taken. Page 8 of 12
UMC Governing Board Clinical Quality and Professional Affairs April 10, 2017 Page 6 of 6 ITEM NO. 10 Identify emerging issues to be addressed by staff or by the Clinical Quality and Professional Affairs Committee at future meetings; and direct staff accordingly. None COMMENTS BY THE GENERAL PUBLIC: At this time, Chair Mackay asked if there were any persons present in the audience wishing to be heard on any items not listed on the posted agenda. SPEAKERS(S): None There being no further business to come before the Committee at this time, at the hour of 4:46 p.m., Chair Dr. Mackay adjourned the meeting. MINTUES PREPARED BY: Terra Lovelin, Administrative Assistant APPROVED: Page 9 of 12
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MEMORANDUM DEPARTMENT TO: FROM: SUBJECT: Hospital Governing Board Medical and Dental Staff Bylaws Revisions DATE: June 12, 2017 The following are revisions to the Medical and Dental Staff Bylaws and Associated Manuals as recommended for approval and voted on by the Medical Executive Committee on April 25, 2017. The revisions were posted for 30 days on the Physician Link website for the Medical Staff to review, comment, and vote. A. DEPARTMENTS AND SECTIONS ORGANIZATION 1. The Medical and Dental Staff shall be organized into departments in order to improve patient continuum of care, establish professional responsibility, and to evaluate staff capabilities. 2. The departments and sections of the Medical and Dental Staff shall be as follows: 1. Department of Ambulatory Care 2. Department of Anesthesiology 3. Department of Emergency Medicine (1) Pediatric Emergency Medicine (2) Adult Emergency Medicine 4. Department of Family Medicine 5. Department of Hand Surgery 5.6. Department of Medicine (1) Allergy/Immunology (2) Cardiology (3) Dermatology (4) Endocrinology/Metabolic Diseases (5) Gastroenterology Section (6) Hematology/Oncology (7) Infectious Disease (8) Internal Medicine (9) Nephrology (10) Neurology (11) Psychiatry (12) Pulmonary Medicine/Respiratory Care (13) Physical Medicine/Rehabilitation (14) Rheumatology Formatted: Outline numbered + Level: 4 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 1.5" + Tab after: 2" + Indent at: 2", Tab stops: 1.75", List tab + Not at 2" Page 11 of 12
(15) Department of Neurosurgery (16) Department of Obstetrics and Gynecology (17) Department of Orthopaedic Surgery o1. Hand Surgery 1.2. Podiatry (17)(18) Department of Pathology (18)(19) Department of Pediatrics Neonatology Pediatric Critical Care (19)(20) Department of Radiology Nuclear Medicine (20)(21) Department of Surgery 1 Bariatrics 2 Cardiovascular/Thoracic Surgery 3 General Surgery 4 Ophthalmology 5 Oral/Maxillofacial Surgery 6 Otorhinolaryngology 7 Pediatric Surgery 8 Plastic Surgery 9 Podiatry (21)(22) Department of Trauma (a) Anesthesia (b) Burn Surgery (c) Emergency Medicine (d) General Surgery (e) Neurosurgery (f) Orthopaedics (g) Pediatric Surgery (h) Surgical Critical Care Formatted: Level 1, Left, Indent: Left: 2.5", No bullets or numbering, Tab stops: 2.5", List tab + Not at -1" F. DEPARTMENT OF HAND SURGERY Page 12 of 12