I. Attendance/Call to Order Chairman Gugenheim called the meeting to order.

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, October 20, 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) Board Chairman M. Hill Hammock (ex officio) and Directors Emilie N. Junge and Mary B. Richardson-Lowry Patrick T. Driscoll, Jr. and Patricia Merryweather (non-director Members) Absent: None (0) Additional attendees and/or presenters were: Krishna Das, MD Chief Quality Officer Claudia Fegan, MD Chief Medical Officer Trevor Lewis, MD John H. Stroger, Jr. Hospital of Cook County Jeff McCutchan Interim General Counsel Annmarie McDonagh Director of Emergency and Trauma Services Deborah Santana Secretary to the Board John Jay Shannon, MD Chief Executive Officer Agnes Therady Chief Nursing Officer Arnold Turner, MD Provident Hospital of Cook County Sharon Welbel, MD System Director of Infection Control 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) C. Report on Infection Control (Attachment #2) D. Report on Nursing (Attachment #3) Dr. Krishna Das, Chief Quality Officer, provided updates on regulatory and accreditation matters. Provident Hospital underwent its triennial survey last week by The Joint Commission (TJC). The surveyors were there for three (3) days; they surveyed the hospital, as well as the clinic for Primary Care Medical Home compliance. There were no findings in the PCMH area, so now all clinics within the System are certified for PCMH. There were some findings in the hospital; almost all of the findings were what is considered limited by TJC, and are therefore easily remediable. Staff are making the corrective actions. Additionally, staff are actively working on accreditation-related activities at Stroger Hospital, as it is also in the window for a visit from TJC. Page 1 of 73

Minutes of the Meeting of the Quality and Patient Safety Committee Friday, October 20, 2017 Page 2 III. Report from Chief Quality Officer (continued) During the discussion of the Stroger Hospital metric regarding surgery start time, Director Richardson- Lowry commented that it is good to hear that the administration is working on the strategy to improve this metric by hiring someone to help with the schedule. Dr. Das responded that this strategy has been in place, but the availability of candidates to fill the position has been limited to date. Dr. Sharon Welbel, System Director of Infection Control, provided an overview of the presentation on Infection Control, which included information on the following subjects: Infection Control Risks / Priorities Infection Control Goals Evaluation Goals, Gaps/Barriers/Best Practice, and Corrective Measures: - Central Line-Associated Bloodstream Infections (CLABSI) - Catheter-Associated Urinary Tract Infections (CAUTI) - Surgical Site Infections (Deep Incisional Primary) - Healthcare Facility Onset Clostridium difficile - Healthcare Facility Onset Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia - Carbapenem-Resistant Enterobacteriaceae (CRE) Data on Infection-Related Ventilator-Associated Complication (IVAC) + Possible Ventilator- Associated Pneumonia Employee Influenza Vaccination, 2012-2017 Hand Hygiene Compliance 2010-2017 Agnes Therady, Chief Nursing Officer, provided an overview of the presentation on Nursing, which included information on the following subjects: Nurse-Sensitive Indicator Scorecards and Action Plans 3 rd Quarter CY2016 to 1 st Quarter CY2017 National Database of Nursing Quality Indicators (NDNQI) Scorecard CCHHS Aggregate Hospital-Acquired Pressure Injury (HAPI) Action Plan Physical Restraints Action Plan Ventilator-Associated Events Action Plan Catheter-Associated Urinary Tract Infections Action Plan Nurse Leader Rounding AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) Compliance Manager Rounding Results Rounding on Patients: Patient Comments Nurse Satisfaction Annual Survey 2017 in progress, survey ends October 22 Appendix IV. Action Items A. Approve appointments and reappointments of Stroger Hospital Department Chair(s) and Division Chair(s) There were none presented for the Committee s consideration. Page 2 of 73

Minutes of the Meeting of the Quality and Patient Safety Committee Friday, October 20, 2017 Page 3 IV. 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 ii. Approve Medical Staff Appointments/Re-appointments/Changes (Attachment #4) Dr. Arthur Turner, Medical Director of Provident Hospital of Cook County, presented the proposed medical staff appointments/reappointments/changes for Provident Hospital for the Committee s consideration. It was noted that there were minor changes to the dates for four (4) physicians being considered for reappointment. Dr. Trevor Lewis, President of the EMS of John H. Stroger, Jr. Hospital of Cook County, presented the proposed medical staff appointments/reappointments/changes for Stroger Hospital for the Committee s consideration. He provided a brief report to the Committee regarding the recent EMS meeting. He stated that Ms. Therady discussed some of the new nursing director hires and her vision for nursing, and Dr. Connie Mennella, Chairman of the Department of Correctional Health, reviewed an informative presentation on Cermak Health Services. The annual EMS meeting will be held on January 23, 2018 at 4:00 P.M. All medical staff are welcome, as are any Directors who would like to attend. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the Medical Staff Appointments/Re-appointments/Changes for John H. Stroger, Jr. Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. Director Suleiman Gonzalez, seconded by Director Driscoll, moved to approve the Medical Staff Appointments/Re-appointments/Changes for Provident Hospital of Cook County, as amended. THE MOTION CARRIED UNANIMOUSLY. C. Minutes of the Quality and Patient Safety Committee Meeting, September 15, 2017 Director Driscoll, seconded by Director Suleiman Gonzalez, moved to accept the Minutes of the Quality and Patient Safety Committee Meeting of September 15, 2017. THE MOTION CARRIED UNANIMOUSLY. D. Any items listed under Sections IV and V V. Closed Meeting Items A. Medical Staff Appointments/Re-appointments/Changes B. Litigation Matter(s) The Committee did not convene into a closed meeting. Page 3 of 73

Minutes of the Meeting of the Quality and Patient Safety Committee Friday, October 20, 2017 Page 4 VI. 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 Requests/follow-up: No requests/follow-up were made at the meeting. Page 4 of 73

Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting October 20, 2017 ATTACHMENT #1 Page 5 of 73

COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Dashboard Overview 20 October 2017 Krishna Das, MD, Chief Quality Officer 1 Page 6 of 73 CCHHS Board QPS Committee

Quality Stroger Page 7 of 73 2 CCHHS Board QPS Committee

Quality Provident Page 8 of 73 3 CCHHS Board QPS Committee

Safety Stroger Page 9 of 73 4 CCHHS Board QPS Committee

Patient Experience Stroger Page 10 of 73 5 CCHHS Board QPS Committee

Patient Experience Provident Page 11 of 73 6 CCHHS Board QPS Committee

ACHN Page 12 of 73 7 CCHHS Board QPS Committee

Board Quality Dashboard Page 13 of 73 8 CCHHS Board QPS Committee

Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting October 20, 2017 ATTACHMENT #2 Page 14 of 73

COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Infection Control Report 20 October 2017 Sharon F. Welbel, HEIC, System Director Page 15 of 73

Infection Control Risks/Priorities Risk for acquisition and transmission of infection Risk for Central line-associated Blood Stream Infections (CLABSI) Risk for Catheter-associated Urinary Tract Infection (CAUTI) Risk for exposure to Influenza and emerging infections Risk for transmission of Multi-drug Resistant Organisms (MDRO) Risk for transmission of infection due to use/misuse of medication vials Risk of low hand hygiene compliance Page 16 of 73

Infection Control Goals 3 1. Implement evidence-based guidelines and strategies to address the prioritized risks identified 2. Reduce health care associated infections CLABSI- 40% (Standardized Infection Ratio 0.60) CAUTI-40% (Standardized Infection Ratio 0.60) SSI -40% (Standardized Infection Ratio 0.60) MDRO Hospital onset MRSA bacteremia - (Standardized Infection Ratio- 0.60) Clostridium difficile infection- (Standardized Infection Ratio- 0.60) Carbapenem Resistant Enterobacteriaceae (CRE)-No hospital transmission 3. Maintain employee influenza vaccination rates above 90% 4. Increase hand hygiene compliance to 90% 5. Limit the transmission of infections associated with procedures, use of medical equipment, devices, and supplies 6. Achieve better use of technology to automate surveillance activities 7. Collaborate with interdisciplinary teams in implementing a culture of safety 8. Engage leadership support to enhance infection prevention and control activities 9. Foster Antimicrobial Stewardship Program 10. Continue to assess readiness for regulatory and accreditation surveys Page 17 of 73

Evaluation 4 Page 18 of 73

5 Goals Baseline SIR =1.1 Reduce CLABSI by 40% (SIR=0.6) by the end of 2017 Goal met: (SIR=0.49, 51% reduction) Illinois SIR=0.71 USA SIR=0.89 Gaps/Barriers/Best Practice Gaps/Barriers: Catheter hubs to be consistently disinfected Daily assessment for catheter need Consistently of CHG Best Practice: Central line use only when absolutely needed Page 19 of 73 Corrective Measures Feedback to leadership and units Educate staff /patients Monitor use of CHG bath and need for central lines Scrub the Hub/Multi-use vial campaign-nursing Fair 2016-2017 Restrict residents from accessing central lines

Goals Baseline SIR =1.4 Reduce CAUTI by 40% (SIR 0.60) by the end of 2017 Goal not met: SIR=1.18 but 22% reduction from baseline Gaps/Barriers Daily assessment for catheter need Need to purchase all-in-one catheter kit Consistently use CHG bath Documentation issues (insertion location-present on admission, discontinuation, care and maintenance) Corrective Measures Feedback to leadership and units Patient education CAUTI Prevention -Nursing Fair (2017=325 MedSurg Nurses and 184 Critical Care Nurses) Monitor CHG bath and use and maintenance of catheters Purchase all-in-one catheter kit 6 IL SIR=0.88, USA-SIR=0.94 Page 20 of 73

Goals Reduce Surgical Site Infections by 40% (SIR-0.60) by the end of 2017 Goal met: January -July 2017 SIR= 0.39 Gaps/Barriers High SIR in hysterectomy and hip surgeries Patient risk factors include morbid obesity, length of surgery, co-morbidities Corrective Measures Feedback to leadership & staff Staff /Patient education Implemented CHG bathing Provided oversight of cleaning, disinfection and sterilization Monitor storage of sterile equipment/ supplies, & processes /procedures in CSPD and MOR 7 Page 21 of 73

IVAC Plus per Unit ( Infection-Related Ventilator Associated Complication + Possible Ventilator Associated Pneumonia) January 2017- August 2017 Standardized Infection Ratio 5 4 3 2 1 Expected= 14.34 # of Infections =9 SIR=0.61 0 BICU CCU MICU NECU SICU TICU SIR 4.53 0.00 0.61 0.00 0.00 0.47 # VentDays 173 67 1690 228 465 1154 # IVACPlus 3 0 3 0 0 3 Expected 0.662 0.196 4.955 0.872 1.778 6.377 SIR= Standardized Infection Ratio=is a summary measure which compares the actual number of Healthcare Associated Infections (HAI) in a facility with the baseline data for standard population. SIR >1.0 indicates more HAIs were observed than predicted, conversely, SIR of <1.0 indicates that fewer HAIs were observed than predicted. NHSN- National Healthcare Safety Network Page 22 of 73

Standardized Infection Ratio (SIR) IVAC Plus ( Infection-Related Ventilator Associated Complication + Possible Ventilator Associated Pneumonia) January 2017-December 2017 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Expected= 14.84 # IVAC Plus= 9 JSHCC-SIR =0.61 Jan-17 Feb-17 Mar- 17 Apr-17 May- 17 # IVAC Plus 0 1 3 2 1 0 0 2 SIR* 0.00 0.28 0.74 0.83 0.74 0.64 0.55 0.61 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Goal 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 SIR= Standardized Infection Ratio=is a summary measure which compares the actual number of Healthcare Associated Infections (HAI) in a facility with the baseline data for standard population. SIR >1.0 indicates more HAIs were observed than predicted, conversely, SIR of <1.0 indicates that fewer HAIs were observed than predicted. NHSN- National Healthcare Safety Network * Cumulative Results; 2015 Baseline Page 23 of 73

Goals Maintain Employee Influenza vaccination above 90% by the end of 2016-2017 season Goal met: 95% compliance Gaps/Best Practice Early onset (October 6, 2017, first Flu A) Best Practices: Mandatory employee compliance with flu policy Strong administrative support Corrective Measures Feedback to leadership and staff. Staff /Patient education Automated orders for isolation Cleaning/disinfection and use of dedicated equipments Enforce respiratory etiquette Continue to enforce mandatory staff vaccination 10 Page 24 of 73

Goals Reduce C-difficile acquisition by 40% (SIR=0.6) the end of 2017 Goal not met: January -September 2017 However SIR= 0.85 which is lower than state or national Gaps/Barriers Increased hospital onset C-difficile in January 2017 to Sept 2017 (48 cases) Increased colonization pressure/ incidence density thus increased possibility of transmission Inappropriate cleaning and disinfection practices/use of bleach Corrective Measures Feedback to leadership and staff Monitor consistent supply/use of bleach disinfectant Automated isolation orders Staff and Environmental Services education (May 2017: EVS=137 staff) Isolation signage, hand hygiene with soap and water Illinois SIR= 1.0 USA SIR=0.92. 11 Page 25 of 73

12 Goals Reduce MRSA acquisition by 40% the end of 2017 Goal met: January -September 2017 SIR= 0.57 Illinois SIR=0.65 USA SIR=0.95 Gaps/Barriers Three cases of MRSA bacteremia, Jan. 2017 to Sept. 2017 Need to continue MRSA screening upon ICU admission as required by law Page 26 of 73 Corrective Measures Feedback to leadership and staff Staff /Patient education Cleaning/disinfection and use of dedicated equipment Automated orders for screening and isolation Continue monitoring for infection control practices

Goals Reduce CRE acquisition by 40% the end of 2017 Goal met: January-September 2017= 0 cases Gaps/Barriers Increased in the number of cases admitted from Nursing Home and outside hospitals Compliance of CRE screening on admission Compliance with infection control practices Corrective Measures Feedback leadership and staff Automated orders for screening and isolation Cleaning/disinfection and use of dedicated equipment Endoscope quarantine and culture procedure XDRO registry reporting/alerts. 13 Page 27 of 73

Goals Improve hand hygiene compliance rate from 72% to 90% by the end of 2017 Hand Hygiene compliance is currently insufficient at 72% (median) Gaps/Barriers Limited observation data Getting timely and accurate data Time consuming data entry Corrective Measures Utilize The Joint Commission targeted solutions tools (TST) Timely compliance feedback Collaborate with other disciplines about improvement initiatives Explore innovative approaches to monitor compliance, i.e. electronic monitoring 14 Page 28 of 73

Appendix 15 Page 29 of 73 Presentation Title in Footer I Date

Risk Assessment Geographic Location and Community Environment John H. Stroger Jr. Hospital of Cook County (JSHCC) cares for all patients of all ages primarily from the Metropolitan Chicago as well as the surrounding suburbs of Cook County and Cook County Jail. The threat of mass casualty, terrorism in all its forms, and other human events are taken into consideration. Characteristics of the Population Served JSHCC serves a diverse community, largely uninsured. A high percentage of the population includes African Americans and Hispanics, as well as foreign born. Sub populations within these groups are trauma (Level 1) and burn patients, high risk neonates (Level 3), those with TB and HIV, and incarcerated persons. Results of Analysis of JSHCC Infection, Prevention and Control Data Data analyzed include daily microbiological (culture) results, Surgical Site Infection (SSI) rates, device related infection rates, communicable disease exposure events and environmental incidents. These data are analyzed and reviewed for variances regularly (daily for microbiology data and monthly for others). Care, Treatment and Services Provided JSHCC has 533 beds. (254 Med/Surg/Burn Step Down, 76 ICU, 52 Neonatal ICU, 28 Pediatrics, 10 PICU, 26 Nursery, 37 OB/Gyne/LDR, 14 Flex Unit, and 36 ED/Trauma Obs.). The high volume and/or high-risk services are assessed for surveillance and adaptable measures that can be followed. Employee Health JSHCC provides a safe working environment for employees through the collaboration of Infection Control and Employee Health to identify potentially infectious conditions that may pose a risk for patients, visitors and staff. Emergency Preparedness JSHCC works continuously to be ready for an internal or external emergency, including but not limited to a short or long term influx of infectious patients. 16 Page 30 of 73

High Risk Priority 1. Risk for acquisition and transmission of infections and Surgical Site Infections (SSI), (Risk Score=7) Improper cleaning, disinfection, and sterilization of medical equipment, devices, and supplies Need for patient, family, staff education on SSI High utilization of Immediate Use Steam Sterilization (IUSS). Need for adherence to Chlorhexidine preoperative bath Lapses in skin prep and infection control during OB/Gyne procedures. Potential for transmission of infections related to ERCP procedures. 2. Risk for exposure to Influenza and Emerging/Reemerging Infectious Diseases, (Risk Score=7) Recent outbreaks of Ebola Virus Disease, Middle East Respiratory Syndrome, Novel Influenza Virus. 3. Risk for Central Line Associated Blood Stream Infections (CLABSI), (Risk Score=7) Need for patient, family, staff education on CLABSI. Inappropriate access, care, and maintenance of CVC lines/hubs/ports Inconsistent use of CHG bath, CHG prep., large drapes. 4. Risk for transmission of Multi-drug Resistant Organisms (MDRO), (Risk Score=7) Emergence of CRE cases admitted from long term care facilities. Increase in SIR of health care onset Clostridium difficile Need for patient, family, staff education on MDRO. 17 Page 31 of 73

High Risk Priority, cont d 5. Low hand hygiene compliance among healthcare workers, (Risk Score=7) Non-compliance with nail hygiene policy. Hand hygiene data do not represent hospital wide practice. Inaccurate, untimely data reporting and time consuming data entry. Lack of consistent staff/leadership commitment and accountability. 6. Risk for Catheter Associated Urinary Tract Infection (CAUTI), (Risk Score=7) Poor compliance with urinary catheter care and maintenance. All-in-one urinary catheter set not available Poor compliance with CHG bath. Inconsistent documentation of catheter assessment, insertion, care, and maintenance. 7. Risk for transmission of blood borne/bacterial infections related to misuse of medication vials, (Risk Score=7) Inappropriate labeling and use of medication vials. Misuse of single-dose/single-use and multiple-dose vials 18 Page 32 of 73

Glossary Carbapenem-resistant Enterobacteriaceae (CRE): Any Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Enterobacter spp. testing resistant to imipenem, meropenem, doripenem, or ertapenem by standard susceptibility testing methods OR by production of a carbapenemase (i.e., KPC, NDM, VIM, IMP, OXA-48) demonstrated using a recognized test (e.g., polymerase chain reaction, metallo-β-lactamase test, modified-hodge test, Carba-NP). Catheter-associated Urinary Tract Infection (CAUTI): A urinary tract infection where an indwelling urinary catheter was in place for >2 calendar days on the date of event. Central line-associated Blood Stream Infections (CLABSI) : A laboratory-confirmed bloodstream infection where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event. Deep Incisional Primary (DIP): A deep incisional surgical site infection that is identified in a primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CBGB). Healthcare-Associated Infections(HAI): An infection patients can get while receiving medical treatment in a healthcare facility. Healthcare Facility-Onset (HO): A laboratory specimen collected >3 days after admission to the facility (i.e., on or after day 4). Standardized Infection Ratio (SIR): A summary measure which compares the actual number of Healthcare Associated Infections (HAI) in a facility with the baseline data for standard population. SIR >1.0 indicates more HAIs were observed than predicted, conversely, SIR of <1.0 indicates that fewer HAIs were observed than predicted. Surgical Site Infection (SSI): An infection of the incision or organ or space that occur after surgery. 19 Page 33 of 73

Infection Control Dashboard Page 34 of 73

Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting October 20, 2017 ATTACHMENT #3 Page 35 of 73

CCHHS Board of Directors Quality and Patient Safety Committee Nursing Presentation Agnes Therady, RN Chief Nursing Officer Page 36 of 73 1

Nurse Sensitive Indicator Scorecards and Action Plans CY16 Q3 to CY17 Q1 Page 37 of 73 2

NDNQI Scorecard CCHHS Aggregate NDNQI Scorecard: CCHHS Aggregate CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target CCHHS (Percentile/Score) NDNQI CCHHS (Percentile/Score) NDNQI CCHHS (Percentile/Score) Total Nursing Hours Per Patient Day N/A N/A N/A N/A 25 th % -0.51-0.14 Total RN Hours Per Patient Day N/A N/A N/A N/A 50 th % -0.43-0.2 Patients with Physical Restraints (Prevalence Survey) 75 th % 0.29 0.01 75 th % 0.44 0.00 75 th % 0.25-0.01 Patients with Hospital Acquired Pressure Injuries (Prevalence Survey) NDNQI 50 th % 0.09-0.01 50 th % 0.04 0.02 75 th % 0.46 0.03 Total Patient Falls Per 1,000 Patient Days 25 th % -0.41 0.03 50 th % -0.28 0.03 25 th % -0.34 0.05 Injury Falls Per 1,000 Patient Days 25 th % -0.52 0.02 50 th % 0.06 0.04 50 th % 0.00 0.03 Total Patient Falls Per 1,000 Patient Visits/Cases 25 th % -0.21 0.07 25 th % -0.10 0.08 25 th % -0.09 0.07 Injury Falls Per 1,000 Patient Visits/Cases 25 th % -0.29 0.15 75 th % 0.18 0.13 25 th % -0.12 0.1 Ventilator-Associated Events per 1000 Ventilator Days 75 th % 0.44-0.04 75 th % 0.50 0.00 75 th % 1.09-0.03 Catheter Associated Urinary Tract Infections per 1000 Catheter Days Central Line Associated Blood Stream Infections per 1000 Central Line Days 75 th % 0.75-0.02 25 th % -0.12-0.05 75 th % 0.76-0.01 25 th % -0.22 0.03 10 th % -0.46 0.06 50 th % 0.22 0.01 Peripheral IV Sites with Infiltrations 10 th % -0.21 0.02 10 th % -0.23 0.03 10 th % -0.2 0.03 Page 38 of 73 3

Hospital Acquired Pressure Injury (HAPI) Action Plan PERIOD TARGET STATUS PLAN CY16 Q3-0.01 0.09 Wound care RN team (2) hired as of September 25. Increased focus on HAPI prevention. CY16 Q4 0.02 0.04 CY17 Q1-0.03 0.46 Nursing leadership conducts daily skin rounds on units not meeting target. New safe patient handling program implemented, will assist the staff to turn Q2, and reduce friction erosion and shear during transfer. Multidisciplinary HAPI prevention team in place and will review monthly HAPI reports. High risk patients will receive care in appropriate beds with pressure redistribution surfaces. Page 39 of 73 4

Physical Restraints Action Plan PERIOD TARGET STATUS PLAN CY16 Q3 0.01 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. CY16 Q4 0.00 0.44 Categorize patients according to risk for selfextubation. Restraint Rounds utilizing definitions to reduce restraint use. CY17 Q1-0.01 0.25 Individualized care plans for restraint reduction. Page 40 of 73 5

Vent-Associated Events Action Plan ACTION PLAN TARGET STATUS PLAN CY16 Q3-0.04 0.44 Best practices in use include: Closed suction system, break the circuit only if necessary Chlorohexidine oral care Daily Sedation vacation and spontaneous breathing trail unless medically contraindicated Early mobilization and exercise (safe patient CY16 Q4 0.00 0.50 handling go live on November 27 th ) Head of Bed elevation Continuous ongoing staff education and competency assessment CY17 Q1-0.03 1.09 Daily monitoring of on VAP bundle compliance Celebrate success and make improvements Page 41 of 73 6

Catheter Associated Urinary Tract Infections Action Plan PERIOD TARGET STATUS PLAN CY16 Q3-0.02 0.75 Daily monitoring of CAUTI bundle compliance Use of alternate urine-collection methods to avoid disruption of closed catheter system CY16 Q4-0.05-0.12 Catheter use on as-needed basis CY17 Q1-0.01 0.76 Page 42 of 73 7

Nurse Leader Rounding Data Collection Period: August to Present (standardized tool). Previous data collection processes variable. Rounding Tool Tool Link Response Tracking Link AIDET Compliance AIDET Compliance Tool AIDET Compliance Tracking Purposeful Rounding: Patient Experience Patient Experience Rounding Tool Inpatient Rounding Tool Patient Experience Tracking Inpatient Rounding Tracking Rounding Checklists Maternal Child Rounding Tool NICU Rounding Tool Maternal Child Rounding Tracking NICU Rounding Tracking Page 43 of 73 8

AIDET Compliance Manager Rounding Results AIDET: Acknowledge, Introduce, Duration, Explanation, and Thank You Rounding Tool Scorecard Topbox % Green = At or Above Target AIDET Compliance Red = Below Target Med-Surg Units Goal: 85% or above Critical Care Units Maternal Child and Peds Units Emergency Department Staff knocks on the door and asks permission to come in. 91.0% 100.0% 98.7% 92.7% Staff states his/her name and classification. 99.2% 100.0% 100.0% 91.0% Staff checks patient name and date of birth before proceeding to administration of meds, procedures or 98.6% 100.0% 99.1% 69.4% treatment. Staff explains any treatments or procedures. 98.2% 97.8% 100.0% 85.9% Staff addresses all of patient's questions/concerns. 98.0% 95.7% 100.0% 92.2% Staff explains the amount of time a procedure or treatment takes. 93.3% 84.8% 100.0% 66.7% Staff tells patient Thank you if applicable. 98.3% 72.3% 99.6% 86.4% Staff informs patient when she/he is leaving and another nurse will provide care. 95.1% 74.2% 100.0% 41.7% Page 44 of 73 9

Rounding on Patients: Patient Comments COMMENT THEME Staff Attitude Call Light Response Cleanliness Communication EXAMPLES It is not all of the nurse. the majority of the nurses are good but some of them need to change their attitude. The day shift is really nice but I felt the nice shift nurse felt bothered. She was gracious but ned [sic] to smile. The nurse need to come when I need help. I tried to reach my call light and couldn t, my room mate had to call the nurse. Answer my call light sooner. Just one nurse acted like she did not want to answer my call light. Took 20 mins It should be cleaner for a hospital. "The Nurses are great but housekeeping is sorely lacking." Improve communicate[sic] among themselves so that when a nurse is relieving another nurse they know what's going[sic] Better bedside manner by some nursing staff. Not all. Some are very good. Food Interpreters Pain Management The food is not enough and does not taste good. Need to choice on what type of food to be served. The food can be better and trays too late. Be patient because of the language barrier. Nurses use interpreter phone sometime but it best to have an in person interpreter. "I am in pain, I have surgery on my right thigh. Tell them to give me my pain medications Anticipate my need. When sick can't help self. Pain medication on time. Staff sometimes slow. Next time the doctors say that they are going to write something for pain, they need to do it. Before leaving the floor because it is hard for the nurses to get them once they leave. Page 45 of 73 10

Nurse Satisfaction Annual Survey 2017 in progress, survey ends October 22 Page 46 of 73 11

Questions? Page 47 of 73 12

APPENDIX Page 48 of 73 13

Nursing Hours Per Patient Day Unit-level Data Med-Surg Units Unit Result NDNQI Mean 4 Flex - 8970347 8.57 8.86 6 East - 8970346 7.3 8.86 6 West - 8970328 7.12 8.86 6 South - 8970344 6.69 8.86 7 East - 8970340 6.95 8.86 7 West - 8970342 6.71 8.86 7 South - 8970343 6.98 8.86 8 East - 8970329 6.6 8.8 8 West - 8970330 6.68 8.8 8 South - 8970331 6.18 8.8 Critical Care Units Unit Result NDNQI Mean Critical Care Burn - 8970351 17.18 16.94 Critical Care Coronary - 8970354 15.9 16.94 Critical Care Medical - 8970355 16.94 16.94 Critical Care Neurology - 8970349 19 16.94 Critical Care Surgical - 8970350 17.66 16.94 Critical Care Trauma - 8970358 20.77 16.94 Maternal Child Units Unit Result NDNQI Mean PICU 8970324 21.91 19.48 Pediatrics - 8970362 14.07 12.85 NICU - 8970363 15 12.52 OB - 8970317 6.39 7.14 Gyne - 8970320 10.17 11.5 Green = At or Above Target Red = Below Target NDNQI Mean = Average number of nursing hours per patient day Page 49 of 73 14

Patients with Physical Restraints Critical Care Units Data collected through quarterly point prevalence survey. NDNQI Scorecard: Critical Care CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Patients with Physical Restraints (Limb and/or Vest) Adult Critical Care Cohort 26.11 14.14 18.33 14.90 21.11 16.51 Critical Care Burn - 8970351 0.00 14.14 66.67 14.90 33.33 16.51 Critical Care Coronary - 8970354 0.00 14.14 0.00 14.90 0.00 16.51 Critical Care Medical - 8970355 30.00 14.14 16.67 14.90 22.22 16.51 Critical Care Neurology - 8970349 50.00 14.14 20.00 14.90 20.00 16.51 Critical Care Surgical - 8970350 22.22 14.14 0.00 14.90 28.57 16.51 Critical Care Trauma - 8970358 75.00 14.14 75.00 14.90 14.29 16.51 Burn Step Down - 8970352 0.00 4.33 0.00 6.39 0.00 1.14 Page 50 of 73 15

Hospital Acquired Pressure Injuries Critical Care Units Data collected through quarterly point prevalence survey. NDNQI Scorecard: Critical Care CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Patients with Hospital Acquired Pressure Injuries Adult Critical Care Cohort 13.33 4.64 12.50 5.39 14.29 5.50 Critical Care Burn - 8970351 0.00 4.64 0.00 5.39 33.33 5.50 Critical Care Coronary - 8970354 0.00 4.64 0.00 5.39 0.00 5.50 Critical Care Medical - 8970355 10.00 4.64 27.78 5.39 16.67 5.50 Critical Care Neurology - 8970349 16.67 4.64 0.00 5.39 0.00 5.50 Critical Care Surgical - 8970350 22.22 4.64 25.00 5.39 14.29 5.50 Critical Care Trauma - 8970358 25.00 4.64 25.00 5.39 14.29 5.50 Burn Step Down - 8970352 0.00 4.90 14.29 4.65 0.00 1.79 Page 51 of 73 16

Patients with Physical Restraints Med-Surg Units NDNQI Scorecard: Med-Surg CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit Unit Unit NDNQI Patients with Physical Restraints (Limb and/or Vest) Adult Medical Cohort 0 0.7 0 0.62 0 0.51 6 East - 8970346 0 0.7 0 0.62 0 0.51 6 West - 8970328 4.17 0.7 0 0.62 0 0.51 6 South - 8970344 0 0.7 3.85 0.62 0 0.51 7 East - 8970340 0 0.7 4.35 0.62 0 0.51 7 West - 8970342 5.88 0.7 0 0.62 4.55 0.51 7 South - 8970343 0 0.7 0 0.62 0 0.51 4 Flex - 8970347 0 0.7 0 0.62 0 0.51 Adult Med-Surg Combined Cohort 0 0.41 0 0.63 0 0.4 8 East - 8970329 0 0.41 4.55 0.63 0 0.4 8 West - 8970330 0 0.41 0 0.63 0 0.4 8 South - 8970331 0 0.41 0 0.63 3.85 0.4 Page 52 of 73 17

Hospital Acquired Pressure Injuries Med-Surg Units NDNQI Scorecard: Med-Surg CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Patients with Hospital Acquired Pressure Injuries Adult Medical Cohort 0 1.47 0 1.57 0 1.65 6 East - 8970346 0 1.47 0 1.57 5.88 1.65 6 West - 8970328 4.17 1.47 0 1.57 0 1.65 6 South - 8970344 0 1.47 3.85 1.57 0 1.65 7 East - 8970340 0 1.47 0 1.57 9.09 1.65 7 West - 8970342 0 1.47 0 1.57 4.55 1.65 7 South - 8970343 0 1.47 0 1.57 0 1.65 4 Flex - 8970347 0 1.47 0 1.57 0 1.65 Adult Med-Surg Combined Cohort 0 1.22 0 1.34 0 1.28 8 East - 8970329 0 1.22 0 1.34 0 1.28 8 West - 8970330 4.76 1.22 0 1.34 9.09 1.28 8 South - 8970331 0 1.22 0 1.34 0 1.28 Page 53 of 73 18

Pressure Injuries and Restraints Women and Children Services NDNQI Scorecard: Women and Children Services CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Patients with Physical Restraints (Limb and/or Vest) Critical Care Pediatrics - 8970362 No Data 8.21 0.00 4.58 0.00 3.95 Critical Care Neonatal - 8970363 0.00 0.10 0.00 0.00 0.00 0.02 Pediatrics - 8970324 No Data 0.30 0.00 0.27 0.00 0.22 Patients with Hospital Acquired Pressure Injuries Critical Care Pediatrics - 8970362 No Data 1.72 33.33 2.91 0.00 4.05 Critical Care Neonatal - 8970363 0.00 0.21 0.00 0.56 0.00 0.34 Pediatrics - 8970362 No Data 0.20 0.00 0.34 0.00 0.19 Page 54 of 73 19

Patient Falls with Injury Critical Care Units NDNQI Scorecard: Critical Care CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Injury Falls Per 1,000 Patient Days Adult Critical Care Cohort 0.00 0.20 0.00 0.18 0.00 0.19 Critical Care Burn - 8970351 0.00 0.20 0.00 0.18 0.00 0.19 Critical Care Coronary - 8970354 0.00 0.20 0.00 0.18 0.00 0.19 Critical Care Medical - 8970355 0.00 0.20 0.00 0.18 0.00 0.19 Critical Care Neurology - 8970349 0.00 0.20 0.00 0.18 1.83 0.19 Critical Care Surgical - 8970350 0.00 0.20 0.00 0.18 0.00 0.19 Critical Care Trauma - 8970358 0.00 0.20 0.00 0.18 0.00 0.19 Burn Step Down - 8970352 0.00 0.29 0.00 0.38 0.00 0.17 Page 55 of 73 20

Patient Falls with Injury Med-Surg Units NDNQI Scorecard: Med-Surg CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Injury Falls Per 1,000 Patient Days Adult Medical Cohort 0.00 0.64 0.51 0.69 0.50 0.68 6 East - 8970346 0.00 0.64 0.00 0.69 0.50 0.68 6 West - 8970328 0.00 0.64 0.51 0.69 0.00 0.68 6 South - 8970344 0.00 0.64 1.48 0.69 1.39 0.68 7 East - 8970340 0.59 0.64 0.52 0.69 0.00 0.68 7 West - 8970342 0.00 0.64 0.00 0.69 0.50 0.68 7 South - 8970343 0.00 0.64 1.08 0.69 0.99 0.68 4 Flex - 8970347 0.00 0.64 0.00 0.69 0.00 0.68 Adult Med-Surg Combined Cohort 0.00 0.59 0.51 0.58 0.91 0.58 8 East - 8970329 0.00 0.59 0.57 0.58 0.48 0.58 8 West - 8970330 0.00 0.59 0.51 0.58 0.94 0.58 8 South - 8970331 0.53 0.59 0.00 0.58 0.91 0.58 Page 56 of 73 21

Patient Falls with Injury Women and Children Services NDNQI Scorecard: Women and Children Services CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Injury Falls Per 1,000 Patient Days Critical Care Pediatrics - 8970362 0.00 0.08 0.00 0.08 4.13 0.15 Critical Care Neonatal - 8970363 0.00 0.00 0.00 0.00 0.00 0.00 Pediatrics - 8970324 0.00 0.42 2.19 0.36 0.00 0.51 4 South OB - 8970317 0.00 0.04 0.77 0.04 0.00 0.09 4 North Gyne - 8970320 0.00 0.15 0.00 0.40 0.00 0.10 Page 57 of 73 22

Patient Falls with Injury Emergency Dept. & Trauma NDNQI Scorecard: Emergency Dept. & Trauma CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Injury Falls Per 1,000 Patient Visits/Cases Emergency Room - 8910512 0.00 0.09 0.23 0.08 0.03 0.07 Trauma Observation - 8970356 0.00 0.50 4.33 0.67 0.00 0.30 Trauma Resuscitation - 8970357 0.00 No Data 0.00 0.05 No Data 0.12 Page 58 of 73 23

Patient Falls with Injury Perioperative Services NDNQI Scorecard: Perioperative Services CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Injury Falls Per 1,000 Patient Visits/Cases PACU - 8970365 No Data 0.00 0.00 0.00 0.00 0.01 Clinic C Preadmission testing - 8910513 0.00 0.01 No Data 0.02 0.00 0.01 Same Day Surgery - 8970369 0.00 0.06 0.00 0.05 0.00 0.04 Endoscopy - 8970367 0.00 0.02 0.77 0.03 0.77 0.03 Oak Forest Endoscopy 0.00 0.02 0.00 0.03 0.00 0.03 Page 59 of 73 24

Patient Falls with Injury Procedural Units NDNQI Scorecard: Procedural CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Injury Falls Per 1,000 Patient Visits/Cases Dialysis - 8977412 0.00 0.03 0.00 0.03 0.00 0.04 Infusion Clinic - 8977407 0.00 0.06 0.00 0.05 0.00 0.05 Pain Clinic - 8977413 0.00 0.03 0.00 0.03 0.00 0.04 Page 60 of 73 25

Patient Falls with Injury Ambulatory Clinics NDNQI Scorecard: Ambulatory Clinics CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Injury Falls Per 1,000 Patient Visits/Cases Antepartum Testing Unit - 8970315 0.00 0.03 0.00 0.03 0.00 0.15 CORE Center - 8941301 0.00 0.03 0.00 0.03 0.00 0.15 Employee Health - 8970284 0.00 0.03 0.00 0.03 0.00 0.15 Fantus Adult Medical Specialties 0.00 0.03 0.00 0.03 0.05 0.15 Fantus General Medicine Clinic 0.00 0.03 0.00 0.03 0.00 0.15 Maternal Child Clinic 0.00 0.03 0.00 0.03 0.00 0.15 Oak Forest Health Center Specialty Care Center - 8930434 0.00 0.03 0.13 0.03 0.00 0.15 Oak Forest Primary Care 0.00 0.03 0.00 0.03 0.00 0.15 Public Health Department 0.00 0.03 0.00 0.03 0.00 0.15 Robbins Health and Cottage Grove Health Center 0.00 0.03 0.00 0.03 0.00 0.15 Sengstacke (Specialty and Primary Care) 0.00 0.03 0.00 0.03 0.00 0.15 South Region and Austin - 8930422 0.00 0.03 0.00 0.03 0.00 0.15 Stroger Specialty Clinics 0.03 0.03 0.06 0.03 0.06 0.15 West and North Region 0.00 0.03 0.00 0.03 0.00 0.15 Page 61 of 73 26

Vent-Associated Events Critical Care Units NDNQI Scorecard: Critical Care CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Ventilator-Associated Events per 1000 Ventilator Days Adult Critical Care 16.49 6.85 13.79 6.44 11.82 6.08 Critical Care Burn - 8970351 No Data 6.85 17.86 6.44 23.81 6.08 Critical Care Coronary - 8970354 No Data 6.85 0.00 6.44 0.00 6.08 Critical Care Medical - 8970355 16.49 6.85 9.73 6.44 13.59 6.08 Critical Care Neurology - 8970349 0.00 6.85 25.64 6.44 0.00 6.08 Critical Care Surgical - 8970350 No Data 6.85 0.00 6.44 10.05 6.08 Critical Care Trauma - 8970358 18.40 6.85 24.63 6.44 21.18 6.08 Page 62 of 73 27

CAUTI and CLABSI Critical Care Units NDNQI Scorecard: Critical Care CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Catheter Associated Urinary Tract Infections per 1000 Catheter Days Adult Critical Care 5.43 1.41 0.00 1.36 3.06 1.28 Critical Care Burn - 8970351 No Data 1.41 0.00 1.36 6.41 1.28 Critical Care Coronary - 8970354 0.00 1.41 0.00 1.36 0.00 1.28 Critical Care Medical - 8970355 0.00 1.41 2.15 1.36 1.07 1.28 Critical Care Neurology - 8970349 16.81 1.41 0.00 1.36 5.05 1.28 Critical Care Surgical - 8970350 5.43 1.41 0.00 1.36 0.00 1.28 Critical Care Trauma - 8970358 7.22 1.41 2.00 1.36 6.12 1.28 Burn Step Down - 8970352 No Data No Data 0.00 1.90 0.00 3.14 Central Line Associated Blood Stream Infections per 1000 Central Line Days Adult Critical Care 0.00 0.95 0.00 0.92 0.00 0.86 Critical Care Burn - 8970351 No Data 0.95 0.00 0.92 0.00 0.86 Critical Care Coronary - 8970354 0.00 0.95 0.00 0.92 0.00 0.86 Critical Care Medical - 8970355 0.00 0.95 0.00 0.92 1.54 0.86 Critical Care Neurology - 8970349 0.00 0.95 0.00 0.92 0.00 0.86 Critical Care Surgical - 8970350 0.00 0.95 0.00 0.92 0.00 0.86 Critical Care Trauma - 8970358 0.00 0.95 0.00 0.92 5.28 0.86 Burn Step Down - 8970352 No Data No Data 0.00 0.82 0.00 1.24 Page 63 of 73 28

Central Line Associated Blood Stream Infections Med-Surg Units NDNQI Scorecard: Med-Surg CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Central Line Associated Blood Stream Infections per 1000 Central Line Days Adult Medical 0.00 0.89 0.00 0.96 0.00 0.68 6 East - 8970346 0.00 0.89 0.00 0.96 0.00 0.68 6 West - 8970328 0.00 0.89 0.00 0.96 0.00 0.68 6 South - 8970344 0.00 0.89 0.00 0.96 0.00 0.68 7 East - 8970340 0.00 0.89 0.00 0.96 0.00 0.68 7 West - 8970342 0.00 0.89 0.00 0.96 0.00 0.68 7 South - 8970343 0.00 0.89 0.00 0.96 0.00 0.68 4 Flex - 8970347 0.00 0.89 No Data 0.96 No Data 0.68 Adult Med-Surg Combined 0.00 0.74 0.00 0.70 0.00 0.61 8 East - 8970329 0.00 0.74 0.00 0.70 0.00 0.61 8 West - 8970330 6.13 0.74 0.00 0.70 0.00 0.61 8 South - 8970331 0.00 0.74 No Data 0.70 0.00 0.61 Page 64 of 73 29

CAUTI, CLABSI and PIV Women and Children Services NDNQI Scorecard: Women and Children Services CY16 Q3 CY16 Q4 CY17 Q1 Green = At or Above Target Red = Below Target Unit NDNQI Unit NDNQI Unit NDNQI Catheter Associated Urinary Tract Infections per 1000 Catheter Days Critical Care Pediatrics - 8970362 15.15 1.36 0.00 1.68 34.48 1.86 Pediatrics - 8970324 0.00 1.28 0.00 0.26 0.00 0.30 Central Line Associated Blood Stream Infections per 1000 Central Line Days Critical Care Pediatrics - 8970362 0.00 0.98 0.00 1.43 0.00 0.94 Critical Care Neonatal - 8970363 0.00 1.50 1.98 1.25 0.00 0.91 Pediatrics - 8970324 0.00 0.75 0.00 0.74 0.00 0.62 Percent of Peripheral IV Sites with Infiltrations Critical Care Pediatrics - 8970362 0.00 0.19 0.00 0.79 No Data 0.51 Critical Care Neonatal - 8970363 0.00 1.65 No Data 1.62 No Data 1.71 Pediatrics - 8970324 0.00 0.97 0.00 0.41 0.00 0.66 Page 65 of 73 30

Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting October 20, 2017 ATTACHMENT #4 Page 66 of 73

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