Quality Council Minutes February 19, 2013 Attendance: Excused: Guest(s): Sue Carlisle, Elaine Coleman, Sue Currin, Terry Dentoni, Tom Holton, William Huen, Rachel Kagan, Elaine Lee (represented by Yvette Gamble), Tina Lee, Anson Moon, Iman Nazeeri-Simmons, Roland Pickens, Sue Schwartz, Troy Williams Alice Chen, Morgen Elizabethchild, Doug Eckman, Valerie Inouye, Shermineh Jafarieh, Cheryl Kalson, Kathy Jung, Jay Kloo, Todd May, Cathryn Thurow, Shannon Thyne, Lann Wilder, David Woods Kathy Ballou, Brandi Frazier, Grad Green, Joseph Griffin, Mark Leary, Laure Marshall, Kim Nguyen, Edna Paredes, Dennise Rosas, Baljeet Sangha, Linda Sims, Sharon Wicher. TOPIC DISCUSSION ACTION ADMINISTRATIVE Sue Currin and Will Huen chaired the meeting. Agenda for today s meeting was presented for review. The Minutes of the January 2013 meeting were presented for approval. Joseph Griffin, new Health Educator, was introduced to the group. Agenda reviewed Minutes approved POLICIES AND PROCEDURES The following policy and procedures were presented by Sue Schwartz: Policy 8.14-HIPPA Compliance : Policy for Secure Transmission of Protected Health Information (PHI) Adapted existing DPH policy language to SFGH Policy 9.19-Influenza Vaccine: Staff, Inclusive of Employees, Faculty, Contractors, Volunteers, and Students No changes. Policy 18.01-Boarding Infant of the Readmitted Post-Partum Mother Minor changes to the admitting process were added. The AOD will now be notified of a boarding infant admission. The Nursery Attending physician will record a daily note on the infant's status. All policies and procedures were approved 1
Psychiatry/PES Kathy Ballou and Mark Leary presented the performance improvement report for Psychiatry and Psychiatric Emergency Services (PES): Seclusion 7A-7B-7C AIM: Maintain seclusion rate at less than 2% 2012 7A Seclusion rate = 3.31% 8/116 patients accounted for 37% of total seclusion episodes Seclusion is the least restrictive intervention in order to interrupt patient escalation and avoid assaults. Restraints 7A-7B-7C AIM: Maintain restraint rate at less than 2%. 2012 7A Restraint rate = 1.6% - Met AIM [total episodes per month / total psych inpatient days x100] 4/66 patients had >5 restraint episodes and accounted for 32% of total restraint episodes Ongoing Psychiatric Rapid Response Training Continuous monitoring of use of seclusion in locked inpatient psychiatric units. Initiate Psychiatry Medication Agitation Protocol to insure patients admitted to 7A from PES and 7L have adequate medications. 7A Safety Workgroup AIM: Reduce violence and improve safety on Unit 7A by reducing the incidents of Patient to Patient and Patient to Staff assaults to 0. Changes implemented included: Revised various Communication protocols such as SBAR tool Developed algorithms for Management of Escalating Psychiatric Emergency on unit 7A. Developed Medication Acute Agitation Protocol for inpateint admissions from PES and Med/Surg Initiated paging of Code Green on unit 7A to alert staff of escalating patient situation. Implemented staff coaching on communication style with patients to assist with managing escalating patient situations. There was discussion about incorporating patient transfer to next level of care into algorithims or protocols initiated in acute Psychiatry (e.g. to BHC). Units 7A-7B-7C Patient to Staff Assaults Review of collection of patient to staff assaults AIM: Reduce total patient to staff assault incidents on Units 7A-7B-7C to 0. Review Safety Workgroup recommendations at Inpatient Steering Meeting-February 2013 Review effectiveness of in reducing patient to patient and patient to staff assault in June and December 2013. In the future, algorithms will incorporate patients moving to next level of care. 2
Psychiatry/PES 23% Overall Decrease patient to Staff Assaults 2011-2012 2012 Rate of Staff Assaults 7A/7B/7C =.16% a decrease from.44% in 2011. Decrease in incidents of staff assaults by patients with organic deficits from 43% in response to staff education on safe management of patients with organic deficits. Analysis of patient to staff assaults identified several contributing factors, including: Staff engaging with an agitated patient, adequate staff back up with agitated patients, need for adequate staff vigilance with high risk assault patients. 7A-7B-7C patient to patient Assault AIM: Reduce total patient to patient assault incidents on Units 7A-7B-7C to 0 7.3% overall Decrease Patient to Patient Assaults 2011 to 2012 Patient to patient assaults during change of shift; 7A=25% [5/20], 7B=80% [4/5] 7B 60% [patient to patient assaults were by patients with cognitive disorders 7A 50% of patients who attacked were diagnosed with Personality D/o and 50% were diagnosed with Substance Abuse/Dependence 67% of known assault triggers due to social disagreements/conflicts between patients. Majority of patient to patient assaults was not witnessed by staff and involved roommates Follow up actions include: Medication related improvements: Use of Medication Agitation Protocol and nursing education on appropriate use of as needed and emergency medications. Staff training focused on building skills for handling escalating patient situations. Improving communication, such as consistent use of 7A whiteboard to alert staff of high risk assault patients, use of revised SBAR to ensure high risk information is documented and communicated. Psychiatric Emergency Service Seclusion and Restraints AIM: Maintain seclusion rate at less than 10%. Maintain restraint rate at less than 5%. 2012 total number of PES Intakes = 6509 % Restraints = 4.9% of total intakes Met AIM % Seclusion = 9.0% of total intakes Met AIM PES patient to Staff and patient to patient Assaults AIM: Reduce total patient to staff and patient to patient assault incidents in PES to 0. Results 2012 Total Number PES Discharges = 6293 % patient to patient Assaults =.03% of total discharges % patient to Staff Assaults =.19% of total discharges 50% [6/12] staff assaults occurred within 3 hours of patient admission to PES with 4/12 staff assaults occurring within the first hour of PES patient admission. PES- Condition Red AIM: Maintain PES Condition Red status below 25% Ongoing Psychiatric Rapid Response Training for all PES staff. Continuous monitoring of use of seclusion and restraints Staff education regarding timely and appropriate use of medications. Staff coaching on safely intervening with escalating patients. 3
Psychiatry/PES 2012 Average % Condition Red = 15% - Met AIM Influencing Factors: New PES Medical Director appointed in July 2012 and identified need to decrease PES length of stay by initiating: Focus on patients who have been in PES >18 hours. Culture change around allowing patients who arrive mid-late in the day to stay the night in PES. Improving interdisciplinary [RN/MD] collaboration Enhanced PES collaboration with outside services Enhanced PES collaboration and processes with the psych inpatient team Initiated several organizational and procedural changes in PES. Council members commended the accomplishments of PES in decreasing Condition Red status in a short period of time. Decrease PES average length of stay (ALOS) to increase capacity. Ongoing collaboration with DPH Placement Team to discharge inpatients in a timely manner. Streamline PES admission process. 2013 AIM: Decrease Condition Red status below 10%. Patient Satisfaction Units 7A-7B-7C AIM: Overall patient satisfaction will increase when comparing survey results 2011 and 2012. Comparison of patient satisfaction regarding: Informed of reason for hospitalization, Orientation and adjustment to unit, Explanation of treatment plan, Attentiveness of staff to patient needs, feeling of safety and respect, cultural and language needs met. Results varied by unit Highest scores were in areas of: Respected by staff (73-88%) Cultural and language needs addressed (79-100%) Feeling safe on unit (69-81%) Lowest scores were in areas of: Told why I was in the hospital (59-61%) Explanation of treatment plan was clear (42-69% Factors influencing patient satisfaction include reorganization of Unit 7A as the only locked acute unit, which resulted in increased admissions, patient acuity and decreased length of stay. Additionally, Unit 7B changed to a sub-acute unit, with noted decrease in patient satisfaction on the 2012 survey. Explore strategies for increasing patient participation in satisfaction surveys on Units 7A/7B/7C Explore feasibility of initiating patient satisfaction surveys in Psychiatric Emergency Service Revise survey tool to more effectively gather information in the areas of service excellence, safety and clinical quality. Grad Green presented on performance initiatives in the Behavioral Health Center (BHC) Skilled Nursing Facility (SNF): Continue with current violence reduction plan 4
SFBHC SNF TOPIC DISCUSSION ACTION SFBHC SNF Resident-to-Resident Assaults AIM: To decrease incidents of Resident to Residents assaults by 5% in the Fiscal Year 2011-2012. In FY 11-12, incidents of assault increased to 52 (from 38 in previous 2 years), which was attributed to increase in patient census. In August of 2012, the census of the SFBHC SNF was decreased to 17 residents per unit (2 North and 2 South) and residents assigned to single rooms. 25 residents with diverse diagnosis, including dementia of different types, were discharged. The number of assaults dropped to 7 for the last 6 months after the census was reduced. It is anticipated that more space per patient will reduce incidents of assault. Wellness and Service Excellence initiatives are being rolled out in BHC and will be measured moving forward to assess the effectiveness in reducing assaults. SFBHC MHRC Insulin Administration Error Reduction (SNF) AIM: To reduce medication errors related to insulin transcription and administration by 30% of all episodes of insulin administration by December 2012. A staff survey was conducted regarding the safety, efficacy and ease of prevention insulin administration medical errors There was 1 insulin related medication error in 2012. There was discussion requesting additional analysis in the report and inclusion of additional performance improvement initiatives that are ongoing at the BHC. Topics were suggested, such as Assessments, Referrals to Rehab, Wellness activities for residents, staff satisfaction. Many issues that are being addressed were originally part of plans of corrections, which can be used as a reference. Linda Sims presented on performance initiatives in the Mental Health Rehabilitation Center (MHRC): SFBHC/MHRC Client to Client Assaults AIM: To decrease incidents of client to client and client to staff assaults by 10% by December 31 2012 Assault in long term care settings is defined by a wide range of behaviors that constitute intentional physical contact including pushing to use of weapons. There were 14 client to client assaults in 2012. 3 Clients had two or more assaults and Follow up was requested addressing: Utilization of current staff given reduction in census. Reporting on sexual assaults and actions taken. Continue with ongoing UO monitoring for insulin errors and re-evaluation if this data suggests we continue to have problems Performance measure metrics reflective of current initiatives to be added to report and resubmitted to Quality Council in March 2013. Continue with current violence reduction plan SMART training is continuing for staff to educate and prepare for 5
accounted for 8 of the assaults. Client to staff assaults increased by four in 2012, to 6 assaults. Three assaults were significant and one resulted in a staff injury. A violence reduction plan is in place, which includes: Immediate staff debriefing after an incident, including all staff involved Additional debriefing with larger staff group, including input from staff for training. Staff Education including follow up concerns from debriefing and SMART training. Review of resident individual service plans (ISP) and case conferences. There was discussion about the wide definition of assault and the need to confirm the regulatory definition from the licensing entity, California Dept of Social Services. Insulin Administration Error Reduction (MHRC) AIM: To reduce medication errors related to insulin administration to <1% of all episodes of insulin administration by December 31 2012. A staff survey was conducted regarding the safety, efficacy and ease of prevention insulin administration medical errors There was no insulin related medication error in 2012. assaults. Elaine Coleman will follow up on assault definition. 4A/SNF Edna Paredes presented performance improvement initiatives on unit 4A SNF: Environment of Care AIM: Provide a safe environment 100% of the time, free of obstacles and/or broken equipment for residents and staff by June 30, 2013. Background: Environmental rounds were completed to determine level of, clutter obstacles, and /or broken equipment for residents and staff. Reached & maintained goal for 2011 & 2012. 96 Environmental rounds complete Bi-weekly Environmental checks completed for 12 months with 100% compliance. Mock Survey in 4A was completed by the Regulatory last October, 2012 with no deficiencies. Updated Charge Nurse Round check list for each shift Continue tracking until June, 2013 Data presented quarterly during leadership and staff meetings. 6
Medication Administration Side Effects AIM: All residents will be educated on side effects of medication as well as indication for taking medication 100% of the time by June 30, 2013. 22 residents indicated that Staff always informed them of the side effects of their medications. Only one resident stated that a nurse sometimes informed him of the Side effects of medication being given. Goal was met for 2011 but declined on the first quarter of 2012. Q2 - Q4 2012, rate was maintained to 100 Nursing Documentation AIM: Care plan, pain assessment and reassessment, weights, wound care, resident education, I &Os documentation will be done with 100% compliance of the residents by June 30, 2013 Goal met for 2012 Additional performance improvement projects include: Response to DHS survey finding requiring sanitizing bedside tables prior to placing items Updated Med Pass Audit tool, in service for staff and ongoing monitoring. Implementation of new requirement for documenting behavior justifying indications for psychotropic medications on MD order. Compliance is 70% with follow up training done by pharmacist and ongoing monitoring. Wound Vac Identification of increase in wound maceration led to staff education from the Wound CNS to train staff on appropriate techniques for placing wound vacs. Data presented quarterly during leadership and staff meetings. 4A will continue to educate staff on informing patients about side effects and dosage levels. Monitoring of medication teaching will be revised to include patient teach back to assess patient understanding. Council members noted that the SNF has been working on improving patient flow and tracking Length of Stay (LOS), which has made a positive impact on the flow in 4A. A request was made to revise the report to include the LOS work. Additionally, in the future, 4A is encouraged to initiate performance improvement work that goes beyond quality control metrics and reflects the important work underway to improve efficiency and enhance the resident experience. There was discussion about the importance of assuring consistency in policies and procedures across all SFGH long term care settings, including 4A and the BHC. Edna will revise the current report to include LOS improvement and re-submit to Quality Management. New performance measures for 2013 will be reflective of current improvement work to be selected and tracked. 7
UPDATE: Patient Safety Plan Thomas Holton and Elaine Dekker presented an update on the patient safety plan. Highlights include: Hand Hygiene: Have achieved 90% compliance with hand hygiene. Goal for 2013 is 92% compliance CLABSI: Working towards goal to decrease the rate of Central line associated blood stream infections (CLABSI) by 25% (9 patients) by December 2013. This goal has been reached in 2012 (5 patients), with no CLABSI in PICC lines. CLABSI reduction is partly due to a 27% decrease in central line days. Of the 5 CLABSI, 3 were related to dialysis lines. CLIP (Central Line Insertion Practice) bundle compliance is 98% of the submitted CLIP forms. Based on data collected by Patient Safety staff, 75% of inserted central lines have a CLIP form submitted. Full Patient Safety Plan is on file. CLABSI preventability assessment letters are sent to providers involved in care. Elaine Dekker will follow up with dialysis staff re: central line practice. Terry Dentoni will follow up with areas where CLIP forms are most often missing. VAP: Working towards decreasing ventilator associated pneumonia (VAP) by 25% by December 2014 (1 patient), through work being led by the critical care committee (3 VAPs in 2012) NHSN will be moving toward tracking ventilator associated events moving forward, and revising the definition of VAP. SSI: Working towards decreasing the rate of surgical site infections by 25% and increasing compliance with SCIP measures to 100% by December 2014 through work spearheaded by the SSI/ SCIP team. Discussion of higher SSI rate for C-Section/Hysterectomy. OB/GYN staff implemented enhanced infection prevention techniques. Had 41 catheter related urinary tract infections (CAUTI) in 2012. Working towards decreasing CAUTIs by 25% by December 2014 Working towards decreasing Clostridium Difficile (CDiff) by 25% compared to 2010, by December 2015. Current rate at 1.37, up from 1.33 in 2011. Will Huen and Terry Dentoni will follow up to involve the new OB CNS in improvement work. ANNOUNCEMENTS NEXT MEETING No Announcements March 19, 2013, 10am to Noon, 2A6 8