Oregon Patient Safety Commission Board of Directors DRAFT Public Meeting Minutes April 14, 2015 Convened 12:30 p.m. Adjourned 3:30 p.m. Legacy Meridian Park Medical Center Community Health Education Center BOARD CHAIR Melinda Muller MEMBERS PRESENT MEMBERS ABSENT EXECUTIVE DIRECTOR Bethany Walmsley Marita Aguas, Beth Biggs, Gayle Evans, Linda Farris, Kecia Norling, Natasha Tobias- White, Amy Heinlen Norm Gruber, Ken Lindsey, Csaba Mera, Maureen Ober, Naomi Kaufman Price, Jill Rissi, Dana Selover MINUTES Carrie DeLong Parrish OTHER STAFF PRESENT Melissa Parkerton, Mary Post, Nicole Staudinger GUESTS Diane Waldo, Oregon Association of Hospitals and Health Systems; Jan Johnson, The Lund Report Call to Order / Introductions / Public Comment / Board Updates Melinda Muller called this meeting of the Oregon Patient Safety Commission Board of Directors to order at 12:30 p.m. with a quorum present. Melinda welcomed our newest board member, Amy Heinlen, who is filling the board s Public Purchaser seat. Board members, staff, and guests introduced themselves. Approval of Minutes Motion: Board members made a motion (Linda Farris) and seconded the motion (Gayle Evans) to approve the minutes of February 10, 2015 as written; the motion passed unanimously. Communications Carrie and Nicole provided a final report of 2014 Communications Plan achievements and an overview of 2015 Communication Plan objectives. All achievements and objectives are organized in four categories: website, social media, newsletter, and media relations. Nicole used an online tool called Storify to give board members an overview of the Commission s first year of social media outreach: https://storify.com/orpatientsafety/oregon-patient-safety-commission Treasurer Report Natasha provided an overview of the financial dashboard. The Commission has collected 99% of 2015 fees. Bethany updated the board on the following budget-related issues: The board-approved administrative rules that modify the Commission s fee structure will undergo a public hearing in June. (Note: after the board meeting, the opportunity to combine the budget and administrative rules modifications hearings into one hearing was discussed. The combined hearing will occur in June to avoid the need for two separate hearings since the budget must be adopted before 7/1/2015. These minutes and the board materials from the meeting have been updated and board members have been informed of this change. BW) To support implementation of the modified rules, the Commission is currently developing an organizational policy to demonstrate a standard
Oregon Patient Safety Commission Board Meeting April 14, 2015 Page 2 approach for calculating the annual adjustment to fees based on the Consumer Price Index This policy will be reviewed at the August board meeting prior to the billing cycle for 2016. The Commission s 2013-2015 biennium financial review will occur in September or October 2015. The board reviewed the budget for the 2015-2017 biennium. Revenue is increasing by 18%; expenses are approximately 16% higher than the last biennium, due in part to cost increases in personnel, overhead, travel, and technology (new server). The Board discussed its strategic plan and how the budget supports the North Star goals. To best support the goals of the plan, the board had previously discussed the possibility of including a new PSRP Director by mid-2016. Currently, the Executive Director manages the Patient Safety Reporting Program directly, in addition to the other operational responsibilities for the organization. However, Bethany recommended to the board the opportunity to hold hiring a PSRP Director for one more year in order to allow the Commission to overcome the deficit created by continuing to operate for over a decade with no relief from the rising costs of goods and services. The current budget was approved with the assumption that; The PSRP Director would relieve the Executive Director of the role of managing the full reporting program team, but not until mid-2017. The Commission may wish to consider budgeting for a PSRP Director for a partial year, however, the board agreed that they were comfortable with placing a temporary hold on hiring a PSRP Director, at least for this review. The discussion will be revisited in December when the Commission s budget will be amended. Bethany concluded the conversation with details about the $15,000 in the budget for gifts and contributions. Along with many other funders from across the country, the money goes to the National Collaborative for Accountability and Improvement, which supports the development of communication and resolution programs nationally. Other Collaborative members/funders include the University of Michigan, University of Washington, University of Illinois, Stanford, and others. The Collaborative is currently working on a relationship with the National Patient Safety Foundation and the National Quality Forum to establish sustainable, long-term funding. Tom Gallagher, MD, a physician researcher with the University of Washington, and the current leader of the Collaborative, will present more information about the Collaborative to the board at the Commission s next board meeting. He will provide information about the current objectives, progress to date, and three-year strategic initiatives for the Collaborative. Motion: Board members made a motion (Beth Biggs) and seconded the motion (Natasha Tobias-White) to approve the 2015-2017 Biennium Budget as written; the motion passed unanimously. North Star 1: Quality Improvement and Disseminating Best Practices Mary provided an update on the Commission s Oregon Stop Urinary Tract Infection (UTI) Initiatives two urinary tract infection prevention grants: 1) AHRQ Long-Term Care Collaborative and Portland Metro Collaborative Pilot. While there has been some dropout from participating facilities, the dropout rate for Oregon s effort has been lower than what is being seen in other, similar collaboratives nationally. Collaborative participants are just beginning surveillance and there is room for improvement in how data is being collected. Current data shows a decrease in the Catheter-Associated UTI rate; an increase in catheter utilization (may be due to how data is being collected), and a decrease in urine culture orders (which can reduce the unnecessary use of antibiotics to treat UTIs). All collaborative participants have received the results of their AHRQ Nursing Home Survey on Patient Safety Culture. Sixty nine percent of respondents rated resident safety in their facilities as very good or excellent. Eighty one percent would tell friends that their facility is a safe nursing home for their family. The survey identified opportunities to improve safety through training and skills and communication openness. 2
Oregon Patient Safety Commission Board Meeting April 14, 2015 Page 3 Improvement opportunities beyond CAUTI prevention are being identified and addressed, including: Continued emphasis on reducing unnecessary urine cultures Keep messaging very simple and easy to do Acute care hospital partnership is crucial Senior leader support is essential North Star 2: Patient Safety Reporting Program Bethany provided an update on current PSRP efforts, which include: Continued quarterly face-to-face trainings for ambulatory surgery centers, hospitals, nursing facilities, and community pharmacies on conducting root cause analysis and developing strong action plans Developing metrics to demonstrate how much the Commission s patient safety consultants are used to provide feedback to participants Dashboard enhancements are currently underway; a newly redesigned dashboard is anticipated to launch in May 2015 Recognition Targets were released to participants in March 2015 PSRP annual summary is expected to be published in early May Patient Safety Annual Events (Patient Safety Breakfast and peer support training day) The Commission collected post-event surveys from 30% of attendees. Responses were very positive. A $9,000 surplus remains from event sponsorship and ticket sales. The board discussed options for how best to use the funds; options included: Investing in a more expensive, well-known speaker Holding money to pay for future annual event costs in case sponsorship levels drop Sponsor complimentary seats for students and frontline staff Treat Commission staff to a meal as a thank you and job well done Members agreed to carry forward the surplus funding to support any or all of the items discussed. Bethany encouraged board members to contact her if they have any speaker recommendations for future events. We are already looking for our speaker for the 2016 Patient Safety Breakfast and we will likely have additional slots to fill in terms of faculty to support training and education for the remainder of the day. Engaging Non-Reporting Pharmacies The Commission is working to develop strategy to improve community pharmacy engagement in PSRP. One potential method of targeted outreach includes partnering with the Board of Pharmacy to help promote PSRP through their communication channels. The Board discussed the appropriateness of partnering with the Board of Pharmacy when they are in a regulatory position and the Commission is providing an independent/safe table. Board members had no concerns as long as messaging clearly communicates the extent of separation between the two groups and clearly states the benefits of engaging with the PSRP program. North Star 3: Early Discussion and Resolution Melissa provided an overview of the current status of work related to EDR, including: 20 notices have been filed by a mixture of providers and patients Continue to explore methods for educating patients and the public Outreach opportunities to educate provider and patient groups continues First annual report about EDR will be published in the fall of 2015 3
Oregon Patient Safety Commission Board Meeting April 14, 2015 Page 4 The term of service for four Task Force members is ending this summer, including for the Patient Advocate seat, which has been filled by Bonnie Thompson. Having a board member serve both groups has provided a nice connection and synergy. The Commission hopes to identify another board member who would be willing to fill the Patient Advocate seat on the Task Force; however, the seat can be filled by someone not on the board. Board Subcommittees Board Recruitment Motion: Board members made a motion (Kecia Norling) and seconded the motion (Linda Farris) to approve the three existing officers for another term (Melinda Muller, Chair; Jill Rissi, Vice-chair; Natasha Tobias- White, Treasurer). The motion passed unanimously. The Public Purchaser seat has finally been filled. Welcome Amy Heinlen! Bonnie Thompson has taken a new position and is no longer able to fill the hospital administrator seat. Currently open seats are the Consumer seat and the Hospital Administrator seat. Marita Aguas and Norm Gruber are finishing their second terms in July. At that time, open seats will include the Nurse seat and another Hospital Administrator seat. Current efforts to locate new members include: Contact with associations Relationships/referrals from existing board members Website Legislative Subcommittee We are watching twelve bills; however, after Friday s legislative deadline, several of those bills will not progress in this session. The subcommittee identified three bills for the Board to review and recommends that the board take a neutral stance: HB 3378, SB 469, and HB 2930. Board discussion included: The subcommittee worked extensively to vet these bills from their perspective as advocates for the Commission so that the full board would not have to invest the same amount of time in formulating a recommendation. Since the Commission is intended to be independent and a neutral party, the board should have ongoing discussion to understand what the Commission s role is if we are approached to take position on a bill. Our visibility has changed, which is also requiring that our process for reviewing bills may need to change in the future. The board should explore a charter or guidance for our stance/process for managing legislative recommendations. In some cases, the Commission may very well support the concept of a particular bill to improve patient safety, but may not necessarily support that it is appropriate for a legislative mandate. Motion: Board members made a motion (Kecia Norling) and seconded the motion (Linda Farris) to take a neutral stance on HB 3378, SB 469, and HB 2930; the motion passed unanimously. Public Comment Members of the public had no comments. Executive Session Members reviewed a candidate for the Consumer seat of the board and agreed to encourage applicant to submit an Executive Interest Form as long as there is the support of the Governor s Office. The candidate disclosed two issues that are being evaluated in terms of conflict of interest to assure compliance with the 4
Oregon Patient Safety Commission Board Meeting April 14, 2015 Page 5 definition of the consumer seat mandated state statute. Meeting Evaluation Board members completed an evaluation of the meeting. Adjournment The meeting was adjourned at 3:30pm. The next meeting will be June 9 at Legacy Meridian Park s CHEC Center, 19300 SW 65 th Ave., Tualatin OR 97062. The 2015 schedule is posted on the Board of Directors page at the Commission s website. 5