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 Tuesday, February 16, 2016 at the hour of 10:30 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 Director Emilie N. Junge (Substitute Member) (2) Present Telephonically: Board Chairman M. Hill Hammock (ex-officio) and Patricia Merryweather (non-director Member) Director Wayne M. Lerner, DPH, LFACHE (1) and Patrick T. Driscoll, Jr. (non-director Member) Absent: Director Erica E. Marsh, MD, MSCI (1) Director Junge, seconded by Chairman Gugenheim, moved to allow Director Lerner to participate as a voting member for the meeting telephonically. THE MOTION CARRIED UNANIMOUSLY. Additional attendees and/or presenters were: Krishna Das, MD System Chief Quality Officer Karen Duncan, MD Interim Chief Operating Officer, Hospital-Based Services Jeff McCutchan Interim General Counsel Deborah Santana Secretary to the Board John Jay Shannon, MD Chief Executive Officer 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 (Attachment #1) Dr. Krishna Das, Chief Quality Officer, reviewed a presentation regarding an update on the regulatory progress at Stroger Hospital, as a follow-up to the survey by representatives from The Joint Commission (TJC). The Committee reviewed and discussed the information. Included in the update was information on the following subjects: Timeline from initial survey dates through follow-up survey; Direct Impact Findings; Indirect Impact Findings; and Organizational Response. Board Chairman Hammock inquired regarding the external consultants, Compass Consulting, who are involved in preparing for the re-survey; he noted that, after the re-survey is completed and the consultants leave, he hopes that staff will continue to maintain these high standards that have been set. Dr. Das responded that a lot of these metrics will be incorporated into regular reporting metrics for the various quality committees; the education efforts and other activities to keep the management on track will continue. Board Chairman Hammock inquired whether other institutions engage external consultants to periodically conduct mock surveys. Page 1 of 48
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, February 16, 2016 Page 2 III. Report from Chief Quality Officer A. Regulatory and Accreditation Updates (continued) Dr. Das responded in the affirmative; she stated that having regular mock surveys is a really good way to know how the organization is doing she believes that CCHHS should continue to have this done in the future. Ms. Merryweather referenced the number of current and forthcoming requirements relating to this subject; she inquired whether the Quality Department has an adequate number of staff that is needed to sustain the work being done. Dr. John Jay Shannon, Chief Executive Officer, stated that the number of Quality Department staff will need to be increased. The Department will need a director who will specifically focus on regulatory updates and accreditation and education of staff; it will also need boots on the ground - individuals who are embedded in those key service lines. CCHHS has historically engaged outside expertise to assist in mock survey activities in an irregular fashion over the last ten (10) years. Dr. Shannon expects that, in staffing-up the Quality Department, mock survey activities will become a part of CCHHS own routine practice; he added that there will also be a need to periodically bring in outside expertise. Director Lerner requested an update on the activities relating to construction in the Operating Rooms (OR) and Sterile Processing Department (SPD). Dr. Karen Duncan, Interim Chief Operating Officer, Hospital-Based Services, stated that construction has been completed in the SPD; right now, staff are working on organizing it to make it more operationally efficient. She stated that, with regard to the third floor OR area, the design has been completed. Construction permits are now being secured and discussions are being held with the contractors; construction is expected to begin in March on that area. B. Metrics (Attachment #2) Metrics were presented for the Committee s information; Chairman Gugenheim indicated that they will be reviewed and discussed at the Board Meeting. IV. Action Items A. 2016 Quality Assessment and Performance Improvement Plan (Attachment #3): i. John H. Stroger, Jr. Hospital of Cook County Dr. Das reviewed the presentation on the 2016 Quality Assessment and Performance Improvement Plan for Stroger Hospital. She noted that staff are still in the process of writing the full formal plan; she is planning to get some consultant input on it and will send it out next week when it is finalized. Director Junge inquired whether, from a quality standpoint, Cermak patients are monitored to determine whether there have been readmissions. Dr. Shannon responded that he was unsure whether staff monitor as a specific sub-population of 30-day readmissions those Cermak patients who are admitted to Stroger Hospital from the Department of Corrections (DOC) and are discharged back to the DOC. During the discussion of the information on Key Performance Indicators (slide 16), Ms. Merryweather inquired further regarding 30-day readmissions. Dr. Das stated that Stroger Hospital has a high readmission rate and does get penalized for it. That measure is included as part of the departmental dashboard; it will also be incorporated into the general Med-Surg dashboard. Ms. Merryweather noted that she did not see anything relating to discharge planning and managed care coordination; that is really essential as a hospital-centric measurement. She also recommended that measurements be included relating to prevention, perhaps involving mammograms or diabetic disease management. She added that one of the most key components which is not included in the plan that drives the institution s readmission rates relates to the social determinants of health. Page 2 of 48
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, February 16, 2016 Page 3 IV. Action Items A. 2016 Quality Assessment and Performance Improvement Plan: i. John H. Stroger, Jr. Hospital of Cook County (continued) Dr. Shannon stated that many of the other pieces around Ambulatory uplift and activities relating to population health management are reflected a little bit more in the Ambulatory plan; he noted that the Committee eventually sees and approves plans for Stroger Hospital, Provident Hospital and the Ambulatory and Community Health Network. Director Lerner suggested that a discussion be held at a future date regarding the need for a quality plan that goes across the whole System and includes Managed Care; he stated that this is the only way to really focus on prevention, to address the continuum of care and really look at how the organization can affect the social determinants of a population. Dr. Das noted that there will be a quality plan presented specifically for Managed Care; she added that Stroger Hospital, Provident Hospital and the ACHN are each required to generate a quality plan, as the Centers for Medicare and Medicaid Services (CMS) requires each institution with a CMS certification number to do so. Director Lerner, seconded by Director Junge, moved to approve the 2016 Quality Assessment and Performance Improvement Plan for John H. Stroger, Jr. Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. 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) Director Lerner, seconded by Director Junge, moved to approve the Medical Staff Appointments/Reappointments/Changes. THE MOTION CARRIED UNANIMOUSLY. C. Minutes of the Quality and Patient Safety Committee Meeting, January 19, 2016 Director Lerner, seconded by Director Junge, moved to accept the Minutes of the Quality and Patient Safety Committee Meeting of January 19, 2016. 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 recess the open meeting and convene in a closed meeting. Page 3 of 48
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, February 16, 2016 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 Page 4 of 48
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes February 16, 2016 ATTACHMENT #1 Page 5 of 48
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Dashboard Overview 16 February 2016 Krishna Das, MD, Chief Quality Officer 1 Page 6 of 48 CCHHS Board QPS Committee
Quality Stroger Page 7 of 48 2 CCHHS Board QPS Committee
Quality Provident Page 8 of 48 3 CCHHS Board QPS Committee
Safety Stroger Page 9 of 48 4 CCHHS Board QPS Committee
Patient Experience Stroger Page 10 of 48 5 CCHHS Board QPS Committee
Patient Experience Provident Page 11 of 48 6 CCHHS Board QPS Committee
ACHN Page 12 of 48 7 CCHHS Board QPS Committee
Board Quality Dashboard Page 13 of 48 8 CCHHS Board QPS Committee
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes February 16, 2016 ATTACHMENT #2 Page 14 of 48
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Regulatory Update 16 February 2016 Krishna Das, MD, Chief Quality Officer Page 15 of 48
Stroger Joint Commission Survey Initial Survey: October 13- October 16 4 surveyors, 4 days Medicare Follow-up Survey 11/23/2015 45 day ESCs submitted 12/11/2015 60 day ESCs submitted 12/23/2015 All ESCs accepted by the Joint Commission Follow up survey in 2 months 2 Page 16 of 48 QPS Regulatory Update
Direct Impact Findings Finding Correction Plan Compliance Repair process defective biomedical equipment Air pressure and ventilation in OR areas; door latches Planning during construction (X 2) Document staff competency on hire Policy, procedures, and logs for sterilization equipment Medication refrigerators monitored Policy completed. Nursing units are being monitored for compliance All pressures differentials corrected. Doors fixed. Weekly monitoring in all areas cited. 76% 100% in all areas Daily rounds in construction areas 100% Competency policy approved. File review of newly hired staff to assess completion Policies completed, staff competencies documented; monitor log entries Reinforce policy, implement oversight by reviewing logs for correct entries 100% >91% >99% Exp dates on meds/ solutions Policies rewritten, compliance measured 100% Page 17 of 48 3 QPS Regulatory Update
Direct Impact Findings, cont d. Finding Correction Plan Compliance Order sets reviewed by committee PICU sedation assessment TPN orders consistent Avoid therapeutic duplication Label all meds on operative fields Nursing care plans to include all problems Process change; all order sets receive review by multidisciplinary medical staff committee EMR modification for compliance; training complete; monitoring weekly EMR modified; duplicate orders reviewed for feedback and correction Existing policy reviewed; daily rounds to assess compliance Train staff on existing policies; monitor % of care plans including >90% of problems >96% 100% 96% >94% 100% >98% Crash cart monitoring Crash carts contain up to date equipment 100% Restraint order renewal Daily monitoring of restraint renewal >98% Monitoring POC testing Monitor solutions and expiration dates >91% Page 18 of 48 4 QPS Regulatory Update
Indirect Impact Findings Findings Correction Plan Compliance Risk of chemical exposure: eyewash station logs Soiled utility rooms inspected and cleaned Quality control checks in CT scan License verification (after renewal) Inspect and record eye wash stations 100% Proportion of utility rooms inspected and found compliant with standards Monitor existing process of documenting daily quality checks Policy for verification revised; monitor proportion verified >94% 100% Monitor IC in dietary Daily rounds and log review 100% PHI on computer in storage room Governing body responsible for care Present reminders at shift changes 100% Corrective actions are presented monthly to leadership and governing body In progress Compliant 5 Page 19 of 48 QPS Regulatory Update
Indirect Impact Findings, contd. Finding Correction Plan Compliance Leaders have oversight of policies and procedures Scope of pre-procedure history & physical defined Restraint use documented in nursing care plan Dates and times on paper documents Confirm registration of tissue suppliers Time out to include all team members Policy oversight committee convened, updates to leadership meetings Policy modified, training complete; monitor compliance Re-educate on policy; review care plans on patients on restraints Re-educate on policy; process redesign; monitor compliance FDA tissue registrations to be reported annually Random observations with measured compliance Compliant >90% >97% 100% Compliant 100% 6 Page 20 of 48 QPS Regulatory Update
Organizational Response Weekly meetings with ESC teams to track compliance data Regular rounding with a checklist to ensure compliance Tracers focusing on ESC areas to ensure reliable responses in all areas Regulatory readiness weekly meetings with hospital managers to review standards, policies and progress Regular communication with leaders, managers, medical staff Patient Safety newsletter for staff education 7 Page 21 of 48 QPS Regulatory Update
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes February 16, 2016 ATTACHMENT #3 Page 22 of 48
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Stroger Hospital Quality Plan Summary 16 February 2016 Krishna Das, MD, Chief Quality Officer Page 23 of 48
Goals of a Quality Program To comply with law and regulations which govern quality management in the healthcare setting To continually improve quality processes and outcomes To improve patient safety and to comply with laws regarding safety event evaluation and reporting To assure successful accreditation and certification To create value for the organization 2 Page 24 of 48 Quality Plan 2016 Overview
Regulatory Standards: CMS Conditions of Participation: 42 CFR 482.21 The hospital must develop, implement, and maintain an effective ongoing, hospital-wide, data-driven quality assessment and performance improvement program (a) Program scope: To show measurable improvement in indicators with evidence that it will improve health outcomes and identify and reduce medical errors Track indicators including adverse patient events to assess care, hospital service and operations 3 Page 25 of 48 Quality Plan 2016 Overview
Regulatory Standards: CMS Conditions of Participation: 42 CFR 482.21 (b) Program data Incorporate quality data Use the data to monitor the effectiveness and safety of services and identify opportunities for improvement The frequency and detail of data collection must be specified by the hospitals governing body (c) Program activities Set priorities for performance improvement Track medical errors Implement performance improvement activities, measure success and track improvement 4 Page 26 of 48 Quality Plan 2016 Overview
Regulatory Standards: CMS Conditions of Participation: 42 CFR 482.21 (d) Performance improvement projects Hospital conducts performance improvement projects Projects must be proportional to the scope and complexity of the hospital s services and operations (e) Executive responsibilities Leaders governing body, hospital administration and medical staff, ensure that a Quality Assessment and Performance Improvement plan is created and reviewed annually Assures resources for assessing and improving performance 5 Page 27 of 48 Quality Plan 2016 Overview
Joint Commission Standards Leadership LEADERSHIP Quality and Safety Quality, safety and performance improvement planning is hospital wide. Work processes are designed to focus individuals on quality and safety issues Leaders set priorities for performance improvement activities and patient health outcomes Leaders give priority to high-volume, high-risk or problem prone processes Leaders implement a hospital wide safety program An individual or a multidisciplinary group manages the safety program The scope of the safety programs ranges from potential or no harm errors (near misses or close calls) to hazardous conditions and sentinel events 6 Page 28 of 48 Quality Plan 2016 Overview
Joint Commission Standards Performance Improvement PERFORMANCE IMPROVEMENT The hospital collects data to monitor its performance Leaders set priorities for data collection Hospital compiles and analyzes the data Presents data in usable forms; tracks and trends Benchmarks data to external sources Uses data to identify improvement opportunities Hospital improves performance on an ongoing basis Prioritizes improvement opportunities Takes action on improvement priorities Evaluates actions to confirm that they resulted in improvements 7 Page 29 of 48 Quality Plan 2016 Overview
Current Challenges Quality projects often performed in silos Quality management efforts are not widely disseminated Front line staff are not engaged in quality/pi Event reporting is good but PI efforts/ feedback loops must be completed Regulatory compliance manager education and accountability 8 Page 30 of 48 Quality Plan 2016 Overview
Accountability for Quality Management and Reporting Existing departmental and committee structures are used for reporting data and provide governance Use concept of reporting groups to align reporting efforts and support robust discussion Regulatory readiness efforts are aligned with existing structure Incorporate readiness challenges into reporting group dashboards Local leaders report on local performance and lead improvement efforts Support leaders with quality data specific to their areas of authorityenhance reports Support leaders with guidance on performance improvement methods Continue to develop patient safety initiatives for areas which are high risk, high volume or problem prone. 9 Page 31 of 48 Quality Plan 2016 Overview
Hospital Quality Innovations Nursing Quality and Safety Committee and Nursing Quality Council planned Align nursing indicators with National Database for Nursing Quality Indicators (NDNQI) Nursing oversight reconfigured Environment of care committee reporting redesign Combine life safety, clinical engineering, EOC, emergency management 10 Page 32 of 48 Quality Plan 2016 Overview
Quality Committee ED Services General Med-Surg Infection Control Critical Care & Emergency Response Diagnostic Imaging Behaviora l Health Record of Care Nursing Care Hospital Quality Improvement and Patient Safety Committee HQuIPS Diagnostic Testing Periop Services Patient Experienc e of Care Med Mgmt Maternal Child Environ of Care Medical Education 11 Page 33 of 48 Quality Plan 2016 Overview
Overview of Reporting Groups 12 Reporting Group Departments or Divisions Committees or Workgroups Perioperative Surgery, Anesthesia OR, PI team Medication Management Environment of Care Infection Control Critical Care/ Emergency Response General Med-Surg Emergency Services Pharmacy Environmental, Police, B&G, CE Infection Control, OR/SPD, Nursing Critical Care (various), Palliative Care Family Medicine, Medicine, Surgery, Case Management EM, Trauma/Burn, Nursing Page 34 of 48 Drug & Formulary, Med safety, DUE Environment of Care Infection Control Critical Care, Resuscitation, Bioethics Stroke, Diabetes, Immunization, UM/CM, NSQIP Capacity Management Joint Commission Chapter Medication Management EOC, Life Safety, Emergency Management Infection Control Provision of Care Provision of Care Provision of Care Quality Plan 2016 Overview
Overview of Reporting Groups Reporting Group Departments or Divisions Committees or Workgroups Joint Commission Chapter Maternal Child Pediatrics, Ob-Gyne Perinatal Network Provision of Care Behavioral Health Psychiatry, Nursing Bioethics Provision of Care, Patient Rights Diagnostic Testing Pathology SFRC, IT Committees Radiology/ Radiation Safety Radiology Radiation Safety Nursing Services Nursing Nursing Quality Nursing, Provision of Care Hospital Information Management HIM HIM, IT Committees Record of Care and Information Management 13 Patient Experience of Care Patient Experience, Patient Relations Medical Education GME GMEC Page 35 of 48 Patient Experience Council Patient Rights Quality Plan 2016 Overview
HQuIPS Reporting, cont d. Reporting Group All Reporting Groups listed Cancer Committee Contract Compliance Correctional Health Food/Nutrition Human Resources Oral Health Patient Safety Council and Oversight Functions Transfusion Committee Frequency Quarterly Annual Annual Annual Quarterly Monthly, then Quarterly Semi-annual Monthly Annually 14 Page 36 of 48 Quality Plan 2016 Overview
Reporting Group Dashboards Core measures referable to a reporting group Departmental indicators: Process measures (eg VTE prophylaxis) Preventive measure (eg immunization) Patient safety measure (time outs, HAI) Documentation measures (H&P or Op notes) Efficiency measures (clinic follow up or readmissions) Patient safety events hospital acquired events, sentinel events, medication safety events, procedural complications PI activity related to patient safety events PI activity related to ongoing regulatory readiness Patient experience data and patient complaints Dashboards are updated at least monthly 15 Page 37 of 48 Quality Plan 2016 Overview
Key Performance Indicators Hospital Indicator 1 Operating Room: OR on-time starts (%) Operating Room: OR room turnaround time (minutes) Core Measure: VTE Prophylaxis General Care Prevention: Influenza Vaccination Patient Satisfaction: Recommend the Hospital Patient Satisfaction: Communication with Nurses is good Fall rate/ falls with injury Hospital Acquired Pressure Ulcers Baseline Q3 2015 Target 50 th %ile 2 90 th %ile Reporting Interval 47 80 64 88 Quarterly 47 min 35 min 29 23 Quarterly 89 99 88 99 Quarterly 75 90 93 100 Quarterly 69 84.7 72.4 84.7 Quarterly 69 85.7 79.5 85.7 Quarterly 0.6 25% reduction 0.6 25% reduction - - Quarterly - - Quarterly 16 Page 38 of 48 Quality Plan 2016 Overview
Focus Areas- High Risk, High Volume, Problem Prone High Risk Emergency department wait times and throughput Operating room start times and throughput High Volume VTE (venous thromboembolism) prevention Vaccinations Problem Prone* Procedural safety (time outs) Medication safety Alarm management Cognitive or psychiatric impairments in patients 17 *Related to Joint Commission Safety Goals Page 39 of 48 Quality Plan 2016 Overview
Next Steps Approve plan Build out detailed dashboards in conjunction with reporting groups Work closely with BI team to automate and distribute dashboard data Work closely with Nursing quality to develop unit based performance improvement Train and deploy quality staff to coach performance improvement efforts in all departments Develop safety priorities and safety plan 18 Page 40 of 48 Quality Plan 2016 Overview
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes February 16, 2016 ATTACHMENT #4 Page 41 of 48
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