Quality Council Minutes January 19, 2010 Attendance: Excused: Guest(s): Sue Carlisle, Susan Currin, Doug Eckman, Fred Hom for Sharon Kotabe, Valerie Inouye, Kathy Jung, Rachael Kagan, Elaine Lee, Todd May, Sharon McCole-Wicher, Anson Moon, Iman Nazeeri-Simmons, Roland Pickens, Maggie Rykowski, Sue Schwartz,, Pat Skala, Cathryn Thurow Lann Wilder, Hal Yee Kathy Eng, Jay Kloo, Kathy Murphy, Marti Paschal Ocean Berg, Patty Coggan, Terry Dentoni, Louise DiMattio, Genevieve Farr, Liz Gray, Michael Grills, Linda Henson, Fe Hortinela, David Kutys, Ed Ochi, Michael Pfeffer, Nela Ponferrada, Shilu Ramchand, Christine Schwartz, Maya Vasquez TOPIC DISCUSSION ACTION ADMINISTRATIVE Minutes of the December 15 2009 meeting were approved. Agenda for today s meeting reviewed. Informational ANNOUNCEMENTS None Informational FOLLOW-UP ISSUES Food Services - Lann Wilder reported that front line staff were not aware of the seriousness of the CMS findings. Monitoring of performance improvement plan activities is improving not yet 100%. Improvements on test trays and other safety areas have been noted. Drafts of position descriptions with specific assigned tasks and class specific competencies almost completed. Issue regarding air gaps in drains is still being investigated whether OSHPD permits will allow for an easier fix. Flu Vaccine Lisa Winston has agreed to be the point person on issues related to the H1N1 vaccine. It was reported that staff who has not been vaccinated with both the seasonal and the H1N1 vaccines are wearing masks. A reminder that masks are required for those not vaccinated was sent by the Dean s Office to providers. Making flu vaccine as a condition of employment is being Elaine Lee will explore whether job descriptions and job announcements can be more specifics in regards to compliance issues, especially those related to infection controls
investigated with legal counsel. APPROVAL OF IMPROVEMENT (PI) PLANS: CRITICAL CARE Terry Dentoni provided an update on the 2008 performance measures for Nursing in the areas of Critical Care, Perioperative Service, and outpatient surgical clinics and reported their 2009 measures. Critical Care: Door to Balloon Time for ST segment elevation myocardial infarction (STEMI) patients within 90 minutes: 57% in 2008, 78% in 2009. Aim is 100% by end of 2010 as communication improves between the Cardiac Catheterization Laboratory, the Emergency Department and Cardiology. Readmission to ICU within 48 hours: Aim was to reduce rate to less than 5%. This has been accomplished by monitoring readmissions and using this knowledge to gauge the appropriateness of transfer-outs. Perioperative Services Operating Room cases held waiting for Post Anesthesia Care Unit (PACU) beds: 23% in 2008, 5% in 2009. Aim is 0% by December 2010 as staff continues to address barriers to PACU discharges, as communication between ICU and PACU Charge Nurses improves, and as Come and Stay patients are entered into the Bedtracking System (identify need of a bed) upon admission rather than at discharge. Pacific Biomedical will achieve 100% of the performance measures related to Autotransfusion throughout 2010 by continuous monitoring of the contract. Outpatient Specialty Services Improve Show Rates for Ophthalmology: 73% in 2008 and 76% in 2009. Goal is to achieve 90% by end of 2010 by providing primary care (General Medicine and Family Health) with 50 appointment slots each week, establishing the Optometry Clinic as the portal of entry for all Ophthalmology patients, and by piloting a new flow process. See attached report
100% of patients requiring outpatient intravenous therapy will have access to this service due to hour extension in the 4C Infusion Center. CLINICAL NUTRITION Christine Schwartz reported on Clinical Nutrition s support of the Food Services Audit Plan by tracking compliance with measured weight and intake and output documentation by nursing. Education with Nursing has begun. A second effort is the verification that provider orders are followed by assuring written orders in the medical record match the diet orders entered into the hospital computer system (INVISION-LCR) and into the Diet Office computer system (CBORD). Audit results show improvement, topping at 85%. The IS Department is working with Clinical Nutrition to make the diet order process/pathways in INVISION/LCR more intuitive and user friendly. A third effort is reviewing providers completion (signature) of stickers (placed on every dietary note) acknowledging the Dietitian s recommendations. Results are between 90% and 95%. NURSING PERINATAL Nela Ponferrada, Shilu Ramchand and Ocean Berg presented for Nursing Perinatal. Perinatal s performance measures of 2008 were reviewed. Rate for timing of cesarean section antibiotic prophylaxis 30-60 minutes before skin incision is 90% (target is 95%). Data is incomplete from Anesthesia, which may account for lower rate. Patient satisfaction with education about infant feeding and teaching about danger signs to look for after discharge was good (100%), but it was acknowledged that the return rates of these surveys were low. For 2009, the Infant Care Center focused on standardizing feeding management of Late Preterm Infants (LPI). Actions taken included the creation of a breastfeeding policy for the LPI, RN education, and LPI feeding guideline order added to the pre-printed admission order. Between October and December 2009, feeding guidelines were implemented in 60% of LPI cases, educational material were given to parents in 18% of the cases (may be a documentation issue), and discharge It was suggested that this should be made into a formal research project.
feeding plans were given to parents in 24% of cases (also may be a documentation issue). The Infant Care Center will continue with this project. The 6C Birth Center looked at increasing the utilization of Intermittent Auscultation (use of Doppler device to listen to fetal heart tones) to monitor fetal well-being during labor for eligible women. Actions taken included policy revisions, education, and availability of Doppler in every Labor and Delivery room. EVIRONMENTAL HEALTH AND SAFETY Linda Henson and Ed Ochi presented for Environmental Health and Safety. Issues being addressed are: Equipment in hallways continue to be an issue Respiratory Protection - working with Cal/OSHA and CA Hospital Association on Cal/OSHA Interim Enforcement Guidelines for Aerosol Transmissible Disease Standard, changed fit-testing practices, evaluated and contracted for alternate N95 Respirators, and issued guidance & educational materials. Specimen Transport effort to end practice of staff messengers wearing gloves while transporting specimens. The concern is potential contamination of patients, visitors, staff and environment. Concern of messengers is fear of themselves being contaminated during specimen pick-up. Actions taken include development of specimen packaging standards, and staff education. The 2009 Annual Environment of Care/Safety Management Report was presented for approval. Report approved. Report attached. Failure Modes and Effects Analysis (FMEA) Discussion of FMEA project for 2010 postponed until next month. Informational
JUST CULTURE Maggie Rykowski provided an update on the incorporation of a Just Culture framework throughout the hospital. It is expected that the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey will be issued in February 2010 education and training for leadership will start in March, and development of an implementation plan in May. The Organizational Roll-out for implementation will begin in June 2010. POLICIES AND PROCEDURES Admin 3.04 Medical Emergency Response Team (MERT) Approved NEXT MEETING February16, 2010, 10:00am to Noon, 2A6 Informational