December 8, 2017 NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Quality Council Committee meeting at 7:00AM on Thursday December 14, 2017, in the Kaweah Delta Medical Center Acequia Wing Executive Office Conference Room {400 W. Mineral King, Visalia}. The Board of Directors of the Kaweah Delta Health Care District will meet in a Closed Quality Council Committee meeting immediately following the 7:00AM Open Quality Council Committee meeting on Thursday December 14, 2017, in the Kaweah Delta Medical Center Acequia Wing Executive Office Conference Room {400 W. Mineral King, Visalia} pursuant to Health and Safety Code 32155 & 1461. All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room. The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page http://www.kaweahdelta.org. KAWEAH DELTA HEALTH CARE DISTRICT Lynn Havard Mirviss, Secretary/Treasurer Cindy Moccio Board Clerk, Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff http://www.kaweahdelta.org/ 400 West Mineral King Avenue Visalia, CA (559) 624 2000 www.kaweahdelta.org
KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS QUALITY COUNCIL Thursday, December 14, 2017 Kaweah Delta Medical Center Acequia Wing 400 W. Mineral King Avenue, Visalia, CA Executive Conference Room ATTENDING: OPEN MEETING 7:00AM Herb Hawkins Committee Chair, Board Member; Nevin House, Board Member; Gary Herbst, CEO; Tom Rayner, SVP & COO; Regina Sawyer, RN, VP & CNO; Edward Hirsch, MD, CMO/CQO; Douglas Leeper, VP & CIO; Harry Lively, MD, Chief of Staff; Byron Mendenhall, MD, Professional Staff Quality Committee Chair; Monica Manga, MD, Secretary/Treasurer; Dan Boken, MD, Past Chief of Staff; Lori Winston, MD, DIO; Tom Gray, MD, Quality and Patient Safety Medical Director; Sandy Volchko, Director of Quality and Patient Safety; Evelyn McEntire, Director of Risk Management; Ben Cripps, Compliance Officer, Rose Newsom, Director of Nursing Practice; and Heather Goyer, Recording. Call to order Herb Hawkins, Committee Chair & Board Member Public / Medical Staff participation Members of the public wishing to address the Committee concerning items not on the agenda and within the subject matter jurisdiction of the Committee may step forward and are requested to identify themselves at this time. Members of the public or the medical staff may comment on agenda items after the item has been discussed by the Committee but before a Committee recommendation is decided. In either case, each speaker will be allowed five minutes. 1. Leadership Clinical Quality Goals Status Update- Review of key leadership quality indicators related to infection prevention. Melissa Janes, Infection Prevention Manager 2. Telesitter Failure Modes Effects Analysis (FMEA) A summary of a proactive risk assessment on the processes focused on telesitters in the medical center. Kari Knudsen, Director of Post- Surgical Care; Stacey Cajimat, Clinical Analyst for Quality and Patient Safety 3. Telemetry Management Quality Focus Team Report- Status report on improvements made to the telemetry management process. Jon Knudsen, Director of Renal and Oncology Services 4. Approval of Quality Council Closed Meeting Agenda Kaweah Delta Medical Center Executive Conference Room immediately following the open Quality Council meeting o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Byron Mendenhall, MD, and Professional Staff Quality Committee Chair; Thursday, December 14, 2017 Quality Council Page 1 of 2 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III Carl Anderson Zone IV Nevin House Zone V Board Member Secretary/Treasurer Board Member President Board Member
o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Evelyn McEntire, Director of Risk Management. Adjourn Open Meeting Herb Hawkins, Committee Chair & Board Member CLOSED MEETING Immediately following the 7:00AM open meeting Call to order Herb Hawkins, Committee Chair & Board Member 1. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Byron Mendenhall, MD, and Professional Staff Quality Committee Chair 2. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) Evelyn McEntire, Director of Risk Management. Adjourn Open Meeting Herb Hawkins, Committee Chair & Board Member In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) 624-2330. Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors committee meeting. Thursday, December 14, 2017 Quality Council Page 2 of 2 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III Carl Anderson Zone IV Nevin House Zone V Board Member Secretary/Treasurer Board Member President Board Member
KDHCD Board Goals-*HAI Report Health Outcomes Base SIR Goal SIR +Actual SIR Action CAUTI 0.738 <=0.517 1.52 Increase this Qtr. CAUTI Team: Source/action plan Clostridium difficile SSI Colon SSI Hysterectomy 1.500 <=0.924 1.03 Significant improvement. MDRO-C Team action plan. Changed policy/protocols. 0.625 <=0.438 1.49 Increase this year. Stakeholders developed action plan. Adherence to bundle. 3.19 <=0.762 **2.30 1 this year. Hyster Bundle 3/17/17. *Healthcare Associated Infections ** Manually calculated CDC NHSN SIR (Standardized Infection Ratio) + 3 rd Qtr. 2017 KDHCD data
TeleSitter FMEA 2017 Stacey Cajimat RN Clinical Analyst and Kari Knudsen RN Director of Post-Surgical Care
TeleSitter Program
Pre FMEA Data Trends Identified 14 events 7 6 6 TeleSitter Related Events 10/14/2015-12/06/2016 6 5 4 3 2 2 1 0 Falls with Telesitter Pulled Out Lines Falls-No Telesitter
What is an FMEA? Tool used to help with risk prevention Identifies possible risks, ranks them based on occurrence, detection and severity and generates risk priority numbers to help in assessing and preventing risks. Designed to reduce the chances of failure by driving actions for improvements TeleSitter program selected for FMEA to review the new program and related patient care events
Pareto Chart 80/20 Rule 80 percent of effects always come from 20 percent of the causes Separate the vital few from the trivial many
#1 Highest Risk Priority Area Delay in response to patient with unsafe behavior and/or delay in initiation of telesitter TeleSitter distracted Unable to view patient (curtain pulled) Privacy mode initiated and not resumed TeleSitter order not received
Actions for #1 Highest Risk Priority New expectations set for TeleSitters and agreement signed Department relocated to quiet room with less distractions Implemented visual confirmation process of viewing the correct patient TeleSitters perform a quick look to see if privacy mode if on and still needed
#2 Highest Risk Priority Area Communication and redirection of patient not working Patient ignores the TeleSitters attempt to redirect them Patient s preferred name not used Patient hard of hearing, confused Patient refuses to listen to TeleSitter s redirection
Actions for #2 Highest Risk Priority Preferred name on TeleSitter form, staff confirms form is complete If patient requiring redirection (3 times in 30 minutes) and or use of STAT alert alarm (more than 3 times in 30 minutes) to obtain physical sitter TeleSitter to contact charge nurse and/or house supervisor for physical sitter
#3 Highest Risk Priority Area Alerting Staff Unable to hear STAT alarm Staff not near room Other alarms going off at same time Staff busy with other patients
Actions for #3 Staff remain in pod close to high risk patients Alarm fatigue continually being improved TeleSitters to contact CNA first if patient not responding to redirection
#4 Highest Risk Priority Area Physical Need for Sitter Sitters are limited Staff hesitant to ask for sitter and do not want to pull resources off the floor Physical sitter not placed but continue to have TeleSitter
Actions for #4 Use chain of command if physical sitter not available
Conclusion FMEA lessons learned shared with TeleSitter staff No events identified since conclusion of FMEA FMEA concluded September 2017 Continue to monitor event data
2a. Risk Priority Assessment.xlsx 1 Steps Process Step Failure Mode Cause(s) Failure Effects (All effect have potential harm to patient or removal of medical devices) Occurrence Likelihood (1-10) Detection Likelihood (1-10) Severity (1-10) Risk Priority Number (RPN) Action 10 Patient displaying unsafe behavior Not seen timely. TeleSitter re-directing another patient/distracted Patient not monitored New TeleSitter expectations set & reviewed at staff meeting- March 2017 All TeleSitters signed agreement & understanding of new expectations- March 2017 Department relocation to private area update on Monday 06/5/17. Move planned beginning of August 2017. TeleSitter move complete 08/23/17. 6 14 16 10 5 Set-up camera: plug-in, Two patients in the room. position to view patient. If patient is in danger of immediate physical harm, TeleSitter activates STAT alarm (alarm sounds only in the patient's room). Camera placed on privacy mode. Patient displaying unsafe behavior Obtain camera (wall or rolling camera). Total of 22 wall and 7 rolling cameras. Staff unable to hear alarm & does not respond. TeleSitter not notified to turn on camera Patient too quick displaying unsafe behaviors. Staff prefer rolling cameras and may not use wall brackets. TeleSitter does not know which patient to monitor or monitoring the wrong patient. Staff not near room. Other alarms going off. Too noisy to hear. Staff busy/forget No time to respond Staff may say "never mind" to request of TeleSitter if rolling camera not available. Wall bracket cameras set-up process cumbersome. Not monitoring patient Alarm not heard Patient not monitored. Potential harm/fall TeleSitter not placed/delayed 4 7 9 252 3 8 8 192 2 9 9 162 8 2 8 128 6 2 9 108 2 9 4 72 Evaluate area on 3W- Who: Chuck- Complete Assess current placement of wall brackets - Who: Chuck- Complete Collaborate with 3W manager regarding need for more wall brackets and/or different placement of current brackets- Who: Susan- Possibility of having brackets placed in more of the single occupancy rooms. Add criterion for admitting to single rooms with existing brackets to include consideration for patients who need TeleSitters. Initiate fail safe process where Q shift staff stand by pt being monitored by TeleSitter (to confirm right pt being monitored and/or which pt in room A & room B)- On hold for now. Possibility of placing lamented signage close to wall bracket which includes which bed is being monitored by tele sitter. In place of having additional brackets installed on 3W and adding signage, the fail safe process will be initiated, when tele sitter is initiated in the double occupancy rooms staff will be asked to stand in the cameras view to identify that the correct patient is being monitored and correct bed (A or B). Susan will educate TeleSitters during staff meeting on 09/19/17 about this new process. Susan educated TeleSitter staff on 09/19/17 at staff meeting regarding the change to have 3W staff stand and wave to the camera when patient is set up with TeleSitter in double rooms. Check if Stat alarm has varying volume settings- Susan- Complete. Only one volume available. Staff sit in PODS close to high risk pts- Ongoing Alarm fatigue committee discuss dynamics of Stat alarms- Ongoing TeleSitters to do quick look after 7 min privacy window exhausted- Already being practiced by some TeleSitters but will be the new expectation. Privacy mode always used when PT working with pt- Susan to discuss with Jag. Susan met with Molly Niederreiter, PT Manager. Molly will educate her staff regarding appropriate use of privacy mode. Stacey will follow up with Molly to verify all staff were educated. Molly educated her staff during May & June 2017 staff meetings. Follow up with Tele sitters to verify that PT staff are using privacy mode appropriately post education. Susan informed Molly after our July 26th meeting that therapy staff continue to use privacy mode despite education. Molly reeducated staff about appropriate use of privacy mode again but the practice continues. Will brainstorm new ideas to determine barriers. PT staff continue to use privacy mode anytime PT works with the pt. Susan will follow up with Molly. Update from 09/19/17 TeleSitter staff meeting, proper use of privacy mode by therapy staff has improved. Care of impulsive patient included in current policy Establish par levels of brackets on all units except 2S & 3S-Kari & Susan. Kari emailed all her managers responses pending. Susan to follow up with 4N. BP, 3N, 4S, 2N and 4T have brackets set up in all rooms. Nurse managers to assess need for additional wall brackets- Kari & Susan Occurrence likelihood: 1-10; 10 Very likely to occur. Detection likelihood: 1-10; 10 = very unlikely to detect. Severity: 1-10; 10 = most severe effect, RPN = product of 3 scores
2a. Risk Priority Assessment.xlsx 2 Steps Process Step Failure Mode Cause(s) 17 TeleSitter discontinued Pre-mature discontinuation 15 8 11 13 4 1 6 5 2 6 9 Patient needing redirection, redirection ineffective, or use of STAT alarm (3 times in 30 min). Obtain Sitter. TeleSitter input patient demographics into software and initiates surveillance (set up individualized settings). TeleSitter communicates to patient for redirection by recorded messages or with own voice. Patient not successfully redirected & TeleSitter calls CNA to go to patient room. Staff call TeleSitter confirm receipt of form & availability of camera Nursing assessment reveals need for TeleSitter Sitters are limited Pt does not respond to formal name and goes by nickname. Patient does not listen Unable to reach multiple staff (taking up time). Staff forget to call Incomplete assessment leading to not obtaining TeleSitter when needed. Set-up camera: plug-in, Patient not in position to be position to view patient. seen (3W). Obtain camera (wall or rolling camera). Total of 22 wall and 7 rolling cameras. Patient meets TeleSitter inclusion criteria and charge nurse notified Rolling camera not available. Patient placed on wait list. Patient borderline in meeting criteria and nurse allows for more time to assess if TeleSitter really necessary. Set-up camera: plug-in, Rolling Camera not in the position to view patient. position to view patient. TeleSitter visualizes and monitors patient (1:16 ratios) Privacy mode utilized Failure Effects (All effect have potential harm to patient or removal of medical devices) Patient condition no longer met inclusion criteria at the time of discontinuation but met criteria Patient not monitored later in shift/visit (example - TeleSitter not needed during day Staff hesitant to ask for sitter and do not want to pull resources off of the floor. Nickname/preferred name not known Sitter not placed, but continues to have TeleSitter Patient ignores TeleSitter communication. Patient is hard of Patient continues with hearing/confused/does not care. unsafe behavior. Staff busy and unresponsive. Staff busy, or pulled away to another task. Nurse busy, distracted, or lack of available information TeleSitter on 3W cannot see patient because patient in A bed. Only B bed can be seen. opposite wrong bed. All rolling cameras being used. 2S and 3S have no wall brackets. Staff unsure if patient really needs TeleSitter. Staff does not respond to patient in need. Delayed TeleSitter TeleSitter not placed. Cannot visualize patient. Delay in TeleSitter Delayed TeleSitter Staff inadvertently moved camera or does not know correct Cannot visualize patient. position of camera. Request by staff due to providing assisted care (ADL). Patient not monitored. Occurrence Likelihood (1-10) Detection Likelihood (1-10) Severity (1-10) Risk Priority Number (RPN) 2 5 5 50 2 3 8 48 1 8 5 40 6 1 6 36 4 1 9 36 2 5 3 30 2 3 4 24 3 1 8 24 7 1 3 21 3 2 3 18 3 1 6 18 9 1 2 18 Action The use of TeleSitter service for pts that are frequently monitored on and off during their hospital stay will be discussed at PCM by Susan on August 3. Susan presented at PCM on August 3rd, no additional follow up necessary. Reinforce the use of the chain of command if patient requiring frequent redirection or use of stat alarm (3x in 30 min) and if issue not addressed contacting Susan directly.- Susan to educate TeleSitters during Sept 19th staff meeting. Susan reinforced use of the chain of command during TeleSitter staff meeting on 09/19/17. Require that the preferred name field on form be completed by staff and if not completed TeleSitters to contact staff for information. Susan to take to PCM on Aug 3rd and educate TeleSitters at staff meeting on Sept 19th. Susan presented to PCM, which has increased completion of the preferred name field and TeleSitters will follow up with staff if incomplete after educated during staff meeting Sept. 19th. Susan informed TeleSitters on 09/19/17 during staff meeting to follow up with staff if preferred name field is incomplete Reinforce the use of the chain of command if patient requiring frequent redirection or use of stat alarm (3x in 30 min) and if issue not addressed contacting Susan directly.- Susan to educate TeleSitters during Sept 19th staff meeting. Susan reinforced use of the chain of command during TeleSitter staff meeting on 09/19/17. CNA will be the first line of contact. Once fax is received the pt is set up by TeleSitters and monitored regardless if staff call or not. Problem is that fax machine does not alert TeleSitters when fax received. Susan will follow up to make sure that fax in new location rings. TeleSitters moved to new location 08/23/17 and fax machine is being made to ring when faxes are received. TeleSitter department location is very quiet and fax machine is heard now Occurrence likelihood: 1-10; 10 Very likely to occur. Detection likelihood: 1-10; 10 = very unlikely to detect. Severity: 1-10; 10 = most severe effect, RPN = product of 3 scores
2a. Risk Priority Assessment.xlsx 3 Steps Process Step Failure Mode Cause(s) 11 13 7 2 8 10 9 3 4 5 8 16 TeleSitter communicates to patient for redirection by recorded messages or with own voice. Patient not successfully redirected & TeleSitter calls CNA to go to patient room. Provide patient education. Patient meets TeleSitter inclusion criteria and charge nurse notified TeleSitter input patient demographics into software and initiates surveillance (set up individualized settings). Patient displaying unsafe behavior TeleSitter visualizes and monitors patient (1:16 ratios) TeleSitter request form complete and faxed to TeleSitters. Staff call TeleSitter confirm receipt of form & availability of camera Obtain camera (wall or rolling camera). Total of 22 wall and 7 rolling cameras. TeleSitter input patient demographics into software and initiates surveillance (set up individualized settings). Camera placed on privacy mode. Mic not working TeleSitter cannot be heard by patient. Staff not available Equipment not working or tested. CNA busy with another patient Failure Effects (All effect have potential harm to patient or removal of medical devices) Patient can not hear TeleSitter and does not respond to redirection. Staff does not respond to patient in need. Education not provided RN busy/forget/no family Patient/family upset Nurse going from memory and not all inclusion/exclusion elements reviewed or considered. Incorrect language set up/language unknown TeleSitter hesitant to call or redirect because of routine behavior (example - patient constantly sitting up and always ok not getting out of bed) Curtain pulled and cannot see patient. Receipt of fax unknown to TeleSitters. Only one TeleSitter staffed with high acuity patients Pt room with no bracket and may have to move patient. Wrong patient information into program Human error going from memory. Failing to review criteria on form. Specific language not available. Patient appear to be safe. TeleSitter not placed. Pt does not understand commands. Redirection by TeleSitter not effective. No redirection or delayed redirection Staff or family pull curtain for Patient not monitored. patient privacy. TeleSitter room noisy and unable to hear fax. TeleSitter Delayed TeleSitter monitoring patients. High acuity patient(s) needing redirection while monitoring Delay in tele or physical other active patients. Wait time sitter. to call more staff in. Not all rooms have brackets. Human error Delay in TeleSitter Wrong patient information System malfunction Red alert does not display Patient not monitored. Occurrence Likelihood (1-10) Detection Likelihood (1-10) Severity (1-10) Risk Priority Number (RPN) 3 1 6 18 2 1 9 18 3 5 1 15 1 3 4 12 2 1 6 12 3 2 2 12 5 1 2 10 3 1 3 9 3 1 3 9 3 1 3 9 1 9 1 9 1 1 8 8 Action 7 Provide patient education. Pt not able to understand or fails to see need for TeleSitter for their safety. Pt not able to comprehend/understand Patient/family upset 7 1 1 7 Occurrence likelihood: 1-10; 10 Very likely to occur. Detection likelihood: 1-10; 10 = very unlikely to detect. Severity: 1-10; 10 = most severe effect, RPN = product of 3 scores
2a. Risk Priority Assessment.xlsx 4 Steps Process Step Failure Mode Cause(s) Failure Effects (All effect have potential harm to patient or removal of medical devices) Occurrence Likelihood (1-10) Detection Likelihood (1-10) Severity (1-10) Risk Priority Number (RPN) Action 3 TeleSitter request form complete and faxed to TeleSitters. Unable to print form and fax to TeleSitters. System down/faxed to wrong number Delayed TeleSitter 9 TeleSitter visualizes and monitors patient (1:16 ratios) 17 TeleSitter discontinued 4 12 Staff call TeleSitter confirm receipt of form & availability of camera Patient successfully redirected System goes down. Not enough cameras and prioritized to other patients. Malfunction of equipment. No power. Broken antenna. System/Server down. High census of patients requiring TeleSitters. Delay in monitoring patient Patient not monitored. All 29 cameras are being used Delay in tele or physical Camera not available. by other patients. Evaluate need sitter. for physical sitter. None NA NA 2 1 3 6 2 1 3 6 1 1 5 5 1 1 3 3 0 Occurrence likelihood: 1-10; 10 Very likely to occur. Detection likelihood: 1-10; 10 = very unlikely to detect. Severity: 1-10; 10 = most severe effect, RPN = product of 3 scores
Ordering of Telemetry Telemetry Quality Focus Team
So what s the issue? # of Teles Active Orders Expired Orders No Orders 2N 30 13 43.3% 13 43.3% 4 13.3% 2S 8 7 87.5% 0 0.0% 1 12.5% 3N 15 3 20.0% 11 73.3% 1 6.7% 3S 11 2 18.2% 9 81.8% 0 0.0% 4N 10 4 40.0% 5 50.0% 1 10.0% 4S 16 5 31.3% 9 56.3% 2 12.5% 4T 19 11 57.9% 6 31.6% 2 10.5% TOTAL 109 45 41.3% 53 48.6% 11 10.1%
Not enough tele boxes Triaging patients off telemetry Calling physicians, with/without order Indefinite order Monitoring for just in case
QFT Dr. Lively, Jon Knudsen Nurse Managers Nurse Educators and APNs Telemetry Technicians Quality and Patient Safety Staff
Telemetry Orders 2 classes with indications Class 1 = 72 hours Class 2 = 48 hours Nursing communication order: will allow for removal when order expires based on criteria
Physician/Staff education Medical Executive Committee Medical staff departments of: Surgery, Critical Care, Anesthesia, Cardiology, Family Practice, Hospitalists Hospital Staff Department staff meetings Online Net Learning course Go Live July 6, 2017
Results
Additional Benefits Reduced telemetry monitoring Allowing better ratios (48:1) Now monitoring ER patients Room for growth, 5T, ER expansion No need to purchase more monitors; currently 40-50 available daily ($2,500 each) Every 12 hour report for reconcillation