Quality Council Minutes June 18, 2013 Attendance: Excused: Guest(s): Jenny Chacon, Terry Dentoni, Margaret DiLaura, William Huen, Valerie Inouye, Shermineh Jafarieh, Kathy Jung, Tina Lee, Todd May (Co-Chair), Anson Moon, Iman Nazeeri-Simmons, Roland Pickens, Baljeet Sangha, Sue Schwartz, Shannon Thyne, Cathryn Thurow. Sue Carlisle, Elaine Coleman, Sue Currin (Co-Chair), Alice Chen, Thomas Holton, Rachael Kagan, Jay Kloo, Elaine Lee, Troy Williams, David Woods. Andy Brunner, Emily Claymore, David Dao, Danielle Duong, Brandi Frazier, Cheryl Kalson, Jasmeen Karan, Laure Marshall, Jessica Morton, Bruce Occena, Dennise Rosas. I. ADMINISTRATIVE Todd May chaired the meeting. The Minutes of the May 21, 2013 meeting were presented for approval. Minutes approved. II. POLICIES AND PROCEDURES The following policy and procedures were presented by Cheryl Kalson: Policy - 1.10 Patient Leaving SFGH Prior to Completion of Their Evaluation or Treatment (AMA or AWOL) Andy Brunner, UCSF Risk Manager reviewed substantive changes Committee members agreed on the need to communicating the policy and new process re: Surrogate consent to hold to staff. It was suggested that a memo go to staff from the SFSD and Medical Staff office announcing the revised policy. Policy 2.02 Prioritization of Intensive Care Unit Beds Policy - 3.05 Claims Policy - 3.09 Consent to Medical and Surgical Procedures Policy - 3.17 Assignment of ICU & Admitting Service Critically Ill Patients Leaving the Emergency Department All policies were approved with the exception of 16.06. Iman Nazeeri-Simmons and Troy Williams will follow up re: dissemination of policy information to staff. 1
POLICIES AND PROCEDURES Policy 4.05 Patient Diversion Criteria III. PERFORMANCE MEASURES REPORTING INTERPRETER SERVICES Policy 15.07 Computer Based Training Policy 16.06 Photographing/Videotaping/Recording Patients in Hospital or Clinic Policy tabled for further review. Some council members raised concerns about policy wording such as use of dedicated camera or secure mobile device, and the need to reexamine patient consent policy for photography. Bruce Occena, VMI Coordinator and David Dao, Interpreter Services Supervisor reported on performance improvement activities for Interpreter Services. Timely Interpreter Services Access AIM: To maintain timely access to interpreter services for healthcare providers and Limited English Proficient (LEP) patients throughout the hospital. Access to a medical interpreter on SFGH campus remains between 3 to 5 minutes. Expansion of Interpreter Services AIM: Extend remote interpreter services to the entire campus by March 2013. At the same time, address the needs for additional interpreter remote service devices as part of the LEAN Initiative at SFGH. Interpreter Services continues to provide between~ 120,000 and 130,000 interpretations yearly at SFGH. Additional remote devices were added, as part or of Lean work, to 3M Surgical and the Urgent Care Clinic. Interpreter Services also provided additional devices to several patient care areas based on requests. Areas included: Psychiatry, Eligibility, OR/PACU, and several clinics. There was discussion of previous recommendations from the Language Access Task Force regarding implementation of daily proactive interpreter rounds for inpatients. At this time, Interpreter staffing of this service would be challenging, but the team agreed to test this improvement idea. Cheryl Kalson to send out PDF of policy 16.06 and work with Privacy Committee to revise further. Medical Executive Committee (MEC) will table review of policy 16.06. Develop and implement 2013 Performance Improvement project focused on improving access and use of interpreter services on inpatient units, including: -Creating a pilot in Unit 5A of Interpreter Orientation for all new LEP admissions. -Developing interpreter training for Positive Patient Identification. The Language Access TF will continue to work on feasibility of this recommendation. 2
PERFORMANCE MEASURES REPORTING INTERPRETER SERVICES VMI Expansion AIM: Begin to extend VMI access to the Interpreter Call Center from other clinical venues of the S.F. DPH. Completed planning for two stage roll out of VMI to Laguna Honda Hospital (LHH) in Fall 2012. Implement LHH VMI service by June 2013 and complete by September 2013. Call Center Expansion AIM: Add an additional 12 stations to the Interpreter Call Center. Completed build-out of 5 new workstations in September 2012. VMI to be expanded to COPC Health Centers between October 2013 and March 2014. Dr. Todd May (Co-Chair) asked about feasibility of providing dual handset phones in the PACU to improve privacy of interpretation services. At this time, the phone wiring in the PACU is not in place to accommodate the needed equipment. Operational Efficiency AIM: Increase the operational efficiency of the remote interpreter system by instituting automated call routing system by December 2012. The automated call routing system was installed and operational in December 2012. Interpreter staff and provider training completed in February 2013. Current practice of using polycom phones will continue. Service Data Reliability AIM: Increase the reliability of the service data associated with Interpreter Services through the installation of a new database (Touchpaper) by December 2012. New Interpreter Services database was designed and installed in December 2012. First quarter 2013 focused on addressing systems issues and staff training. Wireless VMI Activation AIM: Activate Wireless VMI in sections of SFGH by February 2013. Wireless activation was not accomplished within the planned timeframe due to challenges associated with the hospital s wireless infrastructure. In March 2013 a design solution was found but Installation, testing and rollout delayed due to wireless access issues which will be addressed through summer 2013. Interpreter Services to work with IS (Tina Lee) on upgrading computers to support new system which would enable data service reporting. IV. QUALITY MEASURES Sue Schwartz, Director of Performance Improvement, presented the Quarter 4 (Q4) 2012 and Q1 2013 Quality and Safety Metrics Dashboard data (Hospital-wide and Service specific). 3
QUALITY MEASURES Highlights included: Surgical Care Improvement (SCIP) All measures above 95%: Heart Failure discharge instructions assuring that the discharge medication list is included in the medical record continues to be challenging. Corrective actions to address the issue were mentioned. ED Pain Management Median Time to Pain Management for long bone fracture Time decreased from 167 min (Q1 2012) to 83 min (Q4 2012). The ED is currently reviewing an analysis of this data by Race and Gender to identify potential disparities in care and inform improvement efforts. Hospital scores on HCAHPS questions continue to be lower than NRC Picker (survey vendor) average. Service Excellence Committee will be reviewing data regularly and identifying priorities for improvement through the Patient Experience Workgroup. PUBLIC ACCESS TO QUALITY DASHBOARDS IV. JOINT COMMISSION SURVEY PREPARATION LEADERSHIP CHAPTER Laure Marshall, Data Center Manager, reminded the group that various data dashboards are available on the Data Center Website which lives on the CHN Intranet. UCSF staff are often unable to access the site. There was discussion about moving the dashboards to a public internet site to allow broader access. Council members expressed concern about publishing Service specific data on a public site, and recommended continuing to have the dashboards posted within the Intranet. Iman Nazeeri-Simmons, Chief Quality Officer, reported on the updated Executive Staff Talking Points for the Joint Commission s Opening session with surveyors. SFGH will schedule its Joint Commission Focused Standards Review survey (previously called the PPR survey) for sometime this Fall. This survey will prepare the organization for our full accreditation survey that is expected sometime in Spring/Summer of 2014 (although we are currently in the window for the survey). Iman reviewed the Talking Points document, including the Priority Focus Report items and asked for updates/edits to the document. Laure Marshall to meet with Tina Lee (IS) to address accessing CHN Intranet from UC server. Iman Nazeeri-Simmons, to email out talking points to (for feedback) along with Priority Focus Area report and the California JC Survey Guide (informational). Iman Nazeeri-Simmons to get updated staff vacancy rates from Human Resources. Terry Dentoni, Interim Chief Nursing Officer, to provide latest Organ Conversion rates for Talking Points. 4
ANNOUNCEMENTS No Announcements NEXT MEETING July 16, 2013, 10am to Noon, The Learning Center, Building 30, 2 nd Floor 5