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, December 6, 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 Directors Mary Driscoll, RN, MPH and Layla P. Suleiman Gonzalez, PhD, JD (3) Telephonically Present Absent: None (0) Board Chairman M. Hill Hammock (ex-officio) and Director Emilie N. Junge Patricia Merryweather (non-director Member) Patrick T. Driscoll, Jr. (non-director Member) Additional attendees and/or presenters were: Krishna Das, MD Chief Quality Officer Valerie Hansbrough, MD Provident Hospital of Cook County Charlene Luchsinger Director of Medical Staff Services Suja Mathew, MD Chairman, Department of Medicine Jeff McCutchan Interim General Counsel Deborah Santana Secretary to the Board John Jay Shannon, MD Chief Executive Officer Ozuru Ukoha, MD John H. Stroger, Jr. Hospital of Cook County Samuel Williams Executive Director of Facilities 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 B. Metrics (Attachment #1) Dr. Krishna Das, Chief Quality Officer, provided an overview of the metrics. The Committee reviewed and discussed the information. With regard to the measure on slide 2, regarding influenza and pneumococcal vaccinations, Dr. Das noted that the table presented will need to be changed, as staff are now only looking at influenza vaccination data. During further discussion of the vaccination measure, she stated that some of the issues identified in the process include some defects in screening and that it is not being administered consistently. A System-wide group has been assembled to look into the matter further. Director Driscoll requested that Dr. Das provide additional information on the issues at the next meeting of the Committee. Director Junge requested a status update on receiving quality reports for Cermak Health Services. Dr. Das stated that a discussion was held on all of the metrics that Cermak provides; staff are in the process of trying to add those to the overall dashboards. When the dashboards are updated, the Cermak metrics will be incorporated on a separate slide, to be presented in a closed meeting. Page 1 of 50
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, December 6, 2016 Page 2 III. Report from Chief Quality Officer (continued) C. Report on Environmental Services (Attachment #2) Samuel Williams, Executive Director of Facilities, provided an overview of the Report on Environmental Services. The Committee reviewed and discussed the information. The Report contained information on the following subjects: Importance of the Function of Environmental Services Performance Metrics Scope of Responsibility Assessment of Staffing, Tools / Equipment, Education / Training, Practices Recommendations / Strategies for Improvement During the discussion of the Report, Chairman Gugenheim noted that, with regard to the strategies for improvement, perhaps the titles of the frontline staff should be revised, as building service worker does not necessarily inspire pride. Mr. Williams concurred. Board Chairman Hammock requested that a couple of metrics relating to this subject be added to the Committee s regular list, and presented monthly or quarterly. It was noted that the metrics would be based on existing measures of internal assessment. It was noted that Mr. Williams will return in July for a report on the subject. Director Suleiman Gonzalez requested that he be invited to return in three (3) months for an update, not a full report. IV. Action Items A. Approve reappointments of Stroger Hospital Department Chair(s) and Division Chair(s) (Attachment #3) Dr. Suja Mathew, Chairman of the Department of Medicine, presented the two (2) Stroger Hospital Division Chair reappointments for the Committee s consideration. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the two (2) proposed Stroger Hospital Division Chair reappointments. THE MOTION CARRIED UNANIMOUSLY. B. Approve proposed Amendments to the Bylaws of the John H. Stroger, Jr. Hospital of Cook County Medical Staff (Attachment #4) Dr. Ozuru Ukoha, President of the Executive Medical Staff (EMS) of Stroger Hospital, provided an overview of the proposed Amendments to the Bylaws of the John H. Stroger, Jr. Hospital of Cook County Medical Staff. He stated that these changes are being made at the request of Dr. Das, in order to meet regulatory requirements. He noted that this is being presented as an Urgent Amendment, because it needs to be in effect as soon as possible. Should the Board approve these Amendments, they become provisional and will go back to the Medical Staff for approval; following the Medical Staff s approval, they will return to the Board for final approval, at which point they are no longer provisional but are actively in effect. Page 2 of 50
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, December 6, 2016 Page 3 IV. Action Items B. Approve proposed Amendments (continued) Dr. Das provided additional information regarding the proposed Amendments. She noted that the Ambulatory Quality Council has been in existence for several years already, but the reporting process for it has been informal to the EMS at Stroger Hospital. This Amendment formalizes the reporting of the Ambulatory Quality Council to Stroger Hospital s Quality Committee, which reports to the Stroger Hospital EMS. Director Driscoll stated that she hopes that CCHHS moves to a System-wide Quality Committee in the future, that is not necessarily based under hospital quality, but instead looking at the System as a whole. The hospital would be a subcommittee under that, as well as ACHN, CORE Center, etc. Dr. Das responded that she would like to see movement in that direction as well, but noted that challenges exist due to the fact that the Centers for Medicare and Medicaid Services (CMS) has specific requirements to report and be overseen by medical staff specific to the Medicare and license number that CMS grants. Dr. John Jay Shannon, Chief Executive Officer, stated that the organization is moving toward a uniform standard and uniform ways of measuring across the organization, not only in its quality reporting but in medical staff processes, privileging requirements, etc. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the proposed Amendments to the Bylaws of the John H. Stroger, Jr. Hospital of Cook County Medical Staff. THE MOTION CARRIED UNANIMOUSLY. C. 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 The Committee took action on the Medical Staff Appointments/Re-appointments/Changes following the adjournment of the closed meeting. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the Medical Staff Appointments/Re-appointments/Changes for John H. Stroger, Jr. Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to approve the Medical Staff Appointments/Re-appointments/Changes for Provident Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. D. Minutes of the Quality and Patient Safety Committee Meeting, October 18, 2016 Director Suleiman Gonzalez, seconded by Director Driscoll, moved to accept the Minutes of the Quality and Patient Safety Committee Meeting of October 18, 2016. THE MOTION CARRIED UNANIMOUSLY. E. Any items listed under Sections IV and V Page 3 of 50
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, December 6, 2016 Page 4 V. Closed Meeting Items A. Provident Hospital Medical Staff Credentialing Matter B. Medical Staff Appointments/Re-appointments/Changes C. Litigation Matter(s) Director Driscoll, seconded by Director Suleiman Gonzalez, moved to recess the open meeting and convene into a closed meeting, pursuant to the following exceptions to the Illinois Open Meetings Act: 5 ILCS 120/2(c)(1), regarding the appointment, employment, compensation, discipline, performance, or dismissal of specific employees of the public body or legal counsel for the public body, including hearing testimony on a complaint lodged against an employee of the public body or against legal counsel for the public body to determine its validity, 5 ILCS 120/2(c)(11), regarding litigation, when an action against, affecting or on behalf of the particular body has been filed and is pending before a court or administrative tribunal, or when the public body finds that an action is probable or imminent, in which case the basis for the finding shall be recorded and entered into the minutes of the closed meeting, and 5 ILCS 120/2(c)(17), regarding the recruitment, credentialing, discipline or formal peer review of physicians or other health care professionals for a hospital, or other institution providing medical care, that is operated by the public body. On the motion to recess the open meeting and convene into a closed meeting, a roll call was taken, the votes of yeas and nays being as follows: Yeas: Chairman Gugenheim and Directors Driscoll and Suleiman Gonzalez (3) Nays: None (0) Absent: None (0) THE MOTION CARRIED UNANIMOUSLY and the Committee recessed into a closed meeting. Chairman Gugenheim declared that the closed meeting was adjourned. The Committee reconvened into the open meeting. Director Driscoll, seconded by Director Suleiman Gonzalez, moved to adopt the recommendation of the Provident Hospital Medical Executive Committee, which was to adopt the recommendation of the Provident Hospital Medical Staff Hearing Committee, and the grounds and findings in support thereof as set forth in the Hearing Committee s Report and Recommendation, and deny the application for reappointment and request for clinical privileges of Provident Provider #1, who was the subject of the Provident Hospital Medical Staff credentialing matter considered in today s closed session. THE MOTION CARRIED UNANIMOUSLY. Page 4 of 50
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, December 6, 2016 Page 5 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 5 of 50
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes December 6, 2016 ATTACHMENT #1 Page 6 of 50
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Pa7ent Safety Commi9ee Dashboard Overview 6 December 2016 Krishna Das, MD, Chief Quality Officer 1 CCHHS Board QPS Commi9ee Page 7 of 50
Quality Stroger 2 CCHHS Board QPS Commi9ee Page 8 of 50
Quality Provident 3 CCHHS Board QPS Commi9ee Page 9 of 50
Safety Stroger 4 CCHHS Board QPS Commi9ee Page 10 of 50
PaBent Experience Stroger 5 CCHHS Board QPS Commi9ee Page 11 of 50
PaBent Experience Provident 6 CCHHS Board QPS Commi9ee Page 12 of 50
ACHN 7 CCHHS Board QPS Commi9ee Page 13 of 50
Board Quality Dashboard 8 CCHHS Board QPS Commi9ee Page 14 of 50
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes December 6, 2016 ATTACHMENT #2 Page 15 of 50
COOK COUNTY HEALTH & HOSPITALS SYSTEM Environmental Services Update Quality and Patient Safety Committee 6 December 2016 Samuel Williams Executive Director of Facilities 1 Page 16 of 50 Environmental Services Update
Why Is the Environmental Services (EVS) Function Critical in Healthcare settings? Patient Satisfaction A clean environment delivered by helpful and pleasant staff promotes satisfaction among consumers and distinguish the hospital from its competition Staff satisfaction Maintain appropriate environment for professional operations 2 Health System Reputation EVS staff can improve a hospital s reputation simply by interacting pleasantly with patients and explaining what they are doing and why it is important, the utilization of AIDET Acknowledge, Introduce, Duration, Explain, Thank Page 17 of 50 Environmental Services Update
Why Is Environmental Services (EVS) Function Important? (continued) Patient Safety i. EVS staff are vital to helping prevent the spread of disease ii. Safety for patients and staff: Assure low levels of combustibles by waste management Reduce fire hazard by dusting Assure appropriate disposal of hazardous material including chemical wastes Maintain infection control I. Reduce environmental transmission of pathogens II. Assure full cleaning by environmental surveillance 3 Page 18 of 50 Environmental Services Update
Background: C. difficile Infection CMS indicator and pay for performance measure Variation noted in the incidence of C. difficile infections Peaks correlated with disinfection practices and environmental transmission Incidence improved after strict practices of cleaning with bleach 4 Page 19 of 50 Environmental Services Update
How Are We Performing? 100 90 Stroger - Cleanliness 80 70 % Top Box 60 50 40 46 49 51 59 54 52 53 53 54 43 46 52 47 50 51 52.4 51.2 49.7 51.8 50.3 54.5 53 53.4 30 Top Box in Percent 20 50 th %ile 10 90 th %ile 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2011 2012 2013 2014 2015 2016 5 Page 20 of 50 Environmental Services Update
Scope of responsibility John H. Stroger Hospital Central Campus Buildings Provident Hospital Ambulatory Centers Oak Forest 1,159,232 square feet 814,994 square feet 446,650 square feet 237,306 square feet 469,298 square feet Total Area 3,127,480 square feet 6 Page 21 of 50 Environmental Services Update
Staffing Leadership/management My Assessment i. Lack of leadership by management company/director on site ii. Lack of motivational approach to team huddles iii. Failure to round on employees iv. Failure to gain input from frontline staff on improving the department v. Failure to provide coaching and mentoring of frontline staff vi. Failure to provide proper training entire term of contract vii. Failure to discipline employees 7 Frontline Staff- 161 i. General concerns with trust in management company leadership ii. Lack of coaching from leadership to the team iii. Lack of departmental pride throughout department iv. Lack of employee engagement Page 22 of 50 Environmental Services Update
My Assessment (continued) Tools/Equipment i. Need more/new equipment ii. Need preventive maintenance service contract for equipment iii. Low quantity of micro-fiber mops iv. Improve replenishment frequency of supplies 8 Page 23 of 50 Environmental Services Update
My Assessment (continued) Education/Training: Training of staff inconsistent until the last 7 months of a 5 year contract i. Inconsistent Leadership -6 Directors in 5 years -8 Operations Managers in 5 years ii. Inconsistent Training Managers -3 Training Managers in 5 years 9 Page 24 of 50 Environmental Services Update
My Assessment (continued) Practices Inconsistent level of cleanliness i. Patient rooms ii. Public corridors iii. Elevator tracks iv. Stairwells v. Soiled utility rooms vi. Procedural Areas 10 Page 25 of 50 Environmental Services Update
My Recommendations/ Strategies for Improvement Leadership i. Hire Effective Leaders Director of Environmental Services: On-going search Interviewing 3 Candidates 2 Managers of Environmental Services 1 Candidate to begin December 28, 2016 ii. Frontline Staffing 9 Building Service Workers Relocated to Main Campus Effective November 15,2016 iii. Accountability Director, Managers, and Frontline Staff 11 Page 26 of 50 Environmental Services Update
My Recommendations/ Strategies for Improvement (continued) Education/Training i. AIDET Acknowledge, Introduce, Duration, Explain, Thank ii. Proactively engaging, listening to, communicating, building relationships with and supporting important customers: Rounding on Direct Reports (Staff) Senior Leader Rounding Rounding on Patients Rounding on Areas Served/Internal Customers 12 Page 27 of 50 Environmental Services Update
13 Practice My Recommendations/ Strategies for Improvement (continued) Improve Communication between EVS Staff and Patients AIDET Daily cleaning of all areas needs to be more consistent Projects need to be consistent and on a rotating schedule Cleaning projects need to be prioritized based on clinical needs. Dedicated Staff should be maintained in the following areas: Sterile Processing Direct Patient Care Areas Procedural Areas, including operating rooms Emergency / Trauma Ancillary Departments Hospital Clinics Page 28 of 50 Environmental Services Update
My Recommendations/ Strategies for Improvement (continued) Goal Setting and Feedback within EVS i. Solicit feedback from staff on how to improve the department ii. iii. iv. Set SMART goals Discuss tactics with staff to achieve goals Leadership team to review comments pertaining to hospital cleanliness from HCAHPS during daily huddles with staff v. Display dashboard with scores by clinical unit within the EVS Department 14 Page 29 of 50 Environmental Services Update
My Recommendations/ Strategies for Improvement (continued) Ambulatory Services: Health Centers Contracted Day Springs awarded contract effective November 15, 2016 15 Page 30 of 50 Environmental Services Update
When to Expect Change Within six months of hire of new leadership team, Director and 2 Managers Update to the Board to be provided July 2017 16 Page 31 of 50 Environmental Services Update
Questions? 17 Page 32 of 50 Environmental Services Update
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes December 6, 2016 ATTACHMENT #3 Page 33 of 50
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Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes December 6, 2016 ATTACHMENT #4 Page 35 of 50
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Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes December 6, 2016 ATTACHMENT #5 Page 40 of 50
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