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, March 15, 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 Erica E. Marsh, MD, MSCI and Mary B. Richardson-Lowry (Substitute Member) (2) Directors Emilie N. Junge and Carmen Velasquez Present Telephonically: Patrick T. Driscoll, Jr. and Patricia Merryweather (non-director Members) Board Chairman M. Hill Hammock (ex-officio) and Director Wayne M. Lerner, DPH, LFACHE (1) Absent: None (0) Director Richardson-Lowry, 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 Chief Quality Officer Richard Keen, MD Chairman, Department of Surgery Jeff McCutchan Interim General Counsel Jayne Mitton, RN - Interim Service Line Director, Perioperative Services 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 called upon the following registered public speaker: 1. George Blakemore Concerned Citizen III. Report from Chief Quality Officer A. Regulatory and Accreditation Updates B. Metrics (Attachment #1) Dr. Krishna Das, Chief Quality Officer, provided an update on the follow-up survey that took place on March 10 th and 11 th by a representative from The Joint Commission (TJC). There was one (1) surveyor on-site for the two (2) day period; she reviewed all of the outstanding action items, and has cleared Stroger Hospital of the vast majority of those. This is based on a verbal report; the administration is awaiting the final report from TJC to see what action items remain, in terms of ongoing monitoring. Dr. Das noted that it usually takes a week after the survey for the final report to be received. DRAFT for 3/25/16 CCHHS Board Meeting
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, March 15, 2016 Page 2 III. Report from Chief Quality Officer (continued) Director Richardson-Lowry inquired whether the surveyor provided any indication as to remaining areas that will need more work. Dr. Das responded that, not surprisingly, the surveyor commented on the cleanliness of the place and had some findings along those lines. During the discussion of the Stroger Hospital quality metrics, Dr. Das provided additional information regarding the metric relating to care for stroke patients. She stated that the data is abstracted for that metric in a combination of electronic and manual methods. With regard to manual abstraction of data, if information can be found in the progress notes, then it can be coded; however, there is only one (1) abstractor for the hospital, so it is not feasible for her to look through every progress note. Appropriate care is being provided, this is just an issue with documentation. Ms. Merryweather inquired whether there is a way to put that information in the electronic health record (EHR) and the provider just checks it off. Dr. Das responded that the function exists in the EHR today; however, the neurologists want to do the stroke education themselves, and the check-off is located in a nursing window, so that gap has not yet been bridged. C. Operating Room Performance Improvement (Attachment #2) Dr. Richard Keen, Chairman of the Department of Surgery, and Jayne Mitton, Interim Service Line Director, Perioperative Services, reviewed the presentation on Operating Room (OR) Performance Improvement. The Committee reviewed and discussed the information. Included in the update was information on the following subjects: Definition and Importance of First Case On-Time Starts; National Benchmarks; On-Time Start Data; Delay reasons; OR Process Fishbone Diagram; and Planned Immediate Focus. Director Lerner inquired regarding future updates on the subject. Dr. Keen responded that slight improvement is being seen every month; he expects that marked improvement should be seen within three (3) months. Director Lerner requested that the Committee receive a follow-up report in three (3) months. Dr. John Jay Shannon, Chief Executive Officer, noted that this data is presented in the montly dashboard for Stroger and Provident Hospitals; he suggested that the metrics continue to be reflected in this manner, and if expected improvement does not happen, then the Committee can ask the surgical team to come back and report on the matter. IV. Action Items A. 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 #3) Director Lerner, seconded by Director Marsh, moved to approve the Medical Staff Appointments/Reappointments/Changes. THE MOTION CARRIED UNANIMOUSLY. DRAFT for 3/25/16 CCHHS Board Meeting
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, March 15, 2016 Page 3 IV. Action Items (continued) B. Minutes of the Quality and Patient Safety Committee Meeting, February 16, 2016 Director Marsh, seconded by Director Lerner, moved to accept the Minutes of the Quality and Patient Safety Committee Meeting of February 16, 2016. THE MOTION CARRIED UNANIMOUSLY. C. Any items listed under Sections IV and V V. Recommendations, Discussion / Information Item A. Strategic planning discussion (Attachment #4) Dr. Shannon provided an introduction. He stated that a binder with strategic planning materials will be provided to the Directors at the end of this meeting; that binder is expected to grow over the next few months as the strategic planning conversations take place. On February 26 th, CCHHS kicked off its strategic planning process; what is expected to happen, particularly over the course of this month, is that content experts from the leadership team will present background information on current drivers for the dimension that is being discussed. This month, topics reviewed will include the following: quality; an overview of current ambulatory practices and the processes around that; a review of CCHHS current labor force - what they look like, where they are, what they do; and a broad context on the financial underpinnings of CCHHS. Dr. Shannon stated that providing high-level, high-quality, safe and reliable care has to be one of the key tenets of the organization s strategy. To introduce that conversation, he asked Dr. Das to walk through the high-level overview of quality and reliability. Dr. Das reviewed the presentation, which included information on the following subjects: Quality: A Definition; Safety versus Quality; Quality from a Patient s Perspective; Dimensions of Quality Safe, Timely, Effective, Efficient, Equitable and Patient-Centered; High Reliability A Definition; Reliability the Challenge; Building Reliability; Reliability Leadership; The Path to High Reliability; Principles of High Reliability; Reliability Culture; Errors: Role of Serial Defenses; Errors versus Adverse Events; Concept of Latent Errors; Culture of Safety; Reliability Process Improvement; Hierarchy of Reliability; Institute for Healthcare Improvement (IHI) Triple Aim; National Quality Strategy 2011; and Summary. DRAFT for 3/25/16 CCHHS Board Meeting
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, March 15, 2016 Page 4 V. Recommendations, Discussion / Information Item A. Strategic planning discussion (continued) In response to a comment from Ms. Merryweather regarding one of the requirements included in the Affordable Care Act that will go into effect on January 1, 2017 that requires hospitals to participate in a patient safety organization (PSO), Dr. Shannon stated that CCHHS has participated in a PSO within Vizient (formerly University HealthSystem Consortium) now for a few years. Ms. Merryweather noted that the patient experience should include involving the patient and families beyond asking them what they think; they should be engaged in the discussions. She noted that Ann & Robert H. Lurie Children's Hospital of Chicago established a children s advisory council; that council not only helped them with their designs of the hospital, but also with improving their interactions with patients. Director Junge noted that, quite often, the front-line staff are the first ones to hear patient complaints and comments. She believes that front-line staff should always be involved in discussions about what is working and not working. Director Velasquez stated that, when talking about quality, the Board also has to talk about personnel, particularly with regard to the language and culture of the patients. When engaging patients, that is something that has to be seriously and more aggressively considered. Board Chairman Hammock noted that, as the strategic planning process is structured, a lot of topics are going to overlap different areas. For example, the technology agenda for the strategic plan will need to be integrated in a way that assures that quality efforts will be supported and data will be reliably collected; the Quality and Technology teams will need to communicate their needs and expectations of each other. That goes the same with the Quality and Human Resources Departments Human Resources is going to be implementing cultural education efforts in training and leadership; what Human Resources is doing is that which supports and completes the work of the Quality Department, and they are not operating in silos. With regard to technology, Dr. Shannon noted that, in the past year, the Board has approved a contract for a more deep engagement with the Vizient clinical database product that has a membership of approximately 150 health systems; CCHHS sends data to Vizient, and it reflect backs with a variety of different benchmarks and performance metrics. This is an example where the administration is deploying a technology and a tool that will address several of the objectives discussed as high-level principles for the strategy going forward. That tool should illuminate areas that are performing poorly from a quality standpoint and from an expense, or cost per unit of service standpoint. This company has been around for 30 years. It started as a collaborative learning and data sharing organization used particularly by medical school-based medical centers in the 1980s. It has evolved and its value has been shown. Membership allows an organization to get information analyzed externally and benchmarked; membership also allows for exploratory benchmarking with similar institutions. Director Marsh concurred with comments regarding internal inter-connectedness as referenced earlier by Board Chairman Hammock; she also recommended that the administration look externally at the challenges and successes of other health systems. She stated that there are organizations that have had the resources and personnel to be investing in these systems for over a decade in some cases, and are therefore more evolved; she encouraged the administration to reach out to some of these local organizations to get the benefit of their experiences. DRAFT for 3/25/16 CCHHS Board Meeting
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, March 15, 2016 Page 5 V. Recommendations, Discussion / Information Item A. Strategic planning discussion (continued) Chairman Gugenheim inquired whether the contents of this presentation are routinely shared throughout the organization. Dr. Shannon responded that this is the first compilation being presented in this fashion. In the day-to-day micro environments, there needs to be a more diverse group of human tentacles out in the environments themselves that are aware of what good care looks like; this group would most likely consist of a subpopulation at the manager level - this information will be a part of the management development curriculum that has been previously discussed. Additionally, the administration will be using mass communication strategies and posters/reflections. On the subject of mass communication, Chairman Gugenheim noted that, with regard to cleanliness, for example, if the janitorial staff were to see this presentation, might it give them a better understanding of the critical nature relating to cleanliness? Would that help solve the problem, and if so, how would the administration undertake a mass education? It would have to be strategic with a timetable to accomplish it. Dr. Shannon responded that he will take that point for further consideration. Director Lerner provided two points to consider as the Board continues its strategic planning discussions. First, it is very important to think about the relationship between quality and financial performance; if it is then related to the Managed Care strategy, this should help to achieve a healthier population. Secondly, he stated that he is constantly amazed by the number of organizations who achieve Baldrige Award status or some other highquality status who quickly fall out of that position of being number one if a CEO or governance change occurs, or if some other big change occurs in the organization. He believes that the Board needs to think about how the actions it is taking today will carry through for generations to come. Director Richardson-Lowry requested that background information be provided regarding Vizient that includes a list of competing organizations and a list of the health systems that compose its membership. Additionally, she requested that information on any prior strategic plans be provided. VI. 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. VII. Adjourn As the agenda was exhausted, Chairman Gugenheim declared the meeting ADJOURNED. DRAFT for 3/25/16 CCHHS Board Meeting
Minutes of the Meeting of the Quality and Patient Safety Committee Tuesday, March 15, 2016 Page 6 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 DRAFT for 3/25/16 CCHHS Board Meeting
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes March 15, 2016 ATTACHMENT #1
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Dashboard Overview 15 March 2016 Krishna Das, MD, Chief Quality Officer 1 CCHHS Board QPS Committee
Quality Stroger Variance is target to most recent month VTE data collection format to change in 2016 2 CCHHS Board QPS Committee
Quality Provident Variance is target to most recent month VTE data collection format to change in 2016 3 CCHHS Board QPS Committee
Safety Stroger 4 CCHHS Board QPS Committee
Patient Experience Stroger 5 CCHHS Board QPS Committee
Patient Experience Provident 6 CCHHS Board QPS Committee
ACHN 7 CCHHS Board QPS Committee
Board Quality Dashboard 8 CCHHS Board QPS Committee
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes March 15, 2016 ATTACHMENT #2
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee OR Process Improvement Project Report Jayne Mitton, RN Richard Keen, MD
Definition of First Case On-Time Starts Per national benchmark data, we have chosen wheels in the room as our start time. Any case that falls out of five minutes after the scheduled start time is considered late. Cases in the data base are those on the schedule at 2:00 PM the prior day. 2 OR Process Update QPS 3.15.2016
Importance of First Case On-Time Starts Improves Operating Room efficiency to build capacity Improves the patient experience Improves surgeon satisfaction Improves revenue by adding cases and reducing overtime 3 OR Process Update QPS 3.15.2016
National Benchmarks METRIC 50 th %ile 90 th %ile 95 th %ile First case on time starts (%) 64 88 91 *McKesson: OR Benchmark Collaborative 4 OR Process Update QPS 3.15.2016
On-Time Start Data 5 OR Process Update QPS 3.15.2016
DELAY REASONS 20% 19% 18% 120 15% 15% 14% 100 80 10% 60 7% 7% 7% 7% 6% 40 5% 20 0% 0 6 OR Process Update QPS 3.15.2016
OR Process Fishbone Diagram 7 OR Process Update QPS 3.15.2016
Planned Immediate Focus PATIENT CENTERED EFFORTS 1. Notify Service of patients who were not reached by phone to possibly change case order 2. Require all cancellation reasons to be validated by surgeon. 3. Scan ID information into chart in Clinic C 4. Move OR in-room time for ICU patients to 6:30 AM PROCESSED CENTERED EFFORTS 1. At Time Out in room delay cause if any is agreed upon by all to improve data 2. Surgeons who are late will receive a letter which will be in their file and tracked for frequency. 3. OR Charge Nurse will round at 6:30 to ensure staff is in room and doing setup 4. SPD is currently reconfiguring surgeon preference trays and implementing instrument tracking system over the next two months. 8 OR Process Update QPS 3.15.2016
Thank you 9 OR Process Update QPS 3.15.2016
Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes March 15, 2016 ATTACHMENT #3
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Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Minutes March 15, 2016 ATTACHMENT #4
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Quality and Patient Safety Committee Quality and Reliability in Health Care Krishna Das, MD, Chief Quality Officer 15 March 2016
Quality: A Definition The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge - Institute of Medicine, Crossing the Quality Chasm, 2002 2 Quality and Reliability 3.15.2016
Safety versus Quality Quality- addresses the intended results of the health care system Safety- is concerned with the many ways in which the system can fail to function Both are important in improving care Vincent et al. NHS Safety Briefing 3 Quality and Reliability 3.15.2016
Quality from a Patient s Perspective Help me Evidence based, high quality practice Don t hurt me Prevent medical errors & adverse events Be nice to me Treat me with respect and humanity Adapted from Don Berwick, MD 4 Quality and Reliability 3.15.2016
Dimensions of Quality What are the components of quality? IOM listed and defined the dimensions of quality in health care This process also summarized research findings in contributors to quality Institute of Medicine (IOM): Crossing the Quality Chasm, 2002 5 Quality and Reliability 3.15.2016
Safe Patients should not be harmed by the care that is intended to help them Safe health care systems reduce risks and hazards attributable to the process of care 6 IOM: Crossing the Quality Chasm, 2002 Quality and Reliability 3.15.2016
Timely Waits and sometimes-harmful delays in care should be reduced both for those who receive care and those who give care In most industries timeliness is an important quality metric 7 IOM: Crossing the Quality Chasm, 2002 Quality and Reliability 3.15.2016
Effective Care should be based on scientific knowledge and offered to all who could benefit, and not to those not likely to benefit We match the science of medicine to the care we provide 8 IOM: Crossing the Quality Chasm, 2002 Quality and Reliability 3.15.2016
Efficient Care should be given without wasting equipment, supplies, ideas and energy Don t allow ideas and suggestions from front line to go to waste 9 IOM: Crossing the Quality Chasm, 2002 Quality and Reliability 3.15.2016
Equitable Care should not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socioeconomic status Must close the gap in justice in health care 10 IOM: Crossing the Quality Chasm, 2002 Quality and Reliability 3.15.2016
Patient Centered Care should be respectful of and responsive to individual patient preferences, needs and values Nothing about me without me 11 IOM: Crossing the Quality Chasm, 2002 Quality and Reliability 3.15.2016
Six Dimensions of Quality (and care) S: Safe T: Timely E: Effective E: Efficient E: Equitable P: Patient Centered 12 IOM: Crossing the Quality Chasm, 2002 Quality and Reliability 3.15.2016
Over 15 Years Later We still see 100,000 deaths annually due to medical care Equivalent to one 747 full of passengers Crashing every other day
High Reliability The consistent performance at high levels of safety over long periods of time Ability of organizations to avoid preventable adverse events which might be expected due to hazardous or complex environments Examples of high reliability organizations (HROs): nuclear industry, aircraft carriers, airlines, amusement parks 14 Quality and Reliability 3.15.2016
Reliability the Challenge Application of evidence (effective treatments) Evidence is known but not consistently applied Over 7,000 patients studied by RAND* 55% received recommended care: Preventive care Acute care Care for chronic conditions 15 * McGlynn et al. The Quality of Healthcare Delivered to Adults in the US. NEJM 2003 Quality and Reliability 3.15.2016
Reliability the Challenge Complexity of health care 99% error free sounds good? If only 1% of 1,000,000 surgical procedures contain an error 100,000 procedures will be performed with an error If only 1% of 35,760,000 hospitalized patients experience an error in their care that is 357,607 medical errors 16 Quality and Reliability 3.15.2016
Reliability the Challenge Complexity of health care, cont d Medication administration 10 steps from writing orders to administering medications Assume each step is 99% accurate To perform all 10 steps = 90% accurate 17 Quality and Reliability 3.15.2016
Building Reliability R E A D I N E S S T O C H A N G E O R G A N I Z A T I O N A L L E A R N I N G L E A D E R S H I P C U L T U R E I M P R O V E M E N T M I S S I O N A N D V I S I O N S H A R E D V A L U E S 18 Chassin & Loeb. The Ongoing Quality Improvement Journey. Health Aff. 2011 Quality and Reliability 3.15.2016
Reliability Leadership Commitment to the process Board of Directors Senior Leadership Physician Leadership Prioritize quality and reliability Recognize it is a long term process Commit to organizational learning 19 Chassin & Loeb. The Ongoing Quality Improvement Journey. Health Aff. 2011 Quality and Reliability 3.15.2016
The Path to High Reliability Characteristic Early Developing Approaching Leadership Safety Culture Focus on regulatory Little IT support MDs not engaged Culture not assessed CEO leads quality Measurable QI targets set Initial safety culture measures done Commitment to high reliability Goal of zero harm Safety culture established RCAs limited to sentinel events Safety culture is given a high priority Near misses reported Process Improvement No formal QI/PI process Adoption of QI strategy Robust PI with staff training PI focused on regulatory PI expanded to all adverse events Patients engaged in QI/PI 20 Quality and Reliability 3.15.2016
Principles of High Reliability Preoccupation with failure Attentiveness to possibility of an error Reluctance to simplify Processes are complex, always dig deeper Sensitivity to operations Awareness of what s working, or not Commitment to resilience Ability to handle, learn from adverse events Deference to expertise Who really knows the work? (front line staff) 21 Quality and Reliability 3.15.2016
Reliability Culture Safety culture required to maintain reliability Trust front line workers must trust each other to report safety issues Report must occur without negative feedback Improve management must help fix the problems reported 22 Chassin & Loeb. The Ongoing Quality Improvement Journey. Health Aff. 2011 Quality and Reliability 3.15.2016
Errors: Role of Serial Defenses Reason, J. 2000 BMJ 23 Quality and Reliability 3.15.2016
Errors versus Adverse Events Adverse event final outcome in chain of events Error may play a causal role in an adverse event Adverse events which result from errors are potentially preventable Errors Potentially Preventable Events Adverse Events 24 Quality and Reliability 3.15.2016
Concept of Latent Errors Patient Safety Events 10% Latent Errors 90% Reporting Latent Errors Patient Safety 25 Quality and Reliability 3.15.2016
Culture of Safety Safe Practice Improve Process Learn from Errors Praise for Reporting Report Events Reporters must feel safe Leaders must commit to correct latent errors Increases reporting Increases staff satisfaction and retention Improves safety and reliability 26 Quality and Reliability 3.15.2016
Reliability Process Improvement Reliability = Number of actions that achieve the desired result / Total number of actions taken 10-1 10-2 = one defect in 10 attempts = one defect in 100 attempts and so on 27 Quality and Reliability 3.15.2016
Reliability Process Improvement Industrial approaches to quality improvement Lean approach Six sigma Robust process improvement (RPI) Reliable measurement Ascertain root causes Sustain improvement 28 Chassin & Loeb. The Ongoing Quality Improvement Journey. Health Aff. 2011 Quality and Reliability 3.15.2016
Hierarchy of Reliability Audit Hardwire Processes Training and Competency Policies plus Education Policies and Procedures 29 Quality and Reliability 3.15.2016
IHI Triple Aim Experience of care quality and safety, STEEEP Population health SES, behavioral factors, prevention, access Cost of care PMPM or equivalent 30 Quality and Reliability 3.15.2016
National Quality Strategy - 2011 Builds on the Triple Aim Patient experience of care improve overall quality by making health care more patient-centered, reliable, accessible and safe Population health improve the health of the US population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher quality care Cost and value reduce the cost of quality health care for individuals, families, employers and government 31 Quality and Reliability 3.15.2016
Summary Goals of quality are enunciated in the IOM reports, the Triple Aim and the National Quality Strategy Patient experience of care may be summarized in STEEEP Reliability strategies are based on leadership, culture of safety and robust process improvement Shared values and organizational learning are drivers of quality 32 Quality and Reliability 3.15.2016