BOARD QUALITY REVIEW COMMITTEE
OPEN SESSION AGENDA
MONDAY, JUNE 20, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:00 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064
Time Form A Target PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING Page # CALL TO ORDER 6:00 Establishment of Quorum 1 N/A 6:01 Public Comments1 15 N/A 6:16 Information Item(s)
1. *Review/Approve: Minutes – Monday, May 16, 2016 (Addendum A, Page 8 -16) 4 3 6:20 Standing Item(s) 1. The Patient Experience (Addendum B, Page 17 - 23) Tina Pope, Manager, Service Excellence a) Letters from Patients/Families b) Video of Dr. Tom Lee on Teamwork and Patient Expectations 15 4 6:35 c) Video of Christy Dempsey on the Compassionate, Connected Care Model d) Patient Experience Dashboard and Action Plan Update
2. Quality and Safety Dashboards (Addendum C, Page 24 - 26) 15 5 6:50 Valerie Martinez, Director, Quality, Patient Safety and Infection Control 3. Journal Club: “Toward a Safer Health Care System-The Critical Need to Improve Measurement” 5 6 6:55 by Ashish Jha, MD, MPH and Peter Pronovost, MD, PhD (Addendum D, Pages 27 - 29) New Business 1. Emergency Management/Environment of Care (Addendum E, Pages 30 - 52) 20 7 7:15 Dan Farrow, AVP, Hospitality and Facilities
Public Comments1 15 N/A 7:30
FINAL ADJOURNMENT 7:30 NOTE: The open session agenda, without public comments, is scheduled for 1 hour. Based on above agenda, without public comments the meeting starts at 6:00 p.m. and adjourns at 7:00 p.m.
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BOARD QUALITY REVIEW COMMITTEE
OPEN SESSION AGENDA
MONDAY, JUNE 20, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:00 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064
Board Quality Review Committee Members VOTING MEMBERSHIP NON-VOTING MEMBERSHIP
Aeron Wickes, MD – Chairperson, Board Member Bob Hemker, FACHE, President & CEO Linda Greer, RN, Board Member Frank Beirne, FACHE, EVP, Operations Dara Czerwonka, Board Member Alan Conrad, MD, EVP, Physician Alignment
Richard Engel, MD – Interim Chair of Medical Staff Quality Management Della Shaw – EVP, Strategy Committee for Palomar Medical Center Maria Sudak, RN, MSN, CCRN, NEA-BC – Interim VP, Palomar Medical Center Charles Callery, MD - Chair of Medical Staff Quality Management and Chief Nursing Office, Palomar Medical Center Committee for Pomerado Hospital Larry LaBossiere, RN, MSN, CEN, CNS, MBA, Interim VP/Interim CNO, Pomerado Sheila Brown, VP, Continuum Care Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient Safety Committee Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Co-Chair of Patient Safety Committee
NOTE: If you have a disability, please notify us by calling 760-740-6353, 72 hours prior to the event so that we may provide reasonable accommodations
Asterisks indicate anticipated action. Action is not limited to those designated items.
1 5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in meeting room.
2 Page 2
Attendance Roster, Minutes and Acronym Glossary Board Quality Review Committee Meeting Monday, May 16, 2016
TO: Board Quality Review Committee
MEETING DATE: Monday, June 20, 2016
FROM: Christine Breese, Executive Assistant
Background: The minutes of the Board Quality Review Committee held on Monday, May 16, 2016, are respectfully submitted for approval. Included are the attendance roster and Acronym Glossary for the Committee’s review (Addendum A).
Budget Impact: N/A
Staff Recommendation: Approval
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum A 3
The Patient Experience Board Quality Review Committee
TO: Board Quality Review Committee
MEETING DATE: Monday, June 20, 2016
FROM: Christine Breese, Executive Assistant
Background: Included in the packet for the Committee’s review are four letters received from patients and/or family members regarding their experience (Addendum B). Jerry Kolins, MD, Vice President, Patient Experience will share a short video of Tom Lee, MD, Chief Medical Officer for Press Ganey, regarding Teamwork and Patient Expectations. Tina Pope, Manager, Service Excellence, will share a short video of Christy Dempsey, SVP and CNO for Press Ganey, regarding Compassionate, Connected Care. Tina Pope will review the Patient Experience Dashboard and provide an update of the Action Plan (Addendum B).
Budget Impact: N/A Staff Recommendation: For information only Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum B 4
Quality and Safety Dashboards Board Quality Review Committee
TO: Board Quality Review Committee
MEETING DATE: Monday, June 20, 2016
FROM: Christine Breese, Executive Assistant
Background: Valerie Martinez, Director, Quality, Patient Safety and Infection Control will share the latest data from the Facility- Wide quality dashboard for the Committee (Addendum C).
Budget Impact: N/A Staff Recommendation: For information only Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum C 5
Journal Club Assignment “Toward a Safer Health Care System - The Critical Need to Improve Measurement” by Ashish Jha, MD, MPH and Peter Pronovost, MD, PhD
TO: Board Quality Review Committee
MEETING DATE: Monday, June 20, 2016
FROM: Christine Breese, Executive Assistant
Background: The Journal Club assignment for June 2016 is to read the article titled, “Toward a Safer Health Care System - The Critical Need to Improve Measurement” by Ashish Jha, MD, MPH and Peter Pronovost, MD, PhD (Addendum D).
Budget Impact: N/A
Staff Recommendation: For information only
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum D 6
Emergency Management / Environment of Care Board Quality Review Committee
TO: Board Quality Review Committee
MEETING DATE: Monday, June 20, 2016
FROM: Christine Breese, Executive Assistant
BACKGROUND: Dan Farrow, Assistant Vice President, Hospitality and Facilities, will share the latest performance improvement activities for Emergency Management and Environment of Care (Addendum E).
Budget Impact: N/A Staff Recommendation: For information only
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A - Addendum E 7
ADDENDUM A
8
BOARD QUALITY REVIEW COMMITTEE - MEETING MINUTES – MONDAY, MAY 16, 2016
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY
CALL TO ORDER
The meeting, held at Pomerado Hospital located at 15615 Pomerado Road, Poway, CA 92064, in Conference Room E, was called to order at 6:34 p.m. by Committee Chairman, Aeron Wickes, MD.
ESTABLISHMENT OF QUORUM
Quorum comprised of Directors Wickes, Greer, Czerwonka, Dr. Charles Callery, Dr. Richard Engel Excused Absences: Ø Guest Directors: Ø
NOTICE OF MEETING
Notice of Meeting was posted at Palomar Health’s Administrative Office as well as with the Full Agenda Meeting Packet on the Palomar Health web site on Friday, May 6, 2016, which is consistent with legal requirements. Notice of that posting was also made via email to the Board of Directors and staff.
PUBLIC COMMENTS
There were no public comments.
INFORMATION ITEMS
1. APPROVAL OF MEETING MINUTES – BOARD QUALITY REVIEW COMMITTEE – APRIL 18, 2016
There was no discussion. MOTION: By Director Czerwonka, seconded by Director Greer and carried to approve the April 18, 2016, Board Quality Review Committee meeting minutes as submitted. All in favor. None opposed.
2. APPROVAL OF QUALITY ASSURANCE PERFORMANCE IMPROVEMENT PLAN
Jerry Kolins, MD, Vice President, Patient Experience informed the Committee that the Patient MOTION: By Director Wickes, seconded by Director Czerwonka and carried to Safety and Quality Performance Improvement Plan has been renamed to Quality Assurance approve the Quality Assurance Performance Improvement Plan as submitted. Performance Improvement (QAPI) Plan and was rewritten and updated to reflect current All in favor. None opposed. processes and regulatory requirements (Attachment #1).
05.16.16 - MINUTES - BQRC Meeting FINAL.doc Page 1 of 2 9 BOARD QUALITY REVIEW COMMITTEE - MEETING MINUTES – MONDAY, MAY 16, 2016
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY
STANDING ITEMS
1. JOURNAL CLUB
For the Journal Club assignment, the Committee discussed the article entitled, “Era 3 for Medicine and Healthcare” by Don Berwick, MD (Attachment #2). Jerry Kolins, MD, Vice President, Patient Experience shared an email from Amanda Holden, MD regarding the changes she made to her rounding methods and practices. These changes were due to the information she learned at the recent Patient Experience meeting where Christy Dempsey, SVP and CNO of Press Ganey spoke about Compassionate Connected Care (Attachment #3).
NEW BUSINESS
1. SERVICE EXCELLENCE AND PATIENT GRIEVANCE REPORTING
Tina Pope, Manager, Service Excellence presented the FY2016 Q3 results from Press Ganey and HCAHPS. Tina also shared data with the Committee about the number of compliments, grievances and complaints received during the month of March 2016.
Tina and Maria Sudak, Chief Nursing Officer and Interim Vice President of Palomar Medical Center shared the outcomes from the recent Deep Dive meetings that took place in April and May (Attachment #4).
2. EMPLOYEE SAFETY
Russ Riehl, Director, Employee and Corporate Health gave a presentation to the Committee MOTION: By Director Czerwonka, seconded by Director Greer and carried to about Employee Safety. A Workers Compensation Trend Analysis reviewing the claims filed by begin receiving quarterly reports from Corporate Health regarding Employee employees, their frequency and severity was discussed (Attachment #5). The Committee Safety and Workers Compensation claims. This information will then be recommended ongoing reporting, on a quarterly basis, by Employee/Corporate Health to the reviewed by the full Board of Directors each quarter. All in favor. None Quality Review Committee as well as the full Board of Directors. opposed.
PUBLIC COMMENTS
There were no public comments
ADJOURNMENT MOTION: By Director Wickes, seconded by Director Czerwonka and carried to adjourn the meeting at 7:58 p.m. All in favor. None opposed. APPROVED
COMMITTEE CHAIR
Aeron Wickes, MD SIGNATURES:
COMMITTEE SECRETARY Christine Breese
05.16.16 - MINUTES - BQRC Meeting FINAL.doc Page 2 of 2 10 Board Quality Review Committee Meeting
OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2016
Palomar Health Meeting Dates: By-Laws’ 1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16 Voting Members Membership DIRECTOR AERON WICKES , MD – CHAIR Board Member P P P P P DIRECTOR LINDA GREER, RN Board Member P P P P P DIRECTOR DARA CZERWONKA Board Member P P P E P DIRECTOR HANS SISON (ALT) Board Member P ------QMC Chair, FRANK MARTIN, MD P P -- P -- Palomar Medical Ctr Interim QMC Chair, RICHARD ENGEL, MD -- -- P P P Palomar Medical Ctr QMC Chair, CHARLES CALLERY, MD P P P P P Pomerado Hospital Non-Voting Members BEIRNE, FRANK EVP, Operations P P P P P BROWN, SHEILA, RN, FACHE VP, Continuum Care -- -- P P P CONRAD, ALAN, MD EVP,Physician Alignment P P P -- -- Interim CNO, PHDC & GOWER, JUNE, PH.D. ------Pomerado Hospitals HEMKER, BOB President & CEO P P P E P KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient P P P P P Safety Committee Interim VP/CNO LABOSSIERE, LARRY ------P Pomerado Hospitals Co-Chair, Patient Safety MARTINEZ, VALERIE, RN, BSN, MHA, CIC P P P P P Committee Interim VP, PHDC & OLSON, CHERYL P P P P ------Pomerado Hospitals SHAW, DELLA EVP, Strategy P P P CNO & Interim VP, SUDAK, MARIA, MSN, CCRN, NEA-BC, RN P P P P P Palomar Medical Center Guests ADELMAN, MARCY, RN P BARNES, DEBBIE, RN, CDS FARROW, DAN GOELITZ, BRIAN, MD P GRIFFITH, JEFF (BOARD MEMBER) HANSEN, DIANE P KAUFMAN, JERRY (BOARD MEMBER) KIM, JESSICA P P P LEE, DAVID, MD P P P P P LEE, JEREMY P P MCCUNE, RAY (BOARD MEMBER) NAMENYI, JASMINA P NEUSTEIN, PAUL, MD P 05.16.16 - ROSTER - BQRC Meeting Attendance Roster.docx Page11 1 of 2 Meeting Dates: 1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16 Guests (continued) NICPON, GREGORY, MD P PHILLIPS, DONITA, MBA, ARM P P P P P POPE, TINA P P P P P RIEHL, RUSSELL P ROLIN, DONNA P ROSENBURG, JEFFREY P E E E E SCHULTZ, DIANA P SOLOMON, LESLIE TERRELL, CEDRIC P P TURNER, BRENDA P P WATSON, RAE ANNE P
05.16.16 - ROSTER - BQRC Meeting Attendance Roster.docx Page12 2 of 2 Patient Experience Division ACRONYM GLOSSARY Updated: 06/07/2016
AAPL: Academy of Applied Physician Leadership AAR: After Action Report ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACR: American College of Radiology AHP: Arch Health Partners AHRQ: Agency for Healthcare, Research and Quality ALICE: Alert Lockdown Inform Counter Evacuate AMI: Acute Myocardial Infarction ARB: Angiotension Receptor Blocker ARU: Acute Rehab Unit ATS: Automatic Transfer Switch BETA: BETA Healthcare Group (PH Insurer) BQRC: Board Quality Review Committee BSC: Balanced Score Card BSIS: Bureau of Security and Investigative Services CALNOC: Collaborative Alliance for Nursing Outcomes CAP: Child Abuse Program CAP: College of American Pathologists CAP: Community-Acquired Pneumonia CAPG: The Voice of Accountable Physician Groups CAUTI: Catheter Associated Urinary Tract Infection CC: Complications and Comorbidities CCTP: Community-Based Care Transitions Program CDAD: Clostridium Difficile Associated Diarrhea CDC: Center for Disease Control CDI: Clinical Documentation Improvement CDI: C. Difficile Infections C-diff: Clostridium difficile CDPH: California Department of Public Health CHA: California Hospital Association CHF: Congestive Heart Failure CIHQ: Center for the Improvement in Healthcare Quality CLABSI: Central Line Blood Stream Infection CLIP: Central Line Insertion Practices CMMI: Center for Medicare and Medicaid Innovation CMS: Centers for Medicare & Medicaid Services COP: Conditions of Participation COPD: Chronic Obstructive Pulmonary Disease CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 1 of 4 13 Patient Experience Division ACRONYM GLOSSARY Updated: 06/07/2016
CSHE: California Society Healthcare Engineers CVICU: Cardio Vascular Intensive Care Unit CY: Calendar Year DI: Diagnostic Imaging DM: Diabetes Mellitus DRT: Diabetes Resource Team DVT: Deep Vein Thrombosis EBP: Evidence Based Practice ED: Emergency Department EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EMS: Emergency Medical Services EMT: Emergency Medical Technician EMT: Executive Management Team EOC: Environment of Care EOP: Emergency Operations Plan EVS: Environment of Care Services / Environmental Services FANS: Food and Nutrition Services FHS: Forensic Health Services FMEA: Failure Mode Effects Analysis FY: Fiscal Year HAC: Hospital Acquired Conditions HAI: Healthcare Associated Infections HAPU: Hospital Acquired Pressure Ulcers HbA1c: Hemoglobin A1C HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCC: Hospital Command Center HCP: Health care provider HDL: High Density Lipoprotein Cholesterol HICS: Hospital Incident Command System HLD: High Level Disinfectant HF: Heart Failure HIPAA: Health Insurance Portability and Accountability Act HPP: Hospital Preparedness Program HPRO: Hip Replacement Surgery HRRP: Hospital Readmission Reduction Program HVA: Hazard Vulnerability Analysis IC: Infection Control ICU: Intensive Care Unit IHA: Integrated Healthcare Association IHI: Institute for Healthcare Improvement ILSM: Interim Life Safety Measures IMI: Inpatient Mortality Indicator
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 2 of 4 14 Patient Experience Division ACRONYM GLOSSARY Updated: 06/07/2016
IMM-2: Influenza Immunization IOM: Institute of Medicine IP: Infection Prevention (RN Staff) IPCC: Infection Prevention and Control Committee ISBARR: Introduction, Situation, Background, Assessment, Recommendations, Read back KP: Kaiser Permanente KPRO: Knee Replacement Surgery LSC: Life Safety Conditions MAB: Management of Assaultive (or Aggressive) Behavior MAC: Medicare Administrative Contractor MCC: Major Complications and Comorbidities MCI: Mass Casualty Incident MDRO: Multi Drug Resistant Organism MERP: Medication Error Reduction Plan MRI: Magnetic Resonance Imaging MRSA: Methicillin-resistant Staphylococcus aureus MSPRC: Medical Staff Peer Review Committee MY: Measurement Year NDNQI: National Database of Nursing Quality Indicators NHQM or NIHQM: National Improvement for Healthcare Quality Measure NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NIMS: National Incident Management System NPSF: National Patient Safety Foundation NPSG: National Patient Safety Goals NQF: National Quality Forum OB: Obstetrics OES: Office of Emergency Services OPPE: Ongoing Professional Practice Evaluation OSHA: Occupational Safety and Health Administration OSHPD: Office of Statewide Health Planning and Development PASS: Pull Aim Squeeze Sweep PCEA: Patient Controlled Epidural Analgesia PCM: Perinatal Care Measure PDCA: Plan Do Check Act PH: Palomar Health PI: Performance Improvement PM: Preventative Maintenance PMC: Palomar Medical Center PN: Pneumonia POCT: Point of Care Testing PPE: Personal Protective Equipment PPFR: Physician Performance Feedback Report
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 3 of 4 15 Patient Experience Division ACRONYM GLOSSARY Updated: 06/07/2016
PSI: Patient Safety Indicator QAPI: Quality Assurance Performance Improvement QIO: Quality Improvement Organization QRR: Quality Review Report RAC: Revenue Cycle Audits RACE: Rescue Alert Confine Extinguish RCA: Root Cause Analysis RT: Respiratory Therapist RHIT: Registered Health Information Technician RVT: Registered Vascular Tech SART: Sexual Assault Response Team SCIP: Surgical Care Improvement Project SDHDC: San Diego Healthcare Disaster Coalition SDS: Safety Data Sheet SHP: Strategic Healthcare Program SIR: Standardized Infection Ratio SIRS: Systemic Inflammatory Response Syndrome SIT: Security Integration Team SMILE: Share yourself, Make it clear, Inform on timing, Listen with care, End with Kindness SNF: Skilled Nursing Facility SNS: Strategic National Stockpile SOC: Statement of Conditions SSI: Surgical Site Infection STK: Stroke TAT: Turn Around Time THA: Total Hip Arthroplasty TICU: Trauma Intensive Care Unit TJC or JC: The Joint Commission TKA: Total Knee Arthroplasty TRAIN: Triage Resource Allocation for In-patients UST: Underground Storage Testing US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Associated Pneumonia VBAC: Vaginal Birth After Caesarian Section VBP: Value Based Purchasing VRE: Vancomycin-resistant enterococcus VTE: Venous Thrombo-embolism WHO: World Health Organization
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 4 of 4 16
ADDENDUM B
17 18
From: Ziaullah Yazdani [mailto:[email protected]] Sent: Sunday, May 22, 2016 1:15 PM To: [email protected] Subject: Shamie Gerwick's Stay in Hospital
Hello, I am writing on behalf of a recent patient at Palomar Hospital. Her name is Shamie Gerwick and she was treated at Palomar Hospital the first week of April of this year. I am writing this message because Shamie requested me to do so since she does not have access to a computer.
Shamie would like to express her heartfelt gratitude and deep sense of appreciation for the excellent quality of care that she received during her stay at the hospital. The nurses and other support staff that attended to her were exemplary and highly professional in caring for her. They made her stay a very pleasant experience which no doubt contributed greatly to her expeditious healing.
In particular Shamie would like to mention her attending physician Dr. Afshin Nahavandi. He was very kind, respectful, compassionate and caring in his interaction with her. She felt very safe with her care in his hands and felt that he went beyond the call of duty while treating her for her health condition.
Shamie feels that Palomar Hospital should be proud of having Dr. Nahavandi, the nurses and other support staff that interacted with her working at the hospital. She feels that they should be commended for their good attitude and work.
Respectfully,
Zia Yazdani
19 20 21 Palomar Medical Center 8 East - Medical Acute Care
FY2016 Q3 Domains/Question April 2016 May 2016 June 2016 July 2016 Results
n Ranking n Ranking n Ranking n Ranking n Ranking
HCAHPS: Communication with Nurses (Domain) 63 19 19 55 19 10
HCAHPS: Communication with Doctors (Domain) 63 18 19 60 19 1
PG: How well staff worked together to care for you 60 84 17 9 19 15
≥ 90 = Green ≤ 89 = Red
Palomar Health Service Excellence Department/(760) 740-6357 1 of 2 22 Pomerado Hospital Med/Surg/Tele - Medical/Surgical/Telemetry (4th Floor Only)
FY2016 Q3 Domains/Question April 2016 May 2016 June 2016 July 2016 Results
n Ranking n Ranking n Ranking n Ranking n Ranking
HCAHPS: Communication with Nurses (Domain) 126 4 35 32 32 50
HCAHPS: Communication with Doctors (Domain) 126 8 35 53 32 40
PG: How well staff worked together to care for you 124 9 34 69 30 85
≥ 90 = Green ≤ 89 = Red
Palomar Health Service Excellence Department/(760) 740-6357 2 of 2 23
ADDENDUM C
24 FACILITY-WIDE DASHBOARD - POMERADO HOSPITAL Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q1 for SIR Apr 2016 CY16 Q1 CY16 YTD C. Difficile Infections (CDI) 4 4 8 1.16 0.50 Methicillin-Resistant Staphylococcus Aureus 0 1 1 0.27 0.50 (MRSA) Surgical Site Infection (SSI): Colon 0 0 0 0.00 0.50 Surgical Site Infection (SSI): Abdominal 0 0 0 0.00 0.50 Hysterectomy Catheter-Associated Urinary Tract 0 1 1 0.41 0.50 Infection (CAUTI) Central Line-Associated Blood 2 0 2 0.00 0.50 Stream Infection (CLABSI)
FACILITY-WIDE DASHBOARD - PALOMAR MEDICAL CENTER Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q1 for SIR Apr 2016 CY16 Q1 CY16 YTD C. Difficile Infections (CDI) 6 22 28 1.42 0.50 Methicillin-Resistant Staphylococcus Aureus 0 0 0 0.00 0.50 (MRSA) Surgical Site Infection (SSI): Colon 1 3 4 0.30 0.50 Surgical Site Infection (SSI): Abdominal 0 0 0 0.00 0.50 Hysterectomy Catheter-Associated Urinary Tract 1 6 7 0.52 0.50 Infection (CAUTI) Central Line-Associated Blood 1 5 6 0.61 0.50 Stream Infection (CLABSI)
FACILITY-WIDE DASHBOARD - PALOMAR HEALTH DOWNTOWN CAMPUS Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q1 for SIR Apr 2016 CY16 Q1 CY16 YTD C. Difficile Infections (CDI) 1 6 7 N/A 0.50 Methicillin-Resistant Staphylococcus Aureus 0 0 0 0.00 0.50 (MRSA) Surgical Site Infection (SSI): Abdominal 0 0 0 0.00 0.50 Hysterectomy Catheter-Associated Urinary Tract 0 2 2 N/A 0.50 Infection (CAUTI) Central Line-Associated Blood 0 0 0 0.00 0.50 Stream Infection (CLABSI)
25 National Health System Performance Comparisons (all systems)
PERFORMANCE MEASURE BENCHMARK PEER GROUP OF DIFFERENCE PERCENTAGE HOW TOP 15 HEALTH HEALTH SYSTEMS U.S. HEALTH DIFFERENCE SYSTEMS COMPARE SYSTEMS WITH PEERS
Mortality Index1 0.86 1.01 (0.15) (14.7%) Lower mortality Complications Index1 0.84 0.99 (0.15) (15.1%) Fewer complications Core Measures mean percentage3 95.3 93.2 2.14 NA Better care compliance
30-day mortality rate (%)3 11.8 12.0 (0.14) NA Lower 30-day mortality
30-day readmission rate (%)4 15.0 15.7 (0.78) NA Fewer 30-day readmissions
Average length of stay (days)1 4.5 5.0 (0.51) (10.3) Shorter average length of stay
ED measures mean minutes5 146.0 166.4 (20.41) (12.3) Shorter time to service
Medicare spending per beneficiary 0.94 0.99 (0.05) (4.9) Lower episode cost index5
HCAHPS score5 269.5 262.4 7.09 2.7% Better patient experience
Note: Measure values are rounded for reporting. 1 Mortality, complications and average length of stay based on present-on-admission-enabled risk models applied to Medicare Provider Analysis and Review data for 2013 and 2014. (Average length of stay is 2014 data only). 2Core Measures data from CMS Hospital Compare Oct 1, 2013 – Sept. 30, 2014 data set. 330-day mortality rates include AMI, HF, pneumonia, COPD and stroke patients from CMS Hospital Compare July 1, 2011 – June 30, 2014 data set. 430-day readmission rates include AMI, HF, pneumonia, hip/knee arthroplasty, COPD and stroke patients from CMS Hospital Compare July 1, 2011 – June 30, 2014 data set. 5Emergency department measure, spending per beneficiary and HCAHPS data from CMS Hospital Compare Jan. 1, 2014 – Dec. 31, 2014 data set. AMI=acute myocardial infarction; HF=heart failure; COPD=chronic obstructive pulmonary disease; HCAHPS=Hospital Consumer Assessment of Healthcare Providers and Systems survey26
ADDENDUM D
27 Opinion
VIEWPOINT Toward a Safer Health Care System The Critical Need to Improve Measurement
Ashish Jha, MD, MPH It has been more than 15 years since To Err Is Human, should not be between using flawed approaches that Department of the landmark report by the Institute of Medicine penalize the best physicians and hospitals or not mea- Health Policy and (IOM), revealed the substantial morbidity and mortal- suring adverse events at all. Management, Harvard ity related to medical errors in the United States. Two Federal policy makers, especially the Centers for T. H. Chan School of Public Health, Boston, recent developments have refocused policy makers on Medicare & Medicaid Services (CMS), could take 3 steps Massachusetts. getting patient safety right. The first are data suggest- for meaningful progress. First, CMS needs to eliminate ing that deaths associated with medical errors may unnecessary, unreliable metrics from government pro- PeterPronovost,MD, exceed 400 000 annually,1 although this number is grams and oversee the development of a standardized PhD controversial, with questions about the degree to set of validated metrics. For example, the Patient Safety Armstrong Institute for Patient Safety and which medical errors truly caused each of these deaths Indicator (PSI) 90 is a conglomeration of various ad- Quality, Johns Hopkins and how many deaths were attributable to a medical verse events of varying importance that rely on admin- Medicine, Baltimore, error when death was inevitable. Regardless, medical istrative data. Administrative data have low validity com- Maryland. error is likely a major cause of death and disability in pared with clinical data (B. D. Winters, MD, PhD, et al, the United States. The second is the Affordable Care unpublished data, 2015) and are marked by long delays Act, which has, through programs like Value-Based in reaching clinicians, which hampers their usefulness. Purchasing and Hospital-Acquired Conditions penal- Instead of focusing on PSIs, CMS instead should focus ties, made patient safety a financial priority for hospi- on the most common and clinically meaningful causes tals. While greater focus on safety is a welcome devel- of harm and should use clinical data, not billing data, and opment, there is little reason to believe that added monitor and report the validity of the measures. Such attention alone will lead to safer care. Why? Because an approach will enable hospitals to focus on improv- the health care industry lacks valid patient safety mea- ingpatientsafetyratherthanchangingcoding,asthecur- sures, which are fundamental to improvement. With- rent programs have encouraged. out these measures, the key ingredient in these efforts What specific events should CMS focus on? Epide- is missing: systematic, real-time data on adverse miologic studies of adverse events find that the most events with timely feedback to clinicians and health common causes of iatrogenic harm to hospitalized pa- care organizations. Without effective measurement tients are adverse drug events, nosocomial infections, and reporting, progress in patient safety will be ardu- venous thromboemboli, decubitus ulcers, falls, and sur- ous and slow. gical complications. A recent IOM report also highlights Whether meaningful progress has occurred within the importance and the burden of diagnostic errors.4 patient safety is controversial. The Obama Administra- However, the current national patient safety strategy tion’s internal evaluations suggest modest improve- uses a validated, clinically based approach to measur- ment on a subset of patient safety measures. Despite ing only 1 of these, nosocomial infections. The Centers some questions about these findings, mostly due to a for Disease Control and Prevention (CDC) and its Na- lackofavalidapproachtomeasurementandevaluation,2 tional Healthcare Safety Network have a very good track there is no disagreement that policy makers should do record of working effectively with professional soci- more to improve safety measurement. eties and hospitals on a subset of these infections to de- Journalists and private companies are now begin- velop valid and reliable measures. The CDC’s work has ning to fill the void in measurement left by policy mak- made substantial gains in making hospital care safer, par- ers. For example, ProPublica, a nonprofit investigative ticularly with regard to central line–associated blood- journalism outlet, provoked intense debate with its stream infections and surgical site infections. The CMS profile of 17 000 surgeons, using certain readmissions should work with the CDC to expand this proven model as a surrogate for complications. This follows many fed- to other types of patient harm. eral government efforts that measure safety with a How might the CDC expand its efforts on patient similar approach: using billing data and counting the safety measurement? The CDC could harness clinical number of adverse events coded. Identifying complica- data from electronic health records to develop algo- tions through billing data can be problematic because rithms for detecting the other leading causes of prevent- hospitals that are diligent about identifying and docu- able harm, including adverse drug events, venous throm- menting adverse events may be more likely to be boemboli, and others (Table). With modest effort, this 3 Corresponding labeled as unsafe, a form of “surveillance bias.” The may be achievable. Even in the 1990s, before the de- Author: Ashish Jha, best organizations may then be labeled as the worst velopment of sophisticated health information technol- MD, MPH, 42 Church and consequently may receive the largest penalties ogy systems, this approach was shown to be nearly as St, Cambridge, MA 02138 (ajha@hsph under pay-for-performance schemes. In the most sensitive—while far less resource intensive—as manual .harvard.edu). expensive health care system in the world, the choice chart reviews at detecting adverse drug events, such as
jama.com (Reprinted) JAMA May 3, 2016 Volume 315, Number 17 1831 Copyright 2016 American Medical Association. All rights reserved. 28 Downloaded From: http://jama.jamanetwork.com/ by Palomar Health, JERRY KOLINS on 05/09/2016 Opinion Viewpoint
Table. Common Causes of Hospital Adverse Events and Potential narrowly focused on high-value metrics, and technically sound. Measures and Data Sources Whatever agency plays this role, it will foster a system in which dif- ferent payers, clinicians, health care organizations, and even Data Sources From Events Potential Measures Electronic Health Records patient groups can reasonably disagree about which measures are Adverse drug events Allergic reactions, elevated Order entry, laboratory most important. But they all should have a common set of sound blood creatinine following results, clinical notes nephrotoxin prescription, for confirmation metrics. prescription of antidotes Third, Congress needs to find funding for systems engineering (eg, naloxone) research. There are competing funding priorities, but the payoff for Deep vein Rate of postoperative DVT, Radiology reports, thrombosis (DVT) rate of pulmonary laboratory results, clinical the health care system, including the federal budget, of these embolism, laboratory notes for confirmation investments can be substantial. For instance, the checklist inter- abnormalities (eg, elevated D-dimer) vention that substantially reduced central line infections was ini- Falls Rate of falls among older Nursing notes, clinical tially supported by a $500 000 grant from the Agency for Health- patients notes, radiology reports care Research and Quality. Complications are expensive, and Decubitus ulcers Rate of decubitus ulcers Nursing notes, physician notes, nurse-completed reducing their frequency can provide significant savings to payers. single-question ulcer Reducing complications such as central line infections not only assessment Nosocomial Rate of nosocomial Nursing notes, laboratory likely saved thousands of lives but also billions of dollars, much of it pneumonia pneumonia results, radiology reports to the Medicare program. Improving safety depends on having Diagnostic errors Rate of missed diagnosis of Clinical notes, good systems in place rather than on the efforts of individual acute myocardial infarction electrocardiogram, 7 laboratory results clinicians. As such, the government—the largest payer in health care—needs to fund practically applicable studies on systems engi- allergic reactions or nephrotoxicity due to medications.5 Given the neering to promote efficient, safe health care. sensational advances in computing in the past 2 decades and that Despite thousands of deaths each year related to unsafe care, most US hospitals now have electronic health records,6 there are suf- policy actions have not matched the scale of the problem. How- ficient data that could be exploited to detect a wide variety of ad- ever, tools are now available to make meaningful progress in safety, verse events. With the CDC’s expertise in engaging professional so- starting with systematic collection and dissemination of high- cieties, measurement experts, and consumers, these types of quality, clinically based data. The marketplace is not standing still; measures can be pilot tested and improved over time. organizations that promote public reporting are using available data Second, CMS should task an agency with defining standards of to make pronouncements about which clinicians and hospitals are what makes good measures and setting accuracy requirements safe and unsafe. Some efforts will be better than others, but none before implementing measures in pay-for-performance and public of them will be as good as they could be because the metrics they reporting. Such an agency would serve a similar role for health care use are only as good as the data going into them. Without stan- as the Federal Accounting Standards Advisory Board does for dards of accuracy or timeliness, some rating programs will label some financial reporting. Under this system, professionals set accounting of the best clinicians and hospitals as unsafe and some of the ne- standards, performance is audited and transparently reported, and glectful ones as safe, which has the potential to do more harm than journalists report on validated measures, working from a common good. Better data, valid metrics, and greater transparency repre- source of standards. The National Quality Forum is the natural sent the best formula for making the United States a world leader agency to play such a role in health care, but it must be efficient, in patient safety.
ARTICLE INFORMATION REFERENCES 5. Jha AK, Kuperman GJ, Teich JM, et al. Identifying Published Online: April 14, 2016. 1. James JT. A new, evidence-based estimate of adverse drug events: development of a doi:10.1001/jama.2016.3448. patient harms associated with hospital care. computer-based monitor and comparison with J Patient Saf. 2013;9(3):122-128. chart review and stimulated voluntary report. JAm Conflict of Interest Disclosures: The authors have Med Inform Assoc. 1998;5(3):305-314. completed and submitted the ICMJE Form for 2. Pronovost P, Jha AK. Did hospital engagement Disclosure of Potential Conflicts of Interest. networks actually improve care? N Engl J Med. 6. Adler-Milstein J, DesRoches CM, Furukawa MF, Dr Pronovost reports grants from the CDC and the 2014;371(8):691-693. et al. More than half of US hospitals have at least a basic EHR, but stage 2 criteria remain challenging Agency for Healthcare Research and Quality; 3. Bilimoria KY, Chung J, Ju MH, et al. Evaluation of contracts through Johns Hopkins University with for most. Health Aff (Millwood). 2014;33(9):1664- surveillance bias and the validity of the venous 1671. Ernst and Young; participation as a nonpaid thromboembolism quality measure. JAMA.2013; scientific advisor to Leapfrog Group; and speaking 310(14):1482-1489. 7. Pronovost PJ, Bo-Linn GW. Preventing patient honoraria from various hospitals. No other harms through systems of care. JAMA. 2012;308 disclosures were reported. 4. McGlynn EA, McDonald KM, Cassel CK. (8):769-770. Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine. JAMA. 2015;314(23):2501-2502.
1832 JAMA May 3, 2016 Volume 315, Number 17 (Reprinted) jama.com Copyright 2016 American Medical Association. All rights reserved. 29 Downloaded From: http://jama.jamanetwork.com/ by Palomar Health, JERRY KOLINS on 05/09/2016
ADDENDUM E
30 Annual Report Environment of Care and the Emergency Management Programs
CY 2015
Submitted by: Dan Farrow: AVP Hospitality and Facilities Steve Miller: Director of Facilities Lisha Wiese: Program Manager – Emergency Mgt and Safety
31 2015 Key Activities and Accomplishments Environment of Care (EOC) & Emergency Management (EM) Programs Safety Management • Multi-disciplinary environment of care rounding – Documented in Sentact and issues sent to Director to resolve and close out in Sentact. Hazardous Materials Management • Process Improvement Project for the EOC identified – 2014 first responder decontamination training met quarterly to review plans, communication details and gaps, and plan for next decontamination exercise. Security Management: • Ongoing active shooter and Management of Assaultive Behavior training • Multiple collaborations with Escondido PD SWAT and K-9 personnel with trainings at vacant Surgery Center.
32
2015 Key Activities and Accomplishments Environment of Care & Emergency Management Programs Continued
Fire Prevention Management • Fire prevention devices tested and maintained per regulatory standards. • Fire safety training provided for PMC kitchen staff. Medical Equipment Management: • Enhancement of Medical Equipment Management Plan to comply with The Joint Commission Standards Utilities Management • Utility failures monitored by EOC committee to ensure issues were resolved, follow up actions taken promptly Emergency Management • Continued collaboration with SD County Emergency Medical Services (EMS) on Hospital Preparedness Program (HPP) grant funding and grant funds were received. • Two disaster exercises and two tabletop exercises completed and evaluated for effectiveness 33 Key Areas of Focus for 2016 Environment of Care & Emergency Management Programs
Safety Management: • General safety awareness training and provide reference materials for staff (emergency code kardex ) • Implementation of system wide ‘Department Safety Captain’ program in conjunction with the Staff On Safety Program • Deployment of monthly safety and disaster training programs Security Management: • Continue with Code Silver and Management of Behavior Training • Continue cultivating relationships with community law enforcement partners • Installation of Knox boxes at each hospital facility at key access points • Interdisciplinary team formed to implement Cal OSHA’s new Violence in the Workplace regulation Hazardous Materials Management: • Provide another round of 16-hour hands on decontamination training and recertification • Continue with decontamination team committee Utilities Management: • Continue to ensure utility system reliability and minimize the risk of utility system failures.
34 Key Areas of Focus for 2016 Environment of Care (EC) & Emergency Management (EM) Programs Continued Fire Prevention Management: • Modification of fire drill evaluation forms to better capture staff involvement and participation in fire drills • Complete standardization of fire response education district-wide Medical Equipment Management: • Collaborate with Supply Chain to drive >20% savings with rented mobile medical equipment • Successful department consolidation of medical equipment Emergency Management: • Transition to the new Everbridge Mass Notification platform • Continue collaborating with hospital partner Emergency Managers, law enforcement, Red Cross, fire, County OES (Office of Emergency Services), and County EMS during monthly San Diego County Healthcare Disaster Coalition meetings. • Implement streamlined process, using T.R.A.I.N (Triage Resource Allocation for In-patients) to effectively address patient transportation needs during an evacuation. 35 36
Prepared by: Lisha Wiese: Program Manager – Emergency Management and Safety
Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado Satellite Buildings
Annual Evaluation of the Environment of Care Management Plans and the
Emergency Operations Plan
2015
Date prepared: April 5, 2016 37
2 EVALUATION - ENVIRONMENT OF CARE - OBJECTIVES
Introduction Permeating every aspect of our medical centers and satellite buildings, the Environment of Care is an essential aspect of patient safety, from the first patient contact, through the assessment, treatment, discharge and continuing care. The Environment of Care overlaps with Infection Prevention and the management of Human Resources, as well as plays an integral part with Performance Improvement, Risk Management, and Patient Safety standards. The objectives of the various Environment of Care Management plans have been to provide a safe, functional, supportive and effective environment for patients, visitors, staff, volunteers and members of our physician community. This is critical to providing quality patient care.
Achieving our objectives is dependent upon performing the following central processes: •Strategic and on-going master planning by organization leadership (Plan / Design) •Educating staff about the role of the environment that supports patient care (Teach) •Implementing various components of design (Implement) •Measuring standards that we have set for ourselves (Respond) •Gathering information about our outcomes (Monitoring / Measuring / Evaluating) •Making decisions about our findings (Improving)
The Environment of Care Management plans address six elements, which include Safety, Security, Hazardous Materials and Waste, Fire Prevention, Medical Equipment and Utilities Management. Emergency Management addresses the Emergency Operations Plan (EOP). There is much diversity in the seven management plan elements, but each have parallels with planning, teaching, implementing, responding, monitoring and improving. Through the work of our staff, the purpose with the Environment of Care is to ensure ongoing diminishment of risk (e.g., possible loss or injury) within our medical centers. The Environment of Care Committee provides a leadership framework for the management of risks, promoting a teamwork approach, and ongoing attention to programs, plans, and related activities that point toward risk reduction. Whenever possible, the Environment of Care is integrated with the Occupational Safety and Health Administration objectives (e.g., regulatory requirements), as well as other agencies having jurisdiction, enforcing standards that encourage continued improvement in the workplace.
Evaluation of Objectives – Safety Management Plan. The Safety Management plan is designed to provide a physical environment wherein risks associated with physical harm and hazards will be minimized for the patient-care population, staff, volunteers, physicians, contracted workers and visitors. It is an accreditation/standards-based and regulatory driven plan. There are fundamental activities inherent in daily routines that support the ability to identify risk prior to any incident. These include formal proactive risk assessments such as accreditation, regulatory or insurer surveys, ongoing environmental surveillance, safety and infection prevention procedures that are based upon accreditation standards and regulations, and ongoing education. Educating employees to the hazards that may pose risk, or contribute to an injury has been ongoing, as well as the efforts relating to accident investigation post injury. We continue to meet our objective relating to the minimization of risk within the built environment and continue to be poised to provide safety for our patients.
Evaluation of Objectives – Security Management Plan. Through a medium of care and respect for everyone who comes to our facilities, the Security Management plan is designed to provide the highest quality safety and security. We strive to provide a challenging work environment for Security staff, as we work to create and support a peaceful environment so that people will feel at ease when they come to our medical centers. Overall, our Security Management program has catapulted into a higher level of awareness since the events of 9-11-01, and subsequent terrorist events worldwide, including the increasing Code Gray and Silver incidents at medical facilities. Our Security Management plan has provided a deterrent to criminal activity on our campuses, which has allowed us to meet our objective of promoting a peaceful environment. Security staff are visible in uniforms, and are service oriented to the public, as well as being trained in de-escalation techniques. Security has camera systems and ongoing monitoring that has allowed us to spot activity or trends that have assisted us in reducing security risks. The objectives of the Security Management Plan have been met, and we will continue to promote the reduction of risk throughout the year 2015, focusing on proactive activities, and ongoing education.
38 3
Annual Evaluation of Objectives, continued
Evaluation of Objectives: Hazardous Materials and Waste Management Plan. The objectives of the Hazardous Materials Management Plan are to ensure that information about the risks of hazardous chemicals / materials and wastes used in the facilities are known by affected employees, and to ensure that the information is given to employees in the form of SDS (Safety Data Sheets), education, and labeling. Another objective is to ensure that hazardous waste products do not endanger the health of the environment. Taken together, these objectives minimize the risk of exposures to hazardous chemicals within our facility and community. Minimization of risk not only applies to our medical centers, but to the community at large (e.g., minimization of spills into the environment). Equally important, is our effort to reduce waste and to use non-hazardous products whenever feasible. Educating employees to the risks relating to hazardous material use, storage and disposal has been a program element designed to meet our objectives. Other activities within the medical centers have contributed to meeting our stated objective, and these include: assessing staff knowledge relative to the hazardous materials and waste management program, manifesting hazardous materials in accordance with regulations, the development of procedures, and the use of appropriate personal protective wear.
Evaluation of Objectives: The Fire Prevention Management Plan. The objectives of the Fire Prevention Management plan are to provide a physical environment free from physical harm and hazards created by fire, the risk of fire, or the products of combustion for the patient care population, staff, volunteers, physicians and visitors. The risk of fire carries with it the most significant single threat to the environment of care as our patients are routinely incapable of self-preservation, and must rely on correct staff response and building fire protection features to assure their safety. Compliance with the Life Safety Code supports meeting our objectives, as well as practicing fire drills throughout the medical centers and testing correct staff response during the drills. Proactively identifying life safety risks during routine surveillance (e.g., observing for doors that do not close and latch properly, wall and ceiling penetrations, illegal latching hardware, etc.) additionally supports meeting this objective. There are programs in place that increase the likelihood of our objectives being met, which include fire equipment testing and maintenance, annual certifications for fire detection and protection systems, and the ongoing monitoring of the Statement of Conditions which identifies any life safety vulnerabilities, and our plans and financial commitment to correct / enhance or minimize them.
Evaluation of Objectives: The Medical Equipment Management Plan. The objective of the Medical Equipment Management Plan includes a joint effort of the clinical and non-clinical departments to minimize the risks inherent in the use of medical equipment that is used on our patients, and to ensure proper performance. In order to meet these objectives, multiple programs need to be in place, which include, but are not limited to: risk assessment of all incoming medical equipment, preventive and corrective maintenance programs, “out-of-service” program for equipment that needs repair, and general education of equipment and user / maintainer training programs. Quarterly monitoring of preventive maintenance completion rates for our medical equipment affords us the opportunity to promote quality performance, thereby minimizing the risks associated with medical equipment failures, which supports our patient safety efforts. These programs are in place throughout the medical centers, and have been effective in allowing us to meet the stated objectives.
Evaluation of Objectives: The Utility Management Plan. The objectives of the Utility Management Plan include complying with regulatory-driven and accreditation standards to provide Facilities that are safe, controlled, comfortable, and maintained in accordance with applicable regulation, requirement, and accepted engineering practice. Through a system of procedures, education, and ongoing quality monitoring and evaluation, the objectives are to provide the utility system users and operators with emergency response guidance in the event of a utility system failure, and to promote the reliability and performance of our utility systems. Risks, identified through the use of the a computerized data base program, factor adverse equipment experience into the quality assessment, risk management, and utility management functions. Our procedures, preventive maintenance program, education and quality monitoring all support the accomplishment of meeting our stated objectives, and also support our patient safety goals.
Evaluation of Objectives: The Emergency Operations Plan. One primary objective of the Emergency Operations Plan is to mitigate harm to life and property due to unforeseen circumstances and risks identified in the Hazard Vulnerability Analysis. The Emergency Operations Plan comprehensively describes the organization’s approach to responding to emergencies within the organization or in its community that would suddenly and significantly affect the need for the organization’s services, or its ability to provide those services. The Disaster Preparedness Committee has been very active in the design and implementation of the Emergency Operations Plan, and it is expected to continue in this direction in 2015. The plan is intended to identify risks to the organization and addresses how the medical centers are prepared to respond as well as identify strategies in place to mitigate the risks. These plan elements and other activities in the medical centers relating to emergency preparedness (e.g., education of staff, disaster exercise implementation / evaluation, and performance improvement demonstrate that the medical centers have been effective in meeting the stated objective. 39 FIRE PREVENTION 4 EVALUATION OF THE SCOPE 1. Performance standards and thresholds established for 2015. 2. Fire drills conducted and evaluated by Security staff, one per shift per quarter, with additional drills completed per staffing requirements or construction areas and satellite buildings. Evaluation of the Scope of the Environment of Care 3. Statement of Conditions (SOC) reviewed and kept updated by Facility Managers. Management plans: The scope of each management plan 4. Annual fire detection systems tested and certified. applies to all personnel in each facility and satellite building. 5. Annual fire extinguisher maintenance completed. Each facility and building is surveyed, and every attempt is 6. Facility Manager Environment of Care reports reviewed in each quarter. 7. Collaboration with Escondido Fire and other SD fire agencies in the made to ensure risks are identified that may have an impact on usage of the vacant Surgery Center to complete fire rescue training and the reduction of accidents or injury. Staff are required to work in simulated structure fire. a safe manner, and to report unsafe acts or observations, 8. Fire safety and response training provided to PMC kitchen staff. without any fear of reprisal. The following Environment of Care 9. Preventive maintenance for fire equipment completed. 10. Annual evaluation of the Fire Prevention Management plan completed: accomplishments throughout the year 2015 represent the Objectives, Scope, Performance Standards and Overall Effectiveness. emphasis on safe work behaviors and risk reduction, and MEDICAL EQUIPMENT validate leadership’s support of safety throughout the physical 1. Performance standards and thresholds established for 2015. environments of our medical centers and satellites, as well 2. Medical equipment failures and recalls monitored by Biomedical leadership with appropriate actions taken. as support and dedicate attention to high standards of safe 3. Preventive maintenance and corrective maintenance monitored for life work behaviors for all staff. The multitude of accomplishments support and non-life support medical equipment. validate a breadth and depth of the scope of our Environment 4. Enhancement of the Medical Equipment Management Plan (MEMP) to comply with The Joint Commission standards. of Care management plans and the Emergency Operations 5. Added laser safety check quantities to quarterly EOC report. Plan. 6. Annual evaluation of the Medical Equipment plan and program completed: Objectives, Scope, Performance, Effectiveness SAFETY UTILITIES MANAGEMENT 1. Performance standards – Review of performance standards for the 1. Performance standards and thresholds established for 2015. Environment of Care for 2015, including re-assessing thresholds of 2. Generator testing completed per regulatory standards. performance. 3. Preventive maintenance monitored. 2. Reporting schedule established for the Environment of Care committee. 4. Facility Manager Environment of Care reports reviewed in each quarter 3. POM Facility Manager conducted monthly rounds and reviewed disaster and 2015. fire training with Villa Pomerado staff to increase knowledge. 5. Utility failures reported to Environment of Care committee, each resolved 4. Facility Manager Environment of Care reports reviewed in each quarter. with follow-up actions documented. 5. Preparedness activities for El Nino weather completed at each facility (i.e. 6. Annual evaluation of the Utility Management plan and program roof drain clearing, roof repairs, etc.). completed: Objectives, Scope, Performance Standards and Overall 6. Multi-disciplinary environmental surveillance: ongoing, with deficiencies Effectiveness identified and documented in Sentact and issues sent to Director for she / he EMERGENCY MANAGEMENT to resolve and close out in Sentact 1. Performance standards and thresholds established for 2015. 7. Annual Evaluation of the Safety Management plan completed: Objectives, 2. Disaster preparedness multidisciplinary committee meetings held with Scope, Performance standards and Overall Effectiveness completed. multiple activities accomplished. SECURITY 3. Emergency Management leadership participated in community tabletop 1. Performance standards and thresholds established for 2015. at Poway FD HQ. Scenario: Wildfires with Santa Ana winds and 2. Quarterly reports for Security completed, including incident review. Pomerado Hospital / Villa Pomerado response and collaboration. 3. Security staff actively participating in disaster drills, and have assumed the 4. Wildfire preparedness tabletop completed at POM and VP in October. “Security Branch Director” role in the command centers. Worked in collaboration with Poway FD and City of Poway disaster 4. Consolidation of SIT (Security Integration Team) into monthly EOC coordinator. Committee meetings. 5. Hazard Vulnerability Analysis (HVA) reviewed / revised for 2015 with the 5. Fence, additional lighting and security cameras installed around Grand Bldg. top five hazards identified. 6. Ongoing active shooter (ALiCE – Alert, lockdown, inform, counter, evacuate) 6. Everbridge notification drills completed semi-annually to coincide with and Management of Assaultive Behavior (MAB) training by staff / physician county and statewide exercises. Over 900 physicians included in request. Over 25 classes conducted for staff, both clinical and non-clinical, in notification exercises. the areas of ALiCE, personal security tactics, MAB, and pepper spray safety. 7. Ongoing membership with San Diego Healthcare Disaster Coalition 7. Code Pink/Purple drills conducted and evaluated with effective outcomes. (SDHDC) which strengthens community ties with the other San Diego 8. Workplace violence prevention multidisciplinary planning team began County hospitals, SD County Emergency Medical Services (EMS), SD meeting. County Office of Emergency Services (OES), Red Cross, SD County 9. Through the Security Integration Teams, a follow up survey was sent to staff Public Health, and law enforcement agencies. to evaluate the effectiveness of communication, access control, parking, and 8. Continued collaboration with SD County Emergency Medical Services visitor management. (EMS) in the area of Hospital Preparedness Program (HPP) grant 10. Collaboration with Escondido SWAT and K-9 units in the usage of vacant funding. All deliverables completed in May 2015 and grant funds were Surgery Center building to conduct multiple security and safety response received. trainings. 9. Everbridge emergency notification system is used exclusively during 11. Annual Evaluation for the EOC for the Security Management Plan completed: exercises and actual events. Objectives, Scope, Performance Standards and Overall Effectiveness 10. Satellite phone hard lines installed in the three hospital command completed. centers as a communication redundancy. HAZARDOUS MATERIALS 11. Disaster surge cart medical supplies inventoried by supply chain staff to 1. Performance standards and thresholds established for 2015. ensure expiration dates are monitored and supplies are rotated into the 2. No spills requiring outside agency assistance reported. supply stream. 3. Performance Improvement (PI) Project for the EOC identified: the 12. Continued collaboration with Kaiser Emergency Management colleagues participants of the 2014 first responder decontamination training meet to ensure communication is flawless during disaster events. quarterly to review plans, communication details, and plan for next decon 13. Countywide disaster exercise completed at each site May 2015. exercise Scenario: decontamination and patient surge due to HAZMAT and MCI 4. Annual Evaluation of the EOC for Hazardous Materials Management Plan (mass casualty incident). completed: Objectives, Scope, Performance Standards, Overall Effectiveness 14. Statewide disaster exercise completed at each site November 2015. Scenario: Anthrax detected in atmosphere, causing the need for SNS (strategic national stockpile) cache of medicine to be deployed for hospital staff, their families, patients and physicians. 15. Annual evaluation for the Emergency Operations Plan completed: Objectives, Scope, Performance, Effectiveness. 40 5 EVALUATION: PERFORMANCE STANDARDS OVERVIEW. The attached data sheets represent the evaluation of established performance standards, areas chosen on one or more of the following criteria: 1. The performance standard represents a measurable area of one of the EOC components. 2. The performance standard indicates a key reflection of the scope of the component. 3. The performance standard represents a high volume activity, or low volume but high risk consequences. 4. The performance standard requires improvement, or the existing process could be enhanced.
Safety Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of O2 bottles found unsecured during monthly Environment of Care (EOC) rounds (2) Unsafe condition reports resolved by individual Facility Managers within 24 hours of submission (if actual unsafe condition)
Security Performance Standards The following performance activities were undertaken in 2015: (1) Begin upgrade and enhancement of the security video observation, access control, and alarm systems (2) 100% of security officers obtain CA Bureau of Security and Investigative Services (BSIS) guard card certification (3) Make available for all staff: quarterly offerings of security classes in the areas of Code Silver response, Managing Aggressive Behavior (MAB), and personal security practices (4) <2 automobile thefts per quarter by facility (5) Implement badge ID awareness / compliance campaign (6) Establish liaison contacts with local law enforcement and fire officials
Hazardous Materials and Waste Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of hazardous material containers inspected / labeled incorrectly during monthly Environment of Care (EOC) rounds (2) Staff knowledge in obtaining SDS (Safety Data Sheet) information during monthly Environment of Care (EOC) rounds (90% threshold) (3) Monitoring of number of hazardous chemical incidents involving outside agency assistance for cleanup (4) Monitoring of number of biohazard waste incidents involving outside agency assistance for cleanup
Fire Prevention Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of actual fires reported inside the facility (2) Staff knowledge on the meanings of R.A.C.E (Rescue, Alert, Confine, Extinguish) and P.A.S.S (Pull, Aim, Squeeze, Sweep) acronyms during monthly EOC rounds (90% threshold) (3) Monitoring of building and / or protection system monitoring – problems, significant incidents, unexpected repairs
Medical Equipment Performance Standards The following performance activities were undertaken in 2015: (1) Preventative maintenance (PM) completion rate for Priority 1 life support equipment (100% threshold) (2) Preventative maintenance (PM) completion rate for non-life support equipment (95% threshold) (3) <2% of equipment service requests that were related to user errors (4) <5% of unable to locate pieces of medical equipment (5) ≥90% of equipment repairs completed within 30 days
Utility Equipment Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of utility failures (2) Occurrences requiring external reporting (3) Monitoring of tube system failures (4) Monitoring of elevator failures (5) Emergency generator testing compliance per regulatory standards (100% threshold) Emergency Management Performance Standards The following performance activities were undertaken in 2015: (1) Conduct / manage two disaster drills or actual events per year at each facility according to top Hazard Vulnerability Analysis (HVA) risks and evaluate event using The Joint Commission standards or SD County Medical Health After Action Report (AAR) matrix (90% threshold) (2) Staff knowledge in articulating where his or her units disaster supplies are located during monthly Environment of Care (EOC) rounds (90% threshold) (3) Staff knowledge in articulating where the hospital command center (HCC ) and labor pools are located during monthly Environment of Care (EOC) rounds (90% threshold) 41
6 EVALUATION: PERFORMANCE STANDARDS
EOC Component: SAFETY MANAGMENT Performance Standard: The following performance activities were undertaken in 2015: 1. O2 bottles found unsecured during monthly EOC rounds monitoring 2. 100% of unsafe condition reports submitted by staff to be resolved within 24 hours Safety Management Plan Evaluation: for Improvement: 1. During monthly We will continue to Environment of Care (EOC) multi- monitor unsecured O2 tanks disciplinary rounds, facility throughout the district during managers monitored areas for monthly EOC rounds, and add unsecured O2 tanks. If any additional unannounced monitoring were found, the tank was first to weekly rounding schedule to secured properly, and the ensure O2 tanks are being stored department manager was notified and transported safely. and just in time training was We will continue to ensure that provided to staff on the risks of unsafe condition work orders are unsecured tanks. resolved within 24 hours of O2 bottles found unsecured: submittal. 2. Unsafe condition work orders are entered by staff on Sentact. 5 An email is immediately sent to the affected facility manager for 4 him to assign the task. 3 We have met our goal of 1 Q 2015 unsafe condition work orders 3 being resolved within 24 hours. 2 2 Q 2015 2 There were no identifiable trends 3 Q 2015 witnessed in 2015. 1 4 Q 2015 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Center Palomar Health Pomerado Hospital Villa Pomerado Downtown Campus Unsafe condition work orders received and closed out within 24 hours: 3
2 2 2 1 Q 2015 2 Q 2015 1 1 1 1 1 3 Q 2015 1 4 Q 2015
0 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Center Palomar Health Downtown Pomerado Hospital Villa Pomerado Satellite Buildings Campus
PMC: POM: Satellite Buildings: PHDC: 3Q15: Installation of dome mirror 1Q15: Concrete light post repair VP: 3Q15: Trip / fall hazard repair 2Q15: Burning odor that could to prevent gurney collisions (ED) due to vehicle backing into it None (Andreason) not be duplicated by Facilities 4Q15: Trip hazard repair (OR) (ED parking) staff (parking garage) 4Q15: Broken edges on hand 3Q15: Repair of sharp broken 4Q15: Trip hazard repair (Mail sanitizer repair (OR) baseboard tile (L&D) room) 3Q15: Exit door constantly
blocked by equipment (OR).
Addressed with OR manager to
keep exits clear at all times. 42 EOC Component: SECURITY MANAGEMENT 7 Performance Standard: The following performance activities were undertaken in 2015: 1. Continued upgrade/enhancement of security video operation, access control, and alarm systems Evaluation: 2. 100% of Security officers obtain CA Bureau of Security Investigative Services 1. Throughout 2015 many (BSIS) guard card certification Security related projects took 3. Made available for all staff: quarterly offerings of security classes in the areas place to enhance observation, of Code Silver, response, Managing Aggressive Behavior (MAB), and personal access control, and alarm security practices systems. 4. <2 automobile thefts per quarter per campus
5. Conditioned to foster liaison contacts with local law enforcement/fire officials 2. 100% of Security Officers were certified by the CA BSIS (Bureau of Security Investigative 2015 Quarterly Security Services) and obtained Guard Training: Cards. st 1 Quarter – 2015 Quarterly Security NOTE: All new security officers are • Active shooter (Grand Building Required to obtain this certification Projects: staff) Prior to employment with PH. • Managing Aggressive Behavior 1st Quarter – 3. Our Security manager (PMC 4 & 5 staff) taught over 30 security related • Managing Aggressive Behavior • Door access upgrade classes in 2015. Hundreds of (PMC EVS staff) (San Marcos Ambulatory employees and volunteers in • Code Pink drills (POM & PHDC) Care Center) Multiple disciplines were trained.
rd nd 3 Quarter – 4. We met our goal of <2 2 Quarter – • Infant monitoring system vehicle thefts per quarter at • Active shooter (PMC ED staff) th each campus. There was one • Personal security awareness upgrade (PHDC 7 floor) vehicle stolen from PMC in the (Healthy Development staff) • Hard drive addition for nd 2 quarter. • Fire safety (Healthy video recording servers
Development staff) (PMC) 5. Security worked closely with • Addition of 10 camera the marketing department to • Managing Aggressive Behavior licenses to Sky point send out periodical id security, (Infection Prevention staff) safety and parking messages to all • Managing Aggressive Behavior • Badge reader addition th staff via the staff portal. (PMC OR staff) (POM 5 floor) • Addition of 10 cameras 6. Security manager worked 3rd Quarter - (PMC) closely in cultivating relationships with local law and fire officials • Managing Aggressive Behavior 4th Quarter: throughout 2015. This will be (Staff on Safety committee) an ongoing goal of relation- • Fire safety (Acute Rehab staff) • Radio repeater addition ship enhancement in 2016. w/ antenna (PMC) 4th Quarter – • Bureau of Security Investigative Plan for Improvement: Services (Security staff) We will continue our plans • Code Pink drill (POM) of strengthening our security observation capability, Automobile thefts: access control, and alarm <2 threshold system functionality in 2015. Various security trainings were 5 offered in 2015 and badge 4 awareness campaigning and observation will continue. 1 Q 2015 3 2 2 Q 2015 1 1 3 Q 2015 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Q 2015 Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado 43 8 EOC Component: HAZARDOUS MATERIALS AND WASTE MANAGEMENT Performance Standard: The following performance activities were undertaken in 2015: 1. Monitoring of the number of hazardous material containers inspected Evaluation: / labeled incorrectly during monthly EOC rounds monitored 1. During monthly 2. Staff knowledge in obtaining Safety Data Sheet (SDS) information Environment of Care (EOC) multi- during monthly EOC rounds (90% threshold) disciplinary rounds, facility 3 & 4. Monitoring of the number of hazardous waste and bio hazardous managers monitored hazardous material containers for inappropriate waste incidents requiring outside agency cleanup labeling. There were no deficiencies found in 2015. Inappropriate labeling on hazardous material container monitoring:
2. During monthly EOC rounds, 5 facility managers monitored staff knowledge regarding how to locate Safety Data Sheet (SDS) information. 4 Our threshold is 90% and was met at 1 Q 2015 each facility each quarter. 3 2 Q 2015 3 and 4. Number of hazardous and 2 3 Q 2015 bio hazardous waste incidents requiring outside assistance for 1 4 Q 2015 cleanup was zero, however, there were two small spills that occurred at 0 0 0 0 0 0 0 0 0 0 0 0 0 st 0 PMC in the 1 quarter (Formalin in the Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado OR) and the 4th quarter (Methyl Center Downtown Campus Methacrylate in the OR). Cleanup was done by Palomar Health staff due to the spills being small amounts. We will continue to monitor in 2016. Staff knowledge on how to obtain Safety Data Sheet (SDS) information: 90% threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015
0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado
Number of hazardous and bio hazardous waste incidents: Plan for Improvement: 5 We will continue monitoring for correct staff response relating 4 to various program 1 Q 2015 elements in our 3 hazardous materials 2 Q 2015 plan, as high levels of compliance promote risk 2 3 Q 2015 1 1 reduction relating to 4 Q 2015 hazardous materials 1 and waste usage. 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado 44 Center Downtown Campus
EOC Component: FIRE PREVENTION MANAGEMENT 9 Performance Standard: The following performance activities were undertaken in 2015: 1. Monitoring of actual fires reported inside the facilities 2. Staff knowledge of RA.C.E (Rescue, Alarm, Contain, Extinguish / Evacuate), Evaluation: and P.A.S.S (Pull, Aim, Squeeze, Sweep) acronyms (90% threshold) 1. There were no fires reported at 3. Monitoring of building and / or protection systems – problems, significant any Palomar Health campus in incidents, and unexpected repairs 2015.
Number of actual fires reported inside the facilities: 2. During monthly EOC rounds, facility managers monitored staff 5 knowledge regarding the R.A.C.E and P.A.S.S acronyms. Our 4 threshold is 90% and was met at 1 Q 2015 each facility each quarter. 3 2 Q 2015 3. In January 2015, POM 2 experienced flooding due to a 3 Q 2015 broken fire sprinkler in one of the 4 Q 2015 first floor restrooms. Fire watches 1 were performed by Security and 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Facilities staff while repairs were 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado made. Center Downtown Campus
Staff knowledge of R.A.C.E and P.A.S.S acronyms: Threshold = 90%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015
0% Palomar Medical Center Palomar Health Downtown Pomerado Hospital Villa Pomerado Campus
Plan for Improvement: We will continue to monitor staff knowledge Building protection system problems, significant incidents, unexpected repairs: of R.A.C.E and P.A.S.S and continue to promote fire safety awareness and “readiness” in staff in the 10 event of a fire. We will 9 continue monitoring any 8 significant events at our campuses. 7 1 Q 2015 6 5 2 Q 2015 4 3 Q 2015 3 4 Q 2015 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus 45 10 EOC Component: MEDICAL EQUIPMENT MANGEMENT Performance Standard: 1. Preventative maintenance (PM) completion rate for priority 1 life Evaluation: support equipment (100% threshold) 1. Biomed consistently met 2. Preventative maintenance (PM) completion rate for non-life their 100% threshold of support equipment (95% threshold) preventative maintenance on 3. <2% of equipment service requests that were related to user life support equipment errors throughout 2015. 4. <5% of unable to locate pieces of medical equipment
2. Biomed consistently 5. ≥90% of equipment repairs completed within 30 days met their 95% threshold of preventative maintenance on Preventative maintenance completion rates on life support devices: non-life support equipment 100% PM completion threshold throughout 2015, except for the 3rd and 4th quarter at Villa Pomerado due to two devices that could not be 100% located.
3. When biomedical staff respond to a work order that was 1 Q 2015 caused by an operator error, 2 Q 2015 technicians offer on the spot training for the operator and 3 Q 2015 it is noted in the work order. 4 Q 2015 If an equipment user has repeated errors on the same model of equipment, the department 0% manager is advised and Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus additional training is recommended.
4. The threshold was met consistently throughout 2015 on <5% of unable to Plan for Improvement: locate pieces of medical We will continue monitoring PM completion equipment at each facility, except at rates as high completion rates for both Villa Pomerado due to two pieces of life support and non life support medical medical devices (patient lifts) that equipment promotes operational reliability could not be located. These devices of equipment that is used on our patients, and were removed from inventory after supports our patient safety goals. being missing for 90 days. We will continue to monitor our other goals
and watch for any apparent trends or gaps. 5. The threshold was met consistently throughout 2015 at all facilities on ≥90% of equipment repairs completed within 30 days.
Preventative maintenance completion rates on non-life support devices: 95% PM completion threshold 99% 99% 99% 99% 99% 99% 99% 99% 100% 100% 97% 95% 96% 97% 95% 91% 95% threshold
71% 1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015 Linear (4 Q 2015) 0% Palomar Medical Center Palomar Health Downtown Pomerado Hospital Villa Pomerado Campus 46 Medical Equipment continued 11 <2% of equipment service requests related to user errors:
10% 1 Q 2015 2 Q 2015 3 Q 2015 6% 4 Q 2015
4%
2% 2% 2% 2% 2% <2% threshold 1% 1% 1% 1% 1% 0% 0% 0% 0% 0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado
<5% of unable to locate pieces of medical equipment:
30% 29% 1 Q 2015 2 Q 2015 20% 3 Q 2015 4 Q 2015
10% 7% 4% 3% 2% 2% 2% <5% threshold 1% 1% 1% 1% 1% 1% 0% 0% 0% 0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado
≥90% of equipment repairs completed within 30 days:
99% 99% 99% 99% 98% 100% 99% 98% 98% 100% 100% 95% 95% 100% 92% 93% 91% ≥90% threshold
1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015
0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado 47 EOC Component: UTILITY EQUIPMENT MANAGEMENT 12 Performance Standard: 1.Monitoring of utility failures 2. Occurrences requiring outside reporting 3. Monitoring of tube system failures 4. Monitoring of emergency generator testing compliance per r Evaluation: regulatory standard 1. Utility failure monitoring includes any electricity, water, Utility failure monitoring: natural and medical gas Electricity, water, natural and medical gas failures failures. PMC experienced a breaker failure in September when normal testing was conducted. Breaker 2 was replaced and no issues were identified. The automatic transfer switch (ATS) failed at PHDC in January. PHDC lost power due to a 1 Q 2015 SDG&E breaker issue in July. 1 1 1 1 1 Generators ran as designed in each 1 2 Q 2015 event. POM and VillaPOM experienced 3 Q 2015 a power outage in July due to SDG&E (cause unknown). 4 Q 2015 No major issues identified. 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado 2. There were three incidents requiring Center Downtown Campus reporting to an outside regulatory agency in 2015 relating to utility failures / repairs. The automatic transfer switch (ATS) failed at PHDC in January. PHDC lost power due to a Plan for Improvement: SDG&E breaker issue in July. We will continue Generators ran as designed in each monitoring, keeping event. At POM, due to a visitor our efforts on prevention, causing damage to a fire sprinkler in and utility equipment a restroom, caused >$200,000 in operational reliability damages in January. which strengthens our patient safety focus. 3. Tube system failures were monitored throughout 2015.
4. Elevator failures were monitored throughout 2015. Outside agency reporting: 5. Generator testing, which is considered life support utility equipment, was completed at 100% at all facilities 2 in 2015.
1 Q 2015 1 1 1 1 2 Q 2015 3 Q 2015 4 Q 2015
0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus
48 Utility Equipment 13 continued Tube system failure monitoring:
10 9 8 8 8 7 1 Q 2015 6 5 5 2 Q 2015 4 3 Q 2015 3 4 Q 2015 2 1 1 1 0 0 0 0 0 0 0 0 Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital
Elevator failure monitoring:
10 10 9 9 8 8 8 7 6 6 6 1 Q 2015 6 5 2 Q 2015 4 4 3 Q 2015 3 4 Q 2015 2 2 1 0 0 0 0 Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital
Emergency generator testing per regulatory standard: 100% threshold
100%
1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015
0% Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus 49 EOC Component: EMERGENCY MANAGEMENT / EMERGENCY OPERATIONS PLAN (EOP) 14 In 2015 multiple events occurred in the area of emergency management. The Disaster Committee met regularly with a standing agenda developed by the Program Manager to address the growth of disaster preparedness and the preparedness needs throughout the district.
The National Incident Management System (NIMS) and Hospital Incident Command System (HICS) principles are incorporated into exercise planning and actual event response. Committee members also reviewed the Hazard Vulnerability Analysis (HVA) documents which were completed with risks prioritized for the medical centers and balanced against mitigation strategies in place. Input was solicited from our medical staff, and community partners (San Diego County Emergency Medical Services (EMS) / San Diego County Office of Emergency Services (OES) and the other SD County medical centers and fire departments) who provided recommendations for our HVA’s. We have several disaster equipment storage trailers that are inventoried annually and Supply Chain maintains the medical supplies on each disaster supply cart at each of our ED’s. Also utilized is an exercise / actual event evaluation tool that establishes performance standards in accordance with The Joint Commission emergency management standards (the six critical areas of communications, resources and assets, staff roles and responsibilities, security, utilities, and patient support services).
In 2015, the medical centers participated in several countywide exercises and in actual events. For the purposes of this report, two exercises, in which the EOP was activated, at each facility will be evaluated to ensure our 90% objective threshold. PMC: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination conducted by PMC staff, using the decon trailer that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The scenario also involved a cyber attack which caused multiple power outages. • Event score: 92% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms and Security practiced with a traffic flow exercise. • Event score: 95% with follow up activities identified. PHDC: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination conducted by PHDC staff, using the decon tent that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The scenario also involved a cyber attack which caused multiple power outages. • Event score: 92% with follow up activities identified. 2. Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms . • Event score: 94% with follow up activities identified.
POM: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination conducted by POM staff, using the decon tent that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The scenario also involved a cyber attack which caused multiple power outages. • Event score: 90% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms. • Event score: 91% with follow up activities identified.
VillaPOM: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Since this exercise involved power outage, staff practiced completing Department Status Worksheets in which critical devices being plugged into red outlets was tested. We also captured potential staff shortages and planned for steps to take if staff shortage was ever identified. • Event score: 94% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms. • Event score: 94% with follow up activities identified.
Satellite Buildings, including Home Health: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Outside area staff are tasked with completing ‘Department Status Worksheets’ and reporting to the command center any staffing shortages, or staff that would be available for the labor pool. • Event score: 92% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Outside area staff are tasked with completing ‘Department Status Worksheets’ and reporting to the command center any staffing shortages, or staff that would be available for the labor pool. Home Health tested the process of receiving SNS medication and delivering it to our home bound population. • Event score: 96% with follow up activities identified.
Plan for Improvement: For the disaster exercises and events, debriefings Plan for Improvement: occurred with plans for improvement identified. We will continue testing The Disaster Committee has assumed the correct staff response responsibility for implementing the improvement relating to our actions. We will continue with pre-planning for Emergency Operations drills, identifying objectives that test stressing Plan. our systems. 50 Emergency Management 15 continued
EOC Component: EMERGENCY MANAGEMENT Performance Standard: 1. Conduct / manage two disaster exercises or actual events per year at each facility according to top Hazard Vulnerability Analysis (HVA) risks and evaluate event using The Joint Commission standards or SD County Medical Health After Action Report (AAR) matrix (90% threshold) 2. Staff knowledge during EOC surveillance rounds in articulating where his or her unit’s disaster supplies are located (90% threshold) 3. Staff knowledge during EOC surveillance rounds in articulating where the hospital command center (HCC) and labor pool are located (90% threshold)
Evaluation of disaster exercises / actual events using The Joint Commission Emergency Management chapter standards: 90% threshold
95% 90% 91% 96% 100% 92% 92% 94% 94% 94% 92%
Threshold = 90%
MCI / Power Outage Exercise Anthrax Evaluation: 1. During each of the Exposure exercises in 2015, the threshold of 0% Exercise 90% was met consistently at each Palomar Palomar Pomerado Villa Outside Medical Health Hospital Pomerado Areas medical center and outside area. Center Downtown Action items were identified post Campus event as well as what items went well. These items were forwarded Staff knowledge during EOC surveillance rounds in articulating to the disaster and environment where his or her unit’s disaster supplies are located: 90% threshold of care committees for review.
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 2 and 3. During monthly EOC 100% rounds, facility managers Threshold = 90% monitored staff knowledge regarding the locations of disaster equipment, hospital 1 Q 2015 command centers and labor 2 Q 2015 pools. Our threshold is 90% and was met at each facility by quarter, 3 Q 2015 with the exception of the 4th quarter at PMC. Staff was given 4 Q 2015 just in time training on the locations during the rounding. 0% Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus
Staff knowledge during EOC surveillance rounds in articulating where the hospital command center and labor pools are located: 90% threshold
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Threshold = 90%
60% 1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015 0% 51 Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado 16 Annual Evaluation - Overall Effectiveness – 2015
SAFETY. Based upon the objectives, scope and performance standards, outcomes were positive, and thresholds were impressively met for the safety management program at Palomar Health facilities. Based on the high level of commitment to education, surveillance, and ongoing activities, the Management Plan for Safety is highly effective in promoting safety standards for the organization, and in guiding the direction of safety-related activities. We will plan on doing additional unsecured O2 tank rounding throughout the organization, in addition to monthly EOC rounds to ensure departments understand the importance of proper O2 tank storage.
SECURITY. The Management Plan for Security and the security program is effective across the district, with the objectives being met in 2015. Incidents were monitored routinely, and performance standards were met regarding requirements specific to their department standards and expectations. Code Pink (infant abduction) and Purple (child abduction) drills were completed on a routine basis with excellent staff response. For the year 2016, we will continue monitoring security trends to identify areas of risk to the medical centers and offsite areas, and we will continue with the management of assault training and infant and child abduction security drills, focusing on continued education and effective drill outcomes.
HAZARDOUS MATERIALS. The Management Plan for Hazardous Materials and the overall Hazardous Materials program at Palomar Health facilities is effective, as there were no spills requiring an outside response team. Objectives were met for 2015, and the threshold was met for staff knowledge relating to program elements of the Hazardous Materials Management Plan. Hazardous waste was manifested in accordance with agencies having jurisdiction. This focus on ongoing education reflects Palomar Health’s commitment to the safety of our employees, especially is it relates to hazardous materials issues. We strengthened our program in 2015 and continued to meet on a quarterly basis with the group that was trained as first receivers during 2014 decontamination training. We will plan for another round of 16-hour first responder training in 2016, which will allow recertification to those in need.
FIRE PREVENTION MANAGEMENT. Based upon the objectives, scope and performance standards, the Fire Prevention Management plan is effective. Fire drills were completed for the hospital and offsite areas, with performance standards monitored, and found to be in compliance throughout the year. Fire equipment inspection, maintenance and testing was completed, with ongoing monitoring of the Statement of Conditions in effect. Infection Prevention assessment continued to be integrated into construction activities.
MEDICAL EQUIPMENT MANAGEMENT. Based upon the objectives, scope and performance standards, the Medical Equipment Plan and program are effective at the medical centers. Preventive maintenance was monitored quarterly, with established thresholds met. The separation of our inventory (i.e., life support medical equipment from non-life support medical equipment) places a higher focus on the safety of our patient, and keeps the Environment of Care closely integrated with Patient Safety standards. The Medical Equipment Plan and program are effective in promoting safe equipment usage for our patients. We will continue to monitor equipment user errors and equipment that is not located for > 30 days and be prepared to observe and report out any trending that may occur.
UTILITY EQUIPMENT MANAGEMENT. There were no trends or unusual patterns associated with utility failures. All generators were completed at 100% compliance and various utility failures were noted throughout the year. The Utility Equipment Management plan is an effective way to manage the Utility Equipment program based on the successful completion of goals and performance standard monitoring.
EMERGENCY MANAGEMENT. Based upon the objectives, scope and performance standards, the Emergency Management and Operations Plan is effective. Several actual events and SD County disaster exercises occurred in 2015, all of which were based upon likely scenarios in our Hazard Vulnerability Analysis's. The events were evaluated with overall successful outcomes, with plans for improvement identified and implemented. The Disaster Preparedness Committee was very active with exercise design and planning. This continues to be a highly effective and energetic committee that will continue to meet and oversee the day-to-day emergency planning in 2016. The Hazard Vulnerability Analysis's are reviewed annually, and found to be an effective tool in prioritizing critical events, and assessing the prioritization against the medical center’s preparedness. Staff were monitored for their knowledge relating to components in our Emergency Operations plan, and their roles in a disaster, and found to respond at a very high compliance rate. Palomar Health as a district is actively involved with community-wide preparedness activities, which strengthens our ties with agencies having jurisdiction. 52