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Palomar Pomerado Health 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. 1 Page 1 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
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