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Board Quality Review Committee BOARD QUALITY REVIEW COMMITTEE AGENDA MONDAY, June 18, 2018 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:00 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 5:30 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025 Time Form A Target PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING Page # ROOM CALL TO ORDER 5:30 Establishment of Quorum ............................................................................................................. 1 N/A 5:31 Public Comments 1 ....................................................................................................................... 15 N/A 5:46 Approval: 1. *Approval: Minutes – Monday, May 21, 2016 (ADD A, Pages 13-26 ) .............................. 5 3 5:51 Information Item(s) 1. *Follow-up Information Items a. Discharge Planning – Cynthia Laughton (ADD B, Pages 28-29) .................................... 4 b. Infection Control – Valerie Martinez (ADD C, Page 31 ) .................................................. 5 c. Pharmacy Diversion Prevention Monthly Report – Kathy Chang/Jeremy Lee (ADD D, 15 6 6:06 Pages 33-35) ..................................................................................................................... d. Regulatory Audits reviewed at Quality Management Committee of June 13, 2018 (ADD 7 E, Pages 37-151) ............................................................................................................... Standing Item(s) 1. Journal Club Assignment: - Managing the Social Determinants of Health: Part 1 “Fundamental Knowledge for 10 8 6:16 Professional Case Management” (ADD F, Pages 153-175) ........................................ 2. Regulatory Readiness Report Valerie Martinez, RN and Director, Quality/Patient Safety/Infection Prevention and Control/Diabetes 10 6:26 Health & Stroke Programs/Regulatory Coordination 3. MEC Update Sabiha Pasha, MD, Chair, Quality Management Committee Palomar Medical Center Escondido 5 6:31 Edward Gurrola, MD, Chair, Quality Management Committee Palomar Medical Center Poway New Business 1. *Quarterly Report – Operative and Invasive Services – efforts of the Joint Commission Plan of Correction (ADD G, Pages 177-179) Marcia Cavanaugh, Director, Surgical Services 15 9 6:46 Presentation – 5 minutes Questions & Answers – 10 minutes 2. *Annual Report – Management of the Care Environment (ADD H, pages 181-211) ........... Dan Farrow, VP, Hospitality and Facilities Presentation – 5 minutes 15 10 7:01 Questions & Answers – 10 minutes 3. *Annual Report – Respiratory Service (ADD I, Pages 213-223) ......................................... Larry LaBossiere, Chief Nursing Officer, PMC Poway and Downtown Escondido Kerwin Pipersburgh, District Manager, Respiratory Services and Krysti Johnson, Supervisor. 15 11 7:16 Respiratory Services Presentation – 5 minutes Questions & Answers – 10 minutes 1 Page 1 BOARD QUALITY REVIEW COMMITTEE AGENDA MONDAY, June 18, 2018 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:00 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 5:30 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025 PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM ADJOURNMENT TO EXECUTIVE SESSION Pursuant to Health and Safety Code Section 32155 30 7:46 - Report of Hospital Medical Audit/Quality Assurance ADJOURNMENT TO OPEN SESSION 1 7:47 Action taken, if any 1 7:48 Public Comments 1 ....................................................................................................................... 15 N/A 8:03 FINAL ADJOURNMENT 1 8:04 Note: The agenda, without public comments, is scheduled for 2 hours, 4 minutes. Based on above agenda, without public comments the meeting starts at 5:30 pm and adjourns at 7:34 pm. Board Quality Review Committee Members VOTING MEMBERSHIP NON-VOTING MEMBERSHIP – Chairperson, Board Member Diane Hansen, CPA, Chief Executive Officer Jerry Kolins, MD, FACHE, Chief Quality Officer Chair of Patient Safety Douglas Moir, MD – Chairperson, Board Member Committee Dara Czerwonka, MSW, Board Member Omar Khawaja, MD, Chief Medical Officer Ray McCune, RN, Board Member Sheila Brown, RN, MBA, FACHE, Chief Operating Officer - Chair of Medical Staff Quality Management Sabiha Pasha, MD Mel Russell, RN, MSN, Interim CNO, Palomar Medical Center Escondido Committee for Palomar Medical Center Escondido Ed Gurrola, MD - Chair of Medical Staff Quality Management Larry LaBossiere, MBA, MSN, RN, CNS, CEN, CNO, Palomar Medical Committee for Palomar Medical Center Poway Center Poway and Downtown Escondido Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Director, Quality/Patient Safety/Infection Prevention and Control/Diabetes & Stroke Programs Jim Lyon, Chair, Patient Family Advisory Council Paul Patterson, Chair Elect, Patient Family Advisory Council 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 Board Quality Review Committee Meeting Monday, June 18, 2018 Attendance Roster and Meeting Minutes TO: Board Quality Review Committee MEETING DATE: Monday, June 18, 2018 FROM: LouAnn Quibuyen, Executive Assistant, Quality Department and BQRC Committee Assistant Background: The minutes of the Board Quality Review Committee Open / Executive Session meeting, held on Monday, May 21, 2018 are respectfully submitted for approval. Also included is the attendance roster for the Committee’s review. Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum A – 05.21.18_Open_Executive Session Meeting Minutes Attendance Roster 3 Board Quality Review Committee Meeting Monday, June 18, 2018 Clinical Resource Management Quarterly Report – Discharge Planning TO: Board Quality Review Committee MEETING DATE: Monday, June 18, 2018 FROM: Cindy Laughton, RN and Director, Clinical Resource Management Background: Cindy Laughton, RN and Director, Clinical Resource Management will present the quarterly report for Discharge Planning. Budget Impact: N/A Staff Recommendation: Information only. Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum B – CRM Discharge Planning Qrtrly Report 4 Board Quality Review Committee Monday, June 18, 2018 Monthly Report – Infection Control TO: Board Quality Review Committee MEETING DATE: Monday, June 18, 2018 FROM: Valerie Martinez, RN and Director, Quality/Pt. Safety/Infection Prevention & Control/Regulatory/Diabetes and Stroke Programs Background: A monthly report for Infection Control was provided to the Board Quality Review Committee for their review. Budget Impact: N/A Staff Recommendation: Information only. Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum C – Quarterly Report-Infection Control 5 Board Quality Review Committee Monday, June 18, 2018 Monthly Report – Pharmacy Controlled Substance Diversion Committee TO: Board Quality Review Committee MEETING DATE: Monday, June 18, 2018 FROM: Kathy Chang, PharmD, and District Director, Pharmacy Services and Jeremy Lee, PharmD and District Manager, Pharmacy Services Background: A monthly report from the Pharmacy Controlled Substance Diversion Committee was provided to the Board Quality Review Committee for their review. Budget Impact: N/A Staff Recommendation: Information only. Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum D – Monthly Report – Diversion Committee 6 Board Quality Review Committee Monday, May 2, 2018 Regulatory Audits reviewed at Quality Management Committee June 13, 2018 TO: Board Quality Review Committee MEETING DATE: Monday, May 21, 2018 FROM: Jerry Kolins, MD, Chief Quality Officer and Medical Director, Laboratories Background: Regulatory Audits reviewed at the Quality Management Committee of June 13, 2018 are presented to the Board Quality Review committee for information and discussion. Budget Impact: N/A Staff Recommendation: Information only. Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum E – Regulatory Audits – QMC – 6.13.18 7 Board Quality Review Committee Monday, June 18, 2018 Journal Club Article Managing the Social Determinants of Health, Part 1 Fundamental Knowledge of Professional Case Management TO: Board Quality Review Committee MEETING DATE: Monday, June 18, 2018 FROM: Jerry Kolins, MD, Vice President, Patient Experience and Medical Director, Laboratories Background: The reading for the BQRC Journal Club is on ”Managing the Social Determinants of Health, Part 1 – Fundamental Knowledge of Professional Case Management”, written by Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, Professional Case Management, Volume 23, No. 3, 107- 129, 2018 Wolters Kluwer Health, Inc. Budget Impact: N/A Staff Recommendation: For information only Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum F - Journal Club Article – Managing the Social Determinants of Health Part
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