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

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.

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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 1 8

Board Quality Review Committee Monday, June 18, 2018 Quarterly Report – Operative and Invasive Services

TO: Board Quality Review Committee

MEETING DATE: Monday, June 18, 2018

FROM: Mel Russell, RN and Interim Chief Nursing Officer and Marcia Cavanaugh, RN and Director, Surgical Services

Background: A quarterly report for Operative and Invasive Services 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 G – Quarterly Report-Operative and Invasive Services 9

Board Quality Review Committee Monday, June 18, 2018 Annual Report – Management of the Care Environment

TO: Board Quality Review Committee

MEETING DATE: Monday, June 18, 2018

FROM: Dan Farrow, VP, Hospitality and Facilities and Lisha Wiese, Program Manager, Emergency Management and Safety.

Background: Annual presentation to the Board Quality Review Committee on Management of the Care Environment at Palomar Health.

Budget Impact: N/A

Staff Recommendation: For information only

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A – Addendum H – Annual Report – Management of the Care Environment 10

Board Quality Review Committee Monday, June 18, 2018 Annual Report - Respiratory Services

TO: Board Quality Review Committee

MEETING DATE: Monday, June 18, 2018

FROM: Larry LaBossiere, RN and Chief Nursing Officer Poway and Downtown Escondido; Kerwin Pipersburgh, District Manager, Pulmonary Services and Krysti Johnson, District Supervisor, Pulmonary Services

Background: Annual presentation to the Board Quality Review Committee on Respiratory Services at Palomar Health.

Budget Impact: N/A

Staff Recommendation: For information only

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A – Addendum I– Annual Report – Respiratory Services 11

ADDENDUM A

Addendum A

BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

CALL TO ORDER

The meeting - held in the Learning and Development Center, 418 Grand Avenue, Escondido, CA – was called to order at 5:30 p.m. by Director and Chair, Doug Moir, MD.

ESTABLISHMENT OF QUORUM  Quorum comprised of Board Directors: Douglas Moir, M.D, Dara Czerwonka, MSW, Physician Chairs of the Medical Staff Quality Management Committees, Dr. Sabiha Pasha, Palomar Medical Center Escondido, and Dr. Edward Gurrola, Palomar Medical Center Poway  Excused Board Absences: Ray McCune, RN

NOTICE OF MEETING The Notice of Meeting was posted at Palomar Health Administrative Office; also posted with full agenda packet on the Palomar Health website on Friday, May 18, 2018 which is consistent with legal requirements.

PUBLIC COMMENT There were no public comments.

1. * REVIEW / APPROVAL: OPEN/EXECUTIVE SESSION MEETING MINUTES / ATTENDANCE ROSTER – APRIL 16, 2018

The BQRC Open / Executive Session meeting minutes of April 16, 2018 were presented for MOTION: by Director Czerwonka and N/A Y review and approval. Director Czerwonka motioned for approval with recommended revisions second by Edward Gurrola, MD and and was second by Edward Gurrola, MD. There were no additional questions presented for carried to approve the meeting minutes discussion. All were in favor. None were opposed. of April 16, 2018 with recommended revisions. All in favor. None opposed. Minutes were approved. (See Addendum A for additional information) 2. * REVIEW / APPROVAL: INFECTION PREVENTION & CONTROL RISK ASSESSMENT AND SURVEILLANCE PLAN

Utilizing the information provided within the meeting packet, Valerie Martinez, RN and District MOTION: by Director Czerwonka, Infection Control Director Y Director of Quality, Patient Safety, Infection Prevention and Control, and Regulatory presented second by Edward Gurrola, MD to to work collaboratively to the committee the Infection Prevention and Control Risk Assessment and Surveillance Plan submit to Board of Directors with the with Risk Management for 2018. recommendation for approval. to assure feedback from Risk on Infection Control Plan. Valerie reported that an annual infection prevention and control risk assessment is completed and the results of this assessment drive the current Infection Prevention and Control Plan. Most of the information contained within the plan is regulatory driven. The risk assessment grid or table included within the plan prioritizes the risks identified as a result of the assessment. This grid includes the risk level, the summary of risk mitigation strategies and effectiveness of

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Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY these strategies. Should there be any changes during the course of the year, this plan is updated to reflect those changes. Valerie reported that the Infection Prevention and Control Committee is chaired by the Infectious Disease physician. The committee is a multidisciplinary team which reviews, approves and submits recommendations to the appropriate committee reporting structure i.e. Patient Safety, Quality Management, Board Quality Review and Board of Directors, for final approval. Director Czerwonka inquired if Risk Management has been involved in this plan. All agreed that participation of Risk Management is the Infection Control Plan is appropriate. Additional items that were included in this year’s plan are related to the high prevalence of influenza. The plan addresses surveillance of those areas that we are mandated to review. If trends are identified from the previous year, then adjustments are made accordingly to ensure compliance. Dr. Pasha inquired if there are any identified issues of concern that were observed. Valerie reported that there have been upward trends identified in CAUTI/CLABSI. More detailed information will be shared later in the meeting when the annual report on Infection Prevention and Control is discussed. There were no additional questions presented for discussion. (See Addendum B for additional information)

OLD BUSINESS There were no old business items identified for discussion.

FOLLOW-UP ACTION ITEMS Quarterly Report – Discharge Planning

MOTION: N/A Director of CRM to return N Utilizing the information provided in the meeting packet, Valerie Martinez, Director, Quality and next month for further Patient Safety, Infection Prevention and Control, and Regulatory provided a quarterly update discussions on the on the Discharge Planning data on behalf of Mary Scott, Interim Director of Clinical Resource presented data. Management (CRM). Valerie reported data on CRM Assessment of patients within 24 hours of admission and The committee made a Date/Time of Discharge documentation. Both of these indicators were the result of the CMS recommendation to Surveys conducted in August and October 2017. Data presented were from October 2017 provide action plans for through April 2018. Established benchmark is set at 100%. Opportunities for improvement indicators that do not were identified for CRM Assessment of patient within 24 hours of admission. Date/Time of reach established Discharge Documentation reported at 100% compliance. benchmarks.

Director of CRM to return Director Czerwonka queried, if the Date/Time of Discharged Documentation is a Cerner next month for further mandated field and our numerator and denominator are only 20, then why not do a 100% discussion on the sample size? sample size for The committee requested the Director of CRM return next month for further discussions on the Date/Time of Discharge presented data. documentation.

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Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

(See Addendum C for additional information)

Quarterly Report – FANS (Dietary)

Utilizing the presentation provided in the meeting packet, Vice President, Hospitality and MOTION: N/A Statisticians recommend Y Facilities on behalf of Margaret Mertens, Interim Director of Food and Nutritional Services sample size to be a provided a quarterly update on the Food and Nutrition Services (Dietary) Department. minimum of 30 or 10% of the population studied, Dan Farrow reported that a permanent Director has been hired for the role of Director, Food whichever is greater. and Nutritional Services. Margaret Mertens will return to her role of Manager, Registered Dietitians within the department.

Dan also reported that the FANS Team was recognized by CDPH during the last survey for sustaining quality improvement efforts. Performance data and their current state were reviewed and discussed for the period of November 2017 through March 2018. April 2018 data is currently still being analyzed.

The Quality Assurance Performance Improvement Plan for 2017 had 4 elements. Two elements were retired due to sustained compliance. The two elements that are still being monitored are Test Trays – for accuracy of temperature, and Food Allergy documentation by clinical dietitian.

Director Czerwonka questioned if there was a specific formula that we are using in determining an appropriate sample size? In collaboration with Quality, the standard sample size is 30 however, upon further review the sample size was increased as it was not a true representation of the data. Samples are now collected at all three meals (breakfast, lunch and dinner).

(See Addendum D for additional information ) Quarterly Report – Nursing Services - OB

Utilizing the presentation provided in the meeting packet, Interim Chief Nursing Officer, MOTION: N/A N/A Y Palomar Medical Center Escondido Mel Russell and Chief Nursing Officer, Palomar Medical Center Downtown Escondido and PMC Poway, Larry LaBossiere provided an update on Nursing Services for Obstetrics (OB) at Palomar Health. Data was presented and discussed. Mel Russell reported that this is the 8th year of participation with BETA quality and safety initiatives. PMC Escondido successfully completed Group Tier 1 – which includes acceptable policies and procedures, RN job descriptions, rules and regulations, and analytics for both nurses and physicians on knowledge and medical record review. With the completion of Tier 1, we received a 2% savings on our BETA premium. Mel reported that the plan is to work towards completion of Tier 2. Larry LaBossiere reported that this too is PMC Poway’s 8th year of participating with BETA. Larry reported that PMC Poway received 3 Tier awards this year. Tier 1 for utilizing the National Institute of Child Health and Development (NICHD) Terminology for Fetal Heart Rate Interpretation, Tier 2 for Nulliparous Cesarean Section (Year 2) and Tier 2 for Second Stage Labor Management.

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Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY Tier 2 interventions resulted in reducing our Primary Cesarean Sections, occurring during the 2nd stage of labor, from 11% to 3% allowing us to achieve Healthy People 2020 goals. The established benchmark for HP 2020 is less than 23.9%. Larry reported that as of the end of next year, we will not be reimbursed for C-sections at the C- section rate if our rates are higher than the established benchmark of 23.9%. They are incentivizing facilities to keep rates below the established benchmark. The completion of Tier 1 and Tier 2 objectives resulted in a 6% reduction in our Malpractice Insurance premiums. Dr. Pasha inquired if we are comparing ourselves to the other San Diego hospitals. National average C-section rate is 33% and in the San Diego area it is roughly 30%. However, we are continue a downward trend from 33% to less than 24%. BETA Heart was a good driver for Palomar Health moving forward with this initiative. Overall the quality improvement initiatives are things that need to be worked on regardless of whether we were with BETA or not. This is the right thing to do for our patients. Larry also reported on PMC Poway’s exclusive breastfeeding rate is 85% well above the Joint Commission recommendation of greater than 52%. We are number 1 in the region and one of the top facilities in the State of California for primary breastfeeding rates. Congratulations and kudos to all of the teams.

(See Addendum E for additional information) Quarterly Report – Operative and Invasive Services

The quarterly report on Operative and Invasive Services was deferred until the next meeting. MOTION: N/A Due to transition in N leadership, the quarterly report was deferred until June 2018

Quarterly Report – Service Excellence

Utilizing the presentation data provided in the meeting packet, Chief Quality Officer Jerry MOTION: N/A Dr. Kolins to look into Y Kolins, MD provided a quarterly update on the Service Excellence data. why there is a difference Dr. Kolins presented HCAHPS data for review and discussion. PMC Poway took the Bronze between the State of award for Communication with Nurses, the Silver award in Communication with Doctors, the California and National Silver award for Response of Hospital Staff, and the Gold award for pain management. averages and report However, opportunities for improvement were identified in Room and Bathroom Cleanliness back to BQRC. and Quietness of Hospital Environment. Subsequent to the Room cleanliness and Quietness of Hospital Environment data from 2016-2017 was presented meeting Press Ganey and discussed. Virginia Barragan, VP Continuum Care wanted to point out that data presented reported that the is from 2016-2017. The CDPH surveyors recently commented on the cleanliness of the facility. difference between This shows great progress has been made in this area. California and the Larry LaBossiere reported that quietness is so important to healing. Jim Lyon, Patient Family National averages has Advisory member has been in collaboration with the healthcare team on a noise reduction not been thoroughly protocol at PMC Poway. Some items have already be put into place such as posters, PBX investigated. Possible Announcements, placement of wheels on our carts, timing of lab draws after 10:00 pm and explanations offered by 052118-MINUTES BQRC Board Meeting DRAFT V2 4 16

Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY minimizing lab draws during the night unless necessary, and minimizing vital signs if they are Press Ganey include: not required. access issues, diverse Director Czerwonka queried why the California average on all presented data is lower than the populations, language, national average. Is it because our patient population has higher expectations? Dr. Kolins to culture, healthcare look in to this and provide further clarification. literacy. Press Ganey also point out that Reported that 10 principle graphs that are being shown. Only once did Escondido out score California has the 6th Poway, and that was on “how do you rate the hospital.” largest economy in the This is the only report that will show the comparative to the other hospitals in the area. world and one of the Director Czerwonka provided kudos to the care transition and discharge planning teams in a highest poverty rates in job well done. the nation. Yet it was emphasized that There were no additional questions presented for discussion. evidence based studies (See Addendum F for additional information) are not available.

*STANDING ITEMS 1. Journal Club Assignment

Utilizing the information provided in the meeting packet, Chief Quality Officer, Dr. Jerry Kolins MOTION: N/A N/A Y opened the discussion on the LeapFrog Hospital Safety Grade Scoring Methodology and the Explanation of Hospital Safety Grades – Spring 2018. Further discussion ensued on the accuracy of the report. A lot of the information is rated on administrative data i.e. data obtained from Medicare bills. From these billings, Leapfrog determines your quality performance. It was also stated that hospital acquired conditions (HAC) is especially important because the data collection process is standardized across the nation. Deviations in HAC indicates an opportunity to improve. Leapfrog weighs HAC heavily.

There were no additional comments presented for discussion.

(See Addendum G for additional information) 2. *Regulatory Readiness Report

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AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

The Director of Quality, Patient Safety, Infection Prevention and Control and Regulatory Valerie MOTION: N/A Director of Quality/Pt. Y Martinez provided an update on the CMS Survey from April 2018. We are still waiting for the Safety/Infection 2567 Statement of Deficiencies and Plan of Correction from CMS. However, upon their exit in Control/Regulatory to April, we were verbally made aware of some of the deficiencies. Plans of corrections for those send draft Plan of deficiencies have been developed and implemented. Once the 2567 has been received we will Correction to CEO. CEO have 10 calendar days to respond. Medicare/Medicaid termination is currently scheduled for will forward to Board May 30, 2018. We are unsure if they will be extending this date. Communications with both members for review and CMS and CDPH have been very positive. input. Director Czerwonka recommended that perhaps we should send the draft plan of corrections (POC) to the Board for their review and input. Director of Quality/Pt. Safety/IC, and Regulatory to send draft POCs to the CEO who will then send out to the board members for review.

The Director of Quality, Patient Safety, Infection Prevention and Control and Regulatory reported to the committee that last Thursday (5/17/18) a meeting was held at CDPH / CMS in San Diego and included a teleconference with Baltimore headquarters. Key leaders of Palomar Health discussed the changes that have occurred since the new administration took corrective actions. Concerns shared were on the sustainability of the plans of correction. Palomar Health received positive comments on the presentation that was provided.

As part of the plan, Palomar Health has partnered with CIHQ, Center for Improvement in Healthcare Quality, a nationally recognized quality improvement organization. They are one of only 4 organizations that have the ability to provide deeming authority besides The Joint Commission. CIHQ conducted a Mock Survey May 16-18, 2018 at the Palomar Medical Center Escondido and Downtown Escondido facilities. Rick Curtis, CEO of CIHQ will be on site May 29-30 to review with key leaders the results of this survey.

There were no additional questions presented for discussion. 3. *Medical Executive Committees Update

Dr. Edward Gurrola provided a verbal update from the Medical Executive Committee of MOTION: N/A Dan Farrow, VP Y Palomar Medical Center Poway. Hospitality and Facilities  After confirming with BETA Heart, the Department of OB/GYN requested taking the to address corrective induction with Pitocin off the list that requires an update. actions to assist providers with  Steve Ellis, Director of Corporate Supply informed the committee of the role of supply compliance with surgical chain within the organization. attire in the OR suites.  Dr. Michael Burke, Chair, Department of Radiology, provided an update on medical staff peer review process.

Dr. Sabiha Pasha provided a verbal update from the Medical Executive Committee of Palomar Medical Center Escondido which concurred with the above statements in addition to the following item:  MEC met on 5/21/19 – Reported out on surgical attire. Reported that all leaders present agreed to ensuring appropriate use of surgical attire as outlined in our current Lucidoc procedure.

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Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY  Compliance would be easier to achieve with a mirror available in the area of gowning. This will help assure all hair is covered.  Requested hooks be installed for gowns/coats for accessibility and cost containment.  Education – for those providers that are non-compliant. If a case is started, then immediately following the case, the provider should be reported to the Chief of Staff and suspension will be used as form of enforcement. Provider will also have a meeting with Chief of Staff. A document is being drafted that the provider must review and sign indicating informed consent of the appropriate use of surgical attire.  Non-compliance will be reported to the appropriate leaders and the Regulatory Readiness meeting (R2).

Director Czerwonka queried for the simple fixes, how does that go about happening? Dan Farrow, VP Hospitality and Facilities to address the simple fixes within 30 days. There were no additional questions presented for discussion.

NEW BUSINESS 1. *Annual report to the Board – Contract Services

Utilizing the presentation included in the meeting packet, Interim CNO of Palomar Medical MOTION: N/A N/A Y Center Escondido Mel Russell provided an annual report on contracted services to the committee.

Data reports for cultures on dialysis equipment and water purity for both facilities were presented and discussed. These reports are from DaVita which is our contracted services for dialysis.

The Joint Dialysis Operating Committee which consists of members from Infection Control and leaders from both campuses, and Palomar Health’s Infection Prevention and Control team, review these reports and forward all concerns to the QMC.

Should there be any failure points, this information is then communicated immediately to both DaVita and Palomar Health and escalated as appropriate through the event escalation process.

There were no additional questions presented for discussion.

(See Addendum H for additional details) 1. *Annual report to the Board – Infection Prevention and Control

Utilizing the presentation included in the meeting packet, Director of Quality, Patient Safety, MOTION: N/A Infection Control data on N Infection Prevention and Control, and Regulatory, Valerie Martinez, provided the 2017 Annual areas with identified review and program assessment of the Infection Prevention and Control Surveillance Plan to the opportunities for Board Quality Review Committee. The program assessment provides information to direct the improvement to be Infection Prevention and Control Department to the issues that are the principle focus for the presented monthly until upcoming year. Each measure is evaluated for effectiveness and is considered to be the driver for determined otherwise. departmental and unit based action planning. Process and outcome measures are shared at the

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AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY physician and nursing level and used to maintain or improve patient care activities.

The mission of Infection Prevention is to develop and maintain an Infection Prevention and Control program that reflects the Mission, Vision and Values of Palomar Health. The program promotes patient safety by reducing the risk of acquiring and transmitting infections among patients, healthcare providers, volunteers, and visitors. The program is guided by Quality and Regulatory standards developed by The Joint Commission (TJC), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), California Department of Public Health (CDPH), Division of Occupational Safety and Health (Cal OSHA), and other nationally recognized organizations.

 Surveillance data for the following areas was presented to the committee:  Central Line Associated Bloodstream Infection (CLABSI)  Catheter-Associated Urinary Tract Infections (CAUTI)  Ventilator-Associated complications  Multi-drug Resistant Organism (MDRO) Lab identified event  Clostridium difficile Infection (CDI)  Surgical Site Infection (SSI) Colon  Surgical Site Infection (SSI) Abdominal hysterectomy  Hand Hygiene

Opportunities for improvement were reported for most of the areas listed above.

Director Czerwonka commented on why some of the indicators went up or increased in 2017 and what happens to address these fallouts. Are there written plans developed to address the below benchmark trends? Valerie Martinez reported that this information is reported quarterly to the Infection Prevention and Control Committee (IPCC) which reports to Quality Management Committee. The data and action plans are reviewed and discussed at this committee. Valerie also reported that this information has only been presented to the Board Quality Review Committee on an annual basis. However our plan is to revise reporting calendar to provide data quarterly to this committee.

Director Czerwonka reminded the committee of the importance of the information being provided up to the Board of Directors. When trends are identified going in the wrong direction, there has to be a process to alert the Board.

Further discussion ensued on current solutions that are either being trialed or have been put into place to assist in the reduction of hospital acquired infections.

The Board would like to know the action plans in place to address the opportunities for improvement.

There were no additional questions presented for discussion. (See Addendum I for additional details) 1. *Annual report to the Board – Rehabilitation Services

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Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY

Utilizing the presentation included in the meeting packet, VP, Continuum Care, Virginia Barragan MOTION: N/A N/A Y and Director of Rehabilitation Services, William Levanduski, provided an Annual Report on the Rehabilitation Services at Palomar Health. Key activities for the overall health system for FY2018 include

1. Patient Satisfaction 2. Centers of Excellence (Joint Replacement, Spine, Cardiac and Stroke) 3. Interdisciplinary District Fall Prevention Team 4. Employee Injury Prevention 5. Staff on Safety Team 6. Employee Engagement

Department Specific Activities for FY2018 includes:

1. Integration of Orthopedic Center of Excellence Rehab program across continuum 2. Rehabilitation Participation in Fall Prevention 3. Music therapy expansion (Inpatient and Satellite) 4. Expansion of Outpatient Rehab-Poway

Key Accomplishments for FY2018 are listed below: 1. American Academy of CardioVascular Pulmonary Rehabilitation Recertification (AACVPR) 2. Standardized scripting and patient rounding for Resource Utilization Groups (RUG) levels – Villa Pomerado 3. Standardization of patient education and exercise programs for orthopedic patients (Inpatient PMC Escondido and PMC Poway) 4. Rehabilitation website re-design.

Performance indicators, outcomes and current state for Rehabilitation Institute, Outpatient Rehabilitation and Cardiac Rehabilitation, and Inpatient Rehabilitation-Villa Pomerado were also presented.

Key areas of focus for FY2019 includes Ongoing Continuum for support – Centers of Excellence (Orthopedic, Spine, Cardiac and Stroke), National Registry Benchmarking of Cardiac Rehab, Patient Satisfaction, Employee Engagement, Patient Centered Care Focus: Villa Pomerado, Speech collaboration: RN competency in Nurse Swallow Screen (The Joint Commission requirement) and pilot speech program for Thirst Relief Bundle at PMC Escondido ICU and Villa Pomerado Subacute.

There were no additional questions presented for discussion.

(See Addendum J for additional details) ADJOURNMENT TO EXECUTIVE SESSION MOTION: by Director Doug Moir, MD, second by Edward Gurrola, MD and carried to adjourn to Executive Session 8:08 pm. All in favor. None opposed.  Pursuant to Health and Safety Code Section 32155 - Report of Hospital Medical Audit / Quality Assurance 21 052118-MINUTES BQRC Board Meeting DRAFT V2 9

Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MAY 21, 2018

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY ADJOURNMENT TO OPEN SESSION MOTION: by Director Doug Moir, MD, second by Edward Gurrola, MD and carried to adjourn to Open Session at 8:09 p.m. All in favor. None opposed.

Actions taken, if any. MOTION: N/A N/A Y There were no follow-up actions identified.

PUBLIC COMMENTS There were no public comments.

FINAL ADJOURNMENT - The meeting adjourned at 8:10 p.m. MOTION: by Director Doug Moir, MD, second by Edward Gurrola, MD and carried to final adjournment of the meeting at 8:10 p.m. All in favor. None opposed.

COMMITTEE CHAIR Doug Moir, MD SIGNATURES:

COMMITTEE ASSISTANT LouAnn Quibuyen

052118-MINUTES BQRC Board Meeting DRAFT V2 10 22 Addendum A

Board Quality Review Committee Meeting

OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2018

Meeting Dates: Palomar Health 2/19/18 9/17/18 By-Laws’ 1/15/18 Cancell 3/19/18 4/16/18 5/21/18 6/18/18 7/16/18 8/20/18 10/16/18 11/19/18 12/17/18 Annl Rpt Voting Members Membership ed DIRECTOR DOUGLAS MOIR, MD - CHAIR Board Member P P P P DIRECTOR DARA CZERWONKA, MSW Board Member P P Ex P DIRECTOR JERRY KAUFMAN, PTMA Board Member ------DIRECTOR JEFF GRIFFITH, EMT-P Board Member

(ALTERNATE) SABIHA PASHA, MD QMC Chair, Palomar Medical Center P P P P Escondido EDWARD GURROLA, MD QMC Chair, Palomar Medical Center P P P P Poway

BROWN, SHEILA, RN, FACHE Chief Operating Officer P P P P HANSEN, DIANE CPA Chief Executive Officer P P P P KHAWAJA, OMAR, MD Chief Medical Officer Ex P Ex KOLINS, JERRY, MD, FACHE Chief Quality Officer and Chair, Patient Safety P P P P Committee LABOSSIERE, LARRY, MBA, MSN, RN, CNS, CENCNO, PMC Poway P P Ex P MARTINEZ, VALERIE, RN, BSN, MHA, CIC, NEADirector,- Quality / Patient BC Safety P P P P RUSSELL, MEL Interim CNO, PMC Escondido P AUGUST, PRUDENCE VP, Information Technology P P Ex PATTERSON, PAUL Patient Family Advisory Council (PFAC) Chair P P P Ex LYON, JIM Patient Family Advisory Council (PFAC) P P P P Immediate Past Chair Meeting Dates: 1/15/18 2/19/18 3/19/18 4/16/18 5/21/18 6/18/18 7/16/18 8/20/18 9/17/18 10/15/18 11/19/18 12/17/18 Guests (continued) BARRAGAN, VIRGINIA P P P BURKE, MICHAEL, MD P CALLERY, CHARLES, MD P P P COHEN, BRIAN FARROW, DAN P P P FREIDBERG, BRUCE MD P 23Page 1 of 2 Addendum A

GOOD, DILAN P GUNNETT, MICHELLE P HADDEN, DESIREE P HANSEN, ALLAN MD P HELM, HALA P P HUSSAIN, YASMIN P P P JANUSZEWICZ, LOURDES P P JENNINGS, TAMRAH P P LEE, DAVID, MD P LEE, JEREMY P MARTIN, FRANK, MD MCCUNE, RAY (BOARD MEMBER) NAMENYI, JASMINA P PHILLIPS, DONITA, MBA, ARM P P P P PADUGA, REMIA MD P POPE, TINA P P P SCHULTZ, DIANA P SISON, HANS CHRISTIAN (BOARD MEMBER) STEVENS, TIM P

24Page 2 of 2 Addendum A

Board Quality Review Committee Meeting

EXECUTIVE SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2018

Meeting Dates: Palomar Health 2/19/18 By-Laws’ 1/15/18 Cancell 3/19/18 4/16/18 5/21/18 6/18/18 7/16/18 8/20/18 9/17/18 10/16/18 11/19/18 12/17/18 Annl Rpt Voting Members Membership ed DIRECTOR DOUGLAS MOIR - CHAIR Board Member P P P P DIRECTOR DARA CZERWONKA, MSW Board Member P P Ex P DIRECTOR JERRY KAUFMAN, PTMA Board Member ------DIRECTOR JEFF GRIFFITH, EMT-P -- (ALTERNATE) ------SABIHA PASHA, MD QMC Chair, Palomar Medical Center P P P P Escondido EDWARD GURROLA, MD QMC Chair, Palomar Medical Center P P P P Poway

BROWN, SHEILA, RN, FACHE Chief Operating Officer P P P P HANSEN, DIANE CPA Chief Executive Officer P P P P KHAWAJA, OMAR, MD Chief Medical Officer Ex P Ex KOLINS, JERRY, MD, FACHE Chief Quality Officer and Chair, Patient Safety P P P P Committee LABOSSIERE, LARRY, MBA, MSN, RN, CNS, CENCNO, PMC Poway P P Ex P MARTINEZ, VALERIE, RN, BSN, MHA, CIC, NEADirector,- Quality / Patient BC Safety P P P P RUSSELL, MEL, RN, MSN Interim CNO, PMC Escondido P AUGUST, PRUDENCE VP, Information Technology P P Ex PATTERSON, PAUL Patient Family Advisory Council (PFAC) Chair P P P Ex LYON, JIM Patient Family Advisory Council (PFAC) P P P P Immediate Past Chair

25Page 1 of 2 Addendum A

Meeting Dates: 1/15/18 2/19/18 3/19/18 4/16/18 5/21/18 6/18/18 7/16/18 8/20/18 9/17/18 10/15/18 11/19/18 12/17/18 Guests (continued) BARRAGAN, VIRGINIA CALLERY, CHARLES, MD P COHEN, BRIAN FARROW, DAN P P P FREIDBERG, BRUCE MD GUNNETT, MICHELLE HADDEN, DESIREE HANSEN, ALLAN MD HELM, HALA P P HUSSAIN, YASMIN JANUSZEWICZ, LOURDES P JENNINGS, TAMRAH P LEE, DAVID, MD P LEE, JEREMY MARTIN, FRANK, MD MCCUNE, RAY (BOARD MEMBER) PHILLIPS, DONITA, MBA, ARM P P P P PADUGA, REMIA MD P POPE, TINA P P P SISON, HANS CHRISTIAN (BOARD MEMBER) STEVENS, TIM

26Page 2 of 2

ADDENDUM B

27 Addendum B

Quality Management Committee ISBARR Executive Summary

Topic/Project: Discharge Planning

Submitted By: Cindy Laughton

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? (A812) 482.43(b)(6) Documentation of Evaluation Introduction (CMS 2567 pg. 63-64) [The hospital must] include the discharge planning evaluation in the patient’s medical record for use in establishing an appropriate discharge plan…

Situation This STANDARD was not met as evidenced by: Based on interview, record and document review, Hospital B failed to ensure an Initial Case Management Assessment was

documented in the medical record in accordance with the hospitals policy for 1 of 56 sampled patient’s. The lack of documented evidence did not ensure initiation of the patient’s discharge needs were assessed and communicated amongst healthcare professionals and providers at the time of the patient’s admission. Background This standard was not met based of failure to meeting the current hospital procedure. This procedure was last updated in 2014. The CRM department has been very robust attempting to assess every patient within 24 hours of admission regardless of consult or discharge planning needs from the CRM staff. Assessment Per procedure and best practice, Discharge planning begins on admission as actual or potential needs are identified with the initiation/completion of the Admission Assessment & History by the attending RN. The attending RN will make a referral if indicated to the CRM and the CRM will initiate the ongoing assessment. Currently, the CRM department is 97% compliant with this process with one fallout. Coaching was completed to the one employee. Department education was completed by 6/8/2018 for all staff regarding the change in policy. The department guidelines will still hope the staff accountable for ongoing assessments starting within 48 hours of admission. Recommendation Update procedure – completed 6/6/2018 Educate staff regarding new procedure – completed by 6/8/18 Audits – 5 charts per day for 3 months with expectation of 100% compliance.

Date Printed: June 11, 2018 1

28 Addendum B

PMC Escondido Plan Do - Measurement Numerator Indicator % compliance for assessment within 48 hours of referral (Successes) Denominator CRM - Assessment of patients within 48 hours of referral # of charts audited (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Cindy Laughton - Director of CRM Summary Num Den % Target 100% Month May 2018107 110 97% 100% Month June 34 35 97% 100% 80% Month July #N/A 100% 60% Month September #N/A 100% Month Oct #N/A 100% 40% #N/A 100% % Compliant #N/A 100% 20% #N/A 100% #N/A 100% 0% Month MayMonth 2018 JuneMonthMonth July SeptemberMonth Oct #N/A 100%

#N/A 100% % Target #N/A 100%

Analysis Actions Taken PMCE CRM department showed 100% during previous audits. It was identified Education and conversation was provided to all onsite case managers from our during the last survey, the onsite case managers from our partner payers were partnering payers. All patients are included in the audits, regardless to payer or case not included in the audit. During the survey, it appeared the fallouts were our manager. Procedure was updated to meet the required standard and current practice partnering onsite case managers. Their policy is 48 hours and PMC must be across the industry. 100% complicant regardless to payer. The procedure reviewed during the past survey had not been updated sind 2014.

ADDENDUM C

30 Addendum C

Infection Control Surveillance Data Summary

PMC ESCONDIDO PMC POWAY PMC Downtown ARU

April & May CY2018 Q1 April & May CY2018 Q1 April & May CY2018 Q1 SIR (Cases) SIR (Cases) SIR (Cases)

Catheter Associated Urinary Tract Infection (CAUTI) 1.023 (4)↑ 0.814 (5)↑ 0.000 (0)↓ 2.693 (3)↑ 0.000 (0)↓ NC (1)

Central Line Associated Blood Stream Infection 0.600 (1)↑ 1.139 (3)↑ 0.000 (0)↓ NC (1) 0.000 (0)↓ 0.000 (0)↓ (CLABSI)

Clostridium difficile Infection (CDI) NC (3)* 1.152 (11)↑ 0.000 (0)↓ 0.448 (1)↓ 0.000 (0)↓ 0.000 (0)↓

Methicillin Resistant Staphylococcus Aureus NC (1) 1.477 (2)↑ 0.000 (0)↓ NC (1) 0.000 (0)↓ 0.000 (0)↓ Associated‐Blood Stream Infection (MRSA‐BSI)

Surgical Site Infection (SSI) ‐ Colon 0.00 (0) 0.000 (0)↓ 0.000 (0)↓ 0.000 (0)↓ N/A N/A

Surgical Site Infection (SSI) ‐ Abdominal 0.000 (0) NC (1) 0.000 (0)↓ 0.000 (0)↓ N/A N/A Hysterectomy

Legend:

↓ = Favorable ↑ = Unfavorable NC = Not calculated by NHSN * cannot calculate CDI SIR until last month of each quarter when CDI test type is verified

ADDENDUM D

32 Addendum D

Passion. People. Purpose.TM

Pharmacy BQRC Report – June, 2018 Kathy Chang, District Director Pharmacy Services Jeremy Lee, Manager Pharmacy Services 6/13/18

1 1

33 Addendum D

Diversion Prevention

• Continue to develop additional reports to support the monthly review of “Outlier” staff • Expand the number of diversion prevention QAPI metrics and consolidate to one report

# of Outlier Revews Sent Out 45 40 39 35 30 29 25 20 19 17 15 15 10 5 0 Jan Feb Mar Apr May

*waste review added in April

34 Addendum D

Other Major Corrective Actions

• Inspect EVERY dose of medication in every area of the hospitals. • Robust staff education • Randomly inspecting staff members’ work (i.e. delivery round audits) • Revised Sterile Compounding QAPI Report • Met all reporting deadlines for June

ADDENDUM E

36 Addendum E

Columbia Suicide Severity Rating Scale (C‐SSRS) EMERGENCY DEPARTMENT | JAN2018

1 1

37 Addendum E

Learning Objectives

• By the end of this training module, the learner will be able to: – Discuss the importance of screening for suicide. – Explain when a suicide screen needs to be performed. – Demonstrate how to use the Columbia Suicide Severity Rating Scale.

38 Addendum E

Suicide Risk Screening • To be most effective, a suicide risk screen should be performed on all patients at every encounter to a healthcare facility. • Why should a suicide risk screen be completed at every point of entry? – Suicide is a major Public Health Crisis – Suicide is among the Top 10 Causes of Death • Screening is an opportunity to save lives – Patients who present to ED for other issues may also have suicidal behaviors that do not get identified

39 Addendum E

Why use the Columbia Severity Rating Scale (C‐SSRS) or Screener? • Anyone can complete this short screen. – NO mental health training or education is needed • Using the C‐SSRS can help you reduce liability. – It is the most evidence supported suicide risk screen available – It is recommended by The Joint Commission – There are clear guidelines for when to take next steps • The C‐SSRS has a 99% reliability which helps to prevent and decrease the rates of suicide.

40 Addendum E

Why use the C‐SSRS or Screener?

• Utilizes a standardized tool that supports the clinician to classify a person’s suicidal ideation and behavior, determine level of risk, and make clinical decisions about care. • Using the C‐SSRS and its uniform definitions can help ensure that the healthcare team are all speaking the same language, thus leading to better and more consistent patient care. • The C‐SSRS is a comprehensive measure that includes only the most critical suicidal characteristics. – Streamlining questioning helps save triaging nurses’ valuable time and reduces false positives.

41 Addendum E

What is the C‐SSRS Screener?

• Ask a minimum of 3 questions OR a maximum of 6 questions. • Assesses for suicidal ideation, ideation intensity, and suicidal behavior. • All patients will be asked Questions 1 & 2. • Your patient’s response to Question 2 will determine if you will need to complete Questions 3, 4 & 5. • All patients will be asked Question 6.

42 Addendum E

What is the C‐SSRS Screener?

• Questions 1 & 2 assess for suicidal ideations. – Watch C‐SSRS IDEATION Demonstration Video https://www.youtube.com/watch?v=2kpB3Tq2mgU

43 Addendum E

What is the C‐SSRS Screener?

• Questions 3, 4 & 5 assess for ideation intensity – Includes intent with OR without a plan – Watch C‐SSRS Screener Demonstration Video https://www.youtube.com/watch?v=XS2nB9DySAo&in dex=3&list=PL6aDiz41aYV32agsRLvOaKmVhiCMTF9Xa

44 Addendum E

What is the C‐SSRS Screener?

• Question 6 assesses for suicidal behavior. – Watch C‐SSRS Behavior Demonstration Video https://www.youtube.com/watch?v=2Fk0XuQwcMc

45 Addendum E

What is actually changing? • Stop asking a single “Yes” or “No” question for Behavioral Health Suicide Risk Screening in the ED.

• Stop using the old Full Suicide Assessment from CIHQ.

46 Addendum E

What is actually changing? • Start asking ALL patients the 3 initial suicide screening questions.

• Start using the C‐SSRS Screener for patients who respond YES to one of the initial 3 questions

47 Addendum E

Where can I find the C‐SSRS Screener?

• The C‐SSRS Screener has been added to the…… that you are currently using.

48 Addendum E

Initial Suicidal Screening

• ALL patients will be asked 3 initial screening questions at point of entry to Palomar Health (ED, OB, Surgery and Inpatient)

INSERT SCREEN SHOT

• Any YES response to one of the 3 initial questions will require the RN to complete the C‐SSRS Screener.

49 Addendum E

C‐SSRS Screener Questions

• Starts with asking questions for suicidal ideation. • ALL questions MUST be asked using the EXACT wording on the C‐SSRS tool (see Reference Text). • You MUST ask Q1, Q2 & Q6.

INSERT SCREEN SHOT

50 Addendum E

C‐SSRS Screener Questions

• If the answer to Q2 is NO, then Q6 will be available to ask about suicidal behavior.

• If the patient answers NO to Q1, Q2 & Q6, then the screening is NEGATIVE and you are finished with the screener. Continue with current Plan of Care

51 Addendum E

Asking questions about Examples of suicidal behavior is IMPORTANT behavior to consider… • • The patient took pills, Helps determine if a behavior collected pills, OR took out is an actual suicide attempt or pills, but didn’t swallow any not. • Tried to shoot themselves, • Suicide Attempt is defined as a obtained a gun, OR held a self‐injurious act committed gun, but changed their mind with at least some intent to or was interrupted die as a result of that act. • Tried to hang themselves • The act DOES NOT have to be • Cut themselves any injury or cause harm, just • Went to the roof, but didn’t jump the potential for it. • Wrote a Will or suicide note • Gave away valuables

52 Addendum E

C‐SSRS Questions

• If the patient answers YES Q1, NO to Q2 and NO to Q6, then he/she is a LOW risk for suicide attempt. • The RN will complete the Interdisciplinary Plan for Low Risk and initiate the appropriate interventions per unit procedure.

53 Addendum E

C‐SSRS Screener Questions

• If the answer to Q6 is YES, then you will need to determine the time frame of when the patient displayed suicidal behaviors.

54 Addendum E

C‐SSRS Screener Questions

• If the patient’s suicidal behaviors were more than 1 year ago, then he/she is at LOW risk for suicide.

• The RN will complete the Interdisciplinary Plan for Low Risk and initiate the appropriate interventions per unit procedure.

55 Addendum E

C‐SSRS Screener Questions

• If the patient’s suicidal behaviors were within the past 12 months, then he/she is at MODERATE to HIGH risk for suicide.

• The RN will complete the MODERATE to Interdisciplinary Plan for MODERATE to HIGH Risk and initiate the appropriate interventions per unit procedure.

56 Addendum E

C‐SSRS Screener Questions

• If the answer to Q2 is YES, then you will need to ask Q3, Q4, Q5 and Q6.

57 Addendum E

C‐SSRS Screener Questions • If the patient answers YES to Q3, Q4, or Q5 then he/she is at MODERATE to HIGH risk for suicide.

• The RN will complete the MODERATE to Interdisciplinary Plan for MODERATE to HIGH Risk and initiate the appropriate interventions per unit procedure.

58 Addendum E

Ongoing Reassessment may be needed

• If your patient is determined to be at risk of suicide based off the C‐SSRS screen, continued reassessment will need to be done. • Complete the C‐SSRS – Frequent Screener Q Shift & PRN to assess for changes and implement the appropriate interventions per unit procedure.

59 Addendum E

ALGORITHM: Suicide Assessment and Prevention ‐ Emergency Department

Screen for suicide risk with C‐SSRS – Screener Version ACTIONS based on YES responses (triage RN) (act on highest level of risk)

Ask Q1: Have you wished you were dead or wished you  Complete Interdisciplinary NO to YES to 1 could go to sleep and not wake up? Plan & Initiate Interventions both OR NO to Ask Q2: Have you actually had any thoughts of killing per Unit Procedure NO to 2 risk 2 & 6 LOW yourself?  Provide Crisis Hotline Info  Consider referral to BHS NO to 1 & YES to 2 OR YES to both  Consider patient education

YES to 3 Ask Q3: Have you been thinking about how you might & NO to  Notify ED physician kill yourself? 4, 5 & 6 risk  Complete Interdisciplinary MOD Plan & Initiate Interventions per Unit Procedure Ask Q4: Have you had these thoughts and had some  Order BH/Psych Consult

intention of acting on them? YES to 4 risk

HIGH  Order POA /1:1 sitter Ask Q5: Have you started to work out or worked out &/OR 5 the details of how to kill yourself? NO to 6 Do you intend to carry out this plan? risk

HIGH Within last year: Ask Q6: Have you ever done anything started to do  Implement MODERATE to anything, or prepared to do anything to YES to 6 HIGH risk ACTIONS listed above end your life? If yes, determine time frame risk MOD

If ≥ 1 year ago: NO to Q1, Q2 & Q6 is a NEGATIVE screen

risk  Implement LOW risk LOW Continue with Plan of Care ACTIONS listed above

60 Addendum E

Suicide Assessment Workflow ‐ Emergency Department

ANY “YES “ Response Non – BH Environments ALL “NO “ Responses (Triage) 3 Suicide Screening Questions

ED RN will Complete NEGATIVE Screen C‐SSRS – Screener Version No additional interventions 6 questions Continue Plan of Care

ED RN will Complete ED RN will Complete Interdisciplinary Plan & Ongoing C‐SSRS Screener Implement Interventions Q12 hours & PRN per Unit Procedure Update Plan & Interventions accordingly

 Provide Crisis Hotline Info

risk  Consider referral to BHS LOW  Consider patient education

 Notify ED physician BH/Psych Consult will risk MOD  Initiate RN Interventions Complete C‐SSRS Comprehensive Assessment  Order BH/Psych Consult &  Order POA/1:1 sitter Risk & Protective Factors risk HIGH

61 Addendum E

Yes to Q1 OR Q2

Consider BH Referral at Discharge Consider Patient Education at Discharge

62 Addendum E

ED Interdisciplinary Plans (RN Interventions)

MODERATE to

Consult BHL to any immediate needs or safety concerns

Notify ED physician

63 Addendum E

Quality Management Committee ISBAR Executive Summary

Topic/Project: BHU Plan of Correction: Patient Safety December 2017

Submitted By: Sharon Pudlo, Program Manager, Center for Behavioral Health Services

Situation On December 19, 2017 at 1645, a patient was found hanging and unresponsive by Behavioral Health Unit Mental Health Worker and Nurse. Staff immediately removed ligature device, activated Code Blue, 911 and began life saving measures. Rapid Response Team was onsite within minutes. Chain of Command was also activated with Psychiatric providers, VP and Director on site to assist is sentinel event process and implementation of safety measures for other patients. Background Staff is expected to round on patients not to exceed Q15 minutes and document rounding in real time. The Q15 minute check form in use at the time had preprinted times to record the checks. Q15 rounding staff was performing a number of other tasks while responsible for rounding. The form also did not have sufficient documentation prompts for location, behavior, etc. Transition of care documentation occurs any time a staff member hands off care to someone else (breaks, change of shift, etc.). Assessment Behavioral Health Leadership are visually observing staff members completing patient safety rounds 10 times/week and are auditing 10 charts per week for patient safety rounds and transition of care documentation. Non‐compliance is addressed through Just Culture and Progressive Discipline. Staff reported some challenges related to completing observations within 15 minutes at change of shift. Current chart audits include 10 records per week, with any safety rounds occurring outside of 15 minutes resulting in the total chart being counted as non‐compliant. Transition of care documentation has been at 100% since initiation of audit. Recommendation A multidisciplinary task force was formed to revise the Q15 check form removing preprinted times and adding additional prompts for documenting location, behavior, etc. (completed). Staff received education on revised rounding expectations to include staff responsible for rounds are not to be responsible for other tasks and rounds are to be continuous not to exceed Q15 minutes (completed). Supervisors responsible for observing staff complete one completed round on all patients, 10 rounds/week and review of rounds documentation to verify compliance. (ongoing).

Date Printed: June 14, 2018 1

64 Addendum E

Quality Management Committee ISBAR Executive Summary

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? Changes to rounding assignments made resulted in increased compliance with observation of rounds. Staff coaching and discipline ongoing. Recommend changing the chart audit for patient safety rounds to a denominator of the total number of 15 minute intervals and the numerator of the total number of rounds completed within the 15 minute time frame. This will result in more accurate compliance reporting.

Date Printed: June 14, 2018 2

65 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Number of Charts with 100% accuracy with Patient Safety Rounds Indicator (Successes) Documentation Denominator Patient Safety Rounds Documentation Number of Charts Audited (Total)

Start Date: 4/1/2018 Target: 100% Responsible Leader: [Insert Name] Summary Num Den % Target100% Week 1 4/1 6 10 60% 100% Week 2 4/8 9 10 90% 100%80% Week 3 4/15 10 10 100% 100% 60% Week 4 4/22 7 10 70% 100% Week 5 4/29 10 10 100% 100%40% Week 6 5/6 8 10 80% 100%% Compliant Week 7 5/13 9 10 90% 100%20% Week 8 5/20 10 10 100% 100% Week 9 5/27 9 10 90% 100%0% Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week Week Week Week 10 #N/A 100% 4/1 4/8 4/15 4/22 4/29 5/6 5/13 5/20 5/27 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken Behavioral Health staff had some challenges initially with the new process of Staff coaching/progressive discipline for instances of documentation outside of the 15 hand‐writing rounding times and ensuring rounds occurred within 15 minutes of minute time frame. Changes in staff assignments allowed for better management of last round for each patient. There were also challenges around ensuring no continuous patient rounds at change of shift time. Would like to change the audits greater than 15 minutes lapsed in rounding at change of shift. Initially there were moving forward to reflect a denominator of total number of patient safety rounds multiple fall‐outs per chart. Recent audits show one fifteen minute round out of audited, and the numerator to show the total number of rounds documented within compliance resulted in the entire medical record being shown as a fall‐out. 15 minutes of previous round. Follow‐up with individual staff to determine cause of fall‐outs and opportunities for process improvement.

66 Addendum E

Quality Management Committ ee ISBARR Executive Summary

Topic/Project: BHU Plan of Correction for Restraint Finding

Submitted By: Sharon Pudlo, Program Manager Behavioral Health Services

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? Introduction On April 12, 2018, as a result of a CDPH survey, it was determined that the Standard {A175) 482.13(e)(10) Patient Rights: Restraint or Seclusion was not met as the facility failed to ensure RN documentation of vital signs every 15 minutes while a patient was in restraints, as required per facility policy. As a result, there was potential for an unidentified change of condition for the patient.

Situation On March 23, 2018, nursing staff failed to document vital signs every 15 minutes on a patient in restraints, as required by Lucidoc 11445. The nurse caring for the patient stated she was unable to obtain vital signs due to the patient’s movements. The inability to obtain vital signs and notification of physician were not documented in the electronic medical record. Background Staff are expected to obtain vital signs upon initiation and every 15 minutes while patients are in restraints. If staff are unable to obtain vital signs (or patient refuses), the expectation is that the refusal or inability to obtain will be communicated to the provider and documented in the electronic medical record. Assessment Behavioral Health Leadership reviewed restraint documentation and found there were multiple occurrences where the inability to obtain vital signs was not documented or communicated to the provider. It was determined there was a lack of understanding of Lucidoc 11445. Recommendation Behavioral Health staff educated regarding documentation requirements when patients are in seclusion or restrained. Behavioral Health Leadership will continue to

audit 100% of patients who are in restraints for accurate restraint documentation including vital signs, and notify provider if patient refuses vital signs.

Date Printed: June 14, 2018 1

67 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Total Number of Restraint Events on BHU with V/S Documentation (Successes) Denominator BHU Restraint V/S Documentation Total Number of Restraint Events on BHU (Total)

Start Date: 3/24/2018 Target: 100% Responsible Leader: Sharon Pudlo Summary Num Den % Target 100% March 1 2 50% 100% April 2 4 50% 100% 80% May 3 3 100% 100% 60% June #N/A 100% July #N/A 100% 40% August #N/A 100% % Compliant September #N/A 100% 20% October #N/A 100% November #N/A 100% 0% December #N/A 100% January #N/A 100% % Target February #N/A 100%

Analysis Actions Taken While monitoring, it was noted that staff did not initially equate physical holds In addressing the issue from a Just Culture standpoint, coaching was provided to staff, with restraints, and therefore were not consistently documenting vital signs discussions occurred with staff in roundings and huddles regarding documentation according to the Restraint Lucidoc. The occurrences of non‐compliance with vital requirements for physical holds, and an updated restraint checklist and job aid were sign documentation in March and April were related to patients who were in provided in a restraint binder that is kept in the nurses' station. The Behavioral Health physical holds lasting one to four minutes. After coaching, education, checklist Administrator on Call is notified any time there is a seclusion or restraint, including and job aide were provided, there was 100% compliance with vital sign physical hold. The Charge RN audits the seclusion/restraint documentation for documentation in May with physical holds lasting one to three minutes. There completeness before the end of each shift, and the Nurse Manager audits the have been no episodes of seclusion, restraint, or physical holds in June. documentation as well.

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Quality Management Committ ee ISBARR Executive Summary

Topic/Project: Discharge Planning

Submitted By: Cindy Laughton

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? (A812) 482.43(b)(6) Documentation of Evaluation Introduction (CMS 2567 pg. 63‐64) [The hospital must] include the discharge planning evaluation in the patient’s medical record for use in establishing an appropriate discharge plan…

Situation This STANDARD was not met as evidenced by: Based on interview, record and document review, Hospital B failed to ensure an Initial Case Management Assessment was

Date Printed: June 14, 2018 1

69 Addendum E

PMC Escondido Plan Do ‐ Measurement Numerator Indicator % compliance for assessment within 48 hours of referral (Successes) Denominator CRM ‐ Assessment of patients within 48 hours of referral # of charts audited (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Cindy Laughton ‐ Director of CRM Summary Num Den % Target 100% Month May 107 110 97% 100% Month June 34 35 97% 100% 80% Month July #N/A 100% 60% Month Septe #N/A100% Month Oct #N/A 100% 40% #N/A 100% % Compliant #N/A 100% 20% #N/A 100% #N/A 100% 0% Month May 2018Month JuneMonth JulyMonth SeptemberMonth Oct #N/A 100% #N/A 100% % Target #N/A 100%

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Quality Management Committ ee ISBARR Executive Summary

Topic/Project: Restraint Use Mortality Reporting to CMS

Submitted By: Bunny Krall

Situation Updated Death Reporting Requirements to CMS Background Hospitals must report the following deaths associated with restraint and seclusion directly to their CMS regional office no later than the close of business on the next business day following knowledge of the patient's death:

 Each death that occurs while a patient is in restraint or seclusion, excluding those in which only 2‐point soft wrist restraints were used and the patient was not in seclusion at the time of death;

 Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion, excluding those in which only 2‐point soft wrist restraints were used and the patient was not in seclusion within 24 hours of their death; and

 Each death known to the hospital that occurs within one week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death, regardless of the type(s) of restraint used on the patient during this time.

Hospitals must record in an internal hospital log or other system those deaths that occur in the circumstances listed below. Hospitals are not required to send reports of these deaths directly to the regional office:

 Each death that occurs while a patient is in restraint but not seclusion and the only restraints used on the patient were applied exclusively to the patient's wrist(s) and were composed solely of soft, non‐rigid, cloth‐like materials; and

 Each death that occurs within 24 hours after the patient has been removed from restraint, when no seclusion has been used and the only restraints used on the patient

Date Printed: June 11, 2018 1

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Quality Management Committ ee ISBARR Executive Summary

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? were applied exclusively to the patient's wrist(s) and were composed solely of soft, non‐rigid, cloth‐like materials.

Daily Mortality with Restraint Order Report initiated 4/16/2018. Initially reviewed by Quality Department. In process of educating nursing leadership and will transition to unit leadership for initial case review with ISBAR back to quality department. Quality Department will validate data, keep log and place note in patient’s chart. Assessment Any death where patient in restraints or seclusion or any type of restraint past 7 days must be escalated up chain of command so case reviewed and determination is made as to whether to report to CMS or not. Daily report and log initiated April 16th. .

100% Compliance or No Cases required reporting to CMS

Recommendation Providers please be aware of CMS Death Reporting Requirements. Communicate to Nursing Staff if you feel restraint or seclusion contributed directly or indirectly to the patient’s death so event can be escalated up chain of command.

Date Printed: June 11, 2018 2

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Quality Management Committee ISBARR Executive Summary

Topic/Project: Cath Lab/IR Time Out Audits – In response to CMS Finding & POC

Submitted By: Peter Petropoulos

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committeee? Introduction During the April 2018 CMS survey while reviewing a medical record an Informed Consent from IR/Cath Lab was discovered to have the patient’s name incorrectly entered where the physician’s name wass required to be entered. The error was not picked up and corrected during the Time Out process in the procedural suite. Situation Properly executed informed consent forms for procedures and treatments specified en patient by the medical staff, or by Federal or State law if applicable, to require writt consent.

This standard is not met as evidenced by: Based on interview and record/document review the hospital failed to implement written policies and procedures for 1/56 sampled patients. Did not ensure Informed Consent had correct name of MD Finding #3: (A466) Content of record: Informed Consent 482.24(c) (4) (v) There has been extensive education and auditing of the Informed Consent procedure in the IR/Cath Procedural department dating back too July 2017. The Plan of Correction submitted for this finding includes education and to continue Time Out procedure audits (more detail below). Background Time Out audits were initially started July 2017. Between 7/17 – 5/18 165 Time Out audits have been completed in the Cath Lab and 293 in the Interventional Radiology department. Compliance with all elements is between 93%‐98.5%. Education, coaching and discipline have been provided in response to past findings and incidents within the department/organization.

Date Printed: June 8, 2018 1

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Quality Management Committee ISBARR Executive Summary

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? Assessment Ongoing Time Out audits by department leadership is an opportunity to focus on the CMS finding by allowing the auditor to see and hear the procedural team during the Time Out procedure. In addition to ensuring all required elements of the Time Out procedure are met the auditor is specifically listening for and validating that the informed consent is completed correctly and that during the Time Out it is verbalized correctly to ensure the patient’s and physician’s names are correct on the Informed Consent document. YTD audits have had a high rate of compliance. The finding in April was not related to any other education or past findings. However, the overarching issue has continued to be a complacency to ensuring 100% accuracy to all elements of the time out process including the informed consent document. Education, monitoring and accountability are all being utilized to ensure lasting results and 100% compliance with the Time Out procedure. Recommendation Corrective Action – Cath Lab/Interventional Radiology Department: 1. Staff education occurred via staff meeting on 4/24/18, followed by email sent to staff on 4/26/18 addressing completeness and accuracy of consents. Informed consent

policy read and sign started 5/4/18. Read and sign target completion date 6/15/18. Daily huddles and staff rounding addressing completeness and accuracy of consent for surgery and procedures started 4/25/18. Monitoring: 1. Cath Lab/Interventional Radiology leadership will complete 30 audits for compliance of the time out process. Initial report to QMC: 2017 2. Audit compliance and data analysis will be reported monthly to the Quality Management Committee (QMC) and Board Quality Review Committee. The QMC will review the data analysis, provide feedback and will determine the need and/or frequency of additional audits. Start: 6/2018 Ongoing until goal achieved

Date Printed: June 8, 2018 2

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Quality Management Committ ee ISBARR Executive Summary

Topic/Project: Surgical Attire Adherence Escondido

Submitted By: Marcia Cavanaugh

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? Introduction Infection control is tracking surgical attire adherence in the operating rooms and procedure rooms as one of CMS quality compliance measures. Situation Surgical attire adherence is trending up but still not meeting the target of 100%.

Background Surgical attire adherence was identified by the CMS surveyors during the past several surveys as not being 100% compliant. Items not in compliance have included nape of

neck and sideburns not covered, facial hair visible, visible undergarments, cloth caps not completely covered. Assessment Variation is adherence is apparent with increasing compliance in the last two months of observation. Overall compliance is 94% for the observation period.

Recommendation Visual aids were posted for staff and physicians at entrances to the operating room and procedure area dressing rooms. New beard covers and larger caps provided to staff and physicians. Chief of Staff and Director of Surgery holding staff and physicians accountable for non‐compliance initiated 5/22/18 and ongoing.

Date Printed: June 8, 2018 1

75 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Number of surgical attire compliant observations assessing 9 Indicator (Successes) elements Denominator Surgical Attire Adherence, 9 Elements Assessed Number of total surgical attire observations assessing 9 elements (Total)

Start Date: 8/19/2017 Target: 100% Responsible Leader: Marcia Cavanaugh, Valerie Martinez Summary Num Den % Target 100% M1 21 26 81% 100% M2 1062 1130 94% 100% 80% M3 2725 2784 98% 100% 60% M4 121 161 75% 100% M5 53 57 93% 100% 40% M6 12 12 100% 100% % Compliant M7 118 133 89% 100% 20% M8 42 66 64% 100% M9 139 159 87% 100% 0% M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M10 226 252 90% 100% M11 #N/A 100% % Target M12 #N/A 100%

Analysis Actions Taken Monthly, starting August 2017 surgical attire has been tracked by month. 1. Distributed one page surgical attire instruction sheet to ancillary departments that Variation in adherence is apparent with increasing compliance in the last two enter restricted areas for review with staff in huddles. Completed 4/27/18 months of observations. Overall compliance is 94% for the observation period 2. Memo send to Medical Staff on the expectation of compliance with surgical attire (N=4780). Trends include; 1. nape of neck and sideburns not covered, 2. facial procedure. April 30, 2018 hair visible, 3.visible undergarments, 4. cloth caps not completely covered. New 3. Updated Surgical Attire procedure #11600 to meet nationally recognized infection larger caps and beard covers have been provided. control standards. Completed May 21, 2018 4. Posted visual aids for appropriate surgical attire. Completed May 22, 2018 5. Provided education to staff and Physicians on the updated procedure. Completed May 22, 2018 6. Accountability for non‐compliance by Chief of staff and Surgical Services Director when necessary. Initiated 5/22/18 ongoing. 7. Alternative caps and beard covers provided to ensure all hair is covered. Completed May 25, 2018

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Quality Management Committ ee ISBARR Executive Summary

Topic/Project: Inspection of Instrument Tray Ready for Use

Submitted By: Marcia Cavanaugh June 8, 2018

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? Introduction Sterile Processing Department, SPD, is tracking sterility compliance with surgical instrument trays, specifically with removing tape from instruments. Situation SPD is tracking sterility compliance with surgical instrument trays. Audits are performed weekly on trays available, those not currently in use, for sterility elements condition and presence of any tape on the instruments.

Background During the April 2018 CMS survey an instrument tray was opened and examined by a surveyor. The surveyor found instruments with old tape, etchings on a few

instruments. There were also found a couple of difficult to open instrument hinges.

Assessment The instrument trays assessed have found to have high compliance, trending is 96‐ 99% compliance.

Recommendation Staff is removing tape from instrument trays opened for assessment. New instruments are being purchased as needed when identified during processing. Outside maintenance vendor is also removing tape from trays as they are being maintained.

Date Printed: June 8, 2018 1

77 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Number of instrument compliant observations assessing 12 Indicator (Successes) elements Denominator Instrument Tray Compliance Audit, 12 Elements Assessed Number of total instrument observations assessing 12 elements (Total)

Start Date: 9/17/2017 Target: 100% Responsible Leader: Marcia Cavanaugh, Valerie Martinez Summary Num Den % Target 100% Week 1 423 440 96% 100% Week 2 289 298 97% 100% 80% Week 3 449 452 99% 100% 60% Week 4 #N/A 100% Week 5 #N/A 100% 40% Week 6 #N/A 100% % Compliant Week 7 #N/A 100% 20% Week 8 #N/A 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken Audits are performed weekly with SPD staff doing daily assessments of 1. Provided SPD Staff education including removing taped instruments from service. instruments and removing instruments with tape. 4/12/18 2. Purchasing new instrumentation as needed when identified during processing. Started 4/12/18 and ongoing. 3. Sterile Processing and Department staff removing and segregate taped instrumentation for removal. 4/12/18 and ongoing. 4. Prescribed vendor is removing tape from instrumentation two times monthly. Started 4/12/18 and ongoing.

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PMC Escondido Plan Do ‐ Measurement Numerator Number of point‐of‐use decontamination measures compliant, Indicator (Successes) assessing 3 elements Denominator Number of total point‐of‐use decontamination measures, Point‐Of‐Use Decontamination Compliance, 3 Elements Assessed (Total) assessing 3 elements

Start Date: 5/21/2018 Target: 100% Responsible Leader: Marcia Cavanaugh, Valerie Martinez Summary Num Den % Target 100% Week 1 3 3 100% 100% Week 2 6 6 100% 100% 80% Week 3 63 78 81% 100% 60% Week 4 58 60 97% 100% Week 5 124 144 86% 100% 40% Week 6 #N/A 100% % Compliant Week 7 #N/A 100% 20% Week 8 #N/A 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100% Week 19, 2018 Week 20, 2018 Week 21, 2018 Week 25, 2018 Total Question Yes No Compliance Yes No Compliance Yes No Compliance Yes No Compliance Yes No Compliance Gross contamination removed/instruments saturated w ith enzymatic pre-cleaner. 1 1 50.00% 20 6 76.92% 19 1 95.00% 1 0 100.00% 41 8 83.67% Instrument hinges are open. 1 1 50.00% 19 7 73.08% 19 1 95.00% 1 0 100.00% 40 9 81.63% No fluids. 1 1 50.00% 24 2 92.31% 20 0 100.00% 1 0 100.00% 46 3 93.88% Total 3 3 50.00% 63 15 80.77% 58 2 96.67% 3 0 100.00% 127 20 86.39% Analysis Actions Taken During week one staff were informed about this issues and were instructed on 1. Communicated findings through small group meetings with Surgical Services and process. At that time compliance was high (100%). During week three staff had Sterile Processing Staff. some questions about what gross contamination was and audit revealed decline Initiated 5/8/18 Completed 5/22/18 in compliance (81%). Additional attestation, questions in iXpand to measure 2. Updated procedure for Point of Use Decontamination. understanding and competency was initiated with compliance up again to 100% Initiated 5/9/18 in approval process in week 4. Ongoing audits and staff competency. 3. Reinforcement of “Stop the Line” training for SPD staff. Initiated 5/10/18 Completed 5/10/18 4. Inservice provided with attestation for Point of Use Decontamination during Surgical Services Staff meeting. Initiated 5/15/18 Completed 5/15/18 5. Ongoing read and sign education with signed attestation required. Initiated 5/16/18 Completed 6/5/18 6. Infection Control observations of case carts in SPD. Initiated 5/16/18 Completed

79 Addendum E

Plan Do ‐ Measurement Numerator Indicator Employee Influenza Documentation on File (Successes) Denominator Total Number of Employees (Total)

Start Date: 4/18/2018 Target: 100% Responsible Leader: Russell Riehl, Employee Health & Safety Summary Num Den % Target 100% 4.18.18 4092 4555 90% 100% #N/A 100% 80% 4.24.18 4167 4524 92% 100% 60% #N/A 100% 4.25.18 4154 4512 92% 100% 40% #N/A 100% % Compliant 4.27.18 4349 4568 95% 100% 20% #N/A 100% 5.01.18 4629 4750 97% 100% 0% 4.18.18 4.24.18 4.25.18 4.27.18 5.01.18 #N/A 100% #N/A 100% % Target #N/A 100%

Analysis Actions Taken Baseline Analysis on 4.18.2018 indicated 90% compliance with employee • Employee flu vaccine information was obtained and placed in employee file. vaccination or declination documentation on file in Employee Health. • Auditing 100% of employee medical records for influenza vaccination April 24, 2018. Action Steps from 4.18.2018 to 5.01.2018 increase compliance to 97%. • Initiated weekly vaccination reports April 24, 2018. Automated tracking utilizing HR data system is required to ensure 100% comliance for 2018‐2019 influenza season. • Identifying employees who have not participated in the program using weekly vaccination reports.

• Contacting employees identified as non‐participants, and collecting vaccination or declination documentation.

• Notifying Leadership to have employees to follow up with EHS.

• Creating an influenza vaccination tracking system in Human Resources Personnel data system for use during 2018‐2019 influenza season.

Trends Healthcare personnel influenza vaccination rates continue to increase, but at a slow rate. We increased 400 healthcare personnel comparred to the previous influenza season

Organizationally, we continued to struggle with getting 100 percent of healthcare personnel to have either documentation of vaccination or declination.

Action plans for 2018‐2019 influenza season should mitigate this annual trend.

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PMC Escondido Plan Do ‐ Measurement Numerator Indicator Number of compliant meningitis isolation cases (Successes) The facility failed to ensure prompt placement of isolation for 1/56 sampled Denominator Number of patients with headache, or meningitis as reason for visit patients (51) with suspected Meningitis. (Total)

Start Date: 9/17/2017 Target: 100% Responsible Leader: Michelle Gunnett Summary Num Den % Target 100% Week 1 5 5 100% 100% Week 2 4 4 100% 100% 80% Week 3 1 1 100% 100% 60% Week 4 #N/A 100% Week 5 #N/A 100% 40% Week 6 #N/A 100% % Compliant Week 7 #N/A 100% 20% Week 8 #N/A 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken 1. Provided Infectious Disease education weekly for huddles based on current emerging infectious diseases starting with Meningitis. Initiated 4/25/18 and ongoing. 2. Provided teaching tool on meningitis for staff to review and address in huddles 5/4/18 3. Auditing patients with need for isolation precautions for timely isolation Initiated 5/1/18 and ongoing. 4. Emergency Department Medical Staff approval of auto order isolation triggers at 5/17/18 meeting. 5. Utilizing Cerner to trigger orders for isolation based on diagnostic studies. IT request submitted May 7, 2018, testing for Droplet precautions auto order on June 6, 2018. 6. Infection Preventionist and ED Director attended ED medical staff meeting to teach on isolation for infectious diseases requiring isolation. 7. Conduct quarterly mock patient drill for emerging infections presenting to triage. Evaluate staff response and appropriate isolation.

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Quality Management Committ ee ISBARR Executive Summary

Topic/Project: Nursing Audit Compliance Data

Submitted By: Mel Russell, RN, Interim Chief Nursing Officer, Escondido

Situation  I specifically called a meeting this past week, working with a collaborative team to better understand where we were from a nursing perspective regarding audits.  This was also used to set expectations as we move forward.  All audits at PMC Escondido will continue as outlined below. These audits will continue to be reported out at the monthly QMC meeting.  This is essential to hardwiring practice and to assure our success with a culture shift.

 Background Timely shift assessment audit o 30 Audits a month inpatients o Responsibility: Vicki Veronese / Mel Russell o Jimmy and Isabel currently looking at automating report  Pain reassessment o This is a previously established audit o 30 Audits a month inpatients o Responsibility: unit leadership, reported out at QMC by Pharmacy, Jeremy Lee / Mel Russell  Cath lab time out o 30 Audits a month IR and Cath Lab o This is a previously established audit o Has been tracked in‐house and on the Platform with acceptable compliance o Will ask at QMC to stop in all areas other than IR & Cath o Responsibility: Peter Petropoulos / Mel Russell  Timeliness with tube feeding initiation o 30 Audits a month inpatients o Jimmy and Isabel to build in Midas o Responsibility: Vicki Veronese / Mel Russell  Order for post op drains – Specifically for 5E – post open heart patients o 30 Audits or 100% of patients a month 5E currently o Jimmy Ortiz and Isabel Cheong to build in Midas o This will be rolled out hospital wide after the build is complete and we have more clarity on drains and tube orders

Date Printed: June 12, 2018 1

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Quality Management Committ ee ISBARR Executive Summary

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? o Responsibility Vicki Veronese / Mel Russell  Med pass Audit o 30 Audits a month inpatients o Med pass audit has been updated to capture specific POC line item o Responsibility: Diana Agnello / Mel Russell  Handoff Report Audit o This has been compliant and will ask to remove from Audit  High Risk IV Infusion Meds Audit o Compliant and will ask to remove  IV Fluids Hung with Label Audit o Will ask to decrease to once a quarter and stop o Responsibility: unit leadership / Mel Russell  Pressure Injury Staging Audit o Units 100% x 2 months o Asking to decrease to prevalent study  Specimen Audit o Asking to remove  Surgery Procedure Chart Audit  Surgical Services Counting Audit  Surgical Services Debrief o Asking to stop these three audits and use the Surgical Comprehensive Compliance Audit

Assessment This audit process and compliance is essential to hardwiring practice and to assure our success with a culture shift. Audit Results: • Timely shift assessment audit o Compliance rate for the month of May is 96.7% • Pain reassessment o Compliance rate for month of May is 94% for PRN and 66% for one time dose • Cath lab time out o Compliance rate for month of May 97%

Date Printed: June 12, 2018 2

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Quality Management Committ ee ISBARR Executive Summary

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? • Timeliness with tube feeding initiation o Compliance rate for the month of May is 100% • Order for post op drains – Specifically for 5E – post open heart patients o Compliance rate for month of May is 100% • Med pass Audit o Compliance rate for month of May is 73% • Handoff Report Audit – Graphing not currently available o This has been compliant and will ask to remove from Audit

• High Risk IV Infusion Meds Audit o Compliant and will ask to remove

• IV Fluids Hung with Label Audit o Will ask to decrease to once a quarter and stop o Responsibility: unit leadership / Mel Russell • Pressure Injury Staging Audit o Units 100% x 2 months o Asking to decrease to prevalent study

• Specimen Audit o Asking to remove

• Surgery Procedure Chart Audit • Surgical Services Counting Audit • Surgical Services Debrief o Asking to stop these three audits and use the Surgical Comprehensive Compliance Audit Recommendation Continue the current audit process while looking at some of the audits that can be discontinued secondary to compliance.

Date Printed: June 12, 2018 3

84 Addendum E Plan Do ‐ Measurement Numerator Number of assessments done within acceptable timeframe Indicator (Successes)

Pain assessment/reassessment done within acceptable timeframe (PRN Denominator Total number of assessments performed only) (Total)

Start Date: 4/8/2018 Target: 100% Responsible Leader: Mel Russell

Summary 100%

Month 80% Num Den % % Target 60% Week 1 40% 4/8 3285 3471 95% 100% Week 2 % Compliant 20% 4/15 3585 3749 96% 100% 95% 0% Week 3 Week 1 4/8 Week 2 Week 3 Week 4 Week 5 5/6 Week 6 Week 7 Week 8 4/22 3433 3623 95% 100% 4/15 4/22 4/29 5/13 5/20 5/27 Week 4 % Target 4/29 3539 3728 95% 100% Week 5 5/6 3122 3311 94% 100% Week 6 5/13 3560 3801 94% 100% 94% Week 7 5/20 3161 3372 94% 100% Week 8 5/27 3233 3416 95% 100%

Plan Do ‐ Measurement Numerator Number of assessments done within acceptable timeframe Indicator (Successes)

Pain assessment/reassessment done within acceptable timeframe (One‐ Denominator Total number of assessments performed Time only) (Total)

Start Date: 4/8/2018 Target: 100% Responsible Leader: Mel Russell

Summary 100%100%

Month 80%80% Num Den % % Target 60%60% Week 1 40% 4/8 304 607 50% 100% 40% % Compliant 20% Week 2 % Compliant 20% 4/15 331 659 50% 100% 0% 51% 0% Week 3 Week 1 4/8 Week 2 Week 3 Week 4 Week 5 5/6 Week 6 Week 7 Week 8 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 4/22 360 726 50% 100% 4/15 4/22 4/29 5/13 5/20 5/27 4/8 4/15 4/22 4/29 5/6 5/13 5/20 5/27 Week 4 % Target 4/29 355 644 55% 100% % Target Week 5 5/6 413 637 65% 100% Week 6 5/13 474 715 66% 100% 66% Week 7 5/20 407 630 65% 100% Week 8 5/27 462 659 70% 100%

85 Addendum E

Plan Do ‐ Measurement Numerator Total number of audits with time out performed correctly Indicator (Successes)

Denominator Time Out Compliance Total number of audits performed (Total)

Start Date: 4/8/2018 Target: 100% Responsible Leader: Mel Russell

Summary 100%

Month 80% Num Den % % Target 60% Week 1 40% 4/8 32 32 100% 100% Week 2 % Compliant 20% 4/15 21 22 95% 100% 0% 98% Week 3 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 4/22 25 25 100% 100% 4/8 4/15 4/22 4/29 5/6 5/13 5/20 5/27 Week 4 % Target 4/29 52 53 98% 100% Week 5 5/6 41 41 100% 100% Week 6 5/13 21 22 95% 100% 98% Week 7 5/20 35 35 100% 100% Week 8 5/27 25 26 96% 100%

86 Addendum E

Plan Do ‐ Measurement Numerator Number of cases full process followed Indicator (Successes)

Denominator Medication Pass Audit Compliance Total number of audits performed (Total)

Start Date: 4/8/2018 Target: 100% Responsible Leader:

Summary 100%

Month 80% Num Den % % Target 60% Week 1 4/8 96 124 77% 100% 40%

Week 2 4/15 91 125 73% 100% % Compliant 20% 76% Week 3 4/22 100 121 83% 100% 0% Week 4 4/29 79 110 72% 100% Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 4/8 4/15 4/22 4/29 5/6 5/13 5/20 5/27 Week 5 5/6 45 69 65% 100% Week 6 5/13 69 96 72% 100% % Target 73% Week 7 5/20 72 85 85% 100% Week 8 5/27 80 112 71% 100%

87 Addendum E

PMC Escondido Plan Do ‐ Measurement Numerator Number of nursing shift assessments completed within 6 hrs of Indicator (Successes) start of shift Denominator CVS Patient with Physician Order for Post Op Drains Total number of nursing shift assessments (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: V.Veronese Summary Num Den % Target 100% Week 1 5 5 100% 100% Week 2 3 3 100% 100% 80% Week 3 1 2 50% 100% 60% Week 4 5 5 100% 100% Week 5 16 16 100% 100% 40% Week 6 #N/A 100% % Compliant Week 7 #N/A 100% 20% Week 8 #N/A 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken Overall compliance is 96.7 %. One missed documentation due to pt having Rapid 1. Education to Stat Pool RNs on Shift Assessment expectations and Adult Inpatient Response and Code Blue Standards.

88 Addendum E

PMC Escondido Plan Do ‐ Measurement Numerator Number of patients who had appropriate documentation of gastric tube Indicator (Successes) insertion

Denominator Appropriate documentation of gastric tube insertions Total number of patients who had gastric tubes inserted (Total)

Start Date: 5/1/2018Target: 100% Responsible Leader: Victoria Veronese Summary 100% Num Den % Month % Target 80% Week 1 8 10 80% 100% Week 2 9 9 100% 100% 60% 91% Week 3 6 7 86% 100% 40%

Week 4 10 10 100% 100%% Compliant 20% Week 5 #N/A 100% 0% Week 6 #N/A 100% Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 7 #N/A 100% % Target Week 8 #N/A 100% Unit Specific Data 4E 4NW 4SW 5E 5W Num Den % Num Den % Num Den % Num Den % Num Den % Week 1 0 2 0% 1 1 100% 3 3 100% 1 1 100% 1 1 100% Week 2 1 1 100% 1 1 100% 3 3 100% 1 1 100% 2 2 100% Week 3 0 1 0% 1 1 100% 4 4 100% Week 4 2 2 100% 1 1 100% 3 3 100% 3 3 100% Week 5 Week 6 Week 7 Week 8

6E 6W 7E 7W 8E (Med Surg) Week 1 1 1 100% Week 2 1 1 100% Week 3 1 1 100% Week 4 1 1 100% Week 5 Week 6 Week 7 Week 8

9E Short Stay 8E (Mother Baby) 8W (L&D) Other Week 1 1 1 100% Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Analysis Actions Taken During the month of May 2018 91% of patients who had gastric tubes Continue to reinforce with staff documentation requirements for gastric tube insertion. inserted had documentation completed per Palomar Health guidelines. Continue audits weekly to ensure sustainability.

89 Addendum E

PMC Escondido Plan Do ‐ Measurement

Indicator Numerator Number of Wound Packing Removal Events Not Receiving Alert

Denominator Wound Packing Alerts Number of Wound Packing Removal Events

Start Date: 4/5/2018 Target: 100% Responsible Leader: [Insert Name] Summary Month 100% Num Den % % Target

4/5 ‐ 4/7 4 4 100% 100% 80% 4/8 ‐ 4/14 29 33 88% 100% 4/15 ‐ 4/21 23 32 72% 86% 100% 60% 4/22 ‐ 4/28 38 41 93% 100% 4/29 ‐ 5/5 10 11 91% 100% 40% 5/6 ‐ 5/12 21 21 100% 100% % Compliant 5/13 ‐ 5/19 17 19 89% 100% 94% 20% 5/20 ‐ 5/26 35 38 92% 100% 5/27 ‐ 6/2 26 27 96% 100% 0% 6/3 ‐ 6/9 #N/A 100% 6/10 ‐ 6/16 #N/A 100% 6/17 ‐ 6/23 #N/A 6/24 ‐ 6/30 #N/A 100%

Analysis Actions Taken

90 Addendum E

PMC Poway Plan Do ‐ Measurement

Indicator Numerator Number of Wound Packing Removal Events Not Receiving Alert

Denominator Wound Packing Alerts Number of Wound Packing Removal Events

Start Date: 4/5/2018 Target: 100% Responsible Leader: [Insert Name] Summary Month 100% Num Den % % Target

4/5 ‐ 4/7 0 0 #N/A 100% 80% 4/8 ‐ 4/14 0 0 #N/A 100% 4/15 ‐ 4/21 2 2 100% 71% 100% 60% 4/22 ‐ 4/28 1 2 50% 100% 4/29 ‐ 5/5 2 3 67% 100% 40% 5/6 ‐ 5/12 0 0 #N/A 100% % Compliant 5/13 ‐ 5/19 1 1 100% 100% 100% 20% 5/20 ‐ 5/26 0 0 #N/A 100% 5/27 ‐ 6/2 5 5 100% 100% 0% 6/3 ‐ 6/9 #N/A 100% 6/10 ‐ 6/16 #N/A 100% 6/17 ‐ 6/23 #N/A 6/24 ‐ 6/30 #N/A 100%

Analysis Actions Taken

91 Addendum E

PMC Escondido Plan Do ‐ Measurement Numerator Number of CVS Patients with Physician order for Post Op Surgical Indicator (Successes) Drains Denominator CVS Patient with Physician Order for Post Op Drains Total number of CVS Patient with Surgical Post Op Drains (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: V.Veronese Summary Num Den % Target 100% Week 1 6 6 100% 100% Week 2 3 3 100% 100% 80% Week 3 6 6 100% 100% 60% Week 4 2 2 100% 100% Week 5 3 3 100% 100% 40% Week 6 #N/A 100% % Compliant Week 7 #N/A 100% 20% Week 8 #N/A 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken Overall Compliance is 100%. 1. Education completed with 5E staff on expectation to have Physician order for any post op surgical drains. 2. Unit leadership reviews patients in realtime for appropriate orders.

92 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Number of patients who had appropriate documentation(all 4 Indicator (Successes) elements) of feeding tube insertion

Denominator Appropriate documentation of feeding tube insertions (4 elements) Total number of patients who had feeding tubes inserted (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Victoria Veronese Summary 100% Num Den % Month % Target 80% Week 1 8 10 80% 100% Week 2 9 9 100% 100% 60% 91% Week 3 6 7 86% 100% 40%

6E 6W 7E 7W 8E (Med Surg) Week 1 1 1 100% Week 2 1 1 100% Week 3 1 1 100% Week 4 1 1 100% Week 5 Week 6 Week 7 Week 8

9E Short Stay 8E (Mother Baby) 8W (L&D) Other Week 1 1 1 100% Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Analysis Actions Taken During the month of May 2018 91% of patients who had feeding tubes Continue to reinforce with staff documentation requirements for feeding tube insertion. inserted (small bore and large bore feeding tubes) had documentation Continue audits weekly to ensure sustainability. completed per Palomar Health guidelines. This was a sampling for the month Still have salem sump (large bore feeding tube) that do not have the cm marking, working n=36 with supply to have them removed and replaced with the new product that has the cm The 4 elements of required documentation are: markings. 1. activity Moving forward, revised automated report will include not just insertion documention but 2. cm marking ongoing tube maintenence documentation of the four required elements for both small bore 3. verification and large bore feeding tubes and will be reviewed weekly by unit leadership for follow up for 4. outcome any outliers.

93 Addendum E

PMC Escondido Plan Do ‐ Measurement Numerator Number of patients who had "OK to use" order written before meds, Indicator (Successes) flushes, or tube feedings were started

"OK to use" order written by provider post feeding tube insertion before Denominator Total number of patients who had feeding tubes inserted meds, flushes, tube feedings started (Total)

Start Date: 5/1/2018Target: 100% Responsible Leader: Victoria Veronese Summary 100% Num Den % Month % Target 80% Week 1 9 10 90% 100% Week 2 9 9 100% 100% 60% 98% Week 3 7 7 100% 100% 40%

Week 4 10 10 100% 100%% Compliant 20% Week 5 #N/A 100% 0% Week 6 #N/A 100% Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 7 #N/A 100% % Target Week 8 #N/A 100% Unit Specific Data 4E 4NW 4SW 5E 5W Num Den % Num Den % Num Den % Num Den % Num Den % Week 1 1 2 50% 1 1 100% 3 3 100% 1 1 100% 1 1 100% Week 2 1 1 100% 1 1 100% 3 3 100% 1 1 100% 2 2 100% Week 3 1 1 100% 1 1 100% 4 4 100% Week 4 2 2 100% 1 1 100% 3 3 100% 3 3 100% Week 5 Week 6 Week 7 Week 8

6E 6W 7E 7W 8E (Med Surg) Week 1 1 1 100% Week 2 1 1 100% Week 3 1 1 100% Week 4 1 1 100% Week 5 Week 6 Week 7 Week 8

9E Short Stay 8E (Mother Baby) 8W (L&D) Other Week 1 1 1 100% Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Analysis Actions Taken During the month of May 2018 98% of patients audited (n=36) that had Continue to reinforce with providers the need to have an "OK to use order" post feeding tube feeding tubes inserted had an "OK to use order" prior to installation of insertion. Continue audits weekly to ensure sustainability. medications, flushes, or tube feedings. Based on workgroup created to review practice at PMC for small bore and large bore feeding tubes, recommendation to get an "ok to use" order for all small bore and large bore gastric and post‐pyloric feeding tubes after insertion not just if it will be used to instill medications, flushes, or tube feedings.

94 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Number of patients who had tube feeding orders initated within 8 hours Indicator (Successes) from physician order Denominator Timely initiation of tube feedings Total number of patients who had tube feeding orders (Total)

Start Date: 5/1/2018Target: 100% Responsible Leader: Victoria Veronese Summary 100% Num Den % Month % Target 80% Week 1 6 6 100% 100% Week 2 8 8 100% 100% 60% 100% Week 3 8 8 100% 100% 40%

Week 4 8 8 100% 100%% Compliant 20% Week 5 #N/A 100% 0% Week 6 #N/A 100% Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 7 #N/A 100% % Target Week 8 #N/A 100% Unit Specific Data 4E 4NW 4SW 5E 5W Num Den % Num Den % Num Den % Num Den % Num Den % Week 1 1 1 100% 1 1 100% 3 3 100% Week 2 1 1 100% 1 1 100% 2 2 100% 1 1 100% 2 2 100% Week 3 2 2 100% 1 1 100% 1 1 100% 4 4 100% Week 4 1 1 100% 3 3 100% 3 3 100% Week 5 Week 6 Week 7 Week 8

6E 6W 7E 7W 8E (Med Surg) Week 1 1 1 100% Week 2 1 1 100% Week 3 Week 4 1 1 100% Week 5 Week 6 Week 7 Week 8

9E Short Stay 8E (Mother Baby) 8W (L&D) Other Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Analysis Actions Taken During the month of May 2018 100% of patients who had tube feedings Continue to reinforce with staff goal that all tube feeding orders are iniated within 8 hours ordered were initiated within 8 hours from physician order. from MD order. Continue audits weekly to ensure sustainability.

95 Addendum E

Quality Management Committ ee ISBARR Executive Summary

Topic/Project: Wound Packing Documentation Discrepancies

Submitted By: Dawn Lopez, and Bunny Krall

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? Introduction Retention of wound packing Situation Palomar Medical Center Escondido received a CDPH 2567 related to retention of wound packing Background ∙ Patient had infected pacemaker site. ∙ Pacemaker removed and wound packed with iodoform gauze. ∙ Later ordered for removal 6” per day “until gone”. ∙ During the stay, the gauze end disappeared. ∙ Patient had been in CCU, TIMC, and MST. ∙ Patient was discharged to home with family. ∙ Approximately two weeks later, the patient was seen in the Wound Care Clinic where three feet of gauze was removed. Wound/dressing care orders were unclear. ∙ Nursing communication order written instead of a dressing change order. ∙ Orders for daily dressing changes by removing 6” of gauze and leaving a wick. ∙ Staff was unfamiliar with what to do and did not escalate to leadership or CNS. ∙ Nursing documentation was inconsistent. ∙ Handoffs were inconsistent.

Date Printed: June 11, 2018 1

96 Addendum E

Quality Management Committ ee ISBARR Executive Summary

1) Are we trending up or down? 2) Where is the opportunity? 3) What is the action plan to address the opportunity? 4) Any impact to MDs? 5) What do you need from the committee? Assessment

Recommendation Providers must document in progress notes number of dressings inserted/removed into a wound and communicate this to the nurse caring for the patient so these numbers can be documented in clarity.

Providers may NOT order any cutting of wound dressing once in the wound. Providers to enter order as Dressing Change orders and not communication order

Date Printed: June 11, 2018 2

97 Addendum E

Quality Management Committ ee ISBARR Executive Summary

Topic/Project: Cervical Collar Documentation Compliance

Submitted By: RaeAnne Watson

Introduction An Unstageable Hospital Acquired Pressure Injury was identified 2/16/2017.

Situation A reportable Hospital Acquired Pressure Injury related to a cervical collar was identified on a trauma patient on 7W on 2/16/18.

Background This patient was admitted to PMCE ICU as a trauma on 2/4/18. He was diagnosed with a C‐7 cervical fracture without spinal cord injury and was placed in a cervical collar. On 2/9/18 he went to surgery for a spinal fusion, with an order to be in a C‐ Collar post op. First documentation of the potential Hospital Acquired Pressure Injury was on 2/16/18. When the chart was reviewed, documentation of the skin under the C‐Collar did not follow our current Adult Inpatient Standards that say the skin needs to be assessed Q2 hours. Assessment The nursing staff was not assessing and documenting the skin under the C‐Collar per our current Adult Inpatient Standards.

Recommendation Staff Education on care of the patient with a C‐Collar to be completed by June 30, 2018. The updated Standards of Care for the Adult Inpatient (Lucidoc #18222) will include:

1. Information about where to document in Clarity. 2. Skin assessment under C‐collar using a 2 person technique to be completed each shift and PRN. 3. Documentation to presence and type of device, special precautions and condition of the skin under the brace. 4. When to change or replace collar pads. 5. Patient and family education in special precautions.

Date Printed: June 14, 2018 1

98 Addendum E

PMC Escondido Plan Do ‐ Measurement Numerator Number of shifts the RN assessed/documented skin checks under Indicator (Successes) the C‐Collar per current Adult Inpatient Standards (q 2 hours) Denominator Did the RN document c‐collar skin checks per procedure Number of patients with c‐collars (Total)

Start Date: 4/9/2018 Target: 100% Responsible Leader: Rae Anne Watson Summary Num Den % Target 100% Month 1 100% April 100% 80% 39 41 95% 4/9/18‐ 100% 60% 4/30/18 100% Month 2 100% 40% May 100% % Compliant 5/1/18‐ 100% 20% 5/31‐18 81 87 93% 100% #N/A100% 0% #N/A100% #N/A100% % Target Linear (%) #N/A100%

Analysis Actions Taken From March 16‐April 16 staff re‐educated on current documentation requirements Our Plan of Correction includes CNS/NES rounding on all patients with cervical related skin and C‐collars. collars, this began in April. iXpand education is underway and will be completed by June30th for the new documentation standard. On April 26, 2018, CEC approved practice change to reflect current best practice recommendations, this includes assessing the skin once a shift and PRN. On June 1st, iXpand module launched to educate staff on the changes in the new documentation standards that will roll out July 1st, 2018.

99 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of times the proper pulse oximeter sensor was used (Successes) Denominator pulse oximeter sensor Number of patients using continuous pulse oximetry (Total)

Start Date: 11/29/2017 Target: 100% Responsible Leader: Respiratory and Nursing Leadership Summary Num Den % Target 100% Week 1 6 6 100% 100% Week 2 9 9 100% 100% 80% Week 3 5 8 63% 100% 60% Week 4 5 7 71% 100% Week 5 5 5 100% 100% 40% Week 6 3 3 100% 100% % Compliant Week 7 12 14 86% 100% 20% Week 8 7 8 88% 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken We are seeing an improvement but still have some challenges in the CCU and • Respiratory Leadership will continue to audit and report findings to the Nursing TICU using neonatal probes on earlobes. Compliance rate: 4/15 to 5/15/2018 ‐ Leadership, Patient Safety and QMC next month. 83%; 5/15 to 6/11/2018 to date is 90% • Non‐Disposable ear probes have been ordered and are now available for use. • Nursing Leadership will provide education to the nursing staff regarding the availability of non‐disposable ear probes. • Nursing and Respiratory will meet with the vendor on 6/11/2018 to discuss disposable options that are compatible with our equipment.

100 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Heparin drips started within 2 hrs (Successes) Denominator Timeliness of starting Heparin drip (2 hrs or less) Total number of heparin drips ordered (Total)

Start Date: 9/17/2017 Target: 100% Responsible Leader: V. Veronese Summary Num Den % Target 100% Week 1 23 27 85% 100% Week 2 18 18 100% 100% 80% Week 3 11 14 79% 100% 60% Week 4 19 20 95% 100% Week 5 #N/A 100% 40% Week 6 #N/A 100% % Compliant Week 7 #N/A 100% 20% Week 8 #N/A 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken Chart reviews done on any heparin drip started > 2 hrs, several were pulled out 1. Education in the form of iXpand modules went out to all RNs on medication due to patient having procedure done that required heparin to be held or administration from Pharmacy in May with deadline of 6/7/18. delayed start due to risk of bleeding. Of the remaining outliers, they were over 2. Outliers to be sent to Nurse Managers for follow up. the 2 hr mark but started within 2 hrs 30 mins and the heparin orders were put 3. Work with Pharmacy on possible changes to order set to convey urgency of starting in as Routine versus ASAP or Stat. medication

101 PMC Escondido Plan Do ‐ MeasurementAddendum E

Indicator Numerator Number of Wound Packing Removal Events Not Receiving Alert

Denominator Wound Packing Alerts Number of Wound Packing Removal Events

Start Date: 4/5/2018 Target: 100% Responsible Leader: Dawn Lopez Summary Month 100% Num Den % % Target

Analysis Actions Taken April: Steep learning curve with new documentation expectations. Errors with 3/22/18 Alert initated in Clarity documentation noted. April Developing education module to support staff understanding of wound packing May: Improvements seen. Identified opportunity to capture documentation process and escalation requirements. Launching of daily wound packing reports with discrepancies. real‐time rounding and feedback with staff. 5/27‐6/2/18 1 failed, upon investigation RN incorrectly documented the # of 5/8/18 "Wound Packing Discrepancy" QRR Initiated "Inserted" causing alert to fire when "Removed" number differed. Alert worked May: OR Staff education to document wound packing insertion in iView to support appropriately. continuum of care and handoff. Based on May Analysis, the QRR was Revised to "Wound Packing Event" to capture findings within the Daily Wound Packing Report and went live 6/5/18. 5/27‐6/2/18 "Inserting" RN confirmed typographical error and corrected documentation. QRR and investigation completed to track variance and follow‐up.

102 PMC Poway Plan Do ‐ MeasurementAddendum E

Indicator Numerator Number of Wound Packing Removal Events Not Receiving Alert

Denominator Wound Packing Alerts Number of Wound Packing Removal Events

Start Date: 4/5/2018 Target: 100% Responsible Leader: [Insert Name] Summary Month 100% Num Den % % Target

Analysis Actions Taken n is small, leadership rounding daily with Daily Wound Packing Report. Nurses correcting documentation errors as leaders round.

103 Addendum E

Palomar Medical Center Downtown Frequency May, 2018 Diversion Prevention / Controlled Substance QAPI Report CII Safe Results "All Pyxis CII Safe Events " report reviewed for unusual activity Daily 65%, n=31 "Open Discrepancy Report " reviewed Daily 23%, n=31 "Pyxis vs C II Safe Compare report " reviewed Daily 100%, n=31 Count of "Resolved Discrepancies" for the month Monthly n=0 "Migration Report " reviewed Monthly Yes Verify all controlled substances are in a secured storage location (i.e locked). Check refrigerator locations Monthly Yes as well. Inventory of controlled substances stored in the CII Safe performed per procedure 32532, Pharmacy Monthly Yes Controlled Substance Vault CII safe Pending Destruction Box was included in monthly inventory Monthly Yes Pyxis MedStations Outlier reviews completed within 10 days Monthly 100%, n=1 Controlled Substance Discrepancies Resolved Within 24 hours Monthly 100%, n=13 Controlled Substance Pyxis Inventory Weekly 100%, n=35 Pyxis Override Monthly 0.01% Cancelled Transaction Report for drugs that could be tampered with (# of outliers) Monthly 0 Documentation tracer audits: Controlled Substances (Pyxis removal tied to order and charting event) Monthly 99%, n=103 Documentation tracer audits: Non‐Controlled Substances (Pyxis removal tied to order and charting event) Monthly 100%, n=30 Executive Summary: "All Pyxis CII Safe Events" report reviewed daily; previously just one employee was reviewing. Changed review to be done by DE pharmacist shift daily "Open Discrepancies" report reviewed daily: previously just PIC checking. Changed review to be done by DE pharmacist shift daily

104 Addendum E

Palomar Medical Center Escondido Frequency May, 2018 Diversion Prevention / Controlled Substance QAPI Report CII Safe Results "All Pyxis CII Safe Events " report reviewed for unusual activity Daily 100%, n=31 "Open Discrepancy Report " reviewed Daily 100%, n=31 "Pyxis vs C II Safe Compare report " reviewed Daily 100%, n=31 Count of "Resolved Discrepancies" for the month Monthly n=1 "Migration Report " reviewed Monthly Yes Verify all controlled substances are in a secured storage location (i.e locked). Check refrigerator locations Monthly Yes as well. Inventory of controlled substances stored in the CII Safe performed per procedure 32532, Pharmacy Monthly Yes Controlled Substance Vault CII safe Pending Destruction Box was included in monthly inventory Monthly Yes Pyxis MedStations Outlier reviews completed within 10 days Monthly 73 %, n=15 Controlled Substance Discrepancies Resolved Within 24 hours Monthly 85%, n=120 Controlled Substance Pyxis Inventory Weekly 99.7%, n=355 Pyxis Override Monthly 1.6% Cancelled Transaction Report for drugs that could be tampered with (# of outliers) Monthly 0 Documentation tracer audits: Controlled Substances (Pyxis removal tied to order and charting event) Monthly 99%, n=1005 Documentation tracer audits: Non‐Controlled Substances (Pyxis removal tied to order and charting event) Monthly 97%, n=1476 Executive Summary: One instance of "resolved discrepancy" because it involved a waste that was performed on the wrong product (lacosamide vial instead of drip) and waste transactions cannot be reversed. Outlier reviews had 4 cases returned past the preferred 10 days. 3 of these were returned at 12 days, and 1 was late because a new manager had to be trained on the process.

105 Addendum E

Palomar Medical Center Poway Frequency May, 2018 Diversion Prevention / Controlled Substance QAPI Report CII Safe Results "All Pyxis CII Safe Events " report reviewed for unusual activity Daily 94%, n=31 "Open Discrepancy Report " reviewed Daily 97%, n=31 "Pyxis vs C II Safe Compare report " reviewed Daily 100%, n=24 Count of "Resolved Discrepancies" for the month Monthly n=1 "Migration Report " reviewed Monthly Yes Verify all controlled substances are in a secured storage location (i.e locked). Check refrigerator locations Monthly Yes as well. Inventory of controlled substances stored in the CII Safe performed per procedure 32532, Pharmacy Monthly Yes Controlled Substance Vault CII safe Pending Destruction Box was included in monthly inventory Monthly No Pyxis MedStations Outlier reviews completed within 10 days Monthly 100%, n=3 Controlled Substance Discrepancies Resolved Within 24 hours Monthly 92%, n=25 Controlled Substance Pyxis Inventory Weekly 94.5%, n=110 Pyxis Override Monthly 1.4% Cancelled Transaction Report for drugs that could be tampered with (# of outliers) Monthly 0 Documentation tracer audits: Controlled Substances (Pyxis removal tied to order and charting event) Monthly 99%, n=634 Documentation tracer audits: Non‐Controlled Substances (Pyxis removal tied to order and charting event) Monthly 100%, n=30 Executive Summary: "All Pyxis CII Safe Events" and "Open Discrepancy Report" reports not at goal. Will discuss with staff an reinforce process. Count of "Resolved Discrepancies" for the month: There was one disrepancy that needed to be changed to the right number in May. Lacosamide IV was inadvertently wasted to the oral version and there is no way to reverse this error. Count was just corrected instead. Full inventory of all accesible and secured medications is conducted each month by 2 licensed individuals: Not done because this is a new requirement. Use to be quarterly. CII safe Pending Destruction Box was included in monthly inventory: Last performed on April 12. Done again on June 6, 2018. Process reviewed with pharmacist‐in‐charge and procedures put in place to ensure monthly reconciliation moving forward.

106 Addendum E

Palomar Medical Center Downtown Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report Ante Room Required Results Results Ante room must test minimum Bi Annual ISO7 n/a n/a Pressure between ante room and pharmacy (inches wc higher than pharmacy) Daily 0.02 n/a n/a CFU in air may not exceed Bi Annual 10 Pass (Feb, 2018) Pass (Feb, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Feb, 2018) Pass (Feb, 2018) Air Exchanges Anteroom minimum Bi Annual 30 n/a n/a Temperature anteroom Daily 20‐25 C See note below* See note below* Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Ante Room. n/a n/a Positive Pressure Buffer Room Required Results Results Positive Pressure Buffer Room must test minimum Bi Annual ISO7 n/a n/a pressure between ante room and positive pressure buffer room (inches higher than ante) Daily 0.02 n/a n/a CFU in air may not exceed Bi Annual 10 Pass (Feb, 2018) Pass (Feb, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Feb, 2018) Pass (Feb, 2018) Air Exchanges in Positive Buffer room minimum Bi Annual 30 Pass (Feb, 2018) Pass (Feb, 2018) Temperature positive pressure buffer room Daily 20‐25C Pass Pass Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Positive Pressure Buffer Room. n/a n/a Negative Pressure Buffer Room Required Results Results Negative Pressure Buffer Room must test minimum Bi Annual ISO7 n/a n/a pressure between ante room and negative pressure buffer room (inches wc lower than ante) Daily 0.01 to 0.03 n/a n/a CFU in air may not exceed Bi Annual 10 n/a n/a CFU surfaces may not exceed Bi Annual 5 n/a n/a Air Exchanges neg buffer room minimum Bi Annual 30 n/a n/a Temperature in negative pressure buffer room Daily 20‐25C Pass Pass Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Negative Pressure Buffer Room. n/a n/a Primary Engineering Control Positive Pressure #1 (IV Room Hood #1) Required Results Results Positive Pressure PEC #1 must test minium Bi Annual ISO5 Pass (Feb, 2018) Pass (Feb, 2018) CFU in air may not exceed Bi Annual 1 Pass (Feb, 2018) Pass (Feb, 2018) CFU on surfaces inside PEC may not exceed Bi Annual 3 Pass (Feb, 2018) Pass (Feb, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in positive pressure PEC#1. Cannot use PEC until retested and results are within acceptable limits PASS PASS Primary Engineering Control Negative Pressure #1 (Chemo Hood) Required Results Results Negative Pressure PEC#1 must test minimum Bi Annual ISO5 Pass (Feb, 2018) Pass (Feb, 2018) CFU in air may not exceed Bi Annual 1 Pass (Feb, 2018) Pass (Feb, 2018)

107 Addendum E

Palomar Medical Center Downtown Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report CFU on surfaces may not exceed Bi Annual 3 Pass (Feb, 2018) Pass (Feb, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in negative pressure PEC#1. Cannot use PEC until retested and results are within acceptable limits PASS PASS Personnel Validation Action Level Results Results Gloved Fingertip (LAFW Hood) Annual >3 CFU 87% n = 15 87% n = 15 Media Fills (LAFW Hood) Annual Positive Growth 87% n = 15 87% n = 15 Process Validation: garbing, cleaning and aseptic technique (LAFW Hood) Annual Pass / Fail 87% n = 15 87% n = 15 Gloved Fingertip (BSC Hood) Annual >3 CFU 80% n = 15 80% n = 15 Media Fills (BSC Hood) Annual Positive Growth 80% n = 15 80% n = 15 Process Validation: garbing, cleaning and aseptic technique (BSC Hood) Annual Pass / Fail 87% n = 15 87% n = 15 Competency Exam Annual incomplete exam 0 % n = 15 0% n = 15 0% n=15 0% n=15 End Product Testing Action Level Results Results Potency Quarterly per USP (Drug Specific) n/a n/a Note: If potency test fails, develop action plan and retest.

Extended Dating Product Testing Action Level Results Results Stability through 28 days New formula per USP (Drug Specific) n/a n/a FTM (Fungal) Per Batch Positive Growth n/a n/a TSB QT (Bacterial) testing Per Batch Positive Growth n/a n/a A new formula is required whenever a manufacturer or storage device/conditions are changed. PASS PASS Miscellaneous Action Level Results Results Were all products purchased from outside compounding pharmacies previously approved for purchase? Quarterly Unapproved Purchase n/a n/a Review email recipients for Medkeeper alerts Quarterly n/a n/a n/a PASS PASS Executive Summary: ‐ "n/a" means "not applicable." The Downtown campus IV room is not operating under USP 797 standards as a clean room, and is therefore applying 12‐hour beyond use dating. ‐ The annual competency exam will be administered before the end of the fiscal year, June 30, 2018. ‐ Plan of correction: Two pharmacists who have not been tested for LAFW and BSC validation will be tested by Jun 30, 2018. One pharmacist not tested for BSC validation will be tested by June 30, 2018.

108 Addendum E

Palomar Medical Center Escondido Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report Ante Room Required Results Results Ante room must test minimum Bi Annual ISO7 Pass (Jan, 2018) Pass (Jan, 2018) Pressure between ante room and pharmacy (inches wc higher than pharmacy) Daily 0.02 100% (n=30) 100% (n=31) CFU in air may not exceed Bi Annual 10 Pass (Jan, 2018) Pass (Jan, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Jan, 2018) Pass (Jan, 2018) Air Exchanges Anteroom minimum Bi Annual 30 Pass (Jan, 2018) Pass (Jan, 2018) Temperature anteroom Daily 20‐25 C See note below* See note below* Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Ante Room. PASS PASS Positive Pressure Buffer Room Required Results Results Positive Pressure Buffer Room must test minimum Bi Annual ISO7 Pass (Jan, 2018) Pass (Jan, 2018) pressure between ante room and positive pressure buffer room (inches higher than ante) Daily 0.02 100% (n=30) 100% (n=31) CFU in air may not exceed Bi Annual 10 Pass (Jan, 2018) Pass (Jan, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Jan, 2018) Pass (Jan, 2018) Air Exchanges in Positive Buffer room minimum Bi Annual 30 Pass (Jan, 2018) Pass (Jan, 2018) Temperature positive pressure buffer room Daily 20‐25C See note below* See note below* Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Positive Pressure Buffer Room. PASS PASS Negative Pressure Buffer Room Required Results Results Negative Pressure Buffer Room must test minimum Bi Annual ISO7 Pass (Jan, 2018) Pass (Jan, 2018) pressure between ante room and negative pressure buffer room (inches wc lower than ante) Daily 0.01 to 0.03 100% (n=30) 100% (n=31) CFU in air may not exceed Bi Annual 10 Pass (Jan, 2018) Pass (Jan, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Jan, 2018) Pass (Jan, 2018) Air Exchanges neg buffer room minimum Bi Annual 30 Pass (Jan, 2018) Pass (Jan, 2018) Temperature in negative pressure buffer room Daily 20‐25C See note below* See note below* Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Negative Pressure Buffer Room. PASS PASS Primary Engineering Control Positive Pressure #1 (IV Room Hood #1) Required Results Results Positive Pressure PEC #1 must test minium Bi Annual ISO5 Pass (Jan, 2018) Pass (Jan, 2018) CFU in air may not exceed Bi Annual 1 Pass (Jan, 2018) Pass (Jan, 2018) CFU on surfaces inside PEC may not exceed Bi Annual 3 Pass (Jan, 2018) Pass (Jan, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in positive pressure PEC#1. Cannot use PEC until retested and results are within acceptable limits PASS PASS

109 Addendum E

Palomar Medical Center Escondido Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report Primary Engineering Control Positive Pressure #2 (IV Room Hood #2) Required Results Results Positive Pressure PEC #2 must test minium Bi Annual ISO5 Pass (Jan, 2018) Pass (Jan, 2018) CFU in air may not exceed Bi Annual 1 Pass (Jan, 2018) Pass (Jan, 2018) CFU on surfaces inside PEC may not exceed Bi Annual 3 Pass (Jan, 2018) Pass (Jan, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in positive pressure PEC#2. Cannot PASS PASS use PEC until retested and results are within acceptable limits Primary Engineering Control Negative Pressure #1 (Chemo Room Hood) Required Results Results Negative Pressure PEC#1 must test minimum Bi Annual ISO5 Pass (Jan, 2018) Pass (Jan, 2018) CFU in air may not exceed Bi Annual 1 Pass (Jan, 2018) Pass (Jan, 2018) CFU on surfaces may not exceed Bi Annual 3 Pass (Jan, 2018) Pass (Jan, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in negative pressure PEC#1. Cannot use PEC until retested and results are within acceptable limits PASS PASS Personnel Validation Action Level Results Results Gloved Fingertip (LAFW Hood) Annual >3 CFU 71% n=78 77% n=78 Media Fills (LAFW Hood) Annual Positive Growth 71%, n=78 77%, n=78 Process Validation: garbing, cleaning and aseptic technique (LAFW Hood) Annual Pass / Fail 71%, n=78 77%, n=78 Gloved Fingertip (BSC Hood) Annual >3 CFU 7% n=70 14% n=70 Media Fills (BSC Hood) Annual Positive Growth 7% n=70 14% n=70 Process Validation: garbing, cleaning and aseptic technique (BSC Hood) Annual Pass / Fail 71%, n=78 77%, n=78 Competency Exam Annual incomplete exam 0%, n=78 0%, n=78 0%, n=78 0%, n=78 End Product Testing Action Level Results Results Potency Quarterly per USP (Drug Specific) PASS PASS Note: If potency test fails, develop action plan and retest.

Extended Dating Product Testing Action Level Results Results Stability through 28 days New formula per USP (Drug Specific) Pass, n=1 Pass, n=5 FTM (Fungal) Per Batch Positive Growth 100%, n=21 100%, n=21 TSB QT (Bacterial) testing Per Batch Positive Growth 100%, n=21 100%, n=21 A new formula is required whenever a manufacturer or storage device/conditions are changed. PASS PASS Miscellaneous Action Level Results Results Were all products purchased from outside compounding pharmacies previously approved for purchase? Quarterly Unapproved Purchase Yes, April, 2018 Yes, April, 2018 Review email recipients for Medkeeper alerts Quarterly n/a Yes, April, 2018 Yes, April, 2018

110 Addendum E

Palomar Medical Center Escondido Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report PASS PASS Executive Summary: Room temperature is reported to be comfortable by staff. Monitoring each room with Aeroscout pucks will commence the week of June 11, 2018. Testing in the BSC Hood just began in April; during the month of June several staff will be tested. As of June 30th, only staff that have been validated in the BSC hood will be scheduled for the duty. The annual competency exam will be administered before the end of the fiscal year, June 30, 2018.

111 Addendum E

Palomar Medical Center Poway Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report Ante Room Required Results Results Ante room must test minimum Bi Annual ISO7 Pass (Feb, 2018) Pass (Feb, 2018) Pressure between ante room and pharmacy (inches wc higher than pharmacy) Daily 0.02 100% (n=30) 100% (n=30) CFU in air may not exceed Bi Annual 10 Pass (Feb, 2018) Pass (Feb, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Feb, 2018) Pass (Feb, 2018) Air Exchanges Anteroom minimum Bi Annual 30 Pass (Feb, 2018) Pass (Feb, 2018) Temperature anteroom Daily 20‐25 C See note below* See note below* Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Ante Room. PASS PASS Positive Pressure Buffer Room Required Results Results Positive Pressure Buffer Room must test minimum Bi Annual ISO7 Pass (Feb, 2018) Pass (Feb, 2018) pressure between ante room and positive pressure buffer room (inches higher than ante) Daily 0.02 100% (n=30) 100% (n=30) CFU in air may not exceed Bi Annual 10 Pass (Feb, 2018) Pass (Feb, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Feb, 2018) Pass (Feb, 2018) Air Exchanges in Positive Buffer room minimum Bi Annual 30 Pass (Feb, 2018) Pass (Feb, 2018) Temperature positive pressure buffer room Daily 20‐25C See note below* See note below* Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Positive Pressure Buffer Room. PASS PASS Negative Pressure Buffer Room Required Results Results Negative Pressure Buffer Room must test minimum Bi Annual ISO7 Pass (Feb, 2018) Pass (Feb, 2018) pressure between ante room and negative pressure buffer room (inches wc lower than ante) Daily 0.01 to 0.03 100% (n=30) 100% (n=30) CFU in air may not exceed Bi Annual 10 Pass (Feb, 2018) Pass (Feb, 2018) CFU surfaces may not exceed Bi Annual 5 Pass (Feb, 2018) Pass (Feb, 2018) Air Exchanges neg buffer room minimum Bi Annual 30 Pass (Feb, 2018) Pass (Feb, 2018) Temperature in negative pressure buffer room Daily 20‐25C See note below* See note below* Notes: Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in Negative Pressure Buffer Room. PASS PASS Primary Engineering Control Positive Pressure #1 (IV Room Hood #1) Required Results Results Positive Pressure PEC #1 must test minium Bi Annual ISO5 Pass (Feb, 2018) Pass (Feb, 2018) CFU in air may not exceed Bi Annual 1 Pass (Feb, 2018) Pass (Feb, 2018) CFU on surfaces inside PEC may not exceed Bi Annual 3 Pass (Feb, 2018) Pass (Feb, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in positive pressure PEC#1. Cannot use PEC until retested and results are within acceptable limits PASS PASS

112 Addendum E

Palomar Medical Center Poway Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report Primary Engineering Control Positive Pressure #2 (IV Room Hood #2) Required Results Results Positive Pressure PEC #2 must test minium Bi Annual ISO5 Pass (Feb, 2018) Pass (Feb, 2018) CFU in air may not exceed Bi Annual 1 Pass (Feb, 2018) Pass (Feb, 2018) CFU on surfaces inside PEC may not exceed Bi Annual 3 Pass (Feb, 2018) Pass (Feb, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in positive pressure PEC#2. Cannot PASS PASS use PEC until retested and results are within acceptable limits Primary Engineering Control Negative Pressure #1 (Chemo Room Hood) Required Results Results Negative Pressure PEC#1 must test minimum Bi Annual ISO5 Pass (Feb, 2018) Pass (Feb, 2018) CFU in air may not exceed Bi Annual 1 Pass (Feb, 2018) Pass (Feb, 2018) CFU on surfaces may not exceed Bi Annual 3 Pass (Feb, 2018) Pass (Feb, 2018) Any highly pathogenic microorganism and/or molds and yeast reported will require immediate action and retesting in negative pressure PEC#1. Cannot use PEC until retested and results are within acceptable limits PASS PASS Personnel Validation Action Level Results Results Gloved Fingertip (LAFW Hood) Annual >3 CFU 96% n=25 96% n=25 Media Fills (LAFW Hood) Annual Positive Growth 96% n=25 96% n=25 Process Validation: garbing, cleaning and aseptic technique (LAFW Hood) Annual Pass / Fail 96% n=25 96% n=25 Gloved Fingertip (BSC Hood) Annual >3 CFU 0% n=25 0% n=25 Media Fills (BSC Hood) Annual Positive Growth 0% n=25 0% n=25 Process Validation: garbing, cleaning and aseptic technique (BSC Hood) Annual Pass / Fail 0% n=25 0% n=25 Competency Exam Annual incomplete exam 0% n=25 0% n=25 0% n=25 0% n=25 End Product Testing Action Level Results Results Potency Quarterly per USP (Drug Specific) PASS PASS Note: If potency test fails, develop action plan and retest.

Extended Dating Product Testing Action Level Results Results Stability through 28 days New formula per USP (Drug Specific) Pass, n=1 Pass, n=1 FTM (Fungal) Per Batch Positive Growth 100%, n=4 100%, n=4 TSB QT (Bacterial) testing Per Batch Positive Growth 100%, n=4 100%, n=4 A new formula is required whenever a manufacturer or storage device/conditions are changed. PASS PASS Miscellaneous Action Level Results Results Were all products purchased from outside compounding pharmacies previously approved for purchase? Quarterly Unapproved Purchase Yes, April, 2018 Yes, April, 2018 Review email recipients for Medkeeper alerts Quarterly n/a Yes, April, 2018 Yes, April, 2018

113 Addendum E

Palomar Medical Center Poway Frequency Date Tested  Apr, 2018 May, 2018 Sterile Compounding QAPI Report PASS PASS Executive Summary: Executive Summary: Room temperature is reported to be comfortable by staff. Monitoring each room with Aeroscout pucks will commence the week of June 11, 2018. Testing in the BSC Hood just began in June; during the month of June several staff will be tested. As of June 30th, only staff that have been validated in the BSC hood will be scheduled for the duty. The annual competency exam will be administered before the end of the fiscal year, June 30, 2018.

114 Addendum E

Palomar Health ISBARR Executive Summary Introduction Medication Pass Audits Situation As part of our CMS plan of correction, we committed to conducting regular medication pass audits to ensure that staff are following proper procedures when administering medications. Background An extensive med pass audit tool was developed. Education was provided to nursing leadership on the use of the tool on Nov 14, 2017. Pharmacy leaders are also each conducting audits monthly. Assessment Indicator: % of audits on which every single audit question was performed correctly  In the first 3 weeks in November, compliance ranged from 33% ‐ 53%.

 The Questions that fell below 90% follow for May Medication Pass Audits follow. Question % Compliance

1. If medication taken out of package and not immediately administered, 76% were they labeled with the medication name, concentration, strength (if not apparent) and expiration date? 2. Did the nurse ensure that ONLY medications that may be crushed with 85% Silent Night Pill crusher are crushed (no hazardous, Enteric coated or other medication on the do not crush list)? 3. Was controlled substance waste documented with a witness in Pyxis 83% including witness of actual disposal, and (when feasible) witness of withdrawal from original container? 4. Did the nurse ensure that a FIN # was entered into the Alaris Pump and 86% add it if it not entered?

Prepared by Diana Schultz, Manager Medication Safety, and Jeremy Lee, Manager of Pharmacy Services 6/7/18 1 115 Addendum E

5. Did the nurse ensure that all bulk containers (e.g. inhaler, cream) are in 71% ziplock bags and the outside is wiped down before returning to the patient specific med room bin? 6. Was site of administration for IM, NGT, Subcutaneous, and topical 72% patches?

Recommendation 1. Reviewed results from April Med Pas Audit at Escondido and Poway Nurse Leadership to identify any barriers and instruct leaders to ensure that labels and pill cutters are stocked on the floor and remind that fin # can be added to Alaris® pumps without turning pump off. 2. iXpand waste documentation module completed June 8th, those who did not complete were put on administrative leave. 3. Added content for questions on returning bulk items of the required 3rd Quarter Medication Safety Competency. 4. Required site documentation for patches scheduled to go live June 14th. 5. Question about site administration documentation modified; NGT removed. 6. Continue to monitor, consider decreasing frequency of audits after CMS visit. Read Back There has not been improvement on the overall compliance rate, but the types of questions falling out each month continue to change, indicating that previous action plans on previously non‐compliant questions have had success. Medication pass audits have identified areas that required improvement. Education and process improvements continue address the specific questions that fall out each month. Medication pass audits should continue on a regular basis.

Prepared by Diana Schultz, Manager Medication Safety, and Jeremy Lee, Manager of Pharmacy Services 6/7/18 2 116 Addendum E

Palomar Health ISBARR Executive Summary Introduction CMS Corrective Action Plan Educational Efforts Related to Medication Management

Situation Palomar Health has deployed 3 education iXpand modules related to medication management issues. Background The following 3 iXpand modules were launched in the month of May, 2018.  Proper Disposal of Controlled Substances (Nursing and Pharmacy) o Increase awareness of diversion cases at Palomar Health o Clarify proper controlled substance wasting process o Empower staff to refuse to serve as a witness if proper process not followed  Medication Management and Provider Notification (Nursing and Pharmacy) o How to manage a late medication dose o Proper documentation of missed or late doses o Explain when the provider needs to be notified for medication errors  Pharmacy: Key Tactics to Support Safe Medication Practices (Pharmacy) o Educate pharmacy staff on all findings from the April CMS survey

Assessment Completion rates for these modules as of 2pm on June 7th:

Course Title Completed Enrolled % Completed

Proper Disposal of Controlled Substances 1522 64 96% Medication Management and Provider Notification 1248 164 88% Pharmacy: Key Tactics to Support Safe Medication 61 55 53% Practices

The first two modules have a completion date of June 8. The third module is due June 15. Supervisors receive regular updates on who has not completed the course so they can follow up with staff. Any staff who have not completed the modules by the due date will be placed on administrative leave of absence.

Recommendation This report is for awareness. The educational efforts are proceeding well, and staff that do not complete the modules by the due date will be placed on administrative leave.

Read Back Education related to medication management issues is being completed by staff.

Prepared by Jeremy Lee, Manager Pharmacy Services 6/7/18 1 117 6/7/2018 Addendum E Plan Quality Assurance Performance Improvement Plan for Pharmacy 30832 Official (Rev: 8)

Source: Applies to Facilities: Applies to Departments: Administrative PMC Escondido Pharmacy Plans PMC Poway PMC Downtown Escondido Differences between version 8 and 9 . I. PURPOSE:

A. To define the pharmacy department's Quality Assurance Performance Improvement (QAPI) Plan which must: 1. Include an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes 2. Be an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors 3. Measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations 4. Incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the Quality Management department.

II. DEFINITIONS: QAPI : quality assurance and performance improvement

III. STANDARDS OF PRACTICE:

IV. A. The QAPI plan will: 1. Monitor the effectiveness and safety of services and quality of care 2. Identify opportunities for improvement and changes via a. Quality indicators metrics b. Medication Error Reports (Internal and External) c. Regulatory inspections and updates d. Annual review of Pharmacy Procedures e. Standards of Practice 3. Priorities for its performance improvement activities that are determined by: a. Focus on high-risk, high-volume, or problem-prone areas; b. Consider the incidence, prevalence, and severity of problems in those areas; and c. Affect health outcomes and quality of care. d. Affect patient safety. 4. Integrate with the Medication Error Reduction Plan (MERP) and Palomar Health's overall QAPI activities B. Actions based on QAPI results 1. Causes for poor quality or process must be analyzed 2. Actions must be implemented that include feedback and learning for throughout the hospital 3. Performance must be tracked to assure that any improvements are sustained 4. Actions resulting in operational or clinical procedure changes will be educated prior to implementation. C. The QAPI plan will be reviewed annually and updated as needed. The following review schedule will be followed to ensure that the QAPI plan is appropriate and comprehensive. 1. Annual review of Medication Use Procedures including pharmacy clinical monitoring, sterile compounding and medication storage & distribution procedures. 2. Annual review of the Medication Error Reduction plan. 3. Annual review of Pharmacy strategic initiative. 4. Quality indicators will be reviewed as indicated below.

118 1/4 6/7/2018 Addendum E i. QAPI Areas:

Medication P&T Audit Management Activity Reporting Frequency Node Schedule 1. Selection & a. Medication Errors of drugs approved by Quarterly Quarterly Procurement P&T in last year. b. Quality Assurance for outside Quarterly Quarterly compounding pharmacies 2. Product labeling, a. Unidentified Medication Bar Code Scan packaging and Monthly Quarterly Alerts nomenclature 3. Storage and a. Pyxis Controlled substance inventory audit Weekly Quarterly Distribution b C ontrolled substance discrepancy Monthly Quarterly resolution within 24 hours c. CII Safe Inventory audit Monthly Quarterly 4. Prescribing and Prescription Order a. Accuracy of the EMAR Audits Monthly Quarterly Communication b. Turn Around Time Audits Monthly Quarterly 5. Compounding and Quarterly a. USP 797 compliance Dispensing Monthly Quarterly b. Pyxis Override Rate Monthly Quarterly 6. Administration a. Bar Code Medication Administration Monthly Quarterly Compliance b. Alaris Guardrail Compliance Quarterly Quarterly c. Rate of Not Administered Medications Monthly Quarterly d. Medication Dispensed versus Administered Monthly Quarterly Audits 7. Monitoring & Use a. Zero Harm Index Monthly Quarterly 8. Education a. Nursing Medication Safety Test Completion Annually Annually

V. PUBLICATION HISTORY: Revision Effective Date Document Owner Version Notes Number 8 (this 10/01/2017 Diana Schultz, Mgr Medication Safety Quality indicators modified version) based on analysis of performance and regulatory requirements. Reviewed 2017, P&T September, QMC and MEC October. 7 01/18/2017 Diana Schultz, Mgr Medication Safety Addition of review schedule for (Changes) procedures, strategic initiative and quality indicators. Reviewed and approved at P&T, MEC and QMC 11/16 6 02/07/2016 Diana Schultz, Mgr Medication Safety Annual Review. Removed (Changes) Glycemic Care QAPI reporting and Pharmacist Alert Response reporting. Updated reporting schedule for some of the QAPI 119 2/4 6/7/2018 Addendum E under the monitoring section. Reviewed at P&T 11/2015 QMC and MEC 1/2016 5 02/11/2015 Diana Schultz, Mgr Medication Safety Annual Review- Updated to (Changes) include monitoring measures for pain, anticoagulation and glycemic management. Reviewed at MSC 11/14, P&T 11/14, QMC 11/14, Approved by POM MEC 1/15, PMC MEC 1/15 4 04/03/2014 Diana Schultz, Mgr Medication Safety Correction of formatting only (Changes) 3 02/05/2014 Diana Schultz, Mgr Medication Safety Change in QAPI areas to match (Changes) CDPH MERP medication use processes. Addition of several indicators including temperature monitoring, TSB inspections, pharmacist competency completion and scanning compliance. Reviewed at P&T 11/13 Reviewed at QMC 12/13 2 03/12/2012 Diana Schultz, Mgr Medication Safety Reformatted to meet Lucidoc (Changes) standards P&T approved 1/12 QMC approved 2/12 Formatted by tw 1 10/27/2011 Ashley Tortorici, Quality and Medication Removal of selected measures (Changes) Safety Pharmacy Specialist (reason) 1. Pyxis stock outs (data not readily obtainable). 2. Pomerado night overrides (24/7 coverage now available). 3. Medication errors/ADRs (addressed in other procedures). 4. PCA audits (results difficult to improve) 5. Handwriting (clarity launched 6/2011) 6. Removed Order Entry Accuracy Audit (Clarity launched 6/2011) 7. Charting Timeliness (Barcode administration added) Changes made: 1. Drug Shortages Added 2. Annual review required (changed from annual update required). 3. Medication Errors is now included in this procedure. 4.Accuracy of the EMAR Audits added 0 06/09/2008 John Eastham (Changes)

Authorized Signer(s): ( 09/30/2017 Reviewers Bailey, 07:00PM PST ) Brandon Jeremy Lee, Kruse, PharmD, BCPS, Michael Dir Pharmacy Lee, Services Jeremy ( 10/01/2017 Mendenhall,

120 3/4 6/7/2018 Addendum E 01:38PM PST ) Suzy Maureen Murray, Malone, AVP Janice Clinical and Nguyen, Diagnostic Srvs Truong Nitta, Eri Schultz, Diana Torres, Christine Turner, William

VI. REFERENCES: Reference Type Title Notes

Paper copies of this document may not be current and should not be relied on for official purposes. The current version is in Lucidoc at https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:30832$8&ref2=pphealth:30832$9.

121 4/4 Addendum E

Palomar Health ISBARR Executive Summary Introduction Pharmacy Tech Delivery Rounds Audits

Situation Pharmacy began doing audits of pharmacy technicians performance during medication delivery rounds. Background Medications were found in Pyxis units on the floors that were either expired or missing beyond use date stickers. In order to ensure that pharmacy technicians are performing their tasks correctly during delivery, regular delivery round audits are being performed immediately after technicians perform their deliveries. The inspections look for:

IV delivery:  Check in/out bin for cleanliness and that they were emptied.  Unused doses were removed  Cleanliness

Pyxis deliveries:  Short dated products contain beyond use dates, the date is entered correctly in Pyxis, and stock is rotated.  Do the same for 10 other non‐short date product  Check for cleanliness  Compare Patient specific meds to current census  Return bin was emptied (when appropriate)  Outdates were removed

Any findings are shared with the individual staff member along with the appropriate level of disciplinary action (e.g. coaching, verbal warning, etc.)

Assessment Audits were started on 5/29/2018, with a goal to complete at least 5 per week.

As of 15:30 on 6/7/2018, the Pharmacy is meeting the completion rate goal for these audits: Week # Number of Audits Performed Number of Findings 1 9 1 2 5 2

Recommendation These audits are proving to be extremely effective at identifying training and performance opportunities. Pharmacy technicians are very aware that these audits are being performed, and an increased level of compliance with procedures has been observed.

Read Back Pharmacy delivery round audits are being performed and are resulting in improved performance.

Prepared by Jeremy Lee, Manager Pharmacy Services 6/7/18 1 122 Addendum E

Palomar Health ISBARR Executive Summary Introduction New Drug Product Screening

Situation Pharmacy implemented a screening process for new products to ensure they are added to the automated systems appropriately and stored under proper conditions. Background The April, 2018 CMS survey found one product that was not stored under light protection as indicated on the product label.

Each individual medication can by produced by a number of manufacturers. Each unique product (drug, strength, size, manufacturer) has its own National Drug Code (NDC). Because of shortages and other availability issues, the pharmacy frequently has to substitute a previously stocked product with a different, but equivalent product. Even though the product is therapeutically equivalent, it may have different storage requirements. For example, we had stocked labetalol vials that hadn’t required light protection, but the new product we had to bring in did require light protection. That difference was missed, leading to the CMS finding. Assessment A new process was established on April 29, 2018 whereby the pharmacy buyer would ensure that each new NDC that was purchased would be screened to determine whether it had different storage requirements than the previous product (e.g. light protection, temperature requirements, etc.).

On May 17, an auditing program was established to monitor performance on this new process. Results for May 17‐31 were as follows:

Location Month May New NDCs Purchased 37 New NDC Reviewed 24 PMCE New NDC Compliance 65% New NDCs Purchased 27 New NDC Reviewed 6 PMCP New NDC Compliance 22% New NDCs Purchased 15 New NDC Reviewed 0 PMCD New NDC Compliance 0% New NDCs Purchased 79 New NDC Reviewed 30 District New NDC Compliance 38%

Performance on the new procedure was poor in two weeks monitored.

Prepared by Diana Schultz, Manager Medication Safety, and Jeremy Lee, Manager Pharmacy Services 6/6/18 1 123 Addendum E

Recommendation  Perform screening on all new NDC’s that were missed in this monitoring period (completed).  Proceed with disciplinary conversations with all staff responsible for this duty (completed).  Escalate all non‐compliant findings in real time to management, rather than waiting till the end of the monitoring period. Read Back Pharmacy implemented a new process to ensure that new drug products are screened for proper storage conditions. Initial performance was low, but performance feedback and increased frequency of monitoring will drive improvement in June.

Prepared by Diana Schultz, Manager Medication Safety, and Jeremy Lee, Manager Pharmacy Services 6/6/18 2 124 Addendum E

Palomar Health ISBARR Executive Summary Introduction Pain Assessment/Reassessment

Situation Found pain not reassessed within defined time frame. Pain reassessment was sited again during the April, 2018 CMS Survey Background Daily Pain Assessment report emailed out. Automated report that indicates if pain reassessed within the timeframes identified for pain medications. Report has had many adjustments to create a more meaningful, reliable report.

Initial auditing = 100% daily x 8 weeks.

For prn pain reassessments: 12/2017: Implemented PRN reassessment task to nursing task list.

Found lacking reassessment with ONE time pain med administration – One time pain medications do not generate a reassessment task on eMar or nursing task list. Initially it was thought that there was not an IT fix for this but after research it was found that a task could be set to fire for scheduled pain medications. Assessment

Prepared by Diana Schultz, Manager Medication Safety, and Jeremy Lee, Manager Pharmacy Services 6/6/18 1 125 Addendum E

PRN pain reassessments remain above 90%. One time pain medication reassessment has increased from 39% before several IT fixes were in place to 79% for the week of 5/27. A snapshot look at data from 6/5/18 (Post IT fix) showed a 92.8% compliance rate with one time pain re‐assessments done per procedure for 363 of 391 one time pain medication administrations. Actions:  Pain reassessment procedure changed so that ED patients still in the Lobby will be reassessed with next set of vital signs. 4/18  ED location of lobby added to pain reassessment report so re‐assessment does not fall out for these patients if done with the next set of vitals. 4/18  An icon for pain reassessment was added to the tracking shell in order to drive ED nursing workflow. 4/18  PRN pain reassessments suppressed when patient has Cerner location in peri‐operative area. 4/18  PRN reason added to PRN pain reassessment report 5/18. This helps nurse managers to target non‐compliance.  Reassessment tasks for scheduled medications went live 5/24th.

Recommendation With the latest process change implementation on 5/24, we now appear to be in compliance for both PRN and one‐time pain reassessments.  Continue to monitor the effects of one time medication pain re‐assessment.  Continue to monitor through automated report.  Nurse leaders to follow‐up on non‐compliant pain reassessment via data from daily report. Read Back Audits will be continue to be conducted on nursing compliance for documentation of pain assessment and reassessment following the administration of pain medication. Compliance data will be reviewed and analyzed. Trended data will be reported to QMC and Patient Safety Committee where any changes to plan and frequency of monitoring will be determined.

Prepared by Diana Schultz, Manager Medication Safety, and Jeremy Lee, Manager Pharmacy Services 6/6/18 2 126 Addendum E

Palomar Health ISBARR Executive Summary Introduction Provider Notification of Medications Not Administered Situation CMS did not find documentation of notification of provider when medication not given Background Audit: 30/day by Quality RNs x 8 weeks. Most common medications not administered: Insulin, respiratory inhalations, antihypertensive, stool softeners consistently for 8 weeks and provider notification stagnant at 30%. Suspend auditing until changes in place by subgroup.

Provider notification 30% compliance throughout 8 weeks. Found that most meds being held really don’t warrant provider notification. Subgroup of Pharmacy and Therapeutics worked to address this. Main focus is on implementing changes to decrease the need for provider notification:

Completed items:  Added comments that provider notification is not needed if patient refuses to non‐opioid pain medications and stool softeners. Done 1/26/18.  Developed protocol for when and how a Respiratory Care Provider (RCP) should notify about missed doses of respiratory medications. Approved at January Pharmacy and Therapeutics Committee. Education of RCP’s completed in February.  Clarifying in procedure that provider notification not required for stool softeners/laxatives, non‐opiate pain medications, and vitamins. Approved at January P&T.  Clarify in procedure how to reschedule medications rather than holding them when there is an unavoidable delay (e.g. patient off the floor). Approved at January P&T.

Assessment Recently Completed Items:  Launched mandatory education via iXpand module to all nurses and pharmacists to clarify the requirements of provider notification. Module launched 5/8/2018. Staff given 30 days to complete. Staff who didn’t complete the module on time placed on administrative leave of absence.  Sent out a memo to explain the changes to our providers. Completed 5/9/2018.

Recommendation  Resume measuring provider notification, timely and appropriate medication administration on June 11th. Read Back Procedures have been clarified and education has been launched. We expect significant improvement in compliance as the education is completed. Resume measuring this metric.

Prepared by Diana Schultz, Manager Medication Safety and Jeremy Lee, Manager of Pharmacy Services 6/7/18 1 127 Addendum E

Passion. People. Purpose.TM

FANS 2018 CMS PLAN OF CORRECTION

• Café Temperature Logs • Protein Needs

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128 Addendum E

PMCE & PMDC Steam Table Audits

Palomar Medical Centers Joint Medical Staff Patient Safety Committee (PSC) Reporting ISBARR

Topic/Project: MAY 2108 JC POC/QAPI/QMC Dietetic Services

Reporting Period: APRIL 2018 ‐ JUNE 2018 Prepared by: Javier Guerrero

Facility: PMCE, PHDC Area(s): FANS

Based on the findings from the CMS Validation Survey which occurred in April of I Introduction 2018 the FANS leadership with oversight from the Quality Department created Plans of Actions with audit tools to audit the steam table temperatures in retail. S Situation The findings centered on batch steam table holding temperatures in retail. The FANS leadership revised and provided training for FANS staff on the new B Background steam table log. Food Service Manager will audit the logs on a weekly basis for compliance. Staff has been consistent in using log. Temperatures have been within range and Assessment corrective actions were taken for any non‐compliant instances that included just‐ A in‐time training. We identified minor revisions to assure temperature critical control points are monitored. A revised temperature log was implemented.  Continue with audits weekly as part of management walkthroughs.  New revision of the log will be implemented which will include the production temperatures as well as the steam table temp prior to service. R Recommendation FANS Managers will continue audit and inspect areas for compliance, analyzing the data and reporting out at various committees for feedback and recommendations. Read back Revised form, audit Steam Table logs weekly for the next 3 months, continue R (Summary) training and oversight, analyze data, and report out any discrepancies.

129 Addendum E

PMCE Breakfast Steam Table Logs

Numerator Indicator Number of times batch temps were recorded (Successes) Denominator Breakfast Steam table temp logs Required number of times batch temps must be recorded (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Margaret Mertens Summary 100% Num Den % Target Week 1 14 14 100% 100% 80% Week 2 19 19 100% 100% 60% Week 3 21 21 100% 100% 40%

Week 4 21 21 100% 100%% Compliant 20% #N/A 100% #N/A 100% 0% Week Week Week Week #N/A 100% 1 2 3 4 % Target 100%

Analysis Actions Taken May ‐ FANS started a new form for the café hot food. It was Informed Supervisor to provide correct form. revised several times for efficiency and clarity. For this preliminary dashboard, we are showing 4 weeks of data. Future dashboards will be monthly, the 25th through the 24th. 100% compliance noted.

130 Addendum E

PMCE Lunch Steam Table Logs

Numerator Indicator Number of times batch temps were recorded (Successes) Denominator Breakfast Steam table temp logs Required number of times batch temps must be recorded (Total)

Start Date: 5/1/2018Target: 100% Responsible Leader: Margaret Mertens Summary 100% Num Den % Target Week 1 14 14 100% 100% 80% Week 2 19 19 100% 100% 60% Week 3 21 21 100% 100% 40%

Week 4 21 21 100% 100%% Compliant 20% #N/A 100% #N/A 100% 0% Week Week Week Week #N/A 100% 1 2 3 4 % Target 100%

131 Addendum E

PMCE Dinner Steam Table Logs

Indicator Numerator (Successes) Number of times batch temps were recorded

Denominator Dinner Steam table temp logs Required number of times batch temps must be recorded (Total) Start 5/1/2018Target: 100% Responsible Leader: Margaret Mertens Date: Summary Num Den % Target 100% Week 1 14 14 100% ## 80% Week 2 14 14 100% ## 60% Week 3 14 14 100% ## 40% Week 4 14 14 100% ## ## % Compliant 20% ## 0% ## Week 1 Week 2 Week 3 Week 4 % Target ##

132 Addendum E

PMCD Breakfast Steam Table Logs

Denominator Breakfast Steam table temp logs Required number of times batch temps must be recorded (Total)

Start Date: 5/1/2018Target: 100% Responsible Leader: Margaret Mertens Summary 100% Num Den % Target Week 1 7 7 100% 100% 80% Week 2 7 7 100% 100% 60% Week 3 10 10 100% 100% 40%

Week 4 100%% Compliant 20% 100% 100% 0% Week Week Week Week 100% 1 2 3 4 % Target 100%

133 Addendum E

PMCD Lunch Steam Table Logs

Numerator Indicator Number of times batch temps were recorded (Successes) Denominator Required number of times batch temps must be Lunch Steam table temp logs (Total) recorded

Start Date: 5/1/2018Target: 100% Responsible Leader: Margaret Mertens Summary Num Den % Target 100% Week 1 9 9 100% ### 80% Week 2 8 8 100% ### 60% Week 3 15 15 100% ### 40% Week 4 ### ### % Compliant 20% ### 0% ### Week Week Week Week 1 2 3 4 % Target ###

Analysis Actions Taken May ‐ FANS started a new form for the café hot food. It was revised Informed Supervisor to provide correct form. several times for efficiency and clarity. For this preliminary dashboard, we are showing 4 weeks of data. Future dashboards will be monthly, the 25th through the 24th. 100% compliance noted.

134 Addendum E

PMCD Dinner Steam Table Logs

Indicator Numerator (Successes) Number of times batch temps were recorded

Denominator Dinner Steam table temp logs Required number of times batch temps must be recorded (Total) Start 5/1/2018 Target: 100% Responsible Leader: Margaret Mertens Date: Summary Num Den % Target 100% Week 1 8 8 100% ## 80% Week 2 7 7 100% ## 60% Week 3 8 8 100% ## 40% Week 4 ## ## % Compliant 20% ## 0% ## Week 1 Week 2 Week 3 Week 4 % Target ##

135 Addendum E

PMCP Breakfast Steam Table Logs

Numerator Indicator Number of times batch temps were recorded (Successes) Denominator Breakfast Steam table temp logs Required number of times batch temps must be recorded (Total)

Start Date: 5/1/2018Target: 100% Responsible Leader: Khristina Teope Summary 100% Num Den % Target Week 1 16 16 100% 100% 80% Week 2 16 16 100% 100% 60% Week 3 15 15 100% 100% 40%

Week 4 17 17 100% 100%% Compliant 20% #N/A 100% #N/A 100% 0% Week Week Week Week #N/A 100% 1 2 3 4 % Target 100%

136 Addendum E

PMCP Lunch Steam Table Logs

Numerator Indicator Number of times batch temps were recorded (Successes) Denominator Required number of times batch temps must be Lunch Steam table temp logs (Total) recorded

Start Date: 5/1/2018Target: 100% Responsible Leader: Khristina Teope Summary Num Den % Target 100% Week 1 17 17 100% ### 80% Week 2 14 14 100% ### 60% Week 3 16 16 100% ### 40% Week 4 15 15 100% ### #N/A ### % Compliant 20% #N/A ### 0% #N/A ### Week Week Week Week 1 2 3 4 ### % Target

137 Addendum E

PMCP Dinner Steam Table Logs

Indicator Numerator (Successes) Number of times batch temps were recorded

Denominator Dinner Steam table temp logs Required number of times batch temps must be recorded (Total) Start 5/1/2018 Target: 100% Responsible Leader: Khristina Teope Date: Summary Num Den % Target 100% Week 1 7 7 100% ## 80% Week 2 8 8 100% ## 60% Week 3 9 9 100% ## 40% Week 4 8 8 100% ## #N/A ## % Compliant 20% #N/A ## 0% #N/A ## Week 1 Week 2 Week 3 Week 4 % Target ##

138 Addendum E

PMCE & PMCD Protein Needs

Plan Do ‐ Measurement Numerator Indicator number of compliance (Successes)

Denominator Accurate assessment of protein needs number of charts audited monthly (30) (Total)

Start Date: 6/1/2018 Target: 100% Responsible Leader: Margaret Mertens

Summary 100% Num Den % Target 80% Jun 8 8 100% 100% 60% Jul 100% 40% Aug 100%

% Compliant 20% Sept 100% 0% Oct 100% Jun Jul Aug Sept Oct % Target 100%

Analysis Actions Taken

Audits began June 1st. Clinical RDs have all completed required training on protein needs assessment formulas and have passed required competency assessment. Nutrition care specialist is currently auditing charts.

139 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Ice Machines Maintained (Successes) Denominator A749 ‐ Infection Prevention‐ Ice Machine Maintenance Total Number of Ice Machines (Total)

Start Date: 6/1/2018 Target: 100% Responsible Leader: Roy B. Bacho Summary Num Den % Target 100% June 6‐7 7 7 100% 100% June 6‐21 #N/A 100% 80% July #N/A 100% 60% July #N/A 100% #N/A 100% 40% #N/A 100% % Compliant #N/A 100% 20% #N/A 100% #N/A 100% 0% June 6‐ June 6‐ July July #N/A 100% 7 21 #N/A 100% % Target #N/A 100%

Analysis Actions Taken Ice machine not maintained to sanitary requirements. 1. This is a repeat finding 1. Ice machine immediately taken out of service. from the survey 8/2017 and as a result, facilities staff have increased from Completed – April 12, 2018 monthly inspections to twice a month inspections for a period of 3 months. 2. Facilities Department staff inspected the ice machine, refastened screw and Initiated – May 2018; 2. Discrepancies found will be submitted as work orders repaired condensation drain. and repaired. Results of the inspections will be analyzed by the Facilities Completed – April 12, 2018 Operations Manager and reported to the Infection Control Committee for 3. Facilities Department contacted vendor to conduct maintenance on the ice review, feedback and recommendations. Initiate – June 2018 machine. Completed – April 22, 2018 4. Facilities Operations Manager provided education for the facility operations staff on what to look for when reviewing field reports and when conducting physical inspections. Completed – April 2018

140 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of stairwells that passed inspection (Successes) Denominator K211 ‐ Means of Egress. Number of Stairwells Passing Inspection Checks done per month (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Roy Bacho Summary Num Den % Target 100% May 31 31 100% 100% June 8 8 100% 100% 80% July #N/A 100% 60% Aug #N/A 100% Sept #N/A 100% 40% Oct #N/A 100% % Compliant Nov #N/A 100% 20% Dec #N/A 100% #N/A 100% 0% May June July Aug Sept Oct Nov Dec #N/A 100% #N/A 100% % Target #N/A 100%

Analysis Actions Taken Aisles, Corridors and Ramp width were inspected and are cleaned of debris or No actions to take this time. 100% passing rate. broken glasses. This report will be presented at our next EOC meeting and will be voted on as to whether we continue this weekly inspection or remove from the list and place them back to normal door inspection program regular frequency

141 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Monthly Maintenance Conducted (Successes) Denominator K 291 ‐ Emergency Lighting. Number of Maintenance Completed Number of Monthly Maintenance Required (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Roy Bacho Summary Num Den % Target 100% May 1 1 100% 100% June 1 1 100% 100% 80% July #N/A 100% 60% Aug #N/A 100% Sept #N/A 100% 40% Oct #N/A 100% % Compliant Nov #N/A 100% 20% Dec #N/A 100% #N/A 100% 0% May June July Aug Sept Oct Nov Dec #N/A 100% #N/A 100% % Target #N/A 100%

Analysis Actions Taken In stairwell 6, the battery operated emergency light between floor 7 & 8 failed to Facilities Operations staff replaced the battery powered emegency light 4/12/2018 illuminate. • The existing monthly preventative maintenance check for battery‐ powered lights will be used to identify failures. Discrepancies found will be submitted as work order and repaired. Results of the inspection will be analyzed by the Facilities Operations Manager and reported to Environment of Care Committee (EOC) for review, feedback and recommendations.

142 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Monthly Maintenance Conducted (Successes) Denominator K293 ‐ Exit Signage. Number of Maintenance Completed Number of Monthly Maintenance Required (Total)

Analysis Actions Taken 2.On the 9th floor outside of the dining room, two exit signs equipped with Facilities Department staff replaced the five exit signs with battery packs for back‐up battery packs for back‐up power failed to illuminate when the test button was power which failed to illuminate when tested or were missing test button. pushed. 3. The exit sign outside of room 920 was equipped with battery packs (4/12/2018) for back‐up power failed to illuminate when the test button was pushed. 4. The • Facilities Operations staff inspected the entire facility to ensure no additional battery exit sign outside of room 924 was equipped with a battery pack for back‐up operated exit signs exist. None were found. (4/12/2018) power was missing test button and the battery’s function could not be verified. • Facilities Department staff performed 90 minute test on exit signs with battery packs 5. The exit sign outside of room 928 was equipped with battery packs for back‐ for back‐up power. (4/12/2018) up power failed to illuminate when the test button was pushed. 6. No records of • Facilities Operations Manager added the monthly and annual testing requirements the annual 90 minute test for exit signs which have battery back‐up. for exit signs equipped with battery packs for back‐up power to the maintenance • The existing preventative maintenance check list for exit signs has been check list. (4/12/2018) modified to include monthly and annual testing of the battery packs for these • In‐service training was conducted on deficiencies and correction to the Plant signs. (4/12/2018) Discrepancies found will be submitted as work order and Operators by the Facility Operations Manager. (4/12/2018) repaired. Results of the inspection will be analyzed by the Facilities Operations Manager and reported to Environment of Care Committee (EOC) for review, feedback and recommendations

143 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of pull stations inspected (Successes) Denominator K345 ‐ Sprinkler System. Number of Pull Stations Inspected. Number of pull stations (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Roy Bacho Summary Num Den % Target 100% May 31 31 100% 100% June 31 31 100% 100% 80% July #N/A 100% 60% Aug #N/A 100% Sept #N/A 100% 40% Oct #N/A 100% % Compliant Nov #N/A 100% 20% Dec #N/A 100% #N/A 100% 0% May June July Aug Sept Oct Nov Dec #N/A 100% #N/A 100% % Target #N/A 100%

Analysis Actions Taken Fire Alarm System Testing and Maintenance ‐ A pull station was blocked on the Noactions to take this time. 100% passing rate. loading dock. The loading dock is being inspected daily by the Facilities Opearations staff for three months to ensure the awareness training was effective.

144 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Quarterly Reviews Conducted (Successes) Denominator K345 ‐ Sprinkler System. Number of Quarterly Inspection Reviewed Number of Quarterly Reviews (Total)

Start Date: 5/1/2018 Target: 100% Responsible Leader: Roy Bacho Summary Num Den % Target 100% Q2 1 1 100% 100% Q3 1 1 100% 100% 80% Q4 #N/A 100% 60% #N/A 100% #N/A 100% 40% #N/A 100% % Compliant #N/A 100% 20% #N/A 100% #N/A 100% 0% Q2 Q3 Q4 #N/A 100% #N/A 100% % Target #N/A 100%

Analysis Actions Taken Private Branch Exchange (PBX) office the Main Fire Panel did not emit an audible • Fire System Contractor out immediate service and repair. Component repaired, signal when tested. Inspection results are reviewed on a quarterly basis by the tested and put back into service with‐in the hour. (4/12/2018) Facility Operations Manager and Lead. Results of the inspection will be analyzed • Facility Operations Manager reviewed prior inspection and testing of that device. No by the Facilities Operations Manager and reported to the Environment of Care discrepancies were found for past 12 months. (4/12/2018) Committee (EOC) for review, feedback and recommendations.

145 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Monthly Maintenance Conducted (Successes) Denominator K345 ‐ Sprinkler System. Number of Inspections Conducted Number of Monthly Maintenance Required (Total)

Analysis Actions Taken Battery‐ powered smoke alarm not being maintained. • Facilities staff continues • The battery powered smoke alarm was not part of the facility fire alarm system. to inspect all hospital spaces to ensure that all smoke alarms are part of the Facilities Staff removed the smoke alarm. (4/12/2018) existing fire alarm systems. Discrepancies found are submitted as work orders and repaired. Results of the inspections will be analyzed by the Facilities Operations Manager and reported to the Environment of Care Committee (EOC) for review, feedback and recommendations.

146 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Monthly Maintenance Conducted (Successes) Denominator K500 ‐ Building Services. Number of Monthly Maintenance Completed Number of Monthly Maintenance Conducted (Total)

Analysis Actions Taken Failure to maintain electrical appliances (electric clothes dryer and vent) on the • Facilities Department staff conducted maintenance on the dryer and vent. 9th floor of the McLeod Tower. Facilities staff will conduct inspection and (4/12/23018) maintenance on the dryer and vent monthly according to manufacture • Facilities Operations Manager added the maintenance requirements of the dryer recommendation. Discrepancies found are submitted as work orders and and vent per manufacturer recommendations to the Computerized Maintenance repaired. Results of the inspections will be analyzed by the Facilities Operations Management System (CMMS) (4/12/2018) Manager and reported to the Environment of Care Committee (EOC) for review, • In‐service training was conducted by facility operations Manager to facility feedback and recommendations operations staff and hospital staff on deficiencies and correction. (4/12/2018)

147 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of Semi‐annual Maintenance Conducted (Successes) Denominator K781 ‐ Portable Space Heaters. Number of Monthly Maintenance Completed Number of Semi‐annual Maintenance Required (Total)

Start Date: 4/12/2018 Target: 100% Responsible Leader: Roy Bacho Summary Num Den % Target 100% April 1 1 100% 100% #N/A 100% 80% #N/A 100% 60% #N/A 100% #N/A 100% 40% #N/A 100% % Compliant #N/A 100% 20% #N/A 100% #N/A 100% 0% April #N/A 100% #N/A 100% % Target #N/A 100%

Analysis Actions Taken Portable space heater was in use in the PBX office. Facilities staff inspects all • Facilities Department staff removed the portable heater. (4/12/2018) areas in each building semiannually. Portable heaters will be added to the check • Awareness training for the PBX staff was conducted. (4/13/2018) list of items which are prohibited in healthcare occupancies. Discrepancies found • Repair to the main heating system was completed. (4/13/2018) will result in equipment being removed and additional awareness training for the • Facilities Department staff conducted an inspection of all health care occupancy offending department. Results of the inspection will be analyzed by the Facilities areas for additional space heaters (none were found). (4/12/2018) Operations Manager and reported to Environment of Care Committee (EOC) for review, feedback and recommendations.

148 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of sprinkler heads found clear from debris. (Successes) Denominator K353 Sprinkler System ‐ Maintenance and Testing Number of sprinkler heads rounded per week. (Total)

Start Date: 4/15/2018 Target: 100% Responsible Leader: Marcos Fierro Summary Num Den % Target 100% Week 1 54 54 100% 100% Week 2 54 54 100% 100% 80% Week 3 54 54 100% 100% 60% Week 4 52 54 96% 100% Week 5 54 54 100% 100% 40% Week 6 54 54 100% 100% % Compliant Week 7 54 54 100% 100% 20% Week 8 54 54 100% 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken Facilities Operations will inspect fire sprinkler heads to ensure that they are clean monitoring will continue at the same frequency. data will be analyzed and reported to and clear from debris or anything that alters spread of water when running. the infection control committee for further analysis and recommended next steps NFPA 101. Week 4 ‐ facops found two patient room sprinklers on the 7th floor west side (rooms Fire sprinkler heads were inspected during rounding by Facilities operations. 705, 722) unit that had a minimal of debris. Removed onsite and back at 100%. Facilies divided each zone / floor up and will inspect 54 per week. 54 is based off average per patient floor. If more are found, that bumber will be added to the denominator and values well change based off of that.

149 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of areas found within compliance. (Successes) K920 ‐ Electrical Equipment ‐ Power Cords and Extension Cords.Facilities Denominator Number of areas inspected. (this number is based of an average Operations will round and inspect areas for non approved extension (Total) number per floor)

Start Date: 4/15/2018 Target: 100% Responsible Leader: Marcos Fierro Summary Num Den % Target 100% Week 1 12 12 100% 100% Week 2 12 12 100% 100% 80% Week 3 12 12 100% 100% 60% Week 4 12 12 100% 100% Week 5 12 12 100% 100% 40% Week 6 12 12 100% 100% % Compliant Week 7 12 12 100% 100% 20% Week 8 12 12 100% 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken K920 ‐ Electrical Equipment ‐ Power Cords and Extension Cords. Facilities monitoring will continue at the same frequency. data will be analyzed and reported to Operations will round and inspect areas for non approved extension the infection control committee for further analysis and recommended next steps cords/power supplying units (surge protectors) that are not UL‐1363A or 1363 approved. Power cords and Extension cords are inspected during facility rounds 5 days a week, 12 locations within the 5 days. Facilities is looking for non approved power sources that do not comply with UL‐1363 and UL1363A standards.

150 PMC Escondido Plan Do ‐ MeasurementAddendum E Numerator Indicator Number of floors rounded per week and in compliance. (Successes) K922 ‐ Gas Equipment. Facilities Operations will round and inspect areas of the Denominator Number of floors rounded per week total. building for free standing O2 gas cylinders. (Total)

Start Date: 4/15/2018 Target: 100% Responsible Leader: Marcos Fierro Summary Num Den % Target 100% Week 1 10 10 100% 100% Week 2 10 10 100% 100% 80% Week 3 10 10 100% 100% 60% Week 4 10 10 100% 100% Week 5 10 10 100% 100% 40% Week 6 10 10 100% 100% % Compliant Week 7 10 10 100% 100% 20% Week 8 10 10 100% 100% Week 9 #N/A 100% 0% Week Week Week Week Week Week Week Week Week Week Week Week Week 10 #N/A 100% 1 2 3 4 5 6 7 8 9 10 11 12 Week 11 #N/A 100% % Target Week 12 #N/A 100%

Analysis Actions Taken O2 cylinders is the main focus of this indicator and will be rounded on each monitoring will continue at the same frequency. data will be analyzed and reported to week. This has been added to facilies rounds and 10 floors will be rounded per the Environment of Care Committee for further analysis and recommended next week indefinitley. The focus is around free standing cylinders and compliance steps. Staff education has also taken place with NFPA and EOC standards. along with reporting out during the daily district wide huddle calls for awareness.

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179 Page 33 of 273

ADDENDUM H

180 Addendum H

Passion. People. Purpose.TM

Annual Evaluation CY 2017 Environment of Care and Emergency Management Programs

Dan Farrow, Vice President, Hospitality and Facilities | June 18, 2018 Board Quality Review Committee

1 1

181 Addendum H

Seven Plans to Manage the Environment of Care • Safety • Security • Medical equipment • Utilities • Fire Prevention • Hazardous Materials • Emergency Management

182 Addendum H

2017 Key Activities and Accomplishments Safety Management: – Staff on Safety (SOS) • Wildfire safety • Ergonomics • Code Silver / Yellow / Pink / Purple / Green staff response tactics and expectations • MRI safety – Evaluation of Environment of Care (EOC) staff knowledge questions

183 Addendum H

2017 Key Activities and Accomplishments Security Management : – Expansion of security presence (satellite buildings) – Workplace violence prevention involvement (CalOSHA) – Development of visitor check‐in processes Medical Equipment Management: – Monitoring of equipment failures and recalls – Standardization of defibrillator platforms Utilities Management: – Monitoring of all utility failure and escalation process

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2017 Key Activities and Accomplishments

Fire Prevention Management: – Fire simulation training resource – Fire safety training for high risk departments – Monitoring of unplanned activations, repairs, and bypasses of fire / life safety system • Escalation process • Reporting to local fire

185 Addendum H

2017 Key Activities and Accomplishments Hazardous Materials Management: – Zero spills requiring outside agency assistance – Decontamination Team training

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2017 Key Activities and Accomplishments Emergency Management: – Integration of new CMS standards – ‘Ready, Prep, GO!’ preparedness outreach fair (2nd annual) – Hospital Preparedness Program (HPP) grant funding – County / Statewide disaster exercise involvement – Completion of quarterly ‘mini‐drills’ – Training sessions for leaders • HICS / NIMS (Hospital Incident Command System / National Incident Management System) • WebEOC • NLO (New Leader Orientation)

187 Addendum H

2018 Program Goals Safety Management Performance metrics: • Monitoring unsecured O2 tanks – Just in time training • Monitoring of staff knowledge of RACE (rescue, alert, confine, extinguish) – Expansion of questions to validate compliance • Monitoring of staff knowledge of PASS (pull, aim, squeeze, sweep) – Expansion of questions to validate compliance

188 Addendum H

2018 Program Goals Security Performance Metrics: • Measuring Code Gray and Code Green response rate to ensure communication process is being followed properly – Debrief and escalation • Strengthen security observation capability – Access control – Alarm system functionality • Upgrade access groups in ID badge system

189 Addendum H

2018 Program Goals Hazardous Materials Performance Metrics: • Improper labeling for any trends / training needs • Staff knowledge of obtaining safety data sheet (SDS) • Hazardous chemical incidents • Monitoring of bio‐hazard waste incidents • Expansion of Code Orange (chemical spill) response team

190 Addendum H

2018 Program Goals Fire Prevention Performance Metrics: • Actual fires • Unscheduled fire system activations / failures • Fire wall penetration compliance • Number of fire drills requiring additional training and drills • Number of staff participating in drills

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2018 Program Goals Medical Equipment Performance Metrics: • 100% Preventative Maintenance (PM) completion rate for high risk medical equipment • ≥ 90% Preventative Maintenance (PM) completion rate for non‐high risk medical equipment • < 5% of medical equipment not located in scheduled month • ≥ 90% repairs completed within 30 days of work order creation • <5 day turnaround time for ‘urgent’ work orders • ≥73% of clinical department satisfaction score

192 Addendum H

2018 Goals Utilities Performance Metrics: • Utility failures – Tracking of both internal and external – Tracking escalation • Pneumatic tube system failures • Number of elevator entrapments • Number of sewage failures – Causes • Emergency generator testing per standard

193 Addendum H

2018 Program Goals Emergency Preparedness Performance Metrics: • Conduct at least two disaster exercises per year, using top hazard vulnerability analysis (HVA) risks and evaluate exercises, with a ≥ 90% goal • ≥ 90% ‐ Staff knowledge of location of department disaster supplies • ≥ 90% ‐ Staff knowledge of Emergency and Safety Response guide • ≥ 90% ‐ Staff knowledge of actions to take during and earthquake • ≥ 90% ‐ Staff knowledge of role to take during a Code Triage • ≥ 90% ‐ Staff knowledge of actions to take when an Everbridge notification is received • Conduct at least six disaster preparedness / safety trainings per quarter

194 Addendum H

Questions?

195 Addendum H

Prepared by: Lisha Wiese: Program Manager – Emergency Management and Safety

Palomar Medical Center Escondido Palomar Medical Center Downtown Campus Palomar Medical Center Poway Villa Pomerado Satellite Buildings

Annual Evaluation of the Environment of Care Management Plans and the Emergency Operations Plan

2017

Date prepared: May 21, 2018

196 Addendum H

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 and Satellite Buildings. 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 and security 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 2017, focusing on proactive activities, and ongoing education.

197 Addendum H

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 satellite buildings 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 assessmentof 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 multidisciplinary 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 2018. 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 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 stated objectives.

198 Addendum H

FIRE PREVENTION 4 EVALUATION OF THE SCOPE 1. Performance standards – Review of performance standards for the Environment of Care for 2017, including re-assessing thresholds of Evaluation of the Scope of the Environment of Care performance. Management plans: The scope of each management plan 2. Fire drills conducted and evaluated by Security staff, one per shift per quarter, with additional drills completed per staffing requirements or applies to all personnel in each facility and satellite building. construction areas and satellite buildings. Each facility and building is periodically surveyed, and every 3. Statement of Conditions (SOC) reviewed and kept updated by Facility attempt is made to ensure risks are identified that may have an Managers. impact on the reduction of accidents or injury. 4. Annual fire detection systems tested and certified. Staff are required to work in a safe manner, and to report 5. Annual fire extinguisher maintenance completed. unsafe acts or observations, without any fear of reprisal. 6. Facility Environment of Care reports reviewed quarterly by the The following Environment of Care accomplishments Environment of Care Committee. 7. Fire safety and response training provided to PMC Escondido kitchen throughout the year 2017 represent the staff. emphasis on safe work behaviors and risk reduction, and 8. Interactive fire simulation device utilized for a more robust fire validate leadership’s support of safety throughout the physical extinguisher training experience for staff. environments of our medical centers and satellite buildings, 9. Annual evaluation of the Fire Prevention Management plan completed: as well as support and dedicate attention to high standards of Objectives, Scope, Performance Standards and Overall Effectiveness. safe work behaviors for all staff. The multitude of accomplishments UTILITIES MANAGEMENT validate a breadth and depth of the scope of our Environment 1. Performance standards – Review of performance standards for the of Care management plans and the Emergency Operations Plan. Environment of Care for 2017, including re-assessing thresholds of performance. 2. Generator testing completed per regulatory standards. SAFETY MANAGEMENT 3. Preventive maintenance and corrective maintenance monitored for high 1. Performance standards – Review of performance standards for the risk (including life support equipment) and non-high risk utility Environment of Care for 2017, including re-assessing thresholds of equipment. performance. 4. Facility Environment of Care reports reviewed quarterly by the 2. Reporting schedule established for the Environment of Care committee. Environment of Care Committee. 3. Continuing linkage of safety and environment of care training items on 5. Utility failures reported to Environment of Care committee, each resolved current Staff on Safety (SOS) meeting agenda’s. SOS is a district wide with follow-up actions documented. training program in which departmental staff are empowered with knowledge, 6. Annual evaluation of the Utility Management plan and program and are expected to educate their department peers. completed: Objectives, Scope, Performance Standards and Overall 4. Facility Manager Environment of Care reports reviewed quarterly by the Effectiveness Environment of Care Committee. EMERGENCY MANAGEMENT 5. Multi-disciplinary environmental surveillance: ongoing, with deficiencies 1. Performance standards – Review of performance standards for the identified and documented in Sentact and issues sent to Director for she / he Environment of Care for 2017, including re-assessing thresholds of to resolve and close out in Sentact performance. 6. 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 MANAGEMENT 3. Hazard Vulnerability Analysis (HVA) reviewed / revised for 2017 with the 1. Performance standards – Review of performance standards for the top five hazards identified for each medical center. Environment of Care for 2017, including re-assessing thresholds of 4. Everbridge notification drills completed semi-annually to coincide with performance. county and statewide exercises. Over 900 physicians included in 2. Exterior door identifier signage installed at PMC P and Villa Pomerado. This notification exercises. will assist first responders and staff in covering specific doors in case of 5. Development of curriculum for nursing units on the TRAIN (Triage by security incidents. Resource Allocation for Inpatients) evacuation concept. 3. Ongoing active shooter (ALiCE – Alert, lockdown, inform, counter, evacuate) 6. The second annual disaster preparedness and safety community and Management of Assaultive Behavior (MAB) training by staff / physician ‘outreach event’ titled ‘Ready, Prep, GO! provided for Palomar Health request. staff and community members in September in order to empower the 4. Expansion of Security services at satellite buildings. community to get prepared. 5. Code Pink/Purple drills conducted and evaluated with effective outcomes. 7. Ongoing membership with San Diego Healthcare Disaster Coalition 6. Workplace violence prevention multidisciplinary team continued collaborating. (SDHDC) which strengthens whole-community relationships with other 7. Annual Evaluation of the Security Management Plan completed: Objectives, San Diego County hospitals, SD County Emergency Medical Services Scope, Performance Standards and Overall Effectiveness completed. (EMS), SD County Office of Emergency Services (OES), Red Cross, SD HAZARDOUS MATERIAL MANAGEMENT County Public Health, and law enforcement agencies. 1. Performance standards – Review of performance standards for the 8. Continued collaboration with SD County Emergency Medical Services Environment of Care for 2017, including re-assessing thresholds of (EMS) in the area of Hospital Preparedness Program (HPP) grant performance. funding. All deliverables completed in May 2017 and grant funds were 2. No spills requiring outside agency assistance reported throughout 2017. received totaling $64,702. 3. Annual Evaluation of the EOC for Hazardous Materials Management Plan 9. Everbridge emergency notification system used exclusively during completed: Objectives, Scope, Performance Standards, Overall exercises and actual events. Effectiveness. 10. Disaster surge cart medical supplies inventoried by supply chain staff to MEDICAL EQUIPMENT MANAGEMENT ensure expiration dates are monitored and supplies are rotated into the 1. Performance standards – Review of performance standards for the supply stream. Environment of Care for 2017, including re-assessing thresholds of 11. Continued collaboration with Kaiser Emergency Management and performance. Rady’s Children’s colleagues to ensure communication is flawless during 2. Medical equipment failures and recalls monitored by Biomedical leadership disaster events. with appropriate actions taken. 12. Countywide disaster exercise completed at each site May 2017. 3. Preventive maintenance and corrective maintenance monitored for high risk 13. Statewide disaster exercise completed at each site November 2017. (including life support equipment) and non-high risk medical equipment. 14. Annual evaluation for the Emergency Operations Plan completed: 4. Annual evaluation of the Medical Equipment plan and program completed: Objectives, Scope, Performance, Effectiveness. Objectives, Scope, Performance, Effectiveness.

199 Addendum H

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 Management Plan Performance Standards The following performance activities were undertaken in 2017: (1) Monitoring of O2 bottles found unsecured during monthly Environment of Care (EOC) rounds (2) Staff knowledge on the meaning 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)

Security Management Plan Performance Standards The following performance activities were undertaken in 2017: (1) Implementation of CA Senate Bill 1299 – Workplace Violence Prevention program (2) Secure Lenel security access control, alarm and CCTV integration systems, secure PRISM video management system, and upgrade server capabilities (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

Hazardous Materials and Waste Management Plan Performance Standards The following performance activities were undertaken in 2017: (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 Management Plan Performance Standards The following performance activities were undertaken in 2017: (1) Monitoring of actual fires reported inside the facilities (2) Monitoring of building and / or protection system monitoring – problems, significant incidents, unexpected repairs

Medical Equipment Management Plan Performance Standards The following performance activities were undertaken in 2017: (1) Preventative maintenance (PM) completion rate for high risk equipment, including life support equipment (100% threshold) (2) Preventative maintenance (PM) completion rate for non-life support equipment (95% threshold) (3) <5% of unable to locate pieces of medical equipment (4) ≥90% of equipment repairs completed within 30 days (5) <2% of user errors

Utility Equipment Management Plan Performance Standards The following performance activities were undertaken in 2017: (1) Monitoring of facility utility failures (2) Occurrences requiring external reporting (3) Monitoring of elevator failures (4) Emergency generator testing compliance per regulatory standards (100% threshold)

Emergency Operations Plan Performance Standards The following performance activities were undertaken in 2017: (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) (4) Conduct at least six emergency management / safety training sessions for staff per quarter 200 Addendum H

6 EVALUATION: PERFORMANCE STANDARDS

EOC Component: SAFETY MANAGMENT Performance Standard: The following performance activities were undertaken in 2017: 1. O2 bottles found unsecured during monthly EOC rounding 2. Staff knowledge of RA.C.E (Rescue, Alarm, Contain, Extinguish / Evacuate), Evaluation: 1. During monthly and P.A.S.S (Pull, Aim, Squeeze, Sweep) acronyms (90% threshold) Environment of Care (EOC) multi- Safety Management Plan for Improvement: disciplinary rounds, facility - We will continue to monitor unsecured O2 operations staff monitored areas for tanks throughout the district during monthly unsecured O2 tanks. If any EOC rounds to ensure O2 tanks are being were found, the tank was first stored and transported safely. secured properly, and the - We will continue to ensure that staff are able to department leader was notified define the meanings of RACE and PASS during and just in time training was monthly EOC rounding. provided to staff on the risks of Monitoring to continue on quarterly EOC reports. unsecured tanks. We saw an increase of unsecured tanks at PMC E in the 2nd and 3rd quarters, however, with staff education and diligent monitoring, O2 bottles found unsecured during monthly rounds: we were able to reduce our numbers drastically in the 4th 10 quarter. 9 2. During monthly EOC rounds, 8 7 facility operations staff monitored 1 Q 2017 staff knowledge regarding the 6 5 R.A.C.E and P.A.S.S acronyms. 5 2 Q 2017 Our threshold is 90% and was met 4 3 Q 2017 at each facility each quarter. 3 2 In the 1st quarter, rounding occurred 2 4 Q 2017 in unoccupied areas of PMC DT, 1 00000000000000 so staff knowledge was unable to 0 be obtained. PMC E PMC D PMC P VP

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 2017 2 Q 2017 3 Q 2017 4 Q 2017

0% 0% PMC E PMC D PMC P VP

201 Addendum H

EOC Component: SECURITY MANAGEMENT 7 Performance Standard: The following performance activities were undertaken in 2016: 1. Implementation of CA Senate Bill 1299 – Workplace Violence Prevention Program 2. Secure Lenel security access control, alarm, and CCTV integration system; secure PRISM video management system and upgrade server capabilities 3. Made 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 per campus

Evaluation:

1. Palomar Health campuses have aging CCTV systems, access control and server technology dating back many decades. 2017 Quarterly Security Classes: Plan for Improvement: Some systems are outdated 1Q17 – and / or are sun setting. • 3 Classes: ALiCE (Alert, 1. Security management will begin Upgrading and Lockdown, inform, Counter, Measuring Code Gray responses enhancements are critical. A Evacuate) to ensure, PH employees are capital project to upgrade this • 1 Classes: MAB (Managing following procedure by system is currently under Aggressive Behavior) calling all Code Grays in to PBX, review in the Capital and PBX putting the information Improvement Committee. • 2 Classes: Other security topics out overhead. 2. Security leadership 2Q17 – 2. Security management will begin taught over 21 security • 1 Classes: ALiCE (Alert, Measuring Code Green responses related classes in 2017. Lockdown, inform, Counter, to ensure, PH employees are Hundreds of employees , Evacuate) following procedure by volunteers and • 1 Classes: MAB (Managing calling all Code Greens into PBX, Medical Staff were trained. Aggressive Behavior) and PBX putting the information • 1 Class: Personal security out overhead 3. We met our goal of <2 vehicle thefts per quarter at awareness 3. Security Services will continue each campus. There were no • 1 Classes: Other security topics our plans of strengthening our vehicle thefts in 2017. 3Q17 - Security observation capability, access control, and alarm 4. Tighter access control • 2 Classes: ALiCE (Alert, system functionality in 2018 by procedures were implemented at Lockdown, inform, Counter, upgrading the LENEL integration PMC DT and PMC Escondido Evacuate) system and adding the in the ED. A check in and visitor • 2 Classes: MAB (Managing PRISM video management system stickering process was added, Aggressive Behavior) at PMC Poway. greatly enhancing current access and visitor control . • 1 Class: Personal security awareness 4. Security services has partnered • 1 Classes: Other security topics with a vendor to clean up, and upgrade access groups and areas 4Q17 – in the PH ID Badge system. • 3 Classes: ALiCE (Alert, Lockdown, inform, Counter, Evacuate) • 1 Classes: Management of Aggressive Behavior (MAB) • 1 Classes: Other security topics

202 Addendum H

8 EOC Component: HAZARDOUS MATERIALS AND WASTE MANAGEMENT Performance Standard: The following performance activities were undertaken in 2017: 1. Monitoring of the number of hazardous material containers inspected / labeled incorrectly during monthly EOC rounds 2. Staff knowledge in obtaining Safety Data Sheet (SDS) information Evaluation: during monthly EOC rounds (90% threshold) 1. During monthly 3 & 4. Monitoring of the number of hazardous waste and bio hazardous Environment of Care (EOC) multi- waste incidents requiring outside agency cleanup disciplinary rounds, facility Operations staff monitored hazardous Inappropriate labeling on hazardous material container monitoring: material containers for inappropriate labeling. There were no deficiencies found in 2017. 5

2. During monthly EOC rounds, 4 facility staff monitored staff knowledge regarding how to locate 1 Q 2017 3 Safety Data Sheet (SDS) information. 2 Q 2017 Our threshold is 90% and was met at each facility each quarter, except for 2 3 Q 2017 PMC DT in which staff was not 4 Q 2017 surveyed. 1 3 and 4. Number of hazardous and 0000000000000000 bio hazardous waste incidents 0 requiring outside assistance for PMC E PMC D PMC P VP cleanup was zero in 2017.

Staff knowledge on how to obtain Safety Data Sheet (SDS) information: 90% threshold 100%

1 Q 2017 2 Q 2017 3 Q 2017 4 Q 2017

0% PMC E PMC D PMC P VP

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 2017 elements in our 3 hazardous materials 2 Q 2017 plan, as high levels of compliance promote risk 2 3 Q 2017 reduction relating to 4 Q 2017 hazardous materials 1 and waste usage. 000000000000000 0 0 PMC E PMC D PMC P VP 203 Addendum H

EOC Component: FIRE PREVENTION MANAGEMENT 9 Performance Standard: The following performance activities were undertaken in 2017: 1. Monitoring of actual fires reported inside the facilities 2. Monitoring of building and / or fire protection systems - failures

Evaluation: Number of actual fires reported inside the facilities: 1. There were no incidents of fires at any of the facilities in 2017. 5 4 2. At PMC DT, PMC P, and VP, 1 Q 2017 there were no significant building 3 protection failures in 2017. 2 Q 2017 In the 1st quarter, PMC E experienced a failure with the lower 2 3 Q 2017 level switch gear, causing failure 4 Q 2017 to ER, OB, and other surrounding 1 areas. Fire watch was performed as procedure. 000000000000000 0 0 PMC E PMC D PMC P VP

Building fire protection system failures:

4 1 Q 2017 3 2 Q 2017 2 3 Q 2017 1 4 Q 2017 1 00000000000000 0 PMC E PMC D PMC P VP

Plan for Improvement: We will continue to minimize the risk of fire and smoke in all Palomar Health facilities. We will continue monitoring any significant failures at our campuses.

204 Addendum H

10 EOC Component: MEDICAL EQUIPMENT MANGEMENT Performance Standard: 1. Preventative maintenance (PM) completion rate for high risk Evaluation: medical equipment (100% threshold) 1. Biomed consistently met 2. Preventative maintenance (PM) completion rate for non-high risk their 100% threshold of medical equipment (95% threshold) preventative maintenance on high 3. <2% of equipment service requests that were related to user risk medical equipment errors throughout 2017 at PMC P and VP. 4. <5% of unable to locate pieces of medical equipment In the 1st and 2nd quarters at PMC E, 5. ≥90% of equipment repairs completed within 30 days And the 2nd quarter at PMC DT, we were out of compliance due to Preventative maintenance completion rates on high risk medical a non-located external pacemaker equipment: and two missing defibrillators. 100% PM completion threshold

99%100% 100% 100% 100%100%100% 100% 100% 100% 100% 100% 2. Biomed consistently 100% 98% 100% 100% met their 95% threshold of 95% preventative maintenance on non-life support equipment throughout 2017, with the exception of several of the quarters. This was caused by pieces of equipment that 1 Q 2017 were not able to be located. 2 Q 2017 3. When biomedical staff 3 Q 2017 respond to a work order that was caused by an operator error, 4 Q 2017 technicians offer on the spot training for the operator and it is noted in the work order. If an equipment user has repeated 0% errors on the same model of PMC E PMC D PMC P VP equipment, the department manager is advised and Plan for Improvement: additional training is recommended. We will continue monitoring PM completion rates as high completion rates for both 4. The threshold was met high risk and non high risk medical consistently throughout equipment promotes operational reliability 2017 on <5% of unable to of equipment that is used on our patients, and locate pieces of medical supports our patient safety goals. equipment throughout the district. We will continue to monitor our other goals and watch for any apparent trends or gaps. 5. The threshold was met consistently throughout 2017 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 97% 98% 98% 100% 100% 100% 100% 96%94% 95% 96% 100% 90% 90% 85% 81% 95% threshold

67% 1 Q 2017 2 Q 2017 3 Q 2017 4 Q 2017

0% PMC E PMC D PMC P VP

205 Addendum H

Medical Equipment continued 11 <2% of equipment service requests related to user errors:

10% 1 Q 2017

2 Q 2017

3 Q 2017

4 Q 2017

<2% 1% 1% 1% 1%

0% District Totals

<5% of unable to locate pieces of medical equipment:

30% 1 Q 2017 2 Q 2017 20% 3 Q 2017 4 Q 2017

10% 4% 4% 3% 2% <5% threshold 0% District

≥90% of equipment repairs completed within 30 days:

95% 95% 100% 90% 90% ≥90% threshold

1 Q 2017 2 Q 2017 3 Q 2017 4 Q 2017

0% District

206 Addendum H

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 regulatory standard Utility failure monitoring: Evaluation: Electricity, water, natural and medical gas failures 1. Utility failure monitoring includes any electricity, water, natural and medical gas 2 failures. In the 1st quarter, PMC E experienced a failure with the lower level switch gear, causing failure to ER, OB, and other surrounding 1 Q 2017 areas. Emergency generators 1 performed as design. 1 2 Q 2017 3 Q 2017 2. There was one utility failure at 4 Q 2017 PMC E that required external notification. In the 1st quarter, PMC E 000000000000000 experienced a failure with the lower 0 level switch gear, causing failure PMC E PMC D PMC P VP to ER, OB, and other surrounding areas. Emergency generators performed as design.

3. Tube system failures were Plan for Improvement: monitored throughout 2017. We will continue monitoring, keeping 4. Elevator entrapments were monitored our efforts on prevention, throughout 2017. and utility equipment operational reliability 5. Generator testing, which is which strengthens our considered high risk patient safety focus. utility equipment, was completed at 100% at all facilities in 2017.

Outside agency reporting:

1 Q 2017 1 1 2 Q 2017 3 Q 2017 4 Q 2017

000000000000000 0 PMC E PMC D PMC P VP

207 Addendum H

Utility Equipment 13 continued Tube system failure monitoring:

10 9 8 7 1 Q 2017 6 5 2 Q 2017 4 3 Q 2017 3 4 Q 2017 2 1 000000000000 0 PMC E PMC D PMC P

Elevator entrapment monitoring:

15 14 13 12 11 10 1 Q 2017 9 8 2 Q 2017 7 6 3 Q 2017 5 4 4 Q 2017 4 3 3 2 111 1 1 1 0 0 0 0 0 0 PMC E PMC D PMC P

Emergency generator testing per regulatory standard: 100% threshold

100%

1 Q 2017 2 Q 2017 3 Q 2017 4 Q 2017

0% PMC E PMC D PMC P VP

208 Addendum H

EOC Component: EMERGENCY MANAGEMENT / EMERGENCY OPERATIONS PLAN (EOP) 14 In 2017 multiple events occurred in the area of emergency management. The multidisciplinary 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 and community.

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 in 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 2017, Palomar Health participated in several county and statewide exercises : 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 E: 1.June 8– Countywide exercise involvement. Simulated a complex coordinated terrorist attack across SD County causing multi casualties with patient surge across the county. • Event score: 96% with follow up activities identified. 2. November 17 – Statewide exercise involvement. Scenario was a terrorist attack across SD County. All hospitals experienced security issues. • Event score: 96% with follow up activities identified. PMC D: 1.June 8– Countywide exercise involvement. Simulated a complex coordinated terrorist attack across SD County causing multi casualties with patient surge across the county. • Event score: 96% with follow up activities identified. 2. November 17 – Statewide exercise involvement. Scenario was a terrorist attack across SD County. All hospitals experienced security issues. • Event score: 96% with follow up activities identified.

PMC P: 1.June 8– Countywide exercise involvement. Simulated a complex coordinated terrorist attack across SD County causing multi casualties with patient surge across the county. • Event score: 96% with follow up activities identified. 2. November 17 – Statewide exercise involvement. Scenario was a terrorist attack across SD County. All hospitals experienced security issues. • Event score: 96% with follow up activities identified.

Villa Pomerado: 1.June 8– Countywide exercise involvement. Simulated a complex coordinated terrorist attack across SD County causing multi casualties with patient surge across the county. • Event score: 96% with follow up activities identified. 2. December 15 – Wildfire in the immediate area of Villa Pomerado • Event score: 92% with follow up activities identified.

Satellite Buildings, including Home Health: 1.June 8– Countywide exercise involvement. Simulated a complex coordinated terrorist attack across SD County causing multi casualties with patient surge across the county. • Event score: 96% with follow up activities identified. 2. November 17 – Statewide exercise involvement. Scenario was a terrorist attack across SD County. All hospitals experienced security issues. • 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 collaborating The Disaster Committee has assumed the With outside agencies to responsibility for implementing the improvement Ensure we approach disaster actions. We will continue with pre-planning for Preparedness with a ‘whole drills, identifying objectives that test stressing Community’ approach. our procedures and systems.

209 Addendum H

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) 4. Conduct at least six emergency management / safety training sessions for staff per quarter.

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% Evaluation: 1. During each of the Countywide exercises in 2017, the threshold of Ex 90% was met consistently at each Statewide Ex medical center and satellite building. Action items were identified post event as well as what items went 0% well. These items were forwarded PMC E PMC D PMC P VP Outside Areas to the disaster and environment of care committees for review.

2 and 3. During monthly EOC Staff knowledge during EOC surveillance rounds in articulating rounds, Emergency Management where his or her unit’s disaster supplies are located: 90% threshold Staff monitored staff knowledge regarding the locations of 100% disaster equipment, hospital Threshold = 90% command centers and labor pools. Our threshold is 90% and was met at each facility by quarter, 1 Q 2017 with several exceptions at PMC E and PMC P. Staff was given 2 Q 2017 just in time training on the 3 Q 2017 locations during the rounding, and a follow up email was sent to 4 Q 2017 department leadership with instructions to complete training.

0% 4. Training sessions: PMC E PMC D PMC P VP 1st quarter = 16 trainings 2nd quarter = 15 trainings 3rd quarter = 12 trainings 4th quarter = 8 trainings Staff knowledge during EOC surveillance rounds in articulating where the hospital command center and labor pools are located: 90% threshold 100% Threshold = 90% 1 Q 2017 2 Q 2017 3 Q 2017 4 Q 2017 0% PMC E PMC D PMC P VP 210 Addendum H

16 Annual Evaluation - Overall Effectiveness – 2017

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.

SECURITY. The Management Plan for Security and the security program is effective across the district, with the objectives being met in 2017. 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 2017, we will continue monitoring security trends to identify areas of risk to the medical centers and satellite buildings, 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 2017, 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 2017 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 8-hour first responder training in 2017, 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 medical centers and satellite buildings, 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., high risk medical equipment from non-high risk 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 2017, 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 2017. The Hazard Vulnerability Analysis's are reviewed annually and are 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, creating a whole-community approach to Emergency Management.

211

ADDENDUM I

212 Addendum I

Passion. People. Purpose.TM

Pulmonary Services Annual Report FY 2018

Kerwin Pipersburgh, District Manager Respiratory Care Krysti Johnson, District Supervisor Respiratory Care

1 1

213 Addendum I

Ventilator Days Results FY 2017: Results YTD FY 2018: PMC Escondido: 7.2 % decrease in vent days PMC Escondido: 7 % decrease in vent days PMC Poway: 3.2 % decrease in vent days PMC Poway: 24 % decrease in vent days

PMC‐ESCONDIDO PMC‐Poway 5600 1400 5400 1200 5200 1000 2016 2016 5000 800 2017 2017 4800 600 2018 2018 4600 400 4400 200 4200 0 Ventilator Days Ventilator Days

214 Addendum I

Rapid Shallow Breathing Index (RSBI) Ventilator Weaning Protocol Goal: 1. Initiate ventilator weaning protocol by 8 am every day 100% of the time. 2. Decrease ventilator days. Outcome: PMC: 98% POM: 95% Oversight: Pulmonary Committee and Critical Care Committee.

215 Addendum I

Ventilator Utilization (Standardized Utilization Ratio) 2

1.8

1.6

1.4

1.2

0.8

0.6

0.4

0.2

0 2017Q1 2017Q2 2017Q3 2017Q4 2018Q1 PMCE CCU PMCE Trauma PMCP ICU

216 Addendum I

Goals for FY 2019

• Decrease length of stay on a ventilator for weanable patients using the best practice weaning guidelines. • Work collaboratively with the physician and nursing to identify patients at risk for intubation. – Early identification and skillful use of BiPAP and high‐ flow nasal cannula (HFNC) can avoid intubation and improve outcomes. • Decrease in SUR will result in a decrease in Standard Infection Ratio (SIR) for Ventilator‐Associated Events. • Have the RCPs consistently participate in multidisciplinary rounds at Poway and Escondido.

217 Addendum I

Initiative To Reduce Respiratory Device Related Pressure Injuries

• Respiratory continues to work collaboratively with our nursing partners. • A bundle identifying those patients at high risk for injury, was created, educated to, and implemented. • Education in this initiative was given to: – RCP’s, Nursing in CCU (Esc, Poway), IMC (Esc, Poway), UPC, CEC • Audits with real time feed‐back is given to practitioners. • Since implementation, positive outcomes have been seen.

218 Addendum I

What is included in the new bundle? • The RCP is working collaboratively with the primary nurse to identify patients who are at a high risk for skin breakdown. • Once the patient is identified as high risk, the BiPAP mask will be rotated every two hours. • Mepilex to bridge of nose on all patients. • The skin is assessed and documented every two hours by a respiratory therapist.

219 Addendum I

Respiratory Device Related Pressure Injury Data

25 Results 20 11/5/2018 to 4/4/2018 PMC Escondido: 22 15 PMC Poway: 4

10 4/4/2018 to 6/10/2018 PMC Escondido: 2 5 PMC Poway: 0

0 HAPI HAPI

Escondido Poway

220 Addendum I

221 Addendum I

222 Addendum I

Thank you

223