2016 Quality & Patient Safety Annual Report to the Board of Directors

Table of Contents

Agenda

Introduction and Overview

Presentations

Centers of Excellence Distinctions

2016 Nursing Division Quality & Patient Safety

Annual Report to the Hospital Compare Data

Board of Directors

Regulatory Report

Compliments, Complaints and Grievances September 19, 2016 Service Excellence and Quality Dashboards

Quality and Patient Safety Reports Presented to BQRC in 2016

Acronym Glossary

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Table of Contents

September 19, 2016

2016 Annual Quality and Patient Safety Report to the Board of Directors September 19, 2016 Table of Contents

Tab # Page #

1. Table of Contents

2. Agenda

3. Introduction and Overview: A. Autonomy, Mastery and Purpose in Achieving a Patient First Culture ...... 3-1 . Jerry Kolins, MD, MAOM, CPE, FACHE, Vice President, Patient Experience

4. Presentations: A. Sepsis - Quality Assurance Performance Improvement (QAPI) ...... 4-1 . Valerie Martinez, RN, BSN, MHA, CPHQ, NEA-BC, Director, Quality, Patient Safety & Infection Control . Asaf Presente, MD, CEP Intensivist, Pulmonary Disease . Eva “Bunny” Krall, RN, MSN, APRN, ACNS-BS, CMS, CDE, Clinical Nurse Specialist . Jessica Cordova, RN, BSN, Clinical Nurse II, PMC, 4E

B. Falls Prevention ...... 4-13 . Valerie Martinez, RN, BSN, MHA, CPHQ, NEA-BC, Director, Quality, Patient Safety & Infection Control . Neha Sampath, MD, CEP Hospitalist, Internal Medicine . Jennifer Paull, DPT, Supervisor, Rehab Services . Meghan Jaremczuk, MSN, RN-BC, PCCN, Nurse Manager

C. Patient Family Advisory Council ...... 4-31 . Tina Pope, Manager Service Excellence . Jim Lyon, Chair, Patient/Family Advisor . Estelle Wolf, Co-Chair, Patient/Family Advisor . Lynn Morris, RN, BSN, Clinical RN III, SOS Committee

5. Centers of Excellence Distinctions ...... 5-1

6. Nursing Division ...... 6-1

7. Hospital Compare Data ...... 7-1

8. Regulatory Report ...... 8-1

9. Compliments, Complaints and Grievances ...... 9-1

10. Service Excellence and Quality Dashboards ...... 10-1

11. Quality and Patient Safety Reports Presented to BQRC in 2016: A. Annual Infection Prevention and Control Report ...... 11-1 B. Environment of Care/Emergency Management Report ...... 11-32 C. Medication Use Report ...... 11-54 D. Workers Compensation Trend Analysis ...... 11-77

12. Acronym Glossary ...... 12-1

Tab 1 - Table of Contents 1-1

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Agenda

September 19, 2016

Posted Monday

September 12, 2016 SPECIAL BOARD MEETING ANNUAL QUALITY AND PATIENT SAFETY REPORT TO THE BOARD OF DIRECTORS

Monday, September 19, 2016 Palomar Health Downtown Campus Immediately following 5:30 p.m. Special Full Board Meeting Graybill Auditorium 555 E. Valley Parkway 5:00 p.m. Buffet for Board members and invited guests Escondido CA 92025

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING

Mission and Vision “The mission of Palomar Health is to heal, comfort and promote health in the communities we serve.”

“The vision of Palomar Health is to be the health system of choice for patients, physicians and employees, recognized nationally for the highest quality of clinical care and access to comprehensive services.” —Guests may leave the meeting following their presentation(s)— Time Target I. CALL TO ORDER 6:30 II. ESTABLISHMENT OF QUORUM III. PUBLIC COMMENTS1 15 min 6:45 IV. 2016 ANNUAL QUALITY/PATIENT SAFETY REPORT - INTRODUCTION Autonomy, Mastery and Purpose in Achieving a Patient First Culture (Tab 3, Page 3-1) 10 min 6:55  Jerry Kolins, MD, MAOM, CPE, FACHE, Vice President, Patient Experience V. 2016 ANNUAL QUALITY/PATIENT SAFETY REPORT – PRESENTATIONS 1. Sepsis - Quality Assurance Performance Improvement (Tab 4, Page 4-1) 20 min 7:15 . Valerie Martinez, RN, BSN, MHA, CPHQ, NEA-BC, Director, Quality, Patient Safety & Infection Control . Asaf Presente, MD, CEP Intensivist, Pulmonary Disease . Eva “Bunny” Krall, RN, MSN, APRN, ACNS-BS, CMS, CDE, Clinical Nurse Specialist . Jessica Cordova, RN, BSN, Clinical Nurse II, PMC, 4E

2. Falls Prevention (Tab 4, Page 4- 13) . Valerie Martinez, RN, BSN, MHA, CPHQ, NEA-BC, Director, Quality, Patient Safety & 20 min 7:35 Infection Control

. Neha Sampath, MD, CEP Hospitalist, Internal Medicine . Jennifer Paull, DPT, Supervisor, Rehab Services . Meghan Jaremczuk, RN-BC, MSN, PCCN, Nurse Manager 20 min 7:55 3. Patient Family Advisory Council (Tab 4, Page 4-31) . Tina Pope, Manager Service Excellence . Jim Lyon, Chair, Patient/Family Advisor . Estelle Wolf, Co-Chair, Patient/Family Advisor . Lynn Morris, RN, BSN, Clinical RN III, SOS Committee VI. Q UESTIONS & ANSWERS 10 min 8:05 VII. PUBLIC COMMENTS1 15 min 8:20 FINAL ADJOURNMENT 8:20

Tab 2 - Agenda Page 1 of 2 2-1

Distribution:

Board of Directors Board Quality Review Committee Aeron Wickes, MD – BQRC Committee Chair Bob Hemker, FACHE, President & CEO

Linda Greer, RN – Board of Directors Chair Frank Beirne, FACHE, Executive Vice President, Operations Dara Czerwonka, MSW Alan Conrad, MD, Executive Vice President, Physician Integration Hans Sison, LVN Della Shaw, Executive Vice President, Strategy Maria Sudak, RN, MSN, CCRN, NEA-BC, Vice President and Chief Nursing Officer, Jerry Kaufman, PTMA Palomar Medical Center Jeff Griffith, EMP-P Jeannette Skinner, RN, MBA, FACHE, Vice President, Pomerado Hospital Larry LaBossiere, RN, MSN, CEN, CNS, MBA, Interim Chief Nursing Officer, Pomerado Ray McCune, RN Hospital Jerry Kolins, MD, FACHE, Vice President, Patient Experience and Co-Chair of Patient

Safety Committee Valerie Martinez, RN, BSN, MHA, CPHQ, CIC, NEA-BC, Co-Chair of Patient Safety

Committee and Director, Quality, Patient Safety and Infection Control Sheila Brown, FACHE, Vice President, Continuum Care Richard Engel, MD, Interim Chair of Medical Staff Quality Management Committee, Palomar Medical Center Charles Callery, MD, Chair of Medical Staff Quality Management Committee, Pomerado Debbie Hollick, Board Secretary Hospital

NOTE: If you have a disability, please notify us by calling 760-740-6375 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.

Tab 2 - Agenda 2-2

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Introduction & Overview

September 19, 2016

The Need for Autonomy, Mastery and Purpose in Order to Achieve a Patient First Culture

On May 7, Larry McEvoy, MD, ED physician and past CEO of Memorial Health System, Colorado Springs, spoke at our AAPL session on achieving personal satisfaction in the workplace and living our Palomar Health mission while avoiding burning out. He recommended reading "Drive" by Daniel H. Pink for a more thorough understanding of achieving happiness in life and work. Daniel Pink describes three "platforms" or operating systems in the history of human existence. Let me share his interesting view.

Daniel Pink's first operating system or Motivation 1.0 occurred long ago. We learned to avoid being eaten by hungry animals and found food and shelter for survival. Then came Motivation 2.0. It was brought to us by the management guru Frederick Winslow Taylor. He thought business was being run poorly in the 19th and 20th centuries. He said people wouldn't commit to a task unless you provided extrinsic motivating forces. He said use carrots and sticks. In other words, reward the good and punish the bad.

This approach worked for more than a century. But there are huge problems with Motivation 2.0 in the 21st century. You cannot achieve a Patient First culture and be a world class organization without encouraging autonomy, mastery and purpose.

Daniel Pink describes his Motivation 3.0 as the high performing organization with a culture that fosters autonomy, mastery and purpose. This thought is not new but has been slowly embraced in the last 50 years. We are learning that work has an integral role in achieving satisfaction and meaning in life.

You may remember Herzberg as the psychologist turned management professor by showing that employees were not made happy by money or other extrinsic factors like working conditions and job security (he called them hygiene factors). Their absence created dissatisfaction but their presence did not lead to job satisfaction and engagement. For job satisfaction and engagement we need to create the conditions for the healthcare workforce that provides joy and meaning in the work itself, genuine achievement and personal growth. How do we get that?

One key is autonomy. But autonomy is not independence. We are not talking about the American cowboy. We are talking about the autonomy that comes with the interdependence of working together.

Greatness comes when we work together to achieve something that cannot be achieved by any one person alone. Last year when I spoke to this Board about Quality and Safety I referred to the gene of cooperation. At that time I thought the concept was original but Dr. Aeron Wickes pointed out that the gene was well described in the August 2015 issue of Scientific American.

Page 1 of 3

Tab 3 - Introduction & Overview 3-1 The Need for Autonomy, Mastery and Purpose in Order to Achieve a Patient First Culture

The cooperation gene supports the hypothesis that we humans survived the earlier years of Motivation 1.0 through cooperation with each other in order to protect ourselves and our food supply from invaders/enemies.

This story is important to all of us because we chose healthcare as an important purpose of our lives. We chose an endeavor that is not a game for the cowboy. It is a team sport requiring not independence but both autonomy and interdependence (cooperation). Mihaly Csikszentmihalyi of the University of Chicago and Claremont Graduate University comments: "I think that evolution has had a hand in selecting people who had a sense of doing something beyond themselves."

Consider what happened after the 2008 economic debacle. Students gave us the MBA Oath. As referenced by Daniel Pink in his book "Drive" the MBA Oath states "As a manager, my purpose is to serve the greater good by bringing people and resources together to create value that no single individual can create alone." This is the opportunity we have at Palomar Health. And this is being taught to us by HR and our Organizational Development team. Let me explain.

As evidence of Organizational Development leading the way, I offer the thinking of Robert B. Reich, former US Secretary of Labor. When he visits a workplace he'll ask people questions about the company. Do the workers refer to the company as "they" or do they describe it in terms of "we." The "we" organizations are different, engaged and perform at a higher level with autonomy, mastery and purpose. Our Organizational Development at Palomar Health brought this concept to us via a guest speaker, Dave Logan. His book on Tribal Leadership speaks to the high performing organizations and their continual use of the pronoun "we."

As you listen to the presentations tonight from medical staff, nursing as well as all the support services (those services that do not require a stethoscope), you will hear of the quest for mastery and the commitment to purpose. Their goal is to pursue purpose--and to use profit (net contribution to margin) as the catalyst rather than the objective.

Understanding and embracing purpose requires all of us to speak to the "why we do the things we do." Let me give an example of the importance of "The why." A study at the University of Pennsylvania divided employees at a call center into three groups. The purpose of the call center was to perform a university fundraising operation. Prior to calling prospective donors, one group read stories from previous employees about the personal benefits of working the job. A second group read stories from people whose lives were changed by the scholarships from the funds the callers recruited. The third group, the control group, read no stories. There was no difference in performance between the control group and the first group that read stories about the personal benefits to themselves. But the group that read stories about the meaning the funds had to those who received the scholarships raised more than twice the money as the other two groups.

Quality and safety reaches the very core of our purpose to heal, comfort and promote health. We must consider our own health and that of the patients we serve. In fact evidence shows that once "we realize that the boundaries between work and play are artificial, we can take matters in hand and begin the difficult task of making life more livable." Mihaly Csikszentmihaly

Page 2 of 3

Tab 3 - Introduction & Overview 3-2 Tab 3 - Introduction & Overview 3-3 Doctor-Patient Relationship 1891 vs. 2010

Jerry Kolins, MD

Tab 3 - Introduction & Overview 3-4 The Doctor 1891 by Luke Fildes

Tab 3 - Introduction & Overview 3-5 Crayon Drawing 2010 by 7-year-old girl

Tab 3 - Introduction & Overview 3-6 Tab 3-Introduction & Overview Top Box Percentage/Number of Stars 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Memorial Hospital 68% 71% Sharp 5

Top Box Percentage Box Top 84%

PatientsDischarged SeptemberBetweenOctoberand2013 Hospital Scripps Green 5

82% Palomar Medical Center/ PHDC 4

78% HCAHPS HCAHPS RateHospital 0 Hospital - La Memorial Scripps Jolla *Publicly *Publicly Reported July 2015 4 Star Rating Star 77% Medical Center UCSD 4

73% Facility Foundation San Diego Hospital -

Kaiser CA Average CA 3

71%

- 10 Memorial Hospital - Encinitas

Scripps 3

69% Medical Tri-City Center NATL Average NATL 3 2014 68%

Hospital Scripps Mercy 3

66% Pomerado Hospital 68% 71% 3

64% 3-7

Tab 3-Introduction & Overview Top Box Percentage/Number of Stars 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Memorial Hospital 68% 72% Sharp 5

Top Box Percentage Box Top 83%

PatientsDischarged SeptemberBetweenOctoberand2014 Hospital Scripps Green 4

79% Palomar Medical Center/ PHDC 4

76% HCAHPS HCAHPS RateHospital 0 Hospital - La Memorial Scripps Jolla *Publicly *Publicly Reported July 2016 4 Star Rating Star 76% Medical Center UCSD 3

72% Facility Memorial Hospital - Encinitas Scripps

CA Average CA 3

71%

- 10 Pomerado Hospital

3

70% Foundation San Diego Hospital - Kaiser NATL Average NATL 3 2015 69%

Hospital Scripps Mercy 3

67% Medical Tri-City Center 68% 72% 2

61% 3-8

HCAHPS National Percentile Ranking - Rate Hospital 0-10 *Official Quarterly Results 110

100 93 91 92 90 89 88 87 87 85 90 82 84 80 76

70

60 56

50 39 39 38 Percentile Ranking Percentile 35 40 32 28 29 30 25 26 17 19 20

10

0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 Quarter

PMC National Percentile Ranking POM National Percentile Ranking

Tab 3 - Introduction & Overview 3-9

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Presentations

September 19, 2016

2016 Annual Quality/Patient Safety Report 2016 Annual Quality/Patient Safety Report PALOMAR HEALTH’S SEPSIS CAMPAIGN

Presented to The Board Of Directors September 19, 2016

Asaf Presente MD PhD, Critical Care and Pulmonary Medicine Associate Medical Director for PMC, Intensivists Bunny Krall APRN MSN ACNS-BC CDE CMSRN Clinical Nurse Specialist Quality and Patient Safety Jessica Cordova RN,BSN, CNIII PMC 4E

Tab 4 - Presentations 4-1 Sepsis - Quality Assurance Performance Improvement (QAPI) What is Sepsis?

• Overwhelming Infection

• Palomar Health Sepsis Campaign CMS core measure

• Challenge: Detection and Action

Tab 4 - Presentations 4-2 Sepsis - Quality Assurance Performance Improvement (QAPI) Interdisciplinary Team Engagement CEP ED, Hospitalist; Intensivists Kaiser Pharmacy Informatics

PATIENT w/ SEPSIS Sepsis Steering Organization (UPC/Intensivist/ Learning Quality (CMS) Laboratory

Care Providers Nursing Quality RT Nurses and RRNs Analysts CEC

Tab 4 - Presentations 4-3 Sepsis - Quality Assurance Performance Improvement (QAPI) Mrs Peacock

85 year old woman complaints of fevers, chills, nausea, brought to ER

o 101.3 F, RR 22, HR 104 BP 85/75 Taskmanager: lower abdominal pain, looks toxic

SIRS alert fires Orders White count, Lactic acid and Creatinine elevated Powerform: Positive Urinalysis Sepsis alert fires

Septic Shock Detection! Fluids and Antibiotics

Tab 4 - Presentations 4-4 Sepsis - Quality Assurance Performance Improvement (QAPI) Sepsis Ordersets: Mrs Peacock

Admitted to ICU

Still hypotensive, increased lactic acid increased acidosis and work of breathing Reassessment Powerform: Intubated Central line is placed, Pressors begun, Abx broadened CT scan negative

Family discussion about her critical illness with physician and nursing staff

Tab 4 - Presentations 4-5 Sepsis - Quality Assurance Performance Improvement (QAPI) Mrs Peacock

Next day: Blood pressure stabilizes Blood and urine cultures grow E. Coli

Following Day: Renal failure resolves Extubated

Later: Discharged home with home PT (and a new bowel regimen)

Documentation Specialist Code this case for CMS

Tab 4 - Presentations 4-6 Sepsis - Quality Assurance Performance Improvement (QAPI) Palomar Health SEP-1 Early Management Bundle % of Measure Success Cases 100%

SEP-1 data Group Work collection Update Orders (Abx) 80% Design 2 Physician Sepsis Steering forms Implement Sepsis Kick Off Identify Alert Program 60% Suppression 58% 60% Establish Subgroups Sepsis Std approved Sepsis Physician Design Education Awareness 44% orders Month Automate

Physician 2nd revision Repeat Lactic 40% Education Documentation Physician Form On-line Module Sepsis Standard and Orders Transition to Classroom Alerts Operations Education Pocket Guides Physician Lead 20% Antibiotics (Pharmacy) Huddle Highlight Rounding Transition Medical/Nsg CNSs Committees Leaders

0% IT Educators Jun 2015 Jul 2015 Aug 2015 Sep 2015 CY15 Q4 CY16 Q1 CY16 Q2

Tab 4 - Presentations 4-7 Sepsis - Quality Assurance Performance Improvement (QAPI) Total Alerts 2015 vs. 2016 300 266 GOAL: Alerts be

250 Meaningful; Avoid Decrease is Better Alarm Fatigue

200

150 128 102

Numberof Alerts 100 2015 2016 48 39 40 50 29 31 19 19 25 17 12 8 2 3 0 MST3 POM MST4 POM Grand Total 6E Tele PMC 8E MED PMC ED HoldPMC 6W PCU PMC 4NW SURGPMC Unit

Tab 4 - Presentations 4-8 Sepsis - Quality Assurance Performance Improvement (QAPI) Next Steps

• Continue to Evaluate, monitor and improve processes where needed • Anticipate Examining Outcome Benchmarks • Transition to Operations Team

Tab 4 - Presentations 4-9 Sepsis - Quality Assurance Performance Improvement (QAPI) Nursing Role in Sepsis Initiative

• KNOW Sepsis • Infection Prevention • Respond to Alerts • Education

Tab 4 - Presentations 4-10 Sepsis - Quality Assurance Performance Improvement (QAPI) Physician Role in Sepsis Initiative • Physician Leadership and Education • Champion for Medical Staff • Automate process for physician workflow • Identify obstacles and opportunities • Education

Tab 4 - Presentations 4-11 Sepsis - Quality Assurance Performance Improvement (QAPI) Questions

Tab 4 - Presentations 4-12 Sepsis - Quality Assurance Performance Improvement (QAPI) 2016 Annual Quality/Patient Safety Report 2016 Annual Quality/Patient Safety Report Creating A Culture of Safety: Fall Prevention

Presented to The Board Of Directors September 19, 2016

Neha Sampath MD Meghan Jaremczuk MSN, RN-BC, PCCN, RN Jennifer Paul DPT

Tab 4 - Presentations 4-13 Sepsis - Quality Assurance Performance Improvement (QAPI) Falls Video

Tab 4 - Presentations 4-14 Sepsis - Quality Assurance Performance Improvement (QAPI) Patients are vulnerable when they are in the hospital and their greatest expectation is that we deliver safe care.

Falls resulting in injury are a prevalent hospital safety problem. Every year in the United

States, hundreds of thousands of patients fall in hospitals. (JC 2015)

Behind every fall is a person (someone’s loved one). Falls cause functional decline, injuries, Person behind increased length of stay/cost and sometimes death. each fall

Standardization and Behavior Expectations will serve as a framework in achieving our Patients First Experience relating to Fall Prevention.

Tab 4 - Presentations 4-15 Sepsis - Quality Assurance Performance Improvement (QAPI) What is a FALL?

• Witnessed vs Not Witnessed • Assisted vs Not Assisted • Accidental vs Physiological • Physiological Anticipated Vs Unanticipated

Tab 4 - Presentations 4-16 Sepsis - Quality Assurance Performance Improvement (QAPI) A Patient Story and Impact

Tab 4 - Presentations 4-17 Sepsis - Quality Assurance Performance Improvement (QAPI) Falls Team

• Interdisciplinary Membership

• Look at literature and incorporate into practice

• Standardize Practice across the system

Tab 4 - Presentations 4-18 Sepsis - Quality Assurance Performance Improvement (QAPI) Communication and Education • Medical Committees • Staff on Safety members did 1:1 with physicians • Nursing Leadership • Professional Practice Council • Educational Module for all clinical and non- clinical staff • Flyer out to Volunteers

Tab 4 - Presentations 4-19 Sepsis - Quality Assurance Performance Improvement (QAPI) Ways to Identify Fall Risk Patients 1 2 3

Yellow Falls Sunflower (on door) Yellow Socks Risk Band Sunflower placard in GPU/MHU

Tab 4 - Presentations 4-20 Sepsis - Quality Assurance Performance Improvement (QAPI) Staff Behavior Expectations

L LOOK into the room E Evaluate/Enter A Alert the Nurse F Follow through

Tab 4 - Presentations 4-21 Sepsis - Quality Assurance Performance Improvement (QAPI) What do we do for every patient?

UNIVERSAL INTERVENTIONS – Orient patient/family to their environment and use of equipment • Teach how to use call bell/return demo – Use of non-skid footwear – Keep bed in lowest position; wheels locked – Keep walkers next to bed – Patient Safety Agreement/Education – Safe Patient Handling Practices (Bariatric equipment) – Consider orthostatic vital signs on patients > age 65

Tab 4 - Presentations 4-22 Sepsis - Quality Assurance Performance Improvement (QAPI) What do we do for a patient that is identified as a fall risk? ALL FALL RISK PATIENTS: • Educate about fall prevention, risk factors and interventions specific to patient • Gait belt when getting out of bed/ambulation, if not contraindicated • Bed/Chair alarms as appropriate • Rehab services to call RN prior to working with patient and talk with RN at end of therapy if leaving out of bed.

Tab 4 - Presentations 4-23 Sepsis - Quality Assurance Performance Improvement (QAPI)

Interventions Specific to Patient Risk

GAIT UNSTEADY ELDERLY (> 65 years) • Accompany patient with walker Consider orthostatic BP • Rehab Consult Teach to get out of be slowly/exercises • Patient to wear own shoes with neuropathy of the feet MUSCLE WEAKNESS Get out of bed

Walking program PATIENT FORGET LIMITS Rehab consult for strengthening • “All about Me Form” • Move to SAFE or ACE unit URINARY INCONTINENCE OR FREQUENCY Scheduled toileting • Diversional activities • Observe every one hour

POLYPHARMACY  Pharmacy med review as appropriate/new confusion

Tab 4 - Presentations 4-24 Sepsis - Quality Assurance Performance Improvement (QAPI) Sunflowers in Bloom July 18 Kick off of Code Sunflower and Fall Prevention

Tab 4 - Presentations 4-25 Sepsis - Quality Assurance Performance Improvement (QAPI) Palomar Health Total Falls Trend Line 70

60

50 50 44 43 41 40 40 36 37 35 MORSE Ref. Text 33 34 34 into Clarity 28 Sunflower/ 30 MORSE FALL Fall Standard 26 SCALE Education PMC ED Education Module Fall/Post Waiting Sunflowers

20 Fall Huddle Room Pilot Blooming

Total Number of System Falls Systemof Number Total ARU: Pilot Quick Establish Classes for Release Belts (3/4) Falls Team all CNAs at

separate from Villa POM; 10 4E Pilot: POSEY SOS to update Update Post Alarm: Room Fall Prevention & Fall Huddle Number Prevention Procedure Form 0 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16… Month / Year

Tab 4 - Presentations 4-26 Sepsis - Quality Assurance Performance Improvement (QAPI) Code Sunflower • Goals: Rapid Response Nurse provide guidance to bedside Nurse. Support a thorough patient assessment, interventions and getting to the “why” of the patient fall

• One Month Pilot

Tab 4 - Presentations 4-27 Sepsis - Quality Assurance Performance Improvement (QAPI) Physician Role • Medication Reconciliation – Polypharmacy • Know National Guidelines for BP management and prescribe accordingly • LEAF Behaviors • Know patient is a risk for falls, discontinue lines as soon as possible • Evaluate activity and diet and get moving/eating as soon as possible

Tab 4 - Presentations 4-28 Sepsis - Quality Assurance Performance Improvement (QAPI)

Next Steps • Reimplementation of the Walk-About Program with Pathmakers • In- Depth Patient Assessment • Automatic Consult to pharmacy with Age > 65, Positive Fall Screening and on multiple High Risk Medications. • Evaluate orders with bedrest • Fall team integrated back into Staff on Safety Team

Tab 4 - Presentations 4-29 Sepsis - Quality Assurance Performance Improvement (QAPI)

Tab 4 - Presentations 4-30 Sepsis - Quality Assurance Performance Improvement (QAPI) 2016 Annual Quality/Patient Safety Report Patient and Family Advisory Council

Tina Pope, Manager Service Excellence Jim Lyon, Council Chair Estelle Wolf, Council Vice Chair Ann Lynne Morris, SOS Past Chair

Tab 4 - Presentations 4-31 Sepsis - Quality Assurance Performance Improvement (QAPI) Palomar Health’s Patient and Family Advisor Council (PFAC)

Has been a functioning council for 2 years

10 patient and family members + 2 ad hoc members Interdisciplinary committee members from front-line staff to leaders and physicians

Meets monthly, with the exception of July and December

Tab 4 - Presentations 4-32 Sepsis - Quality Assurance Performance Improvement (QAPI) Development of Patient Education Materials

• Medication Cards | POM Pharmacy • Infant Demise/Loss Booklet | PHDC • Grieving and Loss Booklet | System • Falls and Handwashing Materials SOS Committee | System • Discharge Material Packet | POM • Hip Fracture | System • Various Marketing Materials| System • Care Partner/Visitation Guidelines | System

Tab 4 - Presentations 4-33 Sepsis - Quality Assurance Performance Improvement (QAPI) Committee Participation • Care Partner “Visitation” Policy/Guidelines • Community Relations | Board Level • Med/Surg/Tele Patient Experience Committee | 4E PMC • Emergency Department PMC | Front-End Care • Patient Education Council | PMC • Parking and Wayfinding | PMC • SOS | Staff on Safety

Tab 4 - Presentations 4-34 Sepsis - Quality Assurance Performance Improvement (QAPI) Projects and Presentations

• Deep Dives | PMC/POM and follow-up meetings at PMC • Patient Safety Conference | participated in mock trial • Nurses’ Week |spoke at each presentation • Participated in brand perception interviews • Hiring Panels for new leaders • Patient Experience Videos • Over 700 Volunteer Hours

Tab 4 - Presentations 4-35 Sepsis - Quality Assurance Performance Improvement (QAPI) Current Status and Goals • 10 active members (12-14 max) • 4 additional members to join this year (increase diversity/demographics) • PFAC members are requested to serve on various committees and councils, throughout the organization • Goal is to further integrate the patient voice at all levels to ensure transparency and improve Quality, Safety and Patient Experience outcomes

Tab 4 - Presentations 4-36 Sepsis - Quality Assurance Performance Improvement (QAPI) Jim Lyon, Chair Patient and Family Advisor Committee

Former city planner in Poway

Former patient

Committed to the patient-first experience Share a common goal to ensure top-notch care

Tab 4 - Presentations 4-37 Sepsis - Quality Assurance Performance Improvement (QAPI) Estelle Wolf, Vice Chair Patient and Family Advisor Committee

Rancho Bernardo resident for 19 years

Former nurse with experience in quality management

Former patient

Enjoy serving as a patient advocate

Tab 4 - Presentations 4-38 Sepsis - Quality Assurance Performance Improvement (QAPI)

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS Centers of Excellence Distinctions

September 19, 2016

Centers of Excellence

Orthopedic - Hip and Knee Replacement Pomerado Hospital Orthopedic – Spine Surgery Palomar Medical Center

Bariatric Surgery Pomerado Hospital Gastric Banding & Stapling Pomerado Hospital

Stroke Center Palomar Medical Center and Pomerado Hospital

Cardiac Care and Rehab Palomar Medical Center

CARF - Inpatient Rehab (Adults & Children) CARF – Stroke Program

Maternity Palomar Medical Center and Pomerado Hospital Tab 5 - Centers of Excellence Distinctions 5-1

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Nursing Division

September 19, 2016

Nursing Annual Report

August 2016

Tab 6 - Nursing Division Report 6-1 Pomerado Hospital: Emergency Services Accomplishments

Tab 6 - Nursing Division Report 6-2 Pomerado Emergency Services Accomplishments

• Implementation of the Front End Redesign process for the ED. – Start date 9/22/2016

• Roll out of Hip Fracture Pathway

• Throughput: Greatest Improvement seen in over 6 months. – Decreased TAT-D times • 198minutes in April to 169.5minutes in May. – 25 minute improvement in ESI 3 patients. – 24 minute improvement in ESI 4 patients. – LWOTs below 1%

Tab 6 - Nursing Division Report 6-3 Pomerado Inpatient Services Accomplishments

Tab 6 - Nursing Division Report 6-4 Pomerado Inpatient Services Accomplishments

• Implemented Deep Dive in May to improve Patient Experience on the 4th floor. – HCAHPS percentile ranking for “ Rate the Hospital” • ICU/IMC 99, • MST 85. – POM MED/SURG/TELE • “Communication with Nurses” percentile ranking 96 in June from 17 in March. • “Communication with Doctors 83 in June from 26 in March. – New Manager, Arnold DeLuna , MSN

Focus groups for ICU/IMC 3/4 completed by August 2016. – O (CAUTI) – O (VAP) – O FALLS

Tab 6 - Nursing Division Report 6-5 Pomerado Hospital Perioperative and Women’s Services Accomplishments

Tab 6 - Nursing Division Report 6-6 Pomerado Hospital Perioperative & Women’s Services Accomplishments

• Successful full re-certification as a MBSAQIP Accredited Center of Bariatric Services

• Successful consolidation of Pre-Admission testing into one department located in the Pomerado Outpatient Pavilion

• Performs above the 95th percentile for patient satisfaction in Ambulatory Surgery/Endoscopy

• Certified as a COE for Joint Replacement Surgery

Tab 6 - Nursing Division Report 6-7 Pomerado Hospital Perioperative & Women’s Services Accomplishments

• BS Center of Distinction for Obstetrical Care based upon quality metrics

• Successful full recertification of Newborn Hearing Screen Program (NHSP)

• Awarded Tier 2 Beta status since 2012. Along with PHDC OB, this represents a $450+K reduction in insurance premiums. (additional slides for Beta were previously sent)

• Leader in District 9 for Exclusive Breast Feeding Rates

Tab 6 - Nursing Division Report 6-8 8E Interdisciplinary Deep Dive Initiative

RaeAnne Watson

Tab 6 - Nursing Division Report 6-9 What is the Interdisciplinary Deep Dive?

Bring together all departments and services that touch our patients to better understand the impact the team has on the patients experience.

8E was chosen as the pilot unit at PMC because many of the patients come from other units, the ED, or other inpatient units. These patients are affected by most of our interdisciplinary departments at one time or another during their stay.

Tab 6 - Nursing Division Report 6-10

The kick off meeting was held April 7th. Department leaders were asked to bring front line staff that would participate in the actual Deep Dive.

Deep Dive Focus on Managing Up across teams and departments while

making the patient connection.

A smaller work group of key department staff continues to meet to formulate their action plans. Assistance and implementation of the action plans was provided.

Tab 6 - Nursing Division Report 6-11 Tab 6 - Nursing Division Report 6-12 Next Steps

1. Continued focus on Managing Up and making the patient connection.

2. Rounding on interdisciplinary teams to offer support.

3. Plan to spread tools and lessons learned to other units.

Tab 6 - Nursing Division Report 6-13 Epilepsy Monitoring Unit (EMU)

RaeAnne Watson

Tab 6 - Nursing Division Report 6-14 Purpose of the EMU

Allow patients with suspected seizure disorders to be safely monitored 24 hrs. a day to evaluate their seizure activity.

Two beds are located on 7W/Neuro at PMC.

In partnership with our EEG department, Neurologists and specially trained nursing staff manage the care of this patient population.

Tab 6 - Nursing Division Report 6-15 The EMU saw it’s first patient on 12/8/15.

Currently 1-2 EMU patients are seen per week, with an average length of stay of 4 days.

Approximately 50 patients were seen between December 2015 and the end of the fiscal year.

Tab 6 - Nursing Division Report 6-16 Schwartz Rounds at Palomar Health

RaeAnne Watson

Tab 6 - Nursing Division Report 6-17 What is Schwartz Rounds?

Schwartz Rounds is a multidisciplinary forum that offers healthcare providers a regularly scheduled time to openly and honestly discuss social and emotional issues that arise in caring for patients.

In contrast to traditional medical rounds, the focus is on the human dimension of medicine. Caregivers have the opportunity to share their experiences, thoughts and feelings on topics drawn from actual patient cases and is open to all disciplines.

Tab 6 - Nursing Division Report 6-18

In June of 2016 ,Schwartz Rounds was also held at Pomerado Hospital. Since there was so much positive feedback, rounds will be held there in the future.

Tab 6 - Nursing Division Report 6-19

Palomar Medical Center: Intensive Care Unit Quality Improvement Projects

Melvin Russell

Tab 6 - Nursing Division Report 6-20 5W/4SW ICU Quality Improvement Projects

Goal: To utilize current evidenced based practices to help reduce the number of hospital acquired complications (HAIs) in the ICU

Catheter Associated Urinary Tract Infection (CAUTI) o Mandatory competency on foley catheter insertion o Implementation of a nurse driven foley catheter removal protocol o Daily CAUTI prevention bundle audits

Pressure Ulcers (HAPUs) o ICU specific mandatory education on identification of PUs and prevention measures o Staff member Ann Fish EBP project on prevention of HAPUs in the ICU

Central Line Associated Blood Stream Infections (CLABSI) o Implementation of Chlorohexidine (CHG) wipes for daily bathing of ICU patients

Ventilator Associated Pneumonias (VAPs) o Re-education on oral care and early mobility pathway

Use of Restraints o Mandatory education on use of mitts vs. soft wrist restraints

During daily multidisciplinary rounds, safety checklist includes discussion on indications for foley catheters, central lines, ETT, and restraints and if able to discontinue. Also discuss patient's at risk for HAPUs and whether all preventative measures are in place.

Tab 6 - Nursing Division Report 6-21 Palomar Medical Center Cardiovascular Progressive Care Unit 5 East

Tab 6 - Nursing Division Report 6-22 Cardiovascular Center of Excellence

Awarded in January 2016

Cardiac Surgery

Cardiology Program

Tab 6 - Nursing Division Report 6-23 Quality Outcomes 5 East

 CY16 Q2 o Cauti: 0 o CLASBI: 1 o Cdif: 0 o HAPU: 0

Tab 6 - Nursing Division Report 6-24 Upskilling for the RN

 All Nurses doing cardiovascular center of excellence upskills  Surgical pathways  Pre & post operative patient education  Chest tube  Pacemaker  A-line  Fem-stop  Cardiac drips

Tab 6 - Nursing Division Report 6-25 The Patient Experience

 Goal to improve patient experience

 Measurable outcomes

 HCAPS & Press Ganey

 Patient Experience committee

Tab 6 - Nursing Division Report 6-26 Palomar Medical Center Emergency Department

Tab 6 - Nursing Division Report 6-27 Emergency Department – PMC Managing volume

Tab 6 - Nursing Division Report 6-28 Emergency Department – PMC

• Low Risk Chest Pain • Front Care Project. Protocol. Discharging low • Focused on ESI levels 3, 4 & 5 to risk chest pain patients and improve turn around time to setting up outpatient stress tests discharge (TAT D). is saving 2-3 beds per day. • 52 min improvement in 6 months • CSU. Optimizing patient flow with 23% volume increase to the Crisis Stabilization Unit. Saving 4-6 ED beds • 70-90 patients seen in Front Care. • Telehealth. Partnering with • LWOT 1.5% despite volume local fire departments for a increase telehealth piolet to reduce • Expanded provider coverage in unnecessary transports to the triage ED

Tab 6 - Nursing Division Report 6-29 Palomar Health Birth Centers

Elizabeth Dawodu & Elizabeth RemsburgBell

Tab 6 - Nursing Division Report 6-30 Palomar Health Birth Centers

• Palomar Health voluntarily participates annually in the BETA Healthcare Quest for Zero: Excellence in OB to reduce risk events and harm to our patients.

• Since its inception in 2009, the Quest for Zero, now has 32 participating hospitals. Of those, 24 hospitals have reached completion of Tier 2, earning their organizations up to a maximum of 9% credit on their risk premiums.

• Palomar Health Downtown Campus and Pomerado Hospital have successfully achieved Tier 2 status since 2012.

Tab 6 - Nursing Division Report 6-31 2015 Goals “We did it!”

Tab 6 - Nursing Division Report 6-32 Tier 2 Achieved with Collaboration Across Teams

 All Providers seeking initial OB privileges are required to complete the GNOSIS Perinatal Safety Curriculum. In addition, all Providers currently privileged, complete the GNOSIS perinatal Safety Curriculum annually. This requirement is written into privileging criteria for medical staff.

 All new Registered nurses upon hire in the Labor and Delivery unit are required to complete GNOSIS prior to starting their floor orientation. All current Labor and Delivery RN’s complete the module annually as well.

 Current NICHD terminology (2008) for Fetal Heart Monitoring interpretation is reflected throughout clinical practice, policy and procedures and all medical record documentation.

Tab 6 - Nursing Division Report 6-33 Tier 2: How we achieved our “Quest”

• Multidisciplinary participation of simulation drills were conducted to review patient management scenarios of Uterine Rupture and Eclampsia.

• Large, retrospective review of medical records to provide insight on management of the Nulliparous, transverse singleton, vertex (NTSV) pregnancy and how labor management correlates to cesarean birth were performed by the CNS and Educator.

• Introduction of the CMQCC toolkit on Eclampsia and Preeclampsia management. Early recognition and treatment of hypertension with first line anti-hypertensives in the Perinatal setting.

• Standardized order sets, and creation of an Eclampsia and Preeclampsia virtual medication kits within Pyxis.

• Collaboration with all healthcare providers, to promote Evidenced base care of the Eclampsia and Pre-Eclampsia patient.

Tab 6 - Nursing Division Report 6-34

Tab 6 - Nursing Division Report 6-35 Nursing Practice & Research

Isis Montalvo

Tab 6 - Nursing Division Report 6-36 Nursing Peer Review Council (NPRC)

• The Chair and Co-Chair began serving a 2 year • Trends identified term vs. 1 year as was originally required. This – IV extension tubing coming apart from brings the NPRC up to par with the requirements the IV catheter during CT scans of the other Nursing Councils. – Mislabeled specimens being sent to the lab • The Nursing Peer Review process was *The organization concurrently identified streamlined through use of a private electronic similar trends and work groups were created drive. This system was meant to eliminate within the organization to evaluate and sending secure information via email. problem solve. – Complications: • Not all computers have the ability to • In an effort to recruit members, the NPRC had access the drive a table during the Nurse’s Week Celebration, • Some members had difficulty finding at all 3 campuses, displaying the NPRC poster, computers equipped for access (this brochure and applications. Other means of continues to be an issue) boosting membership will be ongoing. *Given the challenges, the approach is being re- evaluated. • To provide optimum alignment and realize operational efficiency, as of July 2016, NPRC will be reporting through the Medical Peer • The case review form was revised and made into an editable PDF document. Allowing direct Review on a routine basis with oversight by the Quality Department. computer entry in the document and the ability

to save accordingly without manually entering

information and scanning the document. Tab 6 - Nursing Division Report 6-37

Professional Practice council (PPC)

What is Professional Practice Council? • Professional Practice Council (PPC) is a monthly, system-wide shared governance council at Palomar Health. PPC consists of the chairs from the Unit Practice Councils (UPC), PPC facilitator, Nursing Leadership and members of the Clinical Excellence Council. What does PPC do? • PPC’s purpose is reporting on outcomes of unit-specific work plans (from the UPC’s) related to Evidence-Based Practice (EBP), Patient Satisfaction, Nurse Satisfaction, Quality and Patient Safety. PPC is an important component of Palomar Health’s collaborative practice structure by providing a forum for nursing to interface with nursing leadership. Why is PPC important to Palomar Health? • PPC contributes to Palomar Health’s vision of providing relationship based care through evidence-based practices, inter-professional representation of disciplines, developing, mentoring and coaching the future leaders of Palomar health.

PPC Evidence Based Projects • Throughout the year, UPC chairs collaborate on the unit level to produce an EBP project that will elevate practice and improve patient care. Evidence based practice is an integral component of providing quality, efficient and cost effective care at Palomar Health. • PPC’s final report out for unit-based EBP Projects will be in November with poster presentations followed by presentations to the Board of Directors as has been done previously. PPC looks toward 2017 with an EBP focus and a collaborative approach to patient care at Palomar Health.

Tab 6 - Nursing Division Report 6-38 Investigational Review Committee (IRC) • The Investigational Review Committee (IRC) has been in transitions with multiple changes in personnel. We have had 2 administrator changes since last year. Our focus has been to simplify and update the EBP process, remove barrier of requiring Evidence Based Practice (EBP) and Quality Improvement Projects (QI) to go to full committee, and educating and mentoring staff through the EBP submission process. Additionally, we have been following up on open EBP projects to determine status, get closure where indicated and post outcomes to the projects when available.

• There have been a total of 10 new EBP projects this year (beginning Aug 2015). Of these projects, 3 have been completed with outcomes. The Telephone triage for heart failure resulted in reduction of readmissions below national average and increased quality of life scores for participant. The Diabetic Ketoacidosis readmission study revealed gaps in our community coverage. Ninety-eight percent of these patients did not have care transitions consults, and 30 out of the 50 did not get a Certified Diabetic Education consult.

• The coaching and leadership skills study resulted in an improved HCAP score for the question “doctors listen carefully” in both acute care hospitals.

• The remaining new studies focus on rapid response for sepsis, C-diff reduction bundle implementation, hospital acquired pressure ulcer (HAPU) reduction via a HAPU bundle, and risk for readmission with GI bleed after total joint replacement. Ongoing open studies are now collecting data on the interdisciplinary and Clinical Nurse Specialist (CNS) consults process following a change in the electronic medical record for ID request. There is also a “phone for 40” diabetes study that is still collecting data. Tab 6 - Nursing Division Report 6-39 IRC Con’t / Evidenced-Based Practice Projects Type of Focus Description Progress project Structure Updated EBP and Research Submission Revised forms, updated contact Completed. Staff support and mentoring information, presentation of process ongoing. to EBP, creation of secure Research Drive Quality: EBP Interdisciplinary Consults To standardize the interdisciplinary Clarity consult list standardized and consult process so patient needs are expanded to include multiple disciplines. identified early in hospitalization, Barriers to requesting consult removed. interdisciplinary consults initiated Task sent electronically versus required and patient has a safe and timely phone call. Presented at leadership. discharge Wound consult policy revision.

Quality and Unit Based CNS Consults The purpose of this study is to Clarity design process ongoing. Research determine how and why CNS’s are consulted on their respective areas. When performing a literature search it was found that there is little to no research currently in this area. Evidence Palomar Health Diabetes Ketoacidosis This study looked at 50 readmissions Study results available on request. Based Practice (DKA) Study for diabetic ketoacidosis. The study determined common elements to all readmissions that will guide future care of this vulnerable population.

Tab 6 - Nursing Division Report 6-40 IRC Con’t / Evidenced-Based Practice Projects

Type of Focus Description Progress project

EBP and CMS CODE SEPSIS This study looks at the rapid Ongoing evaluation and reporting . response nurse role in responding to a code sepsis. EBP San Diego Catheter Associated Urinary Tract Implementation of nurse driven Reduced CAUTI rates in ICU Infection (CAUT() urinary catheter removal protocol Quality Wound Photos in Clarity In process; financial savings, Cameras identified, process almost decrease staff and wound nurse complete time, increase patient outcomes EBP Clostridium Difficile (C Diff) Bundle Improve process: Clostridium difficile Approval Aug 2016 Transmission Prevention Bundle EBP Design a plan to reduce patient GI bleed Reducing Readmission Risk Factors Approval Aug 2016 complications. for Total Joint Replacement Patients EBP To provide education to patient, family, Patient Safety with Nerve Blocks & Approval Aug 2016 staff and ancillary staff to provide a safe Education post-op environment at hospital and at home.

EBP Implement a bundle of pressure ulcer Pressure Ulcer Prevention Bundle for Approval Aug 2016 prevention measures in the critical care Critical Care Patients areas at Palomar Medical Center and Pomerado Hospital with the goal of decreasing HAPU incidence.

Tab 6 - Nursing Division Report 6-41 Clinical Excellence Council (CEC)

Purpose • The Clinical Excellence Council (CEC) demonstrates system leadership by developing, implementing, and improving standards for nursing clinical practice across the continuum of care for patients, families, staff, and the organization while advancing safety, quality, and clinical outcomes.

Specific Activities of the Committee • Utilize needs assessments, customer feedback, and outcome data to support organizational initiatives and plan council priorities. • Identify and implement evidence-based practices. • Improve patient and staff satisfaction. • Improve quality care processes and ensure regulatory compliance. • Evaluate nurse sensitive measures and improve patient outcomes. • Collaborate with clinical and organizational partners. • Contribute to the Nursing Annual Report

The next several slides reflect the work of the CEC in various areas of practice.

Tab 6 - Nursing Division Report 6-42 Educational Needs Assessment RN/LVN 2016

. GOAL TO ASSESS THE EDUCATIONAL NEEDS OF THE FRONT LINE CLINICAL STAFF . CREATE ORGANIZATIONAL AND UNIT BASED EDUCATION PLANS . COLLABORATE WITH PHYSICIAN, NURSING, AND ANCILLARY SUPPORT STAFF EXPERTS TO SPONSOR MONTHLY EDUCATION . COURSE CONTENT, ENROLLMENT, ATTENDANCE, AND CEUS TRACKED THROUGH IXPAND FOR EASY RETRIEVAL

Example of general educational needs

Example of specific educational needs

Orthopedics (Select up to 2) 80.0% 60.0% 40.0% 20.0% 0.0% Assessment of Post-op Ortho Equipment: Uses Post Op Complications: Other (please specify) Ortho Patient and Care Compartment Syndrome Tab 6 - Nursing Division Report 436-43 Evidence-Based Practice On-line Learning

Meeting the educational needs with evidence based practice Meeting the educational needs with evidence based practice -Specialty specific series providing ongoing, in-depth presented by multiple disciplines.-Specialty Enrollmentspecific series is voluntary. providing ongoing, in-depth presented by multiple disciplines. Enrollment is voluntary. -Online based educational modules. Brief IXpand courses assigned based on the applicable-Online based position educational codes. Provides modules. the Brief ability IXpand to reach courses a maximum assigned number based on of the learnersapplicable in the position fastest codes. time. Provides the ability to reach a maximum number of learners in the fastest time.

2016 New Evidence Based Practice Course CEUs Number of Offerings Online Learning Modules for RN's Answer Man Series 2 4 – Varied content (ED Resuscitation education) Number of learners Orthopedic and 2 4- Varied Content Spine series Medical Surgical 1 4- Varied Content 1600 Series 1400 IMC Care Series 3.75 1 Wound Care 2-3 5 1200 Palliative Care Series 2 1 1000 Schwartz Rounds 1 10 800 600 400 200 0 Reducing Patient Vascular Access Morse Falls Score Core Sepsis Falls Device Education

Tab 6 - Nursing Division Report 6-44 Sepsis and Falls/Safety Training

The following reflects system education and training provided to multiple professionals in various areas.

 Sepsis and Falls/Safety training done system wide in collaboration with Quality

 Modules and classes for all staff

 iXpand Core Sepsis for CNAs/HCAs/ED techs – 341 completed

 iXpand Core Sepsis for RNs – 1500 completed

 Sepsis Pathophysiology Management and Treatment ( Dr. Hirsch & ICU nurses) -117 attended

 Sepsis Bundle for Rapid Response Nurses/CNS/Educators – 52 attended

 iXpand: Creating a culture of safety: reducing patient falls-3730 completed

 iXpand: Creating a culture of safety. Implementing EBP -1378 completed

 IXpand: Morse Fall Risk: Acute Care, ED, & OB-1175 completed

 Collaboration with pharmacy: Medication safety lunch and learn. Falls and antihypertensives - 12 attended

Tab 6 - Nursing Division Report 6-45 New Graduate Nurse Residency & New to Specialty Programs

The New Graduate (NG) Nurse Residency Program provides the new graduate nurse a 12 month, mentored experience to facilitate the transition from student to professional nurse. The Program consists of two distinct phases: • Phase 1: during the first 12-16 weeks, Nurse Residents will practice at the bedside under the supervision of an experienced preceptor. Included in this phase are 120-160 hours of didactic learning designed to assess and reinforce clinical skills, and professional transition discussions to assist the novice in continuing their professional development. • Phase 2: for the remainder of the Residency program, Nurse Residents will receive a full clinical assignment, but will be provided an experienced “buddy” to serve as resource and mentor. Continuing professional development support will be provided to include the Nurse Resident, preceptors/mentors, and nursing education staff. The New to Specialty (NTS) Program focuses on the experienced nurse moving to a different specialty. Classes are offered along with a precepted clinical orientation. Retention Outcomes:

100% retention among New Graduate RN 95% retention among New to Specialty RNs New Grad / New to Specialty

18 18 20 15 15 13 13 15 Nov-15 10 7 6 Feb-16

5

0 New Graduate RN New to Specialty RN Retention NG Retention NTS

Tab 6 - Nursing Division Report 6-46 Practice Initiatives in Multiple Areas Completed or in progress

Project Project Lead(s) Description Status VAD Procedure Update Marilyn Dolatshahi Vascular Access Device (VAD) procedure updated per Infusion Nurses Completed July 2. Society (INS) & Centers for Disease Control (CDC) practice recommendations. C. Diff Bundle Marilyn Dolatshahi C. diff bundle implemented to reduce Hospital Acquired C.diff rates. In Progress (PMC 8E)

CIWA Protocol Update Carol Suarez & Updating Clinical Institute for Withdrawal Assessment for Alcohol In Development – iXpand Michael Kruse (CIWA) protocol to improve the management of patients experiencing module being created. alcohol withdrawal. Unit Brochure for Family In Progress (PMC 6W) Members 6W UPC & Brochure for visitors and family members that share helpful Carol Suarez information on unit rules and scheduling

Multidisciplinary Rounds Patient Experience The inter-professional team consists of Nutritional Services, In Progress (PMC 8E & 5E) Group Environmental Services, Pharmacy, Respiratory Therapy, Speech Therapy, Physical Therapy, Occupational Therapy, Lab, Radiology, Transport, RNs and MDs; focused on using “warm hand-off”.

Safety Communication Ella Laxa; Stacy Interdisciplinary communication board at bedside to help prevent falls In Progress (PMC 4E & POM 4th Tool & Updated Patient Nilsen by indicating assistance needs. Patient Safety Agreement form is Flr) Safety Agreement updated to allow RNs to educate pts about fall prevention measures.

Tab 6 - Nursing Division Report 6-47 Practice Initiatives in Multiple Areas -Con’t Completed or in progress

Project Project Lead(s) Description Status Posey Chair Alarms Bunny Krall Room number recorded on Posey chair alarms to indicate where fall In Progress (PMC 4E, 6W, & 7W) risk patient is located.

CAM-ICU Tool ICU UPC & Confusion Assessment Method for the ICU is a tool used for In Progress (ICU units) Kim Coburn assessment of delirium in ICU patients.

Hip Fracture Pathway Malou Magallon- Creating Hip Fracture Pathway for the care of orthopedic patients with In Progress (Ortho pts) Ignacio hip fractures.

CV Post Procedure Carol Suarez, Kim Creating a powerplan for cardiovascular post-procedures detailing In Development (CV pts) Powerplan Coburn, & Ella Laxa evidence-based guidelines and medical treatment modalities, with the incorporation of arterial compression devices.

Cardiac Rhythm Stacy Nilsen Annual Cardiac Rhythm Interpretation iXpand module created for tele In Progress (all tele monitoring Competency & CNS/NES team. techs and RNs. Exam given during annual nursing skills days. staff)

Home Med IT Educators & Doris Evidence-based quality improvement project on the “effect of In Progress (4E, 6E, 8E, 9E) Documentation Meehan education by IT educators on home medication documentation”.

Tab 6 - Nursing Division Report 6-48 Wound / Ostomy Care

• Implementation of new VAC (Vacuum-Assisted Closure) VeraFlo Therapy including development of power plan, pharmacy process, nursing documentation, education and in-servicing • Development of District-Wide Pressure Ulcer Prevention Plan • Changed brand of Odor Eliminator product for cost savings • Offered multiple wound VAC and Ostomy classes and provided training to new hires

Restraint and Pressure Ulcer Survey Quarterly Report • Streamlined data collection process to provide real-time education of bedside nurse and increase team member knowledge • Realized $10,000 annual savings by changing reporting process from two vendors to one

Tab 6 - Nursing Division Report 6-49 Wound / Ostomy Care con’t

Tab 6 - Nursing Division Report 6-50 Palomar Health Patient Throughput FY16 August 2016

Nick Metzger

Tab 6 - Nursing Division Report 6-51 Five Focus Areas

Inpatient Throughput

ED Patient Throughput

Radiology Turn Around Times

Lab Turn Around Times

Centralized Placement & Staffing

Tab 6 - Nursing Division Report 6-52 PMC ED Volumes & TAT-D TAT D Dec Jan Feb Mar Apr May June PMC (150 min goal) 220 225 228 228 208 206 207 9000

8750 8628 8524 8439 8481 8500

8250

8000 7897

7750 7524 PMC FY14 7500 7353 7341 7386 7638 7224 7257 7443 7250 7117 PMC FY15

7000 7141 7192 PMC FY16 6952 6750 6869 6885 6785 6833 6835 6811 Linear (PMC FY16) 6500 6671 6557 6588 6490 6250 6429 6280 6268 6000 6134 6179 6055 6075 5968 5750 5921

5500 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Tab 6 - Nursing Division Report 6-53 POM ED Volumes & TAT-D TAT D Dec Jan Feb Mar Apr May June POM (125 min goal) 177 184 192 180 182 164 172

3250

3067 3000 2921 2890 2827 2830 2781 2780 2787 2824 2750 2721 2732 2750 2676 2694 POM FY14 2663 2672 2651 2621 POM FY15 2651 2589 2626 POM FY16 2544 2554 2519 2590 2500 2540 2487 Linear (POM FY16) 2508 2418 2425 2410 2422 2342 2347 2250 2315 2249

2000 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Tab 6 - Nursing Division Report 6-54 Palomar Health Admission/Census Trends (Average Daily Admits) 140

120 115 111 112 110 109 109 109 106 104 104 101 102 100

82 82 81 80 81 81 78 79 78 79 79 79 80 ED Admits for Month Avg Daily Direct Admits for Month 73 71 71 72 Avg Daily PACU Admits for Month 68 69 68 68 60 65 Avg Daily Total Admits for Month 62 63 64 Avg Daily Total DCs for Month

40 30 30 28 27 26 26 26 25 25 25 24 25

20

18 17 14 15 14 15 14 12 13 11 10 11 0 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-55 PMC Admission/Census Trends (Average Daily Admits) 100

90 87 86 85 85 84 84 83 80 81 78 79 80 75

68 70 66 66 67 66 67 67 67 64 64 64 65

60 Avg Daily Non-Kaiser ED Admits for Month Avg Daily Direct Admits for Month

50 Avg Daily PACU Admits for Month 42 Avg Daily Total Admits for Month 39 38 39 39 39 39 40 37 37 Avg Daily Kaiser ED Admits for Month 35 35 35 Avg Daily Total DCs for Month

30 22 22 23 20 20 20 20 19 19 19 18 18 20 17 16 17 17 16 14 15 15 15 15 15 15

10 13 11 12 11 10 10 9 9 6 6 6 0 5 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-56 POM Admission/Census Trends (Average Daily Admits) 30 28 27 26 26 26 26 25 25 25 25 24 24 24

20

17 POM ED Admits for Month 15 15 15 15 Avg Daily Direct Admits for Month 15 14 14 14 14 14 Avg Daily PACU Admits for Month 13 13 15 15 15 14 14 14 14 14 14 14 Avg Daily Total Admits for Month 13 Avg Daily Total DCs for Month 12 10 8 7 7 7 6 6 6 6 6 6 6 5 5 6 5 5 5 5 5 5 5 5 4 4 4

0 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-57 PMC EVS Total Cleans vs Turn Time

1:55:12 3000 2791 2789 2760 2738 2744 2722 2720 2670 2642 2593 2606 2597 1:47:03 1:40:48 1:42:37 1:41:351:42:17 1:38:48 2500 1:36:301:37:34 1:37:12 1:36:22 1:32:49 1:26:24 1:31:111:31:04

2000 1:12:00

Avg Response Time 0:57:41 Avg Clean Next Response 0:57:36 0:54:02 0:54:55 1500 0:51:45 Avg Clean Time 0:48:59 0:49:37 0:49:50 0:49:05 0:49:36 0:47:32 0:53:51 0:54:51 Avg Total Turn Time 0:45:540:52:11 0:52:48 0:53:13 0:51:23 0:50:52 0:44:09 0:49:31 0:50:03 Total Cleans 0:43:12 0:47:50 0:43:49 0:44:23 1000

0:28:48 0:22:13 0:23:03 0:22:06 0:20:42 0:20:03 0:20:35 0:20:49 0:18:27 0:18:50 0:19:20 0:18:28 500 0:13:21 0:14:24

0:00:00 0 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-58 POM EVS Total Cleans vs Turn Time 1:40:48 900

809 795 767 800 1:26:24 752 712 697 693 697 690 684 679 663 700

1:12:00 1:13:02 1:14:05 1:12:031:11:39 1:11:11 1:11:29 600 1:09:141:09:30 1:04:461:03:32 0:57:36 1:02:531:02:22 500 Avg Response Time Avg Clean Time 0:45:54 0:45:56 0:45:19 0:46:23 0:43:44 Avg Turn Time 0:43:16 0:43:15 0:42:32 0:42:05 0:43:02 400 0:43:12 0:41:54 0:38:58 Total Cleans

300

0:28:48 0:30:50 0:29:46 0:30:11 0:29:42 0:29:21 0:28:04 0:27:13 0:26:30 0:25:48 0:25:52 0:25:24 200 0:21:55 0:14:24 100

0:00:00 0 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-59

TAT- A Current Standings: June 2016

Pomerado PMC Non Kaiser PMC Kaiser

Overall TAT-A 327 (+35) 378 (-1) 390 (+27)

Admit Orders to Patient in Bed 68 (+7) 94 (+4) 94 (+6)

Time Admit to Around Turn

Throughput Metrics Goal Patient ED arrival to patient in admitted bed 250 min

Admit Orders to Patient in Bed 60 min Decision to admit to admit orders 30 min

Tab 6 - Nursing Division Report 6-60

PMC Kaiser/Hospitalist ED Admits Combined TAT-A Fiscal Year 2016

600 200

180 497 500 455 173 460 160 429 416 158

403 396 140 381 384 400 371 135 136 120 331 125 305 119 300 107 100 94 87 90 89 80 200 75 60

40 100 52 53 56 54 56 56 57 54 54 Daily Median Turnaround Time in Minutes Timein Turnaround Median Daily 49 49 50 20

0 0 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June PMC TOTAL Avg Door to Admit 305 331 381 403 416 455 497 460 429 396 371 384 PMC Avg TOTAL Daily Admits 49 49 50 52 53 56 54 56 56 57 54 54 PMC TOTAL Avg Orders to Admit 75 87 90 119 135 158 173 136 125 107 89 94

Tab 6 - Nursing Division Report 6-61

POM TAT-A Fiscal Year 2016 500 110 101 99

90 90 83 400 82 78 75 75 75 68 68 354 70 344 333 331 61 300 325 321 327 307 298 299 288 292 50

200

30

Daily Median Turnaround Time in Minutes Timein Turnaround Median Daily 17 13 14 14 14 15 15 15 15 14 14 14 100 10

0 -10 July August Sept Oct Nov Dec Jan Feb March April May June Door to Admitted 288 298 299 307 333 331 354 344 325 321 292 327 Admission Orders to Admitted 68 75 82 75 99 83 101 90 75 78 61 68 Avg Daily Number of ED Admits for the Month 13 14 14 14 15 15 15 17 15 14 14 14

Tab 6 - Nursing Division Report 6-62 June: 2417 Patients Discharged (All Locations) Avg. 81 pts per day Median time from Order to Depart 173 minutes

Year--> 2016 Month--> June 7E ORTHO PMCW 95 4SW CC PMCW 119 MS2 POM 130 8E MED PMCW 149 7W NEURO PMCW 164 5E CARDIO PMCW 167 4E SURG PMCW 176

MST4 POM 178

MST3 POM 186

9E MED PMCW 193 Goal = < 90 min 5W CC PMCW 200 4NW SURG PMCW 221 6W PCU PMCW 223 6E Tele PMCW 228

Tab 6 - Nursing Division Report 6-63 June: 57% of Patients Discharged (HOME) Avg. 46 pts per day Median time from Order to Depart 130 minutes

Year--> 2016 Month--> June 8E MED PMCW 95 7W NEURO PMCW 99 MS2 POM 99 7E ORTHO PMCW 102 9E MED PMCW 105 MST4 POM 114 4SW CC PMCW 119

5E CARDIO PMCW 124

MST3 POM 125

6W PCU PMCW 142 Goal = < 60 min 6E Tele PMCW 156 4E SURG PMCW 162 4NW SURG PMCW 184 5W CC PMCW 189

Tab 6 - Nursing Division Report 6-64 June: 20% of Patients Discharged (Home Health Needs) Avg. 16 pts per day Median time from Order to Depart 308 minutes

Year--> 2016 Month--> June 7E ORTHO PMCW 52 4SW CC PMCW 98 MST4 POM 147 9E MED PMCW 148 8E MED PMCW 164 MS2 POM 175 7W NEURO PMCW 185

6W PCU PMCW 209

5E CARDIO PMCW 221.5

6E Tele PMCW 275 MST3 POM 291 4E SURG PMCW 307 4NW SURG PMCW 336 5W CC PMCW 1700

Tab 6 - Nursing Division Report 6-65 June: 16% of Patients Discharged (SNF) Avg. 13 pts per day Median time from Order to Depart 356 minutes

Year--> 2016 Month--> June MS2 POM 252 5E CARDIO PMCW 282 4SW CC PMCW 329 5W CC PMCW 329 6E Tele PMCW 345 MST4 POM 348 7W NEURO PMCW 352

4NW SURG PMCW 362

6W PCU PMCW 363

8E MED PMCW 372 Goal = < 300 min 4E SURG PMCW 385 MST3 POM 388 7E ORTHO PMCW 402 9E MED PMCW 479

Tab 6 - Nursing Division Report 6-66 PH System Assign to Occupy Time (Avg in Minutes) 110

100

90

80 78

73 72 70 70 70 69 70 69 69 67 66 67 PH System Avg

60

50

40

30 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-67 Palomar Medical Center Assign to Occupy (Average in Minutes)

110

100

90

80 80 79 78 76 76 74 74 74 72 71 72 71 70 PMC Campus

60

50

40

30 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-68 Pomerado Hospital Assign to Occupy Time (Avgerage in Minutes) 110

100

90

80

70 70 Pomerado Campus 65

59 60 60 58 54 54 52 51 51 50 47 43

40

30 July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Tab 6 - Nursing Division Report 6-69 CMS Hospital Compare – VERY LARGE ED May 2016 (reporting period through June 30th, 2015)

450 410 400

350 343 311 300

250 Palomar Medical Center California Avg 200 163 National Avg 150 134 107 100

50

0 Median Turn Around Time to Admit Median Admission to Admit Bed

Tab 6 - Nursing Division Report 6-70 CMS Hospital Compare – Medium Size ED May 2016 (reporting period through June 30th, 2016) 350

305 300 290

262

250

200 Pomerado Hospital California Avg 150 National Avg 118 99 100 90

50

0 Median Turn Around Time to Admit Median Admission to Admit Bed

Tab 6 - Nursing Division Report 6-71 Progress to Date  Outcomes Achieved  Expanded Centralized Patient Placement Center for all admissions and transfers to and within the acute care facilities, including staffing office integration, and district Transportation/Lift Services.  Improved turnaround time for select laboratory tests and imaging modalities for all patients presenting to the emergency departments  Created a Standardized Discharge Process for all Emergency Department Patients  Achieved <30min Order to Discharge times for All Discharged ED Patients  Continued ED, Inpatient Provider, and nursing collaboration ongoing with throughput initiative  Completion of FMEA - Inpatient Discharge Process  Several Discharge Process Collaborations have started (HM, CRM, IT)  Completed Front-End redesign at Palomar Medical Center Emergency Department(Front Care)  Completed integration of Short Stay Unit and Crisis Stabilization Unit into Patient Placement Center  Next Steps  Heighten patient awareness of discharge process from admission  Process improvement for Inpatient Discharges and in-house patient transfers  Process improvement for SNF discharges, Home Health and DME needs, and CRM  Front-End redesign at POM Emergency Department  I-Stat Lab implementation, increased lab automation, and workflow analysis  Ongoing workflow analysis and standardization of radiology utilization  Integration of OB and ARU into Centralized Placement Center

Tab 6 - Nursing Division Report 6-72 FY16 Goals

 TAT- Admit Orders to Admit  PMC – 60 minutes  POM – 60 minutes  TAT - Admission  PMC – 250 minutes  POM – 180 minutes  TAT – Discharge  PMC – 150 minutes (including additional ESI level goals)  POM – 125 minutes (including additional ESI level goals)  Inpatient Discharge Order to Discharge  PMC – 90 minutes  POM – 90 minutes  Lab & Radiology Turn Around Times  Decrease TAT-Lab times to premier benchmarks  10% decrease in ED Radiology use across MRI, CT, and Ultrasound  Throughput Labor Savings  2015 $1,000,000 = $808,967  2016 $ 500,000 = $625,980  Combined $1,500,000 = $1,434,947

Tab 6 - Nursing Division Report 6-73 Cardiology 2016

Linda Acklin & Mary Russell

Tab 6 - Nursing Division Report 6-74 Echo Alerts

 Review echocardiograms results for indications of AHA/ACC recommended valvular disease scoring for Cardiologist review and recommend appropriateness of Cardiovascular Surgeon consult.

 Multidisciplinary Team Members: •Physician Champions: Dr. Bayat & Dr. Malik •All Echo Cardiography Technicians •Mary Russell, Nurse Practitioner •Linda Acklin, Director •COE Committee Members.

Tab 6 - Nursing Division Report 6-75 Echo Alerts  Echocardiograms are completed

 If Progressive Valve disease the information is communicated to Valve Coordinator

 If Severe Valve disease the information is communicated to Valve Coordinator and the On-Call Cardiologist.

 Complete chart review is performed by Valve Coordinator

 Appropriate consults and follow up (CVS) continue, letters are mailed to patients primary MD monthly

Tab 6 - Nursing Division Report 6-76 Echo Alerts

 Average per month = 100 alerts (both Progressive and Severe)

 Kaiser is included in the count, these charts are not reviewed.  Average Kaiser Echo’s = 20

 Increase in awareness regarding those patients with valvular disease.  A patient diagnosed with AS, left untreated has less than two years survivability.

Tab 6 - Nursing Division Report 6-77 Low Risk Chest Pain Clinic

• Collaborate with ED physicians regarding severity of chest pain by providing on-site cardiac stress tests or cardiac stress test scheduled within 72 hours of discharge. • Implementation & utilization of AHA Heart Score

• Outcome: Reduce admission to hospital for cardiac stress test, increase through-put and reduce costs

• Interdisciplinary Team: • Dr. Bayat, Cardiologist • Dr. Friedberg, ED Physician • Mary Russell, NP • Linda Acklin, Director Cardiology Staff

Tab 6 - Nursing Division Report 6-78 Low Risk Chest Pain Clinic Virtual Clinic – Started in September 2015

Chest Pain Differential Diagnosis’ National Statistics: o 8-10 million patients with chest pain present to an ED annually in the United States, accounting for 1 in every 18 patients we see. o Over 50% receive lengthy inpatient cardiac evaluations o Expose patients to unnecessary risks of testing and treatments o Annual cost $10-13 Billion o <10% of patients have an acute coronary syndrome (ACS) requiring further intervention

Obligation for a workup – AHA o A comprehensive evaluation .Serial cardiac biomarkers with second set drawn in the 6-12 hour time frame. .Need to do a provocative test such as stress testing or cardiac imaging

Literature states provocative testing can be done within 72 hours (even as an Outpatient)

Tab 6 - Nursing Division Report 6-79 Low Risk Chest Pain Patients Heart Score 1-3

 Low Risk Chest Pain Patients o Heart Score in ED o Troponins normal, EKG normal o Scheduled for outpatient stress testing within 72 hours o Decreased admissions to a hospital bed. o Prior to starting this – these patients were admitted, given a “bed”, stressed the next morning and if negative were discharged.

Tab 6 - Nursing Division Report 6-80 Implementation of Heart Score

Tab 6 - Nursing Division Report 6-81 Intermediate chest pain patients Heart Score 4-6

 Implemented June, 2016

 Multidisciplinary team – o Cardiology, Cardiologist, ED team, ED physician, Registration, Nuclear Medicine, Pharmacy, IT.

 Same criteria as the low risk (Heart Scoring Tool) o Referred over from the ED same day

 No resting scans – o increase throughout, decrease patient radiation, reduce costs of isotopes.

 If negative, can be discharged (than previously getting a “bed” and stressed the next day).

 If positive, they are cared for faster (than previously getting a “bed” and stressed the next day).

Tab 6 - Nursing Division Report 6-82 Resting Scan Implemented June, 2016

 History: o Every Persantine ordered received a “resting scan”, either the morning of the test or the night before. Then the stress portion the next day.

 Current State: o Resting scans are NOT routinely done on Persantine ordered tests. o If the Persantine/read is positive, the patient will go to angiography or be treated medically. o If negative, then its negative. o In the event the provider would like a resting scan, they can go back in the powerplan and order this separately.

Tab 6 - Nursing Division Report 6-83 Resting Scans – Why?/Why Not?

 Quality Improvement o Decrease use of hospital beds o Increase Time for staff (NM, transport,) o Improves patient satisfaction and outcomes

 Radiation Reduction

 Patient Safety, patient satisfaction.

 Rest Imaging does not change management

Tab 6 - Nursing Division Report 6-84 Cardiac Stress Powerplan

Implemented June 2016

 History o Multiple ways of ordering a stress o Most were ordered incorrectly, therefor meds were not available. Orders needed to be revised causing a delay in patient care/testing. o Is the right test being ordered??

 Current State o Any synonym used will bring you to this PP o New colored coded PP (a first at Palomar!!) o Populated fields • When a test is chosen, it is automatically sent to appropriate departments (NM, Pharmacy, Nursing)

Tab 6 - Nursing Division Report 6-85 New Cardiac Stress Powerplan

Tab 6 - Nursing Division Report 6-86 Low and Intermediate Chest Pain Patients

Bed Savings Cost – Source: Manual Count *$5500.00/day for Tele bed # patients

– January – 16 $88,000 – February – 33 $181,500 – March – 28 $154,000 – April – 35 $192,500 – May – 36 $198,000 – June – 51 $286,000 – July – 36 $198,000

Total $1,301,000

*Source: Patient Access

Tab 6 - Nursing Division Report 6-87 Cardiology Progress and Awards

 A STEMI Committee started 7/2015

 “Silver” Performance Achievement Award for 2016.  Action Registry – AHA/ACC GWTG ED, Cath Lab, Cardiology, ICU, All staff & Units.  Award recognizes Palomar’s commitment and success for the care of the MI patients  Required to follow GWTG for 6 consecutive quarters and meet a performance standard of 90% in specific area  On track for continuing awards. Goal=“Platinum”

Tab 6 - Nursing Division Report 6-88 Staff Education & Development

 Monthly staff meetings/in-services  Physical Therapy: Patient positioning  Code Sunflower  Fall Prevention  Code Blue and Improved Signage  Gate Belts  Increase customer service & patient satisfaction  Patient Brochures, Educational pamphlets, Valet Parking, Meal coupons, cardiology folder.  Team building: Celebration CV week, weekly pot lucks  Lead Position  Documentation  Conference attendance

Tab 6 - Nursing Division Report 6-89

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Hospital Compare Data

September 19, 2016

Executive Summary of Palomar Health’s performance according to data posted on https://www.medicare.gov/hospitalcompare website as of September 2016

Note: the graphs on the following pages reflect hospital performance during measurement period October 2014 – September 2015

In most instances, we perform comparably or favorably when compared to National and State averages. Hospital-specific data for other San Diego hospitals are also published for comparison.

Ostensibly, our greatest opportunity for improvement lies with influenza vaccination rates of our hospital healthcare workers, particularly at Pomerado. We have identified a reporting problem (we have apparently been reporting lower than actual rates of vaccination) and are taking steps to correct this problem. By way of reminder, Palomar Health has a mandatory influenza prevention program in place that requires healthcare workers either to receive influenza vaccinations at the beginning of each flu season or else wear a mask throughout the duration of the flu season.

Another area of interest involves Blood Clot Prevention & Treatment at Pomerado. Numbers lag state and national averages by a little and indicate opportunities for improvement.

One final area of focus for the coming year will center on decreasing the amount of time it takes patients who present to our emergency departments with broken bones to be administered pain medication. Physician and nurse leaders are aware of our unfavorable statistics and have been asked to study the reason(s) for the delay in order to formulate an effective corrective action plan.

Tab 5 - Hospital Compare Data 7-1 EMERGENCY DEPARTMENT CARE - Average (median) time patients who came to the emergency department with broken bones had to wait before getting pain medication 100

80 80 83 73 73 60 67 60 60 53

Minutes 40 50 36 20 N/A 0 Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

EMERGENCY DEPARTMENT CARE - Percentage of patients who left the emergency department before being seen 6% 5% 5% 5%

4%

3% 2% 2% 2% 2% 2% 1% 1% 1% 1% 1% N/A 0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-1 EMERGENCY DEPARTMENT CARE - Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival 100%

80% 83% 76% 60% 68% 69% 59% 64% 40%

20% N/A N/A N/A N/A N/A 0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

EMERGENCY DEPARTMENT CARE - Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient 600

500 531 494

400 423 419 300 379 344 315 336 Minutes 292 200 251 248 100

0 Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-2 EMERGENCY DEPARTMENT CARE - Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room 400

300 350

200

Minutes 180 100 166 134 137 121 108 100 79 101 108 0 Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

EMERGENCY DEPARTMENT CARE - Average (median) time patients spent in the emergency department before leaving from the visit 300 298 250 276 241 200 204 202 188 202 150 174 178 167 Minutes 100

50 N/A 0 Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-3 EMERGENCY DEPARTMENT CARE - Average (median) time patients spent in the emergency department before they were seen by a healthcare professional 120

100 102

80

60

Minutes 40 39 40 20 32 34 37 35 25 N/A 15 23 0 Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

STROKE CARE - Ischemic stroke patients who got medicine to break up a blood clot within 3 hours after symptoms started 100% 98% 100% 100% 100% 80% 89% 89% 93% 92% 84% 60%

40%

20% N/A N/A 0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-4 STROKE CARE - Ischemic stroke patients who received medicine known to prevent complications caused by blood clots within 2 days of hospital admission 100% 98% 98% 100% 100% 100% 97% 97% 100% 100% 99% 97% 80%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

STROKE CARE - Ischemic or hemorrhagic stroke patients who received treatment to keep blood clots from forming anywhere in the body within 2 days of hospital admission 100% 97% 98% 98% 100% 99% 100% 97% 100% 98% 98% 80% 94%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-5 EFFECTIVE STROKE CARE - Ischemic stroke patients who received a prescription for medicine known to prevent complications caused by blood clots at discharge 100% 99% 99% 100% 100% 100% 99% 100% 100% 100% 100% 100% 80%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

EFFECTIVE STROKE CARE - Ischemic stroke patients with a type of irregular heartbeat who were given a prescription for a blood thinner at discharge 100% 97% 97% 100% 100% 100% 100% 100% 100% 80% 93%

60%

40%

20% N/A N/A 0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-6 EFFECTIVE STROKE CARE - Ischemic stroke patients needing medicine to lower bad cholesterol, who were given a prescription for this medicine at discharge 100% 97% 97% 100% 97% 100% 96% 99% 100% 100% 99% 97% 80%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

EFFECTIVE STROKE CARE - Ischemic or hemorrhagic stroke patients or caregivers who received written educational materials about stroke care and prevention during the hospital stay 100% 99% 100% 100% 100% 99% 94% 95% 97% 97% 98% 80% 89%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-7 EFFECTIVE STROKE CARE - Ischemic or hemorrhagic stroke patients who were evaluated for rehabilitation services 100% 98% 99% 100% 100% 100% 96% 99% 100% 100% 99% 99% 80%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

BLOOD CLOT PREVENTION & TREATMENT - Patients who got treatment to prevent blood clots on the day of or day after hospital admission or surgery 100% 99% 98% 98% 94% 94% 93% 95% 97% 95% 80% 89% 88%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-8 BLOOD CLOT PREVENTION & TREATMENT - Patients who got treatment to prevent blood clots on the day of or day after being admitted to the intensive care unit (ICU) 100% 97% 97% 97% 100% 99% 100% 100% 99% 98% 96% 80% 94%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

BLOOD CLOT PREVENTION & TREATMENT - Patients with blood clots who got the recommended treatment, which includes using two different blood thinner medicines at the same time 100% 100% 100% 99% 100% 100% 99% 99% 80% 94% 95% 92% 93%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-9 BLOOD CLOT PREVENTION & TREATMENT - Patients with blood clots who were treated with an intravenous blood thinner, and then were checked to determine if the blood thinner caused unplanned complications

100% 99% 99% 100% 100% 100% 98% 100% 100% 100% 80% 91% 95% 60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

BLOOD CLOT PREVENTION & TREATMENT - Patients with blood clots who were discharged on a blood thinner medicine and received written instructions about that medicine 100% 98% 100% 96% 98% 100% 100% 80% 92% 94% 94% 95% 91%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-10 PREGNANCY & DELIVERY CARE - Percent of mothers whose deliveries were scheduled too early (1-2 weeks early), when a scheduled delivery was not medically necessary 12%

10%

8%

6% 5%

4% 3% 2% 2% 2% 2% 2% 1% 0% 0% 0% 0% 0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

PREVENTATIVE CARE - Patients assessed and given influenza vaccination

100% 99% 100% 99% 94% 94% 94% 97% 98% 96% 80% 89% 91%

60%

40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-11 PREVENTATIVE CARE - Healthcare workers given influenza vaccination

100% 94% 80% 91% 92% 89% 88% 87% 84% 82% 79% 80% 60% 63% 40%

20%

0% Avg. Avg. PMC/ Pomerado Kaiser Sharp Grossmont Scripps Scripps Tri-City UCSD U.S. So. Cal. PHDC Hospital Permanente Memorial Hospital - Encinitas - La Jolla Hospital Hospital Hospitals Hospital

Tab 5 - Hospital Compare Data 7-12

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Regulatory Report

September 19, 2016

Licensing & Accreditation Fiscal Year 2016 Annual Report to Palomar Health Board of Directors September 19, 2016 Deborah Barnes RN, MSN, CPQH, HACP, CHC Director Regulatory Coordination

Tab 8 - Regulatory Report 8-1 California Department of Public Health Investigations • 63 Investigations opened for the Health System – 52 Closed • 44 with no deficiencies – 11 Open • 34 Consumer/Anonymous Complaints • 29 Self Reported

Tab 8 - Regulatory Report 8-2 Investigations by Hospital

Hospital Total Consumer Self Opened Closed No Deficiency Cases Reported Reported Deficiency PMC 42 24 18 8 34 28 6 Pomerado 10 4 6 3 7 6 1 PHDC 11 6 5 0 11 10 1

Tab 8 - Regulatory Report 8-3 Significant Cases • Fall with Major Injury at PMC – Case remains open • 1 Case Failure to Report Retained Foreign Objects – Failed to report sponges retained from previous surgery that was done at a Non Palomar Health Facility. – Patient was notified – Previous surgery was done in 2012 – Penalty for late reporting that is under appeal

Tab 8 - Regulatory Report 8-4

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS Compliments, Complaints & Grievances

September 19, 2016

Executive Summary

Compliments/Complaints/Grievances

FY2016 Results

The Service Excellence Department is responsible for the management and resolution tracking of all compliments/complaints/grievances that come into the Palomar Health District.

The following reports detail the FY2016 data associated with the management and closure of our compliments/complaints/grievances.

Any written complaint is considered a grievance and therefore requires we respond in writing to the individual making the complaint within seven (7) business days. This is a CMS requirement.

An internal tracking process is in place to ensure proper investigation, closure, and if necessary, escalation. Palomar Health has set a goal to complete the investigation and closure of each complaint/grievance within 30 days. The results are shared with the BQRC committee on a yearly basis.

We are currently closing complaints/grievances within 13 days on average.

The accompanying pie chart shows the breakdown of all complaints/grievances for the month of June 2016. The linear graph shows the trend of Palomar Health’s compliments versus complaints/grievances over time.

Tab 9 - Compliments, Complaints and Grievances 9-1 Types of Complaints/Grievances to Palomar Health from 39 Patients (June 2016) 0.0% Lost/Broken Item

7.7% Facility 7.7% Lack of Compassion/Respect - 35.9% Complication (n=14) Care not Timely - 12.8% (n=5)

Don't Want to Pay - 12.8% (n=5) 10.3% 35.9% Lack of Compassion/Respect Discharged too Soon Misdiagnosis/Inaccurate Documentation/Medications - 12.8% (n=5) Discharged too Soon - 10.3% (n=4) 12.8% Misdiagnosis/Inaccurate Documentation/Medications Complication - 7.7% (n=3)

Facility - 7.7% (n=3)

12.8% Lost/Broken Item - 0.0% (n=0) 12.8% Care not Timely Don't want to Pay

Tab 9 - Compliments, Complaints and Grievances 9-2 Percentage of Compliments vs. Complaints/Grievances *Official Monthly Results 100.0%

90.0%

80.0% 74.0%

70.0% 66.7% 58.5% 60.0% 53.0%

50.0% Percentage 40.0% 47.0% 41.5% 30.0% 37.4%

20.0% 26.0%

10.0%

0.0% June 2015 January 2016 March 2016 June 2016 Month

Compliments Complaints/Grievances

Tab 9 - Compliments, Complaints and Grievances 9-3

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS Service Excellence and Quality Dashboards

September 19, 2016

Executive Summary Patient Experience Results for FY2016 Q4

At the end of each quarter, we evaluate the performance of each department and unit, as it relates to the Patient Experience. All data and associated trends are made available to Leadership who in turn reviews the results with their respective departments. These reports are also shared at the Board Quality Review Committee (BQRC) on a quarterly basis.

The System score is only available through Press Ganey and is benchmarked against the national database. These scores are shared as a Percentile Ranking. Press Ganey scores are related to the perceived quality of care.

Each hospital is ranked individually using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Percentile Ranking for the questions “Rate Hospital 0-10” and “Quietness of Hospital Environment”, as well as the domains “Communication with Nurses” and “Communication with Doctors”. The HCAHPS questions are those associated with Value Based Purchasing (VBP). The Percentile Ranking goal for FY2016 was the 90th percentile, for Palomar Medical Center (PMC), Palomar Health Downtown Campus (PHDC) and Pomerado Hospital (POM).

The end of FY2016 shows that Palomar Medical Center hovers in the top quartile of performance as rated by our patients. Thousands of hospitals are benchmarked against PMC, yet from the patient’s perspective we are top quartile performers.

Pomerado Hospital has shown improvement during the past three quarters moving from the bottom quartile to the second quartile.

We included a comparison of both Palomar Medical Center and Pomerado Hospital from the public website www.hospitalcompare.hhs.gov. Palomar Medical Center is ranked 3rd (4 star performance) amongst 10 of the nearest hospitals in our region. This information is based on the question “Rate Hospital 0-10” and is always posted as lagging data (meaning the timeframe reported on the public website is one year old). This report shows the results of patients discharged between October 2014 and September 2015.

Tab 10 - Service Excellence and Quality Dashboards 10-1 Overall Quarterly Press Ganey Inpatient System Percentile Ranking Trend: Palomar Health 100

90 85 83 80 77 80 75 76 76 71 72 67 70

60

50 54 54 40 Percentile Ranking Percentile

30

20

10

0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=953 n=924 n=1,134 n=1,143 n=1,173 n=1,118 n=1,259 n=1,216 n=1,227 n=1,074 n=1,337 n=1,221 Quarter

Inpatient System Percentile Ranking

Tab 10 - Service Excellence and Quality Dashboards 10-2 Tab 10 -Service Excellence andQuality Dashboards Top Box Percentage/Number of Stars 100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Memorial Hospital 68% 72% Sharp 5

Top Box Percentage Box Top 83%

PatientsDischarged SeptemberBetweenOctoberand2014 Hospital Scripps Green 4

79% Palomar Medical Center/ PHDC 4

76% HCAHPS HCAHPS RateHospital 0 Hospital - La Memorial Scripps *Publicly *Publicly Reported July 2016 27, Jolla 4 Star Rating Star 76% Medical Center UCSD 3

72% Facility Memorial Hospital - Encinitas Scripps

CA Average CA 3

71% -

10 Pomerado Hospital

3

70% Foundation San Diego Hospital - Kaiser NATL Average NATL 3 2015 69%

Hospital Scripps Mercy 3

67% Medical Tri-City Center 68% 72% 2

10-3 61%

Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Rate Hospital 0-10: Palomar Medical Center

100 93 91 92 90 87 89 87 88 90 84 85

82 78% 80 84% 83% 82% 80% 82% 81% 82% 80% 82% 81% 70 79% 76 60

50

40

30

Top Box Percentage/Percentile Ranking Percentage/Percentile Box Top 20

10

0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=391 n=559 n=606 n=681 n=774 n=799 n=836 n=802 n=842 n=744 n=916 n=877 Quarter

HCAHPS Top Box Percentage National Percentile Ranking

Tab 10 - Service Excellence and Quality Dashboards 10-4 Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Communication with Nurses: Palomar Medical Center

100

90

82% 81% 82% 81% 80% 80% 80% 80% 79% 77% 80% 80 76%

70 71

60 53 63 65 50 56 52 54 40 49 50 49

30

Top Box Percentage/Percentile Ranking Percentage/Percentile Box Top 20 28 23 10

0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=396 n=559 n=612 n=683 n=782 n=806 n=849 n=812 n=853 n=750 n=928 n=879 Quarter

HCAHPS Top Box Percentage National Percentile Ranking

Tab 10 - Service Excellence and Quality Dashboards 10-5 Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Communication with Doctors: Palomar Medical Center

100

90 83% 83% 83% 83% 82% 81% 81% 82% 82% 82% 79% 82% 80

70

60 66 62 61 62 62 62 50 57 58 53 40 45 48 30 36

Top Box Percentage/Percentile Ranking Percentage/Percentile Box Top 20

10

0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=394 n=557 n=613 n=682 n=781 n=806 n=845 n=809 n=850 n=747 n=926 n=879 Quarter

HCAHPS Top Box Percentage National Percentile Ranking

Tab 10 - Service Excellence and Quality Dashboards 10-6 Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Rate Hospital 0-10: Pomerado Hospital

100

90

80 73% 70% 70% 66% 69% 66% 66% 68% 66% 67% 70 62% 64% 60

50 56 40

30 39 39 38 32 35

Top Box Percentage/Percentile Ranking Percentage/Percentile Box Top 29 20 28 25 26 10 17 19

0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=210 n=255 n=350 n=280 n=296 n=224 n=290 n=290 n=283 n=250 n=317 n=277 Quarter

HCAHPS Top Box Percentage National Percentile Ranking

Tab 10 - Service Excellence and Quality Dashboards 10-7 Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Communication with Nurses: Pomerado Hospital

100

90 85

82% 78% 79% 79% 79% 78% 80 74% 76% 76% 76% 76% 84% 70 71

60

50 49 44 40

30 40 40 31 Top Box Percentage/Percentile Ranking Percentage/Percentile Box Top 20 25 21 20 10 15 17 0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=212 n=256 n=351 n=280 n=298 n=227 n=294 n=290 n=285 n=255 n=321 n=278 Quarter

HCAHPS Top Box Percentage National Percentile Ranking

Tab 10 - Service Excellence and Quality Dashboards 10-8 Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Communication with Doctors: Pomerado Hospital

100 88 86 87 90 83% 84% 84% 85% 85% 83% 79% 82% 81% 80 87% 86% 87% 81 70 74 74 75 60 65 62 50 59

40 45 30 33

Top Box Percentage/Percentile Ranking Percentage/Percentile Box Top 20

10

0 7/1/13- 10/1/13- 1/1/14- 4/1/14- 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/13 12/31/13 3/31/14 6/30/14 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=211 n=257 n=350 n=279 n=297 n=227 n=293 n=289 n=285 n=255 n=321 n=278 Quarter

HCAHPS Top Box Percentage National Percentile Ranking

Tab 10 - Service Excellence and Quality Dashboards 10-9 Palomar Medical Center 4E Surgical Acute Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.3 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.6 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 2 0.93 4 0.91 2.48

Falls with Injury per 1000 Patient Days 1 0.47 1 0.23 0.45

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 0 1 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 1 1.72% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 0 0.00% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-10 Palomar Medical Center 4NW Surgical & Trauma Progressive Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 3 6.86 3 3.46 1.8 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 1 4.41 1 1.77 0.7 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 4 4.26 5 2.59 2.36

Falls with Injury per 1000 Patient Days 0 0.00 1 0.52 0.36

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 03N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 2 9.09% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-11 Palomar Medical Center 4SW Trauma ICU Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 2 2.93 3 2.14 4.1 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 1 1.98 1 0.86 1.2 (CLABSI) Rate per 1000 Central Line Days Ventilator-Associated Pneumonia (VAP) 1 2.19 1 0.98 0.0

Falls per 1,000 Patient Days 0 0.00 0 0.00 0.78

Falls with Injury per 1000 Patient Days 0 0.00 0 0.00 0.00

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 3 5 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 1 6.25% 11.11% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-12 Palomar Medical Center 5E Cardiovascular Progressive Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.2 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 1 4.31 1 2.15 0.6 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 4 1.90 8 1.85 2.36

Falls with Injury per 1000 Patient Days 1 0.48 3 0.69 0.36

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 0 1 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 0 0.00% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-13 Palomar Medical Center 5W ICU

Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 2 1.60 4 1.49 1.7 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 2 1.93 4 1.64 0.8 (CLABSI) Rate per 1000 Central Line Days Ventilator-Associated Pneumonia (VAP) 0 0.00 0 0.00 0.0

Falls per 1,000 Patient Days 1 0.58 3 0.81 0.78

Falls with Injury per 1000 Patient Days 0 0.00 2 0.54 0.00

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 2 5 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 2 14.29% 5 15.15% 11.11% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-14 Palomar Medical Center 6E Med-Surg Progressive Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.2 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.6 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 5 2.31 9 2.08 2.36

Falls with Injury per 1000 Patient Days 2 0.93 4 0.92 0.36

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 5 7 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 0 0.00% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-15 Palomar Medical Center 6W Progressive Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 2 1.24 1.8 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 0 0.00 2 1.97 0.7 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 3 1.58 5 1.27 2.36

Falls with Injury per 1000 Patient Days 3 1.58 4 1.02 0.36

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 0 3 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 1 2.38% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-16 Palomar Medical Center 7E Ortho Acute Better than or no different than Benchmark Worse than Benchmark

QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.0 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.3 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 3 1.47 6 1.43 2.48

Falls with Injury per 1000 Patient Days 2 0.98 3 0.72 0.45

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 0 0 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 0 0.00% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-17 Palomar Medical Center 7W Neuro Progressive Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 1 0.91 1.2 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.7 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 6 3.81 16 4.94 2.36

Falls with Injury per 1000 Patient Days 2 1.27 6 1.85 0.36

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 0 1 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 0 0.00% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50

Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50

Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-18 Palomar Medical Center 8E/9E Medical Acute Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.2 (CAUTI) Rate per 1000 Catheter Days - 8E Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.2 (CAUTI) Rate per 1000 Catheter Days - 9E Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.7 (CLABSI) Rate per 1000 Central Line Days - 8E Central Line-Associated Blood Stream Infection 0 0.00 1 1.08 0.7 (CLABSI) Rate per 1000 Central Line Days - 9E Falls per 1,000 Patient Days 15 4.23 22 2.90 2.93 Falls with Injury per 1000 Patient Days 2 0.56 5 0.66 0.49

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) - 8E 2 7 N/A

C. Difficile Infections (CDI) - 9E 4 4 N/A

CY16 Q2CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 0 0.00% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark Jun 2016 CY16 Q2 CY16 YTD CY16 Q2 for SIR C. Difficile Infections (CDI) 5 17 39 1.05 0.50 Methicillin-Resistant Staphylococcus Aureus (MRSA) 0 0 0 0.00 0.50 Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50 Surgical Site Infection (SSI): Abdominal Hysterectomy 0 0 0 0.00 0.50 Catheter-Associated Urinary Tract Infection (CAUTI) 5 7 13 0.66 0.50 Central Line-Associated Blood Stream Infection 1 5 10 0.62 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-19 Pomerado Hospital ICU Better than or no different than Benchmark Worse than Benchmark

QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2 CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.3 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 2 4.93 2 2.32 0.7 (CLABSI) Rate per 1000 Central Line Days Ventilator-Associated Pneumonia (VAP) 0 0.00 0 0.00 0.0 Falls per 1,000 Patient Days 0 0.00 0 0.00 0.78 Falls with Injury per 1000 Patient Days 0 0.00 0 0.00 0.00

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 68N/A

CY16 Q2 CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 3 27.27% 9 39.13% 11.11% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 511153.62 0.50 Methicillin-Resistant Staphylococcus Aureus (MRSA) 0010.00 0.50 Surgical Site Infection (SSI): Colon 011N/A 0.50 Surgical Site Infection (SSI): Abdominal Hysterectomy 0000.00 0.50 Catheter-Associated Urinary Tract Infection (CAUTI) 0 0 1 0.00 0.50 Central Line-Associated Blood Stream Infection 0 3 3 2.57 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 Flu Season Only # of % Measure # of % Measure FY17 VBP Successes Success Successes Success Threshold IMM-2 Influenza Immunization 69 88.46% 424 91.38% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-20 Pomerado Hospital Med-Surg-Tele & IMC Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2 CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.2 (CAUTI) Rate per 1000 Catheter Days - T2 Med/Surg Catheter-Associated Urinary Tract Infection 0 0.00 0 0.00 1.2 (CAUTI) Rate per 1000 Catheter Days - T3 Med/Surg Catheter-Associated Urinary Tract Infection 0 0.00 1 0.91 1.2 (CAUTI) Rate per 1000 Catheter Days - T4 Med/Surg Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.7 (CLABSI) Rate per 1000 Central Line Days - T2 Med/Surg Central Line-Associated Blood Stream Infection 1 3.62 1 1.67 0.7 (CLABSI) Rate per 1000 Central Line Days- T3 Med/Surg Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.7 (CLABSI) Rate per 1000 Central Line Days- T4 Med/Surg Falls per 1,000 Patient Days 11 2.78 17 2.12 2.48 Falls with Injury per 1000 Patient Days 4 1.01 4 0.50 0.45

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) - T2 Med/Surg 00N/A

C. Difficile Infections (CDI) - T3 Med/Surg 23N/A

C. Difficile Infections (CDI) - T4 Med/Surg 45N/A

CY16 Q2 CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.00% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 1 1.75% 3 2.63% 0.00% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark Jun 2016 CY16 Q2 CY16 YTD CY16 Q2 for SIR C. Difficile Infections (CDI) 511153.62 0.50 Methicillin-Resistant Staphylococcus Aureus (MRSA) 0010.00 0.50 Surgical Site Infection (SSI): Colon 011N/A 0.50 Surgical Site Infection (SSI): Abdominal Hysterectomy 0000.00 0.50 Catheter-Associated Urinary Tract Infection (CAUTI) 0 0 1 0.00 0.50 Central Line-Associated Blood Stream Infection (CLABSI) 0 3 3 2.57 0.50

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 Flu Season Only # of % Measure # of % Measure FY17 VBP Successes Success Successes Success Threshold IMM-2 Influenza Immunization 69 88.46% 424 91.38% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-21 Pomerado Hospital Obstetric Unit

Better than or no different than Benchmark Worse than Benchmark

QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q1 CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate PC-01 Elective Delivery Prior to 39 Completed Weeks 0 0.00% 0 0.00% 2% Gestation - % Measure Failure Cases

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 511153.62 0.50

Methicillin-resistant Staphylococcus aureus (MRSA) 0010.00 0.50

Surgical Site Infection (SSI): Abdominal Hysterectomy 0000.00 0.50

Catheter-Associated Urinary Tract Infection (CAUTI) 0 0 1 0.00 0.50

Central Line-Associated Blood Stream Infection 0 3 3 2.57 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 Flu Season Only # of % Measure # of % Measure FY17 VBP Successes Success Successes Success Threshold IMM-2 Influenza Immunization 69 88.46% 424 91.38% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-22 Palomar Health Downtown Campus Acute Rehab Unit Better than or no different than Benchmark Worse than Benchmark QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q2 CY16 YTD Benchmark # of # of Occurrences Rate Occurrences Rate Catheter-Associated Urinary Tract Infection 0 0.00 2 5.41 2.5 (CAUTI) Rate per 1000 Catheter Days Central Line-Associated Blood Stream Infection 0 0.00 0 0.00 0.4 (CLABSI) Rate per 1000 Central Line Days Falls per 1,000 Patient Days 8 4.49 22 6.26 4.4

Falls with Injury per 1000 Patient Days 2 1.12 4 1.14 0.6

CY16 Q2 CY16 YTD Benchmark

# of Infections # of Infections C. Difficile Infections (CDI) 01N/A

CY16 Q2 CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate % of Patients with Hospital Acquired Pressure 0 0.00% 0 0.00% 0.0% Ulcers (HAPU) - Stage II or Above % of Patients with Physical Restraints 0 0.00% 0 0.00% 0.0% (Limb and/or Vest)

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 017N/A 0.50 Methicillin-Resistant Staphylococcus Aureus (MRSA) 0000.00 0.50 Surgical Site Infection (SSI): Abdominal Hysterectomy 0000.00 0.50 Catheter-Associated Urinary Tract Infection (CAUTI) 0 0 2 0.00 0.50

Central Line-Associated Blood Stream Infection 0 0 0 0.00 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-23 Palomar Health Downtown Campus Obstetric Unit

Better than or no different than Benchmark Worse than Benchmark

QUALITY DASHBOARD - UNIT SPECIFIC CY16 Q1 CY2015 Benchmark # of # of Occurrences Rate Occurrences Rate PC-01 Elective Delivery Prior to 39 Completed 0 0.00% 0 0.00% 2% Weeks Gestation - % Measure Failure Cases

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 017N/A 0.50

Methicillin-Resistant Staphylococcus Aureus 0000.00 0.50 (MRSA) Surgical Site Infection (SSI): Abdominal 0000.00 0.50 Hysterectomy Catheter-Associated Urinary Tract Infection (CAUTI) 0 0 2 0.00 0.50

Central Line-Associated Blood Stream Infection 0 0 0 0.00 0.50 (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold

IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Last updated: 8/5/2016 Tab 10 - Service Excellence and Quality Dashboards 10-24 Better than or no different than Benchmark Palomar Medical Center Worse than Benchmark

QUALITY DASHBOARD - UNIT SPECIFIC Measure / Unit Performance for Performance for Benchmark CY16 Q2 CY16 YTD

Catheter-Associated Urinary Tract # of Rate per 1000 # of Rate per 1000 NHSN Mean 2 Infection (CAUTI) CAUTI Catheter Days CAUTI Catheter Days

4E Surgical Acute 0 0.00 0 0.00 1.3 4NW Surgical & Trauma Progressive 3 6.86 3 3.46 1.8 4SW Trauma ICU 2 2.93 3 2.14 4.1 5E Cardiovascular Progressive 0 0.00 0 0.00 1.2 5W ICU 2 1.60 4 1.49 1.7 6E Med-Surg Progressive 0 0.00 0 0.00 1.2 6W Progressive 0 0.00 2 1.24 1.8 7E Ortho Acute 0 0.00 0 0.00 1.0 7W Neuro Progressive 0 0.00 1 0.91 1.2 8E Medical Acute 0 0.00 0 0.00 1.2 9E Medical Acute 0 0.00 0 0.00 1.2

Rate per 1000 Rate per 1000 Central Line-Associated Blood # of # of Central Line Central Line NHSN Mean 2 CLABSI CLABSI Stream Infection (CLABSI) Days Days 4E Surgical Acute 0 0.00 0 0.00 0.6 4NW Surgical & Trauma Progressive 1 4.41 1 1.77 0.7 4SW Trauma ICU 1 1.98 1 0.86 1.2 5E Cardiovascular Progressive 1 4.31 1 2.15 0.6 5W ICU 2 1.93 4 1.64 0.8 6E Med-Surg Progressive 0 0.00 0 0.00 0.6 6W Progressive 0 0.00 2 1.97 0.7 7E Ortho Acute 0 0.00 0 0.00 0.3 7W Neuro Progressive 0 0.00 0 0.00 0.7 8E Medical Acute 0 0.00 0 0.00 0.7 9E Medical Acute 0 0.00 1 1.08 0.7

Ventilator-Associated Pneumonia # of Rate per 1000 # of Rate per 1000 Internal Goal (VAP) VAP Vent Days VAP Vent Days

4SW Trauma ICU 1 2.19 1 0.98 0.0 5W ICU 0 0.00 0 0.00 0.0

Last Updated: 8/5/2016 ‐ 1 of 4 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-25 Measure / Unit Performance for Performance for Benchmark CY16 Q2 CY16 YTD C. Difficile Infections (CDI) # of Infections # of Infections 4E Surgical Acute 0 1 N/A 4NW Surgical & Trauma Progressive 03N/A 4SW Trauma ICU 35N/A 5E Cardiovascular Progressive 01N/A 5W ICU 25N/A 6E Med-Surg Progressive 57N/A 6W Progressive 03N/A 7E Ortho Acute 00N/A 7W Neuro Progressive 01N/A 8E Medical Acute 27N/A 9E Medical Acute 44N/A

Previous Quarter # of Rate per 1000 # of Rate per 1000 Magnet 50th Falls Falls Patient Days Falls Patient Days Percentile 1 4E Surgical Acute 2 0.93 4 0.91 2.48 4NW Surgical & Trauma Progressive 4 4.26 5 2.59 2.36 4SW Trauma ICU 0 0.00 0 0.00 0.78 5E Cardiovascular Progressive 4 1.90 8 1.85 2.36 5W ICU 1 0.58 3 0.81 0.78 6E Med-Surg Progressive 5 2.31 9 2.08 2.36 6W Progressive 3 1.58 5 1.27 2.36 7E Ortho Acute 3 1.47 6 1.43 2.48 7W Neuro Progressive 6 3.81 16 4.94 2.36 8E/9E Medical Acute 15 4.23 22 2.90 2.93

Previous Quarter # of Injury Rate per 1000 # of Injury Rate per 1000 Magnet 50th Falls with Injury Falls Patient Days Falls Patient Days Percentile 1 4E Surgical Acute 1 0.47 1 0.23 0.45 4NW Surgical & Trauma Progressive 0 0.00 1 0.52 0.36 4SW Trauma ICU 0 0.00 0 0.00 0.00 5E Cardiovascular Progressive 1 0.48 3 0.69 0.36 5W ICU 0 0.00 2 0.54 0.00 6E Med-Surg Progressive 2 0.93 4 0.92 0.36 6W Progressive 3 1.58 4 1.02 0.36 7E Ortho Acute 2 0.98 3 0.72 0.45 7W Neuro Progressive 2 1.27 6 1.85 0.36 8E/9E Medical Acute 2 0.56 5 0.66 0.49

Last Updated: 8/5/2016 ‐ 2 of 4 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-26 Measure / Unit Performance for Performance for Benchmark CY16 Q2 CY16 YTD # of Pts # of Pts Previous Quarter Hospital Acquired Pressure Ulcers % Pt with % Pt with with with Magnet 50th HAPU II+ HAPU II+ (HAPU) - Stage II or Above HAPU II+ HAPU II+ Percentile 1 4E Surgical Acute 0 0.00% 1 1.72% 0.00% 4NW Surgical & Trauma Progressive 0 0.00% 0 0.00% 0.00% 4SW Trauma ICU 0 0.00% 0 0.00% 0.00% 5E Cardiovascular Progressive 0 0.00% 0 0.00% 0.00% 5W ICU 0 0.00% 0 0.00% 0.00% 6E Med-Surg Progressive 0 0.00% 0 0.00% 0.00% 6W Progressive 0 0.00% 0 0.00% 0.00% 7E Ortho Acute 0 0.00% 0 0.00% 0.00% 7W Neuro Progressive 0 0.00% 0 0.00% 0.00% 8E/9E Medical Acute 0 0.00% 0 0.00% 0.00%

# of Pts # of Pts Previous Quarter % Pt with % Pt with with with Magnet 50th Physical Restraints (Limb and/or Vest) Restraints Restraints Restraints Restraints Percentile 1 4E Surgical Acute 0 0.00% 0 0.00% 0.00% 4NW Surgical & Trauma Progressive 0 0.00% 2 9.09% 0.00% 4SW Trauma ICU 0 0.00% 1 6.25% 11.11% 5E Cardiovascular Progressive 0 0.00% 0 0.00% 0.00% 5W ICU 2 14.29% 5 15.15% 11.11% 6E Med-Surg Progressive 0 0.00% 0 0.00% 0.00% 6W Progressive 0 0.00% 1 2.38% 0.00% 7E Ortho Acute 0 0.00% 0 0.00% 0.00% 7W Neuro Progressive 0 0.00% 0 0.00% 0.00% 8E/9E Medical Acute 0 0.00% 0 0.00% 0.00%

Benchmark Source / Notes: 1. Benchmark for falls, HAPU and restraint measures is the Magnet median (50th percentile) from NDNQI (National Database of Nursing Quality Indicators) for the quarter of 1/1/2016 - 3/31/2016. HAPU and restraint data come from skin prevalence study. 2. Benchmark for CLABSI and CAUTI rates is the NHSN mean for a period of 3 months from 1/1/2016 - 3/31/2016.

Last Updated: 8/5/2016 ‐ 3 of 4 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-27 Palomar Medical Center Better than or no different than Benchmark Worse than Benchmark

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR 5 Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 17 39 1.05 0.50 Methicillin-Resistant Staphylococcus Aureus 0 0 0 0.00 0.50 (MRSA) Surgical Site Infection (SSI): Colon 0 2 5 0.51 0.50 Surgical Site Infection (SSI): Abdominal 0 0 0 0.00 0.50 Hysterectomy Catheter-Associated Urinary Tract 5 7 13 0.66 0.50 Infection (CAUTI) Central Line-Associated Blood 1 5 10 0.62 0.50 Stream Infection (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY2017 VBP Flu Season Only Successes Success Successes Success Threshold 6 IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Benchmark Source / Notes (continued): 3. An SIR (standardized infection ratio) > 1.0 indicates that more infections were observed than predicted, accounting for differences in the types of patients followed; conversely, an SIR < 1.0 indicates that fewer infections were observed than predicted. Monthly SIR is not available as NHSN calculates quarterly SIR only. In order to provide the most current performance for C. Diff, MRSA, SSI for colon surgery and abdominal hysterectomy, we show # of infections for the month. SIR values only calculated if number of expected infections >= 1. 4. C. difficile data for the most current month is preliminary. Data may change. 5. Benchmark for the Healthcare-Associated Infections SIR was developed internally. Lower ratio is better. 6. Benchmark for IMM-2 is the FY2017 VBP threshold. Higher rate is better.

Last Updated: 8/5/2016 ‐ 4 of 4 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-28 Better than or no different than Benchmark Pomerado Hospital Worse than Benchmark

QUALITY DASHBOARD - UNIT SPECIFIC Measure / Unit Performance for Performance for Benchmark CY16 Q2 CY16 YTD

Catheter-Associated Urinary Tract # of Rate per 1000 # of Rate per 1000 NHSN Mean 2 Infection (CAUTI) CAUTI Catheter Days CAUTI Catheter Days ICU 0 0.00 0 0.00 1.3 T2 Med/Surg 0 0.00 0 0.00 1.2 T3 Med/Surg 0 0.00 0 0.00 1.2 T4 Med/Surg 0 0.00 1 0.91 1.2

Rate per 1000 Rate per 1000 Central Line-Associated Blood # of # of Central Line Central Line NHSN Mean 2 CLABSI CLABSI Stream Infection (CLABSI) Days Days ICU 2 4.93 2 2.32 0.7 T2 Med/Surg 0 0.00 0 0.00 0.7 T3 Med/Surg 1 3.62 1 1.67 0.7 T4 Med/Surg 0 0.00 0 0.00 0.7

Ventilator-Associated Pneumonia # of Rate per 1000 # of Rate per 1000 Internal Goal (VAP) VAP Vent Days VAP Vent Days ICU 0 0.00 0 0.00 0.0

C. Difficile Infections (CDI) # of Infections # of Infections

ICU 68N/A T2 Med/Surg 00N/A T3 Med/Surg 23N/A T4 Med/Surg 45N/A

Previous Quarter # of Rate per 1000 # of Rate per 1000 Magnet 50th Falls Falls Patient Days Falls Patient Days Percentile 1 ICU 0 0.00 0 0.00 0.78 Med-Surg-Tele & IMC 11 2.78 17 2.12 2.48

Last Updated: 8/5/2016 ‐ 1 of 3 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-29 Measure / Unit Performance for Performance for Benchmark CY16 Q2 CY16 YTD Previous Quarter # of Injury Rate per 1000 # of Injury Rate per 1000 Magnet 50th Falls with Injury Falls Patient Days Falls Patient Days Percentile 1 ICU 0 0.00 0 0.00 0.00 Med-Surg-Tele & IMC 4 1.01 4 0.50 0.45

Previous Quarter # of % Pt with # of % Pt with Hospital Acquired Pressure Ulcers Magnet 50th HAPU II+ HAPU II+ HAPU II+ HAPU II+ (HAPU) - Stage II or Above Percentile 1 ICU 0 0.00% 0 0.00% 0.00% Med-Surg-Tele & IMC 0 0.00% 0 0.00% 0.00%

# of Pts # of Pts Previous Quarter % Pt with % Pt with with with Magnet 50th Physical Restraints (Limb and/or Vest) Restraints Restraints Restraints Restraints Percentile 1 ICU 3 27.27% 9 39.13% 11.11% Med-Surg-Tele & IMC 1 1.75% 3 2.63% 0.00%

Measure / Unit Performance for Performance for Benchmark CY16 Q1 CY2015

PC-01 Elective Delivery Prior to 39 # of % Measure # of % Measure State Average 3 Completed Weeks Gestation Failures Failure Cases Failures Failure Cases

Obstetric 0 0.00% 0 0.00% 2%

Benchmark Source / Notes:

1. Benchmark for falls, HAPU and restraint measures is the Magnet median (50th percentile) from NDNQI (National Database of Nursing Quality Indicators) for the quarter of 1/1/2016 - 3/31/2016. HAPU and restraint data come from skin prevalence study. 2. Benchmark for CLABSI and CAUTI rates is the NHSN mean for a period of 3 months from 1/1/2016 - 3/31/2016. 3. Benchmark for PC-01 is the state average rate for a period of 12 months from 1/1/2015 - 12/31/2015. Lower rate is better.

Last Updated: 8/5/2016 ‐ 2 of 3 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-30 Pomerado Hospital Better than or no different than Benchmark Worse than Benchmark

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark CY16 Q2 for SIR 6 Jun 2016 CY16 Q2 CY16 YTD C. Difficile Infections (CDI) 5 11 15 3.62 0.50 Methicillin-Resistant Staphylococcus Aureus 0 0 1 0.00 0.50 (MRSA) Surgical Site Infection (SSI): Colon 0 1 1 N/A 0.50 Surgical Site Infection (SSI): Abdominal 0 0 0 0.00 0.50 Hysterectomy Catheter-Associated Urinary Tract 0 0 1 0.00 0.50 Infection (CAUTI) Central Line-Associated Blood 0 3 3 2.57 0.50 Stream Infection (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 # of % Measure # of % Measure FY17 VBP Flu Season Only 7 Successes Success Successes Success Threshold IMM-2 Influenza Immunization 69 88.46% 424 91.38% 95%

Benchmark Source / Notes (continued): 4. An SIR (standardized infection ratio) > 1.0 indicates that more infections were observed than predicted, accounting for differences in the types of patients followed; conversely, an SIR < 1.0 indicates that fewer infections were observed than predicted. Monthly SIR is not available as NHSN calculates quarterly SIR only. In order to provide the most current performance for C. Diff, MRSA, SSI for colon surgery and abdominal hysterectomy, we show # of infections for the month. SIR values only calculated if number of expected infections >= 1. 5. C. difficile data for the most current month is preliminary. Data may change. 6. Benchmark for the Healthcare-Associated Infections SIR was developed internally. Lower ratio is better. 7. Benchmark for IMM-2 is the FY2017 VBP threshold. Higher rate is better.

Last Updated: 8/5/2016 ‐ 3 of 3 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-31 Palomar Health Downtown Campus Better than or no different than Benchmark Worse than Benchmark

QUALITY DASHBOARD - UNIT SPECIFIC Measure / Unit Performance for Performance for Benchmark CY16 Q2 CY16 YTD

Catheter-Associated Urinary Tract # of Rate per 1000 # of Rate per 1000 NHSN Mean 2 Infection (CAUTI) CAUTI Catheter Days CAUTI Catheter Days Acute Rehab 0 0.00 2 5.41 2.5

Rate per 1000 Rate per 1000 Central Line-Associated Blood # of # of Central Line Central Line NHSN Mean 2 CLABSI CLABSI Stream Infection (CLABSI) Days Days Acute Rehab 0 0.00 0 0.00 0.4

C. Difficile Infections (CDI) # of Infections # of Infections

Acute Rehab 0 1 N/A

Previous Quarter # of Rate per 1000 # of Rate per 1000 Magnet 50th Falls Falls Patient Days Falls Patient Days Percentile 1 Acute Rehab 8 4.49 22 6.26 4.44

Previous Quarter # of Injury Rate per 1000 # of Injury Rate per 1000 Magnet 50th Falls with Injury Falls Patient Days Falls Patient Days Percentile 1 Acute Rehab 2 1.12 4 1.14 0.63

Measure / Unit Performance for Performance for Benchmark CY16 Q2 CY16 YTD # of Pts # of Pts Previous Quarter Hospital Acquired Pressure Ulcers % Pt with % Pt with with with Magnet 50th HAPU II+ HAPU II+ (HAPU) - Stage II or Above HAPU II+ HAPU II+ Percentile 1 Acute Rehab 0 0.00% 0 0.00% 0.00%

# of Pts # of Pts Previous Quarter % Pt with % Pt with with with Magnet 50th Physical Restraints (Limb and/or Vest) Restraints Restraints Restraints Restraints Percentile 1 Acute Rehab 0 0.00% 0 0.00% 0.00%

Last Updated: 8/5/2016 ‐ 1 of 2 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-32 Measure / Unit Performance for Performance for Benchmark CY16 Q1 CY2015

PC-01 Elective Delivery Prior to 39 # of % Measure # of % Measure State Average 3 Completed Weeks Gestation Failures Failure Cases Failures Failure Cases

Obstetric 0 0.00% 0 0.00% 2%

FACILITY-WIDE DASHBOARD Healthcare-Associated Infections # of Infections SIR for Benchmark 6 Jun 2016 CY16 Q2 CY16 YTD CY16 Q2 for SIR C. Difficile Infections (CDI) 0 1 7 N/A 0.50

Methicillin-Resistant Staphylococcus Aureus 0 0 0 0.00 0.50 (MRSA) Surgical Site Infection (SSI): Abdominal 0 0 0 0.00 0.50 Hysterectomy Catheter-Associated Urinary Tract 0 0 2 0.00 0.50 Infection (CAUTI) Central Line-Associated Blood 0 0 0 0.00 0.50 Stream Infection (CLABSI)

Core Measure Performance for Performance for Benchmark Mar 2016 Oct 2015 - Mar 2016 [PMC & PHDC Combined] # of % Measure # of % Measure FY17 VBP Flu Season Only Successes Success Successes Success Threshold 7 IMM-2 Influenza Immunization 80 90.91% 470 93.25% 95%

Benchmark Source / Notes: 1. Benchmark for falls, HAPU and restraint measures is the Magnet median (50th percentile) from NDNQI (National Database of Nursing Quality Indicators) for the quarter of 1/1/2016 - 3/31/2016 for acute rehab unit. HAPU and restraint data come from skin prevalence study. 2. Benchmark for CLABSI and CAUTI rates is the NHSN mean for a period of 3 months from 1/1/2016 - 3/31/2016. 3. Benchmark for PC-01 is the state average rate for a period of 12 months from 1/1/2015 - 12/31/2015. Lower rate is better. 4. An SIR (standardized infection ratio) > 1.0 indicates that more infections were observed than predicted, accounting for differences in the types of patients followed; conversely, an SIR < 1.0 indicates that fewer infections were observed than predicted. Monthly SIR is not available as NHSN calculates quarterly SIR only. In order to provide the most current performance for C. Diff, MRSA, SSI for colon surgery and abdominal hysterectomy, we show # of infections for the month. SIR values only calculated if number of expected infections >= 1. 5. C. difficile data for the most current month is preliminary. Data may change. 6. Benchmark for the Healthcare-Associated Infections SIR was developed internally. Lower ratio is better. 7. Benchmark for IMM-2 is the FY2017 VBP threshold. Higher rate is better.

Last Updated: 8/5/2016 ‐ 2 of 2 ‐ Tab 10 - Service Excellence and Quality Dashboards 10-33

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Quality and Patient Safety Reports Presented to BQRC in 2016

September 19, 2016

Palomar Health

Summary and Evaluation of the Calendar Year 2015 Infection Prevention and Control Program Plan and the Working Plan for Calendar Year 2016

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-1 EVALUATE THE EFFECTIVENESS OF THE INFECTION PREVENTION AND CONTROL PROGRAM FOR 2015

Mission: Develop and maintain an Infection Prevention and Control program that reflects the Mission and Vision of Palomar Health. The program includes 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) and other nationally recognized organizations. To assure implementation of prevention measures, and monitoring outcomes with the ultimate goal of preventing and controlling infection transmission among patients, employees, medical staff, contracted service workers, volunteers, students, and visitors.

Purpose: To provide structure for an organization-wide, facility specific approach to identify and reduce the risk of endemic and epidemic healthcare-associated infections (HAI). To ensure optimal provision of services, the management of the infection prevention and control process is assigned to qualified personnel by virtue of education, training, certification or licensure, and experience.

Authority Statement: The hospital has designated one or more individual(s) as its Infection Control Officer(s) per CMS. The Infection Control Officer(s) is/are qualified and maintain(s) qualifications through education, training, experience or certification related to infection control consistent with hospital policy. The Infection Control Officer(s) have the authority and responsibility for ensuring the implementation of a planned and systematic process for monitoring and evaluating the quality and appropriateness of the Infection Prevention and Control Program. The Infection Control Committee, through its chairperson and/or Director of the Infection Prevention and Control Program, are granted authority to institute any appropriate emergency control measures throughout the health system when there is a reasonable risk or danger to any patient or personnel. Department Structure:

The Infection Prevention and Control Department falls under the Patient Experience Division. Dr. Jerry Kolins is the Vice President; Valerie Martinez is the District Director, and Dr. Steve Kuriyama, Medical Director of Infection Control and the Chair of the Infection Control Committee. In addition, there are four Infection Preventionists, located at each of the acute care campuses and are resources to all programs across the continuum of care.

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-2 Evaluation of 2015 Program Effectiveness

Effectiveness Target Outcome Surveillance Activity Goal Goal Goal Met Not Met Hand Hygiene Compliance System wide: System 2015 95% Met 90% of 90% Compliance 2014 82% observed HCW will perform appropriate hand hygiene.

90% compliance PMC: Not Met 2015 88% 2014 76%

90% compliance PHDC Met 2015 100% 2014 91%

90% compliance POM Met 2015 100% 2014 90%

HAND HYGIENE NOTE: Secret Observers having difficulty with form. A new form has been created for 2016, educated secret observers and rolled out.

Central Line- Associated System: Reduce # CLABSI 2015 - 14 Not Met Bloodstream Infections (CLABSI) Eliminate in 2015 2014 – 11 Reduction CLABSIs compared from 2014

Facility: PMC SIR < 0.50 2015 SIR 0.384 Met 2014 SIR 0.224

PHDC SIR < 0.50 2015 SIR 0.0 Met 2014 SIR 0.0

PHDC ARU SIR < 0.50 2015 SIR 0.0 Met 2014 SIR 0.0

Not Met POM SIR <0.50 2015 SIR 0.642 2014 SIR 0.345

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-3 Effectiveness Target Outcome Surveillance Activity Goal Goal Goal Met Not Met CLABSI Summary: PMC overall SIR remains below the SIR target of 0.50, ARU had ZERO CLABSI, however Pomerado is above the SIR target. This accounted for 3 CLABSI events at Pomerado which all occurred in the 2nd half of the year. There was a change in the elimination of the dedicated Peripherally Inserted Central Catheter (PICC) team and the service transitioned to Interventional Radiology. There was an increase in CLABSI noted during the transition with new IR PICC team, however no trends were identified. 2015 Interventions: The Central Line Insertion Practice (CLIP) form was evaluated for change and made available to Physician inserters to encourage use among the practitioners. Physician education provided through the ICU committee. Ongoing CLIP data collection and reporting to appropriate committees. The annual CVC line prevalence study shows improvement. 2016 Interventions: Implement Chlorhexidine baths daily in ICU (evidence based practice and community standard). Evaluate increasing IV tubing hang time from 72 hours to seven days, to decrease the number of device access times, thus decreasing CLABSI. Dedicated PICC team reinstated with dedicated insertions and dressing changes. Implement UV light disinfection (Xenex) upon discharge/transfer of CCU rooms. Healthcare Onset MDRO System: Reduce # 2015 - 7 Not Met Methicillin-resistant Eliminate MRSA BSI in 2014 – 7 Staphylococcus aureus (MRSA) Healthcare Onset 2015 bloodstream infection (BSI) (HO) MRSA compared to 2014 Facility: PMC SIR < 0.50 2015 SIR 1.797 Not Met 2014 SIR 0.735

PHDC ARU Rate zero 2015 SIR 0 Met 2014 SIR 0.997 (1 event)

POM SIR < 0.50 2015 SIR 0.0 Met 2014 SIR 1.457

HO Clostridium-difficile (C. diff) System: Reduce # of 2015 - 87 Met Reduction Eliminate HO HO-CDIFF in 2014 – 99 C. difficile 2015 Infection compared to 2014 Facility: PMC SIR < 0.50 2015 SIR 1.029 Not Met 2014 SIR 1.394

PHDC SIR < 0.50 2015 SIR 0.00 Met 2014 SIR 0.101

PHDC ARU Rate Zero 2015 Rate 10.432 Not Met (4 events)

POM SIR < 0.50 2015 SIR 1.479 Not Met 2014 SIR 1.641

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-4 Effectiveness Target Outcome Surveillance Activity Goal Goal Goal Met Not Met HO Vancomycin Resistant System: Reduce # VRE PMC, POM and Met Enterococcus (VRE) BSI Eliminate HO BSI in 2015 PHDC had Zero VRE BSI compared to VRE BSI 2014 MRSA BSI Summary: MRSA BSI infections increased in 2015 at PMC. PMC had 7 MRSA BSI in 2015 as compared to 4 MRSA BSI in 2014. Pomerado had zero MRSA BSI in 2015 compared to 2 MRSA BSI in 2014. 2015 Interventions: Active MRSA screening upon admit continues with contact isolation until discharge. Thorough review of the cases at PMC revealed no possible secondary source in 3 of 7 cases. Possible secondary sources included respiratory, gastrointestinal, and wounds. 2016 Interventions: Focus on Xenex use in MRSA patient rooms at discharge and transfers. CLABSI prevention and contact precautions adherence with hand hygiene and PPE compliance. Explore the use of Chlorhexadine bathing for patients who are positive for MRSA.

C-difficile Summary: The overall Hospital Onset (HO) C. difficile cases decreased at both PMC and Pomerado in 2015 as compared from 2014, however both campuses and ARU are all above the SIR target. 2015 Interventions: The interdisciplinary Healthcare Associated Infection (HAI) prevention team reconvened. The focus is on data review, case review and prevention of HO MDRO’s including C-difficile. 2016 Interventions: Focus on compliance with PPE and Hand Hygiene using secret shoppers and supplemented by the SOS team. Monitor early identification of patients with diarrhea and automatic MD order. Collaborate with Pharmacy on antibiotic and Proton Pump Inhibitor utilization; explore probiotic use and fecal transplant. Implement stool containment systems and focused Xenex UV light disinfection use. Surgical Site Infection (SSI) SIR System: Reduce # SSI in 2015 - 72 Not Met Eliminate SSIs 2015 compared 2014 - 72 Surveillance performed on 25 from 2014 surgical procedures Facility SIR <0.50 2015 SIR 0.500 Met Focused on 4 surgical procedures PMC 2014 SIR 0.632 with CMS impact and/or high SIR (D=5013)

PHDC SIR <0.50 2015 SIR 0.430 Met (D=1152) 2014 SIR 0.615

POM SIR <0.50 2015 SIR 0.976 Not Met (D=1564) 2014 SIR 0.682

PMC Hip Replacement (HPRO) SSI Eliminate Reduce # HPRO 2015 - 2 Not Met Prevention HPRO SSIs SSI 2014 – 0

SIR<0.50 2015 SIR- 0.256 Met 2014 SIR 0.0

POM Hip Replacement (HPRO) Eliminate Reduce # HPRO 2015- 5 Met SSI Prevention HPRO SSIs SSI 2014 – 6

SIR <0.50 2015 SIR 3.227 Not met 2014 SIR 3.659

PMC Knee Replacement (KPRO) Eliminate Reduce # KPRO 2015 - 2 Met SSI Prevention KPRO SSIs SSI 2014 – 7 5 | P a g e

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-5 Effectiveness Target Outcome Surveillance Activity Goal Goal Goal Met Not Met

SIR <0.50 2015 SIR 0.195 Met 2014 SIR 0.859

POM Knee Replacement (KPRO) Eliminate Reduce # KPRO 2015 - 5 Not Met SSI Prevention KPRO SSIs SSI 2014 - 4

SIR <0.50 2015 – SIR 1.496 Not Met 2014 – SIR 2.137 PMC Colorectal Surgery Eliminate SSIs Reduce # Colon 2015 - 12 Met SSI 2014 -13

SIR<0.50 2015 SIR 1.304 Not Met 2014 SIR 1.326

POM Colorectal Surgery Eliminate SSIs Reduce # Colon 2015 - 1 Met SSI 2014 – 2

SIR <0.50 2015 – 0.422 Met 2014 SIR 1.232

PMC Hysterectomy Surgery Eliminate SSIs Reduce # 2015 - 2 Not Met Hysterectomy 2014 – 0 SSI

SIR<0.50 2015 SIR 0.974 Not Met 2014 SIR 0.0

POM Hysterectomy Surgery Eliminate SSIs Reduce # 2015 - 2 Not Met Hysterectomy 2014 - 1 SSI

SIR <0.50 2015 SIR 2.174 Not Met 2014 SIR 0.813

PHDC Hysterectomy Surgery Eliminate SSIs Reduce # 2015 - ZERO Met Hysterectomy 2014 1 SSI 2015 ZERO Met 2014 SIR (1) 6 | P a g e

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-6 Effectiveness Target Outcome Surveillance Activity Goal Goal Goal Met Not Met

SSI Summary: The overall SSI SIR (for all 26 required surgical procedures) for PMC and PHDC was below the SIR target, while Pomerado was above at 0.976. These account for 41 SSI at PMC and 22 SSI for Pomerado. There are 4 surgical procedures of note when reviewing SSI. Colorectal, Abdominal, Hip Prosthesis (HPRO) and Knee Prosthesis (KPRO). Colorectal and Abdominal Hysterectomy surgeries both fall under the Value Based Purchasing (VBP) and Healthcare Acquired Conditions (HAC) CMS penalty programs.

PMC had two Hip surgery SSI’s in 2015 which increased from 0 in 2014, however remains well below the SIR 0.50 targets. Pomerado had 5 Hip SSI which was a decrease from 6 2014; however was well above the SIR 0.50 targets. PMC had 2 Knee surgeries SSI which is decreased from 7 in 2015 and below 0.50 targets. Pomerado had 3 Knee SSI and is above the SIR 0.50 target.

PMC had 12 Colon SSI which decreased from 13 in 2014, however remains above the SIR 0.50 target. The number of Colon SSI was higher in the1st half of 2015 compared to the 2nd half of the year which contributed to Physician collaboration and focused review of SSI cases. Pomerado had 1 Colon SSI and remains below the target.

PMC and Pomerado above SIR 0.50 target for hysterectomy SSI which accounts for 2 SSI for each campus.

2015 Interventions: Noted this year were inconsistent pre-operative practices at both PMC and Pomerado. These include pre-op showers with chlorhexidine, S. aureus screening and treatment when indicated, and peri-op antibiotic dosage. These measures were addressed with the Orthopedic Centers of Excellence, Orthopedic Committee and OR leadership. In November 2015 data collection demonstrated implementation of these prevention measures improved. Infection Preventionist (IP) performed OR case observations and made recommendations to surgical services regarding opportunities for improvement. 2016 Interventions: Intermittent OR case observations with immediate feedback to OR leadership and Surgeons. Explore a different MRSA decolonizing nasal treatment for improved patient compliance. Conduct a mini RCA for each SSI with Surgeon, IP and ID Physician to review for trends and opportunities. Continue standardization and monitoring of prevention pre-op measures. Explore the use of a bundle for colon surgeries for SSI prevention.

Ventilator-associated System: Reduce # Total 2015 - 2 Met Events/Pneumonia (VAE/VAP) Eliminate VAP in 2015 2014 - 8 VAEs compared to There is no SIR benchmark for 2014 VAE/VAP.

PMC 5th floor < 2014 Rate 2015 rate 0.302 Met ICU 2014 rate 0.886

PMC Trauma < 2014 Rate 2015 rate 0.626 Met ICU 2014 rate 3.081

Pom ICU < 2014 Rate 2015 rate 0.00 Met 2014 rate 0.00

VAP NOTE: At this time VAE/VAP is not mandatory for any public reporting. The rates account for total VAP during 2015. Pomerado ICU went with Zero VAP for the entire 2015 and PMC CCU/TICU decreased VAP rate as compared to 2014. VAP bundle measures are monitored and compliance rates are high. There were no trends identified.

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-7 Effectiveness Target Outcome Surveillance Activity Goal Goal Goal Met Not Met

Catheter-associated Urinary Tract System: Reduce # CAUTI 2015 - 28 Met Infections (CAUTI) Reduction Eliminate in 2015 as 2014 - 42 CAUTI compared to 2014

Facility: PMC SIR <0.50 2015 SIR 0.432 Met 2014 SIR 2.058

PHDC ARU SIR <0.50 2015 SIR 1.876 Not Met 2014 SIR 0.812

POM SIR <0.50 2015 SIR 0.102 Met 2014 SIR 1.778

CAUTI Summary: PMC and Pomerado have shown significant reduction of CAUTI SIR in 2015, and remains below SIR 0.50 target. However, ARU is above SIR target at 1.876, which accounts for 4 CAUTI cases. 2015 Interventions: Implemented nurse driven Foley Cath removal protocol to remove unnecessary catheters. Nursing skills day with return demo of Foley insertion and management by all RNs system wide. 2016 Interventions: Collect and assess the compliance of bundle measures in all areas with Foley catheters. Assess and share device utilization rates in all units as removal of unnecessary catheters remains the number one prevention measure. Conduct a point prevalence study to assess real time prevention bundle compliance, staff knowledge, and insertion/management of the catheter. Reportable Disease Surveillance Meet Report 100% of 100% Met requirement identified and for reporting requested reportable reportable diseases to diseases per Department of Confidential Public Health Morbidity Report

.

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-8 Resource Allocation - Needs for 2016 to effectively manage IP office  Needs as assessed through observational and direct use requirements: . Five Computers o NHSN SAMS certificate for new assistant o Additional IT support increasing automated data pulls for NHSN(ICD-10 and mapping) . Resource Guides (update as needed) o CDC guidelines o APIC Text or online access o AORN Text or online access . Personnel o Administrative support as necessary . Supplies o Office Supplies and IC week supplies

Major Incidents/Investigations/Activities 2015 – INFECTION CONTROL LOG (other than surveillance)

SUBJECT RECOMMENDATIONS/ACTION Disinfection of semi- Collaboration with Endoscopy Team district-wide on CDC recommendations for critical devices procedure review. Double disinfection of ERCP scopes was implemented. Developed follow up plan for inadequate or failed disinfection processes and published in Lucidoc. Measles Response Coordinated with county public health department on all cases. Provided education to medical and other staff, fielded and prioritized cases, enhanced source control by masking at first point of contact and symptoms, created signage for all building with patient access, and developed a plan for assessing outpatients prior to onsite visit. Villa Pomerado IC support Close collaboration and IC mentorship with Villa Pom IC liaison after CDPH annual survey. Implemented enhanced data collection methods, assisted with analyzing data and reports, provided staff education, continue to meet on a regular basis with VP team. Disaster Drill – Anthrax Partnered with Emergency Preparedness with a successful drill. antibiotic dispensing

New Jersey RN uses One and Only CDPH Campaign (One Needle, One Syringe, ONLY ONE TIME). syringes for multiple Increased communication via signage, FAQs, CME and real time assessment patients. CDPH memo during EOC rounds.

TB (patient) exposure to Followed CDPH guidance, collaborated with CDPH TB control, surveillance staff and other patients screening performed.

Major flood and Worked closely with the EVS, Facilities, and Construction teams to ensure safe renovation protocols are followed throughout the process. Infection Control Risk Assessment (ICRA) protocols followed with oversight from Infection Control.

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-9 SURVEILLANCE PLAN 2016 Priority score “M”= System mandate Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M” Central Line- System: Central line All patients Enter all data into Standardize CMS Associated Eliminate insertion Practices with central National Healthcare Infection Ratio mandatory Blood CLABSIs (CLIP) lines (both Safety Network (SIR) = for ICU and Stream ICU and (NHSN). # of infections all inpatient Infections Facility: Minimize the use of Med/Surg, # of expected units. Reduce Central Lines by adult, Mandatory CLABSI SIR inserting midlines pediatric and requirement by 2016 NHSN CDPH from 2015 NICU) CDPH and CMS. definitions will mandatory be used. CLIP entry Analysis of central Data downloaded for into NHSN. line bundle check internal Central line lists. Develop dissemination. insertion action plans based checklist on results. IC Committee and analysis: % other stakeholder compliance Conduct point committees and with bundle prevalence study to departments at least approach to identify quarterly reduce CLASBI opportunities for staff education Case Finding Methodology: 1. Infections will be identified through prospective and retrospective review of blood cultures and clinical record. If case meets NSHN definition for CLABSI the case will be entered into the NHSN database. 2. July 2015 “Go live” with Cerner Infection Control data mining module. This has enhanced case finding and improved inefficiencies in data mining.

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M” Catheter System: Continue to use IC All patients Enter all data into Standardize CMS Associated- Eliminate catheter and with Foley NHSN. Infection Ratio mandatory Urinary CAUTI Prevention of catheters Mandatory (SIR) = for ICU and Tract CAUTI Bundle (both ICU requirement by CMS. # of infections all inpatient Infections Facility: (silver catheter, and adult # of expected units. Reduce tamper evident Med/Surg) Data downloaded for CAUTI SIR seal, care of internal 2016 NHSN CMS from 2015 catheter tubing and dissemination definition will mandatory bag, prompt be used. for all removal of IC Committee and inpatient catheter) other stakeholder Foley Cath Med/Surg committees and bundle units Maintain and departments at least insertion effective encourage Nurse quarterly checklist 1/1/2015 driven Foley Cath analysis: % removal protocol. compliance Monitor device with bundle utilization mean. approaches to reduce CAUTI

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-10 Pilot and implement alternative external female catheter.

Review daily Foley Cath line list

Foley insertion competencies review

Case Finding Methodology: 1. Prospective and retrospective review of cultures and clinical record. If case meets NSHN definition for CAUTI the case will be entered into NHSN database. 2. July 2015 “Go live” with Cerner Infection Control module. This will enhance case finding and improve inefficiencies in data mining.

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M” Ventilator- System: VAP Prevention All adult (>18 Enter all data into Incidence rate Not Associated Eliminate Bundle measures yrs.) patients NHSN (out of plan). per 1000 Mandatory Events VAE/VAPs and compliance on a Not mandatory ventilator rate on all patients ventilator. requirement but will days. Facility: placed on a have ability to Reduce ventilator. benchmark. 2016 NHSN VAE rate definition will from 2015 Daily assessment of IC Committee, other be used. ventilator necessity stakeholder and weaning committees and process. departments on a regular basis.

Case Finding Methodology: Infections will be identified through review of positive respiratory and blood cultures, radiologic exam, clinical record, FiO2, PEEP based on NHSN VAE/VAP definitions and institution of new antibiotics in a vented patient.

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-11 Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M” Surgical Site System: Continue SCIP Surgical Enter all data into Standardize CDPH Infections Eliminate recommendations Procedures: NHSN. Infection Ratio mandatory (SSI) for SSIs Hip Prosthesis (SIR) = for 26 CDPH Implement Knee Prosthesis Mandatory # of infections surgical targeted 25 Facility: Evidence based Fusion requirement by # of expected procedures surgical Reduce SSI practices for joint Refusion CDPH and CMS. procedures SIR from replacement Laminectomy 2016 NHSN CMS 2015 surgeries (Institute Fracture Data downloaded definition will mandatory for Healthcare Abdominal for internal be used. Hysterectomy Improvement Hysterectomy dissemination. and Colon Project JOINTS) Vaginal Hysterectomy Implement Final Ovary IC Committee and HICPAC Guideline C-section other stakeholder on Prevention of AAA committees and SSIs. CABG departments at Standardization of with/without least quarterly pre-op patient prep donor site Cardiac Collaborate with Pacemaker Surgeons to Thoracic implement post Biliary discharge Rectal surveillance Appy Chole Implement ICD9-10 Small bowel diagnosis codes to Colorectal flag readmits for Neph SSI Spleen Gastric Meet with individual Surgeon if trend identified Case Finding Methodology: Infections will be identified through a review of wound cultures, antibiotics prescribed, readmissions, a report from the surgeon, and diagnosis codes. Patient records will be reviewed initially to obtain surgical data for the specific patient, then as needed. Post discharge surveillance will be developed for these procedures. July 2015 “Go live” with Cerner Infection Control data mining module. This has enhanced case finding and improve inefficiencies in data mining.

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M”

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-12 Hospital System: Develop evidence- HO MDRO Enter all data into Incidence and CMS and Onset (HO) MRSA, VRE, based practice cases NHSN. prevalence as CDPH MDROs – C. difficile strategies using calculated by mandatory MRSA and < 0.5/1000 APIC and HICPAC Mandatory NHSN for VRE patient Guidelines. requirement by C. diff and Bloodstream days CDPH and CMS. MDRO process MRSA infection Targeted UV light measures bacteremia. C. difficle(HO) C. difficile: disinfection for Data downloaded for compliance HO <0.50 rooms and internal rate - collected VRE bathrooms with dissemination. by “secret bacteremia Facility: patients who have observers” and not Reduce C-difficile. IC Committee and by IP during mandatory MDRO other stakeholder rounds (gown, but a rates from Observe EVS committees and glove, use continued 2015 cleaning practices. departments at least patient MDRO focus Use “glow germ” quarterly education, and environmental isolation, and cultures to assess hand hygiene cleaning. practice)

Participate in CDPH HAI C-diff reduction collaborative Case Finding Methodology: Review of cultures and PCR screens, positive isolates, clinical records, and definitions for healthcare onset from NHSN surveillance definitions. July 2015 “Go live” with Cerner Infection Control data mining module. This has enhanced case finding and improved inefficiencies in data mining.

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M” Hand Corporate: Increase quantity of All – select IC Committee and Percentage of CDPH, CMS Hygiene 90% Hand Hygiene sample of other stakeholder compliance and Joint Compliance observations in all observations committees and Commission departments and on a monthly departments at least mandatory to Facility: by discipline. basis quarterly have a Hand To improve Hygiene facility rate Campaign for hand program from 2015 hygiene in 2016.

Case Finding Methodology: (#compliant / #observations) x 100 – Health Care providers are observed by a “secret observer” assigned to different units and augmented by unit leaders/staff. Data to be presented by unit and by discipline to various medical and other committees.

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M”

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-13 Influenza Achieve Continue All clinical Enter all data into Compliance CDPH and Vaccination >95% mandatory mask and non- NHSN rate is CMS acceptance program clinical calculated by mandatory of influenza employees, IC Committee and number of vaccination Implement volunteers, other stakeholder staff, MDs, Influenza Vaccine physicians, committees and students, Campaign students, departments residents, etc. beginning in contractors, divided by 100 September working in for % the facility compliance. Target top two for at least reasons for one day Data will be declination in during the separated out previous year influenza by discipline season. Collect declinations for exclusion per CDC guidelines

Collaborate with Physician partners on vaccination documentation Employee Health oversight with Infection Control collaboration. Employee Health collaboration with medical staff to improve process for data collection.

Surveillance Goal Actions to Reduce Patient Data Entry and Method of Priority Activity Risk with Population Reporting Analysis Score (Indicator) Revisions “M” Sharps/ Reduce the Implement All Employee Health Log # needle sticks CDPH, CMS, Blood borne number of education to employees, and Cal OSHA Pathogen needle encourage safe volunteers, IC Committee and #blood/body mandatory to (BBP) sticks and needle practices, physicians, other stakeholder fluid exposures have a BBP Exposures blood use of personal surgeons, committees and plan borne protective residents, departments at least Operating pathogen equipment (PPE) medical quarterly room rate by exposures and proper students and #surgical from 2013 disposal. anyone procedures PPE readily working in available for the facility immediate use Encourage correct PPE during splash- producing procedures

Case Finding Methodology: All exposures reported through Employee Health with appropriate follow up.

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-14 STRATEGIES TO REDUCE AND ELIMINATE INFECTION RISK

Strategies Description Plan A. Environmental The Infection Preventionist (IP)  Participate in monthly  Environmental participates in environmental environmental rounds with Rounds rounds with other facility team other facility team members members to assess patient and environmental safety and quality.

 Dialysis Testing Water used to prepare dialysis  Continue testing per existing solutions must meet AAMI requirements and guidelines. Standards for hemodialysis water quality. Total viable bacterial counts in water used to prepare dialysate or to reprocess hemodialyzers should not exceed 2000 cfu/ml. Total viable count for dialysate should not exceed 200 cfu/ml. Chemical monitoring of treated water should be done at least annually if RO or deionizers are used, and more often if other treatment methods are used.

 Sterilizer Testing Sterilizer testing is done in  Continue autoclave testing per accordance to AORN, AAMI and existing requirements and CDC recommendations. guidelines.

 Water System  Periodic water testing. Testing The Infection Preventionist collaborates with the Facility Plant  All test results are presented to Ops team regarding facility the IC Committee on a regular waterborne pathogen prevention basis. If results are out of strategies. acceptable range, a plan of correction is created. B. Construction An Infection Control Risk  Work with the construction Assessment (ICRA) is completed team prior to work to on areas for renovation or new determine infection control construction in the facility. The risks via the ICRA. Attend pre- ICRA determines which barriers con meetings as needed. and practices, air monitoring  Continue monitoring hospital- precautions, negative pressure wide construction activities. monitoring (HEPA), patient placement, and cleanup are required to eliminate and/or reduce dust and debris during construction.

C. CDC Recommendations Assess compliance with CDC  Outpatient IP rounding at least for Outpatient Settings Guidelines in PH Outpatient areas. annually and as needed. Areas assessed: Expresscare,  Continued education following Corporate Health, Outpatient CDC Ambulatory Care Guide Rehab, Wound Care, and  Site leadership to address any Outpatient Behavioral Health. issues noted, with IP follow up.

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-15 Strategies Description Plan D. Outbreak Management An outbreak is described as the  A full scale investigation will be sudden occurrence or increase of conducted in the event of a infectious and non-infectious suspected outbreak using diseases and conditions. The sound epidemiological Infection Prevention and Control principles as outlined in the team investigates potential Outbreak Investigation outbreaks to identify the source Procedure. and/or likely cause of infections.  Work in consultation with In addition the team investigates County Epidemiology for patients who have pathogens with direction and support. high transmission potential to assure that control measures appropriate to the pathogen have been instituted. In circumstances where a significant potential for transmission of an infectious pathogen from either a patient or employee has been identified, the Infection Prevention team works closely with the Employee Health Program to identify both patients and employees who may be at risk for disease acquisition and to intervene as appropriate to the circumstance. E. Infection Control Infection Control procedures are  Continue procedure review Procedures based on State and Nationally every three years and as recognized guidelines and necessary. applicable laws and regulations.  Procedures will reflect current The procedures address the accepted and approved prevention of infection Infection Prevention practices transmission among patients, based on regulatory employees, visitors, and recommendations, standards, environmental issues. Procedures and guidelines. are reviewed and approved within three years and/or as needed based on regulatory recommendations and guidelines. IC Risk Assessment/Plan, Blood borne pathogen, and Tuberculosis Control are reviewed annually.

F. Facilitate Health Care Facilitate and/or participate in  Potential cases will be referred Associated (HAI) case review of identified cases of to Quality/Risk Management review or other unanticipated deaths or major and IC Medical Director to infection related permanent loss of function initiate the review process. processes requiring RCA associated with a healthcare and/or FMEA review. associated infection.

G. Communication Communication regarding the Hospital Level – Data Provided Infection Prevention and Control  Leadership – monthly Program is ongoing. leadership meeting Communication between local and  Physician committees and regional health care organizations physician newsletter offers opportunities for early  Staff – reports to managers identification of infections. responsible for sharing with 16 | P a g e

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-16 Strategies Description Plan staff Communication to County  Students and Volunteers – IC Epidemiology and TB control is orientation ongoing and is required for  Staff education - unit in- specified circumstances. services, orientation, fact sheets, 5-minute updates and Huddle Highlights  IP rounding on units  New Leader Employee Orientation

Community Level  Between hospitals (referring hospital will be notified when an infection is identified in transferred patient)  Public Health Departments – reportable diseases  Local IC Chapter meeting – monthly  Health Department/ hospital meetings H. Education Infection prevention education is  Staff: new employee and provided to employees at hire and Leader orientation, nursing annually as required based on job orientation, huddles updates description. Additionally,  LIPs: newsletters education is provided to LIPs,  Patients, visitors, families: fact patients, visitors, and families. sheets, signage I. Influx/Surge of The Infection Preventionist Refer to PH Disaster Plans Potentially Infectious participates in the facility plan, Patients response, and recovery of activities related to the influx of infectious patients and other emergency situations. J. Data Analysis Case definitions for healthcare  All data collected for infection associated infections shall be control should be presented in those developed, adopted and a rate/ratio based format for published by the National clarity and comparison Healthcare Safety Network purposes. For data that have (NHSN), unless another authority established bench-marks, i.e., dictates otherwise. NHSN, these shall be used.  For data that are in the NHSN system and have an available standardized infection ratio (SIR), these shall be used for comparisons and for presentation as part of the Quality Assurance and Performance Improvement program. K. Cleaning of Medical The Infection Preventionist  A system for the cleaning of Equipment, Supplies collaborates with hospital medical equipment will be and Devices departments and the Environment implemented that assures of Care Committee to assure that a equipment is cleaned on a system for the cleaning of medical 17 | P a g e

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-17 Strategies Description Plan equipment, devices, supplies and routine basis. The cleaning supply rooms is implemented. process must be in accordance Surgical services and IP perform with the manufacturer’s audits of HLD and sterilization recommendations. processes and report to IC  Germicidal Sani-cloths and committee. sodium hypochlorite wipes will be available in areas where medical equipment is handled and cleaned.  “Wet Contact Time” is defined and will be used during the cleaning process.  IPs will work with EVS to assure supply closets are cleaned and work with Pharmacy, Materials Management and other departments to assure supply bins are cleaned.  If the facility is reprocessing single use items with a selected vendor – the items will be placed in the appropriately labeled containers provided by the company and follows all reprocessing guidelines.  A monitoring system is implemented to assure compliance with cleaning of medical equipment, devices and supplies. L. Facility Response to a In the event of a sterilization or  Notification chain established. recognized exposure high level disinfection failure  Determine if any instruments event involving Palomar Health has a plan to have been used for patient care reusable medical identify potentially exposed devices. patients, facilitate patient contact,  Responsibility defined: document all follow up and retain  Infection Prevention and records, and systematically Control will: provide appropriate testing and o Define exposure result notification. o Identify patients at risk o Maintain list of patient and procedure including date performed o Review patient records as indicated for exposure follow up.  Risk Manager and/or VP Patient Experience will: o Establish a call center as needed o Arrange for appropriate 18 | P a g e

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-18 Strategies Description Plan laboratory testing  Call Center will: o Maintain patient log o Other duties as assigned  The Vice President, Patient Experience will: o Answer medical questions o Provide physician order for testing  Marketing will: o Provide a statement for the community.  Patient notification of results established process.

M. Injection Safety Prevent transmission of  CDPH one and only campaign bloodborne viruses to patients. materials in high risk areas.  Physician Champion  Provide CME  Glucometer cleaning focus of Environment of Care rounds.  Visual cues where meds are administered

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-19

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-20

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-21

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-22

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-23

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-24

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Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-25 Infection Prevention and Control Annual Summary Calendar Year 2015

Presented to Board Quality Review Committee April 18, 2016 Valerie Martinez RN, BSN, MHA, CIC ,CPHQ

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-26 Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-27 Surveillance and Activities

Central Line MRSA/VRE Ventilator Catheter C-difficile Surgical Site Bloodstream Bloodstream Associated Associated Infections Infections Infections Urinary Tract Infections Pneumonia Infections 26 All units All units All units All units Surgical25 Critical procedur All All All Surgical Care All es hospitals hospitals hospitals hospitals procedures units

Collaborate Rounds Facilities (water supply, All patient care units, Kitchen, ventilation), construction, review Pharmacy, OR, EVS, Villa Pom, SPD, all procedures related to IC, EOC rounds, and all outpatient outbreak management, Disaster patient care departments and Regulatory preparedness, Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 Dialysis, Public Health 11-28 Accomplishments

VAP Reduction CAUTI Reduction CLABSI and MRSA BSI Reduction PMC - 79% ARU- ZERO PMC CCU - 65% Pomerado – 94% Pomerado – ZERO PMC TICU – 79% ARU - 23% MRSA Pomerado - ZERO

Overall SSI SSI Specific C-difficile Reduction Reduction Reduction PMC Knee – 77% PMC – 21% PHDC – 30% Pomerado Colon – 65%

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-29

Infection Control Surveillance Focus

• Standardization of prevention measures SSI prevention • Explore implementation of Colon “bundle” • Mini RCA on SSI cases with Surgeons and staff • IC periodic case observation • Interdisciplinary HAI prevention team • Targeted UV light disinfection (Xenex) C-difficile • Collaboration with Pharmacy • EVS cleaning measures • Compliance with PPE use and hand hygiene

CLABSI and MRSA • Expand Chlorhexadine bathing • Central Line point prevalence study Bloodstream • Explore extended hang time for IV tubing Infection • MRSA nasal screening compliance upon admit

Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-30 Tab 11 - Quality and Patient Safety Reports Presented to BQRC in 2016 11-31

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

Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado Satellite Buildings

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

2015

Date prepared: April 5, 2016

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-32

2 EVALUATION - ENVIRONMENT OF CARE - OBJECTIVES

Introduction Permeating every aspect of our medical centers and satellite buildings, the Environment of Care is an essential aspect of patient safety, from the first patient contact, through the assessment, treatment, discharge and continuing care. The Environment of Care overlaps with Infection Prevention and the management of Human Resources, as well as plays an integral part with Performance Improvement, Risk Management, and Patient Safety standards. The objectives of the various Environment of Care Management plans have been to provide a safe, functional, supportive and effective environment for patients, visitors, staff, volunteers and members of our physician community. This is critical to providing quality patient care.

Achieving our objectives is dependent upon performing the following central processes: •Strategic and on-going master planning by organization leadership (Plan / Design) •Educating staff about the role of the environment that supports patient care (Teach) •Implementing various components of design (Implement) •Measuring standards that we have set for ourselves (Respond) •Gathering information about our outcomes (Monitoring / Measuring / Evaluating) •Making decisions about our findings (Improving)

The Environment of Care Management plans address six elements, which include Safety, Security, Hazardous Materials and Waste, Fire Prevention, Medical Equipment and Utilities Management. Emergency Management addresses the Emergency Operations Plan (EOP). There is much diversity in the seven management plan elements, but each have parallels with planning, teaching, implementing, responding, monitoring and improving. Through the work of our staff, the purpose with the Environment of Care is to ensure ongoing diminishment of risk (e.g., possible loss or injury) within our medical centers. The Environment of Care Committee provides a leadership framework for the management of risks, promoting a teamwork approach, and ongoing attention to programs, plans, and related activities that point toward risk reduction. Whenever possible, the Environment of Care is integrated with the Occupational Safety and Health Administration objectives (e.g., regulatory requirements), as well as other agencies having jurisdiction, enforcing standards that encourage continued improvement in the workplace.

Evaluation of Objectives – Safety Management Plan. The Safety Management plan is designed to provide a physical environment wherein risks associated with physical harm and hazards will be minimized for the patient-care population, staff, volunteers, physicians, contracted workers and visitors. It is an accreditation/standards-based and regulatory driven plan. There are fundamental activities inherent in daily routines that support the ability to identify risk prior to any incident. These include formal proactive risk assessments such as accreditation, regulatory or insurer surveys, ongoing environmental surveillance, safety and infection prevention procedures that are based upon accreditation standards and regulations, and ongoing education. Educating employees to the hazards that may pose risk, or contribute to an injury has been ongoing, as well as the efforts relating to accident investigation post injury. We continue to meet our objective relating to the minimization of risk within the built environment and continue to be poised to provide safety for our patients.

Evaluation of Objectives – Security Management Plan. Through a medium of care and respect for everyone who comes to our facilities, the Security Management plan is designed to provide the highest quality safety and security. We strive to provide a challenging work environment for Security staff, as we work to create and support a peaceful environment so that people will feel at ease when they come to our medical centers. Overall, our Security Management program has catapulted into a higher level of awareness since the events of 9-11-01, and subsequent terrorist events worldwide, including the increasing Code Gray and Silver incidents at medical facilities. Our Security Management plan has provided a deterrent to criminal activity on our campuses, which has allowed us to meet our objective of promoting a peaceful environment. Security staff are visible in uniforms, and are service oriented to the public, as well as being trained in de-escalation techniques. Security has camera systems and ongoing monitoring that has allowed us to spot activity or trends that have assisted us in reducing security risks. The objectives of the Security Management Plan have been met, and we will continue to promote the reduction of risk throughout the year 2015, focusing on proactive activities, and ongoing education.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-33 3

Annual Evaluation of Objectives, continued

Evaluation of Objectives: Hazardous Materials and Waste Management Plan. The objectives of the Hazardous Materials Management Plan are to ensure that information about the risks of hazardous chemicals / materials and wastes used in the facilities are known by affected employees, and to ensure that the information is given to employees in the form of SDS (Safety Data Sheets), education, and labeling. Another objective is to ensure that hazardous waste products do not endanger the health of the environment. Taken together, these objectives minimize the risk of exposures to hazardous chemicals within our facility and community. Minimization of risk not only applies to our medical centers, but to the community at large (e.g., minimization of spills into the environment). Equally important, is our effort to reduce waste and to use non-hazardous products whenever feasible. Educating employees to the risks relating to hazardous material use, storage and disposal has been a program element designed to meet our objectives. Other activities within the medical centers have contributed to meeting our stated objective, and these include: assessing staff knowledge relative to the hazardous materials and waste management program, manifesting hazardous materials in accordance with regulations, the development of procedures, and the use of appropriate personal protective wear.

Evaluation of Objectives: The Fire Prevention Management Plan. The objectives of the Fire Prevention Management plan are to provide a physical environment free from physical harm and hazards created by fire, the risk of fire, or the products of combustion for the patient care population, staff, volunteers, physicians and visitors. The risk of fire carries with it the most significant single threat to the environment of care as our patients are routinely incapable of self-preservation, and must rely on correct staff response and building fire protection features to assure their safety. Compliance with the Life Safety Code supports meeting our objectives, as well as practicing fire drills throughout the medical centers and testing correct staff response during the drills. Proactively identifying life safety risks during routine surveillance (e.g., observing for doors that do not close and latch properly, wall and ceiling penetrations, illegal latching hardware, etc.) additionally supports meeting this objective. There are programs in place that increase the likelihood of our objectives being met, which include fire equipment testing and maintenance, annual certifications for fire detection and protection systems, and the ongoing monitoring of the Statement of Conditions which identifies any life safety vulnerabilities, and our plans and financial commitment to correct / enhance or minimize them.

Evaluation of Objectives: The Medical Equipment Management Plan. The objective of the Medical Equipment Management Plan includes a joint effort of the clinical and non-clinical departments to minimize the risks inherent in the use of medical equipment that is used on our patients, and to ensure proper performance. In order to meet these objectives, multiple programs need to be in place, which include, but are not limited to: risk assessment of all incoming medical equipment, preventive and corrective maintenance programs, “out-of-service” program for equipment that needs repair, and general education of equipment and user / maintainer training programs. Quarterly monitoring of preventive maintenance completion rates for our medical equipment affords us the opportunity to promote quality performance, thereby minimizing the risks associated with medical equipment failures, which supports our patient safety efforts. These programs are in place throughout the medical centers, and have been effective in allowing us to meet the stated objectives.

Evaluation of Objectives: The Utility Management Plan. The objectives of the Utility Management Plan include complying with regulatory-driven and accreditation standards to provide Facilities that are safe, controlled, comfortable, and maintained in accordance with applicable regulation, requirement, and accepted engineering practice. Through a system of procedures, education, and ongoing quality monitoring and evaluation, the objectives are to provide the utility system users and operators with emergency response guidance in the event of a utility system failure, and to promote the reliability and performance of our utility systems. Risks, identified through the use of the a computerized data base program, factor adverse equipment experience into the quality assessment, risk management, and utility management functions. Our procedures, preventive maintenance program, education and quality monitoring all support the accomplishment of meeting our stated objectives, and also support our patient safety goals.

Evaluation of Objectives: The Emergency Operations Plan. One primary objective of the Emergency Operations Plan is to mitigate harm to life and property due to unforeseen circumstances and risks identified in the Hazard Vulnerability Analysis. The Emergency Operations Plan comprehensively describes the organization’s approach to responding to emergencies within the organization or in its community that would suddenly and significantly affect the need for the organization’s services, or its ability to provide those services. The Disaster Preparedness Committee has been very active in the design and implementation of the Emergency Operations Plan, and it is expected to continue in this direction in 2015. The plan is intended to identify risks to the organization and addresses how the medical centers are prepared to respond as well as identify strategies in place to mitigate the risks. These plan elements and other activities in the medical centers relating to emergency preparedness (e.g., education of staff, disaster exercise implementation / evaluation, and performance improvement demonstrate that the medical centers have been effective in meeting the stated objective.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-34 FIRE PREVENTION 4 EVALUATION OF THE SCOPE 1. Performance standards and thresholds established for 2015. 2. Fire drills conducted and evaluated by Security staff, one per shift per quarter, with additional drills completed per staffing requirements or construction areas and satellite buildings. Evaluation of the Scope of the Environment of Care 3. Statement of Conditions (SOC) reviewed and kept updated by Facility Managers. Management plans: The scope of each management plan 4. Annual fire detection systems tested and certified. applies to all personnel in each facility and satellite building. 5. Annual fire extinguisher maintenance completed. Each facility and building is surveyed, and every attempt is 6. Facility Manager Environment of Care reports reviewed in each quarter. 7. Collaboration with Escondido Fire and other SD fire agencies in the made to ensure risks are identified that may have an impact on usage of the vacant Surgery Center to complete fire rescue training and the reduction of accidents or injury. Staff are required to work in simulated structure fire. a safe manner, and to report unsafe acts or observations, 8. Fire safety and response training provided to PMC kitchen staff. without any fear of reprisal. The following Environment of Care 9. Preventive maintenance for fire equipment completed. 10. Annual evaluation of the Fire Prevention Management plan completed: accomplishments throughout the year 2015 represent the Objectives, Scope, Performance Standards and Overall Effectiveness. emphasis on safe work behaviors and risk reduction, and MEDICAL EQUIPMENT validate leadership’s support of safety throughout the physical 1. Performance standards and thresholds established for 2015. environments of our medical centers and satellites, as well 2. Medical equipment failures and recalls monitored by Biomedical leadership with appropriate actions taken. as support and dedicate attention to high standards of safe 3. Preventive maintenance and corrective maintenance monitored for life work behaviors for all staff. The multitude of accomplishments support and non-life support medical equipment. validate a breadth and depth of the scope of our Environment 4. Enhancement of the Medical Equipment Management Plan (MEMP) to comply with The Joint Commission standards. of Care management plans and the Emergency Operations 5. Added laser safety check quantities to quarterly EOC report. Plan. 6. Annual evaluation of the Medical Equipment plan and program completed: Objectives, Scope, Performance, Effectiveness SAFETY UTILITIES MANAGEMENT 1. Performance standards – Review of performance standards for the 1. Performance standards and thresholds established for 2015. Environment of Care for 2015, including re-assessing thresholds of 2. Generator testing completed per regulatory standards. performance. 3. Preventive maintenance monitored. 2. Reporting schedule established for the Environment of Care committee. 4. Facility Manager Environment of Care reports reviewed in each quarter 3. POM Facility Manager conducted monthly rounds and reviewed disaster and 2015. fire training with Villa Pomerado staff to increase knowledge. 5. Utility failures reported to Environment of Care committee, each resolved 4. Facility Manager Environment of Care reports reviewed in each quarter. with follow-up actions documented. 5. Preparedness activities for El Nino weather completed at each facility (i.e. 6. Annual evaluation of the Utility Management plan and program roof drain clearing, roof repairs, etc.). completed: Objectives, Scope, Performance Standards and Overall 6. Multi-disciplinary environmental surveillance: ongoing, with deficiencies Effectiveness identified and documented in Sentact and issues sent to Director for she / he EMERGENCY MANAGEMENT to resolve and close out in Sentact 1. Performance standards and thresholds established for 2015. 7. Annual Evaluation of the Safety Management plan completed: Objectives, 2. Disaster preparedness multidisciplinary committee meetings held with Scope, Performance standards and Overall Effectiveness completed. multiple activities accomplished. SECURITY 3. Emergency Management leadership participated in community tabletop 1. Performance standards and thresholds established for 2015. at Poway FD HQ. Scenario: Wildfires with Santa Ana winds and 2. Quarterly reports for Security completed, including incident review. Pomerado Hospital / Villa Pomerado response and collaboration. 3. Security staff actively participating in disaster drills, and have assumed the 4. Wildfire preparedness tabletop completed at POM and VP in October. “Security Branch Director” role in the command centers. Worked in collaboration with Poway FD and City of Poway disaster 4. Consolidation of SIT (Security Integration Team) into monthly EOC coordinator. Committee meetings. 5. Hazard Vulnerability Analysis (HVA) reviewed / revised for 2015 with the 5. Fence, additional lighting and security cameras installed around Grand Bldg. top five hazards identified. 6. Ongoing active shooter (ALiCE – Alert, lockdown, inform, counter, evacuate) 6. Everbridge notification drills completed semi-annually to coincide with and Management of Assaultive Behavior (MAB) training by staff / physician county and statewide exercises. Over 900 physicians included in request. Over 25 classes conducted for staff, both clinical and non-clinical, in notification exercises. the areas of ALiCE, personal security tactics, MAB, and pepper spray safety. 7. Ongoing membership with San Diego Healthcare Disaster Coalition 7. Code Pink/Purple drills conducted and evaluated with effective outcomes. (SDHDC) which strengthens community ties with the other San Diego 8. Workplace violence prevention multidisciplinary planning team began County hospitals, SD County Emergency Medical Services (EMS), SD meeting. County Office of Emergency Services (OES), Red Cross, SD County 9. Through the Security Integration Teams, a follow up survey was sent to staff Public Health, and law enforcement agencies. to evaluate the effectiveness of communication, access control, parking, and 8. Continued collaboration with SD County Emergency Medical Services visitor management. (EMS) in the area of Hospital Preparedness Program (HPP) grant 10. Collaboration with Escondido SWAT and K-9 units in the usage of vacant funding. All deliverables completed in May 2015 and grant funds were Surgery Center building to conduct multiple security and safety response received. trainings. 9. Everbridge emergency notification system is used exclusively during 11. Annual Evaluation for the EOC for the Security Management Plan completed: exercises and actual events. Objectives, Scope, Performance Standards and Overall Effectiveness 10. Satellite phone hard lines installed in the three hospital command completed. centers as a communication redundancy. HAZARDOUS MATERIALS 11. Disaster surge cart medical supplies inventoried by supply chain staff to 1. Performance standards and thresholds established for 2015. ensure expiration dates are monitored and supplies are rotated into the 2. No spills requiring outside agency assistance reported. supply stream. 3. Performance Improvement (PI) Project for the EOC identified: the 12. Continued collaboration with Kaiser Emergency Management colleagues participants of the 2014 first responder decontamination training meet to ensure communication is flawless during disaster events. quarterly to review plans, communication details, and plan for next decon 13. Countywide disaster exercise completed at each site May 2015. exercise Scenario: decontamination and patient surge due to HAZMAT and MCI 4. Annual Evaluation of the EOC for Hazardous Materials Management Plan (mass casualty incident). completed: Objectives, Scope, Performance Standards, Overall Effectiveness 14. Statewide disaster exercise completed at each site November 2015. Scenario: Anthrax detected in atmosphere, causing the need for SNS (strategic national stockpile) cache of medicine to be deployed for hospital staff, their families, patients and physicians. 15. Annual evaluation for the Emergency Operations Plan completed: Objectives, Scope, Performance, Effectiveness.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-35 5 EVALUATION: PERFORMANCE STANDARDS OVERVIEW. The attached data sheets represent the evaluation of established performance standards, areas chosen on one or more of the following criteria: 1. The performance standard represents a measurable area of one of the EOC components. 2. The performance standard indicates a key reflection of the scope of the component. 3. The performance standard represents a high volume activity, or low volume but high risk consequences. 4. The performance standard requires improvement, or the existing process could be enhanced.

Safety Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of O2 bottles found unsecured during monthly Environment of Care (EOC) rounds (2) Unsafe condition reports resolved by individual Facility Managers within 24 hours of submission (if actual unsafe condition)

Security Performance Standards The following performance activities were undertaken in 2015: (1) Begin upgrade and enhancement of the security video observation, access control, and alarm systems (2) 100% of security officers obtain CA Bureau of Security and Investigative Services (BSIS) guard card certification (3) Make available for all staff: quarterly offerings of security classes in the areas of Code Silver response, Managing Aggressive Behavior (MAB), and personal security practices (4) <2 automobile thefts per quarter by facility (5) Implement badge ID awareness / compliance campaign (6) Establish liaison contacts with local law enforcement and fire officials

Hazardous Materials and Waste Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of hazardous material containers inspected / labeled incorrectly during monthly Environment of Care (EOC) rounds (2) Staff knowledge in obtaining SDS (Safety Data Sheet) information during monthly Environment of Care (EOC) rounds (90% threshold) (3) Monitoring of number of hazardous chemical incidents involving outside agency assistance for cleanup (4) Monitoring of number of biohazard waste incidents involving outside agency assistance for cleanup

Fire Prevention Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of actual fires reported inside the facility (2) Staff knowledge on the meanings of R.A.C.E (Rescue, Alert, Confine, Extinguish) and P.A.S.S (Pull, Aim, Squeeze, Sweep) acronyms during monthly EOC rounds (90% threshold) (3) Monitoring of building and / or protection system monitoring – problems, significant incidents, unexpected repairs

Medical Equipment Performance Standards The following performance activities were undertaken in 2015: (1) Preventative maintenance (PM) completion rate for Priority 1 life support equipment (100% threshold) (2) Preventative maintenance (PM) completion rate for non-life support equipment (95% threshold) (3) <2% of equipment service requests that were related to user errors (4) <5% of unable to locate pieces of medical equipment (5) ≥90% of equipment repairs completed within 30 days

Utility Equipment Performance Standards The following performance activities were undertaken in 2015: (1) Monitoring of utility failures (2) Occurrences requiring external reporting (3) Monitoring of tube system failures (4) Monitoring of elevator failures (5) Emergency generator testing compliance per regulatory standards (100% threshold) Emergency Management Performance Standards The following performance activities were undertaken in 2015: (1) Conduct / manage two disaster drills or actual events per year at each facility according to top Hazard Vulnerability Analysis (HVA) risks and evaluate event using The Joint Commission standards or SD County Medical Health After Action Report (AAR) matrix (90% threshold) (2) Staff knowledge in articulating where his or her units disaster supplies are located during monthly Environment of Care (EOC) rounds (90% threshold) (3) Staff knowledge in articulating where the hospital command center (HCC ) and labor pools are located during monthly Environment of Care (EOC) rounds (90% threshold) Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-36 6 EVALUATION: PERFORMANCE STANDARDS

EOC Component: SAFETY MANAGMENT Performance Standard: The following performance activities were undertaken in 2015: 1. O2 bottles found unsecured during monthly EOC rounds monitoring 2. 100% of unsafe condition reports submitted by staff to be resolved within 24 hours Safety Management Plan Evaluation: for Improvement: 1. During monthly We will continue to Environment of Care (EOC) multi- monitor unsecured O2 tanks disciplinary rounds, facility throughout the district during managers monitored areas for monthly EOC rounds, and add unsecured O2 tanks. If any additional unannounced monitoring were found, the tank was first to weekly rounding schedule to secured properly, and the ensure O2 tanks are being stored department manager was notified and transported safely. and just in time training was We will continue to ensure that provided to staff on the risks of unsafe condition work orders are unsecured tanks. resolved within 24 hours of O2 bottles found unsecured: submittal. 2. Unsafe condition work orders are entered by staff on Sentact. 5 An email is immediately sent to the affected facility manager for 4 him to assign the task. We have met our goal of 3 1 Q 2015 unsafe condition work orders 3 being resolved within 24 hours. 2 2 Q 2015 2 There were no identifiable trends 3 Q 2015 witnessed in 2015. 1 4 Q 2015 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Center Palomar Health Pomerado Hospital Villa Pomerado Downtown Campus Unsafe condition work orders received and closed out within 24 hours: 3

2 2 2 1 Q 2015 2 Q 2015 1 1 1 1 1 3 Q 2015 1 4 Q 2015

0 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Center Palomar Health Downtown Pomerado Hospital Villa Pomerado Satellite Buildings Campus

PMC: POM: Satellite Buildings: PHDC: 3Q15: Installation of dome mirror 1Q15: Concrete light post repair VP: 3Q15: Trip / fall hazard repair 2Q15: Burning odor that could to prevent gurney collisions (ED) due to vehicle backing into it None (Andreason) not be duplicated by Facilities 4Q15: Trip hazard repair (OR) (ED parking) staff (parking garage) 4Q15: Broken edges on hand 3Q15: Repair of sharp broken 4Q15: Trip hazard repair (Mail sanitizer repair (OR) baseboard tile (L&D) room) 3Q15: Exit door constantly

blocked by equipment (OR).

Addressed with OR manager to

keep exits clear at all times.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-37 EOC Component: SECURITY MANAGEMENT 7 Performance Standard: The following performance activities were undertaken in 2015: 1. Continued upgrade/enhancement of security video operation, access control, and alarm systems Evaluation: 2. 100% of Security officers obtain CA Bureau of Security Investigative Services 1. Throughout 2015 many (BSIS) guard card certification Security related projects took 3. Made available for all staff: quarterly offerings of security classes in the areas place to enhance observation, of Code Silver, response, Managing Aggressive Behavior (MAB), and personal access control, and alarm security practices systems. 4. <2 automobile thefts per quarter per campus

2. 100% of Security Officers were 5. Conditioned to foster liaison contacts with local law enforcement/fire officials certified by the CA BSIS (Bureau of Security Investigative 2015 Quarterly Security Services) and obtained Guard Training: Cards. 1st Quarter – NOTE: All new security officers are 2015 Quarterly Security • Required to obtain this certification Active shooter (Grand Building Projects: Prior to employment with PH. staff) • Managing Aggressive Behavior st 3. Our Security manager (PMC 4 & 5 staff) 1 Quarter – taught over 30 security related • Managing Aggressive Behavior • Door access upgrade classes in 2015. Hundreds of (PMC EVS staff) (San Marcos Ambulatory employees and volunteers in • Code Pink drills (POM & PHDC) Care Center) Multiple disciplines were trained.

3rd Quarter – 4. We met our goal of <2 2nd Quarter – vehicle thefts per quarter at • Active shooter (PMC ED staff) • Infant monitoring system th each campus. There was one • Personal security awareness upgrade (PHDC 7 floor) vehicle stolen from PMC in the (Healthy Development staff) • Hard drive addition for 2nd quarter. • Fire safety (Healthy video recording servers (PMC) 5. Security worked closely with Development staff) • Addition of 10 camera the marketing department to • Managing Aggressive Behavior send out periodical id security, (Infection Prevention staff) licenses to Sky point safety and parking messages to all • Managing Aggressive Behavior • Badge reader addition th staff via the staff portal. (PMC OR staff) (POM 5 floor) • Addition of 10 cameras 6. Security manager worked rd (PMC) closely in cultivating relationships 3 Quarter - with local law and fire officials • Managing Aggressive Behavior th throughout 2015. This will be (Staff on Safety committee) 4 Quarter: an ongoing goal of relation- • Fire safety (Acute Rehab staff) • Radio repeater addition ship enhancement in 2016. w/ antenna (PMC) 4th Quarter – • Bureau of Security Investigative Plan for Improvement: Services (Security staff) We will continue our plans • Code Pink drill (POM) of strengthening our security observation capability, Automobile thefts: access control, and alarm <2 threshold system functionality in 2015. Various security trainings were 5 offered in 2015 and badge 4 awareness campaigning and observation will continue. 1 Q 2015 3 2 2 Q 2015 1 1 3 Q 2015 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Q 2015 Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-38 8 EOC Component: HAZARDOUS MATERIALS AND WASTE MANAGEMENT Performance Standard: The following performance activities were undertaken in 2015: 1. Monitoring of the number of hazardous material containers inspected Evaluation: / labeled incorrectly during monthly EOC rounds monitored 1. During monthly 2. Staff knowledge in obtaining Safety Data Sheet (SDS) information Environment of Care (EOC) multi- during monthly EOC rounds (90% threshold) disciplinary rounds, facility 3 & 4. Monitoring of the number of hazardous waste and bio hazardous managers monitored hazardous waste incidents requiring outside agency cleanup material containers for inappropriate labeling. There were no deficiencies found in 2015. Inappropriate labeling on hazardous material container monitoring:

2. During monthly EOC rounds, 5 facility managers monitored staff knowledge regarding how to locate Safety Data Sheet (SDS) information. 4 Our threshold is 90% and was met at 1 Q 2015 each facility each quarter. 3 2 Q 2015 3 and 4. Number of hazardous and 2 3 Q 2015 bio hazardous waste incidents requiring outside assistance for 1 4 Q 2015 cleanup was zero, however, there were two small spills that occurred at 0 0 0 0 0 0 0 0 0 0 0 0 0 st 0 PMC in the 1 quarter (Formalin in the Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado OR) and the 4th quarter (Methyl Center Downtown Campus Methacrylate in the OR). Cleanup was done by Palomar Health staff due to the spills being small amounts. We will continue to monitor in 2016. Staff knowledge on how to obtain Safety Data Sheet (SDS) information: 90% threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015

0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado

Number of hazardous and bio hazardous waste incidents: Plan for Improvement: 5 We will continue monitoring for correct staff response relating 4 to various program 1 Q 2015 elements in our 3 hazardous materials 2 Q 2015 plan, as high levels of compliance promote risk 2 3 Q 2015 1 1 reduction relating to 4 Q 2015 hazardous materials 1 and waste usage. 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-39 EOC Component: FIRE PREVENTION MANAGEMENT 9 Performance Standard: The following performance activities were undertaken in 2015: 1. Monitoring of actual fires reported inside the facilities 2. Staff knowledge of RA.C.E (Rescue, Alarm, Contain, Extinguish / Evacuate), Evaluation: and P.A.S.S (Pull, Aim, Squeeze, Sweep) acronyms (90% threshold) 1. There were no fires reported at 3. Monitoring of building and / or protection systems – problems, significant any Palomar Health campus in incidents, and unexpected repairs 2015.

Number of actual fires reported inside the facilities: 2. During monthly EOC rounds, facility managers monitored staff 5 knowledge regarding the R.A.C.E and P.A.S.S acronyms. Our 4 threshold is 90% and was met at 1 Q 2015 each facility each quarter. 3 2 Q 2015 3. In January 2015, POM 2 experienced flooding due to a 3 Q 2015 broken fire sprinkler in one of the 4 Q 2015 first floor restrooms. Fire watches 1 were performed by Security and 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Facilities staff while repairs were 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado made. Center Downtown Campus

Staff knowledge of R.A.C.E and P.A.S.S acronyms: Threshold = 90%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015

0% Palomar Medical Center Palomar Health Downtown Pomerado Hospital Villa Pomerado Campus

Plan for Improvement: We will continue to monitor staff knowledge Building protection system problems, significant incidents, unexpected repairs: of R.A.C.E and P.A.S.S and continue to promote fire safety awareness and “readiness” in staff in the 10 event of a fire. We will 9 continue monitoring any 8 significant events at our campuses. 7 1 Q 2015 6 5 2 Q 2015 4 3 Q 2015 3 4 Q 2015 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-40 10 EOC Component: MEDICAL EQUIPMENT MANGEMENT Performance Standard: 1. Preventative maintenance (PM) completion rate for priority 1 life Evaluation: support equipment (100% threshold) 1. Biomed consistently met 2. Preventative maintenance (PM) completion rate for non-life their 100% threshold of support equipment (95% threshold) preventative maintenance on 3. <2% of equipment service requests that were related to user life support equipment errors throughout 2015. 4. <5% of unable to locate pieces of medical equipment

5. ≥90% of equipment repairs completed within 30 days 2. Biomed consistently met their 95% threshold of preventative maintenance on Preventative maintenance completion rates on life support devices: non-life support equipment 100% PM completion threshold throughout 2015, except for the 3rd and 4th quarter at Villa Pomerado due to two devices that could not be 100% located.

3. When biomedical staff respond to a work order that was 1 Q 2015 caused by an operator error, 2 Q 2015 technicians offer on the spot training for the operator and 3 Q 2015 it is noted in the work order. 4 Q 2015 If an equipment user has repeated errors on the same model of equipment, the department 0% manager is advised and Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus additional training is recommended.

4. The threshold was met consistently throughout 2015 on <5% of unable to Plan for Improvement: locate pieces of medical We will continue monitoring PM completion equipment at each facility, except at rates as high completion rates for both Villa Pomerado due to two pieces of life support and non life support medical medical devices (patient lifts) that equipment promotes operational reliability could not be located. These devices of equipment that is used on our patients, and were removed from inventory after supports our patient safety goals. being missing for 90 days. We will continue to monitor our other goals

and watch for any apparent trends or gaps. 5. The threshold was met consistently throughout 2015 at all facilities on ≥90% of equipment repairs completed within 30 days.

Preventative maintenance completion rates on non-life support devices: 95% PM completion threshold 99% 99% 99% 99% 99% 99% 99% 99% 100% 97% 95% 96% 97% 95% 100% 91% 95% threshold

71% 1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015 Linear (4 Q 2015) 0% Palomar Medical Center Palomar Health Downtown Pomerado Hospital Villa Pomerado Campus Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-41 Medical Equipment continued 11 <2% of equipment service requests related to user errors:

10% 1 Q 2015 2 Q 2015 3 Q 2015 6% 4 Q 2015 4%

2% 2% 2% 2% 2% <2% threshold 1% 1% 1% 1% 1% 0% 0% 0% 0% 0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado

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

30% 29% 1 Q 2015 2 Q 2015 20% 3 Q 2015 4 Q 2015

10% 7% 4% 3% 2% 2% 2% <5% threshold 1% 1% 1% 1% 1% 1% 0% 0% 0% 0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado

≥90% of equipment repairs completed within 30 days:

99% 99% 99% 99% 98% 100% 99% 98% 98% 100% 100% 95% 95% 100% 92% 93% 91% ≥90% threshold

1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015

0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-42 EOC Component: UTILITY EQUIPMENT MANAGEMENT 12 Performance Standard: 1.Monitoring of utility failures 2. Occurrences requiring outside reporting 3. Monitoring of tube system failures 4. Monitoring of emergency generator testing compliance per r Evaluation: regulatory standard 1. Utility failure monitoring includes any electricity, water, Utility failure monitoring: natural and medical gas Electricity, water, natural and medical gas failures failures. PMC experienced a breaker failure in September when normal testing was conducted. Breaker 2 was replaced and no issues were identified. The automatic transfer switch (ATS) failed at PHDC in January. PHDC lost power due to a 1 Q 2015 SDG&E breaker issue in July. 1 1 1 1 1 Generators ran as designed in each 1 2 Q 2015 event. POM and VillaPOM experienced 3 Q 2015 a power outage in July due to SDG&E (cause unknown). 4 Q 2015 No major issues identified. 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado 2. There were three incidents requiring Center Downtown Campus reporting to an outside regulatory agency in 2015 relating to utility failures / repairs. The automatic transfer switch (ATS) failed at PHDC in January. PHDC lost power due to a Plan for Improvement: SDG&E breaker issue in July. We will continue Generators ran as designed in each monitoring, keeping event. At POM, due to a visitor our efforts on prevention, causing damage to a fire sprinkler in and utility equipment a restroom, caused >$200,000 in operational reliability damages in January. which strengthens our patient safety focus. 3. Tube system failures were monitored throughout 2015.

4. Elevator failures were monitored throughout 2015. Outside agency reporting: 5. Generator testing, which is considered life support utility equipment, was completed at 100% at all facilities 2 in 2015.

1 Q 2015 1 1 1 1 2 Q 2015 3 Q 2015 4 Q 2015

0 0 0 0 0 0 0 0 0 0 0 0 0 Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-43 Utility Equipment 13 continued Tube system failure monitoring:

10 9 8 8 8 7 1 Q 2015 6 5 5 2 Q 2015 4 3 Q 2015 3 4 Q 2015 2 1 1 1 0 0 0 0 0 0 0 0 Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital

Elevator failure monitoring:

10 10 9 9 8 8 8 7 6 6 6 1 Q 2015 6 2 Q 2015 5 4 4 3 Q 2015 4 Q 2015 3 2 2

1 0 0 0 0 Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital

Emergency generator testing per regulatory standard: 100% threshold

100%

1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015

0% Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-44 EOC Component: EMERGENCY MANAGEMENT / EMERGENCY OPERATIONS PLAN (EOP) 14 In 2015 multiple events occurred in the area of emergency management. The Disaster Committee met regularly with a standing agenda developed by the Program Manager to address the growth of disaster preparedness and the preparedness needs throughout the district.

The National Incident Management System (NIMS) and Hospital Incident Command System (HICS) principles are incorporated into exercise planning and actual event response. Committee members also reviewed the Hazard Vulnerability Analysis (HVA) documents which were completed with risks prioritized for the medical centers and balanced against mitigation strategies in place. Input was solicited from our medical staff, and community partners (San Diego County Emergency Medical Services (EMS) / San Diego County Office of Emergency Services (OES) and the other SD County medical centers and fire departments) who provided recommendations for our HVA’s. We have several disaster equipment storage trailers that are inventoried annually and Supply Chain maintains the medical supplies on each disaster supply cart at each of our ED’s. Also utilized is an exercise / actual event evaluation tool that establishes performance standards in accordance with The Joint Commission emergency management standards (the six critical areas of communications, resources and assets, staff roles and responsibilities, security, utilities, and patient support services).

In 2015, the medical centers participated in several countywide exercises and in actual events. For the purposes of this report, two exercises, in which the EOP was activated, at each facility will be evaluated to ensure our 90% objective threshold. PMC: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination conducted by PMC staff, using the decon trailer that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The scenario also involved a cyber attack which caused multiple power outages. • Event score: 92% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms and Security practiced with a traffic flow exercise. • Event score: 95% with follow up activities identified. PHDC: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination conducted by PHDC staff, using the decon tent that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The scenario also involved a cyber attack which caused multiple power outages. • Event score: 92% with follow up activities identified. 2. Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms . • Event score: 94% with follow up activities identified.

POM: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination conducted by POM staff, using the decon tent that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The scenario also involved a cyber attack which caused multiple power outages. • Event score: 90% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms. • Event score: 91% with follow up activities identified.

VillaPOM: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Since this exercise involved power outage, staff practiced completing Department Status Worksheets in which critical devices being plugged into red outlets was tested. We also captured potential staff shortages and planned for steps to take if staff shortage was ever identified. • Event score: 94% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms. • Event score: 94% with follow up activities identified.

Satellite Buildings, including Home Health: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Outside area staff are tasked with completing ‘Department Status Worksheets’ and reporting to the command center any staffing shortages, or staff that would be available for the labor pool. • Event score: 92% with follow up activities identified. 2. November 19 – Statewide exercise involvement. Outside area staff are tasked with completing ‘Department Status Worksheets’ and reporting to the command center any staffing shortages, or staff that would be available for the labor pool. Home Health tested the process of receiving SNS medication and delivering it to our home bound population. • Event score: 96% with follow up activities identified.

Plan for Improvement: For the disaster exercises and events, debriefings Plan for Improvement: occurred with plans for improvement identified. We will continue testing The Disaster Committee has assumed the correct staff response responsibility for implementing the improvement relating to our actions. We will continue with pre-planning for Emergency Operations drills, identifying objectives that test stressing Plan. our systems. Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-45 Emergency Management 15 continued

EOC Component: EMERGENCY MANAGEMENT Performance Standard: 1. Conduct / manage two disaster exercises or actual events per year at each facility according to top Hazard Vulnerability Analysis (HVA) risks and evaluate event using The Joint Commission standards or SD County Medical Health After Action Report (AAR) matrix (90% threshold) 2. Staff knowledge during EOC surveillance rounds in articulating where his or her unit’s disaster supplies are located (90% threshold) 3. Staff knowledge during EOC surveillance rounds in articulating where the hospital command center (HCC) and labor pool are located (90% threshold)

Evaluation of disaster exercises / actual events using The Joint Commission Emergency Management chapter standards: 90% threshold

92% 95% 92% 94% 90% 91% 94% 94% 92% 96% 100%

Threshold = 90%

MCI / Power Outage Exercise Evaluation: Anthrax 1. During each of the Exposure exercises in 2015, the threshold of 0% Exercise 90% was met consistently at each Palomar Palomar Pomerado Villa Outside Medical Health Hospital Pomerado Areas medical center and outside area. Center Downtown Action items were identified post Campus event as well as what items went well. These items were forwarded Staff knowledge during EOC surveillance rounds in articulating to the disaster and environment of care committees for review. where his or her unit’s disaster supplies are located: 90% threshold

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 2 and 3. During monthly EOC 100% rounds, facility managers Threshold = 90% monitored staff knowledge regarding the locations of disaster equipment, hospital 1 Q 2015 command centers and labor 2 Q 2015 pools. Our threshold is 90% and was met at each facility by quarter, 3 Q 2015 with the exception of the 4th quarter at PMC. Staff was given 4 Q 2015 just in time training on the locations during the rounding. 0% Palomar Medical Palomar Health Pomerado Hospital Villa Pomerado Center Downtown Campus

Staff knowledge during EOC surveillance rounds in articulating where the hospital command center and labor pools are located: 90% threshold

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Threshold = 90%

60% 1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015 0% Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-46 16 Annual Evaluation - Overall Effectiveness – 2015

SAFETY. Based upon the objectives, scope and performance standards, outcomes were positive, and thresholds were impressively met for the safety management program at Palomar Health facilities. Based on the high level of commitment to education, surveillance, and ongoing activities, the Management Plan for Safety is highly effective in promoting safety standards for the organization, and in guiding the direction of safety-related activities. We will plan on doing additional unsecured O2 tank rounding throughout the organization, in addition to monthly EOC rounds to ensure departments understand the importance of proper O2 tank storage.

SECURITY. The Management Plan for Security and the security program is effective across the district, with the objectives being met in 2015. Incidents were monitored routinely, and performance standards were met regarding requirements specific to their department standards and expectations. Code Pink (infant abduction) and Purple (child abduction) drills were completed on a routine basis with excellent staff response. For the year 2016, we will continue monitoring security trends to identify areas of risk to the medical centers and offsite areas, and we will continue with the management of assault training and infant and child abduction security drills, focusing on continued education and effective drill outcomes.

HAZARDOUS MATERIALS. The Management Plan for Hazardous Materials and the overall Hazardous Materials program at Palomar Health facilities is effective, as there were no spills requiring an outside response team. Objectives were met for 2015, and the threshold was met for staff knowledge relating to program elements of the Hazardous Materials Management Plan. Hazardous waste was manifested in accordance with agencies having jurisdiction. This focus on ongoing education reflects Palomar Health’s commitment to the safety of our employees, especially is it relates to hazardous materials issues. We strengthened our program in 2015 and continued to meet on a quarterly basis with the group that was trained as first receivers during 2014 decontamination training. We will plan for another round of 16-hour first responder training in 2016, which will allow recertification to those in need.

FIRE PREVENTION MANAGEMENT. Based upon the objectives, scope and performance standards, the Fire Prevention Management plan is effective. Fire drills were completed for the hospital and offsite areas, with performance standards monitored, and found to be in compliance throughout the year. Fire equipment inspection, maintenance and testing was completed, with ongoing monitoring of the Statement of Conditions in effect. Infection Prevention assessment continued to be integrated into construction activities.

MEDICAL EQUIPMENT MANAGEMENT. Based upon the objectives, scope and performance standards, the Medical Equipment Plan and program are effective at the medical centers. Preventive maintenance was monitored quarterly, with established thresholds met. The separation of our inventory (i.e., life support medical equipment from non-life support medical equipment) places a higher focus on the safety of our patient, and keeps the Environment of Care closely integrated with Patient Safety standards. The Medical Equipment Plan and program are effective in promoting safe equipment usage for our patients. We will continue to monitor equipment user errors and equipment that is not located for > 30 days and be prepared to observe and report out any trending that may occur.

UTILITY EQUIPMENT MANAGEMENT. There were no trends or unusual patterns associated with utility failures. All generators were completed at 100% compliance and various utility failures were noted throughout the year. The Utility Equipment Management plan is an effective way to manage the Utility Equipment program based on the successful completion of goals and performance standard monitoring.

EMERGENCY MANAGEMENT. Based upon the objectives, scope and performance standards, the Emergency Management and Operations Plan is effective. Several actual events and SD County disaster exercises occurred in 2015, all of which were based upon likely scenarios in our Hazard Vulnerability Analysis's. The events were evaluated with overall successful outcomes, with plans for improvement identified and implemented. The Disaster Preparedness Committee was very active with exercise design and planning. This continues to be a highly effective and energetic committee that will continue to meet and oversee the day-to-day emergency planning in 2016. The Hazard Vulnerability Analysis's are reviewed annually, and found to be an effective tool in prioritizing critical events, and assessing the prioritization against the medical center’s preparedness. Staff were monitored for their knowledge relating to components in our Emergency Operations plan, and their roles in a disaster, and found to respond at a very high compliance rate. Palomar Health as a district is actively involved with community-wide preparedness activities, which strengthens our ties with agencies having jurisdiction.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-47 Annual Report Environment of Care and the Emergency Management Programs

CY 2015

Submitted by: Dan Farrow: AVP Hospitality and Facilities Steve Miller: Director of Facilities Lisha Wiese: Program Manager – Emergency Mgt and Safety

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-48 2015 Key Activities and Accomplishments Environment of Care (EOC) & Emergency Management (EM) Programs Safety Management • Multi-disciplinary environment of care rounding – Documented in Sentact and issues sent to Director to resolve and close out in Sentact. Hazardous Materials Management • Process Improvement Project for the EOC identified – 2014 first responder decontamination training met quarterly to review plans, communication details and gaps, and plan for next decontamination exercise. Security Management: • Ongoing active shooter and Management of Assaultive Behavior training • Multiple collaborations with Escondido PD SWAT and K-9 personnel with trainings at vacant Surgery Center.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-49 2015 Key Activities and Accomplishments Environment of Care & Emergency Management Programs Continued

Fire Prevention Management • Fire prevention devices tested and maintained per regulatory standards. • Fire safety training provided for PMC kitchen staff. Medical Equipment Management: • Enhancement of Medical Equipment Management Plan to comply with The Joint Commission Standards Utilities Management • Utility failures monitored by EOC committee to ensure issues were resolved, follow up actions taken promptly Emergency Management • Continued collaboration with SD County Emergency Medical Services (EMS) on Hospital Preparedness Program (HPP) grant funding and grant funds were received. • Two disaster exercises and two tabletop exercises completed and evaluated for effectiveness

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-50 Key Areas of Focus for 2016 Environment of Care & Emergency Management Programs

Safety Management: • General safety awareness training and provide reference materials for staff (emergency code kardex ) • Implementation of system wide ‘Department Safety Captain’ program in conjunction with the Staff On Safety Program • Deployment of monthly safety and disaster training programs Security Management: • Continue with Code Silver and Management of Behavior Training • Continue cultivating relationships with community law enforcement partners • Installation of Knox boxes at each hospital facility at key access points • Interdisciplinary team formed to implement Cal OSHA’s new Violence in the Workplace regulation Hazardous Materials Management: • Provide another round of 16-hour hands on decontamination training and recertification • Continue with decontamination team committee Utilities Management: • Continue to ensure utility system reliability and minimize the risk of utility system failures.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-51 Key Areas of Focus for 2016 Environment of Care (EC) & Emergency Management (EM) Programs Continued

Fire Prevention Management: • Modification of fire drill evaluation forms to better capture staff involvement and participation in fire drills • Complete standardization of fire response education district-wide Medical Equipment Management: • Collaborate with Supply Chain to drive >20% savings with rented mobile medical equipment • Successful department consolidation of medical equipment Emergency Management: • Transition to the new Everbridge Mass Notification platform • Continue collaborating with hospital partner Emergency Managers, law enforcement, Red Cross, fire, County OES (Office of Emergency Services), and County EMS during monthly San Diego County Healthcare Disaster Coalition meetings. • Implement streamlined process, using T.R.A.I.N (Triage Resource Allocation for In-patients) to effectively address patient transportation needs during an evacuation.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-52 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-53 Medication Use Report 02/19/16 Diana Schultz, Manager of Medication Safety

Section One: Executive Summary

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-54 Medication Usage Report

• Pharmacy Services monitors the eleven nodes of medication management delineated in Palomar Health’s Medication Error Reduction Plan as well as procurement and adverse medication events. Monitoring includes: Selection, Procurement, Product Labeling & Nomenclature, Storage, Distribution, Prescribing, Prescription Order Communication, Compounding, Dispensing, Administration, Monitoring, Education, Medication Errors and Adverse Drug Reactions (Lucidoc procedure 30832) • Key Areas of Focus for 2016 – Transitions of Care – Ambulatory Services – Outpatient Pharmacy – Pharmacy Clinical Services – Pharmacy Operational Performance Improvement

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-55 Medication Usage Report Pharmacy Operational PI Transitions of Care • Error Proofing Unit Dosed Medication Streamlining consulting, prioritization & • ATP → Manufacturer Unit Dose documentation process Medication • Hospital specific bar code WASP label data base → centralized data base • Nurse tablet splitting → pharmacy • 340B accumulator program • RIVA Optimization • Products ↑ from 2 → 6 • Items ↑ from 200 → 700 per week • Medication Delivery LEAN project

Ambulatory Care/ Outpatient • Growth of Pharmacist Services at Arch & Neighborhood Health • Specialty Pharmacy Growth • Discharge counseling via WebEx

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-56

Medication Usage Report • Challenge: Admission Medication Reconciliation – Barriers: Documenting home medications in Cerner PRIOR to provider performing admission medication reconciliation. Med Recs tools in Cerner not intuitive and process not standardized. – Plan: Physician education on admission medication reconciliation and proper workflow. Nursing education on home medication documentation. Workflow improvements with Pharmacy technicians and nursing task list to complete home medication history. December 2015 Admit Meds Rec Not Done % of admits with Med History completed by Pharmacy Technician Admit Meds Rec Completed b/f Home Meds Documented w/in 24 hours Admit Meds Rec Completed After Home Meds 80% 76% Documented 70% 67% 69% 62% 63% 62% 64% 63% 60% 58% 54% 50% 40% 38% 30% 50% 20% 10% 0% 12%

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-57 Medication Usage Report Challenge: Turn Around Time for Delivery of Non-Pyxis Medication • Barriers to timely delivery: Physical distances, patient transfers, delivery of controlled substances, ED/PACU hold patients, # of delivery locations. • Plan: LEAN methodology project, dose tracking technology with tracking board, redistribution of staff, optimization of Pyxis.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-58 Medication Usage Report Key Area of Focus for Next Reporting Period • Continued focus on Transitions of Care, Ambulatory Services, Outpatient Pharmacy Services and Pharmacy Operational Performance Improvement. Emphasis on implementation of LEAN in Pharmacy Operations

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-59 Section Two –Performance Improvement project Pharmacy Pharmacist Student Program Development and Residency Program Optimization

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-60 Strategic Initiative Link

1. Financial Strength- Increases pharmacist productivity. Extends pharmacy services 2. Customer Service -Builds relationships with pharmacy schools. 3. Quality -Enables development of clinical services such as discharge counseling, discharge med reconciliation, and inpatient medication therapy management that have been shown to improve patient outcomes and reduce readmissions while decreasing the need for addition of FTEs. 4. Workforce/ Workplace –Improves the ability to assess pharmacy service impact and direct future focus. Strengthens future workforce

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-61 Problem Statement • Palomar Health pharmacy department’s residency and student program growth was not optimized. Needs were identified by pharmacy schools for established venues to lead clinical skills sessions and assist with other teaching responsibilities, by the pharmacy profession for more residency experiences and by Palomar Health for resident teaching opportunities and pharmacists with residency experience.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-62 Opportunity Growth of the pharmacist resident and student programs will: • provide teaching opportunities and a learning environment for residents and pharmacists, • improve pharmacist productivity, • provide an opportunity for more research and medication use evaluation.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-63 Plan 1. Build relationships with KGI and UCSD 2. Expand Residency Program 3. Develop and expand student rotations 4. Optimize summer pharmacist interns 5. Create Summer Student Research Program

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-64 Do  Align Pharmacy School and Palomar Health’s Goals – Joint Faculty Positions Established in Ambulatory Care and Transitions of Care – Compounding Skills Lab –Our pharmacists help teach and KGI training materials is used to help train our staff.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-65 Do  Align Summer Student Research Projects with Palomar Health’s Areas of Focus. Six research projects centered around ambulatory care, transitions of care and pharmacy operational performance improvement

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-66

Do Align Pharmacy Student Rotations with Residency Program . Residents now support student teaching in Internal Medicine, ICU and AST rotations. Formalize Summer Intern Program

2 shift per month Interview & Summer 1 Summer 2 commitment Selection process Program Program during School Year

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-67 Do

Align residency program with Palomar Health’s areas of focus – Addition of two PGY1 hospital residents (2 to 4 total – Addition of 1 ambulatory care PGY1 – Addition of 2nd year residency (PGY2) in administration and transitions of care

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-68 Check • Successful accreditation of 2nd year residency program in 2015 • Successful re-accreditation of 1st year residency program in 2015 • > 180 resident applicants for 5 resident positions available in 2016 • 11 former residents currently work as pharmacists at Palomar Health • > 8 summer interns supporting pharmacy operations throughout the year Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-69 Act

• Sustain and Continue to Optimize Program via feedback and formal evaluation process • Grow summer research program by involving all managers • Communicate successes Next Steps Second Year Residency Program in Ambulatory Care

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-70 Section Three – Data on Division Performance

1. Financial Strength 1. Achieve Profitability 2. Demonstrate business growth 2. Customer Service 1. Develop loyal Patients 2. Increase physician loyalty 3. Quality 1. Demonstrate high quality and safe patient care 2. Optimize processes and systems 4. Workforce/ Workplace 1. Develop culture that innovates change, innovation, accountability 2. Provide tools and equipment for optimal performance

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-71 Financial Strength • 340b Program Optimization • Drug Savings-(e.g. inhaler automatic substitution = $100,000 annual savings) • Productivity

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-72 Customer Service

Prescription Medication Assistance Program (PMAP) for Discharging Patients: Drugs at No or Low Cost

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-73 Quality- QAPI Metrics

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-74 Quality-Adverse Drug Events

There were no medication errors reported that caused permanent harm during the above reporting period. The most frequent type of medications errors reported were delays or omissions in medication administration.

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-75 Workforce/ Workplace

• Development of Resident and Student Program (See PDCA above) • Formalization of Pharmacy Technician Orientation Program

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-76 PALOMAR HEALTH Workers’ Compensation Trend Analysis

Russ Riehl & Dr. Bower March 24, 2016

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-77 Workers’ Compensation Loss & Payroll History

Valued as of March 1, 2016

TOTAL MEMBER NO. OF EXP LOSS PROGRAM YEAR FTE PAYROLL PAID RESERVES OPEN INCURRED CONTRIBUTION LOSSES MOD RATIO (2) 07/01/2015 – 07/01/2016 3,025 $ 265,079,230 $ 145,379 $ 616,942 $ 762,321 $ 3,230,797 141 88 0.84 23.6% Alpha Fund - Guaranteed Cost

(2) 07/01/2014 – 07/01/2015 3,025 $ 270,257,748 $ 1,108,436 $ 815,128 $ 1,923,564 $ 2,998,461 158 46 0.74 64.2% Alpha Fund - Guaranteed Cost

(1) 07/01/2013 – 07/01/2014 3,035 $ 258,482,183 $ 2,260,229 $ 638,580 $ 2,898,809 $ 2,772,997 146 21 0.72 104.5% Alpha Fund - Guaranteed Cost

(1) 07/01/2012 – 07/01/2013 3,321 $ 261,096,430 $ 1,517,482 $ 730,854 $ 2,248,336 $ 2,772,844 188 13 0.59 81.1% Alpha Fund - Guaranteed Cost

(1) 07/01/2011 – 07/01/2012 3,052 $ 225,186,959 $ 1,252,403 $ 129,011 $ 1,381,414 $ 2,481,560 137 3 0.58 55.7% Alpha Fund - Guaranteed Cost

Totals 15,458 $1,280,102,550 $ 6,283,929 $ 2,930,515 $ 9,214,444 $ 14,256,659 770 171 65% 5 Year Average (excluding current year) 3,136 $ 248,255,191 $ 1,676,705 $ 499,482 $ 2,176,186 $ 2,675,800 157 12.33 0.63 80.4%

(1) Final payrolls, FTE and member contributions provided by Alpha Fund (2) Estimated annual payroll & member contribution

• The average cost per claim for FY 2016 is $10,083 as compared to $5,407 in FY 2012 • The number of claims filed per FTE has slowly been increasing since FY 2012 with a noticeable spike in 2016.

1 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-78 CLAIM FREQUENCY & SEVERITY

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-79 Claim Frequency & Severity

Frequency by DEPARTMENT Top 10 Departments

2.84% 2.13% 2.84% Environmental Services 14.18% Food Services 4.26% Critical Care 4.26% 8e/8w Medical Acute Patient Transport 4.26% 10.64% Emergency Room 4.26% Labor/Delivery/Recovery 5.67% Medical Surgical Central Services Security

• The chart represents only the top 10 departments by claim volume.

3 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-80 Claim Frequency & Severity

Severity by DEPARTMENT Top 10 Departments

3.98% 2.73% Post Anesthesia Care 4.60% 4.70% 26.98% 8e/8w Medical Acute 5.19% Critical Care Medical Staffing 5.28% Emergency Room 5.62% Supply Chain Services Labor/Delivery/Recovery 6.33% 16.71% Plant Maintenance Radiology-Diagnostic Environmental Services • Only top 10 departments are considered in this analysis. • PACU has highst severity, and is not in the top 10 in frequency. • EVS, had the highest frequency, but lowest severity. 4 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-81 Claim Frequency & Severity

Frequency by CAUSE Top 10 Causes of Injury

4.26% 3.55% 4.26% Patient Handling 4.26% Manual Handling - Lifting 31.91% Repetitive Motion 5.67% Pushing/Pulling Object 6.38% Slip/Trip/Fall from Same Level 7.09% Struck By Object/Person

7.80% 17.73% Strain or Injury by, NOC Operating Machine or Equipment Reaching Exposure-Contact with

• Patient handling continues to be the leading cause of injuries by quite a large margin. 5 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-82 Claim Frequency & Severity

0.96% Severity by CAUSE 1.23% Top 10 Causes of Injury

0.89% 0.66% 4.53% Pushing/Pulling Object Slip/Trip/Fall from Same Level 6.16% 29.06% Patient Handling 12.14% Manual Handling - Lifting Reaching Strain or Injury by, NOC 20.28% Repetitive Motion 22.95% Operating Machine or Equipment Struck By Object/Person Slip/Trip; Did Not Fall

• More than half of Palomar Health’s overall total incurred is derived from just two causes of injury, Patient Handling and Repetitive Trauma.

6 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-83 NEXT STEPS – Creating a Culture of Safety

Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-84 Employee Safety Culture - RISKS

Reality/Risks • Lack of Safety Culture

– No dedicated Safety Officer

– Silo’d Safety Programs

– Okay to Get Hurt?

- Unknown Safety Procedures

- Employee Choice??

– Minimal dept. investigations

– No formal injury investigations

10 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-85 Is this Safe?

August 31, 2016 11 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-86 Is this Safe?

• Ultrasound Machine • 350+ Pounds • No motorized drive assist • Staff expected to use as mobile machine.

• OSHA Regulations requires mobile equipment over specific push forces to have drive assist or require 2 persons.

• Would you want to use this daily?

August 31, 2016 12 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-87 Employee Safety Culture - RISKS

Reality/Risks • Safety Awareness – Limited review of safety compliance • Accountability – Clear Expectations – Leadership Handcuffed?

• Modified Duty Program – Reluctance to accommodate – Handcuffed from Accountability – Productivity Fears – Hassle to manage

13 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-88 What’s Behind Locked Doors?

Cases stacked 6 high • Fall Hazard • Overhead Lift Hazard

Heavy Item over 6 feet • Overhead Lift Hazard

Is this the norm?

August 31, 2016 14 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-89 What’s Behind Locked Doors?

Observation • Two employees • Both under 5’5” • Needed Item on Top Shelf • Top Shelf over 7.5 feet tall

One employee held shelving unit, while another employee stood on a 4-wheeled supply cart. Then used the cart to climb to the 3rd shelf to reach the item on the top shelf.

Awareness… This is our newest campus. What are our older facilities like?

August 31, 2016 15 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-90 Employee Safety Culture

Recommendations • Create Culture of Safety – Experienced Safety Officer – Connect Safety across system • Employee • Environment • Patient – Enhance Incident Reporting • Real-time • Dept. Investigations – Implement Formal Investigations • Loss Work Time Cases

16 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-91 Employee Safety Culture

Recommendations • Accountability for Working Safe – Educate on Safety Expectations • Leadership Role & Importance • Employee Procedures – Discipline for non-compliance • Modified Duty/Return to Work – Expectation is to accommodate – Create System Task List – Increase Education • Leadership – Program • New Employee – Philosophy • Annual Safety - Culture

17 Tab 11 - Quality and Patient Safety Reports Presented to the BQRC in 2016 11-92

2016 QUALITY & PATIENT SAFETY ANNUAL REPORT TO THE BOARD OF DIRECTORS

Acronym Glossary

September 19, 2016

Patient Experience Division ACRONYM GLOSSARY Updated: 08/12/2016

AAPL: Academy of Applied Physician Leadership AAR: After Action Report ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACNS-BC: Adult Health Clinical Nurse Specialist-Board Certified ACR: American College of Radiology AHP: Arch Health Partners AHRQ: Agency for Healthcare, Research and Quality ALICE: Alert Lockdown Inform Counter Evacuate AMI: Acute Myocardial Infarction APRN: Advanced Practice Registered Nurse ARB: Angiotension Receptor Blocker ARU: Acute Rehab Unit ATS: Automatic Transfer Switch BCACP: Board Certified Ambulatory Care Pharmacist BETA: BETA Healthcare Group (PH Insurer) BQRC: Board Quality Review Committee BSC: Balanced Score Card BSN: Bachelor of Science in Nursing BSIS: Bureau of Security and Investigative Services CALNOC: Collaborative Alliance for Nursing Outcomes CAP: Child Abuse Program CAP: College of American Pathologists CAP: Community-Acquired Pneumonia CAPG: The Voice of Accountable Physician Groups CARF: Commission on Accreditation of Rehabilitation Facilities CAUTI: Catheter Associated Urinary Tract Infection CC: Complications and Comorbidities CCTP: Community-Based Care Transitions Program CDAD: Clostridium Difficile Associated Diarrhea CDC: Center for Disease Control CDE: Certified Diabetes Educator CDI: Clinical Documentation Improvement CDI: C. Difficile Infections C-diff: Clostridium difficile CDPH: California Department of Public Health CEP: California Emergency Physicians CHA: California Hospital Association CHF: Congestive Heart Failure CIHQ: Center for the Improvement in Healthcare Quality CLABSI: Central Line Blood Stream Infection CLIP: Central Line Insertion Practices CMMI: Center for Medicare and Medicaid Innovation

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Tab 12 - Acronym Glossary 12-1 Patient Experience Division ACRONYM GLOSSARY Updated: 08/12/2016

CMS: Centers for Medicare & Medicaid Services COP: Conditions of Participation COPD: Chronic Obstructive Pulmonary Disease CPE: Certified Physician Executive (American College of Physician Executives) CPHQ: Certified Professional in Healthcare Quality CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management CSHE: California Society Healthcare Engineers CVICU: Cardio Vascular Intensive Care Unit CY: Calendar Year DI: Diagnostic Imaging DM: Diabetes Mellitus DPT: Doctor of Physician Therapy DRT: Diabetes Resource Team DVT: Deep Vein Thrombosis EBP: Evidence Based Practice ED: Emergency Department EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EMS: Emergency Medical Services EMT: Emergency Medical Technician EMT: Executive Management Team EOC: Environment of Care EOP: Emergency Operations Plan EVS: Environment of Care Services / Environmental Services FACHE: Fellow American College of Healthcare Executives FACPM: Fellow of the American College of Preventive Medicine FANS: Food and Nutrition Services FHS: Forensic Health Services FMEA: Failure Mode Effects Analysis FY: Fiscal Year HAC: Hospital Acquired Conditions HAI: Healthcare Associated Infections HAPU: Hospital Acquired Pressure Ulcers HASFZ: Heart Attack and Stroke Free Zone HbA1c: Hemoglobin A1C HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCC: Hospital Command Center HCP: Health Care Provider HDL: High Density Lipoprotein Cholesterol HDS: Healthy Development Services HHSA: Health and Human Services Agency HICS: Hospital Incident Command System

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Tab 12 - Acronym Glossary 12-2 Patient Experience Division ACRONYM GLOSSARY Updated: 08/12/2016

HLD: High Level Disinfectant HF: Heart Failure HIPAA: Health Insurance Portability and Accountability Act HPP: Hospital Preparedness Program HPRO: Hip Replacement Surgery HRRP: Hospital Readmission Reduction Program HVA: Hazard Vulnerability Analysis IC: Infection Control ICU: Intensive Care Unit IHA: Integrated Healthcare Association IHI: Institute for Healthcare Improvement ILSM: Interim Life Safety Measures IMI: Inpatient Mortality Indicator IMM-2: Influenza Immunization IOM: Institute of Medicine IP: Infection Prevention (RN Staff) IPCC: Infection Prevention and Control Committee ISBARR: Introduction, Situation, Background, Assessment, Recommendations, Read back KP: Kaiser Permanente KPRO: Knee Replacement Surgery LSC: Life Safety Conditions MAB: Management of Assaultive (or Aggressive) Behavior MAC: Medicare Administrative Contractor MCC: Major Complications and Comorbidities MCI: Mass Casualty Incident MDRO: Multi Drug Resistant Organism MERP: Medication Error Reduction Plan MHA: Masters of Healthcare Administration MOM: Master of Arts in Organizational Management MPH: Master of Public Health MRI: Magnetic Resonance Imaging MRSA: Methicillin-resistant Staphylococcus aureus MSN: Master of Science in Nursing MSPRC: Medical Staff Peer Review Committee MY: Measurement Year NACo: National Association of Counties NDNQI: National Database of Nursing Quality Indicators NEA-BC: Nurse Executive Advanced-Board Certified NHQM or NIHQM: National Improvement for Healthcare Quality Measure NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NIMS: National Incident Management System NPSF: National Patient Safety Foundation NPSG: National Patient Safety Goals

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Tab 12 - Acronym Glossary 12-3 Patient Experience Division ACRONYM GLOSSARY Updated: 08/12/2016

NQF: National Quality Forum OB: Obstetrics OES: Office of Emergency Services OPPE: Ongoing Professional Practice Evaluation OSHA: Occupational Safety and Health Administration OSHPD: Office of Statewide Health Planning and Development PASS: Pull Aim Squeeze Sweep PCCN: Progressive Care Credentialed Nursing PCEA: Patient Controlled Epidural Analgesia PCM: Perinatal Care Measure PDCA: Plan Do Check Act PH: Palomar Health PharmD: Doctor of Pharmacology PI: Performance Improvement PM: Preventative Maintenance PMC: Palomar Medical Center PN: Pneumonia POCT: Point of Care Testing PPE: Personal Protective Equipment PPFR: Physician Performance Feedback Report PRIME: Public Hospital Redesign and Incentives in Medi-Cal PSI: Patient Safety Indicator PSR: Patient Service Representative QAPI: Quality Assurance Performance Improvement QIO: Quality Improvement Organization QRR: Quality Review Report RAC: Revenue Cycle Audits RACE: Rescue Alert Confine Extinguish RCA: Root Cause Analysis RN-BC: Registered Nurse-Board Certified RT: Respiratory Therapist RHIT: Registered Health Information Technician RVT: Registered Vascular Tech SART: Sexual Assault Response Team SCIP: Surgical Care Improvement Project SDHDC: San Diego Healthcare Disaster Coalition SDS: Safety Data Sheet SHP: Strategic Healthcare Program SIR: Standardized Infection Ratio SIRS: Systemic Inflammatory Response Syndrome SIT: Security Integration Team SMILE: Share yourself, Make it clear, Inform on timing, Listen with care, End with Kindness SNF: Skilled Nursing Facility SNS: Strategic National Stockpile

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Tab 12 - Acronym Glossary 12-4 Patient Experience Division ACRONYM GLOSSARY Updated: 08/12/2016

SOC: Statement of Conditions SSI: Surgical Site Infection STK: Stroke TAT: Turn Around Time THA: Total Hip Arthroplasty TICU: Trauma Intensive Care Unit TJC or JC: The Joint Commission TKA: Total Knee Arthroplasty TRAIN: Triage Resource Allocation for In-patients UST: Underground Storage Testing US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Associated Pneumonia VBAC: Vaginal Birth After Caesarian Section VBP: Value Based Purchasing VRE: Vancomycin-resistant enterococcus VTE: Venous Thrombo-embolism WHO: World Health Organization

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Tab 12 - Acronym Glossary 12-5