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

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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
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