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Board Quality Review Committee BOARD QUALITY REVIEW COMMITTEE AGENDA MONDAY, APRIL 17, 2017 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:30 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 6:00 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025 Time Form A Target PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING Page # CALL TO ORDER ROOM 6:00 Establishment of Quorum ............................................................................................................. 1 N/A 6:01 Public Comments 1 ....................................................................................................................... 15 N/A 6:16 Information Item(s) 1. *Approval: Open Session Meeting Minutes/Attendance Roster – Monday, March 20, 2017 (ADD A, Page 7 - 14) ................................................................................................. 5 3 6:21 2. “Approval: Closed Session Meeting Minutes Attendance Roster – Monday, March 20, 2017 (ADD B, Page 15 - 18) .................................................................................................. 3 4 6:24 3. Update: Joint Commission Survey – PMC Escondido and PMC Poway 10 N/A 6:34 Deborah Barnes, District Director, Regulatory Coordination Standing Item(s) 1. Journal Club Assignment: - “Bad typography has ruined more than just the Oscars” Video by Christophe and 10 N/A 6:44 Haubursin and Benjamin Bannister, VOX Understand the news New Business 1. Infection Prevention and Control (ADD C, Page 19 -80) .................................................... 45 5 7:29 a. Infection Prevention and Control 2016 Annual Review and Program Assessment b. *Infection Prevention and Control 2017 Risk Assessment and Plan (ADD D, Page 81 - 101) .................................................................................................................................... Valerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA-BC District Director, Quality/Patient Safety/Infection Prevention Presentation – 40 minutes Questions & Answers – 5 minutes 2. Resource Utilization – Presentation was deferred until June 19, 2017 ............................... -- N/A -- Marcy Adelman, RN, MSN, CCM, ACM, District Director Clinical Resource Management Public Comments 1 ....................................................................................................................... 15 N/A 7:44 ADJOURNMENT 1 7:45 Note: The agenda, without public comments, is scheduled for 1 hour, 15 minutes. Based on above agenda, without public comments the meeting starts at 6:00 pm and adjourns at 7:15 pm. 1 Page 1 BOARD QUALITY REVIEW COMMITTEE AGENDA MONDAY, APRIL 17, 2017 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:30 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 6:00 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025 PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM Board Quality Review Committee Members VOTING MEMBERSHIP NON-VOTING MEMBERSHIP – Chairperson, Board Member Bob Hemker, FACHE, President & CEO Joy Gorzeman, RN – Chairperson, Board Member Frank Beirne, FACHE, EVP, Operations Hans Sison, LVN, Board Member Alan Conrad, MD, EVP, Physician Alignment Dara Czerwonka, MSW, Board Member Della Shaw – EVP, Strategy Sabiha Pasha, MD - Chair of Medical Staff Quality Management Maria Sudak, RN, MSN, CCRN, NEA-BC – VP, Palomar Medical Center Committee for Palomar Medical Center Escondido Escondido Ed Gurrola, MD - Chair of Medical Staff Quality Management Jeannette Skinner, RN, MBA, FACHE -VP, Palomar Medical Center Committee for Palomar Medical Center Poway Poway and Palomar Medical Center Downtown Escondido Karen Buckley, CNO, Palomar Medical Center Escondido Sheila Brown, RN, MBA, FACHE – VP, Continuum Care Larry LaBossiere, MBA, MSN, RN, CNS, CEN, Palomar Medical Center Poway Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient Safety Committee Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Co-Chair of Patient Safety Committee NOTE: If you have a disability, please notify us by calling 760-740-6353, 72 hours prior to the event so that we may provide reasonable accommodations Asterisks indicate anticipated action. Action is not limited to those designated items. 1 5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in meeting room. 2 Page 2 Attendance Roster and Meeting Minutes Board Quality Review Committee Meeting Monday, April 17, 2017 TO: Board Quality Review Committee MEETING DATE: Monday, April 17, 2017 FROM: LouAnn Quibuyen, Executive Assistant Background: The minutes of the Board Quality Review Committee Open Session meeting, held on Monday, March 20, 2017, are respectfully submitted for approval. Also included is the attendance roster for the Committee’s review. Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum A – 03.20.17_Open Session Meeting Minutes/Attendance Roster 3 Attendance Roster and Meeting Minutes Board Quality Review Committee Meeting Monday, April 17, 2017 TO: Board Quality Review Committee MEETING DATE: Monday, April 17, 2017 FROM: LouAnn Quibuyen, Executive Assistant Background: The minutes of the Board Quality Review Committee Closed Session meeting, held on Monday, March 20, 2017, are respectfully submitted for approval. Also included is the attendance roster for the Committee’s review. Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum B – 03.20.17_Closed Session Meeting Minutes/Attendance Roster 4 Board Quality Review Committee Monday, April 17, 2017 2016 Infection Prevention and Control Annual Review and Assessment Report TO: Board Quality Review Committee MEETING DATE: Monday, April 17, 2017 FROM: Valerie Martinez, District Director, Quality / Patient Safety and Infection Control and Prevention Background: Valerie Martinez, District Director, Quality / Patient Safety and Infection Prevention & Control will present the 2016 Infection Prevention and Control Annual Review and Assessment Report. Budget Impact: N/A Staff Recommendation: For information only Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum C - 2017 Infection Control and Prevention Annual Report 5 Board Quality Review Committee Monday, April 17, 2017 2017 Infection Prevention and Control Risk Assessment and Plan TO: Board Quality Review Committee MEETING DATE: Monday, April 17, 2017 FROM: Valerie Martinez, District Director, Quality / Patient Safety and Infection Control and Prevention Background: Valerie Martinez, District Director, Quality / Patient Safety and Infection Prevention & Control will present the 2017 Annual Infection Prevention and Control Risk Assessment and Plan for approval. Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum C - 2017 Infection Control and Prevention Annual Report 6 ADDENDUM A 7 Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, MARCH 20, 2017 AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY CALL TO ORDER The meeting – held in the iExplore Conference Room of the Palomar Health Learning & Development Center, 418 E. Grand Avenue, Escondido, CA – was called to order at 6:01 p.m. by Committee Chair Joy Gorzeman ESTABLISHMENT OF QUORUM Quorum comprised of Board Directors: Gorzeman, Sison, Czerwonka, and both physician Chairs of Medical Staff Quality Management Committees, Dr. Sabiha Pasha, Palomar Medical Center Escondido and Dr. Edward Gurrola, Palomar Medical Center Poway Excused Board Absences: None NOTICE OF MEETING Notice of Meeting was posted at Palomar Health Administrative Office; also posted with full agenda packet on the Palomar Health website on Wednesday, March 15, 2017 which is consistent with legal requirements. A revised agenda packet was posted on the Palomar Health website on Monday, March 20, 2017. PUBLIC COMMENTS There were no public comments. *INFORMATION ITEMS Tina Pope, Manager, Service Excellence introduced the Patient Family Advisory Council (PFAC) members Estelle Wolf, Chair, PFAC and Jim Lyon, Immediate Past Chair, PFAC. The backgrounds of both members were shared with the committee. Estelle Wolf reported she has lived in Rancho Bernardo for 20 years, is a Registered Nurse, retired in 2010 and is a former patient Palomar Health. Estelle joined the Patient Family Advisory Council last year. She also has an active role in San Diego County as the immediate past chair of the Aging and Independence Advisory Council. Jim Lyon worked in city government in the areas of development and planning. He is retired and a former patient of Palomar Health. Director Gorzeman welcomed the new Patient Family Advisory Council members to the Board Quality Review Committee. The Committee recognizes the value of the key stakeholders, i.e., the patient and the family. Dr. Jerry Kolins announced that LouAnn Quibuyen has accepted the position of Executive Assistant for the Patient Experience Division. 1. *Minutes: Board Quality Review Committee Meeting – Monday, March 23, 2017 No discussion MOTION: by Director Czerwonka, N/A Y second by Board Member Edward Gurrola MD and
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