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Palomar Pomerado Health BOARD QUALITY REVIEW COMMITTEE OPEN SESSION AGENDA MONDAY, AUGUST 15, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:30 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064 Time Form A Target PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING Page # CALL TO ORDER 6:30 Establishment of Quorum 1 N/A 6:31 Public Comments1 15 N/A 6:46 Information Item(s) 1. *Review/Approve: Minutes – Monday, June 20, 2016 (Addendum A, Page 8 -17) 4 3 6:50 Standing Item(s) 1. Journal Club Article (Addendum B, Page 18 - 20) “Workplace Violence in Health Care - A Critical Issue With a Promising Solution” in Journal of the 10 4 7:00 American Medical Association, written by Ron Wyatt, MD, MHA, DMS (HON), Kim Anderson- Drevs, PhD, RN and Lynn M. Male, PhD 2. The Patient Experience (Addendum C, Page 21 - 39) Tina Pope, Manager, Service Excellence a) Letters from Patients/Families 15 5 7:15 b) Service Excellence Quarterly Reports 3. Quality and Safety Dashboards (Addendum D, Page 40 - 48) a) CMS Star Ratings Report, Jerry Kolins, MD, Vice President, Patient Experience b) CMS Healthcare Associated Infections Report, David Lee, MD, Medical Quality Officer 15 6 7:30 c) CMS HAC (Hospital Acquired Conditions) Report, Valerie Martinez, RN, BSN, MHA, CPHQ, CIC, NEA-BC, Director, Quality, Patient Safety & Infection Control New Business 1. Arch Health Annual Report Update (Addendum E, Pages 49 - 65) GB “Robin” Rowland, MD, MPH, FACPM 20 7 7:50 Deanna Kyrimis, Executive Director, Arch Health Partners Jessica Gharbawy, PharmD Public Comments1 15 N/A 8:05 FINAL ADJOURNMENT 8:05 NOTE: The open session agenda, without public comments, is scheduled for 1 hour, 5 minutes. Based on above agenda, without public comments the meeting starts at 6:30 p.m. and adjourns at 7:35 p.m. 1 Page 1 BOARD QUALITY REVIEW COMMITTEE OPEN SESSION AGENDA MONDAY, AUGUST 15, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:30 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064 Board Quality Review Committee Members VOTING MEMBERSHIP NON-VOTING MEMBERSHIP Aeron Wickes, MD – Chairperson, Board Member Bob Hemker, FACHE, President & CEO Linda Greer, RN, Board Member Frank Beirne, FACHE, EVP, Operations Dara Czerwonka, Board Member Alan Conrad, MD, EVP, Physician Alignment Richard Engel, MD – Interim Chair of Medical Staff Quality Della Shaw – EVP, Strategy Management Committee for Palomar Medical Center Maria Sudak, RN, MSN, CCRN, NEA-BC – Vice President and Chief Charles Callery, MD - Chair of Medical Staff Quality Nursing Officer, Palomar Medical Center Management Committee for Pomerado Hospital Jeannette Skinner, RN, MBA, FACHE, Vice President, Pomerado Hospital Larry LaBossiere, RN, MSN, CEN, CNS, MBA, Interim Chief Nursing Officer, Pomerado Hospital and Director, Clinical Operations Improvement Sheila Brown, FACHE, VP, Continuum Care Jerry Kolins, MD, FACHE – VP, 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 & Infection Control 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, Minutes and Acronym Glossary Board Quality Review Committee Meeting Monday, July 18, 2016 TO: Board Quality Review Committee MEETING DATE: Monday, August 15, 2016 FROM: Christine Breese, Executive Assistant Background: The minutes of the Board Quality Review Committee meeting, held on Monday, July 18, 2016, are respectfully submitted for approval. Included are the attendance roster and Acronym Glossary for the Committee’s review (Addendum A). Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum A 3 Journal Club Article “Workplace Violence in Health Care - A Critical Issue With a Promising Solution” from Journal of the American Medical Association TO: Board Quality Review Committee MEETING DATE: Monday, August 15, 2016 FROM: Christine Breese, Executive Assistant Background: The Journal Club assignment for August 2016 is to read the article titled, “Workplace Violence in Health Care - A Critical Issue With a Promising Solution” from Journal of the American Medical Association, written by Ron Wyatt, MD, MHA, DMS (HON), Kim Anderson-Drevs, PhD, RN and Lynn M. Male, PhD (Addendum B). Budget Impact: N/A Staff Recommendation: For information only Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum B 4 The Patient Experience Board Quality Review Committee TO: Board Quality Review Committee MEETING DATE: Monday, August 15, 2016 FROM: Christine Breese, Executive Assistant Background: Included in the packet for the Committee’s review are three pieces of correspondence from staff, patients and family members regarding their experience at Palomar Health (Addendum C). Tina Pope, Manager, Service Excellence will review the Overall Quarterly Inpatient HCAHPS Top Box Percentage and National Percentile Ranking Trend – Rate Hospital 0-10 for both Palomar Medical Center and Pomerado Hospital for 4th Quarter FY2016. She will also discuss the Pomerado Hospital Med/Surg/Telemetry HCAHPS scores for the same time period on the following three domains 1) Communication with Nurses, 2) Communication with Doctors and 3) Rate Hospital 0-10 (Addendum C). Finally, Tina will share the latest pie chart reports evaluating the Compliments, Complaints and Grievances received in the month of June 2016 (Addendum C). Budget Impact: N/A Staff Recommendation: For information only Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum C 5 Quality and Safety Reports Board Quality Review Committee TO: Board Quality Review Committee MEETING DATE: Monday, August 15, 2016 FROM: Christine Breese, Executive Assistant Background: Jerry Kolins, MD, Vice President, Patient Experience, will share the CMS Star Ratings Report and a Cliff Notes Summary of the Medicare Star Rating Program. David Lee, MD, Medical Quality Officer will share the CMS Healthcare Associated Infections Report for both Palomar Medical Center and Pomerado Hospital Valerie Martinez, Director, Quality, Patient Safety and Infection Control will share the CMS Hospital Acquired Conditions (HAC) Report (Addendum D). Budget Impact: N/A Staff Recommendation: For information only Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum D 6 Arch Health Partners Annual Report to BQRC Board Quality Review Committee TO: Board Quality Review Committee MEETING DATE: Monday, August 15, 2016 FROM: Christine Breese, Executive Assistant BACKGROUND: GB “Robin” Rowland, MD, MPH, FACPM with Arch Health Partners will share the latest performance improvement activities and outcomes from Arch Health Partners (Addendum E). Budget Impact: N/A Staff Recommendation: For information only Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A - Addendum E 7 ADDENDUM A 8 BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, JULY 18, 2016 AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY CALL TO ORDER The meeting – held in Conference Room E at Pomerado Hospital, 15615 Pomerado Road, Poway, CA 92064 – was called to order at 6:00 p.m. by Committee Chair, Dr. Aeron Wickes. ESTABLISHMENT OF QUORUM Quorum comprised of Directors Wickes, Greer, Czerwonka and Chair, Quality Management Committee, Pomerado Hospital, Dr. Charles Callery Excused Absences: Interim Chair, Quality Management Committee, Palomar Medical Center, Dr. Richard Engel NOTICE OF MEETING Notice of Meeting was posted at PH’s Administrative Office; also posted with full agenda packet on the PH web site on Monday, July 11, 2016 which is consistent with legal requirements. Notice of that posting was also made via email to the Board and staff. PUBLIC COMMENTS There were no public comments. *INFORMATION ITEMS 1. *Minutes: Board Quality Review Committee Meeting – Monday, June 20, 2016 No discussion. MOTION: by Director Czerwonka, N/A Y second by Director Greer and carried to approve the June 20, 2016 Board Quality Review Committee meeting minutes. All in favor. None opposed STANDING ITEM(S) 1. The Patient Experience The Committee was given several examples of recent communications received by patients None None Y and/or patient family members (Attachment #1). The Committee watched two videos from Press Ganey’s leadership team discussing Teamwork, Patient Expectations and the Compassionate, Connected Care Model. Tina Pope, Manager, Service Excellence reviewed the quarterly results for PMC 7 East on nine HCAHPS domains (Attachment #2). Rae Anne Watson, Director, Progressive and Acute Care, read a letter from a patient about their positive experience in Ortho surgery. 07.18.16 - MINUTES - BQRC Meeting.doc 9 BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, JULY 18, 2016 AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL?
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