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 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 - 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? RESPONSIBLE PARTY

2. Quality and Safety Dashboards

Valerie Martinez, Director, Quality, Patient Safety and Infection Control shared the Core None None Y Compliance and Benchmark reports for Palomar Medical Center and Pomerado Hospital. The reports cover the period of CY15 Q2 through CY16 Q1 (Attachment #3).

3. Journal Club

There was no Journal Club article for July. None None Y

NEW BUSINESS

1. Continuum Care Annual Report

Sheila Brown, FACHE, Vice President, Continuum Care presented the performance None None Y improvement activities and key accomplishments of the Continuum Care division over the last 12 months (Attachment #4). Sheila also provided the Committee with an article written by Anna Gorman of Kaiser Health News regarding gaps in care during transition from hospital to home (Attachment #5).

PUBLIC COMMENTS

There were no public comments

FINAL ADJOURNMENT Meeting adjourned by Director Wickes at 7:18 p.m.

COMMITTEE CHAIR Aeron Wickes, MD

SIGNATURES:

COMMITTEE SECRETARY Christine Breese

07.18.16 - MINUTES - BQRC Meeting.doc 2 10 Board Quality Review Committee Meeting

OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2016

Palomar Health Meeting Dates: By-Laws’ 1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16 Voting Members Membership DIRECTOR AERON WICKES , MD – CHAIR Board Member P P P P P E P DIRECTOR LINDA GREER, RN Board Member P P P P P P P DIRECTOR DARA CZERWONKA Board Member P P P E P P P DIRECTOR HANS SISON (ALT) Board Member P ------QMC Chair, FRANK MARTIN, MD P P -- P ------Palomar Medical Ctr Interim QMC Chair, RICHARD ENGEL, MD -- -- P P P P -- Palomar Medical Ctr QMC Chair, CHARLES CALLERY, MD P P P P P P P Pomerado Hospital Non-Voting Members BEIRNE, FRANK EVP, Operations P P P P P P E BROWN, SHEILA, RN, FACHE VP, Continuum Care -- -- P P P P P CONRAD, ALAN, MD EVP,Physician Alignment P P P -- -- P P Interim CNO, PHDC & GOWER, JUNE, PH.D. ------Pomerado Hospitals HEMKER, BOB President & CEO P P P E P E E KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient P P P P P P P Safety Committee Interim VP/CNO LABOSSIERE, LARRY ------P P P Pomerado Hospitals Co-Chair, Patient Safety MARTINEZ, VALERIE, RN, BSN, MHA, CIC P P P P P P P Committee Interim VP, PHDC & OLSON, CHERYL P P P P ------Pomerado Hospitals SHAW, DELLA EVP, Strategy P P P P -- CNO & Interim VP, SUDAK, MARIA, MSN, CCRN, NEA-BC, RN P P P P P P P Palomar Medical Center Guests ADELMAN, MARCY, RN P ANDREWS, SHELLY, RN P BARNES, DEBBIE, RN, CDS FARROW, DAN P GOELITZ, BRIAN, MD P GRIFFITH, JEFF (BOARD MEMBER) P HANSEN, DIANE P KAUFMAN, JERRY (BOARD MEMBER) KIM, JESSICA P P P P LEE, DAVID, MD P P P P P P E LEE, JEREMY P P MCCUNE, RAY (BOARD MEMBER) NAMENYI, JASMINA P Page11 1 of 2 Meeting Dates: 1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16 Guests (continued) NEUSTEIN, PAUL, MD P NICPON, GREGORY, MD P PHILLIPS, DONITA, MBA, ARM P P P P P P P POPE, TINA P P P P P P P RIEHL, RUSSELL P ROLIN, DONNA P ROSENBURG, JEFFREY P E E E E SCHULTZ, DIANA P SOLOMON, LESLIE P TERRELL, CEDRIC P P TURNER, BRENDA P P P WATSON, RAE ANNE P P WIESE, LISHA P

Page12 2 of 2 Patient Experience Division ACRONYM GLOSSARY Updated: 08/01/2016

AAPL: Academy of Applied Physician Leadership AAR: After Action Report ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor 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 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 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 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 CMS: Centers for Medicare & Medicaid Services COP: Conditions of Participation COPD: Chronic Obstructive Pulmonary Disease CPOE: Computerized Physician (Provider) Order Entry

To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 1 of 5 13 Patient Experience Division ACRONYM GLOSSARY Updated: 08/01/2016

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 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 FACPM: Fellow of the American College of Preventive Medicine FANS: Food and 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 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

To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 2 of 5 14 Patient Experience Division ACRONYM GLOSSARY Updated: 08/01/2016

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 MPH: Master of Public Health MRI: Magnetic Resonance Imaging MRSA: Methicillin-resistant Staphylococcus aureus 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 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 PCEA: Patient Controlled Epidural Analgesia PCM: Perinatal Care Measure PDCA: Plan Do Check Act PH: Palomar Health

To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 3 of 5 15 Patient Experience Division ACRONYM GLOSSARY Updated: 08/01/2016

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 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 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

To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 4 of 5 16 Patient Experience Division ACRONYM GLOSSARY Updated: 08/01/2016

VBAC: Vaginal Birth After Caesarian Section VBP: Value Based Purchasing VRE: Vancomycin-resistant enterococcus VTE: Venous Thrombo-embolism WHO: World Health Organization

To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 5 of 5 17

ADDENDUM B

18 Opinion

VIEWPOINT Workplace Violence in Health Care A Critical Issue With a Promising Solution

Ron Wyatt, MD, MHA, Workplace safety is a critical issue in health care. The mate partner violence; and homicide. In addition to DMS (HON) National Institute for Occupational Safety and Health de- emergency departments, workplace violence most Office of Quality finesworkplaceviolenceas“violentacts(includingphysi- frequently occurs in behavioral health settings, and Patient Safety, cal assaults and threats of assaults) directed towards per- extended-care facilities, and inpatient units.6 Female The Joint Commission, 1 Oakbrook Terrace, sons at work or on duty.” This Viewpoint discusses the nursing staff and psychiatric assistants most fre- Illinois. scope and characteristics of workplace violence in health quently experience assaults.5 Approximately 60% of care settings, relevant government regulations, the re- reported threats and assaults occur between noon Kim Anderson-Drevs, sponsibility of health care leaders in addressing work- and midnight.5 PhD, RN place violence, a model program for violence preven- Office of Quality and Patient Safety, tion in health care settings, and a comprehensive Government Regulations Addressing Health Care The Joint Commission, environmental risk analysis. Workplace Violence Oakbrook Terrace, The Occupational Safety and Health Act of 1970, 26 Illinois. Extent and Characteristics of Workplace Violence states, and 2 US territories now require elements of com-

Lynn M. Van Male, PhD in Health Care prehensive health care violence prevention programs. Workplace Violence Approximately 24 000 workplace assaults occurred in A 2016 Government Accountability Office report Prevention Program, health care settings between 2010 and 2013, resulting made recommendations for how violence prevention in Veterans Health in major and minor physical injury, psychological harm, health care settings is addressed in the United States.7 Administration, Oregon Health and Science temporary or permanent physical disability, and The office recommended that the Occupational Safety University, Portland. death.2 The Joint Commission analyzed 33 homicides, and Health Administration develop, implement, and en- force standards addressing the unique attributes of violence prevention in Workplace violence prevention health care workplaces, including penal- should be addressed aggressively izing employers for exposing employ- ees to potential workplace violence. and comprehensively in health care. A specific example is exposing employ- ees to the hazard of violent behavior 38 assaults, and 74 rapes in health care workplaces from and being physically assaulted by patients with 2013 to 2015. Health care workers identified in these known histories of violence or the identified potential events included 10 nurses, 2 physicians, 3 security em- for violence. ployees, and 7 other health care workers.3 These senti- nel events resulted in death, permanent harm, or se- Leadership Responsibility vere temporary harm. The most common root causes of Leadership commitment is manifested by establishing these events were failures in communication, inad- a violence prevention program, encouraging reporting equate patient observation, lack of or noncompliance of violent and behavioral safety events, reassuring em- with policies addressing workplace violence preven- ployees that appropriate actions will be taken, engag- tion, and lack of or inadequate behavioral health assess- ing personnel and patients in safety plans, and measur- menttoidentifyaggressivetendenciesinpatients.3 Com- ing performance of violence prevention programs. prehensive behavioral health assessments may be able Although zero-tolerance policies for workplace vio- to identify biopsychosocial factors known to increase the lence have been suggested, such language may create risk of violent behavior. barriers to program success by inhibiting reporting of In US hospitals, there has been an increase in vio- safety issues and concerns. Rather, leaders have a duty lent crime, from 2.0 events per 100 beds in 2012 to 2.8 to their employees to institute programs and ensure ad- events per 100 beds in 2015.3 A disproportionate num- herence to policies requiring all reported events be taken ber of aggravated assaults (44%) and other assaults seriously, assessed appropriately, and managed indi- Corresponding (46%) occurred in emergency departments compared vidually and ethically. Author: Ron Wyatt, with the entire hospital.4 Bureau of Labor statistics data MD, MHA, DMS (HON), document that while less than 20% of workplace inju- Health Care Violence Prevention Program: Office of Quality and Patient Safety, ries involve health care workers, 50% of workplace- Model and Process The Joint Commission, related assaults involve health care workers. In 2013, 27 Workplace violence prevention should be part of new- One Renaissance Blvd, of 100 health care worker or patient fatalities in health employee training and ongoing training of existing Oakbrook Terrace, IL care settings were attributable to assaults and violence.2 employees. Programs aimed at prevention of work- 60181 (rwyatt @jointcommission Workplace violence in health care includes verbal, place violence should include employee training and .org). sexual, and physical assaults; threats; stalking; inti- awareness, reporting, threat assessment, management

jama.com (Reprinted) JAMA Published online July 18, 2016 E1 Copyright 2016 American Medical Association. All rights reserved. 19 Downloaded From: http://jama.jamanetwork.com/ by a Palomar Health User on 07/18/2016 Opinion Viewpoint

plans, and a communication strategy. All employees should have Informing employees of the management plan should enable training relevant to the risk for violence that may exist in their theongoingcycleofeffectiveviolencepreventionprogramming:em- respective workplaces. ployees are educated and trained regarding the management plan Reporting is an essential element of a successful workplace vio- and have the skills necessary to implement it; they report the out- lence prevention program. Without efficient and fully utilized event come of implementing the plan; information regarding the manage- reporting systems, employees have a limited ability to communi- ment plan’s effectiveness is assessed (or reassessed) and modified cate their safety and risk issues to leadership. Reporting helps lead- according to risk; and such modifications are then communicated ershipdeveloprelevantviolencepreventionprograms.However, per- back to employees. sonnel underreport violent events because they believe these experiences are part of the job, reporting is either cumbersome or Environmental Analysis and Interventions unlikely to result in action from leadership, or they fear retaliation Organizations should assess risk factors for violence in the internal for reporting.6 For these reasons, reporting systems should be environment and the surrounding community. Internal environ- simple, trusted, secure, and with optional anonymity; result in trans- mental assessment focuses on dynamic factors (eg, staffing levels, parent outcomes and delivery of a report confirmation; and be fully census,weather,andtraffic)andstaticfactors(eg,floorplans,alarms, supported by leadership, labor unions, and management. surveillance equipment, entry points, and reception areas). The sur- Every report of alleged workplace violence should be assessed rounding community should be assessed by examining the type and and managed individually, using evidence-based, data-driven as- severity of crime and violence, including the frequency with which sessment of violence risk and management best practices, and in- the health care organization provides care for victims of violence. volve a multidisciplinary team trained in the fundamentals of vio- Physical security measures should align with known risks of com- lence risk and threat management. Multidisciplinary threat munity-based violence migrating into the health care setting. Re- assessment teams usually operate under the authority of a facili- current comprehensive environmental risk analysis identifies emerg- ty’s chief medical officer and are chaired by senior clinicians trained ing vulnerabilities, allowing for relevant employee training, proactive in threat assessment practice (most commonly, behavioral science modification of existing processes, and the development of new risk professionals). Teammembers should include representatives from management measures. the behavioral sciences, security/law enforcement, labor union(s), known high-risk workplaces, employee education (eg, trainers), pa- Conclusions tient advocates, and legal counsel. Workplace violence prevention should be addressed aggressively If the reported behavior is determined by the multidisciplinary and comprehensively in health care. Safety in health care work- threat assessment team to pose an ongoing safety or security risk, places relies on leadership enacting appropriate policies; trained then a treatment and safety management plan should be devel- employees intervening and reporting; multidisciplinary teams using oped and implemented to reduce the likelihood of safety risk expo- evidence-based threat assessment and management practices, sure. Such plans augment relevant protective factors and reduce communicating safety plans, and analyzing the environmental con- identified risk factors. Management plans may include noninvasive text; and ongoing evaluation of program effectiveness. A work- interventions (eg, conversation with the individual or individuals; place violence prevention program should be a required compo- written letters expressing behavioral expectations) to more restric- nent of the patient safety system of all health care organizations. tive approaches (eg, limiting the time, place, or manner in which safe Comprehensive patient safety systems can effectively manage a and effective health care may be delivered). The safety manage- broad range of worker safety risks in health care, including work- ment plan should not permanently bar an individual from care. place violence.

ARTICLE INFORMATION Violence for Healthcare and Social Services violence (type II) on hospital workers: a review of Published Online: July 18, 2016. Workers. OSHA 3148-04R 2015. OSHA website. the literature and existing occupational injury data. doi:10.1001/jama.2016.10384. https://www.osha.gov/Publications/osha3148.pdf. J Safety Res. 2013;44:57-64. 2015. Accessed June 20, 2016. Conflict of Interest Disclosures: All authors have 6. Speroni KG, Fitch T, Dawson E, Dugan L, completed and submitted the ICMJE Form for 3. The Joint Commission. Sentinel Event Data. Atherton M. Incidence and cost of nurse workplace Disclosure of Potential Conflicts of Interest and Oakbrook Terrace, IL: The Joint Commission; 2016. violence perpetrated by hospital patients or patient none were reported. 4. International Association of Healthcare Safety visitors. J Emerg Nurs. 2014;40(3):218-228. and Security Foundation. 2016 Healthcare Crime 7. US General Accountability Office (GAO). REFERENCES Survey. http://c.ymcdn.com/sites/www.iahss.org Workplace Safety and Health: Additional Efforts 1. Centers for Disease Control and Prevention /resource/collection/48907176-3B11-4B24 Needed to Help Protect Healthcare Workers From (CDC)/National Institute for Occupational Safety -A7C0-FF756143C7DE/2016CrimeSurvey.pdf. Workplace Violence (GAO-16-11). http://www.gao and Health. Violence: Occupational Hazards in Accessed June 15, 2016. .gov/assets/680/675858.pdf. 2016. Accessed Hospitals. CDC website. http://www.cdc.gov/niosh 5. Pompeii L, Dement J, Schoenfisch A, et al. March 18, 2016. /docs/2002-101/. 2002. Accessed July 6, 2016. Perpetrator, worker and workplace characteristics 2. Occupational Safety and Health Administration associated with patient and visitor perpetrated (OSHA). Guidelines for Preventing Workplace

E2 JAMA Published online July 18, 2016 (Reprinted) jama.com Copyright 2016 American Medical Association. All rights reserved. 20 Downloaded From: http://jama.jamanetwork.com/ by a Palomar Health User on 07/18/2016

ADDENDUM C

21 22 23 24 25

Jerry Kolins, MD, Vice President, Patient Experience Tina Pope, Manager, Service Excellence Jerry Rybak, Program Assistant/Data Specialist, Service Excellence

26 HCAHPS Rate Hospital 0-10 Patients Discharged Between October 2014 and September 2015 *Results Updated July 27, 2016 100%

90%

80% 72% 72% 70%

60% 68% 68%

50%

40% 83%

79% 76% 76% 72% 71% 70% 69%

30% 67% 61%

Top Box Percentage/Number Stars of Percentage/Number Box Top 20% 5 10% 4 4 4 3 3 3 3 3 2

0% Sharp Scripps Palomar Scripps UCSD Scripps Pomerado Kaiser Scripps Tri-City Memorial Green Medical Memorial Medical Memorial Hospital Foundation Mercy Medical Hospital Hospital Center/ Hospital - Center Hospital - Hospital - Hospital Center PHDC La Jolla Encinitas San Diego Facility

Top Box Percentage Star Rating CA Average NATL Average 27 Displayed by Discharged Date *Next Update October 2016 HCAHPS Communication with Doctors Patients Discharged Between October 2014 and September 2015 *Results Updated July 27, 2016 100%

90% 82% 82% 80%

70% 78% 78%

60%

50%

40% 87% 82% 82% 81% 81% 81% 79% 79% 78% 77% 30%

Top Box Percentage/Number Stars of Percentage/Number Box Top 20% 5 10% 3 3 3 3 3 3 3 3 2

0% Scripps Pomerado UCSD Kaiser Scripps Sharp Palomar Scripps Scripps Tri-City Green Hospital Medical Foundation Memorial Memorial Medical Mercy Memorial Medical Hospital Center Hospital - Hospital - Hospital Center/ Hospital Hospital - Center San Diego La Jolla PHDC Encinitas Facility

Top Box Percentage Star Rating CA Average NATL Average 28 Displayed by Discharged Date *Next Update October 2016 HCAHPS Communication with Nurses Patients Discharged Between October 2014 and September 2015 *Results Updated July 27, 2016 100%

90% 80% 80% 80%

70% 75% 75% 60%

50%

40% 82% 82% 80% 79% 78% 77% 76% 76% 76% 75% 30%

Top Box Percentage/Number Stars of Percentage/Number Box Top 20%

10% 4 4 4 3 3 3 3 3 3 3

0% Scripps Sharp Scripps UCSD Pomerado Palomar Kaiser Scripps Scripps Tri-City Green Memorial Memorial Medical Hospital Medical Foundation Memorial Mercy Medical Hospital Hospital Hospital - Center Center/ Hospital - Hospital - Hospital Center La Jolla PHDC San Diego Encinitas Facility

Top Box Percentage Star Rating CA Average NATL Average 29 Displayed by Discharged Date *Next Update October 2016 Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Rate Hospital 0-10: Palomar Medical Center

100 91 92 89 87 88 90 84 85 78% 80 84% 82% 81% 82% 80% 82% 81% 70 76 60

50

40

30

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

10

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

HCAHPS Top Box Percentage National Percentile Ranking 30 Displayed by Received Date Overall Quarterly Inpatient HCAHPS Top Box Percentage & National Percentile Ranking Trend - Rate Hospital 0-10: Pomerado Hospital

100

90

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

50 56 40

30 39 35 38 20 Top Box Percentage/Percentile Ranking Percentage/Percentile Box Top 25 26 10 17 19 0 7/1/14- 10/1/14- 1/1/15- 4/1/15- 7/1/15- 10/1/15- 1/1/16- 4/1/16- 9/30/14 12/31/14 3/31/15 6/30/15 9/30/15 12/31/15 3/31/16 6/30/16 n=296 n=224 n=290 n=290 n=283 n=250 n=317 n=277 Quarter

HCAHPS Top Box Percentage National Percentile Ranking 31 Displayed by Received Date POM MED/SURG/TELE ‐ Communication with Nurses HCAHPS Actual Percentile Ranking & FY2016 Target Percentile Ranking *Official Monthly Results by Discharge Date 110

100 96 90 90 87 90 80 80

70 57 60 Ranking

50 51

Percentile 40 26 30 30

20 17 5 10 1 15 3 0 7/1/15‐ 8/1/15‐ 9/1/15‐ 10/1/15‐ 11/1/15‐ 12/1/15‐ 1/1/16‐ 2/1/16‐ 3/1/16‐ 4/1/16‐ 5/1/16‐ 6/1/16‐ 7/31/15 8/31/15 9/30/15 10/31/15 11/30/15 12/31/15 1/31/16 2/29/16 3/31/16 4/30/16 5/31/16 6/30/16 n=69 n=49 n=48 n=72 n=60 n=68 n=55 n=55 n=63 n=39 n=49 n=24 Month

Actual Percentile Ranking Target Percentile Ranking

Palomar Health Service Excellence Department/(760) 740-6357 17 of 18 32 POM MED/SURG/TELE ‐ Communication with Doctors HCAHPS Actual Percentile Ranking & FY2016 Target Percentile Ranking *Official Monthly Results by Discharge Date 110

100 90 90 90

80 78 83 70 70 60 54 Ranking

50 51 Percentile 40 48 41 30

20 26 26 23 10 18 4 0 7/1/15‐ 8/1/15‐ 9/1/15‐ 10/1/15‐ 11/1/15‐ 12/1/15‐ 1/1/16‐ 2/1/16‐ 3/1/16‐ 4/1/16‐ 5/1/16‐ 6/1/16‐ 7/31/15 8/31/15 9/30/15 10/31/15 11/30/15 12/31/15 1/31/16 2/29/16 3/31/16 4/30/16 5/31/16 6/30/16 n=69 n=49 n=48 n=72 n=60 n=68 n=55 n=55 n=63 n=39 n=49 n=24 Month

Actual Percentile Ranking Target Percentile Ranking

Palomar Health Service Excellence Department/(760) 740-6357 17 of 18 33 POM MED/SURG/TELE ‐ Rate Hospital 0‐10 HCAHPS Actual Percentile Ranking & FY2016 Target Percentile Ranking *Official Monthly Results by Discharge Date 110

100 90 90 90

80 65 70 61 57 60 55 Ranking

50 41

Percentile 40 31 30 33 19 24 20 16 9 10 19

0 7/1/15‐ 8/1/15‐ 9/1/15‐ 10/1/15‐ 11/1/15‐ 12/1/15‐ 1/1/16‐ 2/1/16‐ 3/1/16‐ 4/1/16‐ 5/1/16‐ 6/1/16‐ 7/31/15 8/31/15 9/30/15 10/31/15 11/30/15 12/31/15 1/31/16 2/29/16 3/31/16 4/30/16 5/31/16 6/30/16 n=68 n=49 n=45 n=71 n=60 n=68 n=55 n=54 n=63 n=38 n=49 n=24 Month

Actual Percentile Ranking Target Percentile Ranking

Palomar Health Service Excellence Department/(760) 740-6357 17 of 18 34 Total Number of Communications to Palomar Health from 89 Patients (June 2016)

41.5% Complaints/Grievances Compliments - 58.5% (n=55) Complaints/Grievances - 41.5% (n=39) 58.5% Compliments

35 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

36 Total Number of Compliments by Unit to Palomar Health from 55 Patients (June 2016) 1.8% 1.8% PMC 9 East 1.8% 1.8% SMACC Wound Care 1.8% POM POP Wound Care 1.8% Imaging PMC 6 West PMC 8 East 1.8% PMC 4 NW PMC Lab - 30.9% (n=17) 3.6% POM M/S/T (3rd PMC 7 East - 20.0% (n=11) Floor) PMC ED - 12.7% (n=7) 3.6% 30.9% PMC Lab PMC 5 East - 5.5% (n=3) POM ICU PMC 4 East - 3.6% (n=2) 3.6% PMC 7 West - 3.6% (n=2) PMC Surgery PMC Surgery - 3.6% (n=2) 3.6% POM ICU - 3.6% (n=2) PMC 7 West POM Med/Surg/Tele (3rd Floor) - 3.6% (n=2) PMC 4 NW - 1.8% (n=1) 3.6% PMC 6 West - 1.8% (n=1) PMC 4 East 5.5% PMC 8 East - 1.8% (n=1) PMC 5 East PMC 9 East - 1.8% (n=1) POM Imaging - 1.8% (n=1) 20.0% POP Wound Care - 1.8% (n=1) PMC 7 East 12.7% SMACC Wound Care - 1.8% (n=1) PMC ED

37 Total Number of Complaints/Grievances by Unit to Palomar Health from 39 Patients 2.6% (June 2016) POM M/S/T 2.6% (3rd Floor) 2.6% 2.6% POM POM M/S/T (4th POP Wound Care Floor) Surgery 2.6% 2.6% PMC 6 West PMC 7 East PMC ED - 35.9% (n=14) 2.6% POM ED - 23.1% (n=9) PMC 5W ICU PMC 8 East - 7.7% (n=3) 2.6% 35.9% PMC 4 East PMC ED PMC Imaging - 5.1% (n=2) 2.6% PMC Surgery - 5.1% (n=2) PHDC PHDC BHU - 2.6% (n=1) BHU PMC 4 East - 2.6% (n=1) 5.1% PMC Surgery PMC 5W ICU - 2.6% (n=1) PMC 6 West - 2.6% (n=1) 5.1% PMC 7 East - 2.6% (n=1) PMC Imaging POM Med/Surg/Tele (3rd Floor) - 2.6% (n=1) POM Med/Surg/Tele (4th Floor) - 2.6% (n=1) 7.7% POM Surgery - 2.6% (n=1) PMC 8 East POP Wound Care - 2.6% (n=1)

23.1% POM ED

38 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 39

ADDENDUM D

40 CMS Star Ratings Report 7/28/2016

CMS Star Leapfrog Grade Hospital Rating (Spring 2016) (July 2016) Kaiser Foundation Hospital – San Diego A 3 Scripps Memorial Hospital – La Jolla A 5 Tri-City Medical Center A 2 UC San Diego Medical Center* A 3 Scripps Memorial Hospital - Encinitas B 4 Scripps Mercy Hospital B 3 Scripps Green Hospital B 5 Sharp Grossmont Hospital B 3 Alvarado Hospital C 4 Palomar Medical Center C 3 Paradise Valley Hospital C 4 Pomerado Hospital C 3 Sharp Chula Vista Medical Center C 4 Sharp Memorial Hospital C 4

* includes campuses in Hillcrest and La Jolla

41 Cliff Notes Summary of the Medicare Star Rating Program

After a three-month delay and negative chatter from many stakeholder groups, CMS released its Overall Hospital Quality Star Rating program in full Wednesday on its Hospital Compare website.

Here are 12 things to know about the program, its methodology, the pushback against it and how stakeholders are responding.

1. In a post on CMS' blog, Kate Goodrich, MD, director of the Center for Clinical Standards and Quality, wrote that the agency released the overall ratings "to help millions of patients and their families learn about the quality of hospitals, compare facilities in their area side-by-side, and ask important questions about care quality when visiting a hospital or other healthcare provider."

2. The Overall Hospital Quality Star Rating combines 64 measures that are already public on Hospital Compare into one star rating. The measures fall into seven groups: mortality, safety of care, readmission, patient experience, effectiveness of care, timeliness of care and efficient use of medical imaging.

3. Because the quality measures used for the overall rating reflect routine care and hospital- acquired infections, specialized care provided by certain hospitals is not reflected in the ratings.

4. A hospital's rating is only calculated using as many measures for which data is available. That means hospitals' star ratings could be based on as few as nine measures or as many as 64; the average is roughly 40.

5. CMS assigns weights to the group scores (mortality, safety, readmission and patient experience are each weighted 22 percent, and effectiveness of care, timeliness of care and efficient use of medical imaging each get 4 percent) and then assigns a summary score. If a hospital is missing data in a group, the agency redistributes the weights among the other categories. Then, CMS calculates an overall rating using the summary score.

6. If a hospital doesn't have data for three measures within at least three of the seven measure groups, including one outcome group (meaning mortality, safety or readmission), the hospital doesn't get a score. Currently, 937 hospitals do not have an overall star rating.

7. CMS developed the program's methodology with input from a technical expert panel and then refined it after public input, according to the agency, and CMS plans to "consider public feedback to make enhancements to the scoring methodology as needed."

8. Star ratings will be updated each quarter. Currently, 102 hospitals have five stars, 934 have four stars, 1,770 have three stars, 723 have two stars and 133 have one star.

9. The July 27 release date is roughly three months after the planned release date on April 21. CMS delayed launchingthe program because of pushback it received from stakeholders and members of Congress, who argued that because the methodology is not risk-adjusted and doesn't account for socioeconomic factors, it puts certain hospitals, like academic medical centers and safety-net hospitals, at a disadvantage.

Page 1 of 2 42 Cliff Notes Summary of the Medicare Star Rating Program

10. Per Dr. Goodrich's blog post, CMS "paused to give hospitals additional time to better understand our methodology and data" and has "conducted significant outreach and education to hospitals to understand their concerns and directly answered their questions" in the three months between the delay and the release of the program. This included hosting two national calls with more than 4,000 hospital representatives and holding meetings with hospital associations to explain data and answer questions.

11. Even with the three-month delay and tweaks to the methodology, stakeholders are still not pleased with the program. Rick Pollack, president and CEO of the American Hospital Association, called the ratings "confusing" in a statement Wednesday and said the AHA is "especially troubled that the current ratings scheme unfairly penalizes teaching hospitals and those serving higher numbers of the poor."

Similarly, Chip Kahn, president and CEO of the Federation of American Hospitals, released a statement Wednesday saying "the new hospital star ratings fall short and are not ready for prime time," and said there were "many important defects" in the methodology because it doesn't "recognize the often significant differences between large and small hospitals, teaching and nonteaching, and those hospitals providing care in underprivileged areas."

Bruce Siegel, MD, president and CEO of America's Essential Hospitals, also said AEH is "disappointed" in CMS for releasing the ratings "when so many questions remain about the data behind the ratings and their value to consumers."

12. Despite being disappointed with CMS for releasing the overall ratings right now, most stakeholder groups still back the overall goal of the program — to be more transparent and allow stakeholders to make informed decisions.

"FAH will continue to work with policy makers and our health care partners to ensure this process is transparent and to fix the technical flaws in the star rating process so that it ultimately yields value-added information for patients as well as hospitals," Mr. Kahn said.

Mr. Pollack from AHA said, "We want to work with CMS and the Congress to fix the hospital star ratings so that it is helpful and useful to both patients and the hospitals that treat them."

And finally, Dr. Siegel from AEH said, "Consumers deserve accurate, comprehensive and relevant information to make healthcare decisions. Hospitals Deserve to be on a level playing field. The star ratings accomplish neither. We urge CMS to work with hospitals and independent experts to revise the star ratings to correct shortcomings in its methodology and to immediately share all its data, so hospitals can confirm the agency's calculations."

Page 2 of 2 43

House Introduces Bill to Delay CMS Hospital Star Ratings By Vera Gruessner on July 28, 2016

The Hospital Quality Rating Transparency Act of 2016 was introduced in the House to postpone release of the CMS hospital star ratings system. The Centers for Medicare & Medicaid Services (CMS) hospital star ratings may be postponed due to a new bill introduced on Monday, July 25 by House Representatives Jim Renacci (R-OH) and Kathleen Rice (D-NY). The reasoning for the delay is due to ensuring the hospital star ratings system is flawless and dependable, according to the American Hospital Association (AHA).

The bill is called the Hospital Quality Rating Transparency Act of 2016 and asks to push back the date for unveiling the CMS hospital star ratings system to no earlier than July 31, 2017. Additionally, the bill is calling for CMS to establish a comment period of 60 days in which the public can inform the federal agency of any issues or discrepancies with the methodology and data included in the hospital star ratings program.

Another important point that the bill includes is its requirement of having a third party confirm the methodology and data provided by CMS. Any star ratings available on the Hospital Compare website operating through CMS are asked to be taken down prior to the enactment of the Hospital Quality Rating Transparency Act of 2016.

The American Hospital Association and members of Congress have previously expressed some concerns about potential flaws in the CMS hospital star ratings system, which is why there is more pressure to postpone the deadline for releasing this particular program.

“Patients need clear, meaningful information to make important healthcare decisions,” Tom Nickels, Executive Vice President of Government Relations and Public Policy at the American Hospital Association, said in a public statement. “Yet, thus far, it is unclear whether the Centers for Medicare & Medicaid Services’ (CMS) star ratings actually provide accurate and reliable data to the public. As a result, we applaud and thank Reps. James Renacci (R-OH) and Kathleen Rice (D-NY) for introducing a bill to delay, for at least one year, the introduction of the CMS hospital star ratings.”

“Hospitals and members of Congress are in agreement: CMS can do better,” Nickels continued. “The majority of Congress – 60 members of the Senate and more than 225 members of the House – asked CMS to delay and improve upon the star ratings. Our own analysis of preliminary data continues to raise questions and concerns about the methodology, which may unfairly penalize teaching hospitals and those serving the poor.”

Originally, this past April, CMS had promised to incorporate a hospital star ratings system on the Hospital Compare website, which would have improved healthcare transparency greatly for

Page 1 of 2 44 consumers. The way this star ratings would work is by using patient surveys, readmissions and complications data, medical imaging rates, and the amount of Medicare beneficiaries served.

CMS has already delayed its unveiling of the hospital star ratings program until the end of July due to concern from the House of Representatives. This past April, a large number of representatives sent a letter to CMS to postpone the implementation of this rating system since it did not have quality benchmarks for measuring which hospitals serve patients with the most complex medical conditions.

Additionally, the representatives argued in the letter that the star ratings system was not transparent enough with the methodology it uses to compare hospitals. Five dozen US Senators also wrote a letter in which they urged the delay of the hospital star ratings system due to a lack of transparency and inadequacies regarding clinical quality measures.

“We are writing to express our concerns with the Centers for Medicare and Medicaid Services’ upcoming release of the Hospital Compare Star Ratings,” the letter stated. “While we support the public reporting of provider quality data, we are concerned that the current Star Ratings system may not accurately take into account hospitals that treat patients with low socioeconomic status or multiple complex chronic conditions.”

Despite this bill, CMS unveiled the first version of the Hospital Quality Star Rating system on the Hospital Compare website yesterday, according to a press release from the federal agency. This will allow patients and families to compare hospitals on a five-point scale side-by-side.

CMS has worked with stakeholders across the aisles to create this rating system for hospitals in order to simplify the entire process of comparing hospitals and helping patients better understand the quality of care they would receive at their respective medical facilities. A Technical Expert Panel along with public input were used to create the hospital star ratings program.

CMS also stated in the release much support from patient advocacy groups in favor of having these type of rating systems set in place for greater healthcare transparency for consumers. This is especially important if looking at the type of hospitals that have had much lower rates of hospital readmissions and mortality.

“Consumers will be able to make smarter, better informed choices about their health care thanks to the hospital star ratings tool the Centers for Medicare & Medicaid Services (CMS) released today," Debra L. Ness, President of the National Partnership for Women & Families, said in a public statement. "Publication of the hospital quality performance scores to the CMS Hospital Compare website will strengthen our country’s health care system. Millions of patients and family members can now access a tool that provides important information on how their hospitals are performing on key health quality measures. Consumers can use this trustworthy program to compare hospitals side-by- side. This is a huge step forward."

Since some of the aspects used within the star ratings system relies mostly on patient feedback, it is understandable why a number of opponents are looking to delay this hospital comparing program. Time will tell whether this bill will pass and whether CMS will be left to renovate its hospital star ratings system to alleviate the concerns from Congress.

Page 2 of 2 45 Page 17 of 19 Report Run Date: 07/22/2016 Hospital Compare Preview Report: Improving Care Through Information – Inpatient Hospital Performance Reporting Period for Healthcare Associated Infection Measures: First Quarter 2015 through Fourth Quarter 2015 Discharges 050115 - PALOMAR HEALTH DOWNTOWN CAMPUS Healthcare Associated Infection Hospital Quality Measures Your Device or Your Ratio of Reported Your State Standardized National Hospital's Patient Hospital's to Predicted Hospital's Infection Ratio, State Standardized Reported Days Predicted Infections (SIR) Performance Lower Limit, State Upper Infection Ratio Number of /Procedures Number of (Lower Limit, Upper Limit of 95% Interval Infections Infections Limit of 95% Estimate Interval Estimate) Healthcare Associated Infection Measures Better than Central Line Associated Bloodstream Infection (ICU + 0.385(0.179,0.73 8 11701 20.804 the National 0.555 (0.531, 0.580) 0.573 select Wards) 0) Benchmark Better than Central Line Associated Bloodstream Infection (ICU 0.402(0.163,0.83 6 6996 14.938 the National 0.535 (0.504, 0.567) 0.540 only) 5) Benchmark Better than Catheter Associated Urinary Tract Infections (ICU + 0.518(0.295,0.84 14 15145 27.026 the National 0.650 (0.625, 0.676) 0.580 select Wards) 9) Benchmark No Different 0.896(0.498,1.49 than Catheter Associated Urinary Tract Infections (ICU only) 13 7600 14.510 0.745 (0.708, 0.783) 0.645 4) National Benchmark No Different 1.471(0.683,2.79 than SSI-Colon Surgery 8 169 5.439 1.136 (1.066, 1.209) 1.029 3) National Benchmark No Different 0.000(--,1.752)(8 than SSI-Abdominal Hysterectomy 0 168 1.710 0.971 (0.851, 1.103) 0.884 ) National Benchmark No Different 1.559(0.682,3.08 than MRSA Bacteremia 7 103824 4.491 0.916 (0.853, 0.983) 0.962 3) National Benchmark No Different 0.948(0.730,1.21 Clostridium Difficile (C.Diff) 60 98261 63.260 than 1.084 (1.064, 1.105) 0.931 2) National

Footnote Legend 1 . The number of cases/patients is too few to report. 3 . Results are based on a shorter time period than required. 4 . Data suppressed by CMS for one or more quarters. 5 . Results are not available for this reporting period. 7 . No cases met the criteria for this measure. 8 . The lower limit of the confidence interval cannot be calculated if the number of observed infections equals zero. 12 . This measure does not apply to this hospital for this reporting period. 13 . Results cannot be calculated for this reporting period. 46 Page 17 of 18 Report Run Date: 07/22/2016 Hospital Compare Preview Report: Improving Care Through Information – Inpatient Hospital Performance Reporting Period for Healthcare Associated Infection Measures: First Quarter 2015 through Fourth Quarter 2015 Discharges 050636 - POMERADO HOSPITAL Healthcare Associated Infection Hospital Quality Measures Your Device or Your Ratio of Reported Your State Standardized National Hospital's Patient Hospital's to Predicted Hospital's Infection Ratio, State Standardized Reported Days Predicted Infections (SIR) Performance Lower Limit, State Upper Infection Ratio Number of /Procedures Number of (Lower Limit, Upper Limit of 95% Interval Infections Infections Limit of 95% Estimate Interval Estimate) Healthcare Associated Infection Measures No Different Central Line Associated Bloodstream Infection (ICU + 0.643(0.164,1.75 than 3 3509 4.665 0.555 (0.531, 0.580) 0.573 select Wards) 0) National Benchmark No Different Central Line Associated Bloodstream Infection (ICU 0.441(0.022,2.17 than 1 1510 2.266 0.535 (0.504, 0.567) 0.540 only) 6) National Benchmark Better than Catheter Associated Urinary Tract Infections (ICU + 0.107(0.005,0.52 1 6181 9.369 the National 0.650 (0.625, 0.676) 0.580 select Wards) 6) Benchmark No Different 0.442(0.022,2.18 than Catheter Associated Urinary Tract Infections (ICU only) 1 1738 2.260 0.745 (0.708, 0.783) 0.645 2) National Benchmark No Different 0.778(0.039,3.83 than SSI-Colon Surgery 1 43 1.285 1.136 (1.066, 1.209) 1.029 8) National Benchmark SSI-Abdominal Hysterectomy 2 55 0.457 N/A(13) N/A 0.971 (0.851, 1.103) 0.884

MRSA Bacteremia 0 24086 0.923 N/A(13) N/A 0.916 (0.853, 0.983) 0.962 No Different 1.495(0.927,2.29 than Clostridium Difficile (C.Diff) 19 21720 12.708 1.084 (1.064, 1.105) 0.931 2) National Benchmark

Footnote Legend 1 . The number of cases/patients is too few to report. 3 . Results are based on a shorter time period than required. 4 . Data suppressed by CMS for one or more quarters. 5 . Results are not available for this reporting period. 7 . No cases met the criteria for this measure. 8 . The lower limit of the confidence interval cannot be calculated if the number of observed infections equals zero. 12 . This measure does not apply to this hospital for this reporting period. 13 . Results cannot be calculated for this reporting period. 47 PALOMAR HEALTH Hosptial Acquired Condition (HAC) Data

PMC POM Metric Decile Decile CLABSI Jan 2014 - Dec 2015 4th 3rd Jan 2013 - Dec 2014 4th 3rd CAUTI Jan 2014 - Dec 2015 9th 8th Jan 2013 - Dec 2014 9th 10th SSI Jan 2014 - Dec 2015 8th 9th Jan 2013 - Dec 2014 9th 6th MRSA Jan 2014 - Dec 2015 8th 6th CDI Jan 2014 - Dec 2015 8th 10th

Decile definition: 1st = Best 10th = Worst

"Annual" Report covers 2 calendar years

48

ADDENDUM E

49

Quality Review Committee Report

August 15, 2016

50 QUALITY MANAGEMENT GB “ROBIN” ROWLAND, MD, MPH, FACPM

51 QUALITY DEPARTMENT

TRIPLE AIM EDUCATION DATA PHARMACY • Low Cost • Physician Staff • Physician TEAM • High Quality • Clinical Staff Dashboard INTEGRATION • Clinical • Access & • Administrative • Transition of Care CLINICAL CARE Satisfaction Staff Operations Care GUIDELINES Opportunity • Chronic Care Dashboard Management • Medication Refill

MANAGING QUALITY

Physician Orthopedic Escondido Escondido North Independent Associates of Pulmonary Cardiology County Medical North and Sleep Associates Geriatrics Group County Medicine

52 SERVICES

FFS PATIENT MANAGED CARE NEW PATIENTS TOTAL VISITS PANEL PATIENT PANEL • 68,652 • 18,661 • 33,680 • 4,620

53 PATIENT SATISFACTION

100.00% 98.00% 96.00% 94.00% 92.00% 90.00% 88.00% 86.00% 84.00% 2011 2012 2013 2014 2015 2016

Press Ganey Mean Patient Satisfaction Scores 54 CLINICAL QUALITY MANAGEMENT

Quality Improvement Committee • Workgroups • Refill Center • Hypertension • Diabetes • Patient Centered Medical Home

55 QUALITY & OPERATIONS ALIGN

Mind the Gaps Baldrige Framework Patient Centered Medical Home & Patient Centered • Care Opportunity Reports • 10 Arch Leaders Attended Specialty Practice • Putting them in the hands • Beginning our Baldrige of the clinical team Journey • Clinic Transformation • Care Coordination: Primary Care/specialty interface • Patient Engagement • Behavioral Health Integration

56 CLINICAL QUALITY DASHBOARD • Data Transparency

57 Well Managed Care Metric Arch Health Partners Target

Commercial Med-Surg 127 96 Days/1000

Senior Med-Surg Days/1000 782 826

Commercial Med-Surg 29.7 29 Admits/1000

Senior Med-Surg 184.4 200 Admits/1000

Readmission Rate 12.00% 15.06%

SCMG REPORT 2016 58 CLINIC TRANSFORMATION

KIOSKS • Implemented “express check-in” kiosks at our clinics in March, 2016. • “Self-serve” kiosks improve the patient experience by providing a “faster and easier” check-in process. • Kiosks allow patients to scan driver’s licenses and insurance cards, make co-payments and pay outstanding balances, update patient information, sign forms electronically as well as verify their insurance. • We anticipated that 50% of our patients would shift to the check-in kiosks during the transition year; however, the transition has been higher than anticipated at 70%. • Kiosks have reduced the check-in time overall for patients. The average check-in time for new patients is 2:48 and 1:07 minutes for return patients • The PSR’s are able to spend more time with patients who need additional support.

59 Medical Quality Awards

Awarding Organization Award 2011 2012 2013 2014 2015

Integrated Healthcare Association Excellence in Healthcare

Most Improved

Top Performer

California Association of Physician Exemplary Award Groups

Elite Award

60 PHARMACY: THE FOUNDATION OF OUR QUALITY MANAGEMENT JESSICA GHARBAWY, PHARMD, BCACP, CDE

61 Refill Center June 2016 Refill Prescriptions

N=3486 (39%) Refill Center N=5500 Other (61%) Total = 8986 • Increase prescriber’s direct patient care time • Quality improvement – Snapshot: 4-6 over due labs and appointments found per day • Connect patients to care they need

62 Hypertension

300 July 1: 251 Patients • CMMI Heart Attack and 250 Stroke Free Zone (HASFZ)

200

• Goal: enroll 300 patients 150 by August 31, 2016 100 Number of Patients Number of 50 • Reduce heart attacks and

0 stroke in San Diego by 50%

Month Enrollment Target

63 Diabetes

• Team based approach – Outreach – Referrals

• Pharmacy students and residents

64 65