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Board Quality Review Committee BOARD QUALITY REVIEW COMMITTEE AGENDA MONDAY, January 15, 2018 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:00 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 5:30 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 # ROOM CALL TO ORDER 5:30 Establishment of Quorum .................................................................................................................... 1 N/A 5:31 Public Comments 1 .............................................................................................................................. 15 N/A 5:46 Approval: 1. *Review / Approval: Open/Executive Session Meeting Minutes/Attendance Roster – 5 3 5:41 December 18, 2017 (ADD A, Pages 13-22) ............................................................................... 2. *Review / Approval: Annual Review of Palomar Health Board Quality Review Committee By- 3 4 5:44 Laws Section 6.2.4 - Now listed as 6.2.6 (ADD B, Page 24) ...................................................... 3. *Review / Approval: Annual Review of Board Member Position Description from Lucidoc 3 5 5:47 Procedure #26952 – Board Responsibilities (ADD C, Pages 26-32) .......................................... 4. *Review / Approval: Annual Review of the 2018 Reporting Calendar (ADD D, Pages 34-35) .. 5 6 5:52 Information Item(s) 1. Follow-up Action Items a. Patient Rights – Informed Denial 10 7 5:57 b. Quarterly Reports (ADD E, Page 38) ...................................................................................... Standing Item(s) 1. Journal Club Assignment: Perspective: A Culture of Respect, Part 1 The Nature and Causes 5 8 6:02 of Disrespectful Behavior by Physicians (ADD F, Pages 40-55) ....................................................... 2. Hospital Acquired Conditions Reduction Program Report (ADD G, Pages 57-59) ........................... 5 9 6:07 3. Regulatory Readiness (ADD H, Page 61 – Report to be distributed at meeting) .............................. Deborah Barnes, RN and Director, Regulatory Coordination 10 10 6:17 Valerie Martinez, RN and Director, Quality, Patient Safety and Infection Prevention & Control 4. Report from Medical Executive Committees ...................................................................................... Sabiha Pasha, MD, and QMC Chair, Palomar Medical Center Escondido 5 6:22 Edward Gurrola, MD and QMC Chair, Palomar Medical Center Poway New Business 1. *Annual Report to the Board – Diabetes Health Program (ADD I, Pages 63-80) ...................... 15 11 6:37 Alan Conrad, MD, EVP Physician Alignment and Medical Director Diabetes Program Tamrah Jennings, MSEd, MSN, APRN, ACCNS-AG, CDE and Clinical Nurse Specialist-Diabetes Health Presentation – 10 minutes Questions & Answers – 5 minutes 2. *Annual Report to the Board – Stroke Program (ADD J, Pages 82-91) ...................................... 15 12 6:52 Remia Paduga, MD, Medical Director, Stroke Program Lourdes Januszewicz, MSN, APRN, ACNS-BC, SCRN, CCRN and District Stroke Program Coordinator, Clinical Nurse Specialist Presentation – 10 minutes Questions & Answers – 5 minutes 1 Page 1 BOARD QUALITY REVIEW COMMITTEE AGENDA MONDAY, January 15, 2018 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:00 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 5:30 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 ADJOURNMENT TO EXECUTIVE SESSION 1 6:53 Pursuant to Health and Safety Code Section 32155 30 7:23 - Report of Hospital Medical Audit/Quality Assurance ADJOURNMENT TO OPEN SESSION 1 7:24 Action taken, if any 1 7:25 Public Comments 1 ............................................................................................................................ 15 N/A 7:40 FINAL ADJOURNMENT 1 7:41 Note: The agenda, without public comments, is scheduled for 1 hour 41 minutes. Based on above agenda, without public comments the meeting starts at 5:30 pm and adjourns at 7:11 pm. Board Quality Review Committee Members VOTING MEMBERSHIP NON-VOTING MEMBERSHIP – Chairperson, Board Member Diane Hansen, CPA, Interim President & CEO Joy Gorzeman, RN – Chairperson, Board Member Frank Beirne, FACHE, EVP, Operations Dara Czerwonka, MSW, Board Member Alan Conrad, MD, EVP, Physician Alignment Douglas Moir, MD, 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, MHA, BSN, RN, CENP, CNO, Palomar Medical Center Escondido Sheila Brown, RN, MBA, FACHE – VP, Continuum Care Leslie Solomon, VP, Culture and Talent Planning Larry LaBossiere, MBA, MSN, RN, CNS, CEN, CNO, Palomar Medical Center Poway Jerry Kolins, MD, FACHE – VP, Patient Experience and Chair of Patient Safety Committee Valerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA-BC, Director, Quality/Patient Safety/Infection Prevention Paul Patterson, Chair, Patient Family Advisory Council Jim Lyon, Immediate Past Chair, Patient Family Advisory Council 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 Board Quality Review Committee Meeting Monday, January 15, 2018 Attendance Roster and Meeting Minutes TO: Board Quality Review Committee MEETING DATE: Monday, January 15, 2018 FROM: LouAnn Quibuyen, Executive Assistant, Patient Experience Division and BQRC Committee Assistant Background: The minutes of the Board Quality Review Committee Open / Executive Session meeting, held on Monday, December 18, 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 – 12.18.17_Open_Executive Session Meeting Minutes Attendance Roster 3 Board Quality Review Committee Meeting Monday, January 15, 2018 2018 Board Quality Review Committee Annual Review and Approval of Palomar Health Bylaws Section 6.2.6 TO: Board Quality Review Committee MEETING DATE: Monday, January 15, 2018 FROM: Background: The 2018 Board Quality Review Committee Bylaws Section 6.2.6 is respectfully submitted for annual approval. Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum B – Bylaws Section 6.2.6 4 Board Quality Review Committee Monday, January 15, 2018 2018 Board Quality Review Committee Board Member Position Description Annual Review and Approval TO: Board Quality Review Committee MEETING DATE: Monday, January 15, 2018 FROM: Background: The 2018 Board Quality Review Board Member Position Description is respectfully submitted for annual review and approval. Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum C - Board Member Position Description 5 Board Quality Review Committee Monday, January 15, 2018 2018 Board Quality Review Committee Performance Improvement Reporting Calendar - Annual Review and Approval TO: Board Quality Review Committee MEETING DATE: Monday, January 15, 2018 FROM: Jerry Kolins, MD, Vice President Patient Experience and Director, Medical Laboratories Background: Jerry Kolins, MD, VP Patient Experience and Medical Director, Laboratories will present the 2018 BQRC Performance Improvement Reporting Calendar for annual review and approval. Budget Impact: N/A Staff Recommendation: Approval Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum D – 2018 BQRC Reporting Calendar 6 Board Quality Review Committee Monday, January 15, 2018 30-Day All-Cause Unplanned Readmission Rate TO: Board Quality Review Committee MEETING DATE: Monday, January 15, 2018 FROM: Mary Scott, RN and Interim Director, Clinical Resource Management Background: Mary Scott, RN and Interim Director, Clinical Resource Management will present a report on 30-day All Cause Unplanned Readmission Rate Budget Impact: N/A Staff Recommendation: For information only Committee Questions: COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time: Form A – Addendum E– 30-Day Readmission Rate 7 Board Quality Review Committee Monday, January 15, 2018 Journal Club Article “Pespective: A Culture of Respect, Part 1 The Nature and Causes of Disrespectfuul Behavior by Physicians” authored by Lucian L. Leape, MD; Miles F, Shore, MD; Jules L. Dienstag, MD; Robert J. Mayer, MD; Susan Edgmann-Levitan, PA; Gregg S. Meyer, MD, MSc and Gerald B. Healy, MD published in the Academic Medicine: July 2012 – Volume 87 – Issue 7 – p 845-852 TO: Board Quality Review
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