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
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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.
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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 Committee
MEETING DATE: Monday, January 15, 2018
FROM: Jerry Kolins, MD, Vice President, Patient Experience and Medical Director, Laboratories
Background: The reading for the BQRC Journal Club is an article 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 on “Perspective: A Culture of Respect, Part 1 The Nature and Causes of Disrespectful Behavior by Physicians.
Budget Impact: N/A
Staff Recommendation: For information only
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum F - Journal Club Article – “ Perspective: A Culture of Respect, Part 1 8
Board Quality Review Committee Monday, January 15, 2018 Hospital Acquired Conditions Reduction Program Report
TO: Board Quality Review Committee
MEETING DATE: Monday, January 15, 2018
FROM: Jerry Kolins, MD, VP, Patient Experience and Medical Director Laboratories and Valerie Martinez, RN and Director, Quality/Patient Safety/Infection Prevention and Control/Diabetes and Stroke Programs
Background: Jerry Kolins, MD, VP, Patient Experience and Medical Director Laboratories and Valerie Martinez, RN and Director, Quality/Patient Safety/Infection Prevention and Control/Diabetes and Stroke Programs will present information on the Hospital Acquired Conditions (HAC) Reduction Program.
Budget Impact: N/A Staff Recommendation: For information only Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum G– Balanced Scorecard 9
Board Quality Review Committee Monday, January 15, 2018 Regulatory Readiness Dashboard Reports
TO: Board Quality Review Committee
MEETING DATE: Monday, January 15, 2018
FROM: Deborah Barnes, RN and Director, Regulatory Coordination and Valerie Martinez, RN and Director, Quality/Patient Safety/Infection Prevention and Control/Diabetes and Stroke Programs
Background: Deborah Barnes, RN and Director, Regulatory Coordination and Valerie Martinez, RN and Director, Quality/Patient Safety/Infection Prevention and Control/Diabetes and Stroke Programs will present a Regulatory Readiness Dashboard Reports.
Budget Impact: N/A Staff Recommendation: For information only Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum H– Regulatory Readiness 10
Board Quality Review Committee Monday, January 15, 2018 Annual Diabetes Health Program Report
TO: Board Quality Review Committee
MEETING DATE: Monday, January 15, 2018
FROM: Alan Conrad, MD, EVP Physician Alignment & Medical Director for Diabetes Health, Valerie Martinez, Director Quality, Patient Safety and Infection Prevention and Control and Tamrah Jennings, RN Diabetes Clinical Nurse Specialist
Background: Alan Conrad, MD, EVP Physician Alignment & Medical Director for Diabetes Health, Valerie Martinez, Director Quality, Patient Safety and Infection Prevention and Control and Tamrah Jennings, RN Diabetes Clinical Nurse Specialist will present the Annual Diabetes Health Program Report.
Budget Impact: N/A Staff Recommendation: For information only Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A – Addendum I – Diabetes Health 11
Board Quality Review Committee Monday, January 15, 2018 Annual Stroke Program Report
TO: Board Quality Review Committee
MEETING DATE: Monday, January 15, 2018
FROM: Rema Paduga, MD, Medical Director Stroke Program, Valerie Martinez, Director Quality, Patient Safety and Infection Prevention & Control and Lourdes Januszewicz, RN, District Stroke Program Coordinator
BACKGROUND: Rema Paduga, MD, Medical Director Stroke Program, Valerie Martinez, Director Quality, Patient Safety and Infection Prevention and Control and Lourdes Januszewicz, RN, District Stroke Program Coordinator will present the Annual Stroke Program Report.
Budget Impact: N/A Staff Recommendation: For information only
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
Form A- Addendum J – Stroke Program 12
ADDENDUM A
13
Addendum A
BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, DECEMBER 18, 2017
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY
CALL TO ORDER
The meeting - held in the Learning and Development Center, 418 Grand Avenue, Escondido, CA – was called to order at 6:00 p.m. by Director and Chair, Joy Gorzeman, RN.
ESTABLISHMENT OF QUORUM Quorum comprised of Board Directors: Joy Gorzeman, RN, Douglas Moir, M.D and the Physician Chair of the Medical Staff Quality Management Committee, Dr. Sabiha Pasha, Palomar Medical Center Escondido Excused Board Absences: Dara Czerwonka, MSW, Hans Sison, LVN, Physician Chair of the Medical Staff Quality Management Committee, Dr. Edward Gurrola, Palomar Medical Center Poway
NOTICE OF MEETING The Notice of Meeting was posted at Palomar Health Administrative Office; also posted with full agenda packet on the Palomar Health website on Wednesday, November 15, 2017 which is consistent with legal requirements.
PUBLIC COMMENT
There were no public comments.
INTRODUCTION OF NEW NON-VOTING BQRC MEMBER - PAUL PATTERSON
Tina Pope, District Manager, Service Excellence introduced Paul Patterson as the new BQRC Patient Family Advisory (PFAC) Member who will be participating in our future meetings. He is our incoming Chair of the PFAC Committee. A brief overview of his background was shared with the committee. Paul reported that he is employed by a defense contractor here in San Diego as Quality Assurance Manager. He has over 27 years of experience in the defense industry with 10 years focused in the Quality Assurance role. Paul joins Jim Lyon as our two representatives from PFAC on BQRC.
OLD BUSINESS
There were no old business items identified for discussion.
FOLLOW-UP ACTION ITEMS There were no follow-up action items identified for this meeting.
1. * REVIEW / APPROVAL: OPEN/EXECUTIVE SESSION MEETING MINUTES / ATTENDANCE ROSTER – NOVEMBER 20, 2017
The BQRC Open / Executive Session meeting minutes of November 20, 2017 were presented MOTION: by Sabiha Pasha, MD, N/A Y for review and approval. Sabiha Pasha, MD motioned for approval and was seconded by second by Director Douglas Moir, MD Director Douglas Moir, MD. There were no additional questions presented for discussion. All and carried to approve the meeting minutes of November 20, 2017 as 14 121817-MINUTES BQRC Board Meeting DRAFT - V4
Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, DECEMBER 18, 2017
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY
were in favor. None were opposed. submitted. All in favor. None opposed. (See Addendum A for additional information) Minutes were approved.
2. * REVIEW / APPROVAL: REVISED BOARD QUALITY REVIEW COMMITTEE 2018 PERFORMANCE IMPROVEMENT REPORTING CALENDAR
Utilizing the presentation provided in the meeting packet, Dr. Jerry Kolins provided an update MOTION: by Director Moir, second by The 2018 BQRC Y on proposed revisions to the 2018 Board Quality Review Committee Performance Improvement Sabiha Pasha, MD and carried to Performance reporting calendar. Areas identified with a red asterisk are suggested to be reported quarterly approve the proposed revisions for Improvement Reporting to BQRC. quarterly reporting in the 2018 schedule will be revised calendar. to include quarterly reporting of identified Director Moir motioned to have the items designated for quarterly reporting inclusive of areas. Discharge planning – this calendar reflects more frequent reporting from areas of concern as well as some new areas added to the reporting calendar. All in favor. None were opposed.
There were no additional questions presented for discussion.
*STANDING ITEMS
1. *Medical Executive Committees Update
Dr. Sabiha Pasha provided a verbal update from the Medical Executive Committee of MOTION: N/A N/A Y Palomar Medical Center Escondido Medical Executive Committee met on December 3, 2017. Physicians approved changes to critical value reporting for troponin and total CK in order to more effectively communicate lab results indicative of a heart attack. There was a discussion on bariatric privileges and barriers to entry in this specialty. Both MECs hosted their annual holiday party. At Palomar Medical Center Escondido, a presentation on Palliative Care was provided. At Palomar Medical Center Poway, Dr. Callery recognized the contributions of medical staff and the medical staff office.
There were no additional questions presented for discussion. 2. Journal Club Assignment
The journal club assignment was entitled “A Culture of Respect, Part 1 The Nature and Causes MOTION: N/A The journal club article Y of Disrespectful Behavior by Physicians” authored by Leape, Lucian L., MD; Sore, Miles F. MD; discussion was deferred Dienstag, Jules L. MD; Mayer, Robert J. MD; Edgman-Levitan, Susan PA; Meyer, Gregg S. to the January 15, 2018 MD, MSc; Healy, Gerald B. and published in Academic Medicine: July 2012 – Volume 87 – meeting. Issue 7 – p 845-852.
The discussion on this article was deferred to the January 15, 2018 meeting.
Additional discussion ensued surrounding the Board Quality Review Committee meeting time MOTION: N/A BQRC meeting time will Y for calendar year 2018. Director Gorzeman, Chairman-elect for 2018 is currently in the process change from 6:00 pm – 15 121817-MINUTES BQRC Board Meeting DRAFT - V4 2
Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, DECEMBER 18, 2017
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY
of finalizing Board member assignments for all of the committees for the upcoming year. 8:00 pm on the 3rd Director Gorzeman announced that she will continue to chair this committee; Dr. Moir will join Monday of every month this committee as well as Director Dara Czerwonka. to 5:30 pm – 7:00 pm on rd the 3 Monday of every month. After considerable discussion, the proposed meeting time was changed to 5:30 pm – 7:00 pm. All in favor. None opposed.
3. Regulatory Readiness
Deborah Barnes, RN and District Director Regulatory Coordination provided an overview and The most recent 2567 was just received Deborah Barnes, RN N update on our current regulatory status on the Plan of Action (POA) for the August 14-18 2017 and the Board will receive/review a and Director, Regulatory Centers of Medicare & Medicaid Services (CMS) full validation survey and the October 16-19, copy of the Plan of Correction. Coordination 2017 focused CMS survey. The Plan of Action submitted for the CMS full validation survey stated the Board Quality Review Committee (BQRC) would receive updates on effectiveness The Committee will review the actions action taken. and results at least quarterly, but will receive an update at each monthly meeting to assure we sustain gains. In August 14-18, 2017, Palomar Medical Center Escondido and Palomar Medical Center Downtown Escondido were found to be out of compliance in the following Conditions of Participation: (1) Governing Body; (2) Quality Assurance Performance Improvement (QAPI); (3) Infection Control; (4) Discharge Planning; (5) Nursing; (6) Food and Nutrition Services; and (7) Pharmacy.
Debbie reported that all plans of actions have been implemented and actions are currently being audited, data is being analyzed and reported through the appropriate committee structure. Additionally, the plan of action for the October 16-19, 2017 focused CMS survey was received and will be completed and submitted to CMS/CDPH by Friday, December 22, 2017 well in advanced of the December 26, 2017 submission deadline. (See Addendum D for additional information)
California Department of Public Health conducted resurvey at Palomar Medical Center Escondido and Escondido Downtown on October 16 – 19, 2017. The following Conditions of Participation were cleared: (1) Governing Body, (2) QAPI, (3) Infection Control, (4) Discharge Planning and (5) FANS
Karen Buckley, RN and Chief Nursing Officer, Palomar Medical Center Escondido and Valerie Board and committee members asked Karen Buckley, RN and Martinez, RN and Director Quality/Pt. Safety and Infection Prevention & Control presented an questions to ensure interdisciplinary CNO, PMC Escondido, Executive summary and data results for CMS audits implemented in Nursing and Pharmacy. infrastructures and decision making is Valerie Martinez, RN and (Data handouts were provided at the meeting) in place. The adverse event log was Director, Quality/Pt. discussed in the executive session and Safety/Infection there will be further conversation Prevention and Control Areas that still require increased focus include: (1) Pain medication assessment/reassessment regarding follow-up and trends to for one time dose; (2) Pressure ulcer staging and documentation; (3) Handoff form completion; identify high risk areas. (4) Pre-procedure checklist in obstetrics and (5) Compliance to surgical attire. These areas to be updated as follow-up in the January meeting. 16 121817-MINUTES BQRC Board Meeting DRAFT - V4 3
Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, DECEMBER 18, 2017
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY
The recommendation at this time is to continue the current process of monitoring, analyzing A progress report will be provided data and reporting performance through the appropriate committee structure and more frequent monthly until sustained gains have report at BQRC. been noted. Will return in January with effectiveness checks report.
Director Gorzeman queried the presenters as to the barriers identified for optimal performance. Karen Buckley reported that the key barrier is lack of standardization of processes across the system.
Dr. Moir asked about the method to address the non-compliance related to surgical attire. Karen Buckley reported that this being addressed with leadership changes, teaming up with Infection Control for increased rounding in the OR and working with individual physicians. The focus will be redirected towards compliance of this indicator. Dr. Moir also asked about the booties that are used in the surgical area. All personal protective equipment (PPE) with the exception of the bonnet is to be removed and discarded appropriately prior to leaving the OR Suites.
There were no additional questions presented for discussion.
In addition to the regulatory report provided above, Jeremy Lee, PharmD, BCPS, District BQRC chair is request information Continued monitoring, N Director Pharmacy Services and Maureen Malone, AVP, Clinical and Diagnostic Services regarding controlled substance analyzing data and provided an overview and current state (inclusive of data results) of the plan of correction from reports at the January executive reporting through the the August 2017 CMS Validation Survey. (An Executive Summary and data handouts were session. appropriate committee provided at the meeting) structure, which is a newly transitioned Listed below are the six (6) pharmacy findings: medication management committee. Medication storage issues o Protect from light o Refrigerated storage o Separated storage (IV fluids stored in medication room) o Dirty storage containers o Overstocking of crash carts o Storing room temp meds in refrigerator Controlled substance records on distribution, use, and disposition Secure storage (saline in unlocked warmer in trauma bay) Controlled substance storage Follow manufacturer instructions (sterile water irrigation bottles found in warmer) Expired medication NOTE: BQRC chair is requesting information regarding controlled substance reports at the January executive session.
Jeremy reported that most of these findings were remedied either during the survey or very shortly afterwards. Some of the most significant interventions include: Mandatory education on how to conduct their monthly unit inspections more thoroughly 17 121817-MINUTES BQRC Board Meeting DRAFT - V4 4
Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, DECEMBER 18, 2017
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY
Pharmacy leaders conducting monthly unit inspections Implementing an electronic dashboard to monitor all cleaning activities to ensure they are completed timely. To date, the corrective action plan has been successful in achieving the desired results. The results from the audit inspections outside of the pharmacy are encouraging. The most challenging areas include: • Timely completion of the cleaning logs • Assigning the appropriate Beyond Use Date • Expired medications • Refrigerated medications
Recommendation is to continue to monitor, analyze the data and report performance through the appropriate committee structure.
Frank Beirne commented that even though we are expecting a “focused survey,” any time a surveyor walks through the building, we have to be in the continuous readiness position to all conditions of participation across the system.
There were no additional questions presented for discussion. NEW BUSINESS
1. *Communication of Adverse Events
Dr. Jerry Kolins presented to the Board Quality Review Committee the Draft policy titled MOTION: N/A Director Gorzeman to N “Extraordinary Event Management Policy.” He also referenced the “Event Escalation” take the Event algorithm. Escalation Policy and Event Escalation Algorithm to the One of the challenges to Operations is learning the information that needs to be reported to the Governance Committee Board. For example, a patient fall without injury was not expected to be escalated to the for further review and Board. However, if a Root Cause Analysis (RCA) was performed, this would be discussed at discussion to assure BQRC. alignment with the Extraordinary Event Director Gorzeman reported that the Board has had recent conversation on the escalation of Management Policy. events at the Governance Committee. This policy she believes was approved pending minor revisions made by Operations recommendations. Director Gorzeman reported that she will follow-up on the status of this policy. She also agreed that there needs to be further clarification on the Event Escalation process.
Director Gorzeman will take the Escalation Event procedure to the Governance committee for further review and discussion.
Director Gorzeman expressed her intent to share with the full Board in January the work with 18 121817-MINUTES BQRC Board Meeting DRAFT - V4 5
Addendum A BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, DECEMBER 18, 2017
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL? RESPONSIBLE PARTY
Mayo Clinic on quality assurance.
There were not additional items presented for discussion.
ADJOURNMENT TO EXECUTIVE SESSION MOTION: by Director Douglas Moir, MD, second by Sabiha Pasha, MD and carried to adjourn to Executive Session 7:03 pm. All in favor. None opposed Pursuant to Health and Safety Code Section 32155 - Report of Hospital Medical Audit / Quality Assurance
ADJOURNMENT TO OPEN SESSION MOTION: by Sabiha Pasha, MD, second by Director Joy Gorzeman and carried to adjourn to Open Session at 8:38 p.m. All in favor. None Opposed.
Actions taken, if any. MOTION: N/A N/A Y
PUBLIC COMMENTS There were no public comments.
FINAL ADJOURNMENT - The meeting adjourned at 8:40 p.m. MOTION: by Sabiha Pasha, MD, second by Director Joy Gorzeman and carried to final adjournment of the meeting at 8:40 p.m. All in favor. None opposed
COMMITTEE CHAIR Joy Gorzeman, RN SIGNATURES:
COMMITTEE ASSISTANT
LouAnn Quibuyen
19 121817-MINUTES BQRC Board Meeting DRAFT - V4 6 Addendum A
Board Quality Review Committee Meeting
OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2017
Meeting Dates: 8/21/ 9/18/1 Palomar Health 5/1/1 5/15/ 6/19 7/17/ 10/16/ 1/16/17 2/23/17 3/20/17 4/17/17 17 7 11/20/17 12/18/17 By-Laws’ 7 17 /17 17 CANC Annl 17 Voting Members Membership ELED Rpt DIRECTOR JOY GORZEMAN, RN - CHAIR Board Member P P P P P P Ex P P P P DIRECTOR DARA CZERWONKA Board Member P P P Ex Ex P P Ex P P Ex DIRECTOR HANS SISON, LVN Board Member P Ex P P P P Ex P P Ex Ex DIRECTOR DOUGLAS MOIR (ALT) Board Member - A P P -- P P -- -- P QMC Chair, P SABIHA PASHA, MD P Ex P Ex Ex P P P P P Palomar Medical Center Escondido QMC Chair, EDWARD GURROLA, MD P P P P P P P P P Ex Palomar Medical Center Poway P Non-Voting Members BEIRNE, FRANK, FACHE EVP, Operations P P P P P P P P P P P P BUCKLEY, KAREN, RN, BSN, MHA, P P P P P P P Ex P P CENP CNO, PMC Escondido BROWN, SHEILA, RN, FACHE VP, Continuum Care P P P P Ex P P P P P P
CONRAD, ALAN, MD EVP, Physician Alignment
P P P Ex P P P P P P P FULL FULL Board Board Special Special Meeting
HANSEN, DIANE Interim President & CEO P P HEMKER, BOB, FACHE President & CEO P P P P P P P P P Ex VP, Patient Experience and Co-Chair, P KOLINS, JERRY, MD, FACHE P P P P P P P P P P Patient Safety Committee LABOSSIERE, LARRY, MBA, MSN, RN, CNS, CEN CNO, PMC Poway P P P Ex P P P P P Ex Ex ARTINEZ ALERIE RN, BSN, MHA, CIC, NEACo--Chair, Patient Safety Committee P M , V , P P P P P P P P P P BC SHAW, DELLA EVP, Strategy A A P A Ex P Ex P P Ex Ex VP, PMC Poway and PMC Downtown Ex SKINNER, JEANNETTE, RN, MBA, FACHE P P P P P P P P Ex P Escondido SOLOMON, LESLIE VP, Culture and Talent Planning P A P P Ex Ex Ex P P P P SUDAK, MARIA, MSN, CCRN, NEA-BC, RN VP, Palomar Medical Center Escondido P P P P P P P P P Ex P Patient Family Advisory Council (PFAC) Ex WOLF, ESTELLE P P P P P Ex Ex Ex Chair Patient Family Advisory Council (PFAC) LYON, JIM P P P P P P P P Immediate Past Chair Ex PATTERSON, PAUL Patient Family Advisory Council (PFAC) Incoming Chair P Meeting Dates: 20Page 1 of 2 Addendum A
5/15/ 6/19/ 7/17 8/21/ 9/18/ 10/16/ 11/20/ 1/16/17 2/23/17 3/20/17 4/17/17 5/1/17 12/18/17 17 17 /17 17 17 17 17 Guests ACKLIN, LINDA P ANDREWS, SHELLY, RN AUSTRIA, GLORIA P BANDICK, BRET BARNES, DEBBIE, RN, CDS P P P P P BRIED, JAMES, MD P CALLERY, CHARLES, MD P P P COHEN, BRIAN P DELANGE, NICOLE P P P FARROW, DAN P P P P FERNANDEZ, ERIK O. (CHEU / CNA P REPRESENTATIVE) GOELITZ, BRIAN, MD GRIFFITH, JEFF (BOARD MEMBER) P JANUSZEWICZ, LOURDES P JENNINGS, TAMRAH P HUSSAIN, YASMIN P KAUFMAN, JERRY (BOARD MEMBER) P KIM, JESSICA LEE, DAVID, MD P P P P P P P P P LEE, JEREMY P P MALEK, MIKHAIL, MD P LOPEZ, DAWN, RN P MALONE, MAUREEN P P P P P P P MARTIN, FRANK, MD P MCCUNE, RAY (BOARD MEMBER) P NAMENYI, JASMINA NEU, MARK P NGUYEN, ANDREW, MD P NICPON, GREGORY, MD PETROPOULOS, PETER P PHILLIPS, DONITA, MBA, ARM P P P P P P P P P POPE, TINA P P P P Ex P P P P p P RIEHL, RUSSELL P ROLIN, DONNA P SAUCIER, JACQUELINE P SCHULTZ, DIANA SINGH, TEJA, MD P STEEBER, DANIEL P P WATSON, RAE ANNE WIESE, LISHA P ZUBENIA, JOHAN P
21Page 2 of 2 Addendum A
Board Quality Review Committee Meeting
EXECUTIVE SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2017
Meeting Dates: Palomar Health 12/18 By-Laws’ 1/16/17 2/23/17 3/20/17 4/17/17 5/1/17 5/15/17 6/19/17 7/17/17 8/21/17 9/18/17 10/16/17 11/20/17 Annl Rpt /17 Voting Members Membership DIRECTOR JOY GORZEMAN, RN - CHAIR Board Member P P P P P P Ex P Cx P P P DIRECTOR DARA CZERWONKA Board Member P P P Ex Ex P P Ex Cx P P Ex DIRECTOR HANS SISON, LVN Board Member P Ex P P P P Ex P Cx P Ex Ex DIRECTOR DOUGLAS MOIR (ALT) Board Member - A P P -- P P Cx -- -- P SABIHA PASHA, MD QMC Chair, P Palomar Medical Center P Ex P Ex Ex P P Cx P P P Escondido EDWARD GURROLA, MD QMC Chair, Palomar Medical Center P P P P P P P P Cx P P Ex Poway Non-Voting Members BEIRNE, FRANK, FACHE EVP, Operations P P P P P P P P Cx P P P P BUCKLEY, KAREN, RN, BSN, MHA, P P P P P P P Cx Ex P P CENP CNO, PMC Escondido BROWN, SHEILA, RN, FACHE VP, Continuum Care P P P P Ex P P P Cx P P P EVP, Physician P CONRAD, ALAN, MD P P P Ex P P P Cx P P P Alignment HANSEN, DIANE Interim President & CEO P P HEMKER, BOB, FACHE President & CEO P P P P P P P P Cx P Ex Ex KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient P P P P P P P P Cx P P P Safety Committee LABOSSIERE, LARRY, MBA, MSN, RN, CNS, CENCNO, PMC Poway P P P Ex P P P P Cx P Ex Ex Co-Chair, Patient Safety MARTINEZ, VALERIE, RN, BSN, MHA, CIC, NEA- P P P P P P P P Cx P P P BC Committee SHAW, DELLA EVP, Strategy A A P A Ex P A P Cx P Ex Ex SKINNER, JEANNETTE, RN, MBA, FACHE VP, PMC Poway and PMC Downtown P P P P Ex P P P Cx P Ex P Escondido VP, Culture and Talent SOLOMON, LESLIE P Cx P P P Planning VP, Palomar Medical SUDAK, MARIA, MSN, CCRN, NEA-BC, RN P P P P P P P P Cx P Ex P Center Escondido Patient Family Advisory ESTELLE WOLF P P Ex Ex Ex Ex Cx Ex Council (PFAC) Chair Patient Family Advisory JIM LYON P P Ex Ex Ex Ex Cx Ex P P Council (PFAC) Chair PAUL PATTERSON Patient Family Advisory Council (PFAC) P Immediate Past Chair 22Page 1 of 2 Addendum A
Meeting Dates: 12/18 1/16/17 2/23/17 3/20/17 4/17/17 5/1/17 5/15/17 6/19/17 7/17/17 8/21/17 9/18/17 10/16/17 11/20/17 /17 Guests GRIFFITH, JEFF (BOARD MEMBER) P Cx KAUFMAN, JERRY (BOARD MEMBER) P Cx MARTIN, FRANK, MD P Cx MCCUNE, RAY (BOARD MEMBER) P Cx PHILLIPS, DONITA Cx P P POPE, TINA Cx P
23Page 2 of 2
ADDENDUM B
24 Addendum B
6.2.4 Quality Review Committee.
(a) Voting Membership. The Committee shall consist of five voting members, including three members of the Board and the Chairs of Medical Staff Quality Management Committees of Palomar Medical Center Escondido and Palomar Medical Center Poway.
(b) Non-Voting Membership. President and Chief Executive Officer; Executive Vice President, Physician Alignment; Executive Vice President, Operations; Executive Vice President, Strategy; Vice President, Continuum Care; Vice President, Palomar Medical Center Escondido; Vice President, Palomar Medical Center Poway; Vice President, Culture and Talent Planning; Vice President, Patient Experience; Chief Nursing Officer, Palomar Medical Center Escondido; Chief Nursing Officer, Palomar Medical Center Poway; Chair or Co-Chairs of the Patient Safety Committee, and two members of the Patient Family Advisory Committee.
(c) Duties. The duties of the Committee shall include but are not limited to:
(i) Oversight of performance improvement, patient safety and risk management. All referrals and/or recommendations will be sent to the Board for final approval.
(ii) Annual review of the credentialing and privileging process of the medical staff;
(iii) Periodic review of caregiver performance using objective data to recognize success and identify opportunities for improvement.
6.2.4 Quality Review Committee Recommended revisions 2018 -DRAFT 25
ADDENDUM C
26 Addendum C
PALOMAR HEALTH BOARD QUALITY REVIEW COMMITTEE (BQRC)
Board Member Position Description
Function:
It is the responsibility of BQRC Board Members to assure that the quality of care rendered in the District's facilities is at the highest possible level when compared to National, State and Local standards and those actions are taken on behalf of the Board to ensure the safety and well-being of the patients we serve.
Responsibilities:
1. Review and approve the Palomar Health Quality Assurance Performance Improvement (QAPI) Plan annually to assure the identification, assessment and resolution of patient care issues. 2. Assure that the health system is meeting regulatory and governmental requirements and standards pertaining to the delivery of quality clinical care in all of its facilities and programs. 3. Monitor institutional liability/risk experience and assure that proper systems are in place to reduce exposure to loss. 4. Assure that the process of credentialing and privileging of Medical Staff and Allied Health staff is based on demonstrated professional competence and adherence to the bylaws and code of conduct of the Medical Staff. 5. Govern the development and management of educational endeavors to improve employee, medical staff and board performance in the skills necessary to perform their duties. 6. Review and assess quality and patient experience reports from programs and departments within the health system using objective data to identify trends in patient care and recommend stewardship action when appropriate. 7. Perform other duties as assigned by the Committee Chair.
Requirements:
1. Commit the time and energy necessary to meet committee responsibilities and meeting requirements.. 2. Aspire to expand knowledge in the arena of quality, patient safety, service excellence, and risk management. 3. Continue to develop an understanding of the effects of potential adverse events on quality, safety, and finance and the role of risk management and Fair and Just Culture in the prevention/amelioration of such events. 4. Comply with other Board position description requirements.
2018 Board Quality Review Committee Description - DRAFT Approved by BQRC on ______27 Addendum C ÿ ÿ !" #$#%#&# ÿ()011#2#%ÿ34567ÿ)8
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ADDENDUM D
34 Addendum D Palomar Health BOARD QUALITY REVIEW COMMITTEE 2018 Performance Improvement Reporting Calendar Approved 10/16/17 Revised 01/10/18 Yellow - Annually Blue - Quarterly Reports due Patient Experience Executive Assistant 5-Jan 2-Mar 6-Apr 4-May 1-Jun 6-Jul 3-Aug 7-Sep 5-Oct 2-Nov 7-Dec JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC Meeting Date 15 19* 19 16 21 18 16 20 17 15 19 17 Annual BQRC Assessment √ Annual Quality & Patient Safety Report to the Board of Directors √ Annual Review of By-Laws and Board Member Position Description √ Annual Review of Credentialing Process and Peer Review Process √ Alan Conrad, MD, EVP, Physician Alignment Annual Review of Quality Assurance Performance Improvement Plan 42 CFR (482.21 QA-1) √ Valerie Martinez, Director Quality, Patient Safety & Infection Control Annual Review of Reporting Calendar √ Quarterly Review of Service Excellence & Patient Grievance Reporting 42 CFR (482.13 PR-4) Karen Buckley, MHA, BSN, RN, CENP, CNO, Palomar Medical Center Escondido √ √ √ √ Larry LaBossiere, RN, MBA, MSN, CNS, CEN, CNO, Palomar Medical Center Poway Tina Pope, Manager, Service Excellence
Medical Group Quality Reports √ Arch Healthcare, Graybill, Neighborhood Health,SCMG, and North County Health Services
Anesthesia Services 42 CFR (482.52 AN-1) Omar Khawaja, MD, Medical Director, PeriOperative Services √ Mark Goldsworthy, MD, Chair, Anesthesia Department, PMC Escondido William Grant, MD, Chair, Anesthesia Departmnt, PMC Poway Continuum of Care Sheila Brown, VP, Continuum Care √ Behavioral Health Services, ExpressCare, Home Health, SNF Contracted Services: Dialysis and Wound Care 42 CFR (482.12 GL-8) Maria Sudak, VP, Palomar Medical Center Escondido √ Jeannette Skinner, VP, Palomar Medical Center Poway Diabetes Health Program Alan Conrad, MD, Medical Director Diabetes Health Program √ Valerie Martinez, Director Quality, Patient Safety & Infection Control DietaryServices (Food and Nutrition Services) 42 CFR (482.28 NU-1) * Margaret Mertens, RD, Interim Director, FANS √ √ √ √ Discharge Planning (Clinical Resource Management) 42 CFR (482.43 DC-5) * Diane Hansen, EVP, Finance √ √ √ √ Mary Scott, Interim Director, Clinical Resource Management Management of the Care Environment (EOC including maintenance, safety of equipment and facilities) 42 CFR (482.41 CE-8) 42 CFR (482.41 CE-10) √ Infection Control & Prevention 42 CFR (482.42 IC-1) and 42 CFR (482.24 IC-9) * Valerie Martinez, Director Quality, Patient Safety & Infection Control √ √ √ √ Laboratory Services 42 CFR (482.27 LB-1) Maureen Malone, AVP. Clinical & Diagnostic Services √ Management of the Medical Record 42 CFR (482.24 MR-6) √ 35 Kim Jackson, Director, Health Information Services Page 1 of 2 Revised: 1/12/2018 Addendum D Palomar Health BOARD QUALITY REVIEW COMMITTEE 2018 Performance Improvement Reporting Calendar Approved 10/16/17 Revised 01/10/18 Yellow - Annually Blue - Quarterly Reports due Patient Experience Executive Assistant 5-Jan 2-Mar 6-Apr 4-May 1-Jun 6-Jul 3-Aug 7-Sep 5-Oct 2-Nov 7-Dec JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC Meeting Date 15 19* 19 16 21 18 16 20 17 15 19 17 Medication Managment (Pharmacy) 42 CFR (482.25 MM-21) and (482.25 MM-31) * Maureen Malone, AVP, Clinical & Diagnostic Services √ √ √ √ Jeremy Lee, RPh Director, Pharmacy Diana Scultz, RP, Medication Management Manager Stroke Program Remia Paduga, MD, Medical Director. Stroke Program √ Valerie Martinez, Director, Quality, Patient Safety & Infection Control Nursing Services 42 CFR (482.23 NS-1) Karen Buckley, CNO, Palomar Medical Center Escondido √ Larry LaBossiere, CNO, Palomar Medical Center Poway Operative and Invasive Services 42 CFR (482.51 OI-1) Karen Buckley, CNO, Palomar Medical Center Escondido √ Larry LaBossiere, CNO, Palomar Medical Center Poway Outpatient Services 42 CFR (482.54 OS-1) Sheila Brown, VP Continuum of Care √ Radiology Services 42 CFR (482.26 RD-1) and Nuclear Medicine Services 42 CFR (482.53 NM-1) √ Greg Nicpon, MD, Chair, Department of Radiology Rehabilitation Services 42 CFR (482.56 RB-1) √ Sheila Brown, VP, Continnum of Care Respiratory Services 42 CFR (482.57 RT-1) √ Maureen Malone, AVP, Clinical & Diagnostics Centers of Excellence - Orthopedic/Spine Services - Brian Cohen, Director, Jim Bried, MD, Andrew Nguyen, MD √ - Cardiovascular Services - Peter Petropoulos, Director, Mikail Malek, MD - Bariatric Services - Charles D. Callery, M.D, General Surgeon
36 Page 2 of 2 Revised: 1/12/2018
ADDENDUM E
37 Addendum E
30-Day All-Cause Unplanned Readmission Rate Discharges between 1/1/2015 - 8/31/2017
Numerator = 30-day all-cause unplanned readmits Denominator = Qualified discharges (excluding newborns, expired pts, transfers to another acute-care facility, AMA)
30‐Day All‐Cause Unplanned Readmission Rate Discharges between 1/1/2015 ‐ 8/31/2017
ESC All Pts ESC Kaiser Pts ESC NonKaiser Pts National Average *
12%
10%
8%
6%
4%
2%
0% CY2015 CY2016 CY2017 (thru Aug)
Year ESC All Pts ESC Kaiser Pts ESC NonKaiser Pts National Average * CY2015 8.16% 6.68% 8.78% 7.63% CY2016 8.48% 6.91% 9.16% 7.67% CY2017 (thru Aug) 8.32% 6.71% 8.98% 7.57%
* National average in the Truven database
Source: Truven CDA CIS:\Kaiser\Readmission38 Reports
ADDENDUM F
39 Addendum F
Perspective: A Culture of Respect, Part 1 The Nature and Causes of Disrespectful Behavior by Physicians Leape, Lucian L. MD; Shore, Miles F. MD; Dienstag, Jules L. MD; Mayer, Robert J. MD; Edgman-Levitan, Susan PA; Meyer, Gregg S. MD, MSc; Healy, Gerald B. MD
Academic Medicine: July 2012 - Volume 87 - Issue 7 - p 845–852 doi: 10.1097/ACM.0b013e318258338d Culture of Medicine
Abstract Author Information Article Outline
A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. The authors identify a broad range of disrespectful conduct, suggesting six categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.
At one end of the spectrum, a single disruptive physician can poison the atmosphere of an entire unit. More common are everyday humiliations of nurses and physicians in training, as well as passive resistance to collaboration and change. Even more common are lesser degrees of disrespectful conduct toward patients that are taken for granted and not recognized by health workers as disrespectful.
Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. Nurses and students are particularly at risk, but disrespectful treatment is also devastating for patients. Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfillment in work for all health care workers and contributes to turnover of highly qualified staff. Disrespectful behavior is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of “production pressure,” such as the requirement to see a high volume of patients.
Dr. Leape is adjunct professor of health policy, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts.
Dr. Shore is Bullard Professor of Psychiatry, Emeritus, and chair, Promotions and Review Board, Harvard Medical School, Boston, Massachusetts.
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Dr. Dienstag is Carl W. Walter Professor of Medicine and dean for medical education, Harvard Medical School, Boston, Massachusetts.
Dr. Mayer is Stephen B. Kay Family Professor of Medicine, Department of Medicine, and faculty associate dean for admission, Harvard Medical School, Boston, Massachusetts.
Ms. Edgman-Levitan is executive director, Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital, Boston, Massachusetts.
Dr. Meyer is lecturer in medicine, Harvard Medical School, and senior vice president for quality and safety, Massachusetts General Hospital, Boston, Massachusetts.
Dr. Healy is professor of otology and laryngology, Harvard Medical School, Boston, Massachusetts, and senior fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts.
Correspondence should be addressed to Dr. Leape, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115; telephone: (617) 432-2008; e-mail: [email protected].
Abstract The Scope of the Problem Disruptive behavior Humiliating, demeaning treatment of nurses, residents, and ... Passive-aggressive behavior Passive disrespect Dismissive treatment of patients Systemic disrespect The Effects of Disrespectful Behavior: Why Is It a Concern? The Causes of Disrespectful Behavior Endogenous factors Exogenous factors Summary References
The slow pace of improvement in patient safety has been a source of widespread dissatisfaction for policy makers and the public, but even more to the health professions. Despite extensive efforts by many institutions and individuals, recent studies show little improvement in the rate of preventable patient harm since the Institute of Medicine’s (IOM’s) “To Err Is Human”1 sounded the alarm and issued its call for a nationwide safety improvement effort 12 years ago.1–4
One explanation for this poor record is that the problem is so large and its causes are so varied. For example, the Centers for Disease Control and Prevention estimates that 5,000 people acquire an infection in our hospitals every day,5 and the IOM estimates that 1.5 million patients are injured by medication errors every year.6 Other reasons include our lack of knowledge of how to prevent most complications of treatment, inadequate government investment in patient safety initiatives, and insufficient preventive and remedial measures.7
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We believe, however, that the fundamental cause of our slow progress is not lack of know-how or resources but a dysfunctional culture that resists change. Central to this culture is a physician ethos that favors individual privilege and autonomy—values that can lead to disrespectful behavior. We propose that disrespectful behavior is the “root cause” of the dysfunctional culture that permeates health care and stymies progress in safety and that it is also a product of that culture.
Disrespectful behavior threatens organizational culture and patient safety in multiple ways. A sense of privilege and status can lead physicians to treat nurses with disrespect, creating a barrier to the open communication and feedback that are essential for safe care. A sense of autonomy can underlie resistance to following safe practices, resulting in patient harm. Absence of respect undermines the teamwork needed to improve practice. Dismissive treatment of patients impairs communication and their engagement as partners in safe care.
In addition to its toxic impact on patient safety, disrespectful behavior affects many other aspects of health care. Quality suffers when caregivers do not work in teams. Disrespect saps meaning and satisfaction from daily work and is one reason nurses experience burnout, resign from hospitals, or leave nursing altogether.8 Lack of respect poisons the well of collegiality and cooperation, undermines morale, and inhibits transparency and feedback. It is a major barrier to health care organizations becoming collaborative, integrated, supportive centers of patient-centered care.
Students and residents suffer from disrespectful treatment. “Education by humiliation” has long been a tradition in medical education and still persists. Patients suffer when physicians do not listen, show disdain for their questions, or fail to explain alternative approaches and fully involve them in the decision-making process.9,10 Failure to provide full and honest disclosure when things go wrong is the epitome of disrespect and is a major reason patients file malpractice suits.11
Respectful behavior is a moral value esteemed in its own right. Respect is also a foundational element of professionalism that forms the core of the self-image of most physicians. Professionalism is a critical element of the six competencies that form the foundation of medical education and practice espoused by the Accreditation Council on Graduate Medical Education, the standard-setter for graduate medical education, and by the American Board of Medical Specialties (ABMS), the standard-setter for all medical specialties.12 Although professionalism embraces a number of other behaviors and attitudes, showing respect for others is central to all aspects of professionalism.
The vast majority of physicians treat others respectfully most of the time; however, some do not. In a recent national survey, two out of three physicians reported witnessing other physicians disrupting patient care or collegial relationships at least once a month. One in nine physicians reported seeing disruptive behavior every day.13
A culture of disrespect is harmful for many reasons, but it is its effect on the safety and well-being of our patients that makes it a matter of urgency. In simple terms, we believe that a health care organization that supports and tolerates disrespectful behavior is unsafe for its patients and hostile for its workers. Although disrespectful behavior permeates all of health care, physicians dominate the culture and set the tone; therefore, in this discussion we focus on physicians.
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Here, we present a call to action. Our intent is to motivate individuals at all levels in health care institutions to take action toward creating a culture of respect and to provide them with the evidence they need to support improvements in the cultures of their institutions. The Scope of the Problem Disrespectful behavior takes many forms, ranging from outbursts of outrageous, aggressive behavior to subtle patterns that are so firmly embedded in our culture as to seem normal. On the basis of our collective personal experience, we suggest the following as a useful classification of disrespectful behaviors in the health care setting.
Disruptive behavior At one end of the spectrum of disrespect are physicians whose behavior has been characterized as disruptive, defined by the Ontario College of Physicians and Surgeons as “inappropriate conduct, whether in words or action, that interferes with, or has the potential to interfere with, quality health care delivery.”14 Hickson and Pichert15 define disruptive behavior as “any behavior that impairs the medical team’s ability to achieve intended outcomes.” Disruptive physicians are found in almost all hospitals. Although most observers agree that only 5% or 6% of physicians fall into this category,16 the detrimental influence of this small minority far outweighs their numbers.
Disruptive actions include angry outbursts, verbal threats, shouting, swearing, and the threat or actual infliction of unwarranted physical force that legally would be considered battery. Having a temper tantrum, throwing objects, and breaking things are other forms of disruptive behavior, as is any unwanted physical contact of a sexual nature. Disruptive conduct may be directed at anyone—nurses, colleagues, residents, medical students, ward staff, hospital administrators, and even patients and their family members.
Disruptive behavior includes profane, disrespectful, insulting, or abusive language; loud or inappropriate arguments; demeaning comments or intimidation; shaming others for negative outcomes; and simple rudeness. Violations of physical boundaries and sexual harassment are in this category, as are gratuitous negative comments about other physicians’ care and passing severe judgment or censuring colleagues or staff in front of patients, visitors, or other staff. Also included are bullying; insensitive comments about a patient’s medical condition, appearance, or situation; and jokes or nonclinical comments about race, ethnicity, religion, sexual orientation, age, physical appearance, or socioeconomic or educational status.
Humiliating, demeaning treatment of nurses, residents, and students Much more common than egregious forms of disruptive behavior are patterns of demeaning or humiliating treatment of subordinates, particularly nurses, residents, and medical students.
17 18
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Abuse of nurses by physicians has a long history. Twenty years ago, Cox17 , 18 reported on the high rate of verbal abuse of nurses and its negative effects. A recent review of the literature yielded 10 U.S. studies since 2000 of abusive treatment of nurses.19 A large percentage of nurses reported being subjected to abuse or disruptive behavior, and in four of the studies, more than 90% of nurses reported that they had experienced such abuse. In one large study, 31% of nurses reported knowing a nurse who had left the hospital because of disruptive physician behavior.19
Medical students, at the bottom of the patient care team hierarchy, are very vulnerable to disrespect from faculty, house staff, nurses, and others through verbal or physical abuse, belittlement, humiliation, harassment, intimidation and exploitation, or simply by being ignored. Nurses and residents may make them feel insignificant or “in the way.” Annual surveys by the Association of American Medical Colleges show that 14% to 17% of graduating students report having been subjected to or witnessing some form of mistreatment.20 However, other studies and informal discussions with students suggest that the prevalence of student mistreatment is much higher.20 , 21 Recent reports that 53% of medical students experience “burnout”22 and that 14% suffer clinically significant depression23 provide further evidence that the environment in many of our academic medical centers and medical schools is sometimes hostile and quite toxic.
In our experience, students indicate that they seldom report disrespectful acts because they are concerned about being seen as troublemakers and fear reprisal or vindictive retaliation, such as a lower grade, a critical evaluation, or a poor recommendation for residency applications. Disrespect can also occur in the preclinical classroom or laboratory, but it is more common in clinical settings like hospital wards or clinics. Women students are more vulnerable than men.21 , 24 Anecdotally, students report that barbs related to gender, race, or sexual orientation are heard more commonly in high-stress areas, such as the operating room and the emergency department. Often, students relate that when such disrespectful behavior is reported, corrective measures are not apparent, sending the message that disrespectful behavior is tolerated, if not celebrated.
Examples of serious disrespectful behavior toward medical students reported in one academic year are presented in Box 1.20
Box 1 Passive-aggressive behavior
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Passive-aggressive behavior is defined as a pattern of negativistic attitudes and passive resistance to demands for adequate performance.25 Unable to express anger in a healthy way, passive-aggressive individuals harm others through actions that seem normal on the surface. They tend to be unreasonably critical of authority and blame others for their failures. They frequently complain of being misunderstood and treated unfairly.
Passive-aggressive behavior includes refusing to do tasks or doing them in a way intended to annoy others. Passive-aggressive individuals go out of their way to make others look bad while pretending innocence, fail to follow through on agreements, and deliberately delay responding to calls, covering the delays with excuses. They often make negative comments about their institution, hospital, group, or colleagues. The defining characteristics of passive aggression are concealed anger, negativism, and intent to cause psychological harm.
We know of no studies undertaken to quantify these types of behaviors, but we have encountered widespread agreement among clinicians that such behaviors are not rare.
Passive disrespect By contrast, passive disrespect is common; it consists of a range of uncooperative behaviors that are not malevolent or rooted in suppressed anger. Whether because of apathy, burnout, situational frustration, or other reasons, passively disrespectful individuals are chronically late to meetings, respond sluggishly to calls, fail to dictate charts or operating notes in a timely fashion, and do not work collaboratively or cooperatively with others. They resist following safe practices, such as hand disinfection, checklists, and “time-outs,” even when the rationale has been sufficiently described. They may decline to participate in quality improvement efforts, or, if they do, they are indifferent or poor team players. All of these behaviors are manifestations of disrespect—for others, for the institution, and for expert opinions.
Although this type of behavior would be included in Hickson’s definition of disruptive behavior,14 it is usually not perceived as such by colleagues, who tend to accept it as a fact of life that some people are “difficult.”
Dismissive treatment of patients Again, incidence data are lacking, but anecdotal evidence abounds in the form of patient stories regarding demeaning, disrespectful, and dismissive treatment by physicians. Patients may describe this treatment in a number of ways: “He treats me like an idiot,” “He makes me feel like I’m wasting his time,” “She won’t return my calls,” “They ignore me on rounds. They talk about me but not to me,” or, “It was clear he doesn’t like people who ask questions.”
Not only does such behavior violate the fundamental obligation of the physician to provide support and healing, it can be devastating for the already-apprehensive patient. Patients seldom file formal complaints to the hospital about dismissive behavior, but as more hospitals implement the Consumer Assessment of Health Plans Survey as part of Center for Medicare and Medicaid Services Hospital Compare reporting,26 these sentiments are now beginning to be captured in a systematic fashion.
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Dismissive treatment and put-downs are not limited to patients. Some physicians treat nurses, students, residents, and even peers with disdain, making easy communication and collaboration impossible. However, because they are so dependent on the doctor for their well-being, patients are especially vulnerable to dismissive treatment.
Systemic disrespect Many features of our health care system are so firmly entrenched that they are taken as givens and not recognized for the disrespect they represent. A classic example is waiting. Everyone—patients, doctors, nurses, clerks, and administrators—seems to accept the fact that patients should wait for services. There is a reason we label our reception areas as “waiting rooms”! Making a person wait, however, sends the unambiguous message that the physician considers his or her time more valuable than the patient’s.
Physicians are also victimized by a scheduling system that doesn’t respect their time. The productivity demands of the short appointment times characteristic of present-day ambulatory medicine mean that to have necessary additional time with one patient requires the physician to make the next (and all subsequent) patients wait. This type of scheduling is institutional disrespect of both the physician and the patient, ignoring the physician’s need to have enough time to do a professional job.
The unnecessary nature of waiting is apparent from the success that increasing numbers of institutions— offices, clinics, hospitals, operating rooms, and even emergency rooms—have had in streamlining flow, with marked reductions in and sometimes elimination of waiting.27–29 But even when systems fail and emergencies create delays, apologizing for waiting demonstrates respect.
A more serious example of systemic disrespect is the hostile working conditions that are so universally ingrained that we take them for granted as “normal.” Unduly long hours, sleep deprivation, and excessive workloads are well-known causes of errors and patient harm.30–36 Requiring residents or nurses to work under these conditions not only is disrespectful of their well-being and potentially harmful for them (residents who have been on continuous duty for 24 hours or more are more likely to have a fatal automobile accident when driving home)35 but also violates their right to work under conditions that do not increase the likelihood that they will harm their patients. And, of course, it is disrespectful to patients to knowingly put them at increased risk of injury.
Hospitals also demonstrate lack of respect for nurses and other workers when they fail to ensure their physical safety by taking appropriate measures to prevent injury, such as needlesticks and back strain. The fact that these are often accepted as risks of the job illustrates the extent to which disrespect is institutionalized in hospitals.
At the patient level, a serious form of covert systemic disrespect is the failure to engage and inform patients fully about their care. Failure to provide the reasons for tests, the meaning of test results, the options for diagnosis and treatment choices, and, most important, thorough explanations of the risks and benefits of each option, are failures of respect of the patient’s right to information and of his or her ability to understand and make decisions. Shared decision making is not just a good idea, it is showing respect.
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Minor forms of systemic disrespect of patients abound. One is the ubiquitous clipboard questionnaire about demographic and medical history information that patients fill out for every doctor, even when the physicians are in the same institution and have access to a common electronic medical record that already contains this information. Another is the simple failure of health care workers to greet patients, introduce themselves, and say “please” and “thank you.” Addressing patients by their first names without seeking permission for this level of familiarity may be interpreted as disrespect. Calling a patient by terms of endearment, such as “honey” or “dear,” infantilizes the patient and enforces a power differential with the clinician.
Perhaps the most serious form of systemic patient disrespect is the failure to admit and explain fully what happened when things go wrong and to apologize when we or our system has failed. Honoring the patient’s right and need to know everything that is relevant to his or her well-being is fundamental to doctoring and reflects respect for the “doctored.” The Effects of Disrespectful Behavior: Why Is It a Concern? Humiliating, degrading, or shaming behavior is a threat to patient safety because it can have both immediate and long-term negative effects on the recipient. In the immediate aftermath of an episode of humiliation, the recipient experiences a mixture of intense feelings: fear, anger, shame, confusion, uncertainty, isolation, self- doubt, frustration, and depression. These feelings affect significantly a person’s ability to think clearly, making an error in decision making or performance more likely. In addition, intimidation may stimulate a person to commit an unsafe act.37
Long-term consequences of humiliating and intimidating behavior stem from the recipient’s very rational response: Avoid the person inflicting the hurtful behavior. For a nurse or resident, this may be expressed by reluctance to call a disrespectful attending physician with questions for clarification of an order, or for clinical concerns that are not clear-cut. In such cases, caregivers may divert their attention from the patient to self- protection. When communication on the health care team is limited to that which is absolutely necessary, the loser is the patient, who may suffer from delayed or erroneous diagnoses or treatment.
Everyone suffers in an atmosphere of intimidation. A hostile work environment lowers morale, creates self- doubt, and is a cause of burnout.38–40 Not surprisingly, some health care professionals choose to leave rather than endure such an environment.41 Malpractice suits are more common against physicians who intimidate or insult patients.42
Teamwork is another casualty of disrespect because it requires mutual trust and respect among all its members. Even less severe forms of disrespect, such as not learning individuals’ names, habitual tardiness for meetings, and expecting deferential treatment, are detrimental to teamwork.43 Teamwork is essential for the management of patients with multiple or complicated diseases. It is also the cornerstone of safe practice. The most effective safe practices, such as prevention of central line infections by adherence to proper insertion technique and prevention of surgical complications through “time-outs” and checklists, require smoothly
44 45
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As noted, disrespect underlies failure of physician compliance with safe practices. Lack of respect for the organization and the expert opinions of others leads some physicians to disobey rules with which they do not agree, such as the requirement to disinfect hands before touching a patient or to perform a “time-out” before surgery.
Disrespectful behavior is also a barrier to improving safety. The major safety efforts have focused on implementing new safe practices. Both implementing standard practices and developing new practices require collaboration among all members of the care team. If the physician fails to participate constructively in such efforts, progress is virtually impossible.
Students are especially vulnerable to degrading or humiliating treatment by their teachers. In addition to the anger, humiliation, shame, and frustration that anyone feels as a result of humiliating treatment, students may experience feelings of self-doubt and loss of self-esteem. A harshly negative judgment from a respected senior physician carries great weight and sometimes leads a student to question his or her fitness to be a physician. Students are also vulnerable because they are subject to faculty evaluation. A negative assessment can make a student less competitive for residency positions.
But the most serious effect on students comes from within. Disrespect is learned behavior, and students learn it from their role models, the faculty. The power of role models is strong, particularly in the clinical years. Although some students will encounter disrespectful behavior and draw the opposite lesson, many students will emulate the behavior they see, ensuring a never-ending cycle of disrespect.
Disrespectful behavior can also be very harmful to patients. Insulting and stifling comments from physicians render patients reluctant to be forthcoming and volunteer information, cutting the physician off from important information that only the patient can provide about symptoms or complications of therapy and observed failures of the care system. Even when they have minor ailments, virtually all patients have some fear and anxiety when interacting with the health care system. Doctors and nurses have the power to reduce this distress substantially by being sympathetic and understanding. Conversely, they have the power to increase distress substantially by ignoring patients’ concerns or treating them with scorn or indifference. Such fears are magnified many-fold in the aftermath of a medical complication, whether or not it is caused by an error. Patients can be devastated if caregivers are not open, honest, and understanding in these situations. Dismissive or dissembling treatment undermines the trust that is the cornerstone of the doctor–patient relationship. The Causes of Disrespectful Behavior Disrespectful behavior results from multiple factors related both to the individual (endogenous) and to the environment in which he or she works (exogenous).
http://journals.lww.com/academicmedicine/Fulltext/2012/07000/Perspective___A_Culture_of_Respect,_Part_1___The.10.aspx 10/30/17, 12 20 PM Page 9 of 16 48 Addendum F Endogenous factors Certain personality characteristics are associated with disrespectful behavior. Many are associated with threats to self-esteem. Self-esteem is especially important to physicians. It is closely linked to their perception of their own competence and reputation. Because they invest a substantial amount of time and energy to achieve competence and professional success, doctors may be sensitive to any threats to self-esteem. When their self- esteem is threatened, physicians may react with destructive interpersonal behavior as a way of reestablishing professional dominance. These reactions may be manifest in several ways.
Insecurity and anxiety. Some physicians are particularly prone to insecurity and anxiety stemming from concern about whether they are up to the challenges of practicing medicine. Especially when they are overworked or stressed, doctors who are not confident about their skills may react to stress by blaming others when things go wrong or by making demeaning or hypercritical comments.
Depression. Surveys show that physicians have higher levels of depression—and higher suicide rates—than the public at large.47 These individuals become depressed by threats to their professional competence, blaming themselves for real or fancied inadequacy. In addition to being hypercritical of themselves, depressed individuals may cope by being hypercritical of others.
Narcissism. The investment of time and energy necessary to succeed professionally in medicine requires a high degree of self-involvement, which in some individuals may accentuate narcissistic character traits. Highly narcissistic individuals believe that they and their ideas are special. They have difficulty tolerating people they view as ordinary, have a sense of entitlement to favorable treatment by others, and are insensitive to the feelings and needs of other people. Banja48 has coined the term “medical narcissism” to reflect the observation that some aspects of narcissism, such as high self-esteem and feelings of superiority, authority, perfectionism, and self-absorption, are often found in physicians. For some, these characteristics may be essential to mastering the highly complex demands of practice and achieving self-preservation in a stressful environment.
Although few physicians exhibit these characteristics to the degree that would be classified as pathological narcissism, Banja48 notes that many physicians and other health professionals nevertheless demonstrate a kind of muted or closeted narcissism whose associated behaviors serve as a form of self-protection when their feelings of adequacy, control, or competency are threatened.
He believes that these feelings are a common cause of the difficulty many physicians have in disclosing and apologizing after adverse events.
Aggressiveness. Highly aggressive people enjoy combat and confrontation, have hair-trigger tempers, and find reassurance in being able to bully others as a defense against helplessness. Professional setbacks may be experienced as helplessness, triggering an aggressive response. Highly aggressive people may find that their behavior is better tolerated in the health care environment than in others and that, in some hospitals, it is even rewarded.49
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Prior victimization. Doctors who have suffered bad experiences, such as bullying, during their formative years may be so traumatized that imitative behavior becomes engrained in their unconscious. Their reaction to stress is to bully, reflecting their earlier experiences.
Exogenous factors Exogenous factors are characteristics of the workplace that facilitate disrespectful behavior. The culture of an institution—“the way we do things here”—defines acceptable and unacceptable behavior. That culture, in turn, is influenced heavily by the customs and mores of society at large. In the United States, a culture of aggressive crudity has taken hold in the past 10 to 20 years, sparked originally by the “let it all hang out” and assertiveness-training era.50–52 The result is that civility is regarded as weakness and as an invitation to exploitation. This trend is obvious in the media, in literature, and in conversation; a certain degree of demeaning disrespect has been elevated to a normal style of communication that is tolerated and that elicits little comment.53–55 The rise of “social media” has greatly expanded the reach of insulting and derogatory speech that, in earlier times, would have fallen on few ears. Not unexpectedly, some of this society-wide tolerance for disrespect spills over into health care.
In addition to this societal acceptance of disrespect, contemporary health care culture is characterized by features that foster disrespectful behavior. One such feature is its hierarchical nature. Disrespect, which is closely tied to status, usually flows down, not up. Medical students rarely are outwardly disrespectful toward their professors, house officers toward their seniors or their attending physicians, or nurses to their supervisors because of the likelihood of repercussions. On the other hand, students and residents often make disrespectful and derogatory comments about their superiors when out of earshot.
Disrespectful behavior may actually affirm status by rewarding the person behaving disrespectfully, who is typically highly sensitive to the hierarchy and keenly aware of the consequences of disrespect directed up the status gradient. In a hierarchical environment, the ability to disrespect others with impunity is a measure of status. The department chair or world-class cardiac surgeon can often “get away with” conduct that is not tolerated among those lower down the ladder.
But the major exogenous factor leading to disrespectful behavior is the stressful environment of modern hospitals, in particular large academic teaching centers, where many people work unduly long hours, have unreasonably heavy work loads, and experience multiple conflicting demands on their time and psyche. Burnout is common not only among staff doctors and nurses but even among medical students and residents.22 ,56 Workplace stress creates anxiety and depression and leads individuals to focus inwardly, accentuating self-absorption and decreasing empathy and the willingness to cooperate. A person looks naturally for others to blame for what appears to be an unsolvable situation.
The stressful environment of health care organizations has multiple causes, but primary among them is production pressure. The U.S. business model of health care places enormous pressure on health care organizations and physicians to increase output; income for both the group and the individual depends on the number of patients treated. Short outpatient appointments, shortened hospital stays, and increasingly complicated, sometimes dangerous procedures mean that pressured staff are often performing at the edge of
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In addition to production pressure, physicians face complex documentation requirements and increasing demands to improve quality and safety—with no increase in time or compensation—as well as the frustrations that come from trying to make a clumsy system work to meet patients’ needs. This situation is a prescription for anger and exasperation that, not surprisingly, results sometimes in outbursts or disrespectful behavior.
Many other industries, however, have succeeded in creating supportive and satisfying work environments in spite of production pressures and complex regulatory and documentation requirements. For example, commercial aviation firms pay substantial attention to duty hours and workloads. Former Alcoa CEO Paul O’Neill57 emphasizes the importance of treating employees with respect and dignity, of providing them with the resources necessary to carry out their work, and of showing appreciation for their contributions. A first principle is to guarantee the workers’ physical safety and psychological safety. Such focus on and concern for the workforce are conspicuously absent at all levels in many, perhaps most, health care organizations.
For example, physical safety in health care settings lags far behind safety in industry. The average number of days lost because of injury per worker per year in health care is 2.8; for Alcoa, the number is 0.15.57 Psychological safety, which includes feeling safe about reporting an error and being supported when things go wrong, is also often lacking. A recent report by the Agency for Healthcare Research and Quality on culture surveys conducted in 1,052 hospitals showed that more than half (56%) of responders did not feel safe to report an error.58 In large hospitals (which include most teaching hospitals), the rate was even higher: 60%.58 Summary Disrespectful behavior is pervasive in health care and takes many forms. The six types we identify are associated with different, sometimes unique, threats to the safety and well-being of patients and health care workers. Although disruptive behavior has drawn increasing attention in recent years, other types of disrespect are far more common and potentially more harmful overall. “Institutionalized” disrespect, such as unduly long work hours, burdensome high work loads, physical hazards, and psychological intimidation, is so common in health care that it is often accepted as normal.
Although personality characteristics predispose some individuals to disrespectful behavior, for the most part, disrespect is learned behavior that is supported and reinforced by the authoritarian, status-based culture found in most hospitals. We address these cultural and educational issues elsewhere,59 but we hope the definitions and discussion of disrespectful behavior we have provided in this article will enhance awareness and understanding of the harm that such behavior causes for everyone on the health care team and the patients they serve.
Acknowledgments: This article is a product of the deliberations of a working group on professionalism whose members include, in addition to the listed authors, Ronald A. Arky, MD, Daniel D. Federman Professor of Medicine and Medical Education and Master, Francis Weld Peabody Society, Harvard Medical School; Maureen T. Connelly, MD, assistant professor of population medicine and dean for faculty affairs, Harvard
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Medical School; Daniel D. Federman, MD, emeritus professor of medicine and former dean for medical education, Harvard Medical School; Edward D. Hundert, MD, senior lecturer in medical ethics and director, Academy Center for Teaching and Learning, Harvard Medical School; Paul S. Russell, MD, John Homans Distinguished Professor of Surgery and Chair of the Standing Committee on Faculty Conduct, Harvard Medical School; Luke Sato, MD, assistant clinical professor of medicine, Harvard Medical School, and senior vice president and chief medical officer, CRICO/Risk Management Foundation of the Harvard Medical Institutions, Inc.; Richard M. Schwartzstein, MD, professor of medicine, director of the academy, and vice president for education, Beth Israel Deaconesss Medical Center, Harvard Medical School; and Anthony D. Whittemore, professor of surgery, Harvard Medical School, and chief medical officer, emeritus, Brigham and Women’s Hospital. The authors also gratefully acknowledge two anonymous reviewers and an editor of Academic Medicine for valuable suggestions that considerably strengthened the manuscript.
Funding/Support: None.
Other disclosures: None.
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© 2012 Association of American Medical Colleges
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ADDENDUM G
56 Addendum G
Palomar Medical Center Escondido
Hospital Acquired Conditions Reduction Program
Performance Period Performance Period Performance Period = CY2013 = CY2014 = CY2015 ‹#› 57 Addendum G
Palomar Medical Center Poway
Hospital Acquired Conditions Reduction Program
Performance Period Performance Period Performance Period = CY2013 = CY2014 = CY2015 ‹#› 58 Addendum G
PMC Joint Medical Staff Hospital Acquired Conditions Reduction Program Report
‹#› 59
ADDENDUM H
60 Addendum H
Regulatory Readiness update reports will be distributed at the meeting.
61
ADDENDUM I
62 Addendum I
Passion. People. Purpose.TM
Diabetes Services BQRC January 2018
Alan J. Conrad, MD Valerie Martinez Tamrah Jennings Jasmina Namenyi Blanca Jimenez‐Harding
1 1
Glucometrics
Dr. Conrad
• Mean Glucoses by Patient Day ICU • Mean Glucoses by Patient Day non‐ICU • Mean Glucose by Hospital • Hypoglycemia by Population
2
63 Addendum I
Mean Glucoses by Patient Day PMC Escondido 4 SW 2017 100.0
90.0
80.0
70.0
P 60.0 e r c 50.0 >180 e 90-180 n 40.0 t
30.0
20.0
10.0
0.0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Month
3
Mean Glucoses by Patient Day PMC Escondido 5W 2017 100.0
90.0
80.0
70.0
P 60.0 e r c 50.0 >180 e n 90-180 40.0 t
30.0
20.0
10.0
0.0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Month
4
64 Addendum I
Mean Glucoses by Patient Day ICU PMC Poway 2017 100.0
90.0
80.0
70.0
P 60.0 e r c 50.0 >180 e 90-180 n 40.0 t
30.0
20.0
10.0
0.0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Month
5
Mean Glucoses by Patient Day PMC Escondido 2017 100
90
80
70
P 60 e r c 50 >180 e n 90-180 40 t
30
20
10
0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month
6
65 Addendum I
Mean Glucoses by Patient Day PMC Poway 2017 100.0
90.0
80.0
70.0
60.0
50.0 >180 90-180 40.0
30.0
20.0
10.0
0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Percent
7
Mean Glucoses by Patient Day PMC Downtown 2017 100.0
90.0
80.0
70.0
P 60.0 e r c 50.0 >180 e n 90-180 40.0 t
30.0
20.0
10.0
0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month
8
66 Addendum I
Mean Glucose by Hospital 2017 200.0
180.0
M 160.0 e a n 140.0
G l 120.0 PHDC u c PMC ARU 100.0 o PMC MHU s POM e 80.0 POM GPU m PMC g 60.0 / d L 40.0
20.0
0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month
9
Hypoglycemia Rates by Total Population Palomar Health 2017 2.5
2.0 2.0 2.0 2.0 2.0 2.0 2.0
1.6 P 1.5 1.5 e r c % <70 e n %<40 t 1.0 1.0 1.0 1.0 1.0
0.5
0.13 0.1 0.09 0.1 0.1 0.07 0.07 0.05 0.06 0.08 0.08 0.08 0.0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month
10
67 Addendum I
To‐Dos
• Continue to work with the hospitalist groups on glycemic control • Promote use of Intravenous Insulin on the Intermediate Care Units when indicated • Additional roll‐out of Glycemicare • Submission of glucose data to the Society of Hospital Medicine eQuips software
11
Diabetes Services Tamrah Jennings, MSEd, MSN, APRN, ACCNS‐AG, CDE
12
68 Addendum I
Physician Documentation of Diabetes Classification: PMC Escondido
13
Physician Documentation of Diabetes Classification: PMC Poway
14
69 Addendum I
Documentation of Patient Understanding of A1c: PMC Escondido
15
Documentation of Patient Understanding of A1c: PMC Poway
16
70 Addendum I
Blood Glucose Testing in Orthopedic Patients Receiving Steroids: PMC Escondido
17
Blood Glucose Testing in Orthopedic Patients Receiving Steroids: PMC Poway
18
71 Addendum I
Joint Commission Measures: Opportunities and Action Plan • Diabetes Classification: – Providers to continue to use other nomenclature for diabetes than accepted classification of Type 1, Type 2, or Gestational diabetes, measure not at goal of 90%. • Communicate with physicians that are not compliant with use of correct diabetes classification • Stress importance of correct diabetes classification in medical staff meetings • A1c Monitoring: – Measure not at goal of 80% for Palomar Health Poway • Continue to provide data to nursing units and leadership. • Education slide regarding A1c monitoring provided to unit nurse leadership nurses to be shared at huddles. • Stress A1c monitoring in nursing orientation and Quarter 2 diabetes competencies • Update of Diabetes Education book to emphasize A1c and diabetes survival skills • Press Ganey Diabetes Specific Data: – Question regarding helpfulness of diabetes self care handouts decreased from 89.9% in 2015 to 83.6% in 2017. • Continue to provide data to nursing units and leadership. • Educate staff on location and re‐ordering of Diabetes Education books for nursing units
19
Joint Commission Intracycle Call
• Anticipated call January 2018 • Retire Measures: Orthopedic Surgery Patients Receiving Steroids (Unable to obtain support from Orthopedic physicians for blood glucose testing) Reduction of Basal Insulin after Hypoglycemic Event (Unable to build valid report due to Cerner limitations) • Proposed new measures: Documentation of hypoglycemic events in iView Administration of insulin within 30 minutes of POCT glucose
20
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PERFORMANCE IMPROVEMENT ACTIVITIES AND PRESS GANEY DIABETES SPECIFIC DATA
21
Performance Improvement Activities
• Quarter 2 Nursing Diabetes Education modules updated to reflect EBP and current ADA and JC standards • Made improvements to Diabetes intranet page for nursing ease of use, added job aids for nursing staff • RRN/Phone for 40 Program instituted at Palomar Health Poway • Lucidoc Procedures updated to reflect EBP and current ADA standards • Hypoglycemia Standardized Procedure (Lucidoc # 21170) updated to include new ADA definition of severe hypoglycemia. All Nursing staff given iXpand module for this change.
22
73 Addendum I
Performance Improvement Activities:
• Ongoing collaboration with Anesthesia, Peri‐op team, Pharmacy regarding blood glucose management in perioperative patients • Taught multiple Stop the Line classes • Diabetes presentation created and now provided to RN new hires during orientation. • Created Insulin meal tray delivery work group to address opportunities in charting % meal eaten, blood glucose testing, and insulin administration for meals • Collaborated with Pre‐Admission regarding safe admission practice for patient with insulin pumps
23
Performance Improvement Activities: Glycemicare • ICU Go‐Live January 2017: Educated ICU staff on use of Glycemicare and its insulin calculators • IMC Go‐Live July 2017: Educated RN staff on IV Insulin drip, Powerplans, and Glycemicare • ED Go‐Live July 2017: Collaborated with ED CNS and physicians to create new ED Hyperglycemia Powerplan with subphases, educated staff on Powerplan and use of Glycemicare and its insulin calculators • OB anticipated spring 2018: Glycemicare education anticipated with new OB Powerplan roll‐out
24
74 Addendum I
Updates
• Poster presentation at Sharp Healthcare’s Innovations and Technology conference
• Bachelor’s prepared diabetes nurse educator, Blanca Harding, joined the Diabetes Services team
• CNS, Tamrah Jennings, passed the NBCDE’s Certified Diabetes Educator (CDE) exam
25
Diabetes Awareness Month November 2017 • Collaborated with Marketing department and FANs department to create social media and hospital‐wide promotion
• Placed videos on the Palomar Health home Page with introduction by Tamrah Jennings, Diabetes CNS, and Dr. Illich, and interviews of staff members living with diabetes.
26
75 Addendum I
Diabetes Awareness Month November 2017 • Table tents placed at all campuses in the lobbies and café
• Tables set up outside cafés of Poway and Escondido campus with information regarding all aspects of diabetes health and management
27
Mean Trends Inpatient Palomar Medical Center Escondido Question - Helpful diabetes self-care handouts
Palomar Medical Center Escondido
Displayed by Received Date
76 Addendum I
Mean Trends Inpatient Palomar Medical Center Poway Question - Helpful diabetes self-care handouts
Palomar Medical Center Poway
Displayed by Received Date
Mean Trends Inpatient Palomar Medical Center Escondido Question - Understanding diabetes medications
Palomar Medical Center Escondido
Displayed by Received Date
77 Addendum I
Mean Trends Inpatient Palomar Medical Center Poway Question - Understanding diabetes medications
Palomar Medical Center Poway
Displayed by Received Date
Mean Trends Inpatient Palomar Medical Center Escondido Question - Understanding diabetes medications
Palomar Medical Center Escondido
Displayed by Received Date
78 Addendum I
Mean Trends Inpatient Palomar Medical Center Poway Question - Understanding diabetes medications
Palomar Medical Center Poway
Displayed by Received Date
Mean Trends Inpatient Palomar Medical Center Escondido Question - Helpful diabetes self-care handouts
Palomar Medical Center Escondido
Displayed by Received Date
79 Addendum I
Mean Trends Inpatient Palomar Medical Center Poway Question - Helpful diabetes self-care handouts
Palomar Medical Center Poway
Displayed by Received Date
80
ADDENDUM J
81 Addendum J
Passion. People. Purpose.TM
Disease Specific Stroke Program
Presented to Board Quality Review Committee January 15, 2018
Lourdes Januszewicz MSN APRN ACNS‐BC SCRN CCRN Remia Paduga, MD, Medical Director Valerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA‐BC
1
Joint Commission (JC) Stroke Core Measures
• STK‐1 Venous Thromboembolism (VTE) Prophylaxis • STK‐2 Discharged on Antithrombotic Therapy • STK‐3 Anticoagulation Therapy for Atrial Fibrillation/Flutter • STK‐4 Thrombolytic Therapy • STK‐5 Antithrombotic Therapy By End of Hospital Day 2 • STK‐6 Discharged on Statin Medication • STK‐8 Stroke Education • STK‐10 Assessed for Rehabilitation
2
82 Addendum J
Stroke Core Measures CY 2017 Qtrs. 1‐3
JC Stroke Core Measures JC Stroke Core Measures PMC Escondido PMC Poway 100% 100%
80% 80%
60% 1st Qtr 60% 1st Qtr 2nd Qtr 2nd Qtr 40% 3rd Qtr 40% 3rd Qtr 4th Qtr 4th Qtr 20% 20%
0% 0%
3
Performance Improvement Stroke Core Measures
• Goal: Core Measures meet at 98% or > • Action Plan: – Review of all cases that fall out – Follow‐up with Nursing or Medical Providers – Continue to monitor for compliance – Provide Education in 2018: • Review of Core Measures
‹#›
83 Addendum J
Current Program Status
Total Number of Stroke Cases per Year
1200 1061 1019 1000 917 834 804 800 773 671 600 539 571 400 211 215 209 169 196 173 200 116 134 127 0
PMC Escondido PMC Poway
2016 and 2017 Stroke Cases: includes Ischemic Strokes and Hemorrhagic Strokes; TIAs not included
5
Current Program Status
Total Number of Patients receiving Tissue Plasminogen Activator (tPA) 120 106 100 92 89
80 71 PMC 65 Escondido 60 47 47 40 34 32 PMC 23 19 Poway 20 15 16 14 10 7 5 6 0
Years: Program Start to Present
6
84 Addendum J
Summary: Alteplase (tPA) Administered 2017
Palomar Health • Total Administration of Alteplase (tPA): 135 patients • PMC Escondido –89 patients received Alteplase • % compliance
7
Stroke Alteplase (tPA) Measures PMC Escondido Plan Do ‐ Measurement
Numerator Indicator (Successes) Alteplase (tPA) administration
Denominator Alteplase (tPA) Administration
Start Date: 1/1/2017 Target: 50% Responsible Leader: Lourdes Januszewicz
Summary 100% Num Den % Target
Jan‐17 6 10 60% 50% 80% Feb‐17 5 7 71% 50% Mar‐17 1 3 33% 50% 60% Apr‐17 10 12 83% 50% May‐17 4 7 57% 50% 40% % Compliant Jun‐17 5 7 71% 50% 20% Jul‐17 2 4 50% 50% Aug‐17 3 6 50% 50% 0% Sep‐17 3 3 100% 50% Oct‐17 7 13 54% 50%
Nov‐17 4 8 50% 50% % Target Dec‐17 7 9 78% 50%
85 Addendum J
Performance Improvement 2017 PMC Escondido Pit Stop Process Adoption
• Door to Provider: – Goal
• Door to CT Start: • Goal
• Door to CT Results: – Goal
• Door to S. Creatinine: • Goal
Stroke Alteplase (tPA) Measures
PMC Poway Plan Do ‐ Measurement
Numerator Indicator (Successes) Alteplase (tPA) administration
Denominator Alteplase (tPA) Administration
Start Date: 1/1/2017 Target: 50% Responsible Leader: Lourdes Januszewicz
Summary Num Den % Target 100% Jan‐17 3 6 50% 50% Feb‐17 5 6 83% 50% 80% Mar‐17 2 3 67% 50% 60% Apr‐17 3 7 43% 50% May‐17 0 4 0% 50% 40%
Jun‐17 0 1 0% 50% % Compliant Jul‐17 1 3 33% 50% 20% Aug‐17 3 3 100% 50% Sep‐17 4 5 80% 50% 0% Oct‐17 0 2 0% 50% Nov‐17 1 2 50% 50% % Target Dec‐17 3 4 75% 50%
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Performance Improvement PMC Poway Pit Stop Process
• Rollout November 13 2017 • Purpose: – Improve Process times to meet the 60 min window for tPA administration • Measures to be monitored for improvement: – Door to Provider: Goal
• ***iSTAT Point of Care for Chemistry Lab adopted in October 2017
Program Status: JC Cycle % Compliance Door 2 Drug (D2D) <60 min
• PMC Escondido ‐ Cycle May 2017 –April 2019 – Total tPA Cases: 57 – Total tPA Cases D2D <60 min: 35 – % Compliance JC Cycle: 61%
• PMC Poway –Cycle May 2017 –April 2019 – Total tPA Cases: 24 – Total tPA Cases D2D <60 min: 12 – % Compliance JC Cycle: 50%
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Neuro Interventional Radiology (IR) Current Program Status
Total Number of Patients receiving Neuro IR Procedures
70 62 59 60 55
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40
30
20 14
10
0 2014 2015 2016 2017
Years: Program Start to Present
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2017: Average D2P MIN 260 240 Neuro220 IR: 2017 Door to 200 189 180 145 Puncture(D2P)160 136 140 124 125 110 107 120 96 99 100 100 Avg80 Minutes/Month 60 47 40 20 0 0
2017 Average D2P : 116 Minutes
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ACCOMPLISHMENTS AND PROJECT IMPROVEMENT ACTIVITIES
Accomplishments: Community Education 2017
• Feb 2017: Stroke Talk by Stroke Medical Director • Mar 2017: Stroke Educational Program at University of San Diego by Stroke Coordinator • May 2017: Stroke Talk by Stroke Medical Director • Aug 2017: Dine with Docs Program at the RB Inn – Speakers Mayo Clinic Provider and Stroke Medical Director • Aug 2017: Stroke Education to Poway Fire by Stroke Coordinator • Sept 2017: Stroke Education to Valley Center Fire by Assistant Base Hospital Coordinator in collaboration with Stroke Coordinator
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Accomplishments: Community Volunteer Events 2017
• Feb 2017: Participation in AHA/ASA Love Your Heart • May 2017: Participation in Strike Out Stroke Event at the San Diego Padres (rained out) • July 2017: Participation in Rancho Penasquitos Lutheran Church Annual Health Fair • Sept 2017: Participation in Strike Out Stroke Event at the San Diego Padres (Make up day) • Sept 2017: Participation in the AHA/ASA 1st North County Heart Walk • Oct 2017: Participation in San Diego Aging Expo
Accomplishments: Stroke Program 2017
• Feb 2017: Stroke Coordinator certified thru ANCC as Stroke Certified RN (SCRN) • May 23 2017: – Successful 5th Joint Commission Recertification for Advanced Primary Stroke Center at PMC Escondido • May 24 2017: – Successful 5th Joint Commission Recertification for Advanced Primary Stroke Center at PMC Poway
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Proposed Quality Improvement Projects 2018
• Continue to Improve Pit Stop Process to meet Target Stroke Phase 2 Goals – Goal 1: Door to Drug tPA
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Contact Information
Lourdes Januszewicz MSN APRN ACNS‐BC SCRN CCRN District Stroke Program Coordinator Palomar Health Office 442‐281‐2092 [email protected]
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