april 11, 2005 king/drew medical center implementation plan update hospital advisory board

April 11, 2005

King/Drew Medical Center

Implementation Plan Update

Hospital Advisory Board

King/Drew Medical CenterImplementation Plan Update - April 11, 2005

Background and Assessment

• The County of Los Angeles entered into a Memorandum of Understanding (MOU) with the Centers for Medicare and Medicaid Services (CMS) which required the engagement of an outside contractor to provide interim managerial support at King/Drew Medical Center to assess the major systems and operations and assist in the restructuring of KDMC’s operations based on that assessment.

• Navigant Consulting (NCI) was contracted with in October of 2004 to provide these services.

• NCI conducted a comprehensive assessment of all systems and operations at KDMC which included a detailed action plan to address each of the deficiencies/inefficiencies identified.

• The initial assessment of acute care operations and the identification of performance improvement opportunities at KDMC was completed January 3, 2005.

• The assessment of ambulatory services and the final assessment of governance and programs/services was completed February 1, 2005.


Identification of Critical Success Factors

• Upon completion of the assessment several factors were identified that are critical to success:

– An integrated, prioritized focused plan with ownership and commitment to its success by all stakeholders

– “Real” governance

– “Sleeves rolled up, visible” leadership

– Partnership with CMS, JCAHO and regulators in “finding solutions” versus “finding fault”

– Disciplined execution of the plan with an “attention to detail mentality”

– Defined individual roles and accountability “deep” into MLK

– Sufficient, capable resources to enable success

– Sufficient time to execute

– Definition and commitment to the mission and vision of MLK

– Communication, communication, communication – inside and out


Situational Analysis Report: Baptist Health Care Leadership Institute

• As part of the assessment the Baptist Health Care Leadership Institute conducted a Situational Analysis Report to:

– Identify current strengths as they relate to service and operational excellence– Identify opportunities for improvement– Recommend strategies for areas to focus on over the coming year to move MLK/Drew

forward.

• KDMC employees were asked to complete the Service Excellence Survey™. More than 400 employees at various levels of the organization responded to the survey. The survey analysis lends its focus on five key dimensions of service and operational excellence.

• Other tools were used to assess the current culture at KDMC and include qualitative research methods, such as:

– Medical Staff interviews and focus groups– Employee and Directors focus groups– Interviews with community leaders, Drew University representatives, Department of Health

Services leaders, and union representatives.

• First Impression Audits were conducted by walking around the facility.


Situational Analysis Report

Summary of Findings

• KDMC has a rich history, a diverse work force and is positioned with a desire to move the organization toward greater achievements and fulfillment of its mission and vision.

• There is a large group of dedicated and passionate employees and physicians paired with a sense of commitment to serving the community which can be leveraged to take the organization to greater levels of achievement in the area of service and operational excellence.

• As KDMC introduces proven strategies and practices focused on service excellence, the organization should be able to create the synergistic energy needed for substantial breakthrough advancements. However, organizations often find it difficult to transform their culture.

Overview of Identified Strengths

• Strengths identified include, but are not limited to: – Employee and physician pride in the hospital.– Long-term employees’ commitment and loyalty.– An understanding and support of the mission of providing comprehensive medical care to the community.

• Other strengths revealed through the analysis were: – The affiliation with Drew University.– The diversity of the work force. – The support from the community.


Required Culture Changes

• Findings indicate that KDMC has a culture of excuses and blaming. • Opportunities for improvement include:

– Involvement and participation– Leader visibility and approachability– Leaders leading by example– Leadership development– Planning and direction (the organization is reactive versus proactive)– Accountability– HR practices as they relate to service excellence– Communication– Cross-departmental teamwork– A consistent and well-deployed customer service focus in every department

• There needs to be a re-dedication to the stated mission and vision of KDMC which are:

– Mission: To provide quality, comprehensive medical care, that is accessible, acceptable and adaptable to the needs of the community we serve.

– Vision: An academic medical center of excellence that is caring, compassionate and competent, focusing on the needs of our culturally diverse community as well as ways to continually improve our service.

• Values need to be developed and internalized.


Implementation Plan: 1,066 Recommendations 3,662 Action Steps*

*Note: The implementation plan is a “living” workplan. As such, the number of recommendations and action steps may change over the course of the workplan implementation.

Governance 14 Management/Structure 7 Risk Management 22 Regulatory 23 Performance and Quality Improvement 52 Infection Control 27 Budget 11 Productivity 7 Space Planning 5 Environment of Care 14 Facilities Management 10 Materials Management 13 Contracted Services (Respiratory) 6 Contracted Services (Dietary) 7 Contracted Services (Security) 2 Communications 8 Case Management and Utilization 46 Capacity and Throughput 30 Physical Therapy 6 Transport 1 Emergency Services 64 Perioperative Services 45 Med Admin - Clinical Programs and Medical Departments

34

Med Admin - Medical Staff Affairs 52 Med Admin - Quality, Performance Improvement, Utilization and Case Management

24

Med Admin - Administrative Issues / Medical Admin 10 Nursing Services - overall 82 Psychiatric Services - overall 42 Information Technology - overall 17 Health Information Management - overall 66 Human Resources - overall 29 Radiology 31 Laboratory/Pathology 55 Pharmacy 31 Cardiology 13 Neuroscience 8 Ambulatory Services - overall 103 Programs & Services - overall 49

KDMC Total 1,066

Total Num of Recommendations

Initiative


Implementation Plan: Measurement and Tracking

• Results Management Office was established to provide discipline and structured tracking and measurement that are critical to the success of the Implementation Plan.

• Each Initiative has a Workplan that was developed in collaboration with KDMC Leadership. The Workplan components include:

– Time frame for each Recommendation

– Action Steps

– Accountable person for each Action Step

– Due Date for each Action Step

– Implementation Risks Identified

• The Workplan is a “living” plan. It is updated to reflect changes in course deemed appropriate. Timelines however, will not be changed without agreement of the KDMC CEO and COO.

• Each Action Step is reviewed at their due date to ensure completion. Any Action Steps that are not achieved will be ‘flagged’ and a remediation plan is identified and executed.


Supportive Groups: HR, Facilities and Information Technology

• Three sub groups composed of select KDMC, DHS and LAC meet regularly to support completion of the Action Steps.

– Human Resources – Facilities and Equipment– Information Technology

• The Human Resource Group supports:– Performance evaluation and management process– Management training and organizational development– Monitoring of regulatory compliance– Employee relations including grievance remediation– Recruitment and retention– Provision of operating report and data– Development of KDMC policies and procedures– Classification

• The Facilities/Equipment Group supports the identification, planning and implementation of facility changes. This group also supports the identification of needed equipment and expedites their acquisition.

• The Information Technology Group supports and coordinates technology required to execute the plan. They also prioritize department upcoming/existing job requests and allocate resources appropriately.


Tracking Workplan Implementation

Sample WorkplanSection: S10 - Ancillary ServicesInitiative: I02 - Laboratory/PathologyKDMC Management: L. McAuleyKDMC Senior Staff: P. ValenzuelaNCI Support: J. RodasUpdate Lead: H. Mohamed

Status Update Through: 4/1/05

ID Workplan Status UpdateFilter

Rec Identifier

Time Frame Description

Recommendation Description Group Action Step Num

Action Step Description Due Date Action Step Due

This Week?

Complete? (Yes/No)

Status (Red/

Yellow/ Green)

Risk Identified? (Yes/No)

Remediation Plan (if status is red/yellow or if

action step is not completed)

Comments

S10-I02-R017 Urgent Revamp patient registration/check in process for blood collection; incorporate home collected specimen drop off.

OVERALL 0 N/A 2/28/05 DUE! Yes Green


ACTIONS 1 Outline new patient check in and registration process; obtain approval from lab manager/director

1/18/05 DUE! Yes Green No


ACTIONS 2 Identify patient sign-in sheets and establish new patient flow logistics (I.e. . Sign in Vs number system)



ACTIONS 3 Prepare area for home collected specimen drop off and processing



ACTIONS 4 Incorporate runner pick up/delivery into new process



ACTIONS 5 Convene meeting with nurse managers to discuss new specimen drop off station; operational changes



ACTIONS 6 Write and/or update pertinent protocols and policies to support new process



ACTIONS 7 Complete staff training and competency validation


S10-I02-R018 Short-term Initiate phlebotomy services for psychiatry. OVERALL 0 N/A 6/30/05 Yellow New phlebotomy staff has been hired (3/30). Service implementation plan currently underway. Planned go-live

S10-I02-R018 Short-term Initiate phlebotomy services for psychiatry. ACTIONS 1 Convene meeting with Psychiatry manager and conduct needs assessment


S10-I02-R018 Short-term Initiate phlebotomy services for psychiatry. ACTIONS 2 Evaluate psychiatry unit needs Vs available phlebotomy resources and schedules


S10-I02-R018 Short-term Initiate phlebotomy services for psychiatry. ACTIONS 3 Develop phlebotomy training program (of high risk area); complete staff training; validate competency

4/1/05 DUE! No Yellow No Although a slight delay was experienced due to the need to hire new staff, the laboratory and Psych. Department are back in track with the target

S10-I02-R018 Short-term Initiate phlebotomy services for psychiatry. ACTIONS 4 Write pertinent protocols, policies, and procedures

5/1/05 No

S10-I02-R018 Short-term Initiate phlebotomy services for psychiatry. ACTIONS 5 Verify nurse proficiency and competency ordering labs in Affinity (complete additional training if needed)

5/1/05 No

S10-I02-R018 Short-term Initiate phlebotomy services for psychiatry. ACTIONS 6 Provide access to secure unit to all phlebotomy personnel

5/1/05 No

Bi-Weekly Update


Management of Risk

• Established a Chief Implementation Officer to oversee the implementation of the Workplan and establishment of performance measures.

• A warning dashboard system was defined to communicate issues to KDMC leadership on recommendations behind the plan timeframe or at risk for other reasons.

Green Completed or to be completed by the identified due date without major obstacles.

Yellow Completion is likely, however it may be delayed (not major delay). The issues are manageable.

Red Major risk has been identified, and/or completion will be delayed (major delay).

• KDMC leadership review the dashboard and proactively identify and revise action plans to manage the risk identified.


Recommendations and Identified Status

All Recommendations

"Green" Recommendations

"Yellow" Recommendations

"Red" Recommendations

Count % Count % Count %

Governance 14 13 93% 1 7% - 0%Management/Structure 7 7 100% - 0% - 0%Risk Management 22 21 95% 1 5% - 0%Regulatory 23 20 87% 3 13% - 0%Performance and Quality Improvement 52 48 92% 4 8% - 0%Infection Control 27 27 100% - 0% - 0%Budget 11 11 100% - 0% - 0%Productivity 7 4 57% 3 43% - 0%Space Planning 5 3 60% 1 20% 1 20%Environment of Care 14 12 86% 1 7% 1 7%Facilities Management 10 9 90% 1 10% - 0%Materials Management 13 10 77% 2 15% 1 8%Contracted Services (Respiratory) 6 6 100% - 0% - 0%Contracted Services (Dietary) 7 7 100% - 0% - 0%Contracted Services (Security) 2 2 100% - 0% - 0%Communications 8 8 100% - 0% - 0%Case Management and Utilization 46 41 89% 5 11% - 0%Capacity and Throughput 30 26 87% 4 13% - 0%Physical Therapy 6 6 100% - 0% - 0%Transport 1 1 100% - 0% - 0%Emergency Services 64 64 100% - 0% - 0%Perioperative Services 45 44 98% 1 2% - 0%Med Admin - Clinical Programs and Medical Departments

34 31 91% 3 9% - 0%

Med Admin - Medical Staff Affairs 52 52 100% - 0% - 0%Med Admin - Quality, Performance Improvement, Utilization and Case Management

24 24 100% - 0% - 0%

Med Admin - Administrative Issues / Medical Admin 10 10 100% - 0% - 0%Nursing Services - overall 82 78 95% 4 5% - 0%Psychiatric Services - overall 42 39 93% 3 7% - 0%Information Technology - overall 17 10 59% 7 41% - 0%Health Information Management - overall 66 52 79% 12 18% 2 3%Human Resources - overall 29 25 86% 4 14% - 0%Radiology 31 26 84% 4 13% 1 3%Laboratory/Pathology 55 46 84% 7 13% 2 4%Pharmacy 31 23 74% 6 19% 2 6%Cardiology 13 - 0% - 0% - 0%Neuroscience 8 - 0% - 0% - 0%Ambulatory Services - overall 103 0% 0% 0%Programs & Services - overall 49 0% 0% 0%

KDMC Total 1,066 806 76% 77 7% 10 1%


Initiative

Note: As of 4/1/05, Recommendations in areas of Cardiology, Neuroscience, Ambulatory and Program&Services do not have their "status" defined. As a result, total number of recommendations in Green, Yellow and Red do not add up to 100%.


Performance Measures

• In addition to tracking the status of the recommendations and workplans, we are establishing performance measures that will measure the success of the plan.

• Creating organizational performance measures in the following areas:. • Human Resources

• Productivity

• Finance

• Regulatory

• Quality and Performance Improvement

• Establishing key performance measures for each initiative/department.• Planning to initiate a Press Ganey - patient satisfaction survey.• Planned implementation of the UHC Patient Safety Net and Near Miss Reporting

System.


Planned Performance Measure Roll-out

KDMC Hospital-wide Performance Measures - Mar05

Human Resources Measures

Labor Productivity Monitoring - May05

Regulatory Monitoring

Department-Specific "Compass"

Materials Mgmt

Report to BOS, HAB

Maintained within Depts

RadiologyPharmacyLaboratory

EDPeriop

Environment Facilities Mgmt

Case Mgmt & Utilization

Capacity & Thruput

Ambulatory

HIM

Cardiology

Neuroscience

Nursing Svcs Psych Svcs

Performance Improvement & Quality Improvement, Risk Management - May05

(Same accountability holds for Department Compass as for Workplan)

Incorporate / Link with

other reports

UHC "Key Indicator Report" Aug05

HQA "Hospital Quality

Measures"

Press Ganey "Patient

Satisfaction Survey"

LAC "Performance

Measure"

Infection Control Monitoring

Financial Monitoring - May05

IT


Sample Performance Measures: HR

KDMC Management: H. Wells

KDMC Senior Staff: M. Henry

Lead: S. Stern

Monthly Performance Measures

Item Nov/Dec Target Jan-05 Feb-05 Mar-05 Corrective Action

Turnover rate (KDMC Total) 6.5% <10% 15.7% 15.5% 15.0%Identify action steps based on the Service Excellence Survey. Identify causes of "unhealthy" turnover. Develop an employee retention strategy.

Turnover rate (KDMC Supervising Staff Nurses, RNs, and LVNs) NC TBD 21.9% 20.2% Continue vigorous recruitment activities.Overall number of PARs 161 TBD 259 "Cleaned up" the PAR data. Review monthly.Number of approved PARs 48 TBD 198 Continue vigorous recruitment activities.Average time to fill a position from approved PAR 161 60-90 days 195 161 208 Identified key position recruitment list to track the recruitment process.Number of recruited approved PARs 48 NA 27 32 78 Enhance recruitment effort including a targeting of key positions.Net gain or loss of staff total 6 TBD 15 7 -4 See above.Net gain or loss registered nurses NC TBD 6 3 -1 See above.Net gain or loss LVNs NC TBD -1 1 0 See above.Number of staff non-compliant with annual health service screening (excluding ELP)

NC 0Sending out a letter 1 month prior to due date to alert staff. Establishing a policy on consequences of non-compliance.

Percentage of sick hours to regular hours worked NC TBD 10.5% 11.8% NYA Monitor % by department to identify trends/issues.Percentage of AWOP (authorized) sick hours of regular hours worked

NC TBD 0.7% 0.6% NYA Monitor % by department to identify trends/issues.

Percentage UNAWOP (unauthorized) sick hours of regular hours worked

NC TBD 2.5% 2.2% NYA Monitor % by department to identify trends/issues.

Number of staff on ELP (Extended Leave Program) NC NA 108 101 NYA Implement program to improve management.

Number of open claims to total employee population NC NA 605 591Established a case management program to manage cases. 8 new hires to manage cases (target caseload 1:50)

Percentage of open claims to total employee population NC 20% 25.6% NYA See above.Total number of lost hours for workmans compensation cases NC TBD 1941 1409 NYA See above.Total number of lost FTEs for workmans compensation cases NC TBD 9.3 7 NYA See above.

Number of active third level employee grievances NC NA 38 25

Redesigned and educated senior management on the Performance Management function (including key functions and activities, role clarification, identifying the team, creating an "issue" referral algorithm. Created an "issue" referral priority system and targeted response time. Collecting KDMC feedback on the Performance Management function.

Percentage of active third level employee grievances to total employee population

NC <5% 1.6% NYA See above.

Number of open discipline cases NC NA 184 179 See above.Percentage of open discipline cases to total employee population NC 5% 7.8% NYA See above.

Percentage of staff with completed performance evaluation - nonMAPP

8% 100% 53.7% 64.5%

"Cleaned up" the measurement and tracking. Identified barriers to completion of PEs. Established a group-wise notification to managers of those PEs that are due and upcoming due. Clarified PE manager expectations including required attachments. Review all PE forms for opportunities to streamline while meeting overall goals and JCAHO. Deadline for backlog completion is the end of April.

Percentage of MAPP staff with completed performance evaluation NC 100% NYA See above.

Percentage of staff with documented attendance at orientation (cumulative)

NC 95% 50% 74%Identified 91 noncompliant people. Names distributed to supervisors. Adding additional classes to the schedule. If failure to comply HR will institute disciplinary actions.

Percentage of agency and traveler staff with documented attendance at orientation (cumulative)

NC 95% Developing a reorientation package. Identifying strategies for automating.

Percentage of compliance with annual health update


Sample Performance Measures: Laboratory

KDMC Management: L. McAuley

KDMC Senior Staff: P. Valenzuela

Lead: H. Mohamad

Monthly Performance Measures

Item Baseline Target Jan-05 Feb-05 Corrective Action

Percentage of STAT test requests to all test requests 40-83% <20% 35% 35%1. Lab Advisory Committee is currently revamping the STAT test menu 2. New test menu finalized, policy currently in draft format 3. New test menu and policy to be introduced in April 2005

Overall STAT turnaround time (minutes from received to reported)

72 min < 60 min 59 63

1. Test menu consolidation is underway (have completed initial correlation studies to enable the process) 2. Work station consolidation planned for end of April (once all systems have been tested) 3. Conducting additional root cause analysis of TAT process to further improve the process

Overall turnaround time from the time test is ordered (hours) 3 hours <1.5 hours 2.7 2.9

1. Test menu consolidation is underway (have completed initial correlation studies to enable the process) 2. Work station consolidation planned for end of April (once all systems have been tested) 3. Conducting additional root cause analysis in the pre-analytical steps of the process 4. Additional phlebotomy support has been hired and is currently in training

Ratio of Type and Cross match to transfusion <2:1 <2:1 1.8 1.8 On target, but monitoring all systems in placePercentage of blood transfusion incidents to transfusions <1% <2% 1% 1% On target, but monitoring all systems in placeBlood product waste rate 5.6% <2% 4.4% 2.8% On target, but working with blood usage committee to further decrease wastePercentage of critical result read-back documentation 75% 100% 95% 97% 1. Continue to work with technical staff and re-enforce policy

Percentage of specimen rejection >2% 1.5% 1.1% 1.0%1. Developed incident report tracking tool to conduct root cause analysis 2. Currently working with Risk Manager to evaluate data and corrective action

Percentage of documented Incidents (based on number of lab requests received)

NC < 0.5% 0.3% 0.5%

1. Incident tracking tool has been developed and tested 2. Have identified the ED as the main source of incidents 3. Began meetings/discussions with ED to address various issues 4. Have tested ED printers and will begin to print STAT results remotely (exact date in April TBD)

Blood culture contamination rate 8% <3% 4.8% 5.0%

1. Conducting additional root cause analysis of remaining areas of concern that are leading to contaminated blood cultures 2. Continue to re-enforce policy requiring only phlebotomists to draw blood cultures 3. Have added additional phlebotomists to staff, including the night shift where dedicated phlebotomists weren't available

Percentage of outpatient visit wait time less than 5 minutes NC 75%1. Have obtained the initial data to establish a baseline 2. Currently considering a patient comment card to be located in the phlebotomy area

Customer satisfaction rating - External (Outpatient Lab) NC 80%1. Currently reviewing Q-Track tool available through the College of American Pathologists, which has allowed the laboratory to collect initial data. Reported quarterly.

Customer satisfaction rating - Internal NC 80%1. A work group led by Dr. Theresa Loya has developed a satisfaction survey 2. NCI has reviewed and provided input on the survey format and measurement tool 3. Survey will be released on schedule by April 15, 2005

Percentage of Point of Care Testing (POCT) non-compliance 0.72% < 1.5% 0.72% 0.55% On target. Will continue to monitor.

Surgical pathology turnaround time (overall days) 2.5 < 3 days 2.5 2.5On target, but considering additional improvements in the physical lay-out of the transcription department, new dictation system, and a revamped work flow process to further improve TAT

Surgical frozen section turnaround time (minutes) 16.8 < 20 min 16.8 18.2% On target. Will continue to monitor.

Cytology Non-GYN turnaround time (days) 2.8 < 3 days 2.8 2.2On target, but considering additional improvements in the physical lay-out of the transcription department, new dictation system, and a revamped work flow process to further improve TAT


Sample Department Specific Performance Measures: Perioperative Services (1)

OR Overall Suite Utilization, without TOT

75%

26%

21%24%

22%

0% 0% 0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Target Baseline Oct-Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05

Pe

rce

nta

ge

First Case On-Time Starts

95%

52% 51%

57%

47%

0% 0% 0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Target Baseline Oct-Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05

Pe

rce

nta

ge


Sample Department Specific Performance Measures: Perioperative Services (2)

Patient In to Incision Time

26

20 20 20

0 0 0

44

49

44 43

0 0 00

5

10

15

20

25

30

35

40

45

50

55

Baseline Oct-Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05

Min

ute

s

Target Actual

PAR LOS

120

349

393

311

257

0 0 00

50

100

150

200

250

300

350

400

450

Target Baseline Oct-Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05M

inu

tes


Implementation Plan: Reporting

• Status of the recommendations, workplans, performance measures and results are reviewed with the KDMC leadership and management staff, Advisory Board, Board of Supervisors and regulatory bodies.

• Status updates are reviewed with KDMC leadership and management staff every other week. This group provides oversight and management of the plan. This group also serves as the discussion forum for interdependencies and synchronization of action steps. They review all performance variance in actions steps due that week for completion and discuss risks and issues with future actions steps.

• Status updates will be reported to the newly created KDMC Hospital Advisory Board and the Board of Supervisors monthly and will include the following:

– Overall status of progress by Section (Initiative).

– Measurement of Key Performance Measures.

– Areas of performance variance and corrective action plans.

– Identification of implementation risks.


Completed Recommendations

Total Recommendations

Completed

Num of Urgent Recommendations

Count %

Governance 14 5 36%Management/Structure 7 4 57%Risk Management 22 1 5%Regulatory 23 14 61%Performance and Quality Improvement 52 7 13%Infection Control 27 25 93%Budget 11 - 0%Productivity 7 1 14%Space Planning 5 1 20%Environment of Care 14 4 29%Facilities Management 10 - 0%Materials Management 13 - 0%Contracted Services (Respiratory) 6 3 50%Contracted Services (Dietary) 7 2 29%Contracted Services (Security) 2 2 100%Communications 8 2 25%Case Management and Utilization 46 7 15%Capacity and Throughput 30 7 23%Physical Therapy 6 - 0%Transport 1 1 100%Emergency Services 64 14 22%Perioperative Services 45 15 33%Med Admin - Clinical Programs and Medical Departments

34 5 15%

Med Admin - Medical Staff Affairs 52 8 15%Med Admin - Quality, Performance Improvement, Utilization and Case Management

24 7 29%

Med Admin - Administrative Issues / Medical Admin 10 - 0%Nursing Services - overall 82 17 21%Psychiatric Services - overall 42 25 60%Information Technology - overall 17 7 41%Health Information Management - overall 66 33 50%Human Resources - overall 29 20 69%Radiology 31 5 16%Laboratory/Pathology 55 20 36%Pharmacy 31 13 42%Cardiology 13 - 0%Neuroscience 8 - 0%Ambulatory Services - overall 103 - 0%Programs & Services - overall 49 - 0%

KDMC Total 1,066 275 26%


Initiative

Total Recommendations

Completed


Count %

1,066 275 26%



Urgent and Short Term “Red” Recommendations

Initiative Rec Identifier Time Frame Description

Recommendation Description Remediation Plan (if status is red/yellow or if action step is not

completed)

Space Planning S02-I09-R002 Urgent Identify critical space requirements and implement remediation plan for areas such as outpatient pharmacy.

Currently evaluating all vacant space to determine potential uses of space that can solve our critical space issues (pharmacy, OR, ER, and psych) in an effort to reduce construction time/costs.The ER has been removed from the critical needs list since there have been no CMS or JCAHO citations relative to plant that cannot be adressed by process. OSHPD plans approved, last fall, to redesign the PES triage area will be evaluated to determine if that can be fast tracked. Alternate space/set up for cashiers has been identified in the women's center that will provide additional contiguous pharmacy space at little cost. The architect presented two options for OR renovation. One is lower cost but does not include many of the patient flow and clean corridor needs. We are working with DPW to present the materials to the BOS for approval to move forward. Expect final decisions in June 2005.

Pharmacy S10-I03-R008 Urgent Build and install GE PIS. Awaiting DHS decision and implementation schedule. Continued discussion of short term strategies at the KDMC IT Group.

Environment of Care S02-I10-R013 Short-term Design and implement an infant abduction system.

Determined to not be essential by the Facilities/Equipment workgroup comprised of County based on the fact that none of the other hospitals have an infant abduction system and there is no specific JCAHO or CMS regulation requiring one.

Materials Management S02-I12-R011 Short-term Increase communication with physicians, with support from hospital leadership, to increase standardization of clinical product selection.

Discussion/meeting between CFO and COO is scheduled for 4/11/05 to seek ways to enhance VAF function and collaboration between VAF and Materials Management. CFO and COO will also discuss optimal form of standardization subgroups.

Laboratory/Pathology S10-I02-R011 Short-term Evaluate the operational logistics in place for the physician review and attestation of completed laboratory reports. Consider printing reports remotely to the requesting physician and/or the electronic attestation of reports with specific monitoring tools in place

Affinity does not support electronic process to attest lab reports on line. Currently considering a manual process, while continuing to work with IT to evaluate the capabilities of 'chart management' in Affinity. Initiating remote printing on a limited basis to support the ED (implementation planning is currently underway with end of April as a target).


Urgent and Short Term (June 30) Recommendations Completed

Urgent Recommendations Only Short-term Recommendations Only


Urgent Recommendations

Completed

Num of Short-term Recommendations

Count % Count %225 21% 190 84%

Short-term Recommendations Only All Recommendations

Num of Short-term Recommendations

Short-term Recommendations

Completed

"Green" Recommendations

Count % Count %429 40% 71 17%


Accomplishments to Date

Management/Leadership• Implemented revised organizational charts for the Chief Executive Officer, Medical

Director, Chief Nursing Officer and Chief Operating Officer.• Initiated recruitment for all interim executive/management positions in March.• Revised all functional job descriptions for Executive and Senior Managers and

identified goals and objectives for each. • Conducting ongoing assessment of current KDMC leadership capabilities against the

functional job descriptions.• Moved public relations from an ad-hoc process to a formalized functioning office. A

DHS Communication employee is now serving half time at KDMC to assist with management of the flow of public information, provide advice to hospital leadership on public relations issues, and assist with crafting key internal and external messaging.

• Redesigned the employee newsletter to keep all KDMC employees apprised of administration and regulatory updates, campus events, HR initiatives and other news items.



Regulatory/Quality and Performance Improvement• Separated the performance and quality improvement functions from the regulatory

function to allow more focus on each. • Appointed an Interim Director for Quality Management/Performance Improvement. • Developed action plans for all 288 deficiencies/citations related to Joint Commission

standards, Residency Review Committee (RRC)/Graduate Medical Education Committee (GMEC), CMS Conditions of Participation and Title 22 regulations.

• Established and communicated accountability by individual manager their specific role is to restore Accreditation.

• Began a mock survey program this month to ensure that implemented improvement plans have achieved their outcomes and change has been sustained.

• Overhauled the critical/sentinel event notification process to ensure that all staff understand and report events; issues are investigated within 24 hours; and a multidisciplinary route cause analysis is completed in a timely manner.

• The Infection Control Committee has reviewed and approved the new Infection Control plan. Revisions have been made to the data collection process to produce meaningful analysis of performance of the infection control process.



Clinical Care• Stabilized staffing to meet (and sometimes exceed) California ‘required ratios’.• Ensured that all nurses are licensed with the appropriate certification ACLS, etc.• Increased the available staffed beds for patients requiring telemetry.• Developed level of care criteria for ICU and intermediate care to ensure patients are

receiving care in the right level of bed.• Instituted an arrhythmia interpretation test to ensure standard knowledge base for

telemetry nurses.• Instituted a practice for RNs (in addition to the telemetry technician) to interpret and

document rhythm strips every shift for patients on telemetry.• Instituted management of assaultive behavior training for 100% of staff. Successful

removal of CMS Immediate Jeopardy. • Defined role expectations for Nurse Managers including daily rounds with physicians

and chart reviews to ensure care provision.• Instituted shift to shift rounding with the Nurse Manager and Charge Nurse to provide

care consistency.• Instituted daily interdisciplinary care coordination rounds to coordinate care.



• Ongoing mentoring of nursing supervisors to provide enhanced off shift support and oversight, improving decision making – 2 new supervisors hired.

• Conducting cardiopulmonary mock drills to provide ‘hands-on’ multidisciplinary training and education to staff in management of arrests.

• Formally reviewing all arrests (completing an evaluation tool) to critique the response and outcomes and to identify issues and learning needs.

• Developed and instituted an 8-hour ventilator care course - continuing to offer until all staff caring for ventilator patients attend.



Medical Staff• Reconfigured medical administration staff to include Associate Medical Director

(AMD) position for Med Staff Affairs and Utilization Management (UM) and Clinical Programs. Goals and objectives have been developed for each position.

• Implemented a resident supervision policy identifying department specific protocols for resident supervision for each medical department.

• Implementing proctoring protocols and a resident supervisory process. • Bylaws and rules and regulations have been updated and are now compliant with

CMS and JCAHO regulations and standards.



Psychiatry • Implemented a new treatment model for Psychiatric Emergency Services (PES). • Instituted weekly focus group meetings to discuss and revise the patient treatment

model. • Improved programming has begun with therapeutic groups being run by all

disciplines. • Instituted seven-day/week coverage for occupational therapy, recreational therapy

and social workers was instituted for all inpatient units and PES. • Improved the therapeutic milieu by providing consistent staff coverage on each unit

and PES. • Instituted daily rounds on all units and PES to review the patient’s care plan. • Developed a quality improvement plan with indicators to be monitored by each

specific discipline and reported to the Psychiatric Management Team. • Developed criteria for prompt pediatric/adolescent disposition for PES patients

awaiting admission.



Emergency Department• Closed the Trauma Center March 1 with few issues. • Established an ED Joint Practice Committee for nursing and medical staff to identify,

discus and resolve issues.• Implemented a new diversion policy establishing objective criteria to determine ED

saturation. – Reduced the time frame from 4 to 2 hours reducing diversion hours from 71% in January;

55% in February and 21% in March.

• Implemented a new triage process that will appropriately send patients to Fast Track and subsequently decrease the load on the acute side.

• Initiated care protocols to help ensure appropriate, timely and safe care.• Revised MAC transfer policy to decrease number of request out to Med Alert Center.



Perioperative• Instituted and enforced policies that ensure correct person identification/procedure

and site verification.• Enforced the sponge/instrument count policy/procedure and initiate discipline to staff

for non-compliance.• Instituted multidisciplinary round in the OR and Post Anesthesia Recovery (PAR) to

plan patient flow and ensure appropriate staffing – including the evaluations to ensure that there is a bed available at the required level of care – canceling surgeries if appropriate.

– Length of time patients stay in the Post Anesthesia Recovery area have decreased from 311 minutes in January to 257 minutes in February.

• Instituted mock cardio pulmonary arrests in the PAR to assess and provide training as appropriate.

• Initiated a multidisciplinary OR Governance group to ‘govern’ policies and procedures that support the delivery of quality care.

• Conducted a Charting the Course session in which nurses, physicians and staff collaborated to redesign procedures in the “Perioperative Care Center” to be more patient centered.

• Implemented improved monitoring of patients with moderate sedation in all areas - establishing the same standard of care.



Ancillary Areas• Utilized current teleradiology capabilities to send films off site to a radiologist for

interpretation, increasing the turn around time of preliminary reports x-rays during periods when there are a physician shortages.

• Revamped and improved phlebotomy services to include a larger suite, improved patient flow process and the introduction of a specimen drop off station.Eliminated a bar coding label to improve patient safety.

• Successfully passed CAP accreditation with a perfect score and AABB inspection deemed the lab exemplary by the reviewer.

• Expanded phlebotomy services, leading to a reduction in blood culture contamination rates (from 8% to 4%), as well as a reduction in specimen rejections in blood bank.

• Reduced transcribed medical report turnaround time from 30 hours to 10 hours.• Improved medical record availability in General Surgery clinic from 80% to 95%.• Established criteria for reviewing deficiencies in the quality and content of the medical

record.



• Improved the availability of outpatient medical records, increasing delivery rates from the mid 80s to 95%.

• Ensured all pharmacy registry staff completed new employee orientation.• All pharmacy staff passed their competency testing.• Installed security cameras working with Safety Police to ensure their monitoring and

oversight.• Tracking and improving processes to decrease medication turnaround time.• A pharmacy and nursing joint practice group has been formed to resolve issues with

medication processes; ordering, dispensing, distribution and administration.• Completed a gap analysis for Chapter 797.



Environment of Care• Physically inventoried all occupied and vacant space.• Newly configured Space Committee is prioritizing new space requests. • Evaluating current space and how it may better support operations as well as

assisting in the prioritization of changes to meet regulatory requirements. • Identified four critical space/construction needs: OR, ER, Psychiatry and Outpatient

Pharmacy.– Development of renovation plans is underway in the operating room and psychiatry.

OSHPD has given preliminary approval to proceed with the OR, cost estimates are being completed.

– In initial stages of evaluation of the ER. An initial cost estimate breakdown of the refurbishment items has been made.

– The Field Assessment Report for the psychiatric areas in Hawkins has been reviewed and all are in agreement as to the priority items that present safety hazards in the rooms.

– Outpatient pharmacy plans are in development.

• Completed an inventory of all equipment is being completed including the tagging and bar coding all items.



Human Resources• ‘Cleaned up’ the PAR process and prioritized recruitment efforts. Currently 198

approved PARs.• Have partnered with HR to provide efficient disciplinary actions to staff.

– Instituted 91 performance management cases.

– Currently 179 open disciplinary cases.

• Increased performance feedback increasing formal compliance for evaluations from 8% to 64%. The backlog will be completed by the end of April.

• Instituted case management program to better manage disability cases and reduce lost work time.

• Developed a comprehensive class program based on a needs assessment. Mandatory training has been identified for appropriate levels and care areas.

• Ensuring attendance of staff at orientation improved to 74% with efforts underway for 100% compliance.

april 11, 2005 king/drew medical center implementation plan update hospital advisory board

Documents