board quality review committee meeting open agenda · 5/19/2014 · p g orzeman, j oy, rn, msn,...
TRANSCRIPT
BOARD QUALITY REVIEW COMMITTEE MEETING
*
Monday, May 19, 2014
5:30 p.m. (Buffet Dinner for Committee members & invited guests) 1st Floor Conference Room
6:00 p.m. Meeting 456 E. Grand Avenue, Escondido CA
Open Agenda
Time Target CALL TO ORDER 6:00
Establishment of Quorum ............................................................................................................ ..........
Public Comments ......................................................................................................................... 5 6:05
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.
Information Item(s)
1. * Approval: Minutes – Monday, April 21, 2014 (Addendum A - Page 2 - 5) ............................ 5 6:10
New Business
a) Approval of Board Policy 11232 “Performance Improvement” (Addendum B – Page 6) ...... Questions & Answers – 10 minutes
10
6:20
b) Patient Flow Update (Addendum C – Page 7 - 33) ............................................................... Lorie Shoemaker, Chief Nurse Executive Presentation – 15 minutes Questions & Answers – 10 minutes
25 6:45
c) Nursing Peer Review (Addendum D – Page 34 – 51) ........................................................... Maria Sudak, Director of Clinical Operations Improvement Presentation – 15 minutes Questions & Answers – 5 minutes
20 7:05
d) Update on Operational Initiatives #1 and #2 (Addendum E - Page 52 - 55) ......................... Opal Reinbold, Chief Quality Officer and Lorie Shoemaker, Chief Nurse Executive Presentation – 15 minutes Questions and Answers – 10 minutes
25 7:30
ADJOURNMENT TO CLOSED SESSION 7:30
~ pursuant to Health & Safety Code Section 32155 Report of Medical Audit/Report of Q.A. Committee
Immediately
following end of closed session
RESUMPTION OF OPEN SESSION
Action Resulting From Closed Session Discussion – IF ANY ............................................
FINAL ADJOURNMENT
8:15
Board Quality Review Committee Members Linda Greer, RN - Chairperson Opal Reinbold, MBA Gerald Bracht, MBA
Aeron Wickes, MD Michael Covert, CEO, FACHE David Tam, MD
Jerry Kaufman, PTMA Lorie Shoemaker, RN Sheila Brown, RN, FACHE
Charles Callery, MD Della Shaw Jerry Kolins, MD, FACHE
Daniel Harrison, MD Valerie Martinez, RN, BSN, MHA, CIC
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
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Addendum A
2
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Addendum A
3
1 | P a g e Updated: 2/14/2014
ABBREVIATIONS GUIDE
ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACR: American College of Radiology ARB: Angiotension Receptor Blocker BETA: PPH Insurer BSC: Balanced Score Card CALNOC: Collaborative Alliance for Nursing Outcomes CAP: College of American Pathologists CAUTI: Catheter Associated Urinary Tract Infection CCTP: Community-Based Care Transitions Program CDAD: Clostridium Dificile Associated Diarrhea CDC: Center for Disease Control CDI: Clinical Documentation Improvement C-diff: Clostridium difficile CDPH: California Department of Public Health CHA: California Hospital Association CIHQ: Center for the Improvement in Healthcare Quality CLABSI: Central Line Blood Stream Infection CLIP: Central Line Insertion Practices CMS: Centers for Medicare & Medicaid Services CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management DI: Diagnostic Imaging DRT: Diabetes Resource Team EBP: Evidence Based Practice EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EVS: Environment of Care Services / Environmental Services FANS: Food and Nutrition Services FMEA: Failure Mode Effects Analysis HAI: Healthcare Associated Infections HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCP: Health care provider HDL: High Density Lipoprotein Cholesterol HLD: High Level Disinfectant IC: Infection Control IHI: Institute for Healthcare Improvement IP: Infection Prevention (RN Staff) MDRO: Multi Drug Resistant Organism MRSA Methicillin-resistant Staphylococcus aureaus MSPRC: Medical Staff Peer Review Committee NDNQI: National Database of Nursing Quality Indicators NHQM or NIHQM: National Improvement for Healthcare Quality Measure
Addendum A
4
2 | P a g e Updated: 2/14/2014
ABBREVIATIONS GUIDE
NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NPSG: National Patient Safety Goals NQF: National Quality Forum PCEA: Patient Controlled epidural Analgesia PDCA: Plan Do Check Act POCT: Point of Care Testing QRR: Quality Review Report RAC: Revenue cycle Audits RCA: Root Cause Analysis RVT: Registered Vascular Tech SCIP: Surgical Care Improvement Project SIR: Standardized Infection Ratio SNF: Skilled Nursing Facility SSI: Surgical Site Infection TAT: Turn Around Time TJC or JC: The Joint Commission US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Acquired Pneumonia VBAC: Vaginal Birth After Caesarian Section VRE: Vancomycin-resistant enterococ
Addendum A
5
I. PURPOSE:
To provide directions to the employees of PPH from the Board of Directors relative to establishing and maintaining an organization that is committed to ongoing performance improvement culture, thereby meeting and striving to exceed regulatory and professional standards.
II. DEFINITIONS:
III. TEXT / STANDARDS OF PRACTICE:
A Performance Improvement Plan will serve as a framework that describes how the following will be accomplished, including:
A. Designing Processes. B. Monitoring through data collection. C. Analyzing current performance. D. Determining and prioritizing improvement opportunities. E. Modifying processes. F. Sustaining improvements. G. Periodically assessing PPH performance in accordance with recent benchmark data.
IV. ADDENDUM:
V. DOCUMENT / PUBLICATION HISTORY:
VI. CROSS-REFERENCE DOCUMENTS:
V. PUBLICATION HISTORY:
VI. REFERENCES:
Paper copies of this document may not be current and should not be relied on for official purposes. The current version is in Lucidoc at .
https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:11232
Policy
Performance Improvement11232 Official (Rev: 1)
Source:Administrative Board of Directors
Applies to Facilities: Applies to Departments:
Revision Number
Effective Date
Document Owner at Publication Version Notes
1 (this version)
12/17/2001 Dr. Valentino Tesoro, SVP Quality and Clinical Effectiveness
Original Version
Authorized Signer(s): ( 12/17/2001 ) George G. Gigliotti, Chairman
Reference Type Title NotesSource Documents 1
JCAHO CAMH Standard Improving Organization Performance
JCAHO CAMH Standard Leadership
JCAHO CAMH Standard Governance
Page 1 of 1Performance Improvement
5/12/2014https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:11232/frame/DOCBODY
Addendum B
6
Board Quality Review Committee May 19, 2014
According to the National Institutes of Health…
“Increasing wait times predict increasing mortality for emergency medical admissions… Delay[s] to admission[s] have been shown to be independently adversely related to mortality outcome. We recommend maximal target limits of 4 and 6 hours for referrals and admissions, respectively, based on these mortality observations.”
Plunkett et al., 2011
Addendum C
7
Improved Care Coordination and Throughputhave been identified as Strategic and Operational
Initiatives for FY’14-17
Strategic Initiative #3: Improve Care Coordination:Develop a delivery model that supports care coordination and transitions across the continuum, with emphasis on chronic disease management, illness prevention and patient involvement.
Operational Initiative #2: Improve Satisfaction and Throughput:Create a positive experience for all key stakeholders by improving clinical and business throughput and efficiency through all transitions of care.
Hospital Compare – Timely & Effective Care Timely and effective care in hospital emergency
departments is essential for good patient outcomes. Delays before receiving care in the emergency
department can reduce the quality of care and increase risks and discomfort for patients with serious illnesses or injuries.
Waiting times at different hospitals can vary widely, depending on the number of patients seen, staffing levels, efficiency, admitting procedures, or the availability of inpatient beds.
CMS, 2014
Addendum C
8
Baseline Data – Hospital Compare
Addendum C
9
Addendum C
10
Addendum C
11
Addendum C
12
ED LOS for Admitted Patients (minutes)
Decision to Admit to Inpatient Bed (minutes)
PHDC – 346 Pomerado - 298 Scripps La Jolla – 218 Sharp Memorial – 218 Tri-City Medical – 364 Scripps Encinitas - 297 Fallbrook – 288
PHDC – 145 Pomerado - 142 Scripps La Jolla – 90 Sharp Memorial – 69 Tri-City Medical – 98 Scripps Encinitas - 96 Fallbrook – 78
Addendum C
13
Overall Goals: 1. Create an innovative, seamless process for
patient flow that is efficient, effective, and measurable to assure maximum use of the organizational resources and patient and physician satisfaction.
2. Provide additional resources to assist physicians in their efforts to avoid compliance issues with patient status and meeting regulatory compliance.
Primary Focus Areas:1. Patient access, including ED, OR, direct
admits2. Centralized bed control function3. Unit-based bed control function4. Optimization of Teletracking tool5. Overall patient experience
Addendum C
14
Key Milestones of Phase I:1. Cerner Case Management module fully
functional2. CERME (electronic InterQual criteria)
implemented3. 24/7 Clinical Resource Management (CRM)
staffing for ED 4. New CRM Supervisor and Director hired5. Executive Health Resources implemented and
monitored for appropriate utilization 6. Standardized process for daily discharge
huddles developed, piloted, and rolling out across the system
The Current state of throughput at Palomar Health is a confusing and slow process
The current process around admissions includes: Level of Care vs. Acuity vs. Ratios vs. Skill of the RN Who has the final say for patient placement? We have Physician Preferences vs. Expectations We have differences between facilities at same level
of care We give mixed messages to patients and staff PMC has unintentionally created uniquely specialized
units
Addendum C
15
There is a 14 step work flow for every admission Every admission is reviewed by 5‐6 RNs after a physician
determines level of care Multiple people have multiple interpretations for same
admission criteria Considerable amount of discussion related to the
appropriateness of admissions happens throughout the day There is no integrated patient placement process There is a lack of urgency related to
patient flow and throughput
Resulting in . . .RigidityUnnecessary Transfers PushbackDelays
Addendum C
16
Time to Reconstruct
Partnership with CEP America (ED Physicians and Hospitalists) o Resources and expertise to augment our existing
expertise/efforts/projects/people Include all three campuses in the process Standardize processes to the extent possible
at all three campuses
Addendum C
17
General Overview Overall Executive Sponsors:
oOpal ReinboldoLorie Shoemaker
Overall Project Vision: oIn partnership with CEP America, create an innovative, seamless process for patient flow that is efficient, effective and measurable to assure maximum use of organizational resources and patient and physician satisfaction
Meets 3rd Monday, 0800-0930, LDC iExplore
Replaces Existing Patient Flow Meeting
Opal Reinbold Lorie Shoemaker Della Shaw Performance Excellence-
Chris/Angie/Rick Andrew Smith (CEP) Joy Gorzeman Cathy Prante Michelle Gunnett Rae Anne Watson Beth Remsburg-Bell Mark Reyes
Kim Colonnelli Joanne Barnett Marcy Adelman Maria Sudak Prudence August Steve Ellis Diane Hansen Cindi Burns Frank Martin, MD John Fredericks, MD Jaime Rivas, MD Sabiha Pasha, MD
Addendum C
18
Some Quick Definitions…o TAT-A… Turn Around Time to Admissiono TAT-D… Turn Around Time to Dischargeo Centralized Placement… Patient Placement
Department facilitating admissions at all three acute care hospitals
Centralized Placement (TAT-A)
ED Throughput (TAT-D)
Urinalysis Unit-Based Bed Control Radiology
Phase I CarryoverED Patient Focus ED Patient Focus
Addendum C
19
General Overview of Projects‐ Each project includes all three campuses to assure consistency ‐ Top down support from administration and facility leadership‐ Charter and work plan created for each project‐ Collaborate and agree upon improvement metrics‐
Recommendation
Urinalysis Radiology TAT -D TAT-A
Timeline 1-2 month 3-6 months 3-6 months 6-12 months
Difficulty to Implement
Low Medium Medium High
Risk Factor Low Low Low Medium
Project Lead Joanne Barnett Michael Barnett Nick Metzger/Michelle Gunnett
Kimberly Lopez
Project Sponsor Tim Barlow Mark Reyes Kim Colonnelli Joy Gorzeman
•Patient placement pilot•Throughput scorecardTAT-A
•Standardize discharge work flow from practitioner and nurse
•Improve triage and intake processTAT-D
•Standardize physician ordering•Pilot collection process for urine and portable
ultrasound for imaging
Imaging and Urinalysis
•Redefine admission criteria•Standardize bed huddle
Unit Based Management
Recommendation
See Addendum Slides for More Details
Addendum C
20
Centralized Placement
Department
Housekeeping
Transport
Direct Admission
Outreach
Intra- facility Transfer
Facility Admissions
and Throughput
A Major Culture Change
Who is involved??Centralized Patient Placement includes:
o Patient Access o Registration/Admittingo House Supervisoro ED Flow Facilitatoro Unit Supervisors / Charge Nurses o Bedside Nurseso Clinical Resource Managemento Transporto EVS
Addendum C
21
Step 1• Orders are placed in Clarity/Teletracking
Step 2• Requests are reviewed by the Centralized
Placement Department and a bed is assigned
Step 3• Report is then called to floor and the patient is
transported to floor
Recommendation
Overall TAT-A Goals: Patient ED arrival to patient in admitted bed = 220 mins Admit order to patient in bed = 60 mins Ready bed assigned to patient in bed = 30 mins
Addendum C
22
Monitoring for Success
Monitoring for Success
Addendum C
23
Monitoring for Success
Patient Flow Phase II focuses on Five Primary Projectso Turnaround Time for Admitted Patients from EDo Turnaround Time for Discharged Patients in EDo Turnaround Time for Urinalysiso Turnaround Time for Imaging Studieso Unit-based Daily Bed Huddles
All projects are well underway with project leads, plans, timelines and outcome measures
Pilot projects are being conducted on all three campuses
A Throughput Dashboard is being developed to monitor success in the areas of admissions, efficiency, and discharges
Addendum C
24
Plunkett PK, Byrne DG, Breslin T, Bennett K, Silke B. Increasing wait times predict increasing mortality for emergency medical admissions. Eur J Emerg Med. 2011 Aug;18(4):192-6. doi: 10.1097/MEJ.0b013e328344917e. PubMed PMID: 21317786.
Hospital Compare. (2014, May). Retrieved May 4, 2014, from Medicare. Gov: http://www.medicare.gov/hospitalcompare/Data/Measures.html
Hospital Compare. (2014, May). Retrieved May 4, 2014, from Medicare. Gov:
http://www.medicare.gov/hospitalcompare/profile.html#profTab=2&vwgrph=1&ID=050115&loc=ESCONDIDO%2C
%20CA&lat=33.1192068&lng=-117.086421&name=PALOMAR%20HEALTH%20DOWNTOWN%20CAMPUS
Addendum C
25
Centralized Placement (TAT-A)
ED Throughput (TAT-D)
Urinalysis Unit-Based Bed Control Radiology
Five Primary Focus Projects – Progress to Date
Focus – Create a centralized bed placement system that works as a single entry point for all admissions and transfers for all hospitals:
o Improve throughputo Decrease length of stayo Decrease the number of patients that leave the ED without being
seeno Improve customer satisfactiono Improve quality of care
Pilot Projects Underway – Mon to Wed a non-clinician and Administrative Supervisor are working in a central location to standardize and streamline how patients move through the hospital
Addendum C
26
Outcomes -o Decreased ED arrival time to admission time by 100 minutes on
pilot dayso Identified barriers in moving patients through the hospitalo Switched the work load of a ED patient flow nurse back into
patient care
Next Steps -o Incorporate Pomerado Hospital into centralized placement
processo Centralize transport and housekeeping leads for
deployment of resources based upon centralized patient placement needs
o Partner with Clinical Resource Management for patient placement into correct billing status on the front-end
Focus –o Current state of turnaround time to discharge and overall patient
length of stays in Emergency Departments are well above the desired benchmark metrics for ED patient throughput standards.
o Implementation of standardized throughput processes system-wide create greater focus and accountability for all staff, improve provider and staff communication, and increase patient satisfaction and decrease overall throughput times.
Pilot Projects Underway – See Next Slides for Detailso Implementation of a Standardized Discharge Process at all EDs.o Initial Implementation at PHDC ED
Addendum C
27
43 43
44 44
Addendum C
28
Outcomes –o First 2 weeks of Standardized Discharge (DC) Process Pilot
(PHDC ED) Median “DC Order to Door” Time: ~14min Majority of Patients “DC Order to Door” Time: <10min Unprecedented ED Provider / nursing collaboration during
project implementation Next Steps –
o IT updates at PMC and Pomerado preparing for DC process o Simplification / re-design of staff education plan o ED Standardized DC Process rollout at Pomerado ED
• Planned May 27o ED Standardized DC Process rollout at PMC ED
• Planned June 9o Complete system-wide ED reports needs/design
Focus –o Imaging goal is to decrease the order to completion time on every
order/test from the ED by 10 minutes in all modalities, Ultrasound (US), CT, MRI, and Diagnostic Imaging.
Pilot Projects Underway -o US pilot started on 4/16/14o All non-invasive ED studies will be performed at the bedside
by the sonographers. o This is roughly 69% of the orders and the remaining ED studies
will be conducted in the US rooms as before.o This goal will be accomplished by standardizing the order
sentences in Clarity, maximizing the sonographers productivity by improving their workflow and minimizing staffing issues.
Addendum C
29
Outcomes – See Next Slide for Detailso Pilot goal currently not met.
o TAT trending down in a positive direction over timeo Staffing related issues have impeded progresso US work flow not consistent among technicians
Next Steps –o Work with the US Lead to standardize work flowo Continue to monitor and measure the piloto Begin pilots on other imaging modalities when US pilot more
hardwired
US exam TAT for studies performed at PMC ordered by the EDAs of May 8, 2014
0:00
0:15
0:30
0:45
1:00
1:15
1:30
1:45
0
5
10
15
20
25
30
35
n
Baseline Volume
Median
Baseline Time
Poly. (Median)
Addendum C
30
Focus –o Decreasing turnaround time from order to urine specimen
collection to 20 minuteso Decreasing turnaround time from order to completion to 60
minutes
Pilot Projects Underway –Conducting pilot at Pomerado ED
o Identified 8 most common chief complaints where urinalysis would likely be needed
o Obtaining urine specimen right after triage and holding specimen until order is entered in Clarity
o “Beaker” icon added to tracking board to include UA not collected within 30 min
o Colored placard to identify patients still needing to provide a specimen so all staff are aware of need
Outcomes – See Next Slide for DetailsOverall mixed results
o Turnaround time from order to collect well below target some days with significant outlier times on other days
o Turnaround time from order to complete mirrors the order to collect data
Next Steps –o Work with ED physicians to change standard clean catch urine
specimen orders to include straight catheter order if no specimen collected within 30 min of order
o Pilot new process at PMC after TAT-D and Imaging pilots are further hardwired
Addendum C
31
POM ED UA Specimen Collection Time Minutes From Order to Specimen Collection
0102030405060708090
100110120130140150160170180190200210
4‐Apr
6‐Apr
8‐Apr
10‐Apr
12‐Apr
14‐Apr
16‐Apr
18‐Apr
20‐Apr
22‐Apr
24‐Apr
26‐Apr
28‐Apr
30‐Apr
2‐M
ay
4‐M
ay
6‐M
ay
Average Daily Minutes to Collect
Order to Collect
Order to Complete
April 9, 1st day of pilot
Minutes
Order to Collect Target = 20
5/12/2014
*357 minutes on 24‐Apr
Order to Complete Target = 60
Focus -Patient Placement procedure:
o Redesign the patient placement procedure to decrease the possibility of multiple interpretations
o Decrease the rigid guidelineso Allow more flexibility on where patients are placed
Bed huddles:o Standardize the bed huddle process at both PMC and Pomeradoo Improve communication on admissions, discharges and transfers o Identify barriers with discharging patients
Pilot Projects Underway –o Charge nurses at PMC and Pomerado are using a new bed huddle
template as a tool to report out their unit’s activities; Notifying inpatients units of ED saturation and removing the “ black out” times for inpatient admissions
Addendum C
32
Outcomes o Teletracking up to date and accurateo Improved communication at huddleso Increased awareness of all units’ bed situationso Consistent huddle meeting 4x a day at both campuses
Next Steps o Only use technology for bed huddle report (eliminate written tool)o Present proposed changes to bed placement procedure to medical
staff and nursing committees across the organization
Addendum C
33
Nu
rsin
g Pe
er R
evie
w
Palo
mar
Hea
lth
Mar
ia S
ud
ak R
N, M
SN, C
CR
N, N
EA-B
C
Clin
ical
Lea
der
ship
Co
un
cil
May
7, 2
01
4
EMT
Safe
ty &
Ser
vice
M
ay 1
3, 2
01
4
QM
C
May
14
, 20
14
B
QR
C
May
19
, 20
14
Addendum D
34
2 T
rack
s e
Rev
iew
Ch
ange
s In
tro
du
ctio
n
Nu
rsin
g C
olle
agu
es, w
ith
th
e as
sist
ance
of
a ve
ry e
ner
gize
d a
nd
en
gage
d s
taff
pee
r re
view
co
un
cil a
nd
Tra
ci F
icke
l we
w
ill b
e m
akin
g re
visi
on
s to
th
e p
eer
revi
ew q
ues
tio
ns
in e
Rev
iew
se
t to
go
live
wit
h e
valu
atio
ns
com
ing
du
e s
tart
ing
July
1.
Situ
atio
n
The
team
sta
rted
wit
h t
he
ori
gin
al q
ues
tio
ns
and
des
crip
tio
ns
wit
hin
eR
evie
w a
nd
wo
rked
to
fo
rmu
late
mea
nin
gfu
l st
atem
ents
/qu
esti
on
s th
at w
ill o
ffer
sta
ff fe
ed
bac
k o
n t
hei
r p
ract
ice
wh
ile s
imp
lifyi
ng
the
pro
cess
.
Bac
kgro
un
d
Pee
r Ev
alu
atio
n is
a c
reat
ive
way
to
ob
tain
fee
db
ack
fro
m t
ho
se w
ho
un
der
stan
d w
ho
yo
u e
mp
loye
e ar
e an
d w
hat
yo
u d
o
to c
on
trib
ute
at
wo
rk e
very
day
. It
is in
ten
ded
to
en
han
ce q
ual
ity
of
wo
rk a
nd
per
form
ance
.
The
pee
r re
view
pro
cess
sti
mu
late
s p
rofe
ssio
nal
ism
th
rou
gh in
crea
sed
acc
ou
nta
bili
ty a
nd
pro
mo
tes
self
-reg
ula
tio
n o
f p
ract
ice.
In a
dva
nce
of y
ou
r an
nu
al e
valu
atio
n, y
ou
will
be
aske
d t
o c
om
ple
te a
sel
f-ev
alu
atio
n a
s w
ell a
s 3
no
min
ate
pee
rs f
or
the
Pee
r R
evie
w p
roce
ss. Y
ou
r d
irec
t su
per
viso
r w
ill a
lso
be
req
uir
ed t
o s
elec
t 3
pee
rs t
o c
om
ple
te t
he
Pee
r R
evie
w p
roce
ss
for
you
.
Ass
ess
men
t
RN
sta
ff w
ill b
e as
ked
to
sco
re e
ach
of
the
10 q
ues
tio
ns/
stat
emen
ts a
nd
hav
e th
e ab
ility
to a
dd
a c
om
men
t. T
he
pee
r
revi
ew e
nd
s w
ith
2 r
efle
ctio
n q
ues
tio
ns
aski
ng
revi
ewer
s to
co
mm
ent
on
on
e at
trib
ute
th
at e
very
on
e sh
ou
ld k
no
w a
bo
ut
thei
r p
eer
and
on
e ar
ea t
hat
co
uld
be
imp
rove
d o
n.
Th
e d
om
ain
s ad
dre
ssed
wit
hin
Pee
r R
evie
w:
1. C
linic
al P
ract
ice
- Evi
den
ce B
ased
Pra
ctic
es
2.C
linic
al P
ract
ice
- P
atie
nt
Po
pu
lati
on
3.
Co
llab
ora
tio
n -
Inte
rper
son
al S
kills
4.
Co
llab
ora
tio
n -
Flex
ibili
ty
5. Q
ual
ity
- C
om
mit
men
t 6.
Qu
alit
y -
Dem
on
stra
tio
n
7. C
ult
ure
an
d C
arin
g - C
om
mit
men
t 8.
Cu
ltu
re a
nd
Car
ing
- Dem
on
stra
tio
n
9. E
du
cati
on
- C
om
mit
men
t 10
. Ed
uca
tio
n -
Dem
on
stra
tio
n
Rec
om
men
dat
ion
A
ll R
egis
tere
d N
urs
es w
ill c
om
ple
te t
he
Pee
r R
evie
w P
roce
ss w
ith
in e
Rev
iew
fo
r th
emse
lves
by
no
min
atin
g p
eers
an
d f
or
oth
ers
by
com
ple
tin
g th
e p
roce
ss w
hen
no
min
ated
.
Rea
d B
ack
Nu
rsin
g P
eer
Rev
iew
pro
mo
tes
safe
pra
ctic
e an
d p
rofe
ssio
nal
ism
.
The
new
fo
rmat
will
be
assi
gned
to
all
RN
s w
ho
se e
valu
atio
n is
co
min
g d
ue
in J
uly
1 a
nd
bey
on
d.
For
you
r an
nu
al e
valu
atio
n y
ou
are
ask
ed t
o n
om
inat
e 3
pee
rs a
nd
yo
ur
sup
ervi
sor
will
no
min
ate
3 p
eers
.
If y
ou
can
no
t co
mp
lete
th
e p
eer
revi
ew in
on
e si
ttin
g yo
u c
an c
lick
the
SAV
E an
d E
xit,
th
en c
om
e b
ack
late
r to
co
mp
lete
.
Nu
rsin
g P
ee
r R
evie
w C
ou
nci
l
•C
olla
bo
rati
ve S
tru
ctu
re
•St
aff
Co
un
cil
–C
hai
r =
Cat
hy
Jaco
bs
–C
o c
hai
r =
Kat
ie S
mit
hso
n
•Fa
cilit
ated
•Pa
ralle
ls M
edic
al S
taff
Pee
r R
evie
w
•Fo
cus
on
Nu
rsin
g P
ract
ice
•R
eco
gniz
e
–Ex
emp
lary
pra
ctic
e
–Sy
stem
Issu
es
–Ed
uca
tio
nal
Op
po
rtu
nit
ies
Addendum D
35
Def
init
ion
s ta
b
for
refe
ren
ce
Addendum D
36
Pro
vid
es y
ou
th
e
op
po
rtu
nit
y to
ad
d a
co
mm
ent
Addendum D
37
Allo
ws
you
to
fre
e
text
yo
ur
resp
on
ses
Addendum D
38
Addendum D
39
NU
RS
ING
PE
ER
RE
VIE
W I
S C
OM
NG
SO
ON
AR
E Y
OU
RE
AD
Y?
Cath
y
Jaco
bs
- C
hair
R
N,
PM
C E
D
Kati
e S
mit
hso
n -
Co
Ch
air
R
N,
PO
M C
C
Kim
L
op
ez
Faci
lita
tor
Lis
a
Wri
gh
t R
N,
Flo
at
Po
ol
Lo
urd
es
Jan
usz
ewic
z
Faci
lita
tor
Mari
a
Su
dak
F
aci
lita
tor
MJ
McN
utt
R
N,
PM
C O
BS
Patr
icia
N
oo
nan
R
N,
Flo
at
Po
ol
Pat
Bu
shn
ell
R
N,
PM
C E
D
Ter
ri
Bad
agli
acc
o-C
abre
ra
RN
, P
MC
RR
N
Addendum D
40
A
NA
6 P
rin
cip
les
of
Peer
Rev
iew
A p
eer
is s
om
eon
e o
f th
e sa
me
ran
k.
Peer
rev
iew
is p
ract
ice
focu
sed
.
Feed
bac
k is
tim
ely,
ro
uti
ne
and
a c
on
tin
ual
ex
pec
tati
on
.
Peer
rev
iew
fo
ster
s a
con
tin
uo
us
lear
nin
g cu
ltu
re
of
pat
ien
t sa
fety
an
d b
est
pra
ctic
es
Feed
bac
k is
no
t an
on
ymo
us.
Feed
bac
k in
corp
ora
tes
the
dev
elo
pm
enta
l sta
ge o
f th
e n
urs
e.
Addendum D
41
Pro
ject
Pla
n T
imel
ine
July
20
13
•Pla
nn
ing
of
Co
un
cil S
tru
ctu
re
•Cri
teri
a an
d T
oo
l Dev
elo
pm
ent
star
ted
•Rev
iew
of
staf
f co
nce
rns
and
fea
rs
•Rev
iew
of
Pati
ent
Car
e St
and
ard
s
Au
gust
20
13
•Ove
rvie
w o
f P
hys
icia
n P
eer
Rev
iew
Pro
cess
•Rev
iew
of
AN
A S
tan
dar
ds
•Det
erm
ine
Team
Pu
rpo
se
•Beg
in d
efin
ing
Stee
rin
g Te
am
Mem
ber
ship
Sep
tem
be
r 2
01
3
•Def
inin
g th
e n
eed
fo
r a
Peer
Rev
iew
•Rev
iew
of
ISB
AR
R
•Def
ine
Co
un
cil m
emb
ersh
ip &
C
ou
nci
l Str
uct
ure
•Rev
iew
of
the
6 S
tep
s o
f Pe
er R
evie
w
Oct
ob
er
20
13
•Rev
iew
of
feed
bac
k fr
om
Au
gust
P
rese
nta
tio
n
•eR
evie
w P
eer
Rev
iew
pro
cess
•Rev
ise
qu
esti
on
s fo
r th
e eR
evie
w
Peer
Rev
iew
Pro
cess
No
vem
be
r 2
01
3
•Rev
iew
an
d F
inal
ize
eRev
iew
q
ues
tio
ns
pro
po
sed
•Les
son
s le
arn
ed f
rom
Med
ical
St
aff
Peer
Rev
iew
De
cem
be
r 2
01
3
Jan
uar
y 2
01
4
•Pro
ced
ure
wri
tin
g an
d r
evis
ion
s
•Ch
art
revi
ew /
pee
r re
view
pro
cess
as
a g
rou
p f
or
pra
ctic
e
Feb
ruar
y 2
01
4
•Des
ign
an
d c
reat
e ed
uca
tio
n
•Cre
ate
talk
ing
po
int
to g
o o
ut
to
RN
sta
ff a
nd
org
aniz
atio
n
•Ch
ose
Ch
air,
Co
-Ch
air
and
Fa
cilit
ato
rs f
or
Edu
cati
on
an
d
Pro
ced
ura
l Pro
cess
Mar
ch 2
01
4
•Ed
uca
tio
n M
on
th
•In
corp
ora
te le
arn
ing
bo
oth
at
skill
s d
ays
•Bu
ild M
idas
Rep
ort
Addendum D
42
Pro
ject
Pla
n T
imel
ine
Ap
ril 2
01
4
•Pre
sen
tin
g ed
uca
tio
nal
ou
tlin
e at
Pro
fess
ion
al P
ract
ice
Co
un
cil
•Pre
sen
tin
g ed
uca
tio
nal
ou
tlin
e at
Sta
ff o
n S
afet
y
•Bu
dge
t p
rop
ose
d f
or
25
mem
ber
s
•Ski
lls D
ay: P
ost
er, F
lyer
s an
d A
pp
licat
ion
•Ret
reat
4/3
0
•Fin
aliz
e M
emb
ersh
ip, P
roce
du
re, a
nd
Ed
uca
tio
nal
Pro
cess
•Des
ign
to
wn
hal
ls/
foru
ms
for
qu
esti
on
s an
d a
nsw
ers
•Rec
ruit
men
t -
ho
w a
nd
wh
ere?
•Rev
iew
list
of
case
s an
d c
ho
ose
on
es t
o r
evie
w in
May
•Rev
iew
ab
stra
ct f
or
CA
LNO
C c
on
fere
nce
in O
cto
ber
May
20
14
•GO
LIV
E
•Pre
sen
tin
g ed
uca
tio
nal
an
d p
roce
du
ral o
utl
ine
to L
ead
ersh
ip
•Rev
iew
mem
ber
ship
ap
plic
atio
ns
Addendum D
43
Addendum D
44
Emai
l Bo
x:
NPe
erR
evie
w
Addendum D
45
Exem
pla
ry C
are
Le
tter
of
Inq
uir
y Le
arn
ing
Op
po
rtu
nit
y N
o Is
sue
Addendum D
46
Nu
rsin
g Pe
er R
evie
w S
har
ed G
ove
rnan
ce R
epo
rtin
g St
ruct
ure
Addendum D
47
Co
nfi
den
tial
ity
Gu
ide
lines
•
The
nu
rsin
g re
view
co
mm
itte
e fu
nct
ion
s in
acc
ord
ance
wit
h
the
req
uir
emen
ts o
f th
e C
alif
orn
ia N
urs
e P
ract
ice
Act
.
•Th
at a
rtic
le p
rovi
des
per
son
s p
arti
cip
atin
g in
go
od
fai
th in
th
e p
eer
revi
ew p
roce
ss w
ith
ext
ensi
ve p
rote
ctio
n a
gain
st
incu
rrin
g ci
vil l
iab
ility
bec
ause
of
thei
r p
arti
cip
atio
n.
•W
ith
ou
t su
ch p
rote
ctio
n, i
t w
ou
ld b
e ve
ry d
iffi
cult
fo
r p
eer
revi
ew c
om
mit
tees
to
op
erat
e.
•It
is n
eces
sary
to
pro
tect
no
t o
nly
th
e n
urs
e b
ein
g re
view
ed,
bu
t al
so t
o f
acili
tate
th
e o
pen
dis
cuss
ion
of
op
inio
ns
by
mem
ber
s an
d o
ther
par
tici
pan
ts in
th
e p
roce
ss.
•V
iola
tin
g th
ese
con
fid
enti
alit
y p
rovi
sio
ns
cou
ld r
esu
lt in
ex
po
sure
to
civ
il lia
bili
ty b
oth
fo
r th
e p
erso
n b
reac
hin
g co
nfi
den
tial
ity
and
th
e co
mm
itte
e it
self.
•Th
e fo
llow
ing
guid
elin
es a
re d
esig
ned
to
ass
ist
par
tici
pan
ts t
o
avo
id a
ny
inad
vert
ent
bre
ach
es o
f co
nfi
den
tial
ity.
Addendum D
48
Nu
rsin
g Pe
er R
evie
w P
roce
du
re D
RA
FT
I. P
UR
PO
SE:
•To
en
sure
th
at t
he
ho
spit
al, t
hro
ugh
th
e ac
tivi
ties
of
its
nu
rsin
g st
aff,
asse
sses
th
e p
erfo
rman
ce o
f in
div
idu
als
(em
plo
yee
or
con
trac
tor)
an
d
use
s th
e re
sult
s o
f su
ch a
sses
smen
ts t
o im
pro
ve c
are.
II. G
OA
LS:
•C
reat
e a
cult
ure
wit
h a
po
siti
ve a
pp
roac
h t
o p
eer
revi
ew b
y re
cogn
izin
g p
ract
itio
ner
exc
elle
nce
as
wel
l as
iden
tify
ing
imp
rove
men
t o
pp
ort
un
itie
s.
•M
on
ito
r in
div
idu
al n
urs
es’ p
erfo
rman
ce in
an
eff
ort
to
imp
rove
qu
alit
y o
f ca
re’
•Id
enti
fy o
pp
ort
un
itie
s fo
r p
erfo
rman
ce im
pro
vem
ent.
•M
on
ito
r si
gnif
ican
t tr
end
s b
y an
alyz
ing
aggr
egat
e d
ata.
•En
sure
th
at t
he
pro
cess
fo
r p
eer
revi
ew is
cle
arly
def
ined
, fai
r, d
efen
sib
le,
tim
ely,
an
d u
sefu
l.
Addendum D
49
Addendum D
50
Qu
esti
on
s
Addendum D
51
5/12/2014
Initiative Status:
EDW
•Initial build
for Phase I (Cerner Data) nearly complete
•Started Business Objects training for analysts rep
orting across
multiple divisions
•Completion of Phase I scope now targeted for March 1.
•Phase One is complete –planning for Phase 2 with Decision
Support Steering
Truven
•Quality Nurses actively extracting core m
easures into Truven
•Action 0I hand‐off to Finance/Human
Resources complete
•CareD
iscovery
Advance down load
complete. Planning for
next step
s through
Decision Support Steering
Initiative Risks:
•Must develop and adhere to the guidelines of the Decision
Support Advisory Group before EDW/Truven rep
orts are
created to assure m
axim
ization of resources, appropriate
prioritization and avoidance of duplicative rep
orting.
Outcome M
easure:
•Threshold: Implemen
t Phase 1 scope of ED
W or achieve
Phase 1 parallel go‐live for Truven Analytics
•Target: Im
plement Phase 1 scope of ED
W and achieve Phase
1 parallel go‐live for Truven Analytics
•Maxim
um: Implemen
t Phase 1 scope of ED
W and achieve
Phase 1 final go‐live for Truven Analytics
Milestones:
A. In
itiate development of an
Enterprise Data Warehouse (ED
W)
1.
Select EDW solution partner
2.
Create a decision support advisory group, rep
orting to IT
Governance
3.
Develop work plan to achieve Phase 1 scope
4.
Implemen
t Phase 1 Scope
B. Partner with VHA/Truvenan
d im
plement an
alytic toolset
1.
Hold stakeholder presentations and determine required resources
2.
Develop im
plemen
tation project plan and allocate resources
3.
Begin build
of Care Discovery Quality Measures (CDQM) and Action OI
4.
Begin submitting CY13Q3 data into CDQM parallel w
ith Premier and validate
accuracy
5.
Begin build
of CareD
iscovery
Advance
6.
Begin submitting CY13Q4 data using CDQM and exit Premier contract
7.
Submit FY14Q1 data into Action OI (data available for use within 45 days)
8.
Submit data into CareD
iscovery
Advance (available for use within 30 days)
Report Date:A
pril 25, 2014
Reporting Committees: Board Finance, EMT System
s and Resources
EMT Sponsors: B
ob Hem
ker, Opal Reinbold
Initiative M
anagers: R
yan Olsen
(ED
W), Chris Bryan
(Truven)
Physician Lead
er(s): Kolins, M
D, Lee, M
D, Kanter, M
DOutcome Measure: Develop and im
plemen
t an
Enterprise Data
Wareh
ouse and Analysis Tool kit
July 13
June 14
Initiative Budget: To be included
in FY14 Budget
Budget Status:
Jan 14
Mar 14
Sept 13
Nov 13
A2
A4
A3
A1
May 14
B6
B2
B3B4B5
B1
FY
14 O
per
atio
nal
Init
iati
ve 1
:B
uild
and
ope
rate
a d
ecis
ion
anal
ytic
s st
ruct
ure
that
sup
port
s th
e re
al ti
me
avai
labi
lity
and
stan
dard
ized
use
of i
nfor
mat
ion
and
expe
rtis
e fo
r kn
owle
dge
man
agem
ent a
nd m
easu
rem
ent o
f va
lue
base
d m
etric
s of
car
e.
B7
B8
Addendum E
52
5/12/2014
FY
201
4 –
2017
Mile
sto
nes
FY2014 M
ilestones
FY2015 M
ilestones
FY2016 M
ilestones
FY2017 M
ilestones
•Select EDW solution
partner
•Create a decision support
advisory group, reporting
to IT Governance
•Develop EDW work plan
to achieve Phase 1 scope
•Im
plemen
t ED
W Phase 1
Scope
•Im
plemen
t threeTruven
Analytic tools,
CareDiscovery
Quality
Measures, CareDiscovery
Advance, and Action OI
•Use Truven data to
prioritize opportunities
and begin im
plementing
changes
Utilizing the data wareh
ouse
and proactive tool sets, create
a data analytics support
structure to address:
•Business planning
•Concurrent clinical decision
support
•Clinically integrated
inform
ation technology
platform
(in support of
shared
management
processes for providers,
nursing and clinical support
staff) across the continuum
to support efficient and
effective support of
population health across
all settings
•Pr ovides support to m
eet
the changing regulatory
and public data reporting
needs
•Move toward a fully
integrated
inform
ation
and knowledge transfer
support structure to
manage Palomar Health
populations efficien
tly and
effectively in a tim
ely
manner to assure
flexibility and rapid
change in
response to the
market place
•Obtainfeed
back from
users on effectiven
ess of
initial EDW capabilities
•Fully dep
loy the data
analytics tool kit across the
continuum to facilitate
an
integrated
“plug and play”
capability to m
eet rapidly
changing market driven
needs for population
health m
anagement
Operational In
itiative 1: Create an
integrated data analytics support process to enable proactive business
planning, nim
ble reaction to new
market changes that is automated, concurrent and tim
ely.
EMT Sponsors: Opal Reinbold, B
ob Hem
ker
2
Addendum E
53
5/12/2014
FY
14 O
per
atio
nal
Init
iati
ve 2
:C
reat
e a
posi
tive
expe
rienc
e fo
r al
l key
sta
keho
lder
s by
impr
ovin
g cl
inic
al a
nd
busi
ness
thro
ughp
ut a
nd e
ffici
ency
thro
ugh
all t
rans
ition
s of
car
e.
Outcome M
easure:
1.
HCAHPS real tim
e top box results for Ra
te Hospital 0‐10for
each hospital
2.
Press Ganey
survey results for physicians and employees
Initiative Status:
•Charters, m
ilestones, and outcome measures developed
for 5 Patient Flow sub‐
group projects.; all projects are being actively worked
on; Pilot projects are
underway in all 5 areas; dashboard created
for ongoing monitoring
•Dyad developmen
t Modules 2, 3, 4
and 5 of AAPL are complete; M
odule 6
sched
uled for 4/26. Consolidated
dashboards for dyads completed
•Em
ployee En
gagemen
t Survey closed at 76% response rate and with a 50%th
percentile overall score. Physician Engagemen
t Survey closed with 54% response
rate and an 18t
hpercentile overall score.
•Hourly rounding, bed
side shift report, and executive rounding im
provemen
t bundles from the IHI/VHA Collaborative have been im
plemen
ted. Audits being
developed
for compliance.
•3 Patient and Fam
ily Advisor, Facility‐Specific Focus groups are sched
uled for the
last week in April. Results from Focus Groups to be review
ed at May PFA
C
Steering Committee Meeting.
Milestones:
1.
Create a standardized
patient flow process to enhance
efficien
cy and satisfaction for all key stakeholders
2.
Engage the med
ical staff to m
axim
ize efficien
cy and to enhance
patient care, safety and service (Dyads)
3.
Implemen
t and spread
best practices across the health system
from activities learned
by participation in the IHI/VHA
Collaborative
4.
Further the plan to engage the hearts and minds of the staff and
med
ical staff in
developing respectful partnerships with
patients/fam
ilies and each other (Patient/Family Advisor Role)
Report Date: April 29, 2014
Reporting Committees: Board Quality Review Committee, EMT
Safety and Service
EMT Sponsor: Sheila Brown, O
pal Reinbold, Lorie Shoem
aker
Initiative M
anager: Tina Pope, Leslie Solomon, M
aria Sudak
Physician Lead
er: Pasha, M
D, Kolins, M
D, B
uringrud, M
D, Martin,
MD
Initiative Risks
•Competing priorities
•Financial constraints
Jul 13
Jun 14
Initiative Budget: To be included
in FY14 Budget
Budget Status:
Outcome M
easures:
•HCAHPS Target: 80% top box percentage fo
r both hospitals
•Press Gan
ey Physician Engagement Target: 35% Overall Score
•Press Gan
ey Employee Engagement Target: 75% Overall Score
Overall Outcome M
easure:
Threshold: 1 of 3 m
et at target level
Target:
2 of 3 m
et at target level
Maxim
um:3 of 3 m
et at target level
Sept 13
Nov 13
Jan 14
Mar 14
May 14
12
34
1
HCAHPS Results:
PMC Q1: 79%
PMC Q3: 81%
POM Q1: 66%
POM Q3: 66%
PMC Q2: 76%
PMC Q4:
POM Q2: 69%
POM Q4:
Addendum E
54
5/12/2014
FY
201
4 –
2017
Mile
sto
nes
FY2014 M
ilestones
FY2015 M
ilestones
FY2016 M
ilestones
FY2017 M
ilestones
•Create a standardized
flowprocess
to enhance efficiency and
satisfaction for all key stakeholders
(Throughput)
•En
gage the m
edical staff to m
axim
ize
efficien
cy and to enhance patient
care, safety and service (on‐boarding
new
hospitalists; Med
ical/N
ursing
Director Dyad education)
•Im
plemen
t and spread
best
practices across the health system
from activities learned
by
participation in the IH
I/VHA
Collaborativ e
•Further the plan to engage the
hearts and m
inds of the staff and
med
ical staff in developing
respectful partnerships
(patient/family advisor role and
infrastructure)
•Expand patient flow to
the continuum to
maxim
ize the efficiency
and effectiven
ess of care
and key stakeholder
satisfaction
•Hardwire Med
ical/N
ursing
Director dyad model with
a structure, goal setting,
metric review
and
ongoing im
provement
process
•Expand involvem
ent of
patients and fam
ilies in
evaluation of care and
satisfaction with
particular em
phasis on
Centers of Excellence
•Broaden
the
Med
ical/N
ursingDirector
dyad m
odel to an
integrated
model that
includes patients and
families with an emphasis
on population
management to im
prove
revenue capture and
efficien
cies across the
continuum of care
•Utilize the
integrated
model to
assure flexibility and
nim
bleness to
respond to the
changing healthcare
environment
through
affiliations
and emerging
financial m
odels
Operational In
itiative 2: Create a positive experience for all key stakeholders by im
proving clinical and business
throughput and efficiency through
all transitions of care.
EMT Sponsors: Sheila Brown, O
pal Reinbold, Lorie Shoem
aker
2
Addendum E
55