board quality review committee open agenda · 1/16/2017 · board quality review committee monday...
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BOARD QUALITY REVIEW COMMITTEE
MONDAY JANUARY 16, 2017 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:30 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 6:00 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025
Page 1
OPEN AGENDA
PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM
Time Form A Page
#
Target
CALL TO ORDER 6:00
Establishment of Quorum ............................................................................................................. 1 N/A 6:01
Public Comments 1 ....................................................................................................................... 15 N/A 6:16
Information Item(s)
1. *Review/Approve: Minutes – Monday, November 21, 2016 (ADD A, Pages 10-15) ......... 5 3 6:21
2. *Review/Approve: 2017 BQRC Bylaws Section and Board Member Position Description (ADD B, Pages 16-18) ........................................................................................................... 1 4 6:22
3. *Review/Approve: 2017 BQRC Meeting/Reporting Calendar (ADD C, Pages 19-20) .......... 1 5 6:23
Standing Item(s)
4. Journal Club Assignment: - The existing state of the Board Quality Review Committee versus Recommendations of
the Governance Institute. (ADD D, Pages 21-45) ............................................................
10 6 6:33
Old Business
5. Continued Discussion on Patient Family Advisors (ADD E, Pages 46-74) ......................... a. Accountability – Leslie Solomon, VP, Culture Talent Planning b. Just Culture – Leslie Solomon, VP, Culture Talent Planning c. Patient/Family Representatives - Tina Pope, Manager, Service Excellence Presentation – 10 minutes Questions & Answers – 5 minutes
15 7 6:48
New Business
6. Diabetes Health Program (ADD F, Pages 75--90) .......................................................... Alan Conrad, MD, MMM, CPE, FAAPL, FACHE, Executive Vice President, Physician Alignment, Medical Director, Diabetes Health Program Valerie Martinez, Director, Quality, Patient Safety & Infection Prevention and Control Tamrah Jennings, RN, MSEd, MSN, RN, ACCNS-AG, Diabetes Clinical Nurse Specialist Presentation – 10 minutes Questions & Answers – 5 minutes
15 8 7:02
7. Stroke Program (ADD G, 91-100) ................................................................................... Rema Paduga, MD, Medical Director Stroke Program Valerie Martinez, Director, Quality, Patient Safety & Infection Prevention and Control Lourdes Januszewicz, MSN, APRN, ACNS-BC, CCRN, District Stroke Program Coordinator and Clinical Nurse Specialist – Float Pool Team Presentation – 10 minutes Questions & Answers – 5 minutes
15 9 7:17
Public Comments 1 ....................................................................................................................... 15 N/A 7:33
ADJOURNMENT 7:33
NOTE: The open session agenda, without public comments, is scheduled for 1 hour, 3 minutes. Based on above
agenda, without public comments the meeting starts at 6:00 pm and adjourns at 7:03 pm.
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BOARD QUALITY REVIEW COMMITTEE
MONDAY JANUARY 16, 2017 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:30 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 6:00 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025
Page 2
OPEN AGENDA
PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM
Board Quality Review Committee Members
VOTING MEMBERSHIP NON-VOTING MEMBERSHIP
Joy Gorzeman, RN – Chairperson, Board Member Bob Hemker, FACHE, President & CEO
Hans Sison, LVN, Board Member Frank Beirne, FACHE, EVP, Operations
Dara Czerwonka, MSW, Board Member Alan Conrad, MD, EVP, Physician Alignment
Frank Martin, MD - Chair of Medical Staff Quality Management
Committee for Palomar Medical Center Escondido Della Shaw – EVP, Strategy
Ed Gurrola, MD - Chair of Medical Staff Quality Management
Committee for Palomar Medical Center Poway Maria Sudak, RN, MSN, CCRN, NEA-BC – VP, Palomar Medical Center Escondido
Jeannette Skinner, RN, MBA, FACHE -VP, Palomar Medical Center
Poway and Palomar Medical Center Downtown Escondido Sheila Brown, RN, MBA, FACHE – VP, Continuum Care
Karen Buckley, CNO, Palomar Medical Center Escondido
Larry LaBossiere, MBA, MSN, RN, CNS, CEN, Palomar Medical Center
Poway Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient Safety Committee
Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Co-Chair of Patient Safety Committee
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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Attendance Roster and Minutes Board Quality Review Committee Meeting
Monday, January 16, 2017
Form A
TO: Board Quality Review Committee MEETING DATE: Monday, January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive
Assistant Background: The minutes of the Board Quality Review Committee
meeting, held on Monday, November 21, 2016, 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:
3
2017 Board Quality Review Committee Bylaws Section and Board Member Position Description
Form A
TO: Board Quality Review Committee MEETING DATE: Monday, January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive
Assistant Background: The 2017 Board Quality Review Committee Bylaws
Section and Board Member Position Description is respectfully submitted for approval.
Budget Impact: N/A
Staff Recommendation: Approval
Committee Questions:
COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time:
4
2017 Board Quality Review Committee Meeting / Reporting Calendar
Form A
TO: Board Quality Review Committee MEETING DATE: Monday, January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive
Assistant Background: The 2017 BQRC Meeting / Reporting calendar is
respectfully submitted for approval.
Budget Impact: N/A
Staff Recommendation: Approval
Committee Questions:
COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time:
5
Journal Club Article
The Governance Institute – “The existing state of the Board Quality Review Committee versus Recommendations of the Governance
Institute”
Form A
TO: Board Quality Review Committee MEETING DATE: Monday, January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive
Assistant Background: The reading for the BQRC Journal Club is a White Paper
written by The Governance Institute. The paper is titled,
“The existing state of the Board Quality Review Committee
versus Recommendations of the Governance Institute”.
Budget Impact: N/A
Staff Recommendation: For information only
Committee Questions:
COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time:
6
Continued Discussion on Accountability, Just Culture and Patient/Family Representatives
Form A
TO: Board Quality Review Committee MEETING DATE: Monday January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive
Assistant Background: Leslie Solomon, VP Culture Talent Planning will provide a
presentation on Accountability and Just Culture. Tina
Pope, Manager Service Excellence will provide a
presentation on the Patient Family Advisors Orientation to
Palomar Health for a continued discussion on
patient/family advisors participating on identified Medical
Staff and Board related meetings.
Budget Impact: N/A
Staff Recommendation: Approval for vetted Patient/Family Advisory members participation on identified Medical Staff and Board related meetings.
Committee Questions:
COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time:
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Annual Diabetes Health Program Report
Form A
TO: Board Quality Review Committee MEETING DATE: Monday, January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive
Assistant 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:
8
Annual Stroke Program Report
Form A
TO: Board Quality Review Committee MEETING DATE: Monday, January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive
Assistant 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:
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ADDENDUM A
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11.21.16 - MINUTES - BQRC Meeting - DRAFT
BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, NOVEMBER 21, 2016
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY
FINAL?
CALL TO ORDER
The meeting – held in Conference Room E at Palomar Medical Center Poway, 15615 Pomerado Road, Poway, CA 92064 – was called to order at 6:00 p.m. by Committee Chair, Dr. Aeron Wickes.
ESTABLISHMENT OF QUORUM
Quorum comprised of Board Directors: Wickes, Greer, Czerwonka
Excused Board Absences: None
NOTICE OF MEETING
Notice of Meeting was posted at Palomar Health Administrative Office; also posted with full agenda packet on the Palomar Health website on Monday, October 10, 2016 which is consistent with legal requirements. Notice of that posting was also made via email to the Board and staff.
PUBLIC COMMENTS
There were no public comments.
*INFORMATION ITEMS
1. *Minutes: Board Quality Review Committee Meeting – Monday, October 17, 2016
No discussion MOTION: by Director Greer, second by
Director Czerwonka and carried to approve the October 17, 2016, Board Quality Review Committee (BQRC) meeting minutes. All in favor. None opposed
N/A Y
STANDING ITEM(S)
1. Quality and Patient Safety Posters
Committee reviewed Falls and Catheter Associated Urinary Tract Infection (CAUTI) reduction process improvement posters, which were recently presented at the Hospital Quality Institute
None None Y
2. Journal Club
Committee discussed elements from the assigned reading of select pages of the Governance Institute’s White Paper “Maximizing the Effectiveness of the Board’s Quality Committee: Leading Practices and Lessons Learned”
None None Y
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11.21.16 - MINUTES - BQRC Meeting - DRAFT 2
BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, NOVEMBER 21, 2016
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY
FINAL?
OLD BUSINESS
1. Discussion of two Patient/Family Advisors serving on BQRC
Board members requested information re: best practices in this regard. Recommended inclusion of Vice President Culture and Talent Planning on this committee
Discussion with best practice information to be brought forth to next meeting for discussion
Committee member N
NEW BUSINESS
1. Annual Review of Credentialing Process for Medical Staff Membership Privileges
Executive Vice President Physician Alignment Dr. Alan Conrad presented the 2016 annual review. Committee recommendation to bring this information to the full board via an education session
Recommend sharing information with full board as future education session
Committee member /
Vice President Culture and Talent Planning
N
2. Quarterly Review of Service Excellence/Patient Complaint Reporting
The Committee reviewed the data, requesting future presentations to include trends over time. None None Y
3. Nursing Operations Report
Palomar Medical Center Poway and Escondido Downtown Chief Nursing Officer Larry Labossiere shared the annual report for FY2016, which included data and information on work being done by nursing in areas of focus such as Patient Experience, Quality, Business Development, Regulatory and Finance
None None Y
4. Surgery & Procedures – Palomar Medical Center Poway
Review of 2016 data re: OR Quality Initiatives -
• Surgical Site Infection (SSI)
• Turnover & On-Time Starts
• Center of Excellence Certification
• Pain Control: Total Joint Patients
• Leapfrog Results
2017 OR Quality Initiatives -
• Capital Investment of Equipment
• Expanding/Building Service Lines
• SPD Refurbishment
None None Y
PUBLIC COMMENTS
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11.21.16 - MINUTES - BQRC Meeting - DRAFT 3
BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, NOVEMBER 21, 2016
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY
FINAL?
There were no public comments
FINAL ADJOURNMENT
The meeting was adjourned by Director Wickes at 7:54 p.m.
SIGNATURES:
COMMITTEE CHAIR
Aeron Wickes, MD
BOARD ASSISTANT
Debbie Hollick
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Page 1 of 2
Board Quality Review Committee Meeting
OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2016
Voting Members
Palomar Health By-Laws’
Membership
Meeting Dates:
1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 Annl Rpt
10/17/16 11/21/16 12/19/16 CANCELLED
DIRECTOR AERON WICKES , MD – CHAIR Board Member P P P P P E P P P P
DIRECTOR LINDA GREER, RN Board Member P P P P P P P P P P
DIRECTOR DARA CZERWONKA Board Member P P P E P P P E P
DIRECTOR HANS SISON (ALT) Board Member P -- -- -- -- -- -- -- P --
FRANK MARTIN, MD QMC Chair, Palomar Medical Ctr
P P -- P -- -- -- -- P --
RICHARD ENGEL, MD Interim QMC Chair, Palomar Medical Ctr
-- -- P P P P -- -- -- --
CHARLES CALLERY, MD QMC Chair, Pomerado Hospital
P P P P P P P P P P
Non-Voting Members BEIRNE, FRANK EVP, Operations P P P P P P E P P P
BROWN, SHEILA, RN, FACHE VP, Continuum Care -- -- P P P P P P E P
CONRAD, ALAN, MD EVP,Physician Alignment P P P -- -- P P P E P
GOWER, JUNE, PH.D. Interim CNO, PHDC & Pomerado Hospitals
-- -- -- -- -- -- -- --
HEMKER, BOB President & CEO P P P E P E E P E E
KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient
Safety Committee P P P P P P P P P P
LABOSSIERE, LARRY CNO, Pomerado Hospital -- -- -- -- P P P P E P
MARTINEZ, VALERIE, RN, BSN, MHA, CIC Co-Chair, Patient Safety Committee
P P P P P P P P P P
OLSON, CHERYL Interim VP, PHDC & Pomerado Hospitals
P P P P -- -- -- -- -- --
SHAW, DELLA EVP, Strategy P P P P -- -- -- --
SKINNER, JEANNETTE VP, Pomerado Hospital -- -- -- -- -- -- -- P -- P
SUDAK, MARIA, MSN, CCRN, NEA-BC, RN CNO & VP, Palomar Medical Center
P P P P P P P P -- P
Guests ADELMAN, MARCY, RN P
ANDREWS, SHELLY, RN P
BANDICK, BRET P
BARNES, DEBBIE, RN, CDS
DELANGE, NICOLE P
FARROW, DAN P
GOELITZ, BRIAN, MD P
GRIFFITH, JEFF (BOARD MEMBER) P
HANSEN, DIANE P P
KAUFMAN, JERRY (BOARD MEMBER)
KIM, JESSICA P P P P
LEE, DAVID, MD P P P P P P E P P
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Page 2 of 2
LEE, JEREMY P P
Meeting Dates:
1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16
Guests (continued) MCCUNE, RAY (BOARD MEMBER) P
NAMENYI, JASMINA P
NEUSTEIN, PAUL, MD P
NICPON, GREGORY, MD P
PASHA, SABIHA, MD P
PHILLIPS, DONITA, MBA, ARM P P P P P P P P P
POPE, TINA P P P P P P P P P
RIEHL, RUSSELL P
ROLIN, DONNA P
ROSENBURG, JEFFREY P E E E E
SCHULTZ, DIANA P
SKINNER, JEANETTE P
SOLOMON, LESLIE P
TERRELL, CEDRIC P P
TURNER, BRENDA P P P
WATSON, RAE ANNE P P
WIESE, LISHA P
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ADDENDUM B
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13 REVISED 10/15/2016
(iv) Review regulations and reports regarding facilities and grounds from external agencies, accrediting bodies and insurance carriers; make recommendations for appropriate action regarding the same to the Board;
(v) Approve the annual Facilities Development Plan and regularly review updates on implementation of plan;
(vi) Receive a biannual Environment of Care report;
(vii) Perform such other duties as may be assigned by the Board
6.2.6 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 and Palomar Health Downtown Campus/Pomerado Hospital.
(b) Non-Voting Membership. The President and Chief Executive Officer, the Executive Vice President Physician Alignment, the Executive Vice President Operations, the Executive Vice President Strategy, the Vice President Continuum Care, the Vice Presidents of Palomar Medical Center and Palomar Health Downtown Campus/Pomerado Hospital, the Chief Nursing Officers of Palomar Medical Center and Palomar Health Downtown Campus/Pomerado Hospital, the Vice President Patient Experience, and the Chair or Co-Chairs of the Patient Safety Committee.
(c) Duties. The duties of the Committee shall include but are not limited to:
(i) Pursuant to the Palomar Health Performance Improvement/Patient Safety Plan oversees the performance improvement, patient safety and risk management activities (including but not limited to claims and potential litigation's) of the hospitals and other facilities, if applicable, and shall periodically report this conclusion and recommendations to the Board; and
(ii) Yearly review of credentialing process;
(iii) Yearly review of physician satisfaction scores;
(iv) Nursing survey regarding physician behavior will be reviewed when appropriate; and
(v) Quarterly review of customer satisfaction scores.
6.2.7 Community Relations Committee.
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2017 Board Quality Review Committee Description - DRAFT Approved by BQRC on ____________
PALOMAR HEALTH
BOARD QUALITY REVIEW COMMITTEE
Board Member Position Description
Function:
It is the responsibility of the Board Member to assure 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 that actions are
taken on behalf of the Board to ensure the safety and well-being of the citizens served.
Responsibilities:
1. Regularly review and approve the systems annual and long term quality assurance plans to
ensure the identification, assessment and resolution of patient care issues.
2. Ensure that the system is meeting regulatory and governmental requirements and standards
pertaining to the delivery of quality medical clinical care in all of its facilities and programs.
3. Monitor institutional liability/risk experience and ensure that proper systems are put into
place to reduce exposure to loss.
4. Ensure that credentials of Medical and Allied Health staff are reviewed and privileges
granted and renewed on the basis of demonstrated professional competence and adherence to
the bylaws and code of conduct set forth by the Medical Executive Committee of the
Healthcare practitioners involved.
5. Provide oversight to the development and management of educational endeavors to improve
staff performance and skills in the completion' of their clinical care responsibilities.
6. Regularly review and assess Quality care reports, statistics and programs from Medical Staff
and System departments to identify trends or clinical care issues and to recommend
stewardship action.
7. Perform other duties as may be assigned by the Committee Chair.
Requirements:
1. Interest and willingness to commit the time and energy necessary to meet committee
responsibilities in meeting requirements.
2. Background and familiarity with aspects of clinical care issues and willingness to expand
knowledge in this arena.
3. An appreciation for risk management and the relationship of medical care, clinical
competence and financial/legal issues resulting from potential adverse events.
4. Compliance with other Board position description requirements.
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ADDENDUM C
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Palomar Health
BOARD QUALITY REVIEW COMMITTEE
2017 Performance Improvement Reporting Calendar
DRAFT Yellow - Annually Blue - Quarterly
Reports due Patient Experience Executive Assistant 29-Dec 2-Feb 2-Mar 30-Mar 27-Apr 1-Jun 29-Jun 3-Aug 31-Aug 28-Sep 2-Nov 30-Nov
Meeting Date
JAN
16
FEB
28*
MAR
20
APR
17
MAY
15
JUN
19
JUL
17
AUG
21
SEPT
18
OCT
16
NOV
20
DEC
18
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
Valerie Martinez, Director Quality, Patient Safety & Infection Control √
Annual Review of Reporting Calendar √
Quarterly Review pf Service Excellence & Patient Grievance Reporting
Tina Pope, Manager, Service Excellence√ √ √ √
Medical Group Quality Reports
Arch Healthcare, Graybill, Neighborhood Health and SCMG√
Clinical and Diagnositc Services
Maureen Malone, AVP, Clinical & Diagnostic Services
Pharmacy, Imaging, Respiratory Therapy & Laboratory√
Continuum of Care
Sheila Brown, VP, Continuum Care
Wound Care, Behavioral Health Services, ExpressCare, Home Health, Rehabilitation Services,
Corporate and Employee Health, SNF
√
Diabetes Health Program
Valerie Martinez, Director Quality, Patient Safety & Infection Control √
Emergency Management/Environment of Care/Hospitality (EVS & FANS)Dan Farrow, AVP, Hospitality and Facilities √
Infection Control & PreventionValerie Martinez, Director Quality, Patient Safety & Infection Control √
Resource UtilizationMarcy Adelman, Director, Clinical Resource Management √
Risk Management
Donita Philips, Director Risk Management√ √ √ √
Stroke Program
Valerie Martinez, Director, Quality, Patient Safety & Infection Control√
Nursing Operations (Inpatient, Obsetrics & Platform)
Karen Buckley, CNO, Palomar Medical Center Escondido
Larry LaBossiere, CNO, Palomar Medical Center Poway√
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
√
* Tenative meeting date due to President's Day Holiday on February 20th.
DRAFT
N
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M
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Page 1 of 1 Revised: 1/10/201720
ADDENDUM D
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To: Board of Directors, Members of the Board Quality Review Committee (BQRC), the Executive Management Team and The Chiefs of Staff
From: Jerry Kolins, MD, VP, Patient Experience
Date: December 23, 2016
Re: Maximizing the Effectiveness of the Board’s Quality Committee
Last year Bob asked us to review the attached article from The Governance Institute entitled “Maximizing the Effectiveness of the Board’s Quality Committee.” This article focuses on the role of the hospital board of directors in assuring quality and patient safety. There are several best practices described in this paper. This memo highlights those practices that are under development at Palomar Health.
At the January 16 meeting of the BQRC, we will discuss these opportunities and consider next steps in our maturation as a high reliability organization. In addition, Valeria Martinez, Director of Quality/Safety/ and Infection Control, will provide an update on the status of our Centers of Excellence in Diabetes Health, and Stroke. One year ago we were contemplating best approaches to (1) cascading levels of accountability. We were undecided about a timeframe for (2) implementation of “just culture.” We did not have (3) representation of patients/families on many committees within Palomar Health. These three key elements of a high reliability health system are recommendations from The Governance Institute. Page references to these elements are noted below. Our gaps are closing. We will review our current state and future state at the January 16 meeting to be held in the Learning and Development Center (LDC) in the iExplore room. At Bob’s direction Leslie Solomon, VP Culture and Talent Planning, will prepare an educational program in 2017 for the full board of directors on the meaning and relevance of “just culture” in healthcare. Therefore further discussion on the value of “Just Culture” will occur after the educational program planned for the full board of directors.
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2
1) State of "cascading levels of accountability.” A concrete example begins at the bottom right column p.13: "Recently the JHM Patient Safety and Quality Board Committee became involved in addressing ED wait times at Johns Hopkins Hospital. Performance deteriorated to the point that it was affecting patient satisfaction and health... This deterioration in performance led to a lengthy telephone call during which committee members and hospital leaders discussed a new game plan for improvement... The board quality committee will continue to monitor performance and the issue will remain on its agenda until improvement occurs and targets are met." 2) A commitment to training in just culture See p.7 -- "Board quality committees should recommend that the full board adopt a 'just culture' approach to dealing with safety and quality issues. This approach recognizes that bad things happen and that most of them are due to problems with systems rather than individual behaviors. It further pledges that no individual will be held accountable for such systems problems but rather will be recognized positively for speaking up openly about these problems." 3) Representation of patients/families on the BQRC See page p.8 "...recommends that two patient and family members serve as voting members of the board quality committee... Having one patient/family representative is not adequate, as this individual may feel isolated and hence not participate in discussions." Please see attached the draft calendar of reporting for 2017.
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ADDENDUM E
46
The Palomar Health Patient and Family Advisor Council is a partnership of patient and family members and healthcare teams dedicated to exceeding our patients’ and family members’ expectations.
47
The Patient and Family Advisor Council will have an active role in improving the patient and family care experience by providing feedback on patient and family centered care.
Actively participate both in and out of meetings to achieve the purpose
Work effectively with other council members, as well as Palomar Health Staff, patients and families to ensure a patient and family centered care experience
Facilitate change to support the achievement and continued improvement of patient and family centered care
Review materials provided prior to the meetings so that each member is prepared to ask questions, contribute ideas, and provide input
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Decision-making will normally be by consensus. If consensus is not reached, decisions will be made by a majority of all members. All members are expected to support the decisions once a meeting is adjourned
Be willing to work on projects and/or sub-committees beyond the 1 hour monthly commitment
Be willing to serve on the PFAC for a term of 2 years (or 1-2 years as may be determined by the committee)
Adhere to the Palomar Health Code of Conduct and all signed, required and agreed to documents for volunteers
All meetings will be the 3rd Tuesday of the month, starting at 4:00 p.m. and ending at 5:00 p.m.
Refreshments will be provided at all meetings Patient and Family-Centered Care Program
Manager and/or Chairman/Co-Chair are points of contact concerning committee issues
Patient and Family Advisors (PFAs) are expected to attend a minimum of eight (8) meetings annually.
In addition to the monthly meetings, PFA’s are encouraged to participate in sub-committee activities as needed
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A patient and/or family member of Palomar Health may be nominated by his/her provider or by Palomar Health staff
Each PFA nominee must have an interest in health care
Each PFA nominee must fill out an application Each PFA nominee must attend the Palomar Health
Orientation process The Chairman/Co-Chair and the Program Manager
will review the applications and select those to be interviewed
Each PFA nominee will be interviewed by at least one of the Co-Chairs and the Program Manager
Following a positive recommendation by the Chair/Co-Chair and the Program Manager will forward the approved application to the Volunteer Director to:◦ Complete background check◦ Assure all Palomar Health volunteer requirements
are completed and in the PFAs secure file• When a PFA nominee is approved, he/she will
become a member of the PFAC
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A PFA may be removed from the PFAC by unanimous agreement of the Program Manager and Chair/Co-chairs if any of the following occur:◦ The PFA no longer has relationship with Palomar
Health◦ The PFA has continuous and frequent absences from
PFAC meetings without prior notices◦ Violation of the Palomar Health Code of Conduct and
required agreements A PFA member may resign at any time. The
resignation is to be submitted to either of the Chair/Co-Chairs or the Program Manager in writing
PFAC Officers◦ Chairman (1 co-chair should you decide)◦ Program Manager (ex-oficio)◦ Scribe (Palomar Health Staff or PFA member)
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For the first year of the PFAC, one Co-Chair will be the Program Manager, and the other Co-Chair will be a PFA member selected in OCTOBER.
The election of the second PFA Co-Chair will be in APRIL of 2015. This will allow for continuity of experience during change of Officers.
Nominations for the PFAC Officers shall be given to the Program Manager. PFA members may nominate themselves or other members. Nominations will be accepted prior to the April and September PFAC meetings
Ballots will be prepared and elections will occur during the October and April meetings.
Officers will serve a one-year term and may remain in the position up to two years.
If a Co-Chair position becomes vacant, the Program Manager will assume the office until a PFA is elected to the position. The replacement Co-Chair term will be for the balance of the vacated term.
The outgoing Co-Chair will meet with the newly elected Co-Chair one month prior to assuming office for orientation/mentoring session
52
Chair/Co-Chair ◦ The Chair/Co-Chairs will have equal responsibility and are
expected to work closely with the Program Manager. The responsibilities of the Chair/Co-chairs are as follows: Convene and facilitate meetings efficiently Set and prioritize agendas with the Program Manager Ensure PFAC abides by the Team agreements and the
responsibilities set in this Charter Work effectively with Palomar Health Staff, relative to the
goals of Patient and Family Centered Care, in pursuance of the PFAC Purpose
Work closely with Palomar Health Staff between meetings as needed
Be accountable to the PFAC Participate in leadership training, coaching, and mentoring as
needed Participate or assign facilitators responsibilities as necessary
for sub-committees or projects.
Scribe –◦ (This role is currently held by the Service
Excellence Program Assistant). He can continue in the role or the group can decide to elect a scribe. Scribe duties are as follows: The scribe will be responsible for taking notes at
each PFAC meeting and will distribute the notes electronically to the PFAC members after each meeting. PFAC member can be elected or volunteer for the position. This position will ensure each meeting has coverage. Focus of this role is to capture action item, tasks assigned and progress on projects.
53
Guide to Patient and Family Engagement
Patient and Family Advisor Orientation Manual
54
Guide to Patient and Family Engagement
Table of Contents
About This Orientation Manual .............................................................................................. 1
Section 1. Responsibilities and Expectations ......................................................................... 2
Section 2. Tips for Being an Engaged Advisor ....................................................................... 5
Section 3. Working With Advisors to Improve the Quality and Safety of Health Care .......... 10
Section 4. How Things Work at Palomar Health ................................................................... 12
Section 5. Ways to Learn More ............................................................................................ 17
Notes ................................................................................................................................... 19
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Guide to Patient and Family Engagement :: 1
About This Orientation Manual
This orientation manual will help prepare you for your role as an advisor. It is organized
into the following sections:
Section 1. Information to help you understand the responsibilities of and
expectations for patient and family advisors
Section 2. Tips for being an engaged patient and family advisor
Section 3. Information about how patient and family advisors help us
improve hospital quality and safety
Section 4. How things work at Palomar Health
Section 5. Ways to learn more about health care quality, patient safety, and
being a patient and family advisor
This orientation manual is intended to accompany other training you will receive from the
hospital to help prepare you to be a patient and family advisor.
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Guide to Patient and Family Engagement :: 2
Section 1. Responsibilities and Expectations
As a patient and family advisor, your experiences are a powerful tool for inspiring change at our hospital. By sharing your
perspectives and working with hospital staff and other patient and family advisors, you can make a real difference. The
time and energy you invest help us make important changes and improve the care experience for other patients and
families.
As an advisor, there are things that we will ask you to do. There also are things we will do to make sure we are doing our
best to build a strong partnership with you.
We promise to:
Provide you with the training you need to be
an engaged advisor.
Provide you with the resources and
organizational support you need to do your
job well.
Identify a staff liaison who will help you
prepare for meetings; provide you with
information; and be available if you have
comments, questions, or concerns about your
role.
Listen and respond to your ideas and
suggestions.
Keep you informed about how your feedback
and ideas contribute to changes and
improvements.
You promise to:
Support and commit to the mission and
vision of our hospital.
Attend orientation and training.
Prepare for meetings as needed
by reviewing materials, reading a report,
or completing a task before a meeting.
Attend meetings as required. If for some
reason, you cannot attend a meeting, please
call your staff liaison. You can also ask if there
is another way you can participate (for
example, by phone).
Actively participate in meetings by sharing
your input and opinions.
Maintain confidentiality. As a patient and
family advisor, you may have access to health
information about other patients that must
remain private.
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Guide to Patient and Family Engagement :: 3
Key contacts for the patient and family advisor program
Tina Pope, District Manager of Service Excellence,
coordinates all the activities of patient and family
advisors and will be your liaison to Palomar Health. She
will make sure you get the training you need and that you
complete all the necessary requirements.
She is available to you by phone, email, or in person to
answer any questions you have or to discuss your
participation as an advisor:
Tina Pope – 760-740-6366
Christine Breese, Executive Assistant 760-822-6195
In addition, your Patient and Family Advisor Chairperson
is also available to you and can answer any questions you
may have about your role as an Advisor:
2016 Chairman – Jim Lyon
2016 Co-Chair/2017 Chairperson – Estelle Wolfe
(Contact information on Roster).
Training and orientation
We are committed to making sure you have the training
you need to feel confident in your role as a patient and
family advisor. This manual is only one part of your
training. Other parts of your training will include:
Tours of facilities and departments
Regular Monthly meetings with the team and leaders
of the organization
Presentations at Committee meetings
Participation in the special projects and committees
Attendance at Annual Safety Conference
Other requirements
All Patient and Family Advisors (PFAC members) are
required to attend volunteer orientation, pass a
background check and complete a Confidentiality
Statement.
Time commitments
The amount of time you spend on advisor activities
depends on your specific role.
PFAC Meetings are held once a month at Palomar
Medical Center on the third Tuesday of the month
from 3:30 – 5:00 p..m. Invites, agendas and minutes
will be sent to you each month.
If you are an officer of the PFAC (Chairman or Co-char)
you may spend 8 hours a month or more in that
service, depending on your level of interest and
commitment (committees and projects).
You may be asked to review materials to prepare for a
meeting. We will make sure you have enough time to
review them and will send them to you either by mail
or by email, depending on your preference.
Palomar Health has both short term and long term
projects. PFAC members will be offered the
opportunity to accept or decline any request, based on
their availability
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Guide to Patient and Family Engagement :: 4
Confidentiality agreements
As a patient and family advisor, you may have access to
health information about other patients. It is important
to know that a federal law called HIPAA (Health
Insurance Portability and Accountability Act) protects
how health information can be used and disclosed.
Health information cannot be shared outside the hospital
or health care facility. It cannot be shared in any written,
verbal, or email communications with friends, family, or
anyone else unless specifically permitted.
The easiest way to remember what HIPAA means is
the saying, “What you see or hear here must remain
here.” We will ask you to read and sign a confidentiality
agreement to indicate your understanding of and
cooperation with these requirements.
Feedback and review process
Your feedback helps us better understand how we can
support you and your fellow advisors. The staff liaison will
meet with you regularly to get your feedback on how
things are going. These meetings are also a chance for
you to let the staff liaison know how we can improve and
expand our advisory activities. During these meetings,
the staff liaison will also ask you about your goals and
whether there are any areas in which you would like to
strengthen or expand your skills.
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Guide to Patient and Family Engagement :: 5
Section 2. Tips for Being an Engaged Advisor
This section contains tips from other patient and family advisors about how to be an engaged advisor. As you read, make
note of things that you think might be challenging for you. Discuss these with your staff liaison and ask for more help if
needed. Above all, have faith in your participation as an advisor and keep at it. Bring your sense of humor and expect the
best from your experience.
Six tips for being an engaged advisor
Tip 1. Share your views
You have been asked to be an advisor because your ideas
are valuable. You know what it is like to get care in our
hospital. We want to hear your ideas about how we can
improve the quality and safety of the care we provide and
help make sure that other patients and families have a
good experience.
Focus on problem solving. It is important to build
on positive experiences. For example, “We found that
things worked well for our family when…” It also is
helpful to share negative experiences. When you do,
try to offer suggestions and possible solutions.
Problemsolving is always appreciated.
Think carefully about the words you use. If you
want to tell a story that will bring up strong emotions,
ask your staff liaison or another advisor to help you
think about what you want to say and how you want to
say it. Try to remember that anger usually does not
produce good results.
Respect people’s privacy. Feel free to share your
experiences and the experiences of patients and family
members other than yourself. If you do share someone
else’s story, let people know that this experience did
not happen to you and avoid using the person’s name.
When speaking about experiences in the hospital, try
not to use the names of staff members.
Tip 2. Draw on your communication skills
As an advisor, you will work with many types of people
from different backgrounds. You may work with health
care providers, hospital staff, hospital leaders, and other
patients and family members. Good communication skills
will help you explain your ideas clearly and develop good
working relationships.
Keep an open mind. Be willing to see past your own
views and experiences. You will be working with
doctors, nurses, hospital staff, and other patient and
family advisors who bring their own views. Different
perspectives can lead to better conversations and
outcomes.
Listen well. When someone is speaking, it is natural
to think about what you are going to say in response.
However, it is important to give all of your attention to
the person who is speaking and to hear them out
before you respond.
Make sure you understand what other people are
saying. One way to make sure you understand
someone’s point is to say, “What I hear you saying is…”
and then repeat what you heard them say. This gives
people a chance to clarify their points if needed.
Be aware of how you are sharing time with others
when you are speaking. If needed, make
adjustments to give others time to express their ideas.
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Guide to Patient and Family Engagement :: 6
Tip 3. Ask questions
When you or your family members were in the hospital,
there may have been times when hospital staff used
language that you did not understand. That can happen
when you are working as an advisor, too. If it does, speak
up and ask people to explain what they mean.
Ask clarifying questions. For example, “Let me make
sure I understand correctly. I heard you say…”
Ask for definitions of medical terms,
abbreviations, or other terms. For example, “I’m
not sure I know what CAHPS means. Would you please
explain it to me?” (See the Working With Advisors to
Improve the Quality and Safety of Health Care section
of this orientation manual for information about the
CAHPS® Hospital Survey.)
Ask for more details. For example, “Can you walk me
through this so I can picture it?”
Tip 4. Be ready for disagreements
Disagreements are a natural part of working on a team.
Expressing your views when they are different from the
views of others can be challenging. However, your honest
opinion can lead to greater understanding.
Describe your point of view in terms of your
perception or opinion rather than as a fact or the
truth for all patients and families. For example: “I
see it differently,” “I have a different priority,” or “That
doesn’t work so well for me.”
Ask for more background information when
people say that a change is not possible. For
example: “Help me understand why this change is not
possible. What have you tried?” Sometimes doctors,
nurses, and other hospital staff are so used to the way
things have always been done that it is hard for them
to see other ways of doing things. Sometimes, there
are things that really cannot be changed. In this case,
you should ask about the reasons why.
If you find yourself upset after a meeting, talk to your
staff liaison at the hospital. Your staff liaison can make
sure that your concerns are addressed and help you
resolve them.
Tip 5. Ask for information to help you
understand your commitments
When you agree to become an advisor, make sure you
fully understand the commitment you are makin, and
then keep that commitment.
Prepare for meetings. If there are responsibilities
that you are asked to fulfill between meetings, come to
the meeting prepared to share information about your
progress on these activities and projects. Be on time
for meetings and stay until the end.
Keep the staff liaison informed about your
schedule. If you are not able to attend a meeting in
person, ask if you can call in (through conference call or
speaker phone) as an option. If you cannot participate
in a meeting, notify your key contact or staff liaison.
Ask if you can get an update before the next meeting.
If you find that you are having difficulty balancing your
personal and family life with advisory activities, talk to
your staff liaison about whether you can cut back on
some of your advisor duties or take a short-term break.
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Guide to Patient and Family Engagement :: 7
Tip 6. Ask for feedback
One of the best ways to develop your skills as an advisor
is to ask for feedback. Talk to your staff liaison about your
participation, including what is going well and what skills
you would like to enhance. Getting feedback is especially
important if you would like to expand your involvement
and take on new roles and responsibilities.
Ask for feedback after you have completed a
task. If you are participating in a one-time discussion
group or very short-term work group, ask your staff
liaison if you can talk to him or her about your
participation after you have completed the task.
Ask for regular feedback meetings with your
staff liaison. If you will be serving as an advisor for
several months or more, ask your staff liaison to meet
with you on a regular basis so that you can become
aware of your strengths and areas for improvement.
Ask how you can learn more. If there is a topic you
would like to learn more about or some skill you would
like to work on, ask your staff liaison for resources,
individuals to meet with, or time to discuss it further.
Ask for support from other advisors when you
need it and always be ready to provide support to
them.
Participate in the advisor review process. The
hospital’s volunteer office will have your staff liaison
complete an annual review with you to identify how to
continue to best support you as an advisor and to help
you improve your participation as an advisor.
Sharing your story
Sharing your story can help others understand your
health care experiences and how these experiences have
affected you and your family. It can also be a powerful
way to show the need for specific changes and
improvements at the hospital.
As an advisor, you may be asked to share your story with
a variety of people. For example, you may be asked to
share your story with hospital leaders to help them
understand why it is important for our hospital to work
with patient and family advisors. You may be asked to
help educate doctors, nurses, and other hospital staff
about why it is important to conduct bedside shift reports
or involve patients and families in the discharge process.
Or you may be asked to speak to a group of patients and
family members about becoming advisors.
We will provide you with training and support for each of
these opportunities. You should accept invitations to
speak only if you are comfortable with the request.
Before you agree to share your story
Before you agree to share your story in a training,
meeting, or presentation, get information about what is
expected of you and what you can expect. Ask the
following questions:
When, where, and for how long do you want me to
speak?
What do you hope will happen as a result of me sharing
my story?
Who is the audience? How many people will be there?
Who else will be speaking?
Will I be answering audience questions?
Will the session be audio or videotaped?
Is there reimbursement for child-care or
transportation?
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Guide to Patient and Family Engagement :: 8
Preparing to share your story
If you have decided to share your story, think about what
you want to say and how you want to say it. Some people
write down their main points to keep them focused. You
can use the worksheet below called Sharing Your Story to
help you organize your thoughts.
Before you speak in a meeting or to a group, it also helps
to practice. Time yourself and see if you are staying
within the requested time frame.
As you are preparing what you want to say, think about
the following questions:
Why was I asked to share my story?
What are the key messages I want to share?
What are the two or three specific points that I want to
the audience to remember?
What am I willing to share? What is too private to
share?
What examples can I give of when things went well?
What examples can I give of things that could have
gone better?
What ideas do I have about how my experience could
have been improved?
Also keep in mind the following tips:
Only share what you want to share. If you still feel
angry about a certain situation or event and do not
think you can talk about it in a helpful manner, it may
be best not to share that part. You can also talk about
it with someone you trust. Ask for ideas about how to
share that part of the story in a way in which people
will listen.
Focus on experiences rather than individuals. Try
to avoid using the names of doctors, nurses, and other
staff. If you talk about another facility where you have
received care, please do not mention it by name.
Be prepared for emotional reactions. Expect that
some people who hear your story may be deeply
moved. Also remember that you may feel emotional
when you tell your story.
Remember that you are in control. If people ask
you questions and you do not know the answer, it is
okay to say so. If you do not want to answer a
question, it is okay to say that as well.
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Guide to Patient and Family Engagement :: 9
Sharing your story — A planning worksheet(1)
Use this worksheet to help plan what you want to share about your hospital experience.
Key points about your hospital experiences
What went well during your hospital experience? What things did people say or do that were helpful?
[Blank]
[Blank]
[Blank]
[Blank]
[Blank]
What did not go well during your hospital experience?
What things did people say or do that were not helpful?
[Blank]
[Blank]
[Blank]
[Blank]
[Blank]
[Blank]
What improvements would you suggest? What would you rather have happened?
[Blank]
[Blank]
[Blank]
[Blank]
[Blank]
[Blank]
1 Adapted from University of Washington Medical Center, Patient and Family Centered Care and Education Services, 1959 N.E. Pacific Street, Box 358126, Seattle, WA, 98195
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Guide to Patient and Family Engagement :: 10
Section 3. Working With Advisors to Improve the Quality and Safety of Health Care
At Palomar Health, we want to make sure that everyone who comes into the hospital has the best experience possible. One
of your jobs as a patient and family advisor is to give us feedback about your experiences and suggesting changes and
improvements. This can help make care better for all patients.
How advisors help improve health care quality and safety
Improving health care quality and safety is a challenging task. Health care is a lot better when patients, families, doctors,
nurses, and other hospital staff work together to ensure the quality and safety of the care we provide. Because health care
quality and safety have a direct effect on patients and families, it is particularly important for patients and family members
to participate in changes and improvements.
As an advisor, you will be asked to share your ideas about ways to improve the quality and safety of care that patients get in
our hospital. This helps make sure the care and services we provide are based on “patient- and family-identified” needs
rather than the assumptions of clinicians and hospital staff about what patients and families want.
Specific ways in which we may ask patient and family advisors to help include:
Participating in discussions about health care quality and safety with doctors, nurses, hospital staff, and other
patients and families, including helping to identify places where errors might occur
Sharing ideas about how to make sure that patients and families have meaningful opportunities to participate in their
care and decisions about their care
Revising or helping to create materials for patients and families
Sharing your story during training sessions for doctors, nurses, and other hospital staff
“Patient and family advisors have knowledge we don’t have. It is so humbling to realize that patients and families know
more about [the hospital] than you do.”
Pat Sodomka, Former Vice President for Patient and Family Centered Care, Georgia Health Sciences Health System
(formerly MCGHealth), Augusta, GA
Improving the care we provide
As an advisor, you may be able to think of times when you or your family member got good quality care in the hospital. You
also may be able to think of times when you or your family member did not get good quality care.
We want to make sure that every patient who comes into the hospital gets good quality care. To us, this means that:
Patients get the right care for their condition. Patients get the tests and treatments that are recommended for their
condition.
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Guide to Patient and Family Engagement :: 11
Patients get care that is safe and free from medical errors. The tests and treatments that patients get do not cause
them any harm. Health care providers follow appropriate safety precautions (for example, washing their hands and
checking medications before giving them to patients).
There are no delays in care. Patients get the care they need when they need it. They get the tests and treatments
they need at the time when they will do the most good.
Patients are not treated differently based on their race, ethnicity, income, level of education, or social
status. Everyone is entitled to high-quality health care. This includes people of all cultures and backgrounds.
Patients get care that is patient and family-centered. This means that:
o Clinicians and hospital staff ask about and respect each patient’s and family’s values, preferences, goals, and
cultural backgrounds
o Clinicians and hospital staff communicate clearly and share complete, unbiased, and timely information with
patients and families
o Patients and families are encouraged to participate in their care and decision making to the extent they choose
o The patient’s care represents a partnership between the patient, family, clinicians, and hospital staff
Above all, we want to make sure that patients and families have good experiences and feel supported while they are in the
hospital. We welcome your thoughts and ideas about how to make sure this happens.
Identifying ways we can improve
In addition to asking patient and family advisors for feedback, there are other ways that we identify areas for improvement.
One way to identify areas for improvement is to look at whether the right things happen as part of our patients’
treatment. For example, do patients get the medicines they need when they are supposed to? Do they get the correct tests
and treatments? If not, why are these things not happening?
Another important way to identify areas for improvement is to ask patients about their experiences. For example, many
hospitals ask patients to fill out surveys about their experiences in the hospital.
One survey that you may hear about as an advisor is called the CAHPS® Hospital Survey (also called HCAHPS). Most
hospitals in the United States give this survey to patients. Results from the CAHPS® Hospital Survey help us learn where we
could be doing a better job.
The CAHPS® Hospital Survey asks patients to answer questions on how well health care providers did at sharing
information and listening. The survey also asks patients to rate how well their care was coordinated, how well their pain
was managed, and whether they had the information they needed to take care of themselves after going home.
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Guide to Patient and Family Engagement :: 12
Section 4. How Things Work at Palomar Hospital
Our Mission
To heal, comfort, and promote health in the
communities we serve.
Our Vision
Palomar Health will be the health system of choice for
patients, physicians, and employees, recognized
nationally for the highest quality of clinical care and
access to comprehensive services.
Core Values / Palomar Health Staff
Patients' Well Being: We passionately give and support
heartfelt care that encourages patient comfort and
safety.
Professionalism: Each of us takes pride in teamwork,
self-discipline, our skills and trustworthiness.
Highest Quality: We are each accountable for providing
the safest, most effective and innovative care.
Palomar Health Board of Directors
Function:
It is the responsibility of the Board Member to develop
and ensure that the organization's mission and vision
statements are carried out in an effective and ethical
manner. To that end, the member is accountable for
oversight and implementation of policies and monitoring
of the organizations performance in establishment of
strategic direction, financial stewardship, quality
outcomes and leadership of the Healthcare District.
Specific Responsibilities:
Regularly review and, where appropriate, update the mission and vision statements for the System and subsidiaries to ensure the needs of the citizens of the District are being met in accordance with its Charter.
Approve a system-wide quality assurance plan and monitor the effectiveness of the organization in meeting targets of performance to insure the health, well-being and safety of those served.
Work closely with Medical Staff and Administrative Leadership to insure that effective clinical care is being provided in the system's facilities and that competency of Medical and Allied Health staff are assured on behalf of the citizens of the District.
Review and approve all financial policies, plans and programs for the system and enhance the preservation of the organization's assets and resources on behalf of the District.
Review and approve a comprehensive strategic plan, consistent with the organization's mission and vision that aligns the system's financial, human resources, facilities, technology and quality plans.
Advocate on behalf of the Healthcare District's policies, programs and plans within the community served and with other constituency groups.
Recruit, employ and evaluate the performance of the Chief Executive Officer in accordance with goals and objectives established on a short and long term basis with the CEO.
Establish and implement ethical policies that minimize conflicts of interest and insure compliance with governmental, regulatory and other agency standards, laws and principles relative to excellent stewardship of the Public Healthcare District.
Regularly evaluate the Board's performance and the individual performance of each Board member to continually enhance the effective stewardship of the system.
Perform other duties as may be assigned by the Board.
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Guide to Patient and Family Engagement :: 13
Requirements:
Interest and willingness to commit time and energy to completion of Board responsibilities and meeting requirements.
Ability to work in a civil, ethical and collaborative manner with other members of the Board.
Have an appreciation for group process, open-mindedness, respect for others and an ability to think objectively, logically and analytically.
Have effective oral and written communication and negotiation skills.
A knowledge of health and medical care issues and a willingness to expand one’s knowledge through various educational opportunities.
2016 Monthly Board Committee Meeting Schedule
Executive Management Team
Robert A. Hemker
President & CEO
760.740.6395
Frank Beirne
Executive Vice President, Operations
760.740.6300
Alan J. Conrad, MD, MMM, CPE, FACHE
Executive Vice President, Physician Alignment
Alan,[email protected]
858.605.9961
Diane Hansen, CPA
Executive Vice President, Finance
760.740.6385
Della Shaw
Executive Vice President, Strategy
760.740.6371
Jim Harris
Interim Executive Vice President, Human Resources
760.740.6335
Prudence August
Vice President, Information Systems
858.675.5179
Sheila Brown, RN, MBA, FACHE
Vice President, Continuum Care
760.739.3110
Jerry Kolins, MD, MAOM, CPE, FACHE
Vice President, Patient Experience
760.740.6353
Mark Neu, MHA, CHC
Vice President, Compliance, Audit and Legal
442.281.3630
Timothy T. Nguyen, MHA, FHFMA, CRCR
Vice President, Revenue Cycle
760.740.6323
Jeannette Skinner, RN, MBA, FACHE
Vice President, Pomerado Hospital
858.613.4710
Maria Sudak, RN, MSN, CCRN, NEA-BC
Vice President, Palomar Medical Center
442.281.1003
Dan Farrow, BSB, MHA
Assistant Vice President, Hospitality and Facilities
760-739-3186
Jean Larsen
President and Chief Philanthropy Officer
760.739.2785
Maureen Malone Assistant Vice President, Clinical & Diagnostic Services [email protected] 760-740-6374
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Guide to Patient and Family Engagement :: 14
Larry Labossiere, RN, MBA, MSN, CNS, CEN Chief Nursing Officer, Palomar Medical Center Poway [email protected] 858-613-4505
Karen Buckley, RN, BSN, MHA, CENP Chief Nursing Officer, Palomar Medical Center Escondido [email protected] 442-281-1001
Award-Winning Care in San Diego County
Palomar Health is proud to provide nationally-
recognized care to our patients in the San Diego region.
Our recent recognitions include:
National Recognitions
2016 NCDR-ACTION Registry - GWTG Silver
Performance Achievement Award
from the American College of Cardiology
Palomar Medical Center
2015 Humane Society of the United States
Palomar Health
Plant-Based Menu and Sustainability Practices
Achievement Award
2015 Press Ganey Guardian of Excellence Award
for Employee Engagement
Villa Pomerado
2015 CALNOC Recognition
Pomerado Hospital
Reduction of Injury Falls and Reduction of Central Line-
Associated Blood Stream Infections
CALNOC Nurse Quality Indicators Database
2015 CEP America Distinguished Practice Award
Palomar Health/Pomerado Hospital
Emergency Department/Hospital Medicine/Skilled
Nursing Facility
CEP America
2014 5th Most Technologically Advanced Hospital
in the World
Palomar Medical Center
Top Master's in Healthcare Administration
2013 One of the 50 Greenest Hospitals
Palomar Medical Center
Becker's Hospital Review
2013 Risk Management Education Award
Beta Funds
2013 Silver Award for The Guidelines Quality
Improvement Program
American Heart Association and American Stroke
2013 Get With the Guidelines Sustained
Performance
American Heart Association
2013 5 Star Bariatric Surgery Excellence Award
Pomerado Hospital
2013 Partner for Change Award
Practice Greenhealth
2012 Top 15 Health Systems
Palomar Health
Thompson Reuters
2012 Orthopedic Care Facility for Total Joint
Replacement
Palomar Medical Center
Aetna Institute of Quality
2012 Partner for Change Award
Practice Greenhealth
2011 Most Innovative Healthcare District
Palomar Health
Association of California Healthcare Districts
2011 Partner for Change Award
Practice Greenhealth
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Guide to Patient and Family Engagement :: 15
2011 Certificate of Distinction for Inpatient Diabetes
Care
Palomar Medical Center & Pomerado Hospital
Joint Commission
2010 Maternal Child Excellence Award
Palomar Health
HealthGrades
2010 Breast Imaging Center of Excellence
Jean McLaughlin Women's Center for Health
American College of Radiology
2009 First Public Health District in California to
Achieve Magnet® Recognition
Palomar Health
American Nurses Credentialing Center
2009 Citation for Healthcare Facilities Design
Modern Healthcare
2008 Top 100 Places to Work in Healthcare
Palomar Health
Modern Healthcare
2008 Premier Award for Quality
Palomar Medical Center
Premier, Inc.
2007 Compass Award Winner
Palomar Health
Press Ganey, Inc.
2006 Best Place to Work in San Diego County
The Society of Human Resource Management
2006 3rd Best Place to Work in San Diego County
Palomar Health
San Diego Magazine
2006 Marble Award for Best Employer
Palomar Health
The Society of Human Resource Management
2006 California Awards for Performance Excellence
(CAPE)
Bronze Award
Palomar Health
The California Council for Excellence
2005 Malcolm Baldrige Award
State Award Recipient
2005 Health Care District Special Award
The Association of California Healthcare Districts
2005 Health Care District Special Achievement
Award
Palomar Health
The Association of California Healthcare Districts
Initial Performance Achievement Award
Pomerado Hospital
American Heart Association/American Stroke
Association’s Get with the Guidelines (GWTG) program
Sustained Performance Achievement Award (24
consecutive months)
Palomar Medical Center
American Heart Association/American Stroke
Association’s Get with the Guidelines (GWTG) program
Hospital of the Future Awards
2013 Design Award for Built Projects Over $25 M
American Institute of Architects (AIA)/Academy of
Architecture for Health
2013 National Recognition Award
American Council of Engineering Companies (ACEC)
2013 Design Award for Built Projects Over $25M
American Institute of Architects/Academy of
Architecture for Health
2012 National Recognition Award
American Council of Engineering Companies (ACEC)
2012 Engineering Excellence Honor Award
California American Council of Engineering Companies
(ACEC)
70
Guide to Patient and Family Engagement :: 16
2012 Best Healthcare Project (National)
Engineering News Record (ENR), 2012
2012 Best Overall Project
Engineering News Record (ENR)
2012 Best Health Care Project
Engineering News Record (ENR)
2010 BIM Design Excellence
AIA Technology in Architectural Practice (TAP) Building
Information Model Awards
2010 Healthcare Sector Building of the Year
Shortlist
World Architecture News Awards
2007 Citation for Healthcare Facilities Design Award
Palomar Medical Center
Modern Healthcare
2007 Merit Award
Palomar Medical Center
American Institute of Architects/Los Angeles Chapter
2006 Citation of Merit
Palomar Medical Center
Healthcare Design Architectural Showcase
2006 Merit Award
American Institute of Architects
71
Guide to Patient and Family Engagement :: 17
Section 5. Ways to Learn More
The Web sites listed below have information about health care quality, patient safety
and being a patient and family advisor.
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (AHRQ)
is a U.S. Government Agency that is part of the
Department of Health and Human Services. AHRQ funds,
conducts, and disseminates research to improve the
quality, safety, efficiency, and effectiveness of health
care. Its Web site has information to help patients,
families, clinicians, leaders, and others make informed
decisions about health care. Web site:
http://www.ahrq.gov
Consumers Advancing Patient Safety
Consumers Advancing Patient Safety believes that
consumers and health care providers should work
together as partners to create health care systems that
are safe, compassionate, and just. Its Web site has
information and resources for patients and health care
providers.
Web site: http://www.patientsafety.org/
Institute for Healthcare Improvement
The Institute for Healthcare Improvement is a nonprofit
organization dedicated
to improving health care. Its Web site has
resources and improvement tools to promote
health care quality and safety.
Web site: http://www.ihi.org/
Institute for Patient and Family-Centered Care
The Institute for Patient- and Family-Centered Care
provides guidance, information, and resources related to
multiple aspects of patient- and family-centered care,
including how to involve patients and family advisors in
the planning, delivery, and evaluation of care.
Web site: http://www.ipfcc.org
Josie King Foundation
The Josie King Foundation offers information and
resources on patient safety, the prevention of medical
errors, and how health care providers and consumers can
work together.
Web site: http://www.josieking.org/
Medically Induced Trauma Support Services
Medically Induced Trauma Support Services is a nonprofit
organization that creates awareness, promotes open and
honest communication, and provides services to patients,
families, and clinicians affected by medically induced
trauma.
Web site: http://www.mitss.org/
72
Guide to Patient and Family Engagement :: 18
Medline Plus
Medline Plus is the National Institutes of Health’s Web
site for patients and families. It has information about
diseases, conditions, and wellness issues in plain
language and includes a medical dictionary.
Web site: http://www.nlm.nih.gov/medlineplus
National Family Caregivers Association
The National Family Caregivers Association provides
information and support for individuals who care for
others who are aged, disabled, or chronically ill. Its Web
site has tools and stories to educate and empower
caregivers.
Web site: http://www.nfcacares.org/
National Patient Safety Foundation
The National Patient Safety Foundation is dedicated to
improving the safety of patients through education and
raising public awareness. Its Web site offers information
on patient safety issues and has a variety of resource
links.
Web site: http://www.npsf.org/
73
Guide to Patient and Family Engagement :: 19
Notes
Use the space below to make notes and write down any questions you have for your staff liaison.
Tina Pope, District Manager Service Excellence – 760-740-6366; [email protected]
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74
ADDENDUM F
75
1
Disease Specific Diabetes Program
Presented to Board Quality Review CommitteeJanuary 16, 2017
Passion. People. Purpose.TM
Alan J. Conrad, MD, MMM, CPE, FAAPL, FACHETamrah Jennings, MSEd, APRN, MSN, ACCNS‐AGValerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA‐BC
‹#›
Program Overview
• First certified ‐ 2006
• Recertified – 2008, 2010, 2012, and 2014
• Last certification – December 2016
• Medical Director ‐ Alan J. Conrad, MD, MMM, CPE, FAAPL, FACHE
• Program Director – Valerie Martinez RN, BSN, MHA, CIC, CPHQ, NEA‐BC
• CNS – Tamrah Jennings, MSEd, APRN, MSN, ACCNS‐AG
• CNS ‐ Jasmina Namenyi, MSN, APRN, ACCNS‐AG
• CNS ‐ Eva (Bunny) Krall, MSN, APRN, CMSRN, ACNS‐BC, CDE
• Open ‐ Part Time Nurse Educator
2
76
‹#›
Diabetes Medical Advisory Committee (DMAC)
• Interdisciplinary Committee
44
Diabetes Health GlucometricsReport to the Board Quality Review CommitteeJanuary 2017
Passion. People. Purpose.TM
77
5
6
78
7
8
79
9
10
80
11
12
81
13
14
82
15
JOINT COMMISSION INDICATORS
15
‹#›
Palomar Medical Center Escondido and PowayDiabetes Education Needs Assessment
16
83
‹#›17
Palomar Medical Center Escondido and PowayDiabetes Survival Skills
‹#›
Palomar Medical Center Escondido and PowayBasal Insulin Use
84
‹#›19
Palomar Medical Center EscondidoProblem List
‹#›20
Palomar Medical Center PowayOB Diabetes Intra‐partum PowerPlan
N=7GDM1=7
85
‹#›
Interventions to Improve Outcomes
• MD education onboarding and re‐credentialing
• Diabetes Needs Assessment form a mandatory field in EMR
• Diabetes Fundamentals Class/ Diabetes Symposium
• New report to capture basal insulin data
• Focused primarily on Hospitalist group as prescribers of basal insulin
• Data dissemination to stakeholder committees
• CY ‘16 Q2 diabetes modules for staff education
• Continuous Glucose Monitors
• Diabetes tool bar
• Incorporated communication into “Huddle Highlights”
• New grad class/education module on Needs Assessment/Survival Skills
‹#›
• Glycemicare software tool
• Discharge appointments prior to discharge
• Patient Education
– Diabetes Education Book
• DKA and HHS
– Provider and Nursing education
– Separation of Power Plans
• Insulin Pumps
– Updated forms
Performance Improvement Projects
86
‹#›
Performance Improvement Projects
• Peri‐operative Project
• Diabetes Press Ganey Survey
• Medication Safety
– IV insulin transition
– U500
– Insulin Double Check
• Hypoglycemia
– Phone for 40
24
Performance Improvement Activities, PMC Poway
• CDAPP guidelines incorporated into OB Power Plans
• Provider and Nursing education
• Indicator narrowed
• Revisions to Power Plans with Provider input
• Nursing education ‐Care of Diabetes and Pregnancy module and Power Plans
• Ongoing Provider communication and feedback
• Discharge appointments prior to discharge
24
87
‹#›
Interventions 2017 To Improve Outcomes
• Incorporate Needs Assessment into admission documentation• Update Survival Skills to 2016 ADA guidelines• Task for Survival Skills that “need further teaching”• Glycemicare software tool – Launch January 2017• Phone for 40 ‐ Early 2017 for Poway campus
• Implement new Joint Commission Indicators– Patient verbalizes understanding of A1c prior to discharge– Blood Glucose Management in the elective hip and knee orthopedic
surgery patient population– Change in Basal Insulin Dose by 10% within 24 hours of 1 or greater
hypoglycemic event– Physician Documentation of Diabetes Classification
‹#›
86.190.2
80.984.9 84.1
79.3
86.383.6
87.8 87.1 87.083.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1/1/16‐1/31/16n=61
2/1/16‐2/29/16n=51
3/1/16‐3/31/16n=64
4/1/16‐4/30/16n=58
5/1/16‐5/31/16n=55
6/1/16‐6/30/16n=58
7/1/16‐7/31/16n=40
8/1/16‐8/31/16n=61
9/1/16‐9/30/16n=41
10/1/16‐10/31/16n=58
11/1/16‐11/30/16n=50
12/1/16‐12/31/16n=39
Mean Score
Month
PMC Escondido/Downtown Escondido ‐ Helpfulness of Diabetes Handouts*Official Monthly Results
88
‹#›
91.786.4
78.6 80.6
72.2
94.2
86.1
77.1
89.3
79.284.1
92.7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1/1/16‐1/31/16n=18
2/1/16‐2/29/16n=22
3/1/16‐3/31/16n=14
4/1/16‐4/30/16n=18
5/1/16‐5/31/16n=9
6/1/16‐6/30/16n=13
7/1/16‐7/31/16n=9
8/1/16‐8/31/16n=12
9/1/16‐9/30/16n=7
10/1/16‐10/31/16n=12
11/1/16‐11/30/16n=11
12/1/16‐12/31/16n=17
Mean Score
Month
PMC Poway ‐ Helpfulness of Diabetes Handouts*Official Monthly Results
‹#›
91.3 90.584.6
90.6 87.5 85.291.3
86.291.5
87.991.5 88.4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1/1/16‐1/31/16n=69
2/1/16‐2/29/16n=55
3/1/16‐3/31/16n=68
4/1/16‐4/30/16n=69
5/1/16‐5/31/16n=58
6/1/16‐6/30/16n=66
7/1/16‐7/31/16n=46
8/1/16‐8/31/16n=65
9/1/16‐9/30/16n=44
10/1/16‐10/31/16n=62
11/1/16‐11/30/16n=53
12/1/16‐12/31/16n=43
Mean Score
Month
PMC Escondido/Downtown Escondido ‐ Understanding Diabetes Medications
*Official Monthly Results
89
‹#›
91.388.0 88.3
80.375.0
94.293.8
84.188.9
82.1
90.094.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1/1/16‐1/31/16n=20
2/1/16‐2/29/16n=23
3/1/16‐3/31/16n=15
4/1/16‐4/30/16n=19
5/1/16‐5/31/16n=10
6/1/16‐6/30/16n=13
7/1/16‐7/31/16n=8
8/1/16‐8/31/16n=11
9/1/16‐9/30/16n=9
10/1/16‐10/31/16n=14
11/1/16‐11/30/16n=15
12/1/16‐12/31/16n=17
Mean Score
Month
PMC Poway ‐ Understanding Diabetes Medications*Official Monthly Results
3030
90
ADDENDUM G
91
1
Disease Specific Stroke Program
Presented to Board Quality Review CommitteeJanuary 16, 2017
Passion. People. Purpose.TM
Lourdes Januszewicz MSN APRN ACNS‐BC CCRN Remia Paduga, MD, Medical DirectorValerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA‐BC
Program Overview
• Established the program in 2008.
• First certified in 2009
• Recertified in 2011, 2013, and 2015
• Due for Recertification 2017
– Window for recertification @ PMC‐Escondido: January – April 2017
– Window for recertification @ PMC‐Poway: February – May 2017
• PMC Medical Director and Hospitalist Neurologist – Dr. Remia Paduga
• Program Director – Valerie Martinez RN BSN MHA CIC CPHQ NEA‐BC
• Program Coordinator – Lourdes Januszewicz MSN APRN ACNS‐BC CCRN
2
92
Stroke Committee
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
4
93
Stroke Core Measures CY 2016 Qtrs. 1‐3
5
Current Program Status
539 571671
773
9171019 1061
755
116169 211 215 196 209 173
123
0
200
400
600
800
1000
1200
2009 2010 2011 2012 2013 2014 2015 Nov-16
Tota
l Nu
mb
er o
f C
ases
Total Number of Stroke Cases per Year
PMC Escondido PMC Poway
6
94
Current Program Status
15 19 1623
6571
106
91
7 5 6 10 14
34 32
47
0
20
40
60
80
100
120
2009 2010 2011 2012 2013 2014 2015 2016
Years: Program Start to Present
Total Number of Patients receiving Tissue Plasminogen Activator (tPA)
PMCEscondido
PMCPoway
7
• PMC gave 84 patients tPA through 11/2016
• Total Acute Ischemic Stroke (AIS) through 11/2016: 609
• 13.8% patients received tPA through 11/2016
• sICH after tPA: 2
• Deaths after Spontaneous Intracranial Hemorrhage (sICH) after tPA: 2
• POM gave 45 patients tPA through 11/2016
• Total AIS through 11/2016: 117
• 38.5% patients received tPA through 11/2016
• sICH after tPA: 0
• Deaths after sICH after tPA: 0
• Palomar Health 129 patients received tPA patients: 17.8%
tPA Administered YTD Nov 2016
8
95
2016 Post tPA Outcomes
9
66
1
28 27
2 1 2
11
0
10
20
30
40
50
60
70
80
Discharge Status - 138 tPA Patients
Nu
mb
er o
f tP
A P
atie
nts
Home/HH
Home on Hospice
ARU
SNF/AL
Tx Acute Care
AMA
Expire-ICH
Expire-ComfortCare
Program Status: JC Cycle
% Compliance Door 2 Drug (D2D) < 60 min
• PMC Escondido ‐ Cycle Mar 2015 – Dec 2016
– Total tPA Cases: 189
– Total tPA Cases D2D < 60 min: 138
– % Compliance JC Cycle: 73%
• PMC Poway – Cycle Mar 2015 – Dec 2016
– Total tPA Cases: 75
– Total tPA Cases D2D < 60 min: 43
– % Compliance JC YTD: 57%
10
96
JC Cycle: PMC Escondido
90% 88%
100%
70%75%
43%
88%93%
67% 67% 67%
89% 88%
75%70%
50%
67%
75%
57%
38%
50%
57%
0%
20%
40%
60%
80%
100%
120%
% tPA < 60 Minutes 50 % of the time
JC Cycle: PMC Poway
100%
50%
60%
0%
33%
ND
33% 33%
50%
86%
50% 50%
40%
67%
75%
67%60%
75% 75%
67%
100%
0%
20%
40%
60%
80%
100%
120%
% tPA < 60 Minutes 50% of the time
ND
97
Neuro Interventional Radiology (IR)
Current Program Status
14
59 62
0
10
20
30
40
50
60
70
2014 2015 2016
Years: Program Start to Present
Total Number of Patients receiving Neuro IR Procedures
PMC
13
2016 Neuro IR Case Outcomes
14
14
2
9
18
1
16
0
2
4
6
8
10
12
14
16
18
20
Discharge Status - 62 Thrombectomy/Embolectomy
Num
ber
of P
atie
nts
Home/HH
Home on Hospice
ARU
SNF/LTAC
Exp - sICH
Exp - Comfort Care
98
Program Updates 2016
• Improve D2D compliance < 60 minutes 50% of the time
– ED Providers are ordering tPA and not waiting for Neurology
• PMC‐Escondido: ED Providers have given 25% of the tPA for eligible patients
• PMC‐Poway: ED Providers have given 50% of the tPA for eligible patients
• Improve Lab Turn Around Times (TATs) for Results
– PMC‐Escondido: iSTAT device for Chem 8 Labs increased to 72% use
– PMC‐Poway: heightened awareness with Stroke Labs
– Ordering Troponin with Stroke Panel ‐ 99% compliance
• Improve accuracy of tPA dosing
– Purchased scaled gurneys at PMC Escondido and PMC Poway
15
Quality Improvement Projects 2017• Target Stroke Phase 2 – Implement new D2D administration times
• Door to Drug tPA in 45 min – 50% of the time; Door to Drug tPA in 60 min – 75% of the time
– Adopt (Pit Stop) Concept for meeting new targets
• PMC Escondido: Go Live was December 20th 2016
– Monitor for improvement in D2D times: Target Stroke Phase 2
• PMC Poway: Begin project for (Pit Stop) Concept during 1st Qtr. CY 2017
• Improve Lab TATs for Results
– PMC‐Poway: work towards obtaining the iSTAT device for Chem 8 Labs
– PMC Escondido: continue to monitor for compliance
• Neuro Interventional Radiology for Stroke
– Improve Door to Groin times to < 120 minutes 50% of the time
• American Heart Association (AHA)/American Stroke Association (ASA) Get With the Guidelines participation
16
99
Contact Information
Lourdes Januszewicz MSN APRN ACNS‐BC CCRN
Stroke Program Coordinator
Palomar Health
Office 442‐281‐2092
17
100