february compliance report on parkland memorial hospital

Submitted To:

Centers for Medicare and Medicaid Services and Parkland Health & Hospital System

Submitted By:

Alvarez & Marsal Healthcare Industry Group, LLC Columbia Square 555 Thirteenth Street, NW, 5th Floor West Washington, DC 20004 +1 202 729 2100

Report of the Independent Consultative Expert (ICE)

Monthly Progress Report – February 2013

on

Parkland Health & Hospital System

Dallas, Texas

March 12, 2013

Parkland Health & Hospital System – Alvarez & Marsal Progress Report to CMS – February 2013

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EXECUTIVE SUMMARY ......................................................................................................................................... 3

SIGNIFICANT GOALS MET IN FEBRUARY .................................................................................................................... 4 SIGNIFICANT GOALS STILL OUTSTANDING IN FEBRUARY .......................................................................................... 5 OVERALL IMPRESSIONS FROM FEBRUARY.................................................................................................................. 6

CASE MANAGEMENT ............................................................................................................................................. 7

HUMAN RESOURCES .............................................................................................................................................. 7

COMPETENCIES .......................................................................................................................................................... 8 EMPLOYEE PERFORMANCE MANAGEMENT ................................................................................................................ 9

NURSING ADMINISTRATION................................................................................................................................ 9

“ONE-TO-ONE” OBSERVATION ................................................................................................................................ 10 ACUITY BASED STAFFING ........................................................................................................................................ 10

PATIENT SAFETY / QUALITY ............................................................................................................................. 10

PATIENT SAFETY NETWORK (PSN) EVENT REPORTS ............................................................................................... 10 ROOT CAUSE ANALYSIS (RCAS) ............................................................................................................................. 11 PATIENT RELATIONS ................................................................................................................................................ 11

HOUSE-WIDE ISSUES ............................................................................................................................................ 12

A&M GENERAL AUDIT RESULTS ............................................................................................................................. 12 PATIENT IDENTIFICATION ........................................................................................................................................ 14 SPECIMEN LABELING ............................................................................................................................................... 15

DEPARTMENT AND UNIT SPECIFIC FINDINGS ............................................................................................ 16

CLINICS .................................................................................................................................................................... 16 CONTRACT SERVICES ............................................................................................................................................... 17 EMERGENCY SERVICES ............................................................................................................................................ 17 LABORATORY SERVICES .......................................................................................................................................... 18 PSYCHIATRIC SERVICES ........................................................................................................................................... 18 WOMEN AND INFANT SPECIALTY HEALTH (WISH) SERVICES ................................................................................. 19

CONCLUSION .......................................................................................................................................................... 19


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Executive Summary

Alvarez & Marsal Healthcare Industry Group LLC (A&M) is serving as the Independent Consultative Expert (ICE) under the Systems Improvement Agreement (SIA) between Parkland Health & Hospital System (Parkland) and the Centers for Medicare and Medicaid Services (CMS). On February 29, 2012, A&M delivered a Corrective Action Plan (CAP) to Parkland, as required under the SIA. This CAP was approved by CMS and was subsequently accepted by the Parkland Board of Managers on March 8, 2012.

Under the SIA, the ICE is required to present monthly reports to CMS on the progression and status of the CAP, including identification of problems that may jeopardize the successful implementation of the CAP and actions underway to address those problems. This report constitutes A&M’s 12th report on Parkland’s progress under the CAP. By agreement with CMS, the “start date” for timelines and deadlines under the CAP was set as March 19, 2012.

During the month of February Parkland continued to make progress in meeting most of the deadlines established in the CAP. Since the implementation of the CAP on March 19, 2012 a total of 475 tasks have been completed. An analysis of tasks completed by Work Stream is below:

Also, presented below is the detail for the seven action streams with incomplete or delayed initiatives of 95 percent compliance in meeting target dates for their CAP initiatives.

WS # Work Stream NameTotal

InitiativesCompleteInitiatives

% Complete

On timeInitiatives

DelayedInitiatives

Missed Deadline /

Not Sustainable

% Complete and On Time

1Governance, Leadership, and

Org Structure39 36 92% 0 0 3 92%

2 Clinical Operations 174 172 99% 0 0 2 99%

3 Access/Throughput 91 85 93% 1 0 5 95%

4 Nursing 102 92 90% 6 0 4 96%

5 Physicians 34 32 94% 0 0 2 94%

6 QAPI 59 58 98% 0 0 1 98%

499 475 95% 7 0 17 97%TOTAL

AS # Action Stream NameTotal

Initiatives Complete%

CompleteOn Time

InitiativesDelayed

Initiatives

Missed Deadline /

Not Sustainable

% Complete and On Time

1.2 Organization Structure Changes 15 12 80% 0 0 3 80%2.6 Other hospital-based department specific initiatives 5 4 80% 0 0 1 80%3.3 Bed Management 2 1 50% 0 0 1 50%3.4 Case Management, Discharge planning initiatives 25 23 92% 0 0 2 92%3.5 Continuum of care beyond acute care setting 6 5 83% 0 0 1 83%

4.3Nursing roles & responsibilities; staffing levels and staffing models

28 22 79% 2 0 4 86%

5.1 Medical Staff – OPPE 15 13 87% 0 0 2 87%6.2 Patient Safety and Patient Rights 22 21 95% 0 0 1 95%


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Significant Goals Met in February

Case Management

- Implementation of discharge planning conferences to focus on patients with a length of stay greater than four days with successful management of patients to an appropriate level of care

- Filled key management positions: Complex Case, Bed Access, Care Management, Social Work and Care Coordination all with start dates in February/March/April 2013

- Completed assessment of Admission Discharge Transfer (ADT) Department

Contract Services

- Completed review of known legacy contracts and State contracts that are not in contract management system for quality metrics

Emergency Services

- Significant improvements made in patient flow in both Main Emergency Department and Urgent Care Emergency Department that decreased dwell times

Laboratory

- Conducted an assessment and designed improved process of lab specimen handling from unit to lab to decrease mis-labeling errors

- Successful accreditation with College of American Pathologists

Nursing Administration

- Completed implementation of McKesson acuity system and automated scheduling in ANSOS - Restructured 24 job codes for float pool staff, paired positions with salaries and completed for posting - 32 of 50 traveling nurses hired as of end of February to fill RN vacancies throughout the Hospital

Physical Medicine and Rehabilitation (PM&R)

- Parkland’s Operational Excellence Department along with PM&R management conducted a process assessment for the inpatient therapy modalities that will help to appropriately allocate staff to match patient demand for inpatients and outpatients

Psychiatric Services

- In accordance with the recently executed contract for management services, Green Oaks leadership has conducted an assessment of the current state of Psychiatric Services at Parkland and is recruiting for key management positions to be staffed by Green Oaks

WISH

- Completion of throughput assessment of OBICC (Obstetrics Intermediate Care Center) by Parkland’s Operational Excellence Department, which identified opportunities for improvement in resource allocation to match demand to capacity


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Significant Goals Still Outstanding in February

Case Management

- Tele-tracking system implementation delayed until June 2013 to coincide with Epic interface - Management review of policies and procedures was completed in February; however, Departmental

Policy & Procedure Committee must review and adopt revisions. Review now scheduled to be completed by March 31st.

Competencies

- Review of competencies for all clinical staff has been underway; but approximately 50% still under final review

- Similar process for verification of competencies for non-clinical employees has not yet been completed

Clinics

- Throughput pilot program for six outpatient specialty clinics have not produced desired outcome of increased patient flow and access

Contract Services

- Contracts with UTSW and Children’s Medical Center are extensive and complex and may require new contract language to more particularly identify and set forth quality indicators and measures

- Clinical staffing and agency contracts need to have analysis completed on quality indicators and evaluated for compliance with quality indicators

- Some “significant contracts” require quality indicators and some are not performing to quality indicator thresholds

Medical Staff

- The revised processes for Ongoing Professional Practice Evaluation (OPPE)/Peer Review were delayed due to difficulties in data processing obtaining clear electronic data sets; this process is now back on schedule

- Medical Staff leadership continues to work to improve consistent use of the “Notewriter” tool in Epic to capture key portions of resident supervision documentation in the medical record


- Recruiting for positions for the nursing float pool staff had begun the sourcing process in February; positions are expected to begin the recruiting process the first week of March

- High vacancy rates still exist in some key positions including Case Management, Medicine Services and WISH Services

- Nursing Administration working with Human Resources to sponsor job fairs to recruit for positions to fill both float pool and other key nursing areas

- Implementation of decentralized staffing pool pilot in Surgery Services delayed due to difficulty in RN recruitment


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Patient Safety

- The Risk Assessment tool has not been completed – pending clarification of Directors of Public Safety, Patient Safety and Legal

Overall Impressions from February

As we indicated in our reformatted progress reports since October 2012, because most of the Corrective Action Plan (CAP) initiatives have been largely completed, we have shifted most of A&M’s ICE resources to monitoring specific areas of the Hospital and conducting surveys using the same methodologies employed during our initial Gap Analysis. The weekly audits and monthly reviews are being performed as a more holistic and inclusive review to assess compliance with Medicare Conditions of Participation as well as monitor for the sustainability of change in process and performance and the impact of the change on patient safety, rights and quality.

During the month of February, Parkland engaged a team of external consultants to conduct an exhaustive internal survey of Parkland’s compliance with the Medicare Conditions of Participation. This “mock survey” was structured in such a way to mirror as much as possible an actual CMS survey process. To that end the survey was conducted on an unannounced basis by a team of 11 surveyors over a five-day period. The survey team included nurses, physicians, hospital administrators and engineers well versed in life/safety Conditions of Participation (CoP) and code issues.

The organization structure in place to staff and manage the Hospital’s response to a full survey proved to be an efficient and effective one. The Hospital’s management team worked well under the rigorous mock survey process to respond to the surveyors’ requests and review.

A&M’s perspective is that this mock survey process was a comprehensive “practice test” for the organization to experience at this stage of completion of the CAP. The mock survey findings did not uncover any unknown or new major areas for concern with the Hospital’s continued preparation toward a state of survey readiness. The survey results reinforced A&M’s view, shared by Parkland’s senior leadership team, is that the Hospital needs to stay the course with regard to its continued efforts to improve processes and protocols that impact its ability to meet CMS Conditions of Participation by the milestone period of the Systems Improvement Agreement – April 30, 2013.

In February, A&M also did a special assessment of Parkland’s Patient Relations Department (PRD) function, which was recently reorganized under new leadership to report up through the Hospital’s quality organization. The operation of the PRD has improved with the change of leadership, organization structure and roles/responsibilities of staff.

A&M also continued to do environmental rounding on nursing units. In February, A&M completed audits of 32 units/areas throughout the main campus of Parkland. A&M team members also did a process review of specimen labeling throughout the Hospital to detect opportunities to reduce incidences of specimen mis-labeling, which leads to specimens being discarded and new samples having to be drawn.

Parkland continued to make good progress in February with improvements in policies, procedures and processes which impact access, throughput, patient safety, quality and patient satisfaction. Many metrics identified in the CAP have begun to have a positive trend indicating improvements are being hardwired


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throughout the organization. This is evident in many areas including, but not limited to: Emergency Services, Pharmacy, Patient Safety and Quality. While work remains to be done to compete the CAP and to address issues identified by A&M during unit rounding and during the “mock survey” process, we believe that Parkland continues to make measurable progress towards its goal of being compliant with all Medicare Conditions of Participation by the end of April 2013, as provided by the SIA.

Case Management

The newly hired Vice President of Care Coordination (also referred to in this report as “Case Management”) has made significant changes to Case Management structure and process since her start date in early February. A primary focus in February was to stabilize the Department by filling key management positions to replace interim management that has been in place since May of 2012. The use of agency staff was reduced in February and full-time experienced staff is being hired for case management roles. The vacancy rate for the Department has decreased to 17 percent, from previous months averaging 40 – 50 percent.

Hours of coverage and the staffing plan of the Case Management Department were assessed in February, and a plan to expand hours of coverage of case managers and social workers to ensure adequate allocation of resources to the discharge planning function and care management has been developed and will be implemented in March.

A new position, Complex Case Manager, was also created and filled in February. This position is filled by a qualified social worker and has responsibility for coordinating care for patients with extended lengths of stay usually stemming from difficult social and/or financial situations. Also in February, a Complex Care Committee commenced bi-monthly meetings to review patient cases with extended stays and difficult placements. The committee, chaired by the Vice President of Care Coordination, is working in conjunction with Legal and Contracting Departments to develop a post-acute continuum of care alliance with home health agencies, skilled nursing facilities, long term care facilities, etc. so that the continuum may be utilized on an efficient and expeditious basis when attempting to discharge patients who have complex post-acute care needs and limits on financial resources to obtain such post-acute care.

The new Case Management Vice President recognizes that the Department will need to undergo a culture change to achieve the results needed for success. We are encouraged with the direction and advancement thus far under the leadership of the new department head. We will continue to monitor the Case Management Department’s efforts in developing consistent and early case management interventions for all patients.

Human Resources

Personnel vacancy rates continue to be an issue for Parkland and the Hospital’s senior management continues to be focused on efforts for timelier recruitment, hiring and orientation of new employees to critical vacant positions. A fast track hiring initiative was created through a Recruiting Process Outsourcing vendor (RPO). An additional four contractors have also been placed to assist with recruiting for priority areas. Several job fairs for nursing positions have been organized and will occur in March.


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However, in spite of the addition of the RPO and other recruiting and hiring resources, tracking metrics indicate an upward trend in the nursing leadership vacancy rate.

To continue to reduce employee turnover, Parkland formed an Employee Engagement and Retention Committee under leadership of the Human Resources Department. This committee will design, plan and recommend actions to improvement the engagement and retention of Hospital employees, as well as measure and monitor metrics and information regarding employee retention.

Effective recruitment and retention strategies will continue to be integral to Parkland’s ability to hire and maintain a stable workforce. These strategies are needed to ensure the improvements made during the Systems Improvement Agreement are sustained and become the new culture/way that Parkland operates into the future. The interim CEO and senior management is acutely aware of the importance in expediting recruiting and hiring of qualified candidates and reducing the personnel vacancy rates.

Competencies

Clinical Competencies

In order to monitor the progress on the Hospital’s action plan to ensure that current documentation competencies are available in all personnel files, A&M conducted an audit of employee files in February. Sixteen files were reviewed to determine whether all required elements of a personnel file, including job descriptions, certifications, licensure verification, competencies, etc. could be easily found.

All files we reviewed had the correct and up to date job descriptions, licensures, CPR AED, ACLS, PALS, Skills List, and Orientation Evaluations. One file was found to be missing a BLS certification, one missing Institutional Review Board (IRB) competencies and one was missing unit-specific waste hazard competencies.

Overall, there has been an improvement in the organization and completeness of personnel files, but the validation of existence of up-to-date and complete competencies of clinical personnel has not yet been completed. As of the end of February, Parkland reported that 50 percent of the clinical personnel files need additional review by the Clinical Education Department, which is managing this verification process. Additional resources or efforts will need to be made in order to complete this verification process by the end of March.

Non-Clinical Competencies

As we reported in our January report, a process has been developed to ensure that all competencies for non-clinical staff are completed and documented in personnel files. This project is moving slowly, and we are concerned that a completion date of April 1st may not be achieved.

Training in the completion of competencies for the non-clinical staff leadership has been delayed and is now scheduled to begin March 7, 2013. The objective for the training is to equip the managers with the knowledge and resources necessary to define competencies and evaluation methods for employees in the target population. Human Resource Business Partners (HRBP) and Leadership Organizational Development (LOD) staff will be trained in Mid-March, as well, on defining competencies and using HealthStream to track and maintain competencies. HRBP and LOD staff will then work with the non-


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clinical staff leadership to ensure competencies are developed and implemented and then entered into HealthStream by April 1, 2013.

Documentation of current competencies both for clinical and non-clinical employee is a critical HR function and we have advised Parkland’s senior management that this review process must be completed prior to the end of April 2013.

Employee Performance Management

In December A&M performed a review of personnel files to assess the completeness of these files with respect to appropriate corrective action and progressive discipline as a follow up to concerns identified in the Gap Analysis.

We conducted our February employee corrective action review by starting with 24 instances of potential policy non-compliance by employees identified in safety reports. These events were logged across several inpatient hospital units between the period of January 1st and January 31st. The objective was to determine: 1) whether there was an appropriate corrective action issued to the employee who was accountable for the breach in a process or policy; 2) if the corrective action was appropriately located in the employees HR file, and 3) if the corrective action followed the Hospital’s HR policy. Interviews were conducted with unit managers and documentation from HR records was reviewed.

Our review of these employee corrective action episodes indicate some continuing issues with regard to these HR processes, including: - Inconsistent “closing the loop” by department-level management in cases of adverse safety events

that stem from personal accountability; - Inconsistency in applying the corrective action protocols in accordance with HR policies and

procedures; and - Inconsistency in following HR policies and procedures on documentation of corrective action.

Continued education and management training is needed and is in progress to ensure department level managers are well versed and compliant with HR policies and procedures on performance management.


As discussed in previous reports, Parkland’s ability to change staffing levels in response to changes in patient census and acuity is based upon having “standby” resource for additional nurses to staff these positions. We have encouraged Parkland to focus efforts on building the resources required for a nurse float pool while building the infrastructure and technology to be tracking patient acuity between ANSOS and McKesson.

Under the leadership of the Associate Chief Nursing Officer (ACNO), progress on implementation of the new nurse float pool model has advanced. The traveler program, which was increased by 50 nurses, has been filled with 32 positions by the end of February. The pilot for surgical services has not been implemented due to development of job descriptions.


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Other improvements in Nursing Administration have occurred with the Nursing Administrative Officer (NAO) role. Nursing staff in these roles now provide round-the-clock coverage to assist with issues requiring nursing supervision. NAOs are heavily involved with the Admissions Discharge Transfer Department and work collaboratively to improve patient flow and bed management.

“One-to-One” Observation

Because of physical, cognitive or behavioral issues, many Parkland patients require continuous observation by caregiver staff, often referred to as “one to one” observation. During the month of February, a compliance review was conducted on the adherence to Parkland’s one-to-one observation policy and procedures. Parkland personnel functioning in an “observer” or “sitter” role in 12 different units were interviewed and patient charts were reviewed for appropriateness of documentation.

Staff members performing an observer role were consistently able to answer questions regarding policy, procedure and their responsibilities in performing this role. There were no deficiencies in their responses or observations of practice during the review.

During this review, nurses were consistently able to explain the patient’s care plan and requirements to the one-to-one status. Documentation as to the reason for the need for this observation was documented in the patient record 80 percent of the time and the individual’s name and identification was documented 60 percent of the time.

There has been much improvement in the training and knowledge of the Parkland employees assuming a patient observer role. Documentation by nursing of observer need and status, however, can still be improved in some cases in the elements of naming the employee in the role, the employee’s identification number, and the reason for the one-to-one observation status.

Acuity Based Staffing

The “go-live” for the McKesson acuity staffing system occurred on February 20th. All nursing units are now utilizing the system and nursing leadership reports the system is well tuned and is working appropriately. All scheduling is now completed in the ANSOS system and is no longer a manual process. Jackie Brock, VP of Nursing for Surgical Services and Kelly Heathman, Director of Nursing for Medicine Services should be recognized for their dedication and hard work to bring this project to completion.

Patient Safety / Quality

Patient Safety Network (PSN) Event Reports

In an effort to ensure that each potential patient safety event reported to the Patient Safety Network (PSN) system is appropriately investigated and resolved, the Patient Safety Department created a “close the loop” process. A PSN Closure Report will now be generated monthly and distributed to appropriate key management and leadership personnel responsible for investigating and closing the loop for their areas. Trends will be reported to the Quality of Care & Patient Safety Committee of the Hospital and Quality of


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Care & Patient Safety Committee of the Board. The closure report process will require a manager to “check the box” indicating an adverse event report in the PSN is closed. In March, the Patient Safety Department will begin to audit the quality of the action plans and resolution of adverse event reports have been taken and are appropriate.

Root Cause Analysis (RCAs)

Over the past several months, an improved process has been implemented at the Hospital to develop a “fast track” root cause analysis (RCA) process. The new process requires a case review and resolution plan to be drafted within two meetings or less with key stakeholders. The first meeting is organized as an event debriefing with the key stakeholders involved in the event. The facts are discussed with the key people and their testimony is documented into the RCA tool. The second meeting is a two hour meeting to determine the root cause(s) and contributing factors that resulted in the untoward event. The action plan is also developed with key stakeholders to address the root causes and contributing factors that will minimize these types of event to recur. This revised RCA process appears to be working more efficiently that the previous process, with the goal of having a meaningful and prompt action and remediation plan for all safety events elevated to the RCA process. We will, however, continue to monitor the RCA process to see that meetings are conducted and action plans issued in a prompt manner, and follow through to ensure an action plan is performed.

Patient Relations

In February A&M conducted an additional review of Parkland’s Patient Relations Department (PRD) to assess changes the Department has made since undergoing a recent reorganization under a new leader. Parkland’s Patient Relations Department processes complaints and grievances made by patients or their family members. The PRD coordinates activities related to complaints and grievances with Risk Management, Patient Safety, and Legal as required or indicated.

The Patient Relations Department operates under a policy/procedure that clearly outlines the process that was recently revised to meet the CMS Condition of Participation regarding Patient Rights. Timeframes for communication with the patient/family were revised and the maximum time allowable to complete the entire process was amended. The policy is in compliance with CMS guidelines and was approved by the Board of Managers at its February 2013 meeting.

The PRD has made significant changes to its processes to improve grievance and complaint response/resolution times. From October, 2011 to October, 2012 the average time to resolve complaints/grievances was 22.75 days with a range of 9 to 44 days. In January 2013 the average time to resolve complaints/grievances was 5.8 days with a range of 1 to 10 days. In February the improvement continued with an average of 4.6 days and a range of 1 – 12 days. The aforementioned metrics relate to five categories that the PRD has chosen to focus on over the last several months. PRD leadership is working to develop reports to provide accurate information on closure and volume metrics for all data points.

The PRD Director is in the process of implementing other measures that will improve the time to resolve complaints and grievances, but also reduce the number of complaints that are categorized into grievances.


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The Department has partnered with the Nursing Administrative Officers (NAO) as an additional “sensing arm” to log any interactions they have with patients regarding complaints at the time of the event and will work with both the Police force and Chaplains in a similar way.

The functioning of the PRD has significantly improved with the change of leadership, organization structure and roles/responsibilities of staff. The changes that are contributing to the improvements are a customer focus, quality – not quantity – of work, accountability, and collaboration across departments.

House-wide Issues

A&M General Audit Results

In February, A&M completed audits of 32 units/areas throughout the main campus of Parkland Hospital. The general audits were conducted by rounding the unit with the Charge RN/Unit Manager/Area Manager and covered five main areas of compliance: - Effectiveness of services provided by Environmental Services (EVS) and Facilities - General conditions of Environment of Care (EOC) - Hand hygiene compliance (through observations) - Medication management compliance and knowledge - Assessing staff knowledge and involvement in facilitating discharge management and unit operations

(typically from charge nurse or unit manager).

A&M’s audits also included observational rounds conducted in collaboration with Environmental Services (EVS) and Infection Prevention (IP). This initiative was designed to include a multi-disciplinary and audit focus of environment of care issues and a “real time” sharing of findings and recommendations with department-level management and senior leadership.

Any event requiring immediate remediation is discussed with local management during the assessment, identified as a “key finding” and sent to the leadership team on a daily basis. A&M organized these findings into five categories as shown in the chart below.


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The majority of occurrences found in the audits were related to EVS and fall under the Environment of Care (50 percent). The most common EVS events were unclean floors (46 percent) and/or a general sub-standard cleanliness/appearance of the unit. Presented below is a detailed breakout of A&M’s Environment of Care findings:

Compliance with infection prevention protocols and medication management procedures accounted for approximately 25 percent of all occurrences. Key findings included several dusty areas including air vents, floors and table tops, and poor hand hygiene practice.

4%

5%

16%

25%

50%

0 5 10 15 20 25 30

Biomed

Life Safety

Med Mgmt

Infection Prevention

EOC

Number of Occurrences

Categories of "Key Findings" from February's Rounding Audits

46%

14%

14%

11% 7% 7%

Categories of Environment of Care Findings

Floors

Doorways

Other

PHI

Garbage

Storage


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A majority of the medication management incidents (16 percent) had to do with medications left in unsecured areas and inappropriate labeling. A&M has recommended the nursing staff re-visit education of these protocols. Other findings made during these rounds included the continuing lack of consistency of timely interventions by Case Management (social workers and case managers) on units.

Patient Identification

Parkland’s nursing leaders have developed a patient safety plan to address compliance with consistent use of the two patient identifier system. Under the two patient identifier system, a patient must be identified in more than one way (e.g., full name, date of birth) by each caregiver when medications, blood products, tests, etc. are administered.

Several audits will continue to be conducted at Parkland to measure the practice of using two patient identifiers with the aforementioned practices. The first audit for the use of two patient identifiers was conducted for medication administration. This medication audit was multi-faceted and covered not only two patient identifiers but also ensuring that the six rights of medication administration were being executed by nurses.

The medication audit was conducted by the Nurse Excellence team and 25 episodes of medication administration in 17 nursing units. The results showed that 98 percent of medication administration cases utilized two patient identifiers correctly.

Nursing Documentation

Pain Assessment Documentation In February A&M conducted a chart review for correctness of pain documentation elements. Thirty (30) charts were reviewed for the following elements: - Was the pain assessment documented? - Was a pain number documented? - Was pain medication given? - Was a reassessment documented? - Was a pain scale number documented on the reassessment? - Was the reassessment documented within 30 minutes of giving an IV medication or within 60

minutes of giving an oral medication? - Was the pain medication given for the indicated pain scale that was documented? - Was the patient a pediatric patient? - What pain scale was utilized? In the 30 charts reviewed for surgical services, 100 percent were in compliance with all the required elements of pain administration. Chart reviews of the WISH and Medical Services units revealed an


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opportunity for improvement in the appropriate documentation of all the required elements of pain administration.

Restraint Documentation

Audits were completed in February to evaluate use of patient restraints against Parkland’s revised restraint policy and procedure, along with revisions to the Epic EMR system to ensure easier and more accurate documentation. These restraint documentation audits were conducted by selected staff members from each unit to engage ownership of nursing practice.

The Non-Violent/Non-Self Destructive restraint audit results indicated there is some room for improvement in documentation. The areas that require significant attention are documentation by the nurse for assessment and re-assessment every two hours and documentation of the restraints being removed. Additional attention needs to be made with documentation of alternative methods offered, physician order reflected in nursing flow sheet, restraint method applied, and the behavior the patent was exhibiting.

The documentation for patients who exhibit Violent/Self Destructive behaviors is essential to ensure that patients are safe and quality of care is maintained during the time during which the patient is on restraints. There is also an opportunity to improve documentation in the areas of physician face-to-face within one hour of order and assessment and re-assessments every two hours and removal of restraints.

Wound Care Documentation In February, A&M also conducted a chart review of wound care documentation. The purpose of the audit was to determine documentation of wound assessment by nurses on each shift per Hospital policy. Thirty (30) charts were reviewed; ten charts from surgical services, ten charts from medical services, and ten charts from WISH services. Charts reviewed in the WISH and Surgical units were documented appropriately and with appropriate frequency. The audit indicates room for improvement in Medicine Services, where four out of ten charts lacked appropriate wound care documentation. All audit results are shared with nursing leadership so that action plans can be developed for targeted areas where improvement is needed.

Specimen Labeling

Due to a number of incidents with mislabeling/misidentification of specimens for laboratory testing, a process assessment was conducted by A&M to document the work flow, identify inconsistencies in the process as well as barriers and breakdowns and to identify opportunities for improvement. The scope of the assessment included a review of processes for orders, collection, labeling and processing from the patient to the laboratory. Interviews were conducted with Lab personnel, Nursing and Laboratory leadership.


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In general the process of labeling specimens at Parkland is impacted by technology limitations and inconsistent processes among units. Workarounds have been developed to try to overcome these issues, which have increased the variation, process time, decreased efficiency and increased patient safety incidents and error rates.

A&M made several recommendations including IT programming changes, process redesign, staff education and retraining in order to improve the process of specimen labeling.

Two specific recommendations that should be implemented as soon as possible include the following: - The Hospital should create a laboratory nursing task force that includes representatives from various

inpatient nursing units to develop a standardized and streamlined process for orders, labels (and storage), labeling, acquisition and processing; and

- Begin a pilot program in the Emergency Department using recommended specimen labeling processes.

In late February, Lab and Nursing leadership met to discuss the findings and recommendations of our assessment, and to initiate the ED pilot program.

Department and Unit Specific Findings

Clinics

Community Oriented Primary Care Clinics (COPC)

The new care delivery model continues to be implemented in the remaining COPCs:

- Virtual visits were implemented in the Southeast Dallas COPC - New provider templates were implanted in Southeast Dallas and Vickery COPCs - Pre-visit planning was implemented in Irving and Vickery.

Jessica Hernandez, Senior Vice President Community Oriented Primary Care, continues to strive to improve patient throughput within the COPC system. In February, exceptional physician productivity at the Bluitt Flowers COPC was studied and practices used there will be implemented in other clinics in future months. Analyses of no show rates for new and established patients, as well as ways to improve “Today Clinic” capacity are also underway.

An infection prevention corrective action plan was developed to address issues specifically identified in the COPCs on Environmental Services and Infection Prevention Rounds.

Outpatient Clinics (OPC)

Several months ago, the Hospital implemented initiatives in six clinics designed to increase patient access and throughput. Metrics for appointment wait times and clinic dwell times, however, have not improved as expected. In January, A&M asked OPC leadership to re-visit these areas and provide a report in February.


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Throughput metrics for these six clinics remain unchanged. It does not appear that throughput has been analyzed or any corrective action has been taken to try to improve patient flow. Improvement in patient throughput in the outpatient specialty clinics can relieve emergency room volume and improve patient care. We strongly suggest greater focus on this initiative to: 1) obtain all data needed to evaluate throughput and patient flow: 2) evaluate and analyze the data; and 3) create an action plan to improve throughput and wait times.

Contract Services

Significant work remains to be done within the contract services work stream. The Contract Oversight Committee formed in January was formed to support the work of the contract services work stream and act as liaison between contract business owners, senior management and the Board of Managers. The Committee has the responsibility to review contracts and report significant findings to the Board. Several “significant contracts” are below requirements for acceptable quality scoring. This work stream needs to accelerate the workplan to have all vendor contracts, with a clinical component 1) inventoried; 2) evaluated for the existence of quality metrics; 3) evaluate and measure the vendor against those metrics; and 4) require the “business owner” of the contract to implement corrective action against the vendor when the quality metrics are not met.

Emergency Services

Process improvements implemented in Parkland’s Emergency Services throughout the past several months have made a significant impact on patient throughput in both the Main Emergency Department (ED) and the Urgent Care Emergency Department (UCED). Patient “dwell times” have decreased significantly in both the ED and UCED, and the number of patients who left without being seen has also decreased dramatically. A contributing factor to the favorable metrics in the UCED is the extension of service hours in February.

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

0

50

100

150

200

250

300

350

400

450

500

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Main ED Throughput Metrics

Average Dwell Timefor Dialysis Patients inMain ED (Minutes)Door to Home(Minutes)

Door to First Provider(Minutes)

Left Without BeingSeen


18

The ED is making changes to nurse management as recommended by our January report. Instead of one charge nurse for Main ED East and West, an additional charge nurse will be added so each area will be covered. Because of the increase in UCED hours, the Department will also need to hire additional RNs for coverage.

The ED continues to work on areas for improvement that are highlighted in ongoing audits, and they are making significant progress. Clifann McCarley, Vice President of Emergency Services, has provided excellent leadership in all CAP initiatives and she and her ED management team are to be commended for the marked improvements in ED Services.

Laboratory Services

In an effort to understand the high volume of specimen labeling errors occurring throughout the Hospital, A&M conducted a process assessment and provided recommendations for improvement. (Details of that review appear above in this report.) The Laboratory and Main Emergency Department have collaborated in March with a pilot program to implement many of the A&M recommendations.

Compliance with critical turnaround time has remained constant at 98 to 99 percent for several months. The Laboratory Services Department has developed a reporting process which now provides chiefs of service with outliers in an attempt to improve compliance even more.


While some progress has been made in filling critical provider vacancies, there are still many instances of insufficient professional staff coverage on the March schedule for the behavioral health units. Staff vacancies continue to present challenges with several key vacant positions still requiring qualified people. Staffing coverage is currently being tracked by the hospital unit coordinator (HUC) every four hours.

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

0

50

100

150

200

250

300

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

UCC Throughput Metrics

Door to Home(Minutes)Door to FirstProvider (Minutes)Door to Room Time(MinutesLeft Without BeingSeen


19

This tool demonstrates where staffing holes are occurring but the analysis needs to be more representative of staffing shortages and not simply calculated by averaging the non-coverage hours by staff position.

The ED and PED are collaborating daily to discuss throughput and behavioral health patient issues in the ED. This collaboration, while going in a positive direction, is still evolving for effectiveness. Communication from the staff to the leadership in the PED needs to be more prescriptive and timely. The shift report is assisting in the communication but not all pertinent events are recognized by the charge nurse such as discussing possible capping with ED when the PED is not nearly at capacity.

The transition of Parkland’s behavioral health management functions to Green Oaks leadership under the new management contract began in February. Green Oaks will begin selection of candidates for key management positions during early March.

Women and Infant Specialty Health (WISH) Services

Parkland’s Operational Excellence group did a study in February on Parkland’s Obstetrics Intermediate Care Center (OBICC) that revealed many opportunities for improvement in process and patient flow in the OBICC. Opportunities for a more streamlined process with greater patient flow are in the following areas:

- Provider assignment to patient (faculty versus resident versus mid-level) - Triage - Discharge processing time - Utilization of treatment space and exam rooms.

This report by Parkland’s Operational Excellence Department provided verification and detail to many of the findings in A&M’s Gap Analysis and subsequent reassessment conducted in January 2013. The Operational Excellence team’s simulation and recommendations indicates significant improvements can be made in patient access and throughput.

As reported last month, the labor and delivery area of WISH is challenged with staff turnover. Parkland’s Human Resources department has increased recruiting efforts and will be holding job fairs in March.

Conclusion

In the one year since the Gap Analysis report was delivered to the Parkland Board of Managers and nearly one year since the Corrective Action Plan was accepted by Parkland, much work has been done to address issues identified in the Gap Analysis and to implement initiatives specified in the CAP. The extensive “mock survey” conducted in February validated the progress that Parkland has made in many areas of care delivery and patient safety including with Parkland’s provision and organization of emergency services. However, several areas continue to need focus to come to completion.

With less than 60 days left under requirement under the amended Systems Improvement Agreement (SIA) that Parkland be ready for a full Medicare Condition of Participation survey, the Hospital must accelerate its corrective action activities and refocus its efforts on a number of areas:


20

Case Management

- Conduct audits of medical records to ensure that case management intervention is appropriately and timely documented and in accordance with Medicare COP

- Direct observations and interviews of key processes with staff in patient care and other patient care support areas to validate consistency with policies and procedures

- Continue communication efforts to front-line staff with regard to the expectations of compliance - Onboarding of key management positions - Review and adoption of all departmental policies and procedures - Expansion of case management hours of service - Consistent, early (within 24 hours of admission) and often intervention by case management on all

patients

Competencies

- Completion of clinical and non-clinical competency validation initiative

Contracts

- Complete review key clinical contracts for quality indicators and ensure all contracts are appropriately categorized as clinical or non-clinical

Human Resources / Nursing

- Completion of clinical and non-clinical competency validation initiative - Three weeks of job fairs for nursing (OR, Med/Surg, WISH, Case Management) - Restructure of recruiting process - Formation of Employee Engagement and Retention Committee

Laboratory

- Implementation of recommendations from A&M lab specimen assessment

Medical Staff / Physicians

- Ensure 100 percent use of “Notewriter” tool to document floor based procedures by residents - Continue to complete education and auditing efforts around changes to enhance and provide

additional documentation on resident/attending physician interaction - Complete initial run of medical staff recredentialing applications through the revised Ongoing

Professional Practice Evaluation (OPPE) process.


- Source, recruit and hire adequate resources to staff nursing float pool - Attending job fairs in March to recruit Med/Surg, WISH and ED OR nurses - Determine education plan for “one-to-one” observations for patients with behavioral health issues - Develop plan for acute nurse practitioner responsible for management of one-to-one observations - Continue chart documentation audits around issues such as: Plan of Care, pain reassessments, patient

education, use of restraints


21

Patient Safety

- Audit quality and completeness of closure/resolution of adverse patient events reported in PSN and returned to departmental management for follow up

Pharmacy

- Focused work on preventable adverse drug events relating to blood glucose levels - Continued performance improvement work relating to behavioral health prescriptions in the

Psychiatric Emergency Department and Jail

Physical Medicine and Rehabilitation (PM&R)

- Ensure that “time out” practices are in accordance with Hospital policy - Implementation of recommendations from Operational Excellence assessment related to matching

staff to patient demand (inpatient/outpatient)

Policies & Procedures

- Inventory and review the policies and procedures to ensure that standardization of form and substance and appropriate approval processes are in place


- Ensure an effective transition and onboarding of new management of Psychiatric Services under the Green Oaks management agreement

- Conduct audits of medical records to ensure that case management intervention is appropriately and timely documented and in accordance with Medicare COP

- Direct observations of key processes and interviews with staff in patient care and other patient care support areas to validate consistency with policies and procedures

- Continue communication efforts to front-line staff with regard to the expectations of compliance; - Multidisciplinary review on physical space changes currently being funded - Continue to recruit personnel for outstanding vacancies – clinical provider (e.g., physician, nurse,

nurse practitioner) and support staff - Focus on earlier discharges from PED and reducing time from discharge order to actual disposition

WISH

- Implement recommendations to change processes and roles/responsibilities to improve patients access and throughput consistent with policies and procedures of the other Emergency Services areas of the Hospital

The results of the February “mock survey” provided valuable insight into Parkland’s state of readiness for a full CMS/State survey. The survey found an organization where quality and safety metrics are continuing to improve. Over the next 60 days, and into the future, those quality and safety gains must be held and the remaining work in the areas noted above must be completed and sustained for Parkland to be ready for its full CMS survey.

# Tasks/Initiatives Accountability Work Stream

Target Date Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion

1.01 MEC to prepare a comprehensive plan to implement Ongoing Professional Performance Evaluation (OPPE). Review 5% of Medical Staff OPPE Profiles at conclusion of next eight-month cycle.

Patricia Bergen, MD 5.1 1/31/2013

1.02 Hospital senior management to revise the Parkland ESD Policy Manual to include written policies and procedures regarding documentation of Teaching Attending Physician oversight of Residents. Brad Marple, MD 5.3 5/18/2012 Y

1.03 Hospital senior management, in collaboration UTSW and A&M to create a standing rounding, evaluation and auditing process to collect data on Resident oversight. Brad Marple, MD 5.3 8/31/2012 Y

1.04 Require quality “dashboard” report from Hospital Quality Department Jackie Sullivan 6.4 5/25/2012 Y

1.05Commence reviews of “scorecards” for significant outsourced and contracted clinical services. Design a Board-specific QAPI plan. Jackie Sullivan 6.4 6/1/2012 Y

1.06 Review and revise BOM committees. Paul Leslie 1.1 6/8/2012 Y

1.07 Review performance management and progressive discipline implementation plan from Human Resources. Jim Johnson 1.5 6/8/2012 Y

1.08 Review comprehensive plan to create better communication and coordination among the Hospital’s Legal, Compliance, Internal Audit and Quality Departments. Jody Springer 1.2 6/8/2012 Y

1.09 Review Hospital plan on continuum of care. Sharon Phillips 3.5 10/30/2012 Y

1.10 Appoint Task Force to review Hospital's current Disaster Plan and all other plans indicating how the Hospital and community would respond to rectuion, closure, or diminishment of services or care by Parkland Paul Leslie 1.10 7/13/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Percentage of contracts (outsourced vendors) reviewed for quality measures 1 Contract Svcs 100% 96.1% 85.7% 96.0% 100.0% 100.0% 100.0%

Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started

1. Self-reported by Parkland Staff or EPIC Reports2. Reported through Parkland's Patient Safety Network (PSN's)3. Reported by Parkland's Internal Audit Group4. Reported through Alvarez and Marsal's Daily Audits

Governance (Section 2.01)

Comments1.01 - Results on OPPE for pilot clinics to be presented to the MEC in April


1



2.01 Redesign progressive disciplinary policies and procedures and performance management system. Jim Johnson 1.5 5/25/2012 Y2.02 Redraft goals of the Leadership and Organization Development Department. Jody Springer 1.2 5/25/2012 Y2.03 Develop education materials for new processes and policies. Jim Johnson 1.5 5/25/2012 Y2.04 Conduct training for management and employees. Jim Johnson 1.5 7/13/2012 Y

2.05 Expand the role of Business Partner, require they take a more active role with front-line managers and supervisors. Jody Springer 1.2 5/25/2012 Y

2.06 Business partners to audit evaluations for the next two evaluation cycles. Jim Johnson 1.6 10/31/2012 Y2.07 Evaluate current HR staffing model. Jody Springer 1.2 7/13/2012 Y2.08 Analyze resource allocation within HR Department. Jody Springer 1.2 7/13/2012 Y

2.09 Develop Parkland employee retention strategy. Jim Johnson 1.8 9/14/2012 Y

2.10 Develop policies, procedures and training material regarding employee retention strategy. Jim Johnson 1.8 9/14/2012 Y2.11 Develop master list of all competencies required for each department by job code. Jim Johnson 1.6 9/14/2012 Y2.12 Review and revise LMS system to ensure all required competencies are reflective in the system. Jim Johnson 1.6 9/24/2012 Y2.13 Review all personnel files for completeness. Jim Johnson 1.6 9/14/2012 Y2.14 Educate employees on proper and complete paper work (licensure/certifications). Jim Johnson 1.6 6/4/2012 Y2.15 Ensure accurate and complete paper work is immediately forwarded to Nursing Administration. Jim Johnson 1.6 7/13/2012 Y

2.16 Form standing committee to review polices and procedures with representation from administrative, clinical, and support areas Jim Johnson 1.5 4/6/2012 Y

2.17 Develop policies and processes to be used for HR policy review. Jim Johnson 1.5 4/27/2012 Y

# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Percentage of supervisors (and above) who have attended training administered by clinical education 1 House-Wide 100% 72% 99% 97% 99% N/A N/A

2a Evaluation scores on histogram or bar chart for each department (annual evaluations) - below expectations 1 HR 0.4% 5.0% 0.5% N/A N/A

2b Evaluation scores on histogram or bar chart for each department (annual evaluations) - meets expectations 1 HR 33.9% 55.0% 48.9% N/A N/A

2c Evaluation scores on histogram or bar chart for each department (annual evaluations) - above expectations 1 HR 65.7% 40.0% 50.6% N/A N/A

3 Percentage of licensing validations presented prior to the day of hire 1 HR 100% 100% 100% 100% 100%4 Time from occurrence to corrective action signed by employee (days) 1 HR 10 11.9 11.1 9.0 12.6 18.0 10.6

Human Resources (Section 2.02)


2

Human Resources (Section 2.02)

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Feb-13 Feb-135a Turnover Rate (%) - Nursing 1 HR 16.5% 14.5% 12.8% 9.5% 12.7% 16.7% 16.2% 17.6%5b Turnover Rate (%) - Total 1 HR 15.0% 14.1% 10.6% 9.5% 12.0% 13.6% 12.8% 12.7%6 First year turnover rate 1 HR 20.0% 6.3% 9.8% 24.1% 17.9% 27.8% 25.3%

7Percentage of employees (annually) who leave for stated reasons of better opportunity (compensation, job duties, benefits) 1

HR 35.1% 25.0% 50.0% 44.7% 41.2% 28.7% 34.7% 38.7%

8 Employee satisfaction scores 1 HR 76.0%9 Number of corrective actions 1 HR 40 N/A 74 95 83 84 58 3110 Absent Hours (as a percentage of total hours worked) 1 House-Wide 1.3% 0.96% 1.13% 1.29% 1.63% 1.23%11 Percentage of current licensure 1 HR 100% 100.0% 100.0% 100.0% 99.9% 100.0% 100.0%12 Percentage of current certifications 1 HR 100% 99.2% 99.5% 99.4% 99.4% 98.5% 99.2%13 Time for recruiting to fill an open external job position 1 HR 59.9 55.0 72.3 68.4 73.8 73.5 75.4 77.2



Comments


3



3.01 Review of scheduling templates and actual scheduling patterns at COPC sites in comparison with best practices for teaching clinics along with analysis of schedule utilization versus capacity by clinic

Jessica HernandezHolt Oliver, MD 3.6 9/30/2012 Y

3.02 Conduct analysis of no show rates by clinic, day, session, and provider. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

3.03 Conduct a physician productivity analysis based upon a review of current process and development of analytics. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

3.04 Document current process workflow diagrams, identify barriers to throughput and develop solutions that might increase productivity and result in additional capacity


3.05 Review ED utilization and most common diagnoses by patient admission times to analyze opportunities for changes or improvements in COPC hours of operation Lonnie Roy 3.1 7/13/2012 Y

3.06 Develop the post-acute care network. Deanna Bokinsky 3.5 10/30/2012 Y

3.07 Case Management to generate a study report by physician or service showing average time of discharge for patients and physicians or services consistently discharging patients late in the day.

Robin Stults w/ Clinical

Intelligence3.4 6/12/2012 Y

3.08 Chief Medical Officer to meet with the Medicine and Critical Care Service Chiefs and Hospital Directors to determine barriers to earlier discharge of patients on the units and develop a solution.

Christopher Madden, MD 3.4 10/15/2012

3.09 Conduct a physician productivity analysis based on agreed upon industry standards. Jessica HernandezHolt Oliver, MD 3.6 5/11/2012 Y

3.10 Conduct a feasibility study for a dedicated observation unit Josh Floren 1.7 7/13/2012 Y3.11 Conduct a feasibility study to determine the best use of 4SS space Josh Floren 1.7 7/13/2012 Y3.12 Conduct a study to determine appropriate expansion of the dialysis unit. Josh Floren 1.7 7/13/2012 Y

3.13 Design “Bed Czar” concept to report to ADT Miriam Gomez 3.3 7/1/2012 Y

3.14 Establish strict standards regarding communication and patient placement timelines with ADT to enhance patient placement. Miriam Gomez 3.3 3/14/2013

3.15 Complete an assessment of the current flow of acute emergent dialysis patients through the emergency department, including potential delays, arrival time patterns, and boarding in the Emergency Department.

Kim McCloudLinda Licata

Barbara Mims2.6 6/1/2012 Y

Access/Throughput (Section 2.03)


4




3.16 Define a patient flow process that will reduce and/or eliminate boarding of dialysis patients in the emergency department.Kim McCloudLinda Licata


3.17 Define and obtain approval for resources necessary to implement process, including expansion of serivces.Kim McCloudLinda Licata


3.18 Develop protocols and obtain resources for implementation of defined patient flow process.Kim McCloudLinda Licata


3.19 Fully implement patient flow process and expansion of services to eliminate boarding of dialysis patients in the emergency department. Josh Floren 2.6 11/30/2012

# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

1a Capacity - Family Medicine (patients seen/best practice # of visits per month) 1 COPC 86.0% 100.0% 100.3% 101.3% 97.0% 98.5% 98.3% 102.8%

1b Capacity - Internal Medicine (patients seen/best practice for # of visits per month) 1 COPC 90.0% 100.0% 95.9% 94.9% 95.3% 95.8% 96.4% 93.8%

1c Capacity - Geriatrics (patients seen/best practice # of visits per month) 1 COPC 96.0% 100.0% 102.8% 99.8% 102.4% 102.8% 107.8% 99.3%2 Number of additional appointments through virtual visits 1 COPC 550 402 531 565 697 1383 14893 Percentage of observation patients outside of observation unit 1 ADT 50% 42% 43% 42% 40% 43%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-134 Utilization rates by session by clinic (hours of activity/hours of capacity) Clinics5 Percentage of discharges (medicine, surgery) by 11:00 a.m. 1 Care Mgmnt 4.7% 5.1% 5.2% 5.8% 5.0% 6.5%6 No show rates - COPC 1 COPC 17.2% 17.7% 17.7% 17.5% 18.1% 17.5% 17.9%7 Physician (Hospitalists) productivity (based upon Rolling 12 Month RVUs/Average FTE Count) 1 Med Staff 5768 5991 6032 6465 5713 6907 69078a Physician (Clinics) productivity (based on visits/hour) - Family Medicine 1 COPC 2.62 2.57 2.60 2.49 2.52 2.52 2.578b Physician (Clinics) productivity (based on visits/hour) - Internal Medicine 1 COPC 2.49 2.34 2.36 2.29 2.31 2.33 2.268c Physician (Clinics) productivity (based on visits/hour) - Geriatrics 1 COPC 1.59 1.64 1.60 1.63 1.65 1.76 1.589 Number of new patients on wait list - COPC 1 COPC 20,605 20,698 18,603 18,893 17,83610 Number of established patients on wait list - COPC 1 COPC 17,888 17,783 17,391 15,731 18,68511 Number of bed days occupied by observation status (by unit) 1 Care Mgmnt 1,512 1,204 1,216 1,204 1,261 1,029 12 Average bed turn time (hours:minutes) 1 EVS 1:00 1:12 0:59 1:00 0:59 1:00 0:59

13a Average minutes of boarding in Main ED 1 ED 112.5 142.0 112.3 139.4 164.7 110.913b Average minutes of boarding in ICC 1 ED 107.6 138.8 100.5 116.1 115.3 95.714 Average Length of Stay (1 month lag) 1 Care Mgmnt 5.0 5.0 4.6 4.7 5.0 5.0 5.015 Percent inpatient occupancy (census) by division 1 ADT 85.0% 86% 87% 83% 83% 88% 85%16 Bed Request to Bed Assign, average from bed assigned to patient in bed 1 EVS 45 71 79 62 73 96 7517 Hours on red/yellow bed ADT 524 0 70 29 63 358 59


5


3.14 - Implementation of teletracking tool to go-live in June 2013 Task/initiative largely on schedule for completion3.19 - Implementation of dialysis process flow is pending construction in the ED Task/initiative may be delayed from Target Date completion

Task/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


6



4.01 Define nursing supervisor role expectations and competencies. Jackie BrockJohn Raish 4.3 4/20/2012 Y

4.02 Revise job description to meet role expectations. Jackie BrockJohn Raish 4.3 4/27/2012 Y

4.03 Meet with HR leadership to determine most appropriate and fair way to move forward in establishing a broader more accountable house supervisor role.

Jackie BrockJohn Raish 4.3 4/27/2012 Y

4.04 Meet with existing nursing supervisors and explain new responsibilities and go forward plan. Mary Eagen 4.1 5/4/2012 Y

4.05 Initiate new role expectations. Jackie BrockJohn Raish 4.3 9/14/2012 Y

4.06 Conduct a comprehensive review of the nursing structure under the direction of the new CNO. Mary Eagen 4.1 3/30/2012 Y

4.07 Develop internal and external recruitment plan for new organizational structure. Jackie BrockJohn Raish 4.3 5/11/2012 Y

4.08 Written Timeline conversion to new organizational structure. Mary Eagen 4.1 4/13/2012 Y

4.09Review of all nursing practice standards, policies, and procedures for compliance and relevance. Upon review of nursing standards, policies and procedures, a list of gaps identified must be written so there is a documented source to help drive educational plans and strategies.

Barbara MimsValerie Harvey 4.2 8/31/2012 Y

4.10 Revise policies/procedures and nursing standards to reflect best practices, as appropriate. Barbara MimsValerie Harvey 4.2 10/5/2012 Y

4.11 Develop a house-wide educational plan to correct the current deficiencies in patient care. Barbara MimsValerie Harvey 4.2 9/30/2012 Y

4.12 Develop nurse leadership competencies for all managers. Emilie Allen 4.4 10/31/2012 Y

4.13 Develop a collaborative process with Human Resources to monitor and develop corrective action plans for nursing staff who violate policies and procedures. Jim Johnson 1.5 11/14/2012 Y

4.14 The CNO should determine approach for developing an acuity assessment methodology, e.g., internal historical record review, an automated tool, etc.


Provision of Care (POC) (Section 2.04)


7




4.15 Once selected, roll out acuity tool. Jackie BrockJohn Raish 4.3 3/22/2013

4.16 Develop flexible staffing strategies, PRN pools, per diem staff, etc. Rose Labriola 4.3 10/5/2012

4.17 Monitor core patient care ratios for trends. Jackie BrockJohn Raish 4.3 3/22/2013

4.18 Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (electronic solution) Jackie BrockJohn Raish 4.3 6/28/2013

4.18b Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (interim solution) Jackie BrockJohn Raish 4.3 11/1/2012 Y

4.19 Establish standards of nursing practices, focusing particularly on the plan of care. (Clinical Competencies) Barbara MimsValerie Harvey 4.2 5/11/2012 Y

4.20 Develop house-wide nursing education program (Clinical Competencies) Barbara MimsValerie Harvey 5.3 11/2/2012 Y

4.21 Develop a house-wide competency plan that also addresses a tracking and monitoring system. Jim Johnson 1.6 10/31/2012 Y

4.22 Develop tracking methodology in conjunction with Clinical Education and HR to track competencies by employee and by department. Jim Johnson 1.2 11/3/2012 Y

4.23 Establish standards of nursing practices, focusing particularly on the plan of care. (Plan of Care) Barbara MimsValerie Harvey 4.2 5/11/2012 Y

4.24 Develop house-wide nursing education program. (Plan of Care) Barbara MimsValerie Harvey 4.2 11/4/2012 Y

4.25 Create evaluation tools to measure nurse understanding of education and success of program. Barbara MimsValerie Harvey 4.2 9/14/2012 Y

4.26 Initiate nursing grand clinical rounds. Barbara MimsValerie Harvey 4.2 11/5/2012 Y

4.27 Develop report out tool for grand round results. Barbara MimsValerie Harvey 4.2 10/1/2012 Y

4.28 Through the QAPI Department, develop and report verbal order trends monthly to providers and nurses. Brett Moran, MD 6.4 9/14/2012 Y

4.29 Review all restraint policies. Barbara MimsValerie Harvey 4.2 4/20/2012 Y

4.30 Develop and execute restraint education. Barbara MimsValerie Harvey 4.2 11/1/2012 Y

4.31 Review Epic restraint documentation structure to improve the quality of documentation. Barbara MimsValerie Harvey 4.2 3/23/2012 Y

4.32 Develop a mandatory education for medical staff on the required elements of performance related to restraints. Joseph Minei, MD 5.4 12/1/2012 Y

4.33 Develop a strict discipline policy that leads to termination of staff who violate the Restraint policy or a patients’ rights Jim Johnson 1.5 5/25/2012 Y


8


# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Nursing leadership vacancy rate 1 Nursing 12.9% 9.3% 7.7% 8.2% 9.1% 9.3%2 Percentage of completed competencies in personnel files for all nurses and units 1 HR 100.0% N/A N/A N/A N/A 17.1% 50.0%3 Percentage of travelers (hospital-wide) 1 Nursing 3.0% 2.9% 2.4% 1.9% 2.8% 3.4%4 Nursing vacancy rate 1 Nursing 14.3% 10.7% 11.7% 13.2% 10.5% 11.3%5 Percentage of Plan of Care documented according to policies and procedures - Emergency Services 1 Nursing 100% 77% 95%6 Percentage of Plan of Care documented according to policies and procedures - Medicine Services 1 Nursing 100% 98%7 Percentage of Plan of Care documented according to policies and procedures - Surgery Services 1 Nursing 100% 97% 98%8 Percentage of compliance in hand-off's - Emergency Services 1 Nursing 100% 21% 11%9 Percentage of compliance in hand-off's - Medicine Services 1 Nursing 100% 71%10 Percentage of compliance in hand-off's - Surgery Services 1 Nursing 100% 95% 91%11 Volume of non-violent restraint cases (hospital-wide) 1 Nursing 143 185 156 183 186 167

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-1312 Number of days per month nurse staffing ratios were above/below grid Nursing13 Percentage of cases with verbal orders 1 Nursing 2.2% 1.4% 1.4% 1.2% 1.0% 1.0% 1.1%14 Verbal order compliance rate (signed within 48 hours) 1 Nursing 90% 82% 84% 82% 86% 86% 87%15 Sitter Compliance 3 Nursing 100% 95% 95% 92%

4.15, 4.17 - Acuity tool has been implemented, pending validity of inter-rater reliability Task/initiative largely on schedule for completion4.16 - Float pool decentralized pilot program to be implemented in March, full scale implementation is still pending Task/initiative may be delayed from Target Date completion



Comments


9



5.01

Evaluate infrastructure and performance of the Care Management Department to include merging Utilization Management function. The evaluation of the Care Management Department will also include a review of all resources and personnel currently committed to the Care Management function to determine whether the Department has adequate resources and personnel to perform all of its required functions. The evaluation of the Care Management Department will also include a plan to merge Hospital Utilization Management functions into Care Management.



5.02 Re-align goals and strategy of department to promote collaboration between Case Managers, Social Work, Utilization Review and Nursing.



5.03 Develop nursing-wide education plan defining roles and responsibilities of case managers, social workers, and utilization management along with the inter-relationships between the functions.



5.04 Identify metrics needed on a daily basis to properly analyze cases.Robin Stults w/

Clinical Intelligence

3.4 6/1/2012 Y

5.05 Produce an Extended Stay High Cost Outlier Report to identify inpatients that could move to a post-acute care setting if funding permitted.



5.06Based on evaluation of creating discharge care sites for patients without means, enter into agreements such as leasing beds in a Skilled Nursing Facility (SNF), reduced rates for Durable Medical Equipment (DME) and home oxygen, long stay hotels, etc.

Rose LabriolaMarilyn Callies 3.5 1/31/2013

5.07 Revise position expectations of the ED Case Manager .Robin Stults w/


3.4 6/1/2012 Y

5.08 ED Case managers should evaluate all potential admissions on whether they meet acute care criteria and assess patients’ potential discharge planning needs.



5.09 ED case managers should perform an initial assessment on all patients being admitted to the hospital. Robin Stults w/ Clinical 3.4 8/30/2012 Y

5.10 Create or revise policies and procedures that define screening, assessment and discharge planning process to identify high risk patients.

Robin Stults w/ External

Resources3.4 6/15/2012 Y

5.10 Educate nursing care management staff on proper procedure for the Discharge Planning Assessment Tool within Epic to ensure appropriate screening and referrals.

Marilyn CalliesRose Labriola 3.4 6/15/2012

5.11 Evaluate for each Nursing Unit the best mechanisms to promote interdisciplinary communication, e.g., “brief daily huddles”, rounds, EMR notations only, etc. Based on findings, pilot and implement the most effective methods.



5.12 Create a screening tool for case managers to include long term stay patient, avoidable days and other areas of focus.Robin Stults w/


3.4 7/20/2012 Y

5.13 Move Utilization Management within Care Management Department.Robin Stults w/


3.4 8/31/2012 Y

Care Management (Section 2.05)


10




5.14 The Utilization Review Plan should be re-written to include the required elements which are necessity of admission, length of stay and appropriateness of use of drugs.



5.15 Policies and Procedures should be revised to reflect the revised plan, and associated roles and responsibilities of staff. Robin Stults w/


3.4 7/30/2012 Y

5.16 Revise the current UR logs to ensure that all required elements are collected and formatted in order to analyze and trend type data.



5.17 Develop process to export Case Management Care Web documentation whereby the data are analyzed and trended.Robin Stults w/


3.4 6/30/2012 Y

5.18 Select UR metrics for tracking, monitoring, and trending. (utilize national best practices as examples for targets).Robin Stults w/


3.4 6/30/2012 Y

5.19 Utilize data from a comparative database that is clinically adjusted and severity adjusted to assist the Committee in identifying areas for improvement.



5.20 Analyze, trend, and summarize agreed upon data elements to the UR Committee on a regular basis. (Recommendations for actions need to be documented and reported to the Medical Executive Committee.)



5.21 Report unfavorable physician trends to the Patient Care Review Committee (PCRC). Unexpected results will be reported to Performance Improvement (PI).



5.22 Monitor progress on targeted metrics and re-evaluate targeted improvement goal and/or metrics being measured.Robin Stults w/


3.4 7/31/2012 Y

# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Compliance in performing medical necessity screening in ED 1 CM 90.1% 89.3% 91.8% 96.1% 98.1% 98.1%2 Audit Results of Number of Hospital-Wide Cases Intervened on 1st day of admission 1 CM3 Percentage of cases with CM screening for discharge needs - ED 1 CM 95.0% 28.5% 59.0% 74.8% 94.6% 94.7% 98.1%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-134 Number of Cases with Outlier Length of Stay (LOS) (per Month) 1 CM 1,013 954 978 1,111 1,184 1,008 1,0815 Number of Avoidable Days (per Month) 1 CM 5,184 4,853 4,440 5,157 5,384 5,114 5,4006 Number of One-Day Stays (per Month) 1 CM 443 488 580 686 593 554 5817 30 day Readmission Trends (percent of total discharges) 1 CM 8.7% 8.4% 10.2% 9.9% 10.9% 10.2% 9.8%


11




Comments

5.10 - New Case Management leadership is affecting the effectiveness of the tool5.06 - Although work has accelerated on contracting with post-acute care facilities, execution of contracts is not expected until April 2013


12



6.01 Coordinate a multi-disciplinary team to represent the EVS department that is impacted by turnaround of beds; Nursing, ADT, EVS, ESD, House Supervision, Administration. Kurt Dierking 3.7 4/27/2012 Y

6.02 If required, conduct a demand vs. capacity, throughput process workflow assessment and an EVS labor productivity study. Kurt Dierking 3.7 9/14/2012 Y

6.03 If required, develop a future work flow process. Kurt Dierking 3.7 9/14/2012 Y

6.04 Provide EVS various communication devices, hand held transmitters, pagers, cell phones, etc. to the EVS managers and EVS staff to expedite and validate the current status of the unit. Kurt Dierking 3.7 4/11/2012 Y

6.05 Minimized delays in placing patients on unit with efficient communication and temporary deployment of additional EVS staff from other units to the unit experiencing an influx of patients. Kurt Dierking 3.7 4/23/2012 Y

6.06 Track work orders and their respective resolutions. Analyze the issues and their resolutions to determine trends. Provide action plans for decreasing recurring issues. Kurt Dierking 3.7 4/27/2012 Y

6.07 Create a plan for an initial cleaning “campaign” and ongoing schedule for cleaning, maintenance and incorporate monitoring. Kurt Dierking 3.7 4/6/2012 Y

6.08 Convene the environment of care team to establish mission, charter, goals and processes to address EOC activities. Kurt Dierking 3.7 4/6/2012 Y

6.09 Conduct a one-time, accelerated plan for deep cleaning and repairs. Kurt Dierking 3.7 6/8/2012 Y

6.10 Develop a budget and prioritization for the “campaign” on potential staff or capital needs for senior leadership review. Kurt Dierking 3.7 4/13/2012 Y

6.11EVS to review existing checklists and expand where necessary for an EOC checklist for department surveillance. Issue checklists to Department Directors to ensure preparedness and awareness. Issue infraction notices to Department Director, Divisional VP and EVS Director.

Kurt Dierking 3.7 4/13/2012 Y

6.12 Conduct analysis on EVS staffing and evaluate and compare to industry benchmarks to ensure adequate resources exist to maintain the facility. Kurt Dierking 3.7 5/11/2012 Y

6.13 Create an analysis of the current EVS process workflow to determine things such as barriers, potential improvements, productivity and performance. Develop new process flow if necessary. Kurt Dierking 3.7 6/8/2012 Y

6.14 EOC team to submit monthly report to COO and CNO based the EOC rounds and on the action plans. Kurt Dierking 3.7 6/8/2012 Y

6.15 Review existing scope of activities/tasks as well as frequency of cleaning schedules for each unit/space of the Hospital (and ambulatory sites) to ensure it is adequate to meet the “new” standards and/or adjustments. Kurt Dierking 3.7 6/8/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

1 Percentage of Patient Rooms, Procedure Areas, and Operating Rooms, meeting all elements of EVS requirements 1 House-Wide 100% 97.4% 97.1% 97.6% 98.3% 98.6% 98.7%

2 Compliance to infection prevention audits on surface cleanliness 1 EVS 100% 98.0% 98.1% 98.9% 97.5% 99.5% 99.0%3 Percentage of procedure areas with up to date daily terminal cleaning logs 1 House-Wide 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%4 Number of patient complaints about environmental issues 1 EVS 0 3 4 1 4 2 1

Environment of Care (EOC) (Section 2.06)


13

Environment of Care (EOC) (Section 2.06)

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-135 Bed turnaround time 1 EVS 1:00 1:12 0:59 1:00 0:59 1:00 0:596 Percentage of turns greater than 60 minute goal EVS 25% 48% 41% 37% 38% 38% 39%7a Work order completion time - EVS (days) 1 EVS 1 1.91 0.42 0.92 0.84 1.05 0.777b Work order completion time - Engineering (days) 1 Facilities 2 2.01 3.21 1.88 2.65 1.78 3.07c Work order completion time - Clinical Engineering (days) 1 Clin Eng 3 2.47 2.42 3.23 2.82 2.36 3.028 Vacancy Rate - EVS HR 3% 7.9% 6.1% 9.2% 6.3%



Comments


14



7.01Each Divisional Vice President (VP) will submit all department specific Infection Prevention (IP) related policies and procedures to IP.



7.02 The IP department Director and Chief of Infection Prevention will review and make revisions of all departmental and house-wide IP policies, if applicable. Janet Glowicz 6.3 9/30/2012 Y

7.03 All departmental IP policies are returned to the department for their review and acceptance Janet Glowicz 6.3 6/8/2012 Y

7.04 Approve reviewed departmental and house-wide IP policies. Janet Glowicz 6.3 6/8/2012 Y

7.05 Divisional VP and Department Directors to develop a communication roll out with IP Director on the revised IP policies and procedures.



7.06 Each department assigns an IP delegate to be the contact and participant in the IP prevention education program.Kim McCloudLinda Licata


7.07 Provide a full-time Chief Infection Prevention Officer. Jody Springer 1.2 6/8/2012 Y

7.08 Survey monthly all departments for IP compliance. Survey results are sent to Department IP representative, Department Director and Divisional VP for follow up and corrective action needed and expected completion date. Janet Glowicz 6.3 3/23/2012 Y

7.09 Execute EOC surveillance program to ensure consistency with cleaning methods and standards to support IP principles. Janet Glowicz 6.3 3/23/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Percentage of policies that have been drafted/revised (by department) 1 IP 100% 100% 100% 100% 100% 100% 100%2 Volume of non-compliant observations for hand hygiene - Hospital Audit 1 House-wide 0 243 322 284 298 315 209

3a Volume of non compliant hand hygiene observations - support staff 1 House-wide 0 61 85 56 71 71 223b Volume of non compliant hand hygiene observations - physicians 1 House-wide 0 67 93 119 82 128 613c Volume of non compliant hand hygiene observations - nursing 1 House-wide 0 115 144 109 145 116 1264 Compliance in hand hygiene 1 House-wide 100% 98.6% 99.3% 99.3% 99.3% 99.7% 98.5%5 Percentage of compliant observations with sterile technique in procedure areas 1 Surgery 100% 100% 100% 100% 100% 100%6 Percentage of Infection Prevention completed surveys by each department, monthly 1 IP 100% 100% 100% 100% 100% 100% 100%7 Volume of non-compliant observations by Infection Prevention Practice Team 1 House-wide 173 377 311 382 548 3288 Compliance percentage of Infection Prevention Practice Team rounding 1 House-wide 100% 95% 92% 92% 91% 91% 88%9 Number of blood stream infections 1 House-wide 0% 0 1 0 0 0 0

Infection Control (Section 2.07)


15

Infection Control (Section 2.07)

Audits # 7 and 8 - A new "secret shopper" process was implemented by Infection Prevention, resulting in a smaller volume of non-compliant Task/initiative largely on schedule for completion observations Task/initiative may be delayed from Target Date completion



Comments


16



8.01 Conduct a medication override audit. Vivian Johnson 2.3 6/8/2012 Y

8.02 Enhance P&T agenda with cost studies, outcomes for alternative drug options, ADR, Overrides, dosing guidelines. Vivian Johnson 2.3 4/5/2012 Y

8.03 P&T Committee to provide report summarizing and action plans on medication analysis, ADR summaries, Narcan utilization, off label med utilization, and medication reconciliation issues to QCC. Vivian Johnson 2.3 6/8/2012 Y

8.04 Establish baseline and develop a tool to “flag” ADRs. Vivian Johnson 2.3 5/11/2012 Y

8.05Trending reports based on type of reaction, location, provider, etc. and report to P&T Committee and other appropriate medical staff committees. Actions should be taken and documented on trends by the P&T Committee and reported up through the QCC Committee and Governing Board.

Vivian Johnson 2.3 6/8/2012 Y

8.06 Potential trends should be monitored with corrective action taken, e.g., ADRs identified on the same drugs, same units, same diagnoses, same physicians, etc. Vivian Johnson 2.3 6/8/2012 Y

8.07 Explore alternatives for clinical trial identifiers. Vivian Johnson 2.3 4/27/2012 Y8.08 Ensure all “off label” medication use is reviewed and approved by the P&T Committee. Vivian Johnson 2.3 4/27/2012 Y

8.09 Establish a Medication Reconciliation task force to develop a consistently compliant process. Judy HerringtonVicki Crane 4.5 5/11/2012 Y

8.10 Conduct chart audit of medication reconciliation compliance to establish current baseline. Judy HerringtonVicki Crane 4.5 6/15/2012 Y

8.11 Evaluate appropriateness of providing pharmacy tech support for medication reconciliation. Vivian Johnson 2.3 5/11/2012 Y8.12 Develop and provide education for pilot study for the participating Pharmacy Techs and RNs. Vivian Johnson 2.3 6/8/2012 Y8.13 Conduct pilot study. Collect and present results. Vivian Johnson 2.3 6/8/2012 Y8.14 Develop future state work flow processes. Vivian Johnson 2.3 6/8/2012 Y8.15 Pilot the new work flow process. Vivian Johnson 2.3 7/13/2012 Y

8.16 Implement new reconciliation process (in EPIC). Judy HerringtonVicki Crane 4.5 9/14/2012 Y

8.17 Reassign the crash cart management under the Sterile Processing Department and/or Pharmacy. Judy HerringtonVicki Crane 4.5 4/13/2012 Y

8.18 Assess the space requirements and human resources needed for case cart management within SPD. Judy HerringtonVicki Crane 4.5 7/16/2012 Y

8.19 Revisit the cart management processes for supplies and pharmaceuticals. Judy HerringtonVicki Crane 4.5 5/11/2012 Y

8.20 Ensure the supply and pharmaceutical lists match the components in the carts and validate the accuracy of lists and components with Pharmacy and Nursing Education.

Judy HerringtonVicki Crane 4.5 3/22/2013 Y

8.21 Implement an accountability process and sign off process to ensure accuracy and products are not expired. Judy HerringtonVicki Crane 4.5 8/13/2012 Y

8.22 Conduct cart initial audit for validation after transferring case cart management to SPD. Judy HerringtonVicki Crane 4.5 10/1/2012 Y

Medication Management (Section 2.08)


17




8.23 Present drug storage audit and data collection program. Vivian Johnson 2.3 6/8/2012 Y8.24 Pharmacy Resources and Nurse Liaisons (Charge Nurse) are assigned for each unit. Vivian Johnson 2.3 6/8/2012 Y

8.25 Pharmacy & Unit-Based Nursing Resources conduct audits (Nursing - part of daily checklist for eight weeks); Pharmacy (monthly as a part of trending & monitoring) Vivian Johnson 2.3 6/8/2012 Y

8.26 Nursing Liaison collects, collates and summarizes audit results and submits on the data tool to the Pharmacy Resource weekly. Vivian Johnson 2.3 6/8/2012 Y

8.27 Pharmacy Resource analyzes data from Nurse Liaison reports and provides monthly summary interim reports to Nurse Liaison, Unit Manager and Department Director. Vivian Johnson 2.3 6/8/2012 Y

8.28 Pharmacy Resource collects collates and summarizes audit results and submits monthly audit on the data tool. Vivian Johnson 2.3 6/8/2012 Y

8.29 Establish a multi-disciplinary RCI Medication Safety Team. Vivian Johnson 2.3 4/13/2012 Y

8.30 Investigate the root causes of the medication errors and categorize the errors and provide tactical plans towards resolution. Vivian Johnson 2.3 6/8/2012 Y

8.31 Review the medication ordering, preparation and administration process through a work flow process. Vivian Johnson 2.3 6/8/2012 Y8.32 Revise medication administration process based on finding of work flow analysis. Vivian Johnson 2.3 6/8/2012 Y

8.33 Provide the education plan base on the work flow model findings that address the gaps in the safe delivery of medications. Vivian Johnson 2.3 9/14/2012 Y

8.34 Develop core competence education program for all the clinical staff in regards to the practices of safe medication delivery. This module should be included in the staff’s annual competency evaluation. Vivian Johnson 2.3 9/14/2012 Y

8.35 In conjunction with current internal hospital initiatives, define those care settings that moderate sedation is required versus pain management.


8.36 Ensure all clinicians are qualified to administer medications that have the clinical effect of moderate sedation. Judy HerringtonVicki Crane 4.5 8/13/2012 Y

8.37 Ensure compliance with new moderate sedation practice standards. Judy HerringtonVicki Crane 4.5 8/13/2012 Y

8.38 Review the medications in Pyxis on the IP units that have access to “moderate sedation categorized” medications to determine how they should be “flagged” for monitoring.


8.39 Conduct an audit on the daily Pyxis report (Epic Clarity Report) on Narcan use in patients undergoing pain management and moderate sedation in non-procedure based units. Vivian Johnson 2.3 3/22/2013 Y

# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 MD Max Overrides reviewed by RPH 1 Pharmacy 100% 100% 100% 100% 100% 100% 100%2 Compliance in medication reconciliation at admission (inpatient only) 1 Physicians 53% 90.3% 92.0% 95.1% 92.1% 94.5% 95.4%3 Compliance in medication reconciliation at discharge (inpatient only) 1 Physicians 83% 83.7% 83.5% 83.5% 88.4% 96.2% 95.9%4 Compliance in medication reconciliation - COPCs Physicians 83.6% 86.0% 94.0% 98.0%5 Percentage of locations with unsecured medications 1 Pharmacy 0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%6 Percentage of compliant crash carts 1 SPD 100.0% 92.9% 90.0% N/A 93.0% 100.0%7 Volume of adverse events related to moderate sedation 1 House-Wide 0 0 1 2 1 1 08 Number of improper or lack of medication labeling 2 Pharmacy 59 73 60 66 54 55


18


# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-139 Number of off-label medications in use, not reviewed by P&T 1 Pharmacy 0 0 0 1 0 0 0

10 Number of adverse drug reactions 1 Pharmacy 19 31 108 94 157 125 153 16511 Number of preventable adverse drug reactions 1 Pharmacy 1 12 29 2312 Missed medications 1 Pharmacy 7.4% 7.3% 7.8% 7.6% 7.7%13 Percentage of medications administered within 60 minutes of order 1 Pharmacy 97% 96% 96% 97% 96% 96%14 Percentage of medications administered within 30 minutes of order 1 Pharmacy 88% 87% 87% 88% 87% 87%15 Number of opioid induced respiratory depressions naloxone administration 1 Pharmacy 0 0 2 6 2 4 116 Number of preventable opiod induced respiratory depressions naloxone administration 1 Pharmacy 0 0 1 1 2 0 0



Comments


19



9.01 Create job description for new Chief Patient Rights and Safety Officer (CPRSO). Jody Springer 1.2 3/30/2012 Y9.02 Name Interim Chief Patient Rights and Safety Officer (CPRSO)9.03 National search to recruit new Chief Patient Rights Quality and Safety Officer (CPRSO) (CQSO) Chris Madden 1.2 10/1/2012

9.04

The following quality and safety functions at Parkland would be reorganized to report directly to the CPRSO CQSO in recognition of recent changes in the Quality, Safety and Performance Improvement Department: - Patient Safety - Patient Safety Investigations - Root Cause Analysis (RCA) - Patient Safety Incident Reporting - PSN Database Maintenance and Reporting State, Federal and Joint Commission Reporting - “Continual Readiness”/CMS, State and Joint Commission Survey Preparation “Daily Rounding” Function - Infection Prevention and Control · - Patient Relations (Patient complaints and grievances, which currently reports to Nursing)

Chris Madden 1.2 5/11/2012

9.05 New job descriptions for all employees and managers, supervisors and department heads in units and divisions now reporting to the CPRSO CQSO. Chris Madden 1.2 5/11/2012

9.06 Review and redesign of all patient rights and safety related policies and procedures. Lisa Betterson 6.2 6/8/2012 Y9.07 Develop education plan for all employees regarding patient safety and rights policy/procedure changes. Lisa Betterson 6.2 8/15/2012 Y

9.08

Reorganize and redesign its Quality Department and its centralized Quality Assessment/Performance Improvement (QAPI) functions to include: Clinical Data Management Performance ImprovementRapid Cycle Improvement

Jackie Sullivan 6.1 6/8/2012 Y

9.09 Create new Human Resources policy on violations of Patient Rights/Patient Safety obligations. Jim Johnson 1.5 6/8/2012 Y9.10 Create a Patient Rights/Patient Safety Awareness Campaign. Lisa Betterson 6.2 4/27/2012 Y9.11 Create a “Safe Patient Hand offs”/Continuity of Patient Care Awareness Campaign Lisa Betterson 6.2 5/11/2012 Y

9.12 New education and training for current and new employees and physicians on safe patient handoffs and continuity of patient care. Lisa Betterson 6.2 9/30/2012 Y

9.13Parkland should conduct a study to look at best practices of other large hospital police departments to compare the level of specialized training provided to Parkland Police Department against other hospital police departments. Best practice for reporting structure should also be investigated.

Jody Springer 1.2 4/13/2012 Y

9.14 Patient Rights and Safety Department Study and Task Force (to include Nursing, Police, Patient Safety, and Patient Relations representatives) on Elopements and Patients leaving. Lisa Betterson 6.2 6/1/2012 Y

9.15Work with Parkland Police Department and Nursing the Patient Rights and Safety Department should conduct a study of all documented elopements in 2011 and determine reasons for elopement (e.g., breeches in security, caregiver training, etc.) and provide action plan and recommendations for reducing elopements.

Lisa Betterson 6.2 3/30/2012 Y

9.16

Patient Rights and Safety Department should then begin to conduct chart reviews for all patients who elope or leave AMA. The review should separately categorize all departments, including a separate review for elopements and patients leaving AMA in the Emergency Department. The chart review should then develop a list of reasons as to why patients leave elope or leave AMA, and subsequent reports should trend in these categories.


Patient Safety/Rights (Section 2.09)


20




9.17 Complete current RCI initiative regarding 1:1 observation procedure and competencies required for staff. Lisa Betterson 6.2 6/1/2012 Y

9.18 Evaluate additional CM staff to ED.Robin Stults w/


3.4 7/31/2012 Y

9.19

Establish a documentation committee, led by HIM, that includes Clinical support from Chief Nursing Officer and Chief Medical Officer, Support Services, ADT, Legal, Patient Safety, Performance Improvement and HIM representation to address the inconsistencies of properly executed documents, lack of complete and accurate documentation, and lack of compliance.


9.20 Develop and implement an action plan that addresses non-compliance and the steps to the solution. Lisa Betterson 6.2 9/14/2012 Y

9.21 Review all policies and procedures related to the areas of non-compliance to determine and ensure policies are updated to current regulations or standards of practice. Lisa Betterson 6.2 10/31/2012 Y

9.22 Determine where and if the resources are available or needed to meet the documentation requirements. Lisa Betterson 6.2 9/14/2012 Y

9.23HIM shall conduct routine chart audits to document that all patients have been provided with: 1) required information on their rights under Medicare, federal law and state law; 2) required information on advance directives. Chart audits shall also assess whether all Medicare patients are receiving the notice entitled: “Important Message from Medicare.”

Lisa Betterson 6.2 9/14/2012

9.24 Review Hospital policy for Patient Grievance procedure and compare to best practice, including those noted above. Lisa Betterson 6.2 5/25/2012 Y

9.25 Develop monitoring system to ensure timelines required by Hospital policy are met. Lisa Betterson 6.2 6/8/2012 Y

9.26

Patient Relations Department should create a new monthly reporting system for all patient grievances and complaints. The reporting system should show, at a minimum: number of complaints/grievances received; actionable categories for all complaints/grievances (some complaints/grievances may fall in several categories); person making complaint (patient, family member, staff, physician, etc.); time between receipt of complaint and response to patients; documentation that patient agreed/disagreed that compliant/grievance was resolved; inventory of complaint/grievance by department/unit/floor and confidentiality by employee and physician; trending of grievances/complaints over months/years in all above categories.


9.27 Develop and implement a Privacy task force to identify areas of non-compliance (including HIPAA), indicators to measure, and to develop an awareness campaign. Lisa Betterson 6.2 6/8/2012 Y

9.28 Conduct Patient Privacy Awareness Campaign to reacquaint staff on HIPAA and other privacy obligations. Privacy Awareness campaign should include examples of recent privacy breaches. Lisa Betterson 6.2 9/14/2012 Y

9.29 Review current privacy training materials. Require annual competency on HIPAA and other patient rights but revise competency annually to refresh materials and learning behaviors for better retention of information. Lisa Betterson 6.2 9/14/2012 Y

9.30 Utilize tool developed by Executive VP of Operations or another developed tool to conduct weekly customer relations tours. Lisa Betterson 6.2 7/1/2012 Y

9.31 Develop a dashboard and track and trend the indicators for Patient Rights and the progress to the target thresholds. Lisa Betterson 6.2 9/14/2012 Y


21


# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Percentage of policies and procedures reviewed and/or revised 1 Pat Safety 100% 100% 100% 100% 100% 100% 100%2 Attendance for state mandated training courses for members of Police Department 1 Police 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%3 Average time from event to closure of patient safety investigation (days) 1 Pat Safety 10 33 45 31 31 41 414 Percentage of regulatory reports submitted within 5 business days 1 Perf Imp 74% 100% 88.9% 92.9% 92.9% 100.0% 93.3% 100.0%5 Percentage of state-mandated regulatory reports submitted within 2 business days 1 Perf Imp 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%6 Number of patient complaints and grievances 1 Pat Griev N/A N/A N/A N/A N/A N/A7 Average time from event to resolution of patient complaint or grievance (days) 1 Pat Griev N/A N/A N/A N/A N/A N/A8 Percentage of inpatients receiving advance directive notice 1 PFS 98.0% 98.0% 98.5% 98.0% 98.0% 98.0%

9Percentage of patients who received appropriate notifications (under applicable Medicare, state and other laws, "Important Message from Medicare", others), as audited by HIM - Care Management 1

CM 98% 76.7% 79.5% 82.8% 92.0% 94.3% 96.8%

10Percentage of patients who received appropriate notifications (under applicable Medicare, state and other laws, "Important Message from Medicare", others), as audited by HIM - PFS 1

PFS 98% 91.7% 91.8% 95.5% 96.0% 98.3% 98.8%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-1311 Number of Patient Safety Investigations 1 Pat Safety 47 58 35 42 30 2712 Percentage of Root Cause Analyses (RCA) completed within 45 days Pat Safety 80% 100% 75% 57% 83% 67% 80%13 Volume of privacy and security breaches 1 House-Wide 36 53 42 32 17 2214 Number of elopements, AWOLS, AMA (excluding ED) 1 Pat Safety 59 53 62 54 70 55 67

9.03 - 9.05 - Still interviewing for Chief Quality and Safety Officer (CQSO) Task/initiative largely on schedule for completion9.23 - Compliance has not reached 98% but is steadily increasing Task/initiative may be delayed from Target Date completionAudits # 6 and 7 - Results are "N/A" as Patient Relations leadership is vetting the accuracy of metrics Task/initiative is past the Target Date deadline

Initiative tracking not yet started


Comments


22

# Tasks/Initiatives Accountability Work Stream Target Date Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion

10.01 Develop an OPPE/FPPE review template for each medical department and/or service. Patricia Bergen, MD 5.10 4/20/2012 Y

10.02 Develop a written procedure explaining the OPPE process, criteria and physician referral process for FPPE. Patricia Bergen, MD 5.10 4/20/2012 Y

10.03 Define required physician profile elements for all physicians. Patricia Bergen, MD 5.1 4/20/2012 Y

10.04 Provide all department chairs the required template, guidance, and a timeline for completion of departmental criteria, indicators, and thresholds of performance.

Patricia Bergen, MD 5.1 1/31/2013

10.05 Review and “sign off” of CMO and QAPI of the departmental OPPE plans Professional Staff Quality Management Plan for relevance and compliance.

Patricia Bergen, MD 5.1 7/30/2012 Y

10.06 Review and obtain approval of OPPE/FPPE process and criteria by MEC, and then the Governing Board. Patricia Bergen, MD 5.1 7/13/2012 Y

10.07 Each department should develop a standard set of metrics for use on cases sent for peer review. Patricia Bergen, MD 5.1 1/31/2013 Y

10.08 Medical Staff Office Quality Department to establish a methodology to track and trend all cases brought to peer review Patricia Bergen, MD 5.1 1/31/2013 Y

10.09 Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review. Patricia Bergen, MD 5.1 8/31/2012 Y

10.10 Determine necessity to expand Medical Staff resources. Patricia Bergen, MD 5.1 7/13/2012 Y

10.11Charter a joint Hospital/GME Faculty Task Force. Create a venue for collaboration and discussion of issues between Hospital and Faculty to inform and appraise between residency update periods. Members to include Hospital VPs and Faculty Medical Staff.

Brad Marple, MD 5.3 4/27/2012 Y

10.12

Develop an audit and reporting method for compliance with the ACGME 2012 Common Program Requirements that will require each departmental residency program to specify the types of patient events that will require a Resident to call the teaching physician. Use the audit to develop an operational report to concurrently manage the Residents during the academic year.

Brad Marple, MD 5.3 7/30/2012 Y

10.13 Develop a training module enabling faculty to instruct residents when to escalate issues to their Attending Physicians. Brad Marple, MD 5.3 8/31/2012 Y

10.14Standardize use of Innovations (resident management software) across the system to create a web-enabled database of individual resident certification profile; (presently nurse can access the department grid, see what a PGY-2 is qualified to do, and then look up the name of a particular PGY2 and determine whether he/she is certified to it.

10.14a Interim option for access to resident qualifications Brad Marple, MD 5.3 7/30/2012 Y

10.15Modify Grid to highlight those events or add link to the list of and procedures that require concurrent notification of the attending physician that is available to all departments. Brad Marple, MD 5.3 7/30/2012 Y

10.16 Review Grid or list to ensure that it includes the list of all events that require escalation notification to an Attending (i.e., lower the reporting threshold). Brad Marple, MD 5.3 7/30/2012 Y

10.17 Create policy contingencies for alternate modes of supervision or escalation, i.e., what to do when the expected senior resident or Teaching Physician is not accessible in the expected time period. Brad Marple, MD 5.3 5/11/2012 Y

Medical Staff (Section 2.10)


23

Medical Staff (Section 2.10)


10.18 Evaluate Parkland’s Epic functionality, to determine improvement to be made in documentation or note entry to provide consistent and reliable documentation of Attending Physician oversight, approval and concurrence with Resident orders. Brad Marple, MD 5.3 7/30/2012 Y

10.19Evaluate Parkland’s call system ability to properly attribute the Resident and Attending Physician to each patient. Create an audit tool for weekly confirmation that call system is accurately and timely attributing Residents and Attending Physicians to each patient.

Joseph Minei, MD 5.4 8/31/2012 Y

10.20 Upgrade Epic with user capability to concurrently update treatment teams through use of the physician order entry function. Joseph Minei, MD 5.4 8/31/2012 Y

10.21 Standardize call schedule procedure for consulting services. Joseph Minei, MD 5.4 8/31/2012 Y

10.22 Ensure the accuracy Amcom scheduling system (source of truth maintained by Parkland) Joseph Minei, MD 5.4 8/31/2012 Y

10.23 Create contingencies for alternate modes of supervision or escalation.

10.24 Parkland’s GME Director should review the current training and education materials for Residents on documentation, particularly documentation of H&Ps. Brad Marple, MD 5.3 5/11/2012 Y

10.25 Refresher education and training should be conducted for all Residents. Brad Marple, MD 5.3 8/31/2012 Y

10.26 Perform audit of Residents' History and Physicals (H&P) documentation for completion and adherence to Parkland policy and procedures. Brad Marple, MD 5.3 3/22/2013 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Number of referrals to peer review 1 Med Staff 15 192 120 114 127 151 1452 Utilization of Notewriter System for Procedures Performed by Residents 1 Med Staff 100% 79% 87% 87%3 Percentage of compliance in completion of H&P's 1 Med Staff 100% N/A 90% 94% 88% 81% 81%4 Nursing Knowledge for Finding Resident Qualifications 1 Nursing 100% 52% 71% 86% 85%



Comments10.04 - Results on OPPE for pilot clinics to be presented to the MEC in April


24



11.01Conduct a quantitative demand and process analyses of the ESD in order to properly balance work flow, capacitate the various components of the split flow system, and accurately determine any changes in bed capacity, service hours or staffing.

Clifann McCarley 3.2 4/27/2012 Y

11.02Throughput and productivity assessment of the “current state” in the form of a process work flow diagram including the following elements: inputs, activity steps, decision points, enablers, functions and outputs


11.03 Identify rate limiting factors such as lack of equipment/technology, availability and/or staffing within budget guidelines, and hours of operations. Clifann McCarley 3.2 4/27/2012 Y

11.04 Server cycle times need to be measured and applied to the design of care teams in the Triage and the Intake areas. Clifann McCarley 3.2 4/27/2012 Y

11.05Conduct a benchmarking study of its Emergency Department labor productivity to industry standards in order to determine if there are opportunities to improve productivity and thereby increase capacity for each service area.


11.06Redesign of the future process flow to eliminate waste, such as: removing or combining steps, automating any manual activity steps, if possible, transferring elements to other departments, changing the location where the steps are done, and finally altering/modify the activity step


11.07 Work flow models should be piloted with Rapid Cycle Testing and refined as necessary and then training provided Clifann McCarley 3.2 1/13/2013 Y

11.08 Periodic reviews of process work flow using Plan-Do-Check-Adjust (PDCA) Lean techniques. Clifann McCarley 3.2 3/14/2013 Y

11.09 Change functionality in Epic to reflect changes in work flow processes and new treatment areas. Clifann McCarley 3.2 6/8/2012 Y

11.10 Recruitment, credentialing and on-boarding of qualified physicians. Patricia Bergen, MD 5.1 6/8/2012 Y

11.11 Pathology to scope operations, licensing, certification requirements for Point of Care labs. Deb Perrault 2.2 5/11/2012 Y

11.12 Develop signage text consistent with the educational level and primary languages of the population served that is consistent across the institution. Clifann McCarley 3.2 5/11/2012 Y

11.13 List all sites and specific rooms requiring posting of signage Clifann McCarley 3.2 5/11/2012 Y

11.14 Obtain approval of final language for signage Clifann McCarley 3.2 5/25/2012 Y

11.15 Physical Plant and Facilities to arrange for printing and posting final approved signs. Clifann McCarley 3.2 6/8/2012 Y

11.16 Post new signage Clifann McCarley 3.2 7/13/2012 Y

11.17 Review and revise all EMTALA related Policy and Procedures. Clifann McCarley 3.2 6/8/2012 Y

11.18 Create/Revise training materials for new EMTALA Policy and Procedures Clifann McCarley 3.2 7/13/2012 Y

11.19 Re-educate on new EMTALA Policy and Procedures. Clifann McCarley 3.2 3/22/2013 Y

11.20 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/20/201311.21 Re-educate staff on new patient registration policies on Emergency Registration Process Emilie Allen 4.4 6/8/2012 Y

11.22 Develop and finalize a survey technique. Clifann McCarley 3.2 5/12/2013

Emergency Services (Section 2.11)


25




11.23 Develop a patient flow process to eliminate disparate treatment in evaluation and delay in the care of a person presenting to the ESD seeking Psychiatric emergency care. Clifann McCarley 3.2 9/14/2012

11.24 Review and revise all Hand-Off related Policy and Procedures. Barbara MimsValerie Harvey 4.2 5/25/2012 Y

11.25 Create/Revise training materials for new Hand-Off Policy and Procedures. Barbara MimsValerie Harvey 4.2 7/13/2012 Y

11.26 Re-educate on new Hand-Off Policy and Procedures. Barbara MimsValerie Harvey 4.2 9/30/2012 Y

11.27 Work with IT/Epic to develop access to information required by law. Clifann McCarley 3.2 6/8/2012 Y

11.28 Develop reporting function with Epic for output of Central Log Reports. Clifann McCarley 3.2 6/8/2012 Y

11.29 Create training materials for accessing information required by law and reporting functions through Epic. Clifann McCarley 3.2 7/13/2012 Y

11.30 Re-educate staff on accessing information required by law and reporting functions through Epic. Clifann McCarley 3.2 9/14/2012 Y

11.31 Monitor and audit compliance to determine if management can generate a central patient log. Clifann McCarley 3.2 9/14/2012 Y

11.32 Review and revise policy and procedures on receiving hospital transfer requirements. Clifann McCarley 3.2 4/13/2012 Y

11.33 Create/Revise training materials for new policy and procedures. Clifann McCarley 3.2 4/27/2012 Y

11.34 Re-educate on new policy and procedures. Clifann McCarley 3.2 5/18/2012 Y

11.35 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/12/2013

11.36 Review and revise policy and procedures on Memorandum of Transfer requirements. Clifann McCarley 3.2 4/13/2012 Y

11.37 Create/Revise training materials for new policy and procedures. Clifann McCarley 3.2 4/27/2012 Y

11.38 Re-educate on new policy and procedures. Clifann McCarley 3.2 5/18/2012 Y

11.39 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/12/2013

11.40 Review and revise policy and procedures on nursing assessment and plan of care requirements. Emilie Allen 4.4 9/9/2012 Y

11.41 Create/Revise training materials for new policy and procedures. Emilie Allen 4.4 9/21/2012 Y11.42 Re-educate on new policy and procedures. Emilie Allen 4.4 9/21/2012 Y11.43 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/18/2013

11.44 The Emergency Services Director of Nursing should determine approach for developing an acuity assessment methodology, e.g., internal historical record review, an automated tool, etc.


11.45 Once selected, roll out acuity tool. Jackie BrockJohn Raish 4.3 3/22/2013

11.46 Develop flexible staffing strategies, PRN pools, per diem staff, etc. Jackie BrockJohn Raish 4.3 3/22/2013 Y

11.47 Monitor core patient care ratios for trends. Jackie BrockJohn Raish 4.3 3/22/2013 Y

11.48 Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs. Jackie BrockJohn Raish 4.3 6/28/2013


26


# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13Main ED

1 Treated visits 1 ESD 9734 9859 9539 9845 11105 96522 Total number of hours of ED boarding 1 ESD 2671 2654 3536 2231 2879 4102 26653 Average number of patients in ED that are boarding per day 1 ESD 40.0 47.2 48.2 39.7 41.3 48.2 51.54 Average number of dialysis patients in Main ED at 6AM 1 ESD 10.9 10.2 10.3 11.3 9.6 10.85 Average "Compassionate" dialysis patients transferred from ED/day 1 ESD 17.3 13.8 15.5 16.0 17.3 16.8 17.16 Average dwell time for dialysis patients in Main ED ESD 415.5 412 396 415 449 454 4117 Turnaround time to discharge patients to home (door to home, in minutes) 1 ESD 379 408 389 324 350 358 3248 Door to seen by 1st Provider (minutes) 1 ESD 92 125 114 76 87 93 729 Hours on resource alert 1 ESD 394 238 22 40 225 6

10 Door to Room Time (minutes) 1 ESD 93 65 70 43 57 61 4411 Left without being seen 1 ESD 9.2% 8.3% 4.3% 5.2% 5.5% 3.1%12 Left without being treated 1 ESD 2.3% 1.9% 1.8% 1.6% 1.7% 1.7%13 Percentage of patients admitted 1 ESD 26.9% 27.5% 26.8% 26.8% 25.4% 26.6%14 Percentage of patients discharged 1 ESD 64.3% 63.3% 63.6% 63.4% 64.4% 62.1%15 Average ED throughput time - time from patient arrival to patient disposition 1 ESD 326 354 342 286 306 320 28416 Compliance to environment of care 1 ESD 100% 91% 89% 95% 90% 89% 90%

Urgent Care Clinic (UCC)17 Treated visits 1 ESD 4161 4225 4270 4206 5019 420918 Turnaround time to discharge patients to home (door to home, in minutes) 1 ESD 194 253 274 243 235 230 22119 Door to seen by 1st Provider (minutes) 1 ESD 126 187 194 171 162 167 14120 Door to Room Time (minutes) 1 ESD 107 173 183 143 135 140 11321 Left without being seen 1 ESD 10.1% 11.4% 8.6% 7.8% 7.5% 6.9%22 Left without being treated 1 ESD 1.1% 0.8% 0.8% 1.1% 0.3% 0.4%23 Percentage of patients admitted 1 ESD 0.1% 0.0% 0.0% 0.1% 0.0% 0.0%24 Percentage of patients discharged 1 ESD 92.8% 93.5% 92.8% 91.5% 92.7% 92.3%25 Average ED throughput time - time from patient arrival to patient disposition 1 ESD 164 231 253 222 211 209 19826 Compliance to environment of care 1 ESD 100% 92% 92% 95% 92% 96% 96%


27


# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13OB Gyn Intermediate Care Center (ICC)

27 Treated visits 1 WISH 1934 1927 1815 1743 1992 174428 Total number of hours of ED boarding 1 WISH 127 108 166 117 125 142 11929 Average number of patients in ED that are boarding per day 1 WISH 2.3 2.0 2.3 2.3 2.2 2.4 2.730 Turnaround time to discharge patients to home (door to home, in minutes) 1 WISH 456 465 494 458 416 473 45131 Door to seen by 1st Provider (minutes) 1 WISH 105 59 56 52 40 56 4332 Hours on resource alert 1 WISH 0 0 6 0 0 3233 Door to Room Time (minutes) 1 WISH 264 260 268 256 207 261 22634 Left without being seen 1 WISH 1.9% 1.8% 1.8% 1.1% 2.6% 1.9%35 Left without being treated 1 WISH 11.8% 14.8% 14.2% 10.9% 14.2% 12.4%36 Percentage of patients admitted 1 WISH 9.4% 8.1% 8.3% 8.2% 8.0% 8.7%37 Percentage of patients discharged 1 WISH 70.4% 68.1% 68.5% 72.5% 69.0% 70.9%38 Average ED throughput time - time from patient arrival to patient disposition 1 WISH 400 406 426 400 364 416 39239 Compliance to environment of care 1 WISH 92% 91% 95% 92% 95% 91%# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

40 Labor Productivity (staffing to include acuity) ESD

41Total ED throughput time - time from patient arrival in ANY ED to discharge home from ANY ED (hours:minutes) 1

ESD 6:43 6:42 5:55 6:13 6:28 6:03

42 Percentage of travelers - ED 1 ESD 24.0% 19.3% 10.4% 11.9% 17.5% 17.8%

11.23 - Initiative missed deadline due to lack of physician coverage in Team C Task/initiative largely on schedule for completion11.45 - Acuity solution has been implemented, pending interrater reliability of information in staffing reports Task/initiative may be delayed from Target Date completion



Comments


28



12.01 Develop clear “vision” of a psychiatric services (with particularly focus on PED) care delivery model. Sharon Phillips 2.1 4/27/2012 Y

12.02 Hire interim management for Psychiatric Director and psychiatric experienced/trained Nursing Manager for PED. Sharon Phillips 2.1 4/27/2012 Y

12.03 Commence national search for permanent Director of Psychiatric Services. Sharon Phillips 2.1 6/8/2012 Y

12.04 Develop a detailed implementation plan (based on this corrective action plan) led by the psychiatric management team. Define a management scorecard that can be utilized. Sharon Phillips 2.1 5/14/2012 Y

12.05 Create by discipline specific roles and responsibilities in alignment with new care delivery model. Sharon Phillips 2.1 6/22/2012 Y12.06 Create new competencies and education models. Emilie Allen 4.4 5/25/2012 Y

12.07 Create permanent staffing grids for PED and 8 North based upon census and acuity. Jackie BrockJohn Raish 4.3 7/31/2012 Y

12.08 Further develop the charge nurse role in the PED and on 8 North. Jackie BrockJohn Raish 4.3 7/31/2012 Y

12.09 Develop, test, and validate acuity methodologies for PED and 8 North. Jackie BrockJohn Raish 4.3 7/31/2012 Y

12.10 Validate Social Workers coverage and effectiveness. Sharon Phillips 2.1 4/13/2012 Y12.11 Implement short term strategy for consistent physician coverage. Sharon Phillips 2.1 9/14/2012 Y12.12 Continue recruitment efforts aggressively to fill permanent positions. Jody Springer 1.2 6/8/2012 Y12.13 Identify staff knowledge gaps. Emilie Allen 4.4 6/8/2012 Y12.14 Utilize psychiatric–trained resources for competency development and training. Emilie Allen 4.4 6/1/2012 Y12.15 Develop comprehensive PED education plan. Sharon Phillips 2.1 6/8/2012 Y

12.16 Incorporate required physician competencies into OPPE/FPPE. Patricia Bergen, MD 5.1 6/8/2012 Y

12.17 Implement a discharge huddle with the MD, nursing staff, social worker, and a designated facilitator. Sharon Phillips 2.1 5/1/2012 Y12.18 Develop interdisciplinary communication and planning for the plan of care. Sharon Phillips 2.1 9/28/2012 Y12.19 Develop suicide risk and behavioral quadrant assessment tools. Sharon Phillips 2.1 6/8/2012 Y12.20 Conduct a pilot on the suicide risk and behavioral quadrant assessment tools. Sharon Phillips 2.1 6/29/2012 Y

12.21 Educate team members on the purpose and the usability of the tool and how it’s integrated into the plan of care. Sharon Phillips 2.1 7/13/2012 Y

12.22 Develop cross-functional Parkland behavioral health team. Sharon Phillips 3.5 9/24/2012 Y12.23 Analyze the patient population served by all of Parkland behavioral health disciplines. Sharon Phillips 3.5 9/24/2012 Y

12.24 Work with DBHLT on reducing or eliminating identified gaps in care across the continuum of care in Dallas County. Sharon Phillips 3.5 9/24/2012 Y

12.25 Continue redesign planning of day room and back entrance for better space utilization. Sharon Phillips 2.1 6/8/2012 Y12.26 Initiate multi-disciplinary team to consider PED space redesign. Sharon Phillips 2.1 6/8/2012 Y12.27 Develop alternative workflows for continued PED patient care during physical space construction/redesign. Sharon Phillips 2.1 6/8/2012 Y12.28 Develop budget for recommended physical changes. Sharon Phillips 2.1 6/8/2012 Y12.29 Develop alternative safety alerts for day room restroom. Sharon Phillips 2.1 4/20/2012 Y

Psychiatry Services (Section 2.12)


29

Psychiatry Services (Section 2.12)

# Audit/Measures Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-133 Percentage of patients seen by social workers (PED) 1 Psych 97.7% 97.6% 98.7% 94.8% 98.6% 97.3%4 Hours on resource alert 1 PED 0 0 0 0 0 05 Percentage of patients with a documented discharge huddle 1 Psych 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%6 Percentage of patients admitted 1 Psych 1.6% 3.1% 3.0% 3.1% 2.0% 3.0%7 Percentage of patients discharged to home 1 Psych 73.3% 74.0% 72.8% 66.1% 66.6% 68.1%8 Percentage of patients transferred to acute care facility 1 Psych 23.1% 20.7% 21.8% 28.2% 29.6% 26.9%9 Turnaround time to discharge patients to home (door to home) 1 PED 649 588 573 532 652 724 62310 Door to seen by 1st Psych Provider (minutes in any ED) 1 PED 166 402 363 341 N/A 132 N/A11 Door to Room Time 1 (PED pt arrived in any ED and placed in any ED room) PED 60 61 47 47 N/A N/A N/A12 Compliance to environment of care 1 Psych 100.0% 99.1% 94.7% 99.1% 99.6% 98.6% 98.7%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-1313 Labor productivity (staffing to include acuity) PED14 Volume of restraint cases - personal hold 1 Psych 15 26 15 10 17 1115 Volume of restrain cases - seclusion 1 Psych 3 7 4 3 8 216 Number of patients with scheduled appointments at discharge 1 Psych17 Percentage of travelers - Psych 1 Psych 8.3% 0.0% 0.0% 0.0% 0.0% 0.0%

18 Total PED throughput time - time from patient arrival to patient disposition (arrival in PED to discharge in PED) 1 PED 537 481 463 464 N/A N/A N/A

19 Total PED throughput time - time from patient arrival to patient disposition (arrival in any ED to discharge in PED) 1 PED 971 872 844 N/A N/A N/A

20 24-hour bounce back rate 1 PED 2.4% 3.0% 3.2% 3.8% 2.0% 2.0%21 Proportion of total Psychiatric Services patients discharged from Main ED by Team C 1 Psych 14.0% 13.6% 13.9% 17.5% 20.0% 20.0%

Audit/Metric results with "N/A" for February are due to the revising of reporting and data accuracy for the Psych ED. Metrics will be reported in March. Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


30



13.01 Ensure plan of care practices are standardized and followed regularly. Barbara MimsValerie Harvey 4.2 3/22/2013 Y

13.02 Standardize hand off procedures. Educate staff. Barbara MimsValerie Harvey 4.2 9/30/2012 Y

13.03 Begin recruitment of key leadership positions – Nursing Director (L&D) and Nursing Manager (L&D).


13.04 Evaluate job description and determine best solution to work load balance for Nurse Manager (Postpartum).


13.05 Begin recruitment of additional Nurse Manager candidates (Postpartum). Jackie BrockJohn Raish 4.3 5/11/2012 Y

13.06Evaluate job descriptions of Nurse Managers to determine if additional administrative support is required. Paula Turicchi 2.4 7/15/2012 Y

13.07 Begin recruitment for administrative support roles (if appropriate).

13.08 Recruit, hire and train additional staff to fill vacancies. Jackie BrockJohn Raish 4.3 6/8/2012 Y

13.09 Evaluate nurse staffing needs based upon any plans for increase in capacity. Jackie BrockJohn Raish 4.3 4/27/2012 Y

13.10 Recruit, hire and train additional staff as required. Jackie BrockJohn Raish 4.3 6/8/2012 Y

13.11 Re-design staffing model to include adjustment for acuity. Jackie BrockJohn Raish 4.3 6/8/2012 Y

13.12 Evaluate job descriptions for inclusion of appropriate competencies and to ensure duties assigned are within scope of practice. Paula Turicchi 2.4 6/1/2012 Y

13.13 WISH Nursing Director and Chief Nursing Officer (CNO) must ensure all nursing personnel working within scope of practice.


13.14 Nursing Directors of each area should review competencies required for the care of their patient population in accordance with nursing practice standards. Emilie Allen 4.4 6/1/2012 Y

Women and Infant's Specialty Health (WISH) (Section 2.13)


31




13.15 A full assessment of current staff should be conducted to establish a current baseline of competencies. Emilie Allen 4.4 7/13/2012 Y

13.16 Review all personnel files for completed competencies. Emilie Allen 4.4 7/13/2012 Y

13.17 Gaps identified in competencies should be addressed with education and audit. Emilie Allen 4.4 7/13/2012 Y

13.18 Conduct newborn resuscitation competency education and audit. Emilie Allen 4.4 7/13/2012 Y

13.19 Evaluate the need for an additional FTE’s to assist in the responsibility of supply stocking, storage, and environmental rounds on all WISH units. Paula Turicchi 2.4 5/31/2012 Y

13.20

Establish recommended AORN practices of setting up the sterile back table for delivery table set-up. Determine if additional staffing is required for L&D OR and LDR for sterile supply set up.Hire additional staff, if needed.

Suzanne Sims 2.5 4/13/2012 Y

13.21 Ensure plan of care practices are standardized and followed regularly.13.22 Standardize hand off procedures. Educate staff.

13.23Women Infant and Specialty Health (WISH) operations and nursing leadership with Chief Nursing Officer (CNO) to develop plan and budget for required changes. Paula Turicchi 2.4 6/8/2012 Y

13.24 Present plan to senior leadership. Paula Turicchi 2.4 5/25/2012 Y

13.25 Design care model that provides for rooming-in options for infants. Jackie BrockJohn Raish 4.3 6/30/2012 Y

13.26 Establish a census tracking tool for newborns. Paula Turicchi 2.4 5/11/2012 Y

13.27 Review and revise infant security and abduction plan. Paula Turicchi 2.4 4/6/2012 Y

13.28 Conduct at least one Code Pink drills per year. Emilie Allen 4.4 5/11/2012 Y

13.29Identify space that can be made available for emergency equipment within the post partum unit (department reports plan underway to convert treatment rooms for this purpose).

Paula Turicchi 2.4 7/31/2012 Y


32




13.30 Establish monthly mock equipment drills and verify emergency equipment is immediately available where newborns are housed. Paula Turicchi 2.4 7/31/2012 Y

13.31 Discard all “six pack” transport carts. Paula Turicchi 2.4 4/6/2012 Y

13.32Conduct a multidisciplinary assessment of conditions of WISH units related to supplies/medications including refrigeration, cleanliness, appropriate storage of supplies, and other conditions related to infection prevention.

Paula Turicchi 2.4 4/15/2012 Y

13.33 Evaluate the need for an additional FTE’s to assist in the responsibility of supply stocking, storage, and environmental rounds on all WISH units.

13.34 Establish an alternative protocol for delivery table set-up to ensure sterile field. Suzanne Sims 2.5 4/6/2012 Y

13.35 Educate staff on storage requirements for specimens. Emilie Allen 4.4 4/27/2012 Y

13.36 Revise dirty utility room flow and practice. Paula Turicchi 2.4 7/15/2012 Y

13.37 Department reports a plan is in progress for construction to ensure proper dirty utility room flow. (No start date supplied) Josh Floren 1.7 7/12/2012 Y

13.38 Review Parkland policy on securing medications PHR-D-067 Inventory Management – Procurement, Storage


13.39 Anesthesia medication trays should be stored in a locked, secure area. Judy HerringtonVicki Crane 4.5 4/13/2012 Y

13.40 Store floor stock in Pyxis. Judy HerringtonVicki Crane 4.5 4/13/2012 Y

13.41Educate staff on the importance of two patient identifiers and include in initial and annual competencies. Emilie Allen 4.4 3/31/2012 Y

13.42 Educate staff of National Patient Safety Goals and Hospital policy. Emilie Allen 4.4 3/30/2012 Y

# Audit/Measures Responsibility Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Compliance to Infection Prevention practice 1 WISH 100.0% 96.0% 72.7% 68.8% 96.5% 82.5% 82.5%2 Compliance to Environment of Care 1 WISH 100.0% 96.0% 96.0% 97.4% 97.3% 97.1% 97.2%


33


# Metric Responsibility Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-133 Labor productivity (Staffing to include acuity) WISH4 Staffing hours per patient day 1 WISH 11.65 12.42 13.07 14.02 14.00 13.39 13.89

5a Hallway and Classroom Beds in use in L&D (avg duration in minutes) 1 WISH 98 79 81 72 505b Hallway and Classroom Beds in use in L&D (instances) 1 WISH 192 165 216 167 816 Volume of patients doubling-up on Post-Partum 1 WISH 1384 906 834 617 659 846 5347 Induction Interruption WISH8 Induction Delay WISH9 Direct Admits to Post-Partum 1 WISH 122 138 99 106 98 74

10 Bounce-Back from Post-Partum to L&D Recovery WISH 31 29 28 34 26



Comments


34



14.01 Conduct daily infection control audits in all areas of the Main OR, PACU, PreOp Holding, DSU, Anesthesia Workroom, ASC and PAEC. Suzanne Sims 2.5 8/31/2012 Y

14.02Execute the progressive disciplinary action and performance improvement plan for staff/physicians who exhibit failure to follow infection prevention policies and procedures. Suzanne Sims 2.5 6/8/2012 Y

14.03 Conduct environment of care rounds every shift in each perioperative area. Suzanne Sims 2.5 8/31/2012 Y14.04 Review and follow Parkland policy Admin 6-33 “Labeling of Medications On/Off the Sterile Field”. Suzanne Sims 2.5 8/31/2012 Y14.05 Review and follow Parkland policy Admin 6-43, “Using Two (2) Patient Identifiers”. Suzanne Sims 2.5 8/31/2012 Y14.06 Provide training for alternative options for medication solution transfer. Suzanne Sims 2.5 7/13/2012 Y14.07 Conduct daily audits of various medication management measures to determine compliance. Suzanne Sims 2.5 8/31/2012 Y14.08 Review and follow the Parkland policy Admin 6-30 “Universal Policy”. Suzanne Sims 2.5 7/13/2012 Y

14.09 Conduct daily audits of various patient right initiatives to determine compliance: Critical Equipment Suzanne Sims 2.5 8/31/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Compliance to using two patient identifiers 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%2 Compliance percentage of Infection Prevention by audit, monthly 1 Surgery 100.0% 100.0% 100.0% 95.0% 96.2% 100.0% 100.0%3 Compliance percentage of Environment of Care by audit, monthly 1 Surgery 100.0% 100.0% 99.2% 99.0% 98.2% 98.5% 98.6%4 Compliance to site marking procedure 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

5Compliance to medication management measures (labeling, transferring from the circulator to scrub, securing and other measures) 1

Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

6 Compliance with critical equipment 1 Surgery 100.0% 100.0% 100.0% 100.0% 99.5% 99.5% 100.0%7 Compliance to Time Out procedure 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 99.8% 100.0%

Perioperative Services (Section 2.14)


35

Perioperative Services (Section 2.14)

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-138 Number of medication-related safety event 1 Surgery 0 5 1 2 2 6 09 Number of blood transfusion errors 2 Surgery 2 5 0 0 0 0

10 Number of incorrect consents 2 Surgery 3 1 1 2 0 111 Number of wrong site surgeries or wrong site markings 2 Surgery 0 0 0 0 0 012 Number of lab specimen mis-labeling 2 Surgery 0 5 0 2 0 513 Percentage of travelers - OR 1 Surgery 13.9% 9.5% 6.8% 7.5% 8.5% 8.5%14 Surgical Site infection rate (2 month lag) 1 Surgery 1.71% 0% 1.6% 1.8% 2.4% 4.3% 2.0% 2.3%



Comments


36



15.01 Conduct a weekly environment of care tour to ensure infection prevention measures are in compliance.Kim McCloudLinda Licata


15.02 Conduct audit on invasive procedures in the restricted procedure rooms on the proper medication management on and off the sterile field. Suzanne Sims 2.5 8/31/2012 Y

15.03 Review Parkland's policy on Surgical Attire and OSHA regulation on Personal Protective Equipment. Suzanne Sims 2.5 8/31/2012 Y

15.04 Cardiologist performing the procedure to conduct the “pause” to ensure surgical team is properly attired. Suzanne Sims 2.5 8/31/2012 Y

15.05 Conduct an education program and competency on maintaining the sterile field. Suzanne Sims 2.5 8/31/2012 Y15.06 Conduct an audit to ensure compliance with surgical attire policy. Suzanne Sims 2.5 8/31/2012 Y

15.07 Nurse manager to develop daily EOC tool/checklist to ensure compliance.Kim McCloudLinda Licata


15.08 Review PHHS policy Admin 6-33 and PS 04-33 on proper handling of medications. Suzanne Sims 2.5 3/30/2012 Y

15.09 Educate staff of the existing Parkland Universal Protocol policy. Suzanne Sims 2.5 8/31/2012 Y

15.10 Develop Time Out procedure “flash cards” to be used as a help guide. Suzanne Sims 2.5 8/31/2012 Y15.11 Conduct an audit on Time Out on all invasive procedures. Suzanne Sims 2.5 8/31/2012 Y

15.12 Provide mandatory education on proper site marking to all new and existing physicians. Provide education to staff nurses and techs to ensure they understand the proper site marking requirement based on NPSG. Suzanne Sims 2.5 9/28/2012 Y

15.13 Review Parkland's policy PS 04-43 regarding sponge and sharp counts. Suzanne Sims 2.5 8/31/2012 Y

15.14 Surgical Services to provide an educational session on the proper procedure of conducting sponge and needle/sharp counts. Develop and implement an annual competency on proper procedure on performing counts. Emilie Allen 4.4 4/20/2012 Y

15.15 Develop and implement a dashboard key measure all the required elements on correct counts to include instruments and sponges. Suzanne Sims 2.5 9/28/2012 Y

15.16 Review Parkland policy Admin 6-33 and PS 04-33 on proper handling of medications. Suzanne Sims 2.5 3/30/2012 Y15.17 Develop unit specific medication management competencies. Emilie Allen 4.4 4/20/2012 Y15.18 Initiate an awareness program verifying the medication they transfer on and off the sterile field. Suzanne Sims 2.5 4/27/2012 Y

15.19 Conduct audit to assure needles and syringes are being stored in a safe and proper place and incorporate into daily environmental rounds. Suzanne Sims 2.5 8/31/2012 Y

15.20 Audit proper transfer and verifying of medications on/off sterile field. Suzanne Sims 2.5 8/31/2012 Y15.21 Add medication management to the key measures to department quality dashboard. Suzanne Sims 2.5 8/31/2012 Y15.22 Establish action plan for non-compliance. Suzanne Sims 2.5 6/30/2012 Y

15.23 Enter the procedural nurse hand off communication to the recovery nurse into Epic. Barbara MimsValerie Harvey 4.2 9/30/2012 Y

Procedural Services - Catherization Lab/Endoscopy (Section 2.15)


37

Procedural Services - Catherization Lab/Endoscopy (Section 2.15)

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Compliance percentage to Infection Prevention practice 1 Surgery 100.0% 98.9% 98.6% 92.5% 85.7% 81.4% 87.5%2 Compliance percentage of environment of care by audit, monthly 1 Surgery 100.0% 97.1% 97.9% 98.3% 98.8% 99.0% 99.6%3 Compliance to site marking procedure in cath lab by audit 1 Surgery 100.0% 100.0% 100.0% 99.3% 100.0% 100.0% 100.0%4 Compliance to Time Out procedure by audit 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5%5 Compliance to sponge, needle, sharp and instrument count in cath lab 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

6Compliance to medication management measures (labeling, transferring from the circulator to scrub, securing and other measures) by audit 1

Surgery 100.0% 92.0% 88.0% 78.0% 89.0% 89.0% 100.0%

7 Compliance to using two patient identifiers by audit 1 Surgery 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 100.0%8 Compliance to proper scrub attire and sterile gowning in restricted areas in cath lab by audit 1 Surgery 100.0% 100.0% 100.0% 87.5% 100.0% 100.0% 100.0%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-139 Number of wrong site surgeries 2 Surgery 0 0 0 0 0 010 Number of incorrect consents 2 Surgery 0 1 2 2 0 011 Number of medication related safety events 1 Surgery 0 1 0 0 1 2 112 Number of lab specimen mis-labeling 2 Surgery 1 3 0 0 0 013 Number of return to surgery for retained objects 2 Surgery 0 1 0 0 0 0



Comments


38



16.01 Perform demand to capacity, throughput process workflow assessment and labor productivity analysis. Scott Cummins 2.2 7/13/2012 Y16.02 Define the current backlog of appointment needs and additional capacity to meet backlog. Scott Cummins 2.2 3/23/2012 Y16.03 Provide assessment of rate limiting factors contributing to the backlog. Scott Cummins 2.2 4/6/2012 Y16.04 Develop a current state process workflow diagram. Scott Cummins 2.2 5/4/2012 Y16.05 Develop future process work flow state. Scott Cummins 2.2 5/4/2012 Y16.06 Conduct a labor productivity benchmarking. Scott Cummins 2.2 4/20/2012 Y16.07 Pilot future state process work flow model. Scott Cummins 2.2 7/13/2012 Y16.08 Provide training. Scott Cummins 2.2 7/13/2012 Y

16.09 Implement the new process flow department wide Scott Cummins 2.2 7/13/2012 Y

16.10 Review of the existing Parkland "time out" policy to ensure clarification of required process and/or revise as appropriate. Suzanne Sims 2.5 6/1/2012 Y

16.11Provide Time Out procedure “flash cards” to be used as a help guide until newly learned behavior has been established and is codified. Suzanne Sims 2.5 8/31/2012 Y

16.12 Establish Time Out procedure as a one of the competencies of personnel. Emilie Allen 4.4 5/11/2012 Y16.13 Execute progressive counseling/disciplinary action plan for infractions. Scott Cummins 2.2 6/8/2012 Y

16.14a Development of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI - Radiology Jackie Sullivan 6.4 9/30/2012 Y

16.14bDevelopment of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI - Hospital-Wide Jackie Sullivan 6.4 9/30/2012 Y

16.15 Ensure needles and syringes are secured in an area that is not accessible to unauthorized persons. Scott Cummins 2.2 7/13/2012 Y16.16 Review Parkland policy on medications on and off the sterile field. Suzanne Sims 2.4 8/31/2012 Y16.17 Review Parkland policy on labeling medications on and off the sterile field. Suzanne Sims 2.4 8/31/2012 Y

16.18 Develop and review the smart order sets that have foley insertions to determine whether Lidocaine jelly should be added. Judy HerringtonVicki Crane 4.5 7/13/2012 Y

16.19 Review Parkland policy on properly securing medications. Judy HerringtonVicki Crane 4.5 3/23/2012 Y

16.20 Develop an annual department-specific medication competency on all staff Emilie Allen 4.4 6/8/2012 Y

16.21 Assign role and responsibilities to ensure all tasks including the disposal of opened and unused supplies to Interventional Radiology (IR) tech. Scott Cummins 2.2 5/11/2012 Y

16.22 Distribute Parkland Policy G-1 on radiation safety. Scott Cummins 2.2 4/6/2012

16.23 Develop annual unit specific competency on radiation safety competency for all staff, physicians and vendors. Scott Cummins 2.2 6/29/2012 Y

16.24 Audit the Main and ASC Operating Room staff and providers proper wear of personal protective attire during a procedure when operating the mini-fluoroscopy and other radiation safety requirements. Scott Cummins 2.2 9/14/2012 Y

16.25 Initiate the education plan for the physicians requiring the need to meet the credentialing criteria. Patricia Bergen, MD 5.1 5/4/2012 Y

Radiology (Section 2.16)


39




16.26 Collate all credentialing documents and provide to the committee for review and approval. Patricia Bergen, MD 5.1 5/11/2012 Y

16.27Ensure a person who is approved to operate the mini-fluoroscopy unit is in procedures where the surgeon has not been granted privileges. Scott Cummins 2.2 6/8/2012 Y

16.28 Develop an interface or investigate on how to tie in an alert of physician’s privileges at point of scheduling a procedure. Scott Cummins 2.2 6/8/2012 Y

16.29 Inquire and implement a functionality in Epic for the ordering physician to cognitively select whether to use the establish protocol or use orders as written. Scott Cummins 2.2 9/14/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Compliance to use of two patient identifiers 1 Radiology 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%2 Compliance to the Time Out procedure 1 Radiology 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%3 Compliance to proper securing of medications and medication supplies (needles, syringes) 1 Radiology 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%4 Compliance to medication management (labeling, scrub and circulator exchange) 1 Radiology 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%


40


# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13Mammography - Diagnostic

5 Labor productivity - Mammography - Diagnostic (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 0.5 0.5 0.5 0.5 0.5 0.5 0.56 Number of days to third next available appointment - Mammography - Diagnostic (urgent patient) 1 Radiology 95 14 9 30 13 7 8 157 Number of days to third next available appointment - Mammography - Diagnostic (not urgent patient) 1 Radiology 42 398 Current utilization of slots - Mammography - Diagnostic 1 Radiology 130% 125% 189% 103% 108% 107% 109% 79%9 No show rate - Mammography - Diagnostic 1 Radiology 19% 18% 14% 17% 13% 20% 31% 21%

MRI10 Labor productivity - MRI (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 1.9 1.9 2.3 2.4 2.4 2.5 1.811 Number of days to third next available appointment - MRI 1 Radiology 64 14 8 12 20 12 5 812 Current utilization of slots - MRI 1 Radiology 115% 130% 111% 113% 108% 112% 108% 117%13 No show rate - MRI 1 Radiology 28% 27% 21% 18% 19% 19% 17% 19%

CT14 Labor productivity - CT (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 0.7 0.7 0.6 0.6 0.7 0.7 0.715 Number of days to third next available appointment - CT 1 Radiology 12 14 1 1 1 1 1 116 Current utilization of slots - CT 1 Radiology 117% 120% 110% 107% 104% 108% 109% 123%17 No show rate - CT 1 Radiology 11% 10% 8% 8% 8% 9% 9% 8%

US18 Labor productivity - US (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 0.8 0.8 1.0 0.9 0.8 1.0 0.919 Number of days to third next available appointment - US 1 Radiology 15 14 2 1 2 1 1 120 Current utilization of slots - US 1 Radiology 118% 120% 101% 102% 103% 103% 105% 94%21 No show rate - US 1 Radiology 18% 17% 11% 12% 11% 13% 12% 10%

IR22 Labor productivity - IR (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 1.2 1.2 2.1 1.5 1.9 1.4 1.823 Number of days to third next available appointment - IR 1 Radiology 26 14 13 11 13 15 13 1124 Current utilization of slots - IR 1 Radiology 116% 120% 113% 104% 105% 94% 117% 125%25 No show rate - IR 1 Radiology 17% 16% 14% 17% 15% 12% 14% 14%

Overall26 Number of Incorrect consents 2 Radiology 0 0 0 2 0 0 027 Number of incorrect tests or wrong results placed 2 Radiology 0 0 0 2 3 3 028 Number of cancelled surgeries due to unavailable films 2 Radiology 0 0 0 0 0 0 029 Number of medication related safety events 1 Radiology 0 0 0 1 4 0 230 Number of lab specimen mis-labeling 2 Radiology 0 0 1 1 0 0 031 Number of wrong site exams 2 Radiology 0 0 2 1 1 0 0


41


16.22 - Only 80 percent of required medical staff have taken training module Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


42


17.01 Develop education plan for phlebotomy staff including new orientees. Debbie Perrault 2.2 3/30/2012 Y17.02 Conduct random audits of phlebotomy carts. Debbie Perrault 2.2 5/11/2012 Y

17.03 Ensure there is a regular cleaning schedule with EVS for the affected Laboratory areas.Kim McCloudLinda Licata


17.04 Establish environment of care rounds with EVS and Infection control leaders.Kim McCloudLinda Licata


17.05 Initiate department-level Infection Control accountability and metrics.Kim McCloudLinda Licata


17.06 Educate laboratory staff on expected cleaning standards and schedules. Debbie Perrault 2.2 4/13/2012 Y

17.07 Define with EVS an escalation process for cleaning.Kim McCloudLinda Licata


17.08 Utilize reagent that requires validation of results prior to testing. Debbie Perrault 2.2 3/23/2012 Y

17.09 Lab Director will develop an education plan and competency to ensure all current employees and new hires understand the confirmation process prior to individual patient reporting. Debbie Perrault 2.2 6/8/2012 Y

17.10 Listen to periodic transcription tapes to ensure transcriptionist is reporting variances. Debbie Perrault 2.2 5/25/2012 Y17.11 Review Parkland reporting critical value policy. Debbie Perrault 2.2 4/13/2012 Y17.12 Develop and implement an education plan and competencies on critical value reporting. Debbie Perrault 2.2 4/13/2012 Y

17.13 Monitor the effectiveness of the education program with the turnaround time of the critical value reporting. Debbie Perrault 2.2 7/31/2012 Y

17.14 Review Parkland policy Admin 6-30 Universal Protocol. Suzanne Sims 2.5 8/31/2012 Y17.15 Conduct five weekly random Time Out observations in the FNA clinic. Debbie Perrault 2.2 6/8/2012 Y17.16 Collect Time Out observation results and add to clinic QAPI indicators. Debbie Perrault 2.2 5/11/2012 Y

17.17 Retrain current staff to ensure awareness of the availability of the ALVIN video translator or the language line for patients that require a certified translator. Debbie Perrault 2.2 6/8/2012 Y

17.18 Provide Medical Assistant staffing for FNA clinic. Debbie Perrault 2.2 6/8/2012 Y

Laboratory Services (Section 2.17)


43

Laboratory Services (Section 2.17)


17.19 Meet with MIO and an Epic representative to enhance Epic documentation to “hardwire” autopsy documentation requirements. Debbie Perrault 2.2 4/27/2012 Y

17.20 Add autopsy documentation requirements to dictation template, including pathology checklist. Debbie Perrault 2.2 6/8/2012 Y

17.21 Educate morgue staff on required two identifier process and their empowerment to stop the autopsy without proper consent. Emilie Allen 4.4 4/6/2012 Y

17.22 Perform audit of autopsy records for evidence of family communication, pathology notification by nursing, consent, and any other required elements. Debbie Perrault 2.2 6/8/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Compliance to accession and grossing the specimen by audit 1 Lab 100% 100% N/A N/A 100% N/A N/A

2 Compliance to the use of the two patient identifiers with transcription post specimen processing by audit 1 Lab 100% 100% N/A N/A 100% N/A N/A

3 Compliance to autopsies having formal orders 1 Lab 100% 50% 100% 100% 100% 100% 100%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-134 Percent compliance to 60 minute critical value turnaround time 1 Lab 98.0% 99.0% 98.0% 99.0% 98.0% 99.0% 98.0%5 Number of patient safety events relating to non-compliance in critical value reporting 2 Lab 6 1 5 5 0 0



Comments


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18.01 Change procedure to ensure all unused trays are collected after meals. Usha Kollipara 2.2 5/30/2012 Y

18.02 Educate nursing staff to communicate with F&NS to re-order or hold a tray if a patient is not available for a meal.Kim McCloudLinda Licata


18.03 Acquire thermometers for freezers. Usha Kollipara 2.2 4/4/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Compliance with all nutrition services equipment and food temperatures 1 FNS 100% 100% 100% 100% 100% 100% 100%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-132 Percentage of units surveyed which do not reheat food trays FNS 95% 95% 96% 90%



Food & Nutrition Services (Section 2.18)

Comments


45



19.01 Develop a process to ensure Organ Procurement quality improvement functions are reported to QCC regularly. Jackie Sullivan 6.4 9/14/2012 Y

19.02 Develop documentation for annual training program attendance. Emilie Allen 4.4 9/14/2012 Y


Organ and Tissue (Section 2.19)

Comments


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20.01 Conduct an assessment of the factors contributing to the backlog to include: demand vs. capacity, current space and labor productivity. Jenni Burnes 2.2 4/20/2012 Y

20.02 Upon completing elements of the assessment, develop an overall “current state” process work flow diagram noting process failures and operational barriers. Jenni Burnes 2.2 5/4/2012 Y

20.03 Analyze current staffing patterns and address shortages. Jenni Burnes 2.2 5/4/2012 Y20.04 Redesign future process flows to address identified barriers. Jenni Burnes 2.2 6/29/2012 Y20.05 Complete pilot of revised process flow to assess effectiveness and any additional needed changes. Jenni Burnes 2.2 6/29/2012 Y

20.06 Develop targeted improvement levels: for backlog, patient and physician communication, productivity, etc. to assess impact of changes. A consistent tool to assess effectiveness is needed to ensure consistency in assessing progress. Jenni Burnes 2.2 6/29/2012 Y

20.07 Identify core requirements for assessment and documentation for proper patient care and educate staff. (Nursing) Barbara Mims 4.2 8/1/2012 Y

20.07 Identify core requirements for assessment and documentation for proper patient care and educate staff. (PMR) Jenni Burnes 2.2 8/1/2012 Y

20.08 Develop a methodology to ensure all elements of care have been addressed and assessed. Jenni Burnes 2.2 6/8/2012 Y

20.09 Establish key metrics for inpatient rehab. Barbara MimsValerie Harvey 4.2 5/25/2012 Y

20.10 Develop methodology to track required metrics are being reported. Jenni Burnes 2.2 9/14/2012 Y20.11 Determine legal requirements for DME license. Jody Springer 1.2 4/13/2012 Y20.12 Determine methodology dispensing DME (hospital vs. contract supplier). Jenni Burnes 1.2 4/20/2012 Y

20.13 Develop and implement Infection Prevention training. Kim McCloudLinda Licata


20.14 Non–compliance with proper infection control procedures should be addressed immediately and ongoing non-compliance should result in progressive disciplinary action. Jenni Burnes 2.2 6/8/2012 Y

20.15 Develop methodology to track wound care infection rates. Jenni Burnes 2.2 5/4/2012 Y

Physical Medicine and Rehabilitation (PMR) (Section 2.20)


47


# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Percent of all elements of care that have been assessed and addressed 1 PMR 96.2% 93.0% 92.0% 96.0% 96.0% 92.0%2 Compliance to Environment of Care 1 PMR 100% 98.2% 98.0% 99.7% 99.4% 97.7% 99.7%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13Occupational Therapy (OT)

3 No show rate - OT 1 PMR 15.2% 10.0% 16.9% 13.9% 16.1% 19.3% 21.3% 17.7%4 Total Orders (OT) 1 PMR 413 348 484 371 373 391 3985 Total Backlog (OT) 1 PMR 52 916 Backlogged Referrals that are Pending Patient Follow-Up (OT) 1 PMR 35 257 Backlogged Orders that are Pending Authorizations from Financial Counseling (OT) 1 PMR 15 548 Backlogged that are Pending Triage (OT) 1 PMR 2 159 Cancelled Orders (> 60 days or 2 follow-up calls with out a call back from patient) (OT) 1 PMR 32 11

10 Vacancy rate - OT 1 PMR 21.0% 21.0% 14.0% 14.0% 7.0% 7.0%11 Labor productivity (percentage of targeted appointments per FTE) - OT 1 PMR 87.5% 100.0% 73.8% 101.8% 90.3% 95.1% 87.1% 85.9%

Physical Therapy (PT)12 No show rate - PT 1 PMR 15.6% 10.0% 15.4% 17.0% 16.7% 22.9% 24.9% 23.2%13 Total Orders (PT) 1 PMR 1214 1212 1316 1123 1026 1342 122914 Total Backlog (PT) 1 PMR 171 25015 Backlogged Referrals that are Pending Patient Follow-Up (PT) 1 PMR 132 5916 Backlogged Orders that are Pending Authorizations from Financial Counseling (PT) 1 PMR 38 15417 Backlogged that are Pending Triage (PT) 1 PMR 1 7818 Cancelled Orders (> 60 days or 2 follow-up calls with out a call back from patient) (PT) 1 PMR 93 019 Vacancy rate - PT 1 PMR 4.3% 15.0% 12.0% 8.0% 4.0% 4.0%20 Labor productivity (percentage of targeted appointments per FTE) - PT 1 PMR 61.1% 100.0% 68.4% 81.9% 80.7% 72.2% 67.0% 72.2%

Speech Therapy (ST)21 No show rate - ST 1 PMR 13.8% 10.0% 14.9% 13.8% 10.7% 18.2% 25.2% 11.5%22 Total Orders (ST) 1 PMR 98 90 88 80 77 79 7123 Total Backlog (ST) 1 20 2424 Backlogged Referrals that are Pending Patient Follow-Up (ST) 1 13 1025 Backlogged Orders that are Pending Authorizations from Financial Counseling (ST) 1 5 1026 Backlogged that are Pending Triage (ST) 1 1 027 Cancelled Orders (> 60 days or 2 follow-up calls with out a call back from patient) (ST) 1 9 428 Vacancy Rate - ST 1 PMR 2.0% 0.0% 0.0% 0.0% 0.0% 0.0%29 Labor productivity (percentage of targeted appointments per FTE) - ST 1 PMR 71.9% 100.0% 81.5% 98.5% 86.2% 78.5% 73.1% 73.1%


48




Comments


49



21.01 Analyze staffing levels and provided recommendations. Edward Best 2.2 4/13/2012 Y21.02 Adjust staffing and/or shifts to agreed upon staffing grid. Edward Best 2.2 5/11/2012 Y21.03 Develop targeted improvement in missed treatments and a timeline for expected improvements. Edward Best 2.2 3/22/2013 Y21.04 Explore the ability to analyze missed treatments per shift through Epic. Edward Best 2.2 4/13/2012 Y

21.05 Determine a mechanism to track “assigned, completed, and missed” by therapist through a daily shift report document. Edward Best 2.2 6/8/2012 Y

21.06 Documentation educational program for all Respiratory Therapy (RT) staff. Edward Best 2.2 6/8/2012 Y21.07 Initiate documentation review process to ensure patient quality of care. Edward Best 2.2 9/14/2012 Y21.08 Initiate patient rounds to obtain feedback regarding effectiveness of respiratory treatments. Edward Best 2.2 9/14/2012 Y

21.09 Review the current oxygen tank use, storage, and refilling procedure for gaps in guidance to both RT staff as well as other clinicians.

Kim McCloudLinda Licata 2.7 4/6/2012 Y

21.10 Meet with clinical leaders who store oxygen tanks and determine responsibilities of staff in which oxygen tanks are stored.



21.11 Develop a house-wide education/awareness for all staff that addresses all areas of responsibility.Kim McCloudLinda Licata


21.12 Audits of oxygen tank safety.Kim McCloudLinda Licata


21.13 Long term strategy for an annual assessment of therapy care to ensure that there are no gaps in process or care. Edward Best 2.2 9/14/2012 Y

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Percentage of missed treatments related to Therapist not being available 1 RT 0% 2.4% 1.1% 0.2% 0.5% 2.8% 0.4%2 Number of missed treatments (RT self-reporting) 1 RT 699 744 662 810 902 8393 Respiratory Care documentation accuracy 1 RT 95.0% 95.5% 97.0% 97.0% 98.0% 98.1% 97.6%4 Compliance in oxygen tank storage 1 House-wide 100% 99.9% 99.0% 99.7% 100.0% 100.0% 99.6%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-135 Productivity Metrics (Weighted Procedures/Hours Paid) 1 RT 2.74 2.65 2.88 2.80 2.90 2.64 2.52 2.586 Ventilator Associated Pneumonia Rate 1 RT 3.29% 1.8% 0.5% 1.0% 0.0% 1.0% 0.9% 0.5%



Respiratory Therapy (Section 2.21)

Comments


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22.01 Develop medication documentation training program for all staff responsible for medication administration. Judy HerringtonVicki Crane 4.5 6/8/2012 Y

22.02 Develop and implement processes to reconcile controlled substances in Medlock clinic. Vivian Johnson 2.3 3/23/2012 Y

22.03 Develop and implement audit tool to track controlled substance reconciliation. Judy HerringtonVicki Crane 4.5 5/11/2012 Y

22.04 Implement electronic medical record (EMR)/Pharmacy interface to allow for Pharmacy to provide oversight to prescribing and administration at correctional facilities visited by the mobile clinic. Vivian Johnson 2.3 6/20/2012 Y

22.05 Review results of Medicine specialty clinic pilot and determine viability of implementation to other clinics for medication reconciliation solution.


22.06 Formulate alternative solution to medication reconciliation issue. Judy HerringtonVicki Crane 4.5 5/11/2012 Y

22.07 Empower and educate staff on basic standards related to environment of care and the normal chain of command for addressing issues as they arise. Also include a process on issue escalation when issues are not addressed.


22.08 Create comprehensive environment of care gaps. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

22.09 Meet with the appropriate leaders responsible for environmental cleaning and maintaining the environment to discuss the gaps and develop plan for improvement.

Kim McCloudLinda Licata 2.7 5/11/2012 Y

22.10 Establish multi-disciplinary monitoring of clinic locations. Kim McCloudLinda Licata


22.11 Load plans of care into Jail electronic medical record (EMR). Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

Community Oriented Primary Care (COPC) (Section 2.22)


51

Community Oriented Primary Care (COPC) (Section 2.22)



22.12 Conduct training for staff on plan of care standards and proper documentation and individualized plan of care. Barbara MimsValerie Harvey 4.2 8/1/2012 Y

22.13 Conduct a chart audit to evaluate staff compliance regarding plan of care process. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

22.14 Develop a process for patients who do not have a common diagnosis and their plan of care. Barbara MimsValerie Harvey 4.2 7/20/2012 Y


1Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation 1

COPC 100.0% 100.0% 99.0% 100.0% 99.7% 100.0%

2 Compliance percentage of environment of care by audit, monthly 1 COPC 97.0% 97.5% 97.4% 98.6% 97.5% 98.3%3 Compliance to the use of two patient identifiers 1 COPC 100.0% 99.4% 100.0% 100.0% 100.0% 99.8%4 Compliance to infection prevention practice 1 COPC 100% 91.9% 97.4% 93.5% 93.7% 92.4% 92.0%5 Compliance in medication reconciliation 1 COPC 96.0% 97.0% 98.0% 95.0% 94.0% 98.0%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-136 Number of medication related safety events 1 COPC 0 4 1 2 3 3 07 Number of lab specimen mis-labeling by clinic 2 COPC 2 1 4 1 4 08 Third next available appointment 1 COPC 97.2 78.0 81.1 75.6 74.2 79.3 84.49 No show rate 1 COPC 17.2% 17.7% 17.7% 17.5% 18.1% 17.5% 17.9%



Comments


52



23.01 Ensure “hard-stop” process in Epic is engaged. Vivian Johnson 2.3 9/14/2012 Y

23.02 Determine EVS scope and schedule. Jessica HernandezHolt Oliver, MD 3.6 3/30/2012 Y

23.03 Clinic leadership to round clinic areas to monitor PHI security. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

23.04 Clinic leadership to develop and implement disciplinary actions for staff violations of HIPAA policies. Jessica HernandezHolt Oliver, MD 3.6 5/7/2012 Y

23.05 Develop clinic-wide training and awareness program for proper time-out procedure. Suzanne Sims 2.5 10/31/2012 Y23.06 Conduct time-out training for all areas where patient procedures are performed. Suzanne Sims 2.5 10/31/2012 Y


1 Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation OPC 100.0% 99.0% 100.0% 97.0% 99.4% 99.6%

2 Compliance percentage of environment of care by audit, monthly 1 OPC 98.6% 98.0% 99.0% 99.0% 98.9% 99.8%3 Compliance to the use of two patient identifiers OPC 99.5% 98.5% 100.0% 100.0% 100.0% 99.5%4 Medication Reconciliation compliance OPC 99.0% 96.0% 96.0%

Specialty Clinics (Section 2.23)


53


# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-135 Number of medication related safety events 1 0 0 0 0 0 0 06 Number of lab specimen mis-labeling by clinic 2 0 2 1 1 1 2 37 Compliance to HIPAA/privacy standards (based on EOC audit) 100.0% 97.3% 96.8% 100.0% 96.0% 99.0% 100.0%

General Surgery8 No Show Rate 1 OPC 25% 30% 24% 30% 34%9 Third next available appointment 1 OPC 14 128 150 120 91 13810 Average dwell time (minutes) 1 OPC 90 151 116 197 132 130

Urology 11 No Show Rate 1 OPC 25% 22% 24% 24% 22%12 Third next available appointment 1 OPC 14 115 63 56 39 6413 Average dwell time (minutes) 1 OPC 90 143 164 156 164 164

Surgery Oncology14 No Show Rate 1 OPC 24% 22% 24% 26% 23%15 Third next available appointment 1 OPC 14 94 89 73 87 7316 Average dwell time (minutes) 1 OPC 120 148 157 170 165 208

Cardiology17 No Show Rate 1 OPC 26% 24% 27% 26% 22%18 Third next available appointment 1 OPC 14 65 60 49 56 7219 Average dwell time (minutes) 1 OPC 120 118 123 114 116 124

GI/Liver20 No Show Rate 1 OPC 25% 21% 30% 25% 25%21 Third next available appointment 1 OPC 14 145 117 121 119 11322 Average dwell time (minutes) 1 OPC 120 155 148 148 150 145

Renal23 No Show Rate 1 OPC 23% 27% 26% 31% 26%24 Third next available appointment 1 OPC 14 67 61 51 40 3725 Average dwell time (minutes) 1 OPC 120 128 130 116 123 132


54




Comments


55


24.01 Create database of all contracted patient service arrangements.

Muthusamy Anandkumar, MD

Ciel Murphy 6.5 3/22/2013 Y

24.02 Review department specific quality indicators for all contracts.



24.03 Request quality monitors from vendors who have not supplied them.



24.04 Determine Parkland specific quality indicators for each contract.



24.05 Each department to report contract monitoring elements at the department’s next regularly scheduled reporting appointment.



24.06 Review all contracts using department specific indicator list. Each department to have a specific list of all contracts, appropriate indicators, and existence of indicators.



24.07 Contract Management Unit to provide a schedule of all contracted services affecting patient care to the BOM Quality Committee along with a template on how contracts will be scored for quality.



24.08 Contract Management Unit to provide first batch of contracts for quality score and review – and proposed scores against template – to BOM Quality Committee.



Contract Services (Section 2.24)


56

Contract Services (Section 2.24)

# Audit/Measures Accountability Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131 Percent of current contracts in database 1 Contracts 100%2 Percent of current contracts that have department specific quality indicators 1 Contracts 89% 100% 90% 89% 91% 90%

# Metric Accountability Baseline Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-133 Number of "significant" contracts meeting requirements for quality scoring 1 Contracts 59% 78% 48% 66%4 Number of "by exception" contracts meeting requirements for quality scoring 1 Contracts 88% 81% 93% 98%



Comments


57


Q.01

Revise QAPI plan · Include CMS elements · Prioritize efforts and resources · Customize indicators to reflect specific patient populations in each department · Define methodology to capture and analyze data · Define formal process for reporting to Quality of Care Committee (QCC) and the BOM Quality Committee. · Identify a regular reporting schedule for each department

Jackie Sullivan 6.1 5/25/2012 Y

Q.02 Approval of QAPI plan by the QCC and BOM Quality Committee. Jackie Sullivan 6.1 5/25/2012 YQ.03 Capture and analyze baseline data from initial tracers for survey readiness. Jackie Sullivan 6.1 6/15/2012 YQ.04 Develop and implement corrective action plan for survey readiness Jackie Sullivan 6.1 6/30/2012 Y

Q.05 Performance Improvement group should implement rounding as a method to collect data for adverse patient events Jackie Sullivan 6.1 6/30/2012 Y

Q.06 Performance Improvement group to develop a list of resources from which to pull adverse patient events Jackie Sullivan 6.1 9/30/2012 Y

Q.07 Develop methodology to trend, analyze and report adverse patient events Jackie Sullivan 6.1 11/31/2012 YQ.08 Work with A&M to improve RCA process Jackie Sullivan 6.1 9/30/2012 Y

Q.09 Develop a master report of all RCAs conducted. Include incident date, date of RCA commencement, date of RCA conclusion, general results and actions taken. Jackie Sullivan 6.1 6/30/2012 Y

Q.10 Review standing reports generated by CIS and meet with end users/management to determine relevance and meaningfulness. Discontinue generation of reporting that does not add value to end user/management. Jackie Sullivan 6.1 5/25/2012 Y

Q.11 Establish a schedule for CIS with due dates of all necessary reporting Jackie Sullivan 6.1 5/25/2012 YQ.12 Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review Jackie Sullivan 6.1 5/18/2012 YQ.13 Create survey and initial tracers to collect baseline data in the form of a Quality Assessment (QA). Jackie Sullivan 6.1 6/30/2012 YQ.14 Complete Quality Assessment survey and tracer work. Jackie Sullivan 6.1 6/30/2012 Y

Q.15 Complete department-specific Performance Improvement (PI) plan with indicators appropriate for department’s patient population. Jackie Sullivan 6.4 5/25/2012 Y

Q.16 Implement corrective actions per department’s PI plan. Jackie Sullivan 6.1 9/30/2012 Y

Q.17 Report PI plan status on at least semi-annual basis to QCC. Jackie Sullivan 6.1 5/25/2012 Y


QAPI

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february compliance report on parkland memorial hospital

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