May 11, 2017

NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Quality Council Committee meeting at 7:00AM on Wednesday, May 17, 2017, in the Kaweah Delta Health Care District Blue Room {Basement of Mineral King Wing}.

The Board of Directors of the Kaweah Delta Health Care District will meet in a Closed Quality Council Committee meeting immediately following the 7:00AM open Quality Council Committee meeting on Wednesday, May 17, 2017, in the Kaweah Delta Health Care District Blue Room {Basement of Mineral King Wing} pursuant to Health and Safety Code 32155 & 1461.

All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room.

The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center – Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page http://www.kaweahdelta.org. KAWEAH DELTA HEALTH CARE DISTRICT Lynn Havard Mirviss, Secretary/Treasurer

Cindy Moccio Board Clerk, Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff http://www.kaweahdelta.org/ 400 West Mineral King Avenue · Visalia, CA · (559) 624 2000 · www.kaweahdelta.org

KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS

QUALITY COUNCIL Wednesday, May 17, 2017

Kaweah Delta Medical Center – Mineral King Wing 400 W. Mineral King Avenue, Visalia, CA Blue Room

ATTENDING: Herb Hawkins – Committee Chair, Board Member; Nevin House, Board Member; Tom Rayner, Interim CEO / SVP & COO; Regina Sawyer, RN, VP & CNO; Edward Hirsch, MD, CMO/CQO; Douglas Leeper, VP & CIO; Dan Boken, MD, Chief of Staff; Harry Lively, MD, Professional Staff Quality Committee Chair; Byron Mendenhall, MD, Secretary/Treasurer; William Roach, MD, Past Chief of Staff; Lori Winston, MD, DIO; Tom Gray, MD, Quality and Patient Safety Medical Director; Sandy Volchko, Director of Quality and Patient Safety; Venus Buckner, Director of Risk Management; Ben Cripps, Compliance Officer, Rose Newsom, Director of Nursing Practice; and Heather Goyer, Recording.

OPEN MEETING – 7:00AM

Call to order – Herb Hawkins, Committee Chair & Board Member

Public / Medical Staff participation – Members of the public wishing to address the Committee concerning items not on the agenda and within the subject matter jurisdiction of the Committee may step forward and are requested to identify themselves at this time. Members of the public or the medical staff may comment on agenda items after the item has been discussed by the Committee but before a Committee recommendation is decided. In either case, each speaker will be allowed five minutes.

1. National Surgical Quality Improvement Program (NSQIP) - A review of key quality indicators in the surgical population. Joseph P. Manuele, MD, General Surgery; Cindy Conley, RN, Surgical Quality Coordinator

2. Home Health Quality Report- Review of quality indicators relating to the care of home health patients. Jag Batth, DPT, Director of Orthopedic Service Line.

3. Approval of Quality Council Closed Meeting Agenda – Kaweah Delta Medical Center Blue Conference Room – immediately following the open Quality Council meeting

Wednesday, May 17, 2017 – Quality Council Page 1 of 2 Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ Carl Anderson – Zone IV ⃰⃰ Nevin House– Zone V Board Member Secretary/Treasurer Board Member President Board Member

o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) – Harry Lively, MD, and Professional Staff Quality Committee Chair; James McNulty, Director of Pharmacy

o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) –Venus Buckner, Director of Risk Management.

Adjourn Open Meeting – Herb Hawkins, Committee Chair & Board Member

CLOSED MEETING – Immediately following the 7:00AM open meeting

Call to order – Herb Hawkins, Committee Chair & Board Member

1. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) – Harry Lively, MD, and Professional Staff Quality Committee Chair; James McNulty, Director of Pharmacy

2. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) –Venus Buckner, Director of Risk Management.

Adjourn Open Meeting – Herb Hawkins, Committee Chair & Board Member

In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) 624-2330. Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors committee meeting.

Wednesday, May 17, 2017 – Quality Council Page 2 of 2 Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ Carl Anderson – Zone IV ⃰⃰ Nevin House– Zone V Board Member Secretary/Treasurer Board Member President Board Member

ACS NSQIP REPORT (American College of Surgeons

National Surgical Quality Improvement Program)

JANUARY 2017 SAR (SEMI-ANNUAL REPORT)

Dr. Manuele – Surgeon Champion Cindy Conley BSN RN SCR – Surgical Quality Coordinator

Kassie Waters BSN MPA CPHQ-Quality Improvement Manager Crystal Clark – Data Analyst

What is ACS NSQIP? • Web-Based data collection software • Quality Improvement Tool

• Risk-Adjusted, outcomes based data

• Clinically Validated data

• Benchmarking

Data Collection

• Demographics

• Surgical Profile

• Pre-Operative Data (Risk Factors)

• Intra-Operative Data

• Post-Operative Data (Outcomes)

RISK ADJUSTMENT:

OBSERVED vs EXPECTED O/E RATIOS • O/E Ratio=Par on a golf course-the score that is expected • An O/E ratio is a mathematical construct accurately

showing the risk-adjusted outcome for a specific site • “O” = the total number of observed postoperative events

(deaths or complications) • “E” = the number of expected events based on the

preoperative risk and other factors in a given patient population

• An O/E Ratio <1 = the site is performing better than expected

• An O/E Ratio >1 = the site is performing worse than expected.

• O/E Ratios show that risk adjustment has a profound effect in determining the true performance of a Medical Center

CY 2014-2015 Comparison O/E Ratio

Expected Ratio

Calendar Year 2014-2015 6 Month January-July 2016 Pneumonia Unplanned Intubation Ventilator>48 Hours Renal Failure UTI SSI Sepsis ROR CY 2014 1.71 1.04 1.92 3.57 1.64 1.11 1.54 1.37 CY 2015 0.76 0.89 1.19 0.78 0.54 0.86 0.6 0.89 6 Mo.2016 1.28 0.76 1.32 1.03 0.61 0.89 0.89 0.86

0

0.5

1

1.5

2

2.5

3

3.5

4

Pneumonia UnplannedIntubation

Ventilator>48Hours

Renal Failure UTI SSI Sepsis ROR

ACS NSQIP Comparison Data O/E Ratio All Cases

CY 2014

CY 2015

6 Mo.2016

ExpectedRatio

Site Summary July 2015 (CY 2014) Model Observed Rate Expected Rate Odds Ratio Decile Comment Mortality 0.013513514 0.009131952 1.327712385 10 Needs ImprovementMorbidity 0.084152334 0.053250366 1.667327835 10 Needs ImprovementCardiac 0.007985258 0.005478508 1.272629228 9 As expected Pneumonia 0.013597033 0.007418372 1.711882432 9 Needs Improvement Unplanned Intubation 0.006756757 0.006243426 1.041815707 7 As expectedVentilator > 48 Hours 0.014136447 0.006956203 1.916029415 10 Needs Improvement VTE 0.003071253 0.006425899 0.713827678 1 Exemplary Renal Failure 0.017901235 0.004019692 3.570471297 10 Needs ImprovementUTI 0.017402113 0.009785777 1.635042236 9 Needs ImprovementSSI 0.020961776 0.018613906 1.110238825 7 As expected Sepsis 0.011838006 0.00689993 1.539079946 9 Needs Improvement ROR 0.027641278 0.018641275 1.370919537 10 Needs ImprovementReadmission 0.055282555 0.046688649 1.151161173 9 As expected

SITE SUMMARY JULY 2016 (CY 2015)

Site Summary January 2017 6 Month

Model Observed Rate Expected Rate Odds Ratio Decile CommentMortality 0.88% 0.83% 1.04 6 As expectedMorbidity 4.66% 4.55% 1.02 6 As expectedCardiac 0.57% 0.52% 1.06 7 As expectedPneumonia 0.94% 0.69% 1.28 8 As expectedUnplanned Intubation 0.25% 0.76 0.46 1 ExemplaryVentilator > 48 Hours 0.69 0.48 1.32 8 As expectedVTE 0.31 0.58 0.77 2 As expectedRenal Failure 0.38 0.35 1.03 6 As expectedUTI 0.44 0.94 0.61 1 ExemplarySSI 1.33 1.54 0.89 4 As expectedSepsis 0.45 0.55 0.89 4 As expectedROR 1.32 1.68 0.86 3 As expectedReadmission 3.71 4.37 0.89 2 As expected

SITE SUMMARY JANUARY 2017

PROJECTS

Patient Care Team

1. SURGERY • Surgeons • Surgical Residents • Advanced Practice Providers • Office Staff

1. ANESTHESIA • Anesthesiologists • CRNA’s • Pain Service • Pre-Anesthesia Testing

2. COORDINATOR • Social Work • PT • IT • Pharmacist • Nutritionist

3. NURSING • Outpatient Clinic (KATS) • Peri-operative Nurses • Surgical Nurses • Inpatient Nurses • Nursing Assistants • Wound Care Nurses • Educators

Enhanced Recovery After Surgery ALGORITHM

Pre-op Assessment Day before Surgery Admission

Surgery

PACU Surgical Floor Post-op Day1 Post op Day 2

PATIENT/FAMILY EDUCATION on ERAS plan; postoperative pain management, nutrition, early ambulation, ostomy (if applicable) Referral to clinics if applicable

Pre Surgery call: NPO status, CHG bathing, Mechanical Bowel Prep

Education: Review ERAS plan with patient; Pain management, Administration of alvimopan if appropriate. VTE protocol, Glycemic protocol if applicable

Goal directed Fluid Therapy, Multimodal Pain Management (Blocks), Normothermia, Glycemic Control, Minimally invasive, Limit opioids, Avoid abdominal drains, Remove NG Tube befor e patient leaves the operating room.

Goal directed Fluid Therapy, Pain management plan, avoid narcotics, epidural analgesia if applicable, Normothermia, Glycemic control if applicable

Pain Management: Pain assessment, Review Management plan with patient & family member. Mobilization: Review Mobilization plan with patient & family member. Patient out of bed POD 0 if applicable. Meals in chair. Early ambulation. Normothermia, Glycemic control if applicable Nutrition/GI Recovery: Review plan with patient/family. Postoperative Clear liquids= No carbonation, no straws.

Pain Management: Oral acetaminophen, IV Toradol, Limit Epidural and/or IV Opioids Mobilization: Time out of bed: Goal is 180 minutes, Up in chair for all meals Remove Urinary Catheter within 24 hours after surgery Nutrition: Post-op Clear Liquids (Goal approximately 1500 ml) with appropriate protein supplement drinks. Saline lock IV: Avoid IV fluids DISCHARGE PLANNING

Pain Management: Stop Epidural and/or IV Opioids (Do not remove epidural catheter until ordered) Oral Acetaminophen, IV Toradol, Oral narcotics as ordered by physician. Mobilization: Time out of bed-Goal > 240 minutes. Up in chair for all meals Postoperative Solid Diet DISCHARGE PLANNING

Enhanced Recovery After Surgery

Post-op Day 3 Discharge 30-day Follow-up

Pain Management: Oral Pain Medication Mobilization: Time out of bed- >360 minutes , Up in chair for all meals Nutrition: Post-op Solid diet

Discharge when patient meets criteria for pain management, ambulation, flatus/BM, and diet.

Phone call for feedback from the patient about the ERAS program

Jag Batth, Sheryl Engstrom, Tiffany Bullock, and Kevin Bartel

Home Health Quality Report Star Rating

Home Health Quality Report

• Quality • Patient Experience

2 Separate Star Ratings in Home Health

• 7 year pilot project (2022) in 9 states • Payment increase or decrease by 8%

Began in July 2015 – Base year

Kaweah Delta Home Health Star Rating

Home Health Compare – April 2017 – Jan 2017 – October 2016 – July 2016

National Star Rating Distribution

Home Health Compare

Home Health Quality Report

Star rating contains 9 Quality Measures (24 total)

• 3 Process of Care Measures – How often an agency • 6 Outcome of Care Measures – How often the patient

9 Quality Measures grouped into

• OASIS (Outcome and Assessment Information Set) • Medicare Claims Data

Information is collected from

Home Health Star Rating

Outcome Measures Measure Improvement in Ambulation

Measure Improvement in Bed Transferring

Measure Improvement in Bathing

Measure Improvement in Pain Interfering with Activity

Measure Improvement in Shortness of Breath

Required Acute Care Hospitalization

Hospital Health Quality Report

Process Measures Timely Initiation of Care

Measure Drug Education on all Medications

Measure Received Flu Vaccine for Current Season

Quality of Patient Care Star Rating Home Health Process of Care Measures

Timely Initiation of Care Below National Average

Home Health (HH)-Kaweah 92.5 National 94.4

Resources Needed: Staffing

Barriers/Difficulties: Within 48 hours of referral or

Resumption of Care (ROC).

Referral date clarification.

Updating and/or revising referrals.

Actions Taken/To Be Taken: OASIS education provided at staff

meeting in February 2017.

Chart audits to determine if correct referral, Start of Care (SOC)/ROC

dates are being used.

Charts returned to clinician to be corrected prior to OASIS submission.

Drug Education on all Medications Below National Average

HH-Kaweah 83.3 National 98.2

Barriers/Difficulties: Comprehension of the OASIS

question by clinicians. OASIS question auto-

populating in new charting system.

Therapy’s perception of their role in drug education.

Actions Taken/To Be Taken: Medication Task Force.

OASIS training course attended by Home Health Leaders in December

2016. OASIS education provided at staff

meeting in February 2017 regarding drug education OASIS question.

Reinforced the roles of nurses and therapists in medication at February &

April 2017 staff meeting. Defined different examples of what can be considered drug education at

February 2017 staff meeting. Continue to monitor current scores

through Home Health Gold.

Received Flu Vaccine for Current Season

Below National Average HH-Kaweah 59.3

National 73.7

Barriers/Difficulties: OASIS question auto-populating in

new charting system.

Actions Taken/To Be Taken: Education to staff at nursing and

therapy meetings in February 2017 regarding this OASIS

question and the auto populating with a No answer during the time

frame of October 1 through March 31.

Barriers/Difficulties: Chronic conditions that have

worsened. Patient status that has not or will

not change. Patient goes from walking

independently to using a cane, walker, or wheelchair.

Nursing assessment vs. Therapy assessment.

Actions Taken/To Be Taken:

Emphasis on SOC audits to identify low functional scores for possible

correction after therapy evaluation.

Reinforced different examples for how to properly grade patients on

ambulation at April 2017 staff meeting.

Quality of Patient Care Star Rating Home Health Process of Care Measures

Improvement in Bed Transferring

Above National Average HH-Kaweah 71.7

National 64.5

Improvement in Bathing Above National Average

HH-Kaweah 74.8 National 71.6

Improvement in Ambulation Below National Average

HH-Kaweah 65.2 National 68.37

Quality of Patient Care Star Rating Home Health Process of Care Measures

Improvement in Pain Interfering with Activity

Below National Average HH-Kaweah 59.9

National 71.5

Resources Needed: Training/education of

the intent of OASIS questions relating to

pain.

Barriers/Difficulties: Comprehension of the OASIS

question by clinicians. Pain is subjective; it is what the

patient says it is: Example: On SOC/ROC pain can be

rated at 2, but on discharge pain can be rated at 3, which results in no

improvement in pain.

Actions Taken/To Be Taken: Provide OASIS training at future

staff meeting specific to this OASIS question.

Reinforce pain management strategies such as:

Adequate pain medication prescribed and compliance with

taking. Keeping MD informed of any new or

increased pain.

Improvement in Shortness of Breath Above National Average

HH-Kaweah 78.8 National 70.2

Acute Care Hospitalization Same as National Average

HH-Kaweah 16.4 National 16.1

Barriers/Difficulties: Palliative care patients.

Severity of health status (cancer, pain, etc.)

Discharged from acute setting too early.

Medications (does not have in the home, non-compliance, etc.)

Actions Taken/To Be Taken: Front loading of nursing visits during the

first few weeks of home care. Medication reconciliation throughout

episode of care. Importance of making sure that follow

up tests and MD appointments are made.

Identifying which patients are at high risk of re-hospitalization.

A recent audit in Home Hold Gold showed improvement: 12% down from

16.4%, with the national average at 16.1%.

Questions