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SONOMA VALLEY HEALTH CARE DISTRICT

QUALITY COMMITTEE

REGULAR MEETING AGENDA

Wednesday, July 25, 2012

5:00 p.m. Call to Order

5:01 p.m. (Closed Session)

5:20 p.m. (Open Session)

Location: Schantz Conference Room

Sonoma Valley Hospital – 347 Andrieux Street, Sonoma CA 95476

AGENDA ITEM RECOMMENDATION

MISSION STATEMENT The mission of the SVHCD is to maintain, improve, and restore the health

of everyone in our community.

1. CALL TO ORDER Nevins

2. PUBLIC COMMENT SECTION ON CLOSED SESSION Nevins

3. CLOSED SESSION:

A. Calif. Health & Safety Code § 32155 – Medical Staff

Credentialing & Peer Review Report

Smith Inform/Action

4. REPORT OF CLOSED SESSION Nevins Inform

5. PUBLIC COMMENT SECTION

At this time, members of the public may comment on any item not

appearing on the agenda. It is recommended that you keep your

comments to three minutes or less, Under State Law, matters

presented under this item cannot be discussed or acted upon by the

Committee at this time For items appearing on the agenda, the public

will be invited to make comments at the time the item comes up for

Committee consideration. At all times please use the microphone.

Nevins

6. CONSENT CALENDAR:

A. Prior Meeting Minutes – June 27, 2012

B. Tracking Report for Uncorrected Items

Nevins/Lovejoy Inform/Action

7. QUALITY REPORT Lovejoy Inform

8. ANNUAL HUMAN RESOURCES REPORT Davis Inform

9. ANNUAL PERFORMANCE IMPROVEMENT

PROGRAM EVALUATION

Lovejoy Inform

10. POLICIES & PROCEDURES:

A. Chain of Command for Management of Patient Care

Concerns

B. Organization-wide Performance Improvement Plan

C. Department Specific Performance Improvement

D. Quality Monitoring and Reporting

Lovejoy Inform/Action

11. CLOSING COMMENTS Nevins

12. ADJOURN

6.A.

MINUTES

6.27.12

1


QUALITY COMMITTEE

REGULAR MEETING MINUTES

Wednesday, June 27, 2012

Schantz Conference Room

Committee Members Present Committee Members Absent Administrative Staff Present

Kevin Carruth, Chair

Dr. Jerome Smith

Dr. Paul Amara

Dr. Robert Cohen

Leslie Lovejoy

Joel Hoffman

Sharon Nevins

Bob Burkhart

Mark Kobe, Director of Nursing

AGENDA ITEM DISCUSSION CONCLUSIONS/ACTION FOLLOW-UP/

RESPONSIBLE PARTY

MISSION AND VISION

STATEMENTS

The mission of the SVHCD is to maintain, improve,

and restore the health of everyone in our community.

The vision of the SVHCD is that:

SVH will be a nationally recognized, compassionate

place of healing and known for excellence in clinical

quality. We serve as the guide and indispensable link

for our community’s health care journey.

1. CALL TO ORDER 5:03 p.m.

2. PUBLIC COMMENT SECTION

ON CLOSED SESSION

There was no public comment.

4. REPORT OF CLOSED SESSION MOTION: by Carruth; second by

Hoffman to forward the Credentialing

Report to the Board and carried. All in

favor; none opposed.

5. PUBLIC COMMENT

At this time, members of the public may

comment on any item not appearing on

the agenda. It is recommended that you

keep your comments to three minutes or

less. Under State Law, matters presented

under this item cannot be discussed or

acted upon by the Committee at this

There was no public comment.

2


RESPONSIBLE PARTY

time. For items appearing on the

agenda, the public will be invited to

make comments at the time the item

comes up for Committee consideration.

At all times please use the microphone.

6. CONSENT CALENDAR

A. Prior Meeting Minutes 5.23.12

B. Tracking Report for

Uncorrected Items

Item B was not discussed. MOTION: by Smith; second by

Hoffman with a minor change on Item

A on the Consent Calendar and carried.

All in favor; none opposed.

7. QUALITY REPORT Leslie Lovejoy

Ms. Lovejoy reported that the EHR implementation

was doing well and staff was adjusting. The

nutritional issues from the state survey had been

cleared. Nutritional Services and Facilities scored

100 out of 100 on their National Patient Safety

Survey, as part of their Sodexo contract. SNF had

done extremely well for their annual state licensing

survey where there were no findings on patient care

issues.

Ms. Lovejoy reported nurse leaders were working to

align as a nursing department across the continuum

from acute to Home Health and SNF. They were also

developing a strategic map of where nursing would be

in the future and identified opportunities for education

and alignment with the Hospital’s strategic plan.

The Hospital was working on a palliative care

program and hoped to partner with Hospice by the

Bay. Dr. Brian Sebastian would be Medical Director

of the program and Geoffrey van den Brande would

be the Nurse Practitioner. Policies and procedures for

the program would be developed beginning in

August.

Lovejoy to discuss Human

Resources annual report

and annual Performance

Improvement Program

Evaluations at next month’s

meeting.

8. ANNUAL REPORT OF

PROCESS FAILURES,

SENTINEL EVENTS, AND

STAFFING ISSUES

Lorna Gantenbein / Chris Kutza

Ms. Gantenbein discussed the risk management

3


RESPONSIBLE PARTY

process, including accident loss, property loss,

income loss, and key personnel loss for the

organization.

Mr. Kutza summarized the risk reduction strategies

for medication management beginning with error

reporting, a regulatory requirement, but more

importantly, a method to identify trends and to be

proactive with risk reduction with relation to

medication reporting of near misses. Error reporting

is graded based on severity with a rating scale of A-I.

(“A” and “B” rating meant it did not reach the patient.

C-I are escalating levels of harm. A “C” rating meant

it reached a patient, but caused no harm. A “D” rating

would require monitoring to ensure the patient was

satisfactory. An “E” rating or higher meant

temporary or permanent harm may have occurred.)

The evaluation categorization process was dictated

by the State (i.e., Medication Error Reduction Plan

(MERP)) through the Health & Safety Code and Title

22 with regard to how the process was regulated and

elements which needed to be categorized on error

reports, including: 1) prescribing, 2) prescription

order communication, 3) product labeling, 4)

packaging, 5) compounding, 6) dispensing, 7)

distribution, 8) administration, 9) education, 10)

monitoring, and 11) use.

Mr. Kutza also explained CPS (Comprehensive

Pharmacy Services), a management company which

helps smaller hospitals such as SVH manages their

pharmacy services. It provides resources such as

specialists in various areas and regulatory experts.

Lastly, he discussed the Electronic Health Record,

which would improve continuity of care with ready

access to patient information, when applicable.

4


RESPONSIBLE PARTY

9. POLICIES AND PROCEDURES:

CHAIN OF COMMAND FOR

MANAGEMENT OF PATIENT

CARE CONCERNS:

Leslie Lovejoy

Ms. Lovejoy explained the “Chain of Command”

policy. The Hospital policy is to help the medical

staff with patient care concerns, as wells as how to

manage and address them.

10. CLOSING COMMENTS Kevin Carruth

There was no closing comment.

11. ADJOURN 6:20 p.m.

6.B.

TRACKING

REPORT

Quality Committee

Outstanding Items Log

Item # & Topic Discussion Follow-up Date Due Date Completed Update/Comments

082511-2 Central Sterile A TJC citing regarding the

potential for cross

contamination of instruments.

Requires physical plant

structural changes in OR.

Monthly report on

progress in Quality

Report until completed.

9/22/12 OSHPD Permitted

7.

QUALITY REPORT

T0: Sonoma Valley Health Care District Board Quality Committee FROM: Leslie Lovejoy, Director, Quality and Resource Management DATE: 7/18/2012 SUBJECT: Quality Report

JULY PRIORITIES:

1) Electronic Health Record 2) Regulatory Compliance 3) Topic for discussion this month and next month 1. Electronic Health Record For the most part all is going well. The ED electronic process is experiencing some opportunities

from both the physician and nursing workflow sides. Mark Kobe, Dr. Hubbell, and Dr. Cohen have created a Task Force to address issues and find resolutions. For the inpatient units the adjustment has been smooth, and we are in the quick tips and how-to’s phase of helping staff more effectively navigate the system. We have also entered the Meaningful Use portion of the implementation process where we need to collect the required data to ensure we meet CMS criteria for implementation and receive some of our investment back. At this point in time, we are meeting all of what is required. I.T. is monitoring this weekly and the plan will be to attest to meeting Meaningful Use at the end of September. The Skilled Nursing Facility is slated to begin the change over and Case Management modules will be built so that their documentation moves to electronic as well.

2. Regulatory Compliance Plans of correction were submitted for the Skilled Nursing recertification survey and the Skilled

Nursing Interim Life Safety Survey. The deficiencies were as follows:

Deficiencies

Did not post the results of last year’s survey in its entirety. Done

Need to keep a log of all bruises, skin tears, falls, accidents, etc. that might indicate abuse or neglect. Done

Labeling of clean equipment. Done

Keeping clean linen carts covered and closed at all times. Done

Labeling of spices and maintaining tight fitting lids on food containers. Done

Drainage pipes for the dishwashers in Dietary. Requires architects and OSHPD will place on log.

Cracked and broken tiles in the shower room. Done

Need to adjust door closing mechanisms and replace three fire detectors. Done

Repair penetrations, escutcheon plates, and clean sprinkler heads. Done

Store oxygen cylinders in a different room and place signage. Done

Remove surge protector from Activity Room. Done

3. Topic for Discussion This month: there will be two topics: the Annual Human Resources Report and the Annual

Performance Improvement Program Evaluation. Next month will report on the Medicare Breakeven Project and reducing waste through utilization and resource management.

8.

ANNUAL

HUMAN RESOURCES

REPORT

SONOMA VALLEY HOSPITAL


Interoffice Correspondence

TO: District Board of Directors DATE: May 17, 2012

FROM: Paula Davis, SUBJECT: 2011 Human

Chief Human Resources Officer Resources Annual Report to the

Board of Directors

In this annual report to the Board of Directors, it is my responsibility to provide a synopsis of the activities that

surround the maintenance of staff competence, the response to their educational needs, the staff compliance to

regulatory standards and the human resource activities during the past year.

At 2011 calendar year end, there were 431 employees at Sonoma Valley Hospital – 209 full time, 95 part time

with benefits and 144 per diem employees or those who do not qualify for benefits. Total Human Resources

employment activity for 2011 included 93 terminations and 89 new hires (31 nursing, 29 clinical and 29 support

staff). An important note here is that there is no personnel litigation pending and the hospital remains non-union.

Turnover statistics at SVH for 2011 match the statewide annual totals of 150 hospitals that participated in a

California Hospital Association sponsored survey last year. All hospital benefited employee turnover statewide

is 9.1% and SVH is 9.0%. Northern California survey results show all hospital benefited employee turnover at

9.3%. These percentages do not include the per diem employees as this statistic escalates these percentages

dramatically; however per diem employees usually always have jobs elsewhere and work to cover sick, vacation

or extra shifts. Their availability changes and many do not comply with the annual mandatory HR requirements

such as TB testing and annual safety training, etc., which results in removal from payroll records.

Performance Evaluations/Assessing Competence

It is required that each employee receive an annual performance evaluation as validation of competency in their

particular role, goal setting and feedback on their performance. In 2011, all employees received a performance

evaluation that linked to their job description. In addition, direct patient care personnel are also evaluated on

their technical skills and knowledge through individual and departmental competency assessment tools. All

performance evaluations are completed during the first three months of the year. 2010 performance evaluations

were completed January, February and March of 2011; 2011 performance evaluations were completed January,

February and March of 2012.

Employee Health

I feel it is important for the Board to know the past year’s events for Employee Health and Workers’

Compensation. All employees and volunteers are required to be screened for TB bacteria. Mandatory

surveillance screening requirements were met for 2011. There was one workers’ compensation claim filed in

2011. The total SVH workers’ compensation costs for 2011 injuries were $31,443 including third party case

management administrator’s fees. Total 2011 workers’ compensation costs for all open claims were $82,034. It

is due to our good fortune and diligent work that I have been able to continually report over the years our

excellent experience in the workers’ compensation area. In 2003 we became self-insured for our costs. With

workers’ compensation insurance annual premiums at the $400,000 to $600,000 range, we would have not been

able to financially sustain commercial coverage. In 2011we did, however, obtain excess workers’ compensation

coverage for claims that might reach over $500,000. We have a very strong return to work program and

modified work program for work-related injuries.

Measurement Monitoring

In 2011 we began to measure more important goals in order to achieve the satisfaction and cultural shift desired

at SVH. As we move into 2012, we will have more data to compare to the scores listed below. It is exciting to

be the champion of the staff-related surveys and to report on our efforts.

Measurement Goal Actual

Staff Satisfaction Response 75% 62.4%

Staff Satisfaction Rate 75% 70.6%

Support Service Satisfaction 80% 81.6

Turnover Rate 12% 9%

Workers’ Compensation Claims 5 or less 1

2011 Human Resource Challenges and Accomplishments

In 2011 we experienced an entirely different style of leadership than previously. We saw a leader who knew and

understood best practices and encouraged us to go and see what best practices were ‘out there’ and bring those to

our hospital. This was something new and different to our organization. We were challenged to create our goals

and create a system where we were held accountable to reach those goals. Each leader created a dashboard

including the pillars of service, quality, people, finance and community. Human Resources appropriately is the

leader for the people pillar resulting in organizing the Press Ganey Staff Satisfaction survey and the Support

Services Staff survey. Effective January 1, 2011 there was an increase for health insurance benefit costs to SVH,

however there was no increased costs passed on to the employees. This was a rare experience as each year for

many years the cost of health insurance was in some fashion passed through to staff. Clearly, the cost of group

health insurance benefits is continuing to increase but I am hopeful that in discussions with Marin General

Hospital and our broker we will be able to mitigate these exorbitant increases and/or improve our benefits

platform with a new product in development, namely Western Health Advantage. Also effective in late

November of 2010 a 3% pay increase was granted. Having come from a previous year of pay cuts and

furloughs, this was indeed a welcome event. In October of 2011, we were able to give the overdue step

adjustments to our Registered Nurses to bring them to their appropriate pay step based on their experience levels.

As an example of accountability, attached you will find the 2011 Leader Board that I maintain and bring to each

of our monthly Leadership meetings. You can see the extended categories and how each leader is monitored for

their completed requirements.

During the year 2011, we achieved many goals and continued to improve our progress into becoming a best

practice hospital. Some of the projects that involved Human Resources in 2011:

Performance Evaluation and Job Descriptions templates revised

New hire applicant/interview process revised to include values acceptance and team interviews

Leadership Development institutes – March, May, and October

Staff Satisfaction Survey/Action Plans

Staff Open Forums – Mandatory May and November

Support Service Survey – July

Health Stream Mandatory Annual Education (completed by 100% of staff or removed from schedule)

Annual Service Awards Luncheon

Leadership University (education for 2nd level Leaders)

Salary Administration

Studer Leader Evaluation Manager training

Open Enrollment (health insurance)

Healing Garden

From a Human Resources perspective, it was an exciting year and a year full of new experiences and

achievements. I believe our staff feels a renewed hope for the future and is exhilarated to be a part of the NEW

Sonoma Valley Hospital.

Thank you for your continued support of our Hospital employees and the appreciation you show for their

invaluable contributions. As always, I am happy to answer any questions you may have regarding this report.

Respectfully submitted,

Paula Davis

Chief Human Resources Officer

02/08/12

2011 SVH LEADER BOARD

LEADER LDI

ATTENDANCE March 8 & 9;

May 10; Oct. 13

STAFF

FORUM

ATTENDANCE May & November

STAFF SATISFACTION

ACTION PLAN

PARTICIPATION RATES

MONTHLY

DASHBOARDS & 90

DAY PLANS

SCOUTING

REPORT

COMMUNITY

EVENT(S) (2 Required)

HR FUNCTIONS

& COMPLIANCE (Supp. Svy; Job Des;

HStream; EH)

CULTURE TEAM

Alvarado 1 of 3 100%/100% COMPLETE; 57% 7,8,9,10,11 Compl. SS;JD;EH;HS COM TRUST

Cohen 2 of 3 N/A N/A 5, 6,7,8,9,10,12 N/A 2 //;JD;EH;HS COM TRUST

Cole 2 of 3 40%/100% COMPLETE; 28% 7,8,9,10,11,12 Compl. 4 SS;JD;EH;HS COM TRUST

Davis 3 of 3 100%/100% COMPLETE; 100% 5, 6,7,8,9,10,11,12 N/A 5 SS;JD;EH;HS LEADERS/HEALTH

Donaldson 2 of 3 96% COMPLETE; 47% 5, 6,7,8,9,10,11,12 Compl. 1 SS;JD;EH;HS HEALTH

Durrance 3 of 3 N/A N/A 5, 6,7,8,9,10,11,12 N/A 3 SS;JD;EH;HS COM TRUST

Evans 3 of 3 74%/96% COMPLETE; 63% 5, 6,7,8,9,10,11,12 Compl. 2 SS;JD;EH;HS R & R

Finkenbinder 1 of 3 56%/90% COMPLETE; 31% 8,9,10,11,12 Compl. 2 //;JD;EH;HS R & R

Gantenbein 2 of 3 N/A N/A 7,8,9,10 N/A 2 SS;//;EH;HS R & R

Headley 3 of 3 61%/86% COMPLETE; M/S 42%;

BP 38%

5, 6,7,8,9,10,11,12 Compl. 2 SS;JD;EH;HS LEADERS

Kobe 0of 3 29%/59% COMPLETE; ED 25%;

ICU 47%

5, 6,7,8,10,11,12 Compl. 2 //;JD;EH;HS COM TRUST

Kutza 0 of 3 67%/83% COMPLETE; 58% 5,6,7,8,9,10,12 Compl. SS;JD;EH;HS LEADERS

Kuwahara 3 of 3 88%/100% COMPLETE; 66% 5, 6,7,8,9,10,11,12 Compl. 4 SS;JD;EH;HS HEALTH

Lee 2 of 3 71%/89% COMPLETE; 67% 5, 6,7,8,9,10,11,12 Compl. 4 SS;JD;EH;HS COM TRUST

Lenson 3 of 3 60%/100% COMPLETE; 80% 6,7,8,9,10,11, Compl. 3 SS; JD;EH;HS LEADERS

Lovejoy 3 of 3 100%/100% COMPLETE; 67% 5, 6,7,8,9,10,11,12 N/A 1 SS;JD;EH;HS R & R

Lyons 3 of 3 69%/76% COMPLETE; 66% 5, 6,7,8,9,10,11,12 Compl. 4 SS;JD;EH;HS COM TRUST

Mather 3 of 3 100%/100% COMPLETE; 90% 5, 6,7,8,9,10,11,12 N/A 6 SS;JD;EH;HS HEALTH

McMahon 3 of 3 N/A N/A 7,8,9,10,11,12 N/A 2 SS;//;EH;HS LEADERS

Naidoo 3 of 3 40%/100% COMPLETE; 51% 5, 6,7,8,9,10,11,12 N/A 2 SS;JD;EH;HS LEADERS

Reid 1 of 3 75%/84% N/A; 100% 9,10,11,12 N/A 1 //;EH;HS LEADERS

Richards 3 of 3 71%/87% COMPLETE; 100% 5, 6,7,8,9,10,11 Compl. 4 SS;JD;EH LEADERS

Sendaydiego 3 of 3 100%/100% COMPLETE; 100% 5, 6,7,8,9,10 Compl. 2 SS;EH;JD;HS R & R

Shannahan 2 of 3 (ES on LOA) 100%100% COMPLETE; 100% 5, 6,7,8,9,10,11,12 Compl. 4 SS;JD;EH;HS R & R

Starr 0 of 3 100%/91% COMPLETE; 0% 5, 6,7,8,9,10,11,12 Compl. 2 SS;JD;EH;HS R & R

Tarver 1 of 3 75%/80% N/A 100% 9,10,12 Compl. SS;JD;EH;HS LEADERS

Valenzuela 3 of 3 54%/80% COMPLETE; 81% 5, 6,7,8,9,10,11,12 Compl. 2 //;JD;EH; COM TRUST

9.

ANNUAL

PERFORMANCE

IMPROVEMENT

PROGRAM

EVALUATION

PI Program Evaluation 2011 Page 1 of 4

Performance Improvement Plan/Program Annual Program Evaluation 2011

Purpose

The Quality Department, in cooperation with the Performance Improvement Committee and the Administrative leadership, has completed an appraisal of the Performance Improvement Program. The purpose of this appraisal is to:

Evaluate the comprehensiveness and scope of the program

Assess the effectiveness of the FOCUS/PDSA model

Measure the extent of interdisciplinary collaboration

Assure that all key functions and dimensions of performance have been addressed

Provide the Governance, Administration and Medical Staff leaders with the results of prior year activities to assist in development of priorities for improvement

Determine the extent to which the Performance Improvement Program supported the mission and vision

Scope and Applicability

This is an organization-wide program. It applies to all settings of care and services provided by Sonoma Valley Hospital.

Findings

In 2011 the organization went through a number of accreditation and licensing surveys that identified some opportunities for improvement within the organization’s Performance Improvement Program. The main concerns were a lack of a performance improvement infrastructure and department specific performance improvement such that each department identified the complexity of work flow processes and opportunities to improve based on some form of prioritization process. The senior team had performed a formal organization-wide Performance Improvement Project prioritization process that identified three projects: Bariatric Services, Patient Satisfaction, and the Electronic Health Record implementation. The latter two projects were deemed to be two-year staged projects. It is clear that the scope of the program needs to be both organization-wide and department specific. While the plan speaks to the use of PDSA, there was little evidence that this process was being used by the end of the second quarter 2011. There has been a change is some leadership and it was noted that there was a need for education on the use of the method and the way quality monitoring and performance improvement is recorded and reported. Additionally, there is a range of abilities in the use of and interpretation of data as well as the tools to make decisions about process variation.


Interdisciplinary collaboration was demonstrated through the FMEA process, root cause analysis process, and Performance Improvement Committee project reports. Of concern was the Performance Improvement Committee schedule of meetings did not allow for consistent and coordinated reporting of projects and mandated activities. Thus some key functions and dimensions of performance were not addressed or not given the amount of time required to be thorough (example: Pharmacy and Therapeutics). There is a medical staff standards requirement that the following be reported as part of medical staff performance improvement. The following have not been reported for 2011:

Pre/post-operative diagnosis discrepancies

Data on adverse events related to procedural sedation

Annual report of high risk look-alike, sound-alike medications

On-going physician performance evaluation and any focused physician performance evaluation The Performance Improvement Program does support the hospital’s mission and is well on the way to supporting an organizational Culture of Quality and Safety.

Assessment of Performance

The effectiveness of the PI program is measured by its accomplishments. Data was collected and aggregated on the performance measures and thoroughly analyzed. Intensive assessments were completed when SVH detected or suspected a significant undesirable performance or variation. Some of the accomplishments for 2011 are as follows:

Education of Leaders regarding performance improvement and quality monitoring

Restructure of PI Committee meeting and reporting format

Improved Patient Satisfaction from a mean score of 35 to 85

Review of judicious antimicrobial use, specifically use of Zosyn; analysis of data completed. CME and comparison before and after intervention was completed.

Fall Prevention-Implementation of the 3 “P” on Nursing Rounds in 2010 demonstrated a decrease in patient falls from 3.8 per 1,000 patient days in 2010 to 2.8 per 1,000 patient days in 2011.

Improved Oryx/Core Measure Performance to state and national benchmarks

Used Lean principles to improve the courier process

Infection Control Prevention Measures including prevention of SSI, MDRO, and CLABSI

Improved IT infrastructure in preparation for Electronic Health Record

Work plan and charters for Quality and Governance Committees of the Board

Leadership Development Training Program implementation of AIDET, hourly rounding and bedside shift report; rounding on customers and employees

Case Management Transformation and Hospitalist Huddles reduced excess days and improved length of stay

Joint Replacement Program implementation of PHDX benchmarking database


Bariatric Program serves 25 patients

New management oversight of Engineering, EVS and Food Services, ED/ICU

New job description templates

Successful TJC hospital, lab and home health accreditation, CDPH/CMS, Home Health licensing, SNF licensing surveys

PAPR training of high-risk staff in compliance with Cal/OSHA ATD Standard

Improved transfusion process and reaction reporting

Implementation of Press Ganey databases to assist with OPPE and decision support.

Measured employee satisfaction and developed action plans

Improved the credentialing process

Implemented HealthStream web-based learning for annual competencies

Re-vitalized the Safety Committee which includes patient and employee safety

Assessment of Effectiveness

The Performance Improvement Program is meeting the needs of the Performance Improvement Committee, Medical Executive Committee and Sonoma Valley Hospital.

Objectives for Next Evaluation Period

I. Performance Improvement Infrastructure:

Department-specific performance improvement plans and quality monitoring indicators developed and implemented

Provide education to leaders on using of tools and using and interpreting graphs

Identify and purchase data analysis tool to support decision making process

Develop structural policies and procedures for how performance improvement and quality monitoring is done

Attach quality goals to Leadership Evaluation Manager

Work with medical staff groups to identify key performance indicators

Complete OPPE score card and implement quarterly

Ensure key performance indicators are measured and reported II. Performance Improvement efforts in 2012 will include a focus on:

Patient Satisfaction Measurement and Improvement Team to continue to improve the patient experience of care

Electronic Health Record Implementation to ensure quality and completeness of documentation and data capture

Medicare Breakeven Project to move to improving resource utilization and waste reduction


Level of care transitions to reduce re-admissions and improve handing off communication

SSI prevention and hand hygiene

Development of an Emergency Department Transitional Care Record

Patient Flow Process to improve ED throughput

Nursing Education to build a professional nursing model and improve competencies

Ongoing Oryx/Core Measure staff and physician education and compliance with best care practices

Antimicrobial stewardship

Strengthen the organization’s Culture of Quality and Patient Safety through implementation of Patient Safety initiatives

Implementation of web-based policy and procedure management system

Improvement of Code Blue and Rapid Response reviews and mock codes

Remote Data Entry for the hospital notification process

Policy Update

Annual PI Program Evaluation 2012

Standards

TJC - LD.03.02.01, LD.03.05.01, LD.04.04.03, LD.04.04.05, PC.03.02.11, PI.01.01.01, PI.02.01.01, PI.03.01.01 CMS - §482.21, §482.22, §482.23, §482.26, §482.30, §482.42

10.A.

CHAIN OF COMMAND

FOR MANAGEMENT

OF PATIENT CARE

CONCERNS

SUBJECT: Chain of Command for Management Of Patient Care Concerns

POLICY # LD15 -404

PAGE 1 OF 3

DEPARTMENT: Organizational EFFECTIVE: 4/30/2012

APPROVED BY: Chief Nursing Officer REVISED:

Purpose:

Every healthcare provider holds a duty of care, under her/his scope of practice, to the patient. The duty requires that questions regarding the medical treatment plan are resolved by direct communication between the physician and the questioning healthcare professional. It is the intent of the Administration and Medical Staff to establish and support a Chain of Command to be followed to expedite and resolve patient care management issues that cannot be resolved between the attending physician and staff RN/ancillary health care professional. Within the Medical Staff structure, physician leaders have the authority to review the patient’s medical needs in this situation and to provide the medical interventions immediately needed. Concurrently or following the resolution of the patient’s medical crisis, the physician leader may consult with the treating physician as the patient’s situation allows. In all such cases, the quality review notification process will be employed retrospectively to identify opportunities for learning and practice enhancement.

Policy: If a healthcare professional has reason to doubt or question the care provided any patient, or believes that the best interests of patients have been, or may be jeopardized by the behavior of any hospital employee or Medical Staff member, intervention is required. Procedure: A. When an RN has a specific concern about the appropriateness or timeliness of medical interventions for a given patient, it is that RN’s responsibility to communicate those concerns to the treating physician to seek resolution.

An employee within the Nursing Department is obligated to report concerns to the RN assigned to the patient. If the RN does not respond as needed, the employee will seek guidance from the Charge Nurse/Nurse Manager or Nursing Supervisor.


POLICY # LD15 -404

PAGE 2 OF 3



B. When an ancillary healthcare professional has a specific concern about the appropriateness or timeliness of medical interventions, it is that professional’s responsibility to collaborate with the RN who is coordinating care for that patient. If issues remain following collaboration, the RN will proceed to seek resolution.

The term “healthcare professional” in this policy refers to any licensed healthcare provider. Collaboration with the RN in charge of the patient’s care may not be indicated where the healthcare professional has independent authority to obtain physician’s orders. For example, pharmacists, respiratory therapists, licensed social workers, dieticians, etc. However, should care management issues remain after contact or attempted contact with the treating physician, the health care professional should then coordinate with the RN to engage the Chain of Command.

C. If the RN and the treating physician are unable to resolve the concerns, or if the treating physician is unavailable, the RN must promptly notify the Charge Nurse of Supervisor. D. The Charge Nurse/Supervisor is responsible for validating that a problem does exist and for communicating to the treating physician to seek resolution. E. If resolution at this level is not achieved, or if the treating physician is unavailable, the Nurse Manager/Supervisor will inform, or attempt to inform the treating physician that the Chain of Command will be engaged to reach resolution of the divergent clinical opinions. F. the Nurse Manager/Supervisor will then immediately contact the Chief Medical Officer or Department Medical Chair of the service. The problem will be outlined using SBAR and medical intervention requested. G. If resolution at this level is not achieved, the Nurse Manager/Supervisor will contact the President of the Medical Staff. H. Concurrently, the nurse Manager/Supervisor will contact the Director of Nurses or the Chief Nursing Officer and/or the Risk Manager, if applicable. I. Clinical concerns regarding patient care are to be documented in the notification system. J. The patient’s record should indicate the times the treating physician was called and the time and content of subsequent medical intervention. The medical record should not contain documentation of the administrative efforts to obtain the medical intervention.


POLICY # LD15 -404

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Reference: The Joint Commission LD.03.01.01 Leaders create and maintain a culture of safety and quality.

10.B.

ORGANIZATION-WIDE

PERFORMANCE

IMPROVEMENT PLAN

SUBJECT: Performance Improvement Plan POLICY # PI 8610-100

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DEPARTMENT: Organizational EFFECTIVE:

APPROVED BY: Chief Quality Officer REVISED: 1/2011; 6/2012

PURPOSE: This Performance Improvement (PI) Program promotes the mission of Sonoma Valley Hospital (SVH) by establishing a formal, organization-wide system to monitor and continuously improve patient outcomes and client services. The purpose of this document is to provide guidelines for how this organization develops, implements, and maintains an effective, ongoing, organization-wide, data-driven quality assessment and performance improvement program that is interdisciplinary in approach. POLICY: Quality is defined as the degree to which care meets or exceeds the standards set by the Board of Directors and the Administrative Leaders of SVH. The standards will be based on one or more of the following: input from our clients, current expert knowledge, literature review, internal and external comparison, and benchmarking. SCOPE & APPLICABILITY: This is an organization-wide plan. It applies to all departments, care, treatment, and service settings including those services furnished under contract or arrangement. See policies: PI8610-101; PI8610 - 102 for additional information regarding the structure of this program. RESPONSIBILITIES: Governing Body The Governing Body authorizes the establishment of this performance improvement program. The Governing Body is responsible for assuring:

That an ongoing program for quality improvement is defined, implemented, and maintained

That an ongoing program for patient safety, including the reduction of medical errors, is defined, implemented, and maintained

That the organization-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated

That clear expectations for safety are established


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That adequate resources are allocated for measuring, assessing, improving, and

sustaining the hospital’s performance and patient safety

That a determination of the number of distinct improvement projects is conducted annually

Medical Executive Committee / Performance Improvement Committee

The Governing Body delegates the development, implementation, and evaluation of this program to the Medical Executive Committee (MEC). The MEC is responsible for monitoring and improving, the quality of care, safety and service provided its medical staff. The MEC has formed a Quality Management Committee to carry out this responsibility.

Administration Management/Leadership

The Governing Body also delegates the development, implementation, and evaluation of this program to the organization’s Administration and Management/Leadership team. Administration and Management/Leadership are responsible for improving the quality of care, safety, and service provided by organization staff. The Administration and Management/Leadership team have developed structures and processes to carry out this responsibility. Quality and Resource Management

The MEC and/or Administration delegate structural, reporting, and facilitation functions of this program to the Chief Quality Officer. The Quality and Resource Management department provide education, data aggregation and reporting, team facilitation and training in order to support the success of the program. This department is also responsible for mandated reporting of quality measures and communicating the results of that reporting.

Employees are responsible for: learning the principles of performance improvement; reporting any potential quality issues to their department manager or supervisor, or directly to the Performance Improvement Department; and serving on PI Teams when requested and assisting in carrying out the functions of the team.


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Performance Improvement Teams

The PI Teams are responsible for carrying out the PDSA process to investigate and resolve improvement opportunities, reporting findings and recommendations to the appropriate departments, and for monitoring actions taken to assure continued resolution. PROCEDURE: A. Collecting Data on Performance 1. Scope of Data Collection: At a minimum, the organization will collect data in the

following areas:

Performance improvement priorities identified by leaders

Operative or other procedures that place patients at risk of disability or death

All significant discrepancies between preoperative and postoperative diagnoses, including pathologic diagnoses

Adverse patient events

Adverse events related to using moderate or deep sedation or anesthesia

The use of blood and blood components

All confirmed transfusion reactions

The results of resuscitation

Restraint use

Significant medication errors

Significant adverse drug reactions

Patient perception of the safety and quality of care, treatment, and services

Processes that improve patient outcomes

Prevention and reduction of medical errors

Processes as defined in the organization’s Infection Control Program, Environment of Care Program, and Patient Safety Program

Conversion rate data supplied from the Organ Procurement Organization

CMS core measure and ORYX data

The organization may also consider collecting data on the following: Staff opinions and needs Staff perceptions of risk to individuals Staff suggestions for improving patient safety Staff willingness to report adverse events


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Measurement of the above areas may be organization-wide in scope, targeted to specific areas, departments and services, or focused on selected populations.

B. Frequency of Data Collection

By acceptance of this program, the Governing Body has defined the frequencies of data collection to be ongoing, time limited, episodic, intensive, or recurring. The duration, intensity, and frequency of data collection to measure a specific indicator shall be based on the needs of the organization, external requirements, and the result of data analysis.

C. Detail of Data Collection

By approval of this program, the Governing Body has determined that data shall be collected in sufficient detail to provide the user of that data with sufficient information to make timely, accurate, and data-driven decisions.

D. Aggregation and Analysis of Data 1. The purpose of data aggregation and analysis is to:

Establish a baseline level of performance

Determine the stability of process

Determine the effectiveness of a process or desirability of an outcome as compared to internal or external targets (benchmarks)

Identify opportunities for improvement

Identify the need for more focused data collection

Determine whether improvement has been achieved and/or sustained

2. Construct: Performance measures should have a construct to assure that data is appropriately identified, collected, aggregated, displayed, and analyzed. In general, the construct should consist of:

A definition of the measure

The population to be measured (including, when appropriate, criteria for inclusion and/or exclusion)

The type of measurement (i.e., rate based or event based)

If rate based, a calculation formula (i.e., defined numerator/denominator)

The minimum sampling size (where appropriate) to assure statistical validity

The frequency of data collection/aggregation

The methodology by which data will be collected


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The department primarily responsible for data collection

The manner in which aggregated data will be displayed

The department(s) to which the aggregated data will be reported for analysis and action

3. Compilation of Data: Data shall be compiled in a manner that is usable to those

individuals and entities charge both with analyzing the data, and taking action on the information derived from data analysis. Where appropriate, statistical tools and techniques are used in data display, to assist in appropriate analysis.

4. Analysis of Data: Data on performance measures is analyzed to:

Monitor the effectiveness and safety of services and quality of care

Identify opportunities for improvement and changes that will lead to improvement

5. Analysis of Aggregated Data: Data on rate based performance measures are aggregated to determine patterns, trends, and variation (common or special cause). Data may be aggregated for a single point in time or over time, depending on the needs of the organization and the reason for monitoring performance. In general, measurement designed to establish the desired stability of a process or a desired outcome will be measured over time until target levels of performance are met.

Once a process is considered stable, and/or a desired level of performance has been achieved, then an analysis of performance measures may be conducted in a more episodic fashion.

Data that is event based is analyzed in singular or aggregated form depending on the number of data elements in the performance measure. In general, event based measurements are monitored on an ongoing basis. When possible, data is compared against internal and/or external benchmarks to allow for comparative performance over time.

6. Intensive Assessments: Data will be intensively assessed when the organization detects

or suspects a significant undesirable performance or variation. Intense analysis is called for when:

Levels of performance, patterns, or trends vary significantly and undesirably from those expected

Performance varies significantly and undesirably from that of other organizations or recognized standards


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A sentinel event has occurred (root cause analysis)

The hospital also conducts a Failure Modes and Effects Analysis as an intense analysis in order to prevent potential errors that place patients at high risk for an adverse outcome. Based on the scope of care or services provided by Sonoma Valley Hospital, intense analysis will be performed for the following:

Confirmed transfusion reactions

Significant adverse drug reactions

Significant medication errors and hazardous conditions

Major discrepancies between preoperative and postoperative (including pathologic) diagnoses

Significant adverse events associated with moderate or deep sedation and anesthesia use

Hazardous conditions

Oryx Core Measure Data that, over three or more consecutive quarters for the same measure, identify the hospital as a negative outlier

Staffing effectiveness

E. Improving Performance 1. Performance Model: The organization will undertake efforts to improve existing

processes and outcomes and then sustain the improved performance. To accomplish this, Sonoma Valley Hospital has adopted the following performance improvement model:

FOCUS PDSA: Plan Do Study Act to be used for complex processes involving more than one department where the root cause and processes steps are not well known. Example: Patient Throughput. Rapid Cycle PDSA to be used when the process problem is well known and can be addressed more rapidly or when the improvement process will involve cycle of quick changes towards a clear outcome. Example: Improving patient satisfactions scores in a specific department. This model is used – formally or informally – in improvement efforts throughout the organization. In addition, LEAN principles may be employed as part of the PDSA model to ensure a more robust methodology and more effective improvement outcome.


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2. Prioritizing Performance Improvement Activities; Sonoma Valley Hospital Senior

Leadership prioritizes organization-wide performance improvement activities that address processes that:

Focus on high-risk, high or low-volume, or problem-prone areas

Consider the incidence, prevalence, and severity of problems in those areas

Affect health outcomes, patient safety, quality of care, and fiscal stewardship

New services or programs

Departmental Leaders use the same process to identify those activities within their department.

3. Performance Improvement Projects: As part of its quality assessment and performance

improvement program, the organization must conduct performance improvement projects.

The number and scope of distinct improvement projects conducted annually shall be proportional to the scope and complexity of the hospital’s services and operations.

The organization shall document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

While the organization is not required to participate in a CMS Quality Improvement Organization (QIO) cooperative project, its own projects shall be of comparable effort.

4. Improving Performance: Performance improvement activities shall – at a minimum –

track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the organization.

The organization shall take actions aimed at performance improvement and after implementing those actions, the organization shall measure its success and track performance to ensure that improvements are sustained.

When planned improvements are not achieved or sustained, the process will undergo an intense analysis to gain an understanding of why planned improvements have not worked and a new plan will be developed, implemented and monitored.


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5. Reporting of Performance Improvement Activities: Regular reports on the status and

effectiveness of performance improvement activities shall be made to the Governing Body as well as the leadership of the organization and its medical staff.

6. Information Sources and Benchmarking: Sonoma Valley Hospital uses a variety of

information sources in accomplishing the goal of improving organization performance. Both the financial and clinical information systems, including the health information management database, will be used to contribute information for the identification of opportunities to improve care and the assessment of the stability and success of new and existing processes. In addition the organization makes use of external benchmarking and best practice strategies, some of which are listed below.

Evidence-based medical and surgical best practices from Centers of

Excellence

Regulatory standards changes

Sentinel Event Alerts and national Patient Safety best practice benchmarks

CMS and ORYX data

National nursing and ancillary providers standards of practice

Magnate status principles

National risk reduction strategies

F. Flow of Information

The Board of Directors and the Medical Executive Committee will receive regular reports from the PI Committee identifying the organizational performance improvement activities, including the scope of items reviewed, the number of opportunities identified for improvement, the actions proposed or taken, and results of those actions. This information is derived from activities of the aforementioned committees, departments, teams, etc. There will be periodic reporting of the status of documented problems to track improvements or resolutions.

Minutes and Reports Complete, accurate minutes for each meeting conducted will be kept in the prescribed format. Minutes will contain the date and duration of the meeting, all persons present and absent with their titles. The minutes will show the major findings, conclusions, recommendations and actions to be taken, and the plan to assess the effectiveness of the actions (follow-up). Applicable documentation and substantiating data will be maintained and available for review by appropriate parties.


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Confidentiality All medical information shall be maintained to service the patient, healthcare providers, and the medical center, in accordance with legal, accrediting and regulatory agency requirements. All patient care information will be regarded as confidential and will be available only to authorized users, according to law. Medical data, which is a byproduct of the original medical record, shall be protected with the same diligence as the original medical record. This data includes all indices and other medical information maintained by the medical center that is individually identifiable by patient or provider. To maintain confidentiality all references in minutes, studies or monitoring reports of individual patients and/or practitioners will be made in coded form. Members of the medical staff and administration responsible for implementing performance improvement activities or monitoring recommendations will have access to coded identifiers in order to implement recommendations. All reports, minutes and other documentation emanating from the Performance Improvement Program will be maintained as required to insure confidentiality and compliance with medical center policy and all applicable Federal, State and local statutes and standards. Access to performance improvement data and information will be limited to those medical staff members and medical center personnel who required such data in the performance of their duties. This data will not be available to external sources, except in accordance with accreditation or statutory regulations. All performance improvement reports and record will be destroyed in a manner which will render them useless when they are no longer required. All PI Program participants will be informed of their responsibility to maintain confidentiality of all data and/or information gained through committee activity or review. All persons to whom an offer of employment is tendered will be informed of the confidentiality of data and the rules and regulations governing that data.


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Evaluation of the Performance Improvement Program

The PI Program will be re-evaluated at least annually to assure that the expected integrated, coordinated efforts are taking place and that the performance of organization wide processes and outcomes has improved through the activities of the PI Program. This re-evaluation shall include:

1. Assessment of the effectiveness of the PDSA model

2. Measurement of the extent of interdisciplinary collaboration

3. Assurance that all key functions and dimensions of performance have been addressed

4. Evaluation of the comprehensiveness and scope of the program

5. Provision to the Board of Directors, Administration and Medical Staff leaders of results of prior year activities to assist in development of priorities for improvement

6. Determination of the extent to which SVH’s mission, vision and values were supported by the Performance Improvement Program

REFERENCES 1. Joint Commission Standards for Acute Care Hospitals 2. CMS Conditions of Participation for Acute Care Hospitals, 482.21

10.C.

DEPARTMENT

SPECIFIC

PERFORMANCE

IMPROVEMENT

SUBJECT: Department Specific Performance Improvement POLICY # PI8610 -101

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DEPARTMENT: Organizational EFFECTIVE: 7/2012

APPROVED BY: Chief Quality Officer REVISED:

PURPOSE: To provide a structure for departments to consider the complexity of their services and identify quality monitoring and performance improvement activities that promotes a departmental culture of quality and continuous improvement. POLICY: The hospital has an organization-wide performance improvement program that includes department specific quality monitoring and performance improvement activities. Department Directors/Managers will develop and maintain a department specific performance improvement and quality monitoring plan that encapsulates the department’s complexity of services.

PROCEDURE: A. Write a Department Specific Performance Improvement Plan:

1. Using the template located on the S drive, Readiness folder, PI Subfolder, the

department leader will develop a department specific plan that includes both performance improvement activities and quality control monitoring.

2. The complexity of the department’s services will be reflected using a workflow process assessment that uses the following four criteria to identify potential performance improvement activities:

a. High Risk: those workflow processes that place patient safety and patient care

outcomes at risk. b. High Volume: those processes that are done so often that there is a chance for

errors to occur related to habituation. c. Low Volume: those processes that are not performed often and require a skill set

that may be lost over time. d. Problem Prone: those processes that have a history of or the potential for errors to

occur that either impact the way services are delivered or patient care outcomes.

3. The department leader includes the departmental staff in the development of the work flow process analysis and the identification of potential performance improvement activities at least annually as reflected in the department’s staff meeting minutes.

SUBJECT: Department Specific Performance Improvement POLICY # PI8610 -101

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DEPARTMENT: Organizational EFFECTIVE: 7/2012

APPROVED BY: Chief Quality Officer REVISED:

4. The department leader includes a listing of all quality control monitoring indicators as

part of the plan and updates this listing when indicators are retired or new indicators are formed. The listing includes the following items:

a. The name of the indicator; b. The type of indicator (outcome or process); c. The goal or threshold that performance is expected to meet; d. The frequency of measurement; and e. The total number of observations (sample size) to be completed.

5. The department leader reviews the completed plan with their senior leader at least

annually as reflected in the minutes using the Monthly Meeting Model format for standing meetings.

6. The department leader is responsible for maintaining documentation of all of the above.

7. The department leader provides the Quality & Resource Management Department with a

copy of their performance improvement plan.

B. Annual Evaluation of the Performance Improvement Plan:

1. At the end of the fourth quarter of each calendar year, the department leader provides the Quality Department, their staff and their senior leader with a program evaluation using a template that may be found on the S drive, Readiness folder, PI subfolder.

2. Clinical department leaders will present this evaluation annually to the Medical Staff

Performance Improvement Committee. C. Update of Performance Improvement Plan:

1. The plan will be updated and submitted to Quality every three years. REFERENCES:

TJC LD.03.05.01; LD.04.04.01; PI. 01.01.01; & PI.03.01.01 CMS Conditions of Participation: Quality Assurance Program

10.D.

QUALITY

MONITORING AND

REPORTING

SUBJECT: Reporting of Quality Monitoring and Performance

Improvement Activities POLICY # PI8610-102

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PURPOSE: To outline a structure for reporting of quality monitoring and performance improvement data for both routine activities and for ensuring regulatory compliance post survey. POLICY: Performance improvement activities are reported up through the Medical Staff Performance Improvement Committee if they impact patient care directly; other performance improvement activities are reported annually in the Performance Improvement Annual Evaluation. All department leaders are accountable for ensuring that all activities are completed and reported in a timely manner to the Quality Department and to their Senior Leader. Performance improvement, quality monitoring and action plan execution are reported up to the Board through the Quality Committee, a sub-committee of the Board of Directors. PROCEDURE: A. Departmental Reporting Requirements

1. Quality Control Monitoring: all departments will submit to the Quality Department their quality control monitoring (QC) reports on a quarterly basis. Reporting months are: January, April, August, and October.

a. Department leaders will use the template provided on the S drive unless a different

format is approved by the Director, Quality & Resource Management, in order to meet reporting needs from the department.

2. Department specific performance improvement will be reported to the Quality

Department when the project has begun, monthly thereafter and upon completion.

a. The method of reporting will be the use of either the Rapid Cycle PDSA worksheet or the Focused PDSA worksheet located on the S drive, Readiness folder.

B. Regulatory Agency Action Plan development and quality monitoring

1. Post Survey: upon completion of a survey by a regulatory agency, the department leaders who are responsible for a cited deficiency will meet with the Quality Director to begin the development of an action plan and quality monitoring process.

SUBJECT: Reporting of Quality Monitoring and Performance

Improvement Activities POLICY # PI8610-102

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a. Action plans will be written using the template provided by the Quality Department and returned to the Quality Department within seven days of citation notification.

b. The Quality Director or the Quality Data Analyst will assist the leader in identifying an

audit tool and data entry tool to ensure that compliance is demonstrated. Quality will also provide timelines for completion and reporting as they will vary depending on the regulatory body.

c. The departmental leader will provide updates to their senior leader regarding the

action plan and efforts to bring the department into regulatory compliance.

2. The results of regulatory agency surveys, action plans, and progress toward compliance will be reported to the medical staff through the Performance Improvement Committee and to the Board of Directors through the Quality Committee.

REFERENCE: TJC LD.03.05.01; LD.04.04.01; PI. 01.01.01; & PI.03.01.01 CMS Conditions of Participation: Quality Assurance Program

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