BOARD QUALITY REVIEW COMMITTEE MEETING

*

Monday, May 19, 2014

5:30 p.m. (Buffet Dinner for Committee members & invited guests) 1st Floor Conference Room

6:00 p.m. Meeting 456 E. Grand Avenue, Escondido CA

Open Agenda

Time Target CALL TO ORDER 6:00

Establishment of Quorum ............................................................................................................ ..........

Public Comments ......................................................................................................................... 5 6:05

5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in meeting room.

Information Item(s)

1. * Approval: Minutes – Monday, April 21, 2014 (Addendum A - Page 2 - 5) ............................ 5 6:10

New Business

a) Approval of Board Policy 11232 “Performance Improvement” (Addendum B – Page 6) ...... Questions & Answers – 10 minutes

10

6:20

b) Patient Flow Update (Addendum C – Page 7 - 33) ............................................................... Lorie Shoemaker, Chief Nurse Executive Presentation – 15 minutes Questions & Answers – 10 minutes

25 6:45

c) Nursing Peer Review (Addendum D – Page 34 – 51) ........................................................... Maria Sudak, Director of Clinical Operations Improvement Presentation – 15 minutes Questions & Answers – 5 minutes

20 7:05

d) Update on Operational Initiatives #1 and #2 (Addendum E - Page 52 - 55) ......................... Opal Reinbold, Chief Quality Officer and Lorie Shoemaker, Chief Nurse Executive Presentation – 15 minutes Questions and Answers – 10 minutes

25 7:30

ADJOURNMENT TO CLOSED SESSION 7:30

~ pursuant to Health & Safety Code Section 32155 Report of Medical Audit/Report of Q.A. Committee

Immediately

following end of closed session

RESUMPTION OF OPEN SESSION

Action Resulting From Closed Session Discussion – IF ANY ............................................

FINAL ADJOURNMENT

8:15

Board Quality Review Committee Members Linda Greer, RN - Chairperson Opal Reinbold, MBA Gerald Bracht, MBA

Aeron Wickes, MD Michael Covert, CEO, FACHE David Tam, MD

Jerry Kaufman, PTMA Lorie Shoemaker, RN Sheila Brown, RN, FACHE

Charles Callery, MD Della Shaw Jerry Kolins, MD, FACHE

Daniel Harrison, MD Valerie Martinez, RN, BSN, MHA, CIC

NOTE: If you have a disability, please notify us by calling 760-740-6353, 72 hours prior to the event

so that we may provide reasonable accommodations

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Addendum A

3

1 | P a g e Updated: 2/14/2014

ABBREVIATIONS GUIDE

ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACR: American College of Radiology ARB: Angiotension Receptor Blocker BETA: PPH Insurer BSC: Balanced Score Card CALNOC: Collaborative Alliance for Nursing Outcomes CAP: College of American Pathologists CAUTI: Catheter Associated Urinary Tract Infection CCTP: Community-Based Care Transitions Program CDAD: Clostridium Dificile Associated Diarrhea CDC: Center for Disease Control CDI: Clinical Documentation Improvement C-diff: Clostridium difficile CDPH: California Department of Public Health CHA: California Hospital Association CIHQ: Center for the Improvement in Healthcare Quality CLABSI: Central Line Blood Stream Infection CLIP: Central Line Insertion Practices CMS: Centers for Medicare & Medicaid Services CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management DI: Diagnostic Imaging DRT: Diabetes Resource Team EBP: Evidence Based Practice EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EVS: Environment of Care Services / Environmental Services FANS: Food and Nutrition Services FMEA: Failure Mode Effects Analysis HAI: Healthcare Associated Infections HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCP: Health care provider HDL: High Density Lipoprotein Cholesterol HLD: High Level Disinfectant IC: Infection Control IHI: Institute for Healthcare Improvement IP: Infection Prevention (RN Staff) MDRO: Multi Drug Resistant Organism MRSA Methicillin-resistant Staphylococcus aureaus MSPRC: Medical Staff Peer Review Committee NDNQI: National Database of Nursing Quality Indicators NHQM or NIHQM: National Improvement for Healthcare Quality Measure

Addendum A

4

2 | P a g e Updated: 2/14/2014

ABBREVIATIONS GUIDE

NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NPSG: National Patient Safety Goals NQF: National Quality Forum PCEA: Patient Controlled epidural Analgesia PDCA: Plan Do Check Act POCT: Point of Care Testing QRR: Quality Review Report RAC: Revenue cycle Audits RCA: Root Cause Analysis RVT: Registered Vascular Tech SCIP: Surgical Care Improvement Project SIR: Standardized Infection Ratio SNF: Skilled Nursing Facility SSI: Surgical Site Infection TAT: Turn Around Time TJC or JC: The Joint Commission US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Acquired Pneumonia VBAC: Vaginal Birth After Caesarian Section VRE: Vancomycin-resistant enterococ

Addendum A

5

I. PURPOSE:

To provide directions to the employees of PPH from the Board of Directors relative to establishing and maintaining an organization that is committed to ongoing performance improvement culture, thereby meeting and striving to exceed regulatory and professional standards.

II. DEFINITIONS:

III. TEXT / STANDARDS OF PRACTICE:

A Performance Improvement Plan will serve as a framework that describes how the following will be accomplished, including:

A. Designing Processes. B. Monitoring through data collection. C. Analyzing current performance. D. Determining and prioritizing improvement opportunities. E. Modifying processes. F. Sustaining improvements. G. Periodically assessing PPH performance in accordance with recent benchmark data.

IV. ADDENDUM:

V. DOCUMENT / PUBLICATION HISTORY:

VI. CROSS-REFERENCE DOCUMENTS:

V. PUBLICATION HISTORY:

VI. REFERENCES:

Paper copies of this document may not be current and should not be relied on for official purposes. The current version is in Lucidoc at .

https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:11232

Policy

Performance Improvement11232 Official (Rev: 1)

Source:Administrative Board of Directors

Applies to Facilities: Applies to Departments:

Revision Number

Effective Date

Document Owner at Publication Version Notes

1 (this version)

12/17/2001 Dr. Valentino Tesoro, SVP Quality and Clinical Effectiveness

Original Version

Authorized Signer(s): ( 12/17/2001 ) George G. Gigliotti, Chairman

Reference Type Title NotesSource Documents 1

JCAHO CAMH Standard Improving Organization Performance

JCAHO CAMH Standard Leadership

JCAHO CAMH Standard Governance

Page 1 of 1Performance Improvement

5/12/2014https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:11232/frame/DOCBODY

Addendum B

6

Board Quality Review Committee May 19, 2014

According to the National Institutes of Health…

“Increasing wait times predict increasing mortality for emergency medical admissions… Delay[s] to admission[s] have been shown to be independently adversely related to mortality outcome. We recommend maximal target limits of 4 and 6 hours for referrals and admissions, respectively, based on these mortality observations.”

Plunkett et al., 2011

Addendum C

7

Improved Care Coordination and Throughputhave been identified as Strategic and Operational

Initiatives for FY’14-17

Strategic Initiative #3: Improve Care Coordination:Develop a delivery model that supports care coordination and transitions across the continuum, with emphasis on chronic disease management, illness prevention and patient involvement.

Operational Initiative #2: Improve Satisfaction and Throughput:Create a positive experience for all key stakeholders by improving clinical and business throughput and efficiency through all transitions of care.

Hospital Compare – Timely & Effective Care Timely and effective care in hospital emergency

departments is essential for good patient outcomes. Delays before receiving care in the emergency

department can reduce the quality of care and increase risks and discomfort for patients with serious illnesses or injuries.

Waiting times at different hospitals can vary widely, depending on the number of patients seen, staffing levels, efficiency, admitting procedures, or the availability of inpatient beds.

CMS, 2014

Addendum C

8

Baseline Data – Hospital Compare

Addendum C

9

Addendum C

10

Addendum C

11

Addendum C

12

ED LOS for Admitted Patients (minutes)

Decision to Admit to Inpatient Bed (minutes)

PHDC – 346 Pomerado - 298 Scripps La Jolla – 218 Sharp Memorial – 218 Tri-City Medical – 364 Scripps Encinitas - 297 Fallbrook – 288

PHDC – 145 Pomerado - 142 Scripps La Jolla – 90 Sharp Memorial – 69 Tri-City Medical – 98 Scripps Encinitas - 96 Fallbrook – 78

Addendum C

13

Overall Goals: 1. Create an innovative, seamless process for

patient flow that is efficient, effective, and measurable to assure maximum use of the organizational resources and patient and physician satisfaction.

2. Provide additional resources to assist physicians in their efforts to avoid compliance issues with patient status and meeting regulatory compliance.

Primary Focus Areas:1. Patient access, including ED, OR, direct

admits2. Centralized bed control function3. Unit-based bed control function4. Optimization of Teletracking tool5. Overall patient experience

Addendum C

14

Key Milestones of Phase I:1. Cerner Case Management module fully

functional2. CERME (electronic InterQual criteria)

implemented3. 24/7 Clinical Resource Management (CRM)

staffing for ED 4. New CRM Supervisor and Director hired5. Executive Health Resources implemented and

monitored for appropriate utilization 6. Standardized process for daily discharge

huddles developed, piloted, and rolling out across the system

The Current state of throughput at Palomar Health is a confusing and slow process

The current process around admissions includes: Level of Care vs. Acuity vs. Ratios vs. Skill of the RN Who has the final say for patient placement? We have Physician Preferences vs. Expectations We have differences between facilities at same level

of care We give mixed messages to patients and staff PMC has unintentionally created uniquely specialized

units

Addendum C

15

There is a 14 step work flow for every admission Every admission is reviewed by 5‐6 RNs after a physician 

determines level of care Multiple people have multiple interpretations for same 

admission criteria Considerable amount of discussion related to the 

appropriateness of admissions happens throughout the day There is no integrated patient placement process There is a lack of urgency related to                                                  

patient flow and throughput

Resulting in . . .RigidityUnnecessary Transfers PushbackDelays

Addendum C

16

Time to Reconstruct

Partnership with CEP America (ED Physicians and Hospitalists) o Resources and expertise to augment our existing

expertise/efforts/projects/people Include all three campuses in the process Standardize processes to the extent possible

at all three campuses

Addendum C

17

General Overview Overall Executive Sponsors:

oOpal ReinboldoLorie Shoemaker

Overall Project Vision: oIn partnership with CEP America, create an innovative, seamless process for patient flow that is efficient, effective and measurable to assure maximum use of organizational resources and patient and physician satisfaction 

Meets 3rd Monday, 0800-0930, LDC iExplore

Replaces Existing Patient Flow Meeting

Opal Reinbold Lorie Shoemaker Della Shaw Performance Excellence-

Chris/Angie/Rick Andrew Smith (CEP) Joy Gorzeman Cathy Prante Michelle Gunnett Rae Anne Watson Beth Remsburg-Bell Mark Reyes

Kim Colonnelli Joanne Barnett Marcy Adelman Maria Sudak Prudence August Steve Ellis Diane Hansen Cindi Burns Frank Martin, MD John Fredericks, MD Jaime Rivas, MD Sabiha Pasha, MD

Addendum C

18

Some Quick Definitions…o TAT-A… Turn Around Time to Admissiono TAT-D… Turn Around Time to Dischargeo Centralized Placement… Patient Placement

Department facilitating admissions at all three acute care hospitals

Centralized Placement (TAT-A)

ED Throughput (TAT-D)

Urinalysis Unit-Based Bed Control Radiology

Phase I CarryoverED Patient Focus ED Patient Focus

Addendum C

19

General Overview of Projects‐ Each project includes all three campuses to assure consistency ‐ Top down support from administration and facility leadership‐ Charter and work plan created for each project‐ Collaborate and agree upon improvement metrics‐

Recommendation

Urinalysis Radiology TAT -D TAT-A

Timeline 1-2 month 3-6 months 3-6 months 6-12 months

Difficulty to Implement

Low Medium Medium High

Risk Factor Low Low Low Medium

Project Lead Joanne Barnett Michael Barnett Nick Metzger/Michelle Gunnett

Kimberly Lopez

Project Sponsor Tim Barlow Mark Reyes Kim Colonnelli Joy Gorzeman

•Patient placement pilot•Throughput scorecardTAT-A

•Standardize discharge work flow from practitioner and nurse

•Improve triage and intake processTAT-D

•Standardize physician ordering•Pilot collection process for urine and portable

ultrasound for imaging

Imaging and Urinalysis

•Redefine admission criteria•Standardize bed huddle

Unit Based Management

Recommendation

See Addendum Slides for More Details

Addendum C

20

Centralized Placement

Department

Housekeeping

Transport

Direct Admission

Outreach

Intra- facility Transfer

Facility Admissions

and Throughput

A Major Culture Change

Who is involved??Centralized Patient Placement includes:

o Patient Access o Registration/Admittingo House Supervisoro ED Flow Facilitatoro Unit Supervisors / Charge Nurses o Bedside Nurseso Clinical Resource Managemento Transporto EVS

Addendum C

21

Step 1• Orders are placed in Clarity/Teletracking

Step 2• Requests are reviewed by the Centralized

Placement Department and a bed is assigned

Step 3• Report is then called to floor and the patient is

transported to floor

Recommendation

Overall TAT-A Goals: Patient ED arrival to patient in admitted bed = 220 mins Admit order to patient in bed = 60 mins Ready bed assigned to patient in bed = 30 mins

Addendum C

22

Monitoring for Success

Monitoring for Success

Addendum C

23

Monitoring for Success

Patient Flow Phase II focuses on Five Primary Projectso Turnaround Time for Admitted Patients from EDo Turnaround Time for Discharged Patients in EDo Turnaround Time for Urinalysiso Turnaround Time for Imaging Studieso Unit-based Daily Bed Huddles

All projects are well underway with project leads, plans, timelines and outcome measures

Pilot projects are being conducted on all three campuses

A Throughput Dashboard is being developed to monitor success in the areas of admissions, efficiency, and discharges

Addendum C

24

Plunkett PK, Byrne DG, Breslin T, Bennett K, Silke B. Increasing wait times predict increasing mortality for emergency medical admissions. Eur J Emerg Med. 2011 Aug;18(4):192-6. doi: 10.1097/MEJ.0b013e328344917e. PubMed PMID: 21317786.

Hospital Compare. (2014, May). Retrieved May 4, 2014, from Medicare. Gov: http://www.medicare.gov/hospitalcompare/Data/Measures.html

Hospital Compare. (2014, May). Retrieved May 4, 2014, from Medicare. Gov:

http://www.medicare.gov/hospitalcompare/profile.html#profTab=2&vwgrph=1&ID=050115&loc=ESCONDIDO%2C

%20CA&lat=33.1192068&lng=-117.086421&name=PALOMAR%20HEALTH%20DOWNTOWN%20CAMPUS

Addendum C

25

Centralized Placement (TAT-A)

ED Throughput (TAT-D)

Urinalysis Unit-Based Bed Control Radiology

Five Primary Focus Projects – Progress to Date

Focus – Create a centralized bed placement system that works as a single entry point for all admissions and transfers for all hospitals:

o Improve throughputo Decrease length of stayo Decrease the number of patients that leave the ED without being

seeno Improve customer satisfactiono Improve quality of care

Pilot Projects Underway – Mon to Wed a non-clinician and Administrative Supervisor are working in a central location to standardize and streamline how patients move through the hospital

Addendum C

26

Outcomes -o Decreased ED arrival time to admission time by 100 minutes on

pilot dayso Identified barriers in moving patients through the hospitalo Switched the work load of a ED patient flow nurse back into

patient care

Next Steps -o Incorporate Pomerado Hospital into centralized placement

processo Centralize transport and housekeeping leads for

deployment of resources based upon centralized patient placement needs

o Partner with Clinical Resource Management for patient placement into correct billing status on the front-end

Focus –o Current state of turnaround time to discharge and overall patient

length of stays in Emergency Departments are well above the desired benchmark metrics for ED patient throughput standards.

o Implementation of standardized throughput processes system-wide create greater focus and accountability for all staff, improve provider and staff communication, and increase patient satisfaction and decrease overall throughput times.

Pilot Projects Underway – See Next Slides for Detailso Implementation of a Standardized Discharge Process at all EDs.o Initial Implementation at PHDC ED

Addendum C

27

43 43

44 44

Addendum C

28

Outcomes –o First 2 weeks of Standardized Discharge (DC) Process Pilot

(PHDC ED) Median “DC Order to Door” Time: ~14min Majority of Patients “DC Order to Door” Time: <10min Unprecedented ED Provider / nursing collaboration during

project implementation Next Steps –

o IT updates at PMC and Pomerado preparing for DC process o Simplification / re-design of staff education plan o ED Standardized DC Process rollout at Pomerado ED

• Planned May 27o ED Standardized DC Process rollout at PMC ED

• Planned June 9o Complete system-wide ED reports needs/design

Focus –o Imaging goal is to decrease the order to completion time on every

order/test from the ED by 10 minutes in all modalities, Ultrasound (US), CT, MRI, and Diagnostic Imaging.

Pilot Projects Underway -o US pilot started on 4/16/14o All non-invasive ED studies will be performed at the bedside

by the sonographers. o This is roughly 69% of the orders and the remaining ED studies

will be conducted in the US rooms as before.o This goal will be accomplished by standardizing the order

sentences in Clarity, maximizing the sonographers productivity by improving their workflow and minimizing staffing issues.

Addendum C

29

Outcomes – See Next Slide for Detailso Pilot goal currently not met.

o TAT trending down in a positive direction over timeo Staffing related issues have impeded progresso US work flow not consistent among technicians

Next Steps –o Work with the US Lead to standardize work flowo Continue to monitor and measure the piloto Begin pilots on other imaging modalities when US pilot more

hardwired

US exam TAT for studies performed at PMC ordered by the EDAs of May 8, 2014

0:00

0:15

0:30

0:45

1:00

1:15

1:30

1:45

0

5

10

15

20

25

30

35

n

Baseline Volume

Median

Baseline Time

Poly. (Median)

Addendum C

30

Focus –o Decreasing turnaround time from order to urine specimen

collection to 20 minuteso Decreasing turnaround time from order to completion to 60

minutes

Pilot Projects Underway –Conducting pilot at Pomerado ED

o Identified 8 most common chief complaints where urinalysis would likely be needed

o Obtaining urine specimen right after triage and holding specimen until order is entered in Clarity

o “Beaker” icon added to tracking board to include UA not collected within 30 min

o Colored placard to identify patients still needing to provide a specimen so all staff are aware of need

Outcomes – See Next Slide for DetailsOverall mixed results

o Turnaround time from order to collect well below target some days with significant outlier times on other days

o Turnaround time from order to complete mirrors the order to collect data

Next Steps –o Work with ED physicians to change standard clean catch urine

specimen orders to include straight catheter order if no specimen collected within 30 min of order

o Pilot new process at PMC after TAT-D and Imaging pilots are further hardwired

Addendum C

31

POM ED UA Specimen Collection Time Minutes From Order to Specimen Collection 

0102030405060708090

100110120130140150160170180190200210

4‐Apr

6‐Apr

8‐Apr

10‐Apr

12‐Apr

14‐Apr

16‐Apr

18‐Apr

20‐Apr

22‐Apr

24‐Apr

26‐Apr

28‐Apr

30‐Apr

2‐M

ay

4‐M

ay

6‐M

ay

Average Daily Minutes to Collect

Order to Collect

Order to Complete

April 9, 1st day of pilot

Minutes

Order to Collect Target = 20

5/12/2014

*357 minutes on 24‐Apr

Order to Complete Target = 60

Focus -Patient Placement procedure:

o Redesign the patient placement procedure to decrease the possibility of multiple interpretations

o Decrease the rigid guidelineso Allow more flexibility on where patients are placed

Bed huddles:o Standardize the bed huddle process at both PMC and Pomeradoo Improve communication on admissions, discharges and transfers o Identify barriers with discharging patients

Pilot Projects Underway –o Charge nurses at PMC and Pomerado are using a new bed huddle

template as a tool to report out their unit’s activities; Notifying inpatients units of ED saturation and removing the “ black out” times for inpatient admissions

Addendum C

32

Outcomes o Teletracking up to date and accurateo Improved communication at huddleso Increased awareness of all units’ bed situationso Consistent huddle meeting 4x a day at both campuses

Next Steps o Only use technology for bed huddle report (eliminate written tool)o Present proposed changes to bed placement procedure to medical

staff and nursing committees across the organization

Addendum C

33

Nu

rsin

g Pe

er R

evie

w

Palo

mar

Hea

lth

Mar

ia S

ud

ak R

N, M

SN, C

CR

N, N

EA-B

C

Clin

ical

Lea

der

ship

Co

un

cil

May

7, 2

01

4

EMT

Safe

ty &

Ser

vice

M

ay 1

3, 2

01

4

QM

C

May

14

, 20

14

B

QR

C

May

19

, 20

14

Addendum D

34

2 T

rack

s e

Rev

iew

Ch

ange

s In

tro

du

ctio

n

Nu

rsin

g C

olle

agu

es, w

ith

th

e as

sist

ance

of

a ve

ry e

ner

gize

d a

nd

en

gage

d s

taff

pee

r re

view

co

un

cil a

nd

Tra

ci F

icke

l we

w

ill b

e m

akin

g re

visi

on

s to

th

e p

eer

revi

ew q

ues

tio

ns

in e

Rev

iew

se

t to

go

live

wit

h e

valu

atio

ns

com

ing

du

e s

tart

ing

July

1.

Situ

atio

n

The

team

sta

rted

wit

h t

he

ori

gin

al q

ues

tio

ns

and

des

crip

tio

ns

wit

hin

eR

evie

w a

nd

wo

rked

to

fo

rmu

late

mea

nin

gfu

l st

atem

ents

/qu

esti

on

s th

at w

ill o

ffer

sta

ff fe

ed

bac

k o

n t

hei

r p

ract

ice

wh

ile s

imp

lifyi

ng

the

pro

cess

.

Bac

kgro

un

d

Pee

r Ev

alu

atio

n is

a c

reat

ive

way

to

ob

tain

fee

db

ack

fro

m t

ho

se w

ho

un

der

stan

d w

ho

yo

u e

mp

loye

e ar

e an

d w

hat

yo

u d

o

to c

on

trib

ute

at

wo

rk e

very

day

. It

is in

ten

ded

to

en

han

ce q

ual

ity

of

wo

rk a

nd

per

form

ance

.

The

pee

r re

view

pro

cess

sti

mu

late

s p

rofe

ssio

nal

ism

th

rou

gh in

crea

sed

acc

ou

nta

bili

ty a

nd

pro

mo

tes

self

-reg

ula

tio

n o

f p

ract

ice.

In a

dva

nce

of y

ou

r an

nu

al e

valu

atio

n, y

ou

will

be

aske

d t

o c

om

ple

te a

sel

f-ev

alu

atio

n a

s w

ell a

s 3

no

min

ate

pee

rs f

or

the

Pee

r R

evie

w p

roce

ss. Y

ou

r d

irec

t su

per

viso

r w

ill a

lso

be

req

uir

ed t

o s

elec

t 3

pee

rs t

o c

om

ple

te t

he

Pee

r R

evie

w p

roce

ss

for

you

.

Ass

ess

men

t

RN

sta

ff w

ill b

e as

ked

to

sco

re e

ach

of

the

10 q

ues

tio

ns/

stat

emen

ts a

nd

hav

e th

e ab

ility

to a

dd

a c

om

men

t. T

he

pee

r

revi

ew e

nd

s w

ith

2 r

efle

ctio

n q

ues

tio

ns

aski

ng

revi

ewer

s to

co

mm

ent

on

on

e at

trib

ute

th

at e

very

on

e sh

ou

ld k

no

w a

bo

ut

thei

r p

eer

and

on

e ar

ea t

hat

co

uld

be

imp

rove

d o

n.

Th

e d

om

ain

s ad

dre

ssed

wit

hin

Pee

r R

evie

w:

1. C

linic

al P

ract

ice

- Evi

den

ce B

ased

Pra

ctic

es

2.C

linic

al P

ract

ice

- P

atie

nt

Po

pu

lati

on

3.

Co

llab

ora

tio

n -

Inte

rper

son

al S

kills

4.

Co

llab

ora

tio

n -

Flex

ibili

ty

5. Q

ual

ity

- C

om

mit

men

t 6.

Qu

alit

y -

Dem

on

stra

tio

n

7. C

ult

ure

an

d C

arin

g - C

om

mit

men

t 8.

Cu

ltu

re a

nd

Car

ing

- Dem

on

stra

tio

n

9. E

du

cati

on

- C

om

mit

men

t 10

. Ed

uca

tio

n -

Dem

on

stra

tio

n

Rec

om

men

dat

ion

A

ll R

egis

tere

d N

urs

es w

ill c

om

ple

te t

he

Pee

r R

evie

w P

roce

ss w

ith

in e

Rev

iew

fo

r th

emse

lves

by

no

min

atin

g p

eers

an

d f

or

oth

ers

by

com

ple

tin

g th

e p

roce

ss w

hen

no

min

ated

.

Rea

d B

ack

Nu

rsin

g P

eer

Rev

iew

pro

mo

tes

safe

pra

ctic

e an

d p

rofe

ssio

nal

ism

.

The

new

fo

rmat

will

be

assi

gned

to

all

RN

s w

ho

se e

valu

atio

n is

co

min

g d

ue

in J

uly

1 a

nd

bey

on

d.

For

you

r an

nu

al e

valu

atio

n y

ou

are

ask

ed t

o n

om

inat

e 3

pee

rs a

nd

yo

ur

sup

ervi

sor

will

no

min

ate

3 p

eers

.

If y

ou

can

no

t co

mp

lete

th

e p

eer

revi

ew in

on

e si

ttin

g yo

u c

an c

lick

the

SAV

E an

d E

xit,

th

en c

om

e b

ack

late

r to

co

mp

lete

.

Nu

rsin

g P

ee

r R

evie

w C

ou

nci

l

•C

olla

bo

rati

ve S

tru

ctu

re

•St

aff

Co

un

cil

–C

hai

r =

Cat

hy

Jaco

bs

–C

o c

hai

r =

Kat

ie S

mit

hso

n

•Fa

cilit

ated

•Pa

ralle

ls M

edic

al S

taff

Pee

r R

evie

w

•Fo

cus

on

Nu

rsin

g P

ract

ice

•R

eco

gniz

e

–Ex

emp

lary

pra

ctic

e

–Sy

stem

Issu

es

–Ed

uca

tio

nal

Op

po

rtu

nit

ies

Addendum D

35

Def

init

ion

s ta

b

for

refe

ren

ce

Addendum D

36

Pro

vid

es y

ou

th

e

op

po

rtu

nit

y to

ad

d a

co

mm

ent

Addendum D

37

Allo

ws

you

to

fre

e

text

yo

ur

resp

on

ses

Addendum D

38

Addendum D

39

NU

RS

ING

PE

ER

RE

VIE

W I

S C

OM

NG

SO

ON

AR

E Y

OU

RE

AD

Y?

Cath

y

Jaco

bs

- C

hair

R

N,

PM

C E

D

Kati

e S

mit

hso

n -

Co

Ch

air

R

N,

PO

M C

C

Kim

L

op

ez

Faci

lita

tor

Lis

a

Wri

gh

t R

N,

Flo

at

Po

ol

Lo

urd

es

Jan

usz

ewic

z

Faci

lita

tor

Mari

a

Su

dak

F

aci

lita

tor

MJ

McN

utt

R

N,

PM

C O

BS

Patr

icia

N

oo

nan

R

N,

Flo

at

Po

ol

Pat

Bu

shn

ell

R

N,

PM

C E

D

Ter

ri

Bad

agli

acc

o-C

abre

ra

RN

, P

MC

RR

N

Addendum D

40

A

NA

6 P

rin

cip

les

of

Peer

Rev

iew

A p

eer

is s

om

eon

e o

f th

e sa

me

ran

k.

Peer

rev

iew

is p

ract

ice

focu

sed

.

Feed

bac

k is

tim

ely,

ro

uti

ne

and

a c

on

tin

ual

ex

pec

tati

on

.

Peer

rev

iew

fo

ster

s a

con

tin

uo

us

lear

nin

g cu

ltu

re

of

pat

ien

t sa

fety

an

d b

est

pra

ctic

es

Feed

bac

k is

no

t an

on

ymo

us.

Feed

bac

k in

corp

ora

tes

the

dev

elo

pm

enta

l sta

ge o

f th

e n

urs

e.

Addendum D

41

Pro

ject

Pla

n T

imel

ine

July

20

13

•Pla

nn

ing

of

Co

un

cil S

tru

ctu

re

•Cri

teri

a an

d T

oo

l Dev

elo

pm

ent

star

ted

•Rev

iew

of

staf

f co

nce

rns

and

fea

rs

•Rev

iew

of

Pati

ent

Car

e St

and

ard

s

Au

gust

20

13

•Ove

rvie

w o

f P

hys

icia

n P

eer

Rev

iew

Pro

cess

•Rev

iew

of

AN

A S

tan

dar

ds

•Det

erm

ine

Team

Pu

rpo

se

•Beg

in d

efin

ing

Stee

rin

g Te

am

Mem

ber

ship

Sep

tem

be

r 2

01

3

•Def

inin

g th

e n

eed

fo

r a

Peer

Rev

iew

•Rev

iew

of

ISB

AR

R

•Def

ine

Co

un

cil m

emb

ersh

ip &

C

ou

nci

l Str

uct

ure

•Rev

iew

of

the

6 S

tep

s o

f Pe

er R

evie

w

Oct

ob

er

20

13

•Rev

iew

of

feed

bac

k fr

om

Au

gust

P

rese

nta

tio

n

•eR

evie

w P

eer

Rev

iew

pro

cess

•Rev

ise

qu

esti

on

s fo

r th

e eR

evie

w

Peer

Rev

iew

Pro

cess

No

vem

be

r 2

01

3

•Rev

iew

an

d F

inal

ize

eRev

iew

q

ues

tio

ns

pro

po

sed

•Les

son

s le

arn

ed f

rom

Med

ical

St

aff

Peer

Rev

iew

De

cem

be

r 2

01

3

Jan

uar

y 2

01

4

•Pro

ced

ure

wri

tin

g an

d r

evis

ion

s

•Ch

art

revi

ew /

pee

r re

view

pro

cess

as

a g

rou

p f

or

pra

ctic

e

Feb

ruar

y 2

01

4

•Des

ign

an

d c

reat

e ed

uca

tio

n

•Cre

ate

talk

ing

po

int

to g

o o

ut

to

RN

sta

ff a

nd

org

aniz

atio

n

•Ch

ose

Ch

air,

Co

-Ch

air

and

Fa

cilit

ato

rs f

or

Edu

cati

on

an

d

Pro

ced

ura

l Pro

cess

Mar

ch 2

01

4

•Ed

uca

tio

n M

on

th

•In

corp

ora

te le

arn

ing

bo

oth

at

skill

s d

ays

•Bu

ild M

idas

Rep

ort

Addendum D

42

Pro

ject

Pla

n T

imel

ine

Ap

ril 2

01

4

•Pre

sen

tin

g ed

uca

tio

nal

ou

tlin

e at

Pro

fess

ion

al P

ract

ice

Co

un

cil

•Pre

sen

tin

g ed

uca

tio

nal

ou

tlin

e at

Sta

ff o

n S

afet

y

•Bu

dge

t p

rop

ose

d f

or

25

mem

ber

s

•Ski

lls D

ay: P

ost

er, F

lyer

s an

d A

pp

licat

ion

•Ret

reat

4/3

0

•Fin

aliz

e M

emb

ersh

ip, P

roce

du

re, a

nd

Ed

uca

tio

nal

Pro

cess

•Des

ign

to

wn

hal

ls/

foru

ms

for

qu

esti

on

s an

d a

nsw

ers

•Rec

ruit

men

t -

ho

w a

nd

wh

ere?

•Rev

iew

list

of

case

s an

d c

ho

ose

on

es t

o r

evie

w in

May

•Rev

iew

ab

stra

ct f

or

CA

LNO

C c

on

fere

nce

in O

cto

ber

May

20

14

•GO

LIV

E

•Pre

sen

tin

g ed

uca

tio

nal

an

d p

roce

du

ral o

utl

ine

to L

ead

ersh

ip

•Rev

iew

mem

ber

ship

ap

plic

atio

ns

Addendum D

43

Addendum D

44

Emai

l Bo

x:

NPe

erR

evie

w

Addendum D

45

Exem

pla

ry C

are

Le

tter

of

Inq

uir

y Le

arn

ing

Op

po

rtu

nit

y N

o Is

sue

Addendum D

46

Nu

rsin

g Pe

er R

evie

w S

har

ed G

ove

rnan

ce R

epo

rtin

g St

ruct

ure

Addendum D

47

Co

nfi

den

tial

ity

Gu

ide

lines

•

The

nu

rsin

g re

view

co

mm

itte

e fu

nct

ion

s in

acc

ord

ance

wit

h

the

req

uir

emen

ts o

f th

e C

alif

orn

ia N

urs

e P

ract

ice

Act

.

•Th

at a

rtic

le p

rovi

des

per

son

s p

arti

cip

atin

g in

go

od

fai

th in

th

e p

eer

revi

ew p

roce

ss w

ith

ext

ensi

ve p

rote

ctio

n a

gain

st

incu

rrin

g ci

vil l

iab

ility

bec

ause

of

thei

r p

arti

cip

atio

n.

•W

ith

ou

t su

ch p

rote

ctio

n, i

t w

ou

ld b

e ve

ry d

iffi

cult

fo

r p

eer

revi

ew c

om

mit

tees

to

op

erat

e.

•It

is n

eces

sary

to

pro

tect

no

t o

nly

th

e n

urs

e b

ein

g re

view

ed,

bu

t al

so t

o f

acili

tate

th

e o

pen

dis

cuss

ion

of

op

inio

ns

by

mem

ber

s an

d o

ther

par

tici

pan

ts in

th

e p

roce

ss.

•V

iola

tin

g th

ese

con

fid

enti

alit

y p

rovi

sio

ns

cou

ld r

esu

lt in

ex

po

sure

to

civ

il lia

bili

ty b

oth

fo

r th

e p

erso

n b

reac

hin

g co

nfi

den

tial

ity

and

th

e co

mm

itte

e it

self.

•Th

e fo

llow

ing

guid

elin

es a

re d

esig

ned

to

ass

ist

par

tici

pan

ts t

o

avo

id a

ny

inad

vert

ent

bre

ach

es o

f co

nfi

den

tial

ity.

Addendum D

48

Nu

rsin

g Pe

er R

evie

w P

roce

du

re D

RA

FT

I. P

UR

PO

SE:

•To

en

sure

th

at t

he

ho

spit

al, t

hro

ugh

th

e ac

tivi

ties

of

its

nu

rsin

g st

aff,

asse

sses

th

e p

erfo

rman

ce o

f in

div

idu

als

(em

plo

yee

or

con

trac

tor)

an

d

use

s th

e re

sult

s o

f su

ch a

sses

smen

ts t

o im

pro

ve c

are.

II. G

OA

LS:

•C

reat

e a

cult

ure

wit

h a

po

siti

ve a

pp

roac

h t

o p

eer

revi

ew b

y re

cogn

izin

g p

ract

itio

ner

exc

elle

nce

as

wel

l as

iden

tify

ing

imp

rove

men

t o

pp

ort

un

itie

s.

•M

on

ito

r in

div

idu

al n

urs

es’ p

erfo

rman

ce in

an

eff

ort

to

imp

rove

qu

alit

y o

f ca

re’

•Id

enti

fy o

pp

ort

un

itie

s fo

r p

erfo

rman

ce im

pro

vem

ent.

•M

on

ito

r si

gnif

ican

t tr

end

s b

y an

alyz

ing

aggr

egat

e d

ata.

•En

sure

th

at t

he

pro

cess

fo

r p

eer

revi

ew is

cle

arly

def

ined

, fai

r, d

efen

sib

le,

tim

ely,

an

d u

sefu

l.

Addendum D

49

Addendum D

50

Qu

esti

on

s

Addendum D

51

5/12/2014

Initiative Status:

EDW

•Initial build

 for Phase I (Cerner Data) nearly complete

•Started Business Objects training for analysts rep

orting across 

multiple divisions

•Completion of Phase I scope now targeted for March 1.

•Phase One is complete –planning for Phase 2 with Decision 

Support Steering

Truven

•Quality Nurses actively extracting core m

easures into Truven

•Action 0I hand‐off to Finance/Human

 Resources complete

•CareD

iscovery

Advance down load

 complete.  Planning for 

next step

s through

 Decision Support Steering

Initiative Risks:

•Must develop and adhere to the guidelines of the Decision 

Support Advisory Group before EDW/Truven rep

orts are 

created to assure m

axim

ization of resources, appropriate 

prioritization and avoidance of duplicative rep

orting.

Outcome M

easure:

•Threshold: Implemen

t Phase 1 scope of ED

W or achieve 

Phase 1 parallel go‐live for Truven Analytics

•Target:  Im

plement Phase 1 scope of ED

W and achieve Phase 

1 parallel go‐live for Truven Analytics

•Maxim

um: Implemen

t Phase 1 scope of ED

W and achieve 

Phase 1 final  go‐live for Truven Analytics

Milestones:  

A.  In

itiate development of an

 Enterprise Data Warehouse (ED

W)

1.

Select EDW solution partner

2.

Create a decision support advisory group, rep

orting to IT

 Governance

3.

Develop work plan to achieve Phase 1 scope

4.

Implemen

t Phase 1 Scope

B.  Partner with VHA/Truvenan

d im

plement an

alytic toolset

1.

Hold stakeholder presentations and determine required resources

2.

Develop im

plemen

tation project plan and allocate resources

3.

Begin build

 of Care Discovery Quality Measures (CDQM) and Action OI

4.

Begin submitting CY13Q3 data into CDQM parallel w

ith Premier and validate 

accuracy

5.

Begin build

 of CareD

iscovery

Advance

6.

Begin submitting CY13Q4 data using CDQM and exit Premier contract

7.

Submit FY14Q1 data into Action OI (data available for use within 45 days)

8.

Submit data into CareD

iscovery

Advance (available for use within 30 days)

Report Date:A

pril 25, 2014

Reporting Committees:  Board Finance, EMT System

s and Resources

EMT Sponsors: B

ob Hem

ker, Opal Reinbold

Initiative M

anagers: R

yan Olsen

 (ED

W), Chris Bryan

 (Truven)

Physician Lead

er(s): Kolins, M

D, Lee, M

D, Kanter, M

DOutcome Measure:  Develop and im

plemen

t an

 Enterprise Data 

Wareh

ouse and Analysis Tool kit   

July 13

June 14

Initiative Budget:  To be included

 in FY14 Budget    

Budget Status: 

Jan 14

Mar 14

Sept 13 

Nov 13

A2

A4

A3

A1

May 14

B6

B2

B3B4B5

B1

FY

14 O

per

atio

nal

Init

iati

ve 1

:B

uild

and

ope

rate

a d

ecis

ion

anal

ytic

s st

ruct

ure

that

sup

port

s th

e re

al ti

me

avai

labi

lity

and

stan

dard

ized

use

of i

nfor

mat

ion

and

expe

rtis

e fo

r kn

owle

dge

man

agem

ent a

nd m

easu

rem

ent o

f va

lue

base

d m

etric

s of

car

e.

B7

B8

Addendum E

52

5/12/2014

FY

201

4 –

2017

Mile

sto

nes

FY2014 M

ilestones

FY2015 M

ilestones

FY2016 M

ilestones

FY2017 M

ilestones

•Select EDW solution 

partner

•Create a decision support 

advisory group, reporting 

to IT Governance  

•Develop EDW work plan 

to achieve Phase 1 scope

•Im

plemen

t ED

W Phase 1 

Scope

•Im

plemen

t threeTruven 

Analytic tools, 

CareDiscovery

Quality 

Measures, CareDiscovery

Advance, and Action OI

•Use Truven data to 

prioritize opportunities 

and begin im

plementing  

changes

Utilizing the data wareh

ouse 

and proactive tool sets, create 

a data analytics support 

structure to address:

•Business planning

•Concurrent clinical decision 

support

•Clinically integrated

 inform

ation technology 

platform

 (in support of 

shared

 management 

processes for providers, 

nursing and clinical support 

staff) across the continuum 

to support efficient and 

effective support of 

population health across 

all settings

•Pr ovides support to m

eet 

the changing regulatory 

and public data reporting 

needs

•Move toward a fully 

integrated

 inform

ation 

and knowledge transfer 

support structure to 

manage Palomar Health 

populations efficien

tly and 

effectively in a tim

ely 

manner to assure 

flexibility and rapid 

change in

 response to the 

market place

•Obtainfeed

back from 

users on effectiven

ess of 

initial EDW capabilities 

•Fully dep

loy the data 

analytics tool kit across the 

continuum to facilitate

an 

integrated

  “plug and play” 

capability to m

eet rapidly 

changing market driven 

needs for population 

health m

anagement

Operational In

itiative 1: Create an

 integrated data analytics support process to enable proactive business 

planning, nim

ble reaction to new

 market changes  that is automated, concurrent and tim

ely.

EMT Sponsors: Opal Reinbold, B

ob Hem

ker

2

Addendum E

53

5/12/2014

FY

14 O

per

atio

nal

Init

iati

ve 2

:C

reat

e a

posi

tive

expe

rienc

e fo

r al

l key

sta

keho

lder

s by

impr

ovin

g cl

inic

al a

nd

busi

ness

thro

ughp

ut a

nd e

ffici

ency

thro

ugh

all t

rans

ition

s of

car

e.

Outcome M

easure:  

1.

HCAHPS real tim

e top box results for Ra

te Hospital 0‐10for 

each hospital

2.

Press Ganey

survey results for physicians and employees

Initiative Status:

•Charters, m

ilestones, and outcome measures developed

 for 5 Patient Flow sub‐

group projects.; all projects are being actively worked

 on; Pilot projects are 

underway in all 5 areas; dashboard created

 for ongoing monitoring

•Dyad developmen

t Modules  2, 3, 4

 and 5 of AAPL are complete; M

odule 6 

sched

uled for 4/26.  Consolidated

 dashboards for dyads completed 

•Em

ployee En

gagemen

t Survey closed at 76% response rate and with a 50%th 

percentile overall score.  Physician Engagemen

t Survey closed with 54% response 

rate and an 18t

hpercentile overall score.

•Hourly rounding, bed

side shift report, and executive rounding im

provemen

t bundles from the IHI/VHA Collaborative have been im

plemen

ted.  Audits being 

developed

 for compliance. 

•3 Patient and Fam

ily Advisor, Facility‐Specific Focus groups are sched

uled for the 

last week in April. Results from Focus Groups to be review

ed at May PFA

C 

Steering Committee Meeting.

Milestones: 

1.

Create a standardized

 patient flow process to enhance 

efficien

cy and satisfaction for all key stakeholders

2.

Engage the med

ical staff  to m

axim

ize efficien

cy and to enhance 

patient care, safety and service (Dyads)

3.

Implemen

t and spread

 best practices across the health system 

from activities learned

 by participation in the IHI/VHA 

Collaborative

4.

Further the plan to engage the hearts and minds of the staff and 

med

ical staff in

 developing respectful partnerships with 

patients/fam

ilies and each other (Patient/Family Advisor Role)

Report Date:  April 29, 2014

Reporting Committees:  Board Quality Review Committee, EMT 

Safety and Service

EMT Sponsor: Sheila Brown, O

pal Reinbold, Lorie Shoem

aker

Initiative M

anager:  Tina Pope, Leslie Solomon, M

aria Sudak 

Physician Lead

er: Pasha, M

D, Kolins, M

D, B

uringrud, M

D,  Martin, 

MD

Initiative Risks

•Competing priorities

•Financial constraints

Jul 13

Jun 14

Initiative Budget:  To be included

 in FY14 Budget

Budget Status:

Outcome M

easures: 

•HCAHPS Target: 80% top box percentage fo

r both hospitals

•Press Gan

ey Physician Engagement Target: 35% Overall Score

•Press Gan

ey Employee Engagement Target: 75% Overall Score

Overall Outcome M

easure:

Threshold: 1 of 3 m

et at target level

Target: 

2 of 3 m

et at target level

Maxim

um:3 of 3 m

et at target level

Sept 13

Nov 13

Jan 14

Mar 14

May 14

12

34

1

HCAHPS Results:

PMC Q1: 79%

PMC Q3: 81%

POM Q1: 66%

POM Q3: 66%

PMC Q2: 76%

PMC Q4:

POM Q2: 69%

POM Q4:

Addendum E

54

5/12/2014

FY

201

4 –

2017

Mile

sto

nes

FY2014 M

ilestones

FY2015 M

ilestones

FY2016 M

ilestones

FY2017 M

ilestones

•Create a standardized

 flowprocess  

to enhance efficiency and 

satisfaction for all key stakeholders 

(Throughput)

•En

gage the m

edical staff to m

axim

ize 

efficien

cy and to enhance patient 

care, safety and service (on‐boarding 

new

 hospitalists; Med

ical/N

ursing 

Director Dyad education)

•Im

plemen

t and spread

  best 

practices across the health system 

from activities learned

 by 

participation in the IH

I/VHA 

Collaborativ e

•Further the plan to engage the 

hearts and m

inds of the staff and 

med

ical staff in developing 

respectful partnerships 

(patient/family advisor role and 

infrastructure)

•Expand patient flow to 

the continuum to 

maxim

ize the efficiency 

and effectiven

ess of care 

and key stakeholder

satisfaction

•Hardwire Med

ical/N

ursing

Director dyad model with 

a structure, goal setting, 

metric review

 and 

ongoing im

provement 

process

•Expand involvem

ent of 

patients and fam

ilies in

 evaluation of care and 

satisfaction with 

particular em

phasis on 

Centers of Excellence 

•Broaden

the 

Med

ical/N

ursingDirector 

dyad m

odel to an 

integrated

 model that 

includes patients and 

families with an emphasis 

on population 

management to im

prove 

revenue capture and 

efficien

cies  across the 

continuum of care 

•Utilize the 

integrated

 model to 

assure flexibility and 

nim

bleness to 

respond to the 

changing healthcare 

environment 

through

 affiliations 

and emerging 

financial m

odels

Operational In

itiative 2:  Create a positive experience for all key stakeholders by im

proving clinical and business 

throughput and efficiency through

 all transitions of care. 

EMT Sponsors: Sheila Brown, O

pal Reinbold, Lorie Shoem

aker

2

Addendum E

55