*

BOARD HUMAN RESOURCES COMMITTEE

Tuesday, July 19, 2016 Palomar Medical Center, 2185 Citracado Parkway, Escondido, CA 6:00 p.m. Meeting Raymond Family Conference Center, 2

nd Floor

NOTE: If you have a disability, please notify us 72 hours prior to the event so we may provide reasonable accommodations. 1

Five minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details and policy, see Request for Public Comment

notices available in meeting room

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM

Time

Form A Page

Target Time

CALL TO ORDER 6:00

Public Comments1 15

APPROVAL/INFORMATION ITEMS(S)

1. Approval Minutes from Tuesday, June 21, 2016 Hans C. Sison, Chair

(Addendum A, Pages 4-8)

2 X 6:15

2. Information Code Care John Van Cleef, Manager, Community Development and

Spiritual Care Val Martinez, Director, Quality and Patient Safety

(Addendum B, Pages 9-13)

15 X 6:17

3. Information HIPAA Guidelines Kim Jackson, Director, Health Information Services

Robin Ford, Manager, Information Systems Security

(Addendum C, Pages 14-20)

20 X 6:32

4. Information Standing Item: Balanced Scorecard Heathcare Staffing Susan Gray, Director, Workforce Management

(Addendum D, Pages 21-29)

20 X 6:52

Public Comments1 15 7:12

ADJOURNMENT 7:27

Human Resources Committee, Voting Members

Hans C. Sison, LVN, Director, Chair Jeff Griffith, EMT-P, Director Ray McCune, RN, Director

Human Resources Committee, Alternate Voting Member

Jerry Kaufman PTMA, Director

Human Resources Committee Non-Voting Members Bob Hemker, President & CEO Brenda Turner, EVP Human Resources Frank Beirne, EVP, Operations

Jeanette Skinner, VP, POM/PHDC Maria Sudak, VP, Interim CNO, PMC Beverly Albers, Committee Secretary

Code CARE

TO: Human Resources Committee MEETING DATE: July 19, 2016 FROM: John Van Cleef, Manager, Community Development and

Spiritual Care BACKGROUND: Code CARE was developed following an adverse event last

fall. During the RCA for this event, staff expressed feelings of being unsupported by leadership. This discovery prompted an interdisciplinary team to gather and implement a scalable, system-wide response. Code CARE (Compassion, Acceptance, Resilience, Encouragement) is a peer-based approach to support staff and teams who experience an acute stressor and/or vicarious trauma in the course of providing care to others.

BUDGET IMPACT: N/A STAFF RECOMMENDATION: COMMITTEE QUESTIONS:

COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: X Required Time:

HIPAA Guidelines

TO: Human Resources Committee MEETING DATE: July 19, 2016 FROM: Kim Jackson, Director, Health Information Services

Robin Ford, Manager, Information Systems Security BACKGROUND: Informational presentation of the ongoing educational

efforts provided to Palomar Health workforce, in support of HIPAA/Information Security and Privacy – regulatory compliance.

BUDGET IMPACT: N/A STAFF RECOMMENDATION: N/A COMMITTEE QUESTIONS:

COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: X Required Time:

Balanced Scorecard: Healthcare Workforce Update

TO: Human Resources Committee MEETING DATE: July 19, 2016 FROM: Susan Gray, Director, Workforce Management BACKGROUND: This presentation provides an update regarding the state

of the healthcare workforce in the State of California, reviewing data from HASC and also review of HASC’s Specialty RN study.

BUDGET IMPACT: N/A STAFF RECOMMENDATION: N/A COMMITTEE QUESTIONS:

COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: X Required Time:

ADDENDUM A

1

Board Human Resources Committee Meeting

Attendance Roster and Meeting Minutes

Calendar Year 2016

MEETING DATES

MEMBERS 1/20/16 2/16/16

3/15/16 NOT HELD

4/19/16 NOT HELD

5/17/16 6/21/16 7/19/16 8/16/16 9/20/16 10/18/16 11/15/16 12/20/16

HANS C. SISON, CHAIR X X X X

JEFFREY GRIFFITH X X X X

RAY MCCUNE X X X

DARA CZERWONKA, SUBSTITUTE MEMBER X

JERRY KAUFMAN – ALTERNATE

EXECUTIVE MANAGEMENT

BOB HEMKER, PRESIDENT & CEO X X X X

BRENDA TURNER, EVP, HUMAN RESOURCES X X X X

FRANK BEIRNE, EVP, OPERATIONS X X

LARRY LABOSSIERE, INTERIM VP, PHDC AND POM X X X

MARIA SUDAK, INTERIM VP, PHC X X X X

DELLA SHAW, EVP, STRATEGY X X X

BEVERLY ALBERS, BOARD COMMITTEE ASSISTANT X X X X

LESLIE SOLOMON, VP CULTURE /TALENT PLANNING X X X

CHERYL OLSON, INTERIM VP, PHDC AND POM X

STAFF, PRESENTERS AND INVITED GUESTS

SHERRI ROMO, DIRECTOR, BENEFITS/HRIS X X X

SUSAN GRAY, DIRECTOR, WORKFORCE MGMT. X

MEL RUSSELL X X X

JESSICA KIM X X

NINA KIM, MGR, INTERNAL COMMUNICATIONS X

FRAN WALLER, DIR, COMMUNITY ENGAGEMENT X

BRAD KRIETZBERG, DIR, ORG LEARNING X X

JOE MOLINOSKI, LEARNING DEV FACILITATOR X X

JEANETTE EBALO-GANGOY, LEARNING DEV FAC II X

BOARD HUMAN RESOURCES COMMITTEE – MEETING MINUTES – TUESDAY, JUNE 21, 2016

CALL TO ORDER

The meeting, held in the Raymond Family Conference Center at Palomar Medical Center, 2185 Citracado, Escondido, CA 92025, was called to order at 6:00 p.m. by Chair Hans C. Sison

ESTABLISHMENT OF QUORUM

In attendance were Chair Sison, Director McCune, and Director Griffith

PUBLIC COMMENTS

Two individuals made public comments at the beginning of the meeting, and two individuals made comments at the end of the meeting

ACTION/APPROVAL ITEMS

1. MINUTES – MAY 17, 2016 MOTION: By Director Griffith, seconded by Director McCune, and carried to recommend approval of the Minutes from the Wednesday, May 17, 2016, meeting. All in favor, none opposed.

FINAL Y

A reading of the minutes was made

2. 415m AMENDMENT MOTION: By Director McCune, seconded by Director Griffith, and carried to recommend approval of the 415m Amendment. All in favor, none opposed.

FINAL Y

Sherri Romo relayed information regarding the 415m Amendment. It is a standing document which needs modification due to the creation of the Vice President, Culture and Talent Planning position which was accepted by the Committee to be forwarded to the full Board for approval.

INFORMATIONAL ITEMS

Orientations – Brad Krietzberg; Darcy Wright; Hope Kersh-Lingenfelser; Joe Molinoski

As presented by Brad Krietzberg, orientations are held in several areas of Palomar

NEO (New Employee Orientation) – Presented by Darcy Wright o Class is held on every employee’s first day o Average class size 20-30 for first day, predominantly regulatory issues

Topics include Compliance and Ethics; Infection Control and Life Safety; Abuse/ Neglect and Risk Management; Information Security and Privacy; and, Navigating the system, including computer access

o Average class size is 45 for second day which must be attended within 90 days, this class being more directed toward culture Topics covered are Mission and Values; Communication; history of Palomar Heath; Complementary Therapies; Quality, Safety

and Service; and, workforce support o Critical Success Factors include a warm welcome to all employees; providing a supportive learning environment; covering Joint

Commissions requirements; assisting new hires to access basic computer applications; and, promoting a patient first culture

NSO (Nursing Services Orientation) – Presented by Hope Kersh-Lingenfelser o This class is provided twice a month with three full days of class time o Topics covered are: Nursing Vision and Professional Nursing Practice; online resources; online resources; quality improvement, national

patient safety goals, core measures, nurse sensitive indicators; patient experience Press Ganey, HCAPHS; relationship based care model of nursing; cultural and spiritual care; computer documentation and medication administration

o Critical success factors include full coverage of regulatory material; patient-first culture using the Relationship Based Care nursing model; provision of Electronic Health Records (EHR) training

BOARD HUMAN RESOURCES COMMITTEE – MEETING MINUTES – TUESDAY, JUNE 21, 2016

NLO (New Leader Orientation) – presented by Darcy Wright o Average class size is ten and class is held every other month o The objective of this class is to share Palomar Health procedures/processes which relate to managing labor and non-labor expenses;

introduce individuals to experts through the system; provide tools and support to manage resources o Content for this course includes the recruitment process; union contracts; performance management; employee records; leaves of

absence; workforce compliance issues; workers compensation; employee engagement; quality and service excellence

NPO (New Provider Orientation) – Presented by Joe Molinoski o This program was launched a few months ago and only a few sessions have been held thus far o The course is offered monthly with breakfast for the 7-10 individuals attending. This includes an introduction to the Peer Mentor

program o Course content focuses on quality and service excellence, as well as finance o When Chair Sison asked what the Board can do to help with this program, it was suggested that the Board can assist by being an

advocate for it.

Balanced Scorecard – Employee Voice Survey – Leslie Solomon; Dionne Blaha

Leslie Solomon introduced Dionne Blaha who presented information on recent Press Ganey results

In preface, it was explained that employees need to be engaged throughout the organization for effective change to be made

Regularly scheduled surveys provide the best feedback and increased responsiveness and accuracy about perceptions

The annual employee engagement scores have changed upwards across the board with overall scores moving up from 50 percentile to 61, with the target percentile being 90. Villa Pomerado’s scores remain the highest, having moved from 83.2 to 90

The new dashboard system includes easy to understand snapshots of each measured area

Facility results numbers on the Pulse Survey questions have dropped but are each within an acceptable range

The Improvement strategy utilizes comparisons to hospital systems across the countryActions going forward to continue to improve our scores include Organizational Development support for action planning and LEAP training to build front-line leadership capabilities with include communication; development; feedback ability; and, recognition

ALICE Training Information – Bret Bandick

Palomar Health holds ALICE training classes to inform staff what to do in an Active Shooter situation. Bret Bandick has being providing this training at Palomar for six years. This last year, Bret has taught 25 security classes and 18 of them were ALICE training. Nine classes have been taught so far this year. It was explained that ALICE is an acronym for Alert, Lockdown, Inform, Counter, and Evacuate, and is designed to give individuals proactive options, empowering them to protect themselves and others. While escape is an option in an active shooter situation, fighting back is also a possibility – surprise being an advantage people have to resist and possibly overcome an attacker. It typically takes the police three to five minutes to get to the location of an active shooting incident, and can take as long as 15 minutes. In this time victims can best help themselves by not just hiding, but by barricading themselves if they cannot simply escape the situation. In response to the question as to whether Palomar is prepared to handle this type of a situation if it happened now, there is no good answer. In these classes, staff are taught to be a leader, but the fact is the public also inhabits our buildings daily, and are most likely untrained and would not know what to do. With regard to what the Board can do to assist in rolling out this training further, Board endorsement of the program would help to lend strength to the whole plan. When a question was raised about our security staff carrying firearms, Bret proposed that a police officer stationed at the hospitals would help, but

BOARD HUMAN RESOURCES COMMITTEE – MEETING MINUTES – TUESDAY, JUNE 21, 2016

additional training for security staff to allow them to carry firearms would not be the best avenue. A mock situation was proposed on what to do if someone broke into this Board Committee Meeting, and while their appearance would be a surprise to us, we could wreak havoc, also known as Throw and Go, by bombarding the invader with whatever items might be available to us: dishes, computers, chairs, tables, etc., as a first line of defense, then make every effort to get away while the attacker is disoriented. The Human Resources Board Committee was very interested, and would like information with regard to upcoming classes, or a class held for the full Board.

Code CARE – John Van Cleef

This presentation has been referred to next meeting.

With no further business to come before the Committee, the meeting was adjourned at 7:45 p.m. by Director Sison

SIGNATURES:

COMMITTEE CHAIR

Hans C. Sison

COMMITTEE SECRETARY

Beverly Albers

ADDENDUM B

7/12/2016

1

compassion acceptance resilience encouragement

Code CARE

What and Why?

Incident

• Recent adverse event

RCA

• RCA conducted

• Traumatic event

• Support after event

Code CARE

• Interdisciplinary team

• Code CARE

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Palomar

Health’s

mission

requires a

healthy,

world-class

workforce

supporting

a patient

first

culture…

Employee prescriptions

were filled in 2015 for

cardiovascular disease,

behavioral health, diabetes

and pain management

28,000 HOWEVER,

Employee Turnover

rose from 9.6% to

13.2%

ALSO

Hours of unscheduled PTO

in the past 12 months

OVER

85,000

AND

175 W/C injuries

700 FMLAs

in the past 12 months

AND

26% of employees self-report

Stress, Anxiety &

Overwhelm and

35% have less than optimal

health

Stress

Spectrum

Acute Incident Driven

Sub-acute The Effects of

Multi-day Stress

Chronic Enduring and On-going

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Acute Incident Driven

Sub-acute The Effects of

Multi-day Stress

Chronic Enduring and On-going

Code CARE

Something really bad just happened, and I need to talk

to someone…

Code CARE provides someone

with whom the person or team can talk

Acute Stressor | “I need to talk.”

Code CARE | “I’m here to listen.”

Assessment | “What happened?”

Appropriate Response | “How can I help?”

Follow-up | “How are you doing?”

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ADDENDUM C

7/12/2016

1

Privacy & Information Security Workforce Education

Kim Jackson, District Director Medical Records, PBX Communications, Privacy Officer

Robin Ford

Manager Information Systems Security

What is HIPAA

A large body of Federal legal requirements for the protection of patient privacy and information security.

Develop and follow procedures that ensure the confidentiality and security of protected health information when it is transferred, received, handled, or shared.

Applies to all forms of Patient Health Information (PHI), e.g. paper, oral, and electronic, etc.

Only the minimum health information necessary to conduct business is to be used or shared.

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2

Our training program should prepare our workforce to carry out: ◦ Their roles and responsibilities in safeguarding

patients’ health information and complying with the HIPAA Rules as supported by Palomar Health procedures.

Reinforce workforce training with reminders. ◦ Our ongoing education and reminders always tie

back to Palomar Health procedures

OCR Recommendations for HIPAA Education and the Workforce

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3

Ongoing Privacy & Information Security Training and Awareness

Regular On-Going Training and Awareness o Annual Safety Exam o Awareness Messages

Information Security - “CyberWatch” Awareness and Important Warning Messages

Privacy – Palomar Health Confidential Awareness Messages o Environment Of Care (EOC) Rounding o Mobile/Portable & Removable Storage Device Security User Agreement

Ad-Hoc Training o iXpand

Re-training Modules for Focused Remedial Training Updated training for Regulation Changes Removable Storage Device Security and User Agreement

o Move Preparedness Manager Awareness & Sign Off o Privacy/Information Security In-services

Snooping Awareness & Prevention

Annual Safety Privacy & Information Security

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Snooping Awareness & Prevention

Workforce Members Responsibilities

Understand and follow policies and department specific procedures appropriate to their role and responsibilities.

Protect information from unauthorized access, use and disclosure.

Notify your manager if tools or equipment are needed to help keep our patient information secure.

Maintain safeguards for protection of information.

Report and/or secure protected health information found unattended or unsecured.

Report known or suspected instances of unauthorized access, use or disclosure of confidential information.

Report suspicion that another individual may be using or sharing passwords.

Lucidoc Procedure – 11321 Privacy – Confidentiality and Access to Patient Information

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Management Responsibilities

It shall be the responsibility of Information Systems and the applicable Director/designee to assign the appropriate level of paper and electronic patient

information access for individual staff. Considerations will include job code, and job assignment in compliance with minimum necessary standard. Information

Systems may consult the Privacy Officer for questionable access requests.

Establishing safeguards to protect privacy and security of information, and

monitoring privacy and security on their work unit.

Establishing Business Associate Agreements as outlined in Palomar Health

procedure

Knowing and following procedures to report improper disclosures and other

violations

Adhering to Human Resource procedures for corrective action.

Notifying the appropriate departments of their workforce member termination.

Lucidoc Procedure – 11321 Privacy – Confidentiality and Access to Patient Information

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Plan of Correction

After an investigation is completed, the involved department(s) is required to complete a Plan of Correction (POC): ◦ Re-education

◦ Process Improvement

◦ Monitoring Process

◦ Preventing this type of incident from reoccurring

Questions?

ADDENDUM D

7/12/2016

1

Healthcare Workforce

Update

Susan Gray

Director, Workforce Management

Human Resources Board Committee

July 19, 2016

2015 Healthcare Survey Report

• Hospital Association of Southern California

• California Hospital Association

• Hospital Council of Northern & Central California

• Hospital Association of San Diego and Imperial Counties

• Future Sense

• University of California, San Francisco

7/12/2016

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Survey Participants

• 194 facilities - 174 acute care hospitals

• Other participants included:

– Rehab hospitals

– Children’s hospitals

– Ambulatory surgery center

– Orthopedic hospitals

2015 Annual Totals Turnover

Rate

Average Vacancy

Rate

CA Statewide (all positions) 10.4% 4.9%

CA Statewide Registered Nurse 10.8% 5.9%

No. CA (all positions) 10% 4.0%

No. CA Registered Nurse 9.8% 4.5%

So. CA (all positions) 10.8% 4.9%

So. CA Registered Nurse 11.6% 6.2%

San Diego, CA (all positions) 9.9% 9.6%

San Diego, CA Registered Nurse 11.5% 10.2%

Palomar Health (all positions) 12.9% 10.1%

Palomar Health, Registered Nurse 12.8% 11%

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RN Length of Service Before Termination

0%

5%

10%

15%

20%

25%

30%

35%

< 1 Year 1-2 Years 3-5 Years More than 5 years

Level of Difficulty in Hiring % indicating “Extremely Difficult”

0%

10%

20%

30%

40%

50%

60%

Direct Care RN RN -other Clinical LabScientist

Pharmacist PhysicalTherapist

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Top 3 Reasons for Difficulty in Hiring

• Lack of relevant work experience

• Low number of applicants

• Wages

Top 5 Concerns for Workforce Adequacy

1. Aging Workforce

2. Leaves of Absence

3. Impact of Healthcare Reform

4. Impact of Budget Cuts for Healthcare Education

5. Disability Accommodation and Physical Limitations

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Aging Workforce - % over Age 55

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

RN - DirectCare

RN - Other CNS CLS Pharmacists SocialWorkers

Palomar Health % over 50

0%

10%

20%

30%

40%

50%

60%

70%

80%

RN - DirectCare

RN- Other CNS CLS Pharmacist SocialWorker

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IMPACTS Limited Services Due to Vacancies

• Direct Care RNs – 42%

• RNs – Other - 29%

• Physical Therapists – 24%

HASC – Specialty RN Study

• Why is hard to find experienced RNs for Specialty Positions?

• What can be done about it?

• Partnered with HealthImpact to conduct a root cause analysis.

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Specialty Focus Areas

• Perioperative

• Critical Care

• Emergency

• Labor & Delivery

• Neonatal ICU

• Care Coordinator & Case Manager

Root Causes Identified by Supply & Demand

1. Loss of specialty nurses due to increased retirements

2. Turnover caused by intensity and stress of these work environments

3. High cost of recruitment and onboarding

4. Insufficient pre-licensure education specific to specialties

5. New demands of regulation

6. Increased acuity in these settings

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Recommendations

• Student Elective Courses for Specialty Roles

• RN Transition Programs for Specialty Roles

• Case Management and Care Coordination Course or Series

Next Steps

• Phase II: Regional Planning and Program Design

– Develop rollout plan to identify regional partners

– Design program and pricing structure

– Create evaluation and ROI measurement tools

• Phase III: Program Rollout and Communication

• Phase IV: Measure Program Impact, Adapt as Needed, Confirm Sustainability Plan