Board of Trustees

CLINICAL AFFAIRS COMMITTEE MEETING

April 15, 2019 - 11:00 a.m. - Libbey Hall, Second Floor, Main Dining Room

Sharon Speyer - Chair, Patrick J. Kenney - Vice Chair

Alfred A. Baker, Will Lucas - Trustees

Kyle D. Bergen, Hedyeh Elahinia - Student Trustees

Shobha Ratnam - Faculty Representative

Gary P. Thieman - Community Member

2. Action Items2. Action Items

-- University of Toledo Health Science Campus2018 Annual Evaluation of Environment of CareManagement Plans

a) Environment of Care, Life Safety and Emergencya) Environment of Care, Life Safety and EmergencyManagement Annual EvaluationManagement Annual Evaluation

Presentation for a)

3. Discussion Items3. Discussion Items

4. Education Items4. Education Items

5. Executive Session5. Executive Session

6. Other Business6. Other Business

11:00 a.m. 1. Call to Order1. Call to Order

a) Clinical Affairs Committee Meeting Minutes forFebruary 18, 2019

-- Annual Performance Evaluation for 2018

a) Faculty Research Highlight: State-of-the-ArtHypertension Research at The University of Toledo

Executive Session to discuss privileged informationrelated to the evaluation of medical staff personnelappointments and quality reporting

a) Approval of April Chief of Staff Report

7. Adjournment7. Adjournment

Clinical Affairs Committee Meeting - April 15, 2019Clinical Affairs Committee Meeting - April 15, 2019

AgendaAgenda

Minutes The University of Toledo Board of Trustees

Clinical Affairs Committee Meeting February 18, 2019

Committee Chair Ms. Sharon Speyer was present with Committee members Mr. Alfred A. Baker, Mr. Stephen P. Ciucci, Mr. Will Lucas and Student Trustee Mr. Kyle D. Bergen. Committee members absent included Mr. Patrick J. Kenney and Student Trustee Ms. Hedyeh Elahinia. Other Trustees who attended included Mr. Jeffrey C. Cole, Mr. Daniel J. Guttman, Mr. Birdel F. Jackson, III and Ms. Mary Ellen Pisanelli. Faculty Representative Dr. Shobha Ratnam and Community member Mr. Gary Thieman were absent. Others in attendance were Mr. Daniel Barbee, Dr. Christopher Cooper, Ms. Meghan Cunningham, Dr. Sharon Gaber, Mr. Charles Jake, Dr. Samer Khouri, Ms. Adrienne King, Ms. Diane Miller, Mr. Peter Papadimos, Mr. Matthew Schroeder, and Ms. Joan Stasa.

ATTENDANCE

The meeting was called to order at 11:30 a.m. by Trustee Speyer in Libbey Hall’s Main Dining room. Ms. Joan Stasa, Secretary to the Board, recorded the minutes.

CALL TO ORDER

Trustee Speyer requested a motion to waive the reading of the minutes from the December 17, 2018 Committee meeting and approve them as written. A motion for approval was provided by Trustee Baker, seconded by Trustee Lucas, and approved by the Committee.

APPROVAL OF MINUTES

Trustee Speyer requested a motion to enter Executive Session to discuss privileged information related to the evaluation of medical staff personnel appointments and quality reporting. The motion was received from Trustee Lucas, seconded by Trustee Baker. Roll call was taken by Ms. Stasa: Mr. Baker, yes; Mr. Lucas, yes; and, Ms. Speyer, yes. After discussions, the Committee exited Executive Session.

EXECUTIVE SESSION

Ms. Speyer requested a motion to approve the Chief of Staff Report as presented in Executive Session. A motion for approval of the report was received from Trustee Lucas, seconded by Trustee Baker, and approved by the Committee. The Chief of Staff Report is attached.

CHIEF OF STAFF REPORT

With no further business before the Committee, Trustee Speyer adjourned the meeting at 11:55 a.m.

ADJOURNMENT

CHIEF OF STAFF SUMMARY REPORT February 18, 2019

I. Initial Appointments - Physicians/Dentists Brochin, Kenneth, DDS Surgery/Dentistry Lobar, Bruce, MD Neurology Nandi, Tina, MD Medicine/Dermatology Schultz, Paul, MD Family Medicine II. Initial Appointments - Allied Health Professionals (AHPS) Graham, Amy, CNP Medicine/Hospice & Palliative Care Hartman, Jessica, CNP Surgery/General Surgery III. Reappointments - Physicians, Dentists, Psychologists

1. Abbas, Jihad, MD Surgery/Vascular Surgery Courtesy 2. Abouarrage, Adelle, DDS Surgery/Dentistry Courtesy 3. Balkany, Louis, MD Surgery/Vascular Surgery Membership Only 4. Baskara, Arunkumar, MD Surgery/General Surgery Active 5. Bourell, Lauren, DDS Surgery/Dentistry Courtesy 6. Branam, Stephen, DDS Surgery/Dentistry Courtesy 7. Brunicardi, Francis, MD Surgery/General Surgery Active 8. Cellier, Stephen, DDS Surgery/Dentistry Courtesy 9. Chaudhuri, Prabir, MD Surgery/General Surgery Active 10. Cohen, Michael, DDS Surgery/Dentistry Active 11. Czerniak, Lauren, DDS Surgery/Dentistry Courtesy 12. Dabiri, Darya, DDS Surgery/Dentistry Courtesy 13. Davis, William, DDS Surgery/Dentistry Active 14. Delos Reyes, Arthur, MD Surgery/Vascular Surgery Courtesy 15. Dietrich, Matthew, DDS Surgery/Dentistry Courtesy 16. Duckett, Timothy, MD Surgery/General Surgery Courtesy 17. Fahncke, Charles, DDS Surgery/Dentistry Active 18. Greenwood, Boley, DDS Surgery/Dentistry Courtesy 19. Greenwood, Courtney, DDS Surgery/Dentistry Courtesy 20. Haerian, Andre, DDS Surgery/Dentistry Courtesy 21. Heenan, Mark, DMD Surgery/Dentistry Courtesy 22. Ho, David, DDS Surgery/Dentistry Courtesy 23. Johnson, Houston, MD Surgery/General Surgery Membership Only 24. Klepacz, Heather, MD Surgery/General Surgery Active 25. Knierim, Erin, DMD Surgery/Dentistry Courtesy 26. Ludwig, Jennifer, DDS Surgery/Dentistry Courtesy 27. Martinez, Bernardo, MD Surgery/Vascular Surgery Courtesy

28. McCabe, Patrick, DDS Surgery/Dentistry Courtesy 29. McCullough, Daniel, MD Surgery/General Surgery Courtesy 30. Nakfoor, Matthew, DDS Surgery/Dentistry Courtesy 31. Nazzal, Munier, MD Surgery/Vascular Surgery Active 32. Nedley, Michael, DDS Surgery/Dentistry Active 33. Ortiz, Jorge, MD Surgery/General Surgery Active 34. Osman, Mohamed, MD Surgery/Vascular Surgery Active 35. Pace, Frank, DMD Surgery/Dentistry Active 36. Palmer, Lawrence, DDS Surgery/Dentistry Courtesy 37. Pannell, Stephanie, MD Surgery/General Surgery Active 38. Paulus, Ashley, DDS Surgery/Dentistry Courtesy 39. Sferra, Joseph, MD Surgery/General Surgery Membership Only 40. Shall, David, DDS Surgery/Dentistry Courtesy 41. Shall, Stephen, DDS Surgery/Dentistry Courtesy 42. Sprague, Philip, DDS Surgery/Dentistry Courtesy 43. Stanek, Stephen, MD Surgery/General Surgery Courtesy 44. Stengle, John, MD Surgery/General Surgery Membership Only 45. Tang, Jianlin, MD Surgery/General Surgery Active 46. Thomas, Richard, DDS Surgery/Dentistry Courtesy 47. Vicente, David, MD Surgery/Vascular Surgery Courtesy 48. Voss, Timothy, DDS Surgery/Dentistry Courtesy 49. White, Beth, MD Surgery/General Surgery Courtesy

IV. Reappointments - Allied Health Professionals

1. Bauer, Karen, CNP Surgery/Vascular Surgery AHP 2. Behnfeldt, Sarah, CNP Surgery/Vascular Surgery AHP 3. Elsayed, Khaled, CSA Surgery/General Surgery AHP 4. Hinkle, Megan, RNFA Surgery/General Surgery AHP 5. Horvat, Shelly, AUD Surgery/General Surgery AHP 6. Kamer, Corinne, RNFA Surgery/General Surgery AHP 7. Kaser, Rachel, CNP Surgery/Vascular Surgery AHP 8. Khandaker, Kathryn, CNP Surgery/Vascular Surgery AHP 9. Kirk, Jill, RNFA Surgery/General Surgery AHP 10. Koester, Melissa, RNFA Surgery/General Surgery AHP 11. Kunckel, Dale, CSA Surgery/General Surgery AHP 12. Lovett, Michele, RD Surgery/General Surgery AHP 13. Maldonado, Henrry, CNP Surgery/Vascular Surgery AHP 14. Mansour-Shousher, Randa, AUD Surgery/General Surgery AHP 15. Mason, Kristi, RD Surgery/General Surgery AHP 16. Mueller, Connie, CNP Medicine/Cardiology AHP 17. Nachman, Adam, RD Surgery/General Surgery AHP 18. O’Neill, Dawn, RD Surgery/General Surgery AHP 19. Randolph, Dianna, AUD Surgery/General Surgery AHP 20. Steer, Jeffery, CSA Surgery/General Surgery AHP

V. Additional/Withdrawal Privileges -None VI. Change in Staff Category - Physicians

1. Hashmi, Fayaz, MD- Surgery/CT Surgery – Approve request for a leave of absence until 8/31/19.

VII. Change in Staff Category - Allied Health Professionals - None

VIII. Removal from FPPE - Transition to OPPE - Physicians 1. Hanna, Maged, MD- Orthopedic Surgery- Approve removal from FPPE process and transition to

OPPE process. 2. Kovach, Julie, MD- Medicine/Cardiology- Approve removal from FPPE process and transition to

OPPE process. 3. Migliori, Jamie, MD- Psychiatry- Approve removal from FPPE process and transition to OPPE

process. 4. Ortiz, Jorge, MD- Surgery/General Surgery- Approve removal from FPPE process for additional

privileges in Wound Care and HBOT and transition into OPPE process. 5. Rees, Michael, MD- Urology- Approve removal from FPPE for additional privileges in lithotripsy

renal stone/ureteral stone and holmium lasers and transition into OPPE process. 6. Zoorob, Dani, MD- Obstetrics & Gynecology- Approve removal from FPPE process and transition

to OPPE process.

IX. Extension of FPPE - Physicians

1. Thornton, James, MD- Surgery/CT Surgery- Approve FPPE extension for six months due to limited clinical activity.

X. Removal from FPPE - Transition to OPPE - AHPs

1. Bush, Katie, CNP- Psychiatry- Approve removal from FPPE process and transition to OPPE process.

2. Galliers, Jennifer, CNP- Medicine/Hospice & Palliative Care- Approve removal from FPPE process and transition to OPPE process.

3. Huntzinger, Jill, CNP- Emergency Medicine- Approve removal from FPPE process and transition to OPPE process.

4. Kaser, Rachel, CNP- Surgery/Vascular Surgery- Approve removal from FPPE process and transition to OPPE process.

5. Malenfant, Jacqueline, CNP- Medicine/Gastroenterology- Approve removal from FPPE process and transition to OPPE process.

6. Mikolay, Jeffrey, PharmD- Urology- Approve removal from FPPE process and transition to OPPE process.

7. Nachman, Adam, RD- Surgery/General Surgery- Approve removal from FPPE process and transition to OPPE process.

8. Nedley, Amy, PA-C- Medicine/Endocrinology- Approve removal from FPPE process and transition to OPPE process.

9. Pittman, Angela, CAA- Anesthesiology- Approve removal from FPPE process and transition to OPPE process.

10. Tighe, Ryan, CAA- Anesthesiology- Approve removal from FPPE process and transition to OPPE process.

XI. Physician/Dentists Departures - Informational

1. Elliot, David, MD Radiation Oncology Active - Effective date 03/11/2019

XII. Allied Health Professional Departures - Informational-None XIII. Proposed Revisions to Delineation of Privileges

1. The Department of Surgery is requesting a minor revision to the Certified Surgical Assistant Delineation of Privileges.

UNIVERSITY OF TOLEDO HEALTH SCIENCE CAMPUS (HSC)

2018 ANNUAL EVALUATION OF ENVIRONMENT OF CARE MANAGEMENT PLANS

UNIVERSITY OF TOLEDO HEALTH SCIENCE CAMPUS 2018 ANNUAL SAFETY REPORT AND

EVALUATION OF ENVIRONMENT OF CARE MANAGEMENT PLANS

INTRODUCTION

The Joint Commission (JC) requires that an annual evaluation of the “objectives, scope, performance and effectiveness” of the Environment of Care management plans be completed. In addition, it highlights upgrades and improvements to the various areas of the Environment of Care. The sections of the Environment of Care (EofC) are: Safety, Fire/Life Safety, Security, Hazardous Materials and Waste, Utilities Management and Medical Equipment.

SAFETY OBJECTIVE(S): To create and sustain a physical environment as free of foreseeable hazards as can be reasonably expected; to proactively anticipate and respond to safety concerns; to investigate accidents and other incidents that need corrective action; to educate new employees in safety and maintain safety readiness in current employees; and to reduce the accident/injury rate through education, surveillance of the physical plant and investigation of accidents that occur, in order to determine the root cause of those accidents, and to implement preventive measures. SCOPE: Health Science Campus-wide: all buildings, all persons in those buildings, on the grounds, and at off-campus satellite locations. PERFORMANCE: The objectives of the safety management program are achieved through performance of the following activities or initiatives: Safety education of new employees and refresher training for current employees Environmental safety rounds Injury/illness reporting and accident and safety investigations Meetings of the HSC Safety & Health Committee Ad-hoc task forces (i.e. needlestick). EFFECTIVENESS: Regulatory Measures In CY 2018, the OSHA accident/injury rate for the HSC was 3.27. Although the rate slightly increased from 3.19 in CY 2017, it is consistently lower than in previous years. The rate is calculated annually to provide a benchmark for safety concerns, employee injuries, and return-to-work initiatives. The national average rate for “hospitals, state government” will be available in December of 2019, (SOURCE: U.S. Department of Labor Bureau of Labor Statistics). The 2017 national average for the “hospitals, state government” was 7.7. The achievement of a rate of 3.27 shows the effectiveness of new employee safety orientation training, environmental safety rounds, and post-incident accident investigation protocols.

Annual Safety Report 2018 Page 2 Performance Improvement The needlestick task force was extremely active in monitoring sharp injuries, eliminating non-safety sharps, and education of staff. There was a slight increase in the needlestick incident rate (incidents per 100 Occupied Beds/Year) from CY 2017 (39.4) to CY 2018 (46.5). Injury/illness and needlestick follow-up was completed for all injuries/needlesticks in 2018. The Environment of Care Task Force, on behalf of the Safety Committee, continued to monitor corrective action of items found during environmental rounds. Weekly Leadership follow-up occurs during Administrative Rounds for items found during environmental rounds and tracers. Reports of items found and closed out are presented in a quarterly report to the Safety Committee. In 2018, an average of 66% of total findings for each quarter were closed out. Closure of findings will continue to be monitored. This is a decrease from 72% in 2017. Additional to the normally scheduled rounds, a multifaceted group, including key individuals leading the Environment of Care, participated in a Tracer program that rounded inpatient and clinic areas in 2018. Additional Key Improvements In addition, the following initiatives were completed: Suicide/Ligature Risk Assessments were updated in both the Adolescent and Adult

Behavioral Health Kobacker Facility, Emergency Room, Detox, and inpatient units to meet the newest guidelines.

The Environmental Rounds database was updated to make it more user friendly by color-coding the open items for ease of follow-up.

The reporting structure for re-calls was improved by making the Safety Committee the central hub for quarterly reports.

Goals for 2019 Complete a review of the on-line learning management system media and questions for the

Environment of Care. Develop case studies for needlestick injuries to utilize for staff training. All performance-monitoring data/benchmarks were within established parameters; therefore, this component of EC was considered effective in CY 2018. The Safety Management Plan was reviewed and assessed in CY 2018.

Annual Safety Report 2018 Page 3

FIRE SAFETY

OBJECTIVE(S): To establish, monitor and maintain an environment that is fire-safe and compliant with all local, state and national/JC fire standards; and to reduce the number of actual Code Red (fire) incidents. SCOPE: Health Science Campus-wide: All buildings and all employees in those buildings, and all off-campus satellite. PERFORMANCE: The objectives of the life safety/fire safety management program are achieved through performance of the following activities or initiatives: Fire drills Fire alarm notification systems Fire suppression systems and their regular testing and inspection Annual inspection of fire extinguisher network by a certified outside vendor Review of items to be purchased for compliance with fire retardancy or resistance standards Meetings of the HSC Safety and Health Committee to anticipate life safety issues and to

review life safety reports Fire safety/prevention questions on the computerized employee safety test bank that is an

annual requirement for all clinical/Hospital employees. EFFECTIVENESS: Regulatory Measures As required by the Joint Commission, UTMC follows the 2012 NFPA 101 Life Safety Code. The effectiveness of fire response training is evaluated annually and was found to meet the regulatory requirements. The training is excellent, as evidenced by employees’ quick knowledge during fire drills of the R.A.C.E. acronym for fire response, as outlined in the institutional fire response plan; employee knowledge of issues of compartmentalization in patient care areas; their skill in describing what steps they take in preparing patients for transport to areas of refuge away from a fire, the considerations they must make when planning such actions, and the efficient manner in which employees respond during fire drills. The computerized alert system ensures that annual preventative maintenance is performed on all fire detection systems. All preventative maintenance was completed at 100% per the Joint Commission and Life Safety Code. UTMC also conducted fire drills campus wide in 2018 in accordance with the Joint Commission Environment of Care Standards. The Hospital and Kobacker drills were conducted quarterly, per shift, +/- 10 days randomly to ensure varying conditions and unexpected times. Business occupancies were conducted annually +/- 30 days randomly.

Annual Safety Report 2018 Page 4 Additional Key Improvements In addition, the following initiatives were completed: Upgraded the Fireworks program of all alarm points and installed on new computers. Goals for 2019 Complete a review of the on-line learning management system media and questions for Life

Safety. All performance-monitoring data/benchmarks were within established parameters; therefore, this component of EC was considered effective in CY 2018. The Fire Safety Management Plan was reviewed and assessed in CY 2018.

Annual Safety Report 2018 Page 5

SECURITY OBJECTIVES: The Health Science Campus Security Department is charged with the responsibility of serving and protecting students, patients, faculty and staff within our area of responsibility. We do this with a proactive approach of deterring, detecting, denying and delaying the negative influences within the Health Science Campus. The Security Department is funded, trained and equipped to respond, secure and de-conflict incidents that escalate to an unmanageable level within patient care areas. SCOPE: Health Science Campus-wide: all buildings and grounds, and some off-campus satellite locations. PERFORMANCE: The objectives of the security management program are achieved through the performance of the following activities or initiatives: Visible routine patrols of parking lots, clinics and centers Quarterly crime analysis review of trends and patterns on campus Administrative documentation of events, police reports and supplements Investigation of workplace incidents for theft, conflict or violent action Risk Assessments highlighting physical security vulnerabilities; lighting, locks & egress Weekly Command Staff meeting with HSC Security, UT Police and Environmental Health

and Radiation Safety EFFECTIVENESS: Regulatory Measures UT Police and Hospital Security work in concert to ensure the safety and security of the UT

Medical Center and surrounding campus. Effectiveness is evidenced by quick response time. UTPD response time is reduced by posting one UTPD Officer on HSC.

Security risk assessments were completed in all high-risk areas including Kobacker, the Emergency Department and all Pharmacy Locations in CY2018.

Annual crime stats are located at http://www.utoledo.edu/offices/internalaudit/clery-act/docs/security-fire-safety-report-2018.pdf

Performance Improvements UTPD and Hospital Security offered A.L.I.C.E. training classes on the Health Science

Campus in 2018 training over 380 Faculty, Staff and Students. Non-Abusive Physical and Psychological Intervention (NAPPI) training has continued to

grow. There were 75 individuals across campus given an abbreviated, de-escalation only, version of the training. This version of the training allows more people to receive the training geared toward their specific work environments. In addition to in-person training sessions, de-escalation training has been added to the safety test bank in order provide information to a wider scope of our campus.

Annual Safety Report 2018 Page 6 Additional Key Improvements In addition, the following initiatives were completed: A fully functional active shooter exercise was completed in August of 2018. The exercise

included a de-escalation component and mass casualty simulation in the UT Emergency Department. The exercise participants consisted of Emergency Department Staff who actively cared for simulated patients during a simulated active shooter events.

Identified vulnerabilities were eliminated by the addition of cameras and panic buttons to the Mulford Library Building,

Updated door security measures were added to sensitive areas within the hospital building, and panic buttons were added to the expanding Detox unit.

Cameras were added within the pharmacies throughout campus to provide an extra layer of security.

Additional signage was added to the trauma bay to divert wrong way traffic through the heavily traveled, emergency area.

Security officer radios were upgraded from Motorola APX 4000 to the Motorola XTS 5000. Conducted lock down drills to verify proper operation and continued improvement in the

functional hardware and software. Goals for 2019 Provide University De-Escalation training to a wider scope of individuals across campus. Continued risk assessments to identify and eliminate causes of crime throughout campus. Update Policy Number: 3364-100-20-13 Plan for Prisoner-Patients Who Require Security

Services Provided by a Law Enforcement Agency.

All performance-monitoring data/benchmarks were within established parameters; therefore, this component of EC was considered effective in CY 2018. The Security Plan was reviewed and assessed in 2018.

Annual Safety Report 2018 Page 7

HAZARDOUS MATERIALS & WASTE OBJECTIVES: To create and maintain an environment in which hazardous materials are safely handled and disposed of, and to create a systematic process for the ordering, receiving, transportation, use, pickup and safe disposal of hazardous materials/chemicals. Tracking of such products from “cradle to grave” will ensure that use of such materials remains within regulatory parameters established by the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), and state and local regulatory bodies. SCOPE: Health Science Campus-wide: all buildings, with special emphasis on those areas, units and buildings containing hazardous materials. PERFORMANCE: The objectives of the hazardous materials management program are achieved through the performance of the following activities or initiatives: Managing the hazardous materials spill response program Monitoring the ordering, handling, use, storage and disposal of hazardous materials, vapors

and waste IH monitoring Ensuring institutional compliance with all applicable OSHA, JC, EPA and state and local

regulations and standards governing ordering, using, storing, transporting, and disposing of hazardous materials and waste

EFFECTIVENESS: Regulatory Measures All air sampling results for hazardous agents were below occupational exposure limits. Performance Improvement A conscience effort was put in place to reduce costs by changing the type of packaging

system used in the surgical areas to reduce improper segregation of infectious and non -infectious waste.

The HSC generated and disposed of 266,405 lbs. of infectious waste. This is an increase from 2017 (256,183 lbs.)

The HSC generated and disposed of 19,287 lbs. of Hazardous Waste. This is an increase from 2017 (18,225 lbs.)

There were three hazardous material spills requiring a response by the Environmental Health and Radiation Safety Department in the hospital or clinical buildings on HSC in CY2018 compared to zero hazardous material spills in 2017.

Additional Key Improvements In addition, the following initiatives were completed: Eliminated the use of Glutaraldehyde and Cidex OPA in clinical operations. Completed air sampling for new high-level disinfection chemical agents. Improved hazard communication to include chemical specific training in the annual training

requirements.

Annual Safety Report 2018 Page 8 Completed successful Radiation Generating Equipment (RGE) inspections via the Ohio

Department of Health at both UTMC and Regency. Goals for 2019 Complete the implementation of the cactus system for disposal of non-hazardous waste

pharmaceuticals. Improve the black bin hazardous waste pharmaceutical process by changing out the

containers currently used to make them more secure. Complete wipe sampling for compliance with USP800 post DCC re-model. Implement the standardization of the hazardous waste collection utilization standardized

containers. Prepare for the College of American Pathologist (CAP) survey as well as the Ohio

Department of Health Radioactive Material survey in 2019. This program continued its efficient operation in CY 2018. The process for ordering, handling, removal of and disposal of hazardous materials on the HSC ran without any significant deficiencies in CY 2018. In addition, all reports required by regulatory agencies, local, state and federal, were filed as required. All performance-monitoring data/benchmarks were within established parameters, therefore, this component of EC was considered effective in CY 2018. The Hazardous Materials Plan was reviewed and assessed in 2018.

Annual Safety Report 2018 Page 9

UTILITIES

OBJECTIVES: To create and maintain a consistent flow of utilities to all segments of the campus community and its buildings, with special emphasis on the provision of safe, reliable utility service to patient care units; and to assess potential weak links in the system while actively taking steps to upgrade the system and reduce interruptions. SCOPE: Health Science Campus-wide: all buildings, with special emphasis on patient care units and academic laboratories. PERFORMANCE: The objectives of the utility systems plan are achieved through performance of the following activities or initiatives: Regular preventive maintenance (which includes inspecting, testing and repairing as needed)

of utility system components, in particular critical systems related to patient care functions Development and maintenance of utility system operational plans that will ensure

consistency and reliability in the provision of those utilities Completion of work orders and requests for service from building occupants EFFECTIVENESS: Regulatory Measures 100 % of preventative maintenance work orders were completed on time. Performance Improvements Facilities instituted an ongoing daily inspection and PM work on patient rooms. Facilities created a new work order for preventative maintenance to include monthly touch-

up painting throughout the clinical areas. Additional Key Improvements In addition, Facilities Maintenance oversaw the completion of improvement projects in CY2018 including: New generators were brought online that now cover the entire hospital. Continued implementation of the re-lamping project to LED lights. Installation of low consumption toilets during the upgraded to the ADA restrooms. Installed new Drives for energy efficiency. Goals for 2019 Continue implementation of the re-lamping project to LED lights Continue implementation of the installation of new Drives for energy efficiency.

Annual Safety Report 2018 Page 10 All performance-monitoring data/benchmarks were within established parameters, therefore, this component of EC was considered effective in CY 2018. The Utilities Systems Plan was reviewed and assessed in 2018.

Annual Safety Report 2018 Page 11

MEDICAL EQUIPMENT

OBJECTIVES: To create and maintain a medical equipment management program that ensures and promotes the safe and effective use of medical equipment for both patients and users. SCOPE: Primary focus is on patient care units, buildings and medical equipment, although other aspects of the medical equipment management program extend campus-wide, to academic laboratories and all campus buildings and departments. PERFORMANCE: The objectives of the medical equipment management plan are achieved through performance of the following activities or initiatives: Use of a screening grid to ensure acquisition of safe and functional medical equipment Assessment performed on all equipment in the program to ensure adequate preventive

maintenance frequencies are achieved Tracking and monitoring of medical equipment histories Compliance with all provisions of the Safe Medical Device Act of 1990 Monitoring and tracking of all medical equipment hazard notices and recalls EFFECTIVENESS: Regulatory Measures 100% of preventative maintenance work orders were completed on time. Less than 5% of equipment malfunctions were due to operator error. 100% of chemical and biological water testing was completed. 100% of performance testing of sterilizers was completed. Performance Improvements Performed review of monthly preventative maintenance reports to ensure correct information was being sent to the appropriate people. Additional Key Improvements In addition, the following initiatives were completed: Participated and provided information for a successful ODH inspection Replaced Stryker Neptunes that were no longer supported in the Operating Room Replaced entire fleet of IV Pumps which provided upgraded software for a more efficient

user interface Successful transition of monitoring from 3AB to 3CD. Updated Preventive Maintenance stickers used on equipment to allow for easier detection of

over-due equipment by the staff Goals Provide more technical training in the imaging area to continue to reduce costs and increase

efficiencies Upgrade current Biomed CMMS or replace with more robust system

Annual Safety Report 2018 Page 12 Restructure department to increase staff efficiency and better meet the needs of our

customers. All performance-monitoring data/benchmarks were within established parameters; therefore, this component of EC was considered effective in CY 2018. The Medical Equipment Plan was reviewed and assessed in CY2018. Heather Lorenz, MSOH, CIH, CSP, CMLSO Director, Environmental Health and Radiation Safety Department January 27, 2019 Safety and Health Committee Review and Approval Date: March 28, 2019

UTMC EM PERFORMANCE EVAL. 2018 1 OF 6

ANNUAL PERFORMANCE EVALUATION FOR 2018

Program: Emergency Management Reviewer: Nicole M Meagher Review Date: January 2019 Safety and Health Committee Review and Approval Date: March 28, 2019 Review of Program A. PURPOSE

To assure compliance of all Emergency Management standards as required by the

Joint Commission. An emergency in the University of Toledo Medical Center

(UTMC) and associated clinics or within our community could suddenly and

significantly affect the need for our services or our ability to provide those services.

UTMC has an Emergency Operations Plan that comprehensively describes our

approach to handling these emergencies.

B. SCOPE

The Emergency Operations Plan (EOP) covers the Medical Center and other

associated clinics. The EOP describes an “all-hazards” command structure for

coordinating six critical areas within the facility during an emergency. The program

serves as a resource for all facilities and staff where patient services are provided.

C. AUTHORITY The Director of Environmental Health and Radiation Safety or designee serves as

the program manager and is charged with the overall responsibility to direct and

coordinate the emergency management program, along with other members of the

Environmental Health & Radiation Safety Department. The Emergency

Preparedness Task Force of the UT-HSC Safety and Health Committee is

responsible to review, critique, monitor and revise all emergency management

activities. A report from the Emergency Preparedness Task Force is a standing item

on the Safety and Health Committee agenda.

UTMC EM PERFORMANCE EVAL. 2018 2 OF 6

D. MEETING ATTENDANCE Task Force members are expected to attend all meetings. If they are unable to

attend, they are to notify the chair of their absence before the meeting or send a

representative. Members who notify the chair are given an excused absence. In the

event of an absence, members are still expected to review the minutes and give

feedback on any materials related to the meeting. Members are part of a taskforce

that reports regularly to the Safety and Health committee.

C. ANNUAL INVENTORY

UTMC maintains an inventory for supplies including critical items such as PPE and

other consumable medical supplies. This inventory is reviewed annually. It is

available for hard-copy in the resource manual (MLB Board Room 201) and

electronically on the shared Z:drive.

The organization keeps a cache of supplies in the event our normal supply sources

are negatively impacted during an emergency. The caches are maintained in the

area below the Emergency Department, Decontamination Trailer, and Central

Supplies.

UTMC EM PERFORMANCE EVAL. 2018 3 OF 6

F. REVIEW OF KEY PROCESSES/ACCOMPLISHMENTS

Elements of Performance

Met

Not Met

Partially Met

EM.01.01.01 The organization engages in planning activities prior to developing its written Emergency Operations Plan.

X

EM.02.01.01 The organization has an Emergency Operations Plan.

X

EM.02.02.01 As part of its EOP, the organization prepares for how it will communicate during emergencies.

X

EM.02.02.03 As part of its EOP, the organization prepares for how it will manage resources and assets during emergencies.

X

EM.02.02.05 As part of its EOP, the organization prepares for how it will manage security and safety during an emergency.

X

EM.02.02.07 As part of its EOP, the organization prepares for how it will manage staff during an emergency.

X

EM.02.02.09 As part of its EOP, the organization prepares for how it will manage utilities during an emergency.

X

EM.02.02.11 As part of its EOP, the organization prepares for how it will manage patients during emergencies.

X

EM.02.02.13 During disasters, the organization may grant disaster privileges to volunteer licensed independent practitioners (LIPs).

X

EM.02.02.15 During disasters, the organization may assign disaster responsibilities to volunteer practitioners who are not LIPs, but who are required by law and regulation to have a license, certification, or registration.

X

EM.03.01.01 The organization evaluates the effectiveness of its emergency planning activities.

X

EM.03.01.03 The organization evaluates the effectiveness of its EOP.

X

UTMC EM PERFORMANCE EVAL. 2018 4 OF 6

G. SUMMARY REVIEW OF PROGRAM EFFECTIVENES UTMC underwent a successful Ohio Department of Health Survey of Emergency Management for the Hemo Dialysis unit. The 2018 EOP was updated to include detailed response information involving the need for request of a 1135 waiver as required by Joint Commission. An 1135 waiver request grants authority to operate at an alternate location if necessary and would waive or modify certain Medicare and Medicaid requirements during an emergency. NIMS/HICS 100, 200, and 700 was offered on-line through FEMA for new management staff. Training is tracked utilizing the online UT test bank. Additional HICS training, for upper level staff requiring advanced level ICS courses, was also offered. Annually a hazard vulnerability analysis (HVA) is performed and utilized to direct areas of exercise and training for the year. The 2018 HVA indicated the following high risk areas: Combative Situation (50%), Electrical Failure (50%), IT Failure/ Mass Casualty Incident/Supply Shortage/Internal Floods (44%). The following high-risk areas were selected to be exercised:

1. Combative Situation: Throughout 2018 HSC Security held Non-Abusive

Psychological and Physical Intervention (NAPPI) training for officers and De-escalation training for clinical staff.

2. Electrical Failure: In 2018, new generators were brought on-line to cover the entire hospital, allowing for additional coverage during an outage event.

3. IT Risk: UT information technology performed routine tests to identify and

minimize weaknesses within our system. During the Code Copper (power loss) event modifications were made to the policy to aid in communication with IT. Additional IT considerations were made to the badge security process to allow for business continuity.

4. Mass Casualty Incident: UTMC conducted a simulated active shooter drill in the

Simulation Center to test the Active Shooter Annex and the Code Violet as well as our capabilities for an internal mass casualty situation. As part of the drill, the ED practiced triage utilizing over 25 student (patient) volunteers. In addition, staff began regular training for MCI events that provided staff education, Code Yellow procedural review, and trauma training.

5. Supply Shortage/Internal Floods: While there is a high probability of occurrence

for these type of events, we are confident in our ability to respond as a result of consistent tests of our emergency response procedure as well as a secure internal/external response capability that includes regional Memorandums of Understanding (MOUs) with community partners.

UTMC EM PERFORMANCE EVAL. 2018 5 OF 6

UTMC and associated clinics completed the following exercises (and real events) as well participated in community and regional exercises including multiple communication drills and a Regional drill exercising our Code Green procedure

• 01/06/2018 Fire Suppression Line Break Event • 02/06/2018 Lucas County Community Drill (non-support drill) • 03/26/2018 Regency Radiology & PT Code White Table Top Drill • 04/03/2018 Renee’s Survivor Shop Code White Tabletop Drill • 07/17/2018 Code Brown Real Event • 08/02/2018 Active Shooter Functional Drill • 08/25/2018 Code Copper Event • 09/27/2018 Code Green Evacuation Drill (Coalition Surge Test) • 10/02/2018 Code Brown Real Event • 10/05/2018 Code Brown Real Event • 10/18/2018 Code Brown Real Event • 10/18/2018 Code Brown Real Event • 10/20/2018 Code Brown Real Event • 10/22/2018 Code Brown Real Event • 10/24/2018 Code Brown Real Event • 11/15/2018 Code Adam Functional Exercise • 11/20/2018 Code Yellow Phase 0 Event

ASPR grant items were purchased:

• 7 Powered Air-Purifying Respirator (PAPR) systems for use during response to infectious disease events.

UTMC EM PERFORMANCE EVAL. 2018 6 OF 6

Updated/Revised documents: Code Yellow, Code Gray, Code Orange, Code Black, Code Green, Code White, Code Copper, Code Red Fire Response, Emergency Communications Plan, Infectious Disease Agent Plan (IDA), Volunteer Management Plan, COOP Plan, and an annual review of the Emergency Operations Plan were completed. H. Goals for 2019:

• Plans/Procedures o Annual EOP for UTMC o COOP Plan and all seven Emergency Code Procedures.

• Exercises and Training (Based in part on 2018 HVA) o Continue to secure NIMS/HICS 100/200/300/400 training for

management o Continue NAPPI and A.L.I.C.E. training o Community and regional exercises o Supply Shortage (included in community drill) o Code Brown and Code Adam Functional Exercise o Active Shooter Functional Exercise o Code Yellow Triage Tag Training o Code Yellow regular round table review with a cross disciplinary team

CHIEF OF STAFF SUMMARY REPORT April 15, 2019

I. Initial Appointments- Physicians/Clinical Psychologists Gavin, Marijo, PhD Psychiatry Parenteau, Gary, MD Surgery/CT Surgery II. Initial Appointments- Allied Health Professionals (AHPS)

Mason, Shawn, CSA Surgery/General Surgery Ocasio, Joseph, PA-C Family Medicine III. Reappointments- Physicians- None IV. Reappointments- Allied Health Professionals- None V. Additional/Withdrawal of Privileges- Physicians

1. McCullumsmith, Robert, MD- Psychiatry- Approve additional privilege for ECT under FPPE. VI. Additional/ Withdrawal of Privileges- Allied Health Professionals-None VII. Change in Staff Category- Physicians- None VIII. Change in Staff Category- Allied Health Professionals- None IX. Removal from FPPE- Physicians- None X. Extension of FPPE- Physicians- None XI. Removal from FPPE- AHPs

1. Maldonado, Henrry, CNP- Surgery/Vascular Surgery- Approve removal from FPPE process and transition to OPPE process for additional privileges in insertion/exchange CVP lines and dialysis catheters and insertion of percutaneous arterial lines.

XII. Physician/Dentists Departures- Informational

1. Gard, Elloise, MD- Medicine/Hospice Palliative Care- effective 02/01/2019. XIII. Allied Health Professional Departures- Informational-None XIV. Proposed Revisions to Delineation of Privileges- None