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BOARD QUALITY REVIEW COMMITTEE MEETING
Thursday, February 19, 2015
5:30 p.m. (Buffet Dinner for Committee members & invited guests) iExplore Conference Room
6:00 p.m. Meeting 418 E. Grand Avenue, Escondido CA
Page 1 of 2
Open Agenda
Time Target CALL TO ORDER 6:00
Establishment of Quorum ...............................................................................................................
Public Comments ............................................................................................................................ 10 6:10 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, January 19, 2015 (Addendum A - Pages 2 - 7) .................. 5 6:15 (**Includes Attendance Roster and Abbreviations Guide)
2. Surgery and Procedures Written Report – Palomar Medical Center (Addendum B – Page 8) Rosie Ross, Director Surgery and Procedures Services Questions & Answers – 10 minutes
10 6:25
Standing Item(s):
1. Patient Experience Update 10 6:35
Journal Club – “Why Hospitals Should Fly” by John Nance (Reference page 1 – 31 of book)
New Business: 1. Medication Usage Update (Addendum C – Pages 9 - 30) ......................................................
Diana Schultz, Manager Medication Safety
Presentation 10 minutes, Questions & Answers 10 minutes
20 6:55
2. Surgery & Procedures Update – Pomerado and PHDC (Addendum D – Pages 31 - 46) ........ Kim Colonnelli, Chief Nursing Officer Presentation 10 minutes, Questions & Answers 10 minutes
20 7:15
3. Wound Care Update (Addendum E – Pages 47 - 57) ............................................................... Rupa Sidhu, Director Wound Care Presentation - 10 minutes, Questions & Answers - 10 minutes
20 7:35
4. Value Based Purchasing Program Overview (Addendum F – Pages 58 - 73) ........................ David Lee, MD, Medical Quality Officer Presentation 10 minutes, Questions & Answers 10 minutes
20 7:55
ADJOURNMENT TO CLOSED SESSION 7:55
One item of potential/pending litigation (Government Code Section 54956.9)
RESUMPTION OF OPEN SESSION ...................................................................................... Immediately following end of
closed session
Action Resulting From Closed Session Discussion – IF ANY
FINAL ADJOURNMENT 8:10
BOARD QUALITY REVIEW COMMITTEE MEETING
Thursday, February 19, 2015
5:30 p.m. (Buffet Dinner for Committee members & invited guests) iExplore Conference Room
6:00 p.m. Meeting 418 E. Grand Avenue, Escondido CA
Page 2 of 2
Open Agenda
Board Quality Review Committee Members VOTING MEMBERSHIP NON-VOTING MEMBERSHIP
Aeron Wickes, MD – Chairperson, Board Member Bob Hemker, President & CEO
Jerry Kaufman, PTMA, Board Member Lorie Shoemaker, RN, DHA - VP, Palomar Medical Center
Ray McCune, RN, Board Member Della Shaw – EVP, Strategy
Frank Martin, MD - Chair of Medical Staff Quality Management
Committee for Palomar Medical Center David Tam, MD - VP, Pomerado Hospital and Palomar Health Downtown Campus
Charles Callery, MD - Chair of Medical Staff Quality
Management Committee for Pomerado Hospital Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient Safety Committee
Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Co-Chair of Patient Safety Committee
Maria Sudak, RN – Chief Nursing Officer Kim Colonnelli, RN - Chief Nursing Officer
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
* Asterisks indicate anticipated action. Action is not limited to those designated items.
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Page 1 of 3
ABBREVIATIONS GUIDE Updated: 2/26/2015
AAPL: Academy of Applied Physician Leadership ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACR: American College of Radiology AHRQ: Agency for Healthcare, Research and Quality AMI: Acute Myocardial Infarction ARB: Angiotension Receptor Blocker ARU: Acute Rehab Unit BETA: PPH Insurer BQRC: BSC:
Board Quality Review Committee Balanced Score Card
CALNOC: Collaborative Alliance for Nursing Outcomes CAP: College of American Pathologists CAP: Community-Acquired Pneumonia 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 CHF: Congestive Heart Failure 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 COPD: Chronic Obstructive Pulmonary Disease CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management CVICU: Cardio Vascular Intensive Care Unit DI: Diagnostic Imaging DRT: Diabetes Resource Team EBP: Evidence Based Practice ED: Emergency Department EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EMT: Emergency Medical Technician EMT: Executive Management Team EVS: Environment of Care Services / Environmental Services FANS: Food and Nutrition Services FMEA: Failure Mode Effects Analysis HAC: Hospital Acquired Conditions HAI: Healthcare Associated Infections
Page 2 of 3
ABBREVIATIONS GUIDE Updated: 2/26/2015
HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCP: Health care provider HDL: High Density Lipoprotein Cholesterol HLD: High Level Disinfectant HF: Heart Failure HIPPA: Health Insurance Portability and Accountability Act HPRO: Hip Replacement Surgery HRRP: Hospital Readmission Reduction Program IC: Infection Control ICU: Intensive Care Unit IHI: Institute for Healthcare Improvement IMI: Inpatient Mortality Indicator IP: Infection Prevention (RN Staff) ISBARR: Introduction, Situation, Background, Assessment, Recommendations, Read back KP: Kaiser Permanente KPRO: Knee Replacement Surgery MDRO: Multi Drug Resistant Organism MRI: Magnetic Resonance Imaging 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 NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NPSG: National Patient Safety Goals NQF: National Quality Forum OB: Obstetrics OPPE: Ongoing Professional Practice Evaluation OSHPD: Office of Statewide Health Planning and Development PCEA: Patient Controlled epidural Analgesia PCM: Perinatal Care Measure PDCA: Plan Do Check Act PN: Pneumonia POCT: Point of Care Testing PPE: Personal Protective Equipment PPFR: Physician Performance Feedback Report PSI: Patient Safety Indicators QRR: Quality Review Report RAC: Revenue cycle Audits RCA: RT:
Root Cause Analysis Respiratory Therapist
RHIT: Registered Health Information Technician RVT: Registered Vascular Tech SCIP: Surgical Care Improvement Project SIR: Standardized Infection Ratio SNF: Skilled Nursing Facility
Page 3 of 3
ABBREVIATIONS GUIDE Updated: 2/26/2015
SSI: Surgical Site Infection STK: Stroke TAT: Turn Around Time THA: Total Hip Arthroplasty TICU: Trauma Intensive Care Unit TJC or JC: The Joint Commission TKA: Total Knee Arthroplasty US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Associated Pneumonia VBAC: Vaginal Birth After Caesarian Section VBP: Value Based Purchasing VRE: Vancomycin-resistant enterococcus VTE: Venous Thrombo-embolism WHO: World Health Organization
1/30/2015/rdr
Surgery and Procedures Department
PMC
Performance Improvement Report
February 2015
Executive Summary
1. Current Performance Improvement (PI) Focus
• 101 Back to Basics Initiative
• Launch Jan 2015
• Objective:
– Maintain a culture of safety (Infection Control (IC), Universal Protocol (UP),
Medication Safety, Documentation)
– Raise the bar across all disciplines
– Physician champion engagement
– Staff engagement
– Physician driven UP policy revision (March completion anticipated)
• Goal:
– 90 % overall compliance in 2015 (Roll up of 40 quality elements)
• Method:
– Real time audits/education with monthly report outs
– Front-line leader collaboration
(OR/Pre-op/PACU leaders will conduct audits outside of their immediate areas of
oversight to create fair and un-biased observations)
• OR On-time starts
• Re-launched August 2014
• Objective:
– Patient experience (the core of our efforts)
– Contribute to the overall efficiency = Patient experience
– Improve physician/staff satisfaction = Patient experience
• Goal:
– 75% or better for on-time starts/month
_ August thru Sept we have reached avg. of 75% (prior to August at ≤ 60%)
• Method:
– Real time mentoring/monitoring and report out
– Physician leader participation in audit process
2. Summary of other ongoing PI
• Improvements have been sustained over time in:
– IUSS (Immediate Use Sterilization) Rate from 18% /Jan 2014 to 3% /Nov 2014
– Surgical Site Infection (SSI) Rates are on trend - Q1/14 1.024 - Q4/14 0.089
– SCIP measure are at 100%
• Opportunities/Action Planning
– OR Efficiency/Engagement of all team members
– Continued monitoring of all PI activities – review at weekly OR Operations team
meeting and staff meetings, specialty service line and OR physician led meetings
– Drive accountability at all levels; Encourage/Support and Celebrate wins across the
teams
Attachment #1
Med
icat
ion
Use
Rep
ort
0
2/1
9/1
5
Dia
na
Sch
ult
z,
Man
ager
of
Med
icat
ion
Saf
ety
Sect
ion
On
e: E
xecu
tive
Su
mm
ary
Attachment #2
Med
icat
ion
Usa
ge R
epo
rt
•P
ha
rma
cy S
ervi
ces
mo
nit
ors
th
e el
even
no
des
of
med
ica
tio
n m
an
ag
emen
t d
elin
eate
d in
Pa
lom
ar
Hea
lth
’s M
edic
ati
on
Err
or
Red
uct
ion
Pla
n a
s w
ell a
s p
rocu
rem
ent
an
d a
dve
rse
med
ica
tio
n e
ven
ts.
Mo
nit
ori
ng
incl
ud
es:
Sele
ctio
n, P
rocu
rem
ent,
Pro
du
ct L
abel
ing
& N
om
encl
atu
re, S
tora
ge,
Dis
trib
uti
on
, Pre
scri
bin
g, P
resc
rip
tio
n O
rder
Co
mm
un
icat
ion
, C
om
po
un
din
g, D
isp
ensi
ng,
Ad
min
istr
atio
n, M
on
ito
rin
g, E
du
cati
on
, M
edic
atio
n E
rro
rs a
nd
Ad
vers
e D
rug
Rea
ctio
ns
(Lu
cid
oc
pro
ced
ure
30
83
2)
•K
ey A
reas
of
Focu
s fo
r 2
01
5
1.
Ph
arm
acy
Safe
ty D
ata
2.
Ph
arm
acy
Clin
ical
Ser
vice
s
3.
Tran
siti
on
s o
f C
are
4.
Am
bu
lato
ry C
are
Serv
ices
5.
Ou
tpat
ien
t Se
rvic
es
Attachment #2
Med
icat
ion
Usa
ge R
epo
rt
Ph
arm
acy
Serv
ices
- Sp
otl
igh
t o
n W
arfa
rin
Ser
vice
s Tr
ansi
tio
ns
of
Car
e
Am
bu
lato
ry C
are
Serv
ices
Ou
tpat
ien
t R
x Se
rvic
es
Ph
arm
acy
Safe
ty D
ata
Ph
arm
acy
Clin
ical
Ser
vice
s
Tran
siti
on
s o
f C
are
Attachment #2
Key
Are
a o
f Fo
cus
for
Nex
t R
epo
rtin
g Pe
rio
d
•C
on
tin
ued
fo
cus
on
–Tr
ansi
tio
ns
of
Car
e
–A
mb
ula
tory
Ser
vice
s
–O
utp
atie
nt
Ph
arm
acy
Serv
ice
s
•R
enew
ed f
ocu
s o
n
–P
har
mac
y O
rgan
izat
ion
al S
tru
ctu
re
–P
har
mac
y O
per
atio
nal
Per
form
ance
Im
pro
vem
ent
Med
icat
ion
Usa
ge R
epo
rt
Attachment #2
Sect
ion
Tw
o –
Pe
rfo
rman
ce
Imp
rove
me
nt
pro
ject
P
har
mac
y
Vig
ilan
z Im
ple
men
tati
on
: P
har
mac
y C
linic
al D
ecis
ion
Su
pp
ort
So
ftw
are
Attachment #2
Stra
tegi
c In
itia
tive
Lin
k 1
.Fi
nan
cial
Str
en
gth
- In
crea
ses
ph
arm
acis
t p
rod
uct
ivit
y. F
acili
tate
s b
ench
mar
kin
g o
f p
har
mac
y se
rvic
es w
ith
Tru
ven
®.
2.
Cu
sto
me
r Se
rvic
e -
Pro
vid
es r
eal t
ime
surv
eilla
nce
an
d p
rio
riti
zes
clin
ical
w
ork
load
so
th
at t
he
ph
arm
acis
t ca
n o
pti
miz
e th
e p
atie
nt’
s m
edic
atio
n t
her
apy
in r
eal t
ime.
3.
Qu
alit
y -D
ecre
ases
err
ors
ass
oci
ated
wit
h t
he
de
par
tmen
t’s
curr
ent
pat
ien
t m
anag
emen
t sy
stem
. Fa
cilit
ates
dis
tric
t w
ide
com
mu
nic
atio
n a
nd
sh
arin
g o
f re
sou
rces
. En
able
s d
evel
op
men
t o
f cl
inic
al s
erv
ice
s su
ch a
s d
isch
arge
co
un
selin
g,
dis
char
ge m
ed r
eco
nci
liati
on
, an
d in
pat
ien
t m
edic
atio
n t
her
apy
man
agem
ent
(via
at
ten
dan
ce o
f m
ult
idis
cip
linar
y ro
un
ds
and
/or
med
icat
ion
pro
file
rev
iew
) t
hat
hav
e b
een
sh
ow
n t
o im
pro
ve p
atie
nt
ou
tco
mes
an
d r
edu
ce r
ead
mis
sio
ns
wh
ile d
ecre
asin
g th
e n
eed
for
add
itio
n o
f FT
Es.
4.
Wo
rkfo
rce
/ W
ork
pla
ce –
Imp
rove
s th
e ab
ility
to
man
age
pro
toco
l-d
rive
n w
ork
, w
hic
h is
oth
erw
ise
dif
ficu
lt t
o m
on
ito
r. P
rovi
des
th
e fr
amew
ork
to
mo
nit
or
ph
arm
acis
t p
erf
orm
ance
.
Attachment #2
Pro
ble
m S
tate
men
t •
Ph
arm
acis
t cl
inic
al d
ocu
men
tati
on
an
d
wo
rkfl
ow
wer
e n
ot
op
tim
al.
–la
ck o
f re
al-t
ime
aler
tin
g,
–w
aste
d la
bo
r in
man
agin
g th
e p
atie
nt
man
agem
ent
syst
em,
–ge
ner
al la
ck in
th
e u
se o
f co
mp
ute
r-as
sist
ed
iden
tifi
cati
on
of
med
icat
ion
pro
ble
ms,
an
d
–in
abili
ty t
o m
easu
re c
linic
al p
rod
uct
ivit
y.
Attachment #2
Op
po
rtu
nit
y
Imp
lem
ent
a cl
inic
al p
har
mac
ist
do
cum
enta
tio
n
syst
em t
hat
will
•P
rovi
de
real
-tim
e ru
le-b
ased
pat
ien
t w
ork
list
s
•Im
pro
ve p
har
mac
ist
pro
du
ctiv
ity
by
elim
inat
ing
the
nee
d t
o t
ran
scri
be
dat
a an
d
man
age
pap
er m
on
ito
rin
g fo
rms,
•P
rovi
de
a m
ore
fo
cuse
d w
ork
list
th
at g
uid
es
ph
arm
acis
t w
ork
,
Attachment #2
•P
rovi
de
mu
ch m
ore
so
ph
isti
cate
d c
linic
al
rep
ort
s th
at w
ill e
nab
le p
har
mac
ists
to
en
gage
in
th
e n
ew a
dva
nce
d r
ole
s ca
lled
fo
r in
th
e p
har
mac
y st
rate
gic
pla
n,
•P
rovi
de
the
abili
ty t
o m
easu
re p
har
mac
ist
clin
ical
pro
du
ctiv
ity
and
per
form
ance
,
•D
ecre
ase
ph
arm
acy’
s re
lian
ce o
n a
dva
nce
d
pro
gram
mer
ski
lls
Op
po
rtu
nit
y (c
on
tin
ue
d)
Attachment #2
Pla
n
•Im
ple
men
t a
Clin
ical
ph
arm
acis
t d
ocu
men
tati
on
sys
tem
1.
Sele
ct P
rod
uct
2.
Bu
ild c
linic
al r
ule
s, m
on
ito
rin
g te
mp
late
s an
d
ph
arm
acis
t w
ork
qu
eues
.
3.
Trai
n p
har
mac
ists
via
did
acti
c m
od
ule
s an
d 1
:1
ph
arm
acis
t tr
ain
ing
.
4.
Dev
elo
p n
ew w
ork
flo
ws
for
revi
ew a
nd
act
ion
Attachment #2
Do
Clin
ical
inte
rven
tio
n c
ateg
ori
es d
evel
op
ed a
nd
qu
anti
fied
W
rite
Clin
ical
Ru
les
that
will
cre
ate
aler
ts a
nd
gu
ide
ph
arm
acis
t’s
clin
ical
wo
rk
Nam
e
Des
crip
tio
n
Co
st
Tim
eAllo
cate
d
.AD
E P
reve
nti
on
- M
ajo
r D
efin
itel
y P
reve
nte
d M
ajo
r A
dve
rse
Dru
g Ev
ent
(e.g
. per
man
ent
har
m o
r in
crea
sed
len
gth
of
stay
or
leve
l of
care
) $
2
,20
0
10
.AD
E P
reve
nti
on
- M
ajo
r -
Med
R
ec
Sub
seq
uen
t to
med
icat
ion
rec
on
cilia
tio
n, D
efin
itel
y P
reve
nte
d M
ajo
r A
dve
rse
D
rug
Even
t (e
.g. p
erm
anen
t h
arm
or
incr
ease
d le
ngt
h o
f st
ay o
r le
vel o
f ca
re)
$
2,2
00
5
.AD
E P
reve
nti
on
- M
ino
r D
efin
itel
y P
reve
nte
d M
ino
r A
dve
rse
Dru
g Ev
ent
(e.g
. NO
N-M
ajo
r er
ror
or
adve
rse
dru
g re
acti
on
) $
2
20
1
0
.AD
E P
reve
nti
on
- M
ino
r -
Med
R
ec
Sub
seq
uen
t to
med
icat
ion
rec
on
cilia
tio
n, D
efin
itel
y P
reve
nte
d M
ino
r A
dve
rse
D
rug
Even
t (e
.g. N
ON
-Maj
or
erro
r o
r ad
vers
e d
rug
reac
tio
n)
$
22
0
5
.An
tib
ioti
c St
ewar
dsh
ip
Ad
vise
d f
or
anti
bio
tic
SELE
CTI
ON
or
DU
RA
TIO
N
$
90
1
0
.Th
erap
y O
pti
miz
atio
n
Rec
om
men
dat
ion
s/C
han
ges
mad
e af
ter
clin
ical
rev
iew
(e
.g. a
dd
dru
g, s
top
d
rug,
ad
just
mo
nit
ori
ng
pla
n, g
lyce
mic
man
agem
ent,
SU
P, V
TE p
rop
h, n
arro
w
ther
apeu
tic
ind
ex d
rug
do
sin
g/m
on
ito
rin
g, e
tc.)
$
75
5
Ru
leN
ame
D
escr
ipti
on
K
eyD
rug
Ke
yLab
*Ch
eck
Do
se*
of
Acy
clo
vir
PO
wit
h
CrC
l (C
G IB
W)
10
- 2
5 m
L/m
in
DIS
REG
AR
D IF
USU
AL
DO
SE IS
20
0-4
00
MG
Q4
HR
S O
R 4
00
mg
Q8
H. I
f u
sual
do
se is
80
0m
g q
4 h
ou
rs, a
dju
st d
ose
to
80
0m
g ev
ery
8 h
ou
rs.
Acy
clo
vir
Cre
atin
ine
Cle
aran
ce
IBW
(C
G)
Attachment #2
Do
Dev
elo
p w
ork
flo
ws
D
evel
op
ele
ctro
nic
clin
ical
mo
nit
ori
ng
form
s
Attachment #2
Do
Trai
n S
up
er
Use
rs
Test
Ru
les
&
Wo
rkfl
ow
s
Tr
ain
Use
rs
Go
Liv
e P
has
e
Oct
. 20
14
Attachment #2
Ch
eck
Has
Vig
ilan
z im
pro
ved
th
e c
are
yo
u p
rovi
de
to
pat
ien
ts?
56
% Y
es
4
3%
No
Has
Vig
ilan
z m
ade
it e
asie
r to
do
cum
en
t yo
ur
clin
ical
in
terv
en
tio
ns?
72
% Y
es
28
% N
o
Has
Vig
ilan
z im
pro
ved
yo
ur
abili
ty t
o id
en
tify
an
d p
rio
riti
ze t
he
in
terv
en
tio
ns
that
yo
u h
ave
to
mak
e?
7
0%
Yes
3
0%
No
Has
Vig
ilan
z im
pro
ved
co
mm
un
icat
ion
han
do
ff?
7
0%
Yes
3
0%
No
We
re y
ou
sat
isfi
ed
wit
h t
he
Vig
ilan
z tr
ain
ing
(We
bex
pri
me
r,
Ph
ase
I, P
has
e 2
, an
d I
nte
ract
ive
Su
pe
r u
ser
sess
ion
s)?
8
8%
Ye
s 1
1%
No
Po
st –
Imp
lem
enta
tio
n S
urv
ey
Attachment #2
Ch
eck
-Rev
iew
of
Inte
rven
tio
ns
P
re-V
igila
nz
(6/2
/13
-6/2
9/1
3)
•2
43
In
terv
enti
on
s
•6
56
W
ritt
en c
lari
fica
tio
ns
•2
27
A
llerg
ies
•1
12
6 T
ota
l In
terv
enti
on
s
Po
st-V
igila
nz
(12
/28
/14
– 1
/24
/15
)
•In
terv
enti
on
Cat
ego
ry
To
tal
•A
DE
Pre
ven
tio
n -
Maj
or
2
08
•A
DE
Pre
ven
tio
n -
Maj
or
- TO
C
7
•A
DE
Pre
ven
tio
n -
Min
or
9
7
•A
DE
Pre
ven
tio
n -
Min
or
- TO
C
7
•A
nti
bio
tic
Stew
ard
ship
92
6
•C
lari
fy D
rug
Ord
er
1
81
•C
lari
fy D
rug
Ord
er –
TO
C
8
1
•Th
erap
y O
pti
miz
atio
n
7
9
•Th
erap
y O
pti
miz
atio
n –
TO
C
35
•G
ran
d T
ota
l
1
62
1
Info
rma
tio
n b
asi
c a
nd
dif
ficu
lt t
o
det
erm
ine
tren
ds
or
reso
luti
on
O
f th
e 1
62
1 in
terv
enti
on
s, 1
03
3
wer
e ru
le b
ase
d in
terv
enti
on
s.
Det
aile
d
inte
rven
tio
n
da
ta t
ha
t in
clu
des
re
solu
tio
n
Attachment #2
Act
•
Co
nti
nu
e to
Op
tim
ize
Wo
rkfl
ow
•C
on
tin
ue
mo
nit
ori
ng
•Su
stai
n a
nd
co
nti
nu
e im
pro
vem
ent
•C
om
mu
nic
ate
succ
esse
s
Nex
t St
eps
Stre
amlin
e A
nti
bio
tic
Stew
ard
ship
p
rogr
am, D
evel
op
new
clin
ical
ru
les
to
enh
ance
pat
ien
t sa
fety
, Tie
inte
rven
tio
ns
to p
har
mac
ist
pro
du
ctiv
ity.
Attachment #2
Sect
ion
Th
ree
– D
ata
on
Div
isio
n
Pe
rfo
rman
ce
1
.Fi
nan
cial
Str
en
gth
1.
Ach
ieve
Pro
fita
bili
ty
2.
Dem
on
stra
te b
usi
nes
s gr
ow
th
2.
Cu
sto
me
r Se
rvic
e
1.
Dev
elo
p lo
yal P
atie
nts
2.
Incr
ease
ph
ysic
ian
loya
lty
3. Q
ual
ity
1.
Dem
on
stra
te h
igh
qu
alit
y an
d s
afe
pat
ien
t ca
re
2.
Op
tim
ize
pro
cess
es a
nd
sys
tem
s
4. W
ork
forc
e/
Wo
rkp
lace
1.
Dev
elo
p c
ult
ure
th
at in
no
vate
s ch
ange
, in
no
vati
on
, acc
ou
nta
bili
ty
2.
Pro
vid
e to
ols
an
d e
qu
ipm
ent
for
op
tim
al p
erf
orm
ance
Attachment #2
Fin
anci
al S
tren
gth
Dru
g Sa
vin
gs E
xam
ple
s -
Ther
apeu
tic
Sub
stit
uti
on
s P
ersa
nti
ne
= $
5 f
or
Lexi
scan
= $
20
0,
Car
imm
un
e fo
r o
ther
IVIG
pro
du
cts
-O
pti
mal
use
of
An
tib
ioti
cs v
ia s
urv
ellia
nce
& In
fect
iou
s D
isea
se r
estr
icti
on
s
-U
se o
f N
ebu
lizer
s in
stea
d o
f M
ult
i-D
ose
Inh
aler
s
Attachment #2
Cu
sto
mer
Ser
vice
Fo
r Em
plo
yees
& f
or
Pa
tien
ts
Fro
m A
dm
issi
on
To
Dis
cha
rge
Attachment #2
Qu
alit
y- Q
AP
I Met
rics
Attachment #2
Qu
alit
y-A
dve
rse
Dru
g Ev
ents
. P
MC
P
OM
P
MC
P
OM
P
MC
P
OM
P
MC
P
OM
Me
asu
res
Targ
et
Ben
ch
mar
k
FY
Q3
20
14
FY
Q4
20
14
FY
Q1
20
15
FY
Q2
20
15
1.G
oo
d C
atch
es/
Ne
ar M
iss
Me
d
Erro
rs (
# Er
rors
/1
0,0
00
Do
ses
Dis
pe
nse
d)
3.5
- 1
0
0.4
6
0.3
7
0.8
2
0.4
8
0.9
5
0.4
9
3.5
0
.67
2. M
ed
icat
ion
Err
ors
wit
h N
o H
arm
R
esu
ltin
g
(# E
rro
rs/
10
,00
0 D
ose
s D
isp
en
sed
)
≤ 3
.5
0.9
9
0.6
3
1.2
1
.17
0
.87
0
.08
0
.86
1
.25
3. M
ed
icat
ion
Err
ors
Re
sult
ing
in
Har
m
(# E
rro
rs/
10
,00
0 D
ose
s D
isp
en
sed
)
≤ 0
.2
0.1
3
0.0
5
0.1
7
0
.16
0
.02
0
.0
0.2
1
0
.33
4. A
dve
rse
Dru
g R
eac
tio
n R
ate
(#
Err
ors
/1
0,0
00
Do
ses
Dis
pe
nse
d)
≤ 3
.5
0.2
8
0.8
9
0.2
1
0.8
0
.22
0
.82
0
.8
0.8
9
Attachment #2
Wo
rkfo
rce
/ W
ork
pla
ce
Incr
ease
d t
o a
n a
ll ti
me
hig
h o
f
28
ed
uca
tio
nal
in-s
ervi
ces
in F
Y Q
1 2
01
5
Attachment #2
1 P
HD
C &
Pom
era
do
Hospital
Surg
ery
& P
rocedure
s
Ja
nua
ry 2
015
Attachment #3
2
Qu
alit
y O
verv
iew
: 20
15
•O
R In
itia
tive
s /
NP
SG
•Su
rgic
al S
ite
Infe
ctio
ns
(SSI
)
•Tu
rno
ver
& O
n-T
ime
Star
ts
•Sp
ecim
en E
rro
rs
•Im
med
iate
-Use
Ste
riliz
atio
n
Attachment #3
3
Qu
alit
y O
verv
iew
: 20
15
•C
urr
ent
PI p
roje
cts
•P
hys
icia
n-l
ed T
imeo
ut/
WH
O
•C
on
solid
ate
inst
rum
ent
clea
nin
g an
d
rep
roce
ssin
g to
Ste
rile
Pro
cess
ing.
•O
R R
emo
del
Attachment #3
4
Pom
erad
o H
osp
ital
: Sta
nd
ard
ized
Infe
ctio
n R
atio
(S
IR)
0.5
07
0
.53
4
1.0
48
0.4
92
0
0.2
0.4
0.6
0.81
1.2
20
14
Q1
20
14
Q2
20
14
Q3
20
14
Q4
POM SIR
NH
SN T
hre
sho
ld
SIR
Attachment #3
5
Palo
mar
Hea
lth
Do
wn
tow
n C
amp
us
St
and
ard
ized
Infe
ctio
n R
atio
(SI
R)
0.5
53
0.8
1
0.3
33
0.6
49
0
0.2
0.4
0.6
0.81
1.2
20
14
Q1
20
14
Q2
20
14
Q3
20
14
Q4
PHDC SIR
NH
SN T
hre
sho
ld
SIR
Attachment #3
6
PO
M O
R T
urn
ove
r 2
4 m
in. (
Go
al ≤
30
)
Min
ute
s
Min
ute
s Minutes
Attachment #3
7
PH
DC
- O
R T
urn
ove
r 2
3 m
in. (
Go
al ≤
30
)
05
10
15
20
25
30
Minutes
Attachment #3
8
On
-Tim
e St
art
– P
OM
82
% (
Go
al ≥
80
)
Attachment #3
9
Firs
t C
ase
On
-Tim
e St
art
-PH
DC
0
10
20
30
40
50
60
Percentage
Attachment #3
10
IUSS
Rat
e 0
% (
Go
al <
10
%)
- P
OM
Attachment #3
11
Spec
imen
Acc
ura
cy -
PH
DC
Number of specimen errors per month
Attachment #3
12
Spec
imen
Acc
ura
cy: P
OM
Number of specimen errors per month
Attachment #3
13
PO
M O
R R
emo
del
: Pro
gres
s
•P
OM
OR
Re
mo
de
l: A
ll fo
ur
mai
n O
R’s
co
mp
lete
d r
emo
del
to
sta
te-o
f-th
e-ar
t lig
hts
, HD
imag
ing
& c
eilin
g-m
ou
nte
d
equ
ipm
ent.
–P
roje
ct c
om
ple
ted
No
vem
ber
20
14
–O
nly
usi
ng
th
ree
roo
ms
un
til v
olu
me
incr
ease
s
Attachment #3
14
Ph
ysic
ian
-Led
Tim
eou
t
•C
ham
pio
ned
sta
nd
ard
ized
ver
ific
atio
n &
“t
ime-
ou
t” p
roce
ss fo
r su
rger
y &
pro
ced
ure
s
•Ti
me-
ou
t in
itia
ted
by
the
ph
ysic
ian
per
form
ing
the
pro
ced
ure
•Ti
me-
ou
t im
med
iate
ly b
efo
re s
tart
of
pro
ced
ure
in a
ll ar
eas
Attachment #3
Nex
t St
eps
Attachment #3
16
Qu
estio
ns?
Attachment #3
WOU
ND C
ARE
CENT
ERS
PE
RFO
RM
AN
CE
IMP
RO
VE
ME
NT
RE
PO
RT
Pre
sent
ed b
y:R
upa
Sid
hu, M
BA
Pro
gram
Dire
ctor
–W
ound
Car
e C
ente
rs
Exe
cutiv
e S
pons
or:
She
ila B
row
n , R
N ,
FAC
HE
Vice
Pre
side
nt –
Con
tinuu
m C
are
Med
ical
Dire
ctor
;R
oger
Sch
echt
er ,
MD
, FA
CE
P , F
CC
WS
Ass
ocia
te M
edic
al D
irect
or:
Bra
dley
Bai
ley
, MD
, FA
AE
M ,
FCC
WS
Attachment #4
Whe
re w
e ar
e an
d W
hat w
e do
oS
tate
-of-t
he-a
rt O
utpa
tient
Clin
ical
Wou
nd C
are
and
Hyp
erba
ric M
edic
ine
oE
vide
nce-
base
d be
st-p
ract
ice
met
hodo
logi
es u
sing
a
varie
ty o
f clin
ical
trea
tmen
ts, t
hera
pies
and
sup
port
serv
ices
to tr
eat c
hron
ic w
ound
so
Indi
catio
ns fo
r wou
nd th
erap
y in
clud
e di
abet
ic u
lcer
s,
pres
sure
ulc
ers,
ven
ous
insu
ffici
ency
, sur
gica
l and
tra
umat
ic w
ound
s, v
ascu
litis
and
oth
er c
hron
ic, n
on-
heal
ing
wou
nds
oH
yper
baric
Oxy
gen
Ther
apy
help
s th
e bo
dy’s
oxy
gen
–de
pend
ent,
wou
nd-h
ealin
g m
echa
nism
s fu
nctio
n m
ore
effic
ient
ly. W
hile
enc
lose
d in
a c
ham
ber o
f gre
ater
-than
-no
rmal
atm
osph
eric
pre
ssur
e, p
atie
nts
brea
the
pure
O2,
sa
tura
ting
thei
r blo
od p
lasm
a an
d al
low
ing
it to
car
ry fr
om
15 to
20
time
the
norm
al a
mou
nt o
f hea
ling
oxyg
en to
the
body
’s ti
ssue
s.o
App
rove
d in
dica
tions
for H
BO
T in
clud
e di
abet
ic u
lcer
of
the
low
er e
xtre
miti
es, s
oft
tissu
e ra
dion
ecro
sis
&
oste
orad
ione
cros
is, c
hron
ic re
fract
ory
oste
omye
litis
, co
mpr
omis
ed s
kin
graf
ts a
nd fl
aps,
, ac
ute
perip
hera
l ar
teria
l ins
uffic
ienc
y, n
ecro
tizin
g fa
sciit
is.
Attachment #4
How
we
Mea
sure
Qua
lity
Qua
lity
Met
ric S
ourc
esoC
linic
al O
utco
mes
-iH
eal,
a cl
inic
al o
utco
me
track
ing
softw
are
plat
form
is u
sed
to m
onito
r w
ound
out
com
es a
nd h
ealin
g pr
ogre
ss o
n ve
ry
wou
nd a
sses
sed.
oP
atie
nt S
atis
fact
ion
-Pre
ss-G
aney
Info
ED
GE
repo
rts to
trac
k su
rvey
resp
onse
Attachment #4
Our
Per
form
ance
Impr
ovem
ent A
ppro
ach
PDC
Ao
Pla
n -
Roo
t Cau
se A
naly
sis
usin
g w
hy-w
hyo
Do
–In
sert
the
solu
tions
oC
heck
–B
efor
e an
d af
ter
oA
ct -
How
we
plan
to m
aint
ain
the
gain
s
Attachment #4
Clin
ical
Key
Per
form
ance
Indi
cato
rs
89
1927
91
14
26
90
1828
Hea
ling
Rat
e(%
)O
utlie
rs(%
)M
edia
n D
ays
toH
eal(n
umbe
r of d
ays
tohe
al)
2013
2014
Ben
chm
ark
Benc
hmar
k -b
ased
on H
ealog
ics’ n
ation
al be
st –p
racti
ces
acro
ss ne
arly
600 C
enter
sHe
aling
Rat
e –To
tal nu
mber
of w
ound
s with
Hea
led o
utcom
e/Tota
l num
ber o
f wo
unds
with
an O
utcom
e.Ou
tlier
s–To
tal nu
mber
of pa
tients
not h
ealed
in 14
wee
ks/T
otal n
umbe
r of a
ctive
patie
ntsMe
dian
day
s to
Heal
–math
emati
cal m
edian
of da
ys fr
om da
y of fi
rst vi
sit to
last
visit
to las
t visi
t for a
ll wou
nds w
ith a
Heale
d ou
tcome
Attachment #4
Cont
inuo
us Im
prov
emen
t Pro
cess
to fo
cus
on Q
ualit
y M
etric
sIn
dica
tor
Act
ion
Rev
iew
Freq
uenc
yB
y
Hea
ling
Rat
eM
edic
al s
urve
illanc
e re
view
s
Tim
ely
orde
rs/re
view
of d
iagn
ostic
st
udie
s
Wee
kly
Dai
ly
Med
. Dir.
/RN
S
uper
viso
r/Dir.
Cas
e M
anag
er
Out
liers
Eva
luat
ion
of w
ound
vol
ume
redu
ctio
nP
atie
nt c
ompl
ianc
e on
wee
kly
visi
ts
Wee
kly
Ong
oing
Med
. Dir.
/RN
S
uper
viso
r/Dir
RN
Sup
ervi
sor
Cas
e M
anag
erM
edia
n D
ays
to H
eal
Pat
ient
edu
catio
nTi
mel
yor
derin
g/us
e of
adv
ance
d th
erap
ies
Rev
iew
hea
ling
prog
ress
Ong
oing
Wee
kly
Wee
kly
Cas
e M
anag
erC
ase
Man
ager
Med
. Dir.
/RN
S
uper
viso
r/Dir
Attachment #4
Patie
nt S
atis
fact
ion
Feed
back
92
56
208
93.3
62
237
Mea
n S
core
Per
cent
ilen
size
2013
2014
Attachment #4
Actio
n Pl
an –
initi
ated
in J
uly
2014
Issu
esA
ctio
nsSu
cces
s M
etric
sR
esul
tsE
ase
of
regi
stra
tion
proc
ess
Reg
istra
tion
Pac
kets
bei
ng
mai
led
to n
ew p
atie
nts
and
also
m
ade
avai
labl
e at
refe
rring
ph
ysic
ian
offic
es
Mov
e fro
m 2
1%ile
in
Apr
il –J
une’
14 2
014
to
82%
ile b
y A
pril-
June
’15
2015
73%
ile d
urin
gO
ct-D
ec’1
4
Sta
ff co
ncer
n fo
r co
mfo
rt
Mag
azin
es/w
ater
/impr
oved
lig
htin
gin
wai
ting
area
sTe
mpe
ratu
re m
onito
red
clos
ely
Incl
ude
in In
take
scr
iptin
gan
d du
ring
RN
Sup
ervi
sor
roun
ding
Mov
e fro
m 2
7%ile
in
Apr
il-Ju
ne’1
4 to
82%
ile
by A
pril-
June
’15
66%
ile d
urin
g O
ct-D
ec’1
4
Ove
rall
ratin
g of
ca
re
Wee
kly
lead
ersh
ip m
eetin
gsP
hone
calls
by
Dire
ctor
to
new
pa
tient
s w
ithin
72
hrs
of fi
rst v
isit
Dis
char
ge R
N s
crip
ting
“did
we
addr
ess
all y
our c
once
rns
toda
y?”
Mov
e fro
m 5
8%ile
in
Apr
il-Ju
ne’1
4 to
82%
ile
by A
pril-
June
’15
68%
ile d
urin
gO
ct-D
ec’1
4
Attachment #4
Patie
nt F
irst …
mov
ing
the
need
le
2127
58
73
6268
8282
82
Eas
e of
Reg
istra
tion
Pro
cess
Sta
ff C
once
rn fo
r Com
fort
Ove
rall
ratin
g of
car
e
Apr
il-Ju
ne'1
4O
ct-D
ec'1
4G
OA
L%
ileSc
ores
Attachment #4
Colla
bora
tion
of C
are…
•In
FY
2014
our
Cen
ters
col
labo
rate
d w
ith 6
75 p
hysi
cian
s in
the
com
mun
ity to
dev
elop
com
preh
ensi
ve w
ound
car
e pl
ans
for 9
71
patie
nts
and
hea
led
1,11
3 ch
roni
c w
ound
s.•
In F
Y20
15 w
e ar
e po
ised
to g
row
our
phy
sici
an re
ferra
l bas
e to
ove
r 75
0, h
eal o
ver 1
,270
chr
onic
wou
nds
and
serv
e ov
er 1
,110
pat
ient
s.•
In F
Y20
15 o
ur W
ound
Car
e ph
ysic
ians
hav
e ex
tend
ed s
peci
alty
w
ound
car
e co
nsul
ts in
the
PH
Inpa
tient
set
ting
wor
king
col
labo
rativ
ely
with
the
Wou
nd C
are
and
Ost
omy
RN
Spe
cial
ists
.•
Our
Cen
ters
con
tinue
to c
olla
bora
te w
ith H
ome
Hea
lth a
genc
ies
and
SN
Fs in
the
com
mun
ityan
d ou
r Med
ical
Dire
ctor
s w
ork
clos
ely
with
A
rch
Hea
lth P
artn
ers,
hos
pita
list a
nd e
mer
genc
y ph
ysic
ian
grou
ps to
pr
ovid
e s
eam
less
con
tinuu
m o
f car
e fo
r our
pat
ient
pop
ulat
ion.
Attachment #4
Than
k yo
u
Attachment #4
2015 V
alu
e B
ase
d P
urc
hasi
ng
Pro
gra
m O
verv
iew
D
avid
M.
Lee,
MD
Medic
al Q
uality
Off
icer
Pati
ent
Experi
ence M
eeti
ng
Febru
ary
12,
2015
Attachment #5
Key C
oncepts
Valu
e =
𝑄𝑢𝑎𝑙𝑖𝑡𝑦
𝐶𝑜𝑠𝑡
Public r
eport
ing:
Hosp
ital perf
orm
ance o
n
many c
om
ponents
of
VBP is
post
ed o
n t
he
Hosp
ital Com
pare
websi
te
h
ttp:/
/w
ww
.medic
are
.gov/hosp
italc
om
pare
Perf
orm
ance D
ata
Peri
od:
appro
xim
ate
ly 2
years
pri
or
to t
he p
aym
ent
adju
stm
ent
year
Attachment #5
Key C
oncepts
fro
m p
.1
4 D
om
ain
s
1)
Clinic
al Pro
cess
of
Care
(Core
Measu
res)
2)
Pati
ent
Experi
ence o
f Care
(H
CAH
PS)
3)
Outc
om
e (
Mort
ality
, Pati
ent
Safe
ty Indic
ato
r,
Healt
hcare
-Ass
ocia
ted I
nfe
cti
ons)
4)
Eff
icie
ncy (
Medic
are
Spendin
g P
er
Benefi
cia
ry)
D
om
ain
s are
weig
hte
d d
iffe
rentl
y, a
nd w
eig
hti
ng c
an s
hif
t over
tim
e
2013
2014
2015
2016
Pro
cess
70%
45%
20%
10%
Pati
ent
Experi
ence
30%
30%
30%
25%
Outc
om
e
N/A
25%
30%
40%
Eff
icie
ncy
N/A
N
/A
20%
25%
Attachment #5
Attachment #5
Key C
oncepts
fro
m p
.2
Pro
gra
m “
Contr
ibuti
on” –
CM
S w
ill hold
back a
perc
enta
ge o
f each
hosp
ital's
Inpati
ent
Pro
specti
ve P
aym
ent
Syst
em
(IP
PS)
Opera
ting
Paym
ents
: 1.5
% in F
Y 2
015,
1.7
5% in F
Y 2
016,
and 2
% in F
Y 2
017
Est
imate
d c
ontr
ibuti
ons
for
2015 p
rogra
m
$673,4
00 f
or
PM
C
$260,9
00 f
or
Pom
era
do
Ass
um
ing n
o c
hange in IPPS,
est
imate
d c
ontr
ibuti
ons
for
2017
$897,8
67 f
or
PM
C
$347,8
67 f
or
Pom
era
do
Lin
ear
Payout
Functi
on F
acto
r –
will depend o
n h
ow
all t
he
oth
er
hosp
itals
in t
he p
rogra
m p
erf
orm
Attachment #5
Attachment #5
Key C
oncepts
fro
m p
.3
Pro
cess
Dom
ain
= s
ele
cte
d C
ore
Measu
res
Thre
shold
(50
th %
ile)
vs.
Benchm
ark
(to
p d
ecile)
Perf
orm
ance (
2 y
rs a
go)
vs.
Base
line (
4 y
rs a
go)
Achie
vem
ent
Poin
ts v
s. Im
pro
vem
ent
Poin
ts
Attachment #5
Attachment #5
Key C
oncepts
fro
m p
.4
Pati
ent
Experi
ence D
om
ain
= H
CAH
PS (
Hosp
ital
Consu
mer
Ass
ess
ment
of
Healt
hcare
Pro
vid
ers
and
Syst
em
s)
Consi
stency m
att
ers
Attachment #5
Attachment #5
Key C
oncepts
fro
m p
.5
O
utc
om
e D
om
ain
=
30-D
ay m
ort
ality
rate
for
specif
ic c
ondit
ions
PSI (P
ati
ent
Safe
ty Indic
ato
r) C
om
posi
te
H
ealt
hcare
-Ass
ocia
ted I
nfe
cti
ons
Som
e o
f th
ese
measu
res
als
o s
how
up in o
ther
federa
lly-a
dm
inis
tere
d “
pay f
or
perf
orm
ance”
(penalize f
or
poor
perf
orm
ance)
pro
gra
ms
Attachment #5
Attachment #5
Key C
oncepts
fro
m p
.6
Eff
icie
ncy =
Medic
are
Spendin
g P
er
Benefi
cia
ry
(MSPB)
All M
edic
are
Part
A a
nd P
art
B c
laim
s paid
fro
m 3
days
pri
or
to a
hosp
ital
adm
issi
on t
hro
ugh 3
0 d
ays
follow
ing
dis
charg
e
Pri
ce s
tandard
ized a
nd r
isk-a
dju
sted f
or
pati
ent
popula
tion
Attachment #5
Attachment #5
The B
ott
om
Lin
e (
goin
g b
ack t
o p
.2)
As
of
August
2014 C
HA D
ata
Suit
e e
stim
ate
s th
at
the n
et
loss
for
Palo
mar
will
be in t
he $
180K-$
310K r
ange
the n
et
loss
for
Pom
era
do w
ill be in t
he $
30K-$
90K r
ange
Attachment #5
Quest
ions?
Attachment #5
