Ninth compliance report on Parkland Memorial Hospital

7/29/2019 Ninth compliance report on Parkland Memorial Hospital

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Submitted To:

Centers for Medicare and Medicaid

Services and Parkland Health & Hospital

System

Submitted By:

Alvarez & Marsal Healthcare Industry Group, LLC

Columbia Square

555 Thirteenth Street, NW, 5th Floor WestWashington, DC 20004

+1 202 729 2100

Report of the Independent Consultative Expert (ICE)

Monthly Progress Report November, 2012

on

Parkland Health & Hospital System

Dallas, Texas

December 13, 2012


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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012

2

EXECUTIVE SUMMARY.........................................................................................................................................3

SIGNIFICANT CAP-RELATED GOALS MET IN NOVEMBER ..........................................................................................4

SIGNIFICANT CAP-RELATED GOALS STILL OUTSTANDING IN NOVEMBER.................................................................4

OVERALL IMPRESSIONS FROM NOVEMBER.................................................................................................................5

ACCESS AND THROUGHPUT................................................................................................................................6

CARE MANAGEMENT .................................................................................................................................................6

ENVIRONMENT OF CARE......................................................................................................................................7

HUMAN RESOURCES ..............................................................................................................................................9

NURSING COMPETENCIES.........................................................................................................................................10

CORRECTIVE ACTIONS .............................................................................................................................................10

MEDICAL STAFF ....................................................................................................................................................10

ONGOING PROFESSIONAL PRACTICE EVALUATION (OPPE)/PEER REVIEW ..............................................................11

PRIVILEGES AND CREDENTIALS ...............................................................................................................................11

NURSING/PROVISION OF CARE ........................................................................................................................11

NURSING PRACTICE AND NURSING UNITS ...............................................................................................................11

NURSING FLOAT POOL .............................................................................................................................................12

PRESSURE ULCERS...................................................................................................................................................12

RESIDENT SUPERVISION.....................................................................................................................................13

HOUSE-WIDE ISSUES............................................................................................................................................13

ABUSE SCREENING...................................................................................................................................................13

CONTRACT SERVICES...............................................................................................................................................14

INFECTION PREVENTION ..........................................................................................................................................14

INFORMED CONSENT TO TREATMENT FORMS AND PROCEDURES.............................................................................15

ROOT CAUSE ANALYSIS (RCA)...............................................................................................................................16SAFE PATIENT DISCHARGES.....................................................................................................................................16

DEPARTMENT AND UNIT SPECIFIC FINDINGS ............................................................................................18

CHEMOTHERAPY INFUSION CENTER ........................................................................................................................18

COMMUNITY ORIENTED OUTPATIENT CLINICS (COPC) ..........................................................................................18

HEMODIALYSIS ........................................................................................................................................................20

MEDICATION MANAGEMENT ...................................................................................................................................21

PATIENT RELATIONS ................................................................................................................................................21

PHARMACY ..............................................................................................................................................................22

PSYCHIATRIC SERVICES ...........................................................................................................................................23

RADIOLOGY .............................................................................................................................................................23

STERILE PROCESSING DEPARTMENT ........................................................................................................................24

URGENT CARE CLINICS............................................................................................................................................25

FOCUS AREAS FOR NEXT 30 DAYS...................................................................................................................26

CONCLUSION ..........................................................................................................................................................28


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Executive Summary

Alvarez & Marsal Healthcare Industry Group LLC (A&M) is serving as the Independent Consultative

Expert (ICE) under the Systems Improvement Agreement (SIA) between Parkland Health & Hospital

System (Parkland) and the Centers for Medicare and Medicaid Services (CMS). On February 29, 2012,

A&M delivered a Corrective Action Plan (CAP) to Parkland, as required under the SIA. This CAP was

approved by CMS and was subsequently accepted by the Parkland Board of Managers on March 8, 2012.

Under the SIA, the ICE is required to present monthly reports to CMS on the progression and status of the

CAP, including identification of problems that may jeopardize the successful implementation of the CAP

and actions underway to address those problems. This report constitutes A&Ms ninth report on

Parklands progress under the CAP. By agreement with CMS, the start date for timelines and deadlines

under the CAP was set as March 19, 2012.

During the month of November Parkland continued to make progress in meeting most of the deadlines

established in the CAP for November 2012. Since the implementation of the CAP on March 19, 2012 a

total of 465 tasks have been completed. An analysis of tasks completed by Work Stream is below:

Also, presented below is a breakout by action streams, for the two work streams performing under 95percent compliance in meeting target dates for their CAP initiatives.

WS # Work Stream Name

Total

Initiatives

Complete

Initiatives

%

Complete

On time

Initiatives

Delayed

Initiatives

Missed

Deadline /

Not

Sustainable

% Complete

and On Time

1Governance, Leadership, and

Org Structure59 49 83% 1 0 9 85%

2 Clinical Operations 183 164 90% 11 0 8 96%

3 Access/Throughput 111 111 100% 0 0 0 100%

4 Nursing 38 38 100% 0 0 0 100%

5 Physicians 60 58 97% 2 0 0 100%

6 QAPI 48 45 94% 3 0 0 100%

499 465 93% 17 0 17 97%TOTAL

AS # Action Stream NameTotal

InitiativesComplete

%

Complete

On Time

Initiatives

Delayed

Initiatives

Missed

Deadline /

Not

Sustainable

% Complete

and On Time

3.3 Bed Management 2 1 50% 0 0 1 50%

1.2 Organization Structure Changes 14 11 79% 0 0 3 79%

2.6 Other hospital-based department specific initiatives 5 4 80% 0 0 1 80%

3.5 Continuum of care beyond acute care setting 6 4 67% 1 0 1 83%

6.4 Metrics for Departmental QAPIs 7 6 86% 0 0 1 86%

3.4 Case Management, Discharge planning initiatives 25 23 92% 0 0 2 92%4.4 Clinical Competency Oversight 27 21 78% 4 0 2 93%

4.3Nursing roles & responsibilities; staffing levels and s taffing

models28 22 79% 4 0 2 93%


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Significant CAP-related Goals Met in November

Admit, Discharge and Transfer (ADT) Department

- Full implementation of the bed czar model within the ADT department. Patient Flow coordinators

routinely round on Hospital floors and interact with nursing to manage bed placement

Care Management

- Implemented interdisciplinary team meetings (IDT) across the Hospital. A&M presented its findings

on the success of these meetings in this report.

- Created/revised policies to determine high risk patients.

Emergency Department

- Implemented and successfully audited a central patient log.

Human Resources

- Developed tracking mechanism and disciplinary process for nursing department in regards to

corrective action.

Patient Safety

- Reported trending of adverse events through the patient safety network (PSNs) to the Board of

Managers.

Physical Medicine & Rehabilitation (PM&R)

- Selected a contract supplier for durable medical equipment (DME).

Psychiatric Services

- Identified a team to discuss post-acute care planning for psychiatric patients. Team has met several

times and will continue to identify potential providers for post-acute Parkland patients.

Significant CAP-related Goals Still Outstanding in November

Access/Throughput

- Transition of continuum of care accountability from CAP leadership to clinical/operations leadership

has not yet been completed.

- House-wide strategy on continuum of care requires completion.

Case Management

- Transition of Case Management from CAP leadership to clinical/operations leadership has not yet

been completed.

- Demonstration of improvement in Case Management metrics, which would indicate a robust

discharge planning process was underway.

-Have not yet developed full consistency in format and attendance of multi-disciplinary team membersat IDT care management meetings as well as consistency in improved outcomes for discharge

planning.

- Engagement of physicians to promote earlier discharges of patients in order to improve patient flow

and bed management/allocation.

- Development and education to staff for new Discharge Planning Assessment Tool


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Clinical Support

- 100 percent attendance/completion rate for fluoroscopy and general radiation safety training modules

to nursing and medical staff has not yet been achieved.


-

Completion of a GAP analysis for revision of new nursing policies and procedures.Nursing

- Comprehensive and coordinated plan to recruit an effective nursing float pool has not yet been

developed and implemented.

- Development of updated nursing leadership competencies, specifically related to new nursing

managers in Psychiatric Services, still requires completion.

- Nursing audit plans needs to transition.

Patient Safety / Patient Rights

- Hiring and organization decision for permanent Chief Patient Rights and Safety Officer (CPRSO).

- Sustaining compliant audit results for delivering Important Message from Medicare to relevant

patients by Care Management and Patient Financial Services (PFS).

Physicians

- Development and finalization of effective reporting and trending on verbal order, resident oversight,

History & Physical (H&P) documentation and effectiveness of on-call system. Although much work

has been accomplished towards this goal, yet to publish complete data.

Overall Impressions from November

As we indicated in our reformatted progress report for October, because most of the Corrective Action

Plan (CAP) initiatives have been largely completed, we have begun to shift more of A&Ms ICE

resources to monitor specific areas of the Hospital and conducting surveys using the same methodologies

employed during our initial Gap Analysis. The monthly audits and reviews are being performed as a moreholistic and inclusive review to assess compliance with CMS Conditions of Participation as well as

monitor for the sustainability of change in process and performance and the impact of the change on

patient safety, rights and quality.

The areas of focus for November were: the Chemotherapy Infusion Center, Community Oriented Patient

Care (COPC) Clinics, Hemodialysis Service Line, Nursing Services, Pharmacies, Radiology and the

Sterile Processing Department (SPD). Separate reports were provided to senior leadership and unit-

specific management for each area.

As we stated in previous progress reports, although much progress has been made in implementing the

CAP and correspondingly changing the culture of care delivery at Parkland, we still continue to see

instances on the front-line of care delivery where certain safety and quality checks are not universally

conformed or adhered to. For example, in some of our unit specific reviews in November, we continued

to see instances of the two patient identifier check not being observed. Although compliance with hand

hygiene protocol has greatly improved, on our floor and unit rounding and in rounding by Parklands

Infection Prevention department, non-compliance with hand hygiene protocols has still been observed.

And we have observed or been notified about potential patient safety events occurring because of failure

to follow all safe patient handoff protocols. As we stated in our October progress report, all levels of

management must continue to focus on transmitting the message to front line employees to work towards

100 percent compliance with all patient safety and quality checks, such as: two patient identifiers; the five


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rights of medication administration; documented and effective time outs prior to all procedures; 100%hand hygiene protocol adherence; safe patient hand-offs; 100% safeguarding of protected health

information (PHI); and 100% access to informed consent to treatment forms.

On a management and organization level, we remain concerned by the lack of progress in completing the

changes to Care Management organization and recruitment of permanent leadership to this important

function. As Parkland begins to experience high seasonal levels of occupancy and emergency room visitsin December, January and February, having a well-organized and fully functioning care managementdepartment is essential. We also continue to be concerned by the lack of progress in increasing the

number of discharges occurring before 11:00 a.m. We will be working with physician and nursing

leadership in December to gather additional data on services or units that would benefit from more

immediate intervention to have more timely discharge.

Finally, we will continue to work with the Hospitals senior leadership to ensure that all of the required

patient safeguards for Parklands behavioral health services, inpatient and psychiatric emergencydepartment (PED) are adhered to on a consistent and aspirationally 100 percent basis. As noted below in

this report, the Psychiatric Services Department continues to be challenged with potential (or actual)

patient safety events and issues. There continues to be a lack of a well-coordinated management team,

particularly in the PED. Several additional changes were made in late November and early December tobring additional resources to ensure a continuously safe environment. However, the Hospitals seniorleadership needs to continue to devote significant time and resources, as necessary, to ensure that this

critical service adopt every measure to assure a consistently safe environment for each patient, employee

and staff member.

Access and Throughput

Care Management

The Care Management (CM) Department is continuing its reorganization, which includes a completeoverhaul of its structure and personnel and re-tooling of roles and responsibilities for all positions in the

department. Vacancy rates continue to be high and key director positions have not yet been filled. In

addition, there remains a void in consistent leadership of the department.

In November, 74% of patients who presented to or were admitted from the Emergency Department (ED)

received intervention by care managers at time of admission. While there is significant room for

improvement, we recognize the steady gain and look forward to continued progress in December.

Education related to the proper procedure and use of the discharge planning assessment tool is scheduled

for both nursing and care management staff in early December. This tool will be used for 100% of

patients requiring care management intervention. A&M will further investigate the progress in this area

and in December we will be shadowing case managers and social workers to observe their day-to-day

operations and patient and staff interactions.

The physician advisor model is now in full operation, which enables the Hospital to receive a second

review regarding admission criteria from a third party group of physicians when medical necessity

clarification is needed. In November, the Hospital began to form an internal physician advisor program

and has identified a physician champion to spearhead the program. Josh Floren, Executive Vice President,

has undertaken the management of this project. In addition, training of the use of Milliman Care

Guidelines for medical necessity was completed in November for all Care Management staff.


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Discharges before 11:00 a.m. was a metric developed in the CAP to measure effectiveness and timelinessof discharge process to effectively improve bed flow and throughput. Discharges before 11:00 a.m.

remain low, with only 5.2% (see chart below) of all discharges occurring before 11:00 a.m. in November.

Physician leadership has suggested obtaining additional analysis to look at a number of cases discharged

late in the day to identify if avoidable barriers to discharge existed. This information will be used toformulate a corrective plan in December.

A&M continued to monitor the progress of the case management Interdisciplinary Team (IDT) meetings

held in various units of the Hospital. Care Management has transferred the ownership of these meetings to

nursing leadership due to the number of meetings taking place on a daily basis. Many IDT meetings

began in November and are works in progress; however, we observed a lack of consistency in the format

and effectiveness of these meetings. Additionally, in many cases, we noted a significant dearth in IDT

attendance, especially among physicians, physical rehabilitation, and even care management. In some

cases, we noted a general lack of understanding regarding the purpose of the IDT meetings.

These interdisciplinary meetings should be just that multi-disciplinary stakeholders meetings to

formulate plans for care and discharge planning of patients on those units. Without appropriate level of

attendance and participation by ALL key stakeholders and without a clear agenda and consistent format,

the intended purpose of this process appropriate care and discharge planning will not be achieved.

A&Ms view is that the lack of consistency in day-to-day leadership of these IDTs is the main reason that

this important element of Care Management has not excelled at the pace required to impact the

organization.

Environment of Care

In the month of November, additional environment of care audits were performed in hospital units,

community oriented primary care clinics (COPCs) and in the operating room (OR).

Overall, A&M observed 92% compliance across the health system in the areas of cleanliness, medication

management and patient rights/safety.

Inpatient, Outpatient and Operating Room Results

Area Compliance Sample

Cleanliness 92% 44

Med Management 95% 44

5.0%

4.4%

4.8%4.7%

5.1%5.2%

4.0%

4.5%

5.0%

5.5%

Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12

Percentage of Discharges < 11:00 AM


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Patient Rights 93% 44

Patient Safety 94% 44

Overall 92% 44

Out of the 44 audits conducted, 30 were conducted across the medicine, surgery and women and infant

specialty health (WISH) inpatient services. Within those 30 units, the major areas of concern remain inthe areas of cleanliness, patient rights and privacy, and medication management.

Environment of Care (EOC)

- Observations were made of cleaning supplies not being secured, hallways not being cleared of

equipment and general appearances of sub-par levels of cleanliness.

- A&M observed lack of compliance with hand washing protocols

Patient Rights and Privacy

-

A&M observed computer screens displaying patient charts, thus not being properly closed out whenunattended.

- Observations were made of drapes not being closed during patient transfers.

Medication Management

- Several units were observed with crash cart log inaccuracies ranging from incorrect dates when the

crash cart was last checked to incorrect cart and lock numbers.

- Observations were made of IV tubing with incorrect labeling.

- There were also instances of expired medications that were brought to the attention of both the charge

nurse and unit managers during the EOC rounding by A&M.

Operating Room (OR)

- Several observations of incomplete count boards sharps/scratch pads not included on board.

- Observations of non-compliant hand hygiene nurse coordinator entered operating room without

washing hands. Also an observation was made of faculty physician not scrubbing after de-gloving

from the operating room.

- An expired IV tube was observed connected to an Alaris pump.

Observations for the outpatient clinics can be found in the Community Oriented Patient Care section in

this report.

In November, A&M also observed environmental services daily rounding meetings. The purpose of thesemeetings is for staff members to hear daily safety updates and gather their supplies for the day. As

environment of care issues are still apparent, A&M recommends that these daily huddles be re-

structured. Staff members should be provided an agenda so they can read the daily/weekly safety updates

as theyre gathering supplies since its difficult for everyone to pay full attention as theyre preparing for

their shifts. Providing staff members with information on audit results can help staff understand what

areas should be top of mind. The meetings would be a good forum to present metrics, such as bed


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turnaround time, to share with environmental services staff that their work is affecting items being

reported to senior level executives and the Centers for Medicare and Medicaid Services (CMS).

Also, as referenced in the October report, significant numbers of environmental services staff were unable

to articulate information on the CAP, CMS re-survey, and other key issues. Primary language may be a

barrier, preventing staff from understanding items discussed during the daily huddles. Leadership should

consider translating safety and other important updates given during the daily huddles into differentlanguages for staff to more easily understand.

Human Resources

The Human Resources (HR) department made progress in November on the selection of a RecruitmentProcess Outsourcing (RPO) firm to assist with the Hospitals hiring and recruiting needs. HR leadership

advises that a contract will be executed with the RPO in early December and immediate focus will be

placed on Nursing, Care Management, and Physical Rehabilitation open positions. In addition, an outside

search firm was engaged to identify an appropriate candidate for the director of Workforce Planning andRecruitment.

There has been a positive trend in the decrease of the Nursing Departments vacancy rates since the

implementation of the CAP. Although values did increase in November, with the on-boarding of the RPO

and applicant tracking system (ATS), we should continue to see these metrics continue trend in the right

direction.

Although emphasis has intended results on lowering nursing vacancy rates, other areas such as

Occupational and Physical Therapy still have high vacancy rate (based upon size of these departments)

and needs to be addressed.

Parklands Human Resource (HR) department will continue to engage Mercer Consulting to implement

their recommendations regarding organizational changes and talent assessment. Implementation is

projected to begin in January 2013 and will continue through September 2013.

24.9%

12.7%17.5%

12.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%


Nursing Vacancy Rates

Nursing

Leadeship

Nursing

Overall


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Nursing Competencies

Audits have been in progress with Clinical Education and Human Resources to assess the completion of

clinical competencies in employees personnel files. Initial findings indicate that competencies are poorly

organized within the personnel files and are incomplete in many instances. Currently, A&M does not

believe that Parkland is meeting the Conditions of Participation that require a complete record of

employees competencies, including training, skills and knowledge that make them uniquely qualified for

their position. A&M will continue to work with the Hospital in December to improve the organization

and compliance for staff members clinical competencies.

Corrective Actions

In November, A&M performed a review of personnel files to assess the completeness of these files, as a

follow up to concerns raised during the Gap Analysis survey regarding incomplete personnel records.

The Gap Analysis report found that Parkland was not effectively utilizing the corrective action process.

For example, it was difficult to trace back a history of absenteeism to formal corrective actions given to

these employees. As part of our file review, 25 personnel files were reviewed to assess the correlation

between evaluation scores and corrective actions as well as adherence to the three event rule before the

employee is terminated.

A&M found documentation for several employees who received one or more corrective actions in a year,

but who were still given a fully successful evaluation score from 2006 to 2011. Additionally, there

were instances of promotions within the same year as a corrective action being filed. Many of the

counsels listed in the personnel file related to tardiness.

This limited file review suggests that management and HR are tracking the volume of corrective actions.

Hence, any employee in the sample reviewed, who received three corrective actions in year, was

terminated in accordance with policy.

A&M will continue to assess whether Parkland management is correctively utilizing the recently

redesigned corrective action policy in December.

Finally, as noted above with respect to nursing personnel files, we continue to observe instances of

personnel files not being up to date, complete and/or organized with respect to documentation of clinical

competencies.

Medical Staff

The Hospital continues to refine tracking processes for verbal orders and their authentication within 48

hours. Incorrect attribution of verbal orders has been identified as a barrier to the accurate reporting of

verbal order authentication. New procedures are in place to ensure that physicians return mis-attributedorders to the source, and nurses are being educated on the proper attribution of orders. This statistic will

continue to be reported and will become more accurate when mis-attribution issues are not included in the

data.


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Ongoing Professional Practice Evaluation (OPPE)/Peer Review

Progress continued to be made in October and November on implementing the revised OPPE process.

Indicators/triggers have been identified for all of the five pilot departments (Cardiology, Behavioral

Health, Anesthesia, Emergency Medicine and Emergency General Surgery/Trauma). Work is still

required to determine how this data will be captured and recorded. Staffing to support the revised OPPE

and peer review process is still not in place, however recruiting is on-going.

The Professional Staff Peer Review Oversight Committee is established and is meeting regularly. The

committee is meeting twice monthly. Committee meetings were on the following dates October 15,

November 2 and November 19. Two meetings are scheduled with agendas for December.

Additionally, the EthicsPoint contract has been executed and is in the development stage. EthicsPoint

provides integrated hotline and web-based ethics reporting systems and software and will serve as a

secure site to manage peer review referrals. Build sessions began in December.

Privileges and Credentials

An audit was conducted on Parkland's Operating Room (OR) schedule to test the physician privileging

system. The objective was to determine if the surgeon was properly credentialed to perform the surgical

procedure listed on the schedule. To accomplish this objective A&M utilized data from the operating

room schedule and the Parkland Core Privilege Viewer. A&M examined records for 25 patients

scheduled for surgery on Monday, November 26 and Tuesday, November 27, 2012. Of the 25 records

reviewed, 100% of the physicians were appropriately privileged to perform the procedure listed on the

Operating Room schedule.

Nursing/Provision of Care

Nursing Practice and Nursing Units

A review was conducted by A&M of compliance within inpatient areas of nursing services during the

month of November 2012. Observations were made on 12 units during A&Ms review and 24 charts werereviewed for documentation in those same units. In addition to surveying the nursing processes and

documentation, the environment of care was also observed including: infection control, hand washing,

two patient identifiers, time out, consent process, patient safety and medication management.

A full assessment was shared with Parkland leadership early December. Overall, A&M concluded that

there has been much improvement in the environment of care and consistent adherence to policy and

procedure in many of the medicine/surgery units. Exception observations around patient privacy, handwashing, medication reconciliation, pain documentation, medication management (security) and

consistent use of two patient identifier policy, suggest that improvements are still required to reach close

to 99 percent compliance ranges for a successful re-survey.

Across the house, there is a lack of consistent use of the two-patient identifier policy. Clinical and

operational leadership need to develop a plan to address improvement in the consistent use of two-patient

identifiers for all patient interactions in all care settings.


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Nursing Float Pool

Our October progress report noted our continuing concern with the Hospitals lack of a flexible staffing

pool and the impact this will have on staff levels when acuity-based staffing is implemented in January.In November, some progress was made toward understanding the Hospitals needs, but work still remains.

Nursing leadership still does not seem to have a clearly communicated and comprehensive strategy or

plan for development of a float pool to address these critical staffing needs.

We have recommended to senior leadership that decisions on centralized versus decentralized staffing

strategies must be made, as well as understand a clear financial picture of future needs, so that the

organization may appropriately prepare for increased flexible staffing requirements to meet fluctuations in

staffing due to changes in acuity of patient mix.

Pressure Ulcers

In October, six cases of hospital acquired pressure ulcers (HAPU) were reported by Parkland to CMS and

the Texas Department of State Health Services (DSHS). This series of pressure ulcer reports prompted

our review in November of Parklands pressure ulcer or wound care program. A review of the six cases

suggests the a lack of an interdisciplinary approach to managing HAPUs as well as a lack of

communication or hand-off among team members about patients with or at risk of HAPUs.

To determine whether PHHS was executing good skin care practices, an inquiry was made into the

National Database of Nursing Quality Indicators (NDNQI), a national repository of nursing-sensitive

indicators to patient outcomes when benchmarking against other hospitals with similar demographics.

HAPUs are one of the nursing-sensitive indicators to track in NDNQI.

Parklands nursing leadership has been participating in NDNQI and conducting pressure ulcer prevalence

surveys since March of 2011. In April 2012, nursing had stopped submitting information to NDNQI

although full surveys continued to be conducted every quarter. Several significant NDNQI benchmark

reports were not being disseminated to the wound care team or to nursing leadership. As of November 27,

2012, the NDNQI program was transferred from the Nursing Excellence Department to the Performance

Improvement (PI) Department. The PI department and the wound care team under the leadership of

nursing are collaborating to reassess the revitalize the skin care program.

In order to determine prevalence of HAPUs at Parkland a data review was necessary. Prevalence studies

are conducted quarterly for all medical/surgical, critical care, step down and rehabilitation units.

Prevalence studies are conducted weekly in the intensive care units. These benchmark reports providedinsight into the skin care program where further investigation is required to understand the gaps in the

skin care processes. The Parkland HAPU prevalence report from September 2012 was benchmarked to

their NDNQI comparator group. Twenty seven inpatient nursing units were benchmarked and eight

inpatient units fell into the low 25th percentile, 15 units in the 15th quartile and four units in the upper

75th quartile to their comparator group inpatient units.


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A task force including the Performance Improvement Department, senior leadership and wound care

representation was assembled to develop an action plan from the NDNQI preliminary data. A SWOT

(Strength, Weaknesses, Opportunities, and Threats) analysis was conducted by the task force. As a result,

the initial step is to conduct a prevalence study on the eight units that fell into the twenty-fifth quartile and

review the results to determine gaps. The study will be conducted by December 7, 2012.

Resident Supervision

Procedure Competencies

In November we interviewed five Registered Nurses (RNs) in the Parkland Main Operating Room with

the intent of gaining an understanding of their knowledge of the resident supervision grid. The purpose of

this verification was to determine if the surgical resident had the proper oversight present for the

procedure being performed and understood how to locate the oversight supervision grid. The results

concluded that:

- 80% of the nurses interviewed had trouble locating the online site (GME Supervision).

- 100% could not verbalize the post-graduate year (PGY) of the resident performing the procedure.

- 100% had minimal knowledge of how to use the supervision grid.

- 100% had minimal knowledge of how to interpret the findings on the grid.

It is evident from the small sampling that there is opportunity for additional education for the nursing staff

related to use of this system. Understanding aspects of the resident and physician oversight as it relates to

the procedure being performed in the operating room or other patient care area is vital.

Documentation

The Hospital has developed a template within Epic called Notewriter which assists residents and their

supervising physicians with appropriate documentation required for procedures. Within Notewriter,residents record a need for direct or indirect supervision, physician supervision information, and all

elements required for a complete procedure note. Significant education regarding the use of Notewriter

was developed and distributed to residents and faculty. Audits were conducted by Parklands Internal

Audit department on the use of Notewriter and the accuracy of the documentation. These weekly auditswere reviewed by physician leaders and the tool was modified and staff were re-educated as nuances with

the tool were identified. Preliminary data in the first full month indicates Notewriter is a valuable tool to

ensure proper documentation and supervision of procedures, and more accurate data is expected in

December.

House-wide Issues

Abuse Screening

As reported in the October CMS report, audit results around compliance for utilizing the abuse screening

questionnaire varied by department. The Women and Infant Specialty Health (WISH) Operations VP,

Paula Turicchi, spearheaded an initiative to standardize the questionnaire across the Hospital. Under Ms.


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Turicchis direction, a universal abuse screening questionnaire and response process flow for all divisions

for the electronic medical record (EMR) was developed. The Information Technology (IT) department

has developed test screens to denote the placement and instructions on how to navigate through the

documentation for each of the departments. All department representatives have agreed to the revisions.

Changes have been made to administrative policy 5-29 and will be cross-referenced to other

administrative policies including: 501, 5-01A, 5-02, 5-26 which all related to abuse screening. The

policies will be presented to the Documentation Committee on December 10 and then to the Pre-posting

Committee during the following week.

Communication regarding the changes to the EMR changes to the abuse screening questionnaire will be

emailed to the clinical staff after the Documentation Committee approval and EMR changes are

implemented.

Contract Services

Web conferences to educate contract owners on the contract quality program including definitions of

contracts to be included in the quality-indicator monitoring program are scheduled in November and

December. These sessions will also educate contract owners on how to use the contract management

system as well as post-execution contract administration procedures.

Currently, 115 contracts have been reviewed for quality indicators and are being monitored. The Quality

of Care Committee (QCC) has identified 18 significant contracts that require quarterly reporting to the

QCC. Of these 18 contracts, only 59% of the associated quality indicators are within acceptable limits.

A full inventory of contracts has not yet been completed, but there are 102 known contracts with quality

indicators that are not being monitored at this time. The majority of these contracts are related to human

resources, i.e., contract labor and will be addressed in January, 2013. In addition, the Hospital anticipatesa complete review of legacy contracts not in their current contract management system will be in

process from January through March 2013.

We strongly encouraged the Director of Contract Services to conduct an inventory of all contracts as soon

as possible. We also expect focused attention on identified unmet quality indicators.

Infection Prevention

The Infection Prevention Department has instituted monthly rounding on all inpatient units and the jail to

perform thorough audits alerting management and staff members of potential infection prevention-relatedissues. Audits are performed quarterly for the outpatient community oriented patient care (COPC) clinics.

Although real-time feedback is provided to staff members and most citations are corrected within 24hours, compliance still remains at approximately 92% across the system for October and November 2012.

This figure has been trending downward since the audits began in August.


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Specific units falling below 85% compliance in infection prevention include the following:

Area Unit

Medicine Services 9SWISH 5S

(Two Consecutive Months < 85%)

Medicine Services 9SS


WISH L&D OR


Surgical Services 6W CSS Pharmacy

WISH 3SS NNICU CSS Radiology Breast Health

Key themes observed from these areas include:

-General dustiness around cabinets, floors and crash carts;

- Deteriorating floor tiles in patient rooms;

- Lack of monitoring on refrigerator temperatures; and

- Shipping boxes in medication storage rooms.

In December, A&M will work with the Chief Implementation Officer to establish a matrix of

accountability for deficiencies in these areas. To date, audit results are only shared with unit managers

and not risen up through the chain of command to higher level positions reaching Vice Presidents.

Informed Consent to Treatment Forms and Procedures

A task force has been meeting regularly to discuss varying issues related to processing and posting of

informed consent to treatment forms. In November, the informed consents task force agreed to delay the

scanning of consent forms into the EMR until a patients discharge due to a problem of nurses trying to

find scanned consents in the electronic medical record chart. Nursing staff did not have confidence that

the consent form would be in the chart. Also, locating the consents is difficult for nursing staff since the

forms are not always found in the electronic medical record for the current hospital encounter.

Additionally, scanned documents are difficult to locate in the EMR since staff members use an ambiguous

naming convention when labeling the documents.

To respond to this problem of not being able to locate consent forms in the EMR, the Health Information

Management (HIM) department developed a tutorial to assist nursing staff with locating consents in

patient charts through several different methods.

Parklands patient population includes a high volume of Spanish-speaking patients who prefer their

healthcare information to be provided to them in their primary language, Spanish. Consents to treatment,

along with other important documents and forms, need to be provided to patients in their primary

language with the presence of an interpreter. As part of our nursing assessment document review, we saw

documentation determining whether or not the question is asked of the patient on their preferred language.


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However results of the question (English, Spanish, etc.) are not often found in the patients chart. The

Nursing department is working with Parklands IT department to construct an alert in the EMR clearly

indicating a patients preferred language.

Finally, as noted in the nursing assessment section below under Nursing/Provision of Care, A&M did

not observe staff members appropriately using two-patient identifiers before providing consent to

treatment forms to the patient.

Root Cause Analysis (RCA)

The root cause analysis (RCA) process is used to analyze an adverse event or systems issue that may lead

to patient harm. To conduct a root cause analysis, Parklands Patient Safety Department assembles multi-

disciplinary key stakeholders of the adverse event as well as representatives from the Performance

Improvement Department. The purpose of these RCA meetings is to ask questions and analyze the

findings of any investigations to determine the root cause(s) and contributing factors to the adverse

patient event and to develop an action plan to ensure similar events do not occur in the future. An actionplan is formalized, often by the department leadership immediately, to address infractions that need

immediate attention to prevent and minimize recurrence.

Recently, the RCA process at Parkland was revised under the leadership of the Quality and Patient Safety

departments. The Patient Safety department is now using the Joint Commission RCA method for

conducting RCAs. Four RCA action plans were reviewed by Alvarez & Marsal to monitor the

implementation the new methodology. Our review led to the following observation:

- It often required one to five RCA meetings for the formulation of an action plan. Several

implementation phases of action plans dating back to adverse events occurring in July, 2012 had still

not been completed at the time A&M investigated cases.

- There is not consistent physician engagement in responding to action plan formulation, and in some

cases physicians are a barrier to implementation of plan

- Timing for implementation of some action plans were too aggressive, did not allow proper time to

vet process changes with all key stakeholders, which may lead to ineffective implementation and/or

poor results

The Patient Safety Department should continue to refine the RCA process per The Joint Commissions

best practice. A goal stated by the Vice President of Performance Improvement was to finalize all action

plans during the first RCA meeting for a particular adverse event. A&M will continue to attend RCAmeetings and monitor for implementation of change during upcoming months.

Safe Patient Discharges

Unsafe or unauthorized departures of patients who are not appropriately or formally discharged from care

continue to be an issue for Parkland in the ED and within outpatient and inpatient settings. Under the

direction of the Quality Department, the Hospital created a Safe Patient Departure Task Force.


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While the Task Force meets regularly, there is not yet a comprehensive plan or strategy for a system-wideset of solutions to mitigate and/or reduce unsafe departures.

The Task Force met on November 28th and reviewed data of house-wide unauthorized discharges. The

data was stratified by division and department, and by type of departure (against medical advice, left

without treatment completed, and left without being seen). This data will be further analyzed by

department and unit managers to enable them to identify specific areas for improvement. The Task Forcemembers have been tasked with development of action plans for each department and are due forsubmission in early December.

The number of elopements (patients leaving against medical advice, before treatment complete or beforebeing seen by a provider) or patients leaving without screening or treatment within ED patient

populations is trending down since August.

1,9192,314

2,433

2,111 2,080

1,433

0

500

1,000

1,500

2,000

2,500

3,000


Volume of Elopements - ED

(Main, UCC, ICC, PED)

64 6669

5360

52

0

20

40

60

80


Volume of Elopements - Non-ED

(In/Outpatient)


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Department and Unit Specific Findings

Chemotherapy Infusion Center

In November 2012, A&M performed a review of patient and process flow and compliance withmedication management, hand washing, two patient identifiers, and environment of care within the

Chemotherapy Infusion Center.

A full assessment has been delivered to Parkland leadership and key findings from the areas listed above

include:


- Medications were being delivered to an open in-box at the nurses charting station. This station is

not always manned and therefore the medications are not secure.

- Needles and flushes were being stored in the mobile medication cart which has a key lock. However,

the key was in the lock during the site visit and therefore the medications and sharps were not secure.- It was suggested that the station be re-designed so that the medications and all flushes and sharps

could be stored in the closed cabinet. In addition, it was recommended that supply levels not exceed

that which can be utilized in one day.

Patient/Process Flow

- Only two patients were in the process of receiving treatment at 8:30 a.m. However, the bays were

fully staffed with registered nurses (RNs), while the waiting area had approximately 30 patients

waiting for registration, lab, or treatment.

- Patient flow is reflective of the chair utilization report underutilization of the chairs prior to 10:00

AM and after 2:00 p.m. In addition, there is peak activity with back-ups from 10 a.m. to 2 p.m. The

RNs have difficulty securing relief for breaks and lunch during this time.- Patients come to the clinic well in advance of their appointment in the hope of getting seen sooner.

The back-up is similar to that seen in the Urgent Care Center (UCC).

Community Oriented Outpatient Clinics (COPC)

In follow up to findings from the Gap Analysis report of February 2012, several A&M team members

visited four of Parklands COPC sites in November 2012 to assess their progress of initiatives included in

the CAP. The four surveyed clinics included:

- Garland Clinic (Garland)

-South East Dallas Clinic (SE Dallas, South East)

- DeHaro Saldivar Clinic (DeHaro)

- Oak West Clinic (Oak West)

The purpose of these visits was to follow-up on findings from the Gap Analysis revolving around general

cleanliness, access/throughput, and medication safety and to assess compliance with the CAP. Presented

below are high-level findings across all of the four surveyed clinics, as well as clinic-specific information.


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Environment of Care (EOC)

Since the original Gap Analysis was issued, general aesthetic and cleanliness issues have much improved

across all four of the surveyed clinics.

However, local management at several clinics expressed a need for increased onsite time for

environmental services (EVS) employees. We found opportunities for improvement in Oak West and inseveral clinic pharmacies as detailed below.

Pharmacy

The general state of cleanliness of the pharmacies at all four surveyed locations needs improvement.

There appeared to be throughput issues with patients at the Garland, SE Dallas, and DeHaro clinics.

Patient lines to pick up prescriptions were extremely long. A high volume of e-fax prescriptions come

through during the day, approximately 150-200/day at Garland and SE Dallas. The process entails a

patient being issued a number and standing in line to determine if the medication is ready. If the

medication is ready, the patient has to stand in line again to pay in the cashier line.

Clinics are generally open until 5:00 p.m. but the pharmacy will stop issuing numbers around 4:00 p.m. to

ensure the staff members can provide service to the patients who are waiting for medications. Patients

may wait until 6:00 p.m. to fill their medications. Often times, pharmacy staff must stay overtime to

ensure patients will have their medications first thing in the morning. Some staff members stay as late as

7:30 p.m. preparing for the following days medication refills.

To help prevent increased costs and decreased employee satisfaction with the added overtime hours,

pharmacy techs should be cross trained with pharmacists on how to prepare medications to be

filled/refilled as well as performing cashier duties. However, pharmacy techs still need the pharmacist to

verify the order. Also, an assessment should be performed analyzing the impact of implementing an

additional shift at the busier COPC pharmacies to expedite filling medications.

Patient Privacy

Clinic staff at all four clinics were found announcing patients first and last names when calling them to

the cashier desk, pharmacy counter, exam room and laboratory. A&M informed staff members that this

was not in accordance with industry best practice and is a Health Insurance Portability and Accountability

Act (HIPAA) violation. Therefore, re-education should be delivered to clinic staff to use a patients last

name and first initial when summoning a patient.

Conclusion

Overall, major improvements were observed in touring the four COPC clinics. In the eight-month time

period since the release of the CAP, key issues such as access and throughput and environment of care

have been addressed. There are still areas of improvement, as noted above, to ensure all clinics are ready

for a re-survey by CMS.

The most commonly found issues were the sub-par environmental conditions of the pharmacies at each of

the four clinics and consistent compliance in protecting patients privacy.


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Hemodialysis

During the month of November, A&M performed a direct observation assessment of Parklands

Hemodialysis Service, including touring the Hemodialysis Units, Moderate Intensive Care Unit (MICU)

and Emergency Department (ED). The assessment included: interviewing management, staff, providers

and patients.

Parklands Hemodialysis services provides inpatient and Emergency Department (ED) referred apheresis

and emergent acute hemodialysis in two areas: eight beds in 5th floor Outpatient Clinic (OPC) and six

beds on the 10th floor. Plans are also in progress to gain three additional beds by moving apheresis to 7

West and any of the Critical Care Units. The unit is open Monday through Saturday from 6:00 AM

11:30 p.m. Night hours, Sundays and holidays are covered on-call. The daily patient volume ranges from

36-40 patients.

Equipment Monitoring

Parklands Clinical Engineering Department provides extensive equipment monitoring and maintenance

of the unit equipment including the BBraun Dialog Plus dialysis machines. In collaboration with unit

staff, clinical engineering has implemented an effective communication system to address equipment

concerns and remediation. This new system results in more timely equipment intervention and return to

use. Significant back-up equipment is available in the unit, ensuring treatment is not delayed. There is a

back-up for every two dialysis machines. The unit dialysis equipment techs practice demonstrates high

compliance to the numerous quality controls required for equipment, refrigerators, eye wash station,

water (cultures, hardness, chlorine, PH/conductivity, reverse osmosis), disinfection and documentation of

the checks.

Ongoing Improvement Efforts

The Hemodialysis Service leadership has focused on addressing environment of care issues identifiedwithin A&Ms Gap Analysis report, earlier this year. Through a collaborative effort with the

Environmental Services Department, the general cleanliness of the units has much improved. The proper

storage of equipment has been a priority tackled through identification of storage spots for each piece of

equipment and virulence in keeping halls cleared, reinforced with ongoing audits and staff education.

The 10th

floor unit does have areas of significant wall damage. A plan is underway with the Infection

Prevention department to refurbish the area in a staged schedule as patient care continues.

Patient throughput is an ongoing challenge. Recent efforts addressed responsiveness to the patients

presenting to the ED as well as the increasing inpatient volume. Expanding hours of operation, improved

equipment availability, and the impending addition of two patient stations in the 5th floor OPC are

organically impacting the flow of hemodialysis patients from the ED. The addition of ED phlebotomists

appears to have positively impact the turnaround time of lab results essential to diagnosing the need for

acute dialysis, the first key step in the acute hemodialysis patient process. The Hemodialysis Service

Medical and Nursing leadership have established a daily report that rollups up into a monthly quality

dashboard. Performance is routinely assessed and issues addressed. Ongoing performance is now

reviewed within the Nephrology Division and reported to the Quality Care Committee (QCC) on a routine

basis.


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Overall, the level of care and overall leadership within the service is appropriate. The Manager and

Medical Director are both very committed to identifying and addressing any issues in the area.


As we have reported in past months, Parklands Pharmacy leadership has made great strides in theimplementing performance improvement initiatives of the Corrective Action Plan. In collaboration with

Respiratory Therapy the Hospital has significantly reduced the number of respiratory events due to

missed medications by improving communication and education. The chart below indicates an

impressive trend tracking the reduction of missed respiratory treatments.

In November, Radiology and Pharmacy began ongoing meetings to review medication managementstandards relating to contrast reactions and extravasations, as there have been a number of related patient

safety events of late. Meetings will include review of regulatory requirements, protocol and process

review, identification of educational needs, and review of verbal orders and medication order sets.

Development of radiology-specific medication management monthly audit tool is a goal of this group.

The Pharmacy has implemented two new best practice strategies as endorsed by the Institute for Safe

Medication Practices:

- To increase compliance with two-patient identifier procedures, ambulatory pharmacies are now

required to inspect prescription labels on medication with the patient at the point of sale to verify the

correct order.

- To reduce errors in Pyxis restocking, the Pyxis platform has been upgraded to include additional

safety features such as bar coding. In addition, a No Interruption Zone sign has been placed on all

medication rooms to reduce interruptions and distractions.

Patient Relations

As reported in the October report, the Hospital made significant changes to leadership and placed the

Patient Relations Department under the direction of the Quality and Patient Safety departments. In

896

1042

919

699 744 662

38 27 59 17 8 10

200

400

600

800

1000

1200

Respiratory Therapy Missed Treatments

Total Missed Treatment

Total Missed Treatment -

Therapist Not Available


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November, a full assessment of the department was completed, and a presentation will be made to theBoard of Managers outlining the current state, gap analysis and proposed re-design of the department.

Good progress has been made in this area in just a few short weeks. Issues addressed in November

include:

-

New director identified.- Immediate assessment of all current complaints and grievances began November 12

th.

- Patient Advocates assignments have been changed for each to focus on a specific hospital areas and

patient populations to develop an expertise.

- Patient Advocates have been re-focused on a proactive approach aimed at intervening immediately at

point of care delivery.

Assessment of patient relations software will begin in January to ensure optimum utilization of the system

and maximization of reporting features.

Pharmacy

During November, A&M performed a focused assessment of the Pharmacy Department. We surveyed

both the Central and Employee Pharmacy Centers. A full report was provided to Parkland leadership of

which key findings are highlighted below:

- Central Pharmacy

o Greeters were found to be consistently and appropriately assisting patients in determining

pharmacy order statuses, directing them to the appropriate area, and using two patient

identifiers.

o Within the processes of refilling and filling new prescription order services, we observed

isolated incidents of the following:

Pharmacy techs were observed not thoroughly reviewing patient history whenrefilling medications.

Pharmacists were observed interacting with Spanish speaking patients without the

use of an interpreter.

Pharmacy tech did not verify and correct misspelling of the ordering physicians

name while entering the scripts into Epic.

Unsecured medications found with protected health information (PHI) present on the

labels.

o Within the Medication fill area,

We found workspace that was cluttered, dusty and congested.

Pharmacy techs were appropriately filling orders, using two patient identifiers and

verifying scripts.

- Employee Pharmacy

o With regard to our review of appropriate securing and storage of medication, we found:

All areas properly secured.

Shipping boxes were found among the patient supplies which present a potential

infection control problem.


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Subsequent reviews will be conducted to recheck for evidence of corrective action in those areas.


The Psychiatric Services Department continues to be challenged with potential and in some cases actual

patient safety issues. There continues to be a lack of a well-coordinated management team, particularly in

the Psychiatric Emergency Department (PED). In late November, the decision was made by senior

leadership to incorporate Parkland management resources from the Dallas County Jail System to assist

with development of best practices policies and procedures. This is an encouraging development and

A&M looks forward to the recommendations and implementation plan from the Dallas County Jail

clinical and management team that should begin in December.

As reported in October, it was determined that policies and procedures were not completed for the

Behavioral Health service line. The Policy and Procedure work group has reviewed approximately 90

policies and has performed a gap analysis to determine remaining policies needed. All policies and

procedures are scheduled to appear on the Hospital intranet during the month of December and be made

available to all Behavioral Health employees.

In October, A&M requested that the nursing competencies recently revised by the Clinical Education

Department be reviewed by Behavioral Health leadership to ensure agreement. After review, the decision

was made to revise the competencies to reflect those of the Dallas County Jail, which leadership considers

more comprehensive. This work will be underway in December.

In December, training for staff will be focused on three primary areas: policies and procedures, Crisis

Prevention Institute (CPI) training, and process mapping. Nonviolent crisis intervention training from

CPI will educate staff on strategies to safely and effectively respond to anxious, hostile, or violent

behavior while balancing the responsibilities of care.

Radiology

During November, A&M conducted a policy and procedure compliance review of the Diagnostic Imaging

department the elements of review included: infection control, hand washing, two patient identifiers, time

out, consent process, environment of care (EOC) and medication management. The following modalities

were assessed:

- Computed Tomography (CT)

- Emergency Department Computed Tomography (ED-CT)

- Magnetic Resonance Imaging (MRI)

- Nuclear Medicine

- Ultrasound (US)

-Mammography (Invasive)

- Interventional Radiology (IR)

- Fluoroscopy.

The results of the review were shared with the Diagnostic Imaging Director, Geoffrey Camp, after each

modality was reviewed. Mr. Camp initiated corrective actions and education immediately upon feedback.

This was evident as the audits progressed.


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Overall, results from A&Ms observations were positives. Some of our key findings are outlined below:

- Computed Tomography (CT)

o Issue around performing patient identification process before administering medication

(contrast)

- Emergency Department Computed Tomography (ED-CT)

o Staff members found handling dirty linen un-glovedo Hand hygiene issues

- Magnetic Resonance Imaging (MRI)

o Issue around performing patient identification process before administering medication

(contrast)

- Nuclear Medicine

o Hand hygiene issue found with a patient transporter

- Ultrasound (US) no issues found

- Mammography (Invasive)

o Out of date time-out reminder card was found during an invasive procedure

o Electrical equipment (radios) found that were not cleared for use

- Interventional Radiology (IR) no issues found

-Fluoroscopy no issues found.

Sterile Processing Department

A nationally recognized subject matter expert on sterile processing techniques was added to the A&M

team in November to provide a full reassessment of Parklands Sterile Processing Department (SPD). The

detailed report was shared with SPD management and Parklands senior leadership team; a few key

findings are included below:

Staffing

-SPD should perform a market analysis to determine competitive wages to assist with filling vacanciesand retaining staff.

- Parkland should reimburse staff for training to achieve certifications in sterile processing.

- Parkland should develop an action plan to replace the agency technicians with permanent full time

employees and allow more time in the schedule for training and education of staff to ensure sufficient

training and employee satisfaction.


- The AAMI TIR 12 is a recommendation for hospitals to test and validate scope and cannulated

instruments cleaning processes. These products are to either test for

protein/hemoglobin/carbohydrate residues or for residual adenosine triphosphate (ATP). Parkland

should consider purchasing these products.

-Parkland should perform regular quantitative checks using ATP or hydrogen peroxide on instrumentsthat have box locks and lumens (versus just visual inspections).

- Staff should have manufacturers recommendation for Instructions for Use (IFUs) materials for

cleaning, sterilizing instruments and equipment readily available in the decontamination area.

- Instruments should be placed on stringers to meet correct washing requirements. Studies have shown

a potential for bacterial growth in the lumens of flexible endoscopes when stored for more than five

days. The thought leaders have not validated if the longer hang times develop bacterial growth. For


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best practice, Parkland should conduct a study to determine the hang time limits using ATP testingwith varying intervals of time.

- Observations of staff should occur for individuals with uncovered facial hair in the pick and pack area.

Monitor for appropriate personal protective equipment (PPE) and ensure all facial hair is covered.

- Parkland should ensure sterilization carts are not overloaded with instrument trays when placed in the

sterilizers to ensure proper dispersion of heat around the trays by following manufacturers

recommendation on proper cart loading.

Standards of Practice

- Parkland should subscribe to AAMI for benchmarking purposes as well as access to current sterile

processing standards.

o Using AAMIs benchmarking for comparison to like facilities can help drive budget numbers,

staff numbers, etc.

o Parkland should download two free AAMI amendments (2011-A2 & 2012-A3) from their

website regarding the latest sterilization maintenance.

- Parkland should implement a 24 hour report sheet for activities that need to be performed daily and to

ensure documentation of these duties have been completed.

Technology Enablers

- Parkland should better optimize its automatic surgical instrument tracking system, Censitrac. It

should also be used for improving infection control and providing data for meaningful benchmarking,

continuous process improvement and root cause analysis.

- Parkland should investigate adding the KeyDot or InfoDot bar coding system to high dollar

equipment and instruments. This is a data matrix bar coding labeling system that is applied to

instruments or equipment to assist in tracking its location.

Unit specific findings were also identified for the Operating Room, Gastrointestinal Lab, Labor &

Delivery units and the Ambulatory Surgery Center.

Urgent Care Clinics

Beginning November 1, 2012, Parkland engaged EmCare, a physician staffing company, to outsource its

physician coverage for the Urgent Care Center (UCC). To assist in monitoring this initiative, A&M

analyzed key throughput metrics for the UCC. Overall, the shift in skill set of emergency providers (vs.

urgent care providers) of EmCare has had a positive impact on patient throughput.


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All three of the UCC throughput metrics were dramatically decreased, which can in large part be

attributed to the expanded capacity and the use of emergency medicine physicians who can see an

expanded patient population. A&M will continue to monitor that patient care is not being compromisedby the increased throughput times.

Focus Areas for Next 30 Days

In the month of December, Parkland will continue to work toward its CMS Survey with A&Msmonitoring assistance.

Key activities occurring in December will cover the following areas:

Admit, Discharge, Transfer (ADT) Department

- To continue with on-boarding this function into the restructured Care Management organization

- To develop a structured feedback with nursing and physician leaders based on A&M observation

from nursing administrative officer (NAO) rounding

Care Management

- To identify qualified leadership and continue restructuring the department including filling vacant

positions

- To finalize discharge assessment planning tool and implement house-wide

- To implement Clickview software to track and report on metric trending

- Improve IDT meeting form and achieve consistency in attendance of key stakeholders of the care

team

0

50

100

150

200

250

300


Urgent Care Center

Throughput Metrics (Minutes)

Patient Arrival to Patient

Disposition

Patient Arrival to First Seen

by Provider

Patient Arrival to Room

Assignment

Onboarding of

EmCare Ph sicians


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Clinical Support

- Environmental Services to develop a routine and frequent cleaning schedule for busiest areas of

Hospital (ED, PED, etc.)

- Pharmacy to ensure units are compliant in medication management through ongoing audits and to

investigate options to improve throughput efficiencies for outpatient pharmacies

- Physical Medicine & Rehabilitation to develop metrics for backlog and timing to schedule and

provide therapy for new referrals and implement scheduling changes

Clinics (Specialty and COPC)

- To continue with implementation of Blue Cottages recommendations around the new delivery model

in outpatient clinics

- To work with pharmacy leadership of assessing throughput issues in outpatient pharmacies

- To revisit adding physician leadership over both the on-campus and off-campus clinics

Continuum of Care

- To reconvene task force to perform analysis on current post-acute care contracts, review complex

case committees role and perform financial analyses

- To have first kick-off meeting of task force in December

Contract Services

- To ensure list of contracts for review of quality indicators is comprehensive of all contacts, even pre-

dating 2009

- To establish a methodology for determining which contracts and indicators are significant and

should be reported to the QCC

- To work with Parkland business partners, holding them accountable for supplying Contract Services

with key information and metrics


- To complete construction in Main ED and UCC

- To continue assessing added value of EmCare contractors in UCC

Human Resources

- To finalize contract with recruiting process outsourcing firm (RPO)

- To implement applicant tracking system in accordance with onboarding of RPO

-

To revisit tracking and reporting of corrective action logs by department/Vice President


- To revisit escalation process for unit managers/directors/vice presidents as issues are identified by

Infection Prevention staff


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Nursing

- To develop a comprehensive and coordinated plan for building a flexible staffing float pool for

nursing

- To continue designing McKesson acuity-based staffing solution

- To develop and perform unit-level plan of care chart documentation audits

Patient Safety

- To continue with restructuring of root cause analyses process

- To finalize transfer of patient relations department and continue to refine processes and structure of

that function

- To assess the success of patient safety network communication and reporting functions

Physicians

- To finalize accuracy of physician attribution relating to verbal order reporting

-

To implement action plans based on audits of resident supervision privileging and documentation- To revisit discharge planning and discharge orders across different time and shifts


- To finalize revising all policies to best practice and conduct training for psychiatric staff members

- To work with Clinical Education to ensure the correct competencies are updated for employees

- To work with Patient Financial Services (PFS) on use of separate wrist bands in PED, causing some

patient identifier issues

- To collaborate with IT on changing the front end interface of EPIC to prevent staff mistakes in Psych

ED and 8N inpatient unit

Women and Infant Specialty Health (WISH)

- To open new unit (4SS)

- To continue to onboard new registered nurses

- To perform a root cause analysis for patients who have left before their treatment was complete or

before they were seen by a provider in the intermediate care center (ICC)

Conclusion

As we concluded in our October report we will repeat here that Parkland is a different and demonstrably

improved organization now than it was one year ago. We have seen evidence of a culture being created

that is working to ensure a safe care experience for all patients where the quality of all care andprocedures can be objectively measured.

However, as we stated in previous progress reports, although much progress has been made in

implementing the CAP and correspondingly changing the culture of care delivery at Parkland, we still

continue to see instances on the front-line of care delivery where certain safety and quality checks are

not universally conformed or adhered to. For example, in some of our unit specific reviews in November,

we continued to see instances of the two patient identifier check not being observed. Although


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compliance with hand hygiene protocol has greatly improved, on our floor and unit rounding and inrounding by Parklands Infection Prevention department, non-compliance has still been observed. And we

have observed or been notified about potential patient safety events occurring because of failure to follow

all safe patient handoff protocols. As we stated in our October progress report, all levels of

management must continue to focus on transmitting the message to all front line employees to worktowards 100 percent compliance with all patient safety and quality checks, such as: two patient identifiers;

the five rights of medication administration; documented and effective time outs prior to allprocedures; 100% hand hygiene; safe patient hand-offs; 100% safeguarding of protected health

information (PHI); and 100% access to informed consent to treatment forms.

With respect to management and organization, we remain concerned by the lack of progress in

completing the changes to Care Management organization and recruitment of permanent leadership to this

important function. As Parkland begins to experience high seasonal levels of occupancy and emergency

room visits in December, January and February, having a well-organized and functioning care

management department is essential. We also continue to be concerned by the lack of progress in

increasing the number of discharges occurring before 11 AM. We will be working with physician and

nursing leadership in December to gather additional data on services or units that would benefit from

more immediate intervention to have more timely discharge.

Finally, we continue have concerns about Parklands behavioral health services, particularly the

psychiatric emergency department (PED), and having a consistently safe and controlled environment for

all patients, employees and staff. We will continue to work with the Hospitals senior leadership to

ensure that all of the required patient safeguards for Parklands behavioral health services, inpatient unit

and PED are adhered to on a consistent and aspirationally 100 percent basis. As noted below in this report,

the Psychiatric Services Department continues to be challenged with potential patient safety issues. There

continues to be a lack of a well-coordinated management team, particularly in the PED. Several

additional changes were made in late November and early December to bring additional resources to

ensure a continuously safe environment. However, the Hospitals senior leadership needs to continue to

devote significant time and resources, as necessary, to ensure that this critical service adopt every

measure to assure a safe environment for each patient, employee and staff member and that behavioral

health managers in the PED and inpatient unit exercise the leadership and direction necessary to ensure

that every staff member is consistently following all policies and procedures established to ensure the

safety and security of each psychiatric patient.

We have discussed these observations with the Hospitals senior leadership and the Board of Managers,

all of whom are committed to driving this message of personal accountability to all staff members.


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Tasks/Initiatives

Accountability

Work

Stream

Targ

et

Date

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Completion

1.0

1

MECtoprepareacomprehensiveplantoimple

mentOngoingProfessionalPerformanceEvaluation(OPPE

).Review5%

ofMedicalStaffOPPEProfilesatconclusionofnexteight-monthcycle.

PatriciaBergen,

MD

5.1

1/31/2013

1.0

2

HospitalseniormanagementtorevisetheParklandESDPolicyManualtoincludewrittenpoliciesandproc

edures

regardingdocumentationofTeachingAttendin

gPhysicianoversightofResidents.

BradMarple,MD

5.3

5/18/2012

Y

1.03

Hospitalseniormanagement,incollaborationU

TSWandA&Mtocreateastandingrounding,evaluationa

ndauditing

processtocollectdataonResidentoversight.

BradMarple,MD

5.3

8/31/2012

Y

1.04

RequirequalitydashboardreportfromHospitalQualityDepartment

JackieSullivan

6.4

5/25/2012

Y

1.05

Commencereviewsofscorecardsforsignificantoutsourcedandcontractedclinicalservices.DesignaBoard-specific

QAPIplan.

JackieSullivan

6.4

6/1/20

12

Y

1.0

6

ReviewandreviseBOMcommittees.

PaulLeslie

1.1

6/8/20

Documents

Ninth compliance report on Parkland Memorial Hospital