OO17 A description of the infrastructure, the ... · the decision-making bodies specifically designed to oversee the quality of patient care. Background In support of the Advocate

OO17 Advocate BroMenn Medical Center 1

Organizational Overview EXEMPLARY PROFESSIONAL PRACTICE

OO17 – A description of the infrastructure, the organizational committees, and the decision-making bodies specifically designed to oversee the quality of patient care.

Background

In support of the Advocate Health Care (AHC) vision to be a faith-based system providing the safest environment and best health outcomes while building lifelong relationships with the people we serve, the core value of excellence is fundamental. Excellence at AHC is defined as empowering people to continually improve the outcomes of service, to advance quality, and to increase innovation and openness to new ideas. Advocate BroMenn Medical Center (ABMC) is one of eleven acute care hospitals in the AHC system.

AHC’s quality policy is “Safety, Quality, and Service Always through Continual Improvement”. Leaders and associates of AHC execute this policy through the organization’s Quality Management System (QMS) and commitment to continual improvement for the enhancement of patient and associate safety, health outcomes, operational excellence, and patient satisfaction.

In support of a systematic approach to achieve and sustain excellence, AHC utilizes a balanced scorecard involving six key result areas (KRAs). Performance improvement initiatives are driven by performance gaps as measured by the KRAs and opportunities identified by leadership. AHC’s performance measurement and improvement approaches are data-driven. They rely heavily on the principles of evidence-based practice and use of the International Standards Organization (ISO) 9001 standards as a foundation for performance improvement. The ISO foundation includes a wholistic approach to performance improvement which embraces the use of a variety of performance improvement tools for turning ideas and theories into action. Improvement tools and techniques used within AHC include use of the Plan-Do-Study- Act (PDSA) methodology, as well as a variety of Change Acceleration, LEAN and LEAN six sigma methodologies. The methodology primarily used by ABMC, however, is the PDSA model.

Documents that outline the QMS for AHC and ABMC include the AHC Quality Manual (Exhibit OO17.1 AHC Quality Manual) and the Integrated Quality and Patient Safety Plan (Exhibit OO17.2 Quality and Patient Safety Plan, 2016).


Infrastructure

There are a variety of system committees and organizational structures within AHC that provide support to the quality and patient safety functions in each AHC hospital, including:

AHC Board of Directors – The governing body is responsible for overseeing thebusiness management functions of AHC. There is two-way communication andinteraction between the Board, AHC senior leadership, and each hospital’sGoverning Councils within AHC. The Medical Executive Committees at eachhospital report both to the site Governing Councils and to the System ISO 9001Quality Management Oversight Committee (System QMOC).

AHC Health Outcomes Council/System QMOC – These two councils providethe leadership and resources to support system quality management objectives.System QMOC interacts and is accountable to both the AHC Board of Directorsand AHC senior leadership. The AHC Health Outcomes Council and the SystemQMOC are responsible for monitoring and improving system health outcomes,and for authorizing clinical excellence and patient safety initiatives throughout thesystem.

Quality Management Representative – The system and each hospital(including ABMC) within the AHC system has a Quality ManagementRepresentative. These individuals are responsible to provide oversight for thedevelopment, implementation and management of the Quality ManagementSystem (QMS). Site Quality Management Representatives work in collaborationwith the system Quality Management Representative to address system and siteissues as identified by the management review process.

AHC System Support Departments - Support departments exist within the AHCinfrastructure to coordinate activities, facilitate workflow, and provide neededinformation and guidance related to support processes including but not limitedto:

o Center for Health Information Management – Responsible for KRAreporting and data analysis, a consistent approach to the management ofpublicly reported data, and for the development and maintenance of thesystem’s data analytics platforms

o Clinical Effectiveness Department – Leverages physician leadership,evidence-based practices, and multidisciplinary teams to implement newpractices at the point of care to enhance safety, quality and cost- effectiveness


o Project Management Office – Coordinates system projects and evaluates proposed projects for the achievement of AHC’s 2020 strategic goals and priorities.

o Patient Safety Department – Establishes a planned, systematic

approach to patient safety, and provides access to resources useful in enhancing the culture of safety

o Quality & Regulatory Coordination – Establishes a planned, systematic

approach to ISO 9001 implementation and regulatory compliance, and provides access to resources useful for process evaluation and improvement.

Additional ABMC Hospital-Specific Infrastructure – The Quality Resource Management Department at ABMC provides support to the ABMC Quality Management Representative for management of the QMS.

o 13.9 FTEs, working within the ABMC Quality Resource Management

department, consult with and provide expertise and assistance to associates and physicians within the medical center for performance measurement and reporting, data analysis, process improvement work, infection prevention, surveillance and control, medical staff peer review, regulatory compliance, and public reporting activities.

o In addition, the medical center retains a full-time patient safety manager and a full-time risk manager to provide support for coaching and mentoring associates in safety, for safety event review (including near- miss and good-catch events), and for risk mitigation and reduction activities.

o A significant financial commitment has also been made by the medical center in order to support a number of electronic software programs for quality and risk management data collection and analysis. The programs, which supply rich data for process improvement, include but are not limited to:

MIDAS Quality Reporting Software, which includes a program for anonymous reporting of actual and near-miss safety events

Press-Ganey National Database for Nursing Quality Indicators (NDNQI)

American College of Surgeons National Surgical Quality Improvement program (ACS-NSQIP)

Get-With-The-Guidelines (GWTG) Stroke Program Society of Thoracic Surgeons Database (STS) A number of American College of Cardiology (ACC) databases Comparion Hospital-Physician Profiling System


ABMC Organizational Committees

For the purposes of quality management review, improved patient outcomes, and reduction in morbidity and mortality, a number of committees have been designated at each site, including ABMC, by the System QMOC to provide professional and peer self- evaluation of the adequacy of patient care. At ABMC these committees include but are not limited to the:

ABMC Quality Management Oversight Committee (QMOC) – Coordinates quality monitoring, clinical process improvement, patient safety, and quality reporting activities in alignment with the AHC mission, vision, philosophy and goals. This includes developing, innovating, implementing and supporting best health outcomes and best patient experience within the medical center by hardwiring best practices, identifying and responding to shared departmental issues and opportunities, creating efficiencies and cost-savings, and ensuring the appropriate oversight of results. Information and metrics reported to the QMOC include:

o Results of QMS audits o Patient satisfaction measures o Process performance and product conformity measures o Health outcomes measures o Status of preventive and corrective actions o Changes that could affect the QMS

o Recommendations for process and/or product improvements

ABMC Patient Safety Committee - Provides oversight for the ABMC’s patient safety program, fostering a culture of safety and high reliability throughout the medical center. This includes providing collaboration for the prioritization and implementation of site safety initiatives based on event reporting and cause analysis data, and providing support to proactively reduce risks to patient safety and system failures.

ABMC Medical Care Evaluation Committee – Responsible for reviewing the

quality and appropriateness of medical care through all clinical departments, and forwarding recommendations to other medical staff committees, as appropriate, for the resolution of identified patient care concerns .

ABMC Nursing Practice Council - Implements and maintains evidence-based standards of clinical practice and patient care aligned with the Advocate Nursing vision and philosophy, practice model and national foundational documents including but not limited to the Scope and Standards for Nursing Practice (American Nurses Association [ANA]), Code of Ethics (ANA) and Nursing’s Social Policy Statement (ANA).


A copy of the ABMC Quality Management Oversight Committee Structure has been included as an attachment to this document to further illustrate the organizational committee structure for quality and patient safety within the hospital (Exhibit OO17.3 ABMC Quality Management Oversight Committee Structure).

In addition to the site and system committees and organizational structures referenced earlier in this document, all departments in the medical center play a role in the quality and safety of care provided, particularly the clinical and clinical support departments.

Guided by AHC’s performance improvement philosophy which relies on data-based decision-making, all clinical and clinical support departments within ABMC are asked to annually develop a Quality Plan that includes the identification of the department or service’s performance improvement priorities for the year, and metrics that will be utilized to evaluate performance. The metrics are tracked and trended throughout the year using a standardized reporting format, and the data is used to both identify opportunities for improvement and gauge performance improvement in response to preventive and corrective actions that are implemented. Preventive and corrective actions are documented within the body of each Quality Plan, data displays and dashboards are regularly prepared for the presentation of information to associates and physicians, and process management reports are presented regularly to the QMOC in keeping with a pre-defined reporting schedule (Exhibit OO17.4 ABMC QMOC Reporting Plan, 2016).

Cross-departmental opportunities for process improvement are evaluated and recommendations are made by the Executive Team on an annual basis.

At the end of each calendar year, a year-end review is conducted to evaluate effectiveness of the site and system QMS (Exhibit OO17.5 QMS Year-End Review for Calendar Year 2015).

Decision-making Bodies

AHC’s Board of Directors assumes ultimate accountability for the quality and safety of patient care and services provided at the AHC hospitals, including ABMC, and for providing the leadership and resources necessary to support system quality management objectives.

While oversight of the system Quality and Patient Safety Program is provided by the AHC Board, the AHC site Governing Councils (ABMC) are given delegated responsibility and authority to guide direction of the individual hospital programs.

Responsibility is further delegated from ABMC’s Governing Council to ABMC Administration, the ABMC QMOC and the ABMC Medical Staff Executive Committee to implement and maintain the scope of activities addressed within the system Quality and Patient Safety Plan. A variety of medical staff and hospital committees assist these groups in carrying out this function, in keeping with the Medical Staff Bylaws/Rules and Regulations and the hospital committee charters approved through the QMOC. Each


committee’s scope of activity and responsibility (including decision-making), membership, meeting frequency, and reporting relationships are detailed within the committee charters.

7.27.16 jlm

QUALITY MANUAL For Advocate Health Care Quality Management System (QMS)

Approved: 07/17/2015 Revision: 4.0

This Quality Manual provides an overview of the Quality Management System for Advocate Health Care. It is maintained in compliance with the policy for Document Control. Printed copies of this manual are uncontrolled.

Exhibit OO17.1 Advocate BroMenn Medical Center 1

Exhibit OO17.1 Advocate BroMenn Medical Center

Quality Manual

Scope and Exclusions

Scope: Geographically located in Illinois, Advocate Health Care is a faith based healthcare system with community and teaching hospitals, including ten acute care hospitals, one critical access hospital and one integrated Children's hospital. Care is also provided in a variety of ambulatory settings, including outpatient centers and clinics operationally supported by three Support Centers. Labs at Advocate Health Care maintain College of American Pathologists (CAP) accreditation certificates.

The extensive range of health care services provided by Advocate Health Care include Acute Medical, Surgical, Critical Care, Cardiac, Rehabilitative, Occupational Health, Obstetrical, Pediatric, Emergency Care, Laboratory Services, Radiology Services, Behavioral Health (at select locations), as well as additional services that are offered at specific sites.

This Quality Manual provides guidance in coordination with the Advocate Integrated Quality and Patient Safety Plan which is established on an annual basis.

ISO 9001:2008 Quality Management System Requirements Advocate Health Care develops, implements, and maintains an ongoing system for managing quality in accordance with ISO 9001:2008 and has established (6) ISO policies in conjunction with this Quality Manual which include:

• Document Control

• Control of Records

• Quality Management System (QMS) Audits

• Control of Nonconforming Product

• Corrective Action for Continual Improvement

• Preventive Action

Exclusions and Necessary Justifications: Exclusion 7.3: Advocate Health Care has determined an exclusion for design of product based upon Advocate Health Care using only proven methods, treatments, equipment and medications. Advocate Health Care also does not participate in development of new methods, treatments, equipment and medications.

Quality Policy

The Advocate Health Care quality policy is: Safety, Quality, and Service Always Through Continual Improvement. The leadership and associates of Advocate Health Care executeour quality policy through our quality management system and a commitment to continual improvement to enhance patient safety, health outcomes, operational excellence, and patient satisfaction. Quality and Patient Safety Plans are maintained by the sites to provide operational framework. Advocate’s quality policy encompasses our philosophy and framework in addition to our performance measurement system which includes our Key Result Areas.

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Philosophy and Framework

Mission Statement: The mission of Advocate Health Care is to serve the health needs of individuals, families and communities through a wholistic philosophy rooted in our fundamental understanding of human beings as created in the image of God.

Vision Statement: The vision of Advocate Health Care is to be a faith-based system providing the safest environment and best health outcomes while building lifelong relationships with the people we serve.

The Advocate Experience: Advocate lives our Mission, Values and Philosophy (MVP) through the Advocate Experience, with our commitment to create the safest and best place for our patients, associates and physicians – always.

The Advocate Experience is: An experience without harm – Safety An experience of excellence – Quality An experience of engagement and trust – Service Always

Values The Statement of Values of Advocate Health Care serves as an internal compass to guide our relationships and actions:

Compassion We embrace the whole person and respond to emotional, ethical and spiritual concerns, as well as physical needs in our commitment to unselfishly care for others.

Equality We affirm the worth and spiritual freedom of each person and treat all people with respect, integrity and dignity.

Excellence We empower people to continually improve the outcomes of our service, to advance quality and to increase innovation and openness to new ideas.

Partnership We collaborate as employees, physicians, volunteers and community leaders to utilize the talents and creativity of all persons.

Stewardship We are responsible and accountable to all that we are, have and do.

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Philosophy The Philosophy of Advocate Health Care is grounded in the principles of human ecology, faith and community-based health care. These principles arise from an understanding of human beings as whole persons in light of their relationship to God, themselves, their families and the society in which they live. Through our actions we affirm these principles.

• We believe each person is created in the image of God.

• We respect, include and serve people without regard to race, religion, age,

disability, gender, sexual orientation or socio-economic status.

• We seek to assure the spiritual freedom of all persons.

• We extend our concern for the whole person to our patients, employees,

physicians, volunteers, trustees and their families.

• We address clinical, business, corporate and social-ethical issues from a faith perspective and assist individuals, families and professionals in the resolution of these issues.

• We are guided by the principles of justice in addressing our social responsibility

as a corporate citizen in this society.

• We are responsible and accountable in the spirit of stewardship for all the

resources under our management to assure the accomplishment of our Mission.

• We believe in effective collaboration with those individuals and entities interested in addressing the health care needs of our region.

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The table below offers a profile summary for the hospitals within Advocate Health Care.

Advocate BroMenn Medical Center

Normal, IL

221

4

Level – II

Level – II

• Chest Pain Center Accreditation

• Primary Stroke Center Certification

Advocate Christ Medical Center • ANCC as Magnet nursing hospital • Advanced Heart Failure Certification • Comprehensive Level – IIIc Stroke Center

Certification (Children’s • Ventricular Assist Oak Lawn, IL 690 5 Level – I Hospital) Device Certification

Advocate Condell Medical Center • Chest Pain Center Accreditation • Primary Stroke Libertyville, IL 273 9 Level – I Level – II+ Center Certification

Advocate Good Samaritan Hospital • ANCC as Magnet nursing hospital • Chest Pain Center Accreditation • 2010 Malcolm Baldrige National Quality Award Downers Grove, • Primary Stroke IL 333 4 Level – I Level – III Center Certification

Advocate Good Shepherd Hospital • ANCC as Magnet Nursing hospital • Primary Stroke Center Certification • Chest Pain Center Barrington, IL 169 8 Level – II Level - IIe Accreditation

Advocate Illinois Masonic Medical • ANCC as Magnet Center nursing hospital

• Primary Stroke Chicago, IL 408 8 Level – I Level – III Center Certification

Advocate Lutheran General • ANCC as Magnet Hospital Level – III nursing hospital

(Children’s • Primary Stroke Park Ridge, IL 521 4 Level – I Hospital) Center Certification

Advocate South Suburban Hospital • Primary Stroke Hazel Crest, IL 284 1 Level - IIe Center Accreditation

Advocate Sherman Hospital • ANCC as Magnet nursing hospital • Primary Stroke Center Certification • Chest Pain Center Elgin, IL. 255 10 Level-11 Level - IIe Accreditation

Advocate Trinity Hospital • Primary Stroke Chicago, IL 193 2 Level - IIe Center Certification

Advocate Eureka Hospital Eureka, IL 25 -

HOSPITAL PROFILE SUMMARY

Rehabilitation Graduate Neonatal Services

Licensed Offsite Medical Trauma Intensive Care Accreditation Additional Hospital Location Beds Locations Education Center Level (NICU) by CARF Accreditations

Acute Care Hospitals:

Children’s Hospital: Advocate Children’s Hospital

Oak Lawn

Oak Lawn, IL

106

-

Level – IIIc

Park Ridge

Park Ridge, IL

117

-

Level – I

Level – III

Critical Access Hospital:

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Acute Care Hospitals:

Advocate BroMenn Medical Center (ABMC) In addition to the main campus, ABMC operates four off campus locations including:

• Advocate BroMenn Outpatient Center, Normal, IL - providing women’s imaging,

therapy, and laboratory services

• Advocate BroMenn Adult Day Services, Normal, IL- providing life enrichment

services for aging adults along with assistance and respite for caregivers

• Wound Healing Center, Normal, IL - providing outpatient hyperbaric treatment and

care of patients with chronic wounds

• Family Health Clinic, Normal, IL - providing outpatient family medicine services

Advocate Christ Medical Center (ACMC) In addition to the main campus, ACMC operates five off-campus locations including:

• Advocate Christ Center for Breast Care, Oak Lawn, IL– providing diagnostic breast health studies and dexascan

• Advocate Christ Medical Center Outpatient Center, Tinley Park, IL - providing services for sleep disorders and rehabilitation

• High Tech Park, Palos Heights, IL, providing Cardiac Rehabilitation Services

• Advocate Christ Medical Center Outpatient Center, Lockport, IL- providing services for rehabilitation, diagnostic imaging, cardiodiagnostics, pain management and sleep studies

• Advocate Christ Medical Center Outpatient Center. Palos Heights, IL – providing sleep lab

Advocate Condell Medical Center In addition to the main campus, Advocate Condell Medical Center operates nine offsite locations, including:

• Advocate Condell Imaging Center, Gurnee, IL– providing imaging services, such

as open MRI, ultrasound, CT Scan, general X-ray, and mammography screening to facilitate a patient’s diagnosis and treatment

• Advocate Condell Immediate Care Center, Gurnee, IL– The Advocate Gurnee

Condell Immediate Care Center services include treatment for minor illnesses and injuries and in-house X-ray and laboratory services to facilitate diagnosis and

Key: CARF = Commission on Accreditation of Rehabilitation Facilities

ANCC = American Nursing Credentialing Center = YES

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treatment. The center also performs screenings, physicals and occupational health services

• Advocate Condell Immediate Care Center, Round Lake, IL– Services includes

treatment for minor illnesses and injuries and in-house X-ray and laboratory services to facilitate diagnosis and treatment. This center also performs screenings, physicals and occupational health services

• Advocate Condell Immediate Care Center, Vernon Hills, IL–Services include

treatment for minor illnesses and injuries and in-house X-ray and laboratory services to facilitate diagnosis and treatment. This center also performs screenings, physicals and occupational health services

• Centre Club, Gurnee, IL - providing outpatient rehab services

• Centre Club, Libertyville, IL - providing outpatient rehab services

• Physical Therapy Clinic, Grayslake, IL - providing outpatient rehab services

• Advocate Condell Medical Center Lincolnshire Rehab/Complete Orthopedic care, Lincolnshire, IL – providing outpatient rehab services

• Advocate Condell Physical Therapy, Vernon Hills, IL – providing outpatient rehab services

Advocate Good Samaritan Hospital (AGSH) In addition to the main campus, AGSH operates three off campus locations and one location on campus but physically separate from the hospital, including:

• Advocate Good Samaritan Outpatient Center, Downers Grove, IL - providing immediate care, physical therapy, diagnostic imaging and laboratory services

• Advocate Good Samaritan Outpatient Center, Lemont, IL- providing immediate care, physical therapy, diagnostic imaging and laboratory services

• Advocate Good Samaritan Imaging Center, Woodridge, IL - providing diagnostic imaging services

• Good Samaritan Health & Wellness Center, Downers Grove, IL, providing outpatient physical therapy services in a 90,000 square foot medical model fitness center located on the campus of Good Samaritan Hospital

Advocate Good Shepherd Hospital In addition to the main campus, the following comprise the locations of clinical care provided by Advocate Good Shepherd Hospital:

• Advocate Good Shepherd Hospital Sleep Lab Center, Barrington, IL – providing

diagnostic and therapeutic sleep testing

• Advocate Good Shepherd Immediate Care Center, Crystal Lake, IL – providing

immediate care, diagnostic imaging and laboratory services

• Advocate Good Shepherd Outpatient Center, Lake Zurich, IL – providing

diagnostic imaging and pediatric only rehabilitation

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• Advocate Good Shepherd Hospital Health and Fitness Center, Barrington, IL–

providing outpatient physical and occupational therapy for adult’s including Lymph

edema, Aquatic and Hand Therapy services in a 69,000 square ft. medical model fitness center located off campus

• Advocate Good Shepherd Outpatient Center, Algonquin, IL – providing diagnostic

imaging and Pediatric Cardiac Clinical Echo 2D services

• Advocate Good Shepherd Outpatient Center, Crystal Lake IL – providing pediatric

physical, occupational and speech therapy and physical therapy for adults including Lymph edema

• Advocate Good Shepherd Diabetes Center, Barrington, IL– providing

comprehensive assessment and education for individuals with Type 1, 2 and Gestational Diabetes

• Advocate Good Shepherd Radiation Oncology, Barrington, IL– providing single

beam radiation therapy

Advocate Illinois Masonic Medical Center (AIMMC) In addition to the main campus, AIMMC has eight offsite locations:

• Antenatal Resource Center, Chicago, IL – providing Ultrasound, Fetal Assessment, Prenatal Diagnosis, Fetal Echocardiography, Genetic Counseling and Maternal- Fetal Medicine Consultation

• Health and Wellness Clinic, Chicago IL - a pharmacist-managed clinic currently providing anticoagulation and lipid management and smoking cessation services

• Chicago Anesthesia Pain Specialists/Pain Center, Chicago, IL – providing advanced treatments for a wide variety of acute and chronic conditions, including patient education specific to personal pain management

• Creticos Cancer Center, Chicago, IL – providing individualized, comprehensive, leading edge cancer care

• Infusion Center, Chicago, IL – providing Intravenous, Intramuscular and Subcutaneous Medication treatment

• Outpatient Diagnostic Center, Chicago, IL – providing imaging services for general x-ray, CT, MRI, PET and Stress testing

• Women’s Imaging Center, Chicago, IL – providing Women’s imaging services in Mammography and Ultrasound

• Behavioral Health Services (Outpatient) , Chicago, IL – providing individual, group and family therapy, substance abuse treatment, and psychiatric services for adults and children

Advocate Lutheran General Hospital (ALGH) In addition to the main campus, ALGH has four off site locations including:

• Center for Advanced Care featuring the leading edge Cancer Care Center, Center for Advanced Imaging and the Richard G. and Carol Caldwell Breast Center, Park Ridge, IL – providing full range of advancements in cancer treatment, state of the art radiation therapy, advanced imaging capabilities that allow for accurate

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screening evaluation and diagnosis of illness and injuries including x-ray, Cat scan, MRI, nuclear medicine, PET and ultrasound, digital mammography including 3D tomosynthesis screening

• Center for Advanced Care featuring the Behavioral Health Adult Day Program providing behavioral health services for adults 18 and above with mood and anxiety disorders, focusing on cognitive behavioral therapy

• Patient Resource Center featuring advanced wound care, Niles, IL – providing Advanced Wound Care through an interdisciplinary model including physical therapy, advanced practice nursing, and physicians

• Patient Resource Center featuring anticoagulation management, Niles, IL – providing assistance to physicians in the monitoring and management of patients receiving anticoagulant therapy, ongoing patient assessment, changes in therapy and maintaining communication with providers, and patient and provider education

• Older Adult Services, Des Plaines, IL – providing a medical model Adult Day Service, Home delivered meals, senior information and resources, emergency response systems and expressions at early Alzheimer’s program as well as outpatient rehabilitation services

Advocate Sherman Hospital In addition to the main campus, Advocate Sherman Hospital operates eleven offsite locations including:

• Advocate Cardiac Rehab, Elgin, IL - provides comprehensive services involving

medical evaluation, prescribed exercise, risk-factor modification through education counseling and behavioral intervention

• Advocate Sherman Imaging, Elgin, IL - provides imaging services, MRI, digital mammography, general diagnostic and breast ultrasound, angiograph, body and joint CT, general nuclear medicine and nuclear cardiology, cardiac (Echo) ultrasound

• Advocate Sherman Outpatient Center, Algonquin, IL– provides immediate care services, occupational health, physical therapy, outpatient lab and medical imaging including CT, ultrasound and mammography

• Advocate Sherman Outpatient Center, Elgin, IL – provides immediate care services, occupational health, physical therapy, outpatient lab and medical imaging including CT and ultrasound

• Advocate Sherman Outpatient Center, South Elgin, IL - provides immediate care services, occupational health, physical therapy, outpatient lab and medical imaging including CT, ultrasound and mammography

• Anticoagulant clinics in Elgin and Algonquin IL - provide consultative services for INR monitoring by a pharmacist with oversight by a cardiologist and pathologist

• Advocate Sherman Park Place, Streamwood, IL - provides physical therapy services including aquatic therapy

• Advocate Sherman Physical Therapy at the Elgin Centre, Elgin, IL - provides physical therapy services

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• Advocate Sherman Diabetes Center at the Elgin Centre, Elgin, IL – provides education in the self-management of diabetes and related conditions, offering ongoing follow-up and support to the patients and families

• Center street campus, Elgin, IL – includes a Center for Sleep Disorder providing comprehensive sleep studies; and, Advocate Sherman Center for Occupational Rehab and Evaluation (SCORE) sees patients by appointment only providing functional capacity evaluations and various pre-work screenings

Advocate South Suburban Hospital

In addition to the main campus, Advocate South Suburban Hospital operates one off campus sleep center:

• South Suburban Hospital Sleep Center, Tinley Park, IL – providing treatment for sleep disorders

Advocate Trinity Hospital (ATH) In addition to the main campus, ATH operates two off campus locations including:

• Advocate Trinity Hospital Sleep Lab, Chicago, IL – providing treatment for sleep disorders

• Advocate Trinity Hospital Wound Care Center, Chicago, IL- providing treatment for non-healing wounds

Advocate Children’s Hospital

• Advocate Children’s Hospital, Oak Lawn, IL In addition to the main campus, Advocate Children’s Hospital in Oak Lawn operates 6 off-campus locations including:

Advocate Children’s Hospital - Oak Lawn, IL – providing outpatient pediatric therapy services

Advocate Children’s Hospital - Oak Lawn, IL – providing consultative therapy services to ACH Pediatric Specialty Clinics in addition to individualized diagnostic/therapy services of Audiology, Speech, Physical and Occupational Therapies

Advocate Christ Medical Center Outpatient Center, Lockport, IL – providing pediatric physical, occupational and speech therapy services

Ambulatory Clinics Advocate Children’s Hospital – Oak Lawn - Providing outpatient primary care including a wide array of integrated specialty services

Advocate Children’s Hospital-Oak Lawn, IL, Keyser Family Pediatric Cancer Center-providing individualized services to children with cancer and hematologic disease

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• Advocate Children’s Hospital- Park RidgeAttached to the main campus, Advocate Children’s Hospital in Park Ridgeoperates:

Yacktman Children's Pavilion (Outpatient Services) – Park Ridge, IL – providing a comprehensive range of pediatric outpatient services – from pediatric primary care and subspecialties, to diagnostics and therapies

Critical Access Hospital:

Advocate Eureka Hospital (AEH) No offsite campuses

Advocate Health System Clinical, Support, and Business Services Overview The following narrative overviews support the diagram entitled Advocate Health Care Process Map on the page that follows.

Advocate Health System Clinical Services The clinical services offered by the hospitals in Advocate Health Care share three common clinical processes. The process begins when the patient is admitted or accesses the hospital clinical services. The patient then enters the diagnosis/treat phase. In this phase there are several clinical and ancillary or diagnostic services. Some of these services vary by hospital but all hospitals offer the services shown on the process map. Once the patient completes the diagnostic and treat phase, they are discharged or transitioned. The discharge/transition process is addressed throughout the entire patient stay. If transitioned, patients may transition to home or another facility.

Advocate Health System Support Services The Advocate support services provide service and material support to the clinical services and the organization as a whole. The support services processes that occur either at the system or site level include fiscal, ancillary, general, human resources, clinical transformation and contracted services. The contracted services vary by site.

Advocate Health System Management The Advocate Health Care Board of Directors oversees the business management functions of the Advocate System. There is two way communication and interaction between the Board and Advocate system senior leadership and the site Governing Councils. The system ISO 9001 Quality Management Review Committee interacts and is accountable to these two groups. The Medical Executive Committees at each hospital report to the site Governing Councils.

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Safety, Quality, Service: The Advocate Experience Advocate Process Map

Leadership Oriented Processes

ACCESS DIAGNOSE/ TREAT

TRANSITION

Patient Oriented Processes

Patient Oriented Support Processes

Support Processes

2/9/2015

Infection Prevention Facilities EVS Medical Staff

Services HIM Biomedical Engineering

Revenue Cycle

Human Resources

Contracted Services Security Education Research

Guest Services/ Patient

Relations

Quality/Risk/ Safety

Innovation Supply Chain Information

Systems

Community and Wellness

Care Management

Rehab/ Therapy Services

Wound Care CV Services Respiratory Pharmacy

Laboratory Nutrition Imaging Ambulatory Clinic

Surgical & Procedural Services

Mission & Spiritual Care

Patient Access

Post Partum

Labor and Delivery Nursery

Key Work System

Inpatient Care

MVP Legal & Ethics Oversight Finance Marketing Charitible

Foundation

Business Development

Strategic Planning

Administration/ Medical Staff

Governing Council

Home

Key Work System

Emergency Care

Key Work System

Outpatient Care

Home Health/ Hospice Transition

of Care

Skilled Nursing/

Rehab Behavioral Health

Long Term Acute Care Hospital

Med/Surg Pediatrics Tele Critical Care

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Quality Management Oversight Committee Structure

System ISO 9001

Quality Management

Oversight Committee

(Sr. Leadership Team)

Site Governing

Councils

Site Executive

Team

Site ISO 9001 Quality Management Oversight Committee

* BroMenn * Christ * Condell * Eureka * Good Samaritan

* Good Shepherd * Illinois Masonic * Lutheran General

* Sherman * South Suburban * Trinity

Medical Executive

Committee (MEC)

Advocate Health Care

Board of Directors

Reporting

Exchange

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Advocate Health Performance Measurement System Key Result Areas (KRA’s) are established to support strategic objectives; measures are established to monitor the performance for each KRA. Accountability for performance is addressed through an objective leadership evaluation system in which management performance objectives directly align to KRA performance. Performance improvement initiatives are driven by performance gaps as measured by KRA’s and opportunities identified by leadership. The KRA’s and the Performance Measurement System is illustrated in the diagrams below.

Key Result Areas (KRA)

Performance Measurement System

10

9

3 Determine

Comparisons

Set Targets (1-5)

7

1B 1A Annual AHC

Strategic Planning

Site

Strategic Planning

Ongoing

Review of

Metrics for

Relevance

Annual

(or as needed)

Results

Reviewed

4 Goal Cascading

(AMS)

Systematic

Review and

Analysis of Data

(Schedule)

6 Select Key

In-Process

Measures

5

Data Collected

2 Select Key Outcome

Performance

Measures

8 Gap Plans

PI Projects

(as appropriate)

Environmental

Scan

Regulatory

Requirements SWOT Vision

Coordinated Care

AdvocateCare Index

Funding Our Future

Operating Margin

Hospital Cost per Discharge

Medical Group Cost per Visit

Philanthropy

Growth

Net Revenue Growth

Quality Service

Health Outcomes Index

Patient Satisfaction Percentile

Associate Engagement Percentile

Physician Engagement Percentile

Safety

Serious Safety Events

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Organizational Quality Documents

Document Type

Document Name

Quality Policies

Quality Manual

Document Control

Control of Records

Quality Management System (QMS) Audits

Control of Nonconforming Product

Corrective Action for Continual Improvement

Preventive Action

NIAHOM

Documents

Medical Staff Bylaws (site specific)

Scopes of Service (site specific)

Integrated Quality and Patient Safety Plan (site specific)

Patient Rights and Responsibilities

Utilization Management Plan

Physical Environment Management System Plan

Infection Prevention Plan (site specific)

Nursing Documents

Lippincott Manual

Other Service Agreements

Revision Log

Revision Approval By Date Notes

1 ISO Steering Committee 03/19/2013 Original release

2 ISO Steering Committee 01/22/2014 Updates


3.1 ISO Steering Committee 04/20/2015 Update and input into ADS


Revision 4: 08/03/2015 14

2016 Quality & Patient Safety Plan

Integrated Quality and Patient Safety Plan 2016

I. Philosophy and Framework In support of Advocate’s vision to be a faith-based system providing the safest environment and best health outcomes while building lifelong relationships with the people we serve, the core value of excellence is fundamental. Excellence at Advocate Health Care is defined as empowering people to continually improve the outcomes of our service, to advance quality, and to increase innovation and openness to new ideas.

In support of a systematic approach to achieve and sustain excellence, Advocate Health Care utilizes a balanced scorecard involving six Key Result Areas (KRA’s):

• Safety• Quality• Service• Growth• Funding Our Future• Coordinated Care

Advocate lives our MVP through the Advocate Experience, with our commitment to create the safest and best place for our patients, associates and physicians – always. The Advocate Experience is: An experience without harm – Safety An experience of excellence – Quality An experience of engagement and trust – Service Always

II. Quality Management System

Quality Policy: The Advocate Health Care quality policy is: Safety, Quality and Service Always through Continual Improvement. The leadership and associates of Advocate Health Care execute our quality policy through our quality management system and a commitment to continual improvement to enhance patient safety, health outcomes, operational excellence, and patient satisfaction. Quality and Patient Safety Plans are maintained by the sites to provide operational framework.

Advocate Health Care is committed to evidence-based performance improvement using a holistic approach to problem solving. The organization is steeped in a culture of continual improvement to enhance patient safety, health outcomes, service and operational excellence from the patient’s perspective. Accountability for performance is addressed through an objective leadership evaluation system in which management performance objectives directly align to KRA performance.

Performance improvement initiatives are driven by performance gaps as measured by KRA’s and opportunities identified by leadership. Advocate’s measurement philosophy is supported by a robust business intelligence environment:

• Responsible leadership demands familiarity with and rigorous use of data

1 | P a g e10/20/15 Addendums 2/29/16 Exhibit OO17.2 Advocate BroMenn Medical Center


• Processes are in place to accurately and consistently obtain a balanced set of measures that

monitor health outcomes, customer satisfaction, functional status, and resource utilization that ultimately supports a culture of accountability

• Data driven decisions are made that assist in identifying opportunities and corresponding improvement strategies

ISO 9001 is the foundation for performance improvement for Advocate. The ISO foundation includes a wholistic approach to performance improvement methods that includes PDSA as the core performance improvement approach and includes the Change Acceleration Process (CAP), Lean and Six Sigma tools and methodologies. The Change Acceleration Process is a change model designed to increase the success and accelerate the implementation of organizational change efforts. It addresses how to create a shared need for the change; understand and deal with resistance from key stakeholders; and build an effective strategy and communication plan for the change. Lean Six Sigma is a business process philosophy that focuses on the customer and increasing value and improving quality, safety and productivity. Recognizing the complementary nature of the two methodologies, Advocate uses a blended approach of Lean and Six Sigma concurrently, utilizing different tools to address specific improvement problems along a value stream and/or project. The 2016 KRAs are listed in the 2016 Balanced Scorecard posted on the intranet. A. Quality Management System Oversight and Structure

The Advocate Health Care Board of Directors oversees the business management functions of the Advocate System. There is two way communication and interaction between the Board and Advocate system senior leadership and the site Governing Councils. The system ISO 9001 Quality Management Review Committee interacts and is accountable to these two groups. The Medical Executive Committees at each hospital report to the site Governing Councils. The site Quality Management Oversight Committees report to the site Governing Councils and to the system Quality Management Oversight Committee. The system and site Quality Management Oversight Committees provide leadership and resources to support the quality management system objectives. For the purposes of quality review, improved patient outcomes and reduction in morbidity and mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee will designate specific site committees to provide professional and peer self-evaluation of the adequacy of patient care. These may include but are not limited to:

• Patient Safety Committees • Health Outcomes Committees • Morbidity and Mortality Committees • Peer Review Committees • Cause Analysis Committees

The system and each hospital have a Quality Management Representative. The site Quality Management Representatives report site information to the system Quality Management Representative.

2 | P a g e 10/20/15 Addendums 2/29/16 Exhibit OO17.2 Advocate BroMenn Medical Center


The Advocate Health Care Quality Manual provides an overview of the Quality Management System. Results from the quality management system audits, corrective and preventive actions will be reviewed and acted upon by the Quality Management Review Committees at the site and system level. B. Quality Management System Metrics The following are required to be reported to the Quality Management Oversight Committee:

• Results of Quality Management System (QMS) audits • Patient feedback • Process performance and product conformity • Status of preventive and corrective actions • Follow-up actions from previous management reviews • Changes that could affect the QMS, and • Recommendations for improvement.

Additional data may also be submitted.

III. Patient Safety Program The goal of Advocate’s patient safety program is to eliminate all events of serious harm within the system by December 31, 2020, with a target of achieving an 80% reduction in the rate of serious events between 2013 and 2017. In 2012, a strategic plan for patient safety was completed and implementation initiated. This plan maps out a multi-year plan for achieving high reliability in care delivery across Advocate. The development of the plan involved the collective efforts of key executive leaders from across the system, site and system patient safety leaders as content experts together with input from front line associates and physicians. The strategic plan outlines four key strategies, including:

1. Establish patient safety as the foundation of care 2. Teach leaders how to lead to safety 3. Empower the front line to address safety issues 4. Engage patients and families in patient safety

The strategic plan will serve as the primary roadmap for operational work in patient safety for the system in the near future. In 2015, the focus of the patient safety program included: 1. Transition from a primary focus on leadership to a focus on safety at the front line through

the creation of High Reliability Units (HRUs). HRUs will be clinical departments in which there is a focused training effort in high reliability healthcare, training on error prevention techniques, coaching to integrate the techniques into front line clinical work, and front-line problem solving with issues that impact the safety of care delivered.

2. Engagement of the front line in safety efforts through implementation of a Safety Coach and Physician Champion program

3. Launch of the system simulation program focused on in-situ simulated learning, along with establishing the first hospital-based simulation lab.



1. Completion of the high reliability leader training series. 2. Greater focus on the integration of the Advocate Experience through the development of a

Leader tool box for safety, quality and service. 3. Initiation of actions to address items on the Safety Top Ten list. 4. Improved reporting of patient safety events. 5. Establishing a baseline for Advocate’s hospital Serious Safety Event Rate. 6. Full standardization of the RCA process throughout the system. 7. Realignment of the patient safety reporting structure across the system to enable safety

standard work. 8. Implementation of the updated version of the Cause Analysis Database (CAD 2.0) for the

collection and utilization of system causal data. 9. Improved focus and utilization of Advocate’s Just Culture Decision Matrix.

In 2016, the focus of the patient safety program as outlined in the strategic plan strategies and tactics will include: 1. Launch the front line High Reliability Units (HRU) with all clinical departments at Advocate

hospitals across the system. The HRU initiative will appoint and train a team of safety coaches in each clinical department, training in high reliability principles, coaching techniques and the PDSA model for front line problem solving.

2. Expand the front line approach to include the medical staff, through launch of the Physician Safety Champion program. Physician safety champions, as partners to the safety coaches, will serve to influence the culture of the medical staff in Advocate towards high reliability.

3. Continued development of the system simulation program through in-situ simulations focused on high risk areas as identified by the Serious Safety Event Rate, opening of the first hospital-based simulation center at Illinois Masonic Medical Center, and acquisition of funds and planning for three additional hospital-based simulation labs.

4. Pilot of the Cognitive Bias and Diagnostic Error program throughout all Emergency Departments across the system

5. Refreshing the Patient Safety Strategic Plan to identify strategies and tactics to guide safety efforts between 2016 and 2020.

Classifying and Measuring Patient Harm

Advocate utilizes the Serious Safety Event Rate (SSER), through Healthcare Performance Improvement (HPI) as the foundational measure of patient harm within the system. The SSER classifies patient harm according to severity (severe, moderate or minimal) and duration (temporary or permanent), using standardized definitions. The methodology used also classifies near miss events based on the type of barrier that prevented the event from reaching the patient. The SSER will serve as a key metric for the advancement of Advocate toward a culture of high reliability.



In 2013 Advocate revised the medical staff peer review process in order to align peer review cases classified as a patient safety event with key reporting metrics. As such, the SSER will include cases identified as a patient safety event by the peer review process and determined to be a serious safety event through application of harm classification.

AHRQ Culture of Safety Survey

Advocate Health Care participates annually in the AHRQ Culture of Safety Survey for associates. This survey serves as a key metric for the movement towards high reliability facilitated by the strategic plan. It is the expectation that Advocate sites will implement unit/department based action planning to facilitate advancement of the culture.

A. Patient Safety Program Oversight and Structure

Advocate’s patient safety program is endorsed by the Advocate Board of Directors. The Health Outcomes Committee of the Board is the safety and clinical oversight committee of the Board. Advocate’s Health Outcomes Council oversees the system-wide safety and clinical performance improvement projects and initiatives. The Health Outcomes Council reports to Advocate's Quality Management Oversight Committee. For the purposes of quality review, improved patient outcomes and reduction in morbidity and mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee will designate specific site committees to provide professional and peer self-evaluation of the adequacy of patient care. These may include but are not limited to:

• Patient Safety Committees • Health Outcomes Committees • Morbidity and Mortality Committees • Peer Review Committees • Cause Analysis Committees

Patient Safety Team A corporate patient safety department supports system-wide safety initiatives, reports, data, education and consultation. Strategic collaboration occurs to enhance this work, including but not limited to:

• The risk management department collaborates with patient safety to reduce and eliminate actual and potential risk factors that may impact the safety of care provided to our patients.

• The center for health information services (CHIS) oversees system-wide clinical data measurement, reporting, analytics and provides public data expertise.

• The department of quality management and regulatory collaborates to integrate safety with Advocate’s ISO 9001 Quality Management System, and into the Advocate Experience.



• The patient experience department collaborates to integrate safety into the AdvocateExperience.

All sites of care within Advocate Health Care have identified safety leaders that report directly to the system safety department. Additionally, each site has a committee that guides clinical safety and quality initiatives. Together, leaders at the system and site collaborate on key strategies, programs and tactics that enhance the safety of the system.

B. Patient Safety System Metrics A variety of metrics are used in the patient safety program. The majority are included in either the 2016 Balanced Scorecard or the Safety & Quality Close. Both dashboards are distributed to sites monthly.

The following are key patient safety metrics for 2016 reported on the Safety & Quality Close and reported to the Quality Management Oversight Committee:

• Safety Event Reporting Rate• AHRQ Culture of Safety Survey Results• Serious Safety Event Rate Change• RCA Aging• OSHA Employee Injury Rate• Unassisted Falls Percentile

V. Authorities and Structures that Support Quality and Patient Safety at Advocate BroMenn Medical Center

The Advocate Healthcare (AHC) Board of Directors assumes ultimate accountability for the quality and safety of the patient care and services provided at Advocate’s hospitals and for providing the leadership and resources to support system quality management objectives. While oversight of the system Quality and Patient Safety Program is provided by the AHC Board of Directors, the Advocate BroMenn and Eureka Governing Council guides the direction of Advocate BroMenn Medical Center’s (BroMenn) quality and patient safety program, and has delegated functional responsibility to Administration, the BroMenn Quality Management Oversight Council (QMOC), and the Executive Committee of the Medical Staff for implementation and maintenance of the scope of activities addressed in this plan. Authority for the activities included in this plan is further delineated in the Medical Staff Bylaws/Rules and Regulations, a variety of hospital committee and council charters, and at times, hospital policy and procedure. As noted within the BroMenn QMOC charter, BroMenn’s QMOC together with the AHC System ISO 9001 QMOC, are responsible for the quality of patient care delivered at BroMenn and for providing the leadership and resources necessary to support the hospital’s quality management objectives.



The organization structure and reporting of activities addressed in this plan are illustrated within the BroMenn Quality Management Committee Structure diagram and the Quality Management Reporting Plan, which have been included as attachments to this document. The Quality Management Committee Structure is reviewed, and the Quality Management Reporting Plan is prepared annually, outlining information to be reported to the BroMenn QMOC each calendar year. A listing of performance improvement priorities is developed in conjunction with the AHC KRA structure, and a year-end review is completed annually to evaluate effectiveness of the quality management system.

V. Attachments BroMenn Quality Management Committee Structure BroMenn Quality Management Oversight Reporting Structure


Medical Executive

Committee

BROM Quality Management

Oversight Council

Medical Staff

Committees

- Medical Care

Evaluation

- Medical Staff

Committees

(Function Specific)

Medical Staff

Departments

DATE:

02-29-2016

Advocate Health Care

Board of Directors

Critical Processes *

- Accreditation

- Advocate Experience

- Document Control

- QMS Auditing

- Clinical Data Management

- Infection Prevention

- Patient Safety

- Physical Environment

- Utilization Management

- Nursing Practice

QM7 Functions

BROM Governing Council

* multidisciplinary

representation

System ISO 9001

Quality Management

Oversight Council

ADVOCATE BROMENN MEDICAL CENTER

QUALITY MANAGEMENT OVERSIGHT

BROM Executive Team

Hospital Service Lines and

Collaborative Practice Teams


ABMC QMOC

2016 Reporting Plan

QMOC

Reporting

2016

Jan 25

2016

Feb 22

2016

Apr 4

2016

May 23

2016

Jun 27

2016

Jul 25

2016

Aug 22

2016

Sep 26

2016

Oct 24

Internal-External Audit Findings Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg Schaumburg

QMOC Dashboard Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick

CAPA Logs & Reviews Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick Frederick

RCA Reviews Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe Wolfe

SR1 Threats to Safety/Pt Safety Wolfe Wolfe

SR2 Medication Management Pinneke Pinneke

SR2 Pharmacy Services Pinneke Pinneke

SR3 Operative & Invasive Procedures (Surgical, OB, Cath) Bartley Harper

Mueller

Bartley Harper

Mueller

SR4 Anesthesia / Moderate Sedation Bartley Bartley

SR5 Blood & Blood Components Durdle Durdle

SR6 Restraint Use / Seclusion Moore

SR7 Pain Management Harper Harper

SR8 Infection Prevention & HAIs Bierbaum

SR9 Utilization Management Frederick Frederick

SR10 Patient Flow (Quarterly)Bartley Moore Bartley Moore Bartley Moore

SR11 Customer Satisfaction (Quarterly) Donaldson Donaldson Donaldson

SR12 Discrepant Pathology Durdle Durdle

SR13 Unanticipated Deaths (Quarterly) Frederick Frederick Frederick Frederick

SR14 Adverse Events / Near Misses Wolfe Wolfe

SR15 Readmissions (Quarterly) Frederick Frederick Frederick Frederick

SR15 Unplanned Returns to OR Bartley Bartley

SR16 Critical Processes - Therapies & Safe Handling (in

February)

Vogel Vogel

SR16 Critical Processes - Spiritual Care Ward Ward

SR16 Critical Processes - Wound Healing Center Brown Brown

SR16 Critical Processes - Cardiac Services Mueller Mueller

SR16 Critical Processes - Stroke Care Peterson Peterson

Bartley

Moore

Donaldson

Moore

Bierbaum

2016

Dec 5

Schaumburg

Frederick

Frederick

Wolfe


ABMC QMOC

2016 Reporting Plan

QMOC

Reporting

2016

Jan 25

2016

Feb 22

2016

Apr 4

2016

May 23

2016

Jun 27

2016

Jul 25

2016

Aug 22

2016

Sep 26

2016

Oct 24

SR16 Critical Processes - Nursing Services/Nursing Sensitive

Indicators/Magnet

Harper Harper

CR16 Critical Processes - Lab Services Durdle Durdle

CR16 Critical Processes - Beh Health Mgmt Donaldson

CR16 Critical Processes - Staff Mgmt Coletta

CR16 Critical Processes - Contracted Services Meissner

CR16 Critical Processes - Radiology Downen

CR16 Critical Processes - Food, EVS, Linen Mellon

CR16 Critical Processes - Health Info Mgmt Sweeney Sweeney

SR17 Medical Records Delinquency Sweeney Sweeney

SR18 Physical Environment (Quarterly) Bassett Bassett Bassett

MI2.SR3 Radiation Badges Downen

TO2.SR2 Death Notification/Organ Donation Harper Harper

IC1.SR4 OSHA Illness & Injury Rates Coletta

SM7.SR4b Performance Distribution Rates Coletta

SM7.SR6 CBT Completion / Staff Turnover Coletta

Other Quality Plans Review & Research Projects Update Lareau Bartley Lareau Bartley

Date: September 2015

Revised: November 2015

Revised: February 2016 (Leadership Changes Noted)

Coletta

Bassett

Downen

Coletta

Coletta

Meissner

Downen

Mellon

2016

Dec 5

Donaldson

Coletta


Advocate BroMenn Medical Center 2015 Quality Management Achievements Summary Report

Prepared: February 2016

This site-specific report has been prepared as a supplement to the “Advocate Quality Management System (QMS) Report”, which summarizes Advocate Health Care’s QMS accomplishments, goals, and planned focus from 2015.

ISO Required Processes Key Accomplishments Focus in 2016 Accountability Through the QMS • Identified key QM7 process owners

• Management review process redesigned forimplementation in 2016

• Key process measures dashboard established• Quality Management Oversight Committee

co-chaired by Chief Nurse Executive andVice-President Medical Management

• Add a user-friendly display of trended datato the key process measures dashboard

• Re-evaluate effectiveness of the processchanges made at the end of the year

Document Control • Utilizing the Advocate Document System forcontrol of policies, procedures ormanagement plans

• Now expanding document control to otherdocuments within the organization, e.g.medical record and non-medical recordforms, patient education

• Timely policy review improved from 75% to88%

• Complete comprehensive inventory ofdocuments requiring control

• Establish controlled locations and processesfor review and updating of inventorieddocuments

• Improve timeliness of policy review to 90%

Record Control • The record control matrix and staffunderstanding and utilization of the matrixwere audited in July. No issues wereidentified through the audit.

Control of Non-Conforming Product

• In September the “green bin process” wasaudited with clinical and supply chainassociate knowledge of the process at 99%.An opportunity was identified across the

Page 1 of 9 Form Date: 4-21-15 Exhibit OO17.5 Advocate BroMenn Medical Center



ISO Required Processes Key Accomplishments Focus in 2016 system to strengthen supply chain and finance leader knowledge and use of the non-conforming products database and write-off process. This opportunity is currently being addressed by the system.

Quality Management System Audits

• Implementation of audit software• Audits focused on high risk processes and

processes at risk• 29 system & third party QMS audits• 5 site-specific QMS audits

• Increase the number of site-specific QMSaudits to 6

Corrective Action/Preventive Action

• 45 corrective and preventive action planswere opened in 2015

• Corrective/preventive action plans (CAPAs)opened in 2015 were driven from:o Internal QMS audits (13)o Top safety priorities (2)o External QMS audits (25)o QMS management review (1)o Root cause analyzes (4)

• 29 process improvements were implementedthrough the CAPA process

• 44 corrective and preventive action planswere closed in 2015

• Average time to CAPA closure – 6.4 months

• Reduce the time to CAPA closure by 20%



Prepared: February 2016 Part II: Summary of Quality Metrics Required for ISO 9001 Certification:

ISO Required Measurement Key Accomplishments and Issues SR 1 Threats to Patient Safety

• Safety event (including near miss and good catch events) reporting increased in 2015 from 3.5 events/patient day to 6.7 event/patient days

• In contrast, the serious safety event rate declined by 47.2%. When peer reviewed were added to this number, the decline was 56.9%

• Patient handling injuries were reduced from 2.69/200,000 productive hours in 2014 to 0.39 in 2015, following formation of a safe patient handling team in April

• In response to a number of falls initiatives and weekly auditing of compliance, the unassisted falls rate dropped and achieved 84th percentile performance nationally by the end of the year

• In response to a number of pressure ulcer initiatives, the stage II and greater pressure ulcer rate decreased from 2.33/patient day in 2014 to 1.84 in 2015

SR 2 Medication Therapy

• Pharmacists have been added to assist with the initiation of medication histories at the time of admission and with discharge medication instruction

• Medication scan rates remain strong at 96% • A drill-down on medication incident rates, which appeared higher in 2015 than 2014, revealed

the rate increase was due to good catch or near miss reporting rather than actual adverse events. In response, the calculation of this metric will be changed in 2016 to separate this information

• With relocation of the Pharmacy, all USP 797 clean room standards are met for the IV preparation and compounding room

SR 3 Operative Procedures

• National surgical quality improvement program (NSQIP) as reported on the Advocate KRA dashboard met or exceeded all performance targets for the year

• The elective delivery at 1.5%remains low and beneath the target of 3% • Coronary artery bypass surgery performance is strong with a composite rating on the Society of

Thoracic Surgeons (STS) database at 2 stars




ISO Required Measurement Key Accomplishments and Issues SR 4 Moderate Sedation/Anesthesia • Anesthesia and moderate sedation events declined by 35% in 2015 from 1.08/mo. to 0.7/mo.

• No PACU re-intubations were required• Sedation documentation for bedside procedure is currently being revised to improve the ease of

data collectionSR 5 Blood and Blood Components Utilization

• Successful development and utilization of a massive transfusion protocol• Steady improvement in single unit transfusion compliance - from a rate of 19% at the beginning

of the year to an average of 44% for the last six months of 2015• Red blood cell utilization is low at 16.6/1000 patient days and well beneath the target of

26.7/1000 patient days• Transfusion reactions were few in number at 0.2% and well beneath the 3% target

SR 6 Restraint Utilization • Restraint use has increased slightly over the past year to 6.30 non-violent patient episodes/1000adjusted patient days and 0.35 violent patient episodes/1000 adjusted patient days

• A restraints audit was conducted in November which demonstrated an opportunity to improverestraint documentation. This opportunity is currently being addressed by the RestraintsWorkgroup established over the summer.

SR 7 Pain Management • HCAHPS satisfaction with pain management ended the year at the 88th percentile nationallySR 8 Infection Control • The Infection control composite ended the year at 83 (target 100). The areas of greatest

opportunity within the composite are the reduction of catheter associated infections (CAUTI)and select surgical site infections. Staff education was provided on best practices for thereduction of CAUTIs. In addition, in-depth surgical case reviews were completed on allrelevant surgical infection data analyzed. No specific opportunities for improvement wereidentified from the surgical cases and data reviewed.

• Hand hygiene has been identified as an opportunity for improvement within the system as“secret shopper” observations in December revealed compliance to be 53%. This was incontrast to “known” observations for which compliance averaged 92%. A corrective actionplan has been established for the improvement of this rate.

• A Managing Infection Risks (MIR) standards gap analysis was completed by DNV in August




ISO Required Measurement Key Accomplishments and Issues SR 9 Utilization Management

• CAPA related to the provision of discharge information to the next provider of care was closed with audit results demonstrating compliance with timely provision of information >90%

• An audit of inpatient admission orders and physician certifications found the hospital to be in compliance with Medicare conditions of participation

• No issues identified from the ongoing review of appropriateness of professional services • Medical and surgical length of stay (LOS) are low and above the 90th percentile nationally • Work continues on the development and implementation of a supportive care program to

improve cross-continuum coordination of care for high utilizers SR 10 Patient Flow

• No issues identified with post-anesthesia recovery or inpatient LOS • No PACU extended stays (>12 hours) were required this year • Emergency department left without being seen, at 1.9%, remained beneath the target of 2% • Opportunity for improvement, however, was identified with emergency department

throughput (see scorecard below) and a corrective action plan has been developed in response SR 11 Customer Satisfaction

• HCAHPS inpatient satisfaction improved from the 70th to 80th percentile nationally • Press-Ganey outpatient satisfaction improved from the 58th to the 67th percentile nationally • Press-Ganey’s Behavioral Health satisfaction survey was implemented in March, with year-end

satisfaction at the 88th percentile • Improvement efforts are currently focused on the emergency department and outpatient

services, as these are the two satisfaction surveys not yet achieving 75th percentile performance SR 12 Discrepant Pathology • Discrepancy rates were all low and beneath target for 2015 SR 13/14 Unanticipated Deaths, Adverse Events and Near Misses

• Autopsy results for 12 months ending June 2015 (46 cases) revealed no diagnostic discrepancies • The mortality index at the end of the year was 1.13 (target 0.88). This was a decrease of 25%

from 1.38 at the beginning of the year. • Each mortality case continues to be reviewed individually and in aggregate to identify

opportunities for improvement in care delivery, documentation for coding, and/or registration • Death in low mortality DRGs was 0 • 21 root cause and 41 apparent cause analyzes were conducted in 2015 in an effort to identify

opportunities to improve patient safety Page 5 of 9

Form Date: 4-21-15 Exhibit OO17.5 Advocate BroMenn Medical Center



ISO Required Measurement Key Accomplishments and Issues SR 15 Readmissions and Unplanned Returns to OR

• The readmissions ratio (actual to expected, within 30 days) in 2015 was 1.03 (target 0.95)• Readmissions from the post-acute network within 30 days were 1.15 (target 1.19)• In response to the readmissions findings, a new risk readmissions scoring and interventions

process was implemented, care management services were added to the EmergencyDepartment, a fifth skilled care facility was added to Advocate’s post-acute care network, andwork began on the establishment of a supportive care program for better cross-continuum caremanagement of patients with high utilization and readmission rates

• Unplanned returns to OR are low averaging 0.5 per monthSR 16 Critical Processes (include Organ Donation information)

• Awarded the American Heart Association’s (AHA) Get With the Guidelines Gold Plus awardfor quality of stroke care

• Recipient of the AHA/Stroke Associations’ Target Stroke Honor Roll for timeliness ofthrombolytic therapy.

• Awarded the AHA Mission Lifeline Gold Plus award for quality of heart attack (STEMI) care• Tele-psychiatry was implemented in April in an effort to assess and treat patients’ underlying

behavioral health issues that previously may have gone unrecognized• Required organ donor death notification was 100%; the eligible donor conversion rate was 71%• Compliance with national standards for the management of sepsis was found to be 67%

(baseline performance). In response, efforts are currently being focused on the provision ofsepsis education and the identification/removal of barriers to sepsis guideline compliance

SR 17 Medical record delinquency • Medical record delinquency remains low at an average monthly rate of 3.5% (range 1.8-5%)SR 18 Physical environment management (include Radiation Badge readings)

• Life safety metric performance was good (e.g., fire drills with passing score 99%)• Critical preventive maintenance completion and year-end monitoring of hazardous materials

exposure was 100%, with no issues identified• No issues were identified with utility safety this year• No radiation badges exceeded the 750 mRem threshold• Physical environment rounding demonstrated staff understanding of their emergency

management expectations (100%)




Part III: Key Result Areas/Project Outcomes:

KRA Metric 2015

Target Year-End

Result KRA Metric 2015

Target Year-End

Result Serious Safety Event Rate -20% -47.2% Patient Engagement Overall 75 67 Safety Event Reporting 3.5 6.7 Inpatient Satisfaction 75 80 Health Outcomes Score 100 113 Emergency Department Satisfaction 75 40 Complications Index 0.87 0.78 Outpatient Satisfaction 75 67 Mortality Index 0.88 1.13 Associate Engagement 80 >90 LOS – Medical 4.21 3.79 Physician Engagement 75 51 LOS - Surgical 3.27 3.69 Net Revenue Growth (% vs Prior Year) 2.82% 3.21% Readmissions Ratio 0.95 1.05 Operating Margin -5.27% -4.84% Unassisted Falls Percentile 80 84 Hospital Cost per Discharge $6548 $6513 Infection Control Composite 100 88 Philanthropy (000) $2,000 $5,046 PHO Clinical Integration Score 80% 95% Advocate Care Index 100 99 Culture of Safety Survey 75 74 ICU Ventilator Days 0.85 0.73 AHRQ PSI Composite 8 8 Inpatient Core Measure Composite 100 114

Other Priorities 2015 Target

Year-End Result

Sepsis Composite Compliance – Establish Baseline Level of Performance

75% 67% Baseline

ED Core (Throughput) Measure Compliance 100 73 Safe Patient Handling Injuries 2.32 0.35 ED Behavioral Health Plans of Care Develop Completed Support Care Program Develop Piloting 2-2016

Green – Performance Targets Met

Yellow – Improvement Shown

Red – Performance Targets Unmet




Part IV: Accreditation Survey Findings:

• NIAHO Accreditation – Annual survey conducted September 2015, re-accredited December 2015• ISO 9001: 2008 Certification – Survey conducted September 2015, certification received February 2016• Stroke Certification – Annual survey conducted November 2015, re-certified November 2015,

Part V: Grievance Review:

• 16 grievances were reported in 2015, a 53% reduction from 2014• Written responses were provided in an average of 4.5 days• 12 (75%) of the grievances related to care in the Emergency Department, 2 (13%) to care in Radiology, 1 (6%) to care in Same Day Surgery,

and 1 (6%) to Medicare beneficiary billing• Many of the concerns were expressed after a bill was received from the hospital and/or were related to dissatisfaction with medical

treatment or quality of the care received – 12/16 (81%)• Additionally, 1 concern was related to a treatment complication, 1 was a request for release of battery charges, and 1 was a Medicare co-

insurance dispute

Part VI: Staffing Management:

• The house-wide voluntary turnover rate for 2015, at 10.3%, was slightly beneath the target of 10.4%• First year turnover has increased from last year, at 29.8%, to 34.5%• Timely computer-based training completion was 94% for the year and performance review timeliness was 85%• The OSHA illness and injury rate is low at 4.3 injuries or illnesses/200,000 hours worked (target 6.8)

Part VII: Peer Review:

• 94 peer review cases were logged in 2015, 62 have now been reviewed and closed, 32 are still in the process of review• 43 cases were from the Department of Surgery, 15 from Internal Medicine, 12 from the Department of Radiology, 11 from OB-Gynecology, 8

from the Emergency Department, and 5 from Family Medicine




• Of the 62 cases reviewed and closed, 37 were found to have no opportunity for improvement. Instructional letters were sent in response to15 of the cases, trending was recommended in response to 8 of the cases, and counseling by the Department Chair and/or Vice-President ofMedical Management occurred in response to 2 cases.

• Ongoing practitioner provider reports were provided in July for all active, credentialed physician and allied health providers

Part VIII: Contracted Services Review:

• 205 contracts were reviewed in 2015• 169 found to meet quality and safety requirements, and were approved for continuation• 19 were retired as they were no longer needed• A correction action plan was requested for 17 contracts found to be in need of updating.• All of the contracts within the corrective action plan have now been updated with the exception of one, which will be completed early in

2016 when the contract renewal window opens again.

Part VIV: Summary of Changes and Recommendations for Improvement to the Quality Management System:

• Adoption of Advocate Health Care’s 2016 KRA (key result area) structure and metrics• KRA metrics to be aligned with both leader and associate performance evaluation in 2016• Identified areas of opportunity for improvement in 2016 include:

o Evaluate effectiveness of redesigned management review processo Expand scope of the document control program and improve timeliness of policy reviewo Reduce CAPA closure timeo Further reduction of the mortality, readmission, CAUTI and ED throughput rateso Further increase in single unit transfusion and patient satisfaction rateso Improved hand hygiene, restraints documentation and sepsis guideline compliance
