10th Monthly Compliance Report on Parkland Memorial Hospital

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 West Washington, DC 20004 +1 202 729 2100

Report of the Independent Consultative Expert (ICE)

Monthly Progress Report – December 2012

on

Parkland Health & Hospital System

Dallas, Texas

January 11, 2013

Parkland Health & Hospital System – Alvarez & Marsal Progress Report to CMS – December 2012

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

SIGNIFICANT CAP-RELATED GOALS MET IN DECEMBER .................................................................................................... 4 SIGNIFICANT CAP-RELATED GOALS STILL OUTSTANDING IN DECEMBER ................................................................................ 4 OVERALL IMPRESSIONS FROM DECEMBER ..................................................................................................................... 5

CASE MANAGEMENT ............................................................................................................................................. 6

CASE MANAGEMENT ASSESSMENT .............................................................................................................................. 6 CONTINUUM OF CARE .............................................................................................................................................. 8 INTERDISCIPLINARY TEAM MEETINGS (IDTS).................................................................................................................. 9

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

RECRUITMENT ........................................................................................................................................................ 9 CORRECTIVE ACTIONS ............................................................................................................................................ 10 NURSING COMPETENCIES DOCUMENTATION ............................................................................................................... 11

NURSING/PROVISION OF CARE ............................................................................................................................ 13

MID-LEVEL PRACTITIONERS ..................................................................................................................................... 13 NURSING ADMINISTRATIVE OFFICER (NAO) ................................................................................................................ 13 PRESSURE ULCERS ................................................................................................................................................. 15

PATIENT RIGHTS/SAFETY ..................................................................................................................................... 16

PATIENT SAFETY NETWORK (PSN) ADVERSE EVENTS FOLLOW-UP ASSESSMENT ................................................................... 17

HOUSE-WIDE ISSUES ............................................................................................................................................ 18

DISCHARGE PLANNING ........................................................................................................................................... 18 INFORMED CONSENT TO TREATMENT FORMS AND PROCEDURES ....................................................................................... 20 MEDICAL STAFF .................................................................................................................................................... 21 NURSING FLOAT POOL ........................................................................................................................................... 22

DEPARTMENT AND UNIT SPECIFIC FINDINGS ....................................................................................................... 22

COMMUNITY ORIENTED PRIMARY CARE (COPC) CLINICS ............................................................................................... 22 CONTRACT SERVICES .............................................................................................................................................. 23 EMERGENCY SERVICES............................................................................................................................................ 23 FOOD AND NUTRITION SERVICES (FNS) ...................................................................................................................... 24 INFECTION PREVENTION ......................................................................................................................................... 24 JAIL SERVICES....................................................................................................................................................... 25 LABORATORY SERVICES........................................................................................................................................... 26 MEDICINE SERVICES .............................................................................................................................................. 26 PHARMACY ......................................................................................................................................................... 27 PHYSICAL MEDICINE AND REHABILITATION (PM&R) ..................................................................................................... 28 PSYCHIATRIC SERVICES ........................................................................................................................................... 29 STERILE PROCESSING DEPARTMENT (SPD) .................................................................................................................. 29 WOMEN AND INFANT SPECIALTY HEALTH (WISH) SERVICES ............................................................................................ 30

FOCUS AREAS FOR NEXT 30 DAYS ........................................................................................................................ 31

CONCLUSION ....................................................................................................................................................... 33


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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&M’s tenth report on Parkland’s 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 December 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 469 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 six action streams performing at or below 95 percent compliance in meeting target dates for their CAP initiatives.

WS # Work Stream NameTotal

InitiativesCompleteInitiatives

% Complete

On timeInitiatives

DelayedInitiatives

Missed Deadline /

Not Sustainable

% Complete and On Time

1Governance, Leadership, and

Org Structure109 94 86% 4 2 9 90%

2 Clinical Operations 129 127 98% 0 0 2 98%

3 Access/Throughput 98 93 95% 4 0 1 99%

4 Nursing 59 58 98% 1 0 0 100%

5 Physicians 62 57 92% 4 0 1 98%

6 QAPI 42 40 95% 2 0 0 100%

499 469 94% 15 2 13 97%TOTAL

AS # Action Stream NameTotal

Initiatives Complete%

CompleteOn Time

InitiativesDelayed

Initiatives

Missed Deadline /

Not Sustainable

% Complete and On Time

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%3.4 Case Management, Discharge planning initiatives 25 23 92% 0 0 2 92%

4.3Nursing roles & responsibilities; staffing levels and staffing models

28 22 79% 4 0 2 93%

5.1 Medical Staff – OPPE 15 13 87% 0 2 0 87%6.2 Patient Safety and Patient Rights 22 21 95% 0 0 1 95%


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Significant CAP-related Goals Met in December

Case Management

- Development and implementation of a high risk screening tool used by the Emergency Department and inpatient unit case managers to improve the discharge planning process. Screening for discharge needs on every admission is reportedly monitored on a daily basis. Compliance with the tool is over 95 percent. A&M will conduct separate audits in January to confirm compliance.

- Re-prioritization of a task force to develop a robust post-acute care network.

Emergency Department

- Completion of renovations to house “doctors in triage” in Main Emergency Department and completion of “Pod 6”, a “results waiting area” for ED patients.

Medicine/Surgery Nursing Services

- Continued self-audit adherence to patient safety and quality metrics such as: environment of care, hand hygiene protocol compliance, nursing plan of care compliance and safe patient “hand-off” compliance.

Physicians

- Reporting and positive trending on verbal order compliance, resident oversight documentation, history & physical (H&P) documentation and effectiveness of on-call system.

Significant CAP-related Goals Still Outstanding in December

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 members at IDT case management meetings.

Continuum of Care

- Creation of discharge care sites for patients without means, through entering into agreements such as leasing beds in a Skilled Nursing Facility (SNF), reduced rates for Durable Medical Equipment (DME) and home oxygen, long stay hotels, etc.

Contract Services

- Development of a central database repository for all current and legacy contracts. - Development of a robust contract management indicator list for all current contracts.


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Emergency Services

- Development of a patient flow process to promote consistency in evaluation and reduce delays that may occur from consults in the care of a person presenting to the Emergency Services Department potentially seeking emergency psychiatric care or behavioral health crisis care.

Medicine/Surgery Nursing Services

- Sustainable achievement and positive trending of goals on patient safety and quality metrics such as: environment of care, hand hygiene protocol compliance, nursing plan of care compliance and safe patient “hand-off” compliance.

- Implementation of McKesson electronic solution for staffing to acuity. - Completion of expanded nurse “float pool”, critical solution to provide flexibility to staff to census

and acuity.

Physicians

- Implementation of Ongoing Professional Practice Evaluation (OPPE) process for five pilot departments is delayed due to issue with obtaining metrics electronically.

Radiology

- 100 percent completion rate for fluoroscopy and general radiation safety training modules to nursing and medical staff has not yet been achieved. The deficit is due in part to an incorrect denominator identified as the “required audience” as many physicians were included in error in the population required to be trained. Corrections will be made in January and the percentage of physician completion should be closer to 100 percent.

Overall Impressions from December

As we indicated in our reformatted progress reports for October and November, because most of the Corrective Action Plan (CAP) initiatives have been largely completed, we have begun to shift more of A&M’s 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 more holistic 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 December were: the Case Management Department, Jail Services, the Nursing Administrative Officer (NAO) role, Physical Medicine and Rehabilitation (PM&R) and Telemetry Services. Separate reports on these focus areas 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, even though self-audits represent 98 percent compliance in environment of care (EOC Progress Report), routine rounding on all patient care floors in December by the A&M team continue to show issues on certain units with cleanliness and general presentation.


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On a management and organization level, we remain concerned by the lack of progress in completing the changes to Case Management organization and the delayed recruitment of permanent leadership. A permanent leader for the Case Management Department was finally recruited and selected at the end of December, which is a positive development. Case Management continues to experience significant vacancies and 31 of the 50 budgeted positions are still vacant as of the end of December. In December, the external consultants for case management, Clinical Intelligence, performed a limited assessment of the Admission Discharge Transfer (ADT) process. This assessment identified issues with obtaining timely medical necessity determinations for direct admissions, as well as availability of documentation to corroborate the necessity of such admissions.

We are also very concerned with lapses that have occurred in implementing corrective action to ensure that all of Parkland’s personnel files for clinical personnel have up to date and accurate information about those clinical staff members, such as licensure information or current clinical competencies. As noted below in the report, improvements that we thought had occurred in these processes by early fall of 2012 had not in fact occurred in a reliable manner. As such, additional work must be done by Human Resources and Clinical Education to ensure that each and every personnel file have timely and accurate information about a clinical employee’s (e.g., nurse, physician assistant, nurse practitioner, etc.) licensure and current competencies.

Finally, as we have stated in previous reports, we will continue to work with the Hospital’s senior leadership to ensure that all of the required patient safeguards for Parkland’s behavioral health services, inpatient and psychiatric emergency department (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 to bring additional resources to ensure a continuously safe environment. However, the Hospital’s 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 consistently safe environment for each patient, employee and staff member.

Case Management

Case Management Assessment

In December, A&M team members conducted a focused review to assess Parkland’s progress in improving case management/discharge planning as required under the Corrective Action Plan (CAP) to both to meet the requirements under the Medicare Conditions of Participation (CoP) and to ensure more efficient patient throughput as well as patient safety.1 This review process included:

- Interviews with Clinical Intelligence consultants and care management employees; - “Shadowing” of Emergency Department (ED) and inpatient social workers, ED and inpatient care

coordinators, and patient flow coordinators; and - Document review of educational materials and tools, interdisciplinary team handoffs, average length

of stay (ALOS) review and Executive Health Resources reference material.

1 Prior reports by A&M, including the Gap Analysis report and Corrective Action Plan have referred to these functions collectively as “care management.” To promote consistency of purpose in this group we have agreed with the Interim CEO that this function should be referred to a “case management” as opposed to “care management.”


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The findings of the review are summarized below. Detailed results were shared with Case Management leadership and other senior leaders at Parkland.

Staffing/Leadership

As a result of the Case Management Department restructuring, many key positions are still vacant. The department director / administrator role remains open and is currently held by a Clinical Intelligence consultant. At the end of December recruitment was completed and an offer was extended to an individual from outside the organization to take over the Case Management Department leadership. The overall vacancy rate in the department at the time of this focused review was approximately 50 percent. Agency staff members are being utilized for approximately eight to ten positions. In order to fill vacancies, A&M recommended the use of agency staff for Case Management with a target goal of 80-90 percent of positions filled as it is difficult to effectively evaluate strategies without a reasonable complement of staff.

During our focused review, Case Management staff expressed confusion as to who is responsible for what aspects of leadership responsibilities. Leadership responsibilities should be clearly defined and shared with staff, as they also appeared to be confused and need clear direction. A&M made specific recommendations regarding the appointment of department “leads” to serve as the day-to-day “go to” person for basic role and responsibility questions of a new staff.

Operations

Although tools have been developed to track “high priority” patients under valid Case Management criteria, there does not appear to be team coordination dedicated to the identification of patients that could be discharged earlier in the day. Currently, the Case Management department huddle focuses on short-term staffing adjustments that need to be made on a daily basis as well as staff questions versus discussion of patient flow issues.

There is a gap in early communication with patient flow coordinators, clinical coordinators and social workers. Critical information such as potential admits and pending discharges are not utilized early in the day to improve patient flow.

Patient flow coordinators from the Admission, Discharge and Transfer Department (ADT) meet with clinical coordinators and round on inpatient units to obtain the charge nurse’s perspective on possible discharges and the status of discharged patients. In general, surgical units are more prepared to discuss the patient status than medical units. Charge nurses frequently do not know the status of patients on the unit, cannot identify potential discharges and appear unaware of the care coordinator’s assessment and perspective of patient status.

During our rounding with Case Management we found that many staff members did not know that the Hospital was on “yellow bed” alert at times and were unsure of the meaning of this alert.

Nursing Administrative Officers (NAO) or House Supervisors are not included in the patient flow function with ADT or Case Management. The NAOs could be a valuable resource to assist with bed management and patient flow.

Currently, over 30 different interdisciplinary team (IDT) meetings are conducted throughout the Hospital with varying degrees of effectiveness. Hospitalist units hold IDT meetings daily and are generally well attended and successful. In other cases, it seems the meetings are scheduled to simply “check the box” of the CoP requirement and attendance is very limited.


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Recommendations

A&M’s focused Case Management report to the Hospital offered recommendations in the following areas:

- Organization, timing, attendees and agendas of team meetings - Expansion of reporting tools - Emphasis on discharge priorities - Enhancement of NAO role to identify potential discharges and ensure proper recording of available

beds in bed tracking system - Evaluate and revise IDT meeting model to optimize physician and staff time - Executive leadership review of bed capacity alert criteria and enforcement of those requirements.

Conclusion

Parkland’s Case Management Department has been restructured to promote greater continuity across the continuum of care and to enhance patient access and flow. However, A&M observed gaps in leadership and the communication process among key stakeholders, particularly the flow coordinators and care coordinators/social workers all of which contribute to decreasing the effectiveness of the Case Management service. We recommend that daily tools and processes be put in place to promote timely discharge of patients.

Filling vacancies within Case Management must be a priority of the Human Resources (HR) Department, including the use of agency staff where approved. Orientation and education should be expanded to include basic day-to-day tips for the services or departments served as described for the ED.

Charge nurses and nursing staff must be accountable for understanding and knowing the plan of care for their patients, and proactively planning for their patients’ discharges. As we reported last year in the Gap Analysis report, it still appears that on many Nursing units, nursing staff often waits for the physician to write discharge plans before acting proactively to initiate discharge planning.

In December, Clinical Intelligence presented a status report to Parkland’s senior management and A&M and included a work plan to complete CAP and other initiatives. A&M requested the plan be amended to include a more detailed timeline for completion of all initiatives. At the time of this report’s completion, we had not yet received the revised plan.

Continuum of Care

In December, a multidisciplinary task force reconvened to discuss the development of a more robust post-acute care network for Parkland. The outcome from this group’s first meeting was a short-term plan involving the revisiting of the function of the Hospital’s complex case committee and focus for a financial analysis exercise. Because this initiative was put on hold in order to place priority on other essential CAP initiatives, including the Case Management initiatives, very little progress has been made in this continuum of care initiative. A&M believes that this task force’s scope is appropriate and will continue to monitor its progress monthly.


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Interdisciplinary Team Meetings (IDTs)

An observational audit of the Interdisciplinary Team (IDT) meetings process was performed in December for the Oncology, Surgery and Women and Infant Specialty Health (WISH) services.

The purpose of the IDT meetings does not appear to be understood by all services. The Oncology IDT meeting functions appropriately with most key stakeholders present. Two of the three Surgery meetings, however, had inconsistent participation and the status of each patient is not always concise. Further, the consistent attendance of physicians continues to be problematic.

Parkland is aware that the IDT meetings are not yet effective across all departments/services and is working to change the model where necessary to achieve same goals. We look forward to reviewing the plan for revised approach.

Human Resources

While many of the CAP initiatives for Human Resources (HR) have been completed, there are still several areas where the efforts have not achieved good outcomes/reached goals and/or are not being sustained. These areas include effective recruitment processes and revised policies and procedures related to corrective actions, performance management and progressive discipline.

Recruitment

The selected Recruiting Process Outsourcing (RPO) vendor was engaged and is actively recruiting as of December 27th, 2012. Over 180 positions identified as “hard to fill” have been assigned to the firm, including those for Case Management, Health Information Management (HIM), Quality Performance Improvement and Sterile Processing Department. The search for the talent acquisition director progressed in December and three candidates have been identified.

Recruitment related metrics including “time to fill vacancies”, however, still require improvement. This is most likely a quality indicator for the RPO contract, so we would hope to see this metric improve in the near future. HR’s internal goal for this metric is 55 days.

87.2 80.5

72.3 68.4 73.8 73.5

0102030405060708090

100

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12

Time to Fill Vacancies (External Candidates) (Days)


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Another HR metric still requiring improvement is the turnover rate. The turnover rate currently lies below HR’s internal goal of 14.6 percent but has steadily climbed since September 2012, from 10.6 percent to 13.6 percent in December.

Corrective Actions

As of the end of December, over 93 percent of required employees completed the training relating to new policies and procedures for performance management and corrective action. Given the results of a recent audit conducted by A&M, we have concerns about the impact the training has actually had in changing process, policy and procedure.

An audit was conducted using twelve (12) Patient Safety Network (PSN) reports which resulted from a lack of compliance of two-patient identifier protocol. The safety events were logged across several inpatient hospital units between the period of November 1st and November 30th. The objective was to determine if there was a corrective action issued to the employee who was accountable for the breach in process, if this corrective action was located in the Human Resources (HR) file and if the corrective action followed Hospital policy. Interviews were conducted with unit managers and documentation from HR records and department files were reviewed.

Our initial audit information was obtained from management in each of the units for which the safety events were reported.

- Of these 12 cases, six employees were given corrective action in the form of a written warning, four were given verbal warnings only, and two had corrective actions pending which had not been finalized as of the time of this audit.

- Although six employees were issued corrective actions by their respective departments, only one of these was found upon review of the HR files.

These findings indicate a clear issue with the transition of the documentation from the department to Human Resources.

In addition to the HR files, five department files were also reviewed as part of this audit.

- Of these five, Corrective Actions were only found in three files. The remaining two employees had only received verbal warnings and department management was quick to note that these types of warnings are not documented.

There appears to be conflicting point of view as to whether or not verbal warnings should be recorded and placed into a file. Department managers are unclear on the process used to handle verbal corrective actions and noted that this was not covered in the recent training, or in the Hospital policy.

Further review of HR and department personnel files by A&M found the following:

- Dates on two of the corrective actions appeared to be issued only subsequent to learning that A&M would be performing an audit (beyond one month after the incident actually occurred)

- One employee had five corrective actions in the departmental file and none in the HR file - One employee had three corrective actions in 2012 prior to the PSN related incident in November but

continued to be given written warnings instead of a final warning or termination - One employee had received a corrective action in September of 2012 but had only received a verbal

warning in November of 2012 for the PSN related incident - Of the four verbal warnings, only two were documented in the department file.


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While the cases reviewed constituted a small sample, there may be a need for senior leadership’s focus on a plan to ensure retraining and/or improved communication to ensure managers understand the policy and procedure for documenting and implementing corrective actions, including responsibility for the process.

The audit uncovered situations in which there did not appear to be an apparent ownership for issuing disciplinary action. Likewise, there are incidents where employees should be receiving final warnings or even termination, but continue to receive written warnings. As a result of these inconsistencies, quality and safety of patient care is at risk. A formalized standard operating procedure for tracking, documenting and transmitting corrective actions should be considered.

A&M will continue to closely monitor and audit appropriate management and administration of corrective actions.

Nursing Competencies Documentation

During the Gap Analysis, A&M reviewed personnel records to validate the presence of appropriate clinical competencies existing within the human resource file and/or unit file. When conducting the Gap Analysis A&M was unable to validate that there was a well-coordinated methodology for tracking clinical competencies. No one in the Hospital was able to demonstrate knowledge of a single process, identify a centralized location (or decentralized) in which all competency data for employees is retained. It was determined that a systematic approach for inventorying and/or ensuring the competencies were completed as required did not exist. While some departments could verbally describe how they assessed competencies, in many cases there were no records to document the competency validation had occurred.

As part of the Corrective Action Plan (CAP) an initiative to improve competency tracking and documentation was assigned to the Human Resources. On October 31, 2012, the Human Resources Department (in coordination with Clinical Education Department which reports to Nursing Administration) submitted evidence of completion to the Chief Implementation Officer and A&M of the competency tracking initiative, as per the CAP process, representing that the organization had completed the following:

- Developed a house-wide competency plan that also addresses a tracking and monitoring system.

As part of their documentation to evidence completion, they submitted:

- A Procedure for Competency Assessment developed and signed by Nursing leadership - Copies of HR Directions Announcements to “All Parkland Leaders” dated September 14, 2012 and

October 24, 2012 which outlined the process HR had undertaken to collect paper files from units which included competency documentation. There was a plan to scan all of these documents into the HRIS (PeopleSoft). There was also a plan described to migrate current and new competencies to an electronic platform (HealthStream).

- Screen shots from Health Stream that demonstrated some competencies were entered, updated and completed for a sampling of personnel.

At the November Meeting of the Parkland Board of Managers, Human Resources represented that all required clinical competencies, over three hundred thousand documents, were scanned into clinical staff files and therefore had completed the CAP initiative.

In the months of November and December, A&M attempted to initiate an audit to validate whether appropriate competencies existed in the file for each employee. During November, we worked with the Clinical Education Department and Human Resources to request files to review. The audit determined


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that the files were not appropriately maintained, given the lack of organization of documents in files, and we were therefore unable to locate competencies in some of the files we reviewed.

During the month of December, A&M again attempted an audit to ensure personnel files were complete. After reviewing a minimal number of files, we determined competencies were not represented in an organized, auditable format and we terminated the audit. Also during the month of December, a State surveyor requested an employee file to identify whether appropriate education and training was provided and found the employee’s file was incomplete and difficult to locate documents. The surveyor’s findings validated A&M concerns that there was very little progress made with the centralization, validation and organization of (paper-based historical) competencies.

We raised our concerns again about the completeness of documentation of all clinical competencies with Parkland’s senior leadership team.

On December 19, 2012 Parkland’s senior leadership directed that a full scale validation process be launched by Clinical Education and Human Resources to ensure that all clinical competency documents were confirmed, organized and logistically identified. This effort is being directed by the new Associate Chief Nursing Officer, Rose Labriola.

While Parkland’s Human Resources department oversaw the collection (of unit-based employee files) and scanning of more than 300,000 documents, the process was completed without validating whether the files were accurate and complete. There was no auditable plan to identify a process for scanning documents moving forward from the initial “entry” of the three hundred thousand documents. Apparently, from the initial entry of these documents, additional documents that were sent to the Human Resources Department have not yet been scanned into the electronic records.

Some personnel files may have as many as up to 100 pages of scanned documents, which are now images in the file and may not be filed in any organized manner (e.g. all competencies in one section). A process has been developed to review competencies for all Clinical Personnel. A multi-staged review process is underway and massive resources are being deployed to “catch up”.

The initial review was a process to identify by job code and by clinical unit whether the right competency documents were present and in the employee’s file. The initial review process revealed that most of the clinical staff files were deficient. The next phase of the review requires a clinically based unit manager reviewing each file with Clinical Education “file checker”. A review of personnel files of Non-Clinical Personnel has not yet begun.

We have several concerns related to the manner in which this CAP requirement has been pursued:

- Although we have repeatedly cautioned Parkland to ensure that the CAP initiatives are fully implemented and sustainable and do not take a “check the box” approach, the collection and scanning of files process appears to be just that – a “check the box” exercise. It was not a robust review of data and as such now is requiring a significant rework and a redoubling of efforts.

- We are concerned that this process is going to take much longer than anticipated and planned for by the current plan submitted by the stakeholders. We await a revised plan and timeline to be authored by Nursing Administration, Human Resources and Clinical Education. A&M has recommended that a parallel (not sequential) review be instituted for competency review of all non-clinical personnel. As of the writing of this report, we are uncertain that parallel process has been not yet been established.

A&M will continue to closely monitor this progress and has requested regular updates.


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Nursing/Provision of Care

Nursing staff members have continued to self-audit their unit performance in the following areas: environment of care, hand hygiene protocol compliance, nursing plan of care compliance and safe patient “hand-off” compliance. While the reported metrics appear to have improved generally, on a month-to-month basis, on self-audits of environment of care and hand hygiene, progress on compliant patient hand-offs appears to have regressed slightly.

Beginning in January, A&M will perform additional rounding of the patient care areas to assess these and another issues related to the CAP initiatives and Medicare CoP. Results will be shared real-time with staff members and leadership.

We continue to request that Nursing leadership and the Hospital’s senior leadership emphasize basic patient safety and patient rights protections for all nursing staff and all other staff providing or assisting with direct patient care such as:

- 100 percent use of two patient identifiers. - Reduction of possibility for medication error through consistent use of “five rights” of medication

administration. - Adherence to “safe patient handoff” procedures, including consistent use where required of “peer to

peer” handoffs. - Full adherence to hand hygiene protocol and reminding all ancillary and medical staff on units about

full adherence to hand hygiene protocol. - Protection of patient health care information (PHI) in accordance with Parkland policy. There is still a need to hardwire all of these practices to ensure sustainability of performance improvement and CAP related initiatives that impact Patient Safety and Quality and compliance with Medicare CoP.

Mid-Level Practitioners

As an ongoing assessment, the A&M team has continued to monitor the progress of various initiatives related to the authorities and roles of Mid-level Practitioners at Parkland. In December, a multidisciplinary team re-drafted the Prescriptive Authority Delegation and Collaborative Practice Agreement that all Mid-Level practitioners will need to agree to and sign on to on an annual basis. This document was revised to be in compliance with the existing Texas Nursing Practice Act and the Texas State Board of Medical Examiners rules and regulations regarding Physician Assistants.

Previously, only informal agreements existed and delegated practice was not standardized. This new formal agreement will clearly outline the roles and responsibilities of all parties involved.

The A&M team will continue to follow-up on the approval and implementation of these policies in January 2013 and audit/monitor for compliance.

Nursing Administrative Officer (NAO)

As part of the Corrective Action Plan (CAP), A&M recommended that the role of the shift nursing supervisor or “house supervisor” be further developed at Parkland. A&M recommended that Parkland’s nursing leadership should define the competencies required for a house supervisor and key functions and responsibilities for this house supervisor role. To meet this CAP recommendation, Parkland’s nursing leadership revised the house supervisor role and created a new position of “Nursing Administrative Officers” (NAOs).


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To determine how these NAOs were working in practice, A&M met with three of the Nursing Administrative Officers (NAO) and shadowed two of them on their rounds of inpatient units in the month of October. Our observations from those rounding sessions and the interactions between the NAOs and other Hospital leaders and staff are set forth in this assessment report.

In October 2012, we presented our findings and recommendations to the Chief Nursing Officer and the Vice President of Excellence & Safety in Nursing drawn from our assessment of the then current state of the new NAO positions. Those October findings were as follows:

- Training materials were neither available for the NAOs in orientation, nor available for reference for the preceptor.

- NAOs are not versed on critical Parkland policies and procedures. - No formal plan was in place for training the NAOs. - Lack of appropriate shift report/hand-off from p.m. shift to NAOs. NAOs are not advised of

anticipated discharges. - At the time of our observations, frontline staff appeared uninformed of the NAO’s new role and

responsibilities. - NAOs are not fully engaged to facilitate patient throughput nor are they directed to do so within their

scope of work. Communication between the bed management function of the Hospital, the Admission-Discharge-Transfer Department (ADT) and the NAOs, does not exist.

- During their rounds, NAOs evaluate all one-to-one observers (or “sitters”) to determine whether they have awareness and knowledge of their assigned patient and responsibilities.

- The NAOs do look for staffing opportunities to move staff to challenging areas and communicate staffing information to the staffing office. There appears to be a reluctance of some charge nurses to notify the staffing office and suggest their staff to move to another area.

- NAOs are not equipped with House cell phones. - NAOs are not on the distribution list for Disaster Notification.

One of the NAOs was new to their position. The NAOs are now meeting with the Nursing Leadership to acquaint themselves with the management and to participate in various nursing committees and to better define their role.

The NAOs are currently assigned to almost all shifts most days. Upon reviewing the NAO schedule, however, we found that there was not day shift coverage on several Tuesdays. We were not able to determine the role or the need for the NAO during the day shift. It’s unclear what role exists for the NAOs during the day shift, Monday through Friday, when a there is a complete staffing complement of nursing administration, leadership and local unit management and a enhanced role with ADT to facilitate bed coordination.

There is confusion regarding the NAOs’ role regarding disciplinary processes with unit-level nursing leadership. During the evening and night shifts, the NAO may find an employee who may have committed an infraction and is identified to be sent home. The NAOs sometimes meet resistance from some the nursing managers in allowing the NAOs to take temporary corrective action against the employee.

During our recent interviews and shadowing rounds of the NAOs in December, we made the following observations:

- There appeared to be an improved awareness of the NAO’s role for evenings and nights on the part of local unit management even though the originally conceived communications campaign has not yet been fully executed.


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- The NAOs have successfully developed a collaborative relationship with the Patient Relations Department to assist in patient complaint resolutions.

- The NAOs appear to have developed some better communications with ADT, however it is still inconsistent and NAOs are not completely aligned with ADT on bed management.

- NAOs now have access to the ADT bed board, however, that information is not always current and hinders NAOs knowledge of the status of the “house”.

- The NAOs are not consistently informed when a service is on diversion (e.g., Emergency Department or Psychiatric Services diversions). There needs to be a continued improvement and collaborative model for these two functions – NAOs and ADT -- to work effectively in managing the house.

- The NAOs have successfully developed a shift report that includes census, adverse events and other significant issues. Communication from the departments, at times, does not include notifying the NAOs as the staff tends to contact their own department leadership and not the NAO.

- We confirmed that the NAO orientation checklist was completed for the two recent hires. - During these “House” Rounds, the other following items were identified:

o Patient health information was found on top of nursing station desk in public view on 9E and BICU.

o Pediatric Crash Cart Log was found in CPICU on top of Adult Crash Cart but MICU does not routinely use a Pediatric Crash Cart. Log Book was removed by charge nurse.

o First and last name of the patient were written on the name plate outside patient room. Charge nurse thought the patient may have written her first name on the tag.

o Sitter worksheet was not completed by RN on patient in BICU to provide updated patient status information.

In summary, the Nursing Administrative Officer (NAO) role appears to be developing and improving within Parkland. In addition to the recommendations made above, we would emphasize again that more staff communication needs to occur to educate them on the role and importance of the NAO. We would also emphasize the need for continuing, closer interaction between the NAO and the ADT function.

Pressure Ulcers

A&M continued to review Parkland’s progress in its initiatives to monitor and reduce incidences of pressure ulcers. Stage Three and State Four hospital-acquired pressure ulcers (HAPUs) that occur during hospitalization are among the conditions considered preventable by the Centers for Medicare and Medicaid Services (CMS).

Six cases of potential hospital-acquired pressure ulcers (HAPU) were surveyed by the Texas State Department of Health in December. These six cases prompted a prevalence study to be performed by the Quality Performance Improvement Department to determine the current state of existing pressure ulcers within the Hospital.

Parkland had performed a HAPU prevalence study in September 2012, but those results had not been submitted to the national database for comparison. Parkland re-enrolled in the National Database of Nursing Quality Indicators (NDNQI) in November 2012 in order to utilize the database to contrast to the Parkland prevalence study to NDNQI compare group.

Parkland is implementing a ten point action plan to monitor and reduce HAPU incidences, which includes the following elements:

- Reinforcement with nursing directors, unit managers, and front line staff nurses on the urgent need to prioritize skin integrity assessment and documentation on admission and every shift throughout the patient stay using the Braden Scale;


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- Require entry of adverse events on the Patient Safety Network for all “present on admissions” (POAs) and all HAPUs upon occurrence and detection;

- Initiate a S.W.O.T. (strengths, weaknesses, opportunities and threats) analysis that will identify opportunities for improvement;

- Initiated a unit base Skin Team base pilot (Surgical Intensive Care Unit) aimed at rapid adoption and application of evidence-based pressure ulcer prevention strategies;

- Develop methods for determining staff nurse adherence to every two hour re-positioning; - Implement method for tracking to identify and correct documentation deficiencies involving pressure

ulcers in real-time during the patient stay; - Educate nurses and providers on requirements for documentation; - Provide on-going education regarding skin assessment, pressure ulcer prevention and intervention

strategies; and - Provide adequate inventory of pillows for patient positioning.

The effectiveness of this action plan will be measured by tracking the progress on the point prevalence rate. Point Prevalence studies will be increased from quarterly to monthly and the data results along with the NDNQI comparator information will be distributed to the nursing unit managers. The unit managers will use this information to educate and identify factors contributing to the presence of pressure ulcers and provide strategies to minimize occurrence or further skin breakdown which would leads to a reportable event. A&M will continue to monitor the Wound Care Department’s progress in pressure ulcer-related initiatives in January 2013. Patient Rights/Safety

In December, Parkland finalized the transition of leadership of the Patient Relations Department, which now reports through Parkland’s Quality and Performance Improvement departments. Key activities include redesign of the Patient Relations waiting area to improve patient satisfaction, increased accountability for leadership to resolve complaints/grievances and a more pro-active and timely follow up process to reduce the incidences of patient complaints turning into patient grievances. A new model for conducting Root Cause Analyses (RCA) meetings was also piloted in December, increasing the total meeting time to two hours from one hour, thus reducing the need for multiple meetings spanning several weeks. Although not all of these shortened meetings have run smoothly, a more streamlined process will be put into place in January to ensure meeting participants have adequately prepared for these more efficient meetings and more expeditious outcomes are achieved. With respect to the recruitment of a new Chief Patient Rights and Safety Officer (CPRSO), we have had a number of meetings with Parkland’s Board of Managers, its Quality Committee and Parkland’s senior leadership about the design of this position. When the CPRSO position was recommended as part of the CAP, we were concerned whether the quality and safety department functions at the Hospital that then existed could continue to ensure that patient safety concerns were elevated throughout the organization and that the Board of Managers had direct visibility into patient safety and rights issues. To ensure that this occurred, the CAP recommended the creation of the CPRSO position, which would assume patient safety, patient rights, patient relations and patient grievances and infection prevention functions, which were then assigned in different areas of the Hospital. We believed it was important to centralize those functions under common leadership. We also thought it was important that the CPRSO independently report to the Board of Managers.


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Since the adoption of the CAP, significant changes have occurred in the organization and staffing of Parkland’s medical affairs, quality and patient safety functions. The areas that we recommended be centralized under common leadership – patient safety, patient relations, patient rights and now infection prevention – have been centralized within the Quality Department and with the exception of infection prevention are being directly overseen by Jacqueline Sullivan, RN, Ph.D., Vice President of Performance Improvement. A&M has been working with the Parkland BOM’s Quality Committee Chairperson and the Interim Chief Medical Officer to redesign the Parkland Quality Department function to ensure that a position will exist within the organization that will assume leadership for the patient safety, patient rights, patient relations and infection prevention functions and have direct reporting to the Board of Managers and protections on hiring and retention, similar to those of the Hospital’s Chief Compliance Officer and Internal Auditor. As part of that reorganization, the CPRSO role may be further redesigned and the recruitment of a candidate to fill those functions will be further redesigned with oversight from A&M and the Board of Managers. For that reason, we have recommended redesigning and refocusing the CPRSO recruitment activities to meet the new realities of a redesigned Quality Department. Finally, the Patient Safety Department is continuing to improve its management of the daily adverse events filed through the Patient Safety Network (PSN) system. Recommendations are presented in the below section to ensure appropriate follow up and corrective actions regarding adverse events.

Patient Safety Network (PSN) Adverse Events Follow-Up Assessment

In December 2012, A&M performed an assessment of Parkland’s management of adverse events filed through the Patient Safety Network (PSN) system. In September 2012, the Patient Safety Department revamped the process in which adverse events were communicated to the Hospital. These findings have been presented in previous months’ reports to the Centers for Medicare and Medicaid Services (CMS).

The focus of A&M’s assessment was to audit the process of the Department in “closing the loop” on reports of adverse events occurring in their areas. As the volume of reported events has increased in the past year, it is imperative that these events are investigated promptly with appropriate follow-up actions documented not only to improve quality and safety but to be able to respond quickly and effectively to any Texas Department of State Health Services or CMS surveys and investigations related to those events.

A&M met with the following areas to assess their management of patient safety event reports and their documentation of follow-up actions, focusing on a sample of 15 reported adverse events:

- Patient Safety - Emergency Services - Medicine Services - Anesthesia/Surgical Services - Patient Relations - Women and Infant Specialty Health (WISH) Services - Radiology Services - Compliance/Privacy Parkland utilizes an electronic system to manage the filing, communication and reporting functions of adverse events. This system, United Healthcare Patient Safety Net (PSN), is a national patient safety consortium with a number of member academic and public hospital system. This PSN system is used by


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Parkland’s Patient Safety department to document follow-up actions on adverse events. Through interviews and observations, we found that consistency of each department’s participation in the system varies. Some departments routinely utilize PSN to document what action was taken to correct or prevent the adverse event from occurring in the future. Other areas utilize external processes to house this information.

Regardless of whether the department documented their follow up actions in UHC or at all, all Parkland staff members could speak to how the events in question were closed. A&M received a satisfactory response with the actions taken, ranging from corrective actions with employees, referrals to the peer review system, root cause analyses and task forces to work on process improvements. However, we did not always find complete documentation in the PSN system outlining what actions were taken in response to a safety event. In only three of the areas that had more robust event management processes were thorough follow-up notes housed in databases outside of UHC.

Recommendations

A&M recommended that all major areas of the Hospital adopt a robust process for managing the reporting and close out of patient safety events. The process should include documentation, distribution and reporting of all PSN’s affecting each area. Weekly adverse event and monthly all staff meetings are appropriate venues to discuss closing the loop on such events and next steps. The management of these events is imperative in identifying process improvement and corrective action/discipline opportunities across the Hospital. Consistency among departments will be important for successful survey activities as well as building a sustainable process going forward.

Policies should explicitly outline the correct process for all areas of the Hospital to document and respond to patient safety events. Vice Presidents and Directors should receive weekly reports outlining events with inadequate follow-up documentation or cases that are still open.

House-wide Issues

Discharge Planning

Safe Patient Departure Task Force

Monitoring trends and auditing the Hospital’s approach to reducing safe patient departures continues to be a focus of the A&M team. In November/December, the Nursing Leadership team developed strategies to minimize the number of “unauthorized” patient departures. “Unauthorized” patient departures are categorized into three groups:

1) Against Medical Advice (AMA); 2) Left Before Treatment Completed (LBTC); and 3) Left Without Being Seen (LWBS).

Hospital data is collected and analyzed monthly by a “Safe Patient Departure Task Force.” This task force has been meeting for the past several months in order to identify initiatives to reduce the number of “unauthorized” departures. November results indicate some improvement in reducing the number of “unauthorized” patient departures in both inpatient areas and the Emergency Department. Please note that the data outlined below does not tie exactly to figures in the Patient Safety progress report due to a few exclusions made by the Task Force.


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A&M will continue to monitor this data.

Timely Discharges In an effort to identify and evaluate any trends that may be leading to delays in discharges (after the “targeted discharge hour” of 11:00 a.m.), the Health Information Management (HIM) Department performed an initial review on 15 charts where the time of discharge was after 11:00 a.m.

Of those 15 charts only two (13 percent) had discharge orders written before 11:00 a.m.

The split of the discharge times were as follows:

Discharge Time # of Cases

% of Total Cases

Between 11:00 a.m. and 1:00 p.m. 2 13% Between 1:01 p.m. and 3:00 p.m. 10 67% After 3:00 p.m. 3 20%

Delays not related to the writing of orders included the following:

Discharge Delay Reason # of Cases Patient arranged transportation 5 Hospital arranged transportation 3 Medication needed before D/C 1 Consultation with MD specialty 1 Rehabilitation service clearance 1 Lengthy time between order written and order signed off by nursing 1

While no definitive conclusions can be drawn from this small sample, some potential trends should be evaluated on further chart review. These include:

66 69

53 60

52 56

0

10

20

30

40

50

60

70

80


Volume of Elopements Non-ED (In/Outpatient)


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- Evaluation of patient transportation needs by Case Management early in the hospitalization – both patient arranged and hospital arranged;

- Earlier screening and identification of patients with potential discharge needs by Case Management – proactive versus reactive stance;

- Earlier rounding by physicians to facilitate timely discharge; - Timely physical therapy treatments; and - Setting the expectations with the family for arranging transportation for discharge as soon as the order

is written.

Informed Consent to Treatment Forms and Procedures

Informed consent to treatment forms at Parkland are manually signed on paper by a patient or their representative and then scanned into the Epic electronic medical record (EMR). In November, a special Task Force responsible for Informed Consent Performance Improvement agreed to delay the scanning of consent forms into Epic until AFTER a patient is discharged. This new procedure was instituted as the result of several incidents of nurses not being able to find the scanned consents in the Epic chart. To respond to the 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.

Based on reports through the Patient Safety Network (PSN) system, there were no incidents of missing consents in the month of December 2012. The scanning of the consents and other forms are being scanned after patient discharge, reportedly within 24 hours after discharge.

A&M conducted an audit of ten charts and only three of the charts had scanned-in operative consent and anesthesia consent forms. Of the medical records audited, patients had been discharged at least twenty-four hours and up to four days. The current scanning process appears to be unreliable and the technology appears to be unstable at times. Documents are not reconciled when they picked by the HIM staff to determine if all needed consent documents are received. The nursing staff did not always identify the urgency of scanning in some instances. Scanning equipment had episodes of failures and consents could not be viewed.

Language Version Consents There have been no significant changes with the use of Spanish consents for patients who preferred communication about their healthcare to be provided in Spanish. To assist in this effort, an identifying icon was to be placed in the banner line of the EMR denoting that the patient prefers their healthcare information to be provided in Spanish. The icon would alert providers to note this preference from the patient and to ensure the consents and forms were in Spanish. This task has not been completed to date. No education or communication has been delivered to the nursing or the providers regarding the requirements of language preference.


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Medical Staff

Resident Oversight Documentation

As noted in our November 2012 report, the Epic EMR “Notewriter” tool was developed to ensure proper documentation of Resident supervision and notification of Attending Physicians of certain procedures done by Resident Physicians. Data reviewed for December 2012 indicates that Notewriter was utilized in 79 percent of the resident performed procedures. A further chart review indicates that appropriate supervision was documented in 91 percent of cases. Results of these audits are communicated on a weekly and monthly basis to the Chief Resident Committee and University of Texas Southwestern Medical Center (UTSW) and Parkland physician leadership.

Nursing Administration Officers (NAOs) currently audit all nursing units to validate unit knowledge on querying the system to determine resident qualifications to perform certain procedures. Current compliance is 71 percent, which is a significant improvement from the November compliance rate of 52 percent. Education occurs at the time of the audit and results of these audits are communicated to nursing leadership.

Verbal Order Authentication

An audit process was established to give feedback to physicians on their compliance with authenticating verbal orders within 48 hours. A daily and weekly report is sent to providers and Chiefs for review and follow-up. The daily report also identifies verbal orders that have been attributed to the wrong provider. Nursing staff now receives a mis-attribution report that includes all reassigned orders and it is now their responsibility to properly reassign the orders. Compliance in authentication of verbal orders within 48 hours for December was 86 percent.

Language Preference

Consent / Form

Form Language

Provider Documentation Present?

Discharge Date

Scanned Document Found?

Comments

Spanish NF NF N 1/4/2013 N interpreter present Spanish NF NF N 1/8/2013 N interpreter present

English OR/Anes English NA 1/8/2013 Y Scanned in at clinic visit

English OR/Anes English NA 1/8/2013 Y English NF NF NA 1/8/2013 N Spanish NF NF N 1/7/2013 N interpreter present Vietnamese NF NF N 1/5/2013 N English NF NF NA 1/5/2013 N Spanish OR/Anes English N 1/6/2013 Y

English NF NF NA 1/6/2013 N

other consents were found for dialysis but none the procedures performed


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Ongoing Professional Practice Evaluation (OPPE)/Peer Review

A&M continued to monitor the progress of initiatives regarding the new Ongoing Professional Practice Evaluation (OPPE) and Peer Review processes. The five trial departments have chosen their indicators for the department specific section of the OPPE template. Charts that are in the regular review process will additionally be trended for this section.

One barrier that exists to an on-time implementation by January 31, 2013 is the automation of the reporting functionality for these triggers. A&M and the Patient Safety Department will continue to work with the Information Technology (IT) Department to initiate the reporting of these indicators.

The Peer Review process is proceeding on schedule with additional departments slated to be added in 2013. Once a department is added they will transition to the new OPPE methodology.

Nursing Float Pool

Parkland’s nursing leadership presented a plan for development of a nursing float pool with goals to utilize a float pool to respond to changes in patient census and acuity requiring critical and supplemental staffing needs. The plan combines a centralized and de-centralized strategy and creates a tiered system designed to provide a breadth of nurses with skills and abilities to care for a wide range of patients.

Medicine units within the Hospital still have a significant vacancy rate for registered nurses and are currently using a large number of the limited resources of the existing centralized float pool. To relieve the current high utilization of float pool nurses and to stabilize current staffing, nursing leadership will fill several of the current float pool vacancies with traveler nurses.

Nursing leadership proposes to have the new float pool model implemented by February 28, 2013. A&M recognizes that work required to remediate the float pool model is a large undertaking and therefore we are concerned that these timelines may not be met. At the time of this writing, it does not appear that the new float pool plan presented by nursing leadership has been approved the CEO or CFO for additional resources.

Department and Unit Specific Findings

Community Oriented Primary Care (COPC) Clinics

The Community Oriented Primary Care clinics (COPCs) have developed various initiatives to improve clinic efficiency, access and quality to the patients they serve. These initiatives aim to align resources with clearly defined patient care pathways, improve the care delivery structure and enhance clinical guidelines and best practices in the COPC. The “virtual visit” initiative has been rolled out to several clinics with marked success. This initiative requires COPC providers to perform visits by telephone on pre-selected patients who do not require a face-to-face appointment.

The number of additional appointments created per month has increased from 200 in July to nearly 700 in December. With the enormous volume of new and established patients the COPC treats, we recognize this is a small step, but encourage the clinics to investigate the use of virtual visits on a broader scale as this initiative seems to successfully increase patient throughput.

Additional ongoing initiatives include the piloting of “extended hours” clinics to increase patient access to COPCs and the reorganization of pre-visit planning with Patient Financial Services (PFS).


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A third party has been brought in to analyze patient throughput in the outpatient pharmacies. A&M observed long wait times during its October rounding and Parkland leadership immediately responded engaging an external vendor to conduct an assessment.

Good progress is being made in the outpatient clinics and A&M will continue to monitor its initiatives in January 2013.

Contract Services

As a result of concerns raised in the November report regarding delays in the CAP initiative to implement a comprehensive program for quality oversight of outside, contracted vendors, an oversight committee was formed to heighten visibility of and compliance with contract administration responsibilities, including quality monitoring. The committee consists of General Counsel, Chief Financial Officer, Controller, Vice President of Compliance, Chief Operation Officer, Director of Contract management, Director of Supply Chain Contracts and the Procurement Attorney. Meetings will be held monthly, with the first meeting scheduled for February 6, 2013.

The Hospital has 102 executed, in-force contracts not yet monitored by business owners and contract services for quality indicators. Criteria used to determine “significant” contracts which require quarterly reporting to the Quality of Care Committee (QCC) are under review and are expected to be modified. The new draft set of criteria will be presented to the oversight committee in February.

Emergency Services

The Main Emergency Department (Main ED) continues to make progress with patient throughput and we expect to see additional improvements once the new Pod 6 “results waiting area” and the enhanced triage examination areas are opened in early January 2013. December statistics for patients who left without being seen (LWBS) and left before treatment (LBTC) are among the lowest the Hospital has ever seen.

The Results Waiting Room (Pod 6) will open January 2, 2013. Triage rooms are now complete and in operation along with the treatment room located in the triage area. The remainder of the construction project in the Main Emergency Department is scheduled to be complete in January 2013.

10.2% 11.2%

9.2% 8.3%

4.3% 5.2%

1.8% 2.4% 2.3% 1.9% 1.8% 1.6%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%


Unauthorized Discharges - Main ED

Left Without Being Seen (LWBS) Left Before Treatment Complete (LBTC)


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Triage in the Main ED is now staffed with a physician who also provides oversight to four mid-level practitioners in Pod 6.

According to plan, Pod 6 will be used as a dialysis patient holding area upon installation of telemetry, which should occur in February.

Patient throughput metrics continue to show improvement in the Urgent Care Emergency Department (UCED) as the Hospital completes the second full month with the new EmCare physician contract. Construction in the UCED is on track to be completed by mid-January.

Food and Nutrition Services (FNS)

Beginning in November 2012, Food and Nutrition Services (FNS) staff members began performing audits of clinical staff on their compliance to the reheating of patient trays. Since the beginning of the audit, one out of the 20 staff members audited replied “yes” to the occasional reheating of trays. Instant feedback was delivered to their staff member and unit manager. Therefore audits will continue to be performed until 100 percent sustainable compliance is achieved.

Infection Prevention

The Infection Prevention (IP) Department continued its monthly rounding of all inpatient units and quarterly rounding of outpatient clinics. Unfortunately overall results for compliance to Parkland’s infection prevention standards have decreased as the IP department has surveyed larger and larger volumes of clinical and non-clinical areas.

0

50

100

150

200

250

300


Urgent Care Center Throughput Metrics (Minutes)

Patient Arrival to PatientDispositionPatient Arrival to First Seenby ProviderPatient Arrival to RoomAssignment

Implementation of Emcare Contract


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A communication plan is in place to send detailed results of the IP compliance audits to unit managers, directors and vice presidents to increase the accountability for owning infection prevention standards in each of their units. However, compliance continues to shift downwards. This issue has been raised to the Senior Leadership Team and will be monitored closely by the A&M team.

Jail Services

During the month of December 2012, A&M revisited the jail health services operations, particularly to see how deficiencies identified during the Gap Analysis survey had been rectified and improved. Plan of Care Physicians now assign acuity levels for all patients under ongoing care and treatment with three levels of care. Per policy, the higher acuity patients (levels 1 and 2) are required to have individualized care plans. A&M found care plans present in medical records and all documentation was complete on all reviewed charts, as per policy. Plans of care are generated based on provider notes, infirmary admit orders and nursing assessment. The care plans reviewed reflected primary diagnoses, e.g., diabetes, and also additional individualized problems identified by the nursing staff. Other areas in which inmates are co-horted are being reviewed to determine if there is opportunity to consider formalize plans of care for those inmates as well. A template for shift-to-shift report has been developed to ensure appropriate patient information is shared between shifts. Multi-disciplinary treatment plans continue in the psychiatric services as noted during the assessment.

Medication Management

During our review, all medication carts assessed were found to be secured and locked. Open medication carts were not left unattended. Stored medications were properly labeled and stored with expiration dates noted. Those medication vials with expiration dates within 30 days had a different color label, to serve as a flag to staff.

97.0%

94.4% 94.8%

92.2% 92.0% 90.6%

80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%

100.0%


Infection Prevention Unit/Clinic Rounding Results


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Multiple medication passes were observed. Two identifiers were consistently utilized. Either the patient’s name, date of birth and/or booking number was used to identify the patient. Patients were also assessed for the potential of hiding of medications on their bodies. Quality Assessment and Performance Improvement (QAPI) Jail services are now incorporated into Parkland-wide quality initiatives, e.g., two patient identifiers, etc. Staff members were well versed in quality initiatives and improvements made, and evidence of quality initiatives were posted in the departments. Quality initiatives specific to the facility were also reviewed. Monthly summaries of initiatives such as timely provider visits and reduction in acute psychiatric visit through improved patient management were noted. The leadership team has an ongoing quality improvement program that is trending measurable improvements in care. Conclusion Corrections to findings in the Gap Analysis report related to Jail Health services appear to have been implemented. We encourage leadership to continue to maintain their diligence in monitoring processes to ensure that compliance with Medicare CoP is maintained.

Laboratory Services

The Laboratory has initiated its corrective action plan from its recent Clinical Laboratory Improvement Amendment (CLIA) surveys. Some of the corrective action plan changes made involved new practices to ensure that lab test draws meet standards of practice. The initial change resulted in a high rejection rate of the lab test samples; however with additional education the rejection rate has been significantly reduced.

Patient Safety Network (PSN) reports have indicated issues with critical value reporting. The Laboratory is seeking nurses to conduct chart audits to determine turnaround times for critical value reporting and if the number of issues in contacting providers with critical value on a timely basis. Several safety reports identify incidents where the lab attempted to contact treating providers with critical value reports and were unable to expeditiously reach the provider. Laboratory leadership is requesting an audit to replicate the timelines and the documentation of contacting the providers in order to determine the length of time in reporting the critical values and were any orders given as a result of the test values.

Medicine Services

The Medicine Services nursing staff members have continued to self-audit their unit performance in: environment of care, hand hygiene protocol compliance, nursing plan of care compliance and safe patient “hand-off” compliance. While the reported metrics appear to have improved generally, on a month-to-month basis, on self-audits of Environment of Care and hand hygiene, progress on compliant patient hand-offs appear to have regressed.


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Self-audits by nursing reflected the following compliance on the medical/surgical inpatient units:

Environment of Care

Sample Size (observations) 106

Compliance 99%

Hand Hygiene

Sample Size (observations) 13,384

Compliance 99%

Nursing Plan of Care

Sample Size (charts) 54

Compliance 92%

Patient Hand-offs:

Sample Size (observations) 41

Compliance 71%

Pharmacy

During A&M’s month-end meetings with clinical operations units, Parkland’s Pharmacy leadership presented medication management audits demonstrating a trend of nursing units failing to provide monthly self-audit data. In November there were four nursing units that did not submit audit data and in December, an additional seven units failed to submit their data. A plan will be developed and implemented to address this failure to submit audit data. Pharmacy and Nursing leadership will work together to ensure if failure occurs then the frequency of the audits will be adjusted and increased. The discipline of audit should be used to sustain the 100% compliance with medication management.

As mentioned previously in the COPC section of this report, a consulting company, Maxor, National Pharmacy Services Corporation, has been selected to assist Parkland retail pharmacy Point of Sale processes, especially for the COPC pharmacies. The consultants will conduct an assessment to address the lengthy waits, staffing, roles and responsibilities, hours of operation, throughput from receipt of prescription or renewals, filling prescriptions and to point of purchase payment.

Medication Reconciliation

A series of dashboards have been created over the past several months measuring compliance with medication reconciliation across Parkland’s inpatient and outpatient areas. All reports have been reviewed with the appropriate leadership. The results of these automated audits are of concern, with some results below 20 percent compliance. Presented below are the compliance trends in Parkland’s inpatient and outpatient units:


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Although inpatient and COPC areas have higher compliance rates than the remaining OPCs, all areas are below 95 percent compliance. With the availability of this data, physician and nursing leadership need to take a deeper dive into investigating rapid cycle improvements to achieve near-100 percent compliance in this area.

A&M will follow-up with senior leadership to ensure these improvements are implemented.

Physical Medicine and Rehabilitation (PM&R)

The Physical Medicine and Rehabilitation (PM&R) Department continues to struggle with implementing a plan to schedule patients in the therapy backlog. Initial data that indicated a significant backlog of patients waiting for physical, occupational and speech therapy appointments was determined to be inaccurate.

Additional analysis was conducted to determine the actual backlog of patients. It was determined that nearly 50 percent of the patients waiting in the queue were contacted by the scheduler and the patients had not returned calls to schedule their therapy appointments. Second and third attempts are made to contact these patients and these patients remain in the queue until the 60 day order expires. After reviewing the data and excluding the physical therapy patients who never returned calls, there were very few patients awaiting appointments.

The data presented below is a more accurate depiction of the current backlog with PM&R orders. The department will continue to clean up the backlogged orders that are pending patient follow up based on a new policy to cancel all orders after two attempts to contact the patient have been made.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Nov-12 Dec-12

Medication Reconciliation Compliance

Inpatient (at admission)

Inpatient (at discharge)

COPCs

Medicine OPCs

Surgery OPCs

WISH Clinics


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As of 1/7/13

Total Orders in Backlog (as of 7th of current month) 448

Backlogged Orders that are Physical Therapy Class Referrals 202

Backlogged Orders that are Pending Patient Follow-Up 185

Backlogged Orders that are Pending Authorizations from Financial Counseling 50

Backlogged Orders that are Pending Triage 11

Total Cancelled Orders (> 60 days or followed up with patients over 2 times without a call back) 213

At this time, PM&R does not over book to fill in the scheduling gaps where there are predictable average number of no shows and cancellations every day. No-show rate for PM&R was significant at an average of 20% across the three disciplines in December. Cancellations are not considered as scheduling opportunities for over booking. In addition, the current methodology used for scheduling group classes is inappropriate. The classes are not over booked although data analysis shows up to a twenty-four percent no show rate. In addition, we recommend developing plans to establish classes in the COPC facilities and add classes to the main campus.

No other staffing models and patient scheduling options have been considered by PM&R. A&M offered suggestions on staffing model options and scheduling options which have not been vetted nor developed for analysis.

Psychiatric Services

Parkland’s Psychiatric Services division 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 to bring additional resources to ensure a continuously safe environment. Another review and cataloguing of all psychiatric services policies and procedures was completed in December. And additional training was conducted with staff particularly on the subject of safe entrance and exit into all controlled spaces within the psych units.

However, the Hospital’s 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 consistently safe environment for each patient, employee and staff member. The Hospital is exploring opportunities to bring additional resources to assist in the oversight and safety of all of the behavioral health services and we support senior leadership in completing those efforts as soon as possible.

Sterile Processing Department (SPD)

During the GAP Analysis survey in 2012, a number of issues were observed with non-compliant crash carts. Changes were undertaken to re-organize carts oversight, transferring the responsibilities from Materials Receiving and Distribution (MRD) to the Sterile Processing Department (SPD). Audits were


30

conducted frequently to ensure accuracy. After several attempts to ensure one hundred percent accuracy, the goal was finally met.

Audits in the last few months, however, are again showing deficiencies in crash cart compliance. Deficiencies are most often related to expiration dates on crash cart drawers and missing items.

A&M has been made aware that changes are again being made to the crash cart contents to add supplies that are not on the approved , uniform list a sort of and supply “creep.” Currently, Parkland’s Rapid Assessment Team (RAT) team is managing the crash cart contents however there were no set criteria and timing of when contents are reviewed and validated for changes. The new action plan is that Anne Tudhope will establish the criteria with the RAT team and those changes will be vetted with standards of practice.

However, any changes to the uniform list of crash cart contents needs to have objective criteria and needs to be reviewed by additional resources to ensure control and proper management of the carts.

An action plan is under development to address the deficiencies being seen. A&M will closely monitor Parkland’s efforts to once again achieve 100 percent compliance. There needs to be immediate attention to return to sustainable compliance.

Women and Infant Specialty Health (WISH) Services

Open nursing positions in the WISH area are being filled. All director positions have been filled, with the last of the positions starting on January 7, 2013. Nurses specializing in newborns have been hired and will be oriented in mid-January. The WISH department has utilized the nursing residency program to fill several vacancies.

WISH continues to struggle with metric reporting of induction delays and interruptions. Data used for hallway occupancy was discovered to erroneous in past months and will be restated. December data indicates a significant increase in hallway occupancy in December. An analysis of data from September through December shows that over 50 percent of these incidents lasted over two hours.

99.3% 100.0% 100.0% 100.0% 100.0% 92.9% 90.0%

76.2%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Chart Cart Compliance

Transfer of Leadership to SPD


31

Focus Areas for Next 30 Days

Case Management

- Continue to identify qualified individuals to fill department vacancies - Determine modifications or changes in format/structure needed to improve effectiveness of IDT

meetings - Establish an education and training schedule for ongoing care coordination education - Implement pilot to include medical necessity for direct admits within Bed Access Management (ADT

department) - Perform root cause analysis to determine cause and corrective action regarding non-compliance with

Important Message From Medicare presentation

Community Oriented Primary Care (COPC) Clinics

- Continue implementation of “new delivery care model” in remaining clinics - Continue work with third party consultant on assessment of patient access/throughput in outpatient

pharmacies - Provide analysis on results of the pilot on extended-hour clinics

Continuum of Care

- Revisit function of Complex Case Committee as a way to develop Parkland’s post-acute care network - Perform financial analysis on contracting with high-priority post-acute care facilities

Contract Services

- Completion of education of business owners regarding their responsibilities related to contracts, post-executive contract administration and quality monitoring

- Development of revised criteria for significant contracts and the gap analysis between the new contracts and contracts already identified

- Continuation of identifying executed contracts requiring inclusion in the quality monitoring program

Emergency Services

- Completion of construction in Main Emergency Department and UCED - Completion of work flow model processes - Continuation of finalizing agreement with Children’s Medical Center - Finalization of comprehensive pain procedure to be used in all ED settings

Human Resources

- Interviews and final selection of talent acquisition director - Implementation of applicant tracking system provided by new RPO - Development of corrective action tracking system to monitor and report execution of progressive

discipline - Preparation for A&M personnel file audit, including conduct random file audits for required

immunization documentation

Infection Prevention

- Continuation of high-transparency and focus of rounding results with Parkland leadership and unit/clinic managers


32

Laboratory Services

- Collection of data for the new CLIA indicators - Assignment of resources to conduct audits on critical value turnaround times

Nursing

- Continuation of implementing the new software-based staffing to acuity system - Completion of work on introducing EMR (electronic medical record) based automation to reporting

and intervention in patient restraints. - Continuation of initiatives on detection of and reduction of hospital acquired pressure ulcers (HAPU).

Nursing Float Pool

- Completion of salary comparisons for incumbent staff transitioning into the new model - Completion of market analysis for competitive rates - Creation of new job descriptions - Development of notice period for incumbent staff

Pharmacy

- Initiation of retail pharmacy assessment - Development of plan with Nursing on medication management audits - Performance improvement efforts on reducing the potential for duplicate dosing medication errors - Performance improvement initiatives for the use of two patient identifiers in ambulatory pharmacies - Initiation of Moderate Sedation Performance Improvement program plan for auditing

o Separation of the moderate sedation audits by clinical units to address specific moderate sedation issues

o Development of moderate sedation documentation workflows to allow for easier data extraction and relevant reporting

Physical Medicine and Rehabilitation (PM&R)

- Providing group class schedules demonstrating overbooking of classes and access to more classes to meet demand

- Developing staffing models to meet patient needs and ordered therapies - Determining true backlog numbers by canceling out all orders that two contacts to the patient have

been made - Providing update on IT interface changes in alerting staff to enter progress notes - Revisiting staffing needs base on true productivity measurements used in the industry - Providing an update on DME contract execution by January 25 and implementation plan for the DME

program - Providing an aging report from the timing of the therapy order to patient’s first scheduled

appointment. - Providing metrics on the number of “cancelled orders for not returned calls”, “waiting to be

scheduled”, “pending patient coming in” and “financial counseling”, - Collecting data from audit on the success rate for first versus second call back when scheduling

appointments - Providing detailed and descriptive listing of patients and reasons why they are awaiting their financial

approvals


33

Physicians

- The CEO has committed to a performance improvement project on five units to promote timely discharges. Work in January will concentrate on chart reviews and physician and nurse interviews to identify areas of focus.

- Continue to vet the automated Notewriter audit tool and send out weekly reporting to providers - Continue to identify targeted opportunities and across departments and work with medical leadership

to improve compliance with treatment team documentation - Provide focused education to areas where resident qualification procedure are needed - Present verbal order/attribution plan to Nursing NOC in January to educate nurses on what they can

do to decrease verbal orders and misattribution

Conclusion

As we stated in previous recent monthly progress reports, although much progress has been made in implementing the Corrective Action Plan (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. In order to be “survey ready” all of these safety and quality “checks” must be consistently, uniformly and universally performed.

On a management and organization level, we remain concerned by the lack of progress in completing the changes to Case Management organization and the delayed recruitment of permanent leadership. A permanent leader for the Case Management department was finally recruited and selected at the end of December. This is a positive development. Case Management continues to experience significant vacancies and 31 of the 50 budgeted positions are still vacant as of the end of December. In December, the external consultants for case management, Clinical Intelligence, performed a limited assessment of the Admission Discharge Transfer (ADT) process. This assessment identified issues with obtaining timely medical necessity determinations for direct admissions, as well as availability of documentation to corroborate the necessity of such admissions.

We are also very concerned with lapses that have occurred in implementing corrective action in ensuring that Parkland’s personnel files for clinical personnel has up to date and accurate information about a clinical staff members, such as a nurses’, licensure information and current clinical competencies. As noted below in the report, improvements that we thought had occurred in these processes by summer of 2012 had not in fact occurred in a reliable manner. As such, additional work must be done by Human Resources and Clinical Education to ensure that each and every personnel file have timely and accurate information about a clinical employee’s (e.g., nurse, physician assistant, nurse practitioner, etc.) licensure and current competencies.

As we have stated in previous reports, we will continue to work with the Hospital’s senior leadership to ensure that all of the required patient safeguards for Parkland’s behavioral health services, inpatient and psychiatric emergency department (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 to bring additional resources to ensure a continuously safe environment. However, the Hospital’s 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 consistently safe environment for each patient, employee and staff member. Parkland made tremendous progress in 2012 in addressing safety and quality issues. In order for those


34

improvements to be sustainable, however, vigilance in adhering to all safety practices cannot slip. We have already seen instances were significant progress was made in 2012 in areas such as compliantly stocked crash carts, or environment of care, or safe patient hand-offs, only to have compliance rates in these areas fall in November and December. Only when consistent, month-over-month CAP audit results are shown that consistently improve, achieve the number or percentage goal and do not regress can the Hospital be said to be ready to undergo a full CMS / State audit to demonstrate full compliance with all Medicare Conditions of Participation.

The progress and sustainability achieved in recent months can be credited to the leadership of the senior management team at Parkland. Although many of these senior leaders are in “interim” positions, they have formed a cohesive and collaborative leadership team that has provided stable and effective direction to the organization for the past several months. This steady, continued direction and support is needed to lead the organization through the next few months and through a successful survey.

# Tasks/Initiatives Accountability Work Stream

Target Date Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Completion

1.01 MEC to prepare a comprehensive plan to implement Ongoing Professional Performance Evaluation (OPPE). Review 5% of Medical Staff OPPE Profiles at conclusion of next eight-month cycle.

Patricia Bergen, MD

5.1 1/31/2013

1.02 Hospital senior management to revise the Parkland ESD Policy Manual to include written policies and procedures regarding documentation of Teaching Attending Physician oversight of Residents.

Brad Marple, MD 5.3 5/18/2012 Y

1.03 Hospital senior management, in collaboration UTSW and A&M to create a standing rounding, evaluation and auditing process to collect data on Resident oversight.


1.04 Require quality “dashboard” report from Hospital Quality Department Jackie Sullivan 6.4 5/25/2012 Y

1.05 Commence reviews of “scorecards” for significant outsourced and contracted clinical services. Design a Board-specific QAPI plan.

Jackie Sullivan 6.4 6/1/2012 Y

1.06 Review and revise BOM committees. Paul Leslie 1.1 6/8/2012 Y

1.07 Review performance management and progressive discipline implementation plan from Human Resources. Jim Johnson 1.5 6/8/2012 Y

1.08 Review comprehensive plan to create better communication and coordination among the Hospital’s Legal, Compliance, Internal Audit and Quality Departments.

Jody Springer 1.2 6/8/2012 Y

1.09 Review Hospital plan on continuum of care. Sharon Phillips 3.5 10/30/2012 Y

1.10Appoint Task Force to review Hospital's current Disaster Plan and all other plans indicating how the Hospital and community would respond to rectuion, closure, or diminishment of services or care by Parkland Paul Leslie 1.1 7/13/2012 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Percentage of contracts (outsourced vendors) reviewed for quality measures 1 Contract Svcs 100% N/A N/A 96.1% 85.7% 96.0% 100.0%

Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started

1. Self-reported by Parkland Staff or EPIC Reports2. Reported through Parkland's Patient Safety Network (PSN's)3. Reported by Parkland's Internal Audit Group4. Reported through Alvarez and Marsal's Daily Audits

Governance (Section 2.01)

Comments1.01 - Initiative is at risk to meet deadline due to barriers in automating indicator reports for OPPE. A backup plan is in place.

Parkland Health & Hospital System–Alvarez & Marsal Progress Report to CMS–December 2012

1


Target Date

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Completion

2.01 Redesign progressive disciplinary policies and procedures and performance management system. Jim Johnson 1.5 5/25/2012 Y2.02 Redraft goals of the Leadership and Organization Development Department. Jody Springer 1.2 5/25/2012 Y2.03 Develop education materials for new processes and policies. Jim Johnson 1.5 5/25/2012 Y2.04 Conduct training for management and employees. Jim Johnson 1.5 7/13/2012 Y

2.05 Expand the role of Business Partner, require they take a more active role with front-line managers and supervisors. Jody Springer 1.2 5/25/2012 Y

2.06 Business partners to audit evaluations for the next two evaluation cycles. Jim Johnson 1.6 10/31/2012 Y2.07 Evaluate current HR staffing model. Jody Springer 1.2 7/13/2012 Y2.08 Analyze resource allocation within HR Department. Jody Springer 1.2 7/13/2012 Y

2.09 Develop Parkland employee retention strategy. Jim Johnson 1.8 9/14/2012 Y

2.10 Develop policies, procedures and training material regarding employee retention strategy. Jim Johnson 1.8 9/14/2012 Y2.11 Develop master list of all competencies required for each department by job code. Jim Johnson 1.6 9/14/2012 Y2.12 Review and revise LMS system to ensure all required competencies are reflective in the system. Jim Johnson 1.6 9/24/2012 Y2.13 Review all personnel files for completeness. Jim Johnson 1.6 9/14/2012 Y2.14 Educate employees on proper and complete paper work (licensure/certifications). Jim Johnson 1.6 6/4/2012 Y2.15 Ensure accurate and complete paper work is immediately forwarded to Nursing Administration. Jim Johnson 1.6 7/13/2012 Y

2.16Form standing committee to review polices and procedures with representation from administrative, clinical, and support areas

Jim Johnson 1.5 4/6/2012 Y

2.17 Develop policies and processes to be used for HR policy review. Jim Johnson 1.5 4/27/2012 Y

# Audit/Measures Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Percentage of supervisors (and above) who have attended training administered by clinical education 1 House-Wide 100% 46% 72% 99% 97% 99%

2a Evaluation scores on histogram or bar chart for each department (annual evaluations) - below expectations 1 HR 0.4% 5.0% 0.5%

2b Evaluation scores on histogram or bar chart for each department (annual evaluations) - meets expectations 1 HR 33.9% 55.0% 48.9%

2c Evaluation scores on histogram or bar chart for each department (annual evaluations) - above expectations 1 HR 65.7% 40.0% 50.6%

3 Percentage of licensing validations presented prior to the day of hire 1 HR 100% 100% 100%4 Time from occurrence to corrective action signed by employee (days) 1 HR 10 13.7 24.2 11.9 11.1 9.0 12.6

Human Resources (Section 2.02)


2

Human Resources (Section 2.02)

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-125a Turnover Rate (%) - Nursing 1 HR 16.5% 14.5% 9.7% 21.5% 12.8% 9.5% 12.7% 16.7%5b Turnover Rate (%) - Total 1 HR 15.0% 14.1% 9.2% 15.2% 10.6% 9.5% 12.0% 13.6%6 First year turnover rate 1 HR 20.0% 18.4% 13.6% 6.3% 9.8% 24.1% 17.9%

7Percentage of employees (annually) who leave for stated reasons of better opportunity (compensation, job duties, benefits) 1

HR 35.1% 25.0% 31.3% 36.7% 50.0% 44.7% 41.2% 28.7%

8 Employee satisfaction scores 1 HR 76.0% 69.0%9 Percentage of competencies updated on/before due date 1 Clinical Ed 100% 60% 87% 93% 100% 100% N/A10 Number of corrective actions 1 HR 40 N/A 73 87 74 95 83 8411 Absent Hours (as a percentage of total hours worked) 1 House-Wide 1.2% 1.3% 1.3% 0.96% 1.13% 1.29%12 Percentage of current licensure 1 HR 100% 88.0% 96.2% 100.0% 100.0% 100.0% 99.9%13 Percentage of current certifications 1 HR 100% 99.2% 99.5% 99.4% 99.4%14 Time for recruiting to fill an open external job position 1 HR 59.9 55.0 87.2 80.5 72.3 68.4 73.8 73.5

Audit # 9 - Please reference competency section on narrative report Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


3


Target Date


3.01Review of scheduling templates and actual scheduling patterns at COPC sites in comparison with best practices for teaching clinics along with analysis of schedule utilization versus capacity by clinic

Jessica HernandezHolt Oliver, MD 3.6 9/30/2012 Y

3.02 Conduct analysis of no show rates by clinic, day, session, and provider.Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

3.03 Conduct a physician productivity analysis based upon a review of current process and development of analytics.Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

3.04Document current process workflow diagrams, identify barriers to throughput and develop solutions that might increase productivity and result in additional capacity


3.05Review ED utilization and most common diagnoses by patient admission times to analyze opportunities for changes or improvements in COPC hours of operation

Lonnie Roy 3.1 7/13/2012 Y

3.06 Develop the post-acute care network. Deanna Bokinsky 3.5 10/30/2012 Y

3.07Case Management to generate a study report by physician or service showing average time of discharge for patients and physicians or services consistently discharging patients late in the day.

Robin Stults w/ Clinical

Intelligence3.4 6/12/2012 Y

3.08Chief Medical Officer to meet with the Medicine and Critical Care Service Chiefs and Hospital Directors to determine barriers to earlier discharge of patients on the units and develop a solution.

Christopher Madden, MD

3.4 10/15/2012

3.09 Conduct a physician productivity analysis based on agreed upon industry standards. Jessica HernandezHolt Oliver, MD

3.6 5/11/2012 Y

3.10 Conduct a feasibility study for a dedicated observation unit Josh Floren 1.7 7/13/2012 Y3.11 Conduct a feasibility study to determine the best use of 4SS space Josh Floren 1.7 7/13/2012 Y3.12 Conduct a study to determine appropriate expansion of the dialysis unit. Josh Floren 1.7 7/13/2012 Y

3.13 Design “Bed Czar” concept to report to ADT Miriam Gomez 3.3 7/1/2012 Y

3.14Establish strict standards regarding communication and patient placement timelines with ADT to enhance patient placement.

Miriam Gomez 3.3 3/14/2013

3.15Complete an assessment of the current flow of acute emergent dialysis patients through the emergency department, including potential delays, arrival time patterns, and boarding in the Emergency Department.

Kim McCloudLinda Licata

Barbara Mims2.6 6/1/2012 Y

Access/Throughput (Section 2.03)


4



Target Date


3.16 Define a patient flow process that will reduce and/or eliminate boarding of dialysis patients in the emergency department.Kim McCloudLinda Licata


3.17 Define and obtain approval for resources necessary to implement process, including expansion of serivces.Kim McCloudLinda Licata


3.18 Develop protocols and obtain resources for implementation of defined patient flow process.Kim McCloudLinda Licata


3.19Fully implement patient flow process and expansion of services to eliminate boarding of dialysis patients in the emergency department.


Barbara Mims2.6 11/30/2012

# Audit/Measures Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12

1a Capacity - Family Medicine (patients seen/best practice # of visits per month) 1 COPC 86.0% 100.0% 86.5% 104.0% 100.3% 101.3% 97.0% 98.5%

1b Capacity - Internal Medicine (patients seen/best practice for # of visits per month) 1 COPC 90.0% 100.0% 96.8% 98.7% 95.9% 94.9% 95.3% 95.8%

1c Capacity - Geriatrics (patients seen/best practice # of visits per month) 1 COPC 96.0% 100.0% 101.2% 100.1% 102.8% 99.8% 102.4% 102.8%2 Number of additional appointments through virtual visits 1 COPC 550 203 232 402 531 565 6973 Percentage of observation patients outside of observation unit 1 ADT 61% 60% 50% 42% 43% 42%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-124 Utilization rates by session by clinic (hours of activity/hours of capacity) Clinics5 Percentage of discharges (medicine, surgery) by 11:00 a.m. 1 Care Mgmnt 4.4% 4.8% 4.7% 5.1% 5.2% 5.8%6 No show rates - COPC 1 COPC 17.2% 17.0% 17.0% 17.7% 17.7% 17.5% 18.1%7 Physician (Hospitalists) productivity (based upon Rolling 12 Month RVUs/Average FTE Count) 1 Med Staff 5768 6053 6209 5991 6032 6465 57138a Physician (Clinics) productivity (based on visits/hour) - Family Medicine 1 COPC 2.62 2.75 2.57 2.60 2.49 2.528b Physician (Clinics) productivity (based on visits/hour) - Internal Medicine 1 COPC 2.49 2.41 2.34 2.36 2.29 2.318c Physician (Clinics) productivity (based on visits/hour) - Geriatrics 1 COPC 1.59 1.61 1.64 1.60 1.63 1.659 Number of new patients on wait list - COPC 1 COPC 20,605 20,698 18,60310 Number of established patients on wait list - COPC 1 COPC 17,888 17,783 17,39111 Number of bed days occupied by observation status (by unit) 1 Care Mgmnt 2,753 2,951 1,512 1,204 1,216 1,204 12 Average bed turn time (hours:minutes) 1 EVS 1:00 1:24 1:06 1:12 0:59 1:00 0:5913a Average minutes of boarding in Main ED 1 ED 142.5 189.6 112.5 142.0 112.3 139.413b Average minutes of boarding in ICC 1 ED 138.9 107.5 107.6 138.8 100.5 116.114 Average Length of Stay (1 month lag) 1 Care Mgmnt 5.0 5.0 5.3 5.0 4.6 4.7 5.015 Percent inpatient occupancy (census) by division 1 ADT 85.0% 87.0% 90.6% 86.0% 87.4% 83.0% 83.0%16 Bed Request to Bed Assign, average from bed assigned to patient in bed 1 EVS 45 79 108 71 79 62 7317 Hours on red/yellow bed ADT 524 164 213 0 70 29 63


5


3.08 - Revisiting approach to discharge planning with Physician, Nursing and Operational Leadership Task/initiative largely on schedule for completion3.19 - Pending completion of Emergency Department construction project Task/initiative may be delayed from Target Date completion

Task/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


6


Target Date


4.01 Define nursing supervisor role expectations and competencies. Jackie BrockJohn Raish

4.3 4/20/2012 Y

4.02 Revise job description to meet role expectations. Jackie BrockJohn Raish

4.3 4/27/2012 Y

4.03Meet with HR leadership to determine most appropriate and fair way to move forward in establishing a broader more accountable house supervisor role.

Jackie BrockJohn Raish

4.3 4/27/2012 Y

4.04 Meet with existing nursing supervisors and explain new responsibilities and go forward plan. Mary Eagen 4.1 5/4/2012 Y

4.05 Initiate new role expectations. Jackie BrockJohn Raish

4.3 9/14/2012 Y

4.06 Conduct a comprehensive review of the nursing structure under the direction of the new CNO. Mary Eagen 4.1 3/30/2012 Y

4.07 Develop internal and external recruitment plan for new organizational structure. Jackie BrockJohn Raish

4.3 5/11/2012 Y

4.08 Written Timeline conversion to new organizational structure. Mary Eagen 4.1 4/13/2012 Y

4.09Review of all nursing practice standards, policies, and procedures for compliance and relevance. Upon review of nursing standards, policies and procedures, a list of gaps identified must be written so there is a documented source to help drive educational plans and strategies.

Barbara MimsValerie Harvey 4.2 8/31/2012 Y

4.10 Revise policies/procedures and nursing standards to reflect best practices, as appropriate. Barbara MimsValerie Harvey

4.2 10/5/2012 Y

4.11 Develop a house-wide educational plan to correct the current deficiencies in patient care. Barbara MimsValerie Harvey

4.2 9/30/2012 Y

4.12 Develop nurse leadership competencies for all managers. Emilie Allen 4.4 10/31/2012

4.13Develop a collaborative process with Human Resources to monitor and develop corrective action plans for nursing staff who violate policies and procedures.

Jim Johnson 1.5 11/14/2012 Y

4.14The CNO should determine approach for developing an acuity assessment methodology, e.g., internal historical record review, an automated tool, etc.


4.3 10/5/2012 Y

Provision of Care (POC) (Section 2.04)


7



Target Date


4.15 Once selected, roll out acuity tool. Jackie BrockJohn Raish

4.3 3/22/2013

4.16 Develop flexible staffing strategies, PRN pools, per diem staff, etc. Jackie BrockJohn Raish

4.3 10/5/2012

4.17 Monitor core patient care ratios for trends. Jackie BrockJohn Raish

4.3 3/22/2013

4.18 Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (electronic solution) Jackie BrockJohn Raish

4.3 6/28/2013

4.18 Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (interim solution) Jackie BrockJohn Raish

4.3 11/1/2012 Y

4.19 Establish standards of nursing practices, focusing particularly on the plan of care. (Clinical Competencies) Barbara MimsValerie Harvey

4.2 5/11/2012 Y

4.20 Develop house-wide nursing education program (Clinical Competencies) Barbara MimsValerie Harvey

4.2 8/1/2012 Y

4.21 Develop a house-wide competency plan that also addresses a tracking and monitoring system. Jim Johnson 1.6 10/31/2012 Y

4.22Develop tracking methodology in conjunction with Clinical Education and HR to track competencies by employee and by department.

Jim Johnson 1.6 10/31/2012 Y

4.23 Establish standards of nursing practices, focusing particularly on the plan of care. (Plan of Care) Barbara MimsValerie Harvey

4.2 5/11/2012 Y

4.24 Develop house-wide nursing education program. (Plan of Care) Barbara MimsValerie Harvey

4.2 8/1/2012 Y

4.25 Create evaluation tools to measure nurse understanding of education and success of program. Barbara MimsValerie Harvey

4.2 9/14/2012 Y

4.26 Initiate nursing grand clinical rounds. Barbara MimsValerie Harvey

4.2 7/13/2012 Y

4.27 Develop report out tool for grand round results. Barbara MimsValerie Harvey

4.2 10/1/2012 Y

4.28 Through the QAPI Department, develop and report verbal order trends monthly to providers and nurses. Brett Moran, MD 6.4 9/14/2012 Y

4.29 Review all restraint policies. Barbara MimsValerie Harvey

4.2 4/20/2012 Y

4.30 Develop and execute restraint education. Barbara MimsValerie Harvey

4.2 11/1/2012 Y

4.31 Review Epic restraint documentation structure to improve the quality of documentation. Barbara MimsValerie Harvey

4.2 3/23/2012 Y

4.32 Develop a mandatory education for medical staff on the required elements of performance related to restraints. Joseph Minei, MD

5.4 12/1/2012 Y

4.33 Develop a strict discipline policy that leads to termination of staff who violate the Restraint policy or a patients’ rights Jim Johnson 1.5 5/25/2012 Y


8


# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Nursing leadership vacancy rate 1 Nursing 12.4% 14.4% 12.9% 9.3% 7.7% 8.2%2 Percentage of completed competencies for all nurses and units 1 HR 100.0% 86.0% 80.0% 100.0% 100.0% 100.0% N/A3 Percentage of travelers (hospital-wide) 1 Nursing 2.9% 3.3% 3.0% 2.9% 2.4% 1.9%4 Nursing vacancy rate 1 Nursing 11.7% 15.1% 14.3% 10.7% 11.7% 13.2%5 Percentage of Plan of Care documented according to policies and procedures 1,4 Nursing 100.0% 70% 1 85% 4 76% 1 82% 1 92% 1 87% 1

6 Percentage of compliance in hand-off's 3 Nursing 100.0% 92.4% 90.4% 88.0% 82.0% 74.0% 75.0%7 Volume of non-violent restraint cases (hospital-wide) 1 Nursing 166 192 143 185 156 183

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-128 Number of days per month nurse staffing ratios were above/below grid Nursing9 Percentage of cases with verbal orders 1 Nursing 2.2% 1.8% 1.5% 1.4% 1.4% 1.2% 1.0%10 Verbal order compliance rate (signed within 48 hours) 1 Nursing 90.0% 83.1% 84.0% 81.8% 84.3% 82.0% 86.0%11 Percentage of staff who attended Plan of Care training 1 Nursing 100.0% 90.0% 98.3% 98.7% 100.0% 100.0% 100.0%

4.12 - Initiative is pending demonstration of updated competencies for new managers in Psych Services Task/initiative largely on schedule for completion4.16 - Nursing management has not yet developed a clear plan for flexible staffing strategy (float pool) Task/initiative may be delayed from Target Date completion



Comments


9


Target Date


5.01

Evaluate infrastructure and performance of the Care Management Department to include merging Utilization Management function. The evaluation of the Care Management Department will also include a review of all resources and personnel currently committed to the Care Management function to determine whether the Department has adequate resources and personnel to perform all of its required functions. The evaluation of the Care Management Department will also include a plan to merge Hospital Utilization Management functions into Care Management.



5.02Re-align goals and strategy of department to promote collaboration between Case Managers, Social Work, Utilization Review and Nursing.



5.03Develop nursing-wide education plan defining roles and responsibilities of case managers, social workers, and utilization management along with the inter-relationships between the functions.



5.04 Identify metrics needed on a daily basis to properly analyze cases.Robin Stults w/

Clinical Intelligence

3.4 6/1/2012 Y

5.05Produce an Extended Stay High Cost Outlier Report to identify inpatients that could move to a post-acute care setting if funding permitted.



5.06Based on evaluation of creating discharge care sites for patients without means, enter into agreements such as leasing beds in a Skilled Nursing Facility (SNF), reduced rates for Durable Medical Equipment (DME) and home oxygen, long stay hotels, etc.

Deanna Bokinsky 3.5 1/31/2013

5.07 Revise position expectations of the ED Case Manager .Robin Stults w/


3.4 6/1/2012 Y

5.08ED Case managers should evaluate all potential admissions on whether they meet acute care criteria and assess patients’ potential discharge planning needs.



5.09 ED case managers should perform an initial assessment on all patients being admitted to the hospital. Robin Stults w/ Clinical

3.4 8/30/2012 Y

5.10Create or revise policies and procedures that define screening, assessment and discharge planning process to identify high risk patients.

Robin Stults w/ External

Resources3.4 6/15/2012 Y

5.10Educate nursing care management staff on proper procedure for the Discharge Planning Assessment Tool within Epic to ensure appropriate screening and referrals.

Robin Stults w/ External

Resources3.4 6/15/2012

5.11Evaluate for each Nursing Unit the best mechanisms to promote interdisciplinary communication, e.g., “brief daily huddles”, rounds, EMR notations only, etc. Based on findings, pilot and implement the most effective methods.



5.12 Create a screening tool for case managers to include long term stay patient, avoidable days and other areas of focus.Robin Stults w/


3.4 7/20/2012 Y

5.13 Move Utilization Management within Care Management Department.Robin Stults w/


3.4 8/31/2012 Y

Care Management (Section 2.05)


10



Target Date


5.14The Utilization Review Plan should be re-written to include the required elements which are necessity of admission, length of stay and appropriateness of use of drugs.



5.15 Policies and Procedures should be revised to reflect the revised plan, and associated roles and responsibilities of staff. Robin Stults w/


3.4 7/30/2012 Y

5.16Revise the current UR logs to ensure that all required elements are collected and formatted in order to analyze and trend type data.



5.17 Develop process to export Case Management Care Web documentation whereby the data are analyzed and trended.Robin Stults w/


3.4 6/30/2012 Y

5.18 Select UR metrics for tracking, monitoring, and trending. (utilize national best practices as examples for targets).Robin Stults w/


3.4 6/30/2012 Y

5.19Utilize data from a comparative database that is clinically adjusted and severity adjusted to assist the Committee in identifying areas for improvement.



5.20Analyze, trend, and summarize agreed upon data elements to the UR Committee on a regular basis. (Recommendations for actions need to be documented and reported to the Medical Executive Committee.)



5.21Report unfavorable physician trends to the Patient Care Review Committee (PCRC). Unexpected results will be reported to Performance Improvement (PI).



5.22 Monitor progress on targeted metrics and re-evaluate targeted improvement goal and/or metrics being measured.Robin Stults w/


3.4 7/31/2012 Y

# Audit/Measures Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Compliance in performing medical necessity screening in ED 1 CM 90.1% 89.3% 91.8% 96.1%2 Audit Results of Number of Hospital-Wide Cases Intervened on 1st day of admission 1 CM3 Percentage of cases with CM screening for discharge needs - ED 1 CM 95.0% 28.5% 59.0% 74.8% 94.6%4 Percentage of compliance in completion of H&P's 1 CM 85.0% 85.3% N/A 90.0% 94.0% 88.0%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-125 Number of Cases with Outlier Length of Stay (LOS) (per Month) 1 CM 1,013 928 965 954 978 1,111 9856 Number of Avoidable Days (per Month) 1 CM 5,184 4,547 5,816 4,853 4,440 5,154 5,5337 Number of One-Day Stays (per Month) 1 CM 443 428 427 488 580 689 5938 30 day Readmission Trends (percent of total discharges) 1 CM 8.7% 8.3% 9.2% 8.4% 10.2% 10.0% 9.0%


11




Comments5.10 - Cannot educate staff until large volume of Care Management staff vacancies are filled


12


Target Date


6.01 Coordinate a multi-disciplinary team to represent the EVS department that is impacted by turnaround of beds; Nursing, ADT, EVS, ESD, House Supervision, Administration.

Kurt Dierking 3.7 4/27/2012 Y

6.02 If required, conduct a demand vs. capacity, throughput process workflow assessment and an EVS labor productivity study.


6.03 If required, develop a future work flow process. Kurt Dierking 3.7 9/14/2012 Y

6.04 Provide EVS various communication devices, hand held transmitters, pagers, cell phones, etc. to the EVS managers and EVS staff to expedite and validate the current status of the unit.


6.05 Minimized delays in placing patients on unit with efficient communication and temporary deployment of additional EVS staff from other units to the unit experiencing an influx of patients. Kurt Dierking 3.7 4/23/2012 Y

6.06 Track work orders and their respective resolutions. Analyze the issues and their resolutions to determine trends. Provide action plans for decreasing recurring issues. Kurt Dierking 3.7 4/27/2012 Y

6.07 Create a plan for an initial cleaning “campaign” and ongoing schedule for cleaning, maintenance and incorporate monitoring.


6.08 Convene the environment of care team to establish mission, charter, goals and processes to address EOC activities. Kurt Dierking 3.7 4/6/2012 Y

6.09 Conduct a one-time, accelerated plan for deep cleaning and repairs. Kurt Dierking 3.7 6/8/2012 Y

6.10 Develop a budget and prioritization for the “campaign” on potential staff or capital needs for senior leadership review. Kurt Dierking 3.7 4/13/2012 Y

6.11EVS to review existing checklists and expand where necessary for an EOC checklist for department surveillance. Issue checklists to Department Directors to ensure preparedness and awareness. Issue infraction notices to Department Director, Divisional VP and EVS Director.


6.12 Conduct analysis on EVS staffing and evaluate and compare to industry benchmarks to ensure adequate resources exist to maintain the facility.


6.13 Create an analysis of the current EVS process workflow to determine things such as barriers, potential improvements, productivity and performance. Develop new process flow if necessary.


6.14 EOC team to submit monthly report to COO and CNO based the EOC rounds and on the action plans. Kurt Dierking 3.7 6/8/2012 Y

6.15 Review existing scope of activities/tasks as well as frequency of cleaning schedules for each unit/space of the Hospital (and ambulatory sites) to ensure it is adequate to meet the “new” standards and/or adjustments. Kurt Dierking 3.7 6/8/2012 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12

1 Percentage of Patient Rooms, Procedure Areas, and Operating Rooms, meeting all elements of EVS requirements 1 House-Wide 100% 95.9% 96.6% 97.4% 97.1% 97.6% 98.3%

2 Compliance to infection prevention audits on surface cleanliness 1 EVS 100% 95.7% N/A 98.0% 98.1% 98.9% N/A3 Percentage of procedure areas with up to date daily terminal cleaning logs 1 House-Wide 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%4 Number of patient complaints about environmental issues 1 EVS 0 2 2 3 4 1 4

Environment of Care (EOC) (Section 2.06)


13

Environment of Care (EOC) (Section 2.06)

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-125 Bed turnaround time 1 EVS 1:00 1:24 1:06 1:12 0:59 1:00 0:596 Percentage of turns greater than 60 minute goal EVS 25% 58% 48% 48% 41% 37% 38%7a Work order completion time - EVS (days) 1 EVS 1 1.77 2.76 1.91 0.42 0.92 0.847b Work order completion time - Engineering (days) 1 Facilities 2 2.07 2.77 2.01 3.21 1.88 2.657c Work order completion time - Clinical Engineering (days) 1 Clin Eng 3 4.47 1.91 2.47 2.42 3.23 2.828 Vacancy Rate - EVS HR 3% 7.9% 6.1% 9.2%

Audit # 2 - Audit results was not submitted timely. Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


14



7.01 Each Divisional Vice President (VP) will submit all department specific Infection Prevention (IP) related policies and procedures to IP.



7.02 The IP department Director and Chief of Infection Prevention will review and make revisions of all departmental and house-wide IP policies, if applicable. Janet Glowicz 6.3 9/30/2012 Y

7.03 All departmental IP policies are returned to the department for their review and acceptance Janet Glowicz 6.3 6/8/2012 Y

7.04 Approve reviewed departmental and house-wide IP policies. Janet Glowicz 6.3 6/8/2012 Y

7.05 Divisional VP and Department Directors to develop a communication roll out with IP Director on the revised IP policies and procedures.



7.06 Each department assigns an IP delegate to be the contact and participant in the IP prevention education program.Kim McCloudLinda Licata


7.07 Provide a full-time Chief Infection Prevention Officer. Jody Springer 1.2 6/8/2012 Y

7.08 Survey monthly all departments for IP compliance. Survey results are sent to Department IP representative, Department Director and Divisional VP for follow up and corrective action needed and expected completion date. Janet Glowicz 6.3 3/23/2012 Y

7.09 Execute EOC surveillance program to ensure consistency with cleaning methods and standards to support IP principles. Janet Glowicz 6.3 3/23/2012 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Percentage of policies that have been drafted/revised (by department) 1 IP 100% 100% 100% 100% 100% 100% 100%2 Volume of non-compliant observations for hand hygiene - Hospital Audit 1 House-wide 0 1006 577 243 322 284 298

3a Volume of non compliant hand hygiene observations - support staff 1 House-wide 0 197 156 61 85 56 713b Volume of non compliant hand hygiene observations - physicians 1 House-wide 0 263 155 67 93 119 823c Volume of non compliant hand hygiene observations - nursing 1 House-wide 0 546 266 115 144 109 1454 Compliance in hand hygiene 1 House-wide 100% 97.7% 98.6% 98.6% 99.3% 99.3% 99.3%5 Percentage of compliant observations with sterile technique in procedure areas 1 Surgery 100% 100% 100% 100% 100% 100%6 Percentage of Infection Prevention completed surveys by each department, monthly 1 IP 100% 100.0% 100% 100% 100% 100%7 Volume of non-compliant observations by Infection Prevention Practice Team 1 House-wide 79 202 173 377 311 3828 Compliance percentage of Infection Prevention Practice Team rounding 1 House-wide 100% 97.0% 94.4% 94.8% 92.2% 92.0% 90.6%9 Number of blood stream infections 1 House-wide 0% 0 0 0 1 0 0

Infection Control (Section 2.07)


15

Infection Control (Section 2.07)



Comments


16


Target Date


8.01 Conduct a medication override audit. Vivian Johnson 2.3 6/8/2012 Y

8.02 Enhance P&T agenda with cost studies, outcomes for alternative drug options, ADR, Overrides, dosing guidelines. Vivian Johnson 2.3 4/5/2012 Y

8.03P&T Committee to provide report summarizing and action plans on medication analysis, ADR summaries, Narcan utilization, off label med utilization, and medication reconciliation issues to QCC.

Vivian Johnson 2.3 6/8/2012 Y

8.04 Establish baseline and develop a tool to “flag” ADRs. Vivian Johnson 2.3 5/11/2012 Y

8.05Trending reports based on type of reaction, location, provider, etc. and report to P&T Committee and other appropriate medical staff committees. Actions should be taken and documented on trends by the P&T Committee and reported up through the QCC Committee and Governing Board.


8.06Potential trends should be monitored with corrective action taken, e.g., ADRs identified on the same drugs, same units, same diagnoses, same physicians, etc.


8.07 Explore alternatives for clinical trial identifiers. Vivian Johnson 2.3 4/27/2012 Y8.08 Ensure all “off label” medication use is reviewed and approved by the P&T Committee. Vivian Johnson 2.3 4/27/2012 Y

8.09 Establish a Medication Reconciliation task force to develop a consistently compliant process. Judy HerringtonVicki Crane

4.5 5/11/2012 Y

8.10 Conduct chart audit of medication reconciliation compliance to establish current baseline. Judy HerringtonVicki Crane

4.5 6/15/2012 Y

8.11 Evaluate appropriateness of providing pharmacy tech support for medication reconciliation. Vivian Johnson 2.3 5/11/2012 Y8.12 Develop and provide education for pilot study for the participating Pharmacy Techs and RNs. Vivian Johnson 2.3 6/8/2012 Y8.13 Conduct pilot study. Collect and present results. Vivian Johnson 2.3 6/8/2012 Y8.14 Develop future state work flow processes. Vivian Johnson 2.3 6/8/2012 Y8.15 Pilot the new work flow process. Vivian Johnson 2.3 7/13/2012 Y

8.16 Implement new reconciliation process (in EPIC). Judy HerringtonVicki Crane

4.5 9/14/2012 Y

8.17 Reassign the crash cart management under the Sterile Processing Department and/or Pharmacy. Judy HerringtonVicki Crane

4.5 4/13/2012 Y

8.18 Assess the space requirements and human resources needed for case cart management within SPD. Judy HerringtonVicki Crane

4.5 7/16/2012 Y

8.19 Revisit the cart management processes for supplies and pharmaceuticals. Judy HerringtonVicki Crane

4.5 5/11/2012 Y

8.20Ensure the supply and pharmaceutical lists match the components in the carts and validate the accuracy of lists and components with Pharmacy and Nursing Education.

Judy HerringtonVicki Crane

4.5 3/22/2013 Y

8.21 Implement an accountability process and sign off process to ensure accuracy and products are not expired. Judy HerringtonVicki Crane

4.5 8/13/2012 Y

8.22 Conduct cart initial audit for validation after transferring case cart management to SPD. Judy HerringtonVicki Crane

4.5 10/1/2012 Y

Medication Management (Section 2.08)


17



Target Date


8.23 Present drug storage audit and data collection program. Vivian Johnson 2.3 6/8/2012 Y8.24 Pharmacy Resources and Nurse Liaisons (Charge Nurse) are assigned for each unit. Vivian Johnson 2.3 6/8/2012 Y

8.25Pharmacy & Unit-Based Nursing Resources conduct audits (Nursing - part of daily checklist for eight weeks); Pharmacy (monthly as a part of trending & monitoring) Vivian Johnson 2.3 6/8/2012 Y

8.26Nursing Liaison collects, collates and summarizes audit results and submits on the data tool to the Pharmacy Resource weekly.


8.27Pharmacy Resource analyzes data from Nurse Liaison reports and provides monthly summary interim reports to Nurse Liaison, Unit Manager and Department Director.


8.28 Pharmacy Resource collects collates and summarizes audit results and submits monthly audit on the data tool. Vivian Johnson 2.3 6/8/2012 Y

8.29 Establish a multi-disciplinary RCI Medication Safety Team. Vivian Johnson 2.3 4/13/2012 Y

8.30Investigate the root causes of the medication errors and categorize the errors and provide tactical plans towards resolution.


8.31 Review the medication ordering, preparation and administration process through a work flow process. Vivian Johnson 2.3 6/8/2012 Y8.32 Revise medication administration process based on finding of work flow analysis. Vivian Johnson 2.3 6/8/2012 Y

8.33Provide the education plan base on the work flow model findings that address the gaps in the safe delivery of medications. Vivian Johnson 2.3 9/14/2012 Y

8.34Develop core competence education program for all the clinical staff in regards to the practices of safe medication delivery. This module should be included in the staff’s annual competency evaluation.


8.35In conjunction with current internal hospital initiatives, define those care settings that moderate sedation is required versus pain management.


4.5 8/13/2012 Y

8.36 Ensure all clinicians are qualified to administer medications that have the clinical effect of moderate sedation. Judy HerringtonVicki Crane

4.5 8/13/2012 Y

8.37 Ensure compliance with new moderate sedation practice standards. Judy HerringtonVicki Crane

4.5 8/13/2012 Y

8.38Review the medications in Pyxis on the IP units that have access to “moderate sedation categorized” medications to determine how they should be “flagged” for monitoring.


4.5 8/13/2012 Y

8.39Conduct an audit on the daily Pyxis report (Epic Clarity Report) on Narcan use in patients undergoing pain management and moderate sedation in non-procedure based units.


# Audit/Measures Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 MD Max Overrides reviewed by RPH 1 Pharmacy 100% 100% 100% 100% 100% 100% 100%2 Compliance in medication reconciliation at admission (inpatient only) 1 Physicians 53% 78.0% 85.2% 90.3% 92.0% 95.1% 92.1%3 Compliance in medication reconciliation at discharge (inpatient only) 1 Physicians 83% 80.9% 83.1% 83.7% 83.5% 83.5% 88.4%4 Compliance in medication reconciliation - COPCs Physicians 83.6% 86.0%5 Compliance in medication reconciliation - Medicine Clinics Physicians 68.2% 67.3%6 Compliance in medication reconciliation - Surgery Clinics Physicians 23.0% 24.5%7 Compliance in medication reconciliation - WISH Clinics Physicians 29.9%8 Percentage of locations with unsecured medications 1 Pharmacy 0% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0%9 Percentage of compliant crash carts 1 SPD 100.0% N/A 100.0% 92.9% 90.0% 76.2%

10 Volume of adverse events related to moderate sedation 1 House-Wide 0 0 4 0 1 2 111 Number of improper or lack of medication labeling 2 Pharmacy 91 94 59 73 60 66


18


# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-1212 Number of off-label medications in use, not reviewed by P&T 1 Pharmacy 0 0 0 1 013 Number of adverse drug reactions 1 Pharmacy 19 31 128 70 108 94 157 12514 Number of preventable adverse drug reactions 1 Pharmacy 1 1215 Missed medications 1 Pharmacy 7.42% 7.33% 7.80%16 Percentage of medications administered within 60 minutes of order 1 Pharmacy 97.0% 96.4% 96.0% 96.8%17 Percentage of medications administered within 30 minutes of order 1 Pharmacy 88.0% 86.5% 87.0% 88.2%18 Number of opioid induced respiratory depressions naloxone administration 1 Pharmacy 0 5 2 0 2 6 N/A19 Number of preventable opiod induced respiratory depresssions naloxone administration 1 Pharmacy 0 3 1 0 1 1 N/A



Comments

results on next month's reportAudits # 17 and 18 - Results are not reported since workgroup creating this metric did not meet over the holidays. Will report December and January


19



9.01 Create job description for new Chief Patient Rights and Safety Officer (CPRSO). Jody Springer 1.2 3/30/2012 Y9.02 Name Interim Chief Patient Rights and Safety Officer (CPRSO)9.03 National search to recruit new Chief Patient Rights and Safety Officer (CPRSO) Chris Madden 1.2 10/1/2012

9.04

The following quality and safety functions at Parkland would be reorganized to report directly to the CPRSO: Patient Safety Patient Safety Investigations Root Cause Analysis (RCA) Patient Safety Incident Reporting PSN Database Maintenance and Reporting State, Federal and Joint Commission Reporting “Continual Readiness”/CMS, State and Joint Commission Survey Preparation “Daily Rounding” Function Infection Prevention and Control · Patient Relations (Patient complaints and grievances, which currently reports to Nursing)

Chris Madden 1.2 5/11/2012

9.05 New job descriptions for all employees and managers, supervisors and department heads in units and divisions now reporting to the CPRSO. Chris Madden 1.2 5/11/2012

9.06 Review and redesign of all patient rights and safety related policies and procedures. Lisa Betterson 6.2 6/8/2012 Y9.07 Develop education plan for all employees regarding patient safety and rights policy/procedure changes. Lisa Betterson 6.2 8/15/2012 Y

9.08

Reorganize and redesign its Quality Department and its centralized Quality Assessment/Performance Improvement (QAPI) functions to include: Clinical Data Management Performance ImprovementRapid Cycle Improvement


9.09 Create new Human Resources policy on violations of Patient Rights/Patient Safety obligations. Jim Johnson 1.5 6/8/2012 Y

9.10 Create a Patient Rights/Patient Safety Awareness Campaign. Lisa Betterson 6.2 4/27/2012 Y9.11 Create a “Safe Patient Hand offs”/Continuity of Patient Care Awareness Campaign Lisa Betterson 6.2 5/11/2012 Y

9.12 New education and training for current and new employees and physicians on safe patient handoffs and continuity of patient care. Lisa Betterson 6.2 9/30/2012 Y

9.13Parkland should conduct a study to look at best practices of other large hospital police departments to compare the level of specialized training provided to Parkland Police Department against other hospital police departments. Best practice for reporting structure should also be investigated.

Jody Springer 1.2 4/13/2012 Y

9.14 Patient Rights and Safety Department Study and Task Force (to include Nursing, Police, Patient Safety, and Patient Relations representatives) on Elopements and Patients leaving. Lisa Betterson 6.2 6/1/2012 Y

9.15Work with Parkland Police Department and Nursing the Patient Rights and Safety Department should conduct a study of all documented elopements in 2011 and determine reasons for elopement (e.g., breeches in security, caregiver training, etc.) and provide action plan and recommendations for reducing elopements.

Lisa Betterson 6.2 3/30/2012 Y

9.16

Patient Rights and Safety Department should then begin to conduct chart reviews for all patients who elope or leave AMA. The review should separately categorize all departments, including a separate review for elopements and patients leaving AMA in the Emergency Department. The chart review should then develop a list of reasons as to why patients leave elope or leave AMA, and subsequent reports should trend in these categories.


Patient Safety/Rights (Section 2.09)


20




9.17 Complete current RCI initiative regarding 1:1 observation procedure and competencies required for staff. Lisa Betterson 6.2 6/1/2012 Y

9.18 Evaluate additional CM staff to ED.Robin Stults w/


3.4 7/31/2012 Y

9.19

Establish a documentation committee, led by HIM, that includes Clinical support from Chief Nursing Officer and Chief Medical Officer, Support Services, ADT, Legal, Patient Safety, Performance Improvement and HIM representation to address the inconsistencies of properly executed documents, lack of complete and accurate documentation, and lack of compliance.


9.20 Develop and implement an action plan that addresses non-compliance and the steps to the solution. Lisa Betterson 6.2 9/14/2012 Y

9.21 Review all policies and procedures related to the areas of non-compliance to determine and ensure policies are updated to current regulations or standards of practice. Lisa Betterson 6.2 10/31/2012 Y

9.22 Determine where and if the resources are available or needed to meet the documentation requirements. Lisa Betterson 6.2 9/14/2012 Y

9.23HIM shall conduct routine chart audits to document that all patients have been provided with: 1) required information on their rights under Medicare, federal law and state law; 2) required information on advance directives. Chart audits shall also assess whether all Medicare patients are receiving the notice entitled: “Important Message from Medicare.”

Lisa Betterson 6.2 9/14/2012

9.24 Review Hospital policy for Patient Grievance procedure and compare to best practice, including those noted above. Lisa Betterson 6.2 5/25/2012 Y

9.25 Develop monitoring system to ensure timelines required by Hospital policy are met. Lisa Betterson 6.2 6/8/2012 Y

9.26

Patient Relations Department should create a new monthly reporting system for all patient grievances and complaints. The reporting system should show, at a minimum: number of complaints/grievances received; actionable categories for all complaints/grievances (some complaints/grievances may fall in several categories); person making complaint (patient, family member, staff, physician, etc.); time between receipt of complaint and response to patients; documentation that patient agreed/disagreed that compliant/grievance was resolved; inventory of complaint/grievance by department/unit/floor and confidentiality by employee and physician; trending of grievances/complaints over months/years in all above categories.


9.27 Develop and implement a Privacy task force to identify areas of non-compliance (including HIPAA), indicators to measure, and to develop an awareness campaign. Lisa Betterson 6.2 6/8/2012 Y

9.28 Conduct Patient Privacy Awareness Campaign to reacquaint staff on HIPAA and other privacy obligations. Privacy Awareness campaign should include examples of recent privacy breaches. Lisa Betterson 6.2 9/14/2012 Y

9.29 Review current privacy training materials. Require annual competency on HIPAA and other patient rights but revise competency annually to refresh materials and learning behaviors for better retention of information. Lisa Betterson 6.2 9/14/2012 Y

9.30 Utilize tool developed by Executive VP of Operations or another developed tool to conduct weekly customer relations tours. Lisa Betterson 6.2 7/1/2012 Y

9.31 Develop a dashboard and track and trend the indicators for Patient Rights and the progress to the target thresholds. Lisa Betterson 6.2 9/14/2012 Y


21


# Audit/Measures Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Percentage of policies and procedures reviewed and/or revised 1 Pat Safety 100% 100% 100% 100% 100% 100% 100%2 Percentage of staff provided education on patient rights and patient safety 1 Pat Safety 100% 54.0% 75.2% 98.8% 99.2% 99.5% 99.5%3 Percentage of staff provided education on safe patient hand offs - area to area 1 Nursing 100% 98.0% 98.0% 100.0% 100.0% 100.0% 100.0%4 Percentage of staff provided education on safe patient hand offs - shift to shift 1 Nursing 100% 0.0% 0.0% 100.0% 100.0% 100.0% 100.0%5 Attendance for state mandated training courses for members of Police Department 1 Police 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%6 Average time from event to closure of patient safety investigation (days) 1 Pat Safety 10 10 27 33 45 31 317 Percentage of regulatory reports submitted within 5 business days (or 2 days for state-mandated reports) 1 Perf Imp 74% 100% 92.3% 82.1% 90.0% 94.4% 93.3% 100.0%8 Number of patient complaints and grievances 1 Pat Griev 464 403 226 418 372 2229 Average time from event to resolution of patient complaint or grievance (days) 1 Pat Griev 25 41 22 23 17 1510 Percentage of inpatients receiving advance directive notice 1 PFS 97.8% 98.0% 98.0% 98.5% 98.0%

11Percentage of patients who received appropriate notifications (under applicable Medicare, state and other laws, "Important Message from Medicare", others), as audited by HIM - Care Management 1

CM 98% 45.0% 67.3% 76.7% 79.5% 82.8% 92.0%

12Percentage of patients who received appropriate notifications (under applicable Medicare, state and other laws, "Important Message from Medicare", others), as audited by HIM - PFS 1

PFS 98% 77.0% 91.0% 91.7% 91.8% 95.5% 96.0%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-1213 Number of Patient Safety Investigations 1 Pat Safety 67 81 47 58 34 3014 Percentage of Root Cause Analyses (RCA) completed within 45 days Pat Safety 80% 100%15 Volume of privacy and security breaches 1 House-Wide 34 42 36 53 42 3216 Number of elopements, AWOLS, AMA (excluding ED) 1 Pat Safety 59 66 69 53 60 52 56

9.03 - 9.05 - Still conducting interviews for Chief Patient Rights and Safety Officer (CPRSO) Task/initiative largely on schedule for completion9.23 - Audit results are still below 98% compliance level, but are trending in the right direction Task/initiative may be delayed from Target Date completion



Comments


22

# Tasks/Initiatives Accountability Work Stream Target Date Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Completion

10.01 Develop an OPPE/FPPE review template for each medical department and/or service. Patricia Bergen, MD 5.1 4/20/2012 Y

10.02 Develop a written procedure explaining the OPPE process, criteria and physician referral process for FPPE. Patricia Bergen, MD 5.1 4/20/2012 Y

10.03 Define required physician profile elements for all physicians. Patricia Bergen, MD 5.1 4/20/2012 Y

10.04 Provide all department chairs the required template, guidance, and a timeline for completion of departmental criteria, indicators, and thresholds of performance.

Patricia Bergen, MD 5.1 1/31/2013

10.05 Review and “sign off” of CMO and QAPI of the departmental OPPE plans Professional Staff Quality Management Plan for relevance and compliance.

Patricia Bergen, MD 5.1 7/30/2012 Y

10.06 Review and obtain approval of OPPE/FPPE process and criteria by MEC, and then the Governing Board. Patricia Bergen, MD 5.1 7/13/2012 Y

10.07 Each department should develop a standard set of metrics for use on cases sent for peer review. Patricia Bergen, MD 5.1 1/31/2013 Y

10.08 Medical Staff Office Quality Department to establish a methodology to track and trend all cases brought to peer review Patricia Bergen, MD 5.1 1/31/2013 Y

10.09 Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review. Patricia Bergen, MD

5.1 8/31/2012 Y

10.10 Determine necessity to expand Medical Staff resources. Patricia Bergen, MD 5.1 7/13/2012 Y

10.11Charter a joint Hospital/GME Faculty Task Force. Create a venue for collaboration and discussion of issues between Hospital and Faculty to inform and appraise between residency update periods. Members to include Hospital VPs and Faculty Medical Staff.


10.12

Develop an audit and reporting method for compliance with the ACGME 2012 Common Program Requirements that will require each departmental residency program to specify the types of patient events that will require a Resident to call the teaching physician. Use the audit to develop an operational report to concurrently manage the Residents during the academic year.


10.13 Develop a training module enabling faculty to instruct residents when to escalate issues to their Attending Physicians. Brad Marple, MD 5.3 8/31/2012 Y

10.14Standardize use of Innovations (resident management software) across the system to create a web-enabled database of individual resident certification profile; (presently nurse can access the department grid, see what a PGY-2 is qualified to do, and then look up the name of a particular PGY2 and determine whether he/she is certified to it.

10.14a Interim option for access to resident qualifications Brad Marple, MD 5.3 7/30/2012 Y

10.15 Modify Grid to highlight those events or add link to the list of and procedures that require concurrent notification of the attending physician that is available to all departments. Brad Marple, MD 5.3 7/30/2012 Y

10.16 Review Grid or list to ensure that it includes the list of all events that require escalation notification to an Attending (i.e., lower the reporting threshold). Brad Marple, MD 5.3 7/30/2012 Y

10.17 Create policy contingencies for alternate modes of supervision or escalation, i.e., what to do when the expected senior resident or Teaching Physician is not accessible in the expected time period. Brad Marple, MD 5.3 5/11/2012 Y

Medical Staff (Section 2.10)


23

Medical Staff (Section 2.10)


10.18 Evaluate Parkland’s Epic functionality, to determine improvement to be made in documentation or note entry to provide consistent and reliable documentation of Attending Physician oversight, approval and concurrence with Resident orders. Brad Marple, MD 5.3 7/30/2012 Y

10.19Evaluate Parkland’s call system ability to properly attribute the Resident and Attending Physician to each patient. Create an audit tool for weekly confirmation that call system is accurately and timely attributing Residents and Attending Physicians to each patient.

Joseph Minei, MD 5.4 8/31/2012 Y

10.20 Upgrade Epic with user capability to concurrently update treatment teams through use of the physician order entry function. Joseph Minei, MD 5.4 8/31/2012 Y

10.21 Standardize call schedule procedure for consulting services. Joseph Minei, MD 5.4 8/31/2012 Y

10.22 Ensure the accuracy Amcom scheduling system (source of truth maintained by Parkland) Joseph Minei, MD 5.4 8/31/2012 Y

10.23 Create contingencies for alternate modes of supervision or escalation. Joseph Minei, MD 5.4 5/11/2012

10.24 Parkland’s GME Director should review the current training and education materials for Residents on documentation, particularly documentation of H&Ps. Brad Marple, MD 5.3 5/11/2012 Y

10.25 Refresher education and training should be conducted for all Residents. Brad Marple, MD 5.3 8/31/2012 Y

10.26 Perform audit of Residents' History and Physicals (H&P) documentation for completion and adherence to Parkland policy and procedures. Brad Marple, MD 5.3 3/22/2013 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Number of referrals to peer review 1 Med Staff 15 34 192 120 114 1272 Percentage of Medical Staff enrolled in new OPPE system Perf Imp



Comments10.04 - Initiative is at risk to meet deadline due to barriers in automating indicator reports for OPPE. A backup plan is in place.


24


Target Date


11.01Conduct a quantitative demand and process analyses of the ESD in order to properly balance work flow, capacitate the various components of the split flow system, and accurately determine any changes in bed capacity, service hours or staffing.

Clifann McCarley 3.2 4/27/2012 Y

11.02Throughput and productivity assessment of the “current state” in the form of a process work flow diagram including the following elements: inputs, activity steps, decision points, enablers, functions and outputs


11.03Identify rate limiting factors such as lack of equipment/technology, availability and/or staffing within budget guidelines, and hours of operations.


11.04Server cycle times need to be measured and applied to the design of care teams in the Triage and the Intake areas. Clifann McCarley 3.2 4/27/2012 Y

11.05Conduct a benchmarking study of its Emergency Department labor productivity to industry standards in order to determine if there are opportunities to improve productivity and thereby increase capacity for each service area.


11.06Redesign of the future process flow to eliminate waste, such as: removing or combining steps, automating any manual activity steps, if possible, transferring elements to other departments, changing the location where the steps are done, and finally altering/modify the activity step


11.07Work flow models should be piloted with Rapid Cycle Testing and refined as necessary and then training provided

Clifann McCarley 3.2 1/13/2013

11.08 Periodic reviews of process work flow using Plan-Do-Check-Adjust (PDCA) Lean techniques. Clifann McCarley 3.2 3/14/2013

11.09 Change functionality in Epic to reflect changes in work flow processes and new treatment areas. Clifann McCarley 3.2 6/8/2012 Y

11.10 Recruitment, credentialing and on-boarding of qualified physicians. Patricia Bergen, MD

5.1 6/8/2012 Y

11.11 Pathology to scope operations, licensing, certification requirements for Point of Care labs. Deb Perrault 2.2 5/11/2012 Y

11.12Develop signage text consistent with the educational level and primary languages of the population served that is consistent across the institution.


11.13 List all sites and specific rooms requiring posting of signage Clifann McCarley 3.2 5/11/2012 Y

11.14 Obtain approval of final language for signage Clifann McCarley 3.2 5/25/2012 Y

11.15 Physical Plant and Facilities to arrange for printing and posting final approved signs. Clifann McCarley 3.2 6/8/2012 Y

11.16 Post new signage Clifann McCarley 3.2 7/13/2012 Y

11.17 Review and revise all EMTALA related Policy and Procedures. Clifann McCarley 3.2 6/8/2012 Y

11.18 Create/Revise training materials for new EMTALA Policy and Procedures Clifann McCarley 3.2 7/13/2012 Y

Emergency Services (Section 2.11)


25



Target Date


11.19 Re-educate on new EMTALA Policy and Procedures. Clifann McCarley 3.2 3/22/2013 Y

11.20 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/20/201311.21 Re-educate staff on new patient registration policies on Emergency Registration Process Emilie Allen 4.4 6/8/2012 Y

11.22 Develop and finalize a survey technique. Clifann McCarley 3.2 5/12/2013

11.23Develop a patient flow process to eliminate disparate treatment in evaluation and delay in the care of a person presenting to the ESD seeking Psychiatric emergency care.

Clifann McCarley 3.2 9/14/2012

11.24 Review and revise all Hand-Off related Policy and Procedures. Barbara MimsValerie Harvey

4.2 5/25/2012 Y

11.25 Create/Revise training materials for new Hand-Off Policy and Procedures. Barbara MimsValerie Harvey

4.2 7/13/2012 Y

11.26 Re-educate on new Hand-Off Policy and Procedures. Barbara MimsValerie Harvey

4.2 9/30/2012 Y

11.27 Work with IT/Epic to develop access to information required by law. Clifann McCarley 3.2 6/8/2012 Y

11.28 Develop reporting function with Epic for output of Central Log Reports. Clifann McCarley 3.2 6/8/2012 Y

11.29Create training materials for accessing information required by law and reporting functions through Epic.


11.30 Re-educate staff on accessing information required by law and reporting functions through Epic. Clifann McCarley 3.2 9/14/2012 Y

11.31 Monitor and audit compliance to determine if management can generate a central patient log. Clifann McCarley 3.2 9/14/2012 Y

11.32 Review and revise policy and procedures on receiving hospital transfer requirements. Clifann McCarley 3.2 4/13/2012 Y

11.33 Create/Revise training materials for new policy and procedures. Clifann McCarley 3.2 4/27/2012 Y

11.34 Re-educate on new policy and procedures. Clifann McCarley 3.2 5/18/2012 Y

11.35 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/12/2013


26



Target Date


11.36 Review and revise policy and procedures on Memorandum of Transfer requirements. Clifann McCarley 3.2 4/13/2012 Y

11.37 Create/Revise training materials for new policy and procedures. Clifann McCarley 3.2 4/27/2012 Y

11.38 Re-educate on new policy and procedures. Clifann McCarley 3.2 5/18/2012 Y

11.39 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/12/2013

11.40 Review and revise policy and procedures on nursing assessment and plan of care requirements. Emilie Allen 4.4 9/9/2012 Y

11.41 Create/Revise training materials for new policy and procedures. Emilie Allen 4.4 9/21/2012 Y11.42 Re-educate on new policy and procedures. Emilie Allen 4.4 9/21/2012 Y11.43 Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen 4.4 5/18/2013

11.44The Emergency Services Director of Nursing should determine approach for developing an acuity assessment methodology, e.g., internal historical record review, an automated tool, etc.


4.3 10/5/2012 Y

11.45 Once selected, roll out acuity tool. Jackie BrockJohn Raish

4.3 3/22/2013

11.46 Develop flexible staffing strategies, PRN pools, per diem staff, etc. Jackie BrockJohn Raish

4.3 3/22/2013 Y

11.47 Monitor core patient care ratios for trends. Jackie BrockJohn Raish

4.3 3/22/2013 Y

11.48 Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs. Jackie BrockJohn Raish

4.3 6/28/2013


27


# Audit/Measures Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12Main ED

1 Treated visits 1 ESD 10146 10093 9734 9859 9539 98452 Total number of hours of ED boarding 1 ESD 2671 3434 5209 2654 3536 2231 28793 Average number of patients in ED that are boarding per day 1 ESD 40.0 46.6 53.2 47.2 48.2 39.7 41.34 Average number of dialysis patients in Main ED at 6AM 1 ESD 12.0 12.2 10.9 10.2 10.3 11.35 Average "Compassionate" dialysis patients transferred from ED/day 1 ESD 17.3 14.5 15.0 13.8 15.5 16.0 17.36 Average dwell time for dialysis patients in Main ED ESD 415.5 413 431 412 396 415 4497 Turnaround time to discharge patients to home (door to home, in minutes) 1 ESD 379.4 431.4 430.0 408.3 389.2 324.2 350.18 Door to seen by 1st Provider (minutes) 1 ESD 92 131 61 125 114 76 879 Hours on resource alert 1 ESD 496 608 394 238 22 40

10 Door to Room Time (minutes) 1 ESD 93 90 63 65 70 43 4711 Left without being seen 1 ESD 10.2% 11.2% 9.2% 8.3% 4.3% 5.2%12 Left without being treated 1 ESD 1.8% 2.4% 2.3% 1.9% 1.8% 1.6%13 Percentage of patients admitted 1 ESD 26.9% 27.6% 26.9% 27.5% 26.8% 26.8%14 Percentage of patients discharged 1 ESD 64.3% 62.3% 64.3% 63.3% 63.6% 63.4%15 Average ED throughput time - time from patient arrival to patient disposition 1 ESD 326 371 371 354 342 286 30616 Compliance to environment of care 1 ESD 100% 90% 91% 89% 95% 90%

Urgent Care Clinic (UCC)17 Treated visits 1 ESD 4727 4722 4161 4225 4270 420618 Turnaround time to discharge patients to home (door to home, in minutes) 1 ESD 194.2 235.2 240.8 252.9 273.6 243.2 234.719 Door to seen by 1st Provider (minutes) 1 ESD 126 176 176 187 194 171 16220 Door to Room Time (minutes) 1 ESD 107 159 161 173 183 143 13521 Left without being seen 1 ESD 8.4% 7.5% 10.1% 11.4% 8.6% 7.8%22 Left without being treated 1 ESD 0.9% 1.3% 1.1% 0.8% 0.8% 1.1%23 Percentage of patients admitted 1 ESD 0.1% 0.1% 0.1% 0.0% 0.0% 0.1%24 Percentage of patients discharged 1 ESD 93.0% 92.0% 92.8% 93.5% 92.8% 91.5%25 Average ED throughput time - time from patient arrival to patient disposition 1 ESD 164 217 219 231 253 222 21126 Compliance to environment of care 1 ESD 100% 89% 92% 92% 95% 92%

OB Gyn Intensive Care Clinic (ICC)27 Treated visits 1 WISH 2000 1978 1934 1927 1815 174328 Total number of hours of ED boarding 1 WISH 127 185 149 108 166 117 12529 Average number of patients in ED that are boarding per day 1 WISH 2.3 2.6 2.7 2.0 2.3 2.3 2.230 Turnaround time to discharge patients to home (door to home, in minutes) 1 WISH 456.2 499.2 461.2 465.3 493.9 457.7 416.231 Door to seen by 1st Provider (minutes) 1 WISH 105 68 53 59 56 52 4032 Hours on resource alert 1 WISH 0 72 0 0 6 033 Door to Room Time (minutes) 1 WISH 264 289 271 260 268 256 20734 Left without being seen 1 WISH 3.5% 2.4% 1.9% 1.8% 1.8% 1.1%35 Left without being treated 1 WISH 15.6% 14.1% 11.8% 14.8% 14.2% 10.9%36 Percentage of patients admitted 1 WISH 11.5% 10.4% 9.4% 8.1% 8.3% 8.2%37 Percentage of patients discharged 1 WISH 64.4% 67.0% 70.4% 68.1% 68.5% 72.5%38 Average ED throughput time - time from patient arrival to patient disposition 1 WISH 400 437 406 406 426 400 36439 Compliance to environment of care 1 WISH 90% 92% 91% 95% 92%


28


# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-1240 Labor Productivity (staffing to include acuity) ESD

41Total ED throughput time - time from patient arrival in ANY ED to discharge home from ANY ED (hours:minutes) 1

ESD 6:57 7:05 6:43 6:42 5:55 6:13

42 Percentage of travelers - ED 1 ESD 21.9% 21.4% 24.0% 19.3% 10.4% 11.9%

11.23 - Still perfecting the role, responsibility and staffing of Team C in the Main ED Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


29


Target Date


12.01 Develop clear “vision” of a psychiatric services (with particularly focus on PED) care delivery model. Sharon Phillips 2.1 4/27/2012 Y

12.02 Hire interim management for Psychiatric Director and psychiatric experienced/trained Nursing Manager for PED. Sharon Phillips 2.1 4/27/2012 Y

12.03 Commence national search for permanent Director of Psychiatric Services. Sharon Phillips 2.1 6/8/2012 Y

12.04Develop a detailed implementation plan (based on this corrective action plan) led by the psychiatric management team. Define a management scorecard that can be utilized.

Sharon Phillips 2.1 5/14/2012 Y

12.05 Create by discipline specific roles and responsibilities in alignment with new care delivery model. Sharon Phillips 2.1 6/22/2012 Y12.06 Create new competencies and education models. Emilie Allen 4.4 5/25/2012 Y

12.07 Create permanent staffing grids for PED and 8 North based upon census and acuity. Jackie BrockJohn Raish

4.3 7/31/2012 Y

12.08 Further develop the charge nurse role in the PED and on 8 North. Jackie BrockJohn Raish

4.3 7/31/2012 Y

12.09 Develop, test, and validate acuity methodologies for PED and 8 North. Jackie BrockJohn Raish

4.3 7/31/2012 Y

12.10 Validate Social Workers coverage and effectiveness. Sharon Phillips 2.1 4/13/2012 Y12.11 Implement short term strategy for consistent physician coverage. Sharon Phillips 2.1 9/14/2012 Y12.12 Continue recruitment efforts aggressively to fill permanent positions. Jody Springer 1.2 6/8/2012 Y12.13 Identify staff knowledge gaps. Emilie Allen 4.4 6/8/2012 Y12.14 Utilize psychiatric–trained resources for competency development and training. Emilie Allen 4.4 6/1/2012 Y12.15 Develop comprehensive PED education plan. Sharon Phillips 2.1 6/8/2012 Y

12.16 Incorporate required physician competencies into OPPE/FPPE. Patricia Bergen, MD

5.1 6/8/2012 Y

12.17 Implement a discharge huddle with the MD, nursing staff, social worker, and a designated facilitator. Sharon Phillips 2.1 5/1/2012 Y12.18 Develop interdisciplinary communication and planning for the plan of care. Sharon Phillips 2.1 9/28/2012 Y12.19 Develop suicide risk and behavioral quadrant assessment tools. Sharon Phillips 2.1 6/8/2012 Y12.20 Conduct a pilot on the suicide risk and behavioral quadrant assessment tools. Sharon Phillips 2.1 6/29/2012 Y

12.21 Educate team members on the purpose and the usability of the tool and how it’s integrated into the plan of care. Sharon Phillips 2.1 7/13/2012 Y

12.22 Develop cross-functional Parkland behavioral health team. Sharon Phillips 3.5 9/24/2012 Y12.23 Analyze the patient population served by all of Parkland behavioral health disciplines. Sharon Phillips 3.5 9/24/2012 Y

12.24 Work with DBHLT on reducing or eliminating identified gaps in care across the continuum of care in Dallas County. Sharon Phillips 3.5 9/24/2012 Y

12.25 Continue redesign planning of day room and back entrance for better space utilization. Sharon Phillips 2.1 6/8/2012 Y12.26 Initiate multi-disciplinary team to consider PED space redesign. Sharon Phillips 2.1 6/8/2012 Y12.27 Develop alternative workflows for continued PED patient care during physical space construction/redesign. Sharon Phillips 2.1 6/8/2012 Y12.28 Develop budget for recommended physical changes. Sharon Phillips 2.1 6/8/2012 Y12.29 Develop alternative safety alerts for day room restroom. Sharon Phillips 2.1 4/20/2012 Y

Psychiatry Services (Section 2.12)


30

Psychiatry Services (Section 2.12)

# Audit/Measures Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Audit Results of number of Psych Inpatient cases intervened by CM on first day of admission 1 PED/CM 100% N/A N/A N/A 100% 94% 100%2 Treated Visits (PED) PED 578 535 554 605 541 5493 Percentage of patients seen by social workers (PED) 1 Psych 98.5% 99.8% 97.7% 97.6% 98.7% 94.8%4 Hours on resource alert 1 PED 722 724 0 0 0 05 Percentage of patients with a documented discharge huddle 1 Psych 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%6 Percentage of patients admitted 1 Psych 2.1% 1.7% 1.6% 3.1% 3.0% 3.1%7 Percentage of patients discharged to home 1 Psych 65.9% 66.9% 73.3% 74.0% 72.8% 66.1%8 Percentage of patients transferred to acute care facility 1 Psych 29.8% 29.9% 23.1% 20.7% 21.8% 28.2%9 Turnaround time to discharge patients to home (door to home) 1 PED 649 608 706 588 573 532 65210 Door to seen by 1st Psych Provider (minutes in any ED) 1 PED 166 404 560 402 363 341 N/A11 Door to Room Time 1 (PED pt arrived in any ED and placed in any ED room) PED 60 68 N/A 61 47 47 N/A12 Compliance to environment of care 1 Psych 100.0% 99.1% 94.7% 99.1% 99.6%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-1213 Labor productivity (staffing to include acuity) PED14 Volume of restraint cases - personal hold 1 Psych 11 12 15 26 15 1015 Volume of restrain cases - seclusion 1 Psych 1 6 3 7 4 316 Number of patients with scheduled appointments at discharge 1 Psych17 Percentage of travelers - Psych 1 Psych 14.8% 11.1% 8.3% 0.0% 0.0% 0.0%

18 Total PED throughput time - time from patient arrival to patient disposition (arrival in PED to discharge in PED) 1 PED 537 501 588 481 463 464 N/A

19 Total PED throughput time - time from patient arrival to patient disposition (arrival in any ED to discharge in PED) 1 PED 1,114 1,294 971 872 844 N/A

20 24-hour bounce back rate 1 PED 2.6% 2.2% 2.4% 3.0% 3.2% 3.8%21 Proportion of total Psychiatric Services patients discharged from Main ED by Team C 1 Psych 16.0% 17.0% 14.0% 13.6% 13.9% 17.5%

Audit # 10, 11, 18 and 19 - Results were found to be inaccurate, will be self-reported by Psyhiatric Services Leadership in the January report. Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


31



13.01 Ensure plan of care practices are standardized and followed regularly. Barbara MimsValerie Harvey

4.2 3/22/2013 Y

13.02 Standardize hand off procedures. Educate staff. Barbara MimsValerie Harvey

4.2 9/30/2012 Y

13.03 Begin recruitment of key leadership positions – Nursing Director (L&D) and Nursing Manager (L&D).


4.3 6/8/2012 Y

13.04 Evaluate job description and determine best solution to work load balance for Nurse Manager (Postpartum).


4.3 4/13/2012 Y

13.05 Begin recruitment of additional Nurse Manager candidates (Postpartum). Jackie BrockJohn Raish

4.3 5/11/2012 Y

13.06Evaluate job descriptions of Nurse Managers to determine if additional administrative support is required. Paula Turicchi 2.4 7/15/2012 Y

13.07 Begin recruitment for administrative support roles (if appropriate).

13.08 Recruit, hire and train additional staff to fill vacancies. Jackie BrockJohn Raish

4.3 6/8/2012 Y

13.09 Evaluate nurse staffing needs based upon any plans for increase in capacity. Jackie BrockJohn Raish

4.3 4/27/2012 Y

13.10 Recruit, hire and train additional staff as required. Jackie BrockJohn Raish

4.3 6/8/2012 Y

13.11 Re-design staffing model to include adjustment for acuity. Jackie BrockJohn Raish

4.3 6/8/2012 Y

13.12 Evaluate job descriptions for inclusion of appropriate competencies and to ensure duties assigned are within scope of practice.

Paula Turicchi 2.4 6/1/2012 Y

13.13 WISH Nursing Director and Chief Nursing Officer (CNO) must ensure all nursing personnel working within scope of practice.


4.3 4/13/2012 Y

13.14 Nursing Directors of each area should review competencies required for the care of their patient population in accordance with nursing practice standards.

Emilie Allen 4.4 6/1/2012 Y

Women and Infant's Specialty Health (WISH) (Section 2.13)


32




13.15 A full assessment of current staff should be conducted to establish a current baseline of competencies.


13.16 Review all personnel files for completed competencies. Emilie Allen 4.4 7/13/2012 Y

13.17 Gaps identified in competencies should be addressed with education and audit. Emilie Allen 4.4 7/13/2012 Y

13.18 Conduct newborn resuscitation competency education and audit. Emilie Allen 4.4 7/13/2012 Y

13.19 Evaluate the need for an additional FTE’s to assist in the responsibility of supply stocking, storage, and environmental rounds on all WISH units.


13.20

Establish recommended AORN practices of setting up the sterile back table for delivery table set-up. Determine if additional staffing is required for L&D OR and LDR for sterile supply set up

Suzanne Sims 2.5 4/13/2012 Y

13.21 Ensure plan of care practices are standardized and followed regularly.13.22 Standardize hand off procedures. Educate staff.

13.23 Women Infant and Specialty Health (WISH) operations and nursing leadership with Chief Nursing Officer (CNO) to develop plan and budget for required changes.


13.24 Present plan to senior leadership. Paula Turicchi 2.4 5/25/2012 Y

13.25 Design care model that provides for rooming-in options for infants. Jackie BrockJohn Raish

4.3 6/30/2012 Y

13.26 Establish a census tracking tool for newborns. Paula Turicchi 2.4 5/11/2012 Y

13.27 Review and revise infant security and abduction plan. Paula Turicchi 2.4 4/6/2012 Y

13.28 Conduct at least one Code Pink drills per year. Emilie Allen 4.4 5/11/2012 Y

13.29Identify space that can be made available for emergency equipment within the post partum unit (department reports plan underway to convert treatment rooms for this purpose).



33




13.30 Establish monthly mock equipment drills and verify emergency equipment is immediately available where newborns are housed.


13.31 Discard all “six pack” transport carts. Paula Turicchi 2.4 4/6/2012 Y

13.32Conduct a multidisciplinary assessment of conditions of WISH units related to supplies/medications including refrigeration, cleanliness, appropriate storage of supplies, and other conditions related to infection prevention.


13.33 Evaluate the need for an additional FTE’s to assist in the responsibility of supply stocking, storage, and environmental rounds on all WISH units.

13.34 Establish an alternative protocol for delivery table set-up to ensure sterile field. Suzanne Sims 2.5 4/6/2012 Y

13.35 Educate staff on storage requirements for specimens. Emilie Allen 4.4 4/27/2012 Y

13.36 Revise dirty utility room flow and practice. Paula Turicchi 2.4 7/15/2012 Y

13.37 Department reports a plan is in progress for construction to ensure proper dirty utility room flow. (No start date supplied)

Josh Floren 1.7 7/12/2012 Y

13.38 Review Parkland policy on securing medications PHR-D-067 Inventory Management – Procurement, Storage


4.5 5/18/2012 Y

13.39 Anesthesia medication trays should be stored in a locked, secure area. Judy HerringtonVicki Crane

4.5 4/13/2012 Y

13.40 Store floor stock in Pyxis. Judy HerringtonVicki Crane

4.5 4/13/2012 Y

13.41 Educate staff on the importance of two patient identifiers and include in initial and annual competencies.


13.42 Educate staff of National Patient Safety Goals and Hospital policy. Emilie Allen 4.4 3/30/2012 Y

# Audit/Measures Responsibility Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Compliance to Infection Prevention practice 1 WISH 100.0% 96.0% 96.0% 96.0% 72.7% 68.8% 96.5%2 Compliance to Environment of Care 1 WISH 100.0% 95.6% 96.0% 96.0% 97.4% 97.3%


34


# Metric Responsibility Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-123 Labor productivity (Staffing to include acuity) WISH4 Staffing hours per patient day 1 WISH 11.65 11.97 12.88 12.42 13.07 14.02 14.005 Number of days per month staffing ratios were above/below grid 1 WISH 20 22 17 21 21 216a Hallway and Classroom Beds in use in L&D (avg duration in minutes) 1 WISH 104 80 N/A6b Hallway and Classroom Beds in use in L&D (instances) 1 WISH 192 164 N/A7 Volume of patients doubling-up on Post-Partum 1 WISH 1384 1207 979 906 834 617 6598 Induction Interruption WISH9 Induction Delay WISH10 Direct Admits to Post-Partum 1 WISH 114 121 122 138 99 10611 Bounce-Back from Post-Partum to L&D Recovery WISH 115 107

Audit # 6a and 6b - WISH Leadership is working on vetting this metric. Will report accurate figure in January report. Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


35



14.01Conduct daily infection control audits in all areas of the Main OR, PACU, PreOp Holding, DSU, Anesthesia Workroom, ASC and PAEC. Suzanne Sims 2.5 8/31/2012 Y

14.02Execute the progressive disciplinary action and performance improvement plan for staff/physicians who exhibit failure to follow infection prevention policies and procedures. Suzanne Sims 2.5 6/8/2012 Y

14.03 Conduct environment of care rounds every shift in each perioperative area. Suzanne Sims 2.5 8/31/2012 Y14.04 Review and follow Parkland policy Admin 6-33 “Labeling of Medications On/Off the Sterile Field”. Suzanne Sims 2.5 8/31/2012 Y14.05 Review and follow Parkland policy Admin 6-43, “Using Two (2) Patient Identifiers”. Suzanne Sims 2.5 8/31/2012 Y14.06 Provide training for alternative options for medication solution transfer. Suzanne Sims 2.5 7/13/2012 Y14.07 Conduct daily audits of various medication management measures to determine compliance. Suzanne Sims 2.5 8/31/2012 Y14.08 Review and follow the Parkland policy Admin 6-30 “Universal Policy”. Suzanne Sims 2.5 7/13/2012 Y

14.09 Conduct daily audits of various patient right initiatives to determine compliance: Critical Equipment


# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Compliance to using two patient identifiers 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%2 Compliance percentage of Infection Prevention by audit, monthly 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 95.0% 96.2%3 Compliance percentage of Environment of Care by audit, monthly 1 Surgery 100.0% 100.0% 98.0% 100.0% 99.2% 99.0% 98.2%4 Compliance to site marking procedure 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

5Compliance to medication management measures (labeling, transferring from the circulator to scrub, securing and other measures) 1

Surgery 100.0% 99.2% 99.3% 100.0% 100.0% 100.0% 100.0%

6 Compliance with critical equipment 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.5%7 Compliance to Time Out procedure 1 Surgery 100.0% 99.9% 100.0% 100.0% 100.0% 100.0% 100.0%

Perioperative Services (Section 2.14)


36

Perioperative Services (Section 2.14)

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-128 Number of medication errors 1 Surgery 0 2 3 5 1 2 29 Number of blood transfusion errors 2 Surgery 1 0 2 5 0 0

10 Number of incorrect consents 2 Surgery 5 3 3 1 1 211 Number of wrong site surgeries or wrong site markings 2 Surgery 0 0 0 0 012 Number of lab specimen mis-labeling 2 Surgery 3 0 5 0 213 Percentage of travelers - OR 1 Surgery 11.9% 13.5% 13.9% 9.5% 6.8% 7.5%14 Surgical Site infection rate (2 month lag) 1 Surgery 1.71% 0% 3.8% 1.4% 1.6% 1.8% 2.4% 4.3%



Comments


37


Target Date


15.01 Conduct a weekly environment of care tour to ensure infection prevention measures are in compliance.Kim McCloudLinda Licata


15.02Conduct audit on invasive procedures in the restricted procedure rooms on the proper medication management on and off the sterile field.


15.03 Review Parkland's policy on Surgical Attire and OSHA regulation on Personal Protective Equipment. Suzanne Sims 2.5 8/31/2012 Y

15.04 Cardiologist performing the procedure to conduct the “pause” to ensure surgical team is properly attired. Suzanne Sims 2.5 8/31/2012 Y

15.05 Conduct an education program and competency on maintaining the sterile field. Suzanne Sims 2.5 8/31/2012 Y15.06 Conduct an audit to ensure compliance with surgical attire policy. Suzanne Sims 2.5 8/31/2012 Y

15.07 Nurse manager to develop daily EOC tool/checklist to ensure compliance.Kim McCloudLinda Licata


15.08 Review PHHS policy Admin 6-33 and PS 04-33 on proper handling of medications. Suzanne Sims 2.5 3/30/2012 Y

15.09 Educate staff of the existing Parkland Universal Protocol policy. Suzanne Sims 2.5 8/31/2012 Y

15.10 Develop Time Out procedure “flash cards” to be used as a help guide. Suzanne Sims 2.5 8/31/2012 Y15.11 Conduct an audit on Time Out on all invasive procedures. Suzanne Sims 2.5 8/31/2012 Y

15.12Provide mandatory education on proper site marking to all new and existing physicians. Provide education to staff nurses and techs to ensure they understand the proper site marking requirement based on NPSG. Suzanne Sims 2.5 9/28/2012 Y

15.13 Review Parkland's policy PS 04-43 regarding sponge and sharp counts. Suzanne Sims 2.5 8/31/2012 Y

15.14Surgical Services to provide an educational session on the proper procedure of conducting sponge and needle/sharp counts. Develop and implement an annual competency on proper procedure on performing counts.


15.15Develop and implement a dashboard key measure all the required elements on correct counts to include instruments and sponges.


15.16 Review Parkland policy Admin 6-33 and PS 04-33 on proper handling of medications. Suzanne Sims 2.5 3/30/2012 Y15.17 Develop unit specific medication management competencies. Emilie Allen 4.4 4/20/2012 Y15.18 Initiate an awareness program verifying the medication they transfer on and off the sterile field. Suzanne Sims 2.5 4/27/2012 Y

15.19Conduct audit to assure needles and syringes are being stored in a safe and proper place and incorporate into daily environmental rounds.


15.20 Audit proper transfer and verifying of medications on/off sterile field. Suzanne Sims 2.5 8/31/2012 Y15.21 Add medication management to the key measures to department quality dashboard. Suzanne Sims 2.5 8/31/2012 Y15.22 Establish action plan for non-compliance. Suzanne Sims 2.5 6/30/2012 Y

15.23 Enter the procedural nurse hand off communication to the recovery nurse into Epic. Barbara MimsValerie Harvey

4.2 9/30/2012 Y

Procedural Services - Catherization Lab/Endoscopy (Section 2.15)


38

Procedural Services - Catherization Lab/Endoscopy (Section 2.15)

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Compliance percentage to Infection Prevention practice 1 Surgery 100.0% 100.0% 97.0% 98.9% 98.6% 92.5% 85.7%2 Compliance percentage of environment of care by audit, monthly 1 Surgery 100.0% 99.5% 95.3% 97.1% 97.9% 98.3% 98.8%3 Compliance to site marking procedure in cath lab by audit 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 99.3% 100.0%4 Compliance to Time Out procedure by audit 1 Surgery 100.0% 100.0% 98.8% 100.0% 100.0% 100.0% 100.0%5 Compliance to sponge, needle, sharp and instrument count in cath lab 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0%

6Compliance to medication management measures (labeling, transferring from the circulator to scrub, securing and other measures) by audit 1

Surgery 100.0% 100.0% 97.6% 92.0% 88.0% 78.0% 89.0%

7 Compliance to using two patient identifiers by audit 1 Surgery 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 98.3%8 Compliance to proper scrub attire and sterile gowning in restricted areas in cath lab by audit 1 Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 87.5% 100.0%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-129 Number of wrong site surgeries 2 Surgery 0 0 0 0 010 Number of incorrect consents 2 Surgery 2 0 1 2 211 Number of medication errors 1 Surgery 0 1 1 1 0 0 112 Number of lab specimen mis-labeling 2 Surgery 4 1 3 0 013 Number of return to surgery for retained objects 2 Surgery 0 0 1 0 0

Audits # 1 and 6 - Poor compliance noted in Gastrointestinal (GI) Lab. Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


39



16.01 Perform demand to capacity, throughput process workflow assessment and labor productivity analysis. Scott Cummins 2.2 7/13/2012 Y16.02 Define the current backlog of appointment needs and additional capacity to meet backlog. Scott Cummins 2.2 3/23/2012 Y16.03 Provide assessment of rate limiting factors contributing to the backlog. Scott Cummins 2.2 4/6/2012 Y16.04 Develop a current state process workflow diagram. Scott Cummins 2.2 5/4/2012 Y16.05 Develop future process work flow state. Scott Cummins 2.2 5/4/2012 Y16.06 Conduct a labor productivity benchmarking. Scott Cummins 2.2 4/20/2012 Y16.07 Pilot future state process work flow model. Scott Cummins 2.2 7/13/2012 Y16.08 Provide training. Scott Cummins 2.2 7/13/2012 Y

16.09 Implement the new process flow department wide Scott Cummins 2.2 7/13/2012 Y

16.10Review of the existing Parkland "time out" policy to ensure clarification of required process and/or revise as appropriate. Suzanne Sims 2.5 6/1/2012 Y

16.11Provide Time Out procedure “flash cards” to be used as a help guide until newly learned behavior has been established and is codified. Suzanne Sims 2.5 8/31/2012 Y

16.12 Establish Time Out procedure as a one of the competencies of personnel. Emilie Allen 4.4 5/11/2012 Y16.13 Execute progressive counseling/disciplinary action plan for infractions. Scott Cummins 2.2 6/8/2012 Y

16.14a Development of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI - Radiology Jackie Sullivan 6.4 9/30/2012 Y

16.14bDevelopment of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI - Hospital-Wide Jackie Sullivan 6.4 9/30/2012 Y

16.15 Ensure needles and syringes are secured in an area that is not accessible to unauthorized persons. Scott Cummins 2.2 7/13/2012 Y16.16 Review Parkland policy on medications on and off the sterile field. Suzanne Sims 2.4 8/31/2012 Y16.17 Review Parkland policy on labeling medications on and off the sterile field. Suzanne Sims 2.4 8/31/2012 Y

16.18Develop and review the smart order sets that have foley insertions to determine whether Lidocaine jelly should be added.

Judy HerringtonVicki Crane 4.5 7/13/2012 Y

16.19 Review Parkland policy on properly securing medications. Judy HerringtonVicki Crane 4.5 3/23/2012 Y

16.20 Develop an annual department-specific medication competency on all staff Emilie Allen 4.4 6/8/2012 Y

16.21Assign role and responsibilities to ensure all tasks including the disposal of opened and unused supplies to Interventional Radiology (IR) tech. Scott Cummins 2.2 5/11/2012 Y

16.22 Distribute Parkland Policy G-1 on radiation safety. Scott Cummins 2.2 4/6/2012

16.23 Develop annual unit specific competency on radiation safety competency for all staff, physicians and vendors. Scott Cummins 2.2 6/29/2012

16.24Audit the Main and ASC Operating Room staff and providers proper wear of personal protective attire during a procedure when operating the mini-fluoroscopy and other radiation safety requirements. Scott Cummins 2.2 9/14/2012 Y

16.25 Initiate the education plan for the physicians requiring the need to meet the credentialing criteria. Patricia Bergen, MD 5.1 5/4/2012 Y

Radiology (Section 2.16)


40




16.26 Collate all credentialing documents and provide to the committee for review and approval. Patricia Bergen, MD 5.1 5/11/2012 Y

16.27Ensure a person who is approved to operate the mini-fluoroscopy unit is in procedures where the surgeon has not been granted privileges. Scott Cummins 2.2 6/8/2012 Y

16.28 Develop an interface or investigate on how to tie in an alert of physician’s privileges at point of scheduling a procedure. Scott Cummins 2.2 6/8/2012 Y

16.29Inquire and implement a functionality in Epic for the ordering physician to cognitively select whether to use the establish protocol or use orders as written. Scott Cummins 2.2 9/14/2012 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Compliance to use of two patient identifiers 1 Radiology 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%2 Compliance to the Time Out procedure 1 Radiology 100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%3 Compliance to proper securing of medications and medication supplies (needles, syringes) 1 Radiology 100% 96.0% 96.5% 100.0% 100.0% 100.0% 100.0%4 Compliance to medication management (labeling, scrub and circulator exchange) 1 Radiology 100% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0%


41


# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12Mammography - Diagnostic

5 Labor productivity - Mammography - Diagnostic (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.56 Number of days to third next available appointment - Mammography - Diagnostic 1 Radiology 95 14 87 4 9 30 13 77 Current utilization of slots - Mammography - Diagnostic 1 Radiology 130% 125% 141% 190% 189% 103% 108% 131%8 No show rate - Mammography - Diagnostic 1 Radiology 19% 18% 18% 15% 14% 17% 13% 20%

MRI9 Labor productivity - MRI (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 1.9 1.9 2.2 2.2 2.3 2.4 2.4 2.5

10 Number of days to third next available appointment - MRI 1 Radiology 64 14 7 11 8 12 20 1211 Current utilization of slots - MRI 1 Radiology 115% 130% 118% 123% 111% 113% 108% 112%12 No show rate - MRI 1 Radiology 28% 27% 23% 20% 21% 18% 19% 19%

CT13 Labor productivity - CT (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 0.7 0.7 0.7 0.7 0.6 0.6 0.7 0.714 Number of days to third next available appointment - CT 1 Radiology 12 14 4 1 1 1 1 115 Current utilization of slots - CT 1 Radiology 117% 120% 118% 120% 110% 107% 104% 108%16 No show rate - CT 1 Radiology 11% 10% 9% 8% 8% 8% 8% 9%

US17 Labor productivity - US (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 0.8 0.8 0.9 0.9 1.0 0.9 0.8 1.018 Number of days to third next available appointment - US 1 Radiology 15 14 9 1 2 1 2 119 Current utilization of slots - US 1 Radiology 118% 120% 119% 115% 101% 102% 103% 103%20 No show rate - US 1 Radiology 18% 17% 15% 12% 11% 12% 11% 13%

IR21 Labor productivity - IR (Paid Hours/Unit of Service) (1 month lag) 1 Radiology 1.2 1.2 1.4 1.3 2.1 1.5 1.9 1.422 Number of days to third next available appointment - IR 1 Radiology 26 14 15 12 13 11 13 1523 Current utilization of slots - IR 1 Radiology 116% 120% 96% 117% 113% 104% 105% 94%24 No show rate - IR 1 Radiology 17% 16% 9% 13% 14% 17% 15% 12%

Overall25 Number of Incorrect consents 2 Radiology 0 0 0 0 0 2 026 Number of incorrect tests or wrong results placed 2 Radiology 0 0 1 0 0 2 327 Number of cancelled surgeries due to unavailable films 2 Radiology 0 0 0 0 0 028 Number of medication errors 1 Radiology 0 1 0 0 0 1 429 Number of lab specimen mis-labeling 2 Radiology 0 3 2 0 1 1 030 Number of wrong site exams 2 Radiology 0 0 0 2 1 1


42


16.22 - 16.23 - Training has still not been taken by all required medical staff Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


43


17.01 Develop education plan for phlebotomy staff including new orientees. Debbie Perrault 2.2 3/30/2012 Y17.02 Conduct random audits of phlebotomy carts. Debbie Perrault 2.2 5/11/2012 Y

17.03 Ensure there is a regular cleaning schedule with EVS for the affected Laboratory areas.Kim McCloudLinda Licata


17.04 Establish environment of care rounds with EVS and Infection control leaders.Kim McCloudLinda Licata


17.05 Initiate department-level Infection Control accountability and metrics.Kim McCloudLinda Licata


17.06 Educate laboratory staff on expected cleaning standards and schedules. Debbie Perrault 2.2 4/13/2012 Y

17.07 Define with EVS an escalation process for cleaning.Kim McCloudLinda Licata


17.08 Utilize reagent that requires validation of results prior to testing. Debbie Perrault 2.2 3/23/2012 Y

17.09 Lab Director will develop an education plan and competency to ensure all current employees and new hires understand the confirmation process prior to individual patient reporting.

Debbie Perrault 2.2 6/8/2012 Y

17.10 Listen to periodic transcription tapes to ensure transcriptionist is reporting variances. Debbie Perrault 2.2 5/25/2012 Y17.11 Review Parkland reporting critical value policy. Debbie Perrault 2.2 4/13/2012 Y17.12 Develop and implement an education plan and competencies on critical value reporting. Debbie Perrault 2.2 4/13/2012 Y

17.13 Monitor the effectiveness of the education program with the turnaround time of the critical value reporting. Debbie Perrault 2.2 7/31/2012 Y

17.14 Review Parkland policy Admin 6-30 Universal Protocol. Suzanne Sims 2.5 8/31/2012 Y17.15 Conduct five weekly random Time Out observations in the FNA clinic. Debbie Perrault 2.2 6/8/2012 Y17.16 Collect Time Out observation results and add to clinic QAPI indicators. Debbie Perrault 2.2 5/11/2012 Y

17.17 Retrain current staff to ensure awareness of the availability of the ALVIN video translator or the language line for patients that require a certified translator. Debbie Perrault 2.2 6/8/2012 Y

17.18 Provide Medical Assistant staffing for FNA clinic. Debbie Perrault 2.2 6/8/2012 Y

Laboratory Services (Section 2.17)


44

Laboratory Services (Section 2.17)


17.19 Meet with MIO and an Epic representative to enhance Epic documentation to “hardwire” autopsy documentation requirements.

Debbie Perrault 2.2 4/27/2012 Y

17.20 Add autopsy documentation requirements to dictation template, including pathology checklist. Debbie Perrault 2.2 6/8/2012 Y

17.21 Educate morgue staff on required two identifier process and their empowerment to stop the autopsy without proper consent. Emilie Allen 4.4 4/6/2012 Y

17.22 Perform audit of autopsy records for evidence of family communication, pathology notification by nursing, consent, and any other required elements. Debbie Perrault 2.2 6/8/2012 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Compliance to accession and grossing the specimen by audit 1 Lab 100% 100% 100% 100% N/A N/A 100%2 Compliance to the use of the two patient identifiers with transcription post specimen processing by audit 1 Lab 100% 100% 100% 100% N/A N/A 100%3 Compliance to autopsies having formal orders 1 Lab 100% 100% 100% 50% 100% 100% 100%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-124 Number of incorrect reporting of lab/pathology results 2 Lab 0 9 6 1 5 55 Percent compliance to 60 minute critical value turnaround time 1 Lab 98.0% 99.0% 99.0% 99.0% 98.0% 99.0% 98.0%6 Number of patient safety events relating to non-compliance in critical value reporting 2 Lab 2 1 0 0 0 0



Comments


45


Target Date


18.01 Change procedure to ensure all unused trays are collected after meals. Usha Kollipara 2.2 5/30/2012 Y

18.02 Educate nursing staff to communicate with F&NS to re-order or hold a tray if a patient is not available for a meal.Kim McCloudLinda Licata


18.03 Acquire thermometers for freezers. Usha Kollipara 2.2 4/4/2012 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Compliance with all nutrition services equipment and food temperatures 1 FNS 100% 100% 100% 100% 100% 100% 100%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-122 Percentage of units surveyed which do not reheat food trays FNS 95% 95%

Metric # 2 - Out of the 21 units surveyed, one nurse responded "yes," to reheating trays on his/her unit. Feedback was given immediately. Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Food & Nutrition Services (Section 2.18)

Comments


46



19.01 Develop a process to ensure Organ Procurement quality improvement functions are reported to QCC regularly. Jackie Sullivan 6.4 9/14/2012 Y

19.02 Develop documentation for annual training program attendance. Emilie Allen 4.4 9/14/2012 Y


Organ and Tissue (Section 2.19)

Comments


47


Target Date


20.01 Conduct an assessment of the factors contributing to the backlog to include: demand vs. capacity, current space and labor productivity.

Jenni Burnes 2.2 4/20/2012 Y

20.02 Upon completing elements of the assessment, develop an overall “current state” process work flow diagram noting process failures and operational barriers.


20.03 Analyze current staffing patterns and address shortages. Jenni Burnes 2.2 5/4/2012 Y20.04 Redesign future process flows to address identified barriers. Jenni Burnes 2.2 6/29/2012 Y20.05 Complete pilot of revised process flow to assess effectiveness and any additional needed changes. Jenni Burnes 2.2 6/29/2012 Y

20.06 Develop targeted improvement levels: for backlog, patient and physician communication, productivity, etc. to assess impact of changes. A consistent tool to assess effectiveness is needed to ensure consistency in assessing progress. Jenni Burnes 2.2 6/29/2012 Y

20.07 Identify core requirements for assessment and documentation for proper patient care and educate staff. (Nursing) Barbara Mims 4.2 8/1/2012 Y

20.07 Identify core requirements for assessment and documentation for proper patient care and educate staff. (PMR) Jenni Burnes 2.2 8/1/2012 Y

20.08 Develop a methodology to ensure all elements of care have been addressed and assessed. Jenni Burnes 2.2 6/8/2012 Y

20.09 Establish key metrics for inpatient rehab. Barbara MimsValerie Harvey

4.2 5/25/2012 Y

20.10 Develop methodology to track required metrics are being reported. Jenni Burnes 2.2 9/14/2012 Y20.11 Determine legal requirements for DME license. Jody Springer 1.2 4/13/2012 Y20.12 Determine methodology dispensing DME (hospital vs. contract supplier). Jenni Burnes 1.2 4/20/2012 Y

20.13 Develop and implement Infection Prevention training. Kim McCloudLinda Licata


20.14 Non–compliance with proper infection control procedures should be addressed immediately and ongoing non-compliance should result in progressive disciplinary action.


20.15 Develop methodology to track wound care infection rates. Jenni Burnes 2.2 5/4/2012 Y

Physical Medicine and Rehabilitation (PMR) (Section 2.20)


48

Physical Medicine and Rehabilitation (PMR) (Section 2.20)

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Percent of all elements of care that have been assessed and addressed 1 PMR 94.0% 95.0% 96.2% 93.0% 92.0% 96.0%2 Compliance to Environment of Care 1 PMR 100% 96.5% 98.2% 98.0% 99.7% 99.4%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-123 Total Orders in Backlog (as of 7th of current month) 1 PMR 4484 Backlogged Orders that are Physical Therapy Class Referrals 1 PMR 2025 Backlogged Orders that are Pending Patient Follow-Up 1 PMR 1856 Backlogged Orders that are Pending Authorizations from Financial Counseling 1 PFS 507 Backlogged Orders that are Pending Triage 1 PMR 118 Total Cancelled Orders (> 60 days or followed up with patients over 2 times without a call back) 1 PMR 213

Occupational Therapy (OT)9 No show rate - OT 1 PMR 15.2% 10.0% 12.0% 14.5% 16.9% 13.9% 16.1% 19.3%

10 Total Orders (OT) 1 PMR 413 415 429 348 484 371 37311 Vacancy rate - OT 1 PMR 31.0% 21.0% 21.0% 14.0% 14.0%12 Labor productivity (percentage of targeted appointments per FTE) - OT 1 PMR 87.5% 100.0% 80.5% 97.2% 73.8% 101.8% 90.3% 95.1%

Physical Therapy (PT)13 No show rate - PT 1 PMR 15.6% 10.0% 15.1% 15.9% 15.4% 17.0% 16.7% 22.9%14 Total Orders (PT) 1 PMR 1214 1253 1363 1212 1316 1123 102615 Vacancy rate - PT 1 PMR 4.3% 4.3% 15.0% 12.0% 8.0%16 Labor productivity (percentage of targeted appointments per FTE) - PT 1 PMR 61.1% 100.0% 72.2% 80.1% 68.4% 81.9% 80.7% 72.2%

Speech Therapy (ST)17 No show rate - ST 1 PMR 13.8% 10.0% 11.0% 5.9% 14.9% 13.8% 10.7% 18.2%18 Total Orders (ST) 1 PMR 98 116 119 90 88 80 7719 Vacancy Rate - ST 1 PMR 10.0% 2.0% 0.0% 0.0% 0.0%20 Labor productivity (percentage of targeted appointments per FTE) - ST 1 PMR 71.9% 100.0% 102.7% 122.3% 81.5% 98.5% 86.2% 78.5%



Comments


49


Target Date


21.01 Analyze staffing levels and provided recommendations. Edward Best 2.2 4/13/2012 Y21.02 Adjust staffing and/or shifts to agreed upon staffing grid. Edward Best 2.2 5/11/2012 Y21.03 Develop targeted improvement in missed treatments and a timeline for expected improvements. Edward Best 2.2 3/22/2013 Y21.04 Explore the ability to analyze missed treatments per shift through Epic. Edward Best 2.2 4/13/2012 Y

21.05 Determine a mechanism to track “assigned, completed, and missed” by therapist through a daily shift report document. Edward Best 2.2 6/8/2012 Y

21.06 Documentation educational program for all Respiratory Therapy (RT) staff. Edward Best 2.2 6/8/2012 Y21.07 Initiate documentation review process to ensure patient quality of care. Edward Best 2.2 9/14/2012 Y21.08 Initiate patient rounds to obtain feedback regarding effectiveness of respiratory treatments. Edward Best 2.2 9/14/2012 Y

21.09Review the current oxygen tank use, storage, and refilling procedure for gaps in guidance to both RT staff as well as other clinicians.


2.7 4/6/2012 Y

21.10 Meet with clinical leaders who store oxygen tanks and determine responsibilities of staff in which oxygen tanks are stored.Kim McCloudLinda Licata


21.11 Develop a house-wide education/awareness for all staff that addresses all areas of responsibility.Kim McCloudLinda Licata


21.12 Audits of oxygen tank safety.Kim McCloudLinda Licata


21.13 Long term strategy for an annual assessment of therapy care to ensure that there are no gaps in process or care. Edward Best 2.2 9/14/2012 Y

# Audit/Measures Accountability Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-121 Percentage of missed treatments related to Therapist not being available 1 RT 0% 2.6% 6.4% 2.4% 1.1% 0.2% 0.5%2 Number of missed treatments (RT self-reporting) 1 RT 1042 919 699 744 662 8103 Respiratory Care documentation accuracy 1 RT 95.0% 89.6% 94.7% 95.5% 97.0% 97.0% 98.0%4 Compliance in oxygen tank storage 1 House-wide 100% 96.0% 99.4% 99.9% 99.0% 99.7% 100.0%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-125 Productivity Metrics (Weighted Procedures/Hours Paid) 1 RT 2.74 2.65 2.93 2.64 2.88 2.80 2.90 2.646 Ventilator Associated Pneumonia Rate 1 RT 3.29% 1.8% 1.4% 3.6% 0.5% 1.0% 0.0% 1.0%



Respiratory Therapy (Section 2.21)

Comments


50



22.01 Develop medication documentation training program for all staff responsible for medication administration. Judy HerringtonVicki Crane 4.5 6/8/2012 Y

22.02 Develop and implement processes to reconcile controlled substances in Medlock clinic. Vivian Johnson 2.3 3/23/2012 Y

22.03 Develop and implement audit tool to track controlled substance reconciliation. Judy HerringtonVicki Crane 4.5 5/11/2012 Y

22.04 Implement electronic medical record (EMR)/Pharmacy interface to allow for Pharmacy to provide oversight to prescribing and administration at correctional facilities visited by the mobile clinic. Vivian Johnson 2.3 6/20/2012 Y

22.05 Review results of Medicine specialty clinic pilot and determine viability of implementation to other clinics for medication reconciliation solution.

Judy HerringtonVicki Crane 4.5 5/11/2012 Y

22.06 Formulate alternative solution to medication reconciliation issue. Judy HerringtonVicki Crane 4.5 5/11/2012 Y

22.07 Empower and educate staff on basic standards related to environment of care and the normal chain of command for addressing issues as they arise. Also include a process on issue escalation when issues are not addressed.


22.08 Create comprehensive environment of care gaps. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

22.09 Meet with the appropriate leaders responsible for environmental cleaning and maintaining the environment to discuss the gaps and develop plan for improvement.


2.7 5/11/2012 Y

22.10 Establish multi-disciplinary monitoring of clinic locations. Kim McCloudLinda Licata


22.11 Load plans of care into Jail electronic medical record (EMR). Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

Community Oriented Primary Care (COPC) (Section 2.22)


51

Community Oriented Primary Care (COPC) (Section 2.22)



22.12 Conduct training for staff on plan of care standards and proper documentation and individualized plan of care. Barbara MimsValerie Harvey 4.2 8/1/2012 Y

22.13 Conduct a chart audit to evaluate staff compliance regarding plan of care process. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

22.14 Develop a process for patients who do not have a common diagnosis and their plan of care. Barbara MimsValerie Harvey 4.2 7/20/2012 Y


1Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation 1

COPC 99.4% 100.0% 100.0% 99.0% 100.0%

2 Compliance percentage of environment of care by audit, monthly 1 COPC 94.7% 96.0% 97.0% 97.5% 97.4% 98.6%3 Compliance to the use of two patient identifiers 1 COPC 98.0% 100.0% 99.4% 100.0% 100.0%4 Compliance to infection prevention practice 1 COPC 100% 96.0% 91.9% 97.4% 93.5% 93.7%5 Compliance in medication reconciliation 1 COPC 94.0% 96.0% 97.0% 98.0% 95.0%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-126 Number of medication errors 1 COPC 0 4 1 4 1 2 37 Number of lab specimen mis-labeling by clinic 2 COPC 11 1 2 1 4 18 Third next available appointment 1 COPC 97.2 102.9 92.2 78.0 81.1 75.6 74.29 No show rate 1 COPC 17.2% 17.0% 17.0% 17.7% 17.7% 17.5% 18.1%



Comments


52



23.01 Ensure “hard-stop” process in Epic is engaged. Vivian Johnson 2.3 9/14/2012 Y

23.02 Determine EVS scope and schedule. Jessica HernandezHolt Oliver, MD 3.6 3/30/2012 Y

23.03 Clinic leadership to round clinic areas to monitor PHI security. Jessica HernandezHolt Oliver, MD 3.6 6/8/2012 Y

23.04 Clinic leadership to develop and implement disciplinary actions for staff violations of HIPAA policies. Jessica HernandezHolt Oliver, MD 3.6 5/7/2012 Y

23.05 Develop clinic-wide training and awareness program for proper time-out procedure. Suzanne Sims 2.5 10/31/2012 Y23.06 Conduct time-out training for all areas where patient procedures are performed. Suzanne Sims 2.5 10/31/2012 Y


1 Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation

OPC 98.7% 100.0% 99.0% 100.0% 97.0%

2 Compliance percentage of environment of care by audit, monthly 1 OPC 92.0% 96.3% 98.6% 98.0% 99.0% 99.0%3 Compliance to the use of two patient identifiers OPC 99.5% 99.5% 98.5% 100.0% 100.0%4 Number of completed medication reconciliations by audit - Medicine Clinics OPC 68.2% 67.3%5 Number of completed medication reconciliations by audit - Surgery Clinics OPC 23.0% 24.5%

Specialty Clinics (Section 2.23)


53


# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-126 Number of medication errors 1 0 0 8 2 3 1 07 Number of lab specimen mis-labeling by clinic 2 0 4 5 2 1 1 18 Compliance to HIPAA/privacy standards (based on EOC audit) 100.0% 92.2% 97.3% 96.8% 100.0% 96.0%

General Surgery9 No Show Rate 1 OPC 25% 30% 24%

10 Third next available appointment 1 OPC 14 128 150 12011 Average dwell time (minutes) 1 OPC 90 151 116 197

Urology 12 No Show Rate 1 OPC 25% 22% 24%13 Third next available appointment 1 OPC 14 115 63 5614 Average dwell time (minutes) 1 OPC 90 143 164 156

Surgery Oncology15 No Show Rate 1 OPC 24% 22% 24%16 Third next available appointment 1 OPC 14 94 89 7317 Average dwell time (minutes) 1 OPC 120 148 157 170

Cardiology18 No Show Rate 1 OPC 26% 24% 27%19 Third next available appointment 1 OPC 14 65 60 4920 Average dwell time (minutes) 1 OPC 120 118 123 114

GI/Liver21 No Show Rate 1 OPC 25% 21% 30%22 Third next available appointment 1 OPC 14 145 117 12123 Average dwell time (minutes) 1 OPC 120 155 148 148

Renal24 No Show Rate 1 OPC 23% 27% 26%25 Third next available appointment 1 OPC 14 67 61 5126 Average dwell time (minutes) 1 OPC 120 128 130 116


54




Comments


55



24.01 Create database of all contracted patient service arrangements.

Muthusamy Anandkumar, MD

Ciel Murphy 6.5 3/22/2013

24.02 Review department specific quality indicators for all contracts.


Ciel Murphy 6.5 6/1/2012 Y

24.03 Request quality monitors from vendors who have not supplied them.



24.04 Determine Parkland specific quality indicators for each contract.



24.05 Each department to report contract monitoring elements at the department’s next regularly scheduled reporting appointment.


Ciel Murphy 6.5 3/22/2013

24.06 Review all contracts using department specific indicator list. Each department to have a specific list of all contracts, appropriate indicators, and existence of indicators.



24.07 Contract Management Unit to provide a schedule of all contracted services affecting patient care to the BOM Quality Committee along with a template on how contracts will be scored for quality.



24.08 Contract Management Unit to provide first batch of contracts for quality score and review – and proposed scores against template – to BOM Quality Committee.



Contract Services (Section 2.24)


56

Contract Services (Section 2.24)


1 Percent of current contracts in database 1 Contracts2 Percent of current contracts that have department specific quality indicators 1 Contracts N/A N/A 89% 100% 90% 89%

# Metric Accountability Baseline Goal Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-123 Number of "significant" contracts meeting requirements for quality scoring 1 Contracts 59.0% 78.0%4 Number of "by exception" contracts meeting requirements for quality scoring 1 Contracts 88.0% 81.0%

Metrics # 3 - 4 - "Significant" contracts are regularly reviewed by QCC while" by exception" contracts may be requested to be reviewed by QCC at any time. Task/initiative largely on schedule for completionTask/initiative may be delayed from Target Date completionTask/initiative is past the Target Date deadlineInitiative tracking not yet started


Comments


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Q.01

Revise QAPI plan · Include CMS elements · Prioritize efforts and resources · Customize indicators to reflect specific patient populations in each department · Define methodology to capture and analyze data · Define formal process for reporting to Quality of Care Committee (QCC) and the BOM Quality Committee. · Identify a regular reporting schedule for each department


Q.02 Approval of QAPI plan by the QCC and BOM Quality Committee. Jackie Sullivan 6.1 5/25/2012 YQ.03 Capture and analyze baseline data from initial tracers for survey readiness. Jackie Sullivan 6.1 6/15/2012 YQ.04 Develop and implement corrective action plan for survey readiness Jackie Sullivan 6.1 6/30/2012 Y

Q.05 Performance Improvement group should implement rounding as a method to collect data for adverse patient events Jackie Sullivan 6.1 6/30/2012 Y

Q.06 Performance Improvement group to develop a list of resources from which to pull adverse patient events Jackie Sullivan 6.1 9/30/2012 Y

Q.07 Develop methodology to trend, analyze and report adverse patient events Jackie Sullivan 6.1 11/31/2012 YQ.08 Work with A&M to improve RCA process Jackie Sullivan 6.1 9/30/2012 Y

Q.09 Develop a master report of all RCAs conducted. Include incident date, date of RCA commencement, date of RCA conclusion, general results and actions taken.


Q.10 Review standing reports generated by CIS and meet with end users/management to determine relevance and meaningfulness. Discontinue generation of reporting that does not add value to end user/management. Jackie Sullivan 6.1 5/25/2012 Y

Q.11 Establish a schedule for CIS with due dates of all necessary reporting Jackie Sullivan 6.1 5/25/2012 YQ.12 Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review Jackie Sullivan 6.1 5/18/2012 YQ.13 Create survey and initial tracers to collect baseline data in the form of a Quality Assessment (QA). Jackie Sullivan 6.1 6/30/2012 YQ.14 Complete Quality Assessment survey and tracer work. Jackie Sullivan 6.1 6/30/2012 Y

Q.15 Complete department-specific Performance Improvement (PI) plan with indicators appropriate for department’s patient population. Jackie Sullivan 6.4 5/25/2012 Y

Q.16 Implement corrective actions per department’s PI plan. Jackie Sullivan 6.1 9/30/2012 Y

Q.17 Report PI plan status on at least semi-annual basis to QCC. Jackie Sullivan 6.1 5/25/2012 Y


QAPI

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10th Monthly Compliance Report on Parkland Memorial Hospital

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Transcript of 10th Monthly Compliance Report on Parkland Memorial Hospital