Parkland Memorial Hospital's Monthy Compliance Progress Report For April 2012

Report of the Independent Consultative Expert (ICE) Monthly Progress Report April, 2012 on Parkland Health & Hospital
l System
Dallas, Texas
May 10th, 2012
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
Parkland Health & Hospital System - Progress Report to CMS - April 2012
Summary of Progress in April 2012 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 April 8, 2012. Under the SIA, the ICE is required to present monthly reports to CMS on the progression and status of the CAP, including identification of problems that may jeopardize the successful implementation of the CAP and actions underway to address those problems. This report constitutes A&Ms second report on Parklands progress under the CAP. By agreement with CMS, the start date for timelines and deadlines under the CAP was set as March 19, 2012. During the month of April Parkland continued to make progress in meeting most of the deadlines set in the CAP for the month of April. Over 100 tasks in the CAP were completed within the deadline periods. Significant goals were met in the areas of: board organization and oversight; medication management oversight and review; and nursing administration re-organization. Significant efforts were also made in April by the Nursing Clinical Education Department to design content and deliver training modules for CAP initiatives requiring an education/training or competency component. A house-wide education program addressing many topics in the CAP is planned for early May and includes hands-on demonstration and testing of clinical competencies. Additional resources have been hired to lead the education and training efforts needed to support the CAP and design a sustainable and robust training platform for the organization in the future. Some of the required training has been delayed due to available resources to meet competing needs of different work streams, inability to access a training solution that tracks education for Attending physicians and the need to build/buy some training content materials. Significant work is still needed to coordinate physician education. Work was also completed in April to design audit tools to document and validate many of changes and improvements required by the CAP. Beginning in early May, audits of patient care, clinical and related activities are now being routinely conducted in many areas. Additionally significant work was done in April to identify and collect the data necessary to track the 100+ performance metrics in the Performance Report. Many of these data elements have now been collected and this Performance Report includes the first report of some of these metrics for the month of April 2012. However, CAP deadlines and objectives were not met in April, or may not be on schedule for being completed in the area of recruiting permanent leadership in the psychiatric services units, including recruiting additional psychiatric physician resources. CAP deadlines and objectives
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were not met or may not be on schedule for being met relating to revisions to the Medical Staff Ongoing Professional Practice Evaluation (OPPE) program and audit and oversight tool implementation for Resident physician oversight.
Significant Activities Completed in April 2012 The six work stream leaders (WSL) under the CAP -- Governance, Clinical Operations, Access and Throughput, Nursing, Physicians and Quality Assessment/Performance Improvement (QAPI) continued to work with their teams to meet work stream deadlines. At the end of April, the Chief Implementation Officer (CIMO) and A&M conducted an extensive debriefing with each WSL to review task-by-task, item-by-item of the CAP to determine which goals had been met, and which ones had not. Documentation was provided by each WSL to the CIMO and A&M to document that certain tasks had been accomplished. If the documentation was acceptable as reviewed by A&M, certain tasks were noted on this Performance Report as having been complete. Key activities during the month of April to implement the CAP included the following: The Parkland Board of Managers (BOM) adopted changes to its meeting structure, as was recommended by the CAP, to streamline committee meetings and functions and promote the use of most board time to CAP activities and quality of care functions. The BOM also started periodic review of outsourced vendor contracts for clinical indicators, as was recommended by the CAP. The Emergency Department continued to make progress in designing and implementing provisions in the CAP to improve throughput and patient safety The Human Resources related CAP items accelerated in April with the retention of an external consultant Mercer Consulting to assist in the redesign of several HR functions such as the performance management systems; reorganizing the Leadership and Organization Development Department; developing education materials for new HR processes and procedures; and evaluating the roles and responsibilities of HR business partners. The nursing reorganization was completed and reviewed and approved by the BOM. All but one of the new senior nursing positions has been filled. The Quality Department and Quality Committee of the BOM continued its reorganization tasks and functions. The Quality Department and BOM continued work on a comprehensive monthly Quality Dashboard incorporating significant quality indicators and metrics for BOM review.
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The Quality Committee also continued work to harmonize and institutionalize departmental level QAPI (Quality Assessment/Performance Improvement) goals and indicators.
Summary of Tasks/Milestones Met on Schedule
Tasks and milestones met in April to advance the CAP include the following: Care Management: o During the month of April, Parkland contracted with an outside case management consulting firm, Clinical Intelligence, to provide consulting services with respect to: case management, discharge planning, utilization review and management and social work assistance. This consulting firm began its work in April with a sizable on-site team. Although the timelines for implementing some of the care management CAP requirements were delayed pending the arrival of the case management consultants, the delays are within an acceptable range given that the case management consultants will be performing an even more extensive review and reorganization of Parklands case management functions than that contemplated under the CAP. A&M has reviewed the case management consultants preliminary work plan and work team and believe that they are now on course, with modified deadlines, for implementing the case management, discharge planning, utilization review and management and social work assistance changes required under the CAP. Emergency Department/Emergency Services: o The ED action plan team continued to work along the CAP schedule to redesign and implement throughput improvements to patient registration, triage, assessment, treatment and discharge. ED policies and procedures were also reviewed and revised, particularly those on safe patient hand-offs. Environment of Care: o Improvements were implemented to the processes for Environmental Services (EVS) to validate appropriateness of cleaning services performed by EVS and improvements in the cleanliness and condition of many units. Governance/Organization: o The Board of Managers (BOM) streamlined its committee structure and frequency of meetings in accordance with CAP recommendations. o BOM initiated reviews on outside vendor contracts for clinical quality indicators.
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Infection Prevention: o The IP action plan team undertook a review and revision to departmental and house-wide infection prevention policies and procedures and initiated new procedures to survey departments for IP compliance. Medication Management: o A medication override audit was initiated; the Pharmacy & Therapeutics (P&T) Committee instituted a review and analysis of: medication errors, Narcan utilization, off label usage, and medication reconciliation; institution of a medication reconciliation task force; and, drafting a new procedure and policy on moderate sedation. Nursing/Provision of Care: o Review conducted on all policies and procedures on patient restraints and documentation of restraints in EPIC, the electronic medical record (EMR system). o Reorganization of the nursing structure has been completed and key roles have been filled. Review of all nursing practice standards, policies and procedures - is actively underway. Quality/Safety: o The search for a new Chief Patient Rights and Safety Officer (CPRSO), which is a required action item under the CAP, continued with the national search firm starting to review and source appropriate candidates. o Commenced complete review of all patient rights and safety policies and procedures and procedures on patient grievances, including review of best practices; revised QAPI plan for presentation to BOM; started design of awareness campaigns on patient rights and safety and safe patient hand-offs; completed a preliminary study of 2011 patient elopements; implemented rapid cycle improvement project on use of one-to-one observers (sitters) for patients needing continuous observation. Women and Infants Specialty Health (WISH): o Initiated recruitment for key leadership positions: Hired 3 unit managers for post-partum Hired 1 director for Infant Services Posted a unit manager for 5 South Summary of Tasks/Milestones Not on Schedule
Several activities have not been completed in April in accordance with the CAP timetables. Tasks not completed in April include: 1) migration of the ownership of crash carts from Materials Resources Department to Central Sterile Departments has not been completed on schedule, but is in process; 2) implementation of 100 percent, concurrent case management
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review of all Emergency Department admissions; and, 3) expanded and consistent Attending psychiatric physician coverage in the Psychiatric Emergency Department (PED) and recruitment and placement of permanent inpatient and outpatient unit nursing and administrative leadership within the psychiatric services units. Additionally, CAP deadlines and objectives may not be met or may not be on schedule for being met on revisions to the Medical Staff Ongoing Professional Practice Evaluation (OPPE) program and to create an audit and oversight tool implementation for resident oversight. With respect to crash cart supply, maintenance and testing, since our March report, work has been done to getting this action item back on track, but it is still not complete. Additionally, although Parkland has worked in April to begin to recruit additional psychiatrists for the PED and for nurse managers to serve as directors of the inpatient and outpatient psychiatric service units, those recruitments and placements have not yet been completed. We will continue to work with the CIMO and the work stream leaders to have these issues and tasks addressed in May. Level of Engagement We continue to have been favorably impressed by the dedication that the Parkland BOM has demonstrated towards successful implementation of the CAP. The BOM has directed Parklands senior management to devote the requisite time and financial resources necessary to implement each aspect of the CAP. This direction has been evidenced by the potential hiring of additional outside consultants in the areas of human resources, case management and board governance to provide the resources necessary to effect change in those areas. We have also been favorably impressed by the preliminary work and dedication of nearly all of the work stream leaders, the action stream leaders and executive sponsors of the CAP. We are continuing to address the level of management engagement necessary to plan, institute and complete the important work of revising the Medical Staff OPPE processes and procedures and for implementing additional oversight and auditing methods for Resident physician supervision. During the month of April (and into early May), we were made aware of patient care incidents that occurred either in April or prior to April or in May, where inadequate or untimely supervision of Resident physicians may have been at issue. Additionally, allegations asserted in a recently publicized federal lawsuit against the Hospital, whether proven or not, underscore the need for Parkland to maintain vigilance and to continue to affirmatively demonstrate that all Resident physicians are being appropriately and adequately supervised by Attending physicians as required in accordance with all CMS rules and regulations and State laws and regulations. We will continue to closely monitor the CAP work stream action items related to Resident physician supervision.
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Structure of Monthly Report This Performance Report itemizes each of the Action Items (Tasks/Initiatives) from the CAP, along with the associated target date for completion. Each of these Tasks/Initiatives is then assessed in terms of completion or status towards completion with a Red, Yellow or Green dot. Under this convention Green means that a Task/Initiative is largely on schedule for completion. Yellow means that a Task/Initiative may be delayed from Target Date completion. The Yellow does not mean that the Task/Initiative will not be completed in the required time, but that redoubled efforts may be necessary to ensure timely completion. A Red dot indicates that the Task/Initiative is past the Target Date deadline. A Black dot denotes a task or initiative where tracking has not yet started. Each area of the CAP also has several associated metrics to demonstrate whether the required Task/Initiative has been successful in reaching its desired effect and has been sustainable (e.g., nursing plans of care are consistently documented, or hand hygiene audits have consistent positive scores.) While this April report begins to include several of the metric measurements, because a large part of the initial work under the CAP includes the creation of audit tools to validate successful implementation of several of the associated tasks not all metric reporting elements are currently ongoing and therefore represented in this report.
Next 30 Days As the report notes on specific task items, we are concerned that some tasks and milestones may not be on schedule for timely completion under the CAP. Some of these delays have resulted from the need to acquire outside consulting assistance on some of the action plan items. Redoubled efforts and focus will be required in the month of May to ensure that these items are completed under the timetables required by the CAP. These include tasks in the following areas: Human Resources: Timelines for much of the HR strategic initiatives may be necessarily delayed due to time necessary to contract with outside consulting firm to assist in HR efforts under the CAP. A HR consultant has been engaged and is working to bring up to date many of the HR initiatives under the CAP. A&M was part of the process to select the HR consultant and believe that the selected firm has the qualifications to assist Parkland in addressing all of the HR related CAP items. Medical Staff: CAP deadlines in the following work areas may not be met as required under the CAP: Implementation of expanded Ongoing Professional Practice Evaluation (OPPE) for all medical staff members; and, review of and implementation of new and improved auditing mechanisms for Resident physician oversight; and implementation of new and improved
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technology platform to document Resident physician competencies. A&M is providing additional resources to assist Parkland in completing these initiatives. Training & Education: Changes to nursing competencies, tracking of competencies and new competency training procedures may be delayed due to the need to implement a new information technology platform to track these competencies. The Education and Training Support Work Stream will be working with Medical Staff Office of UT Southwestern Medical Center to determine if there are common platforms of training that can be provided to Attending physicians on the Parkland Medical Staff who require Parkland training and education. Care Management: Implementation of reorganization/restructuring of Care Management Department and related services (case management, discharge planning, social worker services, utilization management / review) has been delayed, given time necessary to contract with outside consulting firm to assist with reorganization. However, a consultant team has been engaged and has started work on all of the care management related action items in the CAP. Additionally, Parkland has decided to expand the role and scope of the case management consulting team beyond the required corrective action steps in the CAP. Patient Safety: Parkland has retained a prominent national recruiting firm that is actively underway with identifying and sourcing candidates for the - Chief Patient Rights & Safety Officer position. The recruiting firm hopes to present candidate profiles for the position to Parkland by June. In advance of the recruitment of the CPRSO, A&M will continue to work with the Patient Safety action stream leader to ensure that patient safety policy and procedure and organization components required under the CAP continue to advance. Psychiatric Services: Delays may continue to occur with completing a plan for obtaining and guaranteeing consistent psychiatric physician coverage in Psychiatric Emergency Department (PED); and, recruitment of permanent nurse managers for the Psychiatric Emergency Department and inpatient Psychiatric Unit. Consistent leadership has been and still is the missing key element for this service. WISH (Women Infants and Specialty Health): A significant amount of work may continue to be required to create a longer term plan to address several dated standards of practice and to implement more contemporary care model, and completion of that work may fall outside of the current CAP timetable. A short consulting engagement should provide some further direction during the month of May. Barriers We did not encounter major barriers to implementing the CAP in the month of April. However, we believe that we may continue encounter barriers in the following areas that might result in delays to timely completion of CAP tasks and initiatives:
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Need to acquire new technology and information systems to house and support: Acuitybased Staffing Models; Training and education; and Competency tracking. Time availability from practicing physicians on the Medical Staff to lead and/or participate in CAP initiatives as currently designed and assigned. Need to develop and expand training and education platforms for content development and delivery to employees and staff. Process and timelines to engage outside consultants and subject matter experts to assist in CAP implementation. Bandwidth and implementation resources to continue at the pace and rigor.
Additionally, we need to refocus and intensify the work efforts to evaluate the current OPPE processes and procedures for the Medical Staff and plan for and implement necessary changes and improvements to the OPPE process so that Parklands OPPE is in full compliance with CMS standards and standards of The Joint Commission. And, given additional events and legal proceedings highlighting the issue of Resident physician supervision, efforts must continue to be focused to initiate and complete all elements of the CAP related to Resident supervision. Finally, although several positive changes have been made in Emergency Department operations and oversight, continued focus needs to be paid hospital-wide to ensure that ALL hospital employees, and not only Emergency Department workers, fully understand the obligations that the Hospital has to all individuals seeking emergency medical services or treatment, not only to provide such care but to advise and counsel all such individuals on their right to obtain such emergency screening, examination and if necessary treatment and care. We will work with the Emergency Department leaders as well as senior hospital leaders to ensure that such education, training and messaging extends to ALL Hospital employees, and especially all employees who may have reason to encounter an individual seeking emergency medical services or treatment. We will continue to work with the executive sponsors and the Parkland BOM to anticipate these potential barriers and find ways in which to address and eliminate these and other barriers as they may arise. Summary We believe that Parkland has continued to make measurable progress in April to implement CAP action items in accordance with the established deadlines. We will continue to emphasize to Parkland management and the WSL the need to redouble efforts to meet deadlines and complete actions particularly noted above related to the areas of: employee and clinician training and education, staffing for psychiatric services, and completion of revisions to OPPE and Resident physician supervision processes.
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Parkland CMS Progress Reports
Governance (Section 2.01) # 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Tasks/Initiatives Accountability Work Stream 5.1 5.3 5.3 6.4 6.4 1.1 1.5 1.2 3.5 1.1 Target Date 10/31/2012 5/18/2012 5/18/2012 5/25/2012 6/1/2012 6/8/2012 6/8/2012 6/8/2012 7/13/2012 7/13/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
MEC to prepare a comprehensive plan to implement Ongoing Professional Performance Evaluation (OPPE). Review 5% Patricia Bergen, of Medical Staff OPPE Profiles at conclusion of next eight-month cycle. MD Brad Marple, 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. MD Hospital senior management, in collaboration UTSW and A&M to create a standing rounding, evaluation and auditing Brad Marple, process to collect data on Resident oversight. MD Require quality dashboard report from Hospital Quality Department Jackie Sullivan Commence reviews of scorecards for significant outsourced and contracted clinical services. Design a Board-specific Jackie Sullivan QAPI plan. Review and revise BOM committees. Paul Leslie Review performance management and progressive discipline implementation plan from Human Resources. John Dragovits
Review comprehensive plan to create better communication and coordination among the Hospitals Legal, Compliance, Jody Springer Internal Audit and Quality Departments. Review Hospital plan on continuum of care. Appoint 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 Audit/Measures Perecentage of contracts (outsourced vendors) reviewed for quality measures Dr. Royer Jackie Stephens Paul Leslie
# 1
Accountability
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Comments 1.01, 1.02, 1.03 - Initiatives related to OPPE and resident oversight are not progressing at pace required to meet deadlines. 1.07 - Performance management and progressive discipline initiatives dependent upon completion of consulting report. 1.10 - External resources only recently added to the Task force for reviewing the Disaster Plan; time will need to be made up to meet 7/13 deadline.
Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
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Human Resources (Section 2.02) # 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 Tasks/Initiatives Redesign progressive disciplinary policies and procedures and performance management system. Redraft goals of the Leadership and Organization Development Department. Develop education materials for new processes and policies. Conduct training for management and employees. Expand the role of Business Partner, require they take a more active role with front-line managers and supervisors. Business partners to audit evaluations for the next two evaluation cycles. Evaluate current HR staffing model. Analyze resource allocation within HR Department. Develop Parkland employee retention strategy. Develop policies, procedures and training material regarding employee retention strategy. Accountability John Dragovits Jody Springer John Dragovits John Dragovits Jody Springer John Dragovits Jody Springer Jody Springer John Dragovits John Dragovits Work Stream 1.5 1.2 1.5 1.5 1.2 1.5 1.2 1.2 1.8 1.8 1.6 1.6 1.6 1.6 1.6 1.5 1.5 Target Date 5/25/2012 5/25/2012 5/25/2012 7/13/2012 5/25/2012 9/14/2012 7/13/2012 7/13/2012 9/14/2012 9/14/2012 9/14/2012 7/13/2012 9/14/2012 6/4/2012 7/13/2012 4/6/2012 4/27/2012 Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
Develop master list of all competencies required for each department by job code. Jim Johnson Review and revise LMS system to ensure all required competencies are reflective in the system. Jim Johnson Review all personnel files for completeness. Jim Johnson Educate employees on proper and complete paper work. Jim Johnson Ensure accurate and complete paper work is immediately forwarded to Nursing Administration. Jim Johnson Form standing committee to review polices and procedures with representation from administrative, clinical, and support John Dragovits areas Develop policies and processes to be used for HR policy review. John Dragovits Linda Wilkerson John Dragovits
Frame desired culture as the foundation for all HR related elements of the Action Plan
1.4
7/13/2012
# 1 2 3 4 5 6
Audit/Measures Percentage of supervisors (and above) who have attending training Evaluation scores on bell curve for each department (annual evaluations) Percentage of competencies/job descriptions completed Percentage of personnel files audited Percentage of licensing validations presented prior to the day of hire Time from occurrence to corrective action signed by employee
Accountability
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
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Human Resources (Section 2.02) CYE 2012 Goal
# 1
Metric Turnover Rate by category (%) Nursing Total First year turnover rate Percentage of employees (annually) who leave for stated reasons of better opportunity (compensation, job duties, benefits) Employee satisfaction scores Percentage of competencies updated on/before due date Percentage of performance improvement (corrective action) plans by job class Percentage of current licensure Percentage reduction in absenteeism/tardiness rate
Accountability Baseline
Current
2 3 4 5 6 7 8
9.19% 8.33% 16.86% 34.31%
100% 1
Comments
Most initiatives dependent upon the deliverables from consulting engagement. Consultant has been selected and will assist in making progress. Although original deadlines may not be met, good progress is being made to provide a thorough and long term solution.
1
Unverified by A&M
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Access/Throughput (Section 2.03) # Tasks/Initiatives Review 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 Accountability Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Lonnie Roy Dr. Royer Jackie Stephens Work Stream 3.6 Target Date 6/8/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
3.01
3.02
Conduct analysis of no show rates by clinic, day, session, and provider.
3.6
5/15/2012
3.03
Conduct a physician productivity analysis based upon a review of current process and development of analytics.
3.6
5/15/2012
3.04
Document current process workflow diagrams, identify barriers to throughput and develop solutions that might increase productivity and result in additional capacity Review ED utilization and most common diagnoses by patient admission times to analyze opportunities for changes or improvements in COPC hours of operation Develop the post-acute care network. Case 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.
3.6
7/13/2012
3.05 3.06
3.1 3.5
7/13/2012 7/13/2012
3.07
3.08
3.09
Robin Stults w/ External Resources Robin Stults w/ Chief Medical Officer to meet with the Medicine and Critical Care Service Chiefs and Hospital Directors to determine External barriers to earlier discharge of patients on the units and develop a solution. Resources Jessica Hernandez Conduct a physician productivity analysis based on agreed upon industry standards. Holt Oliver, MD Conduct a feasibility study for a dedicated observation unit Conduct a feasibility study to determine the best use of 4SS space Conduct a study to determine appropriate expansion of the dialysis unit. Design Bed Czar concept to report to ADT Establish strict standards regarding communication and patient placement timelines with ADT to enhance patient placement. Increase the capacity of care of Hemodialysis Patients, end inefficient use of ESD treatment space to house them, and improve patient hospital throughput. Facilitate dialysis in the morning for patients arriving in the ESD after 11 PM John Dragovits John Dragovits John Dragovits Miriam Gomez Miriam Gomez Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims
3.4
5/11/2012
3.4
7/13/2012
3.6
5/11/2012
3.10 3.11 3.12 3.13 3.14 3.15 3.16
1.7 1.7 1.7 3.3 3.3 2.6 2.6
7/13/2012 7/13/2012 7/13/2012 6/8/2012 8/1/2012 8/31/2012 8/31/2012
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Access/Throughput (Section 2.03) # 1 2 3 4 Audit/Measures Projections for percentage (or appointments/hours) of capacity to be gained through physician productivity and/or improved throughput efficiency Number of additional appointments to be gained by factoring in 'no show' by clinic session Percentage of observation patients outside of observation unit Number of community resources that have been identified, and of those identified, number receptive to being postdischarge care source for Parkland. Accountability Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
# 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Metric Number of days to next third available appointment (primary care, geriatric, pediatrics, medicine and surgical specialties) Utilization rates by session by clinic (hours of activity/hours of capacity) Hours of "dead bed" time (hours cleaned beds go unfilled) Percentage of discharges (medicine, surgery) by 11:00 a.m. No show rates (primary care, geriatric, pediatrics, medicine & surgery specialities) Physician (clinic, Hospitalists) productivity (based upon RVUs) to MGMA benchmarks Time from decision to admit to bed assignment Number of patients on wait list for clinics Number of bed days occupied by observation status (by unit) Average, min and max bed turn times (by unit) Average number of dialysis patients in ED at start of morning shift Average Length of Stay by service (benchmark to UHC) Percent inpatient occupancy (census) by division Average time from bed assigned to patient in bed (by unit)
Current
CYE 2012 Goal
Care Mgmnt
6.2%
COPC Care Mgmnt EVS ED Care Mgmnt ADT
5.0
21,922 1,928 1:13 10.98 5.1 84.49%
1:00
Comments 3.07- Dependent upon work plan developed by external consultant. 3.10-3.12 - More comprehensive and detailed approach has been undertaken to evaluate bed capacity, utilization and projected requirements which will result in slightly delayed, but better outcome in product.
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Provision of Care (POC) (Section 2.04) # 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Tasks/Initiatives Define nursing supervisor role expectations and competencies. Revise job description to meet role expectations. Meet with HR leadership to determine most appropriate and fair way to move forward in establishing a broader more accountable house supervisor role. Meet with existing nursing supervisors and explain new responsibilities and go forward plan. Initiate new role expectations. Conduct a comprehensive review of the nursing structure under the direction of the new CNO. Develop internal and external recruitment plan for new organizational structure. Written Timeline conversion to new organizational structure. Accountability Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish John Wood Mary Eagen Jackie Brock John Raish John Wood Mary Eagen Jackie Brock John Raish John Wood Mary Eagen Work Stream 4.3 4.3 4.3 4.1 4.3 4.1 4.3 4.1 4.2 4.2 4.2 4.4 4.3 4.3 Target Date 4/20/2012 4/27/2012 4/27/2012 5/4/2012 9/14/2012 5/11/2012 5/11/2012 4/13/2012 7/13/2012 6/8/2012 8/1/2012 8/1/2012 9/14/2012 10/5/2012 Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y Y Y
Review of all nursing practice standards, policies, and procedures for compliance and relevance. Upon review of nursing Barbara Mims standards, policies and procedures, a list of gaps identified must be written so there is a documented source to help drive Valerie Harvey educational plans and strategies. Barbara Mims Revise policies/procedures and nursing standards to reflect best practices, as appropriate. Valerie Harvey Barbara Mims Develop a house-wide educational plan to correct the current deficiencies in patient care. Valerie Harvey Develop nurse leadership competencies for all managers. Emilie Allen Develop a collaborative process with Human Resources to monitor and develop corrective action plans for nursing staff Jackie Brock who violate policies and procedures. John Raish The CNO should determine approach for developing an acuity assessment methodology, e.g., internal historical record Jackie Brock review, an automated tool, etc. John Raish
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Provision of Care (POC) (Section 2.04) # 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 4.33 Once selected, roll out acuity tool. Develop flexible staffing strategies, PRN pools, per diem staff, etc. Monitor core patient care ratios for trends. Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs. Establish standards of nursing practices, focusing particularly on the plan of care. Develop house-wide nursing education program. Develop a house-wide competency plan that also addresses a tracking and monitoring system. Develop tracking methodology in conjunction with Clinical Education and HR to track competencies by employee and by department. Establish standards of nursing practices, focusing particularly on the plan of care. Develop house-wide nursing education program. Create evaluation tools to measure nurse understanding of education and success of program. Initiate nursing grand rounds. Develop report out tool for grand round results. Through the QAPI Department, develop and report verbal order trends monthly to providers and nurses. Review all restraint policies. Develop and execute restraint education. Review Epic restraint documentation structure to improve the quality of documentation. Develop a mandatory education for medical staff on the required elements of performance related to restraints. Develop a strict discipline policy that leads to termination of staff who violate the Restraint policy or a patients rights Tasks/Initiatives Accountability Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jim Johnson Jim Johnson Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jackie Sullivan Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Joseph Minei, MD John Dragovits Work Stream 4.3 4.3 4.3 4.3 4.2 4.2 1.6 1.6 4.2 4.2 4.2 4.2 4.2 6.4 4.2 4.2 4.2 5.4 1.5 Target Date 3/22/2013 10/5/2012 3/22/2013 6/28/2013 5/11/2012 8/1/2012 3/22/2013 3/22/2013 5/11/2012 8/1/2012 9/14/2012 7/13/2012 10/1/2012 9/14/2012 4/20/2012 6/1/2012 3/23/2012 5/11/2012 5/25/2012 Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
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Provision of Care (POC) (Section 2.04) # 1 2 3 4 5 6 7 8 Audit/Measures Percentage of nursing leadership roles filled by qualified personnel Percentage of completed competencies for all nurses and units Percentage of utilization PRN travelers and per diem Nursing vacancy rate by unit Percentage of completion of education activities Percentage of Plan of Care documented according to policies and procedures. Percentage of sitters needs filled by centralized nurse staffing office Number and types of restraints and seclusions, and length of time (average/min/max) Accountability Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
# 1 2 3 4
Metric Labor productivity (staffing to include acuity) Staffing hours per patient day (by unit) Number of days per month nurse staffing ratios were above/below grid Reduction of verbal orders by physician Medications Procedures
Accountability
Baseline
Current
CYE 2012 Goal
7.8% 9.8%
Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
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Care Management (Section 2.05) # Tasks/Initiatives Accountability Work Stream Target Date Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
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 Jody Springer 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. Re-align goals and strategy of department to promote collaboration between Case Managers, Social Work, Utilization Review and Nursing. Robin Stults w/ External Resources Robin Stults w/ Develop nursing-wide education plan defining roles and responsibilities of case managers, social workers, and utilization External management along with the inter-relationships between the functions. Resources Robin Stults w/ Identify metrics needed on a daily basis to properly analyze cases. External Resources Robin Stults w/ Produce an Extended Stay High Cost Outlier Report to identify inpatients that could move to a post-acute care setting if External funding permitted. Resources Based on evaluation of creating discharge care sites for patients without means, enter into agreements such as leasing Dr. Royer beds in a Skilled Nursing Facility (SNF), reduced rates for Durable Medical Equipment (DME) and home oxygen, long Jackie Stephens stay hotels, etc. Robin Stults w/ Revise position expectations of the ED Case Manager . External Resources Robin Stults w/ ED Case managers should evaluate all potential admissions on whether they meet acute care criteria and assess patients External potential discharge planning needs. Resources Robin Stults w/ ED case managers should perform an initial assessment on all patients being admitted to the hospital. External Resources Create or revise policies and procedures that define screening, assessment and discharge planning process to identify Robin Stults w/ high risk patients. Educate nursing staff on proper procedure for the Discharge Planning Assessment Tool within Epic to External ensure appropriate screening and referrals. Resources Robin Stults w/ Evaluate for each Nursing Unit the best mechanisms to promote interdisciplinary communication, e.g., brief daily External huddles, rounds, EMR notations only, etc. Based on findings, pilot and implement the most effective methods. Resources Robin Stults w/ Create a screening tool for case managers to include long term stay patient, avoidable days and other areas of focus. External Resources Move Utilization Management within Care Management Department. Jody Springer
1.2
4/27/2012
5.02
3.4
4/27/2012
5.03
3.4
6/8/2012
5.04
3.4
4/27/2012
5.05
3.4
4/27/2012
5.06
3.5
7/13/2012
5.07
3.4
4/13/2012
5.08
3.4
3/23/2012
5.09
3.4
3/23/2012
5.10
3.4
4/13/2012
5.11
3.4
5/11/2012
5.12 5.13
3.4 1.2
3/23/2012 4/27/2012
5/10/2012
Care Management (Section 2.05) # 5.14 Tasks/Initiatives The 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. Accountability Work Stream 3.4 Target Date 4/27/2012 Mar-12 Mar-12 May-12 Jun-12 Jul-12 Aug-12 Completion
5.15
5.16
5.17
5.18
5.19
5.20
5.21
5.22
Robin Stults w/ External Resources Robin Stults w/ Policies and Procedures should be revised to reflect the revised plan, and associated roles and responsibilities of staff. External Resources Robin Stults w/ Revise the current UR logs to ensure that all required elements are collected and formatted in order to analyze and trend External type data. Resources Robin Stults w/ Develop process to export Case Management Care Web documentation whereby the data are analyzed and trended. External Resources Robin Stults w/ Select UR metrics for tracking, monitoring, and trending. (utilize national best practices as examples for targets). External Resources Robin Stults w/ Utilize data from a comparative database that is clinically adjusted and severity adjusted to assist the Committee in External identifying areas for improvement. Resources Robin Stults w/ Analyze, trend, and summarize agreed upon data elements to the UR Committee on a regular basis. (Recommendations External for actions need to be documented and reported to the Medical Executive Committee.) Resources Robin Stults w/ Report unfavorable physician trends to the Patient Care Review Committee (PCRC). External Resources Robin Stults w/ Monitor progress on targeted metrics and re-evaluate targeted improvement goal and/or metrics being measured. External Resources Accountability
3.4
4/27/2012
3.4
4/27/2012
3.4
4/6/2012
3.4
5/11/2012
3.4
5/11/2012
3.4
5/11/2012
3.4
6/8/2012
3.4
4/13/2012
# 1 2
Audit/Measures Audit Results of Number of ED Cases Intervened by CM Prior to Admission Percentage of Case Management Intervention of 1st Day Admission.
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
# 1 2 3 4
Metric Number of Medical Necessity Denials (per Month) Number of Cases with Outlier Length of Stay (LOS) (per Month) Number of Avoidable Days (per Month) 30 day Readmission Trends (per Month)
Current
CYE 2012 Goal
5/10/2012
10
Care Management (Section 2.05) Comments Although many initiatives are indicated RED, as missed deadlines, they have been delayed due to the need to identify an external resource to evaluate the entire case management function. The consultant engagement is underway. A&M will meet with the vendor regularly to establish revisions to original deadlines and monitor progress to plan. There is a good solid plan in place for a long-term and sustainable solution
5/10/2012
11
Environment of Care (EOC) (Section 2.06) # 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 Tasks/Initiatives Coordinate a multi-disciplinary team to represent the EVS department that is impacted by turnaround of beds; Nursing, ADT, EVS, ESD, House Supervision, Administration. If required, conduct a demand vs. capacity, throughput process workflow assessment and an EVS labor productivity study. If required, develop a future work flow process. 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. 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. Track work orders and their respective resolutions. Analyze the issues and their resolutions to determine trends. Provide action plans for decreasing recurring issues. Create a plan for an initial cleaning campaign and ongoing schedule for cleaning, maintenance and incorporate monitoring. Convene the environment of care team to establish mission, charter, goals and processes to address EOC activities. Conduct a one-time, accelerated plan for deep cleaning and repairs. Develop a budget and prioritization for the campaign on potential staff or capital needs for senior leadership review. EVS 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. Conduct analysis on EVS staffing and evaluate and compare to industry benchmarks to ensure adequate resources exist to maintain the facility. 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. EOC team to submit monthly report to COO and CNO based the EOC rounds and on the action plans. 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. Accountability Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Work Stream 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 Target Date 4/27/2012 9/14/2012 9/14/2012 4/11/2012 4/23/2012 4/27/2012 4/6/2012 4/6/2012 6/8/2012 4/13/2012 4/13/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 Y Y Y Y Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
5/10/2012
12
Environment of Care (EOC) (Section 2.06) # 1 2 3 4 5 Audit/Measures Number of Charge Nurse complaints of unsatisfactory conditions per unit Percentage of Patient Rooms, Procedure Areas, and Operating Rooms, meeting all elements of EVS requirements Percentage of infection issues identified through Infection Prevention audits Percentage of procedure areas with up to date daily terminal cleaning logs Number of patient complaints about environmental issues Accountability Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
# 1 2 3
Metric Bed turnaround time Work order completion time to include EVS, Facilities, and Clinical Engineering (average/min/max) EVS labor productivity to benchmarks
Accountability Baseline EVS EVS
Current 1:13 .02

1
CYE 2012 Goal 1:00
Comments
6.06 - Beginning to track, but not enough data to provide appropriate level of analytics to validate completion
Defined as payable hours/cleanable sq ft
5/10/2012
13
Infection Control (Section 2.07) # 7.01 7.02 7.03 7.04 7.05 Tasks/Initiatives Each Divisional Vice President (VP) will submit all department specific Infection Prevention (IP) related policies and procedures to IP. The IP department Director and Chief of Infection Prevention will review and make revisions of all departmental and house-wide IP policies, if applicable. All departmental IP policies are returned to the department for their review and acceptance Approve reviewed departmental and house-wide IP policies. Accountability Kim McCloud Linda Licata Barbara Mims Janet Glowicz Janet Glowicz Janet Glowicz Work Stream 2.8 6.3 6.3 6.3 2.8 Target Date 4/20/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
7.06 7.07 7.08 7.09
Kim McCloud Divisional VP and Department Directors to develop a communication roll out with IP Director on the revised IP policies Linda Licata and procedures. Barbara Mims Kim McCloud Each department assigns an IP delegate to be the contact and participant in the IP prevention education program. Linda Licata Barbara Mims Provide a full-time Chief Infection Prevention Officer. Jody Springer
2.8 1.2 6.3 6.3
6/8/2012 6/8/2012 3/23/2012 3/23/2012
Survey monthly all departments for IP compliance. Survey results are sent to Department IP representative, Department Janet Glowicz Director and Divisional VP for follow up and corrective action needed and expected completion date. Execute EOC surveillance program to ensure consistency with cleaning methods and standards to support IP principles. Janet Glowicz
Y Y
# 1 2 3 4
Audit/Measures Percentage of policies that have been drafted/revised (by department) Percentage of compliant observations with hand hygiene audits Percentage of compliant observations with sterile technique in procedure areas Percentage of Infection Prevention completed surveys by each department, monthly
Accountability
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
# 1 2 Infection Prevention benchmark by department
Metric
Current
CYE 2012 Goal
Number of Infection Prevention issues identified in the surveys/audits conducted by each department monthly
5/10/2012
14
Medication Management (Section 2.08) # 8.01 Conduct a medication override audit. Tasks/Initiatives Accountability Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Work Stream 2.3 Target Date 6/8/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
8.02 8.03 8.04
Enhance P&T agenda with cost studies, outcomes for alternative drug options, ADR, Overrides, dosing guidelines. P&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. Establish baseline and develop a tool to flag ADRs.
2.3 2.3 2.3
4/5/2012 6/8/2012 5/11/2012
8.05
Trending reports based on type of reaction, location, provider, etc. and report to P&T Committee and other appropriate Vivian Johnson medical staff committees. Actions should be taken and documented on trends by the P&T Committee and reported up Dr. Shannon through the QCC Committee and Governing Board. Potential trends should be monitored with corrective action taken, e.g., ADRs identified on the same drugs, same units, Vivian Johnson same diagnoses, same physicians, etc. Dr. Shannon Explore alternatives for clinical trial identifiers. Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Anne Tudhope Judy Herrington Vicki Crane
2.3
6/8/2012
8.06
2.3
6/8/2012
8.07
2.3
4/27/2012
8.08
Ensure all off label medication use is reviewed and approved by the P&T Committee.
2.3
4/27/2012
8.09
Establish a Medication Reconciliation task force to develop a consistently compliant process.
4.5
5/11/2012
8.10
Conduct chart audit of medication reconciliation compliance to establish current baseline.
Anne Tudhope Judy Herrington Vicki Crane Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon
4.5
5/11/2012
8.11
Evaluate appropriateness of providing pharmacy tech support for medication reconciliation.
2.3
5/11/2012
8.12
Develop and provide education for pilot study for the participating Pharmacy Techs and RNs.
2.3
6/8/2012
8.13
Conduct pilot study. Collect and present results.
2.3
6/8/2012
5/10/2012
15
Medication Management (Section 2.08) # 8.14 Develop future state work flow processes. Tasks/Initiatives Accountability Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Anne Tudhope Judy Herrington Vicki Crane Work Stream 2.3 Target Date 6/8/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
8.15
Pilot the new work flow process.
2.3
7/13/2012
8.16
Implement new reconciliation process.
4.5
6/8/2012
8.17
Reassign the crash cart management under the Sterile Processing Department and/or Pharmacy.
Anne Tudhope Judy Herrington Vicki Crane
4.5
4/13/2012
8.18
Assess the space requirements and human resources needed for case cart management within SPD.
4.5
4/13/2012
8.19
Revisit the cart management processes for supplies and pharmaceuticals.
4.5
5/11/2012
8.20
Ensure the supply and pharmaceutical lists match the components in the carts and validate the accuracy of lists and components with Pharmacy and Nursing Education.
4.5
3/22/2013
8.21
Implement an accountability process and sign off process to ensure accuracy and products are not expired.
4.5
5/11/2012
8.22
Conduct cart initial audit for validation after transferring case cart management to SPD.
4.5
6/8/2012
5/10/2012
16
Medication Management (Section 2.08) # 8.23 Tasks/Initiatives Present drug storage audit and data collection program. Accountability Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Work Stream 2.3 Target Date 6/8/2012 3/1/2012 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
8.24
Pharmacy Resources and Nurse Liaisons (Charge Nurse) are assigned for each unit.
2.3
6/8/2012
8.25
Pharmacy & Unit-Based Nursing Resources conduct audits (Nursing - part of daily checklist for eight weeks); Pharmacy Vivian Johnson (monthly as a part of trending & monitoring) Dr. Shannon Nursing Liaison collects, collates and summarizes audit results and submits on the data tool to the Pharmacy Resource weekly. Pharmacy Resource analyzes data from Nurse Liaison reports and provides monthly summary interim reports to Nurse Liaison, Unit Manager and Department Director. Pharmacy Resource collects collates and summarizes audit results and submits monthly audit on the data tool. Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Vivian Johnson Dr. Shannon Anne Tudhope Judy Herrington Vicki Crane
2.3
6/8/2012
8.26
2.3
6/8/2012
8.27
2.3
6/8/2012
8.28
2.3
6/8/2012
8.29
Establish a multi-disciplinary RCI Medication Safety Team. Investigate the root causes of the medication errors and categorize the errors and provide tactical plans towards resolution. Review the medication ordering, preparation and administration process through a work flow process.
2.3
4/13/2012
8.30
2.3
6/8/2012
8.31
2.3
6/8/2012
8.32
Revise medication administration process based on finding of work flow analysis. Provide the education plan base on the work flow model findings that address the gaps in the safe delivery of medications. Develop 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 staffs annual competency evaluation.
2.3
6/8/2012
8.33
2.3
9/14/2012
8.34
2.3
9/14/2012
8.35
In conjunction with current internal hospital initiatives, define those care settings that moderate sedation is required versus pain management.
4.5
5/11/2012
5/10/2012
17
Medication Management (Section 2.08) # Tasks/Initiatives Accountability Anne Tudhope Judy Herrington Vicki Crane Work Stream Target Date 3/1/2012 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
8.36
Ensure all clinicians are qualified to administer medications that have the clinical effect of moderate sedation.
4.5
6/29/2012
8.37
Ensure compliance with new moderate sedation practice standards.
4.5
6/29/2012
8.38
Review 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
5/11/2012
8.39
Conduct an audit on the daily Pyxis report (Epic Clarity Report) on Narcan use in patients undergoing pain management Vivian Johnson and moderate sedation in non-procedure based units. Dr. Shannon
2.3
3/22/2013
# 1 2 3 4 5
Audit/Measures Number of physician overrides Number of completed med reconciliations (by audit) Number of unsecured medications (by unit, by audit) Percentage of crash cart audits identifying issues Number of improper or lack of medication labeling (by unit, by audit)
Accountability
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
# 1 2 3 4 5
Metric Percentage of off label medication reviewed by P&T Committee Number of adverse drug reactions Missed medications by unit Time from physician medication order to first dose by unit Number of NARCAN reversals
Current
CYE 2012 Goal
Pharmacy
21
5/10/2012
18
Patient Safety/Rights (Section 2.09) # 9.01 9.02 9.03 Tasks/Initiatives Create job description for new Chief Patient Rights and Safety Officer (CPRSO). Name Interim Chief Patient Rights and Safety Officer (CPRSO) National search to recruit new Chief Patient Rights and Safety Officer (CPRSO) 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) New job descriptions for all employees and managers, supervisors and department heads in units and divisions now reporting to the CPRSO. Review and redesign of all patient rights and safety related policies and procedures. Develop education plan for all employees regarding patient safety and rights policy/procedure changes. Reorganize and redesign its Quality Department and its centralized Quality Assessment/Performance Improvement (QAPI) functions to include: Clinical Data Management Performance Improvement Rapid Cycle Improvement Create new Human Resources policy on violations of Patient Rights/Patient Safety obligations. Create a Patient Rights/Patient Safety Awareness Campaign. Create a Safe Patient Hand offs/Continuity of Patient Care Awareness Campaign New education and training for current and new employees and physicians on safe patient handoffs and continuity of patient care. Parkland 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. Patient Rights and Safety Department Study and Task Force (to include Nursing, Police, Patient Safety, and Patient Relations representatives) on Elopements and Patients leaving. Accountability Jody Springer Jody Springer Jody Springer Work Stream 1.2 1.2 1.2 Target Date 3/30/2012 4/6/2012 5/11/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
9.04
Jody Springer
1.2
5/11/2012
9.05 9.06 9.07 9.08
Jody Springer Lisa Betterson Judie Byers Lisa Betterson Judie Byers Jody Springer
1.2 6.2 6.2 1.2
5/11/2012 6/8/2012 8/15/2012 6/8/2012
9.09 9.10 9.11 9.12 9.13 9.14
John Dragovits Lisa Betterson Judie Byers Lisa Betterson Judie Byers Lisa Betterson Judie Byers Jody Springer Lisa Betterson Judie Byers
1.5 6.2 6.2 6.2 1.2 6.2
6/8/2012 4/27/2012 5/11/2012 8/15/2012 4/13/2012 6/1/2012
9.15
Work with Parkland Police Department and Nursing the Patient Rights and Safety Department should conduct a study of Lisa Betterson all documented elopements in 2011 and determine reasons for elopement (e.g., breeches in security, caregiver training, Judie Byers etc.) and provide action plan and recommendations for reducing elopements. 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 Lisa Betterson leaving AMA in the Emergency Department. The chart review should then develop a list of reasons as to why patients Judie Byers leave elope or leave AMA, and subsequent reports should trend in these categories.
6.2
3/30/2012
9.16
6.2
3/22/2013
5/10/2012
19
Patient Safety/Rights (Section 2.09) # 9.17 9.18 Tasks/Initiatives Complete current RCI initiative regarding 1:1 observation procedure and competencies required for staff. Evaluate additional CM staff to ED. 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. Develop and implement an action plan that addresses non-compliance and the steps to the solution. Accountability Lisa Betterson Judie Byers Robin Stults w/ External Resources Lisa Betterson Judie Byers Work Stream 6.2 3.4 Target Date 6/1/2012 4/6/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
9.19
6.2
9/14/2012
9.20 9.21 9.22
Lisa Betterson Judie Byers Review all policies and procedures related to the areas of non-compliance to determine and ensure policies are updated to Lisa Betterson current regulations or standards of practice. Judie Byers Lisa Betterson Determine where and if the resources are available or needed to meet the documentation requirements. Judie Byers HIM shall conduct routine chart audits to document that all patients have been provided with: 1) required information on Lisa Betterson their rights under Medicare, federal law and state law; 2) required information on advance directives. Chart audits shall Judie Byers also assess whether all Medicare patients are receiving the notice entitled: Important Message from Medicare. Review Hospital policy for Patient Grievance procedure and compare to best practice, including those noted above. Develop monitoring system to ensure timelines required by Hospital policy are met. Lisa Betterson Judie Byers Lisa Betterson Judie Byers
6.2 6.2 6.2
9/14/2012 9/14/2012 9/14/2012
9.23
6.2
9/14/2012
9.24 9.25
6.2 6.2
5/25/2012 9/14/2012
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, Lisa Betterson family member, staff, physician, etc.); time between receipt of complaint and response to patients; documentation that Judie Byers 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. Develop and implement a Privacy task force to identify areas of non-compliance (including HIPAA), indicators to measure, and to develop an awareness campaign. Conduct Patient Privacy Awareness Campaign to reacquaint staff on HIPAA and other privacy obligations. Privacy Awareness campaign should include examples of recent privacy breaches. 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. Utilize tool developed by Executive VP of Operations or another developed tool to conduct weekly customer relations tours. Develop a dashboard and track and trend the indicators for Patient Rights and the progress to the target thresholds. Lisa Betterson Judie Byers Lisa Betterson Judie Byers Lisa Betterson Judie Byers Lisa Betterson Judie Byers Lisa Betterson Judie Byers
6.2
9/14/2012
9.27 9.28 9.29 9.30 9.31
6.2 6.2 6.2 6.2 6.2
6/8/2012 9/14/2012 9/14/2012 5/11/2012 9/14/2012
5/10/2012
20
Patient Safety/Rights (Section 2.09) # 1 2 3 4 5 6 7 8 9 10 Audit/Measures Percentage of policies and procedures reviewed and/or revised. Percentage of staff provided education on patient rights and patient safety Percentage of staff provided education on safe patient hand offs Percentage of completed competencies for members of Policy Department Average time from event to completion of patient safety investgiation Number of regulatory reports that exceed the time to report based on policy or regulations Number of patient complaints and grievances by category Average time from event to resolution of patient complaint or grievance Percentage of patients that have documented evidence of receiving patient rights Percentage of patients who did not receive appropriate notifications (under applicable Medicare, state and other laws, "Important Message from Medicare", others), as audited by HIM Accountability Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
# 1 Number of Patient Safety Investigations
Metric
Current 31
CYE 2012 Goal
Comments
9.04 and 9.05 - Due dates need to be revised as Interim CPRSO not being hired; awaiting full time search and hire before full reorganization of function.
5/10/2012
21
Medical Staff (Section 2.10) # Tasks/Initiatives Accountability Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Work Stream 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.3 Target Date 4/20/2012 4/20/2012 4/20/2012 4/20/2012 6/8/2012 7/13/2012 5/11/2012 6/8/2012 5/11/2012 7/13/2012 4/27/2012 Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
10.01 Develop an OPPE/FPPE review template for each medical department and/or service. 10.02 Develop a written procedure explaining the OPPE process, criteria and physician referral process for FPPE. 10.03 Define required physician profile elements for all physicians. 10.04 Provide all department chairs the required template, guidance, and a timeline for completion of departmental criteria, indicators, and thresholds of performance.
10.05 Review and sign off of CMO and QAPI of the departmental OPPE plans for relevance and compliance. 10.06 Review and obtain approval of OPPE/FPPE process and criteria by MEC, and then the Governing Board. 10.07 Each department should develop a standard set of metrics for use on cases sent for peer review. 10.08 Medical Staff Office to establish a methodology to track and trend all cases brought to peer review. 10.09 Patient Safety to revise and standardize scoring system used to refer cases to peer review. 10.10 Determine necessity to expand Medical Staff resources.
Charter a joint Hospital/GME Faculty Task Force. Create a venue for collaboration and discussion of issues between Brad Marple, 10.11 Hospital and Faculty to inform and appraise between residency update periods. Members to include Hospital VPs and MD Faculty Medical Staff. 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 Brad Marple, 10.12 MD the teaching physician. Use the audit to develop an operational report to concurrently manage the Residents during the academic year. Brad Marple, 10.13 Develop a training module enabling faculty to instruct residents when to escalate issues to their Attending Physicians. MD Standardize use of Innovations (resident management software) across the system to create a web-enabled database of Brad Marple, 10.14 individual resident certification profile; (presently nurse can access the department grid, see what a PGY-2 is qualified to MD do, and then look up the name of a particular PGY2 and determine whether he/she is certified to it. 10.15 Modify Grid to highlight those events and procedures that require concurrent notification of the attending physician that Brad Marple, is available to all departments. MD Review Grid to ensure that it includes all events that require escalation notification to an Attending (i.e., lower the Brad Marple, 10.16 reporting threshold). MD Create policy contingencies for alternate modes of supervision or escalation, i.e., what to do when the expected senior Brad Marple, 10.17 resident or Teaching Physician is not accessible in the expected time period. MD
5.3
5/18/2012
5.3
6/8/2012
5.3
5/11/2012
5.3 5.3 5.3
5/11/2012 6/8/2012 5/11/2012
5/10/2012
22
Medical Staff (Section 2.10) # 10.18 Tasks/Initiatives Accountability Work Stream 5.3 Target Date 5/11/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
Evaluate Parklands Epic functionality, to determine improvement to be made in documentation or note entry to provide Brad Marple, consistent and reliable documentation of Attending Physician oversight, approval and concurrence with Resident orders. MD
Evaluate Parklands call system ability to properly attribute the Resident and Attending Physician to each patient. Create Joseph Minei, 10.19 an audit tool for weekly confirmation that call system is accurately and timely attributing Residents and Attending MD Physicians to each patient. Joseph Minei, Upgrade Epic with user capability to concurrently update treatment teams through use of the physician order entry 10.20 function. MD Joseph Minei, 10.21 Standardize call schedule procedure for consulting services. MD Joseph Minei, 10.22 Ensure the accuracy Amcom scheduling system (source of truth maintained by Parkland) MD Joseph Minei, 10.23 Create contingencies for alternate modes of supervision or escalation. MD Parklands GME Director should review the current training and education materials for Residents on documentation, Brad Marple, 10.24 particularly documentation of H&Ps. MD Brad Marple, 10.25 Refresher education and training should be conducted for all Residents. MD Perform audit of Residents' History and Physicals (H&P) documentation for completion and adherence to Parkland Joseph Minei, 10.26 policy and procedures. MD # 1 2 3 Audit/Measures Number of incidents Decrease in the percentage of misattributed Attending Physicians in Epic Number of times alternate mode of supervision is activated Responsibility
5.4 5.4 5.4 5.4 5.4 5.3 5.3 5.4
6/8/2012 5/11/2012 4/27/2012 5/18/2012 5/11/2012 5/11/2012 6/8/2012 3/22/2013
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Comments All initiatives are delayed or not progressing at rate to meet deadlines. Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
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Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Work Stream 3.2 Target Date 4/27/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
Conduct a quantitative demand and process analyses of the ESD in order to properly balance work flow, capacitate the 11.01 various components of the split flow system, and accurately determine any changes in bed capacity, service hours or staffing. 11.02 11.03 Throughput 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 Identify rate limiting factors such as lack of equipment/technology, availability and/or staffing within budget guidelines, and hours of operations.
3.2 3.2 3.2 3.2
4/27/2012 4/27/2012 4/27/2012 7/13/2012
Y Y Y
11.04 Server cycle times need to be measured and applied to the design of care teams in the Triage and the Intake areas. 11.05 Conduct 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.
Redesign of the future process flow to eliminate waste, such as: removing or combining steps, automating any manual 11.06 activity steps, if possible, transferring elements to other departments, changing the location where the steps are done, and finally altering/modify the activity step 11.07 Work flow models should be piloted with Rapid Cycle Testing and refined as necessary and then training provided 11.08 Periodic reviews of process work flow using Plan-Do-Check-Adjust (PDCA) Lean techniques. 11.09 Change functionality in Epic to reflect changes in work flow processes and new treatment areas. 11.10 Recruitment, credentialing and on-boarding of qualified physicians. 11.11 Pathology to scope operations, licensing, certification requirements for Point of Care labs. 11.12 Develop signage text consistent with the educational level and primary languages of the population served that is consistent across the institution.
3.2 3.2 3.2 3.2 5.1 2.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2
5/25/2012 7/13/2012 9/14/2012 6/8/2012 6/8/2012 5/11/2012 5/11/2012 5/11/2012 5/25/2012 6/8/2012 7/13/2012 6/8/2012 7/13/2012
11.13 List all sites and specific rooms requiring posting of signage 11.14 Obtain approval of final language for signage 11.15 Physical Plant and Facilities to arrange for printing and posting final approved signs. 11.16 Post new signage 11.17 Review and revise all EMTALA related Policy and Procedures. 11.18 Create/Revise training materials for new EMTALA Policy and Procedures
Clifann McCarley Clifann McCarley Clifann McCarley Patricia Bergen, MD Brad Simmons Jenni Burnes Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley
5/10/2012
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Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Work Stream 3.2 4.4 4.4 3.2 3.2 4.2 4.2 4.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 4.4 Target Date 3/22/2013 5/20/2012 6/8/2012 7/13/2012 9/14/2012 5/25/2012 7/13/2012 7/13/2012 6/8/2012 6/8/2012 7/13/2012 9/14/2012 9/14/2012 4/13/2012 4/27/2012 5/18/2012 5/12/2012 Y Y Y Y Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
11.19 Re-educate on new EMTALA Policy and Procedures. 11.20 11.21 11.22 11.23 11.24 11.25 11.26 11.27 11.28 11.29 11.30 11.31 11.32 11.33 11.34 11.35
Clifann McCarley Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen Re-educate staff on new patient registration policies on Emergency Registration Process Emilie Allen Clifann Develop and finalize a survey technique. McCarley Develop a patient flow process to eliminate disparate treatment in evaluation and delay in the care of a person presenting Clifann to the ESD seeking Psychiatric emergency care. McCarley Barbara Mims Review and revise all Hand-Off related Policy and Procedures. Valerie Harvey Barbara Mims Create/Revise training materials for new Hand-Off Policy and Procedures. Valerie Harvey Barbara Mims Re-educate on new Hand-Off Policy and Procedures. Valerie Harvey Clifann Work with IT/Epic to develop access to information required by law. McCarley Clifann Develop reporting function with Epic for output of Central Log Reports. McCarley Clifann Create training materials for accessing information required by law and reporting functions through Epic. McCarley Clifann Re-educate staff on accessing information required by law and reporting functions through Epic. McCarley Clifann Monitor and audit compliance to determine if management can generate a central patient log. McCarley Clifann Review and revise policy and procedures on receiving hospital transfer requirements. McCarley Clifann Create/Revise training materials for new policy and procedures. McCarley Clifann Re-educate on new policy and procedures. McCarley Annual review ESD Nurses, Physicians and other Caregivers and Staff. Emilie Allen
5/10/2012
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Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen Emilie Allen Emilie Allen Emilie Allen Emilie Allen Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Work Stream 3.2 3.2 3.2 4.4 4.4 4.4 4.4 4.4 4.3 4.3 4.3 4.3 4.3 Target Date 4/13/2012 4/27/2012 5/18/2012 5/12/2012 9/9/2012 9/9/2012 9/9/2012 5/18/2013 10/5/2012 3/22/2013 3/22/2013 3/22/2013 6/28/2013 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y Y
11.36 Review and revise policy and procedures on Memorandum of Transfer requirements. 11.37 Create/Revise training materials for new policy and procedures. 11.38 Re-educate on new policy and procedures. Annual review ESD Nurses, Physicians and other Caregivers and Staff. Review and revise policy and procedures on nursing assessment and plan of care requirements. Create/Revise training materials for new policy and procedures. Re-educate on new policy and procedures. Annual review ESD Nurses, Physicians and other Caregivers and Staff. The Emergency Services Director of Nursing should determine approach for developing an acuity assessment 11.44 methodology, e.g., internal historical record review, an automated tool, etc. 11.39 11.40 11.41 11.42 11.43 11.45 Once selected, roll out acuity tool. 11.46 Develop flexible staffing strategies, PRN pools, per diem staff, etc.
11.47 Monitor core patient care ratios for trends. 11.48 Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs.
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Emergency Services (Section 2.11) # 1 2 3 4 5 6 7 8 9 10 Audit/Measures Total number of hours of ED boarding Average number of patients in ED that are boarding per day Average "Compassionate" dialysis patients transferred from ED/day Turnaround time to discharge patients to home (door to home) Door to seen by 1st Provider (minutes) Number of ED admits that should have been direct admits Hours on diversion Door to Room Time (minutes) Left without being seen Left without being treated Accountability ESD ESD ESD ESD ESD ESD ESD ESD ESD Goal Mar-12 2,081 42.2 17.0 405.22 126 430 120 9.4% 2.3% Apr-12 2,308 46.4 15.3 400.02 131 344 123 8.9% 2.3% May-12 Jun-12 Jul-12 Aug-12
# 1 2
Metric Total ED throughput time - time from patient arrival to patient disposition (all EDs) Labor Productivity (staffing to include acuity)
Accountability Baseline ESD
Current 299.42
CYE 2012 Goal
Comments
Delay in initiatives related to education result of policy not yet finalized.
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Psychiatry Services (Section 2.12) # Tasks/Initiatives Accountability Olga Rodriguez Jody Springer Jody Springer Olga Rodriguez Olga Rodriguez Emilie Allen Jackie Brock John Raish Jackie Brock John Raish Olga Rodriguez Olga Rodriguez Jody Springer Jody Springer Emilie Allen Emilie Allen Olga Rodriguez Patricia Bergen, MD Olga Rodriguez Olga Rodriguez Olga Rodriguez Work Stream 2.1 1.2 1.2 2.1 2.1 4.4 4.3 4.3 2.1 2.1 1.2 1.2 4.4 4.4 2.1 5.1 2.1 2.1 2.1 Target Date 4/27/2012 4/27/2012 6/8/2012 5/14/2012 5/25/2012 5/25/2012 6/8/2012 6/8/2012 6/8/2012 4/13/2012 9/14/2012 6/8/2012 6/8/2012 6/1/2012 6/8/2012 6/8/2012 5/1/2012 8/1/2012 4/20/2012 Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y Y
12.01 Develop clear vision of a psychiatric services (with particularly focus on PED) care delivery model. 12.02 Hire interim management for Psychiatric Director and psychiatric experienced/trained Nursing Manager for PED. 12.03 Commence national search for permanent Director of Psychiatric Services. Develop a detailed implementation plan (based on this corrective action plan) led by the psychiatric management team. 12.04 Define a management scorecard that can be utilized. 12.05 Create by discipline specific roles and responsibilities in alignment with new care delivery model. 12.06 Create new competencies and education models. 12.07 Create permanent staffing grids for PED and 8 North based upon census and acuity. 12.08 Further develop the charge nurse role in the PED and on 8 North. 12.09 Develop, test, and validate acuity methodologies for PED and 8 North. 12.10 Validate Social Workers coverage and effectiveness. 12.11 12.12 12.13 12.14 Implement short term strategy for consistent physician coverage. Continue recruitment efforts aggressively to fill permanent positions. Identify staff knowledge gaps. Utilize psychiatrictrained resources for competency development and training.
12.15 Develop comprehensive PED education plan. 12.16 Incorporate required physician competencies into OPPE/FPPE. 12.17 Implement a discharge huddle with the MD, nursing staff, social worker, and a designated facilitator. 12.18 Develop interdisciplinary communication and planning for the plan of care. 12.19 Develop suicide risk and behavioral quadrant assessment tools.
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28
Psychiatry Services (Section 2.12) # Tasks/Initiatives Accountability Olga Rodriguez Olga Rodriguez Dr. Royer Jackie Stephens Dr. Royer Jackie Stephens Dr. Royer Jackie Stephens Olga Rodriguez Olga Rodriguez Olga Rodriguez Olga Rodriguez Olga Rodriguez Work Stream 2.1 2.1 3.5 Target Date 5/1/2012 6/8/2012 7/13/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
12.20 Conduct a pilot on the suicide risk and behavioral quadrant assessment tools. 12.21 Educate team members on the purpose and the usability of the tool and how its integrated into the plan of care. 12.22 Develop cross-functional Parkland behavioral health team.
12.23 Analyze the patient population served by all of Parkland behavioral health disciplines.
3.5
9/14/2012
12.24 Work with DBHLT on reducing or eliminating identified gaps in care across the continuum of care in Dallas County. 12.25 Continue redesign planning of day room and back entrance for better space utilization. 12.26 Initiate multi-disciplinary team to consider PED space redesign. 12.27 Develop alternative workflows for continued PED patient care during physical space construction/redesign. 12.28 Develop budget for recommended physical changes. 12.29 Develop alternative safety alerts for day room restroom.
3.5 2.1 2.1 2.1 2.1 2.1
9/14/2012 6/8/2012 6/8/2012 6/8/2012 6/8/2012 4/20/2012
# 1 2 3 4 5 6 7 8 9
Audit/Measures Audit Results of Number of PED Cases Intervened by CM Prior to Admission Percentage of patients seen by social workers Hours on diversion Percentage of patients with a documented discharge huddle Percentage of patients discharged versus admitted Percentage and types of restraints and seclusions, and length of time (average/min/max) Turnaround time to discharge patients to home (door to home) Door to seen by 1st Provider (minutes) Door to Room Time (minutes)
Accountability
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
PED
104
Psych PED PED PED
609.11 143 58
698.27 143 33
# 1 2 3 4
Metric Labor productivity (staffing to include acuity) Number of elopements, AWOLS, AMA Percentage of seclusion and restraint Total ED throughput time - time from patient arrival to patient disposition (all EDs)
Current
CYE 2012 Goal
Psych PED
60 1 554.25
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Psychiatry Services (Section 2.12) Comments
12.10 - Hiring of social workers in progress 12.29 - Solution developed but not installed
1
Baseline from October, 2011 - April, 2012
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Women and Infant's Specialty Health (WISH) (Section 2.13) # Tasks/Initiatives Accountability Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Paula Turicchi Paula Turicchi Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Paula Turicchi Jackie Brock John Raish Emilie Allen Work Stream 4.2 4.2 4.3 4.3 4.3 2.4 2.4 4.3 4.3 4.3 4.3 2.4 4.3 4.4 Target Date 3/22/2013 5/11/2012 6/8/2012 4/13/2012 5/11/2012 6/1/2012 6/8/2012 6/8/2012 4/27/2012 6/8/2012 6/8/2012 6/1/2012 4/13/2012 6/1/2012 Y Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
13.01 Ensure plan of care practices are standardized and followed regularly. 13.02 Standardize hand off procedures. Educate staff. 13.03 Begin recruitment of key leadership positions Nursing Director (L&D) and Nursing Manager (L&D). 13.04 Evaluate job description and determine best solution to work load balance for Nurse Manager (Postpartum). 13.05 Begin recruitment of additional Nurse Manager candidates (Postpartum). 13.06 Evaluate job descriptions of Nurse Managers to determine if additional administrative support is required. 13.07 Begin recruitment for administrative support roles (if appropriate). 13.08 Recruit, hire and train additional staff to fill vacancies. 13.09 Evaluate nurse staffing needs based upon any plans for increase in capacity. 13.10 Recruit, hire and train additional staff as required. 13.11 Re-design staffing model to include adjustment for acuity. Evaluate job descriptions for inclusion of appropriate competencies and to ensure duties assigned are within scope of practice. WISH Nursing Director and Chief Nursing Officer (CNO) must ensure all nursing personnel working within scope of 13.13 practice. Nursing Directors of each area should review competencies required for the care of their patient population in 13.14 accordance with nursing practice standards. 13.12
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Women and Infant's Specialty Health (WISH) (Section 2.13) # 13.15 13.16 13.17 13.18 Tasks/Initiatives Accountability Emilie Allen Emilie Allen Emilie Allen Emilie Allen Paula Turicchi Paula Turicchi Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Paula Turicchi Paula Turicchi Jackie Brock John Raish Paula Turicchi Paula Turicchi Emilie Allen Work Stream 4.4 4.4 4.4 4.4 2.4 2.4 4.2 4.2 2.4 2.4 4.3 2.4 2.4 4.4 2.4 Target Date 6/1/2012 7/13/2012 7/13/2012 7/13/2012 4/13/2012 4/13/2012 4/13/2012 7/13/2012 6/8/2012 5/25/2012 5/11/2012 5/11/2012 4/6/2012 5/11/2012 3/30/2012 Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
A full assessment of current staff should be conducted to establish a current baseline of competencies. Review all personnel files for completed competencies. Gaps identified in competencies should be addressed with education and audit. Conduct newborn resuscitation competency education and audit. Evaluate the need for an additional FTEs to assist in the responsibility of supply stocking, storage, and environmental 13.19 rounds on all WISH units. Establish recommended AORN practices of setting up the sterile back table for delivery table set-up. 13.20 Determine if additional staffing is required for L&D OR and LDR for sterile supply set up. Hire additional staff, if needed. 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. 13.25 Design care model that provides for rooming-in options for infants.
13.26 Establish a census tracking tool for newborns. 13.27 Review and revise infant security and abduction plan. 13.28 Conduct at least one Code Pink drills per year. Identify space that can be made available for emergency equipment within the post partum unit (department reports plan Paula Turicchi 13.29 underway to convert treatment rooms for this purpose).
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Women and Infant's Specialty Health (WISH) (Section 2.13) # 13.30 Tasks/Initiatives Accountability Work Stream 2.4 2.4 Target Date 4/20/2012 4/6/2012 Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
Establish monthly mock equipment drills and verify emergency equipment is immediately available where newborns are Paula Turicchi housed. Paula Turicchi
13.31 Discard all six pack transport carts. Conduct 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. Evaluate the need for an additional FTEs to assist in the responsibility of supply stocking, storage, and environmental rounds on all WISH units.
13.32 13.33
Paula Turicchi Paula Turicchi Paula Turicchi Emilie Allen Paula Turicchi
2.4 2.4 2.4 4.4 2.4 1.7
4/15/2012 5/4/2012 4/6/2012 4/27/2012 4/13/2012 6/8/2012
13.34 Establish an alternative protocol for delivery table set-up to ensure sterile field. 13.35 Educate staff on storage requirements for specimens. 13.36 Revise dirty utility room flow and practice.
Y Y
13.37 Department reports a plan is in progress for construction to ensure proper dirty utility room flow. (No start date supplied) John Dragovits Anne Tudhope Judy Herrington Vicki Crane
13.38 Review Parkland policy on securing medications PHR-D-067 Inventory Management Procurement, Storage
4.5
5/18/2012
13.39 Anesthesia medication trays should be stored in a locked, secure area.
4.5
4/13/2012
13.40 Store floor stock in Pyxis.
Anne Tudhope Judy Herrington Vicki Crane Emilie Allen Emilie Allen Responsibility
4.5
4/13/2012
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. # 1 Audit/Measures Percentage of completed competencies for all WISH staff
4.4 4.4
3/31/2012 3/30/2012 Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
Y Y
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Women and Infant's Specialty Health (WISH) (Section 2.13) CYE 2012 Goal
# 1 2 3
Metric Labor productivity (Staffing to include acuity) Staffing hours per patient day Number of days per month staffing ratios were above/below grid
Responsibility Baseline
Current
Comments 13.19 - Awaiting evaluation by Supply Chain; will address departmental needs for WISH upon completion 13.23 - Subject to outside consultant's report and funding for required level of staffing Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
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Perioperative Services (Section 2.14) # 14.01 14.02 14.03 14.04 14.05 14.06 Tasks/Initiatives Conduct daily infection control audits in all areas of the Main OR, PACU, PreOp Holding, DSU, Anesthesia Workroom, ASC and PAEC. Execute the progressive disciplinary action and performance improvement plan for staff/physicians who exhibit failure to follow infection prevention policies and procedures. Conduct environment of care rounds every shift in each perioperative area. Review and follow Parkland policy Admin 6-33 Labeling of Medications On/Off the Sterile Field. Review and follow Parkland policy Admin 6-43, Using Two (2) Patient Identifiers. Provide training for alternative options for medication solution transfer. Accountability Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Anne Tudhope Judy Herrington Vicki Crane Suzanne Sims Work Stream 2.5 2.5 2.5 2.5 2.5 2.5 Target Date 4/13/2012 6/8/2012 4/13/2012 4/13/2012 4/6/2012 6/8/2012 Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
14.07 Conduct daily audits of various medication management measures to determine compliance.
4.5
6/8/2012
14.08 Review and follow the Parkland policy Admin 6-30 Universal Policy. Conduct daily audits of various patient right initiatives to determine compliance: Time out procedure Site marking 14.09 Critical Equipment MH Cart/Drugs Difficult Airway Cart # 1 2 3 4 5 6 7
2.5
4/6/2012
Suzanne Sims
2.5
6/8/2012
Audit/Measures Accountability Compliance to using two patient identifiers Compliance percentage of Infection Prevention by audit, monthly Compliance percentage of environement of care by audit, monthly Compliance to site marking procedure Compliance to medication maangement measures (labeling, transfering from the circulator to scrub, securing and other measures) Compliance with critical equipment Compliance to Time Out procedure
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
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Perioperative Services (Section 2.14) CYE 2012 Goal
# 1 2 3 4 5 6 Number of medication errors Number of blood transfusion errors Number of incorrect consents Number of wrong site surgeries or wrong site markings Number of lab specimen mis-labeling Surgical Site infections
Metric
Current
Surgery
1.71%
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Procedural Services - Catherization Lab/Endoscopy (Section 2.15) # Tasks/Initiatives Accountability Kim McCloud Linda Licata Barbara Mims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Kim McCloud Linda Licata Barbara Mims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Work Stream 2.7 2.5 2.5 2.5 2.5 2.5 2.7 2.5 2.5 2.5 2.5 2.5 2.5 4.4 2.5 2.5 4.4 2.5 2.5 2.5 2.5 2.5 4.4 Target Date 4/15/2012 3/22/2013 3/30/2012 3/30/2012 5/11/2012 6/8/2012 6/8/2012 3/30/2012 4/13/2012 4/13/2012 5/11/2012 4/13/2012 4/13/2012 4/20/2012 3/22/2013 3/30/2012 4/20/2012 4/27/2012 4/6/2012 6/8/2012 6/8/2012 4/9/2012 4/13/2012 Y Y Y Y Y Y Y Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
15.01 Conduct a weekly environment of care tour to ensure infection prevention measures are in compliance. 15.02 15.03 15.04 15.05 15.06 Conduct audit on invasive procedures in the restricted procedure rooms on the proper medication management on and off the sterile field. Review Parkland's policy on Surgical Attire and OSHA regulation on Personal Protective Equipment. Cardiologist performing the procedure to conduct the pause to ensure surgical team is properly attired. Conduct an education program and competency on maintaining the sterile field. Conduct an audit to ensure compliance with surgical attire policy.
15.07 Nurse manager to develop daily EOC tool/checklist to ensure compliance. 15.08 15.09 15.10 15.11
Review PHHS policy Admin 6-33 and PS 04-33 on proper handling of medications. Educate staff of the existing Parkland Universal Protocol policy. Develop Time Out procedure flash cards to be used as a help guide. Conduct an audit on Time Out on all invasive procedures. Provide mandatory education on proper site marking to all new and existing physicians. Provide education to staff nurses Suzanne Sims 15.12 and techs to ensure they understand the proper site marking requirement based on NPSG. Suzanne Sims 15.13 Review Parkland's policy PS 04-43 regarding sponge and sharp counts. 15.14 15.15 15.16 15.17 15.18 15.19 15.20 15.21 15.22 15.23 Surgical 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. Develop and implement a dashboard key measure all the required elements on correct counts to include instruments and sponges. Review Parkland policy Admin 6-33 and PS 04-33 on proper handling of medications. Develop unit specific medication management competencies. Initiate an awareness program verifying the medication they transfer on and off the sterile field. Conduct audit to assure needles and syringes are being stored in a safe and proper place and incorporate into daily environmental rounds. Audit proper transfer and verifying of medications on/off sterile field. Add medication management to the key measures to department quality dashboard. Establish action plan for non-compliance. Enter the procedural nurse hand off communication to the recovery nurse into Epic. Emilie Allen Suzanne Sims
Suzanne Sims Emilie Allen Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Emilie Allen
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Procedural Services - Catherization Lab/Endoscopy (Section 2.15) # 1 2 3 4 5 6 7 9 Audit/Measures Accountability Compliance percentage of Infection Prevention by audit, monthly Compliance percentage of environement of care by audit, monthly Compliance to site marking procedure in cath lab by audit Compliance to Time Out procedure by audit Compliance to sponge, needle, sharp and instrument count in cath lab by udit Compliance to medication maangement measures (labeling, transfering from the circulator to scrub, securing and other measures) by audit Compliance to using two patient identifiers by audit Compliance to proper scrub attire and sterile gowning in restricted areas in cath lab by audit Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
# 1 2 3 4 5 6
Metric Number of wrong site surgeries Number of incorrect consents Number of medication errors Number of lab specimen mis-labeling Number of return to surgery for retained objects Surgical Site infections (Percentage or rate of surgical site infections)
Current
CYE 2012 Goal
Comments Delay in initiatives related to completion of a Dashboard. 15.23 - In process, no evidence of completion received.
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Radiology (Section 2.16) # Tasks/Initiatives Accountability Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Suzanne Sims Suzanne Sims Emilie Allen Brad Simmons Jenni Burnes Jackie Sullivan Brad Simmons Jenni Burnes Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.5 2.5 4.4 2.2 6.4 2.2 Target Date 6/8/2012 3/23/2012 4/6/2012 5/4/2012 5/4/2012 4/20/2012 6/8/2012 6/8/2012 6/8/2012 4/13/2012 5/11/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 Y Y Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
16.01 Perform demand to capacity, throughput process workflow assessment and labor productivity analysis. 16.02 Define the current backlog of appointment needs and additional capacity to meet backlog. 16.03 Provide assessment of rate limiting factors contributing to the backlog. 16.04 Develop a current state process workflow diagram. 16.05 Develop future process work flow state. 16.06 Conduct a labor productivity benchmarking. 16.07 Pilot future state process work flow model. 16.08 Provide training. 16.09 Implement the new process flow department wide 16.10 Review of the existing Parkland "time out" policy to ensure clarification of required process and/or revise as appropriate. Provide Time Out procedure flash cards to be used as a help guide until newly learned behavior has been established and is codified. 16.12 Establish Time Out procedure as a one of the competencies of personnel. 16.11 16.13 Execute progressive counseling/disciplinary action plan for infractions. 16.14 Development of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI. 16.15 Ensure needles and syringes are secured in an area that is not accessible to unauthorized persons.
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39
Radiology (Section 2.16) # Tasks/Initiatives Accountability Paula Turicchi Paula Turicchi Work Stream 2.4 2.4 Target Date 4/27/2012 6/8/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
16.16 Review Parkland policy on medications on and off the sterile field. 16.17 Review Parkland policy on labeling medications on and off the sterile field.
Anne Tudhope 16.18 Develop and review the smart order sets that have foley insertions to determine whether Lidocaine jelly should be added. Judy Herrington Vicki Crane
4.5
7/13/2012
16.19 Review Parkland policy on properly securing medications.
4.5
3/23/2012
Emilie Allen 16.20 Develop an annual department-specific medication competency on all staff Assign role and responsibilities to ensure all tasks including the disposal of opened and unused supplies to Interventional Brad Simmons 16.21 Radiology (IR) tech. Jenni Burnes Brad Simmons 16.22 Distribute Parkland Policy G-1 on radiation safety. Jenni Burnes Brad Simmons 16.23 Develop annual unit specific competency on radiation safety competency for all staff, physicians and vendors. Jenni Burnes Audit the Main and ASC Operating Room staff and providers proper wear of personal protective attire during a procedure Brad Simmons 16.24 when operating the mini-fluoroscopy and other radiation safety requirements. Jenni Burnes Patricia Bergen, Initiate the education plan for the physicians requiring the need to meet the credentialing criteria. 16.25 MD
4.4 2.2 2.2 2.2 2.2 5.1
6/8/2012 5/11/2012 4/6/2012 6/8/2012 9/14/2012 5/4/2012 Y
5/10/2012
40
Radiology (Section 2.16) # 16.26 16.27 16.28 16.29 Tasks/Initiatives Accountability Work Stream 5.1 2.2 2.2 2.2 Target Date 5/11/2012 6/8/2012 6/8/2012 9/14/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
Patricia Bergen, Collate all credentialing documents and provide to the committee for review and approval. MD Ensure a person who is approved to operate the mini-fluoroscopy unit is in procedures where the surgeon has not been Brad Simmons granted privileges. Jenni Burnes Brad Simmons Develop an interface or investigate on how to tie in an alert of physicians privileges at point of scheduling a procedure. Jenni Burnes Inquire and implement a functionality in Epic for the ordering physician to cognitively select whether to use the establish Brad Simmons protocol or use orders as written. Jenni Burnes Audit/Measures Compliance to use of two patient identifiers Compliance to the Time Out procedure Compliance to proper securing of medications and medication supplies (needles, syringes) Backlog for each modality or IR procedure Compliance to medication management (labeling, scrub and circulator exchange) Accountability
# 1 2 3 4 5
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
# 1 2
Metric Labor productivity by each modality Number of days to next third available appointment (Mammography, US, MRI) Mammography - Diagnostic MRI CT US Number of Incorrect consents Number of incorrect tests or wrong results placed Number of cancelled surgeries due to unavailable films Number of medication errors Number of lab specimen mis-labeling Number of drug diversions Next third available appointment for each imaging modality or IR procedure Number of wrong site surgeries
Current
CYE 2012 Goal
Radiology Radiology Radiology Radiology
101 47 27 11
14 14 14 14
3 4 5 6 7 8 9 10
Comments 16.19 - Pending education module to be delivered
5/10/2012
41
Laboratory Services (Section 2.17) # Tasks/Initiatives Accountability Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Brad Simmons Jenni Burnes Kim McCloud Linda Licata Barbara Mims Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Suzanne Sims Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Work Stream 2.2 2.2 2.7 Target Date 3/30/2012 5/11/2012 4/6/2012 Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
17.01 Develop education plan for phlebotomy staff including new orientees. 17.02 Conduct random audits of phlebotomy carts. 17.03 Ensure there is a regular cleaning schedule with EVS for the affected Laboratory areas.
17.04 Establish environment of care rounds with EVS and Infection control leaders.
2.8
4/6/2012
17.05 Initiate department-level Infection Control accountability and metrics. 17.06 Educate laboratory staff on expected cleaning standards and schedules. 17.07 Define with EVS an escalation process for cleaning. 17.08 Utilize reagent that requires validation of results prior to testing. 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.
2.8 2.2 2.7 2.2 2.2 2.2 2.2 2.2 2.2 2.5 2.2 2.2 2.2 2.2
5/15/2012 4/13/2012 4/13/2012 3/23/2012 6/8/2012 5/25/2012 4/13/2012 4/13/2012 6/8/2012 4/6/2012 6/8/2012 5/11/2012 6/8/2012 6/8/2012 Y Y Y Y Y
17.10 Listen to periodic transcription tapes to ensure transcriptionist is reporting variances. 17.11 Review Parkland reporting critical value policy. 17.12 Develop and implement an education plan and competencies on critical value reporting. 17.13 Monitor the effectiveness of the education program with the turnaround time of the critical value reporting. 17.14 Review Parkland policy Admin 6-30 Universal Protocol. 17.15 Conduct five weekly random Time Out observations in the FNA clinic. 17.16 Collect Time Out observation results and add to clinic QAPI indicators. 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.
17.18 Provide Medical Assistant staffing for FNA clinic.
5/10/2012
42
Laboratory Services (Section 2.17) # 17.19 Tasks/Initiatives Meet with MIO and an Epic representative to enhance Epic documentation to hardwire autopsy documentation requirements. Accountability Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Work Stream 2.2 2.2 4.4 2.2 Target Date 4/27/2012 6/8/2012 4/6/2012 6/8/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
17.20 Add autopsy documentation requirements to dictation template, including pathology checklist. 17.21
Educate morgue staff on required two identifier process and their empowerment to stop the autopsy without proper Emilie Allen consent. Perform audit of autopsy records for evidence of family communication, pathology notification by nursing, consent, and Brad Simmons 17.22 any other required elements. Jenni Burnes # 1 2 3 4 Audit/Measures Compliance to accession and grossing the specimen by audit Compliance to the use of the two patient identifiers with transcription post specimen processing by audit Percentage of autopsies without an order Compliance to staffing grid Accountability
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
# 1 2
Metric Number of incorrect reporting of lab/pathology results Dwell time for when the lab specimen received to lab result reported for critical tests
Current
CYE 2012 Goal
Comments 17.12 - Requires solution for content delivery methodology for Faculty. Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
5/10/2012
43
Food & Nutrition Services (Section 2.18) # 18.01 18.02 18.03 Tasks/Initiatives Change procedure to ensure all unused trays are collected after meals. Educate nursing staff to communicate with F&NS to re-order or hold a tray if a patient is not available for a meal. Acquire thermometers for freezers. Accountability Brad Simmons Jenni Burnes Kim McCloud Linda Licata Brad Simmons Jenni Burnes Accountability Work Target Stream Date 2.2 2.8 2.2 4/6/2012 4/13/2012 4/6/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y Y Y
# 1 2
Audit/Measures Compliance with freezer temperature ranges for patient refrigerators Compliance with all patient are proper temperature controlled food
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
# 1 2 Comments Number of returned "uneaten" trays Number of "hold" tray orders for patients
Metric
Current
CYE 2012 Goal
5/10/2012
44
Organ and Tissue (Section 2.19) # Tasks/Initiatives Accountability Jackie Sullivan Emilie Allen Work Target Stream Date 6.4 4.4 9/14/2012 9/14/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
19.01 Develop a process to ensure Organ Procurement quality improvement functions are reported to QCC regularly. 19.02 Develop documentation for annual training program attendance.
5/10/2012
45
Physical Medicine and Rehabilitation (PMR) (Section 2.20) # 20.01 Tasks/Initiatives Accountability Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Barbara Mims Valerie Harvey Brad Simmons Jenni Burnes Jackie Sullivan Jackie Sullivan Jody Springer Jody Springer Kim McCloud Linda Licata Barbara Mims Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Accountability Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 4.2 2.2 6.4 6.4 1.2 1.2 2.8 2.2 2.2 Target Date 4/20/2012 5/4/2012 5/4/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 6/8/2012 5/25/2012 9/14/2012 4/13/2012 4/20/2012 4/13/2012 6/8/2012 5/4/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
Conduct an assessment of the factors contributing to the backlog to include: demand vs. capacity, current space and labor productivity. Upon completing elements of the assessment, develop an overall current state process work flow diagram noting 20.02 process failures and operational barriers. 20.03 Analyze current staffing patterns and address shortages. 20.04 Redesign future process flows to address identified barriers. 20.05 Complete pilot of revised process flow to assess effectiveness and any additional needed changes. 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.
20.07 Identify core requirements for assessment and documentation for proper patient care and educate staff. 20.08 Develop a methodology to ensure all elements of care have been addressed and assessed. 20.09 20.10 20.11 20.12 Establish key metrics for inpatient rehab. Develop methodology to track required metrics are being reported. Determine legal requirements for DME license. Determine methodology dispensing DME (hospital vs. contract supplier).
20.13 Develop and implement Infection Prevention training. 20.14 Noncompliance with proper infection control procedures should be addressed immediately and ongoing noncompliance should result in progressive disciplinary action.
20.15 Develop methodology to track wound care infection rates.
# 1
Audit/Measures Percent of all elements of care that have been assessed and addressed
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
5/10/2012
46
Physical Medicine and Rehabilitation (PMR) (Section 2.20) CYE 2012 Goal
# 1 2 3 4 Labor productivity Infection rate Number of days to next third available appointment Vacancy rate
Metric
Current
Comments 20.01 - In progress and will be completed in May 2012, required operational excellence resources for analytics 20.13 - Training has not yet been completed.
5/10/2012
47
Respiratory Therapy (Section 2.21) # Tasks/Initiatives Accountability Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Brad Simmons Jenni Burnes Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Brad Simmons Jenni Burnes Accountability Respiratory Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.7 Target Date 4/13/2012 5/11/2012 3/22/2013 4/13/2012 6/8/2012 6/8/2012 9/14/2012 9/14/2012 4/6/2012 Y Y Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion Y
21.01 Analyze staffing levels and provided recommendations. 21.02 Adjust staffing and/or shifts to agreed upon staffing grid. 21.03 Develop targeted improvement in missed treatments and a timeline for expected improvements. 21.04 Explore the ability to analyze missed treatments per shift through Epic. 21.05 Determine a mechanism to track assigned, completed, and missed by therapist through a daily shift report document. 21.06 Documentation educational program for all Respiratory Therapy (RT) staff. 21.07 Initiate documentation review process to ensure patient quality of care. 21.08 Initiate patient rounds to obtain feedback regarding effectiveness of respiratory treatments. 21.09 Review the current oxygen tank use, storage, and refilling procedure for gaps in guidance to both RT staff as well as other clinicians. Meet with clinical leaders who store oxygen tanks and determine responsibilities of staff in which oxygen tanks are stored.
21.10
2.7
4/13/2012
21.11 Develop a house-wide education/awareness for all staff that addresses all areas of responsibility.
2.7
5/11/2012
21.12 Audits of oxygen tank safety. 21.13 Long term strategy for an annual assessment of therapy care to ensure that there are no gaps in process or care.
2.7 2.2
5/1/2012 9/14/2012
# 1 2 3
Audit/Measures Number of mussed treatments per month Number of vent days/month Compliance in oxygen tank storage
Goal
Mar-12
Apr-12 665
May-12
Jun-12
Jul-12
Aug-12
# 1 2
Metric Productivity Metrics (Number of Billable Treatments) Number of Ventilator Associated Pneumonia patient days
Current
CYE 2012 Goal
Respiratory
3.29%
4.51%
1.8%
5/10/2012
48
Respiratory Therapy (Section 2.21) Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
5/10/2012
49
Community Oriented Primary Care (COPC) (Section 2.22) # Tasks/Initiatives Accountability Anne Tudhope Judy Herrington Vicki Crane Vivian Johnson Dr. Shannon Anne Tudhope Judy Herrington Vicki Crane Vivian Johnson Dr. Shannon Anne Tudhope Judy Herrington Vicki Crane Work Stream Target Date Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
22.01 Develop medication documentation training program for all staff responsible for medication administration.
4.5
6/8/2012
22.02 Develop and implement processes to reconcile controlled substances in Medlock clinic.
2.3
3/23/2012
22.03 Develop and implement audit tool to track controlled substance reconciliation.
4.5
5/11/2012
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.
2.3
6/20/2012
22.05
Review results of Medicine specialty clinic pilot and determine viability of implementation to other clinics for medication reconciliation solution.
4.5
5/11/2012
22.06 Formulate alternative solution to medication reconciliation issue.
4.5
5/11/2012
22.07
22.08
22.09
22.10
22.11
Jessica Hernandez Holt Oliver, MD Jessica Hernandez Create comprehensive environment of care gaps. Holt Oliver, MD Kim McCloud Meet with the appropriate leaders responsible for environmental cleaning and maintaining the environment to discuss the Linda Licata gaps and develop plan for improvement. Barbara Mims Kim McCloud Establish multi-disciplinary monitoring of clinic locations. Linda Licata Barbara Mims Jessica Hernandez Load plans of care into Jail electronic medical record (EMR). Holt Oliver, MD 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.
3.6
4/6/2012
3.6
6/8/2012
2.7
5/11/2012
2.7
6/8/2012
3.6
6/8/2012
5/10/2012
50
Community Oriented Primary Care (COPC) (Section 2.22) # Tasks/Initiatives Accountability Barbara Mims Valerie Harvey Jessica Hernandez Holt Oliver, MD Barbara Mims Valerie Harvey Accountability Work Stream 4.2 Target Date 8/1/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
22.12 Conduct training for staff on plan of care standards and proper documentation and individualized plan of care.
22.13 Conduct a chart audit to evaluate staff compliance regarding plan of care process.
3.6
6/8/2012
22.14 Develop a process for patients who do not have a common diagnosis and their plan of care.
4.2
6/15/2012
# 1 2 3 4 5
Audit/Measures Compliance with medication meangement to include but not limited to securing, labeling , reconciliation and documentation Compliance percentage of environement of care by audit, monthly Compliance to the use of two patient identifiers Compliance to proper medication management (labeling, documentation and securing) Number of completed medication reconciliations by audit
Goal
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
# 1 2 3 4 5 6
Metric Number of medication errors Number of lab specimen mis-labeling by clinic Number of completed work orders (EVS, Facilities, and Clinical Engineering) Third next available appointment No show rate by clinic Number of narcotic discrepancies at the jail
Current
CYE 2012 Goal
5/10/2012
51
Specialty Clinics (Section 2.23) # 23.01 Ensure hard-stop process in Epic is engaged. Tasks/Initiatives Accountability Vivian Johnson Dr. Shannon Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Suzanne Sims Suzanne Sims Accountability Work Stream 2.3 Target Date 9/14/2012 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
23.02 Determine EVS scope and schedule.
3.6
3/30/2012
23.03 Clinic leadership to round clinic areas to monitor PHI security.
3.6
6/8/2012
23.04 Clinic leadership to develop and implement disciplinary actions for staff violations of HIPAA policies. 23.05 Develop clinic-wide training and awareness program for proper time-out procedure. 23.06 Conduct time-out training for all areas where patient procedures are performed. # 1 2 3 4 5 Audit/Measures Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation Compliance percentage of environement of care by audit, monthly Compliance to the use of two patient identifiers Compliance to proper medication management (labeling, documentation and securing) Number of completed medication reconciliations by audit
3.6 2.5 2.5
5/7/2012 4/27/2012 9/14/2012 Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
# 1 2 3 4 5 6
Metric Number of medication errors Number of lab specimen mis-labeling by clinic Number of PHI breach Third next available appointment No show rate by clinic Number of completed work orders (EVS, Facilities, and Clinical Engineering)
Current
CYE 2012 Goal
5/10/2012
52
Specialty Clinics (Section 2.23) Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
5/10/2012
53
Contract Services (Section 2.24) # Tasks/Initiatives Accountability Muthusamy Anandkumar, MD Ciel Murphy Muthusamy Anandkumar, MD Ciel Murphy Muthusamy Anandkumar, MD Ciel Murphy Muthusamy Anandkumar, MD Ciel Murphy Muthusamy Anandkumar, MD Ciel Murphy Muthusamy Anandkumar, MD Ciel Murphy Muthusamy Anandkumar, MD Ciel Murphy Work Stream Target Date Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
24.01 Create database of all contracted patient service arrangements.
6.5
3/22/2013
24.02 Review department specific quality indicators for all contracts.
6.5
6/1/2012
24.03 Request quality monitors from vendors who have not supplied them.
6.5
6/1/2012
24.04 Determine Parkland specific quality indicators for each contract.
6.5
6/1/2012
24.05
Each department to report contract monitoring elements at the departments next regularly scheduled reporting appointment.
6.5
6/8/2012
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.
6.5
6/8/2012
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.
6.5
3/22/2013
Muthusamy Anandkumar, Contract Management Unit to provide first batch of contracts for quality score and review and proposed scores against 24.08 MD template to BOM Quality Committee. Ciel Murphy
6.5
6/8/2012
5/10/2012
54
Contract Services (Section 2.24) # 1 2 3 Audit/Measures Percent of current contracts in the database Percent of current contract that have department specific quality indicators Percent of current contracts that have PHHS specific quality indicators Accountability Goal Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
# 1
Metric Number of contracts that meet contacting requirements for quality scoring
Current
CYE 2012 Goal
5/10/2012
55
QAPI # Tasks/Initiatives 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 Approval of QAPI plan by the QCC and BOM Quality Committee. Capture and analyze baseline data from initial tracers for survey readiness. Develop and implement corrective action plan for survey readiness Accountability Work Stream Target Date Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Completion
Q.01
Jackie Sullivan
6.1
5/25/2012
Q.02 Q.03 Q.04
Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan
6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.4 6.4 6.1
5/25/2012 4/27/2012 5/25/2012 4/27/2012 4/27/2012 5/11/2012 5/11/2012 5/11/2012 5/25/2012 5/25/2012 5/18/2012 4/27/2012 5/25/2012 5/25/2012 5/25/2012 5/25/2012
Q.05 Performance Improvement group should implement rounding as a method to collect data for adverse patient events Q.06 Performance Improvement group to develop a list of resources from which to pull adverse patient events Q.07 Develop methodology to trend, analyze and report adverse patient events Q.08 Work with A&M to improve RCA process Develop a master report of all RCAs conducted. Include incident date, date of RCA commencement, date of RCA Q.09 conclusion, general results and actions taken. Review standing reports generated by CIS and meet with end users/management to determine relevance and Q.10 meaningfulness. Discontinue generation of reporting that does not add value to end user/management. Q.11 Establish a schedule for CIS with due dates of all necessary reporting Q.12 Patient Safety to revise and standardize scoring system used to refer cases to peer review Q.13 Create survey and initial tracers to collect baseline data in the form of a Quality Assessment (QA). Q.14 Complete Quality Assessment survey and tracer work. Complete department-specific Performance Improvement (PI) plan with indicators appropriate for departments patient Q.15 population. Q.16 Implement corrective actions per departments PI plan. Q.17 Report PI plan status on at least semi-annual basis to QCC. Comments
5/10/2012
56

Parkland Memorial Hospital's Monthy Compliance Progress Report For April 2012

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Parkland Memorial Hospital's Monthy Compliance Progress Report For April 2012

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Report of the Independent Consultative Expert (ICE) Monthly Progress Report April, 2012 on Parkland Health & Hospital

May 10th, 2012

Summary of Tasks/Milestones Met on Schedule

Parkland CMS Progress Reports

Parkland CMS Progress Reports

Parkland CMS Progress Reports

Human Resources (Section 2.02) CYE 2012 Goal

9.19% 8.33% 16.86% 34.31%

Parkland CMS Progress Reports

Conduct analysis of no show rates by clinic, day, session, and provider.

3.10 3.11 3.12 3.13 3.14 3.15 3.16

1.7 1.7 1.7 3.3 3.3 2.6 2.6

7/13/2012 7/13/2012 7/13/2012 6/8/2012 8/1/2012 8/31/2012 8/31/2012

Parkland CMS Progress Reports

CYE 2012 Goal

COPC Care Mgmnt EVS ED Care Mgmnt ADT

21,922 1,928 1:13 10.98 5.1 84.49%

Parkland CMS Progress Reports

Parkland CMS Progress Reports

Parkland CMS Progress Reports

CYE 2012 Goal

Parkland CMS Progress Reports

Parkland CMS Progress Reports

CYE 2012 Goal

Parkland CMS Progress Reports

Parkland CMS Progress Reports

Parkland CMS Progress Reports

Accountability Baseline EVS EVS

Current 1:13 .02

CYE 2012 Goal 1:00

Defined as payable hours/cleanable sq ft

Parkland CMS Progress Reports

7.06 7.07 7.08 7.09

2.8 1.2 6.3 6.3

6/8/2012 6/8/2012 3/23/2012 3/23/2012

# 1 2 Infection Prevention benchmark by department

CYE 2012 Goal

Parkland CMS Progress Reports

8.02 8.03 8.04

2.3 2.3 2.3

4/5/2012 6/8/2012 5/11/2012

Establish a Medication Reconciliation task force to develop a consistently compliant process.

Conduct chart audit of medication reconciliation compliance to establish current baseline.

Evaluate appropriateness of providing pharmacy tech support for medication reconciliation.

Conduct pilot study. Collect and present results.

Parkland CMS Progress Reports

Pilot the new work flow process.

Implement new reconciliation process.

Anne Tudhope Judy Herrington Vicki Crane

Anne Tudhope Judy Herrington Vicki Crane

Revisit the cart management processes for supplies and pharmaceuticals.

Anne Tudhope Judy Herrington Vicki Crane

Anne Tudhope Judy Herrington Vicki Crane

Anne Tudhope Judy Herrington Vicki Crane

Anne Tudhope Judy Herrington Vicki Crane

Parkland CMS Progress Reports

Parkland CMS Progress Reports

Ensure compliance with new moderate sedation practice standards.

Anne Tudhope Judy Herrington Vicki Crane

Anne Tudhope Judy Herrington Vicki Crane

CYE 2012 Goal

Parkland CMS Progress Reports

9.05 9.06 9.07 9.08