AGENDA University Medical Center of Southern Nevada UMC ... · Committee wishes to extend the...

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AGENDA

University Medical Center of Southern Nevada UMC GOVERNING BOARD

CLINICAL QUALITY AND PROFESSIONAL AFFAIRS COMMITTEE February 11, 2019 3:00 p.m.

800 Hope Place, Las Vegas, Nevada UMC Trauma Building, ProVidence Suite (5th Floor)

Notice is hereby given that a meeting of the UMC Governing Board Clinical Quality and Professional Affairs Committee has been called and will be held at the time and location indicated above, to consider the following matters:

SECTION 1. OPENING CEREMONIES

CALL TO ORDER

1. Public Comment

PUBLIC COMMENT. This is a period devoted to comments by the general public about items on this agenda. If you wish to speak to the Committee about items within its jurisdiction but not appearing on this agenda, you must wait until the “Comments by the General Public” period listed at the end of this agenda. Comments will be limited to three minutes. Please step up to the speaker's podium, clearly state your name and address and please spell your last name for the record. If any member of the Committee wishes to extend the length of a presentation, this will be done by the Chair or the Committee by majority vote.

This meeting has been properly noticed and posted in the following locations: University Medical Center CC Government Center Third Street Building Regional Justice Ctr 1800 W. Charleston Blvd. 500 S. Grand Central Pkwy. 309 S. Third St. 200 Lewis Ave., 1st Fl. Las Vegas, NV Las Vegas, NV Las Vegas, NV Las Vegas, NV (Principal Office) City of Las Vegas City of Henderson 400 Stewart Ave. 240 Water St. Las Vegas, NV Henderson, NV

• The main agenda is available on University Medical Center of Southern Nevada’s website http://www.umcsn.com, For copies of agenda items and supporting back-up materials, please contact Terra Lovelin, Board Secretary, at (702) 765-7949. The Clinical Quality and Professional Affairs Committee may combine two or more agenda items for consideration.

• Items on the agenda may be taken out of order. • The Clinical Quality and Professional Affairs Committee may remove an item from the agenda or delay

discussion relating to an item at any time. • Consent Agenda - All matters in this sub-category are considered by the Clinical Quality and Professional

Affairs Committee to be routine and may be acted upon in one motion. Most agenda items are phrased for a positive action. However, the Clinical Quality and Professional Affairs Committee may take other actions such as hold, table, amend, etc.

• Consent Agenda items are routine and can be taken in one motion unless a Committee member requests that an item be taken separately. For all items left on the Consent Agenda, the action taken will be staff's recommendation as indicated on the item.

• Items taken separately from the Consent Agenda by Committee members at the meeting will be heard in order.

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http://www.umcsn.com/

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2. Approval of minutes of the regular meeting of the UMC Clinical Quality and Professional Affairs Committee meeting on November 13, 2018. (For possible action)

3. Approval of Agenda. (For possible action) SECTION 2. BUSINESS ITEMS 4. Receive an update from Patty Scott, Director of Clinical Quality and Patient Safety on

her observations since being at UMC; and direct staff accordingly.

5. Receive a report on current HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, reviewing trended data as well as benchmarks and initiatives for improvement; and direct staff accordingly. (For possible action)

6. Receive an update on Quality Measures and Performance Improvement activities

and direct staff accordingly. (For possible action)

7. Receive an update on ICARE4U; and direct staff accordingly. (For possible action) 8. Identify emerging issues to be addressed by staff or by the Clinical Quality and

Professional Affairs Committee at future meetings; and direct staff accordingly. COMMENTS BY THE GENERAL PUBLIC A period devoted to comments by the general public about matters relevant to the Committee’s jurisdiction will be held. No action may be taken on a matter not listed on the posted agenda. Comments will be limited to three minutes. Please step up to the speaker’s podium, clearly state your name and address and please spell your last name for the record.

All comments by speakers should be relevant to the Committee’s action and jurisdiction. UMC ADMINISTRATION KEEPS THE OFFICIAL RECORD OF ALL PROCEEDINGS OF UMC GOVERNING BOARD

CLINICAL QUALITY AND PROFESSIONAL AFFAIRS COMMITTEE. IN ORDER TO MAINTAIN A COMPLETE AND ACCURATE RECORD OF ALL PROCEEDINGS, ANY PHOTOGRAPH, MAP, CHART, OR ANY OTHER DOCUMENT USED IN ANY PRESENTATION TO THE BOARD SHOULD BE SUBMITTED TO UMC ADMINISTRATION. IF MATERIALS ARE TO BE DISTRIBUTED TO THE COMMITTEE, PLEASE PROVIDE SUFFICIENT COPIES FOR DISTRIBUTION TO UMC ADMINISTRATION.

THE COMMITTEE MEETING ROOM IS ACCESSIBLE TO INDIVIDUALS WITH DISABILITIES. WITH TWENTY-FOUR (24) HOUR ADVANCE REQUEST, A SIGN LANGUAGE INTERPRETER MAY BE MADE AVAILABLE (PHONE: 765-7949).

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University Medical Center of Southern Nevada UMC Governing Board Clinical Quality and Professional Affairs

November 13, 2018 ______________________________________________________________________________ UMC ProVidence Conference Room Trauma Building, 5th Floor 800 Hope Place Las Vegas, Clark County, Nevada November 13, 2018 9:00 a.m. The University Medical Center Governing Board Clinical Quality and Professional Affairs Committee met in the ProVidence Conference Room, Trauma Building, 5th floor, Las Vegas, Clark County, Nevada, at the time and location listed above. The meeting was called to order at the hour of 9:06 a.m. by Chair Dr. Mackay and the following members were present, which constituted a quorum of the members thereof: CALL TO ORDER Board Members:

Present: Donald Mackay, M.D - Chair Jeff Ellis (Via Phone) Renee Franklin Laura Lopez-Hobbs Barbara Fraser – Ex Officio (Via Phone)

Absent:

Also Present: Mason VanHouweling, Chief Executive Officer Tye Master, Attorney Danita Cohen, Chief Experience Officer Terra Lovelin, Administrative Assistant/Board Secretary

SECTION 1. OPENING CEREMONIES ITEM NO. 1 PUBLIC COMMENT

Chair Dr. Mackay asked if there were any persons present in the audience wishing to be heard on any item on this agenda.

Speaker(s): None

ITEM NO. 2 Approval of minutes of the regular meeting of the UMC Governing Board Clinical Quality and Professional Affairs Committee meeting on September 13, 2018. (For possible action)

FINAL ACTION: A motion was made by Member Lopez-Hobbs that the minutes be approved as recommended. Motion carried by unanimous vote.

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UMC Governing Board Clinical Quality and Professional Affairs February 13, 2017 Page 2 of 4

Chair, Dr. Mackay introduced Patricia Scott, UMC’s new Executive Director of Clinical Quality and Patient Safety.

ITEM NO. 3 Approval of Agenda (For possible action)

FINAL ACTION: A motion was made by Member Franklin that the agenda be approved as recommended. Motion carried by unanimous vote.

SECTION 2. BUSINESS ITEMS ITEM NO. 4 Receive an update on UMC Experience Team and physician and hospitalist

collaboration for HCAHPS improvement; and direct staff accordingly (For possible action)

Haley Hammond provided an update on the ICARE4U program. Observations and coaching rounds are occurring to increase patients experience

with communication about their care. Staff is spending time with Sound physicians to handle all concerns and questions immediately with patients. This is helping with patient satisfaction and shows improvements in HCAPHS as well.

Patients are also sharing positive feedback regarding those that have assisted in

their care and the Experience Team is recognizing those individuals. Ms. Cohen added that the Sound Physicians are great to work with and very

patient centered. We have a great working relationship with them. Last week the Experience Team met with a friend of Member Franklin’s and

heard about a bad experience she had at a hospital in Chicago. This bad experience was shared and the team discussed how they could have handled it and what would they have done differently. This was a great opportunity to have a discussion without passing blame or pointing fingers with the goal of avoiding a situation like this at UMC.

The PULSE magazine was shared with the Committee and an event called, The

Night Shift was highlighted. Mason and staff surprised the night shift workers with special visitors, treats and music and give always along with special visitors from the Golden Knights team including the mascot.

Member Lopez-Hobbs and the other committee members really liked that staff

did this and gave Ms. Cohen and her team kudos for such a great idea and morale booster.

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UMC Governing Board Clinical Quality and Professional Affairs February 13, 2017 Page 3 of 4 ITEM No. 5 Discuss and recommend for approval, a final set of objectives as it relates

to the Clinical Quality committee for fiscal 2019; and direct staff accordingly. (For Possible action) Mr. VanHoweling shared a few proposed goals he came up with: 1. Improve (or sustain improvement) publically reported quality measures to

meet / exceed State and National averages. These measures to include: Sepsis Core Measure bundle, VTE prevention, Early elective deliveries, Outpatient Endoscopy measures, patient influenza immunization

2. Improve (or sustain improvement) on publically reported Patient Safety Indicators to meet / exceed State and National averages. Indicators include PSI-90

3. Improvement or Maintenance of publically reported hospital acquired infections below the National SIR of 1.0. Measures include CLABI, CAUTI, MRSA and C-Diff

4. Attain employee influenza vaccination rate at or above 90%

5. Achieve compliance with CMS requirements for electronic Clinical Quality Measures. (eCQM)

6. Implement strategies to improve overall Quality Process Improvement

Patty commented that number 6 may not be a measurable goal Member Franklin commented that the first five are measurable but the challenge is that we were missing a lot of foundational elements to get the improvements. She likes number six because it helps her know where to support the CEO. Member Lopez-Hobbs suggested putting item number six at top as more of an introduction/update to the committee instead of listing it as a goal. Member Franklin suggested that instead of weighing each of these elements, we provide one number as to what they are all worth. Chair Dr. Mackay agreed with this suggestion in order to keep it simple when deciding if the goals have been met. Member Ellis commented that we struggled with looking at our overall score and he thinks we need to start looking at our year over year improvements instead of how we measure up against measurable items. How has UMC done year over

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UMC Governing Board Clinical Quality and Professional Affairs February 13, 2017 Page 4 of 4

year is more important as opposed to how we are doing compared to the national average. Member Fraser stated it’s important to keep our focus on the national standard because that is what we are being benchmarked to. Member Ellis would also like to focus on the question of, Is ICARE4U working and is it driving the results. Where is the program going? Member Lopez-Hobbs agreed with Member Ellis and added that ICARE appears to have a disconnect somewhere. She asked why it isn’t it working and who isn’t listening? Also, what is staff doing to those who are not listening and not following the principles? Member Franklin suggested that the HR Committee have a more in depth discussion on ICARE.

FINAL ACTION: A motion was made by Member Lopez-Hobbs to recommend the above discussed FY2019 Goals to the HR Committee for approval. Motion carried by unanimous vote.

ITEM NO. 6 Identify emerging issues to be addressed by staff or by the Clinical Quality

and Professional Affairs Committee at future meetings; and direct staff accordingly.

Member Franklin would like to hear from Patty, Executive Director of Quality and

Patient Safety on what she has seen since being with UMC, including her view of

our current process.

COMMENTS BY THE GENERAL PUBLIC: At this time, Chair Dr. Mackay asked if there were any persons present in the

audience wishing to be heard on any items not listed on the posted agenda. SPEAKERS(S): None There being no further business to come before the Committee at this time, at the hour of 9:51 p.m., Chair Dr. Mackay adjourned the meeting. MINTUES PREPARED BY: Terra Lovelin, Administrative Assistant APPROVED:

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2019 Priorities are the top five most important factors to patients as well as some of the lowest top box scores for UMC.

2019 UMC Goal is a 5% increase from 2018 overall score. The 2018 Score is 11 months combined into one score for each domain (note this is not an average, but calculated statistically using Top Box Scores only.)

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UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA www.umcsn.com

QUALITY/SAFETY UPDATEUMC Governing Board Committee

Clinical Quality & Professional AffairsFebruary 11, 2019

Center for Quality & Patient Safety – Hospital Quality Analytics

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• Patient Safety Program

• Risk Management

• Performance Improvement

• Quality Management

• Infection Prevention

• Regulatory Readiness

Creating a Culture of Accountability

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UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA www.umcsn.comSlide 2

• 2017 Market Charges

• UMC total $448.5M

• Assumption of 18%


• Improve or sustain publically reporting quality measures• Sepsis• VTE• Early Elective Deliveries• OP Endoscopy• Patient Influenza Immunization

• Improve or sustain publically reported PSI 90• Improve or maintain HAI below SIR of 1.0

• CLABSI• CAUTI• MRSA• C-Diff

• Attain employee influenza vaccine at or above 90%• Achieve compliance with CMS requirements for eCQM• Implement strategies to improve overall Quality/PI

FY 19 Quality Committee

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Foundation for Quality & Safety

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UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA www.umcsn.comSlide 2

• 2017 Market Charges


• Assumption of 18%


Source: Becker's Hospital Review

Patient Safety Framework

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• Focus on the customer.

• Identify and understand how the work gets done.

• Manage, improve and smooth the process flow.

• Remove non-value-added steps and waste.

• Manage by fact and reduce variation.

• Involve and equip the people in the process.

• Undertake improvement activity in a systematic way.

Performance Improvement

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Draft Quality Strategic Plan

QUALITYBetter Care

OUTCOMESBetter Health

EFFICIENCYLower Costs

1. Make Care Safe, Reliable & Efficient

2. Foster Collegiality

1. Improve Coordination of Care

2. Promote Prevention

1. Clinical Documentation Improvement

2. Resource Management

1. Improve VBP & Public Measures

2. Improve HCAHPS3. Improve Patient Safety

Framework4. Improve Regulatory

Readiness

1. Prevent HAC/HAIs2. Reduce Readmissions

1. Improve Physician Engagement

2. Reduce Variation

THREEAIMS

SIXPRIORITIES

EIGHT GOALS

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Analysis/Plan: •Sustained improvement since inception of program. Results above the national rate of 53%.•Daily surveillance and rounding•Working with Epic, Quality, Nursing to develop improved screening tools, streamline workflow (Sepsis Predictive Model)•Monthly education in Physician Lounge for CME•Continue education in Nursing Division (new hire orientation, new grad classes, face-to-face, sepsis rounds)•Code Sepsis/MERT

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PC-01 – Early Elective Delivery• 3Q2018 – 0% sustained results which is better than the state rate of 1% and national

rate of 2% (based on January 2019 Hospital Compare Report)

• Eligible cases 537/Sample size 108

VTE-6 – Hospital Acquired Potentially Preventable Venous Thromboembolism

• 3Q2018 – 0% sustained results which is better than the state rate of 1% and national rate of 3% (based on January 2019 Hospital Compare Report)

• Eligible cases 70/Sample size 70

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OP-29 Analysis• Eligible cases 18/Sample size 6• Follow-up interval for normal

colonoscopy are better than national benchmark for like facilities

• Continued review of cases, feedback provided to surgical services and providers

• Quality queried HIM for coding opportunities-Coding updated to add history of polyps and exclude cases from population

OP-30 Analysis• Eligible cases 5/Sample size 5• Follow-up interval for normal

colonoscopy are better than national benchmark for like facilities

• Continued review of cases, feedback provided to surgical services and providers.

• Improved documentation of previous colonoscopy through Epic flow sheet

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PSI-90 Composite 3Q18 Analysis/Plan:• Average of observed to expected ratios for 10 PSI’s: pressure ulcers (0), iatrogenic pneumothorax (1), CLABSI (0), fall with hip fracture (0), peri-op

hemorrhage or hematoma (7), peri-op physio-metabolic derangement (0), post-op respiratory failure (6), peri-op PE/DVT (10), post-op sepsis (4), post-op wound dehiscence (1), and accidental puncture/laceration (2).

• PI nurse reviews all PSIs – since the beginning of 2018, she has worked with physicians and coding to overturn 37 PSIs, 3 of which were in 3Q18, down from 12 in 2Q18.

• Daily surveillance and rounding• Monthly education in Physician Lounge for CME

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MRSA & C-DIFF

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UMC Electronic Clinical Quality Measures (eCQM) Analysis: • Submission due date to CMS February 28, 2019 – via Medisolv• Submission due date to TJC March 15, 2019 – via Medisolv• Compliance for CY2018 is to submit 1 self reported quarter that includes 4 measures – UMC is submitting STK-2, STK-3, STK-5, STK-6 for 4Q18• Last reported National Rates from CY2015 Abstracted Measures: STK 2 = 99%; STK 3 = 97%; STK 5 = 98%; STK 6 = 97%

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DISCUSSION / QUESTIONS


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