BOARD OF DIRECTORS QUALITY & EDUCATION Committee of · PDF fileboard of directors quality &...

BOARD OF DIRECTORS

QUALITY & EDUCATION Committee of the Whole

MEETING

June 10, 2010, 1:00pm Lee Memorial Hospital Boardroom

2776 Cleveland Ave, Ft. Myers, FL 33901

ELECTRONIC BOARD PACKET

ALL MEETINGS ARE OPEN TO THE PUBLIC AND THE PUBLIC IS INVITED TO ATTEND Any Public Input pertaining to an agenda item is limited to three minutes and a

“Request to Address the Board of Directors” card must be completed and submitted to the Board Assistant prior to the meeting.

Any Public input is limited to three minutes and a “Request to Address the Board of Directors” card must be completed and submitted to the Board Administrator prior to meeting.

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS P.O. BOX 2218 FORT MYERS, FLORIDA

33902

QUALITY & EDUCATION 239-332-1111

COMMITTEE OF THE WHOLE MEETING

CAPE CORAL HOSPITAL Thursday, June 10, 2010

1:00 p.m. GULF COAST MEDICAL CENTER

Lee Memorial Hospital Boardroom

HEALTHPARK MEDICAL CENTER

TENTATIVE AGENDA LEE MEMORIAL HOSPITAL

THE CHILDREN’S HOSPITAL

1. CALL TO ORDER (Steve Brown, MD, Quality & Education Chairman)

THE REHABILITATION HOSPITAL The meeting of the Quality & Education Committee of the Whole of the Lee Memorial Health System Board of Directors will be called to order. Matters concerning the business of Lee Memorial Health System consisting of Gulf Coast Medical Center & Lee Memorial Hospital/ HealthPark Medical Center and its subsidiaries (HealthPark Care Center Inc., Lee Memorial Home Health, Inc., Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital, and Lee Memorial Medical Management, Inc.) may be reported, discussed and recommended by the Committee of the Whole, then referred to the Full Board of Directors for final action.

LEE PHYSICIAN GROUP

LEE CONVENIENT CARE

BOARD OF DIRECTORS

DISTRICT ONE 2. PUBLIC INPUT: Any public input pertaining to items on the Agenda is limited to three

minutes and a “Request to Address the Board of Directors” card must be completed and submitted to the Board Administrator prior to meeting.

Stephen R. Brown, M.D.

Marilyn Stout

DISTRICT TWO

3. Consent Agenda: (Approval) Richard B. Akin A. Quality & Education Committee of the Whole Minutes of May 13, 2010 Nancy M. McGovern, RN, MSM

B. HealthPark Care Center & Rehabilitation Center Annual Report DISTRICT THREE

4. Medical Staff Bylaw Revision: 7.7 Temporary Privileges (Approval) Lois C. Barrett, MBA

(Mark Greenberg, MD, System Medical Director – 10 min) Linda L. Brown, MSN, ARNP 5. Cardiac Cath Lab (Update) DISTRICT FOUR (Beth Moss, RN, MA, System Director, Invasive Cardiovascular Services - 10 min) Frank T. La Rosa Dawson C. McDaniel 6. DNVHC (Det Norske Veritas Healthcare) Post Survey Workgroup Report (Action) (Chris Crawford, System Director/Standards and Quality – 15 min) DISTRICT FIVE

James Green

7. SafeLee Initiative (Updates) Jason Moon A. Encouraging Collegial Relationships (Chuck Krivenko, MD, Chief Medical Officer–10 min) B. Tools & Behaviors (Carol Simonds, System Director, Leadership Development – 15 min)

8. Other Items

A. Pathology Dictation (Chuck Krivenko, MD, Chief Medical Officer) (Verbal Update)

9. Next Regular Quality & Education Committee of the Whole Meeting:

Thursday, August 12, 2010 - 2:00pm

Lee Memorial Hospital Boardroom, 2776 Cleveland Avenue, Fort Myers, FL 33901

10. ADJOURNMENT OF QUALITY & EDUCATION COMMITTEE

V:\PRESENTATIONS\2010\Quality-Education\061010 1pm\061010 Quality Tentative Agenda.doc

___________________ L E E M E M O R I A L HEALTH SYSTEM

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PUBLIC INPUT – AGENDA ITEMS:

Any public input

pertaining to items on the Agenda is limited to three

minutes and a “Request to Address the Board of Directors”

card must be completed and submitted to

the Board Administrator prior to meeting.

Refer to Board Policy: 10:15E: Public Addressing the Board Non-Agenda Item:Individuals wishing to address the Board on an item NOT on the Agenda, the Board office must be notified of subject matter at least seven (7) days prior to the meeting to allow staff time to prepare and to insure the matter is within the jurisdiction of the Board.

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS QUALITY & EDUCATION COMMITTEE OF THE WHOLE MEETING MINUTES

Thursday, May 13, 2010 LOCATION: Lee Memorial Hospital Boardroom, 2776 Cleveland Avenue, Fort Myers, FL 33901 MEMBERS PRESENT: Steve Brown, M.D., Chairman, Quality & Education Committee of the Whole; Richard Akin, Board Chairman; Marilyn Stout, Board Vice Chairman; Dawson McDaniel, Board Treasurer;

Nancy McGovern, Director; Jason Moon, Director; Lois Barrett, MBA, Director; Denise Heinemann, DrPH, Community Representative/Quality & Education Committee; David Berger, M.D., Community Representative/Quality & Education Committee; Tuck Wilson, M.D., Physician Leadership Council Consultant/Quality & Education Committee

MEMBERS ABSENT: Linda Brown, MSN, ARNP, Board Secretary; Frank La Rosa, Director; James Green, Director; Margaret Byrnes, Community Representative/Quality & Education Committee OTHERS PRESENT: Cathy Stephens, Board Administrator; John Wiest, Chief Operating Officer Business & Strategic Services; Larry Antonucci, M.D., Chief Operating Officer-Hospital & Physician Services;

Jon Cecil, Chief Human Resources Officer; Mary McGillicuddy, Chief Legal Officer; Mike Smith, Chief Information Officer; Chuck Krivenko, M.D., Chief Medical Officer/Clinical & Quality Services; Donna Giannuzzi, Chief Patient Care Officer; Doug Luckett, Chief Administrative Officer CCH/GCMC; Mark Greenberg, M. D., System Director Medical Staff Services; John Iacuone, Executive Director Children’s Hospital; Cynthia Christman, System Director Home Health; Sally Jackson, System Director Community Projects; Becky Watt, System Director Decision Support; Marilyn Kole, M.D., System Medical Director, Clinical Services; Kathy Bridge Liles, VP Women’s & Children’s Services; Marjory May, VP Post Acute Services; Karen Krieger, System Director Public Affairs; Jack Eikenberg, Community Representative/Planning Committee; Marliese Mooney, Community Representative/Planning Committee; Don Brown, Guest; Tyler Dupuy, Guest; Yanet Rios, M.D., Guest; Jon Burdzy, D.O., Guest; Chris Hansen, Guest; Gary Eidson, Guest; Frank Gluck, News Press/Reporter; Lisa Ayotte, Executive Secretary/Board of Directors

NOTE: Documents referred to in these minutes are on file by reference to this meeting date in the Office of the Board of Directors and on the Board of Directors website at www.lememorial.org/boardofdirectors, for public inspection.

SUBJECT DISCUSSION ACTION FOLLOW-UP MEETING

CALLED TO ORDER The Quality & Education Committee of the Whole meeting

was CALLED TO ORDER at 2:19p.m. by Steve Brown, M.D.

Chairman, Quality & Education Committee of the Whole

The Board sits as the Lee Memorial Health System Board of Directors of Gulf Coast Medical Center, Lee Memorial Hospital, HealthPark

Medical Center and the Board of Directors of its subsidiary corporations: Cape Memorial Hospital, Inc. doing business as Cape

Coral Hospital; Lee Memorial Medical Management, Inc.; Lee Memorial Home Health, Inc.; and HealthPark Care Center, Inc.

PUBLIC INPUT None at this time.

CONSENT AGENDA Steve Brown asked for approval of the following items on the Consent Agenda

A. Quality/Education Committee of the Whole Minutes of April 8, 2010 B. Risk Management Report, 2nd Qtr, FY2010 (Exhibit 1). C. Lee Memorial Home Health Executive Summary (Exhibit 2).

A motion was made by Marilyn Stout to approve the Consent Agenda consisting of the following items: A. Quality/Education Committee of the Whole Minutes of

April 8, 2010 B. Risk Management Report, 2nd Qtr, FY2010 (Exhibit 1). C. Lee Memorial Home Health Executive Summary

(Exhibit 2). The motion was seconded by Dawson McDaniel and it carried with no opposition.

HOSPITALIST

PEDIATRIC

HOSPITALIST GROUP

DEPARTMENT OF MEDICINE HOSPITALIST

STANDARDS

CONTRACTING

STANDARDS FOR SUPPORTED

HOSPITALISTS

Chuck Krivenko introduced Yanet Rios, who reviewed the Pediatric Hospitalist program (Exhibit 3). She highlighted: their responsibilities; guidelines they follow while treating their patients; the hospitalist communication with primary care physicians of the patients; improved patient satisfaction scores; improved quality of care; and future plans for the pediatric hospitalists group. Chuck Krivenko introduced Jon Burdzy who gave a verbal overview of the Department of Medicine standards for Inpatient care and Hospitalist as noted on Exhibit 3. He highlighted current issues being addressed by the hospitalists, including response time and time recommended to see the patient’s primary care physician. Chuck Krivenko presented Contracting Standards for Supported Hospitalist (Exhibit 4). He reviewed: physicians’ perceptions of hospitalist services; aspects of hospitalist services; and contracting standards for supported hospitalist. He said the patient does have the option to select their own hospitalist group.

A motion was made by Marilyn Stout to endorse the Medical Staff Department of Medicine standards for hospitalists (Medical staff standards to be distinguished from contracted standards). The motion was seconded by Dawson McDaniel and it carried without opposition.

http://www.lememorial.org/boardofdirectors

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS QUALITY & EDUCATION COMMITTEE OF THE WHOLE MEETING MINUTES Thursday, May 13, 2010. Page 2 of 2

SUBJECT DISCUSSION ACTION FOLLOW-UP HOSPITALISTS

CONCERNS David Berger submitted questions pertaining to the hospitalists program (Exhibit 5). Chuck Krivenko & Larry Antonucci fielded the various questions. They provided answers to the list of questions and confirmed hospitalists will be recognized as a specialist group in the next few years, noting some have been doing this for a number of years.

PATIENT SAFETY

INITIATIVE: SAFELEE

Chuck Krivenko gave a review of the Patient Safety Initiative (Exhibit 6). He highlighted: the physician education conference; educational training for staff begins in June; communication group and website is up and running; clinicians added to the physician safety group; recommendations of the physician safety group for safe communications; and announced the new cultural transformation group has been assimilated.

PATHOLOGY DICTATION

Tuck Wilson gave a verbal update on pathology dictation situation. He said in working with Dr. Levine there is still a problem with the anatomic pathology reports. Information Systems, the wave coaches along with the medical staff will be working on this issue. Discussion ensued.

Follow-up report as available

MEDICAL STAFF:

PRE-APPLICATION POLICY

Mary McGillicuddy reviewed the Pre-Application/Minimum Criteria for Appointment Policy (Exhibit 7). Any disputes will be brought to the credentialing committee. Prior to today, this policy has been approved by all Medical Executive Committees, with exception of Cape Coral Med Exec, who will be taking action this evening.

A motion was made by Marilyn Stout to adopt the Pre-Application/Minimum Criteria for Appointment Policy (Exhibit 7). The motion was seconded by Nancy McGovern and it carried with no opposition.

ORGANIZATIONAL

PERFORMANCE SCORECARD 1ST QTR

FY2010

Becky Watt reviewed the Organizational Performance Scorecard 1st Quarter FY2010 (Exhibit 8). Highlights of the report included: re-admits, safety outcomes and mortality rates. Pediatrics has been removed from this report to separate the data. Next quarter, there will be two reports brought to the Board. Doing fantastic with blood stream infection rates; patient satisfaction is improving.

A motion was made by Denise Heinemann to accept the Organizational Performance Scorecard 1st Qtr FY2010 (Exhibit 8). The motion was seconded by Nancy McGovern and it carried with no opposition.

OTHER ITEMS

CALENDAR CHANGES

FOR BOARD MEETINGS

Steve Brown asked when the changes from the Governance meeting will take place. Cathy Stephens explained the proposed changes will be voted on at the May 27th Full Board Meeting, noting if approved, these changes will take place in June. Discussion ensued.

NEXT REGULAR

MEETING The next REGULAR Quality & Education Committee of the Whole meeting is

June 10, 2010 1:00pm. Lee Memorial Hospital Boardroom, 2776 Cleveland Avenue Fort Myers, FL 33901

ADJOURNMENT The Quality & Education Committee of the Whole meeting

was ADJOURNED at 4:03 p.m. by Steve Brown, M.D., Chairman, Quality & Education

Committee of the Whole.

Minutes were recorded by Lisa Ayotte, Executive Secretary/Board of Directors Office ________________________________________________________________ Linda Brown, MSN, ARNP, Board Secretary

V:\PRESENTATIONS\2010\Quality-Education\061010 1pm\HPCC - MAY 2010.doc Page 1 of 2

LEE MEMORIAL HEALTH SYSTEM BOARD OF DIRECTORS ENTITY REPORTING EXECUTIVE SUMMARYENTITY REPORTING EXECUTIVE SUMMARY

ENTITY/BUSINESS NAME: Health Park Care & Rehabilitation Center

DIRECTOR & TITLE: Nancy Zant, Administrator REPORT DATE: June 2010

BUSINESS DESCRIPTION: Health Park Care & Rehabilitation Center is a 112 bed skilled nursing facility licensed by both Medicare and Medicaid. HPCRC provides rehabilitative, short-term as well as long term care services. We provide skilled nursing care to both geriatric, as well as younger patients who require our rehab services.

MISSION STATEMENT: Our mission is to be the best skilled nursing facility in SW Florida by: Ensuring financial viability of HPCRC and updating facility to meet the needs of the community. Attracting, developing, and retaining highly qualified staff to deliver exceptional clinical care and service. Developing profitable specialty programs and building strong brand loyalty to HPCRC internally and externally.

SYSTEM GOAL: Financial Performance • Major Accomplishments • Scorecard Performance

o Revenue o Profit/Loss o Explanation of major variances

• Key Utilization Trends

April 2010 YTD Budget Actual Prior Year

Net Revenue Profit/Loss

$7,033,419

823,760

$6,975,329

837,218

$6,675,124

860,537

• Actual and prior year profits do not include post acute credit, which represents offset of expense for uncompensated care. This increased from $180,922 prior year to $280,671.

• Medicare daily rate increased from $429 prior YTD to $450 YTD in 2010.

• Total net revenue favorable $300,205 as compared to prior year.

• Case Mix Index increased from 2.95 prior year to 3.18

• Positive financial performance compared to prior years and 2010 budget.

• Bad debt expense reduced by 80% over prior year.

SYSTEM GOAL: Quality • Major Accomplishments • Scorecard Performance

o LOS Trends o Outcome Data

• No agency in over three years. • Above average Quality Measures. • 5 Star rating AHCA • 4 Star rating CMS • Person Centered Care Model implemented

SYSTEM GOAL: Service • Major Accomplishments • Scorecard Performance

o Inpatient Satisfaction o Outpatient Satisfaction

• Press Ganey “Likely to Recommend” 84 % for

first two quarters FY 2010 • Name Change: Health Park Care and

Rehabilitation Center to better reflect the markets served

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SYSTEM GOAL: People • Major Accomplishments • Scorecard Performance

o Employee Satisfaction o Vacancy Rates o Personnel Turnover

• Annual turnover rate 14.45% • Staff vacancy rate .57%

SYSTEM GOAL: Community • Major Accomplishments • Scorecard Performance

o Market Share o Community Preference

• Excellent reputation in the community. • Increased number of LMHS referrals. • Sub Acute/Rehab Unit. • RN’s, LPN, C.N.A. students being trained on

sight from Edison, FGCU and Lee VoTech.

Key Challenges & Opportunities • Market Overview

o Key Competitive Developments o Key Legislative or Political Developments o Key Technology Developments o Potential New Ventures and/or Businesses

• Opportunity to further increase Medicare per

diem reimbursement. • IS Capital Projects requested to automate

medication pass and capture ADL’s for reimbursement (EMar, Caretracker)

• Medicare reimbursement reductions anticipated• Medicaid 7% rate reduction vetoed by

Governor Crist.

BOD/Forms/Entity Reporting Executive Summary Form revised 6/1/10

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4. Medical Staff Bylaws Revision:

7.7 Temporary Privileges

(Approval)

(Mark Greenberg, MD, System Medical Director,

Medical Staff Services – 10 min)

CCH, GCMC, HPMC, LMH & TCH Proposed M.S. Bylaws Revision

DRAFT 7.7 Temporary Privileges

7.7.1 Temporary privileges may be granted by the CEO, or designee, acting on behalf

of the Board and based on the recommendation of the President of the Medical Staff or designee to be approved at the next FMEC meeting, provided there is verification of current licensure and current competence. Temporary privileges may be granted only in two (2) circumstances: 1) to fulfill an important patient care, treatment or service need, or 2) when an initial applicant with a complete application that raises no concerns is awaiting review and approval of the FMEC and the Board. Applications pending completion of the initial appointment process must always be reviewed and a recommendation made by the System Credentialing/Privileging Committee prior to the granting of temporary privileges.

7.7.2 Important Patient Care, Treatment or Service Need: Temporary privileges may be granted on a case-by-case basis when an

important patient care, treatment or service need exists that mandates an immediate authorization to practice, for a limited time, not to exceed 120 30 calendar days (from date privileges are granted). Temporary privileges may be extended for two separate 30-day intervals upon approval of the Board of Directors. For the purposes of granting temporary privileges, an important patient care, treatment or service need is defined as including the following:

7.7.2.1 a circumstance in which one or more individual patients will experience

care that does not adequately meet their clinical needs if the temporary privileges under consideration are not granted, (i.e., a patient scheduled for urgent surgery who would not be able to undergo the surgery in a timely manner);

7.7.2.2 a circumstance in which the institution will be placed at risk of not

adequately meeting the needs of patients who seek care, treatment or service from the institution if the temporary privileges under consideration are not granted (i.e., the institution will not be able to provide adequate emergency room coverage in the providers specialty, or the Board has granted privileges involving new technology to a physician on the staff provided the physician is precepted for a specific number of initial cases and the precepting physician, who is not seeking Medical Staff membership, requires temporary privileges to serve as a preceptor);

7.7.2.3 a circumstance in which a group of patients in the community will be

placed at risk if not receiving patient care that meets their clinical needs if the temporary privileges under consideration are not granted (i.e. a physician who has a large practice in the community for which adequate coverage of hospital care for those patients cannot be arranged).

7.7.3 Clean Application (Expedited) Awaiting Approval: Temporary privileges may be granted for up to 120 30 calendar days (from date privileges are issued) approved by the Executive Committee with two 30-day extensions approved by the Board (see the policy and procedure on Expedited Credentialing) when the new applicant for Medical Staff membership and/or privileges is waiting for review and recommendation by the FMEC and approval by the Board.

04-06-10 - Recommended by System Credentials Committee April, 2010 – approved by CCH, GCMC, HPMC, LMH & TCH FMECs June, 2010 – approved by CCH, GCMC, HPMC, LMH & TCH Medical Staffs

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L E E M E M O R I A L HEALTH SYSTEM BBBOOOAAARRRDDD OOOFFF DDDIIIRRREEECCCTTTOOORRRSSS

UPDATE REPORT TO THE BOARD (No Action Required)

DATE: 5/13/2010 NAME OF SERVICE LINE/ENTITY UPDATE: Cape Coral Hospital Cardiac Cath Lab PERSON RESPONSIBLE & TITLE: Beth Moss, RN, MA, System Director, Invasive Cardiovascular Services KEY ACCOMPLISHMENTS - Providing safe, quality care in the Cardiac Cath Lab at Cape Coral Hospital GOALS (MET) To demonstrate quality outcomes for Cardiac Cath procedures in the Cape Coral Hospital Cath Lab.

GOALS (UNMET) None

FINANCIAL STATUS (including cash flow statement, projected cash flow, balance sheet and income statement) N/A PROBLEMS/ISSUES Concern that process for patients having a diagnostic cath at Cape Coral Hospital and then transferred to HealthPark for an intervention is not quality care. ANTICIPATED NEEDS None SUMMARY/COMMENTS

Comparison Data Time Frame- 7/1/09-4/30/10

Total Diagnostic Cape Coral Hospital Diagnostic Cath Patients- 189

Patients Cathed at Cape Coral Hospital with Intervention at HealthPark Total- 12 patients (6.3%) transferred by EMS with sheath in place

Complications from transporting with sheath in place- 0 Patients requiring additional access- 0

Average Fluro Time- 17.2 minutes Average Contrast Amount- 188cc’s

Patients Cathed at HealthPark and had Intervention at HealthPark

Sample Size- 12 patients Average Fluro Time- 12.4 minutes Average Contrast Amount- 153cc’s

Cape Coral Hospital Cath Lab Mortality Rate- 0

Cape Coral Hospital Cath Lab Morbidity Rate (Groin Complications)- 0

BOD/Forms/Board UPDATE Report to the Board Form (Blue Form) – Updated 090209cs

Keep form to one page, SUBMIT (thru SLC Member) ELECTRONICALLY to L Drive – Miscellaneous - BOD Presentations by Noon the Friday before you’re scheduled on agenda.

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RECOMMENDED ACTION FOR BOARD APPROVAL (Action includes Acceptance, Approval, Adoption, etc)

DATE: June 10, 2010

SUBJECT: DNVHC Accreditation Work Group Post Survey Evaluation Report REQUESTOR & TITLE: Chuck Krivenko, Chief Medical Officer & Chris Crawford, System Director Standards & Quality PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations – internal groups which support the recommendation i.e. SLC, Operating Councils, PMTs, etc.)

Board Approved October 29, 2009: From October 8, 2009 Quality & Education Committee of the Whole:

Approved the recommendation to obtain Det Norske Veritas Healthcare (DNVHC) accreditation concurrently with The Joint Commission (TJC) accreditation. After accredited by DNVHC, re-evaluate continued TJC accreditation prior to next survey (2011). SPECIFIC PROPOSED MOTION: Motion subject to Board’s review of post evaluation results. PROS TO RECOMMENDATION

CONS TO RECOMMENDATION

LIST AND EXPLAIN ALTERNATIVES CONSIDERED FINANCIAL IMPLICATIONS Budgeted ____ Non-Budgeted ____ (including cash flow statement, projected cash flow, balance sheet and income statement)

OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) SUMMARY

DNV Accreditation Survey May 17 – 20, 2010 DNVHC Work Group met on June 2, 1010 to conduct a Post-Survey Evaluation. Details and recommendations are contained in attached presentation report.

BOD/Forms/Board (Action) Reporting Form – updated 9/2/09 cs


PATIENT SAFETY WORK PRODUCT – CREATED AS PART OF THE LEE MEMORIAL HEALTH SYSTEMPATIENT SAFETY EVALUATION SYSTEM – PRIVILEGED AND CONFIDENTIAL

DNVHC Work Group Report

Quality Committee of the BoardJune 10, 2010

The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under either Florida state or federal law including but not limited to those under the Patient Safety Quality Improvement Act of 2005 and implementing regulations, 45 C.F.R. Part 3; 42 U.S.C. § 11111; §§395.0193 F.S. and 766.101 F.S.

1PATIENT SAFETY WORK PRODUCT – CREATED AS PART OF THE LEE MEMORIAL HEALTH SYSTEM

PATIENT SAFETY EVALUATION SYSTEM – PRIVILEGED AND CONFIDENTIAL

DNVHC Work Group Background Information

• DNVHC initial reviews: – Senior Leadership– Quality Safety Measurement Committee– Standards & Compliance Committee

• DNVHC Workgroup chartered February, 2009• Deliverables:

- Comparison of DNVHC and TJC- Obtain feedback from DNVHC accredited hospitals- Complete the DNVHC application process



DNV Work Group Background Information

• 3/03/09 & 05/22/09 - Work Group meetings• 6/11/09 – Presented Work Group findings to

the QC of the Board• 8/31/09 – Work Group makes

recommendation to apply for a DNV accreditation survey



DNV Work Group Background Information

• Motion approved and passed to “Obtain DNVHC accreditation concurrently with TJC accreditation and re- evaluate continued TJC accreditation prior to next survey” (Survey window 05/08/10 – 02/08/12)

• 9/08/09 – Hospital Executive Group• 9/29/09 – Senior Leadership Council• 10/08/09 – Quality Committee of the Board• 10/20/09 – Full Board



DNV Accreditation Survey Follow-Up

Was this “survey lite”?



DNV Accreditation Survey May 17 – 20, 2010

• Hospital and Outpatient Locations:• 19 Surveyors 4 days (76 surveyor days)• 17 Findings (2 – NC1; 15 NC2)• Primary Stroke Center Survey:• 2 Locations (GCMC/LMH) for one day• 1 Finding (NC2)

“Next survey will have more findings”



Work Group Post-Survey Evaluation

• 6/02/10 – Work Group Meeting• Deliverables:

- Compare previous Work Group evaluation to actual survey experience

- Obtain feedback from participants in the DNV survey

- Request recommendation on future accreditation



Post-Survey Evaluation: Likes• Involvement in selecting DNV

accreditation resulted in increased survey preparation cooperation

• DNV visited more locations, some of which were never visited by TJC

• There was no tipping point for non-accreditation therefore there was less pressure/stress

• There are only 2 levels of nonconformities which were easy to comprehend

• The company was responsiveness to our concerns during survey

• Surveyors made staff feel comfortable and were non- threatening

• Survey was comprehensive and fair • Surveyors took opportunities to

educate staff on their Standards• Surveyors were collegial and

expressed other opportunities to work with LMHS

• Surveyors offered improvement to current processes

• More frequent surveys with a process improvement focus will help improve outcomes



Post-Survey Evaluation: Dislikes• Staff not having ISO training

prior to the survey• Knowledge of surveyor roles

(clinical versus generalist focus)

• # of surveyors was initially overwhelming

• The first day of survey was not coordinated well

• Surveyor subjectivity & interpretation differences

• Some employees thought that the surveyors were too easy

• Surveyors should have drilled down deeper into the standards, i.e., Medical Staff, Restraints

• Survey was different than what we had in the past so the change was a challenge

• Some leaders felt that the surveyors lacked specialized education i.e. Infection control

• Some of the Life Safety Surveyors operated in the 'Got-Cha' mode

• Some surveyors did not solicit feedback from the staff



Post-Survey Evaluation

Did this survey process meet our strategic goals for changing?

• Consistent compliance with CMS’ Conditions of Participation.

- AHCA comments on DNV• Provide a framework for a quality

management system.- New areas for improvements



Dual Accreditation

Workgroup unanimously voted not continue with dual accreditation with TJC and DNVHC but to focus on DNVHC Accreditation and ISO 9001.

ISO 9001 baseline evaluation to be completed during 2011 survey

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UPDATE REPORT TO THE BOARD (No Action Required)

DATE: 6/10/2010 NAME OF SERVICE LINE/ENTITY UPDATE: Encouraging Collegial Relationships PERSON RESPONSIBLE & TITLE: Chuck Krivenko, MD, Chief Medical Officer KEY ACCOMPLISHMENTS A Medical Staff Seminar on “Encouraging Collegial Behaviors” was attended by > 70 physicians and 25 administrators. The purpose of the seminar by the Vanderbilt Center for Patient & Professional Advocacy was to identify disruptive behavior as a major barrier to safe, quality patient care and to educate the medical staff on a model to deal with this behavior. Dr. Gerald Hickson was the principle presenter during the conference. Dr. Steve Brown attended the seminar as a representative from the Board of Directors. The Seminar was highly rated by physician attendees. Dr. Krivenko will describe the conference and present the model and concepts that the Medical Staff learned during the sessions. GOALS (MET) Educated the medical staff on the implication of not responding to disruptive behavior and a model to prevent it.

GOALS (UNMET) Provide improvement opportunities to improve collegial relations.

FINANCIAL STATUS (including cash flow statement, projected cash flow, balance sheet and income statement) N/A PROBLEMS/ISSUES N/A ANTICIPATED NEEDS

N/A SUMMARY/COMMENTS The Educational Seminar given to members of the Medical Staff by Dr. Hickson, from the Vanderbilt Center for Patient & Professional Advocacy was very successful. A review of the seminar’s models and concepts will be presented to the board for their awareness and education.

BOD/Forms/Board UPDATE Report to the Board Form (Blue Form) – Updated 090209cs


The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under either Florida state or federal law including but not limited to those under the Patient Safety Quality Improvement Act of 2005 and implementing regulations, 45 C.F.R. Part 3; 42 U.S.C. § 11111;

§§395.0193 F.S. and 766.101 F.S.

Encouraging Collegial Relationships: Evaluating, Documenting, Treating and Monitoring Difficult

ColleaguesMay 21,22, 2010May 21,22, 2010

Gerald B. Hickson, MDJames W. Pichert, PhDCharles E. Reiter III, JD

Center for Patient & Professional AdvocacyVanderbilt University School of Medicine

[email protected] @Vanderbilt.edu

[email protected]

3

Pictures are worth a thousand words…

Let’s look at yours…

3 PATIENT SAFETY WORK PRODUCT—Created as part of LPSES - the LMHS Patient Safety Evaluation System

44PATIENT SAFETY WORK PRODUCT—Created as part of LPSES - the LMHS Patient Safety Evaluation System

5

Professionalism and Self-Regulation

5

Professionalism demands self‐regulation

• Personal

• Discipline specific

• Group

• Systems focused

All require the skills to provide and receive feedback

PATIENT SAFETY WORK PRODUCT—Created as part of LPSES - the LMHS Patient Safety Evaluation System

6

Definition of Disruptive Behavior (DB)Behavior that interferes with work or creates a hostile environment, e.g.:

– verbal abuse, sexual harassment, yelling, profanity, vulgarity, threatening words/actions;

– unwelcome physical contact; threats of harm; behavior reasonably interpreted as intimidating;

– passive aggressive behaviors: e.g., sabotage and bad-mouthing colleagues or organization

– behavior that creates stressful environments and interferes with others’ effective functioning

6

Vanderbilt University and Medical Center Policy #HR-027


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“Behaviors that Undermine a Culture of Safety”• Disruptive behaviors• Intimidating behaviors• Inappropriate behaviors• Unprofessional behavior

For purposes of this course, these terms will be used interchangeably.

Several others appear in the literature: bullying, lateral or horizontal violence


8

Barriers to Addressing DB• Lack of policies to deal with disruptive

behaviors: 30%• Lack of awareness of the impact of disruptive

behaviors on outcomes: 30%• Lack of training to deal with disruptive

behaviors: 48%• Leaders don’t apply policies consistently: 69%

June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy


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Infrastructure for Addressing Disruptive Behavior (DB)

1. Leadership commitment2. Supportive institutional policies3. Surveillance tools to capture pt/staff

allegations4. Model to guide graduated interventions5. Processes for reviewing allegations6. Multi-level professional/leader training7. Resources to help disruptive colleagues8. Resources to help disrupted staff and

patients

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Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007.


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Policies will not work if Disruptive Behavior goes

unreported and unaddressed


Apparent pattern

Single “unprofessional" incidents (merit?)

Disruptive Behavior Pyramid

Mandated Issues

"Informal" Cup of Coffee Intervention

Level 1 "Awareness" Intervention

Level 2 "Authority" Intervention

Level 3 "Disciplinary" Intervention

Pattern persists

No ∆

Vast majority of professionals ‐ no issues

Hickson GB, Pichert JW, Webb LE, Gabbe SG,Acad Med, Nov, 2007


1212

Informal: Cup of Coffee Conversation

Awareness: An Awareness Intervention

Authority: EDICTS Conversation

3 Critical Conversations


13

Principles for “Informal” Conversations• Approach using same principles as for giving bad news

to patients - maintain trust and respect• Minimize distractions (have in private or semi-private

area if possible)• Avoid tendency to downplay seriousness of incident(s)• Balance empathy and objectivity• Anticipate range of responses (push-backs)• Understand that the higher in the hierarchy, the more

difficult the conversation and reactions

13 PATIENT SAFETY WORK PRODUCT—Created as part of LPSES - the LMHS Patient Safety Evaluation System

14

Principles for “Informal” Conversations• Your role:

– To report an event– To let the colleague know that the

behavior/action was noticed (surveillance)• It’s not a control contest. (“I am coming to you

as a colleague…”)• Don’t expect thanks (but you can hope)• Know message and “stay on message”• Know your natural default (your

communication style; your “buttons”)14 PATIENT SAFETY WORK PRODUCT—Created as part of LPSES - the LMHS Patient Safety Evaluation System

15

Apparent pattern



Mandated Issues





Pattern persists

No ∆




16

Cup of Coffee vs. Awareness Intervention?

• A pattern has (appears to have) emerged.• Present the data (may be from a sophisticated

surveillance system or something less formal). The person appears to stand out.

• Ask person to “bond” with data; reflect why. (But still no diagnosis, no recommended plan);

• I will follow up…(timeframe)• Document the conversation.

16

What is the difference?


17

“Awareness” Guiding Principles

• Notify in advance what the meeting will be about– Letters marked “confidential”– Personal phone call to set meeting

• Schedule conversation - allow plenty of time to talk• Have clear set goals before having the conversation• Review the events (whatever “data” you have) to be

sure you are familiar with all the data• Have the data with you

17

Set the stage for success


18

Apparent pattern



Mandated Issues





Pattern persists

No ∆




19

Authority vs. Awareness conversation

• Pattern, no improvement• Or, singular significant event• Plan developed:

– Authority figure and individual co-develop a plan; or

– Authority figure develops and specifies plan• Clearly defined consequences if plan not

followed/doesn’t work within defined time

How do they differ?


20

“EDICTS”• Expectations• Deficiencies• Intervention• Consequences• Timeline• Surveillance


21

Some things you might say…• Expectations/Deficiencies:

– “We are here to discuss your behavior, and your behavior is not consistent with…”

– “We discussed similar behaviors (at least) once before…”– “Recall that we have a Credo (standard of conduct),

Professional Behavior policy, and behavior was not…– “We expect that our team acts …”– “Documented previous episodes when you did [or failed

to] _____.”


2222

Some things you might say…• Intervention

– “We/I/you are here to establish a plan”– “I am going to ask you to develop a plan…but I

will have to approve”


Apparent pattern



Mandated Issues





Pattern persists

No ∆




24

What about Level 3 Disciplinary Interventions?

• These must be done according to local governing bylaws, contracts, staff manuals, organizational policies

• These must be done in consultation with HR, CMO (if applicable), and institutional attorneys

• Remember Justice (for all parties involved) and Certainty (don’t go into Level 3 disciplinary interventions unless you are certain via good evidence that the individual truly stands out)


2525

Can a peer based intervention program reduce claims?

• 54 high risk physicians ID’d• Randomized to control/intervention groups• First interventions completed 4/98; yearly follow

up visits through 4/04• 4/07 – all risk management claims files reviewed

4/92-4/04 (statute of limitations)


26

~60% of those who received interventions responded with

lower patient-complaint-based risk scores.


27

Outcomes Summary

• ~60% of physicians receiving interventions reduce risk scores by median of 78%

• Vanderbilt pilot study showed 49% reductions in risk management payouts for physicians intervened upon vs. no change for those give no intervention

• (ROI at Vanderbilt has been at least 5:1)

Pichert JW, Hickson GB, Moore IN: “Using Patient Complaints to Promote Patient Safety.” In: AHRQ (Eds). Advances in Patient Safety: New Directions and Alternative Approaches, 2008.


Update: SafeLee Tools and Behaviors

LMHS Board of DirectorsQuality and Standards Committee

Thursday, June 10, 2010

This document was created as a part of the Lee Memorial Health System Patient Safety Evaluation System (LPSES). The disclosure of this document and the contents herein does not constitute a waiver of any protections afforded Patient Safety Work Product under either state or federal law including, but not limited to, those under the Patient Safety

Quality Improvement Act of 2005 and implementing regulations, 45 C.F.R. Part 3; 42 U.S.C. § 11111.

Leadership Education & Training Lasting Change in Patient Safety

Leadership Behaviors and Error-Prevention ToolsHardwiring for SuccessNext StepsQ&A

Safety Culture TransformationStep 1: Set Expectations- Define Safety Behaviors & Error Prevention

Tools proven to help reduce human error.

Step 2: Educate!- Educate leaders, staff and medical staff about

Safety Behaviors and Error Prevention Tools.

Step 3: Reinforce & Build Accountability- Practice the Safety Behaviors and make them

our personal work habits.

Lasting Change in Patient Safety!

Teamwork Skills + Error Prevention Tools

A powerful combination for error-stopping results!

Error-Prevention Tools for High Reliability Results

System safety tools are the solution.

Tools hardwire the right behaviors into daily life.

Tools help make the complex simple.

Tools capture “best practices” and ensure all team members replicate them.

Tools allow healthcare professionals to apply the art and science of healing.

Tools create team ownership of performance.

Begin Meetings With a Patient Safety Story

Put safety first on the meeting agenda

Tell a story about a patient who experienced a safety event. What happened? How could our behaviors have prevented harm?

Tell a story where our behaviors did prevent harm. How did the “good catch” occur? What did we learn and how did we share the information?

Ask staff to share their stories. Recognize those who do.

“Values that are visible are viable.”

Transmits awareness of our desired culture as it becomes a “way of life” within LMHS:

Encourage Reporting of Safety Events and Problems

Encourage reporting of all near-miss events.Remove the “shame” around reporting mistakes. Utilize IntraLee SafeLee Site. Re-educate use of Incident Reporting System.Learn the process for “common cause analysis”. Explore causes to prevent future errors. Celebrate staff who “raise the safety question”including physically going to that work unit to personally recognize individual staff members.Promote monthly Patient Safety Progress Report.

Safety leaders insist on understanding all instances of suboptimal performance.

Serious Safety Event•Reaches the patient•Results in moderate to severe harm or deathCause Analysis: RCA Required

Precursor Safety Event•Reaches the patient•Results in minimal harm or no detectable harmCause Analysis: ACA, possible RCA

Good Catch Safety Event•Does not reach the patient – error iscaught by a last strong detectionbarrier designed to prevent event

Cause Analysis: report, no formal review

PrecursorSafetyEvents

SeriousSafetyEvents

Good CatchNear Miss

Safety Event

Patient Safety Progress Report

#1 Daily Check-Ins

Conducted by CAO or other senior facility leaderOccurs every day! (365 days a year)Asks series of critical questionsReviews safety issues from last 24/next 24 hrs.Considers staffing statusHighlights any facility issuesCommunicates Plan of the Day

15-minute facility-focused “stand-up” meeting!

#2 Huddles at Start of Every Shift

2-MinuteTeambuildingMake introductionsUse eye contactInvite participation from teamSupport words with actions

Review Plan of Day (Pre-brief)Highlight critical patientsShare staffing statusShare out-of-the ordinary eventsAsk questions to check understandingAcknowledge all communications

Unit-Huddle at Start of Every Shift

#3 Round To Influence

It’s a purposeful conversation that always:Connects to a core value

Assesses knowledge, shares facts and reinforces specific behavior expectations

Identifies problems impacting the ability to follow the behavior expectations

Asks for a commitment

Influencing strategy for building commitment to a vital behavior or performance

Round To Influence

Core Value

Related to our core value of safety protecting patients and employees from harmTell a story or share facts

Can Do’s Reviews practice expectations and share facts

Concerns Asks, “What makes this hard to do?”

Commitment

Asks for a personal commitment:do it yourselfhelp others do itSTOP if you see a safety risk

Individual Conversations With Staff:

# 4 5:1 Feedback5:1 Feedback always includes the behavior and its impact on patient safety.

Reinforcing Feedback: Goal is to ensure a repeat performance!

Corrective Feedback: Goal is to eliminate inappropriate behavior.

5:1 Feedback Is…

TimelyAccurateSincereSpecific

Occurs Frequently!

Hardwiring Leadership Behaviors and Tools Into Daily Operations

Lunch and Learn for Leadership

Behaviors/Tools presented one-by-one

Opportunity to practice

Focus at monthly facility meetings

Peer-Coaches for support

Coming Soon: Team Skills and Error-Prevention Tools for Staff

Train specific skills—discrete, observable behaviors.

Train all the behaviors and tools.

Train all stakeholders, not just care providers.

Use adult learning principles:Motivation (w.i.i.f.m)Practice (skills practice)Reinforcement (feedback and coaching)Transfer (high fidelity)

Multidisciplinary sessions, 3-4 hours, 25-30 participants

Facilitated by designated internal trainers (2X2)

Multi-media, interactive sessions



OTHER ITEMS

A. Pathology Dictation (Chuck Krivenko, MD, Chief Medical Officer) (Verbal Update)



DATE OF THE NEXT REGULARLY SCHEDULED

MEETING

QUALITY Committee of the Whole

MEETING

Thursday, August 12, 2010

2:00pm

Lee Memorial Hospital Boardroom 2776 Cleveland Ave, Ft. Myers, FL 33901

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