BOARD QUALITY REVIEW COMMITTEE OPEN AGENDA · 1/16/2017 · board quality review committee monday...

BOARD QUALITY REVIEW COMMITTEE

MONDAY JANUARY 16, 2017 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:30 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 6:00 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025

OPEN AGENDA

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM

Time Form A Page

#

Target

CALL TO ORDER 6:00

Establishment of Quorum ............................................................................................................. 1 N/A 6:01

Public Comments 1 ....................................................................................................................... 15 N/A 6:16

Information Item(s)

1. *Review/Approve: Minutes – Monday, November 21, 2016 (ADD A, Pages 10-15) ......... 5 3 6:21

2. *Review/Approve: 2017 BQRC Bylaws Section and Board Member Position Description (ADD B, Pages 16-18) ........................................................................................................... 1 4 6:22

3. *Review/Approve: 2017 BQRC Meeting/Reporting Calendar (ADD C, Pages 19-20) .......... 1 5 6:23

Standing Item(s)

4. Journal Club Assignment: - The existing state of the Board Quality Review Committee versus Recommendations of

the Governance Institute. (ADD D, Pages 21-45) ............................................................

10 6 6:33

Old Business

5. Continued Discussion on Patient Family Advisors (ADD E, Pages 46-74) ......................... a. Accountability – Leslie Solomon, VP, Culture Talent Planning b. Just Culture – Leslie Solomon, VP, Culture Talent Planning c. Patient/Family Representatives - Tina Pope, Manager, Service Excellence Presentation – 10 minutes Questions & Answers – 5 minutes

15 7 6:48

New Business

6. Diabetes Health Program (ADD F, Pages 75--90) .......................................................... Alan Conrad, MD, MMM, CPE, FAAPL, FACHE, Executive Vice President, Physician Alignment, Medical Director, Diabetes Health Program Valerie Martinez, Director, Quality, Patient Safety & Infection Prevention and Control Tamrah Jennings, RN, MSEd, MSN, RN, ACCNS-AG, Diabetes Clinical Nurse Specialist Presentation – 10 minutes Questions & Answers – 5 minutes

15 8 7:02

7. Stroke Program (ADD G, 91-100) ................................................................................... Rema Paduga, MD, Medical Director Stroke Program Valerie Martinez, Director, Quality, Patient Safety & Infection Prevention and Control Lourdes Januszewicz, MSN, APRN, ACNS-BC, CCRN, District Stroke Program Coordinator and Clinical Nurse Specialist – Float Pool Team Presentation – 10 minutes Questions & Answers – 5 minutes

15 9 7:17

Public Comments 1 ....................................................................................................................... 15 N/A 7:33

ADJOURNMENT 7:33

NOTE: The open session agenda, without public comments, is scheduled for 1 hour, 3 minutes. Based on above

agenda, without public comments the meeting starts at 6:00 pm and adjourns at 7:03 pm.

1

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MONDAY JANUARY 16, 2017 PALOMAR HEALTH LEARNING & DEVELOPMENT CENTER 5:30 p.m. Buffet Dinner for Committee members & invited guests IEXPLORE CONFERENCE ROOM 6:00 p.m. Meeting 418 E. GRAND AVENUE, ESCONDIDO, CA 92025

OPEN AGENDA

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM

Board Quality Review Committee Members

VOTING MEMBERSHIP NON-VOTING MEMBERSHIP

Joy Gorzeman, RN – Chairperson, Board Member Bob Hemker, FACHE, President & CEO

Hans Sison, LVN, Board Member Frank Beirne, FACHE, EVP, Operations

Dara Czerwonka, MSW, Board Member Alan Conrad, MD, EVP, Physician Alignment

Frank Martin, MD - Chair of Medical Staff Quality Management

Committee for Palomar Medical Center Escondido Della Shaw – EVP, Strategy

Ed Gurrola, MD - Chair of Medical Staff Quality Management

Committee for Palomar Medical Center Poway Maria Sudak, RN, MSN, CCRN, NEA-BC – VP, Palomar Medical Center Escondido

Jeannette Skinner, RN, MBA, FACHE -VP, Palomar Medical Center

Poway and Palomar Medical Center Downtown Escondido Sheila Brown, RN, MBA, FACHE – VP, Continuum Care

Karen Buckley, CNO, Palomar Medical Center Escondido

Larry LaBossiere, MBA, MSN, RN, CNS, CEN, Palomar Medical Center

Poway Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient Safety Committee

Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Co-Chair of Patient Safety Committee

NOTE: If you have a disability, please notify us by calling 760-740-6353, 72 hours prior to the event so that we may provide reasonable accommodations

Asterisks indicate anticipated action. Action is not limited to those designated items. 1

5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in meeting room.

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Attendance Roster and Minutes Board Quality Review Committee Meeting

Monday, January 16, 2017

Form A

TO: Board Quality Review Committee MEETING DATE: Monday, January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive

Assistant Background: The minutes of the Board Quality Review Committee

meeting, held on Monday, November 21, 2016, are respectfully submitted for approval. Also included is the attendance roster for the Committee’s review.

Budget Impact: N/A

Staff Recommendation: Approval

Committee Questions:

COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time:

3

2017 Board Quality Review Committee Bylaws Section and Board Member Position Description

Form A


Assistant Background: The 2017 Board Quality Review Committee Bylaws

Section and Board Member Position Description is respectfully submitted for approval.

Budget Impact: N/A




4

2017 Board Quality Review Committee Meeting / Reporting Calendar

Form A


Assistant Background: The 2017 BQRC Meeting / Reporting calendar is

respectfully submitted for approval.

Budget Impact: N/A




5

Journal Club Article

The Governance Institute – “The existing state of the Board Quality Review Committee versus Recommendations of the Governance

Institute”

Form A


Assistant Background: The reading for the BQRC Journal Club is a White Paper

written by The Governance Institute. The paper is titled,

“The existing state of the Board Quality Review Committee

versus Recommendations of the Governance Institute”.

Budget Impact: N/A

Staff Recommendation: For information only



6

Continued Discussion on Accountability, Just Culture and Patient/Family Representatives

Form A

TO: Board Quality Review Committee MEETING DATE: Monday January 16, 2017 FROM: Deborah Hollick on behalf of Christine Breese, Executive

Assistant Background: Leslie Solomon, VP Culture Talent Planning will provide a

presentation on Accountability and Just Culture. Tina

Pope, Manager Service Excellence will provide a

presentation on the Patient Family Advisors Orientation to

Palomar Health for a continued discussion on

patient/family advisors participating on identified Medical

Staff and Board related meetings.

Budget Impact: N/A

Staff Recommendation: Approval for vetted Patient/Family Advisory members participation on identified Medical Staff and Board related meetings.



7

Annual Diabetes Health Program Report

Form A


Assistant Background: Alan Conrad, MD, EVP Physician Alignment & Medical

Director for Diabetes Health, Valerie Martinez, Director

Quality, Patient Safety and Infection Prevention and

Control and Tamrah Jennings, RN Diabetes Clinical Nurse

Specialist will present the annual Diabetes Health Program

Report.

Budget Impact: N/A




8

Annual Stroke Program Report

Form A


Assistant BACKGROUND: Rema Paduga, MD, Medical Director Stroke Program,

Valerie Martinez, Director Quality, Patient Safety and Infection Prevention and Control and Lourdes Januszewicz, RN, District Stroke Program Coordinator will present the annual Stroke Program Report.

Budget Impact: N/A




9

ADDENDUM A

10

11.21.16 - MINUTES - BQRC Meeting - DRAFT

BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, NOVEMBER 21, 2016

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY

FINAL?

CALL TO ORDER

The meeting – held in Conference Room E at Palomar Medical Center Poway, 15615 Pomerado Road, Poway, CA 92064 – was called to order at 6:00 p.m. by Committee Chair, Dr. Aeron Wickes.

ESTABLISHMENT OF QUORUM

Quorum comprised of Board Directors: Wickes, Greer, Czerwonka

Excused Board Absences: None

NOTICE OF MEETING

Notice of Meeting was posted at Palomar Health Administrative Office; also posted with full agenda packet on the Palomar Health website on Monday, October 10, 2016 which is consistent with legal requirements. Notice of that posting was also made via email to the Board and staff.

PUBLIC COMMENTS

There were no public comments.

*INFORMATION ITEMS

1. *Minutes: Board Quality Review Committee Meeting – Monday, October 17, 2016

No discussion MOTION: by Director Greer, second by

Director Czerwonka and carried to approve the October 17, 2016, Board Quality Review Committee (BQRC) meeting minutes. All in favor. None opposed

N/A Y

STANDING ITEM(S)

1. Quality and Patient Safety Posters

Committee reviewed Falls and Catheter Associated Urinary Tract Infection (CAUTI) reduction process improvement posters, which were recently presented at the Hospital Quality Institute

None None Y

2. Journal Club

Committee discussed elements from the assigned reading of select pages of the Governance Institute’s White Paper “Maximizing the Effectiveness of the Board’s Quality Committee: Leading Practices and Lessons Learned”

None None Y

11

11.21.16 - MINUTES - BQRC Meeting - DRAFT 2



FINAL?

OLD BUSINESS

1. Discussion of two Patient/Family Advisors serving on BQRC

Board members requested information re: best practices in this regard. Recommended inclusion of Vice President Culture and Talent Planning on this committee

Discussion with best practice information to be brought forth to next meeting for discussion

Committee member N

NEW BUSINESS

1. Annual Review of Credentialing Process for Medical Staff Membership Privileges

Executive Vice President Physician Alignment Dr. Alan Conrad presented the 2016 annual review. Committee recommendation to bring this information to the full board via an education session

Recommend sharing information with full board as future education session

Committee member /

Vice President Culture and Talent Planning

N

2. Quarterly Review of Service Excellence/Patient Complaint Reporting

The Committee reviewed the data, requesting future presentations to include trends over time. None None Y

3. Nursing Operations Report

Palomar Medical Center Poway and Escondido Downtown Chief Nursing Officer Larry Labossiere shared the annual report for FY2016, which included data and information on work being done by nursing in areas of focus such as Patient Experience, Quality, Business Development, Regulatory and Finance

None None Y

4. Surgery & Procedures – Palomar Medical Center Poway

Review of 2016 data re: OR Quality Initiatives -

• Surgical Site Infection (SSI)

• Turnover & On-Time Starts

• Center of Excellence Certification

• Pain Control: Total Joint Patients

• Leapfrog Results

2017 OR Quality Initiatives -

• Capital Investment of Equipment

• Expanding/Building Service Lines

• SPD Refurbishment

None None Y

PUBLIC COMMENTS

12

11.21.16 - MINUTES - BQRC Meeting - DRAFT 3



FINAL?

There were no public comments

FINAL ADJOURNMENT

The meeting was adjourned by Director Wickes at 7:54 p.m.

SIGNATURES:

COMMITTEE CHAIR

Aeron Wickes, MD

BOARD ASSISTANT

Debbie Hollick

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Board Quality Review Committee Meeting

OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2016

Voting Members

Palomar Health By-Laws’

Membership

Meeting Dates:

1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 Annl Rpt

10/17/16 11/21/16 12/19/16 CANCELLED

DIRECTOR AERON WICKES , MD – CHAIR Board Member P P P P P E P P P P

DIRECTOR LINDA GREER, RN Board Member P P P P P P P P P P

DIRECTOR DARA CZERWONKA Board Member P P P E P P P E P

DIRECTOR HANS SISON (ALT) Board Member P -- -- -- -- -- -- -- P --

FRANK MARTIN, MD QMC Chair, Palomar Medical Ctr

P P -- P -- -- -- -- P --

RICHARD ENGEL, MD Interim QMC Chair, Palomar Medical Ctr

-- -- P P P P -- -- -- --

CHARLES CALLERY, MD QMC Chair, Pomerado Hospital

P P P P P P P P P P

Non-Voting Members BEIRNE, FRANK EVP, Operations P P P P P P E P P P

BROWN, SHEILA, RN, FACHE VP, Continuum Care -- -- P P P P P P E P

CONRAD, ALAN, MD EVP,Physician Alignment P P P -- -- P P P E P

GOWER, JUNE, PH.D. Interim CNO, PHDC & Pomerado Hospitals

-- -- -- -- -- -- -- --

HEMKER, BOB President & CEO P P P E P E E P E E

KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient

Safety Committee P P P P P P P P P P

LABOSSIERE, LARRY CNO, Pomerado Hospital -- -- -- -- P P P P E P

MARTINEZ, VALERIE, RN, BSN, MHA, CIC Co-Chair, Patient Safety Committee

P P P P P P P P P P

OLSON, CHERYL Interim VP, PHDC & Pomerado Hospitals

P P P P -- -- -- -- -- --

SHAW, DELLA EVP, Strategy P P P P -- -- -- --

SKINNER, JEANNETTE VP, Pomerado Hospital -- -- -- -- -- -- -- P -- P

SUDAK, MARIA, MSN, CCRN, NEA-BC, RN CNO & VP, Palomar Medical Center

P P P P P P P P -- P

Guests ADELMAN, MARCY, RN P

ANDREWS, SHELLY, RN P

BANDICK, BRET P

BARNES, DEBBIE, RN, CDS

DELANGE, NICOLE P

FARROW, DAN P

GOELITZ, BRIAN, MD P

GRIFFITH, JEFF (BOARD MEMBER) P

HANSEN, DIANE P P

KAUFMAN, JERRY (BOARD MEMBER)

KIM, JESSICA P P P P

LEE, DAVID, MD P P P P P P E P P

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LEE, JEREMY P P

Meeting Dates:

1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16

Guests (continued) MCCUNE, RAY (BOARD MEMBER) P

NAMENYI, JASMINA P

NEUSTEIN, PAUL, MD P

NICPON, GREGORY, MD P

PASHA, SABIHA, MD P

PHILLIPS, DONITA, MBA, ARM P P P P P P P P P

POPE, TINA P P P P P P P P P

RIEHL, RUSSELL P

ROLIN, DONNA P

ROSENBURG, JEFFREY P E E E E

SCHULTZ, DIANA P

SKINNER, JEANETTE P

SOLOMON, LESLIE P

TERRELL, CEDRIC P P

TURNER, BRENDA P P P

WATSON, RAE ANNE P P

WIESE, LISHA P

15

ADDENDUM B

16

13 REVISED 10/15/2016

(iv) Review regulations and reports regarding facilities and grounds from external agencies, accrediting bodies and insurance carriers; make recommendations for appropriate action regarding the same to the Board;

(v) Approve the annual Facilities Development Plan and regularly review updates on implementation of plan;

(vi) Receive a biannual Environment of Care report;

(vii) Perform such other duties as may be assigned by the Board

6.2.6 Quality Review Committee.

(a) Voting Membership. The Committee shall consist of five voting members, including three members of the Board and the Chairs of Medical Staff Quality Management Committees of Palomar Medical Center and Palomar Health Downtown Campus/Pomerado Hospital.

(b) Non-Voting Membership. The President and Chief Executive Officer, the Executive Vice President Physician Alignment, the Executive Vice President Operations, the Executive Vice President Strategy, the Vice President Continuum Care, the Vice Presidents of Palomar Medical Center and Palomar Health Downtown Campus/Pomerado Hospital, the Chief Nursing Officers of Palomar Medical Center and Palomar Health Downtown Campus/Pomerado Hospital, the Vice President Patient Experience, and the Chair or Co-Chairs of the Patient Safety Committee.

(c) Duties. The duties of the Committee shall include but are not limited to:

(i) Pursuant to the Palomar Health Performance Improvement/Patient Safety Plan oversees the performance improvement, patient safety and risk management activities (including but not limited to claims and potential litigation's) of the hospitals and other facilities, if applicable, and shall periodically report this conclusion and recommendations to the Board; and

(ii) Yearly review of credentialing process;

(iii) Yearly review of physician satisfaction scores;

(iv) Nursing survey regarding physician behavior will be reviewed when appropriate; and

(v) Quarterly review of customer satisfaction scores.

6.2.7 Community Relations Committee.

17

2017 Board Quality Review Committee Description - DRAFT Approved by BQRC on ____________

PALOMAR HEALTH


Board Member Position Description

Function:

It is the responsibility of the Board Member to assure the quality of care rendered in the District's facilities

is at the highest possible level when compared to National, State and local standards and that actions are

taken on behalf of the Board to ensure the safety and well-being of the citizens served.

Responsibilities:

1. Regularly review and approve the systems annual and long term quality assurance plans to

ensure the identification, assessment and resolution of patient care issues.

2. Ensure that the system is meeting regulatory and governmental requirements and standards

pertaining to the delivery of quality medical clinical care in all of its facilities and programs.

3. Monitor institutional liability/risk experience and ensure that proper systems are put into

place to reduce exposure to loss.

4. Ensure that credentials of Medical and Allied Health staff are reviewed and privileges

granted and renewed on the basis of demonstrated professional competence and adherence to

the bylaws and code of conduct set forth by the Medical Executive Committee of the

Healthcare practitioners involved.

5. Provide oversight to the development and management of educational endeavors to improve

staff performance and skills in the completion' of their clinical care responsibilities.

6. Regularly review and assess Quality care reports, statistics and programs from Medical Staff

and System departments to identify trends or clinical care issues and to recommend

stewardship action.

7. Perform other duties as may be assigned by the Committee Chair.

Requirements:

1. Interest and willingness to commit the time and energy necessary to meet committee

responsibilities in meeting requirements.

2. Background and familiarity with aspects of clinical care issues and willingness to expand

knowledge in this arena.

3. An appreciation for risk management and the relationship of medical care, clinical

competence and financial/legal issues resulting from potential adverse events.

4. Compliance with other Board position description requirements.

18

ADDENDUM C

19

Palomar Health


2017 Performance Improvement Reporting Calendar

DRAFT Yellow - Annually Blue - Quarterly

Reports due Patient Experience Executive Assistant 29-Dec 2-Feb 2-Mar 30-Mar 27-Apr 1-Jun 29-Jun 3-Aug 31-Aug 28-Sep 2-Nov 30-Nov

Meeting Date

JAN

16

FEB

28*

MAR

20

APR

17

MAY

15

JUN

19

JUL

17

AUG

21

SEPT

18

OCT

16

NOV

20

DEC

18

Annual BQRC Assessment √

Annual Quality & Patient Safety Report to the Board of Directors √

Annual Review of By-Laws and Board Member Position Description √

Annual Review of Credentialing Process and Peer Review Process

Alan Conrad, MD, EVP, Physician Alignment√

Annual Review of Quality Assurance Performance Improvement Plan

Valerie Martinez, Director Quality, Patient Safety & Infection Control √

Annual Review of Reporting Calendar √

Quarterly Review pf Service Excellence & Patient Grievance Reporting

Tina Pope, Manager, Service Excellence√ √ √ √

Medical Group Quality Reports

Arch Healthcare, Graybill, Neighborhood Health and SCMG√

Clinical and Diagnositc Services

Maureen Malone, AVP, Clinical & Diagnostic Services

Pharmacy, Imaging, Respiratory Therapy & Laboratory√

Continuum of Care

Sheila Brown, VP, Continuum Care

Wound Care, Behavioral Health Services, ExpressCare, Home Health, Rehabilitation Services,

Corporate and Employee Health, SNF

√

Diabetes Health Program

Valerie Martinez, Director Quality, Patient Safety & Infection Control √

Emergency Management/Environment of Care/Hospitality (EVS & FANS)Dan Farrow, AVP, Hospitality and Facilities √

Infection Control & PreventionValerie Martinez, Director Quality, Patient Safety & Infection Control √

Resource UtilizationMarcy Adelman, Director, Clinical Resource Management √

Risk Management

Donita Philips, Director Risk Management√ √ √ √

Stroke Program

Valerie Martinez, Director, Quality, Patient Safety & Infection Control√

Nursing Operations (Inpatient, Obsetrics & Platform)

Karen Buckley, CNO, Palomar Medical Center Escondido

Larry LaBossiere, CNO, Palomar Medical Center Poway√

Centers of Excellence

- Orthopedic/Spine Services - Brian Cohen, Director, Jim Bried, MD, Andrew Nguyen, MD

- Cardiovascular Services - Peter Petropoulos, Director, Mikail Malek, MD

Bariatric Services - Charles D. Callery, M.D, General Surgeon

√

* Tenative meeting date due to President's Day Holiday on February 20th.

DRAFT

N

o

M

e

e

t

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S

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Page 1 of 1 Revised: 1/10/201720

ADDENDUM D

21

To: Board of Directors, Members of the Board Quality Review Committee (BQRC), the Executive Management Team and The Chiefs of Staff

From: Jerry Kolins, MD, VP, Patient Experience

Date: December 23, 2016

Re: Maximizing the Effectiveness of the Board’s Quality Committee

Last year Bob asked us to review the attached article from The Governance Institute entitled “Maximizing the Effectiveness of the Board’s Quality Committee.” This article focuses on the role of the hospital board of directors in assuring quality and patient safety. There are several best practices described in this paper. This memo highlights those practices that are under development at Palomar Health.

At the January 16 meeting of the BQRC, we will discuss these opportunities and consider next steps in our maturation as a high reliability organization. In addition, Valeria Martinez, Director of Quality/Safety/ and Infection Control, will provide an update on the status of our Centers of Excellence in Diabetes Health, and Stroke. One year ago we were contemplating best approaches to (1) cascading levels of accountability. We were undecided about a timeframe for (2) implementation of “just culture.” We did not have (3) representation of patients/families on many committees within Palomar Health. These three key elements of a high reliability health system are recommendations from The Governance Institute. Page references to these elements are noted below. Our gaps are closing. We will review our current state and future state at the January 16 meeting to be held in the Learning and Development Center (LDC) in the iExplore room. At Bob’s direction Leslie Solomon, VP Culture and Talent Planning, will prepare an educational program in 2017 for the full board of directors on the meaning and relevance of “just culture” in healthcare. Therefore further discussion on the value of “Just Culture” will occur after the educational program planned for the full board of directors.

44

2

1) State of "cascading levels of accountability.” A concrete example begins at the bottom right column p.13: "Recently the JHM Patient Safety and Quality Board Committee became involved in addressing ED wait times at Johns Hopkins Hospital. Performance deteriorated to the point that it was affecting patient satisfaction and health... This deterioration in performance led to a lengthy telephone call during which committee members and hospital leaders discussed a new game plan for improvement... The board quality committee will continue to monitor performance and the issue will remain on its agenda until improvement occurs and targets are met." 2) A commitment to training in just culture See p.7 -- "Board quality committees should recommend that the full board adopt a 'just culture' approach to dealing with safety and quality issues. This approach recognizes that bad things happen and that most of them are due to problems with systems rather than individual behaviors. It further pledges that no individual will be held accountable for such systems problems but rather will be recognized positively for speaking up openly about these problems." 3) Representation of patients/families on the BQRC See page p.8 "...recommends that two patient and family members serve as voting members of the board quality committee... Having one patient/family representative is not adequate, as this individual may feel isolated and hence not participate in discussions." Please see attached the draft calendar of reporting for 2017.

45

ADDENDUM E

46

The Palomar Health Patient and Family Advisor Council is a partnership of patient and family members and healthcare teams dedicated to exceeding our patients’ and family members’ expectations.

47

The Patient and Family Advisor Council will have an active role in improving the patient and family care experience by providing feedback on patient and family centered care.

Actively participate both in and out of meetings to achieve the purpose

Work effectively with other council members, as well as Palomar Health Staff, patients and families to ensure a patient and family centered care experience

Facilitate change to support the achievement and continued improvement of patient and family centered care

Review materials provided prior to the meetings so that each member is prepared to ask questions, contribute ideas, and provide input

48

Decision-making will normally be by consensus. If consensus is not reached, decisions will be made by a majority of all members. All members are expected to support the decisions once a meeting is adjourned

Be willing to work on projects and/or sub-committees beyond the 1 hour monthly commitment

Be willing to serve on the PFAC for a term of 2 years (or 1-2 years as may be determined by the committee)

Adhere to the Palomar Health Code of Conduct and all signed, required and agreed to documents for volunteers

All meetings will be the 3rd Tuesday of the month, starting at 4:00 p.m. and ending at 5:00 p.m.

Refreshments will be provided at all meetings Patient and Family-Centered Care Program

Manager and/or Chairman/Co-Chair are points of contact concerning committee issues

Patient and Family Advisors (PFAs) are expected to attend a minimum of eight (8) meetings annually.

In addition to the monthly meetings, PFA’s are encouraged to participate in sub-committee activities as needed

49

A patient and/or family member of Palomar Health may be nominated by his/her provider or by Palomar Health staff

Each PFA nominee must have an interest in health care

Each PFA nominee must fill out an application Each PFA nominee must attend the Palomar Health

Orientation process The Chairman/Co-Chair and the Program Manager

will review the applications and select those to be interviewed

Each PFA nominee will be interviewed by at least one of the Co-Chairs and the Program Manager

Following a positive recommendation by the Chair/Co-Chair and the Program Manager will forward the approved application to the Volunteer Director to:◦ Complete background check◦ Assure all Palomar Health volunteer requirements

are completed and in the PFAs secure file• When a PFA nominee is approved, he/she will

become a member of the PFAC

50

A PFA may be removed from the PFAC by unanimous agreement of the Program Manager and Chair/Co-chairs if any of the following occur:◦ The PFA no longer has relationship with Palomar

Health◦ The PFA has continuous and frequent absences from

PFAC meetings without prior notices◦ Violation of the Palomar Health Code of Conduct and

required agreements A PFA member may resign at any time. The

resignation is to be submitted to either of the Chair/Co-Chairs or the Program Manager in writing

PFAC Officers◦ Chairman (1 co-chair should you decide)◦ Program Manager (ex-oficio)◦ Scribe (Palomar Health Staff or PFA member)

51

For the first year of the PFAC, one Co-Chair will be the Program Manager, and the other Co-Chair will be a PFA member selected in OCTOBER.

The election of the second PFA Co-Chair will be in APRIL of 2015. This will allow for continuity of experience during change of Officers.

Nominations for the PFAC Officers shall be given to the Program Manager. PFA members may nominate themselves or other members. Nominations will be accepted prior to the April and September PFAC meetings

Ballots will be prepared and elections will occur during the October and April meetings.

Officers will serve a one-year term and may remain in the position up to two years.

If a Co-Chair position becomes vacant, the Program Manager will assume the office until a PFA is elected to the position. The replacement Co-Chair term will be for the balance of the vacated term.

The outgoing Co-Chair will meet with the newly elected Co-Chair one month prior to assuming office for orientation/mentoring session

52

Chair/Co-Chair ◦ The Chair/Co-Chairs will have equal responsibility and are

expected to work closely with the Program Manager. The responsibilities of the Chair/Co-chairs are as follows: Convene and facilitate meetings efficiently Set and prioritize agendas with the Program Manager Ensure PFAC abides by the Team agreements and the

responsibilities set in this Charter Work effectively with Palomar Health Staff, relative to the

goals of Patient and Family Centered Care, in pursuance of the PFAC Purpose

Work closely with Palomar Health Staff between meetings as needed

Be accountable to the PFAC Participate in leadership training, coaching, and mentoring as

needed Participate or assign facilitators responsibilities as necessary

for sub-committees or projects.

Scribe –◦ (This role is currently held by the Service

Excellence Program Assistant). He can continue in the role or the group can decide to elect a scribe. Scribe duties are as follows: The scribe will be responsible for taking notes at

each PFAC meeting and will distribute the notes electronically to the PFAC members after each meeting. PFAC member can be elected or volunteer for the position. This position will ensure each meeting has coverage. Focus of this role is to capture action item, tasks assigned and progress on projects.

53

Guide to Patient and Family Engagement

Patient and Family Advisor Orientation Manual

54

Guide to Patient and Family Engagement

Table of Contents

About This Orientation Manual .............................................................................................. 1

Section 1. Responsibilities and Expectations ......................................................................... 2

Section 2. Tips for Being an Engaged Advisor ....................................................................... 5

Section 3. Working With Advisors to Improve the Quality and Safety of Health Care .......... 10

Section 4. How Things Work at Palomar Health ................................................................... 12

Section 5. Ways to Learn More ............................................................................................ 17

Notes ................................................................................................................................... 19

55

Guide to Patient and Family Engagement :: 1

About This Orientation Manual

This orientation manual will help prepare you for your role as an advisor. It is organized

into the following sections:

Section 1. Information to help you understand the responsibilities of and

expectations for patient and family advisors

Section 2. Tips for being an engaged patient and family advisor

Section 3. Information about how patient and family advisors help us

improve hospital quality and safety

Section 4. How things work at Palomar Health

Section 5. Ways to learn more about health care quality, patient safety, and

being a patient and family advisor

This orientation manual is intended to accompany other training you will receive from the

hospital to help prepare you to be a patient and family advisor.

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Section 1. Responsibilities and Expectations

As a patient and family advisor, your experiences are a powerful tool for inspiring change at our hospital. By sharing your

perspectives and working with hospital staff and other patient and family advisors, you can make a real difference. The

time and energy you invest help us make important changes and improve the care experience for other patients and

families.

As an advisor, there are things that we will ask you to do. There also are things we will do to make sure we are doing our

best to build a strong partnership with you.

We promise to:

Provide you with the training you need to be

an engaged advisor.

Provide you with the resources and

organizational support you need to do your

job well.

Identify a staff liaison who will help you

prepare for meetings; provide you with

information; and be available if you have

comments, questions, or concerns about your

role.

Listen and respond to your ideas and

suggestions.

Keep you informed about how your feedback

and ideas contribute to changes and

improvements.

You promise to:

Support and commit to the mission and

vision of our hospital.

Attend orientation and training.

Prepare for meetings as needed

by reviewing materials, reading a report,

or completing a task before a meeting.

Attend meetings as required. If for some

reason, you cannot attend a meeting, please

call your staff liaison. You can also ask if there

is another way you can participate (for

example, by phone).

Actively participate in meetings by sharing

your input and opinions.

Maintain confidentiality. As a patient and

family advisor, you may have access to health

information about other patients that must

remain private.

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Key contacts for the patient and family advisor program

Tina Pope, District Manager of Service Excellence,

coordinates all the activities of patient and family

advisors and will be your liaison to Palomar Health. She

will make sure you get the training you need and that you

complete all the necessary requirements.

She is available to you by phone, email, or in person to

answer any questions you have or to discuss your

participation as an advisor:

Tina Pope – 760-740-6366

[email protected]

Christine Breese, Executive Assistant 760-822-6195

[email protected]

In addition, your Patient and Family Advisor Chairperson

is also available to you and can answer any questions you

may have about your role as an Advisor:

2016 Chairman – Jim Lyon

2016 Co-Chair/2017 Chairperson – Estelle Wolfe

(Contact information on Roster).

Training and orientation

We are committed to making sure you have the training

you need to feel confident in your role as a patient and

family advisor. This manual is only one part of your

training. Other parts of your training will include:

Tours of facilities and departments

Regular Monthly meetings with the team and leaders

of the organization

Presentations at Committee meetings

Participation in the special projects and committees

Attendance at Annual Safety Conference

Other requirements

All Patient and Family Advisors (PFAC members) are

required to attend volunteer orientation, pass a

background check and complete a Confidentiality

Statement.

Time commitments

The amount of time you spend on advisor activities

depends on your specific role.

PFAC Meetings are held once a month at Palomar

Medical Center on the third Tuesday of the month

from 3:30 – 5:00 p..m. Invites, agendas and minutes

will be sent to you each month.

If you are an officer of the PFAC (Chairman or Co-char)

you may spend 8 hours a month or more in that

service, depending on your level of interest and

commitment (committees and projects).

You may be asked to review materials to prepare for a

meeting. We will make sure you have enough time to

review them and will send them to you either by mail

or by email, depending on your preference.

Palomar Health has both short term and long term

projects. PFAC members will be offered the

opportunity to accept or decline any request, based on

their availability

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mailto:[email protected]



Confidentiality agreements

As a patient and family advisor, you may have access to

health information about other patients. It is important

to know that a federal law called HIPAA (Health

Insurance Portability and Accountability Act) protects

how health information can be used and disclosed.

Health information cannot be shared outside the hospital

or health care facility. It cannot be shared in any written,

verbal, or email communications with friends, family, or

anyone else unless specifically permitted.

The easiest way to remember what HIPAA means is

the saying, “What you see or hear here must remain

here.” We will ask you to read and sign a confidentiality

agreement to indicate your understanding of and

cooperation with these requirements.

Feedback and review process

Your feedback helps us better understand how we can

support you and your fellow advisors. The staff liaison will

meet with you regularly to get your feedback on how

things are going. These meetings are also a chance for

you to let the staff liaison know how we can improve and

expand our advisory activities. During these meetings,

the staff liaison will also ask you about your goals and

whether there are any areas in which you would like to

strengthen or expand your skills.

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Section 2. Tips for Being an Engaged Advisor

This section contains tips from other patient and family advisors about how to be an engaged advisor. As you read, make

note of things that you think might be challenging for you. Discuss these with your staff liaison and ask for more help if

needed. Above all, have faith in your participation as an advisor and keep at it. Bring your sense of humor and expect the

best from your experience.

Six tips for being an engaged advisor

Tip 1. Share your views

You have been asked to be an advisor because your ideas

are valuable. You know what it is like to get care in our

hospital. We want to hear your ideas about how we can

improve the quality and safety of the care we provide and

help make sure that other patients and families have a

good experience.

Focus on problem solving. It is important to build

on positive experiences. For example, “We found that

things worked well for our family when…” It also is

helpful to share negative experiences. When you do,

try to offer suggestions and possible solutions.

Problemsolving is always appreciated.

Think carefully about the words you use. If you

want to tell a story that will bring up strong emotions,

ask your staff liaison or another advisor to help you

think about what you want to say and how you want to

say it. Try to remember that anger usually does not

produce good results.

Respect people’s privacy. Feel free to share your

experiences and the experiences of patients and family

members other than yourself. If you do share someone

else’s story, let people know that this experience did

not happen to you and avoid using the person’s name.

When speaking about experiences in the hospital, try

not to use the names of staff members.

Tip 2. Draw on your communication skills

As an advisor, you will work with many types of people

from different backgrounds. You may work with health

care providers, hospital staff, hospital leaders, and other

patients and family members. Good communication skills

will help you explain your ideas clearly and develop good

working relationships.

Keep an open mind. Be willing to see past your own

views and experiences. You will be working with

doctors, nurses, hospital staff, and other patient and

family advisors who bring their own views. Different

perspectives can lead to better conversations and

outcomes.

Listen well. When someone is speaking, it is natural

to think about what you are going to say in response.

However, it is important to give all of your attention to

the person who is speaking and to hear them out

before you respond.

Make sure you understand what other people are

saying. One way to make sure you understand

someone’s point is to say, “What I hear you saying is…”

and then repeat what you heard them say. This gives

people a chance to clarify their points if needed.

Be aware of how you are sharing time with others

when you are speaking. If needed, make

adjustments to give others time to express their ideas.

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Tip 3. Ask questions

When you or your family members were in the hospital,

there may have been times when hospital staff used

language that you did not understand. That can happen

when you are working as an advisor, too. If it does, speak

up and ask people to explain what they mean.

Ask clarifying questions. For example, “Let me make

sure I understand correctly. I heard you say…”

Ask for definitions of medical terms,

abbreviations, or other terms. For example, “I’m

not sure I know what CAHPS means. Would you please

explain it to me?” (See the Working With Advisors to

Improve the Quality and Safety of Health Care section

of this orientation manual for information about the

CAHPS® Hospital Survey.)

Ask for more details. For example, “Can you walk me

through this so I can picture it?”

Tip 4. Be ready for disagreements

Disagreements are a natural part of working on a team.

Expressing your views when they are different from the

views of others can be challenging. However, your honest

opinion can lead to greater understanding.

Describe your point of view in terms of your

perception or opinion rather than as a fact or the

truth for all patients and families. For example: “I

see it differently,” “I have a different priority,” or “That

doesn’t work so well for me.”

Ask for more background information when

people say that a change is not possible. For

example: “Help me understand why this change is not

possible. What have you tried?” Sometimes doctors,

nurses, and other hospital staff are so used to the way

things have always been done that it is hard for them

to see other ways of doing things. Sometimes, there

are things that really cannot be changed. In this case,

you should ask about the reasons why.

If you find yourself upset after a meeting, talk to your

staff liaison at the hospital. Your staff liaison can make

sure that your concerns are addressed and help you

resolve them.

Tip 5. Ask for information to help you

understand your commitments

When you agree to become an advisor, make sure you

fully understand the commitment you are makin, and

then keep that commitment.

Prepare for meetings. If there are responsibilities

that you are asked to fulfill between meetings, come to

the meeting prepared to share information about your

progress on these activities and projects. Be on time

for meetings and stay until the end.

Keep the staff liaison informed about your

schedule. If you are not able to attend a meeting in

person, ask if you can call in (through conference call or

speaker phone) as an option. If you cannot participate

in a meeting, notify your key contact or staff liaison.

Ask if you can get an update before the next meeting.

If you find that you are having difficulty balancing your

personal and family life with advisory activities, talk to

your staff liaison about whether you can cut back on

some of your advisor duties or take a short-term break.

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Tip 6. Ask for feedback

One of the best ways to develop your skills as an advisor

is to ask for feedback. Talk to your staff liaison about your

participation, including what is going well and what skills

you would like to enhance. Getting feedback is especially

important if you would like to expand your involvement

and take on new roles and responsibilities.

Ask for feedback after you have completed a

task. If you are participating in a one-time discussion

group or very short-term work group, ask your staff

liaison if you can talk to him or her about your

participation after you have completed the task.

Ask for regular feedback meetings with your

staff liaison. If you will be serving as an advisor for

several months or more, ask your staff liaison to meet

with you on a regular basis so that you can become

aware of your strengths and areas for improvement.

Ask how you can learn more. If there is a topic you

would like to learn more about or some skill you would

like to work on, ask your staff liaison for resources,

individuals to meet with, or time to discuss it further.

Ask for support from other advisors when you

need it and always be ready to provide support to

them.

Participate in the advisor review process. The

hospital’s volunteer office will have your staff liaison

complete an annual review with you to identify how to

continue to best support you as an advisor and to help

you improve your participation as an advisor.

Sharing your story

Sharing your story can help others understand your

health care experiences and how these experiences have

affected you and your family. It can also be a powerful

way to show the need for specific changes and

improvements at the hospital.

As an advisor, you may be asked to share your story with

a variety of people. For example, you may be asked to

share your story with hospital leaders to help them

understand why it is important for our hospital to work

with patient and family advisors. You may be asked to

help educate doctors, nurses, and other hospital staff

about why it is important to conduct bedside shift reports

or involve patients and families in the discharge process.

Or you may be asked to speak to a group of patients and

family members about becoming advisors.

We will provide you with training and support for each of

these opportunities. You should accept invitations to

speak only if you are comfortable with the request.

Before you agree to share your story

Before you agree to share your story in a training,

meeting, or presentation, get information about what is

expected of you and what you can expect. Ask the

following questions:

When, where, and for how long do you want me to

speak?

What do you hope will happen as a result of me sharing

my story?

Who is the audience? How many people will be there?

Who else will be speaking?

Will I be answering audience questions?

Will the session be audio or videotaped?

Is there reimbursement for child-care or

transportation?

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Preparing to share your story

If you have decided to share your story, think about what

you want to say and how you want to say it. Some people

write down their main points to keep them focused. You

can use the worksheet below called Sharing Your Story to

help you organize your thoughts.

Before you speak in a meeting or to a group, it also helps

to practice. Time yourself and see if you are staying

within the requested time frame.

As you are preparing what you want to say, think about

the following questions:

Why was I asked to share my story?

What are the key messages I want to share?

What are the two or three specific points that I want to

the audience to remember?

What am I willing to share? What is too private to

share?

What examples can I give of when things went well?

What examples can I give of things that could have

gone better?

What ideas do I have about how my experience could

have been improved?

Also keep in mind the following tips:

Only share what you want to share. If you still feel

angry about a certain situation or event and do not

think you can talk about it in a helpful manner, it may

be best not to share that part. You can also talk about

it with someone you trust. Ask for ideas about how to

share that part of the story in a way in which people

will listen.

Focus on experiences rather than individuals. Try

to avoid using the names of doctors, nurses, and other

staff. If you talk about another facility where you have

received care, please do not mention it by name.

Be prepared for emotional reactions. Expect that

some people who hear your story may be deeply

moved. Also remember that you may feel emotional

when you tell your story.

Remember that you are in control. If people ask

you questions and you do not know the answer, it is

okay to say so. If you do not want to answer a

question, it is okay to say that as well.

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Sharing your story — A planning worksheet(1)

Use this worksheet to help plan what you want to share about your hospital experience.

Key points about your hospital experiences

What went well during your hospital experience? What things did people say or do that were helpful?

[Blank]

[Blank]

[Blank]

[Blank]

[Blank]

What did not go well during your hospital experience?

What things did people say or do that were not helpful?

[Blank]

[Blank]

[Blank]

[Blank]

[Blank]

[Blank]

What improvements would you suggest? What would you rather have happened?

[Blank]

[Blank]

[Blank]

[Blank]

[Blank]

[Blank]

1 Adapted from University of Washington Medical Center, Patient and Family Centered Care and Education Services, 1959 N.E. Pacific Street, Box 358126, Seattle, WA, 98195

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Section 3. Working With Advisors to Improve the Quality and Safety of Health Care

At Palomar Health, we want to make sure that everyone who comes into the hospital has the best experience possible. One

of your jobs as a patient and family advisor is to give us feedback about your experiences and suggesting changes and

improvements. This can help make care better for all patients.

How advisors help improve health care quality and safety

Improving health care quality and safety is a challenging task. Health care is a lot better when patients, families, doctors,

nurses, and other hospital staff work together to ensure the quality and safety of the care we provide. Because health care

quality and safety have a direct effect on patients and families, it is particularly important for patients and family members

to participate in changes and improvements.

As an advisor, you will be asked to share your ideas about ways to improve the quality and safety of care that patients get in

our hospital. This helps make sure the care and services we provide are based on “patient- and family-identified” needs

rather than the assumptions of clinicians and hospital staff about what patients and families want.

Specific ways in which we may ask patient and family advisors to help include:

Participating in discussions about health care quality and safety with doctors, nurses, hospital staff, and other

patients and families, including helping to identify places where errors might occur

Sharing ideas about how to make sure that patients and families have meaningful opportunities to participate in their

care and decisions about their care

Revising or helping to create materials for patients and families

Sharing your story during training sessions for doctors, nurses, and other hospital staff

“Patient and family advisors have knowledge we don’t have. It is so humbling to realize that patients and families know

more about [the hospital] than you do.”

Pat Sodomka, Former Vice President for Patient and Family Centered Care, Georgia Health Sciences Health System

(formerly MCGHealth), Augusta, GA

Improving the care we provide

As an advisor, you may be able to think of times when you or your family member got good quality care in the hospital. You

also may be able to think of times when you or your family member did not get good quality care.

We want to make sure that every patient who comes into the hospital gets good quality care. To us, this means that:

Patients get the right care for their condition. Patients get the tests and treatments that are recommended for their

condition.

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Patients get care that is safe and free from medical errors. The tests and treatments that patients get do not cause

them any harm. Health care providers follow appropriate safety precautions (for example, washing their hands and

checking medications before giving them to patients).

There are no delays in care. Patients get the care they need when they need it. They get the tests and treatments

they need at the time when they will do the most good.

Patients are not treated differently based on their race, ethnicity, income, level of education, or social

status. Everyone is entitled to high-quality health care. This includes people of all cultures and backgrounds.

Patients get care that is patient and family-centered. This means that:

o Clinicians and hospital staff ask about and respect each patient’s and family’s values, preferences, goals, and

cultural backgrounds

o Clinicians and hospital staff communicate clearly and share complete, unbiased, and timely information with

patients and families

o Patients and families are encouraged to participate in their care and decision making to the extent they choose

o The patient’s care represents a partnership between the patient, family, clinicians, and hospital staff

Above all, we want to make sure that patients and families have good experiences and feel supported while they are in the

hospital. We welcome your thoughts and ideas about how to make sure this happens.

Identifying ways we can improve

In addition to asking patient and family advisors for feedback, there are other ways that we identify areas for improvement.

One way to identify areas for improvement is to look at whether the right things happen as part of our patients’

treatment. For example, do patients get the medicines they need when they are supposed to? Do they get the correct tests

and treatments? If not, why are these things not happening?

Another important way to identify areas for improvement is to ask patients about their experiences. For example, many

hospitals ask patients to fill out surveys about their experiences in the hospital.

One survey that you may hear about as an advisor is called the CAHPS® Hospital Survey (also called HCAHPS). Most

hospitals in the United States give this survey to patients. Results from the CAHPS® Hospital Survey help us learn where we

could be doing a better job.

The CAHPS® Hospital Survey asks patients to answer questions on how well health care providers did at sharing

information and listening. The survey also asks patients to rate how well their care was coordinated, how well their pain

was managed, and whether they had the information they needed to take care of themselves after going home.

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Section 4. How Things Work at Palomar Hospital

Our Mission

To heal, comfort, and promote health in the

communities we serve.

Our Vision

Palomar Health will be the health system of choice for

patients, physicians, and employees, recognized

nationally for the highest quality of clinical care and

access to comprehensive services.

Core Values / Palomar Health Staff

Patients' Well Being: We passionately give and support

heartfelt care that encourages patient comfort and

safety.

Professionalism: Each of us takes pride in teamwork,

self-discipline, our skills and trustworthiness.

Highest Quality: We are each accountable for providing

the safest, most effective and innovative care.

Palomar Health Board of Directors

Function:

It is the responsibility of the Board Member to develop

and ensure that the organization's mission and vision

statements are carried out in an effective and ethical

manner. To that end, the member is accountable for

oversight and implementation of policies and monitoring

of the organizations performance in establishment of

strategic direction, financial stewardship, quality

outcomes and leadership of the Healthcare District.

Specific Responsibilities:

Regularly review and, where appropriate, update the mission and vision statements for the System and subsidiaries to ensure the needs of the citizens of the District are being met in accordance with its Charter.

Approve a system-wide quality assurance plan and monitor the effectiveness of the organization in meeting targets of performance to insure the health, well-being and safety of those served.

Work closely with Medical Staff and Administrative Leadership to insure that effective clinical care is being provided in the system's facilities and that competency of Medical and Allied Health staff are assured on behalf of the citizens of the District.

Review and approve all financial policies, plans and programs for the system and enhance the preservation of the organization's assets and resources on behalf of the District.

Review and approve a comprehensive strategic plan, consistent with the organization's mission and vision that aligns the system's financial, human resources, facilities, technology and quality plans.

Advocate on behalf of the Healthcare District's policies, programs and plans within the community served and with other constituency groups.

Recruit, employ and evaluate the performance of the Chief Executive Officer in accordance with goals and objectives established on a short and long term basis with the CEO.

Establish and implement ethical policies that minimize conflicts of interest and insure compliance with governmental, regulatory and other agency standards, laws and principles relative to excellent stewardship of the Public Healthcare District.

Regularly evaluate the Board's performance and the individual performance of each Board member to continually enhance the effective stewardship of the system.

Perform other duties as may be assigned by the Board.

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Requirements:

Interest and willingness to commit time and energy to completion of Board responsibilities and meeting requirements.

Ability to work in a civil, ethical and collaborative manner with other members of the Board.

Have an appreciation for group process, open-mindedness, respect for others and an ability to think objectively, logically and analytically.

Have effective oral and written communication and negotiation skills.

A knowledge of health and medical care issues and a willingness to expand one’s knowledge through various educational opportunities.

2016 Monthly Board Committee Meeting Schedule

Executive Management Team

Robert A. Hemker

President & CEO

[email protected]

760.740.6395

Frank Beirne

Executive Vice President, Operations

[email protected]

760.740.6300

Alan J. Conrad, MD, MMM, CPE, FACHE

Executive Vice President, Physician Alignment

Alan,[email protected]

858.605.9961

Diane Hansen, CPA

Executive Vice President, Finance

[email protected]

760.740.6385

Della Shaw

Executive Vice President, Strategy

[email protected]

760.740.6371

Jim Harris

Interim Executive Vice President, Human Resources

[email protected]

760.740.6335

Prudence August

Vice President, Information Systems

[email protected]

858.675.5179

Sheila Brown, RN, MBA, FACHE

Vice President, Continuum Care

[email protected]

760.739.3110

Jerry Kolins, MD, MAOM, CPE, FACHE

Vice President, Patient Experience

[email protected]

760.740.6353

Mark Neu, MHA, CHC

Vice President, Compliance, Audit and Legal

[email protected]

442.281.3630

Timothy T. Nguyen, MHA, FHFMA, CRCR

Vice President, Revenue Cycle

[email protected]

760.740.6323

Jeannette Skinner, RN, MBA, FACHE

Vice President, Pomerado Hospital

[email protected]

858.613.4710

Maria Sudak, RN, MSN, CCRN, NEA-BC

Vice President, Palomar Medical Center

[email protected]

442.281.1003

Dan Farrow, BSB, MHA

Assistant Vice President, Hospitality and Facilities

[email protected]

760-739-3186

Jean Larsen

President and Chief Philanthropy Officer

[email protected]

760.739.2785

Maureen Malone Assistant Vice President, Clinical & Diagnostic Services [email protected] 760-740-6374

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http://www.palomarhealth.org/media/file/Board_Meetings/Board%20Meetings%202016.pdf

http://www.palomarhealth.org/about-us/robert-a-hemker


http://www.palomarhealth.org/about-us/frank-beirne-executive-vice-president-operations


http://www.palomarhealth.org/about-us/alan-j-conrad-md-executive-vice-president-physician-alignment

mailto:Alan,[email protected]

http://www.palomarhealth.org/about-us/diane-hansen-executive-vice-president-finance


http://www.palomarhealth.org/about-us/della-shaw-executive-vice-president-strategy



http://www.palomarhealth.org/about-us/prudence-august-vice-president-information-systems


http://www.palomarhealth.org/about-us/sheila-brown-chief-clinical-outreach-officer


http://www.palomarhealth.org/about-us/jerry-kolins-md-vice-president-patient-experience


http://www.palomarhealth.org/about-us/mark-neu-vice-president-compliance-audi-and-legal


http://www.palomarhealth.org/about-us/tim-nguyen-vice-president-revenue-cycle


http://www.palomarhealth.org/about-us/jeannette-skinner-rn-mba-fache-vice-president-pomerado-hospital


http://www.palomarhealth.org/about-us/maria-sudak-vice-president-palomar-medical-center


http://www.palomarhealth.org/about-us/dan-farrow-assistant-vice-president-hospitality-and-facilities


http://www.palomarhealth.org/about-us/jean-larsen-philanthropy-officer




Larry Labossiere, RN, MBA, MSN, CNS, CEN Chief Nursing Officer, Palomar Medical Center Poway [email protected] 858-613-4505

Karen Buckley, RN, BSN, MHA, CENP Chief Nursing Officer, Palomar Medical Center Escondido [email protected] 442-281-1001

Award-Winning Care in San Diego County

Palomar Health is proud to provide nationally-

recognized care to our patients in the San Diego region.

Our recent recognitions include:

National Recognitions

2016 NCDR-ACTION Registry - GWTG Silver

Performance Achievement Award

from the American College of Cardiology

Palomar Medical Center

2015 Humane Society of the United States

Palomar Health

Plant-Based Menu and Sustainability Practices

Achievement Award

2015 Press Ganey Guardian of Excellence Award

for Employee Engagement

Villa Pomerado

2015 CALNOC Recognition

Pomerado Hospital

Reduction of Injury Falls and Reduction of Central Line-

Associated Blood Stream Infections

CALNOC Nurse Quality Indicators Database

2015 CEP America Distinguished Practice Award

Palomar Health/Pomerado Hospital

Emergency Department/Hospital Medicine/Skilled

Nursing Facility

CEP America

2014 5th Most Technologically Advanced Hospital

in the World


Top Master's in Healthcare Administration

2013 One of the 50 Greenest Hospitals


Becker's Hospital Review

2013 Risk Management Education Award

Beta Funds

2013 Silver Award for The Guidelines Quality

Improvement Program

American Heart Association and American Stroke

2013 Get With the Guidelines Sustained

Performance

American Heart Association

2013 5 Star Bariatric Surgery Excellence Award

Pomerado Hospital

2013 Partner for Change Award

Practice Greenhealth

2012 Top 15 Health Systems

Palomar Health

Thompson Reuters

2012 Orthopedic Care Facility for Total Joint

Replacement


Aetna Institute of Quality



2011 Most Innovative Healthcare District

Palomar Health

Association of California Healthcare Districts



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2011 Certificate of Distinction for Inpatient Diabetes

Care

Palomar Medical Center & Pomerado Hospital

Joint Commission

2010 Maternal Child Excellence Award

Palomar Health

HealthGrades

2010 Breast Imaging Center of Excellence

Jean McLaughlin Women's Center for Health

American College of Radiology

2009 First Public Health District in California to

Achieve Magnet® Recognition

Palomar Health

American Nurses Credentialing Center

2009 Citation for Healthcare Facilities Design

Modern Healthcare

2008 Top 100 Places to Work in Healthcare

Palomar Health

Modern Healthcare

2008 Premier Award for Quality


Premier, Inc.

2007 Compass Award Winner

Palomar Health

Press Ganey, Inc.

2006 Best Place to Work in San Diego County

The Society of Human Resource Management

2006 3rd Best Place to Work in San Diego County

Palomar Health

San Diego Magazine

2006 Marble Award for Best Employer

Palomar Health

The Society of Human Resource Management

2006 California Awards for Performance Excellence

(CAPE)

Bronze Award

Palomar Health

The California Council for Excellence

2005 Malcolm Baldrige Award

State Award Recipient

2005 Health Care District Special Award

The Association of California Healthcare Districts

2005 Health Care District Special Achievement

Award

Palomar Health

The Association of California Healthcare Districts

Initial Performance Achievement Award

Pomerado Hospital

American Heart Association/American Stroke

Association’s Get with the Guidelines (GWTG) program

Sustained Performance Achievement Award (24

consecutive months)


American Heart Association/American Stroke

Association’s Get with the Guidelines (GWTG) program

Hospital of the Future Awards

2013 Design Award for Built Projects Over $25 M

American Institute of Architects (AIA)/Academy of

Architecture for Health

2013 National Recognition Award

American Council of Engineering Companies (ACEC)

2013 Design Award for Built Projects Over $25M

American Institute of Architects/Academy of

Architecture for Health

2012 National Recognition Award

American Council of Engineering Companies (ACEC)

2012 Engineering Excellence Honor Award

California American Council of Engineering Companies

(ACEC)

70


2012 Best Healthcare Project (National)

Engineering News Record (ENR), 2012

2012 Best Overall Project

Engineering News Record (ENR)

2012 Best Health Care Project

Engineering News Record (ENR)

2010 BIM Design Excellence

AIA Technology in Architectural Practice (TAP) Building

Information Model Awards

2010 Healthcare Sector Building of the Year

Shortlist

World Architecture News Awards

2007 Citation for Healthcare Facilities Design Award


Modern Healthcare

2007 Merit Award


American Institute of Architects/Los Angeles Chapter

2006 Citation of Merit


Healthcare Design Architectural Showcase

2006 Merit Award

American Institute of Architects

71


Section 5. Ways to Learn More

The Web sites listed below have information about health care quality, patient safety

and being a patient and family advisor.

Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality (AHRQ)

is a U.S. Government Agency that is part of the

Department of Health and Human Services. AHRQ funds,

conducts, and disseminates research to improve the

quality, safety, efficiency, and effectiveness of health

care. Its Web site has information to help patients,

families, clinicians, leaders, and others make informed

decisions about health care. Web site:

http://www.ahrq.gov

Consumers Advancing Patient Safety

Consumers Advancing Patient Safety believes that

consumers and health care providers should work

together as partners to create health care systems that

are safe, compassionate, and just. Its Web site has

information and resources for patients and health care

providers.

Web site: http://www.patientsafety.org/

Institute for Healthcare Improvement

The Institute for Healthcare Improvement is a nonprofit

organization dedicated

to improving health care. Its Web site has

resources and improvement tools to promote

health care quality and safety.

Web site: http://www.ihi.org/

Institute for Patient and Family-Centered Care

The Institute for Patient- and Family-Centered Care

provides guidance, information, and resources related to

multiple aspects of patient- and family-centered care,

including how to involve patients and family advisors in

the planning, delivery, and evaluation of care.

Web site: http://www.ipfcc.org

Josie King Foundation

The Josie King Foundation offers information and

resources on patient safety, the prevention of medical

errors, and how health care providers and consumers can

work together.

Web site: http://www.josieking.org/

Medically Induced Trauma Support Services

Medically Induced Trauma Support Services is a nonprofit

organization that creates awareness, promotes open and

honest communication, and provides services to patients,

families, and clinicians affected by medically induced

trauma.

Web site: http://www.mitss.org/

72

http://www.ahrq.gov/

http://www.patientsafety.org/

http://www.ihi.org/

http://www.ipfcc.org/

http://www.josieking.org/

http://www.mitss.org/


Medline Plus

Medline Plus is the National Institutes of Health’s Web

site for patients and families. It has information about

diseases, conditions, and wellness issues in plain

language and includes a medical dictionary.

Web site: http://www.nlm.nih.gov/medlineplus

National Family Caregivers Association

The National Family Caregivers Association provides

information and support for individuals who care for

others who are aged, disabled, or chronically ill. Its Web

site has tools and stories to educate and empower

caregivers.

Web site: http://www.nfcacares.org/

National Patient Safety Foundation

The National Patient Safety Foundation is dedicated to

improving the safety of patients through education and

raising public awareness. Its Web site offers information

on patient safety issues and has a variety of resource

links.

Web site: http://www.npsf.org/

73

http://www.nlm.nih.gov/medlineplus

http://www.nfcacares.org/

http://www.npsf.org/


Notes

Use the space below to make notes and write down any questions you have for your staff liaison.

Tina Pope, District Manager Service Excellence – 760-740-6366; [email protected]

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ADDENDUM F

75

1

Disease Specific Diabetes Program

Presented to Board Quality Review CommitteeJanuary 16, 2017

Passion. People. Purpose.TM

Alan J. Conrad, MD, MMM, CPE, FAAPL, FACHETamrah Jennings, MSEd, APRN, MSN, ACCNS‐AGValerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA‐BC

‹#›

Program Overview

• First certified ‐ 2006

• Recertified – 2008, 2010, 2012, and 2014

• Last certification – December 2016

• Medical Director ‐ Alan J. Conrad, MD, MMM, CPE, FAAPL, FACHE

• Program Director – Valerie Martinez RN, BSN, MHA, CIC, CPHQ, NEA‐BC

• CNS – Tamrah Jennings, MSEd, APRN, MSN, ACCNS‐AG

• CNS ‐ Jasmina Namenyi, MSN, APRN, ACCNS‐AG

• CNS ‐ Eva (Bunny) Krall, MSN, APRN, CMSRN, ACNS‐BC, CDE

• Open ‐ Part Time Nurse Educator

2

76

‹#›

Diabetes Medical Advisory Committee (DMAC)

• Interdisciplinary Committee

44

Diabetes Health GlucometricsReport to the Board Quality Review CommitteeJanuary 2017


77

5

6

78

7

8

79

9

10

80

11

12

81

13

14

82

15

JOINT COMMISSION INDICATORS

15

‹#›

Palomar Medical Center Escondido and PowayDiabetes Education Needs Assessment

16

83

‹#›17

Palomar Medical Center Escondido and PowayDiabetes Survival Skills

‹#›

Palomar Medical Center Escondido and PowayBasal Insulin Use

84

‹#›19

Palomar Medical Center EscondidoProblem List

‹#›20

Palomar Medical Center PowayOB Diabetes Intra‐partum PowerPlan

N=7GDM1=7

85

‹#›

Interventions to Improve Outcomes

• MD education onboarding and re‐credentialing

• Diabetes Needs Assessment form a mandatory field in EMR

• Diabetes Fundamentals Class/ Diabetes Symposium

• New report to capture basal insulin data

• Focused primarily on Hospitalist group as prescribers of basal insulin

• Data dissemination to stakeholder committees

• CY ‘16 Q2 diabetes modules for staff education

• Continuous Glucose Monitors

• Diabetes tool bar

• Incorporated communication into “Huddle Highlights”

• New grad class/education module on Needs Assessment/Survival Skills

‹#›

• Glycemicare software tool

• Discharge appointments prior to discharge

• Patient Education

– Diabetes Education Book

• DKA and HHS

– Provider and Nursing education

– Separation of Power Plans

• Insulin Pumps

– Updated forms

Performance Improvement Projects

86

‹#›

Performance Improvement Projects

• Peri‐operative Project

• Diabetes Press Ganey Survey

• Medication Safety

– IV insulin transition

– U500

– Insulin Double Check

• Hypoglycemia

– Phone for 40

24

Performance Improvement Activities, PMC Poway

• CDAPP guidelines incorporated into OB Power Plans

• Provider and Nursing education

• Indicator narrowed

• Revisions to Power Plans with Provider input

• Nursing education ‐Care of Diabetes and Pregnancy module and Power Plans

• Ongoing Provider communication and feedback

• Discharge appointments prior to discharge

24

87

‹#›

Interventions 2017 To Improve Outcomes

• Incorporate Needs Assessment into admission documentation• Update Survival Skills to 2016 ADA guidelines• Task for Survival Skills that “need further teaching”• Glycemicare software tool – Launch January 2017• Phone for 40 ‐ Early 2017 for Poway campus

• Implement new Joint Commission Indicators– Patient verbalizes understanding of A1c prior to discharge– Blood Glucose Management in the elective hip and knee orthopedic

surgery patient population– Change in Basal Insulin Dose by 10% within 24 hours of 1 or greater

hypoglycemic event– Physician Documentation of Diabetes Classification

‹#›

86.190.2

80.984.9 84.1

79.3

86.383.6

87.8 87.1 87.083.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1/1/16‐1/31/16n=61

2/1/16‐2/29/16n=51

3/1/16‐3/31/16n=64

4/1/16‐4/30/16n=58

5/1/16‐5/31/16n=55

6/1/16‐6/30/16n=58

7/1/16‐7/31/16n=40

8/1/16‐8/31/16n=61

9/1/16‐9/30/16n=41

10/1/16‐10/31/16n=58

11/1/16‐11/30/16n=50

12/1/16‐12/31/16n=39

Mean Score

Month

PMC Escondido/Downtown Escondido ‐ Helpfulness of Diabetes Handouts*Official Monthly Results

88

‹#›

91.786.4

78.6 80.6

72.2

94.2

86.1

77.1

89.3

79.284.1

92.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1/1/16‐1/31/16n=18

2/1/16‐2/29/16n=22

3/1/16‐3/31/16n=14

4/1/16‐4/30/16n=18

5/1/16‐5/31/16n=9

6/1/16‐6/30/16n=13

7/1/16‐7/31/16n=9

8/1/16‐8/31/16n=12

9/1/16‐9/30/16n=7

10/1/16‐10/31/16n=12

11/1/16‐11/30/16n=11

12/1/16‐12/31/16n=17

Mean Score

Month

PMC Poway ‐ Helpfulness of Diabetes Handouts*Official Monthly Results

‹#›

91.3 90.584.6

90.6 87.5 85.291.3

86.291.5

87.991.5 88.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1/1/16‐1/31/16n=69

2/1/16‐2/29/16n=55

3/1/16‐3/31/16n=68

4/1/16‐4/30/16n=69

5/1/16‐5/31/16n=58

6/1/16‐6/30/16n=66

7/1/16‐7/31/16n=46

8/1/16‐8/31/16n=65

9/1/16‐9/30/16n=44

10/1/16‐10/31/16n=62

11/1/16‐11/30/16n=53

12/1/16‐12/31/16n=43

Mean Score

Month

PMC Escondido/Downtown Escondido ‐ Understanding Diabetes Medications

*Official Monthly Results

89

‹#›

91.388.0 88.3

80.375.0

94.293.8

84.188.9

82.1

90.094.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1/1/16‐1/31/16n=20

2/1/16‐2/29/16n=23

3/1/16‐3/31/16n=15

4/1/16‐4/30/16n=19

5/1/16‐5/31/16n=10

6/1/16‐6/30/16n=13

7/1/16‐7/31/16n=8

8/1/16‐8/31/16n=11

9/1/16‐9/30/16n=9

10/1/16‐10/31/16n=14

11/1/16‐11/30/16n=15

12/1/16‐12/31/16n=17

Mean Score

Month

PMC Poway ‐ Understanding Diabetes Medications*Official Monthly Results

3030

90

ADDENDUM G

91

1

Disease Specific Stroke Program

Presented to Board Quality Review CommitteeJanuary 16, 2017


Lourdes Januszewicz MSN APRN ACNS‐BC CCRN Remia Paduga, MD, Medical DirectorValerie Martinez, RN, BSN, MHA, CIC, CPHQ, NEA‐BC

Program Overview

• Established the program in 2008.

• First certified in 2009

• Recertified in 2011, 2013, and 2015

• Due for Recertification 2017

– Window for recertification @ PMC‐Escondido: January – April 2017

– Window for recertification @ PMC‐Poway: February – May 2017

• PMC Medical Director and Hospitalist Neurologist – Dr. Remia Paduga

• Program Director – Valerie Martinez RN BSN MHA CIC CPHQ NEA‐BC

• Program Coordinator – Lourdes Januszewicz MSN APRN ACNS‐BC CCRN

2

92

Stroke Committee

Joint Commission (JC) Stroke Core Measures

• STK‐1 Venous Thromboembolism (VTE) Prophylaxis

• STK‐2 Discharged on Antithrombotic Therapy

• STK‐3 Anticoagulation Therapy for Atrial Fibrillation/Flutter

• STK‐4 Thrombolytic Therapy

• STK‐5 Antithrombotic Therapy By End of Hospital Day 2

• STK‐6 Discharged on Statin Medication

• STK‐8 Stroke Education

• STK‐10 Assessed for Rehabilitation

4

93

Stroke Core Measures CY 2016 Qtrs. 1‐3

5

Current Program Status

539 571671

773

9171019 1061

755

116169 211 215 196 209 173

123

0

200

400

600

800

1000

1200

2009 2010 2011 2012 2013 2014 2015 Nov-16

Tota

l Nu

mb

er o

f C

ases

Total Number of Stroke Cases per Year

PMC Escondido PMC Poway

6

94


15 19 1623

6571

106

91

7 5 6 10 14

34 32

47

0

20

40

60

80

100

120

2009 2010 2011 2012 2013 2014 2015 2016

Years: Program Start to Present

Total Number of Patients receiving Tissue Plasminogen Activator (tPA)

PMCEscondido

PMCPoway

7

• PMC gave 84 patients tPA through 11/2016

• Total Acute Ischemic Stroke (AIS) through 11/2016: 609

• 13.8% patients received tPA through 11/2016

• sICH after tPA: 2

• Deaths after Spontaneous Intracranial Hemorrhage (sICH) after tPA: 2

• POM gave 45 patients tPA through 11/2016

• Total AIS through 11/2016: 117

• 38.5% patients received tPA through 11/2016

• sICH after tPA: 0

• Deaths after sICH after tPA: 0

• Palomar Health 129 patients received tPA patients: 17.8%

tPA Administered YTD Nov 2016

8

95

2016 Post tPA Outcomes

9

66

1

28 27

2 1 2

11

0

10

20

30

40

50

60

70

80

Discharge Status - 138 tPA Patients

Nu

mb

er o

f tP

A P

atie

nts

Home/HH

Home on Hospice

ARU

SNF/AL

Tx Acute Care

AMA

Expire-ICH

Expire-ComfortCare

Program Status: JC Cycle

% Compliance Door 2 Drug (D2D) < 60 min

• PMC Escondido ‐ Cycle Mar 2015 – Dec 2016

– Total tPA Cases: 189

– Total tPA Cases D2D < 60 min: 138

– % Compliance JC Cycle: 73%

• PMC Poway – Cycle Mar 2015 – Dec 2016

– Total tPA Cases: 75

– Total tPA Cases D2D < 60 min: 43

– % Compliance JC YTD: 57%

10

96

JC Cycle: PMC Escondido

90% 88%

100%

70%75%

43%

88%93%

67% 67% 67%

89% 88%

75%70%

50%

67%

75%

57%

38%

50%

57%

0%

20%

40%

60%

80%

100%

120%

% tPA < 60 Minutes 50 % of the time

JC Cycle: PMC Poway

100%

50%

60%

0%

33%

ND

33% 33%

50%

86%

50% 50%

40%

67%

75%

67%60%

75% 75%

67%

100%

0%

20%

40%

60%

80%

100%

120%

% tPA < 60 Minutes 50% of the time

ND

97

Neuro Interventional Radiology (IR)


14

59 62

0

10

20

30

40

50

60

70

2014 2015 2016

Years: Program Start to Present

Total Number of Patients receiving Neuro IR Procedures

PMC

13

2016 Neuro IR Case Outcomes

14

14

2

9

18

1

16

0

2

4

6

8

10

12

14

16

18

20

Discharge Status - 62 Thrombectomy/Embolectomy

Num

ber

of P

atie

nts

Home/HH

Home on Hospice

ARU

SNF/LTAC

Exp - sICH

Exp - Comfort Care

98

Program Updates 2016

• Improve D2D compliance < 60 minutes 50% of the time

– ED Providers are ordering tPA and not waiting for Neurology

• PMC‐Escondido: ED Providers have given 25% of the tPA for eligible patients

• PMC‐Poway: ED Providers have given 50% of the tPA for eligible patients

• Improve Lab Turn Around Times (TATs) for Results

– PMC‐Escondido: iSTAT device for Chem 8 Labs increased to 72% use

– PMC‐Poway: heightened awareness with Stroke Labs

– Ordering Troponin with Stroke Panel ‐ 99% compliance

• Improve accuracy of tPA dosing

– Purchased scaled gurneys at PMC Escondido and PMC Poway

15

Quality Improvement Projects 2017• Target Stroke Phase 2 – Implement new D2D administration times

• Door to Drug tPA in 45 min – 50% of the time; Door to Drug tPA in 60 min – 75% of the time

– Adopt (Pit Stop) Concept for meeting new targets

• PMC Escondido: Go Live was December 20th 2016

– Monitor for improvement in D2D times: Target Stroke Phase 2

• PMC Poway: Begin project for (Pit Stop) Concept during 1st Qtr. CY 2017

• Improve Lab TATs for Results

– PMC‐Poway: work towards obtaining the iSTAT device for Chem 8 Labs

– PMC Escondido: continue to monitor for compliance

• Neuro Interventional Radiology for Stroke

– Improve Door to Groin times to < 120 minutes 50% of the time

• American Heart Association (AHA)/American Stroke Association (ASA) Get With the Guidelines participation

16

99

Contact Information

Lourdes Januszewicz MSN APRN ACNS‐BC CCRN

Stroke Program Coordinator

Palomar Health

Office 442‐281‐2092

[email protected]

17

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