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BOARD QUALITY REVIEW COMMITTEE

MONDAY, JUNE 20, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:00 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064

OPEN SESSION AGENDA

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING Time Form A

Page # Target

CALL TO ORDER 6:00

Establishment of Quorum 1 N/A 6:01

Public Comments1 15 N/A 6:16

Information Item(s)

1. *Review/Approve: Minutes – Monday, May 16, 2016 (Addendum A, Page 8 -16) 4 3 6:20

Standing Item(s)

1. The Patient Experience (Addendum B, Page 17 - 23) Tina Pope, Manager, Service Excellence

a) Letters from Patients/Families b) Video of Dr. Tom Lee on Teamwork and Patient Expectations c) Video of Christy Dempsey on the Compassionate, Connected Care Model d) Patient Experience Dashboard and Action Plan Update

15 4 6:35

2. Quality and Safety Dashboards (Addendum C, Page 24 - 26) Valerie Martinez, Director, Quality, Patient Safety and Infection Control

15 5 6:50

3. Journal Club: “Toward a Safer Health Care System-The Critical Need to Improve Measurement” by Ashish Jha, MD, MPH and Peter Pronovost, MD, PhD (Addendum D, Pages 27 - 29)

5 6 6:55

New Business

1. Emergency Management/Environment of Care (Addendum E, Pages 30 - 52) Dan Farrow, AVP, Hospitality and Facilities

20 7 7:15

Public Comments1 15 N/A 7:30

FINAL ADJOURNMENT 7:30

NOTE: The open session agenda, without public comments, is scheduled for 1 hour. Based on above agenda, without public comments the meeting starts at 6:00 p.m. and adjourns at 7:00 p.m.

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BOARD QUALITY REVIEW COMMITTEE

MONDAY, JUNE 20, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:00 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064

OPEN SESSION AGENDA

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.

Board Quality Review Committee Members

VOTING MEMBERSHIP NON-VOTING MEMBERSHIP

Aeron Wickes, MD – Chairperson, Board Member Bob Hemker, FACHE, President & CEO

Linda Greer, RN, Board Member Frank Beirne, FACHE, EVP, Operations

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

Richard Engel, MD – Interim Chair of Medical Staff Quality Management Committee for Palomar Medical Center

Charles Callery, MD - Chair of Medical Staff Quality Management Committee for Pomerado Hospital

Della Shaw – EVP, Strategy

Maria Sudak, RN, MSN, CCRN, NEA-BC – Interim VP, Palomar Medical Center and Chief Nursing Office, Palomar Medical Center

Larry LaBossiere, RN, MSN, CEN, CNS, MBA, Interim VP/Interim CNO, Pomerado

Sheila Brown, VP, Continuum Care

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

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Attendance Roster, Minutes and Acronym Glossary Board Quality Review Committee Meeting

Monday, May 16, 2016

Form A – Addendum A

TO: Board Quality Review Committee MEETING DATE: Monday, June 20, 2016 FROM: Christine Breese, Executive Assistant Background: The minutes of the Board Quality Review Committee held

on Monday, May 16, 2016, are respectfully submitted for approval. Included are the attendance roster and Acronym Glossary for the Committee’s review (Addendum A).

Budget Impact: N/A

Staff Recommendation: Approval

Committee Questions:

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

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The Patient Experience Board Quality Review Committee

Form A – Addendum B

TO: Board Quality Review Committee MEETING DATE: Monday, June 20, 2016 FROM: Christine Breese, Executive Assistant Background: Included in the packet for the Committee’s review are four

letters received from patients and/or family members regarding their experience (Addendum B).

Jerry Kolins, MD, Vice President, Patient Experience will share a short video of Tom Lee, MD, Chief Medical Officer for Press Ganey, regarding Teamwork and Patient Expectations.

Tina Pope, Manager, Service Excellence, will share a short video of Christy Dempsey, SVP and CNO for Press Ganey, regarding Compassionate, Connected Care.

Tina Pope will review the Patient Experience Dashboard and provide an update of the Action Plan (Addendum B).

Budget Impact: N/A

Staff Recommendation: For information only



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Quality and Safety Dashboards Board Quality Review Committee

Form A – Addendum C

TO: Board Quality Review Committee MEETING DATE: Monday, June 20, 2016 FROM: Christine Breese, Executive Assistant Background: Valerie Martinez, Director, Quality, Patient Safety and

Infection Control will share the latest data from the Facility-Wide quality dashboard for the Committee (Addendum C).

Budget Impact: N/A




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Journal Club Assignment “Toward a Safer Health Care System - The Critical Need to Improve Measurement” by Ashish Jha, MD, MPH and Peter

Pronovost, MD, PhD

Form A – Addendum D

TO: Board Quality Review Committee MEETING DATE: Monday, June 20, 2016 FROM: Christine Breese, Executive Assistant Background: The Journal Club assignment for June 2016 is to read the

article titled, “Toward a Safer Health Care System - The Critical Need to Improve Measurement” by Ashish Jha, MD, MPH and Peter Pronovost, MD, PhD (Addendum D).

Budget Impact: N/A




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Emergency Management / Environment of Care Board Quality Review Committee

Form A - Addendum E

TO: Board Quality Review Committee MEETING DATE: Monday, June 20, 2016 FROM: Christine Breese, Executive Assistant BACKGROUND: Dan Farrow, Assistant Vice President, Hospitality and

Facilities, will share the latest performance improvement activities for Emergency Management and Environment of Care (Addendum E).

Budget Impact: N/A




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ADDENDUM A

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05.16.16 - MINUTES - BQRC Meeting FINAL.doc Page 1 of 2

BOARD QUALITY REVIEW COMMITTEE - MEETING MINUTES – MONDAY, MAY 16, 2016

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY

CALL TO ORDER

The meeting, held at Pomerado Hospital located at 15615 Pomerado Road, Poway, CA 92064, in Conference Room E, was called to order at 6:34 p.m. by Committee Chairman, Aeron Wickes, MD.

ESTABLISHMENT OF QUORUM

Quorum comprised of Directors Wickes, Greer, Czerwonka, Dr. Charles Callery, Dr. Richard Engel

Excused Absences: Ø

Guest Directors: Ø

NOTICE OF MEETING

Notice of Meeting was posted at Palomar Health’s Administrative Office as well as with the Full Agenda Meeting Packet on the Palomar Health web site on Friday, May 6, 2016, which is consistent with legal requirements. Notice of that posting was also made via email to the Board of Directors and staff.

PUBLIC COMMENTS

There were no public comments.

INFORMATION ITEMS

1. APPROVAL OF MEETING MINUTES – BOARD QUALITY REVIEW COMMITTEE – APRIL 18, 2016

There was no discussion. MOTION: By Director Czerwonka, seconded by Director Greer and carried to approve the April 18, 2016, Board Quality Review Committee meeting minutes as submitted. All in favor. None opposed.

2. APPROVAL OF QUALITY ASSURANCE PERFORMANCE IMPROVEMENT PLAN

Jerry Kolins, MD, Vice President, Patient Experience informed the Committee that the Patient Safety and Quality Performance Improvement Plan has been renamed to Quality Assurance Performance Improvement (QAPI) Plan and was rewritten and updated to reflect current processes and regulatory requirements (Attachment #1).

MOTION: By Director Wickes, seconded by Director Czerwonka and carried to approve the Quality Assurance Performance Improvement Plan as submitted. All in favor. None opposed.

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05.16.16 - MINUTES - BQRC Meeting FINAL.doc Page 2 of 2

BOARD QUALITY REVIEW COMMITTEE - MEETING MINUTES – MONDAY, MAY 16, 2016

AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / RESPONSIBLE PARTY

STANDING ITEMS

1. JOURNAL CLUB

For the Journal Club assignment, the Committee discussed the article entitled, “Era 3 for Medicine and Healthcare” by Don Berwick, MD (Attachment #2). Jerry Kolins, MD, Vice President, Patient Experience shared an email from Amanda Holden, MD regarding the changes she made to her rounding methods and practices. These changes were due to the information she learned at the recent Patient Experience meeting where Christy Dempsey, SVP and CNO of Press Ganey spoke about Compassionate Connected Care (Attachment #3).

NEW BUSINESS

1. SERVICE EXCELLENCE AND PATIENT GRIEVANCE REPORTING

Tina Pope, Manager, Service Excellence presented the FY2016 Q3 results from Press Ganey and HCAHPS. Tina also shared data with the Committee about the number of compliments, grievances and complaints received during the month of March 2016. Tina and Maria Sudak, Chief Nursing Officer and Interim Vice President of Palomar Medical Center shared the outcomes from the recent Deep Dive meetings that took place in April and May (Attachment #4).

2. EMPLOYEE SAFETY

Russ Riehl, Director, Employee and Corporate Health gave a presentation to the Committee

about Employee Safety. A Workers Compensation Trend Analysis reviewing the claims filed by

employees, their frequency and severity was discussed (Attachment #5). The Committee

recommended ongoing reporting, on a quarterly basis, by Employee/Corporate Health to the

Quality Review Committee as well as the full Board of Directors.

MOTION: By Director Czerwonka, seconded by Director Greer and carried to

begin receiving quarterly reports from Corporate Health regarding Employee

Safety and Workers Compensation claims. This information will then be

reviewed by the full Board of Directors each quarter. All in favor. None

opposed.

PUBLIC COMMENTS

There were no public comments

ADJOURNMENT MOTION: By Director Wickes, seconded by Director Czerwonka and carried to adjourn the meeting at 7:58 p.m. All in favor. None opposed.

SIGNATURES:

COMMITTEE CHAIR

APPROVED

Aeron Wickes, MD

COMMITTEE SECRETARY

Christine Breese

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05.16.16 - ROSTER - BQRC Meeting Attendance Roster.docx Page 1 of 2

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

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

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

DIRECTOR DARA CZERWONKA Board Member P P P E P

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

FRANK MARTIN, MD QMC Chair, Palomar Medical Ctr

P P -- P --

RICHARD ENGEL, MD Interim QMC Chair, Palomar Medical Ctr

-- -- P P P

CHARLES CALLERY, MD QMC Chair, Pomerado Hospital

P P P P P

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

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

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

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

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

HEMKER, BOB President & CEO P P P E P

KOLINS, JERRY, MD, FACHE VP, Patient Experience

and Co-Chair, Patient Safety Committee

P P P P P

LABOSSIERE, LARRY Interim VP/CNO

Pomerado Hospitals -- -- -- -- P

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

Committee P P P P P

OLSON, CHERYL Interim VP, PHDC & Pomerado Hospitals

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

SHAW, DELLA EVP, Strategy P P P

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

P P P P P

Guests ADELMAN, MARCY, RN P

BARNES, DEBBIE, RN, CDS

FARROW, DAN

GOELITZ, BRIAN, MD P

GRIFFITH, JEFF (BOARD MEMBER)

HANSEN, DIANE P

KAUFMAN, JERRY (BOARD MEMBER)

KIM, JESSICA P P P

LEE, DAVID, MD P P P P P

LEE, JEREMY P P

MCCUNE, RAY (BOARD MEMBER)

NAMENYI, JASMINA P

NEUSTEIN, PAUL, MD P

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05.16.16 - ROSTER - BQRC Meeting Attendance Roster.docx Page 2 of 2

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) NICPON, GREGORY, MD P

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

POPE, TINA P P P P P

RIEHL, RUSSELL P

ROLIN, DONNA P

ROSENBURG, JEFFREY P E E E E

SCHULTZ, DIANA P

SOLOMON, LESLIE

TERRELL, CEDRIC P P

TURNER, BRENDA P P

WATSON, RAE ANNE P

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To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 1 of 4

Patient Experience Division

ACRONYM GLOSSARY

Updated: 06/07/2016

AAPL: Academy of Applied Physician Leadership AAR: After Action Report ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACR: American College of Radiology AHP: Arch Health Partners AHRQ: Agency for Healthcare, Research and Quality ALICE: Alert Lockdown Inform Counter Evacuate AMI: Acute Myocardial Infarction ARB: Angiotension Receptor Blocker ARU: Acute Rehab Unit ATS: Automatic Transfer Switch BETA: BETA Healthcare Group (PH Insurer) BQRC: Board Quality Review Committee BSC: Balanced Score Card BSIS: Bureau of Security and Investigative Services CALNOC: Collaborative Alliance for Nursing Outcomes CAP: Child Abuse Program CAP: College of American Pathologists CAP: Community-Acquired Pneumonia CAPG: The Voice of Accountable Physician Groups CAUTI: Catheter Associated Urinary Tract Infection CC: Complications and Comorbidities CCTP: Community-Based Care Transitions Program CDAD: Clostridium Difficile Associated Diarrhea CDC: Center for Disease Control CDI: Clinical Documentation Improvement CDI: C. Difficile Infections C-diff: Clostridium difficile CDPH: California Department of Public Health CHA: California Hospital Association CHF: Congestive Heart Failure CIHQ: Center for the Improvement in Healthcare Quality CLABSI: Central Line Blood Stream Infection CLIP: Central Line Insertion Practices CMMI: Center for Medicare and Medicaid Innovation CMS: Centers for Medicare & Medicaid Services COP: Conditions of Participation COPD: Chronic Obstructive Pulmonary Disease CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management

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mailto:[email protected]



ACRONYM GLOSSARY

Updated: 06/07/2016

CSHE: California Society Healthcare Engineers CVICU: Cardio Vascular Intensive Care Unit CY: Calendar Year DI: Diagnostic Imaging DM: Diabetes Mellitus DRT: Diabetes Resource Team DVT: Deep Vein Thrombosis EBP: Evidence Based Practice ED: Emergency Department EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EMS: Emergency Medical Services EMT: Emergency Medical Technician EMT: Executive Management Team EOC: Environment of Care EOP: Emergency Operations Plan EVS: Environment of Care Services / Environmental Services FANS: Food and Nutrition Services FHS: Forensic Health Services FMEA: Failure Mode Effects Analysis FY: Fiscal Year HAC: Hospital Acquired Conditions HAI: Healthcare Associated Infections HAPU: Hospital Acquired Pressure Ulcers HbA1c: Hemoglobin A1C HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCC: Hospital Command Center HCP: Health care provider HDL: High Density Lipoprotein Cholesterol HICS: Hospital Incident Command System HLD: High Level Disinfectant HF: Heart Failure HIPAA: Health Insurance Portability and Accountability Act HPP: Hospital Preparedness Program HPRO: Hip Replacement Surgery HRRP: Hospital Readmission Reduction Program HVA: Hazard Vulnerability Analysis IC: Infection Control ICU: Intensive Care Unit IHA: Integrated Healthcare Association IHI: Institute for Healthcare Improvement ILSM: Interim Life Safety Measures IMI: Inpatient Mortality Indicator

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ACRONYM GLOSSARY

Updated: 06/07/2016

IMM-2: Influenza Immunization IOM: Institute of Medicine IP: Infection Prevention (RN Staff) IPCC: Infection Prevention and Control Committee ISBARR: Introduction, Situation, Background, Assessment, Recommendations, Read back KP: Kaiser Permanente KPRO: Knee Replacement Surgery LSC: Life Safety Conditions MAB: Management of Assaultive (or Aggressive) Behavior MAC: Medicare Administrative Contractor MCC: Major Complications and Comorbidities MCI: Mass Casualty Incident MDRO: Multi Drug Resistant Organism MERP: Medication Error Reduction Plan MRI: Magnetic Resonance Imaging MRSA: Methicillin-resistant Staphylococcus aureus MSPRC: Medical Staff Peer Review Committee MY: Measurement Year NDNQI: National Database of Nursing Quality Indicators NHQM or NIHQM: National Improvement for Healthcare Quality Measure NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NIMS: National Incident Management System NPSF: National Patient Safety Foundation NPSG: National Patient Safety Goals NQF: National Quality Forum OB: Obstetrics OES: Office of Emergency Services OPPE: Ongoing Professional Practice Evaluation OSHA: Occupational Safety and Health Administration OSHPD: Office of Statewide Health Planning and Development PASS: Pull Aim Squeeze Sweep PCEA: Patient Controlled Epidural Analgesia PCM: Perinatal Care Measure PDCA: Plan Do Check Act PH: Palomar Health PI: Performance Improvement PM: Preventative Maintenance PMC: Palomar Medical Center PN: Pneumonia POCT: Point of Care Testing PPE: Personal Protective Equipment PPFR: Physician Performance Feedback Report

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ACRONYM GLOSSARY

Updated: 06/07/2016

PSI: Patient Safety Indicator QAPI: Quality Assurance Performance Improvement QIO: Quality Improvement Organization QRR: Quality Review Report RAC: Revenue Cycle Audits RACE: Rescue Alert Confine Extinguish RCA: Root Cause Analysis RT: Respiratory Therapist RHIT: Registered Health Information Technician RVT: Registered Vascular Tech SART: Sexual Assault Response Team SCIP: Surgical Care Improvement Project SDHDC: San Diego Healthcare Disaster Coalition SDS: Safety Data Sheet SHP: Strategic Healthcare Program SIR: Standardized Infection Ratio SIRS: Systemic Inflammatory Response Syndrome SIT: Security Integration Team SMILE: Share yourself, Make it clear, Inform on timing, Listen with care, End with Kindness

SNF: Skilled Nursing Facility SNS: Strategic National Stockpile SOC: Statement of Conditions SSI: Surgical Site Infection STK: Stroke TAT: Turn Around Time THA: Total Hip Arthroplasty TICU: Trauma Intensive Care Unit TJC or JC: The Joint Commission TKA: Total Knee Arthroplasty TRAIN: Triage Resource Allocation for In-patients UST: Underground Storage Testing US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Associated Pneumonia VBAC: Vaginal Birth After Caesarian Section VBP: Value Based Purchasing VRE: Vancomycin-resistant enterococcus VTE: Venous Thrombo-embolism WHO: World Health Organization

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ADDENDUM B

17

From: Ziaullah Yazdani [mailto:[email protected]] Sent: Sunday, May 22, 2016 1:15 PM

To: [email protected]

Subject: Shamie Gerwick's Stay in Hospital

Hello, I am writing on behalf of a recent patient at Palomar Hospital. Her name is Shamie Gerwick and she was treated at Palomar Hospital the first week of April of this year. I am writing this message because Shamie requested me to do so since she does not have access to a computer. Shamie would like to express her heartfelt gratitude and deep sense of appreciation for the excellent quality of care that she received during her stay at the hospital. The nurses and other support staff that attended to her were exemplary and highly professional in caring for her. They made her stay a very pleasant experience which no doubt contributed greatly to her expeditious healing. In particular Shamie would like to mention her attending physician Dr. Afshin Nahavandi. He was very kind, respectful, compassionate and caring in his interaction with her. She felt very safe with her care in his hands and felt that he went beyond the call of duty while treating her for her health condition. Shamie feels that Palomar Hospital should be proud of having Dr. Nahavandi, the nurses and other support staff that interacted with her working at the hospital. She feels that they should be commended for their good attitude and work. Respectfully, Zia Yazdani

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Palomar Medical Center

Domains/Question

n Ranking n Ranking n Ranking n Ranking n Ranking

HCAHPS: Communication with Nurses (Domain) 63 19 19 55 19 10

HCAHPS: Communication with Doctors (Domain) 63 18 19 60 19 1

PG: How well staff worked together to care for you 60 84 17 9 19 15

≤ 89 = Red≥ 90 = Green

8 East - Medical Acute Care

FY2016 Q3 Results April 2016 May 2016 June 2016 July 2016

Palomar Health Service Excellence Department/(760) 740-6357 1 of 2 22

Pomerado Hospital

Domains/Question

n Ranking n Ranking n Ranking n Ranking n Ranking

HCAHPS: Communication with Nurses (Domain) 126 4 35 32 32 50

HCAHPS: Communication with Doctors (Domain) 126 8 35 53 32 40

PG: How well staff worked together to care for you 124 9 34 69 30 85

≥ 90 = Green≤ 89 = Red

Med/Surg/Tele - Medical/Surgical/Telemetry (4th Floor Only)

FY2016 Q3 Results April 2016 May 2016 June 2016 July 2016

Palomar Health Service Excellence Department/(760) 740-6357 2 of 2 23

ADDENDUM C

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FACILITY-WIDE DASHBOARD - POMERADO HOSPITALHealthcare-Associated Infections SIR for

CY16 Q1

Apr 2016 CY16 Q1 CY16 YTD

C. Difficile Infections (CDI) 4 4 8 1.16 0.50

Methicillin-Resistant Staphylococcus Aureus

(MRSA)

0 1 1 0.27 0.50

Surgical Site Infection (SSI): Colon 0 0 0 0.00 0.50

Surgical Site Infection (SSI): Abdominal

Hysterectomy

0 0 0 0.00 0.50

Catheter-Associated Urinary Tract

Infection (CAUTI)

0 1 1 0.41 0.50

Central Line-Associated Blood

Stream Infection (CLABSI)

2 0 2 0.00 0.50

FACILITY-WIDE DASHBOARD - PALOMAR MEDICAL CENTERHealthcare-Associated Infections SIR for

CY16 Q1


C. Difficile Infections (CDI) 6 22 28 1.42 0.50


(MRSA)

0 0 0 0.00 0.50

Surgical Site Infection (SSI): Colon 1 3 4 0.30 0.50


Hysterectomy

0 0 0 0.00 0.50


Infection (CAUTI)

1 6 7 0.52 0.50



1 5 6 0.61 0.50

FACILITY-WIDE DASHBOARD - PALOMAR HEALTH DOWNTOWN CAMPUSHealthcare-Associated Infections SIR for

CY16 Q1


C. Difficile Infections (CDI) 1 6 7 N/A 0.50


(MRSA)

0 0 0 0.00 0.50


Hysterectomy

0 0 0 0.00 0.50


Infection (CAUTI)

0 2 2 N/A 0.50



0 0 0 0.00 0.50

# of Infections Benchmark

for SIR


for SIR


for SIR

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National Health System Performance Comparisons (all systems)

PERFORMANCE MEASURE BENCHMARK HEALTH SYSTEMS

PEER GROUP OF U.S. HEALTH

SYSTEMS

DIFFERENCE PERCENTAGE DIFFERENCE

HOW TOP 15 HEALTH SYSTEMS COMPARE

WITH PEERS

Mortality Index1 0.86 1.01 (0.15) (14.7%) Lower mortality

Complications Index1 0.84 0.99 (0.15) (15.1%) Fewer complications

Core Measures mean percentage3 95.3 93.2 2.14 NA Better care compliance

30-day mortality rate (%)3 11.8 12.0 (0.14) NA Lower 30-day mortality

30-day readmission rate (%)4 15.0 15.7 (0.78) NA Fewer 30-day readmissions

Average length of stay (days)1 4.5 5.0 (0.51) (10.3) Shorter average length of stay

ED measures mean minutes5 146.0 166.4 (20.41) (12.3) Shorter time to service

Medicare spending per beneficiary index5

0.94 0.99 (0.05) (4.9) Lower episode cost

HCAHPS score5 269.5 262.4 7.09 2.7% Better patient experience

Note: Measure values are rounded for reporting. 1 Mortality, complications and average length of stay based on present-on-admission-enabled risk models applied to Medicare Provider Analysis and Review data for 2013 and 2014. (Average length of stay is 2014 data only). 2Core Measures data from CMS Hospital Compare Oct 1, 2013 – Sept. 30, 2014 data set. 330-day mortality rates include AMI, HF, pneumonia, COPD and stroke patients from CMS Hospital Compare July 1, 2011 – June 30, 2014 data set. 430-day readmission rates include AMI, HF, pneumonia, hip/knee arthroplasty, COPD and stroke patients from CMS Hospital Compare July 1, 2011 – June 30, 2014 data set. 5Emergency department measure, spending per beneficiary and HCAHPS data from CMS Hospital Compare Jan. 1, 2014 – Dec. 31, 2014 data set. AMI=acute myocardial infarction; HF=heart failure; COPD=chronic obstructive pulmonary disease; HCAHPS=Hospital Consumer Assessment of Healthcare Providers and Systems survey 26

ADDENDUM D

27

Copyright 2016 American Medical Association. All rights reserved.

Toward a Safer Health Care SystemThe Critical Need to Improve Measurement

It has been more than 15 years since To Err Is Human,the landmark report by the Institute of Medicine(IOM), revealed the substantial morbidity and mortal-ity related to medical errors in the United States. Tworecent developments have refocused policy makers ongetting patient safety right. The first are data suggest-ing that deaths associated with medical errors mayexceed 400 000 annually,1 although this number iscontroversial, with questions about the degree towhich medical errors truly caused each of these deathsand how many deaths were attributable to a medicalerror when death was inevitable. Regardless, medicalerror is likely a major cause of death and disability inthe United States. The second is the Affordable CareAct, which has, through programs like Value-BasedPurchasing and Hospital-Acquired Conditions penal-ties, made patient safety a financial priority for hospi-tals. While greater focus on safety is a welcome devel-opment, there is little reason to believe that addedattention alone will lead to safer care. Why? Becausethe health care industry lacks valid patient safety mea-sures, which are fundamental to improvement. With-out these measures, the key ingredient in these effortsis missing: systematic, real-time data on adverseevents with timely feedback to clinicians and healthcare organizations. Without effective measurementand reporting, progress in patient safety will be ardu-ous and slow.

Whether meaningful progress has occurred withinpatient safety is controversial. The Obama Administra-tion’s internal evaluations suggest modest improve-ment on a subset of patient safety measures. Despitesome questions about these findings, mostly due to alack of a valid approach to measurement and evaluation,2

there is no disagreement that policy makers should domore to improve safety measurement.

Journalists and private companies are now begin-ning to fill the void in measurement left by policy mak-ers. For example, ProPublica, a nonprofit investigativejournalism outlet, provoked intense debate with itsprofile of 17 000 surgeons, using certain readmissionsas a surrogate for complications. This follows many fed-eral government efforts that measure safety with asimilar approach: using billing data and counting thenumber of adverse events coded. Identifying complica-tions through billing data can be problematic becausehospitals that are diligent about identifying and docu-menting adverse events may be more likely to belabeled as unsafe, a form of “surveillance bias.”3 Thebest organizations may then be labeled as the worstand consequently may receive the largest penaltiesunder pay-for-performance schemes. In the mostexpensive health care system in the world, the choice

should not be between using flawed approaches thatpenalize the best physicians and hospitals or not mea-suring adverse events at all.

Federal policy makers, especially the Centers forMedicare & Medicaid Services (CMS), could take 3 stepsfor meaningful progress. First, CMS needs to eliminateunnecessary, unreliable metrics from government pro-grams and oversee the development of a standardizedset of validated metrics. For example, the Patient SafetyIndicator (PSI) 90 is a conglomeration of various ad-verse events of varying importance that rely on admin-istrative data. Administrative data have low validity com-pared with clinical data (B. D. Winters, MD, PhD, et al,unpublished data, 2015) and are marked by long delaysin reaching clinicians, which hampers their usefulness.Instead of focusing on PSIs, CMS instead should focuson the most common and clinically meaningful causesof harm and should use clinical data, not billing data, andmonitor and report the validity of the measures. Suchan approach will enable hospitals to focus on improv-ing patient safety rather than changing coding, as the cur-rent programs have encouraged.

What specific events should CMS focus on? Epide-miologic studies of adverse events find that the mostcommon causes of iatrogenic harm to hospitalized pa-tients are adverse drug events, nosocomial infections,venous thromboemboli, decubitus ulcers, falls, and sur-gical complications. A recent IOM report also highlightsthe importance and the burden of diagnostic errors.4

However, the current national patient safety strategyuses a validated, clinically based approach to measur-ing only 1 of these, nosocomial infections. The Centersfor Disease Control and Prevention (CDC) and its Na-tional Healthcare Safety Network have a very good trackrecord of working effectively with professional soci-eties and hospitals on a subset of these infections to de-velop valid and reliable measures. The CDC’s work hasmade substantial gains in making hospital care safer, par-ticularly with regard to central line–associated blood-stream infections and surgical site infections. The CMSshould work with the CDC to expand this proven modelto other types of patient harm.

How might the CDC expand its efforts on patientsafety measurement? The CDC could harness clinicaldata from electronic health records to develop algo-rithms for detecting the other leading causes of prevent-able harm, including adverse drug events, venous throm-boemboli, and others (Table). With modest effort, thismay be achievable. Even in the 1990s, before the de-velopment of sophisticated health information technol-ogy systems, this approach was shown to be nearly assensitive—while far less resource intensive—as manualchart reviews at detecting adverse drug events, such as

VIEWPOINT

Ashish Jha, MD, MPHDepartment ofHealth Policy andManagement, HarvardT. H. Chan School ofPublic Health, Boston,Massachusetts.

Peter Pronovost, MD,PhDArmstrong Institute forPatient Safety andQuality, Johns HopkinsMedicine, Baltimore,Maryland.

CorrespondingAuthor: Ashish Jha,MD, MPH, 42 ChurchSt, Cambridge, MA02138 ([email protected]).

Opinion

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allergic reactions or nephrotoxicity due to medications.5 Given thesensational advances in computing in the past 2 decades and thatmost US hospitals now have electronic health records,6 there are suf-ficient data that could be exploited to detect a wide variety of ad-verse events. With the CDC’s expertise in engaging professional so-cieties, measurement experts, and consumers, these types ofmeasures can be pilot tested and improved over time.

Second, CMS should task an agency with defining standards ofwhat makes good measures and setting accuracy requirementsbefore implementing measures in pay-for-performance and publicreporting. Such an agency would serve a similar role for health careas the Federal Accounting Standards Advisory Board does forfinancial reporting. Under this system, professionals set accountingstandards, performance is audited and transparently reported, andjournalists report on validated measures, working from a commonsource of standards. The National Quality Forum is the naturalagency to play such a role in health care, but it must be efficient,

narrowly focused on high-value metrics, and technically sound.Whatever agency plays this role, it will foster a system in which dif-ferent payers, clinicians, health care organizations, and evenpatient groups can reasonably disagree about which measures aremost important. But they all should have a common set of soundmetrics.

Third, Congress needs to find funding for systems engineeringresearch. There are competing funding priorities, but the payoff forthe health care system, including the federal budget, of theseinvestments can be substantial. For instance, the checklist inter-vention that substantially reduced central line infections was ini-tially supported by a $500 000 grant from the Agency for Health-care Research and Quality. Complications are expensive, andreducing their frequency can provide significant savings to payers.Reducing complications such as central line infections not onlylikely saved thousands of lives but also billions of dollars, much of itto the Medicare program. Improving safety depends on havinggood systems in place rather than on the efforts of individualclinicians.7 As such, the government—the largest payer in healthcare—needs to fund practically applicable studies on systems engi-neering to promote efficient, safe health care.

Despite thousands of deaths each year related to unsafe care,policy actions have not matched the scale of the problem. How-ever, tools are now available to make meaningful progress in safety,starting with systematic collection and dissemination of high-quality, clinically based data. The marketplace is not standing still;organizations that promote public reporting are using available datato make pronouncements about which clinicians and hospitals aresafe and unsafe. Some efforts will be better than others, but noneof them will be as good as they could be because the metrics theyuse are only as good as the data going into them. Without stan-dards of accuracy or timeliness, some rating programs will label someof the best clinicians and hospitals as unsafe and some of the ne-glectful ones as safe, which has the potential to do more harm thangood. Better data, valid metrics, and greater transparency repre-sent the best formula for making the United States a world leaderin patient safety.

ARTICLE INFORMATION

Published Online: April 14, 2016.doi:10.1001/jama.2016.3448.

Conflict of Interest Disclosures: The authors havecompleted and submitted the ICMJE Form forDisclosure of Potential Conflicts of Interest.Dr Pronovost reports grants from the CDC and theAgency for Healthcare Research and Quality;contracts through Johns Hopkins University withErnst and Young; participation as a nonpaidscientific advisor to Leapfrog Group; and speakinghonoraria from various hospitals. No otherdisclosures were reported.

REFERENCES

1. James JT. A new, evidence-based estimate ofpatient harms associated with hospital care.J Patient Saf. 2013;9(3):122-128.

2. Pronovost P, Jha AK. Did hospital engagementnetworks actually improve care? N Engl J Med.2014;371(8):691-693.

3. Bilimoria KY, Chung J, Ju MH, et al. Evaluation ofsurveillance bias and the validity of the venousthromboembolism quality measure. JAMA. 2013;310(14):1482-1489.

4. McGlynn EA, McDonald KM, Cassel CK.Measurement is essential for improving diagnosisand reducing diagnostic error: a report from theInstitute of Medicine. JAMA. 2015;314(23):2501-2502.

5. Jha AK, Kuperman GJ, Teich JM, et al. Identifyingadverse drug events: development of acomputer-based monitor and comparison withchart review and stimulated voluntary report. J AmMed Inform Assoc. 1998;5(3):305-314.

6. Adler-Milstein J, DesRoches CM, Furukawa MF,et al. More than half of US hospitals have at leasta basic EHR, but stage 2 criteria remain challengingfor most. Health Aff (Millwood). 2014;33(9):1664-1671.

7. Pronovost PJ, Bo-Linn GW. Preventing patientharms through systems of care. JAMA. 2012;308(8):769-770.

Table. Common Causes of Hospital Adverse Events and PotentialMeasures and Data Sources

Events Potential MeasuresData Sources FromElectronic Health Records

Adverse drug events Allergic reactions, elevatedblood creatinine followingnephrotoxin prescription,prescription of antidotes(eg, naloxone)

Order entry, laboratoryresults, clinical notesfor confirmation

Deep veinthrombosis (DVT)

Rate of postoperative DVT,rate of pulmonaryembolism, laboratoryabnormalities(eg, elevated D-dimer)

Radiology reports,laboratory results, clinicalnotes for confirmation

Falls Rate of falls among olderpatients

Nursing notes, clinicalnotes, radiology reports

Decubitus ulcers Rate of decubitus ulcers Nursing notes, physiciannotes, nurse-completedsingle-question ulcerassessment

Nosocomialpneumonia

Rate of nosocomialpneumonia

Nursing notes, laboratoryresults, radiology reports

Diagnostic errors Rate of missed diagnosis ofacute myocardial infarction

Clinical notes,electrocardiogram,laboratory results

Opinion Viewpoint

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ADDENDUM E

30

Annual Report Environment of Care and the

Emergency Management Programs

CY 2015

Submitted by: Dan Farrow: AVP Hospitality and Facilities

Steve Miller: Director of Facilities Lisha Wiese: Program Manager – Emergency Mgt and Safety

31

2015 Key Activities and Accomplishments Environment of Care (EOC) & Emergency Management (EM) Programs

Safety Management

• Multi-disciplinary environment of care rounding – Documented in Sentact and issues sent to Director to resolve and close out in Sentact.

Hazardous Materials Management

• Process Improvement Project for the EOC identified – 2014 first responder decontamination training met quarterly to review plans, communication

details and gaps, and plan for next decontamination exercise.

Security Management:

• Ongoing active shooter and Management of Assaultive Behavior training

• Multiple collaborations with Escondido PD SWAT and K-9 personnel with trainings at vacant Surgery Center.

32

2015 Key Activities and Accomplishments Environment of Care & Emergency Management Programs

Continued

Fire Prevention Management • Fire prevention devices tested and maintained per regulatory standards. • Fire safety training provided for PMC kitchen staff.

Medical Equipment Management: • Enhancement of Medical Equipment Management Plan to comply with The Joint Commission

Standards

Utilities Management • Utility failures monitored by EOC committee to ensure issues were resolved, follow up actions

taken promptly

Emergency Management • Continued collaboration with SD County Emergency Medical Services (EMS) on Hospital

Preparedness Program (HPP) grant funding and grant funds were received. • Two disaster exercises and two tabletop exercises completed and evaluated for effectiveness

33

Key Areas of Focus for 2016 Environment of Care & Emergency Management Programs

Safety Management:

• General safety awareness training and provide reference materials for staff (emergency code kardex )

• Implementation of system wide ‘Department Safety Captain’ program in conjunction with the Staff On Safety Program

• Deployment of monthly safety and disaster training programs

Security Management: • Continue with Code Silver and Management of Behavior Training • Continue cultivating relationships with community law enforcement partners • Installation of Knox boxes at each hospital facility at key access points • Interdisciplinary team formed to implement Cal OSHA’s new Violence in the

Workplace regulation

Hazardous Materials Management: • Provide another round of 16-hour hands on decontamination training and

recertification • Continue with decontamination team committee

Utilities Management: • Continue to ensure utility system reliability and minimize the risk of utility

system failures.

34

Key Areas of Focus for 2016 Environment of Care (EC) & Emergency Management (EM) Programs

Continued

Fire Prevention Management:

• Modification of fire drill evaluation forms to better capture staff involvement and participation in fire drills

• Complete standardization of fire response education district-wide

Medical Equipment Management:

• Collaborate with Supply Chain to drive >20% savings with rented mobile medical equipment

• Successful department consolidation of medical equipment

Emergency Management:

• Transition to the new Everbridge Mass Notification platform

• Continue collaborating with hospital partner Emergency Managers, law enforcement, Red Cross, fire, County OES (Office of Emergency Services), and County EMS during monthly San Diego County Healthcare Disaster Coalition meetings.

• Implement streamlined process, using T.R.A.I.N (Triage Resource Allocation for In-patients) to effectively address patient transportation needs during an evacuation.

35

Prepared by: Lisha Wiese:

Program Manager – Emergency Management and Safety

Palomar Medical Center

Palomar Health Downtown Campus

Pomerado Hospital

Villa Pomerado

Satellite Buildings

Annual Evaluation of the Environment of Care Management Plans and the Emergency Operations Plan

2015

Date prepared: April 5, 2016

37

EVALUATION - ENVIRONMENT OF CARE - OBJECTIVES

Introduction Permeating every aspect of our medical centers and satellite buildings, the Environment of Care is an essential aspect of patient

safety, from the first patient contact, through the assessment, treatment, discharge and continuing care. The Environment of Care

overlaps with Infection Prevention and the management of Human Resources, as well as plays an integral part with Performance

Improvement, Risk Management, and Patient Safety standards. The objectives of the various Environment

of Care Management plans have been to provide a safe, functional, supportive and effective environment for patients, visitors,

staff, volunteers and members of our physician community. This is critical to providing quality patient care.

Achieving our objectives is dependent upon performing the following central processes:

•Strategic and on-going master planning by organization leadership (Plan / Design)

•Educating staff about the role of the environment that supports patient care (Teach)

•Implementing various components of design (Implement)

•Measuring standards that we have set for ourselves (Respond)

•Gathering information about our outcomes (Monitoring / Measuring / Evaluating)

•Making decisions about our findings (Improving)

The Environment of Care Management plans address six elements, which include Safety, Security, Hazardous Materials

and Waste, Fire Prevention, Medical Equipment and Utilities Management. Emergency Management addresses the Emergency

Operations Plan (EOP). There is much diversity in the seven management plan elements, but each have parallels with planning,

teaching, implementing, responding, monitoring and improving. Through the work of our staff, the purpose with the Environment

of Care is to ensure ongoing diminishment of risk (e.g., possible loss or injury) within our medical centers.

The Environment of Care Committee provides a leadership framework for the management of risks, promoting a teamwork

approach, and ongoing attention to programs, plans, and related activities that point toward risk reduction.

Whenever possible, the Environment of Care is integrated with the Occupational Safety and Health Administration objectives

(e.g., regulatory requirements), as well as other agencies having jurisdiction, enforcing standards that encourage continued

improvement in the workplace.

Evaluation of Objectives – Safety Management Plan. The Safety Management plan is designed to provide a physical environment wherein risks associated with physical

harm and hazards will be minimized for the patient-care population, staff, volunteers, physicians, contracted workers and

visitors. It is an accreditation/standards-based and regulatory driven plan. There are fundamental activities inherent in

daily routines that support the ability to identify risk prior to any incident. These include formal proactive risk assessments

such as accreditation, regulatory or insurer surveys, ongoing environmental surveillance, safety and infection prevention

procedures that are based upon accreditation standards and regulations, and ongoing education.

Educating employees to the hazards that may pose risk, or contribute to an injury has been ongoing, as well

as the efforts relating to accident investigation post injury. We continue to meet our objective relating to the minimization of risk

within the built environment and continue to be poised to provide safety for our patients.

Evaluation of Objectives – Security Management Plan. Through a medium of care and respect for everyone who comes to our facilities, the Security Management plan is designed to

provide the highest quality safety and security. We strive to provide a challenging work environment for Security staff,

as we work to create and support a peaceful environment so that people will feel at ease when they come to our medical

centers. Overall, our Security Management program has catapulted into a higher level of awareness since the events

of 9-11-01, and subsequent terrorist events worldwide, including the increasing Code Gray and Silver incidents at medical facilities.

Our Security Management plan has provided a deterrent to criminal activity on our campuses, which has allowed us to meet our

objective of promoting a peaceful environment. Security staff are visible in uniforms, and are service oriented to the public, as well

as being trained in de-escalation techniques. Security has camera systems and ongoing monitoring that has allowed us to spot

activity or trends that have assisted us in reducing security risks. The objectives of the Security Management Plan have been

met, and we will continue to promote the reduction of risk throughout the year 2015, focusing on proactive activities, and

ongoing education.

2

38

Annual Evaluation of Objectives, continued

3

Evaluation of Objectives: Hazardous Materials and Waste Management Plan. The objectives of the Hazardous Materials Management Plan are to ensure that information about the risks of hazardous

chemicals / materials and wastes used in the facilities are known by affected employees, and to ensure that the information is

given to employees in the form of SDS (Safety Data Sheets), education, and labeling. Another objective is to ensure that

hazardous waste products do not endanger the health of the environment. Taken together, these objectives minimize the risk

of exposures to hazardous chemicals within our facility and community. Minimization of risk not only applies to our medical

centers, but to the community at large (e.g., minimization of spills into the environment). Equally important, is our effort to

reduce waste and to use non-hazardous products whenever feasible. Educating employees to the risks relating to

hazardous material use, storage and disposal has been a program element designed to meet our objectives. Other activities

within the medical centers have contributed to meeting our stated objective, and these include: assessing staff knowledge relative

to the hazardous materials and waste management program, manifesting hazardous materials in accordance with regulations,

the development of procedures, and the use of appropriate personal protective wear.

Evaluation of Objectives: The Fire Prevention Management Plan. The objectives of the Fire Prevention Management plan are to provide a physical environment free from physical harm

and hazards created by fire, the risk of fire, or the products of combustion for the patient care population, staff, volunteers,

physicians and visitors. The risk of fire carries with it the most significant single threat to the environment of care as our patients

are routinely incapable of self-preservation, and must rely on correct staff response and building fire protection features to

assure their safety. Compliance with the Life Safety Code supports meeting our objectives, as well as practicing fire drills

throughout the medical centers and testing correct staff response during the drills. Proactively identifying life safety risks

during routine surveillance (e.g., observing for doors that do not close and latch properly, wall and ceiling penetrations,

illegal latching hardware, etc.) additionally supports meeting this objective. There are programs in place that increase the

likelihood of our objectives being met, which include fire equipment testing and maintenance, annual certifications for fire

detection and protection systems, and the ongoing monitoring of the Statement of Conditions which identifies any life

safety vulnerabilities, and our plans and financial commitment to correct / enhance or minimize them.

Evaluation of Objectives: The Medical Equipment Management Plan. The objective of the Medical Equipment Management Plan includes a joint effort of the clinical and non-clinical departments

to minimize the risks inherent in the use of medical equipment that is used on our patients, and to ensure proper performance.

In order to meet these objectives, multiple programs need to be in place, which include, but are not limited to: risk assessment of

all incoming medical equipment, preventive and corrective maintenance programs, “out-of-service” program for equipment that

needs repair, and general education of equipment and user / maintainer training programs. Quarterly monitoring of preventive

maintenance completion rates for our medical equipment affords us the opportunity to promote quality performance, thereby

minimizing the risks associated with medical equipment failures, which supports our patient safety efforts. These programs are

in place throughout the medical centers, and have been effective in allowing us to meet the stated objectives.

Evaluation of Objectives: The Utility Management Plan. The objectives of the Utility Management Plan include complying with regulatory-driven and accreditation standards to provide

Facilities that are safe, controlled, comfortable, and maintained in accordance with applicable regulation, requirement, and accepted

engineering practice. Through a system of procedures, education, and ongoing quality monitoring and evaluation, the

objectives are to provide the utility system users and operators with emergency response guidance in the event of a utility system

failure, and to promote the reliability and performance of our utility systems. Risks, identified through the use of the

a computerized data base program, factor adverse equipment experience into the quality assessment, risk management, and

utility management functions. Our procedures, preventive maintenance program, education and quality monitoring all

support the accomplishment of meeting our stated objectives, and also support our patient safety goals.

Evaluation of Objectives: The Emergency Operations Plan. One primary objective of the Emergency Operations Plan is to mitigate harm to life and property due to unforeseen

circumstances and risks identified in the Hazard Vulnerability Analysis. The Emergency Operations Plan comprehensively

describes the organization’s approach to responding to emergencies within the organization or in its community that would

suddenly and significantly affect the need for the organization’s services, or its ability to provide those services. The

Disaster Preparedness Committee has been very active in the design and implementation of the Emergency Operations Plan,

and it is expected to continue in this direction in 2015. The plan is intended to identify risks to the organization and addresses how

the medical centers are prepared to respond as well as identify strategies in place to mitigate the risks. These plan elements

and other activities in the medical centers relating to emergency preparedness (e.g., education of staff, disaster

exercise implementation / evaluation, and performance improvement demonstrate that the medical centers have been effective

in meeting the stated objective.

39

EVALUATION OF THE SCOPE

SAFETY 1. Performance standards – Review of performance standards for the

Environment of Care for 2015, including re-assessing thresholds of

performance.

2. Reporting schedule established for the Environment of Care committee.

3. POM Facility Manager conducted monthly rounds and reviewed disaster and

fire training with Villa Pomerado staff to increase knowledge.

4. Facility Manager Environment of Care reports reviewed in each quarter.

5. Preparedness activities for El Nino weather completed at each facility (i.e.

roof drain clearing, roof repairs, etc.).

6. Multi-disciplinary environmental surveillance: ongoing, with deficiencies

identified and documented in Sentact and issues sent to Director for she / he

to resolve and close out in Sentact

7. Annual Evaluation of the Safety Management plan completed: Objectives,

Scope, Performance standards and Overall Effectiveness completed.

SECURITY 1. Performance standards and thresholds established for 2015.

2. Quarterly reports for Security completed, including incident review.

3. Security staff actively participating in disaster drills, and have assumed the

“Security Branch Director” role in the command centers.

4. Consolidation of SIT (Security Integration Team) into monthly EOC

Committee meetings.

5. Fence, additional lighting and security cameras installed around Grand Bldg.

6. Ongoing active shooter (ALiCE – Alert, lockdown, inform, counter, evacuate)

and Management of Assaultive Behavior (MAB) training by staff / physician

request. Over 25 classes conducted for staff, both clinical and non-clinical, in

the areas of ALiCE, personal security tactics, MAB, and pepper spray safety.

7. Code Pink/Purple drills conducted and evaluated with effective outcomes.

8. Workplace violence prevention multidisciplinary planning team began

meeting.

9. Through the Security Integration Teams, a follow up survey was sent to staff

to evaluate the effectiveness of communication, access control, parking, and

visitor management.

10. Collaboration with Escondido SWAT and K-9 units in the usage of vacant

Surgery Center building to conduct multiple security and safety response

trainings.

11. Annual Evaluation for the EOC for the Security Management Plan completed:

Objectives, Scope, Performance Standards and Overall Effectiveness

completed.

HAZARDOUS MATERIALS 1. Performance standards and thresholds established for 2015.

2. No spills requiring outside agency assistance reported.

3. Performance Improvement (PI) Project for the EOC identified: the

participants of the 2014 first responder decontamination training meet

quarterly to review plans, communication details, and plan for next decon

exercise

4. Annual Evaluation of the EOC for Hazardous Materials Management Plan

completed: Objectives, Scope, Performance Standards, Overall Effectiveness

FIRE PREVENTION 1. Performance standards and thresholds established for 2015.

2. Fire drills conducted and evaluated by Security staff, one per shift per

quarter, with additional drills completed per staffing requirements or

construction areas and satellite buildings.

3. Statement of Conditions (SOC) reviewed and kept updated by Facility

Managers.

4. Annual fire detection systems tested and certified.

5. Annual fire extinguisher maintenance completed.

6. Facility Manager Environment of Care reports reviewed in each quarter.

7. Collaboration with Escondido Fire and other SD fire agencies in the

usage of the vacant Surgery Center to complete fire rescue training and

simulated structure fire.

8. Fire safety and response training provided to PMC kitchen staff.

9. Preventive maintenance for fire equipment completed.

10. Annual evaluation of the Fire Prevention Management plan completed:

Objectives, Scope, Performance Standards and Overall Effectiveness.

MEDICAL EQUIPMENT 1. Performance standards and thresholds established for 2015.

2. Medical equipment failures and recalls monitored by Biomedical

leadership with appropriate actions taken.

3. Preventive maintenance and corrective maintenance monitored for life

support and non-life support medical equipment.

4. Enhancement of the Medical Equipment Management Plan (MEMP) to

comply with The Joint Commission standards.

5. Added laser safety check quantities to quarterly EOC report.

6. Annual evaluation of the Medical Equipment plan and program

completed: Objectives, Scope, Performance, Effectiveness

UTILITIES MANAGEMENT 1. Performance standards and thresholds established for 2015.

2. Generator testing completed per regulatory standards.

3. Preventive maintenance monitored.

4. Facility Manager Environment of Care reports reviewed in each quarter

2015.

5. Utility failures reported to Environment of Care committee, each resolved

with follow-up actions documented.

6. Annual evaluation of the Utility Management plan and program

completed: Objectives, Scope, Performance Standards and Overall

Effectiveness

EMERGENCY MANAGEMENT 1. Performance standards and thresholds established for 2015.

2. Disaster preparedness multidisciplinary committee meetings held with

multiple activities accomplished.

3. Emergency Management leadership participated in community tabletop

at Poway FD HQ. Scenario: Wildfires with Santa Ana winds and

Pomerado Hospital / Villa Pomerado response and collaboration.

4. Wildfire preparedness tabletop completed at POM and VP in October.

Worked in collaboration with Poway FD and City of Poway disaster

coordinator.

5. Hazard Vulnerability Analysis (HVA) reviewed / revised for 2015 with the

top five hazards identified.

6. Everbridge notification drills completed semi-annually to coincide with

county and statewide exercises. Over 900 physicians included in

notification exercises.

7. Ongoing membership with San Diego Healthcare Disaster Coalition

(SDHDC) which strengthens community ties with the other San Diego

County hospitals, SD County Emergency Medical Services (EMS), SD

County Office of Emergency Services (OES), Red Cross, SD County

Public Health, and law enforcement agencies.

8. Continued collaboration with SD County Emergency Medical Services

(EMS) in the area of Hospital Preparedness Program (HPP) grant

funding. All deliverables completed in May 2015 and grant funds were

received.

9. Everbridge emergency notification system is used exclusively during

exercises and actual events.

10. Satellite phone hard lines installed in the three hospital command

centers as a communication redundancy.

11. Disaster surge cart medical supplies inventoried by supply chain staff to

ensure expiration dates are monitored and supplies are rotated into the

supply stream.

12. Continued collaboration with Kaiser Emergency Management colleagues

to ensure communication is flawless during disaster events.

13. Countywide disaster exercise completed at each site May 2015.

Scenario: decontamination and patient surge due to HAZMAT and MCI

(mass casualty incident).

14. Statewide disaster exercise completed at each site November 2015.

Scenario: Anthrax detected in atmosphere, causing the need for SNS

(strategic national stockpile) cache of medicine to be deployed for

hospital staff, their families, patients and physicians.

15. Annual evaluation for the Emergency Operations Plan completed:

Objectives, Scope, Performance, Effectiveness.

4

Evaluation of the Scope of the Environment of Care Management plans: The scope of each management plan

applies to all personnel in each facility and satellite building.

Each facility and building is surveyed, and every attempt is

made to ensure risks are identified that may have an impact on

the reduction of accidents or injury. Staff are required to work in

a safe manner, and to report unsafe acts or observations,

without any fear of reprisal. The following Environment of Care

accomplishments throughout the year 2015 represent the

emphasis on safe work behaviors and risk reduction, and

validate leadership’s support of safety throughout the physical

environments of our medical centers and satellites, as well

as support and dedicate attention to high standards of safe

work behaviors for all staff. The multitude of accomplishments

validate a breadth and depth of the scope of our Environment

of Care management plans and the Emergency Operations

Plan.

40

EVALUATION: PERFORMANCE STANDARDS OVERVIEW. The attached data sheets represent the evaluation of established performance standards,

areas chosen on one or more of the following criteria:

1. The performance standard represents a measurable area of one of the EOC components.

2. The performance standard indicates a key reflection of the scope of the component.

3. The performance standard represents a high volume activity, or low volume but high risk consequences.

4. The performance standard requires improvement, or the existing process could be enhanced.

Safety Performance Standards

The following performance activities were undertaken in 2015:

(1) Monitoring of O2 bottles found unsecured during monthly Environment of Care (EOC) rounds

(2) Unsafe condition reports resolved by individual Facility Managers within 24 hours of submission (if actual unsafe condition)

5

Security Performance Standards The following performance activities were undertaken in 2015:

(1) Begin upgrade and enhancement of the security video observation, access control, and alarm systems

(2) 100% of security officers obtain CA Bureau of Security and Investigative Services (BSIS) guard card certification

(3) Make available for all staff: quarterly offerings of security classes in the areas of Code Silver response, Managing

Aggressive Behavior (MAB), and personal security practices

(4) <2 automobile thefts per quarter by facility

(5) Implement badge ID awareness / compliance campaign

(6) Establish liaison contacts with local law enforcement and fire officials

Hazardous Materials and Waste Performance Standards The following performance activities were undertaken in 2015:

(1) Monitoring of hazardous material containers inspected / labeled incorrectly during monthly Environment of Care (EOC) rounds

(2) Staff knowledge in obtaining SDS (Safety Data Sheet) information during monthly Environment of Care (EOC) rounds (90% threshold)

(3) Monitoring of number of hazardous chemical incidents involving outside agency assistance for cleanup

(4) Monitoring of number of biohazard waste incidents involving outside agency assistance for cleanup

Fire Prevention Performance Standards


(1) Monitoring of actual fires reported inside the facility

(2) Staff knowledge on the meanings of R.A.C.E (Rescue, Alert, Confine, Extinguish) and P.A.S.S (Pull, Aim, Squeeze, Sweep)

acronyms during monthly EOC rounds (90% threshold)

(3) Monitoring of building and / or protection system monitoring – problems, significant incidents, unexpected repairs

Medical Equipment Performance Standards


(1) Preventative maintenance (PM) completion rate for Priority 1 life support equipment (100% threshold)

(2) Preventative maintenance (PM) completion rate for non-life support equipment (95% threshold)

(3) <2% of equipment service requests that were related to user errors

(4) <5% of unable to locate pieces of medical equipment

(5) ≥90% of equipment repairs completed within 30 days

Utility Equipment Performance Standards The following performance activities were undertaken in 2015:

(1) Monitoring of utility failures

(2) Occurrences requiring external reporting

(3) Monitoring of tube system failures

(4) Monitoring of elevator failures

(5) Emergency generator testing compliance per regulatory standards (100% threshold) Emergency Management Performance Standards


(1) Conduct / manage two disaster drills or actual events per year at each facility according to top Hazard Vulnerability

Analysis (HVA) risks and evaluate event using The Joint Commission standards or SD County Medical Health

After Action Report (AAR) matrix (90% threshold)

(2) Staff knowledge in articulating where his or her units disaster supplies are located during monthly Environment of Care (EOC) rounds

(90% threshold)

(3) Staff knowledge in articulating where the hospital command center (HCC ) and labor pools are located during monthly

Environment of Care (EOC) rounds (90% threshold)

41

EVALUATION: PERFORMANCE STANDARDS 6

EOC Component: SAFETY MANAGMENT

Performance Standard: The following performance activities were undertaken in 2015:

1. O2 bottles found unsecured during monthly EOC rounds monitoring

2. 100% of unsafe condition reports submitted by staff to be resolved within

24 hours

Evaluation: 1. During monthly

Environment of Care (EOC) multi-

disciplinary rounds, facility

managers monitored areas for

unsecured O2 tanks. If any

were found, the tank was first

secured properly, and the

department manager was notified

and just in time training was

provided to staff on the risks of

unsecured tanks.

2. Unsafe condition work orders

are entered by staff on Sentact.

An email is immediately sent to

the affected facility manager for

him to assign the task.

We have met our goal of

unsafe condition work orders

being resolved within 24 hours.

There were no identifiable trends

witnessed in 2015.

Safety Management Plan for Improvement: We will continue to

monitor unsecured O2 tanks

throughout the district during

monthly EOC rounds, and add

additional unannounced monitoring

to weekly rounding schedule to

ensure O2 tanks are being stored

and transported safely.

We will continue to ensure that

unsafe condition work orders are

resolved within 24 hours of

submittal. O2 bottles found unsecured:

0 0 0

2

0 0 0 0 0 0 0 0

3

0 0 0 0

1

2

3

4

5

Palomar Medical Center Palomar Health

Downtown Campus

Pomerado Hospital Villa Pomerado

1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

0 0

1

0 0 0

1

0 0 0

1

0

2

0

1

2

1

0 0 0 0

1

2

3

Palomar Medical Center Palomar Health Downtown

Campus

Pomerado Hospital Villa Pomerado Satellite Buildings

1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Unsafe condition work orders received

and closed out within 24 hours:

PMC:

3Q15: Installation of dome mirror

to prevent gurney collisions (ED)

4Q15: Trip hazard repair (OR)

4Q15: Broken edges on hand

sanitizer repair (OR)

PHDC:

2Q15: Burning odor that could

not be duplicated by Facilities

staff (parking garage)

4Q15: Trip hazard repair (Mail

room)

POM:

1Q15: Concrete light post repair

due to vehicle backing into it

(ED parking)

3Q15: Repair of sharp broken

baseboard tile (L&D)

3Q15: Exit door constantly

blocked by equipment (OR).

Addressed with OR manager to

keep exits clear at all times.

Satellite Buildings:

3Q15: Trip / fall hazard repair

(Andreason)

VP:

None

42

EOC Component: SECURITY MANAGEMENT


1. Continued upgrade/enhancement of security video operation, access control,

and alarm systems

2. 100% of Security officers obtain CA Bureau of Security Investigative Services

(BSIS) guard card certification

3. Made available for all staff: quarterly offerings of security classes in the areas

of Code Silver, response, Managing Aggressive Behavior (MAB), and personal

security practices

4. <2 automobile thefts per quarter per campus

5. Conditioned to foster liaison contacts with local law enforcement/fire officials

Evaluation: 1. Throughout 2015 many Security related projects took place to enhance observation, access control, and alarm systems. 2. 100% of Security Officers were certified by the CA BSIS (Bureau of Security Investigative Services) and obtained Guard Cards. NOTE: All new security officers are Required to obtain this certification Prior to employment with PH. 3. Our Security manager taught over 30 security related classes in 2015. Hundreds of employees and volunteers in Multiple disciplines were trained. 4. We met our goal of <2 vehicle thefts per quarter at each campus. There was one vehicle stolen from PMC in the 2nd quarter. 5. Security worked closely with the marketing department to send out periodical id security, safety and parking messages to all staff via the staff portal. 6. Security manager worked closely in cultivating relationships with local law and fire officials throughout 2015. This will be an ongoing goal of relation- ship enhancement in 2016.

Plan for Improvement: We will continue our plans

of strengthening our security

observation capability,

access control, and alarm

system functionality in 2015.

Various security trainings were

offered in 2015 and badge

awareness campaigning and

observation will continue.

7

0 0 0 0

1

0 0 0 0 0 0 0 0 0 0 0 0

1

2

3

4

5

Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital Villa Pomerado

1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Automobile thefts:

<2 threshold

2015 Quarterly Security

Training: 1st Quarter –

• Active shooter (Grand Building

staff)

• Managing Aggressive Behavior

(PMC 4 & 5 staff)


(PMC EVS staff)

• Code Pink drills (POM & PHDC)

2nd Quarter –

• Active shooter (PMC ED staff)

• Personal security awareness

(Healthy Development staff)

• Fire safety (Healthy

Development staff)


(Infection Prevention staff)


(PMC OR staff)

3rd Quarter -


(Staff on Safety committee)

• Fire safety (Acute Rehab staff)

4th Quarter –

• Bureau of Security Investigative

Services (Security staff)

• Code Pink drill (POM)

2015 Quarterly Security

Projects:

1st Quarter –

• Door access upgrade

(San Marcos Ambulatory

Care Center)

3rd Quarter –

• Infant monitoring system

upgrade (PHDC 7th floor)

• Hard drive addition for

video recording servers

(PMC)

• Addition of 10 camera

licenses to Sky point

• Badge reader addition

(POM 5th floor)

• Addition of 10 cameras

(PMC)

4th Quarter:

• Radio repeater addition

w/ antenna (PMC)

43

8 EOC Component: HAZARDOUS MATERIALS AND WASTE MANAGEMENT


1. Monitoring of the number of hazardous material containers inspected / labeled incorrectly during monthly EOC rounds monitored 2. Staff knowledge in obtaining Safety Data Sheet (SDS) information during monthly EOC rounds (90% threshold) 3 & 4. Monitoring of the number of hazardous waste and bio hazardous waste incidents requiring outside agency cleanup

Plan for Improvement: We will continue

monitoring for correct

staff response relating

to various program

elements in our

hazardous materials

plan, as high levels of

compliance promote risk

reduction relating to

hazardous materials

and waste usage.

Evaluation: 1. During monthly

Environment of Care (EOC) multi-

disciplinary rounds, facility

managers monitored hazardous

material containers for inappropriate

labeling. There were no deficiencies

found in 2015.

2. During monthly EOC rounds,

facility managers monitored staff

knowledge regarding how to locate

Safety Data Sheet (SDS) information.

Our threshold is 90% and was met at

each facility each quarter.

3 and 4. Number of hazardous and

bio hazardous waste incidents

requiring outside assistance for

cleanup was zero, however, there

were two small spills that occurred at

PMC in the 1st quarter (Formalin in the

OR) and the 4th quarter (Methyl

Methacrylate in the OR). Cleanup was

done by Palomar Health staff due to the

spills being small amounts.

We will continue to monitor in 2016.

0 0 0 0 0 0 0 0 0 0 0 0 0 0

1

2

3

4

5

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Inappropriate labeling on hazardous material container monitoring:

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

100%


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Staff knowledge on how to obtain Safety Data Sheet (SDS) information:

90% threshold

1

0 0 0 0 0 0 0 0 0 0 0

1

0 0

1

2

3

4

5

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Number of hazardous and bio hazardous waste incidents:

44

EOC Component: FIRE PREVENTION MANAGEMENT


1. Monitoring of actual fires reported inside the facilities

2. Staff knowledge of RA.C.E (Rescue, Alarm, Contain, Extinguish / Evacuate),

and P.A.S.S (Pull, Aim, Squeeze, Sweep) acronyms (90% threshold)

3. Monitoring of building and / or protection systems – problems, significant

incidents, and unexpected repairs

Evaluation: 1. There were no fires reported at

any Palomar Health campus in

2015.

2. During monthly EOC rounds,

facility managers monitored staff

knowledge regarding the R.A.C.E

and P.A.S.S acronyms. Our

threshold is 90% and was met at

each facility each quarter.

3. In January 2015, POM

experienced flooding due to a

broken fire sprinkler in one of the

first floor restrooms. Fire watches

were performed by Security and

Facilities staff while repairs were

made.

Plan for Improvement: We will continue to

monitor staff knowledge

of R.A.C.E and P.A.S.S

and continue to promote

fire safety awareness and

“readiness” in staff in the

event of a fire. We will

continue monitoring any

significant events at our

campuses.

9

Number of actual fires reported inside the facilities:

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1

2

3

4

5

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Staff knowledge of R.A.C.E and P.A.S.S acronyms:

Threshold = 90%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

100%


Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

0 0

1

0 0 0 0 0 0 0 0 0 0 0 0

0123456789

10

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Building protection system problems, significant incidents, unexpected repairs:

45

EOC Component: MEDICAL EQUIPMENT MANGEMENT Performance Standard: 1. Preventative maintenance (PM) completion rate for priority 1 life

support equipment (100% threshold)

2. Preventative maintenance (PM) completion rate for non-life

support equipment (95% threshold)

3. <2% of equipment service requests that were related to user

errors

4. <5% of unable to locate pieces of medical equipment

5. ≥90% of equipment repairs completed within 30 days

Preventative maintenance completion rates on life support devices:

100% PM completion threshold

Evaluation: 1. Biomed consistently met their 100% threshold of

preventative maintenance on

life support equipment

throughout 2015.

2. Biomed consistently

met their 95% threshold of

preventative maintenance on

non-life support equipment

throughout 2015, except for the 3rd

and 4th quarter at Villa Pomerado

due to two devices that could not be

located.

3. When biomedical staff

respond to a work order that was

caused by an operator error,

technicians offer on the spot

training for the operator and

it is noted in the work order.

If an equipment user has repeated

errors on the same model of

equipment, the department

manager is advised and

additional training is recommended.

4. The threshold was met

consistently throughout

2015 on <5% of unable to

locate pieces of medical

equipment at each facility, except at

Villa Pomerado due to two pieces of

medical devices (patient lifts) that

could not be located. These devices

were removed from inventory after

being missing for 90 days.

5. The threshold was met

consistently throughout 2015

at all facilities on ≥90% of equipment

repairs completed

within 30 days.

0%

100%

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

97% 96% 99% 95%

99% 99% 99% 100% 99% 97% 99%

71%

95% 99% 99%

91%

0%

100%


Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Linear (4 Q 2015)

Preventative maintenance completion rates on non-life support devices:

95% PM completion threshold

95% threshold

Plan for Improvement: We will continue monitoring PM completion

rates as high completion rates for both

life support and non life support medical

equipment promotes operational reliability

of equipment that is used on our patients, and

supports our patient safety goals.

We will continue to monitor our other goals

and watch for any apparent trends or gaps.

10

46

11

Medical Equipment continued

<2% of equipment service requests related to user

errors:

1% 1%

2%

0%

2%

1%

2%

0%

1%

0%

2%

1%

2%

0%

4%

6%

0%

10%


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

<2% threshold

<5% of unable to locate pieces of medical equipment:

1%

4% 2%

7%

1% 0%

2% 0%

1% 3%

1%

29%

1% 2%

1% 0%

0%

10%

20%

30%


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

<5% threshold

≥90% of equipment repairs completed within 30 days:

99% 98% 98% 100% 99% 100% 98% 93%

99%

92% 95%

91%

99% 99% 95%

100%

0%

100%


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

≥90% threshold

47

Evaluation: 1. Utility failure monitoring

includes any electricity, water,

natural and medical gas

failures. PMC experienced a

breaker failure in September when

normal testing was conducted. Breaker

was replaced and no issues were

identified. The automatic transfer

switch (ATS) failed at PHDC in January.

PHDC lost power due to a

SDG&E breaker issue in July.

Generators ran as designed in each

event. POM and VillaPOM experienced

a power outage in July due to SDG&E

(cause unknown).

No major issues identified.

2. There were three incidents requiring

reporting to an outside

regulatory agency in 2015 relating to

utility failures / repairs. The automatic

transfer switch (ATS) failed at PHDC in

January. PHDC lost power due to a

SDG&E breaker issue in July.

Generators ran as designed in each

event. At POM, due to a visitor

causing damage to a fire sprinkler in

a restroom, caused >$200,000 in

damages in January.

3. Tube system failures were

monitored throughout 2015.

4. Elevator failures were monitored

throughout 2015.

5. Generator testing, which is

considered life support

utility equipment, was

completed at 100% at all facilities

in 2015.

Plan for Improvement: We will continue

monitoring, keeping

our efforts on prevention,

and utility equipment

operational reliability

which strengthens our

patient safety focus.

12 EOC Component: UTILITY EQUIPMENT MANAGEMENT

Performance Standard: 1.Monitoring of utility failures

2. Occurrences requiring outside reporting

3. Monitoring of tube system failures

4. Monitoring of emergency generator testing compliance per r

regulatory standard

0

1

0 0 0 0

1 1 1 1

0 0 0 0 0

0

1

2

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Utility failure monitoring:

Electricity, water, natural and medical gas failures

Outside agency reporting:

0

1 1

0 0 0 0 0 0

1

0 0 0 0 0

0

1

2

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

48

0 0

5

0 0

8

0 0

1 1

0

8

0123456789

10

Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital

1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Utility Equipment continued Tube system failure monitoring:

Elevator failure monitoring:

0

10

2

0

8 8

0

4

6 6 6

9

0

1

2

3

4

5

6

7

8

9

10

Palomar Medical Center Palomar Health Downtown Campus Pomerado Hospital

1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Emergency generator testing per regulatory standard:

100% threshold

0%

100%

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

13

49

EOC Component: EMERGENCY MANAGEMENT / EMERGENCY OPERATIONS PLAN (EOP)

Plan for Improvement: We will continue testing

correct staff response

relating to our

Emergency Operations

Plan.

In 2015 multiple events occurred in the area of emergency management. The Disaster Committee met regularly with

a standing agenda developed by the Program Manager to address the growth of disaster preparedness and the preparedness needs

throughout the district.

The National Incident Management System (NIMS) and Hospital Incident Command System (HICS) principles are incorporated into

exercise planning and actual event response. Committee members also reviewed the Hazard Vulnerability Analysis (HVA) documents

which were completed with risks prioritized for the medical centers and balanced against mitigation strategies in place. Input was solicited

from our medical staff, and community partners (San Diego County Emergency Medical Services (EMS) / San Diego County Office of

Emergency Services (OES) and the other SD County medical centers and fire departments) who provided recommendations for our HVA’s.

We have several disaster equipment storage trailers that are inventoried annually and Supply Chain maintains the medical supplies on

each disaster supply cart at each of our ED’s. Also utilized is an exercise / actual event evaluation tool that establishes performance

standards in accordance with The Joint Commission emergency management standards (the six critical areas of communications,

resources and assets, staff roles and responsibilities, security, utilities, and patient support services).

In 2015, the medical centers participated in several countywide exercises and in actual events. For the purposes of this report, two exercises, in which the EOP was activated, at each facility will be evaluated to ensure our 90% objective threshold.

PMC: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination

conducted by PMC staff, using the decon trailer that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The

scenario also involved a cyber attack which caused multiple power outages.

• Event score: 92% with follow up activities identified.

2. November 19 – Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery

of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and

medical staff (per procedure). Pharmacy staff tested current processes and forms and Security practiced with a traffic flow exercise.


PHDC: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination

conducted by PHDC staff, using the decon tent that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The



2. Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery of cache of

medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and medical

staff (per procedure). Pharmacy staff tested current processes and forms .


POM: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Simulated an MCI patient surge with some patients needing decontamination. Decontamination

conducted by POM staff, using the decon tent that is set up just outside the ED entrance, and Pathmaker volunteers were processed through the shower. The



2. November 19 – Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the county. County EMS tested delivery

of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for dispensing to patients, staff, staffs’ families, and

medical staff (per procedure). Pharmacy staff tested current processes and forms.


VillaPOM: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Since this exercise involved power outage, staff practiced completing Department Status

Worksheets in which critical devices being plugged into red outlets was tested. We also captured potential staff shortages and planned for steps to take if

staff shortage was ever identified.


2. November 19 – Statewide exercise involvement. Statewide exercise involvement. Scenario included aerosolized anthrax being dispersed throughout the

county. County EMS tested delivery of cache of medicine from the Strategic National Stockpile (SNS) and Palomar Health would be responsible for

dispensing to patients, staff, staffs’ families, and medical staff (per procedure). Pharmacy staff tested current processes and forms.


Satellite Buildings, including Home Health: 1. May 20 – Countywide ‘Capstone’ exercise involvement. Outside area staff are tasked with completing ‘Department Status Worksheets’ and reporting to the

command center any staffing shortages, or staff that would be available for the labor pool.


2. November 19 – Statewide exercise involvement. Outside area staff are tasked with completing ‘Department Status Worksheets’ and reporting to the

command center any staffing shortages, or staff that would be available for the labor pool. Home Health tested the process of receiving SNS medication and

delivering it to our home bound population.


Plan for Improvement: For the disaster exercises and events, debriefings

occurred with plans for improvement identified.

The Disaster Committee has assumed the

responsibility for implementing the improvement

actions. We will continue with pre-planning for

drills, identifying objectives that test stressing

our systems.

14

50

Emergency Management continued

Evaluation of disaster exercises / actual events using The Joint Commission Emergency Management

chapter standards: 90% threshold

Staff knowledge during EOC surveillance rounds in articulating

where his or her unit’s disaster supplies are located: 90% threshold

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

100%

Palomar Medical

Center

Palomar Health

Downtown Campus


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Threshold = 90%

Staff knowledge during EOC surveillance rounds in articulating where the hospital command center and

labor pools are located: 90% threshold

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

60%

100% 100%

0%

100%


1 Q 2015

2 Q 2015

3 Q 2015

4 Q 2015

Threshold = 90%

92% 92% 90% 94% 92% 95% 94% 91% 94% 96%

0%

100%

Palomar

Medical

Center

Palomar

Health

Downtown

Campus

Pomerado

Hospital

Villa

Pomerado

Outside

Areas

MCI / Power

Outage

ExerciseAnthrax

Exposure

Exercise

Threshold = 90%

15

EOC Component: EMERGENCY MANAGEMENT

Performance Standard: 1. Conduct / manage two disaster exercises or actual events per year at

each facility according to top Hazard Vulnerability Analysis (HVA) risks

and evaluate event using The Joint Commission standards or SD County

Medical Health After Action Report (AAR) matrix (90% threshold)

2. Staff knowledge during EOC surveillance rounds in articulating where

his or her unit’s disaster supplies are located (90% threshold)

3. Staff knowledge during EOC surveillance rounds in articulating where

the hospital command center (HCC) and labor pool are located (90% threshold)

Evaluation: 1. During each of the exercises in 2015, the threshold of 90% was met consistently at each medical center and outside area. Action items were identified post event as well as what items went well. These items were forwarded to the disaster and environment of care committees for review. 2 and 3. During monthly EOC

rounds, facility managers

monitored staff knowledge

regarding the locations of

disaster equipment, hospital

command centers and labor

pools. Our threshold is 90% and

was met at each facility by quarter,

with the exception of the 4th quarter

at PMC. Staff was given

just in time training on the

locations during the rounding.

51

16 Annual Evaluation - Overall Effectiveness – 2015

SAFETY. Based upon the objectives, scope and performance standards, outcomes were positive, and thresholds

were impressively met for the safety management program at Palomar Health facilities. Based on the high level of

commitment to education, surveillance, and ongoing activities, the Management Plan for Safety is highly effective in

promoting safety standards for the organization, and in guiding the direction of safety-related activities. We will plan

on doing additional unsecured O2 tank rounding throughout the organization, in addition to monthly EOC rounds to

ensure departments understand the importance of proper O2 tank storage.

SECURITY. The Management Plan for Security and the security program is effective across the district, with

the objectives being met in 2015. Incidents were monitored routinely, and performance standards were met

regarding requirements specific to their department standards and expectations. Code Pink (infant abduction) and

Purple (child abduction) drills were completed on a routine basis with excellent staff response. For the year 2016, we

will continue monitoring security trends to identify areas of risk to the medical centers and offsite areas, and we will

continue with the management of assault training and infant and child abduction security drills, focusing on continued

education and effective drill outcomes.

HAZARDOUS MATERIALS. The Management Plan for Hazardous Materials and the overall Hazardous Materials

program at Palomar Health facilities is effective, as there were no spills requiring an outside response team.

Objectives were met for 2015, and the threshold was met for staff knowledge relating to program elements of the

Hazardous Materials Management Plan. Hazardous waste was manifested in accordance with agencies having

jurisdiction. This focus on ongoing education reflects Palomar Health’s commitment to the safety of our employees,

especially is it relates to hazardous materials issues. We strengthened our program in 2015 and continued to meet

on a quarterly basis with the group that was trained as first receivers during 2014 decontamination training. We will

plan for another round of 16-hour first responder training in 2016, which will allow recertification to those in need.

FIRE PREVENTION MANAGEMENT. Based upon the objectives, scope and performance standards, the Fire

Prevention Management plan is effective. Fire drills were completed for the hospital and offsite areas, with

performance standards monitored, and found to be in compliance throughout the year. Fire equipment inspection,

maintenance and testing was completed, with ongoing monitoring of the Statement of Conditions in effect. Infection

Prevention assessment continued to be integrated into construction activities.

MEDICAL EQUIPMENT MANAGEMENT. Based upon the objectives, scope and performance standards, the

Medical Equipment Plan and program are effective at the medical centers. Preventive maintenance was monitored

quarterly, with established thresholds met. The separation of our inventory (i.e., life support medical equipment from

non-life support medical equipment) places a higher focus on the safety of our patient, and keeps the Environment of

Care closely integrated with Patient Safety standards. The Medical Equipment Plan and program are effective in

promoting safe equipment usage for our patients. We will continue to monitor equipment user errors and equipment

that is not located for > 30 days and be prepared to observe and report out any trending that may occur.

UTILITY EQUIPMENT MANAGEMENT. There were no trends or unusual patterns associated with utility failures.

All generators were completed at 100% compliance and various utility failures were noted throughout the year. The

Utility Equipment Management plan is an effective way to manage the Utility Equipment program based on the

successful completion of goals and performance standard monitoring.

EMERGENCY MANAGEMENT. Based upon the objectives, scope and performance standards, the Emergency

Management and Operations Plan is effective. Several actual events and SD County disaster exercises occurred in

2015, all of which were based upon likely scenarios in our Hazard Vulnerability Analysis's. The events were

evaluated with overall successful outcomes, with plans for improvement identified and implemented. The Disaster

Preparedness Committee was very active with exercise design and planning. This continues to be a highly effective

and energetic committee that will continue to meet and oversee the day-to-day emergency planning in 2016. The

Hazard Vulnerability Analysis's are reviewed annually, and found to be an effective tool in prioritizing critical events,

and assessing the prioritization against the medical center’s preparedness. Staff were monitored for their knowledge

relating to components in our Emergency Operations plan, and their roles in a disaster, and found to respond at a

very high compliance rate. Palomar Health as a district is actively involved with community-wide preparedness

activities, which strengthens our ties with agencies having jurisdiction.

52

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