Capítulo X: Conclusiones y Recomendaciones
10.4. Futuro de la Industria del Café
Purpose
The purpose of the Quality, Patient Care and Patient Experience Committee (“Quality Committee”) is to advise and assist the El Camino Hospital (ECH) Hospital Board of Directors (“Board”) in constantly enhancing and enabling a culture of quality and safety at ECH, to ensure delivery of effective, evidence-based care for all patients, and to oversee quality outcomes of all services of ECH. The Quality Committee helps to assure that exceptional patient care and patient experience are attained through monitoring organizational quality and safety measures, leadership development in quality and safety methods and assuring appropriate resource allocation to achieve this purpose.
Staff: Eric Pifer, MD, CMO
The CMO shall serve as the primary staff support to the Committee and is responsible for drafting the committee meeting agenda for the Committee Chair’s consideration. Additional clinical representatives may participate in the Committee meetings upon the recommendation of the CMO and subsequent approval from both the CEO and Committee Chair. These may include the Chiefs/Vice Chiefs of the Medical Staff, VP of Patient Care Services, physicians, nurses, and members from the Community Advisory Councils or the community-at-large. The CEO is an ex-officio of this Committee.
Goals Timeline by Fiscal Year
(Timeframe applies to when the Board approves the recommended action from the Committee, if applicable.)
Metrics
1. Review the hospital’s organizational goals and scorecard and ensure that those metrics and goals are consistent with the
strategic plan and set at an appropriate level as they apply to the Quality, Patient Care and Patient Experience Committee.
Q1 Review, complete and provide feedback
given to management, the governance committee and the board.
2. Review any updates to the hospital’s PaCT performance improvement plan and ensure that they are consistent with the strategic plan. Provide expert feedback
on the plan.
Q2 Review, complete and provide feedback
given to management and the board.
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Goals Timeline by Fiscal Year
(Timeframe applies to when the Board approves the recommended action from the Committee, if applicable.)
Metrics
3. Ensure that all committee meetings contain a patient story that reflects the main theme of the meeting.
Ongoing
Meeting agendas reflect patient story
4. Educate one another, members of other committees and the board on best practices in quality management and
oversight.
Ongoing Goal is one educational session per
committee meeting (literature review, didactic etc.) and to do some cross-
committee work.
5. Develop a template to present individual programs and processes to the committee so
as to promote awareness of ECH programs, processes and activities. The template should be no more than one page and should include
metrics that reflect program and process performance, overall program description, tactics for improvement, challenges and risk-
reduction strategies.
Q1: Template Ongoing
Template by Q1
Ongoing program and process presentations using the template as evidenced by the agenda throughout
the year.
6. Ensure that more than 50% of committee time is spent discussing specific metrics and
performance against those metrics.
Ongoing Meeting agendas reflect time spent
discussing metrics and program performance.
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Att 1t - Quality Summary_sep_bod_qual.docx
Quality Summary
September Quality Meeting
Quality Division
Overall the quality division has had a very busy summer with CMS survey, several other on-site investigations and finalization of the annual organizational goals. Several of the specific topics in this packet refer to this work and this is still more work going on in departments and using Lean techniques for improvement.
Transition to CNO role:
Cheryl has transitioned to the Interim CNO position over the enterprise. Cheryl is spending time two days a week at LG to interact and meet with the nurse and clinical leaders as well as the staff of LG. Cheryl is establishing her new direct reports team which includes members of pharmacy and lab along with all the nursing directors. The nursing strategic plan is underway for FY 2014 and we foresee its adoption at the Central Partnership Council in September. This is a requirement for Magnet
Designation. We are ramping up for Magnet designation now because re designation is due to occur in mid 2014.
Other leadership changes have occurred including the appointment of a new Lab Director for the Enterprise, Edwina Sequira who was recruited from Seton Medical Center with 30 years of lab experience.
Jina Canson, RN has transitioned as the Director of Dialysis to the Director of Patient Care Resources (float pool, staffing office, Hospital Supervisors, Flex RN’s, Inpatient Dialysis). There are over 140 employees in this area.
Service Report:
For FY 12-13, there are three domains of the HCAHPS survey that are included on the corporate scorecard and organizational goals in which intensive improvement efforts have occurred. HCAHPS Composite Organizational Goal for
each HCAHPS Domain FY 13
FY 13 YTD Performance In June as per goal measurement period Nurse Communication 75 77.09 Staff Responsiveness 64 61.18 Communication On Medications 60 57.97 Page 137/219
Overall goal achievement is calculated using an average of the scores of all three domains. Goal Metrics Using Domain Average:
Min=65.3 Target: 66.3 Max=67.3
ECH Performance Using Domain Average from QDM Methodology:
65.41 (just above Minimum)
The team continues to work on many of these areas and recruitment for the Director of Patient
Experience is in its final phase of interviews. In FY 14 there will be a tremendous focus on improvement in the patient experience with an organizational investment in a director as well as staff training. We are currently in the process of setting next year’s goals now that year end metrics are available.
CMS Survey:
Nursing had zero findings during the CMS survey. The nurses worked very hard to correct the problems that had been an earlier focus related to patient restraints and falls. Safety checklists were redeployed with nursing feedback to insure all safety issues were addressed. The checklists were completed each shift by charge RN’s.
Lab and pharmacy each had a finding that will be fully addressed in the CMS report which we have not received as yet. We will develop corrective action plans after we more fully understand the finding that will detailed in the CMS report. However, we have put some changes in place already based on surveyor feedback while they were onsite.
Surgery:
We have seen a 10% increase in OR volume at MV recently. More surgeons are interested in using our OR and have asked for privileges here at ECH. The OR has done a great job in accommodating their scheduling and equipment needs.
OB:
Obstetrics has been a leader in the LEAN work this year and has really been a pioneer for the LEAN methodology tools. They also have seen return on their investments. We have piloted a discharge process improvement that calls for a 70% discharge rate by 12N. It took only two months to reach the goal.
Dialysis:
The Evergreen Dialysis Unit treated its last patient on August 5, 2013. All patients were safely and efficiently transferred to other units. All staff that wished to bid on an open position were placed in a position are going through several different training programs including 10 RN’s.
Emergency Room and Nursing units:
The RPIW to improve door to floor continues to sustain improvements. Target goals for 286 minutes were met by fiscal year end. In order to achieve the results, RN’s have changed the way nursing hand off report is given between the ER nurses and the floor RN’s. The change has not been easy. But, the nurses understand the value the change brings to the patient experience.
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Att 2 - Patient Story.pdf
Date: September 16, 2013
To: Board Quality Committee
From: Re:
Eric Pifer, MD Patient Story Dear Committee Members,
In the September meeting of the quality committee, we will be discussing some important issues including C. Diff infection, hospital readmissions, our CMS survey and the information technology platform. The patient story relates to readmissions. This is a very complicated area. To be successful requires a multidisciplinary approach to care as well as a strong relationship with our physician community. The story is related by a member of our readmissions team.
Eric Pifer, M.D. Chief Medical Officer El Camino Hospital
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Att 2.2 - Pat_story_september.docx
Patient: JH is a 71 Year-Old-Male
PMH: Diabetes Mellitus, knee arthroscopies, laser TURP, elevated cholesterol. Patient lives at home with wife, is independent, and still works as a researcher.
FMH: Mother died of colon carcinoma.
August 12, 2013 – routine outpatient colonoscopy revealed large mass in the cecum and multiple polyps. Recommended to have a laparoscopic hemicolectomy.
August 15-17, 2013 (LOS 2 days)
Scheduled admission for Laparoscopic Ileo-Cecetomy and Appendectomy. Patient was NPO first 24hours post- surgery, and then clear liquid diet prior to being discharged home. Discharged home with orders for clear liquid diet and advance as tolerated.
Readmission 1:
August 19-23, 2013 (Elapsed time 2 days, LOS 4 days)
JH was doing well on day 1 post discharge; on day 2 began having nausea and vomiting, increasing abdominal pain and abdominal distension. Surgeon recommended patient go to emergency and was admitted for post- surgical ileus versus small bowel obstruction. Patient had nasogastric tube and remained NPO for 3 days of the hospitalization. 21 hours prior to discharge, tube was discontinued and surgeon ordered clear liquid diet and 2 hours prior to discharge advanced to full liquid diet. Diagnosis on discharge was adynamic ileus.
Readmission 2:
August 25-30, 2013 (Elapsed time 2 days, LOS 5 days)
Approximately 48 hours after discharge, patient returned to emergency department again with nausea, vomiting, abdominal pain and distension. Patient was admitted by surgeon for decompression. Patient had nasogastric tube for 3 days and remained NPO for 4 days. On day 4, patient was advanced to clear liquid diet approximately 30 hours prior to discharge. Patient was advanced to a bland, low fiber diet 8 hours prior to discharge. Discharged with a diagnosis of adynamic ileus.
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Att 3 - Review Corporate Scorecard.pdf
Date: September 16, 2013
To: Board Quality Committee
From: Re:
Eric Pifer, MD
Corporate Scorecard Dear Committee Members,
Please find attached the corporate scorecard updated through June 2013. Excellent
performance continues in core measures, pressure ulcer, patient falls and errors (medication errors and mislabeled specimens). Areas for improvement include service (although good progress has been made particularly in nurse communication and medication communication) and readmissions. Today’s “drill down” discussion will relate to readmissions and more details on the service plan will unfold throughout the year.
Questions:
1. Are there areas where we have no scorecard metrics that you would like further discussion?
2. Are there areas in the current metric set where you would like further discussion at a future meeting?
Eric Pifer, M.D. Chief Medical Officer El Camino Hospital
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