February Compliance Report On Parkland Memorial Hospital

Report of the Independent Consultative Expert (ICE) Monthly Progress Report February 2013 on Parkland Health & Hospital
l System Dallas, Texas
March 12, 2013

Submitted To: Submitted By:
Centers for Medicare and Medicaid Services and Parkland Health & Hospital System
Alvarez & Marsal Healthcare Industry Group, LLC Columbia Square 555 Thirteenth Street, NW, 5th Floor West Washington, DC 20004 +1 202 729 2100
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013
EXECUTIVE SUMMARY .........................................................................................................................................3 SIGNIFICANT GOALS MET IN FEBRUARY ....................................................................................................................4 SIGNIFICANT GOALS STILL OUTSTANDING IN FEBRUARY ..........................................................................................5 OVERALL IMPRESSIONS FROM FEBRUARY..................................................................................................................6 CASE MANAGEMENT .............................................................................................................................................7 HUMAN RESOURCES ..............................................................................................................................................7 COMPETENCIES ..........................................................................................................................................................8 EMPLOYEE PERFORMANCE MANAGEMENT ................................................................................................................9 NURSING ADMINISTRATION................................................................................................................................9 ONE-TO-ONE OBSERVATION ................................................................................................................................ 10 ACUITY BASED STAFFING ........................................................................................................................................ 10 PATIENT SAFETY / QUALITY ............................................................................................................................. 10 PATIENT SAFETY NETWORK (PSN) EVENT REPORTS ............................................................................................... 10 ROOT CAUSE ANALYSIS (RCAS) ............................................................................................................................. 11 PATIENT RELATIONS ................................................................................................................................................ 11 HOUSE-WIDE ISSUES ............................................................................................................................................ 12 A&M GENERAL AUDIT RESULTS............................................................................................................................. 12 PATIENT IDENTIFICATION ........................................................................................................................................ 14 SPECIMEN LABELING ............................................................................................................................................... 15 DEPARTMENT AND UNIT SPECIFIC FINDINGS ............................................................................................ 16 CLINICS .................................................................................................................................................................... 16 CONTRACT SERVICES ............................................................................................................................................... 17 EMERGENCY SERVICES ............................................................................................................................................ 17 LABORATORY SERVICES .......................................................................................................................................... 18 PSYCHIATRIC SERVICES ........................................................................................................................................... 18 WOMEN AND INFANT SPECIALTY HEALTH (WISH) SERVICES ................................................................................. 19 CONCLUSION .......................................................................................................................................................... 19
Executive Summary Alvarez & Marsal Healthcare Industry Group LLC (A&M) is serving as the Independent Consultative Expert (ICE) under the Systems Improvement Agreement (SIA) between Parkland Health & Hospital System (Parkland) and the Centers for Medicare and Medicaid Services (CMS). On February 29, 2012, A&M delivered a Corrective Action Plan (CAP) to Parkland, as required under the SIA. This CAP was approved by CMS and was subsequently accepted by the Parkland Board of Managers on March 8, 2012. Under the SIA, the ICE is required to present monthly reports to CMS on the progression and status of the CAP, including identification of problems that may jeopardize the successful implementation of the CAP and actions underway to address those problems. This report constitutes A&Ms 12th report on Parklands progress under the CAP. By agreement with CMS, the start date for timelines and deadlines under the CAP was set as March 19, 2012. During the month of February Parkland continued to make progress in meeting most of the deadlines established in the CAP. Since the implementation of the CAP on March 19, 2012 a total of 475 tasks have been completed. An analysis of tasks completed by Work Stream is below:
Total Complete % Initiatives Initiatives Complete 39 174 91 102 34 59 499 36 172 85 92 32 58 475 92% 99% 93% 90% 94% 98% 95% On time Initiatives 0 0 1 6 0 0 7 Delayed Initiatives 0 0 0 0 0 0 0 Missed Deadline / % Complete and On Time Not Sustainable 3 2 5 4 2 1 17 92% 99% 95% 96% 94% 98% 97%
WS #
Work Stream Name Governance, Leadership, and Org Structure Clinical Operations Access/Throughput Nursing Physicians QAPI TOTAL
1 2 3 4 5 6
Also, presented below is the detail for the seven action streams with incomplete or delayed initiatives of 95 percent compliance in meeting target dates for their CAP initiatives.
AS # 1.2 2.6 3.3 3.4 3.5 Action Stream Name Total Initiatives 15 5 2 25 6 28 15 22 Complete 12 4 1 23 5 22 13 21 % Complete 80% 80% 50% 92% 83% 79% 87% 95% On Time Initiatives 0 0 0 0 0 2 0 0 Delayed Initiatives 0 0 0 0 0 0 0 0 Missed Deadline / Not Sustainable 3 1 1 2 1 4 2 1 % Complete and On Time 80% 80% 50% 92% 83% 86% 87% 95%
Organization Structure Changes Other hospital-based department specific initiatives Bed Management Case Management, Discharge planning initiatives Continuum of care beyond acute care setting Nursing roles & responsibilities; staffing levels and staffing 4.3 models 5.1 Medical Staff OPPE 6.2 Patient Safety and Patient Rights
Significant Goals Met in February Case Management Implementation of discharge planning conferences to focus on patients with a length of stay greater than four days with successful management of patients to an appropriate level of care Filled key management positions: Complex Case, Bed Access, Care Management, Social Work and Care Coordination all with start dates in February/March/April 2013 Completed assessment of Admission Discharge Transfer (ADT) Department
Contract Services Completed review of known legacy contracts and State contracts that are not in contract management system for quality metrics
Emergency Services Significant improvements made in patient flow in both Main Emergency Department and Urgent Care Emergency Department that decreased dwell times
Laboratory Conducted an assessment and designed improved process of lab specimen handling from unit to lab to decrease mis-labeling errors Successful accreditation with College of American Pathologists
Nursing Administration Completed implementation of McKesson acuity system and automated scheduling in ANSOS Restructured 24 job codes for float pool staff, paired positions with salaries and completed for posting 32 of 50 traveling nurses hired as of end of February to fill RN vacancies throughout the Hospital
Physical Medicine and Rehabilitation (PM&R) Parklands Operational Excellence Department along with PM&R management conducted a process assessment for the inpatient therapy modalities that will help to appropriately allocate staff to match patient demand for inpatients and outpatients
Psychiatric Services In accordance with the recently executed contract for management services, Green Oaks leadership has conducted an assessment of the current state of Psychiatric Services at Parkland and is recruiting for key management positions to be staffed by Green Oaks
WISH Completion of throughput assessment of OBICC (Obstetrics Intermediate Care Center) by Parklands Operational Excellence Department, which identified opportunities for improvement in resource allocation to match demand to capacity
Significant Goals Still Outstanding in February Case Management Tele-tracking system implementation delayed until June 2013 to coincide with Epic interface Management review of policies and procedures was completed in February; however, Departmental Policy & Procedure Committee must review and adopt revisions. Review now scheduled to be completed by March 31st.
Competencies Review of competencies for all clinical staff has been underway; but approximately 50% still under final review Similar process for verification of competencies for non-clinical employees has not yet been completed
Clinics Throughput pilot program for six outpatient specialty clinics have not produced desired outcome of increased patient flow and access
Contract Services Contracts with UTSW and Childrens Medical Center are extensive and complex and may require new contract language to more particularly identify and set forth quality indicators and measures Clinical staffing and agency contracts need to have analysis completed on quality indicators and evaluated for compliance with quality indicators Some significant contracts require quality indicators and some are not performing to quality indicator thresholds
Medical Staff The revised processes for Ongoing Professional Practice Evaluation (OPPE)/Peer Review were delayed due to difficulties in data processing obtaining clear electronic data sets; this process is now back on schedule Medical Staff leadership continues to work to improve consistent use of the Notewriter tool in Epic to capture key portions of resident supervision documentation in the medical record
Nursing Administration Recruiting for positions for the nursing float pool staff had begun the sourcing process in February; positions are expected to begin the recruiting process the first week of March High vacancy rates still exist in some key positions including Case Management, Medicine Services and WISH Services Nursing Administration working with Human Resources to sponsor job fairs to recruit for positions to fill both float pool and other key nursing areas Implementation of decentralized staffing pool pilot in Surgery Services delayed due to difficulty in RN recruitment
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 Patient Safety The Risk Assessment tool has not been completed pending clarification of Directors of Public Safety, Patient Safety and Legal Overall Impressions from February As we indicated in our reformatted progress reports since October 2012, because most of the Corrective Action Plan (CAP) initiatives have been largely completed, we have shifted most of A&Ms ICE resources to monitoring specific areas of the Hospital and conducting surveys using the same methodologies employed during our initial Gap Analysis. The weekly audits and monthly reviews are being performed as a more holistic and inclusive review to assess compliance with Medicare Conditions of Participation as well as monitor for the sustainability of change in process and performance and the impact of the change on patient safety, rights and quality. During the month of February, Parkland engaged a team of external consultants to conduct an exhaustive internal survey of Parklands compliance with the Medicare Conditions of Participation. This mock survey was structured in such a way to mirror as much as possible an actual CMS survey process. To that end the survey was conducted on an unannounced basis by a team of 11 surveyors over a five-day period. The survey team included nurses, physicians, hospital administrators and engineers well versed in life/safety Conditions of Participation (CoP) and code issues. The organization structure in place to staff and manage the Hospitals response to a full survey proved to be an efficient and effective one. The Hospitals management team worked well under the rigorous mock survey process to respond to the surveyors requests and review. A&Ms perspective is that this mock survey process was a comprehensive practice test for the organization to experience at this stage of completion of the CAP. The mock survey findings did not uncover any unknown or new major areas for concern with the Hospitals continued preparation toward a state of survey readiness. The survey results reinforced A&Ms view, shared by Parklands senior leadership team, is that the Hospital needs to stay the course with regard to its continued efforts to improve processes and protocols that impact its ability to meet CMS Conditions of Participation by the milestone period of the Systems Improvement Agreement April 30, 2013. In February, A&M also did a special assessment of Parklands Patient Relations Department (PRD) function, which was recently reorganized under new leadership to report up through the Hospitals quality organization. The operation of the PRD has improved with the change of leadership, organization structure and roles/responsibilities of staff. A&M also continued to do environmental rounding on nursing units. In February, A&M completed audits of 32 units/areas throughout the main campus of Parkland. A&M team members also did a process review of specimen labeling throughout the Hospital to detect opportunities to reduce incidences of specimen mis-labeling, which leads to specimens being discarded and new samples having to be drawn. Parkland continued to make good progress in February with improvements in policies, procedures and processes which impact access, throughput, patient safety, quality and patient satisfaction. Many metrics identified in the CAP have begun to have a positive trend indicating improvements are being hardwired
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 throughout the organization. This is evident in many areas including, but not limited to: Emergency Services, Pharmacy, Patient Safety and Quality. While work remains to be done to compete the CAP and to address issues identified by A&M during unit rounding and during the mock survey process, we believe that Parkland continues to make measurable progress towards its goal of being compliant with all Medicare Conditions of Participation by the end of April 2013, as provided by the SIA. Case Management The newly hired Vice President of Care Coordination (also referred to in this report as Case Management) has made significant changes to Case Management structure and process since her start date in early February. A primary focus in February was to stabilize the Department by filling key management positions to replace interim management that has been in place since May of 2012. The use of agency staff was reduced in February and full-time experienced staff is being hired for case management roles. The vacancy rate for the Department has decreased to 17 percent, from previous months averaging 40 50 percent. Hours of coverage and the staffing plan of the Case Management Department were assessed in February, and a plan to expand hours of coverage of case managers and social workers to ensure adequate allocation of resources to the discharge planning function and care management has been developed and will be implemented in March. A new position, Complex Case Manager, was also created and filled in February. This position is filled by a qualified social worker and has responsibility for coordinating care for patients with extended lengths of stay usually stemming from difficult social and/or financial situations. Also in February, a Complex Care Committee commenced bi-monthly meetings to review patient cases with extended stays and difficult placements. The committee, chaired by the Vice President of Care Coordination, is working in conjunction with Legal and Contracting Departments to develop a post-acute continuum of care alliance with home health agencies, skilled nursing facilities, long term care facilities, etc. so that the continuum may be utilized on an efficient and expeditious basis when attempting to discharge patients who have complex post-acute care needs and limits on financial resources to obtain such post-acute care. The new Case Management Vice President recognizes that the Department will need to undergo a culture change to achieve the results needed for success. We are encouraged with the direction and advancement thus far under the leadership of the new department head. We will continue to monitor the Case Management Departments efforts in developing consistent and early case management interventions for all patients. Human Resources Personnel vacancy rates continue to be an issue for Parkland and the Hospitals senior management continues to be focused on efforts for timelier recruitment, hiring and orientation of new employees to critical vacant positions. A fast track hiring initiative was created through a Recruiting Process Outsourcing vendor (RPO). An additional four contractors have also been placed to assist with recruiting for priority areas. Several job fairs for nursing positions have been organized and will occur in March.
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 However, in spite of the addition of the RPO and other recruiting and hiring resources, tracking metrics indicate an upward trend in the nursing leadership vacancy rate. To continue to reduce employee turnover, Parkland formed an Employee Engagement and Retention Committee under leadership of the Human Resources Department. This committee will design, plan and recommend actions to improvement the engagement and retention of Hospital employees, as well as measure and monitor metrics and information regarding employee retention. Effective recruitment and retention strategies will continue to be integral to Parklands ability to hire and maintain a stable workforce. These strategies are needed to ensure the improvements made during the Systems Improvement Agreement are sustained and become the new culture/way that Parkland operates into the future. The interim CEO and senior management is acutely aware of the importance in expediting recruiting and hiring of qualified candidates and reducing the personnel vacancy rates. Competencies Clinical Competencies In order to monitor the progress on the Hospitals action plan to ensure that current documentation competencies are available in all personnel files, A&M conducted an audit of employee files in February. Sixteen files were reviewed to determine whether all required elements of a personnel file, including job descriptions, certifications, licensure verification, competencies, etc. could be easily found. All files we reviewed had the correct and up to date job descriptions, licensures, CPR AED, ACLS, PALS, Skills List, and Orientation Evaluations. One file was found to be missing a BLS certification, one missing Institutional Review Board (IRB) competencies and one was missing unit-specific waste hazard competencies. Overall, there has been an improvement in the organization and completeness of personnel files, but the validation of existence of up-to-date and complete competencies of clinical personnel has not yet been completed. As of the end of February, Parkland reported that 50 percent of the clinical personnel files need additional review by the Clinical Education Department, which is managing this verification process. Additional resources or efforts will need to be made in order to complete this verification process by the end of March. Non-Clinical Competencies As we reported in our January report, a process has been developed to ensure that all competencies for non-clinical staff are completed and documented in personnel files. This project is moving slowly, and we are concerned that a completion date of April 1st may not be achieved. Training in the completion of competencies for the non-clinical staff leadership has been delayed and is now scheduled to begin March 7, 2013. The objective for the training is to equip the managers with the knowledge and resources necessary to define competencies and evaluation methods for employees in the target population. Human Resource Business Partners (HRBP) and Leadership Organizational Development (LOD) staff will be trained in Mid-March, as well, on defining competencies and using HealthStream to track and maintain competencies. HRBP and LOD staff will then work with the non-
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 clinical staff leadership to ensure competencies are developed and implemented and then entered into HealthStream by April 1, 2013. Documentation of current competencies both for clinical and non-clinical employee is a critical HR function and we have advised Parklands senior management that this review process must be completed prior to the end of April 2013. Employee Performance Management In December A&M performed a review of personnel files to assess the completeness of these files with respect to appropriate corrective action and progressive discipline as a follow up to concerns identified in the Gap Analysis. We conducted our February employee corrective action review by starting with 24 instances of potential policy non-compliance by employees identified in safety reports. These events were logged across several inpatient hospital units between the period of January 1st and January 31st. The objective was to determine: 1) whether there was an appropriate corrective action issued to the employee who was accountable for the breach in a process or policy; 2) if the corrective action was appropriately located in the employees HR file, and 3) if the corrective action followed the Hospitals HR policy. Interviews were conducted with unit managers and documentation from HR records was reviewed. Our review of these employee corrective action episodes indicate some continuing issues with regard to these HR processes, including: Inconsistent closing the loop by department-level management in cases of adverse safety events that stem from personal accountability; Inconsistency in applying the corrective action protocols in accordance with HR policies and procedures; and Inconsistency in following HR policies and procedures on documentation of corrective action.
Continued education and management training is needed and is in progress to ensure department level managers are well versed and compliant with HR policies and procedures on performance management. Nursing Administration As discussed in previous reports, Parklands ability to change staffing levels in response to changes in patient census and acuity is based upon having standby resource for additional nurses to staff these positions. We have encouraged Parkland to focus efforts on building the resources required for a nurse float pool while building the infrastructure and technology to be tracking patient acuity between ANSOS and McKesson. Under the leadership of the Associate Chief Nursing Officer (ACNO), progress on implementation of the new nurse float pool model has advanced. The traveler program, which was increased by 50 nurses, has been filled with 32 positions by the end of February. The pilot for surgical services has not been implemented due to development of job descriptions.
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 Other improvements in Nursing Administration have occurred with the Nursing Administrative Officer (NAO) role. Nursing staff in these roles now provide round-the-clock coverage to assist with issues requiring nursing supervision. NAOs are heavily involved with the Admissions Discharge Transfer Department and work collaboratively to improve patient flow and bed management. One-to-One Observation Because of physical, cognitive or behavioral issues, many Parkland patients require continuous observation by caregiver staff, often referred to as one to one observation. During the month of February, a compliance review was conducted on the adherence to Parklands one-to-one observation policy and procedures. Parkland personnel functioning in an observer or sitter role in 12 different units were interviewed and patient charts were reviewed for appropriateness of documentation. Staff members performing an observer role were consistently able to answer questions regarding policy, procedure and their responsibilities in performing this role. There were no deficiencies in their responses or observations of practice during the review. During this review, nurses were consistently able to explain the patients care plan and requirements to the one-to-one status. Documentation as to the reason for the need for this observation was documented in the patient record 80 percent of the time and the individuals name and identification was documented 60 percent of the time. There has been much improvement in the training and knowledge of the Parkland employees assuming a patient observer role. Documentation by nursing of observer need and status, however, can still be improved in some cases in the elements of naming the employee in the role, the employees identification number, and the reason for the one-to-one observation status. Acuity Based Staffing The go-live for the McKesson acuity staffing system occurred on February 20th. All nursing units are now utilizing the system and nursing leadership reports the system is well tuned and is working appropriately. All scheduling is now completed in the ANSOS system and is no longer a manual process. Jackie Brock, VP of Nursing for Surgical Services and Kelly Heathman, Director of Nursing for Medicine Services should be recognized for their dedication and hard work to bring this project to completion.
Patient Safety / Quality
Patient Safety Network (PSN) Event Reports In an effort to ensure that each potential patient safety event reported to the Patient Safety Network (PSN) system is appropriately investigated and resolved, the Patient Safety Department created a close the loop process. A PSN Closure Report will now be generated monthly and distributed to appropriate key management and leadership personnel responsible for investigating and closing the loop for their areas. Trends will be reported to the Quality of Care & Patient Safety Committee of the Hospital and Quality of
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 Care & Patient Safety Committee of the Board. The closure report process will require a manager to check the box indicating an adverse event report in the PSN is closed. In March, the Patient Safety Department will begin to audit the quality of the action plans and resolution of adverse event reports have been taken and are appropriate. Root Cause Analysis (RCAs) Over the past several months, an improved process has been implemented at the Hospital to develop a fast track root cause analysis (RCA) process. The new process requires a case review and resolution plan to be drafted within two meetings or less with key stakeholders. The first meeting is organized as an event debriefing with the key stakeholders involved in the event. The facts are discussed with the key people and their testimony is documented into the RCA tool. The second meeting is a two hour meeting to determine the root cause(s) and contributing factors that resulted in the untoward event. The action plan is also developed with key stakeholders to address the root causes and contributing factors that will minimize these types of event to recur. This revised RCA process appears to be working more efficiently that the previous process, with the goal of having a meaningful and prompt action and remediation plan for all safety events elevated to the RCA process. We will, however, continue to monitor the RCA process to see that meetings are conducted and action plans issued in a prompt manner, and follow through to ensure an action plan is performed. Patient Relations In February A&M conducted an additional review of Parklands Patient Relations Department (PRD) to assess changes the Department has made since undergoing a recent reorganization under a new leader. Parklands Patient Relations Department processes complaints and grievances made by patients or their family members. The PRD coordinates activities related to complaints and grievances with Risk Management, Patient Safety, and Legal as required or indicated. The Patient Relations Department operates under a policy/procedure that clearly outlines the process that was recently revised to meet the CMS Condition of Participation regarding Patient Rights. Timeframes for communication with the patient/family were revised and the maximum time allowable to complete the entire process was amended. The policy is in compliance with CMS guidelines and was approved by the Board of Managers at its February 2013 meeting. The PRD has made significant changes to its processes to improve grievance and complaint response/resolution times. From October, 2011 to October, 2012 the average time to resolve complaints/grievances was 22.75 days with a range of 9 to 44 days. In January 2013 the average time to resolve complaints/grievances was 5.8 days with a range of 1 to 10 days. In February the improvement continued with an average of 4.6 days and a range of 1 12 days. The aforementioned metrics relate to five categories that the PRD has chosen to focus on over the last several months. PRD leadership is working to develop reports to provide accurate information on closure and volume metrics for all data points. The PRD Director is in the process of implementing other measures that will improve the time to resolve complaints and grievances, but also reduce the number of complaints that are categorized into grievances.
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 The Department has partnered with the Nursing Administrative Officers (NAO) as an additional sensing arm to log any interactions they have with patients regarding complaints at the time of the event and will work with both the Police force and Chaplains in a similar way. The functioning of the PRD has significantly improved with the change of leadership, organization structure and roles/responsibilities of staff. The changes that are contributing to the improvements are a customer focus, quality not quantity of work, accountability, and collaboration across departments. House-wide Issues
A&M General Audit Results In February, A&M completed audits of 32 units/areas throughout the main campus of Parkland Hospital. The general audits were conducted by rounding the unit with the Charge RN/Unit Manager/Area Manager and covered five main areas of compliance: Effectiveness of services provided by Environmental Services (EVS) and Facilities General conditions of Environment of Care (EOC) Hand hygiene compliance (through observations) Medication management compliance and knowledge Assessing staff knowledge and involvement in facilitating discharge management and unit operations (typically from charge nurse or unit manager).
A&Ms audits also included observational rounds conducted in collaboration with Environmental Services (EVS) and Infection Prevention (IP). This initiative was designed to include a multi-disciplinary and audit focus of environment of care issues and a real time sharing of findings and recommendations with department-level management and senior leadership. Any event requiring immediate remediation is discussed with local management during the assessment, identified as a key finding and sent to the leadership team on a daily basis. A&M organized these findings into five categories as shown in the chart below.
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Categories of "Key Findings" from February's Rounding Audits

EOC Infection Prevention Med Mgmt Life Safety Biomed 0 5% 4% 5 10 15 20 Number of Occurrences 25 30 16% 25% 50%
The majority of occurrences found in the audits were related to EVS and fall under the Environment of Care (50 percent). The most common EVS events were unclean floors (46 percent) and/or a general substandard cleanliness/appearance of the unit. Presented below is a detailed breakout of A&Ms Environment of Care findings:
Categories of Environment of Care Findings

7% Floors 46% Doorways Other PHI 14% Garbage Storage
7% 11% 14%
Compliance with infection prevention protocols and medication management procedures accounted for approximately 25 percent of all occurrences. Key findings included several dusty areas including air vents, floors and table tops, and poor hand hygiene practice.
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 A majority of the medication management incidents (16 percent) had to do with medications left in unsecured areas and inappropriate labeling. A&M has recommended the nursing staff re-visit education of these protocols. Other findings made during these rounds included the continuing lack of consistency of timely interventions by Case Management (social workers and case managers) on units. Patient Identification Parklands nursing leaders have developed a patient safety plan to address compliance with consistent use of the two patient identifier system. Under the two patient identifier system, a patient must be identified in more than one way (e.g., full name, date of birth) by each caregiver when medications, blood products, tests, etc. are administered. Several audits will continue to be conducted at Parkland to measure the practice of using two patient identifiers with the aforementioned practices. The first audit for the use of two patient identifiers was conducted for medication administration. This medication audit was multi-faceted and covered not only two patient identifiers but also ensuring that the six rights of medication administration were being executed by nurses. The medication audit was conducted by the Nurse Excellence team and 25 episodes of medication administration in 17 nursing units. The results showed that 98 percent of medication administration cases utilized two patient identifiers correctly. Nursing Documentation Pain Assessment Documentation In February A&M conducted a chart review for correctness of pain documentation elements. Thirty (30) charts were reviewed for the following elements: Was the pain assessment documented? Was a pain number documented? Was pain medication given? Was a reassessment documented? Was a pain scale number documented on the reassessment? Was the reassessment documented within 30 minutes of giving an IV medication or within 60 minutes of giving an oral medication? Was the pain medication given for the indicated pain scale that was documented? Was the patient a pediatric patient? What pain scale was utilized?
In the 30 charts reviewed for surgical services, 100 percent were in compliance with all the required elements of pain administration. Chart reviews of the WISH and Medical Services units revealed an
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 opportunity for improvement in the appropriate documentation of all the required elements of pain administration. Restraint Documentation Audits were completed in February to evaluate use of patient restraints against Parklands revised restraint policy and procedure, along with revisions to the Epic EMR system to ensure easier and more accurate documentation. These restraint documentation audits were conducted by selected staff members from each unit to engage ownership of nursing practice. The Non-Violent/Non-Self Destructive restraint audit results indicated there is some room for improvement in documentation. The areas that require significant attention are documentation by the nurse for assessment and re-assessment every two hours and documentation of the restraints being removed. Additional attention needs to be made with documentation of alternative methods offered, physician order reflected in nursing flow sheet, restraint method applied, and the behavior the patent was exhibiting. The documentation for patients who exhibit Violent/Self Destructive behaviors is essential to ensure that patients are safe and quality of care is maintained during the time during which the patient is on restraints. There is also an opportunity to improve documentation in the areas of physician face-to-face within one hour of order and assessment and re-assessments every two hours and removal of restraints. Wound Care Documentation In February, A&M also conducted a chart review of wound care documentation. The purpose of the audit was to determine documentation of wound assessment by nurses on each shift per Hospital policy. Thirty (30) charts were reviewed; ten charts from surgical services, ten charts from medical services, and ten charts from WISH services. Charts reviewed in the WISH and Surgical units were documented appropriately and with appropriate frequency. The audit indicates room for improvement in Medicine Services, where four out of ten charts lacked appropriate wound care documentation. All audit results are shared with nursing leadership so that action plans can be developed for targeted areas where improvement is needed. Specimen Labeling Due to a number of incidents with mislabeling/misidentification of specimens for laboratory testing, a process assessment was conducted by A&M to document the work flow, identify inconsistencies in the process as well as barriers and breakdowns and to identify opportunities for improvement. The scope of the assessment included a review of processes for orders, collection, labeling and processing from the patient to the laboratory. Interviews were conducted with Lab personnel, Nursing and Laboratory leadership.
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 In general the process of labeling specimens at Parkland is impacted by technology limitations and inconsistent processes among units. Workarounds have been developed to try to overcome these issues, which have increased the variation, process time, decreased efficiency and increased patient safety incidents and error rates. A&M made several recommendations including IT programming changes, process redesign, staff education and retraining in order to improve the process of specimen labeling. Two specific recommendations that should be implemented as soon as possible include the following: The Hospital should create a laboratory nursing task force that includes representatives from various inpatient nursing units to develop a standardized and streamlined process for orders, labels (and storage), labeling, acquisition and processing; and Begin a pilot program in the Emergency Department using recommended specimen labeling processes.
In late February, Lab and Nursing leadership met to discuss the findings and recommendations of our assessment, and to initiate the ED pilot program.
Department and Unit Specific Findings
Clinics Community Oriented Primary Care Clinics (COPC) The new care delivery model continues to be implemented in the remaining COPCs: Virtual visits were implemented in the Southeast Dallas COPC New provider templates were implanted in Southeast Dallas and Vickery COPCs Pre-visit planning was implemented in Irving and Vickery.
Jessica Hernandez, Senior Vice President Community Oriented Primary Care, continues to strive to improve patient throughput within the COPC system. In February, exceptional physician productivity at the Bluitt Flowers COPC was studied and practices used there will be implemented in other clinics in future months. Analyses of no show rates for new and established patients, as well as ways to improve Today Clinic capacity are also underway. An infection prevention corrective action plan was developed to address issues specifically identified in the COPCs on Environmental Services and Infection Prevention Rounds. Outpatient Clinics (OPC) Several months ago, the Hospital implemented initiatives in six clinics designed to increase patient access and throughput. Metrics for appointment wait times and clinic dwell times, however, have not improved as expected. In January, A&M asked OPC leadership to re-visit these areas and provide a report in February.
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 Throughput metrics for these six clinics remain unchanged. It does not appear that throughput has been analyzed or any corrective action has been taken to try to improve patient flow. Improvement in patient throughput in the outpatient specialty clinics can relieve emergency room volume and improve patient care. We strongly suggest greater focus on this initiative to: 1) obtain all data needed to evaluate throughput and patient flow: 2) evaluate and analyze the data; and 3) create an action plan to improve throughput and wait times. Contract Services Significant work remains to be done within the contract services work stream. The Contract Oversight Committee formed in January was formed to support the work of the contract services work stream and act as liaison between contract business owners, senior management and the Board of Managers. The Committee has the responsibility to review contracts and report significant findings to the Board. Several significant contracts are below requirements for acceptable quality scoring. This work stream needs to accelerate the workplan to have all vendor contracts, with a clinical component 1) inventoried; 2) evaluated for the existence of quality metrics; 3) evaluate and measure the vendor against those metrics; and 4) require the business owner of the contract to implement corrective action against the vendor when the quality metrics are not met. Emergency Services Process improvements implemented in Parklands Emergency Services throughout the past several months have made a significant impact on patient throughput in both the Main Emergency Department (ED) and the Urgent Care Emergency Department (UCED). Patient dwell times have decreased significantly in both the ED and UCED, and the number of patients who left without being seen has also decreased dramatically. A contributing factor to the favorable metrics in the UCED is the extension of service hours in February.
Main ED Throughput Metrics

500 450 400 350 300 250 200 150 100 50 0 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Left Without Being Seen Average Dwell Time for Dialysis Patients in Main ED (Minutes) Door to Home (Minutes) Door to First Provider (Minutes)
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UCC Throughput Metrics

300 250 200 150 100 50 0 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Door to Home (Minutes) Door to First Provider (Minutes) Door to Room Time (Minutes Left Without Being Seen
The ED is making changes to nurse management as recommended by our January report. Instead of one charge nurse for Main ED East and West, an additional charge nurse will be added so each area will be covered. Because of the increase in UCED hours, the Department will also need to hire additional RNs for coverage. The ED continues to work on areas for improvement that are highlighted in ongoing audits, and they are making significant progress. Clifann McCarley, Vice President of Emergency Services, has provided excellent leadership in all CAP initiatives and she and her ED management team are to be commended for the marked improvements in ED Services.
Laboratory Services In an effort to understand the high volume of specimen labeling errors occurring throughout the Hospital, A&M conducted a process assessment and provided recommendations for improvement. (Details of that review appear above in this report.) The Laboratory and Main Emergency Department have collaborated in March with a pilot program to implement many of the A&M recommendations. Compliance with critical turnaround time has remained constant at 98 to 99 percent for several months. The Laboratory Services Department has developed a reporting process which now provides chiefs of service with outliers in an attempt to improve compliance even more. Psychiatric Services While some progress has been made in filling critical provider vacancies, there are still many instances of insufficient professional staff coverage on the March schedule for the behavioral health units. Staff vacancies continue to present challenges with several key vacant positions still requiring qualified people. Staffing coverage is currently being tracked by the hospital unit coordinator (HUC) every four hours.
18
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 This tool demonstrates where staffing holes are occurring but the analysis needs to be more representative of staffing shortages and not simply calculated by averaging the non-coverage hours by staff position. The ED and PED are collaborating daily to discuss throughput and behavioral health patient issues in the ED. This collaboration, while going in a positive direction, is still evolving for effectiveness. Communication from the staff to the leadership in the PED needs to be more prescriptive and timely. The shift report is assisting in the communication but not all pertinent events are recognized by the charge nurse such as discussing possible capping with ED when the PED is not nearly at capacity. The transition of Parklands behavioral health management functions to Green Oaks leadership under the new management contract began in February. Green Oaks will begin selection of candidates for key management positions during early March. Women and Infant Specialty Health (WISH) Services Parklands Operational Excellence group did a study in February on Parklands Obstetrics Intermediate Care Center (OBICC) that revealed many opportunities for improvement in process and patient flow in the OBICC. Opportunities for a more streamlined process with greater patient flow are in the following areas: Provider assignment to patient (faculty versus resident versus mid-level) Triage Discharge processing time Utilization of treatment space and exam rooms.
This report by Parklands Operational Excellence Department provided verification and detail to many of the findings in A&Ms Gap Analysis and subsequent reassessment conducted in January 2013. The Operational Excellence teams simulation and recommendations indicates significant improvements can be made in patient access and throughput. As reported last month, the labor and delivery area of WISH is challenged with staff turnover. Parklands Human Resources department has increased recruiting efforts and will be holding job fairs in March. Conclusion In the one year since the Gap Analysis report was delivered to the Parkland Board of Managers and nearly one year since the Corrective Action Plan was accepted by Parkland, much work has been done to address issues identified in the Gap Analysis and to implement initiatives specified in the CAP. The extensive mock survey conducted in February validated the progress that Parkland has made in many areas of care delivery and patient safety including with Parklands provision and organization of emergency services. However, several areas continue to need focus to come to completion. With less than 60 days left under requirement under the amended Systems Improvement Agreement (SIA) that Parkland be ready for a full Medicare Condition of Participation survey, the Hospital must accelerate its corrective action activities and refocus its efforts on a number of areas:
19
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS February 2013 Case Management Conduct audits of medical records to ensure that case management intervention is appropriately and timely documented and in accordance with Medicare COP Direct observations and interviews of key processes with staff in patient care and other patient care support areas to validate consistency with policies and procedures Continue communication efforts to front-line staff with regard to the expectations of compliance Onboarding of key management positions Review and adoption of all departmental policies and procedures Expansion of case management hours of service Consistent, early (within 24 hours of admission) and often intervention by case management on all patients
Competencies Completion of clinical and non-clinical competency validation initiative
Contracts Complete review key clinical contracts for quality indicators and ensure all contracts are appropriately categorized as clinical or non-clinical
Human Resources / Nursing Completion of clinical and non-clinical competency validation initiative Three weeks of job fairs for nursing (OR, Med/Surg, WISH, Case Management) Restructure of recruiting process Formation of Employee Engagement and Retention Committee
Laboratory Implementation of recommendations from A&M lab specimen assessment
Medical Staff / Physicians Ensure 100 percent use of Notewriter tool to document floor based procedures by residents Continue to complete education and auditing efforts around changes to enhance and provide additional documentation on resident/attending physician interaction Complete initial run of medical staff recredentialing applications through the revised Ongoing Professional Practice Evaluation (OPPE) process.
Nursing Administration Source, recruit and hire adequate resources to staff nursing float pool Attending job fairs in March to recruit Med/Surg, WISH and ED OR nurses Determine education plan for one-to-one observations for patients with behavioral health issues Develop plan for acute nurse practitioner responsible for management of one-to-one observations Continue chart documentation audits around issues such as: Plan of Care, pain reassessments, patient education, use of restraints
20
Patient Safety Audit quality and completeness of closure/resolution of adverse patient events reported in PSN and returned to departmental management for follow up
Pharmacy Focused work on preventable adverse drug events relating to blood glucose levels Continued performance improvement work relating to behavioral health prescriptions in the Psychiatric Emergency Department and Jail
Physical Medicine and Rehabilitation (PM&R) Ensure that time out practices are in accordance with Hospital policy Implementation of recommendations from Operational Excellence assessment related to matching staff to patient demand (inpatient/outpatient)
Policies & Procedures Inventory and review the policies and procedures to ensure that standardization of form and substance and appropriate approval processes are in place
Psychiatric Services Ensure an effective transition and onboarding of new management of Psychiatric Services under the Green Oaks management agreement Conduct audits of medical records to ensure that case management intervention is appropriately and timely documented and in accordance with Medicare COP Direct observations of key processes and interviews with staff in patient care and other patient care support areas to validate consistency with policies and procedures Continue communication efforts to front-line staff with regard to the expectations of compliance; Multidisciplinary review on physical space changes currently being funded Continue to recruit personnel for outstanding vacancies clinical provider (e.g., physician, nurse, nurse practitioner) and support staff Focus on earlier discharges from PED and reducing time from discharge order to actual disposition
WISH Implement recommendations to change processes and roles/responsibilities to improve patients access and throughput consistent with policies and procedures of the other Emergency Services areas of the Hospital
The results of the February mock survey provided valuable insight into Parklands state of readiness for a full CMS/State survey. The survey found an organization where quality and safety metrics are continuing to improve. Over the next 60 days, and into the future, those quality and safety gains must be held and the remaining work in the areas noted above must be completed and sustained for Parkland to be ready for its full CMS survey.
21
Governance (Section 2.01) # 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Tasks/Initiatives MEC to prepare a comprehensive plan to implement Ongoing Professional Performance Evaluation (OPPE). Review 5% of Medical Staff OPPE Profiles at conclusion of next eight-month cycle. Hospital senior management to revise the Parkland ESD Policy Manual to include written policies and procedures regarding documentation of Teaching Attending Physician oversight of Residents. Hospital senior management, in collaboration UTSW and A&M to create a standing rounding, evaluation and auditing process to collect data on Resident oversight. Require quality dashboard report from Hospital Quality Department Commence reviews of scorecards for significant outsourced and contracted clinical services. Design a Board-specific QAPI plan. Review and revise BOM committees. Review performance management and progressive discipline implementation plan from Human Resources. Review comprehensive plan to create better communication and coordination among the Hospitals Legal, Compliance, Internal Audit and Quality Departments. Review Hospital plan on continuum of care. Appoint Task Force to review Hospital's current Disaster Plan and all other plans indicating how the Hospital and community would respond to rectuion, closure, or diminishment of services or care by Parkland Accountability Patricia Bergen, MD Brad Marple, MD Brad Marple, MD Jackie Sullivan Jackie Sullivan Paul Leslie Jim Johnson Jody Springer Sharon Phillips Paul Leslie Work Stream 5.1 5.3 5.3 6.4 6.4 1.1 1.5 1.2 3.5 1.10 Target Date 1/31/2013 5/18/2012 8/31/2012 5/25/2012 6/1/2012 6/8/2012 6/8/2012 6/8/2012 10/30/2012 7/13/2012 Y Y Y Y Y Y Y Y Y Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion
# 1
Audit/Measures Percentage of contracts (outsourced vendors) reviewed for quality measures

1
Accountability Contract Svcs Comments
Goal 100%
Sep-12 96.1%
Oct-12 85.7%
Nov-12 96.0%
Dec-12 100.0%
Jan-13 100.0%
Feb-13 100.0%
1.01 - Results on OPPE for pilot clinics to be presented to the MEC in April
Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
1. 2. 3. 4.
Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group Reported through Alvarez and Marsal's Daily Audits
Human Resources (Section 2.02) # 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 # 1 2a 2b 2c 3 4 Tasks/Initiatives Redesign progressive disciplinary policies and procedures and performance management system. Redraft goals of the Leadership and Organization Development Department. Develop education materials for new processes and policies. Conduct training for management and employees. Expand the role of Business Partner, require they take a more active role with front-line managers and supervisors. Business partners to audit evaluations for the next two evaluation cycles. Evaluate current HR staffing model. Analyze resource allocation within HR Department. Develop Parkland employee retention strategy. Develop policies, procedures and training material regarding employee retention strategy. Develop master list of all competencies required for each department by job code. Review and revise LMS system to ensure all required competencies are reflective in the system. Review all personnel files for completeness. Educate employees on proper and complete paper work (licensure/certifications). Ensure accurate and complete paper work is immediately forwarded to Nursing Administration. Form standing committee to review polices and procedures with representation from administrative, clinical, and support areas Develop policies and processes to be used for HR policy review. Audit/Measures Percentage of supervisors (and above) who have attended training administered by clinical education
1
Accountability Jim Johnson Jody Springer Jim Johnson Jim Johnson Jody Springer Jim Johnson Jody Springer Jody Springer Jim Johnson Jim Johnson Jim Johnson Jim Johnson Jim Johnson Jim Johnson Jim Johnson Jim Johnson Jim Johnson Accountability House-Wide
1
Work Stream 1.5 1.2 1.5 1.5 1.2 1.6 1.2 1.2 1.8 1.8 1.6 1.6 1.6 1.6 1.6 1.5 1.5 Baseline
Target Date 5/25/2012 5/25/2012 5/25/2012 7/13/2012 5/25/2012 10/31/2012 7/13/2012 7/13/2012 9/14/2012 9/14/2012 9/14/2012 9/24/2012 9/14/2012 6/4/2012 7/13/2012 4/6/2012 4/27/2012 Goal 100%
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Sep-12 72%
Oct-12 99%
Nov-12 97%
Dec-12 99% 0.5% 48.9% 50.6%
Jan-13 N/A N/A N/A N/A 100% 18.0
Feb-13 N/A N/A N/A N/A 100% 10.6
Evaluation scores on histogram or bar chart for each department (annual evaluations) - below expectations
HR HR HR HR
0.4% 33.9% 65.7%
5.0% 55.0% 40.0% 100% 10 11.9 11.1 100% 9.0
Evaluation scores on histogram or bar chart for each department (annual evaluations) - meets expectations 1 Evaluation scores on histogram or bar chart for each department (annual evaluations) - above expectations 1 Percentage of licensing validations presented prior to the day of hire
1 1
100% 12.6
Time from occurrence to corrective action signed by employee (days)
HR
Human Resources (Section 2.02) # 5a 5b 6 7 8 9 10 11 12 13 Turnover Rate (%) - Nursing Turnover Rate (%) - Total
1 1 1
Metric
Accountability HR HR HR HR HR HR House-Wide HR HR HR Comments
Baseline 16.5% 15.0%
Goal 14.5% 14.1% 20.0%
Sep-12 12.8% 10.6% 6.3% 50.0%
Oct-12 9.5% 9.5% 9.8% 44.7%
Nov-12 12.7% 12.0% 24.1% 41.2%
Dec-12 16.7% 13.6% 17.9% 28.7%
Feb-13 16.2% 12.8% 27.8% 34.7%
Feb-13 17.6% 12.7% 25.3% 38.7%
First year turnover rate Percentage of employees (annually) who leave for stated reasons of better opportunity (compensation, job duties, 1 benefits) Employee satisfaction scores 1 Number of corrective actions 1 Absent Hours (as a percentage of total hours worked) 1 Percentage of current licensure 1 Percentage of current certifications 1 Time for recruiting to fill an open external job position 1
35.1% 76.0% 40
25.0%
N/A 100% 100%
74 1.3% 100.0% 99.2% 72.3
95 0.96% 100.0% 99.5% 68.4
83 1.13% 100.0% 99.4% 73.8
84 1.29% 99.9% 99.4% 73.5
58 1.63% 100.0% 98.5% 75.4
31 1.23% 100.0% 99.2% 77.2
59.9
55.0
Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started 1. 2. 3. 4. Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group Reported through Alvarez and Marsal's Daily Audits
Access/Throughput (Section 2.03) # 3.01 Tasks/Initiatives Review of scheduling templates and actual scheduling patterns at COPC sites in comparison with best practices for teaching clinics along with analysis of schedule utilization versus capacity by clinic Conduct analysis of no show rates by clinic, day, session, and provider. Accountability Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Lonnie Roy Deanna Bokinsky Robin Stults w/ Clinical Intelligence Christopher Madden, MD Jessica Hernandez Holt Oliver, MD Josh Floren Josh Floren Josh Floren Miriam Gomez Miriam Gomez Kim McCloud Linda Licata Barbara Mims Work Stream 3.6 Target Date 9/30/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y
3.02
3.6
6/8/2012
3.03
Conduct a physician productivity analysis based upon a review of current process and development of analytics. Document current process workflow diagrams, identify barriers to throughput and develop solutions that might increase productivity and result in additional capacity Review ED utilization and most common diagnoses by patient admission times to analyze opportunities for changes or improvements in COPC hours of operation Develop the post-acute care network. Case Management to generate a study report by physician or service showing average time of discharge for patients and physicians or services consistently discharging patients late in the day. Chief Medical Officer to meet with the Medicine and Critical Care Service Chiefs and Hospital Directors to determine barriers to earlier discharge of patients on the units and develop a solution. Conduct a physician productivity analysis based on agreed upon industry standards. Conduct a feasibility study for a dedicated observation unit Conduct a feasibility study to determine the best use of 4SS space Conduct a study to determine appropriate expansion of the dialysis unit. Design Bed Czar concept to report to ADT Establish strict standards regarding communication and patient placement timelines with ADT to enhance patient placement. Complete an assessment of the current flow of acute emergent dialysis patients through the emergency department, including potential delays, arrival time patterns, and boarding in the Emergency Department.
3.6
6/8/2012
3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14
3.6 3.1 3.5 3.4 3.4 3.6 1.7 1.7 1.7 3.3 3.3
7/13/2012 7/13/2012 10/30/2012 6/12/2012 10/15/2012 5/11/2012 7/13/2012 7/13/2012 7/13/2012 7/1/2012 3/14/2013
Y Y Y Y
Y Y Y Y Y
3.15
2.6
6/1/2012
Access/Throughput (Section 2.03) # 3.16 Tasks/Initiatives Define a patient flow process that will reduce and/or eliminate boarding of dialysis patients in the emergency department. Accountability Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Josh Floren Work Stream 2.6 Target Date 6/15/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y
3.17
Define and obtain approval for resources necessary to implement process, including expansion of serivces.
2.6
7/1/2012
3.18 3.19
Develop protocols and obtain resources for implementation of defined patient flow process. Fully implement patient flow process and expansion of services to eliminate boarding of dialysis patients in the emergency department. Audit/Measures Capacity - Family Medicine (patients seen/best practice # of visits per month)
1
2.6 2.6
9/30/2012 11/30/2012
# 1a 1b 1c 2 3 # 4 5 6 7 8a 8b 8c 9 10 11 12 13a 13b 14 15 16 17
Accountability COPC COPC COPC COPC ADT Accountability Clinics Care Mgmnt COPC
1
Baseline 86.0% 90.0% 96.0%
Goal 100.0% 100.0% 100.0% 550
Sep-12 100.3% 95.9% 102.8% 402 50%
Oct-12 101.3% 94.9% 99.8% 531 42% Oct-12 5.1% 17.7% 6032 2.60 2.36 1.60 20,605 17,888
Nov-12 97.0% 95.3% 102.4% 565 43% Nov-12 5.2% 17.5% 6465 2.49 2.29 1.63 20,698 17,783 1,216 1:00 112.3 100.5 4.7 83% 62 29
Dec-12 98.5% 95.8% 102.8% 697 42% Dec-12 5.8% 18.1% 5713 2.52 2.31 1.65 18,603 17,391 1,204 0:59 139.4 116.1 5.0 83% 73 63
Jan-13 98.3% 96.4% 107.8% 1383 40% Jan-13 5.0% 17.5% 6907 2.52 2.33 1.76 18,893 15,731 1,261 1:00 164.7 115.3 5.0 88% 96 358
Feb-13 102.8% 93.8% 99.3% 1489 43% Feb-13 6.5% 17.9% 6907 2.57 2.26 1.58 17,836 18,685 1,029 0:59 110.9 95.7 5.0 85% 75 59
Capacity - Internal Medicine (patients seen/best practice for # of visits per month) 1 Capacity - Geriatrics (patients seen/best practice # of visits per month) 1 Number of additional appointments through virtual visits 1 Percentage of observation patients outside of observation unit
1
Metric Utilization rates by session by clinic (hours of activity/hours of capacity) Percentage of discharges (medicine, surgery) by 11:00 a.m. 1 No show rates - COPC
1
Baseline
Goal
Sep-12 4.7%
17.2% 5768 2.62 2.49 1.59
17.7% 5991 2.57 2.34 1.64
Physician (Hospitalists) productivity (based upon Rolling 12 Month RVUs/Average FTE Count) Physician (Clinics) productivity (based on visits/hour) - Family Medicine Physician (Clinics) productivity (based on visits/hour) - Geriatrics Number of new patients on wait list - COPC
1 1 1 1 1 1
Med Staff COPC COPC COPC COPC COPC Care Mgmnt EVS
Physician (Clinics) productivity (based on visits/hour) - Internal Medicine
Number of established patients on wait list - COPC Average bed turn time (hours:minutes) Average minutes of boarding in ICC
1 1 1 1 1
Number of bed days occupied by observation status (by unit) Average minutes of boarding in Main ED Average Length of Stay (1 month lag)
1,512 1:00 1:12 112.5 107.6 5.0 85.0% 45 524 5.0 86% 71 0
1,204 0:59 142.0 138.8 4.6 87% 79 70
ED ED Care Mgmnt ADT EVS ADT
Percent inpatient occupancy (census) by division
Bed Request to Bed Assign, average from bed assigned to patient in bed 1 Hours on red/yellow bed
Access/Throughput (Section 2.03) Comments 3.14 - Implementation of teletracking tool to go-live in June 2013 3.19 - Implementation of dialysis process flow is pending construction in the ED Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
1. 2. 3. 4.
Provision of Care (POC) (Section 2.04) # 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Tasks/Initiatives Define nursing supervisor role expectations and competencies. Revise job description to meet role expectations. Meet with HR leadership to determine most appropriate and fair way to move forward in establishing a broader more accountable house supervisor role. Meet with existing nursing supervisors and explain new responsibilities and go forward plan. Initiate new role expectations. Conduct a comprehensive review of the nursing structure under the direction of the new CNO. Develop internal and external recruitment plan for new organizational structure. Written Timeline conversion to new organizational structure. Review of all nursing practice standards, policies, and procedures for compliance and relevance. Upon review of nursing standards, policies and procedures, a list of gaps identified must be written so there is a documented source to help drive educational plans and strategies. Revise policies/procedures and nursing standards to reflect best practices, as appropriate. Develop a house-wide educational plan to correct the current deficiencies in patient care. Develop nurse leadership competencies for all managers. Develop a collaborative process with Human Resources to monitor and develop corrective action plans for nursing staff who violate policies and procedures. The CNO should determine approach for developing an acuity assessment methodology, e.g., internal historical record review, an automated tool, etc. Accountability Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Mary Eagen Jackie Brock John Raish Mary Eagen Jackie Brock John Raish Mary Eagen Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Emilie Allen Jim Johnson Jackie Brock John Raish Work Stream 4.3 4.3 4.3 4.1 4.3 4.1 4.3 4.1 4.2 4.2 4.2 4.4 1.5 4.3 Target Date 4/20/2012 4/27/2012 4/27/2012 5/4/2012 9/14/2012 3/30/2012 5/11/2012 4/13/2012 8/31/2012 10/5/2012 9/30/2012 10/31/2012 11/14/2012 10/5/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Provision of Care (POC) (Section 2.04) # 4.15 4.16 4.17 4.18 Once selected, roll out acuity tool. Develop flexible staffing strategies, PRN pools, per diem staff, etc. Monitor core patient care ratios for trends. Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (electronic solution) Tasks/Initiatives Accountability Jackie Brock John Raish Rose Labriola Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jim Johnson Jim Johnson Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Brett Moran, MD Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Joseph Minei, MD Jim Johnson Work Stream 4.3 4.3 4.3 4.3 4.3 4.2 5.3 1.6 1.2 4.2 4.2 4.2 4.2 4.2 6.4 4.2 4.2 4.2 5.4 1.5 Target Date 3/22/2013 10/5/2012 3/22/2013 6/28/2013 11/1/2012 5/11/2012 11/2/2012 10/31/2012 11/3/2012 5/11/2012 11/4/2012 9/14/2012 11/5/2012 10/1/2012 9/14/2012 4/20/2012 11/1/2012 3/23/2012 12/1/2012 5/25/2012 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion
4.18b Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (interim solution) 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 4.33 Establish standards of nursing practices, focusing particularly on the plan of care. (Clinical Competencies) Develop house-wide nursing education program (Clinical Competencies) Develop a house-wide competency plan that also addresses a tracking and monitoring system. Develop tracking methodology in conjunction with Clinical Education and HR to track competencies by employee and by department. Establish standards of nursing practices, focusing particularly on the plan of care. (Plan of Care) Develop house-wide nursing education program. (Plan of Care) Create evaluation tools to measure nurse understanding of education and success of program. Initiate nursing grand clinical rounds. Develop report out tool for grand round results. Through the QAPI Department, develop and report verbal order trends monthly to providers and nurses. Review all restraint policies. Develop and execute restraint education. Review Epic restraint documentation structure to improve the quality of documentation. Develop a mandatory education for medical staff on the required elements of performance related to restraints. Develop a strict discipline policy that leads to termination of staff who violate the Restraint policy or a patients rights
Provision of Care (POC) (Section 2.04) # 1 2 3 4 5 6 7 8 9 10 11 # 12 13 14 15 Percentage of cases with verbal orders 1 Verbal order compliance rate (signed within 48 hours) 1 Sitter Compliance
3
Audit/Measures Nursing leadership vacancy rate

1 1
Accountability Nursing HR Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing
Goal 100.0%
Sep-12 12.9% N/A 3.0% 14.3%
Oct-12 9.3% N/A 2.9% 10.7%
Nov-12 7.7% N/A 2.4% 11.7%
Dec-12 8.2% N/A 1.9% 13.2%
Jan-13 9.1% 17.1% 2.8% 10.5% 77% 97% 21% 95%
Feb-13 9.3% 50.0% 3.4% 11.3% 95% 98% 98% 11% 71% 91% 167 Feb-13 1.1% 87% 92%
Percentage of completed competencies in personnel files for all nurses and units Percentage of travelers (hospital-wide) 1 Nursing vacancy rate
1
Percentage of Plan of Care documented according to policies and procedures - Emergency Services 1 Percentage of Plan of Care documented according to policies and procedures - Medicine Services Percentage of Plan of Care documented according to policies and procedures - Surgery Services Percentage of compliance in hand-off's - Emergency Services Percentage of compliance in hand-off's - Medicine Services Percentage of compliance in hand-off's - Surgery Services Volume of non-violent restraint cases (hospital-wide)
1 1 1 1 1 1
100% 100% 100% 100% 100% 100% 143 Baseline 2.2% 90% 100% Goal Sep-12 1.4% 82% 185 Oct-12 1.4% 84% 156 Nov-12 1.2% 82% 183 Dec-12 1.0% 86% 95%
186 Jan-13 1.0% 86% 95%
Metric Number of days per month nurse staffing ratios were above/below grid
Accountability Nursing Nursing Nursing Nursing Comments
4.15, 4.17 - Acuity tool has been implemented, pending validity of inter-rater reliability 4.16 - Float pool decentralized pilot program to be implemented in March, full scale implementation is still pending
1. 2. 3. 4.
Care Management (Section 2.05) # Tasks/Initiatives Evaluate infrastructure and performance of the Care Management Department to include merging Utilization Management function. The evaluation of the Care Management Department will also include a review of all resources and personnel currently committed to the Care Management function to determine whether the Department has adequate resources and personnel to perform all of its required functions. The evaluation of the Care Management Department will also include a plan to merge Hospital Utilization Management functions into Care Management. Re-align goals and strategy of department to promote collaboration between Case Managers, Social Work, Utilization Review and Nursing. Develop nursing-wide education plan defining roles and responsibilities of case managers, social workers, and utilization management along with the inter-relationships between the functions. Identify metrics needed on a daily basis to properly analyze cases. Produce an Extended Stay High Cost Outlier Report to identify inpatients that could move to a post-acute care setting if funding permitted. Based on evaluation of creating discharge care sites for patients without means, enter into agreements such as leasing beds in a Skilled Nursing Facility (SNF), reduced rates for Durable Medical Equipment (DME) and home oxygen, long stay hotels, etc. Revise position expectations of the ED Case Manager . ED Case managers should evaluate all potential admissions on whether they meet acute care criteria and assess patients potential discharge planning needs. ED case managers should perform an initial assessment on all patients being admitted to the hospital. Create or revise policies and procedures that define screening, assessment and discharge planning process to identify high risk patients. Educate nursing care management staff on proper procedure for the Discharge Planning Assessment Tool within Epic to ensure appropriate screening and referrals. Evaluate for each Nursing Unit the best mechanisms to promote interdisciplinary communication, e.g., brief daily huddles, rounds, EMR notations only, etc. Based on findings, pilot and implement the most effective methods. Create a screening tool for case managers to include long term stay patient, avoidable days and other areas of focus. Accountability Work Stream Target Date Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion
5.01
Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Rose Labriola Marilyn Callies Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Robin Stults w/ External Resources Marilyn Callies Rose Labriola Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence
3.4
7/24/2012
5.02
3.4
6/30/2012
5.03
3.4
6/30/2012
5.04
3.4
6/1/2012
5.05
3.4
5/31/2012
5.06
3.5
1/31/2013
5.07
3.4
6/1/2012
5.08 5.09 5.10 5.10 5.11
3.4 3.4 3.4 3.4 3.4
9/30/2012 8/30/2012 6/15/2012 6/15/2012 11/14/2012
Y Y Y
5.12
3.4
7/20/2012
5.13
Move Utilization Management within Care Management Department.
3.4
8/31/2012
10
Care Management (Section 2.05) # 5.14 Tasks/Initiatives The Utilization Review Plan should be re-written to include the required elements which are necessity of admission, length of stay and appropriateness of use of drugs. Policies and Procedures should be revised to reflect the revised plan, and associated roles and responsibilities of staff. Revise the current UR logs to ensure that all required elements are collected and formatted in order to analyze and trend type data. Develop process to export Case Management Care Web documentation whereby the data are analyzed and trended. Accountability Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Accountability CM
1
Work Stream 3.4
Target Date 7/24/2012
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Completion Y
5.15
3.4
7/30/2012
5.16
3.4
7/31/2012
5.17
3.4
6/30/2012
5.18
Select UR metrics for tracking, monitoring, and trending. (utilize national best practices as examples for targets). Utilize data from a comparative database that is clinically adjusted and severity adjusted to assist the Committee in identifying areas for improvement. Analyze, trend, and summarize agreed upon data elements to the UR Committee on a regular basis. (Recommendations for actions need to be documented and reported to the Medical Executive Committee.) Report unfavorable physician trends to the Patient Care Review Committee (PCRC). Unexpected results will be reported to Performance Improvement (PI). Monitor progress on targeted metrics and re-evaluate targeted improvement goal and/or metrics being measured.
3.4
6/30/2012
5.19
3.4
6/12/2012
5.20
3.4
7/31/2012
5.21
3.4
10/31/2012
5.22
3.4
7/31/2012
# 1 2 3 # 4 5 6 7 Number of Avoidable Days (per Month) 1 Number of One-Day Stays (per Month) 1
Audit/Measures Compliance in performing medical necessity screening in ED

1
Baseline
Goal
Sep-12 90.1%
Oct-12 89.3% 59.0% Oct-12 978 4,440 580 10.2%
Nov-12 91.8% 74.8% Nov-12 1,111 5,157 686 9.9%
Dec-12 96.1% 94.6% Dec-12 1,184 5,384 593 10.9%
Jan-13 98.1% 94.7% Jan-13 1,008 5,114 554 10.2%
Feb-13 98.1% 98.1% Feb-13 1,081 5,400 581 9.8%
Audit Results of Number of Hospital-Wide Cases Intervened on 1st day of admission Percentage of cases with CM screening for discharge needs - ED 1 Metric Number of Cases with Outlier Length of Stay (LOS) (per Month) 1
CM CM Accountability CM CM CM CM Baseline 1,013 5,184 443 8.7% 95.0% Goal 28.5% Sep-12 954 4,853 488 8.4%
30 day Readmission Trends (percent of total discharges) 1
11
Care Management (Section 2.05) Comments 5.06 - Although work has accelerated on contracting with post-acute care facilities, execution of contracts is not expected until April 2013 5.10 - New Case Management leadership is affecting the effectiveness of the tool
1. 2. 3. 4.
12
Environment of Care (EOC) (Section 2.06) # 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 Tasks/Initiatives Coordinate a multi-disciplinary team to represent the EVS department that is impacted by turnaround of beds; Nursing, ADT, EVS, ESD, House Supervision, Administration. If required, conduct a demand vs. capacity, throughput process workflow assessment and an EVS labor productivity study. If required, develop a future work flow process. Provide EVS various communication devices, hand held transmitters, pagers, cell phones, etc. to the EVS managers and EVS staff to expedite and validate the current status of the unit. Minimized delays in placing patients on unit with efficient communication and temporary deployment of additional EVS staff from other units to the unit experiencing an influx of patients. Track work orders and their respective resolutions. Analyze the issues and their resolutions to determine trends. Provide action plans for decreasing recurring issues. Create a plan for an initial cleaning campaign and ongoing schedule for cleaning, maintenance and incorporate monitoring. Convene the environment of care team to establish mission, charter, goals and processes to address EOC activities. Conduct a one-time, accelerated plan for deep cleaning and repairs. Develop a budget and prioritization for the campaign on potential staff or capital needs for senior leadership review. EVS to review existing checklists and expand where necessary for an EOC checklist for department surveillance. Issue checklists to Department Directors to ensure preparedness and awareness. Issue infraction notices to Department Director, Divisional VP and EVS Director. Conduct analysis on EVS staffing and evaluate and compare to industry benchmarks to ensure adequate resources exist to maintain the facility. Create an analysis of the current EVS process workflow to determine things such as barriers, potential improvements, productivity and performance. Develop new process flow if necessary. EOC team to submit monthly report to COO and CNO based the EOC rounds and on the action plans. Review existing scope of activities/tasks as well as frequency of cleaning schedules for each unit/space of the Hospital (and ambulatory sites) to ensure it is adequate to meet the new standards and/or adjustments. Accountability Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Kurt Dierking Work Stream 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 Target Date 4/27/2012 9/14/2012 9/14/2012 4/11/2012 4/23/2012 4/27/2012 4/6/2012 4/6/2012 6/8/2012 4/13/2012 4/13/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
# 1 2 3 4
Audit/Measures Percentage of Patient Rooms, Procedure Areas, and Operating Rooms, meeting all elements of EVS requirements Compliance to infection prevention audits on surface cleanliness Number of patient complaints about environmental issues
1 1 1
Accountability House-Wide EVS House-Wide EVS
Goal 100% 100% 100% 0
Sep-12 97.4% 98.0% 100.0% 3
Oct-12 97.1% 98.1% 100.0% 4
Nov-12 97.6% 98.9% 100.0% 1
Dec-12 98.3% 97.5% 100.0% 4
Jan-13 98.6% 99.5% 100.0% 2
Feb-13 98.7% 99.0% 100.0% 1
Percentage of procedure areas with up to date daily terminal cleaning logs 1
13
Environment of Care (EOC) (Section 2.06) # 5 6 7a 7b 7c 8 Bed turnaround time Percentage of turns greater than 60 minute goal Work order completion time - EVS (days)
1 1
Metric
Accountability EVS EVS EVS Facilities
Baseline
Goal 1:00 25%
Sep-12 1:12 48% 1.91 2.01 2.47
Oct-12 0:59 41% 0.42 3.21 2.42 7.9%
Nov-12 1:00 37% 0.92 1.88 3.23 6.1%
Dec-12 0:59 38% 0.84 2.65 2.82 9.2%
Jan-13 1:00 38% 1.05 1.78 2.36 6.3%
Feb-13 0:59 39% 0.77 3.0 3.02
1
2 3 3%
Work order completion time - Engineering (days) 1 Work order completion time - Clinical Engineering (days) Vacancy Rate - EVS
1
Clin Eng HR Comments
14
Infection Control (Section 2.07) # 7.01 7.02 7.03 7.04 7.05 Tasks/Initiatives Each Divisional Vice President (VP) will submit all department specific Infection Prevention (IP) related policies and procedures to IP. The IP department Director and Chief of Infection Prevention will review and make revisions of all departmental and house-wide IP policies, if applicable. All departmental IP policies are returned to the department for their review and acceptance Approve reviewed departmental and house-wide IP policies. Divisional VP and Department Directors to develop a communication roll out with IP Director on the revised IP policies and procedures. Each department assigns an IP delegate to be the contact and participant in the IP prevention education program. Provide a full-time Chief Infection Prevention Officer. Survey monthly all departments for IP compliance. Survey results are sent to Department IP representative, Department Director and Divisional VP for follow up and corrective action needed and expected completion date. Execute EOC surveillance program to ensure consistency with cleaning methods and standards to support IP principles. Accountability Kim McCloud Linda Licata Barbara Mims Janet Glowicz Janet Glowicz Janet Glowicz Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Jody Springer Janet Glowicz Janet Glowicz Work Stream 2.8 6.3 6.3 6.3 2.8 Target Date 4/20/2012 9/30/2012 6/8/2012 6/8/2012 6/8/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y
7.06 7.07 7.08 7.09
2.8 1.2 6.3 6.3
6/8/2012 6/8/2012 3/23/2012 3/23/2012
Y Y Y Y
# 1 2 3a 3b 3c 4 5 6 7 8 9
Audit/Measures Percentage of policies that have been drafted/revised (by department) Volume of non compliant hand hygiene observations - support staff Volume of non compliant hand hygiene observations - physicians Volume of non compliant hand hygiene observations - nursing 1 Compliance in hand hygiene
1 1 1 1 1
Accountability IP House-wide House-wide House-wide House-wide House-wide Surgery

1
Goal 100% 0 0 0 0 100% 100% 100% 0%
Sep-12 100% 243 61 67 115 98.6% 100% 100% 173 95% 0
Oct-12 100% 322 85 93 144 99.3% 100% 100% 377 92% 1
Nov-12 100% 284 56 119 109 99.3% 100% 100% 311 92% 0
Dec-12 100% 298 71 82 145 99.3% 100% 100% 382 91% 0
Jan-13 100% 315 71 128 116 99.7% 100% 100% 548 91% 0
Feb-13 100% 209 22 61 126 98.5% 100% 100% 328 88% 0
Volume of non-compliant observations for hand hygiene - Hospital Audit
Percentage of compliant observations with sterile technique in procedure areas 1 Percentage of Infection Prevention completed surveys by each department, monthly Volume of non-compliant observations by Infection Prevention Practice Team Compliance percentage of Infection Prevention Practice Team rounding Number of blood stream infections
1 1 1
IP House-wide House-wide House-wide
15
Infection Control (Section 2.07) Comments Audits # 7 and 8 - A new "secret shopper" process was implemented by Infection Prevention, resulting in a smaller volume of non-compliant observations Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
1. 2. 3. 4.
16
Medication Management (Section 2.08) # 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 8.18 8.19 8.20 8.21 8.22 Conduct a medication override audit. Enhance P&T agenda with cost studies, outcomes for alternative drug options, ADR, Overrides, dosing guidelines. P&T Committee to provide report summarizing and action plans on medication analysis, ADR summaries, Narcan utilization, off label med utilization, and medication reconciliation issues to QCC. Establish baseline and develop a tool to flag ADRs. Trending reports based on type of reaction, location, provider, etc. and report to P&T Committee and other appropriate medical staff committees. Actions should be taken and documented on trends by the P&T Committee and reported up through the QCC Committee and Governing Board. Potential trends should be monitored with corrective action taken, e.g., ADRs identified on the same drugs, same units, same diagnoses, same physicians, etc. Explore alternatives for clinical trial identifiers. Ensure all off label medication use is reviewed and approved by the P&T Committee. Establish a Medication Reconciliation task force to develop a consistently compliant process. Conduct chart audit of medication reconciliation compliance to establish current baseline. Evaluate appropriateness of providing pharmacy tech support for medication reconciliation. Develop and provide education for pilot study for the participating Pharmacy Techs and RNs. Conduct pilot study. Collect and present results. Develop future state work flow processes. Pilot the new work flow process. Implement new reconciliation process (in EPIC). Reassign the crash cart management under the Sterile Processing Department and/or Pharmacy. Assess the space requirements and human resources needed for case cart management within SPD. Revisit the cart management processes for supplies and pharmaceuticals. Ensure the supply and pharmaceutical lists match the components in the carts and validate the accuracy of lists and components with Pharmacy and Nursing Education. Implement an accountability process and sign off process to ensure accuracy and products are not expired. Conduct cart initial audit for validation after transferring case cart management to SPD. Tasks/Initiatives Accountability Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Judy Herrington Vicki Crane Judy Herrington Vicki Crane Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Work Stream 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 4.5 4.5 2.3 2.3 2.3 2.3 2.3 4.5 4.5 4.5 4.5 4.5 4.5 4.5 Target Date 6/8/2012 4/5/2012 6/8/2012 5/11/2012 6/8/2012 6/8/2012 4/27/2012 4/27/2012 5/11/2012 6/15/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 7/13/2012 9/14/2012 4/13/2012 7/16/2012 5/11/2012 3/22/2013 8/13/2012 10/1/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
17
Medication Management (Section 2.08) # 8.23 8.24 8.25 8.26 8.27 8.28 8.29 8.30 8.31 8.32 8.33 8.34 8.35 8.36 8.37 8.38 8.39 Tasks/Initiatives Present drug storage audit and data collection program. Pharmacy Resources and Nurse Liaisons (Charge Nurse) are assigned for each unit. Pharmacy & Unit-Based Nursing Resources conduct audits (Nursing - part of daily checklist for eight weeks); Pharmacy (monthly as a part of trending & monitoring) Nursing Liaison collects, collates and summarizes audit results and submits on the data tool to the Pharmacy Resource weekly. Pharmacy Resource analyzes data from Nurse Liaison reports and provides monthly summary interim reports to Nurse Liaison, Unit Manager and Department Director. Pharmacy Resource collects collates and summarizes audit results and submits monthly audit on the data tool. Establish a multi-disciplinary RCI Medication Safety Team. Investigate the root causes of the medication errors and categorize the errors and provide tactical plans towards resolution. Review the medication ordering, preparation and administration process through a work flow process. Revise medication administration process based on finding of work flow analysis. Provide the education plan base on the work flow model findings that address the gaps in the safe delivery of medications. Develop core competence education program for all the clinical staff in regards to the practices of safe medication delivery. This module should be included in the staffs annual competency evaluation. In conjunction with current internal hospital initiatives, define those care settings that moderate sedation is required versus pain management. Ensure all clinicians are qualified to administer medications that have the clinical effect of moderate sedation. Ensure compliance with new moderate sedation practice standards. Review the medications in Pyxis on the IP units that have access to moderate sedation categorized medications to determine how they should be flagged for monitoring. Conduct an audit on the daily Pyxis report (Epic Clarity Report) on Narcan use in patients undergoing pain management and moderate sedation in non-procedure based units. Audit/Measures MD Max Overrides reviewed by RPH 1 Compliance in medication reconciliation at admission (inpatient only) 1 Compliance in medication reconciliation at discharge (inpatient only) 1 Compliance in medication reconciliation - COPCs Percentage of locations with unsecured medications 1 Percentage of compliant crash carts
1
Accountability Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Vivian Johnson
Work Stream 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 4.5 4.5 4.5 4.5 2.3
Target Date 6/8/2012 6/8/2012 6/8/2012 6/8/2012 6/8/2012 6/8/2012 4/13/2012 6/8/2012 6/8/2012 6/8/2012 9/14/2012 9/14/2012 8/13/2012 8/13/2012 8/13/2012 8/13/2012 3/22/2013
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
# 1 2 3 4 5 6 7 8
Accountability Pharmacy Physicians Physicians Physicians Pharmacy SPD House-Wide Pharmacy
Baseline 53% 83%
Goal 100%
Sep-12 100% 90.3% 83.7%
Oct-12 100% 92.0% 83.5% 0.0% 92.9% 1 73
Nov-12 100% 95.1% 83.5% 83.6% 0.0% 90.0% 2 60
Dec-12 100% 92.1% 88.4% 86.0% 0.0% N/A 1 66
Jan-13 100% 94.5% 96.2% 94.0% 0.0% 93.0% 1 54
Feb-13 100% 95.4% 95.9% 98.0% 0.0% 100.0% 0 55
0% 0
0.0% 100.0% 0 59
Volume of adverse events related to moderate sedation 1 Number of improper or lack of medication labeling
2
18
Medication Management (Section 2.08) # 9 10 11 12 13 14 15 16 Number of adverse drug reactions 1 Number of preventable adverse drug reactions 1 Missed medications 1 Percentage of medications administered within 60 minutes of order 1 Percentage of medications administered within 30 minutes of order 1 Number of opioid induced respiratory depressions naloxone administration 1 Number of preventable opiod induced respiratory depressions naloxone administration 1 Metric Number of off-label medications in use, not reviewed by P&T 1 Accountability Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started 1. 2. 3. 4. Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group Reported through Alvarez and Marsal's Daily Audits 0 0 97% 88% 0 0 7.4% 96% 87% 2 1 19 Baseline Goal 0 31 Sep-12 0 108 Oct-12 0 94 Nov-12 1 157 1 7.3% 96% 87% 6 1 Dec-12 0 125 12 7.8% 97% 88% 2 2 Jan-13 0 153 29 7.6% 96% 87% 4 0 Feb-13 0 165 23 7.7% 96% 87% 1 0
19
Patient Safety/Rights (Section 2.09) # 9.01 9.02 9.03 Tasks/Initiatives Create job description for new Chief Patient Rights and Safety Officer (CPRSO). Name Interim Chief Patient Rights and Safety Officer (CPRSO) National search to recruit new Chief Patient Rights Quality and Safety Officer (CPRSO) (CQSO) The following quality and safety functions at Parkland would be reorganized to report directly to the CPRSO CQSO in recognition of recent changes in the Quality, Safety and Performance Improvement Department: - Patient Safety - Patient Safety Investigations - Root Cause Analysis (RCA) - Patient Safety Incident Reporting - PSN Database Maintenance and Reporting State, Federal and Joint Commission Reporting - Continual Readiness/CMS, State and Joint Commission Survey Preparation Daily Rounding Function - Infection Prevention and Control - Patient Relations (Patient complaints and grievances, which currently reports to Nursing) New job descriptions for all employees and managers, supervisors and department heads in units and divisions now reporting to the CPRSO CQSO. Review and redesign of all patient rights and safety related policies and procedures. Develop education plan for all employees regarding patient safety and rights policy/procedure changes. Reorganize and redesign its Quality Department and its centralized Quality Assessment/Performance Improvement (QAPI) functions to include: Clinical Data Management Performance Improvement Rapid Cycle Improvement Create new Human Resources policy on violations of Patient Rights/Patient Safety obligations. Create a Patient Rights/Patient Safety Awareness Campaign. Create a Safe Patient Hand offs/Continuity of Patient Care Awareness Campaign New education and training for current and new employees and physicians on safe patient handoffs and continuity of patient care. Parkland should conduct a study to look at best practices of other large hospital police departments to compare the level of specialized training provided to Parkland Police Department against other hospital police departments. Best practice for reporting structure should also be investigated. Patient Rights and Safety Department Study and Task Force (to include Nursing, Police, Patient Safety, and Patient Relations representatives) on Elopements and Patients leaving. Work with Parkland Police Department and Nursing the Patient Rights and Safety Department should conduct a study of all documented elopements in 2011 and determine reasons for elopement (e.g., breeches in security, caregiver training, etc.) and provide action plan and recommendations for reducing elopements. Patient Rights and Safety Department should then begin to conduct chart reviews for all patients who elope or leave AMA. The review should separately categorize all departments, including a separate review for elopements and patients leaving AMA in the Emergency Department. The chart review should then develop a list of reasons as to why patients leave elope or leave AMA, and subsequent reports should trend in these categories. Accountability Jody Springer Chris Madden Work Stream 1.2 1.2 Target Date 3/30/2012 10/1/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y
9.04
Chris Madden
1.2
5/11/2012
9.05 9.06 9.07
Chris Madden Lisa Betterson Lisa Betterson
1.2 6.2 6.2
5/11/2012 6/8/2012 8/15/2012 Y Y
9.08
Jackie Sullivan
6.1
6/8/2012
9.09 9.10 9.11 9.12 9.13 9.14
Jim Johnson Lisa Betterson Lisa Betterson Lisa Betterson Jody Springer Lisa Betterson
1.5 6.2 6.2 6.2 1.2 6.2
6/8/2012 4/27/2012 5/11/2012 9/30/2012 4/13/2012 6/1/2012
Y Y Y Y Y Y
9.15
Lisa Betterson
6.2
3/30/2012
9.16
Lisa Betterson
6.2
3/22/2013
20
Patient Safety/Rights (Section 2.09) # 9.17 9.18 Tasks/Initiatives Complete current RCI initiative regarding 1:1 observation procedure and competencies required for staff. Evaluate additional CM staff to ED. Establish a documentation committee, led by HIM, that includes Clinical support from Chief Nursing Officer and Chief Medical Officer, Support Services, ADT, Legal, Patient Safety, Performance Improvement and HIM representation to address the inconsistencies of properly executed documents, lack of complete and accurate documentation, and lack of compliance. Develop and implement an action plan that addresses non-compliance and the steps to the solution. Review all policies and procedures related to the areas of non-compliance to determine and ensure policies are updated to current regulations or standards of practice. Determine where and if the resources are available or needed to meet the documentation requirements. HIM shall conduct routine chart audits to document that all patients have been provided with: 1) required information on their rights under Medicare, federal law and state law; 2) required information on advance directives. Chart audits shall also assess whether all Medicare patients are receiving the notice entitled: Important Message from Medicare. Review Hospital policy for Patient Grievance procedure and compare to best practice, including those noted above. Develop monitoring system to ensure timelines required by Hospital policy are met. Patient Relations Department should create a new monthly reporting system for all patient grievances and complaints. The reporting system should show, at a minimum: number of complaints/grievances received; actionable categories for all complaints/grievances (some complaints/grievances may fall in several categories); person making complaint (patient, family member, staff, physician, etc.); time between receipt of complaint and response to patients; documentation that patient agreed/disagreed that compliant/grievance was resolved; inventory of complaint/grievance by department/unit/floor and confidentiality by employee and physician; trending of grievances/complaints over months/years in all above categories. Develop and implement a Privacy task force to identify areas of non-compliance (including HIPAA), indicators to measure, and to develop an awareness campaign. Conduct Patient Privacy Awareness Campaign to reacquaint staff on HIPAA and other privacy obligations. Privacy Awareness campaign should include examples of recent privacy breaches. Review current privacy training materials. Require annual competency on HIPAA and other patient rights but revise competency annually to refresh materials and learning behaviors for better retention of information. Utilize tool developed by Executive VP of Operations or another developed tool to conduct weekly customer relations tours. Develop a dashboard and track and trend the indicators for Patient Rights and the progress to the target thresholds. Accountability Lisa Betterson Robin Stults w/ Clinical Intelligence Lisa Betterson Work Stream 6.2 3.4 Target Date 6/1/2012 7/31/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y
9.19
6.2
9/14/2012
9.20 9.21 9.22 9.23
Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson
6.2 6.2 6.2 6.2
9/14/2012 10/31/2012 9/14/2012 9/14/2012
Y Y Y
9.24 9.25
Lisa Betterson Lisa Betterson
6.2 6.2
5/25/2012 6/8/2012
Y Y
9.26
Lisa Betterson
6.2
9/14/2012
9.27 9.28 9.29 9.30 9.31
Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson
6.2 6.2 6.2 6.2 6.2
6/8/2012 9/14/2012 9/14/2012 7/1/2012 9/14/2012
Y Y Y Y Y
21
Patient Safety/Rights (Section 2.09) # 1 2 3 4 5 6 7 8 9 10 Audit/Measures Percentage of policies and procedures reviewed and/or revised
1
Accountability Pat Safety Police Pat Safety Perf Imp Perf Imp Pat Griev
1
Baseline
Goal 100% 100% 10
Sep-12 100% 100.0% 33 88.9% 100.0% N/A N/A 98.0%
Oct-12 100% 100.0% 45 92.9% 100.0% N/A N/A 98.0% 79.5% 91.8%
Nov-12 100% 100.0% 31 92.9% 100.0% N/A N/A 98.5% 82.8% 95.5%
Dec-12 100% 100.0% 31 100.0% 100.0% N/A N/A 98.0% 92.0% 96.0%
Jan-13 100% 100.0% 41 93.3% 100.0% N/A N/A 98.0% 94.3% 98.3%
Feb-13 100% 100.0% 41 100.0% 100.0% N/A N/A 98.0% 96.8% 98.8%
Attendance for state mandated training courses for members of Police Department 1 Average time from event to closure of patient safety investigation (days) 1 Percentage of regulatory reports submitted within 5 business days 1 Percentage of state-mandated regulatory reports submitted within 2 business days 1 Number of patient complaints and grievances
1
74%
100% 100%
Average time from event to resolution of patient complaint or grievance (days)
Pat Griev PFS CM PFS 98% 98%
Percentage of inpatients receiving advance directive notice 1 Percentage of patients who received appropriate notifications (under applicable Medicare, state and other laws, "Important 1 Message from Medicare", others), as audited by HIM - Care Management Percentage of patients who received appropriate notifications (under applicable Medicare, state and other laws, "Important 1 Message from Medicare", others), as audited by HIM - PFS Metric Number of Patient Safety Investigations 1 Percentage of Root Cause Analyses (RCA) completed within 45 days Volume of privacy and security breaches
1 1
76.7% 91.7%
# 11 12 13 14
Accountability Pat Safety Pat Safety House-Wide Pat Safety Comments
Baseline 80% 59
Goal 100%
Sep-12 47 36 53
Oct-12 58 75% 53 62
Nov-12 35 57% 42 54
Dec-12 42 83% 32 70
Jan-13 30 67% 17 55
Feb-13 27 80% 22 67
Number of elopements, AWOLS, AMA (excluding ED)
9.03 - 9.05 - Still interviewing for Chief Quality and Safety Officer (CQSO)
9.23 - Compliance has not reached 98% but is steadily increasing Audits # 6 and 7 - Results are "N/A" as Patient Relations leadership is vetting the accuracy of metrics
1. 2. 3. 4.
22
Medical Staff (Section 2.10) # 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 Tasks/Initiatives Develop an OPPE/FPPE review template for each medical department and/or service. Develop a written procedure explaining the OPPE process, criteria and physician referral process for FPPE. Define required physician profile elements for all physicians. Provide all department chairs the required template, guidance, and a timeline for completion of departmental criteria, indicators, and thresholds of performance. Review and sign off of CMO and QAPI of the departmental OPPE plans Professional Staff Quality Management Plan for relevance and compliance. Review and obtain approval of OPPE/FPPE process and criteria by MEC, and then the Governing Board. Each department should develop a standard set of metrics for use on cases sent for peer review. Medical Staff Office Quality Department to establish a methodology to track and trend all cases brought to peer review Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review. Determine necessity to expand Medical Staff resources. Charter a joint Hospital/GME Faculty Task Force. Create a venue for collaboration and discussion of issues between Hospital and Faculty to inform and appraise between residency update periods. Members to include Hospital VPs and Faculty Medical Staff. Develop an audit and reporting method for compliance with the ACGME 2012 Common Program Requirements that will require each departmental residency program to specify the types of patient events that will require a Resident to call the teaching physician. Use the audit to develop an operational report to concurrently manage the Residents during the academic year. Develop a training module enabling faculty to instruct residents when to escalate issues to their Attending Physicians. Standardize use of Innovations (resident management software) across the system to create a web-enabled database of individual resident certification profile; (presently nurse can access the department grid, see what a PGY-2 is qualified to do, and then look up the name of a particular PGY2 and determine whether he/she is certified to it. Brad Marple, MD Brad Marple, MD Brad Marple, MD Brad Marple, MD 5.3 5.3 5.3 5.3 7/30/2012 7/30/2012 7/30/2012 5/11/2012 Y Y Y Y Accountability Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Patricia Bergen, MD Brad Marple, MD Work Stream 5.10 5.10 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.3 Target Date 4/20/2012 4/20/2012 4/20/2012 1/31/2013 7/30/2012 7/13/2012 1/31/2013 1/31/2013 8/31/2012 7/13/2012 4/27/2012 Y Y Y Y Y Y Y Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y
10.12
Brad Marple, MD
5.3
7/30/2012
10.13
Brad Marple, MD
5.3
8/31/2012
10.14
10.14a Interim option for access to resident qualifications 10.15 10.16 10.17 Modify Grid to highlight those events or add link to the list of and procedures that require concurrent notification of the attending physician that is available to all departments. Review Grid or list to ensure that it includes the list of all events that require escalation notification to an Attending (i.e., lower the reporting threshold). Create policy contingencies for alternate modes of supervision or escalation, i.e., what to do when the expected senior resident or Teaching Physician is not accessible in the expected time period.
23
Medical Staff (Section 2.10) # 10.18 Tasks/Initiatives Evaluate Parklands Epic functionality, to determine improvement to be made in documentation or note entry to provide consistent and reliable documentation of Attending Physician oversight, approval and concurrence with Resident orders. Evaluate Parklands call system ability to properly attribute the Resident and Attending Physician to each patient. Create an audit tool for weekly confirmation that call system is accurately and timely attributing Residents and Attending Physicians to each patient. Upgrade Epic with user capability to concurrently update treatment teams through use of the physician order entry function. Standardize call schedule procedure for consulting services. Ensure the accuracy Amcom scheduling system (source of truth maintained by Parkland) Create contingencies for alternate modes of supervision or escalation. Parklands GME Director should review the current training and education materials for Residents on documentation, particularly documentation of H&Ps. Refresher education and training should be conducted for all Residents. Perform audit of Residents' History and Physicals (H&P) documentation for completion and adherence to Parkland policy and procedures. Audit/Measures Number of referrals to peer review 1 Utilization of Notewriter System for Procedures Performed by Residents Percentage of compliance in completion of H&P's
1 1 1
Accountability Brad Marple, MD
Work Stream 5.3
Target Date 7/30/2012
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Completion Y
10.19 10.20 10.21 10.22 10.23 10.24 10.25 10.26
Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD
5.4 5.4 5.4 5.4
8/31/2012 8/31/2012 8/31/2012 8/31/2012
Y Y Y Y
Brad Marple, MD Brad Marple, MD Brad Marple, MD
5.3 5.3 5.3
5/11/2012 8/31/2012 3/22/2013
Y Y Y
# 1 2 3 4
Accountability Med Staff Med Staff Med Staff Nursing Comments
Goal 15 100% 100% 100%
Sep-12 192 N/A
Oct-12 120 90%
Nov-12 114 94% 52%
Dec-12 127 79% 88% 71%
Jan-13 151 87% 81% 86%
Feb-13 145 87% 81% 85%
Nursing Knowledge for Finding Resident Qualifications
10.04 - Results on OPPE for pilot clinics to be presented to the MEC in April
1. 2. 3. 4.
24
Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Work Stream 3.2 Target Date 4/27/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y
Conduct a quantitative demand and process analyses of the ESD in order to properly balance work Clifann McCarley 11.01 flow, capacitate the various components of the split flow system, and accurately determine any changes in bed capacity, service hours or staffing. Throughput and productivity assessment of the current state in the form of a process work flow Clifann McCarley 11.02 diagram including the following elements: inputs, activity steps, decision points, enablers, functions and outputs Identify rate limiting factors such as lack of equipment/technology, availability and/or staffing Clifann McCarley 11.03 within budget guidelines, and hours of operations. 11.04 Server cycle times need to be measured and applied to the design of care teams in the Triage and the Intake areas. Clifann McCarley
3.2 3.2 3.2
4/27/2012 4/27/2012 4/27/2012
Y Y Y Y
Conduct a benchmarking study of its Emergency Department labor productivity to industry 11.05 standards in order to determine if there are opportunities to improve productivity and thereby increase capacity for each service area. Redesign of the future process flow to eliminate waste, such as: removing or combining steps, 11.06 automating any manual activity steps, if possible, transferring elements to other departments, changing the location where the steps are done, and finally altering/modify the activity step 11.07 Work flow models should be piloted with Rapid Cycle Testing and refined as necessary and then training provided
Clifann McCarley
3.2
7/13/2012
Clifann McCarley
3.2
6/8/2012
Clifann McCarley Clifann McCarley Clifann McCarley Patricia Bergen, MD Deb Perrault Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen Emilie Allen Clifann McCarley
3.2 3.2 3.2 5.1 2.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 4.4 4.4 3.2
1/13/2013 3/14/2013 6/8/2012 6/8/2012 5/11/2012 5/11/2012 5/11/2012 5/25/2012 6/8/2012 7/13/2012 6/8/2012 7/13/2012 3/22/2013 5/20/2013 6/8/2012 5/12/2013
Y Y Y Y Y Y Y Y Y Y Y Y Y Y
11.08 Periodic reviews of process work flow using Plan-Do-Check-Adjust (PDCA) Lean techniques. 11.09 Change functionality in Epic to reflect changes in work flow processes and new treatment areas. 11.10 Recruitment, credentialing and on-boarding of qualified physicians. 11.11 Pathology to scope operations, licensing, certification requirements for Point of Care labs. Develop signage text consistent with the educational level and primary languages of the 11.12 population served that is consistent across the institution. 11.13 List all sites and specific rooms requiring posting of signage 11.14 Obtain approval of final language for signage 11.15 Physical Plant and Facilities to arrange for printing and posting final approved signs. 11.16 Post new signage 11.17 Review and revise all EMTALA related Policy and Procedures. 11.18 Create/Revise training materials for new EMTALA Policy and Procedures 11.19 Re-educate on new EMTALA Policy and Procedures. 11.20 Annual review ESD Nurses, Physicians and other Caregivers and Staff. 11.21 Re-educate staff on new patient registration policies on Emergency Registration Process 11.22 Develop and finalize a survey technique.
25
Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Work Stream 3.2 4.2 4.2 4.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 4.4 3.2 3.2 3.2 4.4 4.4 4.4 4.4 4.4 4.3 4.3 4.3 4.3 4.3 Target Date 9/14/2012 5/25/2012 7/13/2012 9/30/2012 6/8/2012 6/8/2012 7/13/2012 9/14/2012 9/14/2012 4/13/2012 4/27/2012 5/18/2012 5/12/2013 4/13/2012 4/27/2012 5/18/2012 5/12/2013 9/9/2012 9/21/2012 9/21/2012 5/18/2013 10/5/2012 3/22/2013 3/22/2013 3/22/2013 6/28/2013 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion
Develop a patient flow process to eliminate disparate treatment in evaluation and delay in the care Clifann McCarley 11.23 of a person presenting to the ESD seeking Psychiatric emergency care. Barbara Mims 11.24 Review and revise all Hand-Off related Policy and Procedures. Valerie Harvey Barbara Mims 11.25 Create/Revise training materials for new Hand-Off Policy and Procedures. Valerie Harvey Barbara Mims 11.26 Re-educate on new Hand-Off Policy and Procedures. Valerie Harvey 11.27 Work with IT/Epic to develop access to information required by law. 11.28 Develop reporting function with Epic for output of Central Log Reports. Create training materials for accessing information required by law and reporting functions 11.29 through Epic. 11.30 Re-educate staff on accessing information required by law and reporting functions through Epic. 11.31 Monitor and audit compliance to determine if management can generate a central patient log. 11.32 Review and revise policy and procedures on receiving hospital transfer requirements. 11.33 Create/Revise training materials for new policy and procedures. 11.34 Re-educate on new policy and procedures. 11.35 Annual review ESD Nurses, Physicians and other Caregivers and Staff. 11.36 Review and revise policy and procedures on Memorandum of Transfer requirements. 11.37 Create/Revise training materials for new policy and procedures. 11.38 Re-educate on new policy and procedures. 11.39 Annual review ESD Nurses, Physicians and other Caregivers and Staff. 11.40 Review and revise policy and procedures on nursing assessment and plan of care requirements. 11.41 Create/Revise training materials for new policy and procedures. 11.42 Re-educate on new policy and procedures. 11.43 Annual review ESD Nurses, Physicians and other Caregivers and Staff. 11.44 The Emergency Services Director of Nursing should determine approach for developing an acuity assessment methodology, e.g., internal historical record review, an automated tool, etc. Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen Emilie Allen Emilie Allen Emilie Allen Emilie Allen Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish
11.45 Once selected, roll out acuity tool. 11.46 Develop flexible staffing strategies, PRN pools, per diem staff, etc.
11.47 Monitor core patient care ratios for trends. 11.48 Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs.
26
Emergency Services (Section 2.11) # Main ED 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Treated visits 1 Total number of hours of ED boarding
1
Audit/Measures
Accountability ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD
Baseline
Goal
Sep-12 9734
Oct-12 9859 3536 48.2 10.2 15.5 396 389 114 238 70 8.3% 1.9% 27.5% 63.3% 342 89% 4225 274 194 183 11.4% 0.8% 0.0% 93.5% 253 92%
Nov-12 9539 2231 39.7 10.3 16.0 415 324 76 22 43 4.3% 1.8% 26.8% 63.6% 286 95% 4270 243 171 143 8.6% 0.8% 0.0% 92.8% 222 95%
Dec-12 9845 2879 41.3 11.3 17.3 449 350 87 40 57 5.2% 1.6% 26.8% 63.4% 306 90% 4206 235 162 135 7.8% 1.1% 0.1% 91.5% 211 92%
Jan-13 11105 4102 48.2 9.6 16.8 454 358 93 225 61 5.5% 1.7% 25.4% 64.4% 320 89% 5019 230 167 140 7.5% 0.3% 0.0% 92.7% 209 96%
Feb-13 9652 2665 51.5 10.8 17.1 411 324 72 6 44 3.1% 1.7% 26.6% 62.1% 284 90% 4209 221 141 113 6.9% 0.4% 0.0% 92.3% 198 96%
2671 40.0 17.3 415.5 379 92 93
2654 47.2 10.9 13.8 412 408 125 394 65 9.2% 2.3% 26.9% 64.3%
Average number of patients in ED that are boarding per day 1 Average number of dialysis patients in Main ED at 6AM 1 Average "Compassionate" dialysis patients transferred from ED/day 1 Average dwell time for dialysis patients in Main ED Turnaround time to discharge patients to home (door to home, in minutes) 1 Door to seen by 1st Provider (minutes) 1 Hours on resource alert 1 Door to Room Time (minutes) 1 Left without being seen 1 Left without being treated 1 Percentage of patients admitted 1 Percentage of patients discharged 1 Average ED throughput time - time from patient arrival to patient disposition 1 Compliance to environment of care 1 Urgent Care Clinic (UCC) Treated visits 1 Turnaround time to discharge patients to home (door to home, in minutes) 1 Door to seen by 1st Provider (minutes) 1 Door to Room Time (minutes) 1 Left without being seen 1 Left without being treated 1 Percentage of patients admitted 1 Percentage of patients discharged 1 Average ED throughput time - time from patient arrival to patient disposition 1 Compliance to environment of care 1
326 100%
354 91% 4161
194 126 107
253 187 173 10.1% 1.1% 0.1% 92.8%
164 100%
231 92%
27
Emergency Services (Section 2.11) # 27 28 29 30 31 32 33 34 35 36 37 38 39 # 40 41 42 Treated visits 1 Total number of hours of ED boarding 1 Average number of patients in ED that are boarding per day 1 Turnaround time to discharge patients to home (door to home, in minutes) 1 Door to seen by 1st Provider (minutes) 1 Hours on resource alert 1 Door to Room Time (minutes) 1 Left without being seen 1 Left without being treated 1 Percentage of patients admitted 1 Percentage of patients discharged 1 Average ED throughput time - time from patient arrival to patient disposition 1 Compliance to environment of care
1
Audit/Measures OB Gyn Intermediate Care Center (ICC)
Accountability WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH Accountability ESD ESD ESD
Baseline
Goal
Sep-12 1934
Oct-12 1927 166 2.3 494 56 0 268 1.8% 14.8% 8.1% 68.1% 426 91% Oct-12
Nov-12 1815 117 2.3 458 52 6 256 1.8% 14.2% 8.3% 68.5% 400 95% Nov-12
Dec-12 1743 125 2.2 416 40 0 207 1.1% 10.9% 8.2% 72.5% 364 92% Dec-12
Jan-13 1992 142 2.4 473 56 0 261 2.6% 14.2% 8.0% 69.0% 416 95% Jan-13
Feb-13 1744 119 2.7 451 43 32 226 1.9% 12.4% 8.7% 70.9% 392 91% Feb-13
127 2.3 456 105 264
108 2.0 465 59 0 260 1.9% 11.8% 9.4% 70.4%
400 Baseline Goal
406 92% Sep-12
Metric Labor Productivity (staffing to include acuity) Total ED throughput time - time from patient arrival in ANY ED to discharge home from ANY ED (hours:minutes) 1 Percentage of travelers - ED
1
6:43 24.0%
6:42 19.3%
5:55 10.4%
6:13 11.9%
6:28 17.5%
6:03 17.8%
Comments 11.23 - Initiative missed deadline due to lack of physician coverage in Team C 11.45 - Acuity solution has been implemented, pending interrater reliability of information in staffing reports Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
1. 2. 3. 4.
28
Psychiatry Services (Section 2.12) # Tasks/Initiatives Accountability Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Emilie Allen Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Sharon Phillips Sharon Phillips Jody Springer Emilie Allen Emilie Allen Sharon Phillips Patricia Bergen, MD Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Work Stream 2.1 2.1 2.1 2.1 2.1 4.4 4.3 4.3 4.3 2.1 2.1 1.2 4.4 4.4 2.1 5.1 2.1 2.1 2.1 2.1 2.1 3.5 3.5 3.5 2.1 2.1 2.1 2.1 2.1 Target Date 4/27/2012 4/27/2012 6/8/2012 5/14/2012 6/22/2012 5/25/2012 7/31/2012 7/31/2012 7/31/2012 4/13/2012 9/14/2012 6/8/2012 6/8/2012 6/1/2012 6/8/2012 6/8/2012 5/1/2012 9/28/2012 6/8/2012 6/29/2012 7/13/2012 9/24/2012 9/24/2012 9/24/2012 6/8/2012 6/8/2012 6/8/2012 6/8/2012 4/20/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
12.01 Develop clear vision of a psychiatric services (with particularly focus on PED) care delivery model. 12.02 Hire interim management for Psychiatric Director and psychiatric experienced/trained Nursing Manager for PED. 12.03 Commence national search for permanent Director of Psychiatric Services. Develop a detailed implementation plan (based on this corrective action plan) led by the psychiatric management team. 12.04 Define a management scorecard that can be utilized. 12.05 Create by discipline specific roles and responsibilities in alignment with new care delivery model. 12.06 Create new competencies and education models. 12.07 Create permanent staffing grids for PED and 8 North based upon census and acuity. 12.08 Further develop the charge nurse role in the PED and on 8 North. 12.09 Develop, test, and validate acuity methodologies for PED and 8 North. 12.10 12.11 12.12 12.13 12.14 12.15 Validate Social Workers coverage and effectiveness. Implement short term strategy for consistent physician coverage. Continue recruitment efforts aggressively to fill permanent positions. Identify staff knowledge gaps. Utilize psychiatrictrained resources for competency development and training. Develop comprehensive PED education plan.
12.16 Incorporate required physician competencies into OPPE/FPPE. 12.17 12.18 12.19 12.20 Implement a discharge huddle with the MD, nursing staff, social worker, and a designated facilitator. Develop interdisciplinary communication and planning for the plan of care. Develop suicide risk and behavioral quadrant assessment tools. Conduct a pilot on the suicide risk and behavioral quadrant assessment tools.
12.21 Educate team members on the purpose and the usability of the tool and how its integrated into the plan of care. 12.22 Develop cross-functional Parkland behavioral health team. 12.23 Analyze the patient population served by all of Parkland behavioral health disciplines. 12.24 Work with DBHLT on reducing or eliminating identified gaps in care across the continuum of care in Dallas County. 12.25 12.26 12.27 12.28 12.29 Continue redesign planning of day room and back entrance for better space utilization. Initiate multi-disciplinary team to consider PED space redesign. Develop alternative workflows for continued PED patient care during physical space construction/redesign. Develop budget for recommended physical changes. Develop alternative safety alerts for day room restroom.
29
Psychiatry Services (Section 2.12) # 3 4 5 6 7 8 9 10 11 12 # 13 14 15 16 17 18 19 20 21 Hours on resource alert

1 1
Audit/Measures Percentage of patients seen by social workers (PED)

1
Accountability Psych PED Psych Psych Psych Psych
Baseline
Goal
Sep-12 97.7% 0 100.0% 1.6% 73.3% 23.1%
Oct-12 97.6% 0 100.0% 3.1% 74.0% 20.7% 573 363 47 94.7% Oct-12 26 7 0.0% 463 872 3.0% 13.6%
Nov-12 98.7% 0 100.0% 3.0% 72.8% 21.8% 532 341 47 99.1% Nov-12 15 4 0.0% 464 844 3.2% 13.9%
Dec-12 94.8% 0 100.0% 3.1% 66.1% 28.2% 652 N/A N/A 99.6% Dec-12 10 3 0.0% N/A N/A 3.8% 17.5%
Jan-13 98.6% 0 100.0% 2.0% 66.6% 29.6% 724 132 N/A 98.6% Jan-13 17 8 0.0% N/A N/A 2.0% 20.0%
Feb-13 97.3% 0 100.0% 3.0% 68.1% 26.9% 623 N/A N/A 98.7% Feb-13 11 2 0.0% N/A N/A 2.0% 20.0%
Percentage of patients with a documented discharge huddle Percentage of patients admitted 1 Percentage of patients discharged to home
1
Percentage of patients transferred to acute care facility 1 Turnaround time to discharge patients to home (door to home) Door to seen by 1st Psych Provider (minutes in any ED)
1 1 1
PED PED PED Psych
649 166 60 100.0% Baseline Goal
588 402 61 99.1% Sep-12 15 3 8.3%
Door to Room Time (PED pt arrived in any ED and placed in any ED room) Compliance to environment of care
1
Metric Labor productivity (staffing to include acuity) Volume of restraint cases - personal hold Volume of restrain cases - seclusion Percentage of travelers - Psych
1 1 1 1
Accountability PED Psych Psych Psych Psych PED

1
Number of patients with scheduled appointments at discharge
Total PED throughput time - time from patient arrival to patient disposition (arrival in PED to discharge in PED) 1 Total PED throughput time - time from patient arrival to patient disposition (arrival in any ED to discharge in PED) 24-hour bounce back rate 1 Proportion of total Psychiatric Services patients discharged from Main ED by Team C
1
537
481 971 2.4% 14.0%
PED PED Psych Comments
Audit/Metric results with "N/A" for February are due to the revising of reporting and data accuracy for the Psych ED. Metrics will be reported in March.
1. 2. 3. 4.
30
Women and Infant's Specialty Health (WISH) (Section 2.13) # Tasks/Initiatives Accountability Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Paula Turicchi Work Stream 4.2 4.2 4.3 4.3 4.3 2.4 Target Date 3/22/2013 9/30/2012 6/8/2012 4/13/2012 5/11/2012 7/15/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y
13.01 Ensure plan of care practices are standardized and followed regularly. 13.02 Standardize hand off procedures. Educate staff. 13.03 Begin recruitment of key leadership positions Nursing Director (L&D) and Nursing Manager (L&D). Evaluate job description and determine best solution to work load balance for Nurse 13.04 Manager (Postpartum).
13.05 Begin recruitment of additional Nurse Manager candidates (Postpartum). 13.06 Evaluate job descriptions of Nurse Managers to determine if additional administrative support is required.
13.07 Begin recruitment for administrative support roles (if appropriate). 13.08 Recruit, hire and train additional staff to fill vacancies. 13.09 Evaluate nurse staffing needs based upon any plans for increase in capacity. 13.10 Recruit, hire and train additional staff as required. 13.11 Re-design staffing model to include adjustment for acuity. Evaluate job descriptions for inclusion of appropriate competencies and to ensure duties assigned are within scope of practice. WISH Nursing Director and Chief Nursing Officer (CNO) must ensure all nursing 13.13 personnel working within scope of practice. Nursing Directors of each area should review competencies required for the care of 13.14 their patient population in accordance with nursing practice standards. 13.12 Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Paula Turicchi Jackie Brock John Raish Emilie Allen 4.3 4.3 4.3 4.3 2.4 4.3 4.4 6/8/2012 4/27/2012 6/8/2012 6/8/2012 6/1/2012 4/13/2012 6/1/2012 Y Y Y Y Y Y Y
31
Women and Infant's Specialty Health (WISH) (Section 2.13) # 13.15 Tasks/Initiatives Accountability Emilie Allen Emilie Allen Emilie Allen Emilie Allen Paula Turicchi Work Stream 4.4 4.4 4.4 4.4 2.4 Target Date 7/13/2012 7/13/2012 7/13/2012 7/13/2012 5/31/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y
A full assessment of current staff should be conducted to establish a current baseline of competencies. 13.16 Review all personnel files for completed competencies. 13.17 Gaps identified in competencies should be addressed with education and audit. 13.18 Conduct newborn resuscitation competency education and audit. Evaluate the need for an additional FTEs to assist in the responsibility of supply 13.19 stocking, storage, and environmental rounds on all WISH units. Establish recommended AORN practices of setting up the sterile back table for delivery table set-up. 13.20 Determine if additional staffing is required for L&D OR and LDR for sterile supply set up. Hire additional staff, if needed. 13.21 Ensure plan of care practices are standardized and followed regularly. 13.22 Standardize hand off procedures. Educate staff. 13.23 Women Infant and Specialty Health (WISH) operations and nursing leadership with Chief Nursing Officer (CNO) to develop plan and budget for required changes.
Suzanne Sims
2.5
4/13/2012
Paula Turicchi Paula Turicchi Jackie Brock John Raish Paula Turicchi Paula Turicchi Emilie Allen Paula Turicchi
2.4 2.4 4.3 2.4 2.4 4.4 2.4
6/8/2012 5/25/2012 6/30/2012 5/11/2012 4/6/2012 5/11/2012 7/31/2012
Y Y Y Y Y Y Y
13.24 Present plan to senior leadership. 13.25 Design care model that provides for rooming-in options for infants. 13.26 Establish a census tracking tool for newborns. 13.27 Review and revise infant security and abduction plan. 13.28 Conduct at least one Code Pink drills per year. Identify space that can be made available for emergency equipment within the post 13.29 partum unit (department reports plan underway to convert treatment rooms for this purpose).
32
Women and Infant's Specialty Health (WISH) (Section 2.13) # 13.30 Tasks/Initiatives Establish monthly mock equipment drills and verify emergency equipment is immediately available where newborns are housed. Accountability Paula Turicchi Paula Turicchi Work Stream 2.4 2.4 Target Date 7/31/2012 4/6/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y
13.31 Discard all six pack transport carts. Conduct a multidisciplinary assessment of conditions of WISH units related to 13.32 supplies/medications including refrigeration, cleanliness, appropriate storage of supplies, and other conditions related to infection prevention. Evaluate the need for an additional FTEs to assist in the responsibility of supply 13.33 stocking, storage, and environmental rounds on all WISH units. 13.34 Establish an alternative protocol for delivery table set-up to ensure sterile field. 13.35 Educate staff on storage requirements for specimens. 13.36 Revise dirty utility room flow and practice. 13.37 Department reports a plan is in progress for construction to ensure proper dirty utility room flow. (No start date supplied) Review Parkland policy on securing medications PHR-D-067 Inventory Management 13.38 Procurement, Storage
Paula Turicchi
2.4
4/15/2012
Suzanne Sims Emilie Allen Paula Turicchi Josh Floren Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Emilie Allen Emilie Allen Responsibility WISH WISH
2.5 4.4 2.4 1.7 4.5 4.5 4.5 4.4 4.4
4/6/2012 4/27/2012 7/15/2012 7/12/2012 5/18/2012 4/13/2012 4/13/2012 3/31/2012 3/30/2012 Goal 100.0% 100.0% Sep-12 96.0% 96.0% Oct-12 72.7% 96.0% Nov-12 68.8% 97.4% Dec-12 96.5% 97.3% Jan-13 82.5% 97.1% Feb-13 82.5% 97.2%
Y Y Y Y Y Y Y Y Y
13.39 Anesthesia medication trays should be stored in a locked, secure area. 13.40 Store floor stock in Pyxis. Educate staff on the importance of two patient identifiers and include in initial and annual competencies. 13.42 Educate staff of National Patient Safety Goals and Hospital policy. 13.41 # 1 2 Audit/Measures Compliance to Infection Prevention practice 1 Compliance to Environment of Care
1
33
Women and Infant's Specialty Health (WISH) (Section 2.13) # 3 4 5a 5b 6 7 8 9 10 Metric Labor productivity (Staffing to include acuity) Staffing hours per patient day 1 Hallway and Classroom Beds in use in L&D (avg duration in minutes) Hallway and Classroom Beds in use in L&D (instances) 1 Volume of patients doubling-up on Post-Partum Induction Interruption Induction Delay
1 1
Responsibility WISH WISH WISH WISH WISH WISH WISH WISH WISH
Baseline 11.65
Goal
Sep-12 12.42
Oct-12 13.07 98 192
Nov-12 14.02 79 165 617
Dec-12 14.00 81 216 659
Jan-13 13.39 72 167 846
Feb-13 13.89 50 81 534
1384
906
834
Direct Admits to Post-Partum 1 Bounce-Back from Post-Partum to L&D Recovery
122
138 31
99 29
106 28
98 34
74 26
Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started 1. 2. 3. 4. Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group Reported through Alvarez and Marsal's Daily Audits
34
Perioperative Services (Section 2.14) # 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 Tasks/Initiatives Conduct daily infection control audits in all areas of the Main OR, PACU, PreOp Holding, DSU, Anesthesia Workroom, ASC and PAEC. Execute the progressive disciplinary action and performance improvement plan for staff/physicians who exhibit failure to follow infection prevention policies and procedures. Conduct environment of care rounds every shift in each perioperative area. Review and follow Parkland policy Admin 6-33 Labeling of Medications On/Off the Sterile Field. Review and follow Parkland policy Admin 6-43, Using Two (2) Patient Identifiers. Provide training for alternative options for medication solution transfer. Conduct daily audits of various medication management measures to determine compliance. Review and follow the Parkland policy Admin 6-30 Universal Policy. Conduct daily audits of various patient right initiatives to determine compliance: Critical Equipment Audit/Measures Compliance to using two patient identifiers 1 Compliance percentage of Infection Prevention by audit, monthly 1 Compliance percentage of Environment of Care by audit, monthly 1 Compliance to site marking procedure 1 Compliance to medication management measures (labeling, transferring from the circulator to scrub, securing and other measures) 1 Compliance with critical equipment 1 Compliance to Time Out procedure
1
Accountability Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims
Work Stream 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5
Target Date 8/31/2012 6/8/2012 8/31/2012 8/31/2012 8/31/2012 7/13/2012 8/31/2012 7/13/2012 8/31/2012
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Completion Y Y Y Y Y Y Y Y Y
# 1 2 3 4 5 6 7
Accountability Surgery Surgery Surgery Surgery Surgery Surgery Surgery
Goal 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Sep-12 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Oct-12 100.0% 100.0% 99.2% 100.0% 100.0% 100.0% 100.0%
Nov-12 100.0% 95.0% 99.0% 100.0% 100.0% 100.0% 100.0%
Dec-12 100.0% 96.2% 98.2% 100.0% 100.0% 99.5% 100.0%
Jan-13 100.0% 100.0% 98.5% 100.0% 100.0% 99.5% 99.8%
Feb-13 100.0% 100.0% 98.6% 100.0% 100.0% 100.0% 100.0%
35
Perioperative Services (Section 2.14) # 8 9 10 11 12 13 14 Number of medication-related safety event 1 Number of blood transfusion errors 2 Number of incorrect consents 2 Number of wrong site surgeries or wrong site markings 2 Number of lab specimen mis-labeling 2 Percentage of travelers - OR 1 Surgical Site infection rate (2 month lag) 1 Metric Accountability Surgery Surgery Surgery Surgery Surgery Surgery Baseline Goal 0 Sep-12 5 2 3 0 0 13.9% 1.71% 0% 1.6% Oct-12 1 5 1 0 5 9.5% 1.8% Nov-12 2 0 1 0 0 6.8% 2.4% Dec-12 2 0 2 0 2 7.5% 4.3% Jan-13 6 0 0 0 0 8.5% 2.0% Feb-13 0 0 1 0 5 8.5% 2.3%
Surgery
Comments
36
Procedural Services - Catherization Lab/Endoscopy (Section 2.15) # Tasks/Initiatives Accountability Kim McCloud Linda Licata Barbara Mims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Kim McCloud Linda Licata Barbara Mims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Emilie Allen Suzanne Sims Suzanne Sims Emilie Allen Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Barbara Mims Valerie Harvey Work Stream 2.7 2.5 2.5 2.5 2.5 2.5 2.7 2.5 2.5 2.5 2.5 2.5 2.5 4.4 2.5 2.5 4.4 2.5 2.5 2.5 2.5 2.5 4.2 Target Date 4/15/2012 8/31/2012 8/31/2012 8/31/2012 8/31/2012 8/31/2012 6/8/2012 3/30/2012 8/31/2012 8/31/2012 8/31/2012 9/28/2012 8/31/2012 4/20/2012 9/28/2012 3/30/2012 4/20/2012 4/27/2012 8/31/2012 8/31/2012 8/31/2012 6/30/2012 9/30/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
15.01 Conduct a weekly environment of care tour to ensure infection prevention measures are in compliance. 15.02 Conduct audit on invasive procedures in the restricted procedure rooms on the proper medication management on and off the sterile field. 15.03 Review Parkland's policy on Surgical Attire and OSHA regulation on Personal Protective Equipment.
15.04 Cardiologist performing the procedure to conduct the pause to ensure surgical team is properly attired. 15.05 Conduct an education program and competency on maintaining the sterile field. 15.06 Conduct an audit to ensure compliance with surgical attire policy. 15.07 Nurse manager to develop daily EOC tool/checklist to ensure compliance. 15.08 Review PHHS policy Admin 6-33 and PS 04-33 on proper handling of medications. 15.09 Educate staff of the existing Parkland Universal Protocol policy. 15.10 Develop Time Out procedure flash cards to be used as a help guide. 15.11 Conduct an audit on Time Out on all invasive procedures. 15.12 Provide mandatory education on proper site marking to all new and existing physicians. Provide education to staff nurses and techs to ensure they understand the proper site marking requirement based on NPSG.
15.13 Review Parkland's policy PS 04-43 regarding sponge and sharp counts. 15.14 15.15 15.16 15.17 15.18 15.19 15.20 15.21 15.22 Surgical Services to provide an educational session on the proper procedure of conducting sponge and needle/sharp counts. Develop and implement an annual competency on proper procedure on performing counts. Develop and implement a dashboard key measure all the required elements on correct counts to include instruments and sponges. Review Parkland policy Admin 6-33 and PS 04-33 on proper handling of medications. Develop unit specific medication management competencies. Initiate an awareness program verifying the medication they transfer on and off the sterile field. Conduct audit to assure needles and syringes are being stored in a safe and proper place and incorporate into daily environmental rounds. Audit proper transfer and verifying of medications on/off sterile field. Add medication management to the key measures to department quality dashboard. Establish action plan for non-compliance.
15.23 Enter the procedural nurse hand off communication to the recovery nurse into Epic.
37
Procedural Services - Catherization Lab/Endoscopy (Section 2.15) # 1 2 3 4 5 6 7 8 # 9 10 11 12 13 Number of wrong site surgeries Number of incorrect consents
2 1 2
Audit/Measures Compliance percentage to Infection Prevention practice Compliance percentage of environment of care by audit, monthly 1 Compliance to site marking procedure in cath lab by audit 1 Compliance to Time Out procedure by audit 1 Compliance to sponge, needle, sharp and instrument count in cath lab 1 Compliance to medication management measures (labeling, transferring from the circulator to scrub, securing and other measures) by audit 1 Compliance to using two patient identifiers by audit 1 Compliance to proper scrub attire and sterile gowning in restricted areas in cath lab by audit Metric
1 1
Accountability Surgery Surgery Surgery Surgery Surgery Surgery Surgery Surgery Accountability Surgery Surgery Surgery Surgery Baseline
Goal 100.0% 100.0% 100.0% 100.0%
Sep-12 98.9% 97.1% 100.0% 100.0% 100.0%
Oct-12 98.6% 97.9% 100.0% 100.0% 100.0% 88.0% 100.0% 100.0% Oct-12 0 1 0 3 1
Nov-12 92.5% 98.3% 99.3% 100.0% 100.0% 78.0% 100.0% 87.5% Nov-12 0 2 0 0 0
Dec-12 85.7% 98.8% 100.0% 100.0% 100.0% 89.0% 98.3% 100.0% Dec-12 0 2 1 0 0
Jan-13 81.4% 99.0% 100.0% 100.0% 100.0% 89.0% 100.0% 100.0% Jan-13 0 0 2 0 0
Feb-13 87.5% 99.6% 100.0% 99.5% 100.0% 100.0% 100.0% 100.0% Feb-13 0 0 1 0 0
100.0% 100.0% 100.0% Goal
92.0% 100.0% 100.0% Sep-12 0 0
Number of medication related safety events Number of lab specimen mis-labeling

2
1 1 0
Number of return to surgery for retained objects
Surgery Comments
38
Radiology (Section 2.16) # 16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08 Tasks/Initiatives Perform demand to capacity, throughput process workflow assessment and labor productivity analysis. Define the current backlog of appointment needs and additional capacity to meet backlog. Provide assessment of rate limiting factors contributing to the backlog. Develop a current state process workflow diagram. Develop future process work flow state. Conduct a labor productivity benchmarking. Pilot future state process work flow model. Provide training. Accountability Scott Cummins Scott Cummins Scott Cummins Scott Cummins Scott Cummins Scott Cummins Scott Cummins Scott Cummins Scott Cummins Suzanne Sims Suzanne Sims Emilie Allen Scott Cummins Jackie Sullivan Jackie Sullivan Scott Cummins Suzanne Sims Suzanne Sims Judy Herrington Vicki Crane Judy Herrington Vicki Crane Emilie Allen Scott Cummins Scott Cummins Scott Cummins Scott Cummins Patricia Bergen, MD Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.5 2.5 4.4 2.2 6.4 6.4 2.2 2.4 2.4 4.5 4.5 4.4 2.2 2.2 2.2 2.2 5.1 Target Date 7/13/2012 3/23/2012 4/6/2012 5/4/2012 5/4/2012 4/20/2012 7/13/2012 7/13/2012 7/13/2012 6/1/2012 8/31/2012 5/11/2012 6/8/2012 9/30/2012 9/30/2012 7/13/2012 8/31/2012 8/31/2012 7/13/2012 3/23/2012 6/8/2012 5/11/2012 4/6/2012 6/29/2012 9/14/2012 5/4/2012 Y Y Y Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
16.09 Implement the new process flow department wide 16.10 Review of the existing Parkland "time out" policy to ensure clarification of required process and/or revise as appropriate. Provide Time Out procedure flash cards to be used as a help guide until newly learned behavior has been established and is codified. 16.12 Establish Time Out procedure as a one of the competencies of personnel. 16.13 Execute progressive counseling/disciplinary action plan for infractions. 16.11 16.14a Development of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI - Radiology 16.14b 16.15 16.16 16.17 Development of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI - HospitalWide Ensure needles and syringes are secured in an area that is not accessible to unauthorized persons. Review Parkland policy on medications on and off the sterile field. Review Parkland policy on labeling medications on and off the sterile field.
16.18 Develop and review the smart order sets that have foley insertions to determine whether Lidocaine jelly should be added. 16.19 Review Parkland policy on properly securing medications. 16.20 Develop an annual department-specific medication competency on all staff Assign role and responsibilities to ensure all tasks including the disposal of opened and unused supplies to Interventional Radiology (IR) tech. 16.22 Distribute Parkland Policy G-1 on radiation safety. 16.23 Develop annual unit specific competency on radiation safety competency for all staff, physicians and vendors. 16.24 Audit the Main and ASC Operating Room staff and providers proper wear of personal protective attire during a procedure when operating the mini-fluoroscopy and other radiation safety requirements.
16.21
16.25 Initiate the education plan for the physicians requiring the need to meet the credentialing criteria.
39
Radiology (Section 2.16) # Tasks/Initiatives Accountability Patricia Bergen, MD Scott Cummins Scott Cummins Scott Cummins Work Stream 5.1 2.2 2.2 2.2 Target Date 5/11/2012 6/8/2012 6/8/2012 9/14/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y
16.26 Collate all credentialing documents and provide to the committee for review and approval. 16.27 Ensure a person who is approved to operate the mini-fluoroscopy unit is in procedures where the surgeon has not been granted privileges.
16.28 Develop an interface or investigate on how to tie in an alert of physicians privileges at point of scheduling a procedure. 16.29 Inquire and implement a functionality in Epic for the ordering physician to cognitively select whether to use the establish protocol or use orders as written. Audit/Measures Compliance to use of two patient identifiers 1 Compliance to the Time Out procedure 1 Compliance to proper securing of medications and medication supplies (needles, syringes) 1 Compliance to medication management (labeling, scrub and circulator exchange) 1
# 1 2 3 4
Accountability Radiology Radiology Radiology Radiology
Goal 100% 100% 100% 100%
Sep-12 100.0% 100.0% 100.0% 100.0%
Oct-12 100.0% 100.0% 100.0% 100.0%
Nov-12 100.0% 100.0% 100.0% 100.0%
Dec-12 100.0% 100.0% 100.0% 100.0%
Jan-13 100.0% 100.0% 100.0% 100.0%
Feb-13 100.0% 100.0% 100.0% 100.0%
40
Radiology (Section 2.16) # Mammography - Diagnostic 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Labor productivity - Mammography - Diagnostic (Paid Hours/Unit of Service) (1 month lag) 1 Number of days to third next available appointment - Mammography - Diagnostic (urgent patient) 1 Number of days to third next available appointment - Mammography - Diagnostic (not urgent patient) 1 Current utilization of slots - Mammography - Diagnostic 1 No show rate - Mammography - Diagnostic 1 MRI Labor productivity - MRI (Paid Hours/Unit of Service) (1 month lag) 1 Number of days to third next available appointment - MRI 1 Current utilization of slots - MRI 1 No show rate - MRI 1 CT Labor productivity - CT (Paid Hours/Unit of Service) (1 month lag) 1 Number of days to third next available appointment - CT 1 Current utilization of slots - CT 1 No show rate - CT 1 US Labor productivity - US (Paid Hours/Unit of Service) (1 month lag) 1 Number of days to third next available appointment - US 1 Current utilization of slots - US 1 No show rate - US 1 IR Labor productivity - IR (Paid Hours/Unit of Service) (1 month lag) 1 Number of days to third next available appointment - IR Current utilization of slots - IR No show rate - IR 1 Overall Number of Incorrect consents 2 Number of incorrect tests or wrong results placed 2 Number of cancelled surgeries due to unavailable films 2 Number of medication related safety events Number of lab specimen mis-labeling Number of wrong site exams
2 2 1 1 1
Metric
Accountability Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology
Baseline 0.5 95 130% 19% 1.9 64 115% 28% 0.7 12 117% 11% 0.8 15 118% 18% 1.2 26 116% 17%
Goal 0.5 14 125% 18% 1.9 14 130% 27% 0.7 14 120% 10% 0.8 14 120% 17% 1.2 14 120% 16% 0 0 0 0 0 0
Sep-12 0.5 9 189% 14% 2.3 8 111% 21% 0.6 1 110% 8% 1.0 2 101% 11% 2.1 13 113% 14% 0 0 0 0 0 0
Oct-12 0.5 30 103% 17% 2.4 12 113% 18% 0.6 1 107% 8% 0.9 1 102% 12% 1.5 11 104% 17% 0 0 0 0 1 2
Nov-12 0.5 13 108% 13% 2.4 20 108% 19% 0.7 1 104% 8% 0.8 2 103% 11% 1.9 13 105% 15% 2 2 0 1 1 1
Dec-12 0.5 7 107% 20% 2.5 12 112% 19% 0.7 1 108% 9% 1.0 1 103% 13% 1.4 15 94% 12% 0 3 0 4 0 1
Jan-13 0.5 8 42 109% 31% 1.8 5 108% 17% 0.7 1 109% 9% 0.9 1 105% 12% 1.8 13 117% 14% 0 3 0 0 0 0
Feb-13
15 39 79% 21%
8 117% 19%
1 123% 8%
1 94% 10%
11 125% 14% 0 0 0 2 0 0
41
Radiology (Section 2.16) Comments 16.22 - Only 80 percent of required medical staff have taken training module Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
1. 2. 3. 4.
42
Laboratory Services (Section 2.17) # Tasks/Initiatives Accountability Debbie Perrault Debbie Perrault Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Debbie Perrault Kim McCloud Linda Licata Barbara Mims Debbie Perrault Debbie Perrault Debbie Perrault Debbie Perrault Debbie Perrault Debbie Perrault Suzanne Sims Debbie Perrault Debbie Perrault Debbie Perrault Debbie Perrault Work Stream 2.2 2.2 2.7 Target Date 3/30/2012 5/11/2012 4/6/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y
17.01 Develop education plan for phlebotomy staff including new orientees. 17.02 Conduct random audits of phlebotomy carts. 17.03 Ensure there is a regular cleaning schedule with EVS for the affected Laboratory areas.
17.04 Establish environment of care rounds with EVS and Infection control leaders.
2.8
4/6/2012
17.05 Initiate department-level Infection Control accountability and metrics. 17.06 Educate laboratory staff on expected cleaning standards and schedules. 17.07 Define with EVS an escalation process for cleaning. 17.08 Utilize reagent that requires validation of results prior to testing. Lab Director will develop an education plan and competency to ensure all current employees and new hires understand 17.09 the confirmation process prior to individual patient reporting. 17.10 Listen to periodic transcription tapes to ensure transcriptionist is reporting variances. 17.11 Review Parkland reporting critical value policy. 17.12 Develop and implement an education plan and competencies on critical value reporting. 17.13 Monitor the effectiveness of the education program with the turnaround time of the critical value reporting. 17.14 Review Parkland policy Admin 6-30 Universal Protocol. 17.15 Conduct five weekly random Time Out observations in the FNA clinic. 17.16 Collect Time Out observation results and add to clinic QAPI indicators. Retrain current staff to ensure awareness of the availability of the ALVIN video translator or the language line for 17.17 patients that require a certified translator. 17.18 Provide Medical Assistant staffing for FNA clinic.
2.8 2.2 2.7 2.2 2.2 2.2 2.2 2.2 2.2 2.5 2.2 2.2 2.2 2.2
5/15/2012 4/13/2012 4/13/2012 3/23/2012 6/8/2012 5/25/2012 4/13/2012 4/13/2012 7/31/2012 8/31/2012 6/8/2012 5/11/2012 6/8/2012 6/8/2012
Y Y Y Y Y Y Y Y Y Y Y Y Y Y
43
Laboratory Services (Section 2.17) # 17.19 17.20 17.21 17.22 Tasks/Initiatives Meet with MIO and an Epic representative to enhance Epic documentation to hardwire autopsy documentation requirements. Add autopsy documentation requirements to dictation template, including pathology checklist. Educate morgue staff on required two identifier process and their empowerment to stop the autopsy without proper consent. Perform audit of autopsy records for evidence of family communication, pathology notification by nursing, consent, and any other required elements. Audit/Measures Compliance to accession and grossing the specimen by audit 1 Compliance to the use of the two patient identifiers with transcription post specimen processing by audit 1 Compliance to autopsies having formal orders
1
Accountability Debbie Perrault Debbie Perrault Emilie Allen Debbie Perrault
Work Stream 2.2 2.2 4.4 2.2
Target Date 4/27/2012 6/8/2012 4/6/2012 6/8/2012
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Completion Y Y Y Y
# 1 2 3 # 4 5
Accountability Lab Lab Lab
Goal 100% 100% 100% Baseline Goal 98.0%
Sep-12 100% 100% 50% Sep-12 99.0% 6
Oct-12 N/A N/A 100% Oct-12 98.0% 1
Nov-12 N/A N/A 100% Nov-12 99.0% 5
Dec-12 100% 100% 100% Dec-12 98.0% 5
Jan-13 N/A N/A 100% Jan-13 99.0% 0
Feb-13 N/A N/A 100% Feb-13 98.0% 0
Metric Percent compliance to 60 minute critical value turnaround time

1 2
Accountability Lab Lab Comments
Number of patient safety events relating to non-compliance in critical value reporting
44
Food & Nutrition Services (Section 2.18) # 18.01 Tasks/Initiatives Change procedure to ensure all unused trays are collected after meals. Accountability Usha Kollipara Kim McCloud Linda Licata Barbara Mims Usha Kollipara Work Stream 2.2 Target Date 5/30/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y
18.02
Educate nursing staff to communicate with F&NS to re-order or hold a tray if a patient is not available for a meal.
2.8
4/13/2012
18.03
Acquire thermometers for freezers.
2.2
4/4/2012
# 1 # 2
Audit/Measures Compliance with all nutrition services equipment and food temperatures Metric Percentage of units surveyed which do not reheat food trays
1
Accountability FNS Accountability FNS Comments Baseline
Goal 100% Goal
Sep-12 100% Sep-12
Oct-12 100% Oct-12
Nov-12 100% Nov-12 95%
Dec-12 100% Dec-12 95%
Jan-13 100% Jan-13 96%
Feb-13 100% Feb-13 90%
45
Organ and Tissue (Section 2.19) # Tasks/Initiatives Accountability Jackie Sullivan Emilie Allen Work Stream 6.4 4.4 Target Date 9/14/2012 9/14/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y
19.01 Develop a process to ensure Organ Procurement quality improvement functions are reported to QCC regularly. 19.02 Develop documentation for annual training program attendance.
Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
46
Physical Medicine and Rehabilitation (PMR) (Section 2.20) # 20.01 20.02 20.03 20.04 20.05 20.06 Tasks/Initiatives Conduct an assessment of the factors contributing to the backlog to include: demand vs. capacity, current space and labor productivity. Upon completing elements of the assessment, develop an overall current state process work flow diagram noting process failures and operational barriers. Analyze current staffing patterns and address shortages. Redesign future process flows to address identified barriers. Complete pilot of revised process flow to assess effectiveness and any additional needed changes. Develop targeted improvement levels: for backlog, patient and physician communication, productivity, etc. to assess impact of changes. A consistent tool to assess effectiveness is needed to ensure consistency in assessing progress. Accountability Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Barbara Mims Jenni Burnes Jenni Burnes Barbara Mims Valerie Harvey Jenni Burnes Jody Springer Jenni Burnes Kim McCloud Linda Licata Barbara Mims Jenni Burnes Jenni Burnes Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 4.2 2.2 2.2 4.2 2.2 1.2 1.2 2.8 2.2 2.2 Target Date 4/20/2012 5/4/2012 5/4/2012 6/29/2012 6/29/2012 6/29/2012 8/1/2012 8/1/2012 6/8/2012 5/25/2012 9/14/2012 4/13/2012 4/20/2012 4/13/2012 6/8/2012 5/4/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
20.07 Identify core requirements for assessment and documentation for proper patient care and educate staff. (Nursing) 20.07 Identify core requirements for assessment and documentation for proper patient care and educate staff. (PMR) 20.08 Develop a methodology to ensure all elements of care have been addressed and assessed. 20.09 Establish key metrics for inpatient rehab. 20.10 Develop methodology to track required metrics are being reported. 20.11 Determine legal requirements for DME license. 20.12 Determine methodology dispensing DME (hospital vs. contract supplier). 20.13 Develop and implement Infection Prevention training. Noncompliance with proper infection control procedures should be addressed immediately and ongoing non-compliance should result in progressive disciplinary action. 20.15 Develop methodology to track wound care infection rates. 20.14
47
Physical Medicine and Rehabilitation (PMR) (Section 2.20) # 1 2 # Occupational Therapy (OT) 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 No show rate - OT Total Orders (OT)
1 1 1 1
Audit/Measures Percent of all elements of care that have been assessed and addressed Compliance to Environment of Care
1 1
Accountability PMR PMR
Goal 100% Baseline 15.2% 413 Goal 10.0%
Sep-12 96.2% 98.2% Sep-12 16.9% 348
Oct-12 93.0% 98.0% Oct-12 13.9% 484
Nov-12 92.0% 99.7% Nov-12 16.1% 371
Dec-12 96.0% 99.4% Dec-12 19.3% 373
Jan-13 96.0% 97.7% Jan-13 21.3% 391 52 35 15 2 32
Feb-13 92.0% 99.7% Feb-13 17.7% 398 91 25 54 15 11 7.0% 85.9% 23.2% 1229 250 59 154 78 0 4.0% 72.2% 11.5% 71 24 10 10 0 4 0.0% 73.1%
Metric
Accountability PMR PMR PMR PMR PMR PMR

1
Total Backlog (OT)
Backlogged Referrals that are Pending Patient Follow-Up (OT) Backlogged that are Pending Triage (OT) Vacancy rate - OT
1 1
Backlogged Orders that are Pending Authorizations from Financial Counseling (OT) 1 Cancelled Orders (> 60 days or 2 follow-up calls with out a call back from patient) (OT) Labor productivity (percentage of targeted appointments per FTE) - OT Physical Therapy (PT) No show rate - PT 1 Total Orders (PT)
1 1 1
PMR PMR PMR PMR PMR PMR PMR 87.5% 15.6% 1214 100.0% 10.0% 21.0% 73.8% 15.4% 1212 21.0% 101.8% 17.0% 1316 14.0% 90.3% 16.7% 1123 14.0% 95.1% 22.9% 1026
7.0% 87.1% 24.9% 1342 171 132 38 1 93
Total Backlog (PT)
Backlogged Referrals that are Pending Patient Follow-Up (PT) 1 Backlogged Orders that are Pending Authorizations from Financial Counseling (PT) Backlogged that are Pending Triage (PT) 1 Cancelled Orders (> 60 days or 2 follow-up calls with out a call back from patient) (PT) Vacancy rate - PT
1 1 1 1
PMR PMR PMR PMR PMR PMR PMR 61.1% 13.8% 98 100.0% 10.0% 4.3% 68.4% 14.9% 90 15.0% 81.9% 13.8% 88 12.0% 80.7% 10.7% 80 8.0% 72.2% 18.2% 77
4.0% 67.0% 25.2% 79 20 13
Labor productivity (percentage of targeted appointments per FTE) - PT Speech Therapy (ST) No show rate - ST Total Orders (ST)
1 1 1 1
Total Backlog (ST)
Backlogged Referrals that are Pending Patient Follow-Up (ST) Backlogged that are Pending Triage (ST) 1
Backlogged Orders that are Pending Authorizations from Financial Counseling (ST)
5 1 9 PMR 2.0% 71.9% 100.0% 81.5% 0.0% 98.5% 0.0% 86.2% 0.0% 78.5% 0.0% 73.1% PMR
Cancelled Orders (> 60 days or 2 follow-up calls with out a call back from patient) (ST) 1 Vacancy Rate - ST
1 1
Labor productivity (percentage of targeted appointments per FTE) - ST
48
Physical Medicine and Rehabilitation (PMR) (Section 2.20) Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started 1. 2. 3. 4. Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group Reported through Alvarez and Marsal's Daily Audits
49
Respiratory Therapy (Section 2.21) # 21.01 21.02 21.03 21.04 Tasks/Initiatives Analyze staffing levels and provided recommendations. Adjust staffing and/or shifts to agreed upon staffing grid. Develop targeted improvement in missed treatments and a timeline for expected improvements. Explore the ability to analyze missed treatments per shift through Epic. Accountability Edward Best Edward Best Edward Best Edward Best Edward Best Edward Best Edward Best Edward Best Kim McCloud Linda Licata Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Edward Best Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.7 2.7 Target Date 4/13/2012 5/11/2012 3/22/2013 4/13/2012 6/8/2012 6/8/2012 9/14/2012 9/14/2012 4/6/2012 4/13/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y Y Y Y
21.05 Determine a mechanism to track assigned, completed, and missed by therapist through a daily shift report document. 21.06 Documentation educational program for all Respiratory Therapy (RT) staff. 21.07 Initiate documentation review process to ensure patient quality of care. 21.08 Initiate patient rounds to obtain feedback regarding effectiveness of respiratory treatments. Review the current oxygen tank use, storage, and refilling procedure for gaps in guidance to both RT staff as well as 21.09 other clinicians. 21.10 Meet with clinical leaders who store oxygen tanks and determine responsibilities of staff in which oxygen tanks are stored.
21.11 Develop a house-wide education/awareness for all staff that addresses all areas of responsibility.
2.7
5/11/2012
21.12 Audits of oxygen tank safety. 21.13 Long term strategy for an annual assessment of therapy care to ensure that there are no gaps in process or care.
2.7 2.2
5/1/2012 9/14/2012
Y Y
# 1 2 3 4 # 5 6 Ventilator Associated Pneumonia Rate 1 Number of missed treatments (RT self-reporting) 1 Respiratory Care documentation accuracy 1 Compliance in oxygen tank storage 1
Audit/Measures Percentage of missed treatments related to Therapist not being available 1
Accountability RT RT RT House-wide
Goal 0% 95.0% 100% Baseline 2.74 3.29% Goal 2.65 1.8%
Sep-12 2.4% 699 95.5% 99.9% Sep-12 2.88 0.5%
Oct-12 1.1% 744 97.0% 99.0% Oct-12 2.80 1.0%
Nov-12 0.2% 662 97.0% 99.7% Nov-12 2.90 0.0%
Dec-12 0.5% 810 98.0% 100.0% Dec-12 2.64 1.0%
Jan-13 2.8% 902 98.1% 100.0% Jan-13 2.52 0.9%
Feb-13 0.4% 839 97.6% 99.6% Feb-13 2.58 0.5%
Metric Productivity Metrics (Weighted Procedures/Hours Paid) 1
Accountability RT RT Comments
50
Community Oriented Primary Care (COPC) (Section 2.22) # Tasks/Initiatives Accountability Judy Herrington Vicki Crane Vivian Johnson Judy Herrington Vicki Crane Vivian Johnson Judy Herrington Vicki Crane Judy Herrington Vicki Crane Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Kim McCloud Linda Licata Kim McCloud Linda Licata Barbara Mims Jessica Hernandez Holt Oliver, MD Work Stream 4.5 2.3 4.5 2.3 4.5 4.5 3.6 Target Date 6/8/2012 3/23/2012 5/11/2012 6/20/2012 5/11/2012 5/11/2012 4/6/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y Y Y Y Y Y
22.01 Develop medication documentation training program for all staff responsible for medication administration. 22.02 Develop and implement processes to reconcile controlled substances in Medlock clinic. 22.03 Develop and implement audit tool to track controlled substance reconciliation. Implement electronic medical record (EMR)/Pharmacy interface to allow for Pharmacy to provide oversight to prescribing 22.04 and administration at correctional facilities visited by the mobile clinic. Review results of Medicine specialty clinic pilot and determine viability of implementation to other clinics for medication 22.05 reconciliation solution. 22.06 Formulate alternative solution to medication reconciliation issue. 22.07 Empower and educate staff on basic standards related to environment of care and the normal chain of command for addressing issues as they arise. Also include a process on issue escalation when issues are not addressed.
22.08 Create comprehensive environment of care gaps. 22.09 Meet with the appropriate leaders responsible for environmental cleaning and maintaining the environment to discuss the gaps and develop plan for improvement.
3.6 2.7 2.7
6/8/2012 5/11/2012 6/8/2012
Y Y Y
22.10 Establish multi-disciplinary monitoring of clinic locations.
22.11 Load plans of care into Jail electronic medical record (EMR).
3.6
6/8/2012
51
Community Oriented Primary Care (COPC) (Section 2.22) # Tasks/Initiatives Accountability Barbara Mims Valerie Harvey Jessica Hernandez Holt Oliver, MD Barbara Mims Valerie Harvey Accountability COPC COPC COPC COPC COPC Metric Number of medication related safety events Third next available appointment 1 No show rate 1
1 2
Work Stream 4.2 3.6 4.2
Target Date 8/1/2012 6/8/2012 7/20/2012
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Completion Y Y Y
22.12 Conduct training for staff on plan of care standards and proper documentation and individualized plan of care. 22.13 Conduct a chart audit to evaluate staff compliance regarding plan of care process. 22.14 Develop a process for patients who do not have a common diagnosis and their plan of care.
# 1 2 3 4 5 # 6 7 8 9
Audit/Measures Compliance with medication management to include but not limited to securing, labeling , reconciliation and 1 documentation Compliance percentage of environment of care by audit, monthly Compliance to the use of two patient identifiers Compliance to infection prevention practice 1 Compliance in medication reconciliation 1
1 1
Goal
Sep-12 100.0% 97.0% 100.0%
Oct-12 100.0% 97.5% 99.4% 97.4% 97.0% Oct-12 1 1 81.1 17.7%
Nov-12 99.0% 97.4% 100.0% 93.5% 98.0% Nov-12 2 4 75.6 17.5%
Dec-12 100.0% 98.6% 100.0% 93.7% 95.0% Dec-12 3 1 74.2 18.1%
Jan-13 99.7% 97.5% 100.0% 92.4% 94.0% Jan-13 3 4 79.3 17.5%
Feb-13 100.0% 98.3% 99.8% 92.0% 98.0% Feb-13 0 0 84.4 17.9%
100%
91.9% 96.0%
Accountability COPC COPC COPC COPC Comments
Baseline
Goal 0
Sep-12 4 2 78.0 17.7%
Number of lab specimen mis-labeling by clinic
97.2 17.2%
52
Specialty Clinics (Section 2.23) # 23.01 Ensure hard-stop process in Epic is engaged. 23.02 Determine EVS scope and schedule. Tasks/Initiatives Accountability Vivian Johnson Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Suzanne Sims Suzanne Sims Accountability OPC OPC OPC OPC Work Stream 2.3 3.6 Target Date 9/14/2012 3/30/2012 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion Y Y
23.03 Clinic leadership to round clinic areas to monitor PHI security.
3.6
6/8/2012
23.04 Clinic leadership to develop and implement disciplinary actions for staff violations of HIPAA policies. 23.05 Develop clinic-wide training and awareness program for proper time-out procedure. 23.06 Conduct time-out training for all areas where patient procedures are performed. # 1 2 3 4 Audit/Measures Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation 1 Compliance percentage of environment of care by audit, monthly Compliance to the use of two patient identifiers Medication Reconciliation compliance
3.6 2.5 2.5
5/7/2012 10/31/2012 10/31/2012 Goal Sep-12 100.0% 98.6% 99.5% Oct-12 99.0% 98.0% 98.5% Nov-12 100.0% 99.0% 100.0% Dec-12 97.0% 99.0% 100.0% 99.0% Jan-13 99.4% 98.9% 100.0% 96.0% Feb-13 99.6% 99.8% 99.5% 96.0%
Y Y Y
53
Specialty Clinics (Section 2.23) # 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Number of medication related safety events 1 Number of lab specimen mis-labeling by clinic Compliance to HIPAA/privacy standards (based on EOC audit) General Surgery No Show Rate
1 1 2
Metric
Accountability
Baseline
Goal 0 0 100.0%
Sep-12 0 2 97.3%
Oct-12 0 1 96.8% 25%
Nov-12 0 1 100.0% 30% 150 116 22% 63 164 22% 89 157 24% 60 123 21% 117 148 27% 61 130
Dec-12 0 1 96.0% 24% 120 197 24% 56 156 24% 73 170 27% 49 114 30% 121 148 26% 51 116
Jan-13 0 2 99.0% 30% 91 132 24% 39 164 26% 87 165 26% 56 116 25% 119 150 31% 40 123
Feb-13 0 3 100.0% 34% 138 130 22% 64 164 23% 73 208 22% 72 124 25% 113 145 26% 37 132
OPC OPC OPC OPC

1
Third next available appointment Average dwell time (minutes) Urology No Show Rate
1 1
14 90
128 151 25%
Third next available appointment Average dwell time (minutes) Surgery Oncology No Show Rate
1 1
OPC OPC OPC
14 90
115 143 24%
Third next available appointment Average dwell time (minutes) Cardiology No Show Rate
1 1
OPC OPC OPC
14 120
94 148 26%
Third next available appointment Average dwell time (minutes) GI/Liver No Show Rate
1 1
OPC OPC OPC
14 120
65 118 25%
Third next available appointment Average dwell time (minutes) Renal No Show Rate
1 1
OPC OPC OPC
14 120
145 155 23%
Third next available appointment Average dwell time (minutes)

1
OPC OPC
14 120
67 128
54
Specialty Clinics (Section 2.23) Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started 1. 2. 3. 4. Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group Reported through Alvarez and Marsal's Daily Audits
55
Contract Services (Section 2.24) # Tasks/Initiatives Accountability Muthusamy Anandkumar, MD Ciel Murphy Work Stream Target Date Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion
24.01
Create database of all contracted patient service arrangements.
6.5
3/22/2013
24.02
Review department specific quality indicators for all contracts.
Muthusamy Anandkumar, MD Ciel Murphy
6.5
6/1/2012
24.03
Request quality monitors from vendors who have not supplied them.
6.5
6/1/2012
24.04
Determine Parkland specific quality indicators for each contract.
6.5
7/31/2012
24.05
Each department to report contract monitoring elements at the departments next regularly scheduled reporting appointment.
6.5
3/22/2013
24.06
Review all contracts using department specific indicator list. Each department to have a specific list of all contracts, appropriate indicators, and existence of indicators.
6.5
8/30/2012
24.07
Contract Management Unit to provide a schedule of all contracted services affecting patient care to the BOM Quality Committee along with a template on how contracts will be scored for quality.
6.5
8/30/2012
24.08
Muthusamy Contract Management Unit to provide first batch of contracts for quality score and review and proposed scores against Anandkumar, MD template to BOM Quality Committee. Ciel Murphy
6.5
8/30/2012
56
Contract Services (Section 2.24) # 1 2 # 3 4 Percent of current contracts in database 1 Percent of current contracts that have department specific quality indicators 1 Metric Number of "significant" contracts meeting requirements for quality scoring 1 Number of "by exception" contracts meeting requirements for quality scoring 1 Audit/Measures Accountability Contracts Contracts Accountability Contracts Contracts Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started 1. 2. 3. 4. Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group Reported through Alvarez and Marsal's Daily Audits Baseline Goal 89% Sep-12 100% Oct-12 90% Nov-12 59% 88% 89% Dec-12 78% 81% 91% Jan-13 48% 93% Goal Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 100% 90% Feb-13 66% 98%
57
QAPI # Tasks/Initiatives Accountability Work Stream Target Date Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Completion
Revise QAPI plan Include CMS elements Prioritize efforts and resources Q.01 Customize indicators to reflect specific patient populations in each department Define methodology to capture and analyze data Define formal process for reporting to Quality of Care Committee (QCC) and the BOM Quality Committee. Identify a regular reporting schedule for each department Q.02 Approval of QAPI plan by the QCC and BOM Quality Committee. Q.03 Capture and analyze baseline data from initial tracers for survey readiness. Q.04 Develop and implement corrective action plan for survey readiness Q.05 Performance Improvement group should implement rounding as a method to collect data for adverse patient events Q.06 Performance Improvement group to develop a list of resources from which to pull adverse patient events Q.07 Develop methodology to trend, analyze and report adverse patient events Q.08 Work with A&M to improve RCA process Develop a master report of all RCAs conducted. Include incident date, date of RCA commencement, date of RCA Q.09 conclusion, general results and actions taken. Q.10 Q.11 Q.12 Q.13 Q.14 Review standing reports generated by CIS and meet with end users/management to determine relevance and meaningfulness. Discontinue generation of reporting that does not add value to end user/management.
Jackie Sullivan
6.1
5/25/2012
Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan Jackie Sullivan
6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.4 6.1 6.1
5/25/2012 6/15/2012 6/30/2012 6/30/2012 9/30/2012 11/31/2012 9/30/2012 6/30/2012 5/25/2012 5/25/2012 5/18/2012 6/30/2012 6/30/2012 5/25/2012 9/30/2012 5/25/2012
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Establish a schedule for CIS with due dates of all necessary reporting Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review Create survey and initial tracers to collect baseline data in the form of a Quality Assessment (QA). Complete Quality Assessment survey and tracer work. Complete department-specific Performance Improvement (PI) plan with indicators appropriate for departments patient Q.15 population. Q.16 Implement corrective actions per departments PI plan. Q.17 Report PI plan status on at least semi-annual basis to QCC.
Comments Task/initiative largely on schedule for completion Task/initiative may be delayed from Target Date completion Task/initiative is past the Target Date deadline Initiative tracking not yet started
58

February Compliance Report On Parkland Memorial Hospital

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February Compliance Report On Parkland Memorial Hospital

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Report of the Independent Consultative Expert (ICE) Monthly Progress Report February 2013 on Parkland Health & Hospital

l System Dallas, Texas

March 12, 2013

Patient Safety / Quality

Categories of "Key Findings" from February's Rounding Audits

Categories of Environment of Care Findings

Department and Unit Specific Findings

Main ED Throughput Metrics

UCC Throughput Metrics

Competencies Completion of clinical and non-clinical competency validation initiative

Laboratory Implementation of recommendations from A&M lab specimen assessment

Audit/Measures Percentage of contracts (outsourced vendors) reviewed for quality measures

Accountability Contract Svcs Comments

Dec-12 99% 0.5% 48.9% 50.6%

Jan-13 N/A N/A N/A N/A 100% 18.0

Feb-13 N/A N/A N/A N/A 100% 10.6

0.4% 33.9% 65.7%

5.0% 55.0% 40.0% 100% 10 11.9 11.1 100% 9.0

Time from occurrence to corrective action signed by employee (days)

Accountability HR HR HR HR HR HR House-Wide HR HR HR Comments

Baseline 16.5% 15.0%

Goal 14.5% 14.1% 20.0%

Sep-12 12.8% 10.6% 6.3% 50.0%

Oct-12 9.5% 9.5% 9.8% 44.7%

Nov-12 12.7% 12.0% 24.1% 41.2%

Dec-12 16.7% 13.6% 17.9% 28.7%

Feb-13 16.2% 12.8% 27.8% 34.7%

Feb-13 17.6% 12.7% 25.3% 38.7%

N/A 100% 100%

74 1.3% 100.0% 99.2% 72.3

95 0.96% 100.0% 99.5% 68.4

83 1.13% 100.0% 99.4% 73.8

84 1.29% 99.9% 99.4% 73.5

58 1.63% 100.0% 98.5% 75.4

31 1.23% 100.0% 99.2% 77.2

Baseline 86.0% 90.0% 96.0%

Goal 100.0% 100.0% 100.0% 550

Sep-12 100.3% 95.9% 102.8% 402 50%

17.2% 5768 2.62 2.49 1.59

17.7% 5991 2.57 2.34 1.64

Physician (Clinics) productivity (based on visits/hour) - Internal Medicine

1,204 0:59 142.0 138.8 4.6 87% 79 70

ED ED Care Mgmnt ADT EVS ADT

Percent inpatient occupancy (census) by division

Audit/Measures Nursing leadership vacancy rate

Sep-12 12.9% N/A 3.0% 14.3%

Oct-12 9.3% N/A 2.9% 10.7%

Nov-12 7.7% N/A 2.4% 11.7%

Dec-12 8.2% N/A 1.9% 13.2%

Jan-13 9.1% 17.1% 2.8% 10.5% 77% 97% 21% 95%

186 Jan-13 1.0% 86% 95%

Accountability Nursing Nursing Nursing Nursing Comments

5.08 5.09 5.10 5.10 5.11

3.4 3.4 3.4 3.4 3.4

9/30/2012 8/30/2012 6/15/2012 6/15/2012 11/14/2012

Move Utilization Management within Care Management Department.

Work Stream 3.4

Target Date 7/24/2012

Audit/Measures Compliance in performing medical necessity screening in ED

Oct-12 89.3% 59.0% Oct-12 978 4,440 580 10.2%

Nov-12 91.8% 74.8% Nov-12 1,111 5,157 686 9.9%

Dec-12 96.1% 94.6% Dec-12 1,184 5,384 593 10.9%