Board Quality Review Committee

47 Pages·2016·5.68 MB·English

BOARD QUALITY REVIEW COMMITTEE

OPEN SESSION AG ENDA

MONDAY, OCTOBER 17, 2016 POMERADO HOSPITAL
5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E
6:00 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064
Time Form A Target
PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING
Page #
CALL TO ORDER 6:00
 Establishment of Quorum 1 N/A 6:01
 Public Comments1 15 N/A 6:16
 Information Item(s)
1. *Review/Approve: Minutes – Monday, August 15, 2016 (Addendum A, Pages 8 - 18) 4 3 6:20
 Standing Item(s)
1. Journal Club Article: Clinical Excellence Council (CEC) Newsletter (Addendum B, Pages 19 - 27)
10 4 6:30
Ella Laxa, Nurse Education Specialist
2. Quality and Patient Experience Dashboard (Addendum C, Pages 28 - 29)
10 5 6:40
Valerie Martinez, RN, Director, Quality, Patient Safety & Infection Control
 New Business
1. Changes in the Sterile Processing Department (SPD) – a Mayo Clinic influenced Lean
improvement project (Addendum D, Pages 30 - 47) 20 6 7:00
Danielle McCarthy, RN, MSNed, Director of Surgery and Procedure Services
2. BQRC Annual Assessment
30 7 7:30
Leslie Solomon, Vice President, Culture and Talent Planning
 Public Comments1 15 N/A 7:45
FINAL ADJOURNMENT 7:45
NOTE: The open session agenda, without public comments, is scheduled for 1 hour, 15 minutes. Based on the above agenda,
without public comments, the meeting starts at 6:00 p.m. and adjourns at 7:15 p.m.
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BOARD QUALITY REVIEW COMMITTEE

OPEN SESSION AG ENDA

MONDAY, OCTOBER 17, 2016 POMERADO HOSPITAL
5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E
6:00 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064
Board Quality Review Committee Members
VOTING MEMBERSHIP NON-VOTING MEMBERSHIP
Aeron Wickes, MD – Chairperson, Board Member Bob Hemker, FACHE, President & CEO
Linda Greer, RN, Board Member Frank Beirne, FACHE, EVP, Operations
Dara Czerwonka, Board Member Alan Conrad, MD, EVP, Physician Alignment
Richard Engel, MD – Interim Chair of Medical Staff Quality Della Shaw – EVP, Strategy
Management Committee for Palomar Medical Center
Maria Sudak, RN, MSN, CCRN, NEA-BC – Vice President and Chief
Charles Callery, MD - Chair of Medical Staff Quality Nursing Officer, Palomar Medical Center
Management Committee for Pomerado Hospital
Jeannette Skinner, RN, MBA, FACHE, Vice President, Pomerado Hospital
Larry LaBossiere, RN, MSN, CEN, CNS, MBA, Chief Nursing Officer,
Pomerado Hospital
Sheila Brown, FACHE, VP, Continuum Care
Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient
Safety Committee
Valerie Martinez, RN, BSN, MHA, CPHQ, CIC, NEA-BC, Co-Chair of Patient
Safety Committee and Director, Quality, Patient Safety & Infection Control

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

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

1 5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment
notices available in meeting room.
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Attendance Roster, Minutes and Acronym Glossary
Board Quality Review Committee Meeting
Monday, August 15, 2016

TO: Board Quality Review Committee

MEETING DATE: Monday, October 17, 2016

FROM: Christine Breese, Executive Assistant

Background: The minutes of the Board Quality Review Committee
meeting, held on Monday, August 15, 2016, are
respectfully submitted for approval. Included are the
attendance roster and Acronym Glossary for the
Committee’s review (Addendum A).

Budget Impact: N/A

Staff Recommendation: Approval

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A – Addendum A
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Journal Club Article
Clinical Excellence Council (CEC) Newsletter - September 2016

TO: Board Quality Review Committee

MEETING DATE: Monday, October 17, 2016

FROM: Christine Breese, Executive Assistant

Background: The Journal Club reading assignment for October 2016 is
the Clinical Excellence Council (CEC) Newsletter for
September 2016 (Addendum B).

Budget Impact: N/A

Staff Recommendation: For information only

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:
Form A – Addendum B
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Quality and Safety Dashboard
Board Quality Review Committee

TO: Board Quality Review Committee

MEETING DATE: Monday, October 17, 2016

FROM: Christine Breese, Executive Assistant

Background: Valerie Martinez, RN, Director, Quality, Patient Safety and
Infection Control will share a system-wide dashboard
showing Patient Safety and Quality metrics and their actual
performance/value outcomes (Addendum C).

Budget Impact: N/A
Staff Recommendation: For information only
Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:
Form A – Addendum C
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Changes in the Sterile Processing Department (SPD)
Board Quality Review Committee

TO: Board Quality Review Committee

MEETING DATE: Monday, October 17, 2016

FROM: Christine Breese, Executive Assistant

Background: Danielle McCarthy, RN, MSNed, Director of Surgery and
Procedure Services will present the latest efforts for
improving the flow of instruments and supplies in the sterile
processing department (SPD) for surgery and procedures
conducted at Palomar Medical Center (Addendum D).

Budget Impact: N/A
Staff Recommendation: For information only
Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:
Form A – Addendum D
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Annual Board Committee Assessment
Board Quality Review Committee

TO: Board Quality Review Committee
MEETING DATE: Monday, October 10, 2016
FROM: Christine Breese, Executive Assistant
Background: Leslie Solomon, Vice President, Culture and Talent
Planning will lead the Committee in a review of the
accomplishments achieved in 2016 and a discussion of
goals and opportunities for 2017.

Budget Impact: None

Staff Recommendation: For information only

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A - No Addendum - Annual Assessment.docx
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ADDENDUM A
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BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, AUGUST 15, 2016
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL?
RESPONSIBLE PARTY
CALL TO ORDER
The meeting – held in Conference Room E at Pomerado Hospital, 15615 Pomerado Road, Poway, CA 92064 – was called to order at 6:30 p.m. by Committee Chair, Dr. Aeron
Wickes.
ESTABLISHMENT OF QUORUM
 Quorum comprised of Directors Wickes, Greer, McCune (as Board alternate), Dr. Charles Callery
 Excused Absences: Director Czerwonka, Dr. Richard Engel
 Guest Directors: Ø
NOTICE OF MEETING
Notice of Meeting was posted at PH’s Administrative Office; also posted with full agenda packet on the PH web site on Monday, August 8, 2016 which is consistent with legal
requirements. Notice of that posting was also made via email to the Board and staff.
PUBLIC COMMENTS
There were no public comments.
*INFORMATION ITEMS
1. *Minutes: Board Quality Review Committee Meeting – Monday, July 18, 2016
No discussion. MOTION: by Director Greer, second by N/A Y
Director McCune and carried to
approve the July 18, 2016, Board
Quality Review Committee meeting
minutes. All in favor. None opposed
STANDING ITEM(S)
1. Journal Club
The Committee was given an article in their agenda packet from the Journal of the None None Y
American Medical Association, titled, “Workplace Violence in Health Care – A Critical Issue
with a Promising Solution” (Attachment #1).
Bret Bandick, Manager, Security shared with the Committee information regarding
A.L.I.C.E. (Alert, Lockdown, Inform, Counter and Evacuate) which is a specialized training
he teaches to staff members to protect themselves and patients during an active shooter
event.
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08.15.16 - MINUTES - BQRC Meeting - FINAL.doc
BOARD QUALITY REVIEW COMMITTEE MEETING MINUTES – MONDAY, AUGUST 15, 2016
AGENDA ITEM CONCLUSION/ACTION FOLLOW UP / FINAL?
RESPONSIBLE PARTY
2. The Patient Experience
The Committee was given three samples of recent communications received by patients None None Y
and/or patient family members, in their agenda packet (Attachment #2).

Tina Pope, Manager, Service Excellence, reviewed the Q4 FY2016 HCAHPS reports for
Palomar Medical Center and Pomerado Hospital as well as a summary of the Compliments,
Complains and Grievances received from patients and/or family members during the month
of June 2016 (Attachment #3).

Larry LaBossiere and Jeanette Skinner explained the results for the Pom Med/Surg/Tele –
Communication with Doctor and Rate Hospital 0-10 HCAHPS scores.
3. Quality and Safety Dashboards
As part of the Quality and Safety Dashboard, the Committee received the following reports None None Y
for their review and consideration (Attachment #4):
 CMS Star Ratings Report dated July 28, 2016
 Cliff Notes Summary of the Medicare Star Rating Program
 Article from Health Payer Intelligence titled, “House Introduces Bill to Delay CMS
Hospital Star Ratings”
 Hospital Compare Preview Report: Improving Care through Information – Inpatient for
both Palomar Medical Center and Pomerado Hospital.
 Hospital Acquired Conditions (HAC) Data Report

Valerie Martinez, Director, Quality, Patient Safety and Infection Control and David Lee, MD,
Medical Quality Officer, shared a presentation about our CAUTI rates titled, “A CAUTIonary
Tale” (Attachment #5).
NEW BUSINESS
1. Arch Health Partners Annual Report
GB “Robin” Rowland, MD, MPH, FACPM of Arch Health Partners presented an overview of None None Y
the services provided by Arch Health Partners as well as the improvement activities and key
accomplishments achieved since August 2015 (Attachment #6).
PUBLIC COMMENTS
There were no public comments
FINAL ADJOURNMENT
Meeting adjourned by Director Wickes at 7:43 p.m.
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