Board Quality Review Committee Meeting

92 Pages·2016·4.64 MB·English

BOARD QUALITY REVIEW COMMITTEE

AGENDA

MONDAY, April 18, 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 Target
PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING
A
ROOM
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, March 21, 2016 (Addendum A, Page 9 - 17) 4 3 6:20
2. Follow-up on Patient Complaint (Addendum B, Pages 18 - 21)
10 4 6:30
Jerry Kolins, MD, Vice President, Patient Experience
 Standing Item(s)
1. Journal Club: Page 29 – 31 of “Free from Harm: Accelerating Patient Safety Improvement Fifteen
10 5 6:40
Years after “To Err Is Human” by National Patient Safety Foundation (NPSF) (Add B, Pages 22 - 24)
 New Business
1. a) Annual Summary and Evaluation of the CY 2015 Infection Prevention & Control Program Plan 6
and Working Plan for CY 2016 (Addendum C, Pages 25 - 56)

Valerie Martinez, Director, Quality, Patient Safety and Infection Control

25 7:05
b) *Review/Approve: CY 2016 Revised Infection Prevention & Control Risk Assessment and
7
Surveillance Plan (Addendum D, Pages 57 - 90)
Valerie Martinez, Director, Quality, Patient Safety and Infection Control
2. Resource Utilization (Addendum E, Page 91 - 92) 10 8 7:15
Marcy Adelman, Director, Clinical Resource Management
Frank Martin, MD, Physician Advisor, Revenue Cycle Management

 Public Comments1 15 N/A 7:30
FINAL ADJOURNMENT 7:30
NOTE: The open session agenda, without public comments, is scheduled for 1 hour. Based on above agenda, without public
comments the meeting starts at 6:00 p.m. and adjourns at 7:00 p.m.
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BOARD QUALITY REVIEW COMMITTEE

AGENDA

MONDAY, April 18, 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

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING
ROOM Board Quality Review Committee Members
VOTING MEMBERSHIP NON-VOTING MEMBERSHIP
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 (through May Maria Sudak, RN, MSN, CCRN, NEA-BC – Interim VP, Palomar Medical
2016) Center and Chief Nursing Office, Palomar Medical Center
Charles Callery, MD - Chair of Medical Staff Quality Management JCuhneery Gl Oowlseorn, ,R InNt,e MrimS NV,P C, CPRomN,e rNaEdAo -HBoCs p–i tCahl iaenf dN PurHs iDngo wOnfftiocwern, CPaalmompuasr
Committee for Pomerado Hospital Manedd iIcnatel rCimen CteNrO , Pomerado Hospital and Palomar Health Downtown
JCJuearnmreyp GKuoosl winesr,, MRDN,, FPAh.CDH. E– I–n tVePri,m P Cathieienft NEuxrpseinrige nOcfefi caenrd, PCoom-C &h aPirH oDf C
Patient Safety Committee
Valerie Martinez, RN, BSN, MHA, CPHQ, CIC – Co-Chair of Patient
Safety Committee
Sheila Brown, VP, Continuum Care

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, March 21, 2016

TO: Board Quality Review Committee

MEETING DATE: Monday, April 18, 2016

FROM: Christine Breese, Executive Assistant

Background: The minutes of the Board Quality Review Committee held
on Monday, March 21, 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
3
Follow-up on Patient Complaint and
Review of Correspondence from Patients & Family Members
Board Quality Review Committee

TO: Board Quality Review Committee

MEETING DATE: Monday, April 18, 2016

FROM: Christine Breese, Executive Assistant

Background: Jerry Kolins, MD, Vice President, Patient Experience will
provide an update to the Committee regarding his
investigation of the complaint which was shared with the
Committee at their last meeting held on March 21, 2016.
In addition to this update, several letters from patients and
family members are included for the Committee’s
information and will be discussed (Addendum B).

Budget Impact: N/A

Staff Recommendation: For information only

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A
4
Journal Club Assignment
Page 29 - 31 of “Free from Harm: Accelerating Patient Safety
Improvement Fifteen Years after To Err Is Human”

TO: Board Quality Review Committee

MEETING DATE: Monday, April 18, 2016

FROM: Christine Breese, Executive Assistant

Background: The Journal Club assignment for April 2016 is to read page
29, 30 and 31 of the article titled, “Free from Harm:
Accelerating Patient Safety Improvement Fifteen Years
after To Err Is Human” which was published by the
National Patient Safety Foundation (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
5
Annual Summary and Evaluation of the 2015 Infection
Prevention and Control Program Plan and the Working
Plan for 2016
Board Quality Review Committee

TO: Board Quality Review Committee

MEETING DATE: Monday, April 18, 2016

FROM: Christine Breese, Executive Assistant

Background: Valerie Martinez, Director, Quality, Safety and Infection
Prevention has provided the annual “Summary and
Evaluation of the Calendar Year Infection Prevention and
Control Program Plan and the Working Plan for Calendar
Year 2016” for the Committee’s review (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
6
2016 Revised Infection Prevention & Control Risk
Assessment and Surveillance Plan – Lucidoc Policy #15412
Board Quality Review Committee

TO: Board Quality Review Committee

MEETING DATE: Monday, April 18, 2016

FROM: Christine Breese, Executive Assistant

Background: Valerie Martinez, Director, Quality, Patient Safety and
Infection Prevention has provided a draft of the Calendar
Year 2016 Revised Infection Prevention & Control Risk
Assessment and Surveillance Plan (Lucidoc Policy
#15412) for the Board Quality Review Committee’s review
and approval (Addendum D).

Included is a red-line draft showing the proposed changes
to Lucidoc Policy #15412.

Budget Impact: N/A

Staff Recommendation: Approval

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A - Addendum D
7
Resource Utilization Update
Board Quality Review Committee

TO: Board Quality Review Committee

MEETING DATE: Monday, April 18, 2016

FROM: Christine Breese, Executive Assistant

Background: Marcy Adelman, Director, Clinical Resource Management
has provided an update for the Committee’s review of the
performance improvement activities for Resource
Utilization (Addendum E).

Budget Impact: N/A

Staff Recommendation: For information only

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion:

Individual Action:

Information:

Required Time:

Form A - Addendum E
8
ADDENDUM A
9
Addendum A
Board Quality Review Committee Meeting

OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES
CALENDAR YEAR 2016

Palomar Health Meeting Dates:
By-Laws’
1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16
Voting Members Membership
DIRECTOR AERON WICKES , MD – CHAIR Board Member P P P
DIRECTOR LINDA GREER, RN Board Member P P P
DIRECTOR DARA CZERWONKA Board Member P P P
DIRECTOR HANS SISON (ALT) Board Member P
FRANK MARTIN, MD QMC Chair,
P P
Palomar Medical Ctr
RICHARD ENGEL, MD Interim QMC Chair,
P
Palomar Medical Ctr
CHARLES CALLERY, MD QMC Chair,
P P P
Pomerado Hospital
Non-Voting Members
BEIRNE, FRANK EVP, Operations P P P
CONRAD, ALAN, MD EVP,Physician Alignment P P P
GOWER, JUNE, PH.D. Interim CNO, PHDC &
-- -- -- -- -- -- -- -- -- --
Pomerado Hospitals
HEMKER, BOB President & CEO P P P
KOLINS, JERRY, MD, FACHE VP, Patient Experience
and Co-Chair, Patient P P P
Safety Committee
MARTINEZ, VALERIE, RN, BSN, MHA, CIC Co-Chair, Patient Safety P P P
Committee
OLSON, CHERYL Interim VP, PHDC &
P P P
Pomerado Hospitals
SHAW, DELLA EVP, Strategy P
SUDAK, MARIA, MSN, CCRN, NEA-BC, RN CNO & Interim VP, P P P
Palomar Medical Center
Guests
BARNES, DEBBIE, RN, CDS
BROWN, SHEILA, RN, FACHE P
FARROW, DAN
GOELITZ, BRIAN, MD P
GRIFFITH, JEFF (BOARD MEMBER)
HANSEN, DIANE P
KAUFMAN, JERRY (BOARD MEMBER)
KIM, JESSICA P P P
LEE, DAVID, MD P P P
LEE, JEREMY P P
MCCUNE, RAY (BOARD MEMBER)
NAMENYI, JASMINA P
NEUSTEIN, PAUL, MD P
NICPON, GREGORY, MD P
PHILLIPS, DONITA, MBA, ARM P P P
POPE, TINA P P P
03.21.16 - ROSTER - BQRC Meeting Attendance Roster.docx Page1 1 0of 2