BOARD QUALITY REVIEW COMMITTEE MEETING

* Monday, October 20, 2014

5:30 p.m. (Buffet Dinner for Committee members & invited guests) 1st Floor Conference Room

6:00 p.m. Meeting 456 E. Grand Avenue, Escondido CA

Open Agenda

Time Target CALL TO ORDER 6:00

Establishment of Quorum ............................................................................................................

Public Comments ........................................................................................................................ 5 6:05

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. Information Item(s)

1. * Approval: Minutes – Monday, July 21, 2014 (ADD A - Page 2 - 7) ..................................... 5 6:10

New Business

a) Update on Palomar Health Ebola Preparation ............................................................................ Valerie Martinez, Director Quality, Patient Safety and Infection Control

10 6:20

b) Diabetes Services Update (ADD B – Page 8 - 33) .................................................................... Alan Conrad, MD, Medical Director, Clinical Outreach Services

Presentation – 10 minutes Questions and Answers – 10 minutes

20 6:40

ADJOURNMENT TO CLOSED SESSION 6:40

~ pursuant to Health & Safety Code Section 32155 Report of Medical Audit/Report of Q.A. Committee

RESUMPTION OF OPEN SESSION Immediately

following end of closed session

Action Resulting From Closed Session Discussion – IF ANY ............................................

FINAL ADJOURNMENT 8:10

Board Quality Review Committee Members Linda Greer, RN - Chairperson Opal Reinbold, MBA Della Shaw

Aeron Wickes, MD Bob Hemker, CEO David Tam, MD

Jerry Kaufman, PTMA Lorie Shoemaker, RN Sheila Brown, RN, FACHE

Charles Callery, MD Jerry Kolins, MD, FACHE

Daniel Harrison, MD Valerie Martinez, RN, BSN, MHA, CIC

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

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Addendum A

5

Page 1 of 2

ABBREVIATIONS GUIDE Updated: 8/25/2014

AAPL: ABX:

Academy of Applied Physician Leadership Antibiotics

ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACR: American College of Radiology AHRQ: ARB:

Agency for Healthcare, Research and Quality Angiotension Receptor Blocker

BETA: PPH Insurer BQRC: BSC:

Board Quality Review Committee Balanced Score Card

CALNOC: Collaborative Alliance for Nursing Outcomes CAP: College of American Pathologists CAUTI: Catheter Associated Urinary Tract Infection CCTP: Community-Based Care Transitions Program CDAD: Clostridium Dificile Associated Diarrhea CDC: Center for Disease Control CDI: Clinical Documentation Improvement C-diff: Clostridium difficile CDPH: California Department of Public Health CHA: California Hospital Association CIHQ: Center for the Improvement in Healthcare Quality CLABSI: Central Line Blood Stream Infection CLIP: Central Line Insertion Practices CMS: Centers for Medicare & Medicaid Services CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management CVICU: Cardio Vascular Intensive Care Unit DI: Diagnostic Imaging DRT: Diabetes Resource Team EBP: Evidence Based Practice ED Emergency Department EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EMT: Emergency Medical Technician EMT: Executive Management Team EVS: Environment of Care Services / Environmental Services FANS: Food and Nutrition Services FMEA: Failure Mode Effects Analysis HAI: Healthcare Associated Infections HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCP: Health care provider HDL: High Density Lipoprotein Cholesterol HLD: High Level Disinfectant HPRO: Hip Replacement Surgery IC: Infection Control

Addendum A

6

Page 2 of 2

ABBREVIATIONS GUIDE Updated: 8/25/2014

IHI: Institute for Healthcare Improvement IP: Infection Prevention (RN Staff) ISBARR: Introduction, Situation, Background, Assessment, Recommendations, Read back KPRO: Knee Replacement Surgery MDRO: Multi Drug Resistant Organism MRI: Magnetic Resonance Imaging MRSA: Methicillin-resistant Staphylococcus aureaus MSPRC: Medical Staff Peer Review Committee NDNQI: National Database of Nursing Quality Indicators NHQM or NIHQM: National Improvement for Healthcare Quality Measure NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NPSG: National Patient Safety Goals NQF: National Quality Forum OB: Obstetrics PCEA: Patient Controlled epidural Analgesia PDCA: Plan Do Check Act POCT: Point of Care Testing PPFR: Physician Performance Feedback Report QRR: Quality Review Report RAC: Revenue cycle Audits RCA: Root Cause Analysis RVT: Registered Vascular Tech SCIP: Surgical Care Improvement Project SIR: Standardized Infection Ratio SNF: Skilled Nursing Facility SSI: Surgical Site Infection STK: Stroke TAT: Turn Around Time TICU Trauma Intensive Care Unit TJC or JC: The Joint Commission US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Associated Pneumonia VBAC: Vaginal Birth After Caesarian Section VBP: Value Based Purchasing VRE: Vancomycin-resistant enterococcus

Addendum A

7

1

Diabetes ServicesPalomar Health

Board Quality Review CommitteeOctober 2014

Performance Improvement Activities

• Joint Commission Disease Specific Certification for Inpatient Diabetes

• Medication Management• Transitions of Care• Computerized Glucose Management Software• Surgical Care Improvement Project (SCIP)• Ongoing Data Collection• Patient Satisfaction

Addendum B

8

2

Performance Improvement Activities

• Joint Commission Disease Specific Certification in Inpatient Diabetes

• Medication Management• Transitions of Care• Patient Satisfaction• Ongoing Data Collection

Future Activities

• Perioperative Glycemic Management Initiative• Computerized Glucose Management Software• Continuation of All Current Foci of Care• Development of Yearly Goals

Addendum B

9

Executive Summary Diabetes Services

Board Quality Review Committee October 20, 2014

Diabetes Services at Palomar Health continues to work towards the best possible medical care for our patients with diabetes. Diabetes Services works in collaboration with Medical Staff, Nursing Staff, Food and Nutrition Services, Pharmacy Services and the Laboratory in continuous performance improvement. Feedback from our partners is crucial in this endeavor. At least twenty five percent of our inpatients have diabetes mellitus as either a primary or secondary diagnosis during admission. Diabetes touches every aspect of the hospital and the delivery of care. Diabetes Services Performance Improvement Activities include:

Joint Commission Disease Specific Certification in Inpatient Diabetes Four outcome indicators Point of Care Glucose Test Interval to Administration of Insulin Diabetes Educational Assessment within 24 hours of Admission Process of Transition from Intravenous Insulin to Subcutaneous Insulin Dosing of Basal Insulin on Transition from Intravenous to Subcutaneous Insulin Transitions of Care: Follow-up appointments for all patients diagnosed with diabetes Recertification due January to March 2015

Medication Management Hypoglycemia Prevention and Education Pharmacy collaboration regarding insulin pumps and use of U-500 Insulin Removal of oral diabetes agents from the ICU setting and adjustment of administration times in the non-ICU setting Intravenous Insulin Task Force to review PowerPlans and education regarding IV insulin Feasibility of intravenous insulin use outside of the ICU setting Monthly Diabetes Hospitalist Newsletter: Practical practice information NPH insulin to be dosed by pharmacy to match the process with the administration of Lantus insulin: Safety and compliance issue

Diabetes Resource Team Composed of 30 unit staff nurses, Pharmacy, Lab, FANS and Utilization Review Bimonthly 2 hour meeting Resource to staff, auditing, education, Joint Commission preparation and to provide clinical recommendations for practice

Transitions of Care Perioperative Glycemic Management Initiative Collaborative initiative to evaluate and improve our care of patients with diabetes during the pre-peri-post operative period Diabetes Patient Education Needs Assessment on admission: Identify needs early Providing follow-up appointments at discharge for all patients with diabetes Diabetes Clinical Nurse Specialist day of discharge consults for education and insulin administration instruction Collaboration with CCTP personnel for safe transitions home Improving the nurse handoff process Improving communication between physicians and nurses regarding changes in treatment plans Creation of a diabetes “depart” folder to facilitate the ordering of appropriate medications and equipment and to simplify the work of the discharging physician

Addendum B

10

Computerized Glucose Management System Preparation and implementation of Glycemicare, a Cerner based glucose management software application for Medical and Nursing Staff The software will provide for a more comprehensive view within Clarity regarding our patients with hyperglycemia and their treatment as well as tools for physicians for the administration of insulin Palomar Health will serve as a development partner with the vendor to enhance the offerings and capabilities of the software

Surgical Care Improvement Project (SCIP) Collaborative work with Cardiovascular Services to implement the care pathway for Cardiovascular Surgery patients Attainment of 100% compliance with CV Surgery SCIP measure: Cardiac Surgery patients must have a postoperative glucose ≤180 mg/dL in the time frame 18 to 24 hours after anesthesia end time

Ongoing data collection Diabetes Services compiles monthly data regarding: Hypoglycemia Rates by Population Hypoglycemia Rates by Patient Day Mean Glucoses by Patient Day and Unit-ICU and non-ICU Mean Glucoses by Patient Day-Orthopedics Mean Glucoses by Patient Day-Hospitalist Group Mean Glucoses by Facility Percentage of Patients with Blood Glucoses Greater than 180 mg/dl, 4 or more Days Information is shared monthly with the Medical Director group

Patient Satisfaction Creation of a Diabetes Education Booklet in English and Spanish; utilized in bedside education by the Nursing Staff Upcoming education for the Nursing Staff in carbohydrate consistent diets and carbohydrate counting Post Discharge phone calls by our Diabetes Nurse Specialists

Monthly Inpatient Rounding with Dr. Conrad, Diabetes Nurse Specialists, Medical Directors, Nursing Managers and bedside Nurses This serves as an educational opportunity for all those involved

Diabetes Clinical Nurse Specialists Patient/Family Sphere Focus on low volume, high risk patients, Type 1 and Type 1.5 patients, Pregnancy and Diabetes, hypoglycemia, new diagnosis of diabetes, insulin pumps, U-500, Diabetes Ketoacidosis, patients new to insulin Nursing Practice Nursing content experts, research and review of literature, education of nursing on diabetes care and practice guidelines and standards. Lead Diabetes Resource Team. Annual Nursing Skills Day Organization Collaboration with multiple departments. Members of committees throughout system

Addendum B

11

Plan-Do-Check-Act

Plan

Introduction Situation

Background

Purpose and Background (relevant to the organization): In current state, there are two electronic powerplans in critical care that utilize IV insulin infusions. Prior to converting to CPOE in June, 2012, these powerplans were paper-based.

1) IV insulin infusion for the treatment of hyperglycemia 2) DKA/HHNS for the treatment of DKA or HHNS 3) IV insulin infusion for the OB population

In the emergency department, there is a simplified ED DKA/HHNS powerplan. Over the past 5 years, several revisions have been made to the powerplans based upon feedback from nursing and medical staff. Several insulin drip tools have been developed by the diabetes team and pharmacy, including an IV insulin initiation & adjustment calculator and a DKA/HHNS calculator for IV fluid adjustments. In addition, a nursing checklist titled “Simplifying the DKA and IV Insulin Powerplan” has been developed. These tools can be accessed via Clarity via the Diabetes Tools_Insulin drip calculator icon. Despite education via a skills day event (2012), one-on-one training, and the insulin drip tools in clarity, nurse's report that the current electronic view has made it more difficult for the nurse to follow the orders in the DKA /HHNS and IV insulin gtt powerplans. This has led to confusion, missed orders, medication errors, IV fluid mismanagement, lack of physician notification and inaccurate documentation. As reported by the submission of Quality Review Reports from the Diabetes Nurse Specialists and direct reports from nurses, APRN's, Pharmacists, and regulatory surveys, the following are occurring: medication errors including missed orders, inaccurate incomplete nursing documentation, fluid mismanagement, and misuse of the insulin calculators. The stated problem or goal: Currently, Palomar Health has no standardized method to train and educate nurses on the following: 1) Navigating the IV insulin drip and DKA/HHNS powerplans 2) Use of the insulin drip calculator for hyperglycemia 3) Use of the DKA/HHNS calculator for IV fluid management 4) DKA disease process and its treatment vs. hyperglycemia and its treatment 5) IV insulin drip documentation For OB patients, practice currently varies and not utilizing CDAPP guidelines. Pharmacy reports duplicate IV insulin orders are being seen.

Addendum B

12

To ensure patient safety our goals are to: 1) To create a standardized method to train and educate nurses on care of the patient with Diabetes Ketoacidosis (DKA) , Hyperglycemia Hypersmolar Nonketotic Syndrome, OB patients & hyperglycemic patients requiring IV insulin and their respective treatments. 2) Create an electronic view of the IV insulin (including OB) and DKA/HHNS powerplans that is easier to read and follow, thereby creating proper use.

4) Increase nursing knowledge of the disease processes. 5) Increase the proper use of the appropriate calculators.

6) Improve nursing documentation.

7) Increase nurse confidence with the use of the powerplans.

8) Eliminate duplicate IV insulin orders

DO

Assessment Recommendation

Intervention (Describe the work done to correct the problem stated in the purpose and background/include dates): February 2014: Diabetes team proposal to APRN- approved. Development of APRN-led transdisciplinary IV Insulin/Education Taskforce March 2014: First meeting of IV Insulin Education/PowerplanTaskforce

Named a Chair (Doris Meehan)

Created objectives/goals/outcome measurements/timeline

Assigned action items: 1) -Pre-Survey of Nurses on knowledge, confidence/satisfaction,

documentation (Bunny & Rochelle to start first draft) 2) QI IRC application (Bunny to start first draft). OB wants to track use

of IV insulin (number of cases. Doris to contact Jeremy to obtain information)

3) Workgroups - Powerplans: Desiree, Eddy, Breana, Bunny, Pharmacy, Kim Duong - Education- Doris, Rochelle, Kristen Beske, Ann Watts (staff nurse), Terry law ( staff nurse),Peggy Morris (staff nurse, Lourdes J.(CNS) Each workgroup to take minutes and report to taskforce

Action items:

Create timeline of activities-

Workgroups to obtain staff membership

Members to go back to their respective units and find out the following 1) how are their staff currently being educated/trained 2) what resources are they using.

Addendum B

13

April 7, 2014: Doris attended SOS committee for the purpose or requesting staff participation. ISBARR created. May 17th IV powerplan workgroup 1st meeting develop plan ( see minutes) May 29th IV education workgroup 1st meeting develop plan (see minutes). OB will create separate IRC application/education/pre-survey, as content and new plans are coming. Taskforce to support as needed. June-August: Monthly workgroup meetings. (see minutes) July 30, 2014: Alerted Chris Saflar & Mike Flanders regarding upcoming module plans for video and requesting Sept video slots. July 31st Email to Melissa regarding upcoming plan for nursing education. Outcome: Melissa to CLC to obtain permission for mandatory education. July 30, 2014 OB submitted IRC application for Aug 14 review August 1, 2014 Submitted Pre-Survey to Nina Kim September 2014: Powerplan workgroup completed work. Only change will be to ED DKA plan. Eddie submitted Change request and changes approved. Workgroup meetings stopped and Taskforce now meeting at CEC. September 15-30: IV Insulin Pre survey sent to nurses in CC, S & P, ED at PMC, POM, PMCD September 23, 2014: Taskforce working on a new IV insulin set-up Mosby Skills and competency checklist. First draft of scenarios/scripts created for 3 educational modules ( Hyperglycemia requiring IV insulin therapy, Care of DKA, Care of HHNS). Group has decided to hold education off so that we can incorporate GlycemiCare content September 24, 2014 Diabetes Tools bar revised and IV insulin algorithm completed and posted as a reference for nurses. October Taskforce Work: Review of Survey, Complete Mosby IV Insulin Skills reference for nurses and inform nurses of content.

Participants: Diabetes Services APRN's & Nurse Educators from POM & PMC in CCU, OB, ED Pharmacy (Jeremy Lee & Diana Schultz) Nursing Informatics ( Breana Feistel) Staff nurses

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Check Pre-intervention Timeframe (year/month or quarter): March 2014-June 2014 Action items:

1) QI IRC submission (meets 2nd Thurs of the month. Must be in 2 weeks before meeting to Melissa). May 7, 2014 IRB meeting.

2) Create pre-survey of

nurses. End of May 2014 send out.

3) Recruit staff & meet with workgroups (May 2014) Education workgroup- create education plan Powerplan workgroup-submit to IT change requests the end of June

4) Taskforce meeting in June

Intervention Timeframe (year/month or quarter): July 2014- October 2014

1. Submit IT work 2. Create pre-

survey & education modules

3. Pre-Survey to nurses Sept 15-30

4. Create Scripts 5. Complete

Mosby skills 6. Attend CC

meeting and ED MD meetings with powerplan suggestions

7. APN's to obtain feedback from staff on units on powerplan suggestions for change

8. Collaborate with Patient Placement team for IMC drips- on hold till 2015

9. Collaborative Practice presentation for Provider awareness & input

10. Collaborate with IT for powerplan changes

Post-intervention Timeframe (year/month or quarter): Jan-March 2015 1) Complete 3 educational modules with GlycemiCare 2) April- June 2nd quarter competency- Education of nurses

Pre-Implementation Data: QRR reports- # of med errors Pharmacy audits-# of duplicate orders Diabetes Services Monthly IV insulin data sheets-# of documentation issues, med errors, misuse of calculators, incorrect IV fluids

Post-Implementation Data: QRR reports- med errors Pharmacy audits-duplicate orders Diabetes Services Monthly IV insulin data sheets- documentation issues, med errors, misuse of calculators, incorrect IV fluids

Act

Readback

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Data

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0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

P

e

r

c

e

n

t

Unit

Mean Glucoses by Patient Day and Unit PMC

April 2014

>180

90-180

<70

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273

302 286

245 251 267

294 283

296

11

38 24 20 18 18 16 8 7

1.2

1.6 1.4

1.2 1.3 1.5 1.5

1.7 1.7

0.05 0.2 0.1 0.1 0.1 0.1 0.08 0.05 0.04% 0

1

2

3

4

5

0

25

50

75

100

125

150

175

200

225

250

275

300

325

350

375

400

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

P

e

r

c

e

n

t

a

g

e

N

u

m

b

e

r

month

Hypoglycemia by Population 2014

<70

<40

% <70

%<40

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0.0

50.0

100.0

150.0

200.0

250.0

300.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

m

g

/

d

L

Month

Mean Glucoses by Hospital Campus 2014

PHDC

PMC ARU

PMC MHU

POM

POM GPU

PMC

0

10

20

30

40

50

60

70

80

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

P

e

r

c

e

n

t

a

g

e

Month

2 Glucoses Greater than 180 mg/dL for 4 or More Days During Admission

2014

PMC

Pomerado

PHDC

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0

5

10

15

20

25

30

35

40

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

P

e

r

c

e

n

t

a

g

e

Month

2 Glucoses Greater Than 180 mg/dL for 4 or More Days During Admission

ICU 2014

PMC

Pomerado

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