Quality, Safety & Patient Experience Committee Meeting ... · Reporting Expectations • The Committee report is presented at the next Lee Health Board meeting (may include recommended

Quality, Safety & Patient Experience Committee Meeting

Thursday, April 25, 2019

9:00 a.m.

AGENDA QUALITY, SAFETY & PATIENT EXPERIENCE (QSPE) COMMITTEE MEETING

August 29, 2019 AT 9:00 A.M. Gulf Coast Medical Center – Boardroom (Medical Office Building)

13685 Doctor’s Way, Ft. Myers, FL 33912

1. Welcome and Introductions from Committee Chair – Therese Everly, BS, RRT, Chair

2. Committee Minutes – April 25, 2019

3. Performance Oversight – Scott Nygaard, MD

4. System Safety Scorecard – Scott Nygaard, MD

5. Readmissions Steering Committee – Joby Kolsun, MD

6. ExceptionalLee Patient Experience and Engagement – Lisa Sgarlata, DNP

7. Hospital Acquired Infection Performance/CMS Star Ratings – Marilyn Kole, MD

8. TBD – TBD

9. Celebrations – Scott Nygaard, MD

10. Committee Member Reports – Committee Members

11. Meeting Evaluation – Therese Everly, BS, RRT, Chair

12. Adjourn – Therese Everly, BS, RRT, Chair

Date of the next QSPE Committee Meeting:

October 31, 2019 at 9:00 a.m. Gulf Coast Medical Center – Boardroom 13685 Doctors Way, Ft. Myers, FL 33912

QUALITY, SAFETY AND PATIENT EXPERIENCE (QSPE) COMMITTEE MEETING

Administrative Sponsor:Scott Nygaard, MD, MBAChief Operating Officer

April 25, 2019

LEE HEALTH BOARD OF DIRECTORS

Welcome & Introductions

Presented by:Therese Everly, BS, RRT

Committee ChairLee Health Board of Directors

All public input will take place at the Board of Directors Meetings, (not Committee Meetings).

At that time input is limited to three minutes and a “Request to Address the Board of Directors” card

should be completed and submitted to the Board Staff prior to meeting.

Non-Committee members are present to observe only and not to participate.

Please contact the Board Office with any questions. (239) 343-1500

Public Input Statement

Agenda

1. Committee Orientation:a) Review of Committee Charterb) Sunshine Law

2. Committee Minutes

3. Performance Oversight

4. System Safety Scorecard

5. Readmissions Steering Committee

6. ExceptionalLee Patient Experience and Engagement

7. Hospital Acquired Infection Performance/CMS Star Ratings

8. Pediatrics

9. Celebrations

10.Adjournment

4

5

Current and Upcoming Agenda Schedule

Sunshine LawReview of Committee Charter

Committee Orientation

6

Presented by:Mary McGillicuddyChief Legal OfficerLegal Services

Quality, Safety & Patient Experience

Committee

BOARD COMMITTEE ORIENTATION

April 25, 2019

• Committee’s Purpose

• Mission, Vision and Values

• Strategic Priorities

• Board / Medical Staff / Administration

• Committee Charter Highlights

• Board’s Omnibus Policy on Committees Highlights

• Sunshine Law

• Handling Questions / Concerns

Orientation Topics

Our Mission, Our Vision, Our Values

Mission: (Why we exist)

To be a trusted partner, empowering healthier lives

through care and compassion

Vision: (Our aspiration)

To inspire hope and be a national leader for health

and healing

Values: (Who we are)

Respect | Excellence | Compassion | Education

9

Exceptional Experience

We will provide safe, effective

care to ensure the best health

results for those we serve.

Excellent Health Outcomes

Deliver a caring and compassionate experience every time.

Committee’s Purpose

To assist the Lee Health Board of Directors with its responsibilities for oversight of the health system’s clinical quality, patient safety and experience to support achievement of the Lee Health mission, vision and strategic goals.

Lee Health

LEE HEALTH Board of Directors

Finance & Investment Committee (4)

AuditCommittee (2)

Quality, Safety & Patient Experience

Committee (4)

Community Health Improvement Committee (2)

GovernanceCommittee (2)

MEMBERS (7) MEMBERS (9) MEMBERS (7) MEMBERS (5) MEMBERS (4)

Board Members:David CollinsDonna ClarkeChris Hansen

Stephanie Meyer, BSN, RN

2 Community Members:TBD

1 Physician Member:TBD

Board Members:Stephen Brown, MD

Therese Everly, BS, RRTSanford Cohen, MD

Stephanie Meyer, BSN, RN

Recommended Physician Members:

Asif Azam, MDKeri Mason, DO

Larry Hobbs, MDEric Eason, DO

Mitko Badov, MD

Board Members:David Collins

Therese Everly, BS, RRTChris Hansen

Nancy McGovern, RN, MSM


1 Physician Member:TBD

Board Members:Jessica Carter PeerDiane Champion

Nancy McGovern, RN, MSM


Board Members:Jessica Carter PeerDiane Champion

Donna ClarkeSanford Cohen, MD

Administrative Sponsor Chief Financial Officer

Administrative Sponsor Chief Operating Officer

Administrative Sponsor Chief Foundation &

Development Officer

Administrative Sponsor VP Compliance & Internal

Audit

Administrative Sponsor Chief Legal Officer

Draft 4/25/2019

Medical Staff

Board of Directors

Administration

Lee Health Quality

LEE HEALTH Board of Directors

• Board delegated authority and responsibility to direct and control practitioners with privileges to perform professional services (Enabling Act, Section 9)

• Accountable to the Board for the professional performance and the quality of medical care provided to patients (MS Bylaws, Section 1)

• Authorized to establish a medical staff

• Ultimate responsibility for the quality of medical care provided to patients

• Ultimate authority to approve the granting of Medical Staff Membership and/or Clinical Privileges

(Enabling Act, Section 9 and MS Bylaws, Section 1)

• Board delegated authority and responsibility for the day-to-day management and operation of the health system

• Accountable to the Board of Directors

(Enabling Act Section 10)

LEE HEALTH Medical Staff

LEE HEALTH Chief Executive Officer

Quality - Authority

MEDICAL STAFF GOVERNANCEMEDICAL STAFF QUALITY AND PROCESS IMPROVEMENT

Board of Directors

PLCData Stewardship Subcommittee

Data Governance

SEC

CCC/CCG

GCHSWFMEC/Hospitals

Dyads

GCMCMEC/Hospitals

Dyads

HPMCMEC/Hospitals

Dyads

LMHMEC/Hospitals

Dyads

CCHMEC/Hospitals

Dyads

MSQ Peer

ReviewJOC

MSQ Peer

ReviewJOC

MSQ Peer

ReviewJOC

MSQ Peer

ReviewJOC

MSQ Peer

ReviewJOC

Board Quality, Safety & Patient Experience Committee

QSPE Charter

Purpose & Authority

Purpose: To assist the Board with its responsibilities

for oversight of the health system’s clinical quality,

patient safety and experience to support

achievement of the Lee Health mission, vision and

strategic goals.

• Advisory role

• Make recommendations to the LH Board

• Not authorized to direct the work of management

• Act collectively, not individually

QSPE Committee’s Responsibilities

• Oversee patient care, clinical quality, patient safety, and patient experience for the health system

• Support the health system’s program of continuous quality improvement

• Recommend system-wide quality goals, parameters, and metrics to the Lee Health Board

• Oversee quality improvement systems, priorities, and plans

• Make recommendations related to the Medical Staff Bylaws such as criteria and process for appointment and reappointment and credentialing

Responsibilities Review Continued

• Monitor the health system’s performance against

policies, goals, systems, and plans

• Oversee the system’s compliance with quality and

safety accreditation standards

• Make recommendations for education that relates to

the Committee’s purpose

Members

• Members understand the health system’s clinical quality, patient safety and experience performance and strategic goals.

• Basic knowledge of core quality concepts and the use of systems for quality improvement in the health system.

• Understanding of quality of care measures imposed by outside agencies and the ability to read and interpret fundamental clinical quality and safety metrics.

Members - continued

• Without limiting the number of terms Committee

members may serve, Committee members serve a one

year term on the Committee.

• Committee members serve as voting members.

• Committee members serve in a voluntary capacity and

receive no compensation.

Committee Leadership

• A Lee Health Board member is selected by the Board

Chair to serve as the Chair of the Committee.

• The Chair serves as the primary liaison to the Lee

Health Board and works in conjunction with the

administrative sponsor.

Committee Meetings

• Minimum of four times per years in accordance with a

calendar approved by the Lee Health Board

• Noticed in accordance with Florida’s open meetings

law

Administrative Sponsor

• The administrative sponsor of the Committee is the

health system’s Chief Operating Officer (COO).

• The COO will collaborate with the Chief Patient Care

Officer.

• The COO and the Committee Chair works together to

develop agendas and assure appropriate materials

for each meeting of the Committee.

Administrative Support

• The primary administrative support for the Committee

is provided by the administrative staff of the COO.

• Assistance from Clinical Quality and Patient Safety

and Experience colleagues, as needed.

• Activities of the Committee are coordinated with the

Board Office.

Reporting Expectations

• The Committee report is presented at the next Lee

Health Board meeting (may include recommended

action).

• Minutes will be kept and posted on the Lee Health

Board’s website after approval by the Committee.

• Additional reporting to the Lee Health Board will be

consistent with Lee Health Board policy.

Group Functioning Guidelines• Members are encouraged to participate actively

during meetings – both sharing ideas and listening to

other members’ ideas.

• The Committee will strive for consensus decision-

making, in which all members’ opinions have been

heard and considered.

• Any non-Committee members attending this

Committee meeting will be asked to observe only; not

to participate.

Board Committee Omnibus Policy

• Committees serve in an advisory role to the Board,

with the Board ultimately making final decisions.

• A majority of the members of the Committee plus one

(1) shall constitute a quorum for a meeting.

• The affirmative vote of a majority of Board Members

serving on the Committee and the affirmative vote of

all Committee members present at the meeting shall

be required to constitute action of the Committee.

Policy Highlights

• Committee members are expected to attend 75% or

more of the meetings for the Committees on which they

serve.

• In an emergency situation, and with prior Board Chair

approval, a Committee member may participate in a

meeting of the Committee by means of teleconference as

long as all persons participating in the meeting can

speak to and hear each other at the same time and each

member can participate.

Conflicts of Interest

• Generally, a conflict of interest exists when a committee member has any interests, financial or otherwise and directly or indirectly engages in any business transaction or professional activity or incurs any obligation of any nature which is in substantial conflict with the proper discharge of his or her duties.

• The Conflict of Interest Policy is designed to not unreasonably impede the recruitment and retention of those best qualified to serve.

• Committee members have a duty to bring perceived conflicts of interest to the attention of Board Counsel.

• A committee member may request an opinion of Board Counsel, who will provide an opinion as to whether a conflict of interest exists.

Information Flow Principles

• Since it is best practice for Committees and the Board to consider governance topics, not operational topics, governance-level topics will be presented.

• The vast majority of governance level information will flow through Committees.

• Committees focus on more detailed oversight information; ask important questions; identify issues and determine if additional information is needed.

• Except in extenuating circumstances:

• Materials will provided at least 7 days in advance of the meeting

• Neither Committees or the Board will be asked to vote on major decisions during the same meeting the information is first received

JAN FEB MAR APR MAY JUN AUG SEP OCT NOV

Fiduciary Approvals / Discussions

Legislative Agenda

External Audit Report

Corporate Compliance Plan

Draft Board Policies

Strategic Discussion

Strategic Planning

Board Officer Elections


Board Policies


TBD


Budget Assump-tions

External Investment Report


Legislative Briefing


Strategic Planning

TBD


Final Budget


Draft CEO Short-term Incentive Plan


CEO Short-term Incentive Plan

Board Meeting Calendar

External Investment Report


Approval Items at Every Meeting

Agenda Items Quarterly/Semi-Annually/Annually

Agenda Items As Needed

Consent Agenda Board Meeting Minutes Committee Recommended Actions (Green Sheet) Medical Staff Credentialing

Finance - Report (Q) QSPE - Strategic Dashboard (Q) QSPE – National Reporting Data (Q) QSPE – Internal Benchmarks (Q) QSPE – Patient Experience (Q) Audit – Risk Management (S-A) Gov. – CEO Evaluation Process (A) Gov. - Board Education (A) Gov. – Board and Committee Performance Evaluation (A) Gov. – Board Committee Members (A) Gov. – CEO Long-Term Incentive Plan (every 3 years) CHI – Community Benefit Report (A) CHI – Lee Community Healthcare Clinics (A) CHI – CHNA and Implementation Plan (every 3 years)

Regulatory Items Finance – Strategic Facility Capital Project and

Update Finance – Real Property Acquisitions Finance – Bank Loan Refinancing QSPE – DNV & ISO-9001 Gov. – CEO Contract Gov. - Board and Committee Orientation Education

DRAFT - Board’s Annual Topics Calendar

Sunshine Law

• Provides a right of access to governmental proceedings of public boards.

• Generally applies to any gathering, whether formal or casual, of two (2) or more members of the same board to discuss some matter on which foreseeable action will be taken.

• Applies to advisory committees created by public agencies that have been delegated decision-making, even though committee recommendations are not binding upon the agency that created the committee

• The Sunshine Law requires a public board and its committees to meet in public.

• Discussions related to matters that are foreseeable to come before a public board or its committees may not occur via written communication, emails, or text messages.

Sunshine Law – Procedural Requirements

Unless an exemption applies, there are three (3) basic

requirements:

• Meetings of boards or committees must be open and

accessible to the public.

• Reasonable notice of such meetings must be given.

• Minutes of meetings must be taken.

Communication with Staff Members

• May call upon and meet with staff members for

factual information and advice.

• Staff members may not circulate the thoughts or

comments made by individual board or committee

members among other board or committee members

relating to matters that are foreseeable to come

before the board or committee for action.

Sunshine Law Violations

• An unintentional violation of the Sunshine Law is a non-criminal infraction punishable by a fine of up to $500.

• A knowing or intentional violation is a 2nd degree misdemeanor punishable by a fine of not more than $500 and/or a jail term of not more than 60 days.

• Any public official who intentionally violates the provisions of the Sunshine Law may be subject to suspension or removal from office.

• Attorney’s fees and court costs are available to the requestor that prevails in a civil suit for access.

Handling Concerns

• Questions and concerns are forwarded to the Board

Office Coordinator or Board Assistant

• Process ensures timely review and response

Thank You!

QUESTIONS?

Committee Minutes

No Minutes to Approve

40

PERFORMANCE OVERSIGHTPresented by:Scott Nygaard, MDChief Operating Officer

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Update Frequency: Monthly

Percentile Stars

0-19

20-39

40-59

60-79

80-100

CMS 5 Star Campus Summary Score Trend

Performance periods: Mortality:3Q14-2Q17, Readmission: 3Q14-2Q17; 3Q16-2Q17 (Hosp-Wide), HAIs (2Q17-1Q18) , PSI90 (4Q15-2Q17), COMP-HIP-KNEE (2Q14-1Q17), HCAHPS (2Q17-1Q18), Efficient Use of Medical Imaging (3Q16-2Q17), Timeliness (2Q17-1Q18), Effectiveness of Care (2Q17-1Q18)

Updated Frequency: July & DecemberData Source: CMS Star Rating

Update Frequency: April & OctoberData Source: LeapFrog

Current Leapfrog GradesFall 2018

#3

400

.159

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FYTD 19 System Strategic Scorecard UpdatePresented by:Scott Nygaard, MD

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Exceptional Patient Experience

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Strategic Priority Key Performance Indicator

Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT CULTURE

84.2% 73.7% 75.9% 68.2%

81.3% 69.6% 73.0% 67.3%

Exceptional

Patient

Experience

Patient Experience (Adult Acute IP HCAHPS)

Patient Access(Adult LPG Access Perception)

Higher is

Better

Higher is

Better

Does not

MeetFYTD Mar

Does not

MeetFYTD Mar

Right Care

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Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT CARE

118 188 118 161

Patient Impact(National Healthcare Safety Network nursing units,

NHSN)

Lower is

Better

Meets

Goal

12-mos

ending Jan

2019

Excellent Health

Outcomes

Mortality(Lee Health facilities only)

1.57%Lower is

Better1.52% <1.52% 1.55%

Does not

MeetFYTD Feb

Higher is

Better7,000 8,400 13,833

Better

than GoalFYTD Mar

Increase the LPG Primary

Care Patient Base--

Patient Impact by Condition

50

Coordinated Care Model

51


Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT TIME & PLACE

14.6% 15.5% 14.6% 15.2%

Lower is

Better15.8%

Medicare Payor 30-day

Readmission Rate (Lee Health facilities only)

Lower is

Better

Meets

GoalFYTD Jan

Coordinated

Care

Model 15.1% 15.9%Does not

MeetFYTD Feb

Adult IP Ambulatory Care

Sensitive Condition Rate14.4%

Right Cost

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Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT COST-- 25.0% 30.0% 32.8%

Higher is

Better3.0% 3.5% 4.2%

Better

than GoalFYTD Mar

Year over year freestanding

outpatient revenue growth (2018 vs 2019)

Higher is

Better

Better

than GoalFYTD Mar

Strong Financial

Results Operating Margin % 4.6%

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Thank You

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READMISSION STEERING

COMMITTEE

Presented by:John Chomeau

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System Initiatives Impacting Readmissions

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Epic 30 day Readmission Risk Stratification Scoring on all inpatients

Over 9,000 prescriptions per month being delivered at the bedside or from the Lee Health outpatient pharmacy prior to patients leaving the hospital

Pharmacists involvement with discharge medication reconciliation for 33 % of all discharges per month –focusing on high risk patients

Follow up appointments being scheduled for about 500 high risk patients prior to being discharged from the hospital

We are also deploying a new Qlik analytic tool for readmissions analysis

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60

61

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ExceptionalLee Patient Experience and Engagement

Presented by:Lisa Sgarlata, DNP, MSN

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Key Focus Areas

According to Catalyst, moving the score on the following dimensions of HCAHPS will make the biggest impact on overall score for all inpatient areas across Lee Health.

• Communication with Nurses

• Care Transitions

• Responsiveness of Staff

Engagement – Lee Health IP Adult

HCAHPS: Dimension

Patient Experience Strategy 2019

Patient

Voice

PatientVoice

PatientVoice

Patient Family Advisory Councils (PFACs)

Background:

• HealthPark PFAC sunsetted in February 2019

• Planning underway to launch systemwide ExceptionalLee PFAC

• HealthPark PFAC Interviews

• Inaugural workgroup: May, 2019

Patient Family Advisory Councils (PFACs)

PFAC Objectives:

• Provide a safe and meaningful way for patients/family members to share feedback on their experience with Lee Health

• Incorporate community voice into ExceptionalLee

• Serve as focus group and partner in designing more patient-friendly services and processes

• Inform decision making

• Nurture and activate Lee Health champions in the community

Physician Engagement

Physician Agenda

ExceptionalLee Leadership: A New Day at Lee Health

7:30 am – 8:00 am

Breakfast & Networking

8:00 am – 8:45 am

Welcome & Executive Panel Discussion

8:45 am- 9:15 am

Debrief Panel Discussion

9:15 am – 9:25 am

Break

9:25 am- 9:55 am

Mission, Vision & Values

9:55 am – 10:15 am

Trust Builders & Trust Breakers

10:15 am – 10:50 am

Self-Assessment Leadership Essentials

10:50 am – 11:05 am

Break

11:05 am – 11:30 am

Feedback,Survey Results & Managing Up

11:30 am – 12:00 pm

Dream Team Activity

12:00 pm- 12:30 pm

The “Concept of Why” – Simon Sinek

Closing Comments

• Format: 4.5 Hour In-Person Sessions

• Targeted Start: May 2019

• Repurpose core content from Fall Leader Sessions

• Draft agenda, detailed agenda and facilitator guide developed and currently under review

ExceptionalLee Employee Town Halls

Forum for Employees to

Connect with Senior Leaders

Demonstrate Alignment Among

Leadership

Further Build Trust by Showing Responsiveness

To Feedback

Provide an Update on ExceptionalLee and Our

Journey

Letter Campaign Leader Materials

Engagement Guide Discussion Guide

Training PowerPoint

Letter Campaign Employee Materials

One Pager Video

NEW: ICARE Lunch & Learn Series

Goals:

• Further hardwire the consistent and effective use of ICARE across the organization

• Equip leaders to engage those they lead around ICARE by modeling effective use of prepared tools/resources

• Provide a regular forum for leaders/employees to ask questions about ICARE or other PX issues

ExceptionalLee Appreciation Week

Overview

• Align with National Patient Experience Week – April 22-26, 2019

• Special “thank you” for our patients at all locations

• Focus on simple, relational activities to create “feel good” moments

• Provide opportunity to model servant leadership among system leaders

Purpose: Nurse Leader Patient Rounding

• To reconnect and support the evidenced-based practices which support the ExceptionalLee Promise as well as our ICARE Standards of Behavior.

• To ensure these best practices are shared with our patients, families and each other in an intentional and meaningful way with personal connection, compassionand empathy.

EBPs: Nurse Leader Patient Rounding

• Establish patient centered evidence based questions

• Asking consistent evidence based questions will confirm that the following is heart wired

Next Steps: Nurse Leader Patient Rounding

• A needs analysis presentation to campus dyads on key strategic EBP to improve patient experience

• Partnering with campus dyads to present to their leaders

• PX Engagement Specialist collaborated with designated directors and managers to refocus on purposeful, intentional Nurse Leader patient rounds, initially focusing on quality and intent vs. quantity

SPIRIT Awards

• SPIRIT Awards provide a way for patients and their family members to provide feedback on an exceptional employee, nurse or physician. Employee nominations are no longer accepted.

Nursing Clinical Excellence

• Highest professional honor for Lee Health nurses

• Qualifications have been updated to reflect ExceptionalLee

• Desire to get moreand better nominationsin 2019

Passion for the Promise Award

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HOSPITAL ACQUIRED INFECTION PERFORMANCECLABSI,CAUTI AND C DIFF, MRSA, SSI, AND PE/DVTPSI’S

Presented by:Marilyn Kole, MD

CLABSI Performing at 4-Star LevelCentral line-associated bloodstream infections

86

90 Day Action Plan - Current:

• Focus on high line utilization and early removal of lines• Adding CHG treatment for any planned line and IVAD access• Infection Prevention CCG collating all 5 Whys• Re-education provided this month for maintenance and collection of

specimens

Benchmark: CMS Value-Based Purchasing National Percentiles

90 Day Action Plan – Previously:

• Continued focus on line utilization days and early removal• Infection Preventionist identified as new “Coordinator” role for

workgroup with Physicians• Increased Infection Prevention surveillance at every campus

The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.

CAUTI Performing at 5-Star LevelCatheter Associated Urinary Tract Infections

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90 Day Action Plan – Current:

• Re education on algorithm for CAUTI prevention• Continued focus on line utilization and early removal• Infection Prevention CCG collating all 5 Whys• Increased Infection Prevention surveillance at every campus



• Continued focus on line utilization and early removal• Re-education provided at Nursing education leadership meeting for

bundle• Infection Preventionist is new “Coordinator” with lead Physicians • Increased Infection Prevention surveillance at every campus


C Diff: Performing at 4-Star LevelClostridioides Difficile

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• Re education of cancelled orders

• Nursing to address GI panel restricted to ED on floor

• Compliance metrics with CHG treatment

90 Day Action Plan – Previously: • Redesign of C diff Process:

• Change in testing methodology/collection Process/Ordering process

• Provider education underway for new changes• Staff education underway• Infection Preventionist is new system “Coordinator” Team Leader

with Provider• Collaborating with Quality/Infection Prevention at Tampa General,

Medicare Consultant(QIO), and Rochester for redesign


MRSA: Performing at 3-Star LevelMethicillin Resistant Staph Aureus



• Peripheral IV focus (50 chart reviews completed)• Chlorhexidine gluconate (CHG) treatment• Early removal• Increased surveillance

• Evaluation of Blood Culture process and early collection• Infection Prevention led Process Improvement Team at

each campus activated

90 Day Action Plan - Previously:

• Clinical Consensus Group- MRSA Workgroup • Peripheral IV’s focus• Chlorhexidine gluconate (CHG) Treatment• Developing recommendations• Blood Cultures early for patients with wounds,

chronic osteomyelitis, prior MRSA bacteremia(Ongoing)

• Weekly MRSA report to Campus Leadership (Ongoing)• LAB identification-not Hospital Acquired Infection

surveillance• Infection Prevention led Process Improvement Team at

each campus


SSI-COLO: Performing at 4-Star LevelColorectal: Surgical Site Infections

90



• Increasing adoption of ERAS, (Enhanced Recovery after Surgery)• Documentation improvement increased with real time Surgeon

and/or Operating Room Director notifications • SSI Bundle Checklist Compliance Infection Prevention plan active• Continuing 1:1 surgeon meetings• New EPIC surgeon dashboard being validated


• Presenting data at Campus level Surgical meetings• Antibiotics for surgical case review completed (Antibiotic

Stewardship opportunities)• Increase adoption of ERAS, (Enhanced Recovery after Surgery)• Documentation improvement pilot with real time Surgeon and

Operating Room Director notifications • SSI Bundle Checklist Compliance plan


Medicare PE/DVT: Performing at 5-Star LevelPulmonary Embolus-Deep Vein thrombosis


• Letters to Surgeon/Hospitalist/Advanced Providers• New EPIC risk tools for high risk Surgical and Medical

patients approved and in development• Surgical patient safety indicators redesign with real time

review • SSI and PE/DVT 1:1 Surgeon meetings • Documentation improvement pilot with surgeons real

time



• Letters to Surgeon/Hospitalist/Advanced Providers to notify them of cases and request chart review(New)

• Developing new risk tool for high risk patients with recommendation for treatment (New)

• Standardize pre-op and post-op DVT chemo prophylaxis/Sequential compression devices, and ambulation with evidenced based practice (Ongoing)

• SSI and /PE/DVT 1:1 Surgeon meetings (Ongoing)• MD-PA-Pharmacy review of all PE/DVT cases weekly

(Ongoing)• Coding/ Process Analytic ongoing meetings for real time data

validation and Provider review(Ongoing) • Encourage campus Surgeon/Anesthesia group meetings to

review Surgical Site (Recommended)


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HAC Reduction

PEDIATRIC QUALITY METRICS

Presented by:Susan Ryckman, MSN


95

PRIORITIES MEASURING SUCCESS OUTCOME MEASURE

HIGHLIGHTS

Exceptional Patient

Experience Deliver a caring

and compassionate

experience every time

Top Box Scores at or > 75th%ile

(>86.2-inpt) (>76.6-ED)

February YTD

84.3 (inpt) 65th %tile

88.8 (ED) >95th %tile

Kudos to the following GCHSWFL Units Top Box Scores at or above 75

th Percentile:

PICU-22 consecutive months @ 100%!

Pediatric Oncology-5 consecutive months @ 100%

Emergency Room


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HIGHLIGHTS


Empower healthier lives through personalized

coordinated care

30 DAY READMISSION <6.1%-6.9%

January YTD 30 DAY

READMISSION 5.97%

Readmission rate goal is the Florida Hospital Association Target for Readmissions

Area of Focus Opportunities Identified 90-day actions

Readmission Rate • Reduced Target from 8.0 to 6.01 Readmissions per 100 IP Discharges to meet FHA Target Benchmark

• Sustain and Improve current Readmission Rate

• Real time review of readmissions in daily safety huddle

• Retrospective review for trends upon monthly data distribution

• Discussion with Clinical Dyads on areas for improvement

Right Care

98


HIGHLIGHTS

Excellent Health Outcomes

Provide safe, effective care to ensure the best

health for those we serve

CLABSI: SIR <.253 Hospital Acquired C-DIFF: <.244/1000 Patient Days MRSA Bacteremia: SIR <2.37

FY19

CLABSI SIR-.000

Hospital Acquired C-DIFF

.154/1000 Patient

Days

MRSA Bacteremia:

SIR-.000

Kudos to the following GCHSWFL Units on ZERO CLABSI for FY19:

PICU

NICU

Hematology-Oncology

Medical/Surgical 6th & 7th Floor Kudos to the following GCHSWFL Units on ZERO CDIFF for FY19:

Medical/Surgical 6th & 7th Floor

PICU Kudos to the following GCHSWFL Units on ZERO CLABSI for FY19:

PICU

NICU

Hematology-Oncology

Medical/Surgical 6th & 7th Floor

Right Care: Patient Impact by Condition

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Right Care: Children’s Hospitals’ Solutions for Patient Safety

100

Area of Focus Opportunities Identified 90-day actions

Join Children's Hospitals’ Solutions for Patient Safety Network: Pediatric HIIN with 130+ Children’s Hospitals

• Need Pediatric focused HIIN to Reduce Harm by utilizing the All Teach, All Learn method

• Employee high-reliability concepts and quality improvement science methods to reduce harm in the following Pediatric Specific dimensions:

• Readmissions < 7 Days• Adverse Drug Events• Antimicrobial Stewardship• Central Line-Associated Blood

Stream Infections• Falls with Injury• Nephrotoxic Acute Kidney

Injury• Peripheral IV Infiltrates• Pressure Injuries• Surgical Site Infections• Unplanned Extubations• Ventilator Associated Events

• February 2019: Getting Started Webinar

• Participate in best practice conference calls, webinars and learning sessions

• Implement and measure all standard bundle elements

• March 2019: • Submit Participation

Agreement

• April 2019: • Complete HAC/Bundle GAP

Analysis

CELEBRATIONS

Presented by:

Scott Nygaard, MD, MBA

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102

DNV Certification

We had one of our most successful DNV Surveys in 2019

Lee Health is now certified for three years

for the new System ISO 9001:2015

AND

DNV-GL certified for three years

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Platinum Certified Zero

Total cost of quality has reduced by $5.2 million dollars from FY17 to FY19

104

Predicted FY2020 Penalties:HAC: $0VBP: -$560,000HRRP: -$1,900,000

TOTAL: -$2,460,000

Lee Health is not expecting penalties for the HAC Reduction Program for FY 2020. This assessment is based on hospital performance using Medicare claims and CDC measures

105

Committee Members Reports

106

Meeting Evaluation

Adjournment

108

Date of the Next Meeting:

QUALITY, SAFETY, & PATIENT EXPERIENCE COMMITTEE

Thursday, August 29, 20199:00 AM

Gulf Coast Medical CenterMedical Office Building

13685 Doctors WayFort Myers, FL 33912

Documents

Quality, Safety & Patient Experience Committee Meeting ... · Reporting Expectations • The Committee report is presented at the next Lee Health Board meeting (may include recommended