Ninth Compliance Report On Parkland Memorial Hospital

Report of the Independent Consultative Expert (ICE) Monthly Progress Report November, 2012 on Parkland Health & Hospital
l System Dallas, Texas
December 13, 2012

Submitted To:
Centers for Medicare and Medicaid Services and Parkland Health & Hospital System
Submitted By:
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 SystemAlvarez & Marsal Progress Report to CMSNovember 2012
EXECUTIVE SUMMARY .........................................................................................................................................3 SIGNIFICANT CAP-RELATED GOALS MET IN NOVEMBER ..........................................................................................4 SIGNIFICANT CAP-RELATED GOALS STILL OUTSTANDING IN NOVEMBER.................................................................4 OVERALL IMPRESSIONS FROM NOVEMBER.................................................................................................................5 ACCESS AND THROUGHPUT ................................................................................................................................6 CARE MANAGEMENT .................................................................................................................................................6 ENVIRONMENT OF CARE......................................................................................................................................7 HUMAN RESOURCES ..............................................................................................................................................9 NURSING COMPETENCIES.........................................................................................................................................10 CORRECTIVE ACTIONS .............................................................................................................................................10 MEDICAL STAFF ....................................................................................................................................................10 ONGOING PROFESSIONAL PRACTICE EVALUATION (OPPE)/PEER REVIEW ..............................................................11 PRIVILEGES AND CREDENTIALS ...............................................................................................................................11 NURSING/PROVISION OF CARE ........................................................................................................................11 NURSING PRACTICE AND NURSING UNITS ...............................................................................................................11 NURSING FLOAT POOL .............................................................................................................................................12 PRESSURE ULCERS ...................................................................................................................................................12 RESIDENT SUPERVISION.....................................................................................................................................13 HOUSE-WIDE ISSUES ............................................................................................................................................13 ABUSE SCREENING...................................................................................................................................................13 CONTRACT SERVICES ...............................................................................................................................................14 INFECTION PREVENTION ..........................................................................................................................................14 INFORMED CONSENT TO TREATMENT FORMS AND PROCEDURES .............................................................................15 ROOT CAUSE ANALYSIS (RCA) ...............................................................................................................................16 SAFE PATIENT DISCHARGES.....................................................................................................................................16 DEPARTMENT AND UNIT SPECIFIC FINDINGS ............................................................................................18 CHEMOTHERAPY INFUSION CENTER ........................................................................................................................18 COMMUNITY ORIENTED OUTPATIENT CLINICS (COPC) ..........................................................................................18 HEMODIALYSIS ........................................................................................................................................................20 MEDICATION MANAGEMENT ...................................................................................................................................21 PATIENT RELATIONS ................................................................................................................................................21 PHARMACY ..............................................................................................................................................................22 PSYCHIATRIC SERVICES ...........................................................................................................................................23 RADIOLOGY .............................................................................................................................................................23 STERILE PROCESSING DEPARTMENT ........................................................................................................................24 URGENT CARE CLINICS ............................................................................................................................................25 FOCUS AREAS FOR NEXT 30 DAYS ...................................................................................................................26 CONCLUSION ..........................................................................................................................................................28
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 ninth 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 November Parkland continued to make progress in meeting most of the deadlines established in the CAP for November 2012. Since the implementation of the CAP on March 19, 2012 a total of 465 tasks have been completed. An analysis of tasks completed by Work Stream is below:
WS # Work Stream Name Governance, Leadership, and Org Structure Clinical Operations Access/Throughput Nursing Physicians QAPI TOTAL Total Complete % Initiatives Initiatives Complete 59 183 111 38 60 48 499 49 164 111 38 58 45 465 83% 90% 100% 100% 97% 94% 93% On time Initiatives 1 11 0 0 2 3 17 Delayed Initiatives 0 0 0 0 0 0 0 Missed Deadline / % Complete and On Time Not Sustainable 9 8 0 0 0 0 17 85% 96% 100% 100% 100% 100% 97%
1 2 3 4 5 6
Also, presented below is a breakout by action streams, for the two work streams performing under 95 percent compliance in meeting target dates for their CAP initiatives.
AS # Action Stream Name Total Initiatives 2 14 5 6 7 25 27 28 Complete % Complete 50% 79% 80% 67% 86% 92% 78% 79% On Time Initiatives 0 0 0 1 0 0 4 4 Delayed Initiatives 0 0 0 0 0 0 0 0 Missed Deadline / Not Sustainable 1 3 1 1 1 2 2 2 % Complete and On Time 50% 79% 80% 83% 86% 92% 93% 93%
3.3 1.2 2.6 3.5 6.4 3.4 4.4
Bed Management Organization Structure Changes Other hospital-based department specific initiatives Continuum of care beyond acute care setting Metrics for Departmental QAPIs Case Management, Discharge planning initiatives Clinical Competency Oversight Nursing roles & responsibilities; staffing levels and staffing 4.3 models
1 11 4 4 6 23 21 22
Significant CAP-related Goals Met in November

Admit, Discharge and Transfer (ADT) Department Full implementation of the bed czar model within the ADT department. Patient Flow coordinators routinely round on Hospital floors and interact with nursing to manage bed placement
Care Management Implemented interdisciplinary team meetings (IDT) across the Hospital. A&M presented its findings on the success of these meetings in this report. Created/revised policies to determine high risk patients.
Emergency Department Implemented and successfully audited a central patient log. Developed tracking mechanism and disciplinary process for nursing department in regards to corrective action.
Human Resources
Patient Safety Reported trending of adverse events through the patient safety network (PSNs) to the Board of Managers.
Physical Medicine & Rehabilitation (PM&R) Selected a contract supplier for durable medical equipment (DME). Psychiatric Services Identified a team to discuss post-acute care planning for psychiatric patients. Team has met several times and will continue to identify potential providers for post-acute Parkland patients.
Significant CAP-related Goals Still Outstanding in November

Access/Throughput Transition of continuum of care accountability from CAP leadership to clinical/operations leadership has not yet been completed. House-wide strategy on continuum of care requires completion. Transition of Case Management from CAP leadership to clinical/operations leadership has not yet been completed. Demonstration of improvement in Case Management metrics, which would indicate a robust discharge planning process was underway. Have not yet developed full consistency in format and attendance of multi-disciplinary team members at IDT care management meetings as well as consistency in improved outcomes for discharge planning. Engagement of physicians to promote earlier discharges of patients in order to improve patient flow and bed management/allocation. Development and education to staff for new Discharge Planning Assessment Tool
Case Management
Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Clinical Support 100 percent attendance/completion rate for fluoroscopy and general radiation safety training modules to nursing and medical staff has not yet been achieved. Completion of a GAP analysis for revision of new nursing policies and procedures.
Emergency Department Nursing Comprehensive and coordinated plan to recruit an effective nursing float pool has not yet been developed and implemented. Development of updated nursing leadership competencies, specifically related to new nursing managers in Psychiatric Services, still requires completion. Nursing audit plans needs to transition. Hiring and organization decision for permanent Chief Patient Rights and Safety Officer (CPRSO). Sustaining compliant audit results for delivering Important Message from Medicare to relevant patients by Care Management and Patient Financial Services (PFS). Development and finalization of effective reporting and trending on verbal order, resident oversight, History & Physical (H&P) documentation and effectiveness of on-call system. Although much work has been accomplished towards this goal, yet to publish complete data.
Patient Safety / Patient Rights
Physicians -
Overall Impressions from November

As we indicated in our reformatted progress report for October, because most of the Corrective Action Plan (CAP) initiatives have been largely completed, we have begun to shift more of A&Ms ICE resources to monitor specific areas of the Hospital and conducting surveys using the same methodologies employed during our initial Gap Analysis. The monthly audits and reviews are being performed as a more holistic and inclusive review to assess compliance with CMS 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. The areas of focus for November were: the Chemotherapy Infusion Center, Community Oriented Patient Care (COPC) Clinics, Hemodialysis Service Line, Nursing Services, Pharmacies, Radiology and the Sterile Processing Department (SPD). Separate reports were provided to senior leadership and unitspecific management for each area. As we stated in previous progress reports, although much progress has been made in implementing the CAP and correspondingly changing the culture of care delivery at Parkland, we still continue to see instances on the front-line of care delivery where certain safety and quality checks are not universally conformed or adhered to. For example, in some of our unit specific reviews in November, we continued to see instances of the two patient identifier check not being observed. Although compliance with hand hygiene protocol has greatly improved, on our floor and unit rounding and in rounding by Parklands Infection Prevention department, non-compliance with hand hygiene protocols has still been observed. And we have observed or been notified about potential patient safety events occurring because of failure to follow all safe patient handoff protocols. As we stated in our October progress report, all levels of management must continue to focus on transmitting the message to front line employees to work towards 100 percent compliance with all patient safety and quality checks, such as: two patient identifiers; the five
Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 rights of medication administration; documented and effective time outs prior to all procedures; 100% hand hygiene protocol adherence; safe patient hand-offs; 100% safeguarding of protected health information (PHI); and 100% access to informed consent to treatment forms. On a management and organization level, we remain concerned by the lack of progress in completing the changes to Care Management organization and recruitment of permanent leadership to this important function. As Parkland begins to experience high seasonal levels of occupancy and emergency room visits in December, January and February, having a well-organized and fully functioning care management department is essential. We also continue to be concerned by the lack of progress in increasing the number of discharges occurring before 11:00 a.m. We will be working with physician and nursing leadership in December to gather additional data on services or units that would benefit from more immediate intervention to have more timely discharge. Finally, we will continue to work with the Hospitals senior leadership to ensure that all of the required patient safeguards for Parklands behavioral health services, inpatient and psychiatric emergency department (PED) are adhered to on a consistent and aspirationally 100 percent basis. As noted below in this report, the Psychiatric Services Department continues to be challenged with potential (or actual) patient safety events and issues. There continues to be a lack of a well-coordinated management team, particularly in the PED. Several additional changes were made in late November and early December to bring additional resources to ensure a continuously safe environment. However, the Hospitals senior leadership needs to continue to devote significant time and resources, as necessary, to ensure that this critical service adopt every measure to assure a consistently safe environment for each patient, employee and staff member.
Access and Throughput Care Management

The Care Management (CM) Department is continuing its reorganization, which includes a complete overhaul of its structure and personnel and re-tooling of roles and responsibilities for all positions in the department. Vacancy rates continue to be high and key director positions have not yet been filled. In addition, there remains a void in consistent leadership of the department. In November, 74% of patients who presented to or were admitted from the Emergency Department (ED) received intervention by care managers at time of admission. While there is significant room for improvement, we recognize the steady gain and look forward to continued progress in December. Education related to the proper procedure and use of the discharge planning assessment tool is scheduled for both nursing and care management staff in early December. This tool will be used for 100% of patients requiring care management intervention. A&M will further investigate the progress in this area and in December we will be shadowing case managers and social workers to observe their day-to-day operations and patient and staff interactions. The physician advisor model is now in full operation, which enables the Hospital to receive a second review regarding admission criteria from a third party group of physicians when medical necessity clarification is needed. In November, the Hospital began to form an internal physician advisor program and has identified a physician champion to spearhead the program. Josh Floren, Executive Vice President, has undertaken the management of this project. In addition, training of the use of Milliman Care Guidelines for medical necessity was completed in November for all Care Management staff.
Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Discharges before 11:00 a.m. was a metric developed in the CAP to measure effectiveness and timeliness of discharge process to effectively improve bed flow and throughput. Discharges before 11:00 a.m. remain low, with only 5.2% (see chart below) of all discharges occurring before 11:00 a.m. in November. Physician leadership has suggested obtaining additional analysis to look at a number of cases discharged late in the day to identify if avoidable barriers to discharge existed. This information will be used to formulate a corrective plan in December.
Percentage of Discharges < 11:00 AM

5.5% 5.0% 5.0% 4.5% 4.0% Jun-12 4.4% Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 4.8% 4.7% 5.1% 5.2%
A&M continued to monitor the progress of the case management Interdisciplinary Team (IDT) meetings held in various units of the Hospital. Care Management has transferred the ownership of these meetings to nursing leadership due to the number of meetings taking place on a daily basis. Many IDT meetings began in November and are works in progress; however, we observed a lack of consistency in the format and effectiveness of these meetings. Additionally, in many cases, we noted a significant dearth in IDT attendance, especially among physicians, physical rehabilitation, and even care management. In some cases, we noted a general lack of understanding regarding the purpose of the IDT meetings. These interdisciplinary meetings should be just that multi-disciplinary stakeholders meetings to formulate plans for care and discharge planning of patients on those units. Without appropriate level of attendance and participation by ALL key stakeholders and without a clear agenda and consistent format, the intended purpose of this process appropriate care and discharge planning will not be achieved. A&Ms view is that the lack of consistency in day-to-day leadership of these IDTs is the main reason that this important element of Care Management has not excelled at the pace required to impact the organization.
Environment of Care
In the month of November, additional environment of care audits were performed in hospital units, community oriented primary care clinics (COPCs) and in the operating room (OR). Overall, A&M observed 92% compliance across the health system in the areas of cleanliness, medication management and patient rights/safety. Inpatient, Outpatient and Operating Room Results Area Cleanliness Med Management Compliance Sample 92% 44 95% 44
Patient Rights Patient Safety Overall
93% 94% 92%
44 44 44
Out of the 44 audits conducted, 30 were conducted across the medicine, surgery and women and infant specialty health (WISH) inpatient services. Within those 30 units, the major areas of concern remain in the areas of cleanliness, patient rights and privacy, and medication management. Environment of Care (EOC) Observations were made of cleaning supplies not being secured, hallways not being cleared of equipment and general appearances of sub-par levels of cleanliness. A&M observed lack of compliance with hand washing protocols
Patient Rights and Privacy A&M observed computer screens displaying patient charts, thus not being properly closed out when unattended. Observations were made of drapes not being closed during patient transfers.
Medication Management Several units were observed with crash cart log inaccuracies ranging from incorrect dates when the crash cart was last checked to incorrect cart and lock numbers. Observations were made of IV tubing with incorrect labeling. There were also instances of expired medications that were brought to the attention of both the charge nurse and unit managers during the EOC rounding by A&M.
Operating Room (OR) Several observations of incomplete count boards sharps/scratch pads not included on board. Observations of non-compliant hand hygiene nurse coordinator entered operating room without washing hands. Also an observation was made of faculty physician not scrubbing after de-gloving from the operating room. An expired IV tube was observed connected to an Alaris pump.
Observations for the outpatient clinics can be found in the Community Oriented Patient Care section in this report. In November, A&M also observed environmental services daily rounding meetings. The purpose of these meetings is for staff members to hear daily safety updates and gather their supplies for the day. As environment of care issues are still apparent, A&M recommends that these daily huddles be restructured. Staff members should be provided an agenda so they can read the daily/weekly safety updates as theyre gathering supplies since its difficult for everyone to pay full attention as theyre preparing for their shifts. Providing staff members with information on audit results can help staff understand what areas should be top of mind. The meetings would be a good forum to present metrics, such as bed
Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 turnaround time, to share with environmental services staff that their work is affecting items being reported to senior level executives and the Centers for Medicare and Medicaid Services (CMS). Also, as referenced in the October report, significant numbers of environmental services staff were unable to articulate information on the CAP, CMS re-survey, and other key issues. Primary language may be a barrier, preventing staff from understanding items discussed during the daily huddles. Leadership should consider translating safety and other important updates given during the daily huddles into different languages for staff to more easily understand.
Human Resources
The Human Resources (HR) department made progress in November on the selection of a Recruitment Process Outsourcing (RPO) firm to assist with the Hospitals hiring and recruiting needs. HR leadership advises that a contract will be executed with the RPO in early December and immediate focus will be placed on Nursing, Care Management, and Physical Rehabilitation open positions. In addition, an outside search firm was engaged to identify an appropriate candidate for the director of Workforce Planning and Recruitment. There has been a positive trend in the decrease of the Nursing Departments vacancy rates since the implementation of the CAP. Although values did increase in November, with the on-boarding of the RPO and applicant tracking system (ATS), we should continue to see these metrics continue trend in the right direction.
Nursing Vacancy Rates

30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 24.9% 17.5% 12.7% 12.0% Nursing Leadeship Nursing Overall
Although emphasis has intended results on lowering nursing vacancy rates, other areas such as Occupational and Physical Therapy still have high vacancy rate (based upon size of these departments) and needs to be addressed. Parklands Human Resource (HR) department will continue to engage Mercer Consulting to implement their recommendations regarding organizational changes and talent assessment. Implementation is projected to begin in January 2013 and will continue through September 2013.
Nursing Competencies
Audits have been in progress with Clinical Education and Human Resources to assess the completion of clinical competencies in employees personnel files. Initial findings indicate that competencies are poorly organized within the personnel files and are incomplete in many instances. Currently, A&M does not believe that Parkland is meeting the Conditions of Participation that require a complete record of employees competencies, including training, skills and knowledge that make them uniquely qualified for their position. A&M will continue to work with the Hospital in December to improve the organization and compliance for staff members clinical competencies.
Corrective Actions
In November, A&M performed a review of personnel files to assess the completeness of these files, as a follow up to concerns raised during the Gap Analysis survey regarding incomplete personnel records. The Gap Analysis report found that Parkland was not effectively utilizing the corrective action process. For example, it was difficult to trace back a history of absenteeism to formal corrective actions given to these employees. As part of our file review, 25 personnel files were reviewed to assess the correlation between evaluation scores and corrective actions as well as adherence to the three event rule before the employee is terminated. A&M found documentation for several employees who received one or more corrective actions in a year, but who were still given a fully successful evaluation score from 2006 to 2011. Additionally, there were instances of promotions within the same year as a corrective action being filed. Many of the counsels listed in the personnel file related to tardiness. This limited file review suggests that management and HR are tracking the volume of corrective actions. Hence, any employee in the sample reviewed, who received three corrective actions in year, was terminated in accordance with policy. A&M will continue to assess whether Parkland management is correctively utilizing the recently redesigned corrective action policy in December. Finally, as noted above with respect to nursing personnel files, we continue to observe instances of personnel files not being up to date, complete and/or organized with respect to documentation of clinical competencies.
Medical Staff
The Hospital continues to refine tracking processes for verbal orders and their authentication within 48 hours. Incorrect attribution of verbal orders has been identified as a barrier to the accurate reporting of verbal order authentication. New procedures are in place to ensure that physicians return mis-attributed orders to the source, and nurses are being educated on the proper attribution of orders. This statistic will continue to be reported and will become more accurate when mis-attribution issues are not included in the data.
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Ongoing Professional Practice Evaluation (OPPE)/Peer Review

Progress continued to be made in October and November on implementing the revised OPPE process. Indicators/triggers have been identified for all of the five pilot departments (Cardiology, Behavioral Health, Anesthesia, Emergency Medicine and Emergency General Surgery/Trauma). Work is still required to determine how this data will be captured and recorded. Staffing to support the revised OPPE and peer review process is still not in place, however recruiting is on-going. The Professional Staff Peer Review Oversight Committee is established and is meeting regularly. The committee is meeting twice monthly. Committee meetings were on the following dates October 15, November 2 and November 19. Two meetings are scheduled with agendas for December. Additionally, the EthicsPoint contract has been executed and is in the development stage. EthicsPoint provides integrated hotline and web-based ethics reporting systems and software and will serve as a secure site to manage peer review referrals. Build sessions began in December.
Privileges and Credentials

An audit was conducted on Parkland's Operating Room (OR) schedule to test the physician privileging system. The objective was to determine if the surgeon was properly credentialed to perform the surgical procedure listed on the schedule. To accomplish this objective A&M utilized data from the operating room schedule and the Parkland Core Privilege Viewer. A&M examined records for 25 patients scheduled for surgery on Monday, November 26 and Tuesday, November 27, 2012. Of the 25 records reviewed, 100% of the physicians were appropriately privileged to perform the procedure listed on the Operating Room schedule.
Nursing/Provision of Care
Nursing Practice and Nursing Units

A review was conducted by A&M of compliance within inpatient areas of nursing services during the month of November 2012. Observations were made on 12 units during A&Ms review and 24 charts were reviewed for documentation in those same units. In addition to surveying the nursing processes and documentation, the environment of care was also observed including: infection control, hand washing, two patient identifiers, time out, consent process, patient safety and medication management. A full assessment was shared with Parkland leadership early December. Overall, A&M concluded that there has been much improvement in the environment of care and consistent adherence to policy and procedure in many of the medicine/surgery units. Exception observations around patient privacy, hand washing, medication reconciliation, pain documentation, medication management (security) and consistent use of two patient identifier policy, suggest that improvements are still required to reach close to 99 percent compliance ranges for a successful re-survey. Across the house, there is a lack of consistent use of the two-patient identifier policy. Clinical and operational leadership need to develop a plan to address improvement in the consistent use of two-patient identifiers for all patient interactions in all care settings.
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Nursing Float Pool

Our October progress report noted our continuing concern with the Hospitals lack of a flexible staffing pool and the impact this will have on staff levels when acuity-based staffing is implemented in January. In November, some progress was made toward understanding the Hospitals needs, but work still remains. Nursing leadership still does not seem to have a clearly communicated and comprehensive strategy or plan for development of a float pool to address these critical staffing needs. We have recommended to senior leadership that decisions on centralized versus decentralized staffing strategies must be made, as well as understand a clear financial picture of future needs, so that the organization may appropriately prepare for increased flexible staffing requirements to meet fluctuations in staffing due to changes in acuity of patient mix.
Pressure Ulcers
In October, six cases of hospital acquired pressure ulcers (HAPU) were reported by Parkland to CMS and the Texas Department of State Health Services (DSHS). This series of pressure ulcer reports prompted our review in November of Parklands pressure ulcer or wound care program. A review of the six cases suggests the a lack of an interdisciplinary approach to managing HAPUs as well as a lack of communication or hand-off among team members about patients with or at risk of HAPUs. To determine whether PHHS was executing good skin care practices, an inquiry was made into the National Database of Nursing Quality Indicators (NDNQI), a national repository of nursing-sensitive indicators to patient outcomes when benchmarking against other hospitals with similar demographics. HAPUs are one of the nursing-sensitive indicators to track in NDNQI. Parklands nursing leadership has been participating in NDNQI and conducting pressure ulcer prevalence surveys since March of 2011. In April 2012, nursing had stopped submitting information to NDNQI although full surveys continued to be conducted every quarter. Several significant NDNQI benchmark reports were not being disseminated to the wound care team or to nursing leadership. As of November 27, 2012, the NDNQI program was transferred from the Nursing Excellence Department to the Performance Improvement (PI) Department. The PI department and the wound care team under the leadership of nursing are collaborating to reassess the revitalize the skin care program. In order to determine prevalence of HAPUs at Parkland a data review was necessary. Prevalence studies are conducted quarterly for all medical/surgical, critical care, step down and rehabilitation units. Prevalence studies are conducted weekly in the intensive care units. These benchmark reports provided insight into the skin care program where further investigation is required to understand the gaps in the skin care processes. The Parkland HAPU prevalence report from September 2012 was benchmarked to their NDNQI comparator group. Twenty seven inpatient nursing units were benchmarked and eight inpatient units fell into the low 25th percentile, 15 units in the 15th quartile and four units in the upper 75th quartile to their comparator group inpatient units.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 A task force including the Performance Improvement Department, senior leadership and wound care representation was assembled to develop an action plan from the NDNQI preliminary data. A SWOT (Strength, Weaknesses, Opportunities, and Threats) analysis was conducted by the task force. As a result, the initial step is to conduct a prevalence study on the eight units that fell into the twenty-fifth quartile and review the results to determine gaps. The study will be conducted by December 7, 2012.
Resident Supervision
Procedure Competencies In November we interviewed five Registered Nurses (RNs) in the Parkland Main Operating Room with the intent of gaining an understanding of their knowledge of the resident supervision grid. The purpose of this verification was to determine if the surgical resident had the proper oversight present for the procedure being performed and understood how to locate the oversight supervision grid. The results concluded that: 80% of the nurses interviewed had trouble locating the online site (GME Supervision). 100% could not verbalize the post-graduate year (PGY) of the resident performing the procedure. 100% had minimal knowledge of how to use the supervision grid. 100% had minimal knowledge of how to interpret the findings on the grid.
It is evident from the small sampling that there is opportunity for additional education for the nursing staff related to use of this system. Understanding aspects of the resident and physician oversight as it relates to the procedure being performed in the operating room or other patient care area is vital. Documentation The Hospital has developed a template within Epic called Notewriter which assists residents and their supervising physicians with appropriate documentation required for procedures. Within Notewriter, residents record a need for direct or indirect supervision, physician supervision information, and all elements required for a complete procedure note. Significant education regarding the use of Notewriter was developed and distributed to residents and faculty. Audits were conducted by Parklands Internal Audit department on the use of Notewriter and the accuracy of the documentation. These weekly audits were reviewed by physician leaders and the tool was modified and staff were re-educated as nuances with the tool were identified. Preliminary data in the first full month indicates Notewriter is a valuable tool to ensure proper documentation and supervision of procedures, and more accurate data is expected in December.
House-wide Issues
Abuse Screening
As reported in the October CMS report, audit results around compliance for utilizing the abuse screening questionnaire varied by department. The Women and Infant Specialty Health (WISH) Operations VP, Paula Turicchi, spearheaded an initiative to standardize the questionnaire across the Hospital. Under Ms.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Turicchis direction, a universal abuse screening questionnaire and response process flow for all divisions for the electronic medical record (EMR) was developed. The Information Technology (IT) department has developed test screens to denote the placement and instructions on how to navigate through the documentation for each of the departments. All department representatives have agreed to the revisions. Changes have been made to administrative policy 5-29 and will be cross-referenced to other administrative policies including: 501, 5-01A, 5-02, 5-26 which all related to abuse screening. The policies will be presented to the Documentation Committee on December 10 and then to the Pre-posting Committee during the following week. Communication regarding the changes to the EMR changes to the abuse screening questionnaire will be emailed to the clinical staff after the Documentation Committee approval and EMR changes are implemented.
Contract Services
Web conferences to educate contract owners on the contract quality program including definitions of contracts to be included in the quality-indicator monitoring program are scheduled in November and December. These sessions will also educate contract owners on how to use the contract management system as well as post-execution contract administration procedures. Currently, 115 contracts have been reviewed for quality indicators and are being monitored. The Quality of Care Committee (QCC) has identified 18 significant contracts that require quarterly reporting to the QCC. Of these 18 contracts, only 59% of the associated quality indicators are within acceptable limits. A full inventory of contracts has not yet been completed, but there are 102 known contracts with quality indicators that are not being monitored at this time. The majority of these contracts are related to human resources, i.e., contract labor and will be addressed in January, 2013. In addition, the Hospital anticipates a complete review of legacy contracts not in their current contract management system will be in process from January through March 2013. We strongly encouraged the Director of Contract Services to conduct an inventory of all contracts as soon as possible. We also expect focused attention on identified unmet quality indicators.
Infection Prevention
The Infection Prevention Department has instituted monthly rounding on all inpatient units and the jail to perform thorough audits alerting management and staff members of potential infection prevention-related issues. Audits are performed quarterly for the outpatient community oriented patient care (COPC) clinics. Although real-time feedback is provided to staff members and most citations are corrected within 24 hours, compliance still remains at approximately 92% across the system for October and November 2012. This figure has been trending downward since the audits began in August.
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Specific units falling below 85% compliance in infection prevention include the following: Area Unit WISH 5S (Two Consecutive Months < 85%) WISH L&D OR (Two Consecutive Months < 85%) CSS Pharmacy CSS Radiology Breast Health
Medicine Services 9S Medicine Services 9SS (Two Consecutive Months < 85%) Surgical Services 6W WISH 3SS NNICU Key themes observed from these areas include: -
General dustiness around cabinets, floors and crash carts; Deteriorating floor tiles in patient rooms; Lack of monitoring on refrigerator temperatures; and Shipping boxes in medication storage rooms.
In December, A&M will work with the Chief Implementation Officer to establish a matrix of accountability for deficiencies in these areas. To date, audit results are only shared with unit managers and not risen up through the chain of command to higher level positions reaching Vice Presidents. Informed Consent to Treatment Forms and Procedures A task force has been meeting regularly to discuss varying issues related to processing and posting of informed consent to treatment forms. In November, the informed consents task force agreed to delay the scanning of consent forms into the EMR until a patients discharge due to a problem of nurses trying to find scanned consents in the electronic medical record chart. Nursing staff did not have confidence that the consent form would be in the chart. Also, locating the consents is difficult for nursing staff since the forms are not always found in the electronic medical record for the current hospital encounter. Additionally, scanned documents are difficult to locate in the EMR since staff members use an ambiguous naming convention when labeling the documents. To respond to this problem of not being able to locate consent forms in the EMR, the Health Information Management (HIM) department developed a tutorial to assist nursing staff with locating consents in patient charts through several different methods. Parklands patient population includes a high volume of Spanish-speaking patients who prefer their healthcare information to be provided to them in their primary language, Spanish. Consents to treatment, along with other important documents and forms, need to be provided to patients in their primary language with the presence of an interpreter. As part of our nursing assessment document review, we saw documentation determining whether or not the question is asked of the patient on their preferred language.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 However results of the question (English, Spanish, etc.) are not often found in the patients chart. The Nursing department is working with Parklands IT department to construct an alert in the EMR clearly indicating a patients preferred language. Finally, as noted in the nursing assessment section below under Nursing/Provision of Care, A&M did not observe staff members appropriately using two-patient identifiers before providing consent to treatment forms to the patient.
Root Cause Analysis (RCA)

The root cause analysis (RCA) process is used to analyze an adverse event or systems issue that may lead to patient harm. To conduct a root cause analysis, Parklands Patient Safety Department assembles multidisciplinary key stakeholders of the adverse event as well as representatives from the Performance Improvement Department. The purpose of these RCA meetings is to ask questions and analyze the findings of any investigations to determine the root cause(s) and contributing factors to the adverse patient event and to develop an action plan to ensure similar events do not occur in the future. An action plan is formalized, often by the department leadership immediately, to address infractions that need immediate attention to prevent and minimize recurrence. Recently, the RCA process at Parkland was revised under the leadership of the Quality and Patient Safety departments. The Patient Safety department is now using the Joint Commission RCA method for conducting RCAs. Four RCA action plans were reviewed by Alvarez & Marsal to monitor the implementation the new methodology. Our review led to the following observation: It often required one to five RCA meetings for the formulation of an action plan. Several implementation phases of action plans dating back to adverse events occurring in July, 2012 had still not been completed at the time A&M investigated cases. There is not consistent physician engagement in responding to action plan formulation, and in some cases physicians are a barrier to implementation of plan Timing for implementation of some action plans were too aggressive, did not allow proper time to vet process changes with all key stakeholders, which may lead to ineffective implementation and/or poor results
The Patient Safety Department should continue to refine the RCA process per The Joint Commissions best practice. A goal stated by the Vice President of Performance Improvement was to finalize all action plans during the first RCA meeting for a particular adverse event. A&M will continue to attend RCA meetings and monitor for implementation of change during upcoming months.
Safe Patient Discharges

Unsafe or unauthorized departures of patients who are not appropriately or formally discharged from care continue to be an issue for Parkland in the ED and within outpatient and inpatient settings. Under the direction of the Quality Department, the Hospital created a Safe Patient Departure Task Force.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 While the Task Force meets regularly, there is not yet a comprehensive plan or strategy for a system-wide set of solutions to mitigate and/or reduce unsafe departures. The Task Force met on November 28th and reviewed data of house-wide unauthorized discharges. The data was stratified by division and department, and by type of departure (against medical advice, left without treatment completed, and left without being seen). This data will be further analyzed by department and unit managers to enable them to identify specific areas for improvement. The Task Force members have been tasked with development of action plans for each department and are due for submission in early December. The number of elopements (patients leaving against medical advice, before treatment complete or before being seen by a provider) or patients leaving without screening or treatment within ED patient populations is trending down since August.
Volume of Elopements - ED (Main, UCC, ICC, PED)

3,000 2,500 2,000 1,500 1,000 500 0 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 2,314 1,919 2,433 2,111 2,080 1,433
Volume of Elopements - Non-ED (In/Outpatient)

80 60 40 20 0 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 64 66 69 53 60 52
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Department and Unit Specific Findings
Chemotherapy Infusion Center

In November 2012, A&M performed a review of patient and process flow and compliance with medication management, hand washing, two patient identifiers, and environment of care within the Chemotherapy Infusion Center. A full assessment has been delivered to Parkland leadership and key findings from the areas listed above include: Medication Management Medications were being delivered to an open in-box at the nurses charting station. This station is not always manned and therefore the medications are not secure. Needles and flushes were being stored in the mobile medication cart which has a key lock. However, the key was in the lock during the site visit and therefore the medications and sharps were not secure. It was suggested that the station be re-designed so that the medications and all flushes and sharps could be stored in the closed cabinet. In addition, it was recommended that supply levels not exceed that which can be utilized in one day.
Patient/Process Flow Only two patients were in the process of receiving treatment at 8:30 a.m. However, the bays were fully staffed with registered nurses (RNs), while the waiting area had approximately 30 patients waiting for registration, lab, or treatment. Patient flow is reflective of the chair utilization report underutilization of the chairs prior to 10:00 AM and after 2:00 p.m. In addition, there is peak activity with back-ups from 10 a.m. to 2 p.m. The RNs have difficulty securing relief for breaks and lunch during this time. Patients come to the clinic well in advance of their appointment in the hope of getting seen sooner. The back-up is similar to that seen in the Urgent Care Center (UCC).
Community Oriented Outpatient Clinics (COPC)

In follow up to findings from the Gap Analysis report of February 2012, several A&M team members visited four of Parklands COPC sites in November 2012 to assess their progress of initiatives included in the CAP. The four surveyed clinics included: Garland Clinic (Garland) South East Dallas Clinic (SE Dallas, South East) DeHaro Saldivar Clinic (DeHaro) Oak West Clinic (Oak West)
The purpose of these visits was to follow-up on findings from the Gap Analysis revolving around general cleanliness, access/throughput, and medication safety and to assess compliance with the CAP. Presented below are high-level findings across all of the four surveyed clinics, as well as clinic-specific information.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Environment of Care (EOC) Since the original Gap Analysis was issued, general aesthetic and cleanliness issues have much improved across all four of the surveyed clinics. However, local management at several clinics expressed a need for increased onsite time for environmental services (EVS) employees. We found opportunities for improvement in Oak West and in several clinic pharmacies as detailed below. Pharmacy The general state of cleanliness of the pharmacies at all four surveyed locations needs improvement. There appeared to be throughput issues with patients at the Garland, SE Dallas, and DeHaro clinics. Patient lines to pick up prescriptions were extremely long. A high volume of e-fax prescriptions come through during the day, approximately 150-200/day at Garland and SE Dallas. The process entails a patient being issued a number and standing in line to determine if the medication is ready. If the medication is ready, the patient has to stand in line again to pay in the cashier line. Clinics are generally open until 5:00 p.m. but the pharmacy will stop issuing numbers around 4:00 p.m. to ensure the staff members can provide service to the patients who are waiting for medications. Patients may wait until 6:00 p.m. to fill their medications. Often times, pharmacy staff must stay overtime to ensure patients will have their medications first thing in the morning. Some staff members stay as late as 7:30 p.m. preparing for the following days medication refills. To help prevent increased costs and decreased employee satisfaction with the added overtime hours, pharmacy techs should be cross trained with pharmacists on how to prepare medications to be filled/refilled as well as performing cashier duties. However, pharmacy techs still need the pharmacist to verify the order. Also, an assessment should be performed analyzing the impact of implementing an additional shift at the busier COPC pharmacies to expedite filling medications. Patient Privacy Clinic staff at all four clinics were found announcing patients first and last names when calling them to the cashier desk, pharmacy counter, exam room and laboratory. A&M informed staff members that this was not in accordance with industry best practice and is a Health Insurance Portability and Accountability Act (HIPAA) violation. Therefore, re-education should be delivered to clinic staff to use a patients last name and first initial when summoning a patient. Conclusion Overall, major improvements were observed in touring the four COPC clinics. In the eight-month time period since the release of the CAP, key issues such as access and throughput and environment of care have been addressed. There are still areas of improvement, as noted above, to ensure all clinics are ready for a re-survey by CMS. The most commonly found issues were the sub-par environmental conditions of the pharmacies at each of the four clinics and consistent compliance in protecting patients privacy.
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Hemodialysis
During the month of November, A&M performed a direct observation assessment of Parklands Hemodialysis Service, including touring the Hemodialysis Units, Moderate Intensive Care Unit (MICU) and Emergency Department (ED). The assessment included: interviewing management, staff, providers and patients. Parklands Hemodialysis services provides inpatient and Emergency Department (ED) referred apheresis and emergent acute hemodialysis in two areas: eight beds in 5th floor Outpatient Clinic (OPC) and six beds on the 10th floor. Plans are also in progress to gain three additional beds by moving apheresis to 7 West and any of the Critical Care Units. The unit is open Monday through Saturday from 6:00 AM 11:30 p.m. Night hours, Sundays and holidays are covered on-call. The daily patient volume ranges from 36-40 patients. Equipment Monitoring Parklands Clinical Engineering Department provides extensive equipment monitoring and maintenance of the unit equipment including the BBraun Dialog Plus dialysis machines. In collaboration with unit staff, clinical engineering has implemented an effective communication system to address equipment concerns and remediation. This new system results in more timely equipment intervention and return to use. Significant back-up equipment is available in the unit, ensuring treatment is not delayed. There is a back-up for every two dialysis machines. The unit dialysis equipment techs practice demonstrates high compliance to the numerous quality controls required for equipment, refrigerators, eye wash station, water (cultures, hardness, chlorine, PH/conductivity, reverse osmosis), disinfection and documentation of the checks. Ongoing Improvement Efforts The Hemodialysis Service leadership has focused on addressing environment of care issues identified within A&Ms Gap Analysis report, earlier this year. Through a collaborative effort with the Environmental Services Department, the general cleanliness of the units has much improved. The proper storage of equipment has been a priority tackled through identification of storage spots for each piece of equipment and virulence in keeping halls cleared, reinforced with ongoing audits and staff education. The 10th floor unit does have areas of significant wall damage. A plan is underway with the Infection Prevention department to refurbish the area in a staged schedule as patient care continues. Patient throughput is an ongoing challenge. Recent efforts addressed responsiveness to the patients presenting to the ED as well as the increasing inpatient volume. Expanding hours of operation, improved equipment availability, and the impending addition of two patient stations in the 5th floor OPC are organically impacting the flow of hemodialysis patients from the ED. The addition of ED phlebotomists appears to have positively impact the turnaround time of lab results essential to diagnosing the need for acute dialysis, the first key step in the acute hemodialysis patient process. The Hemodialysis Service Medical and Nursing leadership have established a daily report that rollups up into a monthly quality dashboard. Performance is routinely assessed and issues addressed. Ongoing performance is now reviewed within the Nephrology Division and reported to the Quality Care Committee (QCC) on a routine basis.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Overall, the level of care and overall leadership within the service is appropriate. The Manager and Medical Director are both very committed to identifying and addressing any issues in the area.
Medication Management
As we have reported in past months, Parklands Pharmacy leadership has made great strides in the implementing performance improvement initiatives of the Corrective Action Plan. In collaboration with Respiratory Therapy the Hospital has significantly reduced the number of respiratory events due to missed medications by improving communication and education. The chart below indicates an impressive trend tracking the reduction of missed respiratory treatments.
Respiratory Therapy Missed Treatments

1200 1000 800 600 400 200 0 38 27 59 896 1042 919 699 744 662 Total Missed Treatment Total Missed Treatment Therapist Not Available 17 8 1
In November, Radiology and Pharmacy began ongoing meetings to review medication management standards relating to contrast reactions and extravasations, as there have been a number of related patient safety events of late. Meetings will include review of regulatory requirements, protocol and process review, identification of educational needs, and review of verbal orders and medication order sets. Development of radiology-specific medication management monthly audit tool is a goal of this group. The Pharmacy has implemented two new best practice strategies as endorsed by the Institute for Safe Medication Practices: To increase compliance with two-patient identifier procedures, ambulatory pharmacies are now required to inspect prescription labels on medication with the patient at the point of sale to verify the correct order. To reduce errors in Pyxis restocking, the Pyxis platform has been upgraded to include additional safety features such as bar coding. In addition, a No Interruption Zone sign has been placed on all medication rooms to reduce interruptions and distractions.
Patient Relations
As reported in the October report, the Hospital made significant changes to leadership and placed the Patient Relations Department under the direction of the Quality and Patient Safety departments. In
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 November, a full assessment of the department was completed, and a presentation will be made to the Board of Managers outlining the current state, gap analysis and proposed re-design of the department. Good progress has been made in this area in just a few short weeks. Issues addressed in November include: New director identified. Immediate assessment of all current complaints and grievances began November 12th. Patient Advocates assignments have been changed for each to focus on a specific hospital areas and patient populations to develop an expertise. Patient Advocates have been re-focused on a proactive approach aimed at intervening immediately at point of care delivery.
Assessment of patient relations software will begin in January to ensure optimum utilization of the system and maximization of reporting features.
Pharmacy
During November, A&M performed a focused assessment of the Pharmacy Department. We surveyed both the Central and Employee Pharmacy Centers. A full report was provided to Parkland leadership of which key findings are highlighted below: Central Pharmacy o Greeters were found to be consistently and appropriately assisting patients in determining pharmacy order statuses, directing them to the appropriate area, and using two patient identifiers. o Within the processes of refilling and filling new prescription order services, we observed isolated incidents of the following: Pharmacy techs were observed not thoroughly reviewing patient history when refilling medications. Pharmacists were observed interacting with Spanish speaking patients without the use of an interpreter. Pharmacy tech did not verify and correct misspelling of the ordering physicians name while entering the scripts into Epic. Unsecured medications found with protected health information (PHI) present on the labels. o Within the Medication fill area, We found workspace that was cluttered, dusty and congested. Pharmacy techs were appropriately filling orders, using two patient identifiers and verifying scripts. Employee Pharmacy o With regard to our review of appropriate securing and storage of medication, we found: All areas properly secured. Shipping boxes were found among the patient supplies which present a potential infection control problem.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Subsequent reviews will be conducted to recheck for evidence of corrective action in those areas.
Psychiatric Services
The Psychiatric Services Department continues to be challenged with potential and in some cases actual patient safety issues. There continues to be a lack of a well-coordinated management team, particularly in the Psychiatric Emergency Department (PED). In late November, the decision was made by senior leadership to incorporate Parkland management resources from the Dallas County Jail System to assist with development of best practices policies and procedures. This is an encouraging development and A&M looks forward to the recommendations and implementation plan from the Dallas County Jail clinical and management team that should begin in December. As reported in October, it was determined that policies and procedures were not completed for the Behavioral Health service line. The Policy and Procedure work group has reviewed approximately 90 policies and has performed a gap analysis to determine remaining policies needed. All policies and procedures are scheduled to appear on the Hospital intranet during the month of December and be made available to all Behavioral Health employees. In October, A&M requested that the nursing competencies recently revised by the Clinical Education Department be reviewed by Behavioral Health leadership to ensure agreement. After review, the decision was made to revise the competencies to reflect those of the Dallas County Jail, which leadership considers more comprehensive. This work will be underway in December. In December, training for staff will be focused on three primary areas: policies and procedures, Crisis Prevention Institute (CPI) training, and process mapping. Nonviolent crisis intervention training from CPI will educate staff on strategies to safely and effectively respond to anxious, hostile, or violent behavior while balancing the responsibilities of care.
Radiology
During November, A&M conducted a policy and procedure compliance review of the Diagnostic Imaging department the elements of review included: infection control, hand washing, two patient identifiers, time out, consent process, environment of care (EOC) and medication management. The following modalities were assessed: Computed Tomography (CT) Emergency Department Computed Tomography (ED-CT) Magnetic Resonance Imaging (MRI) Nuclear Medicine Ultrasound (US) Mammography (Invasive) Interventional Radiology (IR) Fluoroscopy.
The results of the review were shared with the Diagnostic Imaging Director, Geoffrey Camp, after each modality was reviewed. Mr. Camp initiated corrective actions and education immediately upon feedback. This was evident as the audits progressed.
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Overall, results from A&Ms observations were positives. Some of our key findings are outlined below: Computed Tomography (CT) o Issue around performing patient identification process before administering medication (contrast) Emergency Department Computed Tomography (ED-CT) o Staff members found handling dirty linen un-gloved o Hand hygiene issues Magnetic Resonance Imaging (MRI) o Issue around performing patient identification process before administering medication (contrast) Nuclear Medicine o Hand hygiene issue found with a patient transporter Ultrasound (US) no issues found Mammography (Invasive) o Out of date time-out reminder card was found during an invasive procedure o Electrical equipment (radios) found that were not cleared for use Interventional Radiology (IR) no issues found Fluoroscopy no issues found.
Sterile Processing Department

A nationally recognized subject matter expert on sterile processing techniques was added to the A&M team in November to provide a full reassessment of Parklands Sterile Processing Department (SPD). The detailed report was shared with SPD management and Parklands senior leadership team; a few key findings are included below: Staffing SPD should perform a market analysis to determine competitive wages to assist with filling vacancies and retaining staff. Parkland should reimburse staff for training to achieve certifications in sterile processing. Parkland should develop an action plan to replace the agency technicians with permanent full time employees and allow more time in the schedule for training and education of staff to ensure sufficient training and employee satisfaction.
Infection Prevention The AAMI TIR 12 is a recommendation for hospitals to test and validate scope and cannulated instruments cleaning processes. These products are to either test for protein/hemoglobin/carbohydrate residues or for residual adenosine triphosphate (ATP). Parkland should consider purchasing these products. Parkland should perform regular quantitative checks using ATP or hydrogen peroxide on instruments that have box locks and lumens (versus just visual inspections). Staff should have manufacturers recommendation for Instructions for Use (IFUs) materials for cleaning, sterilizing instruments and equipment readily available in the decontamination area. Instruments should be placed on stringers to meet correct washing requirements. Studies have shown a potential for bacterial growth in the lumens of flexible endoscopes when stored for more than five days. The thought leaders have not validated if the longer hang times develop bacterial growth. For
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 best practice, Parkland should conduct a study to determine the hang time limits using ATP testing with varying intervals of time. Observations of staff should occur for individuals with uncovered facial hair in the pick and pack area. Monitor for appropriate personal protective equipment (PPE) and ensure all facial hair is covered. Parkland should ensure sterilization carts are not overloaded with instrument trays when placed in the sterilizers to ensure proper dispersion of heat around the trays by following manufacturers recommendation on proper cart loading.
Standards of Practice Parkland should subscribe to AAMI for benchmarking purposes as well as access to current sterile processing standards. o Using AAMIs benchmarking for comparison to like facilities can help drive budget numbers, staff numbers, etc. o Parkland should download two free AAMI amendments (2011-A2 & 2012-A3) from their website regarding the latest sterilization maintenance. Parkland should implement a 24 hour report sheet for activities that need to be performed daily and to ensure documentation of these duties have been completed.
Technology Enablers Parkland should better optimize its automatic surgical instrument tracking system, Censitrac. It should also be used for improving infection control and providing data for meaningful benchmarking, continuous process improvement and root cause analysis. Parkland should investigate adding the KeyDot or InfoDot bar coding system to high dollar equipment and instruments. This is a data matrix bar coding labeling system that is applied to instruments or equipment to assist in tracking its location.
Unit specific findings were also identified for the Operating Room, Gastrointestinal Lab, Labor & Delivery units and the Ambulatory Surgery Center.
Urgent Care Clinics

Beginning November 1, 2012, Parkland engaged EmCare, a physician staffing company, to outsource its physician coverage for the Urgent Care Center (UCC). To assist in monitoring this initiative, A&M analyzed key throughput metrics for the UCC. Overall, the shift in skill set of emergency providers (vs. urgent care providers) of EmCare has had a positive impact on patient throughput.
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Urgent Care Center Throughput Metrics (Minutes)

300 250 200 150 100 50 0 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12
Patient Arrival to Patient Disposition Patient Arrival to First Seen by Provider Patient Arrival to Room Assignment
Onboarding of EmCare Physicians
All three of the UCC throughput metrics were dramatically decreased, which can in large part be attributed to the expanded capacity and the use of emergency medicine physicians who can see an expanded patient population. A&M will continue to monitor that patient care is not being compromised by the increased throughput times. Focus Areas for Next 30 Days In the month of December, Parkland will continue to work toward its CMS Survey with A&Ms monitoring assistance. Key activities occurring in December will cover the following areas: Admit, Discharge, Transfer (ADT) Department To continue with on-boarding this function into the restructured Care Management organization To develop a structured feedback with nursing and physician leaders based on A&M observation from nursing administrative officer (NAO) rounding
Care Management To identify qualified leadership and continue restructuring the department including filling vacant positions To finalize discharge assessment planning tool and implement house-wide To implement Clickview software to track and report on metric trending Improve IDT meeting form and achieve consistency in attendance of key stakeholders of the care team
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Clinical Support Environmental Services to develop a routine and frequent cleaning schedule for busiest areas of Hospital (ED, PED, etc.) Pharmacy to ensure units are compliant in medication management through ongoing audits and to investigate options to improve throughput efficiencies for outpatient pharmacies Physical Medicine & Rehabilitation to develop metrics for backlog and timing to schedule and provide therapy for new referrals and implement scheduling changes
Clinics (Specialty and COPC) To continue with implementation of Blue Cottages recommendations around the new delivery model in outpatient clinics To work with pharmacy leadership of assessing throughput issues in outpatient pharmacies To revisit adding physician leadership over both the on-campus and off-campus clinics
Continuum of Care To reconvene task force to perform analysis on current post-acute care contracts, review complex case committees role and perform financial analyses To have first kick-off meeting of task force in December
Contract Services To ensure list of contracts for review of quality indicators is comprehensive of all contacts, even predating 2009 To establish a methodology for determining which contracts and indicators are significant and should be reported to the QCC To work with Parkland business partners, holding them accountable for supplying Contract Services with key information and metrics
Emergency Department To complete construction in Main ED and UCC To continue assessing added value of EmCare contractors in UCC
Human Resources To finalize contract with recruiting process outsourcing firm (RPO) To implement applicant tracking system in accordance with onboarding of RPO To revisit tracking and reporting of corrective action logs by department/Vice President
Infection Prevention To revisit escalation process for unit managers/directors/vice presidents as issues are identified by Infection Prevention staff
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 Nursing To develop a comprehensive and coordinated plan for building a flexible staffing float pool for nursing To continue designing McKesson acuity-based staffing solution To develop and perform unit-level plan of care chart documentation audits
Patient Safety To continue with restructuring of root cause analyses process To finalize transfer of patient relations department and continue to refine processes and structure of that function To assess the success of patient safety network communication and reporting functions
Physicians To finalize accuracy of physician attribution relating to verbal order reporting To implement action plans based on audits of resident supervision privileging and documentation To revisit discharge planning and discharge orders across different time and shifts
Psychiatric Services To finalize revising all policies to best practice and conduct training for psychiatric staff members To work with Clinical Education to ensure the correct competencies are updated for employees To work with Patient Financial Services (PFS) on use of separate wrist bands in PED, causing some patient identifier issues To collaborate with IT on changing the front end interface of EPIC to prevent staff mistakes in Psych ED and 8N inpatient unit
Women and Infant Specialty Health (WISH) To open new unit (4SS) To continue to onboard new registered nurses To perform a root cause analysis for patients who have left before their treatment was complete or before they were seen by a provider in the intermediate care center (ICC) Conclusion As we concluded in our October report we will repeat here that Parkland is a different and demonstrably improved organization now than it was one year ago. We have seen evidence of a culture being created that is working to ensure a safe care experience for all patients where the quality of all care and procedures can be objectively measured. However, as we stated in previous progress reports, although much progress has been made in implementing the CAP and correspondingly changing the culture of care delivery at Parkland, we still continue to see instances on the front-line of care delivery where certain safety and quality checks are not universally conformed or adhered to. For example, in some of our unit specific reviews in November, we continued to see instances of the two patient identifier check not being observed. Although
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Parkland Health & Hospital SystemAlvarez & Marsal Progress Report to CMSNovember 2012 compliance with hand hygiene protocol has greatly improved, on our floor and unit rounding and in rounding by Parklands Infection Prevention department, non-compliance has still been observed. And we have observed or been notified about potential patient safety events occurring because of failure to follow all safe patient handoff protocols. As we stated in our October progress report, all levels of management must continue to focus on transmitting the message to all front line employees to work towards 100 percent compliance with all patient safety and quality checks, such as: two patient identifiers; the five rights of medication administration; documented and effective time outs prior to all procedures; 100% hand hygiene; safe patient hand-offs; 100% safeguarding of protected health information (PHI); and 100% access to informed consent to treatment forms. With respect to management and organization, we remain concerned by the lack of progress in completing the changes to Care Management organization and recruitment of permanent leadership to this important function. As Parkland begins to experience high seasonal levels of occupancy and emergency room visits in December, January and February, having a well-organized and functioning care management department is essential. We also continue to be concerned by the lack of progress in increasing the number of discharges occurring before 11 AM. We will be working with physician and nursing leadership in December to gather additional data on services or units that would benefit from more immediate intervention to have more timely discharge. Finally, we continue have concerns about Parklands behavioral health services, particularly the psychiatric emergency department (PED), and having a consistently safe and controlled environment for all patients, employees and staff. We will continue to work with the Hospitals senior leadership to ensure that all of the required patient safeguards for Parklands behavioral health services, inpatient unit and PED are adhered to on a consistent and aspirationally 100 percent basis. As noted below in this report, the Psychiatric Services Department continues to be challenged with potential patient safety issues. There continues to be a lack of a well-coordinated management team, particularly in the PED. Several additional changes were made in late November and early December to bring additional resources to ensure a continuously safe environment. However, the Hospitals senior leadership needs to continue to devote significant time and resources, as necessary, to ensure that this critical service adopt every measure to assure a safe environment for each patient, employee and staff member and that behavioral health managers in the PED and inpatient unit exercise the leadership and direction necessary to ensure that every staff member is consistently following all policies and procedures established to ensure the safety and security of each psychiatric patient. We have discussed these observations with the Hospitals senior leadership and the Board of Managers, all of whom are committed to driving this message of personal accountability to all staff members.
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Parkland Health & Hospital System - Alvarez & Marsal Progress Report to CMS - November 2012
Governance (Section 2.01) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Patricia Bergen, MD 5.1 5.3 5.3 6.4 6.4 1.1 1.5 1.2 3.5 1.1 7/13/2012 10/30/2012 Y 6/8/2012 6/8/2012 6/8/2012 6/1/2012 5/25/2012 8/31/2012 5/18/2012 1/31/2013 Y Y Y Y Y Y Y Brad Marple, MD Brad Marple, MD Jackie Sullivan Jackie Sullivan Paul Leslie Jim Johnson Jody Springer Sharon Phillips Paul Leslie Accountability Work Stream Target Date Oct-12 Nov-12 Completion
1.01
1.02
1.03
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.
1.04
Require quality dashboard report from Hospital Quality Department
1.05
1.06
Commence reviews of scorecards for significant outsourced and contracted clinical services. Design a Board-specific QAPI plan. Review and revise BOM committees.
1.07
Review performance management and progressive discipline implementation plan from Human Resources.
1.08
Review comprehensive plan to create better communication and coordination among the Hospitals Legal, Compliance, Internal Audit and Quality Departments.
1.09
Review Hospital plan on continuum of care.
1.10
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
#
1
Audit/Measures Contract Svcs Comments
Accountability
Goal 100%
Jun-12 85.7%
Jul-12 N/A
Aug-12 N/A
Sep-12 96.1%
Oct-12 85.7%
Nov-12 96.0%
Percentage of contracts (outsourced vendors) reviewed for quality measures
1.09 - Hospital is re-formulating task force to focus on post-acute care
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.
Self-reported by Parkland Staff or EPIC Reports Reported through Parkland's Patient Safety Network (PSN's) Reported by Parkland's Internal Audit Group
4.
Reported through Alvarez and Marsal's Daily Audits
Human Resources (Section 2.02) Tasks/Initiatives 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
1
Accountability
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
2.01 2.02 2.03 2.04 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 4/6/2012 4/27/2012 Goal 100% 0.4% 33.9% 65.7% HR
1
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. 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
Work Stream 1.5 1.2 1.5 1.5
Target Date 5/25/2012 5/25/2012 5/25/2012 7/13/2012
2.05
Expand the role of Business Partner, require they take a more active role with front-line managers and supervisors.
2.06 2.07 2.08
Business partners to audit evaluations for the next two evaluation cycles. Evaluate current HR staffing model. Analyze resource allocation within HR Department.
2.09
Develop Parkland employee retention strategy.
2.10 2.11 2.12 2.13 2.14 2.15
2.16
2.17 Audit/Measures House-Wide

1
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. Jun-12
Jul-12
Aug-12 46% 5.0% 55.0% 40.0% 100%
Sep-12 72%
Oct-12 99%
Nov-12 97%
1 HR HR HR
Percentage of supervisors (and above) who have attended training administered by clinical education
2a
Evaluation scores on histogram or bar chart for each department (annual evaluations) - below expectations
2b
1
Evaluation scores on histogram or bar chart for each department (annual evaluations) - meets expectations 1
2c
Evaluation scores on histogram or bar chart for each department (annual evaluations) - above expectations
Percentage of licensing validations presented prior to the day of hire
100% HR 10 18.3 13.7 24.2 11.9 11.1 9.0
Time from occurrence to corrective action signed by employee (days)
Human Resources (Section 2.02) Metric HR 14.5% 14.1% 20.0% 35.1% 76.0% 100% 40 N/A 1.1% 100% 100% 59.9 55.0 62.9 87.2 80.5 98.8% 88.0% 1.2% 54 73 87 1.3% 96.2% 75% 60% 87% 69.0% 93% 74 1.3% 100.0% 99.2% 72.3 100% 95 0.96% 100.0% 99.5% 68.4 100% 83 1.13% 100.0% 99.4% 73.8 25.0% 36.8% 31.3% 36.7% 50.0% 19.1% 18.4% 13.6% 6.3% 17.5% 9.2% 15.2% 10.6% 24.9% HR HR HR HR Clinical Ed HR
1
# 16.5% 15.0% 9.5% 9.8% 44.7% 9.7% 21.5% 12.8% 9.5%
Accountability
Baseline
Goal
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12 12.7% 12.0% 24.1% 41.2%
5a
Turnover Rate (%) - Nursing 1
5b
Turnover Rate (%) - Total
8
1
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
9 House-Wide HR HR
1
Percentage of competencies updated on/before due date
10
Number of corrective actions
11
Absent Hours (as a percentage of total hours worked)
12 HR Comments
Percentage of current licensure 1
13
Percentage of current certifications
14
Time for recruiting to fill an open external job position
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) Tasks/Initiatives Jessica Hernandez Holt Oliver, MD 3.6 9/30/2012 Jessica Hernandez Holt Oliver, MD 3.6 6/8/2012 Jessica Hernandez Holt Oliver, MD 3.6 6/8/2012 Jessica Hernandez Holt Oliver, MD 3.6 3.1 3.5 3.4 3.4 3.6 1.7 1.7 1.7 3.3 3.3 5/11/2012 7/13/2012 7/13/2012 7/13/2012 7/1/2012 8/1/2012 10/15/2012 Y Y Y Y Y 6/12/2012 10/30/2012 7/13/2012 7/13/2012 Lonnie Roy Deanna Bokinsky Accountability Work Stream Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Target Date Nov-12 Completion Y
3.01
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
3.02
Conduct analysis of no show rates by clinic, day, session, and provider.
3.03
Conduct a physician productivity analysis based upon a review of current process and development of analytics.
3.04
Document current process workflow diagrams, identify barriers to throughput and develop solutions that might increase productivity and result in additional capacity
Y Y Y Y
3.05
Review ED utilization and most common diagnoses by patient admission times to analyze opportunities for changes or improvements in COPC hours of operation
3.06
Develop the post-acute care network.
3.07
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.
3.08
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.
3.09
Conduct a physician productivity analysis based on agreed upon industry standards.
3.10 3.11 3.12 Miriam Gomez Miriam Gomez
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.
Robin Stults w/ Clinical Intelligence Christopher Madden, MD Jessica Hernandez Holt Oliver, MD Josh Floren Josh Floren Josh Floren
3.13
Design Bed Czar concept to report to ADT
3.14
Establish strict standards regarding communication and patient placement timelines with ADT to enhance patient placement. Kim McCloud Linda Licata Barbara Mims
3.15
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.
2.6
6/1/2012
Access/Throughput (Section 2.03) Tasks/Initiatives 2.6 6/15/2012 Accountability Work Stream Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Target Date Nov-12 Completion Y
3.16
Define a patient flow process that will reduce and/or eliminate boarding of dialysis patients in the emergency department.
3.17
Define and obtain approval for resources necessary to implement process, including expansion of serivces.
2.6
7/1/2012
3.18
Develop protocols and obtain resources for implementation of defined patient flow process.
2.6
9/30/2012
3.19
Fully implement patient flow process and expansion of services to eliminate boarding of dialysis patients in the emergency department. 2.6 11/30/2012
Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Accountability COPC COPC COPC 96.0% 550 100.0% 174 60% Baseline Goal Jun-12 5.0% 17.2% 5768 2.62 2.49 1.59 COPC COPC 17.0% 5991 90.0% 100.0% 86.0% 100.0% Baseline Goal Jun-12 Jul-12 86.5% 96.8% 101.2% 203 61% Jul-12 4.4% 17.0% 6053 Aug-12 104.0% 98.7% 100.1% 232 60% Aug-12 4.8% 17.0% 6209 2.75 2.41 1.61 Sep-12 100.3% 95.9% 102.8% 402 50% Sep-12 4.7% 17.7% 5991 2.57 2.34 1.64
Audit/Measures
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
1a
Capacity - Family Medicine
1b
Capacity - Internal Medicine 1

1
1c COPC
1
Capacity - Geriatrics ADT
Number of additional appointments through virtual visits
Percentage of observation patients outside of observation unit
Metric Utilization rates by session by clinic (hours of activity/hours of capacity)

1
# 4 5 COPC Med Staff COPC COPC COPC

1
Percentage of discharges (medicine, surgery) by 11:00 a.m.
Accountability Clinics Care Mgmnt
No show rates - COPC
Physician (Hospitalists) productivity (based upon Rolling 12 Month RVUs/Average FTE Count) 1
8a
1
Physician (Clinics) productivity (based on visits/hour) - Family Medicine
8b
1 1 1
Physician (Clinics) productivity (based on visits/hour) - Internal Medicine 1
8c
Physician (Clinics) productivity (based on visits/hour) - Geriatrics
Number of new patients on wait list - COPC
10
Number of established patients on wait list - COPC
11
1
Number of bed days occupied by observation status (by unit)
Care Mgmnt EVS ED ED Care Mgmnt 5.0 ADT

1
2,721 1:00 1:13 126.4 126.2 5.2 85.0% EVS ADT 524 45 84.1% 63 0
2,753 1:24 142.5 138.9 5.0 87.0% 79 164
2,951 1:06 189.6 107.5 5.3 90.6% 108 213
1,512 1:12 112.5 107.6 5.0 86.0% 71 0
1,204 0:59 142.0 138.8 4.6 87.4% 79 70
1,216 1:00 112.3 100.5 4.7 83.0% 62 29
12
Average bed turn time (hours:minutes) 1
13a
Average minutes of boarding in Main ED
13b
1
Average minutes of boarding in ICC 1
14
Average Length of Stay (1 month lag)
15
Percent inpatient occupancy (census) by division
16
17
Bed Request to Bed Assign, average from bed assigned to patient in bed Hours on red/yellow bed
Access/Throughput (Section 2.03) 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
3.08 - Still finalizing the reporting of discharges before 11AM 3.14 - Related to electronic teletracking tool, to look into prolonging target date due to scale of implementation 3.19 - To be complete in early January, pending the completion of the ED construction project
1. 2. 3. 4.
Provision of Care (POC) (Section 2.04) Tasks/Initiatives 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 10/31/2012 11/14/2012 10/5/2012 Y Y 9/30/2012 10/5/2012 8/31/2012 4/13/2012 5/11/2012 3/30/2012 9/14/2012 5/4/2012 4/27/2012 4/27/2012 4/20/2012 Accountability Work Stream Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Target Date Nov-12 Completion Y Y Y Y Y Y Y Y Y Y Y
4.01
Define nursing supervisor role expectations and competencies.
4.02
Revise job description to meet role expectations.
4.03
4.04
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.
4.05
Initiate new role expectations.
4.06
Conduct a comprehensive review of the nursing structure under the direction of the new CNO.
4.07
Develop internal and external recruitment plan for new organizational structure.
4.08 Barbara Mims Valerie Harvey
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
4.09
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.
4.10
Revise policies/procedures and nursing standards to reflect best practices, as appropriate.
4.11
Develop a house-wide educational plan to correct the current deficiencies in patient care.
4.12 Jim Johnson Jackie Brock John Raish
Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Emilie Allen
4.13
4.14
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.
Provision of Care (POC) (Section 2.04) Tasks/Initiatives 4.3 4.3 4.3 4.3 4.3 4.2 4.2 1.6 1.6 4.2 4.2 4.2 4.2 4.2 6.4 4.2 4.2 4.2 5.4 Jim Johnson 1.5 9/14/2012 7/13/2012 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 8/1/2012 5/11/2012 10/31/2012 10/31/2012 8/1/2012 5/11/2012 11/1/2012 6/28/2013 Y Y Y Y Y Y Y Y Y Y 3/22/2013 10/5/2012 3/22/2013 Accountability Work Stream Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Target Date Nov-12 Completion
4.15
Once selected, roll out acuity tool.
4.16
Develop flexible staffing strategies, PRN pools, per diem staff, etc.
4.17
Monitor core patient care ratios for trends.
4.18
Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (electronic solution)
4.18
Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (interim solution)
4.19
Establish standards of nursing practices, focusing particularly on the plan of care. (Clinical Competencies)
4.20
Develop house-wide nursing education program (Clinical Competencies)
4.21 Jim Johnson
Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jim Johnson
4.22
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.
4.23
Establish standards of nursing practices, focusing particularly on the plan of care. (Plan of Care)
4.24
Develop house-wide nursing education program. (Plan of Care)
4.25
Create evaluation tools to measure nurse understanding of education and success of program.
4.26
Initiate nursing grand clinical rounds.
4.27 Brett Moran, MD
Develop report out tool for grand round results.
Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey
4.28
Through the QAPI Department, develop and report verbal order trends monthly to providers and nurses.
4.29
Review all restraint policies.
4.30
Develop and execute restraint education.
4.31
Review Epic restraint documentation structure to improve the quality of documentation.
4.32
Develop a mandatory education for medical staff on the required elements of performance related to restraints.
Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Joseph Minei, MD
4.33
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) Audit/Measures Nursing

1
# 12.1% 100.0% 3.0% 13.9% 100.0% 100.0% 100.0% 181 Baseline 2.2% 90.0% 100.0% 54.0% 1.7% 1.8% 83.1% 90.0% Goal Jun-12 Jul-12 166 192 Aug-12 1.5% 84.0% 98.3% 67% 1 75.0% 70% 1 92.4% 85% 4 90.4% 44.0% 80.0% 66.7% 100.0% 76% 1 88.0% 143 Sep-12 1.4% 81.8% 98.7% 11.7% 15.1% 14.3% 2.9% 3.3% 3.0% 100.0% 86.0% 80.0% 100.0% 2.9% 10.7% 100.0% 82% 1 82.0% 185 Oct-12 1.4% 84.3% 100.0% 12.4% 14.4% 12.9% 9.3% 100.0% HR Nursing Nursing
1
Accountability
Goal
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12 7.7% 100.0% 2.4% 11.7% 100.0% 92% 1 74.0% 156 Nov-12 1.2% 82.0% 100.0%
Nursing leadership vacancy rate 1
Percentage of completed competencies for all nurses and units
3 Nursing
1,4
Percentage of travelers (hospital-wide)
4 Nursing Nursing
1
Nursing vacancy rate
Percentage of completion of education activities
6 Nursing Metric Nursing Nursing

1
Percentage of Plan of Care documented according to policies and procedures
Percentage of compliance in hand-off's
8 Accountability
Volume of non-violent restraint cases (hospital-wide)
9 Nursing Nursing Comments
Number of days per month nurse staffing ratios were above/below grid
10
1
Percentage of cases with verbal orders
11
Verbal order compliance rate (signed within 48 hours)
12
Percentage of staff who attended Plan of Care training
4.01 - To re-validate effectiveness of house supervisor role in December 4.12 - Initiative is pending demonstration of updated competencies for new managers in Psych Services 4.16 - Nursing management has not yet developed a clear plan for flexible staffing strategy (float pool) 4.18 4.28 - Still having issues in correctly reporting on physician attribution for verbal orders
1. 2. 3. 4.
Care Management (Section 2.05) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Accountability Work Stream Target Date Oct-12 Nov-12 Completion
5.01
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. Robin Stults w/ Clinical Intelligence 3.4 7/24/2012 3.4 6/30/2012
5.02
Re-align goals and strategy of department to promote collaboration between Case Managers, Social Work, Utilization Review and Nursing. 3.4 6/30/2012
5.03
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. 3.4 6/1/2012
5.04
Identify metrics needed on a daily basis to properly analyze cases.
5.05
Produce an Extended Stay High Cost Outlier Report to identify inpatients that could move to a post-acute care setting if funding permitted. 3.4 5/31/2012 Deanna Bokinsky 3.5 1/31/2013
Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence
5.06
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. 3.4 6/1/2012
5.07
Revise position expectations of the ED Case Manager .
5.08
ED Case managers should evaluate all potential admissions on whether they meet acute care criteria and assess patients potential discharge planning needs. 3.4 3.4 3.4
9/30/2012 8/30/2012 6/15/2012
Y Y Y
5.09
ED case managers should perform an initial assessment on all patients being admitted to the hospital.
5.10
Create or revise policies and procedures that define screening, assessment and discharge planning process to identify high risk patients.
5.10
Educate nursing care management staff on proper procedure for the Discharge Planning Assessment Tool within Epic to ensure appropriate screening and referrals.
3.4
6/15/2012
5.11
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.
3.4
11/14/2012
5.12
Create a screening tool for case managers to include long term stay patient, avoidable days and other areas of focus.
3.4
7/20/2012
5.13
Move Utilization Management within Care Management Department.
Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Robin Stults w/ External Resources Robin Stults w/ External Resources Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence Robin Stults w/ Clinical Intelligence 3.4
8/31/2012
10
Care Management (Section 2.05) Tasks/Initiatives 3.4 7/24/2012 Accountability Work Stream Jun-12 Jul-12 Aug-12 Sep-12 Target Date Oct-12 Nov-12 Completion Y
5.14
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. 3.4 7/30/2012
5.15
Policies and Procedures should be revised to reflect the revised plan, and associated roles and responsibilities of staff.
5.16
Revise the current UR logs to ensure that all required elements are collected and formatted in order to analyze and trend type data. 3.4 7/31/2012 3.4 6/30/2012
5.17
Develop process to export Case Management Care Web documentation whereby the data are analyzed and trended.
5.18
Select UR metrics for tracking, monitoring, and trending. (utilize national best practices as examples for targets). 3.4 6/30/2012
5.19
Utilize data from a comparative database that is clinically adjusted and severity adjusted to assist the Committee in identifying areas for improvement. 3.4 6/12/2012 3.4 7/31/2012
5.20
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.) 3.4 10/31/2012
5.21
Report unfavorable physician trends to the Patient Care Review Committee (PCRC). Unexpected results will be reported to Performance Improvement (PI). 3.4
5.22
Monitor progress on targeted metrics and re-evaluate targeted improvement goal and/or metrics being measured.
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 7/31/2012 Accountability CM CM CM CM 95.0% 85.0% Accountability CM CM CM CM Baseline 1,013 5,184 443 8.7% Goal Jun-12 1,037 5,182 409 10.3% Jul-12 928 4,538 428 8.3% 85.3% Aug-12 964 5,806 427 9.2% 28.5% N/A Sep-12 950 4,832 491 8.4% Baseline Goal Jun-12 Jul-12 Aug-12 Sep-12 90.1%
Audit/Measures
Oct-12 89.3% 59.0% 90.0% Oct-12 977 4,488 583 10.2%
Nov-12 91.8% 74.8% 94.0% Nov-12 1,116 5,123 689 8.7%
Compliance in performing medical necessity screening in ED 1
Audit Results of Number of Hospital-Wide Cases Intervened on 1st day of admission 1
Percentage of cases with CM screening for discharge needs - ED 1
4 Metric
Percentage of compliance in completion of H&P's 1
Number of Cases with Outlier Length of Stay (LOS) (per Month) 1
Number of Avoidable Days (per Month) 1
Number of One-Day Stays (per Month) 1
30 day Readmission Trends (percent of total discharges) 1
11
Care Management (Section 2.05)
Comments 5.06 - Initiative is being targeted through the 1115 waiver work. However implementation of initiatives will take around a year. Hospital executives to revisit need to implement short-term solution.
1. 2. 3. 4.
12
Environment of Care (EOC) (Section 2.06) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 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 3.7 3.7 3.7 3.7 3.7 4/13/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 3.7 4/13/2012 3.7 6/8/2012 3.7 4/6/2012 3.7 4/6/2012 3.7 4/27/2012 3.7 4/23/2012 3.7 4/11/2012 3.7 9/14/2012 3.7 9/14/2012 3.7 4/27/2012 Accountability Work Stream Target Date Oct-12 Nov-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
6.01
6.02
6.03
6.04
6.05
6.06
6.07
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.
6.08
Convene the environment of care team to establish mission, charter, goals and processes to address EOC activities.
6.09
Conduct a one-time, accelerated plan for deep cleaning and repairs.
6.10
Develop a budget and prioritization for the campaign on potential staff or capital needs for senior leadership review.
6.11
6.12
6.13
6.14
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.
6.15
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.
#
1
Audit/Measures
Accountability House-Wide EVS

1
Goal 100% 100% House-Wide EVS 100% 0
Jun-12 85.6% 97.2% 87.5% 5
Jul-12 95.9% 95.7% 100.0% 2
Aug-12 96.6% N/A 100.0% 2
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
1
1
Percentage of Patient Rooms, Procedure Areas, and Operating Rooms, meeting all elements of EVS requirements
2
1
Compliance to infection prevention audits on surface cleanliness
Percentage of procedure areas with up to date daily terminal cleaning logs
Number of patient complaints about environmental issues
13
Environment of Care (EOC) (Section 2.06) Metric Baseline 1:00 25% 1:13 52% 0.64 1.95 1.91 4.47 1.91 2.07 2.77 2.01 2.47 58% 1.77 48% 2.76 48% 1.91 1:24 1:06 1:12 Goal Jun-12 Jul-12 Aug-12 Sep-12 EVS EVS EVS Accountability 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%
6 7a
Bed turnaround time Percentage of turns greater than 60 minute goal
Work order completion time - EVS (days) 1
1
2 3 3%
7b Clin Eng HR Comments
Work order completion time - Engineering (days)
Facilities
7c
Work order completion time - Clinical Engineering (days) 1 Vacancy Rate - EVS
1. 2. 3. 4.
14
Infection Control (Section 2.07) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Kim McCloud Linda Licata Barbara Mims 2.8 6.3 6.3 6.3 2.8 6/8/2012 6/8/2012 6/8/2012 9/30/2012 4/20/2012 Janet Glowicz Janet Glowicz Janet Glowicz Accountability Work Stream Target Date Oct-12 Nov-12 Completion Y Y Y Y Y
7.01
Each Divisional Vice President (VP) will submit all department specific Infection Prevention (IP) related policies and procedures to IP.
7.02
The IP department Director and Chief of Infection Prevention will review and make revisions of all departmental and house-wide IP policies, if applicable.
7.03
All departmental IP policies are returned to the department for their review and acceptance
7.04
Approve reviewed departmental and house-wide IP policies.
7.05
Divisional VP and Department Directors to develop a communication roll out with IP Director on the revised IP policies and procedures. 2.8 1.2 6.3 6.3 3/23/2012 3/23/2012 6/8/2012 6/8/2012
7.06 Jody Springer Janet Glowicz Janet Glowicz
Each department assigns an IP delegate to be the contact and participant in the IP prevention education program.
Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims
Y Y Y Y
7.07
Provide a full-time Chief Infection Prevention Officer.
7.08
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.
7.09
Execute EOC surveillance program to ensure consistency with cleaning methods and standards to support IP principles.
# IP
1
Audit/Measures House-wide House-wide House-wide House-wide House-wide Surgery

1
Accountability
Goal 100% 0 0 0 0 100%
Jun-12 98.0% 896 185 255 456 97.9% 100%
Jul-12 100% 1006 197 263 546 97.7% 100%
Aug-12 100% 577 156 155 266 98.6% 100%
Sep-12 100% 243 61 67 115 98.6% 100%
Oct-12 100% 322 85 93 144 99.3% 100%
Nov-12 100% 280 56 119 109 99.3% 100%
1
1
Percentage of policies that have been drafted/revised (by department) 1
2
1
Volume of non-compliant observations for hand hygiene - Hospital and IP Audit
3a
1
Volume of non compliant hand hygiene observations - support staff
3b
Volume of non compliant hand hygiene observations - physicians
3c
Volume of non compliant hand hygiene observations - nursing
Compliance in hand hygiene
5
1
Percentage of compliant observations with sterile technique in procedure areas 1
6
1
Percentage of Infection Prevention completed surveys by each department, monthly
IP House-wide House-wide House-wide
100% 100% 0%
64.7% 79 97.0% 0 0
100.0% 202 94.4% 0
100% 173 94.8% 0
100% 377 92.2% 1
100% 311 92.0% 0
Volume of non-compliant observations by Infection Prevention Practice Team
Compliance percentage of Infection Prevention Practice Team rounding
Number of blood stream infections
15
Infection Control (Section 2.07) 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.
16
Medication Management (Section 2.08) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson 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 9/14/2012 4/13/2012 7/16/2012 5/11/2012 3/22/2013 8/13/2012 10/1/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 7/13/2012 6/15/2012 5/11/2012 4/27/2012 4/27/2012 2.3 6/8/2012 2.3 6/8/2012 2.3 5/11/2012 2.3 6/8/2012 2.3 4/5/2012 Accountability Oct-12 Nov-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
8.01
Conduct a medication override audit.
Work Stream 2.3
Target Date 6/8/2012
8.02
Enhance P&T agenda with cost studies, outcomes for alternative drug options, ADR, Overrides, dosing guidelines.
8.03
8.04
8.05
8.06
8.07 8.08
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.
8.09
Establish a Medication Reconciliation task force to develop a consistently compliant process.
8.10
Conduct chart audit of medication reconciliation compliance to establish current baseline.
8.11 8.12 8.13 8.14 8.15
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.
8.16
Implement new reconciliation process (in EPIC).
8.17
Reassign the crash cart management under the Sterile Processing Department and/or Pharmacy.
8.18
Assess the space requirements and human resources needed for case cart management within SPD.
8.19
Revisit the cart management processes for supplies and pharmaceuticals.
8.20
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.
8.21
Implement an accountability process and sign off process to ensure accuracy and products are not expired.
8.22
Conduct cart initial audit for validation after transferring case cart management to SPD.
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
17
Medication Management (Section 2.08) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson 4.5 4.5 4.5 4.5 2.3 8/13/2012 8/13/2012 8/13/2012 8/13/2012 3/22/2013 2.3 9/14/2012 2.3 9/14/2012 2.3 2.3 6/8/2012 6/8/2012 2.3 6/8/2012 2.3 4/13/2012 2.3 6/8/2012 2.3 6/8/2012 2.3 6/8/2012 2.3 6/8/2012 Accountability Work Stream 2.3 2.3 Oct-12 Target Date 6/8/2012 6/8/2012 Nov-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
8.23 8.24
8.25
8.26
8.27
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.
8.28
Pharmacy Resource collects collates and summarizes audit results and submits monthly audit on the data tool.
8.29
8.30
8.31 8.32
8.33
8.34
8.35
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.
8.36
Ensure all clinicians are qualified to administer medications that have the clinical effect of moderate sedation.
8.37
Ensure compliance with new moderate sedation practice standards.
8.38 Vivian Johnson
Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane
8.39
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
1 1
Accountability Pharmacy Physicians Physicians Physicians Physicians Physicians Pharmacy SPD
Baseline 53% 83%
Goal 100%
MD Max Overrides reviewed by RPH
Jun-12 100% 59.8% 83.9%
Jul-12 100% 78.0% 80.9%
Aug-12 100% 85.2% 83.1%
Sep-12 100% 90.3% 83.7%
Oct-12 100% 92.0% 83.5%
Nov-12 100% 95.1% 83.5% 83.6% 68.2% 23.0% 0% House-Wide Pharmacy 0 121 1.7% 100.0% 0.2% 100.0% 0 91 0.0% N/A 4 94 0.0% 100.0% 0 59 0.0% 92.9% 1 73 0.0% 90.0% 2 60
Compliance in medication reconciliation at admission (inpatient only)
Compliance in medication reconciliation at discharge (inpatient only) Compliance in medication reconciliation - Ambulatory Services
5
1
Compliance in medication reconciliation - Medicine Clinics
Compliance in medication reconciliation - Surgery Clinics
7
1
Percentage of locations with unsecured medications
8
2
Percentage of compliant crash carts
Volume of adverse events related to moderate sedation
10
Number of improper or lack of medication labeling
18
Medication Management (Section 2.08) Metric Baseline 0 19 97.0% 88.0% 0 8 5 2 0 31 126 128 70 108 94 7.42% 96.4% 86.5% 2 Jun-12 Jul-12 Aug-12
1
# Pharmacy Pharmacy Pharmacy

1
Accountability Sep-12 0
Goal
11
Number of off-label medications in use, not reviewed by P&T
Oct-12 0
Nov-12 1 157 7.33% 96.0% 87.0% 6
12 Pharmacy Pharmacy
1
Number of adverse drug reactions
13
Missed medications
14 Pharmacy Comments
Percentage of medications administered within 60 minutes of order
15
Percentage of medications administered within 30 minutes of order 1
16
Number of opioid induced respiratory depressions naloxone administration
1. 2. 3. 4.
19
Patient Safety/Rights (Section 2.09) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Jody Springer Chris Madden 1.2 10/1/2012 Accountability Oct-12 Nov-12 Completion Y Work Stream 1.2 Target Date 3/30/2012
9.01 9.02 9.03
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 and Safety Officer (CPRSO)
9.04
The following quality and safety functions at Parkland would be reorganized to report directly to the CPRSO: 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) Chris Madden 1.2 5/11/2012 Chris Madden Lisa Betterson Lisa Betterson 6.2 6.2 6/8/2012 8/15/2012 1.2 5/11/2012
9.05
9.06 9.07
New job descriptions for all employees and managers, supervisors and department heads in units and divisions now reporting to the CPRSO. 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.
Y Y
9.08
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 Jackie Sullivan 6.1 6/8/2012 Jim Johnson Lisa Betterson Lisa Betterson Lisa Betterson Jody Springer Lisa Betterson 6.2 6.2 6.2 1.2 6.2 1.5 6/8/2012 4/27/2012 5/11/2012 9/30/2012 4/13/2012 6/1/2012
9.09
Create new Human Resources policy on violations of Patient Rights/Patient Safety obligations.
Y Y Y Y Y Y
9.10 9.11
9.12
9.13
9.14
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. Lisa Betterson
9.15
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.
6.2
3/30/2012
9.16
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.
Lisa Betterson
6.2
3/22/2013
20
Patient Safety/Rights (Section 2.09) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Lisa Betterson Robin Stults w/ Clinical Intelligence 3.4 7/31/2012 Lisa Betterson 6.2 9/14/2012 6.2 6/1/2012 Accountability Work Stream Target Date Oct-12 Nov-12 Completion Y Y
9.17
Complete current RCI initiative regarding 1:1 observation procedure and competencies required for staff.
9.18
Evaluate additional CM staff to ED.
9.19
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. Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson 6.2 9/14/2012 6.2 9/14/2012 6.2 10/31/2012 6.2 9/14/2012
9.20
Develop and implement an action plan that addresses non-compliance and the steps to the solution.
Y Y Y
9.21
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.
9.22
Determine where and if the resources are available or needed to meet the documentation requirements.
9.23
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. Lisa Betterson Lisa Betterson 6.2 6.2 5/25/2012 6/8/2012
9.24
Review Hospital policy for Patient Grievance procedure and compare to best practice, including those noted above.
Y Y
9.25
Develop monitoring system to ensure timelines required by Hospital policy are met.
9.26
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. Lisa Betterson 6.2 Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson 6.2 6.2 6.2 6.2 6.2
9/14/2012
9.27
6/8/2012 9/14/2012 9/14/2012 7/1/2012 9/14/2012
Y Y Y Y Y
9.28
9.29
9.30
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.
9.31
Develop a dashboard and track and trend the indicators for Patient Rights and the progress to the target thresholds.
21
Patient Safety/Rights (Section 2.09) Audit/Measures Baseline 100% 100% 100% 100% 100% 10 74% 584 22 25 464 100% 92.3% 92.3% 82.1% 403 41 97.8% 98% 98% 45.0% 77.0% 67.3% 91.0% 15 10 27 100.0% 100.0% 100.0% 0.0% 0.0% 0.0% 98.0% 98.0% 98.0% 100.0% 100.0% 100.0% 33 80.0% 226 22 98.0% 76.7% 91.7% 0.0% 54.0% 75.2% 98.8% 44% 100% 100% 100% Jun-12 Jul-12 Aug-12 Sep-12
1
# Pat Safety
1
Accountability Pat Safety Nursing Nursing Police Pat Safety Perf Imp Pat Griev Pat Griev PFS CM PFS
1
Goal
Oct-12 100% 99.2% 100.0% 100.0% 100.0% 45 94.1% 418 23 98.0% 79.5% 91.8%
Nov-12 100% 99.5% 100.0% 100.0% 100.0% 31 100% * 372 17 98.5% 82.8% 95.5%
Percentage of policies and procedures reviewed and/or revised
Percentage of staff provided education on patient rights and patient safety
Percentage of staff provided education on safe patient hand offs - area to area 1
4
1
Percentage of staff provided education on safe patient hand offs - shift to shift
Attendance for state mandated training courses for members of Police Department 1
6
1
Average time from event to closure of patient safety investigation (days)
Percentage of regulatory reports submitted within 5 business days 1
Number of patient complaints and grievances
Average time from event to resolution of patient complaint or grievance (days) 1
10
11
12
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 Baseline 80% 59 100% 47 64 34 66 Goal Pat Safety Pat Safety House-Wide
1
Accountability
Jun-12 61
Jul-12 67
Aug-12 81 42 69
Sep-12 47 36 53
Oct-12 58 53 60
Nov-12 32 42 52
13
14 Pat Safety Comments
Number of Patient Safety Investigations Percentage of Root Cause Analyses (RCA) completed within 45 days
15
Volume of privacy and security breaches
16
Number of elopements, AWOLS, AMA (excluding ED)
9.03 - 9.05 - Still conducting interviews for Chief Patient Rights and Safety Officer (CPRSO) 9.23 - Audit results are still below 98% compliance level, but are trending in the right direction 9.26 - Patient Relations department is restructuring dashboard under new leadership Audit # 7 - Contains both reports that are required to be submitted within two days. A&M will break out this metric for December.
1. 2. 3. 4.
22
Medical Staff (Section 2.10) Tasks/Initiatives 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 Jun-12 Jul-12 Aug-12 Sep-12 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.3 Accountability Work Stream Oct-12 Nov-12 Completion Y Y Y
10.01
Develop an OPPE/FPPE review template for each medical department and/or service.
10.02
Develop a written procedure explaining the OPPE process, criteria and physician referral process for FPPE.
10.03
Define required physician profile elements for all physicians.
10.04
10.05
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.
10.06
Review and obtain approval of OPPE/FPPE process and criteria by MEC, and then the Governing Board.
10.07
Each department should develop a standard set of metrics for use on cases sent for peer review.
10.08
Medical Staff Office Quality Department to establish a methodology to track and trend all cases brought to peer review
10.09
Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review.
10.10 Brad Marple, MD
Determine necessity to expand Medical Staff resources.
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
10.11
10.12
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. Brad Marple, MD 5.3 Brad Marple, MD 5.3
7/30/2012
10.13
Develop a training module enabling faculty to instruct residents when to escalate issues to their Attending Physicians.
8/31/2012
10.14
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
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) Tasks/Initiatives Target Date 7/30/2012 Jun-12 Jul-12 Aug-12 Sep-12 Brad Marple, MD 5.3 Accountability Work Stream Oct-12 Nov-12 Completion Y
10.18
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. Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD Brad Marple, MD Brad Marple, MD Brad Marple, MD 5.3 3/22/2013 5.3 8/31/2012 5.3 5/11/2012 5.4 5/11/2012 5.4 8/31/2012 5.4 8/31/2012 5.4 8/31/2012 5.4 8/31/2012
10.19
Y Y Y Y
10.20
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.
10.21
Standardize call schedule procedure for consulting services.
10.22
Ensure the accuracy Amcom scheduling system (source of truth maintained by Parkland)
10.23
Create contingencies for alternate modes of supervision or escalation.
10.24
Parklands GME Director should review the current training and education materials for Residents on documentation, particularly documentation of H&Ps.
Y Y Y
10.25
Refresher education and training should be conducted for all Residents.
10.26
Perform audit of Residents' History and Physicals (H&P) documentation for completion and adherence to Parkland policy and procedures. Audit/Measures Med Staff Perf Imp Comments Accountability Goal 15
Jun-12 40
Jul-12 34
Aug-12
Sep-12 192
Oct-12 120
Nov-12 114
Number of referrals to peer review 1 Percentage of Medical Staff enrolled in new OPPE system
1. 2. 3.
4.
24
Emergency Services (Section 2.11) Tasks/Initiatives Jun-12 Y Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 3.2 4/27/2012 Accountability Work Stream Target Date Completion
3.2 3.2 3.2 4/27/2012 4/27/2012
4/27/2012
Y Y Y 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. Clifann McCarley
Server cycle times need to be measured and applied to the design of care teams in the Triage and 11.04 the Intake areas. Clifann McCarley 3.2 7/13/2012
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. Clifann McCarley 3.2 6/8/2012
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 Clifann McCarley Clifann McCarley Clifann McCarley Patricia Bergen, MD 5.1 2.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2 5/11/2012 5/11/2012 5/25/2012 6/8/2012 7/13/2012 6/8/2012 7/13/2012 5/11/2012 6/8/2012 Deb Perrault Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley 3.2 6/8/2012 3.2 3/14/2013 3.2 1/13/2013
11.07
Work flow models should be piloted with Rapid Cycle Testing and refined as necessary and then training provided
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.
Y Y Y Y Y Y Y Y Y Y
11.10 Recruitment, credentialing and on-boarding of qualified physicians.
11.11 Pathology to scope operations, licensing, certification requirements for Point of Care labs.
11.12
Develop signage text consistent with the educational level and primary languages of the 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
25
Emergency Services (Section 2.11) Tasks/Initiatives Jun-12 Y Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Clifann McCarley Emilie Allen Emilie Allen Clifann McCarley 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 4/27/2012 5/18/2012 5/12/2013 4/13/2012 9/14/2012 9/14/2012 7/13/2012 6/8/2012 6/8/2012 9/30/2012 7/13/2012 5/25/2012 9/14/2012 Y Y Y Y Y Y Y Y Y Y Y 3.2 5/12/2013 4.4 4.4 5/20/2013 6/8/2012 3.2 3/22/2013 Accountability Work Stream Target Date Completion
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.
Develop a patient flow process to eliminate disparate treatment in evaluation and delay in the care Clifann McCarley 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 Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen
11.23
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.
11.29
Create training materials for accessing information required by law and reporting functions 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.
26
Emergency Services (Section 2.11) Tasks/Initiatives Jun-12 Y Y Y Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen Emilie Allen Emilie Allen Emilie Allen Emilie Allen Jackie Brock John Raish 4.3 4.3 4.3 4.3 4.3 6/28/2013 3/22/2013 3/22/2013 3/22/2013 Y Y 10/5/2012 4.4 4.4 4.4 9/21/2012 9/21/2012 5/18/2013 4.4 9/9/2012 Y Y 4.4 5/12/2013 3.2 5/18/2012 3.2 4/27/2012 3.2 4/13/2012 Accountability Work Stream Target Date Completion
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.
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.
Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish
27
Emergency Services (Section 2.11) Audit/Measures ESD

1
# 10208 2671 40.0 12.7 12.0 12.2 10.9 10.2 34.5 46.6 53.2 47.2 48.2 39.7 10.3 2829 3434 5209 2654 3536 2231 10146 10093 9734 9859 9539
Accountability
Baseline
Goal
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Main ED ESD
1
1 ESD ESD
1
Treated visits
2
1
Total number of hours of ED boarding
Average number of patients in ED that are boarding per day
Average number of dialysis patients in Main ED at 6AM
Average "Compassionate" dialysis patients transferred from ED/day Average dwell time for dialysis patients in Main ED
1 1
5 6 7 ESD ESD
1
Turnaround time to discharge patients to home (door to home, in minutes) 92 334 93 6.0% 2.3% 25.6% 65.8% 326 100% 4225 194.2 126 107 198 172 10.6% 0.9% 0.0% 91.9% 164 100% 1945 127 2.3 456.2 WISH WISH
1
ESD ESD ESD 99 496 90 10.2% 1.8% 26.9% 64.3% 371 371 90% 4727 235.2 176 159 8.4% 0.9% 0.1% 93.0% 240 217 4722 240.8 176 161 7.5% 1.3% 0.1% 92.0% 219 89% 2000 120 1.9 446.4 105 WISH WISH WISH 264 63 0 247 4.1% 14.9% WISH 10.5% WISH WISH WISH 400 66.9% 385 185 2.6 499.2 68 0 289 3.5% 15.6% 11.5% 64.4% 437 1978 149 2.7 461.2 53 72 271 2.4% 14.1% 10.4% 67.0% 406 90% 27.6% 62.3% 2.4% 11.2% 63 65 9.2% 2.3% 26.9% 64.3% 354 91% 4161 252.9 187 173 10.1% 1.1% 0.1% 92.8% 231 92% 1934 108 2.0 465.3 59 0 260 1.9% 11.8% 9.4% 70.4% 406 92% 608 394 70 131 61 125 114 238 70 8.3% 1.9% 27.5% 63.3% 342 89% 4225 273.6 194 183 11.4% 0.8% 0.0% 93.5% 253 92% 1927 166 2.3 493.9 56 0 268 1.8% 14.8% 8.1% 68.1% 426 91%
17.3 415.5 379.4
14.4 422 364.0
14.5 413 431.4
15.0 431 430.0
13.8 412 408.3
15.5 396 389.2
16.0 415 324.2 76 22 43 4.3% 1.8% 26.8% 63.6% 286 95% 4270 243.2 171 143 8.6% 0.8% 0.0% 92.8% 222 95% 1815 117 2.3 457.7 52 6 256 1.8% 14.2% 8.3% 68.5% 400 95%
8
1
Door to seen by 1st Provider (minutes) ESD ESD

1
9
1
Hours on resource alert
10 ESD
1
Door to Room Time (minutes)
11 ESD ESD
1
Left without being seen
12
Left without being treated
13 ESD ESD ESD ESD ESD ESD ESD ESD ESD

1
Percentage of patients admitted 313
14
1
Percentage of patients discharged 1
15
Average ED throughput time - time from patient arrival to patient disposition
16
Compliance to environment of care
Urgent Care Clinic (UCC) 258.4
17
Treated visits 1
18
Turnaround time to discharge patients to home (door to home, in minutes) 1
19
Door to seen by 1st Provider (minutes) 1
20
Door to Room Time (minutes) 1
21
Left without being seen 1
22 ESD
1
Left without being treated 1
23 ESD ESD WISH

1
Percentage of patients admitted 1
24
Percentage of patients discharged
25
Average ED throughput time - time from patient arrival to patient disposition
26
Compliance to environment of care 1
OB Gyn Intensive Care Clinic (ICC) WISH

1 1
27 WISH WISH
Treated visits 1
28
Total number of hours of ED boarding
29
1
Average number of patients in ED that are boarding per day
30
1
Turnaround time to discharge patients to home (door to home, in minutes)
31
Door to seen by 1st Provider (minutes)
32
1 1 1 1
33
Door to Room Time (minutes)
34
Left without being seen
35
Left without being treated
36
Percentage of patients admitted
37
Percentage of patients discharged
38
Average ED throughput time - time from patient arrival to patient disposition 1
39
Compliance to environment of care 1
28
Emergency Services (Section 2.11) Metric 6:28 20.9% 21.9% 21.4% 24.0% 19.3% 10.4% 6:57 7:05 6:43 6:42 5:55 Baseline Goal Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12
# 40 41
Labor Productivity (staffing to include acuity)
42 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
Accountability ESD ESD Total ED throughput time - time from patient arrival in ANY ED to discharge home from ANY ED 1 ESD Percentage of travelers - ED
11.23 - Still perfecting the role, responsibility and staffing of Team C in the Main ED 11.40 - Still waiting on complete documentation from Vice President of Peri-operative Services
1. 2. 3. 4.
29
Psychiatry Services (Section 2.12) Tasks/Initiatives Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips 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 Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips 2.1 2.1 2.1 2.1 2.1 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 4/13/2012 9/14/2012 6/8/2012 6/8/2012 6/1/2012 6/8/2012 7/31/2012 7/31/2012 7/31/2012 6/22/2012 5/25/2012 2.1 5/14/2012 2.1 6/8/2012 2.1 4/27/2012 Accountability Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 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 Sharon Phillips Y Y Y Y Y
12.01 Develop clear vision of a psychiatric services (with particularly focus on PED) care delivery model.
Work Stream 2.1
Target Date 4/27/2012
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 Sharon Phillips Sharon Phillips Sharon Phillips
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.
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
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.
30
Psychiatry Services (Section 2.12) Audit/Measures PED/CM PED Psych PED

1
# 100% 85% 514 97.4% 672 100.0% 3.9% 67.3% 26.7% 649 166 60 100.0% Baseline 8 6 26.9% 537 564 1,198 1.0% 10.0% Goal Jun-12 Jul-12 11 1 14.8% 501 1,114 2.6% 16.0% Aug-12 12 6 11.1% 588 1,294 2.2% 17.0% 46 68 531 404 682 608 706 560 N/A 29.8% 29.9% 65.9% 66.9% 2.1% 1.7% 100.0% 100.0% 100.0% 1.6% 73.3% 23.1% 588 385 61 99.1% Sep-12 15 3 8.3% 481 971 2.4% 14.0% 722 724 0 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% N/A 578 98.5% N/A 535 99.8% N/A 554 97.7% 100% 605 97.6%
Accountability
Baseline
Goal
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12 94% 541 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%
1 2 3 Psych Psych
1
Audit Results of number of Psych Inpatient cases intervened by CM on first day of admission 1 Treated Visits (PED)
Percentage of patients seen by social workers (PED) 1
5 Psych
1
Percentage of patients with a documented discharge huddle
6 Psych
1
Percentage of patients admitted
7 PED PED PED Psych Metric

1
Percentage of patients discharged to home
Percentage of patients transferred to acute care facility
Turnaround time to discharge patients to home (door to home)
10
Door to seen by 1st Psych Provider (minutes in PED) 1
11
Door to Room Time (minutes in PED)
12
Compliance to environment of care
# 13 14 Psych
1
Labor productivity (staffing to include acuity)
Volume of restraint cases - personal hold Psych Psych

1
Accountability PED Psych
15
Volume of restrain cases - seclusion
16
Number of patients with scheduled appointments at discharge
17 PED
1
Percentage of travelers - Psych 1
18 PED PED
1
Total PED throughput time - time from patient arrival to patient disposition (arrival in PED to discharge in PED)
19
Total PED throughput time - time from patient arrival to patient disposition (arrival in any ED to discharge in PED)
20 Psych Comments
24-hour bounce back rate
21
Proportion of total Psychiatric Services patients discharged from Main ED by Team C
1. 2. 3. 4.
31
Women and Infant's Specialty Health (WISH) (Section 2.13) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 4.2 4.2 4.3 4.3 4.3 2.4 7/15/2012 5/11/2012 4/13/2012 6/8/2012 9/30/2012 3/22/2013 Accountability Work Stream Target Date 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.
Begin recruitment of key leadership positions Nursing Director (L&D) and Nursing 13.03 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). Paula Turicchi
Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish
Evaluate job descriptions of Nurse Managers to determine if additional administrative 13.06 support is required.
13.07 Begin recruitment for administrative support roles (if appropriate). 4.3 4.3 4.3 4.3 2.4 4.3 4.4 6/1/2012 4/13/2012 6/1/2012 6/8/2012 6/8/2012 4/27/2012 6/8/2012 Y Y Y Y Y Y Y
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. Paula Turicchi Jackie Brock John Raish Emilie Allen
Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish
Evaluate job descriptions for inclusion of appropriate competencies and to ensure 13.12 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.
32
Women and Infant's Specialty Health (WISH) (Section 2.13) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Emilie Allen Emilie Allen Emilie Allen Emilie Allen Paula Turicchi Suzanne Sims 2.5 4/13/2012 2.4 5/31/2012 4.4 7/13/2012 4.4 7/13/2012 4.4 7/13/2012 4.4 7/13/2012 Accountability Work Stream Target Date Completion Y Y Y Y Y Y
A full assessment of current staff should be conducted to establish a current baseline of 13.15 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 13.21 Ensure plan of care practices are standardized and followed regularly. 13.22 Standardize hand off procedures. Educate staff. Paula Turicchi 2.4 4.3 2.4 2.4 4.4 2.4 7/31/2012 5/11/2012 4/6/2012 5/11/2012 6/30/2012 5/25/2012 2.4 6/8/2012
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.
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. Paula Turicchi Emilie Allen Paula Turicchi
Paula Turicchi Jackie Brock John Raish Paula Turicchi
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).
33
Women and Infant's Specialty Health (WISH) (Section 2.13) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Paula Turicchi Paula Turicchi 2.4 4/6/2012 2.4 7/31/2012 Accountability Work Stream Target Date Completion Y Y
Establish monthly mock equipment drills and verify emergency equipment is 13.30 immediately available where newborns are housed.
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. Paula Turicchi 2.4 4/15/2012 Suzanne Sims Emilie Allen Paula Turicchi 1.7 4.5 4.5 4.5 4.4 4.4 Goal 100.0% 100.0% 3/30/2012 Jun-12 96.7% Jul-12 96.0% Aug-12 96.0% 95.6% Sep-12 96.0% 96.0% Oct-12 72.7% 96.0% 3/31/2012 4/13/2012 4/13/2012 5/18/2012 7/12/2012 2.4 7/15/2012 4.4 4/27/2012 2.5 4/6/2012
13.34 Establish an alternative protocol for delivery table set-up to ensure sterile field.
Y Y Y Y Y Y Y Y Y Nov-12 68.8% 97.4%
13.35 Educate staff on storage requirements for specimens.
13.36 Revise dirty utility room flow and practice.
Department reports a plan is in progress for construction to ensure proper dirty utility Josh Floren 13.37 room flow. (No start date supplied) Review Parkland policy on securing medications PHR-D-067 Inventory Management Judy Herrington 13.38 Vicki Crane Procurement, Storage Judy Herrington 13.39 Anesthesia medication trays should be stored in a locked, secure area. Vicki Crane Judy Herrington 13.40 Store floor stock in Pyxis. Vicki Crane Educate staff on the importance of two patient identifiers and include in initial and Emilie Allen 13.41 annual competencies. Emilie Allen 13.42 Educate staff of National Patient Safety Goals and Hospital policy. Audit/Measures WISH WISH Responsibility
Compliance to Infection Prevention practice 1
Compliance to Environment of Care 1
34
Women and Infant's Specialty Health (WISH) (Section 2.13) Responsibility WISH WISH Baseline 11.65 20 104 192 1384 811 1207 979 906 834 22 17 21 21 80 164 617 13.10 11.97 12.88 12.42 13.07 14.02 Goal Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 WISH WISH WISH WISH WISH WISH WISH 114 121 122 138 WISH 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
3 4
Metric Labor productivity (Staffing to include acuity)
Staffing hours per patient day 1
Number of days per month staffing ratios were above/below grid 1
6a
Hallway and Classroom Beds in use in L&D (avg duration in minutes) 1
6b
Hallway and Classroom Beds in use in L&D (instances) 1
Volume of patients doubling-up on Post-Partum 1 Induction Interruption Induction Delay
7 8 9 10
11
Direct Admits to Post-Partum 1 Bounce-Back from Post-Partum to L&D Recovery
99 115
Audit # 1 - Audit results are from Labor and Delivery Operating Rooms (L&D ORs)
1. 2. 3. 4.
35
Perioperative Services (Section 2.14) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims 2.5 8/31/2012 2.5 2.5 2.5 2.5 2.5 2.5 8/31/2012 8/31/2012 8/31/2012 7/13/2012 8/31/2012 7/13/2012 2.5 6/8/2012 2.5 8/31/2012 Accountability Work Stream Target Date Nov-12 Completion Y Y Y Y Y Y Y Y Y
14.01
14.02
14.03 14.04 14.05 14.06 14.07 14.08
14.09
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 Jun-12 100.0% 97.6% 99.8% 99.0% Surgery Surgery Surgery Surgery Surgery Surgery Surgery 100.0% 100.0% 100.0% 99.8% 100.0% 100.0% 100.0% 100.0% Accountability Goal Jul-12 100.0% 100.0% 100.0% 100.0% 99.2% 100.0% 99.9% Aug-12 100.0% 100.0% 98.0% 100.0% 99.3% 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%
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
Compliance to Time Out procedure 1
36
Perioperative Services (Section 2.14) Metric Baseline 0 0 6 0 3 9.5% 1.71% 0% 1.5% 3.8% 1.4% 11.9% 13.5% 0 13.9% 1.6% 0 5 3 3 1 0 2 5 1 0 5 9.5% 1.8% 2 2 3 5 1 Goal Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Surgery Surgery Surgery Surgery Surgery Surgery Accountability Nov-12 2 0 1 0 0 6.8% 2.4%
Number of medication errors 1
Number of blood transfusion errors 2
10
Number of incorrect consents 2
11
Number of wrong site surgeries or wrong site markings 2
12
Number of lab specimen mis-labeling 2
13
Percentage of travelers - OR 1
14 Comments
Surgical Site infection rate (2 month lag) 1
Surgery
1. 2. 3. 4.
37
Procedural Services - Catherization Lab/Endoscopy (Section 2.15) Tasks/Initiatives Kim McCloud Linda Licata Barbara Mims 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 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 8/31/2012 8/31/2012 8/31/2012 3/30/2012 6/8/2012 8/31/2012 8/31/2012 8/31/2012 8/31/2012 8/31/2012 4/15/2012 Suzanne Sims Suzanne Sims Suzanne Sims Accountability Work Stream Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Target Date Nov-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Suzanne Sims Suzanne Sims Suzanne Sims Barbara Mims Valerie Harvey Y
15.01 Conduct a weekly environment of care tour to ensure infection prevention measures are in compliance.
Conduct audit on invasive procedures in the restricted procedure rooms on the proper medication management on and off 15.02 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. 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 Kim McCloud Linda Licata Barbara Mims Suzanne Sims
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.
Surgical Services to provide an educational session on the proper procedure of conducting sponge and needle/sharp 15.14 counts. Develop and implement an annual competency on proper procedure on performing counts.
15.15
15.16 15.17 15.18
15.19
15.20 15.21 15.22
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.
38
Procedural Services - Catherization Lab/Endoscopy (Section 2.15) Audit/Measures

1
# 1 2
1
Compliance percentage to Infection Prevention practice Compliance percentage of environment of care by audit, monthly 1 Surgery Surgery
1
Accountability Surgery Surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Baseline Goal Jun-12 Jul-12 99.6% 100.0% 94.6% 100.0% 98.3% 100.0% Aug-12 0 2 0 1 1 1 4 0 99.5% 100.0% 97.6% 100.0% 92.0% 100.0% 100.0% Sep-12 0 0 1 1 0 98.2% 100.0% 98.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 88.0% 100.0% 100.0% Oct-12 0 1 0 3 1
Goal 100.0% 100.0%
Jun-12 99.0%
Jul-12 100.0% 99.5%
Aug-12 97.0% 95.3%
Sep-12 98.9% 97.1%
Oct-12 98.6% 97.9%
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
3
1
Compliance to site marking procedure in cath lab by audit Surgery Surgery Surgery Surgery Accountability Surgery Surgery Surgery Surgery
2
Compliance to Time Out procedure by audit
7
1
Compliance to sponge, needle, sharp and instrument count in cath lab 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
8 Metric
Compliance to proper scrub attire and sterile gowning in restricted areas in cath lab by audit
Number of wrong site surgeries 2
10
Number of incorrect consents
11 Surgery Comments
Number of medication errors
12
Number of lab specimen mis-labeling
13
Number of return to surgery for retained objects
Audits # 1 and 6 - Poor compliance noted in Gastrointestinal (GI) Lab.
1. 2. 3. 4.
39
Radiology (Section 2.16) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 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 2.2 2.4 2.4 4.5 4.5 4.4 2.2 2.2 2.2 Scott Cummins Patricia Bergen, MD 2.2 5.1 6.4 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 6.4 9/30/2012 4.4 2.2 5/11/2012 6/8/2012 2.5 8/31/2012 2.5 6/1/2012 2.2 7/13/2012 Accountability Nov-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08
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.
Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2
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
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 16.11 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.
16.14a 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.
Scott Cummins Suzanne Sims Suzanne Sims Judy Herrington Vicki Crane Judy Herrington Vicki Crane Emilie Allen Scott Cummins Scott Cummins Scott Cummins
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 16.21 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.
Audit the Main and ASC Operating Room staff and providers proper wear of personal protective attire during a 16.24 procedure when operating the mini-fluoroscopy and other radiation safety requirements.
16.25 Initiate the education plan for the physicians requiring the need to meet the credentialing criteria.
40
Radiology (Section 2.16) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Patricia Bergen, MD 5.1 2.2 2.2 2.2 9/14/2012 6/8/2012 6/8/2012 5/11/2012 Scott Cummins Scott Cummins Scott Cummins Accountability Work Stream Target Date Nov-12 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 Jun-12 100.0% 100.0% 91.0% 98.7% 100.0% 96.0% 100.0% 100.0% Jul-12 Radiology Radiology Radiology Radiology 100% 100% 100% 100% Accountability Goal Aug-12 100.0% 100.0% 96.5% 99.5%
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%
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
41
Radiology (Section 2.16) Metric Goal 0.5 14 125% 18% 1.9 14 130% 27% 0.7 14 120% 10% 0.8 14 120% 17% 1.2 14 116% 17% 120% 16% 0 0 Radiology Radiology Radiology Radiology 0 0 0 0 2 1 3 10% 0.8 2 121% 22% 1.6 18 127% 13% 0 0 134% 0 0.6 0.6 4 118% 9% 0.7 9 119% 15% 1.9 15 96% 9% 0 0 24% 23% 123% 118% 20% 0.6 1 120% 8% 0.9 1 115% 12% 1.4 12 117% 13% 0 1 0 0 2 0 24 7 11 123% 1.8 1.9 2.2 2.2 8 111% 21% 0.7 1 110% 8% 0.9 2 101% 11% 1.3 13 113% 14% 0 0 0 0 0 0 19% 18% 15% 14% 136% 141% 190% 189% 119 87 4 9 0.6 0.5 0.5 0.5 0.6 30 103% 17% 2.3 12 113% 18% 0.6 1 107% 8% 1.0 1 102% 12% 2.1 11 104% 17% 0 0 0 0 1 2 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology Radiology 26 1.2 18% 118% 15 0.8 11% 117% 12 0.7 28% 115% 64 1.9 19% 130% 95 0.5 Accountability Baseline Nov-12 0.5 13 1% 13% 2.4 20 1% 19% 0.6 1 104% 8% 0.9 2 103% 11% 1.5 13 105% 15% 2 2 0 1 1 1
Mammography - Diagnostic
Labor productivity - Mammography - Diagnostic (Paid Hours/Unit of Service) (1 month lag) 1
Number of days to third next available appointment - Mammography - Diagnostic 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
10
Number of days to third next available appointment - MRI 1
11
Current utilization of slots - MRI 1
12
No show rate - MRI 1 CT
13
Labor productivity - CT (Paid Hours/Unit of Service) (1 month lag) 1
14
Number of days to third next available appointment - CT 1
15
Current utilization of slots - CT 1
16
No show rate - CT 1 US
17
Labor productivity - US (Paid Hours/Unit of Service) (1 month lag) 1
18
Number of days to third next available appointment - US 1
19
Current utilization of slots - US 1
20
No show rate - US 1 IR
21
Labor productivity - IR (Paid Hours/Unit of Service) (1 month lag) 1
22
Number of days to third next available appointment - IR 1
23
Current utilization of slots - IR 1
24
No show rate - IR 1 Overall
25
Number of Incorrect consents 2
26
Number of incorrect tests or wrong results placed 2
27
Number of cancelled surgeries due to unavailable films 2
28
Number of medication errors 1
29
Number of lab specimen mis-labeling 2
30
Number of wrong site surgeries 2
42
Radiology (Section 2.16) 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.
43
Laboratory Services (Section 2.17) Tasks/Initiatives Target Date 3/30/2012 5/11/2012 4/6/2012 Jun-12 Jul-12 Aug-12 Sep-12 Accountability Oct-12 Nov-12 Completion Y Y Y Work Stream 2.2 2.2 2.7
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. 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 5/25/2012 4/13/2012 4/13/2012 7/31/2012 8/31/2012 6/8/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 3/23/2012 4/13/2012 4/13/2012 5/15/2012
Y Y Y Y Y Y Y Y Y Y Y Y Y Y
17.06 Educate laboratory staff on expected cleaning standards and schedules.
17.07 Define with EVS an escalation process for cleaning.
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
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 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.
17.09
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 patients 17.17 that require a certified translator. 17.18 Provide Medical Assistant staffing for FNA clinic.
44
Laboratory Services (Section 2.17) Tasks/Initiatives Target Date 4/27/2012 6/8/2012 4/6/2012 6/8/2012 Jun-12 Jul-12 Aug-12 Sep-12 Debbie Perrault Debbie Perrault Emilie Allen Debbie Perrault 2.2 4.4 2.2 2.2 Accountability Work Stream Oct-12 Nov-12 Completion Y Y Y Y
17.19
17.20
17.21
17.22
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 Jun-12 100% 100% 100% Jun-12 99.0% 2 100% 100% Jul-12 99.0% 2 100% Jul-12 Lab
1
# 100% 100% 100% Baseline 0 98.0% Goal Lab Lab Metric

2
Accountability
Goal
Aug-12 100% 100% 100% Aug-12 9 99.0% 1
Sep-12 100% 100% 50% Sep-12 6 99.0% 0
Oct-12 N/A N/A 100% Oct-12 1 98.0% 0
Nov-12 N/A N/A 100% Nov-12 5 99.0% 0
1
1
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
3 Accountability Lab
1
Compliance to autopsies having formal orders
# Lab
2
4 Lab Comments
Number of incorrect reporting of lab/pathology results
Percent compliance to 60 minute critical value turnaround time
Number of patient safety events relating to non-compliance in critical value reporting
1. 2. 3. 4.
45
Food & Nutrition Services (Section 2.18) Tasks/Initiatives Usha Kollipara 2.2 5/30/2012 Accountability Work Stream Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Target Date Nov-12 Completion Y
18.01
Change procedure to ensure all unused trays are collected after meals.
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.
Kim McCloud Linda Licata Barbara Mims 2.8 4/13/2012 Usha Kollipara 2.2 4/4/2012
18.03
Acquire thermometers for freezers.
#
1
Audit/Measures FNS Accountability FNS Comments Baseline Goal Jun-12 100% 100% 100% Jul-12
Accountability
Goal
Jun-12
Jul-12
Aug-12 100% Aug-12
Sep-12 100% Sep-12
Oct-12 100% Oct-12
Nov-12 100% Nov-12 95%
Compliance with all nutrition services equipment and food temperatures
Metric Percentage of units surveyed which do not reheat food trays
Metric # 2 - Out of the 21 units surveyed, one nurse responded "yes," to reheating trays on his/her unit. Feedback was given immediately.
1. 2. 3. 4.
46
Organ and Tissue (Section 2.19) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Jackie Sullivan Emilie Allen 4.4 9/14/2012 6.4 9/14/2012 Accountability Work Stream Oct-12 Target Date Nov-12 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
47
Physical Medicine and Rehabilitation (PMR) (Section 2.20) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Barbara Mims Jenni Burnes Jenni Burnes 4.2 2.2 1.2 1.2 2.8 2.2 2.2 9/14/2012 4/13/2012 4/20/2012 4/13/2012 6/8/2012 5/4/2012 5/25/2012 2.2 6/8/2012 2.2 8/1/2012 4.2 8/1/2012 2.2 6/29/2012 2.2 2.2 2.2 5/4/2012 6/29/2012 6/29/2012 2.2 5/4/2012 2.2 4/20/2012 Accountability Work Stream Target Date Oct-12 Nov-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
20.01
20.02
20.03 20.04 20.05
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.
20.06
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.
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. Jenni Burnes Jenni Burnes
Barbara Mims Valerie Harvey Jenni Burnes Jody Springer Jenni Burnes Kim McCloud Linda Licata Barbara Mims
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
48
Physical Medicine and Rehabilitation (PMR) (Section 2.20) Audit/Measures Jun-12 90.1% 100% Baseline 15.2% 13.8% 432 87.5% 15.6% 27.0% 0.0% 33.0% 1182 61.1% 13.8% 25.4% 100.0% 10.0% 0.0% 69.7% 12.8% 26.7% 86 71.9% 100.0% 75.8% 10.0% 13.8% 100.0% 81.4% 80.5% 15.1% 36.0% 1267 72.2% 11.0% 17.9% 117 102.7% 412 0.0% 15.7% 15.5% 18.5% 362 31.0% 97.2% 15.9% 38.2% 1131 4.3% 80.1% 5.9% 21.6% 97 10.0% 122.3% 10.0% 15.0% 12.0% 14.5% Goal Jun-12 Jul-12 Aug-12 Sep-12 16.9% 14.7% 415 21.0% 73.8% 15.4% 30.6% 1253 4.3% 68.4% 14.9% 18.1% 116 2.0% 81.5% 96.5% 98.2% 94.0% 95.0% 96.2% Jul-12 Aug-12 Sep-12
1
# PMR PMR Metric PMR

1
Accountability
Goal
Oct-12 93.0% 98.0% Oct-12 13.9% 4.0% 429 21.0% 101.8% 17.0% 6.2% 1363 15.0% 81.9% 13.8% 2.5% 119 0.0% 98.5%
Nov-12 92.0% 99.7% Nov-12 16.1% N/A 348 14.0% 90.3% 16.7% N/A 1212 12.0% 80.7% 10.7% N/A 90 0.0% 86.2%
Percent of all elements of care that have been assessed and addressed
2 Accountability
Compliance to Environment of Care
Occupational Therapy (OT)
3 PMR PMR PMR

1
No show rate - OT
Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - OT
5 PMR PMR PMR PMR PMR

1
Total Orders (OT)
Vacancy rate - OT
Labor productivity (percentage of targeted appointments per FTE) - OT Physical Therapy (PT)
No show rate - PT 1
Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - PT 1
10 PMR PMR PMR PMR PMR

1
Total Orders (PT)
11
Vacancy rate - PT
12
Labor productivity (percentage of targeted appointments per FTE) - PT Speech Therapy (ST)
13
No show rate - ST 1
14
Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - ST 1
15 PMR Comments
Total Orders (ST)
16
Vacancy Rate - ST
17
Labor productivity (percentage of targeted appointments per FTE) - ST
Metric # 4, 9 and 14 - Inaccuracies were found in data, will report November and December metrics in December report.
1. 2. 3. 4.
49
Respiratory Therapy (Section 2.21) Tasks/Initiatives Edward Best Edward Best Edward Best Edward Best Edward Best 2.2 2.2 2.2 2.7 2.7 4/13/2012 4/6/2012 6/8/2012 9/14/2012 9/14/2012 2.2 6/8/2012 Accountability Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Completion Y Y Y Y Y Y Y Y Y Y
21.01 21.02 21.03 21.04
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.
Work Stream 2.2 2.2 2.2 2.2
Target Date 4/13/2012 5/11/2012 3/22/2013 4/13/2012
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.
Meet with clinical leaders who store oxygen tanks and determine responsibilities of staff in which oxygen tanks are 21.10 stored. 2.7 5/11/2012
21.11 Develop a house-wide education/awareness for all staff that addresses all areas of responsibility.
21.12 Audits of oxygen tank safety. Edward Best 2.2 9/14/2012
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 2.7 5/1/2012
Y Y
21.13 Long term strategy for an annual assessment of therapy care to ensure that there are no gaps in process or care.
# RT RT RT House-wide Metric RT RT Comments

1
Audit/Measures
Accountability
Goal 0% 95.0% 100% Baseline 2.74 3.29% Goal 2.65 1.8%
Jun-12 4.2% 896 87.7% 75.0% Jun-12 3.04 3.5%
Jul-12 2.6% 1042 89.6% 96.0% Jul-12 2.93 1.4%
Aug-12 6.4% 919 94.7% 99.4% Aug-12 2.64 3.6%
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%
1
1
Percentage of missed treatments related to Therapist not being available 1
Number of missed treatments (RT self-reporting) 1
Respiratory Care documentation accuracy
4 Accountability
Compliance in oxygen tank storage 1
Productivity Metrics (Weighted Procedures/Hours Paid) 1
Ventilator Associated Pneumonia Rate
1. 2. 3. 4.
50
Community Oriented Primary Care (COPC) (Section 2.22) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 4.5 2.3 4.5 2.3 4.5 4.5 3.6 4/6/2012 5/11/2012 5/11/2012 6/20/2012 5/11/2012 3/23/2012 6/8/2012 Accountability Work Stream Oct-12 Target Date Nov-12 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. Vivian Johnson
Judy Herrington Vicki Crane Vivian Johnson Judy Herrington Vicki Crane
22.04
Implement electronic medical record (EMR)/Pharmacy interface to allow for Pharmacy to provide oversight to prescribing 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. Judy Herrington Vicki Crane Judy Herrington Vicki Crane Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD 3.6 2.7 2.7 6/8/2012 5/11/2012 6/8/2012
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.
Y Y Y
22.09
Meet with the appropriate leaders responsible for environmental cleaning and maintaining the environment to discuss the gaps and develop plan for improvement. Kim McCloud Linda Licata Kim McCloud Linda Licata Barbara Mims Jessica Hernandez Holt Oliver, MD 3.6 6/8/2012
22.10 Establish multi-disciplinary monitoring of clinic locations.
22.11 Load plans of care into Jail electronic medical record (EMR).
51
Community Oriented Primary Care (COPC) (Section 2.22) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Barbara Mims Valerie Harvey 4.2 3.6 4.2 7/20/2012 6/8/2012 8/1/2012 Jessica Hernandez Holt Oliver, MD Barbara Mims Valerie Harvey Accountability Jun-12 Jul-12 COPC COPC COPC COPC COPC Metric Baseline 0 97.2 17.2% Goal COPC
2
Accountability
Work Stream
Target Date
Oct-12
Nov-12
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.
Goal
Aug-12 99.4%
Sep-12 100.0% 96.0% 98.0% 96.0% 94.0% 97.0% 100.0% 91.9% 96.0%
Oct-12 100.0% 97.5% 99.4% 97.4% 97.0%
Nov-12 99.0% 97.4% 100.0% 93.5% 98.0%
1
1
Audit/Measures Compliance with medication management to include but not limited to securing, labeling , reconciliation and 1 documentation 95.5% 100% 94.7%
1
Compliance percentage of environment of care by audit, monthly
Compliance to the use of two patient identifiers
Compliance to infection prevention practice 1
5 Accountability COPC COPC COPC Comments
Compliance in medication reconciliation 1
Jun-12 1 2 115.8 17.0%
Jul-12 4 11 102.9 17.0%
Aug-12 1 1 92.2 17.0%
Sep-12 4 2 78.0 17.7%
Oct-12 1 1 81.1 17.7%
Nov-12 2 4 75.6 17.5%
Number of lab specimen mis-labeling by clinic
Third next available appointment
No show rate 1
1. 2. 3. 4.
52
Specialty Clinics (Section 2.23) Tasks/Initiatives Jun-12 Jul-12 Aug-12 Sep-12 Vivian Johnson Jessica Hernandez Holt Oliver, MD 3.6 3/30/2012 Jessica Hernandez Holt Oliver, MD 3.6 6/8/2012 Jessica Hernandez Holt Oliver, MD 3.6 2.5 2.5 Goal Jun-12 10/31/2012 10/31/2012 Jul-12 Aug-12 98.7% 94.2% 92.0% 96.3% 99.5% 92.0% Sep-12 100.0% 98.6% 99.5% 95.0% Oct-12 99.0% 98.0% 98.5% 97.0% Nov-12 100.0% 99.0% 100.0% 96.0% 5/7/2012 Suzanne Sims Suzanne Sims Accountability Clinic Clinic Clinic Clinic Accountability Oct-12 Nov-12 Completion Y Y Work Stream 2.3 Target Date 9/14/2012
23.01 Ensure hard-stop process in Epic is engaged.
23.02 Determine EVS scope and schedule.
23.03 Clinic leadership to round clinic areas to monitor PHI security.
23.04 Clinic leadership to develop and implement disciplinary actions for staff violations of HIPAA policies.
Y Y Y
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.
2 3 4
Audit/Measures Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation Compliance percentage of environment of care by audit, monthly 1 Compliance to the use of two patient identifiers Number of completed medication reconciliations by audit
53
Specialty Clinics (Section 2.23) Metric Baseline 0

2
# Goal 0 4 92.2% 97.3% 4 5 2 0 8 2 3 1 Jun-12 Jul-12 Aug-12 Sep-12
Accountability
Oct-12
Nov-12 1 1
Number of lab specimen mis-labeling by clinic Compliance to HIPAA/privacy standards (based on EOC audit)
96.8% 25% 128 151 25% 115 143 24% 94 148 26% 65 118 25% 145 155 23% 67 128
100.0% 30% 150 116 22% 63 164 22% 89 157 24% 60 123 21% 117 148 27% 61 130
General Surgery
No Show Rate
10
Average dwell time (minutes) Urology
11
No Show Rate
12
Third next available appointment 1
13
Average dwell time (minutes) Surgery Oncology
14
No Show Rate
15
16
Average dwell time (minutes) Cardiology
17
No Show Rate
18
19
Average dwell time (minutes) 1 GI/Liver
20
No Show Rate
21
22
Average dwell time (minutes) Renal
23
No Show Rate
24
25
Average dwell time (minutes) 1
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.
55
Contract Services (Section 2.24) Tasks/Initiatives Target Date Jun-12 Jul-12 Aug-12 Sep-12 Accountability Work Stream Oct-12 Nov-12 Completion
24.01
Create database of all contracted patient service arrangements. 6.5 3/22/2013
Muthusamy Anandkumar, MD Ciel Murphy
24.02
Review department specific quality indicators for all contracts. 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
Contract Management Unit to provide first batch of contracts for quality score and review and proposed scores against template to BOM Quality Committee.
6.5
8/30/2012
56
Contract Services (Section 2.24) Audit/Measures Jun-12 Jul-12 Aug-12 Sep-12 Contracts
1
Accountability
Goal
Oct-12
Nov-12
1 Contracts Accountability Baseline Goal Jun-12 Jul-12 Aug-12

1
Percent of current contracts in database 1 100% Sep-12 N/A N/A 89%
2 Metric Contracts
1
Percent of current contracts that have department specific quality indicators
100% Oct-12
90% Nov-12 59.0% 88.0%
# Contracts Comments
Number of "significant" contracts meeting requirements for quality scoring
Number of "by exception" contracts meeting requirements for quality scoring
Metric # 1 - Still reviewing "legacy" contracts dating prior to 2009. Metrics # 3 - 4 - "Significant" contracts are regularly reviewed by QCC while" by exception" contracts may be requested to be reviewed by QCC at any time.
1. 2. 3. 4.
57
QAPI Tasks/Initiatives Target Date Jun-12 Jul-12 Aug-12 Sep-12 Accountability Work Stream Oct-12 Nov-12 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 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 6.4 6.1 6.1 6.1 6.1 6.1 6.1 6.1 5/25/2012 5/25/2012 5/18/2012 6/30/2012 6/30/2012 5/25/2012 9/30/2012 5/25/2012 6.1 6/30/2012 6.1 6.1 11/31/2012 9/30/2012 6.1 9/30/2012 6.1 6/30/2012 6.1 6.1 6.1 5/25/2012 6/15/2012 6/30/2012
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
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
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
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.
Q.11 Q.12 Q.13 Q.14
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

Ninth Compliance Report On Parkland Memorial Hospital

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Report of the Independent Consultative Expert (ICE) Monthly Progress Report November, 2012 on Parkland Health & Hospital

l System Dallas, Texas

December 13, 2012

3.3 1.2 2.6 3.5 6.4 3.4 4.4

Significant CAP-related Goals Met in November

Significant CAP-related Goals Still Outstanding in November

Patient Safety / Patient Rights

Overall Impressions from November

Access and Throughput Care Management

Percentage of Discharges < 11:00 AM

Patient Rights Patient Safety Overall

93% 94% 92%

Nursing Vacancy Rates

Ongoing Professional Practice Evaluation (OPPE)/Peer Review

Privileges and Credentials

Nursing Practice and Nursing Units

Nursing Float Pool

Root Cause Analysis (RCA)

Safe Patient Discharges

Volume of Elopements - ED (Main, UCC, ICC, PED)

Volume of Elopements - Non-ED (In/Outpatient)

Department and Unit Specific Findings

Chemotherapy Infusion Center

Community Oriented Outpatient Clinics (COPC)

Respiratory Therapy Missed Treatments

Sterile Processing Department

Urgent Care Clinics

Urgent Care Center Throughput Metrics (Minutes)

Onboarding of EmCare Physicians

Require quality dashboard report from Hospital Quality Department

Review Hospital plan on continuum of care.

Audit/Measures Contract Svcs Comments

Percentage of contracts (outsourced vendors) reviewed for quality measures

1.09 - Hospital is re-formulating task force to focus on post-acute care

Reported through Alvarez and Marsal's Daily Audits

Work Stream 1.5 1.2 1.5 1.5

Target Date 5/25/2012 5/25/2012 5/25/2012 7/13/2012

2.06 2.07 2.08

Develop Parkland employee retention strategy.

2.10 2.11 2.12 2.13 2.14 2.15

2.17 Audit/Measures House-Wide

Aug-12 46% 5.0% 55.0% 40.0% 100%

Percentage of licensing validations presented prior to the day of hire

100% HR 10 18.3 13.7 24.2 11.9 11.1 9.0

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

# 16.5% 15.0% 9.5% 9.8% 44.7% 9.7% 21.5% 12.8% 9.5%

Nov-12 12.7% 12.0% 24.1% 41.2%

Turnover Rate (%) - Nursing 1

Turnover Rate (%) - Total

Percentage of competencies updated on/before due date

Number of corrective actions

Absent Hours (as a percentage of total hours worked)

Percentage of current licensure 1

Percentage of current certifications

Time for recruiting to fill an open external job position

Conduct analysis of no show rates by clinic, day, session, and provider.

Develop the post-acute care network.

Conduct a physician productivity analysis based on agreed upon industry standards.

3.10 3.11 3.12 Miriam Gomez Miriam Gomez