Sunday, October 28, 2012

CCHHS Quality and Patient Safety Committee Meeting, October 16, 2012

CCHHS will complete its survey of safety status by the end of February 2013 to be ready for the JointCommission's accreditation visit.   (Accreditation must now be renewed every three years or the Center for Medicare and Medicaid Services won’t reimburse the system for services rendered.)  The Commission uses tracer methodology, which means following patients throughout the process: speaking to their families, checking the credentials of all those who touch them, etc.; so CCHHS did a mock tracer study in advance.  A Committee member asked to see the results of this mock study.


The Joint Commission has 1700 areas of performance: Stroger’s Big Five are Environment of Care; Life Safety (both focused on the building); Infection Control; Provision of Care; and Performance Improvement (how to use data). Each has a multidisciplinary subgroup assigned to it, which meets weekly.  The Life Safety team has called for increased training and closer supervision of contracted staff such as Sheriff’s personnel who bring prisoners into the hospital.  There’s now a hotline to report problems with cleanliness and all staff are urged  take personal responsibility for hand-washing and IV removal to prevent infection.

The Provision of Care group has focused on special care for vulnerable populations (pediatric, psychiatric and the elderly).  In response to a question, Dr. Das noted that the needs of non-English speakers are addressed through a 24-hour phone interpreter service.

Reports from the Medical Staff Executive Committees
No report from Provident; Dr. Wakin was absent.

Dr. Goldberg of Stroger reported a focus on meeting the time frames of the Affordable Care Act: “We want patients to keep choosing us.”  He invited Board members to schedule attendance at the “Schwartz rounds” to learn about the hospital’s multidisciplinary approach.  In response to a question Goldberg said the use of Electronic Medical Records (EMRs) had not reduced physician productivity–“the doctors just spend more time.” 

Electronic Medical Records Update from Chief Information Officer Dr. Hota

Chairman Michael again cautioned the staff to “make sure we’re not collecting useless information.”  The CORE Center reported an inability to complete departure notes in the new EMR, and asked for additional office support to relieve doctors and nurses of the task.  Dr. Hota noted that the hospital earned $12 million in Federal incentives ($44,000 per “eligible provider,” of whom there are 400) this year for meeting the EMR requirements of the Affordable Care Act, which include not only a specific timeline but specific prescribed software.  (These compliance subsidies will continue, at a steadily reducing level, til 2016, when they’ll be replaced by penalties for failure to comply.)

Committee member Dr. Munoz pointed out that if doctors did all the EMR departure notes (include review of all medications and aftercare instructions for patients) themselves they’d only be able to see two patients an hour, and urged the staff to consider whether someone else could take on the task.  Dr. Hota responded that each clinic establishes its own work-flow. 

On July 31 the system installed 1800 new computers and set up Web training to handle the continuous inflow of new staff and supplement the ½-time trainer.  By now 98% of the nurses and 70+% of the doctors are trained.  In some areas EMR use is very good: 100% of vital signs are recorded electronically and most divisions are using e-prescribe.  Chairman Michael asked the staff to prepare an estimate of necessary additional training resources.

Current Quality Measures/Reporting
PQRS (the Physician Quality and Reporting System) suffers from slowdown due to overuse, but CCHHS is adding additional servers and other infrastructure which will save time and the number of clicks per transaction.

The system is now working with Microsoft to have its old databases converted for use on the new system by exporting them to a Virtual Private Cloud Database.  In addition, they’re using an open-source reporting system created by two staff members using free software, which will be easier to tweak and update than software provided by a vendor.  Again personnel is needed: a team of data analysts and additional training.  Chairman Michael asked whether it was clear what should be measured. Hota responded that there were plenty of “obvious targets.”

Developing a Quality Dashboard
The staff proposed that the CCHHS Dashboard include:


1.                  Core Measures
2.                  Hospital-acquired conditions
3.                  Re-admission (though may result from outside factors, e.g. lack of primary medical care)
4.                  Immunization
5.                  Patient satisfaction (driven by the experience coming in the door and going out the door, plus “how we talk to you while you’re here”)

Chairman Michael suggested that the Committee make recommendations about what to include on the Dashboard, and share those with the full Board at its next meeting.

Dr. Das explained that the design of the dashboard should reflect the system’s aims, whether comparative or strategic.  An individual dashboard can show both  absolute measures (e.g. numbers of timely catheter removals, because Medicare/Medicaid will no longer reimburse hospitals for procedures resulting in catheter-related infections) and comparative measures (throughput in the emergency department: the state average is 2 hours, ours is now 10; how are we progressing?).  CCHHS will focus first on patient-safety and hospital-acquired conditions (falls, trauma, infections) because there are protocols to prevent these harms.  The Chair asked to see these statistics monthly, and Dr. Das agreed to come back in November with a recommendation of what the Committee should examine every month.

Updating the Quality Plan
The current quality plan will cover CCHHS through accreditation, but the system is now considering improvements for 2013 and should have a new plan by this year’s end.  The main aims should come from the medical staff and be considered by the Committee and then the full Board.   Dr. Murray of the Public Health Department reminded the Committee that the plan must look beyond the hospital at things like whether there are populations in Cook County that are inequitably served, and Dr. Mason concurred: “Public health is more important than what we [at the hospital] do.”  Chairman Michael suggested separating aims within CCHHS’s control from those that are not; the latter requires engaging outside partners such as the state and other hospitals.  He also stressed making sure the system is using the right data: there is a lot of information about Medicare patients, but 40% of CCHHS's patients are uninsured.  Dr. Mason pointed out the importance of measuring employees’ experience and satisfaction.

Patient Safety Indicators
In response to an earlier question by Committee member Mary Driscoll, Chairman Michael reported the advice of legal counsel that the Committee can’t review individual cases in which patient safety has become an issue without compromising patient confidentiality.  But as the Committee needs to be aware of safety issues, two of its members (Drs. Velzquez and Munoz) have agreed to serve on existing hospital committees and report back to the Committee on those issues.  Driscoll agreed the Committee didn’t need to see individual cases but “we need to understand the process.”  The chair promised that Dr. Mason would continue to educate the Committee on these issues, “but the key is learning about problems before they’re lawsuits.  We can’t do that here, but we’ll participate in existing committees and hear about risk management.”  

--Submitted by Observer Kelly Klein

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