Dr. Mason reported that the Joint Commission had made its accreditation site visit ahead of schedule on November 2. (The federal Center for Medicare and Medicaid Services [CMS] uses the Joint Commission to evaluate and approve hospitals on its behalf.) Formal findings will be available in January, but the results were mostly positive.
- The hospital received no CMS Condition Citations (which would require correction before restoration of Federal reimbursement).
- The hospital received Direct Impact Citations (calls for improvement) in life safety, including employee exposure to hazardous materials and lack of adequate smoke detectors. It also received Direct Impact Citations having to do with documentation of care and the related issue of cooperation among disciplines (e.g., the emergency room and the surgical department). Dr. Mason stressed that the issue was not quality of care but reporting, and noted the need for additional personnel to bring reporting up to snuff.
- The hospital also received an Indirect Impact Citation for bylaws issues, including the fact that currently the Medical Executive Committee can override the full staff in considering bylaws amendments. Dr. Goldberg reported that the medical staff will vote in 10 days on a bylaws revision permitting the staff to bring amendments to the Board even if the Executive Committee disapproves, and that he will bring the approved revision to the December Board meeting.
Response plans are due to the Joint Commission by December 17 (for Direct Impact Citations) and January 1 (for Indirect Impact Citations), but the hospital has four months to provide supporting data showing that the plans actually solve the problems identified. Chairman Michael asked about the 1-3% of patients, about 30 per month, who wait more than 24 hours in the Emergency Room. Nursing Chief Russell responded that these patients are monitored closely and receive an "almost-inpatient level of care," but the requirement is to complete a broader assessment, including various cultural issues, within 24 hours. Michael asked how many additional nurses it would take to do that for the ER’s 45-60 daily patient load; Russell said she needed 3 additional nurses short-term, and more long-term if the hospital wants a dedicated ER admissions team. ER Chief Dr. Shadur uses tracking reports to identify the 2 patients who wait an exceptionally long time, so it should be possible to conduct a full assessment at the 18-hour mark to assure its completion within the mandated time.
Medical records continue to be "delinquent" (updated belatedly) because old charts can’t be sent electronically, and because of some system bugs now being worked out by Chief Information Officer Dr. Hoda. Again the Committee asked if the medical staff needs more training in the system and if there’s a training department to provide it; again Dr. Mason replied that the system has only one half-time trainer. He will report on record-keeping progress at the December meeting so the Committee can determine whether additional training staff is required.. Dr. Hoda said there are training hours included in the hospital’s latest contract for Electronic Medical Records, so teams are going out to clinics on training tours. In the next month or so he’ll know how effective that approach is and whether there’s actually a training deficit.
Mindy Malecki, Assistant Director for Management, reported that a draft disclosure policy would come to the Committee in December, once the legal department and Dr. Raju sign off on it.
Dr. Mason then showed another video, "Boards and Dashboards," with the latter term meaning a display of levels of performance for the staff to improve and the Board to assess. Two types of dashboard are in common use: the strategic, which measures progress against major goals, and the comparative, which measures progress against competitors or regulations. Though Boards must refrain from intervening in clinical care, they can measure quality by attending to outputs such as mortality rates.
For a strategic dashboard, each major goal (or "Big Dot," or "breakthrough quality aim") comes with a certain number of drivers--items contributing to its achievement--each of which in turn consists of a number of projects. So, for instance, for the goal "Reduce Mortality," the drivers might be Teamwork, Evidence-based medicine, and End-of-life care, each with specific projects.
The monthly "run chart" (dashboard report) should show projects and results for each driver. If insufficient progress is being made, Board and staff alike must ask, "Are we not executing our plan, or do we need a new plan?" Perhaps the projects aren’t getting done, or perhaps the projects don’t really affect the drivers or the drivers don’t really affect the goal. Every goal should include three stark measures: How good? By when? As measured by?
On a comparative dashboard, the Board should see any regulatory measures from which the hospital is deviating, and should be provided with an Exception Report for this purpose. This doesn’t have to happen every month, but it should occur regularly and must occur annually in advance of setting the following year’s quality goals.
Strategic dashboards are more useful because comparative data are always 6+ months out of date. In addition, if staff are rewarded or punished based on comparisons, they’re apt to argue about the quality of the data instead of improving the quality of care. Finally, comparative data make the Board complacent: doing well 50% of the time might look good compared to other systems, but in a system serving 100,000 patients that means 50,000 people are being harmed. Beware of measuring "the cream of the crap." Now that the Joint Commission inspection is done, Chairman Michael asked Dr. Mason to identify next steps. He proposed and the committee agreed on creating the 2013 Quality Aims and the dashboard to go with them. Committee member Dr. Munoz urged using the Joint Commission’s findings as a guide for the coming year, and de-emphasizing comparisons with other hospital systems. But he also asked the Committee to consider the hospital’s overall objectives for service: "We can’t deliver every service to everyone at every level. We need to find our areas of excellence and not deliver redundant care." The Chairman noted the task is to choose which priorities to focus on in 2013: "We don’t need to complete everything in one year."
After much discussion among Board members, Chairman Michael concluded that three items (hospital-acquired conditions, readmission and patient satisfaction) be considered by the full Board to serve as the Big Dot goals. He also suggested spending the Committee’s December meeting looking at other providers and identifying useful comparisons. He asked Dr. Hoda to advise the Committee about whether it’s looking at the right measures, and whether its sources of information are valid.
The Committee then accepted the 2011 Department of Public Health annual report and the reports on the hospital’s planning for emergencies and for the NATO meeting.
Dr. Wakim then reported that the gastro-intestinal initiative at Provident was going well, and that they were preparing to establish a fund specifically to support the GI unit there. They’re still staffing up the pulmonary clinic, a joint initiative of the city and county. He asked the fate of the existing strategic plan (the answer seemed to be, it’s about to be superseded by the new goals) and of Provident itself now that the Medicaid waiver has been approved (no answer).
After approving the minutes of the October 16 meeting and the recommended medical
appointments, the Committee adjourned at 1:20 pm.
--Submitted by Kelly Kleiman
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