CCHHS Quality and Patient Safety Committee Meeting, November 13, 2012

The meeting opened with a comment from a member of the public, a regular attendee, who in this case objected to the closing of Oak Forest Hospital and pointed out that the Committee had no black members. (County Commissioner Butler was once again absent.) Note: the staff who meet with the Committee are overwhelmingly non-white, including blacks and South Asians.

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

Cook County Hospital Quality and Patient Safety Committee Meeting, August 21, 2012

This meeting served essentially as an orientation for the new members of the Committee, most of whom are also new to service on the Hospital’s Board. Dr. Mason, the new System Chief Medical Officer, gave a report prior to the arrival of the observer. 

Ms. Russell, System Interim Chief Nursing Officer, reported that the system is facing a wave of nurse retirements: in 2013, 196 nurses will be eligible to retire after 25 years of service and another 43 after 30 years of service.  While there are obviously pension consequences to this large group of retirees, Ms. Russell reported on it as something to be considered in maintaining the quality of patient care throughout the system.

Dr. Mason then showed the group a video explaining the responsibility of the CCHHS Board for the quality of care at the hospital.  The Board (like hospital Boards everywhere) was originally an honorific and philanthropic Board only, with quality and patient care concerns left to the medical staff.  However, a 1960s court decision (the Darling case) found that a mistreated patient could hold the hospital, and not merely its doctors, liable.  As a result, hospital Boards now have responsibility for overseeing the medical staff as well as hospital management.  These oversight responsibilities are discharged at CCHHS through its committees.  Committee member Driscoll asked why the Quality and Patient Safety Committee no longer received Mortality and Morbidity reports–are the Committee’s discussions discoverable in court?  CCHHS Associate General Counsel Helen Mason promised to research and respond to the question in writing.  She noted that those reports are discussed within a committee of the medical staff.  The Committee agreed informally that it doesn’t need to see details of individual cases but wants to know about processes for correction, perhaps through an annual or half-yearly event report.  Ms. Mason assured the Committee that the Board will see all public reports.

Dr. Das, System Interim Director of Quality and Patient Safety, then briefly reviewed the status of the hospital’s accreditation.  He explained that the accreditation process for public hospitals was new, and that Stroger had submitted its application supported by the hospital’s strategic plan and the WePLAN 2015, which prescribes actions in accordance with the strategic plan.  The Joint Commission will pay an accrediting site visit in July, 2013.  At the moment, only 80 of the nation’s 3000 public hospitals are accredited; Cook County intentionally submitted Stroger to the process early, and hopes to be accredited next year. 

Dr. Murray, Director of the Department of Public Health, then explained  that the Board of Health oversees all state-certified health departments.  In Cook County, there are 6 of these: Chicago, Evanston, Oak Park, Skokie, Stickney, and Cook County itself, which covers the rest of the county.   

She then reviewed a series of Health Department reports, offering the following details:

     •    The Department is now benchmarking indicators for lead poisoning.   In the coming year it will expand its role from screening and treatment to prevention and education.

     •    The Department handles food safety inspection for unincorporated Cook County and on contract for 34 suburban communities.  This is a revenue generator.  It doesn’t usually check farmers’ markets because it is worried more about meat contamination than about produce.

     •    The Department monitors syphilis and has reduced the extent of spread to 1 contact (.6 contact means no syphilis at all).  Its outreach efforts focus on young people.  The chair asked about drug-resistant gonorrhea, and Dr. Murray replied that the department informs doctors and tries to prevent the ailment through education about safe sex and through contact tracing.  Finding contacts is challenging, though, and the problem can only be solved through wider testing and education.

     •    The Department is identifying the zip codes with the highest-risk infants so as to concentrate its prenatal, neonatal and maternal care resources there.

     •    The Department monitors tuberculosis everywhere in the county but Chicago, and provides care for the entire county (by contract with Chicago).  The proportion of TB cases is up in the suburbs.

     •    The chair asked about pertussis, and Dr. Murray said that communicable diseases in general were not going down, and that she suspected pertussis was under-reported.  This demonstrates, she said, that the county’s vaccination coverage is not what it should be, pointing out that the legal requirement that children be vaccinated for school is ignored.
 
The Department meets with the state Department of Public Health (which can instruct local departments to test more frequently) and with its counterparts throughout the state. “We monitor specific diseases but we’re also concerned about process improvements.”

     •    Commissioner Munoz asked about the flu, and Dr. Murray reported that there has been no human-to-human transmission of swine flu; it has shown up only in children petting hogs at the state fair. 

The Committee approved four reports–Food Access in Cook County; The Suburban Cook County Food System: An Assessment and Recommendations; Communicable Disease Update, August 2012; and Annual Tuberculosis Surveillance Report,2011–which will now be posted on the CCHHS Website.

This fall the Department will update its report on the Strategic Plan and release a Quality Improvement Plan. 

Dr. Wakim then reported on the status of Provident Hospital: within 4 to 6 weeks it will be
prepared to take Stroger’s overflow, and able particularly to provide much more gynecological care. 

The Committee then approved medical staff appointments and the minutes of its June meeting. There being no call for a closed session, the meeting was adjourned.

--Submitted by Observer Kelly Kleiman

Cook County HHS Board Meeting - March 29, 2012

The meeting was called to order at 7:30am by Vice-chairman Ramirez in the absence of Chairman Batts.

Highlights of Committee Reports included:

Quality and Patient Safety Committee - Director Ansell stated that there were nurse retirements in December that resulted in bed closures at the hospital (I presumed Stroger Hospital although he didn't state which hospital). He also said that some of the beds had been reopened but that nurse recruitment was progressing slowly.

Finance Committee - Director Carvalho singled out one of the contracts being presented for approval. It was for up to $9m to contract out the care of long term ventilator patients if they were "self pay". He stated that an analysis had been done and it was cheaper to contract out services for these patients than it was to keep them in-house. Many of these patients are undocumented he said. All the contracts presented for approval were approved.

A request to execute a Data Sharing Agreement between IDHS and CCHHS was proposed. Dr. Raju, CEO of CCHHS, stated that this would facilitate the process of getting medicaide approval for those patients seeking to be qualified. Dr. Raju said that he has been meeting with the state every 2 weeks regarding the medicaide qualification process and it continues to be slow resulting in cash flow issues for the county. The request for the agreement was approved.

An update was given on the Oak Forest Health Center Capital Renovation Project by those working on this project. This is the first phase ($3m) of a $19m renovation planned for this building that is converting Oak Forest to a primary care and specialty care center. The plan is to have diagnostic imaging, central registration, laboratory and care link on the first floor of Bldg New E with a schedule for destruction bids to come in April and the project to be completed by October. Dr. Mason, chief medical officer, stated that at the present time services continue to be offered but they are spread out throughout the Oak Forest Campus and the intent is to consolidate most services into the New E Building. He also stated that they are looking ahead to establishing a relationship with U of I Extension for doing some gardening on the grounds at Oak Forest so that chronic disease treatment and nutrition will be integrated into future treatment at the center. There was also talk of going back to the CCHHS Strategic Plan that was developed a few years ago to assess progress and to see how the plan needs to proceed or be revised.

Dr. Raju in his report stated that while medicaid revenue has improved slightly in February he predicts they will still not end the year with a balanced budget. He continues to lobby legislators to expand medicaide and indicated that CCHHS is in for a very tough time if the ACA is overturned. He also thanked the Price Waterhouse Coopers team whose contact is not being renewed. They have been transitioning their functions over the last 3 months to Cook County employees and the services they provided will now be done in-house.

Dr. Ansell pressed for more information on the revenue shortfall with medicaide. Dr. Raju stated he thinks the system has a $100m functional deficit because there are a certain number of patients that cannot pay for their care, therfore the system will never run in the black. How to make up the difference is the question.

At 9:00am the meeting went into closed session and the observer left.

Cynthia Schilsky

LWVCC Observer