Miles Moffeit - 111920127014 - Report CMS Parkland October 2012 AM Report (11 15 2012) 2

Report of the Independent Consultative Expert (ICE) Monthly Progress Report October, 2012 on Parkland Health & Hospital
l System
Dallas, Texas
November 15th, 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 System Alvarez & Marsal Progress Report to CMS October 2012
EXECUTIVE SUMMARY .........................................................................................................................................2 SIGNIFICANT CAP-RELATED GOALS MET IN OCTOBER .............................................................................................3 SIGNIFICANT CAP-RELATED GOALS STILL OUTSTANDING IN OCTOBER....................................................................4 CHANGE IN REPORT FORMAT/OVERALL IMPRESSIONS FROM OCTOBER.....................................................................5 CULTURE....................................................................................................................................................................6 IMPACT OF ORGANIZATION STRUCTURE ....................................................................................................................6 COMMUNICATION EFFECTIVENESS INTERVIEWS ........................................................................................................6 ACCESS AND THROUGHPUT ................................................................................................................................9 CASE MANAGEMENT AND DISCHARGE PLANNING ................................................................................................... 10 MONITORING INTERDISCIPLINARY TEAM ROLL OUT ............................................................................................... 12 NURSING/PROVISION OF CARE ........................................................................................................................ 13 NURSING DOCUMENTATION ..................................................................................................................................... 13 ABUSE AND PAIN ASSESSMENT................................................................................................................................ 13 STAFFING TO ACUITY AND FLEXIBLE STAFFING ...................................................................................................... 14 HOUSE SUPERVISORS ............................................................................................................................................... 14 HUMAN RESOURCES (HR) ................................................................................................................................... 16 WORKFORCE PLANNING AND RECRUITMENT ........................................................................................................... 16 HOUSE-WIDE ISSUES ............................................................................................................................................ 17 SAFE PATIENT DISCHARGE ...................................................................................................................................... 17 ONE TO ONE OBSERVATION ..................................................................................................................................... 17 INFORMED CONSENTS .............................................................................................................................................. 17 PATIENT RELATIONS AND PATIENT GRIEVANCE PROCESS ....................................................................................... 18 AN IMPORTANT MESSAGE FROM MEDICARE............................................................................................................ 18 VERBAL ORDERS ..................................................................................................................................................... 19 RESIDENT SUPERVISION..................................................................................................................................... 20 ENVIRONMENT OF CARE.................................................................................................................................... 21 FACILITIES AND MAINTENANCE ............................................................................................................................... 21 DEPARTMENT AND UNIT SPECIFIC FINDINGS ............................................................................................ 22 EMERGENCY SERVICES ............................................................................................................................................ 22 PSYCHIATRIC SERVICES ........................................................................................................................................... 22 ENDOSCOPY (GI LAB) .............................................................................................................................................. 23 PHYSICAL MEDICINE & REHABILITATION PM&R ................................................................................................. 24 LABORATORY .......................................................................................................................................................... 25 RADIOLOGY ............................................................................................................................................................. 25 MEDICATION MANAGEMENT ................................................................................................................................... 26 CAP FOCUS AREAS FOR NEXT 30 DAYS .......................................................................................................... 26 CONCLUSION .......................................................................................................................................................... 28
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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 eighth 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 October Parkland continued to make progress in meeting most of the deadlines established in the CAP for October 2012. Since the implementation of the CAP on March 19, 2012 a total of 454 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 Complet % Total e Complet Initiatives Initiative e s 39 174 91 103 33 59 499 33 171 76 90 30 54 454 85% 98% 84% 87% 91% 92% 91% On time Initiatives 1 1 4 9 3 3 21 Delayed Initiatives 0 0 1 0 0 0 1 Missed Deadline / % Complete and On Time Not Sustainable 5 2 10 4 0 2 23 87% 99% 88% 96% 100% 97% 95%
1 2 3 4 5 6
Also, presented below is a breakout by action streams, for the two work streams performing under 90 percent compliance in meeting target dates for their CAP initiatives.
AS # Action Stream Name Total Complet Initiative e s 14 9 57 30 2 25 6 10 7 55 25 0 22 1 % Complete 71% 78% 96% 83% 0% 88% 17% On Time Initiatives 0 1 0 3 0 1 0 Delayed Initiatives 0 0 0 0 0 0 1 Missed Deadline / % Complete Not and On Time Sustainabl e 4 71% 1 2 2 2 2 4 89% 96% 93% 0% 92% 17%
1.2 1.5 2.2 3.2 3.3 3.4 3.5
Organization Structure Changes HR Performance Management and Progressive Discipline Policies & Procedures Shared Services Departments Emergency Department/ Trauma/UCC Throughput Initiatives Bed Management Case Management, Discharge planning initiatives Continuum of care beyond acute care setting
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Significant CAP-related Goals Met in October

Access/Throughput Developed protocols and obtained resources for implementation of defined patient flow process for dialysis patients.
Case Management Continued reorganization of Case Management department. Created a metric dashboard, which is reported routinely to the Performance Improvement department. Developed a dashboard to report on key metrics in the Physical Medicine and Rehabilitation (PM&R) area. Conducted audits of crash cart process after transferring ownership of crash cart stocking and maintenance to the Sterile Processing Department (SPD). However, results did not demonstrate 100% compliance in October.
Clinical Support
Emergency Department Additional steps taken to improve patient access and throughput, which resulted in significant decompression of bed utilization (bed hours) in the Main ED in October. Determined a methodology for interim acuity staffing solution. Designed a process for Business Partners to audit annual employee performance evaluations based on volume and severity of corrective actions delivered to staff. Will not be fully implemented until 2013 evaluations are completed. Developed process, procedures and training materials on a new employee retention strategy. Worked with Clinical Education to ensure all required competencies were uploaded in the new HealthStream electronic tool.
Human Resources
Nursing Communicated role and responsibility of the newly expanded Nursing Administrative Officer (NAO) to staff. Continued to revise nursing policies and procedures based on implementation of Lippincott guidance. Nursing leaders determined methodology for acuity-based staffing solution to prepare for McKesson implementation. Nursing leaders, in partnership with Clinical Education and Human Resources (HR), developed a methodology to load, track, and trend competencies for clinical and non-clinical staff utilizing the HealthStream electronic tool. Developed a tool and process to report out on clinical grand rounding results. Report out meetings have been well received by staff. Implemented restraint education for nursing and medical staff based on re-revision of policies and procedures. Training on new patient restraint policies included in person demonstrations, instructional videos, and follow up retention exams. Revised front-end documentation process relating to patient restraints, improving the quality and accuracy of notes in the electronic medical record (EMR) as well as reporting capabilities.
Patient Safety Developed an education plan for all employees regarding changes to patient safety policies and procedures. 3 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Created a dashboard demonstrating key metrics relating to the Patient Relations department, which handles patient complaints and grievances. Also, a process was implemented to ensure that required timelines and deadlines are met by Parkland in terms of resolving grievances and complaints. Reviewed current patient privacy training materials, including compliance with HIPAA regulations. Implemented a new dashboard to present tracking and trending of key metrics relating to Patient Safety, including unsafe discharges, time to resolve regulatory investigations, and volume of open investigations. Filled vacancies in nursing leadership, including full-time nursing managers.
Psychiatric Services -
Significant CAP-related Goals Still Outstanding in October

Access/Throughput Transition of continuum of care accountability from CAP leadership to clinical/operations leadership has not yet been completed. Determination of house-wide strategy on continuum of care. Development of a cross-functional behavioral health team focusing on determination of appropriate post-acute care for behavioral health patients. Bed Czar role has been designed but not yet implemented house wide. Staffing vacancies still exist. 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. Engagement of physicians in 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. 100 percent attendance/completion rate for fluoroscopy and general radiation safety training modules to nursing and medical staff has not yet been achieved.
Case Management
Clinical Support
Emergency Department Completion of a GAP analysis for revision of new nursing policies and procedures Human Resources 100 percent attendance/completion rate for education of management and staff on new performance management and corrective action processes not yet achieved.
Nursing Creation of a plan to recruit an effective nursing float pool. Development of updated nursing leadership competencies, specifically related to new nursing managers in Psychiatric Services.
Patient Safety Hiring 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). 4 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Physicians Development of an effective reporting and trending on verbal order, resident oversight, compliance with of History & Physical (H&P) documentation and effectiveness of on-call system. Although much work accomplished towards this goal, yet to publish complete data.
Change in Report Format/Overall Impressions from October

As most of the Corrective Action Plan (CAP) initiatives have been largely completed, and transitioned into the clinical and operations leadership under the Hospital organization structure, A&M has augmented and changed several of our monthly review and auditing practices in order to ascertain where CAPrequired changes and improvements can be consistently demonstrated. As part of this change, 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 will be performed as a more holistic and inclusive review to monitor for the sustainability of change in process and performance and the impact of the change on patient safety, rights and quality. Accordingly, the format of this report has been revised from previous months and will follow the format of the initial Gap Analysis report conducted in February, 2012. Areas of focus on our monthly work plans will be highlighted in this report. Although Parkland has made significant, and in some cases vast, improvements over the past year in observable and documented changes to improve patient safety and quality of care, we continue to have concerns that some CAP initiatives have not yet resulted in sustainable practices within certain areas and/or departments. While much progress has been made, we sense that some initiatives required under the CAP have been viewed as a means to simply passing a full survey rather than creating a new operating model or level of performance in providing patient care. Parklands executive leadership and senior medical leadership have demonstrated a strong sense of commitment to adopting and implementing change, but this level of engagement or awareness has not been transmitted consistently to all members of the front line staff, in all areas of organization. The Culture section of this months report describes the audit and investigation methods employed by A&M and Parklands senior leadership to identify some of the possible reasons for this disconnect from senior leadership throughout the ranks to front-line personnel. In the month of October, the organization experienced and reported a number of patient safety events that might have been avoided through more vigilance and/or accountability on the part of several employees. While root cause analysis processes have been followed and re-focus on training and education will take place, all employees must continue to adopt a culture of personal accountability in order to ensure that each and every patient encounter is performed in accordance with established policy and procedure and patient safeguards. Some of the recent patient safety events in October were partially attributable to lack of: Consistent use of two patient identifiers; Ensuring appropriate protocols are followed; Appropriate communication in patient handoffs; and Personal accountability in performance of job duties.
We have discussed these concerns with Parklands senior leadership and they have agreed that a redoubled effort is needed in communication and direct-line management to ensure that all CAP-related safety and quality initiatives are transmitted to all front-line staff and consistently executed at the bed-side, with each patient.
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Culture
In response to several patient safety events in early October, A&M worked with senior leadership to identify the reasons for the recent events, several of which seemed to be linked to accountability and/or lack of compliance with established process or policy and procedure. Since extensive training and education has been provided throughout the entire institution on topics such as two-patient identifiers, safe patient handoffs, communication and personal accountability, we suspected that either the message might not be appropriately communicated to and/or reached the front-line. Impact of Organization Structure Our hypothesis is that there has been successful engagement and communication throughout several layers of management from senior leadership through the Director level, but that once the fourth or fifth level of separation from senior leadership is reached, that gaps begin to exist in driving down the new safety or quality messaged or related policies and procedures. To test this theory, we conducted a brief review of the degrees of separation from senior level leadership to the front-line personnel, and then interviewed over 100 front-line employees and physicians to test their familiarity with new CAP policies, procedures and messages related to patient safety and quality of care. In evaluation of span of control from the C-Suite to the front-line, we find the degrees of separation vary between five and seven levels averaging six in most areas. We reviewed span of control in a few clinical (nursing specialties) and non-clinical (Facilities/EVS) functions. Our subjective findings conclude that the increased degrees of separation do not impact the effectiveness of the communication, but the philosophy and engagement of 2nd level of management in enforcing a cascading and direct system of communication throughout their reporting structure. Some of the nursing specialties, under the leadership of Nursing Vice Presidents, have the best communication results. Communication Effectiveness Interviews In October the A&M team interviewed 107 Parkland employees and physicians to gauge the effectiveness of cascading communication about the Corrective Action Plan and the CMS/State re-survey timeline. A standardized approach, which included four questions, was asked of front-line employees, ranging from support services employees to patient caregivers, nurses and physicians: 1. What is your understanding of the Corrective Action Plan? 2. What is your understanding on the reasons for and timing of CMS re-survey? 3. What are the most important areas youve been asked to focus on to improve patient safety, rights and quality? 4. Do you receive updates on the Corrective Action Plan? If so, from what means of communication? The results of these interviews and questions are summarized as follows:
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Compliance to Cultural Effectiveness Interviews

CAP Understanding (Q1) CMS Re-Survey Timing (Q2) Areas of Focus (Q3) Communication of CAP (Q4) 0% 20% 40% 60% 64% 80% 100% 13% 82% 55%
The interviews indicated that only 55% of staff members could articulate an understanding of the Corrective Action Plan. Only 13% of staff interviewed were aware of the timing of CMS re-survey of Parkland. In order to better understand where communication breakdown might be occurring, we reviewed the results of the data by licensed versus non-licensed staff. Overall, licensed, employed staff members were more well-informed across all of the audit questions than non-licensed or and medical staff members.
Compliance to Communication Effectiveness Audit by Licensure

100% 80% 60% 40% 20% 0% 77% 32% 36% 89% 80% 64% 79% 54% 36% 16% 13% 0% 64% 45% 34% Non-Licensed (44) Licensed (53) Medical Staff (11)
The interview data further provided insight into communication effectiveness by identifying specific areas and departments where additional efforts will need to be made to improve communication and education around the CAP initiatives and need for personal accountability. The nursing areas appear to be more well-informed around CAP initiatives than EVS employees, Clinical Support and Medical Staff members, but there are definite areas of improvement across all four areas.
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Compliance to Communication Effectiveness Audit by Department

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 66% 50% 36% 10% 91% 78% 75% 68% 60%64% 25% 13% 0% 0% 36% 10% 61% 54% 34% 20% Clinical Support (20) EVS (10) Nursing (67) Medical Staff (11)
We further tested perception of what types of communication staff members have relied upon to receive updates about the CAP initiatives and status. The most popular answers were through email (Postmaster), online training modules, and ad hoc huddles with their units. Very few staff members across the Hospital could speak to receiving updates through regularly scheduled unit-specific meetings or meetings with higher level of leadership. No clear process was communicated on a top-down approach of informing staff of key areas of focus based on the Gap Analysis, Corrective Action Plan, or monthly CMS reports. In conclusion, A&M will continue to work with Parklands senior leadership and Medical Staff leadership to identify methods for communicating and ensuring the top-down message regarding importance of CAP initiatives in preparation for CMS survey and personal accountability are deployed further down through the multiple layers of management and supervisory personnel to the front-line. The need for effective communication will only increase during the next few months as the organization prepares for a full CMS/State survey, which could occur as early as late winter/early spring 2013. We recommend that a more expansive approach of employee/staff communication be launched within the coming months to include: Regular schedule of frequent rounding in clinical and patient care delivery units by EVERY member of senior leadership on ALL SHIFTS; Each Chief (of the C-suite) be responsible for meeting with the multiple degrees of separation of leadership (down to front-line supervisory personnel and unit managers) to provide an update on CAP initiatives and progress to date under the CAP, timeline for CMS re-survey, expectations of each supervisor/manager in holding their employees accountable and providing the message; Schedule leadership forums for the months of December and January to provide ALL leaders (anyone with direct reports) with an update by Parkland leadership, A&M (and maybe the regulators) on the status, progress and road ahead; Developing a robust communication platform around the message of in the moment of care.
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Access and Throughput An access and throughput working committee, which was essentially charged with deployment of resources to further improvement of access and patient flow, has been meeting weekly since early September and is focused on evaluating patient flow improvement opportunities across the system including the appropriate deployment and management of beds. The committee has been tracking a list of access and throughput improvements that are currently being put in place and should be completed by January. The team will be tracking the impact of these changes to ensure the outcomes are meeting the intended objectives and will modify plans as needed. The current diversion policy and red bed (high census) policy is being reviewed for improvements in triggers and immediate actions for times when the Hospital is at capacity. Although mentioned in previous monthly reports, the following is a brief recap of improvements that are being put in place to improve access and throughput. Increase physician staffing levels in Pod 5 in the Main ED: The main emergency room increased physician coverage on nights Monday through Friday, beginning October 15th. Since this coverage expansion the department has had a slight drop in 7:00 AM census. Lower census at the start of the day may positively impact the ability to handle mid-late morning surges. A simulation analysis suggests the patient length of stay could be decreased by 28 minutes per patient. New Physician Resources for the Urgent Care Clinic ED (UCC ED) On November 1st Parkland contracted with an outside, national emergency room physician company, EmCare, to provide all physician staffing in the Urgent Care Clinic Emergency Department (UCC ED). The UCC had previously been staffed with family practitioners. With the new arrangement with EmCare, the UCC should now be able to treat and release patients that would have presented to UCC and ultimately been transferred to the Main ED for ultimate treatment and disposition. This addition of resources should reduce some of the volume in the ED to the UCC. The Hospital estimates a 75 minute decrease in patient length of stay, which translates to a 20% reduction in ED patient length of stay. Dialysis Expansion During October, the dialysis unit added additional evening shifts with the addition of an in-house nephrology provider. The dialysis service will also be adding three additional machines in December once the apheresis service is moved to another location in the Hospital. The incidents of dialysis patients boarding in the ED and waiting for dialysis are estimated to decrease dramatically, which translates to an additional 69 bed hours available per day in the ED. Additional Medicine/Surgery Beds and Telemetry Additions In November, 18 medicine/surgery beds will be brought back into service throughout the Hospital. In addition, the Hospital is adding telemetry capability to 4 additional surgical units. This additional capacity along with the 13 new beds on a new secure medical/psychiatric unit (described below) is thought to provide enough inpatient capacity to adequately address the average number of patients boarding in the ED waiting for a bed. Main Emergency Department The Main Emergency Department (ED) is currently being renovated and expanded. The renovation will add three new exam rooms as well as 18 recliner chairs in a new Results Waiting Area, and is scheduled to be completed in December. The renovation has also added four new triage rooms (which are complete), one exam room to the triage area/function and 27 additional seats to the waiting room. With this renovation, the Main ED will be able to use a physician at triage model of care. The ability to treat 9 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 and release at triage when appropriate, as well as the additional capacity for patients who are awaiting disposition (in the new results waiting area) are expected to significantly decompress the main emergency room volumes, which should result in a safer care environment. The new Results Waiting Room is estimated to reduce patients length of stay with ESI level 3 by as much as 100 minutes. New Secured Medical/Psychiatric Unit The hospital will be adding 13 new patient beds in January 2013. This new unit will be utilized as a secured behavioral health/medical unit that is co-managed by hospitalists and psychiatry for medical patients that are high risk due to a co-occurring behavioral diagnoses, altered mental status, brain injury, etc. The approach of managing this patient population on a well-secured, dual staffed unit is a significant improvement to the current practice of having this patient population randomly placed throughout various medicine/surgical units, being secured through the use of one-to-one observers or sitters as required for the patients safety. Case Management and Discharge Planning The Care Management (CM) Department continued to progress in its reorganization of organization structure and redefined roles and responsibilities during October. As of October 31st, the department reported a 40% vacancy rate. Most significant is the 100% vacancy rate for Manager and 75% vacancy in Care Coordinator positions. These positions will need to be filled in order for the department to make progress in implementing a new model of care management and discharge planning. As we reported in September, if delays continue in completing the care management reorganization and reorientation, the Hospital may be challenged with bed capacity as the Hospital moves towards winter months (December, January, February) with traditionally high census and bed utilization. A physician champion, Dr. Stephen Harder, has been identified to begin to lead efforts for reinvigorating utilization review and utilization management functions to support the Department. While efforts are underway to build an Epic-based Discharge Planning Assessment Tool to ensure appropriate screening and referrals (as stated in CAP 5.1 4.4) and was anticipated to be completed by the end of October, this project is significantly behind schedule. Once completed, comprehensive education will be required to implement the new assessment tool. A&M has requested an opportunity to review the assessment tool before it is finalized and put into use. Our September report showed that patients that present or are admitted from the ED are still not consistently receiving intervention by care managers at time of admission for discharge planning and placement needs. The chart below shows similar findings during the month of October: only 59% of ED patients were screened for discharge needs. Although a tool has been developed, staff have not yet been trained on the use of the tool, in part due to redefining roles, responsibilities and experience/required skill set of incumbents in case management roles. In addition, training of the use of Milliman care criteria for medical necessity is not scheduled until November.
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Percentage of Patients Screened for Discharge Needs in ED

100% 80% 60% 40% 20% 0% 95% Compliance 59% 29% Sep-12 Oct-12 Goal
As demonstrated below by the flat trend in the metric Percentage of Discharges before 11:00 AM., little progress has been made in engaging physicians to change practice and rounding patterns in order to facilitate earlier discharges. To improve this discharge statistic, in October A&M recommended that the Chief Medical Officer (CMO) work with the Medical Staff Executive Committee and other physician committees and groups to begin an education/awareness campaign with regard to the impact of late discharges to patient flow.
Percentage of Discharges Before 11AM

7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 6.4% 5.0% 4.4% 4.8% 4.7% 5.1%
The slight decrease in the length of stay (LOS) in October may be attributable to the introduction of new Interdisciplinary Team meetings and heightened awareness from physicians and nursing. However, more than two months of decreases in LOS must be observed to demonstrate consistent reduction in LOS and to demonstrate that LOS outliers are not impacting the average.
Metric Average Length of Stay (ALOS) Percentage of Discharges before 11AM May, 2012 5.3 6% June, 2012 5.2 5% July, 2012 5.0 4% August, 2012 5.3 5% Sept, 2012 5.0 5% October, 2012 4.6 5%
As with many other CAP initiatives, the management of Case Management needs to be transitioned from its action and work stream leaders into the Hospitals clinical and operations leadership and organization structure.
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 The CAP initiatives around Care Management could not be fully implemented until the organization restructure was completed and it is now time to begin to break down any further barriers and accelerate change in process, approach and demonstrate measureable progress in all aspects of the CAP initiatives. While both Robin Stults and Sharon Phillips have expended countless hours and energy working closely with the external care management consultant (Clinical Intelligence), interim management and internal Hospital leadership are now necessary to advance the care management CAP initiative to completion. Because an experienced and/or skilled internal leader for care management does appear to presently exist within the organization, we have strongly recommended an interim management solution for care management. Neither the transition plan nor the timing of the transition from the CAP structure to operations/clinical leadership was finalized by the end of October and will need to be a focus for senior leadership in November. Monitoring Interdisciplinary Team Roll Out Throughout the Hospital, interdisciplinary meetings are occurring in order to ensure a smooth and complete transition throughout the continuum of care from admission to discharge/post-discharge. Some of these meetings, for example the Burn Unit have been occurring for several years. Other groups such as the Hospitalists and several Surgery units, have just begun to convene during past few weeks. The A&M team attended several of these care planning meetings in order to assess their effectiveness in ensuring patients are provided complete, quality care as well as improving patient throughput by removing barriers to discharge. Overall, the interdisciplinary meetings we attended appeared to be effective. Multi-disciplinary stakeholders from nursing, medical staff, physical therapy, radiology and laboratory all participated in discussions. In most cases a clear agenda was used and adequate information available for decision making. These are generally led by a member of the medical staff who demonstrated a strong knowledge of all patients in their respective units. The interdisciplinary team meetings need to standardized in approach, agenda, available data and consistency in attendance across the entire Hospital. A&M will continue to audit the effectiveness of the interdisciplinary meetings as they are implemented in November.
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Nursing/Provision of Care Nursing Documentation A&M continues to review nursing documentation in medical records to ensure compliance with Medicare Conditions of Participation (CoP) and monitors audits conducted by the Hospital. In October, audits were focused on plan of care documentation, documentation of abuse screening and pain assessments. Documentation reviews performed by the Hospital on plan of care documentation focuses on the following components: Plan of care was initiated within 24 hours of admission; Complete and current - all active medical conditions being treated and nurse drive processes stated; Individualized goals and plans for each identified problem; Problems resolved when indicated; Plan of care has been communicated to patient and/or family; and Care plan is present from each discipline providing care.
As evidenced by the graph below, 98 charts were reviewed by the Hospital, with an overall compliance rate of 82%. Audit results indicate a large opportunity for improvement with completeness of care plans, documentation of resolution of identified issues, and individualized plans of care. While audit results were being reported to Nursing Operational Excellence, the results were not being parsed by unit and shared with individual unit management of late. A&M has met with Nursing leadership and requested that an alternative method of auditing and monitoring plan of care documentation be achieved during the month of November.
Abuse and Pain Assessment Abuse Screening A&M reviewed 44 patient charts to determine if patients are screened for potential abuse. We discovered that the Hospital does not use a consistent process within Epic to document abuse screening, and 13 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 information may be present in the chart but not easily located. We have recommended that Nursing work with IT to standardize this process. Pain Assessment Upon review of 20 charts, we discovered generally good results in compliance with pain assessment and reassessment guidelines. We did see documentation of pain assessments and reassessments within the charts reviewed, but there were some limited issues with compliance to Hospital policy and procedures: The type of pain scale utilized was not always documented on re-assessment in one chart; More than one hour elapsed between assessments in one instance; Pain score noted as higher than before, no medication given and no intervention noted in one chart; and Post medication assessment rated at 0 but nurse documented medication given in one instance. Staffing to Acuity and Flexible Staffing The need to create a float/flexible nurse staffing pool was identified in both the GAP and Corrective Action Plan reports. Although there has been progress on the action stream related to implementing a staffing grid that factors acuity and census and changes staffing requirements in consideration of acuity, there has been little to no active pursuit of building a flexible staffing solution for when the acuity-based staffing model is implemented. This initiative was not prioritized until very recently, and only after A&M raised as a barrier to staffing to acuity. As of the end of October, the Hospitals Operation Excellence Department was engaged to work with nursing leadership to assist in providing some analytics to size the need for float pool based upon historic data. While progress has been made in lower vacancy rates throughout various nursing departments, there will need to be an increased focus on recruitment of qualified nurses to fill positions of a flexible staffing/float pool in the near future. Work continues with the McKesson installation which will allow for patient acuity recording. This information will be linked to the current ANSOS staffing system allow for automated acuity-based staffing. The current timeline for the system to go live and be fully functional is February, 2013. In the meantime, most nursing units are using a manual system to record acuity and adjust assignments but are not using this information for staffing. WISH units are currently staffing to acuity based on their manual system. House Supervisors The GAP Analysis identified a need for improvement in the Nursing organization related to the role of the House Supervisor. The Corrective Action Plan required that the responsibilities be redefined from nurse staffing position to that of a leadership position. The CAP requires that the House Supervisor role should serve as the administrative voice, eyes and ears for both Nursing leadership and the executive leadership team. Progress on initiatives related to the refinement of the House Supervisor role and onboarding of new staff has been slow. The Action Stream leaders have reported the redefinition of the responsibilities and roles into a revised job description. The position is re-named as the Nurse Administrative Officer (NAO). Also, in October a number of the vacant roles were filled. 14 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 A&M observed three NAOs on the PM shift (3:00 PM 11:30 PM) in October. At that time, two of the three NAOs were in orientation; one was on the first day of orientation and the second NAO was nearing the end of orientation. The Chief Nursing Officer and Vice President of Excellence & Safety in Nursing have received a comprehensive report out of our observations and recommendations. We will continue to work with the CNO in November to ensure that issues noted during our observations are addressed. Findings: Training materials were neither available for the NAOs in orientation, nor available for reference for the preceptor. NAOs are not versed on critical policies and procedures. No formal plan in place for training the NAOs. Lack of appropriate shift report/hand-off from PM shift to NAOs. NAOs are not advised of anticipated discharges. At the time of our observations, frontline staff appeared uninformed of the NAOs new role and responsibilities. NAOs are not fully engaged to facilitate patient throughput nor are they directed to do so within their scope of work. Communication between the bed management function of the Hospital, the Admission-Discharge-Transfer Department (ADT) and the NAOs does not exist. During their rounds, NAOs evaluate all one to one sitters to determine whether they have awareness and knowledge of their assigned patient and responsibilities. The NAOs do look for staffing opportunities to move staff to challenging areas and communicate staffing information to the staffing office. There appears to be a reluctance of some charge nurses to notify the staffing office and suggest their staff to move to another area. NAOs are not equipped with house cell phones. NAOs are not on the distribution list for Disaster Notification.
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Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Human Resources (HR) Workforce Planning and Recruitment Parklands Human Resources (HR) department is continuing to receive consulting assistance from Mercer Consulting. Mercer will assist with the selection of a Recruitment Process Outsourcing (RPO) firm to assist with the Hospitals hiring and recruiting challenges. HR leadership has indicated they are hopeful a contract will be executed in November or December. The RPO will provide needed expertise and technology in the recruiting area. In October, the director of Workforce Planning and Recruitment vacated the position. An interim director has been named, and the position has been posted internally. If the internal search is not successful, HR leadership will look to an outside search firm for an appropriate candidate. On-boarding of a new director is foreseen in the January time frame. Enhanced recruitment efforts to fill the high vacancy rates at Parkland have been underway for the past few months and continued through October with a focus on filling nursing vacancies. While progress is being made with regard to lowering nursing vacancy rates; increased focus on recruitment and shift in prioritization of other areas of the hospital with high vacancy rates (e.g. Quality, Safety, Case Management departments) must be sustained for the immediate future.
Nursing Vacancy Rates

19.0% 17.0% 15.0% 13.9% 12.6% 11.7% 12.4% 15.1% 14.3% 14.4% 12.9% 10.7% Nursing Leadeship Nursing Overall
13.0% 13.0% 11.0% 12.1% 9.0%
9.3% 7.0% 5.0% May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
16 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 House-Wide Issues Safe Patient Discharge The Gap Analysis report outlined significant concerns with patient elopements, patients leaving without being seen or treated, and patients leaving against medical advice (AMA). The Corrective Action Plan called for a continued focus on reducing these occurrences by reconstituting a previously defunct task force, conducting a study of 2011 elopements, and establishing an action plan to reduce them. The CAP also required goals for elopement reduction be established. Although these initiatives have been completed, the continued number of patient departures that can be defined into one of these categories does not seem to have been impacted by any of the initiatives completed by the task force. A&M will continue to work with the Quality and Safety departments and senior leadership to refocus priorities on performance improvement initiatives to reduce the incidences of patient elopements, patients leaving AMA or patients leaving without being seen or treated.
One to One Observation Based on interviews with Nurse Administrative Officers (NAO), we discovered that the current reporting of One to One Observers (sitter) compliance had inaccuracies. The one to one observer audit results conducted by the Hospital indicated that the sitters are well informed and compliant with policies and procedures. The NAOs reported they found significant issues with sitters during their nightly rounding. The audit criteria and methodologies have been revised and we look forward to receiving updated information during the month of November. Informed Consents An A&M chart review conducted in September identified two issues related to informed consents: Inconsistencies with locating consents within the electronic medical record; and Inconsistent use of Spanish-language versions of consent forms(where appropriate). 17 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 As a result, A&M requested that Parklands Health Information Management (HIM) department assemble a group of key stakeholders (inpatient and outpatient nursing, anesthesia and legal counsel) to address these issues. Resolution was achieved to ensure Spanish speaking patients will receive consents in Spanish when requested and implementation is planned for November. Unfortunately, there has not yet been a resolution to ensure the reliable management and accessibility of signed consent forms during a patient encounter or stay. Also, audits by Parklands Internal Audit team found issues around staff using dated consent forms. Over 60 citations were issued throughout the Hospital for units discovered with housing old forms. A sweep performed several months ago to rid the Hospital of these old forms has proven ineffective. Another initiative to discard and replace these forms must occur in November. A&M will continue to monitor all issues related to management of consents and work with senior leadership in the development of a plan to rectify in November. Patient Relations and Patient Grievance Process The Corrective Action Plan required extensive reporting and trending of patient complaints and grievances data and action plans directed at improving negative data trends. A dashboard was created and presented to the PHHS Senior Leadership and the Board of Managers (BOM) in the month of October. The dashboard presented includes detailed data on types and sources of grievances and resolution status. While data tracking has been progressing, there has been no progress in developing action plans to address trends. A&M began an assessment of operations and processes in the Patient Relations Department in October to verify CAP required changes were in place and assess the sustainability of any changes. In the midst of our assessment, the Hospital made significant changes to leadership by placing Patient Relations under the direction of the Quality and Safety departments. Our audit was discontinued, as the new leadership will begin a complete assessment and reorganization of the department in November. An Important Message from Medicare Inpatient Medicare beneficiaries must be provided with the standard notice An Important Message from Medicare (IM) within two days of admission and discharge. The chart below indicates that Medicare patients are not consistently receiving information required in the IM. The red line indicates the consistency of providing the IM upon admission. Parklands Patient Financial Services department (PFS) is responsible for providing the IM at the time of admission. The blue line indicates the consistency of providing the IM prior to discharge. Care Management is responsible for providing the IM prior to discharge.
18 11/15/2012
Compliance Percentage in Patients Receiving Important Message from Medicare

100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Jul-12 Aug-12 Sep-12 Oct-12 Patient Financial Services (PFS) 45.0% Care Management 77.0% 67.3% 91.0% 91.7% 76.7% 91.8% 79.5%
Care Management cites the recent reorganization and vacancy rate as a barrier to achieving compliance with this Condition of Participation (CoP). However, the organization needs to implement stop-gap measures to ensure compliance until the Case Management function is able to ensure 100 percent compliance. This may include nursing and/or Patient Financial Services staff to assist. Verbal Orders The CAP requires that verbal orders be tracked and trended as part of Parklands Quality Assessment/Performance Improvement (QAPI) program and reported to nursing and physicians, and ultimately reported to the Quality Committee of the Board of Managers (BOM). To date, this data on use of verbal orders has not been published as there have been concerns on the completeness of the data. The verbal order audit, which was recommended by the CAP, attempts to identify the number of verbal orders that are NOT authenticated within 48 hours. There has been a heightened awareness and education about the appropriate use of verbal orders and documentation requirements and it has been communicated in multiple forums included the Medical Executive Committee, Medical Staff meetings and Residents and Chiefs meetings. We will continue to work with Parklands Medical Staff leadership and Chief Medical Information Officer as they refine the data collection methods for tracking use of and authentication of verbal orders and then construct a plan to reduce instances where verbal orders are not timely authenticated as well as a plan to overall reduce the use verbal orders as possible.
19 11/15/2012
Resident Supervision A dedicated team of physician leaders continue to work to refine the ongoing audit process and audit tools related to assessment of the following: Resident and Attending on-call responsiveness to pages and calls Complete and accurate documentation of H&Ps Escalation to Attending physicians when appropriate and proper qualifications for Residents
A dashboard which has been created to track audit results regarding authentication of verbal orders, completion of post-op notes, validation of resident qualifications, documentation of Resident supervision and most audit results will be shared with physician and Hospital leadership beginning November. The dashboard also includes results from direct observation and interviews in patient care areas, where nursing is required to demonstrate knowledge of the Resident Supervision (listing authorities /qualifications of Residents) Grid. This grid is found on the Hospital intranet and enables nursing and other clinical staff to know if a resident is qualified to perform a specific procedure, or requires direct or indirect supervision. A great deal of effort and attention has been put into refining the audit tools and methodology to ensure data integrity. Physician and Hospital leadership is aware of the need to address any areas of noncompliance upon receipt of audit results.
20 11/15/2012
Environment of Care For the past several months, we have conducted environment of care (EOC) audits on multiple inpatient medical, surgical, and WISH units. These audits cover a vast range of topics from patient safety to environmental services. During general rounding in October, specific observations by A&M were noted with: Isolation signage is not consistently located on outside doors; Patient information found on the Nurses desk visible to the other patients and visitors; Both first and last names were posted on the outside of patients rooms; and Unsecured medications.
There is still variability in the cleanliness of patient rooms, corridors and common areas throughout the campus. Environmental Services needs to maintain a vigilance and regular schedule of inspection and routine cleaning. EOC audits need to be resumed in areas where they have not been recently conducted. Facilities and Maintenance Audits were conducted to locate all negative pressure rooms (isolation rooms) to determine if clinical staff is aware of the policy and procedure to test the negative pressure to ensure in acceptable range. A list of negative pressure rooms was attached to the PHHS policy and was used to validate the locations. The first issue encountered was that the list was incomplete, for example -- the Gastrointestinal (GI) Lab negative pressure rooms were not listed. Second issue identified that the clinical staff were not always aware of the policies, procedures and process and some redundant practices were found. To address the proper checking of negative pressure rooms, a task force, led by Infection Prevention, was formed with the participation of Nursing and Facilities Management. The task force will review the current state of checking procedures and as necessary revise the process for consistency and address any re-education and training needs.
21 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Department and Unit Specific Findings Emergency Services At the request of the Hospital, an A&M subject matter expert conducted a two-day site visit to assess the progress made in the Emergency Department (ED) against multiple CAP initiatives including, but not limited to, construction, appropriate staffing levels, process improvement, revisions to policies and procedures, and programmatic changes. In general, all changes made to Emergency Services are moving in a positive direction. The current state assessment was shared with Emergency Services leadership and highlights are below: Psychiatric patients are still utilizing beds in the Main ED. While safety concerns for this patient population have improved and there is a dedicated provider/social worker team triaged and treating these patients, the impact on Main ED volume is still significant at 10 to 20 patients per day. Implementation of CAP-related and other performance improvement processes are well underway, completed and/or already successfully hardwired. ED policies and procedures have been extensively revised. A&Ms recommendation to adopt same system as inpatient units is under consideration by nursing leadership team. Although significant improvement has been made in the organization of the ED, A&M believes that there is opportunity for further improvement for the use of the Assistant Service Manager role. We recommend that there be a service manager placed on the floor at all times in the main ED, coordinating and managing both sides of the entire unit and waiting room. Physician management and physician in charge still need to be addressed in the main ED. Until the physician performance issues in the main ED are totally addressed, maximum performance and patient flow in this unit will not occur. Extended hours, renovated physical space and a new physician contract should lead to better patient flow in the UCCED. The new UCCED manager appears to be a good fit. Although the recruitment training and retention are improving, there needs to be greater effort in bringing in permanent staff, while reducing travelers and overtime. The plan presented is working toward solution, but it relies heavily on low turnover. Retention should be a major focus. Ongoing discussion with the medical staff continues to try and implement more nurse driven protocols and these should be pursued to increase efficiency and patient flow. Psychiatric Services In response to several actual and potential safety events that occurred with psychiatric patients during the month of October and other ongoing concerns about the service, A&M performed a focused assessment of current state of Psychiatric Services including organization structure, staffing, development and compliance with revised policies and procedures and internal/external communication. Senior leadership has recently implemented a revised organization structure for clinical and operational management with clearly defined and communicated roles, responsibilities, authorities and reporting structure. Until recently, role definition for various members of psychiatric service line leadership has been unclear to the individuals involved, to the staff, medical leadership, and the overall organization. There has also been conflict among the parties, perhaps a result of the lack of clarity of roles and reporting structure. Although previously reported under the CAP work stream as completed, it was recently discovered that not all of the policies and procedures for Psychiatric Services were complete or that all policies had been comprehensively reviewed and revised. Under the leadership and direction of the Chief Operating Officer (COO), the critical policies/procedures will be reviewed and/or developed by November 13th. An education plan will be required for any new or changed practices.
22 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Many new processes have been designed and implemented to help improve communication and a multi-disciplinary care plan. An audit plan should now be put into effect to monitor the sustainability of these changes. Progress has been made in areas identified in the GAP related to integrated multi-disciplinary plans of care, but the nursing component remains the link in the triad of the care team (physician, social worker and nursing) requiring the most continued intervention. This is due in part to the inability to fill vacant nursing leadership roles until recently. There remain patient flow issues in the PED as staff adjusts to the renovated environment of the PED The care delivery model for inpatients in 8 North has incorporated psychologists on a more consistent basis and created an interdisciplinary care planning process. There have also been new therapeutic, goal-oriented patient groups added to the care delivery. The interdisciplinary care planning processes are still under development and are being revised based on trials and staff feedback. The Associate Medical Director for Psychiatric Services Quality has been coordinating ongoing monitoring of performance metrics Psychiatric Services. There has been progress in many metrics e.g., LWBT, readmissions to the PED within 24 hours, etc. These monitors should be revised to reflect more detailed analysis since stability has been sustained in some monitors. Endoscopy (GI Lab) In response to concerns about several recent safety events within Endoscopy/GI lab, A&M conducted a focused review of processes to determine progress made under the CAP and related to compliance with Medicare Conditions of Participation. Labeling of Medication/Medication Administration Through direct observations of (a limited number of) patient procedures, we evaluated compliance with best practice in the following areas: All medications were appropriately labeled once they were withdrawn from the vial. Labeling included name of drug, date, and nurse initials. All medications given were based on verbal orders from the physician during the procedure. Dosing and additional orders from the physician were based on the patients response to the medication. Patients were re-assessed every five minutes during the procedure. There were frequent verbal checks with the patient on comfort level as well as therapeutic, supportive statements to the patient. Drugs not given were either returned to the Pyxis if the vial had not been opened or wasted (and witnessed by another RN.)
Completion of medication administration being announced verbally by the RN was inconsistent, during our observation. Patient Handoffs Since the GAP Analysis report and the implementation of the CAP, changes have been made to the EPIC documentation to improve the ease of documentation of patient hand-offs between nurses. Documentation of nursing handing off of care and receiving care are now required. The receiving nurse documents the acceptance of the patient and from whom report was received. In actual observations in October in the GI Lab, we witnessed that the patient name, procedure, and patient status were communicated to the receiving nurse, all in compliance with best practice.
23 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Infection Prevention / Control-related Issues No scopes were in the process of being cleaned in the procedure rooms during our October observations. The GI Lab staff, generally clean the flexible endoscopes in the decontamination area. However, it has been reported that during high volume/peak procedure days, the staff may be cleaning the scopes in the procedure room to facilitate good turnaround time. This practice is against standards of practice of Society of Gastroenterology and Associates (SGNA). Since Nursing leadership has been made aware, the cleaning of scopes in the procedure room has ceased and all cleaning processes are performed in the decontamination room. A re-design of the decontamination area and processing area is now under development to include a re-design plan and its associated costs. During our October observations, generally appropriate gowning and gloving by staff was noted. One occurrence by a tech was noted in which the tech did not remove gloves before getting additional supplies out of the supply cabinet in the procedure room. During conversations with the VP of Perioperative Services and Procedural Areas and Associate Director of Sterile Processing, it was discovered that scopes that are stored in SICU, MICU and Clinics are not tracked to specific patients (for whom scope was last used) and to the validation of the final sterilization or disinfection. Upon notification, leadership immediate changed the process of scope utilization on the inpatient units and clinics and aligning them to the patient and validation of sterilization/disinfection process. This process will begin in November. Moderate Sedation During our review, we learned of some challenges regarding Anesthesia coverage for the GI Lab for patients who may need oversight when pain management becomes moderate sedation. A comprehensive plan has been developed by leadership to ensure patients requiring management by an Anesthesia provider will be provided. Physical Medicine & Rehabilitation PM&R At the time of the Gap Analysis survey there were approximately 1,800 outstanding referrals for outpatient therapy and services. The Gap Analysis report found that Parkland did not have an effective methodology or system to prioritize need-to-capacity-appointments. The CAP required the PM&R Department to enlist the assistance of the Operational Excellence team to conduct a demand vs. capacity, throughput process workflow assessment and labor productivity analysis to determine the root cause of delayed delivery of care. PM&R department leadership admits that the scheduling capacity has not increased to account for high no-show rates by double booking practices. Also claims down two schedulers is a reason for decrease in productivity. Filled positions/vacancies in scheduler positions should be not become a rate limiting factor in maintaining full utilization of appointment capacity, particularly when there is a backlog of demand. The organization should consider multi-disciplinary approach to cross-training schedulers who can provide coverage to different areas.
24 11/15/2012
# Occupational Therapy (OT) 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 No show rate - OT
1
Metric
Accountability PMR PMR PMR PMR

1
Baseline 15.2% 13.8%
Goal 10.0% 0.0%
May-12 14.7% 13.1% 429
Jun-12 15.0% 15.7% 432 81.4% 13.8% 33.0% 1182 69.7% 12.8% 26.7% 86 75.8%
Jul-12 12.0% 15.5% 412 80.5% 15.1% 36.0% 1267 72.2% 11.0% 17.9% 117 102.7%
Aug-12 14.5% 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%
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%
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%
Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - OT 1 Total Orders (OT) 1 Vacancy rate - OT 1 Labor productivity (percentage of targeted appointments per FTE) - OT Physical Therapy (PT) No show rate - PT Total Orders (PT)
1
PMR PMR PMR PMR PMR PMR PMR PMR PMR PMR
87.5% 15.6% 27.0%
100.0% 10.0% 0.0%
93.6% 16.1% 27.4% 1265
Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - PT 1
1
Vacancy rate - PT 1 Labor productivity (percentage of targeted appointments per FTE) - PT 1 Speech Therapy (ST) No show rate - ST 1 Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - ST 1 Total Orders (ST) 1 Vacancy Rate - ST
1 1
61.1% 13.8% 25.4%
100.0% 10.0% 0.0%
66.7% 7.8% 12.1% 91
Labor productivity (percentage of targeted appointments per FTE) - ST
PMR
71.9%
100.0%
95.4%
Laboratory
In August 2012, CMS conducted a full survey of the Parkland laboratory to determine compliance with CLIA (Clinical Laboratory Improvement Amendments) rules and regulations. The results of the survey were received by the Hospital on October 26, 2012. The Hospitals main lab received four conditional findings and 14 standard-level findings. In addition, the Anatomic Pathology lab received six standardlevel findings. The conditional findings included: Preanalytic systems Lab Dir performing moderate complexity testing Lab Dir performing high complexity testing Technical Supervisor performing high complexity testing.
The Hospital responded on November 9, 2012 with a plan of correction and allegation of compliance.
Radiology
The GAP Analysis report found inordinate wait times for diagnostic mammography appointments. These wait times have been greatly reduced over the past few months, but recently wait times have increased from 9 to 30 days, which were directly related to a physician on leave. We have recommended to the Radiology department that it devises a plan to backfill for physicians who impact key areas of clinical service such as diagnostic mammography. The Hospital should consider remote reading radiologists coverage for screening mammograms and redistribute workload to onsite coverage for diagnostic mammograms, if not already considered.
25 11/15/2012
Number of Days to 3rd Next Available Appointment - Mammography

140 120 100 80 60 40 20 0 119 95 87
30 4 May-12 Jun-12 Jul-12 Aug-12 9 Sep-12 Oct-12
Medication Management
During the month of October, Parklands Pharmacy Department conducted audits of 17 areas including inpatient units, outpatient specialty clinics, COPCs, Jail Health, YFCs, and Class D Pharmacies to assess security of medications, storage and expiration dates of medications on units. Issues identified during the audits included: unsecured medications in two areas, unsecured supplies in one area, expired supplies in one area and sub-standard document of refrigerator temperatures. Any findings were immediately communicated to nursing leadership. In areas where deficiencies have been found, they unit will be placed back on a daily audit tool until sufficient demonstration of sustainable practice is attained. 98% percent of the Nursing Stations submitted and successfully completed self-audits and are now on a monthly schedule. Four units that did not complete audits were: 3 E (WISH) ED West ED East Gyn Clinic (3rd floor). CAP Focus Areas for Next 30 Days Access/Throughput Creation of action plans to improve percentage of patients discharged before 11:00 AM daily Identifying process and people to move forward initiatives on continuum of care Increased throughput in community and onsite clinics
Case Management - Recruitment to lower vacancy rate - Identification of leadership and transition to Operations/Clinical Leadership from CAP leadership - Implementation of IDT meetings
26 11/15/2012
Parkland Health & Hospital System Alvarez & Marsal Progress Report to CMS October 2012 Clinical Support Implementation of additional responsibilities for autopsy clerk to ensure all autopsies performed have properly documented orders by reviewing all cases real-time PM&R to implement scheduling improvements per analysis by Operational Excellence department, including revisit of staffing model, in order to more effectively triage and prioritize demand over capacity (demand backlog) Implementation of observational house-wide moderate sedation audits Finalization of master list of contracts Education of new approval process for vendor contracts with business owners across the Hospital
Contract Services
Human Resources Execution of contract with Recruitment Process Outsourcing vendor Re-structure of recruiting department, including assessment of recruiting staff Implementation of Applicant Tracking System
Nursing Continuation of construction in Emergency Department Development of long-term acuity based staffing solution with McKesson Operational Excellence and Nursing Administration to report out results of float pool assessment and feasibility study Development and implementation of improved audit process for nursing documentation of Plan of Care, Hand-off and Restraints Transition of Patient Grievances area to Patient Safety. Continuation of oversight meetings on the new peer review process Continuation of review of OPPE metrics for five pilot departments Establish goals and refocus priorities for safe patient departure task force for immediate impact to decrease unsafe departures Recruitment
Patient Safety & Quality -
Physicians Finalization of audit on physician supervision documentation Reporting of verbal order metrics and trending in support of action plans to improve overall compliance
Psychiatric Services Formation of policy and procedure subcommittee to perform gap analysis on missing policies and a cross-walk to revised house-wide policies Identification of revised policy and procedures that require training/education of psychiatric services staff
WISH Formalization of schedule template changes to better distribute placement of complication patients to impact hallway observations or queues -- implement changes into EPIC Review of analysis performed by Operations Excellence on usage of hallway beds and other key metrics to support strategic decisions by WISH leadership Integration of ADT processes 27 11/15/2012
Conclusion There is no question 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. Significant groundwork has been laid to bring Parkland into full compliance with all Medicare Conditions of Participation. Where deficiencies have been identified, corrective action has been formulated and operationalized. Now the focus must turn toward personal accountability and sustainability of change. Although great progress has been made over the past 12 months, we remain concerned that some Hospital employees may still have a check the box mentality. We still encounter some staff members in a taskoriented state of mind instead of using process thinking skills, listening to patients, and analyzing order and results, to enable them to understand and participate in a plan of care. The Hospital may continue to be challenged with patient safety incidents until all staff clinical, support and administrative - are truly in the moment and use critical thinking skills to care for all patients. We have discussed these observations with the Hospitals senior leadership, all of whom are committed to driving this message of personal accountability to all staff members. Still, we are greatly encouraged by the leadership that the Hospitals senior management and Medical Staff has brought to bear on making patient safety and quality of care the paramount organizational goals at Parkland. Now, it is incumbent on leadership and management at all levels to ensure that this message on safety and quality consistently cascades throughout the organization, to all front line positions, be they clinical, support services or administrative personnel and particularly to the front-line whether they are direct patient givers or support the patient care experience. Parklands senior leadership should remain focused on hardwiring the culture of accountability during upcoming months and into the new year.
28 11/15/2012
Alvarez & Marsal - October 2012 Report to CMS for Parkland Health and Hospital System
Governance (Section 2.01) # 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Tasks/Initiatives 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. Require quality dashboard report from Hospital Quality Department Commence reviews of scorecards for significant outsourced and contracted clinical services. Design a Board-specific QAPI plan. Review and revise BOM committees. Review performance management and progressive discipline implementation plan from Human Resources. Review comprehensive plan to create better communication and coordination among the Hospitals Legal, Compliance, Internal Audit and Quality Departments. Review Hospital plan on continuum of care. 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 Accountability Patricia Bergen, MD Brad Marple, MD Brad Marple, MD Jackie Sullivan Jackie Sullivan Paul Leslie Jim Johnson Jody Springer Sharon Phillips Paul Leslie Work Stream 5.1 5.3 5.3 6.4 6.4 1.1 1.5 1.2 3.5 1.1 Target Date 1/31/2013 5/18/2012 8/31/2012 5/25/2012 6/1/2012 6/8/2012 6/8/2012 6/8/2012 10/30/2012 7/13/2012 Y Y Y Y Y Y Y Y May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion
# 1
Audit/Measures Percentage of contracts (outsourced vendors) reviewed for quality measures

1
Accountability Contract Svcs Comments
Goal 100%
May-12 80.0%
Jun-12 85.7%
Jul-12 N/A
Aug-12 N/A
Sep-12 96.1%
Oct-12 85.7%
1.09 - Parkland to revisit strategy on continuum of 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. 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
Human Resources (Section 2.02) # 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 # 1 2a 2b 2c 3 4 Tasks/Initiatives 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. Expand the role of Business Partner, require they take a more active role with front-line managers and supervisors. Business partners to audit evaluations for the next two evaluation cycles. Evaluate current HR staffing model. Analyze resource allocation within HR Department. Develop Parkland employee retention strategy. 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. Audit/Measures Percentage of supervisors (and above) who have attended training administered by clinical education
1
Accountability 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 House-Wide
1
Work Stream 1.5 1.2 1.5 1.5 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
Target Date 5/25/2012 5/25/2012 5/25/2012 7/13/2012 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 4/6/2012 4/27/2012 Goal 100%
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Completion Y Y Y
Y Y Y Y Y Y Y Y Y Y Y Y Y May-12 Jun-12 Jul-12 Aug-12 46% Sep-12 72% Oct-12 99%
Evaluation scores on histogram or bar chart for each department (annual evaluations) - below expectations Evaluation scores on histogram or bar chart for each department (annual evaluations) - meets expectations
HR HR HR HR
0.4% 33.9% 65.7%
5.0% 55.0% 40.0% 100% 10 20.9 18.3 13.7 24.2 11.9 11.1
Evaluation scores on histogram or bar chart for each department (annual evaluations) - above expectations 1 Percentage of licensing validations presented prior to the day of hire Time from occurrence to corrective action signed by employee (days)
1
HR
Human Resources (Section 2.02) # 5a 5b 6 7 8 9 10 11 12 13 14 Turnover Rate (%) - Nursing Turnover Rate (%) - Total 1 First year turnover rate Percentage of employees (annually) who leave for stated reasons of better opportunity (compensation, job duties, benefits)
1 1 1
Metric
Accountability HR HR HR HR HR Clinical Ed HR House-Wide HR
Baseline 16.5% 15.0%
Goal 14.5% 14.1% 20.0%
May-12 19.0% 16.8% 19.8% 26.7%
Jun-12 24.9% 17.5% 19.1% 36.8%
Jul-12 9.7% 9.2% 18.4% 31.3%
Aug-12 21.5% 15.2% 13.6% 36.7% 69.0%
Sep-12 12.8% 10.6% 6.3% 50.0%
Oct-12 9.5% 9.5% 9.8% 44.7%
35.1% 76.0%
25.0%
Employee satisfaction scores 1 Percentage of competencies updated on/before due date 1 Number of corrective actions
1
100% 40 N/A 100% 100% 59.9 55.0
71% 29 0.9% 98.8% 66.3
75% 54 1.1% 98.8% 62.9
60% 73 1.2% 88.0% 87.2
87% 87 1.3% 96.2% 80.5
93% 74 1.3% 100.0% 99.2% 72.3
100% 95 0.96% 100.0% 99.5% 68.4
Absent Hours (as a percentage of total hours worked) 1 Percentage of current licensure
1 1 1
Percentage of current certifications
HR HR Comments
Time for recruiting to fill an open external job position
2.04 - Training has not been implemented, but not all participants have taken the . To be complete in November.
1. 2. 3. 4.
Access/Throughput (Section 2.03) # 3.01 Tasks/Initiatives 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 Conduct analysis of no show rates by clinic, day, session, and provider. Accountability Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Work Stream 3.6 Target Date 9/30/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y
3.02
3.6
6/8/2012
3.03
Conduct a physician productivity analysis based upon a review of current process and development of analytics.
3.6
6/8/2012
3.04 3.05 3.06 3.07
Document current process workflow diagrams, identify barriers to throughput and develop solutions that might increase Jessica Hernandez productivity and result in additional capacity Holt Oliver, MD Review ED utilization and most common diagnoses by patient admission times to analyze opportunities for changes or improvements in COPC hours of operation Develop the post-acute care network. Lonnie Roy Deanna Bokinsky
3.6 3.1 3.5 3.4
7/13/2012 7/13/2012 10/30/2012 6/12/2012
Y Y Y Y
3.08 3.09 3.10 3.11 3.12 3.13 3.14
Robin Stults w/ Case Management to generate a study report by physician or service showing average time of discharge for patients and Clinical physicians or services consistently discharging patients late in the day. Intelligence Robin Stults w/ Chief Medical Officer to meet with the Medicine and Critical Care Service Chiefs and Hospital Directors to determine Clinical barriers to earlier discharge of patients on the units and develop a solution. Intelligence Jessica Hernandez Conduct a physician productivity analysis based on agreed upon industry standards. Holt Oliver, MD Conduct a feasibility study for a dedicated observation unit Josh Floren Conduct a feasibility study to determine the best use of 4SS space Josh Floren Conduct a study to determine appropriate expansion of the dialysis unit. Josh Floren Design Bed Czar concept to report to ADT Establish strict standards regarding communication and patient placement timelines with ADT to enhance patient placement. 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. Miriam Gomez Miriam Gomez Kim McCloud Linda Licata Barbara Mims
3.4 3.6 1.7 1.7 1.7 3.3 3.3
10/15/2012 5/11/2012 7/13/2012 7/13/2012 7/13/2012 7/1/2012 8/1/2012 Y Y Y Y
3.15
2.6
6/1/2012
Access/Throughput (Section 2.03) # 3.16 Tasks/Initiatives Define a patient flow process that will reduce and/or eliminate boarding of dialysis patients in the emergency department. Define and obtain approval for resources necessary to implement process, including expansion of serivces. Accountability 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 COPC ADT Accountability Clinics Care Mgmnt COPC Med Staff COPC COPC COPC COPC COPC
1
Work Stream 2.6
Target Date 6/15/2012
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Completion Y
3.17
2.6
7/1/2012
3.18
Develop protocols and obtain resources for implementation of defined patient flow process. Fully implement patient flow process and expansion of services to eliminate boarding of dialysis patients in the emergency department.
2.6
9/30/2012
3.19
2.6
11/30/2012
# 1a 1b 1c 2 3 # 4 5 6 7 8a 8b 8c 9 10 11 12 13a 13b 14 15 16 17 Capacity - Family Medicine

1
Audit/Measures
Baseline 86.0% 90.0% 96.0%
Goal 100.0% 100.0% 100.0% 550
May-12
Jun-12
Jul-12 86.5% 96.8% 101.2%
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
Oct-12 101.3% 94.9% 99.8% 531 42% Oct-12 5.1% 17.7% 60318 2.60 2.36 1.60 20,605 17,888
Capacity - Internal Medicine 1 Capacity - Geriatrics

1
Number of additional appointments through virtual visits 1 Percentage of observation patients outside of observation unit 1 Metric Utilization rates by session by clinic (hours of activity/hours of capacity) Percentage of discharges (medicine, surgery) by 11:00 a.m. 1 No show rates - COPC 1 Physician (Hospitalists) productivity (based upon Rolling 12 Month RVUs/Average FTE Count) 1 Physician (Clinics) productivity (based on visits/hour) - Family Medicine 1 Physician (Clinics) productivity (based on visits/hour) - Internal Medicine Physician (Clinics) productivity (based on visits/hour) - Geriatrics Number of new patients on wait list - COPC
1 1 1
174 57% 60% Jun-12 5.0% 17.0% 5991
203 61% Jul-12 4.4% 17.0% 6053
Baseline
Goal
May-12 6.4%
17.2% 5768 2.62 2.49 1.59
18.1% 5851
Number of established patients on wait list - COPC 1 Number of bed days occupied by observation status (by unit) Average bed turn time (hours:minutes) 1 Average minutes of boarding in Main ED 1 Average minutes of boarding in ICC 1 Average Length of Stay (1 month lag) 1 Percent inpatient occupancy (census) by division 1 Bed Request to Bed Assign, average from bed assigned to patient in bed 1 Hours on red/yellow bed
5
Care Mgmnt EVS ED ED Care Mgmnt ADT EVS ADT 524 5.0 85.0% 45 1:00
2,518 1:18 129.6 100.6 5.3 85.0% 67 0
2,721 1:13 126.4 126.2 5.2 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
Access/Throughput (Section 2.03) Comments 3.08 - Lack of evidence on progress made toward improving volume of discharges prior to 11 AM 3.13 - 3.14 - Staffing is not complete for bed czar role and WISH is not fully integrated in ADT Metric # 7 - Medical staff office not able to supply data timely 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.
Provision of Care (POC) (Section 2.04) # 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Tasks/Initiatives Define nursing supervisor role expectations and competencies. Revise job description to meet role expectations. 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. Initiate new role expectations. Conduct a comprehensive review of the nursing structure under the direction of the new CNO. Develop internal and external recruitment plan for new organizational structure. 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. Revise policies/procedures and nursing standards to reflect best practices, as appropriate. Develop a house-wide educational plan to correct the current deficiencies in patient care. 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. Accountability 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 Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Emilie Allen Jim Johnson Jackie Brock John Raish Work Stream 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 Target Date 4/20/2012 4/27/2012 4/27/2012 5/4/2012 9/14/2012 3/30/2012 5/11/2012 4/13/2012 8/31/2012 10/5/2012 9/30/2012 10/31/2012 11/14/2012 10/5/2012 Y May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y Y Y Y Y Y
Provision of Care (POC) (Section 2.04) # 4.15 4.16 4.17 4.18 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 4.33 Once selected, roll out acuity tool. Develop flexible staffing strategies, PRN pools, per diem staff, etc. Monitor core patient care ratios for trends. Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (electronic solution) Evaluate acuity, nursing care hours annually for trends in patient care and staffing needs (interim solution) Establish standards of nursing practices, focusing particularly on the plan of care. (Clinical Competencies) Develop house-wide nursing education program (Clinical Competencies) 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. Establish standards of nursing practices, focusing particularly on the plan of care. (Plan of Care) Develop house-wide nursing education program. (Plan of Care) Create evaluation tools to measure nurse understanding of education and success of program. Initiate nursing grand clinical rounds. Develop report out tool for grand round results. Through the QAPI Department, develop and report verbal order trends monthly to providers and nurses. Review all restraint policies. Develop and execute restraint education. Review Epic restraint documentation structure to improve the quality of documentation. Develop a mandatory education for medical staff on the required elements of performance related to restraints. Develop a strict discipline policy that leads to termination of staff who violate the Restraint policy or a patients rights Tasks/Initiatives Accountability 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 Jim Johnson Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jackie Sullivan Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Joseph Minei, MD Jim Johnson Work Stream 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 1.5 Target Date 3/22/2013 10/5/2012 3/22/2013 6/28/2013 11/1/2012 5/11/2012 8/1/2012 10/31/2012 10/31/2012 5/11/2012 8/1/2012 9/14/2012 7/13/2012 10/1/2012 9/14/2012 4/20/2012 11/1/2012 3/23/2012 11/1/2012 5/25/2012 Y Y Y Y Y Y Y Y Y Y Y Y Y May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion
Provision of Care (POC) (Section 2.04) # 1 2 3 4 5 6 7 8 # 9 10 11 12 Percentage of cases with verbal orders
1 1 1
Audit/Measures Nursing leadership vacancy rate

1
Accountability Nursing HR Nursing Nursing Nursing

1,4
Goal 100.0%
May-12 13.0% 92.0% 2.8% 12.6%
Jun-12 12.1% 100.0% 3.0% 13.9% 44.0% 67% 75.0% 181 Jun-12 1.7% 54.0%
1
Jul-12 12.4% 86.0% 2.9% 11.7% 80.0% 70% 92.4% 166 Jul-12 1.8% 83.1% 90.0%
1
Aug-12 14.4% 80.0% 3.3% 15.1% 66.7% 85% 90.4% 192 Aug-12 1.5% 84.0% 98.3%
4
Sep-12 12.9% 100.0% 3.0% 14.3% 100.0% 76% 88.0% 143 Sep-12 1.4% 81.8% 98.7%
1
Oct-12 9.3% 100.0% 2.9% 10.7% 100.0% 82% 1 82.0% 185 Oct-12 1.4% 84.3% 100.0%
Percentage of completed competencies for all nurses and units 1 Percentage of travelers (hospital-wide) Nursing vacancy rate
1 1
Percentage of completion of education activities 1 Percentage of Plan of Care documented according to policies and procedures Percentage of compliance in hand-off's
3
100.0% 100.0% 100.0%
45.0% 72% 212

1
Nursing Nursing Nursing
Volume of non-violent restraint cases (hospital-wide) 1 Metric Number of days per month nurse staffing ratios were above/below grid Verbal order compliance rate (signed within 48 hours) Percentage of staff who attended Plan of Care training
Accountability Nursing Nursing Nursing Nursing Comments
Baseline 2.2%
Goal
May-12 1.9%
90.0% 100.0% 0.0%
4.01 - Please reference nursing administrative officer section of narrative report on success of implementation of new roles and responsibilities 4.12 - Initiative has insufficient evidence for completion 4.16 - Hospital is working to analyze data in order to determine a strategy for a float pool 4.28 - Verbal order reports and metrics still need to be reported to Medical Executive Committee and trended over time 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
Care Management (Section 2.05) # Tasks/Initiatives 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. Re-align goals and strategy of department to promote collaboration between Case Managers, Social Work, Utilization Review and Nursing. 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. Identify metrics needed on a daily basis to properly analyze cases. Produce an Extended Stay High Cost Outlier Report to identify inpatients that could move to a post-acute care setting if funding permitted. 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. Revise position expectations of the ED Case Manager . ED Case managers should evaluate all potential admissions on whether they meet acute care criteria and assess patients potential discharge planning needs. ED case managers should perform an initial assessment on all patients being admitted to the hospital. Create or revise policies and procedures that define screening, assessment and discharge planning process to identify high risk patients. Educate nursing care management staff on proper procedure for the Discharge Planning Assessment Tool within Epic to ensure appropriate screening and referrals. 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. Create a screening tool for case managers to include long term stay patient, avoidable days and other areas of focus. Accountability Work Stream Target Date May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion
5.01
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 Deanna Bokinsky 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
7/24/2012
5.02
3.4
6/30/2012
5.03
3.4
6/30/2012
5.04
3.4
6/1/2012
5.05
3.4
5/31/2012
5.06
3.5
1/31/2013
5.07
3.4
6/1/2012
5.08 5.09 5.10
3.4 3.4 3.4
9/30/2012 8/30/2012 6/15/2012
Y Y Y
5.10
3.4
6/15/2012
5.11
3.4
11/14/2012
5.12
3.4
7/20/2012
5.13
Move Utilization Management within Care Management Department.
3.4
8/31/2012
10
Care Management (Section 2.05) # 5.14 Tasks/Initiatives 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. Policies and Procedures should be revised to reflect the revised plan, and associated roles and responsibilities of staff. Revise the current UR logs to ensure that all required elements are collected and formatted in order to analyze and trend type data. Develop process to export Case Management Care Web documentation whereby the data are analyzed and trended. Accountability 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 Accountability CM
1
Work Stream 3.4
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Completion Y
5.15
3.4
7/30/2012
5.16
3.4
7/31/2012
5.17
3.4
6/30/2012
5.18
Select UR metrics for tracking, monitoring, and trending. (utilize national best practices as examples for targets). Utilize data from a comparative database that is clinically adjusted and severity adjusted to assist the Committee in identifying areas for improvement. 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.) Report unfavorable physician trends to the Patient Care Review Committee (PCRC). Unexpected results will be reported to Performance Improvement (PI). Monitor progress on targeted metrics and re-evaluate targeted improvement goal and/or metrics being measured.
3.4
6/30/2012
5.19
3.4
6/12/2012
5.20
3.4
7/31/2012
5.21
3.4
10/31/2012
5.22
3.4
7/31/2012
# 1 2 3 4 # 5 6 7 8 Number of Avoidable Days (per Month) 1 Number of One-Day Stays (per Month) 1
Audit/Measures Compliance in performing medical necessity screening in ED

1
Baseline
Goal
May-12
Jun-12
Jul-12
Aug-12
Sep-12 90.1%
Oct-12 89.3% 59.0% 90.0% Oct-12 996 4,442 581 8.7%
Audit Results of Number of Hospital-Wide Cases Intervened on 1st day of admission Percentage of cases with CM screening for discharge needs - ED 1 Percentage of compliance in completion of H&P's
1
CM CM CM 95.0% 85.0% Baseline 1,013 5,184 443 8.7% Goal May-12 980 4,929 414 9.1% Jun-12 1,051 5,165 409 10.3% Jul-12 947 4,559 429 8.3% 85.3% Aug-12 986 5,766 429 9.2% 28.5% N/A Sep-12 969 4,850 493 8.3%
Metric Number of Cases with Outlier Length of Stay (LOS) (per Month) 1
Accountability CM CM CM CM
30 day Readmission Trends (percent of total discharges) 1
11
Care Management (Section 2.05) Comments 5.06 - Parkland to revisit continuum of care strategy 5.10 - Discharge Planning Assessment Tool has been created, but still needs to be validated by A&M and educated to staff 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.
12
Environment of Care (EOC) (Section 2.06) # 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 Tasks/Initiatives 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. Convene the environment of care team to establish mission, charter, goals and processes to address EOC activities. Conduct a one-time, accelerated plan for deep cleaning and repairs. Develop a budget and prioritization for the campaign on potential staff or capital needs for senior leadership review. 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. 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. Accountability 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 Work Stream 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 3.7 Target Date 4/27/2012 9/14/2012 9/14/2012 4/11/2012 4/23/2012 4/27/2012 4/6/2012 4/6/2012 6/8/2012 4/13/2012 4/13/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
# 1 2 3 4
Audit/Measures Percentage of Patient Rooms, Procedure Areas, and Operating Rooms, meeting all elements of EVS requirements Compliance to infection prevention audits on surface cleanliness Number of patient complaints about environmental issues
1 1 1
Accountability House-Wide EVS House-Wide EVS
Goal 100%
May-12
Jun-12 85.6%
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
97.5% 100% 0 8
97.2% 87.5% 5
Percentage of procedure areas with up to date daily terminal cleaning logs 1
13
Environment of Care (EOC) (Section 2.06) # 5 6 7a 7b 7c 8 Bed turnaround time Percentage of turns greater than 60 minute goal Work order completion time - EVS (days)
1 1
Metric
Accountability EVS EVS EVS Facilities
Baseline
Goal 1:00 0%
May-12 1:18 56% 0.89 1.77 2.52
Jun-12 1:13 52% 0.64 1.95 1.91
Jul-12 1:24 58% 1.77 2.07 4.47
Aug-12 1:06 48% 2.76 2.77 1.91
Sep-12 1:12 48% 1.91 2.01 2.47
Oct-12 0:59 41% 0.42 3.21 2.42 7.9%
Work order completion time - Facilities (days) 1 Work order completion time - Clinical Engineering (days) Vacancy Rate - EVS
1
Clin Eng HR 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. 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
14
Infection Control (Section 2.07) # 7.01 7.02 7.03 7.04 7.05 Tasks/Initiatives Each Divisional Vice President (VP) will submit all department specific Infection Prevention (IP) related policies and procedures to IP. The IP department Director and Chief of Infection Prevention will review and make revisions of all departmental and house-wide IP policies, if applicable. All departmental IP policies are returned to the department for their review and acceptance Approve reviewed departmental and house-wide IP policies. Divisional VP and Department Directors to develop a communication roll out with IP Director on the revised IP policies and procedures. Each department assigns an IP delegate to be the contact and participant in the IP prevention education program. Provide a full-time Chief Infection Prevention Officer. 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. Execute EOC surveillance program to ensure consistency with cleaning methods and standards to support IP principles. Accountability Kim McCloud Linda Licata Barbara Mims Janet Glowicz Janet Glowicz Janet Glowicz Kim McCloud Linda Licata Barbara Mims Kim McCloud Linda Licata Barbara Mims Jody Springer Janet Glowicz Janet Glowicz Work Stream 2.8 6.3 6.3 6.3 2.8 Target Date 4/20/2012 9/30/2012 6/8/2012 6/8/2012 6/8/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y
7.06 7.07 7.08 7.09
2.8 1.2 6.3 6.3
6/8/2012 6/8/2012 3/23/2012 3/23/2012
Y Y Y Y
# 1 2 3a 3b 3c 4 5 6 7 8 9
Audit/Measures Percentage of policies that have been drafted/revised (by department) Volume of non compliant hand hygiene observations - support staff Volume of non compliant hand hygiene observations - physicians Volume of non compliant hand hygiene observations - nursing 1 Compliance in hand hygiene
1 1 1 1 1
Accountability IP House-wide House-wide House-wide House-wide House-wide Surgery

1
Goal 100% 0 0 0 0 100% 100% 100% 0%
May-12 100% 1547 407 380 760 96.8%
Jun-12 98.0% 896 185 255 456 97.9% 100% 64.7%
Jul-12 100% 1006 197 263 546 97.7% 100% 79 97.0%
Aug-12 100% 577 156 155 266 98.6% 100% 100.0% 202 94.4% 0
Sep-12 100% 243 61 67 115 98.6% 100% 100% 173 94.8% 0
Oct-12 100% 322 85 93 144 99.3% 100% 100% 377 92.2% 1
Volume of non-compliant observations for hand hygiene - Hospital and IP Audit
Percentage of compliant observations with sterile technique in procedure areas 1 Percentage of Infection Prevention completed surveys by each department, monthly Volume of non-compliant observations by Infection Prevention Practice Team Compliance percentage of Infection Prevention Practice Team rounding Number of blood stream infections
1 1 1
IP House-wide House-wide House-wide
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. 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
16
Medication Management (Section 2.08) # 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 8.18 8.19 8.20 8.21 8.22 Conduct a medication override audit. Enhance P&T agenda with cost studies, outcomes for alternative drug options, ADR, Overrides, dosing guidelines. 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. Establish a Medication Reconciliation task force to develop a consistently compliant process. Conduct chart audit of medication reconciliation compliance to establish current baseline. 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. Implement new reconciliation process (in EPIC). Reassign the crash cart management under the Sterile Processing Department and/or Pharmacy. Assess the space requirements and human resources needed for case cart management within SPD. Revisit the cart management processes for supplies and pharmaceuticals. 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. Implement an accountability process and sign off process to ensure accuracy and products are not expired. Conduct cart initial audit for validation after transferring case cart management to SPD. Tasks/Initiatives Accountability Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson 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 Work Stream 2.3 2.3 2.3 2.3 2.3 2.3 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 Target Date 6/8/2012 4/5/2012 6/8/2012 5/11/2012 6/8/2012 6/8/2012 4/27/2012 4/27/2012 5/11/2012 6/15/2012 5/11/2012 6/8/2012 6/8/2012 6/8/2012 7/13/2012 9/14/2012 4/13/2012 7/16/2012 5/11/2012 3/22/2013 8/13/2012 10/1/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
17
Medication Management (Section 2.08) # 8.23 8.24 8.25 8.26 8.27 8.28 8.29 8.30 8.31 8.32 8.33 8.34 8.35 8.36 8.37 8.38 8.39 Tasks/Initiatives 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. Pharmacy Resource collects collates and summarizes audit results and submits monthly audit on the data tool. 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. Ensure all clinicians are qualified to administer medications that have the clinical effect of moderate sedation. Ensure compliance with new moderate sedation practice standards. 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 MD Max Overrides reviewed by RPH
1 1 1
Accountability Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson Vivian Johnson 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 Vivian Johnson
Work Stream 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 4.5 4.5 4.5 4.5 2.3
Target Date 6/8/2012 6/8/2012 6/8/2012 6/8/2012 6/8/2012 6/8/2012 4/13/2012 6/8/2012 6/8/2012 6/8/2012 9/14/2012 9/14/2012 8/13/2012 8/13/2012 8/13/2012 8/13/2012 3/22/2013
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
# 1 2 3 4 5 6 7 8 9 10
Accountability Pharmacy Physicians Physicians Physicians Physicians Physicians Pharmacy SPD House-Wide
Baseline 53% 83%
Goal 100%
May-12 100% 62.7% 84.7%
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%
Compliance in medication reconciliation at admission (inpatient only) Compliance in medication reconciliation at discharge (inpatient only) Compliance in medication reconciliation - Ambulatory Services Compliance in medication reconciliation - Medicine Clinics Compliance in medication reconciliation - Surgery Clinics Percentage of locations with unsecured medications 1 Percentage of compliant crash carts Compliance in moderate sedation
1
0%
2.0% 99.3%
1.7% 100.0% 121
0.2% 100.0% 91
0.0% N/A 94
0.0% 100.0% 59
0.0% 92.9% 73
Number of improper or lack of medication labeling
Pharmacy
18
Medication Management (Section 2.08) # 11 12 13 14 15 16 Number of adverse drug reactions Missed medications
1 1
Metric Number of off-label medications in use, not reviewed by P&T 1
Accountability Pharmacy Pharmacy Pharmacy Pharmacy Pharmacy

1 1
Baseline 19 0.67%
Goal 0 31
May-12 194 0.64%
Jun-12 126 0.65%
Jul-12 128 0.67%
Aug-12 70 0.57%
Sep-12 0 108 0.62% 97.0% 88.0%
Oct-12 0 94 0.61% 96.4% 86.5% 2
Percentage of medications administered within 60 minutes of order 1 Percentage of medications administered within 30 minutes of order Number of opioid induced respiratory depressions naloxone administration
Pharmacy Comments
Metric # 8 - Sample size only 14 carts (10% of all returned carts), but an issue was found with in an incorrect size of a
1. 2. 3. 4.
19
Patient Safety/Rights (Section 2.09) # 9.01 9.02 9.03 Tasks/Initiatives 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) 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) 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. 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 Create new Human Resources policy on violations of Patient Rights/Patient Safety obligations. 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. 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. 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. Accountability Jody Springer Jody Springer Work Stream 1.2 1.2 Target Date 3/30/2012 10/1/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y
9.04
Jody Springer
1.2
5/11/2012
9.05 9.06 9.07
Jody Springer Lisa Betterson Lisa Betterson
1.2 6.2 6.2
5/11/2012 6/8/2012 8/15/2012 Y Y
9.08
Jackie Sullivan
6.1
6/8/2012
9.09 9.10 9.11 9.12 9.13 9.14
Jim Johnson Lisa Betterson Lisa Betterson Lisa Betterson Jody Springer Lisa Betterson
1.5 6.2 6.2 6.2 1.2 6.2
6/8/2012 4/27/2012 5/11/2012 9/30/2012 4/13/2012 6/1/2012
Y Y Y Y Y Y
9.15
Lisa Betterson
6.2
3/30/2012
9.16
Lisa Betterson
6.2
3/22/2013
20
Patient Safety/Rights (Section 2.09) # 9.17 9.18 Tasks/Initiatives Complete current RCI initiative regarding 1:1 observation procedure and competencies required for staff. Evaluate additional CM staff to ED. 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. Develop and implement an action plan that addresses non-compliance and the steps to the solution. 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. Determine where and if the resources are available or needed to meet the documentation requirements. 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. Review Hospital policy for Patient Grievance procedure and compare to best practice, including those noted above. Develop monitoring system to ensure timelines required by Hospital policy are met. 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. 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. Develop a dashboard and track and trend the indicators for Patient Rights and the progress to the target thresholds. Accountability Lisa Betterson Robin Stults w/ Clinical Intelligence Lisa Betterson Work Stream 6.2 3.4 Target Date 6/1/2012 7/31/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y
9.19
6.2
9/14/2012
9.20 9.21 9.22 9.23
Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson
6.2 6.2 6.2 6.2
9/14/2012 10/31/2012 9/14/2012 9/14/2012
Y Y Y
9.24 9.25
Lisa Betterson Lisa Betterson
6.2 6.2
5/25/2012 6/8/2012
Y Y
9.26
Lisa Betterson
6.2
9/14/2012
9.27 9.28 9.29 9.30 9.31
Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson Lisa Betterson
6.2 6.2 6.2 6.2 6.2
6/8/2012 9/14/2012 9/14/2012 7/1/2012 9/14/2012
Y Y Y Y Y
21
Patient Safety/Rights (Section 2.09) # 1 2 3 4 5 6 7 8 9 10 11 12 Audit/Measures Percentage of policies and procedures reviewed and/or revised
1 1
Accountability Pat Safety Pat Safety Nursing Nursing

1
Baseline
Goal 100% 100% 100% 100% 100% 10
May-12 21% 0.0% 98.0% 0.0% 83.3% 15 61.3% 442 12
Jun-12 44% 0.0% 98.0% 0.0% 100.0% 15 92.3% 584 22
Jul-12 100% 54.0% 98.0% 0.0% 100.0% 10 92.3% 464 25
Aug-12 100% 75.2% 98.0% 0.0% 100.0% 27 82.1% 403 41 97.8%
Sep-12 100% 98.8% 100.0% 100.0% 100.0% 33 80.0% 226 22 98.0% 76.7% 91.7%
Oct-12 100% 99.2% 100.0% 100.0% 100.0% 45 94.1% 418 23 98.0% 79.5% 91.8%
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 Percentage of staff provided education on safe patient hand offs - shift to shift 1 Attendance for state mandated training courses for members of Police Department Average time from event to closure of patient safety investigation (days) Percentage of regulatory reports submitted within 5 business days Number of patient complaints and grievances 1 Average time from event to resolution of patient complaint or grievance (days) 1 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 Message from Medicare", others), as audited by HIM - PFS 1 Metric Number of Patient Safety Investigations 1 Percentage of Root Cause Analyses (RCA) completed within 45 days Volume of privacy and security breaches
1 1 1 1
Police Pat Safety Perf Imp Pat Griev Pat Griev PFS CM PFS 74%
100%
98% 98%
45.0% 77.0%
67.3% 91.0%
# 13 14 15 16
Accountability Pat Safety Pat Safety House-Wide Pat Safety Comments
Baseline 80% 59
Goal 100%
May-12 50 57 56
Jun-12 61 47 64
Jul-12 66 34 66
Aug-12 78 42 69
Sep-12 46 36 53
Oct-12 56 53 60
Number of elopements, AWOLS, AMA (excluding ED)
9.03 - 9.05 - Interviews are still in progress for CPRSO position 9.23 - Audit results on patients receiving important message from Medicare are not in compliance with CAP goal
1. 2. 3. 4.
22
Medical Staff (Section 2.10) # 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 Tasks/Initiatives Develop an OPPE/FPPE review template for each medical department and/or service. Develop a written procedure explaining the OPPE process, criteria and physician referral process for FPPE. Define required physician profile elements for all physicians. 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. Review and obtain approval of OPPE/FPPE process and criteria by MEC, and then the Governing Board. Each department should develop a standard set of metrics for use on cases sent for peer review. Medical Staff Office Quality Department to establish a methodology to track and trend all cases brought to peer review Patient Safety PCRC to revise and standardize scoring system used to refer cases to peer review. Determine necessity to expand Medical Staff resources. 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. Develop a training module enabling faculty to instruct residents when to escalate issues to their Attending Physicians. 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 Accountability 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 Brad Marple, MD Work Stream 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.1 5.3 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 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y
10.12
Brad Marple, MD
5.3
7/30/2012
10.13
Brad Marple, MD
5.3
8/31/2012
10.14
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) # 10.18 Tasks/Initiatives 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. 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. Standardize call schedule procedure for consulting services. Ensure the accuracy Amcom scheduling system (source of truth maintained by Parkland) Create contingencies for alternate modes of supervision or escalation. Parklands GME Director should review the current training and education materials for Residents on documentation, particularly documentation of H&Ps. Refresher education and training should be conducted for all Residents. Perform audit of Residents' History and Physicals (H&P) documentation for completion and adherence to Parkland policy and procedures. Audit/Measures Number of referrals to peer review Percentage of Medical Staff enrolled in new OPPE system Treatment Team accuracy
1 1
Accountability Brad Marple, MD
Work Stream 5.3
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Completion Y
10.19 10.20 10.21 10.22 10.23 10.24 10.25 10.26
Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD Joseph Minei, MD Brad Marple, MD Brad Marple, MD Brad Marple, MD
5.4 5.4 5.4 5.4 5.4 5.3 5.3 5.3
8/31/2012 8/31/2012 8/31/2012 8/31/2012 5/11/2012 5/11/2012 8/31/2012 3/22/2013
Y Y Y Y
Y Y Y
# 1 2 3
Accountability Med Staff Perf Imp House-Wide Comments
Goal 15
May-12 23 61%
Jun-12 40
Jul-12 34
Aug-12
Sep-12 192
Oct-12 120
Audit #3 - Medical Staff are still finalizing audit process and tool. To report figures in November.
1. 2. 3. 4.
24
Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Clifann McCarley Work Stream 3.2 Target Date 4/27/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y
Conduct a quantitative demand and process analyses of the ESD in order to properly balance work flow, capacitate the 11.01 various components of the split flow system, and accurately determine any changes in bed capacity, service hours or staffing. 11.02 11.03 Throughput and productivity assessment of the current state in the form of a process work flow 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 within budget guidelines, and hours of operations.
Clifann McCarley Clifann McCarley Clifann McCarley
3.2 3.2 3.2
4/27/2012 4/27/2012 4/27/2012
Y Y Y
11.04 Server cycle times need to be measured and applied to the design of care teams in the Triage and the Intake areas. Conduct a benchmarking study of its Emergency Department labor productivity to industry standards in order to determine if there are opportunities to improve productivity and thereby increase capacity for each service area.
11.05
Clifann McCarley
3.2
7/13/2012
Redesign of the future process flow to eliminate waste, such as: removing or combining steps, automating any manual 11.06 activity steps, if possible, transferring elements to other departments, changing the location where the steps are done, and Clifann McCarley finally altering/modify the activity step 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. 11.10 Recruitment, credentialing and on-boarding of qualified physicians. 11.11 Pathology to scope operations, licensing, certification requirements for Point of Care labs. Develop signage text consistent with the educational level and primary languages of the population served that is 11.12 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 Clifann McCarley Clifann McCarley Clifann McCarley Patricia Bergen, MD Deb Perrault Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley
3.2 3.2 3.2 3.2 5.1 2.2 3.2 3.2 3.2 3.2 3.2 3.2 3.2
6/8/2012 1/13/2013 3/14/2013 6/8/2012 6/8/2012 5/11/2012 5/11/2012 5/11/2012 5/25/2012 6/8/2012 7/13/2012 6/8/2012 7/13/2012
Y Y Y Y Y Y Y Y Y Y
25
Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Clifann McCarley Emilie Allen Emilie Allen Clifann McCarley Work Stream 3.2 4.4 4.4 3.2 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 Target Date 3/22/2013 5/20/2013 6/8/2012 5/12/2013 9/14/2012 5/25/2012 7/13/2012 9/30/2012 6/8/2012 6/8/2012 7/13/2012 9/14/2012 9/14/2012 4/13/2012 4/27/2012 5/18/2012 5/12/2013 Y Y Y Y Y Y Y Y Y Y May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y
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 of a person presenting Clifann McCarley 11.23 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 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. Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen
26
Emergency Services (Section 2.11) # Tasks/Initiatives Accountability Clifann McCarley Clifann McCarley Clifann McCarley Emilie Allen Emilie Allen Emilie Allen Emilie Allen Emilie Allen Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Work Stream 3.2 3.2 3.2 4.4 4.4 4.4 4.4 4.4 4.3 4.3 4.3 4.3 4.3 Target Date 4/13/2012 4/27/2012 5/18/2012 5/12/2013 9/9/2012 9/21/2012 9/21/2012 5/18/2013 10/5/2012 3/22/2013 3/22/2013 3/22/2013 6/28/2013 Y Y May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y
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. Annual review ESD Nurses, Physicians and other Caregivers and Staff. Review and revise policy and procedures on nursing assessment and plan of care requirements. Create/Revise training materials for new policy and procedures. Re-educate on new policy and procedures. Annual review ESD Nurses, Physicians and other Caregivers and Staff. The Emergency Services Director of Nursing should determine approach for developing an acuity assessment 11.44 methodology, e.g., internal historical record review, an automated tool, etc. 11.39 11.40 11.41 11.42 11.43 11.45 Once selected, roll out acuity tool. 11.46 Develop flexible staffing strategies, PRN pools, per diem staff, etc.
Y Y
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.
27
Emergency Services (Section 2.11) # Main ED 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Treated visits

1 1
Audit/Measures
Accountability ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD
Baseline
Goal
May-12 9935
Jun-12 10208 2829 34.5 12.7 14.4 422 364.0 99 334 70 6.0% 2.3% 25.6% 65.8% 313
Jul-12 10146 3434 46.6 12.0 14.5 413 431.4 131 496 90 10.2% 1.8% 26.9% 64.3% 371
Aug-12 10093 5209 53.2 12.2 15.0 431 430.0 61 608 63 11.2% 2.4% 27.6% 62.3% 371 90%
Sep-12 9734 2654 47.2 10.9 13.8 412 408.3 125 394 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%
Oct-12 9859 3536 48.2 10.2 15.5 396 389.2 114 238 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%
Total number of hours of ED boarding
2671 40.0 17.3 415.5 379.4 92 93
3135 37.4 10.9 14.8 397 396.2 109 360 79 8.8% 2.1% 27.7% 63.3%
Average number of patients in ED that are boarding per day 1 Average number of dialysis patients in Main ED at 6AM
1
Average "Compassionate" dialysis patients transferred from ED/day 1 Average dwell time for dialysis patients in Main ED Turnaround time to discharge patients to home (door to home, in minutes) Door to seen by 1st Provider (minutes) Hours on resource alert 1 Door to Room Time (minutes) Left without being seen
1 1 1 1
Left without being treated 1 Percentage of patients admitted

1
ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD ESD WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH WISH 400 264 127 2.3 456.2 105 164 100% 194.2 126 107 326 100%
Percentage of patients discharged 1 Average ED throughput time - time from patient arrival to patient disposition 1 Compliance to environment of care 1 Urgent Care Clinic (UCC) Treated visits 1 Turnaround time to discharge patients to home (door to home, in minutes) 1 Door to seen by 1st Provider (minutes) 1 Door to Room Time (minutes) 1 Left without being seen 1 Left without being treated 1 Percentage of patients admitted 1 Percentage of patients discharged 1 Average ED throughput time - time from patient arrival to patient disposition 1 Compliance to environment of care 1 OB Gyn Intensive Care Clinic (ICC) Treated visits 1 Total number of hours of ED boarding 1 Average number of patients in ED that are boarding per day 1 Turnaround time to discharge patients to home (door to home, in minutes) 1 Door to seen by 1st Provider (minutes) 1 Hours on resource alert 1 Door to Room Time (minutes) 1 Left without being seen 1 Left without being treated 1 Percentage of patients admitted 1 Percentage of patients discharged 1 Average ED throughput time - time from patient arrival to patient disposition 1 Compliance to environment of care 1
338
4278 245.3 180 163 9.1% 1.1% 0.0% 91.5% 222
4225 258.4 198 172 10.6% 0.9% 0.0% 91.9% 240
4727 235.2 176 159 8.4% 0.9% 0.1% 93.0% 217
4722 240.8 176 161 7.5% 1.3% 0.1% 92.0% 219 89%
1999 106 2.0 359.1 64 0 193 2.9% 8.9% 10.1% 73.0% 313
1945 120 1.9 446.4 63 0 247 4.1% 14.9% 10.5% 66.9% 385
2000 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%
28
Emergency Services (Section 2.11) # 40 41 42 Metric Labor Productivity (staffing to include acuity) Total ED throughput time - time from patient arrival in ANY ED to discharge home from ANY ED Percentage of travelers - ED
1 1
Accountability ESD ESD ESD Comments
Baseline
Goal
May-12 6:37 20.8%
Jun-12 6:28 20.9%
Jul-12 6:57 21.9%
Aug-12 7:05 21.4%
Sep-12 6:43 24.0%
Oct-12 6:42 19.3%
11.23 - Still working to fill vacancies in Team C 11.31 - Need more time to demonstrate sustainable audit results 11.40 - Initiative has insufficient evidence for completion
1. 2. 3. 4.
29
Psychiatry Services (Section 2.12) # Tasks/Initiatives Accountability Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips 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 Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Sharon Phillips Work Stream 2.1 2.1 2.1 2.1 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 2.1 2.1 2.1 2.1 2.1 Target Date 4/27/2012 4/27/2012 6/8/2012 5/14/2012 6/22/2012 5/25/2012 7/31/2012 7/31/2012 7/31/2012 4/13/2012 9/14/2012 6/8/2012 6/8/2012 6/1/2012 6/8/2012 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 Y Y Y Y Y May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
12.01 Develop clear vision of a psychiatric services (with particularly focus on PED) care delivery model. 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 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.
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) # 1 2 3 4 5 6 7 8 9 10 11 12 # 13 14 15 16 17 18 19 20 21 Audit/Measures Audit Results of Number of PED Cases Intervened by CM Prior to Admission Treated Visits (PED) Percentage of patients seen by social workers (PED) 1 Hours on resource alert
1 1
Accountability PED/CM PED Psych PED Psych Psych Psych
Baseline
Goal 100%
May-12 94% 537 98.2% 532 100.0% 3.7% 67.6% 25.5%
Jun-12 100% 514 97.4% 672 100.0% 3.9% 67.3% 26.7% 682 531 46
Jul-12 100% 578 98.5% 722 100.0% 2.1% 65.9% 29.8% 608 404 68
Aug-12 N/A 535 99.8% 724 100.0% 1.7% 66.9% 29.9% 706 560 N/A
Sep-12 100% 554 97.7% 0 100.0% 1.6% 73.3% 23.1% 588 385 61 99.1%
Oct-12 100% 605 97.6% 678 100.0% 3.1% 74.0% 20.7% 573 363 47 94.7% Oct-12 26 7 0.0% 463 872 3.0% 13.6%
Percentage of patients with a documented discharge huddle 1 Percentage of patients admitted

1 1 1 1
Percentage of patients discharged to home
Percentage of patients transferred to acute care facility Door to seen by 1st Psych Provider (minutes in PED) Door to Room Time (minutes in PED) Compliance to environment of care
1 1 1
Psych PED PED PED Psych Metric Accountability PED Psych Psych
1
Turnaround time to discharge patients to home (door to home)
649 166 60 100.0% Baseline Goal
649 698 45
May-12 29 7 18.8%
Jun-12 8 6 26.9% 564 1,198 1.0% 10.0%
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%
Sep-12 15 3 8.3% 481 971 2.4% 14.0%
Labor productivity (staffing to include acuity) Volume of restraint cases - personal hold Volume of restrain cases - seclusion Percentage of travelers - Psych
1 1 1
Number of patients with scheduled appointments at discharge
Psych Psych
1
Total PED throughput time - time from patient arrival to patient disposition (arrival in PED to discharge in PED)
PED
1
537
555 1,334 1.2% 7.0%
Total PED throughput time - time from patient arrival to patient disposition (arrival in any ED to discharge in PED) 24-hour bounce back rate
1 1
PED PED Psych Comments
Proportion of total Psychiatric Services patients discharged from Main ED by Team C
12.22 - 12.24 - Hospital to reassess continuum of care strategy in November
1. 2. 3. 4.
31
Women and Infant's Specialty Health (WISH) (Section 2.13) # Tasks/Initiatives Accountability Barbara Mims Valerie Harvey Barbara Mims Valerie Harvey Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Paula Turicchi Work Stream 4.2 4.2 4.3 4.3 4.3 2.4 Target Date 3/22/2013 9/30/2012 6/8/2012 4/13/2012 5/11/2012 7/15/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 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. 13.03 Begin recruitment of key leadership positions Nursing Director (L&D) and Nursing Manager (L&D). 13.04 Evaluate job description and determine best solution to work load balance for Nurse Manager (Postpartum). 13.05 Begin recruitment of additional Nurse Manager candidates (Postpartum). 13.06 Evaluate job descriptions of Nurse Managers to determine if additional administrative support is required. 13.07 Begin recruitment for administrative support roles (if appropriate). 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. Evaluate job descriptions for inclusion of appropriate competencies and to ensure duties assigned are within scope of practice. WISH Nursing Director and Chief Nursing Officer (CNO) must ensure all nursing personnel working within scope of 13.13 practice. Nursing Directors of each area should review competencies required for the care of their patient population in accordance 13.14 with nursing practice standards. 13.12
Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Jackie Brock John Raish Paula Turicchi Jackie Brock John Raish Emilie Allen
4.3 4.3 4.3 4.3 2.4 4.3 4.4
6/8/2012 4/27/2012 6/8/2012 6/8/2012 6/1/2012 4/13/2012 6/1/2012
Y Y Y Y Y Y Y
32
Women and Infant's Specialty Health (WISH) (Section 2.13) # 13.15 13.16 13.17 13.18 Tasks/Initiatives Accountability Emilie Allen Emilie Allen Emilie Allen Emilie Allen Paula Turicchi Suzanne Sims Work Stream 4.4 4.4 4.4 4.4 2.4 2.5 Target Date 7/13/2012 7/13/2012 7/13/2012 7/13/2012 5/31/2012 4/13/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y
A full assessment of current staff should be conducted to establish a current baseline of competencies. Review all personnel files for completed competencies. Gaps identified in competencies should be addressed with education and audit. Conduct newborn resuscitation competency education and audit. Evaluate the need for an additional FTEs to assist in the responsibility of supply stocking, storage, and environmental 13.19 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. Hire additional staff, if needed. 13.21 Ensure plan of care practices are standardized and followed regularly. 13.22 Standardize hand off procedures. Educate staff. Women Infant and Specialty Health (WISH) operations and nursing leadership with Chief Nursing Officer (CNO) to 13.23 develop plan and budget for required changes. 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. 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 partum unit (department reports plan 13.29 underway to convert treatment rooms for this purpose).
Paula Turicchi Paula Turicchi Jackie Brock John Raish Paula Turicchi Paula Turicchi Emilie Allen Paula Turicchi
2.4 2.4 4.3 2.4 2.4 4.4 2.4
6/8/2012 5/25/2012 6/30/2012 5/11/2012 4/6/2012 5/11/2012 7/31/2012
Y Y Y Y Y Y Y
33
Women and Infant's Specialty Health (WISH) (Section 2.13) # 13.30 Tasks/Initiatives Establish monthly mock equipment drills and verify emergency equipment is immediately available where newborns are housed. Accountability Paula Turicchi Paula Turicchi Work Stream 2.4 2.4 Target Date 7/31/2012 4/6/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y
13.31 Discard all six pack transport carts. Conduct a multidisciplinary assessment of conditions of WISH units related to 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 stocking, storage, and environmental rounds on all WISH units.
13.32 13.33
Paula Turicchi
2.4
4/15/2012
13.34 Establish an alternative protocol for delivery table set-up to ensure sterile field. 13.35 Educate staff on storage requirements for specimens. 13.36 Revise dirty utility room flow and practice. 13.37 Department reports a plan is in progress for construction to ensure proper dirty utility room flow. (No start date supplied) 13.38 Review Parkland policy on securing medications PHR-D-067 Inventory Management Procurement, Storage 13.39 Anesthesia medication trays should be stored in a locked, secure area. 13.40 Store floor stock in Pyxis. 13.41 Educate staff on the importance of two patient identifiers and include in initial and annual competencies. 13.42 Educate staff of National Patient Safety Goals and Hospital policy. # 1 2 Compliance to Infection Prevention practice Compliance to environment of care
1 1
Suzanne Sims Emilie Allen Paula Turicchi Josh Floren Judy Herrington Vicki Crane Judy Herrington Vicki Crane Judy Herrington Vicki Crane Emilie Allen Emilie Allen Responsibility WISH WISH
2.5 4.4 2.4 1.7 4.5 4.5 4.5 4.4 4.4
4/6/2012 4/27/2012 7/15/2012 7/12/2012 5/18/2012 4/13/2012 4/13/2012 3/31/2012 3/30/2012 Goal 100.0% 100.0% May-12 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%
Y Y Y Y Y Y Y Y Y
Audit/Measures
34
Women and Infant's Specialty Health (WISH) (Section 2.13) # 3 4 5 6a 6b 7 8 9 10 11 Labor productivity (Staffing to include acuity) Staffing hours per patient day
1
Metric
Responsibility WISH WISH WISH

1
Baseline 11.65 118 136 1384
Goal
May-12 12.95 117 62 924
Jun-12 13.10 119 123 811
Jul-12 11.97 20 149 198 1207
Aug-12 12.88 22 120 230 979
Sep-12 12.42 17 83 192 906
Oct-12 13.07 21 104 192 834
Number of days per month staffing ratios were above/below grid 1 Hallway and Classroom Beds in use in L&D (avg duration in minutes) Hallway and Classroom Beds in use in L&D (instances) 1 Volume of patients doubling-up on Post-Partum Induction Interruption Induction Delay
1 1
WISH WISH WISH WISH WISH WISH WISH Comments
Direct Admits to Post-Partum Bounce-Back from Post-Partum to L&D Recovery
114
121
122
138
35
Perioperative Services (Section 2.14) # 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 Tasks/Initiatives 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 Compliance to using two patient identifiers 1 Compliance percentage of Infection Prevention by audit, monthly
1 1
Accountability Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims
Work Stream 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5
Target Date 8/31/2012 6/8/2012 8/31/2012 8/31/2012 8/31/2012 7/13/2012 8/31/2012 7/13/2012 8/31/2012
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Completion Y Y Y Y Y Y Y Y Y
# 1 2 3 4 5 6 7
Accountability Surgery Surgery Surgery Surgery Surgery Surgery Surgery
Goal 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
May-12
Jun-12 100.0% 97.6% 99.8% 99.0%
Jul-12 100.0% 100.0% 100.0% 100.0% 99.2% 100.0%
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%
Compliance percentage of Environment of Care by audit, monthly 1 Compliance to site marking procedure Compliance to medication management measures (labeling, transferring from the circulator to scrub, securing and other 1 measures) Compliance with critical equipment Compliance to Time Out procedure
1 1
99.8%
99.9%
36
Perioperative Services (Section 2.14) # 8 9 10 11 12 13 14 Number of medication errors Number of incorrect consents
1
Metric Number of blood transfusion errors 2

2
Accountability Surgery Surgery Surgery Surgery Surgery Surgery
Baseline
Goal 0
May-12 5
Jun-12 2 0 6
Jul-12 2 1 5
Aug-12 3 0 3 0 3
Sep-12 5 2 3 0 0 13.9% 1.6%
Oct-12 1 5 1 0 5 9.5% 1.8%
Number of wrong site surgeries or wrong site markings 2 Number of lab specimen mis-labeling Percentage of travelers - OR
1 1 2
10.7% 1.71% 0%
9.5% 1.5%
11.9% 3.8%
13.5% 1.4%
Surgical Site infection rate (2 month lag)
Surgery
Comments
37
Procedural Services - Catherization Lab/Endoscopy (Section 2.15) # Tasks/Initiatives Accountability Kim McCloud Linda Licata Barbara Mims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Suzanne Sims Kim McCloud Linda Licata Barbara Mims Suzanne Sims 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 Suzanne Sims Barbara Mims Valerie Harvey Work Stream 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 Target Date 4/15/2012 8/31/2012 8/31/2012 8/31/2012 8/31/2012 8/31/2012 6/8/2012 3/30/2012 8/31/2012 8/31/2012 8/31/2012 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 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-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
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 the sterile field. 15.03 Review Parkland's policy on Surgical Attire and OSHA regulation on Personal Protective Equipment. 15.02 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. 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. 15.14 15.15 15.16 15.17 15.18 15.19 15.20 15.21 15.22 Surgical Services to provide an educational session on the proper procedure of conducting sponge and needle/sharp counts. Develop and implement an annual competency on proper procedure on performing counts. 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) # 1 2 3 4 5 6 7 8 # 9 10 11 12 13 Number of wrong site surgeries Number of incorrect consents
2 2
Audit/Measures Compliance percentage to Infection Prevention practice 1 Compliance percentage of environment of care by audit, monthly Compliance to site marking procedure in cath lab by audit Compliance to Time Out procedure by audit
1 1 1 1
Accountability Surgery Surgery Surgery Surgery Surgery Surgery Surgery

1
Goal 100.0% 100.0% 100.0% 100.0%
May-12
Jun-12 99.0% 100.0% 98.2%
Jul-12 100.0% 99.5% 100.0% 100.0%
Aug-12 97.0% 95.3% 100.0% 98.8% 100.0%
Sep-12 98.9% 97.1% 100.0% 100.0% 100.0% 92.0% 100.0% 100.0% Sep-12 0 0 1 1 0
Oct-12 98.6% 97.9% 100.0% 100.0% 100.0% 88.0% 100.0% 100.0% Oct-12 0 1 0 3 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 Compliance to proper scrub attire and sterile gowning in restricted areas in cath lab by audit Metric
100.0% 100.0% 100.0% Baseline Goal May-12
99.5% 94.6% 99.6% Jun-12
100.0% 100.0% 100.0% Jul-12
97.6% 98.3% 100.0% Aug-12 0 2
Surgery Accountability Surgery Surgery Surgery
Number of medication errors 1 Number of lab specimen mis-labeling

2 2
1 4 0
Surgery Surgery Comments
Number of return to surgery for retained objects
39
Radiology (Section 2.16) # 16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08 Tasks/Initiatives 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. Accountability 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 Scott Cummins Suzanne Sims Suzanne Sims Judy Herrington Vicki Crane Judy Herrington Vicki Crane Emilie Allen Scott Cummins Scott Cummins Scott Cummins Scott Cummins Patricia Bergen, MD Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.5 2.5 4.4 2.2 6.4 6.4 2.2 2.4 2.4 4.5 4.5 4.4 2.2 2.2 2.2 2.2 5.1 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 7/13/2012 6/1/2012 8/31/2012 5/11/2012 6/8/2012 9/30/2012 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 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
16.09 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. 16.11 Provide Time Out procedure flash cards to be used as a help guide until newly learned behavior has been established 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 Development of Time Out dashboard metrics for dashboard and reporting of metrics to departmental QAPI - HospitalWide 16.15 Ensure needles and syringes are secured in an area that is not accessible to unauthorized persons. 16.16 Review Parkland policy on medications on and off the sterile field. 16.17 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. 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. 16.24 Audit the Main and ASC Operating Room staff and providers proper wear of personal protective attire during a 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 Accountability Patricia Bergen, MD Scott Cummins Scott Cummins Scott Cummins Work Stream 5.1 2.2 2.2 2.2 Target Date 5/11/2012 6/8/2012 6/8/2012 9/14/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-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 Compliance to use of two patient identifiers 1 Compliance to the Time Out procedure
1 1
# 1 2 3 4
Accountability Radiology Radiology Radiology Radiology

1
Goal 100% 100% 100% 100%
May-12 100.0% 99.7% 86.0% 95.9%
Jun-12 100.0% 100.0% 91.0% 98.7%
Jul-12 100.0% 100.0% 96.0% 100.0%
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%
Compliance to proper securing of medications and medication supplies (needles, syringes) Compliance to medication management (labeling, scrub and circulator exchange)
41
Radiology (Section 2.16) # Mammography - Diagnostic 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Labor productivity - Mammography - Diagnostic (Paid Hours/Unit of Service) (1 month lag) 1 Number of days to third next available appointment - Mammography - Diagnostic Current utilization of slots - Mammography - Diagnostic 1 No show rate - Mammography - Diagnostic MRI
1 1
Metric
Accountability Radiology Radiology Radiology Radiology

1
Baseline 0.5 95 130% 19% 1.9 64 115% 28% 0.7 12 117% 11% 0.8 15 118% 18% 1.2 26 116% 17%
Goal 0.5 14 125% 18% 1.9 14 130% 27% 0.7 14 120% 10% 0.8 14 120% 17% 1.2 14 120% 16% 0 0 0 0 0 0
May-12
Jun-12 0.6
Jul-12 0.5 87 141% 18% 1.9 7 118% 23% 0.6 4 118% 9% 0.7 9 119% 15% 1.9 15 96% 9% 0 0 1 3
Aug-12 0.5 4 190% 15% 2.2 11 123% 20% 0.6 1 120% 8% 0.9 1 115% 12% 1.4 12 117% 13% 0 1 0 0 2 0
Sep-12 0.5 9 189% 14% 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
Oct-12 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
95 125% 17%
119 136% 19% 1.8
Labor productivity - MRI (Paid Hours/Unit of Service) (1 month lag) Number of days to third next available appointment - MRI Current utilization of slots - MRI 1 No show rate - MRI CT
1 1
Radiology Radiology Radiology Radiology
52 118% 24%
24 123% 24% 0.6
Labor productivity - CT (Paid Hours/Unit of Service) (1 month lag) Number of days to third next available appointment - CT Current utilization of slots - CT 1 No show rate - CT US
1 1
13 130% 11%
0 134% 10% 0.8
Labor productivity - US (Paid Hours/Unit of Service) (1 month lag) Number of days to third next available appointment - US Current utilization of slots - US No show rate - US IR
1 1 1
12 121% 14%
2 121% 22% 1.6
Labor productivity - IR (Paid Hours/Unit of Service) (1 month lag) Number of days to third next available appointment - IR Current utilization of slots - IR No show rate - IR Overall
1 1 1
Radiology Radiology Radiology Radiology Radiology
18 112% 15% 1 0 2
18 127% 13% 0 0 2
Number of Incorrect consents 2 Number of incorrect tests or wrong results placed Number of medication errors
1 2 2
Radiology Radiology Radiology Radiology Radiology
Number of cancelled surgeries due to unavailable films 2 Number of lab specimen mis-labeling Number of wrong site surgeries 2
42
Radiology (Section 2.16) Comments 16.22 - 16.23 - Attendance rates are only at 60% for both training modules 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 Accountability 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 Work Stream 2.2 2.2 2.7 Target Date 3/30/2012 5/11/2012 4/6/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y
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. 17.06 Educate laboratory staff on expected cleaning standards and schedules. 17.07 Define with EVS an escalation process for cleaning. 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 17.09 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. 17.13 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.
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
5/15/2012 4/13/2012 4/13/2012 3/23/2012 6/8/2012 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
Y Y Y Y Y Y Y Y Y Y Y Y Y Y
44
Laboratory Services (Section 2.17) # 17.19 17.20 17.21 17.22 Tasks/Initiatives 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 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 Compliance to autopsies having formal orders
1 1
Accountability Debbie Perrault Debbie Perrault Emilie Allen Debbie Perrault
Work Stream 2.2 2.2 4.4 2.2
Target Date 4/27/2012 6/8/2012 4/6/2012 6/8/2012
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Completion Y Y Y Y
# 1 2 3 # 4 5 6
Accountability Lab Lab Lab
Goal 100% 100% 100% Baseline Goal 0 98.0%
May-12 100% 100% 100% May-12 100.0%
Jun-12 100% 100% 100% Jun-12 99.0% 2
Jul-12 100% 100% 100% Jul-12 99.0% 2
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
Metric Number of incorrect reporting of lab/pathology results

2 1 2
Accountability Lab Lab Lab Comments
Percent compliance to 60 minute critical value turnaround time
Number of patient safety events relating to non-compliance in critical value reporting
Audits #1 and 2 - Results are not reported since audits moved to quarterly due to sustainable 100% compliance when conducted monthly.
1. 2. 3. 4.
45
Food & Nutrition Services (Section 2.18) # 18.01 Tasks/Initiatives Change procedure to ensure all unused trays are collected after meals. Accountability Usha Kollipara Kim McCloud Linda Licata Barbara Mims Usha Kollipara Work Stream 2.2 Target Date 5/30/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y
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.
2.8
4/13/2012
18.03
Acquire thermometers for freezers.
2.2
4/4/2012
# 1 # 2 Volume of reheated trays
Audit/Measures Compliance with all nutrition services equipment and food temperatures Metric
1
Accountability FNS Accountability FNS Comments Baseline
Goal 100% Goal
May-12 100% May-12
Jun-12 100% Jun-12
Jul-12 100% Jul-12
Aug-12 100% Aug-12
Sep-12 100% Sep-12
Oct-12 100% Oct-12
46
Organ and Tissue (Section 2.19) # Tasks/Initiatives Accountability Jackie Sullivan Emilie Allen Work Stream 6.4 4.4 Target Date 9/14/2012 9/14/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-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) # 20.01 20.02 20.03 20.04 20.05 20.06 Tasks/Initiatives 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. 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. Accountability Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Jenni Burnes Barbara Mims Jenni Burnes Jenni Burnes Barbara Mims Valerie Harvey Jenni Burnes Jody Springer Jody Springer Kim McCloud Linda Licata Barbara Mims Jenni Burnes Jenni Burnes Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 4.2 2.2 2.2 4.2 2.2 1.2 1.2 2.8 2.2 2.2 Target Date 4/20/2012 5/4/2012 5/4/2012 6/29/2012 6/29/2012 6/29/2012 8/1/2012 8/1/2012 6/8/2012 5/25/2012 9/14/2012 4/13/2012 4/20/2012 4/13/2012 6/8/2012 5/4/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y Y Y Y Y Y Y
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. 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
Y Y Y
48
Physical Medicine and Rehabilitation (PMR) (Section 2.20) # 1 2 # Occupational Therapy (OT) 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 No show rate - OT
1 1
Audit/Measures Percent of all elements of care that have been assessed and addressed Compliance to Environment of Care
1 1
Accountability PMR PMR
Goal 100% Baseline 15.2% 13.8% Goal 10.0% 0.0%
May-12 91.3%
Jun-12 90.1%
Jul-12 94.0%
Aug-12 95.0% 96.5%
Sep-12 96.2% 98.2% 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%
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%
Metric
Accountability PMR PMR PMR PMR

1
May-12 14.7% 13.1% 429
Jun-12 15.0% 15.7% 432 81.4% 13.8% 33.0% 1182 69.7% 12.8% 26.7% 86 75.8%
Jul-12 12.0% 15.5% 412 80.5% 15.1% 36.0% 1267 72.2% 11.0% 17.9% 117 102.7%
Aug-12 14.5% 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%
Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - OT Total Orders (OT)
1
Vacancy rate - OT 1 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 Total Orders (PT) Vacancy rate - PT
1 1 1 1
PMR PMR PMR PMR PMR PMR PMR PMR PMR PMR
87.5% 15.6% 27.0%
100.0% 10.0% 0.0%
93.6% 16.1% 27.4% 1265
Labor productivity (percentage of targeted appointments per FTE) - PT Speech Therapy (ST) No show rate - ST 1
61.1% 13.8% 25.4%
100.0% 10.0% 0.0%
66.7% 7.8% 12.1% 91
Percentage of expired orders (patients that did not receive treatment within 60 days of physician order) - ST 1 Total Orders (ST) 1 Vacancy Rate - ST
1 1
Labor productivity (percentage of targeted appointments per FTE) - ST
PMR Comments
71.9%
100.0%
95.4%
20.12 - Have identified three vendors for outsourcing, to execute contract by the end of January, 2013
1. 2. 3. 4.
49
Respiratory Therapy (Section 2.21) # 21.01 21.02 21.03 21.04 Tasks/Initiatives 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. Accountability Edward Best Edward Best Edward Best Edward Best Edward Best 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 Edward Best Work Stream 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.7 2.7 Target Date 4/13/2012 5/11/2012 3/22/2013 4/13/2012 6/8/2012 6/8/2012 9/14/2012 9/14/2012 4/6/2012 4/13/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y Y Y Y Y Y Y Y Y
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. 21.10 Meet with clinical leaders who store oxygen tanks and determine responsibilities of staff in which oxygen tanks are stored.
21.11 Develop a house-wide education/awareness for all staff that addresses all areas of responsibility.
2.7
5/11/2012
21.12 Audits of oxygen tank safety. 21.13 Long term strategy for an annual assessment of therapy care to ensure that there are no gaps in process or care.
2.7 2.2
5/1/2012 9/14/2012
Y Y
# 1 2 3 4 # 5 6 Ventilator Associated Pneumonia Rate 1 Number of missed treatments (RT self-reporting) 1 Respiratory Care documentation accuracy 1 Compliance in oxygen tank storage 1
Audit/Measures Percentage of missed treatments related to Therapist not being available 1
Accountability RT RT RT House-wide
Goal 0% 95.0% 100% Baseline 2.74 3.29% Goal 2.65 1.8%
May-12 9.8% 1007 99.5% May-12 2.58 0.4%
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%
Metric Productivity Metrics (Weighted Procedures/Hours Paid) 1
Accountability RT RT Comments
50
Community Oriented Primary Care (COPC) (Section 2.22) # Tasks/Initiatives Accountability Judy Herrington Vicki Crane Vivian Johnson Judy Herrington Vicki Crane Vivian Johnson Judy Herrington Vicki Crane Judy Herrington Vicki Crane Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Kim McCloud Linda Licata Kim McCloud Linda Licata Barbara Mims Jessica Hernandez Holt Oliver, MD Work Stream 4.5 2.3 4.5 2.3 4.5 4.5 3.6 Target Date 6/8/2012 3/23/2012 5/11/2012 6/20/2012 5/11/2012 5/11/2012 4/6/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-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. Implement electronic medical record (EMR)/Pharmacy interface to allow for Pharmacy to provide oversight to prescribing 22.04 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. 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. 22.09 Meet with the appropriate leaders responsible for environmental cleaning and maintaining the environment to discuss the gaps and develop plan for improvement.
3.6 2.7 2.7
6/8/2012 5/11/2012 6/8/2012
Y Y Y
22.10 Establish multi-disciplinary monitoring of clinic locations.
22.11 Load plans of care into Jail electronic medical record (EMR).
3.6
6/8/2012
51
Community Oriented Primary Care (COPC) (Section 2.22) # Tasks/Initiatives Accountability Barbara Mims Valerie Harvey Jessica Hernandez Holt Oliver, MD Barbara Mims Valerie Harvey Accountability COPC COPC COPC COPC COPC Metric Number of medication errors
2 2
Work Stream 4.2 3.6 4.2
Target Date 8/1/2012 6/8/2012 7/20/2012
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-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.
# 1 2 3 4 5 # 6 7 8 9
Audit/Measures Compliance with medication management to include but not limited to securing, labeling , reconciliation and 1 documentation Compliance percentage of environment of care by audit, monthly Compliance to the use of two patient identifiers Compliance to infection prevention practice 1 Compliance in medication reconciliation 1
1 1
Goal
May-12
Jun-12
Jul-12
Aug-12 99.4%
Sep-12 100.0% 97.0% 100.0% 91.9% 96.0% Sep-12 4 2 78.0 17.7%
Oct-12 100.0% 97.5% 99.4% 97.4% 97.0% Oct-12 1 1 81.1 17.7%
95.5% 100%
94.7%
96.0% 98.0% 96.0% 94.0%
Accountability COPC COPC COPC COPC Comments
Baseline
Goal 0
May-12 1 108.7 18.1%
Jun-12 1 2 115.8 17.0%
Jul-12 4 11 102.9 17.0%
Aug-12 1 1 92.2 17.0%
Number of lab specimen mis-labeling by clinic Third next available appointment 1 No show rate 1
97.2 17.2%
52
Specialty Clinics (Section 2.23) # 23.01 Ensure hard-stop process in Epic is engaged. 23.02 Determine EVS scope and schedule. Tasks/Initiatives Accountability Vivian Johnson Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Jessica Hernandez Holt Oliver, MD Suzanne Sims Suzanne Sims Accountability Clinic Clinic Clinic Clinic 94.2% 92.0% Work Stream 2.3 3.6 Target Date 9/14/2012 3/30/2012 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion Y Y
23.03 Clinic leadership to round clinic areas to monitor PHI security.
3.6
6/8/2012
23.04 Clinic leadership to develop and implement disciplinary actions for staff violations of HIPAA policies. 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. # 1 2 3 4 Audit/Measures Compliance with medication management to include but not limited to securing, labeling , reconciliation and documentation 1 Compliance percentage of environment of care by audit, monthly Compliance to the use of two patient identifiers Number of completed medication reconciliations by audit
3.6 2.5 2.5
5/7/2012 10/31/2012 10/31/2012 Goal May-12 Jun-12 Jul-12 Aug-12 98.7% 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%
Y Y Y
53
Specialty Clinics (Section 2.23) # Number of medication errors

1
Metric Number of lab specimen mis-labeling by clinic 2 Compliance to HIPAA/privacy standards (based on EOC audit) General Surgery No Show Rate
1 1
Accountability
Baseline
Goal 0
May-12 2
Jun-12 0 4
Jul-12 0 4
Aug-12 8 5 92.2%
Sep-12 2 2 97.3%
Oct-12 3 1 96.8% 25% 128 152 25% 115 143 24%
Third next available appointment Average dwell time (minutes) 1 Urology No Show Rate
1
Third next available appointment 1 Average dwell time (minutes) Surgery Oncology No Show Rate
1 1 1
Third next available appointment Average dwell time (minutes) 1 Cardiology No Show Rate
1
94 148 26%
Third next available appointment Average dwell time (minutes) GI/Liver No Show Rate
1 1
65 118 25%
Third next available appointment Average dwell time (minutes) Renal No Show Rate
1 1
145 155 23%
Third next available appointment Average dwell time (minutes) 1
67 128
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. 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
55
Contract Services (Section 2.24) # Tasks/Initiatives Accountability Muthusamy Anandkumar, MD Ciel Murphy Work Stream Target Date May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Completion
24.01
Create database of all contracted patient service arrangements.
6.5
3/22/2013
24.02
Review department specific quality indicators for all contracts.
Muthusamy Anandkumar, MD Ciel Murphy
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) # 1 2 # 3 Percent of current contracts in database

1 1
Audit/Measures
Accountability Contracts Contracts Accountability

1
Goal
May-12 100%
Jun-12 100% 100%
Jul-12 N/A N/A Jul-12 N/A
Aug-12 N/A N/A Aug-12 N/A
Sep-12 100% 89% Sep-12 20.7%
Oct-12 100% 100% Oct-12 20.7%
Percent of current contracts that have department specific quality indicators Metric Number of contracts that meet contacting requirements for quality scoring
Baseline
Goal
May-12 74.0%
Jun-12 20.7%
Contracts Comments
24.05 - Extended date to end of calendar year due to longer than expected timing of gathering, organizing, and reporting on all current contracts
1. 2. 3. 4.
57
QAPI # Tasks/Initiatives Accountability Work Stream Target Date May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-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 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 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 Q.11 Q.12 Q.13 Q.14 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.
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
6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.1 6.4 6.1 6.1
5/25/2012 6/15/2012 6/30/2012 6/30/2012 9/30/2012 11/31/2012 9/30/2012 6/30/2012 5/25/2012 5/25/2012 5/18/2012 6/30/2012 6/30/2012 5/25/2012 9/30/2012 5/25/2012
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
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 Q.07 - Performance Improvement has overhauled the Patient Safety Network (PSN) reporting process, however still in pilot phase. 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

Miles Moffeit - 111920127014 - Report CMS Parkland October 2012 AM Report (11 15 2012) 2

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Miles Moffeit - 111920127014 - Report CMS Parkland October 2012 AM Report (11 15 2012) 2

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

November 15th, 2012

1.2 1.5 2.2 3.2 3.3 3.4 3.5

Significant CAP-related Goals Met in October

Significant CAP-related Goals Still Outstanding in October

Change in Report Format/Overall Impressions from October

Compliance to Cultural Effectiveness Interviews

Compliance to Communication Effectiveness Audit by Licensure

Compliance to Communication Effectiveness Audit by Department

Percentage of Patients Screened for Discharge Needs in ED

Percentage of Discharges Before 11AM

Nursing Vacancy Rates

13.0% 13.0% 11.0% 12.1% 9.0%

9.3% 7.0% 5.0% May-12

Compliance Percentage in Patients Receiving Important Message from Medicare

Accountability PMR PMR PMR PMR

Baseline 15.2% 13.8%

Goal 10.0% 0.0%

May-12 14.7% 13.1% 429

87.5% 15.6% 27.0%

100.0% 10.0% 0.0%

93.6% 16.1% 27.4% 1265

61.1% 13.8% 25.4%

100.0% 10.0% 0.0%

66.7% 7.8% 12.1% 91

Labor productivity (percentage of targeted appointments per FTE) - ST

Number of Days to 3rd Next Available Appointment - Mammography

30 4 May-12 Jun-12 Jul-12 Aug-12 9 Sep-12 Oct-12

Patient Safety & Quality -

Audit/Measures Percentage of contracts (outsourced vendors) reviewed for quality measures

Accountability Contract Svcs Comments

1.09 - Parkland to revisit strategy on continuum of care

Y Y Y Y Y Y Y Y Y Y Y Y Y May-12 Jun-12 Jul-12 Aug-12 46% Sep-12 72% Oct-12 99%

0.4% 33.9% 65.7%

Accountability HR HR HR HR HR Clinical Ed HR House-Wide HR

Baseline 16.5% 15.0%

Goal 14.5% 14.1% 20.0%

May-12 19.0% 16.8% 19.8% 26.7%

Jun-12 24.9% 17.5% 19.1% 36.8%

Jul-12 9.7% 9.2% 18.4% 31.3%

Aug-12 21.5% 15.2% 13.6% 36.7% 69.0%

Sep-12 12.8% 10.6% 6.3% 50.0%

Oct-12 9.5% 9.5% 9.8% 44.7%

100% 40 N/A 100% 100% 59.9 55.0

71% 29 0.9% 98.8% 66.3

75% 54 1.1% 98.8% 62.9

60% 73 1.2% 88.0% 87.2

87% 87 1.3% 96.2% 80.5

93% 74 1.3% 100.0% 99.2% 72.3

100% 95 0.96% 100.0% 99.5% 68.4

Percentage of current certifications

Time for recruiting to fill an open external job position

3.04 3.05 3.06 3.07

3.6 3.1 3.5 3.4

7/13/2012 7/13/2012 10/30/2012 6/12/2012

3.08 3.09 3.10 3.11 3.12 3.13 3.14

3.4 3.6 1.7 1.7 1.7 3.3 3.3

10/15/2012 5/11/2012 7/13/2012 7/13/2012 7/13/2012 7/1/2012 8/1/2012 Y Y Y Y

Work Stream 2.6

Target Date 6/15/2012

# 1a 1b 1c 2 3 # 4 5 6 7 8a 8b 8c 9 10 11 12 13a 13b 14 15 16 17 Capacity - Family Medicine

Baseline 86.0% 90.0% 96.0%