board quality review committee meeting
TRANSCRIPT
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Board Quality Review Committee Meeting
OPEN SESSION ATTENDANCE ROSTER & MEETING MINUTES CALENDAR YEAR 2016
Voting Members
Palomar Health By-Laws’
Membership
Meeting Dates:
1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 Annl Rpt
10/17/16 11/21/16 12/19/16 CANCELLED
DIRECTOR AERON WICKES , MD – CHAIR Board Member P P P P P E P P
DIRECTOR LINDA GREER, RN Board Member P P P P P P P P
DIRECTOR DARA CZERWONKA Board Member P P P E P P P E
DIRECTOR HANS SISON (ALT) Board Member P -- -- -- -- -- -- --
FRANK MARTIN, MD QMC Chair, Palomar Medical Ctr
P P -- P -- -- -- --
RICHARD ENGEL, MD Interim QMC Chair, Palomar Medical Ctr
-- -- P P P P -- --
CHARLES CALLERY, MD QMC Chair, Pomerado Hospital
P P P P P P P P
Non-Voting Members BEIRNE, FRANK EVP, Operations P P P P P P E P
BROWN, SHEILA, RN, FACHE VP, Continuum Care -- -- P P P P P P
CONRAD, ALAN, MD EVP,Physician Alignment P P P -- -- P P P
GOWER, JUNE, PH.D. Interim CNO, PHDC & Pomerado Hospitals
-- -- -- -- -- --
HEMKER, BOB President & CEO P P P E P E E P
KOLINS, JERRY, MD, FACHE VP, Patient Experience and Co-Chair, Patient
Safety Committee P P P P P P P P
LABOSSIERE, LARRY CNO, Pomerado Hospital -- -- -- -- P P P P
MARTINEZ, VALERIE, RN, BSN, MHA, CIC Co-Chair, Patient Safety Committee
P P P P P P P P
OLSON, CHERYL Interim VP, PHDC & Pomerado Hospitals
P P P P -- -- -- --
SHAW, DELLA EVP, Strategy P P P P -- --
SKINNER, JEANNETTE VP, Pomerado Hospital -- -- -- -- -- -- -- P
SUDAK, MARIA, MSN, CCRN, NEA-BC, RN CNO & VP, Palomar Medical Center
P P P P P P P P
Guests ADELMAN, MARCY, RN P
ANDREWS, SHELLY, RN P
BANDICK, BRET P
BARNES, DEBBIE, RN, CDS
FARROW, DAN P
GOELITZ, BRIAN, MD P
GRIFFITH, JEFF (BOARD MEMBER) P
HANSEN, DIANE P P
KAUFMAN, JERRY (BOARD MEMBER)
KIM, JESSICA P P P P
LEE, DAVID, MD P P P P P P E P
LEE, JEREMY P P
Page 2 of 2
Meeting Dates:
1/18/16 2/22/16 3/21/16 4/18/16 5/16/16 6/20/16 7/18/16 8/15/16 9/19/16 10/17/16 11/21/16 12/19/16
Guests (continued) MCCUNE, RAY (BOARD MEMBER) P
NAMENYI, JASMINA P
NEUSTEIN, PAUL, MD P
NICPON, GREGORY, MD P
PHILLIPS, DONITA, MBA, ARM P P P P P P P P
POPE, TINA P P P P P P P P
RIEHL, RUSSELL P
ROLIN, DONNA P
ROSENBURG, JEFFREY P E E E E
SCHULTZ, DIANA P
SOLOMON, LESLIE P
TERRELL, CEDRIC P P
TURNER, BRENDA P P P
WATSON, RAE ANNE P P
WIESE, LISHA P
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 1 of 5
Patient Experience Division ACRONYM GLOSSARY
Updated: 09/20/2016
AAPL: Academy of Applied Physician Leadership AAR: After Action Report ABX: Antibiotics ACE: Acute Care for Elderly ACEI: Angiotension Converting Enzyme Inhibitor ACNS-BC: Adult Health Clinical Nurse Specialist-Board Certified ACR: American College of Radiology AHP: Arch Health Partners AHRQ: Agency for Healthcare, Research and Quality ALICE: Alert Lockdown Inform Counter Evacuate AMI: Acute Myocardial Infarction APRN: Advanced Practice Registered Nurse ARB: Angiotension Receptor Blocker ARU: Acute Rehab Unit ATS: Automatic Transfer Switch BCACP: Board Certified Ambulatory Care Pharmacist BETA: BETA Healthcare Group (PH Insurer) BQRC: Board Quality Review Committee BSC: Balanced Score Card BSN: Bachelor of Science in Nursing BSIS: Bureau of Security and Investigative Services CALNOC: Collaborative Alliance for Nursing Outcomes CAP: Child Abuse Program CAP: College of American Pathologists CAP: Community-Acquired Pneumonia CAPG: The Voice of Accountable Physician Groups CARF: Commission on Accreditation of Rehabilitation Facilities CAUTI: Catheter Associated Urinary Tract Infection CC: Complications and Comorbidities CCTP: Community-Based Care Transitions Program CDAD: Clostridium Difficile Associated Diarrhea CDC: Center for Disease Control CDE: Certified Diabetes Educator CDI: Clinical Documentation Improvement CDI: C. Difficile Infections C-diff: Clostridium difficile CDPH: California Department of Public Health CEP: California Emergency Physicians CHA: California Hospital Association CHF: Congestive Heart Failure CIHQ: Center for the Improvement in Healthcare Quality CLABSI: Central Line Blood Stream Infection CLIP: Central Line Insertion Practices CMMI: Center for Medicare and Medicaid Innovation
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 2 of 5
Patient Experience Division ACRONYM GLOSSARY
Updated: 09/20/2016
CMS: Centers for Medicare & Medicaid Services COP: Conditions of Participation COPD: Chronic Obstructive Pulmonary Disease CPE: Certified Physician Executive (American College of Physician Executives) CPHQ: Certified Professional in Healthcare Quality CPOE: Computerized Physician (Provider) Order Entry CRE: Carbapenem-resistant Enterobacteriaceae CRM: Clinical Resource Management CSHE: California Society Healthcare Engineers CVICU: Cardio Vascular Intensive Care Unit CY: Calendar Year DI: Diagnostic Imaging DM: Diabetes Mellitus DPT: Doctor of Physician Therapy DRT: Diabetes Resource Team DVT: Deep Vein Thrombosis EBP: Evidence Based Practice ED: Emergency Department EHR: Electronic Health Record ELNEC: End of Life Nursing Education Consortium EMS: Emergency Medical Services EMT: Emergency Medical Technician EMT: Executive Management Team EOC: Environment of Care EOP: Emergency Operations Plan EVS: Environment of Care Services / Environmental Services FACHE: Fellow American College of Healthcare Executives FACPM: Fellow of the American College of Preventive Medicine FANS: Food and Nutrition Services FHS: Forensic Health Services FMEA: Failure Mode Effects Analysis FY: Fiscal Year HAC: Hospital Acquired Conditions HAI: Healthcare Associated Infections HAPU: Hospital Acquired Pressure Ulcers HASFZ: Heart Attack and Stroke Free Zone HbA1c: Hemoglobin A1C HCAHPS: Hospital Consumer Assessment of Healthcare Providers & Systems HCC: Hospital Command Center HCP: Health Care Provider HDL: High Density Lipoprotein Cholesterol HDS: Healthy Development Services HHSA: Health and Human Services Agency HICS: Hospital Incident Command System
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 3 of 5
Patient Experience Division ACRONYM GLOSSARY
Updated: 09/20/2016
HLD: High Level Disinfectant HF: Heart Failure HIPAA: Health Insurance Portability and Accountability Act HPP: Hospital Preparedness Program HPRO: Hip Replacement Surgery HRRP: Hospital Readmission Reduction Program HVA: Hazard Vulnerability Analysis IC: Infection Control ICU: Intensive Care Unit IHA: Integrated Healthcare Association IHI: Institute for Healthcare Improvement ILSM: Interim Life Safety Measures IMI: Inpatient Mortality Indicator IMM-2: Influenza Immunization IOM: Institute of Medicine IP: Infection Prevention (RN Staff) IPCC: Infection Prevention and Control Committee ISBARR: Introduction, Situation, Background, Assessment, Recommendations, Read back KP: Kaiser Permanente KPRO: Knee Replacement Surgery LSC: Life Safety Conditions MAB: Management of Assaultive (or Aggressive) Behavior MAC: Medicare Administrative Contractor MCC: Major Complications and Comorbidities MCI: Mass Casualty Incident MDRO: Multi Drug Resistant Organism MERP: Medication Error Reduction Plan MHA: Masters of Healthcare Administration MOM: Master of Arts in Organizational Management MPH: Master of Public Health MRI: Magnetic Resonance Imaging MRSA: Methicillin-resistant Staphylococcus aureus MSN: Master of Science in Nursing MSPRC: Medical Staff Peer Review Committee MY: Measurement Year NACo: National Association of Counties NDNQI: National Database of Nursing Quality Indicators NEA-BC: Nurse Executive Advanced-Board Certified NHQM or NIHQM: National Improvement for Healthcare Quality Measure NHSN: National Healthcare Safety Network NICHE: Nurses Improving the Care for Hospital System Elders NIMS: National Incident Management System NPSF: National Patient Safety Foundation NPSG: National Patient Safety Goals
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 4 of 5
Patient Experience Division ACRONYM GLOSSARY
Updated: 09/20/2016
NQF: National Quality Forum OB: Obstetrics OES: Office of Emergency Services OPPE: Ongoing Professional Practice Evaluation OSHA: Occupational Safety and Health Administration OSHPD: Office of Statewide Health Planning and Development PASS: Pull Aim Squeeze Sweep PCCN: Progressive Care Credentialed Nursing PCEA: Patient Controlled Epidural Analgesia PCM: Perinatal Care Measure PDCA: Plan Do Check Act PH: Palomar Health PharmD: Doctor of Pharmacology PI: Performance Improvement PM: Preventative Maintenance PMC: Palomar Medical Center PN: Pneumonia POCT: Point of Care Testing PPE: Personal Protective Equipment PPFR: Physician Performance Feedback Report PRIME: Public Hospital Redesign and Incentives in Medi-Cal PSI: Patient Safety Indicator PSR: Patient Service Representative QAPI: Quality Assurance Performance Improvement QIO: Quality Improvement Organization QRR: Quality Review Report RAC: Revenue Cycle Audits RACE: Rescue Alert Confine Extinguish RCA: Root Cause Analysis RN-BC: Registered Nurse-Board Certified RT: Respiratory Therapist RHIT: Registered Health Information Technician RVT: Registered Vascular Tech SART: Sexual Assault Response Team SCIP: Surgical Care Improvement Project SDHDC: San Diego Healthcare Disaster Coalition SDS: Safety Data Sheet SHP: Strategic Healthcare Program SIR: Standardized Infection Ratio SIRS: Systemic Inflammatory Response Syndrome SIT: Security Integration Team SMILE: Share yourself, Make it clear, Inform on timing, Listen with care, End with Kindness
SNF: Skilled Nursing Facility SNS: Strategic National Stockpile
To add to this list, please contact Christine Breese at 760-740-6353 or [email protected] Page 5 of 5
Patient Experience Division ACRONYM GLOSSARY
Updated: 09/20/2016
SOC: Statement of Conditions SSI: Surgical Site Infection STK: Stroke TAT: Turn Around Time THA: Total Hip Arthroplasty TICU: Trauma Intensive Care Unit TJC or JC: The Joint Commission TKA: Total Knee Arthroplasty TRAIN: Triage Resource Allocation for In-patients UDI: Unique Device Identification UST: Underground Storage Testing US: Ultra Sound VAE: Ventilator Associated Event VAP: Ventilator Associated Pneumonia VBAC: Vaginal Birth After Caesarian Section VBP: Value Based Purchasing VRE: Vancomycin-resistant enterococcus VTE: Venous Thrombo-embolism WHO: World Health Organization
BOARD QUALITY REVIEW COMMITTEE
MONDAY, AUGUST 15, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:30 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064
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OPEN SESSION AGENDA
PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING Time Form A
Page # Target
CALL TO ORDER 6:30
Establishment of Quorum 1 N/A 6:31
Public Comments1 15 N/A 6:46
Information Item(s)
1. *Review/Approve: Minutes – Monday, June 20, 2016 (Addendum A, Page 8 -17) 4 3 6:50
Standing Item(s)
1. Journal Club Article (Addendum B, Page 18 - 20) “Workplace Violence in Health Care - A Critical Issue With a Promising Solution” in Journal of the American Medical Association, written by Ron Wyatt, MD, MHA, DMS (HON), Kim Anderson-Drevs, PhD, RN and Lynn M. Male, PhD
10 4 7:00
2. The Patient Experience (Addendum C, Page 21 - 39) Tina Pope, Manager, Service Excellence
a) Letters from Patients/Families b) Service Excellence Quarterly Reports
15 5 7:15
3. Quality and Safety Dashboards (Addendum D, Page 40 - 48) a) CMS Star Ratings Report, Jerry Kolins, MD, Vice President, Patient Experience b) CMS Healthcare Associated Infections Report, David Lee, MD, Medical Quality Officer c) CMS HAC (Hospital Acquired Conditions) Report, Valerie Martinez, RN, BSN, MHA,
CPHQ, CIC, NEA-BC, Director, Quality, Patient Safety & Infection Control
15 6 7:30
New Business
1. Arch Health Annual Report Update (Addendum E, Pages 49 - 65) GB “Robin” Rowland, MD, MPH, FACPM Deanna Kyrimis, Executive Director, Arch Health Partners Jessica Gharbawy, PharmD
20 7 7:50
Public Comments1 15 N/A 8:05
FINAL ADJOURNMENT 8:05
NOTE: The open session agenda, without public comments, is scheduled for 1 hour, 5 minutes. Based on above agenda, without public comments the meeting starts at 6:30 p.m. and adjourns at 7:35 p.m.
BOARD QUALITY REVIEW COMMITTEE
MONDAY, AUGUST 15, 2016 POMERADO HOSPITAL 5:30 p.m. Dinner at Café for Committee members & invited guests CONFERENCE ROOM E 6:30 p.m. Meeting 15615 POMERADO ROAD, POWAY, CA 92064
Page 2
OPEN SESSION AGENDA
NOTE: If you have a disability, please notify us by calling 760-740-6353, 72 hours prior to the event so that we may provide reasonable accommodations
Asterisks indicate anticipated action. Action is not limited to those designated items. 1
5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in meeting room.
Board Quality Review Committee Members
VOTING MEMBERSHIP NON-VOTING MEMBERSHIP
Aeron Wickes, MD – Chairperson, Board Member Bob Hemker, FACHE, President & CEO
Linda Greer, RN, Board Member Frank Beirne, FACHE, EVP, Operations
Dara Czerwonka, Board Member Alan Conrad, MD, EVP, Physician Alignment
Richard Engel, MD – Interim Chair of Medical Staff Quality
Management Committee for Palomar Medical Center
Charles Callery, MD - Chair of Medical Staff Quality
Management Committee for Pomerado Hospital
Della Shaw – EVP, Strategy
Maria Sudak, RN, MSN, CCRN, NEA-BC – Vice President and Chief Nursing Officer, Palomar Medical Center
Jeannette Skinner, RN, MBA, FACHE, Vice President, Pomerado Hospital
Larry LaBossiere, RN, MSN, CEN, CNS, MBA, Interim Chief Nursing Officer, Pomerado Hospital and Director, Clinical Operations Improvement
Sheila Brown, FACHE, VP, Continuum Care
Jerry Kolins, MD, FACHE – VP, Patient Experience and Co-Chair of Patient Safety Committee
Valerie Martinez, RN, BSN, MHA, CPHQ, CIC, NEA-BC, Co-Chair of Patient Safety Committee and Director, Quality, Patient Safety & Infection Control
Copyright 2016 American Medical Association. All rights reserved.
Workplace Violence in Health CareA Critical Issue With a Promising Solution
Workplace safety is a critical issue in health care. TheNational Institute for Occupational Safety and Health de-fines workplace violence as “violent acts (including physi-cal assaults and threats of assaults) directed towards per-sons at work or on duty.”1 This Viewpoint discusses thescope and characteristics of workplace violence in healthcare settings, relevant government regulations, the re-sponsibility of health care leaders in addressing work-place violence, a model program for violence preven-tion in health care settings, and a comprehensiveenvironmental risk analysis.
Extent and Characteristics of Workplace Violencein Health CareApproximately 24 000 workplace assaults occurred inhealth care settings between 2010 and 2013, resultingin major and minor physical injury, psychological harm,temporary or permanent physical disability, anddeath.2 The Joint Commission analyzed 33 homicides,
38 assaults, and 74 rapes in health care workplaces from2013 to 2015. Health care workers identified in theseevents included 10 nurses, 2 physicians, 3 security em-ployees, and 7 other health care workers.3 These senti-nel events resulted in death, permanent harm, or se-vere temporary harm. The most common root causes ofthese events were failures in communication, inad-equate patient observation, lack of or noncompliancewith policies addressing workplace violence preven-tion, and lack of or inadequate behavioral health assess-ment to identify aggressive tendencies in patients.3 Com-prehensive behavioral health assessments may be ableto identify biopsychosocial factors known to increase therisk of violent behavior.
In US hospitals, there has been an increase in vio-lent crime, from 2.0 events per 100 beds in 2012 to 2.8events per 100 beds in 2015.3 A disproportionate num-ber of aggravated assaults (44%) and other assaults(46%) occurred in emergency departments comparedwith the entire hospital.4 Bureau of Labor statistics datadocument that while less than 20% of workplace inju-ries involve health care workers, 50% of workplace-related assaults involve health care workers. In 2013, 27of 100 health care worker or patient fatalities in healthcare settings were attributable to assaults and violence.2
Workplace violence in health care includes verbal,sexual, and physical assaults; threats; stalking; inti-
mate partner violence; and homicide. In addition toemergency departments, workplace violence mostfrequently occurs in behavioral health settings,extended-care facilities, and inpatient units.6 Femalenursing staff and psychiatric assistants most fre-quently experience assaults.5 Approximately 60% ofreported threats and assaults occur between noonand midnight.5
Government Regulations Addressing Health CareWorkplace ViolenceThe Occupational Safety and Health Act of 1970, 26states, and 2 US territories now require elements of com-prehensive health care violence prevention programs.A 2016 Government Accountability Office reportmade recommendations for how violence prevention inhealth care settings is addressed in the United States.7
The office recommended that the Occupational Safetyand Health Administration develop, implement, and en-
force standards addressing the uniqueattributes of violence prevention inhealth care workplaces, including penal-izing employers for exposing employ-ees to potential workplace violence.A specific example is exposing employ-ees to the hazard of violent behavior
and being physically assaulted by patients withknown histories of violence or the identified potentialfor violence.
Leadership ResponsibilityLeadership commitment is manifested by establishinga violence prevention program, encouraging reportingof violent and behavioral safety events, reassuring em-ployees that appropriate actions will be taken, engag-ing personnel and patients in safety plans, and measur-ing performance of violence prevention programs.
Although zero-tolerance policies for workplace vio-lence have been suggested, such language may createbarriers to program success by inhibiting reporting ofsafety issues and concerns. Rather, leaders have a dutyto their employees to institute programs and ensure ad-herence to policies requiring all reported events be takenseriously, assessed appropriately, and managed indi-vidually and ethically.
Health Care Violence Prevention Program:Model and ProcessWorkplace violence prevention should be part of new-employee training and ongoing training of existingemployees. Programs aimed at prevention of work-place violence should include employee training andawareness, reporting, threat assessment, management
Workplace violence preventionshould be addressed aggressivelyand comprehensively in health care.
VIEWPOINT
Ron Wyatt, MD, MHA,DMS (HON)Office of Qualityand Patient Safety,The Joint Commission,Oakbrook Terrace,Illinois.
Kim Anderson-Drevs,PhD, RNOffice of Qualityand Patient Safety,The Joint Commission,Oakbrook Terrace,Illinois.
Lynn M. Van Male, PhDWorkplace ViolencePrevention Program,Veterans HealthAdministration, OregonHealth and ScienceUniversity, Portland.
CorrespondingAuthor: Ron Wyatt,MD, MHA, DMS (HON),Office of Qualityand Patient Safety,The Joint Commission,One Renaissance Blvd,Oakbrook Terrace, IL60181 ([email protected]).
Opinion
jama.com (Reprinted) JAMA Published online July 18, 2016 E1
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Palomar Health User on 07/18/2016
Attachment #1
Copyright 2016 American Medical Association. All rights reserved.
plans, and a communication strategy. All employees should havetraining relevant to the risk for violence that may exist in theirrespective workplaces.
Reporting is an essential element of a successful workplace vio-lence prevention program. Without efficient and fully utilized eventreporting systems, employees have a limited ability to communi-cate their safety and risk issues to leadership. Reporting helps lead-ership develop relevant violence prevention programs. However, per-sonnel underreport violent events because they believe theseexperiences are part of the job, reporting is either cumbersome orunlikely to result in action from leadership, or they fear retaliationfor reporting.6 For these reasons, reporting systems should besimple, trusted, secure, and with optional anonymity; result in trans-parent outcomes and delivery of a report confirmation; and be fullysupported by leadership, labor unions, and management.
Every report of alleged workplace violence should be assessedand managed individually, using evidence-based, data-driven as-sessment of violence risk and management best practices, and in-volve a multidisciplinary team trained in the fundamentals of vio-lence risk and threat management. Multidisciplinary threatassessment teams usually operate under the authority of a facili-ty’s chief medical officer and are chaired by senior clinicians trainedin threat assessment practice (most commonly, behavioral scienceprofessionals). Team members should include representatives fromthe behavioral sciences, security/law enforcement, labor union(s),known high-risk workplaces, employee education (eg, trainers), pa-tient advocates, and legal counsel.
If the reported behavior is determined by the multidisciplinarythreat assessment team to pose an ongoing safety or security risk,then a treatment and safety management plan should be devel-oped and implemented to reduce the likelihood of safety risk expo-sure. Such plans augment relevant protective factors and reduceidentified risk factors. Management plans may include noninvasiveinterventions (eg, conversation with the individual or individuals;written letters expressing behavioral expectations) to more restric-tive approaches (eg, limiting the time, place, or manner in which safeand effective health care may be delivered). The safety manage-ment plan should not permanently bar an individual from care.
Informing employees of the management plan should enablethe ongoing cycle of effective violence prevention programming: em-ployees are educated and trained regarding the management planand have the skills necessary to implement it; they report the out-come of implementing the plan; information regarding the manage-ment plan’s effectiveness is assessed (or reassessed) and modifiedaccording to risk; and such modifications are then communicatedback to employees.
Environmental Analysis and InterventionsOrganizations should assess risk factors for violence in the internalenvironment and the surrounding community. Internal environ-mental assessment focuses on dynamic factors (eg, staffing levels,census, weather, and traffic) and static factors (eg, floor plans, alarms,surveillance equipment, entry points, and reception areas). The sur-rounding community should be assessed by examining the type andseverity of crime and violence, including the frequency with whichthe health care organization provides care for victims of violence.Physical security measures should align with known risks of com-munity-based violence migrating into the health care setting. Re-current comprehensive environmental risk analysis identifies emerg-ing vulnerabilities, allowing for relevant employee training, proactivemodification of existing processes, and the development of new riskmanagement measures.
ConclusionsWorkplace violence prevention should be addressed aggressivelyand comprehensively in health care. Safety in health care work-places relies on leadership enacting appropriate policies; trainedemployees intervening and reporting; multidisciplinary teams usingevidence-based threat assessment and management practices,communicating safety plans, and analyzing the environmental con-text; and ongoing evaluation of program effectiveness. A work-place violence prevention program should be a required compo-nent of the patient safety system of all health care organizations.Comprehensive patient safety systems can effectively manage abroad range of worker safety risks in health care, including work-place violence.
ARTICLE INFORMATION
Published Online: July 18, 2016.doi:10.1001/jama.2016.10384.
Conflict of Interest Disclosures: All authors havecompleted and submitted the ICMJE Form forDisclosure of Potential Conflicts of Interest andnone were reported.
REFERENCES
1. Centers for Disease Control and Prevention(CDC)/National Institute for Occupational Safetyand Health. Violence: Occupational Hazards inHospitals. CDC website. http://www.cdc.gov/niosh/docs/2002-101/. 2002. Accessed July 6, 2016.
2. Occupational Safety and Health Administration(OSHA). Guidelines for Preventing Workplace
Violence for Healthcare and Social ServicesWorkers. OSHA 3148-04R 2015. OSHA website.https://www.osha.gov/Publications/osha3148.pdf.2015. Accessed June 20, 2016.
3. The Joint Commission. Sentinel Event Data.Oakbrook Terrace, IL: The Joint Commission; 2016.
4. International Association of Healthcare Safetyand Security Foundation. 2016 Healthcare CrimeSurvey. http://c.ymcdn.com/sites/www.iahss.org/resource/collection/48907176-3B11-4B24-A7C0-FF756143C7DE/2016CrimeSurvey.pdf.Accessed June 15, 2016.
5. Pompeii L, Dement J, Schoenfisch A, et al.Perpetrator, worker and workplace characteristicsassociated with patient and visitor perpetrated
violence (type II) on hospital workers: a review ofthe literature and existing occupational injury data.J Safety Res. 2013;44:57-64.
6. Speroni KG, Fitch T, Dawson E, Dugan L,Atherton M. Incidence and cost of nurse workplaceviolence perpetrated by hospital patients or patientvisitors. J Emerg Nurs. 2014;40(3):218-228.
7. US General Accountability Office (GAO).Workplace Safety and Health: Additional EffortsNeeded to Help Protect Healthcare Workers FromWorkplace Violence (GAO-16-11). http://www.gao.gov/assets/680/675858.pdf. 2016. AccessedMarch 18, 2016.
Opinion Viewpoint
E2 JAMA Published online July 18, 2016 (Reprinted) jama.com
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Palomar Health User on 07/18/2016
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Do
cto
rs
Pat
ien
ts D
isch
arge
d B
etw
ee
n O
cto
be
r 2
01
4 a
nd
Se
pte
mb
er
20
15
*R
esu
lts
Up
dat
ed J
uly
27
, 20
16
Top
Bo
x P
erc
en
tage
Star
Rat
ing
CA
Ave
rage
NA
TL A
vera
ge
Attachment #3
*
Nex
t U
pd
ate
Oct
ob
er 2
01
6
Dis
pla
yed
by
Dis
cha
rged
Da
te
82%
82%
80%
79%
78%
77%
76%
76%
76%
75%
4
4
4
3
3
3
3
3
3
3
75
%
75
%
80
%
80
%
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
Scri
pp
sG
reen
Ho
spit
al
Shar
pM
em
ori
alH
osp
ital
Scri
pp
sM
em
ori
alH
osp
ital
-La
Jo
lla
UC
SDM
ed
ical
Ce
nte
r
Po
me
rad
oH
osp
ital
Pal
om
arM
ed
ical
Ce
nte
r/P
HD
C
Kai
ser
Fou
nd
atio
nH
osp
ital
-Sa
n D
iego
Scri
pp
sM
em
ori
alH
osp
ital
-En
cin
itas
Scri
pp
sM
erc
yH
osp
ital
Tri-
Cit
yM
ed
ical
Ce
nte
r
Top Box Percentage/Number of Stars
Faci
lity
HC
AH
PS
Co
mm
un
ica
tio
n w
ith
Nu
rses
P
atie
nts
Dis
char
ged
Bet
we
en
Oct
ob
er
20
14
an
d S
ep
tem
be
r 2
01
5
*Res
ult
s U
pd
ated
Ju
ly 2
7, 2
01
6
Top
Bo
x P
erc
en
tage
Star
Rat
ing
CA
Ave
rage
NA
TL A
vera
ge
Attachment #3
Dis
pla
yed
by
Rec
eive
d D
ate
82
%
81
%
82
%
80
%
82
%
84
%
81
%
78
%
89
8
7
91
8
4
88
9
2
85
76
0
10
20
30
40
50
60
70
80
90
10
0
7/1
/14
-9
/30
/14
n=7
74
10
/1/1
4-1
2/3
1/1
4n
=79
9
1/1
/15
-3
/31
/15
n=8
36
4/1
/15
-6
/30
/15
n=8
02
7/1
/15
-9
/30
/15
n=8
42
10
/1/1
5-
12
/31
/15
n=7
44
1/1
/16
-3
/31
/16
n=9
16
4/1
/16
-6
/30
/16
n=8
77
Top Box Percentage/Percentile Ranking
Qu
arte
r
Ove
rall
Qu
arte
rly
Inp
atie
nt
HC
AH
PS
Top
Bo
x P
erc
en
tage
&
Nat
ion
al P
erc
en
tile
Ran
kin
g Tr
en
d -
Rat
e H
osp
ital
0-1
0:
Pa
lom
ar
Med
ica
l Cen
ter
HC
AH
PS
Top
Bo
x P
erce
nta
geN
atio
nal
Pe
rce
nti
le R
anki
ng
Attachment #3
Dis
pla
yed
by
Rec
eive
d D
ate
62
%
64
%
68
%
73
%
66
%
70
%
70
%
67
%
17
1
9
35
56
25
39
3
8
26
0
10
20
30
40
50
60
70
80
90
10
0
7/1
/14
-9
/30
/14
n=2
96
10
/1/1
4-1
2/3
1/1
4n
=22
4
1/1
/15
-3
/31
/15
n=2
90
4/1
/15
-6
/30
/15
n=2
90
7/1
/15
-9
/30
/15
n=2
83
10
/1/1
5-
12
/31
/15
n=2
50
1/1
/16
-3
/31
/16
n=3
17
4/1
/16
-6
/30
/16
n=2
77
Top Box Percentage/Percentile Ranking
Qu
arte
r
Ove
rall
Qu
arte
rly
Inp
atie
nt
HC
AH
PS
Top
Bo
x P
erc
en
tage
&
Nat
ion
al P
erc
en
tile
Ran
kin
g Tr
en
d -
Rat
e H
osp
ital
0-1
0:
Po
mer
ad
o H
osp
ita
l
HC
AH
PS
Top
Bo
x P
erce
nta
geN
atio
nal
Pe
rce
nti
le R
anki
ng
Attachment #3
18
54
4
78
51
4148
2626
23
7083
9090
0102030405060708090100
110
7/1/15
‐7/31/15
n=69
8/1/15
‐8/31/15
n=49
9/1/15
‐9/30/15
n=48
10/1/15‐
10/31/15
n=72
11/1/15‐
11/30/15
n=60
12/1/15‐
12/31/15
n=68
1/1/16
‐1/31/16
n=55
2/1/16
‐2/29/16
n=55
3/1/16
‐3/31/16
n=63
4/1/16
‐4/30/16
n=39
5/1/16
‐5/31/16
n=49
6/1/16
‐6/30/16
n=24
Percentile Ranking
Mon
th
POM M
ED/SURG
/TELE ‐C
ommun
ication with
Doctors
HCA
HPS
Actua
l Percentile
Ran
king
& FY2
016 Target Percentile
Ran
king
*Official M
onthly Results by Discharge Date
Actual Percentile
Ran
king
Target Percentile
Ran
king
Attachment #3
31
169
1924
55
41
19
33
5765
61
9090
0102030405060708090100
110
7/1/15
‐7/31/15
n=68
8/1/15
‐8/31/15
n=49
9/1/15
‐9/30/15
n=45
10/1/15‐
10/31/15
n=71
11/1/15‐
11/30/15
n=60
12/1/15‐
12/31/15
n=68
1/1/16
‐1/31/16
n=55
2/1/16
‐2/29/16
n=54
3/1/16
‐3/31/16
n=63
4/1/16
‐4/30/16
n=38
5/1/16
‐5/31/16
n=49
6/1/16
‐6/30/16
n=24
Percentile Ranking
Mon
th
POM M
ED/SURG
/TELE ‐R
ate Hospital 0
‐10
HCA
HPS
Actua
l Percentile
Ran
king
& FY2
016 Target Percentile
Ran
king
*Official M
onthly Results by Discharge Date
Actual Percentile
Ran
king
Target Percentile
Ran
king
Attachment #3
5
26
1
80
15
57
30
317
51
87
9690
90
0102030405060708090100
110
7/1/15
‐7/31/15
n=69
8/1/15
‐8/31/15
n=49
9/1/15
‐9/30/15
n=48
10/1/15‐
10/31/15
n=72
11/1/15‐
11/30/15
n=60
12/1/15‐
12/31/15
n=68
1/1/16
‐1/31/16
n=55
2/1/16
‐2/29/16
n=55
3/1/16
‐3/31/16
n=63
4/1/16
‐4/30/16
n=39
5/1/16
‐5/31/16
n=49
6/1/16
‐6/30/16
n=24
Percentile Ranking
Mon
th
POM M
ED/SURG
/TELE ‐C
ommun
ication with
Nurses
HCA
HPS
Actua
l Percentile
Ran
king
& FY2
016 Target Percentile
Ran
king
*Official M
onthly Results by Discharge Date
Actual Percentile
Ran
king
Target Percentile
Ran
king
Attachment #3
58
.5%
C
om
plim
en
ts
41
.5%
C
om
pla
ints
/Gri
eva
nce
s
Tota
l Nu
mb
er
of
Co
mm
un
icat
ion
s to
Pal
om
ar H
eal
th f
rom
89
Pat
ien
ts
(Ju
ne
20
16
)
Co
mp
limen
ts -
58
.5%
(n
=55
)
Co
mp
lain
ts/G
riev
ance
s -
41.5
% (
n=3
9)
Attachment #3
35
.9%
La
ck o
f C
om
pas
sio
n/R
esp
ect
12
.8%
C
are
no
t Ti
me
ly
12
.8%
D
on
't w
ant
to P
ay
12
.8%
M
isd
iagn
osi
s/In
accu
rate
D
ocu
me
nta
tio
n/M
ed
icat
ion
s
10
.3%
D
isch
arge
d t
oo
So
on
7.7
%
Co
mp
licat
ion
7.7
%
Faci
lity
0.0
%
Lost
/Bro
ken
Ite
m
Typ
es
of
Co
mp
lain
ts/G
riev
ance
s to
Pal
om
ar H
eal
th f
rom
39
Pat
ien
ts
(Ju
ne
20
16
)
Lack
of
Co
mp
assi
on
/Res
pec
t -
35.9
%(n
=14
)
Car
e n
ot
Tim
ely
- 1
2.8
% (
n=5
)
Do
n't
Wan
t to
Pay
- 1
2.8
% (
n=5
)
Mis
dia
gno
sis/
Inac
cura
teD
ocu
men
tati
on
/Med
icat
ion
s -
12.8
% (
n=5
)
Dis
char
ged
to
o S
oo
n -
10
.3%
(n
=4)
Co
mp
licat
ion
- 7
.7%
(n
=3)
Faci
lity
- 7.
7%
(n
=3)
Lost
/Bro
ken
Ite
m -
0.0
% (
n=0
)
Attachment #3
30
.9%
P
MC
Lab
20
.0%
P
MC
7 E
ast
12
.7%
P
MC
ED
5.5
%
PM
C 5
Eas
t
3.6
%
PM
C 4
Eas
t
3.6
%
PM
C 7
We
st
3.6
%
PM
C
Surg
ery
3.6
%
PO
M IC
U
3.6
%
PO
M M
/S/T
(3
rd
Flo
or)
1.8
%
PM
C 4
NW
1.8
%
PM
C 6
We
st
1.8
%
PM
C 8
Ea
st
1.8
%
PM
C 9
Eas
t 1
.8%
P
OM
Im
agin
g
1.8
%
PO
P W
ou
nd
Car
e
1.8
%
SMA
CC
Wo
un
d C
are
Tota
l Nu
mb
er
of
Co
mp
lime
nts
by
Un
it t
o P
alo
mar
He
alth
fro
m 5
5 P
atie
nts
(J
un
e 2
01
6)
PM
C L
ab -
30
.9%
(n
=17
)
PM
C 7
Eas
t -
20
.0%
(n
=11
)
PM
C E
D -
12
.7%
(n
=7)
PM
C 5
Eas
t -
5.5
% (
n=3
)
PM
C 4
Eas
t -
3.6
% (
n=2
)
PM
C 7
We
st -
3.6
% (
n=2
)
PM
C S
urg
ery
- 3
.6%
(n
=2)
PO
M IC
U -
3.6
% (
n=2
)
PO
M M
ed/S
urg
/Tel
e (3
rd F
loo
r) -
3.6
% (
n=2
)
PM
C 4
NW
- 1
.8%
(n
=1)
PM
C 6
We
st -
1.8
% (
n=1
)
PM
C 8
Eas
t -
1.8
% (
n=1
)
PM
C 9
Eas
t -
1.8
% (
n=1
)
PO
M Im
agin
g -
1.8
% (
n=1
)
PO
P W
ou
nd
Car
e -
1.8
% (
n=1
)
SMA
CC
Wo
un
d C
are
- 1
.8%
(n
=1)
Attachment #3
35
.9%
P
MC
ED
23
.1%
P
OM
ED
7.7
%
PM
C 8
Eas
t
5.1
%
PM
C Im
agin
g
5.1
%
PM
C S
urg
ery
2.6
%
PH
DC
B
HU
2.6
%
PM
C 4
Eas
t
2.6
%
PM
C 5
W I
CU
2.6
%
PM
C 6
We
st
2.6
%
PM
C 7
Eas
t
2.6
%
PO
M M
/S/T
(3
rd F
loo
r)
2.6
%
PO
M M
/S/T
(4
th
Flo
or)
2.6
%
PO
M
Surg
ery
2.6
%
PO
P W
ou
nd
Car
e
Tota
l Nu
mb
er
of
Co
mp
lain
ts/G
riev
ance
s b
y U
nit
to
Pal
om
ar H
eal
th f
rom
39
Pat
ien
ts
(Ju
ne
20
16
)
PM
C E
D -
35
.9%
(n
=14
)
PO
M E
D -
23
.1%
(n
=9)
PM
C 8
Eas
t -
7.7
% (
n=3
)
PM
C Im
agin
g -
5.1
% (
n=2
)
PM
C S
urg
ery
- 5
.1%
(n
=2)
PH
DC
BH
U -
2.6
% (
n=1
)
PM
C 4
Eas
t -
2.6
% (
n=1
)
PM
C 5
W IC
U -
2.6
% (
n=1
)
PM
C 6
We
st -
2.6
% (
n=1
)
PM
C 7
Eas
t -
2.6
% (
n=1
)
PO
M M
ed/S
urg
/Tel
e (3
rd F
loo
r) -
2.6
% (
n=1
)
PO
M M
ed/S
urg
/Tel
e (4
th F
loo
r) -
2.6
% (
n=1
)
PO
M S
urg
ery
- 2
.6%
(n
=1)
PO
P W
ou
nd
Car
e -
2.6
% (
n=1
)
Attachment #3
26
.0%
47
.0%
37
.4%
58
.5%
74
.0%
53
.0%
66
.7%
41
.5%
0.0
%
10
.0%
20
.0%
30
.0%
40
.0%
50
.0%
60
.0%
70
.0%
80
.0%
90
.0%
10
0.0
%
Jun
e 2
01
5Ja
nu
ary
20
16
Mar
ch 2
01
6Ju
ne
20
16
Percentage
Mo
nth
Pe
rce
nta
ge o
f C
om
plim
en
ts v
s. C
om
pla
ints
/Gri
evan
ces
*Off
icia
l Mo
nth
ly R
esu
lts
Co
mp
lime
nts
Co
mp
lain
ts/G
rie
van
ces
Attachment #3
CMS Star Ratings Report 7/28/2016
HospitalLeapfrog Grade
(Spring 2016)
CMS Star
Rating
(July 2016)
Kaiser Foundation Hospital – San Diego A 3
Scripps Memorial Hospital – La Jolla A 5
Tri-City Medical Center A 2
UC San Diego Medical Center* A 3
Scripps Memorial Hospital - Encinitas B 4
Scripps Mercy Hospital B 3
Scripps Green Hospital B 5
Sharp Grossmont Hospital B 3
Alvarado Hospital C 4
Palomar Medical Center C 3
Paradise Valley Hospital C 4
Pomerado Hospital C 3
Sharp Chula Vista Medical Center C 4
Sharp Memorial Hospital C 4
* includes campuses in Hillcrest and La Jolla
Attachment #4
Cliff Notes Summary of the Medicare Star Rating Program
Page 1 of 2
After a three-month delay and negative chatter from many stakeholder groups, CMS released its
Overall Hospital Quality Star Rating program in full Wednesday on its Hospital Compare
website.
Here are 12 things to know about the program, its methodology, the pushback against it and how
stakeholders are responding.
1. In a post on CMS' blog, Kate Goodrich, MD, director of the Center for Clinical Standards and
Quality, wrote that the agency released the overall ratings "to help millions of patients and their
families learn about the quality of hospitals, compare facilities in their area side-by-side, and ask
important questions about care quality when visiting a hospital or other healthcare provider."
2. The Overall Hospital Quality Star Rating combines 64 measures that are already public on
Hospital Compare into one star rating. The measures fall into seven groups: mortality, safety of
care, readmission, patient experience, effectiveness of care, timeliness of care and efficient use
of medical imaging.
3. Because the quality measures used for the overall rating reflect routine care and hospital-
acquired infections, specialized care provided by certain hospitals is not reflected in the ratings.
4. A hospital's rating is only calculated using as many measures for which data is available. That
means hospitals' star ratings could be based on as few as nine measures or as many as 64; the
average is roughly 40.
5. CMS assigns weights to the group scores (mortality, safety, readmission and patient
experience are each weighted 22 percent, and effectiveness of care, timeliness of care and
efficient use of medical imaging each get 4 percent) and then assigns a summary score. If a
hospital is missing data in a group, the agency redistributes the weights among the other
categories. Then, CMS calculates an overall rating using the summary score.
6. If a hospital doesn't have data for three measures within at least three of the seven measure
groups, including one outcome group (meaning mortality, safety or readmission), the hospital
doesn't get a score. Currently, 937 hospitals do not have an overall star rating.
7. CMS developed the program's methodology with input from a technical expert panel and then
refined it after public input, according to the agency, and CMS plans to "consider public
feedback to make enhancements to the scoring methodology as needed."
8. Star ratings will be updated each quarter. Currently, 102 hospitals have five stars, 934 have
four stars, 1,770 have three stars, 723 have two stars and 133 have one star.
9. The July 27 release date is roughly three months after the planned release date on April
21. CMS delayed launchingthe program because of pushback it received from stakeholders and
members of Congress, who argued that because the methodology is not risk-adjusted and doesn't
account for socioeconomic factors, it puts certain hospitals, like academic medical centers and
safety-net hospitals, at a disadvantage.
Attachment #4
Cliff Notes Summary of the Medicare Star Rating Program
Page 2 of 2
10. Per Dr. Goodrich's blog post, CMS "paused to give hospitals additional time to better
understand our methodology and data" and has "conducted significant outreach and education to
hospitals to understand their concerns and directly answered their questions" in the three months
between the delay and the release of the program. This included hosting two national calls with
more than 4,000 hospital representatives and holding meetings with hospital associations to
explain data and answer questions.
11. Even with the three-month delay and tweaks to the methodology, stakeholders are still not
pleased with the program. Rick Pollack, president and CEO of the American Hospital
Association, called the ratings "confusing" in a statement Wednesday and said the AHA is
"especially troubled that the current ratings scheme unfairly penalizes teaching hospitals and
those serving higher numbers of the poor."
Similarly, Chip Kahn, president and CEO of the Federation of American Hospitals, released a
statement Wednesday saying "the new hospital star ratings fall short and are not ready for prime
time," and said there were "many important defects" in the methodology because it doesn't
"recognize the often significant differences between large and small hospitals, teaching and
nonteaching, and those hospitals providing care in underprivileged areas."
Bruce Siegel, MD, president and CEO of America's Essential Hospitals, also said AEH is
"disappointed" in CMS for releasing the ratings "when so many questions remain about the data
behind the ratings and their value to consumers."
12. Despite being disappointed with CMS for releasing the overall ratings right now, most
stakeholder groups still back the overall goal of the program — to be more transparent and allow
stakeholders to make informed decisions.
"FAH will continue to work with policy makers and our health care partners to ensure this
process is transparent and to fix the technical flaws in the star rating process so that it ultimately
yields value-added information for patients as well as hospitals," Mr. Kahn said.
Mr. Pollack from AHA said, "We want to work with CMS and the Congress to fix the hospital
star ratings so that it is helpful and useful to both patients and the hospitals that treat them."
And finally, Dr. Siegel from AEH said, "Consumers deserve accurate, comprehensive and
relevant information to make healthcare decisions. Hospitals Deserve to be on a level playing
field. The star ratings accomplish neither. We urge CMS to work with hospitals and independent
experts to revise the star ratings to correct shortcomings in its methodology and to immediately
share all its data, so hospitals can confirm the agency's calculations."
Attachment #4
Page 1 of 2
House Introduces Bill to Delay CMS Hospital Star Ratings By Vera Gruessner on July 28, 2016
The Hospital Quality Rating Transparency Act of 2016 was introduced in
the House to postpone release of the CMS hospital star ratings system.
The Centers for Medicare & Medicaid Services (CMS) hospital star ratings may be postponed due to a
new bill introduced on Monday, July 25 by House Representatives Jim Renacci (R-OH) and Kathleen
Rice (D-NY). The reasoning for the delay is due to ensuring the hospital star ratings system is flawless
and dependable, according to the American Hospital Association (AHA).
The bill is called the Hospital Quality Rating Transparency Act of 2016 and asks to push back the date
for unveiling the CMS hospital star ratings system to no earlier than July 31, 2017. Additionally, the bill
is calling for CMS to establish a comment period of 60 days in which the public can inform the federal
agency of any issues or discrepancies with the methodology and data included in the hospital star
ratings program.
Another important point that the bill includes is its requirement of having a third party confirm the
methodology and data provided by CMS. Any star ratings available on the Hospital Compare website
operating through CMS are asked to be taken down prior to the enactment of the Hospital Quality
Rating Transparency Act of 2016.
The American Hospital Association and members of Congress have previously expressed some
concerns about potential flaws in the CMS hospital star ratings system, which is why there is more
pressure to postpone the deadline for releasing this particular program.
“Patients need clear, meaningful information to make important healthcare decisions,” Tom Nickels,
Executive Vice President of Government Relations and Public Policy at the American Hospital
Association, said in a public statement. “Yet, thus far, it is unclear whether the Centers for Medicare &
Medicaid Services’ (CMS) star ratings actually provide accurate and reliable data to the public. As a
result, we applaud and thank Reps. James Renacci (R-OH) and Kathleen Rice (D-NY) for introducing a
bill to delay, for at least one year, the introduction of the CMS hospital star ratings.”
“Hospitals and members of Congress are in agreement: CMS can do better,” Nickels continued. “The
majority of Congress – 60 members of the Senate and more than 225 members of the House – asked
CMS to delay and improve upon the star ratings. Our own analysis of preliminary data continues to
raise questions and concerns about the methodology, which may unfairly penalize teaching hospitals
and those serving the poor.”
Originally, this past April, CMS had promised to incorporate a hospital star ratings system on the
Hospital Compare website, which would have improved healthcare transparency greatly for
Attachment #4
Page 2 of 2
consumers. The way this star ratings would work is by using patient surveys, readmissions and
complications data, medical imaging rates, and the amount of Medicare beneficiaries served.
CMS has already delayed its unveiling of the hospital star ratings program until the end of July due to
concern from the House of Representatives. This past April, a large number of representatives sent a
letter to CMS to postpone the implementation of this rating system since it did not have quality
benchmarks for measuring which hospitals serve patients with the most complex medical conditions.
Additionally, the representatives argued in the letter that the star ratings system was not transparent
enough with the methodology it uses to compare hospitals. Five dozen US Senators also wrote a letter
in which they urged the delay of the hospital star ratings system due to a lack of transparency and
inadequacies regarding clinical quality measures.
“We are writing to express our concerns with the Centers for Medicare and Medicaid Services’
upcoming release of the Hospital Compare Star Ratings,” the letter stated. “While we support the
public reporting of provider quality data, we are concerned that the current Star Ratings system may
not accurately take into account hospitals that treat patients with low socioeconomic status or
multiple complex chronic conditions.”
Despite this bill, CMS unveiled the first version of the Hospital Quality Star Rating system on the
Hospital Compare website yesterday, according to a press release from the federal agency. This will
allow patients and families to compare hospitals on a five-point scale side-by-side.
CMS has worked with stakeholders across the aisles to create this rating system for hospitals in order
to simplify the entire process of comparing hospitals and helping patients better understand the
quality of care they would receive at their respective medical facilities. A Technical Expert Panel along
with public input were used to create the hospital star ratings program.
CMS also stated in the release much support from patient advocacy groups in favor of having these
type of rating systems set in place for greater healthcare transparency for consumers. This is especially
important if looking at the type of hospitals that have had much lower rates of hospital readmissions
and mortality.
“Consumers will be able to make smarter, better informed choices about their health care thanks to
the hospital star ratings tool the Centers for Medicare & Medicaid Services (CMS) released
today," Debra L. Ness, President of the National Partnership for Women & Families, said in a public
statement. "Publication of the hospital quality performance scores to the CMS Hospital Compare
website will strengthen our country’s health care system. Millions of patients and family members can
now access a tool that provides important information on how their hospitals are performing on key
health quality measures. Consumers can use this trustworthy program to compare hospitals side-by-
side. This is a huge step forward."
Since some of the aspects used within the star ratings system relies mostly on patient feedback, it is
understandable why a number of opponents are looking to delay this hospital comparing program.
Time will tell whether this bill will pass and whether CMS will be left to renovate its hospital star
ratings system to alleviate the concerns from Congress.
Attachment #4
Pag
e 17
of 1
9R
epor
t Run
Dat
e: 0
7/22
/201
6
Ho
spit
al C
om
par
e P
revi
ew R
epo
rt:
Imp
rovi
ng
Car
e T
hro
ug
h In
form
atio
n –
Inp
atie
nt
Hos
pita
l Per
form
ance
Rep
ort
ing
Per
iod
fo
r H
ealt
hca
re A
sso
ciat
ed In
fect
ion
Mea
sure
s: F
irst Q
uart
er 2
015
thro
ugh
Fou
rth
Qua
rter
201
5 D
isch
arge
s05
0115
- P
AL
OM
AR
HE
AL
TH
DO
WN
TO
WN
CA
MP
US
Fo
otn
ote
Leg
end
1 . T
he n
umbe
r of
cas
es/p
atie
nts
is to
o fe
w to
rep
ort.
3 . R
esul
ts a
re b
ased
on
a sh
orte
r tim
e pe
riod
than
req
uire
d.4
. Dat
a su
ppre
ssed
by
CM
S fo
r on
e or
mor
e qu
arte
rs.
5 . R
esul
ts a
re n
ot a
vaila
ble
for
this
rep
ortin
g pe
riod.
7 . N
o ca
ses
met
the
crite
ria fo
r th
is m
easu
re.
8 . T
he lo
wer
lim
it of
the
conf
iden
ce in
terv
al c
anno
t be
calc
ulat
ed if
the
num
ber
of o
bser
ved
infe
ctio
ns e
qual
s ze
ro.
12 .
Thi
s m
easu
re d
oes
not a
pply
to th
is h
ospi
tal f
or th
is r
epor
ting
perio
d.13
. R
esul
ts c
anno
t be
calc
ulat
ed fo
r th
is r
epor
ting
perio
d.
Hea
lth
care
Ass
oci
ated
Infe
ctio
n
Hos
pita
l Qua
lity
Mea
sure
sY
our
Hos
pita
l's
Rep
orte
d N
umbe
r of
In
fect
ions
Dev
ice
or
Pat
ient
D
ays
/Pro
cedu
res
You
r H
ospi
tal's
P
redi
cted
N
umbe
r of
In
fect
ions
Rat
io o
f Rep
orte
d to
Pre
dict
ed
Infe
ctio
ns (
SIR
) (L
ower
Lim
it, U
pper
Lim
it of
95%
In
terv
al E
stim
ate)
You
r H
ospi
tal's
P
erfo
rman
ce
Sta
te S
tand
ardi
zed
Infe
ctio
n R
atio
, Sta
te
Low
er L
imit,
Sta
te U
pper
Li
mit
of 9
5% In
terv
al
Est
imat
e
Nat
iona
l S
tand
ardi
zed
Infe
ctio
n R
atio
Hea
lth
care
Ass
oci
ated
Infe
ctio
n M
easu
res
Cen
tral
Lin
e A
ssoc
iate
d B
lood
stre
am In
fect
ion
(IC
U +
se
lect
War
ds)
811
701
20.8
040.
385(
0.17
9,0.
730)
Bet
ter
than
th
e N
atio
nal
Ben
chm
ark
0.55
5 (0
.531
, 0.5
80)
0.5
73
Cen
tral
Lin
e A
ssoc
iate
d B
lood
stre
am In
fect
ion
(IC
U
only
) 6
6996
14.9
380.
402(
0.16
3,0.
835)
Bet
ter
than
th
e N
atio
nal
Ben
chm
ark
0.53
5 (0
.504
, 0.5
67)
0.5
40
Cat
hete
r A
ssoc
iate
d U
rinar
y T
ract
Infe
ctio
ns (
ICU
+
sele
ct W
ards
) 14
1514
527
.026
0.51
8(0.
295,
0.84
9)
Bet
ter
than
th
e N
atio
nal
Ben
chm
ark
0.65
0 (0
.625
, 0.6
76)
0.5
80
Cat
hete
r A
ssoc
iate
d U
rinar
y T
ract
Infe
ctio
ns (
ICU
onl
y)
1376
0014
.510
0.89
6(0.
498,
1.49
4)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
0.74
5 (0
.708
, 0.7
83)
0.6
45
SS
I-C
olon
Sur
gery
8
169
5.43
91.
471(
0.68
3,2.
793)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
1.13
6 (1
.066
, 1.2
09)
1.0
29
SS
I-A
bdom
inal
Hys
tere
ctom
y 0
168
1.71
00.
000(
--,1
.752
)(8
)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
0.97
1 (0
.851
, 1.1
03)
0.8
84
MR
SA
Bac
tere
mia
7
1038
244.
491
1.55
9(0.
682,
3.08
3)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
0.91
6 (0
.853
, 0.9
83)
0.9
62
Clo
strid
ium
Diff
icile
(C
.Diff
) 60
9826
163
.260
0.94
8(0.
730,
1.21
2)
No
Diff
eren
t th
an
Nat
iona
l 1.
084
(1.0
64, 1
.105
) 0
.931
Attachment #4
Pag
e 17
of 1
8R
epor
t Run
Dat
e: 0
7/22
/201
6
Ho
spit
al C
om
par
e P
revi
ew R
epo
rt:
Imp
rovi
ng
Car
e T
hro
ug
h In
form
atio
n –
Inp
atie
nt
Hos
pita
l Per
form
ance
Rep
ort
ing
Per
iod
fo
r H
ealt
hca
re A
sso
ciat
ed In
fect
ion
Mea
sure
s: F
irst Q
uart
er 2
015
thro
ugh
Fou
rth
Qua
rter
201
5 D
isch
arge
s05
0636
- P
OM
ER
AD
O H
OS
PIT
AL
Fo
otn
ote
Leg
end
1 . T
he n
umbe
r of
cas
es/p
atie
nts
is to
o fe
w to
rep
ort.
3 . R
esul
ts a
re b
ased
on
a sh
orte
r tim
e pe
riod
than
req
uire
d.4
. Dat
a su
ppre
ssed
by
CM
S fo
r on
e or
mor
e qu
arte
rs.
5 . R
esul
ts a
re n
ot a
vaila
ble
for
this
rep
ortin
g pe
riod.
7 . N
o ca
ses
met
the
crite
ria fo
r th
is m
easu
re.
8 . T
he lo
wer
lim
it of
the
conf
iden
ce in
terv
al c
anno
t be
calc
ulat
ed if
the
num
ber
of o
bser
ved
infe
ctio
ns e
qual
s ze
ro.
12 .
Thi
s m
easu
re d
oes
not a
pply
to th
is h
ospi
tal f
or th
is r
epor
ting
perio
d.13
. R
esul
ts c
anno
t be
calc
ulat
ed fo
r th
is r
epor
ting
perio
d.
Hea
lth
care
Ass
oci
ated
Infe
ctio
n
Hos
pita
l Qua
lity
Mea
sure
sY
our
Hos
pita
l's
Rep
orte
d N
umbe
r of
In
fect
ions
Dev
ice
or
Pat
ient
D
ays
/Pro
cedu
res
You
r H
ospi
tal's
P
redi
cted
N
umbe
r of
In
fect
ions
Rat
io o
f Rep
orte
d to
Pre
dict
ed
Infe
ctio
ns (
SIR
) (L
ower
Lim
it, U
pper
Lim
it of
95%
In
terv
al E
stim
ate)
You
r H
ospi
tal's
P
erfo
rman
ce
Sta
te S
tand
ardi
zed
Infe
ctio
n R
atio
, Sta
te
Low
er L
imit,
Sta
te U
pper
Li
mit
of 9
5% In
terv
al
Est
imat
e
Nat
iona
l S
tand
ardi
zed
Infe
ctio
n R
atio
Hea
lth
care
Ass
oci
ated
Infe
ctio
n M
easu
res
Cen
tral
Lin
e A
ssoc
iate
d B
lood
stre
am In
fect
ion
(IC
U +
se
lect
War
ds)
335
094.
665
0.64
3(0.
164,
1.75
0)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
0.55
5 (0
.531
, 0.5
80)
0.5
73
Cen
tral
Lin
e A
ssoc
iate
d B
lood
stre
am In
fect
ion
(IC
U
only
) 1
1510
2.26
60.
441(
0.02
2,2.
176)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
0.53
5 (0
.504
, 0.5
67)
0.5
40
Cat
hete
r A
ssoc
iate
d U
rinar
y T
ract
Infe
ctio
ns (
ICU
+
sele
ct W
ards
) 1
6181
9.36
90.
107(
0.00
5,0.
526)
Bet
ter
than
th
e N
atio
nal
Ben
chm
ark
0.65
0 (0
.625
, 0.6
76)
0.5
80
Cat
hete
r A
ssoc
iate
d U
rinar
y T
ract
Infe
ctio
ns (
ICU
onl
y)
117
382.
260
0.44
2(0.
022,
2.18
2)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
0.74
5 (0
.708
, 0.7
83)
0.6
45
SS
I-C
olon
Sur
gery
1
431.
285
0.77
8(0.
039,
3.83
8)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
1.13
6 (1
.066
, 1.2
09)
1.0
29
SS
I-A
bdom
inal
Hys
tere
ctom
y 2
550.
457
N/A
(13)
N/A
0.97
1 (0
.851
, 1.1
03)
0.8
84
MR
SA
Bac
tere
mia
0
2408
60.
923
N/A
(13)
N/A
0.91
6 (0
.853
, 0.9
83)
0.9
62
Clo
strid
ium
Diff
icile
(C
.Diff
) 19
2172
012
.708
1.49
5(0.
927,
2.29
2)
No
Diff
eren
t th
an
Nat
iona
l B
ench
mar
k
1.08
4 (1
.064
, 1.1
05)
0.9
31
Attachment #4
PALOMAR HEALTH
Hosptial Acquired Condition (HAC) Data
PMC POMMetric Decile Decile
Jan 2014 - Dec 2015 4th 3rd
Jan 2013 - Dec 2014 4th 3rd
Jan 2014 - Dec 2015 9th 8th
Jan 2013 - Dec 2014 9th 10th
Jan 2014 - Dec 2015 8th 9th
Jan 2013 - Dec 2014 9th 6th
Jan 2014 - Dec 2015 8th 6th
Jan 2014 - Dec 2015 8th 10th
Decile definition:
"Annual" Report covers 2 calendar years
CDI
1st = Best 10th = Worst
CLABSI
CAUTI
SSI
MRSA
Attachment #4
a C
AU
TIo
nar
y ta
le
Val
eri
e M
arti
nez
RN
Dav
id L
ee
, MD
Jerr
y K
olin
s, M
D
Au
gust
20
16
Attachment #5
CA
UTI
–
Cat
het
er-
Ass
oci
ate
d U
rin
ary
Trac
t In
fect
ion
s
on
ly a
few
yea
rs a
go, P
alo
mar
Hea
lth
had
bee
n
con
sist
entl
y sc
ori
ng
in t
he
bo
tto
m d
ecile
(b
ott
om
10
th %
ile)
of
all h
osp
ital
s in
th
e U
nit
ed
Stat
es
Attachment #5
CA
UTI
…b
ut
then
th
e n
urs
es, d
oct
ors
, EV
S, a
nd
all
the
oth
er h
osp
ital
sta
ff in
th
e la
nd
join
ed f
orc
es t
o
con
qu
er t
he
evil
CA
UTI
Attachment #5
Wh
at h
app
en
ed
nex
t
In 2
01
5, b
oth
Pal
om
ar a
nd
Po
mer
ado
mad
e tr
emen
do
us
imp
rove
men
t in
red
uci
ng
CA
UTI
ra
tes:
Attachment #5
The
sta
rt o
f th
e b
attl
e (
PM
C C
Y 2
01
4)
Yo
u (
6)
20
.41
-20
.00
-10
.00
0.0
0
10
.00
20
.00
30
.00
40
.00
50
.00
60
.00
Low
CA
UTI
Rat
es
Ran
k O
rde
red
Ho
spit
al-l
evel
CA
UTI
Cu
mu
lati
ve A
ttri
bu
tab
le D
iffe
ren
ce (
CA
D)
Co
mp
are
d t
o H
osp
ital
s in
th
e H
AI P
roje
ct –
Q1
20
14
- Q
4 2
01
4
Attachment #5
Win
nin
g th
e b
attl
e (
PM
C Q
1 2
01
5)
Ran
k O
rde
red
Ho
spit
al-l
evel
CA
UTI
Cu
mu
lati
ve A
ttri
bu
tab
le D
iffe
ren
ce (
CA
D)
Co
mp
are
d t
o H
osp
ital
s in
th
e H
AI P
roje
ct –
Q1
20
15
Yo
u (
77
)-3
.96
-8.0
0
-6.0
0
-4.0
0
-2.0
0
0.0
0
2.0
0
4.0
0
6.0
0
8.0
0
10
.00
Low
CA
UTI
Rat
es
Attachment #5
Win
nin
g th
e b
attl
e (
Q1
– Q
3 2
01
5)
Attachment #5
…b
ut
just
wh
en
we
th
ou
ght
we
had
th
e
up
pe
r h
and
•Ju
ne
20
16
–5
inci
den
ts o
f C
AU
TI a
t Pa
lom
ar
Attachment #5
The
mo
ral o
f th
e s
tory
If y
ou
are
PER
SIST
ENT
you
will
get
it
If y
ou
are
CO
NSI
STEN
T yo
u w
ill k
eep
it
Attachment #5
The
plo
t th
icke
ns…
•C
MS
has
bro
aden
ed t
hei
r at
ten
tio
n o
n t
he
pre
ven
tio
n o
f h
osp
ital
-acq
uir
ed in
fect
ion
s b
eyo
nd
CLA
BSI
(C
entr
al L
ine-
Ass
oci
ated
Blo
od
St
ream
Infe
ctio
n)
and
CA
UTI
to
incl
ud
e o
ther
in
fect
ion
s
•A
no
ther
evi
l ch
arac
ter,
Clo
stri
diu
m d
iffi
cile
(C
. d
iff)
, has
infi
ltra
ted
ou
r h
ealt
h s
yste
m a
nd
ga
ined
a m
enac
ing
foo
tho
ld
Attachment #5
Clo
stri
diu
m d
iffi
cile
(C
. dif
f.)
Met
ric
PM
C
PO
M
Clo
stri
diu
m d
iffi
cile
(C
.dif
f.)
Lab
ora
tory
-id
en
tifi
ed
Even
ts
de
cile
pe
rfo
rman
ce
de
cile
pe
rfo
rman
ce
Jan
20
14
- D
ec 2
01
5
8th
1
0th
Attachment #5
Wh
o is
th
is C
. dif
f an
yway
?
•a
spo
re-f
orm
ing,
Gra
m-p
osi
tive
an
aero
bic
b
acill
us
•p
rod
uce
s tw
o e
xoto
xin
s: t
oxi
n A
an
d t
oxi
n B
•ac
cou
nts
fo
r 1
5-2
5%
of
all e
pis
od
es o
f an
tib
ioti
c-as
soci
ated
dia
rrh
ea
Attachment #5
Wh
at a
re s
om
e t
ypic
al c
linic
al s
ymp
tom
s o
f C
. dif
f in
fect
ion
?
•w
ater
y d
iarr
hea
•fe
ver
•lo
ss o
f ap
pet
ite
•n
ause
a
•ab
do
min
al p
ain
/ten
der
nes
s
Attachment #5
Do
all
pat
ien
ts w
ith
C. d
iff
sho
w
sym
pto
ms?
•N
o –
aro
un
d 2
0%
of
ho
spit
aliz
ed a
du
lts
are
asym
pto
mat
ic C
. dif
f ca
rrie
rs
•Th
ese
pat
ien
ts s
hed
C. d
iff
in t
hei
r st
oo
l bu
t d
o n
ot
exh
ibit
dia
rrh
ea o
r o
ther
clin
ical
sy
mp
tom
s
Attachment #5
Wh
at a
re s
om
e p
ote
nti
al c
om
plic
atio
ns
of
C. d
iff
infe
ctio
n?
•d
ehyd
rati
on
•ki
dn
ey f
ailu
re
•to
xic
meg
aco
lon
–gr
eatl
y d
iste
nd
ed c
olo
n (
meg
aco
lon
)
–le
ft u
ntr
eate
d, t
he
colo
n c
ou
ld r
up
ture
(p
erfo
rate
)
•d
eath
Attachment #5
Ho
w is
C. d
iff
tran
smit
ted
?
•fe
cal-
ora
l
•C
. dif
f is
sh
ed in
fec
es
•Fe
cally
-co
nta
min
ated
su
rfac
es, d
evic
es, o
r m
ater
ials
bec
om
e re
serv
oir
s fo
r C
. dif
f sp
ore
s
•C
. dif
f sp
ore
s ar
e tr
ansf
erre
d t
o p
atie
nts
m
ain
ly v
ia t
he
han
ds
of
hea
lth
care
pe
rso
nn
el
wh
o h
ave
tou
ched
co
nta
min
ated
su
rfac
es o
r it
ems
Attachment #5
Wh
at c
an w
e d
o t
o p
reve
nt
the
tr
ansm
issi
on
of
C. d
iff?
•C
on
tact
Pre
cau
tio
ns
for
pat
ien
ts w
ith
kn
ow
n o
r su
spec
ted
C. d
iff
infe
ctio
n
–p
riva
te r
oo
ms
–gl
ove
an
d g
ow
n w
hen
en
teri
ng
pat
ien
ts’ r
oo
ms
and
du
rin
g p
atie
nt
care
–re
mo
ve g
ow
n a
nd
glo
ves
bef
ore
leav
ing
the
pat
ien
ts’ r
oo
ms
–h
and
hyg
ien
e af
ter
rem
ovi
ng
glo
ves
Attachment #5
Wh
at c
an w
e d
o t
o p
reve
nt
the
tr
ansm
issi
on
of
C. d
iff?
–P
reve
nti
ng
con
tam
inat
ion
of
the
han
ds
via
glo
ve
use
rem
ain
s th
e co
rner
sto
ne
for
pre
ven
tin
g C
. dif
f tr
ansm
issi
on
Attachment #5
Wh
at e
lse
can
we
do
to
pre
ven
t th
e
tran
smis
sio
n o
f C
. dif
f?
•R
ob
ust
en
viro
nm
enta
l cle
anin
g an
d
dis
infe
ctio
n s
trat
egy
–En
sure
ad
equ
ate
clea
nin
g an
d d
isin
fect
ion
of
envi
ron
men
tal s
urf
aces
an
d r
eusa
ble
dev
ices
•Ju
dic
iou
s an
tib
ioti
c u
se
–an
tib
ioti
c u
se p
uts
pat
ien
ts a
t gr
eate
r ri
sk f
or
C.
dif
f co
litis
, wh
ich
is w
hy
it is
imp
ort
ant
to u
se
anti
bio
tics
on
ly w
hen
nee
ded
Attachment #5
So w
hat
are
we
to
do
wit
h o
ur
un
acce
pta
bly
hig
h C
. dif
f ra
tes?
We’
ve b
een
her
e b
efo
re.
We’
ve d
on
e th
is b
efo
re.
Attachment #5
If w
e ar
e P
ERSI
STEN
T w
e w
ill g
et it
If w
e ar
e C
ON
SIST
ENT
we
will
kee
p it
Attachment #5
Ho
w d
o w
e s
tay
CO
NSI
STEN
T?
Pati
ent
Firs
t
Attachment #5
An
d a
ll th
e h
osp
ital
-acq
uir
ed
infe
ctio
ns
we
re b
anis
he
d f
rom
th
e h
eal
th s
yste
m,
and
all
the
pat
ien
ts li
ved
hap
pily
eve
r af
ter…
Attachment #5
Au
gust
15
, 20
16
Q
ual
ity
Rev
iew
Co
mm
itte
e R
epo
rt
Attachment #6
GB
“R
OB
IN”
RO
WLA
ND
, MD
, MP
H,
FAC
PM
Q
UA
LITY
MA
NA
GEM
ENT
Attachment #6
QU
ALI
TY D
EPA
RTM
ENT
TRIP
LE A
IM
•Lo
w C
ost
•H
igh
Qu
alit
y
•A
cces
s &
Sa
tisf
acti
on
EDU
CAT
ION
•P
hys
icia
n S
taff
•C
linic
al S
taff
•A
dm
inis
trat
ive
Staf
f
DAT
A
•P
hys
icia
n
Das
hb
oar
d
•C
linic
al
Op
erat
ion
s C
are
Op
po
rtu
nit
y D
ash
bo
ard
PH
AR
MA
CY
TEA
M
INTE
GR
ATIO
N
•Tr
ansi
tio
n o
f C
are
•C
hro
nic
Car
e M
anag
emen
t
•M
edic
atio
n R
efill
CLI
NIC
AL
CA
RE
GU
IDEL
INES
Ph
ysic
ian
In
de
pen
de
nt
Med
ical
G
rou
p
Ort
ho
ped
ic
Ass
oci
ates
of
No
rth
C
ou
nty
Esco
nd
ido
C
ard
iolo
gy
Ass
oci
ates
No
rth
C
ou
nty
G
eri
atri
cs
Esco
nd
ido
P
ulm
on
ary
and
Sle
ep
Med
icin
e
MA
NA
GIN
G
QU
ALI
TY
Attachment #6
SER
VIC
ES
FFS
PATI
ENT
PAN
EL
•6
8,6
52
MA
NA
GED
CA
RE
PATI
ENT
PAN
EL
•1
8,6
61
NEW
PAT
IEN
TS
•3
3,6
80
TOTA
L V
ISIT
S
•4
,62
0
Attachment #6
PATI
ENT
SATI
SFA
CTI
ON
84
.00
%
86
.00
%
88
.00
%
90
.00
%
92
.00
%
94
.00
%
96
.00
%
98
.00
%
10
0.0
0%
20
11
20
12
20
13
20
14
20
15
20
16
Pre
ss G
aney
Mea
n P
atie
nt
Sati
sfac
tio
n S
core
s
Attachment #6
CLI
NIC
AL
QU
ALI
TY M
AN
AG
EMEN
T
Qu
alit
y Im
pro
vem
ent
Co
mm
itte
e
•W
ork
gro
up
s
•R
efill
Cen
ter
•H
yper
ten
sio
n
•D
iab
etes
•Pa
tien
t C
ente
red
Med
ical
Ho
me
Attachment #6
QU
ALI
TY &
OP
ERAT
ION
S A
LIG
N
Min
d t
he
Gap
s •
Car
e O
pp
ort
un
ity
Rep
ort
s
•P
utt
ing
them
in t
he
han
ds
of
the
clin
ical
tea
m
Bal
dri
ge F
ram
ewo
rk
•1
0 A
rch
Lea
der
s A
tten
ded
•B
egin
nin
g o
ur
Bal
dri
ge
Jou
rney
Pati
ent
Cen
tere
d M
edic
al
Ho
me
& P
atie
nt
Cen
tere
d
Spec
ialt
y P
ract
ice
•C
linic
Tra
nsf
orm
atio
n
•C
are
Co
ord
inat
ion
: P
rim
ary
Car
e/sp
ecia
lty
inte
rfac
e
•Pa
tien
t En
gage
men
t
•B
ehav
iora
l Hea
lth
Inte
grat
ion
Attachment #6
CLI
NIC
AL
QU
ALI
TY D
ASH
BO
AR
D
•D
ata
Tran
spar
ency
Attachment #6
Wel
l Man
aged
Car
e M
etri
c A
rch
He
alth
Par
tne
rs
Targ
et
Co
mm
erc
ial M
ed
-Su
rg
Day
s/1
00
0
12
7
96
Sen
ior
Me
d-S
urg
Day
s/1
00
0
78
2
82
6
Co
mm
erc
ial M
ed
-Su
rg
Ad
mit
s/1
00
0
29
.7
29
Sen
ior
Me
d-S
urg
A
dm
its/
10
00
1
84
.4
20
0
Re
adm
issi
on
Rat
e
12
.00
%
15
.06
%
SCM
G R
EPO
RT
20
16
Attachment #6
CLI
NIC
TR
AN
SFO
RM
ATIO
N
KIO
SKS
•Im
ple
men
ted
“ex
pre
ss c
hec
k-in
” ki
osk
s at
ou
r cl
inic
s in
Mar
ch, 2
01
6.
•“S
elf-
serv
e” k
iosk
s im
pro
ve t
he
pat
ien
t ex
per
ien
ce b
y p
rovi
din
g a
“fas
ter
and
eas
ier”
ch
eck
-in
pro
cess
.
•K
iosk
s al
low
pat
ien
ts t
o s
can
dri
ver’
s lic
ense
s an
d in
sura
nce
car
ds,
mak
e co
-pay
men
ts
and
pay
ou
tsta
nd
ing
bal
ance
s, u
pd
ate
pat
ien
t in
form
atio
n, s
ign
form
s el
ectr
on
ical
ly a
s w
ell a
s ve
rify
th
eir
insu
ran
ce.
•W
e an
tici
pat
ed t
hat
50
% o
f o
ur
pat
ien
ts w
ou
ld s
hif
t to
th
e ch
eck
-in
kio
sks
du
rin
g th
e tr
ansi
tio
n y
ear;
ho
wev
er, t
he
tran
siti
on
has
bee
n h
igh
er t
han
an
tici
pat
ed a
t 7
0%
.
•K
iosk
s h
ave
red
uce
d t
he
che
ck-i
n t
ime
ove
rall
for
pat
ien
ts.
The
ave
rage
ch
eck
-in
tim
e fo
r n
ew p
atie
nts
is 2
:48
an
d 1
:07
min
ute
s fo
r re
turn
pat
ien
ts
•Th
e P
SR’s
are
ab
le t
o s
pen
d m
ore
tim
e w
ith
pat
ien
ts w
ho
nee
d a
dd
itio
nal
su
pp
ort
.
Attachment #6
Medic
al Q
ualit
y A
ward
s
Aw
ard
ing
Org
an
iza
tio
n
Aw
ard
2
011
2012
2013
2014
2015
Inte
gra
ted
He
alth
ca
re A
sso
cia
tio
n
Exce
llen
ce
in
He
alth
ca
re
Mo
st Im
pro
ve
d
To
p P
erf
orm
er
Ca
lifo
rnia
Asso
cia
tio
n o
f P
hysic
ian
Gro
ups
Exe
mpla
ry A
wa
rd
Elit
e A
wa
rd
Attachment #6
JESS
ICA
GH
AR
BA
WY,
PH
AR
MD
, B
CA
CP,
CD
E
PH
AR
MA
CY:
TH
E FO
UN
DA
TIO
N O
F O
UR
QU
ALI
TY M
AN
AG
EMEN
T
Attachment #6
Ref
ill C
ente
r
•In
crea
se p
resc
rib
er’s
dir
ect
pat
ien
t ca
re t
ime
•
Qu
alit
y im
pro
vem
ent
–
Snap
sho
t: 4
-6 o
ver
du
e la
bs
and
ap
po
intm
ents
fo
un
d p
er d
ay
•C
on
nec
t p
atie
nts
to
car
e th
ey n
eed
Jun
e 2
01
6 R
efi
ll P
resc
rip
tio
ns
Ref
ill C
ente
r
Oth
er
Tota
l = 8
98
6
N=3
48
6
(39
%)
N=5
50
0
(
61
%)
Attachment #6
Hyp
erte
nsi
on
0
50
10
0
15
0
20
0
25
0
30
0
Number of Patients
Mo
nth
E
nro
llmen
t Ta
rge
t
July
1: 2
51
Pa
tien
ts
•C
MM
I Hea
rt A
ttac
k an
d
Stro
ke F
ree
Zon
e (H
ASF
Z)
•G
oal
: en
roll
30
0 p
atie
nts
b
y A
ugu
st 3
1, 2
01
6
•R
edu
ce h
eart
att
acks
an
d
stro
ke in
San
Die
go b
y 5
0%
Attachment #6
Dia
bet
es
•Te
am b
ased
ap
pro
ach
–O
utr
each
–R
efer
rals
•P
har
mac
y st
ud
ents
an
d
resi
den
ts
Attachment #6
Attachment #6