Meeting Minutes - Hospice of the Western Reserve

Meeting:Meeting MinutesMedical Advisory and Program COmmittee (CoIrtbined Quality and Program Meeting)Scheduled Start Time: 7:30A Actual: 7:31A Scheduled Stop T~lne: 9:00A Actual: 9:00ALocation: Sturgeon Room, HQ Date: 12/2/2010 Facilitator: Virginia Mooney Minutes by: Shareef~ SaburPresent: Jan Murphy, Elizabeth Pitorak,Bridget Montana, Dr. Charles WellmanAbsent: Susan Figula, Jean Kilgore, Wendy Miano, Mary Ogrinc, David Simpson, Erin Adams, Cynthia Hundorfean·ITEM KEY POINTS OF DISCUSSION OUTCOME/PLAN WHO COMPLETIONDATECall to orderThe meeting was called to order at 7:31 AMApproval of minutesThe minutes were approvedProgram The following is a synopsis of the Program Updates per PROGRAM COMMITTEEStrategic Plan Outline. The detailed report is available SUMMARY REPORT MEMBERSupon request.REVIEWED ANDACCEPTEDDementia Comprised 14.3% of total admissions in 2Qand 3Q 2010.This is an increase over 2009.Majority of new admissions are in alternative homesettings. 40% die in less than two Weeks but others havelength of stay over 180 days. CUrrently evaluating twoproQnostication tools.Cardiopulmonary Cardiac comprised 6.5% of total admissions, down from2Q 2010. 25% died in less than two weeks.Respiratory comprised 6.5% of total admissions, downfrom normal. .Renal Comprised 4% of all admissions. 38% die within twoweeksAIDSSeven new patients admitted. Admissions increasing.Many AIDS patient present with cancersALS/NeuromuscularThree ALS admissions. Consistent with 1Q 2010. Thereis a cross.-organizational committee worki~g on this.Palliative Care Increased admission in 3rdQ. Averages of 60% of thosedischarged from palliative care go to hospice. Problems!Iee:1

NavigatorElisabethSeverance PrentissBereavement CenterPediatricsDisease SpecificMarketing Outreachwith staffing. Evaluating whether to have a clinic toincrease visit efficiency. Palliative care nurses maintainskills through Journal Club. Evaluating an acuity toolsince the visit to FourSeasons Hospice ill North Carolina.Current census is 227. 60% ofpati¢~fshave:volunteers.This program serves as an avenue for the organization tolearn about end stage chronic care. Nursing facilitiesvalue this program. .Plan to develop a business plan focused on communityefforts that center around griefin the workplace, schools,and crisis response. In the process·of conducting.aneeds assessment to determine strategic approach andopportunities to better serve the bereaved and those whoserve them.Total gifts 1/1/2010 to 10/4/2010 equal $145 022Admissions down fmm 2009. Largest diagnosispercentage is congenital anomalies followed byneoplasms. Cleveland Clinic Foundation and Hospice ofthe Western Reserve have had a jointly funded positionsince August 2009. Since that time 45 patients havebeen seen, and prior to that, there were 12 patients from2006-August 2009.·Situation AnalysisHospice of the Western Reserve has been marketingdisease-specific care for almost 10 years. Currentdisease efforts outlined in the strategic plan include:cardiac, dementia, pulmonary, renal, cancer, AIDS andALS/neuromuscular~. Developed to address end-of-Iifeconsiderations for patients with certain diseases, theseprograms have been marketed to the professionalcommunity as well as patients and families; As we moveforward, Hospice of the Western Reserve would like tostrengthen our marketing efforts. to bElttElr meet the needsof the patientswe serve and support the strategic goalsof the agency with regard to increased access, a medianlength of stay of 18 days or greater and increased brandawareness of Hospice of the Western Reserve.Report Reviewed andacceptedCommitteemembersCc:ChallengesCurrently, our marketing efforts for disease outreachhave utilized a broad marketing approach. We havetaken both the disease-specific program message, aswell as· the palliative care message out the pr:ofessionaland general community. As we move into 2011, Wf3 lookto focus our marketing efforts to meet pockets of patientpopulations with a taraeted messaae and approach to2

help support a longer length of stay for patients and amore proportionate patient mix that more closely reflectsthe cause of death of the communities we serve.-, .!OutcomesAs we move forward, we hope our disease-specificoutreach efforts will better support the mission of theorganization and strategic goals of Hospice oitheWestern Reserve as outlined in the strategic plan withregard to increased access, a median length of stay andincreased brand awareness of Hospice of the WesternReserve.Quality The following Is a synopsis of the Quality Updates. Thedetailed report is available upon request.Priority Focus Areas :m;!Quarter 2010:Shareefah SaburShareefah Sabur briefly explained HWR qualityassurance process using the Quality Alert tool. HWR hasimplemented use of the Priority Focus Areas for healthcare organizations as defined by JCAHQ for grouping andanalysis of quality concerns. These results are reviewedin QAPI, and assist in selecting performanceimprovement projects;Third Quarter Priority Focus Areas were reviewed. Thedocument "Priority Focus Area: 2010 Trending Analysis3rd Quarter 2010" was distriputed. Severed graphs areused to illustrate and trend HWR results over time. Asdata continues to be collected; trending will be readilyidentifiable.Also discussed was the increase in Qllality Alerts fallingunder Assessment and Care for the fourth Quarter in arow. The increase for the last three quarters is notexplained by an increase in Quality Alerts.,Cc:Medication Management also stood out as a troublingtrend due to this being a high risk area and with working Evaluate the feasibility Bridgetwith outside vendors. The ongoing Performanceof providing pharmacy,Improvement Project (PIP) with Medical Servicesservices in-houseCompany andOmnicare. There have been someimprovements with Medical Services Company. Hospice Establish aof the Western Reserve is exploring other options and denominator for BridgetiShareefah vvendors to see If we can serve ourselves without a vendor issues usingvendor like Omnicare.the number of Rx3

Policy 1:025 ResearchPolicymeds or deliveries withThe Priority Focus Area of Communication wasthe numerator thendiscussed. The largest area for concern wasbeing the number ofcommunication with entities outside of the organization, issuese.g. nursing facilities, assisted living faGilities, hospitals,and physicians. Second to that is the combination of Evaluatecommunication between patients/familiesand staff and recommendation to Shareefah willwith patienUfamilyeducatiori. contract with forward toneighborhoodContractingpharf)1acists e.g. Supervisor.Walgreens, CVS, etc. Bridget willevaluate from apharmacyperspectiveThis policy revision was approvedQuarterly R~view Report reviewed and CommitteeShareefah Sabur accepted membersPhysician SatisfactionThe documents "2010 Physician SurveySummary 151 _3 rdQuarter 2010". Discuss about physician commentsabout communication confirmed the Priority Focus AreaReport that Communication is an areathat needsattention.Utilization Data: A packet of documents was distributed. These Report reviewed and Committeedocuments were titled as follows: accepted members• Hospice of the Western ReserveAdmissions/Deaths Oct 2009 thru Sept 2010• Hospice of the Western Reserve LOS .Mean/Median - Deaths Only Oct 2009 thru Sept2010• Hospice of the Western Reserve Admissions Jan2008 thru Sept 2010• Hospice of the Western Reserve Deaths Jan2008 thru Sept 2010 '.• Hospice of the WestemReserveMedian LOS-Deaths Only Jan 2008 thruSept 2010• Hospice of the Western Reserve ALaS (Mean)-Deaths Only Jan 2008 thru Sept 2010,Cc:4

There was discussion regarding the following in thedocuments:• Admissions down (416) in Sept 2010, lowest thisyear• Median LOS (21 days) up for Sept 2010, highestthis yearPerformance 0 QAPI committee had extensive discussion aboutImprovement the Safety: High Security Alert PIP. It wasProjects in )determined to expand the draft procedure toProgress:include information provided in the JCAHOShareefah Sabur Sentinel Event Alert0 Performance Improyement Projects are takinglonger than expected to complete. Someidentified areas of delay are:0 Staff are required to participate inmultiple PIP due to their expertise andthe meetings are less frequent0 PIP Teams have spent time identifyingand exploring tangential issues0 Based on the assessment of the PIPs and theirprogress, the following changes will be made:0 Redesign the facilitator training toencourage building and maintainingmomentum0 Charter the teams more·specifically atthe onset0 Focus more on what is being measuredand report the measurement monthlyOther Business: Face-to-Face Encounter will become effective Jan 1,2011. A committee is planning how to manage the large ,volume anticipated for Januarv,2 011Next MeetingThere will be four meetings next year. The Programdiscussion will be included with the Quality for two of themeetings...Please note that the meeting time has been changedfrom 7:30 AM to 4:00 PM'.Cc:March 7, QualityJune 13, Program and QualitySeptember 12, Qualitvt5

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Meeting Minutes..... HOSPICE~ OF THEV~~V WESTERNRESERVEMeeting Title:Medical Advisory and Program Committee (MAPC - Quality)MinutesDate: March 7,2011 ime: 4:00pm - 4:51pm Location: Lakewood OfficeJan MurphyErin AdamsErin Adams, Susan Figula, William Finn, Jean Kilgore, Bridget Montana, Virginia Mooney (via phone), Jan Murphy, Elizabeth Pitorak,Shareefah Sabur, Jim Thomascik, Dr. Chuck Wellman (via phone)Cynthia Hundorfean, Mary OgrincCall To Order:Jan MurphyApproval of Minutes12/2/10:AllPriority Focus Areas 4 thQuarter 2010:Jim Thomascik4:00pmNo additions or corrections to the minutes.The top three 4th Quarter 2010 Priority Focus Areas as well ascorresponding Performance Improvement Projects were reviewed.The document "JCAHO Priority Focus Areas of Concentration andCorresponding Performance Improvement Projects" wasdistributed.ApprovedJan Murphy

Assessment and Care Performance Improvement Projects:• Personal Care at Bedside• Wound CareCommunication Performance Improvement Projects:• Bereavement Enrollment• Performance Improvement ProcessMedication Management Performance Improvement Projects:• Medication and Equipment Management• Medication Reconciliation• MethadonePage 2 ofS•.............~

Quality Indicators 2010:Shareefah SaburShareefah Sabur explained the purpose of and summarized resultsfrom the distributed document "Quality Indicators 2010: IdealPatient Care," The following was noted:Several indicatorswill continue to bemonitored in 2011.Quarterly• Scores have gone up in all four general indicators, whichwere recommended by the Board and are imbedded in theStrategic Plan.• Confidence Scores (D8 and D9) h.ave gone up. ConfidencePIP and Service Excellence Project with Westlake Home CareTeam surrounding ConfidenceFEHC questions was sharedto illustrate a possible explanation as to the increase inscores. Shareefah also shared that Jim Thomascik is readingthrough specific individual survey comments regardingConfidence to further drill into what piece of this indicatorwe need to continue to improve on.• Return rate is currently 37%-40%. National return rate is40%.• Bereavement PIP in process, which is looking at ways toimprove reaching other family members that are not listedas primary caregiver in Suncoast that require bereavementservices; as well as identifying those that are in need of"above standard" support, was discussed in regards to theindicator: How much emotional support did the hospiceteam provide you AFTER patient's death? (% Right Amount)• Personal Needs PIP in process, which is looking at issuesrelated to improving the percentage of question Cion theFEHC survey by having staff use the term "personal care"and defining whatthat entails when talking with theprimary caregiver and family, was discussed in regards tothe indicator: how often were the patient's personal careneeds - such as bathing, dressing, and changing beddingtakencare of as well asthey should have been by thehospice team? (% Always)• In regards to the QAPI Coach Pain indicator: Unacceptablelevel of pain 48 hours after admission, it was discussed thatAccess and Quality looked at the list of patients who did notPage30f8 ~

have their pain relieved within 48 hours of admission fromQAPI c;:oach 3rd Quarter Data. Findings: Access andQuality's review of these charts of patients with pain @ 48hours showed consistently good to excellent assessment,intervention, timeliness, etc. It is noted that many of thesecases could have been anticipated to have problemssubstanceabuse history, already on a pump, admissiondirectly to GIP for pain control, etc. The committee did notfind anything to suggest a problem.• The Quality Indicators will carryover to 2011 and continueto be trended to see if we can sustain improvement.Physician Satisfaction:Susan FigulaThe d"ocuments "2010 Physician Survey Summary 1 st , 2 nd , 3 rd , 4 thQuarter 2010" were distributed and discussed. The PhysicianSatisfaction Survey process was outlined and discussed.Report reviewedand acceptedCommitteemembersThe struggle with these surveys is getting the information back toProfessional Relations once the survey has gone through theQuality Alert Report process. This process is currentlyundergoing review and we are working to improve this process.Discussion suggests that Hospice of the Western Reserve maywant to explore ways of automating this survey process bymaking the survey electronic.Page4of8 ~".

Utilization Data ­Length of Stay &Ad missions/Discharges:Shareefah SaburA packet of documents was distributed. These documents weretitled as follows:• Hospice of the Western Reserve Admissions/Deaths Jan2010 thru Dec 2010• Hospice of the Western Reserve LOS Mean/Median ­Deaths Only Jan 2010 thru Dec 2010Report reviewedand acceptedCommitteemembers• Hospice of the Western Admissions Jan 2008 thru Dec2010• Hospice of the Western Reserve Deaths Jan 2008 thruDec 2010• Hospice of the Western Reserve Median LOS - DeathsOnly Jan 2008 thru Dec 2010• Hospice of the Western Reserve ALaS (Mean) - DeathsOnly Jan 2008 thru Dec 2010There was discussion regarding the following in the documents:• It was noted that December 2010 had the highest amountof admissions (491) since March 2010 (497)• It was noted that September 2010 LOS (Median) of 21was an extremely noticeable spike. Hospice of theWestern Reserve's target is 18 for LOS (Median)Page 5 ofS ~

Qualitv Plan 2011:Jim ThomascikPage 6 - Quality Activities: Jim Thomascik will be going to TeamMeetings to educate staff and deliver feedback regarding QualityAlerts. The Plan, Do, Study, Act Problem Solving Approach will alsobe educated on as well as the Quality Alert Pathway.Quality Plan 2011approvedCommitteemembersPage 10 - Performance Improvement Methods: Failure Modes andEffects Analysis (FMEA) was discussed with use of a handout thatwas distributed titled, "Failure Modes Effects Analysis." It wasnoted that one PIP in FMEA will occur mOst likely in May 2011 andthe purpose of FMEA is to be pro-active.Page 12 - Reporting of Results: Focus for education.Page 14 - 2011 Initiatives: The 2011 Initiatives were discussed.These initiatives included FMEA, NHPCO Self-Assessment/Audit,ongoing education in regard to the Assessment InterventionMeasurement (AIM) measures, which will occur at monthly QAPImeetings, Advanced Adaptive Design Classes focusing onobservation, and PIP Facilitating Classes focusing on transparencyand ongoing education.Hospice ofthe Western Reserve is required to submit on the AIMMeasures beginning October 2012. This will require designing oursystem to collect this data.PerformanceImprovement Projects inProgress:Jim ThomascikThe document titled, "Performance Improvement Projects" wasdistributed and reviewed along with the Priority Focus Areas 4 thQuarter 2010.Page60fS .~

Other Business:AllShareefah Sabur announced that JCAHO will be coming thismonth (March 20ll).Next Meeting:Adjournment:Jan MurphyJan Murphy reiterated the MAPC meeting schedule for 2011:March 7 - QualityJune 6 - Program & QualitySeptember 12 - QualityDecember 12 - Program & QualityJune 6, 2011The meetingadjourned at 4:51pm.Agenda:Program &QualityPage70fS ~.