Download QUALITY PROFESSIONAL SERVICES COMMITTEE MEETING

QUALITY PROFESSIONAL SERVICES
COMMITTEE MEETING
THURSDAY, January 28, 2016
Conference Center Located at Highland Care Pavilion
1411 East 31st Street Oakland, CA 94602
Susana Flores, Clerk of the Board
(510) 535-7515
LOCATION:
Open Session: HCP Conference Center
MINUTES
THE MEETING WAS CALLED TO ORDER AT 3:35PM
ROLL CALL WAS TAKEN AND THE FOLLOWING TRUSTEES WERE PRESENT:
Barry Zorthian, MD, Kinkini Banerjee, Joe DeVries, Maria Hernandez, and Michele Lawrence.
Non-Voting Members present: Drs. Deepak Dhawan, John Iocco and Swapnil Shah.
(General Counsel Announcement as to purpose of Closed Session)
TAB #1
CLOSED SESSION
(Reconvene to Open Session)
TAB #2
ACTION: Consent Agenda
A. Approval of the Minutes of the November 19, 2015 and December 22,
2015 Quality Professional Services Committee Meetings.
B. Approval of Policies and Procedures
Kerin Torpey Bashaw, MPH, RN, Vice President, Quality
January 2016
Alameda Health System Policies
Administration
• Activation, Notification and Alert-Code Triage
• Authorization for Uses and Disclosures Other Than Treatment, Payment and Health\
Care Operations
• Breach Notification Process
• Code Tan
• Disclosure of HIV/AIDS Related Information
• Disclosure of Protected Health Information for Treatment, Payment and Health Care
Alameda Health System
Board of Trustees – Quality Professional Services Committee Meeting - Minutes
January 28, 2016
Page 2 of 4
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Operations
Eyewash Facilities
Locker Assignment in the Acute Tower
Master Clock Policy
Medication Administration (Attachments)
Mitigation of Improper Disclosures
Notification
Parking Policy
Patient Care-Clinical Protocols
Patient Privacy Protection
Patient’s Right to Request Restrictions on Certain Uses and Disclosures of Protected
Health Information
Posting of Posters and Flyers
Privacy Rule Complaint Process
Privacy: Accounting of Disclosures
Privacy: AHS Directory
Respiratory Protection Program
Sorian Clinicals Electronic Health Record (EHR) Downtime Policy
Clinical
• 340B Drug Pricing Program
• Addendum: Code Blue/White Crash Cart Policy
• Antibiotic Desensitization Protocols
• Anticoagulant Therapy in Patients Undergoing PCI
• Elective PCI Patient Selection and Exclusion
• Guidelines for Methadone Use
• Immunizations in Adult Primary Care Protocol
• Intravenous Admixture Program
• Treatment of Chest Pain and NSTEMI
Department
• MCH Certified Nurse Midwife Standardized Procedure: First Surgical Assist for
Cesarean Section
• MCH Certified Nurse Midwife Standardized Procedure: Furnishing Medications
(Attachments)
• MCH Certified Nurse Midwife Standardized Procedure: Infiltration with Local
Anesthetic
• MCH Certified Nurse Midwife Standardized Procedure: Repair of Spontaneous First
and Second Degree Lacerations of the Lower Genital Track; Performance and Repair
of Episiotomy
Alameda Hospital Policies
Clinical
• CAUTI Policy
• CLABSI Prevention Bundle
• Hand Hygiene
• Infection Control Program
• MRI without Contrast-Code Stroke Protocol
• Standard Precautions
• Transmission-Based precautions
• Ventilator Associated Pneumonia(VAP) Prevention Bundle
Department
• Care of Workstations on Wheels (WOW)
Alameda Health System
Board of Trustees – Quality Professional Services Committee Meeting - Minutes
January 28, 2016
Page 3 of 4
Plans
• Infection Control Plan
San Leandro Hospital Policies
Administration
• Influenza Prevention and Outbreak Control Protocol
Clinical
• BiPAP
• Cleaning and Disinfection of External and Internal use Ultrasound Probes
• Influenza Vaccination
• Medication-Transdermal Patch Policy
Department
• Continuum of Care
• Discharge Criteria
• Education of Patients and Families
• Reassessment of Patients
• Request for Services, Inpatient
• Scope of Assessment
• Scope of Services- Rehabilitation
• Standard’s for Delivering Care and Services
Action: A motion was made and seconded to approve the QPSC minutes of November 19,
2015 and December 22, 2015. The motion passed.
AYES: Trustees Banerjee, DeVries, Hernandez, Lawrence, and Zorthian.
NAYS: None
Abstention: None
Action: A motion was made and seconded to approve January 2016 Policies and
Procedures as presented. The motion passed.
AYES: Trustees Banerjee, DeVries, Hernandez, Lawrence, and Zorthian.
NAYS: None
Abstention: None
TAB #3
DISCUSSION: Issue Tracking
The CNE provided an update regarding the Visiting Hours/Visitor policy that was
pulled from the October 2015 consent agenda. The CNE clarified that this item would
be modified to consist of Visiting Hours/Visitor principles where patients may define
the make-up of their family and visitors. The goal is to create a secure environment
that allows family and visitors at all times while maintaining staff safety.
The VP of Quality clarified that the PCP Assignment of Panel Size policy was based
on a memorandum of understanding and a union contract. Stakeholders reviewed
the policy and confirmed that the policy will not move forward. A procedure will be
created to ensure clarity around.
The Visiting Hours/Visitor Policy will return to the Committee as a part of the regular
policy approval process.
Alameda Health System
Board of Trustees – Quality Professional Services Committee Meeting - Minutes
January 28, 2016
Page 4 of 4
TAB #4
REPORT: Legal Counsel’s Report on Action Taken in Closed Session
The Interim General Counsel reported that the Committee approved the credentialing
reports from each of the Medical Staffs and took no other action.
Public Comments - None
Trustee Remarks - None
ADJOURNMENT – 4:35pm
Respectfully submitted by:
Susana Flores
Clerk of the Board
APPROVED AS TO FORM:
Reviewed by:
Mike Moye
Interim General Counsel
Executive Summary for Quality Professional Services Committee
Policies and Procedures
February 2016
Title of Policy
Immunizations in Adult
Primary Care Protocol
Patient Transfer for
Evaluation, Diagnostic
Testing or Treatment
(attachments)
Last
Approved
Date
New
Protocol
New Policy
BOT due
date
from last
approval
?
Next review
date after
BOT
approval?
3 Years
3 Years
Policy
Owner/Author/
Reviewer
Purpose
Steve Kilgore (DonAmbulatory), David
Moskowitz, MD,
(Medical Director,
Hope Center), Guy
Qvistgaard (CAO)
Protocol outlining
the responsibilities of
RNs and LVNs in
adult primary care,
adult immunology
and women’s clinic at
Alameda Health
System to vaccinate
adults who meet the
criteria below
To provide optimal
patient care before,
during and after
transfer to outside
facilities including
Skilled Nursing
Facilities
Reshea Holman
(VP, Patient Care
Services), Kinzi
Richholt (CNE)
Summary
of Changes
History of
Review
Committee
Changes:
•
New
Protocol
•
•
Changes:
New Policy
•
Ambulatory
Operations
Committee
Pharmacy
and
Therapeutics
Committee
Nursing
Executive
Team
Patient Care
Services
Type
Clinical
Clinical
MEC
Reviewer
Title of Policy
Standardized
Procedure: Refill of
Medications in Adult
Primary Care by RN
Standardized
Procedure: Titration of
Hypertension
Medications In Adult
Primary Care
(attachment)
Last
Approved
Date
New
Protocol
New
Protocol
BOT due
date
from last
approval
?
Next review
date after
BOT
approval?
3 Years
3 Years
Policy
Owner/Author/
Reviewer
Purpose
Steve Kilgore (DonAmbulatory), David
Moskowitz, MD,
(Medical Director,
Hope Center), Guy
Qvistgaard (CAO)
The protocol
describes the
functions that a
Registered Nurse
(CNII, CNIII, CNIV)
may perform to refill
chronic medications
in Adult Primary Care
clinics (Highland
Wellness, Adult
Immunology Clinic,
Eastmont Wellness,
Hayward Wellness,
Newark Wellness) at
Alameda Health
System.
This protocol
describes the
functions, which may
be performed by
Registered Nurses
(Clinical Nurse
II/III/IV) in managing
uncomplicated
hypertension in
adults ages 18 and
older in the Adult
Primary Care Clinics.
Steve Kilgore (DonAmbulatory), David
Moskowitz, MD,
(Medical Director,
Hope Center), Guy
Qvistgaard (CAO)
Summary
of Changes
History of
Review
Committee
Changes:
•
New
Protocol
•
•
•
Changes:
•
New
Protocol
•
•
•
Type
Ambulatory
Operations
Committee
Pharmacy
and
Therapeutics
Committee
IDPC
Nursing
Executive
Team
Clinical
Ambulatory
Operations
Committee
Pharmacy
and
Therapeutics
Committee
IDPC
Nursing
Executive
Team
Clinical
MEC
Reviewer
Executive Summary for Quality Professional Services Committee
Policies and Procedures
February, 2016
Title of Policy
Last
Approved
Date
Hospital Acquired
Infection (HAI)
Prevention Policy for
CCU Patients Including
MRSA
4/2014
Lexiscan Administration
During Radionuclide
Myocardial Perfusion
Imaging Test
7/2011
BOT due
date
from last
approval
?
4/2017
7/2014
Next review
date after
BOT
approval?
3 Years
3 Years
Policy
Owner/Author/
Reviewer
Cathy King
(Infection
Preventionist),
Bonnie Panlasigui
(CAO)
Bonnie Panlasigui
(CAO)
Purpose
To reduce the incidence
of HAIs (Hospital Acquired
Infections) in the Critical
Care Unit all patients will
be treated with Mupirocin
(Bactroban) 2% nasal
ointment per MRSA-AST
Protocol.
To identify the critical
components involved in
performing a
pharmacologic myocardial
perfusion imaging (MPI)
stress test with Lexiscan
(Regadenoson).
Summary of
Changes
Changes:
History of Review
Committee
Type
• Infection Control
Committee
Clinical
• Cardiology
• Nuclear Medicine
Clinical
Major revisions
Changes:
Major revisions
1
Executive Summary for Quality Professional Services Committee
Policies and Procedures
February 2016
Title of Policy
Advance Healthcare
Directive (AHD)
Condition 44
Unrepresented Patients
Last
Approved
Date
9/2012
BOT due
date
from last
approval
?
9/2015
New Policy
9/2012
Next review
date after
BOT
approval?
3 Years
3 Years
9/2015
3 Years
Policy
Owner/Author/
Reviewer
Judy Heinemann
(Nurse Educator),
Viki Ardito
(Director, Patient
Care Services),
James Jackson
(CAO)
Gloria Coats
(Manager, Case
Management),
Judy Heinemann
(Nurse Educator),
Viki Ardito
(Director, Patient
Care Services),
James Jackson
(CAO)
Judy Heinemann
(Nurse Educator),
Viki Ardito
(Director, Patient
Care Services),
James Jackson
(CAO)
Purpose
Summary of
Changes
To comply with Patient
Self-Determination Act and
state law.
Changes:
This policy outlines when
Condition Code 44 is
appropriate and what
steps need to be taken for
implementation.
Changes:
This policy guides health
care professionals through
a process to make medical
treatment decisions on
behalf of an incapacitated
patient who lacks a
surrogate decision maker
and when there is no
Changes:
Minor revisions
New policy
Updated reference to
CHA2014 vs. 2012
History of Review
Committee
Type
• Quality and Safety
Committee
Admin
• Utilization
Management
• Quality and Safety
Committee
Admin
• Quality and Safety
Committee
Admin
1
Title of Policy
Last
Approved
Date
Carbapenem Resistant
Enterobacteriaceae
New Policy
Medication – Anesthesia
Narcotic Boxes
9/2012
Multi-Drug Resistant
Organisms (MDRO)
9/2012
Outpatient Surgery
Scheduling
9/2012
BOT due
date
from last
approval
?
9/2015
9/2015
9/2015
Next review
date after
BOT
approval?
Policy
Owner/Author/
Reviewer
3 Years
Gloria Przelenski
(Infection
Preventionist),
Altino McKelvey
(Director,
Infection
Control), James
Jackson (CAO)
3 Years
3 Years
3 Years
Purpose
known family member
who is willing and able to
make medical treatment
decisions on behalf of the
patient.
To prevent the
transmission of
Carbapenem Resistant
Enterobacteriaceae
(CRE) within San Leandro
Hospital.
Summary of
Changes
Changes:
New Policy
Elizabeth
Blackburn
(Pharmacy
Manager), Vicki
Ardito (Director,
Patient Care
Services), James
Jackson (CAO)
To have adequate
accountability of
controlled medications in
Anesthesia and to adhere
to state and federal
regulations.
Changes:
Gloria Przelenski
(Infection
Preventionist),
Altino McKelvey
(Director,
Infection
Control), James
Jackson (CAO)
To ensure that all patients
that have positive cultures
for Multi-Drug Resistant
Organisms (MDRO) are
placed in contact
precautions.
Changes:
Mary Schwind
(Surgical Services
Manager), Tracy
Stone (Director,
Perioperative
To be able to provide the
required staff, room, and
equipment for the planned
procedures and for safe
efficient patient care.
Changes:
Minor revisions
Added CRE
information to policy
Minor revisions
History of Review
Committee
Type
• Infection Control
Committee
• Quality and Safety
Committee
Clinical
• Pharmacy and
Therapeutics
• Quality and Safety
Clinical
• Infection Control
Committee
• Quality and Safety
Committee
Clinical
• Surgery
Committee
• Quality and Safety
Committee
Clinical
2
Title of Policy
Process for Charges
Last
Approved
Date
9/2012
Urinary Catheter
Management Protocol
9/2012
Use of the Germfree
Compounding Aseptic
Isolator (CAI or Glove
Box)
9/2012
BOT due
date
from last
approval
?
Next review
date after
BOT
approval?
9/2015
3 Years
9/2015
9/2015
3 Years
3 Years
Policy
Owner/Author/
Reviewer
Services), James
Jackson (CAO)
Mary Schwind
(Surgical Services
Manager), Tracy
Stone (Director,
Perioperative
Services), James
Jackson (CAO)
Judy Heinemann
(Nurse Educator),
Viki Ardito
(Director, Patient
Care Services),
James Jackson
(CAO)
Elizabeth
Blackburn
(Pharmacy
Manager), Vicki
Ardito (Director,
Patient Care
Services), James
Jackson (CAO)
Purpose
To ensure proper
procedures is followed for
inputting daily charges in
the operating room.
Summary of
Changes
Changes:
Major revisions
To prevent and reduce
catheter associated
urinary tract infections
Changes:
To ensure that the
compounding aseptic
isolator (CAI) is cleaned
and used in a proper
manner.
Changes:
Minor revisions
Minor revisions
History of Review
Committee
Type
• Surgery
Committee
• Quality and Safety
Committee
Clinical
• Nursing
• Quality and Safety
Committee
Clinical
• Pharmacy and
Therapeutics
• Quality and Safety
Clinical
3