King/Drew Medical Center
Implementation Plan Update
Hospital Advisory Board
April 11, 2005
Background and Assessment
•
•
•
•
•
The County of Los Angeles entered into a Memorandum of Understanding (MOU)
with the Centers for Medicare and Medicaid Services (CMS) which required the
engagement of an outside contractor to provide interim managerial support at
King/Drew Medical Center to assess the major systems and operations and assist in
the restructuring of KDMC’s operations based on that assessment.
Navigant Consulting (NCI) was contracted with in October of 2004 to provide these
services.
NCI conducted a comprehensive assessment of all systems and operations at KDMC
which included a detailed action plan to address each of the
deficiencies/inefficiencies identified.
The initial assessment of acute care operations and the identification of performance
improvement opportunities at KDMC was completed January 3, 2005.
The assessment of ambulatory services and the final assessment of governance and
programs/services was completed February 1, 2005.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 2
Identification of Critical Success Factors
•
Upon completion of the assessment several factors were identified that are critical to
success:
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–
–
–
–
–
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An integrated, prioritized focused plan with ownership and commitment to its success by all
stakeholders
“Real” governance
“Sleeves rolled up, visible” leadership
Partnership with CMS, JCAHO and regulators in “finding solutions” versus “finding fault”
Disciplined execution of the plan with an “attention to detail mentality”
Defined individual roles and accountability “deep” into MLK
Sufficient, capable resources to enable success
Sufficient time to execute
Definition and commitment to the mission and vision of MLK
Communication, communication, communication – inside and out
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 3
Situational Analysis Report: Baptist Health Care Leadership Institute
•
As part of the assessment the Baptist Health Care Leadership Institute conducted a
Situational Analysis Report to:
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–
–
•
•
KDMC employees were asked to complete the Service Excellence Survey™. More
than 400 employees at various levels of the organization responded to the survey.
The survey analysis lends its focus on five key dimensions of service and operational
excellence.
Other tools were used to assess the current culture at KDMC and include qualitative
research methods, such as:
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–
–
•
Identify current strengths as they relate to service and operational excellence
Identify opportunities for improvement
Recommend strategies for areas to focus on over the coming year to move MLK/Drew
forward.
Medical Staff interviews and focus groups
Employee and Directors focus groups
Interviews with community leaders, Drew University representatives, Department of Health
Services leaders, and union representatives.
First Impression Audits were conducted by walking around the facility.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 4
Situational Analysis Report
Summary of Findings
•
KDMC has a rich history, a diverse work force and is positioned with a desire to move the
organization toward greater achievements and fulfillment of its mission and vision.
•
There is a large group of dedicated and passionate employees and physicians paired with a
sense of commitment to serving the community which can be leveraged to take the organization
to greater levels of achievement in the area of service and operational excellence.
•
As KDMC introduces proven strategies and practices focused on service excellence, the
organization should be able to create the synergistic energy needed for substantial breakthrough
advancements. However, organizations often find it difficult to transform their culture.
Overview of Identified Strengths
•
Strengths identified include, but are not limited to:
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Employee and physician pride in the hospital.
Long-term employees’ commitment and loyalty.
An understanding and support of the mission of providing comprehensive medical care to the community.
Other strengths revealed through the analysis were:
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The affiliation with Drew University.
The diversity of the work force.
The support from the community.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 5
Required Culture Changes
•
•
Findings indicate that KDMC has a culture of excuses and blaming.
Opportunities for improvement include:
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•
There needs to be a re-dedication to the stated mission and vision of KDMC
which are:
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•
Involvement and participation
Leader visibility and approachability
Leaders leading by example
Leadership development
Planning and direction (the organization is reactive versus proactive)
Accountability
HR practices as they relate to service excellence
Communication
Cross-departmental teamwork
A consistent and well-deployed customer service focus in every department
Mission: To provide quality, comprehensive medical care, that is accessible, acceptable and
adaptable to the needs of the community we serve.
Vision: An academic medical center of excellence that is caring, compassionate and
competent, focusing on the needs of our culturally diverse community as well as ways to
continually improve our service.
Values need to be developed and internalized.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 6
Implementation Plan: 1,066 Recommendations 3,662 Action Steps*
Initiative
Governance
Management/Structure
Risk Management
Regulatory
Performance and Quality Improvement
Infection Control
Budget
Productivity
Space Planning
Environment of Care
Facilities Management
Materials Management
Contracted Services (Respiratory)
Contracted Services (Dietary)
Contracted Services (Security)
Communications
Case Management and Utilization
Capacity and Throughput
Physical Therapy
Transport
Emergency Services
Perioperative Services
Med Admin - Clinical Programs and Medical
Departments
Med Admin - Medical Staff Affairs
Med Admin - Quality, Performance Improvement,
Utilization and Case Management
Med Admin - Administrative Issues / Medical Admin
Nursing Services - overall
Psychiatric Services - overall
Information Technology - overall
Health Information Management - overall
Human Resources - overall
Radiology
Laboratory/Pathology
Pharmacy
Cardiology
Neuroscience
Ambulatory Services - overall
Programs & Services - overall
KDMC Total
Total Num of
Recommendations
14
7
22
23
52
27
11
7
5
14
10
13
6
7
2
8
46
30
6
1
64
45
34
52
24
10
82
42
17
66
29
31
55
31
13
8
103
49
1,066
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 7
*Note: The implementation plan is a
“living” workplan. As such, the
number of recommendations and
action steps may change over the
course of the workplan
implementation.
Implementation Plan: Measurement and Tracking
•
•
Results Management Office was established to provide discipline and
structured tracking and measurement that are critical to the success of the
Implementation Plan.
Each Initiative has a Workplan that was developed in collaboration with KDMC
Leadership. The Workplan components include:
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–
–
–
•
•
Time frame for each Recommendation
Action Steps
Accountable person for each Action Step
Due Date for each Action Step
Implementation Risks Identified
The Workplan is a “living” plan. It is updated to reflect changes in course deemed
appropriate. Timelines however, will not be changed without agreement of the KDMC
CEO and COO.
Each Action Step is reviewed at their due date to ensure completion. Any
Action Steps that are not achieved will be ‘flagged’ and a remediation plan is
identified and executed.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 8
Supportive Groups: HR, Facilities and Information Technology
•
Three sub groups composed of select KDMC, DHS and LAC meet regularly to support
completion of the Action Steps.
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•
The Human Resource Group supports:
–
–
–
–
–
–
–
–
•
•
Human Resources
Facilities and Equipment
Information Technology
Performance evaluation and management process
Management training and organizational development
Monitoring of regulatory compliance
Employee relations including grievance remediation
Recruitment and retention
Provision of operating report and data
Development of KDMC policies and procedures
Classification
The Facilities/Equipment Group supports the identification, planning and implementation of
facility changes. This group also supports the identification of needed equipment and expedites
their acquisition.
The Information Technology Group supports and coordinates technology required to execute
the plan. They also prioritize department upcoming/existing job requests and allocate resources
appropriately.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 9
Tracking Workplan Implementation
Sample Workplan
Section:
Initiative:
KDMC Management:
KDMC Senior Staff:
NCI Support:
Update Lead:
S10 - Ancillary Services
I02 - Laboratory/Pathology
L. McAuley
P. Valenzuela
J. Rodas
H. Mohamed
Bi-Weekly Update
Status Update Through: 4/1/05
ID
Status Update
Workplan
Filter
Rec
Identifier
Time Frame
Description
S10-I02-R017
Urgent
S10-I02-R017
Urgent
S10-I02-R017
Urgent
S10-I02-R017
Urgent
S10-I02-R017
Urgent
S10-I02-R017
Urgent
S10-I02-R017
Urgent
S10-I02-R017
Urgent
S10-I02-R018
Recommendation Description
Group
Action
Step
Num
Action Step Description
Due Date
Action Complete? Status
Risk
Remediation Plan
Step Due (Yes/No)
(Red/ Identified?
(if status is red/yellow or if
This
Yellow/ (Yes/No) action step is not completed)
Week?
Green)
OVERALL
0
N/A
2/28/05
DUE!
Yes
Green
ACTIONS
1
1/18/05
DUE!
Yes
Green
No
ACTIONS
2
1/18/05
DUE!
Yes
Green
No
ACTIONS
3
Outline new patient check in and registration
process; obtain approval from lab
manager/director
Identify patient sign-in sheets and establish new
patient flow logistics (I.e. . Sign in Vs number
system)
Prepare area for home collected specimen drop
off and processing
1/18/05
DUE!
Yes
Green
No
ACTIONS
4
Incorporate runner pick up/delivery into new
process
1/24/05
DUE!
Yes
Green
No
ACTIONS
5
1/26/05
DUE!
Yes
Green
No
ACTIONS
6
Convene meeting with nurse managers to
discuss new specimen drop off station;
operational changes
Write and/or update pertinent protocols and
policies to support new process
1/28/05
DUE!
Yes
Green
No
ACTIONS
7
Complete staff training and competency
validation
1/28/05
DUE!
Yes
Green
No
Short-term
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Revamp patient registration/check in process for blood
collection; incorporate home collected specimen drop
off.
Initiate phlebotomy services for psychiatry.
OVERALL
0
N/A
6/30/05
S10-I02-R018
Short-term
Initiate phlebotomy services for psychiatry.
ACTIONS
1
DUE!
Yes
Green
No
Short-term
Initiate phlebotomy services for psychiatry.
ACTIONS
2
2/18/05
DUE!
Yes
Green
No
S10-I02-R018
Short-term
Initiate phlebotomy services for psychiatry.
ACTIONS
3
Convene meeting with Psychiatry manager and
conduct needs assessment
Evaluate psychiatry unit needs Vs available
phlebotomy resources and schedules
Develop phlebotomy training program (of high
risk area); complete staff training; validate
competency
2/18/05
S10-I02-R018
4/1/05
DUE!
No
Yellow
No
S10-I02-R018
Short-term
Initiate phlebotomy services for psychiatry.
ACTIONS
4
No
Short-term
Initiate phlebotomy services for psychiatry.
ACTIONS
5
5/1/05
No
S10-I02-R018
Short-term
Initiate phlebotomy services for psychiatry.
ACTIONS
6
Write pertinent protocols, policies, and
procedures
Verify nurse proficiency and competency
ordering labs in Affinity (complete additional
training if needed)
Provide access to secure unit to all phlebotomy
personnel
5/1/05
S10-I02-R018
5/1/05
No
New phlebotomy staff has been hired
(3/30). Service implementation plan
currently underway. Planned go-live
Yellow
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 10
Although a slight delay was experienced
due to the need to hire new staff, the
laboratory and Psych. Department are
back in track with the target
Comments
Management of Risk
•
•
Established a Chief Implementation Officer to oversee the implementation of the
Workplan and establishment of performance measures.
A warning dashboard system was defined to communicate issues to KDMC
leadership on recommendations behind the plan timeframe or at risk for other
reasons.
Green Completed or to be completed by the identified due date without major
obstacles.
Yellow Completion is likely, however it may be delayed (not major delay). The
issues are manageable.
Red
Major risk has been identified, and/or completion will be delayed (major
delay).
•
KDMC leadership review the dashboard and proactively identify and revise action
plans to manage the risk identified.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 11
Recommendations and Identified Status
All Recommendations
Initiative
Governance
Management/Structure
Risk Management
Regulatory
Performance and Quality Improvement
Infection Control
Budget
Productivity
Space Planning
Environment of Care
Facilities Management
Materials Management
Contracted Services (Respiratory)
Contracted Services (Dietary)
Contracted Services (Security)
Communications
Case Management and Utilization
Capacity and Throughput
Physical Therapy
Transport
Emergency Services
Perioperative Services
Med Admin - Clinical Programs and Medical
Departments
Med Admin - Medical Staff Affairs
Med Admin - Quality, Performance Improvement,
Utilization and Case Management
Med Admin - Administrative Issues / Medical Admin
Nursing Services - overall
Psychiatric Services - overall
Information Technology - overall
Health Information Management - overall
Human Resources - overall
Radiology
Laboratory/Pathology
Pharmacy
Cardiology
Neuroscience
Ambulatory Services - overall
Programs & Services - overall
KDMC Total
Total Num of
Recommendations
"Green"
Recommendations
"Yellow"
Recommendations
Count
13
7
21
20
48
27
11
4
3
12
9
10
6
7
2
8
41
26
6
1
64
44
31
%
93%
100%
95%
87%
92%
100%
100%
57%
60%
86%
90%
77%
100%
100%
100%
100%
89%
87%
100%
100%
100%
98%
91%
Count
14
7
22
23
52
27
11
7
5
14
10
13
6
7
2
8
46
30
6
1
64
45
34
52
24
52
24
100%
100%
-
10
82
42
17
66
29
31
55
31
13
8
103
49
10
78
39
10
52
25
26
46
23
-
100%
95%
93%
59%
79%
86%
84%
84%
74%
0%
0%
0%
0%
-
1,066
806
76%
77
%
1
1
3
4
3
1
1
1
2
5
4
1
3
4
3
7
12
4
4
7
6
-
7%
0%
5%
13%
8%
0%
0%
43%
20%
7%
10%
15%
0%
0%
0%
0%
11%
13%
0%
0%
0%
2%
9%
"Red"
Recommendations
%
Count
-
-
0%
0%
0%
0%
0%
0%
0%
0%
20%
7%
0%
8%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
-
0%
0%
0%
5%
7%
41%
18%
14%
13%
13%
19%
0%
0%
0%
0%
-
0%
0%
0%
0%
3%
0%
3%
4%
6%
0%
0%
0%
0%
7%
10
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 12
1
1
1
2
1
2
2
-
1%
Note: As of 4/1/05,
Recommendations in
areas of Cardiology,
Neuroscience, Ambulatory
and Program&Services do
not have their "status"
defined.
As a result, total number
of recommendations in
Green, Yellow and Red do
not add up to 100%.
Performance Measures
•
•
In addition to tracking the status of the recommendations and workplans, we are
establishing performance measures that will measure the success of the plan.
Creating organizational performance measures in the following areas:.
•
•
•
•
•
•
•
•
Human Resources
Productivity
Finance
Regulatory
Quality and Performance Improvement
Establishing key performance measures for each initiative/department.
Planning to initiate a Press Ganey - patient satisfaction survey.
Planned implementation of the UHC Patient Safety Net and Near Miss Reporting
System.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 13
Planned Performance Measure Roll-out
KDMC Hospital-wide Performance Measures - Mar05
Human Resources Measures
Incorporate
/ Link with
other reports
Labor Productivity Monitoring - May05
Report to
BOS, HAB
Financial Monitoring - May05
Regulatory Monitoring
UHC
"Key Indicator
Report" Aug05
HQA "Hospital
Quality
Measures"
Press Ganey
"Patient
Satisfaction
Survey"
LAC
"Performance
Measure"
Performance Improvement & Quality Improvement,
Risk Management - May05
Infection Control
Monitoring
Department-Specific "Compass"
Nursing Svcs
Psych Svcs
Laboratory
Neuroscience
Materials Mgmt
Periop
Pharmacy
Ambulatory
Environment
ED
Radiology
Capacity &
Thruput
Facilities Mgmt
Cardiology
Maintained
within Depts
Case Mgmt &
Utilization
HIM
(Same accountability holds for Department Compass as for Workplan)
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 14
IT
Sample Performance Measures: HR
KDMC Management: H. Wells
KDMC Senior Staff: M. Henry
Lead: S. Stern
Monthly Performance Measures
Item
Nov/Dec
Target
Jan-05
Feb-05
Mar-05
Corrective Action
NC
0
NC
TBD
10.5%
11.8%
NYA
Identify action steps based on the Service Excellence Survey. Identify causes of
"unhealthy" turnover. Develop an employee retention strategy.
Continue vigorous recruitment activities.
"Cleaned up" the PAR data. Review monthly.
Continue vigorous recruitment activities.
Identified key position recruitment list to track the recruitment process.
Enhance recruitment effort including a targeting of key positions.
See above.
See above.
See above.
Sending out a letter 1 month prior to due date to alert staff. Establishing a policy on
consequences of non-compliance.
Monitor % by department to identify trends/issues.
NC
TBD
0.7%
0.6%
NYA
Monitor % by department to identify trends/issues.
NC
TBD
2.5%
2.2%
NYA
Monitor % by department to identify trends/issues.
NC
NA
108
101
NYA
Number of open claims to total employee population
NC
NA
605
591
Percentage of open claims to total employee population
Total number of lost hours for workmans compensation cases
Total number of lost FTEs for workmans compensation cases
NC
NC
NC
20%
TBD
TBD
25.6%
1409
7
NYA
NYA
NYA
Number of active third level employee grievances
NC
NA
38
25
Implement program to improve management.
Established a case management program to manage cases. 8 new hires to manage
cases (target caseload 1:50)
See above.
See above.
See above.
Redesigned and educated senior management on the Performance Management
function (including key functions and activities, role clarification, identifying the team,
creating an "issue" referral algorithm. Created an "issue" referral priority system and
targeted response time. Collecting KDMC feedback on the Performance Management
function.
NC
<5%
1.6%
NYA
See above.
NC
NC
NA
5%
184
7.8%
179
NYA
Percentage of staff with completed performance evaluation nonMAPP
8%
100%
53.7%
64.5%
Percentage of MAPP staff with completed performance evaluation
NC
100%
See above.
See above.
"Cleaned up" the measurement and tracking. Identified barriers to completion of PEs.
Established a group-wise notification to managers of those PEs that are due and
upcoming due. Clarified PE manager expectations including required attachments.
Review all PE forms for opportunities to streamline while meeting overall goals and
JCAHO. Deadline for backlog completion is the end of April.
See above.
Percentage of staff with documented attendance at orientation
(cumulative)
NC
95%
NC
95%
Turnover rate (KDMC Total)
6.5%
<10%
Turnover rate (KDMC Supervising Staff Nurses, RNs, and LVNs)
Overall number of PARs
Number of approved PARs
Average time to fill a position from approved PAR
Number of recruited approved PARs
Net gain or loss of staff total
Net gain or loss registered nurses
Net gain or loss LVNs
Number of staff non-compliant with annual health service screening
(excluding ELP)
Percentage of sick hours to regular hours worked
Percentage of AWOP (authorized) sick hours of regular hours
worked
Percentage UNAWOP (unauthorized) sick hours of regular hours
worked
Number of staff on ELP (Extended Leave Program)
NC
161
48
161
48
6
NC
NC
TBD
TBD
TBD
60-90 days
NA
TBD
TBD
TBD
Percentage of active third level employee grievances to total
employee population
Number of open discipline cases
Percentage of open discipline cases to total employee population
Percentage of agency and traveler staff with documented attendance
at orientation (cumulative)
Percentage of compliance with annual health update
15.7%
15.5%
15.0%
21.9%
195
27
15
6
-1
161
32
7
3
1
20.2%
259
198
208
78
-4
-1
0
1941
9.3
NYA
50%
74%
Identified 91 noncompliant people. Names distributed to supervisors. Adding additional
classes to the schedule. If failure to comply HR will institute disciplinary actions.
Developing a reorientation package. Identifying strategies for automating.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 15
Sample Performance Measures: Laboratory
KDMC Management: L. McAuley
KDMC Senior Staff: P. Valenzuela
Lead: H. Mohamad
Monthly Performance Measures
Item
Baseline
Target
Jan-05
Feb-05
Percentage of STAT test requests to all test requests
40-83%
<20%
35%
35%
Overall STAT turnaround time (minutes from received to
reported)
72 min
< 60 min
59
63
Overall turnaround time from the time test is ordered (hours)
3 hours
<1.5 hours
2.7
2.9
Ratio of Type and Cross match to transfusion
Percentage of blood transfusion incidents to transfusions
Blood product waste rate
Percentage of critical result read-back documentation
<2:1
<1%
5.6%
75%
<2:1
<2%
<2%
100%
1.8
1%
4.4%
95%
1.8
1%
2.8%
97%
Percentage of specimen rejection
>2%
1.5%
1.1%
1.0%
Percentage of documented Incidents (based on number of lab
requests received)
NC
< 0.5%
0.3%
0.5%
Blood culture contamination rate
8%
<3%
4.8%
5.0%
Percentage of outpatient visit wait time less than 5 minutes
NC
75%
Customer satisfaction rating - External (Outpatient Lab)
NC
80%
Customer satisfaction rating - Internal
NC
80%
0.72%
< 1.5%
0.72%
0.55%
Surgical pathology turnaround time (overall days)
2.5
< 3 days
2.5
2.5
Surgical frozen section turnaround time (minutes)
16.8
< 20 min
16.8
18.2%
Cytology Non-GYN turnaround time (days)
2.8
< 3 days
2.8
2.2
Percentage of Point of Care Testing (POCT) non-compliance
Corrective Action
1. Lab Advisory Committee is currently revamping the STAT test menu 2. New test menu
finalized, policy currently in draft format 3. New test menu and policy to be introduced in
April 2005
1. Test menu consolidation is underway (have completed initial correlation studies to enable
the process) 2. Work station consolidation planned for end of April (once all systems have
been tested) 3. Conducting additional root cause analysis of TAT process to further
improve the process
1. Test menu consolidation is underway (have completed initial correlation studies to enable
the process) 2. Work station consolidation planned for end of April (once all systems have
been tested) 3. Conducting additional root cause analysis in the pre-analytical steps of the
process 4. Additional phlebotomy support has been hired and is currently in training
On target, but monitoring all systems in place
On target, but monitoring all systems in place
On target, but working with blood usage committee to further decrease waste
1. Continue to work with technical staff and re-enforce policy
1. Developed incident report tracking tool to conduct root cause analysis 2. Currently
working with Risk Manager to evaluate data and corrective action
1. Incident tracking tool has been developed and tested 2. Have identified the ED as the
main source of incidents 3. Began meetings/discussions with ED to address various issues
4. Have tested ED printers and will begin to print STAT results remotely (exact date in April
TBD)
1. Conducting additional root cause analysis of remaining areas of concern that are leading
to contaminated blood cultures 2. Continue to re-enforce policy requiring only phlebotomists
to draw blood cultures 3. Have added additional phlebotomists to staff, including the night
shift where dedicated phlebotomists weren't available
1. Have obtained the initial data to establish a baseline 2. Currently considering a patient
comment card to be located in the phlebotomy area
1. Currently reviewing Q-Track tool available through the College of American Pathologists,
which has allowed the laboratory to collect initial data. Reported quarterly.
1. A work group led by Dr. Theresa Loya has developed a satisfaction survey 2. NCI has
reviewed and provided input on the survey format and measurement tool 3. Survey will be
released on schedule by April 15, 2005
On target. Will continue to monitor.
On target, but considering additional improvements in the physical lay-out of the
transcription department, new dictation system, and a revamped work flow process to
further improve TAT
On target. Will continue to monitor.
On target, but considering additional improvements in the physical lay-out of the
transcription department, new dictation system, and a revamped work flow process to
further improve TAT
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 16
Sample Department Specific Performance Measures:
Perioperative Services (1)
First Case On-Time Starts
OR Overall Suite Utilization, without TOT
100%
100%
90%
90%
80%
75%
70%
70%
60%
60%
Percentage
Percentage
80%
95%
50%
57%
52%
51%
47%
50%
40%
40%
30%
26%
24%
21%
30%
22%
20%
20%
10%
10%
0%
0%
0%
0%
0%
0%
0%
Mar-05
Apr-05
May-05
0%
Target
Baseline
Oct-Dec-04
Jan-05
Feb-05
Mar-05
Apr-05
May-05
Target
Baseline
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 17
Oct-Dec-04
Jan-05
Feb-05
Sample Department Specific Performance Measures:
Perioperative Services (2)
Patient In to Incision Time
PAR LOS
450
55
49
50
45
393
400
44
44
43
349
350
311
40
300
257
Minutes
Minutes
35
30
26
25
20
20
20
250
200
20
150
120
15
100
10
50
5
0
0
0
0
0
0
0
0
0
0
Mar-05
Apr-05
May-05
0
Baseline
Oct-Dec-04
Jan-05
Feb-05
Target
Mar-05
Apr-05
May-05
Target
Baseline
Actual
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 18
Oct-Dec-04
Jan-05
Feb-05
Implementation Plan: Reporting
•
•
•
Status of the recommendations, workplans, performance measures and results
are reviewed with the KDMC leadership and management staff, Advisory Board,
Board of Supervisors and regulatory bodies.
Status updates are reviewed with KDMC leadership and management staff every
other week. This group provides oversight and management of the plan. This group
also serves as the discussion forum for interdependencies and synchronization of
action steps. They review all performance variance in actions steps due that week for
completion and discuss risks and issues with future actions steps.
Status updates will be reported to the newly created KDMC Hospital Advisory
Board and the Board of Supervisors monthly and will include the following:
–
–
–
–
Overall status of progress by Section (Initiative).
Measurement of Key Performance Measures.
Areas of performance variance and corrective action plans.
Identification of implementation risks.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 19
Completed Recommendations
Initiative
Governance
Management/Structure
Risk Management
Regulatory
Performance and Quality Improvement
Infection Control
Budget
Productivity
Space Planning
Environment of Care
Facilities Management
Materials Management
Contracted Services (Respiratory)
Contracted Services (Dietary)
Contracted Services (Security)
Communications
Case Management and Utilization
Capacity and Throughput
Physical Therapy
Transport
Emergency Services
Perioperative Services
Med Admin - Clinical Programs and Medical
Departments
Med Admin - Medical Staff Affairs
Med Admin - Quality, Performance Improvement,
Utilization and Case Management
Med Admin - Administrative Issues / Medical Admin
Nursing Services - overall
Psychiatric Services - overall
Information Technology - overall
Health Information Management - overall
Human Resources - overall
Radiology
Laboratory/Pathology
Pharmacy
Cardiology
Neuroscience
Ambulatory Services - overall
Programs & Services - overall
KDMC Total
Total Num of
Recommendations
14
7
22
23
52
27
11
7
5
14
10
13
6
7
2
8
46
30
6
1
64
45
34
Total
Recommendations
Completed
%
Count
5
36%
4
57%
1
5%
14
61%
7
13%
25
93%
0%
1
14%
1
20%
4
29%
0%
0%
3
50%
2
29%
2
100%
2
25%
7
15%
7
23%
0%
1
100%
14
22%
15
33%
5
15%
52
24
8
7
15%
29%
10
82
42
17
66
29
31
55
31
13
8
103
49
17
25
7
33
20
5
20
13
-
0%
21%
60%
41%
50%
69%
16%
36%
42%
0%
0%
0%
0%
1,066
275
26%
Total Num of
Recommendations
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 20
1,066
Total
Recommendations
Completed
%
Count
275
26%
Urgent and Short Term “Red” Recommendations
Initiative
Rec Identifier Time Frame
Description
Recommendation Description
Remediation Plan
(if status is red/yellow or if action step is not
completed)
Space Planning
S02-I09-R002
Urgent
Identify critical space requirements and
implement remediation plan for areas such
as outpatient pharmacy.
Currently evaluating all vacant space to determine
potential uses of space that can solve our critical space
issues (pharmacy, OR, ER, and psych) in an effort to
reduce construction time/costs.The ER has been
removed from the critical needs list since there have
been no CMS or JCAHO citations relative to plant that
cannot be adressed by process. OSHPD plans
approved, last fall, to redesign the PES triage area will be
evaluated to determine if that can be fast tracked.
Alternate space/set up for cashiers has been identified in
the women's center that will provide additional contiguous
pharmacy space at little cost. The architect presented
two options for OR renovation. One is lower cost but
does not include many of the patient flow and clean
corridor needs. We are working with DPW to present the
materials to the BOS for approval to move forward.
Expect final decisions in June 2005.
Pharmacy
S10-I03-R008
Urgent
Build and install GE PIS.
Awaiting DHS decision and implementation schedule.
Continued discussion of short term strategies at the
KDMC IT Group.
Environment of Care
S02-I10-R013
Short-term
Design and implement an infant abduction
system.
Determined to not be essential by the
Facilities/Equipment workgroup comprised of County
based on the fact that none of the other hospitals have
an infant abduction system and there is no specific
JCAHO or CMS regulation requiring one.
Materials Management
S02-I12-R011
Short-term
Increase communication with physicians,
with support from hospital leadership, to
increase standardization of clinical product
selection.
Discussion/meeting between CFO and COO is scheduled
for 4/11/05 to seek ways to enhance VAF function and
collaboration between VAF and Materials Management.
CFO and COO will also discuss optimal form of
standardization subgroups.
Laboratory/Pathology
S10-I02-R011
Short-term
Evaluate the operational logistics in place for
the physician review and attestation of
completed laboratory reports. Consider
printing reports remotely to the requesting
physician and/or the electronic attestation of
reports with specific monitoring tools in place
Affinity does not support electronic process to attest lab
reports on line. Currently considering a manual process,
while continuing to work with IT to evaluate the
capabilities of 'chart management' in Affinity. Initiating
remote printing on a limited basis to support the ED
(implementation planning is currently underway with end
of April as a target).
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 21
Urgent and Short Term (June 30) Recommendations Completed
Urgent Recommendations Only
Urgent
Num of Urgent
Recommendations
Recommendations
Completed
%
%
Count
Count
225
21%
190
84%
Short-term Recommendations Only
Short-term
Num of Short-term
Recommendations
Recommendations
Completed
%
%
Count
Count
429
40%
71
17%
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 22
Short-term Reco
Accomplishments to Date
Management/Leadership
• Implemented revised organizational charts for the Chief Executive Officer, Medical
Director, Chief Nursing Officer and Chief Operating Officer.
• Initiated recruitment for all interim executive/management positions in March.
• Revised all functional job descriptions for Executive and Senior Managers and
identified goals and objectives for each.
• Conducting ongoing assessment of current KDMC leadership capabilities against the
functional job descriptions.
• Moved public relations from an ad-hoc process to a formalized functioning office. A
DHS Communication employee is now serving half time at KDMC to assist with
management of the flow of public information, provide advice to hospital leadership
on public relations issues, and assist with crafting key internal and external
messaging.
• Redesigned the employee newsletter to keep all KDMC employees apprised of
administration and regulatory updates, campus events, HR initiatives and other news
items.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 23
Accomplishments to Date
Regulatory/Quality and Performance Improvement
• Separated the performance and quality improvement functions from the regulatory
function to allow more focus on each.
• Appointed an Interim Director for Quality Management/Performance Improvement.
• Developed action plans for all 288 deficiencies/citations related to Joint Commission
standards, Residency Review Committee (RRC)/Graduate Medical Education
Committee (GMEC), CMS Conditions of Participation and Title 22 regulations.
• Established and communicated accountability by individual manager their specific
role is to restore Accreditation.
• Began a mock survey program this month to ensure that implemented improvement
plans have achieved their outcomes and change has been sustained.
• Overhauled the critical/sentinel event notification process to ensure that all staff
understand and report events; issues are investigated within 24 hours; and a
multidisciplinary route cause analysis is completed in a timely manner.
• The Infection Control Committee has reviewed and approved the new Infection
Control plan. Revisions have been made to the data collection process to produce
meaningful analysis of performance of the infection control process.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 24
Accomplishments to Date
Clinical Care
• Stabilized staffing to meet (and sometimes exceed) California ‘required ratios’.
• Ensured that all nurses are licensed with the appropriate certification ACLS, etc.
• Increased the available staffed beds for patients requiring telemetry.
• Developed level of care criteria for ICU and intermediate care to ensure patients are
receiving care in the right level of bed.
• Instituted an arrhythmia interpretation test to ensure standard knowledge base for
telemetry nurses.
• Instituted a practice for RNs (in addition to the telemetry technician) to interpret and
document rhythm strips every shift for patients on telemetry.
• Instituted management of assaultive behavior training for 100% of staff. Successful
removal of CMS Immediate Jeopardy.
• Defined role expectations for Nurse Managers including daily rounds with physicians
and chart reviews to ensure care provision.
• Instituted shift to shift rounding with the Nurse Manager and Charge Nurse to provide
care consistency.
• Instituted daily interdisciplinary care coordination rounds to coordinate care.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 25
Accomplishments to Date
•
•
•
•
Ongoing mentoring of nursing supervisors to provide enhanced off shift support and
oversight, improving decision making – 2 new supervisors hired.
Conducting cardiopulmonary mock drills to provide ‘hands-on’ multidisciplinary
training and education to staff in management of arrests.
Formally reviewing all arrests (completing an evaluation tool) to critique the response
and outcomes and to identify issues and learning needs.
Developed and instituted an 8-hour ventilator care course - continuing to offer until all
staff caring for ventilator patients attend.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 26
Accomplishments to Date
Medical Staff
• Reconfigured medical administration staff to include Associate Medical Director
(AMD) position for Med Staff Affairs and Utilization Management (UM) and Clinical
Programs. Goals and objectives have been developed for each position.
• Implemented a resident supervision policy identifying department specific protocols
for resident supervision for each medical department.
• Implementing proctoring protocols and a resident supervisory process.
• Bylaws and rules and regulations have been updated and are now compliant with
CMS and JCAHO regulations and standards.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 27
Accomplishments to Date
Psychiatry
• Implemented a new treatment model for Psychiatric Emergency Services (PES).
• Instituted weekly focus group meetings to discuss and revise the patient treatment
model.
• Improved programming has begun with therapeutic groups being run by all
disciplines.
• Instituted seven-day/week coverage for occupational therapy, recreational therapy
and social workers was instituted for all inpatient units and PES.
• Improved the therapeutic milieu by providing consistent staff coverage on each unit
and PES.
• Instituted daily rounds on all units and PES to review the patient’s care plan.
• Developed a quality improvement plan with indicators to be monitored by each
specific discipline and reported to the Psychiatric Management Team.
• Developed criteria for prompt pediatric/adolescent disposition for PES patients
awaiting admission.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 28
Accomplishments to Date
Emergency Department
• Closed the Trauma Center March 1 with few issues.
• Established an ED Joint Practice Committee for nursing and medical staff to identify,
discus and resolve issues.
• Implemented a new diversion policy establishing objective criteria to determine ED
saturation.
–
•
•
•
Reduced the time frame from 4 to 2 hours reducing diversion hours from 71% in January;
55% in February and 21% in March.
Implemented a new triage process that will appropriately send patients to Fast Track
and subsequently decrease the load on the acute side.
Initiated care protocols to help ensure appropriate, timely and safe care.
Revised MAC transfer policy to decrease number of request out to Med Alert Center.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 29
Accomplishments to Date
Perioperative
• Instituted and enforced policies that ensure correct person identification/procedure
and site verification.
• Enforced the sponge/instrument count policy/procedure and initiate discipline to staff
for non-compliance.
• Instituted multidisciplinary round in the OR and Post Anesthesia Recovery (PAR) to
plan patient flow and ensure appropriate staffing – including the evaluations to ensure
that there is a bed available at the required level of care – canceling surgeries if
appropriate.
–
•
•
•
•
Length of time patients stay in the Post Anesthesia Recovery area have decreased from 311
minutes in January to 257 minutes in February.
Instituted mock cardio pulmonary arrests in the PAR to assess and provide training as
appropriate.
Initiated a multidisciplinary OR Governance group to ‘govern’ policies and procedures
that support the delivery of quality care.
Conducted a Charting the Course session in which nurses, physicians and staff
collaborated to redesign procedures in the “Perioperative Care Center” to be more
patient centered.
Implemented improved monitoring of patients with moderate sedation in all areas establishing the same standard of care.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 30
Accomplishments to Date
Ancillary Areas
• Utilized current teleradiology capabilities to send films off site to a radiologist for
interpretation, increasing the turn around time of preliminary reports x-rays during
periods when there are a physician shortages.
• Revamped and improved phlebotomy services to include a larger suite, improved
patient flow process and the introduction of a specimen drop off station.Eliminated a
bar coding label to improve patient safety.
• Successfully passed CAP accreditation with a perfect score and AABB inspection
deemed the lab exemplary by the reviewer.
• Expanded phlebotomy services, leading to a reduction in blood culture contamination
rates (from 8% to 4%), as well as a reduction in specimen rejections in blood bank.
• Reduced transcribed medical report turnaround time from 30 hours to 10 hours.
• Improved medical record availability in General Surgery clinic from 80% to 95%.
• Established criteria for reviewing deficiencies in the quality and content of the medical
record.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 31
Accomplishments to Date
•
•
•
•
•
•
•
Improved the availability of outpatient medical records, increasing delivery rates from
the mid 80s to 95%.
Ensured all pharmacy registry staff completed new employee orientation.
All pharmacy staff passed their competency testing.
Installed security cameras working with Safety Police to ensure their monitoring and
oversight.
Tracking and improving processes to decrease medication turnaround time.
A pharmacy and nursing joint practice group has been formed to resolve issues with
medication processes; ordering, dispensing, distribution and administration.
Completed a gap analysis for Chapter 797.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 32
Accomplishments to Date
Environment of Care
• Physically inventoried all occupied and vacant space.
• Newly configured Space Committee is prioritizing new space requests.
• Evaluating current space and how it may better support operations as well as
assisting in the prioritization of changes to meet regulatory requirements.
• Identified four critical space/construction needs: OR, ER, Psychiatry and Outpatient
Pharmacy.
–
–
–
–
•
Development of renovation plans is underway in the operating room and psychiatry. OSHPD
has given preliminary approval to proceed with the OR, cost estimates are being completed.
In initial stages of evaluation of the ER. An initial cost estimate breakdown of the
refurbishment items has been made.
The Field Assessment Report for the psychiatric areas in Hawkins has been reviewed and all
are in agreement as to the priority items that present safety hazards in the rooms.
Outpatient pharmacy plans are in development.
Completed an inventory of all equipment is being completed including the tagging and
bar coding all items.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 33
Accomplishments to Date
Human Resources
• ‘Cleaned up’ the PAR process and prioritized recruitment efforts. Currently 198
approved PARs.
• Have partnered with HR to provide efficient disciplinary actions to staff.
–
–
•
•
•
•
Instituted 91 performance management cases.
Currently 179 open disciplinary cases.
Increased performance feedback increasing formal compliance for evaluations from
8% to 64%. The backlog will be completed by the end of April.
Instituted case management program to better manage disability cases and reduce
lost work time.
Developed a comprehensive class program based on a needs assessment.
Mandatory training has been identified for appropriate levels and care areas.
Ensuring attendance of staff at orientation improved to 74% with efforts underway for
100% compliance.
King/Drew Medical Center
Implementation Plan Update - April 11, 2005
Page 34