QUALITY AND PATIENT SAFETY COMMITTEE AGENDA April 10, 2012 The Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System will meet on Tuesday, April 17, 2012 at the hour of 12:00 P.M. at 1900 W. Polk Street, in the Second Floor Conference Room, Chicago, Illinois, to consider the following: Time/Presenter (times are approximate) I. Attendance/Call to Order 12:00/Chairman Ansell II. Public Speakers 12:00-12:10 III. Report from System Chief Medical Officer 12:10-12:15/Dr. T. Mason IV. Report from System Interim Chief Nursing Officer 12:15-12:20/T. Russell V. Report from System Director of Quality and Patient Safety B. Farrell A. Quality report from the Ambulatory and Community Health Network 12:20-1:00/Dr. S. Stabile, of Cook County I. Marks, Dr. J. Neafsey and Dr. E. Martinez VI. Recommendations, Discussion/Information Item A. Reports from the Medical Staff Executive Committees 1:00-1:10 i. Provident Hospital of Cook County Dr. P. Wakim ii. John H. Stroger, Jr. Hospital of Cook County Dr. D. Goldberg VII. Action Items A. Minutes of the Quality and Patient Safety Committee Meeting, 1:10-1:15/Chairman Ansell March 20, 2012 B. Proposed Academic Affiliation Agreements (Renewals and New Agreements) 1:15-1:30/Dr. J. O’Brien C. Any items listed under Sections VI, VII and VIII
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QUALITY AND PATIENT SAFETY COMMITTEE AGENDA
April 10, 2012
The Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System will meet on Tuesday, April 17, 2012 at the hour of 12:00 P.M. at 1900 W. Polk Street, in the Second Floor Conference Room, Chicago, Illinois, to consider the following:
Time/Presenter (times are approximate)
I. Attendance/Call to Order 12:00/Chairman Ansell
II. Public Speakers 12:00-12:10
III. Report from System Chief Medical Officer 12:10-12:15/Dr. T. Mason
IV. Report from System Interim Chief Nursing Officer 12:15-12:20/T. Russell
V. Report from System Director of Quality and Patient Safety B. Farrell
A. Quality report from the Ambulatory and Community Health Network 12:20-1:00/Dr. S. Stabile, of Cook County I. Marks, Dr. J. Neafsey and Dr. E. Martinez
VI. Recommendations, Discussion/Information Item
A. Reports from the Medical Staff Executive Committees 1:00-1:10
i. Provident Hospital of Cook County Dr. P. Wakim ii. John H. Stroger, Jr. Hospital of Cook County Dr. D. Goldberg
VII. Action Items
A. Minutes of the Quality and Patient Safety Committee Meeting, 1:10-1:15/Chairman Ansell March 20, 2012 B. Proposed Academic Affiliation Agreements (Renewals and New Agreements) 1:15-1:30/Dr. J. O’Brien C. Any items listed under Sections VI, VII and VIII
AGENDA Tuesday, April 17, 2012 Meeting of the
Quality and Patient Safety Committee Page 2
VIII. Closed Session Item 1:30-1:35
A. Medical Staff Appointments/Re-appointments/Changes C. Luchsinger Closed Session
Motion to recess the regular meeting and convene into closed session, pursuant to the following exceptions to the Open Meetings Act: 5 ILCS 120/2(c)(17), regarding “the recruitment, credentialing, discipline or formal peer review of physicians or other health care professionals for a hospital, or other institution providing medical care, that is operated by the public body,” and 5 ILCS 120/2(c)(11), regarding “litigation, when an action against, affecting or on behalf of the particular body has been filed and is pending before a court or administrative tribunal, or when the public body finds that an action is probable or imminent, in which case the basis for the finding shall be recorded and entered into the minutes of the closed meeting.”
IX. Adjourn Committee Members: Chairman: Ansell Members: Board Chairman Batts (Ex-Officio) and Directors Butler and Muñoz
Affiliation Agreements for the QPS Committee Meeting April 17, 2012
No. Specialty New/Renewal Partner Reason Dollars/yr # of Res/Yr
1Pulmonary New UIC Agreement formerly between UIC and the
city. CCDPH now running the TB clinics. $0 0.5 FTE fellows
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Pulmonary New McGaw Agreement formerly between UIC and the city. CCDPH now running the TB clinics.
$0
Variable-attend the clinic ½ day/wk
3Psychiatry New Rush
Allow the Rush residents to gain experience with mental illness in incarcerated patients at Cermak $0
Up to 2.0 FTE
4Adolescent Medicine New UIC Joint Fellowship -Allows adolescent fellows
to rotate at both hospitals/clinics $0 1.0 FTE Fellow
5Radiation Oncology New LUMC Provide Radiation Therapy experience for
LUMC $0 0.4 FTE
6Emergency Medicine New McGaw Provide EM experience for OB/Gyne
residents $0 1.0 FTE
7Surgery Critical Care New McGaw Provide SICU experience for OB/Gyne
residents $0 1.0 FTE
8 Orthopedics New McGaw Amend current agreement to allow PGY1’s to rotate here $0 1.0 FTE PGY1
9Allergy/Immunology New Jackson Park Provide A/I experience for Jackson Park
residents $0 0.23 FTE
10 Oral Surgery New Resurrection Provide our Oral Surgery residents Orthognathic cases when they arise $0 Variable
11 Podiatry New Weiss OFH is now a ROC, so interns to rotate at JSH $0 Variable
12 Pediatrics New Alivio Allows one Pediatric Resident to work in high volume clinic $0 0.1 FTE
13 Neurosurgery Renewal Rush Provide care for our neurosurgical patients $74,446 1.0 FTE
14 Neurosurgery Renewal McGaw Provide care for our neurosurgical patients $75,000 1.0 FTE
15 Nephrology Renewal UIC Provide care for our patients with renal failure $156,915
2.0 FTE Fellows
1 of 3 Reviewed by the Work Group on Affiliations on 3/29/12
Affiliation Agreements for the QPS Committee Meeting April 17, 2012
16 General Surgery Renewal UIC
2 Surgery residents from UIC provide clinical coverage on the Colon and Rectal Surgery service $150,379
2.0 FTE Residents
17 ENT Renewal UIC Provide ENT care for our patients (we don’t have our own ENT residents) $229,002 3
18
Surg/Pathology Renewal UIC Provides support to our pathologists (we don’t have our own pathology residents) $330,323 4.0 FTE PGY7
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Urology Renewal ChristResidents provided experience in brachytherapy, infertility, robotic surgery, and pediatric urology
Christ reimbursesJSH salary and benefits
Up to 1.0
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Neurosurgery New Northshore University
Allow our resident experience in spine cases NSU reimburses JSH
salary and benefitsUp to1.0 FTE
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Family Medicine
Renewal of CEMA and Program Addendum
Loyola University Medical Center
Joint Residency –Residents provide:Approx 19,422 Clinic visits/yr; 500 deliveries/yr, and participate with approx. 1700 inpatient admissions annually $2,237,000
32.5 FTE Residents, 1.5 Faculty, support staff
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Master Agreement Renewal UIC Allows the creation of Program Addenda
$0 N/A
23 Pulmonary Renewal Black Lung Clinic
Provide Fellows experience in early treatment of Black Lung Ds $0 N/A
24 Neonatology Renewal Christ Provide Training for Congenital Heart disease in newborn $0
2 fell. spend 4 wks each
25 Pain Renewal National
University
Provides instruction in acupuncture to our pain fellows and clinical experience for acupuncture interns $0
N/A
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General Surgery and Plastic Surgery
Renewal UIC Residents rotate on Burn service to get experience not available at UIC $0
1.0 Gen Surg FTE + 0.66 Plastic Fellow
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Surgery Critical Care Renewal Advocate Allows our SCC fellows to experience
critical care from a remote site $0 1-3 fell. spend 40 hours each
2 of 3 Reviewed by the Work Group on Affiliations on 3/29/12
Affiliation Agreements for the QPS Committee Meeting April 17, 2012
28Toxicology Renewal UIC Joint Fellowship – allows fellows to rotate
at UIC and JSH $0
Variable (4.0 fellows in the program)
29 Toxicology Renewal Northshore University
Allows our Tox fellows to get community experience $0 Variable
30 Pediatrics Renewal Esperanza Allows one Pediatric Resident to work in high volume clinic $0 0.1 FTE
31 Endocrinology Renewal Jackson Park Allows JP FM residents endocrine experience $0 1.0 FTE
3 of 3 Reviewed by the Work Group on Affiliations on 3/29/12
John H. Stroger, Jr. Hospital of Cook County
Medical Staff Appointments/Reappointments and Non-Medical Staff Action Items Subject to Approval by the CCHHS Quality and Patient Safety Committee
Cerner Ambulatory Power ChartCerner Ambulatory Power Chartyy
July 2012 Pilot ImplementationAugust 2012 Go-LiveAugust 2012 Go-Live
QI Components:-Screening and Treatment Prompts-PQRS -Results Pools and Proxy Capability-Message Center Message Center -CPOE-Electronic Results Endorsement
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Other Projects and GrantsOther Projects and Grants
Joint Commission PPR◦ Process related indicators
MERS◦ Incident and Complaint tracking
G tG tGrantsGrants CMMI: Center for Medicare and Medicaid Innovation
1115 W i 1115 Waiver ICAAP: Illinois Chapter, American Academy of Pediatrics
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THANK YOU!
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4/9/2012
Ambulatory and Community Health Network February 2011 to March 2011 Comparison
FEB % Calls Global Average MAR % Calls Global Average
2011 Captured Score Answer
Time 2011 Captured Score Answer
Time
Austin 86 79 1 min 3 sec Austin 89 77 1 min 2 sec
Prieto 85 66 36sec Prieto 92 69 1 min 5 sec
Cicero 83 74 12 sec Cicero 94 90 14 sec
Woodlawn 89 81 45sec Woodlawn 90 84 54 sec
Near South 85 63 1 min 21 sec Near South 87 62 2 min 28 sec
Logan 90 84 40 sec Logan 95 92 33 sec
Englewood 71 37 2 min 22 sec Englewood 88 57 2 min 19 sec
Robbins 50 34 3 min 46 sec Robbins 60 38 8 min 49 sec
WWHC 70 68 39 sec WWHC 77 71 48 sec
Sengstacke 54 37 3 min 22 sec Sengstacke 66 38 12 min 26 sec
Central Apt 58 35 1 min 52 sec Central Apt 76 53 1 min 48 sec
Call Center 66 27 3 min 48 sec Call Center 76 36 3 min 49 sec
Page 7 of 20
4/9/2012
Ambulatory and Community Health Network February 2012 to March 2012 Comparison
FEB % Calls Global Average MAR % Calls Global Average
2012 Captured Score Answer
Time 2012 Captured Score Answer
Time
Austin 90 81 41 sec Austin 95 88 29 sec
Prieto 97 89 12 sec Prieto 96 89 12 sec
Cicero 93 91 11 sec Cicero 92 88 9 sec
Woodlawn 94 92 25 sec Woodlawn 93 92 22 sec
Near South 86 56 36 sec Near South 97 89 13 sec
Logan 94 87 16 sec Logan 96 90 19 sec
Englewood 93 79 23 sec Englewood 97 81 19 sec
Cottage 82 58 1 min 23 sec Cottage 88 65 43 sec
Robbins 77 51 44 sec Robbins 77 52 1 min 10 sec
WWHC 88 75 10 sec WWHC 96 79 8 sec
Sengstacke 81 50 1 min 16 sec Sengstacke 78 52 1 min 18 sec
Central Apt 82 53 39 sec Central Apt 89 74 24 sec
Call Center 92 71 18 sec Call Center 90 60 48 sec
Page 8 of 20
Building Community-Based Medical Homes f ACHNfor ACHN
• ACHN; IL Chapter of the American Academy of Pediatrics (ICAAP); and Division of Specialized Care for Children (DSCC), IL Title V program
• 3 year grant program funded by federal Maternal and Child Health Bureau (with some support from Chicago Community ( pp g yTrust)
• Goals: To spread the Illinois Medical Home Model within the pACHN and provide intensive support to 5 high volume pediatric ACHN centers to establish a medical home quality improvement process
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Who needs a Medical Home?Who needs a Medical Home?
Children and youth with yspecial health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also condition and who also require health and related services of a type or amount beyond that required by beyond that required by children generally.
--Maternal and Child Health Bureau, 1995Maternal and Child Health Bureau, 1995
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The Medical Home ModelThe Medical Home Model
Primary Care Medical HomePrimary Care Medical Home
Acute Care
A Ill V
Preventive Care Chronic Condition CareChronic Condition Care