2019 has brought many changes to the PI Department. We have said good-bye to team members (Aaron Kunoff and Lillie Reder) who have moved on for personal and professional reasons; we have promoted one of our team members internally (John Young); and we look forward to welcoming the two employees that will be transitioning to our team from other YKHC departments.

Here are some additional PI changes that have impacted the Corporation this past year:

TJC

A new tool was developed to assist in completing, tracking, and monitoring progress with the Intra-Cycle Monitoring requirement. We will be meeting with you again to ensure that you all have completed the Plans of Corrections that were submitted related to you areas.

TJC will be coming out in 2020 to evaluate the New Hospital.  Information regarding potential survey dates will be forthcoming.

Patient Safety and Quality: CEO Daily Call

The CEO Daily Safety and Quality call has been taking place for ten months.  We have come a long way since the Pilot program started on February 11, 2019.  My hope is that 2020 will bring the following changes:

• Callers will mute their phones. (I put my phone on speaker and then mute as I am calling into the 800 number waiting for the call to begin.)
• Departments will stay on the call until the last department finishes presenting.
• Departments will call and collaborate with those departments that have presented a quality or safety issue in an attempt to resolve it.
• Issues documented in the Safety Event component of the Quantros reporting program will be presented on the daily call.  In other words, there will be a true transparency in the reporting of all issues.
• Findings/trends identified by PI will be viewed as factual data and will be utilized to improve processes.
• Leaders will celebrate the issues identified and reported by the departments that report to them.

Policy Manager

A big thank you to everyone that has diligently worked on writing and revising the plans, policies, procedures, standard work/job aids, and forms that fall under the purview of your department. An even bigger thank you to those of you that have taken advantage of the block training that is offered.

Remember that the plans, policies, procedures, etc. in your manuals are your responsibility!

• Please work your tasks when you receive the email reminder.
• Take two hours each week and devote it to separating the old policies in your manual(s) into the new templates, updating your policies, and completing your tasks, etc.
• Set an appointment in the Policy Coordinator shared calendar for additional training if needed.

Root Cause Analysis and Safety Event Investigations

The Corporation took very positive steps the first half of 2019 by identifying and requesting PI facilitation of thirteen quality/safety incidents.  This was a vast improvement from the one identified in 2016, three  in 2017, and two in 2018.

The focus of the RCAs that PI facilitates is in identifying process issues and does not find fault or place blame on people. Participants going down that track are re-directed to the process issues at hand.

YKHC as a corporation needs to celebrate the change in the Corporate Culture of Safety and encourage the reporting of safety events and RCAs to ensure that we are providing quality care that is safe for all.

Collaboration with Providers and Raven regarding Performance Measure Results

PI is responsible for reporting on approximately 40 separate measures to seven different regulatory agencies. The specifications for these measures can/do differ slightly from agency to agency.

PI has been working very closely with Raven, Providers, and educators to increase the scores on measures that pull directly from the electronic health record to ensure that YKHC is getting credit for the great work that is being done as we treat our patients.

In 2020, PI will be working more closely with the Chief Nurse Executive (CNE) and allied health departments to engage front line staff as to the importance of their roles in meeting/exceeding the measures.

For any questions regarding these updates or Performance Improvement, contact Jaye Marcus-Ledford at Jacqueline_Marcus-Ledford@ykhc.org or ext. 6131