1. Quality & Safety Report Peter DeBlieux, MD, CMO

2. Quality Updates Regulatory Jan 12, 2016, 340B Compliance audit by the Department of Health and Human Services Health Resources and Services Administration (HRSA) Cancer Commission Feb 23, 2016, Survey scheduled for Program and Care Quality and Safety for Cancer Care Program Focus UMC for 2016 Infection Control HCAHPS (Patient Satisfaction) Patient throughput

3. The Joint Commission Survey – Nov 8, 2015 Six (6) Direct Impact Findings Six (6) Indirect Impact Findings 16 Standard level Federal Findings (No Condition Level findings) No documentation of patient education for chemotherapeutics and for new medication vancomycin (3) Blood glucose monitoring record had no documentation prior to some meals (3 separate findings) Pressure relationships endoscopy area incorrect (corridor was positive) Surgical staff used top of trash can as work space for sterile supplies during surgical procedure Skin site prep not followed per manufactures recommendations (CHG not allowed to dry prior to drape) Uncovered IV pump in clean room (was unknown if clean as it was not covered) Endoscopy did not follow recommendations for scope cleaning (enzymatic cleaner not used) Non-linear work flow for scope cleaning process keeping with evidence based guidelines Soiled instruments not properly transported (pre-treatment not completed, multiple) Wrong type fire extinguishers in the ORs. Did not comply with AORN standards Chemotherapy administration without staff eye protection and no eyewash stations in place ED Door breakaways were locked and did not work Humidity not monitored in areas for storage of sterilized instruments Medication administration dose for pain scale not ordered Assessments documented in EPIC prior to actual assessment (multiple)

4. Journey for Excellence Dashboard 2015 MarAprilMayJunJulyAugSepOctNovDec Regulatory VBP Lab EOC Patient Flow Patient Safety Case Management Medical Staff HCAHPS Nursing ED December

5. Issues and Corrective Actions ScorecardIncludes (Basics) Measure Missed AnalysisAction Regulatory Annual BoT requirements, Medical Records, FMEA, Regulatory Activity 1.Accreditation is pending submission, and/or approval, and/or acceptance of Direct, Indirect, and/or MOS items. 1.Awaiting approval of 60 day action plans from The Joint Commission. Value Based Purchasing (VBP) Core Measures Mortality Rates Readmission Rates Patient Satisfaction Complications Infections 1.Only 1 out of 8 November HCAHPS composite scores met target 2.November CLBASI SIR was too high 1.Continue implementing HCAHPS improvement plan. Plan includes customer service training and educating staff on the updated pain management policy. 2.Remove central lines as early as possible. Will begin calculating SIRs by unit and sending to unit directors in 2016. Environment of Care Fire Safety, Environmental Tours, Emergency Power Systems and Emergency Response Plan 1. Accreditation is pending submission, approval, and acceptance of Direct, Indirect, or MOS items in direct relation to EOC, LS, EM survey findings with the respective regulatory agency. 1. Awaiting approval of 60 day action plans from The Joint Commission. Patient Flow ED throughput Time to Labs Time to CT brain Bed assign and turn Bed Management 1. Designated bed control person met established metrics for bed assignment and placement <10 minutes 2. Plan for scheduled surgeries for following day in bed huddle 3. Discharge patients by 1:00pm. 1. Working with bed management on placement process 2. Bed management used old form in December so data could not be consistently captured. Bed management has already started using correct form. 3. Laminated flyers have been placed in resident/MD areas (and nursing units) displaying the goal of discharge by 1:00pm. CMO discussed discharge process with physicians and emphasized 1:00pm discharge time. Patient Safety Falls, Med Errors Sentinel Events Restraint use Patient ID, NPSG Transfusion safety 1.Patient/ family education regarding blood transfusion 2.Patient/family education regarding falls 3.Fall Rate 4.Return to surgery within 24 hours 5.Mean door to EKG- Chest Pain 1.Senior Director of Medical Surgical Services will meet one on one with the nurses to stress the importance of patient education. Meetings will be documented and trends will be monitored. 2.Monitor and trend individual nurses in critical care. Plan long term EPIC solution regarding patient/family education. 3.Continue hourly rounding and reemphasize fall precautions to staff 4.Cases sent to peer review 5.Senior Director of Critical Care will continue to work with screeners

6. Issues and Corrective Actions ScorecardIncludes (Basics) Measure Missed AnalysisAction Patient Satisfaction Leadership actions to improve 1. 64% of patients rated UMC a 9 or a 10 overall in November. UMCNO must reach 76% to be green. Implement HCAHPS performance improvement plan which includes leadership rounding, clinical rounding and service recovery. Nursing UTI, CLABSI, MDRO, SSI, VTE Prevention Bundles full implementation 1.Daily CHG bathing and linen changes 2.High-risk surgery patient are prescreened and treated for S. aureus 3.Patient/family education on MDRO 4.Appropriate referral completed if indicated by aspiration pneumonia assessment results 1.This topic was included in the quality focused sessions given by the Senior Director of Medical Surgical Services. 86 Patient Care Technicians attended the sessions. 2.“Nose to Toes” program began 1/11/2016 3.Senior Director of Critical Care will track and trend individual nurses 4.Senior Director of Critical Care will follow up with the fallouts because this metric has not been an issue in previous months. Emergency Department Triage level accurate Throughput, Left without MD contact Multiple fallouts linked primarily to throughput challengesMultiple corrective actions including: 1.Opening all 3 RTA areas at staggered times 2.Improve process for patients to go to RTA sub wait and not to main waiting room 3.Working with Lab regarding status of Troponin results to improve Troponin turnaround time

7. Patient Satisfaction Surveys CompositesJanFebMarAprMayJunJulAugSepOctNov National Ave. State Ave. Overall Rating78475263575355667884637176 Willingness to Recommend71625574656447687887697176 Communication about Meds78456271735140466277596569 Communication with Doctors87788187847273888688758287 Discharge Information9181 848287749080847586 Pain Management62 6866736146646883587176

8. Complaints and Grievances Top Five