Joanne's Journal - Thursday, November 30, 2017
First and foremost, I’d like to thank all the staff and providers who were working over the Thanksgiving holiday so the rest of us could enjoy time with our families. We could not do what we need to do for our patients without you!
And thank you for all of the responses to last week’s post! We obviously all have some “interesting” holiday traditions. Please continue sharing your holiday stories with me so I can post in Joanne’s Journal in late December.
I want to spend this journal entry talking about preparation for our Joint Commission revisit that will occur between December 9 and December 24.
As Dr. George Blike, Chief Quality and Value Officer, has mentioned in his messages, The Joint Commission (TJC) made significant changes in its survey methods in January of this year. The Centers for Medicare & Medicaid Services (CMS) has for the past few years driven the Joint Commission to lower its “disparity rating,” which is a measure of the difference in results between a Joint Commission and CMS survey of the same organization. CMS has enforced this by randomly revisiting institutions two weeks after a TJC visit, and now a single episode of noncompliance with a standard is a cited finding.
We had 53 citations, which rolled up into four larger buckets for which we will be reassessed in mid-December. Many of the findings were non-systemic, isolated incidents, relatively insignificant and easily remediated. Some are more difficult because they require major changes to our physical plant. The goal will be to have evidence of 100 percent compliance in all these areas and have a sustainable process and monitoring plan in place to prevent future non-compliance with these standards.
I have discussed our lessons learned with Dr. Blike and Lori Key, Director of Quality Assurance and Safety, who is spearheading our action planning efforts. They said that the number of citations push the accountability to leadership ….and we need to ask ourselves if we are effectively managing and monitoring to the standards.
We may not agree with all of the findings, but if we are really trying to be a high-reliability organization, then being 95 percent successful is not good enough. We need to be 100 percent successful in hitting these and other quality indicators.
We had some nurse/ provider leadership teams in some units (1 East, CVCC, 3 West) that performed at an incredibly high level. We had other areas who really “skinned their knees.” George and Lori emphasized that the effectiveness of the unit leadership teams made all the difference in the world. I would encourage people not to get defensive but to consider how we want to hold ourselves accountable for future performance. We all own this. We will be doing some mock audits (using Vizient) to make sure that we are ready for the return visit. The Quality Assurance and Safety team has been putting in some very late hours helping us prepare. However, this last-minute hustle is not the way to sustainable improvement.
The Board of Governors, in its role as the Medical Executive Committee of DHMC, is stepping up to the plate and owning the quality of care provided in the institution and will have this as an ongoing agenda item during their monthly meetings.
Right now…this is where we need your help:
- Identify power strips in your location. Clinical Engineering will be rounding to inspect power strips, beginning in clinical areas. DO NOT purchase power strips. If needed, call Clinical Engineering for assistance.
- Clean or dirty storage room doors cannot be propped open because it interferes with airflow and can pose an infection risk.
- All temperature logs must be completely filled out (dishwashers, refrigerators, sterilizers, etc.) including actions taken if out of range.
- Electrical panels and shut-off valves cannot have equipment in front of them (Do you know where yours are on your unit?).
- Ceiling tiles have to be changed if stained (report stained or missing tiles to your manager).
- Supplies cannot be stored in cardboard shipping boxes on units.
- CSR processed supplies for intubation should to be kept wrapped until needed.
- Check decentralized storage locations for expired supplies and remove.
- Let us know if there are exit lights that are not illuminated (report to your manager).
- Check for dates and times on consents.
- Complete, including signing, post-procedure notes and H&Ps prior to procedures or transfers.
- Apply BUD labels when opening a multi-use item.
- Pre-processing of instruments with enzymatic spray must be done according to our procedure: Handling, Collection, and Transportation of Contaminated Instruments Procedure
Thanks for your help….we need every set of eyes on these issues. Report issues to: QualityAssurance&Safety@hitchcock.org or call Quality Assurance and Safety at 3-1100. This is all part of getting better every single day.
D-H in the Community: Community Group Practices Provide Comfort to Children in Need
Recently, the Community Group Practices Health Information Services departments in Concord, Manchester and Nashua, led by Cheryl Rowe, donated 21 “comfort cases” to the foster family program at the New Hampshire Division for Youth and Families.
A comfort case is a small duffel bag or backpack that includes toiletries, pajamas, small blankets and other items to provide comfort for children as they enter the foster care system. “I was deeply saddened that these kids get pulled out of their homes with nothing but the clothes on their backs,” said Linda Philbin, Record Management, Health Information Services, and the lead for the D-H Manchester team for the project. “Hearing that broke my heart, and I wanted to do something to make them feel better.”
This is one of the many annual community service projects taken on by the Health Information Services department. In the past, they have donated 500 lbs. of baby food to a local teen shelter, sent care packages to the troops overseas and sent 100 birthday cards to Families in Transition—a non-profit organization that helps homeless individuals and families in the Manchester, Concord and Dover areas—to name a few.
Where at DHMC is this Mural? Here’s the Answer
In last week’s Joanne’s Journal, we challenged our readers to identify the location of the mural (see photo, right) on the DHMC campus. Sixteen people responded to the challenge with the correct answer: the Borwell Building stairwell between Levels 4 and 5. The first five respondents won a surprise gift. Congratulations to: Bret Mason, Shawn Chisholm, Susan Gagnon, Yoni Stevens Nierman and Kevin Williams.
The New Hampshire Lupine Mural is one of 11 murals located throughout the D-H Lebanon campus to encourage employees to take the stairs. These murals were commissioned by Live Well/Work Well (LWWW) Health Improvement Program (HIP) and were created by former DHMC artist-in-residence Kathy Cadow Parsonnet and former D-H employee Kim Wenger-Hall. Parsonnet is currently contracted to support the Art-at-Work program through LWWW, and Wenger-Hall, a local artist and Yoga instructor, is currently teaching the LWWW Monday noon yoga class at DHMC.
In early 2018, LWWW will be releasing a "Stairwell Mural Quest."
Affiliates in Action: New London Hospital Employee Recognized
Catherine Bardier, the director of Wellness and Community Health at New London Hospital, was honored by Dartmouth-Hitchcock’s (D-H’s) Partners for Community Wellness (PCW) with the PCW Alfred L. Griggs’ Ambassador Award on November 8 at the PCW annual meeting. Recipients of the Griggs’ Ambassador Award “have made a commitment to be a part of Dartmouth-Hitchcock’s global health solution by promoting wellness at every level of their community,” according to the PCW website.
“I was incredibly honored and really excited to receive this award,” said Bardier. “I have the greatest job in the world. I have the opportunity to wake up every day and help people around me who are making changes in their lives, whether it is healthy eating or active living. I love the positive changes I see in the community [New London] and with the employees here at the hospital. It’s a really rewarding position, so to be recognized for that is just great.”
Next Facebook Live with Dr. Joanne Conroy – Wednesday, December 13 at 4 pm
On Wednesday, December 13 at 4 pm, Dr. Conroy will participate in the second of her Facebook Live series where she will continue to address topics of interest to D-H employees, patients and the community.
And, as a reminder, for those who want to tune in, go to the D-H Facebook page at the above date and time. To comment on or share the video, you will need to have a personal Facebook profile, but you can view the D-H Facebook page even if you are not logged in. On that day, if you are logged into your Facebook account and already "like" the D-H page, you will likely see a notification that the session is live. Submit questions in advance to email@example.com.