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King/Drew Medical Center. Implementation Plan Update Hospital Advisory Board. April 11, 2005. Background and Assessment.

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King/Drew Medical Center

Implementation Plan Update

Hospital Advisory Board

April 11, 2005

background and assessment
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.
identification of critical success factors
Identification of Critical Success Factors
  • Upon completion of the assessment several factors were identified that are critical to success:
    • 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
situational analysis report baptist health care leadership institute
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:
    • 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.
  • 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:
    • 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.
situational analysis report
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:
    • 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:
    • The affiliation with Drew University.
    • The diversity of the work force.
    • The support from the community.
required culture changes
Required Culture Changes
  • Findings indicate that KDMC has a culture of excuses and blaming.
  • Opportunities for improvement include:
    • 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
  • There needs to be a re-dedication to the stated mission and vision of KDMC which are:
    • 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.
implementation plan 1 066 recommendations 3 662 action steps
Implementation Plan: 1,066 Recommendations 3,662 Action Steps*

*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
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:
    • 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.
supportive groups hr facilities and information technology
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.
    • Human Resources
    • Facilities and Equipment
    • Information Technology
  • The Human Resource Group supports:
    • 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.
management of risk
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. 

GreenCompleted 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.

RedMajor 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. 
recommendations and identified status
Recommendations and Identified Status

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
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.
implementation plan reporting
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.
accomplishments to date
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.
accomplishments to date1
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.
accomplishments to date2
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.
accomplishments to date3
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.
accomplishments to date4
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.
accomplishments to date5
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.
accomplishments to date6
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.
accomplishments to date7
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.
accomplishments to date8
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.
accomplishments to date9
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.
accomplishments to date10
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.
accomplishments to date11
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.