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Minutes of the meeting of the Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System held Tuesday, June 29, 2010 at the hour of 12:00 P.M. at John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison Street, in the fifth floor conference room, Chicago, Illinois.
I. Attendance/Call to Order
Chairman Ansell called the meeting to order. Present: Chairman David Ansell, MD, MPH and Director Hon. Jerry Butler (2)
Lois Elia and Pat Merryweather (Non-Director Members) Absent: Director Luis Muñoz, MD, MPH (1)
Additional attendees and/or presenters were: Janice Benson, MD Robert Cohen, MD Patrick T. Driscoll, Jr. William T. Foley David Goldberg, MD
Aaron Hamb, MD Avery Hart, MD Randolph Johnston Sue Klein Roz Lennon
Charlene Luchsinger Terry Mason, MD Elizabeth Reidy Deborah Santana Anthony J. Tedeschi, MD, MPH, MBA
Miscellaneous
Following the Call to Order, Chairman Ansell reported on his recent return from a public hospital in Port-au-Prince, Haiti. He stated that while he was there, he noticed that there is not an integrated leadership or sense of accountability at the level of the attending physician, or around patients; he added that the real diagnostic test of health systems is based upon how the leadership works.
Introduction of new Director of Diversity and Multicultural Affairs
William T. Foley, Chief Executive Officer of the Cook County Health and Hospitals System, introduced the new System Director of Diversity and Multicultural Affairs, Miriam Gonzalzles.
II. Public Speakers Chairman Ansell asked the Secretary to call upon the registered speakers.
The Secretary responded that there were none.
III. Report from System Chief Medical Officer
Dr. Terry Mason, System Chief Medical Officer, presented information on the following subjects. Update on recruitment efforts for the position of System Director of Quality and Patient Safety
Dr. Mason stated that Ms. Barbara Farrell will be assuming the position of System Director of Quality and Patient Safety on July 26, 2010.
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Quality and Patient Safety Committee Meeting Minutes Tuesday, June 29, 2010
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III. Report from System Chief Medical Officer (continued)
National Association of Public Hospitals (NAPH) Conference Dr. Mason stated that he attended the recent NAPH conference last week with Roz Lennon, System Chief Clinical Officer. He added that Randall Mark, System Director of Intergovernmental Affairs and Policy, also attended and accepted an award on behalf of the System’s Palliative Care program. He noted that two highlights of the conference related to the concept of medical homes and system integration. Dr. Mason stated that the next NAPH conference in 2011 will be held in Chicago; he added that requests for tours of the System facilities are being received.
Update on Dashboard – Measuring System Access
Dr. Mason stated that management is working on a draft dashboard to measure System access. This dashboard will include measures pertaining to patient satisfaction, and relating to emergency departments (how many patients leave the emergency departments at each of the hospitals without being seen); Ambulatory and Community Health Network (ACHN) clinics (percent of specialty care with greater than two-week time, days from IRIS referral to primary care appointment); and Surgery (first-case starts). He stated that he will work with Chairman Ansell to refine the draft; after which it will be made available to the Committee. Update on Review of Grievance Process
With regard to the request at the last Committee meeting for a review of the grievance process for Stroger, Oak Forest and Provident Hospitals, Dr. Mason stated that Mindy Malecki, System Director of Risk Management has gone over the process, and as a result, each site will include reporting a summary of the site-specific grievances as part of reporting to the Quality and Patient Safety Committee at least annually. He added that Ms. Malecki has taken the lead on this initiative.
Quality Service Initiative-Review of Endoscopy
Dr. Mason stated that Dr. Anthony Tedeschi, System Interim Chief Operating Officer, has been championing a quality service initiative related to endoscopy. There have been improvements; they have re-opened the every-other-Saturday sessions to address backlog issues.
Director Butler, seconded by Chairman Ansell, moved to receive and file the report of the System Chief Medical Officer. THE MOTION CARRIED UNANIMOUSLY.
IV. Committee Report
A. Minutes of the Quality and Patient Safety Committee Meeting, May 18, 2010
Director Butler, seconded by Chairman Ansell, moved to accept the minutes of the Quality and Patient Safety Committee Meeting of May 18, 2010. THE MOTION CARRIED UNANIMOUSLY.
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Quality and Patient Safety Committee Meeting Minutes Tuesday, June 29, 2010
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V. Recommendations, Discussion/Information Items
A. Quarterly quality report from Provident Hospital of Cook County
Dr. Aaron Hamb, Chief Medical Officer of Provident Hospital of Cook County, presented the quarterly quality report (Attachment #1). The Committee reviewed and discussed the information. Dr. Hamb reviewed the information provided on anticoagulation therapy. He stated that Pharmacy is monitoring several different indicators within these measures for each of the three drugs. As the switch was made from paper orders to electronic orders, there was a bit of a glitch; they are unable to enter the protocols into Cerner. Now they are pulling together a work group to address the protocol issues and try to address this initially as a pre-printed order protocol for the nurses. Dr. Avery Hart, Chief Medical Officer of Cermak Health Services of Cook County, inquired whether Stroger Hospital already has this issue worked out. Dr. Hamb responded that they are trying to get the setup used by Stroger Hospital configured for Provident Hospital. In response to Dr. Hart’s comment regarding whether this can be configured System-wide, Chairman Ansell responded that it is a very good suggestion.
Director Butler, seconded by Chairman Ansell, moved to receive and file the quarterly quality report of Provident Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY.
VI. Action Items
A. Proposed Academic Affiliation Agreements (Attachment #2) (Agreements with fiscal impact)
Dr. Hamb reviewed the two proposed Academic Affiliation Agreements presented for the Committee’s consideration. Additionally, he stated a correction to the dollar amount for the Midwestern agreement; the total fiscal impact should be $682,984.00.
Director Butler, seconded by Chairman Ansell, moved to approve the proposed Academic Affiliation Agreements, as amended. THE MOTION CARRIED UNANIMOUSLY.
B. Any items listed under Sections IV, V, VI and VII
VII. Closed Session Discussion/Information Items
A. Update on status of preparations for Cermak re-accreditation B. Reports from the Medical Staff Executive Committees
i. Oak Forest Hospital of Cook County ii. Provident Hospital of Cook County iii. John H. Stroger, Jr. Hospital of Cook County
C. Medical Staff Appointments/Re-appointments/Changes D. Reports on the following:
i. Sentinel events or near misses ii. Patient grievance reports iii. “Never” events iv. Recent regulatory visits
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Quality and Patient Safety Committee Meeting Minutes Tuesday, June 29, 2010
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VII. Closed Session Discussion/Information Items (continued)
Chairman Ansell, seconded by Director Butler, moved to recess the regular session and convene into closed session, pursuant to the following exceptions to the Illinois Open Meetings Act: 5 ILCS 120/2(c)(17), which permits closed meetings for consideration of “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.” THE MOTION CARRIED UNANIMOUSLY. Chairman Ansell declared that the closed session was adjourned. The Committee reconvened into regular session. Director Butler, seconded by Chairman Ansell moved to receive and file the medical staff reports presented in closed session. THE MOTION CARRIED UNANIMOUSLY. Director Butler, seconded by Chairman Ansell, moved to approve the Medical Staff Appointments/Re-appointments/Changes (Attachment #3). THE MOTION CARRIED UNANIMOUSLY.
VIII. Adjourn
As the agenda was exhausted, Chairman Ansell declared the meeting ADJOURNED.
Respectfully submitted, Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System XXXXXXXXXXXXXXXXXXXXXX David Ansell, MD, MPH, Chairman
Attest: XXXXXXXXXXXXXXXXXXXXXX Deborah Santana, Secretary
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Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting
June 29, 2010
ATTACHMENT #1
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FIRST QUARTER 2010 SUMMARY OF QUALITY AND PERFORMANCE
IMPROVEMENT ACTIVITIES
1
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INTRODUCTION• The enclosed First Quarter Report will provide outcomes of quality and
ti l t i f J M h 2010 Th t i di id d i t thoperational metrics for January – March 2010. The report is divided into the following sections:
Hospital-wide Performance Improvement Initiativesosp ta w de e o a ce p ove e t t at ves-Core Measures- Patient Flow/Thru-Put - Customer Satisfaction
Intra/Interdepartmental Performance Improvement Initiatives
Departmental Quality and Operational Indicators
2
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HOSPITAL-WIDE PERFORMANCEHOSPITAL WIDE PERFORMANCE IMPROVEMENT INITIATIVES
3
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CORE MEASURESA set of diagnosed based criteria adoptedA set of diagnosed based criteria adopted by CMS and Joint Commission to improve patient outcomes. Core Measures are called ORYX by Joint Commission. The rationale for these National Core Measures is to improve patient care outcomes for p pAcute Myocardial Infarction (AMI) Heart Failure (HF), Community Acquired Pneumonia (CAP) and Surgical CarePneumonia (CAP), and Surgical Care Improvement Project (SCIP).
A multi-disciplinary team comprised of a physician team leader/champion, nursing, medical staff, and ancillary support
4
, y ppservices, has been addressing this ongoing project.
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2010 ACUTE MYOCARDIAL (AM.I.)MEASUREMENT OUTCOMES
PERFORMANCE MEASURE
2009 (CY)Aggregate
2010 (CY)Quarter 1
2010 CYQuarter 2
2010 CYQuarter 3
2010 CYQuarter 4
2010Aggregate
TargetIL. Avg.
TargetNat’lAvg.
MEASUREMENT OUTCOMES
AMI-1 Aspirin at Arrival 100% of 12 patients
100% of 2 patients
95% 95%
AMI-2 Aspirin Prescribed at Di h
100% of 5 ti t
100% of 1 ti t
93% 94%Discharge patients patient
AMI -3 ACEI or ARB Left Ventricular Dysfunction
100% of 1 patient
100% of 1 patient
91% 92%
AMI 4 Ad l S ki 100% f 2 97% 96%AMI-4 Adult Smoking Cessation Advice/Counseling
100% of 2 - 97% 96%
AMI-5 Beta Blocker Prescribed at Discharge
100% of 7 100% of 1 patient
93% 94%
g
AMI-7 Fibrinolytic Therapy Received Within 30 Mnutes of Hospital Arrival
- - - - 31% 45%
AMI-8a Primary PCI - - - - - 82% 82%
5
yReceived Within 90 Minutes of Hospital Arrival
*CY=Calendar
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2010 OUTCOMES FOR HEART
2009 CY 2010 (CY) 2010 (CY) 2010 (CY) 2010 (CY) 2010 Target Target
FAILURE (HF) MEASUREMENTPERFORMANCE MEASURES
2009 CY Aggregate
2010 (CY)Quarter 1
2010 (CY)Quarter 2
2010 (CY)Quarter 3
2010 (CY)Quarter 4
2010 Aggregate Rate
TargetIL. Avg.
TargetNat’lAvg.
HF -1 Discharge Instructions 94% of 257 patients
96% of 85 patients
82% 79%
HF-2 Evaluation of Left Ventricular Function (LVS)
100% of 263 patients
99% of 88 patients
94% 90%
HF-3 ACEI or ARB for LVSD 98% of 132 patients
100% of 73 patients
90% 90%
HF-4 Adult Smoking Cessation Advice/Counseling
99% of 101 patients
100% of 73 patients
96% 93%
6
CY=Calendar Year
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20010 OUTCOMES FOR
PERFORMANCE MEASURES
2009 Aggregate
2010 (CY)Quarter 1
2010 (CY)Quarter 2
2010 (CY)Quarter 3
2010 (CY)Quarter 4
2010 Aggregate
TargetIL.
TargetNat’l
PNEUMONIA MEASUREMENT
PERFORMANCE MEASURESScore
Quarter 1Score Avg. Avg.
PN-2 Pneumococcal Vaccination 83% of 41 patients
90% of 10 patients
86% 87%
PN-3b Blood Cultures Performed in the 82% of 165 89% of 47 94% 92%PN 3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in the Hospital
82% of 165 patients
89% of 47 patients
94% 92%
PN-4 Adult Smoking Cessation Advice/Smoking
96% of 110 patients
100% of 34 patients
93% 91%
PN-5c Initial Antibiotic Received Within 6 Hours of Hospital Arrival
79% of 165 patients
91% of 46 patients
95% 94%
PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient
93% of 136 patients
100% of 10 patients
88% 89%
PN-7 Influenza Vaccination 77% of 69 patients
93% of 30 patients
83% 85%
7
CY=Calendar Year
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INTERVENTIONS FOR NON-COMPLIANCE TO
PNEUMONIA MEASURESPNEUMONIA MEASURES
• The ED Physician Core Measure Team Meeting will continue to review all pneumonia cases within 24 48 hours and provideto review all pneumonia cases within 24-48 hours and provide intervention to the physician staff.
• The Quality Service Staff will continue its concurrent reviewQ y
and provide feedback to the Chair and Nurse Manager of Emergency Medicine as well as the Chief Nursing Officer.
• The Medical Record Coding Staff will contact the responsible physician whenever the final diagnosis is not clear.
• Data will be analyzed to identify patterns by staff shift etcData will be analyzed to identify patterns by staff, shift, etc. and an appropriate action plan will be implemented.
• Visual reminders have been posted.
8
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9
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10
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2010 SCIP MEASUREMENT OUTCOMES
PERFORMANCE MEASURES2009 (CY)AggregateScores
2010 (CY)*Quarter 1
2010 (CY)Quarter 2
2010 (CY)Quarter 3
2010 Aggregate Scores
TargetIL. Avg.
TargetNat’lAvg.
SCIP INF 1 Prophylactic Antibiotic Received Within One Hour
95% of 58 patients
73% of 11 patients
91% 92%Received Within One Hour Prior to Surgical Incision.
patients patients
SCIP INF.2 Prophylactic Antibiotic Selections for Surgical Patient
98% of 57 patients
100% of 11 patients
96% 95%
SCIP INF. 3 Prophylactic Antibiotic 96% of 55 100% of 10 90% 90%DiscontinuedWithin 24 hous After Surgery End Time
patients patients
SCIP INF.4 Cardiac Surgery Patients with Controlled 6 A.M. Post-operative Serum Glucose
- - 92% 91%
p
SCIP INF. 6 Surgery Patients with Appropriate Hair Removal.
96% of 78 patients
100% of 14 patients
97% 98%
SCIP INF VTE1
Surgery Patients with RecommendedV Th b b li
100% of 24 patients
100% of 9 patients
87% 88%
Venous Thromboembolism Prophylaxis Ordered.
SCIP INF.VTE2
Surgery Patient Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 hours Prior to
100% of 24 patients
100% of 9 patients
86% 87%
11
Surgery to 24 Hours After Surgery
CY=Calendar Year
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INTERVENTIONS FOR NON-COMPLIANCE TO SCIP MEASURES
•The variances were a result of failure to follow the established protocol. The timing of the antibiotic exceeded the one hourprotocol. The timing of the antibiotic exceeded the one hourcriterion by 3-10 minutes for the cases in question.
After re ie and disc ssion b the Departments of AnesthesiaAfter review and discussion by the Departments of Anesthesia,Obstetrics/Gynecology, Surgery, and Nursing, the process waschanged from initiation of the antibiotics in the Holding Area to initiation of the antibiotics by the Anesthesiologist in the Operating Room.Data analysis will include identification of patterns/trends byData analysis will include identification of patterns/trends by physician and nursing staff.
•Visual reminders have been posted
12
•Visual reminders have been posted.
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FIRST QUARTER 2010
CUSTOMER SERVICE SCORESPERFORMANCE MEASURES
2009 (CY)*Aggregate
2010 (CY)**Quarter 1
2010 (CY)Quarter 2
2010 (CY)Quarter 3
2010 (CY)Quarter 4
TargetIL. Avg.
TargetNat’lAvg.
Communication with Nurses (Always) 68% 70% 73% 75%
CUSTOMER SERVICE SCORES
( y )
Communication with Doctors (Always) 79% 82% 79% 80%
Responsiveness of Hospital Staff (Always) 46% 51% 60% 63%
Pain Management (Always) 63% 67% 67% 69%
Communication about Medicines (Always) 56% 62% 58% 59%
Cleanliness of Environment 62% 67% 69% 70%
Overall Rating (9-10 Rating) 47% 53% 63% 66%
*CY=Calendar Year Data from
13
Hospital Compare **First Quarter Calendar Year data
from Press-Ganey
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COMPLAINTS FOR 2009
20
22
24
26
INT
S
14
16
18
20
UM
BE
R O
F C
OM
PL
A
Data Points
Average
8
10
12
Jan'09 Feb'09 Mar'09 Apr'09 May'09 June'09 July'09 Aug '09 Sept '09 Oct '09 Nov 09 Dec '09
NU
Jan 09 Feb09 Mar 09 Apr 09 May 09 June 09 July 09 Aug. 09 Sept. 09 Oct. 09 Nov.09 Dec. 09
MONTHLY
14
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COMPLAINTS BY TYPES - 2009
84%89%
93%96% 99%
138.25
158
90%
100%
n=158
37
45%
62%
73%
59.25
79
98.75
118.5
NU
MB
ER
30%
40%
50%
60%
70%
80%
37 3427
18 178 6 5 4 2
23%
0
19.75
39.5
DW
ait T
ime
Other
Rude S
taff
ation
by S
taff
icatio
n Issu
es
d w/Trea
tmen
t
ing Q
uesti
ons
ntBelo
nging
s
Cleanli
ness
ofes
sona
lism
0%
10%
20%
30%
ED
Comm
unica
t
Med
icaPati
ents
Disagr
eed w
Billing
Patien
t C
Unpro
f
15
Page 20 of 60
PROVIDENT HOSPITAL OF COOK COUNTYPROVIDENT HOSPITAL OF COOK COUNTYPATIENT COMPLAINT/GRIEVANCES - JANUARY -MAY 2010
18
20
22
10
12
14
16
Num
ber
of C
ompl
aint
s
Data Points
Average
4
6
8
Jan Feb March April May
TIME FRAME OF MEASUREMENT
16
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TYPES OF COMPLAINTS FIRST QUARTER 2010
98%95%42 100%
n=42
%95%93%
88%83%
79%
69%
57%26.25
31.5
36.75
ER 60%
70%
80%
90%
5
8
16
57%
38%
10.5
15.75
21
NU
MB
E
20%
30%
40%
50%
1112224
5
0
5.25
Rude Staff Long Wait inED
Cleanliness Timeliness ofTest Results
Food Not Good Delay inReceiving
Medication
Other Compensationfor Alleged
Injury
Staff Eating atFront Desk
Bad Signage inOutpt. Pharm.
0%
10%
REASONS FOR COMPLAINTS
17
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INTERVENTIONS TO IMPROVE CUSTOMER SERVICESCUSTOMER SERVICES
•Reactivated Hospital Customer Service Committeep• Mandatory Customer Service Training provided to all hospital staff
during March and April 2010.•Hospital Departments developed Customer Service Goals for 2010•Hospital Departments developed Customer Service Goals for 2010.•Patient Advocate makes daily visits to all new admissions to inform them of our commitment to provide excellent service.Th Di f H k i h i l d h b•The Director of Housekeeping has implemented a process whereby the Housekeeping Supervisors must provide a written and signed report to him at the end of each shift.p
• The Department of Nursing is measuring turn-around time for response to the call lights.
• Press-Ganey Data is being provided to each Nurse Manager
18
• Press-Ganey Data is being provided to each Nurse Manager, Medical Staff Chairs, and Department Head.
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PATIENT FLOW/THRU-PUT
The Joint Commission standards for accreditation s d ds o cc ed orequires that hospitals improve processes to ensure the timely flow of patients through out theflow of patients through-out the hospital. The regulatory agencies have placed special focus on the Emergency Room Overcrowding. Studies have shown that overcrowded Emergency Rooms are caused by failures in processes of departments/support services to
19
departments/support services to the Emergency Room staff.
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Recent ActivitiesRecent Activities
• The multi-disciplinary team noted very little improvement in p y y pthe indicators chosen for FY 2009
– therefore little improvement in patient flow
• Team went back to drawing board with cause and effect diagrams for multiple processes in the movement of patients through the ED from time of triage to time of disposition and t oug t e o t e o t age to t e o d spos t o a dmovement to the floor.
• Root causes were identified and interventions recommended
20
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Problem: Late Rounding of MDs for Di hDischarges
• Re-education of Primary Care Physicians regarding writing Discharge Orders by 10:00amDischarge Orders by 10:00am
• Re-inforce the policy– Department Chairs to discuss at Department Meetingp p g– Dr. Hamb discussed at Quarterly Medical Staff Meeting
4/13/10Develop incentives at department level for compliant– Develop incentives at department level for compliant physicians
– Track progress and post compliance by MD in Physicians’ llounge
• Re-education of Nurse Managers and House Administrator to expedite discharged patients out of bed within 2 hours of order
21
p g pwritten
Page 26 of 60
Problem: Non-aggressive progressive Disciplinary Action on FMLA Abuse andDisciplinary Action on FMLA Abuse and
Time and Attendance Abuse• Re-evaluate FMLA Policy/Practice along with Union y g
Agreement– Train Managers/Directors
• Find alternatives for Managers to serve as a buffer when• Find alternatives for Managers to serve as a buffer when progressive discipline enforced
• Retrain Managers/Directors on the T/A policy• Develop summary Tracking Report from Payroll for Managers
so that Trends can be easily identified.• Post Report of %age of shifts worked by employee code inPost Report of %age of shifts worked by employee code in
each department top put peer pressure on abusers• Improve the accuracy and integrity of time clocks throughout
the institution
22
the institution.
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Problem: Staff holding patients until hif hshift change
• Management Presence 24/7 around clock or at least for two gshifts to expedite movement of patients– Take Nurse Manager out of House Administrator Role
during regular work dayduring regular work day– Increased HA oversight on off-shifts
• Relocate HA office to Main ED once Phase II l dcompleted
• Reemphasize with MDs work-ups on the floor.• Re-enforce faxing of nursing reports if bed available and floorRe enforce faxing of nursing reports if bed available and floor
not willing to receive report within 30 minutes.– Inform HA before movement of patient
23
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Problem: Lack of Urgency on part of StaffProblem: Lack of Urgency on part of Staff
• Must hold management accountableg– Develop different set of expectations– Need senior leadership support to drive this
R l t HA ffi t M i ED• Relocate HA office to Main ED• House Administrator to reconcile available beds on Floor with
patients waiting in the ED every 4 hours.• Re-evaluate Use of Discharge Lounge
– Review Criteria for admissionCh E t ti f M t d St ff t i• Change Expectations of Management and Staff to improve TAT for patients.– Post productivity of staff in highly visible location within
24
department ( peer pressure)
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Next StepsNext Steps
• Discuss interventions with Senior LeadershipDiscuss interventions with Senior Leadership for approval
• Implement interventions as approved• Implement interventions as approved
• Measure outcomes June 14-20, 2010
25
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INTRA & INTER DEPARTMENAL PERFORMANCE IMPROVEMENT
PROJECTS
SIGNIFICANT IMPROVEMENTS
26
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PHCC TEAM PROJECT - STORY BOARD/ QUALITY ROAD MAP Team Information Team Leader: Beverly A. Alexander RN Team Facilitator: Beverly A. Alexander RN
1. Problem Statement Inpatient Preoperative Preparation, patients are not properly prepped prior to coming down to the OR for surgical procedures. Many times the preoperative flowsheets are incomplete and missing vital information necessary for the care of the patient.
Team’s Sponsoring Manager: Lisa Blutcher RN Team Members: L.Wilson RN, N. Johnson RN, S. Hutaserannee RN, B. Agumen RN, A.Uzoaru RN
2. Current Situation Although the inpatient load is relatively small, it is imperative the information received from
Performance Indicators: Goal: 100%
3. Root Cause Analysis 1. Patients not adequately prepped for surgery causing cancellations
the units is accurate and timely. In more than 50% of the inpatient surgeries this is not the case. Perioperative flow sheets are incomplete, labs are missing
d ft th ti t i t
Initial Audit: 44% (baseline)
25 charts reviewed Documentation on Perioperative logs reviewed. 11/25 G i 56%
q y p pp g y g or excessive delays (9) ( i.e. colonoscopies) 2. Unit Nursing staff not aware patient is for Surgery not maintained NPO. (cases can be delayed 8 hrs or possibly cancelled) (6)
3. Changes in patient’s condition not relayed to Surgery. (6)
4. Inadequate Hand-off (i.e. patients on Isolation OR not aware until and often the patient is not properly prepped for the particular surgery they are scheduled for. These situations usually lead to cancellations or delays
Gap variance: 56%(Formula)
Number of incomplete preoperative checklists and/or Patient readiness/Total # of inpatient surgery charts reviewed
patient arrives). (6)
5.Incomplete consents, missing labs (4)
27
y
inpatient surgery charts reviewed
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4. Chosen Solution (Determine Options) 5. Action Plan (Measure the Change)
What
Who
How
When
1) Initial team members meeting with 3-11 Charge nurses from
b h 8 / 8 d i i d AC ff h ld 1 and 2
3
Perioperative and 8E/8West staff
Same as above
Meeting 2/26/10 A il 2010
both 8east/ 8west and Perioperative and PACU staff held on 2/26/2010
2) Develop Fishbone cause and effect analysis.
3) Determine monthly meeting schedule to review data, develop 3 April 2010) y g , p
preoperative training program for staff. Timeline
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec X X X X
28
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100
PRE-OPERATIVE PREPARTIONBaseline 44%
60
70
80
90
100
NC
E
20
30
40
50
CO
MP
LIA
N
0
10
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8
MEASURABLE TIMEFRAME: MARCH-APRIL 2010
29
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PHCC TEAM PROJECT - STORY BOARD/ QUALITY ROAD MAP Team Information
1. Problem Statementea o at o
Team Leader: Carmen Hudson-White, M.D. Department Chair Team Facilitator: Lisa Webb R.N. CNM Team Sponsoring Manager Beverly Alexander, Nurse Manager
. ob e State e t Studies have shown that breastfeeding is the best source of nutrition for the newborn. The Maternal-Child Division has a low percentage of women that initiate breastfeeding.
Team Members: Beverly Alexander, R.N. Nurse Manager, Lisa Webb, R.N. Nurse Clinician, Maternal-Child Staff, O.B./GYN Physicians, Midwifery staff, Ambulatory Clinic Staff
2. Current Situation
Jan. 2010 8/21 mothers were eligible candidates for breast feeding. 8/21 (38%) made the decision to breastfeed
Performance Indicators:Goal (Standard/ Benchmark) United States National Immunization Survey – 2004 Live Births
3. Root Cause Analysis Most Likely Cause: (Nursing)
1. Lack of knowledge r/t breastfeeding (cultural). 2. WIC programs implementation of free formula. 3. Convenience of prepared formula. 4 Late identification of potential candidatesdecision to breastfeed.
Live Births Illinois Benchmark – 72.5% of all delivered mothers initiate breastfeeding.
4. Late identification of potential candidates. 5. Patients undecided.
Formula: Total # of Breastfeeding Mothers Total # of Deliveries
30
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3. Chosen Solution (Determine Options): 4. Action Plan (Measure the Change):
What
I i t ff di
Who
Unit Manager
How
Unit inservices
When
January 2010
1. Identify breastfeeding candidates and preferences during
Inservice staff regarding proposed solutions. See 1-4
Unit Manager
Nursing Staff
Unit inservices
Pamphlets will be
placed in admission packets.
January 2010
February 2010
the admission process.
2. Provide breastfeeding educational material and literature
to all delivered mothers.
3. Staff to support and encourage patients regarding
breastfeeding during the hospital stay
See-5-7
Nurse Manager
Nurse will be
initiated post-partum
March 2010
breastfeeding during the hospital stay.
4. Status of breastfeeding education and status will be
included in the Hand-off Endorsement (nurse to nurse
shift report).
5. Develop and initiate breastfeeding survey for mothers
partum.p g y
by March.
6. Provide breastfeeding literature on admission to LDRP.
7. Remove infant formula from discharge gift baskets for all
breastfeeding mothers. Timeline Jan: X Feb X Mar X Apr May Jun Jul Aug Sep Oct Nov Dec
Implementation Record (Measure the Change) All identified solutions implemented as scheduled.All identified solutions implemented as scheduled.
31
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90
100
BREASTFEEDING INITIATIVE
N=52
60
70
80
20
30
40
50COMPLIANCE
0
10
20
Jan'10 Feb.'10 Mar'10
MEASURABLE TIMEFRAME: JAN-MARCH 2010
32
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DEPARMENTAL INDICATORSDEPARMENTAL INDICATORS
QUALITY AND OPERATIONAL
33
Page 38 of 60
PROVIDENT HOSPITAL OF COOK COUNTY
DIVISION OF PROFESSONAL SERVICES INDICATORS – JANUARY-MARCH 2010
Key: Green : Targeted Goal of 90-100 is met.
Yellow: Targeted goal is not met; outcomes are 80-89%
Red: Targeted Goal is not met; outcomes are 70-79% .
CardiacDiagnostic
Clinical Lab
Outpatient Echocardiogram appointments are scheduled within 6 wks of
Turn-around time of Autopsy Reports
Blood Crossmatched to Infused Ratio
STAT Lab Turnaround Time
Inpt. Diagnostic Tests are performed within 48hrs of receipt of orders
scheduled within 6 wks of request
Hemolytic Transfusion Reactions
receipt of orders
Timely Interpretation of % Transfusion Forms Returned to Blood Bank
Non-Hemolytic Transfusion
Echocardiograms Returned to Blood Bank Reactions
Proficiency Test ScoresScores
Page 39 of 60
I f ti C t l Occupational
PROVIDENT HOSPITAL OF COOK COUNTY
DIVISION OF PROFESSONAL SERVICES INDICATORS – JANUARY-MARCH 2010
Employee Health Infection Control Physical Therapy
Occupational Therapy (OT)
Hand washing
Compliance
Key: Green : Targeted Goal of 90-100% is met;
outcomes where the desired targeted goal is at the lower limit are reflected in green indicating benchmarks are met.
Yellow: Targeted goal is not met;
Outpatient Appointment
Tuberculin Skin Testing
Inpatient Treatments completed as ComplianceYellow: Targeted goal is not met;
outcomes are 80-89%
Red: Targeted Goal is not met; outcomes are 70-79% .
Availability
Response Turn- Patient Corrective Reporting for
scheduled
Surgical Site *around Time (TAT) Satisfaction with
Outpatient O.T.duty-related
injuries/illnesses Infection Rate
0% 1.6% 0% *=Herniorraphy only included.Benchmark: 0.8-3.94
Central Line Associated BSI
Rate
0% 0% 0%Benchmark: 2.9
Page 40 of 60
EXPLANATION OF VARIANCES AND INTEREVENTIONSAND INTEREVENTIONS
• Cardiac-diagnostics: Continue to use overtime. Cardiac agency personnel
are being added to County Wide Agency Contract. Citi College contractare being added to County Wide Agency Contract. Citi College contract affiliation has been approved.
• Physical Therapy: Outpatient wait time is 8.2 weeks (goal 2 weeks). Recently appointed full-time Assistant Director for the department who will ece t y appo ted u t e ss sta t ecto o t e depa t e t w o wbe on site. Agency staff contracts were renewed 3/3/10; additional contract therapist scheduled for several days in May and June; continue to over-schedule and prioritize referrals to ensure that high priority patients are seen timely; have initiated a knee class to manager referrals for patients with chronic knee pain to allow for a more efficient flow of patient thereby increasing the number of initial appointment slots.
36
Page 41 of 60
PROVIDENT HOSPITAL OF COOK COUNTY DIVISION OF PROFESSONAL SERVICES – JANUARY-MARCH 2010
Radiology Pharmacy
Film Reject Rate Indication for Appropriate Anticoagulation Therapy
Enoxaparin
Key: Green : Targeted Goal of 90-100% is met.
Yellow: Targeted goal not met; outcomes are 80-89%.
Red: Targeted goal is not met; outcomes are 70-79%.
Drug Appropriateness Review Prior to IV Contrast Media)
Heparin
Enoxaparin
Inventory of Lead Aprons
Jan: No patients
Warfarin
Page 42 of 60
Dietary Plant Operations SafetyS it
PROVIDENT HOSPITAL OF COOK COUNTY
DIVISION OF SUPPORT SERVICES QUALITY INDICATORS – JANUARY – MARCH 2010
Biomedical Dietary y
Statement of Condition Plan for Improvement
Hospital Thefts Reported within 24 hours
Security
Recipe
Compliance Required Fire Drills
Vendor Response Time
Automatic Fire Extinguishing Equip.
Daily Activity Reports
Staff Knowledge
During Fire Drills
User Knowledge of
Electrical Devices
Sanitation
Evaluation
Portable
Fire Equip.Food/Drug Interaction
EducationFire Alarm and Detection Systems
Testing of Generator
and Transfer Switches
Key: Green : Targeted Goal of 90-100% is met.Yellow: Targeted goal is not met; outcome
is 80-89% Red: Targeted Goal is not met; outcome
is 70-79% .
Page 43 of 60
PROVIDENT HOSPITAL OF COOK COUNTYDIVISION OF NURSING SERVICES QUALITY INDICATORS – JANUARY – MARCH 2010
8E t 8W t E M t l/Child Peri operative & Sterile 8East 8West Critical Care Emergency Department
Maternal/Child Peri-operative & Sterile Processing
Assessment and Pain Management
Assessment and Pain Management
Assessment and Pain
Management
Management of Patients on Cardiac Monitor
Assessment and Pain
Management
Appropriate Cleaning of Scopes
7.6%
Patient Education
Hand-off Endorsement for Dialysis Patients Appropriate Appropriate
Assessment and PainEducation for Dialysis Patients Triage Assessment Management of Post
Partum Hemorrhage
Assessment and Pain Management
Key: Green : Targeted Goal of 90-100 is met.Yellow: Targeted goal is not met; outcome is 80-89% Red: Targeted Goal is not met; outcome is 70-79% .
Page 44 of 60
PROVIDENT HOSPITAL OF COOK COUNTYDIVISION OF NURSING SERVICES QUALITY INDICATORS – JANUARY – MARCH 2010
Transportation Nursing Transportation
Turn-around Time of Patient Transport for ED to Xray and Units to Surgery
Nursing Resources
Reduction in Hospital-wide Falls
Units to Surgery
Individualized Nursing Care PlansCare Plans
Key: Green : Targeted Goal of 90-100% is met.Yellow: Targeted goal is not met; outcomes are 80-89%
Red: Targeted Goal is not met; outcomes are 70-79% .
Page 45 of 60
PROVIDENT HOSPITAL OF COOK COUNTYDIVISION OF FINANCE QUALITY INDICATORS – JANUARY – MARCH 2010
S i l S iHealth & Information Records
Social Services
Timeliness of InterventionDelinquent Medical Records
Key: Green : Targeted Goal of 90 100 is metKey: Green : Targeted Goal of 90-100 is met.Yellow: Targeted goal is not met; outcomes are 80-89% Red: Targeted Goal is not met; outcomes are 70-79% .
Page 46 of 60
A th i l A t i l C iti l C E F il M di i
PROVIDENT HOSPITAL OF COOK COUNTY
DIVISION OF MEDICAL STAFF INDICATORS – JANUARY-MARCH 2010
Anesthesiology Anatomical Laboratory
Critical Care Emergency Medicine
Xray
Discrepancies
Family Medicine General Surgery
Internal Medicine
Readmissions within 31 days
Readmission within 31 Days with same/related condition
Unscheduled Returns to OR
Diagnostic Accuracy in Surgical Pathology
Airway Complicatons
Readmission to Critical Care
condition
Respiratory Complications
Diagnostic Accuracy in Cytology
Central Line Infections
Medication Refill: Follow-up Appt KeptComplications in Cytology Infections Follow-up Appt. Kept
by Patient
Ventilator Associated Pneumonia
Key: Green : Exceeds expected benchmarkYellow: Meets expected benchmark. Red: Does not meet expected benchmark
Page 47 of 60
Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting
June 29, 2010
ATTACHMENT #2
Page 48 of 60
June 29, 2010 – Item VI(A) - Quality and Patient Safety Committee Meeting
Hospital Dept Partner Reason
1
Family Medicine
Loyola University
Sub-agreement renewal - 34 FTE residents to rotate between SH, PH, ACHN and Loyola
2
Emergency Medicine
Midwestern University
PA Renewal – allows EM residents to rotate at PH
Page 49 of 60
Cook County Health and Hospitals System Minutes of the Quality and Patient Safety Committee Meeting
June 29, 2010
ATTACHMENT #3
Page 50 of 60
John H. Stroger, Jr. Hospital of Cook County
Medical and Non-Medical Staff Appointments/Reappointments Subject to Approval tjy the CCHHS Quality and Patient Safety Committee
MEDICAL STAFF INITIAL APPOINTMENT APPLICATIONS
Ansari, Asimul H., MD Medicine/Adult Cardiology Actjve Physician Appointment Effective: June 29, 20 I 0 through June 28, 2012
Lewis, Steven L., MD MedicineINeuro)ogy Voluntary Physician Appointment Effective: June 29, 2010 through June 28, 2012
Logan, Latania K., MD Pediatricsll nfectious Disease Voluntary Physician Appointment Effective: June 29,2010 through June 28, 2012
Matthews, Kameron, MD Correctional Health Serv/Fam Med Active PhYsician Appointment Effective: June 29, 2010 through June 28, 2012
Osei, Albert M., MD MedicineINeph-Hypertension Voluntary Physician Appointment Effective: June 29, 2010 through June 28, 2012
Sanati, Maryam, MD Medicine/Hospital Medicine Active Physician Appointment Effective: June 29, 2010 through June 28,2012
Shah, Meera, MD Medicine/Hospital Medicine Voluntary Physician Appointment Effective: June 29, 2010 through June 28, 2012
Shah, Mousami, MD Medicine/Hema-Oncology Active Physician Appointment Effective: June 29, 2010 through June 28,2012
Weddle, Jessica, MD Psychiatry Voluntary Physician Appointment Effective: June 29, 2010 through June 28, 2012
NON-MEDICAL STAFF ACTION FOR INITIAL PRIVILEGES
Kushnereit, Kelly, Psy.D Correctional Health Service/Psychiatry Clinical Psychologist Appointment Effective: June 29, 2010 through June 28, 2012
MEDICAL STAFF REAPPOINTMENT APPLICATIONS
Department of Anesthesiology
Alexander, Bozana, MD Adult Anesthesia Active Physician Reappointment Effective: July 22, 20 I 0 through July 21,2012
Stojiljkovic, Ljuba, MD Anesthesiology .Voluntary Physg' Reappointment Effective: June 29, 2010 through June 28, 2012 CCHHS. ...
QPS Committee Mtg, 0612912010 APPROVED Item VI1(C) PagBtotttE QUALITY AND PATIENT SAFETY MITTEE
ON JUNE 29, 2010 Page 51 of 60
John H. Stroger, Jr. Hospital of Cook County Medical Staff Reappointment Applications (continued)
Department of Correctional Health Services i
Zawitz, Chad J., MD Med/Surg(CHS) MediInf. Disease (JHS) ACtive Physician Reappointment Effective: July 12,2010 through July 11,2012
Department of Emergency Medicine
Kern, Kevin, DO Reappointment Effective:
Lewis, Trevor, MD Reappointment Effective:
Lu, Jenny Ju-Hsueh, MD Reappointment Effective:
Purim Shem-Tov, Yanina, MD Reappointment Effective:
Schindlbeck, Michael, MD Reappointment Effective:
Skoubis, Andreas, MD Reappointment Effective:
Department of Medicine
Balk, Robert A., MD Reappointment Effective:
Bennin, Bruce, MD Reappointment Effective:
Bressler, Joy E., MD Reappointment Effective:
Cohen, Mardge H., MD Reappointment Effective:
Cohen, Robert A.C., MD Reappointment Effective:
Cooke, Gerald 1., MD Reappointment Effective:
Ezike, Chukwuemeka F., MD Reappointment Effective:
Gueret, Renaud M., MD Reappointment Effective:
Ho, Kevin K., MD Reappointment Effective: QPS Committee Mtg, 06/2912010
Emergency Medicine July 11,2010 through July 10,2012
Emergency Medicine June 29, 2010 through June 28, 2012
Emergency Medicine July 22, 2010 through July 21,2012
Emergency Medicine July 13, 2010 through July 12, 2012
Emergency Medicine July 22, 2010 through July 21,2012
Emergency Medicine July 13,2010 through July 12,2012
Pulmonary/Critical Care July 11,2010 through July 10,2012
Dermatology July 22,2010 through July 21,2012
General Medicine June 20, 2010 through June 19,2012
General Medicine July 22,2010 through July 21, 2012
Pulmonary/Critical Care July 11,2010 through July 10,2012
ACHN/General Medicine July 22,2010 through July 21, 2012
ACHN/General Medicine July 22,2010 through July 21, 2012
Pulmonary/Critical Care June 17,2010 through June 16,2012
Gastroenerology July 22, 20 I 0 through July 21, 2012
Abtive Physician
Abtive Physician
Active Physician
Service Physician
Active Physician
! Service Physician
Voluntary Physician
Co~sulting Physician
Active Physician
Voluntary'Physician
,
A~tive Physician
Acti ve Physician
Active Physician
Active Physician
ActiveE'n. CCHHS '
APPROVED Item Vll(C) g
Pa e2jj,,'THE QUALITY AND PATIENT SAF MITTEE
ON JUNE 29,2010 Page 52 of 60
John H. Stroger, Jr. Hospital of Cook County Medical Staff Reappointment Applications
Department of Medicine (continued)
Husain, Sherfunnissa R., MD Reappointment Effective:
Imran, Muhammed, MD Reappointment Effective:
Jacobs, Elizabeth A., MD Reappointment Effective:
Jolly, Meenakshi A., MD Reappointment Effective:
Joshi, Amit J., MD Reappointment Effective:
Manadan, Augustine M., MD Reappointment Effective:
Marie, Nevenka, MD Reappointment Effective:
Martinez, Enrique, MD Reappointment Effective:
Martinez, Irene, MD Reappointment Effective:
Mourikes, Nike, MD
Reappointment Effective:
Patel, Aiyub, MD Reappointment Effective:
Pelaez, Victor M., MD Reappointment Effective:
Paintsil, Isaac, MD, MPH Reappointment Effective:
Pierre-Louis, Serge J.C., MD Reappointment Effective:
Samuel, Jacob, MD Reappointment Effective:
Shansky, Ronald, MD Reappointment Effective:
QPS Committee Mtg. 06/29/2010 Item VII(C)
ACHN/General Medicine July 22,2010 through July 21, 2012
General Medicine June 20, 2010 through June 19,2012
General Medicine June 20,2010 through June 19,2012
Rheumatology July II, 2010 through July 10,2012
Nephrology/Hypertension July 22, 20 I 0 through July 21, 2012
Rheumatology July 11,2010 through July 10,2012
ACHN/General Medicine July 13, 2010 through July 12,2012
ACHN/General Medicine July 12, 2010 through July 11,2012
General Medicine July 13,2010 through July 12,2012
ACHN/General Med Pediatrics
July 12, 20 I 0 through July 11, 2012
Pulmonary/Critical Care July 22, 2010 through July 21, 2012
Adult Cardiology July II, 2010 through July 10, 2012
ACHN/Hospital Medicine July 13,2010 through July 12,2012
Neurology July 12, 2010 through July 11,2012
Pulmonary/Critical Care June 29, 2010 through June 28, 2012
General Medicine July 13, 2010 through July 12, 2012
Affiliate Physician
Active Physician
Active Physician
I
V 61untaryPhysician
Active Physician
,
Active Physician
Adtive Physician
Affiliate Physician
Active Physician
Active Physician
Active Physician
Att.1iate Physician
Active Physician
Active Physician
Ac~ve Physician
Voiuntary Physician ~
ceHHS ,
APPROVED P.31)"~ QUALITY AND PATIENT SAFETY Co EE
ON JUNE 29,2010
Page 53 of 60
John H. Stroger. Jr. Hospital of Cook County Medical Staff Reappointment Applications
Department of Medicine (cont'd)
Shariff, Ruhi R., MD Reappointment Effective:
Shim, Kyungran, MD Reappointment Effective:
Simon, David M., MD, Ph.D. Reappointment Effective:
Smith, Jennifer, MD Reappointment Effective:
Smith, Patrika, MD Reappointment Effective:
Sturman, Maureen, MD Reappointment Effective:
Turbay, Rafael F., MD Reappointment Effective:
Velinova, Silviya, MD Reappointment Effective:
Weibel, Sharon F., MD Reappointment Effective:
Department of Obstetrics and Gynecology
General Medicine July 13,2010 through July 12,2012
General Medicine July 13,2010 through July ]2,2012
Infectious Disease July 13,2010 through July 12,20]2
General Medicine July ]3,2010 through July 12,2012
General Medicine July 13,2010 through July 12,2012
General Medicine July 13,2010 through July 12,2012
Hospital Medicine July 22, 20] 0 through July 21, 20 t2
ACHN/General Medicine July 22, 2010 through July 2 t, 2012
Infectious Disease July 12, 2010 through July II, 2012
Active Physician
Acti~e Physician
Voluntary Physician
Active Physician
Active Physician
Active Physician
Acti~e Physician
Active Physician
Active Physician
i
I Active Physician
Honorary Physician
ActiVe Physician
Voluntary Physician
ConsJIting Physician
Arlandson, Mary, MD Reappointment Effective:
Keith, Louis, MD Reappointment Effective:
Ungaretti, Joy, MD Reappointment Effective:
Swift, Eddie, MD Reappointment Effective:
Department of Pediatrics
Berry-Kravis, Elizabeth, MD Reappointment Effective:
Obstetrics/Gynecology June 29,2010 through June 28,2012
Gynecology June 29, 2010 through June 29, 2012
Obstetrics/Gynecology July 13,2010 through July 12,2012
Maternal Fetal Medicine June 29, 2010 through June 28, 20]2
Pediatrics June 29 20 I 0 through June 28, 2012
Boyer, Kenneth, MD Peds. Medicine Consulting Physician Reappointment Effective: July 22, 20 I 0 through July 21, 2012
CCRRS £2APPROVEDQPS Committee Mtg. 06/29/2010
Item VII(C) Pa!JjJYII'I[E QUALITY AND PATIENT SAFETY ITTEE ON JUNE 29,2010
Page 54 of 60
John H. Stroger, Jr. Hospital of Cook County Medical Staff Reappointment Applications
Department of Pediatrics (continued)
Giordano, Lisa, MD Reappointment Effective:
Hayden, William, MD Reappointment Effective:
Naheed, Zahra, MD Reappointment Effective:
Peddiniti, Radhika, MD Reappointment Effective:
Soter, Demetra, MD Reappointment Effective:
Department of Psychiatry
Williams, Adedapo, MD Reappointment Effective:
Department of Radiology
Adeniji, Adejimi, MD Reappointment Effective:
Erickson, Paul, MD Reappointment Effective:
Keen, John, MD Reappointment Effective:
Department of Surgery
Abraham, Edward, MD Reappointment Effective:
Bork, Jeffrey, MD Reappointment Effective:
Caruso, Joseph, DDS Reappointment Effective:
Durham, Joseph, MD Reappointment Effective:
Heffez, Leslie, DMD Reappointment Effective:
McCarthy, Theresa, DO Reappointment Effective:
Hematology/One August 0 I, 20 I 0 through July 31, 20 12
Pediatrics June 29, 2010 through June 28, 2012
Pediatrics June 29, 2010 through June 28, 2012
Hematology/Onc June 29,2010 through June 28,2012
Peds/Critical Care June 29,2010 through June 28,2012
Psychiatry July 13,2010 through July 12,2012
Radiology June 29,2010 through June 28,2012
Radiology June 29, 2010 through June 28, 2012
Radiology July 22, 2010 through July 21, 2012
Orthopaedic July 12,2010 through July 11, 2012
Breast Oncology July 22, 2010 through July 21, 2012
OrallMaxillofacial July 11, 2010 through July 10, 2012
Vascular Surgery July 12, 2010 through July 11,2012
Oral/Maxillofacial July 22, 2010 through July 21,2012
Rehabilitation Medicine July 12,2010 through July 11,2012
Active Physician
Volurhary Physician
, Activ~ Physician
Active Physician
Voluntary Physician
Activb Physician
Activ~ Physician
Active 'Physician
ActivePhysicidn
Active Physician
!
Active iPhysician
1
Consulting Dentist
'I
Active Physician
! • Voluntary Dentist
Affiliate Physician CCHHS ~)
QPS Committee MIg. 06/2912010 APPROVED ltemVI1(C) Ptw5fhW QUALITY AND PATIENT SAFETY Co M EE
ON JUNE 29,2010 Page 55 of 60
John H. Stroger, Jr. Hospital of Cook County Medical Staff Reappointment Applications
Department of Surgery (continued)
McDonald, Sara, MD Reappointment Effective:
Micco, Alan, MD Reappointment Effective:
Nichols, Jeffrey, MD Reappointment Effective:
Olivier, Mildred, MD Reappointment Effective:
Patel, Subash, MD Reappointment Effective:
Pearl, Russell, MD Reappointment Effective:
Prinz, Richard, MD Reappointment Effective:
Sisto, John, DDS Reappointment Effective:
Stone, James, MD Reappointment Effective:
Termini, Salvatore, MD Reappointment Effective:
Vidal, Patricia, MD Reappointment Effective:
Whelchel, Joan, MD Reappointment Effective:
Department of Trauma
Joseph, Kimberly, MD Reappointment Effective:
Messer, Thomas, MD Reappointment Effective:
Nagy, Kimberly, MD Reappointment Effective:
Otolaryngology July 13,2010 through July 12,2012
Otolaryngology July] 3, 2010 through July 12, 2012
Ophthalmology July 13,2010 through July 12,2012
Ophthalmology July 13,2010 through July 12,2012
Surgical Critcal Care July 12,2010 through July 11,2012
Colon Rectal July 12,2010 through July 11,2012
General Surgery July 12,2010 through July 11,2012
Oral/Maxillofacial July 11,2010 through Ju]y 10,2012
Neurosurgery July 13,2010 through July 12,2012
Oral/Maxillofacial July 13, 2010 through July 12, 2012
Urology July 13,2010 through July 12,2012
Ophthalmology July 13, 2010 through July 12,2012
Trauma July 22, 2010 through July 21, 2012
Burn July 22, 2010 through July 21, 2012
Trauma July 13,20]0 through July 12,2012
Active Physician
ConsJlting Physician
Active' Physician
Active iPhysician
, Active !Phys ician
, Volunttiry Physician
Voluntary Physician
Active Physician
Voluntary Physician
Active Physician
Active Physician
Active ~hysician
Active physician
Active Physician
Active P6ysician
CCRRS • APPROVED ~ QPS Committee Mtg. 06/2912010 plfj¥ ~QUALITY AND PATIENT SAFETY Co EEitem VlI(C]
ON JUNE 29,2010
Page 56 of 60
John H. Stroger, Jr. Hospital of Cook County (continued)
NON-MEDICAL STAFF ACTION FOR REAPPOINTMENT PRIVIIJEGES
Altez, Carlos C, PA-C Correctional Health Services .physician Assistant With Yu, Van K, DO July 22, 2010 through July 21, 2012 Alternate Baker, Terrance P., MD
Jopp, David, Ph.D. Correctional Health Services/Psychiatry Clinical Psychologist Reappointment Effective: June 29, 2010 through June 28,2012
Martinez, Salvador, PA-C Correctional Health Services Physician Assistant With Richardson, Stamatia Z., MD July 22, 2010 through July 21, 2012
Alternate Cruz, Pedro, MD I I
. Mathew, Lizamma, CNP Medicine / Adult Cardiology NUrse Practitioner With Shapiro, Michael A., MD June 29, 2010 through June 28,2012
Stadnicki, Christopher R., PA-C Correctional Health Services I '
Physician Assistant With Richardson, Lendell, MD July 22, 2010 through July 21, 2012
Alternate DeFuniak, Andrew, MD
Swanson, Robert, Ph.D. Psychiatry / Child Adolescent dinical Psychologist Reappointment Effective: July 13,2010 through July 12,2012
MEDICAL STAFF CHANGES WITH NO CHANGE IN CLINICAL PRIVILEGES
Mosnaim, Giselle S., MD From: Voluntary Physician To: Consulting Physician Pediatrics/Allergy/Immunology
Sierens, Diane, MD, MD From: Voluntary Physician To: Active Physician Surgery/Neurosurgery
Sonenthal, Kathy, MD From: Consulting Physician To: Voluntary Physician Medicine/Pulmonary Critical Care
Williamson, Sunita, MD From: Voluntary Physician To: Active Physician Correctional Health Services/MediSurg
CCHHS ~ APPROVED )QPS Committee Mtg. 06/29/2010 Item VII(C) Page 7 of 1tf:Jy THE QUALITY AND PATIENT SAFETY MMITTEE
ON JUNE 29,2010
Page 57 of 60
---------------._-
Provident Hospital of Cook County
Medical Staff Appointments/Reappointments Subject to Approval by the CCHHS Quality and Patient Safety Committee
MEDICAL STAFF INITIAL APPOINTMENT APPLICATIONS
Escoto, Michael, DO Emergency Medicine Affiliate Physician Appointment Effective: June 29, 2010 through June 28, 2012
i Hall-Ngorima, Regina, MD Family MedicinelPsychiatry Affiliate Physician Appointment Effective: June 29, 2010 through May 18,2012
MEDICAL STAFF REAPPOINTMENT APPLICATIONS
Department of Critical Care
Alahdab, Mohamad T., MD Reappointment Effective: June 29,2010 through June 2S, 2012
AI-Massalkhi, Mohamad I., MD Reappointment Effective: July 12,2010 through July 11,2012
Department of Emergency Medicine
Colbert, Christopher, DO Reappointment Effective: July 22, 2010 through July 21, 2012
Department of Family Medicine
Billingslea, Camille, MD Reappointment Effective:
Ikedionwu, Chukweloka, MD Reappointment Effective:
McPherson, Julita, MD Reappointment Effective:
Miller, Joyce, MD Reappointment Effective:
Family Medicine July 12,2010 through July 11,2012
Family Medicine July 09,2010 through July OS, 2012
Family Medicine July OS, 2010 through July 07, 2012
Psychiatry July 12,2010 through July 11,2012
Department of Internal Medicine
Chey, Howard K., MD Employee Health Services Reappointment Effective: July 22, 2010 through July 21, 2012
Ancillary Physician
1
Ancillary Physician
ACtive Physician
I Active Physician
i
Active Physician
i. . . ActIve PhYSICIan
Active Physician
Active Physician
CCHHS flQPs Committee Mtg. 06/29/2010 Item VJI(C) Page 6 of 10 APPROVED
BY THE QUALITY AND PATIENT SAFET MITTEE ON JUNE 29,2010
Page 58 of 60
Provident Hospital of Cook County Medical StatIReappointment Applications (continued)
Department of Obstetrics and Gynecology
Foggie, Goldwyn, MD Reappointment Effective: July 22, 2010 through July 21, 2012
Ahcillary Physician
Department of Surgery Canning, John, MD Reappointment Effective:
Urology July 22, 2010 through July 21, 2012
Active Physician
~CCRRS APPROVED
QPS Committee Mtg. 06129/2010 Item VIJ(C) Page 90fft TRE QUALITY AND PATIENT SAFE MITTEE
ON JUNE 29,2010
Page 59 of 60
i I
OAK FOREST HOSPITAL OF COOK COUNTY
Medical Staff Appointments and Medical and Non Medical Staff Reappointments Subject to Approval by the CCHHS Quality and Patient Safety Committee
I
MEDICAL STAFF INITIAL APPOINTMENT APPLICATIONS
Hall-Ngorima, Regina, MD Rehabilitation MedlPsychiatry Affiliate Physician Appointment effective: June 29, 2010 through May 18,2012
Tamae-Kakazu, Maximiliano, MD Medicine/ICU Visiting Con~ultant Appointment effective: June 29,2010 through December 30,2011
MEDICAL STAFF REAPPOINTMENT APPLICATIONS
Adusumilli, Chowdary, MD Reappointment effective:
Chow, Carmel, MD Reappointment effective:
Hussain, Anwer M., DO Reappointment effective:
Lachin, Zaia, MD Reappointment effective:
Sheth, Darshana, MD Reappointment effective:
Sigamony, Ranjit, MD Reappointment effective:
Rogers, Ollie, CNP Reappointment effective:
Emergency Medicine June 29,2010 through July 27, 2011
Medicine/Oncology June 29,2010 through June 28, 2012
Emergency Medicine June 29, 2010 through June 28, 2012
Medicine June 29, 2010 through June 28, 2012
Surgery/Anesthesiology June 29, 2010 through June 28, 2012
Emergency Medicine June 29,2010 through June 28, 2012
Affiliate Physician
Active Physician
Active Physician
Active Physician
Active PhYsician
Active Physician
NON-MEDICAL STAFF REAPPOINTMENT
!
Employee Health Services Nurse Practitioner July 22, 2010 through July 21,2012
ceHHS I'~QPS Committee MIg. 06/2912010 Page10of10 APPROVED .Item VII(C)
BY THE QUALITY AND PATIENT SAFETY C MITTEE ON JUNE 29,2010
Page 60 of 60
