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DRAFT Robert Packer Hospital
Clinical Quality Committee Meeting
DATE: Monday, December 17, 2018
TIME: Noon
Present: Brian Fillipo, MD, Douglas Trostle, MD, Theodore Them, MD, Kell Coldiron, Mary Hicks, Kris Maffei, Renni Rodriguez, Jill Stenson, Tom
Heil, Kim Joedicke, Andrew Klee, Deb Luchaco, Sergio Zullich, Tracy O’Reilly.
Meeting Started: 12:07 PM Meeting Adjourned: 12:45 PM
TOPIC DISCUSSION/CONCLUSION RECOMMENDATIONS/
ACTION/FOLLOW UP
/RESPONSIBLE PARTY
I. Old Business Minutes from December 10, 2018 were reviewed. Dr. Trostle motioned to accept minutes Minutes Approved
as presented. There was no dissent.
II. 5 M Nursing Unit – Kelly Coldiron, RN provided report on 5 Main Oncology Unit. Informational
Copy of presentation • Reviewed quality metrics dashboard.
attached to official • Nursing dyad staffing model implemented to deliver care that is responsive to
minutes patient and family needs. This model consists of a Registered Nurse and Care
Partner team that provides care to a specific group of patients.
• Quality project implemented on June 28, 2018 that established interdisciplinary
rounds to increase communication with patients, while also improving
collaboration between physicians and nurses. Next step is to station a designated
Hospitalist on participating nursing units.
• Quality project implemented to discharge patients within one hour of receiving
discharge order. Goal set at 31.3%, unit has exceeded this goal since July 2018.
• Quality project implemented to increase hand hygiene compliance rates.
Interventions include education and tips for success, and weekly follow-up with
low performers. The average unit compliance rate is 86.7% with an overall goal of
90% or above.
• Massage Therapist added to care team on 5 Main, 7 Main and outpatient Infusion
Center.
III. 9 SW Nursing Unit – Kris Maffei, RN provided report on 9 SW Pulmonary Medical / Surgical Unit. Informational
Copy of presentation • Reviewed quality metrics dashboard.
attached to official • Quality project implemented to increase hand hygiene compliance rates.
minutes Currently, all staff are above 79% compliance since October 2018.
• Quality project implemented to reduce supply costs during Fiscal Year 2019.
Goal is to reduce costs by 2%. Interventions include decreasing the use of
specialized office supplies and implementing a process to discontinue rental
equipment upon patient discharge.
• Other quality initiatives include reducing bed readiness times and increasing
HCAPS score for “Recommend this hospital”.
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