ADMINISTRATION/BOARD UPDATE – Randy Ulseth
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Attendance: Brenda Moos, Sandy Zutz-Wiczek, Diane Bankers, Garrett Estenson, Stacey Heins, Leann McMullen, Robert Woods, Ellen Ryan, Randy Ulseth, Brent Thompson, Julie Ray, Karen Renaud, Heather Sanftner, Kim Tepley
Absent: Jill Sawyer, Becky Gallik, Kris Bombard, Mark Vizenor
ADMINISTRATION/BOARD/FINANCIAL UPDATE – Randy Ulseth
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Environment of Care Meeting Summary – August 10, 2016
Equipment Management:
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Attendance: Brenda Moos, Sandy Zutz-Wiczek, Diane Bankers, Garrett Estenson, Stacey Heins, Leann McMullen, Robert Woods, Ellen Ryan, Randy Ulseth, Jill Sawyer, Brent Thompson, Kris Bombard, Julie Ray, Mark Vizenor, Becky Gallik, Karen Renaud, Heather Sanftner, Kim Tepley
Absent: Jo DeFeyter, Gordy Forbort
ADMINISTRATION/BOARD/FINANCIAL UPDATE – Randy Ulseth
Presentation on Board Effect and equipment was distributed to Board members.
2016 Legislative Session update presented by Randy.
Financials for May were reviewed. Expenses were a bit over budget and the bottom line was above budget. …
| TITLE: ENVIRONMENT OF CARE COMMITTEE
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Date May 4, 2016
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| FOCUS
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DISCUSSION
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ACTION/FOLLOWUP/EVALUATION
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ATTENDANCE:
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Ellen Ryan, Karen Renaud, Cindy Teichroew, Kim Carlson, Kris Bombard, Mark Vizenor, Julie Ray, Kris Bombard
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| GOVERNING BOARD RESPONSE:
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Documentation reflects the Governing Board indicates a concurrence to the action of the Safety Committee with no additions or information required for the meeting of February 3, 2016
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MINUTES:
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The Minutes of February 3, 2016 meeting were accepted as written.
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GENERAL SAFETY
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Employee incidents for the 1st quarter of 2016 were reviewed. There were 4 employee injuries and 2 patient related issues.
There were 6 inpatient falls with 2 injuries and 1 eye clinic patient fall with no injuries.
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PERFORMANCE IMPROVEMENT PLAN:
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FROM PREVIOUS MEETING:
Hazardous/Waste and Cleaning product inventory will be discussed next meeting. Working on complete the inventory.
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PLAN:
Mark to develop a plan with Materials Management to identify cleaning materials that are FLHS approved.
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| INFECTION PREVENTION & CONTROL:
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Flu shot vaccination of employees totaled 93%.
There were 2 Construction permits were issued during the 1st quarter- 1 CSR/Decon Wall Project, 1 Mora Eye Clinic
Discussion on Sharp’s vendor – waiting on a proposal from Bio-hazard/Sharps waste vendor. Environmental Service is evaluating proposals from Laundry service providers and will be doing site visits in the near future. There were no sharp’s injuries or blood exposures in the first quarter – great job!
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HAZARDOUS MATERIALS AND WASTE
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Nothing to report at this time.
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HAZARD SURVEILLANCE:
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TLC has completed the hazardous surveillance inspection and Facility Operations is working on rectifying the deficiencies.
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SECURITY:
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Violence Prevention Team update – they are continuing to meet and review incidents along with revising response plans. FROM PREVIOUS MEETING: Panic button solutions are being further explored for all sites.
Digital radios are being passed out during the evening shifts for quicker response time to emergencies.
Security/maintenance new position has been filled.
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FOLLOW UP: Panic button solution is completed and working well. Looking to do the same at Hinckley and Pine City.
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EMERGENCY PREPAREDNESS:
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FLHS participated in the MN state wide exercise MnTrac Exercise on March 29th. Great experience and good training session The Emergency Codes-Flip Charts are being updated and will be distributed to Departments and clinics when complete. The new 3M PAPR’s have arrived and they will be stored near the Emergency Department.
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FOLLOW UP:
FOLLOW UP: Mark Vizenor will forward the Run/hide/fight video to departments to watch and discuss – completed by, June 1, 2016.
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| EDUCATION:
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ü Alpha 53% completed ü Beta 49% compleed ü Gamma 51% completed ü Violence Preventaion 55% completed ü Legal Compliance 60% completed ü HIPAA 60% completed
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EQUIPMENT MANAGEMENT
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TLC has reviewed the Preventative maintenance report (see attached) § 36 Pieces of equipment added § 7 pieces have been retired § 100% of Class I preventable maintenance completed § 100 of Class II has been completed § 0 patient incidents reported § 3 User errors § 2 Misuse errors Recall notices have been uploaded to the Public recall folder and have been forwarded to the appropriate managers.
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FIRE SAFETY:
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All fire drills have been completed for 1st quarter of 2016
Positive feedback noted on fired drill critiques from staff on the laminated smoke compartment maps. Very helpful.
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UTILITY MANAGEMENT
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Lab had a chemical analyzer failure due to heat – has been rectified.
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| OTHER:
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COLA inspection went well.
Discussion on temp trak response time. More discussion at next meeting.
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PLAN: Develop a process for a response plan for temp trak notifications.
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NEXT MEETING:
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Next regular scheduled meeting will be Wednesday, August 3rd at 9am in Small Conference Room.
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Attendance: Brenda Moos, Sandy Zutz-Wiczek, Diane Bankers, Garrett Estenson, Stacey Heins, Leann McMullen, Robert Woods, Ellen Ryan, Randy Ulseth, Jo DeFeyter, Jill Sawyer, Brent Thompson, Kris Bombard, Julie Ray, Mark Vizenor, Becky Gallik, Karen Renaud, Heather Sanftner, Kim Tepley
Absent: Kim Carlson, Gordy Forbort
ADMINISTRATION/BOARD/FINANCIAL UPDATE – Randy Ulseth …
Attendance: Kim Carlson, Brenda Moos, Sandy Zutz-Wiczek, Diane Bankers, Garrett Estenson, Stacey Heins, Leann McMullen, Robert Woods, Ellen Ryan, Randy Ulseth, Jo DeFeyter, Jill Sawyer, Brent Thompson, Gordy Forbort, Kris Bombard, Julie Ray, Mark Vizenor, Becky Gallik
Absent: Karen Renaud, Heather Sanftner, Kim Tepley
ADMINISTRATION/BOARD UPDATE – Randy Ulseth
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The Leadership team met on Wednesday, March 23, 2016. Here are the minutes: …
Attendance: Becky Gallik, Leann McMullen, Kim Tepley, Garrett Estenson, Kris Bombard, Mark Vizenor, Sandy Zutz-Wiczek, Stacy Heins, Randy Ulseth, Diane Bankers, Heather Sanftner, Ellen Ryan, Julie Ray, Brent Thompson, Brenda Moos, Bob Woods, Jo DeFeyter, Karen Renaud, Jill Sawyer
Absent: Gordy Forbort
ADMINISTRATION/BOARD/FINANCIAL UPDATE – Randy Ulseth
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FirstLight Health System
Pine City All Clinic Meeting Agenda
December 17, 2015
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TOPIC
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LEADER
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ACTION POINTS
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| Sandy Zutz-Wichek
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| Drs. Cady at PCC – Update
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The Cady’s will start seeing patients in Pine City 2 Mondays a month.
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January – 2nd and 4th Mondays
February – 1st and 2nd Mondays They will continue to see patients in Mora on Fridays. LEEP and Colp exams can only be scheduled in Mora. When urodynamics are added, those appointments will only be scheduled in Mora also.
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| Additional ED / US Staff
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2 new providers have been hired to support Urgency Services.
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They will begin their training in Mora. Will move to Pine City when ready.
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| 2016 Patient Experience Goals
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This topic will be added to the meeting
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The patient experience questions and answers will be shared.
Last month’s CG CAPS scores were shared. Many of the categories were in the green. Awesome work everyone!
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| InFocus
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FirstLight has providers giving talks about different health issues
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More information will come via the Intranet
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| Leann McMullen
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| Pine City CT / Xray
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Xray and CT are busier now with Urgency Services
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October 182 x-ray exams / 44 CT exams
November – 168 x-ray exams / 48 CT exams December has had a slow start
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| Pine City Ultrasound
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Ultrasound schedules are now open on Monday mornings and Thursday afternoons.
If no patients are scheduled, imaging will check provider schedules to see if there is a possibility of an add-on.
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If no possibility of an add-on, US tech will be sent to Mora to help with the patient load.
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| Breast Screening Quality Goal
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We are at 82%.
We are now sending no answer patient’s letters with a mystery gift coupon. Four mystery gift coupons have been redeemed. We are creating a list of the patients that refuse their mammograms.
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This list is sent to Dawn Brown who will distribute to the providers. Perhaps the providers can encourage these patients to have their mammograms.
We only need approximately 80 more patients to have their mammograms in order to meet the goal of 86.5%.
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| Mammography
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Additional appointments will be available
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These appointments will be added on the mornings that the Cady’s are in Pine City.
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| Children’s Hospital Image Sharing
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FirstLight is now able to share images with Children’s Hospital.
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Providers would be able to have imaging send the images and then call Children’s and set up a consult with one of the providers there.
Leann to send out a workflow with phone numbers.
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| PACS Upgrade
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Going live on January 12.
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Icons will be pushed out to all providers, all patient rooms, Rehab
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| Karen Renaud
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| Staffing
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Phlebotomist has been hired for Pine City
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New temp will start on Jan. 4 or before.
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| DCA Interfaces
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DCA interfaces are now working
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What does this mean? HgbA1c results cross into the computer when completed and auto-verify. These results no longer need to be reviewed by lab staff. This will decrease TAT.
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| Stacey Heins
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| Hinckley Phone Lines
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Patients have been calling 2 different phone numbers, an agent line and a private line. This is causing a disruption in patient care.
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The private line will have a message directing the patient to call the agent line. This change will occur on 12-22.
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| Garrett Estenson
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| Cardiac Rehab Orders
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300 cardiac orders blew into rehab last week.
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Of those 300, only 15 patients had not been seen. Those patients are being contacted.
Holter and event monitor appointments are now available in Pine City.
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| Crutches / Walkers / Canes
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All these supplies are to be billed to Pine City Medical Supply
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Make sure to fill out the paperwork. PC Med Supply will bill insurance.
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| Julie Ray
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| Staffing
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.8 specialty nurse has been hired.
Many staff with FMLA – it has been challenging to cover their shifts.
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Open positions
1.0 resource LPN Casual RN/LPN Scribe Spread the word!
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| Safety
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Winter survival kit brochure handed out
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| Parking
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Please do not park south of the dumpster
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We need to keep this area open in the event that the helicopter needs to land.
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Next Meeting – January 21, 2015 from 12:15 to 12:45
