Leadership Minutes – August 2016

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

  • Managers shared experiences from the Studer books they selected.

Continue reading “Leadership Minutes – August 2016”

August 2016 Environment of Care Report

Environment of Care Meeting Summary – August 10, 2016 

Equipment Management:

  • Recall notices have been uploaded to the Public Recall folder and forwarded to department managers.
  • TLC Safety Report-100% Class I and 99.5% Class II preventative maintenance has been completed. There were 0 patient incidents, 2 user errors and 1 misuse.  There were 4 preventative maintenance failures.

Continue reading “August 2016 Environment of Care Report”

Leadership Minutes – June 2016


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. Continue reading “Leadership Minutes – June 2016”

Environment Of Care Minutes – May 2016

TITLE: ENVIRONMENT OF CARE COMMITTEE

Date May 4, 2016

FOCUS

DISCUSSION

ACTION/FOLLOWUP/EVALUATION

 

ATTENDANCE:

 

Ellen Ryan, Karen Renaud, Cindy Teichroew, Kim Carlson, Kris Bombard, Mark Vizenor, Julie Ray, Kris Bombard

 

 

 GOVERNING BOARD RESPONSE:

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

 

MINUTES:

The Minutes of February 3, 2016 meeting were accepted as written.

 

 

GENERAL SAFETY

 

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.

 

 

 

 

 

 

PERFORMANCE IMPROVEMENT PLAN:

FROM PREVIOUS MEETING:

Hazardous/Waste and Cleaning product inventory will be discussed next meeting. Working on complete the inventory.

 

PLAN:

Mark to develop a plan with Materials Management to identify cleaning materials that are FLHS approved.

 

INFECTION PREVENTION & CONTROL:

 

 

 

 

 

 

 

 

 

 

 

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!

 

 

 

 

 

 

 

.

 

 

 

.

 

 

HAZARDOUS MATERIALS AND WASTE

 

Nothing to report at this time.

 

 

HAZARD SURVEILLANCE:

 

 

TLC has completed the hazardous surveillance inspection and Facility Operations is working on rectifying the deficiencies.

 

 

 

SECURITY:

 

 

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.

 

 

 

 

 

FOLLOW UP:

Panic button solution is completed and working well. Looking to do the same at Hinckley and Pine City.

 

EMERGENCY PREPAREDNESS:

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

FROM PREVIOUS MEETING: The video “RunHide/Fight” video will be shown to new employees as part of orientation and departments will share it with staff as part of education and discussion to help prepare for emergency situations.

 

 

 

FOLLOW UP:
Departments are making revisions and will report back to Jill for final distribution.

 

 

 

 

 

FOLLOW UP:

Mark Vizenor will forward the Run/hide/fight video to departments to watch and discuss – completed by, June 1, 2016.

 

EDUCATION:

 

 

    • 2016 OLE online Training update

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

 

 

EQUIPMENT MANAGEMENT

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

 

FIRE SAFETY:

 

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.

 

 

 

 

 

 

 

UTILITY MANAGEMENT

 

Lab had a chemical analyzer failure due to heat – has been rectified.

 

OTHER:

 

COLA inspection went well.

 

Discussion on temp trak response time. More discussion at next meeting.

 

 

 

PLAN:

Develop a process for a response plan for temp trak notifications.

 

NEXT MEETING:

 

Next regular scheduled meeting will be Wednesday, August 3rd at 9am in Small Conference Room.

 

 

 

May Leadership Minutes

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 Continue reading “May Leadership Minutes”

April Leadership Minutes

 

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
Continue reading “April Leadership Minutes”

Leadership Minutes – January 2016

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

  • Managers shared various wins and patient compliments.
  • Thank you to the Starlight Committee for all their hard work on the Holiday Party!!
  • DSGW provided a presentation to the Board on the design development.
  • Organizational chart was reviewed
  • Round table discussion on the Trustee Conference January 8 – 10th.
  • Annual Board policies reviewed.
  • Reviewed year end financials, great work team!
  • Discussion on employee evaluations and mid-year goal update meetings.

Continue reading “Leadership Minutes – January 2016”

Pine City All-Clinic Staff Meeting; December 17, 2015

FirstLight Health System

Pine City All Clinic Meeting Agenda

December 17, 2015

TOPIC

LEADER

ACTION POINTS

Sandy Zutz-Wichek

 

 

Drs. Cady at PCC – Update

The Cady’s will start seeing patients in Pine City 2 Mondays a month.

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.

 

Additional ED / US Staff

2 new providers have been hired to support Urgency Services.

They will begin their training in Mora. Will move to Pine City when ready.

2016 Patient Experience Goals

This topic will be added to the meeting

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!

InFocus

FirstLight has providers giving talks about different health issues

More information will come via the Intranet

 

 

 

Leann McMullen

 

 

Pine City CT / Xray

Xray and CT are busier now with Urgency Services

October 182 x-ray exams / 44 CT exams

November – 168 x-ray exams / 48 CT exams

December has had a slow start

Pine City Ultrasound

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.

If no possibility of an add-on, US tech will be sent to Mora to help with the patient load.

 

Breast Screening Quality Goal

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.

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%.

Mammography

Additional appointments will be available

These appointments will be added on the mornings that the Cady’s are in Pine City.

Children’s Hospital Image Sharing

FirstLight is now able to share images with Children’s Hospital.

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.

PACS Upgrade

Going live on January 12.

Icons will be pushed out to all providers, all patient rooms, Rehab

 

 

 

Karen Renaud

 

 

Staffing

Phlebotomist has been hired for Pine City

New temp will start on Jan. 4 or before.

DCA Interfaces

DCA interfaces are now working

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.

 

 

 

Stacey Heins

 

 

Hinckley Phone Lines

Patients have been calling 2 different phone numbers, an agent line and a private line. This is causing a disruption in patient care.

The private line will have a message directing the patient to call the agent line. This change will occur on 12-22.

 

 

 

Garrett Estenson

 

 

Cardiac Rehab Orders

300 cardiac orders blew into rehab last week.

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.

Crutches / Walkers / Canes

All these supplies are to be billed to Pine City Medical Supply

Make sure to fill out the paperwork.   PC Med Supply will bill insurance.

 

 

 

Julie Ray

 

 

Staffing

.8 specialty nurse has been hired.

Many staff with FMLA – it has been challenging to cover their shifts.

 

Open positions

1.0   resource LPN

Casual RN/LPN

Scribe

Spread the word!

Safety

Winter survival kit brochure handed out

Parking

Please do not park south of the dumpster

We need to keep this area open in the event that the helicopter needs to land.

Next Meeting – January 21, 2015 from 12:15 to 12:45