Board of Commissioners Meeting
March 5, 2018 4:00 p.m. - France Tower Conference Room A
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HALIFAX HEALTH BOARD OF COMMISSIONERS MEETING 303 No. Clyde Morris Boulevard, Daytona Beach, FL France Tower Conference Room A 4:00 p.m., March 5, 2018
AGENDA
Call to Order Invocation & Pledge of Allegiance Roll Call Mission Statement Page 4
Approval of Minutes (Action) Board of Commissioners Meeting – January 8, 2018 Page 5 Board of Commissioners Meeting – February 5, 2018 Page 13
Approval of Agenda (Action)
Medical Staff Report – Dan Miles, MD (Action) Credentials Committee Actions – January & February 2018 Page 15
Management Report – Jeff Feasel Page 26
Strategic & Community Health Planning Committee – Jeff Feasel Page 31
Audit & Finance Committee Report – Eric Peburn (Information only) FY 2018A Floating Rate Notes Page 35 Audit & Finance Committee Minutes – January 2018 Page 36 Investment Committee Minutes – November 2017 Page 39 Investment Performance Report – December 2017 & January 2018 Page 41 Schedule of Uses of Property Taxes – December 2017 Page 51 Capital Expenditures ($25,000 - $50,000) (Working Capital) Page 52 Neonatal Incubator - $43,651 Page 53 Network Access Control Ports - $42,331 Page 55 EEG Cart - $42,177 Page 57 Omnicell Medication Dispensing Cabinet - $31,884 Page 59 Box Truck w/Lift Gate - $26,500 Page 61 Affiliate Activity (Information Only) Sale of Portion of Deltona Parcel (4.888 Acres) Page 63 120 Howland Boulevard - $1,666,000 (cost basis $1,148,876) Deltona Road & Utility Infrastructure (Phase I) Page 63 120 Howland Boulevard - $787,000 ($430,000 to be paid By HH Holdings and $357,000 to be paid by buyer)
Consent Agenda (Action) Healthy Communities Board Appointment Page 66 Financial Statements Ended December 2017 Page 67 Financial Statements Ended January 2018 Page 91 Capital Expenditures - $50,000 and Over (Working Capital) Page 116 Cardiac Cath Lab Replacement - $1,488,698 Page 117 Pediatric Telemetry Monitoring System - $428,641 Page 119 Merge Hemodynamics System - $348,604 Page 121 Emergency Power Connection at HHPO - $300,000 Page 123 Access Control - $118,687 Page 125 Hemodialysis & Disinfection Equipment - $57,369 Page 127 Disposals – January & February 2018 Page 128 Audit Reports Page 131 Page 1 of 2
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HALIFAX HEALTH BOARD OF COMMISSIONERS MEETING 303 No. Clyde Morris Boulevard, Daytona Beach, FL France Tower Conference Room A 4:00 p.m., March 5, 2018
AGENDA
Old Business (Information Only) CIA Dashboard / Update December 2017 & January 2018 Page 133
New Business CIA Resolution Page 137 2018 Infection Control & Risk Assessment Plan Page 140 2018 Performance Improvement Plan Page 162 2017 Performance Improvement Evaluation of Effectiveness Page 186 2018 Patient Safety Plan Page 189 2017 Environment of Care Summary Page 201
Additional Information Deltona Ambulatory Surgery Center (ASC) Update Page 224 Human Resources Reports December 2017 & January 2018 Page 225 Affiliate Minutes Page 227
Public Participation
Presentation(s) HBS – Community Action Team (CAT) Program Page 238 Quality Update – 4th Quarter FY 2017 Page 248 HR Turnover / Generational Influence & Workforce Strategy Page 272
Next Meetings – May 7, 2018 - France Tower Conf. Room A 4:00 p.m. - Regular HH Board Meeting Closed Strategic Planning and Litigation meetings to follow (Pursuant to FS 395.3035 & FS 286.001)
Adjourn
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HALIFAX HOSPITAL MEDICAL CENTER BOARD OF COMMISSIONERS MEETING Held at 303 North Clyde Morris Boulevard, France Tower, Daytona Beach, FL January 8, 2018 ______Present: Ed Connor, Assistant Secretary (via phone) Dan Francati, Vice Chairman Harold Goodemote, Chairman Carl W. Lentz, M.D., Member Tom McCall, Secretary Glenn Ritchey, Member Susan Schandel, Treasurer
Also Present: Mary Jo Allen, Executive Director, Halifax Hospice Kent Bailey, Director of Finance Mark Billings, Exec. VP/Chief Operating Officer Jeanne Connelly, Exec. Director, Physician Services Margaret Crossman, MD, Sr. VP/Chief Medical Officer Ben Eby, Director of Finance, Halifax Hospice Jeff Feasel, President & Chief Executive Officer Kim Fulcher, VP/Chief Human Resource Officer Vivian Gallo, Sr. VP/General Counsel Bill Griffin, Director, System Research & Planning John Guthrie, Director, Communications Ginny Kwong, MD, VP/Chief Medical Information Officer Arvin Lewis, Sr. VP/Chief Revenue Officer Catherine Luchsinger, Chief Nursing Officer Ann Martorano, Chief Communication Officer Dan Miles, MD, President, Medical Staff Steve Miles, MD, Sr. VP/Chief Quality Officer Jacob Nagib, Director, Engineering, Design & Construction Eric Peburn, Exec. VP/Chief Financial Officer Andy Pollock, Chaplain Raphael Ramirez, Market Development Specialist Dee Schaeffer, Executive Director, Healthy Communities Shelly Shiflet, VP/Corporate Compliance Officer Tom Stafford, VP/Chief Information Officer Lisa Tyler, Corporate Controller Alberto Tineo, VP Operations Bob Wade, Board Compliance Expert, Barnes & Thornburg, LLP Raul Zimmerman, MD, Medical Director, Halifax Hospice Mike Finch, Daytona News Journal ______Chairman Goodemote called the meeting to order at 4:00 p.m. The invocation was given, the Pledge of Allegiance recited, the Mission Statement read, and the roll recorded.
ELECTION OF OFFICERS Discussion: Following the Governor’s reappointment of Commissioners Goodemote, Ritchey and McCall to the Halifax Board of Commissioners, Mr. Goodemote advised that election of offices would be held.
Halifax Health Board of Commissioners – January 8, 2018 - Page 1
Page 5 of 294 Action: Mr. Ritchey moved to keep the current slate of officers (see below). Mr. Francati seconded the motion. Carried unanimously. Chairman, Harold Goodemote Vice Chairman, Dan Francati Treasurer, Susan Schandel Secretary, Tom McCall Assistant Secretary, Ed Connor
APPROAL OF MINUTES Discussion: Mr. Goodemote requested approval of the minutes from the November 6, 2017 Board of Commissioners Meeting.
Action: Mrs. Schandel moved to approve minutes as presented. Mr. McCall seconded the motion. Carried unanimously.
APPROVAL OF AGENDA Action: Mr. Ritchey moved to approve the agenda. Mrs. Schandel seconded the motion. Carried unanimously.
MEDICAL STAFF REPORT Credentials Committee Actions – November & December 2017 Discussion: Dr. Miles advised that the following physicians were in attendance to satisfy the personal appearance requirement and that each had been approved previously by the board: John Conboy, MD Uril Greene, MD Ameigh Worley, MD
Discussion: Dr. Miles requested approval of the following physician applications as recommended by the Credential Committee:
Michael Black, Anesthesiology, Associate Action: Mr. Francati moved to approve application for Dr. Michael Black. Mrs. Schandel seconded the motion. Carried unanimously.
Gary DeCesare, Plastic & Reconstructive Surgery, Associate Action: Mr. Francati moved to approve application for Dr. Gary DeCesare. Mrs. Schandel seconded the motion. Carried unanimously.
Michael Harrington, MD, General Surgery, Associate Action: Mr. Ritchey moved to approve application for Dr. Michael Harrington. Mr. Francati seconded the motion. Carried unanimously.
William Kendall, MD, Transplant Surgery, Associate Action: Mrs. Schandel moved to approve application of Dr. William Kendall. Mr. Francati seconded the motion. Carried unanimously.
Jennifer Kirkman, MD, Medicine/Family Medicine, Associate Action: Dr. Miles advised that Dr. Kirkman was unable to attend and requested board approval with the understanding that Dr. Kirkman will make a future appearance before the board. Mr. Ritchey moved to approve
Halifax Health Board of Commissioners – January 8, 2018 - Page 2
Page 6 of 294 application of Dr. Kirkman. Mr. Francati seconded the motion. Carried unanimously.
Samuel Miller, MD, Family Medicine, Associate Action: Mrs. Schandel moved to approve application of Dr. Samuel Miller. Mr. Francati seconded the motion. Carried unanimously.
Jessica Popelka, MD, Surgery/Podiatry, Associate Action: Mrs. Schandel moved to approve application of Dr. Jessica Popelka. Mr. Francati seconded the motion. Carried unanimously.
Zachary Tyser, MD, OB/GYN, Associate Action: Mr. Ritchey moved to approve application of Dr. Zachary Tyser. Mr. Francati seconded the motion. Carried unanimously.
Karl Unkenholz, MD, Emergency Medicine, Associate Action: Mrs. Schandel moved to approve application of Dr. Karl Unkenholz. Mr. Francati seconded the motion. Carried unanimously.
H. Cory Weitzner, MD, Anesthesiology, Associate Action: Mr. Ritchey moved to approve application of Dr. H. Cory Weitzner. Mrs. Schandel seconded the motion. Carried unanimously.
Discussion: Dr. Miles requested approval of following Resident Affiliate applications (Halifax Family Practice Program): Charity Eko, MD, Family Medicine, Resident Affiliate Benjamin Heyen, MD, Family Medicine, Resident Affiliate Suresh Kandavanam, MD, Family Medicine, Resident Affiliate Cory Pollard, MD, Family Medicine, Resident Affiliate Kara Williams, MD, Family Medicine, Resident Affiliate
Action: Dr. Lentz moved to approve Resident Affiliate status for above physicians. Mrs. Schandel seconded the motion. Carried unanimously.
Discussion: Dr. Miles requested approval of non-physician providers (See Section B of Credentials Committee Actions November/December 2017).
Action: Mr. Ritchey moved to approve non-physician providers as recommended by the Credentials Committee (Section B). Mrs. Schandel seconded the motion. Carried unanimously.
Discussion: Dr. Miles requested approval following as recommended by the Credentials Committee (See Section C-G of Credentials Actions November/December 2017) Physician Reappointments (Section C) Physician Reappointments w/Changes (Section D) Non-Physician Providers Reappointments (Section E) Requests for Additional Privileges/Deletions/Other (Section F) Changes in Status/Specialty/Privileges (Section G)
Action: Dr. Lents moved to approve recommendations included in Sections C–G as presented. Mrs. Schandel seconded the motion. Carried unanimously.
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Discussion: Dr. Miles advised that Sections H-K, which includes Resignations, Leave of Absence, and Locum Tenens, is provided as information only.
MANAGEMENT REPORT Discussion: Mr. Feasel provided update on following:
Halifax Health Celebrates 90 Years of Service to the Community January 3, 2018 marked the 90th year of service for Halifax Health. We are very proud to be the community’s health care leader and of our continued mission to provide all needed health care services to the communities we serve. In addition to the print advertising that began on December 31st, a full marketing and communications plan consisting of internal and external activities and communication vehicles will be utilized throughout the year to celebrate and recognize this milestone.
Joint Commission Annual Survey From November 28th to December 1st, Halifax Health underwent a very successful accreditation survey by the Joint Commission. Approximately every three years, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. It also ensures that the Conditions of Participation are being met by healthcare organizations that participate in the Medicare and Medicaid programs through the Centers for Medicare and Medicaid (CMS).
Joint Commission Primary Stroke Center Survey On December 8, 2017, The Joint Commission was on site to survey Halifax Health’s Primary Stroke Center program. Unlike the three-year comprehensive Joint Commission survey, disease-specific certification demonstrates an organization’s commitment to a higher standard of care in specific areas through the use of continuous performance improvement, high quality, evidenced-based patient care and the continuous reduction of risks.
Deltona Hospital Groundbreaking & Construction Update On December 4, Halifax Health hosted a groundbreaking ceremony celebrating the start of construction for Halifax Health Medical Center of Deltona – the West Volusia city’s first hospital. 60% construction documents were issued to firm the guaranteed maximum price Foundation work for the tower and the central energy plant is in full gear and we should see columns rising up early in 2018 Major equipment list is in progress Communication with AHCA is ongoing with regarding the project timeline and phases of work Team is working diligently on the budget final figures by daily evaluation of cost management items
Halifax Health Board of Commissioners – January 8, 2018 - Page 4
Page 8 of 294 Leadership Academy The 3rd Annual Leadership Academy will be graduating in January 2018. Fifteen emerging leaders from across the organization were selected to be a part of the Leadership Academy. Halifax Health’s emerging leaders have an opportunity to understand the perspective of executive leadership; and likewise, executive leaders learn from Academy members, what their challenges are, along with their ideas and projects within departments and across the organization. Members of the Academy get to know the organization’s leadership as well as community leaders who are invited to attend and speak to the group.
Team Member Engagement Survey Halifax Health conducted the annual Team Member Engagement Survey from October 23rd through November 15th. Participation rate increased from 61% last year to 79% this year. Average response rate for the national benchmark is 74%. Halifax not only improved, but surpassed the national healthcare average. Overall Engagement Score was 3.95, up from 3.92 last year. The Engagement Score is a metric that includes employees’ degree of pride in the organization, intent to stay, willingness to recommend to friends and family for care, and overall satisfaction employees feel towards the workplace.
Radiologic Technology Accreditation Halifax Medical Center’s Radiologic Technology Program is officially recognized by the Joint Review Committee on Education in Radiologic Technology (JRCERT) as an "accredited" radiography program. The program recently underwent a site visit in May 2017. The JRCERT awarded the program accreditation for a five year period. Based on evaluation of a progress report that will be submitted in November 2018, the Board of Directors will maintain or extend accreditation to eight years. Specialized accreditation awarded by the JRCERT offers institutions significant value by providing peer evaluation and assuring the public of quality professional education in the radiologic sciences.
Halifax Health, Brooks Rehabilitation & Easterseals In November Halifax Health and Brooks Rehabilitation, in collaboration with Easterseals Northeast Central Florida, celebrated the grand opening of the Halifax Health/Brooks Rehabilitation-Pediatric Rehabilitation outpatient clinic, located at 201 North Clyde Morris Boulevard, on the campus of Halifax Health Medical Center of Daytona Beach. This child- centered facility offers services provided by Brooks Rehabilitation, a healthcare leader in pediatric therapy programs. This partnership will ensure that comprehensive pediatric therapy services continue to be provided in our community and will expand access to these services for families due to the expanded insurance options available through Halifax Health.
Daytona Blues Festival - Halifax Health NICU In December Dr. Pam Carbiener, of the Daytona Blues Festival, presented a check for $50,000 to the Betty Jane France Level II Neonatal Intensive Care Unit at Halifax Health. The donation was comprised from the proceeds of the 2017 Daytona Blues Festival which took place in October.
Halifax Health Board of Commissioners – January 8, 2018 - Page 5
Page 9 of 294 Quality Rankings – OB Deliveries Halifax Health has been named #1 in the nation for elective deliveries after 39 weeks gestation. Evidence shows that babies delivered at 39 weeks and later give the baby’s body the adequate time it needs to grow. This has been a team effort by our obstetricians and mother/baby staff - all of whom are fully committed to obtaining the best possible outcomes for our patients.
Quality Rankings – Orthopedic Hip and Knee Readmissions Halifax Health has been ranked #1 in the Nation and #2 in the State of Florida for hospital readmissions. Avoidable hospital readmissions are one of the key focus areas today for the Centers for Medicare and Medicaid Services’ (CMS) value-based purchasing program. Reduced readmissions require a multi-disciplinary approach to care, often beginning with educating patients before they arrive as to what to expect before, during and after admission and continuing for as long as 30 days with post- discharge follow-up.
UF Health & Halifax Health Collaboration Dr. Robert Feezor provided an overview of the UF Health & Halifax Health Cardiac, Vascular and Renal Transplant Programs (full presentation attached); and reported that the cardiac surgery program received a 3- star ranking from the Society of Thoracic Surgery. This is the highest ranking assessed by STS and represents that the program’s performance and outcomes is in the top 10% of open heart programs nationally.
STRATEGIC & COMMUNITY HEALTH PLANNING COMMITTEE Discussion: Dee Schaeffer reviewed the Legislative Update (full report attached) and updated the board on the Constitution Review Commission proposals that affect healthcare: Proposals 53, 54, 69 and 100.
AUDIT & FINANCE REPORT Discussion: Mr. Peburn provided an overview of Audited Financial Statements for FY Ended 2017 and reviewed statistical and financial summary for Halifax Medical Center and Halifax Hospice (full reports attached).
CONSENT AGENDA Discussion: Mr. Goodemote requested approval of the Consent Agenda, which included following items: Appointment of Infection Control Officer – Debra Johnson Financial Statements Ended October 2017 Financial Statements Ended November 2017 HHMC Audited Financial Statements FY Ended Sept. 2017 Halifax Hospice Audited Financial Statements FY Ended Sept. 2017 Capital Expenditures - $50,000 and Over (Working Capital) o Data Protection Hardware & Software - $496,641 o Chilled Water Piping Project for Surgical Suites - $463,349 o Chiller for Ormond ROC - $186,532 o Patient Harness System for Inpatient Rehab - $83,315 Disposals – November & December 2017 Resolution – Revenue Bond Series 2018 Issuance
Halifax Health Board of Commissioners – January 8, 2018 - Page 6
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Action: Mr. Ritchey moved to approve the consent agenda as presented. Mr. Schandel seconded the motion. Carried unanimously.
OLD BUSINESS CIA Dashboard/Update Discussion: CIA Dashboards were presented for October & November 2017 as information only.
Action: None. Information Only.
CIA Resolution Discussion: Draft of annual CIA Resolution was presented for review. Approval and signature will be requested at the March 5, 2018 Board meeting.
Action: None. Information Only.
NEW BUSINESS Sale of Parcel - West Clyde Morris Boulevard Discussion: Mr. Griffin advised that a student housing developer (Next Chapter) has submitted a Letter of Intent to purchase 12.5 acres (northwest quadrant) of the West Clyde Morris Boulevard property at a purchase price of $2,500,000 ($200,000 per acre).
Action: Mr. Ritchey moved to approve sale of 12.5 acres at price of $2,500,000 ($200,000 per acre). Mr. Francati seconded the motion. Board discussion ensued.
Mr. McCall requested the board be provided with a copy of the appraisal, including recent comps, prior to presenting real estate transactions for approval. Dr. Lentz requested property map be provided that identifies the 12.5 parcel location. Management would forward appraisal summary with comps and map to the board.
Action: Mr. Ritchey withdrew his motion for approval of sale. Sale of 12.5 acres was tabled for future board meeting.
Amendments to CEO Contract Discussion: Ms. Gallo advised, per the Enabling Act and Board Bylaws, the Board has the authority to approve amendments to the CEO contract including the discretion to approve a raise to the CEO base salary. Ms. Gallo provided a summary of the three (3) proposed amendments (attached) that are before the board for consideration which address the benefits portion of the CEO’s employment agreement: (1) Change to supplemental retirement plan to permit contributions to continue at the current rate and schedule beyond the age of 58; (2) Change of age at which the severance provisions expire from age 58 to age 70; (3) Increase in the total life insurance benefits provided to the CEO with a cap on the annual cost. A letter from outside counsel addressing these amendments is included in the Board materials.
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Page 11 of 294 Mr. Goodemote opened the floor for discussion. Mr. Ritchey stated that the CEO has not had a base salary increase since 2011 and is currently around the 25th percentile for base salary for comparable positions per the Hay Group survey. Based on accomplishments and growth of the organization, would support an increase to the CEO base salary at this time as well.
Action: Dan Francati moved to approve the three (3) proposed amendments to the CEO’s employment agreement as presented in the Board materials packet. Mr. Ritchey seconded the motion. Carried unanimously.
Discussion: Mr. Goodemote proposed and recommended a minimum of 2% increase to CEO base salary, advising that this percentage would be equivalent to the average increase for eligible team members and opened the floor for discussion.
Action: Following discussion, Mr. Ritchey moved to approve 2% increase to the CEO base salary. Mr. Francati seconded the motion. Carried unanimously.
PUBLIC PARTICIPATION Discussion: None.
RECESS Action: The Halifax Health Board of Commissioners meeting recessed at 6:05 pm.
Halifax Hospice Board of Directors meeting was called to order at 6:15pm (see January 8, 2018 Halifax Hospice minutes) and adjourned at 6:34pm.
Halifax Staffing, Inc. Board of Directors meeting was called to order at 6:35pm (see January 8, 2018 Halifax Staffing minutes) and adjourned at 6:45pm.
Halifax Health Board of Commissioners meeting reconvened at 6:45pm.
NEXT MEETING Discussion: Mr. Goodemote advised that the next Board of Commissioners meeting will be on March 5, 2018 at 4pm in France Tower Conf. Room A.
ADJOURN Discussion: There being no further business, the meeting adjourned at 6:48pm.
______Chairman
______Secretary
Halifax Health Board of Commissioners – January 8, 2018 - Page 8
Page 12 of 294 HALIFAX HOSPITAL MEDICAL CENTER BOARD OF COMMISSIONERS MEETING Held at 303 North Clyde Morris Boulevard, France Tower, Daytona Beach, FL February 5, 2018 ______Present: Ed Connor, Assistant Secretary Harold Goodemote, Chairman Carl W. Lentz, M.D., Member Tom McCall, Secretary Glenn Ritchey, Member Susan Schandel, Treasurer
Also Present: Jeff Feasel, President & Chief Executive Officer Vivian Gallo, Sr. VP/General Counsel Bill Griffin, Director, System Research & Planning John Guthrie, Director, Communications Eric Peburn, Exec. VP/Chief Financial Officer Andy Pollock, Chaplain Shelly Shiflet, VP/Corporate Compliance Officer Lisa Tyler, Corporate Controller Ted Lightman, NAI Realvest Charles Wayne Commercial ______
Chairman Goodemote called the meeting to order at 4:05 p.m. The invocation was given, the Pledge of Allegiance recited, the Mission Statement read, and the roll recorded.
APPROVAL OF AGENDA Action: Mr. Ritchey moved to approve the agenda. Mrs. Schandel seconded the motion. Carried unanimously.
OLD BUSINESS Property Sale - 12.5 Acres - West Clyde Morris Boulevard Discussion: Mr. Feasel reported that a market analysis had been completed by NAI Realvest Charles Wayne Commercial and distributed to the board in advance of the meeting. Adding that the analysis supports the proposed sale price of $2,500,000 ($200,000 per acre) and in addition the buyer will be responsible for their portion of the road development which brings the total purchase price to $244,000 per acre. The range of comps in the market analysis are between $124,000 and $163,000 with an average of $136,000/acre. Mr. Feasel recommended approval of the sale of 12.5 acres at the purchase price of $200,000/acre.
The board requested that it be standard practice to provide comps and/or appropriate market analysis/information to the board in advance for future real estate transactions.
Action: Dr. Lentz moved to approve the sale of 12.5 acres on West Clyde Morris property for purchase price of $2,500,000 ($200,000/acre) as recommended. Mr. Ritchey seconded the motion. Carried unanimously.
Halifax Health Board of Commissioners Meeting – February 5, 2018
Page 13 of 294 NEW BUSINESS Discussion: Mr. Feasel provided following updates:
Deltona Medical Office Building & Ambulatory Surgery Center Mr. Feasel briefly outlined the proposed Ambulatory Surgery Center joint venture structure (see attached) with COMPASS Surgical Partners, a company that specializes in joint ventures and manages ambulatory surgery centers. The proposed structure would bring physicians to the hospital campus, medical office building and surgery center, as well as specialists to cover the emergency room and the hospital. The joint venture would be entered into by East Volusia Health Services, a subsidiary company of Halifax Health. General Counsel, Vivian Gallo, advised that outside counsel has been utilized to ensure regulatory compliance as it relates to hospital ownership in ambulatory surgery centers. Mr. Feasel added that when commitments have been further defined with physicians and specialties, a proforma will be brought back to the board with more definitive information. It is anticipated that will be somewhere within 90 to 120 days. The purpose for discussion today was to make the board ware of the model that was being considered and analyzed.
Constitution Review Commission Proposal 69, which sunsets all special districts ability to level ad valorem taxes, was withdrawn by Representative Sprowls who indicated that further education leads him to believe this should be dealt with by legislation at a local level by individuals that better understand more about the purpose of the districts. The other proposal that would have an impact on healthcare is Proposal 54 which eliminates Certificate of Need for hospitals. Will continue to monitor and report back to the board.
Lawsuit Update Ms. Gallo reported that there is slow but steady progress. Hearing on Motion for Summary Judgment, which was filed in October 2017, is set for end of March. Ms. Gallo reviewed the possible outcomes of the Motion for Summary Judgment hearing and advised that we are doing all that we can to keep our costs contained (currently around $500,000). If we do not prevail in our Motion for Summary Judgment, further discovery may be necessary.
Bond Validation Update We have initiated a bond validation process on the recommendation of our bond counsel following which they will issue their unqualified opinion confirming the bond issuance for the Deltona project. Expected timeframe for completion is several months.
University of Florida We continue to explore opportunities to enhance our relationship with UF Health. Discussions are ongoing regarding expanding clinical programs in Daytona and in Deltona. Updates will be provided to the board as they are available.
Halifax Health Board of Commissioners Meeting – February 5, 2018
Page 14 of 294 PUBLIC PARTICIPATION Discussion: None.
NEXT MEETING Discussion: The next Board of Commissioners meeting will be held on March 5, 2018 at 4:00 p.m. in France Tower Conf. Room A
ADJOURN Action: There being no further business, the meeting adjourned at 4:40pm
______Chairman
______Secretary
Halifax Health Board of Commissioners Meeting – February 5, 2018
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TO: Members of the Board of Commissioners FROM: Daniel Miles, MD, Medical Staff President DATE: March 5, 2018 RE: Credentials Committee Actions, January 17, February 19, 2018
The Medical Staff report is attached for the Board’s review and approval at the Board of Commissioner’s meeting on March 5, 2018.
PHYSICIAN INTRODUCTION: Jennifer Kirkman, MD
BOARD APPROVAL REQUIRED
A. INITIAL APPLICATIONS FOR PHYSICIANS Action Required (Applicants present should introduce themselves to the BOC prior to a Motion to Approve for each applicant) The following practitioners were required to appear before the Credentials Committee on January 17 and February 19, 2018 and are presented to the Board of Commissioners for approval:
Joseph J. Ballarini, DO Emergency Medicine Associate Harsh Duphare, MD Medicine / Gastroenterology Associate Tara Fritze, MD Medicine / Family Medicine Associate Robin Guiab, MD Anesthesiology Associate Mircea Mihu, MD Medicine / Critical Care Associate Sumathi Raja, MD Medicine / Internal Medicine Associate Jonathan Silverman, MD Emergency Medicine Associate
B. INITIAL APPLICATIONS FOR NON PHYSICIAN PROVIDERS – Action Required (No appearance required; may propose Motion to Approve for entire group) The following practitioners were reviewed and approved by the Credentials Committee on January 17 and February 19, 2018 and are presented to the Board of Commissioners for approval:
Roberta Isaac, ARNP Psychiatry John Caliendo, MD Patrick Kerr, CRNA Anesthesiology Derrick Payne, MD Mikhail Lezhak, PA Urology Samuel Lawindy, MD Stacey Mckinnon, ARNP OB/GYN John Meyers, MD Linda Meade, CRNA Anesthesiology Derrick Payne, MD Alfrenecia Perkins, DA (functioning as a Pediatric Dentistry Moema Arruda, DMD Dental Assistant) April Shadeed, ARNP Cardiology Humayan Jamidar, MD
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C. REAPPOINTMENTS AND PRIVILEGE CHANGES – Action Required (No appearance required; may propose Motion to Approve for entire group)
REAPPOINTMENT PHYSICIAN APPLICATIONS – SEE SECTION (C) OF THE REPORT REAPPOINTMENT WITH CHANGES – SEE SECTION (D) OF THE REPORT REAPPOINTEMENT NPP APPLICATIONS - SEE SECTION (E) OF THE REPORT REQUESTS FOR ADDITIONAL PRIVILEGES/DELETIONS/OTHER - SEE SECTION (F) OF THE REPORT CHANGES IN STATUS - SEE SECTION (G) OF THE REPORT
BOARD ENDORSEMENT REQUIRED
D. RESIGNATIONS/LEAVE OF ABSENCE/AUTOMATIC RELINQUISHMENTS – The following practitioners have resigned from the Medical Staff, been granted a Leave of Absence, or have had their privileges automatically relinquished, for the reasons specified below:
Practitioner Specialty Status: Reason Blum-Guzman, Juan, MD Gastroenterology No longer with current practice, relocated Huckaby, Jessica, ARNP Emergency Medicine Working in the Outpatient Facility, no longer needs privileges Kim, Kirsten, MD Family Medicine No longer with HH Molyet, Eileen, CRNA Anesthesiology No longer with Sheridan Healthcorp Nashed, Magdy, MD Internal Medicine DEA license expired 10/31/17. State License expired 01/31/2018. No response from provider after multiple attempts Patel, Neha, PA Family Medicine No longer with HH Quintana, Manuel, MD Ob/Gyn Relocated Rachman, Nathan, MD Anesthesiology No longer with Sheridan Healthcorp Walker, John, MD Cardiology Retired from practice Watson-Harris, Brenda, MD OB/Gyn Relocated
E. OTHER - None
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BOARD OF COMMISSIONERS – March 5, 2018 CREDENTIALS COMMITTEE ACTIONS – January 17, February 19, 2018
FOR BOARD ACTION
A. INITIAL PHYSICIAN APPLICATIONS RECOMMENDED FOR APPROVAL
Joseph J. Ballarini, DO Emergency Medicine Associate Harsh Duphare, MD Medicine / Gastroenterology Associate Tara Fritze, MD Medicine / Family Medicine Associate Robin Guiab, MD Anesthesiology Associate Mircea Mihu, MD Medicine / Critical Care Associate Sumathi Raja, MD Medicine / Internal Medicine Associate Jonathan Silverman, MD Emergency Medicine Associate
B. INITIAL NON PHYSICIAN PROVIDERS RECOMMENDED FOR APPROVAL
Roberta Isaac, ARNP Psychiatry John Caliendo, MD Patrick Kerr, CRNA Anesthesiology Derrick Payne, MD Mikhail Lezhak, PA Urology Samuel Lawindy, MD Stacey Mckinnon, ARNP OB/GYN John Meyers, MD Linda Meade, CRNA Anesthesiology Derrick Payne, MD Alfrenecia Perkins, DA Pediatric Dentistry Moema Arruda, DMD (functioning as a Dental Assistant) April Shadeed, ARNP Cardiology Humayan Jamidar, MD
C. PHYSICIAN REAPPOINTMENTS RECOMMENDED FOR APPROVAL
Department of Anesthesiology Payne, Derrick, MD Anesthesiology Active
Department of Emergency Medicine Springer, Peter, MD Emergency Medicine Active
Department of Medicine Ahmed, Ejaz, MD Family Medicine Active Arab, Dinesh, MD Interventional Cardiology Active Davis, Monica, MD Internal Medicine Active Geis, Carolyn, MD Physical Medicine & Rehab Active Potts, Richard, MD Family Medicine Active Wong, Yu, MD Internal Medicine Active
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Page 18 of 294 Department of Obstetrics/Gynecology Gaudier, Francisco L., MD Maternal & Fetal Medicine Courtesy
Department of Oncology Chew, Boon Y., MD Hematology/Oncology Active
Department of Pathology No reappointments this month
Department of Pediatrics English, Robert, MD Pediatric Cardiology Courtesy Lacey, Stephanie, DO Pediatric Cardiology Courtesy Lopez, Ruben, MD Pediatrics Active
Department of Psychiatry No reappointments this month
Department of Radiology Schiering, Michael R., MD Diagnostic Radiology Active
Department of Surgery Rhodes, J. Richard R., MD Orthopaedic Surgery Senior Active Vinas, Federico, MD Neurosurgery Active
D. PHYSICIAN REAPPOINTMENTS (WITH CHANGES) RECOMMENDED FOR APPROVAL DeGroff, Curt, MD Pediatrics Pediatric Cardiology (Associate to Courtesy Affiliate) Halpern, Andrew (Associate to Active) Pediatrics Pediatrics Jackson, Allen, MD (Active to Courtesy Surgery Retina Affiliate) Loe, Shanan M., MD OB/GYN OB/GYN (Associate to Active) Siddharthan, Renuka, MD Medicine Internal Medicine (Active to Courtesy Affiliate, LOA 11/11/17- 11/11/18) Siragusa, Roy J., MD Radiology Diagnostic Radiology (Active to Senior Active)
E. NON PHYSICIAN PROVIDERS REAPPOINTMENTS RECOMMENDED FOR APPROVAL Boggs-Dunne, Kimberly, RNFA Employed, working with First Assist multiple physicians in OR Bringas, Sarah, CRNA Derrick Payne, MD Anesthesiology Dethloff, Ellen, ARNP Carolyn Geis, MD Physical Medicine & Rehab Hill, Sharon, CRNA Derrick Payne, MD Anesthesiology Manley-Beck, Meredith, CRNA Derrick Payne, MD Anesthesiology Moody, Latoya, ARNP Reba Isaac, MD Infectious Disease Newman, John, CRNA Derrick Payne, MD Anesthesiology Olsen, Kate, CRNA Derrick Payne, MD Anesthesiology Peterzell, Marcia, ARNP Jean-Claude Jeanty, MD Pediatrics Zemball, Wendy, CRNFA, CNOR Employed, working with First Assist multiple physicians in OR Zvolanek, Timothy, CCP Cary Meyers, MD CardioThoracic Surgery
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Page 19 of 294 F. REQUEST(S) FOR ADDITIONAL PRIVILEGES / DELETIONS / OTHER RECOMMENDED FOR APPROVAL Bell, Laura, ARNP - OB/GYN Request for one-year Leave of Absence due to medical reasons, effective 01/16/18 – 01/16/19
Chisholm, Shannon, PA Additional supervising physician: Tanuja Nemani, MD, Infectious Disease
Dean, Jonathan, MD Additional privileges: da Vinci Robotic System, 5 Proctored cases complete
Gellermann, Diane, ARNP Additional supervising physician: Abdul Jumani, MD, Nephrology
Goldenberg, Eric, DPM Request for one year Leave of Absence, effective 02/19/18 – 02/19/19
Minor, Stephen, MD Additional privileges: TAVR, required case documentation provided
Nudalo-Briganti, Iszenn,(Jean) ARNP Additional supervising physician: Tanuja Nemani, MD, Infectious Disease
Perkins, Kelly, ARNP Additional privileges: Lumbar Puncture with performance of 5 cases, Neonatology completed four cases, needs one case performed at Halifax Health with a proctor
Rodriguez-Warren, Dinorah, ARNP - Additional privileges: Lumbar Puncture with performance of 5 cases, Neonatology completed one case, needs four, one of those cases must be done at Halifax Health with a proctor
Shepherd, Angela, PA/First Functioning as a First Assist in the OR with additional providers Assist
Sweeney, Marianne, ARNP Additional privileges: Lumbar Puncture with performance of 5 cases, Neonatology completed three cases needs two, one of those cases must be done at Halifax Health with a proctor
Szymanski, Cathy, ARNP Additional privileges: Lumbar Puncture with performance of 5 cases, Neonatology completed six cases, one case must be done at Halifax Health with a proctor
Thek, Kerry, MD Request reinstatement to Active, coming off LOA
G. CHANGE(S) IN STATUS/SPECIALTY/PRIVILEGES RECOMMENDED FOR APPROVAL
None
FOR INFORMATION ONLY
H. RESIGNATIONS: Blum-Guzman, Juan, MD (no longer with current Gastroenterology 03/05/18 practice, relocated) Huckaby, Jessica, ARNP (working in the Outpatient Facility, Emergency Medicine 01/22/18 no longer needs privileges) Kim, Kirsten, MD (no longer with HH) Family Medicine 03/07/18 Molyet, Eileen, CRNA (no longer with Sheridan Healthcorp) Anesthesiology 01/18/18 Nashed, Magdy, MD (DEA license expired 10/31/17. State Internal Medicine 03/05/18 License expired 01/31/2018. No response from provider after multiple attempts) Patel, Neha, PA (no longer with HH) Family Medicine 01/26/18 Quintana, Manuel, MD (Relocated) Ob/Gyn 01/18/18 Rachman, Nathan, MD (no longer with Sheridan Anesthesiology 01/03/18 Healthcorp) 3
Page 20 of 294 Walker, John, MD (Retired from practice) Cardiology 03/05/18 Watson-Harris, Brenda, MD (Relocated) OB/Gyn 03/05/18
I. LEAVE OF ABSENCE: For Information Only: Livingston, Denise, ARNP Surgery Siddharthan, Renuka Internal Medicine
J. LOCUM TENENS PHYSICIANS: For Information Only - Ongoing Privileges this month:
Currently providing services Acevedo, Jorge, MD Neurosurgery Fisher, Anton, DO Psychiatry Upton, Monique, MD Psychiatry
Service provided as needed Casas-Reyes, Carlos, MD Neurosurgery Tiesi, James, MD Neurosurgery Tran, Nam, MD Neurosurgery Hervie, Peter, MD Pediatric Critical Care Liriano, Humberto, MD Pediatric Critical Care Lopez, Debra, MD Pediatric Critical Care
K. OTHER BUSINESS: None
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Page 21 of 294 HALIFAX HEALTH MEDICAL CENTER
BOARD OF COMMISSIONERS NEW PHYSICIAN PROFILES March 5, 2018 (Credentials Committee January 17, February 19, 2018)
V. Joseph Ballarini, DO Emergency Services
V. Joseph Ballarini, DO, is requesting privileges in the Department of Emergency Services and is in practice with Halifax Health Emergency Department of Deltona. Medical Education: Philadelphia College of Osteopathic 08/01/2000 to 06/01/2004 Internship Philadelphia College of Osteo Medicine 07/15/2005 to 08/14/2005 Residency LECOM/Memorial Hospital 02/09/2006 to 02/07/2009 Emergency Medicine Board Certification: American Osteo Board of Emergency Med - Emergency Medicine
Harsh Duphare, MD Gastroenterology
Harsh Duphare, MD, is requesting privileges in the Department of Medicine and is in practice with Advanced Gastroenterology. Medical Education: All India Institute of Medical Sciences 07/01/1975 to 12/31/1980 Residency Michigan State Univ College of Human Med 07/01/1992 to 06/30/1994 Internal Medicine/Gastroenterology Fellowship University of Wisconsin Hospitals and Clinics Program 07/01/1996 to 06/30/1999 Gastroenterology Board Certification: American Board of Internal Medicine - Gastroenterology
Page 22 of 294 HALIFAX HEALTH MEDICAL CENTER
BOARD OF COMMISSIONERS NEW PHYSICIAN PROFILES March 5, 2018 (Credentials Committee January 17, February 19, 2018)
Tara Fritze, MD Family Medicine
Tara Fritze, MD, is requesting privileges in the Department of Medicine and is in practice with Halifax Health Hospitalists. Medical Education: Florida State University 05/01/2010 to 05/31/2010 Internship Halifax Health Family Medicine Residency 07/01/2014 to 07/31/2015 Family Medicine Residency Halifax Family Medicine Residency Program 07/01/2015 to 06/30/2016 Family Medicine Board Certification: American Board of Family Medicine - Family Medicine
Robin Guiab, MD Anesthesiology
Robin Guiab, MD, is requesting privileges in the Department of Anesthesiology and is in practice with Sheridan Healthcorp, Inc.. Medical Education: Penn State University College of Medicine 09/01/1981 to 05/30/1985 Internship Albert Einstein College of Medicine 07/01/1985 to 06/30/1986 General Surgery Residency Albert Einstein College of Medicine 07/01/1986 to 06/30/1989 Anesthesiology Board Certification: American Board of Anesthesiology - Anesthesiology
Page 23 of 294 HALIFAX HEALTH MEDICAL CENTER
BOARD OF COMMISSIONERS NEW PHYSICIAN PROFILES March 5, 2018 (Credentials Committee January 17, February 19, 2018)
Mircea Mihu, MD Critical Care Medicine
Mircea Mihu, MD, is requesting privileges in the Department of Medicine and is in practice with Halifax Health Intensivists. Medical Education: Lucian Blaga University of Sibiu 08/01/1996 to 09/30/2002 Internship Spitalul Municipal Hunedoara 01/01/2003 to 12/31/2003 Medicine and Surgical Residency Sound Shore Medical Center 07/01/2009 to 06/30/2010 Fellowship Albert Einstein College of Medicine 07/01/2014 to 06/30/2015 Critical Care Medicine Board Certification: American Board of Internal Medicine - Critical Care Medicine
Sumathi Raja, MD Internal Medicine
Sumathi Raja, MD, is requesting privileges in the Department of Medicine and is in practice with Halifax Health Hospitalists. Medical Education: UMDNJ-New Jersey Medical School 08/01/2001 to 05/31/2006 Internship JFK Medical Center in Atlantis 07/01/2010 to 06/30/2012 Internal Medicine Residency JFK Medical Center in Atlantis 07/01/2009 to 06/30/2012 Internal Medicine Board Certification: American Board of Internal Medicine - Internal Medicine
Page 24 of 294 HALIFAX HEALTH MEDICAL CENTER
BOARD OF COMMISSIONERS NEW PHYSICIAN PROFILES March 5, 2018 (Credentials Committee January 17, February 19, 2018)
Jonathan Silverman, MD Emergency Services
Jonathan Silverman, MD, is requesting privileges in the Department of Emergency Services and is in practice with Halifax Health Emergency Department of Deltona. Medical Education: SUNY Downstate College of Medicine 08/01/2000 to 05/31/2002 Residency Maimonides Medical Center 07/01/2002 to 06/30/2005 Emergency Medicine Board Certification: American Board of Emergency Medicine - Emergency Medicine
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Management Report – Board of Commissioners March 2018
Presentations HBS Community Action Team – Jeannette Simmons and Felicia Walker Quality Update – Dr. Steve Miles, Suzanne Lovelady and Keith Sofiak HR Turnover / Generational Influence & Workforce Strategy – Kim Fulcher
Deltona Construction Update Construction work is in full gear and on schedule – no working days lost Foundation work is complete and we are rising elevators and stairs shafts Tower columns are up for the 1st floor in preparation of the 2nd floor forming and pouring Central Energy Plant foundation is complete and will start walls in the next few days Storm and sewer underground piping are currently taking place and we are coordinating with designers on Medical Office Building needs 100% construction documents are in final stages and will go to AHCA mid-March Entire team is working to finalize the master budget All users are engaged in equipment review needed for opening
Halifax Behavioral Services – Community Action Team (CAT) The Community Action Team (CAT) is different than traditional mental health services in that services are provided or coordinated by a multi-disciplinary team. Individualized services often do not fit into the standard of medical necessity and are typically not reimbursed by Medicaid or private insurance. Services such as mentoring, tutoring, respite, and transportation are an integral part of serving each family. The family is treated as a unit and all family member needs are addressed. The number of sessions and the frequency at which they are provided is set through collaboration rather than service limits. The team is available on nights, weekends, and holidays. In the event interventions are required which are out of the teams scope of expertise (such as eating disorder treatment, behavior analysis, psychological testing), referrals are made to specialists, with follow up from the team. This flexibility is intended to promote a “whatever it takes” approach to assisting young people and their families to achieve their goals resulting in better outcomes as a lower overall cost when residential services are avoided.
Jeannette Simmons, Team Leader, Community Action Team - Jeannette Simmons, MS, LMHC joined Halifax Health Behavioral Services in 2014 as a Program Therapist. In 2017 she was selected to serve as the Team Lead for the Halifax Health Behavioral Services Community Action Team. Jeannette supervises a team of Program Therapists, Targeted Case Managers, Therapeutic Mentors, and Nurse that provide intense therapeutic services to children, young adults and families in Volusia and Flagler Counties. Jeannette received her Master of Science in Clinical Mental Health Counseling from Stetson University and a Bachelor of Arts from Rollins College.
Page 26 of 294 Felicia Walker, Supervisor, Targeted Case Manager - Felicia is a native Floridian born at Halifax. A graduate from the University of Central Florida, she began her career at Hospice of Volusia/Flagler in the finance department and during her 19 years has held positions as community liaison, targeted case manager, discharge planner, contract manager, case manager supervisor, and CAT administrator. She was a part of the HOVF African American Initiative Board to bring awareness to the minority leaders and faith based community. Ms. Walker assisted with implementing Faith in Action in the first African American Church. She has worked with Habitat for Humanity Family Partners to mentor homeowners and serves as a board member and youth leader of her church alongside her husband.
James Terry, Service Line Administrator - Jim joined the Halifax family in April of 2016 as the Service Line Administrator having 30+ years’ experience in various positions in Behavioral Health. He has worked in both inpatient and outpatient settings with adults and children having earned some national awards from family advocacy groups for his work in system of care development. Jim has both his Bachelors and Masters’ degree from Frostburg State University in Maryland and is a licensed psychologist in West Virginia.
Center for Inpatient Rehab Dr. Carolyn Geis currently serves as Medical Director for the Rehabilitation Service Line. She is responsible for the strategic and clinical integration of Acute Care Therapy, our 40 bed Inpatient Rehabilitation Facility and the PM&R Practice. We are pleased to report that Dr. Geis has been elected Vice Chairman of the American Board of PMR. This is a tremendous honor for Dr. Geis and reflects the confidence that the national certifying board has in her organizational abilities and leadership. The position of Vice Chair is critical in ensuring physicians who practice in our specialty have the necessary clinical skill set to effectively treat the patients that are under their care. This is also another avenue to elevate Halifax Health and Brooks Rehabilitation on the national stage.
Project SEARCH Halifax Health is proud to be a host site for Project SEARCH, a nationally recognized program and successful local joint venture between Volusia County Schools, Progressive Abilities Support Services (PASS) and the Florida Division of Vocational Rehabilitation. The Project SEARCH High School Transition Program is a unique, business-led, one-year school-to-work program that takes place entirely at the workplace. Total workplace immersion facilitates a seamless combination of classroom instruction, career exploration, and hands-on training through worksite rotations. The program provides real-life work experience to help youth with significant disabilities make successful transitions from school to adult life.
Our eight interns are in their third rotation. The program follows the Volusia County School schedule August to May. The interns participate in 3 different rotations during this time. The first rotation was August 27 to December 20; second rotation is January 8 to March 8; and the third rotation will be March 19 to May 30. Rotations include SPD, Laundry, Brooks Rehab, Receiving, Dietary, Emergency Department, Patient Access and Laboratory.
Volusia County School staff are on site during the time that students are participating in the Project SEARCH program. The Project SEARCH Instructor provides classroom time and teaches employability skills, financial literacy and independent living skills; the Employment Advisor provides job coaching and monitors progress on their rotations; and the Progressive Abilities Support Services (PASS) Employment Advisor assists with seeking employment opportunities and monitors progress on the job when employment is obtained.
MARKETING/COMMUNICATIONS UPDATE February Events
Page 27 of 294 February 1. EmployMed Open House. Halifax Health – EmployMed celebrated the opening of its Port Orange location at 944 Bridgewater Drive. EmployMed provides screening services and other occupational health testing.
February 1. Speakers and Sneakers Series. The first Thursday of each month, this educational program for residents offers free presentations at Halifax Health featuring a wide variety of healthcare topics. Participants are encouraged to walk their choice of indoor and outdoor trails at Halifax Health after the presentation event. Walking Logs are available for participants. A light breakfast is also provided.
February 6. Seabreeze High School Student Tour. Halifax Health hosted students in Seabreeze High School’s Allied Health Academy on a tour of Halifax Health Medical Center of Daytona Beach. The students toured the Emergency/Trauma, Radiology, Pediatrics, and Orthopedics departments.
February 8. Diabetes Prevention Q&A - City of Ormond Beach Mayor’s Health & Fitness Challenge. This Q&A event at Halifax Health – Primary Care, Ormond Beach, was part of the Ormond Beach Mayor’s Challenge. Halifax Health is proud to be a sponsor of the Ormond Beach Mayor’s Health & Fitness Challenge, which takes place through April. ormondbeach.org.
February 11: 1st Annual My Heart Matters 5K. Presented by Halifax Health – Center for Cardiology, this race takes place on the campus of Halifax Health Medical Center of Daytona Beach. The course features a .6-mile run/walk up the campus’ six-story parking garage. Proceeds from the race will go to the Center for Cardiology to help fight heart disease in our community.
February 12: NASCAR Foundation Visits Speediatrics. Super Late Model driver Carter Stokes (a member of Ben Kennedy’s team) and top-ranked female poker player Maria Ho will visit Halifax Health’s Speediatrics patients courtesy of the NASCAR Foundation.
February 13: NASCAR Drive for Diversity Drivers Visit Speediatrics. Participants in the NASCAR Drive for Diversity program will visit Halifax Health’s Speediatrics patients courtesy of the NASCAR Foundation.
February 14: NASCAR Driver Bubba Wallace Visits Speediatrics. Bubba Wallace will be on site to visit Halifax Health’s pediatrics patients and Team Members. Wallace is the first full- time African-American driver to compete in NASCAR’s top series in 45 years.
February 22. Daytona Regional Chamber of Commerce 98th Annual Dinner Meeting. Halifax Health is the presenting sponsor of this event which will feature keynote speaker, LT. Col. Oliver North. The event takes place at the Ocean Center, 101 N. Atlantic Avenue in Daytona Beach.
February 22. 22nd Annual Swings for DONNA Golf Tournament. Presented by Halifax Health, this golf tournament raises funds for The DONNA Foundation, a non-profit organization that provides financial assistance for the critical needs of those living with breast cancer. Sugar Mill Golf Club, 100 Club House Circle, New Smyrna Beach.
March Events March 1. Speakers and Sneakers Series. Held the first Thursday of each month, this educational program for residents offers free presentations at Halifax Health featuring a wide variety of healthcare topics. Participants are encouraged to walk their choice of indoor and
Page 28 of 294 outdoor trails at Halifax Health after the presentation event. Walking Logs are available for participants.
March 5. NASA Astronaut Nicole Stott Visits Speediatrics March 7. Free Car Seat Safety Check – Daytona Beach. Halifax Health – Healthy Communities offers free car seat safety checks the first Wednesday of every month from 1:00- 3:00 pm at the Halifax Health Medical Center, France Tower. This program is also presented in conjunction with SafeKids Volusia/Flagler Counties.
March 7. Practice Managers Luncheon
March 15. CARF Accreditation Celebration. Halifax Health|Brooks Rehabilitation – Center for Inpatient Rehabilitation will celebrate its accreditation by CARF International, an independent, nonprofit accreditor of health and human services.
March 21. Colon Health Awareness Event. Halifax Health – Center for Oncology will present this event in recognition of National Colorectal Cancer Awareness Month.
March 22. Free Car Seat Safety Check - Deltona. Halifax Health – Healthy Communities offers free car seat safety checks the fourth Thursday of every month from 1:00-3:00 pm at Halifax Health - Emergency Department of Deltona. This program is also presented in conjunction with SafeKids Volusia/Flagler Counties.
March 22-25. Port Orange Family Days Spring Fair and Food Festival. Halifax Health is the presenting sponsor of this annual event which attracts nearly 30,000 attendees over a four-day period. familydays.com/spring-fair.
March 24. Daytona Beach Mayor’s Fitness Challenge Ends. Halifax Health is a sponsor of this 10-week challenge (January 16-March 24).
March 24. Live Your Life Well Race Series – Tomoka Marathon, Half Marathon & 5K. A part of Halifax Health’s 2018 Live Your Life Well race series, this Ormond Beach race event attracts more than 1,400 runners annually. lylwseries.com.
March 24. Stop the Bleed Colorectal Cancer Awareness Event. Presented by Halifax Health – Center for Oncology, this event will be held in recognition of National Colorectal Cancer Awareness Month.
April Events April 4. Free Car Seat Safety Check – Daytona Beach. Halifax Health – Healthy Communities offers free car seat safety checks the first Wednesday of every month from 1:00- 3:00 pm at the Halifax Health Medical Center, France Tower. This program is also presented in conjunction with SafeKids Volusia/Flagler Counties.
April 5. Speakers and Sneakers Series. This educational program for residents offers free monthly presentations at Halifax Health featuring a wide variety of healthcare topics. Participants are encouraged to walk their choice of indoor and outdoor trails at Halifax Health after the presentation event. Walking Logs are available for participants.
April 6. Halifax 100 Club Celebration
April 21. Corporate 5K and Zumbathon. The Volusia Flagler YMCA and Halifax Health present this event where participants are encouraged to run, walk or Zumba! A part of the Halifax Health Live Your Life Well race series. lylwseries.com.
Page 29 of 294 April 25. Team Member Banquet
April 26. Free Car Seat Safety Check - Deltona. Halifax Health – Healthy Communities offers free car seat safety checks the fourth Thursday of every month from 1:00-3:00 pm at Halifax Health - Emergency Department of Deltona. This program is also presented in conjunction with SafeKids Volusia/Flagler Counties.
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Legislative Update as of February 22, 2018 Prepared by: Dee Schaeffer
2018 Legislative Session Dates
The 2018 legislature convened January 9, 2018 and is scheduled to adjourn March 9, 2018.
CONSTITUTION REVISION COMMISSION
Florida’s Constitution Revision Commission (CRC) meets every 20 years to review the constitution for relevancy and to develop possible amendments to the document. The CRC is comprised of 37 members with 15 members appointed by the Governor; 9 members appointed by the Senate President; 9 members appointed by the Speaker of the House; 3 members appointed by the Chief Justice and the Attorney General is a standing member.
The number of proposals that will go before the full Commission for a vote has been reduced to thirty seven. If a proposed amendment is approved by a majority of the members, it will be forwarded to the Style and Drafting Committee for any necessary revisions and then will return to the full Commission for final approval, for which 22 votes are required. If approved, the proposed amendment is submitted to the Secretary of State for inclusion on the November 2018 general election ballot, for which at least 60% of the voters must vote in favor of the proposal. The deadline for the Commission to complete its work is May 10, 2018.
Commissioners submitted four proposals that pertain to healthcare:
Proposal 53, filed by Kruppenbacher (Governor appointee), creates a Patient’s Bill of Rights “to ensure patients have access to information related to cost, services and other information needed to make healthcare decisions”. The proposal was withdrawn from further consideration.
Proposal 54, also filed by Kruppenbacher, eliminates Certificate of Need for hospitals, nursing homes, hospices and intermediate care facilities. The proposal passed its one committee of reference and will now be heard by the full Commission.
Proposal 69, filed by Rep. Sprowls (Speaker appointee), sunsets all special districts’ ability to levy ad valorem taxes in January 2029; water management districts are exempt. There is a limited exception where debt is involved. The proposal was withdrawn from further consideration.
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Proposal 100, filed by Kruppenbacher, would remove ad valorem tax exemption for any non-profit organization or corporation that paid any non-physician employee more than $300,000 annually. The proposal was withdrawn from further consideration.
Four other proposed constitutional amendments, none of which deal with healthcare, have been certified and will appear on the ballot. Two additional proposals are pending legislative action.
LEGISLATION OF INTEREST
TAXING DISTRICTS/LOCAL GOVERNMENTS
HB 7 (Burton): Establishes requirements for local governments to post certain voting records and financial information on their website. Passed the House. HB 11 (Metz) SB 354 (Stargel): Requires local governments to maintain certain budget documents on their websites. Passed the House.
HEALTHCARE FACILITIES AND LICENSURE
HB 27 (Fitzenhagen): Repeals Certificate of Need for hospitals and rehabilitation centers. Passed the House. HB 23 (Renner) SB 250 (Steube): Expands Ambulatory Surgery stays to 24 hours. Passed the House. HB 23 (Renner): Creates a new licensure category for Recovery Care Centers for 72 hour stays. Passed the House. HB 1099 (Magar) SB1564 (Grimsley): Creates a new licensure category for Advanced Birthing Centers that would be authorized to perform low risk cesarean deliveries and other procedures. HB 1165 (Trumbull) SB 1876 (Young): Places a 3 year moratorium on new trauma centers and thereafter authorizes new centers if need, population and other criteria are met. Various trauma centers that have been the subject to ongoing litigation are grandfathered-in and a Trauma Advisory Council is created and charged with developing an inclusive trauma system. HB 407 (Rommel SB 434 (Passidomo): Provides for a new licensure category for Pediatric Extended Care Centers desiring to provide residential care and treatment for up to six months for infants with Neonatal Abstinence Syndrome (NAS). Defines NAS as postnatal opioid withdrawal of an infant exposed in utero to opioids or agents used to treat opioid addiction.
PHYSICIAN AND WORKFORCE
HB 81 (Gonzalez): Creates new sections in law that would prohibit the Board of Medicine, the Department of Health, healthcare facilities licensed per FS 395 and insurers defined in FS 624 from requiring maintenance of certification or recertification as a condition of licensure, reimbursement, employment or admitting privileges for a physician who has achieved an initial certification. HB 21 (Boyd) SB 458 (Bean): Requires practitioners to complete specified board-approved continuing education to prescribe controlled substances and limits prescribing of opioids for acute pain in certain circumstances.
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Page 32 of 294 HB 35 (Grant): Requires AHCA to develop surveys to assess patient safety culture in hospitals. Passed the House.
INSURANCE
HB 19 (Grall) SB 150 (Lee): Repeals Personal Injury Protection (PIP) insurance and replaces it with bodily injury coverage. Passed the House. HB 37 (Burgess) SB 80 (Lee): Authorizes contracts for Direct Primary Care outside of Department of Insurance regulations. Passed the House. HB 217 (Hager) SB 162 (Steube): Prohibits health insurers from retroactively denying a claim once patient eligibility has been verified and an authorization number is given. HB 793 (Massullo) SB 280 (Bean): Establishes standards of care for telehealth providers and encourages certain insurers to include services provided through telehealth in insurance plans.
MENTAL HEALTH AND SUBSTANCE ABUSE
SB 202 (Steube): Modifies the Baker Act and Marchman Act regulations. SB 270 (Steube): Authorizes a parent, in lieu of law enforcement, to transport a minor under age 14 to a facility for involuntary examination and requires the examination of the child to begin within 8 hours. HB 2251 (Santiago): Appropriations request for $750,000 continuation funding for the Child and Adolescent Community Action (CAT) Team operated by Halifax Behavioral Services. Senator Hukill filed the companion project forms. Funding will be determined during the budget conference process as the appropriation is only in the Senate budget. SB 1434 (Passidomo) HB 5101(Appropriations): Creates a “Mental Health Assistance Allocation” in the K-12 Education budget to assist school districts with establishing or expanding comprehensive school-based mental health programs. $40 million is included in the Senate budget and this will also be a budget conference issue.
RED LIGHT CAMERAS
HB 19 (Grall) HB 6001 (Avila) SB 176 (Hutson) SB 150 (Lee): Repeals local authority and/or overall authority for Red Light cameras. Passed the House.
FLORIDA KIDCARE/CHILDREN’S ISSUES
HB 293 (Duran) SB 108 (Campbell): Establishes a task force within the Department of Health to enhance operational efficiencies in Florida KidCare. HB 115 (Slosberg) SB 92 (Book): Prohibits the person responsible for a child to leave them unattended in a motor vehicle for any length of time. SB 728 (Perry): Increases the age for required child restraint/booster seat for a child from age 5 to age 6.
MISCELLANEOUS
HB 65 (Roth) SB 978 (Baxley): Proposed Constitutional Amendment that would increase the percentage of elector votes required to approve an amendment or revision to the Constitution from 60 % to 66 2/3%.
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HB 7001 (Ways and Means, Leek) SB742 (Stargel): Proposed Constitutional Amendment that would require a 2/3 vote by the House and Senate to impose or increase a tax or fee. Passed the House.
FEDERAL ISSUES
340B Medicare Reductions: 340B hospitals, with some exclusions, are projected to lose significant savings on the purchase of 340B Medicare drugs as a result of a Rule finalized by the Centers for Medicaid and Medicare Services (CMS) that went into effect January 2018. The estimated impact to Halifax remains under review. America’s Essential Hospitals and the American Hospital Association have filed lawsuits alleging CMS over-reached their authority in issuing this Rule and are requesting an immediate moratorium. HR 4392 which currently has 185 bi-partisan co-sponsors has been filed to repeal this provision.
Medicaid DSH Reductions: The latest funding resolution included a two year delay in Medicaid DSH reductions that began in October 2017.
Child Heath Insurance Program (CHIP): Funding for CHIP/Florida KidCare was extended for an additional ten years in two separate Congressional actions.
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TO: Jeff Feasel, President and Chief Executive Officer FROM: Eric Peburn, Executive Vice President and Chief Financial Officer DATE: February 21, 2018 RE: FY 2018A Floating Rate Notes
To provide for additional liquidity over the next few years, Halifax Hospital Medical Center (HHMC) is pursuing issuance of a variable rate borrowing pursuant to Master Trust Indenture of the Obligated Group (HHMC and HH Holdings). Key terms of the proposed borrowing are as follows: Par amount: $85 million Closing date: June 1, 2018 Estimated cost of issuance: $252,500 Interest rate: One-month LIBOR, plus 120 bps Maturity date: October 31, 2020 (29 month term) Lender: JP Morgan Chase Bank, N.A.
The proceeds from the borrowing will be held in reserve and invested over the term. Assuming a 30-day LIBOR rate of 1.59% (plus 120 bps, totaling 2.29%) and income on the invested proceeds of 2.06% (one year US Treasury), the funding, repayment, interest cost and interest income over the term of the loan are summarized as follows:
Cost of Interest Investment Net Interest Period Principal Issuance Expense Earnings and Other Costs 6/1/2018 $ 85,000,000 $ (252,500) $ - $ - $ (252,500) 12/1/2018 (1,187,344) 875,500 (311,844) 6/1/2019 (1,187,344) 875,500 (311,844) 12/1/2019 (1,187,344) 875,500 (311,844) 6/1/2020 (1,187,344) 875,500 (311,844) 10/31/2020 (85,000,000) (989,453) 729,583 (259,870) Total $ - $ (252,500) $ (5,738,829) $ 4,231,583 $ (1,759,746)
The following draft documents for review and consideration are found in the separate board portal workplace: JP Morgan Term Sheet Resolution of the Board of Commissioners authorizing the issuance Trust Indenture Purchase Agreement Ninth Supplemental Indenture Financing Agreement
We will discuss the proposed financing with the Finance Committee and Board of Commissioners at the upcoming meetings.
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Halifax Hospital Medical Center Audit and Finance Committee Meeting 303 N. Clyde Morris Blvd., France Tower, Conference Room A Wednesday, January 3, 2018 ______Present: Ted Serbousek, Chairman Greg Motto, Member Decker Youngman, Member Susan Schandel, Member & Treasurer, Board of Commissioners Daniel Francati, Member & Vice Chairman, Board of Commissioners
Not Present: Ammar Hemaidan, MD, Member & Member, Medical Staff
Also Present: Jeff Feasel, President & CEO Eric Peburn, Executive VP/Chief Financial Officer Shelly Shiflet, Chief Compliance Officer Bill Rushton, Director, Internal Audit Kent Bailey, Director of Finance Lisa Tyler, Corporate Controller Bob Wade, Compliance Expert Mark Billings, Executive VP/Chief Operating Officer Arvin Lewis, Senior VP/Chief Revenue Officer Bill Griffin, Director, System Research and Planning Jill Wheelock, Associate General Counsel Tony Trovato, Director of Business Operations, Halifax Health Hospice Ben Eby, Director of Finance, Halifax Health Hospice Tom Stafford, VP/Chief Information Officer Ryan Weber, RSM Brandon Slauter, RSM ______The meeting was called to order at 4:00 p.m. by Ted Serbousek. Attendance was recorded.
MINUTES Discussion: Minutes from the August 14, 2017 Investment Committee Meeting and from the November 1, 2017 Audit & Finance Committee Meeting were reviewed.
Action: Ms. Schandel moved to approve the minutes as presented and recommends approval by the Halifax Health Board of Commissioners. Mr. Francati seconded the motion and it carried unanimously.
AUDIT COMMITTEE CORPORATE COMPLIANCE Discussion: Monthly Compliance Program Update Dashboard Ms. Shiflet presented the Compliance Dashboard for the months ended November 2017 and October 2017, referencing no issues. Brief discussion ensued regarding the Medicaid Integrity Contractor audit which resulted in the committee not objecting to closing the audit.
Action: None required.
INTERNAL AUDIT Discussion: Mr. Rushton led committee members through the Audit Services Discussion and Analysis presentation, briefing the committee on highlights of the 14 approved projects. He recommended approval of the Cash Collections Management Audit and the Summary of Audit Follow-Up Report.
Action: Ms. Schandel moved to approve the Cash Collections Management Audit as presented and recommends approval by the Halifax Health Board of Commissioners. Mr. Francati
Page 1 of 3 Page 36 of 294
seconded the motion and it carried unanimously.
Action: Ms. Schandel moved to approve the Summary of Audit Follow-Up Report as presented and recommends approval by the Halifax Health Board of Commissioners. Mr. Francati seconded the motion and it carried unanimously.
FY 2017 DRAFT AUDITED FINANCIAL STATEMENTS Discussion: Ms. Tyler introduced Mr. Weber and Mr. Slauter to present the 2017 Summary of Audit Results, highlighting Summary of Status as of January 3, 2018, Required Communications, Risk Areas Use of Internal Audit and Internal Control Deficiencies and Other Recommendations. Discussion ensued regarding the fact that GASB No. 68 is silent as to the treatment of frozen plans. The report concluded by stating the final draft audited financial statements will be presented next month.
Action: Mr. Francati moved to approve the FY 2017 Draft Audited Financial Statements as presented and recommends approval by the Halifax Health Board of Commissioners. Mr. Youngman seconded the motion and it carried unanimously.
FINANCE COMMITTEE FINANCIAL REPORT Discussion: Mr. Peburn reviewed the November 2017 Financial Report, presenting the statistical and financial summaries.
Action: Mr. Francati moved to approve the November 2017 and October 2017 Financial Reports and recommends approval by the Board of Commissioners. Mr. Youngman seconded the motion and it carried unanimously.
ACQUISITIONS, LEASES & DISPOSALS Discussion: Capital Investment Strategy Mr. Bailey presented the September 2017 Capital Investment Strategy monthly update.
Action: None required.
Discussion: Capital Expenditures $50,000 and over Data Protection Hardware & Software $496,641 Chilled Water Piping Project for Surgical Suites $463,349 Chiller for Ormond ROC $186,532 Patient Harness System for Inpatient Rehabilitation $83,315
Action: Mr. Motto moved to approve the list of capital expenditures and recommends approval by the Board of Commissioners. Mr. Youngman seconded the motion and it carried unanimously.
Discussion: Disposals and Sale of Portion of Vacant Land West of Clyde Morris Blvd.
Action: Mr. Motto moved to approve the disposals and the sale of the portion of the vacant land west of Clyde Morris Blvd. and recommends approval by the Board of Commissioners. Mr. Youngman seconded the motion and it carried unanimously.
Discussion: Comparison of Projected and Actual Financial Results for Significant Projects
Action: No report; no action required.
OLD BUSINESS Discussion: Meeting Request Tracker/Checklist Center for Rehabilitation Service Line Report and Annual Update (in packet) Hospice Market Share, Annual Update (in packet)
Action: None required.
Page 2 of 3 Page 37 of 294
NEW BUSINESS Discussion: Resolution Authorizing Issuance of Bonds for Deltona Mr. Peburn explained that the attached Resolution of the Board of Commissioners provides authorization for the issuance of bonds in an amount not-to-exceed $115 million for the purpose of constructing the Deltona Hospital. The Resolution outlines: Authority of Halifax Hospital Medical Center (“District”) to issue the bonds Considerations by the District to pursue healthcare operations in Deltona Manner for issuance of the bonds Role of Halifax Management System (or another affiliate of the District) to act as borrower, construct the Deltona Hospital, and lease the facility to the District
Approval of the Resolution by the Board of Commissioners will allow us to begin the process for obtaining the desired long-term financing and is respectfully requested.
Action: Mr. Francati moved to approve the Resolution Authorizing Issuance of Bonds for Deltona as presented and recommends approval by the Board of Commissioners. Mr. Youngman seconded the motion and it carried unanimously.
INFORMATIONAL REPORTS Discussion: The Discharged Based-Average Length of Stay and Case Mix Index, the Investment Performance Reports for November and September 2017, the Capital Expenditures, $25,000 - $50,000, and the Operating Leases, $50,000-$250,000 were presented under Information Only. The Capital Expenditures $25,000 - $50,000 were as follows: Access Control for Cardiac Intermediate Care Oncology $48,000 Microdebriders $46,126 Hemostasis Analyzers $45,380 EMG/Nerve Conducting Ultrasound Unit $26,876 Bladder Scanners $25,245
Action: None required.
OPEN DISCUSSION Discussion: None.
NEXT MEETING DATE: MONDAY, February 12, 2018, 4:00 p.m. – Investment Committee meeting WEDNESDAY, February 28, 2018, 4:00 p.m. – Regular scheduled meeting
ADJOURNMENT Action: There being no further business, the meeting was adjourned.
______Ted Serbousek, Chairman
Page 3 of 3 Page 38 of 294
Halifax Hospital Medical Center Investment Committee Meeting, Sub Committee Audit & Finance Committee France Tower, Conference Room A, 303 N. Clyde Morris Blvd., Daytona Beach, FL 32114 Monday, November 13, 2017 ______Present: Ted Serbousek, Chairman & Chairman, Audit & Finance Committee Dan Francati, Member & Member, Audit & Finance Committee & Vice Chairman, Board of Commissioners Dave Graffagnino, Member Decker Youngman, Member, Audit & Finance Committee Mike Walsh, Advisor
Via Phone: Susan Schandel, Member & Member, Audit & Finance Committee & Treasurer, Board of Commissioners Joe Petrock, Executive Director, Foundation
Not Present: Greg Motto, Member, Audit & Finance Committee
Also Present: Jeff Feasel, President & Chief Executive Officer Eric Peburn, Executive Vice President & Chief Financial Officer Kent Bailey, Director of Finance Lisa Tyler, Corporate Controller Leslie Wojcik, Ashford Investments Tom McGuire, Retirement Planners & Administrators, Inc. Brian Lunney, Vanguard ______The meeting was called to order at 4:00 p.m. by Ted Serbousek.
Minutes Discussion: Minutes from the August 14, 2017 Investment Committee meeting were reviewed.
Action: Mr. Youngman moved to approve the August 14, 2017 Investment Committee minutes as presented. Mr. Francati seconded the motion and it carried unanimously.
Manager Presentation Discussion: Manager Presentation – Vanguard Brian Lunney from Vanguard was introduced and presented the portfolio update (board portal).
Action: None required.
Manager Assessment and Quarterly Review Discussion: Manager Assessment – Vanguard Mr. Walsh presented the results of his comparative evaluation for Vanguard, supporting his recommendation to remain with Vanguard. Brief discussion ensued.
Action: Mr. Francati moved to remain with Vanguard. Mr. Graffagnino seconded the motion and it carried unanimously.
Discussion: Mr. Walsh, Ashford Investment Advisors, presented the investment review for the 3rd calendar quarter, ended 9/30/2017.
Action: None required.
Page 39 of 294
Old Business Discussion: None.
New Business Discussion: Funding of Loan to HMS Mr. Peburn provided an update to the committee regarding the projected financing stages for the Deltona hospital, which included the following: Stage 1 - Loan to HMS from HH Holdings (variable interest rate plus 25 bps) Stage 2 - Short-term bank loan – taxable interest rate Stage 3 - Long-term tax-exempt financing with SLA structure 1. HHMC is issuer 2. HMS is obligor 3. JP Morgan is lender Brief discussion ensued. Mr. Peburn added that funding is projected to be in place by March 2018 (Stage 2).
Action: None required.
Discussion: 2018 Quarterly Timeline, Investment Committee The 2018 Quarterly Timeline was presented as information only.
Action: None required.
Informational Only Discussion: Investment Performance Report, September 2017
Action: None required.
Next Meeting: Monday, February 12, 2018, 4 p.m. – Regular scheduled meeting
Open Discussion Discussion: None.
Adjournment
______Ted Serbousek
Page 40 of 294 Halifax Health Investment Manager Performance Report - through January 31, 2018
January Calendar Fiscal Performance YTD Year Fixed Income
VFSIX - Vangaurd Short-Term Investment Gr. Perf -0.36% -0.36% -0.31% BMK -0.13% -0.13% -0.47%
VSGDX - Vanguard Short-Term Federal Perf -0.53% -0.53% -0.71% BMK -0.40% -0.40% -0.80%
Ponder Short-term Government/Corporate Perf -0.21% -0.21% -0.03% BMK -0.13% -0.13% -0.47%
Ponder US Treasury Account Perf 0.00% 0.00% 0.13% BMK -0.13% -0.13% -0.53%
Ponder Short-Term Government Perf -0.24% -0.24% -0.25% BMK -0.40% -0.40% -0.80%
Weighted Composite Perf -0.27% -0.27% -0.20% BMK -0.16% -0.16% -0.52%
Equities
DFSVX - DFA Small Cap Value Perf 1.50% 1.50% 5.47% BMK 2.05% 2.05% 4.14%
DFLVX - DFA Large Cap Value Perf 5.14% 5.14% 12.99% BMK 5.33% 5.33% 10.94%
DFIVX - DFA International Value Perf 5.86% 5.86% 11.61% BMK 4.23% 4.23% 8.65%
DFEVX - DFA Emerging Markets Perf 8.78% 8.78% 17.38% BMK 7.44% 7.44% 15.43%
VGELX - Vanguard Energy Perf 3.50% 3.50% 10.17% BMK 6.81% 6.81% 14.09%
VENAX - Vanguard Energy Index Perf 3.20% 3.20% 9.85% BMK 6.45% 6.45% 14.31%
VIGIX -Vanguard Large-Cap Growth Perf 6.87% 6.87% 13.53% BMK 7.86% 7.86% 16.34%
VGHAX - Vanguard Health Care Perf 5.08% 5.08% 5.67% BMK 1.26% 1.26% 2.53%
VSGIX - Vanguard Small-Cap Growth Perf 3.91% 3.91% 9.89% Wellington Large-Cap Value BMKPerf 4.59% 4.59% 9.39%
Weighted Composite Perf 4.91% 4.91% 10.93% BMK 4.79% 4.79% 9.87%
Page 41 of 294 Halifax Health Investment Manager Performance Report - through January 31, 2018
Invested January Calendar Fiscal Balance Performance YTD YTD HH Holdings
VFSIX - Vanguard Short-Term Invest Grade $ 53,529,903 Perf -0.36% -0.36% -0.31% BMK -0.13% -0.13% -0.47%
Ponder Short-Term Gov't/Corporate 32,198,325 Perf -0.21% -0.21% -0.03% BMK -0.13% -0.13% -0.47%
Ponder US Treasury Account 73,802,752 Perf 0.00% 0.00% 0.13% BMK -0.13% -0.13% -0.53%
Total HH Holdings $ 159,530,980 Composite -0.16% -0.16% -0.05% Budget 0.33% HHMC
Ponder Short-Term Government $ 42,313,741 Perf -0.24% -0.24% -0.25% BMK -0.40% -0.40% -0.80%
VSGDX - Vanguard Short-Term Federal 64,169 Perf -0.53% -0.53% -0.71% BMK -0.40% -0.40% -0.80%
Wells Fargo Halifax Hospital Trust 534,104 Perf 0.10% 0.10% 0.35% BMK -0.40% -0.40% -0.80%
Total HHMC $ 42,912,014 Composite -0.24% -0.24% -0.24% Budget 0.33%
Page 1 Page 42 of 294 Halifax Health Investment Manager Performance Report - through January 31, 2018
Invested January Calendar Fiscal Balance Performance YTD YTD Foundation
VFSIX - Vanguard Short-Term Invest Grade $ 22,970,842 Perf -0.36% -0.36% -0.31% BMK -0.13% -0.13% -0.47%
DFSVX - DFA Small Cap Value 3,943,046 Perf 1.50% 1.50% 5.47% BMK 2.05% 2.05% 4.14%
DFIVX - DFA International Value 2,218,871 Perf 5.86% 5.86% 11.61% BMK 4.23% 4.23% 8.65%
DFEVX - DFA Emerging Markets 919,649 Perf 8.78% 8.78% 17.38% BMK 7.44% 7.44% 15.43%
DFLVX - DFA Large Cap Value 9,303,971 Perf 5.14% 5.14% 12.99% BMK 5.33% 5.33% 10.94%
VGELX - Vanguard Energy 524,396 Perf 3.50% 3.50% 10.17% BMK 6.81% 6.81% 14.09%
VENAX - Vanguard Energy Index 235,604 Perf 3.20% 3.20% 9.85% BMK 6.45% 6.45% 14.31%
VIGIX -Vanguard Large-Cap Growth 4,760,128 Perf 6.87% 6.87% 13.53% BMK 7.86% 7.86% 16.34%
VGHAX - Vanguard Health Care 787,665 Perf 5.08% 5.08% 5.67% BMK 1.26% 1.26% 2.53%
VSGIX - Vanguard Small-Cap Growth 4,348,248 Perf 3.91% 3.91% 9.89% BMK 4.59% 4.59% 9.39%
Total Foundation $ 50,012,420 Composite 2.37% 2.37% 5.76% Budget 1.17%
Page 2 Page 43 of 294 Halifax Health Investment Manager Performance Report - through January 31, 2018
Invested January Calendar Fiscal Balance Performance YTD YTD Hospice
VFSIX - Vanguard Short-Term Invest Grade $ 34,055,616 Perf -0.36% -0.36% -0.31% BMK -0.13% -0.13% -0.47%
DFSVX - DFA Small Cap Value 6,126,255 Perf 1.50% 1.50% 5.47% BMK 2.05% 2.05% 4.14%
DFIVX - DFA International Value 3,864,257 Perf 5.86% 5.86% 11.61% BMK 4.23% 4.23% 8.65%
DFEVX - DFA Emerging Markets 1,643,547 Perf 8.78% 8.78% 17.38% BMK 7.44% 7.44% 15.43%
DFLVX - DFA Large Cap Value 13,182,686 Perf 5.14% 5.14% 12.99% BMK 5.33% 5.33% 10.94%
VGELX - Vanguard Energy 115,876 Perf 3.50% 3.50% 10.17% BMK 6.81% 6.81% 14.09%
VENAX - Vanguard Energy Index 627,963 Perf 3.20% 3.20% 9.85% BMK 6.45% 6.45% 14.31%
VIGIX -Vanguard Large-Cap Growth 6,373,364 Perf 6.87% 6.87% 13.53% BMK 7.86% 7.86% 16.34%
VGHAX - Vanguard Health Care 684,902 Perf 5.08% 5.08% 5.67% BMK 1.26% 1.26% 2.53%
VSGIX - Vanguard Small-Cap Growth 6,058,793 Perf 3.91% 3.91% 9.89% BMK 4.59% 4.59% 9.39%
Total Hospice $ 72,733,259 Composite 2.33% 2.33% 4.01% Budget 1.17%
Page 3 Page 44 of 294 Halifax Health Investment Manager Performance Report - through January 31, 2018
Invested January Calendar Fiscal Balance Performance YTD YTD Pension
VFSIX - Vanguard Short-Term Invest Grade $ 131,509,943 Perf -0.36% -0.36% -0.31% BMK -0.13% -0.13% -0.47%
DFSVX - DFA Small Cap Value 24,526,160 Perf 1.50% 1.50% 5.47% BMK 2.05% 2.05% 4.14%
DFIVX - DFA International Value 41,101,200 Perf 5.86% 5.86% 11.61% BMK 4.23% 4.23% 8.65%
DFEVX - DFA Emerging Markets 13,111,270 Perf 8.78% 8.78% 17.38% BMK 7.44% 7.44% 15.43%
DFLVX - DFA Large Cap Value 26,276,713 Perf 5.14% 5.14% 12.99% BMK 5.33% 5.33% 10.94%
VGELX - Vanguard Energy 5,870,916 Perf 3.50% 3.50% 10.17% BMK 6.81% 6.81% 14.09%
VENAX - Vanguard Energy Index 5,247,264 Perf 3.20% 3.20% 9.85% BMK 6.45% 6.45% 14.31%
VIGIX -Vanguard Large-Cap Growth 16,419,357 Perf 6.87% 6.87% 13.53% BMK 7.86% 7.86% 16.34%
VGHAX - Vanguard Health Care 11,032,871 Perf 5.08% 5.08% 5.67% BMK 1.26% 1.26% 2.53%
VSGIX - Vanguard Small-Cap Growth 15,931,291 Perf 3.91% 3.91% 9.89% BMK 4.59% 4.59% 9.39%
Wells Fargo Cash 2,788,908
Wells Fargo Money Market 2,113
Total Pension $ 293,818,006 Composite 2.48% 2.48% 5.64% Budget 2.25% Total Halifax Health, including Pension $ 619,006,679
Total Halifax Health, excluding Pension $ 325,188,673
Page 4 Page 45 of 294 Halifax Health Investment Manager Performance Report - through December 31, 2017
December Calendar Fiscal Performance YTD Year Fixed Income
VFSIX - Vangaurd Short-Term Investment Gr. Perf 0.01% 2.16% -0.04% BMK 0.10% 2.32% -0.13%
VSGDX - Vanguard Short-Term Federal Perf 0.04% 0.80% -0.18% BMK -0.01% 0.69% -0.40%
Ponder Short-term Government/Corporate Perf 0.27% 0.36% 0.27% BMK 0.10% 2.32% -0.13%
Ponder US Treasury Account Perf 0.01% 0.69% 0.13% BMK -0.01% 0.69% -0.40%
Ponder Short-Term Government Perf 0.06% 1.08% 0.08% BMK -0.01% 0.69% -0.40%
Weighted Composite Perf 0.04% 1.62% 0.03% BMK 0.07% 1.84% -0.35%
Equities
DFSVX - DFA Small Cap Value Perf 0.03% 7.21% 3.13% BMK -0.95% 7.84% 2.05%
DFLVX - DFA Large Cap Value Perf 2.31% 18.97% 7.47% BMK 1.46% 13.66% 5.33%
DFIVX - DFA International Value Perf 2.60% 26.09% 5.43% BMK 1.80% 24.21% 4.23%
DFEVX - DFA Emerging Markets Perf 3.70% 33.76% 7.91% BMK 3.59% 37.28% 7.44%
VGELX - Vanguard Energy Perf 3.92% 3.26% 6.45% BMK 4.67% 6.77% 6.81%
VENAX - Vanguard Energy Index Perf 5.24% -2.39% 6.43% BMK 5.23% -2.33% 6.45%
VIGIX -Vanguard Large-Cap Growth Perf 0.73% 27.81% 6.23% BMK 0.78% 30.21% 7.86%
VGHAX - Vanguard Health Care Perf 0.20% 19.66% 0.56% BMK 0.14% 20.14% 1.26%
VSGIX - Vanguard Small-Cap Growth Perf 0.28% 21.94% 5.77% Wellington Large-Cap Value BMKPerf 0.12% 22.17% 4.59%
Weighted Composite Perf 1.68% 19.97% 5.60% BMK 1.18% 19.92% 4.79%
Page 46 of 294 Halifax Health Investment Manager Performance Report - through December 31, 2017
Invested December Calendar Fiscal Balance Performance YTD YTD HH Holdings
VFSIX - Vanguard Short-Term Invest Grade $ 53,724,534 Perf 0.01% 2.16% -0.04% BMK 0.10% 2.32% -0.13%
Ponder Short-Term Gov't/Corporate 32,265,278 Perf 0.27% 0.36% 0.27% BMK 0.10% 2.32% -0.13%
Ponder US Treasury Account 73,799,795 Perf 0.01% 0.69% 0.13% BMK -0.01% 0.69% -0.40%
Total HH Holdings $ 159,789,607 Composite 0.06% 1.12% 0.10% Budget 0.25% HHMC
Ponder Short-Term Government $ 42,413,791 Perf 0.06% 1.08% 0.08% BMK -0.01% 0.69% -0.40%
VSGDX - Vanguard Short-Term Federal 64,508 Perf 0.04% 0.80% -0.18% BMK -0.01% 0.69% -0.40%
Wells Fargo Halifax Hospital Trust 537,577 Perf 0.09% 0.68% 0.24% BMK -0.01% 0.69% -0.40%
Total HHMC $ 43,015,876 Composite 0.06% 1.07% 0.08% Budget 0.25%
Page 1 Page 47 of 294 Halifax Health Investment Manager Performance Report - through December 31, 2017
Invested December Calendar Fiscal Balance Performance YTD YTD Foundation
VFSIX - Vanguard Short-Term Invest Grade $ 23,054,363 Perf 0.01% 2.16% -0.04% BMK 0.10% 2.32% -0.13%
DFSVX - DFA Small Cap Value 3,884,653 Perf 0.03% 7.21% 3.13% BMK -0.95% 7.84% 2.05%
DFIVX - DFA International Value 2,096,112 Perf 2.60% 26.09% 5.43% BMK 1.80% 24.21% 4.23%
DFEVX - DFA Emerging Markets 845,448 Perf 3.70% 33.76% 7.91% BMK 3.59% 37.28% 7.44%
DFLVX - DFA Large Cap Value 8,849,291 Perf 2.31% 18.97% 7.47% BMK 1.46% 13.66% 5.33%
VGELX - Vanguard Energy 506,657 Perf 3.92% 3.26% 6.45% BMK 4.67% 6.77% 6.81%
VENAX - Vanguard Energy Index 228,305 Perf 5.24% -2.39% 6.43% BMK 5.23% -2.33% 6.45%
VIGIX -Vanguard Large-Cap Growth 4,454,154 Perf 0.73% 27.81% 6.23% BMK 0.78% 30.21% 7.86%
VGHAX - Vanguard Health Care 749,613 Perf 0.20% 19.66% 0.56% BMK 0.14% 20.14% 1.26%
VSGIX - Vanguard Small-Cap Growth 4,184,704 Perf 0.28% 21.94% 5.77% BMK 0.12% 22.17% 4.59%
Total Foundation $ 48,853,301 Composite 0.76% 11.47% 3.12% Budget 0.88%
Page 2 Page 48 of 294 Halifax Health Investment Manager Performance Report - through December 31, 2017
Invested December Calendar Fiscal Balance Performance YTD YTD Hospice
VFSIX - Vanguard Short-Term Invest Grade $ 34,179,439 Perf 0.01% 2.16% -0.04% BMK 0.10% 2.32% -0.13%
DFSVX - DFA Small Cap Value 6,035,531 Perf 0.03% 7.21% 3.13% BMK -0.95% 7.84% 2.05%
DFIVX - DFA International Value 3,650,467 Perf 2.60% 26.09% 5.43% BMK 1.80% 24.21% 4.23%
DFEVX - DFA Emerging Markets 1,510,940 Perf 3.70% 33.76% 7.91% BMK 3.59% 37.28% 7.44%
DFLVX - DFA Large Cap Value 12,538,456 Perf 2.31% 18.97% 7.47% BMK 1.46% 13.66% 5.33%
VGELX - Vanguard Energy 111,956 Perf 3.92% 3.26% 6.45% BMK 4.67% 6.77% 6.81%
VENAX - Vanguard Energy Index 608,509 Perf 5.24% -2.39% 6.43% BMK 5.23% -2.33% 6.45%
VIGIX -Vanguard Large-Cap Growth 5,963,695 Perf 0.73% 27.81% 6.23% BMK 0.78% 30.21% 7.86%
VGHAX - Vanguard Health Care 651,815 Perf 0.20% 19.66% 0.56% BMK 0.14% 20.14% 1.26%
VSGIX - Vanguard Small-Cap Growth 5,830,912 Perf 0.28% 21.94% 5.77% BMK 0.12% 22.17% 4.59%
Total Hospice $ 71,081,720 Composite 0.76% 11.35% 3.08% Budget 0.88%
Page 3 Page 49 of 294 Halifax Health Investment Manager Performance Report - through December 31, 2017
Invested December Calendar Fiscal Balance Performance YTD YTD Pension
VFSIX - Vanguard Short-Term Invest Grade $ 132,256,451 Perf 0.01% 2.16% -0.04% BMK 0.10% 2.32% -0.13%
DFSVX - DFA Small Cap Value 24,162,951 Perf 0.03% 7.21% 3.13% BMK -0.95% 7.84% 2.05%
DFIVX - DFA International Value 38,827,275 Perf 2.60% 26.09% 5.43% BMK 1.80% 24.21% 4.23%
DFEVX - DFA Emerging Markets 12,053,411 Perf 3.70% 33.76% 7.91% BMK 3.59% 37.28% 7.44%
DFLVX - DFA Large Cap Value 24,992,585 Perf 2.31% 18.97% 7.47% BMK 1.46% 13.66% 5.33%
VGELX - Vanguard Energy 5,672,312 Perf 3.92% 3.26% 6.45% BMK 4.67% 6.77% 6.81%
VENAX - Vanguard Energy Index 5,084,701 Perf 5.24% -2.39% 6.43% BMK 5.23% -2.33% 6.45%
VIGIX -Vanguard Large-Cap Growth 15,363,948 Perf 0.73% 27.81% 6.23% BMK 0.78% 30.21% 7.86%
VGHAX - Vanguard Health Care 10,499,882 Perf 0.20% 19.66% 0.56% BMK 0.14% 20.14% 1.26%
VSGIX - Vanguard Small-Cap Growth 15,332,090 Perf 0.28% 21.94% 5.77% BMK 0.12% 22.17% 4.59%
Wells Fargo Cash 4,334,568
Wells Fargo Money Market 1,987
Total Pension $ 288,582,161 Composite 0.94% 11.94% 2.85% Budget 1.69% Total Halifax Health, including Pension $ 611,322,664
Total Halifax Health, excluding Pension $ 322,740,504
Page 4 Page 50 of 294 HALIFAX HEALTH MEDICAL CENTER SCHEDULE OF USES OF PROPERTY TAXES FOR THE PERIOD ENDED DECEMBER 31, 2017
in mills
Gross property tax levy $ 1,512,048 0.3781
Tax discounts and uncollectible taxes (40,500) (0.0101) Net property taxes collected 1,471,548 0.3680
Amounts paid to Volusia County and Cities: Tax collector and appraiser commissions (50,250) (0.0126) Volusia County Medicaid matching assessment (738,659) (0.1847) Redevelopment taxes paid to Cities (142,400) (0.0356) Subtotal (931,309) (0.2329)
Net taxes available for community health, wellness and readiness 540,239 0.1351
Amounts paid for community health and wellness services: Preventive health services (clinics, Healthy Kids, etc.) (287,797) (0.0720) Physician services (2,096,200) (0.5242) Trauma services (1,746,405) (0.4367) Pediatric and neonatal intensive care services (93,758) (0.0234) Child and adolescent behavioral services (204,785) (0.0512) Subtotal (4,428,945) (1.1075)
Deficiency of net taxes available to fund hospital operating expenses (3,888,706) (0.9724)
Uncompensated care provided by Halifax Health, at cost (12,769,972) (3.1932)
Total deficiency of net taxes available to fund hospital operating expenses and uncompensated care provided by Halifax Health, at cost $ (16,658,678) (4.1656)
Proforma tax levy to cover uncompensated care, at cost: Gross property tax levy 0.3781 Subsidized uncompensated care costs by operations 4.1656 Equivalent property tax levy expended * 4.5437
* This is an equivalent levy for demonstration purposes only and is not intended to represent a proposed millage rate.
Page 51 of 294 INFORMATIONAL REPORT February 28, 2018
Capital Expenditures $25,000 -- $50,000
DESCRIPTION DEPARTMENT SOURCE OF FUNDS TOTAL
Neonatal Incubator Pediatric Intensive Care Working Capital $43,651 Unit Network Access Control Ports Information Technology Working Capital $42,331 EEG Cart for Halifax Health Main Electroencephalography Working Capital $42,177 Campus Department Omnicell Medication Dispensing Pharmacy Working Capital $31,884 Cabinet Box Truck with Lift Gate Facility Operations Working Capital $26,500
Operating Leases $50,000 -- $250,000
DESCRIPTION DEPARTMENT REPLACEMENT LEASE INTEREST MONTHLY Y/N TERMS RATE PAYMENT
Page 52 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Catherine Luchsinger, RN, Chief Nursing Officer DATE: February 14, 2018 RE: Neonatal Incubator
Halifax Health Pediatric Intensive Care Unit is requesting funds to purchase a neonatal incubator. The new incubator bed will replace a bed that has reached end of life and parts are no longer available.
The incubator is used in the Neonatal Intensive Care Unit (NICU) for infants who have very low birth weight. The specialty incubator allows for quick access to the infant while maintaining temperature, reducing stimuli, and maintaining humidity within the environment. These factors are paramount to positive outcomes for our smallest patients.
With this purchase we can continue to deliver safe, efficient, and compassionate care in the NICU.
The project was approved at the Capital Investment Committee meeting on December 20, 2017.
TOTAL CAPITAL COSTS $43,651
Page 53 of 294
Halifax Health Project Evaluation Neonatal Incubator Chief Operating Officer: Mark Billings Chief Nursing Officer: Catherine Luchsinger Finance Analysis by: Shawn Remington
Summary
Purpose: This project will replace a neonatal bed that has reached end of life and parts are no longer available.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination Compassion X Cost Management Image Information Technology Efficiency X Service Distribution X Financial Position Scale X Managed Care Contracting Competitive Position
Investment Request for Approval $43,651
Recommendation for approval of the project is not based upon incremental return on investment.
Page 54 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Arvin Lewis, Senior Vice President and Chief Revenue Officer CC: Tom Stafford, Vice President and Chief Information Officer DATE: January 19, 2018 RE: Network Access Control Ports
Halifax Health Information Technology is requesting funds to purchase eight (8) Network Access Control (NAC) ports for the Halifax Health network.
NAC unifies endpoint security technology, user or system authentication and network security enforcement. NAC prevents non-Halifax devices from attaching to the network.
The additional ports will expand the current NAC coverage to all ports on the network.
The project was approved at the Capital Investment Committee meeting on January 17, 2018.
TOTAL CAPITAL COSTS $42,331
Page 55 of 294
Halifax Health Project Evaluation Network Access Control Ports (Qty 8) Chief Revenue Officer: Arvin Lewis VP & Chief Information Officer: Tom Stafford Director, IT: Mike Marques Finance Analysis by: Shawn Remington
Summary
Purpose: This project will provide IT security against unauthorized devices connecting to the Halifax internal network.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination Compassion Cost Management Image Information Technology X Efficiency Service Distribution Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $42,331
Recommendation for approval of the project is not based upon incremental return on investment.
Page 56 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Mark Billings, Executive Vice President and Chief Operating Officer Eric Peburn, Executive Vice President and Chief Financial Officer Alberto Tineo, Vice President Operations DATE: January 16, 2018 RE: EEG Cart for Halifax Health Main Campus
Halifax Health Electroencephalography Department is requesting funds to purchase an electroencephalogram (EEG) recording cart for the Halifax Health Main Campus.
In an effort to build a comprehensive neuroscience program and to maintain our JCAHO comprehensive stroke center accreditation, a new EEG cart is needed. The new cart will allow continuous monitoring along with audio and visual recording.
The current EEG carts do not offer continuous monitoring. A nurse is required to manually record notations if unusual seizure-like activity occurs during an EEG. The new equipment will provide continuous monitoring which will reduce the risk that unusual activity is not detected and documented.
Currently, there are two EEG carts at the Main Campus that do not allow for continuous monitoring. These carts will continue to be used for routine EEG testing that does not require continuous monitoring.
The project was approved at the Capital Investment Committee meeting on December 20, 2017.
TOTAL CAPITAL COSTS $42,177
Page 57 of 294
Halifax Health Project Evaluation EEG Cart for Halifax Health Main Campus Chief Operating Officer: Mark Billings Sr. Vice President, Operations: Alberto Tineo Manager, Respiratory: John Walberg Finance Analysis by: Steve Mach
Summary
Purpose: This project is to add an electroencephalogram (EEG) recording cart for the main campus. The cart will be used to monitor patients for seizure activity.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination X Compassion Cost Management Image Information Technology X Efficiency Service Distribution Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $42,177
Recommendation for approval of the project is not based upon incremental return on investment.
Page 58 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Mark Billings, Executive Vice President and Chief Operating Officer CC: Alberto Tineo, Senior Vice President Operations DATE: February 14, 2018 RE: Omnicell Medication Dispensing Cabinet
Halifax Health Pharmacy is requesting funds to purchase an Omnicell automated medication dispensing cabinet for the Daytona Beach Oncology Center.
The Omnicell unit will allow medications to be dispensed safely and securely. The automated equipment will help to prevent the diversion of controlled substances.
This project was approved at the Capital Investment Committee meeting on December 20, 2017.
TOTAL CAPITAL COSTS $31,884
Page 59 of 294
Halifax Health Project Evaluation Omnicell Medication Dispensing Cabinet Chief Operating Officer: Mark Billings Sr. Vice President, Operations: Alberto Tineo Director, Pharmacy: Dominick Damiani Finance Analysis by: Shawn Remington
Summary
Purpose: This project is to purchase an Omnicell automated medication dispensing cabinet for the Daytona Beach Oncology Pharmacy.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination X Compassion Cost Management Image Information Technology Efficiency Service Distribution Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $31,844
Recommendation for approval of the project is not based upon incremental return on investment.
Page 60 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Eric Peburn, Executive Vice President and Chief Financial Officer DATE: January 16, 2018 RE: Box Truck with Lift Gate
Halifax Health Facility Operations is requesting funds to purchase a 16-foot box truck with lift gate.
The truck is used to move equipment and furniture to and from the warehouse. It is also used to move equipment and furniture to all other off-site locations including Hospice care centers and the Deltona FSED.
The project was approved at the Capital Investment Committee meeting on December 20, 2017.
TOTAL CAPITAL COSTS $26,500
Page 61 of 294
Halifax Health Project Evaluation Box Truck with Lift Gate Chief Financial Officer: Eric Peburn Director, Engineering: Jacob Nagib Manager, Facility Operations: Don Barnett Finance Analysis by: Shawn Remington
Summary
Purpose: The truck will be used to move furniture and equipment between various locations within the Halifax Health system.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety Care Coordination Compassion Cost Management X Image Information Technology Efficiency X Service Distribution X Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $26,500
Recommendation for approval of the project is not based upon incremental return on investment.
Page 62 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Bill Griffin, Director, Research and Planning CC: Eric Peburn, Executive Vice President and Chief Financial Officer DATE: February 20, 2018 RE: Sale of portion of Deltona parcel at 120 Howland Blvd
The real estate parcel located at 120 Howland Boulevard, Deltona, consisting of 12.5 acres is owned by H.H. Holdings, Inc. (Holdings). Development of this parcel is being planned, including road and utility infrastructure. Holdings was approached by two potential buyers to sell approximately 5 acres of the 12.5 acre parcel. In October 2017, utilizing the assistance of outside legal counsel, Holdings negotiated the “highest and best offer” from the two buyers for $375,000 per acre, a total purchase price of $1,875,000. The Holdings board of directors approved the sale at this offer price. The highest offer referenced above has been withdrawn. The second offer is to purchase 4.888 acres for $340,834 per acre, a total purchase price of $1,666,000. See parcel overview in Exhibit A. In addition, similar to the highest offer, the party making the second offer has agreed to fund a pro rata share of the cost for infrastructure of access road, utilities and platting. Estimated cost of Phase 1 road and utility infrastructure is $787,000, the not to exceed prorata portion to be paid by Holdings is 55% or $430,000.
Additional background on proposed sale: Buyer’s proposed use: grocery and related retail Remaining parcel for Holdings development is approximately 6 acres, for future urgent care, physician offices and support services Evaluation of proposed selling price: Highest appraised value of land to be sold - $1,266,579 (=$259,120/acre times 4.888 acres; see Exhibit B for appraised values) Cost basis of land to be sold - $1,148,876 Gain on sale - $517,124
We request the H.H. Holdings, Inc. Board of Directors provide approval to: 1. Sell the real estate parcel described above and authorize the Chief Executive Officer or the Chief Financial Officer to execute any related sales documents or agreements. 2. Incur capital costs of up to $430,000 for the development of road and utility infrastructure for the property.
Exhibit A – Parcel Overview Exhibit B – Appraisal and Comparable Sales Results
Page 63 of 294
Page 64 of 294
“Exhibit B – Appraisal and Comparable Sales Results” We have two appraisals for the 120 Howland Blvd, Deltona property. One was done by Heffington & Associates (1/22/17) and the other by Doyle Appraisal Services (8/11/17). The Doyle appraisal report has a value per acre if we sell only a portion of the parcel and a value per acre for the entire parcel.
Appraisal Firm Per Acre Per Square Foot Heffington & Associates $196,157 $4.50 Doyle Appraisal Services (Partial Parcel Sale) $259,120 $5.95 Doyle Appraisal Services (Entire Parcel Sale) $220,240 $5.06
Proposed Sale $340,834 $7.82
The Comparable Sales:
Source/Location Date Per Square Foot Heffington & Associates 830 N SR 415 Deltona (Listing) 9/16 $3.56 NW Corner Glencoe Rd & SR 44 NSB 12/15 $6.13 I/95 & LPGA 12/15 $4.64 3300 Halifax Crossing 11/15 $3.36 Doyle Appraisal Services - 3165 Howland Blvd 6/16 $7.94 3125 Howland Blvd 8/16 $9.06 N/SR 44, NSB 9/16 $4.51
Ted Lightman, Appraiser 890 N SR 415 8/14 $2.15
In a conversation with Ted Lightman the week ending 2/16/18, there are no other comparable sales that are in the area this Deltona parcel to be sold.
Page 65 of 294
TO: Jeff Feasel, President & CEO FROM: Deanna Schaeffer, Executive Director, Halifax Health Healthy Communities DATE: February 5, 2018 RE: Halifax Health Healthy Communities Board Appointment Request
At their January 17, 2018 meeting, the Healthy Communities Board unaimioualy appoved the appointment of Ms. Debbie Hinson Fisher to the Healthy Communities Board and respectfully submits Ms. Fisher to the Halifax Health Board of Commissioners for review and appointment consideration.
Pending approval by the Board of Commissioners, Ms. Fisher will fulfill a three-year term beginning April 1, 2018 through March 31, 2021.
Debbie Hinson Fisher, RN, MSN Coordinator, Health Services /Medicaid Provider Volusia County Schools
Debbie H. Fisher, RN, MSN has been with Volusia County Schools Health Services since 2002. In her 30 years in nursing, Debbie has worked in almost every aspect of health care. Early in her career she worked in pediatric, medical surgical and geriatric specialties. Within Volusia County Schools, Debbie works to make sure the health needs of all students are met.
Upon coming to work as a Nurse at Volusia County Schools, Debbie said she found her niche in the field of school health. She wanted to help prevent health barriers that may hinder a student’s ability to learn because a healthy student has a better opportunity to be successful in the school setting. Her position enables her to have close contact with students and parents. This satisfies her desire to teach and support them through one of their most challenging life experiences, making sure every student can learn to their fullest potential. Debbie says that what also drew her to this field of nursing is the challenge it affords her every working day. “No two student’s cases are exactly alike, and no two days at Volusia County Schools are the same.”
“Make your vision so clear that fears are irrelevant”
Page 66 of 294
Halifax Health Summary Financial Narrative For the three months ended December 31, 2017
The performance of Halifax Health (HH) compared to budget and long-range targets (S&P “A” rated medians) for key financial indicators is as follows. YTD YTD YTD Actual YTD Actual vs. Financial Indicator Actual Budget S&P "A" FY 18 vs. Budget FY 18 FY 18 S&P "A" Total Margin 2.9% 1.1% Favorable 5.8% Unfavorable Operating Margin 0.9% 0.2% Favorable 3.6% Unfavorable EBIDA Mar gin 10.5% 8.5% Favorable 13.1% Unfavorable Operating EBIDA Margin 8.7% 7.7% Favorable 10.8% Unfavorable Adjusted Operating EBIDA Margin * 7.9% 7.4% Favorable N/A N/A Days Cash on Hand 244 258 Unfavorable 249 Unfavorable Cash to Debt 92.8% 102.8% Unfavorable 189.9% Unfavorable Debt to Capitalization 55.3% 53.3% Unfavorable 29.1% Unfavorable
OG MADS Coverage 1.95 1.76 Favorable 4.50 Unfavorable OG Debt to Capitalization 54.4% 52.9% Unfavorable 29.1% Unfavorable
* -Excludes investment income/loss of Foundation recorded as operating income. Halifax Health Medical Center Statistical Summary-- • Admissions for the month and fiscal year-to-date are greater than budget and last year. • Patient days for the month are less than budget and last year; and for the fiscal year-to-date are greater than budget and less than last year. o Observation patient days for the month are less than budget and last year; and for the fiscal year-to-date are greater than budget and less than last year. • Surgery volumes for the month are less than budget and last year; and for the fiscal year-to-date are greater than budget and last year. • Emergency Room visits for the month and fiscal year-to-date are greater than budget and last year. Financial Summary -- • Net patient service revenue for the fiscal year-to-date is 2.1% less than budget. • Total operating expenses for the fiscal year-to-date are 1.4% less than budget. • Loss from operations for the fiscal year-to-date of 907,000 compares unfavorably to budget by $157,000. • Nonoperating gains/losses for the fiscal year-to-date of $428,000, primarily consisting of net investment income, compares unfavorably to the budgeted amount by $108,000. • The decrease in net position for the fiscal year-to-date of $479,000 compares unfavorably to budget by $265,000. Halifax Health Hospice Statistical Summary – • Patient days for the month and fiscal year-to-date are greater than budget and last year. Financial Summary -- • Net patient service revenue for the fiscal year-to-date is 3.0% greater than budget. • Income from operations for the fiscal year-to-date of $326,000 compares favorably to budget by $276,000. • Nonoperating gains/losses for the fiscal year-to-date of $2.3 million, primarily consisting of net investment income, compares favorably to the budgeted amount by $1.6 million. • The increase in net position for the fiscal year-to-date of $2.6 million compares favorably to budget by $1.8 million.
Other Component Units - The financial performance is consistent with budgeted expectations. Page 67 of 294 Halifax Health Statistical Summary
Month Ended Three Months Ended December 31, December 31, 2016 2017 Budget Var. 2016 2017 Budget Var.
Inpatient Activity
1,556 1,583 1,567 1.0% HHMC Adult/Ped Admissions 4,634 4,738 4,665 1.6% 129 147 152 -3.3% HHMCPO Adult/Ped Admissions 406 474 452 4.9% 164 178 156 14.1% Adult Psych Admissions 463 541 464 16.6% 61 64 59 8.5% Rehabilitative Admissions 186 191 170 12.4% 1,910 1,972 1,934 2.0% Total Adult/Ped Admissions 5,689 5,944 5,751 3.4%
8,342 7,741 7,552 2.5% HHMC Adult/Ped Patient Days 25,455 23,237 22,477 3.4% 781 513 648 -20.8% HHMCPO Adult/Ped Patient Days 2,351 1,972 1,930 2.2% 1,477 1,351 1,543 -12.4% Adult Psych Patient Days 4,425 3,918 4,593 -14.7% 865 886 858 3.3% Rehabilitative Patient Days 2,528 2,712 2,505 8.3% 11,465 10,491 10,601 -1.0% Total Adult/Ped Patient Days 34,759 31,839 31,505 1.1%
5.4 4.9 4.8 1.5% HHMC Average Length of Stay 5.5 4.9 4.8 1.8% 6.1 3.5 4.3 -18.1% HHMCPO Average Length of Stay 5.8 4.2 4.3 -2.6% 5.4 4.8 4.8 0.0% HHMC/ HHMCPO Average Length of Stay 5.5 4.8 4.8 1.4% 9.0 7.6 9.9 -23.3% Adult Psych Average Length of Stay 9.6 7.2 9.9 -26.8% 14.2 13.8 14.5 -4.8% Rehabilitative Length of Stay 13.6 14.2 14.7 -3.6% 6.0 5.3 5.5 -2.9% Total Average Length of Stay 6.1 5.4 5.5 -2.2%
370 338 342 -1.0% Total Average Daily Census 378 346 342 1.1%
995 806 769 4.8% HHMC Observation Patient Day Equivalents 2,655 2,454 2,272 8.0% 153 120 181 -33.7% HHMCPO Observation Patient Day Equivalents 448 472 520 -9.2% 1,148 926 950 -2.5% Total Observation Patient Day Equivalents 3,103 2,926 2,792 4.8%
37 30 31 -3.2% Observation Average Daily Census 34 32 30 6.7%
170 147 182 -19.2% HHMC Newborn Births 449 429 480 -10.6% 321 260 348 -25.3% HHMC Nursery Patient Days 832 758 902 -16.0%
460 498 452 10.2% HHMC Inpatient Surgeries 1,346 1,456 1,354 7.5% 2 7 3 133.3% HHMCPO Inpatient Surgeries 9 27 9 200.0% 462 505 455 11.0% Total Inpatient Surgeries 1,355 1,483 1,363 8.8%
Inpatient Surgeries 159 175 Orthopedics 522 502 86 66 General Surgery 220 205 46 30 Neurosurgery 127 97 12 30 Thoracic Surgery 67 97 27 36 Vascular 72 86 132 168 All Other 347 496 462 505 455 11.0% Total Inpatient Surgeries 1,355 1,483 1,363 8.8%
page 2 Page 68 of 294 Halifax Health Statistical Summary
Month Ended Three Months Ended December 31, December 31, 2016 2017 Budget Var. 2016 2017 Budget Var.
Outpatient Activity
6,606 6,778 6,669 1.6% HHMC ED Registrations 19,954 20,573 20,146 2.1% 2,584 2,793 2,592 7.8% HHMCPO ED Registrations 7,501 7,963 7,524 5.8% 0 1,350 1,271 6.2% Deltona ED Registrations 0 3,944 3,772 4.6% 9,190 10,921 10,532 3.7% Total ED 27,455 32,480 31,442 3.3%
444 344 394 -12.7% HHMC Outpatient Surgeries 1,232 1,091 1,168 -6.6% 55 0 0 0.0% HPC Outpatient Surgeries 179 1 0 0.0% 0 125 110 13.6% HHMCPO Outpatient Surgeries 0 371 327 13.5% 329 275 298 -7.7% Twin Lakes Surgeries 1,051 1,002 940 6.6% 828 744 802 -7.2% Total Outpatient Surgeries 2,462 2,465 2,435 1.2%
Outpatient Surgeries 184 167 General Surgery 556 487 184 123 Orthopedics 475 408 44 65 Gastroenterology 231 314 75 69 Obstetrics Gynecology 227 217 59 69 Ophthalmology 166 215 282 251 All Other 807 824 828 744 802 -7.2% Total Outpatient Surgeries 2,462 2,465 2,435 1.2%
Cardiology Procedures 9 16 Open Heart Cases 45 61 115 145 Cardiac Caths 366 490 36 36 CRM Devices 104 92 45 39 EP Studies 130 126 205 236 204 15.7% Total Cardiology Procedures 645 769 673 14.3%
Interventional Radiology Procedures 5 5 6 -16.7% Vascular 17 23 20 15.0% 164 163 169 -3.6% Nonvascular 454 456 467 -2.4% 169 168 175 -4.0% Total Interventional Radiology Procedures 471 479 487 -1.6%
219 214 178 20.2% GI Procedures 590 658 539 22.1%
HH Hospice Activity Patient Days 15,562 16,784 15,501 8.3% Volusia/ Flagler 45,408 49,433 46,004 7.5% 998.0 1,406 1,353 3.9% Orange/ Osceola 2,609.0 4,332 3,847 12.6% 16,560 18,190 16,854 7.9% HH Hospice Patient Days 48,017 53,765 49,851 7.9%
Average Daily Census 502 541 500 8.3% Volusia/ Flagler 494 537 500 7.5% 32 45 44 3.9% Orange/ Osceola 28 47 42 12.6% 534 586 544 7.9% HH Hospice Average Daily Census 522 584 542 7.9%
page 3 Page 69 of 294 Halifax Health Statistical Summary
Month Ended Three Months Ended December 31, December 31, 2016 2017 Budget Var. 2016 2017 Budget Var.
Physician Practice Activity
Primary Care Visits 280 441 245 80.0% Ormond Beach 834 1,191 797 49.4% 1,020 1,015 1,052 -3.5% Daytona Beach 3,060 3,302 3,156 4.6% 696 564 642 -12.1% Port Orange 2,030 2,531 1,876 34.9% 264 264 545 -51.6% Deltona 904 906 1,865 -51.4% - 828 800 3.5% New Smyrna - 2,616 2,400 9.0% 462 615 476 29.2% Ormond Beach (Women's/OB) 1,374 1,863 1,413 31.8% - 377 876 -57.0% Ormond Beach - Urgent Care - 987 2,600 -62.0% 2,722 4,104 4,636 -11.5% Primary Care Visits 8,202 13,396 14,107 -5.0%
Children's Medical Center Visits 895 588 892 -34.1% Ormond Beach 2,683 1,783 2,695 -33.8% - 361 302 19.5% Palm Coast 293 963 999 -3.6% 488 464 682 -32.0% Port Orange 1,441 1,455 2,014 -27.8% 1,383 1,413 1,876 -24.7% Children's Medical Center Visits 4,417 4,201 5,708 -26.4%
Community Clinic Visits 390 311 400 -22.3% Keech Street 1,114 1,015 1,143 -11.2% 269 - - 0.0% Adult Community Clinic 697 92 75 22.7% 659 311 400 -22.3% Community Clinic Visits 1,811 1,107 1,218 -9.1%
page 4 Page 70 of 294 Halifax Health Statistical Summary - Graphic
HHMC Average Daily Census (Monthly)
440
400
360
320
280
240
200 Patients 160
120
80
40
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 - HHMCPO FY18 - HHMC FY17 Budget
ED Visits (Monthly)
12,000
10,000
8,000
Visits 6,000
4,000
2,000
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 - Deltona FY18 - HHMCPO FY18 - HHMC FY17 Budget
page 5 Page 71 of 294 Halifax Health Statistical Summary - Graphic
Surgeries (Monthly)
1,600
1,400
1,200
1,000
800
Surgeries 600
400
200
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 - Twin Lakes FY18 - HHMCPO FY18 - HHMC FY17 Budget
Hospice Average Daily Census (Monthly)
700
600
500
400 Patients 300
200
100
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 ORL FY18 V/F FY17 Budget Budget wo Orlando Market
page 6 Page 72 of 294 Halifax Health Condensed Statement of Net Position ($ in thousands)
December 31, 2017 2016 Change Assets Cash and cash equivalents $21,822 $31,313 ($9,491) Investments 272,163 268,572 3,591 Board designated assets 45,155 44,702 453 Accounts receivable 64,643 61,632 3,011 Restricted assets whose use is limited 6,413 19,149 (12,736) Other assets 50,081 44,225 5,856 Deferred outflow - swap 30,297 30,728 (431) Deferred outflow - loss on bond refunding 16,224 17,148 (924) Deferred outflow - pension 25,403 28,052 (2,649) Property, plant and equipment 353,948 353,696 252
Total Assets $886,149 $899,217 ($13,068)
Liabilities and Net position Accounts payable $31,299 $30,251 $1,048 Other liabilities 94,998 81,428 13,570 Net pension liability 68,592 101,203 (32,611) Long-term debt 346,264 353,808 (7,544) Premium on LTD, net 19,094 19,764 (670) Long-term value of swap 30,297 30,728 (431) Net position 295,605 282,035 13,570
Total Liabilities and Net position $886,149 $899,217 ($13,068)
page 7 Page 73 of 294 Halifax Health Statement of Cash Flows ($ in thousands)
Month Month Three Months Three Months ended ended ended ended December 31, 2017 December 31, 2016 Variance December 31, 2017 December 31, 2016 Variance Cash flows from operating activities: $42,307 $38,949 $3,358 Receipts from third party payors and patients $123,993 $120,023 $3,970 (22,445) (29,855) 7,410 Payments to employees (92,775) (95,028) 2,253 (15,358) (16,016) 658 Payments to suppliers (57,132) (47,692) (9,440) 144 6,376 (6,232) Receipt of ad valorem taxes 306 8,785 (8,479) 6,822 3,583 3,239 Other receipts 9,257 8,953 304 (3,768) (3,158) (610) Other payments (11,144) (10,260) (884) 7,702 (121) 7,823 Net cash provided by (used in) operating activities (27,495) (15,219) (12,276)
Cash flows from noncapital financing activities: 170 13 157 Proceeds from donations received 236 150 86 - 2 (2) Nonoperating gain (loss) - 2 (2) 170 15 155 Net cash provided by noncapital financing activities 236 152 84
Cash flows from capital and related financing activities: (2,285) (307) (1,978) Acquisition of capital assets (5,634) (3,347) (2,287) (201) (195) (6) Payment of long-term debt (602) (585) (17) (6,622) (6,692) 70 Payment of interest on long-term debt (7,299) (7,430) 131 (9,108) (7,194) (1,914) Net cash used in capital financing activities (13,535) (11,362) (2,173)
Cash flows from investing activities: 1,141 1,550 (409) Realized investment income (loss) 1,991 2,405 (414) (1,848) (4,790) 2,942 Purchases of investments/limited use assets (2,818) (5,770) 2,952 - 2,506 (2,506) Sales/Maturities of investments/limited use assets 20 2,534 (2,514)
(707) (734) 27 Net cash provided by (used in) investing activities (807) (831) 24
(1,943) (8,034) 6,091 Net decrease in cash and cash equivalents (41,601) (27,260) (14,341)
23,765 39,347 (15,582) Cash and cash equivalents at beginning of period 63,423 58,573 4,850 $21,822 $31,313 ($9,491) Cash and cash equivalents at end of period $21,822 $31,313 ($9,491)
page 8 Page 74 of 294 Halifax Health Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Actual Favorable Actual Actual Favorable Month Ended Month Ended (Unfavorable) Three Months Three Months (Unfavorable) December 31, 2017 December 31, 2016 Variance December 31, 2017 December 31, 2016 Variance
Operating revenues: $49,454 $52,162 ($2,708) Net patient service revenue, before provision for bad debts $156,034 $148,191 $7,843 (7,163) (12,180) 5,017 Provision for bad debts (29,858) (27,186) (2,672) 42,291 39,982 2,309 Net patient service revenue 126,176 121,005 5,171 504 938 (434) Ad valorem taxes 1,512 2,813 (1,301) 2,433 2,316 117 Other revenue 7,937 6,674 1,263 45,228 43,236 1,992 Total operating revenues 135,625 130,492 5,133
Operating expenses: 22,788 21,967 (821) Salaries and benefits 68,199 69,154 955 6,983 6,147 (836) Purchased services 20,368 17,990 (2,378) 7,850 8,069 219 Supplies 24,125 23,781 (344) 2,113 1,955 (158) Depreciation and amortization 6,332 5,994 (338) 1,401 1,405 4 Interest 4,170 4,259 89 563 614 51 Ad valorem tax related expenses 1,732 1,841 109 791 719 (72) Leases and rentals 2,402 2,143 (259) 2,362 1,920 (442) Other 7,029 6,467 (562) 44,851 42,796 (2,055) Total operating expenses 134,357 131,629 (2,728)
377 440 (63) Excess (deficiency) of operating revenues over expenses 1,268 (1,137) 2,405
Nonoperating revenues, expenses, and gains/(losses): 1,141 1,550 (409) Realized investment income/(losses) 1,992 2,406 (414) (677) (916) 239 Unrealized investment income/(losses) 482 (2,066) 2,548 170 13 157 Donation revenue 235 151 84 634 650 (16) Total nonoperating revenues, expenses, and gains/(losses) 2,709 494 2,215
1,011 1,090 (79) Increase (decrease) in net position before other changes in net position 3,977 (643) 4,620
Other changes in net position: - Change in accounting - post employement benefits other than pension(1) (21,099) - (21,099) - - - Total other changes in net position (21,099) - (21,099)
$1,011 $1,090 ($79) Increase (decrease) in net position ($17,122) ($643) ($16,479)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 9 Page 75 of 294 Halifax Health Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Three Months Ended Three Months Ended (Unfavorable) December 31, 2017 December 31, 2017 Variance December 31, 2017 December 31, 2017 Variance
Operating revenues: $49,454 $50,794 ($1,340) Net patient service revenue, before provision for bad debts $156,034 $152,281 $3,753 (7,163) (8,009) 846 Provision for bad debts (29,858) (23,885) (5,973) 42,291 42,785 (494) Net patient service revenue 126,176 128,396 (2,220) 504 504 - Ad valorem taxes 1,512 1,512 - 2,433 2,165 268 Other revenue 7,937 6,522 1,415 45,228 45,454 (226) Total operating revenues 135,625 136,430 (805)
Operating expenses: 22,788 24,101 1,313 Salaries and benefits 68,199 72,398 4,199 6,983 6,198 (785) Purchased services 20,368 18,443 (1,925) 7,850 8,130 280 Supplies 24,125 24,014 (111) 2,113 2,007 (106) Depreciation and amortization 6,332 6,020 (312) 1,401 1,394 (7) Interest 4,170 4,183 13 563 547 (16) Ad valorem tax related expenses 1,732 1,670 (62) 791 806 15 Leases and rentals 2,402 2,414 12 2,362 2,352 (10) Other 7,029 7,053 24 44,851 45,535 684 Total operating expenses 134,357 136,195 1,838
377 (81) 458 Excess (deficiency) of operating revenues over expenses 1,268 235 1,033
Nonoperating revenues, expenses, and gains/(losses): 1,141 365 776 Realized investment income/(losses) 1,992 1,097 895 (677) (2) (675) Unrealized investment income/(losses) 482 (5) 487 170 58 112 Donation revenue 235 173 62 634 421 213 Total nonoperating revenues, expenses, and gains/(losses) 2,709 1,265 1,444
1,011 340 671 Increase in net position before other changes in net position 3,977 1,500 2,477
Other changes in net position: - - - Change in accounting - post employement benefits other than pension(1) (21,099) - (21,099) - - - Total other changes in net position (21,099) - (21,099)
$1,011 $340 $671 Increase (decrease) in net position ($17,122) $1,500 ($18,622)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 10 Page 76 of 294 Halifax Health Medical Center Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Three Months Ended Three Months Ended (Unfavorable) December 31, 2017 December 31, 2017 Variance December 31, 2017 December 31, 2017 Variance
Operating revenues: $45,551 $47,157 ($1,606) Net patient service revenue, before provision for bad debts $144,883 $141,536 $3,347 (7,003) (7,922) 919 Provision for bad debts (29,504) (23,624) (5,880) 38,548 39,235 (687) Net patient service revenue 115,379 117,912 (2,533) 504 504 - Ad valorem taxes 1,512 1,512 - 1,531 1,392 139 Other revenue 4,899 4,206 693 40,583 41,131 (548) Total operating revenues 121,790 123,630 (1,840)
Operating expenses: 20,787 22,009 1,222 Salaries and benefits 62,178 66,119 3,941 5,717 5,097 (620) Purchased services 16,852 15,178 (1,674) 7,643 7,904 261 Supplies 23,530 23,344 (186) 1,982 1,881 (101) Depreciation and amortization 5,940 5,642 (298) 1,396 1,389 (7) Interest 4,154 4,167 13 563 547 (16) Ad valorem tax related expenses 1,732 1,670 (62) 610 633 23 Leases and rentals 1,864 1,900 36 2,171 2,120 (51) Other 6,447 6,360 (87) 40,869 41,580 711 Total operating expenses 122,697 124,380 1,683
(286) (449) 163 Deficiency of operating revenues over expenses (907) (750) (157)
Nonoperating revenues, expenses, and gains/(losses): 53 180 (127) Realized investment income/(losses) 792 541 251 (118) (2) (116) Unrealized investment income/(losses) (372) (5) (367) 9 - 9 Donation revenue 8 - 8 (56) 178 (234) Total nonoperating revenues, expenses, and gains/(losses) 428 536 (108)
(342) (271) (71) Decrease in net position before other changes in net position (479) (214) (265)
Other changes in net position: - - - Change in accounting - post employement benefits other than pension(1) (19,962) - (19,962) - - - Total other changes in net position (19,962) - (19,962)
($342) ($271) ($71) Decrease in net position ($20,441) ($214) ($20,227)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 11 Page 77 of 294 Halifax Health Medical Center Net Patient Service Revenue ($ in thousands) Actual Actual Static Budget Actual Actual Static Budget Month Ended Month Ended Month Ended Three Months Ended Three Months Ended Three Months Ended December 31, 2016 December 31, 2017 December 31, 2017 December 31, 2016 December 31, 2017 December 31, 2017
$146,311 100.00% $155,134 100.00% $159,829 100.00% Gross charges $439,597 100.00% $480,915 100.00% $477,242 100.00% (5,221) -3.57% (9,557) -6.16% (8,429) -5.27% Charity (24,894) -5.66% (28,028) -5.83% (25,107) -5.26% (92,371) -63.13% (100,026) -64.48% (104,243) -65.22% Contractual adjustments (276,319) -62.86% (308,004) -64.05% (310,599) -65.08% 48,719 33.30% 45,551 29.36% 47,157 29.50% Gross charges, before provision for bad debts 138,384 31.48% 144,883 30.13% 141,536 29.66% (12,073) -8.25% (7,003) -4.51% (7,922) -4.96% Provision for bad debts (26,925) -6.12% (29,504) -6.13% (23,624) -4.95% $36,646 25.05% $38,548 24.85% $39,235 24.55% Net patient service revenue $111,459 25.35% $115,379 23.99% $117,912 24.71%
page 12 Page 78 of 294 Halifax Health Hospice Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Three Months Ended Three Months Ended (Unfavorable) December 31, 2017 December 31, 2017 Variance December 31, 2017 December 31, 2017 Variance
Operating revenues: $3,903 $3,637 $266 Net patient service revenue, before provision for bad debts $11,151 $10,745 $406 (160) (87) (73) Provision for bad debts (354) (261) (93) 3,743 3,550 193 Net patient service revenue 10,797 10,484 313 179 199 (20) Other revenue 555 597 (42) 3,922 3,749 173 Total operating revenues 11,352 11,081 271
Operating expenses: 1,935 2,022 87 Salaries and benefits 5,816 6,069 253 1,229 1,058 (171) Purchased services 3,402 3,138 (264) 207 225 18 Supplies 595 667 72 64 59 (5) Depreciation and amortization 192 178 (14) 176 168 (8) Leases and rentals 523 499 (24) 176 161 (15) Other 498 480 (18) 3,787 3,693 (94) Total operating expenses 11,026 11,031 5
135 56 79 Excess of operating revenues over expenses 326 50 276
Nonoperating revenues, expenses, and gains/(losses): 1,088 185 903 Realized investment income/(losses) 1,200 556 644 (559) - (559) Unrealized investment income/(losses) 854 - 854 161 58 103 Donation revenue 227 173 54 690 243 447 Total nonoperating revenues, expenses, and gains/(losses) 2,281 729 1,552
825 299 526 Increase in net position before other changes in net position 2,607 779 1,828
Other changes in net position: - - - Change in accounting - post employement benefits other than pension (1) (1,137) - (1,137) - - - Total other changes in net position (1,137) - (1,137)
$825 $299 $526 Increase in net position $1,470 $779 $691
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 13 Page 79 of 294 Volusia Health Network / Halifax Management Systems Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Three Months Ended Three Months Ended (Unfavorable) December 31, 2017 December 31, 2017 Variance December 31, 2017 December 31, 2017 Variance
Operating revenues: $0 $0 $0 Net patient service revenue, before provision for bad debts $0 $0 $0 - - - Provision for bad debts ------Net patient service revenue - - - 350 352 (2) Other revenue 1,051 1,055 (4) 350 352 (2) Total operating revenues 1,051 1,055 (4)
Operating expenses: 56 60 4 Salaries and benefits 175 179 4 36 39 3 Purchased services 112 116 4 - 1 1 Supplies - 3 3 67 67 - Depreciation and amortization 200 200 - 5 5 - Interest 16 16 - 5 5 - Leases and rentals 15 15 - 1 4 3 Other 2 12 10 170 181 11 Total operating expenses 520 541 21
180 171 9 Excess of operating revenues over expenses 531 514 17
Nonoperating revenues, expenses, and gains/(losses): - - - Realized investment income/(losses) ------Unrealized investment income/(losses) ------Donation revenue ------Nonoperating gains/(losses), net ------Total nonoperating revenues, expenses, and gains/(losses) - - -
$180 $171 $9 Increase in net position $531 $514 $17
page 14 Page 80 of 294 Halifax Health Foundation Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Three Months Ended Three Months Ended (Unfavorable) December 31, 2017 December 31, 2017 Variance December 31, 2017 December 31, 2017 Variance
Operating revenues: $0 $0 $0 Net patient service revenue, before provision for bad debts $0 $0 $0 - - - Provision for bad debts ------Net patient service revenue - - - 709 114 595 Realized investment income/(losses) 781 341 440 (390) - (390) Unrealized investment income/(losses) 380 - 380 54 108 (54) Donation revenue 271 323 (52) - - - Other revenue - - - 373 222 151 Total operating revenues 1,432 664 768
Operating expenses: 10 10 - Salaries and benefits 30 31 1 1 4 3 Purchased services 2 11 9 - - - Supplies ------Depreciation and amortization ------Interest ------Leases and rentals - - - 14 67 53 Other 82 201 119 25 81 56 Total operating expenses 114 243 129
$348 $141 $207 Increase in net position $1,318 $421 $897
page 15 Page 81 of 294 Halifax Health Medical Center (Obligated Group) Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Three Months Ended Three Months Ended (Unfavorable) December 31, 2017 December 31, 2017 Variance December 31, 2017 December 31, 2017 Variance
Operating revenues: $45,551 $47,157 ($1,606) Net patient service revenue, before provision for bad debts $144,883 $141,536 $3,347 (7,003) (7,922) 919 Provision for bad debts (29,504) (23,624) (5,880) 38,548 39,235 (687) Net patient service revenue 115,379 117,912 (2,533) 504 504 - Ad valorem taxes 1,512 1,512 - 1,531 1,392 139 Other revenue 4,899 4,206 693 40,583 41,131 (548) Total operating revenues 121,790 123,630 (1,840)
Operating expenses: 20,787 22,009 1,222 Salaries and benefits 62,178 66,119 3,941 5,717 5,097 (620) Purchased services 16,852 15,178 (1,674) 7,643 7,904 261 Supplies 23,530 23,344 (186) 1,982 1,881 (101) Depreciation and amortization 5,940 5,642 (298) 1,396 1,389 (7) Interest 4,154 4,167 13 563 547 (16) Ad valorem tax related expenses 1,732 1,670 (62) 610 633 23 Leases and rentals 1,864 1,900 36 2,171 2,120 (51) Other 6,447 6,360 (87) 40,869 41,580 711 Total operating expenses 122,697 124,380 1,683
(286) (449) 163 Deficiency of operating revenues over expenses (907) (750) (157)
Nonoperating revenues, expenses, and gains/(losses): 53 180 (127) Realized investment income/(losses) 792 541 251 (118) (2) (116) Unrealized investment income/(losses) (372) (5) (367) 9 - 9 Donation revenue 8 - 8 1,353 611 742 Income from affiliates 3,319 1,714 1,605 1,297 789 508 Total nonoperating revenues, expenses, and gains/(losses) 3,747 2,250 1,497
1,011 340 671 Increase in net position before other changes in net position 2,840 1,500 1,340
Other changes in net position: - - - Change in accounting - post employement benefits other than pension (1) (19,962) - (19,962) - - - Total other changes in net position (19,962) - (19,962)
$1,011 $340 $671 Increase (decrease) in net position ($17,122) $1,500 ($18,622)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 16 Page 82 of 294 Halifax Health Financial Summary - Graphic
HH Total Margin (Cumulative YTD Basis) (desired trend - increasing) 8.0%
6.0%
4.0%
2.0%
0.0%
-2.0%
-4.0% Margin -6.0%
-8.0%
-10.0%
-12.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
HH Operating Margin (Cumulative YTD Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 6.0%
4.0%
2.0%
0.0% Margin -2.0%
-4.0%
-6.0%
-8.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
page 17 Page 83 of 294 Halifax Health Financial Summary - Graphic
HH EBIDA Margin (Cumulative YTD Basis) (desired trend - increasing) 14.0%
12.0%
10.0%
8.0%
6.0%
4.0% Margin 2.0%
0.0%
-2.0%
-4.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
HH Adjusted Operating EBIDA Margin (Cumulative YTD Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 12.0%
10.0%
8.0%
6.0%
Margin 4.0%
2.0%
0.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget FY17
page 18 Page 84 of 294 Halifax Health Financial Summary - Graphic
HH MADS Coverage Ratio (Annualized Basis) (Excludes unrealized investment gains/losses in accordance with covenant requirements) (desired trend - increasing) 5.0
2.5 Ratio
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" FY17
HH MADS Coverage Ratio - Operations Only (Annualized Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 5.0 Ratio 2.5
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" FY17
page 19 Page 85 of 294 Halifax Health Financial Summary - Graphic
HHMC Obligated Group MADS Coverage Ratio (Annualized Basis) (Excludes unrealized investment gains/losses in accordance with covenant requirements) (desired trend - increasing) 5.0
2.5 Ratio
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" Bond Covenant FY17
HHMC Obligated Group MADS Coverage Ratio - Operations Only (Annualized Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 5.0
Ratio 2.5
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" Bond Covenant FY17
page 20 Page 86 of 294 Halifax Health Financial Summary - Graphic
HH Days Cash on Hand (Annualized Basis) (desired trend - increasing)
400
350
300
250
200 Days
150
100
50
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
HH Cash/Debt (Monthly) (desired trend - increasing) 175.0%
150.0%
125.0%
100.0%
75.0%
50.0% Cash/Long-Term Debt Cash/Long-Term
25.0%
0.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
page 21 Page 87 of 294 Halifax Health Financial Summary - Graphic
HH Debt to Capitalization (Monthly) (desired trend - decreasing) 80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
Debt to to Debt Capitalization 20.0%
10.0%
0.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
HH Days in A/R (Annualized Basis) (desired trend - decreasing) 60.0
50.0
40.0
30.0 Days
20.0
10.0
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
page 22 Page 88 of 294 Halifax Health Financial Summary - Graphic
HH Average Payment Period (Annualized Basis) (desired trend - decreasing) 100.0
90.0
80.0
70.0
60.0
50.0 Days 40.0
30.0
20.0
10.0
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 Budget FY17
HH Average Age of Plant (Annualized Basis) (desired trend - decreasing) 16.0
14.0
12.0
10.0 Years 8.0
6.0
4.0
2.0
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
page 23 Page 89 of 294 Halifax Health Financial Ratios and Operating Indicators Definitions and Calculations
Indicator Definition Calculation
Gauges the relative efficiency with which Net Income Total Margin * the System produces its output. Total Revenues
Gauges the relative efficiency excluding Net income + Int + Depr + Amort EBIDA Margin * capital costs with which the System Total Revenues produces its output.
Measures profitability relative to the MADS Coverage Net Income + Depr + Amort + Int Maximum Principal and Interest Ratio * Maximum Annual Debt Service Payment of Debt
Measures the number of days of average Days Cash on cash expenses that the System maintains Unrestricted Cash and Investments Hand in cash and cash equivalents and (Total Expenses - Depr) / Days in Period unrestricted investments.
Cash to Long-term Measures the percentage of unrestricted Unrestricted Cash and Investments Debt cash and investments to long-term debt. Long-term Debt
Long-term Debt to Measures the reliance on long-term debt Long-term Debt Capitalization financing and ability to issue new debt. Long-term Debt + Net Position
Measures the average time that Days in Accounts Accounts Receivable receivables are outstanding, or the Receivable Net Patient Service Revenue/ Days in Period average collection period.
Provides a measure of the average time Average Payment Current Liabilities that elapses before current liabilities are Period (Total Expenses - Depr) / Days in Period paid.
Average Age of Provides a measure of the average age in Accumulated Depreciation Plant years of the System's fixed assets. Depreciation Expense
Gauges the relative operating efficiency Excess of Operating Revenues Operating Margin with which the System produces its Total Operating Revenues + Bad Debt output.
Excludes realized and unrealized * Operations Only investment income, donations, and Indicators nonoperating gains and losses
page 24 Page 90 of 294
Halifax Health Summary Financial Narrative For the four months ended January 31, 2018
The performance of Halifax Health (HH) compared to budget and long-range targets (S&P “A” rated medians) for key financial indicators is as follows. YTD YTD YTD Actual YTD Actual vs. Financial Indicator Actual Budget S&P "A" FY 18 vs. Budget FY 18 FY 18 S&P "A" Total Margin 4.9% 2.4% Favorable 5.8% Unfavorable Operating Margin 2.7% 1.5% Favorable 3.6% Unfavorable EBIDA Mar gin 12.3% 9.6% Favorable 13.1% Unfavorable Operating EBIDA Margin 10.3% 8.8% Favorable 10.8% Unfavorable Adjusted Operating EBIDA Margin * 9.3% 8.6% Favorable N/A N/A Days Cash on Hand 247 258 Unfavorable 249 Unfavorable Cash to Debt 94.9% 102.8% Unfavorable 189.9% Unfavorable Debt to Capitalization 54.8% 53.3% Unfavorable 29.1% Unfavorable
OG MADS Coverage 2.36 2.13 Favorable 4.50 Unfavorable OG Debt to Capitalization 53.9% 52.9% Unfavorable 29.1% Unfavorable
* -Excludes investment income/loss of Foundation recorded as operating income. Halifax Health Medical Center Statistical Summary-- • Admissions for the month and fiscal year-to-date are greater than budget and last year. • Patient days for the month and fiscal year-to-date are less than budget and last year. o Observation patient days for the month and fiscal year-to-date are greater than budget and last year. • Surgery volumes for the month are greater than budget and less than last year; and for the fiscal year- to-date are greater than budget and last year. • Emergency Room visits for the month and fiscal year-to-date are greater than budget and last year. Financial Summary -- • Net patient service revenue for the fiscal year-to-date is 1.5% less than budget. • Total operating expenses for the fiscal year-to-date are 1.4% less than budget. • Income from operations for the fiscal year-to-date of $1.7 million compares favorably to budget by $278,000. • Nonoperating gains/losses for the fiscal year-to-date of $232,000, primarily consisting of investment income, compares unfavorably to the budgeted amount by $482,000. • The increase in net position for the fiscal year-to-date of $2.0 million compares unfavorably to budget by $204,000. Halifax Health Hospice Statistical Summary – • Patient days for the month and fiscal year-to-date are greater than budget and last year. Financial Summary -- • Net patient service revenue for the fiscal year-to-date is 3.2% greater than budget. • Income from operations for the fiscal year-to-date of $412,000 compares favorably to budget by $301,000. • Nonoperating gains/losses for the fiscal year-to-date of $4.4 million, primarily consisting of investment income, compares favorably to the budgeted amount by $3.3 million. • The increase in net position for the fiscal year-to-date of $3.2 million compares favorably to budget by $2.2 million.
Other Component Units - The financial performance is consistent with budgeted expectations. Page 91 of 294 Halifax Health Statistical Summary
Month Ended Four Months Ended January 31, January 31, 2017 2018 Budget Var. 2017 2018 Budget Var.
Inpatient Activity
1,698 1,684 1,778 -5.3% HHMC Adult/Ped Admissions 6,332 6,418 6,443 -0.4% 158 217 167 29.9% HHMCPO Adult/Ped Admissions 564 691 619 11.6% 166 219 171 28.1% Adult Psych Admissions 629 760 634 19.9% 74 74 74 0.0% Rehabilitative Admissions 260 257 244 5.3% 2,096 2,194 2,190 0.2% Total Adult/Ped Admissions 7,785 8,126 7,940 2.3%
9,036 8,378 8,568 -2.2% HHMC Adult/Ped Patient Days 34,491 31,615 31,045 1.8% 838 701 711 -1.4% HHMCPO Adult/Ped Patient Days 3,189 2,673 2,640 1.3% 1,590 1,552 1,691 -8.2% Adult Psych Patient Days 6,015 5,470 6,284 -13.0% 1,073 1,038 1,067 -2.7% Rehabilitative Patient Days 3,601 3,750 3,572 5.0% 12,537 11,669 12,037 -3.1% Total Adult/Ped Patient Days 47,296 43,508 43,541 -0.1%
5.3 5.0 4.8 3.2% HHMC Average Length of Stay 5.4 4.9 4.8 2.2% 5.3 3.2 4.3 -24.1% HHMCPO Average Length of Stay 5.7 3.9 4.3 -9.3% 5.3 4.8 4.8 0.1% HHMC/ HHMCPO Average Length of Stay 5.5 4.8 4.8 1.1% 9.6 7.1 9.9 -28.3% Adult Psych Average Length of Stay 9.6 7.2 9.9 -27.4% 14.5 14.0 14.4 -2.7% Rehabilitative Length of Stay 13.9 14.6 14.6 -0.3% 6.0 5.3 5.5 -3.2% Total Average Length of Stay 6.1 5.4 5.5 -2.4%
404 376 388 -3.1% Total Average Daily Census 385 354 354 -0.1%
906 1,110 806 37.7% HHMC Observation Patient Day Equivalents 3,561 3,561 3,078 15.7% 245 235 190 23.7% HHMCPO Observation Patient Day Equivalents 693 707 710 -0.4% 1,151 1,345 996 35.0% Total Observation Patient Day Equivalents 4,254 4,268 3,788 12.7%
37 43 32 34.4% Observation Average Daily Census 35 35 31 12.9%
145 139 153 -9.2% HHMC Newborn Births 594 574 633 -9.3% 284 283 306 -7.5% HHMC Nursery Patient Days 1,116 1,041 1,208 -13.8%
452 473 475 -0.4% HHMC Inpatient Surgeries 1,798 1,930 1,829 5.5% 4 8 3 166.7% HHMCPO Inpatient Surgeries 13 35 12 191.7% 456 481 478 0.6% Total Inpatient Surgeries 1,811 1,965 1,841 6.7%
Inpatient Surgeries 177 154 Orthopedics 699 657 78 66 General Surgery 298 271 46 34 Neurosurgery 173 131 24 30 Thoracic Surgery 91 127 30 45 Vascular 102 132 101 152 All Other 448 647 456 481 478 0.6% Total Inpatient Surgeries 1,811 1,965 1,841 6.7%
page 2 Page 92 of 294 Halifax Health Statistical Summary
Month Ended Four Months Ended January 31, January 31, 2017 2018 Budget Var. 2017 2018 Budget Var.
Outpatient Activity
6,980 7,333 7,043 4.1% HHMC ED Registrations 26,934 27,906 27,189 2.6% 2,718 3,147 2,726 15.4% HHMCPO ED Registrations 10,219 11,110 10,250 8.4% 0 1,729 1,271 36.0% Deltona ED Registrations 0 5,673 5,043 12.5% 9,698 12,209 11,040 10.6% Total ED 37,153 44,689 42,482 5.2%
428 364 369 -1.4% HHMC Outpatient Surgeries 1,660 1,455 1,537 -5.3% 68 0 0 0.0% HPC Outpatient Surgeries 247 1 0 0.0% 3 114 110 3.6% HHMCPO Outpatient Surgeries 3 485 437 11.0% 365 315 308 2.3% Twin Lakes Surgeries 1,416 1,317 1,248 5.5% 864 793 787 0.8% Total Outpatient Surgeries 3,326 3,258 3,222 1.1%
Outpatient Surgeries 187 141 General Surgery 743 628 181 125 Orthopedics 656 533 65 84 Gastroenterology 296 398 63 77 Obstetrics Gynecology 290 294 61 51 Ophthalmology 227 266 307 315 All Other 1,114 1,139 864 793 787 0.8% Total Outpatient Surgeries 3,326 3,258 3,222 1.1%
Cardiology Procedures 25 21 Open Heart Cases 70 82 139 155 Cardiac Caths 505 645 28 37 CRM Devices 132 129 37 54 EP Studies 167 180 229 267 274 -2.6% Total Cardiology Procedures 874 1,036 948 9.3%
Interventional Radiology Procedures 7 11 8 37.5% Vascular 24 35 28 25.0% 180 192 185 3.8% Nonvascular 634 647 653 -0.9% 187 203 193 5.2% Total Interventional Radiology Procedures 658 682 681 0.1%
213 217 205 5.9% GI Procedures 803 875 743 17.8%
HH Hospice Activity Patient Days 15,848 16,206 15,501 4.5% Volusia/ Flagler 61,256 65,639 61,505 6.7% 900.0 1,278 1,409 -9.3% Orange/ Osceola 3,509.0 5,610 5,257 6.7% 16,748 17,484 16,910 3.4% HH Hospice Patient Days 64,765 71,249 66,762 6.7%
Average Daily Census 511 523 500 4.5% Volusia/ Flagler 498 534 500 6.7% 29 41 45 -9.3% Orange/ Osceola 29 46 43 6.7% 540 564 545 3.4% HH Hospice Average Daily Census 527 579 543 6.7%
page 3 Page 93 of 294 Halifax Health Statistical Summary
Month Ended Four Months Ended January 31, January 31, 2017 2018 Budget Var. 2017 2018 Budget Var.
Physician Practice Activity
Primary Care Visits 258 447 280 59.6% Ormond Beach 1,092 1,638 1,077 52.1% 1,019 1,149 1,051 9.3% Daytona Beach 4,079 4,451 4,207 5.8% 698 727 638 13.9% Port Orange 2,728 3,258 2,514 29.6% 337 235 695 -66.2% Deltona 1,241 1,141 2,560 -55.4% - 896 800 12.0% New Smyrna - 3,512 3,200 9.7% 484 610 476 28.2% Ormond Beach (Women's/OB) 1,858 2,398 1,889 26.9% - 578 876 -34.0% Ormond Beach - Urgent Care - 1,591 3,476 -54.2% 2,796 4,642 4,816 -3.6% Primary Care Visits 10,998 17,989 18,923 -4.9%
Children's Medical Center Visits 943 610 827 -26.2% Ormond Beach 3,626 2,393 3,522 -32.1% - 448 288 55.6% Palm Coast 293 1,411 1,287 9.6% 530 528 741 -28.7% Port Orange 1,971 1,983 2,755 -28.0% 1,473 1,586 1,856 -14.5% Children's Medical Center Visits 5,890 5,787 7,564 -23.5%
Community Clinic Visits 394 234 404 -42.1% Keech Street 1,508 1,249 1,547 -19.3% 263 - - 0.0% Adult Community Clinic 960 92 75 22.7% 657 234 404 -42.1% Community Clinic Visits 2,468 1,341 1,622 -17.3%
page 4 Page 94 of 294 Halifax Health Statistical Summary - Graphic
HHMC Average Daily Census (Monthly)
440
400
360
320
280
240
200 Patients 160
120
80
40
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 - HHMCPO FY18 - HHMC FY17 Budget
ED Visits (Monthly)
14,000
12,000
10,000
8,000 Visits
6,000
4,000
2,000
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 - Deltona FY18 - HHMCPO FY18 - HHMC FY17 Budget
page 5 Page 95 of 294 Halifax Health Statistical Summary - Graphic
Surgeries (Monthly)
1,600
1,400
1,200
1,000
800
Surgeries 600
400
200
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 - Twin Lakes FY18 - HHMCPO FY18 - HHMC FY17 Budget
Hospice Average Daily Census (Monthly)
700
600
500
400 Patients 300
200
100
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 ORL FY18 V/F FY17 Budget Budget wo Orlando Market
page 6 Page 96 of 294 Halifax Health Condensed Statement of Net Position ($ in thousands)
January 31, 2018 2017 Change Assets Cash and cash equivalents $26,768 $34,599 ($7,831) Investments 274,633 270,191 4,442 Board designated assets 45,038 44,744 294 Accounts receivable 64,416 63,565 851 Restricted assets whose use is limited 6,412 19,152 (12,740) Other assets 43,593 43,863 (270) Deferred outflow - swap 30,297 30,367 (70) Deferred outflow - loss on bond refunding 16,147 17,071 (924) Deferred outflow - pension 28,272 27,979 293 Property, plant and equipment 355,418 353,362 2,056
Total Assets $890,994 $904,893 ($13,899)
Liabilities and Net position Accounts payable $29,740 $31,029 ($1,289) Other liabilities 92,726 84,226 8,500 Deferred inflow - pension 3,290 - 3,290 Net pension liability 68,909 101,831 (32,922) Long-term debt 346,063 353,612 (7,549) Premium on LTD, net 19,038 19,708 (670) Long-term value of swap 30,297 30,367 (70) Net position 300,931 284,120 16,811
Total Liabilities and Net position $890,994 $904,893 ($13,899)
page 7 Page 97 of 294 Halifax Health Statement of Cash Flows ($ in thousands)
Month Month Four Months Four Months ended ended ended ended January 31, 2018 January 31, 2017 Variance January 31, 2018 January 31, 2017 Variance Cash flows from operating activities: $47,489 $40,790 $6,699 Receipts from third party payors and patients $171,482 $160,813 $10,669 (21,086) (21,092) 6 Payments to employees (113,861) (116,120) 2,259 (17,279) (14,162) (3,117) Payments to suppliers (74,411) (61,854) (12,557) 314 647 (333) Receipt of ad valorem taxes 620 9,432 (8,812) 3,183 2,867 316 Other receipts 12,440 11,820 620 (3,617) (3,631) 14 Other payments (14,761) (13,891) (870) 9,004 5,419 3,585 Net cash provided by (used in) operating activities (18,491) (9,800) (8,691)
Cash flows from noncapital financing activities: 36 55 (19) Proceeds from donations received 272 205 67 (7) - (7) Nonoperating gain (loss) (7) 2 (9) 29 55 (26) Net cash provided by noncapital financing activities 265 207 58
Cash flows from capital and related financing activities: (3,478) (1,617) (1,861) Acquisition of capital assets (9,112) (4,964) (4,148) (201) (195) (6) Payment of long-term debt (803) (780) (23) (348) (347) (1) Payment of interest on long-term debt (7,647) (7,777) 130 (4,027) (2,159) (1,868) Net cash used in capital financing activities (17,562) (13,521) (4,041)
Cash flows from investing activities: 242 234 8 Realized investment income (loss) 2,233 2,639 (406) (306) (268) (38) Purchases of investments/limited use assets (3,124) (6,038) 2,914 4 5 (1) Sales/Maturities of investments/limited use assets 24 2,539 (2,515)
(60) (29) (31) Net cash provided by (used in) investing activities (867) (860) (7)
4,946 3,286 1,660 Net increase (decrease) in cash and cash equivalents (36,655) (23,974) (12,681)
21,822 31,313 (9,491) Cash and cash equivalents at beginning of period 63,423 58,573 4,850 $26,768 $34,599 ($7,831) Cash and cash equivalents at end of period $26,768 $34,599 ($7,831)
page 8 Page 98 of 294 Halifax Health Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Actual Favorable Actual Actual Favorable Month Ended Month Ended (Unfavorable) Four Months Ended Four Months Ended (Unfavorable) January 31, 2018 January 31, 2017 Variance January 31, 2018 January 31, 2017 Variance
Operating revenues: $55,174 $47,259 $7,915 Net patient service revenue, before provision for bad debts $211,207 $195,450 $15,757 (7,960) (4,723) (3,237) Provision for bad debts (37,818) (31,909) (5,909) 47,214 42,536 4,678 Net patient service revenue 173,389 163,541 9,848 504 938 (434) Ad valorem taxes 2,016 3,751 (1,735) 2,686 2,380 306 Other revenue 10,624 9,054 1,570 50,404 45,854 4,550 Total operating revenues 186,029 176,346 9,683
Operating expenses: 23,845 23,589 (256) Salaries and benefits 92,044 92,743 699 6,761 6,416 (345) Purchased services 27,130 24,406 (2,724) 8,787 8,107 (680) Supplies 32,912 31,888 (1,024) 2,114 1,950 (164) Depreciation and amortization 8,446 7,944 (502) 1,394 1,406 12 Interest 5,564 5,665 101 517 634 117 Ad valorem tax related expenses 2,249 2,475 226 802 771 (31) Leases and rentals 3,205 2,914 (291) 2,349 2,228 (121) Other 9,379 8,695 (684) 46,569 45,101 (1,468) Total operating expenses 180,929 176,730 (4,199)
3,835 753 3,082 Excess (deficiency) of operating revenues over expenses 5,100 (384) 5,484
Nonoperating revenues, expenses, and gains/(losses): 242 235 7 Realized investment income/(losses) 2,234 2,640 (406) 1,223 1,043 180 Unrealized investment income/(losses) 1,705 (1,023) 2,728 36 55 (19) Donation revenue 271 206 65 1,494 1,333 161 Total nonoperating revenues, expenses, and gains/(losses) 4,203 1,826 2,377
5,329 2,086 3,243 Increase in net position before other changes in net position 9,303 1,442 7,861
Other changes in net position: - - - Change in accounting - post employement benefits other than pension (1) (21,099) - (21,099) - - - Total other changes in net position (21,099) - (21,099)
$5,329 $2,086 $3,243 Increase (decrease) in net position ($11,796) $1,442 ($13,238)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 9 Page 99 of 294 Halifax Health Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Four Months Ended Four Months Ended (Unfavorable) January 31, 2018 January 31, 2018 Variance January 31, 2018 January 31, 2018 Variance
Operating revenues: $55,174 $55,355 ($181) Net patient service revenue, before provision for bad debts $211,207 $207,637 $3,570 (7,960) (8,353) 393 Provision for bad debts (37,818) (32,236) (5,582) 47,214 47,002 212 Net patient service revenue 173,389 175,401 (2,012) 504 504 - Ad valorem taxes 2,016 2,016 - 2,686 2,169 517 Other revenue 10,624 8,690 1,934 50,404 49,675 729 Total operating revenues 186,029 186,107 (78)
Operating expenses: 23,845 25,068 1,223 Salaries and benefits 92,044 97,469 5,425 6,761 6,404 (357) Purchased services 27,130 24,847 (2,283) 8,787 8,532 (255) Supplies 32,912 32,545 (367) 2,114 2,007 (107) Depreciation and amortization 8,446 8,026 (420) 1,394 1,393 (1) Interest 5,564 5,576 12 517 523 6 Ad valorem tax related expenses 2,249 2,193 (56) 802 806 4 Leases and rentals 3,205 3,220 15 2,349 2,352 3 Other 9,379 9,407 28 46,569 47,085 516 Total operating expenses 180,929 183,283 2,354
3,835 2,590 1,245 Excess of operating revenues over expenses 5,100 2,824 2,276
Nonoperating revenues, expenses, and gains/(losses): 242 365 (123) Realized investment income/(losses) 2,234 1,462 772 1,223 (2) 1,225 Unrealized investment income/(losses) 1,705 (7) 1,712 36 58 (22) Donation revenue 271 231 40 1,494 421 1,073 Total nonoperating revenues, expenses, and gains/(losses) 4,203 1,686 2,517
5,329 3,011 2,318 Increase in net position before other changes in net position 9,303 4,510 4,793
Other changes in net position: - - - Change in accounting - post employement benefits other than pension(1) (21,099) - (21,099) - - - Total other changes in net position (21,099) - (21,099)
$5,329 $3,011 $2,318 Increase (decrease) in net position ($11,796) $4,510 ($16,306)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 10 Page 100 of 294 Halifax Health Medical Center Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Four Months Ended Four Months Ended (Unfavorable) January 31, 2018 January 31, 2018 Variance January 31, 2018 January 31, 2018 Variance
Operating revenues: $51,387 $51,696 ($309) Net patient service revenue, before provision for bad debts $196,269 $193,233 $3,036 (7,883) (8,265) 382 Provision for bad debts (37,387) (31,888) (5,499) 43,504 43,431 73 Net patient service revenue 158,882 161,345 (2,463) 504 504 - Ad valorem taxes 2,016 2,016 - 1,171 1,396 (225) Other revenue 6,070 5,602 468 45,179 45,331 (152) Total operating revenues 166,968 168,963 (1,995)
Operating expenses: 21,742 22,964 1,222 Salaries and benefits 83,920 89,083 5,163 5,533 5,300 (233) Purchased services 22,385 20,478 (1,907) 8,600 8,305 (295) Supplies 32,130 31,649 (481) 1,983 1,881 (102) Depreciation and amortization 7,924 7,523 (401) 1,390 1,389 (1) Interest 5,544 5,556 12 517 523 6 Ad valorem tax related expenses 2,249 2,193 (56) 627 633 6 Leases and rentals 2,492 2,533 41 2,132 2,120 (12) Other 8,579 8,481 (98) 42,524 43,115 591 Total operating expenses 165,223 167,496 2,273
2,655 2,216 439 Excess of operating revenues over expenses 1,745 1,467 278
Nonoperating revenues, expenses, and gains/(losses): 173 180 (7) Realized investment income/(losses) 965 721 244 (359) (2) (357) Unrealized investment income/(losses) (731) (7) (724) (3) - (3) Donation revenue 5 - 5 (196) 178 (374) Total nonoperating revenues, expenses, and gains/(losses) 232 714 (482)
2,459 2,394 65 Increase in net position before other changes in net position 1,977 2,181 (204)
Other changes in net position: - - - Change in accounting - post employement benefits other than pension(1) (19,962) - (19,962) - - - Total other changes in net position (19,962) - (19,962)
$2,459 $2,394 $65 Increase (decrease) in net position ($17,985) $2,181 ($20,166)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 11 Page 101 of 294 Halifax Health Medical Center Net Patient Service Revenue ($ in thousands) Actual Actual Static Budget Actual Actual Static Budget Month Ended Month Ended Month Ended Four Months Ended Four Months Ended Four Months Ended January 31, 2017 January 31, 2018 January 31, 2018 January 31, 2017 January 31, 2018 January 31, 2018
$156,818 100.00% $178,420 100.00% $170,260 100.00% Gross charges $596,415 100.00% $659,335 100.00% $647,502 100.00% (10,843) -6.91% (10,816) -6.06% (8,868) -5.21% Charity (35,737) -5.99% (38,845) -5.89% (33,975) -5.25% (102,134) -65.13% (116,217) -65.14% (109,696) -64.43% Contractual adjustments (378,453) -63.45% (424,221) -64.34% (420,294) -64.91% 43,841 27.96% 51,387 28.80% 51,696 30.36% Gross charges, before provision for bad debts 182,225 30.55% 196,269 29.77% 193,233 29.84% (4,529) -2.89% (7,883) -4.42% (8,265) -4.85% Provision for bad debts (31,454) -5.27% (37,387) -5.67% (31,888) -4.92% $39,312 25.07% $43,504 24.38% $43,431 25.51% Net patient service revenue $150,771 25.28% $158,882 24.10% $161,345 24.92%
page 12 Page 102 of 294 Halifax Health Hospice Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Four Months Ended Four Months Ended (Unfavorable) January 31, 2018 January 31, 2018 Variance January 31, 2018 January 31, 2018 Variance
Operating revenues: $3,787 $3,659 $128 Net patient service revenue, before provision for bad debts $14,938 $14,404 $534 (77) (88) 11 Provision for bad debts (431) (348) (83) 3,710 3,571 139 Net patient service revenue 14,507 14,056 451 188 199 (11) Other revenue 743 796 (53) 3,898 3,770 128 Total operating revenues 15,250 14,852 398
Operating expenses: 2,035 2,034 (1) Salaries and benefits 7,851 8,104 253 1,191 1,061 (130) Purchased services 4,593 4,199 (394) 187 226 39 Supplies 781 893 112 64 59 (5) Depreciation and amortization 256 237 (19) 170 168 (2) Leases and rentals 693 667 (26) 166 161 (5) Other 664 641 (23) 3,813 3,709 (104) Total operating expenses 14,838 14,741 (97)
85 61 24 Excess of operating revenues over expenses 412 111 301
Nonoperating revenues, expenses, and gains/(losses): 69 185 (116) Realized investment income/(losses) 1,269 741 528 1,582 - 1,582 Unrealized investment income/(losses) 2,436 - 2,436 39 58 (19) Donation revenue 266 231 35 1,690 243 1,447 Total nonoperating revenues, expenses, and gains/(losses) 3,971 972 2,999
1,775 304 1,471 Increase in net position before other changes in net position 4,383 1,083 3,300
Other changes in net position: - - - Change in accounting - post employement benefits other than pension (1) (1,137) - (1,137) - - - Total other changes in net position (1,137) - (1,137)
$1,775 $304 $1,471 Increase in net position $3,246 $1,083 $2,163
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 13 Page 103 of 294 Volusia Health Network / Halifax Management Systems Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Four Months Ended Four Months Ended (Unfavorable) January 31, 2018 January 31, 2018 Variance January 31, 2018 January 31, 2018 Variance
Operating revenues: $0 $0 $0 Net patient service revenue, before provision for bad debts $0 $0 $0 - - - Provision for bad debts ------Net patient service revenue - - - 346 352 (6) Other revenue 1,397 1,406 (9) 346 352 (6) Total operating revenues 1,397 1,406 (9)
Operating expenses: 57 60 3 Salaries and benefits 232 240 8 37 39 2 Purchased services 149 155 6 - 1 1 Supplies 1 3 2 67 67 - Depreciation and amortization 266 266 - 4 4 - Interest 20 20 - 5 5 - Leases and rentals 20 20 - - 4 4 Other 3 16 13 170 180 10 Total operating expenses 691 720 29
176 172 4 Excess of operating revenues over expenses 706 686 20
Nonoperating revenues, expenses, and gains/(losses): - - - Realized investment income/(losses) ------Unrealized investment income/(losses) ------Donation revenue ------Nonoperating gains/(losses), net ------Total nonoperating revenues, expenses, and gains/(losses) - - -
$176 $172 $4 Increase in net position $706 $686 $20
page 14 Page 104 of 294 Halifax Health Foundation Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Four Months Ended Four Months Ended (Unfavorable) January 31, 2018 January 31, 2018 Variance January 31, 2018 January 31, 2018 Variance
Operating revenues: $0 $0 $0 Net patient service revenue, before provision for bad debts $0 $0 $0 - - - Provision for bad debts ------Net patient service revenue - - - 44 114 (70) Realized investment income/(losses) 825 455 370 829 - 829 Unrealized investment income/(losses) 1,209 - 1,209 108 108 - Donation revenue 380 431 (51) - - - Other revenue - - - 981 222 759 Total operating revenues 2,414 886 1,528
Operating expenses: 11 10 (1) Salaries and benefits 41 42 1 - 4 4 Purchased services 3 15 12 - - - Supplies ------Depreciation and amortization ------Interest ------Leases and rentals - - - 51 67 16 Other 133 269 136 62 81 19 Total operating expenses 177 326 149
$919 $141 $778 Increase in net position $2,237 $560 $1,677
page 15 Page 105 of 294 Halifax Health Medical Center (Obligated Group) Statements of Revenues, Expenses and Changes in Net Position ($ in thousands) Actual Static Budget Favorable Actual Static Budget Favorable Month Ended Month Ended (Unfavorable) Four Months Ended Four Months Ended (Unfavorable) January 31, 2018 January 31, 2018 Variance January 31, 2018 January 31, 2018 Variance
Operating revenues: $51,387 $51,696 ($309) Net patient service revenue, before provision for bad debts $196,269 $193,233 $3,036 (7,883) (8,265) 382 Provision for bad debts (37,387) (31,888) (5,499) 43,504 43,431 73 Net patient service revenue 158,882 161,345 (2,463) 504 504 - Ad valorem taxes 2,016 2,016 - 1,171 1,396 (225) Other revenue 6,070 5,602 468 45,179 45,331 (152) Total operating revenues 166,968 168,963 (1,995)
Operating expenses: 21,742 22,964 1,222 Salaries and benefits 83,920 89,083 5,163 5,533 5,300 (233) Purchased services 22,385 20,478 (1,907) 8,600 8,305 (295) Supplies 32,130 31,649 (481) 1,983 1,881 (102) Depreciation and amortization 7,924 7,523 (401) 1,390 1,389 (1) Interest 5,544 5,556 12 517 523 6 Ad valorem tax related expenses 2,249 2,193 (56) 627 633 6 Leases and rentals 2,492 2,533 41 2,132 2,120 (12) Other 8,579 8,481 (98) 42,524 43,115 591 Total operating expenses 165,223 167,496 2,273
2,655 2,216 439 Excess of operating revenues over expenses 1,745 1,467 278
Nonoperating revenues, expenses, and gains/(losses): 173 180 (7) Realized investment income/(losses) 965 721 244 (359) (2) (357) Unrealized investment income/(losses) (731) (7) (724) (3) - (3) Donation revenue 5 - 5 2,870 617 2,253 Income from affiliates 6,189 2,329 3,860 2,674 795 1,879 Total nonoperating revenues, expenses, and gains/(losses) 6,421 3,043 3,378
5,329 3,011 2,318 Increase in net position before other changes in net position 8,166 4,510 3,656
Other changes in net position: - - - Change in accounting - post employement benefits other than pension (1) (19,962) - (19,962) - - - Total other changes in net position (19,962) - (19,962)
$5,329 $3,011 $2,318 Increase (decrease) in net position ($11,796) $4,510 ($16,306)
(1) Halifax Health implemented GASB 75 as of October 1, 2017.
page 16 Page 106 of 294 Halifax Health Financial Summary - Graphic
HH Total Margin (Cumulative YTD Basis) (desired trend - increasing) 8.0%
6.0%
4.0%
2.0%
0.0%
-2.0%
-4.0% Margin -6.0%
-8.0%
-10.0%
-12.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
HH Operating Margin (Cumulative YTD Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 6.0%
4.0%
2.0%
0.0% Margin -2.0%
-4.0%
-6.0%
-8.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
page 17 Page 107 of 294 Halifax Health Financial Summary - Graphic
HH EBIDA Margin (Cumulative YTD Basis) (desired trend - increasing) 14.0%
12.0%
10.0%
8.0%
6.0%
4.0% Margin 2.0%
0.0%
-2.0%
-4.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
HH Adjusted Operating EBIDA Margin (Cumulative YTD Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 12.0%
10.0%
8.0%
6.0%
Margin 4.0%
2.0%
0.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget FY17
page 18 Page 108 of 294 Halifax Health Financial Summary - Graphic
HH MADS Coverage Ratio (Annualized Basis) (Excludes unrealized investment gains/losses in accordance with covenant requirements) (desired trend - increasing) 5.0
2.5 Ratio
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" FY17
HH MADS Coverage Ratio - Operations Only (Annualized Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 5.0 Ratio 2.5
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" FY17
page 19 Page 109 of 294 Halifax Health Financial Summary - Graphic
HHMC Obligated Group MADS Coverage Ratio (Annualized Basis) (Excludes unrealized investment gains/losses in accordance with covenant requirements) (desired trend - increasing) 5.0
2.5 Ratio
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" Bond Covenant FY17
HHMC Obligated Group MADS Coverage Ratio - Operations Only (Annualized Basis) (Excludes nonoperating gains and losses) (desired trend - increasing) 5.0
Ratio 2.5
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 YTD Budget S&P "A" Bond Covenant FY17
page 20 Page 110 of 294 Halifax Health Financial Summary - Graphic
HH Days Cash on Hand (Annualized Basis) (desired trend - increasing)
400
350
300
250
200 Days
150
100
50
0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
HH Cash/Debt (Monthly) (desired trend - increasing) 175.0%
150.0%
125.0%
100.0%
75.0%
50.0% Cash/Long-Term Debt Cash/Long-Term
25.0%
0.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
page 21 Page 111 of 294 Halifax Health Financial Summary - Graphic
HH Debt to Capitalization (Monthly) (desired trend - decreasing) 80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
Debt to to Debt Capitalization 20.0%
10.0%
0.0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
HH Days in A/R (Annualized Basis) (desired trend - decreasing) 60.0
50.0
40.0
30.0 Days
20.0
10.0
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" Budget FY17
page 22 Page 112 of 294 Halifax Health Financial Summary - Graphic
HH Average Payment Period (Annualized Basis) (desired trend - decreasing) 100.0
90.0
80.0
70.0
60.0
50.0 Days 40.0
30.0
20.0
10.0
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 Budget FY17
HH Average Age of Plant (Annualized Basis) (desired trend - decreasing) 16.0
14.0
12.0
10.0 Years 8.0
6.0
4.0
2.0
0.0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP
FY18 S&P "A" YTD Budget FY17
page 23 Page 113 of 294 Halifax Health Financial Ratios and Operating Indicators Definitions and Calculations
Indicator Definition Calculation
Gauges the relative efficiency with which Net Income Total Margin * the System produces its output. Total Revenues
Gauges the relative efficiency excluding Net income + Int + Depr + Amort EBIDA Margin * capital costs with which the System Total Revenues produces its output.
Measures profitability relative to the MADS Coverage Net Income + Depr + Amort + Int Maximum Principal and Interest Ratio * Maximum Annual Debt Service Payment of Debt
Measures the number of days of average Days Cash on cash expenses that the System maintains Unrestricted Cash and Investments Hand in cash and cash equivalents and (Total Expenses - Depr) / Days in Period unrestricted investments.
Cash to Long-term Measures the percentage of unrestricted Unrestricted Cash and Investments Debt cash and investments to long-term debt. Long-term Debt
Long-term Debt to Measures the reliance on long-term debt Long-term Debt Capitalization financing and ability to issue new debt. Long-term Debt + Net Position
Measures the average time that Days in Accounts Accounts Receivable receivables are outstanding, or the Receivable Net Patient Service Revenue/ Days in Period average collection period.
Provides a measure of the average time Average Payment Current Liabilities that elapses before current liabilities are Period (Total Expenses - Depr) / Days in Period paid.
Average Age of Provides a measure of the average age in Accumulated Depreciation Plant years of the System's fixed assets. Depreciation Expense
Gauges the relative operating efficiency Excess of Operating Revenues Operating Margin with which the System produces its Total Operating Revenues + Bad Debt output.
Excludes realized and unrealized * Operations Only investment income, donations, and Indicators nonoperating gains and losses
page 24 Page 114 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Eric Peburn, Executive Vice President and Chief Financial Officer DATE: February 21, 2018 RE: GASB Statement No. 75
On October 1, 2017, Halifax Health adopted GASB Statement No. 75 – Accounting and Financial Reporting for Postemployment Benefits Other Than Pensions (OPEB). This statement required a change in how the long-term obligations associated with OPEBs are calculated and reported. As a result, as of October 1, 2017, liabilities recorded for OPEBs were increased and net position decreased by approximately $21.1 million.
The adoption of GASB Statement No. 75 was included in the December 2017 and January 2018 financial reports, which will be discussed at the Audit and Finance Committee meeting on February 28, 2018.
Page 115 of 294 CAPITAL EXPENDITURES & OPERATING LEASES Audit & Finance Committee February 28, 2018
Capital Expenditures $50,000 and over
DESCRIPTION DEPARTMENT SOURCE OF FUNDS TOTAL
Cardiac Cath Lab Replacement Cardiology Department Working Capital $1,488,698 Pediatric Telemetry Monitoring System Pediatric/PICU Nursing Working Capital $428,641 Merge Hemodynamics System - Information Technology Working Capital $348,604 Upgrade and Expansion Emergency Power Connection to Air Facility Operations Working Capital $300,000 Handler and Fan Coil Units at HHPO Access Control – License, Network Information Technology Working Capital $118,687 Boards and Card Readers Hemodialysis and Disinfection Dialysis Unit Working Capital $57,369 Equipment
Operating Leases $250,000 and over
DESCRIPTION DEPARTMENT REPLACEMENT LEASE INTEREST MONTHLY Y/N TERMS RATE PAYMENT
Page 116 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Mark Billings, Executive Vice President and Chief Operating Officer CC: Matt Petkus, Vice President Surgical Services DATE: February 14, 2018 RE: Cardiac Cath Lab Replacement
Halifax Health Cardiology Department is requesting funds to upgrade two cardiac cath labs. Similar upgrades were completed for two other cardiac cath labs in 2017. Also, one cath lab was added in 2011. There are a total of five cath labs located at the Halifax Health Main Campus. The two cath labs to be upgraded with this request were installed in 2004 as part of the expansion of cardiology services. The upgraded rooms will provide the latest imaging technology for cardiac, peripheral, electrophysiology, and cardiac implant procedures including the newest solid state detectors, and additional radiation dose reduction algorithms. These systems will provide Halifax Health with the most advanced cardiac imaging systems in the area. This project represents the final component of the complete upgrade of all the cath labs, hemodynamic monitoring, and Picture Archiving and Communication Systems (PACS). The project was approved at the Capital Investment Committee meeting on August 16, 2017.
TOTAL CAPITAL COSTS $1,488,698
Page 117 of 294
Halifax Health Project Evaluation Cardiac Cath Lab Replacement Chief Operating Officer: Mark Billings Vice President Surgical Services: Matt Petkus Manager, Cath Lab: Lismer Castellano Finance Analysis by: Steve Mach
Summary
Purpose: This project will upgrade two (2) cardiac cath labs with the latest technology. These systems will provide Halifax Health with the most advanced cardiac imaging systems in the area.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination X Compassion Cost Management Image X Information Technology Efficiency X Service Distribution X Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $1,488,698
Recommendation for approval of the project is not based upon incremental return on investment.
Page 118 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Mark Billings, Executive Vice President and Chief Operating Officer CC: Eric Peburn, Executive Vice President and Chief Financial Officer Catherine Luchsinger, RN, Chief Nursing Officer DATE: January 16, 2018 RE: Pediatric Telemetry Monitoring System
Halifax Health Pediatric/PICU Nursing is requesting funds to purchase a pediatric telemetry monitoring system. The system includes pediatric telemetry monitors, central stations, servers, licenses, and software. The equipment will monitor the patient’s cardiac activity and interface the data with the electronic medical record. This project is part of the house-wide replacement plan. The current monitoring system has frequent, costly repairs.
The requested monitors will be distributed to the Pediatric and Pediatric ICU units.
The project was approved at the Capital Investment Committee meeting on December 20, 2017.
TOTAL CAPITAL COSTS $428,641
Page 119 of 294
Halifax Health Project Evaluation Patient Monitoring System for Pediatrics and Pediatric Intensive Care Unit Chief Operating Officer: Mark Billings Chief Nursing Officer: Catherine Luchsinger Manager, Pediatric Nursing: Amy Christie Finance Analysis by: Steve Mach
Summary
Purpose: This project is to replace the pediatric patient monitoring system on the Pediatric Unit and Pediatric Intensive Care Unit (PICU).
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination X Compassion Cost Management Image X Information Technology X Efficiency Service Distribution Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $428,641
Recommendation for approval of the project is not based upon incremental return on investment.
Page 120 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Arvin Lewis, Senior Vice President and Chief Revenue Officer CC: Tom Stafford, Vice President and Chief Information Officer DATE: February 14, 2018 RE: Merge Hemodynamics System - Upgrade and Expansion
Halifax Health Information Technology is requesting funds to purchase an upgrade to the Cardiac Cath Lab hemodynamic system and expand the system to the Interventional Radiology Lab. A consolidated system will allow for more efficient maintenance and support.
The hemodynamic system automates the collection of data, inventory management and reporting into a comprehensive digital patient record. The system provides the latest technology for patient monitoring, user-friendly workflows and integration with the Meditech electronic medical record.
Additionally, the upgrade and expansion will enhance the security of data in the hemodynamic system.
The project was approved at the Capital Investment Committee meeting on January 17, 2018.
TOTAL CAPITAL COST $348,604
Page 121 of 294
Halifax Health Project Evaluation Merge Hemodynamics Upgrade Chief Revenue Officer: Arvin Lewis Chief Information Officer: Tom Stafford Manager, Enterprise Imaging : Judy Russo Finance Analysis by: Shawn Remington
Summary
Purpose: This project will upgrade the Hemodynamics system used in Cardiac Cath Lab and Interventional Radiology.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination X Compassion Cost Management Image Information Technology X Efficiency X Service Distribution Financial Position Scale X Managed Care Contracting Competitive Position
Investment Request for Approval $348,604
Recommendation for approval of the project is not based upon incremental return on investment.
Page 122 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Eric Peburn, Executive Vice President and Chief Financial Officer DATE: February 14, 2018 RE: Emergency Power Connection to Air Handler and Fan Coil Units at HHPO
Halifax Health Facility Operations is requesting funds to connect emergency power to the air handler and fan coil units that serve the patient rooms on the third and fifth floors of Halifax Health Port Orange. The availability of emergency power will help ensure the facility will stay operational during an external power loss.
This project is part of the Emergency Preparedness Initiative and has been approved by FEMA. It is anticipated that FEMA will provide $225,000 towards the total capital costs.
The project was approved by the Capital Investment Committee on January 17, 2018.
TOTAL CAPITAL COSTS $300,000
Page 123 of 294
Halifax Health Project Evaluation Emergency Power Connection to Air Handler and Fan Coil Units at HHPO Chief Financial Officer: Eric Peburn Manager, Facility Operations Don Barnett Finance Analysis by: Shawn Remington
Summary
Purpose: This project is to provide emergency power to the air handler and fan coil units that serve the patient rooms located on the third and fifth floors of Halifax Health Port Orange.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination X Compassion Cost Management Image Information Technology Efficiency X Service Distribution X Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $300,000
Recommendation for approval of the project is not based upon incremental return on investment.
2/7/2018 ROI With No Return 1 of 1 Page 124 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Arvin Lewis, Senior Vice President and Chief Revenue Officer CC: Tom Stafford, Vice President and Chief Information Officer DATE: February 14, 2018 RE: Access Control – License, Network Boards and Card Readers
Halifax Health Information Technology is requesting funds to purchase a license, network boards and card readers to upgrade certain access control equipment. The upgrade will add authorized individuals the ability to remotely control access to the Halifax Health Emergency Department main campus, Southeast Volusia Hospice Care Center and the Halifax Heath Port Orange physician lounge on demand. With this upgrade, we will have the ability to control access to substantially all Halifax Health building locations.
The access control upgrade will provide enhanced security for patients and employees.
The project was approved at the Capital Investment Committee meeting on April 19, 2017.
TOTAL CAPITAL COST $118,687
Page 125 of 294
Halifax Health Project Evaluation Access Control - License, Network Boards and Card Readers Chief Revenue Officer: Arvin Lewis Chief Information Officer: Tom Stafford Finance Analysis by: Steve Mach
Summary
Purpose: This project will provide additional access control equipment for the following locations: Halifax Health Emergency Department (main campus), Southeast Volusia Care Center, and Halifax Health Port Orange Doctors' Lounge.
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination Compassion Cost Management Image Information Technology X Efficiency X Service Distribution Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $118,687
Recommendation for approval of the project is not based upon incremental return on investment.
Page 126 of 294
TO: Jeff Feasel, President and Chief Executive Officer FROM: Mark Billings, Executive Vice President and Chief Operating Officer CC: Catherine Luchsinger, RN, Chief Nursing Officer DATE: February 14, 2018 RE: Hemodialysis and Disinfection Equipment
Halifax Health Dialysis Unit is requesting the purchase of two hemodialysis machines and two portable reverse osmosis disinfection machines. These four machines will replace a portion of our current hemodialysis equipment fleet.
The machines are 13 years old and have exceeded the recommended service life. Repairs have increased and parts are being phased out.
Hemodialysis is needed when the function of the kidneys fail. Dialysis acts as an artificial kidney to remove waste, salt and extra water in the body. Dialysis also helps to maintain safe levels of potassium, sodium and bicarbonate and to control blood pressure.
The reverse osmosis disinfection machines will use an automated heat disinfection process that allows for greater bacteria control, reducing the need for chemicals, which leads to less downtime. The machine has programmable auto-flushing to eliminate stagnation and ensure system cleanliness.
The project was approved at the Capital Investment Committee meeting on January 17, 2018.
TOTAL CAPITAL COSTS $57,369
Page 127 of 294
Halifax Health Project Evaluation Hemodialysis and Reverse Osmosis System Chief Operating Officer: Mark Billings Chief Nursing Officer: Catherine Luchsinger Nurse Manager: Deb Reid Finance Analysis by: Shawn Remington
Summary
Purpose: This project is to purchase new hemodialysis and reverse osmosis system for the dialysis department
Strategic Plan Core Competency Achievement: Cornerstone: Physician Integration Safety X Care Coordination X Compassion Cost Management Image X Information Technology Efficiency X Service Distribution X Financial Position Scale Managed Care Contracting Competitive Position
Investment Request for Approval $57,369
Recommendation for approval of the project is not based upon incremental return on investment.
2/8/2018 ROI With No Return 1 of 1 Page 128 of 294 Halifax Health Medical Center Capital Disposals JANUARY 2018
The Board hereby deems the following property to be surplus in that: the items are obsolete, their continued use would be uneconomical or inefficient, or they serve no useful function. Disposition of said property is therefore authorized pursuant to Florida Statutes, Chapter 274. Date Disposition Original Book Asset # Description Department Purchased Status Cost Value 55417 QUICK SLIDE STAINER ORMOND HEMATOLOGY LAB 07/18/06 2,150.00 - 48067 ICE MACHINE CVICU 10/31/97 3,550.16 -
$ 5,700.16 $ -
Total to be Disposed: $ - $ -
Page 129 of 294 Halifax Health Medical Center Capital Disposals FEBRUARY 2018
The Board hereby deems the following property to be surplus in that: the items are obsolete, their continued use would be uneconomical or inefficient, or they serve no useful function. Disposition of said property is therefore authorized pursuant to Florida Statutes, Chapter 274. Date Original Book Asset # Description Department Purchased Cost Value 49500 TREADMILL QUINTONCLUB TRACK HEALTH FITNESS 07/20/98 4,900.00 - 63009-66 MOP KING SYSTEM EVS 06/30/09 3,271.20 - 55559 WHIRLPOOL HIBOY PHYSICAL THERAPY 12/04/06 4,225.70 - 55554 WHIRLPOOL LOBOY PHYSICAL THERAPY 12/04/06 4,158.77 - 55557 WHIRLPOOL FOOT PHYSICAL THERAPY 12/04/06 3,027.73 - 55558 WHIRLPOOL LEG & ARM PHYSICAL THERAPY 12/04/06 2,903.58 - 54552 COPY MACHINE PHYSICAL THERAPY 03/03/05 3,798.00 - 55758 PATIENT EXTREMITY LIFT PHYSICAL THERAPY 11/28/06 3,726.99 - 55176 PHILLIPS MONITOR PEDIATRICS 03/31/06 9,491.05 -
Total to be Disposed: $ 39,503.02 $ -
Page 130 of 294
To: Jeff Feasel, Chief Executive Officer
From: Bill Rushton, Audit Services Director
Date: February 16, 2018
Re: Audit Services Report for Board of Commissioners Packet
The Audit and Finance Committee assists the Board of Commissioners in its exercise of oversight of accounting and financial policies, operational controls and processes of the organization. This includes overseeing the audit plan, reviewing and approving audit reports and inquiring of auditors and management on internal controls to address risk. The Committee recommends acceptance of the Final Audit Report referenced #1 & #2. An overview of the audits are enclosed within the Board of Commissioners packet.
# Approval Date Project Objective(s) Risk Area(s) 1 11/1/17 Network Security Determined whether Halifax Information Testing Health IT and physical security Systems & processes, to prevent malware, Management, were functioning as Management Patient Safety, intended. Compliance, Finance 2 1/3/18 Cash Collections Assessed the controls over Finance, Management Audit receipt, safeguarding and Revenue Cycle, reconciliation of cash. Physician Practices
Page 131 of 294 #1 - Penetration Testing Report Date: August 24, 2017 Location: Halifax Health AUDIT OBJECTIVES AUDIT CONCLUSION Determined whether Halifax Health IT and physical security processes, to prevent malware, were functioning as Management intended. Hacking through malware or non-malware refers to a program with the intent to destroy data, run destructive and intrusive programs, or otherwise compromise the confidentiality, integrity or availability of Halifax's data. RSM performs penetration testing to assist AUDIT SCOPE Management in identifying and mitigating these ever-changing risks. RSM performed external and internal penetration tests and performed certain social techniques to evaluate the effectiveness malware management.
Locations: Halifax Medical Center, Medical Center of Port Orange, Emergency Department of Deltona, Center for Oncology-Port Orange, Primary Care-Deltona, Child & Adolescent Behavioral Services
Time Period: May 25, 2017 through June 16, 2017
Key Information System: Confidential
Data Selected: Confidential
Scope Exclusions: Confidential SUMMARY OF ISSUE RISKS High Risk - 0 Moderate Risk - 2 Low Risk - 2
#2 - Cash Collections Management Audit
Date: December 20, 2017 Location: Halifax Health
AUDIT OBJECTIVES AUDIT CONCLUSION Assessed the controls over receipt, safeguarding, recording and The level of control surrounding the cash collection process varies reconciliation of cash. within Halifax Hospital (HH). Deficiencies were noted with regard to monitoring, physical security and documentation and the AUDIT SCOPE safeguarding of assets. Management has committed to improving Associate education and the design and operation of controls over Audits covered cash collection areas identified by Management as having the cash collection process. operational issues and/or high volume of cash receipts.
Location(s): Cafeterias Thrift Store Port Orange Emergency Departments Cashiering Office Care for Women Oncology Urgent Care Ormond Neurology Office Primary Care New Smyrna Beach
Time Period: Daily Cash Reconciliations: June 12, 2017 through June 16, 2017
Cash Recording and Adjustments: FY 2017
Key Information System: Meditech, eClinical, CBORD, Elevon
Scope Exclusions: Bank reconciliations were outside the scope of this audit. SUMMARY OF ISSUE RISKS High Risk - 2 Moderate Risk - 4 Low Risk - 1
Page 132 of 294
To: Audit and Finance Committee and Board of Commissioners Cc: Jeff Feasel, Chief Executive Officer From: Shelly Shiflet, Vice President and Chief Compliance Officer Date: January 23, 2018 Re: Compliance Dashboard Report for the month ended December 31, 2017
Enclosed is the Compliance Program Dashboard Report for December 2017.
Feel free to contact the Board’s Compliance Expert, Robert Wade, Esq., or me regarding any questions on this report.
Mr. Wade can be reached at: [email protected] Office: 574.485.2002
I can be reached at: [email protected] Office: 386.425.4970
Recommended Action: None. Information only.
Page 133 of 294 Halifax Health Corporate Compliance Program Board Report – 12/31/2017
ON TARGET ALERT I. EMPLOYEE AND BOARD EDUCATION – Halifax Health’s compliance program and Corporate Integrity Agreement requires most employees to acknowledge the Code of Conduct within 30 days of hire. Employees who are considered “Covered Persons” are required to complete 1 hour of general compliance training within 30 days of hire and annually thereafter. Managers and others who are considered “Arrangements Covered Persons” must complete an additional hour of general education and 2 hours of arrangements training within 30 days of becoming an “Arrangements Covered Person,” and annually thereafter. Members of the Board are required to complete 6 hours (2 hours general, 2 hours arrangements, and 2 hours governance) of training within 30 days of becoming a member. The following is the status of education for Halifax Health’s employees: Code of Conduct Attestation1 1. 4,153 Number of Covered Persons and Board Members required to complete as of end of period 2. 100% % of Covered Persons who have completed (On Target at 100%)
CIA Required Training2 1. 4,009 Number of Covered Persons and Board Members required to complete as of end of period 2. 100% % of Covered Persons who have completed (On Target at 100%)
II. SANCTION CHECKS - Halifax Health’s Corporate Integrity Agreement requires all “Covered Persons” be screened for exclusions from participation in federal programs monthly. During the period:
Sanction Check for Covered Persons3 1. 4,914 Number of Covered Persons as of the end of the period 2. 100% % of Covered Persons above who had no sanctions, based on monthly sanction check results (On Target at 100%) III. COMPLIANCE COMMITTEE – Halifax Health has a Compliance Committee responsible for regulatory compliance matters, which meets monthly. Members of senior leadership across service lines as well as representatives from Hospice and the Medical Staff are represented. During the period: 1. 14 Number of members on Compliance Committee 2. 78.6% % of members who attended the meeting (On Target at 70% or Greater) – meeting date 11/29/17 3. 3 Number of meetings in the last quarter (On Target if 2 or more) IV. HELP LINE [844-251-1880] or halifaxhealth.ethicspoint.com 1. 4/ 59 Number of Help Line calls received during month/past 12 months 2. 0 / 34 Of calls in 1, how many related to Human Resource issues 3. 0 Number of open Help Line calls rated as High Priority as of 11/30/2017 4. 0 Number of open Help Line calls rated as High Priority as of 12/31/2017 5. 7 Number of Help Line calls closed since last month V. COMPLIANCE ISSUES 1. 22 Number of issues open as of 11/30/2017 2. 7 Of the issues in item 1, __ remain open as of 12/31/2017 3. 15 Number of issues from item 1 closed as of 12/31/2017 4. 68% Percent of open issues from item 1 closed (On Target at 25% or Greater) VI. COMPLIANCE POLICIES – Halifax Health’s Compliance Program involves the development, implementation and monitoring of policies to ensure the organization conducts business compliant with applicable statutes, rules and regulations. During the period: 1. 1 Number of Compliance Policies reviewed/ updated in the last month (On Target at 1) VII. BILLING AND CODING REVIEWS - Halifax Health will conduct reviews as part of scheduled audits or to investigate concerns brought to the attention of the Compliance Committee or the Compliance Officer. 1. 0 Number of concerns related to billing/coding received during the month 2. 0 Number of concerns from #1 that required a billing/ coding review 3. 0 Number of reviews from #1 still being investigated 4. 0 Number of reviews from #1 closed or pending Committee review 5. 0 Number of reviews from #1 expected to require repayment/processing of claims
1 Code of Conduct Attestation – employees and vendors who meet the definition of a Covered Person and new Board Members. 2 CIA Required Training – employees (except for housekeeping, maintenance and foodservice employees), Medical Staff who are party to a Focus Arrangement and vendors who meet the definition of a Covered Person and new Board Members. 3 Sanction Check for Covered Persons - employees, Medical Staff and vendors who meet the definition of a Covered Person.
Page 134 of 294
To: Audit and Finance Committee and Board of Commissioners Cc: Jeff Feasel, Chief Executive Officer From: Shelly Shiflet, Vice President and Chief Compliance Officer Date: February 19, 2018 Re: Compliance Dashboard Report for the month ended January 31, 2018
Enclosed is the Compliance Program Dashboard Report for January 2018.
Feel free to contact the Board’s Compliance Expert, Robert Wade, Esq., or me regarding any questions on this report.
Mr. Wade can be reached at: [email protected] Office: 574.485.2002
I can be reached at: [email protected] Office: 386.425.4970
Recommended Action: None. Information only.
Page 135 of 294 Halifax Health Corporate Compliance Program Board Report – 1/31/2018
ON TARGET ALERT I. EMPLOYEE AND BOARD EDUCATION – Halifax Health’s compliance program and Corporate Integrity Agreement requires most employees to acknowledge the Code of Conduct within 30 days of hire. Employees who are considered “Covered Persons” are required to complete 1 hour of general compliance training within 30 days of hire and annually thereafter. Managers and others who are considered “Arrangements Covered Persons” must complete an additional hour of general education and 2 hours of arrangements training within 30 days of becoming an “Arrangements Covered Person,” and annually thereafter. Members of the Board are required to complete 6 hours (2 hours general, 2 hours arrangements, and 2 hours governance) of training within 30 days of becoming a member. The following is the status of education for Halifax Health’s employees: Code of Conduct Attestation1 1. 4,108 Number of Covered Persons and Board Members required to complete as of end of period 2. 100% % of Covered Persons who have completed (On Target at 100%)
CIA Required Training2 1. 3,961 Number of Covered Persons and Board Members required to complete as of end of period 2. 100% % of Covered Persons who have completed (On Target at 100%)
II. SANCTION CHECKS - Halifax Health’s Corporate Integrity Agreement requires all “Covered Persons” be screened for exclusions from participation in federal programs monthly. During the period:
Sanction Check for Covered Persons3 1. 4,875 Number of Covered Persons as of the end of the period 2. 100% % of Covered Persons above who had no sanctions, based on monthly sanction check results (On Target at 100%) III. COMPLIANCE COMMITTEE – Halifax Health has a Compliance Committee responsible for regulatory compliance matters, which meets monthly. Members of senior leadership across service lines as well as representatives from Hospice and the Medical Staff are represented. During the period: 1. 14 Number of members on Compliance Committee 2. 85.7% % of members who attended the meeting (On Target at 70% or Greater) – meeting date 1/3/2018 3. 3 Number of meetings in the last quarter (On Target if 2 or more) IV. HELP LINE [844-251-1880] or halifaxhealth.ethicspoint.com 1. 1/ 56 Number of Help Line calls received during month/past 12 months 2. 1 / 33 Of calls in 1, how many related to Human Resource issues 3. 0 Number of open Help Line calls rated as High Priority as of 12/31/2017 4. 0 Number of open Help Line calls rated as High Priority as of 1/31/2018 5. 1 Number of Help Line calls closed since last month V. COMPLIANCE ISSUES 1. 24 Number of issues open as of 12/31/2017 2. 12 Of the issues in item 1, __ remain open as of 1/31/2018 3. 12 Number of issues from item 1 closed as of 1/31/2018 4. 50% Percent of open issues from item 1 closed (On Target at 25% or Greater) VI. COMPLIANCE POLICIES – Halifax Health’s Compliance Program involves the development, implementation and monitoring of policies to ensure the organization conducts business compliant with applicable statutes, rules and regulations. During the period: 1. 1 Number of Compliance Policies reviewed/ updated in the last month (On Target at 1) VII. BILLING AND CODING REVIEWS - Halifax Health will conduct reviews as part of scheduled audits or to investigate concerns brought to the attention of the Compliance Committee or the Compliance Officer. 1. 3 Number of concerns related to billing/coding received during the month 2. 3 Number of concerns from #1 that required a billing/ coding review 3. 3 Number of reviews from #1 still being investigated 4. 0 Number of reviews from #1 closed or pending Committee review 5. 3 Number of reviews from #1 expected to require repayment/processing of claims
1 Code of Conduct Attestation – employees and vendors who meet the definition of a Covered Person and new Board Members. 2 CIA Required Training – employees (except for housekeeping, maintenance and foodservice employees), Medical Staff who are party to a Focus Arrangement and vendors who meet the definition of a Covered Person and new Board Members. 3 Sanction Check for Covered Persons - employees, Medical Staff and vendors who meet the definition of a Covered Person.
Page 136 of 294
To: Board of Commissioners Cc: Jeff Feasel, Chief Executive Officer From: Shelly Shiflet, Vice President and Chief Compliance Officer Date: February 7, 2018 Re: For Approval and signature at the March 5, 2018 Board Meeting – Resolution for Annual Report
Enclosed is the Board Resolution for the annual report to the Office of Inspector General (“OIG”).
Approval and signature will be requested at the March 5, 2018 Board of Commissioners meeting.
Feel free to contact the Board’s Compliance Expert, Robert Wade, Esq., or me regarding this item.
Mr. Wade can be reached at: [email protected] Office: 574.485.2002
I can be reached at: [email protected] Office: 386.425.4970
Recommended Action: Approval and signature at the March 5, 2018 Board of Commissioners meeting.
Page 137 of 294 RESOLUTION OF THE BOARD OF COMMISSIONERS OF HALIFAX HOSPITAL MEDICAL CENTER
WHEREAS, Halifax Hospital Medical Center ("Halifax") entered into a Corporate Integrity Agreement ("CIA") with the Office of the Inspector General of the Department of Health and Human Services dated March 10, 2014; and
WHEREAS, the CIA imposes certain compliance obligations on the Halifax Board of Commissioners ("Board") and requires the Board to adopt a resolution for each reporting period under the CIA summarizing its review and oversight of Halifax's compliance with Federal health care program requirements and the obligations of the CIA; and
WHEREAS, the Board has conducted an ongoing inquiry and review of Halifax’s Compliance Program as required under the CIA, including but not limited to the performance of the Compliance Officer and the Compliance Committee.
NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COMMISSIONERS OF HALIFAX HOSPITAL MEDICAL CENTER that:
1. The Board has made a reasonable inquiry into the operations of Halifax’s Compliance Program including the performance of the Compliance Officer and the Compliance Committee.
2. Based on its inquiry and review the Board has concluded that, to the best of its knowledge, Halifax has implemented an effective Compliance Program to meet Federal health care program requirements and the obligations of the CIA.
3. This Resolution and the conclusions contained herein shall be applicable to the Reporting Periods of the CIA beginning March 10, 2014 and continuing through March 9, 2018.
PASSED AND ADOPTED in public session of the Halifax Hospital Medical Center Board of Commissioners as of the ____ day of ______2018.
Harold L. Goodemote, II, Chairman Dan Francati, Vice Chairman
Susan Schandel, Treasurer Tom McCall, Secretary
Ed Connor, Assistant Secretary Glenn Ritchey, Member
Dr. Carl “Rick” Lentz III, Member
Page 138 of 294
TO: Mr. Jeff Feasel, President & CEO
FROM: Steve Miles, M.D., Sr. VP & Chief Quality Officer
DATE: February 13, 2017
RE: Annual Plans for Board Approval
The following 2017 Plans have been submitted/approved by their respective Committees and are submitted to the Board of Commissioners for approval:
2018 Infection Control Risk Assessment and Plan
Approved by Infection Control Committee - 1/17/18 Submitted to Medical Executive Committee – 2/2/18 via email & 2/5/18 meeting (Approved by Dr. Margaret Crossman & Dr. Steven Miles)
2018 Performance Improvement Plan & Evaluation
Approved by Quality Council - 12/15/17 Approved by Medical Executive Committee - 1/16/18 Approved by Patient Safety Committee - 1/24/18
2018 Patient Safety Plan
Approved by Quality Council - 12/15/17 Approved by Medical Executive Committee - 1/16/18 Approved Patient Safety Committee - 1/24/18
2017 Environment of Care Summary
Environment of Care Committee 2/15/18
Page 139 of 294
HALIFAX HEALTH SYSTEM Infection Prevention Plan 2018
Approved by Infection Control Committee - 1/17/18 Submitted to Medical Executive Committee – 2/2/18 via email & 2/5/18 meeting (Approved by Dr. Margaret Crossman & Dr. Steven Miles)
Page 140 of 294
HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
I. PURPOSE
Halifax Health System wide Infection Prevention and Control Program's overall goal is to minimize, reduce or eliminate the risk of acquiring and transmitting hospital acquired infections (HAI) through these predetermined strategies determined by risk assessment of the previous year’s data, the needs of the Halifax Health System, community, state and national public health issues that have the potential to impact the care and safety of our patients, staff, visitors, first responders.
II. PROGRAM SCOPE
The program is system wide and under the authority of the Director of Infection Prevention/Infection Prevention Officer, the Chief Quality Officer, and the Vice President of Operations. The Infection Prevention Program reports, policies, procedures are reviewed and approved by the Infection Control Committee, Medical Executive Committee and the Board of Commissioners.
The Infection Prevention Program will be reviewed annually and whenever significant changes occur that affect risk within our community and healthcare system of care.
Page 141 of 294
HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
Halifax Health System Summary & Volusia County Geographical Factors Characteristics increase Risk Characteristics decrease risk Located in Volusia County, Halifax Health Medical Center (HMC), Halifax Health Port Orange (HHPO), Halifax Varied level of education, varied Behavioral Health Services (HBS), Deltona Emergency Services, multiple clinics serves the residents of Port cultural teachings on healthcare; Clean air / Sunshine , fresh Orange, New Smyrna Beach and other Southeast Volusia county communities. The system is part of an cultural barriers to treatment high local food, seafood rate of tourism, homelessness extensive integrated network of health care programs and services and at the core is a Level II, tertiary public Weather: humid, subtropical, district hospital that is was founded by the Florida State Legislature, and a member of the Safety Net Hospital Immigration of individuals from mild in spring and fall, with Alliance. The Halifax Health System has oversight by the Board of Commissioners appointed by the Governor counties with endemic infectious increase humidity, temp in of Florida. The system is extensive to include: HMC, the main campus, is a 678 bed facility located in Daytona disease (i.e., TB, Hepatitis B,C, summer with average daily Beach. It has Florida’s largest emergency department which is Level II Trauma designated, 110 beds with 8 Zika) temperature of 70.7 individual clinically designated units. HHPO is an 80 bed acute care community hospital located in Port Orange with a 20 bed emergency department and an 8 bed ICU. Deltona Emergency Services, a free standing 2016 Florida was one of 12 Center for Neurosciences- emergency facility, opened in April 2017, located in Deltona directly off of I-4, and is the centerpiece of what states that reported increase in comprehensive stroke center will be Halifax Crossing Medical Village with phase II to be completed in 2018 which will include a 110 bed Mycobacterium tuberculosis with 24/7 fully staffed acute care hospital, phase III will be medical practice offices and supportive services. Halifax Behavioral a 4.3% increase from neurosurgical OR Services includes child and adult behavioral health services to treat a broad range of behavioral health issues. 2015. Center for Cardiology- HMC has a 14 bed acute Medical/Psychiatric Unit, HBS has a 34 bed child /adolescent inpatient treatment Collaboration with University program. The system has multiple specialized programs and clinics to include Perinatal services, NICU, PICU, Safety Net designated healthcare of Florida, clinical excellence Kidney transplant program, comprehensive Oncology services to include four inpatient Hospice Care Centers, facility for uninsured, homeless, in thoracic surgery. Children’s Grief Center, and resale shops, Children’s Medical Centers in 3 locations, and Community Clinic, mentally ill, which increases risk Center for Oncology- five Keech Pediatric Neighborhood Care. Halifax Health System is one of the largest employers in Volusia County of infection, potential for violence outreach locations, advanced employing over 4000, with 500 physicians on medical staff that represent 54 subspecialties. cancer research, oncology Commercial fishing industry In 2017, system wide, there were 23,213 hospital admissions, 137,838 patient days, with average length of nutritionist, survivorship increase risk of accidents, food program, nurse navigators. stay of 5.3 days. Emergency Department visits: 111,286; Outpatient community clinic visits: 7665; Surgical borne illness, chemical exposure Largest Emergency Services 15,281 inpatient/outpatient7cases in 2013, with average of 41.86 cases per day. department in state of FL Hurricanes: Florida and Volusia with 110 beds, Level II Volusia county census increased in 2016 by over 7% year over year, and has a population estimate of 529,364 county experienced 2 hurricanes trauma center with 24/7 84% white, with over 24% 65 years or older, 50% female, 50% male, in 2017 there was an increased Puerto in 2017 in which impacted the trauma staff and surgeons. Rican population due to the recent hurricane season in which decimated the Puerto Rican islands. The county state and county proper Advanced Radiology area is located on 47 miles of the Atlantic coast, has a subtropical, humid climate with mild springs, very warm significantly. technology to include advance SPECT/CT summers, with average temperature in the 90s, dry winters marked by cold fronts. Patient population consists of local residents, the homeless, and a high tourist population due to the historical beaches, Spring Break Note: All statistical information State of the art hospitals and traditions, Daytona International Speedway and its events, and several motorcycle events to include Daytona expressed in this document was clinics with highly trained Bike Week, and Biketoberfest; all which temporarily increase population and demand for services. The MVA obtained from either Halifax Physicians, Nurses and other Health statistics, Florida fatality rate in 2016 was 23.05 per 100,000 (122), 32 of them motorcycle fatalities. The MVA fatality rate has Healthcare workers. Department of Public Health Data Affiliation with University of increase from 2015 rate of 16.79. Statistics, Centers for Disease Florida and other centers of Control and Prevention. excellence.
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
GEOGRAPHICAL DISEASE STATISTICS Characteristics that Characteristics that Infectious disease is a key indicator in the health status of a community. Florida state epidemiology statistics show Increase Risk Decrease Risk an increased rate of mosquito borne illness in 2016 to include West Nile Virus, Chickaguna, and Zika. HIV/AIDS, rd Hepatitis C, and Sexually transmitted infections have increased in 2016, 2017. Volusia County is 3 in the state for Low rate of adult Increase Halifax Pertussis, and is middle level area for Mycobacterium tuberculosis based upon the county and surrounding county booster immunization Health education rates., and high rate of tourists. High transient regarding infectious population / homeless disease to include Some of the higher rates of infectious disease in Volusia and surrounding counties are: Lack of knowledge residents/students /limited knowledge of Access clinics for rd Pertussis: Volusia County had a 3 highest rate in the state 2017. Pertussis (whooping cough) is a highly disease transmission community disease contagious bacterial illness spread by coughs and sneezes. People sick with Pertussis have severe coughing High IV drug use/abuse information attacks that can last for months. Vaccination is the best defense against whooping cough. However, the immunity High rate of population Increase/expand from vaccines wears off over time and Pertussis booster vaccine rates in adolescents and adults continue to be influx from hurricane HH tuberculin skin low. As a result, Pertussis continues to circulate widely in Florida resulting in the hospitalization and death of affected areas testing young infants who are too young to get their shots. It is recommending that all Floridians make sure that they are Change in climate Review immunized against Pertussis, especially if they are in contact with infants, or work in the healthcare field. /ocean temperature immunization increase risk for status of healthcare Tuberculosis: Mycobacterium tuberculosis complex is from breathing air containing the bacillus. Many cultures shellfish bacteria workers to assess have a “social shame” associated with this treatable disease. There were 639 new cases in 2016 with 93 of those High antibiotic use need for promotion cases confirmed in Volusia and border counties. HMC, HHOP and Deltona are considered medium level facilities High rate of tourists, and /or education with > 7 cases during 2017 and secondary to geographical risks. travel to and from on disease Florida. preventable Salmonella / Campylobacter other enteric food and waterborne illness: Since 2015 there has been a decline Poor hand hygiene vaccines in local confirmed cases, however, due to predominate close proximity to the ocean and the ready availability of Strong antibiotic sea food, Salmonella, campylobacter and other foodborne illness remain potential continuing infectious risk. stewardship; education in Viral Diseases / Varicella: 2016 continued higher than normal rate of varicella in student populations that have community not been vaccinated and risk for increase secondary infections, especially in older individuals. Risk to healthcare Travel education systems, and patient populations. Hand hygiene
Hepatitis: Caused by a virus found in the liver can be acute or chronic. Hepatitis B can be prevented by vaccine, Hepatitis C has no vaccine and can sit dormant for. It is transmitted through blood and body fluids exposure. HBV / HCV is endemic in Mexico and South America, who were born / raised areas where HBV / HCV are endemic.
Travel Related Illness: large number of tourists in Florida each year, with the significant potential and risk for the importation of diseases into the state. Risk of travel related illness depends on destination and traveler characteristics.
Antimicrobial Resistance: 2016 showed an increase in antibiotic resistance specifically with Streptococcus pneumoniae, Carbopenem-resistant Enteobcteriaceae (CRE), MRSA has decreased proportionally in central Florida, however continues to be higher in 25-64 yr. olds
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HOSPITAL RISK ASSESSMENT CHARACTERISTICS THAT MAY CHARACTERISTICS THAT DECREASE RISK CARE, TREATMENT AND SERVICES INCREASE RISKS PROVIDED Infectious patients requiring critical care / ICU / ISU/ Trauma trauma patients, critical surgical patients Negative pressure isolation rooms Decrease nutritional intake Board Certified RN staff (ALS, CCU) Critically ill, critically injured patients Multiple Invasive Line / devices Oral hygiene-oral care Q4-6 hr. /CHG Q 12 hr. Post open heart, transplant Ventilators, immune compromised patient Strict hand hygiene practices, CHG before shift, after lunch. High antibiotic utilization VAP bundle Lack of hand hygiene Central Line kits , full body drapes, CHG HCW declination of immunization CLABSI bundle implementation and surveillance. Central lines, urinary catheters VAE Florida Hospital Association collaborative, CLABSI PI group
Behavioral Health and Rehabilitation Poor nutritional status Nutrition status reviewed Services High infectious disease Physical, speech & occupational therapy immune compromised patients Education staff and patients infection prevention Decreased or no mobility Employee annual Flu vaccine / immunization Inpatient, outpatient, day treatment Poor decision processes Compliance with hand hygiene: patients and HCW psychiatric services
Inpatient rehabilitation facility, outpatient HCW declination of immunization rehabilitation services Lack of hand hygiene
Dialysis Infectious Disease M.D / Nephrologists champions Greater incidence of Infectious disease Certified, highly trained nursing staff Dialysis / Medical Surgical (i.e., TB, MRSA, VRE, C. difficile, ESBL’s) Negative pressure isolation for suspected or confirmed cases of M. Pneumonia tuberculosis and other infectious diseases requiring airborne General Medical, Surgical Tissue/Wound Infections isolation. Infectious Disease Vascular access infections Patient placement (i.e., infectious patients admitted to isolation HCW declination of immunization rooms away from immune compromised patients) Lack of hand hygiene Highly trained / Renal / Dialysis Certified (CDN) nursing staff Central lines, urinary catheters Employee annual influenza vaccination Compliance with hand hygiene Post op Surgical Site Infection (SSI) C- HVAC system, environmental in core within standard Orthopedics/ Neurology-Spine Center Section Aseptic techniques on postoperative care/surgical wounds by Immobility trained staff Surgical /post op surgical unit Colon surgeries Hand hygiene & surgical scrub monitoring Orthopedic Lack of HCW Immunization Compliance with antibiotic stewardship, and OR antibiotic standards Neurology Lack of hand hygiene within one-hour prior to incision, glucose control, VTE, temperature. Central lines/ urinary catheters
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HOSPITAL RISK ASSESSMENT CHARACTERISTICS THAT INCREASE CHARACTERISTICS THAT DECREASE RISK CARE, TREATMENT AND SERVICES PROVIDED RISKS
Labor & Delivery / PICU /NICU Mothers < 18 yr. / poor nutritional status Highly educated, certified RN staff (CPN, ALS) low birth weight infants Consistent Prenatal care Mother with MDRO / Infectious Disease Mother vaccination status up to date Obstetrics & Gynecology Multiple lines Good nutritional status of mother Delivery Ventilators Healthy neonate birth weight Surgical Delivery (C-Section) Post op / post-delivery infection High APGAR score of neonate Operating Room HCW declination of immunization Employees annual Flu vaccine, other immunizations Poor hand hygiene Hand hygiene compliance, OR scrub compliance Lack of standardized sterile processing Standardized sterile processing
Comprehensive Cancer Center Immune compromised patients undergoing Highly trained / certified nursing staff, board certified, chemo therapy (OCN) others have extensive training by the OCN nurses. Oncology patients HCW declination of immunization Segregation of infectious patients with triage of staff Induction chemotherapy Lack of hand hygiene assignments Surgical Oncology post-op Construction / renovation Employee annual influenza vaccine, compliance with Infectious disease/ vaccine Post op wound /infection Compliance with hand hygiene High compliance with standard precautions
Emergency Department Infectious patients who present to ED that Patients are triaged for respiratory illness upon entering are not segregated Isolation for patients suspected of having an airborne All types of emergent and urgent patient populations up to Unknown evolving infectious disease (ex: infectious disease ASAP after arrival Level III trauma. Ebola, MERS, etc.) ED and other hospital staff participate in statewide Potential for presentation of highly infectious emergency preparedness disaster drills and Volusia Largest emergency dept. in state of Florida- 120 beds diseases County Department of Health Syndromic Surveillance. Violent patients, visitors Personal protective equipment (PPE) and HAZ MAT To include: Psychiatric ED, Obstetrics ED, Pediatric ED, Trauma patients equipment available through Halifax Emergency Level II Trauma HCW declination of immunization Management / Florida / Volusia County Emergency Lack of hand hygiene Management. Fast moving environment increases Practice decontamination / transport procedures – disaster likelihood for injury or error exercise Employee--updated immunizations / annual influenza vaccination ED staff trained in crisis prevention intervention
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HOSPITAL RISK ASSESSMENTCARE, CHARACTERISTICS THAT INCREASE CHARACTERISTICS THAT DECREASE RISK TREATMENT AND SERVICES PROVIDED RISKS
Keech Street Community Clinic / Outpatient Mothers < 18 yr. / poor nutritional status, low Consistent Prenatal care clinics/ Twin Lakes income Mother vaccination status up to date Lack of immunization in pediatrics Employees annual Flu vaccine, up to date with Pediatrics HCW declination of immunization immunizations Plastics Poor hand hygiene Hand hygiene compliance /employee IC education Oncology Sterile processing issues Standardized high level disinfection processes Sports Medicine clinic Invasive procedures Standardized storage of vaccine /other injectable Outpatient Surgery Storage vaccines medications Lack of hand hygiene Lack of knowledge of infection prevention
Hospice Centers Immune compromised Highly trained / certified nursing staff, End of life Multiple care needs met HCW declination of immunization Segregation of infectious patients with triage of staff End of life care Lack of hand hygiene assignments Infectious disease/ Employee annual influenza vaccine, compliance with Grief process vaccine Multiple care needs patient /family Compliance with hand hygiene High compliance with standard precautions
Port Orange Medical Center / Deltona Emergency Infectious patients who present to ED that Patients are triaged for respiratory illness at admission are not segregated Isolation for patients suspected of having an airborne HHPO Unknown evolving infectious disease (i.e. infectious disease ASAP after arrival All types of emergent and urgent patient populations, Ebola, MERS, etc.) ED and other hospital staff participate in statewide medical surgical unit, oncology, OR Potential for presentation of highly infectious emergency preparedness disaster drills and Volusia diseases County Department of Health Syndromic Surveillance. Deltona Violent patients, visitors Personal protective equipment (PPE) and HAZ MAT Free standing emergency department currently under Trauma patients equipment available through Halifax Emergency construction of a 110 bed tower Oncology /immune compromised Management / Florida / Volusia County Emergency Post op complications Management. Construction Practice decontamination / transport procedures – disaster HCW declination of immunization exercise Lack of hand hygiene ED staff trained in crisis prevention intervention Fast moving environment increases Best practice in post op surgical care likelihood for injury or error Highly skilled /trained oncology, surgical staff
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
ANALYSIS OF INFECTION PREVENTION AND CONTROL DATA 2016, 2017
Patient Safety
Collected/Tabulated/ Important Aspects of Care Indicators Benchmarks Data Source Data Collection Sample Reported
Hand Hygiene Compliance Hand hygiene Direct observation Infection Prevention 2016, 2017 2017 Halifax Press Ganey Observations : Goal 89% IHI benchmark with approved or designee, Unit Director data 74.5% Direct & Indirect data collection tool /Manager/dept. staff Baseline data High risk Press Ganey Avg. 90.6 Temporary Duty staff / 2015-2016 2016 rate: 86% * High volume Halifax goal 2017: Volunteer collection, Press 2017 rate: 81% * Problem prone 89% Ganey Scores Report: IC Committee
*”secret shopper”
Prevention of Central Line Bacteremia NHSN benchmark Chart review, Infection control via reports 100% of all 2016-2017 Associated Blood Stream related to central review of micro / for line days, evaluation inpatients Infections--CLABSI lines SIR < 1, Rate < 0.5 lab cultures and review of positive with positive Rate > SIR 1.304 central line days. blood cultures of patient blood cultures 33 CLABSI 2016/ 2017 ICU, NICU, PICU, with central lines, mostly that have High risk CLABSI – other clinical retrospectively central line. Report: IC Committee, High-volume ICU,NICU, and areas. CLABSI Committee Problem prone system wide
Prevention of Surgical Site Class I Surgery NHSN benchmark Surgeon lists of EMS reports, report from all positive 2016 Infections--SSI HPRO, KPRO, procedures units, cultures on Class I SSI 27 CABG, LAMI, Class I <0.651 , NHSN data, Microbiology / Lab, census wounds Class II SSI 37 FUSN, PACE Class II < 2.2 medical records, admission data High risk finance dept./ 2017 High volume Class II Surgery coding retrospective data review Class I SSI 25 Problem prone CSEC, COLO, COLO, HYST reported Class II SSI 32 HYST, XLAP into NHSN and IC Committee only *cluster report to IC Committee
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
ANALYSIS OF INFECTION PREVENTION AND CONTROL DATA 2017
Patient Safety
Important Aspects of Indicators Benchmarks Data Source Data Collection Sample Collected/Tabulated/Reported Care
Prevention of Urinary tract Positive lab/micro IC dept. via All positive 2016 Catheter Associated infection related to NHSN Benchmark reports, micro/lab reports, urine micro /lab CAUTI 35 SIR 1.35 Urinary Tract urinary catheter committee, staff, staff report, reports on Infection SIR < 1 isolation list, committee reports patients with a 2017 CAUTI CAUTI medical records urinary catheter CAUTI 43 SIR 2.04 currently or High Risk Goal < NHSN /zero Retrospective data within 2 days. Report into IC Committee, CAUTI High Volume review Committee Problem prone 2016 Prevention of Surveillance of multi- Halifax surveillance rates Infection Control , Review of all CDI 87 SIR 0.982 Multi-Drug Resistant drug resistant as baseline and utilize Lab/ Micro culture Microbiology, positive cultures MRSA 9 SIR 1.020 Organisms organisms review, isolation pharmacy, staff, from Micro/lab 2017 NHSN benchmark reports EVS, retrospective CDI 71 SIR 0.843 High-Risk, High MRSA, VRE, CDI, CDI SIR < 1 review MRSA 4 SIR 0.585 Volume ESBL, CRE, CDI Problem prone *CRE, VRE ESBL below benchmark Report: IC Committee
Evidence based literature Influx of Infectious and other Infection Control Surveillance data, Infection Control Monitoring No increase in infectious disease, Diseases Monitoring of / Emergency Planning Isolation reports, All hospital and actual events, not influx of disease noted. Emergency infectious diseases resources. Emergency dept. contracted medical increase in Management into system in reports, / nursing specific High potential with 2016 and 2017 Biological specified time frame Evaluate against criteria Florida Dept. of employees, organism per hurricane season, Daytona Bike Management set up by the Emergency Health / Volusia ancillary, volunteer, lab, ED, Volusia week, Daytona 500 due to increased Management Plan, , County Health administrative staff; County, tourist population Pandemic Influenza Plan / Dept. Emergency dept., High-risk Ebola Virus Disease Plan, employee health Problem prone etc. Volusia County DOH
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
PRIORITY PRIORITIZED RISK
1 Hand Hygiene Compliance – Halifax Health system wide
2 Catheter Associated Urinary Tract Infections –CAUTI Reduction / Elimination
3 Ventilator Associated Events—VAE reduction
4 Surgical Site Infection—SSI reduction
5 Antibiotic Resistance /Clostridium difficile Infection—CDI Reduction / Elimination
6 Central Line Associated Blood Stream Infections—CLABSI Reduction / Elimination
7 Multi-Drug Resistant Organisms—MDRO Reduction / Elimination
8 Healthcare Worker—Bloodborne Pathogens, Infectious Disease Exposure—Policy, Process, Education
9 Infection Control Emergency Management: Biological Risk /Influx Infectious Patients, Policy, Process, Education
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
HAND HYGIENE COMPLIANCE
FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION RISKS GOALS STRATAGIES Responsible Method and Evaluation Timeframe Persons of Effectiveness Risk of Data to IC Committee / infection from Overall Halifax Health Hand Hygiene task force to be formed to Infection Prevention, units. Monitor data / compare lack of goal is 100% compliance. develop process improvement project, data IC Committee, unit Monitor and trend data data, annual trends to compliance collection and educational strategies. Directors, Executive monthly assure decrease rates with healthcare Increase employee hand Leadership worker (HCW) hygiene compliance from Patient education to be completed, via Initiate team Q1 2018 Hand Hygiene 2017 average of 81% to Patient Safety Fair, Infection Prevention determine efficacy of tool Data collection monthly via 90% Maintain or increase week, posters, etc. Hand Hygiene task / data collection. HH collection tool developed ALL Locations rates: determine “real” force (sub-group of New marketing signs / and approved by task force. rates Round on units, approach HCW that do not IC Committee) patient handouts, iScrub, Utilize APP based system cleanse hands EMS module-HCW. for collection. Goal 2017 89% Develop new educational brochures and Q3 2018 Discharge Monitor for compliance, Goal 2018- signage for family and visitors of patients family brochures / educate correct HH 92% Increase staff / physician on the importance of hand hygiene education on hand observation /documentation, engagement hygiene & Infection monitor HCAPS Increase compliance rate Consider iScrub or similar APP to monitor. prevention Implement Task Group to Utilize temporary duty staff and volunteers ALL employees, all Trend and evaluate data for address HH in system, to help with observations healthcare workers All unit based data to increased compliance, at any Halifax Health Directors/staff. report out monthly to units to Ultimate goal is 100% Work with state HAI group developing a location Implement iScrub post statewide initiative for hand hygiene and education, HH will be part of a state wide study expectations to all staff by end of Q1 2018 Quarterly report to IC Add hand hygiene as condition of Committee, Patient Safety / employment, annual evaluation. Quality Committee, Medical All Physicians, Q4 2018-MD /LIP Executive Committee, Board Display data on all units extenders, education completed. of Governors volunteers and contracted staff, and students
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
EMERGENCY MANAGEMENT—RISK OF INFLUX OF INFECTIOUS DISEASE, BIOTERRISM
FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION
RISKS GOALS STRATEGIES Method and Responsible Timeframe Evaluation of Persons Effectiveness
Collaborate with employee Review /update Exposure Monitor and compare Blood Borne To decrease employee / health and develop process Infection Prevention & Control Plans: BBP /TB sharps injuries from Pathogen exposure Physician injury from to address and trend sharps Control Dept. Plan Q2 2018 2015, 2016 and 2017 (BBP)- sharps injuries sharps. Determine actual injuries with all disciplines. confirm decreasing Risk of infection baseline from the last 3 Employee Health Dept. Develop sub-committee by trend. years end of Q2 2018 with secondary to lack of Determine active staff and IC Committee recommendations and Monitor and compare immunization / immunity To increase employee / active medical staff immune evaluation completed and employee and physician of infectious disease or Physician annual status with MMR, Varicella, Environment of Care presented to IC Committee, immunization rate 2015 virus, Annual tuberculin vaccination for Influenza and Pertussis. TST/Fit Test Committee & Environment of Care by and 2016, 2017 Skin Test (TST) /Fit from Encourage vaccination with end of Q3 2018 Test compliance, high 1:1 education as needed. Sr. Executive Leadership Monitor and compare rate of new onset HIV / Determine staff that do not IC/ EH to determine employee & MD Hepatitis C in have updated immunization Condition of employment for Dept. /Service Line process for evaluating staff compliance with annual community status/ IC access employees, and Bylaws Directors that are current with influenza vaccine 2015 reflect condition updated requirements for and 2016, 2017 for
Standardize sharps requirement for Physicians Medical Staff /Medical immunization by Q3 2018 increasing trend Sharps Injuries throughout system Executive Committee BBP exposure –PPE Lecture series education on Update policies and Monitor employee use Develop Sharps Injury Infectious pathogens / procedures to conversion with vaccine Influenza protocol viruses and how they accommodate changes preventable disease. Varicella impact patient safety Q2 2018 address increasing Measles Assure accountability/ compliance with annual Review all sharps & Mumps compliance with TST /Fit EH / IC to increase influenza vaccine, masking infectious disease Pertussis Testing education to all staff / requirements. Goal: 100% exposure with FMEA /R physicians regarding annual RCA TST/ Fit Test -annual Influenza vaccine.
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
RISK OF CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS (CLABSI) FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION
RISKS GOALS STRATEGIES Method and Responsible Timeframe Evaluation of Persons Effectiveness
Capture accurate line days in the Infection Prevention Dept. Reduce CLABSI to Retrospective review of Risk of Central Line ICU / other units, areas in Decrease CLABSI house- less than NHSN house-wide data for Associated Blood Meditech wide to less than the NHSN PICC RN / DI Team mean pooled rates baseline to be completed Stream Infections mean pooled rate of 0.5 and and /or SIR < 1, in by IC by Jan 2018 (CLABSI) Educate staff in contamination /or < 1 SIR Physicians (Intensivists, ED all units, all areas, Continue review prevention of blood cultures, thus MDs, hospitalists) all locations by reducing # of false positive Minimize central line-related Q4 2018. Prospective surveillance contaminants. bacteremia by following ICU Staff /Nursing all unit of all central lines.
2016 thru 2017 best practice guidelines— CLIP Data Utilize Chlorhexidine 2% for all develop bundles Ancillary Staff (ICU and ER education / input Concurrent surveillance central line skin preps prior to technicians) into Meditech for to monitor rates. 33 CLABSI insertion and line care. CLIP- Central Line Insertion compliance with
Practice compliance Infection Control Committee CDC standard Quarterly reporting of SIR 1.304 Central line dressing kit with CHG Q3 2018 CLABSI IC Committee, 2% skin prep. Decrease use of femoral Lab Dept. & all units Customized Central Line Kit with site insertions. Review blood CHG prep, mask, full drapes, NHSN – SIR < 1 CLABSI PI Team culture gloves, and needle safety contamination data, designs, continue utilization of Increase use of PICC RN nursing antimicrobial patch. for CL placement outside of contamination data IV Protocol revisions based on ICU by Q3 2018 current evidence based
guidelines
Evaluate PICC RN program for
efficacy and quality & increase
presence with care /
maintenance of central lines
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
RISK OF INFECTION MULTI-DRUG RESISTANT ORGANISMS (MDRO)
FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION
RISKS GOALS STRATEGIES Method and Responsible Timeframe Evaluation of Persons Effectiveness
Hospital acquired To reduce Continue utilizing reduction strategies as Infection Control Dept. Data reported out daily on Decreased rate of Infection from preventable outlined by APIC, CDC, TJC, CMS and quality indicators / admission of infection from MRSA Multi-Drug infection from Florida Dept. Of Health. Clinical staff, RN high risk patients. Continue hospital wide by Q4 Resistant occurring in process. Bioquell 2018 compared to 2017 Halifax Health Remain in compliance with CDC, FDOH, Physicians communication. NHSN SIR < 1 Organisms patient Volusia County guidelines. Continued IC population surveillance , reporting and monitoring of all EVS Data to unit Directors monthly Goal: Specialized MRSA positive HAI / MDRO with goal of reviewing infection education & training with Clostridium IC Committee on units in “real time” process the IC Department to be difficile Increase staff / Actively engage employees in prevention of start date Q1 2018 completed by clinical VRE MD infection/ Annual education updated to Patient Safety / Quality staff and designated ESBL engagement include current best practice with Isolation Quarterly data to ICC with ancillary staff prevention CRE with infection IT Department quarterly data to units for of infection by Q4 2018. prevention Update education to Environmental display by Q1 2018 Services staff on prevention of infection / Sr. Leadership CBL and education to
environmental cleaning CBL Annual IC education to (active) MD/LIP to be Review / revise Standardize processes in system. Dept. Directors reflect Antibiotic Stewardship completed by Q4 2018 Isolation Q3 2018 MRSA Bacteremia policies, patient Implement data mining- will increase the Pharmacy 2016-2017 and staff time of notification of infection, increase education patient safety, and improve documentation Complete mandatory training 13 infections information with improved coding of true hospital with all EVS staff by Q4 2018. NHSN SIR 1.1 acquired conditions. Goal to engage in prevention of infection / importance of Antibiotic Stewardship education to all MD thorough and correct all clinical staff environmental cleaning. Standardization in system. Review HO colonization of MRSA by unit
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
RISK OF CATHETER ASSOCIATED URINARY TRACT INFECTION (CAUTI) FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION
RISKS GOALS STRATEGIES Method and Responsible Timeframe Evaluation of Persons Effectiveness
Risk for Catheter Decrease CAUTI , with goal Point prevalence study to determine Point prevalence Decrease in CAUTI 2018 Associated Urinary of elimination CAUTI to < issues with care /maintenance Unit Directors study to be all units, all locations Tract Infection NSHN SIR 1.0 completed Q2 2018 Provide staff with written and verbal Education Evaluate lab cultures daily (CAUTI) Clinical data review of instruction on proper placement, care Review process & coded CAUTI via IC / Education Department. IC Dept. / IC equipment all units, Run reports quarterly to 2016 35 CAUTI Committee all locations Q2 2018 validate NHSN SIR 1.35 Standardize processes for Consider participation with CUSP insertion, care & process. CAUTI PI Team “mini” Root Cause Trend data by unit 2017 43 CAUTI maintenance of urinary Analysis and + quarterly NHSN SIR 2.04 catheters Review RN driven protocol that allows Clinical Staff CAUTI by end of Q1 RN determination of catheter removal. 2018 RCA implementation at Barriers to process Physicians bedside- “real time” Provide IC
Provide ongoing feedback to units on Committee with data Follow up with Medical UTI infection rates. Post rates/ data. and mechanisms for Records / coding improvement by Q2 regarding CAUTI and to Add catheter care, insertion to annual 2018 clinically review as Nursing Skills / Competency to maintain requested. HAC /Infection current information All clinical staff who process. place urinary Compliance with all current standard of catheters to have practice to determine necessity competency completed / signed off by August 2018
Formalize review process of coded data by Q4 2018
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HALIFAX HEALTH SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
RISK OF VENTILATOR ASSOCIATE EVENTS (VAE) FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION RISKS GOALS STRATEGIES Method and Responsible Timeframe Evaluation of Persons Effectiveness
Risk of Infection Decrease the number of Reorganize the VAE Respiratory Therapy Attend all webinars with Rates will decrease in a associated with Ventilator associated events Committee Florida Hospital Association steady manner Ventilators (VAE) by no less than 50% Infection Prevention Q4 2018 Participate in Florida Evidence based Decrease the number of Hospital Association state- ICU, ISU, Resurge VAE Committee Ventilator Associated practices will be Ventilator Associated wide Collaborative to Q1 2018 implemented to prevent Events (VAE) and Pneumonia (VAP) by no prevent VAE Intensivists Probable Ventilator infection less than 50% Review all baseline data Associated Implement evidence based Trauma /analyze and present to Complete collaboration Pneumonia (PVAP) Implement evidence based practices as defined by VAE Committee, IC with FLHA practices to decrease research, not choice Emergency Department Committee by Q1 2018 /eliminate risk of VAE Present PI project to 2016 –99 VAE, 25 Physician engagement with VAE Committee Develop and present Quality Committee PVAP VAE Committee project, evidence and Ultimate goal is ZERO change implemented to Data to be reported into ICU, ISU, Trauma, ED Quality Committee Q2 2018 IC Committee, VAE 2017—92 VAE, 22 engagement with VAE PVAP Team, MEC, and Board Committee of Governors
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RISK OF ANTIBIOTIC RESISTANCE—Risk of Increase in Clostridium difficile infection (CDI)
FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION
RISKS GOALS STRATEGIES Method and Responsible Timeframe Evaluation of Persons Effectiveness
Approved by Infection Control Committee - 1/17/18 Submitted to Medical Executive Committee – 2/2/18 via email & 2/5/18 meeting (Approved by Dr. Margaret Crossman & Dr. Steven Miles)
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HALIFAX HEALTH COMMUNITY SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
Risk of Antibiotic Continue to evolve the ASP committee to review current best Infection control ASP Committee to Review use of antibiotics Resistance Antibiotic Stewardship practice guidelines to determine review current without culture— Program (ASP) process and goals for ASP Pharmacy standards to update Pharmacy to monitor and Risk of Increase in ASP process Q3 report into ASP Educate all clinical staff Collaborate with marketing /education Quality Department 2018 Committee Clostridium difficile /Medical staff on ASP to develop CEU education for clinical Infection (CDI) process, & current staff on ASP / CDI. Infectious Disease Develop plan of standards of practice MD action with marketing Review Antibiogram and Hospital Onset CDI Develop CBL for all clinical staff on /Medical Staff for resistance patterns for all Community education on ASP and CDI reduction IT CEU complete by Q4 units and all locations for 2016 87 HO CDI ASP and CDI 2018 changes in susceptibility NHSN SIR 3.19 Review resistance patterns and ICU / ED Decrease hospital onset Antibiogram. representatives Update CBL for Evaluate infections, 2017 73 HO CDI CDI clinical staff to antibiotic use Implement infection prevention data incorporate ASP and NHSN SIR 2.77 Data mining system to allow mining for early intervention, patient CDI Q3 2018 Work with Pharmacy and
for early intervention safety ASP Committee
Assess, Review data
Implement early recognition / isolation mining vendor- apply
process for CDI for Capitol by Q3 Report all data to IC 2018 Committee, MEC and Board of Governors Attend Staff meetings on all units, all locations to discuss CDI and ASP by Q4 2018
Implement CDI lab/ isolation process by Q2 2018
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HALIFAX HEALTH COMMUNITY SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
RISK OF SURGICAL SITE INFECTION (SSI) FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION RISKS GOALS STRATEGIES Responsible Method and Evaluation of Timeframe Persons Effectiveness
Risk of Surgical Minimize risk of Staff training and education on wound care & post Decreased or elimination of Site Infection infection pre- op infection prevention by IC / Education / RN Education, annual Training & education Class I / II from baseline with (SSI) operatively, intra- specialists RN skills to be completed by expectations of < / = NSHN operatively and post- Q4 2018 mean pooled rate of 0.5%
operatively in all Review current pre-op education regarding Infection (Class I) , / = 4.5 % (Class II) patients requiring infection prevention with Ortho / Cardio / General Prevention / Training / education, NHSN SIR < 1 surgical intervention Surgery/ L&D Quality collaborative effort with Pre-admission Infections are tracked post- Maintain compliance Develop a SSI Prevention Team to determine best Unit Directors team to set up a operatively by Infection with all Surgical practice for ALL surgical procedures preoperatively process for patient Control, Class I/II data to be Care Improvement Surgical Services education on trended, reviewed monthly, and standards of Infection Prevention to educate community facilities Interdisciplinary prevention of SSI for with quarterly reports to practice with shared patients on infection prevention Council all pre-planned OR Directors, Surgical Committee visits (inpatient /
Sterile Processing /OR process improvement MD/Surgeons outpatient) Q3 2018 Active interaction with Peri- Maintain compliance operative services, Surgeons, with FLDOH and Physician engagement /collaboration SPD Director Implement SSI and unit nursing Directors CDC reporting Prevention requirements with Committee Q2 2018 Implementation of Surgical the NHSN Prevention Team Process map /PI Increase project SPD, OR, Observation of sterilization communication and L&D Q2 2018 techniques management of surgical patients IC Director to Review of sterilization logs post op engage local SNF /processes for IC education by Q3 2018 Review or all OR/SPD processes /logs
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HALIFAX HEALTH COMMUNITY SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
INFECTION CONTROL EMERGENCY MANAGEMENT: INFECTIOUS DISEASE, BIOTERRORISM FOR EACH PRIORITIZED RISK, GOALS IDENTIFIED, STRATEGIES, RESPONSIBLE PERSON, TIME FRAME, AND EVALUATION OF EFFECTIVENESS
IMPLEMENTATION
RISKS GOALS STRATEGIES Method and Responsible Timeframe Evaluation of Persons Effectiveness
Surge management of Emergency preparedness Utilize negative pressure Emergency Management Disaster planning/training Evaluate effectiveness with the influx of infectious for patients with highly rooms for those patients Committee and state-wide scheduled Emergency patients, with contagious, infectious with a known or suspected preparedness by Preparedness drills community acquired illness or events. airborne contagion. Infection Control Committee Emergency Management Coordinator, ER Director, or Table top, and review Mass contagion or in event Halifax Health system will Triage incoming patients in Engineering /Facilities designee throughout the Emergency Distribution of bioterrorism, maintain active participation designated area (EOC / EM year as determined by Plan infectious disease or in emergency planning, and policy) during surge. Clinical staff, Physicians FLDOH, Volusia County other infection risk FLDOH and Volusia County and Emergency Maintain NIMS training by disaster drills. Compliance with policies Environment of Care Management Coordinator. all staff, MD’s, regarding safe Committee As determined 2018 See also: Emergency Infection Control to work transportation of infectious Competency training lists of Management Plan, collaboratively with patients & influx of people All other hospital Review current Infection staff maintained by HR or Hazard Vulnerability Emergency Management with infectious diseases. personnel as required process within plan and employee Manager. Coordinator / Emergency (isolation policy) update as needed, and Analysis Management Committee to review annually with IC
assure consistency in Continue planning with Committee and EOC Monitor /review current
training, education and EOC with Emergency By Q4 2018 plans and develop plans for
documentation distribution Preparedness Plan and other evolving diseases
Bioterrorism with Biological NIMS 100 to all staff by Q4
Incident Management Agent Plan. 2018
training employees, MD
NIM’s 100, 200, 700 all Develop Mass Emergency
Hazmat training Directors / Leadership via Distribution plan: Drill plan
CBL, with additional training by Q4 2018
for Directors / Managers as
required. Presentation to
Management.
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HALIFAX HEALTH COMMUNITY SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
Signature on file______Margaret Crossman, MD Date Chief Medical Officer
Signature on file______Steven Miles, MD Date Vice President, Chief Quality Officer
Signature on file______Debra Johnson, MPH, BSN, RN, OCN, CIC Date Director, Infection Prevention and Control Infection Control Officer
REVIEWED: Reviewed/ Approved by Infection Control Committee Jan. 22, 2018 Pending: MEC, Board of Commissioners March, 2018
Note: Replaces 2016/2017 FY format
ORIGINATING DEPARTMENT: INFECTION PREVENTION & CONTROL
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HALIFAX HEALTH COMMUNITY SYSTEM INFECTION PREVENTION & CONTROL RISK ASSESSMENT & PLAN 2018
Page 161 of 294 Halifax Health Performance Improvement Plan
Halifax Health Medical Center Performance Improvement Plan 2018
Halifax Health Approval: Approved by Quality Council – 12/15/17 Approved by Medical Executive Committee - 1/16/18 Approved by Patient Safety Committee – 1/24/18
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Halifax Health
Halifax Health is one of Central Florida’s leading providers in healthcare as well as being one of the largest employers with just over four thousand employees dedicated to offering superior patient centered care. Founded in 1928, Halifax Health is a 678 bed facility, governed by a Board of Directors and one of fifteen legislatively-chartered taxing district healthcare systems in Florida. With over 500 physicians on staff representing 46 medical specialties Halifax operates two hospital locations in Daytona Beach and Port Orange plus the county’s largest hospice system. Being the area’s only trauma center, 24-hour NICU and PICU, pediatric emergency department and catering to 25,000 admissions and over 120,000 emergency room visits annually, Halifax Health fully comprehends the responsibility we have to our patients and their families by providing a safe, efficient and an effective environment of care. The Halifax Health Performance Improvement Plan and its leadership is committed to performance improvement through assessing the plan on a continuing basis while making revisions that meet the goal of ensuring that patient outcomes are continually improved and excellent patient care is provided.
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Table of Contents Halifax Health Performance Improvement Plan Topic Page Halifax Health 2
Mission, Vision & Values attachment 3
Executive Summary 4
Introduction 5
Vision 6
Objectives 7
Design & System Strategies 8
Performance Measures 11
Communication of Results & Improvements 14
Performance Improvement Communication Structure attachment 16
Quality Structure & Action Flow attachment 17
Performance Improvement Model and Process 18
Lean tools, DMAIC Process and Project Charter 19
Performance Improvement Glossary 22
References 24
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Introduction
The Halifax Health Performance Improvement Plan is designed to systematically and objectively evaluate the Health System’s performance, and to facilitate implementation of improvement strategies and methodologies to support the Halifax Health mission, vision and values as endorsed by The Joint Commission and our Board of Directors. The intent of the Halifax Health Performance Improvement Plan is to ensure patient safety and optimal outcomes of care by identifying the approach to improving and sustaining performance through the prioritization, design, implementation, monitoring and analysis of the Halifax Health performance improvement targets. Our improvement plan is ongoing and analyzed annually for its effectiveness, efficiency and accuracy by the Halifax Health Board of Directors, Halifax Health Quality Council, Executive Leadership, Medical Staff and the Chief Quality Officer.
Our approach to improvement adheres to the regulations of Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC) and the Quality Assessment & Performance Improvement (QAPI) Plan. The Halifax Health Performance Improvement Plan will utilize both internal and external resources in an effort to improve the design and implementation of the plan. Our organizational approach to performance improvement is guided by, but not limited to, the following standards:
CMS Condition of Participation (CoP) 42 CFR §482.21: The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement plan. The hospital’s governing body must ensure that the plan reflects the complexity of the hospital’s organization and service; involves all hospital departments and services; and focuses on indicators related to improved health outcomes and the prevention and reduction or medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.
PI.01.01.01 The hospital collects data to monitor its performance
PI.02.01.01 The hospital compiles and analyzes data
PI.03.01.01 The hospital improves performance on an ongoing basis
LD.01.03.01 The governing body is ultimately accountable for the safety and quality of care, treatment and services
LD.02.03.01 The governing body, senior managers and leaders of the organized medical staff regularly communicate with each other on issues of safety and quality
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Page 166 of 294 Halifax Health Performance Improvement Plan LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the hospital
LD.03.02.01 The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality
LD.03.03.01 Leaders use hospital-wide planning to establish structures and processes that focus on safety and quality
LD.03.04.01 The hospital communicates information related to safety and quality to those who need it, including staff, licensed independent practitioners, patients, families and external interested parties
LD.03.05.01 Leaders implement changes in existing processes to improve the performance of the hospital
LD.03.06.01 Those who work in the hospital are focused on improving safety and quality
LD.04.04.01 Leaders establish priorities for performance improvement
LD.04.04.05 The hospital has an organization-wide, integrated patient safety program within its performance improvement activities
Vision
Halifax Health has initiated a commitment to its patients, visitors and staff based on our Cornerstone Common Purpose to provide exceptional service, every encounter, everyday to everyone aligned with our organizational quality standards. In adhering to this philosophy, Halifax Health has developed a realistic and achievable Performance Improvement Plan based on evidence and proven opportunities to allow us to create an environment for exceptional care. Our mission to be the community healthcare leader through the vision of developing talented teams dedicated to providing competent, accountable patient centered healthcare in a financially sustainable manner is the core of the improvement plan.
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Common Purpose: Exceptional Service
Every Encounter
Everyday to Everyone. Incremental
Organizational Quality Standards: Safety
Compassion
Image
Efficiency
Objectives
The hospital’s approach to performance improvement is assessed on an ongoing basis, and is revised. Halifax Health sets forth a core compilation of objectives to provide the highest level of patient care possible. The hospital recognizes that in order to be effective at achieving the triple aim, there must be an integrated and coordinated approach to performance improvement. The following provides a foundational overview of the objectives of our Performance Improvement Plan:
1. Continually assess, revise and evolve the structure that efficiently and effectively promotes performance improvement throughout the organization
2. Improve the data flow and direction of outcome information within Halifax Health
3. Implement root cause analysis studies such as, cause and effect (fishbone) diagrams and the five “whys” diagram to identify problems and the underlying cause (see Root Cause Analysis attachment) from an organizational down to a unit level
4. Improve hospital wide monitoring, measurement and analysis of quality metrics via the Quality Council through a process of review, evaluation and recommendation (See Communication Process attachment)
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Page 168 of 294 Halifax Health Performance Improvement Plan 5. Maintain a facts-driven performance improvement plan promoting the use of systematic monitoring and continuous improvement
6. Align performance improvement efforts with those of Halifax Health’s mission, vision and values as well as the organization’s annual goals
7. Identify and drive performance improvement initiatives that will best align with, but not limited to, the CMS adopted goals of strategy, effective, efficient, patient centered, timely and equitable quality of care
8. Utilize Lean and Six Sigma in the performance improvement plan to help standardize the approach, tools and language used for performance improvement across the organization
9. Continue to monitor the effectiveness of the Performance Improvement Plan and make revisions as necessary
Design & System Strategies
When designing or redesigning Halifax Health’s Performance Improvement Plan, the following key elements are considered relevant and available:
1. The organization’s mission, vision and values 2. Organizational strategy and goals, which incorporate the needs and expectations of patients, staff and visitors 3. Research of current literature and/or industry best practice(s) 4. The fundamentals of Lean and Six Sigma as part of our common approach, (DMAIC: Define, Measure, Analyze, Improve, and Control) 5. Performance trends and national benchmarks
Ultimate oversight of the Halifax Health Performance Improvement Plan rests with the Board of Commissioners. The plan will be guided on an ongoing basis by the Chief Quality Officer and Senior Executive Leadership in conjunction with the Quality Council, which includes Board representation. Quality Council includes performance summary reports as well as performance improvement project presentations. Accountable parties are available for further explanation and elaboration on action plans. Communication in the council is both open and encouraged with the highest level of respect toward each individual present during the meeting. The Quality Council has the ability to assign responsibility of projects to specific areas along with the oversight to request further follow-up analysis.
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Page 169 of 294 Halifax Health Performance Improvement Plan Roles and Responsibilities
Patient Safety Committee The Patient Safety Committee is an interdisciplinary committee charged with the coordination and implementation of programs for ensuring patient safety within Halifax Health, including directing and overseeing proactive risk reduction and patient safety. This Committee evaluates trends from quality reports, adverse event analysis and other sources and recommends appropriate actions to improve patient safety and quality of care.
The Committee’s membership, authority and additional responsibilities/duties are outlined in the Patient Safety Plan
Quality Council: The Quality Council assists the Board and the Medical Executive Committee in overseeing and ensuring the quality of clinical care, patient safety and customer service provided throughout the organization. The Council meets this responsibility through the following:
Develop, implement and oversee the Performance Improvement Plan Description of information in the Performance Improvement Plan, progress on action plans and recommendations are all reported quarterly to the quality council committee Designation of a physician leader involved in the performance improvement strategy, development, evaluation and facilitation of council recommendations Conduct reviews of quality metrics, both current and retrospective Make recommendations on policy decisions Identify and direct resources to suspected patient care quality problematic areas Serve as a review body to review patient care quality issues as appropriate Meet quarterly to analyze and evaluate data obtained via quantitative measurement practices to identify problems, barriers to quality improvement and department/unit specific issues as they arise Request reports on performance improvement activities as appropriate Direct eligible providers, staff and departments to initiate monitoring practices of specific performance improvement topics Review action plans as they are submitted and assign follow-up responsibility where needed Recommend goals and objectives with realistic timelines based on valid, factual data Provide quarterly updates to Halifax Health Board of Directors Annually review Quality Council and the leadership of the Performance Improvement Plan for overall effectiveness and make changes as appropriate
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Page 170 of 294 Halifax Health Performance Improvement Plan Board of Commissioners: The Board of Commissioners has ultimate authority and responsibility for establishing strategic policy, maintaining the quality of care rendered at its facilities, and providing for strategic, organizational management and planning. In addition, the Board shall:
Provide for the effective functioning of activities related to delivering quality patient care, performance improvement, risk management, medical staff credentialing, financial management and post graduate education Provide for coordination and integration among its administration and staff in order to establish appropriate policies, maintain quality patient care, and provide for necessary resources, strategic organizational management and planning
Medical Staff: The organized medical staff has a leadership role in organizational performance improvement activities aimed at improving quality of care, treatment and services and patient safety. In this role the medical staff is actively involved in the measurement, assessment and improvement. Halifax Health has adopted a physician-partnership model to ensure physician leadership in all organizational performance improvement initiatives.
Organizational Leaders: The organization’s leaders have the responsibility to create an environment that promotes performance improvement through the delivery of safe patient care, quality processes, quality outcomes, and high customer satisfaction. The leaders perform the following functions: Support a common approach, DMAIC, to performance improvement and set expectations and priorities for organization-wide performance management Ensure a methodical approach is used to identify systemic error-producing factors in patient care activities Participate performance improvement activities in partnership with the medical staff Allocate adequate resources including personnel, time, and data collection systems for assessment and improvement of the organization’s performance Ensure that leaders and staff are trained in the basic approaches and methods of performance improvement and risk reduction, specifically the DMAIC process Analyze and evaluate the effectiveness of the performance improvement activities
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Page 171 of 294 Halifax Health Performance Improvement Plan Prioritization
Priority planning is a systematic process that stems from the Mission and Values, organizational strategic goals and objectives (short and long term), external regulatory requirements, contributions from populations served, contributions from hospital/medical staff and the community. The leaders of Halifax Health plan and set priorities for organization-wide performance improvement. In making those decisions, leaders give high priority to high-volume, high-risk, problem prone processes. Performance improvement initiatives are reprioritized in response to significant changes in the internal or external environment. Analysis of performance improvement findings against regulatory requirements, industry benchmarks and standards provide useful information in evaluating current performance using statistical tools and techniques.
The leaders of Halifax Health set performance improvement priorities in two stages. First, the leadership develops the strategic plan and identifies short and long term goals and objectives then reviews facility wide processes against these strategic goals to identify key processes for review in the coming year. Second, organizational participation in ongoing quality/safety improvement projects at the organization, state and national levels is considered in prioritization decisions in order to ensure continued focus and adequate allocation of resources dedicated to each project.
Performance Measures
Halifax Health Performance Improvement Plan uses monitoring and evaluation data to identify targets for quality improvement. Both quantitative and qualitative data is used for performance improvement measurement. This system-wide approach is comprehensive and is focused on collecting, analyzing, interpreting and acting on data. High volume and high problem prone processes are identified and those associated outcome indicators are measured and evaluated on an ongoing basis. Data sources may include, but not be limited to, the following: internal data obtained from staff, patients, records and observations; data from quality control and/or risk management activities; external sources such as regulators, insurers or the community. The number of ongoing performance improvement projects is proportional to the scope and complexity of services and operations of the organization.
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Halifax Health Performance Improvement strategy consists of collecting valid forms of data consistent with The Joint Commission and CMS guidelines. Indicators may include, but not be limited to the following:
ORYX General Performance Reporting Requirements for hospitals Accountability measures for the following are trended and analyzed to better predict which internal performance improvement goals have the greatest positive impact on patient care: o Readmission rates o Mortality rates Operative or other procedures that place patients at risk of disability or death All significant discrepancies between preoperative and postoperative diagnoses including pathologic diagnoses Adverse events related to using moderate or deep sedation or anesthesia Use of blood and blood components All reported and confirmed transfusion reactions The results of resuscitation Behavior management and treatment Significant medication errors Significant adverse drug reactions Patient perception of the safety and quality of care, treatment or services Patient thermal injuries that occur during magnetic resonance imaging exams Incidents where ferromagnetic objects unintentionally entered the MRI scanner room; injuries resulting from the presences of these objects in the MRI room Incidents where the radiation dose index, dose length product or size-specific dose estimate from diagnostic CT exams exceeded expected dose index ranges identified in imaging protocols
Monitoring Performance
Data collection is systematic and is used to: Establish a performance baseline Reduce the risk of human error Describe process performance or stability Describe the criticality of processes, functions and outcomes Identify areas in need of more focused data collection Sustain improvement over time, the Control phase of DMAIC
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Data analysis is enhanced through appropriate statistical techniques used to analyze and display data. Variation through the use of statistical tools and methods helps focus the attention and resources on making improvement changes to the processes that will result in better outcomes. Examples of statistical tools used in performance improvement may include, but not be limited to: Run charts Control charts Histograms Pareto charts Cause-and-effect or Fishbone diagrams
Benchmarking
Benchmarking with comparative data is emphasized in the framework for a planned, systematic, organization-wide approach to improving processes and outcomes.
Halifax Health utilizes national and regional benchmarking, review of professional literature and participation in comparative studies to support the achievement of best practice processes.
The Joint Commission’s Sentinel Event Alerts are used to assess the high-risk systems and process that are addressed in the alert and consider redesign of processes as warranted.
Analysis
Intensive analysis is performed in order to identify processes to be targeted for change or improvement and to reduce or eliminate the possibility of adverse care outcomes or recurrence of similar outcomes. A root cause analysis is performed when a Sentinel Event occurs. Intense analysis may also be performed when performance patterns or trends vary significantly and undesirably from those expected.
In addition, the organization also works towards continuous process improvement. As part of this approach, performance improvement initiatives are identified and initiated on an ongoing basis. Priority is given to those initiatives that align with organizational goals, mission and vision. These priorities also align with the CMS value programs and TJC. The DMAIC process is followed to improve:
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Define – the problem, stakeholders, process scope and goals Measure – the current state through quantitative and qualitative data collection Analyze – the data and processes to determine root causes and ideal state Improve – by creating a detailed action plan, pilots as appropriate, communication, and plan for spread Control – the improvements through monitoring
Communication of Results and Improvements
The leadership in each performance improvement initiative will be responsible to implement and report on the results of the performance improvement plan for guidance and approval. At least one performance improvement initiative is shared at the quarterly Quality Council in addition to the Patient Safety Committee and other leadership meetings, e.g., the monthly managers’ meeting.
The results of process improvement initiatives will be communicated as appropriate through the organization in an effort to support transparency, share ideas, gain a better understanding of relevant processes, encourage collaboration and instill concepts of continuous improvement into the organizational culture. The findings and conclusions made at the Quality Council will be shared with Senior Executive Leadership, Board of Directors, front line leadership and other involved stakeholders as indicated. The members of the Quality Council will receive a packet with the most recent completed quarter’s quality data along with any ad-hoc requested reports and results of the implemented performance improvement initiatives.
Employees at all levels are engaged in performance improvement activities. The DMAIC approach supports involvement of front-line staff and multidisciplinary teams throughout the process. Early involvement and buy-in not only helps foster better ideas and implementation, but also helps with communication across the organization.
Halifax Health has adopted standard communication models that will also assist with the accountability and communication of performance improvement: 1. SBAR (Situation, Background, Assessment, Recommendation) 2. RACIE (Recommend, Approve, Consult, Inform, Execute)
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Evaluation of Effectiveness of the PI Plan
In order to determine the effectiveness of organization-wide performance improvement activities and improve patient safety, the leaders: Set measurable goals Gather information Use pre-established, objective process criteria Draw conclusions based on findings Implement improvement activities when needed and Evaluate performance over time to ensure sustained improvement
The leaders of Halifax Health continually measure and asses the effectiveness of performance improvement activities, developing and implementing improvements as necessary. During this process leaders assess the adequacy of human, information, physical and financial resources allocated to support performance improvement and safety improvement activities throughout the organization.
Facility and/or department specific performance improvement indicators with sustained performance meeting or exceeding established benchmarks for three consecutive quarters will be considered accomplished and may be retired at the direction of those Committees, Departments and/or Teams responsible for oversight of that measure.
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Performance Improvement Communication Structure attachment
Board of Directors
Chief Medical Executive Officer & Chief Performance Improvement Leadership Quality Officer Communication Process (2014) Credentialing Quality Council Committee
Quality Improvement & Department Chairs Decision Support
Quality Improvement Planning
Functioning OPPE Patient Safety Clinical Risk Core Measure Clinical Sub- Coordination Recredentialing Committee Management Analytics committees Office
Complaints, Functioning Safety reviews, Unit Specific Accountibility Provider specialty Education & Graduate Medical Sub-committees grievences, Planning Measures Metrics Certification Education requested reports
Value based HIM purchasing metrics
Press Ganey Risk Management HCAHPS – Patient (EMS) System Experience
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Quality Structure & Action Flow attachment
Quality Reports to Structure & Goal & Action Quality Council Board of Directors Flow Board of Directors Action Flow
Indirect Chief Executive Officer Oversight
Chief Operating Officer
Chief Nursing Chief Quality Officer VP of Operations Officer Infection Control Committee
Quality Director / Patient Safety officer Director of Infection Control Director of PI
Implementation & Follow-up Improvement Reporting Improvement Workgroup Goals performance Manager of Manager of Quality Regulatory Data DMAIC Compliance Data Mgmt, Collection, Analysis & Reporting
P N Quality Patient Emergency U
O Patient Care - I IP RN Specialist T Improvement Safety OPPE Coord Preparedness
W Leadership C O
A Mgr Coord
Coord L L T N Patient Safety O N O I F E Quality Emergency
T Committee IP RN Specialist M C &
Improvement Preparedness
E (Monthly Mtg) A S V S Mgr Coord E O C R P O Quality IP RN Specialist R M P I Improvement Mgr IP RN Specialist PI Teams Improvement Quality Goals Improvement Mgr
HIIN Work Groups HIIN Work Quality Council Groups Reporting & HIIN Advisement Work Groups
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Performance Improvement Model and Process
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Lean tools, DMAIC Process and Project Charter In instances where organizational performance improvement targets need additional or advanced analytical resources to achieve goals the below toolkits are available
LEAN Tools
• Fishbone Diagrams – Also called Cause-and- Effect Diagram or Ishikawa Diagram
• 5 Whys – Number of iterations typically required to resolve the problem
• Pareto Analysis
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Page 180 of 294 Halifax Health Performance Improvement Plan The 8 Wastes of Lean Healthcare
5-Why Analysis
5-why analysis, used throughout the kaizen concept and in quality control, is a tool to discover the root causes of a problem
1. Identify the problem.
2. Ask yourself: why did this happen? Come up with all the causes you can think of.
3. For each of the causes you just identified, ask “why did this happen?” again.
4. Repeat until you’ve done steps 2 and 3 for five times. You should have identified the root cause by this stage.
5. Find solutions and countermeasures to fix the root cause.
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Performance Improvement Glossary
A document allowing a person to give directions about future care or to designate Advance another person(s) to make medical decisions if the individual loses decision making Directive capacity. AHCA Agency for Health Care Administration - State of Florida oversight organization. AMI Acute Myocardial Infarction Benchmark Top performing standard as set by Centers for Medicare/Medicaid Services CHF Congestive Heart Failure CLABSI Central Line Associated Blood Stream Infection CLIA Clinical Laboratory Improvement Amendments Clinical Measures designed to evaluate the processes or outcomes of care associated with the Measures delivery of clinical services. CME Continuing Medical Education CMS Centers for Medicare/Medicaid Services) Events occurring in a licensed facility or arising from health care prior to admission to the licensed facility for which the facility had some control and which is associated in whole or in part with the medical intervention rather than the condition for which such intervention occurred and results in: *Death, *Brain or spinal damage, permanent disfigurement, fracture or dislocation of bones or joints, any Code 15 condition that required medical or surgical intervention resulting from non- emergency medical interventions, any condition requiring transfer of a patient to another facility or to higher level of care within the facility or *surgery on wrong patient, wrong site or wrong procedure. *Requires 24 hour report followed by 15 day report. Continuum of Meeting needs with the appropriate level of care across multiple organizations. Care COPD Chronic Obstructive Pulmonary Disease Standardized performance measures that can be applied across accredited health Core care organizations in each of TJC’s accreditation programs. The intent is to identify Measures sound measures that support both the objectives of the ORYX initiative and organizational process improvement. Data collection process initiated 07/01/02. CAUTI Catheter Associated Urinary Tract Infection DRG Diagnostic Related Group - Diagnoses/procedures by body system. The degree to which care is provided in the correct manner, given the current state Effectiveness of knowledge, to achieve the desired or projected outcome(s) for the individual. The degree to which the care of the individual has been shown to accomplish the Efficacy desired or projected outcome(s). Efficiency The relationship between the outcomes (results of care) and the resources used to deliver care. EOC Environment of Care Failure Mode Effects Analysis – A process to examine the use of new products and FMEA the design of new services/processes to determine points of potential failure and what their effect would be, before an error actually occurs. FMQAI Florida Medical Quality Assurance Inc., Medicare PRO HACs Hospital Acquired Condition
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HBIPS Hospital Based Inpatient Psychiatric Services (measures)
HBSI Health Business Services, Inc. (aka Solucient, Inc.) Hazard The identification of potential emergencies and the direct and indirect effects these Vulnerability emergencies may have on the health care organization’s operations and the demand Analysis for its services. (HVA) HCAHPS Hospital Consumer Assessment of Healthcare Providers HCFA Health Care Finance Administration (Federal) HCO Health Care Organization Heath Care Quality Improvement Program - Program designed to improve health HCQIP care for Medicare beneficiaries. HIM Health Information Management IMM Immunization core measure set Intensive Process Analysis - A detailed, intensive credible investigation of what caused the sentinel event, with identification of risk reduction strategies and IPA identification of ways to measure outcomes of risk reduction strategies. Evaluates processes rather than individual performance. Also known as RCA – Root Cause Analysis. ISMP Institute for Safe Medication Practices LIP Licensed Independent Practitioner LTC Long term care MDC Major diagnostic category - group of DRG's by body system. Outcome A measure that indicates the result of the performance or non-performance of a Measure function or process. Data driven continuous accreditation process promoted by TJC. Also known as ORYX “core measures”. Methodology used for Performance Improvement activities: P - Plan (Plan an opportunity for improvement), D - Do (Collect data, design process), C-Check PDCA (Collaborate to make change, measure success), A-Act (Action taken to standardize a successful process change). Payment Error Prevention Program – Medicare program to reduce hospital payment PEPP errors. Performance A quantitative tool to provide an indication of organization's performance Measure PI Performance Improvement aka QA PN Pneumonia PRO Peer Review Organization Process That which focuses on a process which leads to a certain outcome Measure QAPI Quality Assurance Performance Improvement program endorsed by CMS QA Quality Assurance a/k/a PI RCA - Root A detailed, intensive credible investigation of what caused the sentinel event, with Cause identification of risk reduction strategies and identification of ways to measure Analysis outcomes of risk reduction strategies. Evaluates processes rather than individual
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Page 184 of 294 Halifax Health Performance Improvement Plan performance. SCIP Surgical Care Improvement Project An event that occurs infrequently but is high risk for potential for a bad outcome, or Sentinel does result in a bad outcome. Examples include surgery on wrong limb, Event unexpected death, suicide, infant abduction, medication errors resulting in need to provide a higher level of care, hemolytic transfusion reactions. A communication from TJC regarding significant adverse events with Sentinel recommendations related to prevention of similar events in all health care Event Alert institutions. Severity The degree of biomedical risk, morbidities and mortalities of a medical treatment. SI Severity of Illness Classification Statement of Conditions – A proactive document that helps an organization to do a SOC critical self assessment of it’s current level of compliance and describe how to resolve any Life Safety Code deficiencies. SSI Surgical Site Infection STK Stroke core measure set SUB Substance use core measure set Minimum level that must be met to earn 1 (one) achievement value based Threshold purchasing point TJC The Joint Commission VAEs Ventilator Associated Events VHA Voluntary Hospitals of America VTE Venous Thromboembolism Prophylaxis
Reference(s):
Joint Commission Comprehensive Accreditation Manual for Hospitals www.jointcommission.org
Centers for Medicare and Medicaid Services “Conditions of Participation for Hospitals”, 482.21, www.cms.gov
Centers for Medicare and Medicaid Services “Hospital Quality Assessment Performance Improvement (QAPI) Worksheet” www.cms.gov
Agency for Healthcare Research & Quality (AHRQ), www.ahrq.gov
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FY2017 Performance Improvement Evaluation of Effectiveness
PI Priority Goals and Evaluation Conclusions/Actions Patient Safety and Harm Prevention Priorities Fall Prevention: FY2017 Goal: < 3.5 per 1000 patient days (per We have seen significant Agency for Healthcare Research and Quality [AHRQ]) improvement from FY16 with fall • Reduce Fall Rate to 3.5 rates at 6.23 at the main campus or Less FY2017 Actual Fall Rate (Main Campus): 3.93 and 8.05 at the Port Orange campus. A falls team has been
FY2017 Actual Fall Rate (HHPO): 4.35 developed dedicated to reducing falls. They have been successful
with developing protocols, assessments and fall bundles to better help identify patients at high risk patients and intervene as needed. Reduction of the following FY2017 Goals: Both CAUTI and CLABSI teams are Hospital Acquired Conditions: • CAUTI: Incidence Rate 1.0 per 1,000 showing progress towards the goal • Catheter Associated catheter days and CLABSI: Incidence however consistency is the main UTI’s (CAUTI) ICUs only Rate 0.75 per, 1,000 line days focus moving into FY18 with an emphasis on the development of • Central Line Associated standard practices within each Blood Stream Infections FY2017 Actual: measure. The changing of the (CLABSI) ICUs only . CAUTI: 2.05 / 1,000 cath days practices has been a challenge. . CLABSI: 1.57 / 1,000 line days Both of these PI teams will continue to actively work towards zero harm moving forward in FY18. Sepsis Mortality by DRG (470, FY2017 Goal: Based on FY16 rates The sepsis team continues to meet 471, 472) Sepsis Mortality DRG-870: 27.8% (10% decrease) monthly and is now working to Sepsis Mortality DRG-871: 7.0% (10% Decrease) further our engagement with the area post-acute providers. The 870 Sepsis Mortality DRG-872: 0.2% (FY16 Halifax Rate) DRG that we did not meet goal on are our most acute patients and FY2017 Results: often present many challenges
Sepsis Mortality DRG-870: 36.2% once they arrive. The large amount Sepsis Mortality DRG-871: 5.89% of these patients could have been Sepsis Mortality DRG-872: 0.0% placed on hospice prior to their arrival, partnering with palliative care will be key. This measure will continue to be a focus for the sepsis team in FY2018. Safety Indicators (PSI-90) HAC PSI-90 Indicators Goal: (< 1 Risk Adjusted Score, Expected values based on the PSI- reduction program measures observed over expected) (Removal is due to the 90 stats provided by Vizient since measures exceeding the FY16 goal, they will continue to be AHRQ is unable to provide expected monitored but excluded from the priorities) values within the Truven database. . PSI 3: REMOVE In FY18 we will work to improve . PSI 4: unable to report on since AHRQ both physician and front line staff was not able to provide expected rates knowledge & awareness of PSIs via . PSI 6: REMOVE analysis and presentation of data at various committees and meetings. . PSI 9: 4 / 1.60 = 2.5 Continued collaboration with . PSI 8: REMOVE coding to ensure proper . PSI 12: 5 / 2.54 = 1.97 documentation is provided is also . PSI 13: 4 / 4.91 = 0.81 underway. Evaluation of the . PSI 14: REMOVE process of care surrounding these Page 186 of 294
FY2017 Performance Improvement Evaluation of Effectiveness
PI Priority Goals and Evaluation Conclusions/Actions . PSI 15: REMOVE conditions to be evaluated as warranted. Process Improvement Priorities Achieve the National Average for FY2017 Goal: National Average We have exceeded the Truven goal Core Measures perfect care and . PCM-1: 100% (FY16 Score) REMOVE and continue to monitor and work IMM & Sepsis measures . IMM-2: 96.0% (FY16 Goal) with the sepsis team for . SEP-1: 43.2% (Truven Mean, non-profit) improvements. We saw almost a 4% improvement of IMM-2 FY2017 Actual Results: compared to last FY. We are still 2% . IMM-2: 94% short of our goal. We will continue . SEP-1: 43.3% to educate staff and patients on the importance of vaccinations. Pressure Ulcer PI Project - NEW Pressure Ulcer Identification Upon Admission Quality Teams were involved in: Goal - NEW: Develop and implement a new tool CAUTI, CLABSI, VTE, MRSA, C-dff & to better assess the pressure ulcers that that are HCAHPS PI Teams and given the present on admission (POA). Success of this recent HAC reduction program score resources were leveraged to project will be determined by verifying the tool is take part in those PI Teams. We will in place and functioning along with utilizing a need to determine if this project series of process audits which will be developed warrants priority over other as the project progresses. Quality indicators and initiatives for FY2018. baseline data TBD. Improve HCAHPS Performance: FY2017 Goal: > 71.5% Similar to other projects, the • Achieve a rollup average HCAHPS imitative has their own score of all 10 question FY2017 Actual HCAHPS Rollup Score: 67.1% dedicated PI team and have worked domains of 71.5% or diligently to develop new patient rounding techniques through a greater system wide effort of running skills labs to help demonstrate the tools to our front line staff. Units that have completed these labs have seen increases in communication and responsiveness scores. Next steps in FY2018 will be to move training to all units and adjust in the future based on high impact areas of improvement. The overall score saw an increasing trend from Oct ’16 – June ’17 however we finished FY17 with the final 3 months of decreasing scores which negatively impacted our FY overall score. The readmission effort is still Achieve and/or maintain FY2017 Goals: Goals TBD once FY16 rates close currently under reduction in readmissions for the (Goals based on Truven Nat’l Mean or 10% decrease development and will be a following patient populations: to FY16, whichever is lower) focus of the upcoming year. Readmissions that • AMI • AMI: < 8.6% (10% decrease from FY16) have been reviewed by the • CHF: < 13.6% (10% decrease from FY16) • CHF quality team find that • • Pneumonia PN: < 12.4% (Truven FY16 Nat’l Rate) approx. 40-50% of the • COPD • COPD: < 10.8% (10% decrease from FY16) readmissions return for • CABG • CABG: < 8.4% (10% decrease from FY16) reasons outside of their Page 187 of 294
FY2017 Performance Improvement Evaluation of Effectiveness
PI Priority Goals and Evaluation Conclusions/Actions • Stroke • Stroke: < 7.3% (Truven FY16 Nat’l Rate) original diagnosis. Of those • TKA / THA • TKA Complication rate: 1.8% (10% that do return for a related decrease from FY16) condition we see • THA Complication rate: 1.8% (10% medication mis- decrease from FY16) management, noncompliance and high • TKA/THA: 1.8% (10% decrease from FY16) complexity among the leading factors for returns. ACTUAL FY 2017 Results: • AMI: 11.66% • CHF: 14.93% • PN: 12.20% • THA: 4.56% • TKA: 2.29% • COPD: 12.21% • CABG: 8.05% • Stroke: 12.00% • TKA/THA Complication rate for elective TKA/THA: THA = 1.19%, TKA = 0.63%
Priorities for FY2018 will be established around the organizational mission, vision and pillars as well as FY2017 performance results. The priorities and evaluation for FY2018 will be housed within the performance improvement office to allow for consistence measurement and to allow us to stay consistent with PI efforts across the facility.
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Halifax Health Medical Center Patient Safety Plan 2018
Halifax Health Approval: Approved by Medical Executive Committee – 1/16/18 Approved by Quality Council – 12/15/17 Approved by Patient Safety Committee - 1/24/18
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Halifax Health
Halifax Health is one of Central Florida’s leading providers in healthcare as well as being one of the largest employers with just over four thousand employees dedicated to offering superior patient centered care. Founded in 1928, Halifax Health is a 678 bed facility, governed by a Board of Directors and one of fifteen legislatively-chartered taxing district healthcare systems in Florida. With over 500 physicians on staff representing 46 medical specialties Halifax operates two hospital locations in Daytona Beach and Port Orange, a free-standing Emergency Department in Deltona plus the county’s largest hospice system. Being the area’s only trauma center, 24-hour NICU, PICU, pediatric emergency department and catering to 25,000 admissions and over 100,000 emergency room visits annually, Halifax Health fully comprehends the responsibility we have to our patients and their families by providing a safe, efficient and an effective environment of care. The Halifax Health Performance Safety Plan and its leadership is committed to patient safety through assessing the plan on a continuing basis while making revisions that meet the goal of ensuring that patient outcomes are continually improved and excellent patient care is provided.
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The patient safety plan is built around the hospital’s mission, vision and philosophy, which reflect the core values (Safety, Compassion, Image and Efficiency) of Halifax Health Medical Center to ensure patients are safe from medical error or harm. A key element in improving patient safety in any organization is fostering a culture of safety.
A fair and just culture takes into account that individuals are human, fallible, and capable of mistakes, and work in systems that are often flawed. It holds individuals accountable for their actions but does not punish individuals for issues attributed to flawed systems or processes. The aim of a culture of safety is one that balances learning with accountability.
Effective Patient Safety entails proactively identifying the potential and actual risks to safety, identifying the underlying cause(s) of the potential, and making the necessary improvements so risk is reduced. It also entails establishing processes to respond to Sentinel Events/Code 15s, identifying cause through root cause analysis, and making necessary improvements.
The purpose of the Patient Safety Plan at Halifax Health shall be to improve patient safety and reduce risk to patients through an environment that encourages:
Integration of safety priorities into all relevant organization processes, functions, services, departments and programs Recognition and acknowledgment of risks to patient safety and medical/health care errors The initiation of actions to reduce these risks The internal and external reporting of what has been found and the actions taken A focus on processes and systems, and the reduction of process and system failures through use of failure mode effect analysis Minimization of individual blame or retribution for involvement in a medical/health care error Organizational learning about medical/health care errors Support of the sharing of that knowledge to effect behavioral changes in itself and other healthcare organizations
Organization, Authority and Responsibility:
The authority to implement the Patient Safety Plan rests with the Board of Commissioners, Medical Executive Committee, Patient Safety Committee and Quality Council via interdisciplinary collaboration. This plan is evaluated yearly.
The Patient Safety Officer (PSO) enforces the plan at a multidisciplinary level and reports to the Senior VP of Clinical Operations, who provides the strategic oversight of the Patient Safety Program. The PSO will coordinate the risk mitigating efforts on environment of care issues with the organizational Environment of Care Committee to assure membership overlaps and will provide appropriate information to that Committee as needed. Likewise; the Hospital’s Environment of Care Committee will bring patient safety concerns to the Patient Safety Committee as they arise.
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Page 192 of 294 Halifax Health Patient Safety Plan The Patient Safety Committee reports to the Quality Council which in turn flows into the Medical Executive Committee and Board of Commissioners reporting structures.
The leaders of the organization are responsible for fostering a culture of safety through their personal example; emphasizing patient safety as an organizational priority; providing education to medical and hospital staff regarding the commitment to reduction of medical errors; supporting proactive reduction in medical/health care errors; and integrating patient safety priorities into the new design and redesign of all relevant organization processes, functions and services.
Definitions:
1) Potential or no-harm errors (sometimes referred to as near misses or close calls) - any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome. 2) Error – Failure of a planned action to be completed as intended or the use of an incorrect plan to achieve the aim. An unintended act, either of omission or commission, or acts that do not achieve their intended outcome. 3) Sentinel Event – an unexpected occurrence involving death or serious physical or variation for which a recurrence would carry a significant chance of a serious adverse outcome. (see Sentinel Event policy for further definitions of what constitutes a sentinel event) 4) Adverse Incident - means an event over which healthcare personnel could exercise control and which is associated in whole or in part medical intervention, rather than the condition for which such intervention occurred, and which: a) Result in one of the following injuries: 1. Death 2. Brain or spinal damage 3. Permanent disfigurement 4. Fracture or dislocation of bones or joints 5. A resulting limitation of neurological, physical, or sensory function which continues after discharge from the facility 6. Any condition that required special medical attention or surgical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent; or 7. Any condition that required the transfer of the patient, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the patient’s condition prior to the adverse incident; (a.) Was the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patient’s diagnosis or medical condition (b.) Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and document through the informed consent process; or (c.) Was a procedure to remove unplanned foreign objects remaining from a surgical procedure.
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Page 193 of 294 Halifax Health Patient Safety Plan 5) Close call or near miss: a patient safety event that did not reach the patient 6) Hazardous condition: a circumstance (other than a patient’s own disease process or condition) that increases the probability of an adverse event
Safety Culture:
The safety culture is the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety. There are varying levels of a safety culture, but the goal should be working toward the following qualities: o Staff and leaders that value transparency, accountability, and mutual respect. o Safety as everyone’s first priority. o Behaviors that undermine a culture of safety are not acceptable, and thus should be reported to organizational leadership by staff, patients, and families for the purpose of fostering risk reduction. o Collective mindfulness is present, wherein staff realizes that systems always have the potential to fail and staff is focused on finding hazardous conditions or close calls at early stages before a patient may be harmed. Staff does not view close calls as evidence that the system prevented an error but rather as evidence that the system needs to be further improved to prevent any defects. o Staff who do not deny or cover up errors, but rather want to report errors to learn from mistakes and improve the system flaws that contribute to or enable patient safety events. Staff knows that their leaders will not focus on blaming providers involved in errors, but rather focus on the systems issues that contributed to or enabled the patient safety event.
Four beliefs present in a safe and informed culture – Processes that are designed to prevent failure Commitment to detect and learn from error A just culture that disciplines based on risk People who work in teams make fewer errors
Assessment of team perception regarding the culture of safety within the organization is conducted at least annually utilizing established, evidence-based, survey tools such as the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey. Results of this survey are analyzed and may be used to help identify opportunities for improvement and/or opportunity for further education surrounding patient safety initiatives and efforts.
Objectives:
The objectives of the Patient Safety Plan are to:
Encourage organizational learning regarding medical/health care errors. Incorporate recognition of patient safety as an integral job responsibility Provide education of patient safety into job specific competencies Encourage recognition and reporting of errors and near misses without judgment or placement of blame by reporting actual and/or potential occurrences in the occurrence reporting system located on PULSE.
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Page 194 of 294 Halifax Health Patient Safety Plan Involve patients in decisions about their health care and promote open communication about medical errors/consequences which occur. Collect and analyze data, evaluate care processes for opportunities to reduce risk and initiate actions using the DMAIC process (Define, Measure, Analyze, Improve and Control). Report internally what has been found and the actions taken with a focus on processes and systems to reduce risk. Support sharing of knowledge and information to effect behavioral changes in itself and within Halifax Health.
Scope:
The scope of the safety program includes the full range of safety issues, from potential or no-harm errors (near misses) to Sentinel Events/Code 15’s. The Patient Safety Plan encompasses the patient population, visitors, volunteers and staff (including medical staff). The plan shall address maintenance and improvement in patient safety issues in every department throughout the organization.
The complexity of providing care, treatment, and services demands an interdisciplinary collaborative approach. Therefore, communication, collaboration and coordination are among the most important work habits that must be adopted so that care, treatment, and services are provided at the highest level.
The safety and quality of care, treatment, and services depend on many factors, including the following: A culture that fosters safety as a priority for everyone who works in the hospital The planning and provision of services that meet the needs of patients The availability of resources –human, financial, and physical – for providing care, treatment and services The existence of competent staff and other care providers Ongoing evaluation of and improvement in performance.
Just Culture: Halifax Health has adopted a “just culture” philosophy to help ensure a safe and productive environment. Just culture refers to a values-supportive model of shared accountability. The organization is held accountable for the systems designed and for how they respond to staff behaviors fairly and justly. Staff members are accountable for the quality of their choices and for reporting both identified errors and system vulnerabilities.
A just culture environment is one where people can report mistakes, errors, or waste without reprisal or personal risk. This does not mean that individuals are not held accountable for their actions, but it does mean that people are not held responsible for flawed systems. All staff must feel empowered to identify errors, defects, and system failures that could lead to an unsafe environment for patients.
Five key components of a just culture include: Aligning values and expectations Designing better systems Making better behavioral choices 7
Page 195 of 294 Halifax Health Patient Safety Plan Systematic learning Finding justice: use of evidence-based algorithm for determining unjustifiable risk or harm
For additional information refer to policy titled “Just Culture”.
Engage Key Stakeholders:
1. Board Engagement Promoting the Board’s role in quality and patient safety oversight (fiduciary responsibility in the context of system wide improvements) Educate them on their responsibility for quality of care provided Structure Board agenda so quality and safety are priorities Discuss organizational performance in relation to national best practices Educate Board members on quality of care and patient safety issues
2. Physician Engagement Involve physicians as partners and leaders Identify a common purpose by aligning with organizational goals Identify and support physician champions as partners in all organizational improvement initiatives Utilize Lean and Six Sigma to standardize processes
3. Staff Engagement Foster teamwork/collaboration,good communication and use of the DMAIC process Promote the idea that quality and safety is everyone’s job Generate discussion about safety issues at staff orientation and education sessions Include patient safety topics in daily huddles Educate healthcare providers and administrative leaders to advance patient safety agenda
4. Patient & Families Engagement Patients/ families should be invited to collaborate with care providers in making clinical decisions ( patient centered care) Put responsibility for important aspects of self-care and monitoring in patient’s hands ; as well as the tools and support to carry out this responsibility Commit to effective communication and demonstrated understanding between patient and care giver Ensure patients understand care instructions( health literacy) Appreciate a patient’s cultural and ethic identity Consider implementing “Teach Back” method
Patient Safety Committee:
The Patient Safety Committee is an interdisciplinary committee charged with the coordination and implementation of programs for ensuring patient safety within Halifax Health, including directing and overseeing proactive risk reduction and the Patient Safety Plan. This Committee evaluates
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Page 196 of 294 Halifax Health Patient Safety Plan trends from quality reports, adverse event analysis and other sources and recommends appropriate actions to improve patient safety and quality of care.
Duties and Responsibilities:
Prioritizes performance improvement projects related to patient safety and/or quality of care and submits them to the Quality Council for approval. Monitors and analyzes aggregated, trended data and specific case reports related to patient safety such as Quality Reports, Risk Management reports, Sentinel and Significant event reviews and Sentinel Event Alerts Collaborates with other committees to improve patient safety and ensure compliance with the Joint Commission (TJC) standards, Medicare Conditions of Participation and other regulatory requirements related to patient safety Communicates patient safety goals and strategies for improvement via defined institutional communication processes Recommends policies and procedures related to patient safety Oversees, evaluates and revises the Patient Safety Plan Provides regular feedback to the Quality Council and reporting to the Board of Commissioners regarding the effectiveness of the Patient Safety Plan and recommended revisions to the Plan
Board of Commissioners:
The Board of Commissioners has ultimate authority and responsibility for establishing strategic policy, maintaining the quality of care rendered at its facilities, and providing for strategic, organizational management and planning. In addition, the Board shall:
Provide for the effective functioning of activities related to delivering quality patient care, performance improvement, risk management, medical staff credentialing, financial management and post graduate education Provide for coordination and integration among its administration and staff in order to establish appropriate policies, maintain quality patient care, and provide for necessary resources, strategic organizational management and planning
Medical Staff:
The organized medical staff has a leadership role in organizational performance improvement activities aimed at improving quality of care, treatment and services and patient safety. In this role the medical staff is actively involved in the measurement, assessment and improvement of the following: Medical assessment and treatment of patients Use of information about adverse privileging decisions for any practitioner privileged through the medical staff process Use of medications Use of blood and blood components Operative and other procedures Appropriateness of clinical patterns and any significant departure from such patterns 9
Page 197 of 294 Halifax Health Patient Safety Plan Use of developed criteria for autopsies Sentinel Event data Patient safety data
Organizational Leaders:
The organization’s leaders have the responsibility to create an environment that promotes performance improvement through the delivery of safe patient care, quality processes, quality outcomes, and high customer satisfaction. The leaders perform the following functions: Utilize our approach to performance improvement (DMAIC), set expectations and priorities for organization-wide performance management that are designed to improve safe patient care delivery, quality processes and outcomes, and customer satisfaction Ensure error-producing factors in patient care activities are proactively and reactively measured, assessed, and improved throughout the organization Ensure that important processes and activities are measured, assessed, and improved systematically throughout the organization using DMAIC and other Lean and Six Sigma methods and tools Participate in interdisciplinary performance improvement activities in collaboration with the medical staff as physician partners Allocate adequate resources including personnel, time, and data collection systems for assessment and improvement of the organization’s performance and for improving patient safety Assure that leaders and staff are trained in the DMAIC process and other methods of performance improvement and risk reduction, including the tools utilized in proactive and reactive risk assessment and in evaluating processes and systems that contribute to improved patient outcomes Assure that staff members are rewarded for their involvement in patient safety improvement Analyze and evaluate the effectiveness of the quality improvement and patient safety improvement activities
Proactive Approach to Harm Prevention:
Proactive risk reduction prevents harm before it reaches the patient. Through proactive risk reduction efforts such as risk assessments and failure mode and effects analysis process problems can be identified and corrected in order to reduce the likelihood of experiencing adverse events. These processes help to evaluate potential failure points within a process or procedure, understand the possible consequences of such failure and to identify performance improvement opportunities.
When performing proactive risk assessments high-risk, high-volume processes are prioritized. Areas of risk may be identified from internal sources such as ongoing monitoring of the environment, results of previous risk assessments, results of data collection activities or external recommendations such as Sentinel Event Alerts.
The proactive risk assessment may include, but not be limited to:
Identification of the ways in which the process could break down or fail to perform. This will be done through assessment of the intended and actual
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Page 198 of 294 Halifax Health Patient Safety Plan implementation of the process to identify the steps in the process where there is, or may be, undesirable variation. Identify the possible effects of the undesirable variation on patients, and how serious the possible effect on the patient could be Prioritizing the potential processes breakdowns or failures For the most critical effects, conduct a root cause analysis to determine why the undesirable variation leading to that effect may occur Redesign the process and/or underlying systems to minimize the risk of that undesirable variation or to protect patients from the effects of that undesirable variation Test and implement the redesigned process Identify and implement measures of the effectiveness of the redesigned process Implement a strategy for maintaining the effectiveness of the redesigned process over time
Investigation, Analysis, Coordination and Reporting:
A broad range of data analysis will be reported to and reviewed by the Patient Safety Committee. The results of investigations and analytical reviews shall, in turn, be forwarded by the Committee to the appropriate entities for further, in-depth evaluation, review and responses. Responses shall include any corrective action taken or plan for corrective action.
The Patient Safety Committee serves as a clearing house for these data and information that affect patient safety. Any incident, process, event and condition may be subject to investigation through the Root Cause Analysis methods. Intensive assessment may be initiated when undesirable patterns or trends are identified or a serious or sentinel event occurs. Proactively this plan suggests to conduct at least one system based Failure Mode Effect Analysis at a minimum every eighteen months.
Patient safety monitoring and/or reporting may include but not be limited to the following: National Patient Safety Goals (NPSG) Patient Safety Indicators (PSI) Hospital Acquired Conditions (HAC) Outcomes of resuscitation; response to changes in patient condition (Rapid Response Team) Product safety and recall information Sentinel Event Alerts per The Joint Commission Code 15 and/or Sentinel Event summary/trends Event Management System occurrence reporting trends/concerns Restraint utilization, compliance with monitoring and safe use Failure mode and effects analysis conduction and results Hospital Improvement Innovation Network core topics: 1. adverse drug events 2. catheter-associated urinary tract infections (CAUTI) 3. central line-associated blood stream infections (CLABSI) 4. clostridium difficile (C.diff) 5. falls
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Page 199 of 294 Halifax Health Patient Safety Plan 6. pressure ulcers 7. severe sepsis and septic shock 8. surgical site infections 9. ventilator-associated events (VAE) 10. venous thromboembolism (VTE) 11. readmissions
An effective Patient Safety Plan cannot exist without optimal reporting of process/ system failures and medical/health care errors and occurrences; therefore, it shall be the intent of this institution to adopt a non-punitive approach in its management of failures, errors and occurrences. All staff shall be required to report suspected and identified medical/health care errors, and should do so without the fear of reprisal in relationship to their employment. This organization shall support the concept that errors occur due to a breakdown in systems and processes, and shall focus on improving systems and processes, rather than disciplining those responsible for errors and occurrences. A focus shall be placed on remedial actions to assist rather than punish staff members while determining the appropriate course of action to prevent error recurrence.
Medical/health care errors and occurrences, including sentinel events, shall be reported internally and externally, per hospital policy and through the channels established by this plan. External reporting shall be performed in accordance with all state, federal and regulatory body rules, laws and requirements.
For additional information relative to this Plan please contact one of the following:
For patient safety questions contact: Suzanne Lovelady, Patient Safety Officer, at extension #54234 For environment of care or building safety questions contact: Ashley Fisher, Safety Officer, at extension #54292
References:
"Patient Safety Systems." The Joint Commission Comprehensive Accreditation Manual for Hospitals. PS-1-PS-54.
Centers for Medicare and Medicaid Services “Hospital Quality Assessment Performance Improvement (QAPI) Worksheet” www.cms.gov
Centers for Medicare and Medicaid Services “Conditions of Participation for Hospitals”, 482.21, www.cms.gov
Agency for Healthcare Research and Quality “Hospital Survey on Patient Safety Culture”, www.ahrq.gov
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Halifax Health Environment of Care Year End Report 2017
Halifax Medical Center Daytona Beach – Halifax Medical Center Port Orange – Halifax Behavioral Services – Halifax Health Emergency Department-Deltona – Twin Lakes Surgery Center
SUMMARY
The Halifax Health Environment of Care (EOC) is comprised of a group of leaders identified to manage risk, coordinate risk reduction activities and report environmental concerns. This includes threats to the buildings, equipment and people where care is provided to our patients. The following areas make up the EOC.
• Safety & Security • Hazardous Materials & Waste • Fire Safety & Life Safety • Medical Equipment • Utilities • Emergency Management
This annual summary report has been produced to bring together in one document the Halifax Health patient care focus activities for the 2017 calendar year. The EOC chairperson or designee also reports quarterly to the Patient Safety Committee. The annual summary is a compilation of metrics for all facilites.
1. SAFETY MANAGEMENT
Objective:
The objectives of the Safety Management plan are:
• Continual evaluation of the effectiveness of the Safety Management Plan to identify opportunities for performance improvement. • Identification of individuals to oversee development and implementation of these processes. • Communication of issues to appropriate departments/units and the Governing Body. • Knowledgeable staff who participate in safety activities. • Providing a physical environment free of recognized hazards. • Managing staff activities to reduce the risk of injury and illness. • Establishing and reviewing safety-related policies and procedures. • Establishing and maintaining patient and public safety risk assessment activities. • Maintaining effective lines of communication and information sharing.
Scope:
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Hospital leadership has appointed a Safety Officer to implement and oversee the safety management program for Halifax Health. All staff are responsible for ensuring compliance with medical center policies regarding the environment of care.
Halifax Health recognizes that various risks and hazardous conditions are inherent in the health care environment and that processes must be implemented to reduce or eliminate these risks and hazards. These processes include:
• A preventive maintenance program utilizing the Maintenance Connection database and work order generation system. • Routine risk assessments to evaluate the conditions of buildings, grounds, equipment, occupants, and internal systems and their ability to provide patient and public safety. • Ongoing hazard surveillance including product recall/alert evaluation. • Reporting and investigation of emergencies, incidents, injuries, and illnesses • New hire and annual orientation and education for all team members
Performance Goals for 2017:
• Complete eyewash station location inventory, add to Life Safety drawings, and ensure compliance in all HHMC locations. MET
• Decrease employee falls, cuts, injuries as a result of improper body mechanics, and other injuries occurring during high-census months by promoting safety awareness in safety huddles, staff meetings, and Marketing communications to all Team Members. MET
• Continue to reduce focus safety indicators by 5% MET 80% o All safety indicators were reduced by greater than 5%, with the exception of ‘Employees with foreign matter in eyes”.
Employee Safety Metrics
2017 2016 YTY % Indicators for HHMC/HHPO/HBS/TLSC TOTAL TOTAL Change Change SAFETY MANAGEMENT Decrease Employees struck - fellow worker or patient * 21 39 18 -46% Increase Employees w/ foreign matter in eyes* 9 6 -3 +50% Decrease Employee falls* 42 52 10 -19% Decrease Cut - puncture or scrape* 36 46 10 -22% Decrease Injury - twisting, lifting, pushing, reaching* 26 42 16 -38% Decrease Other employee injuries/Misc* 89 104 15 -14% * Source. USIS (United Self-Insured)-TPA (Third Party Administrator) Cause-Nature reports
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Effectiveness:
• There was an equal to or greater than 14% reduction in all OSHA reportable safety indicators for the Halifax Health organization in 2017. This can be attributed to the following, as identified in the 2016 assessment and opportunities for improvement to be implemented in 2017: o Promoting safety awareness in safety huddles and providing focused education to staff, as trends are identified o Targeted safety reminders sent by Marketing communications to all Team Members o An employee struck was reduced by 46%. Greater than 800 Team Members in the Medical-Surgical, Psychiatric, Emergency, and Women’s Services Departments were trained on Non-Violent Crisis Intervention in 2017. o Injuries from twisting, lifting, pushing, and reaching was reduced by 14%. Organizational and Talent Development provided enhanced education to unlicensed assistive personnel on safe lifting processes, appropriate use of assistive devices, a team approach to mobilizing patients, and maintaining life-long back health. Staff exposed to frequent lifting were encouraged to contact the ortho tech department for possible preventative, assistive equipment
• Vizient Southeast, Quality, Safety, and Facility Operations performed an Environment of Care and Life Safety Mock Survey in March, 2017, with an additional focus on ligature risks in the environment. Opportunities for improvement were identified at Halifax Health facilities under the Environment of Care, and corrective action plans were implemented.
• Vizient Southeast, Quality, Safety, and Facility Operations performed an Environment of Care Mock Survey in August, 2017, for Halifax Health facilities under the Environment of Care
• Safety and Emergency Preparedness Coordinators attended a Vizient Life Safety and Emergency Management Seminar in preparation for the revisions to the TJC and National Fire Protection Association Codes and Standards.
• Safety and Emergency Preparedness Coordinators attended the TJC Life Safety Chapter and Environment of Care Base Camp in November, 2017, to enhance knowledge and awareness of revisions and additions to the TJC Standards and National Fire Protection Code requirements.
Performance Goals for 2018:
• Continue to reduce focus safety indicators by 5% • Monitor and evaluate mechanisms of exposure incidents and reduce exposure incidents by 5%. • Organizational Talent and Development to implement a exposure prevention and safe handling program to reduce needle sticks, splashes, and other routes of exposures.
Program Evaluation:
Overall, the Safety Management Plan for the Hospital was effectively managed, with emphasis placed on continuous improvement and monitoring in the coming year.
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2. SECURITY MANAGEMENT
Objective: The objectives of the Security Management plan are: • To provide a safe, secure, and supportive environment for patients, visitors and team members. • To identify and address security issues concerning patients, visitors, team members, and property. • Implement and enforce access control to sensitive or high risk areas. • Regulate non emergency access control to the emergency department. • Continually monitor the environment via 24 hour patrol, security camera surveillance and rapid response to internal and external security threats. • Report and investigate security incidents.
Scope:
The Security Management Plan defines processes through which Halifax Health provides a system of safeguards to protect the physical property of the medical center and to achieve relative security for all people interacting within the organization and its environment. Halifax Health by virtue of it’s locations and hours of operation is susceptible to crime patterns in the surrounding neighborhoods of all our facilites.
Performance Goals for 2017: • Continue to track and trend the classification of weapons being confiscated at Halifax Health facilities to evaluate current protocols and training. MET o Tracked knives, sharp edge instruments, and guns throughout 2017.
• Relocate Telecommunications Operators to another location and reduce scope and responsibilities to solely manage internal and external phone traffic. Security Dispatch Technicians will remain in Dispatch Operations Room and will assume all radio and Emergency Code response communications, alarm response, and surveillance camera monitoring. Limiting the scope and responsibilities for these positions will enhance incident and event response times and will be monitored in 2017 to establish a baseline for performance improvement. NOT MET o Not able to accomplish due to budgetary constraints
• Complete Phase I of the Security Action Plan Access Control Lockdown project implementation (see 2016 Performance Goals) which will enable the following capabilities to enhance safety and security: MET o Rapidly lockdown the hospital in an emergency situation. o Establish a secure perimeter and routing of foot traffic to control entry and exit points. o Enable a partial or complete lockdown, as necessary.
• Convert staffing for all Badging/Information Stations from Volunteers to Security Officers. Security presence will facilitate the following: MET o Enhance situational awareness by identifying potential issues or threats o Enforce access policy compliance o Provide rapid response capabilities for situations requiring intervention. o Report and investigate security incidents o Increase safety and security of the patients, visitors, team members, and facility
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• Security has transitioned the Camera Surveillance System to Information Technology Services for management and maintenance; however, Security will maintain primary access for system utilization and surveillance. MET
YTD 2017 TOTAL 2016 TOTAL SECURITY MANAGEMENT Change % Change Increase Trespass warnings issued 122 115 -7 +6% Decrease Weapons confiscated 149 153 4 -3% Decrease Security officer standbys 1930 2037 107 -5% Increase- Patient Restraints 415 393 -22 +6% Increase Baker/Meyers Acts 4238 4110 -128 +3% Increase Theft / Vandalism 29 24 5 +21% Increase Code Grey - Actual 167 131 36 +27% Decrease Code Grey - False 247 505 258 -51% No Change Code Pink - Actual 0 0 0 0% Decrease Code Pink - False 0 2 2 -100%
Source.Halifax Security Activity Report and Dispatch logs **Artifact: Inadvertent activation of the Code Grey button placement on new Cisco desk sets
Effectiveness: Security Performance Indicators showed a decrease or no change for Weapons Confiscated, Security Officer Standbys, False Code Grey calls, and Actual and False Code Pinks. These may be attributed to the following: • Weapons confiscated reduced by 3% o Signs posted on the exterior of the buildings at the main entrances may be a deterrent to anyone potentially entering the facility with a weapon o Increased situational awareness of Security Officers at entrances of each facility o Increased situational awareness and communication between staff on patient floors and Security Officers • Security Officer Standbys reduced by 5% o May be attributed to a focus on staff de-escalation of violence education and early intervention measures o False Code Grey calls reduced by 51% The Code Grey notification process via the DAKS communication system was transitioned to a direct, 1-button activation, 2-way intercom line located directly on the Cisco desk phones. The Code Grey capable phones are installed in areas
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determined to be high risk. By transferring to a direct intercom line that connects the Code Grey initiator/caller with the Security Dispatch Operator, it reduces accidental activation. Any inadvertent calls or pressing of the Code Grey button can now be identified prior to dispatching Security and overhead paging to the facility. o Actual Code Pinks – no change We will remove from the Security Performance EOC Dashboard, but will continue to monitor and report any actual incidents to the EOC Committee o False Code Pink calls were reduced by 100% Reduction is attributed to the revised notification protocol on the pediatric/Infant Security System monitored locations. We will remove from the Security Performance EOC Dashboard due to 2 years of consistent reductions and Security will continue to monitor internally.
Performance Indicators increased for Trespass Warnings, Patient Restraints, Bakers/Myers Acts, and Theft and Vandalism. These metrics may have increased due to: • More active presence by Security Officers • Security Officer training • Increased staff situational awareness and proactive identification of potential violence • Increase in Daytona Beach crime statistics • Other causes not identified Performance Goals for 2018:
• Implement Garrett hand wand metal detectors to increase a safety presence and decrease the possibility of adverse incidents to patients, visitors, staff, and the facility. Security Officers will be trained and exhibit competency prior to detection training. Persons and their belongings will be briefly scanned during Visitor Check-In process. Detectors will be positioned at the following entry locations: o Halifax Health Medical Center – Daytona Beach France Tower - ED Triage Desk France Tower - ED Ambulance Ramp (I-POD) France Tower - Information Desk Fountain Building - Information Desk In-Patient Adult Psych (Units 2500, 2600, & 2700) Patrol Vehicle o Halifax Health Medical Center – Port Orange Main Entrance Information Desk o Halifax Behavioral Services Main Entrance Desk o Halifax Health - Emergency Department – Deltona Performance indicators for theft and vandalism incidents are primarily vehicular and occur in the parking lots at all times of the day. In an effort to reduce theft and vandalism incidents, there will be a focus in 2018 to increase Security patrol rounds on the campus and work with local law enforcement to: • Review and assess Halifax Health exterior video surveillance • Involving law enforcement to identify previous theft and burglary perpetrators • Trespassing any major or minor theft or burglary perpetrators who steal from any Halifax location
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Security will continue to monitor performance indicators to determine effectiveness of the focus and actions implemented in 2018.
Program Evaluation: The Security Management Plan for Halifax Health was effectively managed in 2017 and met the objectives and goals, with the exception of the transition of Telecommunications Operators. Emphasis is placed on continuous improvement and monitoring in the coming year.
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3. HAZARDOUS MATERIALS & WASTE MANAGEMENT
Objective:
The objectives of the Hazardous Materials and Waste Management plan are:
The Hazardous Materials Management Plan objective is to define the processes by which Halifax Health manages the receipt, use, exposure to, inventory of, and final disposition of hazardous materials. Halifax continually seeks to find the least hazardous chemicals in the smallest quantities available to achieve the need.
• To limit the use of hazardous materials to specific locations, in the smallest necessary quantity and be used only by specifically trained personnel. • To provide on-site processing of hazardous waste for off-site disposal at permitted facilities. • To ensure compliance with applicable local, state, and federal regulations, including notification of spills, overexposures, and abatement, as required. • To ensure that the operation of engineering controls are in place and meet specific manufacturer safety recommendations. • To provide personal protective equipment and clothing as needed to reduce exposure to hazardous materials. • To manage hazardous materials from “cradle to grave.” • To maintain chemical inventories and Safety Data Sheets and/or Material Safety Data Sheets (SDS and/or MSDS).
Scope:
Halifax Health recognizes that the use of hazardous materials is inherent in the health care environment and that processes must be designed and implemented which control the use and disposal of hazardous materials and minimize or reduce the hazards. Specific hazardous materials include, but are not limited to:
• Chemical waste: Departmental specific lists are managed in an online inventory • Pharmaceutical waste • Radioactive materials and radiation emitting equipment. • Medical waste.
Performance Goals for 2017: The Halifax Health Hazardous Materials & Waste Management program continued to develop its team of professionals and operational practices in 2017. The following performance goals were identified in 2017 to further the effectiveness of the program:
• Implement new pharmaceutical waste separation procedure to separate hazardous pharmaceutical from non-hazardous pharmaceutical waste. MET o Pharmaceutical waste totals decreased by 16% due to revised waste separation procedure implemented organizationally. Staff received education at General Orientation, Skills Labs, and Safety Huddles. • Implement re-useable sharps exchange program and continue to reduce total biomedical waste by 5%. MET o Biomedical waste was reduced by 33%, and is attributed to the re-useable sharps exchange program implemented.
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2016 YTY % HAZMAT / WASTE MANAGEMENT 2017 TOTAL TOTAL Change Change Hazardous material spills 0 0 0 0% Decrease Biomedical waste disposal (lbs) * 342,127 510,178 - 16,8051 33% Decrease Pharmaceutical waste (lbs) * 83,429 98,894 - 15,465 16% *Source. EVS transport manifesto logs and Pharmaceutical waste contractor data
Effectiveness: There were no major chemical spills to report during 2017, indicating that Team Member training and the implementation of safe handling procedures for chemicals is being effectively followed and adhered to. All 2017 goals and objectives were met by the department.
• Pharmaceutical waste totals decreased by 15.9%.* • Biomedical waste totals decreased 32.9%.* • Implemented new pharmaceutical waste separation procedure to separate hazardous pharmaceutical from non-hazardous pharmaceutical waste. • Completed training for team members for the new pharmaceutical waste separation. • Revised Waste Separation policy to include the changes to the pharmaceutical waste separation. *Source. EVS transport manifesto logs and Pharmaceutical waste contractor data
The Halifax Health Hazardous Materials & Waste Management program continued to develop its team of professionals and operational practices in 2017.
Performance Focus for 2018 The following performance goals were identified to further the effectiveness of the Hazardous Materials and Waste Management program for 2018:
• Monitor and evaluate the effectiveness of the new pharmaceutical waste separation procedure implemented in 2017, to separate hazardous pharmaceutical from non-hazardous pharmaceutical waste and reduce pharmaceutical waste by 5%. • Modify current computer-based education modules relating to Hazardous Materials and Waste Separation procedures. • Assess clinical staff knowledge to state proper disposal of pharmaceutical waste with a 90% success rate. • Continue to reduce biomedical waste disposal by 5%.
Program Evaluation: The Hazardous Materials and Waste Management Plan for Halifax Health was effectively managed and met the 2017 goals and objectives, with emphasis placed on continuous improvement and monitoring in the coming year.
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4. EMERGENCY PREPAREDNESS MANAGEMENT
Objective: The objectives of the Emergency Preparedness Management plan are: • Provide an all-hazards approach through which to prepare for, respond to, and assist Volusia County, other counties, and other healthcare facilities recover from a wide variety of internal and external emergency events, mass casualty incidents, or natural disasters. • Identify potential risks and implement mitigation activities in an attempt to lessen the severity and impact a disaster or emergency event may have on hospital operations • Implement activities that ensure adequate communication, security, staffing, clinical care, resources, utilities and community partnership response capabilities • To ensure team member training is effective • Assess and monitor staff performance during response to exercises or actual events to ensure understanding of their roles and responsibilities. The findings will be used to identify opportunities for improvement.
Scope: The Emergency Management Plan is designed for effective operations and response to disasters or emergencies affecting the environment of care, while continuing to promote and deliver optimal patient care through effective evaluation and improvement of important processes, and outcomes of patient care provided by all disciplines within the organization (Chapter 252, Florida Statutes – State Emergency Management Act, AHCA, CMS, TJC)
Performance Goals for 2017:
• Continue to provide preparedness and training opportunities for Administrators on Call and House Supervisors who have a role and responsibility during an activation of the Emergency Operations Plan. MET o Administrators On Call and House Supervisors were provided with an In-Service on the HICS process and utilizing the HICS forms for emergency response, a Hospital Incident Command notebook with resources and guidance for Hospital Incident Command positions, operations, and incident response guides for internal and external potential scenarios. o Worked with Command Staff during actual incidents and drills to provide guidance for roles and responsibilities, as needed.
2017 YTY 2016 TOTAL EMERGENCY MANAGEMENT TOTAL Change Number of drills conducted or participated in 6 Number of actual events 7
• Continue to provide preparedness and training opportunities for Administrators on Call and House Supervisors who have a role and responsibility during an activation of the Emergency Operations Plan.
Effectiveness: The following exercises or drills were conducted or participated in. Please note the critical elements met, summary of the exercise or event, and actions taken based on evaluations and findings:
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Exercise/Event Critical Scope/ Evaluation/ Actions Taken Elements Objectives/ Findings Summary 2017 HHMC Exercises: (I=Internal E=External)
APR (E)State/Fed EMResource Communication; Scope: APR: Reported to updated 6 HavBed and Resources and HHMC/HHPO/HBS/ EMResource AUG: EMResource and AUG FLHealthSTAT Availability Assets; DFSED; Objectives: Reported to FLHealthSTAT 29 Drills and Event Provide for the safety FLHealthSTAT SEP: hospital bed SEP HHMC/HHPO/HBS /DFSED of patients;ensure Reported to availability and 5-22 adequate resources FLHealthSTAT resource and assets;ensure information, as interoperable requested by communications with AHCA and Reg.V partners; Summary: ESF-8 Provided bed availability and status of other resources, as requested APR (I) AT&T Business VOIP Communication; All Halifax Health Communication/Com 1) Red Phone 3 Downtime (Actual) Safety and Healthcare and munity Partner directory and HHMC/HHPO/HBS/HFSED/ Security; Staff Business Collaboration: 1) IT instructions for use Bus. Roles and Occupancies ; identified that the put in a Responsibiliites; Objectives: 1) primary phone carrier, downloadable .pdf HICS-Command Maintain patient care AT&T, was format in the Center Activation; capabilities; 2) Isolate experiencing a PULSE Department Utilities; Clinical and repair affected Nationwide, VOIP page, the PULSE and Support information business line outage Department Activities; technology systems; affecting a majority of Directory, and all Community Partner 3) Notify affected end major cities; 2) computer Collaboration suers - supervisory Confirmed outage with Desktops; 2) Utilize staff and provide AT&T; 3) Sent the information line guidance; 4) communication to and Virtual Establish temporary Leadership and IT Switchboard in communications; 5) Team; 4) Opened IT third-party, VOLO Notify patients, staff, Service Desk problem web-based, and the public of with voice message to Emergency alternative communicate outage Notification website communication, as status to all users who to provide an appropriate. called; 5) Outside alternate number to Summary: at 1150, agencies and other publish to staff and IT identified that there community healthcare the public for was an AT&T VOIP partners were provided incoming calls to landline phone with Command Center communicate outage. The inbound Red Phone Command timely information; and outbound phone and Case Management 3) Provide quarterly service to and from contacts for alternate Red Phone Halifax Health was form of comms; 6) reminders to interrupted by a Public notified via departments to national AT&T Facebook; HICS ensure Red Phone outage. Only Red Command Ctr. operations Phones are able to Activation: Opened
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receive inbound calls Command Center and and place outbound staffed w/ IC and HICS calls outside of the Command and Support; Halifax Health Cisco Safety and Security: phone systems. 1) provided additional Service resumed and guidance directing staff was operational at to use ESSEX Red 1528. Phones - Staff determined that some Red Phones were not operational and if operational, were unsure of how to dial outbound. Clinical and Support Activities: 1) PIO provided scripted message to Dispatch Operators and staff instructed to advise patients; 2) HUB utilized runners, as needed, for backup comms; APR (I) Code Pink Infant/Child Communication; Scope: HHMC; Communication: Education provided 27 Abduction Drill HHMC Safety and Objectives: 1) Notification to Security to all Infant/ Security; Staff Ensure the safety of Dispatch was delayed Pediatric staff to Roles and patients, staff, and due to no connectivity of transport infants Responsibilities visitors while initiating the Vocera wireless with 2-staff search procedures for communication badges members; the missing worn by clinical staff education provided infant/child; 2) while in the elevator. to Mother/Baby and Coordinate with law Lengthy description to all staff on elevator enforcement, as Security also delayed emergency required. Summary: Code Pink overhead notification call While transporting an paging, which allowed buttons via Safety infant from 2nd flr the abductor to escape Huddles, Clinical NICU to the 6th flr with the simulated Update, and PEDS, a female infant. Staff Roles and Operations Call. abductor follows RN Responsibilities: Staff Emerg. Prep. 2018 transporter into the response to cover exits CBL to include elevator and and check bags was emerg. elevator call threatens her with a rapid. There was some button function knife. Abductor grabs overlap at exits due to education; Security the infant and staff not sure which exit Dispatch Code proceeds to the 3rd to cover. Safety and Pinnk Checklist flr. She forces the Security: Security revised dto obtain RN to remain on the responded to exterior of only child's age, elevator and escapes facility to intercept sex, and race to with the infant. abductor. immediately overhead page, then obtain remainder of description of abductor, etc.; 2018 CBL to include Dept.- specific assignments for exit door coverage
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MAY (I) Code Pink Drill Communication; Scope: HBS; Communication: Initial Provided 11 HBS Safety; Security; Objectives: 1) notification to Security immediate Roles/Resp.; Ensure the safety of Dispatch and overhead education for Code patients, staff, and paged in less than 1 Pink response visitors while initiating minute. Staff Roles protocol to EVS search procedures for and Responsibilities: staff and to staff the missing child; 2) Staff response to cover who momentarily Coordinate with exits and look for child left exit door; security and law was rapid. There was provided education; enforcement, as some overlap at exits 2018 CBL to required. Summary: due to staff not sure include Dept.- The mother of a 12 yr which exit to cover. EVS specific old patient was employee did not assignments for registering her child respond to drill; staff exit door coverage at the HBS front desk were observed and her 3 yr old was momentarily stepping able to follow an away from exit doors. exiting visitor out the Safety and Security: front door and could Security responded not be immediately from HHMC to exterior found. A Code Pink of facility; was called immediately. MAY (I) Infant Security Upgrade Communication; Scope : HHMC Protective measures Communication 18-19 Downtime (Actual) Safety and Objectives : Provide implemented: assigned went out to staff, HHMC Security; Staff for the safety of additional Security to however, was sent Roles and patients; initiate monitor ingress/egress; in the same format Responsibilities; facility security and assigned additional staff as Meditech Utilities; Clinical protective actions; to perform 15min rm Downtime Notices, and Support Summary : checks per the I.C.S.S. and not as visible. Activities downtime protocol BioMed and IT will (implemented as an provide a after-action item from Communication previous drills) until the and Action Plan upgrade was completed prior to future and system was downtime events. operational. Communication plan and action plan timeline did not reach all those involved in the response. MAY (E) Information Communication; Scope: All Halifax Information Sharing/ Revised IT Threat 14- Technology Threat - Information Health healthcare and Communication: Daily, or Failure ongoi Ransomware (Actual) Sharing; business proactive monitoring of Response Plan and ng All Halifax Health Facilities Community Partner occupancies; worldwide IT threats CBL for all staff. Collaboration; Objectives : 1) and incident information Developed a Risk Resources and Maintain patient care sharing enabled Reduction/Assess Assets; Safety and capabilities; 2) immediate identification ment Policy for Security; Staff Isolate and and communication to Vendors providing Roles and repair/prevent leadership and vendors; IT products. Responsibilities; information Communicated to all technology systems; staff instructing in the 3) Notify potentially identification and affected end user handling of potential leadership and staff threats via all electronic and provide directed devices connected to, guidance on or with potential to information connect to, the Halifax technology systems' internet or intranet; use and prevention of Implemented protective Halifax Health EOC Year End Report 2017 13
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potential measures, including but ransomware; 4) not limited to: 1) Download Isolated vulnerable IT or preventative software Biomedical related and remove/replace equipment/software; 2) potential vulnerable downloaded patches equipment, software, throughout organization etc. for hardening; require all IT or Biomedical vendors to provide a risk assessment and technical product review prior to considering implementation of services/equipment or software SEP (I) Code Pi nk Drill II Communication; Scope: HHMC; Communication: 1) Security Code 8 HHMC Safety and Objectives : 1) Nurse transporter used Pink protocol Security; Staff Communicate with the Emerg. call button in information Roles and Security Dispatch for the elevator to notify gathering prior to Responsibilities; response and Security Dispatch. notification was recovery of a missing Safety and Security: reduced to increase infant/child 2) Ensure The overhead Code rapid notification. the safety of patients, Pink announcement "Code Pink - age - staff, and visitors time was decreased sex" to facilitate while initiating search from previous drill by 2 more rapid procedures while minutes due to more overhead covering exits; rapid, initial notification notification. Once Summary: Similar to Dispatch. Initial paged and scenario to the April information requested immediate 27 Code Pink Drill: by Dispatch was notification Actor abductor reduced, but delayed broadcasted, obtained the infant at the overhead paging, additional knifepoint after which gave the actor information will be following the Nurse abductor time to make it obtained from the transporter into the down the 3rd flr exit caller and updates elevator; stairwell ground flr exit provided overhead, door prior to being to Security stopped. Staff Roles Dispatch via radio, and Responsibilities: and law Staff response enforcement, if throughout the facility needed. was immediate and all observed exit doors, elevators, and stairwells were adequately covered. SEP (E)Hurricane Irma (Actual) Communication; Scope: This event Communication/Com Communication: 10 All Halifax Health Facilities Safety and impacted all Halifax munity Partners: Improve Mgr and Business Security; Staff Health healthcare Internal and external communication to Occupancies Roles & Resp.; and business communication met staff pre-during and Clinical & Support occupancies ; objectives to plan, post event Activities; Utilities; Objectives: Provide prepare, inform, Community HICS; Command continuity of patient respond, and provide Partners: Center Activation; care; ensure safety updates throughout participate in newly Community and security for event. Utilities : formed ESF-8 Partners; patients, staff, Implemented protective Emerg. Response Evacuation visitors, staff families measures; maintained Task Force for pre- and pets seeking continuity of operations; planning and respite, and the HBS evacuated to collaboration; facility; ensure HHMC; phone lines not facilitate County Halifax Health EOC Year End Report 2017 14
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adequate resources operational immediately PIOs to participate and assets; ensure post-storm; Deltona ED in pre-planning interoperable generator was down for Utilities: provide communications with 1-1/2 hrs, but backup generator partners; ensure operational thereafter for DFSED in case adequate staffing; due to facility staff primary goes down; maintain command onsite. Continuity of purchase hand held center operations; Patient care was HAM radio for shelter in place; maintained during backup maintain patient care; downtime. communication and maintain utility Safety/Security: install repeater to operations; HHMC Created improve reception Implement lessons computer-based system inside building; learned from for tracking all staff and Safety/Security: Hurricane Matthew- families seeking respite pre-register staff 2016; Summary: A and identifying w/ color- and families for Category 2-3 coded wristbands; respite; expand Hurricane affecting required families to color-coding band the Daytona Beach provide IDs showing groups for better area and all Halifax same address as identification; HICS Health healthcare and employee, which limited Command: business occupancies sheltering numbers; provide specific installed video HICS training for surveillance on 8th flr General and shelter; HBS Command decompressed several positions; Staff patients and evacuated Roles/Responsibil -1- pt. to HHMC; ities: assign Clinical and Support additional leaders Activities: Improved for respite oversite Labor Pool sign-up at HHPO and system by pre- DFSED to utilized registering for Labor banding system pool; Improved Dietary preps and menus; utilized ROPU for discharged patient holding to free up beds; HICS Command Activation: AOC on Call was IC pre and during storm Scope/ Objectives/ Improvement/Acti Exercise/Event Critical Elements Evaluation/ Findings Summary ons SEP (E) Medical Communication; Scope: All Halifax Utilized ROPU for Lessons learned 12 Surge/Escalation- Post- Safety and Health healthcare discharged patient from Matthew were Hurricane Irma (Actual) - Security; HICS; and business holding to free up beds; implemented All Halifax Health Facilities Command Center occupancies; utilized the Peds ED successfully. and Business Activation; Staff Objectives: Maintain waiting area for Capacity Surge Occupancies Roles and patient care additional triage area Plan was updated Responsibilities; capabilities; ensure and pre- scheduled and protocols Clinical and safety and security for additional staffing pre- revised to reflect Support Activities; patients, staff, and storm to ensure 'Code Purple' Utilities; visitors; adequate staff to cover Action Plan Community post-storm escalation; Partners improved communication enhanced throughput; daily operations briefing facilitated throughput;
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general and special needs sheltering provided by the county assisted with discharge placement for those who were special needs or oxygen dependent
Effectiveness: • Safety and Emergency Preparedness Coordinator actively participated in community and regional Emergency Preparedness and Management collaboration, planning, workgroups, tabletop exercises, and regular meetings. • Attended the TJC Environment of Care and Life Safety Education Seminars • Required drills, exercises, and actual events were performed, responded to, assessed, and opportunities for improvement identified and improvement actions implemented, as required per Joint Commission (TJC) standards • Revised Emergency Code Response mandatory education to incorporate lessons learned from the previous year and will monitor for improved performance.
Performance Goals for 2018: • Continue to provide preparedness and training opportunities for Administrators on Call and House Supervisors who have a role and responsibility during an activation of the Emergency Operations Plan, with a 100% completion rate. • Monitor and assess Team Member knowledge or their role and responsibility during Code Pink, Code Brown, and Code Black drills or actual event responses, with a threshold of 90%. • Conduct drills, exercises, and/or actual events to meet TJC, CMS, and AHCA requirements for all Facilities, with a threshold of 100%.
Program Evaluation: The Emergency Preparedness Management Plan for Halifax Health was effectively managed and met the 2017 objectives and goals, with emphasis placed on continuous improvement and monitoring in the coming year.
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5. FIRE & LIFE SAFETY MANAGEMENT
Objective: The objectives of this plan are: • To assure facilities are in compliance with applicable National Fire Protection Agency (NFPA). • To provide education to team members on the elements of the Life Safety Management program including organization protocols for response to, and evacuation in the event of a fire. • To assure that team member training in the Life Safety Management Program is effective. • To test and maintain the fire alarm, and detection. • To institute interim life safety measures during construction, fire alarm or detection failures. • To maintain the Statement of Condition, as required.
Scope: The scope of this plan encompasses all team members within Halifax Health and includes all areas of the facilities. This program is to design processes to prevent fires, protect patients, team members and visitors in the event of a fire. The program is based on organizational experience, applicable laws, maintaining structural requirements and maintenance of fire safety equipment within the facilities.
Performance Goals for 2017: • Continue to monitor fire safety indicators and reduce accidental activations by 5%. – MET o Accidental activations of the fire alarm system decreased by 17% in 2017. Most accidental fire alarm activations occur during periods of construction, renovation maintenance, and repairs throughout the facility. This decrease can be attributed to the following: Improved coordination between Facility Operations, Engineering/Construction, and contractors. Education of staff during daily safety huddles. • Utilize ReadyPoint survey tool to track fire drill and alarm response deficiencies and monitor to identify opportunities for improvement. Not Met o The ReadyPoint contract was discontinued due to the problematic and cumbersome entry of data and lack of return on investment.
Fire Safety / Life Safety Metrics 2017 2016 YTY % Change LIFE SAFETY MANAGEMENT TOTAL TOTAL Change Construction projects w/ Interim Life Safety Measures(ILSM) 14 9 5 +56% 2017 2016 YTY % Change FIRE SAFETY MANAGEMENT TOTAL TOTAL Change Decrease Fire alarm accidental activation* 29 35 6 -17% Actual Fire Incidents* 0 0 0 0% Source: *Security Dispatch Log Reports
Effectiveness:
• 2017 reflected a significant decrease in false activations of the fire alarm system
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• Code Red Fire Safety plans for HHMC, HHPO, Deltona ED, HBS, and Twin Lakes Surgery Center were revised, as needed, and approved by the respective local fire department having jurisdiction. • Mandatory fire safety education for staff was presented in New Employee Orientation, during safety huddles, daily Operations Calls, and annual computer-based training modules. o Staff competency was also evaluated after fire drills and/or actual alarm activations and a Code Red–Fire Safety and Response In-Service was provided after fire drills and/or actual alarm activations. • The Annual Fire Safety Inspections were performed for HHMC, HHPO, Deltona ED, HBS, and Twin Lakes Surgery Center by the respective local fire department having jurisdiction and deficiencies corrected. • Required fire drills, maintenance, and testing were performed per regulatory requirements.
Performance Goals for 2018: • Review and evaluate the HHMC, HHPO, Deltona ED, HBS, and Twin Lakes Surgery Center, Fire Safety Plans and submit to the respective local Authority Having Jurisdiction/Fire Marshall/Inspector, for annually required approval. • Implement fire and spoke door inspection training for respective staff, per NFPA (National Fire Protection Association) Code requirements, with a target goal of 100%. • Continue to monitor fire safety performance indicators and reduce accidental activations by 5%. • Inspect fire extinguishers monthly and provide annual maintenance, as required, with a target completion rate of 100%. • Conduct fire drill and evaluation per regulatory requirements, with a target rate of 100% completions. • Continue to assess staff Fire Safety Competency during Code Red-Fire Alarm and Fire Drill activations, to establish a baseline for improvement.
Program Evaluation: The Fire & Life Safety Management Plan for Halifax Health was effectively managed, with emphasis placed on continuous improvement and monitoring in the coming year.
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6. MEDICAL EQUIPMENT MANAGEMENT
Objectives: The objectives of the Medical Equipment Management plan are:
• Select and acquire medical equipment and systems that meet patient care and operational needs. • Ensure medical equipment maintenance staff are adequately trained on equipment used. • Respond appropriately to equipment-related emergencies. • Inspect, test, and maintain the equipment according to regulatory standards and manufacturer recommendations (OSHA, NFPA, SMDA, JCHA, and FDA) • Monitor equipment function and report equipment failure incidents to the Patient Safety Committee for review. Revise equipment and/or protocols, as needed. • To establish written criteria to identify, evaluate, and inventory medical equipment to be included in the equipment management program. • To follow up with manufacturer on medical device recalls and alerts • Ensure all devices under AEM program (if applicable) are implemented according to requirement
Scope: The scope of this plan encompasses all team members within Halifax Health and includes all areas of the facilities. To ensure that all medical equipment is well-maintained and safe to use, is replaced when appropriate and replaced with the optimum equipment, and that medical equipment users are adequately trained to operate this equipment.
Performance Goals for 2017:
2017 YTY % MEDICAL EQUIPMENT MANAGEMENT 2016 TOTAL TOTAL Change Change Increase 41 34 +7 +21%
Confirmed / suspected user errors* Increase 256 205 +51 +25% Other user errors (Categorized as CND / NPF)* Increase 67 45 +22 +49% Equipment involved in occurrences**
*Source: Facility Operations Maintenance Connection **Source: Event Management System
• Continue to collect and validate metric data through accurate and timely reporting to the Environment of Care Committee and reduce metrics by 5%. Not Met o Increase in metric data can be attributed to more specific work order reporting by Biomedical technicians, more accurate tracking of equipment through updated Aramark preventative maintenance program, and additions to inventory of equipment initially omitted from tracking and preventative maintenance program. • Increase medical equipment training opportunities with the Aramark partnership. Met o Aramark provided in-service, departmental training and education to Biomedical technicians.
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• Reduce overall medical equipment repairs, maintenance, training, and operating expenses by 5% - Met o Contractual agreements with Aramark provided an overall reduction in equipment repairs, maintenance, training, and operating expenses. • Continue to monitor and assess Medical Equipment Management metrics to reflect consistent work order repair action code typing and classification: Met
Effectiveness: • All equipment types were reclassified and assessed based on the updated, Risk Based Medical Equipment Management System utilized during 2017. This determined the preventative maintenance frequency by equipment type and reduced the overall required P.M.s by an average of 15% or greater. • Monitored, assessed, repaired or replaced all biomedical equipment, as needed. o Reviewed work order completions monthly to ensure Timely completion of repair work orders Proper classification by user errors, cannot duplicate, or no problem found • Monitored and assessed performance indicators and reported to EOC Committee monthly • Ongoing collaboration with IT Security to identify vulnerable medical equipment • Patient Monitoring equipment was replaced in multiple locations throughout the facilities in 2017. The following Departments received equipment replacement: o PACU o Holding and Labor and Delivery PACU • GE provided training on new monitoring equipment prior to installation and during real-time use.
Performance Goals for 2018: • Aramark implementation of updated Medical Equipment Management System “Agilis.” • Implement ongoing specialized training for medical devices and equipment to reduce cost of utilizing outside vendors to perform maintenance and repairs. • Continue to collect and validate metric data through accurate and timely reporting to the Environment of Care Committee • Monitor and identify trends to assess medical equipment user errors to determine additional training needs. • Increase medical equipment training opportunities with the Aramark partnership.
Program Evaluation: The Medical Equipment Management Plan for Halifax Health was effectively managed and improvements, performance goals, and objectives have been established for the coming year.
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7. UTILITY MANAGEMENT
To ensure that all Halifax Health utility systems are maintained in a reliable condition and that staff are knowledgeable of key responsibilities during disruptions of utilities critical to maintaining operations.
Objective: The objectives of the Utility Management plan are: • Assess and Minimize Risks. • Ensure operational reliability. • Identify equipment included in the program. • Insure testing, inspection and maintenance of critical components. • Provide utility system plans and layouts to personnel operating the system. • Investigate utility failures and identify necessary corrective action. • Provide training and education to all personnel responsible for operation and maintenance of the systems. • Develop performance standards for personnel, equipment operation, maintenance, and repair. • Develop emergency procedures detailing the initial response to utility failures.
Scope: The scope of the Utility Management Plan encompasses all Halifax Health facilities. The utility program includes all life support systems, engineered infection control systems, environmental support systems, equipment-support systems, communication systems, and all other utilities and associated equipment supporting the patient care effort. Except for communication systems, and where otherwise designated within this plan, the responsibility for the operation, testing, maintenance, and repair of the utility system shall be the responsibility of the Facility Operations Department.
Performance Goals for 2017: Utilities Management Performance risk reduction strategies and objectives… • Replace of AHU 1 covers Sterile Processing - MET • Replace of AHU 3 covers OR’s HMC 1-6, 10-12 - MET • Replace of AHU 4 covers OR’s HMC 7-9, 14-16, 17, 19 - MET • Replace of AHU 5 covers Cysto, PreOp – MET • Repair damages from Hurricane Matthew: tile roofs and water proofing of windows at Fountain and France Tower – PARTIALLY MET o Tile roof repairs were completed o Water proofing of windows was removed from project list for 2017 • Complete Boiler replacement project 2 nd quarter of calendar year 2017 - MET • Continue to implement temperature and air pressure relationship monitoring device installation project , for visual inspection by team members, as required - MET • Increase organizational Manager work order reporting in Maintenance Connection by 5% - N/A o The percentage increase in Manager work order reporting in the work order system was difficult to isolate; however, there was a significant increase in organizational utilization by ‘Requesters’ (users with work order reporting access in Maintenance Connection) and a decrease in work orders called into the Facility Operations desk. Managers expanded the number of Requesters for each shift to increase timely reporting of deficiencies. As evidenced by the increased Requester utilization, this performance metric will be removed from the EOC Dashboard.
Halifax Health EOC Year End Report 2017 21
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2017 2016 YTY % UTILITY SYSTEM MANAGEMENT TOTAL TOTAL Change Change Power fluctuations >2 seconds (P-planned or U- unplanned) Decrease 5(2-p/3-u) 7 2 *Per FPL, unable to provide accurate Sep. data 29% due to hurricane
Effectiveness: The overall performance of 2017 to meet the objectives of the Utility Management Plan has been effective in maintaining and sustaining facility operations and improving or replacing defective equipment in a timely manner. • Protective measures were implemented for the Hurricane Irma response, to shelter in place and maintain continuity of critical equipment and facility operations: o Pre-staged the following resources to provide secondary critical infrastructure capabilities in the event of primary equipment disruption or failure: Portable generator capable of powering critical infrastructure for the Fountain Buildings (Central Energy Plant at HHMC is capable of providing primary and secondary electrical power to the France Tower) Portable Cold water chiller capable of maintaining temperature and humidity in all operating rooms at HHMC and HHPO Otis elevator technicians staged at both HHMC and HHPO to ensure elevator operations during shelter in place lockdown response to Severe Weather Water and other supplies to sustain patient and staff for the duration of response o Although minor fluctuations occurred, electrical power was maintained for critical infrastructure operations for the duration of the storm response, without a loss of primary or secondary power at HHMC and HHPO. • Overall power fluctuations and outages were reduced in 2017 due to post-Hurricane Matthew hardening of the critical, electrical infrastructure by FPL and Halifax. Electrical utility hardening included maintenance, repairs, and improvements. (Minor fluctuations and/or voltage drops with a duration of 2 seconds or less, are not included in the data) o There were 5 total outages in 2017 that were greater than 2 seconds. Of the 5, 2 were planned and 3 were unplanned: 1. April – 1-planned at HHPO: FPL connected a new transformer gear feeding the Ambulance reels next to the compactor. 2. July – 1-planned at HHMC: FPL performed maintenance to transformers in the south vault. 3. September – 1-unplanned at HBS and 1-unplanned at HH Deltona ED: Both power outages attributed to Hurricane Irma. HBS relocated 1 patient to HHMC until power was restored. HH Deltona ED operated on generator power until primary electrical power was restored. 4. October – 1-unplanned at HHMC: FPL power fluctuation for 4 second duration. Performance Goals for 2018: The following performance goals were identified to maintain and further the effectiveness of the Utilities Management program for 2018:
Halifax Health EOC Year End Report 2017 22
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• Complete the chilled water expansion project, extending from the North Central Energy Plant to the Fountain Building, to enhance capability to maintain consistent temperature and humidity in operating rooms • Continue to monitor and evaluate air pressure relationships o Add the sterile storage rooms to the monthly preventative maintenance program to ensure positive pressure to the hallway, and provide a quarterly report to the Environment of Care Committee with a 100% completion rate. • Provide the following education to facilities staff with a 100% completion rate: o Plant Operators: Revised NFPA fire and smoke door inspection requirements with a target goal of 100% completions o All Facilities Staff: In-Service for ICRA (Infection Control Risk Assessment) and ILSM (Interim Life Safety Measures) for Life Safety - fire system deficiencies Updated Policies and Procedures
Program Evaluation for 2017: The Utility Management Plan for Halifax Health was effective in meeting the Plan Objectives, with emphasis placed on continuous improvement and monitoring in the coming year.
Prepared By:
Ashley Fisher Environment of Care Chair Safety and Emergency Preparedness
APPROVALS: Environment of Care Committee: 02/23/2018 Board of Commissioners: Submitted for review and approval during March 2018 session
Halifax Health EOC Year End Report 2017 23
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TO: Jeff Feasel, President and Chief Executive Officer FROM: Bill Griffin, Director, Research and Planning CC: Eric Peburn, Executive Vice President and Chief Financial Officer DATE: February 20, 2018 RE: Deltona Ambulatory Surgery Center (ASC) Development
The physician interest appears to be coming together with a closing syndication date of March 31, 2018. This is a key component to completing the strategic positioning of the Medical Office Building (MOB). Based upon verbal commitments at this time, Compass Surgical Partners believes that there could be enough demand for up to four operative suites and one/two procedure rooms. The final projections and recommendation will be prepared for consideration at the May 2018 Board of Commissioners meeting. The structure diagram is shown below (same as shared at the February 2018 Board of Commissioner meeting).
Page 224 of 294 Human Resources Executive Summary - December 2017
Recruitment Turnover
^Vacancy Rate 3.71% New Hires 35 *Annualized Turnover Rate 20.09% Number of Applications 2,145 FT 23 *Annualized RN Turnover Rate 23.30% Average Days to Fill 28.8 PT 2 Terminated/Resigned 60 RNs 25.8 Casual Pool 10 Average Number of Employees 4,167 Allied Health 30.2 Core RNs 2 Average Number of FT /PT Employees 3,583
Employee Relations Retention
Employee of the Month: Average Tenure of Active Employees 7.87 Service Awards Active Employees 5 Year 21 Average Tenure 0 - 1 yr 29.83% 10 Year 7 Average Tenure 2 - 5 yr 27.55% 15 Year 6 Average Tenure 6 - 10 yr 11.18% 20 Year 7 Average Tenure > 10 yr 31.44% 25 Year 1 30 Year 1 Seperations 35 Year - Average Tenure 0 - 1 yr 26.67% 40 Year - Average Tenure 2 - 5 yr 48.33% Average Tenure 6 - 10 yr 8.33% Average Tenure > 10 yr 16.67% *Organizational & Talent Development Compensation
**Inservice & Continuing Education Total Evaluations Due 424 Includes 6 Month and Annual Performance Evals Number of Programs 1,831 Early/OnTime Evaluations 205 Participants 18,219 Late Evaluations 139 Instructions Hours 8,817 Outstanding Evaluations 80 *Computer Based Learning 5,103 Avg Score 2.99 Avg Hourly Rate $ 25.95 RN Referral Bonuses Paid $ 2,000.00 At Max/Bonus Paid $ 3,723.20 Tuition Reimbursements 26 @$21,241.97 *Continuing Physcician Education Sign On/Relocation Bonuses $ - Number of Programs 25 Nursing Loan Forgivness 10 @21844.23 Participants 411 Work / Life Benefits & Leave Programs *Continuing Clinical Education Number of Programs 114 Total Employees on Leave 75 Number of Benefits Eligible 3,675 Participants 1,010 Worker's Compensation Claims 2 Number of 457 Plan Participants 50 Leave of Absence Requests 18 Number of 403(b) PlanParticipants 3,712 *Medical Library Family Medical Leave Act Requests 52 1%-3% Contributions 2,819 Patrons 193 Military Leave Requests 1 4% or Higher Contributions 893 Article Sources 433 Voluntary Summer Leave 2 * UNUM Wellness Claims Paid Number of Retirements 5 Disability Claims Paid $ 1,500.00 Worker's Compensation Incidents 21 STD 8@$13,080.65 Administrative Leave 0 LTD $ - Management $ -
Auxilary Visitor Access
Volunteer Hours 4,292 Total Visitors 34,538 Halifax Main Campus 31,816 HHPO 1,536 HBS 1,186
**Based on statistics reported by Date ^Vacancy Rate = Open Positions Entire House *Turnover Rate = FT & PT Seperations Average FT & PT Employees
Executive Summary December 2017.xlsx PagePage 225 1 of 294 Human Resources Executive Summary - January 2018
Recruitment Turnover
^Vacancy Rate 3.62% New Hires 62 *Annualized Turnover Rate 15.07% Number of Applications 2,236 FT 47 *Annualized RN Turnover Rate 10.41% Average Days to Fill 34.5 PT 2 Terminated/Resigned 45 RNs 35.4 Casual Pool 13 Average Number of Employees 4,155 Allied Health 33.7 Core RNs 9 Average Number of FT /PT Employees 3,584
Employee Relations Retention
Employee of the Month: Average Tenure of Active Employees 7.98 Service Awards Active Employees 5 Year 14 Average Tenure 0 - 1 yr 29.60% 10 Year 12 Average Tenure 2 - 5 yr 27.68% 15 Year 10 Average Tenure 6 - 10 yr 11.07% 20 Year 3 Average Tenure > 10 yr 31.65% 25 Year - 30 Year 3 Seperations 35 Year - Average Tenure 0 - 1 yr 53.33% 40 Year - Average Tenure 2 - 5 yr 28.89% Average Tenure 6 - 10 yr 0.04% Average Tenure > 10 yr 0.13% *Organizational & Talent Development Compensation
**Inservice & Continuing Education Total Evaluations Due 351 Includes 6 Month and Annual Performance Evals Number of Programs 146 Early/OnTime Evaluations 155 Participants 1,129 Late Evaluations 102 Instructions Hours 3,461 Outstanding Evaluations 94 *Computer Based Learning 1,050 Avg Score 3.22 Avg Hourly Rate $ 26.13 *Continuing Physcician Education RN Referral Bonuses Paid $ 3,000.00 Number of Programs 18 At Max/Bonus Paid $ 5,408.00 Participants 287 Tuition Reimbursements [email protected] Sign On/Relocation Bonuses $ 5,000.00 *Continuing Clinical Education Nursing Loan Forgivness [email protected] Number of Programs 52 Participants 110 Work / Life Benefits & Leave Programs
*Medical Library Total Employees on Leave 24 Number of Benefits Eligible 3,571 Patrons 186 Worker's Compensation Claims 3 Number of 457 Plan Participants 50 Article Sources 198 Leave of Absence Requests 4 Number of 403(b) PlanParticipants 3,643 Family Medical Leave Act Requests 16 1%-3% Contributions 2,761 Military Leave Requests 0 4% or Higher Contributions 882 Voluntary Summer Leave 0 * UNUM Wellness Claims Paid 49 @$ 3600 Number of Retirements 5 Disability Claims Paid Worker's Compensation Incidents 38 STD 10 @$1794.00 Administrative Leave 1 LTD - Management 1@ $5536
Auxilary Visitor Access
Volunteer Hours 5,333 Total Visitors 37,437 Halifax Main Campus 33,934 HHPO 2,085 HBS 1,418
**Based on statistics reported by Date *Annualized Turnover is multiplied by 12 to create a predictive nature. ^Vacancy Rate = Open Positions This allows us to foresee the annual turnover rate if current rate doesn't change. Entire House Divide by 12 to get the monthly value. *Turnover Rate = FT & PT Seperations Average FT & PT Employees
Executive Summary January 2018.xlsx PagePage 226 1 of 294 General Medical Staff MINUTES 011618 FRANCE TOWER ROOMS D-G MEETING CALLED Daniel T Miles, MD, Chief of Staff BY NOTE TAKER Eve Ann Magoulas, PhD, Medical Staff Coordinator ATTENDEES See attendance log in MDStaff.
TOPIC Call to Order and Approval of General Staff Meeting Minutes The meeting was called to order by Chief of Staff Daniel T Miles, MD at 1837 hrs. A quorum was present. New members to DISCUSSION medical staff were recognized (list on file). Halifax Health’s 90th Anniversary was commemorated by a medical staff photo prior to the meeting. CONCLUSIONS Meeting commenced. Those new members present were recognized.
TOPIC Approval of General Staff Meeting Minutes
DISCUSSION Minutes of the September 19, 2017 general medical staff meeting were reviewed. MOTION: It was moved and seconded to approve the General Staff minutes of September 19, 2017. Motion carried CONCLUSIONS unanimously. TOPIC Treasurer’s Report – Ammar Hemaidan, MD presented by Louis Agnone, MD Total investment value at December 31, 2017 is $355,473.98. Income dividends for the period are $886.61, which reflects a decrease of $773.18 from the previous period. November 2017 $441.26 December 2017 $445.35 $886.61 The Medical Staff Working Capital quarterly expenditures for the quarter: November 2017 $16,676.93 December 2017 $ 4,078.95 DISCUSSION $20,755.88 Deposits for the quarter: November 2017 $9,775.00 December 2017 $5,780.00 $15,555.00 The balance in the operating account as of December 31, 2017 is $220,862.65. Non-attendance fees collected for 2016: $9,000 as of 12/31/2017 Non-attendance fees collected for 2017: $3,200 as of 01/09/2018 CONCLUSIONS MOTION: It was moved and seconded to accept the Treasurer’s report as submitted. Motion carried unanimously. TOPIC Chief of Staff Report – Daniel T Miles, MD Chief of Staff announced: Halifax has been experience a very high daily census the past few weeks The Meditech platform upgrade has a July 1, 2018 go live date DISCUSSION Deltona Hospital slated to open December 2019 VCMS President, Steve Sevigny, MD announced a membership invitation to an event next Tuesday night at the Speedway’s Rolex Lounge. A talk on circadian rhythm will be presented. Members/nonmembers and spouses are invited. RSVP please-see invitation. CONCLUSIONS Information only. TOPIC CMO Report – Margaret Crossman, MD A. MDR video – The CMO explained the multidisciplinary rounds (MDRs) process and encouraged physicians to join the rounding experience. The TJC R3 Report published August 2017 mandates opioid crisis responses by January 2018 from accredited hospitals and systems as part of the solution. Two multidisciplinary teams (entitled Assessing and Managing Pain Safely or AMPS) have convened over last several months to develop standards and review data. Outcomes are in the forms of many initiatives, for example, Drs. Viel and D Peterson working on the plan for ED patients. B. Clinical Observer Policy – Observerships for students to shadow has changed over the past several years and the process became difficult to manage. In response to physician requests, a new process has been developed for bringing students on campus for an opportunity to observe. Policy highlights were provided. C. Announcements – policy regarding medical records was reviewed for correcting documentation with a strikethrough, initial, date and time; no stamped signatures policy was reviewed and electronic signatures are acceptable; cell phone and DISCUSSION device policy was reviewed (do not use in elevators, restrooms, meetings); CMS clarified texting must travel over a secure platform and prohibits texting orders regarding patients. Halifax uses the Vocera solution; 500/170 physician/midlevel not using but 60/10 are using the app. Dr. Kwong will elaborate in her report. Hurricane Irma impacted Puerto Rico where many IV fluid bags made thereby creating shortages; consider judicious use of bags, and pharmacy has put us on alert to consider alternative route. Examples of alternate routes were provided. D. Staff Recognitions – Dr. Kushner sent a note of thanks to the Radiology team for their care in a complex case; a part time resident from the UK wrote about the excellent and compassionate care he received at HHPO; a note was received from patient who stayed in the France Tower and noticed all team members appeared engaged and happy to be working at Halifax; please see the FSU med journal article about alumni returning to Halifax to continue their practice in our community. A. Contact Drs. M Crossman or Estrella for more information. Watch for information regarding AMPS initiatives. B. Policy will be posted on the Physician Portal. CONCLUSIONS C. All policies are posted to the Physician Portal. D. Congratulations to all staff recognized.
General Staff Meeting January 16, 2018 Page 227 of 294 Page 1 of 2 TOPIC Administrator’s Report A short video was presented in celebration of Halifax Health’s 90 years of community service; President & CEO stated Halifax was the first hospital in the area and continues to meet challenges in the current landscape of healthcare. The group photo taken before the meeting will be used for marketing materials throughout the yearlong celebration. Tonight’s attendance attests to TJC feedback regarding the high level of engagement by the medical staff where clinicians are involved and eager to participate in the survey process. The survey focused on life safety, credentials, unattended pharmaceuticals, and the environment of care among other issues. A follow site visit was conducted by TJC to review ceiling tiles, which provide a barrier for fire safety. Congratulations on a successful survey. TJC returned two weeks later to perform a site survey for the Stroke Center. Other recognitions in quality rankings are the OB program ranking #1 in DISCUSSION Florida, #1 in the nation for no early deliveries before 39 weeks- kudos to the team members and physicians. Also recognized is the ortho hip/knee program to reduce readmissions, #1 in Florida and #2 in the nation rate–kudos to team members and physicians. The focus on LOS using MDRs has been the most effective tool we’ve seen in years. Success in the process has the average length of stay below 5 days for the past several months. Please help us on prepare for weekends, which is an area of opportunity. Consider OP testing or let us know about testing not performed on weekends. TJC surveyors say they’d bring their families here and further commented on the cleanliness of the facilities. Deltona project is moving forward with a December 2019 opening planned. Deltona ED volumes reached 70 visits this past weekend. CONCLUSIONS Physicians considering extending practices to Deltona were encouraged to speak to Administrators. TOPIC Unfinished Business DISCUSSION None. CONCLUSIONS No action.
TOPIC New Business A. MIG Board Report – CMIO presented a plan to leverage new technology in 2018; three areas of focus include bringing care back to the bedside with mobile solutions. One example will enable providers to share imaging results with patients. The EHR will go live on a new platform July 1, 2018 with a different look that is compatible with touch screen devices, iPads, MS pros. A new approach using multimodality tools is planned for educating providers through self- learning videos and simulation, along with face to face sessions. Dragon Medical One is an enterprise platform launching March 2018. The tool is smartphone compatible with an app installation allowing dictation directly into EHR from anywhere. A lunch and learn is slated for Feb 5 for providers to DISCUSSION install app to use phone as dictation device. Secure text messaging will become more important for both hospital based and ambulatory practices. Hospital based physicians can use Vocera app that has been shown to reduce time spent communicating by up to 1 hour. Not all hospitals have this capability; Halifax is on the cutting edge in leveraging these technologies. Goal is to deliver safe, quality patient care at Halifax Health. B. Quality Report – CQO explained MedPac and the history of MACRA and MIPS would affect physicians in 2018. MedPac met on 10/05/17 and voted 12 to 2 to rescind requirements. Medical staff has competency-reported quality metrics for the hospital. A. Voice recognition (VR) technology training videos will be available. CONCLUSIONS B. Contact 425.3612 for assistance with Vocera app installation. C. Physicians were encouraged to contact MedPac and thank them for achieving removal of MACRA/MIPS requirements. TOPIC Open Forum Announcements: Moment of Silence for Drs. Lacsamana and Ed Favis – former medical staff members who passed since the last meeting. DISCUSSION Meeting requirement 2 of 3 meetings must be attended according to new medical staff bylaws. Educational documents have been posted to the physician portal. Congratulations to Dr. Prevatte on becoming a new grandfather! CONCLUSIONS Information. TOPIC Adjournment DISCUSSION With no further business to conduct, the Chief of Staff entertained a motion to adjourn. Motion: It was moved and seconded to adjourn. Motion carried unanimously. The meeting closed at 1922 hrs. Next CONCLUSIONS General Staff Meeting slated for May 15, 2018. This interim document contains Confidential and Privileged Information and as such is protected by Florida Statutes 395 and 766 and Federal Health Care Quality Improvement Act and the Patient Safety and Quality Information Act of 2005.
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Meeting Minutes January 10, 2018
Call to Order 8:00 AM Andrew Leech, Halifax Health- Foundation President Joe Petrock, Executive Director Halifax Health- Foundation Roll Call Present: Mary Bennett, Ronnie Bledose, Jeffery Brock, Alex Doberstein, Liz Dusz, Jeff Feasel, Dr. Brent Fulton, John Guthrie, Buck Harris, Mike Jackson, Paul Joachimczyk, Andrew Leech, John Lindsley, Charles Lydecker, Rick Martorano, George Mirabal, Steve Nameth, Bill Olivari, Glenn Padgett, Carl Persis, Joe Petrock, Jennifer Quattrochi, Bud Ritchey, Budd Severino, Edith Shelley, Greg Snell, Bobby Thigpen, Lisa Tyler, W.G.Watts, Dr. Alex White, Patti Earl, Kathryn Nagib
Review of Andrew Leech, Halifax Health- Foundation President called for approval Minutes of the following minutes: 1. Full Board Meeting- October 11, 2017 MOTION by Jennifer Quattrochi to approve the minutes from the Full Board Meeting on October 11, 2017, was seconded by Board Member Glenn Padgett. MOTION CARRIED unanimously.
Presentation Suzanne Lovelady & Keith Sofiak, presented to the Board on Quality Improvement. Reports Liz Dusz, President of Auxiliary 65,162 hours have been donated by volunteers. The recipient of the Joe Petrock Volunteer of the Year was presented to Connie Freer. Bobby Thigpen, Halifax Health- Foundation Treasurer called for approval of the following November financial report: 1. Motion and second to accept report as presented. Motion carried. (Financial Report not included in packets, sent via e-mail) Joe Petrock, Executive Director Halifax Health- Foundation updated the Board on various Foundation projects and events. 1. Foundation Website will be live soon for all events and donations. 2. Florida Blue Foundation Grant: Clinical Support Services DB Homeless Shelter 3. Save the Date (See attached for events and dates)
Page 229 of 294 Approvals Joe Petrock, Executive Director of Halifax Health- Foundation called for approval of the following department requests: 1. Motion and second to accept report as presented. Motion carried. a. NICU- Chairs and specialized cribs b. Speediatrics ER- Speediatrics wall decals c. Consolidation of Foundation funds President/CEO Jeff Feasel, President and CEO of Halifax Health updated and answered Report questions regarding all services provided by Halifax Health. (See attached for Management Report)
Next Foundation Board of Directors Meeting will be on March 14, 2018. The meeting will be held in France Tower Conference Rooms E & F.
______Jennifer Quattrorchi, Halifax Foundation Secretary
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HALIFAX HEALTHY COMMUNITIES Board of Directors Quarterly Meeting Minutes France Tower – Conference Rm “F” January 17, 2018
Members Present: Gwen Azama-Edwards, Vice-Chair Absent: Bob Snyder Patricia Boswell Jeff Davidson Ed Connor Jeff Feasel
Others Present: Deanna Schaeffer, Healthy Communities Alicia Watson, Healthy Communities Steve Parris, Healthy Communities Cher Philio, Healthy Communities
The meeting was called to order at 4:05 p.m. Welcome and Introductions ensued. The minutes of October 18, 2017 were approved as written.
CHAIRMAN’S REPORT/COMMENT:
Board Appointment:
Vice-Chair Azama-Edwards reported that the Halifax Health Board of Commissioners approved reappointment of Mr. Feasel to the Halifax Health Healthy Communities Board. The new term end date is December 31, 2020.
Board Vacancy:
Vice-Chair Azama-Edwards opened for discussion of the Board vacancy. Ms. Schaeffer informed the Board that it would be beneficial to have a West Volusia representative on the Board. She reported that Mr. Parris has reached out to Ms. Debbie Fisher, of Volusia County Schools in this regard. Ms. Schaeffer asked Mr. Parris to provide the Board with an update.
Mr. Parris reported that Ms. Debbie Hinson Fisher is the Coordinator of Student Health Services. She has been with the school board for more than 15 years and has maintained her current role as the Coordinator of Student Health Services for the last seven years. Mr. Parris works collaboratively with Ms. Fisher as a member of the School Health Advisory Committee. She has expressed an interest in serving on the Healthy Communities Board, and he believes that she would be an asset. Discussion ensued.
At this time, Ms. Schaeffer stated that she would like to request the Board’s approval for staff to submit a recommendation to the Halifax Health Board of Commissioners for appointment of Ms. Debbie Fisher to the Healthy Communities Board.
Motion: Mr. Feasel made a motion for the Board to approve Mr. Parris’ recommendation of Ms. Debbie Fisher to serve on the Halifax Health Healthy Communities Board through March 31, 2020 as well as staff’s submission of a request for new appointment to the Halifax Health Board of Commissioners for consideration at its next meeting. Ms. Boswell seconded the motion.
Action: By unanimous decision of the Board, the motion carries.
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Mr. Feasel stated that he would like to identify a means by which Halifax Health can utilize its Pediatricians and Pediatric nurses, who are in leadership roles, to increase the organization’s involvement and support of school health initiatives as well as improve the integration of Halifax Behavioral Services (HBS) within Volusia and Flagler Counties. Additionally, he informed the Board that the organization is challenging its future leaders to become more involved in community initiatives. As such, he welcomes the membership’s input on current and or future opportunities in which the organization can increase its volunteerism in not-for-profit efforts in the two-county area, especially those focusing on at-risk youth.
Ms. Boswell mentioned that adolescent health is an area of unidentified need. She stated that there may be an opportunity for a partnership with Deland High School to increase the availability and utilization of its clinic. Discussion ensued.
Ms. Schaeffer stated that she would bring the Deland High School clinic to the attention of the West Volusia Hospital Authority. Additionally, she advised the Board that HBS currently partners with the school board to have counselors on-site at several of the schools. She is currently working with Jim Terry to identify opportunities and a means to enhance that relationship.
Election of Officers:
Vice-Chair Azama-Edwards opened the floor for the Election of Officers. The positions are Chair, Vice- Chair, and Secretary. Nominations were as follows:
Chairperson
Motion: Jeff moved to nominate Ms. Gwen Azama-Edwards as Chair. Mr. Connor seconded the motion.
Discussion: None.
Action: By consensus of the Board, the motion carries.
Vice-Chair
Motion: Jeff moved to nominate Patricia Boswell as Vice-Chair. Mr. Connor seconded the motion.
Discussion: None.
Action: By consensus of the Board, the motion carries.
Secretary
Motion: Jeff moved to nominate Mr. Jeff Davidson as Secretary. Ms. Boswell seconded the motion.
Discussion: None.
Action: By consensus of the Board, the motion carries.
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PRESIDENT/CEO REPORT – Deanna Schaeffer:
Legislative Update Ms. Schaeffer reviewed the provided report. She informed the Board that there has been little or no change in the bill filing since the time of preparation. (Reference Halifax Health Legislative Update as of December 20, 2017).
Under Constitution Revision Commission: Mr. Connor inquired as to whether a special session has ever been called to amend the constitution. Ms. Schaeffer responded not to her knowledge. However, the legislature can propose constitutional amendments, in regular or special session, as needed. One amendment under consideration for this year as follows:
The increase the voter support requirement for passage of a constitution amendment from 60% to 66 2/3%
Additionally, there are other ways to amend the constitution, such as a citizen ballot initiative. Discussion ensued.
Mr. Feasel inquired as to whether Proposal 69 had been heard in any committee, and how long the committees will meet. Ms. Schaeffer replied that the proposal has been referred to the Local Government as well as the Finance and Tax committees, but has not yet been added to the calendar. Additionally, she stated that the Commission must complete its deliberations in early May.
Mr. Connor inquired as to what taxing districts would be affected by the proposal. Ms. Schaeffer responded that it pertains to all taxing districts except water management districts. Discussion ensued.
Under Legislation of Interest: Mr. Feasel inquired as to whether the Senate is still willing to include the conditional requirement that the Ambulatory Surgery Centers must comply with the same rules and regulations as hospitals in this regard. Ms. Schaeffer responded that, as well as other provisions, are under consideration. Discussion ensued.
Under Federal Issues: Ms. Schaeffer informed the Board that although it is too early to talk about budget,, she and her colleagues are working to keep Medicaid rates as they are in the current year due to the significant industry reductions taken over the most recent five years.
Ms. Azama-Edwards inquired as whether there were any additional Medicaid changes other than the five year work requirement. Ms. Schaeffer stated that the work requirement is targeted at states that expanded Medicaid to include “able-bodied adults”. It excludes pregnant women, children and disabled individuals which is Florida’s primary coverage population; therefore, a major impact to Florida is not anticipated. Discussion ensued.
HEALTHY COMMUNITIES UPDATES: Healthy Communities Annual Report FY 2015-16
Mr. Parris reviewed the provided report (Reference Halifax Health Healthy Communities Annual report October 1, 2016 – September 30, 2017). He informed the Board that the annual report is dedicated to the memory of Mr. Don Quinn, “our dear friend and long-time Board Chairman”. 3 of 7
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The following items were highlighted:
Page 7. Per Mr. Feasel’s request, Ms. Schaeffer explained that the referenced population chart was added. In addition to the areas demographics, the chart also speaks to the state of the local area economy as more than 50% of kids are enrolled in in the Florida KidCare Program, which is the umbrella program that includes the four programs: Healthy Kids, Medicaid, MediKids, and Children’s Medical Services (CMS).
Ms. Boswell inquired as to whether staff was aware that CMS is currently restructuring. Ms. Schaeffer responded yes. The organization will be required to go through a rule process before restructuring can occur. Additionally, they would be required to issue a statewide Request for Proposals.
Mr. Feasel inquired as to the requirements to bid during the RFP process. Ms. Schaeffer responded that you have to be a licensed insurance company or a PSN; you must have a DOI insurance number; and, be regulated by the Department of Insurance (DOI). Discussion ensued.
Page 10. Ms. Schaeffer noted that Healthy Communities is just 30 kids short of awarding 16,000 scholarships since the inception of its water safety program in 1996. Mr. Parris added that it’s very likely that the program has made an impact because despite being surrounded by water, the two-county area of Volusia and Flagler has not been listed as one of the top 10 areas for drowning or near drowning in the state for several years.
Ms. Boswell informed the Board that she will provide Mr. Parris with the 2016 Child Abuse Death review report that was recently released. As a result of its findings, there will be a focus on increasing community safety and injury prevention initiatives. Vicky Whitfield, Chairperson of the Child Abuse and Death review committee, will be scheduling a press conference and summit in the near future. Ms. Schaeffer suggested that Mr. Parris look into this information further and find out how Healthy Communities can get involved. Discussion ensued.
Ms. Gwen Azama-Edwards suggests sharing copies of the annual report with funders as well as other community partners.
Healthy Kids and KidCare Outreach/Enrollment – Steve Parris: Florida KidCare Enrollment Mr. Parris reviewed the provided report. He informed the Board that the enrollment numbers have minimal increases or decreases; however, Medicaid enrollment numbers are only available through November 2017 (Reference Florida KidCare Volusia and Flagler Counties). The program enrollment is as follows:
Medicaid (11/17) – Volusia 54,018; and, Flagler 9,460; MediKids (01/18) – Volusia 726; and, Flagler 129; Children’s Medical Services (01/18) – Volusia 282; and, Flagler 51; and, Healthy Kids (01/18) – Volusia 4,314; and, Flagler 926.
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Ms. Azama-Edwards inquired as to whether we’ve experienced any impact from the displaced families of Puerto Rico. Ms. Schaeffer replied that Deltona has some families; however, counties such as, Osceola, Orange, and Miami-Dade are experiencing the greatest influx. She stated that more than 300,000 individuals are in Florida as a result of the displacement.
KidCare Outreach Mr. Parris reviewed the provided list of Healthy Communities’ community activities (Reference KidCare/Marketplace Outreach Activities and Program Highlights). Additionally, he informed the Board that although the open enrollment period for the Health Care Marketplace ended on December 15, 2017, staff will continue to offer year-round assistance to individuals who may be eligible for a Special Enrollment Period (SEP) as well as those who may be experiencing some issues with their Marketplace enrollment and or coverage.
Safe Kids Outreach Mr. Parris reported the following Safe Kids program update:
A. Child Passenger Safety Program
The monthly car seat check-up events at Halifax Medical Center on the 1st Wednesday of the month continue to be well attended. Monthly car seat check-up events are held at the Halifax Health – Emergency Department of Deltona on the 4th Thursday of each month. However, the December event was canceled due to the holidays. The next event will take place on Thursday, January 25th. Staff continues to provide car seat checks/installations during the week at the Healthy Communities office. Mr. Parris is in the planning process to host a Child Passenger Safety Technician Certification training March 5 – 7 to address partner requests to fulfill a need. Healthy Communities held a Child Passenger Safety Technician Recertification Course on December 7th at the Palm Coast Fire Department.
B. 2018 Safe Kids Swim Scholarship Program
Planning and preparations for the 2018 Water Safety Program will take place prior to the next Board meeting. The goal is to provide 800 scholarships.
C. Never Leave Your Child Alone - Kids In Hot Cars
42 children died after being left in hot cars in the United States in 2017. Six of the 42 children were Florida residents.
Follow us on our Safe Kids Coalition of Volusia and Flagler Counties Facebook page. Find us and like us at www.facebook.com/safekidsvf.
Healthy Start Ms. Philio reviewed the Healthy Start report Screening Results for Service Delivery Area (Volusia & Flagler County Residents) FY 17/18 Qtr 2. All Healthy Start screening and consent goals were met or exceeded. The Quarter 2 rates were as follows:
The infant screening rate of 85.97% exceeded the goal of 84.00%;
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Page 235 of 294 DRAFT
The prenatal screening rate of 83.50% exceeded the goal of 78.00%; The women consenting to the prenatal screen rate of 92.73% exceeded the goal of 90.00%; and, The eligible prenatal referrals consenting to participation at the time of the screen rate of 90.42% did not meet the goal of 96.00%.
Ms. Philio reviewed the delivering facility numbers that attributed to the Infant Screening Rate noting that Halifax Health Medical Center is at 100%. Additionally, she explained that she is currently working closely with one delivering facilities to identify issues that are resulting in their having a significantly lower screening rate that is impacting the overall rate.
Mr. Feasel informed the Board that Halifax Health Medical Center’s Obstetrics Department is the number one program in the State of Florida as well as the nation for the lack of early elective deliveries before thirty-nine weeks. The Board commended the organization on this accomplishment.
Ms. Boswell inquired as to a reason why the Prenatal Screening Rate is so low in December. Ms. Philio indicated that due to the flawed data used to calculate those numbers, the reason is unknown. Discussion ensued.
Ms. Philio reviewed the provided report outlining infant births in Volusia and Flagler Counties. The number of births for the period of July 1, 2016 through June 30, 2017 was as follows:
Volusia County Hospital Name # of births Halifax Health 1565 FL Hospital Memorial 1194 FL Hospital Altamonte 566 FL Hospital Deland 483 Winnie Palmer 356 Central FL Regional 299 FL Hospital Orlando 150 Winter Park 103 Other 204 Total 4920 Flagler County Hospital Name # of births FL Hospital Memorial 290 Flagler Hospital 251 Halifax Health 211 Other 55 Total 807 6 of 7
Page 236 of 294 DRAFT
Ms. Azama-Edwards inquired as to what the facilities were classified as “Other”. Ms. Philio replied that the “Other” category contains a compilation of facilities with an insignificant number of deliveries.
Mr. Feasel inquired as to whether Ms. Philio could track the number of births at the delivering locations outside of Volusia County by physician. Ms. Philio responded that she will look into this request further. Discussion ensued.
OTHER BUSINESS
Ms. Schaeffer acknowledged Alicia Watson’s 20 years of service with Halifax Health. She added that all Healthy Communities staff has 10 or more years with the organization.
ADJOURNMENT There being no further business, the meeting of January 17, 2018 adjourned. The next meeting is scheduled for Wednesday, April 18, 2018 at 4:00 p.m., unless otherwise notified.
7 of 7
Page 237 of 294 Page 238 of 294 Keeping the Family Together Halifax Behavioral Services COMMUNITY ACTION TEAM
Page 239 of 294 Halifax Behavioral Services
• The only child and adolescent behavioral care and Baker Act facility in Volusia and Flagler Counties • Patient panel of 3,000 • Offers inpatient and outpatient care • Works in conjunction with Law Enforcement, School Systems, Children’s Home Society, Department of Child and Family Services, ACT, Community Partnership for Children, Communities
3 Page 240 of 294 The Need
• In 2016 there were over 6,000 intent to harms reported to DCF • Something happens in the family that takes away hope from the family and a call is made. • For some, traditional therapy treatments may not be enough because the situation at home and/or their environment is stressed. When they return home, they are continually exposed to the same behaviors/actions in the family that led them into treatment in the first place.
4 Page 241 of 294 The System Now Has 2 Options
Traditional Department ACT Community Halifax Health Law Outpatient Children & Family Partnership for Behavioral Enforcement Providers Services Children Services
Out of Volusia Halifax Health County Community Action Residential Team (CAT)
5 Page 242 of 294 What is CAT
• Community Action Team started in August 2017 • Best practice from SAMHSA (Substance Abuse and Mental Health Services Administration • Based in community and specifically the home • Physician, Therapist, Mentor, Case Manager, Nurse, Secretary, Contract Mgr, 24-7 • Funded by DCF grant of $750,000 a year (3 yr. non-recurring, legislature funding) • Provides alternative to out of home placement for 6 to 9 months
6 Page 243 of 294 Focus
• Dedicated to: • Improving school related outcomes • Improving family functioning • Decreasing substance abuse • Improving health • Appropriate Transitions to age appropriate services
7 Page 244 of 294 Population Served
• Children 11-21 years old • At risk • Law enforcement involvement • Suspensions • Adolescents aging out of welfare • Service capacity - 49 children and families (waiting list)
8 Page 245 of 294 The Efficient & Effective Outcomes
• 2017 Third Quarter Outcomes • 49 Clients • 9 Clients discharged • 7 clients directly diverted from Child Welfare, Juvenile Justice, Psychiatric Residential
• Total Cost Avoidance $390,530.00
• Total CAT expense $187,500.00
9 Page 246 of 294 Why it Works
• Children get help from residential programs but then return to an environment that continues to be stressed, often bringing them back to square one. These staff members also work with the families to address social and environmental issues as well so the whole family can work together • Halifax Health can take its expertise in behavioral services and bring the expertise to the children and families who have the most barriers to care. By bringing the expertise of our HBS staff into the home where the child lives, we are able to help not just the child, but the entire family learn how to co-exist in a way that gives them the best possible chance of staying together as a family unit.
10 Page 247 of 294 Page 248 of 294 Quality Board Report Q4 – FY2017
Dr. Steven Miles, Chief Quality Officer Suzanne Lovelady, RN Director of Quality Keith Sofiak, Manager Quality Data
Page 249 of 294 ZERO HARM Through High Reliability Initiative
Page 250 of 294 Characteristics of HROs: A high reliability organization • Collective mindfulness (HRO) is an organization that • Sensitivity to operations has succeeded in avoiding • Do not accept “simple” catastrophes in an environment explanations for problems where normal accidents can be • Preoccupied with failure expected due to risk factors and • Defer to expertise complexity • Commitment to resilience
Page 251 of 294 High Leadership Safety Culture Reliability Components Process Improvement
Page 252 of 294 High Reliability…How do we get there?
1. LEADERSHIP 2. SAFETY CULTURE COMMITMENT: - Trust - Board of Commissioners - Senior Leadership - Accountability - Physician and Nurse -Identifying Unsafe Conditions Leaders - Strengthening Systems - Strategic Plan/Quality - Assessment Strategy 3. PROCESS IMPROVEMENT: - Quality Measures - Methods - Spread - Information Technology - Training
Page 253 of 294 Zero Harm Dashboard Zero Harm Measure Source Logic Potential CAUTIs Meditech data (+) Urinary catheter & (+) Urine culture Potential CLABSIs Meditech data (+) Central line or PICC or Port & (+) Blood culture Potential MRSA Meditech data (+) MRSA Blood Culture Potential VAPs Meditech data (+) Respiratory culture (+) for vent Potential C-diff Meditech data (+) CDI Lab 30 day Readmission Meditech data AMI, CHF, Pneumonia, CABG, Stroke, Sepsis, Knee & Hip 3 day Readmission Meditech data All 3 day readmissions Falls w/injury Meditech data Pull “post-fall assessment” for review Pressure Ulcers Meditech data Pull “wound assessment” for review PE / DVT TBD TBD
7 Page 254 of 294 Core Measures (Early Elective Delivery between 37 and 39 weeks)
Early Elective Delivery
FY 2016 Final FY 2017 Final Score Score
100% *99.21%
*1 patient fallout October 2016
Page 255 of 294 Core Measures (Early Elective Delivery between 37 and 39 weeks)
Page 256 of 294 Mortalities
Halifax Reporting CMS Reporting (Truven) (Hospital Compare) 1. Only counts mortalities in-house 1. All mortalities 30 days out 2. We measure all payer types 2. Only Medicare patients 3. Any inpatient mortality will 3. If a patient is enrolled in a count hospice program they are excluded (or w/in the last 12 months)
Page 257 of 294 Inpatient Mortality (AMI, PN, CHF only)
FY 2017 FY 2016 YTD (Oct - Sept) FY16 Truven Mortality Measure Description Mean (Nat'l ) Acute Myocardial Infarction 5.91% 6.93% 7.19% Measure Failure Count 14 16 Denominator Count 237 231 Average Length of Stay 3.4 3.7 Congestive Heart Failure 2.17% 1.83% 2.52% Measure Failure Count 8 7 Denominator Count 369 383 Average Length of Stay 4.4 5.0 Pneumonia (New Population in FY17) 0.71% 2.85% 5.32% Measure Failure Count 3 21 Denominator Count 421 738 Average Length of Stay 4.7 6.7 New Pneumonia population FY16 rate 3.07% (To include sepsis with secondary pneumonia)
Page 258 of 294 Inpatient Mortality Rates
FY 2017 FY 2016 YTD (Oct - Sept) FY16 Truven Mortalities Description Mean COPD Qualified Mortality Rate 0.32% 0.24% 0.46% Measure Failure Count 1 1 Denominator Count 309 420 Average Length of Stay 3.9 3.7 CABG Qualified Mortality Rate 0.77% 1.33% 2.68% Measure Failure Count 1 2 Denominator Count 130 150 Average Length of Stay 6.9 7.4 Stroke Qualified Mortality Rate 5.10% 3.35% 5.54% Measure Failure Count 20 13 Denominator Count 392 388 Average Length of Stay 5.1 5.9
Page 259 of 294 Readmissions
Halifax Reporting CMS Reporting (Truven) (Hospital Compare) 1. Must be readmitted to Halifax 1. Can be readmitted to any facility 2. We measure all payer types 2. Only Medicare patients 3. Does not count if index 3. Does not count if index discharged was AMA discharged was AMA 4. A readmission visit can qualify 4. A readmission visit cannot qualify for another index admission as another index admission
Page 260 of 294 Readmission Quick Compare (Oct. 2016 – Sep. 2017)
17.2% 17.9% 17.7% 19.0% 18.3% 17.9%
15.1% 21.8%
HSAG Readmission Report for Q4-2016 – Q3-2017, released January 2018
(Health Systems Advisory Group) Page 261 of 294 Readmission Rate High Performers
Florida Hospital Association Report; released November 2017 Page 262 of 294 Readmissions (AMI, CHF, PN, COPD)
FY 2017 FY2016 FY 2016 YTD (Oct - Truven Sep) Mean Readmission Measure Description (Nat'l) Acute Myocardial Infarction 9.55% 11.66% 10.86% Measure Failure Count 21 26 Denominator Count 220 223 AMI Average Length of Stay 3.4 3.7 Congestive Heart Failure 15.07% 14.93% 16.19% Measure Failure Count 55 60 Denominator Count 365 402 CHF Average Length of Stay 4.4 5.0 Pneumonia (New Population in FY17) 9.55% 12.20% 12.41% FY16 = 12.40% (with new population) Measure Failure Count 38 95 Denominator Count 398 779 Pneumonia Average Length of Stay 4.7 6.7 Chronic Obstructive Pulmonary Disease 11.94% 12.21% 15.40% Measure Failure Count 37 53 Denominator Count 310 434 COPD Average Length of Stay 3.9 3.7
Page 263 of 294 Readmissions (Knee, Hip, CABG & Stroke)
FY 2017 FY2016 FY 2016 YTD (Oct - Truven Sep) Mean Readmission Measure Description (Nat'l)
Knee Arthroplasty 0.83% 2.29% 3.27% Measure Failure Count 4 11 Denominator Count 483 480 Knee Arthroplasty Average Length of Stay 3.1 2.5 Hip Arthroplasty 5.52% 4.76% 3.71% Measure Failure Count 26 24 Denominator Count 471 504 Hip Arthroplasty Average Length of Stay 3.4 3.3 CABG 9.30% 8.05% 8.71% Measure Failure Count 12 12 Denominator Count 129 149 CABG Average Length of Stay 6.9 7.4 Stroke Readmissions 11.32% 12.00% 7.29% Measure Failure Count 43 48 Denominator Count 380 400 Stroke Average Length of Stay 5.1 5.9
Page 264 of 294 Catheter-Associated Urinary Tract Infections (CAUTI) (Standard Infection Ratio)
CMS VBP FY 2017 Benchmarks FY 2016 YTD (Oct - Threshold Benchmark Sept) (Based on FY- (Based on HAIs Measure Description 2019 FY-2019 (SIR = observed infections / expected infections) Indicators) Indicators) CAUTI (ICUs Only) SIR 0.95 1.03 0.82 0.00 Observed number of CAUTIs 36 23 Expected number of CAUTIs 37.7 22.4 CAUTI (All Units) SIR 0.819 1.23 0.82 0.00 Observed number of CAUTIs 49 50 Expected number of CAUTIs 59.8 40.5
Page 265 of 294 19 Page 266 of 294 Nurse driven removal protocol implemented
20 Page 267 of 294 Central Line Associated Blood Stream Infections (CLABSI) (Standard Infection Ratio)
CMS VBP FY 2017 Benchmarks FY 2016 YTD (Oct - Threshold Benchmark Sept) (Based on FY- (Based on HAIs Measure Description 2019 FY-2019 (SIR = observed infections / expected infections) Indicators) Indicators) CLABSI (ICUs Only) SIR 0.60 0.96 0.86 0.00 Observed number of CLABSIs 14 11 Expected number of CLABSIs 23.5 11.5 CLABSI (All Units) SIR 0.721 1.09 0.860 0.00 Observed number of CLABSIs 24 21 Expected number of CLABSIs 33.3 19.2
Page 268 of 294 Raw numbers in red
4 - Dedicated Vascular Access Team (VAT) - Daily Central Line audits to validate dressing clean, dry & intact 4 - Standardized dressing kits - Suture-less devices - Next up: Drive down suturing & standardize port dressing kits 2 2
1 1 1 1 1
22 Page 269 of 294
HCAHPS
Rollup Score Rollup Percentile Rank Percentile
Page 270 of 294 Questions?
Page 271 of 294 What is Driving Change to Human Resources?
Total Team Member and Registered Nurse Turnover /Generational Influence & Workforce Strategy
Page 272 of 294 Measurement Members, fivethe but more last importantly highlighted focusing on allthese challenges and how they affectour Team HalifaxHuman is continuouslyHealthResources Department which leadership,impact willhealthcare including: healthcareexecutives explores trends 12 report and this year's more than 1,000 B.E.of recentlySmith conducted survey a Leadership Development & SuccessionPlanning Workforce Shortages and RetentionRecruitment Challenges EmployeeSatisfaction Leadership Competencies Population Health and FinancialRegulatoryChanges Pressure Turnover Data Turnover above Strategy Alignment Turnover Benchmark Data Predictivevs Comparison Workforce Planning Reactive National National Rate & Page 273 of294 NSI's 2017 National Healthcare Retention & RN Staffing Report – Highlights (Nursing Solutions, Inc. – National Benchmark) National Landscape: • 136 participating hospitals covering 413,544 employees and 114,052 RNs
• The national average turnover for hospitals decreased slightly from 17.1% to 16.2%
• The current national average turnover for bedside RNs 14.6%, down from 17.2%
• RN turnover fell below the hospital average, (Certified Nurse Assistant Turnover increasing), exceeded all other positions surveyed at 24.6% (Halifax Health CNA Turnover is 34.3%)
• Behavior Health & Emergency Room had the highest turnover rate by specialty while Pediatrics and Women's Health Services continued to record the lowest
• Every one percent change in RN turnover cost saves the average hospital an additional $410,500
• The average cost of RN turnover per hospital is $5.13M - $7.86M
• National RN Vacancy is 8.1% with an RN Recruitment Difficulty Index averaging 86 days. Halifax Health RN Vacancy rate is 5%, averaging 35 days to fill
Page 274 of 294 Halifax Health RN Turnover – Eight (8) Year Historical Lookback
RN Terminations/Exits (Eight Year Look Back)
Job Category Average FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 RNs 214 202 197 218 256 198 137* 141* 135*
Total Team Members Halifax Health
Job Category Average FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 1106 RNs 1116 1111 1133 1107 1061 907* 935* 948* GRAND TOTAL 4021 3999 3989 4084 4018 4017 3672* 3704* 3684*
RN Turnover vs. Non-RN Staff Turnover FT/PT (Eight year look back)
Job Category Average FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017
All Non-RN Staff 15.77% 12.66% 15.53% 16.23% 16.89% 14.79% 14.29% 16.97% **20.03%
RNs 17.58% 18.10% 17.73% 19.24% 23.36% 18.66% 15.11% 15.08% 14.24%
GRAND TOTAL 16.11% 14.18% 16.14% 17.07% 18.64% 15.78% 14.49% 16.49% 17.13%
Page 275 of 294 Benchmark Data – How do we compare? Total Organization Turnover Comparison: RN Turnover Comparison:
Region Turnover Region Total Turnover NSI Data South East 16.5% NSI Data South East 13.9%
NSI Data NSI Data Government – 17.2% Government – 14.0% Acute Care Acute Care NSI Data >500 Beds 13.2% NSI Data >500 Beds 16.0%
NSI Data National Average 16.2% NSI Data National RN 12.6% Turnover Average FHA State 18.10% Halifax Health 14.24% FHA Central 16.60% RNs that returned 2015 - 29 Florida Region to Halifax Health 2016 - 20 2017 - 54 2015 - 14.49% Halifax Health 2016 - 16.49% 2017 - 17.13% National *CNA classification – 82 terms Nursing Solutions, Inc (NSI) – Southeast Region
State & Region -Florida Hospital Association (FHA) – Central Region
Page 276 of 294 Why do Nurses Leave?
Top Five (5) Reasons for RN Turnover - Comparison
Nursing Solutions, Halifax Health Halifax Health 2017 (NSI) 2016 Personal Reasons Accepted New Job **Accepted New Job Relocation Relocation Relocation Career Retirement Retirement Advancement Salary Family Obligations Accept New Job-Competition Workload/Staffing Unsatisfactory Job Family Obligations Ratios Performance
*NSI Reports that Relocation took over the top spot and is the number one reason why employees left. NSI expects to see Retirement move upward as well. With 3 million baby boomers reaching retirement age each year for the next 20 years, expect to see this remain towards the top of the list. In descending order are the top ten (10): Personal Reasons, Relocation Career Advancement, Salary, Workload/Staffing Ratios, Retirement, Scheduling, Immediate Management, Commute/Location & Education rounded out the top ten.[1] *Accepted new job (physician office, attorney, etc. or relocation)
[1] http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/NationalHealthcareRNRetentionReport2016
Page 277 of 294 Why do Nurses Leave? – Partnership with Nursing Solutions, Inc. Focused Retention Efforts for the Less than One Year and Years 1-2 Group for RN’s Hired
What does all this tell us? Halifax Health RN Turnover by Greater than > 1 Year Tenure Less than <1 Year (1-2) 3 Year 5 Year 2015 - 33.58% 2015 - 25.55% 2015 - 9.49% 2015 - 2.19% 2016 - 21.99% 2016 - 41.84% 2016 - 10.64% 2016 - 5.67% 2017 - 15.61% 2017 - 43.41% 2017 - 10.24% 2017 - 4.39%
NSI New RN Insert NSI Data – partnered with NSI Turnover Data by Greater than > 1 Year Tenure Less than <1 Year (1-2) 3 Year 5 Year 2016 - 29.2% 2016 - 21.4% 2016 - 23.1% 2016 - 13.2% 2017 - 25.0% 2017 - 23.0% 2017 - 22.7% 2017 - 14.1%
*This chart clearly shows this is a national issue
Page 278 of 294 What does this mean?
• Halifax Health did have increased Total Employee Turnover; RN turnover decreased from 15.11% to 14.24%. National RN turnover rate is 14.6% • Halifax Health Vacancy Rate averages 5%. National Vacancy Rate is 8.5% • We need an increased focus on Workforce Planning
Retention Strategy: 1. RN Residency Program - local partnerships (DSC, UCF & BCU) 2. Loan Forgiveness Program - (pay for entire nursing degree at state rate) Halifax Health has invested $2.6M in tuition assistance and loan forgiveness for team members since 2006 3. RNs Career Path - (formerly known as Clinical Ladder) for RNs 4. Leadership Academy – now includes Nursing & Physician Leadership 5. RN Governance Council 6. Reinstating Centralized Staffing Float Pool for RNs - to increase flexibility of staffing 7. Formal RN On-boarding Program - conducted by CNO & Human Resources
[1] http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/NationalHealthcareRNRetentionReport2014
Page 279 of 294 Halifax Health Strategy:
The Value we place on our People will have a direct correlation to our commitment, confidence and engagement. We do this through yearly market analysis, commitment to investing through education and an continuous engagement and open dialogue with our Team Members
Continue to build retention capacity, manage vacancy rate, bolster recruitment initiatives and control labor expenses. Halifax Health’s philosophy is to not hire agency, so we continue to be innovative, motivated and non-complacent in a tough market for talent
Halifax Health continues to invest in our local partnerships with Daytona State College, University of Central Florida, Bethune Cookman University, University of Florida and Florida State. During fiscal year 2017, Halifax Health hired 135 RN Graduates. Currently, for the fiscal year of 2018, Halifax Health has hired 44 RN Graduates, with 10 RN Graduates starting in February. So far this year, we’ve invested $263.807.08 in nursing education and supported 58 Team Members
Of the 44, 23 are graduates from the Daytona State College Nursing Program and 9 are graduates from the University of Central Florida Nursing Program. Halifax Health supports DSC with a $50k annual scholarship program. We also support UCF and BCU. Since the inception of the Halifax Health RN Residency program, Halifax Health has hired and trained approximately 400 local RN graduates
Through the data collected and reviewed this year from the annual market analysis, all full & part time, direct patient care RNs received $1.00/hour, which was a 1.5M investment in our RNs
Page 280 of 294 What is Driving Change to Human Resources?
Generational Influence & Workforce Strategy
Page 281 of 294 Workforce Planning = Succession Planning • Workforce Planning and Succession Planning are not the same, yet both are important and related with similar processes • Halifax Health Human Resources/Organizational Development is working on these initiatives • Workforce Planning is a continual process used to align the needs and priorities of the organization with those of its workforce to ensure it can meet its legislative, regulatory and overall organizational goals • Strategic workforce planning usually covers a three-to-five year forecast period, aligned to business needs and outcomes • First, we need to understand what is going on within our employee population how generational influences will affect our future workforce
Page 282 of 294 Average Job Tenure
The average job tenure for workers aged 25-34, the demographic where most employed millennials fall, hasn’t changed in 30 years. Their average tenure is three years.
Source: Deloitte’s 2016 Millennial Survey
Page 283 of 294 Engagement Trends by Generation
Population Definitions
Individuals born prior to 1948 Traditionalist Age ranges for Engagement Survey = 70-74, 75-79, 80-84
Individuals born between 1948 – 1967 Baby Boomer Age ranges for Engagement Survey = 50-54, 55-59, 60-64, 65-69
Individuals born between 1968 – 1982 Generation X Age ranges for Engagement Survey = 35-39, 40-44, 45-49
Individuals born between 1983 – 2000 Millennial Age ranges for Engagement Survey = 18-24, 25-29, 30-34
National This data provided by Press Ganey
This number was taken from the 2018 Halifax Health Engagement Survey Halifax Health Data provided by Press Ganey
Page 284 of 294 Halifax Health Workforce by Generation
70.00%
60.00%
50.00% 45.24% 41.74% 40.00% 38.83% 31.46% 31.43% 31.71% 30.00% 28.04% 24.88% 20.89% 20.00%
10.00%
2.43% 1.91% 1.42% 0.00% Traditionalist Baby Boomer Gen X Millennials 0 - 1947 1948 -1967 1968 - 1982 1983 - 2000
2015 2016 2017
Page 285 of 294 Halifax Health Average Tenure by Generation 25
20
15 13.99 13.29 13.43 12.15 11.66 12.07
10 7.75 6.97 7.12
5 3.42 2.73 2.72
0 Traditionalist Baby Boomer Gen X Millennials 0 - 1947 1948 -1967 1968 - 1982 1983 - 2000
2015 2016 2017
Page 286 of 294 Halifax Health - Engagement Trends by Generation
18–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 Metrics (171) (293) (307) (291) (277) (314) (347) (363) (318) (108)
Engagement 3.78 3.87 3.92 4.02 3.97 4.06 4.06 4.07 4.01 4.14 Indicator
Employee Domain 3.93 4.06 4.02 4.10 4.09 4.11 4.12 4.07 4.13 4.16
Manager Domain 4.00 4.13 4.12 4.14 4.13 4.16 4.11 4.04 4.13 4.17
Organization 3.66 3.67 3.65 3.75 3.65 3.75 3.78 3.76 3.79 3.85 Domain
Key Drivers 3.50 3.52 3.52 3.65 3.56 3.65 3.65 3.69 3.72 3.81
Page 287 of 294 Nationwide - Engagement Trend by Generation
Engagement Items Baby Boomer Gen X Millennial National
I am proud to tell people I work for this 4.28 4.28 4.31 4.27 organization. (237990) (248703) (215030) (792932)
I would like to be working at this 4.22 4.22 4.06 4.16 organization three years from now. (234556) (247865) (213441) (786035)
I would recommend this organization as a 4.12 4.11 4.10 4.08 good place to work. (238132) (248816) (215201) (793472)
I would recommend this organization to 4.29 4.29 4.26 4.26 family and friends who need care. (237418) (248168) (214585) (790874)
I would stay with this organization if offered 3.98 3.92 3.86 3.91 a similar job elsewhere. (234716) (246105) (211748) (775436)
4.08 4.02 3.98 4.01 Overall, I am a satisfied employee. (238189) (248871) (215289) (793692)
Page 288 of 294 Halifax Health - Engagement Trend by Generation
Engagement Items Baby Boomer Gen X Millennial Halifax Health
I am proud to tell people I work for Halifax 4.18 4.16 4.09 4.10 Health. (1136) (882) (771) (3159)
I would like to be working at Halifax Health 4.08 4.14 3.76 3.99 three years from now. (1136) (882) (771) (3107)
I would recommend Halifax Health as a 3.98 3.94 3.84 3.87 good place to work. (1136) (882) (771) (3167)
I would recommend Halifax Health to family 4.24 4.20 4.05 4.13 and friends who need care. (1136) (882) (771) (3164)
I would stay with Halifax Health if offered a 3.91 3.77 3.64 3.74 similar job elsewhere. (1136) (882) (771) (3124)
4.02 3.86 3.77 3.86 Overall, I am a satisfied Team Member. (1136) (882) (771) (3166)
Page 289 of 294 Halifax Health - Side-by-Side Key Driver Items
Key Driver Items Baby Boomer Gen X Millennial (born between 1948 – 1967) (born between 1968 – 1982) (born between 1983 – 2000)
I feel like I belong at Halifax Health. 4.13 4.09 3.93
Halifax Health provides high-quality 4.13 4.07 3.99 care and service.
I have confidence in senior 3.63 3.61 3.60 leadership.
My pay is fair compared to other 2.99 2.71 2.54 healthcare employers in this area.
Page 290 of 294 Halifax Health Terminations by Generation 45%
40% 38.14% 36.68% 35.92% 35.59% 35% 33.69% 31.59%
30% 28.59% 27.82%
25% 24.02%
20%
15%
10%
5% 3.13% 2.58% 2.25%
0% Traditionalist Baby Boomer Gen X Millennials 0 - 1947 1948 -1967 1968 - 1982 1983 - 2000
2015 2016 2017
Page 291 of 294 Halifax Health 2017 New Hires by Generation 60%
51.16% 50%
40%
30% 25.91% 22.46%
20%
10%
0.47% 0% Traditionalist Baby Boomer Gen X Millennials 0 - 1947 1948 -1967 1968 - 1982 1983 - 2000
Page 292 of 294 Halifax Health Leadership by Generation 70.00% 64.29% 64.29%
60.00%
50.00% 50.00%
41.46% 40.00% 35.71% 30.95% 30.00%
20.00%
10.00% 7.32% 4.76% 1.22% 0.00% 0.00% 0.00% 0.00% Executive Director Manager
Traditionalist Baby Boomer Gen X Millennials
Page 293 of 294 Tying it all Together What does the DATA say Driving Change to Human Resources? Generational Influence Aging Workforce Innovative Retention Initiatives Workforce Planning Leadership Development & Succession Planning ENGAGEMENT
Page 294 of 294