Advocate Health Partners

Pathfinder Health Quality/Credentialing Committee Charter 2014

Name of Committee: Quality Committee/Credentialing

Selection of Members:  Chair appointed by Pathfinder Health Board  Chair recommends member slate  Member slate ratified by Pathfinder Health Board

Compensation: Committee members would be compensated per Pathfinder Health Policy.

Members And Voting: Physician Members (voting)  Chairman  Vice Chairman  Physician Credentialing representative  Pathfinder Health Physician Members: o 4 physicians with appropriate regional representation. o In addition, there may be appointed by the Pathfinder Health Board up to two “At Large” members based on Committee need.  Two system representatives as appointed by the Pathfinder Health Board  Other (Non-voting) Members o Clinical Integration Administrator o Quality Representative o Staff members and invited guests as determined by the committee

Term/Limits:  There would be a three-year term for all members after.  There is a maximum term limit of 2 consecutive terms, unless the Pathfinder Health Board approves an exception.

Succession:  New members would rotate onto the Committee in September of each year, or as vacancies arise.  The Committee Chair should coordinate with management approximately one year before the rotation to plan succession.  The affected Regions should also be consulted in developing a slate of replacement members.  The slate of proposed new members should be approved by the Pathfinder Health Board prior to new candidates becoming members of the Committee, typically at the December meeting of the Pathfinder Health Board. Quorum:  A quorum will be constituted by a simple majority of the voting members.

Voting:  Each voting member shall be entitled to one vote. An action will carry based on a simple majority of the voting members in attendance.

Charter &Authority: The committee has oversight responsibilities in the areas of planning and monitoring the Performance Improvement, Patient Safety and Clinical Integration Programs as indicated below:

Planning Activities 1. Oversee the design of the Clinical Integration Program, Performance Improvement and Metric development. Oversee the design and credentialing of the peer review program including credentialing policies. Develop and annually update a three-year plan for the evolution of the Clinical Integration Program. Plan would include recommendations about initiatives to be included in the program, establishment of performance thresholds. Overall program design should be responsive to the payer, employer and regulatory markets, as well as the practical realities of Pathfinder Health member physicians. Present results as a recommendation to the Pathfinder Health Board. 2. Ensure Plan addresses market and regulatory needs, and includes a balance of measures including but not limited to patient experience, cost-effectiveness, quality improvement and patient safety. 3. Develop recommendations to the finance committee, based on management suggestions, for capital and operating costs associated with successful implementation and ongoing administration of planned CI Program and Quality programs to use in annual budgeting process. 4. Develop recommendations in collaboration with the finance committee for the distribution of CI funds and other incentive funds to physicians to reward improved clinical performance and other Pathfinder Health organizational strategies and objectives. Present recommendations to the Pathfinder Health Board as part of the annual update to the CI Program plan. 5. Make recommendations to the Pathfinder Health Board regarding Conditions of Physician Membership necessary to ensure the success of the CI Program and assure a high Quality Network. 6. Prepare and report to the Pathfinder Health Board an annual summary of past year activities, self-assessment of committee effectiveness, and a work plan for the coming year. Also, conduct a formal annual review and assessment of committee charter, and provide a report of any recommended changes to the Pathfinder Health Board.

Monitoring Activities The committee will monitor the activities of management concerning Performance improvement and clinical integration and the success of these programs. This oversight will include review of the following: 1. Review overall performance of CI Program and other Performance improvement and credentialing standards. (e.g., through formal review of aggregate quarterly and annual reporting results). 2. Review plans and recommendations for intervention and remedial action when performance lags target. 3. Champion (e.g., during the annual budget process with Pathfinder Health Board members, etc.) the need for adequate resource allocation to enable realization of this objective.

Sub-Committee Structure

Sub-Committees 1. Meeting shall occur on an as needed basis. Membership shall approximate a third of current Performance Improvement Committee members with additional physician representation on an ad hoc basis based on topics of discussion. No specific distribution of employed, independent, primary or specialty providers is required. All other administrative rules shall remain as above. Activities are assigned and defined by the Performance Improvement Committee. Chair will be the Vice-Chair of the Performance Improvement Committee. Potential Subcommittees may include Clinical Integration Administrative Committee.