BOARD OF DIRECTORS AGENDA PACKET
June 13, 2016
The mission of Palomar Health is to heal, comfort and promote health in the communities we serve.
BOARD OF DIRECTORS
Dara Czerwonka, MSW, Chair Jeffrey D. Griffith, EMT-P, Vice Chair Raymond McCune, RN, Secretary Jerry Kaufman, PTMA, Treasurer Linda C. Greer, RN, CCP, Director Hans Christian M. Sison, LVN, Director Aeron Wickes, MD, Director
Robert A. Hemker, President and CEO
Regular meetings of the Board of Directors are usually held on the second Monday of each month at 6:30 p.m., unless indicated otherwise. For an agenda, locations or further information call (760) 740-6375, or visit our website at www.palomarhealth.org
MISSION STATEMENT
The Mission of Palomar Health is to: Heal, Comfort, Promote Health in the Communities we Serve
VISION STATEMENT
Palomar Health will be the health system of choice for patients, physicians and employees, recognized nationally for the highest quality of clinical care and access to comprehensive services
CORE VALUES
Patient’s Well-Being We passionately give and support heartfelt care that encourages patient comfort and safety
Professionalism Each of us takes pride in teamwork, self-discipline, our skills and trustworthiness
Highest Quality We are each accountable for providing the safest, most effective and innovative care
Affiliated Entities *Palomar Medical Center * Palomar Health Downtown Campus* Arch Health Partners* *Palomar Health Foundation * Palomar Home Care * Pomerado Hospital* *Palomar Health Development, Inc.* North San Diego County Health Facilities Financing Authority* *San Marcos Ambulatory Care Center * Villa Pomerado * Palomar Health Concern * Palomar Health Source*
POSTED TUESDAY, ` JUNE 7, 2016 BOARD OF DIRECTORS MEETING AGENDA Monday, June 13, 2016 Palomar Medical Center 6:00 p.m. Graybill Auditorium 5:30 dinner for board members and invited guests 555 East Valley Parkway Escondido, CA 92592 Mission and Vision “The mission of Palomar Health is to heal, comfort and promote health in the communities we serve.”
“The vision of Palomar Health is to be the health system of choice for patients, physicians and employees, recognized nationally for the highest quality of clinical care and access to comprehensive services." PLEASE TURN OFF CELL PHONE OR SET TO SILENT MODE UPON ENTERING MEETING ROOM
Form A Page Time Target I. CALL TO ORDER 1 6:01
II. ESTABLISHMENT OF QUORUM 2 6:03
III. OPENING CEREMONY 2 6:05 A. Pledge of Allegiance IV. PUBLIC COMMENTS1 15 6:20 V. SPECIAL BOARD BUDGET WORKSHOP (ADD A Pp11-44) 60 7:20 A. *Review/Approval: Capital and Operating Budget for Fiscal Year 2017 1 B. *Review/Approval: Five-Year Strategic Financial & Capital Plan 2 VI. * MINUTES (ADD B) 3 7:23 A. Special Board Education Session - May 9, 2016 (Pp46-47) 3 B. Regular Board of Director's Meeting - May 9, 2016 (Pp48-54) 4 C. Special Board of Directors Meeting - May 23, 2016 (Pp55-56) 5 D. Special Closed Session Board Meeting - May 23, 2016 (Pp57-58) 6
VII. * APPROVAL OF AGENDA to accept the Consent Items as listed (ADD C) 5 7:28 A. Approval of Revolving, Patient Refund & Payroll Fund Disbursements – April 2016 (P60) 1. Accounts Payable Invoices $54,774,717.00 2. Net Payroll $14,085,713.00 Total $68,860,430.00 VIII. REPORTS A. Medical Staffs (ADD D) *1. Palomar Medical Center - Franklin Martin, M.D. 5 7:33 A. Credentialing and Reappointments (Pp62-69) 7 B. Modification of the Neurosurgery Clinical Privilege Checklist – PMC and POM (Pp70-76) 8
*2. Pomerado Hospital - Paul Neustein, M.D. 5 7:38 A. Credentialing and Reappointments (Pp77-78) 9
"In accordance with the ADA (Americans with Disabilities Act) please notify us at 760-740-6375 48 hours prior to the meeting so we may provide reasonable accommodations" Form A Page Time Target B. Administrative 1. Chair of the Palomar Health Foundation - Tom Silberg 5 7:43
2. Chair of the Board - Dara Czerwonka 5 7:48
3. President and CEO - Robert Hemker 5 7:53 a. Arch Health Partners Discussion
IX. INFORMATION ITEMS A. ACHD Update Report for May 2016 (under separate cover) 2 7:55
X. * APPROVAL OF BYLAWS, CHARTERS, POLICIES (ADD E Pp) 5 8:00
(each document to be voted on individually) Item Type Board Committee Action
A. Lucidoc 11234 - Quality Assurance Performance Improvement Policy Quality Review Modified (QAPI) Plan (Pp80-98) B. Lucidoc 55732 - Aid in Dying (P99) Policy Governance New
XI. COMMITTEE REPORTS (ADD F ) 10 8:10 A. Audit & Compliance Committee - Linda Greer, Committee Chair (no meeting in May) B. Community Relations Committee - Dara Czerwonka, Committee Chair (P101) C. Finance Committee - Jerry Kaufman, Committee Chair (no meeting in May) D. Governance Committee - Jeff Griffith, Committee Chair (P102) E. Human Resources Committee - Hans Sison, Committee Chair (P103) F. Quality Review Committee - Dr. Aeron Wickes, Committee Chair (P104) G. Strategic & Facilities Planning Committee - Ray McCune, Committee Chair (5/23/16 Full Board Balanced Scorecard Review meeting held in lieu of May Board Strategic meeting) H. Other Committee Chair Comments on Committee Highlights XII. BOARD MEMBER COMMENTS/AGENDA ITEMS FOR NEXT MONTH 5 8:25 XIII. ADJOURNMENT - TO CLOSED SESSION * A. Reports Involving Trade Secrets Discussion will concern: proposed new service or program 10 8:35 Anticipated date of disclosure: July 1, 2016 Authority: California Health and Safety Code Section 32106 * B. Pursuant to California Government Code §54957(b) Public Employee Performance Evaluation 30 9:05 President and CEO
XIV. RE-ADJOURNMENT TO OPEN SESSION 1 9:06 XV. ACTION RESULTING FROM CLOSES SESSION DISCUSSION – IF ANY 5 9:11 1 XVI. PUBLIC COMMENTS 15 9:26
XVII. FINAL ADJOURNMENT 2 9:28
FY2017 Annual Operating & Capital Budget
TO: Board of Directors
MEETING DATE: Monday, June 13, 2016
FROM: Diane Hansen, EVP Finance
Background: The Annual Operating & Capital Budget for FY2017 is being presented for the Board’s review and approval.
Budget Impact: Operating Budget consistent with that needed as defined in the Financial and Capital Plan, comprised of Earnings Before Interest Expense, Depreciation and Amortization (EBIDA) of $84.0 million A composite charge master rate increase of 8% for FY2017 Capital Budget Reserve of $41.5 million that includes: o $5.5 million for Routine Equipment o $5 million for Facilities Renovation o $5 million for Information Technology o A reserve of $16 million to fund future initiatives and strategies, based upon available cash reserves o A reserve of $10 million to fund the Downtown Relocation
Staff Recommendation: Approval of the Operating Budget, the composite charge master rate increase, and the Capital Budget Reserve.
COMMITTEE RECOMMENDATION:
Motion: X
Individual Action:
Information:
Required Time:
Form A - Budget.doc 1
UPDATED FINANCIAL AND CAPITAL PLAN
TO: Board of Directors
MEETING DATE: Monday, June 13, 2016
FROM: Diane Hansen, EVP Finance
Background: The 5-year Financial and Capital Plan for the District has been updated to reflect actual audited results for FY2015, the Board-approved budget for FY2016, and baseline financial projections for FY2017-FY2021. In addition, the update (previously presented at the May 2016 Board meeting) incorporates approved and planned strategic initiatives, transformational costs, and updated revenue and cost assumptions. Various sensitivities tested in conjunction with the updating were reviewed.
Budget Impact: N/A
Staff Recommendation: Approval
Committee Questions:
COMMITTEE RECOMMENDATION: At the April 27, 2016, Board Finance Committee meeting, approval was recommended: 5 to 0 by the Committee; Board members approved 3 to 0; 1 Committee member was absent.
Motion: X
Individual Action:
Information:
Required Time:
Form A - Fin'l & Cap Plan.doc 2
Minutes Special Board Education Session
Monday, May 9, 2016
TO: Board of Directors
MEETING DATE: Monday, June 13, 2016
FROM: Debbie Hollick, Board Assistant
Background: The minutes from the Monday, May 9, 2016 Special Board Education Session are respectfully submitted for approval.
Budget Impact: N/A
Staff Recommendation: Recommendation to approve the Monday, May 9, 2016 Special Board Education Session minutes.
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
3
Minutes Board of Director’s Meeting
Monday, May 9, 2016
TO: Board of Directors
MEETING DATE: Monday, June 13, 2016
FROM: Debbie Hollick, Board Assistant
Background: The minutes from the Monday, May 9, 2016 Board of Director’s meeting are respectfully submitted for approval.
Budget Impact: N/A
Staff Recommendation: Recommendation to approve the Monday, May 9, 2016 Board of Director’s meeting minutes.
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
4
Minutes Special Board of Director’s Meeting
Monday, May 23, 2016
TO: Board of Directors
MEETING DATE: Monday, June 13, 2016
FROM: Debbie Hollick, Board Assistant
Background: The minutes from the Monday, May 23, 2016 Special Board of Director’s meeting are respectfully submitted for approval.
Budget Impact: N/A
Staff Recommendation: Recommendation to approve the Special Monday, May 23, 2016 Board of Director’s meeting minutes.
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
5
Minutes Special Closed Session Board of Director’s Meeting
Monday, May 23, 2016
TO: Board of Directors
MEETING DATE: Monday, June 13, 2016
FROM: Debbie Hollick, Board Assistant
Background: The minutes from the Monday, May 23, 2016 Special Closed Session Board of Director’s meeting are respectfully submitted for approval.
Budget Impact: N/A
Staff Recommendation: Recommendation to approve the Monday, May 23, 2016 Special Closed Session Board of Director’s meeting minutes.
Committee Questions:
COMMITTEE RECOMMENDATION:
Motion:
Individual Action:
Information:
Required Time:
6 7 8 9
ADDENDUM A
10 FY 2017 Annual Operating and Capital Plan
Palomar Health FY 2017 Annual Operating and Capital Budget
Board of Directors Budget Workshop June 13, 2016
6/1/2016 11 FY 2017 Annual Operating and Capital Plan Agenda . Executive Summary . FY 2017 Budget Overview: Key Budget Drivers Inflationary Assumptions . Key Statistical / Growth Indicators . Revenue Key Revenue Assumptions / Payer Mix Revenue Trend Analysis . Salaries, Wages, Benefits & FTEs: Salary, Benefits and FTE Trend Analysis . Non Labor Analysis: Supplies / Professional Fees / Purchased Services / Other Direct Expense . 2017 Annual Budget Summary / EBIDA Recap . Three Year Capital Planning 6/1/2016 12 2 FY 2017 Annual Operating and Capital Plan Executive Summary
. The FY 2017 Annual Budget provides achievable goals for the coming year which are consistent and aligned with our Strategic Financial and Capital Plan (EBIDA growth of $8.8 million from FY16 Projection), and provides a renewed focus on targeted capital deployment.
. It is the result of a focused effort to absorb inflation and drive greater efficiency in all areas of the organization
. Reflects a concerted effort to hold on all non-essential expenditures
. Incorporates staffing initiatives to drive targeted improvements in utilization of labor resources
. The operating and capital budgets are aligned with our current year and long term strategic plan initiatives
6/1/2016 13 3 FY 2017 Annual Operating and Capital Plan
FY 2017 Budget – Key Drivers & Overview
6/1/2016 14 4 FY 2017 Annual Operating and Capital Plan Key Plan Drivers
. Strategic Plan alignment including targeted $8.8 million EBIDA growth year over year; this growth is consistent with the long-range Financial and Capital Plan targets . Continued reimbursement pressures driven by ACA challenges, including impacts to industry/payer relationships and changes to network patterns. . Expense management strategies and initiatives include reducing labor costs through our “Patient Throughput” initiative as well as, enhancing supply costs savings through utilization and rate efforts . Concerted Revenue Cycle efforts around physician documentation post ICD-10 and IT related enhancements Patient Throughput Supply Exp Reduction Physician Documentation Initiative Initiative Initiative $1,000,000 $1,000,000 $1,300,000 . PHDC closure phased in through December 31, 2016, with support services remaining throughout the fiscal year . Assessment of service lines and contribution margin profitability
6/1/2016 15 5 FY 2017 Annual Operating and Capital Plan Key Plan Drivers
Palomar Health – Baseline Financial Projections ($ thousands)
K Projection Years E K Ratio/Statistic 2016 2017 2018 2019 2020 2021 Y E Operating Income exc. Interest Expense 8,351$ 20,142$ 20,418$ 20,520$ 20,685$ 20,840$ Cash Flow (Net Inc + Depr) 46,113$ 69,975$ 70,771$ 75,895$ 80,965$ 87,845$ Y Capital Expenditures 19,453$ 41,500$ 40,980$ 43,070$ 27,500$ 32,500$ D Profitability R D Operating Margin (3.7%) (1.3%) (1.2%) (1.0%) (0.9%) (0.8%) I Operating Margin (Exc. Int. Exp) 1.2% 2.9% 2.8% 2.7% 2.7% 2.6% R Operating EBIDA Margin (Inc. Prop. Tax) 8.8% 10.7% 10.9% 11.0% 11.1% 11.1% V I E V Liquidity Days Cash On Hand (days) 114 125 124 124 135 145 R E Days Cash On Hand (days) - Ex Intrerest 120 131 130 130 140 150 S R Other S Capital Spending Ratio 38.0% 77.2% 70.6% 69.8% 42.1% 47.0% Prepared by Kaufman Hall and Associates
6/1/2016 16 6 FY 2017 Annual Operating and Capital Plan Inflationary Assumptions Healthcare Industry Inflation Comparison . FY2017 Budget assumes Industry 2017 Budget the absorption of a Expectations significant amount of Implants 1.0% 0-5% industry inflation through General Surgery Supplies 1.0% 0-5% utilization and efficiency; Several targeted supply Surgical Needles 0.0% 1-3% management and strategic Oxygen - Gas 1.5% 1-6% initiatives were identified IV Solutions 14.0% 3-5% . Pharmaceutical and Pharmaceuticals 7.0% 10.2% Implant costs are Radioactive and X-Ray Material 0.50% 0.4-1.4% significant drivers of overall supply costs. As Other Medical 0.0% 0-1.7% such, the inflation on Food / Meat 1.5% 1.6 – 2.8% these two categories will Linen 0.0% 0-2% be a key area of focus and pose the most risk All Other: Cleaning/Forms/Office/Uniforms 0.0 – 1.0% 0–4%
6/1/2016 17 7 FY 2017 Annual Operating and Capital Plan
Key Statistical Indicators
6/1/2016 18 8 FY 2017 Annual Operating and Capital Plan Key Statistical Indicators: INPATIENT . FY 2017 Planned Acute Patient Days are essentially flat year over year . FY 2017 Adjusted Discharges are pacing consistently with FY 2017 Projected Patient Days
Acute Patient Days Adjusted Discharges (incl. SNF)
140,000 50,000 10,897 11,209 120,000 10,750 12,738 24,945 23,570 24,412 28,228 40,000 10,484 100,000 24,530 80,000 30,000 60,000 38,856 38,591 92,092 99,622 96,966 93,330 20,000 31,708 35,603 37,082 40,000 86,184 20,000 10,000 0 0 FY13 FY14 FY15 Proj 16 Bud 17 FY13 FY14 FY15 Proj 16 Bud 17 North South North South
* North includes Palomar Medical Center (PMC) and Palomar Health Downtown Campus (PHDC); South includes Pomerado Hospital (POM)
6/1/2016 19 9 FY 2017 Annual Operating and Capital Plan Key Statistical Indicators: INPATIENT
. FY 2017 Deliveries are increasing by 509 or 10.9% year over year, largely driven by expected increased utilization of the Palomar Medical Center campus . FY 2017 Inpatient Surgeries are flat over FY 2016 projected Deliveries Surgeries
6,000 10,000 1,973 5,000 1,301 8,000 1,967 2,182 2,182 4,000 1,189 1,384 1,289 1,301 1,713 6,000 3,000 4,000 6,900 7,201 7,055 7,055 2,000 3,361 3,141 3,242 3,389 3,898 5,437 1,000 2,000 0 0 FY13 FY14 FY15 Proj 16 Bud 17 FY13 FY14 FY15 Proj 16 Bud 17 North South North South
* North includes Palomar Medical Center (PMC) and Palomar Health Downtown Campus (PHDC); South includes Pomerado Hospital (POM)
6/1/2016 20 10 FY 2017 Annual Operating and Capital Plan Key Statistical Indicators: OUTPATIENT
. Outpatient Surgeries are decreasing 147 or Outpatient Surgery
2.0% 10,000 2,922 . Emergency Visits are decreasing by 4,855 or 3,313 3,102 3,294 3,693 5,000 3.4% as urgent care level visits continue to 5,518 5,864 4,713 4,061 3,515 transition to the Community Clinics 0 . Outpatient Registrations are decreasing by FY13 FY14 FY15 Proj 16 Bud 17 North South 3,656 or 2.1% Outpatient Registration Emergency Visits
200,000 150,000 31,569 33,139 35,634 59,107 29,024 150,000 49,445 61,359 100,000 29,473 83,382 100,000 45,262 74,885 90,971 43,458 63,268 103,016 113,295 119,002 113,094 50,000 50,000 68,657 55,487 22,668 28,919 19,395 16,987 0 0 0 FY13 FY14 FY15 Proj 16 Bud 17 FY13 FY14 FY15 Proj 16 Bud 17 North South North PHDC North PMC South 6/1/2016 21 11 FY 2017 Annual Operating and Capital Plan
Revenue
6/1/2016 22 12 FY 2017 Annual Operating and Capital Plan Key Gross Revenue Considerations Assumptions: . 7.34% overall effective rate FY 2017 Budgeted Payer Mix increase (targeted 8%) Insurance Covered CA Self Pay Work Comp 3% 1% . Bad Debt and Uncompensated 2% 2% CMS Care 1.8%; FY16 Budget = 2.4% Managed Care Cap 0% Medicare . Managed Medi-Cal 4% 23% Deductions 10.2%; FY16 Sr Cap Budget = 9.9% 7% Payer Category Total CHRGS
$ 839,965,322 Medicare $ 827,322,412 Managed Care $ 744,871,893 Medi-cal $ 558,077,258 Sr HMO $ 272,780,555 Sr Cap Sr HMO $ 143,088,007 Managed Care Cap 15% $ 106,631,804 Insurance Managed Care $ 64,134,838 Covered CA Medi-cal 23% $ 58,557,247 Self Pay $ 26,563,850 20% Work Comp
CMS $ 973,360
$ 3,642,966,545 Total * * * Based on Gross Revenue and Excludes Home Health and Clinics 6/1/2016 23 13 FY 2017 Annual Operating and Capital Plan Revenue Trend Analysis . FY 2017 Gross Revenue is expected to be $236M or 7% higher than FY 2016 . Net Revenue is anticipated to be $45M or 7% higher year over year (In thousands) (in Thousands) 4,000,000 3,500,000 665,144 709,927 3,000,000 642,578 2,500,000 601,153 Net Revenue 2,000,000 580,592 Total Deductions 1,500,000 2,513,623 2,741,928 2,933,039 1,000,000 1,810,330 2,093,026 500,000 0 FY13 FY14 FY15 Proj 16 Bud 17
- FY13 FY14 FY15 Proj 16 Bud 17 Total Deductions * 1,810,330 2,093,026 2,513,623 2,741,928 2,933,039 Net Revenue 580,592 601,153 642,578 665,144 709,927 Total Gross Revenue 2,390,922 2,694,180 3,156,201 3,407,072 3,642,967
*Deductions include net capitation impact 6/1/2016 24 14 FY 2017 Annual Operating and Capital Plan
Salaries, Wages, Benefits & FTEs
6/1/2016 25 15 FY 2017 Annual Operating and Capital Plan Labor Impact Summary
. The FY 2017 Operational Budget reflects a concerted effort to develop a more sustainable model for utilization of FTEs and labor dollars
. Several initiatives drive focus away from premium pay and contract labor, toward a more coordinated staffing approach
. Incorporates ninety-five positions for New Graduate or New-to-Specialty RNs
. Significant year-over-year increases in staff education are planned to support achievement of operational initiatives
. Addition of targeted FTEs in various areas
. New Information Technology tools and Human Resources strategies to drive improved scheduling and recruitment
6/1/2016 26 16 FY 2017 Annual Operating and Capital Plan Labor Analysis – FTE’s
2017 Budgeted FTE Roll Forward FTE’s FY 2016 Paid FTE’s (as of 4/30/2016) 3,604 Volume Reductions and Operational Efficiencies (99) Consolidation Impact (35) Targeted FTE Additions 176 FY 2017 Paid FTE’s 3,646
32 . 31 Even with targeted 30 additions, FTEs are 28 relatively flat year 27 26 26 27 over year on a per 26 adjusted discharge 24 basis 22 FTE's per Adjusted Discharge (Incl. SNF) 20 FY13 FY14 FY15 Proj 16 Bud 17
6/1/2016 27 17 FY 2017 Annual Operating and Capital Plan Labor Analysis – Salaries, Wages and Benefits . FY 2017 Total Salaries, Wages and Benefits are increasing $16.5M or 4.4% primarily driven by a $13.8M increase for both contract and merit adjustments . FY 2017 Agency / Registry Expense is expected to decline by $4.4M from current year
Salaries , Wages, & Benefits (in thousands)
400,000 82,965 350,000 73,834 75,422 80,909 71,974 300,000 10,370 6,011 250,000 11,481 6,776 6,459 200,000 304,674 268,361 283,781 285,830 150,000 277,535 100,000 50,000 0 FY13 FY14 FY15 Proj 16 Bud 17 Employee Benefits 73,834 71,974 75,422 80,909 82,965 Registry Expenses 11,481 6,776 6,459 10,370 6,011 Salaries & Wages 277,535 268,361 283,781 285,830 304,674
6/1/2016 28 18 FY 2017 Annual Operating and Capital Plan Labor Analysis – Benefits (excluding PTO)
SUI-FUI . FY 2017 Employee Benefits Other 2% 1% Benefits are increasing Work Comp $2.1M or 3%. Insurance . Group Health Insurance 2% has increased by $1.1M Pension to provide coverage 23% required under ACA Group Health . Decrease of $1.7M in Insurance Worker’s Compensation 45% Insurance
Key Employee Benefits (in thousands) Bud 17 Group Health Insurance 37,757 FICA 22,367 Pension 19,247 Work Comp Insurance 1,545 SUI-FUI 1,200 FICA Benefits Other 1,065 27% Total Benefits 83,181
6/1/2016 29 19 FY 2017 Annual Operating and Capital Plan
Non Labor Analysis
6/1/2016 30 20 FY 2017 Annual Operating and Capital Plan Non Labor Analysis - Summary
. FY 2017 Non Labor expense is increasing $15.9M or 5.4% . Non-labor cost is increasing by $326 per adjusted discharge, primarily driven by supply inflation, the Crisis Stabilization Unit, and Information Technology advances
Trended Non Labor Expense (In thousands) 96,408 100,000 93,498 94,427 90,000 83,701 87,009 80,000 73,637 78,714 70,000 62,312 68,329 60,000 51,414 50,000 40,000 32,671 33,974 37,841 40,114 41,567 30,000 35,918 40,193 20,000 32,066 33,354 33,511 FY13 FY14 FY15 Proj 16 Bud 17 Supplies Professional Fees Purchased Services Other Direct Expenses
6/1/2016 31 21 FY 2017 Annual Operating and Capital Plan Non Labor Analysis - Supplies FY 2017 Supply Roll Forward (in thousands) FY 2016 Supply Expense (Dec 2015 Projection) $94,427 Increases due to Volume and Utilization 1,322 Inflationary Increases (Net of Absorption) 1,659 Supply Reduction Initiative (PRAC*) (1,000) FY 2017 Budgeted Supply Expense $96,408 *Physician Resource Allocation Committee Supplies per Adjusted Discharge (incl. SNF) . FY17 Budgeted 550 supply management 500 500 efforts and 493 Implants / Prosthesis reduction initiatives 450 425 419 416 408 Surgical Supplies 400 total $1M in Pharmaceuticals 365 344 351 savings; which is 350 364 341 340 Other Medical Supplies helping to offset 300 306 303 335 Non-Medical / All Other significant inflation 250 projected for the FY15 Proj 16 Bud 17 coming year
6/1/2016 32 22 FY 2017 Annual Operating and Capital Plan Non Labor Analysis – Professional Fees
. FY 2017 Professional Fees are increasing by $4.3M or 12% . Physician Professional Fees are primarily being driven by increased volume directed to the Hospitalists, the CSU, and a change in providers for Behavioral Health & ICU Professional Fees per Adjusted Discharge (incl . SNF) 450 400 392 343 359 ED Call / Trauma / 350 Hospitalists, etc. 300 Other Physician Fees 250 244 200 189 207 171 All Other Professional Fees 150 154 142 100 FY15 Proj 16 Bud 17
6/1/2016 33 23 FY 2017 Annual Operating and Capital Plan Non Labor Analysis – Purchased Services
. FY 2017 Purchased Services are increasing by $5.1M or 6.9% . Information Technology increases of $3M are the primary driver, along with increases in Reference Lab volumes and prior year transition of Coding Purchased Services per Adjusted Discharge (incl. SNF) 900
700 653 713 589 706 668 Information Technology 500 573 Plant Maintenance / Biomed 300 All Other Purchased Services 212 158 162 100 FY15 Proj 16 Bud 17
6/1/2016 34 24 FY 2017 Annual Operating and Capital Plan Non Labor Analysis – Purchased Services: IT Roadmap FY 2016 Accomplishments
Agilysys Upgrade Airstrip Upgrade and Patient Monitoring
Airwatch Mobile Device Management Crisis Stabilization Unit (by 6/30)
Cresendo (Home Health) Project Epilepsy Monitoring Unit
Experian OrderRite Regional Health Information Exchange (HIE)
Immunizations Integration with County ICD-10 Project
Lighthouse - Readmissions Lighthouse – Infection Control
Short Stay Unit Meaningful Use (Year 2 – Stage 1) FY 2017 Planned Projects
Ascend AP Invoice Imaging Project Axiom Cost Accounting
Cerner v. 2015 Upgrade Clarivia
Population Health Foundation Tools (Phase 1) Long Term Care EMR
LEM Balance Scorecard Health Catalyst – phase 1
Infor Contract Management Cloud base Imaging Solution
Pomerado Infrastructure remediation Lawson Automated Requisitions
6/1/2016 35 25 FY 2017 Annual Operating and Capital Plan Non Labor Analysis – Other Direct Expense
Other Direct Expense per Adjusted Discharge (Incl. SNF) 250 Utilities 224 220 226 225 201 221 200 206 197 Building and Equipment 188 187 Rental 159 150 148 Insurance
100 Other Direct Expense FY15 Proj 16 Bud 17
. FY 2017 Budgeted Other Direct expense is increasing by $1.5M or 3.6% . Increases in professional liability insurance costs of $1.4M and marketing costs of $1.2M
6/1/2016 36 26 FY 2017 Annual Operating and Capital Plan Non Labor Analysis – Depreciation and Interest Expense
Depreciation Expense (in thousands)
60,000 40,000 Depreciation56,711 Expense (in thousands) 35,684 52,924 33,926 32,835 53,718 FY13 50,779 49,795 35,000 33,385 FY14 FY13 50,000 FY15 FY14 29,741 Proj 16 30,000 FY15 Bud 17 Proj 16 Bud 17 Bud 17 Proj 16 Proj 16 25,000 FY15 Bud 17 40,000 FY15 FY14 FY14 FY13 FY13 Interest Expense (in thousands)
. Interest expense reflected for Revenue Bonds only
6/1/2016 37 27 FY 2017 Annual Operating and Capital Plan
Annual Operating Budget Summary / EBIDA Recap
6/1/2016 38 28 FY 2017 Annual Operating and Capital Plan Annual Operating Budget Summary and Trend Budget FY17 Projected FY16 Results FY15 Results FY14 Revenue: Gross Revenue 3,642,966,545 3,407,071,652 3,156,201,150 2,694,179,906 Net Revenue 711,227,191 665,143,799 642,577,733 601,153,488 Other Operating Revenue 12,372,979 13,717,661 16,189,468 13,046,993 Total Operating Revenue $ 723,600,170 $ 678,861,460 $ 658,767,201 $ 614,200,481 Expenses: Salaries, Wages, Registry, Benefits 393,650,506 377,109,473 365,662,152 347,110,826 Supplies 96,408,447 94,427,197 93,498,167 87,008,983 Depreciation 52,924,253 49,795,295 50,779,118 56,711,438 Other 160,474,964 149,669,210 139,681,356 129,640,252 Total Operating Expense $ 703,458,170 $ 671,001,175 $ 649,620,793 $ 620,471,499
Operating Income 20,142,000 7,860,285 9,146,408 (6,271,018) Non-Operating Income (4,825,841) 2,507,119 7,775,298 9,772,515 (Interest Expense) (32,834,866) (33,925,799) (35,684,422) (33,569,486) Property Tax Revenue 15,800,000 15,099,996 14,303,002 13,451,009 Income (Loss) $ (1,718,707) $ (8,458,398) $ (4,459,714) $ (16,616,980) Net Margin % -0.2% -1.2% -0.7% -2.7% OEBIDA Margin (Excl Property Tax Rev) 10.1% 8.5% 9.1% 8.2% OEBIDA Margin (Incl Property Tax Rev) 12.3% 10.7% 11.3% 10.4% EBIDA Margin 11.6% 11.1% 12.4% 12.0% Total Uncompensated Care & Bad Debt 64,118,911 58,585,367 72,994,974 87,221,098 Total Uncompensated Care as % of Gross 1.76% 1.72% 2.31% 3.24% 6/1/2016 39 29 FY 2017 Annual Operating and Capital Plan FY 2017 EBIDA Recap (in thousands) Results Results Results Projected Budget FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Net Income from Ops (22,292) (6,217) 9,146 7,860 20,142
Depreciation Expense 53,718 56,711 50,779 49,795 52,924
OEBIDA 31,426$ 50,494$ 59,925$ 57,655$ 73,066$ OEBIDA Margin (Excl Property Tax Rev) 5.3% 8.2% 9.1% 8.5% 10.1% OEBIDA Margin (Incl Property Tax Rev) 7.5% 10.4% 11.3% 10.7% 12.3%
EBIDA 48,740 73,663 82,003 75,263 84,040 EBIDA Margin 8.2% 12.0% 12.4% 11.1% 11.6%
Total Uncompensated Care & Bad Debt 112,188 87,221 72,995 58,585 64,119 Total Uncompensated Care as % of Gross 4.69% 3.24% 2.31% 1.72% 1.76%
Net Income/(Loss) after Non-Op Income $ (34,718) $ (16,617) (4,460)$ (8,458)$ (1,719)$ 6/1/2016 40 30 FY 2017 Annual Operating and Capital Plan
Capital Plan
6/1/2016 41 31 FY 2017 Annual Operating and Capital Plan Capital Plan
Three Year Capital Budget Summary (in thousands) FY 2017 FY 2018 FY 2019 Total Project Spend Routine Capital: Equipment 5,500 6,500 8,500 20,500 Facility 5,000 14,480 13,570 33,050 Information Technology 5,000 6,000 7,000 18,000 Total Routine Capital Requests 15,500$ 26,980$ 29,070$ $ 71,550 Strategic Capital Reserve 16,000 14,000 14,000 44,000 Downtown Relocation 10,000 - - 10,000 Consolidated Capital Reserve 41,500$ 40,980$ 43,070$ $ 125,550
6/1/2016 42 32 FY 2017 Annual Operating and Capital Plan
FY17 Budget Summary & Key Take-Aways
6/1/2016 43 33 FY 2017 Annual Operating and Capital Plan Summary / Key Take-Aways FY 2017 Budget is achievable and ties to the Strategic Financial & Capital Plan. However, it requires success in the following areas: . Stable Acute Patient Days and Inpatient Surgeries, year over year . 10.9% growth in Deliveries . 7% growth in Net Patient Revenue . Successful implementation of the Crisis Stabilization Unit . Execution of Patient Throughput, Revenue Cycle, and Supply Initiatives, as well as the other planned expense management strategies included in the budget . Transition from reliance on premium pay and registry labor to a coordinated staffing approach . Complete closure of the Palomar Health Downtown Campus by the end of the Fiscal Year Successful Execution will result in: . Net Income improvement of $6.7M year over year; Operating Income improvement of $12.3M year over year . EBIDA of $84M 6/1/2016 44 34
ADDENDUM B
45
SPECIAL BOARD OF DIRECTORS EDUCATION SESSION MINUTES – MONDAY, MAY 9, 2016
AGENDA ITEM CONCLUSION / ACTION FOLLOW UP / RESPONSIBLE PARTY
DISCUSSION
I. CALL TO ORDER
The meeting – held in the Café Conference Room at Pomerado Hospital, 15615 Pomerado Road, Poway, CA, 92064 was called to order at 5:31 p.m. by Board Chair Dara Czerwonka
ESTABLISHMENT OF QUORUM
Quorum comprised of Directors Czerwonka, Griffith, Kaufman, McCune, Greer, Sison, Wickes Excused Absences: Director McCune
NOTICE OF MEETING
Notice of Meeting was posted at PH’s Administrative Office on Monday, May 2, 2016 which is consistent with legal requirements. Notice of that posting was made via email to the Board and staff members
II. PUBLIC COMMENTS
There were no public comments
INFORMATION ITEMS
A. BOARD EDUCATION SESSION Information only
1. Strategic Planning
Utilizing the presentation posted with the meeting packet, Executive Vice President Strategy Della Shaw provided the presentation “The Role of the Board – Strategic Planning”, highlights of which included:
Education about Hospital Boards’ roles and responsibilities for Strategic Planning
Overview of strategic framework
Process review to date and next steps in the Palomar Health strategic planning process
Board expectations regarding our strategic planning process
Board ongoing collaborative involvement in the strategic planning process at Palomar Health
1 46
SPECIAL BOARD OF DIRECTORS EDUCATION SESSION MINUTES – MONDAY, MAY 9, 2016
AGENDA ITEM CONCLUSION / ACTION FOLLOW UP / RESPONSIBLE PARTY
DISCUSSION
VI. PUBLIC COMMENTS
There were no public comments
VII. FINAL ADJOURNMENT The meeting was adjourned at 6:30 p.m. by Board Chair Czerwonka
SIGNATURES:
BOARD SECRETARY Raymond McCune, R.N.
BOARD ASSISTANT Debbie Hollick
2 47
Board of Directors Meeting Minutes – Monday, May 9, 2016
Agenda Item
Discussion Conclusion/Action/Follow Up
I. CALL TO ORDER The meeting, held in Conference Room E of Pomerado Hospital, 15615 Pomerado Road, Poway, CA 92064, was called to order at 6:30 p.m. by Palomar Health Board Chair Dara Czerwonka
II. ESTABLISHMENT OF QUORUM
Quorum comprised of Directors Czerwonka, Griffith, Kaufman, McCune, Greer, Sison, Wickes Excused Absences: Director McCune
III. OPENING CEREMONY
The Pledge of Allegiance was recited in unison
MISSION AND VISION STATEMENTS
The Palomar Health mission and vision statements are as follows:
The mission of Palomar Health is to heal, comfort and promote health in the communities we serve
The vision of Palomar Health is to be the health system of choice for patients, physicians and employees, recognized nationally for the highest quality of clinical care and access to comprehensive services
NOTICE OF MEETING
Notice of Meeting was posted at PH’s Administrative Office; also posted with full agenda packet to the PH web site on Monday, May 2, 2016, which is consistent with legal requirements. Notice of that posting was also made via email to the Board and staff members
IV. PUBLIC COMMENTS
Dr. Rastle and R. Alan Smith spoke about Palomar Health and Arch Health Partners
V. APPROVAL OF MINUTES
050916BD Meeting Minutes 48 1
Board of Directors Meeting Minutes – Monday, May 9, 2016
Agenda Item
Discussion Conclusion/Action/Follow Up
A. MOTION: by Director Kaufman, 2nd by Director Wickes and carried to A. Special Closed Session Board of Director’s Meeting - April 11, 2016 approve the April 11, 2016 Special Closed Session Board of Director’s B. Regular Board of Director's Meeting – April 11, 2016 meeting minutes as presented. All in favor. None opposed
B. MOTION: by Director Sison, 2nd by Director Kaufman and carried to approve the April 11, 2016 Regular Board of Director's meeting minutes as presented. All in favor. None opposed
There was no discussion
VI. * APPROVAL OF AGENDA to accept the Consent Items as listed including – MOTION: by Director Griffith, 2nd by Director Sison and carried to approve Consent Agenda items A. and C. as presented. All in favor. None A. Approval of Revolving, Patient Refund & Payroll Fund Disbursements – March, 2016 opposed. Consent Agenda item B. was pulled for discussion and 1. Accounts Payable Invoices $59,342,541.00 reviewed separately
2. Net Payroll $15,165,276.00 MOTION: by Director Griffith, 2nd by Director Sison and carried to approve Total $74,507,818.00 Consent Agenda item B. as presented. All in favor. None opposed.
B. March 2016 and YTD FY2016 Financial Report - Board Finance Committee
C. Summary of Executed Budgeted Routine Physician Agreements - Board Finance Committee
Agenda item B. was pulled for further discussion; then approved separately by the board
VII. PRESENTATIONS Information Only
A. Alphabet Soup Utilizing the presentation distributed in the meeting packet, Medical Quality Office David Lee, M.D. provided a presentation on the 2016 Alphabet Soup: HAC (Hospital Acquired Condition) Reduction and VBP (Value-Based Purchasing) Program Results
Final results for 2016 HAC Reduction program – both PMC and POM scored 6.75, which was threshold for monetary penalties. Therefore neither facility was penalized Final results for 2016 VBP program – PMC penalized $145K; POM penalized $75K
VIII. * REPORTS A. Medical Staffs 1. Palomar Medical Center A. MOTION: by Director Kaufman, 2nd by Director Griffith and carried to approve the Palomar Medical Center Medical Staff Credentialing A. Palomar Medical Center Medical Staff Credentialing Recommendations Recommendations as presented. All in favor. None opposed
B. Revised Palomar Health Credentialing Process - PMC & POM nd B. MOTION: by Director Wickes, 2 by Director Kaufman and carried to approve the Revised Palomar Health Credentialing Process - PMC & POM as presented. All in favor. None opposed
050916 BoD Meeting Minutes 49 2
Board of Directors Meeting Minutes – Monday, May 9, 2016
Agenda Item
Discussion Conclusion/Action/Follow Up
PMC Chief of Staff Dr. Franklin Martin presented the Palomar Medical Center Medical Staff Executive Committee reports referenced above for review and approval
Dr. Martin announced that he will be assuming the role of Chief of Staff of Palomar Medical Center left vacant by Dr. Rosenburg’s resignation 2. Pomerado Hospital A. MOTION: by Director Wickes, 2nd by Director Griffith and carried to approve the Pomerado Hospital Medical Staff Credentialing A. Pomerado Hospital Medical Staff Credentialing Recommendations Recommendations as presented. All in favor. None opposed Pomerado Hospital Chief of Staff Dr. Paul Neustein presented the Pomerado Hospital Medical Staff Credentialing Recommendations for review and approval
B. Administrative
1. Palomar Health Foundation Information only
Palomar Health Foundation Board President Tom Silberg presented the April 2016 Palomar Health Foundation Board report; copies of which were emailed and distributed to the board in hard copy 2. Chair of the Board Information only
Paloma r Health Board Chair Dara Czerwonka provided the following updates:
Recently attended Governance Institute training in Arizona; highly beneficial and timely. How-to sessions were very informative. Will use this training as we strive to make Palomar Health the best it can be
Attended the recent Patient and Family Advisory Council meeting. This council provides a platform to engage former patients and their family members in sharing their experiences and perspectives; found it to be very informative to hear the patient point of view. Encouraged board member attendance at these meetings
Wished to thank everyone and honor them during National Hospital and Nurse’s Week. The contributions made across the system are immeasurable; the board appreciates all you do every day for our patients and their families 3. President and CEO Information only
In the absence of Palomar Health President and CEO Robert Hemker, PH Executive Vice President Operations Frank Beirne provided the following update on his behalf: Introduced Interim Vice President/Interim CNO Pomerado Hospital Larry LaBossiere, RN, MSN, CEN, CNS, MBA. Larry served 20 years with the United States Navy in a variety of clinical, managerial, education and training capacities, and brings a rich and diverse track record to the role
Echoed Chair Czerwonka’s thanks to the Palomar Health team for all they do to provide the highest possible care to those we are proud to serve. This care is delivered compassionately every day, every time, to every patient. What we do reflects on the strength of the organization as a family; everyone plays a central role and achieves this commitment with compassion, dignity and stability IX. INFORMATION ITEMS
A. The April ACHD Update Report was forwarded electronically to the board members prior to the meeting
X. *APPROVAL OF BYLAWS, CHARTERS, POLICIES
050916 BoD Meeting Minutes 50 3
Board of Directors Meeting Minutes – Monday, May 9, 2016
Agenda Item
Discussion Conclusion/Action/Follow Up
A. Lucidoc 21800 - Conflict of Interest Code A. Motion: by Director Greer, 2nd by Director Wickes and carried to refer Lucidoc 21800 - Conflict of Interest Code back to the Board Governance Committee for follow up vis-à-vis Director Wickes' line of questioning. All in favor. None opposed Director Wickes queried as to whether the members of the executive team are required to file a COI Form 700 with the county as well as where the documents are kept on file for public review. The board agreed to table the motion for approval pending an answer to this question
X. * COMMITTEE REPORTS
A. Audit and Compliance Committee
1. External Audit Engagement 1. Motion: by Director Greer, 2nd by Director Griffith and carried to approve engagement of external auditing firm Moss Adams with a 3 year commitment. All in favor. None opposed Utilizing the presentation distributed in the meeting packet, Senior Internal Auditor Ruhina Livingstone provided a review of the external audit proposals engagement with the firms of Deloitte and Touche, Price, Waterhouse Cooper, and Moss Adams. Said presentation was provided to the Board Governance Committee, which brought forth the recommendation for the Board of Directors to approve engagement of Moss Adams with a 3 year commitment
B. Community Relations Committee Information only
Committee Chair Dara Czerwonka noted there was no meeting in April
C. Finance Committee Request the board
050916 BoD Meeting Minutes 51 4
Board of Directors Meeting Minutes – Monday, May 9, 2016
Agenda Item
Discussion Conclusion/Action/Follow Up
nd Committee Chair Jerry Kaufman noted that the committee meeting summary was included in the 1. Motion: by Director Kaufman, 2 by Director Griffith and carried to board meeting packet approve Resolution 05.09.16(01)-01 – Closure of Banking and Investment Accounts as presented. Roll–call voting was utilized. 1. Resolution 05.09.16(01)-01 – Closure of Banking and Investment Accounts 2. Resolution 05.09.16(02)-02 – Opening of Banking Account Director McCune: aye Director Greer: aye Director Griffith: aye Director Kaufman: aye 3. Resolution 05.09.16(03)-03 – Designating District Officers and Responsible Managing Employee Director Sison: aye Director Wickes: aye for Wholesale Drug Permit, License No. WLS 4090 Director Czerwonka: aye 4. Five-Year Strategic Financial & Capital Plan All in favor. None opposed. Resolution passed.
2. Motion: by Director Kaufman, 2nd by Director Griffith and carried to approve Resolution 05.09.16(02)-02 – Opening of Banking Account as presented. Roll–call voting was utilized. Director McCune: aye Director Greer: aye Director Griffith: aye Director Kaufman: aye Director Sison: aye Director Wickes: aye Director Czerwonka: aye All in favor. None opposed. Resolution passed.
3. Motion: by Director Kaufman, 2nd by Director Griffith and carried to approve Resolution 05.09.16(03)-03 – Designating District Officers and Responsible Managing Employee for Wholesale Drug Permit, License No. WLS 4090 as presented. Roll–call voting was utilized. Director McCune: aye Director Greer: aye Director Griffith: aye Director Kaufman: aye Director Sison: aye Director Wickes: aye Director Czerwonka: aye All in favor. None opposed. Resolution passed
4. Board decision to defer approval to the 6/07/16 Special Board Budget Workshop
1. No discussion 2. No discussion 3. No discussion 4. Utilizing the presentation distributed in the meeting packet, Executive Vice President Finance Diane Hansen reported on the Five-Year Strategic Financial & Capital Plan
D. Governance Committee Information only
050916 BoD Meeting Minutes 52 5
Board of Directors Meeting Minutes – Monday, May 9, 2016
Agenda Item
Discussion Conclusion/Action/Follow Up
Committee Chair Jeff Griffith noted there was no meeting in April
E. Human Resources Committee Information only
Committee Chair Sison noted there was no meeting in April
C. Quality Review Committee Information only
Committee Chair Aeron Wickes noted that the committee meeting summary was included in the board meeting packet. Expressed his thanks Dr. Kolins for leading the meeting discussion, as well as for those who provided the informative presentations F. Strategic & Facilities Planning Committee Information only
1. Crisis Stabilization Unit Presentation
Utilizing the presentation distributed in the meeting packet, Vice President Continuum Care Sheila Brown provided an overview of the new Crisis Stabilization Unit G. Other Committee Chair Comments or Committee Highlights
There were no other committee chair comments or committee highlights
XI. BOARD MEMBER COMMENTS / AGENDA ITEMS FOR NEXT MONTH
Director Greer shared her recognition of Nurse’s Week and appreciation for all Palomar Health nurses, noting that it is nice to see all of the up and coming new nurses
Chair Czerwonka reminded board members of the upcoming annual CEO evaluation process, board organizational culture retreat and strategic planning meetings. Welcomed Dr. Martin in his new role
Director Kaufman noted that many new ideas were gleaned from the Governance Institute visit and Mayo tour, in particular Mayo’s focus on culture. Noted that new Culture and Talent Planning Vice President Leslie Solomon will be taking charge of our culture efforts. Looking forward to upcoming board education sessions, adding that all board members will benefit from additional education re: collaboration with one another and with all levels of staff
Director Sison noted that his main takeaway from the Governance conference is that healthcare is our economy; the two cannot be separated. Our deficit is based on the fact that we have an effective but inefficient system. Recommended this conference to the rest of the board members
Director Wickes requested that an Arch Health Partners discussion be agendized for the June Board of Director’s meeting
XII. PUBLIC COMMENTS
Erik Olson Fernandez spoke about the budget, staffing and equipment
XIII. ADJOURNMENT
Chair Czerwonka adjourned the meeting at 8:25 p.m.
050916 BoD Meeting Minutes 53 6
Board of Directors Meeting Minutes – Monday, May 9, 2016
Agenda Item
Discussion Conclusion/Action/Follow Up
Board Secretary Raymond McCune, R.N. Signatures:
Board Assistant Debbie Hollick
050916 BoD Meeting Minutes 54 7
Special Board of Directors Meeting Minutes – Monday, May 23, 2016
Agenda Item
Discussion Conclusion/Action Follow Up / Responsible Party
I. CALL TO ORDER The meeting, held in the Graybill Auditorium of the Palomar Health downtown Campus, 555 E. Valley Parkway, Escondido, CA 92025, was called to order at 6:01 p.m. by Palomar Health Board member Ray McCune
II. ESTABLISHMENT OF QUORUM Quorum comprised of Directors Griffith, Kaufman, McCune, Greer, Wickes, Sison Excused Absences: Director Czerwonka
NOTICE OF MEETING
Notice of Meeting was posted at PH’s Administrative Office; also posted with full agenda packet to the PH web site on Monday, May 16, 2016, which is consistent with legal requirements. Notice of that posting was also made via email to the Board and staff members
III. PUBLIC COMMENTS
There were no public comments
I V. *INFORMATION ITEMS
A. Q3 Fiscal Year 2016 Balanced Scorecard Review
Utilizing the presentation distributed in the meeting packet, Executive Vice President Strategy Della Shaw and the executive leadership team presented the balanced scorecard data for the third quarter of fiscal year 2016
V. PUBLIC COMMENTS There were no public comments
VI. ADJOURNMENT Director McCune adjourned the meeting at 7:43 p.m.
Signatures: Board Secretary Raymond McCune, R.N.
55 1
Special Board of Directors Meeting Minutes – Monday, May 23, 2016
Agenda Item
Discussion Conclusion/Action Follow Up / Responsible Party
Board Assistant Debbie Hollick
052316 Special BoD Meeting Minutes 56 2
BOARD OF DIRECTORS SPECIAL CLOSED SESSION MEETING MINUTES – MONDAY, MAY 23, 2016
AGENDA ITEM CONCLUSION / ACTION FOLLOW UP / RESPONSIBLE PARTY
DISCUSSION
I. CALL TO ORDER
The meeting – held in the Graybill Auditorium of the Palomar Health Downtown Campus, 555 E. Valley Parkway, Escondido, CA 92025 was called to order at 7:52 p.m. by Vice-chair Griffith (in Chair Czerwonka’s absence)
ESTABLISHMENT OF QUORUM
Quorum comprised of Directors Griffith, Kaufman, McCune, Greer, Wickes, Sison Excused Absences: Director Czerwonka
NOTICE OF MEETING
Notice of Meeting was posted at PH’s Administrative Office on Friday, May 20, 2016 which is consistent with legal requirements. Notice of that posting was made via email to the Board and staff members
II. PUBLIC COMMENTS
There were no public comments
III. * ADJOURNMENT TO CLOSED SESSION A. Reports Involving Trade Secrets Discussion will concern: proposed new service or program Anticipated date of disclosure: July 1, 2016 Authority: California Health and Safety Code Section 32106
IV. RE-ADJOURNMENT TO OPEN SESSION
V. ACTION RESULTING FROM CLOSED SESSION DISCUSSION, IF ANY
There was no action resulting from closed session
VI. PUBLIC COMMENTS
1 052316 Special Closed Session BoD Meeting 57
BOARD OF DIRECTORS SPECIAL CLOSED SESSION MEETING MINUTES – MONDAY, MAY 23, 2016
AGENDA ITEM CONCLUSION / ACTION FOLLOW UP / RESPONSIBLE PARTY
DISCUSSION
There were no public comments
VIII. FINAL ADJOURNMENT The meeting was adjourned at 8:58 p.m. by Vice-Chair Griffith
SIGNATURES:
BOARD SECRETARY Raymond McCune, R.N.
BOARD ASSISTANT Debbie Hollick
2 052316 Special Closed Session BoD Meeting 58
ADDENDUM C
59 60
ADDENDUM D
61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78
ADDENDUM E
79 (By-Laws approved by BQRC on 3/21/16)
6.2.4 Quality Review Committee
(a) Voting Membership. The Committee shall consist of five voting members, namely the three Board of Directors committee members, the Chair of the Medical Staff Quality Management Committee of Palomar Medical Center, and the Chair of the Medical Staff Quality Management Committee of Pomerado Hospital. (b) Non-Voting Membership. The non-voting members of the Committee shall include the President and Chief Executive Officer; the Vice President of Palomar Medical Center; the Vice President of Pomerado Hospital; the Chief Nursing Officer of Palomar Medical Center; the Chief Nursing Officer of Pomerado Hospital; the Vice President, Patient Experience; the Chair and Co-Chairs of the Patient Safety Committee; the Executive Vice President, Physician Alignment; the Executive Vice President, Operations; the Executive Vice President, Strategy; and the Vice President, Continuum Care. (c) Duties. The duties of the Committee shall include (but not be limited to):
(i) Oversight of the Patient Safety and Quality Performance Improvement Plan, focusing on performance improvement, patient safety, and risk management activities of the hospitals but also to include other facilities across the care continuum, when applicable; (ii) Annual review of the credentialing process for medical staff membership; (iii) Annual review of physician performance, as evaluated by an appropriate survey tool; (iv) Quarterly review of customer satisfaction survey results.
80 Quality Assurance Performance Improvement Plan, 11234
Plan Quality Assurance Performance Improvement (QAPI) Plan 11234 Draft (Rev: 10)
Source: Applies to Facilities: Applies to Departments: Administrative All Palomar Health Facilities All Departments
Plans
I. PURPOSE: A. To outline the framework for a leadership driven, systematic, interdisciplinary approach to continuous improvement using our performance improvement model known as Plan, Do, Check, Act (PDCA). Our efforts will focus on all care and service outcomes for our patient populations and meet the mission, vision, and standards of excellence for the Palomar Health system as follows: 1. Mission: The mission of Palomar Health is to heal, comfort, and promote health in the communities we serve. 2. Vision: Palomar Health will be the health system of choice for patients, physicians, and employees, recognized nationally for the highest quality of clinical care and access to comprehensive services.
II. DEFINITIONS: Quality Assurance Performance Improvement (QAPI) Plan A. QAPI is the merger of two complementary approaches to quality, namely Quality Assurance (QA) and Performance Improvement (PI). Both involve seeking and using information, but they differ in key ways: 1. QA is a process of meeting quality standards and assuring that care reaches an acceptable level. Hospitals and health systems typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA is a reactive, retrospective effort to examine why a facility may have failed to meet certain standards. QA activities do improve quality, but efforts frequently end once the standard is met. 2. PI (also called Quality Improvement - QI) is a pro-active and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches in order to fix underlying causes of persistent/systemic problems. PI in hospitals and health systems across the care continuum aims to improve processes involved in health care delivery and quality of life. PI can make good quality even better. QAPI is a data-driven, proactive approach to improving the quality of life, care, and services across the care continuum. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions.
III. STANDARDS OF PRACTICE: A. Core Components--The following are the core components of the framework: 1. Leadership driven through a culture of safety that uses the quality dashboard as the monitoring tool 2. Data driven based on best practices using national benchmarks and comparative data 3. Integrated and coordinated processes to engage all levels of leadership, physicians, employee staff, and community members 4. Proactive in design in order to not just maintain performance but improve quality, safe patient care, and services 5. Communication through a common language created by an ongoing process to prioritize Quality Assurance/Performance Improvement opportunities using consistent methods and statistical tools that are the tenets of PDCA and when appropriate Lean/Six Sigma, i.e., Define, Measure, Analyze, Improve and Control (DMAIC).
Date Extracted from Lucidoc: 02/24/2016 81 Page 1 of 18 Quality Assurance Performance Improvement Plan, 11234
6. A calendar of reporting to ensure ongoing systematic communication to all key constituents, assure accountability and hold the gains for all continuous quality assurance/performance improvement activities 7. Educational programs and meetings to enhance statistically based quality assurance/performance improvement tools for every level of leadership, physicians, staff, patients, and the community. 8. Standardized processes for investigation of events and follow-up on near miss events, adverse and sentinel events. These standardized processes address: a. How corrections will be accomplished b. Who is responsible for the correction c. A description of the monitoring process to prevent a recurrence (see standard operating procedure (SOP) entitled: Near Miss, Adverse and Sentinel Event Investigation and Follow-up). B. Goals 1. As part of the annual evaluation of the Quality Assurance Performance Improvement (QAPI) activities conducted by the Board, leadership and staff, goals are identified for each calendar year to ensure continuous improvement, e.g., infection control goals on catheter-associated urinary tract infection (CAUTI), and central-line associated blood stream infections (CLABSI), CMS Value-Based Purchasing (VBP) goals on patient care, and patient satisfaction goals as measured by comparative benchmarks such as the survey on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The following actions should be taken in forming specific goals: a. Enhance key processes to ensure that "Best Practice" is being considered in all opportunities for improvement of care and services b. Integrate the Quality Assurance/Performance Improvement Plan into a culture of safety that recognizes the key behaviors and attitudes that result in a safe environment for patients, families, employees, and physicians c. Create a support structure for data collection and analysis through collaboration with Information Technology, Strategy, and Finance d. Review and revise as necessary the peer review methodology to ensure a quality driven process that provides a consistent, objective, data driven evaluation of physician and nurse performance via their respective peer review programs e. Identify core components for Quality Assurance/Performance Improvement methods and tools for all levels of the organization. C. Reporting structure, responsibilities and constituents of the Quality Assurance Performance Improvement (QAPI) Plan: 1. Board of Directors. The Board of Directors holds ultimate responsibility for ensuring optimal quality and safe patient care and services. The Board of Directors: a. authorizes administration, the medical staff and hospital employee staff to assess and improve the performance of the organization’s managerial, support and clinical processes and systems; b. delegates oversight of performance improvement functions, the prioritizing of improvement efforts and the provision and management of adequate resources for performing improvement activities to the leadership and medical staff through the Board Quality Review Committee (BQRC), the Medical Staffs of Palomar Medical Center and Pomerado Hospital. (See ‘Quality Assurance Performance Improvement Reporting Structure chart below); c. reviews ongoing reports on the effectiveness of Quality Assurance/Performance Improvement activities d. evaluates and improves the performance of Governance activities. 2. Board Quality Review Committee (BQRC): a. Duties: i. Pursuant to the BQRC Bylaws. The BQRC shall also review the prioritized proposed performance improvement projects and patient safety activities and shall report to the Board of Directors.
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b. Composition: i. Voting Membership: The committee shall consist of five voting members, including three members of the Board of Directors and the Chairs of the Quality Management Committees (QMC) of Palomar Medical Center and Pomerado Hospital. Non-Voting Members include: The President and Chief Executive Officer; Executive Vice President, Operations; Executive Vice President, Physician Alignment; Executive Vice President, Strategy; Vice President of Patient Experience; Vice President, Continuum Care; Vice President of Palomar Medical Center; Vice President, Pomerado Hospital; the Chief Nursing Officers of Palomar Medical Center and Pomerado Hospital; and the Chair or Co-Chairs of the Patient Safety Committee. c. Meetings: i. The BQRC shall meet at least monthly and/or as necessary and maintain a record of its proceedings.
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Date Extracted from Lucidoc: 02/24/2016 84 Page 4 of 18 Quality Assurance Performance Improvement Plan, 11234
3. Medical Staff Executive Committees (MEC): a. Duties: i. The Executive Committees of the Medical Staffs, with the consent of the Board of Directors, and in conjunction with organizational leaders, are responsible for the overall administration and effectiveness of the improvement of organizational performance and safe patient care. ii. The Medical Executive Committees (MECs) review and approve all recommendations submitted by the Quality Management Committee and initiate any special studies or recommendations as deemed appropriate to maintain an effective program. b. Composition: i. The specific composition, responsibilities, meeting requirements, and reporting requirements are as specified in the Medical Staff Bylaws. Pertinent provisions are incorporated herein. c. Meetings: i. The Medical Executive Committee shall meet at least once per month and/or as necessary and maintain a record of its proceedings. 4. The Quality Management Committee (QMC) of the Medical Staffs: a. Duties: i. The QMC provides oversight for the Quality Assurance Performance Improvement (QAPI) activities of both medical staffs and nursing departments and committees. ii. The QMC reviews and prioritizes proposed performance improvement projects. iii. The QMC regularly reviews specified performance metrics recognized as measurements of quality and safety, such as metrics including blood usage, medication usage, pharmacy and therapeutics, nutrition, medical record timeliness, special care review, utilization review, nursing sensitive patient outcomes, infection control, patient safety, and other items identified in the body of this plan. Appropriate summaries and recommendations first referred to the appropriate clinical departments and subcommittees are then forwarded to the appropriate Medical Staff Executive Committee for review and approval. b. Composition: i. The Committee has a Physician Chair (preferably the Chief of Staff-elect at each licensed acute care facility). Committee members will include the department chairs-elect of the medical staffs or their designee, along with representatives from nursing, administration, and staff responsible for overseeing quality assurance and performance improvement activities, e.g., Quality and Infection Control representatives, Pharmacy, Case Management, Utilization Review and Transfusion Review (Blood Use). c. Meetings: i. The QMC shall meet at least every other month and/or as necessary and maintain a record of its proceedings. 5. Medical Staff Peer Review Committee (MSPRC): a. Duties: i. improve physician performance at the individual and aggregate levels by improving patient outcomes and supporting a culture of compassion and respect. ii. promote efficient use of physician and quality staff resources. iii. provide accurate and timely performance data for physician feedback and Ongoing Professional Practice Evaluation (OPPE). iv. review of surgical cases in which a discrepancy is noted in the pre-operative and post-operative diagnosis (Tissue Review). See Lucidoc Policy 13690. v. recognize physician excellence in addition to identifying improvement opportunities. vi. define performance measures and targets that address the 6 general physician competencies (Patient Care, Medical Knowledge, Practice-Based Learning,
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Interpersonal and Communication Skills, Professionalism and Systems-Based Practice) and evaluate performance data for patterns and trends. vii. Individual physicians and their Department Chairs receive performance reports at least twice a year. viii. Privileging decisions are the responsibility of the Department Chairs and the Medical Executive Committee. b. Composition: i. The specific composition, responsibilities, meeting requirements and reporting requirements are as specified in the Medical Staff Peer Review Policy and pertinent provisions of which are incorporated herein by this reference. ii. MSPRC is comprised of members of the medical staff with at least one member from each of the following specialties: Internal Medicine, Surgery, OB/GYN, Emergency Medicine, Anesthesiology, Cardiology and Orthopedics c. Meetings: i. The MSPRC shall meet at least 10 times per year and/or as necessary and maintain a record of its proceedings. A quorum for purposes of making case determinations will be based on the members present at a regularly scheduled meeting. A majority will consist of a majority of voting members present.
7. Other Medical Staff Departments and Committees: Pursuant to the Medical Staff Bylaws, Medical Staff departments and committees are responsible for the quality of care, service and safety of patient care delivered by the members of the departments. Medical Staff Departments and Committees demonstrate quality assurance and performance improvement by: a. participating in departmental and quality assurance/performance improvement activities; b. utilizing results and recommendations from interdisciplinary performance improvement efforts to improve services. c. utilizing information from MSPRC and Patient Experience Division that includes data addressing each of the six physician core competencies for credentialing, privileging and the reappointment process. d. reviewing and analyzing summary reports of trended data by department and/or by physician for processes dependent primarily on the activities of one or more individuals with clinical privileges (e.g. blood use, operative and invasive procedures, medication use). e. sharing responsibility for planning, designing, measuring, assessing, and improving the overall safe care of patients. The following Medical Staff committees and subcommittees have specific responsibilities to the Quality Assurance Performance Improvement (QAPI) Plan as described below and report to QMC as illustrated in the Quality Assurance Performance Improvement Reporting Structure chart above: A. Critical Care Committee (CCC): (a) Duties: The District wide Critical Care Committee is responsible for carrying out the following: i. Identifying indicators for monitoring the important aspects of critical care. ii. Evaluating results of data collected for these indicators. iii. Making recommendations for actions to improve care or correct identified problems. iv. Referring concerns about care entered by individual practitioners to the appropriate Medical Staff department for further review and action. (b) Composition: i. Co-chairs, both of whom will be Medical Directors of ICU, along with broad representation from appropriate areas of the Medical Staff, Administration, Nursing and other disciplines. (c) Meetings:
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i. The CCC shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. B. Diabetes Medical Advisory Committee (DMAC): The purpose of DMAC is to establish, assess and review program procedures governing the scope of diabetes services provided. (a) Duties: DMAC is responsible for, but not limited to: i. Evaluate appropriateness and adequacy through a review of procedures, Power Plans, and clinical practice guidelines ii. A financial analysis of the previous fiscal year and utilization of resources shall occur annually iii. Participate in the Palomar Health quality and performance improvement program (b) Composition: i. The DMAC is comprised of a multidisciplinary team of health professionals including Medical Staff, Diabetes Clinical Nurse Specialist, Pharmacy, Nursing and Nutritional Services. (c) Meetings: i. The DMAC shall meet every other month and/or as necessary and maintain a record of its proceedings. C. Infection Prevention and Control Committee (IPCC): The District wide Palomar Health Infection Prevention and Control Committee is responsible for carrying out the following: (a) Duties: i. Infection Prevention and Control is responsible for an organization-wide approach to act as advocate for control and prevention of infections in the facilities, formulate and monitor patient-care policies, and educate staff. (b) Composition: i. The Committee is composed of a physician chair who is an infectious disease specialist, representatives from Infection Prevention, Nursing, Administration, personnel responsible for overseeing facility infection control activities, e.g., Home Health, Villa Pomerado, representatives from Peri-operative Services, Patient Experience, Facilities, Environmental Services, Food and Nutrition, Pharmacy and Corporate Health. (c) Meetings: i. The IPCC shall meet at least every other month and/or as necessary and maintain a record of its proceedings. D. Patient Safety Committee (PSC): The District wide Patient Safety Committee is responsible for carrying out the following: (a) Duties i. The Patient Safety Committee reports to the QMC and is responsible for the oversight of patient safety culture, monitoring and improvement. Responsibilities include, but are not limited to: 1. Review and approve the Quality Assurance Performance Improvement (QAPI) plan. 2. Receive and review reports of patient safety events. 3. Monitor implementation of corrective actions for patient safety events. 4. Make recommendations to eliminate adverse events. 5. Review and revise the Quality Assurance Performance Improvement Plan, at least once a year, but more often if necessary. Evaluate and update the plan and incorporate advancements in patient safety into the plan as needed.
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6. Provide a reporting system for patient events that allows anyone involved, including, but not limited to healthcare practitioners, facility employees, patients and visitors to make a report of a patient safety event to the health facility. For example, Palomar Health has an independent Global Compliance Hotline (800-850-2551) available to all employees, medical staff and patient/families/consumers providing a confidential option of reporting. Also any individual can report a patient safety event or concern to The Joint Commission via fax (630-792-5636) or email ([email protected]). 7. Provide a process for a team of facility staff to conduct analyses, including, but not limited to, root cause analyses of patient safety events. The team shall be composed of the facility’s various categories of health care professionals, with the appropriate competencies to conduct the required analyses. 8. Provide a process that supports and encourages a culture of safety and reporting patient safety events. 9. Provide a process for providing ongoing patient safety training for facility personnel and health care practitioners. 10. Receive reports and provide recommendations on the quality assurance performance improvement efforts of the Diabetes Certification Program, the Stroke Certification Program and Staff on Safety (SOS) Committee (b) Composition: i. The Committee is composed of the Chair, Vice President of Patient Experience and the Co-Chair, Director of Quality, Patient Safety and Infection Control as well as representatives from the multidisciplinary team of healthcare professionals. These professionals include but are not limited to Administration, Pharmacy, Medical Staff and Nursing. (c) Meetings: i. The PSC shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. E. Pharmacy and Therapeutics Committee (P&TC): (a) Duties: The district wide Pharmacy and Therapeutics Committee is responsible for carrying out the following functions: i. Identifying indicators for monitoring important aspects of drug usage. ii. Assisting the pharmaceutical service in maintaining the Hospital Formulary. iii. Reviewing the Adverse Drug Reaction event program. iv. Monitoring the quality and appropriateness of nutritional support services to patients, including enteral and parenteral nutrition, and clinical dietary consultations. v. Making recommendations to improve care or to correct identified problems to the Quality Management Committee based on analysis and evaluation of data collected through indicators. vi. Any matters within the scope of the Medical Staff’s responsibilities for performance improvement shall be referred to the Chair of the QMC of either PMC or Pomerado Hospital as appropriate. vii. The P&TC will report to the Quality Management Committee. (b) Composition: i. Physician Chair or physician co-chairs, six physician representatives, the Director of Pharmaceutical Services, a pharmacist from each hospital pharmacy, representatives from Administration, Nursing Leadership from each hospital and Allied Healthcare Staff. (c) Meetings: i. The P&TC shall meet every other month and/or as necessary and maintain a record of its proceedings.
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(d) Sub-Committees: i. The sub-committees of the Pharmacy & Therapeutics Committee are: 1. Antibiotic Stewardship Subcommittee: (a) Duties: In view of the dramatic increase in antibiotic resistance, the Antibiotic Subcommittee is responsible for, but not limited to: i. Reviewing new antimicrobial agents. ii. Review antibiotic usage and expenditures, including restricted antibiotics iii. Develop empiric treatment guidelines, protocols, and Power Plans to minimize the development of resistant organisms. (b) Composition: i. The Antibiotic Stewardship Subcommittee is a subcommittee of the Pharmacy and Therapeutics Committee. It is composed of one or more Infectious Disease Physicians, Physicians representing various medical specialties, Antibiotic Stewardship Pharmacist, a Microbiology Representative from the Laboratory and an Infection Preventionist. (c) Meetings: i. The Antibiotic Subcommittee shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. 2. Clinical Decision Support Committee (CDSC): The CDSD is responsible for, but not limited to: (a) Duties: i. Annual review of Clarity Power Plans not already owned by a Medical Staff department ii. Maintaining and revising clinical decision support alert settings and content (drug-drug interactions, contraindications, etc.) iii. Decisions or recommendations regarding medication-related issues requiring optimization for end-users (b) Composition: i. The CDSC is comprised of a multidisciplinary team of health professionals including a clinical informaticist from Information Technology, physicians representing various specialties and Pharmacy. (c) Meetings: i. The CDSC shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. 3. Medication Safety Committee (MSC): (a) Duties: The primary purpose of the committee is to improve the safety of medication use and reduce patient harm due to medication errors by: i. Reviewing medication events (internal and external) to determine actionable solutions. ii. Serving as the overarching committee for systemic improvements in safe medication practices. iii. Maintaining and revising the hospital's Medication Error Reduction Plan. iv. Reviewing recommendations from the following work groups or committees that report up to the Medication Safety Committee: a. Medication Management Steering Committee b. Medication Device Workgroup c. Alaris Infusion Device workgroup.
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(b) Composition: i. The Medication Safety Committee is a subcommittee of the Pharmacy and Therapeutics Committee. It is comprised of a multidisciplinary team of healthcare professionals including but not limited to Administration, Medical Staff, Pharmacy and Nursing. (c) Meetings: i. The MSC shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. (d) Sub-Committees: A sub-committee of the Medication Safety Committee is the Medication Management Steering Committee (MMSC): (a) Duties: i. The Medication Management Steering Committee (MMSC) is a high level and multidisciplinary committee that provides oversight and guidance for the medication use process throughout Palomar Health. MMSC ensures that all components of a closed loop medication process are considered and that they support safe patient care when processes are revised particularly when changes involve automation and technology. ii. The MMSC shall report up to the Medication Safety Committee. (b) Composition: i. The MMSC is comprised of a multidisciplinary team that includes but is not limited to Pharmacists, Pharmacy Technicians, Nurses and Information Technology staff. (c) Meetings: i. The MMSC shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. 4. Nutrition and Therapeutics Committee (N&TC): The purpose of the N&TC is to provide appropriate nutrition care to the patients using evidenced based information, by bridging the gap between research and practice. (a) Duties: The Nutrition and Therapeutics Committee is responsible for, but not limited to: i. Assisting the pharmaceutical service in maintaining the enteral and parenteral Hospital Formulary. ii. Monitoring the quality and appropriateness of nutritional support services to patients, including enteral and parenteral nutrition and clinical dietary consultations. (b) Composition: i. The N&T is comprised of a multidisciplinary team of health professionals including Nutritional Services, Medical Staff, Pharmacy and Nursing. (c) Meetings: i. The N&TC shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. F. Stroke Task Force (STF) Committee: The purpose of the Stroke Task Force Committee is to provide oversight, coordination and direction to the individuals caring for the stroke patients at Palomar Health.
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Evidence-based practice and a coordinated interdisciplinary team approach are needed to achieve the best possible outcome for stroke patients. The district wide Palomar Health Stroke Task Force Committee is responsible for carrying out the following: (a) Duties: i. The Stroke Task Force Committee is responsible for the oversight, coordination and direction to the individuals caring for stroke patients. The purpose of the Stroke Task Force Committee is to establish, assess, and review program procedures governing the scope of stroke services provided. ii. Accountable for the safe, effective and innovative care of our patients with stroke. iii. Evaluate appropriateness and adequacy through a review of procedures, Power Plans, and clinical practice guidelines. iv. Participate in the Palomar Health quality and performance improvement program Coordinate educational programs for staff, patients and families, Emergency Services and the community. (b) Composition: i. The Committee is comprised of a multidisciplinary team of health professionals including Administration, Neurology and other medical staff, Pharmacy, Nursing, Nutritional Services, Stroke program coordinator and any other disciplines involved in the care of the stroke patient. (c) Meetings: The Stroke Task Force shall meet at least quarterly and/or as necessary and maintain a record of its proceedings.
7. Non-Medical Staff QAPI Committees and Functions A. Continuum of Care Operations Improvement Function: a. Entities under the umbrella of the Continuum of Care Operations Improvement Function include: i. Ambulatory Outpatient Services ii. Behavioral Health Services iii. Corporate Health iv. Home Health v. Rehabilitation Services vi. Villa Pomerado vii. Wound Care b. Under the direction of the Vice President, Continuum of Care, and in collaboration with the Continuum of Care staff, the Villa Pomerado Quality Assurance Process Improvement Committee and the Home Health Professional Advisory Committee, the Continuum of Care Operations Improvement Committee promotes improvement of patient safety and outcomes. The purpose of the Continuum of Care Operations Quality Committee is to provide an organization-wide approach to continually assess and improve the quality of health services that we provide to our patients, employees and community outside our acute care facilities. The Continuum Care Director is responsible for the performance improvement and patient safety program at the departmental level. The managers, supervisors, educators and quality managers are responsible for implementation of the QAPI plan within their respective units/ specialties. The ongoing monitoring and analysis of Quality indicators are based on the following: i. Identification of patient needs and expectations and evaluation of how these needs and expectations are met. ii. Identification of staff education and training needs and ongoing measurements to demonstrate sustained improvement. iii. Use of evidence based data from internal and external sources to improve the quality of care. iv. Integration and coordination of quality initiatives across the care continuum including; acute, skilled nursing, home health and ambulatory services. v. Analysis of data to establish priorities and identify opportunities for future improvement.
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Each department establishes priorities based on the following considerations: i. Mission Statement and Strategic Plan of Palomar Health ii. Impact on patient and community outcome iii. Regulatory or accreditation requirements iv. Risk v. Number of services involved vi. Cost vii. Customer service viii. Employee engagement ix. Physician loyalty c. The performance improvement measures that reflect a direct contribution of Continuum of Care achieving quality patient outcomes are: i. Patient satisfaction ii. Employee safety issues: incident rate, experience modification factor, loss rate, biometric data, employee exposures and lost workdays iii. Patient safety issues including: pressure ulcers, patient falls, glycemic control and medication management iv. Physician loyalty B. Disaster Preparedness Committee (DPC): a. Duties: The District wide Disaster Preparedness Committee is responsible for ensuring disaster planning and disaster related activities are managed and implemented. It is the responsibility of the Emergency Management/Safety Program Manager to ensure meetings are scheduled and minutes taken. Information, progress notes and follow-up activities from this committee are reported to the Environment of Care Committee. i. Procedural development. ii. Disaster exercise design, planning, implementation, evaluation and follou up in accordance with current standards. Includes monitoring performance standards relating to staff performance during disaster exercises. iii. Monitoring and keeping an updated Inventory of Organizational Assets relating to disaster, which includes monitoring equipment purchases. iv. Keeping apprised of standards and regulations relating to disaster management. v. Updating the Emergency Operations Plan as needed. vi. Ensuring an annual evaluation of the Emergency Operations Plan is completed every 12 months. b. Composition: i. The Committee is composed of the Chair and Co-chair, Facilities, Risk Management, Security, Infection Control as well as representatives from the multidisciplinary team of healthcare professionals and ancillary departments. These professionals include but are not limited to Administration, and Nursing. c. Meetings: i. The DPC shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. C. Environment of Care (EOC) Committee: a. Duties: The District wide Environment of Care Committee is responsible for the design, implementation, and monitoring of the Safety Management and Injury/Illness Prevention Plans. The members review ongoing performance data related to the six management plans and the Emergency Operations Plan and identify performance improvement opportunities that are reported to the QMC and Board Quality Review Committee. Specific responsibilities include, but are not limited to the following: i. Procedures: The EOC Committee shall have the responsibility to develop and distribute and Environment of Care procedures that are to be reviewed as often as necessary, but not to exceed three years.
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ii. Programs/Plans: The EOC Committee is responsible for the development and monitoring of the Environment of Care management plans, Hazardous Materials and Waste program, Emergency Management program and the Illness and Injury Prevention program. iii. Environmental Surveillance: The EOC Committee is responsible for ensuring that environmental surveillance is completed in the clinical areas every six months, and non-clinical areas is completed every twelve months, and appropriate follow-though occurs. iv. Safety Education: The EOC Committee is responsible for the development and monitoring of new hire and Annual Reorientation for the Environment of Care, and other safety-related education as may be needed (based upon needs assessment, regulatory requirements, and / or results of surveillance or surveys / audits). v. Product Recall Monitoring: The EOC Committee shall monitor quarterly data relating to product and equipment recalls. vi. Regulatory / Accreditation Inspections: The EOC Committee shall monitor the results of regulatory and accreditation inspections, as it relates to the Environment of Care and ensure follow-up is in place. vii. Environment of Care Issues and Recommendations: The EOC Committee has the responsibility of analyzing issues in a timely manner. Recommendations are developed and approved as applicable. Recommendations for one or more performance improvement activities are communicated at least annually to the organization’s leaders. viii. Aggregate Data: The EOC Committee has the responsibility to aggregate data relating to information about hazards and safety practices used to identify safety management issues, records of required reporting to authorities; performance measures of processes and outcomes; and summaries of performance improvement actions. Aggregate data must include the following: a. Summaries of the deficiencies, problems, failures, and user errors in safety management, fire prevention management, equipment management and utilities management, as well as relevant published reports of hazards associated with any of these areas. b. Documented surveys, at least every six months for the clinical areas, and every twelve months for the non-clinical areas of the facility to identify environmental hazards and unsafe practices. c. Reports involving property damage, occupational illness or patient/personnel or visitor injury. d. Security incidents ix. Goals, Performance Standards/Thresholds. The EOC Committee has the responsibility of reviewing and approving goals, performance standards and thresholds on an annual basis, for the Environment of Care. b. Composition: i. The Committee is composed of the Chair and Co-Chair, Facilities, Risk Management, Security, Employee Health, Biomedical Engineering, EVS, Infection Control as well as representatives from the multidisciplinary team of healthcare professionals and ancillary departments. These professionals include but are not limited to Administration and Nursing. c. Meetings: i. The EOC Committee shall meet at least quarterly and/or as necessary and maintain a record of its proceedings. D. Nursing Leadership: a. Under the direction of the Chief Nursing Officers, and in collaboration with nursing management, the medical staff, and ancillary services, the Nurse Leadership Team promotes improvement in patient outcomes. Clinical and organizational decisions are based on data obtained through comprehensive and ongoing monitoring of patient
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outcomes. The Chief Nursing Officers at each facility are responsible for implementation of the performance improvement and patient safety programs at the unit and department levels. b. The ongoing monitoring and analysis of core indicators are based on identified patient outcomes that reflect a collaborative approach to quality care and patient outcomes. This will be demonstrated by: i. Use of evidence-based practice and data from internal and external sources to improve quality of care or resolve identified problems, e.g., falls, hospital associated pressure ulcer, and other Nursing Sensitive Indicators gleaned from National Database of Nursing Quality Indicators (NDNQI). See 8.b.v below ii. Integration and coordination of quality initiatives across inpatient, continuing care, home care, and outpatient clinic sites. iii. Facilitation of unit, department, and interdisciplinary performance improvement initiatives that impact patient care delivery. iv. Provision of education and/or consultation to internal and external clients regarding performance improvement and patient safety initiatives. v. Discussion and exchange of information regarding status and progress of evidence-based practice, performance improvement, and patient safety activities with the nursing staff, interdisciplinary teams, and interdepartmental teams. In compliance with established patient standards the following performance improvement activities will be measured and results compared to national bench marks including but not limited to the National Database of Nursing Quality Indicators (R) (NDNQI)TM, Hospital Compare.gov and BETA Healthcare Group. The performance improvement measures that reflect a direct contribution of nursing in achieving these quality patient outcomes include: (a) Patient safety issues: hospital acquired pressure ulcers, patient falls, glycemic control, vaccine administration, surgical site infections, central line blood stream infections, catheter associated urinary infection, ventilator associated events, and restraint utilization. (b) Patient experience: HCAHPS survey of patients as it relates to Communication of Nurses and other nursing functions. (c) Nursing Peer Review IV. METHODS: A. Understanding that performance improvement and patient safety permeate every level of the organization, the Palomar Health Leadership Team empowers and assigns individuals to lead these by providing time and resources to achieve optimal outcomes. B. Whenever possible, sound statistical methods and the techniques of continuous quality improvement will be utilized. In most projects a Plan-Do-Check-Act Cycle (PDCA) methodology model will be used. C. Prioritization: When selecting Quality Assurance Performance Improvement (QAPI) projects, Palomar Health leaders recognize the importance of using criteria to do ongoing prioritization of Quality Assurance Performance Improvement projects. Therefore, proposed projects will be assigned priorities and coordinated to avoid duplication of projects. D. Designing Processes: When creating or modifying programs and/or processes, consideration is taken to ensure the design: 1. Is consistent with the mission, vision, values, goals, objectives and plans; 2. Meets the needs of individuals served, staff and others; 3. Is clinically sound and current (for instance, use of best practice guidelines, successful practices, information from relevant literature, and clinical standards); 4. Incorporates available information from within the organization and from other organizations about potential risks to patients, including the occurrence of sentinel events in order to minimize risks to patients affected by the new or redesign processes, functions, or services; 5. Utilizes tools and methods to pro-actively identify risk points and eliminate them prior to implementing changes;
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6. Includes analysis and/or pilot testing to determine whether the proposed design/redesign is an improvement; and
7. Incorporates the results of Quality Assurance Performance Improvement activities.
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E. Data Collection: 1. Data is collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement and sustain improvement. Collected data is used to: a. Make comparisons of performance of processes and outcomes over time. b. Compare performance data about processes with information from up-to-date sources. c. Compare performance about processes and outcomes through the use of reference databases. 2. Data is collected on important processes and outcomes and includes, but is not limited to, key processes related to: a. Leadership priorities b. Patient Safety including staff c. Environment of care d. Patient Satisfaction e. Pain Management f. Medication Management g. Blood and blood products h. Restraint and seclusion i. Operative and other invasive procedures j. Resuscitation k. Risk Management l. Utilization of resources m. Quality Control n. Infection Control o. Autopsy p. Research when appropriate F. Benchmarks: Whenever available, benchmarks from local, state and national databases and medical literature will be obtained and used. Available benchmarking systems include but are not limited to: 1. The Joint Commission 2. Centers for Medicare & Medicaid Services (CMS) through HospitalCompare.Gov 3. Society of Thoracic Surgeons Cardiac Surgery Database 4. Center for Disease Control and Prevention (CDC) Database 5. National Database for Nursing Quality Indicators (R) (NDNQITM) 6. Office of Statewide Health Planning and Development (OSHPD) California State Hospital Discharge Annual Database H. Best Practice Core Measures: Proactively engaged with benchmarking systems performance through their involvement with The Joint Commission (TJC) and Centers for Medicare & Medicaid Services (CMS) in order to continuously seek out opportunities to improve our performance based on best practices, such as those promulgated by the National Quality Forum. I. Data Assessment: The data is organized for reporting purposes in a manner that allows for analysis of the results. Data is systematically aggregated and analyzed on an ongoing basis. 1. Aggregated data is analyzed to make judgments about: a. Whether design specifications for processes were met b. The level of performance and stability of important existing processes c. Opportunities for improvement d. Actions to improve the performance of processes e. Whether changes in processes resulted in improvement 2. Appropriate statistical techniques are used to analyze and display data. These techniques include, run charts, control charts, Pareto charts, and other statistical tools as appropriate. J. Failure Mode and Effects Analysis: Failure Mode and Effects Analysis (FMEA) involves the prospective evaluation of processes identified by the organization as being vulnerable to risk, and
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the re-design of such processes to build safety in (e.g., through creating redundancies) before an adverse event occurs. K. Root Cause Analysis (RCA): When a serious, unexpected adverse outcome or near-miss occurs, the RCA process may be used to determine the most basic or immediate factor(s) or causes of variation in performance which led to the adverse outcomes for the patient. This formal process is utilized to determine how the process(s) failed and where improvements need to be made. An action plan is then identified and monitored. See Near Miss, Adverse and Sentinel Event Investigation and Follow- Up. L. Improving and Sustaining Performance: Changes to improve performance are identified, planned, and tested using the PDCA Cycle Model. Effective changes are incorporated into standard operating procedure. M. Training and Education: Training and Education in performance improvement/patient safety is provided to every level of the organization. N. Communication: 1. Communication of Performance Improvement/Patient Safety activities throughout the Medical Staffs and Hospital Staffs occurs through a variety of means including: a. Through the QAPI Committee structure, e.g., the Board of Directors, Sub- Committees of the Board, Nursing Leadership and Medical Staff Committees. b. Through newsletters, memos, education programs, educational offerings, 2. A QAPI report is communicated to the Board of Directors, Patient Safety Committee and Clinical Leadership Committees according to the calendar of reporting approved by the BQRC annually. O. Confidentiality: 1. Data generated by the QAPI Program are considered to be products of the Quality Management Committee of the applicable health facility and are protected from discoverability under Section 1157 of the California Evidence Code. Practitioners and Palomar Health personnel have a duty to preserve this confidentiality. a. The performance improvement activities must abide by the Confidentiality of Medical Information Act in maintaining the confidentiality of the patient's medical information. Compliance is also maintained with all Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. P. Conflict of Interest: 1. A Practitioner may not participate in the review of any case in which he has been or anticipates being professionally involved. Practitioners having either a direct or indirect financial interest in the case(s) being reviewed may not participate in the utilization review activities pertaining thereto. Q. Annual Reappraisal: This QAPI plan is reviewed annually to evaluate the overall effectiveness considering such factors as results achieved, operational problems encountered, cost impact and deficiencies noted. The Plan with any amendments will be forwarded to the Board of Directors Quality Review Committee for final approval.
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V. PUBLICATION HISTORY:
Revision Effective Document Owner at Publication Version Notes Number Date 10 (this Valerie Martinez, Manager, Infection Annual review 2016 version) Prevention & Control, Dir Quality & Patient Safety 9 01/25/2015 Valerie Martinez, Manager, Infection Annual Review. Approved by BQRC Prevention & Control Dir, Quality & Jan.19th 2015 (Changes) Patient Safety 8 01/03/2015 Valerie Martinez, Manager, Infection Annual Review and update 2014 Prevention & Control Dir, Quality & Approved by EMT Safety and Service, (Changes) Patient Safety QMC and Board Quality 2014. 7 12/05/2012 Debbie Barnes Dir Regulatory Revised to reflect current practice. Coordination (Changes) 6 11/19/2012 Debbie Barnes Dir Regulatory Revise to reflect current practice Coordination (Changes) 5 03/27/2012 Debbie Barnes Dir Regulatory QMC February 2011 Coordination MEC PMC February 2011 (Changes) MEC Pomerado February 2011 4 04/25/2011 Debbie Barnes Dir Regulatory Add current attachments Coordination (Changes) 3 11/03/2006 Sonia Lopez Modified numerous areas.
(Changes) 2 02/16/2005 Patrick Correnti, RN, MSN Quality Annual review. Approved by PMC and Management Nurse POM Quality Management (Changes) Committees in December 2004. 1 12/10/2001 Patrick Correnti, RN, MSN Quality Previous Publication Date: 6/1/1998 Management Nurse (Changes) VI.
Reviewers Phillips, Donita Reinbold, Opal VI. REFERENCES:
Reference Type Title Notes Referenced Documents Near Miss, Adverse and Sentinel Event Near Miss, Adverse and Sentinel Event Investigation Investigation and Follow-up and Follow-Up Referenced Documents
Paper copies of this document may not be current and should not be relied on for official purposes. The current version is in Lucidoc at . https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:11234$10
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ADDENDUM F
100
M EMORANDUM
TO: Debbie Hollick, Executive Assistant to the Board
FROM: Tammy Chung, Assistant to the Board Community Relations Committee
DATE: May 25, 2016
RE: Board Community Relations Committee – May 4, 2016 Meeting Summary
INFORMATION ITEMS: The Committee discussed the Sponsorship Request Guidelines and Request Form distributed with the Board packet and requested that the Sponsorship Request Form be edited to require the requestor to provide measurable outcomes of their event/financial request.
Utilizing the presentation distributed with the Board packet, Jean Larsen provided a detailed presentation on Palomar Health’s naming opportunities, current naming plans and policy status. She will continue to rework and clean up the Naming Policy Lucidoc Policy 27932, specifically items III. B. and H. Jean Larsen will also provide a stewardship presentation at a future Board Community Relations Committee meeting.
Jean Larsen also distributed hard copies of the Palomar Health Foundation - Funds Transferred to Hospital Report for FY2016 Quarter 3: 1-1-16 to 3-31-2016 report to the Committee.
Utilizing the power point presentation distributed with the Board packet, Debby Clark, Director of Marketing and Marketing Managers Bobette Brown, Chris Saunders and Pia Mangini provided a detailed overview of the Marketing Department.
Follow up to the February 3, 2016 Committee request, Della Shaw presented an updated/detailed Palomar Health Service Area map incorporating additional cities such as Sabre Springs, Carmel Mountain Ranch and 4S Ranch.
ACTION ITEMS: 1. Minutes – Wednesday, March 2, 2016: Approved as submitted
2. The Bylaws of Palomar Health - 6.2.6 Community Relations Committee: Reviewed, approved as submitted, and will be forwarded to the Full Board for approval once the Board Governance Committee has completed its global bylaws review/revision.
101
Memorandum
TO: Debbie Hollick, Executive Assistant to the Board FROM: Jeff Griffith, Chair, Board Governance Committee
DATE: Thursday, May 19, 2016 RE: Board Governance Committee – May 2, 2016 Meeting Summary
INFORMATION ITEMS:
Palomar Health Bylaws Review – Articles 1 – 5: Committee commenced PH bylaws review / update with Articles 1-5. Will review Articles 6 and 7 at June 6th meeting.
ACTION ITEMS:
Minutes, Monday, March 7, 2016: Approved by committee
Revision of Lucidoc Policy 21805 – Compensation of Board Members: Committee reviewed policy and revised section III. Text / Standards of Practice. Legal Counsel conferring with HR re: pertinent policy data. Once received, revised policy will then be brought to full board for final ratification.
102 M EMORANDUM
TO: Debbie Hollick, Executive Assistant to the Board FROM: Beverly Albers, Assistant to the Board HR Committee DATE: Wednesday, May 18, 2016 RE: Board HR Committee – May 17, 2016, Meeting Summary
INFORMATIONAL ITEMS: Palomar Paws Unite: In conjunction between Fran Waller, Palomar Health’s Director of Community Engagement and Volunteer Development, and three Del Lago scholars, this recently developed this program which will aid in the healing of long term patients by lowering stress levels by reuniting them with their canine from home. There is a protocol for each situation, and the pet must be screened for suitability which includes cleanliness, medical condition and current shot record, and the pet’s emotional stability. This program should also alleviate individuals sneaking pets in to visit patients. LEAP: There has been high praise from the participants of this new program which has been designed to improve the managerial skills of Palomar Health’s leaders. There are three parts to this program: 1) a 2-1/2 day program for entry level managers which should be completed within a year of attaining their management position (with their divisional leader’s direction on timing); 2) a one day class for middle and upper level leadership with contains abridged content and coaching support for managers reporting to them; and, 3) the LEAP Hour which provides information for executive leaders on the program. Thus far, approximately 60% of leaders have participated and classes are regularly being added to the class calendar. LEAP Upskilling is also being attended, however, some managers are choosing to take the full LEAP course instead. Internal Communications: With the previous Employee Survey having been conducted in 2010, the one executed in 2016 has given solid results. In this new survey, there were 909 responders of which 81% were staff. 57% of those were clinical employees and over three quarters of the count were from the hospitals. Over 80% indicated that they feel they are being sufficiently informed about what is going on at Palomar Health. Over 90% felt the information was useful, and that the information being disseminated was through the best channels. Topics preferred were education, benefits, events, organizational updates, as well as messaging from the CEO. IT Education Update: The IT Educators have had a successful year through the creation and updating of classes for staff. Even with the update to ICD-10, their mission critical work of reducing the hassle factors to improve the ease of practice, increasing EHR adoption and utilization, and improving revenue through better documentation, has been a success. In the course of this last year, clinical electronic documentation has increased by approximately 10%. Also, a dedicated WiFi network for physicians has been implemented; a rehab project included conversion of PT/ST/OT for IP and OP notes conversion to electronic format, and Quality mPage for Infection Control and Readmission Criteria has been included. Project support in the near future will include Sepsis updates; Glycemicare; the PHDC OB transition; and, discharge FMEA (medical reconciliation compliance).
103
MEMORANDUM
TO: Debbie Hollick, Executive Assistant to the Board
FROM: Jerry Kolins, MD, Vice President, Patient Experience
DATE: May 19, 2016
RE: Board Quality Review Committee – May 16th Meeting Summary
INFORMATION ITEMS: The Committee discussed the Journal Club article entitled, “Era 3 for Medicine and Healthcare” by Don Berwick, MD. Jerry Kolins, MD, Vice President, Patient Experience shared an email from Amanda Holden, MD regarding the changes she made to her rounding methods and practices. These changes were due to the information she learned at a recent Patient Experience meeting where Christy Dempsey, SVP and CNO of Press Ganey, spoke about Compassionate, Connected Care. Tina Pope, Manager, Service Excellence presented the FY2016 Q3 results from Press Ganey and HCAHPS. Tina also shared data with the Committee about the number of compliments, grievances and complaints received during the month of March 2016. Tina and Maria Sudak, Chief Nursing Officer and Interim Vice President of Palomar Medical Center shared the outcomes from the recent Deep Dive meetings that took place in April and May. Russ Riehl, Director, Employee and Corporate Health gave a presentation to the Committee about Employee Safety. A Workers Compensation Trend Analysis reviewing the claims filed by employees, their frequency and severity were discussed. The Committee recommended and approved ongoing, quarterly reporting by Employee/Corporate Health to the Quality Review Committee, as well as the full Board of Directors.
ACTION ITEMS: Donita Phillips, Director, Risk Management, provided a quarterly report of risk management activities as well as a review of the Open Claims Loss Run Report. This report will now go to the full Board of Directors for their review. Jerry Kolins, MD, Vice President, Patient Experience shared with the Committee that the Patient Safety and Quality Performance Improvement Plan has been renamed to “Quality Assurance Performance Improvement Plan” and was rewritten and updated to reflect current processes and regulatory requirements. The Committee approved the newly named plan which will now go to the full Board of Directors for final approval.
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