Highland Hospital, John George Psychiatric Hospital, Fairmont Hospital, Ambulatory Wellness Medical Staff Medical Executive Committee (MEC) Report to the Quality Professional Services Committee of the Board March 28, 2019 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows: 4 Initial Appointments 18 Reappointments 2 Proctoring Activity 2 Leave of Absence / Staff Status Change 6 Additional Privilege Request/Staff Status 9 Voluntary Resignations 1 vRad Proctoring Activity Medical Staff Provider Clinical Privileges (Exhibit 1) The following privilege form and multi-facility privilege form were approved. Clinical Nurse Midwife OB/GYN Multifacility Provider Education Competency Module 2019 (Exhibit 2) The 2019 provider education competency module was approved which incorporates the 2019 Joint Commission National Patient Safety Goals and other regulatory requirements. B. Professional Services/ Contracting The non-physician contracts report was approved. C. Quality and Outcomes Wings (A&B) Seismic Update o Assessment of the buildings against the building code requirements o Concerns were expressed regarding the lack of engagement by the County regarding maintaining the integrity of the building Surge Report for “Surge Red”/Patient Flow o Performance presented; question raised about occupancy triage beds in the ED. More data is needed True North Metric Dashboard March o Highest patient satisfaction scores we have seen o Quality efforts continue to improve patient care SAPPHIRE Report – Electronic Health Record o Training sessions are ramping up over the next four months Page 1 of 2 Alameda Health System MEC Report to the Board of Trustees March 28, 2019 D. Other Issues AHS and SLH Medical Staff Merger o Medical Executive Committee from the Core and San Leandro have reached an agreement and are prepared to move forward with Bylaws revisions. Medical Staff Medical Executive Committee (MEC) Report to the Quality Professional Services Committee of the Board March 28, 2019 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows: • 7 Initial Appointments • 2 Temporary Privileges • 11 Reappointments • 4 Proctoring Activity • 1 Additional Privileges and/or Staff Status Requests • 3 Voluntary Resignations • 1 Proctoring Activity Additional Credentialing Actions: Medical Staff Provider Clinical Privileges (Exhibit 1) The following multi-facility form was reviewed and approved. This privilege form will be used for providers who apply for clinical privileges at Alameda Hospital and/or Alameda Health System. • OB/GYN Multifacility Provider Education Competency Module 2019 (Exhibit 2) The 2019 provider education competency module was approved. B. Professional Services/Contracting The Non-physician contracts report was presented. C. Quality and Outcomes True North Metric Dashboard March • Overall performance is at 75%; QIP goal is 98.29% - 100% o Incrementally meeting goals and achieving metrics • PRIME and QIP measures are all at or above goal Specialty Coverage • Neurology o Stroke Diversion 3/15/19 – 3/25/19 o Phone coverage from Highland Neurologist o Stabilization needed of the Stroke Program • Gastroenterology o System level solution being explored for coverage and care o Request shorter term solution to expand the call coverage with other GIs on staff Page 1 of 2 MEC Report to the Board of Trustees March 28, 2019 • Cardiology o AH physician is retiring July 1st • Hospitalist o Contracting group is recruiting D. Other Issues System transfers from Highland to Alameda Hospital • Expand the process and workflows for all transfers; including other non-AHS hospitals o Centralize the process local and communication o Remove burden from the physicians • Transfers are occurring to the Hospitalists beyond the CAP • Reports that there are continued issues with the process • Transfers for ERCP procedures from SLH; we are the only facility that does ERCPs o Recommendations to look at this information • Epic transfer modules will be reviewed for optimization Chief Operating Officer / Patient Care Services Report • Report on the January 2019 Financial expenses o Expenses are well managed and out performance is within target o Project meeting EBITA target this fiscal year • FY20 Budget is being worked on at this time o Final budget May 28th o Gap of $100,000,000 being driven by the following: . Total revenue is going down in supplemental programs . GME funding is reduced o Leadership is looking at areas to revisit and close the gap while supporting mission o Capital equipment o $120M in liabilities in the balance sheet that are due by December 2019 • Facility specific projects were provided • Upcoming community events were shared Sapphire Project • Updates were shared on training, testing, order sets Medical Staff Medical Executive Committee (MEC) Report to the Quality Professional Services Committee of the Board March 28, 2019 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows: • 3 Initial Appointments • 2 Reappointments • 4 Proctoring Activity • 3 Resignations • 1 vRad Proctoring Activity Provider Education Competency Module 2019 (Exhibit 2) The 2019 provider education competency module was approved which incorporates the 2019 Joint Commission National Patient Safety Goals and other regulatory requirements. B. Professional Services/Contracting The Non-physician contracts report was presented. C. Quality and Outcomes • The FY 2019 True North Metric Dashboard reviewed; San Leandro Hospital is doing well on the FY19 YTD quality pillars • Public Hospital Redesign and Incentives in Medi-Cal (PRIME) and Quality Improvement Programs (QIP) and the 9 metrics that are being monitored were presented o Our dashboard for February demonstrates 42 PRIME metrics were green, March 43. February 14 QIP green, in March 15 are green • Patient Experience is focusing on implementation of G.I.F.T. (greet, introduce, for, thank) which aims to improve communication amongst staff and patients D. Other Issues • Case Management and Social Services o Concerns were raised regarding understaffed and we are/ may be losing some extremely skilled and competent staff as a result. o CM leadership is focusing on recruiting, developing skillsets of the team, and relationship building. Page 1 of 2 MEC Report to the Board of Trustees March 28, 2019 • San Leandro medical staff integration with the Alameda Health System medical staff Bylaws Revision(s) o We have come to an amicable agreement with AHS medical staff leadership on representation of SLH medical staff on the AHS MEC. We continue to work with AHS medical staff leadership to revise the AHS Bylaws. • SAPPHIRE Report o Go-live will be focused on patient safety and care of the patient o Project Process including the training, testing of charges, orders and documents is underway, go-live decisions for the EHR inbasket Chief Operating Officer / Patient Care Services Report • Report on the January 2019 Financial expenses o Total Expenses under budget o Project meeting EBIDA target this fiscal year • FY20 Preliminary Budget efforts underway to achieve the final budget date of 5/28/19 o Gap of $100,000,000 being driven by the following: . Significant reduction in supplemental revenues/programs . Legislative changes are impacting us i.e. $14million in Medicare GME funding . Operating expenses in labor are increasing within MOU agreements • Facility specific acute rehab project o Project tracking toward completion by June 30, 2019 o Planning continues for move and licensing process o Projected Move–in, November 2019 • Alameda Health System Foundation is supporting fundraising for capital equipment Mammography o $300,000 funding received for new digital mammography; completion 2/2020 Fundraising continues for the following: o 2 Mobile X-rays o Fluoroscopy Equipment o Nuclear Medicine Equipment • Blue Cross contract negotiations are be actively worked on. • Concerns were raised regarding ambulance diversion of patients who reside in the community to other facilities. • Emergency Medicine Department Report o Team from Stanford, CHO and EMS was on site 3/14/19 to assess SLH preparedness for pediatric emergencies, including staffing and equipment – part of Alameda County Disaster Preparedness efforts and ultimately assign designations for hospital EDs (assessment will affect ambulance traffic) o The newly added clinical nurse supervisor roles in the ED have been helpful. There continues to be concerns regarding staffing shortages in the ED resulting in closure of 4 ED beds for up to 8 hours per day. This ultimately impacts patient throughout and flow in the ED. Page 2 of 2 Certified Nurse Midwife - MCH - AHS Delineation of Privileges Applicant's Name: Instructions: 1. Click the Request checkbox to request a group of privileges such as Core Privileges or a Special Privileges. 2. Uncheck any privileges you do not want to request in that group. 3. Check off any special