Minutes. Chris Hammond, Vice Chair Liz McCarty, Member Ryan Winkle, Member excused himself at 6:19 p.m.

Transcription

1 Minutes Maricopa Health Centers Governing Council Compliance and Quality Committee Maricopa Medical Center Maricopa East and West Rooms June 11, :00 p.m. Voting Members Present: Eileen Sullivan, Chair Chris Hammond, Vice Chair Liz McCarty, Member Ryan Winkle, Member excused himself at 6:19 p.m. Non-Voting Members Present: Barbara Harding, Chief Executive Officer, Maricopa Health Centers Governing Council Linda Ross, Director of Ambulatory Operations arrived at 5:09 p.m. LT Slaughter, Chief Compliance Officer participated telephonically Non-Voting Members Absent: Crystal Garcia, VP of Quality Management & Patient Safety Kevin Lopez, M.D. Medical Director, Ambulatory Services Recorded by: Melanie Talbot, Chief Governance Officer Call to Order Chairman Sullivan called the meeting to order at 5:03 p.m. Roll Call Ms. Talbot called roll. Following roll call, it was noted that all four of the voting members of the Maricopa Health Centers Governing Council s Compliance and Quality Committee were present, which represented a quorum. For the benefit of all participants, Ms. Talbot named the individuals present in the meeting room as well as those participating telephonically. She asked any presenters and speakers to announce themselves prior to speaking. Call to the Public Chairman Sullivan called for public comment. There were no comments from the public. General Session, Presentation, Discussion and Action: 1. Approval of Consent Agenda: i. Approve Compliance and Quality Committee meeting minutes dated December 14, 2017 Vice Chairman Hammond moved to approve the consent agenda. Ms. McCarty seconded. Motion passed by voice vote.

2 2. Discuss and Review the Community Needs Assessment for the Federally Qualified Health Center Look-Alike Clinics Service Area Ms. Harding said that a community needs assessment should be completed at minimum every three years. The assessment was a compilation of information about Maricopa County and the community Maricopa Integrated Health System (MIHS) served. It contained information about the gender, age, race, ethnicity, education attainment, veteran status, and income levels of Maricopa County s population. The assessment provided an overview of MIHS contained select MIHS Uniform Data System (UDS) Reports that were submitted to Health Resources and Services Administration (HRSA) for calendar year Information for creating the UDS Report was gathered from Electronic Health Records (EHR). The UDS Report was a reflection of the patients served and services provided. MIHS was required to submit a UDS Report to HRSA every year. Ms. Harding reviewed the income levels of MIHS s patients during the reporting period. Of the 90,661 patients seen, income information was not gathered for 55,398 patients. Its critical to understand the poverty level of patients. She will work with the patient registration staff to do a better job of gathering that information from patients. Mr. Winkle asked if the 55,398 patients whose income level was unknown had a payor source. Ms. Harding noted that payor source did not equate to poverty levels. Payor source meant how the patient as covered for health insurance i.e. Medicare, Medicaid, commercial insurance, no insurance, etc. Poverty level was a patient s income. Ms. Ross added that income levels were usually determined when a patient was screened for eligibility for Arizona Health Care Cost Containment System (AHCCCS), a sliding fee discount, or for other government assistance. However, patients can refuse to disclose that information. Mr. Winkle asked if all patients were screened for some sort of financial assistance. Ms. Ross clarified that if a patient was interested in a sliding fee discount that did not necessarily mean that the patient did not have insurance. However, if a patient was screened for eligibility for a sliding fee discount, it would behoove staff to also screen the patient for other programs that might be available to the patient, such as AHCCCS. Ms. Harding reiterated that the UDS Report generated using information gathered from EHRs. Information was gathered on select diagnoses of patients and services rendered to patients, such as the number of patients diagnosed with diabetes, hypertension, as being overweight, etc. That information would be used when determining priorities and strategized for the future. The UDS Report also contained data on preventative services rendered during calendar year 2017 such as smoking cessation counseling. Ms. Sullivan asked if MIHS s patient population was similar to other valley Federally Qualified Health Centers. The number of patient diagnosed with diabetes, hypertension and obesity seemed to be high. Ms. Harding noted that there were opportunities for improvement. She added that MIHS was the largest FQHC in Maricopa County so there may not be a similar comparison. Ms. Harding reviewed each FQHC Look-Alike Clinic s Health Professional Shortage Area (HPSA) score for primary care, dental and mental health. HPSAs are federal designations that apply to areas, population groups or facilities in which unmet healthcare needs are present. Ms. Harding reviewed the results of the patient health needs surveys for each FQHC Look-Alike Clinic. Each Clinic had to have a minimum of 50 surveys completed. Surveys were available in English and in Spanish. Patients were asked 14 questions about their health and health care needs. 2

3 2. Discuss and Review the Community Needs Assessment for the Federally Qualified Health Center Look-Alike Clinics Service Area, cont., Some of the questions on the survey included: how would you describe your overall health; can you get an appointment when you need it; if the clinic hours met your needs; the top three health challenges that you face; etc. Ms. Harding reviewed the compilation of the results for all FQHC Look-Alike Clinic combined. She reviewed the results for the question please select the top three health challenges you face. The top three responses were high blood pressure/stroke (14%), pain (12%) and none (13%). She was surprised by pain being one of the top three health challenges of MIHS s patient population. It could be a reflection of chronic disease, the need for palliative care or stress which could generate pain. That would need to be further explored. Patients were also surveyed about their access to care. Seventy-six percent indicated that the current clinic hours met their needs, however, five percent preferred Saturday morning, and three percent preferred Sunday morning. Ms. Harding said the second step of the needs assessment was understanding the information and using it to make decisions on services to provide and when making decisions on the locations and hours of operation of the clinics. 3. Discuss, Review and Make Recommendations to the Maricopa Health Centers Governing Council to Accept the 2017 Uniform Data System Submission to Health Resources and Services Administration Ms. Harding reiterated that the UDS Report was generated from information contained in MIHS s patients EHRs. It also contained information about patients gender, age, race, ethnicity, sexual orientation, geographic location, income levels, and medical insurance. Ms. Harding reviewed the quality of care measures that HRSA required be tracked. She suggested that the Governing Council mirror the same measures for quality of care. She then went through the health outcomes and noted that over 7,000 of MIHS s Hispanic/Latino population between the ages of 18 and 85 had hypertension. Almost 6,100 Hispanic/Latino patients had diabetes. This information could help understand what the needs of the patients were in order to help improve health outcomes. Ms. McCarty moved to make a recommendation to the Maricopa Health Centers Governing Count to accept the 2017 Uniform Data System submission to Health Resources and Services Administration. Mr. Winkle seconded. Motion passed by voice vote. 4. Discuss the Quality Dashboard for the Federally Qualified Health Centers Look-Alike Clinics Ms. Harding advised the Committee that she would bring a revised dashboard to the Committee at its next meeting. 5. Discuss, Review and Make Recommendations to the Maricopa Health Centers Governing Council to Approve the Calendar Year 2018 Primary Care Ambulatory and Physician Services Quality Improvement Plan for the Federally Qualified Health Center Look-Alike Clinics The proposed Quality Improvement Plan laid out the Governing Council s responsibility for the quality of care given at the FQHC Look-Alike Clinics. The Plan also listed the responsibilities of the Compliance and Quality Committee. 3

4 5. Discuss, Review and Make Recommendations to the Maricopa Health Centers Governing Council to Approve the Calendar Year 2018 Primary Care Ambulatory and Physician Services Quality Improvement Plan for the Federally Qualified Health Center Look-Alike Clinics, cont., Service area Quality Improvement (QI)Teams would be responsible for the quality improvement work plans; Medical QI Team, Dental QI team and the Dental QI Team. Having representatives from across the organizational structure ensures system wide accountability and communication. Ms. Sullivan commented that she was pleased that dental was included because that service line had not been included in prior quality plans. Ms. McCarty noted MIHS s Values listed in the Plan one of which was Compassion. The statement that supported that value read the We demonstrate sensitivity to our patients and each other by offering emotional, spiritual, cultural and physical support. She asked for clarification on how spiritual support was provided to patients. Ms. Harding stated that chaplain services were offered at Maricopa Medical Center. Ms. McCarty moved make recommendations to the Maricopa Health Centers Governing Council to approve the Calendar Year 2018 Primary Care Ambulatory and Physician Services Quality Improvement Plan for the Federally Qualified Health Center Look-Alike Clinics. Mr. Winkle seconded. Motion passed by voice vote. 6. Discuss and Review the Federally Qualified Health Centers Look-Alike Clinics Quarterly Compliance Report Mr. Slaughter reviewed results from fiscal year 2018 Health Insurance Portability and Accountability Act (HIPAA) and Compliance Training. As of June 4, 2018, 82% of MIHS employees completed the training, 100% of the MIHS medical residents completed training, 62% of the District Medical Group (DMG) providers completed training and only 45% of the DMG contracted providers completed the training. The goal was to be at 100% compliance by June 30, Ms. Sullivan asked why only 82% of employees had completed the training. Mr. Laughter explained that the training began in February 2018 and that employee had until June 30, 2018 to complete the training. Ms. McCarty asked the difference between DMG providers and DMG contracted providers. Mr. Slaughter said that DMG contracted providers were independent contractors and were contracted with DMG, however, they were not DMG employees. Ms. McCarty asked what more Maricopa Integrated Health System could do to ensure that District Medical Group providers and contracted providers completed the training in a timely manner. Mr. Slaughter explained that the best way was through constant reminders. Vice Chairman Hammond asked if the training needed to be completed every year. Mr. Slaughter confirmed that it was annual training that needed to be completed each fiscal year. Mr. Slaughter reviewed the Ethics Line report which showed that there were 15 cases fiscal year-to-date. All 15 cased were reported using the anonymous Hotline. Of the 15 cases reported, nine of them were just in the fourth quarter of the 2018 fiscal year (April 1 to June 30). The average number of days to close a case was 31. 4

5 6. Discuss and Review the Federally Qualified Health Centers Look-Alike Clinics Quarterly Compliance Report, cont., Thirteen cases were closed and 2 were still open. The report broke down each case by issue type including patient care, billing or coding issues, HIPAA, patient s rights, environment/health/safety, etc. Actions taken as a result of the issues included disciplinary action, verbal warning, training, coaching, written warning, or no action was needed. Ms. Sullivan asked why it took 31 days to close a case. Mr. Slaughter remarked that 30 days was best practice and was what to be expected. Once a case wa reported, the Compliance Department staff began the investigation. It was common to have other departments get involved in a case as part of the investigation. The other departments may have to research the case. If disciplinary action was needed as a results of the investigation, the HR Department would have to get involved too. Ms. Sullivan questioned why two cases were still open. Mr. Slaughter noted that those cases were just recently opened. Ms. Sullivan asked about the various alert levels; green, yellow and red. Mr. Slaughter commented that cases were rated with red being serious. A green rating could indicate that it was a frivolous complaint such as an employee complaining that the cafeteria didn t offer a certain coffee brand. A red rating was serious such as an allegation of unfair labor practices or patient privacy. Ms. Sullivan noticed that in the first quarter of the fiscal year, there were no cases reported, in the second quarter there were two cases reported and it kept doubling each quarter with nine cases reported in the fourth quarter, which wasn t over yet. She asked about the rise in issues reported. Mr. Slaughter attributed it to effective compliance training. Of the 15 cases, four were categorized as other. Ms. Sullivan asked what would be considered as other, especially given that the other category had the greatest number of cases. Mr. Slaughter said that he would provide the breakdown to the Committee. Mr. Slaughter reviewed the Compliance Plan and the Internal Audit Plan for the FQHC Look-Alike Clinics. He noted that he would present the fiscal year 2019 FQHC Look-Alike Risk Assessment Process, Compliance Plan and Internal Audit plan for the Committee s review and approval in July Chair and Committee Member Closing Comments/Announcements Ms. Sullivan thanked Ms. Harding and Mr. Slaughter for all of the information provided to the Committee and for their hard work. 8. Review Staff Assignments Ms. Talbot reviewed the outstanding old business including the corrections to the quality dashboard, provided a breakdown of the CGCHAPS and Connect scores. In July, Mr. Slaughter will present the fiscal year 2019 FQHC Look-Alike Risk Assessment Process, Compliance Plan and Internal Audit plan. 5

6 Adjourn Ms. McCarty moved to adjourn the June 11, 2018 Compliance and Quality Committee meeting. Vice Chairman Hammond seconded. Motion passed by voice vote. Meeting adjourned at 6:45 p.m. Melanie Talbot Chief Governance Officer 6