Board of Directors Formal Meeting. March 24, :00 PM. Agenda

Transcription

1 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, :00 PM Agenda

2 Board Members William Bruno, Chair, District 1 Susan Gerard, Vice Chair, District 3 Greg Patterson, District 2 Elbert Bicknell, District 4 Alice Lara, District 5 AGENDA Formal Meeting Board of Directors of the Maricopa County Special Health Care District Maricopa Medical Center Administration Building Auditoriums 1 and E. Roosevelt Phoenix, AZ Clerk s Office Fax Wednesday, March 24, :00 p.m. If you wish to address the Board, please complete a speaker s slip and deliver it to the Clerk of the Board. If you have anything you wish distributed to the Board and included in the official record, please hand it to the Clerk who will distribute the information to the Board Members and Maricopa Integrated Health System Senior Staff. Speakers are limited to (3) three minutes. (NOTE: One or more of the members of the Board of Directors of the Maricopa County Special Health Care District will attend either in person or by telephone conference call.) Pursuant to A.R.S (A)(3), or any applicable and relevant state or federal law, the Board may vote to recess into an Executive Session for the purpose of obtaining legal advice from the Board s attorney or attorneys on any matter listed on the agenda. Pursuant to A.R.S (A)(4), or any applicable and relevant state or federal law, the Board may vote to recess into an Executive Session for the purpose of consulting with its attorneys to consider its position and instruct its attorneys regarding the Board s position regarding any contracts that are subject to negotiations, in pending or contemplated litigation, or in settlement discussions conducted in order to avoid or resolve litigation, and that are listed on the General Session agenda for discussion or action or both. The Board also may wish to discuss any items listed for Executive Session discussion in General Session, or the Board may wish to take action in General Session on any items listed for discussion in Executive Session. To do so, the Board will recess Executive Session on any particular item and reconvene General Session to discuss that item. THE TIMES LISTED FOR AGENDA ITEMS ARE ESTIMATED. ITEMS MAY BE DISCUSSED EARLIER OR IN A DIFFERENT SEQUENCE. Call to Order Roll Call Pledge of Allegiance Agendas are available within 24 hours of each meeting in the Clerk of the Board s Office, Maricopa Medical Center, Administration Bldg, 2 nd Floor 2601 E. Roosevelt, Phoenix, AZ 85008, Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. Accommodations for individuals with disabilities, alternative format materials, sign language interpretation, and assistive listening devices are available upon 72 hours advance notice through the Clerk of the Board s Office, Maricopa Medical Center, Administration Bldg, 2 nd Floor 2601 E. Roosevelt, Phoenix, Arizona 85008, (602) To the extent possible, additional reasonable accommodations will be made available within the time constraints of the request. 3/18/2010 9:50 AM

3 Call to the Public This is the time for the public to comment. The Board of Directors may not discuss items that are not specifically identified on the agenda. Therefore, pursuant to A.R.S (H), action taken as a result of public comment will be limited to directing staff to study the matter, responding to any criticism or scheduling a matter for further consideration and decision at a later date. G eneral Session Presentation, Discussion and Action: 1. Opening Comments and Remarks from President & Chief Executive Officer 15 min Donation from Marisol Credit Union to the Pediatric Fund of the Maricopa Health Foundation Summary of Current Events o Update on accrediting bodies standards o Update on Arizona Department of Corrections numbers Betsey Bayless, MIHS, President & Chief Executive Officer 2. Reports to the Board of Directors: 5 min a. Report on MIHS Urgent Care Center s Viability b. Report on Success of MIHS Marketing Campaign c. Patient Account Write-Offs Under $500, Approval of Consent Agenda 15 min (total consent) Note: Approval of contracts, minutes, IGA s, proclamations, etc. Any matter on the Consent Agenda will be removed from the Consent Agenda and discussed as a regular agenda item upon the request of any Board member. a. Minutes: Review and Approve Special Health Care District Board of Directors Meeting Minutes dated: i. February 4, 2010 Special Meeting ii. February 24, 2010 Formal Meeting iii. March 11, 2010 Special Meeting b. Contracts: i. ii. iii. iv. Approve amendment No. 1 to the Behavioral Health Network Facility Participation Agreements (C and C ) between United Behavioral Health, Inc. and Maricopa County Special Health Care District dba Maricopa Integrated Health System for new per diems and rates. Approve a new contract (C ) between District Medical Group (DMG) and Maricopa County Special Health Care District dba Maricopa Integrated Health System (MIHS) for Medical Director Resuscitation Education. The initial contract term is from January 1, 2010 to December 31, The anticipated fiscal year budget impact is $55,000 for FY 2010 and $110,000 for FY Approve amendment No. 1 to the Contract (C ) for Professional Services between District Medical Group (DMG) and the Maricopa County Special Health Care District dba Maricopa Integrated Health System (MIHS). Approve Amendment No. 2 to the Contract (C ) for Health Plan Administrative Services Between Maricopa County Special Health Care District and University Physicians Healthcare (UPH). v. Approve Amendment No. 2 to the Lease (C ) between MIHS, as Lessor, and MedPro, as Lessee, for space at MIHS Facilities. 2

4 General Session Presentation, Discussion and Action (cont.): c. Board Governance: i. Approve registration fee, travel, lodging, and meal expenses, not to exceed rates allowable under applicable District practices or policies, for Chairman Bruno to attend The 14 th Annual Western Regional Trustees Symposium in Denver, Colorado June 9-11, ii. iii. Approve travel, lodging, and meal expenses, not to exceed rates allowable under applicable District practices or policies, for Vice Chairman Gerard to attend The Governance Institute s Leadership Conference, in Ashville, North Carolina, May 16-19, NOTE: Registration fee for this conference was waived. Approve travel, lodging, and meal expenses, not to exceed rates allowable under applicable District practices or policies, or Ms. Talbot, Clerk of the Board, to attend the International Institute of Municipal Clerk s 64 th Annual Conference, in Reno, Nevada, May 23 27, d. Medical Staff: i. Approve Revisions to Basic and Advanced Trauma Surgery Privileging Criteria ii. Approve Ongoing Professional Practice Profiles for Emergency Medicine End of Consent Agenda 4. Approval of Maricopa Integrated Health System Medical Staff Appointments, Reappointments, FPPE, Change of Privileges/Status, and Resignations for March min Carol Olson, M.D., MIHS, Chief of Staff 5. Approval of Maricopa Integrated Health System Allied Health Professional Staff Appointments, Extensions, Reappointments and FPPE for March min Carol Olson, M.D., MIHS, Chief of Staff 6. Presentation on Performance Improvement and Quality Management 15 min Sherry Stotler, MIHS, Chief Nursing Officer Dan Hobohm, M.D., MIHS, Vice President of Quality and Outcomes Management 7. Discuss and Review February 2010 MIHS Key Indicator Dashboard 15 min MIHS Senior Administration 8. Annual Review of Board Policy Statements; Discuss, Review and Approve Proposed Revisions to the Following Existing Board Policy Statements: 15 min a. Financial Records b. Financials Reports c. Internal Audit d. Investment of Funds e. Revenue Contracts-Medical Services f. Fiscal Responsibility-Financial Planning Guidelines g. Selection of Auditors h. Depositories i. District Treasurer j. President & Chief Executive Officer Evaluation Melanie Talbot, MIHS, Clerk of the Board 3

5 General Session Presentation, Discussion and Action (cont.): 9. Discuss, Review and Approve the MIHS Rate Package for Fiscal Year min Siobhan Mee, MIHS, Director Revenue Management 10. Discuss, Review and Approve Fiscal Year 2011 Budget Parameters: 10 min Preliminary Volumes, Reimbursement and Expense Assumptions; and Cash Goals for Maricopa Integrated Health System and the Maricopa Health Plan Ken Meinke, MIHS, Chief Financial Officer 11. Discuss, Review and Approve the District s Position Regarding Current or Proposed State and Federal Legislative Items 15 min Michael Fronske, MIHS, Legislative and Governmental Affairs Director 12. Concluding Items 10 min a. Future Agenda Item/Report Calendar i. April a. Quarterly Reports: Quality- Whole Systems Measures Dashboard Capital Expenditures Contract Approvals and Asset Disposal President & CEO Goal Attainment for FY 2010 b. Other: Graduate Medical Education Report Match Week Results Employee Medical and Dental Benefits Package District Procurement Code Update on FY 2011 Budget process; Changes in assumptions: Volume, Reimbursement, Expenses Legislative Issues Review Analysis of Claims Information ii. May a. Quarterly Reports: Patient Satisfaction Survey Results - 1 st Quarter CY 2010 Quality - Whole Systems Measures Dashboard Compliance Officer s Report Internal Auditor s Report Performance on Investment of Funds Report on Maricopa Foundation Activities b. Other: Presentation on Nursing and Patient Services Quality of Contract Review Report from Audit and Compliance Committee Maricopa County Treasure s Activities Report for District Transactions Approve FY 2011 Capital Budget Update on FY 2011 Budget process; Significant Changes in assumptions: Volume, Reimbursement, Expenses Legislative Issues b. Board Member Requests for Future Agenda Items or Reports c. Chairman and Member Closing Comment Adjourn 4

6 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 1. No Handout

7 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 2.a. No Information Available at This Time

8 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 2.b. Additional Information Presented at Meeting

9 MIHS MARKETING CAMPAIGN RECAP MARKETING OBJECTIVES Increase awareness of MIHS among the prospective patient community Emphasize the excellent quality of care and the high level of expertise of MIHS physicians and staff Increase visits to MIHS facilities and family health centers MEDIA OBJECTIVES Provide geographically targeted solutions to reach the local community surrounding the hospital and clinics Reach the target audience effectively and efficiently TARGET AUDIENCE Phoenix residents with households near the MIHS facilities and family health centers. CAMPAIGN DETAILS AND RESULTS Media Mix: Hispanic radio and Geo-targeted outdoor Total Ad Spend: $123,360 Total Impressions: 21,767,836 Cost Per Thousand: $5.67 Volume: A comparison of pre-marketing campaign volume at the FHCs during October-January to the same time period in shows a 7.3 percent increase. Individual FHCs targeted by the most outdoor advertising, including 7 th Avenue, Sunnyslope and McDowell, also showed growth during the same time periods: Oct08-Jan09 Oct09-Jan10 % Growth S. Central 4,797 5, % 7th Ave 4,823 4, % Avondale 3,906 3, % Maryvale 7,032 6, % Glendale 6,151 5, % El Mirage 2,332 3, % Mesa 5,755 7, % Chandler 5,425 5, % Guadalupe 3,048 3, % Sunnyslope 4,287 5, % McDowell 2,668 3, % Total 50,224 53, % Flight Dates 30-second Radio: October 5-25, November 2-22, November 30 December 20, January 4 18 KNUV Radio Sponsorship: December 7 March 1 Outdoor Flight Dates: October 5 February 21 Radio 30-second radio spots were run on Spanish-language radio stations reaching Metro Phoenix. A combination of top performing Spanish-language stations was selected to provide adequate reach and frequency over the four month radio campaign. The Phoenix Suns have a tremendous Hispanic following and the season matched well with the campaign timing. Suns play-by-play spots were included, adding to the overall reach and frequency. An additional Page 1 3/25/2010

10 13-week radio sponsorship package on KNUV AM La Buena Onda (Spanish News/Talk) was layered in to provide additional frequency, running December February. Station Dial Position Brand Format Description KSUN 1400 AM Radio Fiesta Regional Mexican Phoenix Suns In Game KSUN 1400 AM Radio Fiesta Regional Mexican Mon Sun 5am-8pm KVIB 95.1 FM Latino Vibe Hispanic Rhythmic Mon Sun 5am-8pm and 5a-12a KNAI 88.3 FM Radio Campesina Regional Mexican Mon Sun 5am-8pm KHOT FM La Nueva Regional Mexican Mon Sun 6am-10pm KQMR FM Recuerdo Spanish Adult Hits Mon Sun 6am-10pm KNUV 1190 AM La Buena Onda Spanish News/Talk/ Sports Weekdays 11am-1pm; Sunday La Voz De La Conciencia Outdoor Nine high traffic billboard locations near MIHS locations were selected to target the surrounding community and prospective patients. A downtown phoenix bus wrap was also used to target both vehicle and pedestrian traffic with a high impact visual reinforcement of the MIHS brand. There were two versions of the billboard, one in Spanish and one in English. Board language and creative (either English or Spanish) was determined based on the demographics of the targeted area. Bus wrap was English language and creative on one side and Spanish language and creative on the other. Targeted Outdoor Locations by Family Health Center Locations Maricopa Medical Center Urgent Care Center McDowell FHC Sunnyslope FHC Bus Wrap Glendale FHC Maryvale FHC El Mirage FHC Billboards Van Buren W of 3 rd Ave X X X Jefferson W of 26 th St X X X Cave Creek N of Cinnabar X Grand Ave N of Indian School X X 24 th St N of Madison X X X Washington E of 28 th St X X X 40 th St S of Washington X X X US 60 S of mm 146 Cave Creek N of Mt. View X X Page 2 3/25/2010

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13 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 2.c.

14 Maricopa County Special Health Care District Summary of Accounts Receivable Write-offs Write-offs or Reclass to Bad Debt requiring CEO approval (Greater than $250,000 to $499,999) Approval Required Month Payer Total Charges Admit Date Discharge Date Moved to Bad Debt Diagnosis CEO Board 10-Feb Self Pay/Undocumented $2,015, /14/2009 8/28/2009 $375,795 Necrotizing Fascitis Yes No Patient Mexican Resident, admitted with serious infection to the face and neck, requiring several surgeries. Billed Section 1011, if paid we will receive $21,669 for the complete stay. Write-offs or Reclass to Bad Debt requiring Board approval (Greater than $500,000) Approval Required Month Payer Total charges Admit Date Discharge Date Moved to Bad Debt Diagnosis CEO Board 10-Feb None

15 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.a.i.

16 Minutes Maricopa County Special Health Care District Board of Directors Meeting Maricopa Medical Center Administrative Conference Room February 4, :00 noon Present: William Bruno, Chair, District 1 - telephonically until 12:22 p.m. Susan Gerard, Vice Chair, District 3 arrived at 12:32 p.m. Greg Patterson, Director, District 2 Alice Lara, Director, District 5 Absent/Excused: Elbert Bicknell, Director, District 4 Others Present: Betsey Bayless, MIHS, Chief Executive Officer Bill Vanaskie, MIHS, Chief Operating Officer Ken Meinke, MIHS, Chief Financial Officer Robert E. Fromm, Jr., M.D., M.P.H., MIHS, Chief Medical Officer Warren Whitney, MIHS, Chief External Affairs Officer Susan Doria, MIHS, Vice President Strategic Planning Louis B. Gorman, District Counsel Donna Pratt, MIHS, Assistant Clerk of the Board Recorded by: Melanie Talbot, Clerk of the Board Call to Order NOTE: Due to Chairman Bruno participating telephonically, Director Patterson chaired the meeting until Chairman Bruno arrived in person. Director Patterson called the meeting to order at 12:10 p.m. Roll Call Ms. Talbot called roll. Following roll call, it was noted that three of the five voting members of the Maricopa County Special Health Care District Board of Directors were present, which represents a quorum. Chairman Bruno arrived in person at 12:22 p.m. Vice Chairman Gerard arrived shortly after roll call. For those participating telephonically, Ms. Talbot named the individuals present at the meeting as well as the individuals participating telephonically. Call to the Public Director Patterson called for public comment. There were no comments.

17 Special Health Care District Board of Directors Meeting Minutes General Session February 4, 2010 General Session Presentation, Discussion and Action: 1. Opening Comments and Remarks from President & Chief Executive Officer Summary of Current Events Ms. Bayless stated that MIHS staff continually strives to meet accrediting body standards. Training for ISO will be initiated for the 2010 DNV accreditation survey. It is anticipated the DNV survey will take place sometime between July and September Ms. Bayless announced that Maricopa Medical Center (MMC) had a site visit in January 2010 by the American College of Surgeons (ACS) The ACS Verification Review Committee s visit was to verify MMC s resources, systems and processes for the adult and pediatric trauma programs. During the visit the site team did not find any deficiencies,therefore, is recommending that MMC receive Level 1 Adult and Level II Pediatric Trauma Center verification. If verification is received, MMC will be the only hospital in Arizona with both Level 1 Adult Trauma and Level II Pediatric Trauma verification. Ms. Bayless distributed a preliminary fiscal year 2011 budget timetable and noted that senior administration is working with the Maricopa Health Center Governing Council (MHCGC) in preparation of the budget for the Federally Qualified Health Center (FQHC) Look-A-Like clinics. Ms. Bayless reminded the Board of the state s proposed funding cuts to AHCCCS, Graduate Medical Education and other areas that would have a tremendous negative impact to Maricopa Integrated Health System (MIHS). Senior administration continues to meet, discuss, and plan for the proposed cuts. Dr. Fromm continues to monitor the care provided by MIHS to Arizona Department of Corrections (ADOC) patients since the contract terminated in November While ADOC patient volumes have decreased, MIHS continues to provide care to those patients who began treatment prior to the cancellation of the contract. Dr. Fromm expects the volumes to continue decreasing in the upcoming months. Ms. Bayless announced that Dr. Crista Johnson and Dr. Michael Grossman are finalists for Arizona Business Magazine s 2010 Health Care Leadership awards. Dr. Johnson oversees the only Refugee Women s Health Care Clinic in Arizona. Dr. Grossman, MIHS Director of Medical Education, has been recognized for his leadership role in advancing medical education at MIHS, the University of Arizona and throughout the state. The winners will be announced on March 3, Reports to the Board of Directors: a. Quality Report Whole Systems Measures Dashboard b. Capital Expenditures for 2 nd Quarter FY 2010 c. Contract Approvals and Asset Disposal for 2 nd Quarter FY 2010 Chairman Bruno acknowledged that the reports were sent to the Board in advance of the meeting. Chairman Bruno noted that some of the contracts listed in the quarterly contract approval report (item 2.c.) appeared to be over the Chief Executive Officer s authority limit of $500,000. He asked senior administration to review the list and follow up with the Board whether or not those contracts should have been brought to the Board for approval. Chairman Bruno pointed out that the Aetna Health contract amendment (C ) listed in the report showed an annual contract amount of $0. He requested that senior administration follow up with the Board to confirm that the information listed was correct. In addition, Chairman Bruno had questions about four (4) new contracts listed in the report for roofing projects, each with an award amount of $250,000. Specifically, he asked if the contracts were Job-ordercontracting (JOC) construction contracts and if the contractors would only be called upon for repairs as needed. Mr. Vanaskie confirmed the $250,000 award amounts were not-to-exceed (NTE) amounts. While the roofs of several MIHS facilities have been replaced, there are still leaks from time to time and a contractor must be contacted to make repairs. 2

18 Special Health Care District Board of Directors Meeting Minutes General Session February 4, 2010 General Session Presentation, Discussion and Action: 3. Discuss and Review Financial Performance Including but not Limited to: December 2009 MIHS Key Indicator Dashboard Report on Performance of the Maricopa Care Advantage Plan Dr. Fromm reviewed the quality key indicators for December The fall rate per 1000 patient days is four (4), which is greater than the target of less than three (3) per 1000 patient days. The percent of patients readmitted to the hospital less than 30 days after being discharged is also greater than target, which is set at less than seven percent per 1000 patient days. All four (4) of the core measures, acute myocardial infarction (AMI), heart failure, pneumonia, and surgical care improvement prevention (SCIP), are below the set targets, however, staff continues to strive toward reaching the goals. He pointed out that it is sometimes difficult for staff to document that the procedures were performed, however, as MIHS moves toward an electronic medical record, the measures should become easier to track and document. Mr. Vanaskie reported on inpatient and outpatient volumes for December Acute admissions and acute patient days were below budget for the month and are below budget year-to-date (YTD). Behavioral health admissions were above budget in December 2009, as well as above budget YTD. The length of stay (LOS) in behavioral health also decreased, which is positive for the patient as well as MIHS. While patient visits to the Family Health Centers (FHCs) were below budget for the month and are below budget YTD, visits YTD are ahead of prior year s performance. Patient visits to the Comprehensive Health Center (CHC) were slightly behind budget in December. Visits to the dental clinics were above budget for the month, as well as above budget YTD. Visits to the Urgent Care Center (UCC) for the month of December were less than anticipated, and visits YTD are lagging behind last year s performance. Vice Chairman Gerard questioned how far behind the UCC visits were and what volume was needed to break even. Mr. Meinke stated that visits were 3.3% less than budget YTD. Visits to the UCC were not budgeted to break even in the 2010 fiscal year. Mr. Vanaskie continued with the report, stating that emergency room visits, which are a combination of pediatric and adult, were behind budget for the month and are close to budget YTD. Surgeries were behind budget for the month of December, mainly due to reduced work schedules during the month as a result of scheduled vacations. Births remain behind budget for the month and YTD. Mr. Vanaskie reported that births are down approximately six to eight percent in Maricopa County and he does not expect the number of deliveries to increase in the near term. Chairman Bruno said that the number of births at MMC is down over 16% this fiscal year compared to the 6-8% decrease in Maricopa County. Mr. Vanaskie stated the majority of maternity patients utilize the Federal Emergency Services Program (FES). The FES has the same income requirements as AHCCCS, however, unlike AHCCCS, FES does not require U.S. citizenship. The requirement for employers to use E-Verify, along with the Legal Arizona Workers Act (also know as employers sanctions law), have attributed to the decrease in births at MMC. Chairman Bruno stated that acute admissions were down behind budget YTD by 18% and asked if senior administration would be addressing the decrease. Mr. Meinke said the senior administration was prepared to discuss the 2011 fiscal year budget process, including the challenges the District is facing with the state s proposed funding cuts to health care programs. 3

19 Special Health Care District Board of Directors Meeting Minutes General Session February 4, 2010 General Session Presentation, Discussion and Action (cont): 3. Discuss and Review Financial Performance Including but not Limited to (cont): December 2009 MIHS Key Indicator Dashboard Report on Performance of the Maricopa Care Advantage Plan Vice Chairman Gerard asked if patient volumes decrease, would expenses, including costs per adjusted patient day, also decrease. Mr. Meinke stated that costs per adjusted patient day are three percent lower when compared to prior year. He said that MIHS is operating more efficiently this fiscal year. Chairman Bruno stated that the December 2009 financial report data shows that the costs per adjusted patient day are over budget. Mr. Meinke stated that the costs per adjusted patient day year-to-date are over budget by two percent, however, costs are three percent lower YTD when compared to prior year. Chairman Bruno expressed concern that acute admissions were 18% behind budget. He asked how the District would be able to sustain its residency programs, which are dependant on patient volumes in order to train residents. He questioned if senior administration had an action plan to address the decrease. Ms. Bayless stated that senior administration has a business development strategy and is engaging physicians on various strategies. Vice Chairman Gerard remarked the business development strategy is a long-term plan. The net income budgeted for the 2010 fiscal year is $18.4 million. As Ms. Bayless mentioned in her opening comments, proposed state funding cuts could have a significant impact on the net income. In addition, senior administration and the Board now need to consider how the loss of volumes will decrease the net income. Mr. Meinke stated senior administration has been developing different scenarios for reductions and will bring the details to the Board at the end of February Senior administration will be prepared to move forward with any one of the plans once legislative cuts are made final and senior administration has received approval from the Board to execute the appropriate plan of action. Mr. Meinke reported on the Maricopa Care Advantage Plan (MCA). He said that it was a joint venture between MIHS and University Physicians Health (UPH). MCA, a Medicare Special Needs Plan, began in January Initially, the Plan was not expected to make a profit during the first year of operation. The Plan became profitable in August For the first 24 months, January 2008 through December 2009, the MCA has lost a $193,000. Senior administration will have specific recommendations for the Plan at the February formal Board meeting. Chairman Bruno questioned if a 5-year proforma was done when the possibility of this joint venture was discussed in If so, he would like for the Board to receive a copy when senior administration brings the recommendation to the Board. It will indicate how the Plan is performing compared to the projections. MOTION: Vice Chairman Gerard moved to recess the general session and reconvene in executive session at 12:52 p.m. Director Lara seconded. Motion unanimously passed. General Session Presentation, Discussion and Action: Chairman Bruno reconvened the general session at 3:22 p.m. NOTE: Director Patterson excused himself from the meeting during the executive session. 4

20 Special Health Care District Board of Directors Meeting Minutes General Session February 4, 2010 General Session Presentation, Discussion and Action (cont.): 4. Discussion, Consideration and Possible Action on the Employment Assignment for Melanie Talbot, Clerk of the Board MOTION: Director Lara moved that the position of the Clerk of the Board have the revised job description as presented to the Board; the salary range of the job description shall be E-14; the title shall be revised to Executive Director of Board Operations and Clerk of the Board. MIHS Human Resources shall perform all tasks necessary to implement the job/position description, salary range, and title set forth. Vice Chairman Gerard seconded. VOTE: 3 ayes: Chairman Bruno, Vice Chairman Gerard, and Director Lara 2 absent: Director Bicknell and Director Patterson. Motion passed. Vice Chairman Gerard commented on how hard Ms. Talbot has worked for the Board of Directors. The old job description did not reflect all of her responsibilities. 5. Annual Review of Board Policy Statements; Discuss, Review and Approve Proposed Revisions to the Following Existing Board Policy Statements: a. Financial Assistance b. Annual External Audit c. Billing d. Bonds e. Collection Efforts f. Construction Surety Bonds g. Discounts h. Fiscal Responsibility/Financial Planning i. Budget ~ Operating and Capital j. Non-Retaliation k. Political Contributions l. Accrediting Bodies This item was not discussed. 6. Discuss, Review and Approve the District s Position Regarding Current or Proposed State and Federal Legislative Items This item was not discussed. 7. Concluding Items a. Future Agenda Item/Report Calendar i. February a. Quarterly Reports: Patient Satisfaction Survey Results 4 th Quarter CY 2009 Compliance Officer s Report on Activities, Quality and Effectiveness Internal Auditor s Report on Activities, Quality and Effectiveness Performance on Investment of Funds Report on Maricopa Foundation Activities 5

21 Special Health Care District Board of Directors Meeting Minutes General Session February 4, 2010 General Session Presentation, Discussion and Action (cont.): 7. Concluding Items (cont.) b. Other: ii. Non-Privileged Patient Care Staff Competency Report delayed from Nov. Employee Satisfaction Survey Results delayed from Jan. Maricopa Health Center Governing Council Report delayed from Dec. Report on CMAR Quality Report Wholes Systems Measures Dashboard District Wide Risk Management Program Report Capital Spending Targets; Strategic Priorities; and Operating/Non- Operating Targets Legislative Session Issues March a. Quarterly Reports: Accrediting Bodies Standards Update (i.e. JC, DNV, CMS, etc.) b. Other: Presentation - Wholes Systems Measures Dashboard Prelim Volume Assumptions; Reimbursement Assumptions; Expense Assumptions Rate Structures Legislative Session Issues Update on Chief Executive Officer s Annual Goals Progress b. Board Member Requests for Future Agenda Items or Reports Schedule and Plan Future Board Retreat c. Chairman and Member Closing Comment This item was not discussed. Adjourn MOTION: Vice Chairman Gerard moved to adjourn the February 4, 2010 Special Health Care District Board of Directors special meeting. Director Lara seconded. Motion passed. Meeting adjourned at 327 p.m. William Bruno, Chair Special Health Care District Board of Directors 6

22 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.a.ii. No Information Available at This Time

23 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.a.iii.

24 Minutes Maricopa County Special Health Care District Board of Directors Meeting Maricopa Medical Center Administrative Conference Room March 11, :00 p.m. Present: William Bruno, Chair, District 1 - telephonically Susan Gerard, Vice Chair, District 3 Greg Patterson, Director, District 2 - telephonically Elbert Bicknell, Director, District 4 - telephonically Alice Lara, Director, District 5 - telephonically Others Present: Betsey Bayless, MIHS, President & Chief Executive Officer Bill Vanaskie, MIHS, Chief Operating Officer Robert E. Fromm, Jr., M.D., M.P.H., MIHS, Chief Medical Officer Louis B. Gorman, District Counsel Recorded by: Melanie Talbot, Clerk of the Board Call to Order NOTE: Due to Chairman Bruno participating telephonically, Vice Chairman Gerard chaired the meeting. Vice Chairman Gerard called the meeting to order at 5:05 p.m. Roll Call Ms. Talbot called roll. Following roll call, it was noted that all five voting members of the Maricopa County Special Health Care District Board of Directors were present, which represents a quorum. Chairman Bruno, Director Bicknell, Director Patterson, and Director Lara participated telephonically. For those participating telephonically, Ms. Talbot named the individuals present at the meeting as well as the individuals participating telephonically. Call to the Public Vice Chairman Gerard called for public comment. There were no comments. General Session Presentation, Discussion and Action: 1. Motion to Recess General Session and Convene in Executive Session MOTION: Director Bicknell moved to recess the general session and convene in executive session at 5:07 p.m. Director Lara seconded. Motion unanimously passed.

25 Special Health Care District Board of Directors Meeting Minutes General Session March 11, 2010 General Session Presentation, Discussion and Action: Vice Chairman Gerard reconvened the general session at 5:42 p.m. 2. Discussion and Possible Action on Maricopa Integrated Health System (MIHS) Health Plan Administrator, Including Current Health Plan Administrator, University Physicians Health Plans (UPH) This item was not discussed. Adjourn MOTION: Director Bicknell moved to adjourn the March 11, 2010 Special Health Care District Board of Directors special meeting. Chairman Bruno seconded. Motion unanimously passed. Meeting adjourned at 5:42 p.m. William Bruno, Chair Special Health Care District Board of Directors 2

26 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.b.i

27 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT dba MARICOPA INTEGATED HEALTH SYSTEM CONTRACT ROUTING APPROVAL FORM Approval Type: X Board of Directors CEO Article 2 CONTRACT NUMBER: C AND 04 NEW CONTRACT X AMENDMENT REQUESTING DEPARTMENT: Managed Care PROCUREMENT /CONTRACT OFFICER: Michael J. Mayer EXT PROPOSED ACTION (MOTION): Approve amendment between United Behavioral Health and Maricopa County Special Health Care District dba Maricopa Integrated Health System (MIHS) that changes inpatient behavioral health rates as set forth below. HISTORICAL BACKGROUND/DISCUSSION: United Behavioral Health (UBH) holds an agreement with MIHS for services at Desert Vista and the Psychiatry Annex. This amendment increases the per diem 6% for the upcoming year and increases the ECT rate 10%. The second year increases 5% across all services. Rates include the professional services of DMG. The new rates will be effective approximately one month after signature by MIHS. There are two documents to be executed (both identical). UBH contracts by site, even though the same organization owns both facilities. EVALUATION PROCESS: MIHS projected net revenue with the amendment rates applied to FY 2009 utilization of MIHS services. FINANCIAL IMPLICATIONS: Based on FY 2009 utilization the projected first year annual revenue is approximately $1.8 million with an expected margin of $500,000. BUDGETED: NA YES NO THE ABOVE NAMED CONTRACT/DOCUMENT HAS RECEIVED ALL INTERNAL APPROVALS AND IS READY FOR SIGNATURE BY APPROPRIATE MIHS AUTHORITY: PROCUREMENT OFFICER DATE BOARD OF DIRECTORS ACTION (IF APPLICABLE): APPROVED DISAPPROVED CLERK OF THE BOARD DATE

28 Workflow Manager Document Workflow Manager Document Subject: Category: Review Type: Time Limit: United Behavioral Health Rate Change Managed Care / Revenue One Reviewer at a Time Keep Sending Reminders After Time Limit Expires No. of Days: 1 Notification: Each Reviewer Author: Michael Mayer Status: Review Complete Date: Feb 02, 2010 Status Date: Feb 02, 2010 Main Document: Attachment 1: Attachment 1 Attachment 2: Attachment 3: Attachment 4: Comments: United Behavioral Health Rate Change (No Document Available) (No Document Available) (No Document Available) United Behavioral Health (UBH) holds an agreement with MIHS for services at Desert Vista and the Psychiatry Annex. This amendment increases the per diem 6% for the upcoming year and increases the ECT rate 10%. The second year increases 5% across all services. Rates include the professional services of DMG. The new rates will be effective approximately one month after signature by MIHS. Based on FY 2009 utilization the projected first year annual revenue is approximately $1.8 million with an expected margin of $500,000. There are two documents to be executed (both identical). UBH contracts by site, even though the same organization owns both facilities. Please call me with any questions. Mike Mayer 8140 Reviewer Comments Gene Cavallo -- 2/5/2010 7:06:00 PM Approved Louis Gorman -- 2/8/2010 9:08:00 AM approve Mary Lee DeCoster -- 2/8/ :31:00 AM Reviewed and approved. ML DeCoster Kenneth Meinke -- 2/15/2010 7:14:00 AM approved Bill Vanaskie -- 2/16/ :27:00 AM approved Betsey Bayless -- 2/16/2010 5:38:00 PM Approve Melanie Talbot -- 2/18/2010 8:24:00 PM Received. This item will be placed on the agenda for the March 2010 Maricopa County Special Health Care District Board of Directors formal meeting. 6:25:37 PM

29 United Behavioral Health Effective One Month After Signature by MIHS 1. Financial Impact Inpatient per diem increases 6% in first year and ECT (in/out) increases 10% in first year. Second year increase is 5% for both categories. Estimated Net Revenue $1.8MM Contribution margin $500, Does the contract permit other payer access to terms? Yes, to United affiliated companies. Agreement includes United Behavioral Systems, Inc., U.S. Behavioral Health, The Travelers Insurance Company, The MetraHealth Insurance Company, Metropolitan Life Insurance Company, and United Health and Life Insurance Company and/or U.S. Behavioral Health Plan, California, and PacifiCare Behavioral Health. This may include administrative service arrangement with employer clients of these firms. 3. Payment Terms Payment of clean claims is due within 45 days or as otherwise required by law). 4. Account Aging 51% under 60 days. 78% under 90 days. We are disputing United treatment of court ordered evaluations for Medicare (as we are with other Medicare behavioral programs). These disputes are included in the over 90 day balances.

30 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.b.ii.

31 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT dba MARICOPA INTEGATED HEALTH SYSTEM CONTRACT ROUTING APPROVAL FORM Approval Type: X Board of Directors CEO Article 2 CONTRACT NUMBER: C X NEW CONTRACT AMENDMENT REQUESTING DEPARTMENT: Administration PROCUREMENT/CONTRACT OFFICER: Brian Maness EXT PROPOSED ACTION (MOTION): Approve a new contract between District Medical Group ( DMG ) and Maricopa County Special Health Care District dba Maricopa Integrated Health System (MIHS) for Medical Director Resuscitation Education. HISTORICAL BACKGROUND/DISCUSSION: The purpose of this agreement is to provide the services of a Medical Director for Resuscitation Education. The Medical Director will provide oversight, direction, instruction, evaluation, and supervision of all activities that relate to resuscitation services conducted at the MIHS Resuscitation Training Center. The initial contract term is from January 1, 2010 to December 31, 2010 and shall automatically renew for additional terms of one year each. Either party may terminate the contract upon ninety (90) days written notice. EVALUATION PROCESS: N/A FINANCIAL IMPLICATIONS: The anticipated annual expense is $110,000 and has been budgeted for operational expenditures. The anticipated fiscal year budget impact is $55,000 for FY2010 and $110,000 for FY2011. BUDGETED: X YES NO N/A THE ABOVE NAMED CONTRACT/DOCUMENT HAS RECEIVED ALL INTERNAL APPROVALS AND IS READY FOR SIGNATURE BY APPROPRIATE MIHS AUTHORITY: PROCUREMENT OFFICER DATE BOARD OF DIRECTORS ACTION (IF APPLICABLE): APPROVED DISAPPROVED CLERK OF THE BOARD DATE

32 Workflow Manager Document Workflow Manager Document Subject: Category: Review Type: Time Limit: Medical Director - Resuscitation Education Board of Directors One Reviewer at a Time Keep Sending Reminders After Time Limit Expires No. of Days: 0 Notification: Each Reviewer Author: BRIAN MANESS Status: Review Complete Date: Jan 25, 2010 Status Date: Jan 25, 2010 Main Document: Attachment 1: Attachment 2: Attachment 3: Attachment 4: Medical Director - Resuscitation Education (No Document Available) (No Document Available) (No Document Available) (No Document Available) Comments: Approve a new agreement between District Medical Group ("DMG") and Maricopa MIHS for a Medical Director - Resuscitation Education. Reviewer Comments Robert Fromm -- 1/27/2010 5:21:00 PM Approve Louis Gorman -- 1/28/2010 5:34:00 PM Approve Bill Vanaskie -- 2/1/ :09:00 AM approved Kenneth Meinke -- 2/3/2010 7:32:00 AM approved Betsey Bayless -- 2/3/2010 2:49:00 PM Approve 12:43:44 PM]

33 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.b.iii.

34 DM DRAFT OF 2/12/10 FIRST AMENDMENT TO CONTRACT FOR PROFESSIONAL SERVICES THIS FIRST AMENDMENT TO CONTRACT FOR PROFESSIONAL SERVICES (this "Amendment") is made as of the day of March, 2010, by and between DISTRICT MEDICAL GROUP, INC., an Arizona nonprofit corporation ("DMG"), and MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT, d/b/a MARICOPA INTEGRATED HEALTH SYSTEM ("MIHS"). RECITALS: WHEREAS, DMG (as assignee of Medical Professional Associates of Arizona, P.C.) and MIHS are parties to a certain Contract for Professional Services dated as of October 1, 2009 (the "Agreement"); WHEREAS, DMG and MIHS desire to amend the Agreement as more particularly set forth herein; and WHEREAS, capitalized terms used herein without definition shall have the meanings given to such terms in the Agreement; NOW, THEREFORE, in consideration of the mutual promises and covenants set forth herein, the parties agree as follows with additions noted with underlines and deletions noted with strikethroughs: 1. Amendment. The General Provisions, Section I, Paragraph 35.B(vi)(a) of the Agreement is hereby amended and restated in its entirety to read as follows: "a. Except as provided in Paragraph 35.B(vi)(b) below, Contractor shall be solely responsible for procuring and maintaining professional liability coverage for any and all professional activities. Such professional liability coverage shall be maintained for the period of October 16, 2007 through the Term of this Contract, with and shall have annual policy period coverage minimum limits (I) of $2,000, per occurrence and $7,000, in the aggregate for Qualified Providers who are employees of Contractor, and (II) of $1,000, per occurrence and $3,000, in the aggregate for Qualified Providers who are Contractor's Independent Contractors (as defined in Section II.F(1)(d) of Exhibit B to this Contract). Such professional liability insurance coverage requirements may be met through a combination of captive insurance and commercially purchased insurance policies. In the event that Contractor's professional liability coverage obligation under this Contract is maintained via a self-funded selfinsurance program, through a wholly owned subsidiary or an DM2\

35 affiliated program or entity, or through an entity whose directors are also employees or contractors of Contractor, or via a captive insurance company, Contractor represents and warrants that such entity is and will remain an Arizona domesticated domiciled organization, that is also licensed to do business in Arizona subject to the jurisdiction of the Arizona Department of Insurance (the "Department of Insurance"). Contractor further represents and warrants that any such professional liability coverage program shall be reviewed for soundness by a qualified actuary, as required by the rules and regulations promulgated by the Department of Insurance, and Contractor is actuarially sound will provide the District with documentation of such reviews on an annual basis, to the extent that such reports do not compromise Contractor's position in any pending or future litigation claims. The professional liability insurance requirements outlined above shall be reviewed annually by the Parties and shall be amended from time to time as agreed by the Parties to be consistent with the levels of professional liability coverage for Qualified Providers prevailing in the community and current insurance market conditions and availability." 2. Representations and Warranties. DMG represents and warrants to MIHS that: (a) Since October 1, 2009, DMG (or its predecessor in interest, Medical Professional Associates of Arizona, P.C.) has maintained insurance coverage as described in Section I, Paragraph 35.B(vi)(a) of the Agreement, as amended by this Amendment; and (b) This Amendment will not affect DMG's annual expense of procuring and maintaining the professional liability coverage referred to in the General Provisions, Section I, Paragraph 35.B(vi)(a) of the Agreement, as amended by this Amendment, except in the event of any further amendment to the Agreement as contemplated by the last sentence of such Section I, Paragraph 35.B(vi)(a) as set forth above. 3. Ratification and Confirmation. The terms and conditions of the Agreement, as assigned to and assumed by DMG pursuant to the Assignment and Assumption Agreement among DMG, MIHS and Medical Professional Associates of Arizona, P.C. effective January 1, 2010, and as amended by this Amendment, are hereby ratified and confirmed and shall continue in full force and effect. 4. Miscellaneous. This Amendment shall have effect as of its date. This Amendment may be executed in two or more counterparts, and by different parties on different counterparts, each of which shall be deemed an original, and in making proof of this Amendment it shall be necessary only to produce sufficient counterparts. This Amendment and the rights and obligations of the parties hereunder shall be construed in accordance with and shall be governed by the laws of the State of Arizona, without regard to conflicts of laws principles. DM2\

36 IN WITNESS WHEREOF, the parties hereto have executed this Amendment as of the day and year first above written. DISTRICT MEDICAL GROUP, INC. By: Koteswara R. Chundu, M.D. President and Chief Executive Officer MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT, d/b/a MARICOPA INTEGRATED HEALTH SYSTEM By: Name: William S. Bruno Title: Chair DM2\

37 DMG DRAFT OF 2/12/10 FIRST AMENDMENT TO CONTRACT FOR PROFESSIONAL SERVICES THIS FIRST AMENDMENT TO CONTRACT FOR PROFESSIONAL SERVICES (this "Amendment") is made as of the day of March, 2010, by and between DISTRICT MEDICAL GROUP, INC., an Arizona nonprofit corporation ("DMG"), and MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT, d/b/a MARICOPA INTEGRATED HEALTH SYSTEM ("MIHS"). RECITALS: WHEREAS, DMG (as assignee of Medical Professional Associates of Arizona, P.C.) and MIHS are parties to a certain Contract for Professional Services dated as of October 1, 2009 (the "Agreement"); WHEREAS, DMG and MIHS desire to amend the Agreement as more particularly set forth herein; and WHEREAS, capitalized terms used herein without definition shall have the meanings given to such terms in the Agreement; NOW, THEREFORE, in consideration of the mutual promises and covenants set forth herein, the parties agree as follows: 1. Amendment. The General Provisions, Section I, Paragraph 35.B(vi)(a) of the Agreement is hereby amended and restated in its entirety to read as follows: "a. Except as provided in Paragraph 35.B(vi)(b) below, Contractor shall be solely responsible for procuring and maintaining professional liability coverage for any and all professional activities. Such professional liability coverage shall be maintained for the period of October 16, 2007 through the Term of this Contract, and shall have annual policy period coverage minimum limits (I) of $2,000, per occurrence and $7,000, in the aggregate for Qualified Providers who are employees of Contractor, and (II) of $1,000, per occurrence and $3,000, in the aggregate for Qualified Providers who are Contractor's Independent Contractors (as defined in Section II.F(1)(d) of Exhibit B to this Contract). Such professional liability insurance coverage requirements may be met through a combination of captive insurance and commercially purchased insurance policies. In the event that Contractor's professional liability coverage obligation under this Contract is maintained via a self-funded selfinsurance program, through a wholly owned subsidiary or an affiliated program or entity, or through an entity whose directors DM2\

38 are also employees or contractors of Contractor, or via a captive insurance company, Contractor represents and warrants that such entity is and will remain an Arizona domiciled organization, that is also licensed to do business in Arizona subject to the jurisdiction of the Arizona Department of Insurance (the "Department of Insurance"). Contractor further represents and warrants that any such professional liability coverage program shall be reviewed for soundness by a qualified actuary, as required by the rules and regulations promulgated by the Department of Insurance, and Contractor will provide the District with documentation of such reviews on an annual basis, to the extent that such reports do not compromise Contractor's position in any pending or future litigation claims. The professional liability insurance requirements outlined above shall be reviewed annually by the Parties and shall be amended from time to time as agreed by the Parties to be consistent with the levels of professional liability coverage for Qualified Providers prevailing in the community and current insurance market conditions and availability." 2. Representations and Warranties. DMG represents and warrants to MIHS that: (a) Since October 1, 2009, DMG (or its predecessor in interest, Medical Professional Associates of Arizona, P.C.) has maintained insurance coverage as described in Section I, Paragraph 35.B(vi)(a) of the Agreement, as amended by this Amendment; and (b) This Amendment will not affect DMG's annual expense of procuring and maintaining the professional liability coverage referred to in the General Provisions, Section I, Paragraph 35.B(vi)(a) of the Agreement, as amended by this Amendment, except in the event of any further amendment to the Agreement as contemplated by the last sentence of such Section I, Paragraph 35.B(vi)(a) as set forth above. 3. Ratification and Confirmation. The terms and conditions of the Agreement, as assigned to and assumed by DMG pursuant to the Assignment and Assumption Agreement among DMG, MIHS and Medical Professional Associates of Arizona, P.C. effective January 1, 2010, and as amended by this Amendment, are hereby ratified and confirmed and shall continue in full force and effect. 4. Miscellaneous. This Amendment shall have effect as of its date. This Amendment may be executed in two or more counterparts, and by different parties on different counterparts, each of which shall be deemed an original, and in making proof of this Amendment it shall be necessary only to produce sufficient counterparts. This Amendment and the rights and obligations of the parties hereunder shall be construed in accordance with and shall be governed by the laws of the State of Arizona, without regard to conflicts of laws principles. DM2\

39 IN WITNESS WHEREOF, the parties hereto have executed this Amendment as of the day and year first above written. DISTRICT MEDICAL GROUP, INC. By: Koteswara R. Chundu, M.D. President and Chief Executive Officer MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT, d/b/a MARICOPA INTEGRATED HEALTH SYSTEM By: Name: William Bruno Title: Chair DM2\

40 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.b.iv.

41 CONTRACT NO.: C AMENDMENT NO.: 02 Page 1 of 1 AMENDMENT #2 TO A CONTRACT FOR HEALTH PLAN ADMINISTRATIVE SERVICES BETWEEN MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT dba: MARICOPA INTEGRATED HEALTH SYSTEM ( MIHS ) AND UNIVERSITY PHYSICIANS HEALTHCARE ( CONTRACTOR ) I. The above named Contract is hereby amended in accordance with Paragraph 4.1 of Term and Termination of the Agreement and Paragraph 9.7. Amendment to extend the Agreement as specified below: A. Extend the term of the Agreement an additional six months through March 31, Any new contract terms negotiated after the date of this agreement will become effective April 1, II. The effective date of this Amendment #2 shall be March 1522, III. All other terms and conditions of the original Contract, as amended, shall remain in full force and effect. UPH deliverables will be in accordance with the contract terms; projects, reporting, meetings, and additional responsibilities/work requested by MIHS to UPH will be agreed upon in advance and based on the current contract terms may result in additional cost to MIHS as allowed for in the contract. IV. With advance notice to MIHS, UPH may designate an alternative member of UPHP Leadership staff to be the MHP manager/liaison ensuring appropriate representation and contract adherence for MHP management. IN WITNESS WHEREOF, the parties agree to the changes indicated herein: UNIVERSITY PHYSICIANS HEALTHCARE MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT dba: MARICOPA INTEGRATED HEALTH SYSTEM BOARD OF DIRECTORS BY: BY: Signature Date William S. Bruno Date Chairman, Board of Directors ATTEST: Typed Name and Title Clerk of the Board

42 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.b.v.

43 CONTRACT NO.: C AMENDMENT NO.: 02 Page 1 of 2 AMENDMENT #2 TO A CONTRACT FOR PROPERTY LEASE SERVICES BETWEEN MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT dba: MARICOPA INTEGRATED HEALTH SYSTEM ( LESSOR ) AND MEDICAL PROFESSIONAL ASSOCIATES OF ARIZONA, P.C. ( LESSEE ) I. The parties entered into a Lease on April 1, 2008 whereby LESSOR leases 21, ,358.3 square feet of space to LESSEE and LESSEE hereby rents such space from LESSOR. The above named Contract is hereby amended in accordance with Section 27 to modify Exhibit A as specified below. II. Amended language shall be identified by strikeout indicating deletions and ALL CAPS indicating additions. A. The parties agree that the Premises will be used by LESSEE for its administrative and billing function. The fifth paragraph on the first page shall be revised as follows: Exhibit "A1" and A2 reflects the parties' agreement that leased space used by LESSEE for its administrative and billing function, including working space for clerical and support staff is being leased to LESSEE at fair market value rates listed. For space used by LESSEE for Department Chairs for both LESSOR's business and for faculty purposes and related administrative purposes, LESSEE will pay one half of the fair market value for such square foot age as reflected in Exhibit "A1" and A2. Lease Term Monthly Rate: $ 33, MONTHLY RATE (ANNUAL RATE OF $ 400,468.12) AT $ PER SQ. FT.) $ 33, MONTHLY RATE (ANNUAL RATE OF $ 402,316.12) AT $ PER SQ. FT.) EFFECTIVE 12/1/2009, AS PER EXHIBIT A1 $ 33, MONTHLY RATE (ANNUAL RATE OF $ 403,481.62) AT $ PER SQ. FT.) EFFECTIVE 1/15/2010, AS PER EXHIBIT A2. B. Pursuant to Paragraph 11, LESSOR consents to the assignment of this Lease by LESSEE to District Medical Group, Inc, as of January 1, 2010.

44 CONTRACT NO.: C AMENDMENT NO.: 02 Page 2 of 2 C. Exhibit A is deleted in its entirety and replaced by new Exhibits A1, and A2, attached hereto. D. Paragraph 19 is amended as follows: Notice to LESSEE: Medical Professional Associates of Arizona, PC DISTRICT MEDICAL GROUP, INC Paul Westover KOTE CHUNDU, MD, CEO 2929 E. THOMAS RD. Phoenix, AZ III. The effective date of this Amendment #2 shall be as indicated in Paragraph II A above. IV. All other terms and conditions of the original Contract, as amended, shall remain in full force and effect. IN WITNESS WHEREOF, the parties on this day of, 2010 agree to the changes indicated herein: LESSOR: Maricopa County Special Health Care District d.b.a. Maricopa Integrated Health System LESSEE: District Medical Group, Inc. Signature Date Signature Date

45 MEDPRO ADMINISTRATIVE OFFICE SPACE BUILDING FLOOR DEPARTMENT/SPACE DESCRIPTION SQUARE FOOTAGE % SQUARE FOOTAGE % Hospital Basement 100% MedPro % Faculty Areas % Chairs Areas st 100% MedPro % Faculty Areas % Chairs Areas nd 100% MedPro % Faculty Areas % Chairs Areas rd 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas Building Total CHC 2nd 100% MedPro % Faculty Areas % Chairs Areas Building Total CAC 2nd 100% MedPro % Faculty Areas % Chairs Areas Building Total Hogan Building 1st 100% MedPro % Chairs Areas MIHS nd 100% MedPro % Faculty Areas MIHS Building Total Building 1st 100% MedPro % Faculty Areas % Chairs Areas nd 100% MedPro % Faculty Areas % Chairs Areas Building Total Desert Vista 1st 100% MedPro % Faculty Areas % Chairs Areas nd 100% MedPro % Faculty Areas % Chairs Areas Building Total TOTAL % Load Factor Total Total Lease Amount at $18.75 sqft $402, Exhibit "A1"

46 MEDPRO ADMINISTRATIVE OFFICE SPACE BUILDING FLOOR DEPARTMENT/SPACE DESCRIPTION SQUARE FOOTAGE % SQUARE FOOTAGE % Hospital Basement 100% MedPro % Faculty Areas % Chairs Areas st 100% MedPro % Faculty Areas % Chairs Areas nd 100% MedPro % Faculty Areas % Chairs Areas rd 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas th 100% MedPro % Faculty Areas % Chairs Areas Building Total CHC 2nd 100% MedPro % Faculty Areas % Chairs Areas Building Total CAC 2nd 100% MedPro % Faculty Areas % Chairs Areas Building Total Hogan Building 1st 100% MedPro % Chairs Areas MIHS nd 100% MedPro % Faculty Areas MIHS Building Total Building 1st 100% MedPro % Faculty Areas % Chairs Areas nd 100% MedPro % Faculty Areas % Chairs Areas Building Total Desert Vista 1st 100% MedPro % Faculty Areas % Chairs Areas nd 100% MedPro % Faculty Areas % Chairs Areas Building Total TOTAL % Load Factor Total Total Lease Amount at $18.75 sqft $403, Exhibit "A2"

47 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.c.i

48 The 14 th Annual WESTERN REGIONAL TRUSTEE SYMPOSIUM COLORADO IDAHO MONTANA NEBRASKA NEVADA NEW MEXICO UTAH WYOMING ARIZONA Keynote speakers include: Steven Summer John Nance Rick Pollack Larry Walker Bill Ward Elevating the Standards of Hospital Governance June 9-11, 2010 Hyatt Regency Denver at Colorado Convention Center Denver, Colorado

49 Elevating the Standards of Hospital Governance Dear Healthcare Trustees & Executives, It's time to start planning for your attendance at the 14 th Annual Western Regional Trustee Symposium in Denver from June This is the only educational event in the western states that is planned by trustees, for trustees, where it is convenient for you to meet and share ideas with over 200 fellow trustees and executives. This year's theme, "Elevating the Standards of Hospital Governance," will address the increasing scope and J. Stephen Glasmann complexity of hospital governance and will teach trustees, both experienced and new, how to cope with the new laws and regulations in healthcare. In an era of rapidly changing healthcare rules, regulations and reimbursements, you will gain the knowledge and tools you need to improve quality, patient care, your financial stability and enhance your community image. All of these issues are of critical importance for the long-term viability and success of your hospital. The people in your community look to you, their appointed or elected representatives, to provide the necessary leadership and to make knowledgeable decisions for the good of the hospital and healthcare in your community. This symposium has been carefully planned to help you identify and manage those critical governance issues with thought-provoking information and practical tools that will help you in these tasks. I personally invite you to Denver, Colorado to attend this outstanding meeting, focused exclusively on the educational needs of healthcare trustees. WRTS has developed a reputation of providing high quality, timely, forward-looking education, plus the opportunity to share information and concerns with other trustees at a very reasonable cost. There will also be opportunities for sightseeing, as the Hyatt is surrounded by a number of fine restaurants, theaters and shops, and the Colorado Rockies at Coors Field. Please take a few minutes to review this brochure and plan to attend what will be another quality educational experience with excellent speakers devoted exclusively to the needs and challenges of the healthcare trustee. Sincerely, J. Stephen Glasmann Chair, 14 th Annual Western Regional Trustee Symposium President, Montrose Memorial Hospital Board of Trustees Montrose, CO What Did 2009 Attendees Value Most? Fantastic. As a newer board member, it was wonderful to attend. The networking is invaluable!! The experience part of this conference is worth the work I miss. The variety and choices of speakers and breakout sessions. The good speakers with understanding of the big picture. I don't believe I could pick just one part. I was able to take something from every presentation. A lot of thought and work has obviously gone into this conference. Everything was super. The availability and willingness of speakers to interact outside of sessions Western Regional Trustee Symposium

50 Who Should Attend? Trustees and executive staff from hospitals and health systems are encouraged to attend as a team, and a discount is provided if four or more individuals attend from the same organization and register under one payment. Spouses and guests are also welcome to attend the group meal functions, but will need to register. Why Should You Attend? Attendees at this symposium will gain increased knowledge about many issues through educational sessions, networking and information exchange with other trustees. The educational sessions provided will address the following important issues to healthcare trustees: Governing in an Era of Uncertainty Trustee Toolkit Experience Dealing With Problematic Doctors National Trends and Emerging Standards for Board Education and Development Physicians and Hospitals as Allies The Board's Role in Assuring Quality Healthcare The Ultimate Flight Plan to Patient Safety Healthcare Payment Systems in 2010: A CFO's Perspective Board Succession Planning Practicing Competency-Based Governance Capital Markets Update The High Stakes of Low Accountability and the Tools to Eliminate It The Board's Role in Disaster Readiness Unconventional Thinking for Board Members AHA Federal Update Where Will It Be Held? The Western Regional Trustee Symposium (WRTS) will be held at the Hyatt Regency Denver at Colorado Convention Center in Denver, Colorado from June 9-11, LODGING INFORMATION: Hyatt Regency Denver at Colorado Convention Center th Street Denver, CO The Hyatt conference rate is $189 (single/double occupancy) per night plus tax. RESERVATIONS: To help keep the symposium registration fee at a reasonable price, attendees are encouraged to stay at the Hyatt Regency Denver. A dedicated booking website has been created for the Western Regional Trustee Symposium. Attendees will be able to make, modify and cancel their hotel reservations online, as well as take advantage of any room upgrades, amenities or other services offered by the hotel. To access the website, go to: by May 18, You can also access the website through A non-refundable one night s room and tax is required at the time of booking. If you have any issues with hotel arrangements, please contact Peggy McCreary, Colorado Hospital Association, at peggy.mccreary@cha.com or at (720) The cut-off date for securing lodging for the WRTS is May 18, AIRPORT: Denver International Airport (DIA) is located approximately 30 miles from downtown Denver. We suggest that attendees give themselves at least one hour of travel time. SHUTTLE SERVICE, RENTAL CARS & TAXI SERVICE: The Western Regional Trustee Symposium has established a discounted rate for shuttle service through SuperShuttle. Log on to aspx?gc=8ssnr and provide the requested information. Reservations can also be made by calling BLUEVAN ( ) give the code 8SSNR to the call taker. WRTS discounted rate is $32 round trip per person or $19 one-way per person. The following car rental companies are also available on site at the airport: Avis, Budget, Enterprise, Dollar, Hertz, National and Thrifty. Enterprise maintains an on-site location at the Hyatt Regency. Taxi service between DIA to the Hyatt Regency Denver is approximately $55 one way. All prices are subject to change without notice. ATTRACTIONS: Welcome to Denver the Mile High City where a thriving arts and cultural scene, 300 days of sunshine, and the Rocky Mountain backdrop combine for the world s most spectacular playground. Denver is as laid-back as it is sophisticated. It's a place where engineers rub elbows with rock climbers at local brewpubs, at art festivals or while strolling along downtown's 16 th Street pedestrian mall. Free shuttles give visitors quick access to world-class art and culture, wine bars, restaurants, and nighttime entertainment and music in Larimer Square or historic LoDo. Upscale shopping awaits at Cherry Creek, while Denver's seven professional sports teams showcase this city's active spirit. Denver's 850 miles of paved biking and walking paths the largest system of its kind in the country connect visitors to unique attractions, parks and diverse neighborhoods. One trip is all it takes to fall in love with this great city. Log on to VISITDENVER.com. 3

51 Wednesday, June 9 10:00 a.m. Registration Opens 11:15 a.m. 11:30 a.m. Welcome and Introductions J. Stephen Glasmann Chair, 14 th Annual Western Regional Trustee Symposium President, Montrose Memorial Hospital Board of Trustees Montrose, CO 11:30 a.m. 12:30 p.m. Symposium Welcome Luncheon The goal of this luncheon is to give attendees the opportunity to welcome and visit with new and longtime colleagues. Keynote Address: 12:45 p.m. 1:45 p.m. Steven J. Summer Governing in an Era of Uncertainty Steven J. Summer, President & CEO, Colorado Hospital Association Greenwood Village, CO In healthcare, we frequently see references to these being turbulent times, or the level of uncertainty with which we operate, or the dynamic nature of our environment. The twists and turns of the political process are at the very root of the fragility within which hospital boards must govern and CEOs lead. These are really only the labels that we place on the landscape. Frankly, the labels are less important than the message of ambiguity they communicate and the importance of building a capacity in the hospital's governance structure that allows the hospital to capitalize on the unexpected, continuously reassess the assumptions, and be nimble in how it responds to the "new" normal. Against this backdrop of uncertainty and change, hospital governing boards must still be able to be certain that they are doing the right things for those they serve and doing them well and that is the important measure of their success. Steven J. Summer was appointed President & CEO of the Colorado Hospital Association in At CHA, he works to represent the unified voice of Colorado's 85 hospitals and 7 health systems, addressing issues such as healthcare reform, access and coverage for all Coloradans, fair and equitable payment, and making hospitals as safe as possible for the patients they serve. Mini-Workshop: 2:00 p.m. 3:15 p.m. & 3:30 p.m. 4:45 p.m. Trustee Toolkit Experience Lanny A. Kope, EdD - Sierra Vista, AZ and Alan J. Spidel, Vice President, Lancaster Pollard Columbus, OH Created for trustees serving in their first term as a hospital trustee, the Trustee Toolkit Experience workshop is designed to help beginning trustees understand the various governance and financial aspects of healthcare. The workshop is organized in three parts: A) Inside the Board Room, which deals with the fundamentals of being a hospital trustee; B) Understanding Hospital Finance, which is directed towards developing an awareness of how hospitals are financed; and C) Outside the Board Room, which encompasses the various healthcare issues with which hospital trustees must deal, as well as the resources available to assist them in this endeavor. Lanny A. Kope has been active in healthcare governance for over 30 years. Serving on the boards of two rural hospitals and one urban hospital in Arizona, he has provided service and leadership to the communities of Phoenix, Payson and Sierra Vista. Alan J. Spidel has published financial articles in the HFMA publications hfm and Big Business for Not-So-Big Hospitals, and has been quoted in HealthLeaders Media and various state-level association newsletters Western Regional Trustee Symposium

52 Concurrent Sessions: 2:00 p.m. 3:15 p.m. Session 1: Dealing With Problematic Doctors: The Board's Role in Disciplinary Actions Todd Sagin, MD, JD, Principal, HG Healthcare Consultants, LLC Salem, WI Tighter monitoring of physician performance in recent years has revealed a growing number of medical staff members with problematic clinical skills or professional conduct. Most medical staff and boards that undertake "corrective action" expose themselves unnecessarily to significant liability from lawsuits by aggrieved physicians. This session will show board members and physician leaders how to steer their organization through the land mines in this highly litigious territory. Medical staff and boards often find it particularly challenging to deal with physicians whose behavior is unprofessional and disruptive. However, there are clear and effective approaches for dealing with these individuals and reducing the damage they inflict on healthcare communities. Dr. Todd Sagin is a physician executive recognized across the nation for his work with hospital boards, medical staff and physician organizations. He is co-founder of HG Healthcare Consultants, which provides guidance on a wide range of healthcare issues. Session 2: The New Governance Mandate: National Trends and Emerging Standards for Board Education and Development Sean Patrick Murphy, Senior Vice President, Corporate General Counsel; Solaris Health System, Legal Affairs Edison, NJ Mr. Murphy will review the emerging trend and new governance mandate: the demand for formal board education, training and development. Currently, 12 states have (or have announced their intention to adopt) some type of formal board education program (10 of which are classified as a board certificate or certification). The demand for better trained boards is also evidenced by state mandated director education requirements (New Jersey) and new pay for governance (P4G) programs that offer "higher payment" from the respective participating state Blue Cross and Blue Shield (Massachusetts and South Carolina). He will also review related developments: the call board and director competencies and new Securities and Exchange Commission disclosure requirements for "qualified" boards. This presentation will review these trends and discuss their significance and potential impact on hospitals, and their governing boards. Sean Patrick Murphy is a Senior Fellow at the Jefferson University School of Population Health and a faculty member of the Governance Institute. He lectures and writes extensively in healthcare and health law, and is a regular contributing author to Health Law Handbook. Session 3: Physicians and Hospitals as Allies Anne Carter, MBA, Vice President of Operations, Quorum Health Resources, LLC - Brentwood, TN The exact changes that future healthcare reform will bring remain elusive. Whether reform shapes quality, prescribes bundled reimbursement or serves to spark innovative approaches in providing care more effectively, the relationship between physicians and hospitals will change. The hospitals that will emerge as "winners" in the new healthcare world order will have leaders who will have connected the dots early on and proactively aligned their physicians with their organization's goals, visions and operations. This presentation will focus on: A) The current and future trends in physician alignment; B) Opportunities for new alignment options; C) Methods for changing the paradigm for physician-hospital relations; and D) Getting physicians on board with the organization's strategic and quality goals. Anne Carter brings over 30 years of experience in the healthcare industry. Her background includes management positions in a broad range of healthcare industries. She has also worked in academic medical centers, teaching hospitals and community hospitals. Session 4: The Board's Role in Assuring Quality Healthcare Ruth Elzer, RN, MS, Practice Leader for Accreditation & Regulatory Compliance, Compass Group, Inc. Cincinnati, OH The Centers for Medicare & Medicaid Services (CMS) requires hospitals to have a governing body (the board) that is legally responsible for the conduct of the hospital as an institution. The board of a hospital is required to hire the CEO, establish a competent medical staff and oversee key aspects of the organization, such as the strategic plan and budget. However, it's the governing body's role in oversight of quality care that is most commonly cited during a complaint survey. Rather than taking an active role in ensuring patient safety, most boards feel forced into a "rubber stamp" approach to quality oversight. In this session, participants will receive updates on the latest expectations for boards in the oversight of quality and compliance, and tips on how to "on-board" new trustees for their role in quality and strategies for making information understandable. Ruth Elzer is an expert at keeping hospitals compliant. Trained as a nurse and a hospital surveyor, she understands healthcare quality on both the clinical and administrative levels. She gives clients practical solutions that work across the board. 3:30 p.m. 4:45 p.m. Concurrent Sessions Repeat 5:00 p.m. 6:00 p.m. Welcome Reception Whether you are a seasoned veteran of the symposium or a new attendee, this informal reception is the perfect conclusion to a full day of activities. 5

53 Thursd ay, June 10 7:30 a.m. 8:45 a.m. Networking Breakfast & Table Topics This symposium provides ample time for attendees to benefit from the knowledge and experience of one another. Enjoy breakfast while networking with colleagues before returning to your session. Tables will be labeled with topics of interest and you may choose the one that interests you most. Keynote Address: 9:00 a.m. 10:15 a.m. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety John J. Nance, JD, John Nance Productions/Author Seattle, WA John J. Nance, JD John Nance is the author of Why Hospitals Should Fly, named the 2009 "Book of the Year" by the American College of Healthcare Executives. The book sparked a small army of hospital CEOs to search for a way to visit the real St. Michael's Hospital, the institution highlighted by his book. It's a hospital in which collegial teamwork, seamless communication and near-perfect patient safety has been achieved by an extraordinarily happy staff. The problem is, St. Michael's is a destination, not an existing institution. While it involves massive cultural change, any hospital in America has the opportunity to rise to that status. The startling ways in which that can be achieved and why it should will be part of Mr. Nance's presentation. The unique aspect is the exciting feeling you get when you realize how truly satisfying it is to embrace such principles. John Nance is a native Texan who grew up in Dallas. He holds a bachelor's degree from SMU and a Juris Doctor from SMU School of Law, and is a licensed attorney. Named Distinguished Alumni of SMU for 2002, he is also a decorated United States Air Force pilot veteran of Vietnam and Operation Desert Storm/Desert Shield and a Lt. Colonel in the USAF Reserve. He is an internationally recognized air safety analyst and advocate, best known to North American television audiences as aviation analyst for ABC World News and aviation editor for Good Morning America. He is also the nationally-known author of 19 major books, 5 non-fiction plus 13 fiction best sellers. He is a pioneering and well-known advocate of using the lessons from the recent revolution in aviation safety to equally revolutionize the patient safety performance of hospitals, doctors, nurses and all of healthcare. Mr. Nance is a founding board member and is on the Executive Committee of the National Patient Safety Foundation. Concurrent Sessions: 10:30 a.m. 11:45 a.m. Session 5: Healthcare Payment Systems in 2010: A Hospital CFO's Perspective Gregg Redfield, CFO, Queen of Peace Hospital New Prague, MN Effective trustees need a basic understanding of healthcare payment systems and other issues and concerns with reimbursement in As a current CFO of a Critical Access Hospital in Minnesota, Mr. Redfield will discuss the sources and types of payment for healthcare facilities, as well as the need to understand the payer mix and how to be more efficient in collecting the appropriate reimbursement from payers and patients. Gregg Redfield has over 20 years of healthcare financial experience, including positions as the vice president of finance for the Minnesota Hospital Association, consulting manager for two regional CPA firms, reimbursement manager for two large healthcare systems in Minnesota, and audit and contracting with Blue Cross Blue Shield of Minnesota. Mr. Redfield has participated in various educational presentations at both the state and national levels for the past 10 years, including topics related to Critical Access Hospitals, facility reimbursement, and hospital staff and board education Western Regional Trustee Symposium

54 Concurrent Sessions: 10:30 a.m. 11:45 a.m. Session 6: Board Succession Planning Mark Andrew, Senior Vice President & Shareholder, Witt/Kieffer Irvine, CA and Sandy Williams, Executive Search Consultant, Witt/Kieffer Oakbrook, IL High performing hospitals and health systems are most often linked to high quality talent and governance. Highly effective healthcare boards develop a deliberate and formal process for identifying and training qualified, committed board members to succeed the board's departing members, as well as preparing existing members for leadership positions. This session will focus on best practices in succession planning and leadership development. Attendees will learn how to: A) Develop a formal approach for board renewal; B) Achieve the appropriate balance of attributes, skills and experiences needed; C) Identify and prepare trustees for leadership responsibilities; D) Attract high quality trustees to the board; E) Develop a leadership pipeline from board membership to officer positions; and F) Develop and retain future board leaders. Mark Andrew brings his clients two decades of experience in healthcare executive search to assist clients with executive compensation, organization structure, succession planning, recruitment and retention. Alexander "Sandy" Williams has a distinguished 30-year career in senior healthcare management and association executive roles, with a special interest in identifying physician executives and other healthcare leaders to chair clinical departments. Session 7: Practicing Competency-Based Governance Mary Totten, President, Totten & Associates Oak Park, IL In this session, Ms. Totten will provide an understanding of trustee competencies and how to use them to improve governance practices, and review the work and recommendations of the American Hospital Association's Blue Ribbon Panel on Trustee Core Competencies, which defines competencies and discusses their value and use by boards in and outside of healthcare. She will also review two sets of competencies, which focus on trustee knowledge skills and personal capabilities that the panel recommends all boards should seek in their members. She will then review a set of integrated tools and resources that are being developed by governance experts based on the panel's findings to show how boards can apply competencies to their work in several areas, including trustee recruitment and selection, board education, board member performance evaluation, board leadership development and succession planning. Mary Totten is a speaker and consultant on issues of quality of care and medical staff credentialing, strategic planning and mission development, governing board orientation, and board self-evaluation and governance restructuring. Session 8: Capital Markets Update on the New World of Financing Matthew J. Lindsay, Vice President, Lancaster Pollard Columbus, OH As the credit markets recover, they won't look the same as they did in years past. The new world requires being flexible in both planning and debt structures, and thinking both locally and federally when seeking affordable financing for construction, renovation and other projects. These changes in access to capital have come as a result of the American Recovery and Reinvestment Act, Congressional action, and changes in both bank and investor attitudes toward healthcare. In this session, we will review how the market is evolving, as well as the various financing solutions available. Topics include: A) Learn how accessing capital has changed following recent market turbulence; B) Understand how to leverage local financial resources and how federal options can provide affordable solutions; and C) Review case studies on how hospitals that accessed capital during the financial turmoil did so, how they fared, and discuss what to expect from the markets in the near term. Matthew Lindsay is a senior banker responsible for underwriting and closing processes. He is focused on community healthcare and senior living and has structured a range of bond transactions and mortgage loans for expansion, new construction and refinance projects. Session 9: Do You Measure Up? The High Stakes of Low Accountability and the Tools to Eliminate It Kathleen Kelly, Kathleen Kelly, Inc. Park City, UT A mindset of accountability for outcomes eludes most leadership groups when the time comes to answer for results. Instead, there is finger-pointing and blame. In this session, Ms. Kelly will provide a useful paradigm of accountability, and the tools to increase accountability, both individually and collectively. These tools can be used with any group where you intend to influence the full utilization of everyone and eliminate low levels of accountability. Kathleen Kelly is a dynamic facilitator, coach and consultant with 20 years of experience in operations management, including healthcare and local government. She works with individuals and organizations to improve team performance, staff management, communication, accountability and leadership skills. 12:00 p.m. 1:15 p.m. Networking Luncheon 1:30 p.m. 2:45 p.m. Concurrent Sessions Repeat 7

55 General Session: 3:00 p.m. 4:30 p.m. Preparing for the Worst, Leading With the Best: The Board's Role in Disaster Readiness Larry Walker, President, The Walker Company Healthcare Consulting, LLC Lake Oswego, OR September 11, 2001 opened everyone's eyes to the reality of terrorist attacks on American soil, and caused the nation and its hospitals to thoroughly examine their readiness for all types of disasters. And most recently, a wake-up call from Haiti. Hospital trustees may well question what role the board plays in disaster readiness, and what accountabilities it has in ensuring the hospital's successful response to any unfortunate disaster. According to Joe Cappiello, past vice president of accreditation field operations for The Joint Commission, much of a hospital's readiness Larry Walker capacity rests with the governing board. Participants attending this session will: A) Gain insight into the board's role and fiduciary responsibilities in disaster preparedness; B) Identify critical questions they should consider in evaluating their hospital or health system's disaster readiness; C) Explore the key elements of comprehensive emergency plan development; D) Learn ways to ensure the capacity for a successful response to disasters; and E) Take a fresh look at crisis communication possibilities in today's world of emerging social media. The Walker Company specializes in governance development, leadership retreats and organizational research for hospitals and health systems. Mr. Walker has been a long-time governance leader, both as a consultant and a trustee. He is also a special consultant to the AHA. He served for six years as chairman of the board of trustees of Gresham, Oregon's Mount Hood Medical Center. He has presented governance education to thousands of trustees nationwide. Friday, June 11 7:15 a.m. 7:45 a.m. Breakfast Buffet Closing Keynote Address: 8:00 a.m. 10:00 a.m. Getting Outside of the Box: Unconventional Thinking for Board Members William J. Ward, Johns Hopkins Bloomberg School of Public Health Baltimore, MD Too often in healthcare, the same "conventional" approaches to problem solving are used to resolve operating, quality and financial issues facing hospitals in today's challenging environment. But these are unconventional times that demand unconventional approaches. Using lecture, photographs, famous quotes, examples from other industries, video clips and discussion questions, the program will prepare board members to challenge the use of conventional approaches and seek new solutions to the problems facing their hospitals. At the conclusion of the program, participants will be able to explain the value of thinking creatively to achieve solutions to persistent healthcare and organizational problems. William J. Ward Bill Ward is the director of the MHS Degree in Health Finance and Management Program at Johns Hopkins Bloomberg School of Public Health and faculty director of the Sommer Scholars Leadership Program. He is a former senior healthcare executive with more than 20 years of experience in healthcare finance and operations. Mr. Ward is the author of two textbooks and numerous articles, and has lectured widely on a variety of healthcare financial and operational subjects Western Regional Trustee Symposium

56 AHA Federal Update: 10:15 a.m. 11:15 a.m. Rick Pollack, Executive Vice President, American Hospital Association Washington, D.C. This session will provide a comprehensive federal perspective on the state of healthcare in America and pending legislation that will impact our nation's hospitals. The federal update is designed to share innovative ideas and information as we collaborate to provide better healthcare services to our communities. Rick Pollack Rick Pollack's professional career began in Washington, D.C. in 1976 when he served as a legislative assistant to Congressman David Obey of Wisconsin. He left Capitol Hill to become a lobbyist and enter the healthcare field when he signed on with the American Nurses Association to become their legislative representative in the early 1980s. He went on to join the AHA's Washington office, where he has been a member of the AHA's advocacy team for the past 28 years. Since 1991, Mr. Pollack has served as executive vice president. In this capacity, he is responsible for the development, implementation and management of the AHA's advocacy, representation and public affairs activities, which were recently cited by Fortune magazine as one of the top 25 most influential and effective lobbying organizations in Washington. Closing Comments: 11:15 a.m. 11:45 a.m. J. Stephen Glasmann, Chair, 14 th Annual Western Regional Trustee Symposium will offer comments to conclude the symposium. John C. Klosterman, Chair-elect for the 15 th Annual Western Regional Trustee Symposium, will provide a preview of the symposium scheduled for June 8-10, 2011 in Omaha, Nebraska. Thank you Sponsors! Silver Sponsors Emergency Preparedness. Peace of Mind. Bronze Sponsors General Sponsors 9

57 General Information A registration form is included with this brochure. There are a number of ways to conveniently register for the symposium. Confirmation will be sent to you within 10 days of receipt of your paid registration. MAIL: FAX: ONLINE: Heather Bullock, Marketing & Events Coordinator Nebraska Hospital Association P.O. Box Lincoln, NE (402) (Credit card registrations only) IMPORTANT NOTE: Payment must accompany your registration and can be made by check or Visa/MasterCard. Checks should be made payable to: Nebraska Hospital Association. The Western Regional Trustee Symposium is reasonably priced, and organizations are encouraged to send multiple attendees and benefit from the group discount. REGISTRATION FEES: Registration deadline is May 18, (A $55 processing fee will be added to registrations received after May 18, 2010 and for any on-site registrations.) Individual Member $495 (Includes Wednesday, Thursday and Friday sessions.) Four or More Members* $450 Individual Non-Member $750 Spouse/Guest** $85 On-site Registration $550 * Registrations must be received together to qualify for the discount. ** The spouse/guest fee includes the Welcome Reception, and Thursday and Friday breakfasts. Luncheons not included. CANCELLATION POLICY: Registration fees are non-refundable unless notice is received by May 18, However, alternates from the same organization can be substituted. If a notice is received prior to May 18, 2010, refunds will be given, less a $75 administrative processing fee. HOTEL CANCELLATION: A non-refundable one night s room and tax is required at the time of booking. CONTINUING EDUCATION CREDIT CATEGORY II (Non-ACHE Credit): Attendees at this program can receive up to hours of pre-approved Category II (non-ache) continuing education credits towards advancement or recertification with the American College of Healthcare Executives. Participants in this program wishing to have the continuing hours applied towards Category II credit should list their attendance when applying for advancement, recertification or reappointment in ACHE. ACCESS TO MEETING: The Western Regional Trustee Symposium wishes to ensure that no individual with a disability is excluded, denied services, segregated or otherwise treated differently from other individuals because of the absence of auxiliary aids and services. If you need any of the auxiliary aids or services identified in the Americans with Disabilities Act, please advise us by indicating any special needs on the registration form provided. You will be personally contacted to make arrangements. Questions? Need More Information? Please contact Heather Bullock at (402) or via hbullock@nhanet.org Western Regional Trustee Symposium

58 Elevating the Standards of Hospital Governance Western Regional Trustee Symposium June 9-11, 2010 Denver, Colorado Registration deadline: May 18, Please fill out a separate registration form for each person attending the meeting. If additional forms are needed, you may make copies. If you have questions or need assistance, contact Heather Bullock at (402) or hbullock@nhanet.org. Please print clearly Name/Title Organization Address City, State, ZIP Phone Fax Name and phone of person completing this form: Registrant Survey: If you are a trustee, how many years have you served? Facility type: (please circle all that apply) Frontier, Rural, Urban, For-profit, Non-profit, CAH, Government REGISTRATION FORM SYMPOSIUM REGISTRATION FEES: (includes Wednesday, Thursday and Friday sessions) Member of Hospital Association: $495/person Four or More Members*: $450/person Non-Member: $750/person TOTAL: $ SPOUSE/GUEST FEE: Spouse/Guest: $85 per person (Includes Welcome Reception, and Thursday and Friday breakfasts. Luncheons not included.) TOTAL: $ Spouse/Guest Name: Welcome Reception (included in spouse registration fee) Attending Not attending MISCELLANEOUS: Late/On-site Fee: $55 per person TOTAL: $ (registrations after May 18, 2010) GRAND TOTAL DUE: $ *Multiple Registration Discount If four or more individuals from your organization submit registrations at the same time, each may register at this reduced rate. This discount does not apply to a spouse and/or guest registering for the symposium. WEDNESDAY, JUNE 9 Governing in an Era of Uncertainty Attending Not attending Mini-Workshop - 2:00-3:15 p.m. & continues from 3:30-4:45 p.m. Trustee Toolkit Experience Concurrent Sessions - Select session you will be attending (one for each time slot) 1. Problematic Doctors 2:00-3:15 p.m. 3:30-4:45 p.m. 2. New Governance Mandate 2:00-3:15 p.m. 3:30-4:45 p.m. 3. Physicians/Hospitals as Allies 2:00-3:15 p.m. 3:30-4:45 p.m. 4. Assuring Quality Healthcare 2:00-3:15 p.m. 3:30-4:45 p.m. Welcome Luncheon Attending Welcome Reception Attending THURSDAY, JUNE 10 Not attending Not attending Concurrent Sessions - Select session you will be attending (one for each time slot) 5. Healthcare Payment Systems 10:30-11:45 a.m. 1:30-2:45 p.m. 6. Board Succession Planning 10:30-11:45 a.m. 1:30-2:45 p.m. 7. Competency-Based Governance 10:30-11:45 a.m. 1:30-2:45 p.m. 8. Capital Markets Update 10:30-11:45 a.m. 1:30-2:45 p.m. 9. Do You Measure Up? 10:30-11:45 a.m. 1:30-2:45 p.m. FRIDAY, JUNE 11 Getting Outside of the Box: Unconventional Thinking for Board Members Attending Not attending AHA Federal Update Attending Not attending METHOD OF PAYMENT: Check (Payable to Nebraska Hospital Association) Visa MasterCard Name on Card Card Number Expiration Date Signature SPECIAL NEEDS: Please list THREE WAYS TO REGISTER: 1. Mail registration form and check payment to: Nebraska Hospital Association, P.O. Box 82653, Lincoln, NE Fax form with credit card information to: (402) Online at For Association Use Only Date Received: Amount Received: Date Posted: For Association Use Only Check Number: Comments:

59 The Western Regional Trustee Symposium is a collaboration of the hospital associations from Colorado, Idaho, Montana, Nebraska, Nevada, New Mexico, Utah, Wyoming and Arizona Log on to for more information Mark Your Calendar! 15 th Annual Western Regional Trustee Symposium June 8-10, 2011 Embassy Suites Omaha, Nebraska

60 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.c.ii

61 Leadership Conference for trustees, physicians, executives, & nurse executives The Grove Park Inn Resort & Spa Asheville, North Carolina May 16 19, 2010 Toll Free (877) Greenwich Drive Suite 200 San Diego, CA GovernanceInstitute.com

62 may leadership conference Nationally recognized as the preeminent source for unbiased governance information, The Governance Institute provides essential knowledge and solutions for hospital and health system trustees, physician leaders, and executive management to achieve excellence in governance. Through our Leadership Conferences, The Governance Institute offers current information, interactive sessions, expert speakers, and the opportunity to meet others with a similar commitment to improving governance and achieving optimal board performance. The 2010 conference programs are based on The Governance Institute s 2010 Education Agenda, available for download at GovernanceInstitute.com. Conference Learning Objectives: Understand the value of an effective board and the roles and responsibilities associated with being a board member. Have greater awareness of board member accountability, the need for transparency, and how to achieve organizational integrity. Address finance, quality and patient safety, and information technology issues to create positive change in your organization. Make sound strategic decisions and develop both short- and long-term strategic goals. Discover new and practical ways to deal with the challenges of today s changing healthcare environment. featured speakers Gerard van Grinsven president & ceo Henry Ford West Bloomfield Hospital Marian C. Jennings, M.B.A. president M. Jennings Consulting, Inc. Brian D. Wong, M.D., M.P.H. founder & ceo The Bedside Trust, LLC James G. Sheehan medicaid inspector general New York State Brian J. Silverstein, M.D. senior vice president The Camden Group Eric D. Lister, M.D. managing director Ki Associates Jeffrey C. Bauer, Ph.D. partner, management consulting futures practice ACS Healthcare Solutions

63 conference program 12:00 p.m. 1:30 4:00 p.m. Concurrent Sessions 4:30 6:00 p.m. General Session 6:00 7:00 p.m. 7:00 a.m. 8:00 9:30 a.m. General Session 9:45 10:45 a.m. Concurrent Sessions 11:00 a.m. 12:30 p.m. General Session 10:00 11:30 a.m. General 12:30 Session p.m. 1:30 3:00 p.m. Concurrent Sessions sunday, may 16 REGISTRATION Governance & Leadership Board Fundamentals Pamela R. Knecht, President, ACCORD LIMITED Given the intense focus on board performance, accountability, and transparency, it is now more important than ever for board members to understand their fiduciary duties and core responsibilities. The session provides an update on those topics and explores recent research from The Governance Institute on recommended practices for boards. HEALTHCARE TRENDS Futurescan Healthcare Trends & Implications, Thomas C. Dolan, Ph.D., FACHE, CAE, President & CEO, American College of Healthcare Executives James A. Rice, Ph.D., FACHE, Vice Chairman, The Governance Institute Developed by a panel of experts, Futurescan highlights key trend areas that are impacting the nation's healthcare organizations, such as economic outlook, payment reform, physician-hospital integration, genomic medicine, information technology, and nursing. This interactive session will demonstrate how to use Futurescan insights in new strategic visioning charrettes. hospital physician relationships Diagnose, Then Treat: A Curative Methodology to Address Complex Organizational Problems Brian D. Wong, M.D., M.P.H., Founder & CEO, The Bedside Trust, LLC This interactive session will clarify the issues that really matter: how to design optimum physician hospital relationships, the perils of "business as usual" mentality, and why treating the symptoms is unsustainable. governance & leadership Take Health & Healing Beyond the Boundaries of Imagination Gerard van Grinsven, President & CEO, Henry Ford West Bloomfield Hospital This session will discuss the simultaneous pursuit of differentiation and low cost, the creation of a new value curve, and how to deliver on the unexpressed wishes and needs of your customers with an emotionally engaged workforce. reception monday, may 17 continental breakfast financial & capital planning Investing Capital in Uncertain Times: The Board s Role Marian C. Jennings, M.B.A., President, M. Jennings Consulting, Inc. The future of the hospital/healthcare industry has never been as uncertain as it is today. Short term, many hospitals and systems have put a "hold" on capital spending. However, this "wait and see" posture can last only so long. How should the board approach prudent long-term capital investment to further the organization s mission while ensuring its financial integrity? governance & leadership Earning the Public s Trust: Zero Defects Governance Pamela R. Knecht It is a new era; non-profit boards must earn the public s (and regulators ) trust through exemplary behavior in key areas. Ms. Knecht will explain how high-performing boards are taking a 'zero defects' approach in areas such as conflicts of interest, executive compensation, and organizational transparency. financial & capital planning Who Will Pay the Bill & How? Marian C. Jennings, M.B.A. With the first baby boomers hitting 65 in less than one year, the need to "flatten the Medicare cost curve" is something all Washington politicians agree on. Agreeing on the "how" is a bit more difficult! This interactive session will examine the economics and politics behind a potential payment revolution and the likely impact on hospitals. GOVERNANCE & LEADERSHIP Intentional Governance: A Deliberate Approach to Board Leadership & Development Sean Patrick Murphy, Senior Vice President, Corporate General Counsel, Solaris Health System Anne D. Mullaney, Partner & Health Care Practice Group Co-Leader, Thorp Reed & Armstrong, LLP Standards and expectations for governing boards are radically changing. This session will discuss the connection between effective board leadership and intentional governance, review national trends in board education and development, and present research and case studies on the barriers to good governance. Medical LEadership Overwhelmed, Inefficient, & Fragmented: How a Cultural Operating System Increases Productivity Brian D. Wong, M.D., M.P.H. How will a "self-organizing" culture change the current state of healthcare? Learn how to replace your individually driven ways with a "community intelligence" approach in this answer-oriented discussion. lunch HOSPITAL PHYSICIAN RELATIONSHIPS Physician Integration Economics Marc D. Halley, Chief Executive Officer, Halley Consulting Group Physician Integration Economics explores the fundamentals of partnering with physicians under the hospital employment model. Learn strategic and financial considerations associated with capturing market share, the flow of referrals, capital generation, and reinvestment.

64 1:30 3:00 p.m. Concurrent Sessions (continued) 7:00 a.m. 8:00 9:30 a.m. General Session 9:45 11:15 a.m. General Session 11:30 a.m. 12:30 p.m. Concurrent Sessions 2:00 4:30 p.m. General Session 7:00 a.m. 8:00 9:30 a.m. General Session 10:00 11:30 a.m. General Session 11:30 a.m. HEALTHCARE TRENDS Medicare: What Is Happening? What Can We Expect? Leslie V. Norwalk, Strategic Council, Epstein Becker & Green, P.C. & Former Acting Administrator for the Centers for Medicare and Medicaid Services Ms. Norwalk will discuss the latest out of Washington D.C., including Medicare and Capital Hill, and how it is expected to impact the healthcare sector generally and hospital reimbursement specifically. hospital physician relationships Root Cause Analysis 101 Brian D. Wong, M.D., M.P.H. Discover how a cultural operating system will reduce the need for complicated process improvements and unnecessary meetings by solving problems at the root level, before they escalate. tuesday, may 18 Continental Breakfast legal & regulatory issues Raised Expectations: Enhanced Governance Responsibilities for Transparent Healthcare Organizations James G. Sheehan, Medicaid Inspector General, New York State The government requires accurate reporting on quality, medical errors, and hospital acquired conditions, as well as mandatory compliance programs, disclosures of payments, and payback of payments received in error. Many organizations lack processes or internal reporting systems to address these responsibilities. Examine issues, audits, and investigation risks from government, media, patients, and the public. healthcare trends Creating Energy from Chaos: Top Actions That Drive Performance in Turbulent Times Brian J. Silverstein, M.D., Senior Vice President, The Camden Group The future of healthcare in America can be characterized as a continued evolution bound by realities. Promising advancements in clinical technology abound, but unlike the past, the pressures of cost-effectiveness and transparency will temper growth. Future success depends on properly channeling the energy of physician relationships and maximizing limited resources. legal & regulatory issues Lessons from Mandatory Compliance James G. Sheehan New York Medicaid requires every hospital to have an eight element compliance program, and certification that it is effective. This session will discuss predictable issues and lessons learned from the implementation of mandatory compliance programs, which are included in all new national healthcare plan proposals. HOSPITAL PHYSICIAN RELATIONSHIPS Balancing Medicine & Management Barry Silbaugh, M.D., M.S., FACPE, Chief Executive Officer, The American College of Physician Executives Dr. Silbaugh will share insights and experiences on developing strong, collaborative physician hospital relationships, how the cultures of medicine and management differ, how to engage physicians in creating a highly reliable health system, and what communication pitfalls to avoid when dealing with physicians. LEGAL & REGULATORY ISSUES Evolving Physician Alignment Models in Light of Healthcare Reform & Beyond Anjana D. Patel, Esq., Sills Cummis & Gross, P.C. This session will provide a discussion of some new and modified hospital physician alignment models and strategies in light of proposed national healthcare reform, as well as recently amended legal restrictions (e.g., the Stark law). Topics will include cutting-edge models such as captive PC employment, gainsharing, pay-for-performance, co-management, accountable care organizations, and medical homes. healthcare trends How Payment Reform Is Shaping the Future Healthcare Delivery System Brian J. Silverstein, M.D., Marian C. Jennings, M.B.A., & James G. Sheehan Misaligned payment incentives which reward utilization have driven healthcare spending to a near breaking point. Wide disparities in the cost and quality of care are giving way to new forms of payment that reward provider coordination and quality outcomes. Learn how your organization can thrive in tomorrow s payment landscape. Wednesday, may 19 Continental Breakfast quality From the Boardroom to the Bedside: Driving Improvement in Quality & Safety Eric D. Lister, M.D., Managing Director, Ki Associates Dr. Lister will frame the quality and safety challenges confronting American hospitals, describe the duties of the board, and outline an approach for effective governance. The session will focus on the role of the board quality committee, the dashboard that supports that committee's work, and the issues less amenable to dashboard metrics but nonetheless important to the oversight function of the board. healthcare trends The Post-Reform Future of Healthcare: Smart Strategic Responses for Dumb Times Jeffrey C. Bauer, Ph.D., Partner, Management Consulting Futures Practice, ACS Healthcare Solutions The dust from the 2009 battle over health reform may have settled, but economic and political conditions still don't make sense. This practical, updated analysis of five general trends that define possibilities for the health systems concludes with specific responses the leaders should consider in response to changes in the marketplace. Adjourn

65 hotel information About the grove park inn resort & spa The Grove Park Inn Resort & Spa is one of the South s most venerable and famous grand resorts. Since opening in 1913, the Inn has become one of the country s most celebrated resorts, welcoming countless luminaries and multiple presidents through its doors. This luxurious property has earned numerous accolades including a place on Fodor s list of Top 10 Luxury Spa Resorts. The property overlooks the Asheville skyline and provides majestic views of the legendary Blue Ridge Mountains. At The Grove Park Inn Resort & Spa, experience 512 unique guest rooms and suites, a wide selection of restaurants and lounges, one of the world s finest spas, a newly restored Donald Ross golf course, tennis, swimming pools, and a state-of-the-art sports complex. Address The Grove Park Inn Resort & Spa 290 Macon Avenue Asheville, North Carolina Hotel phone: (828) Hotel fax: (828) Hotel Reservations There are a limited number of rooms at The Governance Institute rate, so make your room reservations as early as possible. Hotel accommodations are the responsibility of each attendee; conference registration does not secure your room. Reservations phone: (800) Reservations fax: (828) Check in: 4:00 p.m. Check out: 12:00 p.m. Room rate: $259* (SGL/DBL) All reservations must be made by April 15, 2010 to secure this rate. Should the room block become full before April 15, reservations will be accepted on rate/space availability. Note: All room rates and packages are subject to state and local taxes. All taxes are subject to change without notice. All reservations require an advance deposit to confirm the reservation. Room reservation deposits are equal to the first night s room charge. A portion of the room rate will be used to offset catering costs. Cancellation Policy Deposits will be refunded if hotel receives notice of cancellation at least (7) days prior to scheduled arrival. In the event a cancellation is received less than (7) days prior, the individual is responsible for payment of full stay and taxes. Companion program the biltmore estate tour & lunch Monday, May 17, :00 a.m. 4:00 p.m. Be inspired by the relaxed elegance of George and Edith Vanderbilt's 250-room family home and country retreat. Discover original art from masters such as Renoir, magnificent 16th-century tapestries, Napoleon's chess set, a library with 10,000 volumes, a banquet hall with a 70-foot ceiling, 65 fireplaces, an indoor pool, bowling alley, and priceless antiques. This French Renaissance chateáu remains America's largest privately owned home. After the tour enjoy lunch at the Stable Café and then take a stroll through acres of formal and informal gardens designed by America's foremost landscape architect, Frederick Law Olmsted. If time allows, there will be an opportunity to visit the River Bend Farm where you can experience what it was like to live and work on the estate in the 1890s.

66 ongoing governance education medical leadership institute The Governance Institute is proud to provide comprehensive and timely information, practical tools, and conferences to prepare medical staffs for the challenges of leadership. At all Governance Institute Leadership Conferences, sessions will be offered to provide a specific focus for physician leaders and cover important issues for hospital board members to better understand the board s relationship with the medical staff. In addition the Medical Leadership Institute offers the following conferences: April 11 13, 2010 October 3 5, 2010 Medical Leadership Institute Spring Conference The Ritz-Carlton, Naples, Naples, Florida Medical Leadership Institute Fall Conference La Costa Resort and Spa, Carlsbad, California To register or to find more information, please visit GovernanceInstitute.com. conference moderator For the last nine years, attendees at The Governance Institute Leadership Conferences have seen moderator Lynn Phillips as he introduces the general sessions, updates attendees on ongoing educational activities at The Governance Institute, and keeps sessions on schedule. Lynn comes to The Governance Institute having served 32 years as an associate producer for fundraising for non-profit organizations, and as a senior manager for a major publishing company. He uses that experience and talent to bring attendees together, facilitate discovery, and be an ambassador for an enjoyable experience at The Governance Institute Leadership Conferences. In addition, Mr. Phillips serves as a partnership executive for The Governance Institute. In this role, he is creating partnerships to support all of our governance education, services, and products. continuing education credits available ACCME: The Governance Institute is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Governance Institute designates this educational activity for 19 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. ACHE: The Governance Institute is authorized to award 19 credits of preapproved Category II (non-ache) continuing education credit for this program toward advancement, or recertification in the American College of Health Executives. Participants in this program wishing to have the continuing education hours applied toward Category II credit should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification. Nursing continuing education contact hours provided by Nenner Enterprises, Inc. approved by the California Board of Registered Nursing, Provider #15191 for contact hours, depending on the number of sessions actually attended. gavel certificates The Governance Institute provides certificates of achievement for distinguished levels of participation in healthcare governance education. Acknowledge trustees and executive team members for their commitment to staying informed about key healthcare issues. Please call (877) to determine your organization s level of achievement and request your certificate: Silver Gavel: Attend 2 Governance Institute Leadership Conferences in a 2-year period. Gold Gavel: Attend 3 Governance Institute Leadership Conferences in a 3-year period. Platinum Gavel: Attend 4 Governance Institute Leadership Conferences in a 4-year period. partnership The Governance Institute thanks Premier Partners Broadlane and Kaufman, Hall & Associates, Inc. for their continuing support of excellence in healthcare governance. For more information regarding partnership, please visit GovernanceInstitute.com/Partnership. The leading cost management company for healthcare providers

67 conference REGISTRATION For registration information, call toll free (877) Tuition includes all conference materials, general and concurrent sessions, continental breakfast, a lunch, and a reception. We offer three easy ways to enroll: (1) FAX to (858) ; (2) ONLINE at GovernanceInstitute.com/Calendar; (3) MAIL to The Governance Institute, 6333 Greenwich Drive, Suite 200, San Diego, CA Tuition Fees for Leadership Conferences r The Governance Institute Members r Free Member Annual Passes Member fee 60 days before the conference Member fee within 59 days of the conference Non-Members Non-member fee 60 days before the conference Non-member fee within 59 days of the conference # # of persons x $1,450 = $ # of persons x $1,550 = $ # of persons x $1,750 = $ # of persons x $1,850 = $ Total Amount Enclosed $ Total Number of Attendees # Please select any of our 2010 LEADERSHIP Conferences: r r r r r r January 10 13, 2010, The Ritz-Carlton, Naples, Naples, Florida February 21 24, 2010, The Breakers, Palm Beach, Florida March 7 10, 2010, The Grand Del Mar, San Diego, California May 16 19, 2010, The Grove Park Inn Resort & Spa, Asheville, North Carolina September 12 15, 2010, The Broadmoor, Colorado Springs, Colorado October 17 20, 2010, The Greenbrier, White Sulphur Springs, West Virginia 5 FREE Annual Passes for Members Method of Payment: Please Print o Check enclosed (Payable to The Governance Institute) o VISA o mastercard Credit Card Number Card Holder s Name Expiration Date Signature SAFE & SECURE REGISTER ONLINE GovernanceInstitute.com Please note: Conference expenses paid for by a trustee can be claimed as a donation and listed as an itemized deduction on the trustee's income tax return. Please consult your tax advisor for more information. Please call (877) for registration information for the 2010 Chairperson & CEO Conference, June 6 8, at The Cloister at Sea Island, Sea Island, Georgia (members only). Organization information: Please print. Organization Name Name of CEO Address City State Zip Contact Name Contact Title Contact Phone Contact Names and titles of those attending the conference: Please photocopy & fax any additional names. Please print. 1. First Name Last Name Suffix Title p Special Needs First Name (as it should appear on name badge) Companion s Name (as it should appear on name badge) 2. First Name Last Name Suffix Title p Special Needs First Name (as it should appear on name badge) Companion s Name (as it should appear on name badge) 3. First Name Last Name Suffix Title p Special Needs First Name (as it should appear on name badge) Companion s Name (as it should appear on name badge) Cancellations The tuition, less a $250 administration fee per attendee, will be refunded if the cancellation is received in writing (via mail, , or fax) 30 days or more prior to the beginning of the conference. For cancellations received less than 30 days prior to the conference, the tuition, less the administration fee, will be applied toward a future conference within one year. No-shows (cancellations within 72 hours of the conference) cannot be refunded or transferred to another conference (including member passes).

68 2010 Leadership Conferences The Ritz-Carlton, Naples Naples, Florida January 10 13, 2010 The Breakers Palm Beach, Florida February 21 24, 2010 The Grand Del Mar San Diego, California March 7 10, 2010 The Grove Park Inn Resort & Spa Asheville, North Carolina May 16 19, 2010 The Broadmoor Colorado Springs, Colorado September 12 15, 2010 The Greenbrier White Sulphur Springs, West Virginia October 17 20, 2010 PRSRT STD U.S. POSTAGE P A I D SAN DIEGO, CA PERMIT # Governance Support Conference The Grove Park Inn Resort & Spa Asheville, North Carolina August 8 10, chairperson & Ceo Conference The Cloister at Sea Island (members only) Sea Island, Georgia June 6 8, medical leadership institute conferences The Ritz-Carlton, Naples Naples, Florida April 11 13, 2010 La Costa Resort and Spa Carlsbad, California October 3 5, Greenwich Drive Suite 200 San Diego, CA May 16 19, 2010 the grove park inn resort & spa asheville, north carolina

69 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.c.iii

70 2010 PRELIMINARY PROGRAM Adventures in Education 64th IIMC Annual Conference May 23 - May 27, 2010 EARLY BIRD April 5, 2010 Reno, Nevada Virginia City Lake Tahoe

71 ADVENTURES IN EDUCATION RENO-TAHOE, NV Schedule of Events Adventures In Education, keeping that theme in mind, IIMC and the 2010 Reno Host Committee have designed a schedule that incorporates global excellence through imaginative thinking, creativity, diversity and inspiration. Replete with all the amenities and networking opportunities that IIMC members have come to experience over the years, the 64th IIMC Annual Conference also features an outstanding blend of four General Sessions, more than 30 Concurrent Education Sessions, 12 Master Municipal Clerk Academies, and two Athenian Leadership Society Dialogues to make for an excellent and memorable 2010 Conference. Except for the Opening Reception and the All-Conference Event, all education sessions, meetings and registration will be held at the Grand Sierra Hotel. 4 SATURDAY, MAY 22 Conference Registration Opens 2009/10 IIMC Board of Directors Meeting Academy Seminars Athenian Leadership Society Dialogue SUNDAY, MAY 23 MCEF Walk/Run Conference Registration Academy Seminars Athenian Leadership Society Dialogue IIMC Committee Leadership Orientation Institute Directors/Education Chairs Colloquium Exhibit Hall Opens First-Time Delegate Orientation Opening Reception - National Automobile Museum DJ & Dancing MONDAY, MAY 24 Opening Ceremony General Session Concurrent Education Sessions Region Meetings Committee Meetings Exhibit Hall Grand Opening/Luncheon Region Dinners (Optional) DJ & Dancing IIMC 64th Annual Conference TUESDAY, MAY 25 General Session Concurrent Education Sessions Committee Meetings Exhibit Hall Lunch Institute Directors Meeting DJ & Dancing WEDNESDAY, MAY 26 Concurrent Education Sessions General Session Committee Meetings LUNCH ON YOUR OWN All-Conference Event - Virginia City DJ & Dancing THURSDAY, MAY 27 IIMC Annual Business Breakfast Meeting General Session Concurrent Education Sessions 2010/2011 IIMC Board of Directors Meeting Annual Reception Annual Banquet DJ & Dancing *Schedule Subject to Change ATTENTION CONVENERS Are you comfortable speaking in front of others? If you are or even if you re not, being a convener at an IIMC session at the Conference is an excellent forum to hone your speaking skills. Conveners are responsible for introducing speakers and assisting them when necessary. Delegates interested in being a convener at the 2010 Conference, please contact Jennifer Ward, Education Analyst at jward@iimc.com

72 ADVENTURES IN EDUCATION RENO-TAHOE, NV 2010 General Education Sessions This year, we offer four General Education Sessions presented by nationally known speakers who will discuss diverse and timely subjects relevant to the job of the Municipal Clerk. Sessions include Accountability, Ethics, Customer Service and Stress Management. Monday, May 24 1:30 p.m. 2:30 p.m. No More Excuses (Accountability) Sam Silverstein, CSP Sam Silverstein Enterprises, Inc., St. Louis, MO Why do some succeed while others fail? It starts with eliminating excuses, eradicating justifications and taking personal accountability for choices, actions and results. It starts with accountability. For over thirty years, Sam Silverstein has led thriving companies, selling upwards of $100 million in products and services. He has witnessed successful people fail, and seen underdogs triumph. He has distilled his invaluable experiences and observations into a message companies need now more than ever. Sam will share the five accountabilities for personal and organizational growth. He presents the four phases of accountability and the steps necessary to transform organizational cultures to ones of accountability. Sam will challenge your group to take an honest look at themselves; to discover what is blocking them from achieving their goals. Application of Sam s principles improves leadership, increases sales and improves customer service. By creating a culture of accountability, organizations grow stronger. Entrepreneur, business expert, and international author Sam Silverstein s battle cry of No More Excuses has been heard by companies and business professionals the world over. Accountability is today s competitive advantage to reclaim market share and win the heart of a hyperdiscerning consumer. Silverstein knows how to get million-dollar results. His companies have sold upwards of $100 million in products and services, and he successfully sold one of his businesses to a Fortune 500 company. Corporations such as AFLAC and Lucent Technologies rely on Sam to learn how to sell more, be more effective leaders, provide greater service and increase income in trying times. His programs focus on accountability and authenticity, teaching his hard-learned lessons and his winning techniques to build success both personally and professionally. Sam has shared his millionaire secrets on over 450 radio stations and on CNBC s The Big Idea with Donny Deutsch. He has authored ten books, is the creator of the acclaimed Strategic Business Acceleration System, and has been a contributing author to countless publications throughout his incredible career. Upwards of 40,000 business professionals subscribe to his monthly newsletter alone. Sam served as the President of The National Speakers Association and is a Certified Speaking Professional. Originally from Atlanta, he has a Business degree from the University of Georgia and an MBA from Washington University. He is married with four children and currently resides in St. Louis, MO. Tuesday, May 25 8:30 a.m. 9:30 a.m. Ethics: The Ultimate Challenge in Ethics; Are You Really the Person Your Dog Thinks You Are? (Ethics) Howard Putnam Former Southwest Airlines CEO and Author of The Winds of Turbulence, Reno, NV Organizations cannot ignore the need for proactive efforts to ingrain honesty, integrity and trust at every level. Today s environment requires ethical leaders, if they want their businesses to survive and grow. Howard Putnam learned the values of trust and honesty as he grew up on an Iowa farm. He has embodied those principles in his 16 IIMC 64th Annual Conference

73 ADVENTURES IN EDUCATION RENO-TAHOE, NV 2010 General Education Sessions successful business career. He took on the challenge of saving Braniff International only to find the books had been cooked prior to his arrival. He will share this character building experience of taking a major airline through Chapter 11 successfully and offer a flight plan for you to implement in your organization. Howard Putnam s ultimate objective is bottom line improvement. He believes that cultures that place people as their number one priority have the greatest long-term impact and success. He is the former CEO of the highly successful Southwest Airlines whose foundation and culture placed people first. Later, when recruited to be the CEO of failing Braniff International, he was the first CEO to successfully restructure a major airline into through, and out of Chapter 11. Earlier he spent over 20 years with United Airlines, his final position being group vice president of marketing. He has been an entrepreneur and has served as a director of several startup technology companies. He is an author, speaker and advisor on business issues, change, leadership, and ethics. HarperCollins published his first book, The Winds of Turbulence. Harvard University wrote a case study on his Braniff experiences, The Ethics of Bankruptcy. He has an MBA in marketing from the University of Chicago and attended Harvard s Advanced Management Program. Putnam grew up on an Iowa farm and learned to fly out of a pasture. His wife Krista is a native of Ohio and a former flight attendant. Their son Mike is an airline captain based in Charlotte, and daughter Sue is in public relations and advertising in Reno. Putnam and Krista live in the mountains near Reno and Lake Tahoe. Nevada Trivia The longest morse code telegram ever sent was the Nevada state constitution. Sent from Carson City to Washington D.C. in The transmission must have taken several hours. Wednesday, May 26 8:30 a.m. 9:30 a.m. World Class Service Excellence (Customer Service) Michelle Ray, CSP Walkabout Seminars International, Vancouver, BC The Customer Service revolution is still in full swing! Is your front line staff committed to an attitude of gratitude for the business your customers provide? Are they giving a gold medal performance with every customer experience? The first point of contact can make or break customer relationships within seconds. Is your team set up to win the seven second challenge with customers? The theme of this exciting keynote address is based on the reality that almost 70% of customers take there business elsewhere due to an attitude of indifference! Recharge your attitude to client relationships: They are the reason you are in business Learn the six secrets of customer satisfaction to outsmart the competition Improve your internal client relationships to increase bottom line results Learn dynamic communication strategies Master the art of diplomacy with your most annoying clients! Avoid the cost of loss a bad service experience with your organization has immeasurable consequences! Michelle Ray is a highly sought-after international keynote speaker, author and seminar leader who demonstrates a deep understanding of the consequences of low morale, lackluster service and ineffective leadership in the workplace. Born in Australia, Michelle began her career in the media industry during the recession of the early 80 s. She was once told by management that she didn t have what it takes to succeed in the business world. With self- doubt and a lack of mentors, Michelle was inspired to create her own successful international business. She speaks passionately about the impact of attitude in the workplace, the importance of outstanding leadership and the responsibility of positive communication and influence. IIMC 64th Annual Conference 17

74 ADVENTURES IN EDUCATION RENO-TAHOE, NV 2010 General Education Sessions A Certified Speaking Professional, a designation held by less than 10% of members of the National Speakers Association, Ray has already been listed in the 2005 Who s Who of Professional Speakers, and was awarded the Presentation Mastery Award as the Presenter of the Year 2004 for the Vancouver Chapter of the Canadian Association of Professional Speakers. In 2003 she was recognized as the top speaker in Canada for the world s largest international public seminar company. Her own company, Walkabout Seminars International, was listed by Business in Vancouver as one of the top management training companies in Vancouver in 2002 and Michelle s clients include numerous associations, government departments, the healthcare sector, small business and corporations. Her motivating keynotes and interactive workshops have a thought-provoking, amusing, common sense message. Her limitless energy, masterful use of humor and down to earth approach has earned her respect and appreciation by clients around the world. Michelle Ray s depth of knowledge and powerful message is guaranteed to energize, inform and inspire workplaces across the globe! Thursday, May 27 10:15 a.m. 11:30 a.m. Overcommitted, Overwhelmed and Over It! Success Skills for the Blisteringly Busy (Stress Management) Juliet Funt, Talking on Purpose, Inc., Beverly Hills, CA Is your to-do list a novel? Is your inbox jam-packed every morning? Do you find yourself wishing for a fire drill just so you can step away from your desk for 10 minutes? Don t worry. You are not alone. Life is getting busier and more demanding for everyone these days. In fact, the #1 business lifestyle complaint in the world today is having too much to do with too little time. And those timemanagement books aren t much help because they just give you ways to juggle all the work causing the stress. They don t say much about how to actually reduce the stress itself. What would you give to feel relaxed and light-hearted as you face the challenge of this taxing atmosphere where the pressure never stops increasing? Get ready to smile, because Juliet Funt is about to take you on a fast-paced, story packed, hilarious ride to right where the answers lie. Enjoy stories of how real people have rediscovered the excitement of tackling the challenges of work and savoring those precious moments with family and friends. Laugh at the absurdities of the business world and how it drives some people bonkers. Learn the simple but powerful strategies that enable you to manage your inbox, juggle a dozen projects, and shift your point of view from panic to acceptance and from acceptance to fulfillment. If your CFO isn t convinced, remind him that American companies spend $150 billion every year just on stressrelated disability. That s not counting the wasted time from tension, the lost productivity from low morale, and the costs of higher employee turnover. Juliet will help you change the way you think about your goals so you can prioritize the smart way, be more productive, and clarify what s really important. You ll discover... How to define real success in the relentless Age of Never Enough. Commonsense ways to cope with the pace and quantity of your daily tasks. The secret for keeping White Space on your calendar -- it s not a myth! Plus, lots and lots of laughter to lift your mood TODAY! As the daughter of Allen Funt, creator of the Candid Camera television show, Juliet has spent her life observing the hidden truths beneath our social selves. She won t hide a camera in your office but will bring her family tradition of hilarity and warmth to each and every attendee. Juliet lights up the platform with a true wordsmith s love for the poetry of a well-turned phrase. She then backs up her engaging words and rich stories with thought-provoking content that has made her a nationally recognized expert in coping with the pace and pressure of our busy lives. Her uproarious stories and easily applicable 18 IIMC 64th Annual Conference

75 ADVENTURES IN EDUCATION RENO-TAHOE, NV 2010 General Education Sessions points will energize and enlighten you and your audience. Her show biz genes are amplified by years performing improvisational comedy on the professional stage and many, many hours on the platform challenging her audiences to think deeper, laugh harder, and change their lives more profoundly. She helps businesses, groups and associations from top management to front line employees, find and nurture the human capital that is the fuel behind every organizational success. Her diverse work history has taken her through a myriad of roles: from Project Manger for a live events company to Human Relations trainer for the Los Angeles Police Department through the Museum of Tolerance, and even to Israel as a liaison in a Palestinian/Israeli peace project. Juliet began her television career at two years old at the hands of her proud poppa, and since has appeared on national news, television, and radio. She has been featured in the L.A. Times, The Chicago Tribune, Shape, L.A. Parent and Professional Speaker magazine. She has been a weekly columnist for the Womenof.com Internet community, and a co-author of The Communication Path and The Wellness Path, in the Path Training Series. Her programs are great for Associations, Women s Groups, Educators, Financial Professionals, Healthcare, Real Estate, and many other audiences. She is a member of the National Speakers Association and fills her spare time running a fine art photography business with her fabulous and talented husband Lorne, winner of the 2005 Travel Photographer of the Year. (www. resnickfineart.com) Together they have co-founded the Young Stars Project, a non-profit organization building holistic learning schools for children in Uganda. (www. youngstarsproject.org). Conference Discount Program Membership Offers Plenty of Savings There are several ways you and your municipality can save money on the Delegate Registration Fee. To qualify, you MUST BE AN IIMC MEMBER and fit in one of the following categories. 1) $50.00 DISCOUNT FOR FIRST-TIMERS A FIRST-TIMER is an IIMC Member who has NEVER ATTENDED an IIMC Conference. If Reno, NV, will be your FIRST IIMC CONFERENCE, you will receive a $50.00 discount off of the Delegate Registration Fee. 2) $50.00 DISCOUNT FOR REGIONS 8 and 9 CLERKS If you are a Municipal Clerk in Region 8 (AZ, CO, ID, MT, NE, NV, NM, ND, SD, UT, WY) or Region 9 (AK, CA, HI, OR, WA), you will receive a $50.00 discount off of the Delegate Registration Fee. 3) $50.00 DISCOUNT FOR REGION X MEMBERS If you are a Region X (Canada) Member, you will receive a $50.00 discount off of the Delegate Registration Fee. Use any combination to receive your discounts. For example: If you re a FIRST-TIMER and a CLERK FROM REGION 8 OR 9, you will receive $ ($50.00/First-Time and $50.00/ Region 8 or 9 Clerk) off of the Delegate Registration Fee. CATEGORY MEMBER DISCOUNT First-Timer = $50.00 Region 8 or 9 Clerks = $50.00 Region X (Canada) = $50.00 NOTE: Discounts apply ONLY to the full Conference Delegate Registration Fee and not to any other Conference category or area. Discounts DO NOT apply to Retirees, Guests, Non-Members, Institute Directors, Exhibitors, Academy Programs, Single-Day Registration, Individual Tickets, All- Conference Event, Meal Functions, etc. FIRST-TIMER, REGION 8 OR 9 CLERKS AND REGION X DELEGATES CAN AUTOMATICALLY DEDUCT THEIR DISCOUNT ON THEIR CONFERENCE REGISTRATION FORM. Help us make the 2010 Conference in Reno the largest IIMC Conference ever. IIMC 64th Annual Conference 19

76 ADVENTURES IN EDUCATION RENO-TAHOE, NV Concurrent Education Sessions Communication Communicating With Values, Sensitivity and Cultural Awareness Operation Cooperation: Communication and Teamwork The Emerging City Clerk Branding and Marketing Our Profession in a New Era of Local Governance Public Speaking: The Good, The Bad and The Ugly International Relations Finance/Budgeting Internal Controls When Management Overrides Fraud Awareness and Prevention Understanding Municipal Finance For Small Community Clerks Emergency Management The Emergency Management Process The Incident Command System (ICS) Dealing With The Media Incident Walkthrough Recovering From A Major Incident Leadership/Management Leadership in the Age of Distraction Leading Change Ethics Summit The Never Ending Crisis: Leading and Managing in Difficult Times From Crisis to Commitment An Organizational Case Study Leadership is Everyone s Business Planning For Your Future What s In Your Wallet? Why Should I Get Up Out of Bed? Grant Writing Records Management Social Media How to Sell Your City on Citywide Content Management Designing Efficient Filing Systems Records, Records Everywhere! What To Do and Where To Start Conducting A Needs Assessment Best Practices Human Resources Apology and Forgiveness in Business and Life: Mending Relationships, Building Community Conflict Resolution and Mediation Skills: Peace Through Principle Enhancing Inter-Cultural Communication Reducing Employee Complaints and Grievances The Do s and Don ts of Investigations The Golden Rules of Discipline: Just Cause and Due Process Special Session Monday, May 24 5:15 p.m. 6:15 p.m. How May I Help You? An Interactive Session on the CMC and MMC Requirements Emily Maggard MMC Verification Specialist IIMC Marilyn Sanzo CMC Verification Specialist IIMC The IIMC Education Department will answer your questions and discuss the CMC and MMC requirements and processes, explain how to apply your points in each application and which resources to use. Please bring your questions with you to this session. Please do not bring your application and its supporting documents to the conference for review. The Education Department will not accept any documentation at the conference. This session does not qualify for IIMC points. 20 IIMC 64th Annual Conference

77 ADVENTURES IN EDUCATION RENO-TAHOE, NV Print or type all information First Name Last/Surname CMC MMC First IIMC Conf. (Y/N) Home Phone ( ) First Name or Nickname to appear on badge Title Municipality State/Province Country Mailing Address City ZIP/Postal Code Work Phone FAX Please check box if you need special assistance (physically challenged, etc. ) Type of Assistance Discount Program (circle one) (Deduct discounts on this form prior to Total before submiting payment to IIMC.) First Timer Yes No $50.00 Region X (Canada) Member Yes No $50.00 Region 8 or 9 Member Yes No $50.00 GUEST INFORMATION (IIMC Members Cannot Register As Guests) Name First name to appear on badge Municipality State/Province Country REGISTRATION FEES IN U.S. DOLLARS (Payment must be received by 4/05/10) On or Before After Delegate Package No. 4/05/10 (early bird) 4/06/10 (late) Total IIMC $ $ $ IIMC Retired $ $ $ IIMC Region XI (Outside North $ $ $ $ $ $ Guest $ $ $ OPTIONAL ACTIVITIES (All costs in U.S. Dollars) SATURDAY, May 22 - ACADEMY SEMINARS Maverick Thinking: How To Inject Innovation Into Your $ $ Priority Setting for Public $ $ Leaving A Legacy (pre-register by $ $ Conducting Successful $ $ Serv Trac - Professional Service $ $ Generations at Work and $ $ SATURDAY, May 22 Athenian Dialogue - Power Ambition $ $ SUNDAY, May 23 - ACADEMY SEMINARS Building and Repairing Trust As A Public $ $ A Meeting of the Minds - Tap Into the New Science of Communication Success Through Emergenetics(r) (pre-register by $ $ Emergency Response and $ $ Last One Standing: How to Stay Engaged & Motivated After $ $ Understanding The News $ $ Do We Lead, Follow or Get Out of The Way? - Ethics Based Leadership At Its Best (pre-register by $ $ SUNDAY, May 23 MCEF $25.00 $ Athenian Dialogue - Stealing $ $ Submit Registration Form with payment by check/money order credit card (in U.S. funds) by above dates. Payment must accompany registration form. Do not mail and FAX same registration form. Deduct Discount $ CHECK ENCLOSED PAYABLE TO IIMC _ TOTAL $ American Express /Visa /Mastercard # Total Amt. Charged $ Expiration Date Card Holder s Signature You can FAX this Form to IIMC at 909/ OR mail to IIMC, 8331 Utica Avenue, Suite 200, Rancho Cucamonga, CA postmarked by May 1, If you miss this deadline, please bring this Form and payment with you to the Conference Registration Desk at the Grand Sierra Resort. IIMC 64th Annual Conference 23

78 ADVENTURES IN EDUCATION RENO-TAHOE, NV Hotel Information Car Rental Grand Sierra Resort 2500 East Second Street Reno, Nevada HOTEL RESERVATIONS IIMC members and guests can make reservations directly by calling the Grand Sierra at 1-800/ OR log on to this link: grandsierraresort.com/cgi-bin/lansaweb?procfun+rn+ resnet+gsr+funcparms+up(a2560):;iimc10;?/ Conference code: IIMC10 Room rates are: $99.00 for Grand Sierra Rooms and $129 for Summit Rooms with applicable tax (12%). Complimentary Parking AIRPORT INFORMATION The following links provide you with airline and travel information regarding the Reno/Tahoe International Airport: MAP: ITD: The Reno/Tahoe International Airport is less than 10 minutes away from the Grand Sierra Resort. Shuttles are available. IIMC s Official Rental Car Supplier Avis is IIMC s rental car supplier for the 64th Annual Conference in Reno, NV. Attendees wishing to rent a car are eligible to receive discounts from Avis. If you re an IIMC member, you can call or log on to one of the options below: 1) Call Avis directly at to receive the best car rental rates available. The discount is effective 7 days before and 7 days after the event.; OR 2) Log on to: The Avis Worldwide Discount (AWD) Number is J Please use this AWD number when calling. 28 IIMC 64th Annual Conference

79 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.d.i.

80 DEPARTMENT OF SURGERY TRAUMA (BASIC AND ADVANCED) PRIVILEGES Requested BASIC TRAUMA SURGERY Includes: Privileges for pediatric and adult trauma patients to admit, evaluate, diagnose, consult, provide pre-operative, intra-operative and postoperative surgical care, perform surgical intervention when necessary after the diagnosis is made and comprehensively coordinate the care performed by various subspecialty consultants. Criteria to apply for privileges: Applicant must be Board Certified in General Surgery, or Board Eligible (see cover page/instructions), AND Applicant must maintain ATLS certification, AND Applicant must adhere to written guidelines set by the Director of Trauma Surgery Focus Professional Practice Evaluation: Immediate review, under the Trauma Peer Review Process, of trauma cases as performed. Reappointment: To maintain ATLS certification and have current unrestricted General Surgery Core Privileges based on ongoing professional practice evaluation and outcomes. Requested ADVANCED TRAUMA SURGERY Includes: Privileges for pediatric and adult trauma patients to admit, evaluate, diagnose, consult, provide pre-operative, intra-operative and postoperative surgical care, perform surgical intervention when necessary after the diagnosis is made and comprehensively coordinate the care performed by various subspecialty consultants. Criteria to apply for privileges: Applicant must be Board Certified in General Surgery, or Board Eligible (see cover page/instructions), AND Applicant must maintain ATLS certification, AND Applicant must have completed either a Trauma Surgery Fellowship or a Surgical Critical Care Fellowship, AND Applicant must demonstrate experience/expertise in the management of twenty-five (25) trauma cases based upon submission of documented experience, AND Applicant must adhere to written guidelines set by the Director of Trauma Surgery Focus Professional Practice Evaluation: Retrospective review of (5) operative and non-operative patient care management during first six months of initial appointment to be completed under the Trauma Peer Review Process. Reappointment: Management of fifteen (15) trauma patients with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Deleted: (inclusive of any procedure necessitation life-saving measures) Deleted:. Deleted: a minimum of two ( Deleted: 2)

81 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 3.d.ii.

82 Provider : Provider Name Facility: All Facilities Profile : Acute Care Medical Provider Service : Provider Specialty : EMERGENCY MEDICINE Legend: Provider's value leads Specialty range of Blue Provider's value within Specialty range o Green Provider's value lags Specialty range of pyellow Indicator Group Indicator OCT-08 - DEC-09 JAN-09 - MAR-09 APR-09 - JUN-09 JUL-09 - SEP-09 Specialty Range +/-20% Volume C Total Emergency Departmetn Admissions (by Attending) C Total ED patient Procedure Performed (by Procedure Provider) System-Based Practice CDB131 - % ER LOS>6 Hours (by Attending) 0.0% 0.0% 0.0% 0.0% % % CDB132 - % ER Visits Discharged to Outside Acute Care Agencies (by Attending) 0.0% 0.0% 0.0% 0.0% 0.0% C Readmisison to ED <2 days (by Attending) C Readmisison to ED <3 days (by Attending) C ED <3d Readmission Rate (by Attending) Patient Care C Total Emergency Deaths (by Attending) Medical/Clinical Knowledge Focus Core Acute MI (AMI1) - Aspirin on Arrival Focus Core Pneumonia (PN3b) - Blood culture in ED prior to initial antibiotic Focus Core Pneumonia (PN5c) - Antibiotic givin within 6 hours Focus Core Pneumonia (PN6b) - Antibiotic selection for non-icu patients Professionalism C Total Peer Review Cases - Emergency Medicine PRC C Physician/ Practitioner Behavioral Event C Total Patient/ Family Dissatisfaction w/ Physician

83 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 4.

84 Maricopa Integrated Health System Recommended by Credentials Cmt: March 2, 2010 Recommended by MEC DATE: March 9, 2010 Submitted to MSHCDB DATE: March 24, 2010 MARICOPA INTEGRATED HEALTH SYSTEM CREDENTIALS AND ACTION ITEMS REPORT MEDICAL STAFF PART ONE A: CREDENTIALING FAVORABLE RECOMMENDATIONS The credentials of the following individuals including, current licensure, relevant training and experience, malpractice insurance, current competence and the ability to perform the requested privileges have been verified. INITIAL MEDICAL STAFF APPOINTMENT NAME CATEGORY SPECIALTY/PRIVILEGES APPOINTMENT COMMENTS DATES Allan J. Adler, M.D. Courtesy Pediatrics-Pulmonology 03/24/2010 to 02/28/2012 Paola G. Pieri, M.D., FACS Active Surgery/Surgical Critical Care 03/24/2010 to 02/28/2012 Interim Privileges granted February 15, 2010 INITIAL/FOCUSED PROFESSIONAL PRACTICE EVALUATION NAME SPECIALTY/PRIVILEGES RECOMMENDATION EXTEND or PROPOSED STATUS COMMENTS* Karen A. Baker, M.D. Radiology FPPE successfully completed. Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Mammography Privileges Syma A. Hamidi, M.D. Internal Medicine FPPE successfully completed. Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Internal Medicine Core Ajay K. Mathur, M.D. Anesthesiology FPPE successfully completed. Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Anesthesia Core Privileges To Include Pediatric And Adult Alberta Mazzei, M.D. Anesthesiology FPPE successfully completed. Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Anesthesia Core Privileges To Include Pediatric And Adult Diane M. Park, M.D. Psychiatry FPPE successfully completed. Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Psychiatry Core Privileges. Bryan Roth, D.P.M. Podiatry FPPE successfully completed Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Basic Podiatric Medicine & Surgery Core Privileges; Advanced Podiatric Medicine & Surgery Core; and Orif, Or Ex Fix, Of Ankle Fractures And/Or Charcot Reconstruction Dennis D. Weimer, M.D. Psychiatry FPPE successfully completed. Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Psychiatry Core Privileges. REAPPOINTMENTS/ONGOING PROFESSIONAL PRACTICE EVALUATION NAME SPECIALTY/PRIVILEGES APPOINTMENT CATEGORY COMMENTS DATES Yogesh R. Amin, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Maria-Jesus Bailon, M.D., Ph.D. Psychiatry 03/24/2010 to 02/28/2012 Active Karen A. Baker, M.D. Radiology 03/24/2010 to 02/28/2012 Courtesy This is a peer review document of the hospital. It includes privileged and confidential information, which is protected from disclosure pursuant to ARS Code and other provisions of state and federal law. Unauthorized disclosure or duplication is absolutely prohibited. 1 of 3

85 Maricopa Integrated Health System Recommended by Credentials Cmt: March 2, 2010 Recommended by MEC DATE: March 9, 2010 Submitted to MSHCDB DATE: March 24, 2010 REAPPOINTMENTS/ONGOING PROFESSIONAL PRACTICE EVALUATION Paul M. Berkowitz, M.D. Psychiatry 03/24/2010 to 02/28/2012 Active Javier M. Bibb, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Georgetta C. Bidwell, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Esad Boskailo, M.D. Psychiatry 03/24/2010 to 02/28/2012 Active David Michael Burstein, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy C. Dale Collins, M.D. Obstetrics/Gynecology 03/24/2010 to 02/28/2012 Active Eva Joanne Condon, M.D. Pediatrics/Neonatal-Perinatal Medicine 03/24/2010 to 02/28/2012 Courtesy Mary J. Connell, M.D. Radiology 03/24/2010 to 02/28/2012 Active H. Randall Craig, M.D. Obstetrics/Gynecology 03/24/2010 to 02/28/2012 Courtesy Katharine C. Dahl, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Patricia A. Graham, M.D. Obstetrics/Gynecology 03/24/2010 to 02/28/2012 Active Ronald O. Hadden, M.D. Pediatrics/Neurology 03/24/2010 to 02/28/2012 Courtesy Chirag R. Kapadia, M.D. Pediatrics/Endocrinology 03/24/2010 to 02/28/2012 Courtesy Steve E. Kaplan, M.D. Internal Medicine 03/24/2010 to 02/28/2012 Active Julia J. Kelly, M.D. Pediatrics 03/24/2010 to 02/28/2012 Active Lisa L. Kirsch, M.D. Pediatrics 03/24/2010 to 02/28/2012 Courtesy Suresh Lal, M.D. Pediatrics/Critical Care 03/24/2010 to 02/28/2012 Active Sungchun Lee, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Kevin G. Lopez, M.D. Family and Community Medicine 03/24/2010 to 02/28/2012 Active Jasminder W. S. Mand, M.D. Internal Medicine/Pulmonary Diseases/Critical Care 03/24/2010 to 02/28/2012 Active Maria Cecilia K. Mercado, M.D. Pediatrics/Neonatal-Perinatal Medicine 03/24/2010 to 02/28/2012 Courtesy Ajay K. Mathur, M.D. Anesthesiology 03/24/2010 to 02/28/2012 Courtesy Alberta Mazzei, M.D. Anesthesiology 03/24/2010 to 02/28/2012 Courtesy Ross A. McArthur, M.D. Radiology 03/24/2010 to 02/28/2012 Active Alejandro Morales, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Roberto Q. Murillo, M.D. Pediatrics/Pediatric Emergency Medicine 03/24/2010 to 02/28/2012 Active Jeffrey Packer, D.O. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Margaret A. Pearson, M.D. Pediatrics/Genetics 03/24/2010 to 02/28/2012 Courtesy Savas Petrides, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Willie Quon, M.D. Anesthesiology 03/24/2010 to 02/28/2012 Courtesy Junaid I. Qureshi, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Paul Sacks, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Mehrdad Saririan, M.D. Internal Medicine/Cardiovascular Disease 03/24/2010 to 02/28/2012 Active G. Delaney Sturgeon, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Ariv Swaminathan, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Melanie M. Taylor, M.D., M.P.H. Internal Medicine/Infectious Disease 03/24/2010 to 02/28/2012 Courtesy Ann Thomas, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Glenn W. Waterkotte, M.D. Pediatrics/Neonatal-Perinatal Medicine 03/24/2010 to 02/28/2012 Courtesy This is a peer review document of the hospital. It includes privileged and confidential information, which is protected from disclosure pursuant to ARS Code and other provisions of state and federal law. Unauthorized disclosure or duplication is absolutely prohibited. 2 of 3

86 Maricopa Integrated Health System Recommended by Credentials Cmt: March 2, 2010 Recommended by MEC DATE: March 9, 2010 Submitted to MSHCDB DATE: March 24, 2010 REAPPOINTMENTS/ONGOING PROFESSIONAL PRACTICE EVALUATION Valentin Zaharia, M.D. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy Victor Q. Zapanta, M.D. Pediatrics 03/24/2010 to 02/28/2012 Courtesy Ron Zuiderweg, D.O. Internal Medicine/Nephrology 03/24/2010 to 02/28/2012 Courtesy CHANGE IN PRIVILEGES NAME SPECIALTY ADDITION / REDUCTION / WITHDRAWAL COMMENTS Mohammad Abbasian, M.D. Anesthesiology Revision: Advanced Pediatric Anesthesia Core Privileges Unsupervised [Under 3 months, or ASA III & IV] Wolfgang H. Goy, M.D. Radiology Addition: PET/CT Interpretation; Therapeutic Nuclear Unsupervised Medicine (Use of unsealed radioisotopes for therapeutic nuclear radiology) Gujjarappa T. Srinivas, M.D. Radiology Addition: PET/CT Interpretation Unsupervised Syed A.J. Zaidi, M.D. Internal Medicine-Pulmonary Diseases/Critical Care Revision: Percutaneous Dilatational Tracheotomy Unsupervised RESIGNATIONS Information Only NAME SPECIALTY STATUS REASON Larry G. Cromwell, M.D. Radiology Courtesy to Inactive No longer contracted with contracting agency Gael L. DeRouin, D.O. Surgery/Otolaryngology Courtesy to Inactive No longer contracted with contracting agency/non-submission of reappointment application Clarissa Johnston, D.O. Family and Community Medicine/Urgent Care Active to Inactive Amanda Jean Kasem, M.D. Pediatrics-Emergency Courtesy to Inactive No longer contracted with contracting agency Katherine A. Mandeville, M.D. Pediatrics-Emergency Courtesy to Inactive No longer contracted with contracting agency Justin W. Sales, M.D., M.P.H. Pediatrics-Emergency Courtesy to Inactive No longer contracted with contracting agency Miriam L. Sell, M.D. Family and Community Medicine Courtesy to Inactive No longer contracted with contracting agency Reuben J. Washington, M.D., M.P.H., PC Orthopedic Surgery Courtesy to Inactive No longer contracted with contracting agency No longer contracted with contracting agency/non-submission of reappointment application Definitions: Active > 1,000 hours/year Active members of the medical staff have voting rights and can serve on medical staff committees Courtesy < 1,000 hours/year Courtesy members do not have voting rights and do not serve on medical staff committees Provisional All initial Active and Courtesy appointments to the medical staff are provisional in nature for a period of twelve (12) months. During that period, the actions of the applicant shall be observed for demonstrated clinical competence, adherence to the ethics of the profession, the ability to work with others and the ability to provide patient care within the parameters of professional competence. Reappointments Renewal of appointment and privileges is for a period of two years (JCAHO MS Privileges are granted, renewed, or revised and do not exceed a period of two years), unless otherwise specified for a shorter period of time. FPPE Focused professional practice evaluation is a process by which the organization validates current clinical competence. This process may also be used when a question arises regarding a current practitioner s ability to provide safe, high-quality patient care for which he or she possesses current privileges. This is a peer review document of the hospital. It includes privileged and confidential information, which is protected from disclosure pursuant to ARS Code and other provisions of state and federal law. Unauthorized disclosure or duplication is absolutely prohibited. 3 of 3

87 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 5.

88 Maricopa Integrated Health System Recommended by Credentials Cmt: March 2, 2010 Recommended by MEC DATE: March 9, 2010 Submitted to MSHCDB DATE: March 24, 2010 MARICOPA INTEGRATED HEALTH SYSTEM CREDENTIALS AND ACTION ITEMS REPORT ALLIED HEALTH PROFESSIONAL STAFF PART ONE A: CREDENTIALING FAVORABLE RECOMMENDATIONS The credentials of the following individuals including, current licensure, relevant training and experience, malpractice insurance, current competence and the ability to perform the requested privileges have been verified. ALLIED HEALTH PROFESSIONALS - INITIAL APPOINTMENTS NAME CATEGORY/DEPARTMENT PRACTICE PRIVILEGES/ SCOPE OF SERVICE APPOINTMENT DATES COMMENTS/SPONSORING PHYSICIAN (if applicable) Sean C. Blumhoff, C.C.P. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Interim Privileges requested for 3/2/2010 Surgery Michael P. Jukich, C.C.P. Allied Health Professional/ Surgery Practice Prerogatives on file 03/24/2010 to 02/28/2012 Interim Privileges requested for 3/2/2010 PROVISIONAL ALLIED HEALTH PROGESSIONALS-EXTENSIONS NAME SPECIALTY/PRIVILEGES APPOINTMENT DATES COMMENTS* Roy Lee Evans, Jr., N.N.P. Allied Health Professional/ Pediatrics 3/24/2010 to 5/31/2010 INITIAL/FOCUSED PROFESSIONAL PRACTICE EVALUATION NAME SPECIALTY/PRIVILEGES RECOMMENDATION EXTEND or PROPOSED STATUS COMMENTS* Bryan Todd Kaseman, C.R.N.A. Anesthesiology FPPE successfully completed. Chairman has submitted documentation demonstrating practitioner has successfully completed FPPE requirement. ALLIED HEALTH PROFESSIONALS REAPPOINTMENTS NAME CATEGORY/DEPARTMENT PRACTICE PRIVILEGES/ SCOPE OF SERVICE APPOINTMENT DATES David Martin Brewer, C.R.N.A. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Anesthesiology Dawn Catharine Campbell, C.R.N.A. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Anesthesiology COMMENTS/SPONSORING PHYSICIAN (if applicable) This is a peer review document of the hospital. It includes privileged and confidential information, which is protected from disclosure pursuant to ARS Code and other provisions of state and federal law. Unauthorized disclosure or duplication is absolutely prohibited. 1 of 2

89 Maricopa Integrated Health System Recommended by Credentials Cmt: March 2, 2010 Recommended by MEC DATE: March 9, 2010 Submitted to MSHCDB DATE: March 24, 2010 ALLIED HEALTH PROFESSIONALS REAPPOINTMENTS Heather Macaulay Gillis, C.R.N.A. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Anesthesiology Braden E. Hemingway, C.R.N.A. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Anesthesiology Steven J. Huff, Ph.D. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Surgery-Audiology Bryan Todd Kaseman, C.R.N.A. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Anesthesiology Marnie A. Kulbeth, C.R.N.A. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Anesthesiology Ruth A. Lewis, C.R.N.A. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Anesthesiology Margaret V. Roberts, P.A.-C Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Supervising Physician: Dr. Tammy Kopelman Surgery/Trauma-Burn Ian Sadler, Ph.D. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Psychiatry Cathy Jean Suchomel, N.P. Allied Health Professional/ Practice Prerogatives on file 03/24/2010 to 02/28/2012 Psychiatry RESIGNATIONS Information Only NAME DEPARTMENT STATUS REASON Samuel L. Alvarez, F.N.P. Family and Community Medicine Allied Health Professional to Inactive Resigned Patricia L. Wickham, C.R.N.A. Anesthesiology Allied Health Professional to Inactive No longer contracted with contracting agency General Definitions: Allied Health Professional Staff An Allied Health Professional (AHP) is a licensed, certified, or registered health care provider other than in a discipline approved by the Governing Body to practice at a MIHS facility, and who is permitted to initiate, modify, or terminate therapy according to their scope of practice or other applicable law or regulation. Governing Body authorized AHPs are: Certified Registered Nurse Anesthetists; Certified Registered Nurse Midwife; Naturopathic Physician; Optometrists; Physician Assistant; Psychologists (Clinical Doctorate Degree Level); Registered Nurse Practitioners. Practice Prerogatives Scopes of practice summarizing qualifications for the respective category, developed with input from the physician director of the clinical service and the observer/sponsor/responsible party of the AHP, Department Chair, and other representatives of the Medical Staff, Hospital management, and other professionals. Supervision Definitions: (1) General Supervision The procedure is furnished under the physician s overall direction and control, but the physician s presence is not required during the performance of the procedure or provision of the services. (2) Direct Supervision The physician must be present in the office suite or on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (3) Personal Supervision A physician must be in the room during the performance of the procedure. This is a peer review document of the hospital. It includes privileged and confidential information, which is protected from disclosure pursuant to ARS Code and other provisions of state and federal law. Unauthorized disclosure or duplication is absolutely prohibited. 2 of 2

90 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 6.

91 Maricopa Integrated Health System Transforming Quality One Step at a Time.. Every Person, Every Time Quality Management FY2010 February 2010

92 FY2010 Quality Management Semi-Annual Report The Maricopa Integrated Health System (MIHS) Quality Management Report has been created to provide the organization with a semi-annual quality performance review for FY2010. The Quality Management Department supports MIHS s mission to provide a full spectrum of high quality, wellness oriented health care in an organized, cost sensitive, and customer oriented academic environment. The information in this report is designed to demonstrate the organization s continued commitment to provide high quality patient care. Quality Plan The Quality Plan outlines MIHS s definition of quality: Quality at MIHS is the delivery of care, which is patient centered, safe, effective, timely, efficient and equitable. We achieve quality through the application of practices based on scientific evidence, published research, bestdemonstrated practice, and performance standards Every Person, Every Time. Applying this criterion to all quality improvement plans gives MIHS a clear and consistent quality framework. Quality patient care is directed by evidence-based guidelines and organizational consensus. Raising awareness of the quality process improvement strategies that MIHS has implemented or is in process of implementing will further drive quality improvement. Process improvement is accomplished by using the FOCUS-PDCA method. A structured process improvement plan is critical to the infrastructure for building improvements in quality. A task force or workgroup will work on the identified process improvement project by applying the FOCUS-PDCA methodology. The task force or workgroup will report barriers and successes to the appropriate committee with recommended implementation strategies for practice change. FOCUS F = Find an opportunity to improve O = Organize an effort or team for Improvement PLAN C = Clarify current knowledge ACT DO U S = Understand variation and process capability = Select a strategy for improvement CHECK 2

93 Quality Management FY2010 Quality Management Semi-Annual Report Leadership for quality improvement is provided by members of the Quality Improvement Council (QIC) and the Healthcare District Board of Directors for MIHS. These members provide oversight and monitor the selected indicators for FY2010. QIC was created so the organization could move from service silos to an integrated team. The movement fosters the organization s ability to make decisions across service lines. Quality Management (QM) assesses health care quality measures by collecting and analyzing quantitative and qualitative data. Measuring success and identifying gaps in quality patient care is accomplished through regulatory compliance, peer review, data analysis and management, process improvement, and patient safety. In FY2009, the transformation of quality was initiated to achieve local and national recognition as a healthcare leader. In FY2010, the Quality Management Department has continued to provide the data to monitor the goals for continued quality improvement strategies. While oversight for process improvement resides with QM, it is the staff of physicians, nurses and ancillary departments who improve healthcare outcomes at MIHS. Improving Patient Safety MIHS is working to build a strong culture of safety not only for the patients but for the staff as well. This is being accomplished by increasing staff awareness and accountability for reporting errors. This is to increase the focus of being able to identify opportunities for improvement and develop strategies to improve system processes. The Patient Safety Committee has developed subcommittees to address specific areas of patient safety. Falls Falls are calculated per 1000 acute care patient days. A benchmark of <3.01 falls per 1000 acute care patient days has been set for FY2010. Maricopa Medical Center (MMC) is reaching target goal with an overall rate 2.52 per 1000 acute care patient days for FY2010. The Fall-Restraint Subcommittee conducted a retrospective fall analysis which did not identify any trends. The subcommittee then moved forward to address fall education system-wide by raising awareness of fall safety protocols. This The quality indicators for measurement are in the following areas: patient safety o falls o pressure ulcers o medication errors clinical outcomes o mortality rate o readmission rate evidence-based care: o acute myocardial infarction o heart failure o pneumonia o surgical care improvement program patient satisfaction scores from Press Ganey utilization management - total costs per adjusted patient day Overall, hospital performance has met and shown continued improvement for the national performance standards in the areas of heart attack, heart failure, pneumonia, and surgical care. The quality indicators show that much progress has been achieved by MIHS in enhancing the delivery of health care treatments and advancing the level of quality patient care each year. 3

94 FY2010 Quality Management Semi-Annual Report Improving Patient Safety (cont.) included reviewing and updating the assignment list for sitters who are assigned to patients who are at risk for a fall injury. The subcommittee is continuing to work on an evaluation tool to measure the effectiveness of the education. Pressure Ulcers The Pressure Ulcer Subcommittee is developing a resource manual for all units regarding the prevention and treatment of pressure ulcers using the International Pressure Ulcer Advisory Guideline. The committee is also developing an algorithm to elicit real time reporting of pressure ulcers to the Certified Wound RNs and Patient Safety Officer. This will allow for concurrent review and immediate implementation of strategies to prevent further skin breakdown. Nursing indicators below document the completeness of skin and wound documentation. Medication Errors The organization encourages reporting of medication errors by staff, patients, and family. Increased reporting of these errors assists in identifying system issues that can be proactively corrected. The Pharmacy/Nursing Committee compiles and analyzes medication data to develop action plans to improve processes to ultimately reduce errors from reaching the patients. 2nd Qtr FY2010 1st Qtr FY2010 MIHS Med Errors/1000 Acute Care Patient Days IOM: Preventing Medication Errors.Report Brief one of the most effective ways to reduce medication errors, the report concludes, is to move toward a model of health care where there is more of a partnership between the patients and health care providers. 4

95 FY2010 Quality Management Semi-Annual Report Pain Pain assessment is an important part of patient care at MIHS. The Pain Subcommittee is working on developing a Pain Management Clinical Pathway. The committee is working with clinical educators to ensure best practices for pain management are incorporated into the clinical pathway. Documentation of pain assessment is part of the nurse indicators that are routinely monitored. Restraints The Fall-Restraint Subcommittee has been working on developing a model for restraint utilization within the acute care setting. The MIHS Restraint policy has been updated to meet regulatory requirements and the following strategies are being utilized to integrate restraint bestpractice within the acute care setting: 1. Annual training for clinical staff, 2. Restraint manual available on the clinical units, 3. Electronic Restraint log updated consistently by assigned staff to create real time information of all restraints within the inpatient areas at acute care units. 5

96 Clinical Outcomes FY2010 Quality Management Semi-Annual Report Mortality Rates MIHS s overall mortality rate has continued to decline over the last 3 years. All deaths are reviewed and recommendations made if there is an identified issue. Death rates make effective outcome measures for a number of reasons: death is a definitive, unique event (unlike morbidity, which is continuous and difficult to measure consistently); deaths are recorded by law, rendering the records relatively complete and accurate; and death rates are easily understood by the public (IHI 2003) MIHS 3-year Mortality Trend % 20.0% Readmission Rates Congestive Heart Failure (CHF) Task Force was created to reduce CHF readmissions and improve continuity of care post CHF % Readmits within 30 Days discharge. Education starts upon admission to the nursing floor. Care 37.5% Management identifies if a patient has had a previous admission for CHF. Care 25.0% Management has reviewed discharge 20.0% 20.0% issues around CHF and collaborated with 18.2% 16.7% 16.7% 15.0% nursing and outpatient services to 9.1% 9.1% develop a patient flow chart that outlines 6.3% 5.9% each caregiver s role. 0.0% Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Asthma Children s Asthma Care (CAC) Performance Measure In 2003, The Joint Commission launched project activities to examine Children s Asthma performance measures for inclusion in the ORYX performance measurement initiative. The three measures were introduced for implementation effective April 1, 2007: (1) Use of Relievers for Inpatient Asthma, (2) Use of Systemic Corticosteroids for Inpatient Asthma, (3) Home Management Plan of Care Given to Patient/Caregiver. The Pediatric department has implemented a task force to improve asthma home management. This is to ensure that the Asthma Home Management Plan of Care is completed on discharge. The goal is 100% compliance, by continually reviewing and providing interventions that improve compliance and patient outcomes. 0.30% 0.25% 0.20% 0.15% 0.10% 0.05% Pediatric Asthma % Readmits within 30 Days 0.07% 0.17% 0.27% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 6

97 Evidence-based Care FY2010 Quality Management Semi-Annual Report MIHS continues to analyze, trend, and identify opportunities for improvement with The Core Measures standards of care. These measurements provide the methodology for using evidence-based standards that have shown to improve patient outcomes. In FY09, the organization restructured the process of providing feedback to the providers and nursing staff on opportunities for improvement. The communication of need for change flows in a faster and more direct manner leading to rapid improvement by provider and/or nurse. This philosophy of rapid process improvement is being utilized by the organization to achieve quality patient outcomes. The vision of the Quality Improvement Council is to have opportunities for improvement identified at the lowest level of the organization so that personnel feel empowered to initiate corrective actions to improve outcomes. 7

98 FY2010 Quality Management Semi-Annual Report Reducing Healthcare Associated Infections Preventing healthcare associated infections is a national concern. The Centers for Disease Control and Prevention (CDC) estimates that 5%-10% of patients develop a healthcare associated infection (HAI), meaning 2 million HAIs and nearly 100,000 deaths occur per year in U.S. hospitals. It has been shown that HAIs can be prevented through evidence-based practice initiates. These best practice initiatives have been grouped together or bundled. The bundles have been promoted by the Institute for Healthcare Improvement (IHI) for central line associated blood stream infections (CLABSI), ventilator associated pneumonias (VAP), and catheter associated (Foley) urinary tract infections (CAUTI). MMC has instituted bundles for CLABSIs and VAPs. The bundle for CAUTI is being implemented in the 3 rd quarter of FY2010. Central Line Associated Blood Stream Infections (CLABSI) At MMC the initiative is to hardwire a process to decrease and 10.0 prevent CLABSI. The IHI bundle for this initiative was implemented in 8.0 August The goal is to maintain BSI rates within the 25 percentile of the National Healthcare Safety Network (NHSN) benchmarks with the ultimate goal being a rate of zero BSIs at 2.0 Maricopa Medical Center. 0.0 Jul'09 Aug'09 Sept'09 Oct'09 Nov'09 Dec' Central Line Associated Blood Stream Infections 2.7 July'09 Aug'09 Sept'09 Oct'09 Nov'09 Dec'09 Ventilator Associated Pneumonia (VAP) Ventilated patients are some of the most vulnerable patients. For example, to reduce or eliminate VAP, research has strong evidence that elevation of the head of the bed between 30 to 45 degrees, subglottic (inline) suctioning, frequent oral care, and use of an H-2 blocker proton pump inhibitors are listed as part of an audit tool or checklist (Coffin, et. al., 2008). Preventing VAPs is a priority for the ICU teams at MMC. VAP bundles were initiated in August of 2009 and through the hard work of physicians, nurses and respiratory therapists, MMC is seeing a downward Ventilator Associated Pneumonia 20.0 trend. The goal is to maintain VAP rates within the 50th percentile of the National Healthcare Safety Network 10.0 (NHSN) benchmarks (will 9.3 consider reducing to the 25 th 6.5 percentile after all areas 5.0 implemented) with the ultimate goal being a rate of zero VAPs at Maricopa Medical Center

99 FY2010 Quality Management Semi-Annual Report Transforming Quality One Step at a Time In August of 2009, MIHS successfully became accredited by DNV Healthcare, Inc. The surveyors utilize guidelines from the National Integrated Accreditation for Healthcare Organizations (NIAHO SM ). These guidelines are based on CMS Conditions of Participation for Hospitals 42 C.F.R. 482, State Operations Manual Regulations and Interpretive Guidelines for Hospitals and standards of care set by national professional organizations. The next step is to become ISO 9001 certified which is a process improvement approach for a quality management system. This will involve establishing a methodology for quality management, care coordination and operational accountability. The organization s goal is to be ISO 9001 certified by In FY2010, MIHS also began collaborating with the Edwards Foundation for the Surviving Sepsis Campaign. The Edwards Foundation provides many tools that will assist in assessing care processes, structure and outcomes for septic patients. The initiative focuses in on early identification and treatment. The target will be to reduce mortality due to sepsis by 25%. The implementation of an electronic medical record has been in progress since FY2009. The vendor chosen was Epic. The outpatient clinic areas are being operationalized this fiscal year and inpatient build will begin in October 2010 with full inpatient integration targeted for late FY2011. The intersection of healthcare and the electronic medical record brings challenges and opportunities as identified by the outpatient areas. The challenge is transitioning from a paper system to the electronic medical record. The opportunity is in accurately defining processes and then the optimization of those processes. This leads to standardization of practice which has been shown to reduce errors and save lives. Clinical quality improvement will continue to focus on best practice initiatives. The initiatives have performance measures with either an internal or an external benchmark that provide the expected practice analysis. Dedicated physicians, nurses and staff provide the clinical support that enables these initiatives to be successful. Best practice initiatives accelerate MIHS s progress in providing care that is safe, patient centered, effective, timely, efficient and equitable. Dr. Dan Hobohm, Vice President of Quality Management: MIHS is dedicated to providing our patients with quality safe care. Our vision is to be in the 90 th % of national standards for quality and patient safety by

100 FY2010 Quality Management Semi-Annual Report Recognition in Quality Designations MIHS received DNV accreditation August 2009 Burn The MIHS Burn Center received verification from the ACS in September 2009 Trauma Adult and Pediatric Trauma Program received Adult Level I and Pediatric Level II certification in January 2010 APT Arizona Perinatal Trust Verification March 2009 Donor Network of Arizona: o September 18, 2009 Maricopa Medical Center was recognized as an Outstanding Trauma Center by Donor Network of Arizona o Maricopa Medical Center also received National Medal of Honor at the National Donor Network Meeting in October 2009 for Organs Transplanted per patient of greater than 3.75 and Donation after Cardiac Death rate was 10% of all donations Chest Pain Center - State Designation as Chest Pain Center Summer of 2009 Nursing Leadership Accomplishments Stabilization of the Nursing Leadership team Implementation of the Director of the Day which enables staff to directly call and interface with a Director for questions and concerns Restructuring of the Nurse Practice Council which is directed at enabling bedside nurses to make decisions regarding clinical practice Continued support of the Unit Based Council and reintroduction of Managers and Directors to assist in removing barriers to initiatives Introduction of the Nurse Collaborative Council which enables midlevel managers and unit based leadership to make decision and discuss practice issues Monthly Chief Nursing Officer and Director Rounding for outcomes Continued support for the use of forums to answer questions while protecting the privacy of the staff Continued Director Rounds demonstrating appreciation through Tea and Cookies for the Soul Implementation of the Studer Model Nursing Education On campus RN to BSN programs and BSN to Masters programs Implementation of the Clinical Ladder 10

101 FY2010 Quality Management Semi-Annual Report News January 2010: Dr. Jordy Cox, who volunteers for the humanitarian organization Doctors without Borders, went to Haiti to provide medical care after the hurricane. They called me last night to see if I could deploy and my partners are fantastic they ve allowed me to drop what I am doing and go. I don t know what I am going to find when I get there. It s not going to be fun but looking forward to trying to help. January 2010: St. Luke s Health Initiatives article Taxing Matters: Health, Obesity, and Public Policy Choices in Arizona : Pediatrician Tom Eccles, MD, says at least half of the children he sees at the Maryvale Family Health Center are overweight or obese, and many are likely headed for a lifetime of health problems. They lack safe places to exercise in their neighborhoods, safe routes to walk to school and nearby grocery stores that sell fresh fruits and vegetables. Most of my kids don t want to be heavy. They don t have access to the most healthy food choices, Eccles says. Obesity is a public health emergency that we are treating on an individual level. For the sake of convenience and good old-fashioned capitalism, we ve created a new food structure. They re economically unable to commit to a healthy diet, says Janet Davis, who manages the Maryvale clinic, part of Maricopa Integrated Health System. We re begging these people to change their diet and putting the foods that they need out of reach. Many factors including personal choice drive the daily American diet. Eccles says policy options should be mindful of changing family dynamics and acculturated behaviors. Teenagers will gather at fast-food joints, and families will continue to lead busy lives on tighter wallets. It s cheaper to fill up a family with carbohydrates and fat and you get less complaining from your children than it is to buy vegetables and learn how to prepare them, Eccles says. We have to find solutions that fit into the cultural patterns that have developed as opposed to reverting to an agrarian culture that will never return. 11

102 FY2010 Quality Management Semi-Annual Report February 2010: Comfort Care s Penny Matteson: This has been the most awesome experience I stumbled into healthcare and, specifically, care giving, after seeing the dramatic difference my mother s caregiver made late in her life. My mother battled Diabetes and related complications, Multiple Sclerosis, and Parkinson s disease. Our family managed her healthcare around other personal responsibilities until the main caregiver, our father, unexpectedly passed. Because of her caregiver, our mother was able to continue on in her own home, surrounded by all her familiar and treasured things. Years later, I gladly accepted the opportunity to work in the care giving field. My position involves observing a segment of our attendants at work counseling, educating, and encouraging - while also interacting with some clients receiving care. Many of our clients live alone and many don t even have a relative close by to look in on them. Over time, they struggle with some of the basic activities of daily living, but they still want to remain in their own homes. We can help provide that. Caring for another human being is the most awesome, gratifying and humbling experience. It has been an honor to be of service to these wonderful clients, and to work with individuals who care for others, every day, with no real spotlight or recognition. They do this work for the love of it and the knowledge that their assistance makes another person s life better. Article from Impact Magazine Feb

103 FY2010 Quality Management Semi-Annual Report Quality Improvement Council Members Name Robert Fromm, MD Dan Hobohm, MD Carol Olson, MD David Wisinger, MD Steve Stapczynski, MD David Rosenberg, MD Michael Grossman, MD Daniel Caruso, MD Abraham Kuruvilla, MD Dean Coonrod, MD Bill Vanaskie Sherry Stotler, RN Jeff McBee Gene Cavallo Barry Birmingham Wendy Burkholder, RN Valerie Cook, RN Tina Malone, RN Martha Teeman, RN Jana Bosse, RN Martha Steiner, RN Laurie Wood, RN Mary McKelvey, RN Jackie Hernandez Ojeda Crystal Garcia, RN Shashikala Patel, RN Patty Ramey, RN Tamara Kissinger, RN Barb Taylor, LPN Beneka Brown Tracy Hook, RN Jean Morris, RN Roll Chief Medical Officer, MIHS Chair, Chief of Pathology and VP Quality Management Chair, Chief of Psychiatry Chair, Chief of Gen. Med & LTC Chair, Chief of Emergency Medicine Medical Director, Pediatric ICU Director of Medical Education Chair, Chief Surgery, Trauma and Burn Center Chair, Chief Family and Community Medicine Chair, Chief OB/GYN Chief Operating Officer CNO/ VP Patient Care Services VP of Hospital Operations VP, Behavioral Health Services Interim Admin Director of Specialty Services Director of Ambulatory Services Director of Nursing Specialty Services Director of Clinical Operations Director of Nursing - Med Surg Svcs Director of Nursing - Critical Care Director of Nursing - Psych Services Director of Nursing - Women s Services Director of Risk Management Director Medical Imaging Project Manager for Regulatory Compliance Quality Analyst Quality Analyst Quality Analyst Quality Analyst Quality Analyst Quality Analyst Manager, Quality Management 13

104 MCSHCD Board Quality Overview MCSHCD Board Quality Overview Robert Fromm, M.D., Chief Medical Officer Dan W. Hobohm, M.D., V.P. Quality March 2010

105 MCSHCD Board Quality Overview Key Indicators Safety Falls Medication Errors Pressure Ulcers Mortality Rate Hospital Readmission Rate Core Measures Patient Satisfaction Total Cost per Adjusted Patient Day 2

106 MCSHCD Board Quality Overview Measure Definition per Midas definitions Dimension of Quality Measurement Frequency Benchmark Falls/1000 Acute Care Patient Days Medication Errors/1000 Acute Care Patient Days Pressure Ulcer Frequency (All)/1000 Acute Care Admits Overall Inpatient Mortality rate Acute Care Percent Readmit <30 Frequency of patient falls per 1000 acute care inpatient days (excludes Psych and L&D) taken from the risk module (occurrences entered) Safety Monthly Frequency of medication errors/1000 acute care inpatient days (excludes Psych and L&D) taken from the risk module (occurrences entered) Safety Monthly Frequency per 1000 acute care admissions (excludes Psych and L&D) of inpatients with a discharge diagnosis of pressure ulcers, any stage. Includes all pressure ulcers when designated as Present On Admission (POA) or Hospital Acquired (HAI). Safety Monthly Mortality rate for all inpatient admissions (includes all inpatient encounters, Psych, and OB but excludes any observations) (Overall, Acute Care Overall/Acute Care Age >64, Maternal, Newborn, Pediatric) Effective Monthly Proportion of acute care inpatients (excludes Psych and L&D) who were readmitted as non-elective acute care inpatients to the same facility within 31 days of their previous admission. Focus will be congestive heart failure (CHF) and Pediatric Asthma patients. Effective Monthly <3.01 MIDAS+ DataVision TM comparative with other teaching facilities (50 th %). <16.89 MIDAS+ DataVision TM comparative with other teaching facilities (95 th %). <16.93 MIDAS+ DataVision TM comparative with other teaching facilities (25 th %). <2.09 MIDAS+ DataVision TM comparative with other teaching facilities (50 th %). < 7.00 MIDAS+ DataVision TM comparative with other teaching facilities (25 th %). Core Measures (AMI, HF, Pneumonia, SCIP) Patient Satisfaction Scores Total Cost per adjusted patient day % based on: # records meeting indicator criteria/ # records qualifying for audit (meeting inclusion criteria) Effective Quarterly Scores based on patient surveys administered by Press Ganey. In-patient, Ambulatory, Behavioral Health, and Emergency Department Patient - Centered Quarterly Total Operating expenses such as salaries, benefits, purchased services, rent, R&M, etc divided by the Adjusted Patient Days. Defined as total gross revenue divided by inpatient revenue multiplied by patient days Efficient Quarterly > 90 th percentile from Hospital Compare Nat l results 50 th %tile of Press Ganey Nat l Database Internal quarterly comparison will demonstrate efficient utilization resource. 3

107 MCSHCD Board Quality Overview FALL Rate April 1 Redefined occurrence report categories and implemented an educational campaign for training to increase reporting of events Falls/1000 patient days Benchmark < Feb'09 Mar'09 April'09 May'09 June'09 July'09 Aug'09 Sept'09 Oct'09 Nov'09 Dec'09 Jan' Falls/ 1000 Acute Care Patient Days 4th Qtr th Qtr Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09 Q2 09 Q3 09 Q4 09 MIHS 95th 75th 50th 25th Falls Overall fall rate for the last 12 months for inpatient acute care is 2.2 per 1000 patient days. Updating assignment of tasks regarding sitter role for patients at risk for fall or injury. Reassessment of safe room utilization. Comparative Trend Analysis (2008) with 88 teaching facilities from Midas+ DataVision TM. 4

108 MCSHCD Board Quality Overview Medication Error Rate April 1 Redefined occurrence report categories and implemented an educational campaign for training to increase reporting of events Med Errors/1000 patient days Benchmark < Feb'09 Mar'09 Apr'09 May'09 June'09 July'09 Aug'09 Sept'09 Oct'09 Nov'09 Dec'09 Jan'10 44% Medication Errors by Event Type January % 46% An event that did not reach the patient An event that reached the patient but did not cause harm An event that resulted in the need for increased monitoring or intervention Medication Errors - Overall medication error rate for the last 12 months for inpatient acute care is per 1000 patient days. Pharmacy proactively identifies and records near miss events. January Inpt Pharmacy Med Errors rate was 3.67 per 1000 patient days. Each medication error is assigned an event code which allows for proactive identification of potential process flow issues. Pharmacy/ Nursing Committee reviews labeling & ordering of medications and reviews medications that are consistently involved in errors. 5

109 MCSHCD Board Quality Overview Pressure Ulcer Rate April 1 Redefined occurrence report categories and implemented an educational campaign for training to increase reporting of events Pressure Ulcers/1000 Acute Care Admissions Benchmark < Feb'09 Mar'09 Apr'09 May'09 June'09 July'09 Aug'09 Sept'09 Oct'09 Nov'09 Dec'09 Jan'10 Pressure Ulcers - Overall pressure ulcer rate for the last 12 months for inpatient acute care is 9.8 per 1000 patient days. There were a total of 12 pressure ulcers coded for January all were present on admission. Recruiting skin champions as a resource for each unit to assist with wound identification, documentation and appropriate interventions. 6

110 MCSHCD Board Quality Overview Overall Inpatient Mortality Rate Overall Benchmark <2.09 Feb'09 Mar' <4.15 Mortality Benchmark for Acute Care Age >64 Apr'09 May'09 June' July'09 Aug' Sept' Oct'09 Nov' Dec' Overall Mortality Rate Acute Care Mortality Rate Acute Care Age > 64 Mortality Rate Newborn Mortality Rate Pediatric Mortality Rate Jan'10 Note: No maternal deaths for CY 2009 or Jan

111 MCSHCD Board Quality Overview Readmissions Overall % Readmissions <30 days Benchmark < 7.00% Feb'09 Mar'09 Apr'09 May'09 June'09 July'09 Aug'09 Sept'09 Oct'09 Nov'09 Dec'09 Jan'10 CHF % Readmits within 30 Days 0.30% Pediatric Asthma % Readmits within 30 Days 0.27% 40.0% 20.0% 0.0% 16.7% Feb'09 Mar'09 6.3% 15.0% Apr' % May'09 June' % July'09 5.9% 20.0% Aug'09 Sept' % Oct'09 9.1% 16.7% Nov'09 Benchmark < 16.06% 20.0% 20.0% Dec'09 Jan' % 0.20% 0.17% 0.15% 0.10% 0.07% 0.05% 0.00% 0.00% 0.00% 0.00% 0.00% Feb'09 Mar'09 Apr'09 May'09 June'09 July'09 Aug' % 0.00% 0.00% 0.00% 0.00% Sept'09 Oct'09 Nov'09 Benchmark 0.00% Dec'09 Jan'10 Care Management initiative to format a program for CHF patients regarding follow-up care. Very low readmission rate for Peds asthma patients due to utilization of MIHS Asthma Pathway and staff diligence in post-discharge education for the patients and their families. 8

112 MCSHCD Board Quality Overview Core Measures 100% Core Measure Composite Scores 90% 80% 70% 60% Preliminary Data 50% 1Q Q Q Q Q Q Q Q2009 MIHS National 90th% National Mean Arizona Mean MIHS overall average composite scores 9

113 MCSHCD Board Quality Overview Core Measure - AMI 100% 90% 80% 70% 60% 50% 1Q Q Q 2008 Acute Myocardial Infarction 4Q 2008 Committed task force actively facilitating processes from ED to CathLab. Providers from Urgent Care/ED and Cardiology will meet each month to review the 1 to 2 cases that occur monthly with the goal to highlight what works/ what does not and develop solutions to improve the process. Dr. Stapczynski and Dr. Kaufman the leaders for the two areas are directing the drive to improve the process. 1Q 2009 Note: MIHS has a low population of MI 2Q 2009 MIHS National 90th% National Mean Arizona Mean 3Q2009 Preliminary Data 4Q2009 3Q 2009 Indicator AMI 1: Aspirin within 24 hrs AMI 2: Aspirin at DC AMI 3: ACEI or ARB for LVSD AMI 4: Smoking Cessation Advice AMI 5: Beta Blocker at DC AMI 8a: PCI w/in 90 min 100% 92% - 100% 100% 25% Composite Score 83% 10

114 Core Measure Heart Failure MCSHCD Board Quality Overview 100% 80% 60% Heart Failure 3Q 2009 Indicator HF 1: Discharge Instructions 77% 40% HF 2: Eval of LVS Function 100% 20% 0% 1Q Q Q Q Q Q 2009 MIHS National 90th% National Mean Arizona Mean 3Q2009 Preliminary Data 4Q2009 HF 3: ACEI or ARB for LVSD HF 4: Smoking Cessation Advice 87% 100% Composite Score 91% Revised discharge instruction form to include statements to address discharge measures and smoking cessation. Education to physicians regarding documentation of contraindications to ACEI or ARB for LVSD assessment. 11

115 Core Measure - Pneumonia MCSHCD Board Quality Overview 100% 90% Pneumonia 3Q 2009 Indicator PN 2: Pneumococcal Vaccine 60% 80% PN 3a: Blood culture in ICU w/in 24hrs. 100% 70% PN 3b: Blood Culture prior to Abx 80% 60% 50% 1Q Q Q Q Q Q Q2009 MIHS National 90th% National Mean Arizona Mean Preliminary Data 4Q2009 PN 4: Smoking Cessation Advice PN 5b: Abx w/in 6 hrs of arrival PN 6a: Abx selection for ICU 82% 79% 100% Pneumococcal and Influenza Vaccine task force initiated August Pneumoccocal Assessment form revised to increase utilization. Re-education implemented regarding pneumococcal and influenza vaccines for physicians and nursing staff. PN 6b: Abx selection for non-icu PN 7: Influenza Vaccination 92% *** Composite Score 86% ***Measure not collected from April September. 12

116 MCSHCD Board Quality Overview Core Measure - SCIP 100% 90% 80% Surgical Care Improvement Prevention (SCIP) 3Q 2009 Indicator SCIP-Inf-1: Abx w/in 1 hr (overall) SCIP-Inf-2: Abx selection (overall) 91% 91% 70% SCIP-Inf-3: Abx dc'd w/in 24 hrs 88% 60% Preliminary Data SCIP-Inf-6: Appropriate hair removal 97% 50% 1Q Q Q Q Q Q 2009 MIHS National 90th% National Mean Arizona Mean 3Q2009 4Q2009 SCIP-Inf-7: Colorectal post op normothermia SCIP-VTE-1: VTE prophylaxis ordered 100% 68% SCIP-VTE-2: VTE prophylaxis timing 70% VTE Task Force implemented August VTE prophylaxis form revised to increase utilization rolled out to all units October Re-education to physicians and nursing staff regarding VTE prophylaxis. SCIP-CARD-2: Beta blocker prior to admission and periop 50% Composite Score 82% 13

117 MCSHCD Board Quality Overview Press Ganey Overall Hospital Rating 62 Admission Process MIHS - Press Ganey (Inpatient) Patient Satisfaction Survey Results 2nd - 4th Quarter Room Meals Nurses 23 Tests and Treatments 10 Visitors and Family 36 Physician 44 Discharge Process 4Q09 n= Q09 n= Q09 n= Peer Group Ranking Personal Issues 50 Overall Assessment Overall Hospital Emergency Department Patient Satisfaction Survey Results 2nd - 4th Quarter 2009 Arrival Nurses Doctors Tests Family or Friends Personal/ Insurance Info Personal Issues Overall Assessment 4Q09 n= Q09 n= Q09 n= MIHS- Press Ganey(Inpatient Behavioral Health) Patient SatisfactionSurveyResults 2nd- 4thQtr Outpatient Services Patient SatisfactionSurvey Results 2nd - 4thQuarter Overall Hospital Admission Unit Meals NursingPsychiatrist Treatment Team Program Activities Visitors& family Personal Discharge Issues Overall Medical Assessmen Procedures 4Q09 n= Q09n= Q09n= Overall Hospital Rating Registration Facility Test or treatment Personal Issues Overall Assessment 4Q09 n= Q09 n= Q09 n=

118 MCSHCD Board Quality Overview Total Cost/ APD FY 2010 $2,000 $1,900 $1,800 $1,700 $1,600 July'09 Aug'09 Sept'09 Oct'09 Nov'09 Dec'09 Jan'10 Total Cost/ APD $1,751 $1,736 $1,721 $1,817 $1,926 $1,927 $1,993 Budgeted $1,736 $1,742 $1,733 $1,818 $1,836 $1,797 $1,793 Total Cost/ APD 15

119 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 7.

120 Maricopa Integrated Health System Key Indicator Dashboard February 28, 2010

121 Maricopa Integrated Health System Key Indicator Dashboard Dashboard Key Indicator Dashboard - Quality 1 Key Indicator Dashboard - Volume 2 Key Indicator Dashboard - Financial 3

122 Maricopa Integrated Health System Key Indicator Dashboard - Quality February 28, 2010 Current Month Target Month Per 1000 Patient Days Fall Rate < Medication Error Rate < Pressure Ulcer Rate < % Readmissions < 30 Days < Core Measures AMI > Heart Failure > Pneumonia > SCIP > Patient Satisfaction Inpatient 84.2 Emergency Room 78.3 Behavioral Health 77.4 Outpatient 80.5 Page 1

123 Maricopa Integrated Health System Key Indicator Dashboard - Volume February 28, 2010 Inpatient Volume Current Month CY Year to Date PY Year to Date Actual Budget Variance Actual Budget Variance Actual Variance Acute Admissions 1,380 1,623 (243) 10,268 12,494 (2,226) 11,680 (1,412) Length of Stay (LOS) (0.1) (0.3) Patient Days 6,401 7,338 (937) 49,959 57,338 (7,379) 56,034 (6,075) Behavioral Health Admissions ,705 1, , Length of Stay (LOS) (1.0) (1) Patient Days 5,009 4, ,544 41, ,568 1,976 Outpatient Volume Ambulatory Family Health Centers (FHC) 12,033 13,629 (1,596) 107, ,366 (6,889) 100,359 7,118 Comprehensive Health Center (CHC) 10,550 12,018 (1,468) 92,019 97,721 (5,702) 87,169 4,850 Dental Clinics 2,031 1, ,342 15,996 1,346 14,470 2,872 Urgent Care Center (UCC) 1,447 2,203 (756) 11,672 13,088 (1,416) 12,698 (1,026) Hospital Emergency Department (ED) 4,381 4,957 (576) 35,339 36,209 (870) 35, Surgical Center (SURG) ,275 5,435 (160) 5, Deliveries (75) 2,209 2,703 (494) 2,645 (436) Page 2

124 Maricopa Integrated Health System Key Indicator Dashboard - Financial February 28, 2010 Financial Consolidated Financials Current Month CY Year to Date PY Year to Date Actual Budget Variance Actual Budget Variance Actual Variance Maricopa Medical Center $ (5,990) $ 572 $ (6,562) $ 3,274 $ 5,845 $ (2,571) $ 15,364 $ (12,091) Maricopa Health Plan $ 512 $ 1,051 $ (539) $ 5,919 $ 4,668 $ 1,250 $ 5,320 $ 599 Maricopa Care Advantage $ (158) $ 22 $ (180) $ (664) $ 180 $ (844) $ 139 $ (803) Total Margin (000s) $ (5,636) $ 1,645 $ (7,281) $ 8,528 $ 10,693 $ (2,165) $ 20,823 $ (12,295) Financial Indicators Liquidity Total Cash and Investments $ $ 89.3 $ Total Days Cash on Hand Days in Accounts Receivable (Hospital only) (6.0) Cushion Ratio Cash to Debt 545.9% 398.9% 147.0% 479.7% 66% Capital Structure EBITDA Debt Service Coverage (0.0) Debt to Net Assets 13.9% 15.8% 1.9% 14.6% 0.7% Profitability Operating Margin -7.8% -6.5% -1.3% -2.3% -5.5% EBITDA Margin 4.0% 5.2% -1.2% 8.3% -4.3% Excess Margin 1.9% 2.5% -0.6% 6.5% -4.6% Page 3

125 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 7. Financials

126 Maricopa County Special Health Care District Board Financial Report February 28, 2010 Maricopa Medical Center Arizona Burn Center Comprehensive Healthcare Center Family Health Centers McDowell Healthcare Center (HIV Specialty Clinic) Behavioral Health Phoenix Cancer Center Maricopa Attendant Care Program Maricopa Health Plan Maricopa Care Advantage

127 Maricopa Integrated Medical Center Board Report Summary February 28, 2010 Overview: Financial Performance for Current Month The Board shall monitor the integrity of the financial statement of the District by receiving a financial report on a monthly basis which includes but not limited to: a balance sheet, income statement, and cash flow statement. Motion: No motion required Pros Cons 1 Surgeries over budget by 41 1 MMC - Other revenue under budget by (5,509,615) 2 MMC - Self Pay and Bad Debt expense under budget by 612,139 2 MMC - Operating income under budget by (6,556,577) 3 MMC - Operating expenses under budget by 108,029 3 MHP - Operating income under budget by (401,507) 4 MCA - Operating income under budget by (180,044) 5 Patient Days under budget by (748) 6 Adjusted patient days under budget by (1,960) 7 Admissions under budget by (243) 8 Deliveries under budget by (75) 9 ED visits under budget by (576) 10 OP visits under budget by (2,933) 11 7th Ave. Walk-In-Clinic/Urgent Care visits under budget by (756) 12 Contract labor FTE over budget by (46) Policy References: 1. Special Health Care District Board of Directors Bylaws 2. Board Policy 99012G 3. Board Policy 99007G 4. Board Policy 99008G Chief Executive Officer Approved Yes No

128 Maricopa Integrated Health System Monthly Financial Package Finance Reports Board Package MIHS Consolidated Income Statement 1 Admissions 2 Length of Stay 3 Patient Days 4 Adjusted Patient Days 4 Emergency Visits 5 Deliveries 5 Surgeries 5 Ambulatory 6 Inpatient and Outpatient Trended Payor Mix Based on Admissions and Visits 7 CHC and FQHC Trended Payor Mix Based on Visits 8 7th Avenue Walk-in Clinic (7AWIC) and Behavioral Trended Payor Mix Based on Visits and Admission 9 Copa Care and Bad Debts per Adjusted Patient Day 10 Net Operating Revenue per Adjusted Patient Day 10 FTEs 11 RN Hours 12 FTEs per Adjusted Occupied Bed 12 Average Hourly Rate 12 Expenses per Adjusted Patient Day 13 Net Income 14 Property Tax Levy, Cash and Net Accounts Receivable Days 15 MHP Volumes 16 MHP Per Member Per Month 16 MHP Medical Loss Ratio 17 MHP Revenues, Expenses, and Net Income 17 Consolidated Financial Indicators 18 Consolidated Statement of Revenues, Expenses and Changes in Net Assets 19 Consolidated Balance Sheet 20 Consolidated Cash Flow Statement 21 MMC Statement of Revenues, Expenses and Changes in Net Assets 22 MMC Balance Sheet 23 MMC Cash Flow Statement 24 MHP Statement of Revenues, Expenses and Changes in Net Assets 25 MHP Balance Sheet 26 MHP Cash Flow Statement 27 MCA Statement of Revenues, Expenses and Changes in Net Assets 28 MCA Balance Sheet 29 MCA Cash Flow Statement 30 YTD Financial Performance Dashboard 31 YTD Operational Performance Dashboard 33

129 INCOME STATEMENT - MIHS CONSOLIDATED Current Month Year to Date Feb 2010 Feb 2010 Feb 2009 Feb 2010 Feb 2010 Feb 2009 Actual Budget Variance Actual Actual Budget Variance Actual Operating Income / (loss) Maricopa Medical Center $ (5,624,746) $ (4,351,793) $ (1,272,953) $ (1,614,668) $ (31,336,522) $ (34,083,715) $ 2,747,192 $ (23,150,314) GME Program Elimination (5,283,624) 0 (5,283,624) 0 (5,283,624) 0 (5,283,624) 0 Maricopa Medical Center Subtotal (10,908,370) (4,351,793) (6,556,577) (1,614,668) (36,620,146) (34,083,715) (2,536,432) (23,150,314) Maricopa Health Plan 512, ,845 (401,507) 1,012,887 5,634,212 3,600,379 2,033,833 4,847,925 Maricopa Care Advantage (158,248) 21,796 (180,044) 51,305 (664,245) 180,098 (844,343) 138,964 Total: $ (10,554,280) $ (3,416,152) $ (7,138,128) $ (550,476) $ (31,650,179) $ (30,303,238) $ (1,346,942) $ (18,163,425) Total Income / (loss) Maricopa Medical Center $ (706,846) $ 571,780 $ (1,278,626) $ 3,128,967 $ 8,557,276 $ 5,844,758 $ 2,712,519 $ 15,364,376 GME Program Elimination (5,283,624) 0 (5,283,624) 0 (5,283,624) 0 (5,283,624) 0 Maricopa Medical Center Subtotal (5,990,470) 571,780 (6,562,250) 3,128,967 3,273,652 5,844,758 (2,571,105) 15,364,376 Maricopa Health Plan 512,338 1,051,404 (539,066) 1,012,887 5,918,624 4,668,411 1,250,213 5,320,002 Maricopa Care Advantage (158,248) 21,796 (180,044) 51,305 (664,245) 180,098 (844,343) 138,964 Total: $ (5,636,380) $ 1,644,980 $ (7,281,360) $ 4,193,159 $ 8,528,032 $ 10,693,267 $ (2,165,234) $ 20,823,342 Page 1

130 Admissions: Acute Admissions: Behavioral Health 1, , , , ,000 J A S O N D J F M A M J Total YTD FY09A 1,490 1,493 1,430 1,393 1,402 1,494 1,536 1,442 1,365 1,370 1,253 1,221 16,889 11,680 FY10B 1,527 1,559 1,544 1,443 1,514 1,621 1,663 1,623 1,529 1,612 1,450 1,415 18,500 12,494 FY10A 1,299 1,272 1,264 1,278 1,200 1,225 1,350 1,380 10,268 10,268 - J A S O N D J F M A M J Total YTD FY09A ,291 1,547 FY10B ,395 1,594 FY10A ,705 1,705 Admissions: Total 2,500 2,300 2,100 1,900 1,700 1,500 1,300 1, J A S O N D J F M A M J Total YTD FY09A 1,704 1,709 1,619 1,598 1,580 1,699 1,721 1,597 1,543 1,538 1,441 1,431 19,180 13,227 FY10B 1,731 1,763 1,740 1,648 1,710 1,824 1,866 1,806 1,731 1,810 1,653 1,613 20,895 14,088 FY10A 1,503 1,462 1,483 1,544 1,401 1,443 1,574 1,563 11,973 11,973 Page 2

131 Length of Stay: Acute Length of Stay: Acute Without Burn J A S O N D J F M A M J Total YTD FY09A FY10B FY10A J A S O N D J F M A M J Total YTD FY09A FY10B FY10A Length of Stay: Behavioral Health J A S O N D J F M A M J Total YTD FY09A FY10B FY10A Page 3

132 Patient Days: Acute Patient Days: Behavioral Health 9,500 6,500 8,000 5,500 6,500 4,500 5,000 J A S O N D J F M A M J Total YTD FY09A 7,441 6,967 6,217 6,653 6,856 7,281 8,040 6,579 6,345 6,775 6,443 5,815 81,412 56,034 FY10B 7,130 7,313 6,925 6,734 6,839 7,684 7,375 7,338 7,293 6,928 6,583 6,218 84,360 57,338 FY10A 6,291 6,127 6,417 6,502 6,022 5,923 6,276 6,401 49,959 49,959 3,500 J A S O N D J F M A M J Total YTD FY09A 5,057 5,280 5,068 5,029 5,065 5,028 5,208 4,833 5,326 5,114 5,286 5,063 61,357 40,568 FY10B 5,326 5,318 5,182 5,356 5,130 5,300 5,303 4,820 5,351 5,177 5,356 5,157 62,776 41,735 FY10A 5,452 5,513 5,301 5,282 5,257 5,382 5,348 5,009 42,544 42,544 Patient Days: Total Adjusted Patient Days 14,000 22,000 13,000 21,000 12,000 20,000 11,000 19,000 10,000 J A S O N D J F M A M J Total YTD FY09A 12,498 12,247 11,285 11,682 11,921 12,309 13,248 11,412 11,671 11,889 11,729 10, ,769 96,602 FY10B 12,456 12,631 12,107 12,090 11,969 12,984 12,678 12,158 12,644 12,105 11,939 11, ,136 99,073 FY10A 11,743 11,640 11,718 11,784 11,279 11,305 11,624 11,410 92,503 92,503 18,000 J A S O N D J F M A M J Total YTD FY09A 21,215 20,511 19,463 19,400 19,224 19,939 21,738 19,828 21,357 21,669 20,225 19, , ,245 FY10B 21,695 21,291 20,857 21,124 19,743 21,284 21,396 20,523 21,444 21,051 20,638 19, , ,891 FY10A 20,987 20,864 20,801 20,864 18,892 19,169 19,353 18, , ,341 Page 4

133 Adult Emergency Visits Pediatric Emergency Visits 4,000 2,000 3,500 1,500 3,000 1,000 2,500 J A S O N D J F M A M J Total YTD FY09A 3,265 3,462 3,094 3,135 2,847 3,026 2,966 3,083 3,334 3,307 3,313 3,292 38,124 24,878 FY10B 3,372 3,575 3,196 3,238 2,940 3,125 3,063 3,200 3,436 3,309 3,263 3,262 38,979 25,709 FY10A 3,423 3,271 3,226 3,313 2,891 2,729 3,253 2,866 24,972 24, J A S O N D J F M A M J Total YTD FY09A 974 1,150 1,164 1,262 1,186 1,178 1,553 1,726 1,629 1,813 1,757 1,040 16,432 10,193 FY10B 1,006 1,188 1,203 1,301 1,224 1,217 1,604 1,757 1,484 1,401 1, ,558 10,500 FY10A 1,001 1,117 1,485 1,775 1, ,260 1,515 10,367 10,367 Deliveries Surgeries J A S O N D J F M A M J Total YTD FY09A ,725 2,645 FY10B ,772 2,703 FY10A ,209 2, J A S O N D J F M A M J Total YTD FY09A ,972 5,242 FY10B ,208 5,435 FY10A ,275 5,275 Page 5

134 Comprehensive Health Care Center Visits Family Health Care Center Visits 14,000 18,000 12,000 16,000 14,000 10,000 12,000 8,000 J A S O N D J F M A M J Total YTD FY09A 11,278 10,728 11,168 11,793 9,694 10,610 10,953 10,945 12,516 12,864 11,302 12, ,713 87,169 FY10B 12,599 12,124 12,644 13,338 10,907 11,854 12,237 12,018 12,975 13,764 12,821 12, ,008 97,721 FY10A 12,868 12,593 12,520 11,893 10,487 10,486 10,503 10,550 92,019 92,019 10,000 J A S O N D J F M A M J Total YTD FY09A 12,578 12,181 12,494 13,482 11,368 12,632 12,742 12,882 14,967 14,681 13,119 14, ,28 100,35 FY10B 14,405 14,054 14,425 15,517 13,145 14,540 14,651 13,629 13,770 15,248 13,587 13, ,06 114,36 FY10A 13,505 13,757 14,294 14,863 13,051 13,761 12,213 12, ,47 107,47 4,000 Dental Health Care Center Visits 2,600 7th Avenue Walk-in Clinic (7AWIC) Visits 2,200 3,000 1,800 2,000 1,400 1,000 J A S O N D J F M A M J Total YTD FY09A 1,935 1,966 1,879 1,978 1,563 1,683 1,746 1,720 1,829 1,895 1,882 2,032 22,108 14,470 FY10B 2,136 2,168 2,081 2,186 1,728 1,864 1,933 1,900 2,018 1,964 1,878 1,811 23,667 15,996 FY10A 2,254 2,075 2,394 2,572 1,924 1,872 2,223 2,031 17,342 17,342 1,000 J A S O N D J F M A M J Total YTD FY09A 1,530 1,652 1,715 1,506 1,392 1,523 1,780 1,600 1,736 1,588 1,671 1,538 19,231 12,698 FY10B 1,501 1,620 1,682 1,477 1,365 1,494 1,746 2,203 2,170 2,239 1,901 2,007 21,405 13,088 FY10A 1,384 1,474 1,548 1,774 1,426 1,232 1,387 1,447 11,672 11,672 Page 6

135 Maricopa Medical Center Trended Payor Type Cases as a Percentage of Total Inpatient Cases 60% 50% 40% 30% 20% 10% 0% AHCCCS Non MHP AHCCCS - MHP Medicare Medicare Risk HMO/PPO Commercial Self pay Other June 30, % 12% 5% 3% 7% 3% 12% 6% June 30, % 14% 5% 3% 7% 3% 12% 6% YTD FYE 06/30/ % 12% 5% 4% 7% 3% 10% 6% June 30, 2008 June 30, 2009 YTD FYE 06/30/2010 Maricopa Medical Center Trended Payor Type Cases as a Percentage of Total Outpatient Cases (Excluding CHC, FQHC, 7AWIC) 35% 30% 25% 20% 15% 10% 5% 0% AHCCCS Non MHP AHCCCS - MHP Medicare Medicare Risk HMO/PPO Commercial Self pay Other June 30, % 13% 13% 9% 5% 4% 23% 8% June 30, % 14% 12% 8% 5% 4% 21% 7% YTD FYE 06/30/ % 15% 11% 7% 5% 3% 20% 6% June 30, 2008 June 30, 2009 YTD FYE 06/30/2010 Page 7

136 Maricopa Medical Center Trended Payor Type Cases as a Percentage of Total CHC Cases 40% 35% 30% 25% 20% 15% 10% 5% 0% AHCCCS Non MHP AHCCCS - MHP Medicare Medicare Risk HMO/PPO Commercial Self pay Other June 30, % 26% 9% 4% 4% 2% 35% 6% June 30, % 22% 7% 6% 4% 2% 37% 8% YTD FYE 06/30/ % 23% 6% 5% 3% 2% 38% 8% June 30, 2008 June 30, 2009 YTD FYE 06/30/2010 Maricopa Medical Center Trended Payor Type Cases as a Percentage of Total FQHC Cases 30% 25% 20% 15% 10% 5% 0% AHCCCS Non MHP AHCCCS - MHP Medicare Medicare Risk HMO/PPO Commercial Self pay Other June 30, % 23% 8% 5% 3% 1% 21% 17% June 30, % 26% 6% 5% 2% 2% 17% 19% YTD FYE 06/30/ % 26% 6% 4% 2% 1% 22% 14% June 30, 2008 June 30, 2009 YTD FYE 06/30/2010 Page 8

137 Maricopa Medical Center Trended Payor Type Cases as a Percentage of Total 7th Avenue Walk-in Clinic Cases 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% AHCCCS Non MHP AHCCCS - MHP Medicare Medicare Risk HMO/PPO Commercial Self pay Other June 30, % 7% 4% 3% 6% 7% 28% 1% June 30, % 9% 3% 3% 6% 5% 29% 1% YTD FYE 06/30/ % 12% 3% 3% 5% 5% 26% 2% June 30, 2008 June 30, 2009 YTD FYE 06/30/2010 Maricopa Medical Center Trended Payor Type Cases as a Percentage of Total Behavioral Cases 60% 50% 40% 30% 20% 10% 0% AHCCCS Non MHP Agency (RBHA) Medicare Medicare Risk HMO/PPO Commercial Self pay Other June 30, % 49% 17% 9% 18% 3% 2% 0% June 30, % 53% 18% 10% 15% 2% 1% 0% YTD FYE 06/30/2010 2% 54% 15% 9% 13% 2% 5% 0% June 30, 2008 June 30, 2009 YTD FYE 06/30/2010 Page 9

138 Self Pay & Bad Debt Per Adjusted Patient Day (000's) 1,100 1, J A S O N D J F M A M J Total YTD FY09A FY10B FY10A , , ,600 2,400 2,200 Net Operating Revenue Per Adjusted Patient Day (000's) 2,000 1,800 1,600 1,400 1,200 1,000 J A S O N D J F M A M J Total YTD FY09A 1,596 1,685 1,820 1,835 1,729 1,702 1,452 1,708 1,521 1,616 1,622 2,502 1,732 1,687 FY10B 1,554 1,663 1,530 1,560 1,575 1,586 1,569 1,582 1,634 1,593 1,563 1,588 1,584 1,578 FY10A 1,567 1,678 1,593 1,569 1,708 1,723 1,748 1,391 1,624 1,624 Page 10

139 FTEs: Contract Labor FTEs: Nursing Contract Labor J A S O N D J F M A M J YTD FY09A FY10B FY10A J A S O N D J F M A M J YTD FY09A FY10B FY10A FTEs: Non Nursing Contract Labor J A S O N D J F M A M J YTD FY09A FY10B FY10A FTEs: Total (Payroll and Contract Labor) 4,100 4,000 3,900 3,800 3,700 3,600 3,500 J A S O N D J F M A M J YTD FY09A 3,808 3,798 3,743 3,793 3,827 3,830 3,977 3,894 3,746 3,757 3,762 3,727 3,833 FY10B 3,841 3,856 3,838 3,814 3,825 3,911 3,881 4,014 3,869 3,866 3,773 3,719 3,871 FY10A 3,778 3,761 3,814 3,772 3,816 3,778 3,914 3,881 3,810 Page 11

140 RN Hours Per Acute Day RN Hours Per Behavioral Health Day J A S O N D J F M A M J YTD TOT FY09A FY10B FY10A J A S O N D J F M A M J YTD TOT FY09A FY10B FY10A FTEs Per Adjusted Occupied Bed J A S O N D J F M A M J Total YTD FY09A FY10B FY10A Average Hourly Rate J A S O N D J F M A M J YTD RN Clinical/Technical All Other Page 12

141 Salaries and Contract Labor Expense Per Adjusted Patient Day Supplies Expense Per Adjusted Patient Day 1, , J A S O N D J F M A M J Total YTD FY09A , FY10B FY10A J A S O N D J F M A M J Total YTD FY09A FY10B FY10A Total Operating Expense Per Adjusted Patient Day 2,300 2,200 2,100 2,000 1,900 1,800 1,700 1,600 1,500 J A S O N D J F M A M J Total YTD FY09A 1,670 1,749 1,797 1,907 2,129 1,857 1,770 1,790 1,700 1,713 1,820 1,827 1,800 1,831 FY10B 1,736 1,742 1,733 1,818 1,836 1,797 1,793 1,795 1,760 1,758 1,873 1,824 1,785 1,781 FY10A 1,751 1,736 1,721 1,817 1,926 1,927 1,993 1,978 1,853 1,853 Page 13

142 Net Income (Loss) (000's) Maricopa Medical Center Net Income (Loss) (000's) Maricopa Health Plan Net Income (Loss) (000's) 20,000 15,000 10,000 5,000 0 (5,000) (10,000) J A S O N D J F M A M J Total YTD FY09A 3,068 3,372 5,409 3,352 (2,883) 2,049 (2,131) 3, , ,980 40,778 15,364 FY10B 1,107 3, (386) (89) ,209 1,587 (1,343) ,260 5,845 FY10A 1,173 3,837 2,237 (36) (5,990) 3,274 3,274 3,000 2,000 1,000 0 (1,000) (2,000) (3,000) (4,000) J A S O N D J F M A M J Total YTD FY09A 1,119 1,191 1, (1,066) 153 1, ,172 (1,171) (2,766) 3,337 5,320 FY10B 1, ,271 (215) (922) 1, (400) 1,697 1,526 8,009 4,668 FY10A 1,212 1,090 1, ,919 5,919 MCA Joint Venture Net Income (Loss) (000's) Consolidated Net Income (Loss) (000's) , , ,000 0 (100) 4,000 (200) (300) (1,000) (400) J A S O N D J F M A M J Total YTD FY09A FY10B (55) (5) 22 (48) (19) (21) (78) FY10A (143) (214) (328) (279) (158) (664) (664) (6,000) J A S O N D J F M A M J Total YTD FY09A 4,174 4,572 6,979 4,160 (2,297) 1,010 (1,968) 4,193 1,761 3,968 (278) 15,549 44,114 20,823 FY10B 2,788 4,228 2,003 (495) (772) 1,645 2,719 1, ,994 18,424 10,693 FY10A 2,242 4,713 3,585 (252) 1,646 1, (5,636) 8,528 8,528 Page 14

143 Property Tax Levy (000's) MIHS Monthly Trended Consolidated Cash Balance (000's) 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - J A S O N D J F M A M J Total YTD FY ,326 15,366 6,020 1, ,562 1,934 10,349 5, ,292 29,614 FY ,560 12,138 9,407 1, ,697 2,108 11,870 5, ,496 31,728 FY10 2, ,416 15,309 8,736 1,687 1,059 2,014 33,808 33, , , ,000 75,000 50,000 25,000 0 F-09 M-09 A-09 M-09 J-09 J-09 A-09 S-09 O-09 N-09 D-09 J-10 F-10 Total Cash 109, , , , ,304 84, , , , , , , ,317 MMC Cash 59,865 53,645 61,972 60,640 64,876 53,822 74,031 75,982 99,343 85,203 74,544 63,468 61,092 MHP Cash 49,370 54,254 54,749 53,703 39,428 30,223 40,329 41,148 41,738 42,798 44,076 48,154 50,224 Maricopa Medical Center Net Accounts Receivable Days Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 # Days Page 15

144 MHP Member Months 67,000 62,000 57,000 52,000 47,000 42,000 37,000 J A S O N D J F M A M J Total YTD FY09A 38,215 38,612 38,067 45,526 46,353 50,274 51,497 55,140 59,416 56,455 56,109 56, ,614 49,384 FY10B 60,637 61,178 61,725 62,274 62,829 63,386 63,949 64,515 65,085 65,660 66,239 66, ,300 63,692 FY10A 57,913 58,599 61,070 60,285 60,916 62,171 60,159 60, ,587 60,198 MHP Admits Per Thousand MHP Days Per Thousand ,200 1,100 1, J A S O N D J F M A M J FY09A FY10B FY10A YTD AVG 600 J A S O N D J F M A M J FY09A , ,084 1, , FY10B 845 1, , , FY10A YTD AVG Page 16

145 MHP Medical Loss Ratio 110% 100% 90% 80% 70% 60% 50% 40% J A S O N D J F M A M J AVG FY09A 78.22% 78.25% 75.91% 84.82% 86.12% 95.26% 88.46% 83.43% 86.36% 83.81% 95.83% % 86.71% FY10B 81.48% 82.47% 85.70% 89.38% 89.74% 90.09% 90.44% 90.78% 91.13% 91.47% 91.81% 92.12% 88.88% FY10A 82.51% 82.29% 80.41% 82.04% 85.50% 85.71% 85.94% 83.63% 0.00% MHP Revenues, Net Med Expenses, Administration Expenses and Net Income (Twelve Months) (A)ctual (000's) 25,000 20,000 15,000 10,000 5,000 - (5,000) Jul (A) Aug (A) Sep (A) Oct (A) Nov (A) Dec (A) Jan (A) Feb (A) Mar (A) Apr (A) May (A) Jun (A) Total YTD Revenues 18,965 17,675 19,704 12,819 17,925 18,522 18,176 15, , ,642 Net Med Expense 15,648 14,545 15,844 10,517 15,327 15,875 15,620 13, , ,636 Admin Exp 2,105 2,040 2,183 2,239 2,055 2,237 2,145 2,083 17,087 17,087 Net Income 1,212 1,090 1, ,919 5,919 Page 17

146 Financial Indicators - Consolidated Rating Actual Actual Actual Actual Budget Goal Agency June 30, 2007 June 30, 2008 June 30, 2009 YTD - Feb FY2010 FY2011 Averages LIQUIDITY: Total Cash and Investments $64.6M $71.1M $103.0M $110.3M $89.3M Total Days Cash on Hand Days in Accounts Receivable (Hospital only) Cushion Ratio Cash to Debt 193.4% 282.9% 479.7% 545.9% 398.9% 77.0% CAPITAL STRUCTURE: EBITDA Debt Service Coverage Debt to Net Assets 37.8% 19.4% 14.6% 13.9% 15.8% 45.4% PROFITABILITY: Operating Margin -11.5% -2.0% -2.3% -7.8% -6.5% 1.6% 1.1% EBITDA Margin 3.2% 9.0% 8.3% 4.0% 5.2% 10.7% Excess Margin 1.1% 7.1% 6.5% 1.9% 2.5% 3.5% Page 18

147 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT CONSOLIDATED SYSTEM Statement of Revenues, Expenses, and Changes in Net Assets For the Eight Months Ended February 28, 2010 Current Month YTD Feb 2010 Feb 2010 Feb 2009 Feb 2010 Feb 2010 Feb 2009 Actual Budget Variance Actual Actual Budget Variance Actual Operating Revenues Gross patient revenue $ 132,768,164 $ 138,105,792 $ (5,337,628) $ 112,235,390 $ 1,062,612,793 $ 1,112,428,978 $ (49,816,186) $ 952,751,417 Total deductions 87,105,207 90,675,705 3,570,498 68,857, ,881, ,384,154 52,502, ,967,696 Patient service revenue 45,662,957 47,430,087 (1,767,130) 43,377, ,731, ,044,824 2,686, ,783,721 Self-pay and bad debt expense 16,789,370 17,401, ,139 16,647, ,536, ,167,496 (4,368,589) 118,115,681 Net patient service revenue 28,873,587 30,028,578 (1,154,991) 26,730, ,195, ,877,327 (1,681,854) 249,668,040 Other revenue 13,763,919 25,508,958 (11,745,039) 26,848, ,299, ,244,069 (37,944,540) 149,724,037 Total operating revenues 42,637,505 55,537,536 (12,900,030) 53,579, ,495, ,121,397 (39,626,394) 399,392,077 Operating Expenses Salaries and wages 15,846,567 16,445, ,133 15,643, ,112, ,089,141 1,977, ,372,307 Contract labor 592, ,884 (184,414) 807,144 3,619,601 3,017,451 (602,150) 6,427,303 Employee benefits 4,951,135 4,881,555 (69,580) 4,721,398 38,215,803 37,985,399 (230,404) 37,968,219 Medical service fees 4,492,146 4,506,414 14,268 4,136,310 34,865,530 36,896,088 2,030,557 34,667,686 Supplies 5,662,157 5,002,002 (660,156) 4,583,700 39,804,922 40,474, ,249 37,781,723 Purchased services 17,573,230 23,366,019 5,792,789 19,988, ,736, ,897,026 33,160, ,620,663 Other expenses 2,453,688 2,596, ,858 2,789,899 19,982,446 21,016,132 1,033,687 20,780,833 Premium taxes and assessments 427, ,998 52, ,300 3,504,402 3,777, ,372 2,677,750 Depreciation 1,192,690 1,267,569 74,878 1,050,744 8,303,990 8,271,451 (32,539) 7,259,017 Total operating expenses 53,191,785 58,953,688 5,761,902 54,129, ,145, ,424,635 38,279, ,555,501 Operating Income (10,554,280) (3,416,152) (7,138,128) (550,476) (31,650,179) (30,303,238) (1,346,942) (18,163,425) Nonoperating Revenues (Expenses) Noncapital grants 699, , , ,969 4,767,578 3,936, ,298 5,547,310 Noncapital transfers from County 295, ,541 23, ,658 2,365,264 2,365, ,365,264 Investment income 39, ,059 (199,035) 165, ,236 2,172,032 (1,262,796) 2,172,389 Other nonoperating revenue 101,655 82,191 19,464 73, , , , ,101 Noncapital grants related expenses (515,920) (167,476) (348,444) (137,251) (3,010,562) (2,488,383) (522,179) (3,849,287) Interest expense (120,043) (120,239) 196 (116,726) (1,005,779) (991,793) (13,986) (1,172,097) Tax levy 4,418,197 4,418,197 (0) 4,160,261 35,345,576 35,345,576 (0) 33,282,086 Total nonoperating revenues (expenses) 4,917,900 5,061,133 (143,232) 4,743,635 40,178,211 40,996,505 (818,293) 38,986,767 Excess of Revenues Over Expenses Before Extraordinary Items (5,636,380) 1,644,980 (7,281,360) 4,193,159 8,528,031 10,693,266 (2,165,235) 20,823,342 Extraordinary Item Increase in Net Assets (5,636,380) 1,644,980 (7,281,360) 4,193,159 8,528,031 10,693,267 (2,165,235) 20,823,342 Net Assets, Beginning of the Period 202,542, ,378,477 Net Assets, End of the Period $ 196,906,508 $ 196,906,508 Page 19

148 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT CONSOLIDATED SYSTEM Balance Sheet February 28, 2010 Assets February 28, 2010 June 30, 2009 Current Assets Cash and cash equivalents $ 80,597,368 $ 74,301,714 Board designated: Due to Maricopa County 18,517,723 18,517,723 Self-insured obligations 2,427,000 2,444,000 Healthplans statutory requirements 8,714,000 7,701,450 Total Board designated 29,658,723 28,663,173 Patient A/R, net of allowances 64,316,143 53,843,274 Other receivables 5,326,541 1,755,696 Supplies 6,426,681 6,273,024 Prepaid expenses 3,865,527 1,810,289 Estimated amounts due from third-party payors 12,316,031 59,279,248 Due from related parties 7,557,651 1,039,968 Total current assets 210,064, ,966,386 Capital Assets, Net 91,541,116 83,090,057 Other Assets 3,927,160 4,417,200 Total assets $ 305,532,940 $ 314,473,642 Liabilities and Net Assets Current Liabilities Current maturities of long-term debt $ 3,914,941 $ 3,901,518 Accounts payable 29,233,174 32,532,623 Accrued payroll and expenses 15,213,205 20,292,980 Medical claims payable 35,449,862 38,878,115 Other current liabilities 4,617,998 10,088,664 Total current liabilities 88,429, ,693,900 Long-term Debt 20,197,251 21,462,848 Total liabilities 108,626, ,156,748 Net Assets Invested in capital assets, net of related debt 71,343,865 61,627,209 Unrestricted 125,562, ,689,686 Total net assets 196,906, ,316,895 Total liabilities and net assets $ 305,532,940 $ 314,473,642 Page 20

149 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a CONSOLIDATED SYSTEM Cash Flow Statement - Consolidated System February 28, 2010 ($ in 000's) Current Month Year to Date Operating Income (Loss) $ (10,554) $ (31,650) Non-Operating Income 4,918 40,179 Net Income (Loss) (5,636) 8,529 Add: Depreciation 1,193 8,304 Less: Changes in Assets and Liabilities 4,589 3,487 Net cash from operations ,320 Cash spent on capital (2,171) (16,576) Cash - All Other Net increase (decrease) in cash ($2,015) $4,233 Beginning Cash Balance 112, ,023 Ending Cash Balance - February 28, 2010 $110,256 $110,256 Page 21

150 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA MEDICAL CENTER Statement of Revenues, Expenses, and Changes in Net Assets For the Eight Months Ended February 28, 2010 Current Month YTD Feb 2010 Feb 2010 Feb 2009 Feb 2010 Feb 2010 Feb 2009 Actual Budget Variance Actual Actual Budget Variance Actual Operating Revenues Gross patient revenue $ 132,768,164 $ 138,105,792 $ (5,337,628) $ 112,235,390 $ 1,062,612,793 $ 1,112,428,978 $ (49,816,186) $ 952,751,417 Total deductions 87,105,207 90,675,705 3,570,498 68,857, ,881, ,384,154 52,502, ,967,696 Patient service revenue 45,662,957 47,430,087 (1,767,130) 43,377, ,731, ,044,824 2,686, ,783,721 Self-pay and bad debt expense 16,789,370 17,401, ,139 16,647, ,536, ,167,496 (4,368,589) 118,115,681 Net patient service revenue 28,873,587 30,028,578 (1,154,991) 26,730, ,195, ,877,327 (1,681,854) 249,668,040 Other revenue (3,060,211) 2,449,404 (5,509,615) 7,143,790 18,500,389 23,007,069 (4,506,680) 22,379,887 Total operating revenues 25,813,375 32,477,982 (6,664,606) 33,874, ,695, ,884,397 (6,188,534) 272,047,927 Operating Expenses Salaries and wages 15,846,567 16,445, ,133 15,643, ,112, ,089,141 1,977, ,372,307 Contract labor 592, ,884 (184,414) 807,144 3,619,601 3,017,451 (602,150) 6,427,303 Employee benefits 4,951,135 4,881,555 (69,580) 4,721,398 38,215,803 37,985,399 (230,404) 37,968,219 Medical service fees 4,492,146 4,506,414 14,268 4,136,310 34,865,530 36,896,088 2,030,557 34,667,686 Supplies 5,662,157 5,002,002 (660,156) 4,583,700 39,804,922 40,474, ,249 37,781,723 Purchased services 1,531,063 1,713, ,386 1,756,443 15,362,356 14,148,818 (1,213,537) 14,848,460 Other expenses 2,453,688 2,596, ,858 2,789,899 19,982,446 21,016,132 1,033,687 20,780,833 Premium taxes and assessments 0 8,655 8, ,266 69,460 20,193 92,692 Depreciation 1,192,690 1,267,569 74,878 1,050,744 8,303,990 8,271,451 (32,539) 7,259,017 Total operating expenses 36,721,745 36,829, ,029 35,489, ,316, ,968,112 3,652, ,198,240 Operating Income (10,908,370) (4,351,793) (6,556,577) (1,614,668) (36,620,146) (34,083,715) (2,536,432) (23,150,314) Nonoperating Revenues (Expenses) Noncapital grants 699, , , ,969 4,767,578 3,936, ,298 5,547,310 Noncapital transfers from County 295, ,541 23, ,658 2,365,264 2,365, ,365,264 Investment income 39, ,500 (61,476) 165, ,824 1,104,000 (479,176) 1,700,312 Other nonoperating revenue 101,655 82,191 19,464 73, , , , ,101 Noncapital grants related expenses (515,920) (167,476) (348,444) (137,251) (3,010,562) (2,488,383) (522,179) (3,849,287) Interest expense (120,043) (120,239) 196 (116,726) (1,005,779) (991,793) (13,986) (1,172,097) Tax levy 4,418,197 4,418,197 (0) 4,160,261 35,345,575 35,345, ,282,086 Total nonoperating revenues (expenses) 4,917,900 4,923,574 (5,673) 4,743,635 39,893,799 39,928,473 (34,673) 38,514,690 Excess of Revenues Over Expenses Before Extraordinary Items (5,990,470) 571,780 (6,562,250) 3,128,967 3,273,652 5,844,757 (2,571,105) 15,364,376 Extraordinary Item Increase in Net Assets (5,990,470) 571,780 (6,562,250) 3,128,967 3,273,652 5,844,758 (2,571,105) 15,364,376 Net Assets, Beginning of the Period 189,960, ,696,640 Net Assets, End of the Period $ 183,970,292 $ 183,970,292 Page 22

151 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA MEDICAL CENTER Balance Sheet February 28, 2010 Assets February 28, 2010 June 30, 2009 Current Assets Cash and cash equivalents $ 36,465,307 $ 52,760,104 Board designated: Due to Maricopa County 18,517,723 18,517,723 Self-insured obligations 2,427,000 2,444,000 Healthplans statutory requirements 0 0 Total Board designated 20,944,723 20,961,723 Patient A/R, net of allowances 64,316,143 53,843,274 Other receivables 5,326,541 1,755,696 Supplies 6,426,681 6,273,024 Prepaid expenses 3,865,527 1,810,289 Estimated amounts due from third-party payors 17,309,844 39,730,831 Due from related parties 7,557,651 1,039,968 Total current assets 162,212, ,174,909 Capital Assets, Net 91,541,116 83,090,057 Other Assets 3,487,933 3,487,933 Total assets $ 257,241,465 $ 264,752,898 Liabilities and Net Assets Current Liabilities Current maturities of long-term debt $ 3,914,941 $ 3,901,518 Accounts payable 28,356,960 31,920,447 Accrued payroll and expenses 15,213,205 20,292,980 Medical claims payable 2,427,000 2,248,252 Other current liabilities 3,161,814 4,230,214 Total current liabilities 53,073,922 62,593,411 Long-term Debt 20,197,251 21,462,848 Total liabilities 73,271,172 84,056,258 Net Assets Invested in capital assets, net of related debt 71,343,865 61,627,209 Unrestricted 112,626, ,069,431 Total net assets 183,970, ,696,640 Total liabilities and net assets $ 257,241,465 $ 264,752,898 Page 23

152 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA MEDICAL CENTER Cash Flow Statement - Maricopa Medical Center February 28, 2010 ($ in 000's) Current Month Year to Date Operating Income (Loss) $ (10,908) $ (36,620) Non-Operating Income 4,918 39,894 Net Income (Loss) (5,990) 3,274 Add: Depreciation 1,193 8,304 Less: Changes in Assets and Liabilities 2,415 (11,144) Net cash from operations (2,382) 434 Cash spent on capital (2,171) (16,576) Cash - All Other - - Net increase (decrease) in cash ($4,553) ($16,142) Beginning Cash Balance 61,963 73,552 Ending Cash Balance - February 28, 2010 $57,410 $57,410 Page 24

153 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA HEALTH PLAN Statement of Revenues, Expenses, and Changes in Net Assets For the Eight Months Ended February 28, 2010 Current Month YTD Feb 2010 Feb 2010 Feb 2009 Feb 2010 Feb 2010 Feb 2009 Actual Budget Variance Actual Actual Budget Variance Actual Operating Revenues Other revenue 15,855,983 22,091,010 (6,235,027) 18,933, ,357, ,752,176 (33,394,715) 121,792,543 Total operating revenues 15,855,983 22,091,010 (6,235,027) 18,933, ,357, ,752,176 (33,394,715) 121,792,543 Operating Expenses Purchased services 14,915,772 20,705,822 5,790,050 17,511, ,268, ,443,482 35,175, ,359,560 Premium taxes and assessments 427, ,343 43, ,181 3,455,136 3,708, ,179 2,585,058 Total operating expenses 15,343,645 21,177,165 5,833,520 17,920, ,723, ,151,797 35,428, ,944,618 Operating Income 512, ,845 (401,507) 1,012,887 5,634,212 3,600,379 2,033,833 4,847,925 Nonoperating Revenues (Expenses) Investment income - 137,559 (137,559) - 284,412 1,068,032 (783,620) 472,077 Tax levy Total nonoperating revenues (expenses) - 137,559 (137,559) - 284,412 1,068,032 (783,620) 472,077 Excess of Revenues Over Expenses Before Extraordinary Items 512,338 1,051,404 (539,066) 1,012,887 5,918,624 4,668,411 1,250,213 5,320,002 Increase in Net Assets 512,338 1,051,404 (539,066) 1,012,887 5,918,624 4,668,411 1,250,213 5,320,002 Net Assets, Beginning of the Period 12,026, ,620, Net Assets, End of the Period 12,538, ,538, Page 25

154 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA HEALTH PLAN Balance Sheet February 28, 2010 Assets February 28, 2010 June 30, 2009 Current Assets Cash and cash equivalents $ 42,477,396 $ 21,541,610 Board designated: Healthplans statutory requirements 8,082,000 7,701,450 Total Board designated 8,082,000 7,701,450 Estimated amounts due from third-party payors (5,145,050) 19,548,417 Due from related parties 0 0 Total current assets 45,414,346 48,791,477 Capital Assets, Net 0 0 Other Assets 439, ,267 Total assets $ 45,853,573 $ 49,720,744 Liabilities and Net Assets Current Liabilities Accounts payable $ 876,214 $ 612,176 Medical claims payable 31,464,929 36,629,863 Other current liabilities 973,551 5,858,450 Total current liabilities 33,314,694 43,100,489 Long-term Debt 0 0 Total liabilities 33,314,694 43,100,489 Net Assets Invested in capital assets, net of related debt 0 0 Unrestricted 12,538,879 6,620,255 Total net assets 12,538,879 6,620,255 Total liabilities and net assets $ 45,853,573 $ 49,720,744 Page 26

155 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA HEALTH PLAN Cash Flow Statement - Maricopa Health plan February 28, 2010 ($ in 000's) Current Month Year to Date Operating Income (Loss) $ 512 $ 5,633 Non-Operating Income Net Income (Loss) 512 5,917 Add: Depreciation - - Less: Changes in Assets and Liabilities 2,002 14,910 Net cash from operations 2,514 20,827 Cash spent on capital - - Cash - All Other Net increase (decrease) in cash $2,524 $21,316 Beginning Cash Balance 48,035 29,243 Ending Cash Balance - February 28, 2010 $50,559 $50,559 Page 27

156 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA CARE ADVANTAGE Statement of Revenues, Expenses, and Changes in Net Assets For the Eight Months Ended February 28, 2010 Current Month YTD Feb 2010 Feb 2010 Feb 2009 Feb 2010 Feb 2010 Feb 2009 Actual Budget Variance Actual Actual Budget Variance Actual Operating Revenues Other revenue 968, ,544 (397) 771,255 7,441,679 7,484,824 (43,145) 5,551,607 Total operating revenues 968, ,544 (397) 771,255 7,441,679 7,484,824 (43,145) 5,551,607 Operating Expenses Purchased services 1,126, ,748 (179,647) 719,950 8,105,924 7,304,726 (801,198) 5,412,643 Total operating expenses 1,126, ,748 (179,647) 719,950 8,105,924 7,304,726 (801,198) 5,412,643 Operating Income (158,248) 21,796 (180,044) 51,305 (664,245) 180,098 (844,343) 138,964 Nonoperating Revenues (Expenses) Total nonoperating revenues (expenses) Excess of Revenues Over Expenses Before Extraordinary Items (158,248) 21,796 (180,044) 51,305 (664,245) 180,098 (844,343) 138,964 Extraordinary Item Increase in Net Assets (158,248) 21,796 (180,044) 51,305 (664,245) 180,098 (844,343) 138,964 Net Assets, Beginning of the Period 555,585 1,061,582 Net Assets, End of the Period $ 397,337 $ 397,337 Page 28

157 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA CARE ADVANTAGE Balance Sheet February 28, 2010 Assets February 28, 2010 June 30, 2009 Current Assets Cash and cash equivalents $ 1,654,665 $ - Board designated: Healthplans statutory requirements 632,000 0 Total Board designated 632,000 0 Estimated amounts due from third-party payors 151,237 0 Due from related parties 0 0 Total current assets 2,437,902 0 Total assets $ 2,437,902 $ - Liabilities and Net Assets Current Liabilities Medical claims payable 1,557,933 0 Other current liabilities 482,632 0 Total current liabilities 2,040,565 0 Long-term Debt 0 0 Total liabilities 2,040,565 0 Net Assets Unrestricted 397,337 0 Total net assets 397,337 0 Total liabilities and net assets $ 2,437,902 $ - Page 29

158 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT d/b/a MARICOPA CARE ADVANTAGE Cash Flow Statement - Maricopa Care Advantage February 28, 2010 ($ in 000's) Current Month Year to Date Operating Income (Loss) $ (158) $ (664) Non-Operating Income - - Net Income (Loss) (158) (664) Add: Depreciation - - Less: Changes in Assets and Liabilities 172 (277) Net cash from operations 14 (941) Cash spent on capital - - Cash - All Other - - Net increase (decrease) in cash $14 ($941) Beginning Cash Balance 2,273 3,228 Ending Cash Balance - February 28, 2010 $2,287 $2,287 Page 30

159 FINANCIAL PERFORMANCE DASHBOARD For the Eight Months Ended February 28, 2010 Performance Measures - Maricopa Medical Center Year to Date Actual Budget Variance Variance % Prior Year Variance Variance % Oper Rev/APD $ 1,624 $ 1,578 $ % $ 1,687 $ (64) -3.8% Oper Exp/APD $ 1,853 $ 1,781 $ (73) -4.1% $ 1,831 $ (23) -1.2% Labor/APD $ 871 $ 835 $ (36) -4.3% $ 879 $ 9 1.0% Amb. Supplies/visits $ 7.29 $ 7.88 $ % $ 8.01 $ % Psych Supplies/Pt Days $ $ $ (0.15) -1.4% $ 9.41 $ (0.85) -9.0% MMC Supplies/APD $ $ $ (49.09) -11.6% $ $ (59.67) -14.5% Labor %/Tot Op Exp 47.0% 46.9% -0.1% -0.2% 48.0% 1.1% 2.2% Supply %/Tot Op Exp 13.5% 13.5% 0.1% 0.4% 12.8% -0.7% -5.3% Financial Information - Maricopa Medical Center ($ 000s) Year to Date Actual Budget Variance Variance % Prior Year Variance Variance % Operating Revenue $ 258,696 $ 264,884 $ (6,189) -2.3% $ 272,048 $ (13,352) -4.9% Operating Expenses $ 295,316 $ 298,968 $ 3, % $ 295,198 $ (118) 0.0% Operating Income $ (36,620) $ (34,084) $ (2,536) -7.4% $ (23,150) $ (13,470) -58.2% Net Income $ 3,274 $ 5,845 $ (2,571) -44.0% $ 15,364 $ (12,091) 78.7% Operating Margin % -14.2% -12.9% -1.3% -10.0% -8.5% -5.6% -66.3% Capital Expenditures $ 16,576 $ 22,595 $ 6, % $ 10,606 $ (5,970) -56.3% Payer Mix - Based on Gross Charges Year to Date Actual Budget Variance Variance % Prior Year Variance Variance % AHCCCS 34.8% 38.6% -3.8% -9.8% 33.4% 1.4% 4.2% Maricopa Health Plan 10.9% 12.1% -1.2% -9.9% 11.6% -0.7% -5.8% Medicare 15.6% 10.4% 5.3% 50.9% 14.6% 1.0% 7.1% Selfpay 14.7% 21.9% -7.2% -33.0% 13.6% 1.0% 7.7% Other 24.0% 17.0% 7.0% 41.1% 26.8% -2.8% -10.5% Page 31

160 FINANCIAL PERFORMANCE DASHBOARD For the Eight Months Ended February 28, 2010 Maricopa Health Plan Year to Date Actual Budget Variance Variance % Prior Year Variance Variance % Member Months $ 475, ,493 (24,950) -5.0% 363, , % Revenue PMPM $ 293 $ 345 $ (52) -15.1% $ 335 $ (42) -12.5% Medical Expenses PMPM $ 245 $ 302 $ % $ 284 $ % Other Exp/Rev PMPM $ 29 $ 31 $ 2 6.5% $ 31 $ 2 6.5% Net Income PMPM $ 11 $ 5 $ 6 0.0% $ 12 $ (1) 8.3% Maricopa Care Advantage Year to Date Actual Budget Variance Variance % Prior Year Variance Variance % Member Months 7,309 7,564 (255) -3.4% 5,492 1, % Revenue PMPM $ 1,018 $ 990 $ % $ 1,011 $ 7 0.0% Medical Expenses PMPM $ 959 $ 811 $ (148) -18.3% $ 788 $ (171) 0.0% Other Exp/Rev PMPM $ 150 $ 155 $ 5 3.2% $ 198 $ % Net Income PMPM $ (91) $ 24 $ (115) 0.0% $ 25 $ (116) 0.0% Page 32

161 Operational Performance Dashboard Feb 2010 Volume Indicators Efficiency Indicators Patient Satisfaction Indicators Actual Budget Actual Target Raw Score Percentile Admissions 1,563 1,806 Operating Room Utilization 77% 70% Inpatient (Acute) % Adjusted Patient Days 18,564 20,523 OR Percent on Time Starts (Cut Time) 23% 85% Nursing % Average Length of Stay - Acute OR Percent on Time Starts (In Room Time) 23% 85% Physicians % Surgery Cases Cath Lab Utilization 40% 75% Emergency Dept % Inpatient 64.0% 67.0% Percent of Inpts on Pathways N/A N/A Ambulatory % Outpatient 36.0% 33.0% FTE/Adj Pt Day w/o residents % Occupancy 57% 61% Timely Discharge 39% <120 Average Daily Census IP/OP Gross Charge Mix Inpatient 61.5% 59.2% Outpatient 38.5% 40.8% Emergency Department Indicators Financial Indicators Actual Budget Actual Budget Total Visits 4,381 4,957 Total Opr Revenue/Adjusted $1,391 $1,582 Adult 2,866 3,200 Patient t Day Peds 1,515 1,757 Supply Cost/Total Operating 15.4% 13.6% % Converting to Inpatient 17.8% 18.5% Expenses LWOT 3.1% <3% Labor Cost/Total Operating 44.8% 45.8% % of IP Sourced in ED 56.6% 56.6% Expenses ALOS (minutes) 321 <180 Total Cost/Adjusted $1,978 $1,795 Avg Time to Treatment (mins) Patient Day 7 Ave Walk-In- Clinic/UCC Visits 1,447 2,203 Referred to ED 46 4 MHP Revenue PMPM $262 $345 Direct Admits 14 4 MHP Medical Expenses PMPM $219 $302 ED to IP - - MCA Revenue PMPM $1,018 $990 MCA Medical Expenses PMPM $959 $811 Page 33

162 Maricopa County Special Health Care District Summary of Accounts Receivable Write-offs Approval required CEO Board Write-offs or Reclass to Bad Debt requiring CEO approval (Greater than $250,000 to $499,999) Month Payer Total Charges Admit Date Discharge Date Moved to Bad Debt Diagnosis Feb-10 Self Pay/Undocumented $2,015, /14/2009 8/28/2009 $375,795 Fascitis YES NO Patient Mexican Resident, admitted with serious infection to the face and neck, requiring several surgeries. Billed Section 1011, if paid we will receive $21,669 for the complete stay. Write-offs or Reclass to Bad Debt requiring Board approval (Greater than $500,000) Month Payer Total Charges Admit Date Discharge Date Moved to Bad Debt Diagnosis Feb-10 None NO NO

163 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.

164 Maricopa County Special Health Care District Clerk s Office 2601 E. Roosevelt Phoenix, AZ Phone: (602) Fax: (602) DATE: March 11, 2010 TO: Bil Bruno, Chair, District 1 Susan Gerard, Vice Chair, District 3 Greg Patterson, Director, District 2 Elbert Bicknell, Director, District 4 Alice Lara, Director, District 5 FROM: SUBJECT: Melanie Talbot Annual Review/Possible Revisions to Existing Board Policy Statements The Board Policy Statements should be reviewed annually. The policy statements are divided into four categories: finance, governance, conduct, and accreditation. Below is a summary of proposed changes to the policies that fall within the finance category. Governance Board Policy Statements will be brought to the Board for review in April Finance Financial Records o No change Financial Reports o No change Internal Audit o No significant changes Investment of Funds o No change

165 Revenue Contracts Medical Services o No change Selection of Auditors o No change Depositories o No change District Treasurer o No significant changes President & Chief Executive Officer Evaluation o No significant changes

166 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.a.

167 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 08/06 Frequency of Review: Annually Reviewed Dates: 03/10 Revision Dates: 04/09 Policy #: G Policy Title: Board Policy - Finance Financial Records Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: It is the policy of the Board of Directors that all financial records, books, and accounts of the District shall accurately reflect all financial transactions of the District. Maricopa Integrated Health System s (MIHS s) books and records must never include false or misleading information, and must conform to generally accepted accounting principles, governmental accounting standards, and regulatory requirements. Policy #99007 G Board Policy: Finance/Financial Records Page 1 of 1 Date: 04/0903/10 Supersedes: 08/0604/09

168 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.b.

169 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 08/06 Frequency of Review: Annually Reviewed Dates: 03/10 Revision Dates: 04/09 Policy #: G Policy Title: Board Policy - Finance Financial Reports Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: The Board of Directors shall receive a monthly financial package that includes financial reports on a consolidated basis for the District. In addition, the monthly financial package shall include but not limited to, separate financial reports for each of the following business units of the District: Maricopa Medical Center, Maricopa Health Plan, and Maricopa Care Advantage. This financial package will consist of at least a Balance Sheet, Income Statement, and Cash Flow Statement. The Income Statement shall compare the current month s financial results to that of the same month in the previous year and to the current month s budget. Year-to-date results shall be compared to the same measures as well. The Balance Sheet shall compare the current month ending balances to the prior fiscal year ending balances. The Cash Flow Statement shall show the sources and uses of cash for the current month and fiscal yearto-date. The monthly financial package will also include key operating indicators and statistical reports to assist in identifying trends that may be negatively affecting the operations of Maricopa Medical Center, Maricopa Health Plan, or Maricopa Care Advantage. Graphs shall be used where possible. In addition to tracking key operating indicators and statistics, other key ratios shall be identified by management to monitor the organization s financial health. These ratios shall be tracked as part of the normal monthly financial package and they shall also be benchmarked against other similar organizations to identify areas that need to be improved. The use of rating agencies (e.g., Moody s, or Standard and Poor s) that publish the median ratios for hospitals may also be used for rating comparisons. Policy #99008 G Board Policy: Finance/Financial Reports Page 1 of 1 Date: 04/0903/10 Supersedes: 08/0604/09

170 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.c.

171 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 08/06 Frequency of Review: Annually Reviewed Dates: 03/10 Revision Dates: 09/07; 04/09 Policy #: G Policy Title: Board Policy - Finance Internal Audit Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: An internal auditor will be employed or contracted to perform various audits of internal controls throughout the year. The internal auditor will report through the Chief Compliance Officer to the President & Chief Executive Officer. If the internal auditor has a question which relates directly to the Chief Compliance Officer, he/she is authorized to report directly to the President & Chief Executive Officer. If the internal auditor has a question which relates directly to the President & Chief Executive Officer, he/she is authorized to report directly to the Chief Compliance Officer, who will report to the Board. If the internal auditor has a question which relates to both the President & CEOChief Executive Officer and the CCOChief Compliance Officer, he/she is authorized to report directly to the Board of Directors through the Chairman of the Board. A formal audit plan shall be prepared annually and presented to the Board for approval. The audit plan shall identify high risk areas that need to be addressed first and then work down to areas of lesser risk. Formal reporting on internal audit activities shall be made to the Board no less than quarterly. The audit plan shall include input from the CFOChief Financial Officer and President & CEOChief Executive Officer on areas of concern. Any member of Management may request internal audit to review activities or areas that may be of concern. Also, the internal auditor shall work with the compliance officer to identify areas that need to be reviewed that may impact the organization on compliance issues. Policy #99009 G Board Policy: Finance/Internal Audit Page 1 of 1 Date: 04/0903/10 Supersedes: 09/0704/09

172 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.d.

173 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 08/06 Frequency of Review: Annually Reviewed Dates: 03/10 Revision Dates: 04/09 Policy #: G Policy Title: Board Policy - Finance Investment of Funds Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: The District Treasurer, or designee, or others, as authorized by law, shall invest District monies in eligible investments according to state law, except for those that the District Treasurer, or designee, or others, as authorized by law, have agreed to be invested by a national bank or national investment firm that will adhere to all state investment laws. The Board of Directors shall monitor investment returns on a quarterly basis. Policy #99010 G Board Policy: Finance/Investment of Funds Page 1 of 1 Date: 04/0903/10 Supersedes: 08/0604/09

174 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.e.

175 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 08/06 Frequency of Review: Annually Reviewed Dates: 09/07; 03/10 Revision Dates: 04/09 Policy #: G Policy Title: Board Policy - Finance Revenue Contracts Medical Services Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: Revenue contracts and arrangements between the District and a third-party payer must comply with review and signature approval as established by the District s Authorization and Responsibility Matrix as approved and amended from time to time. The Board of Directors may approve or decline revenue contracts and arrangements between the District and third party payers that may place the District at risk if the contract does not cover the District s costs. Reference: Authorization and Responsibility Matrix Policy #99011 G Board Policy: Finance/Revenue Contracts Medical Services Page 1 of 1 Date: 04/0903/10 Supercedes: 09/0704/09

176 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.f. No Information Available at This Time

177 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.g.

178 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 09/06 Frequency of Review: Annual Reviewed Dates: 03/10 Revision Dates: 09/07; 04/09 Policy #: G Policy Title: Board Policy Finance Selection of Auditors Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: The Board of Directors is responsible for selecting, removing, or terminating the District s external auditors. While the Board will consult Maricopa Integrated Health System (MIHS) management on the terms and conditions of a contract with the external auditors, it shall have final authority to approve all audit engagement fees and terms. The Board shall, on at least a triennial basis, obtain a copy of the external auditor s most recent peer review report and shall assess the firm s independence through inquiries of any relationships the firm or its partners and staff might have with the District or MIHS. The Board shall require that the auditing firm they select rotate partners every five (5) years in order to maintain independence between the audit firm and the District. The Board and management are both responsible for implementing and monitoring this policy. Policy #99013 G Board Policy: Finance/Selection of Auditors Page 1 of 1 Date: 04/0903/10 Supersedes: 09/0704/09

179 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.h.

180 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 10/07 Frequency of Review: Annual Reviewed Dates: 03/10 Revision Dates: 04/09 Policy #: G Policy Title: Board Policy Finance Depositories Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: All monies received for the District from any source shall be deposited with the District s Treasurer, its designee, or others as authorized by law to the credit of the District. The Board of Directors may request a report from the District s Treasurer, its designee, or individual specified as authorized by law as to the depositories of District funds. Policy #99016 G Board Policy: Finance/Depositories Page 1 of 1 Date: 04/0903/10 Supersedes: 10/0704/09

181 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.i.

182 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 10/07 Frequency of Review: Annual Reviewed Dates: 03/10 Revision Dates: 04/09 Policy #: G Policy Title: Board Policy Finance District Treasurer Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: The Board of Directors, following the recommendation of the President & Chief Executive Officer, shall appoint a District Treasurer who is responsible for the management, accounting, and investment of all District monies consistent with the provisions of state and federal laws. Reference: A.R.S Policy #99017 G Board Policy: Finance/District Treasurer Page 1 of 1 Date: 04/0903/10 Supersedes: 10/0704/09

183 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 8.j.

184 Maricopa Integrated Health System: District Governance - Board Policy Statement Effective Date: 08/07 Frequency of Review: Annual Reviewed Dates: Revision Dates: 03/09; 03/10 Policy #: G Policy Title: Board Policy Governance President & Chief Executive Officer Evaluation Scope: [X] District Governance(G) [ ] System-Wide(S) [ ] Multi-divisions(MD) [ ] Division(D) [ ] Multi-departments(MT) [ ] Department(T) Signature: [William Bruno, Chair - Board of Directors, Maricopa County Special Health Care District] [Date] Policy: The Board shall conduct an annual evaluation of the District President & CEO within 60 days of the fiscal year end. In preparation for the annual evaluation, the President & CEO shall submit a written statement to the Board: 1. Setting forth each of the goals adopted by the Board and agreed to by the President & CEO at the beginning of the fiscal year. Addressing the degree of success the President & CEO enjoyed in meeting the goals. 2. Addressing all other matters, if any, set forth in the contract between the District and the President & CEO to be reviewed annually by the Board. 3. Reviewing the year in general for MIHS. 4. Addressing any other matter the President & CEO deems relevant for the Board s attention. Throughout the fiscal year, the Board shall provide the President & Chief Executive Officer with quarterly executive session opportunities to evaluate performance toward the annual goals. The Board shall review the President & CEO s written submission, and may meet in executive session, at the pleasure of the Board, without the President & CEO s presence to discuss the President & CEO s submission. The President & CEO may call for the discussion to take place in open session if he or she desires. The Board then shall meet in executive session to discuss each Board member s assessment of the President & CEO s performance. The President & CEO again may call for the discussion to take place in open session if he or she desires. If the Board deems the President & CEO to have merited a performance-based salary increase, the Board may place the matter on an agenda of an open session for approval. At all times the Board clerk or counsel or both shall give all notices to the President & CEO on behalf of the Board to satisfy any applicable law, including the Arizona open-meeting law. Policy #99101 G Board Policy: Governance/Chief Executive Officer Evaluation Page 1 of 1 Date: 03/0903/10 Supersedes: 08/0703/09

185 Maricopa County Special Health Care District Board of Directors Formal Meeting March 24, 2010 Item 9.

186 FY 11 Rate Package Executive Summary