Quality, Safety & Education and Full Board of Directors Meetings Thursday, April 13, :00 p.m.

Transcription

1 Quality, Safety & Education and Full Board of Directors Meetings Thursday, April 13, :00 p.m. Lee Memorial Health System Board of Directors

2 BOARD OF DIRECTORS OFFICE FA: DOCTORS WAY #190 FT MYERS, FLORIDA CAPE CORAL HOSPITAL GULF COAST MEDICAL CENTER HEALTHPARK MEDICAL CENTER LEE MEMORIAL HOSPITAL GOLISANO CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA THE REHABILITATION HOSPITAL LEE PHYSICIAN GROUP LEE CONVENIENT CARE BOARD OF DIRECTORS DISTRICT ONE Stephen R. Brown, M.D. Therese Everly, BS, RRT DISTRICT TWO Donna Clarke Nancy M. McGovern, RN, MSM DISTRICT THREE Sanford N. Cohen, M.D. David Collins DISTRICT FOUR Diane Champion Chris Hansen DISTRICT FIVE Jessica Carter Peer Stephanie Meyer, BSN, RN AGENDA QUALITY, SAFETY & EDUCATION AND FULL BOARD OF DIRECTORS MEETINGS April 13, 2017 at 1:00 p.m. Gulf Coast Medical Center Boardroom (Medical Office Building) Doctors Way, Ft. Myers, FL CALL TO ORDER (Sanford Cohen, M.D., Board Chairman) Lee Memorial Health System Board of Directors, sitting as the Board of Directors for Lee Health, Gulf Coast Medical Center & Lee Memorial Hospital/HealthPark Medical Center and the Board of Directors of its subsidiary corporations, including but not limited to Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital; Lee Memorial Home Health, Inc.; and HealthPark Care Center, Inc. 2. INVOCATION & PLEDGE OF ALLEGIANCE (Rev. Cynthia Brasher, MDiv, BCC) 3. PUBLIC INPUT Agenda Items: Any Public Input is limited to three minutes and a Request to Address the Board of Directors card must be completed and submitted to the Board Staff prior to meeting. Individuals wishing to address the Board on a Non Agenda item must notify the Board Staff of the subject matter at least three (3) days prior to the meeting. 4. RECOGNITION: LARRY ALTIER, SYST. DIR. FOOD & NUTRITION 1. American Heart Association Certification for Meal Preparation (Scott Kashman, Chief Acute Care Officer; Josh Detillio, CAO GCMC & Ancillary Services) 2. AARP Grant (Scott Kashman, Chief Acute Care Officer; Josh Detillio, CAO GCMC & Ancillary Services) 5. INTRODUCTION: VENKAT PRASAD, M.D., CMO LEE PHYSICIAN GROUP (Scott Nygaard, Chief Medical & Clinical Integration Officer) 6. LEE HEALTH VILLAGE AT COCONUT POINT - PROJECT FUNDING (Dave Kistel, Vice President Facilities & Support Services) (Approve) 7. ACTION ITEM CONCERNING POPULATION HEALTH ACTIVITY (John Chomeau, Chief Population Health Officer) (Approve) Quality & Safety Portion: Steve Brown M.D., Quality & Safety Liaison 8. APIC RECOGNITION OF STEPHEN STREED: 2017 CAROLE DEMILLE ACHIEVEMENT AWARD (Chuck Krivenko, CMO Clin. & Quality Services, Chief Patient Safety Officer) 9. HAND HYGIENE REPORT (Accept) (Stephen Streed, System Director Epidemiology/Infection Control) 10. GOLISANO PERFORMANCE INDICATORS (Accept) (Alex Daneshmand, D.O., System Medical Director Quality/GCHSWF) Lee Memorial Health System Board of Directors

3 AGENDA (Page 2 of 2) BOARD OF DIRECTORS OFFICE FA: DOCTORS WAY #190 FT MYERS, FLORIDA CAPE CORAL HOSPITAL GULF COAST MEDICAL CENTER HEALTHPARK MEDICAL CENTER QUALITY, SAFETY & EDUCATION AND FULL BOARD OF DIRECTORS MEETINGS April 13, 2017 at 1:00 p.m. 11. PROCESS ANALYTICS (Accept) (Marcelo Zottolo, System Director Process Analytics) 1. Spring 2017 Leapfrog Grades 2. CMS 5 Star Scorecard 3. Predictive Analytics for Hospital-Associated Infections Using Qlikview (Scott Kashman, Chief Acute Care Officer) (Lisa Sgarlata, Chief Administrative Officer LMH) (Jennifer Higgins, VP Patient Care Services LMH) (Mary Beth Saunders, D.O., System Medical Director Epidemiology) LEE HEALTH BUSINESS Sanford Cohen, M.D., BOARD CHAIRMAN LEE MEMORIAL HOSPITAL GOLISANO CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA THE REHABILITATION HOSPITAL LEE PHYSICIAN GROUP LEE CONVENIENT CARE 12. CONSENT AGENDA (Approve) 1. Finance and Full Board Meeting Minutes of 3/30/17 2. Utilization Management Plan COMPLIANCE REPORT (Accept) (Shelley Koltnow, Chief Compliance Officer) 14. OLD BUSINESS BOARD OF DIRECTORS DISTRICT ONE Stephen R. Brown, M.D. Therese Everly, BS, RRT DISTRICT TWO Donna Clarke Nancy M. McGovern, RN, MSM DISTRICT THREE Sanford N. Cohen, M.D. David Collins DISTRICT FOUR Diane Champion Chris Hansen DISTRICT FIVE Jessica Carter Peer Stephanie Meyer, BSN, RN 15. NEW BUSINESS 16. PRESIDENT S REPORT (Jim Nathan, CEO/President) 17. BOARD MEETING CRITIQUE 18. BOARD OF DIRECTORS REPORTS Date of the next Meeting: April 27, 2017 at 1:00 p.m. Full Board of Directors Gulf Coast Medical Center Boardroom Doctors Way, Ft. Myers, FL ADJOURN (Sanford Cohen, M.D., Board Chairman) Lee Memorial Health System Board of Directors

4 BOARD OF DIRECTORS Invocation & Pledge of Allegiance Lee Memorial Health System Board of Directors

5 BOARD OF DIRECTORS PUBLIC INPUT AGENDA ITEMS: Any public input pertaining to items on the Agenda is limited to three minutes and a Request to Address the Board of Directors card must be completed and submitted to the Board Staff prior to meeting. Refer to Board Policy: 10:15G: Public Addressing the Board Non-Agenda Item: Individuals wishing to address the Board on an item NOT on the Agenda, the Board office must be notified of subject matter at least three (3) days prior to the meeting to allow staff time to prepare and to insure the matter is within the jurisdiction of the Board. Lee Memorial Health System Board of Directors

6 BOARD OF DIRECTORS RECOGNITION: (Scott Kashman, Chief Acute Care Officer; Josh Detillio, CAO GCMC & Ancillary Services) 1. American Heart Association: Certification for Meal Preparation 2. AARP Grant Lee Memorial Health System Board of Directors

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8 BOARD OF DIRECTORS INTRODUCTION: (Scott Nygaard, Chief Medical & Clinical Integration Officer) Lee Memorial Health System Board of Directors

9 BOARD OF DIRECTORS LEE HEALTH VILLAGE AT COCONUT POINT: PROJECT FUNDING (Dave Kistel, Vice President Facilities & Support Services) (APPROVE) Lee Memorial Health System Board of Directors

10 BOARD OFF DIIREECTTORS RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc) Keep form to one page, to: by Noon Eight (8) days PRIOR to presenting. DATE: April 13, 2017 LEGAL SERVICE REVIEW? YES_x_ NO SUBJECT: Lee Health at Coconut Project funding and Guaranteed Maximum Price REQUESTOR & TITLE: Dave Kistel, V.P. Facilities & Support Services PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations internal groups which support the recommendation) On October 22, 2015 Board approved the Architectural agreement with FLAD and Construction Management agreement with Deangelis Diamond Healthcare Group, LLC. On November 17, 2016, the Board approved the early release work for the Lee Health at Coconut Point construction project. SPECIFIC PROPOSED MOTION: Motion to: 1) Approve $127,958, for the construction, furnishings, equipment and information systems required to complete the Lee Health at Coconut Point project 2) Approve the GMP (guaranteed maximum price) amendment, in the amount of $84,052,000.00, to the contract with Deangelis Diamond Healthcare Group, LLC FINANCIAL IMPLICATIONS Budgeted Account x Non-Budgeted (Annual Project Budget and Total Project Budget) Project cost:$139,897, Previously funded by Board: $11,938, Balance of project cost to be funded: $127,958, STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) PURPOSE/REASON FOR RECOMMENDATION Meet the growing healthcare needs of this community Allows us to proceed with the deployment and completion of this important facility for the residents of South Fort Myers SUMMARY (including alternatives considered, Pros and Cons) This healthcare destination for residents of South Fort Myers offers patient focused, integrated medicine and care delivery in one convenient location. A broad array of medical services across the continuum of care is available in a pleasing campus/retail settingaccessible, walkable, and welcoming for patients and families-creating an enhanced patient experience and a healing environment. Lee Memorial Health System Board of Directors Updated 3/2/17

11 Lee Health at Coconut Point Project Budget Projection: $140,000, /22/15 Board approved $6,844, for design and pre construction services 11/17/16 Board approved $5,094, for early release package Total approved to date: $11,938, /13/17 Balance of project funding: $127,958, Total project cost: $139,897, Projected savings over original budget: $102,738.00

12 Lee Health at Coconut Point Dave Kistel, VP Facilities & Support Services April 13, 2017 # Rev. 10/16

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16 Thank You

17 BOARD OF DIRECTORS ACTION ITEM CONCERNING POPULATION HEALTH ACTIVITY (John Chomeau, Chief Population Health Officer) (APPROVE) Lee Memorial Health System Board of Directors

18 BOARD OFF DIIREECTTORS RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc) Keep form to one page, to: by Noon Eight (8) days PRIOR to presenting. DATE: April 13, 2017 LEGAL SERVICE REVIEW? YES_x_ NO SUBJECT: Medicaid Provider Service Network REQUESTOR & TITLE: John Chomeau, Chief Population Health Officer PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) On April 6, 2017, the Board participated in a workshop regarding financial changes to the Medicare and Medicaid programs. SPECIFIC PROPOSED MOTION: Motion to: 1) Provider Service Network: Approve the Lee Health Administration s recommendation that Lee Health continue preparation work to submit a response to the State of Florida s Invitation to Negotiate ( ITN ), signifying Lee Health s interest in exploring participation in the Medicaid PSN program. 2) Legal Structure - Provider Service Network: Approve the creation of a limited liability company created by Lee Health to hold the Provider Service Network contract with the Agency for Health Care Administration ( AHCA ). FINANCIAL IMPLICATIONS Budgeted Account Non-Budgeted _x (Annual Project Budget and Total Project Budget) 1) Provider Service Network: Please refer to slide number 9 in today s presentation. PURPOSE/REASON FOR RECOMMENDATION Please refer to the materials presented at the workshop on April 6, PROS TO RECOMMENDATION CONS TO RECOMMENDATION 1) Improves access to care for our region s elderly 1) Stepping away from traditional fee-for-service and most disadvantaged residents payment mechanisms 2) Anticipated improved reimbursement 2) Initial capital investments 3) Expected enhanced patient outcomes 3) Potential short-term confusion among our 4) Creates new legal entities to promote focus and patients and community providers flexibility 5) Aligns Lee Health with the state and national focus on tying reimbursement to patient outcomes ALTERNATIVES CONSIDERED 1) Decline to respond 2) National partner Evolent (build and operate with 100 percent Lee Health ownership) 3) State PSN partner Community Care Plan (Broward County) with 100 percent Lee Health ownership 4) Contract with National MCO as a High Performing Network (Aetna, United, Magellan, Molina) SUMMARY As presented at the April 6 workshop, two key programs provide incentives to health care providers to engage in more coordinated patient care, and to undertake alternative models to the traditional fee-for-service model. The new models presented at the April 6 workshop included (1) the Medicaid Provider Service Network ( PSN ), and (2) the Medicare Next Generation Accountable Care Organization ( NextGen ACO ). Lee Memorial Health System Board of Directors 3/2/17 Updated

19 BOARD OFF DIIREECTTORS RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc) Keep form to one page, to: by Noon Eight (8) days PRIOR to presenting. DATE: April 13, 2017 LEGAL SERVICE REVIEW? YES_x_ NO SUBJECT: Medicare Next Generation Accountable Care Organization REQUESTOR & TITLE: John Chomeau, Chief Population Health Officer PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) On April 6, 2017, the Board participated in a workshop regarding financial changes to the Medicare and Medicaid programs. SPECIFIC PROPOSED MOTION: Motion to: 1) Medicare Next Generation Accountable Care Organization: Approve the Administration s recommendation to submit a Letter of Intent and an application to create a Medicare Next Generation Accountable Care Organization, signifying Lee Health s interest in exploring participation in the Medicare Next Generation Accountable Care Organization program. 2) Legal Structure Medicare Next Generation Accountable Care Organization: Approve the creation of a limited liability company created by Lee Health to hold the Medicare Next Generation Accountable Care Organization contract with the Centers for Medicare and Medicaid Services ( CMS ). FINANCIAL IMPLICATIONS Budgeted Account Non-Budgeted _x (Annual Project Budget and Total Project Budget) 1) Medicare Next Generation Accountable Care Organization: Please refer to slide number 16 in today s presentation. PURPOSE/REASON FOR RECOMMENDATION Please refer to the materials presented at the workshop on April 6, PROS TO RECOMMENDATION CONS TO RECOMMENDATION 1) Improves access to care for our region s elderly 1) Stepping away from traditional fee-for-service and most disadvantaged residents payment mechanisms 2) Anticipated improved reimbursement 2) Initial capital investments 3) Expected enhanced patient outcomes 3) Potential short-term confusion among our 4) Creates new legal entities to promote focus and patients and community providers flexibility 5) Aligns Lee Health with the state and national focus on tying reimbursement to patient outcomes ALTERNATIVES CONSIDERED 1) Not apply to the CMS Next Generation ACO SUMMARY As presented at the April 6 workshop, new government programs provide incentives to health care providers to engage in more coordinated patient care, and to undertake alternative models to the traditional fee-for-service model. The new models presented at the April 6 workshop included (1) the Medicaid Provider Service Network ( PSN ), and (2) the Medicare Next Generation Accountable Care Organization ( NextGen ACO ). Lee Memorial Health System Board of Directors 3/2/17 Updated

20 Lee Health Moving Care from Volume to Value Population Health Transformation State of Florida Medicaid Opportunity Medicare Next Generation ACO Opportunity

21 Board Action Today, the Lee Memorial Health System Board of Directors is being asked to approve the Lee Health Administration s efforts to pursue two value based models and supporting legal structure State of Florida Medicaid Procurement in Region 8/E as a Provider Service Network (PSN) The CMS advanced payment model known as Medicare Next Generation Accountable Care Organization (ACO) Both models will reposition Lee Health to improve patient care and obtain incentive based payments Both models are highly synergistic and will produce positive returns on investment Both models have off-ramps 2

22 Decision Summary Medicaid PSN Opportunity NextGen ACO Opportunity Recommendation Lee Health Administration is RECOMMENDING Apply for the Medicare Next Generation ACO and the Florida Medicaid Procurement Contract with Evolent to enable our application, operating capability and ROI synergy Rationale Lee Health is the leading PSN in Region 8/E 52% of all Medicaid eligibles in district 8/E are in Lee County Non participation locks LH into payment declines through 2024 It is the right thing to do in our community for our most disadvantaged citizens National operating vendor lowers implementation risk Further aligns our Medicare Community to optimal PCP care Creates ability for Lee Health to engage primary care providers in the Right care, Right place and Right time transformation Enables Lee Health to qualify for automatic 5 15% FFS bonus and drive shared savings to the system, LPG and participating PHO PCP s Impact to Lee Health LH Implementation team needed in 2018 for 2019 launch Improved underwriting margin, system contribution from more appropriate clinical care, reimbursement and patient outcomes Start Up Cost 2017: $1.0m plus $1.5m of regulatory reserves 2018: $4.0m plus $2.2m of regulatory reserves (Reserves remain on LH Balance Sheet) Vendor Run Rate Cost 2019: 9.4% ROI : 178% LH Implementation team needed in 2017 for 2018 launch Provides an attractive value proposition to recruit independent Physicians for network expansion Start Up Cost 2017: $1.8m implementation cost No reserves required Vendor Run Rate Cost 2018: $8.4m operating expense ROI : 1774% 3

23 Legal Organization Design

24 Provider Service Network Key Requirements: (1) Majority owned by Health Care Providers (2) Board is controlled by Health Care Providers LEE HEALTH PHO LPG Providers Evolent PSN, LLC PSN Contract AHCA Risk Assumption Network Development Infrastructure Other Providers Organizational Model: Lee Health would form a wholly owned subsidiary, organized as a Florida Limited Liability Company. The wholly owned subsidiary would serve as the PSN and hold the MMA contract with AHCA. 5

25 Accountable Care Organization Key Requirements: (1) ACO must have a Tax Identification Number (2) The Board of the ACO must be composed of at least 75% participating providers LEE HEALTH PHO LPG Providers Evolent Support Services Contract ACO, LLC (TIN) ACO Contract CMS Providers Model: Lee Health would form a wholly owned subsidiary, organized as a Florida Limited Liability Company. The wholly owned subsidiary would serve as the ACO and would hold the contract with CMS. 6

26 Medicaid PSN Recommendation Rationale

27 Projected Medicaid Fee-For-Service Reimbursement & Margin Medicaid HMO FY Cases 110, , , , ,906 Payments 82,886,947 82,853,792 82,820,651 81,164,238 81,131,772 Payment per Case ( 2% per year) Total Operating Costs 126,219, ,034, ,977, ,656, ,814,152 Gain/(Loss) (43,332,840) (47,180,463) (51,156,481) (55,492,437) (59,682,380) Margin 52% 57% 62% 68% 74% *AHCA Pressure on Hospital Medicaid rates will increase losses $16 million over next 4 years 8

28 Lee Health Medicaid Provider Service Network Financial Projections and Return on Investment Medicaid Members 20,000 21,300 22,685 24,159 25,729 Annual Reimbursement per Member 3,300 3,449 3,604 3,766 3,935 Total Premium Revenues 66,000,000 73,453,050 81,747,736 90,979, ,252,913 Medical Loss Ratio 87.40% 86.96% 86.53% 86.10% 85.67% Administrative Loss Ratio 9.40% 9.40% 9.40% 9.40% 9.40% Amortization of Start Up Costs 1.08% 0.97% 0.87% 0.79% 0.71% Total Expense % of Premiums 97.88% 97.34% 96.80% 96.28% 95.77% Operating Margin % 2.1% 2.7% 3.2% 3.7% 4.2% Operating Margin $ 1,397,714 1,957,202 2,614,331 3,383,828 4,282,478 Initial Investment $ 5,000,000 7 Year Return on Investment 178% Capital Reserve * 1,500,000 6,600,000 7,345,305 8,174,774 9,097,910 10,125,291 *Capital Reserves remain Lee Health asset and are allowed to be deposited in interest bearing account

29 Medicaid Procurement Options Business Options 1. Decline to Respond 2. National Partner Evolent Build and Operate with 100% Lee Health Ownership PROS Keeps focus on In Flight Initiatives Subject Matter Expertise with lower operational and financial risk CONS 5 Year Lockout through 2024 with certain FFS decline Not LH People with our success dependent upon contracted teams and Service Level Agreements 3. State PSN Partner: Community Care Plan (Broward County) with 100% Lee Health Ownership Moderate Risk reduction and a knowledgeable FL Medicaid Operator Emerging organization with high administrative cost and limited support based in Lee County 4. Contract with National MCO as a High Performing Network Aetna, United, Magellan, Molina Downside Risk reduced due to partial contract exposure and FL State collaboration At the mercy of national contracting demands with limits on upside financial gains attributed to performance 10

30 Decision Roadmap Decision Rubric Weighting and Rationale 1=Negative 5=Positive Financial Risk Profile Operating Control Governance ACHA Support Legislative Organization Demands Decline to Respond FFS Decline Certain Disruption to administration to meet margin targets Status Quo Status Quo FFS Administration Keeps LH in the box Status Quo but slows the timeline and scale of VBC Participate with Evolent and Operate with 100% Ownership Participate with PSN Partner: Community Care Plan (Broward County) Participate with National MCO as a High Performing Network Full Risk Adjusted Revenue with RBC, Fixed 9.5% admin Full Upside, Full Downside with Reinsurance Need to build a modest LH MCO Leadership Team LH Governance with an Operating Subsidiary managing Evolent Currently supporting 4 State PSN's and ACHA relationship is positive LH History and Newness of Evolent to FL Full Service Vendor who has successfully managed Medicaid Procurements and Contracts in multiple States Full Risk Adjusted Revenue with RBC, Variable 12% admin Full Upside, Full Downside with Reinsurance Need to build an extensive LH MCO Leadership Team Governance is not 100% clear as CCP has not provided an operating proposal CCP is very entrenched with ACHA and feedback is positive Very active through their legislative affairs team CCP has partners that are struggling to agree on strategies to include SW FL region Partial PMPM Revenue based on negotiated terms MCO Carries the full spectrum of risk. Most likely will require both up and downside risk participation Minimal Independent operating control Clinical Collaboration, Revenue Management and Patient Experiences scorecard Mixed Varies by MCO History and audited findings and sanction history Powerhouse legislative efforts at all levels LH at the direction of the MCO National CEO and Regional CEO and their respective leaders 11

31 Lee Health would make all strategic and operating decisions Operational outsourcing to Evolent to minimize risk Lee Health Medicaid Provider Service Network Board of Directors EVH Function (primarily local) 12

32 Near term financial commitments $5M for implementation plus required reserves BASE CASE (10% MKT SHARE IN Y1) Pre Implementation (License, Invitation to Negotiate (ITN) Response) ASAP $1.0M Implementation (Contingent Upon Contract Signature) ~Early 18 $4.0M Only paid if Lee Health signs contract with Agency For Health Care Administration (AHCA) Minimum Net Worth (Required for Office of Insurance Regulation for license) Spring 17 $1.5M Reserve requirements will on sit LH in interestbearing but account are not bearing account spent Incremental Reserves (Not funded through plan margin) Winter 18 $2.2M $8.7M 13

33 Medicare Next Generation ACO Opportunity

34 Projected Medicare Fee For Service Reimbursement and Margins Medicare Projected FY Cases 261, , , , ,853 Payments (+ 1/2% per year) 404,376, ,507, ,147, ,303, ,534,309 Payment per Case 1,546 1,546 1,554 1,561 1,569 Total Costs 457,837, ,205, ,265, ,090, ,230,544 Gain/(Loss) (53,460,904) (57,697,358) (60,117,091) (67,786,652) (70,696,235) Margin 13% 14% 14% 16% 16% *Medicare losses expected to increase by $17 million over next 4 years 15

35 Medicare Next Generation Accountable Care Organization Financial Projections and Return on Investment Medicare ACO Members 25,000 26,250 27,563 CMS Target Spend per Member per Month 1,123 $ 1,151 $ 1,180 Actual Expected Spend per Member per Month 1,068 1,082 1,096 Savings per Member Per Month Gain Share 16,453,800 21,489,300 27,767,124 Operational Expense % of Target Spend 2.5% 2.5% 2.5% ACO Operating Expense 8,422,185 9,061,322 9,757,059 Margin 8,031,615 12,427,979 18,010,065 Margin % 4.8% 5.8% 7.0% Initial Investment $ 1,800,000 Discounted Cash Flow at 5% 33,727,309 Return on Investment* 1774% * Return prior to any shared savings agreements contracted with the ACO

36 Offload Downside Risk Through Contracting Model Key Terms* Upside: Performance vs. Benchmark 15% Lee Health Upside 5% 0% 5% Lee Health Downside 15% EVH upside EVH downside For first [5%] savings above benchmark, Lee Health keeps 100% of CMS revenue Beyond [5%] savings, Lee Health keeps [80%] of CMS revenue and Evolent keeps [20%] Downside: If Lee Health owes payment back to CMS, Evolent contributes [50%] up to [5%] of benchmark Beyond [5%], Lee Health offloads [90%] of losses to Evolent Evolent Scope: Complete turnkey solution, incl. program staff Evolent Administrative Services Fee: [2.5%] of trended benchmark, inclusive of all Operating Expenses 17

37 Proposed Medicare Next Generation ACO organization includes Lee Health and Evolent resources Lee Health ACO Board / ACO Executive Market President Market Medical Director Senior Director, Clinical Ops Senior Director, Operations Quality Improvement & Training Clinical Operations Risk Adjustment Identifi Platform Data Integration Network Performance Manager, Quality Improvement Population Health Managers Finance & Actuarial & Reporting Clinical Trainer Care Advisor Managers Legal, Compliance & Gov t Relations Analytics Care Advisors Communications & Change Management Extended Care Team 1 Industry leading process and technology to support all Next Gen ACO resources (1) Includes social, worker, behavioral health specialist, and dietician 18

38 Near term financial commitments $1.8M for implementation and ~$8.4M in Y1 operating expense ITEM YEAR COST 1 Medicare Next Generation ACO Implementation (e.g. Tech platform, initial risk adjustment program, hiring leadership and care management staff, communications/change management) 2017 ~$1.8M 2 Medicare Next Generation ACO Operating Expense (e.g. Quality initiatives, risk adjustment, clinical savings/care management, network performance, governance and MD engagement) 2018 ~$8.4M* *Represents total costs required to successfully operate Medicare Next Generation ACO; portion of costs to be funded through reallocation of existing expenses 19

39 Board Action Today, the Lee Memorial Health System Board of Directors is being asked to approve the Lee Health Administration s efforts to pursue two value based models and supporting legal structure State of Florida Medicaid Procurement in Region 8/E as a Provider Service Network (PSN) The CMS advanced payment model known as Medicare Next Generation Accountable Care Organization (ACO) Both models will reposition Lee Health to improve patient care and obtain incentive based payments Both models are highly synergistic and will produce positive returns on investment Both models have off-ramps 20

40 THANK YOU!

41 QUALITY, SAFETY & EDUCATION BOARD OF DIRECTORS MEETING Thursday, April 13, 2017 Steve Brown, M.D. Quality & Safety Liaison

42 BOARD OF DIRECTORS APIC RECOGNITION: 2017 CAROLE DEMILLE ACHIEVEMENT AWARD (Chuck Krivenko, CMO Clin. & Quality Services, Chief Patient Safety Officer) Lee Memorial Health System Board of Directors

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44 BOARD OF DIRECTORS HAND HYGIENE REPORT (Stephen Streed, System Director Epidemiology/Infection Control) (ACCEPT) Lee Memorial Health System Board of Directors

45 BOARD OFF DIIREECTTORS RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc) Keep form to one page, to: by Noon Eight (8) days PRIOR to presenting. DATE: April 13, 2017 LEGAL SERVICE REVIEW? YES NO SUBJECT: Hand Hygiene Summary Report for CY 2016 REQUESTOR & TITLE: Stephen A. Streed, MS, CIC, System Director, Epidemiology/Infection Prevention PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations internal groups which support the recommendation) The Board has previously received and approved prior annual reports and offered administrative support for the continuance of the Lee Health hand hygiene initiatives. SPECIFIC PROPOSED MOTION: Accept the CY 2016 Annual Report on Lee Health Hand Hygiene Conformance with a motion to continue the Board s support for the Hand Hygiene program as a patient safety initiative to help prevent healthcare-associated infections. FINANCIAL IMPLICATIONS Budgeted Account Non-Budgeted (Annual Project Budget and Total Project Budget) No direct financial implications STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) No direct staffing implications PURPOSE/REASON FOR RECOMMENDATION Informational: To convey CY 2016 hand hygiene conformance information to the Board and to request continued Board support for the Lee Health hand hygiene program as a part of our overall patient safety initiative. SUMMARY (including alternatives considered, Pros and Cons) The overall hand hygiene improvement/maintenance program is briefly described along with examples of progress reports provided to leadership and staff. These reports characterize hand hygiene conformance with existing policies and are parsed out by System, Campus, Floor/Unit and Service Line. The reports are a compilation of observations made by stakeholder staff and are updated on a monthly basis to provide real-time performance trends for action as needed. The process is designed to foster continuous awareness of the importance of hand hygiene in the prevention of infections and to detect gaps in conformance if they occur. There are no alternatives to continuation of the Hand Hygiene initiative, although emerging technologies may become available to facilitate data collection and/or provide immediate conformance feedback to caregivers. Lee Memorial Health System Board of Directors Updated 3/2/17

46 Hand Hygiene Stephen A. Streed, MS, CIC April 13, 2017 #2775 Rev. 01/17

47 Quality Non-Conformance Report Finding: Hand Hygiene Conformance Rates Periodically Fall Below Target ( 90%) in Some Locations and/or Service Lines Determination of Cause: Non-compliance with Policy; Lack of Knowledge; Unavailability of Needed Supplies Corrective Action Plan: Peer-to-Peer Real-time Coaching; Observation and Compilation/Reporting of Aggregate HH Metrics by Service Line and Location; Mandatory Education Follow Up Plan & Date: Continuous; Monthly Metrics Updates; New Employee Orientation and Annual 3R s Summary Overall System Hand Hygiene Compliance was between 90% - 95% System goal is to be > 90% Facility wide participation in the Hand Hygiene program continues to increase Some service lines are trending below System goal 1

48 Hand Hygiene Compliance Monitoring Plan 2

49 Hand Hygiene Compliance 2016 Observations by Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 3

50 Hand Hygiene Compliance 2016 System 95% 94% 92% 92% 93% 94% 94% 94% 94% 94% 95% 90% System Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 4

51 Hand Hygiene Compliance 2016 by Campus 100% 90% 80% 70% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CCH GCMC HPMC LMH GCHSWF 5

52 System Hand Hygiene Compliance % Percentage of Compliance 90% 80% 70% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CCH GCMC HPMC LMH GCHSWF System 6

53 Hand Hygiene Compliance 2016 System by Service Line 100% Chart Title 95% 90% 85% 80% 75% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Nursing Respiratory Therapy Mid level 7

54 Hand Hygiene Compliance 2017 Next Steps Continue With Peer to Peer Coaching, Observation, Metrics and Reporting Safety Coach Champions Focus Strengthen Patient/Family Involvement Refresh & Update Signage, Container Labeling Explore and Trial Novel Hand Hygiene Reminder Systems 8

55 Thank You

56 BOARD OF DIRECTORS GOLISANO PERFORMANCE INDICATORS (Alex Daneshmand, D.O., System Medical Director Quality/GCHSWF) Lee Memorial Health System Board of Directors

57 BOARD OFF DIIREECTTORS RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc) Keep form to one page, to: by Noon Eight (8) days PRIOR to presenting. DATE: 4/13/17 LEGAL SERVICE REVIEW? YES NO SUBJECT: GCHSWFL Board Performance Indicators, 1st, 2nd Quarter FY 2017 (Varies 2017) REQUESTOR & TITLE: K. Alex Daneshmand, DO, MBA, FAAP, System Medical Director, Clinical Quality & Safety Services for Golisano Children's Hospital of Southwest Florida PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations internal groups which support the recommendation) This set of indicators, referred to as GCHSWFL Board Performance Indicators, are developed in conjunction with Board of Directors. The indicators have been modified over the years, using Children s Hospital Association benchmarks when possible. SPECIFIC PROPOSED MOTION: Accept the GCHSWFL Semi-Annual Board Performance Measure Indicators: 1st, 2nd Quarters Fiscal Year (Varies 2017) FINANCIAL IMPLICATIONS Budgeted Account Non-Budgeted (Annual Project Budget and Total Project Budget) N/A STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) The System Quality Safety and Management Council reviewed several of the indicators within the system Organizational Performance Measure presentation on August 10, 2016 PURPOSE/REASON FOR RECOMMENDATION N/A SUMMARY (including alternatives considered, Pros and Cons) The disclosure of this report and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations. Lee Memorial Health System Board of Directors Updated 3/2/17

58 Golisano Children s Hospital of SWFL Semi- Annual BOD Performance Indicators Presenter: K. Alex Daneshmand, DO, MBA, FAAP April 13, 2017 # Rev. 10/16 The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations. PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

59 Golisano Children s Hospital of Southwest Florida Quality and Safety Indicators 1 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

60 SCORECARD: Golisano Quality & Safety Indicators Organizational New Metric 2 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

61 SCORECARD: Golisano Quality & Safety Indicators Organizational 3 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

62 Raising the Bar at Golisano Children s Hospital 115 Top Hospitals recognized across the country. The list includes: 9 Top Children s Hospitals 56 Top General Hospitals 21 Top Rural Hospitals 29 Top Teaching Hospitals 4 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

63 Q: GOLISANO CHILDREN S HOSPITAL HAND HYGIENE Description: Pediatric Hand Hygiene. Reported monthly. Formula: Compliance / Opportunity 100 Benchmark: 90% Source: (CDC s) Center for Disease Control National Healthcare Safety Network (NHSN) Why track: Efficient/quality care based on best practices in pediatrics Current 6 Month Status: Hand Hygiene =97.9% Rate Compliance Governing Body: Board of Directors, Pediatric Executive Quality Council 5 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

64 Q: GOLISANO CHILDREN S HOSPITAL 30 DAY READMISSION Description: Pediatric 30-Day Readmissions. Reported monthly, monitored daily. Formula: ALL Pediatric Readmission Excluding Planned Chemotherapy and Fever Neutropenia Benchmark: < 8% Source: Top 10 Children s Hospital Association similar in size Why track: Efficient/quality care based on best practices in pediatrics Lowered from 10% to 8% Current 6 Month Status: 30-Day Readmit = 5.41% Governing Body: Board of Directors, Pediatric Executive Quality Council 6 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

65 Q: GOLISANO CHILDREN S HOSPITAL CAUTI SIR Description: Catheter Associated Urinary Tract Infection. Reported monthly, monitored daily. Formula: Standardized Infection Ratio (SIR) = number observed CLABSIs / number expected CLABSIs Benchmark: < Source: (CDC s) Center for Disease Control National Healthcare Safety Network (NHSN) Why track: Healthcare-associated infection (HAI) outcome metric Current 6 Month Status: CAUTI= 0 SIR Governing Body: Board of Directors, Pediatric Executive Quality Council 7 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

66 Q: GOLISANO CHILDREN S HOSPITAL CLABSI SIR Description: Central Line Associated Bloodstream Infection. Reported monthly, monitored daily. Formula: Standardized Infection Ratio (SIR) = number observed CLABSIs / number expected CLABSIs Benchmark: < Source: (CDC s) Center for Disease Control National Healthcare Safety Network (NHSN) Why track: Healthcare-associated infection (HAI) outcome metric Current 6 Month Status: CLABSI= SIR Governing Body: Board of Directors, Pediatric Executive Quality Council 8 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

67 Q: PICU CLABSI SIR Description: PICU Central Line Associated Bloodstream Infection. Reported monthly, monitored daily. Formula: Standardized Infection Ratio (SIR) = number observed CLABSIs / number expected CLABSIs Benchmark: < Source: Center for Disease Control (CDC s) National Healthcare Safety Network (NHSN) Why track: Healthcare-associated infection (HAI) outcome metric Current 6 Month Status: CLABSI= 0 SIR Certified Zero February 2017 Governing Body: Board of Directors, Pediatric Executive Quality Council 9 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

68 Q: NICU CLABSI SIR Description: NICU Central Line Associated Bloodstream Infection. Reported monthly, monitored daily. Formula: Standardized Infection Ratio (SIR) = number observed CLABSIs / number expected CLABSIs Benchmark: < Source: (CDC s) Center for Disease Control National Healthcare Safety Network (NHSN) Why track: Healthcare-associated infection (HAI) outcome metric Current 6 Month Status: CLABSI= SIR Governing Body: Board of Directors, Pediatric Executive Quality Council 10 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

69 NICU CLABSIs Year CLABSI Standardize every aspect of line care Audit the standardize care by NICU staff Monthly team meeting to review past CLABSIs Help NICU develop a different mindset to get to zero Personalize CLABSI with our staff Intentional rounding to help staff with their questions CLABSI PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

70 Q: PEDIATRIC GENERAL SURGERY - SURGICAL SITE INFECTION (SSIs) Description: Pediatric Surgery Surgical Site Infection. Reported monthly, monitored daily. Formula: Total Infection (within 30 days)/total Number of General Pediatric Surgery Benchmark: < 1 per 100 cases Source: Top 10 Children s Hospital Association Why track: Efficient/quality care based on best practices in pediatrics Current 6 Month Status: SSI=0.612 Rate Per 100 Governing Body: Board of Directors, Pediatric Executive Quality Council 12 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

71 Q: PEDIATRIC ORTHOPEDIC SURGERY - SURGICAL SITE INFECTION (SSIs) Description: Pediatric Orthopedics Surgical Site Infection. Reported monthly, monitored daily. Formula: Total Infection (within 30 days)/total Number of Pediatric Orthopedics Surgery Benchmark: < 1 per 100 cases Source: Top 10 Children s Hospital Association Why track: Efficient/quality care based on best practices in pediatrics Current 6 Month Status: SSI=0.280 Rate Per 100 Governing Body: Board of Directors, Pediatric Executive Quality Council 13 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

72 Q: ACUTE CARE PICU OVERALL MORTALITY Description: Mortality rate is reported monthly, monitored daily. All pediatric patients excluding Newborn & NICU. Formula: Total Pediatric Inpatients Deaths/ Total Pediatric Inpatient Discharges Benchmark: <3% Source: Top10 Children s Hospital Association similar in size Why track: To evaluate the clinical outcomes and delivery of care. Current 6 Month Status: Mortality= 0.94% Among lowest compared to like CHA hospitals. Governing Body: Board of Directors, Pediatric Executive Quality Council 14 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

73 Q: ACUTE CARE NICU OVERALL MORTALITY Description: Mortality rate is reported monthly, monitored daily. NICU including newborn patients (MDC15) Formula: Total Newborn Inpatients Deaths/ Total Newborn Inpatient Discharges Benchmark: <2% Source: Top 10 Children s Hospital Association similar in size Why track: To evaluate the clinical outcomes and delivery of care. Current 6 Month Status: Mortality= 0.567% Among lowest compared to like CHA hospitals. Governing Body: Board of Directors, Pediatric Executive Quality Council 15 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

74 Q: ACUTE CARE ACUTE CARE SEVERITY ADJUSTED ALOS Description: Pediatric Acute Care Severity Adjusted ALOS. Reported monthly. Formula: Pediatric population ALOS/CMI (excludes /PICU & MDC 15) Benchmark: CMI/ALOS< 3 Days Source: Top 10 Children s Hospital Association similar in size Why track: Efficient/quality care based on best practices in children. Current 6 Month Status: CMI/ALOS = 3.02 days Balance between CMI/ALOS and our lowest 30 day readmission Governing Body: Board of Directors, Pediatric Executive Quality Council 16 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

75 Q: ACUTE CARE PICU SEVERITY ADJUSTED ALOS Description: PICU Severity Adjusted ALOS.. Reported monthly. Formula: PICU Patients ALOS/CMI Benchmark: CMI/ALOS< 4.5 Days Source: Top 10 Children s Hospital Association (4.5 Days) GCHSWF PICU prior year 3.2 Days Why track: Efficient/quality care based on best practices in pediatrics. Current 6 Month Status: CMI/ALOS = 3.09 days Governing Body: Board of Directors, Pediatric Executive Quality Council 17 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

76 ACUTE CARE NICU SEVERITY ADJUSTED ALOS Description: NICU Severity Adjusted ALOS. Reported monthly. Formula: NICU Patients ALOS/CMI Benchmark: CMI/ALOS< 6 Days Source: GCHSWF NICU prior year 6.5 Days Why track: Efficient/quality care based on best practices in newborn. Current 6 Month Status: CMI/ALOS = 5.81days Governing Body: Board of Directors, Pediatric Executive Quality Council 18 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

77 Where Are We Going In Our Quality Journey? Building a quality Structure with data reporting capabilities Improve care processes (Safe system, Efficient Care, Patient Centered, Timely Care) PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM Innovative Care in and outside of the hospital settings Quality and Safety Drives the Financial Health of Organization World Class Healthcare Based on Quality Metrics, Perception and National Grades 19

78 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM Thank You

79 BOARD OF DIRECTORS PROCESS ANALYTICS (Marcelo Zottolo, System Director Process Analytics) (ACCEPT) 1. Spring 2017 Leapfrog Grades 2. CMS 5 Star Scorecard 3. Predictive Analytics for Hospital-Associated Infections Using Qlikview (Scott Kashman, Chief Acute Care Officer) (Lisa Sgarlata, Chief Administrative Officer LMH) (Jennifer Higgins, VP Patient Care Services LMH) (Mary Saunders, D.O., System Medical Director Epidemiology) Lee Memorial Health System Board of Directors

80 Leapfrog Spring 2017 Published Grades Marcelo Zottolo April 13, 2017 # Rev. 10/16 PATIENT The disclosure SAFETY of this WORK document PRODUCT: and the CONFIDENTIAL contents herein AND does PRIVILEGED not constitute a waiver of any and all protections afforded INFORMATION Patient Safety CREATED Work Product AS PART under OF the LPSES Patient Safety LEE HEALTH S Quality Improvement PATIENT SAFETY Act of EVALUATION 2005 and implementing SYSTEM regulations.

81 Publish Date Leapfrog will publicly release the Spring Hospital Safety Grades on April 12, 2017 Prior to that date, results are subject to embargo. Safety score evaluation is base on performance periods that depend on the individual metric but vary from Jul2013 Mar PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

82 Lee Health Fall 2016 Versus Spring PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

83 Lee Health Distance From A The threshold to achieve an A safety grade is PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

84 Major Contributing Factors to Score Changes For this publication, only HCAHPS composites data was refreshed. All other hospital performance metrics remained the same as in the previous publication (Fall 2016). Performance period used was 2Q15 through 1Q16: H-Comp 1 Communication with Nurses H-Comp 2 Communication with Doctors H-Comp 3 Staff Responsiveness H-Comp 5 Communication about Medicines H-Comp 6 Discharge Information For the same period, Lee Health rate of improvement was flat or increased but was outperformed by the rest of the nation, causing our numeric scores to decrease. 4 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

85 Lee Health Top Focus By Campus Metrics to Work on for Improvement Cape Coral Hospital 1. PSI H Comp 3 Staff Responsiveness 3. H Comp 2 Communication w/ doctors 4. H Comp 5 Communication about Medicines HealthPark Medical Center 1. SSI Colon 2. PSI H Comp 2 Communication w/ Doctors 4. PSI - 11 Gulf Coast Medical Center 1. H Comp 2 Communication w/ Doctors 2. PSI C-Difficile 4. H Comp 1 Communication w/ nurses Lee Memorial Hospital 1. PSI SSI Colon (LMH substantial Improvement) 3. C-Difficile 4. H Comp 2 Communication w/ Doctors 5. MRSA PSI -12 Most Current Data Lee Health Has Made Substantial Improvement Suggestion: Focus Work on Other 3 Top Metrics by Campus 5 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

86 Preliminary Predictions for Fall 2017 Lee Health performance and national standards were updated to what we believe the performance periods will be: 1. Patient Experience (3Q15 through 2Q16) 2. Hospital Associated Infections (CY16) 3. Pulmonary Embolism Rate (PE/DVT) (3Q14-2Q16) Preliminary Predictions: Cape Coral Hospital B Lee Memorial Hospital A HealthPark Medical Center A Gulf Coast Medical Center B As safety related measures continue to improve, Patient Experience appears to be a primary focus area for further improvement in grades 6 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

87 1. Have better systems in place to prevent medical errors (CPOE, ICU physician staffing, comply with Never Events policy 2. Must have received an A safety grade at time of award (Fall) 3. Must be ranked in the top of their peer group based on the Leapfrog Value Score 4. Embodies the highest standards of excellence as evidenced by mortality measures. CCH & GCHSWF Received this Honor In October 2016 CCH Top General Hospital: 1 of 56 hospital s in the Nation 1 of 7 in the State of Florida. GCHSWF Top Children's Hospital: 1 of 9 hospital s in the Nation 1 of 3 in the State of Florida. CCH & GCHSWF Remain Top Hospital through October 2017 Annual Award 7 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

88 Appendix 8 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

89 Top Hospital Children s, General, and Teaching hospital Criteria: I. A hospital must fully meet Leapfrog s standard for Computerized Physician Order Entry (CPOE). II. III. IV. II. A hospital must fully meet Leapfrog s standard for ICU Physician Staffing (IPS). III. A hospital must fully comply with Leapfrog s Never Events Policy. IV. A hospital must fully meet Leapfrog s standard on at least 50% of applicable measures. V. V. Hospitals eligible for a Leapfrog Hospital Safety Grade must receive an A on the letter grades publicly reported at the time of the Top Hospital public announcement. (Fall) VI. VII. VI. Hospitals must be ranked in the top of their peer group based on the Value Score. VII. Hospitals must satisfy the Top Hospital Selection Committee that in general the hospital embodies the highest standards of excellence worthy of the Leapfrog Top Hospital designation. 9 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

90 CCH Spring PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

91 GCMC Spring PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

92 HPMC Spring PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

93 LMH Spring PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

94 HCAHPS Star Rating Fall 2016 VS Spring 2017 CCH Performance Remained flat After Data Refresh GCMC, HPMC, LMH Small Fluctuation PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM 14

95 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM 15

96 PATIENT SAFETY WORK PRODUCT: CONFIDENTIAL AND PRIVILEGED INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM Thank You

97 BOD CMS 5 Star Dashboard Update Chuck Krivenko, M.D., MHA Chief Medical Officer/Chief Safety Officer Marcelo Zottolo, MS System Director Process Analytics April 13, 2017 *Last Presentation on 2/22/17- Data through Dec 2016 # Rev. 10/16 The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.

98 CMS Star Ratings Program Recap Measures Weighting Safety of Care 22% Patient Experience 22% Readmissions 22% Mortality 22% Effectiveness 4% Timeliness 4% Utilization of Imaging 4% Some metrics are weighted more heavily than others Areas where we currently perform well These metrics have lower weights 1

99 CMS Star Program Performance to Date Data Source: CMS Hospital Compare Website Next CMS update to Overall Hospital Quality Star Rating be in July

100

101 Patient Experience Domain LH ADULT IP PATIENT EPERIENCE HCAHPS Survey Scores % of Respondents Selecting Either 9 or 10 Measure of: Patient Experience Owner: Donna Giannuzzi FY17 Exceeds 74.3% FY17 Meets 71.1% FYTD 69.9% FMTD 69.0% 100% % of Respondents selecting 9 or 10 90% 80% 70% 60% 50% 40% 30% 20% 10% Meets Goal FY16 FY17 0% OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

102 Risk Adjustment for Hospital-Associated Infections has been updated The data source for the Hospital-Associated Infections is the National Healthcare Safety Network (NHSN) In January 2017, NHSN recalculated hospitals performance based on a new 2015 baseline. Previous baseline was 2009 NHSN also created new risk models to calculate the number of expected infections.

103 Risk Adjustment for Hospital-Associated Infections has been updated From an analytics perspective, the practical implications of this new baseline are: Data displayed in this report is based on the new baseline. The new baseline caused the numbers to change (they got worse for all hospitals in the nation) Benchmarks and goals are based on the original baseline until CMS issues new Value Based Purchasing (VBP) goals Lee Health performance compared to national benchmarks and goals is better than estimated here. CMS has issued updated VBP goals based on the new baseline. They are not reflected in this report yet.

104 Safety Domain Hospital-Associated Infections (HAIs) Fiscal Year Performance Performance data source: NHSN data based on new (2015) baseline Percentiles data source: CMS/VPB using NHSN original baseline *Data CAUTI CLABSI Updated through February 2017 SSI Updated through January 2017 Cdiff MRSA Updated through December 2016

105 Safety Domain Hospital-Associated Infections Catheter Associated Urinary Tract Infection LEE HEALTH NHSN UNITS CAUTI SIR (Standardized Infection 3.00 LMHS UNITS: C2&3ICU, C2E, C2W, C4W, G4E, G4W, GMICU, GNEUROICU, H2PD, H2PH, HMICU, HOHICU, HSICU, HTICU, H7W, H8W, HPICU, H5PEDSURG, L4W, Measure of: Safety Owner: Dr. Krivenko FY17 Exceeds (80% ile) FY17 Meets (70% ile) FYTD FMTD Performance Star Rating ** Central Line Associated Bloodstream Infection LEE HEALTH NHSN UNITS CLABSI SIR (Standardized Infection 2.00 LMHS UNITS: C2&3ICU, C2E, C2W, C4W, G4E, G4W, GMICU, GNEUROICU, H2PD, H2PH, HMICU, HOHICU, HSICU, HTICU, H7W, H8W, HPICU, HNICU, Measure of: Safety Owner: Dr. Krivenko FY17 Exceeds (80% ile) FY17 Meets (70% ile) FYTD FMTD Performance Star Rating **** 2.50 New FY17 Percentile Goals 1.50 New FY17 Percentile Goals 2.00 CAUTI SIR CLABSI SIR Oct (3/3.353) Nov (1/3.79) Dec (1/3.606) Jan (7/4.043) Feb (3/3.85) Mar (/) Apr (/) May (/) Jun (/) Jul (/) Aug(/) Sep (/) 0.00 Oct (0/2.605) Nov (1/2.469) Dec (4/2.696) Jan (0/3.017) Feb (1/2.777) Mar (/) Apr (/) May (/) Jun (/) Jul (/) Aug (/) Sep (/) FY2016 FY2017 CAUTI SIR GOAL (0.407) FY2016 FY2017 CLABSI SIR GOAL (0.240)

106 Safety Domain Hospital-Associated Infections Clostridium difficile Methicillin Resistant Staphylococcus Aureus LEE HEALTH NHSN MRSA SIR (Standardized Infection Ratio) SUM OBSERVED MRSA SUM EPECTED MRSA Measure of: Safety Owner: Dr. Krivenko FY17 Exceeds (80% ile) FY17 Meets (50% ile) FYTD FQTD Performance Star Rating */** % reduction MRSA SIR QTR1 (4/4.803) QTR2 (/) QTR3 (/) QTR4 (/) FY2016 FY2017 MRSA VBP SIR (0.767) *CDIFF data same as Feb 22, 2017 presentation

107 Safety Domain Hospital-Associated Infections Surgical Site Infection after Colorectal Surgery LEE HEALTH NHSN SSI COLO SIR (Standardized Infection Ratio) Measure of: Safety Owner: Dr. Krivenko FY17 Exceeds (80% ile) FY17 Meets (50% ile) FYTD FMTD Performance Star Rating */** SSI COLO SIR Oct (3/1.5699) Nov (2/1.0974) Dec (1/1.8287) Jan (3/1.7098) Feb (/) Mar (/) Apr (/) May (/) Jun (/) Jul (/) Aug (/) Sep (/) FY2016 FY2017 SSI COLO SIR GOAL (0.824)

108 Safety Domain Pulmonary Embolism/Deep Vein Thrombosis (PE/DVT)

109 Readmissions Domain - All Cause 30-day Readmissions 16.40% LH 30 Day Acute Care Inpatient Readmission % (Excludes Normal Newborns [DRG 795]) Measure of: Clinical Integration Owner: Dr. Kolsun MEDICARE ONLY FY17 Exceeds 14.60% FY17 Meets 15.50% FYTD 16.40% MTD 14.73% 20% 15% % 30 day Readmission 10% 5% 0% Oct (363/2135) Nov (374/2179) Dec (408/2398) Jan (393/2668) Feb (/) Mar (/) Apr (/) May (/) Jun (/) Jul (/) Aug (/) Sep (/) FY2016 FY2017 FY2017 SCORECARD Meets

110 13 Thru Jan 17

111 14

112 Predictive Analytics for Hospital-Associated Infections using Qlikview Scott Kashman, Lisa Sgarlata, Dr. Mary Beth Saunders, Jen Higgins 4/13/2017 # Rev. 10/16 The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the PATIENT Patient Safety SAFETY Quality WORK Improvement PRODUCT: Act CONFIDENTIAL of 2005 and implementing AND PRIVILEGED regulations. INFORMATION CREATED AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM

113 Lee Health Shared Vision: One Lee Health Acute Care: One Hospital, All Locations Quality Patient COST Cost EPERIENCE Experience The disclosure of this document and the contents herein does not constitute a waiver of any and all PATIENT protections SAFETY afforded WORK Patient PRODUCT: Safety Work CONFIDENTIAL Product under AND the PRIVILEGED Patient Safety Quality Improvement Act of INFORMATION 2005 and implementing CREATED regulations. AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM 2

114 Lee Health Operating System Structure and Responsibilities Tier 1 Governance and organizational alignment Tier 2 Systems design and deployment Tier 3 Daily operations management Facility Medical Executive Committees Physician Governance Council (LPG) Ambulatory Care Leadership Council Medical Staff Physician Leadership Council Clinical Collaboration Council Clinical Implementation Teams Roles and Processes Clinical Consensus Groups Board of Directors Collaborative coordinated communication Acute Care Leadership Council Acute Care Facility Dyad Operating Council IT & Data Governance Steering Committee Administration Strategy & Growth Council (includes RAC) System Leadership Council System Quality Safety Management Council Leader Standard Work Operations Management System Operations Council agenda process SOC Standard Work ACLC agenda process VP Stat Sheet Facility operations review Director Stat Sheet Department Managers Weekly Process Obs. Tier 4 Deliver results and continuous improvement Front Line Staff Huddles Excellent Patient Care Process standard Procedure job instruction April 5, 2017, R Chen

115 ACLC Agenda Process Operational Priorities Performance Targets (KPI) Actionable Projects (PDCA) Review Discipline (Calendar) Standardize and Spread One Lee Health Strategy Mission, Vision, Values Tier 1 Clinical and Business Operations Tier 2 Daily Management and Improvement Projects Tier 3 Outcomes Improve Quality, Cost, Experience Tier 4 LH Operating System

116 Acute Care Council Priorities Operational Priorities Performance Targets (KPI) Actionable Projects Set Cadence (Calendar) Standardize and Spread CAUTI: Wendy Piascik, Dr. Mike Schultz CLABSI: Cindy Brown, Dr. Chuck Krivenko C Diff: Holly Muller, Dr. Stephen Zellner HCAHPS: Jen Higgins, Dr. Mark Greenberg

117 Shared Vision Purpose: 1. Adopt care reliability as the central clinical strategy. 2. Advance the principles of clinical standardization to drive clinical excellence and resource stewardship. 3. Empower clinicians through the Clinical Consensus Group to standardize clinical care through evidence and consensus based best practice standards. 6

118 Medical Staff Governance/Quality 7

119 Hospital-Associated Infections Demo HAI App Demo Dr. Mary Beth Saunders Jen Higgins The disclosure of this document and the contents herein does not constitute a waiver of any and all PATIENT protections SAFETY afforded WORK Patient PRODUCT: Safety Work CONFIDENTIAL Product under AND the PRIVILEGED Patient Safety Quality Improvement Act of INFORMATION 2005 and implementing CREATED regulations. AS PART OF LPSES LEE HEALTH S PATIENT SAFETY EVALUATION SYSTEM 8

120 LIAISON TO CHAIRMAN: Lee Health (Health System) FULL BOARD OF DIRECTORS MEETING Thursday, April 13, 2017 BOARD CHAIRMAN: Sanford Cohen, M.D.

121 BOARD OF DIRECTORS CONSENT AGENDA (APPROVE) 1. Finance and Full Board Meeting Minutes of 3/30/17 2. Utilization Management Plan 2017

122 FINANCE BOARD AND FULL BOARD OF DIRECTORS MEETING MINUTES Thursday, March 30, 2017 LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, Doctors Way, Fort Myers, FL MEMBERS PRESENT: Sanford N. Cohen, M.D., Board Chairman; Donna Clarke, Board Vice Chairman; David Collins, Board Treasurer; Therese Everly, Board Secretary; Chris Hansen, Board Member; Jessica Carter Peer, Board Member; Stephanie Meyer, BSN, RN, Board Member; Nancy McGovern, RN, MSM, Board Member; Diane Champion, Board Member MEMBERS ABSENT: Steven Brown, M.D., Board Member NOTE: Documents referred to in these minutes are on file by reference to this meeting date in the Office of the Board of Directors and on the Board of Directors website at for public inspection. SUBJECT DISCUSSION ACTION FOLLOW- UP MEETING CALLED TO ORDER The LEE HEALTH FINANCE BOARD & FULL BOARD OF DIRECTORS MEETINGS were CALLED TO ORDER at 1:02 p.m. by Sanford Cohen, M.D., Board Chairman. INVOCATION AND PLEDGE OF ALLEGIANCE Chaplain Susan Crowley, MA, BCC, gave the Invocation, followed by the Pledge of Allegiance. PUBLIC INPUT None at this time. RECOGNITIONS Kathy Moore, Director Food Services, recognized Alphoncia (Sis) Dixon for 30 years of service. PRESIDENT S REPORT Jim Nathan presented the President s Report. CHAIRMAN TO FINANCE LIAISON The gavel was turned over to FINANCE Liaison, David Collins, to CONVENE the FINANCE portion of the meeting at 1:30 p.m. CONSENT AGENDA David Collins asked for approval of the Consent Agenda. A motion was made by Therese Everly to approve the Consent Agenda consisting of: 1. Financial and Statistical Reports as of January 31, 2017 The motion was seconded by Nancy McGovern and carried with no opposition. FINANCIAL AND STATISTICAL BUSINESS Ben Spence presented the Financial and Statistical Business. A motion was made by Nancy McGovern to accept Financial and Statistical Business items: 1. Financial and Statistical Reports as of February 28, 2017 The motion was seconded by Chris Hansen and carried with no opposition. PARTIAL REFUNDING OF 2007 A BONDS Ben Spence presented the Partial Refunding of 2007 A Bonds. Lee Memorial Health System Board of Directors A motion was made by Nancy McGovern to adopt the resolution authorizing and approving the refunding and refinancing of a portion of the outstanding Lee Memorial Health System Hospital Revenue Bonds 2007 Series A; approving a direct loan in the principal amount of not to exceed $101,290,000 for the purpose of refunding and

123 LEE HEALTH FINANCE & FULL BOARD OF DIRECTORS MEETING MINUTES Thursday, March 30, 2017 Page 2 of 3 SUBJECT DISCUSSION ACTION FOLLOW- UP refinancing a portion of the 2007 Series A Bonds; approving a form of loan agreement; authorizing the execution and delivery of documents and the taking of all other necessary actions in connection with the loan; providing for severability; and providing an effective date. The motion was seconded by Chris Hansen and carried with no opposition. FINANCE LIAISON TO CHAIRMAN. The next LEE HEALTH Finance Board Meeting is: Thursday May 18, 2017, at 1:00 p.m. Gulf Coast Medical Center, Medical Office, Boardroom Doctors Way, Fort Myers, FL The gavel was turned over to the Board Chairman, Sanford Cohen, to RECONVENE the FULL BOARD portion of the meeting at 2:00 p.m. CONSENT AGENDA Dr. Cohen asked for approval of the Consent Agenda. Therese Everly pulled Consent Agenda items 3-6 for discussion: 10.28C Board Policy-Medico-Administrative Duties Protection 10.29A Board Policy-Peer Reviewer Protection 10.49A Board Policy- Communications for Board Members 30.01C Board Policy-Organized Medical Staff A motion was made by Therese Everly to approve Consent Agenda items: 1. Planning and Full Board Meeting Minutes of 3/2/17 2. Board of Directors Workshop Minutes of 3/16/17 7. BOD CMS 5 Star Dashboard The motion was seconded by Jessica Carter Peer and carried with no opposition. Therese Everly tabled Consent Agenda items: C Board Policy-Medico-Administrative Duties Protection A Board Policy-Peer Reviewer Protection A Board Policy- Communications for Board Members C Board Policy-Organized Medical Staff Therese Everly & Mary McGillicuddy/ Policies MEDICAL STAFF RECOMMENDATIONS AS OF MARCH 22, 2017 Dr. Cohen asked for approval of the Medical Staff Recommendations as of March 22, Nancy McGovern inquired about Sleep Study privileges, discussion followed. Therese Everly inquired about AA privileges, discussion followed. Stephanie Meyer recused herself from voting. A motion was made by Nancy McGovern to approve the Medical Staff Recommendations as of March 22, 2017 for: - Lee Memorial Hospital - Cape Coral Hospital - Gulf Coast Medical Center - HealhPark Medical Center - Golisano Children s Hospital of SWFL The motion was seconded by Chris Hansen and carried with no opposition. OLD BUSINESS 1. Mission, Vision, & Values Kevin Newingham presented the updated Mission, Vision, & Values following input from Board Members. Therese Everly asked that if topics for Workshops were rescheduled, Board Members be notified of the changes. She also asked Board Staff to notify Board Members in advance of the publication of the packet, if items relating to their liaison roles, were scheduled for presentation to the board. A motion was made by David Collins to approve the updated Mission, Vision, & Values. The motion was seconded by Therese Everly and carried with no opposition. Lee Memorial Health System Board of Directors

124 LEE HEALTH FINANCE & FULL BOARD OF DIRECTORS MEETING MINUTES Thursday, March 30, 2017 Page 3 of 3 SUBJECT DISCUSSION ACTION FOLLOW- UP NEW BUSINESS 1. Community Consultant Appointment A motion was by Therese Everly to accept Minnie Jackson as a Community Consultant. The motion was seconded by Nancy McGovern and carried with no opposition. BOARD MEETING CRITIQUE BOARD OF DIRECTORS REPORTS NET REGULAR MEETING Great meeting and very informational. Dr. Cohen would like the Board Members to keep in mind that due to tonight s event some Consent Agenda items have been tabled for further discussion at the next meeting, however future meeting agendas are filling up and there will not be room to continue tabling items. Jessica Carter Peer enjoyed her trip to Tallahassee for the FHA Hospital Days In Legislature Conference. Therese Everly attended the FHA Hospital Days In Legislature Conference in Tallahassee. It was very productive and informational and also informed the Board Members that she will be sending the Report from her visit to South Broward District prior to April 6 th Workshop. Attended her first MEC Meeting at the Cape Coral Hospital, very inspiring to see how involved everyone is and also toured the Lee Community Health Dunbar Clinic. Attended the Golisano Grand Opening for Staff and Physicians, she enjoyed seeing how proud everyone was for the new Children s Hospital. Congratulated Larry Altier for the $500,000 grant received from AARP recognizing the Flavor Harvest Program. Donna Clarke congratulated Dave Kistel for using economies of scale and planning ahead for the Golisano Children s Hospital. Diane Champion thanked and congratulated Lee Memorial Auxiliary for donating $375,000 to the Golisano Children s Hospital s Mental Health Initiative, making a grand total of over $1.1 million donations within the last 5 years. Dr. Cohen apologized for missing the last Board Workshop due to being out of town for a meeting with the Planning Body for the American Hospital Association. The next LEE HEALTH BOARD OF DIRECTORS WORKSHOP/STRATEGY MEETING will be held on April 6, 2017, at 1:00 p.m. in the Gulf Coast Medical Center, Medical Office Building, Boardroom Doctors Way, Fort Myers, FL ADJOURNMENT The LEE HEALTH SYSTEM FINANCE BOARD & FULL BOARD OF DIRECTORS MEETINGS ADJOURNED at 2:32 p.m. by Sanford Cohen, M.D., Board Chairman. Minutes were recorded by Jennifer Zager, Assistant to the Board of Directors Lee Memorial Health System Board of Directors Therese Everly Date approved Board Secretary

125 BOARD OF DIRECTORS UTILIZATION MANAGEMENT PLAN 2017 (Audrey Cantu, System Director of Utilization Management) (APPROVE) Lee Memorial Health System Board of Directors

126 RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc) Keep form to one page, to: by Noon Eight (8) days PRIOR to presenting. DATE: 4/13/17 LEGAL SERVICE REVIEW? YES NO SUBJECT: Utilization Management Plan (Annual Review) REQUESTOR & TITLE: Audrey Cantu, System Director of Utilization Management PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations internal groups which support the recommendation) This is an annual review. The Utilization Management Plan is a Condition of Participation for Medicare and is due to AHCA in May for state annual review. SPECIFIC PROPOSED MOTION: To approve the plan so that it can be forwarded to AHCA for review. FINANCIAL IMPLICATIONS Budgeted Account Non-Budgeted (Annual Project Budget and Total Project Budget) N/A STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) N/A PURPOSE/REASON FOR RECOMMENDATION Condition of participation for Medicare and Medicaid services. Required annual review by AHCA SUMMARY (including alternatives considered, Pros and Cons) Recommendation for approval if no changes recommended. Lee Memorial Health System Board of Directors Updated 3/2/17

127 Lee Health System Utilization Management (UM) Plan Cover Sheet Lee Health System maintains a Utilization Management Plan, drafted by the System Director of Utilization Review, approved by the Utilization Management Committees and the Medical Executive Committees of each facility. The Plan outlines compliance with the Conditions of Participation for Medicare and Medicaid. The plan is reviewed and approved annually by the Board of Directors. Changes or updates to the UM Plan for 2017 are as follows: Changed Lee Memorial Health System to Lee Health System throughout document Changed 2016 to 2017 throughout document Page 4 removed Vice President and added System Director/Care Management Page 4 Changed Manager/Utilization review to Manager/Denials & Appeals Page 4 Representation from added Utilization Management and the Rehab Hospital Page 5 Added full name to acronyms: QIO, RAC, MAC, MIC Page 7 Added: The 2 midnight benchmark is based on the expectation of the need to deliver at least 2 midnights of medically necessary hospital services at the time of the written order. As the 2 nd level review for CMS patients, UM staff may utilize the high risk screening tool to evaluate the need for observation vs. inpatient services. Page 8 Added full name to acronym: FI Page 9 Replaced Business Office representative with Utilization Management department Page 11 Replaced distribution of reports with direct communication Page 13 Added reporting to The UM Committee shall maintain Submitted by: Audrey Cantu, RN, MSN, CCM, CMCN System Director of Utilization Management

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146 BOARD OF DIRECTORS COMPLIANCE REPORT (Shelley Koltnow, Chief Compliance Officer) (ACCEPT) Lee Memorial Health System Board of Directors

147 BOARD OFF DIIREECTTORS RECOMMENDED FOR BOARD ACTION (Action includes Acceptance, Approval, Adoption, etc) Keep form to one page, to: by Noon Eight (8) days PRIOR to presenting. DATE: April 13, 2017 LEGAL SERVICE REVIEW? YES NO SUBJECT: FY 2017 January through March Compliance Report REQUESTOR & TITLE: Shelley Koltnow, Chief Compliance Officer PREVIOUS BOARD ACTION ON THIS ITEM (IF ANY) (justification and/or background for recommendations internal groups which support the recommendation) The Compliance Program Board Policy 10.47C requires updates summarizing compliance activities. SPECIFIC PROPOSED MOTION: Acceptance of the Compliance Report for the period January 2017 March 2017 FINANCIAL IMPLICATIONS Budgeted Account Non-Budgeted (Annual Project Budget and Total Project Budget) N/A STAFFING & OPERATIONAL IMPLICATIONS (including FTEs, facility needs, etc.) N/A PURPOSE/REASON FOR RECOMMENDATION SUMMARY (including alternatives considered, Pros and Cons) This report highlights the Compliance Department activities for the period January March There were no significant compliance issues or concerns that needed to be brought specifically to the attention of the Lee Health Board. The compliance activities encompass the seven elements of a compliance program as contained in the guidelines issued by the Department of Health and Human Services, Office of Inspector General. Lee Memorial Health System Board of Directors Updated 3/2/17

148 Compliance Report Lee Health Board of Directors Report for January, 2017 through March, 2017 Shelley C. Koltnow, JD, MBA, FACHE Lee Health Chief Compliance Officer Compliance Program Update Department Reorganization On January 8, 2017 the Compliance department reorganization was completed. The reorganization comprised newly created positions which were filled by existing Compliance department staff: Assistant to the Chief Compliance Officer (Susan Kennedy), Compliance Specialist (Sarah Kilcrease), and System Director of Compliance Audit and Investigation (Audra Ellis). As part of the reorganization, Compliance now includes Patient Information Privacy ( Privacy ) including the System Privacy Coordinator (Donna Brock). Lisa Whitacre was selected to fill the position of System Director of Compliance Program Effectiveness and Privacy Officer. Evie Brown joined the department as Insurance Audit Specialist to manage recovery audit ( RAC ) and assist the System Director of Compliance Audit and Investigation. The department successfully recruited the System Director of Compliance for LPG and Physician Services (Tammy Gorenyuk), who joined the department on April 3, Compliance has created a new position, Director of Pharmacy and 340B Program Compliance, to provide compliance support to the highly-regulated Federal 340B Drug Pricing Program and Lee Health pharmacy operations. This position was approved and funded for hire. Lee Health posted the position in March, and Compliance is interviewing qualified candidates. The Compliance Hiring Plan, presented at previous meetings, provides for development of two positions for Compliance Managers of Hospital and Health Care Delivery (Cape Coral/Gulf Coast and Lee Memorial/ Health Park) and a third position, Compliance Manager for Post-Acute Care Delivery. These positions are in development. Daniel Fisher is serving the Department as the Manager of Compliance Operations, focusing on the implementation of new technology solutions (see below), process design, and assisting the team with identifying performance metrics, among other things. April 13, 2017

149 The CCO continues to report directly to the President and CEO. The CCO continues to have open access to the Lee Health Board of Directors, with regular meetings with the Board Chair.

150 OIG Measuring Compliance Program Effectiveness: A Resource Guide On March 27, 2017, Daniel Levinson, the Inspector General of the Department of Health and Human Services, presented the "Measuring Compliance Program Effectiveness: A Resource Guide" to the (over 5,000) attendees at the annual Health Care Compliance Association (HCCA) Annual Meeting in Washington, D.C. Mr. Levinson has long been a resource to the healthcare compliance profession, primarily by designing models and guidance documents to build compliance programs that effectively facilitate compliance with laws, regulations and policies. Until now, however, the only definitive source of compliance program elements (and effectiveness) has been found in Chapter 8 of the United States Sentencing Guidelines (USSG). 1 This document contains the "Seven Elements of an Effective Compliance Program" and shows how they can be impactful in gaining leniency after a violation. In 2010 in the Affordable Care Act (ACA), Congress mandated that providers of health care implement compliance programs, although the details are yet to come by way of regulations. 2 The OIG's Compliance Program Effectiveness Resource Guide incorporates the work of a group of compliance professionals, staff from the Department of Health and Human Services, and staff from the OIG, who met in January, 2017 to develop a way to measure the effectiveness of a compliance program, commensurate with the USSG and 1 See, manual/2010/manual pdf/chapter_8.pdf 2 The ACA will require Medicare and Medicaid providers to have a full compliance program in place (See section 6401(a)(7) and (b)(5), which references the Social Security Act section 1866(J)(8)). Here is SSA 1866(J)(8): Compliance programs. In general. On or after the date of implementation determined by the Secretary under subparagraph (C), a provider of medical or other items or services or supplier within a particular industry sector or category shall, as a condition of enrollment in the program under this title, title I, or title I, establish a compliance program that contains the core elements established under subparagraph (B) with respect to that provider or supplier and industry or category.

151 the Department of Justice expectations. 3 The group developed the Resource Guide to provide measurement options to the healthcare industry. These measurement options cover the "seven elements" and indicate how these elements should be established and how to measure their impact and effectiveness. The document defines specific standards for evaluation against government expectations for effectiveness. This document is located along with many other helpful documents on compliance, on the OIG's website, Compliance plans to incorporate the Resource Guide into its program effectiveness work. 3 See, U.S. Department of Justice Criminal Division Fraud Section Evaluation of Corporate Compliance Programs, fraud/page/file/937501/download

152 Update: Compliance Program Effectiveness

153 Open Lines of Communication Open lines of communication means that the organization has effective communication around understanding, discussing, and reporting compliance concerns and issues. Ways an organization can facilitate open lines of communication include: o Access to supervisors and/or the Compliance Officer. Employees must be able to ask questions and report concerns, problems and issues in good faith, in an environment free from the fear of retaliation. Supervisors are the first line of open communications. The Compliance Officer facilitates compliance standards, policies, procedures and clarifies understanding of applicable requirements and policies that drive compliance. Access to the Compliance Officer and the Compliance team is part of meeting this element. Individuals can contact the Compliance Officer or the Compliance Department at any time or call the Hotline to report concerns regarding regulatory requirements, business conduct, organizational policies, conflicts of interest, or any other compliance concerns. o Compliance Hotline. Good faith reports of compliance concerns may be made through the 24/7/365 hotline, which allows such reports to be made anonymously, by any individual at any time. The Hotline at Lee Health is answered live by an agency that records, documents, and coordinates responses to every caller. There is also an online access process. The Hotline Report is presented below. o Newsletters. Communicating about compliance within the organization through timely newsletters helps to keep lines of communication open and share information. o Other forms of communication. Reports, focus groups, Compliance Week, online and verbal presentations and meetings are some examples. Reminder: Questions or concerns may be reported any time through the 24/7, toll free Compliance Hotline. Reporters have the option to disclose their names or remain anonymous and may submit alternatively using an online form. Individuals can also contact any Compliance staff member directly, or submit written questions or concerns by mail. The Compliance Hotline number is The online form is at

154 Lee Health - Compliance Hotline Report Figure 1. Compliance Hotline cases by category between 01/01/17 and 03/31/17. The most common category compliance question or concern was a general inquiry. Compliance continues to work closely with other departments across Lee Health to resolve compliance questions and concerns, e.g., Compliance received eleven (11) Hotline reports related to Human Resources, Diversity, and Workplace Respect.

155 Compliance Committees Executive Compliance and Internal Audit Committee The Executive Compliance and Internal Audit Committee ( Compliance Committee ) met on March 8, 2017, led by its Chair, Sanford Cohen, M.D. The Committee received updates on Compliance Program activities, such as the Compliance Plan, analytic technology solutions, and outreach initiatives. Shelley Koltnow, Chief Compliance Officer, reported progress in the department hiring plan, which included the department s reorganization and successful recruitment of a Compliance Officer for LPG and Physician Services. The Committee received information and education from compliance counsel. Jason Meltzer, System Director of Internal Audit, outlined current internal audit activity per the 2017 Internal Audit Plan. The Committee s next meeting is scheduled for June 9, Management Compliance Sub-committee The Management Compliance Sub-committee ( Management Sub-committee ) met on January 18 and March 17 led by Chair, Shelley Koltnow, Chief Compliance Officer. The Sub-committee reviewed the Compliance Plan and provided feedback in the areas of policy and procedures, outreach, and education. The Sub-committee also completed a self-assessment. Leaders in key areas of Lee Health, e.g., Supply Chain Management, presented ongoing projects that involve compliance review; Leaders stressed the importance of engaging Compliance staff early in the developmental stages of any project. The next meeting is scheduled for May 23, The Management Sub-committee is engaged and members are being educated on the many aspects of compliance. They are sharing, speaking up and becoming involved with a more active approach to facilitating how their areas and functions impact the organization. The New Compliance rebranding strategy will be presented to the Department this month by Marketing. The Standards of Conduct booklets will be updated as a part of this strategy. Education programs are in development. Physician Compensation Compliance Sub-committee The Physician Compensation Compliance Sub-committee ( PCCSC") met on January 10 and 25, February 10 and 20, March 8 and 23, and April 5, led by Chair, Ben Spence, Chief Financial and Business Services Officer. The Sub-committee reviewed physician compensation arrangements as applicable. Representatives of the Physician Contracting Group presented ongoing initiatives to improve contracting processes and Sub-committee materials; this Contracting Group collaboration involves Human

156 Resources, Physician Services, Recruitment, Compliance, Legal Services, and LPG Administration. The Sub-committee continued to promote and approve new policies and procedures that promote compliance in physician compensation. The PCCSC meets every two weeks. Pharmacy and 340B Program Compliance Sub-committee The Pharmacy and 340B Program Compliance Sub-committee ( Pharmacy Subcommittee ) met on January 31, March 9, and April 11, Chaired by John Armitstead, System Director of Pharmacy. The Sub-committee participated in a meeting with representatives of McKesson as a kickoff to the MacroHelix 340B software implementation project. Compliance reported progress in its 340B Program audits. Finance and Outpatient Services suggested steps to ensure compliance with certain administrative Program requirements. Additionally, Compliance announced posting of the position of Director of Pharmacy and 340B Program Compliance, to report directly to the Chief Compliance Officer and work collaboratively with Pharmacy Operations leaders and the Sub-committee. The next Sub-committee meeting is scheduled for May 31, 2017.

157 Compliance Education and Training Annual 3R s Education for Lee Health Employees: The department revised the compliance education that Human Resources includes in its annual Rapid Refresher modules ( 3R s ), assigned to all Lee Health employees. The revised content expands education on conflict of interest and commitment, non-monetary compensation to physicians, and discusses the compliance program. Annual Compliance Education for Lee Health Leaders and Employed Physicians: On November 14, 2016, Compliance assigned the General Compliance Training Bundle to key Lee Health Leaders and employed physicians over the online Learn@Lee platform. This education fulfills Federal compliance program training requirements for organizations that perform certain services as delegates of a Medicare Advantage and/or Prescription Drug Benefit Plan (Medicare Parts C and D). 4 The education also satisfies compliance education requirements of many commercial health insurers. The two (2) Compliance-sponsored modules are titled, Medicare Parts C and D General Compliance Training and Lee Health Standards of Conduct. The Standards and Quality Department also issued an online learning module to satisfy DNV GL Healthcare, Inc. hospital accreditation requirements. Over 90% of those assigned have successfully completed the education, enabling Lee Health to attest to the organization s adherence to compliance education requirements. Compliance will re-assign this education in August, Finance Department Seminar: In February, 2017, the System Directors of Compliance Audit and Investigation and Internal Audit co-presented the topic of physician nonmonetary compensation ( NMC ) to Financial Analysts and Controllers. NMC includes anything of value that the organization provides to a physician or their immediate family member(s), used outside of the hospital or physician office. 5 Business Development and Physician Compensation Departments track NMC to promote compliance with Stark Law and regulatory requirements. Orientations: Compliance has continued to present at weekly New Employee Onboarding, quarterly at LPG Physician Orientation and biweekly at Lee Health Medical Staff Orientation. Compliance is updating their presentation materials to ensure that they are cohesive and representative of current regulations and requirements, as well as important areas of compliance risk. 4 Learn more about new CMS education requirements at pdf CFR

158 Policies and Procedures Along with Standards of Conduct, policies and procedures are one of the most important elements of an effective compliance program. Policies and procedures set forth internal controls for foundational concepts and procedures that help Lee Health effectively implement ethical and compliant business practices. Compliance has participated in the development of policies and procedures to support the physician compensation function. These policies and procedures reflect efforts of the PCCSC and the physician compensation department to establish strong controls and standard operating procedures. The PCCSC reviews and approves these policies and procedures. The Department is working with administration to develop a process to coordinate the development, revision, sunset and distribution of Lee Health Administrative policies and procedures, in keeping with guidance provided in the OIG's Resource Manual, above. Know Your Program In 1991, the U.S. Sentencing Commission published the Federal Sentencing Guidelines for Organizations. These Guidelines established seven types of steps that should be included in an effective program to prevent and detect violations of the law. 1 Those seven elements of a compliance program are: 1. Written compliance guidance, including policies and procedures, as well as Standards of Conduct; 2. High level compliance oversight, a Chief Compliance Officer and supporting compliance committees; 3. A system for screening to ensure that the organization does not do business with individuals likely to violate the law or engage in conduct that conflicts with a compliance and ethics program; 4. Regular compliance training and education for any constituent within the organization, or affiliated with it, that requires education to remain compliant; 5. A reliable system for compliance auditing and investigation, as well as a system for monitoring operational processes for compliance. Open lines of communication for reporting compliance questions and concerns in good faith. 6. Consistent discipline for noncompliance and improper conduct; 7. Appropriate response to offenses and investigations, including corrective action. In 1998, the Office of the Inspector General of the Department of Health and Human Services ( OIG ) began to release model Compliance Guidance for healthcare organizations. The documents outline the benefits of a compliance program and offer strategic insight into developing the Seven Elements. These were supplemented with industry input in United States Sentencing Commission: 1994, Federal Sentencing Guidelines Manual (West Publishing Co., St. Paul, Minnesota). 2 guidance/index.asp

159 Audit, Monitoring, and Risk Assessment Internal Audit: Internal Audit continues to assess system controls pursuant to its 2017 Internal Audit Plan, approved by the Compliance Committee in January, Current audits focus on: construction at the Golisano Children s Hospital, Lee Health development at Coconut Point, and Gulf Coast Medical Center expansion; Quality Management System ( QMS ) requirements, and supporting documentation for services rendered by Medical Directors. The Internal Audit Environment COSO developed an integrated internal control framework that is used throughout the United States to design and standardize practices, effected by an entity s governance process, management, and other personnel, to provide reasonable assurance regarding the achievement of objectives set for operations, reporting, and compliance. 1, 2 Risk assessment of the existing control structure is a significant element of assurance. 3 Some examples of controls are: technology solutions, manual reviews, reconciliations, segregation of duties, approvals and authorizations, safeguarding, inventories, redundancies, and auditing. Risk assessment can identify the strength and adequacy of existing controls, allow for strengthening of existing controls, or can identify the need for new or different controls to assure operational objectives. 4 Effective internal controls help an organization reduce the potential for fraud and improve the organization s ability to achieve its financial and operational goals. 1 Committee of Sponsoring Organizations of the Treadway Commission, a joint initiative to reduce corporate fraud. It was formed in 1985 by five private accounting organizations in the United States to provide integrated guidance on the development and assessment of internal controls. 2 See, This website discusses the use of COSO risk frameworks for strategic and performance assurance through governance and operations at the enterprise (or entity) level. 3 Id. 4 See, AIPCA risk assessment discussion at

160 Compliance Audit and Investigation: The System Director of Compliance Audit and Investigation presented the 2017 Compliance Audit Plan to the Management Subcommittee in January, The Compliance Audit Plan is derived from the Compliance Risk Assessment, as well as from the Health and Human Services Office of the Inspector General s (OIG) 2017 Work Plan. The department continues to complete reviews in areas such as reimbursement, 340B Program conditions of participation, coding outliers, and other compliance matters as assigned. As of Tuesday, April 4, the initial round of interviews of (7) candidates for the two compliance auditor positions is completed. From these, 2-4 will be selected for second interviews. Once the auditors are hired, they will begin working on the 2017 compliance audit work plan based on the 2017 risk assessment. The auditors will facilitate audits from that work plan and other important audits and investigations that arise throughout the year. Government Insurance Audit: The organization has received 38 audit requests from Recovery Audit Contractors ( RACs ): eleven (11) for Lee Memorial Hospital/Health Park Medical Center, six (6) for Cape Coral Hospital, three (3) for Illinois Medicaid, and eighteen (18) for KEPRO. There were 11 requests for Comprehensive Error Rate Testing (CERT) by CMS. The organization has received 308 audit requests from Medicare Administrative Contractors ( MACs ): 302 from First Coast Services Options and six (6) from Wisconsin Physician Services. The Government Insurance Auditor works closely with the Central Business Office ( CBO ) and Appeals Department to resolve open reviews of the Medicaid Emergency Medical Assistance for Non-Citizens ( EMA ). Privacy Donna Brock, Privacy Coordinator, acknowledges that privacy issues generally increase during season. "Red rule" violations (wrong patient receives the wrong documents) comprise one of the most frequent incidences (13 reported in March). In response, the Privacy team is implementing stickers/labels on all printers and fax machines in bold print to remind staff to stop and verify that all pages being retrieved from the device belong to the same patient. Staff members must initial the corner of the document before handing it to a patient, and use the "It Takes Two" procedure. The sticker/label process is in draft, but has obtained approval by Marketing (verbiage/format), IS (printers), Biomed (fax machines) and will go forward to the IT Governance Committee. New posters are now in print and will be distributed and posted around the health system in the next quarter. The posters bring attention to cyber-security, including the risks associated with identity theft, hacking, the security of access to personal and organizational computers, systems, and other equipment.

161 Technology Solutions In December, 2016, the organization executed three (3) agreements for technology solutions to promote compliance and analytic capabilities across the System. Compliance began implementation in January, The CCO will regularly report predicted Return on Investment ( ROI ) to Finance governance. The solutions include: 1) MedeAnalytics Revenue Integrity and Audit Control: Mede/Analytics allows Lee Health to dive into the claims for payment that the System has submitted to insurance programs, including Medicare and Medicaid, and analyze the reimbursement responses that the System receives from those insurance programs. Mede/Analytics will help the System analyze billing and reimbursement trends and outcome measures like patient readmissions in real time and for three (3) years historically. Compliance will administer Mede/Analytics; the CFO, CMO, and other key leaders will have access to the software. Go live is scheduled for May, ) Hayes Management MDaudit Professional and Analytics: MDaudit allows auditors in Compliance and Lee Professional Billing ( LPB ) to analyze physician diagnosis/procedure coding and supporting documentation. Auditors can send inquiries to physicians and correct improper coding to remain compliant. MDaudit also allows users to create visuals that compare LPG physician coding to coding across the nation. Installing MDaudit enhances Coding Educators ability to spend time in LPG offices to meaningfully improve physician coding knowledge. Compliance will administer MDaudit; LPB will use the software daily. Go live is scheduled for June, ) Ludi, Inc. DocTime Log: DocTime Log allows a physician Medical Director to keep their time electronically from any location using their PC or mobile device. The software streamlines the Medical Director timekeeping process and ensures that the process can be audited by Compliance and Internal Audit. Compliance will administer DocTime Log; Physician Services will use the software daily. Go live is scheduled for summer, 2017.

162 Screening and Due Diligence In collaboration with the Medical Staff Office ( MSO ), Compliance continues to track and manage potential or actual conflicts of interest or commitment at Lee Health, using the web-based platform that the department piloted in May. Response rates have remained high since Compliance began to distribute questionnaires electronically. Compliance performs monthly screening of all individuals and entities doing business at/with Lee Health for sanctions, debarment, and exclusion from participation in government health insurance programs (Medicare, Medicaid, SCHIP, and TRICARE). This screening process helps Lee Health avoid doing business with any individual or entity that has been found to have engaged in illegal activities or conduct that would be inconsistent with an effective compliance and ethics program. Using the services of a third-party vendor, Compliance performs sanctions screens as indicated in the following Table: Persons screened for sanctions and exclusions from federal programs Month Category January February March Findings New Employees None Existing Employees 12,988 13,088 13,103 None Medical Staff 1,478 1,492 1,496 None Advanced Practitioners None Vendors 4,213 4,241 4,243 None Referring Physicians 2,658 2,684 2,699 None Table 1. Reporting period between 01/01/17 and 03/31/17. Each month in the reporting period, Compliance screened new employees, existing employees, medical staff, advanced practitioners, vendors, and referring physicians for sanctions and exclusions from federal programs. Compliance had no positive findings during the reporting period.

163 Compliance Plan The goal of a compliance plan is to describe an effective programmatic approach to organizational Compliance. Compliance drafted its 2017 Compliance Plan ( Plan ) and distributed the draft to Compliance Committee Members for their review. Along with an evidence-based approach for assuring the Seven Elements of an effective compliance program are met, the Plan includes updated and new outreach strategies, a newly drawn policy map, hiring and office relocation plans, and plans for new technology solutions (some recently installed, some pending approval). The final Plan will form the basis for future reports to the Board. The Plan will assist the organization in developing, expanding, and maintaining a compliant culture and ethical business practices while providing a structure for employees; physicians; affiliated organizations; contractors and vendors; students; and volunteers to adhere to the Standards of Conduct and Lee Health s policies and procedures, as well as applicable laws and regulations. The Plan also demonstrates the organization s full commitment to following ethical and compliant business practices while providing quality patient care. It also recognizes strategies and tactics for demonstrating adherence to each element of an effective compliance program. Using an evidence-based approach, the Plan describes Key Performance Indicators, or KPIs that will allow Compliance to monitor organizational progress toward compliance program effectiveness. Once approved, the KPI s will be tracked and reported to the Compliance Committee and the Board of Directors. In December, Compliance distributed the draft Plan to Members of the Compliance Committee and Management Sub-committee for their comment. The department will present the final Plan to the Compliance Committee and its Sub-committees in June 2017 after incorporating the feedback from all reviewing groups. Updated Compliance Report Card attached as Exhibit A Questions Contact Lee Health Compliance at any time with questions about Compliance Program activities, questions about the laws and regulations, or thoughts about programming and outreach. Call or message compliance@leehealth.org

164 Exhibit A Compliance Report Card 1. Standards, Policies, and Procedures Goal Publish a Compliance Program Plan for 2017 through Set up an effective communication strategy for administrative policies. Draft Compliance Operations Manual. Complete policy map/framework for Compliance Program elements. Facilitate executive workgroup to revisit the Standards of Conduct. 2. Compliance Program Administration Goal Pass Compliance budget for FY2018. Pass Internal Audit budget for FY2018. Place Compliance staff on key management and governance committees. Charter Compliance Sub-committees tied to key areas of operations Create Key Performance Indicators (KPIs) for Program effectiveness. Publish an organization chart for Compliance and Internal Audit, FY17-FY18. Place Internal Audit leadership. Place Compliance leadership for Pharmacy. Place Compliance leadership for Hospitals. Place Compliance leadership for Physician Services. Place Compliance leadership for Program Effectiveness. Incorporate the Privacy function, and Government Insurance Audit function. 3. Compliance Education and Training Goal Submit Compliance Board reports; present to the Board quarterly. Assign compliance education for Lee Health leaders to comply with Medicare Advantage requirements. Optimize annual online compliance education for all employees. Optimize annual online compliance education for physicians. Conduct Compliance symposium for Lee Health hospitals. Present comprehensive compliance education for the cardiac and other bundled episodes of care. Conduct 2017 Compliance symposium for Physician Services. Publish and distribute booklet on Fraud, Waste, and Abuse (FWA). Publish and distribute booklet on HIPAA and Privacy. Publish and distribute booklet on Compliance Programs. 4. Outreach and Open Lines of Communication Goal Draft a Compliance Program communication plan for FY18 Expand Compliance Hotline functionality. Establish compliance presence at regular system leadership meetings. Conceptualize marketing/outreach framework for Lee Health Compliance Program. Publish and distribute regular newsletter. Participate in HCCA Compliance Week. (November, 2017) Create surveys to measure culture of compliance. 5. Well-publicized Disciplinary Guidelines Goal Introduce "compliants and grievances" as topics to compliance committees to prepare for clinical integration. Facilitate workshop assessing disciplinary guidelines across the System. Incorporate reports on Privacy noncompliance and corrective action into compliance committees. Coordinate with Human Resources to include compliance goals in promotion criteria and SMART Goals. Assure key personnel have an in-person meeting with the Compliance Officer as part of an exit interview. Coordinate job description/exit interview process with Human Resources to incorporate compliance topics. 6. Audit and Risk Assessment Goal Conduct Internal Audit risk assessment for Conduct Compliance risk assessment for Compile Internal Audit Plan for Compile Compliance Audit Plan for Set up tools to track audits and performance measures. Integrate Government Insurance Audit into the Compliance Department. Hire Compliance Auditors. Assist with analytic software implementation. Implement software for hospital compliance analytics. Implement software for Privacy audit and research. Implement software for physician compliance analytics. Implement software for physician timekeeping. 7. Prevention and Remedial Measures Goal Update exclusion screening process to reflect managed care contractual requirements. Review credentialing/background checking processes for physicians, vendors, and employees. Review physician recruitment and contracting processes. Streamline conflict of interest disclosure/management process. Streamline physician non-monetary compensation monitoring process. Facilitate workshops involving clinical and strategic initiatives. Revise policy set for responding to instances of noncompliance. Developed In Development To Be Developed Developed In Development To Be Developed Developed In Development To Be Developed Developed In Development To Be Developed Developed In Development To Be Developed Developed In Development To Be Developed Developed In Development To Be Developed

165 Compliance Update Shelley C. Koltnow, Chief Compliance Officer April 13, 2017 # Rev. 10/16

166 Compliance Program Evidence-based framework for demonstrating intent to comply with applicable laws, regulations, and standards Shows organization pursues ethical business practices Written and endorsed by The US Department of Justice, the Federal Sentencing Guidelines (Ch. 8), and the Office of the Inspector General of Health and Human Services Mandatory under the Affordable Care Act Required for participation in modern payment systems, government programs, and commercial insurance contracts 1

167 Seven Elements of an Effective Compliance Program 1. Written Standards of Conduct, policies and procedures 2. High Level Oversight Board, Chief Compliance Officer, CEO, and Compliance committee(s) 3. Compliance education and training 4. Open lines of communication for good faith reporting of compliance questions and concerns 5. Well-publicized disciplinary guidelines 6. System of compliance audit, investigation, and monitoring 7. Prompt response to potential instances of non-compliance 8. Annual risk assessment 2

168 Compliance Program Report 3

169 Department Reorganization Compliance hiring plan: Design an effective structure Reorganize the existing Department Recruitment Department Reorganization Susan Kennedy - to Assistant to the Chief Compliance Officer Audra Ellis - to System Director, Compliance Audit and Investigation Sarah Kilcrease - to Compliance Specialist Lisa Whitacre - to System Director, Compliance Program Effectiveness and Privacy Officer Donna Brock - to System Privacy Coordinator Evie Brown - to Insurance Audit Specialist 4

170 Department Reorganization Recruitment Two (2) Compliance Auditor positions posted 7 Candidates screened Second interviews scheduled for two candidates Director of Compliance for Pharmacy and 340B Program Approved for recruitment by RAC Posted 3/17 4 candidates in first interview process System Director, Lee Physician Group and Physician Services Compliance On boarded April 3 Job descriptions for approved positions Managers of Hospital and Health Care Delivery Compliance are in development 5

171 Compliance Committee Executive Compliance and Internal Audit Committee (Chair: Sanford Cohen, MD), March 2017 (quarterly) Reviewed and approved Minutes of all Sub-committee meetings Discussed Sub-committee goals/initiatives Discussed progress on finalizing Compliance Plan Presentation and discussion re: developments within the Compliance Program and Department Progress reports on technology solutions: Mede/Analytics Revenue Integrity and Audit Control MDaudit Professional Ludi DocTime Log Presentation and approval of 2017 Internal Audit Plan Presentation by Scott Taebel, Esq. and Katherine Kuchan, Esq. (Advisors)

172 Compliance Sub-committees Management Compliance Sub-Committee (Chair: Shelley Koltnow) Met: January and March, 2017 (Bi-monthly) Reviewed 2017 Compliance Plan elements Conducted self-assessment Participated in activity illustrating Compliance Hotline investigation procedures Physician Compensation Compliance Sub-Committee (Chair: Ben Spence) Met: Jan., Feb, March, April, 2017 (Bi-weekly) Continued policy work for Physician Compensation Policy Manual Oversaw Physician Contracting Group workshop activities Pharmacy/340B Compliance Sub Committee (Chair: John Armitstead) Met: January, March, April, 2017 (Bi-monthly) Initiated all-day kickoff for McKesson MacroHelix software implementation Todd Nova, Sub-Committee Advisor attended all-day sessions 7

173 Education and Outreach 8

174 Compliance Education 2016 Compliance Education Bundle Fraud, Waste and Abuse annual education for Lee Health Leaders and Employed Physicians (11/16) Fulfilled annual CMS compliance education requirements for First Tier, Downstream and Related Entities (FDR s) for Medicare Advantage Plans that delegate services to Lee Health as a First Tier or Downstream entity. Fulfilled education requirements for DNV accreditation Completion rate (to date) > 90% (reminders sent) Rs for all Lee Heath Employees (Human Resources) Compliance content revised; expanded to include elements on conflict of interest and commitment; non monetary compensation; and Compliance Program structure 9

175 Compliance Outreach Compliance Outreach Update Three publications planned: Fraud, Waste, and Abuse in Government Healthcare Programs HIPAA Privacy Compliance Program Information for Employees Compliance/Marketing collaboration to develop messaging, language, and outreach materials consistent with Lee Health brand Compliance newsletter in development Reviewing and updating Compliance policies and procedures Plans for Compliance Week, 2018 Compliance Committee strategies for

176 Technology Solutions 11

177 Mede/Analytics Revenue Integrity & Audit MedeAnalytics Cloud-based system that applies rules to data to provide analysis for more effective compliance and operational performance Real-time claim/remittance analysis Audit and monitoring rules for compliance Drill down approach (high level dashboarding to claim level detail) Patient accounting statistics for revenue realization Enables evidence based performance improvement for coding, billing, and documentation in the hospital setting Strategic Supports role specific analytics (CFO, CCO, CMO, etc.) Supports Compliance Elements of audit/monitoring and continuous performance improvement Supports population health/clinical integration strategies Supports Chief Acute Care Officer role Supports dyad structure 12

178 MDaudit Professional and Analytics System supports high quality professional coding and claims analytics to improve performance at the individual provider and organizational level Professional (physician and APC) coding quality Increases audit efficiency Facilitates performance improvement and documentation education for physicians and APCs. Uses rapid bell curve analytics for benchmarks for accurate physician compensation and billing Frees coding educators to educate providers on documentation and coding principles Professional coding compliance Allows Compliance Auditors to set risk based audit rules Supports Compliance Sub committee goals/evidence basis Supports Revenue Cycle integration 13

179 Ludi DocTime Log Streamlines and improves Medical Director Administrative Director timekeeping process Uses online platform accessible from any e device Assigns timesheets with job duties from contract Calculates wage*time automatically Synergizes Physician Services (LPG/HVI/Hospital) Builds strong internal (process) controls Sets strict approver roles to prevent conflict of duty Shares reports with Compliance and Internal Audit Alerts approvers when physician approaches ceiling Supports Physician Compensation Compliance Sub committee 14

180 Compliance Program Report Card 15

181 Report Card Updated Report Card includes new elements for Calendar Years 2017 and 2018 Incorporates standards from Measuring Compliance Program Effectiveness: A Resource Guide (OIG March 27, 2017) Gives definitive guidance on each of the 7 elements of an effective compliance program Establishes standards for measuring effectiveness of each element Confirms that each element must be in place, evidence based Aligns with Compliance Program Plan and development in process Incorporating into Report Card allows communication / tracking of key next steps and development of meaningful Key Performance Indicators 16

182 Lee Health Compliance Program Report Card 1. Standards, Policies, and Procedures Goal Publish a Compliance Program Plan for 2017 through Set up an effective communication strategy for administrative policies. Draft Compliance Operations Manual. Complete policy map/framework for Compliance Program elements. Facilitate executive workgroup to revisit the Standards of Conduct. 2. Compliance Program Administration Goal Pass Compliance budget for FY2018. Pass Internal Audit budget for FY2018. Place Compliance staff on key management and governance committees. Charter Compliance Sub-committees tied to key areas of operations Create Key Performance Indicators (KPIs) for Program effectiveness. Publish an organization chart for Compliance and Internal Audit, FY17-FY18. Place Internal Audit leadership. Place Compliance leadership for Pharmacy. Place Compliance leadership for Hospitals. Place Compliance leadership for Physician Services. Place Compliance leadership for Program Effectiveness. Incorporate the Privacy function, and Government Insurance Audit function. Developed In Development To Be Developed Developed In Development To Be Developed 17

183 Lee Health Compliance Program Report Card (cont.) 3. Compliance Education and Training Goal Submit Compliance Board reports; present to the Board quarterly. Assign compliance education for Lee Health leaders to comply with Medicare Advantage requirements. Optimize annual online compliance education for all employees. Optimize annual online compliance education for physicians. Conduct Compliance symposium for Lee Health hospitals. Present comprehensive compliance education for the cardiac and other bundled episodes of care. Conduct 2017 Compliance symposium for Physician Services. Publish and distribute booklet on Fraud, Waste, and Abuse (FWA). Publish and distribute booklet on HIPAA and Privacy. Publish and distribute booklet on Compliance Programs. 4. Outreach and Open Lines of Communication Goal Draft a Compliance Program communication plan for FY18 Expand Compliance Hotline functionality. Establish compliance presence at regular system leadership meetings. Conceptualize marketing/outreach framework for Lee Health Compliance Program. Publish and distribute regular newsletter. Participate in HCCA Compliance Week. (November, 2017) Create surveys to measure culture of compliance. Developed In Development To Be Developed Developed In Development To Be Developed 18

184 Lee Health Compliance Program Report Card (cont.) 5. Well-publicized Disciplinary Guidelines Goal Introduce "compliants and grievances" as topics to compliance committees to prepare for clinical integration. Facilitate workshop assessing disciplinary guidelines across the System. Incorporate reports on Privacy noncompliance and corrective action into compliance committees. Coordinate with Human Resources to include compliance goals in promotion criteria and SMART Goals. Assure key personnel have an in-person meeting with the Compliance Officer as part of an exit interview. Coordinate job description/exit interview process with Human Resources to incorporate compliance topics. 6. Audit and Risk Assessment Goal Conduct Internal Audit risk assessment for Conduct Compliance risk assessment for Compile Internal Audit Plan for Compile Compliance Audit Plan for Set up tools to track audits and performance measures. Integrate Government Insurance Audit into the Compliance Department. Hire Compliance Auditors. Assist with analytic software implementation. Implement software for hospital compliance analytics. Implement software for Privacy audit and research. Implement software for physician compliance analytics. Implement software for physician timekeeping. Developed In Development To Be Developed Developed In Development To Be Developed 19

185 Lee Health Compliance Program Report Card (cont.) 7. Prevention and Remedial Measures Goal Update exclusion screening process to reflect managed care contractual requirements. Review credentialing/background checking processes for physicians, vendors, and employees. Review physician recruitment and contracting processes. Streamline conflict of interest disclosure/management process. Streamline physician non-monetary compensation monitoring process. Facilitate workshops involving clinical and strategic initiatives. Revise policy set for responding to instances of noncompliance. Developed In Development To Be Developed 20

186 Thank You

187 OLD BUSINESS Lee Memorial Health System Board of Directors