Meeting. February 1, :00 p.m. Agenda

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1 Maricopa Health Centers Governing Council Meeting February 1, :00 p.m. Agenda

2 Council Members Gino Turrubiartes, Chair Simon Thomas, Vice Chair Gary Tenney, Treasurer Lloyd Asato, Member Terry Benelli, Member Susan Gerard, Ex-Officio Member Chris Hammond, Member Melissa Kotrys, Member April Jordan-Kramer, Member Liz McCarty, Member Julie Roberts, Member Rose Rubio, Member Eileen Sullivan, Member Ryan Winkle, Member AGENDA Maricopa Health Centers Governing Council Mission Statement Serve the population of Maricopa County with excellent, comprehensive health and wellness in a culturally respectful environment. Welcome We welcome your interest and hope you will often attend Maricopa Health Centers Governing Council meetings. Democracy cannot endure without an informed and involved electorate. The Maricopa Health Centers Governing Council (MHCGC) is the governing body for Maricopa Integrated Health System s Federally Qualified Health Center Look Alike clinics. Members are represented in each of the five districts in Maricopa County. Members of the Governing Council are appointed. The Governing Council sets policy and the Chief Executive Officer (CEO) of the MHCGC, who is hired by the Maricopa Integrated Health System (MIHS) and the Governing Council, directs staff to carry out the policies. Meetings The Governing Council generally holds meetings at 6:00 p.m. on the first Wednesday of the month. Please visit or call the Assistant to the MHC Governing Council s Office, at to confirm the date of the next regular meeting. The meeting may appear to proceed quickly, with important decisions reached with little discussion. However, the agenda and meeting material is available to the Governing Council prior to the meeting, giving them the opportunity to study every item and to ask questions of MIHS staff members. If no additional facts are presented at the meeting, action may be taken without further discussion. How Citizens Can Participate The Governing Council values citizen comments and input. Citizens may appear before the Governing Council to express their views. Any member of the public will be given three minutes to address the Governing Council on issues of interest or concern to them. If you wish to address the Governing Council, please complete a Speaker s Slip and deliver it to the Assistant to the MHCGC. If you have anything that you wish distributed to the Governing Council and included in the official record, please hand it to the Assistant who will distribute the information to the Governing Council Members and MIHS Senior Staff. Speakers will be called in the order in which requests to speak are received. Your name will be called when the Call to Public has been opened or when the Governing Council reaches the agenda item which you wish to speak. As mandated by the Arizona Open Meeting Law, governing bodies may not discuss items not on the agenda, but may direct staff to follow-up with the citizen. Agendas are available within 24 hours of each meeting in the Assistant to the Chief Executive Officer (CEO), Maricopa Health Centers Governing Council s Office (MHCGC), located in the Comprehensive Health Center, 1 st floor, 2525 E. Roosevelt, Phoenix, AZ 85008, Monday through Friday between the hours of 7:30 a.m. and 4:00 p.m. and on the internet at Accommodations for Individuals with Disabilities, alternative format materials, sign language interpretation, and assistive listening devices are available upon 72 hours advance notice through the Assistant to the CEO, MHCG s Office, located in the Comprehensive Health Center, 1 st floor, 2525 E. Roosevelt, Phoenix, AZ 85008, (602) To the extent possible, additional reasonable accommodations will be made available within the time constraints of the request. 1/27/ :40 AM

3 When Addressing the Council Please state your name and the city in which you reside. If you reside in Maricopa County, please state the District you live in. If you have an individual concern involving the Governing Council, you are encouraged to contact the Governing Council member at We will do everything possible to be responsive to your individual requests. Public Rules of Conduct The Governing Council Chair shall keep control of the meeting and require the speakers and audience to refrain from abusive or profane remarks, disruptive outbursts, applause, protests, or other conduct which disrupts or interferes with the orderly conduct of the business of the meeting. Personal attacks on Governing Council members, staff, or members of the public are not allowed. It is inappropriate to utilize the Call to Public or other agenda item for purposes of making political speeches, including threats of political action. Engaging in such conduct, and failing to cease such conduct upon request of the Governing Council Chair will be grounds for ending a speaker s time at the podium or for removal of any disruptive person from the meeting room, at the direction of the Governing Council Chair. If you wish to address the Governing Council, please complete a speaker s slip and deliver it to the Assistant to the MHCGC. If you have anything you wish distributed to the Council and included in the official record, please hand it to the Assistant who will distribute the information to the Governing Council and MIHS Staff. Speakers are limited to (3) three minutes. 2

4 Maricopa Medical Center Administration Building Auditorium E. Roosevelt Street. Phoenix, AZ Assistant s Office Fax Wednesday, February 1, :00 p.m. One or more of the members of the Maricopa Health Centers Governing Council may attend telephonically. Governing Council members attending telephonically will be announced at the meeting. Pursuant to A.R.S (A)(3), or any applicable and relevant state or federal law, the Governing Council may vote to recess into an Executive Session for the purpose of obtaining legal advice from the Governing Council s attorney or attorneys on any matter listed on the agenda. The Governing Council also may wish to discuss any items listed for Executive Session discussion in General Session, or the governing Council may wish to take action in General Session on any items listed for discussion in Executive Session. To do so, the Council will recess Executive Session on any particular item and reconvene General Session to discuss that item or to take action on such item. Call to Order Roll Call Call to the Public This is the time for the public to comment. The Maricopa Health Centers Governing Council may not discuss items that are not specifically identified on the agenda. Therefore, pursuant to A.R.S (H), action taken as a result of public comment will be limited to directing staff to study the matter, responding to any criticism or scheduling a matter for further consideration and decision at a later date. ITEMS MAY BE DISCUSSED IN A DIFFERENT SEQUENCE General Session, Presentation, Discussion and Action: 1. Approval of the Consent agenda: 5 min Note: Approval of minutes, committee recommendations, etc. Any matter on the Consent Agenda will be removed from the Consent Agenda and discussed as a regular agenda item upon request of any Council member. a. Approve the Maricopa Health Centers Governing Council Meeting Minutes dated January 4, 2017: b. Accept the Recommendations from the Maricopa Health Centers Governing Council Finance Committee to Approve the Capital Request for Medical-grade Replacement Refrigerators for the Federally Qualified Health Center Look Alike Clinics Utilizing Prop 480 Funds in an amount not to Exceed $156,625.37: End of Consent Agenda 2. Discuss, Review and Approve the Formation of a Maricopa Health Centers Governing Council Standing Membership Committee: 5 min Liz McCarty, Committee Chair, Bylaws Review Committee 3

5 General Session, Presentation, Discussion and Action (cont.): 3. Presentation on the Operational Dashboard Data: 10 min Quentin Booker, Quality Assurance Analysist Wyatt Howell, Chief Executive Officer, Maricopa Health Centers Governing Council 4. Annual Compliance Training for the Maricopa Health Centers Governing Council s Members: 20 min Signing the Code of Conduct and Ethics Forms L.T. Slaughter, Interim Chief Compliance Officer 5. Maricopa Health Centers Governing Council Chief Executive Officer s Report: 10 min Wyatt Howell, Chief Executive Officer, Maricopa Health Centers Governing Council 6. Discuss and Review Maricopa Health Centers Governing Council (MHCGC) Committee Reports: 10 min a. Finance Committee Gary Tenney, Committee Chair, Finance Committee, Treasurer b. Strategic Planning and Outreach Committee Chris Hammond, Committee Chair, Strategic Planning and Outreach Committee 7. Reports to the Maricopa Health Centers Governing Council: 20 min Adjourn a. President and Chief Executive Officer Report Steve Purves, President & Chief Executive Officer, Maricopa Integrated Health System b. District Board Report Susan Gerard, Ex-Officio, Maricopa County Special Health Care District Board of Directors c. Chairman and Member s Closing Comments/Announcements Gino Turrubiartes, Chair, Maricopa Health Centers Governing Council d. Review of Council and Staff Assignments Pam Hjerpe, Assistant to the Chief Executive Officer, Maricopa Health Centers Governing Council i. Old Business January 4, 2017 Clarification on the Operational Dashboard, (explanations to be added to the back of the report). Brief presentation on the Operational Dashboard-Wyatt and team Add Member s Closing Comments/Announcements 4

6 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 1a Consent Agenda Minutes

7 Maricopa Health Centers Governing Council Meeting Minutes General Session January 4, 2017 Draft Minutes Maricopa Health Centers Governing Council General Meeting Maricopa Medical Center Administration Building, Auditorium 2 January 4, :00 p.m. Voting Members Present: Voting Members Absent: Non-Voting Members Present: Others/Guest Presenters: Recorded by: Gino Turrubiartes, Chair Simon Thomas, Vice Chair Gary Tenney, Treasurer Terry Benelli, Member Christine Hammond, Member Melissa Kotrys, Member April Jordan-Kramer, Member Liz McCarty, Member Rose Rubio, Member (participated telephonically) Ryan Winkle, Member Lloyd Asato, Member Julie Roberts, Member Susan Gerard, Ex-Officio Member Wyatt Howell, Chief Executive Officer, Maricopa Health Centers Governing Council Kris Gaw, Chief Operations Officer, Steve Purves, President & Chief Executive Officer LT Slaughter, Interim Chief Compliance Officer John Hitt, MD, Chief Medical Officer Louis Gorman, District Board Legal Counsel Gene Cavallo, Senior Vice President Behavioral Health Kate Rhodes, Executive Director Nursing Ambulatory Services Pamela Hjerpe, Assistant to the Chief Executive Officer, Maricopa Health Centers Governing Council Call to Order Chair Turrubiartes called the meeting to order at 6:00p.m. Roll Call Ms. Hjerpe called roll. Following roll call, Ms. Hjerpe announced that there were ten voting members of the eleven members of the Maricopa Health Centers Governing Council present, representing a quorum. For the benefit of those participating telephonically, Ms. Hjerpe named the individuals present and those participating telephonically. She asked that participants announce themselves prior to speaking. 1

8 Maricopa Health Centers Governing Council Meeting Minutes General Session January 4, 2017 Call to the Public Chairman Turrubiartes asked if any speaker s slips were turned in or if anyone from the public wished to address the Council. There were no comments from the public. General Session, Presentation, Discussion and Action: 1. Approval of the Consent agenda: a. Approve the Maricopa Health Centers Governing Council Meeting Minutes dated December 7, 2016 b. Accept the Recommendations from the Maricopa Health Centers Governing Council Executive to Appoint Eileen Sullivan and Lloyd Asato as Members of the Maricopa Health Centers Governing Council MOTION: Ms. Hammond moved to approve the Consent Agenda. Ms. Jordan-Kramer seconded. Motion passed by voice vote. 2. Update on Maricopa Integrated Health System s Behavioral Health in the Outpatient Setting: Mr. Howell introduced Mr. Cavallo. He is the Senior Vice President of Behavioral Health Services. He runs the inpatient program at Maricopa Integrated Health System (MIHS) as well as our satellite campus at Desert Vista. Mr. Cavalo is a native of Phoenix. He has been in the behavioral health field for thirty years, an alumnus of the University of Norte Dame and holds a degree from Arizona State University (ASU). Mr. Cavalo thanked Mr. Howell, Chairman and members of the council. The expansion of behavioral health at MIHS is exciting. Up until two years ago, MIHs was an inpatient behavioral health provider of care. A small amount of outpatient services was exclusively at the Desert Vista facility with residency-training program. Approximately two years ago, a much larger initiative, with the help from Mr. Purves, our President & Chief Executive Officer. MIHS has expanded the inpatient program, as well as outpatient. The first program based out of the South Central facility, the Family Support and Education. This program is an evidence based practice promoted by the U>S> Department of Health and Human Services Substance Abuse and Mental Health Service Administration (SAMHSA). Clients and families receive information about the illness and learn problem solving, communication and coping skills. Assertive Community Treatment (ACT) program based at our Desert Vista campus, opened August 1, 2016, serving approximately 40 clients with the capacity for 100 clients. The goals are to keep these individuals diagnosed with a Serious Mental Illness (SMI) healthy and living independently in the community, avoiding hospitalizations, incarcerations and homelessness while encouraging employment. Thirteen team members including a psychiatrists, two nurses and specialists in education, in employment, in housing and in substance abuse. The first Episode Center opened yesterday at our Pendergast Community Center. Chair Turrubiartes asked what the population currently that is being treated? Mr. Cavalo responded there is no official clients as of yet. Mr. Cavalo continued with the additional program known as that converted a 14 bed adult unit at Desert Vista into an adolescent unit. Serving this adolescent population is important both to respond to an unmet need in the community and to strengthen our Child Psychiatry Residency Training Program (the only one in Maricopa County) by providing in-house training opportunities. With the opening of the First Episode Center at Pendergast the same week, we have opportunities to meet the needs adolescents experiencing a psychotic illness in both the inpatient and outpatient level of care. Mercy Maricopa Integrated Care (MMIC) the Regional Behavioral Health Authority (REHBA) tracts both adults and adolescents that are in emergency rooms, just over the last year it averages between five to nine adolescents waiting in emergency rooms in Maricopa County for an inpatient behavioral health bed. We are in the process to open a medical/psych unit within the Maricopa Medical Center. Creating the Adolescent Unit at Desert Vista will result in a loss of 14 adult psychiatric beds for MIHS. Given the demand for inpatient adult psychiatric beds continues to grow and that an increasingly higher percentage have comorbid medical 2

9 Maricopa Health Centers Governing Council Meeting Minutes General Session January 4, 2017 conditions, a small group of key leaders assessed the feasibility of creating beds within the Medical Center to service this population. These additional beds in Medical Center will result in a net gain of 8 adult psychiatric beds for MIHs. We now have 219 adult beds. After January 3, 2017, we will have 205 adult psychiatric beds and 14 adolescent psychiatric beds. Completing this project in July of 2017 will result in 227 adult psychiatric beds a total for behavioral health 241 beds. Discussions are underway to create a more formal collaboration between the Seventh Avenue Walk in Clinic and the Urgent Psychiatric Center (UPC), run by Connections of Arizona. This would be a mutually beneficial relationship for both organizations. Many visits to the Maricopa Medical Center s Emergency Department (ED) could be avoided by providing some physical health services at the UPC. A shorter length of stay in the UPC may be possible, which could have a positive impact upstream and permit earlier movement from the ED to the UPC. A number of exciting and innovative behavioral health projects currently under exploration by MIHS and MMIC the creation of a school-based clinic that would provide integrated physical and behavioral health services. Implementation of a Collaborative Care Model to provide behavioral health services in our Family Health Centers (FHC). Exploration of ways that MIHs could provide physical and behavioral health services in the future to some individuals with Serious Mental Illness (SMI). Mr. Howell inquired if there is coordination with leasing beds from Phoenix Children s Hospital (PCH). Mr. Cavalo responded that he has not been involved with that topic. Mr. Tenney commented there have been several presentations at the Finance Committee on this subject. The SMI has been one of the more profitable areas. On the fourteen-bed adolescent, what age group is this? Mr. Cavalo responded targeting 13 to 17 year olds. PCH handles the younger children as well as St. Lukes Behavioral Health does both younger and the adolescents. Teenagers are the normal age group that will be waiting for beds out of the ED. Ms. Kotrys inquired on the First Episode Center, how does the referral process work, is it through MIHS or is it throughout the behavioral health community. Mr. Cavalo responded all and more, a lot of the work is getting the word out. Teams have been going out to schools, hospital, religious organizations as well as through the behavioral health networks. Dr. Kuruvilla added Arizona Health Care Cost Containment System (AHCCCS) is focusing on infants less than two years old by requiring two developmental screenings. Ms. Kotrys asked if the adult inpatient is mandated court order treatment or voluntary. Mr. Cavalo stated Mesa and Desert Vista are exclusively involuntary adults. 3. Maricopa Health Centers Governing Council Chief Executive Officer s Report: a. Operational Dashboard Report Mr. Howell stated that he has received official notification from Health Resources & Services Administration (HRSA) that MIHS FQHC-LA will not be surveyed this year. He stated to keep in mind that as we start to rebuild some of the FHC and new facilities that this may trigger an actual survey. The prep work is continuing with mock surveys with Mr. Slaughter s help. He added the Uniform Data System (UDS) submission to HRSA is due February 15, 2017, Ms. Rhodes leads this effort, which is very labor intensive. He does not have an update on the adult dental benefit from AHCCCS. However, he has met with Mr. John McDonald the Chief Executive Officer of the Primary Care Association here in Maricopa County, who remains optimistic that it is forth coming. Ambetter by Health Net provides the Maricopa County Health Insurance Exchange or Marketplace product for Maricopa County. MIHS is in network with this plan; there has been an increase in new enrollees calling for appointments for primary care services. He reported on the Operational Dashboard that the Early and Periodic Screening, Diagnostic and Treatments (EPSDT) continue to be a struggle with Medicaid children. There are work groups working together to insure these children receive their annual exams. There has been work on communication upgrades using , text and reminder phone calls. Reaching out to the health-plans to provide gift cards to the children that come in and receive their annual wellness exams, in the past there has 3

10 Maricopa Health Centers Governing Council Meeting Minutes General Session January 4, 2017 been some issues with this. There has been some success with doing an EPSDT exam while the child is in Pediatric department for other reasons. Dr. Kuruvilla stated that the EPSDT from a mother s perspective is that if the child is healthy why bother. Children three to six years of age, the mother will find no value in a yearly physical or dental exam. The adolescents will come in for sports physicals and can get an EPSDT exam at that time. High Schools students are the least compliance. Exploring the models with the health-plan would be helpful, the gift-cards in the past did not work well. Ms. Kotrys asked in regards to the calculations, if 15% increase from Fiscal Year 2016 are those numbers the monthly averages, so each month you are trying beat the monthly average. Is it a rolling number and your always trying to beat a monthly average? Mr. Howell responded that he believes that it is annual. It is measured monthly; the target is a 15% increase over the prior year total. Ms. Gaw stated that this is a good point and needs better clarifications. Mr. Thomas had two comments, the first item, the no show rate does meet the target for less than 25 percent, that is an improvement over the 28 percent. However when you see green you become complacent. When you reach that goal, you should change the target or the perimeter. The other comment is for Dr. Kuruvilla can the provider turn over by Full Time Employee (FTE). Presumably, in the five months we had a turnover of 7.4 FTE, knowing that the total FTE is about 58. In five months that turns out to about 13 percent. Therefore, 13% of the FTE just left, it will be a continuum struggle to replenish all those providers that are leaving this organization. Dr. Kuruvilla responded the provider retention, the biggest factor is their believes in serving the underserved. Knowing that the salary will be lower, knowing that patients are going to be a lot tougher to treat than on the private side. If they really believe in the cause, they will stay. Some will come for the job, which you will know in the first three years if this is the patient they wanted to treat. The Epic program is complicated and is too much work. There is no way to stop providers from leaving to the completion on the private side. District Medical Group (DMG) had a number of people in at the end of August leave, for reasons of a better life and salary. At least three of them have returned one doctor and two mid-levels. To get primary care providers is the most difficult task, there just are not that many. As of February, we will be 59 FTE with signed contracts. On top of that, DMG had an unusual amount of Family Medical Leave Act (FMLA). Years ago, we used to manage this by being able to hire three or more than what we have 58 to cover. We were functioning at 60 to 61 FTE. Nevertheless, in 2016, the consultant group called Health Management Associates (HMA) recommendation was that DMG should be held responsible at the contract level and nothing more, in February Dr. Kuruvilla was informed to dismiss two to three people. By June and July, three had left and then we were hit with the high numbers of FMLA. Chair Turrubiartes spoke up and stated this is a discussion that is ongoing and some of the members of the Governing Council are meeting with staff to get a better understanding of this topic. As a Governing Council, not everyone is aware and would like to table his thoughts and better understand this topic at the Executive Committee and then bring it to the Governing Council. Dr. Kuruvilla responded that it is not just the providers to close the issue; it is Medical Assistants (MA) as well. He stated he has been told that there were not enough MA s to cover the providers, not enough staff. It is a bilateral issue. Ms. Gaw stated that we are partnering with the medical staff to solving these issues. The dashboard that we are developing has been socialized with the DMG partners. With our DMG partners that staff the clinics, will be discussed at the Executive Committee meeting. She clarified some points, the contract had 55 in it and that is reconciliation on an annual basis. Three additional FTE s were added to get to the 58. She wanted to make sure that everyone understood that MIHS did not say you need to cut staffing. Mr. Purves interrupted that this conversation has been dealt with in conversations with Ms. Gaw, the medical directors staff in the Family Health Centers to really start to get a handle on the fluctuations in terms of staffing 4

11 Maricopa Health Centers Governing Council Meeting Minutes General Session January 4, 2017 and communication, the planning requires a dyad structure that Ms. Gaw has been working on. It is correct that it is difficult to find mid-level and family practitioners, we do have an environment that is conducive to keeping practitioners. In regards to patients per session, MIHS has never said we want to see staffing below reasonable benchmarks. 4. Discuss and Review Maricopa Health Centers Governing Council (MHCGC) Committee Reports: a. Finance Committee Report b. Bylaws Review Committee c. Compliance & Quality Committee Mr. Tenney stated the visit summary per month has improved somewhat, although we are 13percent. If there are no patients coming into the clinics then we cannot serve their needs. El Mirage at 35% off budget, Sunnyslope was Clinic of the Year at 25% off budget. Mr. McGilvra and his team have worked hard to turn dental around. Chandler was down 23 percent off budget. Mesa dental was 32% above budget, Avondale Dental was 40% above budget, and Pendergast cannot get any traction with 25% under budget. There was a possibility of the Pendergast dental to be one of our more profitable clinics because of the students there. We are currently for the year 11% under budget for expenses. Ms. Gerard asked if the reason for the low numbers was that people are not coming in or is it the uncovered sessions. Mr. Tenney responded that at El Mirage they are down two providers there makes it 25% off, we are down 3.22 at Sunnyslope making it 25% off. Dr. Kuruvilla added El Mirage is down one person, Sunnyslope has one person starting right now, so that will be one less. What is the other side of this is the number of Health Plans related lower enrollment numbers as well as causing the decrease in visits. Ms. Gerard asked if the patients are auto assigned or are they making a choice not to come here. Dr. Kuruvilla responded they were assigned to MIHS by the patients health plan. Ms. Gerard disagreed with Dr. Kuruvilla stating that if you do not have providers to care for the patients in your clinic it does not make any difference. This is a chronic issue, even though this is being worked on you get value-based contracts but if people call to get appointments and cannot get one for six weeks or two months they go elsewhere. Chair Turrubiartes stated to hold this discussion for now. He asked that Mr. Purves, Ms. Gaw and Mr. Howell bring it back at a later time. Mr. Tenney concluded with Healthnet is 140,000 people; we are looking to get 5 to 10% of those members, good numbers. Staff did a real good job-recruiting people on who we are and where we are. Ms. McCarty stated at the last Bylaws Review Committee reviewed the last pages, going through line by line making sure the document says what it needs to say. Staff has been instructed to review the references and there will be one last telephonic meeting to review the final draft. The final draft will be brought to the Governing Council for approval. Ms. Gerard thanked Ms. McCarty for the job her committee has undertaken and greatly appreciated. Ms. McCarty summarized the Compliance & Quality Committee meeting. Mr. Howell discussed the grants for Relink. This is the Medicaid program for recently released prisoners, to be able to continue with their medical health. The committee received a report on the hotline for the clinics for the first quarter of the Fiscal Year There were zero in process, 8 closed and average days open were 24, the goal is below thirty days. The compliance report questionnaire was reviewed; this goes to the clinics for HRSA preparedness site visit. 5

12 Maricopa Health Centers Governing Council Meeting Minutes General Session January 4, 2017 General Session, Presentation, Discussion and Action (cont.) 5. Reports to the Maricopa Health Centers Governing Council: a. District Board Report b. President and Chief Executive Officer Report c. Chairman s Closing Comments/Announcements d. Review of Council and Staff Assignments Ms. Gerard announced the District Board does not meet in December. The District Board will be looking at the missed session s analysis, the collecting of the data and how to resolve the issues. Mr. Purves wished everyone a happy New Year; he stated he had the opportunity to visit all the FHC over the holiday. He had conversations with some patients as well. Affordable Care Act (ACA); he has concerns that the ACA will be repealed and not replaced and MIHS will not receive any of the cuts that were made to Medicaid back or the supplemental funding or DSH (Disproportionate Share Hospital) program. MIHS is very actively working with our congressional delegation. With the advances made in the Behavioral Health Care field thru Prop 480 were emphasized with the government leaders as well. With respect to Prop 480, in November the District Board selected Vanir Construction Management, Inc. to develop a multi-year work plan that aligns the direction and vision with Prop 480. Mr. Purves recognized Ms. Gaw and her hard work on the revenue and keepage programs, as well as the Six Sigma program, 17 people have graduated and are currently green belts. Mr. Tenney added that as an organization MIHS needs to be more competitive, by offering extended hours and weekend hours. Chair Turrubiartes introduced Lloyd Asato after the Behavioral Health presentation and asked Mr. Asato to speak. Mr. Asato stated that he is the Executive Director of a community health organization, Asian and Pacific Community Inaction. This is their 14 th year serving immigrant and refugee communities in Phoenix. Born in Hawai i and raised across the US. Ms. Hjerpe stated the following items are for follow-up: Clarification on the Operational Dashboard on EPSDT, (explanation/dictionary to be added to the back of the report) - Mr. Howell and team. Short presentation on the Operational Dashboard (Dr. Hitt suggested a single indicator at a time.) - Mr. Howell and team Assign a mentor to the new members- volunteers Add an Open session for the members to ask questions to the agenda - Ms. Hjerpe. Adjourn MOTION: Ms. Kotrys moved to adjourn the January 4, 2017 Maricopa Health Centers Governing Council meeting. Ms. Jordan-Kramer seconded. Motion passed by voice vote. The meeting adjourned at 7:58 p.m. Approved by the Maricopa Health Centers Governing Council on: February 1, Pamela Hjerpe, Assistant to the Executive Director, Maricopa Health Centers Governing Council 6

13 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 1b Consent Agenda Capital Request for Medicalgrade Refrigerators

14 CAPITAL EXPENDITURE REQUEST INSTRUCTIONS: 1. Complete all sections (I-V) - Items marked with * MUST be completed 2. Forward completed CER to Kathy Benaquista, VP Finance via 3. PAPER COPIES WILL NOT BE ACCEPTED PROJECT DESCRIPTION: FHC Helmer Medical Refrigerators CER #: PART I - REQUISITION INFORMATION * REQUISITIONER NAME: * DEPARTMENT: * PHONE # : * COST CENTER: * DATE: Pete Fulling Facilities /4/16 PART II - VENDOR SELECTION * SUGGESTED VENDOR: (If Any) * VENDOR CONTACT: * PHONE NUMBER: * FAX NUMBER: Helmer * VENDOR ADDRESS: * STATE: ZIP CODE: * Have you obtained Competitive Quotes? NO * Have you obtained MD Buyline Analysis? NO * If " YES " Quotes and MD Buyline with CER PART III - INTERDEPARTMENTAL COLLABORATION * Which Departments have you consulted with?: Facilities YES BIO-MED YES * Others: (please list) IT YES PART IV - CAPITAL BUDGET INFORMATION * Has this request been BUDGETED?: NO * If " YES " Budget #: Quarter Budgeted: * If " NO " Can this request wait until next Fiscal Year?: * If " NO " Describe the situation/emergency or condition warranting funding below: This replaces the current dormitory style refrigerators/freezers that are out of compliance with current CDC guidelines as well as occurrences of vaccines expiring due to temperature swings and coil failures.while all are very important HOT FHCs include 7th Ave Walk In and Pendergast as * Will this Capital Acquisition result in on-going Operational Costs for your Department or other Department?: NO * Estimated On-going Annual Operating Costs: Describe: PART V - EQUIPMENT REQUEST EQUIPMENT DESCRIPTION: QTY: UNIT PRICE: EXTENDED PRICE: Helmer ILR-120 Large Fridge 13 $ 4, $ 59, Helmer HLR-105 Small Fridge 20 $ 2, $ 42, $ - Helmer ILF-105 Small Freezer 15 $ 3, $ 54, $ - $ - $ - $ - $ - $ - TRAINING INSTALLATION FREIGHT (Estimate) TOTAL $ 156, EQUIPMENT CATEGORY: CONTINGENCY Part VI: To be completed by Materials Management PART VI - PURCHASING & CONTRACTING INFORMATION FINAL SELECTED VENDOR: (If different from above) CONTRACT NUMBER: P.O. NUMBER DATE ORDERED: FINAL PURCHASE PRICE: COST SAVINGS: (If Any) $ 156, DATE RECEIVED:

15 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 2 New Standing Committee Membership Committee

16 Maricopa Healthcare Centers Governing Council Membership Committee Charter Purpose The purpose of the Membership Committee (Committee) of the Maricopa Healthcare Centers Governing Council (Council) is to recruit, recommend, and screen candidates to serve on the Council of the Federally Qualified Health Center Look-Alike (FQHC-LA) designated sites and to assure that the Council is meeting the Health Resources & Services Administration (HRSA) Program Requirements concerning representation on the Council. Membership The Committee shall consist of a Chair, a Vice Chair, and no more than two (2) additional Council members. A voting member of the Council will serve as the Committee Chair. The Committee Chair will recommend and the Committee will appoint a Vice Chair. The Chief Executive Officer of the Council is an ex-officio, non-voting member of the Committee. In addition, the Committee will appoint one (1) MIHS Family Health Center Clinic Manager to sit on the Committee as voting member. In accordance with the Council Bylaws, voting members are appointed by the Council. Voting members shall serve for a two (2) year term with a maximum of two terms. Responsibilities 1. Develop the criteria for qualifications of potential applicants for membership on the Council. Potential applicants should represent the individuals being served by the FQHC LA designated sites in terms of demographic factors such as race, ethnicity, and sex. 2. Actively recruit and screen new applicants. This includes seeking community assistance (which may include local civic, religious and community organizations) in identifying persons interested and qualified for the positon. 3. When seeking potential applicants, the Committee will identify potential applicants that are representative of the community and that the ratio of User Members and Non-user Members is maintained. Non-users should be selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community. Effective Date: Reviewed Date(s): Revision Date(s):

17 Maricopa Healthcare Centers Governing Council Membership Committee 4. Conduct appropriate inquiries into the background and qualifications of interested candidates for the Council. 5. Promote retention of existing Council members. 6. Maintain an awareness of the needs of the Council when recruiting prospective candidates. 7. Periodically review the Committee Charter and make recommendations for suggested revisions to the Council. Meetings Meetings will be held monthly or quarterly or as needed?. Additional meetings can be scheduled at the discretion of the Committee Chair. Meeting Procedures 1. The Committee Chair will facilitate all meetings. The Committee Vice Chair will facilitate meetings in the Chair s absence. 2. Meetings will be attended by Committee members in person or, when circumstances dictate, telephonically. A quorum shall consist of a majority of the voting Committee members, which is necessary for the Committee to meet and to take action. 3. Minutes shall be recorded and maintained for each Committee meeting in compliance with Arizona Open Meeting Laws and shall contain all actions taken by the Committee. Minutes recorded or maintained for Executive Session discussions, however, will be kept confidential pursuant to A.R.S The Committee will report its actions to the Council at the next regularly scheduled Council meeting.

18 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 3 Presentation on the Operational Dashboard

19 AMBULATORY AND PHYSICIAN SERVICES ~ FQHC CLINICS QUALITY DASHBOARD FY 2017: All Clinics Combined Target Threshold Action Trigger Equal or greater than goal < 10% negative variance > 10% negative variance SERVICE Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD No Show Rate Target= < 25% Connect Experience Survey "Would Recommend Providers Clinic" Target= 88.9% n= count of Returned Connect Surveys FQHC 21.7% 21.5% 22.8% 22.4% 21.5% 20.5% 21.7% FQHC 82.2% 82.3% 84.5% 83.9% 84.7% 84.6% 83.3% FQHC CGCAHPS Patient Satisfaction NRC (Quarterly) Target= 76.4% County Owned Average FQHC Quarterly Quarterly 81.0% Quarterly Quarterly Data Pending Quarterly Quarterly Quarterly Quarterly 81.0% n= count of Returned CGCAHPS Surveys FQHC Quarterly Quarterly 273 Quarterly Quarterly Data Pending Quarterly Quarterly Quarterly Quarterly 273 My Chart Usage Target > 50% FQHC 56% 63% 58% 59% 55% 60% 58% % of Abandoned Calls Target: 7.5% QUALITY Average HbA1c for Diabetic Patients Target: 8.0% % CHF Patients on ACEI/ARB Target: 92% % HTN Patients with BP < 140/90 Target: HEDIS 66% EPSDT Volumes for 3-6 Year Olds Target: 15% increase from FY2016>417 EPSDT Volumes for Year Olds Target: 10% increase from FY2016 > 400 FQHC 5.6% 6.1% 5.7% 8.7% 7.4% 5.2% 6.5% FHC/IM 7.70% 7.59% 7.55% 7.57% 7.57% 7.9% 7.6% FHC/IM 92.1% 94.1% 95.5% 93.6% 94.2% 97.2% 94.5% FHC/IM 65.0% 66.1% 65.6% 61.8% 63.4% 66.0% 64.6% Peds Peds PEOPLE Percent of MIHS voluntary turnover Target < 12% FQHC 2.70% 3.10% 5.4% 1.1% 0.1% 4.30% 2.77% Count of Provider turnover by FTE= FQHC n= count of Providers FQHC

20 Data Element Name: No Show Rate Connect Experience Survey CGCAHPS Patient Satisfaction My Chart Abandoned Calls HB A1c CHF Hypertension EPSDT Volumes Collected For: Definition: Format: Allowable Values Data Source: NCQA-PCMH: National Committee for Quality Assurance- Patient Care Medical Home. Quality Process Measure for: CG CAHPS: Clinician and Group Consumer Assessment of Healthcare Providers and Systems. HRSA: Health Resources and Services Administration HEDIS: Healthcare Effectiveness Data and Information Set NCQA-PCMH: National Committee for Quality Assurance- Patient Care Medical Home Quality Process Measure for: CGCAHPS measures related to patient "access to care". Quality Process measure for: CGCAHPS measures related to patient "access to care". HRSA: Health Resources and Services Administration HEDIS:Healthcare Effectiveness Data and Information Set NCQA-PCMH: National Committee for Quality Assurance- Patient Care Medical Home UDS: Uniform Data Systems Application STAR Measure Meaningful Use NCQA-PCMH: National Committee for Quality Assurance- Patient Care Medical Home Star Measure HEDIS:Healthcare Effectiveness Data and Information Set NCQA-PCMH: National Committee for Quality Assurance- Patient Care Medical Home Medicaid HEDIS: Healthcare Effectiveness Data and Information Set NCQA-PCMH: National Committee for Quality Assurance- Patient Care Medical Home Percentage of Scheduled Patients who were a "No Show". Patient failed to keep appointment. Percentage of Connect Experience-MIHS Surveyors who favorably scored (+9 or +10) clinic providers for the question "Would Recommend Providers Clinic" Percentage of National Research Corporation- MIHS surveyors who favorably scored (+9 or +10) clinic providers for the overall CGCAHPS question "Best provider possible or worse provider possible" Percentage of Activated Patients for establishing "My Chart" Percentage of Patients who discontinued phone call after being placed on hold for 30 seconds or more. Average HbA1c for Diabetic Patients % of MIHS Patients with a DX of CHF who were prescribed ace/arb medication % of MIHS Patients with a dx of hypertension who are: 1: Under MIHS care for at least 3 months and; 2. have a blood pressure < 140/90 Total FQHC site EPSDT count for: 1. Patients 3-6 y/o 2. Patients y/o Percentage Percentage Percentage Percentage Percentage Monthly Monthly Monthly Numeric Count 1. No Show Patients 2. Same Day Cancellations "Would Recommend Providers Clinic" Score for all FQHC sites. Adult Score for "Best Provider possible or worse provider possible" Percentage of Patients who "My Chart" Patients who disconnected phone call after being on hold for 30 seconds or more Patients who are listed in the Diabetic Registry 1. Patients dx with CHF 2. Patients who do not have CHF 3. Patients who have a contraindication Patients with a diagnosis of hypertension most recent blood pressure screening. Count of Early-Periodic Screening, Diagnostic and Treatment for: 1. Patients 3-6 y/o 2. Patients y/o EPIC Report: 1. "No Show and Kept Appt Rare by Cost Center Per Provider-CHC" (For CHC Locations) 2. MIHS G Drive: G:\AMB_PHY_SRVCS\FHC_Manager\ Sessions No Show (For FHC Locations) Connect Experience Website National Research Corporation EPIC Report: "MyChart Statuses Per Patients with Visits." Altura Communication Solutions Report EPIC Report: "Diabetic Registry Patient Visits (prior month)" EPIC Report: "CHF Patients- Ace Inhibitors-- All Locations (prior month)" EPIC Report: "Hypertension Patients on SVC 3 months- All Locations (prior month)" EPIC Reports: 1. "EPSDT Visit Data- Quality Analysis (13-18 yrs., prior month)" 2. "EPSDT Visit Data- Quality Analysis (3-6 yrs., prior month)" How is this data element measured? 1. Monthly median percentage for all FQHC sites. 2. FYTD Average 1. Monthly percentage score for all FQHC sites. 2. FYTD Total Score 1. Quarterly percentage Adult CGCAHPS score for all Patient Care Medical Home Sites Surveyed 2. FYTD Total Score 1. Monthly median percentage for all FQHC sites. 2. FYTD Average 1. Monthly median percentage for all FQHC sites. 2. FYTD Average 1. Monthly mean percentage compliance for all FQHC sites. 2. FYTD Average compliance 1. Monthly median percentage compliance for all FQHC sites. 2. FYTD average compliance 1. Monthly median percentage compliance for all FQHC sites. 2. FYTD average compliance 1. Monthly total count for all FQHC sites. 2. FYTD average count MIHS Turnover Quality Process Measure: To monitor Provider turnover as to sustain favorable clinic cycle times. Percent of FQHC MIHS Employees who voluntarily terminated employment Percentage MIHS Employees Voluntarily Terminated Ambulatory Leadership 1. Monthly percentage for all FQHC sites. 2. FYTD Percentage Count of Provider turnover by FTE Quality Process Measure: To monitor Provider turnover, as to sustain patients per session. Total FTE of DMG providers who voluntarily terminated employment Decimal Count Provider FTE decimal count who voluntarily terminated Ambulatory Leadership 1. Monthly count for all FQHC sites. 2. FYTD count Count of Providers Quality Process Measure: To monitor Provider turnover, as to sustain patients per session. Total Count of Providers Numeric Count DMG providers who voluntarily terminated Ambulatory Leadership 1. Monthly count for all FQHC sites. 2. FYTD count

21 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 4 Annual Compliance Training for the MHCGC Members

22 GOVERNING COUNCIL- COMPLIANCE TRAINING: ZONE-IN AND BE PROACTIVE (ZIP)

23 Expectations for Board Oversight of Compliance Program Functions A Board must act in good faith in the exercise of its oversight responsibility for its organization, including making inquiries to ensure: (1) a corporate information and reporting system exists and (2) the reporting system is adequate to assure the Board that appropriate information relating to compliance with applicable laws will come to its attention timely and as a matter of course. 2

24 Expectations for Board Oversight of Compliance Program Functions The existence of a corporate reporting system is a key compliance program element, which not only keeps the Board informed of the activities of the organization, but also enables an organization to evaluate and respond to issues of potentially illegal or otherwise inappropriate activity. 3

25 Objectives In this training, you will learn about our approach: Understand the Business - Overview of MIHS and Key Payers Understand the Healthcare Environment Key Regulations and Trends Risk Assessment Process Identification and Prioritization of Risks Risk Mitigation Process Compliance Program, Internal Audit, Revenue Cycle and Performance Excellence 4

26 METHODOLOGY AND APPROACH

27 Our Methodology and Approach 1 Understand the Business Conducted interviews with various members of MIHS Management and Healthcare Industry leaders; Considered whether any key initiatives or changes to MIHS strategic plan may impact the risk profile of the organization; Reviewed the audit and compliance work plans and priorities of other health systems to determine current areas of focus by others in the industry. 2 3 Risk Assessment Prioritized risks and areas of concern based on the importance to business performance, impact to the organization and the likelihood of control /process issues; Considered the prior year risk assessments and work completed in FY16 & FY17 and the findings from previous internal audit and compliance activities. Prioritized Internal Audit and Compliance Plan Proposed a list of compliance and internal audit projects focused on the risks identified and areas of concern to be completed in FY2017. These will be reassessed quarterly.

28 The Regulatory Gorge

29 ZONE IN and be PROACTIVE (ZIP) Will We Survive? Helmet (Information about Risks) Partner/ Instructor Equipment/ Tools

30 The Compliance Team

31 UNDERSTAND THE HEALTHCARE ENVIRONMENT

32 UNDERSTAND THE BUSINESS

33 Healthcare Regulation Oversight Bodies United States Department of Justice (DOJ) Office of Inspector General (OIG) Office for Civil Rights (OCR) Center for Medicare and Medicaid Services (CMS) MIHS District policies Internal Revenue Service (IRS) Arizona Department of Revenue Arizona Healthcare Cost Containment System (AHCCCS) Food and Drug Administration (FDA) Many Others (OSHA, FCC, DEA, etc.)

34 Affordable Care Act

35 Below are some of the rules and regulations that may affect how you do your oversight. AHCCCS State Medicaid Plan HRSA (Regulates Federally Qualified Health Center (FQHC)) Affordable Care Act (Meaningful Use) Anti-Kickback Statutes Emergency Medical Treatment and Active Labor Act (EMTALA) HIPAA (Health Insurance Portability and Accountability Act) and HITECH. Medicare Rules Condition of Participation False Claims Act Federal Sentencing Guidelines Deficit Reduction Act of 2005 (See policy in SharePoint) OSHA, FDA, and EPA Laws (Occupational Safety and Health Administration, Food and Drug Administration, Environmental Protection Agency). Arizona State Regulations. Others (LEP 1557, Payment Suspensions, 60 Day Rule, etc.)

36 UNDERSTAND THE BUSINESS

37 Understand the Business MIHS s Main Business Units Maricopa Integrated Health System A - Acute Care B Graduate Medical Education (Residency Program) C - FQHC D - CHC E - Behavioral Health F - DMG (District Medical Group) G - Health Plans H Grants and Resea rch

38 Understand the Business MIHS s Major Payers/Revenue Maricopa Integrated Health System 1 AHCCCS (60%) 2 Ad Valorem Tax 3 - Commercial 4 - Medicare 5 - Self Pay

39

40

41 RISK ASSESSMENT

42 The Improbability Principle

43 Spare Tire Story

44 WOW.I DON T KNOW IF I AM READY!

45 The Enterprise Risk Management Process The ERM process includes the following major components: Risk identification Prioritization and scoring of risks Risk response - This involves developing and implementing an action plan to avoid, accept, reduce or finance risks

46

47 Risk Assessment Process - Key Risks In no particular order, the following key risk areas, themes and concerns were identified during our assessment 1. Privacy and Security of Protected Health Information (OCR Audit) 2. Contracts involved in Patient Care and Business Associate Agreements (DNV and OCR) 3. IT Security Risk Mitigation and Application Security (Including PCI Compliance) (Moss Adams Report) 4. Research and IRB Process Improvement (Kelly Willenberg and IntegReview) 5. DMG Contract Compliance 6. Meaningful Use Compliance (EH and EP) 7. Prop 480 and Capital Expenditures B Compliance (FQHC and DSH Compliance) 9. Behavioral Health Billing/MMIC 10. ED to Observation/ Inpatient Process and Documentation 11. Residency Program Controls 12. Health Plan Sale and Reconciliation 13. Application Implementation Review and Control 14. Contract Negotiations and Approval 15. Payer Contract Management, Denied Reimbursement, Underpayments, Recording of Contractual Allowances 16. AHCCCS Reimbursement and State Plan

48 Significance Risk Assessment Process Prioritization Map The map below depicts the highest rated risks based on feedback from interviews and other data gathering. The risks are plotted based on their individual significance to the business along with the likelihood that issues and / or improvement opportunities currently exist. The highest risk areas are shown in Quadrant 1 and generally include those risks that are inherently high for the industry or are a known concern to MIHS. The proposed 2017 Internal Audit and Compliance Work Plans are located on page 6 and 8. LOW HIGH LOW Quadrant 2 Quadrant 1 R13 R17 R24 R1 R10 R8 R5 R20 R15 R12 R14 R4 R3 R18 R21 R7 R2 R22 R23 R16 R9 R6 Quadrant 4 R25 Likelihood R19 R11 Quadrant 3 HIGH R1 Net Patient Revenue / Accounts Receivable R2 Patient Scheduling, Admissions / Registration, Insurance Verification R3 Chargemaster Accuracy and Maintenance R4 General IT - Access to and Integrity of Data, Supporting Infrastructure, etc. R5 Charge Capture and Verification (Overcharging, Undercharging, etc.) R6 Clinical Coding and Documentation Accuracy R7 Billing Accuracy R8 Application Implementation Practices and Facility Readiness R9 Collections, Cash Application, Credit Balances R10 Finance, Reserves, Bonds R11 Payer Contract Management, Denied Reimbursement, Underpayments, Recording of Contractual Allowances R12 DMG Contract Compliance R13 Privacy and Security of Protected Health Information R14 General Ledger Accounting and Integrity of Data R15 Government Reimbursement R16 General Compliance with Medicare Regulations R17 IT Disaster Recovery and Business Continuity R18 Employee Time Reporting and Payroll R19 Cost Management R20 Fraud (Management, Employee, Third Party) R21 Vendor and Contract Management R22 Capital Spending / Projects and Construction (Prop 480) R23 Licensure / Accreditation R24 IT Logical Security (Network / Application Accounts, Password Security, etc.) (Including PCI compliance) R25 Grant and Research Department

49 Likelihood Example Residual Net Risk Map Employee/ Independent Contractors CO-4 Contracts Disaster Recovery IS-4 Healthcare Partnerships CO-5 OIG Compliance CO-6 Implantable Devices OP-2 Hospital Lease CO-7 Customer Satisfaction PC-1 Physician Recruitment CO-2 Leadership Security IS-1 JCAHO Failure CO-3 System Integrity IS-5 Charge Master Table FI-2 Materials Management FI-3 Health and Safety Construction Procedures FS-1 Tax Exempt Status CO-1 Hospital Lease CO-7 Home Health PC-2 Availability OIG Compliance CO-6 Access/Security Management/ HIPAA IS-2 System Acquisition and Implementations IS-3 Payroll HR-1 Budgeting and Planning FI-3 Construction Procedures FS-1 Billing/ Coding FI-1 Coding APCs OP-2 Billing/ Coding FI-1 Access/Security Management/ HIPAA IS-2 Competition Financial Reporting Sensitivity Budgeting and Planning FI-3 Significance

50 Internal Audit

51 Ignorance Not An Excuse 30

52 Internal Control In 1992, the Committee of Sponsoring Organizations of the Treadway Commission (COSO) developed a model for evaluating internal controls. This model has been adopted as the generally accepted framework for internal control. The COSO model defines internal control as: a process, effected by an entity's board of directors, management and other personnel, designed to provide "reasonable assurance" regarding the achievement of objectives in the following categories: o Effectiveness and efficiency of operations o Reliability of financial reporting o Compliance with applicable laws and regulations 31

53 Types of Internal Control Preventive - controls that prevent the loss or harmful event from occurring. o Segregation of duties minimizes the chance an employee can issue fraudulent payments (i.e. one person submits a payment request, but a second person must authorize it). Detective - controls that monitor activity to identify instances where practices or procedures were not followed. o An exception report that detects and lists incorrect or invalid entries or transactions. Corrective - controls that restore the system or process back to the state prior to a harmful event. o A full restoration of a system from backup tapes after evidence is found that someone has improperly altered the payment data. 32

54 Reliable Reliable Determine Controls that Mitigate Risks CONTROL / kun-'trol (noun): to reduce the incidence or severity of, especially to innocuous levels. Control Types Evaluate Controls Design Desirable System-Based Detective Control System-Based Preventive Control People-Based Detective Control People-Based Preventive Control Desirable

55 Examples of Internal Controls Internal controls in their simplest form are anything we do to help us achieve our objective. We all use internal controls to some extent in our daily lives. We lock our homes before we leave for work o to prevent unwanted entry into our homes, thus safeguarding our household contents. We install security/surveillance systems in our homes o to deter, prevent unwanted entry, thus safeguarding assets. Surveillance systems act as a detective control to identify the perpetrator. We keep our credit card or social security number safe o to prevent identity theft and loss of money, thus safeguarding our assets. We keep our on-line banking password in our memory and not written on the back of our keyboard o to prevent unwanted access to our funds and safeguard our assets. 34

56 The Internal Audit Process 35

57 Compliance Program and Code of Conduct and Ethics

58 MIHS Compliance Plan To help the organization follow rules and be ethical, the Office of Inspector General (OIG) has listed seven elements that facilities should include in their corporate compliance plan. MIHS has used the OIG s guideline as a model, and it is the responsibility of all employees to understand ours

59 Element One: Code of Conduct and Ethics ( The Code ) and Policies and Procedures THE CODE The Code has been adopted by MIHS to provide standards by which the Board of Directors, employees, officers, medical staff and agents will conduct themselves to protect and promote organization-wide integrity and to enhance MIHS s ability to achieve its organizational mission. Policies and Procedures All policies and procedures are located in CopaNet and are contained in Compliance 360 (our online policy and procedure management system). 38

60 Element Two: Oversight & Accountability- Chief Compliance Officer MIHS Management has selected L.T. Slaughter, Jr. to be the Chief Compliance Officer. You can reach him directly at (602) or submit a questions through CopaNet at ask the Compliance Officer. 39

61 40

62 Element Three: Effective Training We conduct live New Employee Orientation (NEO) for all new hires and provide APEX computerized training for the annual requirement. We will also be issuing awareness trainings that will cover hot compliance, privacy and IT security topics. Lastly, we have developed specific resources, tools and reference materials that are available in the Compliance page of the CopaNet. What if training is not completed? If the required training is not completed by year-end, then there are disciplinary policies and procedures for employees, medical staff, residents, contractor and other agents. 41

63 Element Four: Lines of Communication The Compliance Hot Line (Ethics Line) is intended to supplement existing internal communication channels. It is not intended to replace your management team, senior management or other corporate resources. The Compliance Hot Line (Ethics Line)is available when you believe that you have exhausted normal MIHS channels or feel uncomfortable about bringing an issue to your supervisor or a higher-level supervisor. The Compliance Hot Line (Ethics Line) is available 24 hours a day, seven days a week MIHS (6447

64 Element Five: Policies, Procedures and Disciplinary Guidelines We have a progressive disciplinary policy provided by Human Resources. This policy is available on the CopaNet and in Compliance 360 our online policy and procedure portal. We have a zero tolerance for non-compliance. Steve Purves President and CEO L.T. Slaughter, Jr., Chief Compliance Officer 43

65 Element Six: Auditing and Monitoring We utilize a risk-based auditing and monitoring approach. We focus on the highest risks and also implement monitoring tools throughout the organization to provide a span on controls and to identify issues as quickly as possible. 44

66 Element Seven: Corrective Actions When an issue has been identified, the Compliance Department will work closely with management to recommend corrective action and may assist with the implementation of the plan and future monitoring for effectiveness. 45

67 Element Eight: Monitoring Effectiveness of the Plan The Finance, Audit and Compliance (FAC) Committee monitors the effectiveness of the internal audit and compliance program. They report their findings to the Board of Directors quarterly and also in an annual report. 46

68 Code of Conduct (Copy on CopaNet)

69 Standards of Conduct and Ethics THE CODE T - Treat all Patients with respect and dignity Providing High Quality Services H - Healthcare Legal and Regulatory Compliance Full Compliance with applicable laws. E - Avoid Every Conflict of Interest maintain a duty of loyalty to MIHS C - Relationships with Payers and Government - Satisfy the Conditions of Payment Required to Payers O Oversight of Relationships with Physicians and other Providers D - Respect for Our Culture Recognize our Diverse workforce E Electronic Information Systems Information is used appropriately and safeguarded zealously.

70 DEVELOP COMPLIANCE AND AUDIT PLAN

71 Proposed 2017 Compliance Work Plan Project Name Audit Timing Est. Audit Hours Risk Assessment and Selection Q1 (Current State Assessment) CQ1.1 Compliance Department Evaluation and Clean-Up of Outstanding Items Q1 250 (Completed) CQ1.2 Privacy and Security Policy and Procedure Review (R4, R13,R24) Q1 200 (Completed) CQ1.3 Compliance Policy and Procedure Review (and review of Compliance IT Systems) (R16) (R15) CQ1.4 Research Department Report Process Improvement (Phase I) (R6), (R7), (R25) Risk Re-assessment and Selection Q2 Q1 Q1 150 (Completed) 200 (Completed) CQ b Pharmacy Compliance (R5), (R16), (R19) Q2 200 (In-process) CQ2.2 Research Department Report Process Improvement (Phase II) (R6), (R7), (R25) CQ2.3 Site visits of all external sites (DNV and HIPAA)(R1), (R2), (R3), (R5), (R9), (R13) CQ2.4 Behavioral Health Billing (R1), (R2), (R3), (R5), (R6), (R7) CQ2.5 Training of Employees, Physicians and Residents (R13), (R23), (R24) Q2 Q2 Q2 Q2 250 (In-process) 200 (In-process) 100 (In-process) 150 (In-process)

72 Proposed 2017 Compliance Work Plan (continued) Risk Re-assessment and Selection Q3 Project Name Audit Timing Est. Audit Hours CQ3.1 Health Plan Sale and Reconciliation (R16) Q3 TBD CQ3.2 IT Disaster Recover and Business Continuity (R8), (R13), (R16), (R17) Q3 TBD CQ3.3 Charge Description Master PWC s Pathway to Excellence Program (Moved from FY 2016) (R3) CQ3.4 MedAssets Contract Manager Accuracy (Moved from FY 2016) (R11) Q3 TBD CQ3.5 Patient Eligibility and Billing (Moved from FY 2016) (R2) Q3 TBD Risk Re-assessment and Selection Q4 CQ4.1 Physicians at Teaching Hospital (Moved from FY 2016) Q4 TBD CQ4.2 Provider Based Clinic Reviews (Moved from FY 2016) (R1), (R2), (R6), (R9) Q4 TBD CQ4.3 Cardiac Interventional Lab (Moved from FY 2016) Q4 TBD Risk Assessment and 2017 Compliance Plan Development Quarterly 120 Special Projects and Other Compliance Requests On-going TBD Compliance Planning, Administration and Meetings Quarterly TBD Q3 TBD

73 Proposed 2017 Internal Audit Plan Risk Assessment and Selection Q1 (Current State Assessment) Project Name Audit Timing Est. Audit Hours IQ1.1 Internal Audit Department Evaluation and Clean-Up of Outstanding Items Q1 250 (Completed) IQ1.2 Contracts involved in Patient Care (Prior Year DNV Exception) (Updated Contract System) (R21) Q1 100 (completed) IQ1.3 Meaningful Use Audit (Phase I) (R13), (R15, (R16), (R24) Q1 100 (Completed) IQ1.4 Business Associate Agreement Review (Updated Contract System) (R13), (R21) Risk Re-assessment and Selection Q2 Q1 200 (Completed) IQ2.1 Meaningful Use Audit (Phase II) (R13), (R15, (R16), (R24) Q2 200 (In-Process) IQ2.2 Application Identification and Security Review (R8), (R13) Q2 350 (In-Process) IQ2.3 P-Card Audit and Travel Expenses (R14), (R20) Q2 150 (In-Process) IQ2.4 IT Security and PCI Compliance (R13), (R24) Q2 200 (In-Process)

74 Proposed 2017 Internal Audit Plan (continued) Risk Re-assessment and Selection Q3 Project Name Audit Timing Est. Audit Hours IQ3.1 Prop 480 Allocated Funds (R22) Q3 TBD IQ3.2 Grants Compliance (R25) Q3 TBD IQ3.3 DMG Contract Compliance Review (R12) Q3 TBD Risk Re-assessment and Selection Q4 IQ4.1 Hospital Cost Report Salaries and DME Payments (Moved from FY 2016) (R10), (R14), (R18) IQ4.2 Self Pay Collections (Moved from FY 2016) (R9) Q4 TBD IQ4.3 Inpatient Outlier Cases and Mechanical Ventilation (R7), (R16) Q4 TBD IQ4.4 Conflict of Interest (Moved from FY 2016) (R16) Q4 TBD Risk Assessment and 2017 Internal Audit Plan Development Quarterly 120 Special Projects and Other Internal Audit Requests On-going TBD Internal Audit Planning, Administration and Meetings Quarterly TBD Q4 TBD

75 What is the difference between Auditing and Monitoring?

76 Compliance Regulations and Other Key Issues

77 Conflict of Interest

78 Conflict of Interest Under the Conflict of Interest law, an employee at MIHS whether full-time, part-time or contract basis who has a conflict of interest must disclose the interest and refrain from participating in this matter. 57

79 Scenario: You are the Manager and it is brought to your attention that: Conflict of Interest An employee has a family member who owns a Durable Medical Equipment Company. She works with these DME referrals at the Clinic. Is this a conflict of interest? Does this employee need to disclose the interest and refrain from participating in this matter? 58

80 EMTALA

81 The Emergency Medical Treatment and Active Labor Act (EMTALA), is also known as the Patient Anti- Dumping Law. All clinical facilities must meet or exceed the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) in providing emergency medical treatment to all patients When an individual arrives alone or with another person at a clinical facility, and a request is made on the individual s behalf for a medical examination or for treatment, a clinical facility must provide for an appropriate medical screening examination within the capability of the facility s emergency department, to determine whether an emergency medical condition exists, or with respect to a pregnant woman having contractions, whether the woman is in labor. The facility must not delay an examination or treatment to inquire about the method of payment or the individual s insurance status If a medical emergency exists, or a woman is in labor, the clinical facility must treat and stabilize the patient before transferring to another facility.

82 Fraud and Abuse: Anti-Kickback

83 Scenario You are the Manager of the Orthopedic Clinic that does business with Sun Valley Orthotic and Prosthetic for the necessary devices used to take care of their patients. Once a month Sun Valley s owner has lunch catered from Giuseppe's Pizza at a $75 value to the Ortho department. The Ortho department appreciates Sun Valley s generosity. What do you think about accepting the catered lunch? If it s happening once a month, should there be a concern? 62

84 Anti-Kickback Statute In the Federal Healthcare programs, paying for referrals is a crime. The federal Anti-Kickback Statute ( Anti-Kickback Statute ) is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business. (See 42 U.S.C. 1320a-7b) 63

85 Anti-Kickback Penalties Penalties: Fines Up to $50,000 plus 3 times the amount of the remuneration Jail Time Program Exclusion Kickbacks in health care can lead to: Overutilization Increased program costs Corruption of medical decision-making Patient steering Unfair competition 64

86 From the Office of Inspector General A federal appeals court on Thursday upheld a $237 million False Claims Act verdict against Tuomey Healthcare System in Sumter, S.C. The sum is believed to be the largest ever levied against a community hospital and exceeds the hospital's annual revenue Florida Hospital System Agrees to Pay the Government $85 Million to Settle Allegations of Improper Financial Relationships with Referring Physicians 65

87 Fraud and Abuse: Stark Law

88 Stark Law Prohibits a Physician from referring patients for designated health services to an entity with which the physician (or immediate family member) has a financial relationship. The law also prohibits an entity from presenting a claim from Medicare or to any other person or entity for Designated Health Services provided under a prohibited referral. 67

89 Advanced HIPAA: Working with Contractors and Vendors

90 69

91 Respect of the Patient s Health Information Six main areas to watch out for in PATIENT CARE: 1. TRASH (do not throw away IV bags, stickers, etc. with patient identifiers on them). 2. DISCUSSION WITH PEERS (Dining Room, elevators, home, etc.) 3. FAXES (make sure you verify the number) 4. S 5. SOCIAL NETWORKS 6. MAILING/PROVIDING patients with paperwork related to their care 70

92 Breach and Obligations Where a covered entity knows of a material breach or violation by the business associate of the contract or agreement, the covered entity is required to take reasonable steps to cure the breach or end the violation, and if such steps are unsuccessful, to terminate the contract or arrangement. If termination of the contract or agreement is not feasible, a covered entity is required to report the problem to the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) 71

93 Business Associate Agreements

94 What is a Business Associate? A BA is a person or entity that performs certain functions or activities that involve the use or disclosure of PHI on behalf of, or provides services to a Covered Entity (CE). A member of the CEs workforce is NOT a business associate A CE can be a BA of another CE 73

95 Reporting Allegations: EthicsPoint

96 What is EthicsPoint? EthicsPoint EthicsPoint is confidential reporting tool to assist management and employees to work together to address fraud, abuse, and other misconduct in the workplace, all while cultivating a positive work environment. Why do we need a system like EthicsPoint? We believe that our employees are our most important asset. By creating open channels of communication, we can promote a positive work environment and maximize productivity. An effective reporting system will augment our other efforts to foster a culture of integrity and ethical decision-making. 75

97 EthicsPoint 76

98 MIHS REPORT CARD Implement a Compliance Program (Seven Elements) Risk Management Plan (Risk Assessment) Contract Reviews (including BAAs) Policies and Procedures Reviews Education Training General and Specific Designate a Compliance Officer, Privacy Officer and Information Security Officer Discipline and Corrective Actions Implement an Ethics Line

99 Video not included

100 Let s Do it Again! We Made It! Questions?

101 Questions?

102 MARICOPA INTEGRATED HEALTH SYSTEM Code of Conduct and Ethics 2016 Summary of Approvals Approval Signatures: November 21, 2016 Chairman, Board of Directors Date Maricopa County Special Health Care District November 21, 2016 President and Chief Executive Officer Date Maricopa Integrated Health System November 21, 2016 Chief Compliance Officer Date Maricopa Integrated Health System Board approved 11/21/ P age

103 Code of Conduct and Ethics Revised and Effective November 21, 2016 I. PURPOSE This Code of Conduct and Ethics (Code) has been adopted by the Maricopa County Special Health Care District d/b/a Maricopa Integrated Health System (MIHS) to provide standards by which the MIHS Board of Directors, employees, officers, medical staff and agents will conduct themselves to protect and promote organization-wide integrity and to enhance MIHS s ability to achieve its organizational mission. The Code is intended to serve as a guide to assist MIHS s Board of Directors, employees, officers, medical staff and agents to make sound decisions in carrying out their day to day responsibilities. II. RESPONSIBILITIES UNDER THE CODE OF CONDUCT and ETHICS Who must comply with MIHS s Code of Conduct and Ethics? The Code applies to all members of the Board of Directors, employees, officers, medical staff, agents of MIHS and MIHS s Business Partners. MIHS recognizes the different missions and services that each Business Partner provides in developing policies and procedures to achieve the standards and goals set forth in the Code while maintaining each Business Partners unique mission and services. What are your responsibilities as an MIHS employee with regard to the Code of Conduct and Ethics? Foster and support an atmosphere of compliance by: Reading the Standards of Conduct and Ethics contained in the Code and think about their application to your work. You should have a basic understanding of issues covered by each Standard and the supplemental compliance policies that apply to your job function. Seeking assistance from your supervisor(s), the Administration, the Chief Compliance Officer, the District Counsel or other MIHS leadership resources when you have questions about the application of the standards and other MIHS policies to your work. Understanding the numerous options that MIHS makes available to you for raising conduct or ethical concerns and promptly raise such concerns. You should raise such concerns with your immediate supervisor or MIHS S Chief Compliance Officer or its District Counsel. If you prefer to raise your concerns anonymously, call the MIHS Compliance Hotline Line MIHS (6447) and/or you can file a concern on the MIHS website under Report a Compliance Concern. Cooperating in MIHS s investigations concerning potential violations of law, government payer regulations and rules, the Code, the MIHS Compliance Program and MIHS s policies and procedures. Completing all required compliance training. Board approved 11/21/ P age

104 What are your responsibilities as MIHS s officers, managers and other supervisors? Build and maintain a culture of compliance by: Leading by example, using your own behavior as a model for all employees. Knowing, understanding and following the statutes, rules and regulations that govern your area(s) of responsibility. Encouraging employees to raise conduct and ethical questions and concerns. Ensuring that all employees, volunteers and contractors complete all required compliance training. Prevent compliance problems by: Identifying potential compliance risks and proposing appropriate policies, procedures and actions to address such risks. Identifying employees whose activities involve issues covered by MIHS s policies and procedures. Providing education and counseling to assist employees to understand the Code, MIHS policies and procedures and applicable law, and government payer regulations and rules. Detect compliance problems by: Maintain appropriate controls to monitor compliance and mechanisms that foster the effective reporting of potential compliance issues. Promoting an environment that permits employees to raise concerns without fear of retaliation. Arranging periodic compliance reviews that are conducted with the assistance of the MIHS Chief Compliance Officer to assess the effectiveness of MIHS s compliance measures and to identify methods of improving them. Respond to compliance problems by: Pursuing prompt corrective action to address weaknesses in compliance issues. Applying corrective action(s) and disciplinary plans when necessary. Consulting with MIHS s Chief Compliance Officer so that compliance issues are promptly and effectively addressed. Board approved 11/21/ P age

105 What are your responsibilities as MIHS s Board of Directors? Build and maintain a culture of compliance by: Reading the Standards of Conduct and Ethics contained in the Code, thinking about them and their application to your work. Leading by example, using your own behavior as a model for others. Making decisions that are in the best interest of MIHS and that are not affected by conflicts of interest. Being knowledgeable about the MIHS Compliance Program and exercise governance and oversight over it. Requiring appropriate reports from management concerning the status of the MIHS Compliance Program, the resources required to maintain its vitality and MIHS s response to identified compliance deficiencies. Receiving and acting on compliance issues, upon advice from management, including MIHS s Chief Executive Officer, District Counsel, and Chief Compliance Officer. Assuring that the Compliance Program is free from undue restraints and influences through direct reporting by the Chief Compliance Officer to the Board of Directors regarding compliance issues that promote the integrity of the Compliance Program and raising any concerns with the Chief Compliance Officer or the District Counsel. Maintaining the confidentiality of all compliance-related information provided to them, subject to the requirements of applicable law. Complete required compliance training. What are your responsibilities as medical staff? Assist MIHS to foster an atmosphere of compliance by: Reading the Standards of Conduct and Ethics contained in the Code and think about their application to your work. You should have an understanding of issues covered by each Standard and the supplemental compliance policies that apply to the services you furnish to MIHS and our patients. Actively participating in compliance activities as requested by MIHS s administration. Maintaining the confidentiality of information provided to you relating to compliance issues. Assisting MIHS in identifying possible compliance issues and in developing possible solutions to address those issues. Board approved 11/21/ P age

106 Understanding the various options that MIHS makes available for raising conduct or ethical concerns and promptly raise such concerns. You should raise such concerns with MIHS S Chief Compliance Officer or District Counsel. If you prefer to raise your concerns anonymously, call the MIHS Compliance Hotline MIHS (6447) and/or you can file a concern on the MIHS website under Report a Compliance Concern. Cooperating in MIHS investigations concerning potential violations of law, MIHS s Code of Conduct and Ethics, the MIHS Compliance Program and MIHS s policies and procedures. Completing required compliance training. What are your responsibilities as agents? Agents are responsible to participate in the MIHS compliance program by: Understanding and applying the Standards of Conduct and Ethics contained in the Code and think about their application to the services you furnish to MIHS. You should have an understanding of issues covered by each standard and the supplemental compliance policies that apply to the services you furnish to MIHS. Actively participating in compliance activities, such as education and training, as requested by MIHS. Understanding the various options that MIHS makes available for raising conduct or ethical concerns and promptly raise such concerns. You should raise such concerns with MIHS S Compliance Officer or District Counsel. If you prefer to raise your concerns anonymously, call the MIHS Compliance Hotline MIHS (6447) and/or you can file a concern on the MIHS website under Report a Compliance Concern. Cooperating in MIHS investigations concerning potential violations of law, the MIHS Code of Conduct and Ethics, the MIHS Compliance Program and MIHS policies and procedures. Completing required compliance training. How May the Code of Conduct and Ethics Be Revised? This Code may be amended, modified or waived only after a review by the Chief Executive Officer and the approval of the Board of Directors. How Frequently will the Compliance Program Be Reviewed? The Compliance Program (including the Code of Conduct and Ethics) will be reviewed annually by the Finance, Audit & Compliance Committee to foster its effectiveness and at such times when changes to it are necessitated by changes in laws and regulations applicable to MIHS. Suggested changes to the MIHS Compliance Program will be presented to the Board of Directors for approval. 5 Page Board approved 11/21/2016

107 III. STANDARDS OF CONDUCT AND ETHICS 1. Patient Relationships: We are committed to providing a high quality of healthcare and services to our patients, their families, visitors and the community. We treat all patients with respect and dignity and provide care that is necessary and appropriate. Principles: * We will recognize the right of our patients to receive quality and appropriate services provided by competent individuals in an efficient, cost effective and safe manner. * We will continually monitor the clinical quality of the services we provide and will endeavor to improve the quality of the services provided. * We will support every patient s right to be free from all types of abuse, and will not tolerate patient abuse in any form. * We will apply our admission, treatment, transfer and discharge policies equally to all patients based upon identified patient needs and regardless of a patient s ability to pay. * We will listen to our patients, families and visitors to understand any concerns or complaints and will involve patients in the decision-making process about their care. * We will demonstrate our commitment to patient safety by continuously reviewing systems, processes and policies to detect and prevent medical errors. * We will provide treatment and medical services without discrimination based on race, color, religion, sex, sexual orientation, national origin, marital status, political belief, age, veteran status or disability. * We will remain sensitive to our position as a regional leader in tertiary and specialty care and research, and to our consequent obligation as a health care leader to all segments of our community. - We will maintain policies and procedures to complete emergency assessments as required for all who request our emergency, trauma, or burn services. - We will fully and fairly evaluate requests to transfer patients to our care from our colleagues and providers in outlying areas, and will accept such transfers as clinically appropriate. * We will maintain licensure and credentialing standards to further the provision of Board approved 11/21/ P age

108 clinical services by properly trained and experienced practitioners. * We will perform background checks of potential employees, medical staff members, contractors and consultants to verify credentials and to assess whether such individuals and entities have ever been excluded from participation in any of the federal or state health care programs, including the Medicare, Medicaid, and AHCCCS programs. * We will respect the privacy of our patients, and we will treat all patient information with confidentiality, in accordance with all applicable laws, regulations and professional standards. 2. General Legal and Regulatory Compliance: MIHS will continuously and vigorously promote full compliance with applicable laws. Principles: * We will continuously study our legal obligations and create policies and procedures that facilitate compliance by our Board of Directors, employees, officers, medical staff and agents with such legal obligations. * We will recognize the critical role of research in improving the health status of our community, and we are committed to conducting all research activities in compliance with the highest ethical, moral, and legal standards. * We will engage in open and fair competition and marketing practices, based on the needs of our community and consistent with the furtherance of our mission. * We will treat our employees with respect, and will engage in human relations practices that promote the personal and professional advancement of each employee. * We will recognize that our employees work in a variety of situations and with a variety of materials, some of which may pose a risk of injury. We are committed to providing a safe work environment, and will maintain and monitor policies and procedures for workplace safety that are designed to comply with federal and state safety laws, regulations, and workplace safety directives. * We will recognize that the provision of health care may in some instances produce hazardous waste products or other risks involving environmental impact. We are committed to compliance with applicable environmental laws and regulations, and will follow proper procedures with respect to handling and disposing of hazardous and bio-hazardous waste. * We will expect our Board of Directors, employees, officers, medical staff and agents to understand the basic legal obligations that pertain to their individual Board approved 11/21/ P age

109 job functions or services they furnish to MIHS and our patients, and will require that they strive to make certain that their decisions and actions are conducted in conformity with such laws, regulations, policies and procedures. * We will support educational and other training sessions to teach MIHS s Board of Directors, employees, officers, and as warranted medical staff and agents, about the impact of the law on their duties and to promote compliance with our collective legal obligations. * We will support and maintain multiple resources for MIHS s Board of Directors, employees, officers, medical staff and agents to voice any questions about the proper interpretation of a particular law, regulation, policy or procedure. 3. Avoidance of Conflicts of Interest: MIHS s Board of Directors, employees, officers, medical staff, and agents maintain a duty of loyalty to MIHS and to all of the citizens of Maricopa County and, as a result, must avoid any activities that may involve (or may appear to involve) a conflict of interest or that may influence or appear to influence the ability of the Board of Director s member, employee, officer, medical staff member or agent to render objective decisions in the course of their job responsibilities, or other services they furnish to MIHS. Principles: Board approved 11/21/2016 * We will maintain policies and procedures that make clear when an individual s private interests may inappropriately interfere with MIHS s interests; and will provide support through which MIHS s Board of Directors, employees, officers, medical staff and agents may pose questions about whether a particular activity or relationship could be construed as a conflict of interest or otherwise improper. * We will articulate expectations of the conduct that must be demonstrated by MIHS s Board of Directors, employees, officers, medical staff and agents in the performance of services for MIHS, and will require that such individuals remain free of conflicts of interest in the performance of their responsibilities and services to MIHS. * The MIHS Conflicts of Interest and Gift Policy, establishes the policy and procedure for MIHS s, Board of Directors, employees, officers, medical staff and agents to evaluate, analyze, and properly remediate potential and apparent conflicts of interest. * We will require MIHS s Board of Directors, employees, officers, medical staff and agents to inform MIHS of personal business ventures and other arrangements that could be perceived as conflicts of interest and will provide for policies and procedures for doing so. * We will not permit MIHS s Board of Directors, employees, officers, medical staff or agents to use any proprietary or non-public information acquired as a 8 P age

110 Board approved 11/21/2016 result of a relationship with MIHS for person gain or for the benefit of another business opportunity. * We will render decisions about the purchase of outside services and goods based on the supplier s ability to best satisfy MIHS s needs and not based on personal relationships. * MIHS Board of Directors, officers and employees shall not use their official position for personal gain. Public influence and confidential or inside information must never be used for personal advantage. Conflict of interest laws, A.R.S et. seq. must be scrupulously observed. The conflict of interest laws prohibit participation by public officers, elected officials, or employees in a decision or contract in which they have a direct or indirect pecuniary or proprietary interest. 4. Relationship with Payers: MIHS will consistently strive to satisfy the conditions of payment required by the payers with which MIHS transacts business. * We will promote compliance with laws governing the submission and review of bills for our services and will deal with billing inquiries in an honest and forthright manner. * We will maintain reasonable measures to prevent the submission or filing of inaccurate, false or fraudulent claims to payers. * We will utilize systematic methods for analyzing the payments we receive and will reconcile inaccurate payments in a timely manner after discovery and review. * When warranted, we will investigate potential or reported inaccurate billings and payments to determine whether changes to current protocol or other remedial steps are necessary. * We will maintain documentation systems sufficient to create and maintain complete and accurate documentation of services provided. * We will review cost reports to be filed with the federal and state health care programs to determine whether such reports accurately and completely reflect the operations and services provided to beneficiaries and to confirm that such reports are completed in accordance with applicable federal and state regulations and MIHS s policies and procedures. * We will, as necessary, rely on internal and external sources to help improve MIHS s billing and coding protocol and to identify potential areas of noncompliance. * We will compensate billing and coding staff and consultants for services rendered, in a manner that is permitted under law and will not compensate such persons in any way related to collections or maximization of revenues. 9 Page

111 5. Relationship with Physicians and Other Providers: MIHS will monitor its business dealings to structure relationships in ways that satisfy the needs of the community. * We will maintain relationships with physicians and other referral sources based only on the needs of our community and consistent with our mission. * We will treat referral sources fairly and consistently, and will not provide remuneration that could be considered payment for referrals, including: Free or below-market rents; Administrative or staff services at no- or belowcost; Grants in excess of amounts for bona fide research or other services rendered; Interest-free loans; or Gifts, perks or other payments intended to induce referrals. * We will maintain policies, procedures and other protocol which require fair market value determinations for services rendered by referral sources and for services rendered by MIHS. * We will maintain procedures to require all agreements with referral sources to be reduced to writing and reviewed and approved as appropriate under law and MIHS s policies and procedures. * We will train the appropriate personnel on the primary laws and regulations governing the referral of patients and other legal restrictions on the manner in which MIHS transacts business, including the penalties that may result for violations of such laws. 6. Respect for Our Culture: We recognize that a diverse workforce enriches the life experience of all employees and our community, and will promote diversity consistent with MIHS s Diversity Plan. * We will provide equal employment opportunities to employees and applicants for employment without regard to race, color, religion, sex, sexual orientation, national origin, marital status, political belief, age, veteran status, or disability, in accordance with applicable law. Board approved 11/21/2016 * We will maintain policies and procedures that promote compliance with laws governing nondiscrimination in personnel actions, including recruiting, hiring, training, evaluation, transfer, workforce reduction, termination, compensation, 10 P age

112 Board approved 11/21/2016 counseling, discipline, and promotion of employees. * We will promote diversity with respect to individuals with disabilities, and will make reasonable accommodations to any individual as required by law. * We will recognize the right of our employees to a workplace free of violence and harassment, and will not tolerate any form of harassment or violence toward our employees. * We will maintain policies and procedures that promote appropriate conduct in the workplace and prohibit unwanted or hostile interaction, including degrading or humiliating jokes, physical or verbal intimidation, slurs, or other harassing conduct. * We will not tolerate any form of sexual harassment, either overt, such as request for sexual favors in return for promotions, or less obvious forms of harassment, such as sexual comments. * We will maintain policies and procedures prohibiting workplace violence, including robbery, stalking, assault, terrorism, hate crimes, or violence directed at supervisors. * We will maintain policies, procedures, and practices prohibiting retaliation in any form for reporting. 7. Information Systems: We recognize that the provision of healthcare services generates business, financial, and patient-related information that requires special protection. We will establish systems that ensure such information is used appropriately and safeguarded zealously. * We are committed to the security and integrity of documents and records in our possession, and will develop systems, policies and procedures sufficient to safeguard the security and integrity of our documents and records, including systems, policies and procedures to: - Establish retention periods and protocols for business, financial, and patient records in the MIHS system. - Prevent the altering, removal, or destruction of records or documents except according to our records retention policy and applicable ethical and legal standards. - Promote the accurate, thorough, detailed, and complete documentation of all business, financial, and patient transactions. - Control and monitor access to MIHS s communications systems, electronic mail, internet access, and voic to ensure that such systems are accessed appropriately and used in accordance with MIHS s policies and procedures. 11 Page

113 - Protect the privacy and security of patient medical, billing, and claims information by maintaining sufficient physical, systemic, and administrative measures to prevent unauthorized access to or use of patient information, and to track disclosures of such information as required by law. - Provide access to medical, billing, and claims information for our patients and their legal representatives as required by law. - Safeguard the personal and human resources information of our employees, including salary, benefits, medical, and other information retained within the human resources system as required by law. IV. VIOLATIONS OF THE CODE OF CONDUCT AND ETHICS MIHS is committed to providing the Board of Directors, employees, officers, medical staff and agents with a means of raising questions and concerns, and reporting any conduct that the Board member, employee, officer, medical staff member or agent suspects is in violation of this Code. Board members, employees, officers, medical staff and agents are expected and required to communicate any suspected, detected or reported violations of the Code to a direct supervisor, the Chief Compliance Officer or the District Counsel, as applicable. If you prefer, you can anonymously call the MIHS Compliance Hotline MIHS (6447) and/or you can file a concern on the MIHS website under Report a Compliance Concern. The Chief Compliance Officer will maintain primary responsibility for investigating reports received on this hotline. The following list, while not exhaustive, describes the type of concerns and questions that you should raise with your supervisor, the Chief Compliance Officer, the District Counsel or through the MIHS Compliance Hotline: Allegations, discrimination or retaliation. The possible submission of false, inaccurate or questionable claims to Medicare, Medicaid, AHCCCS or any other payer. The provision or acceptance of payments, discounts or gifts in exchange for referrals of patients. The utilization of improper physician recruitment techniques under applicable law. Situations that could raise conflict-of- interest concerns. Potential breaches of confidentiality or privacy. Board approved 11/21/ P age

114 PERSONAL COMMITMENT AND CERTIFICATION I acknowledge and certify that I have received and read the Maricopa County Special Health Care District s Code of Conduct and Ethics and I understand my obligations to comply with the Code. I agree to comply with the Maricopa County Special Health Care District s Code of Conduct and Ethics. Initials: Board of Directors: I understand that compliance with this Code is essential to my service on the Board of Directors of the Maricopa County Special Health Care District. Initials: Initials: Initials: Employees and Officers: I understand that compliance with this Code is a condition of my continued employment. I further understand that violation of the Code of Conduct and Ethics may result in disciplinary action up to and including termination. Medical Staff: I understand that compliance with this Code is a condition to my ability to practice my profession at MIHS. I further understand that violation of the Code of Conduct and Ethics may result in disciplinary action as provided in the Bylaws of the Medical Staff. Agents: I understand that compliance with this Code is a condition of my continued ability to furnish services to MIHS. I further understand that violation of the Code of Conduct and Ethics may result in a termination by MIHS of any relationship I have with MIHS. Please sign here: Please print your name: Date: Dept. Board approved 11/21/ P age

115 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 5 MHCGC CEO s Report (No Handout)

116 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 6a MHCGC Committee Reports Finance Committee

117 MARICOPA INTEGRATED HEALTH SYSTEM FEDERALLY QUALIFIED HEALTH CENTERS LOOK-ALIKE FINANCIAL STATEMENT HIGHLIGHTS For the month ending December 31, 2016 OPERATING REVENUE (a) Visits Actual Budget Variance %Variance Month-to-Date 23,061 28,060 (4,999) -17.8% Year-to-Date 149, ,894 (21,844) -12.8% Visits were below budget for the month by 4,999 (17.8%) and 21,844 (12.8%) Year to date. Visits were also below prior month by 1,463 (6.0%). The FHC's and CHC Clinics are all below budget both MTD and YTD. The Walk in Clinic is above budget for the month, but remains below budget YTD. The Dental Clinics are above budget MTD and YTD. The WHH South Central site closed 7/29/2016, earlier than budgeted. (b) Net Patient Service Revenue Actual Budget Variance %Variance Month-to-Date $ 4,076,511 $ 5,254,706 $ (1,178,195) -22.4% Year-to-Date $ 28,589,948 $ 31,748,640 $ (3,158,692) -9.9% Month-to-Date Per Visit $ 177 $ 187 $ (10) -5.6% Year-to-Date Per Visit $ 192 $ 186 $ 6 3.2% Net patient service revenue is below budget for both the month by $1.2M and $3.2M YTD. On a per visit basis, MTD Net patient service revenue is below budget but it remains above budget on a YTD basis. The FHC's and CHC Clinics are all below budget both MTD and YTD. The Walk in Clinic is below budget for the month, but remains above budget YTD. The Dental Clinics are above budget MTD and YTD. (c) PCMH Revenue Actual Budget Variance %Variance Month-to-Date $ 106,399 $ 75,000 $ 31, % Year-to-Date $ 492,206 $ 450,000 $ 42, % Patient Centered Medical Home Revenue is above budget for both the month by $31.4K and $42.2K YTD. (d) Total operating revenues Actual Budget Variance %Variance Month-to-Date $ 4,182,910 $ 5,329,706 $ (1,146,796) -21.5% Year-to-Date $ 29,082,154 $ 32,198,640 $ (3,116,487) -9.7% Month-to-Date Per Visit $ 181 $ 190 $ (9) -4.5% Year-to-Date Per Visit $ 195 $ 188 $ 7 3.6% Total operating revenue is below budget for both the month by $1.1M and $3.1M YTD. budget but it remains above budget on a YTD basis. On a per visit basis, MTD Net patient service revenue is below OPERATING EXPENSES (e) Salaries and Wages Actual Budget Variance %Variance Month-to-Date $ 1,613,004 $ 1,815,563 $ 202, % Year-to-Date $ 9,836,804 $ 10,805,424 $ 968, % Month-to-Date FTEs % Year-to-Date FTEs % Salaries and wages were below budget by $202.6K MTD and $968.6K YTD. FTEs were below budget by 52 MTD and 41 YTD. The Average Salaries and wages per FTE were up compared to the previous month by $ (g) Employee Benefits Actual Budget Variance %Variance Month-to-Date $ 608,511 $ 724,035 $ 115, % Year-to-Date $ 3,374,246 $ 3,814,648 $ 440, % Month-to-Date Per FTE $ 1,938 $ 1,979 $ % Year-to-Date Per FTE $ 10,366 $ 10,396 $ % Employee Benefits were below budget by $115.5K MTD and $440.4K YTD. Most of these benefits are lower due to FTE's being lower than budget. Benefits as a % of Salaries Actual Budget Variance %Variance Month-to-Date 37.7% 39.9% 2.2% 5.4% Year-to-Date 34.3% 35.3% 1.0% 2.8%

118 MARICOPA INTEGRATED HEALTH SYSTEM FEDERALLY QUALIFIED HEALTH CENTERS LOOK-ALIKE FINANCIAL STATEMENT HIGHLIGHTS For the month ending December 31, 2016 OPERATING EXPENSES (continued) (h) Medical Service Fees Actual Budget Variance %Variance Month-to-Date $ 1,318,200 $ 1,573,463 $ 255, % Year-to-Date $ 8,157,173 $ 9,450,482 $ 1,293, % Medical Service Fees were under budget for the month by $255.3K MTD and YTD by $1.3M. (i) Supplies Actual Budget Variance %Variance Month-to-Date $ 221,411 $ 228,213 $ 6, % Year-to-Date $ 1,312,072 $ 1,379,816 $ 67, % Month-to-Date Supplies per Visit $ 9.60 $ 8.13 $ (1.47) -18.0% Year-to-Date Supplies per Visit $ 8.80 $ 8.07 $ (0.73) -9.0% Supplies expense was below budget by $6.8K MTD and $67.7K YTD. Office Supplies $51.5K YTD, Non Chargeable - Medical Supplies $20.1K YTD (j) Purchased Services Actual Budget Variance %Variance Month-to-Date $ 15,520 $ 19,395 $ 3, % Year-to-Date $ 114,584 $ 114,999 $ % Purchased services were below budget by $3.9K MTD and $1.0K YTD. (k) Other Expenses Actual Budget Variance %Variance Month-to-Date $ 144,143 $ 150,774 $ 6, % Year-to-Date $ 896,153 $ 922,928 $ 26, % For the month, other expenses were below budget by $6.6K MTD and $26.7K YTD. (l) Interest Expenses Actual Budget Variance %Variance Month-to-Date $ 1,624 $ 1,624 $ - 0.0% Year-to-Date $ 10,811 $ 10,811 $ - 0.0% Interest Expenses are on track with budget. (m) Allocated Ancillary Expense Actual Budget Variance %Variance Month-to-Date $ 362,640 $ 484,228 $ 121, % Year-to-Date $ 2,250,646 $ 2,857,535 $ 606, % Allocated ancillary expenses were below budget by $125.8K MTD and $611.1K YTD. Lab Gross Revenue continues to be lower than budgeted and therefore the lab expenses are lower than budget. (n) Total operating expenses Actual Budget Variance %Variance Month-to-Date $ 4,297,732 $ 5,004,702 $ 706, % Year-to-Date $ 26,003,676 $ 29,400,663 $ 3,396, % Month-to-Date Per Visit $ $ $ (8) -4.5% Year-to-Date Per Visit $ $ $ (2) -1.4% Total operating expenses were below budget by $711.2K MTD and $3.4M YTD. On a per visit basis, the current month was 4.4% unfavorable and YTD is unfavorable by 1.4%. (o) Margin (before overhead allocation) Actual Budget Variance %Variance Month-to-Date $ (114,823) $ 325,003 $ (439,826) % Year-to-Date $ 3,078,478 $ 2,797,977 $ 280, % Month-to-Date Per Visit $ (4.98) $ $ (17) % Year-to-Date Per Visit $ $ $ % Total margin (before overhead allocation) is below budget by $440.0K MTD, but remains above budget YTD by $280.5K. The majority of the YTD variance is due to lower than budgeted expenses.

119 Maricopa Health Centers Governing Council Meeting February 1, 2017 Item 6b MHCGC Committee Reports Strategic Planning & Outreach Committee

120 Glendale Family Health & Resource Fair Saturday, November 12,

121 Glendale Family Health & Resource Fair Overall Event Summary/Results 315 families served Over 1,000 people attended the event 48 community partners participated 265 turkey gift cards distributed 3

122 Glendale Family Health & Resource Fair MIHS Event Summary/Results Eligibility Specialists 26 AHCCCS eligibility appointments made 34 Family Health Clinic appointments made Cholesterol Screenings 72 Glucose Screenings Blood Pressure Screenings 108 BMI/Height & Weight 79 4

123 Glendale Family Health & Resource Fair MIHS Event Summary/Results Pharmacist Consultations 230 MIHS Information Table Over 500 visits MIHS maps, programs/services collateral Dental Screenings adults (71% require further dental work) 30 children (60% require further work) 5

124 Community Outreach Planned Activities First Quarter, 2017 Community Event Medical Date Estimated Attendance Screenings Regional Collaboration Meeting N/A 1/3/17 5 Mesa Community Action Meeting N/A 1/11/17 20 Regional Collaboration Meeting N/A 1/17/17 5 City of Buckeye Networking Meeting N/A 1/19/17 25 Guadalupe Community Partnership N/A 1/19/17 20 Alhambra Family Resource Center Open House No 1/19/ Junior League of Phoenix s HealthFest Yes 1/21/17 2,000 Pendergast School District Kindergarten N/A 1/23/17 20 Readiness Organizing Meeting City of El Mirage Public Safety Day Yes 1/28/ City of Buckeye Networking Meeting N/A 2/15/17 25 Guadalupe Community Partnership Meeting N/A 2/16/17 20 City of Chandler Preschool Expo Yes 2/25/ Pendergast School District Kindergarten Unsure 3/1/17 1,000 Readiness Event City of Buckeye Networking Meeting N/A 3/15/17 25 Guadalupe Family Partnership N/A 3/16/17 20 Phoenix Family Health and Resource Fair Yes 3/25/17 2,000 Total Anticipated Attendance 6,285 Attendees 6

125 Flyer English and Spanish 7

126 Family Learning Centers & Family Health Center Locations 1. El Mirage Family Health Center W Thunderbird Rd, El Mirage, AZ (623) elmiragefamilyhealthcenter.org Maricopa Integrated Health System El Mirage 2 Glendale 2. Sunnyslope Family Health Center 934 W Hatcher Rd, Phoenix, AZ (602) sunnyslopefamilyhealthcenter.org 3. Glendale Family Health Center 5141 W Lamar Rd, Glendale, AZ (623) glendalefamilyhealthcenter.org Family Learning Centers Phoenix Avondale Maryvale Family Health Center/ Maryvale Family Learning Center 4011 N 51st Ave, Phoenix, AZ (623) maryvalefamilyhealthcenter.org 7. South Central Family Health Center/ South Center Family Learning Center 33 W Tamarisk St, Phoenix, AZ (602) southcentralfamilyhealthcenter.org 8. Avondale Family Health Center 950 E Van Buren St, Avondale, AZ (623) avondalefamilyhealthcenter.org 9. Guadalupe Family Health Center 5825 Calle Guadalupe, Guadalupe, AZ (480) guadalupefamilyhealthcenter.org 10. Mesa Family Health Center 59 S Hibbert, Mesa, AZ (480) mesafamilyhealthcenter.org 10 Mesa Tempe 9 Gilbert Guadalupe 5. McDowell Healthcare Center 1101 North Central Ave, Phoenix, AZ (602) MIHS.org/mcdowell 6. 7th Avenue Family Health Center 1205 S 7th Ave, Phoenix, AZ (602) thavenuefamilyhealthcenter.org January - March Enero - Marzo 2017 Scottsdale 3 11 Chandler Maryvale FLC South Central FLC Chandler FLC 11. Chandler Family Health Center/ Chandler Family Learning Center 811 S Hamilton St, Chandler, AZ (480) chandlerfamilyhealthcenter.org 12. Comprehensive Healthcare Center/ CHC Family Learning Center 2525 East Roosevelt Street, Phoenix, AZ (602) MIHS.org/chc 13. Maricopa Medical Center 2601 East Roosevelt Street, Phoenix, AZ (602) MIHS.org CHC Others 14. Desert Vista Behavioral Health 570 West Brown Road, Mesa, AZ (480) MIHS.org/centers/behavioral-health 15. Maricopa Medical Center Behavioral Health Annex 2619 East Pierce Street, Phoenix, Arizona Pendergast Family Health Center W. Mariposa St., Ste 1, Phoenix, Arizona pendergastfamilyhealthcenter.org /Correo electrónico: flc@mihs.org Website/Sitio de internet: mihs.org/flc Happy New Year! Thank you for all the support you provided our four Family Learning Centers during It was great to have you and your family participate and attend our events and classes. Whatever your goals are for this year, the Family Learning Centers are here to help you. Here are some tips to reach 2017 goals: Be patient with yourself - Remember that most goals worth reaching require time. Write down your goals - Knowing exactly what you want to achieve keeps you motivated until you get there. Team up - Work with someone to hold you accountable. The more you are reminded of your goals daily, the more likely you are motivated to achieve them. Celebrate your achievements - Every step towards achieving your goal is important and should be celebrated. Do something for yourself that will help you stay positive to reach your next goal. Feliz Año Nuevo Gracias por todo su apoyo a nuestros cuatro Family Learning Centers en Fue un gusto contar con usted y con su familia para participar y asistir a nuestros eventos y clases. Sin importar cuáles sean sus metas para este año, los Family Learning Centers están aquí para ayudarle. Aquí hay algunas recomendaciones para que alcance sus metas de Haga equipo con alguien - Trabaje con alguien que le ayude a hacerse responsable. Mientras más se le recuerden sus metas todos los días, más probabilidad tiene de mantenerse motivado para alcanzarlas. Celebre sus logros - Cada paso hacia lograr su meta es importante y debe celebrarse. Haga algo por usted mismo que le ayude a continuar con una actitud positiva para alcanzar su siguiente meta. Presorted Standard US Postage PAID Phoenix, AZ PI 1884 Escriba sus metas - Saber exactamente lo que quiere lograr, le ayuda a mantenerse motivado hasta que lo logre. Maricopa Integrated Health System Family Learning Center 2601 E Roosevelt Street Phoenix, AZ Sea paciente con usted mismo - Recuerde que la mayoría de las metas que valen la pena alcanzar requieren de tiempo.