Minutes of the Meeting of the Board of Directors of the Cook County Health and Hospitals System (CCHHS) held Friday, April 29, 2016 at the hour of 9:00 A.M. at 1900 West Polk Street, in the Second Floor Conference Room, Chicago, Illinois. I. Attendance/Call to Order Chairman Hammock called the meeting to order. Present: Chairman M. Hill Hammock, Vice Chairman Hon. Jerry Butler and Directors Ric Estrada, Ada Mary Gugenheim; Emilie N. Junge; Wayne M. Lerner, DPH, LFACHE; Erica E. Marsh, MD, MSCI; Mary B. Richardson-Lowry; Carmen Velasquez; and Dorene P. Wiese (10) Absent: None (0) Additional attendees and/or presenters were: Ekerete Akpan Chief Financial Officer Elaine Lockwood Bean Cook County Bureau of Asset Management Cathy Bodnar Chief Corporate Compliance and Privacy Officer Debra Carey Chief Operating Officer, Ambulatory Services Krishna Das, MD Chief Quality Officer Karen Duncan, MD Interim Chief Operating Officer, Hospital Based Services Hon. Richard J. Durbin United States Senator Douglas Elwell Deputy CEO of Finance and Strategy Claudia Fegan, MD Executive Medical Director/Medical Director-Stroger Steven Glass Executive Director of Managed Care Gladys Lopez Chief of Human Resources Jeff McCutchan Interim General Counsel Deborah Santana Secretary to the Board Richard H. Sewell - Associate Dean, Community and Public Health Practice at UIC School of Public Health John Jay Shannon, MD Chief Executive Officer Agnes Therady Executive Director of Nursing II. Employee Recognition Dr. John Jay Shannon, Chief Executive Officer, recognized employees for outstanding achievements. Details and further information is included in Attachment #9 - Report from the Chief Executive Officer. III. Board Resolutions A. Proposed Resolutions honoring Lewis M. Collens and Marjorie Collens (Attachment #1) Chairman Hammock stated that there are two (2) proposed Resolutions presented for the Board s approval today. The first Resolution is to recognize former Director Lew Collens valuable service to this Board. The second Resolution is to recognize the memory of Lew s wife, Marge Collens, who passed away suddenly and unexpectedly in December. Marge in her own right was an elected official; she served in many different capacities and provided a great deal of service to the community of Cook County and the larger community. Lew could not be present this morning due to some scheduling issues, but Chairman Hammock shared with him this body s desire to recognize his work on this Board, and to recognize his wife for her many contributions to the community. Director Lerner, seconded by Director Velasquez, moved the approval of the two (2) Resolutions honoring Lewis M. Collens and Marjorie Collens. THE MOTION CARRIED UNANIMOUSLY. Page 1 of 97
Minutes of the Meeting of the CCHHS Board of Directors Friday, April 29, 2016 Page 2 IV. Public Speakers Chairman Hammock asked the Secretary to call upon the registered public speakers. The Secretary called upon the following registered public speakers: 1. Dr. Marjorie Fujara Physician, John H. Stroger, Jr. Hospital of Cook County 2. George Blakemore Concerned Citizen V. Board and Committee Reports A. Minutes of the Board of Directors Meeting, March 25, 2016 Director Lerner, seconded by Director Velasquez, moved the approval of the Minutes of the Board of Directors Meeting of March 25, 2016. THE MOTION CARRIED UNANIMOUSLY. B. Quality and Patient Safety Committee Meeting, April 19, 2016 i. Metrics (Attachment #2) ii. Meeting Minutes, which include the following action items: Approval of Medical Staff Appointments/Reappointments/Changes Approval of proposed clinical training affiliation agreements Director Gugenheim presented the Meeting Minutes and reviewed the metrics with Dr. Krishna Das, Chief Quality Officer. The Board reviewed and discussed the information. Director Gugenheim, seconded by Director Lerner, moved the approval of the Minutes of the Quality and Patient Safety Committee Meeting of April 19, 2016. THE MOTION CARRIED UNANIMOUSLY. C. Audit and Compliance Committee Meeting, April 21, 2016 i. Metrics (Attachment #3) ii. Meeting Minutes Director Velasquez presented the Meeting Minutes and reviewed the metrics with Cathy Bodnar, Chief Corporate Compliance and Privacy Officer. The Board reviewed and discussed the information. Director Velasquez, seconded by Director Lerner, moved the approval of the Minutes of the Audit and Compliance Committee Meeting of April 21, 2016. THE MOTION CARRIED UNANIMOUSLY. Page 2 of 97
Minutes of the Meeting of the CCHHS Board of Directors Friday, April 29, 2016 Page 3 V. Board and Committee Reports (continued) D. Human Resources Committee Meeting, April 22, 2016 i. Metrics (Attachment #4) ii. Meeting Minutes Director Wiese presented the Meeting Minutes and reviewed the metrics with Gladys Lopez, Chief of Human Resources. The Board reviewed and discussed the information. Director Wiese, seconded by Vice Chairman Butler, moved the approval of the Minutes of the Human Resources Committee Meeting of April 22, 2016. THE MOTION CARRIED UNANIMOUSLY. E. Finance Committee Meeting, April 22, 2016 i. Metrics (Attachment #5) ii. Meeting Minutes, which include the following action items: Contracts and Procurement Items (detail was provided as an attachment to this Agenda) Director Estrada provided an overview of the Meeting Minutes, and Douglas Elwell, Deputy CEO of Finance and Strategy, reviewed the metrics and contractual requests that were considered at the Finance Committee Meeting. The Board reviewed and discussed the information. It was noted that request numbers 6 and 8 remain pending review by Contract Compliance; it was also mentioned that request numbers 9 and 16 were withdrawn at the Finance Committee Meeting. Elaine Lockwood Bean, Chief of the Cook County Bureau of Asset Management, provided additional information regarding request number 5, which was a request to amend, extend and increase the contract with Clayco, Incorporated, for development team services relating to the Central Campus Redevelopment. She stated that, with regard to controlling cost overruns, this project is being done a little differently from the traditional design/bid/build process. For this project, the County contracted with a design builder. The benefit of that is that the builder is at the table during the design process, so they are a part of the team; any issues they might have are being resolved in the beginning. In addition to that, the County has hired an independent cost estimator, so every time a budget is received at all of the milestones, the independent cost estimator reviews each and every detailed cost. Although cost overruns are not anticipated, should there be any issues with that, they will be reported back to this body. Director Junge, seconded by Vice Chairman Butler, moved the approval of the Minutes of the Meeting of the Finance Committee of April 22, 2016. THE MOTION CARRIED UNANIMOUSLY. F. Managed Care Committee i. Metrics (Attachment #6) Director Lerner reviewed the Metrics with Steven Glass, Executive Director of Managed Care. The Board reviewed and discussed the information. Page 3 of 97
Minutes of the Meeting of the CCHHS Board of Directors Friday, April 29, 2016 Page 4 VI. Action Items A. Contracts and Procurement Items There were no Contracts and Procurement Items presented directly for the Board s consideration. B. Appointment of Stroger Hospital Department Chair(s) and Division Chair(s) (Attachment #7) Director Gugenheim, seconded by Director Wiese, moved the approval of the proposed Stroger Hospital Department and Division Chair appointments. THE MOTION CARRIED UNANIMOUSLY. C. Any items listed under Sections III, V, VI and X VII. Report from Chairman of the Board A. Quarterly report Board and Committee topics calendar (May-July 2016) (deferred) Chairman Hammock stated that Vice Chairman and Commissioner Jerry Butler was recently recognized by Modern Healthcare magazine for his thirty (30) years of service in the healthcare industry. Vice Chairman Butler has served in many capacities and in many ways; this Board appreciates his contributions and continued service. During the meeting, the Board welcomed United States Senator Richard J. Durbin, who was in the area participating in a roundtable discussion with Illinois public health officials and medical experts to discuss the urgent need for Congress to pass the President s $1.9 billion emergency funding request to help treat and prevent the spread of the Zika virus. He provided information on the Zika virus roundtable discussion (see Attachment #8). Additionally, he commented on the State and nation s opioid and heroin epidemic. VIII. Report from Chief Executive Officer (Attachment #9) Dr. Shannon provided an update on several subjects; detail is included in Attachment #9. IX. Recommendations, Discussion / Information Item A. Strategic planning discussion Topic: Medical Staff, presented by Dr. Claudia Fegan, Executive Medical Director/Medical Director-Stroger (Attachment #10) Page 4 of 97
Minutes of the Meeting of the CCHHS Board of Directors Friday, April 29, 2016 Page 5 IX. Recommendations, Discussion / Information Item A. Strategic planning discussion (continued) Dr. Shannon provided an introduction to the presentation. He also introduced Richard Sewell, Associate Dean of Community and Public Health Practice at UIC School of Public Health, who will be moderating the strategic planning discussions. Dr. Fegan reviewed the presentation, which included information on the following subjects: CCHHS Medical Leadership Provident Medical Leadership Ambulatory Medical Leadership Medical Staff Functions Medical Staff Committees Executive Medical Staff (EMS) Committee Members CCHHS Medical Staff by Category Stroger/Provident Medical Staff Demographics Gender, Race, Age, Years on Staff, Top Non-English Languages Spoken CCHHS Medical Staff by Department Ambulatory and Community Health Network of Cook County (ACHN) Budgeted Physicians by Department Physicians in Ambulatory Care Quality Partnership The Review Process Credentialing and Privileging Medical Staff Credentials Committee Duties Professional Performance Evaluation: The Joint Commission Peer Review: The Joint Commission Medical Staff Peer Review Committee Duty Possible Peer Review Outcomes The Evolving Medical Staff: Strategies for Transforming Organization and Performance The Drivers Medical Staff Strategies Relative Value Units (RVUs) RVUs and Medical Practice Challenges During the discussion of the information on slide 10, regarding Medical Staff Committees, Director Junge inquired as to the reason why there are no committees for Behavioral Health. Dr. Fegan responded that it is not a mandated committee; it was explained that many of the committees listed are required, either by The Joint Commission or by the Centers for Medicare and Medicaid Services. It was noted that Behavioral Health does report in through Quality and to all of the departments. Dr. Fegan stated that Director Junge s question is reasonable; she and staff will review the matter. Director Richardson-Lowry asked which of the Committees listed are not mandated. Dr. Fegan responded that she will provide that information through the Chair. During the discussion of the information on slide 13, regarding Medical Staff Demographics, Directors Estrada and Velasquez requested that data be provided on the Hispanic medical staff; the information presented included data on race, but did not include data on ethnicity. Page 5 of 97
Minutes of the Meeting of the CCHHS Board of Directors Friday, April 29, 2016 Page 6 IX. Recommendations, Discussion / Information Item A. Strategic planning discussion (continued) During the discussion of the information on slide 17, regarding CCHHS Medical Staff by Department, Director Velasquez inquired regarding the number of full-time psychologists currently on staff. Dr. Fegan responded that she will provide that information. X. Closed Meeting Items A. Audit and Compliance Committee Meeting Minutes, April 21, 2016 B. Appointment of Stroger Hospital Department Chair(s) and Division Chair(s) C. Claims and Litigation D. Discussion of personnel matters Chairman Hammock, seconded by Director Gugenheim, moved to recess the open meeting and convene into a closed meeting, pursuant to the following exceptions to the Illinois Open Meetings Act: 5 ILCS 120/2(c)(1), regarding the appointment, employment, compensation, discipline, performance, or dismissal of specific employees of the public body or legal counsel for the public body, including hearing testimony on a complaint lodged against an employee of the public body or against legal counsel for the public body to determine its validity, 5 ILCS 120/2(c)(11), regarding litigation, when an action against, affecting or on behalf of the particular body has been filed and is pending before a court or administrative tribunal, or when the public body finds that an action is probable or imminent, in which case the basis for the finding shall be recorded and entered into the minutes of the closed meeting, and 5 ILCS 120/2(c)(12), regarding the establishment of reserves or settlement of claims as provided in the Local Governmental and Governmental Employees Tort Immunity Act, if otherwise the disposition of a claim or potential claim might be prejudiced, or the review or discussion of claims, loss or risk management information, records, data, advice or communications from or with respect to any insurer of the public body or any intergovernmental risk management association or self insurance pool of which the public body is a member, and 5 ILCS 120/2(c)(17), regarding the recruitment, credentialing, discipline or formal peer review of physicians or other health care professionals for a hospital, or other institution providing medical care, that is operated by the public body, and 5 ILCS 120/2(c) (29), regarding meetings between internal or external auditors and governmental audit committees, finance committees, and their equivalents, when the discussion involves internal control weaknesses, identification of potential fraud risk areas, known or suspected frauds, and fraud interviews conducted in accordance with generally accepted auditing standards of the United States of America. On the motion to recess the open meeting and convene into a closed meeting, a roll call was taken, the votes of yeas and nays being as follows: Page 6 of 97
Minutes of the Meeting of the CCHHS Board of Directors Friday, April 29, 2016 Page 7 X. Closed Meeting Items (continued) Yeas: Chairman Hammock, Vice Chairman Butler and Directors Gugenheim, Junge, Lerner, Marsh, Richardson-Lowry, Velasquez and Wiese (9) Nays: None (0) Absent: Director Estrada (1) THE MOTION CARRIED UNANIMOUSLY and the Board convened into a closed meeting. Chairman Hammock declared that the closed meeting was adjourned. The Board reconvened into the open meeting. XI. Adjourn As the agenda was exhausted, Chairman Hammock declared that the meeting was ADJOURNED. Respectfully submitted, Board of Directors of the Cook County Health and Hospitals System XXXXXXXXXXXXXXXXXXXXXXX M. Hill Hammock, Chairman Attest: XXXXXXXXXXXXXXXXXXXXXXXXX Deborah Santana, Secretary Page 7 of 97
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #1 Page 8 of 97
COOK COUNTY HEALTH AND HOSPITALS SYSTEM BOARD OF DIRECTORS PROPOSED RESOLUTION Sponsored by M. HILL HAMMOCK, CHAIR, THE HONORABLE JERRY BUTLER, VICE CHAIR, RIC ESTRADA, ADA MARY GUGENHEIM, EMILIE N. JUNGE, WAYNE M. LERNER, DPH, ERICA MARSH, MD, MARY B. RICHARDSON-LOWRY, CARMEN VELASQUEZ AND DORENE P. WIESE, EdD, DIRECTORS WHEREAS in June of 2013, Lewis M. Collens was appointed by the President of the Cook County Board of Commissioners, and confirmed by the Board of Commissioners, to serve as a member of the Board of Directors of the Cook County Health and Hospitals System; and WHEREAS, Mr. Collens played an integral role in the governance of the Health System, which demands a considerable time commitment from its volunteer Board members; and WHEREAS, Mr. Collens graciously lent his vast expertise to the Health System by serving as the Chair of the Health System Board s Quality and Patient Safety Committee from August 2013 through November 2014, as Chair of the Health System Board s Finance Committee from December 2014 through March 2016, and as a member of the Health System Board s Human Resources Committee from December 2014 through March 2016; and WHEREAS, while serving on the Health System Board of Directors, Mr. Collens was a part of the leadership team that grew CountyCare, an Illinois Medicaid Demonstration Project, which established a network of providers that adds to CCHHS s current sites and consists of all of the Federally Qualified Health Centers in Cook County and nearly every hospital, including the five academic medical centers. With more than 130 access points, this extensive network allows CountyCare members the ability to access care close to their home and within a network of care utilized by their primary care provider. CountyCare has achieved considerable success providing an unprecedented opportunity for low income adult residents of Cook County to have access to care. Because of CountyCare and the Affordable Care Act, for the first time in the Health System s history, there are more insured patients than uninsured; and WHEREAS, following the transition of CountyCare from being a Demonstration Project to becoming a County Managed Care Community Network, which essentially created a new role and function for the Health System in operating a health plan for the CountyCare members, as Chair of the Health System Board s Finance Committee, Mr. Collens was intimately involved in ensuring CountyCare s success; and WHEREAS during his tenure with the Health System, Mr. Collens earned the genuine respect of his fellow Board members for his keen insight, attention to detail, and knowledge in the areas of finance and legal affairs; and WHEREAS the Health System s leadership team held Mr. Collens in high regard and appreciated his strength and support, as well as his ability to lead with integrity and objectivity. NOW, THEREFORE, BE IT RESOLVED, that the Board of Directors of the Cook County Health and Hospitals System, on behalf of the more than five million residents of Cook County served by the Health System, does hereby gratefully acknowledge Mr. Collens for his extraordinary abilities, outstanding leadership and unwavering commitment to the transformation of the Health System in order to maximize access to quality medical care to all residents of Cook County. Page 9 of 97
COOK COUNTY HEALTH AND HOSPITALS SYSTEM BOARD OF DIRECTORS PROPOSED RESOLUTION IN MEMORY OF THE HONORABLE MARJORIE COLLENS, A REMARKABLE WOMAN Sponsored by M. HILL HAMMOCK, CHAIR, THE HONORABLE JERRY BUTLER, VICE CHAIR, RIC ESTRADA, ADA MARY GUGENHEIM, EMILIE N. JUNGE, WAYNE M. LERNER, DPH, ERICA MARSH, MD, MARY B. RICHARDSON-LOWRY, CARMEN VELASQUEZ AND DORENE P. WIESE, EdD, DIRECTORS WHEREAS, Marjorie Collens served with distinction in many roles over the course of her life: wife, mother, supporter of the arts, community leader and elected official; and WHEREAS, in her role as a wife, Marjorie Collens represented the finest example of a fully engaged and supportive partner for life. She and her beloved husband, Lewis M. Collens, met while attending college at the University of Illinois at Urbana-Champaign and were happily married for 53 years; and WHEREAS, in her role as a mother, Marjorie Collens was nurturing and devoted to her son, Steven. Upon Steven s marriage in 2015 to Caralynn Nowinski, the joy Marjorie Collens radiated in celebration of the event was palpable; and WHEREAS, in her role as a supporter of the arts, Marjorie Collens was involved in many initiatives and programs, as she recognized the vital role that the arts play in civic life. She played a major role in the effort to start what is now ChiArts, the Chicago High School for the Arts. Additionally, she served as a board member and later chaired the board of Hubbard Street Dance Chicago, and accomplished much in her time there; and WHEREAS, in her role as a community leader, Marjorie Collens was a remarkably talented and intelligent woman who used her skills to benefit others in many philanthropic endeavors; and WHEREAS, in her role as an elected official, Marjorie Collens had the unique ability to regularly achieve her goals without rancor and, as a result was genuinely admired and respected by her peers. She honorably served as Alderman of Evanston s Seventh Ward from 1984 to 1991; and WHEREAS, when Marjorie Collens died in early December, she left behind a family, countless friends and a community enriched for having known her. NOW THEREFORE BE IT RESOLVED, that the Board of Directors of the Cook County Health and Hospitals System does hereby extend its deepest sympathies to its fellow Board member Lewis M. Collens and his son Steven and daughter-in-law Caralynn on the loss of their cherished wife and mother, Marjorie Collens; and BE IT FURTHER RESOLVED, that the Board of Directors of the Cook County Health and Hospitals System is grateful to Marjorie Collens for the invaluable contributions she has made over her lifetime, and is grateful to her for her encouragement and support of her husband, Lewis M. Collens, in serving as a member of the Board of Directors of the Cook County Health and Hospitals System; and BE IT FURTHER RESOLVED, that a suitable copy of this Resolution be spread upon the official proceedings of this Body and that an official copy of the same be tendered to the family of Marjorie Collens. Page 10 of 97
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #2 Page 11 of 97
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Dashboard Overview 29 April 2016 Krishna Das, MD, Chief Quality Officer 1 Page 12 of 97
Board Quality Dashboard 2 Page 13 of 97
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #3 Page 14 of 97
CCHHS BOARD OF DIRECTORS Corporate Compliance Metrics April 29, 2016 Page 15 of 97
Reactive Corporate Compliance Volumes Comparison of 1 st Quarter Fiscal Year Activity 164 166 32 47 86 80 125 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 F-YTD 16 The addition of CountyCare reactive issues the count to 172 2 FY 2016 is the 1 st year Compliance will separate reactive activity by business function, health care provider vs. health plan. Page 16 of 97 Board of Directors I April 29, 2016
1 st Quarter 2016 Issue Breakdown by Category 125 1 Reactive Corporate Compliance Issues Were Raised Other 10% Regulatory/Policy Theft 10% 1% False Claims 2% HIPAA 40% Human Resources 21% HC Fraud 4% Conflict of Interest 5% Category Count 1 Privacy (HIPAA) 50 Accurate Books 9 False Claims 2 Other 13 Human Resources 26 Conflict of Interest 6 Theft 1 Regulatory/Policy 13 HC Fraud 5 Accurate Books 7% 1 This is a total count of new issues raised to Corporate Compliance. Page Not all 17 issues of 97 are validated/substantiated. 3 Board of Directors I April 29, 2016
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #4 Page 18 of 97
COOK COUNTY HEALTH & HOSPITALS SYSTEM Human Resources Metrics for CCHHS Board Of Directors April 29, 2016 Gladys Lopez, Chief of Human Resources Page 19 of 97
800 CCHHS Hiring Waterfall & Snapshot (03/31/16) 598 Positions in process Count of positions 700 600 500 400 300 200 100 0 48 42 56 39 36 83 21 239 218 55 79 Shared Responsibility Human Resources Management Human Resources Management Human Resources 2 Our goal is to maintain a vacancy rate equal to or below 750. Labor Hold Update: Completed meetings with NNOC and Local 200; finalizing selections with AFSCME Locals 1178 and 1276. Proceeding with extending offers to internal and candidates in these vacancies. Page 20 of 97 CCHHS Human Resource Committee I 04/29/16
Human Resources Metrics Summary DATA THROUGH: 03/31/16 Gladys Lopez, Chief of Human Resources VACANCIES FILLED FY15 TOTAL Quarter 1 1 Quarter 2 Quarter 3 Quarter 4 FY16 TOTAL CCHHS External 201 52 8 60 CCHHS Internal 127 14 5 19 Total CCHHS: 328 66 13 79 Nursing External 58 5 1 6 Nursing Internal 45 1 1 2 Total Nursing: 103 6 2 8 SEPARATIONS CCHHS Separations 233 150 22 172-61 -26% Total Net New CCHHS: -32-98 -14-112 -80 250% Nursing Separations 67 44 5 49-18 -27% Total Net New Nursing: -9-39 -4-43 -34 378% TURNOVER CCHHS FTEs 6,017 6,273 6,265 6,265 248 4% Total CCHHS Turnover: 3.9% 2.4% 2.7% 2.7% -1.2% -30% CCHHS New Hire FTEs 201 52 8 60-141 -70% CCHHS New Hire Separations 11 4 2 6-5 = -45% Total FY15 New Hire Turnover: 5% 8% 25% 10% 5% 83% OPEN VACANCIES Target Total CCHHS Vacant Positions: 750 767 854 868 868 118 16% Less Deleted Positions / PIDs 11 0 0 Total RTHs in HR (In Process): 744 533 598 598-146 -20% AVERAGE TIME TO HIRE Target Average Days to Hire (Month): 110 140 131 94 124 14 13% 115 110 105 100 95 90 85 (With Credentialed) Average Days to Hire (Month): 110 140 110 92 107-3 -3% (Without Credentialed) 110 Average Time to Hire (Without Credentialed) 92 Fiscal Year 2016 December 1, 2015 - November 30, 2016 Fill Time (YTD) Target (110) 110 80 650 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Page 21 of 97 3 1 Data thru 3/31/16 CCHHS Board of Directors I 04/29/16 900 850 800 750 700 854 Open Vacancies 868 Goal: Continue to maintain open vacancies at 750 or VARIANCE Vacant Positions (YTD) Target (750) 750
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #5 Page 22 of 97
COOK COUNTY HEALTH & HOSPITALS SYSTEM CCHHS Board of Directors Finance Dashboard 29 April 2016 1 Page 23 of 97
Board Finance Dashboard Key Measures 2013 2014 2015 2016 Days in Patient Accounts Receivable (Net)* Change From Prior Period FYTD 16 Budget or Goal % to Budget or Goal 48 37 33 53 1.9% 49.8 6.4% Days Cash on Hand 96 96 108 48 6.7% 60 20.0% Overtime as %tage of Gross Salary 8.3% 8.3% 7.3% 8.5% -10.5% 5.0% 70.0% 2 Page 24 of 97
Board Finance Dashboard 3 Page 25 of 97
Volumes/Stats 4 Page 26 of 97
2,500 2,000 1,500 1,000 500 0 Total Inpatient Discharges- 24 month trend *includes PICU & Nursery 5 Page 27 of 97
Average LOS- 24 month trend 6 5 4 3 2 1 0 *includes PICU & Nursery, hourly census 6 Page 28 of 97
Total Emergency Room Visits - 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000-24 month trend *includes Adult, Peds and Trauma 7 Page 29 of 97
Primary Care Provider Visits 25,000 24 month trend 20,000 15,000 10,000 5,000 0 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 8 Page 30 of 97
Specialty Care Provider Visits 25,000 24 month Trend 20,000 15,000 10,000 5,000 0 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 9 Page 31 of 97
Total Provider Visits 24 month trend 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 10 Page 32 of 97
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #6 Page 33 of 97
CountyCare Metrics Prepared for: CCHHS Board of Directors, April Meeting Steven Glass, Executive Director, Managed Care April 29, 2016 Page 34 of 97
April 16 Dashboard Key Measures Jan'16 Feb'16 Mar'16 Apr'16 % Change From Prior Month Trend FYTD'16 Budget or Goal % to Budget/ Goal 1) QUALITY 1.1) Ambulatory Access - ACA & FHP Adults CountyCare Overall 68.7% 68.7% 68.7% 0.0% -- 83.84% (50th %ile) 81.9% CCHHS 66.3% 66.3% 66.3% 0.0% -- 83.84% (50th %ile) 79.1% MHN ACO 70.7% 70.7% 70.9% 0.3% -- 83.84% (50th %ile) 84.6% ACCESS 67.6% 67.6% 67.6% 0.0% -- 83.84% (50th %ile) 80.6% All Other 69.3% 69.3% 68.8% -0.7% -- 83.84% (50th %ile) 82.1% 2) RISK MANAGEMENT 2.1) Completed HRS/HRA (all populations, cum) Overall 55.1% 56.3% 2.2% 100% 56.3% MHN ACO 75.5% 75.1% -0.5% -- 100% 75.1% La Rabida Care Coordination (CSNs only) 66.5% 68.1% 2.4% 100% 68.1% All Other 34.6% 36.1% 4.3% 100% 36.1% 3) UTILIZATION 3.1) ER Utilization/1,000 ACA 965 924-4.2% 1,017 94.9% FHP 848 727-14.3% ICP 1,391 1,372-1.4% 3.3) CountyCare Net Impact on CCHHS (FYTD) $18,914,133 $31,307,490 $50,124,629 60.1% $89,038,520 56.3% 4) MEMBERSHIP 4.1) Monthly Membership 164,878 165,028 162,740 163,435 0.4% -- 178,457 91.6% ACA 73,523 73,598 71,736 72,738 1.4% 85,000 85.6% FHP 87,685 87,560 86,928 86,438-0.6% -- 90,506 95.5% SPD 3,670 3,870 4,076 4,259 4.5% 2,951 144.3% Home/Community Waiver (incl DD) 617 655 678 699 3.1% LTC 229 251 273 285 4.4% 4.2) FYTD Member Months 329,263 494,291 657,031 820,466 892,285 92.0% ACA 146,710 220,308 292,044 364,782 425,000 85.8% FHP 175,323 262,883 349,811 436,249 452,530 96.4% SPD 7,230 11,100 15,176 19,435 14,755 131.7% 5) OPERATIONS FY'15 Q2 FY'15 Q3 FY'15 Q4 FY'16 Q1 Change from (Mar-May) (Jun-Aug) Page 35 of 97 (Sep-Nov) (Dec-Feb) Prior Q CCHHS # DaysBOD Apr 29, Goal 2016Met 5.3) Claims 2 Payment Turnaround Time (days) 40 38 45 37 18.4% < 35 N
Medicaid Cancellations Due to Rede and Other Reasons Oct-Dec 15 Page 36 of 97 3
Data Charts Provided for Informational Purposes Only Page 37 of 97
Quality Metrics Provided for Informational Purposes Only % Change From Prior Month FYTD'16 Budget or Goal Key: % to Budget/ Goal Key Measures Jan'16 Feb'16 Mar'16 Apr'16 Trend 1) QUALITY 1.1) Ambulatory Access - ACA & FHP Adults CountyCare Overall 68.7% 68.7% 68.7% 0.0% -- 83.84% (50th %ile) 81.9% CCHHS 66.3% 66.3% 66.3% 0.0% -- 83.84% (50th %ile) 79.1% MHN ACO 70.7% 70.7% 70.9% 0.3% -- 83.84% (50th %ile) 84.6% ACCESS 67.6% 67.6% 67.6% 0.0% -- 83.84% (50th %ile) 80.6% All Other 69.3% 69.3% 68.8% -0.7% -- 83.84% (50th %ile) 82.1% 1.2) Ambulatory Access - ICP Adults CountyCare Overall 74.3% 74.3% 75.6% 1.7% 86.91% (75th %ile) 87.0% CCHHS 75.6% 75.6% 77.4% 2.4% 86.91% (75th %ile) 89.1% MHN ACO NA NA NA NA 86.91% (75th %ile) NA ACCESS 69.1% 69.1% 70.5% 2.0% 86.91% (75th %ile) 81.1% All Other 76.1% 76.1% 77.1% 1.3% 86.91% (75th %ile) 88.7% 1.3) CY'15 State P4P Measures (FHP & ACA) Inpatient Follow-Up 45.9% 45.9% 45.9% 0.0% -- 60.0% 76.5% Well Child 15 Months - 6 Visits 6.7% 6.7% 6.7% 0.0% -- 74.47% (90th %ile) 9.0% Well Child Visits, 3-6 years 63.5% 63.5% 63.5% 0.0% -- 78.46% (75th %ile) 80.9% Immunization Status - Combo 3 0.0% 0.0% 0.0% 0.0% -- 71.53% (50th %ile) 0.0% Developmental Screenings 37.9% 37.9% 37.9% 0.0% -- 65.7% 0.0% Post Partum Care 42.5% 42.5% 42.6% 0.0% -- 69% (75th %ile) 61.7% Prenatal Care 78.1% 78.1% 78.2% 0.1% -- 85% (75th %ile) 92.0% @ or Within 5% > 5% From Better of Goal Goal Than Goal 5 Page 38 of 97 CCHHS BOD Apr 29, 2016
Risk Management & Utilization Metrics Provided for Informational Purposes Only % Change From Prior Month FYTD'16 Budget or Goal % to Budget/ Goal Key Measures Jan'16 Feb'16 Mar'16 Apr'16 Trend 2) RISK MANAGEMENT 2.1) Completed HRS/HRA (all populations, cum) Overall 55.1% 56.3% 2.2% 100% 56.3% MHN ACO 75.5% 75.1% -0.5% -- 100% 75.1% La Rabida Care Coordination (CSNs only) 66.5% 68.1% 2.4% 100% 68.1% All Other 34.6% 36.1% 4.3% 100% 36.1% 2.2) High-Risk Stratification (all populations, cum) Overall 2.8% 2.6% -7.1% 3.0% 86.7% MHN ACO 4.5% 4.3% -4.4% 3.0% 143.3% La Rabida Care Coordination (CSNs only) 7.1% 7.1% 0.0% -- 3.0% 236.7% All Other 1.0% 0.8% -20.0% 3.0% 26.7% 3) UTILIZATION 3.1) ER Utilization/1,000 ACA 965 924-4.2% 1,017 94.9% FHP 848 727-14.3% ICP 1,391 1,372-1.4% 3.2) Inpatient Utilization/1,000 ACA 169 161-4.7% 168 100.6% FHP 98 93-5.1% ICP 375 389 3.7% 3.3) CountyCare Net Impact on CCHHS (FYTD) $18,914,133 $31,307,490 $50,124,629 60.1% $89,038,520 56.3% Key: @ or Within 5% > 5% From Better of Goal Goal Than Goal 6 Page 39 of 97 CCHHS BOD Apr 29, 2016
Membership Metrics Provided for Informational Purposes Only % Change From Prior Month 7 Key: FYTD'16 Budget or Goal % to Budget/ Goal Key Measures Jan'16 Feb'16 Mar'16 Apr'16 Trend 4) MEMBERSHIP 4.1) Monthly Membership 164,878 165,028 162,740 163,435 0.4% -- 178,457 91.6% ACA 73,523 73,598 71,736 72,738 1.4% 85,000 85.6% FHP 87,685 87,560 86,928 86,438-0.6% -- 90,506 95.5% SPD 3,670 3,870 4,076 4,259 4.5% 2,951 144.3% Home/Community Waiver (incl DD) 617 655 678 699 3.1% LTC 229 251 273 285 4.4% 4.2) FYTD Member Months 329,263 494,291 657,031 820,466 892,285 92.0% ACA 146,710 220,308 292,044 364,782 425,000 85.8% FHP 175,323 262,883 349,811 436,249 452,530 96.4% SPD 7,230 11,100 15,176 19,435 14,755 131.7% 4.3) Mbrs by Delegated Care Management Group CCHHS (ACHN, LTSS, non-mhn ACO) 83,978 84,209 82,860 84,409 1.9% MHN ACO 80,900 80,819 79,880 79,026-1.1% La Rabida Care Coordination (CSNs only) 1,841 1,766-4.1% 4.4) Members Lost to Medicaid Cancellation # Mbrs Due for Redetermination 3,775 7,362 1,628 6,703 311.7% # Rede Cancellations 4,161 2,773 3,484 25.6% # Coverage Restored 772 838 1,055 25.9% % Cancelled Due to Lack of Rede 89.8% 26.3% 149.2% < 22% 83.7% 4.5) Cook County Enrollment by Health Plan (rank order) Rank Aetna Better Health Inc. 96,824 100,046 103,688 3.6% 6th Blue Cross Blue Shield 196,826 199,468 161,394-19.1% 2nd CountyCare 162,435 161,935 159,147-1.7% 3rd Family Health Network (incl CCAI) 150,893 160,284 162,967 1.7% 1st Harmony Health Plan 104,628 104,077 103,319-0.7% -- 7th IlliniCare Health Plan 106,503 105,007 104,496-0.5% -- 4th Meridian Health Plan 76,076 75,226 74,972-0.3% -- 8th Molina Health Care 77,862 73,589 104,194 41.6% 5th Next Level Health 19,460 Page 18,282 40 of 97 19,910 8.9% 9th CCHHS BOD Apr 29, 2016 @ or Within 5% > 5% From Better of Goal Goal Than Goal
Operations Metrics Provided for Informational Purposes Only Key Measures Jan'16 Feb'16 Mar'16 Apr'16 % Change From Prior Month Trend FYTD'16 Budget or Goal % to Budget/ Goal 5) OPERATIONS 5.1) Member & Provider Services Call Center Goal Goal Met Abandonment Rate 3.95% 1.42% 1.55% 9.2% < 5% Y Hold Time 0:01:08 0:00:55 0:00:47-0:00:13 < :01:00 Y Average Speed to Answer 0:00:31 0:00:15 0:00:18 0:00:03 < :00:45 Y 5.2) Claims/Encounters Acceptance Rate 80.7% 74.0% 80% 92.5% FY'15 Q2 (Mar-May) FY'15 Q3 (Jun-Aug) FY'15 Q4 (Sep-Nov) FY'16 Q1 (Dec-Feb) Change from Prior Q # Days Goal Met 5.3) Claims Payment Turnaround Time (days) 40 38 45 37 18.4% < 35 N Key: @ or Within 5% > 5% From Better of Goal Goal Than Goal 8 Page 41 of 97 CCHHS BOD Apr 29, 2016
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #7 Page 42 of 97
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Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #8 Page 44 of 97
Press Release Press Releases Newsroom U.S. Senator Dick Durbin of Illinois http://www.durbin.senate.gov/newsroom/press-releases/durbin-calls-on-congress-to-pass-e... Page 1 of 2 5/26/2016 04.29.16 Durbin Calls On Congress To Pass Emergency Funding For Zika Virus CHICAGO U.S. Senator Dick Durbin (D-IL) today held a roundtable discussion with Illinois public health officials and medical experts to discuss the urgent need for Congress to pass the President s $1.9 billion emergency funding request to help treat and prevent the spread of the Zika virus. In the absence of Congressional action, the Centers for Disease Control and Prevention (CDC) has begun diverting funding and resources away from Illinois and other states to support Southern states where the Zika threat is higher. The Illinois Department of Public Health and the Chicago Department of Public Health will lose a total of $2 million in Public Health Emergency Preparedness grants as a result. Taking money from one state to give it to another to deal with a public health threat is no way to govern, especially when the President submitted a supplemental request to combat the Zika virus nearly three months ago. We should pass a Zika supplemental so Illinois and other states can keep the funding they need to deal with current public health threats like Elizabethkingia while receiving additional funding to help prepare for the summer months and the Zika threat, Durbin said. While Chicago is further north and at a lower risk for the spread of the mosquitoes that carry the Zika virus, we are not at zero risk and we are a major transportation hub. There is still a lot we do not know about this disease and we must be diligent. The cases of Zika are continuing to grow and inaction and further delay put pregnant women and children in jeopardy. "Zika virus can cause serious disease, more than we anticipated," said Dr. Sharon Welbel, Director of Hospital Epidemiology and Infection Control, CCHHS. "Local funding is critical for a number of reasons; we must educate individuals in our communities about how to avoid infection, educate clinicians about how to identify and manage the disease in their patients and how to report to local authorities. Counseling for pregnant women will be monumental. In order to do this we need money for state health department laboratories and diagnostic testing, as well as tools for monitoring and reporting the disease efficiently." Multi-year funding is needed now for the CDC and state/local health departments across the nation to prepare and respond before the summer mosquito season arrives, and to better understand the threat, educate providers and communities, conduct vector control, and develop a vaccine. In the time since the President asked Congress for funding to help prepare for and combat the Zika virus, more than 1,000 Americans in 42 states have contracted the virus, including more than 90 pregnant women. In Illinois, 13 people have contracted the virus, including at least two pregnant women. Since then, the CDC confirmed that Zika during pregnancy can causes severe birth defects like microcephaly and that the virus can be sexually transmitted. Earlier this month, Durbin led a coalition of 42 Senators in sending a new letter to Senate Republican leaders calling for immediate passage of President Obama s emergency supplemental funding for Zika. The letter called on the Senate Appropriations committee to mark-up the President s emergency funding request as soon as possible to ensure swift passage by the full Senate and House. Page 45 of 97
Press Release Press Releases Newsroom U.S. Senator Dick Durbin of Illinois http://www.durbin.senate.gov/newsroom/press-releases/durbin-calls-on-congress-to-pass-e... Page 2 of 2 5/26/2016 Last week, Durbin also joined Senators Bill Nelson (D-FL), Harry Reid (D-NV), and Chuck Schumer (D-NY) in introducing legislation to fund the Administration s $1.9 billion request to combat the Zika virus. The funding would be used to improve state vector control, surveillance, lab capacity and outbreak response, accelerate efforts to develop a vaccine, and expand education and access to women s health planning services. Page 46 of 97
Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #9 Page 47 of 97
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Cook County Health and Hospitals System Board of Directors Meeting Minutes April 29, 2016 ATTACHMENT #10 Page 54 of 97
Cook County Health and Hospitals System Presentation to Inform Strategic Plan: Medical Staff Claudia M. Fegan, MD, FACP, CHCQM Executive Medical Director April 29, 2016 Page 55 of 97
CCHHS Medical Leadership CCHHS Executive Medical Director Claudia Fegan, MD Director of Professional Education John O'Brien, MD Director of Employee Health Service Patricia Kelleher, MD Medical Director Ambulatory Services Vacant Medical Director Provident Clifford Crawford, MD Chair Department Anesthesiology & Pain Management Gennadiy Voronov, MD Chair Department Correctional Health Connie Mennella, MD Chair Department Emergency Medicine Jeffery Schaider, MD Chair Department Family & Community Medicine Mark Loafman, MD Chair Department Medicine Suja Mathew, MD Chair Department Obstetrics & Gynecology Edward Linn, MD Chair Department Oral Health Jorelle Alexander, DMD Chair Department of Pathology Marion Sekosan, MD Chair Department Pediatrics Lisa Giordano, MD Chair Department Psychiatry Andrew Kulik, MD. Chair Department Radiology Mark Pisaneschi, MD Chair Department Surgery Richard Keen, MD Chair Department Trauma & Burn Faran Bokhari, MD Interim 2 Page 56 of 97 CCHHS Medical Staff I April 29, 2016
Provident Medical Leadership CCHHS Executive Medical Director Claudia Fegan, MD Medical Director Provident Clifford Crawford, MD Chair Department Anesthesiology Chair Department Emergency Medicine Chair Department Internal Medicine Chair Department Pathology Chair Department Radiology Chair Department Surgery Mark Krause, MD Pierre Wakim, DO Suja Mathew, MD Marin Sekosan, MD Kenneth Williams, MD Clifford Crawford, MD Interim 3 Page 57 of 97 CCHHS Medical Staff I April 29, 2016
Ambulatory Medical Leadership CCHHS Executive Medical Director Claudia M. Fegan, MD Medical Director Ambulatory Services VACANT Associate Medical Director Primary Care Thomas Gavagan, MD Associate Medical Director Pediatrics Denise Cunill, MD Associate Medical Director Specialty Care VACANT Community Based Clinics Lead Physicians Fantus Based Clinics Lead Physicians Stroger Based Clinics Lead Physicians Attending Physicians Attending Physicians Attending Physicians 4 Page 58 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Functions The Medical Staff has the overall responsibility for the quality of medical care provided to patients, and for the professional practices and ethical conduct of its members, as well as accounting therefore to the Cook County Health and Hospitals System Board of Directors Preamble, John H. Stroger, Jr. Hospital Bylaws The Medical Staff is responsible for the quality of medical care in the Hospital and accepts and discharges this responsibility subject to the ultimate authority of the Cook County Health and Hospitals System Board of Directors Preamble, Provident Hospital Bylaws 5 Page 59 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Committees: Executive Medical Staff (EMS) Committee Represents and acts on behalf of the Medical Staff Coordinates activities and general policies of the departments Receives and acts on committee reports Implements policies of the Medical Staff Liaison between Medical Staff, COO, CEO and Board Makes recommendations to the Board and Hospital Management on appointment/reappointment clinical privileges and corrective actions Promotes professionally competent and ethical conduct by Medical Staff Assists in implementing and enforcing policies and procedures approved by the Board 6 Page 60 of 97 CCHHS Medical Staff I April 29, 2016
EMS Committee Members Officers of the Medical Staff Chairs of all Medical Departments Chair of Division of General Surgery One member from each of 5 Divisions of Department of Medicine One member from each of 4 Divisions of Department of Surgery Two members each from OB/GYN and Pediatrics One member each from Departments of Anesthesiology & Pain Management, Correctional Health, Family & Community Medicine, Pathology, Psychiatry, Radiology, Trauma & Burn One member from FT non-member practitioners (selected by President) President of the House Staff Ex-officio members: Immediate Past President, COO, Medical Director, Associate Hospital Director, Director of Nursing Services 7 Page 61 of 97 CCHHS Medical Staff I April 29, 2016
Stroger Hospital Executive Medical Staff Committee 2016-2017 Officers Ozuru Ukoha, MD President Trevor Lewis, MD Vice-President Juliet Bradley, MD Secretary Aiman Tulaimat, MD Treasurer 8 Page 62 of 97 CCHHS Medical Staff I April 29, 2016
Provident Hospital Medical Executive Committee 2016-2018 Officers Valerie Hansbrough, MD President Anwer Hussain, DO Vice-President Julita McPherson, MD Secretary Angel Leake, MD Treasurer 9 Page 63 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Committees Blood Bank and Transfusion Committee Bylaws Committee Cancer Committee Credentials Committee Critical Care Committee Drug and Formulary Committee Hospital Quality Improvement and Patient Safety Committee Institutional Review Board (IRB) Joint Conference Committee Medical Education Committee Medical Ethics Committee Medical Information Committee Operating Room Committee Peer Review Committee Resuscitation Committee Surgical Function Review Committee Ad Hoc Committees 10 Page 64 of 97 CCHHS Medical Staff I April 29, 2016
CCHHS Medical Staff by Category Stroger/Provident 900 800 790 700 600 500 400 300 200 189 100 0 44 Active Consulting Service Voluntary 6 11 Page 65 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Demographics* GENDER Female 45% Male 55% *JHS and PH Active/Provisional only Page 66 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Demographics* RACE** Other/No answer 20% Black 17% Pacific Islander 1% Native American less than 1% Asian 22% White 40% 13 *JHS and PH Active/Provisional only **Voluntary reporting Page 67 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Demographics* AGE Less than 30 0% 60-69 14% 70+ 3% 30-39 21% 50-59 33% 40-49 29% 14 *JHS and PH, Active/Provisional only Page 68 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Demographics* YEARS ON STAFF 180 156 165 169 160 140 120 100 81 80 60 40 20 6 0 <5 5-10 11-20 21-30 >30 15 *JHS and PH, Active/Provisional only Page 69 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Demographics* TOP NON-ENGLISH LANGUAGES SPOKEN** TAGALOG 8 GREEK 8 POLISH 11 CHINESE/CANTONESE/MANDARIN 11 GUJARATI 12 RUSSIAN 18 ARABIC 18 FRENCH 22 URDU 23 HINDI 54 SPANISH 125 Bi/Multi-lingual BI/MULTI- LINGUAL 295 16 *JHS and PH, Active/Provisional only **Voluntary reporting Page 70 of 97 CCHHS Medical Staff I April 29, 2016
CCHHS Medical Staff by Department* Surgery, 76 Trauma, 12 Anesthesiology, 30 Pathology, 16 CorrHealth, 30 Radiology, 26 Emergency Med, 51 Psychiatry, 15 Pediatrics, 44 Family Med, 41 Oral Health, 13 OB/Gyn, 20 Medicine, 207 17 *JSH and PH, Active/Provisional only Page 71 of 97 CCHHS Medical Staff I April 29, 2016
ACHN Budgeted* Physicians by Department 1 1 4 7 20 21 MEDICINE FAMILY MEDICINE PEDIATRICS ORAL HEALTH PSYCHIATRY EMERGENCY MEDICINE 18 *FT Providers on ACHN budget, credentialed and privileged Page 72 of 97 by respective department CCHHS Medical Staff I April 29, 2016
Physicians in Ambulatory Care PCPs/Specialists on ACHN Budget (credentialed and privileged by department of specialty) PCPs on Department of Medicine Budget PCPs on Department of Family Medicine Budget PCPs on Department of Pediatrics Budget Specialists on Budgets of Respective Departments 19 Page 73 of 97 CCHHS Medical Staff I April 29, 2016
Quality Partnership Clinical Department Chairs Executive Medical Staff Committee Credentials Committee Peer Review Committee 20 Page 74 of 97 CCHHS Medical Staff I April 29, 2016
Quality Partnership Department Chair Recruits and hires Recommends criteria for clinical privileges Conducts Individual performance evaluation Focused Professional Practice Evaluations/ Ongoing Professional Practice Evaluations(FPPE/OPPE) Ensures department compliance with Medical Staff Bylaws, Rules and Regulations Develops policies and procedures governing department operations and clinical practice Monitors, evaluates and reports on quality assurance activities Credentials Committee Performs detailed review of applications/re-applications, evaluations and related documentation Make recommendations to appoint/re-appoint to Executive Medical Staff/Medical Executive Committee (EMS/MEC) Peer Review Committee Investigates complaints/concerns reported to the committee Makes recommendations to EMS/EMC 21 Page 75 of 97 CCHHS Medical Staff I April 29, 2016
The Review Process 22 Page 76 of 97 CCHHS Medical Staff I April 29, 2016
Credentialing 23 Page 77 of 97 CCHHS Medical Staff I April 29, 2016
Credentialing and Privileging Primary Source Verification: verification from the original source Education Training Certification Licensure Experience (current/past program directors, chairs, peers) Hospital Affiliations Special Qualifications Clinical Competency External Queries (NPDB, OIG, SAMs) 24 Page 78 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Credentials Committee Duties Review the credentials of all Applicants and Members applying for initial appointment, reappointment, and clinical privileges. Review information on applications for appointment and reappointment and communicate with references where appropriate Review any reports referred by the Executive Medical Staff Committee, Medical Information Committee and the Hospital Quality Improvement and Patient Safety Committee that may concern the professional or clinical competence of Members and make recommendations to the Executive Medical Staff Committee regarding privileges of any Members 25 Page 79 of 97 CCHHS Medical Staff I April 29, 2016
Medical Staff Credentials Committee Duties cont. Review and recommend initially and biennially or more frequently, if the Committee determines this to be necessary, the extent to which Non-Member Practitioners will be permitted to exercise Collaborative Clinical Privileges in the Hospital Review requests for and make a written report to the Executive Medical Staff Committee on the initial and continued exercise of Collaborative Clinical Privileges for Non- Member Practitioners Identify any trends with OPPE that would trigger an FPPE and monitor compliance with FPPE 26 Page 80 of 97 CCHHS Medical Staff I April 29, 2016
Professional Performance Evaluation: The Joint Commission MS.08.01.01 The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner s professional performance MS.08.01.03 Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal 27 Page 81 of 97 CCHHS Medical Staff I April 29, 2016