Minutes Maricopa County Special Health Care District Board of Directors Formal Meeting Maricopa Medical Center Auditoriums 1 and 2 November 25, 2013 1:00 p.m. Present: Mary A. Harden, R.N., Chairman, District 1 Mark Dewane, Vice Chairman, District 2 Susan Gerard, Director District 3 Elbert Bicknell, Director, District 4 Terence McMahon, Director, District 5 Others Present: Steve Purves, MIHS, President & Chief Executive Officer Bill Vanaskie, MIHS, Chief Operating Officer Robert E. Fromm, Jr., M.D., M.P.H., MIHS, Chief Medical Officer Warren Whitney, MIHS, Chief External Affairs Officer Louis B. Gorman, MIHS, District Counsel Sherry Stotler, MIHS, Chief Nursing Officer David Wisinger, M.D., MIHS, Chief of Staff Marshall Jones, MIHS, Vice President of Human Resources Kathy Benaquista, MIHS, Vice President of Finance Susan Doria, MIHS, Vice President of Strategic Planning Guest Presenters: Connie Baker, Ernst & Young, Coordinating Partner Recorded by: Melanie Talbot, MIHS, Executive Director of Board Operations Cynthia Cornejo, MIHS, Assistant Clerk of the Board Call to Order Chairman Harden called the meeting to order at 1:03 p.m. Roll Call Ms. Talbot called roll. Following roll call, it was noted that all five voting members of the Maricopa County Special Health Care District Board of Directors were present, which represents a quorum. Pledge of Allegiance The Pledge of Allegiance was led by staff from Central Sterile. Call to the Public Chairman Harden called for public comment. There were no comments from the public. Ms. Talbot welcomed Ms. Cynthia Cornejo, the new Assistant Clerk of the Board.
General Session, Presentation, Discussion and Action: 1. Department Spotlight Chairman Harden asked the representatives from the featured department, Central Sterile, to introduce themselves, describe what they do and how long they have been at MIHS. o o o o Mattie Castro, Manager of Central Sterile and Clinical Equipment, explained the vital role the central sterile department has in the operation of the hospital. Central Sterile is responsible for cleaning, high level disinfecting, assembling, processing and sterilizing surgical instrumentation. Ms. Castro started her career with MIHS is 1979. Mauricio Trejo is the Clinical Equipment Technician and has been with MIHS for 15 years. Anna Clarkson is the Central Sterile Technician II Certified and has been with MIHS for one year. She appreciates the support she received from her manager to continue improving. Roderick Sopson began his career with MIHS as a transporter and is currently the Central Supply Coordinator. Chairman Harden said that MIHS employees are the best asset the District has. Mr. Purves recalled the tour he received from Ms. Castro of the Central Sterile department. He is very impressed by the organized and efficient manner in which the department is run. 2. Approval of Consent Agenda a. Minutes: Review and Approve Special Health Care District Board of Directors Meeting Minutes dated: i. October 30, 2013 Formal b. Contracts: i. Approve a new contract (90-14-080-1) between Medtronic USA, Inc. and Maricopa County Special Health Care District, d.b.a., Maricopa Integrated Health System for Bradycardia, Tachyarrhythmia and Cardiac Resynchronization Products ii. Approve Amendment #2 to the contract (90-11-114-1-02) between Maricopa County Special Health Care District, d.b.a., Maricopa Integrated Health System and District Medical Group, Inc. to jointly fund the position of Director of Business Development iii. Approve Amendment #4 to the Intergovernmental Agreement (90-11-172-1-04) (ADHS11-004397) between Arizona Department of Health Services and MIHS for the provision of HIV testing to clients presenting in the MIHS Adult Emergency Department iv. Approve Amendment #2 to the Grant (90-13-060-1-02) (ADHS12-030743) between Arizona Department of Health Services and MIHS for a Program Manager and two Program coordinators to be hired to connect HIV-positive patients in the MMC Adult ED with primary medical care 2
2. Approval of Consent Agenda (cont.): c. Board Governance: i. Approve registration fee, commercial travel, lodging, meal & incidentals per diem, and Board per diem/stipend, not to exceed rates allowable under applicable District practices or policies, for Director Bicknell and Chairman Harden to attend The Estes Park Institute conference April 27-30, 2014 in San Diego, California ii. Approve No-objection letter for the City of Mesa proposed Foreign Trade Zone subzone for Project Cascade d. Medical Staff: i. Approve MIHS Medical Staff Appointments, FPPEs, Reappointments, Change of Privileges/Status, and Resignations for November 2013 ii. iii iv. Approve MIHS Allied Health Professional Staff Appointments, FPPEs, Reappointments, and Resignations for November 2013 Approve Proposed revisions of Certified Registered Nurse Anesthetist Practice Prerogatives Approve Proposed revisions to the Procedural Sedation Privileging Criteria v. Approve Proposed revisions to the Urgent Care Privileges vi. vii. Approve Proposed revisions to the MIHS Medical Staff Rules & Regulations Confirm Vice Chief of Staff Elect and the Member-At-Large Representatives Elect Vice Chairman Dewane moved to approve the consent agenda. Director Bicknell seconded. Motion passed by voice vote. 3. Discuss and Review Options Available to the District Board of Directors Regarding Hiring Its Own Counsel; Take Possible Action Chairman Harden stated the Board of Directors currently relies on District Counsel for guidance. Should the need arise for outside counsel, the Board will engage an outside firm. Director Gerard asked if there was an issue that arose to warrant the discussion. Chairman Harden stated that the item was posted to gain clarification from the Board on the direction of this item. Director Bicknell stated that he does not see the need to obtain its own counsel unless absolutely necessary. 3
4. Discuss, Review and Accept the Maricopa County Special Health Care District d.b.a. Maricopa Integrated Health System annual Audit for Fiscal Years Ending June 30, 2013 and June 30, 2012; Discuss, review and Accept the Maricopa Health Plan Financial Statements for Fiscal Year Ending June 30, 2013 Ms. Baker reviewed the process and the status the financial audit for Maricopa County Special Health Care District d.b.a. Maricopa Integrated Health System for Fiscal Years ending June 30, 2013 and June 30, 2012. She stated that with the full cooperation of senior administration and staff, the audit is substantially complete and Ernst & Young is prepared to issue an un-modified opinion on the financial statements; which can also be considered a clean audit. The signed opinion is expected to be completed by the end of November 2013. In completing the audit, it was noted that there were no changes to accounting policies adopted by the Board, and it was concluded the District s accounting practices and estimates remain consistent with prior periods and are appropriate. Some internal controls were also tested to ensure there is no material weaknesses resent within the System. None was found. Chairman Harden referred to the Draft Management letter, page 2; which stated In our testing sample, there were three instances where patient accounts receivable were overstated by $10 representing the co-payment for Copa Care patients. These co-payments were recorded twice, once by the hospital and once by the physician billing office. Copa Care patients are only responsible for the one co-payment. Management indicated that the billing office has been aware of this billing issue since March of 2013 and have been manually correcting these patient accounts. A permanent correction has not yet been made in the Epic system to correct the issue. She questioned if the issue of the Copa Care co-payments had been corrected. Ms. Baker stated that there is now a process set-up in the next phase of Epic and will be implemented when that goes live. Vice Chairman Dewane moved to accept the Maricopa County Special Health Care District d.b.a. Maricopa Integrated Health System Annual Audit for Fiscal Years ending June 30, 2013 and June 30, 2012. Director McMahon seconded. Motion passed by voice vote. Director Bicknell moved to accept the Maricopa Health Plan Financial Statements for Fiscal Year ending June 30, 2013. Vice Chairman Dewane seconded. Motion passed by voice vote. 5. Maricopa Integrated Health System Nursing and Patient Services Ms. Stotler introduced Sheri Beardsley, the Magnet Program Manager. Ms. Stotler reviewed the Maricopa Integrated Health System (MIHS) Magnet Journey, which began in 2008. The magnet application was submitted in December 2012, since that time a lot of work has been underway. A steering committee was established. It includes representation from other disciplines within the medical group, as well as participation from the Vice President of Revenue Cycle and the Vice President of Hospital Operations. The Steering Committee began looking at the following areas; a Transformational Leadership Focus Team; Structural Empowerment Focus Team; Exemplary Professional Practice Focus Team; and New Knowledge, Innovation and Improvements Focus Team. 4
5. Maricopa Integrated Health System Nursing and Patient Services (cont.) Ms. Stotler stated that it was soon realized that there was an opportunity for improvement in documenting the wonderful things being done at MIHS. A Writing Team was formed, along with a group of Magnet Champions, which educate staff on the Magnet Journey and encourage participation. A survey completed in August exceeded staff s expectations with a 73 percent return rate. The results revealed that MIHS exceeded in all areas but two; which were at the mean or just below. It was also discovered an opportunity to focus on promoting the nursing model for professional practice; as many employees felt that the medical (physician model) was in place. Ms. Stotler explained that the Magnet Journey is a survey similar to Joint Commission or Det Norske Veritas (DNV). Staff will be working diligently and plan on submitting documentation by August 2014 with the expectation of being surveyed and certified for Magnet sometime in 2015. Chairman Harden asked if the process is usually a 3-year process from the initial application. Ms. Stotler confirmed the timeframe and stated that staff wanted to take time to ensure everything is done correctly. She stated that the measure of RN to BSN will be easier to accomplish than estimated; as many nurses were considering additional education. Chairman Harden asked what type of support the District offers to nurses that are trying to go back to school. Ms. Stotler said that the system offers tuition reimbursement. Staff has also developed a Professional Nursing Council for Scholarships with the Maricopa Health Foundation (MHF). There will be two scholarships awarded by the end of the year. Universities are also trying to be aggressive and attempting to make advanced education affordable for people to attend. Mr. Jones mentioned that MIHS invests $400,000 in tuition reimbursement annually, with a vast majority of that being for advancement of nurses. Director McMahon asked if there is a requirement for continued employment upon completion of studies. Mr. Jones replied that there is a requirement of one year continued employment upon completion. Director McMahon asked if there was a coalition between those employees that take advantage of the opportunity and the retention rate. Mr. Jones stated that the specified group has very little turnover. Ms. Stotler said that staff has been working hard on the succession plan to ensure employees have an opportunity to grow within the organization once they receive advanced education. 6. Discuss, Review and Possible Action on the October 2013 MIHS Key Indicator Dashboards Dr. Fromm reviewed the quality dashboards for October 2013. He noted that that there was an error on the mortality rate included in the information. The correct figure is 0.905 percent; however, that is still higher than target. In reviewing the mortality cases, nothing was identified to be a contributing concern. With the majority of indicators, staff has done fairly well with falls, medication errors. The restraint episode rate is still over target and that will fluctuate, especially in the behavioral health unit. Readmission rate continues to be over target. This can be related to those not seeking care after treatment or discharge from the hospital. There is a process in place for those that are considered highrisk, such as following-up with patient to ensure they are following up with their primary provider after treatment. 5
6. Discuss, Review and Possible Action on the October 2013 MIHS Key Indicator Dashboards (cont.) Director McMahon asked if there was any particular category in which readmissions were higher. Dr. Fromm said that it is spread across the board. Typical readmissions include those patients with heart failure, diabetes and infections. Mr. Vanaskie reviewed the operational dashboard for October 2013. Acute admissions were behind budget for the month as well as year to date. The length of stay was over budget for the month, but on track for the year. Acute observations were higher than anticipated; a result of opening the short stay unit when needed. Behavioral health admissions were strong but less than budget, and the length of stay was higher than budgeted. Visits to the Family Health Centers (FHCs) and Comprehensive Health Center (CHC) were better than budget with the 7 th Ave Walk-In clinic the only one behind budget. Operating room utilization was better than budget for the month with 71 percent utilization and the average surgical case running close to 120 minutes per case. Deliveries were on target for the month and remain better than budget for the year. Visits to both the adult and pediatric emergency departments were close to budget with the adult emergency department (ED) admitting nearly 14 percent. The length of stay continued to be over budget at 300 minutes. After excluding the behavioral health patients from the data it was noted that the length of stay changed to 277 minutes. Vice Chairman Dewane reiterated the Board s request to have the length of stay in the ED exclude the behavioral health patients. Director McMahon stated that, excluding the behavioral health patients, the average length of stay is 277 minutes; well above the budget set. He asked if the budgeted expectation was realistic and attainable. Mr. Vanaskie said that being a teaching hospital has certain challenges. The patient is to be seen by the medical resident and an attending physician; however, the goal is attainable. Ms. Benaquista presented the financial dashboard for October 2013. MIHS recorded a financial loss of $813,000 for October, which is $12,000 below budget. Maricopa Medical Center (MMC) had a larger negative variance of $131,000 for the month. Year to date the consolidated health system s loss is $7.2 million or $7.7 million unfavorable to budget. Staff does not believe that variance will be reduced by the end of the fiscal year. The total cash as of October 31, 2013 was $113.3 million against a budget of $183.7 million. The Graduate Medical Education (GME) payment for fiscal year 2013 has not been received. After reaching out to AHCCCS, senior administration was told that Centers for Medicare and Medicaid Services (CMS) has not released the funds. Staff is hopeful that will arrive prior to the end of the calendar year. Inpatient volumes were under budget for the month, admissions under by 11.5 percent and patient days under by 5 percent. The variances had an impact on gross inpatient revenues that are trending behind budget by 10.6 percent. The outpatient volumes and gross revenue are showing positive results as compared to budget and are trending 2.7 percent higher than budget; which is contributing to a higher adjusted patient day. Self-pay payor mix is running higher than budget for the year, however, October showed some improvement. This improvement resulted in higher net patient revenue for the month. 6
6. Discuss, Review and Possible Action on the October 2013 MIHS Key Indicator Dashboards (cont). Director Gerard commented that the financial indicators are in the red; however there seems to be improvement. She asked if there were adjustments being made to staffing, as the patient days were below budget. Ms. Benaquista stated that staff has been flexing due to patient volumes. Director Gerard questioned that if there is a need to alter the operations or adjust the projections, as the financials are not meeting budget. Mr. Vanaskie stated that there had been occasions when all indicators were meeting the goal. The current fiscal year had a challenging start with a $7 million deficit and remains $7 million behind budget. Adjustments are being made in staffing on a shift-by-shift basis. Staff is doing as much as possible on a day-to-day basis to manage with the volumes. Director Gerard questioned the approach staff will take to compensate for the $7 million variance. She does not recall a surplus of $7 million in the budget passed by the Board for the current fiscal year. The Board has since approved additional initiatives. She asked what staff was prepared to do to correct the situation. Mr. Purves said that the budget should be considered a plan based on trends and previous experiences. Staff wants to have challenging goals to work with and towards; however, senior administration needs to be held accountable to meet those goals. When a non-aggressive budget is in place, it can have unfavorable results. Senior administration will be utilizing better tools for improving outcomes and making assumptions. Director Gerard stated that she would prefer if senior administration investigate why a target is not being met and work towards a solution to correct. Currently it is a matter of increasing the patient volumes and creating a loyal patient base. This will be especially important with the implementation of the Affordable Care Act, when patients will have a choice on where to receive their care. Mr. Purves stated that there are currently meetings with the directors of various departments to review operations and hold staff accountable. 7. Consideration, Discussion and Possible Action on a Merit-Based Salary Increase for Melanie Talbot, Executive Director of Board Operations Director Bicknell moved to award Ms. Talbot a merit adjustment for the maximum allowable amount based on her overall score from her performance evaluation for Fiscal Year 2013. Director Gerard seconded. Motion passed by voice vote. 8. Reports to the Board of Directors; Discussion and Possible Action: a. Patient Satisfaction Survey Results b. Quality Report: Whole System Measures Dashboard c. Compliance Officer s Activities, Quality, and Effectiveness d. Internal Auditor s Activities, Quality, and Effectiveness e. Revenue Integrity Report f. Audit and Compliance Committee Semi-Annual Report g. Arizona Children s Center Activities Report h. Maricopa Health Foundation Activities Report i. Maricopa Integrated Health System s Monthly Employee Turnover Reports j. Patient Account Write Offs (greater than $250,000, less than $500,000) k. Unbudgeted New Positions/FTEs 7
8. Reports to the Board of Directors; Discussion and Possible Action, cont. Chairman Harden asked for a recap of the Monthly Employee Turnover Report, item 8.i. Mr. Jones stated that the voluntary terminations for the month were 1.20 percent for the month of October and 13.38 percent year to date. Chairman Harden questioned if there were exit interviews conducted at the end of employment to gain information as to why employees were choosing to leave MIHS. Mr. Jones said that the questionnaires are voluntary and it is difficult to gain valuable feedback from departing employees. The Human Resources department is looking at different solutions to get the information. 9. Concluding Items a. Future Agenda Items b. Board Member Requests for Future Agenda Items or Reports c. Comments i. Chairman and Member Closing Comment ii. President & Chief Executive Officer Summary of Current Events Chairman Harden reiterated Director Gerard s request on a future policy discussion regarding the establishment of separate corporate entities. Director Gerard also asked that staff review the Authority Matrix for the items that continue to come to the Board for approval. Mr. Gorman stated that Mr. Ayes, Mr. Maness and himself were working on a revision of the Authority Matrix and plan on bringing before the board in January 2014. The Board also requested information on the wait times for patients to be seen by a specialist in the CHC. Ms. Talbot will receive the report and forward information the Board. Mr. Purves stated that he has had some amazing tours around the hospital since his arrival. He has had the opportunity to visit various departments to witness the dedication of the staff at MIHS. His most recent tour was of the MIHS facilities and power plant. He is thoroughly impressed by the operation of this department. The emergency preparedness is excellent and should the facility lose power supply, it has enough resources to operate the entire facility for a week and half. He also shared how the physicians at MIHS are continuing to make their expertise available to the community by sharing their knowledge with the local media. Dr. Eric Katz recently discussed super bugs with ABC 15 and Dr. Kevin Foster was featured on a story which covered the dangers of frying turkeys this holiday season. Adjourn Director McMahon moved to adjourn the November 25, 2013 Special Health Care District Board of Directors Formal Meeting. Director Bicknell seconded. Motion passed by voice vote. 8
Meeting adjourned at 2:25 p.m. Mary A. Harden, R.N., Chairman Special Health Care District Board of Directors 9