Cook County Board Meeting, November 14, 2012

The meeting was called to order at 10:15 am by President Toni Preckwinkle.  All commissioners except Steele and Beavers were in attendance.

All court orders, compensation claims, and employee injury compensation claims presented were approved.  Reappointments were deferred with the exception of Stanley Rakestraw's approval to the Metra Board of Directors.

The Reporting Lost or Stolen Firearms Ordinance was accepted.

A Pay Ordinance that would change the way part-time people appointed to various boards are paid, was discussed at length.  A roll call vote was taken on eliminating benefits, pensions and capping the per diem at $500 per day up to $12,000 per year for those serving on the Employees Appeal Board.  The motion was approved and will be in effect as of June 1, 2013.

Discussion began about applying the same measures to the Zoning and Building Board.  This board meets more often. A long discussion followed about capping the per diem at $500, with a maximum of $20,000 per year. This substitute language created many unanswered questions about grandfathering those still serving a term into the current language. The roll call vote failed and the item will be deferred to the next meeting.

Proposed substitute language for those serving on the Sheriff's Merit Board was also deferred to December 18th to gain more information about state statutes. Commissioners Suffredin and Gainer are leading the effort. All members of the board agreed that changes must be made to all three of these boards;  pensions and benefits will be eliminated.

A resolution was approved to provide for the transfer of funds from the moter fuel tax fund to the public safety fund.

There was a discussion regarding the need to set up an 11-member independent board for Human Rights.

A language change regarding the Cook county Board of Ethics composition and powers was approved.

A Legislative Electronic Document Management System has been adopted that will be an automated workflow solution that enables paperless creation along with a consistent and individual numbering system that will eliminate confusion among County legislative bodies.

The meeting was adjourned at 12:25 pm.

--Submitted by Pat Lind

CCHHS Quality and Patient Safety Committee Meeting, November 13, 2012

The meeting opened with a comment from a member of the public, a regular attendee, who in this case objected to the closing of Oak Forest Hospital and pointed out that the Committee had no black members. (County Commissioner Butler was once again absent.) Note: the staff who meet with the Committee are overwhelmingly non-white, including blacks and South Asians.

Dr. Mason reported that the Joint Commission had made its accreditation site visit ahead of schedule on November 2. (The federal Center for Medicare and Medicaid Services [CMS] uses the Joint Commission to evaluate and approve hospitals on its behalf.) Formal findings will be available in January, but the results were mostly positive.

• The hospital received no CMS Condition Citations (which would require correction before restoration of Federal reimbursement). 
• The hospital received Direct Impact Citations (calls for improvement) in life safety, including employee exposure to hazardous materials and lack of adequate smoke detectors. It also received Direct Impact Citations having to do with documentation of care and the related issue of cooperation among disciplines (e.g., the emergency room and the surgical department). Dr. Mason stressed that the issue was not quality of care but reporting, and noted the need for additional personnel to bring reporting up to snuff.
• The hospital also received an Indirect Impact Citation for bylaws issues, including the fact that currently the Medical Executive Committee can override the full staff in considering bylaws amendments. Dr. Goldberg reported that the medical staff will vote in 10 days on a bylaws revision permitting the staff to bring amendments to the Board even if the Executive Committee disapproves, and that he will bring the approved revision to the December Board meeting.

Response plans are due to the Joint Commission by December 17 (for Direct Impact Citations) and January 1 (for Indirect Impact Citations), but the hospital has four months to provide supporting data showing that the plans actually solve the problems identified.  Chairman Michael asked about the 1-3% of patients, about 30 per month, who wait more than 24 hours in the Emergency Room. Nursing Chief Russell responded that these patients are monitored closely and receive an "almost-inpatient level of care," but the requirement is to complete a broader assessment, including various cultural issues, within 24 hours. Michael asked how many additional nurses it would take to do that for the ER’s 45-60 daily patient load; Russell said she needed 3 additional nurses short-term, and more long-term if the hospital wants a dedicated ER admissions team. ER Chief Dr. Shadur uses tracking reports to identify the 2 patients who wait an exceptionally long time, so it should be possible to conduct a full assessment at the 18-hour mark to assure its completion within the mandated time.

Medical records continue to be "delinquent" (updated belatedly) because old charts can’t be sent electronically, and because of some system bugs now being worked out by Chief Information Officer Dr. Hoda. Again the Committee asked if the medical staff needs more training in the system and if there’s a training department to provide it; again Dr. Mason replied that the system has only one half-time trainer. He will report on record-keeping progress at the December meeting so the Committee can determine whether additional training staff is required.. Dr. Hoda said there are training hours included in the hospital’s latest contract for Electronic Medical Records, so teams are going out to clinics on training tours. In the next month or so he’ll know how effective that approach is and whether there’s actually a training deficit.

Mindy Malecki, Assistant Director for Management, reported that a draft disclosure policy would come to the Committee in December, once the legal department and Dr. Raju sign off on it.

Dr. Mason then showed another video, "Boards and Dashboards," with the latter term meaning a display of levels of performance for the staff to improve and the Board to assess. Two types of dashboard are in common use: the strategic, which measures progress against major goals, and the comparative, which measures progress against competitors or regulations. Though Boards must refrain from intervening in clinical care, they can measure quality by attending to outputs such as mortality rates.

For a strategic dashboard, each major goal (or "Big Dot," or "breakthrough quality aim") comes with a certain number of drivers--items contributing to its achievement--each of which in turn consists of a number of projects. So, for instance, for the goal "Reduce Mortality," the drivers might be Teamwork, Evidence-based medicine, and End-of-life care, each with specific projects.

The monthly "run chart" (dashboard report) should show projects and results for each driver. If insufficient progress is being made, Board and staff alike must ask, "Are we not executing our plan, or do we need a new plan?" Perhaps the projects aren’t getting done, or perhaps the projects don’t really affect the drivers or the drivers don’t really affect the goal. Every goal should include three stark measures: How good? By when? As measured by?

On a comparative dashboard, the Board should see any regulatory measures from which the hospital is deviating, and should be provided with an Exception Report for this purpose. This doesn’t have to happen every month, but it should occur regularly and must occur annually in advance of setting the following year’s quality goals.

Strategic dashboards are more useful because comparative data are always 6+ months out of date. In addition, if staff are rewarded or punished based on comparisons, they’re apt to argue about the quality of the data instead of improving the quality of care. Finally, comparative data make the Board complacent: doing well 50% of the time might look good compared to other systems, but in a system serving 100,000 patients that means 50,000 people are being harmed. Beware of measuring "the cream of the crap." Now that the Joint Commission inspection is done, Chairman Michael asked Dr. Mason to identify next steps. He proposed and the committee agreed on creating the 2013 Quality Aims and the dashboard to go with them. Committee member Dr. Munoz urged using the Joint Commission’s findings as a guide for the coming year, and de-emphasizing comparisons with other hospital systems. But he also asked the Committee to consider the hospital’s overall objectives for service: "We can’t deliver every service to everyone at every level. We need to find our areas of excellence and not deliver redundant care." The Chairman noted the task is to choose which priorities to focus on in 2013: "We don’t need to complete everything in one year."
  
After much discussion among Board members, Chairman Michael concluded that three items (hospital-acquired conditions, readmission and patient satisfaction) be considered by the full Board to serve as the Big Dot goals. He also suggested spending the Committee’s December meeting looking at other providers and identifying useful comparisons. He asked Dr. Hoda to advise the Committee about whether it’s looking at the right measures, and whether its sources of information are valid.
The Committee then accepted the 2011 Department of Public Health annual report and the reports on the hospital’s planning for emergencies and for the NATO meeting.

Dr. Wakim then reported that the gastro-intestinal initiative at Provident was going well, and that they were preparing to establish a fund specifically to support the GI unit there. They’re still staffing up the pulmonary clinic, a joint initiative of the city and county. He asked the fate of the existing strategic plan (the answer seemed to be, it’s about to be superseded by the new goals) and of Provident itself now that the Medicaid waiver has been approved (no answer).

After approving the minutes of the October 16 meeting and the recommended medical
appointments, the Committee adjourned at 1:20 pm.

--Submitted by Kelly Kleiman

Cook County Board Meeting, November 1, 2012

The meeting was called to order at 10:45 a.m. by President Toni Preckwinkle.  All commissioners except Murphy and Reyes were in attendance.   

A Pay Ordinance that would change the way part-time people appointed to various boards are paid, including the elimination of health and pension benefits, was moved to the Finance Committee. The sponsoring Commissioners need time to find more support even if it means a compromise that would make the changes applicable to new appointees while grandfathering current members.  Commissioners Suffredin and Gainer are leading the effort.   The change would affect several influential political appointees that now receive full time pay and benefits for part time service.  

The Regional Transportation Authority wants a $30 million Bond Issue to help offset a $30 billion backlog of deferred maintenance projects.  The RTA initiated a 6-county area Transit Study that will be ready by April 2013 and will make recommendations for a better integration of the CTA, PACE, and Metra services; funding streams for both capital and operating budgets; and a fair distribution between the three regional transit services.  Currently the state owes the region $400 million in transportation funds.Ridership is up 5% but the fair box makes up only 25% of transit costs. 

Electronic Monitoring:  The Sheriff’s office, the Courts, and the Administration are close to issuing an RFP that calls for the consolidation of electronic monitoring equipment under one vendor contract.  “Getting it Right” is important to President Preckwinkle’s goal of reducing the county jail's nonviolent population.  We have written before on the huge cost to the County to hold nonviolent offenders either before, during, or after sentencing.  

News of Interest

Kurt Summers, Chief of Staff for the President is leaving this month.  The Commissioners overwhelmingly lauded his contributions to reforming Cook County Government.

Veterans Day is November 11.  Cook County has 260,000 living veterans which is the largest Vet population in the state. 

Lane Tech High School won the national 2012 Blue Ribbon award – one of two in the entire state and one of 307 across the nation.  Quite an accomplishment!

The meeting was adjourned at 1:40 p.m. 

 Submitted by  Diane Edmundson

Cook County Departmental Budget Hearings October 31, 2012

State’s Attorney’s Budget
State’s Attorney Anita Alvarez stressed that the proposed budget for her department does not reflect what is needed but the realities of what money is available.  While the American Bar Association says that the average case load for prosecutors should be no more than 150 criminal or 450 misdemeanor cases, her assistant state’s attorneys average 217 criminal or 940 misdemeanor cases.  Staffing shortages result in longer case times. There is a backlog in the appellate division, which has resulted in her asking assistant state’s attorneys to volunteer their free time to help write appellate briefs so that court deadlines are met.  She said that she had just heard about a proposal to create a Gun Court, and if that does come into being, she may be coming back to the County Board for more money to staff it.

--Submitted by Priscilla Mims

Cook County Departmental Budget Hearings October 30, 2012

JTDC Administrator Expresses Concern with President’s Recommended Budget
Earl Dunlap, the Federal Court-Appointed Temporary Administrator of the Juvenile Temporary Detention Center (JTDC), expressed concern that the President’s recommended JTDC budget of $42 million would not be enough and could either hamper the ability of the County to at last transition the JTDC from Federal Court supervision to the Chief Judge, or, if that transition occurs, hamper the Chief Judge’s ability to properly operate the facility.  Mr. Dunlap has presented the President with a $45.5 million budget. 

In particular, Mr. Dunlap is concerned that the President’s proposed budget relies on being able to close a second center within the JTDC (one is already closed) by June of 2013 based on being successful in the goal of lowering the daily population.  Mr. Dunlap pointed to the fact that as of that morning, there were 303 youths in the JTDC, which requires the use of the 3 current centers.  Mr. Dunlap says that the daily population can swing dramatically, and that it is common for there to be large increases over the weekend.  The problem is that there is no Judge on duty to make determinations on the weekend as to whether those youths picked up then need to be in the JTDC.  However, Mr. Dunlap did say that 46% of the population is there 7 days or less, which he says calls into question whether most of these youths needed to be in temporary detention at all.  So this is the area to look at if the daily population is to come down.

Budget Director Andrea Gibson told the County Board that unless the daily population does indeed drop, the second center will not be closed.  However, Ms. Gibson said that there is enough flexibility in the budget to handle keeping the third center open beyond June, and, if necessary, through the end of 2013.  Comm. Suffredin asked whether the Federal Judge overseeing the JTDC case has seen the President’s proposed budget.  Mr. Dunlap said “no.”  Comm. Suffredin suggested that the budget resolution to be passed by the Board be made flexible enough so the County could react to any concerns from the Court since the entire 2013 Budget is due to be passed before the Court will see the JTDC budget.

Mr. Dunlap, as in past years, expressed his disdain for the physical plant of the JTDC.   He also said that there were 2 main impediments to transitioning the JTDC to the Chief Judge:  (1) the critical safety issue resulting from a lack of video cameras, and (2) the lack of management technology.  However, there are capital dollars budgeted for 400 or so cameras to at last be installed at the JTDC.  These will provide evidence when youths complain about other youths or staff, and when staff complain about the youths’ behavior. 

A proposal is currently being reviewed by the County’s Chief Information Officer for a management system.  Related to that is the lack of any information from the Juvenile Probation and Court Services Department on youths being admitted to the JTDC.  However, since this department reports to the Chief Judge, it is unclear why information isn’t being given to the JTDC.

On the success side, Mr. Dunlap expressed his admiration for the majority of staff at the JTDC now.  He also said that the mental health services being provided to the JTDC are some of the best in the country.  

--Submitted by Priscilla Mims

Cook County Departmental Budget Hearings October 29, 2012

Health & Hospitals System’s Budget Balanced Thanks to Receiving 1115 Waiver from Fed. Govt. 

David Carvalho, Chair of the Board of the Cook County Health & Hospitals System (HHS), and Dr. Ram Raju, Chief Executive Officer of HHS, both expressed their great pleasure and relief that they were able to announce that the HHS had received an 1115 Medicaid Waiver from the Federal Government allowing them to enroll people now with incomes less than 133% of the poverty level and receive the Medicaid portion from the Federal Government, which is 48 cents on the dollar billed.  Currently, HHS might not be receiving even that amount.  In 2014, when the Affordable Health Care Act goes into effect, HHS will receive 100 cents on the dollar from the Federal Government for these people for 3 years, when it will drop down to 90 cents on the dollar.  (The State of Illinois is supposed to be supplying the remaining portion, but given the State’s financial condition, HHS is not expecting to receive any amount any time soon.)

As a result of this Waiver, HHS was presenting a balanced budget to the Cook County Board, albeit with a continuing subsidy from the County.  HHS expects to net $99 million over the costs of implementing the Waiver.  Absent the Waiver, HHS would have had a $99 million budget shortfall.  However, HHS has to do several things to maintain the Waiver, including signing up 115,000 people under the program.  HHS already has 67,000 qualifying people in its system and there are another 47,000 people in other federally qualified programs.  HHS estimates that there are 215,000 people in Cook County who would qualify under the program, meaning there are another 100,000 or so people that HHS could potentially sign up.  Work is underway to develop methods for reaching out to these people.

2013 Critical to Transforming HHS

Dr. Raju said that the 2013 budget presented to the Board is critical to transforming the health care system under the County to a patient-centered model.  When the Affordable Care Act goes into effect in 2014, many of the patients Cook County currently serves will now have health insurance and thus will have more options for care.  In order to keep patients with insurance who can pay for the care HHS provides, it is critical that they view HHS as an attractive option.  Otherwise, HHS will be left with only those patients who do not qualify to obtain insurance. 

While HHS continues to need significant dollars from the County to balance the HHS budget, Dr. Raju pointed to improvements in the HHS collecting fees from patients.  Revenues are up $100,000 more than in 2011, and physicians are at last billing for their services, with $5.2 million collected already thus far in 2012, and $12 million projected in 2013.  In addition, significant cost savings are being realized due to supply chain improvements.

Dr. Raju said that HHS needs to hire 444 people this year, with 144 positions needing to be filled in the next 8 to 10 weeks, and a plan to hire about 30 new people a month beyond that.  Dr. Raju stressed that HHS actually needs more people, but this budget reflects what can realistically be done during the course of the year.  He also stressed that he has eliminated all positions that won’t be filled this year.  (Often, departments maintain approved positions, but carry them at a $1/year salary.  All such positions have been eliminated from this HHS budget.)

Mr. Carvahlo stressed that one problem facing HHS is that the upper level salaries are not competitive enough to attract the talent needed.  HHS is working with Human Resources and the Shakman Compliance Officer to streamline the hiring process.

Patients from Outside Cook County

Based on a past survey, about 7% of the population being served through HHS comes from outside of the County, which amounts to about $25 to $30 million in costs.  In the past, HHS has not done a good job of keeping track of these people, but expects to do so in the future.  A new Illinois law prohibits a hospital that provides care from billing a patient whose income is less than 200% of poverty, no matter where the patient lives.  But a hospital is not obligated to provide care, except in emergency situations to save the patient’s life.  Currently, HHS provides all care.  The HHS Board is starting to have discussions as to whether there needs to be a change in policy for patients who come from outside the County.  Commissioner Tobolski stressed that Cook County taxpayers cannot continue to be asked to pay for care given to people from outside the County.

--Submitted by Priscilla Mims