2013 Budget Review October 30, 2012

Chief Judge of the Circuit Court, Tim Evans, spoke to commissioners on Tuesday, October 30th regarding his budget for the upcoming year--2013.  His main difference with President Toni Preckwinkle's recommendation for his office is that he wants 25 new employees to staff a Pre-trial Service Center at the court.  The duties of these employees would be to independently and objectively evaluate information given by prosecutors  and defense attorneys about a defendant regarding bail, bond, etc. before the trial takes place.   They would assess risk to the community and would make sure the rules are followed by defendants awaiting trial.  One goal of this is to keep more people out of jail before trial if they are low risk--at a savings of $145 per day.  Currently 57 other employees are doing this job along with their other duties.  He indicated that ideally 200 employees are needed for this Pre-trial Service Center as was the case during the 1990's. Budget Director Andrea Gibson suggested using vacancies already in the Chief Judge budget to fill those positions.  There was some talk of using "turnover" numbers of employees, but it was unclear whether this was effectively used by the Chief Judge last year.

Case Management of Defendants:
Several commissioners questioned the Chief Judge regarding communication between Sheriff Dart's office, the probation department and the courts.  It appears that complete information about defendants (place to stay, phone number, risk, etc.) is not transferred from the court to the Sheriff so that effective electronic monitoring could take place. The length of trials was also discussed (an increase of 3 days from last year), especially the number of continuances.  According to the Chief Judge, 94% of trials take 2 years or less to complete. Basically, the Sheriff is asking for more effective case management of defendants throughout their involvement with the court system.

Juvenile Defendant Issues:
Other commissioners brought up the lack of weekend court for juveniles. If they are arrested early on the weekend, there is no one to release them so they remain in jail for longer than an adult in a similar situation. Evans replied that state law does not require charge or release within 48 hours for juveniles. If the state law were changed, he would provide a weekend judge. There was also talk of supporting staff union issues preventing weekend work.

The Chief Judge is also in charge of the Juvenile Temporary Detention Center (JTDC) which has had a temporary administrator for the past 5 years due to a court order to revamp that center.  Judge Evans feels the court order will soon be satisfied and that he can select a replacement by late spring of 2013.

After much back and forth on these and other issues, Commissioner Daley suggested a "sit down" between the Chief Judge's office and the Sheriff to work out their differences for a more effective system.

Mortgage mediation has again been budgeted at $3.5 million, though $500,000 of this was not spent last year and will be carried over to next year.  Ten full-time judges are assigned to mortgage mediation with about 8,000 cases per judge and over 500 days per case for the foreclosure process.  According to Judge Evans, there is a space issue with not enough courtrooms in the Daley Center to accommodate all these cases.

Cook County Forest Preserve Budget Hearing: October 25, 2012

Commissioners Present: Earleen Collins, John Daley, Gregg Goslin, and Larry Suffredin

Also Present:  Arnold Randall, General Superintendent, CC Forest Preserve District

Testimony began at 6:00 PM at the Skokie Court House, Skokie, IL

1) Kay Havens (Chicago Botanic Garden Staff) spoke about the internship program at the Gardens which began in 2002.  It gives hands on experience in botany, wildlife management, land-usage and conservation.  There have been 75-100 graduates of the program who have gone on to jobs in land conservation.  Federal stimulus dollars have been awarded to this nationally recognized program.

2) Joseph Walsh teaches ecology and genetics at Northwestern University.  He utilizes the forest preserve for his undergraduate classes and urges an increase in funding. There have been many proposals for additional programs in the forest preserve such as building a convention center to get people to interact with nature and building playgrounds.  These suggestions do not really encourage people to interact with nature.  Children are “hardwired” to respond to animals and to nature.  We need to be sure that we are not constructing artificial barriers to such interaction.

Arnold Randall commented that in the past the budget number has been inflated.  Commissioners are trying to be more transparent now and to be clear on what is actually being spent, rather than just putting out a number on paper. He assured Mr. Walsh that proposals that don’t make sense will be filtered out in the planning process.  Comm. Suffredin encouraged Mr. Walsh to continue using the Forest Preserve for his classes at Northwestern.

3) George Blakemore (a concerned citizen) wants citizens, particularly those in the black community, to get a fair share of jobs and contracts.  The commissioners need to educate and enlighten citizens about these meetings.

4) Rett Donnelly (volunteer in FPDCC) was happy to hear that the budget is not actually shrinking.  He and other volunteers have been working to combat invasive species such as buckthorn, Asian parsley.  He urges caring for what we have now rather than initiating new programs like camping, zip lines, etc. The FPD would need to add police for these new programs, which is an added expense.

Mr. Randall said that historically the FPD has not reached out to the general population.  They need to find ways to get people into the Forest Preserves.  People of the next generation need to be involved and learning to care for this resource.

--Submitted by Georgia Gebhardt

Cook County Budget Hearing, Skokie Courthouse, October 25, 2012

The Cook County Budget Hearing took place at 6:30 PM at Skokie Courthouse, Skokie, IL

Commissioners Present: John Daley, Larry Suffredin, Earleen Collins and Gregg Goslin

The following people testified before the commissioners.

1) George Blakemore (a citizen) urged commissioners to maximize use of tax dollars and not to employ illegal immigrants, who take jobs away from the black community.

2) Nefertiti Smith (AFSCME Council 31) was pleased that the budget contained no wholesale layoffs.  She was concerned that no one is being hired to fill current vacancies in the public defenders office, state's attorney, e.g. clerical positions.  Attorneys are forced to handle paperwork themselves because of short staffing.

3) Teayonia Cannon (AFSCME, Local 3696) was pleased that there were no layoffs, but she, too, was concerned that vacancies are not being filled in juvenile probation, forensic clinical services, and public defenders, e.g. She urged commissioners to look for additional revenue for these support staff positions.

4) Joel Africk (Respiratory Health Association) spoke in support of the $1 increase in the cigarette tax.  Young smokers are sensitive to cost and many will quit or not start in the first place.  We can save $25 million in medical expenses if we keep people from smoking.

5) Bruce Edenson (a citizen) said that he is a legal firearms owner and a member of the NRA.  He shoots for recreation and is opposed to the tax on firearms and ammunition.  He cited the 2^nd amendment right to bear arms.  There have been 400 homicides in Chicago, but 99% of bullets used were used in hunting and shooting.  This tax imposes a hardship on the gun owners and does not impede crime.  Gun owners will go outside Cook County for bullets and firearms.

6) Mary Kenney (AFSCME, #3486) represents probation officers.  The budget cuts 35 positions in the adult probation department.  They have lost 14% of work force, number of cases have jumped 82% and 40% of officers are working above case load.  The paperwork is burdensome. With the “second look” program the court will further stress the probation staff.  She urged restoration of at least 35 positions.

Commissioner Collins asked if there was any data on probationers’ recidivism.  Is the probation department effective? She supports reduction of jail population, but then there needs to be good probation services instead.

7) Barry Roseth (a citizen) objected to the taxes related to guns.  He stated that gun owners were being singled out and that is unfair.

8) Don C. Haworth (Owner of firearms school in Chicago and a private investigator) felt that he was being harassed because he recently was ticketed for a sign violation.  He wondered why the County doesn’t do something about all the unsupervised kids. He advocates concealed carry and is against the tax on bullets.  Gun owners will only go to other counties to buy bullets.

9) Jennifer Bobay (a community college teacher) had four students shot and killed.  She supports the tax on firearms and bullets.  She said if something can take someone’s life, it should be expensive to obtain.

10) Richard Feiss (a citizen) said he is a Vietnam vet with many pre-existing conditions.  Many of his fellow citizens are hurting now and need the safety net in Cook County. One should not have to commit a crime to get free health care in the jail. 

11) Diana Hackbarth (Illinois Coalition Against Tobacco) has a PhD. in nursing and takes care of patients with tobacco-related diseases.  She approves of raising tobacco taxes because it will discourage kids and adults from smoking. Taxes will result in savings to long-term health costs for Cook County.

12) Becky Dea Kyne (a citizen) is the mother of a child lost to gun violence.  She supports the bullet tax to combat violence that took her son.

13) Leonard Simpson (SEIU, Local 73) supports tax on tobacco and firearms.  He does not support managed competition and privatization of services. Union workers can provide better services with fewer turnovers. There should not be a “race to the bottom” in wages.

14) Anna Cienkowski (a citizen) opposes the tax on firearms and bullets.  She said she needs to protect her home.  She does not feel safe.  Taxes on “Mom & Pop” shops that sell guns are a hardship.  She supports concealed carry.  She asserts that guns are already regulated by the State Police.  She is against providing services to undocumented people.

15) Vidan Cienkowski is a naturalized citizen who objects to the rise in taxes.  Government makes excuses for raising taxes.  She is opposed to firearm and bullet taxes.

16) Lynn Morris (owner of Morris Gaming) is a naturalized citizen opposed to gaming terminal tax.  The video gaming tax will destroy her business.  It will hurt jobs.

Hearing was declared closed by John Daley. 

--Submitted by Georgia Gebhardt

CCHHS Quality and Patient Safety Committee Meeting, October 16, 2012

CCHHS will complete its survey of safety status by the end of February 2013 to be ready for the JointCommission's accreditation visit.   (Accreditation must now be renewed every three years or the Center for Medicare and Medicaid Services won’t reimburse the system for services rendered.)  The Commission uses tracer methodology, which means following patients throughout the process: speaking to their families, checking the credentials of all those who touch them, etc.; so CCHHS did a mock tracer study in advance.  A Committee member asked to see the results of this mock study.

The Joint Commission has 1700 areas of performance: Stroger’s Big Five are Environment of Care; Life Safety (both focused on the building); Infection Control; Provision of Care; and Performance Improvement (how to use data). Each has a multidisciplinary subgroup assigned to it, which meets weekly.  The Life Safety team has called for increased training and closer supervision of contracted staff such as Sheriff’s personnel who bring prisoners into the hospital.  There’s now a hotline to report problems with cleanliness and all staff are urged  take personal responsibility for hand-washing and IV removal to prevent infection.

The Provision of Care group has focused on special care for vulnerable populations (pediatric, psychiatric and the elderly).  In response to a question, Dr. Das noted that the needs of non-English speakers are addressed through a 24-hour phone interpreter service.

Reports from the Medical Staff Executive Committees

No report from Provident; Dr. Wakin was absent.

Dr. Goldberg of Stroger reported a focus on meeting the time frames of the Affordable Care Act: “We want patients to keep choosing us.”  He invited Board members to schedule attendance at the “Schwartz rounds” to learn about the hospital’s multidisciplinary approach.  In response to a question Goldberg said the use of Electronic Medical Records (EMRs) had not reduced physician productivity–“the doctors just spend more time.” 

Electronic Medical Records Update from Chief Information Officer Dr. Hota

Chairman Michael again cautioned the staff to “make sure we’re not collecting useless information.”  The CORE Center reported an inability to complete departure notes in the new EMR, and asked for additional office support to relieve doctors and nurses of the task.  Dr. Hota noted that the hospital earned $12 million in Federal incentives ($44,000 per “eligible provider,” of whom there are 400) this year for meeting the EMR requirements of the Affordable Care Act, which include not only a specific timeline but specific prescribed software.  (These compliance subsidies will continue, at a steadily reducing level, til 2016, when they’ll be replaced by penalties for failure to comply.)

Committee member Dr. Munoz pointed out that if doctors did all the EMR departure notes (include review of all medications and aftercare instructions for patients) themselves they’d only be able to see two patients an hour, and urged the staff to consider whether someone else could take on the task.  Dr. Hota responded that each clinic establishes its own work-flow. 

On July 31 the system installed 1800 new computers and set up Web training to handle the continuous inflow of new staff and supplement the ½-time trainer.  By now 98% of the nurses and 70+% of the doctors are trained.  In some areas EMR use is very good: 100% of vital signs are recorded electronically and most divisions are using e-prescribe.  Chairman Michael asked the staff to prepare an estimate of necessary additional training resources.

Current Quality Measures/Reporting

PQRS (the Physician Quality and Reporting System) suffers from slowdown due to overuse, but CCHHS is adding additional servers and other infrastructure which will save time and the number of clicks per transaction.

The system is now working with Microsoft to have its old databases converted for use on the new system by exporting them to a Virtual Private Cloud Database.  In addition, they’re using an open-source reporting system created by two staff members using free software, which will be easier to tweak and update than software provided by a vendor.  Again personnel is needed: a team of data analysts and additional training.  Chairman Michael asked whether it was clear what should be measured. Hota responded that there were plenty of “obvious targets.”

Developing a Quality Dashboard

The staff proposed that the CCHHS Dashboard include:

1.                  Core Measures

2.                  Hospital-acquired conditions

3.                  Re-admission (though may result from outside factors, e.g. lack of primary medical care)

4.                  Immunization

5.                  Patient satisfaction (driven by the experience coming in the door and going out the door, plus “how we talk to you while you’re here”)

Chairman Michael suggested that the Committee make recommendations about what to include on the Dashboard, and share those with the full Board at its next meeting.

Dr. Das explained that the design of the dashboard should reflect the system’s aims, whether comparative or strategic.  An individual dashboard can show both  absolute measures (e.g. numbers of timely catheter removals, because Medicare/Medicaid will no longer reimburse hospitals for procedures resulting in catheter-related infections) and comparative measures (throughput in the emergency department: the state average is 2 hours, ours is now 10; how are we progressing?).  CCHHS will focus first on patient-safety and hospital-acquired conditions (falls, trauma, infections) because there are protocols to prevent these harms.  The Chair asked to see these statistics monthly, and Dr. Das agreed to come back in November with a recommendation of what the Committee should examine every month.

Updating the Quality Plan

The current quality plan will cover CCHHS through accreditation, but the system is now considering improvements for 2013 and should have a new plan by this year’s end.  The main aims should come from the medical staff and be considered by the Committee and then the full Board.   Dr. Murray of the Public Health Department reminded the Committee that the plan must look beyond the hospital at things like whether there are populations in Cook County that are inequitably served, and Dr. Mason concurred: “Public health is more important than what we [at the hospital] do.”  Chairman Michael suggested separating aims within CCHHS’s control from those that are not; the latter requires engaging outside partners such as the state and other hospitals.  He also stressed making sure the system is using the right data: there is a lot of information about Medicare patients, but 40% of CCHHS's patients are uninsured.  Dr. Mason pointed out the importance of measuring employees’ experience and satisfaction.

Patient Safety Indicators

In response to an earlier question by Committee member Mary Driscoll, Chairman Michael reported the advice of legal counsel that the Committee can’t review individual cases in which patient safety has become an issue without compromising patient confidentiality.  But as the Committee needs to be aware of safety issues, two of its members (Drs. Velzquez and Munoz) have agreed to serve on existing hospital committees and report back to the Committee on those issues.  Driscoll agreed the Committee didn’t need to see individual cases but “we need to understand the process.”  The chair promised that Dr. Mason would continue to educate the Committee on these issues, “but the key is learning about problems before they’re lawsuits.  We can’t do that here, but we’ll participate in existing committees and hear about risk management.”  

--Submitted by Observer Kelly Klein

Dept. Reviews Cook County 2013 Budget, October 22, 2012

Contract Compliance Director Shannon Andrews (new to the position) explained that this MBE/WBE/VBE office now includes Veterans (as well as minorities and women) in the effort to increase the use of  businesses run by these groups in Cook County contracts.  A relatively new ordinance was passed to accommodate this.  There are 10 FTE employees in this office.  Some accomplishments this year have been to make the registration process easier and more streamlined for these businesses, tracking contract compliance businesses, and having more outreach to minority-, women-, and veteran-run businesses.  The City of Chicago and Cook County now have the same requirements which should make it easier for these businesses to comply.  This year 19% of contracts have been awarded to minority-owned  and 5% to women-owned businesses.

Procurement/Purchasing Agent Lourdes Koss has been working on efficiencies and savings. This department has been training vendors on how to do business with the county.  She has been working on quicker bidding process because so many contracts are extended  instead of being re-bid on time. The cycle time for all contracts is still too high:  64 days for contracts under $25,000 and 264 days for larger contracts.  Much of the department has been restaffed from clerical to professional status and 35% of them are ready to take the qualifying Certified Public Professional Buyer exam.

Several commissioners questioned the use of consulting firm Accenture.  Concerns centered around this company getting paid to reduce expenses (for example in electricity use) when they really had no input on lower prices.  Another commissioner became angry at "middleman" use for office supplies.  Comm. Daley explained that the board had passed an ordinance--"procurement code"--which describes this process.  He did not feel the commissioners could exempt themselves from this code.

Kurt Summers, Chief of Staff, Office of the President explained that fiscal responsibility and streamlined methods transparency and accountability were goals of this office.  The budget calls for a $1.56 million decrease and lower staff numbers.  There are now 16 FTE employees.  The President's Office has partnered with 30 companies on a pro bono basis to improve services and lower costs.   They have reduced energy usage, produced on-time tax bills to save local governments money, and reduced hiring time.  Salaries for new hires are lower than under past administrations.  One commissioner expressed concern that there still isn't an attorney hired for the Board of Commissioners to help with ordinance writing and legal research.  It was explained that candidates have been interviewed and that several commissioners submitted members of their own staff for this position.

The newly named Justice Advisory Council deals with juvenile justice efforts and criminal justice in general.  They have been working on a bond court study to reconfigure bonds for low-risk offenders--reducing bonds so those awaiting trial  do not have to remain in jail.   Other areas of concern reducing the Juvenile Temporary Detention Center population as it is very expensive to house these youth and seems to be unproductive for their eventual release in society.  Fifty fewer youth detainees were held this year than last and the goal is to reduce the population even further.  Employment, housing, and healthcare for released detainees/prisoners is also a concern of this department.

The revamped Homeland Security and Emergency Management Department is designed to prepare for any type of incident--natural and man-made--that might arise in Cook County.  This department has had a lot of controversy in the past and it appears that reorganization, accountability, and more efficient use of equipment are goals.  There is also an increase in obtaining federal grants and in their efficient use.

Cook County 2013 Budget Departmental Reviews, October 22, 2012

October 22, 2012  Bureau of Finance
(CFO, Revenue, Risk Management, Budget and Management, Comptroller)

Commissioners Absent:  Butler, Goslin, Reyes, Murphy, Tobolski

CFO Tariq Malhance presented the balanced budget which had its audits done on time, is paying down the debt, is increasing efficiencies through collaboration with Chicago, and has shown savings in employee health care costs of 1/2 million per month.  This and other practices earned them AAA bond rating allowing lower interest rates for borrowing.

 Highlights of the budget is that it is down 2% from last year and has a revenue shortfall of $267.5 million  (Expenditures-Revenue=Shortfall).  The shortfall has been less each year of the last 3 years.  This gap is closed by eliminating 462 positions, most of which are vacant anyway; employee health care savings; and a hoped-for waiver of $99 million from the state to add non-paying residents to the Medicaid rolls.

Also some additional new taxes are proposed:  an additional $1.00 per pack of cigarettes ($25.6 million); a non-titled use tax for purchases made outside of Cook County by businesses, contractors and residents of Cook County ($15 million); tax on bullets & guns ($1million); gambling machine tax of $800 per machine ($1.3 million).

Special Purpose Funds are down 13.9%,  from $156,221,000 last year to $117,220,000 in the new budget.  Full Time Equivalent employee count is down about 400 positions to 21,526 employees for the next fiscal year.  New hires in Finance Department are 48 employees.  Some new hires will work on Technology and Capital Projects.  Others will be in area of tobacco tax enforcement.

There was a long discussion about the approach to revamping technology for the county.  Twelve new hires will need to start on preparing the scope of new systems. There were questions on why hiring of these important, high-level positions takes so long.  It appears that the Compliance Monitor  (and the inspector general and the plaintiffs) of the Shakman decree are taking up to 6 months to  decide whether a position is Shakman exempt.   These decisions are being negotiated among the parties involved.  Also not enough resumes of qualified people are coming in, probably because of the lower pay compared to private business. It was suggested that perhaps a headhunter could be hired to more efficiently find these needed employees.

Risk management, which deals with employee benefits, liability, safety and workers compensation, has also produced some savings in the new budget.   They have 22 employees with some of the newer hires dealing with disability leave checks.  There have been savings in employee and detainee medical rates. Seventy percent of employees are now in an HMO plan and detainees in the jails have a reduced Medicaid rate.  There has been a $293 million reduction in fringe benefit expenditures.  There will be exploration in encouraging employees to use the Cook County Health and Hospital System (Stroger Hospital).  There was also discussion on reducing the backlog of workers compensation cases by allowing cases under $25,000 to be more quickly processed and spending more resources and time on bigger claims.  There has been an increase of about $2 million per year due to the Affordable Care Act mandate to include children up to age 26 on parent's insurance.  The benefits package in the county (especially insurance) is considered very generous.

Budget and Management director Andrea Gibson stated that STAR management reports are considered in budgeting for the various elected officials and departments .  There will be a growing gap of the budget deficit due to increased wages/benefits, lack of  fees in the Health and Hospital System, and debt payments in years 2015-2017.

Cook County Forest Preserve

Unfortunately, at the last minute I was unable to attend the October 3 Board meeting, but it is worth noting that they have published their 2012 Land Acquisition Plan.  This will guide spending of the $25 million from bonds that were issued earlier this year.  Land Acquisition is one of the only areas in this year's budget where spending was increased,  with the intent to take advantage of low interest rates and a depressed real estate market.  See http://fpdcc.com/land-acquisition-plan/  for details.

Health and Hospitals Systems Board Meeting September 28, 2012

The meeting was called to order by Chairman David Carvalho at 7:35 am. 

In her finance committee report, chairperson Heather O’Donnell noted a concern that grants do not always cover the cost of the service provided, e.g. WIC, the women’s, infants’ and children’s nutrition program.  Carvalho defended the program as central to the CCHHS mission.  Another cited concern was that Carelink does not always screen outpatients to determine their Medicaid eligibility.  Chief Financial System Officer John Cookinham said staff was inadequate to screen everyone on a daily basis, but that the process will change with the 1115 Medicaid waiver, when outside vendors will do the screening.   

Human resources committee representative Maureen O’Donnell said efforts are in place to streamline the Shakman hiring restrictions, anticipating many new hires in connection with the 1115 Medicaid waiver.

CEO Dr. Ram Raju commended the Stroger Hospital trauma center, saying, “The reputation of this hospital was founded on the trauma unit.”  He showed a video of trauma surgeons in action following a shooting.  Additionally he praised the new CORE center, and commended housekeeping staff at all facilities.   Dr. Raju promised a budget before Thanksgiving.

Contracts totaling about $7m were approved to provide temporary admin and clerical staffing; provide temporary staff to determine patient Medicaid eligibility and enroll up to 115,000 new patients; and provide environmental cleaning services.

Dr. Krishna Das presented portions of the second quarter STAR Report, whose goal is to measure CCHHS performance over time in operational efficiency, patient satisfaction, quality/health outcomes, and financial stability.

Sample data for 2011:

Stroger Hospital:  Emergency department volume 138,950 total patients

                            Wait to be seen: 172 minutes average; Left without being seen: 12%

                             % of patients with length of stay greater than 7 days: 19%; goal 15%

                             Would definitely recommend this hospital:  64%

                             Would probably recommend this hospital: 29%

Provident Hospital: Emergency department volume 36,394 total patients

                                 Wait to be seen: 121 minutes average; Left without being seen: 9.1%

                                 Would definitely recommend this hospital: 60%

Dr. Das pointed out that 75% of Illinois hospitals have a higher patient satisfaction rating.  Carvalho said, “Public hospitals tend to be low in these numbers.”  CCHHS readmission numbers are above the national average.  Dr. Das concluded that in general, where Stroger Hospital falls short is in areas requiring multidisciplinary services and teamwork.  “Half of adverse effects are due to communication.”

Dr. Das presented data from Cermak Clinic showing that health nurses required between 45 and 62 hours to complete a face to face assessment; the goal is 24 hours. About 45% of diabetic patients incarcerated for over 120 days demonstrated control over their diabetes. Core Center data show that 91% of HIV patients are on the most recent viral medications.  Of 40,000 outpatients with diabetes, 92.2% were tested, and 22% are in reasonable control of their disease.

The meeting adjourned to closed session at 9:45

--Linda Christianson, LWVCC Observer