Cook County Health and Hospitals System Board of Directors Meeting February 27, 2015

Chairman Hill Hammock called the meeting to order at 9am

Board and Committee Reports minutes were approved

A)     Board of Directors meeting minutes 1-30-15 approved

B)     Quality and Patient Safety Committee meeting 2-17-15

i.                 Metrics:    Director Gugenheim provided a lengthy overview of the QPS Committee organizational structure using a powerpoint [powerpoints presented at BoD meetings are now posted on-line on the CCHHS website under Governance section,click on BoD meetings—this is new and extremely valuable to BoD observers ]   A list of future presentations to the BoD (quarterly) and annually to the QPS Committee were provided.

ii.                  Focus Area Presentation:    A 5 year Accreditation Timetable listing all agencies that accredit any component of CCHHS,  and scheduled upcoming/past inspections listed.   In 2015: the following inspections are expected:   Stroger Hospital (JCAHO); ACHN (Primary Care Medical Home certification); Provident Hospital lab  (College of American Pathologists); Stroger blood bank ( FDA);  Stroger Hospital medical training programs (Graduate Medical Education).   

One of the Directors asked why GME accreditation, which is partially funded by Medicare, should be an issue at CCHHS which sees relatively few Medicare patients. Dr. Krishna Das, Chief Quality Officer, noted that despite few Medicare patients, the CMS licenses payments which applies to the entire Hospital.  Dr. Shannon indicated that JCAHO’s inspection will be unannounced and they will be bringing 5 surveyors for 4 days of inspections and over 1000 questions on the checklist.  JCAHO has deemed status for CMS conditions of participation.  Dr. Das displayed the table of teams that have been organized by discipline/category to prepare for the JCAHO inspection.  A Director asked whether the BoD would be involved in the Leadership Standards component of the JCAHO.  Yes, the Board members may be interviewed and were also invited to the Leadership Team meetings.

The PCMH inspection allows CCHHS to choose the clinic (from ACHN) that is inspected (Dr. Das said they would choose the Prieto Clinic which is the best run with staunch loyalty of patients to the Clinic).  Director Gugenheim questioned that approach “why shouldn’t we try to improve the quality of all of the Clinics?”  (see powerpoint posted on CCHHS web site for detailed information)

Director Gugenheim reported a recent unannounced IDPH survey triggered by a patient complaint for which CCHHS had to provide the Metrics: how do we reach certification goals 1)patient and staff education 2) patient self-management 3) access to care  4) referral management 5)quality performance improvement team approach at the Clinic level.

C)    Audit and Compliance Committee Meeting 2-19-15

Director  Velasquez and Chief Compliance Officer, Cathy Bodnar reported that the CCHHS Internal Audit Charter was audited by the Firm Mcgladrey and Board Rules were reviewed.  A lengthy powerpoint of the  CCHHS Compliance Program Operations Plan was presented including graphs of the number of corporate compliance issues investigated/determined violations which are increasing in number.  A Director asked what the most common violations were and it was reported that HIPPA breaches (determined to be unintentional, not malicious) associated with electronic transmission of patient data. Corrective action includes encryption of all e-mails.

CountyCare Compliance Plan presented including monitoring of Fraud,Waste and Abuse.   Metrics provided included incidence of 1) upcoding 2) boilerplate coding  3) allegation that individual ineligible for CountyCare.  Director Marsh suggested that there should be random routine audits of charts for all health care providers (not to blame but to educate on coding issues etc.)

D)   Managed Care Committee meeting 2-19-15

Director Lerner and Exec. Dir. of Managed Care, Steven Glass presented an update of CountyCare. Goal of enrolled members is 124,318, at the end of Jan. 2015 it was 96,508 which is an improvement from Dec.2014 : 86,562.  Issues discussed included the CountyCare redetermination process, IL State funding of Medicaid, and prescription utilization by CountyCare members.  It was noted that members do not tend to use CCHHS pharmacies.  Dir. Wiese reported an incident of poor customer service in the redetermination process and wondered if this type of issue was responsible for lagging redetermination for eligibility in CountyCare.

E)     Human Resources Committee Meeting, 2-20-15

Director Wiese and HR Director Ms. Lopez reported that the goal was to reduce the Jan. 2015 vacancies of 1018  to 600 by year end with a decrease in the time to hire to 94 days.  One of the Directors wondered if there were excess  positions which may not need to be filled.  Brief discussion on the cost of replacing vacancy (HR time etc.)

F)     Finance Committee Meeting 2-20-15

Doug Elwell Deputy CEO Finance & Strategy noted that the financial metrics reviewed by the committee revealed a small operating surplus at the end of the Quarter with 93 days of cash on hand (good).  Dir. Collens responded that “We [CCHHS] are nowhere close to showing a profit”; and that the timing of reporting of various figures may not reflect the full picture. 

 

National Metrics are planned to be accessed to compare CCHHS financial data to similar hospitals nationally (County/Academic hospitals of comparable size) and to set up goals/measures /targets and benchmarking.  The Committee in the future will look for benchmarking of CCHHS to all hospitals (not just County ones) because Chicago is a town with numerous hospitals that CCHHS must compete with.   

Dir. Collens stated that it would be interesting to know what FTEs unit/work are at CCHHS vs other hospitals.  “Maybe we could decrease FTEs because they are in excess already.”

It was reported that they were looking at services that could be brought in house which would save money. Collective bargaining negotiations with the CCHHS unions ran into a sticking point with a “work rule issue of monitoring phone calls made  for quality purposes”. This has been resolved and the Union dropped their objection when it was documented that monitoring calls was a national standard.

Action Items  BoD approved all contracts except one which had not yet been reviewed by the Finance Committee.

Report of Chair of the Board Chair Hammock referred all to his written report.

Report of CEO Dr. Shannon noted that there were 5 responses to the RFP for the Central Campus redevelopment project.  These will be reviewed and eliminated to 3 in the next few months which will undergo further assessment. 

 

Dr. Shannon reported on legislative issues at the State level including the Governor’s budget calling for cuts to Medicaid which will adversely affect CCHHS.  He mentioned that a continued conversation with State and Federal Legislators on Medicaid funding would be important to advocate against cuts to the Medicaid funding.

Meeting adjourned to Closed Session at 12:15 pm

Submitted by Susan Kern