Unexpected Increase in Charity Care Disclosed at Health and Hospitals System Board Meeting

COOK COUNTY HEALTH AND HOSPITALS SYSTEM BOARD OF DIRECTORS MEETING

November 20, 2015, 10:30am 

Chairman Hill Hammock noted that the CCHHS Finance Committee immediately preceded the Board meeting (9-10:30am) due to scheduling issues which prohibited it from being convened during the prior week.  He determined that the Finance Committee report would not be repeated during the full Board of Directors meeting as all but one Director was able to attend the Finance Committee.

He stipulated that Director Marsh, who could not attend the Finance Committee, was free to pose any questions she thought were warranted for her to be fully informed on all Board actions.

Committee Reports:

Finance Committee:  Director Marsh asked several questions about the $72,099,000, 3 year contract (4-1-16 through 3-31-19) with Valence Health which is replacing IlliniCare as the current 3rd party administrator of CountyCare (Medicaid).  Doug Elwell, Deputy CEO, responded that this was a competitive bid selection and is expected to save CCHHS $10-15 million per year.  Some of the reasons for the savings include bringing in-house some services that IlliniCare was tasked with including Behavioral Health care integration which will now be the responsibility of the individual provider.  Mr. Elwell concurred that the primary reason for severing the contract with IlliniCare, mid-contract period, was the increasing direct competition of IlliniCare’s managed care health plan with CountyCare which was felt to represent a conflict of interest.  Dir. Marsh questioned the level of diversity on the Board of Valence Health and diversity in the other levels of management and contracts with minority owned businesses.  Mr. Elwell and Chair Hammock indicated that Valence met CCHHS’s diversity policy. She asked whether this was the most costly outside contract that CCHHS was signing.  Mr. Elwell replied that it was second to the Cerner contract which was the largest.

  

Doug Elwell reported that October revenues were down due to lower numbers of patient hospitalizations, although length of stay was not decreased, meaning there was a need for better managed care interventions.  CCHHS is still owed $120 million by the State of Illinois (not paid due to budget impasse) and he said CCHHS may have to loan funds to the State to obtain Federal matching funds for Medicaid and other programs.  Director Lerner cautioned about the future when the State will be required to pay 10% of the cost of the newly eligible PPACA members (ObamaCare) by 2020; “the system can not look the same”.

Charity care has unexpectedly increased from what was thought to be a plateau in 2014. This is due to:

1. overflow from other hospitals that have restricted charity care; 
2. patients with an Affordable Care Act plan with unaffordable high deductibles are coming to CCHHS and refusing to complete charity care forms so their care can not be counted as charity for calculating the Federal Disproportionate Share Hospital payments.  Most of this will be considered “bad debt”.

Director Velasquez noted that 17 of the 20 healthcare cooperatives created under the ACA have failed and these patients will be coming to CCHHS.

Chair Hammock noted that the CCHHS 2016 budget was approved by the Cook County Board.  He asked Mr. Elwell whether CCHHS would be able to stay within the budget in 2016 and Elwell responded that he predicted a “breakeven”.

Quality and Patient Safety Committee:  Dr. Das reported that there were no real improvements in the metrics, including patient willingness to recommend Stroger Hospital.  Multidimensional interventions including rounding on the wards by staff are on-going.

  

CEO Shannon reported that they expect the JCAHO inspection before the end of November and all departments are devoting extraordinary care and time to prepare.  Dir. Gugenheim pointed out that the inspectors look at trends and therefore, the slow improvement will overcome the less than optimal metrics.

Special presentation on Group Purchasing Organizations (GPO) which allow group purchasing by member hospitals/groups of supplies, pharmaceuticals, services at a discount taking advantage of the economy of scale. The speaker stated that the 5 top GPOs cover the majority of healthcare in the USA.  Value of GPOs include lower cost, better reliability and transparency of the process. GPOs are free to the member hospitals and charge the vendors for being a part of the group. In addition to major set discounts, hospital members may earn a dividend/rebate (called patronage) based on volume.  CCHHS earns over 1 million dollars a year in this “rebate”.  A 1986 Federal statute grants GPOs a “safe harbor” from the “kickback” laws.

Dir. Lerner wondered what happens when the GPOs consolidate leading to a monopoly.  Dir. Marsh asked whether providers (physicians) had input into the selection of vendors/vendor products and was told “yes”.

Report of the Cook County Department of Public Health (administratively a part of CCHHS)

Dr. Terry Mason presented a powerpoint of the services provided by CCDPH including food establishment inspections, environmental health, vector control, etc.  The lead poisoning prevention program and lead abatement plan is undertaken when the lead level is greater than 10 micrograms/dl. Paint used prior to 1978, still present in many of the older CC buildings, often contained lead. Dir. Lowry, who served in the past as commissioner of Chicago’s Department of Buildings, was concerned that the high level of lead that triggered abatement exceeded the threshold for federal grants and could be a health catastrophe. She indicated that a level of 2 micrograms/dl is the safe level. Dr. Mason agreed, but added that it was very expensive to undertake lead abatement and the money was not available.

The meeting adjourned to closed session at 1:20pm.

Submitted by Susan Kern,MD, LWV CC Health Issues Committee

CCHHS Quality Assurance and Patient Safety Committee October 9, 2013 Meeting

County Commissioner Jerry Butler attended the Committee meeting for the first time in this reporter’s tenure. Chairman Collens characterized him as CCHHS’s strongest champion on the County Board and expressed concern about who would step into that role upon Butler’s retirement.  Committee members attending: Luis Munoz and Wayne Lerner.

The Committee seemed to be getting a bit impatient with the reports it receives, with Collens cautioning the Stroger medical director to report on safety initiatives and not routine business. QA chief Dr. Das will not be able to satisfy this group with reams of data, though she’s still trying; these people want results.

The Committee asked the Department of Public Health to report on its plans for dealing with emergencies like a terrorist attack. Dr. Das reviewed inpatient results of the Culture of Safety survey, which revealed a fear of reporting errors. Collens suggested she figure out how many errors are never reported. She plans to encourage reporters by protecting them from punishment but was vague about how. Lerner urged a strategic approach to safety with supervisors, staff and unions all at the table. Dr. Murray described the strategic plan of the Department of Public Health, which is governed by the CCHHS Board but receives its police powers (e.g. to shut down restaurants) from the County Board.

The Department handles communicable diseases, environmental protection, clinical programs and preventive services. In response to concerns expressed by Munoz about preparation for a national emergency, Murray volunteered to have the Department report on emergency planning. Public Health has Quality Assurance teams addressing lead, environmental health, communicable diseases and high-risk infants. Murray gives her department a C-plus/B-minus for Quality Assurance, though its own clinical programs would be graded higher.

With respect to specific diseases, Murray reported south suburban Cook County is now the state’s epicenter of HIV infection and that the department’s contact-tracing is insufficient even for control of syphilis. Chicago now has only 1.5 times as many TB cases as the suburbs, down from 4 times, though whether this reflects progress in the city or problems in the suburbs is unclear.

Dr. Ukoha reported that Stroger’s burn unit was not re-accredited after a site visit; it has 6 months to correct problems. Asked about progress in safety, he said things are changing under Das’s leadership but there are no substantial results yet.

Submitted by Kelly Kleiman

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

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

Cook County Hospital Quality and Patient Safety Committee Meeting, August 21, 2012

This meeting served essentially as an orientation for the new members of the Committee, most of whom are also new to service on the Hospital’s Board. Dr. Mason, the new System Chief Medical Officer, gave a report prior to the arrival of the observer. 

Ms. Russell, System Interim Chief Nursing Officer, reported that the system is facing a wave of nurse retirements: in 2013, 196 nurses will be eligible to retire after 25 years of service and another 43 after 30 years of service.  While there are obviously pension consequences to this large group of retirees, Ms. Russell reported on it as something to be considered in maintaining the quality of patient care throughout the system.

Dr. Mason then showed the group a video explaining the responsibility of the CCHHS Board for the quality of care at the hospital.  The Board (like hospital Boards everywhere) was originally an honorific and philanthropic Board only, with quality and patient care concerns left to the medical staff.  However, a 1960s court decision (the Darling case) found that a mistreated patient could hold the hospital, and not merely its doctors, liable.  As a result, hospital Boards now have responsibility for overseeing the medical staff as well as hospital management.  These oversight responsibilities are discharged at CCHHS through its committees.  Committee member Driscoll asked why the Quality and Patient Safety Committee no longer received Mortality and Morbidity reports–are the Committee’s discussions discoverable in court?  CCHHS Associate General Counsel Helen Mason promised to research and respond to the question in writing.  She noted that those reports are discussed within a committee of the medical staff.  The Committee agreed informally that it doesn’t need to see details of individual cases but wants to know about processes for correction, perhaps through an annual or half-yearly event report.  Ms. Mason assured the Committee that the Board will see all public reports.

Dr. Das, System Interim Director of Quality and Patient Safety, then briefly reviewed the status of the hospital’s accreditation.  He explained that the accreditation process for public hospitals was new, and that Stroger had submitted its application supported by the hospital’s strategic plan and the WePLAN 2015, which prescribes actions in accordance with the strategic plan.  The Joint Commission will pay an accrediting site visit in July, 2013.  At the moment, only 80 of the nation’s 3000 public hospitals are accredited; Cook County intentionally submitted Stroger to the process early, and hopes to be accredited next year. 

Dr. Murray, Director of the Department of Public Health, then explained  that the Board of Health oversees all state-certified health departments.  In Cook County, there are 6 of these: Chicago, Evanston, Oak Park, Skokie, Stickney, and Cook County itself, which covers the rest of the county.   

She then reviewed a series of Health Department reports, offering the following details:

     •    The Department is now benchmarking indicators for lead poisoning.   In the coming year it will expand its role from screening and treatment to prevention and education.

     •    The Department handles food safety inspection for unincorporated Cook County and on contract for 34 suburban communities.  This is a revenue generator.  It doesn’t usually check farmers’ markets because it is worried more about meat contamination than about produce.

     •    The Department monitors syphilis and has reduced the extent of spread to 1 contact (.6 contact means no syphilis at all).  Its outreach efforts focus on young people.  The chair asked about drug-resistant gonorrhea, and Dr. Murray replied that the department informs doctors and tries to prevent the ailment through education about safe sex and through contact tracing.  Finding contacts is challenging, though, and the problem can only be solved through wider testing and education.

     •    The Department is identifying the zip codes with the highest-risk infants so as to concentrate its prenatal, neonatal and maternal care resources there.

     •    The Department monitors tuberculosis everywhere in the county but Chicago, and provides care for the entire county (by contract with Chicago).  The proportion of TB cases is up in the suburbs.

     •    The chair asked about pertussis, and Dr. Murray said that communicable diseases in general were not going down, and that she suspected pertussis was under-reported.  This demonstrates, she said, that the county’s vaccination coverage is not what it should be, pointing out that the legal requirement that children be vaccinated for school is ignored.
 
The Department meets with the state Department of Public Health (which can instruct local departments to test more frequently) and with its counterparts throughout the state. “We monitor specific diseases but we’re also concerned about process improvements.”

     •    Commissioner Munoz asked about the flu, and Dr. Murray reported that there has been no human-to-human transmission of swine flu; it has shown up only in children petting hogs at the state fair. 

The Committee approved four reports–Food Access in Cook County; The Suburban Cook County Food System: An Assessment and Recommendations; Communicable Disease Update, August 2012; and Annual Tuberculosis Surveillance Report,2011–which will now be posted on the CCHHS Website.

This fall the Department will update its report on the Strategic Plan and release a Quality Improvement Plan. 

Dr. Wakim then reported on the status of Provident Hospital: within 4 to 6 weeks it will be
prepared to take Stroger’s overflow, and able particularly to provide much more gynecological care. 

The Committee then approved medical staff appointments and the minutes of its June meeting. There being no call for a closed session, the meeting was adjourned.

--Submitted by Observer Kelly Kleiman