Cook County Health and Hospitals System Board of Directors Meeting July 31, 2015

Chairman Hammock called the meeting to order at 9:00 am

Public Speakers:  Over 10 speakers representing the Pediatrics Department at CCHHS, including Attending Pediatricians, Residents, medical students, newly graduated residents, pediatricians from the community, pediatric nurses, representatives of faith-based organizations (United Methodist Church, and the Pastor of the Oak Forest Hospital), representative from child protective services, and a Hispanic member of the community who presented her comments via an interpreter rose to object to the rumored closure of the Pediatric in-patient department.  They alluded to an article printed in Crain’s Chicago Business, July 20, 2015 “Kids are Skipping Stroger;Cook County hospital considers phasing out its pediatrics ward” which reported that CCHHS is considering phasing out its inpatient pediatric unit at Stroger and was weighing whether to consolidate its residency training program in pediatrics into another program and focusing its primary pediatric care at outpatient sites.  It reported that the Stroger pediatric unit of 40 staffed beds had an average occupancy of 26%.

The public speakers stressed that: the Pediatric Unit was cost effective and brings in revenue;  Claims were made that the Rush Children’s Hospital (next door to Stroger) “was sucking patients from CCHHS”;  lauded the Stroger Burn and trauma care for children, supported the pediatric residency which trained physicians who would take care of the indigent.  

CEO of CCHHS, Dr. Shannon responded (after 45 minutes of public speakers) that ”the future of CCHHS is ambulatory care, in the Medicaid managed care model, not highly specialized in- patient care.  No Board decisions on the pediatric unit have been made at this time.  The Board will act on behalf of the entire community.”

Picketers with placards and police presence were present outside of the building.  The Board room was packed with members of the pediatric department with a prominent media presence including videotaping of the presentations.

Employee Recognition:  Graduates of the Leadership Development Project were present and acknowledged by the Board.

Annual Meeting Business:  Chairman Hammock was affirmed as Chair of CCHHS Board of Directors and Commissioner Butler as Vice-Chair.

Board and Committee Reports 

 

Quality and Patient Safety Committee

Director Guggenheim and Dr. Das reviewed the May, 2015 Metrics for Stroger Hospital which show that there continues to be a challenge in improving quality metrics including: surgery start on-time (52%) and OR room turn around time, influenza and pneumococcal vaccination (48 %) and patient experience/willingness to recommend the hospital  (71%).  The metrics are little changed from May 2014.

The CORE Center for HIV/Hepatitis /other infectious diseases shows excellent metrics.

Managed Care Committee

Director Lerner and Steven Glass reviewed a few key Metrics:  County Care membership has been drifting lower over the last 4 months from a high of 183,415 in May to 172,873 in July 2015 which are primarily ACA adults and fewer FHP patients.  This is attributed in part, to failure of members to complete the redetermination process which Medicaid requires to insure that they are still eligible for the program.  Membership is still 10% over the budget which is a positive.  More competition may be entering the marketplace in competition with CountyCare as other large health organizations are forming managed care organizations.

Audit and Compliance Committee

Cathy Bodnar reported that the CCHHS audited financial statements for the year ended November 30, 2014 showed exceptional audit results. 

Human Resources Committee

Gladys Lopez reported that nurse hires are higher this year (249) vs 2014 (139) and that the “time to hire” has decreased to 127 days.

Finance Committee

Director Collens and Doug Elwell reported that the 2016 CCHHS budget was being worked on. 

Mr. Elwell noted that CCHHS needed to grow its Medicare business; recent salary contract agreements would result in increased expense to CCHHS; the CCHHS facilities and equipment were aging and would require capital improvements; prescriptions, especially newer very expensive drugs, will be difficult to purchase at a discount and will result in increased cost to CCHHS; uncompensated care will continue to be expensive.  He suggested that CCHHS units that were unused for many years could be closed vs converted to ambulatory care vs consolidated with other units.  Janitorial services which have repeatedly received poor patient ratings on surveys should be assessed for the FTEs per space they clean and outside vendors should be investigated. 

Director Wiese asked whether the Board could be given data on the number of “contract employees” vs. CCHHS employees there were and the cost. Mr. Elwell stated that vendors are paid according to industry standards.  Director Wiese also noted that there were significant parking problems on the CCHHS campus with up to “300 patients a day turned away”. 

Director Junge asked whether there was a proposal to decrease FTEs at CCHHS?  Mr. Elwell responded that the goal was to staff with FTE numbers that were the industry standard.  Dr. Shannon added that they were looking at utilization of services and staffing accordingly. 

 

Mr. Elwell reported that the cost of Cermak is increasing because of enhanced services provided via CCHHS.  The cost of the CC Public Health Department (administratively under CCHHS) was increasing because they were not being awarded sufficient new grants which would contribute to the income.  He added that they were not garnering sufficient grants because of their difficulty in fulfilling them in the past.  Director Marsh requested an overview presentation on the Public Health grant process.  Director Gugenheim responded “why not combine the CC Dept. of Public Health with the Chicago Dept. of Public Health which has been proposed since 1989!  Nothing happens.”

Action Items

Dr. Fagen noted that Stroger Hospital Department Chairs need to be reappointed every 2 years according to the JCAHO standards.  There has been a lapse in reappointments which she recommended the Board to undertake at this time.  The Board moved to reappoint the Chairs.

Report of the CEO

Strategic Plan Update:  CEO, Dr. Shannon explained that the population that CCHHS was serving had changed over the decades despite the same physical facility.  CCHHS needs to change with the different demographics, healthcare industry and local standards.

Provident Hospital has been part of CCHHS for 22 years.  In the past it was a busy hospital but currently its 25 acute care beds have an average occupancy of less than 50% with a $36 million annual loss.  The ER is well used with 36,000 visits a year.  They have a prestigious eye facility.  Much of the building is not in use. The facility and equipment are old and would require $19 million in upgrades plus $11 million to purchase diagnostic imaging equipment.  Analysis shows that the catchment service area around Provident contains 682,000 individuals with good Medicare/dual eligibility/CountyCare mix. 

Dr. Shannon suggested that Provident be repurposed into a regional outpatient center focused on the Eye center, diagnostic imaging, bariatric surgery, orthopedics and prenatal care.  The cost of a new, “green” building which would be more cost effective to operate and equipment is projected to be $50 million. Directors Marsh and Lerner asked “why not partner with an existing hospital rather than going it alone?”  Director Estrada asked whether the Cook County Planning Commission had reviewed this proposal and evaluated the demographics of the area to make sure this was a good idea.  Director Junge questioned whether the ER visit numbers were not really “clinic type medical needs vs. a true ER level of health care need”.  Dr. Shannon replied that “this is an opening discussion, no firm decisions made”.

The meeting was adjourned to closed session at 11:45am.

Submitted by Susan Kern, MD

Cook County Health and Hospital Services Board Meeting June 26, 2015

Chairman Hill Hammock introduced a resolution honoring Susan Greene who died May 22.  Susan led the effort to found CountyCare, which has expanded to serve 179,000 patients, of whom 90,000 were previously uninsured.  CEO Dr. Jay Shannon characterized Susan as “the best bargain we ever had in a contractor.”  Trustees Mary Gugenheim, Carmen Velasquez, and Susan’s daughter Nicole spoke movingly of Susan’s enthusiasm and generous spirit.  Former CCHHS board chair David Carvalho was also present to honor Susan.

Public speaker George Blakemore complained of extended CCHHS contracts: “Waste, fraud, and abuse are in these contracts.  And it’s taxpayers’ money.”

CEO Shannon announced the 4^th leadership development graduation class; a Robert Wood Johnson Foundation grant to address social disparities in the system; and the CCHHS nominating committee having submitted four names to President Preckwinkle for the 11^th CCHHS board position.  Shannon and board member Emilie Junge spoke in support of the Supreme Court decision supporting the ACA: that thanks to the Affordable Care Act, CCHHS has reduced uncompensated care costs from about $500m annually to about $300m.

Meeting Reports

Quality and Patient Safety.  Chair Gugenheim spoke of interventions to prevent patient infections including hand hygiene and unit infection preventionists.  Joint Commission accreditation results are due before November. Shannon presented an explanation of the patient experience data prepared by an outside contractor securing a 15% return on patient surveys.  Stroger satisfaction ranks about “two stars out of five.”  Compared to other area hospitals, Stroger ranks 3^rd lowest, with only Mt. Sinai and Norwegian lower.  “We’re working on this,” Shannon said, through evidence-based interventions, data driven performance improvement, customer service training, leadership and accountability, and operational enhancements including the call center, improved parking access, and improvements in nurse communication.

Human Resources.  Chair Wiese introduced Gladys Lopez, Chief of Human Resources, who addressed vacancies filled and time to hire.  Lopez said her goal is to reduce vacancies to 600.  In 2015, 191 nurses have been hired, vs. 94 in 2014.  Currently hiring requires 139 days on average.  Packets are emailed to hiring managers.  Hiring time can’t be lowered below 90-100 days, Lopez said, though two weeks - one month is standard elsewhere.  Board member Wayne Lerner remarked, “Our people have options; we don’t want to lose good candidates.”

Finance. Deputy CEO Doug Elwell provided an explanation for the three no-bid contracts, that they provided services not available elsewhere.  CCHHS has 80 days’ cash on hand, plus an untapped line of credit, will continue to get fee for service Medicare and Medicaid payments.  Inpatient days dropped  from 9235 in 2013 to 8000 in 2015; outpatient visits also down from about 80,000 in 2013 to about 76,000 in 2015; ER visits down from about 14,000 in 2013 to about 12,000 in 2015. Obstetrics and pediatric visits have also diminished. Lerner pointed out, “These trends are not going to stop; how do you manage the enterprise under those conditions?” 

Managed Care. Steven Glass, Executive Director of Managed Care, said CountyCare membership is now at 179,000, on budget; 159,000 prescriptions were filled in May; readmission is flat.  In a presentation on Behavioral Health (a diagnosis encompassing mental health and substance abuse), Glass showed that these persons die 22 years earlier on average, and that 68% have additional physical disorders.   Behavioral Health has a volatile funding history, with a 5-year decrease in funding.   Psychiatry and chemical dependency are most costly to care for; the ER most frequent admission is for acute alcoholism.  BH represents 10% of CountyCare’s external costs.  To reduce costs, CountyCare is working to streamline intake and strengthen its contracted networks including the Community Counseling Centers of Chicago (C4) who provide 7 psychiatrists, 130 social workers, and a crisis team. There has been an increase in Behavioral Health (BH) patients since 2009; CCHHS has no dedicated BH unit, yet has 10,000 BH admissions; CCHHS has 37 psychiatry staff members.  The largest group of BH patients is at the Cermak Health Center, which currently has 1864 BH diagnoses; the goal is to reduce that number by 600.  State grants for BH to service organizations may terminate June 30.

Outgoing COO Peter Daniels reported on the central medical campus redevelopment. Proposals from three shortlisted developers were due June 26.  Fantus Clinic will be replaced, along with the administrative building; parking capacity will increase; and Stroger Hospital space will be optimized.  A separate proposal will address the highest and best use of the 1914 Cook County Hospital building.  Contract negotiation is due to take place in October/November 2015, budget approval in April/May 2016.

Chairman Hammock acknowledged the board for their consistent attendance and participation in the board and committee meetings, and for attending meetings of committees they are not even appointed to. 

  

The meeting adjourned to closed session at 12:25.

Submitted by Linda Christianson

Cook County Health and Hospitals System Board of Directors Meeting May 29, 2015

        I.          Chairman Hammock called the meeting to order at 9:00am

      II.         Public Speakers: There were 6 speakers representing the public.  A representative from the Service Employees International Union (SEIU) Local 73 representing the Health Care Professionals, Hospital Technologists, Service Employees and Hospital Technicians of CCHHS complained that labor contracts had expired and the new negotiated wages and healthcare changes which had already been approved by the Cook County Board were being held up by the CCHHS Board.  Chair Hammock responded that the Board required comprehensive comparative metrics from other hospitals to determine the criteria for a decision.  This data was now available and a vote would be taken later in the meeting.

Nurses from Stroger Hospital and Cermak and SEIU representatives for the nurse’s union contract spoke.  They stated than there were insufficient nurses per patient leading to unsafe practices.  CCHHS had cut nursing overtime leading to a more severe shortage, there were over 200 nurse position vacancies and wages were inadequate.  One of the nurses from Stroger Hospital stated that “a strike vote by the nurses” had been taken and introduced a representative who served the Chair of CCHHS Board with a formal notice that the nurses will begin picketing. Chair Hammock responded that filling vacancies was a high priority for the CCHHS Board as reflected in the monthly metrics on vacancies.

A citizen spoke complaining that Oak Forest Hospital had been closed and the patients moved to nursing homes. “There is not enough money spent on real health care”,  “the CCHHS leadership don’t receive their  health care at CCHHS, and they should! Its good enough for the poor.”

    III.       Employee Recognition:  CEO Dr. Shannon recognized the CCHHS/Stroger physicians from the “internal medicine jeopardy team” who had progressed to the national semi-finals.  He acknowledged an ophthalmologist who was listed as one of the “40 under 40” by the Ophthalmology Association.

   IV.            Board and Committee Reports

A.  Minutes of the CCHHS BOD from 4-24-15 were approved

B.    Quality and Patient Safety Committee Meeting 5-12-15 

Dr. Das reviewed the metrics of quality measures and 12 month trending pointing out that on-time OR start was only 17% (target 80%) at Provident Hospital and the “patient experience and willingness to recommend the hospital” was 71% at Stroger and 67% at Provident Hospital (target: 85%). This represented a small improvement from the previous 60-70% for Stroger but little change for Provident Hospital. Director Dr. Marsh requested better trending to understand any improvement, not just monthly variations.   Director Weise asked whether a survey of CCHHS employees on whether they would recommend the hospital might be useful. Director Gugenheim reported that Provident Hospital had been granted full accreditation by JCAHO.

               C.  Audit and Compliance Committee

Director Velasquez reported that IlliniCare, Medical Director malfeasance (as reported in the press) was being addressed. Cathy Bodnar reviewed the CountyCare oversight structure (grievances, complaints, appeals etc.).  Fraud Waste and Abuse program training is on-going for staff.  Only 8 allegations of FWA were validated in the previous year.  Director Lerner requested a deeper evaluation of the metrics to include rate of 1) repeat allegation by type and 2) what was the outcome.  Cathy Bodnar noted that the prescription abuse program included restricting a member to a single pharmacy if there was a pattern of abuse and working with the member personally.

 D.  Managed Care Committee

Steve Glass reported that CountyCare membership in May 2015 was 183,415 exceeded the goal of 155,860 but that the “total member months was only at 97.6% of budget."  In the last 6 months (Dec. 2014—June 2015) CountyCare has doubled in size and is now the 2^nd largest Medicaid managed care organization in the area (2^nd to Family Health Network).  Director Junge asked what % of the of membership are due to auto enrollment versus actively choosing CountyCare.  Mr. Glass responded that he would follow-up with the State of IL who would have this information.  State of IL sent out new annual re-enrollment letters to members in February, 2015, with a 60 day deadline for member redetermination which at this time, is reported as 8,000 who had Medicaid cancellation.

                  Director Lerner asked for sources of Medicaid cancellation and the response was that        there were multiple reasons including 1) members not completing the process of                  redetermination and 2) members now employed and no longer meets Medicaid eligibility                   or another such change in status.  Member/provider surveys required by the CCHHS                   contract for Medicaid with the State of IL shows only 99 member responses with 44%                  worried about where they will stay tonight and 32% worried about food availability.

           E.    Human Resources Committee

Director Wiese and Gladys Lopez reported that they are focusing on filling vacancies particularly nursing ones which are reported in the monthly metrics. Lopez noted that compared to May, 2014 when 216 CCHHS vacancies were filled, in May, 2015, 448 were filled.

F.       Finance Committee

Mr.Elwell reviewed the contracts that required action and all were approved with the exception of  item #14, “First Transit,Inc” providing transportation benefit for the Managed Care System, contract $8,000,000  which required further fact checking prior to approval. He reported that CCHHS has YTD  ($23 million) income loss with a poor operating margin compared to other hospitals.  The “plant/buildings/equipment” are aging and now 17 years old and “going in the wrong direction”.  There has been inadequate funding for renewal of this capital equipment, most of which dates from the opening of the new Stroger Hospital. 

Overtime is very high at 8% of worked hours costing CCHHS $40 million. It should be less than 5%.  Monthly Inpatient days (9,225 vs 8,315), emergency room visits (14,261 vs 12,887) and outpatient registration (7,821 vs 7,543)  are all down significantly from 2014 but there is no decrease in the overtime!  

 Mr. Elwell stated that there needs to be realignment of CCHHS managers with the new business model of managed care.  All positions must be looked at to determine whether they are needed.  

Director Marsh inquired about wait time in ER.  Elwell responded that no one is left in the ER waiting room, they are placed in exam rooms waiting for the physician to see them.  

Director Lerner asked about metrics on nursing FTEs per occupied bed.  Elwell responded that they are working on an automated system for nursing documentation to derive the metrics from.

 

      V.             Board Education

     A comprehensive focus area power point presentation and overview of the  responsibilities of the Cook County Department of Public Health, a component of CCHHS, was given by COO of CCDPH Dr. Terry Mason.  It will be posted on-line on the CCHHS web site.

    VI.            Action Items

 The Board adjourned temporarily to Executive Session for 20 minutes to discuss the SEIU   union negotiated wages and healthcare changes for CCHHS employees including SEIU   Local 73 Health Care Professionals, Hospital Technologists, Service Employees and    Hospital Technicians.  The open BOD meeting was reconvened and it was announced that  the Board had approved the contracts.  These do not include the more comprehensive nurses'  contract.

  VII.            Report from the Chairman of the Board

Chair Hammock noted that the Board has invested tremendous efforts into recruiting nurses.

VIII.            Report from the CEO Dr. Shannon

Dr. Shannon rebutted the comments made by various nurses/union representatives public comments. He stated that there are appropriate nursing levels at CCHHS based on the acuity of the patient care derived from national standards and metrics.  Most hospitals no longer base nurse staffing on a specific ratio of nurse to patient, which is what the union wants, but on acuity of care. CCHHS has used “floater nurses” to cover periodic shortage rather than overtime. He disagrees with the nurses’ union demand for a wage increase of 5% for each of the next several years and the demand that seniority not performance serve as the criteria used for retention.  “We are far apart on the terms for the new nursing contract”. Dr. Shannon indicated that the Union must give CCHHS 5 days notice of a strike.  He feels that the BOD could obtain a legal stay of the strike action.  However the CCHHS BOD are creating contingency plans to maintain nurse staffing of CCHHS Hospitals and clinics.

The meeting adjourned at 1:15 pm.

Submitted by Susan Kern, MD,  observer for LWV Cook County, Health Issues Committee