CCHHS Board of Directors Meeting July 25, 2014

The meeting was called to order at 8 am.   All Board members were present except for one who attended by speakerphone.

Public Comments: A member of the public in attendance commented that CCHHS has 4 Board vacancies and therefore conducting the election for Chair and Vice Chair of the Board (on the agenda for this meeting) should be delayed until a full Board was appointed. He also stated that “no bid” contracts approved by the Board was not good governance and member/s of the Board have a conflict of interest because they are involved in the contract benefits.

Chair Carvalho responded to the allegations/concerns:  Cook County President Preckwinkle asked that the current Board of Directors of CCHHS stay on until the transition to the new CEO of CCHHS was complete (Carvalho and Gugenheim have completed their 6 year terms of office and are due to be replaced on the Board).  Ordinance defines the process for selection of new Board members.  Civic organizations (10-12) nominate members for the Board.  They normally meet and slate by 6-30-14, but due to the CEO search, this was delayed. 

 

With respect to “no bid contracts”, Chair Carvalho indicated that he was employed by IDPH (although he had recently resigned from that position and had not finalized  subsequent employment) and some contracts may have constituted a conflict of interest.  He rigorously abstained when there was voting on such contracts.

Board and Committee Reports were approved, including the CCHHS Finance Committee minutes from the July 18, 2014 meeting, which showed CountyCare 6-month revenue at $313,555,104 against expenses of $335,485,843, for a net deficit of $21,930,740.

An Amendment to the Rules and Regulations of the Medical Staff, pursuant to the Bylaws of the Stroger Hospital of CC Medical Staff was passed.  A copy of the Bylaw amendment was not available to the non-Board attendees. The discussion by Dr. Shannon, CEO, and Dr Fagen, Chief Medical Officer, indicated that the bylaw amendment dealt with improper transfer of patients from outside hospitals (dumping) to CCHHS in violation of the Emergency Medical Treatment & Labor Act (EMTALA). The process which will now be in place requires the ER to notify the CCHHS Compliance Dept., which then reports the event to the State of Illinois as a possible EMTALA violation.  Only 6 such violations have been reported this year (not known whether they were validated).  In most cases the transferring hospital calls CCHHS to alert them of the transfer. 

One of the Board members asked who was considered a “qualified provider” in the ER  and whether they all followed “practice guidelines”.  Dr. Fagen indicated that Nurse Practitioners and other allied health providers (non-physicians) were allowed to triage, conduct evaluation and management and treat to the extent of their licenses with the exception of evaluation of “chest pain” which required a physician evaluation.

Chairman of the Board Report:  Chairman Carvalho presented an overview of CountyCare with pros and cons of the transition to a managed care model from the previous “fee for service” funded by intergovernmental transfer.  It was relatively positive for the System model. Going forward, the State of IL requires 50% of Medicaid to be managed care with the expectation that 100% of Cook County Medicaid be managed care by Jan. 2015.

Nursing report:  Dr. Shannon introduced the new Executive Dir. of Nursing,  Agnes Therady (from the VA system), who gave a lengthy power point overview of the Nursing Dept.  including organizational chart, past performance and goals.  A Board member asked her how only 22 FTE of outside agency use by the nursing dept. was possible given the 19.2% vacancy rate in the Dept. of Nursing.  She replied that nurses are cross-trained in different disciplines so that they could cover various areas when needed. They are “competency trained/tested” in all of the disciplines they are assigned to cover. Most of the outside agency use was in the CCHHS clinics/non-hospital use.  The high vacancy rate is due, in part, to the older age of the nurses at CCHHS with frequent retirement.  They are working toward achieving “magnet status” for the nursing dept. over 5-8 years of effort.  Agnes’ goals are to improve the “visibility” of the nursing leadership on the wards, to include the patient/their family when there is change of shift/ pass off of care, and to coordinate transfer between inpatient/outpatient setting.

Report of the CEO:  Dr. Shannon noted President Preckwinkle’s open session on the budget of CCHHS the previous week.  CCHHS has a goal to submit its budget to the CC Board by September 2014.  The CC Board Finance Committee requests monthly updates on the Medicaid program finances.  Dr. Shannon also briefly mentioned the “Stroger Campus Redevelopment plan, next generation” with the relocation of the Fantus Clinic, etc.  Finally,  he recognized the Civic Consulting Alliance students present who were observing/shadowing the CCHHS process.

Election of Chair and Vice Chair of CCHHS Board of Directors: The election of Bill Hammock as Chair, and Jerry Butler as Vice Chair was unanimous.

Meeting adjourned to Closed Session.

--Submitted by Susan Kern

Cook County Health and Hospital Services Board Meeting June 27, 2014

After the public speakers, Chairman David Carvalho adjourned to closed session for discussion to secure a vote to approve the appointment of  Dr. Jay Shannon as the new CEO of CCHHS.  The vote was unanimous, with applause from attendees.

Committee Reports: Dr. Munoz, reporting on the Audit and Compliance committee meeting, noted that audit firm McGladrey noted a weakness in the CCHHS audit due to difficulties in financial reporting on CountyCare.  Dr. Munoz said processes are being put in place to correct this problem.   

Director Wayne Lerner asked whether the full board might be able to meet directly with the auditor, and Carvalho agreed to arrange that.  Lerner requested that hard copies of the audit be distributed to the full board, and this request was also approved.  Lerner also asked whether, by approving the minutes of the meeting, the board was also approving the audit itself.  General Counsel Elizabeth Reedy said that according to the bylaws, if you approve the minutes, you're also approving the report.  Munoz said there has been no practice previously of the full board reviewing the audit.  The County board is the entity that actually approves the financial statement. In this situation the CCHHS board approved the minutes of the meeting, but made it clear that they were not, by so doing, approving the audit report.  

Director Lewis Collens reported that in the Quality and Patient Safety Committee meeting, Dr. Das said that the Stroger Hospital ER average wait time dropped from 140 to 82 minutes.  The CORE Center reports HIV suppression at 59% compared with a 25% national average.

Carvalho commended the Commercial Club, where he spoke yesterday, for having adopted the transformation of CCHHS, encouraging more than 70 entities to donate pro bono time.  Vice Chair Jorge Ramirez commended Carvalho for preparing the public for the budget's shrinking in one area, while possibly expanding in another.

Dr. Shannon, commended the second cohort of 11 CCHHS employees' having graduated from the 12-week "Cook County University" training program. With respect to the Cook County budget, FY2015 projects a $168 million shortfall. The 2014 budget shortfall will be $86 million, with $67 million of that related to the health fund. An improvement plan is in place to reduce costs. In June, a 3-year record 113 vacancies were filled, including 26 nurses.  Dr. Shannon recognized Dr. Robert Weinstein, departing head of the Department of Medicine. Finally, Dr. Shannon acknowledged both Dr. Raju and Toni Preckwinkle for their guidance during his period as interim CEO.

Carvalho noted that new committee appointments are made in July; board members should communicate their preferences.

The board adjourned to closed session at 9:35.

submitted by Linda Christianson

CCHHS Quality Assurance and Patient Safety Committee Meeting March 26, 2014

Attending:  Chairman Collens, Directors Lerner, Guggenheim and Hammock; and a new non-Board member of the Committee, Patrick Driscoll.

Cook County's Public Health Department was accredited for the next five years by the Public Health Accreditation Board.

Surveyors from the Joint Commission made a surprise visit to the Ambulatory Care Center and, though the report is not final, issued only 10 citations (of need for correction) out of 1000 standards.  They made a point of telling the staff the visit had been "excellent."

CCHHS Chief Operating Officer Daniels reported on the system's new Capacity Management Project. The Project is focused on four areas: patient flow through the Emergency Department, bed management, the discharge process and patient acuity. The first is most important because CCHHS gets 72% of its patients through the ED, vs. an industry standard of 50-60%. It’s hoped that under the Affordable Care Act fewer patients will use the ED for primary care, but meanwhile the ED divides its patients into 5 levels of acuity, with 1 being the most serious. 1s are seen "within minutes," 2s and 3s are in the ED appropriately, and 4s and 5s should receive urgent care in another setting. For the moment, the ED has created its own "Doctor Quick" section to treat 4s and 5s.

Some internal goals have already been met: a 20% improvement over FY2013 3rd Quarter; only 6% of patients left without being seen; patients are treated and released within 4 hours or treated and admitted within 8 hours. National goals (3%, 3 hours and 6 hours respectively) will now be adopted.

Daniels credited the improvements to collaboration among all the departments, especially nursing initiatives coupledwith IT analysis which identified bottlenecks and administrative fixes which eliminated them. The next step is a "pilot program in Six-Sigma and Lean," two corporate-based programs which use detailed data simulations to map and fix all processes involved in a system (here, a patient’s progress through stages of care). Daniels acknowledged they’ve "hit a plateau and must push through it" to improve further. The goal is to integrate flow in and out of the ED with the System’s overall care strategy. They’ve already decided to create a "Bed Czar" position to improve bed turnover and availability, and are considering a Short Stay and Observation Unit to "decompress the ED."

Chairman Collens urged dissemination of these metrics to all doctors and nurses, and was assured they’d be widely distributed; they’re apparently already displayed at certain nursing stations. Director Lerner congratulation Daniels but urged him to consider using outside advice and to set higher goals "insiders create fewer stretch goals." He added, "Our benchmarks can’t be public hospitals or people will go elsewhere [now that they can]." Collens expressed concern that the Dr. Quick service would encourage patients to continue to receive primary care in the Emergency Department. Stroger’s Dr. Uchowa responded that only by providing patients with a good experience in their new "medical homes" will they be willing to remain in them.

Provident reported that its medical staff had identified patient registration as a bottleneck, so they’re working with Daniels to figure out how to provide bedside registration. Provident’s lab and pathology departments have just been re-accredited for two years. Provident is not in the program of intensive oversight and weekly meetings.

Submitted by Kelly Kleiman

May 22, 2013 Proceedings of CCHHS Quality and Patient Safety Committee

During the public comment period, a pair of nurses complained that unlicensed Medical Assistants were doing nursing work without supervision.

The meeting was dominated by a long report comparing various measures of hospital quality. The data aren’t consistent even within measures; the CIO is working to reconcile them. There were no data about the supply of Spanish-speaking staff; this will be provided at the next meeting.

Between arrival at the Emergency Department (ED) and actual admission to the hospital, it takes a total of 638 minutes---nearly 11 hours. Many ED patients, lacking primary care, require time-consuming evaluation before the admission decision can be made, but more than 4 hours is spent simply waiting for a hospital bed. All patients with real emergencies are given priority and seen in less than 6 hours. Those ultimately discharged also wait an unacceptably long time (170 minutes).

ED wait times have been calculated based on when a doctor completes his/her notes. But because notes are often delayed, future wait times will be based on when a doctor "signs up" for a patient, unless this is prohibited by the Center for Medicare and Medicaid services.

Consultations with specialists and waiting for MRI results account for most delays. CCHHS will examine other hospitals’ procedures and may call on colleges for process-engineering support.

Patient satisfaction surveys: 72% of patients rate CCHHS "very good" overall, which sounds
great til you learn this means 99% of the nation’s hospitals do better. The biggest difficulties were getting through on the phone or having a call returned, followed by wait time and lack of information about delays. Though wait times at certain clinics are down to 90 minutes, patients don’t perceive the improvement. Wait times for tests and specialty care also need to be reduced. Patients get good care once they can get to doctors but barriers to access are huge.

Dr. Stabile, in charge of the Patient-Centered Medical Home initiative, cited improvements including "patient panels" (care teams to help doctors manage patients) and computerized records. An RN Care Manager coordinates care; this should improve phone response. They’ve also revamped scheduling and hope to offer some 12-14 hour clinic days by year-end. Chairman Michael said, "Overall we’re doing badly and seem to be getting worse." The key problem is lack of respect for patients. "We give the impression we think we’re doing them a favor." Training won’t be enough to create a customer service ethic; incentives would be necessary. Dissatisfied patients represent loss of market share; neighboring hospitals are already pulling in County Care patients. But CCHHS can never be successful if it’s short-staffed.

---Submitted by Kelly Kleiman

March 6, 2013 Proceedings of the CCHHS Quality and Patient Safety Committee

The Committee did not meet in February. During that time, the System hired Dr. Shannon as Director of Quality and Patient Safety, a prospect never mentioned at meetings.

The observer arrived late and missed the report on the System’s quarterly STAR (Set Targets Achieve Results) plans. Dr. Das (Shannon’s predecessor, who will work with him) was reviewing the System Quality Dashboard, a computer format for reporting progress on identified areas requiring improvement. Chairman Michael chided Das for ‘just presenting’ data, asking her to work with Shannon to provide improvement recommendations to the Committee.

Committee member Dr. Munoz argued that while the data could identify centers of excellence in the System, ‘average is where we want to be,’ and the true function of the data was to identify and correct obstacles to that, specifically the shortage of nurses. By contrast, Michael argued for quality improvement even while the Affordable Care Act increases the patient population: "This is an exercise in quality, not volume." Committee member Dr. Velasquez suggested the real function of this data is to inform the public that CCHHS is an institution they can trust and should choose. These three data approaches reflect different approaches to the System’s mission, and they remain unreconciled, so the medical staff makes improvements essentially at random. 

Das reported a significant increase in immunizations. The increase, though, put the System at 42% pneumonia and 30% flu immunization, versus national benchmarks in the mid-80s. Michael asked why the numbers were so low when immunization is so easy; the medical staff responded:

1. The issue is providers as well as patients.

2. Every inpatient gets an order for immunization but with shorter hospital stays by sicker patients the opportunities to immunize are fewer.

3. There are cultural barriers, with patients reluctant to receive vaccines.

Munoz argued that a lack of trust in government is less "cultural" than universal in that it’s reflected among the providers, too. But Dr. Barker, head of the CORE clinic for AIDS and TB patients, urged the group not to set its sights too low, noting that his clinic has a 75% vaccination rate: "the problem can be fixed if there’s attention paid to it." He also noted that the New England Journal of Medicine recommends universal HIV testing, and suggested CCHHS make this a system goal, then a clinic goal and then a provider goal. Many in the general population are put off by the risk-assumption form.

Das further reported improvements in the Emergency Department (ED):

• Through-put: the wait time has gone down from 150 minutes to 117, bettering the internal benchmark of 120 minutes. 

• The number of patients who leave without being seen has declined from about 11.5% to 9.5%, still falling short of an 8% internal benchmark (3.6% is the national average). Das said that a significant number of CCHHS patients come to the ED just to be warm and don’t want to be seen; other "sitters" are patients from nearby closed psych facilities.

Dr. Wakim, head of Provident Hospital and former director of its ED, stressed the need when evaluating ED performance to consider what clinics are available for non-urgent care. Munoz argued the System should be compared to similar safety-net hospitals with similar populations (e.g. Bellevue), and the Stroger chief agreed: comparing patient volume, demographics and doctor/patient ratio will demonstrate the need for resources. Michael concurred that the Committee’s purpose is to identify the resources necessary to achieve the System’s quality goals.

Michael added that the Committee did not propose to set quality goals itself but to adopt goals chosen by the medical and nursing staff. He also stressed the need to implement CountyCare (the Medicaid waiver program) to keep non-emergent patients out of the ED.

Dr. Murray of the Department of Public Health reminded the group that without better data infrastructure it’s impossible to set goals or assess quality. Michael responded that Shannon and Das should be given the chance to build that infrastructure, and that the Committee wants to establish priorities for improvement. Das agreed that once a process is targeted for improvement, actual implementation must take place at the dept/division level based on data. She also noted that the medical staff is using multi-disciplinary teams to improve processes.

The biggest ED logjam is in the time from deciding to admit a patient to the time s/he actually gets moved to a bed: CCHHS is at 226 minutes (that’s nearly 4 hours), versus a benchmark of 96 minutes. No solution was suggested for this problem, probably the result of too few beds. 

Concerning patient satisfaction (which correlates with positive medical outcomes), Das reported CCHHS mostly does well but is in the bottom 1 percentile in hospital environment and in the bottom quintile in communication with patients.

Das suggested that hospital-acquired conditions be tracked in real time on an automated system; the retrospective data now available are of limited use. CCHHS’s mortality rate is slightly better than the national average, while its readmission rate is slightly worse. These two numbers, though, are ambiguous: they reflect mostly socioeconomic status, plus the community’s ability to care for outpatients, the quality of that care and patterns of admission which vary by location.

Das reminded the group that CCHHS must in the future address pay for performance. She also reiterated the process for selecting "Big Dots," major goals for the System: first consider impact on patient outcomes, then system-wide impact, with other measures subordinate.

Dr. O’Brien, Director of Graduate Medical Education, reported:

• Every patient encounter is now staffed by an attending physician. 
• They’re integrating residents into patient quality and safety efforts. 
• They’re using CLER (Clinical Learning Environmental Review) to bring in out-of hospital doctors to help improve care. 
• For 2014 they’re revising the affiliation agreement(s) under which residents rotate to County from their home campuses: if they rotate to get training not available at home (toxicology, OB/GYN) the home institution pays, whereas if they rotate to supply patient needs for skills not available at CCHHS (neurosurgery, ENT), the System pays. 

105 residents are affiliated with the System, including 45 from Rush and 20-some each from McGaw (University of Illinois) and Loyola. Rush has priority, but Dr. Raju stressed that CCHHS is looking for partners to share the System’s vision and respond to its needs first and foremost. "County will leverage our medical education affiliates for the benefit of patients, not for the benefit of other institutions." O’Brien added that a goal was to eliminate duplication of services, e.g. CCHHS ED rotation is excellent so Rush closed its own ED residency.

Dr. Munoz proposed an audit of the entire master agreement process. O’Brien conceded that, while the agreement has been audited for its financial consequences, no outsider has assessed it for its patient impact. Raju responded that CCHHS is already checking the agreement against projected clinical needs. Once that’s complete the Committee and Board can determine whether additional examination is necessary.

Wakim reported that the Provident staff has already met with new quality chief Shannon and is ready to implement improvements in clinical care recommended by PriceWaterhouse. The new Stroger chief will report formally in April.

--Submitted by Kelly Kleiman