Health and Hospital Systems Board Meeting February 1, 2013

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

  

Quality and Patient Safety Committee chair Ed Michael reported challenges in implementing electronic health records, a possible need for more staff.  A full report is due to the CCHHS board on maximizing the use of Provident Hospital.  A short video stressed that transparency yields internal improvement.  If data are available to all, quality improves.  Customers/patients value candor sometimes over quality.  The board must set a clear policy on  transparency.  “Talk about your mistakes!”  He said more data will be on the CCHHS website, and  suggested Dr. Das update board members on performance data at a future meeting. 

Audit and Compliance Committee chair Dr. Luis Munoz reported that McKesson is monitoring physician billing; and the diagnostic coding system, key to bringing in revenue and determining quality measures, will be subject to more intense federal monitoring.  A survey will identify what relationships employees have with external providers, and a firewall will be put in the system to preserve CCHHS business integrity. 

Finance Committee chair Heather O’Donnell reported that under 6,000 new people have been enrolled in the new Countycare Medicaid program; patients are instead choosing Carelink, not realizing that Countycare provides better managed care over time. Patients rejected by Countycare (Medicaid) are eligible for Carelink.  A contracted PR firm, Prairie Group, will assist CCHHS, FQHCs in particular, with patient education and enrollment, hosting enrollment fairs, providing flyers, banners, and posters. 

Human Resources Committee chair Quin Golden reported that 343 vacancies were filled in 2012; 165 managers were trained in Shakman requirements.

William Luallen of Pricewaterhouse Coopers reported general findings on their 3-year association with CCHHS: - CCHHS needs to generate grants and have centers of excellence to compete with other health systems. - Many self created billing systems need coordination.  Currently co-pays can’t be collected at point of service because the Cerner system does not accept credit cards. - There are still paper charges and orders in the system; all needs to be electronic, and this process is about 75% complete. The$12m backlog in uncollected revenue is now down to $2m, similar to Rush and other hospitals.  The coding system has been improved, creating a clear claim for reimbursement.  There have been significant reductions in overtime since the $18m overtime payout.  Ambulatory Care Health Network (ACHN) clinics are not yet working in tandem with shared data. Carvalho asked what other public healthcare systems are doing to collect copays at payment point; NAPH has data on this.  The Cerner system holds all electronic medical records and links to Siemens which is the billing system, so all data should be on Cerner to maximize revenue collection.  Luallen said CCHHS needs a 501c(3) nonprofit foundation and offered to assist in creating such a foundation on a pro bono basis.

The meeting adjourned to closed session at 10:00.

Submitted by Linda Christianson

CCHHS Quality & Patient Safety Committee Meeting January 16, 2013

The Observer arrived after the meeting had started, and the Committee was watching a video focused on how to handle errors and accidents from the standpoint of public and legal exposure. The takeaway: "Choose your lawsuits wisely," be transparent, encourage discussion of mistakes by staff and Board and recognize that public attention, however painful, may bring improvement. Dr. Raju then noted that core data about adverse events will be posted on the CCHHS public Website.

Chairman Michael instructed the staff to provide the Committee with 2012 quality metrics for the next meeting, so it can settle the "Big Dots," overall goals for improvement during 2013.

Nursing Chief Russell reported that the system had fewer retirements than anticipated and thus is less short-staffed, so that "we didn’t have to shut anything down." CCHHS is vaccinating its staff against flu on a continuous basis and has had no outbreak to date.

Dr. Dave Barker reported on the Ruth Rothstein CORE Center, the comprehensive HIV/AIDS treatment facility now expanded to handle the needs of those with other infectious diseases. CORE Center did exceptionally well in 2012, or else its goals were set artificially low:

• Goal of 55,000 routines HIV tests; actually conducted 66,000. Ultimate goal 80,000, which would allow testing every five years of everyone in the relevant community.
• Goal of 99% access to primary care within 10 days; achieved 100%.
• Goal of 80%+ patient satisfaction; achieved 83%.
• Goal of 90% viral load below 1000; achieved 90%. (Those who fail have relapsed into IV drug use; 30% of the CORE Center’s patients have active substance abuse problems.)
• Goal of 75% patient-would-recommend; achieved 81%.
• Goal of 10% or fewer patients receiving meds at CORE; achieved 5.9%, which means budgetary savings.

Peer counselors administered the survey to 588 patients in the CORE waiting room, about 10% of the program’s clinical population. Waiting room patients are disproportionately walk-ins (who haven’t been treated) or the sickest patients (whose treatment is going badly) so it may over-sample problems. But the survey will be repeated in this fashion 3 times/year; CORE regards this as more representative than ‘press-ganging,’ or mass administration of a survey by mail, phone or e-mail. Barker was particularly proud of adjectives describing CORE as "excellent," "respectful" and "friendly," and in the reduction of descriptors such as "busy" and "rushed." Using electronic medical records (EMR) should free up more time for providers to spend with patients, but for the moment, according to Barker, "CORE provides good care and lousy documentation." There are too many providers and too few medical assistants. There should be 2.5-3.5 assistants per doctor, but CORE never exceeds 1:1. For the same reason, CORE has not yet completed the change away from written orders and prescriptions. Another doctor noted that this is a national problem: EMR software was designed to improve billing and not the quality of care. She asked for redoubled efforts to make EMR changes uniformly across the system, because every change affects the flow of care. "Flow should drive what happens with EMR rather than the other way around."

CORE did badly (30-40%) in assuring after-hours access to providers. Of its 80 primary care providers, many are part-time, and CORE has relied on their individual availability to patients. Now it has hired an answering service to improve responsiveness.

Goals for 2013:

• Secure certification as a Patient Centered Medical Home for HIV/AIDS.
• Gain access to special software to aid reporting and reduce personnel hours of data entry.
• Provide real-time Quality Assurance data to providers to promote improvement.
• Complete transition of the Social Services component of CORE to EMR.
• Complete implementation of a CCHHS-wide satisfaction survey for all HIV programs and patients.

Another doctor argued that HIV testing should occur whenever clinics do anything else. CCHHS should also be testing 100% of patients for TB.

Dr. Wakim reported that an all-staff Task Force has been created to consider Provident’s future. The Task Force will check in every two weeks and bring in a proposal whenever it develops one (there is no time-line). Provident’s ER experienced one "sentinel" (problematic) event and will bring the Committee a summary of that once Risk Management approves its description.

The Committee then approved its minutes, approved medical appointments and adjourned.

--Submitted by Kelly Kleiman

CCHHS Quality & Patient Safety Committee December 18, 2012 Meeting

During the public comment period, a citizen suggested that the County save on health care costs by having all employees and hospital Board members go to CCHHS for their care.

Interim Chief Nursing Officer Tamara Russell reported that CCHHS budgeted for 1622 nurses in 2012, and ended the year with 229 vacancies, almost all at Stroger, including in the ER. Thus this year’s budget calls for nearly 100 fewer nurses, with Russell currently determining which vacancies have priority. Chairman Edward Michael asked if the Medicaid waiver would produce a nursing shortage; Russell said no, that last year’s budgeted number of nurses was artificially high. Commr. Velazquez asked whether Russell was recruiting for bilingual nurses, and on learning she is not (CCHHS uses the Language Lines translation service instead) said at least some bilingualism should be required. Russell replied that she’s currently evaluating where in the system the need for Spanish speakers is greatest. Nursing will concentrate on four quality areas in the coming year: communication between nurses during shift change, or "handoff"; medical administration (labeling of drugs and supplies); implementing the universal protocol (a standardized checklist for patient care); and reducing hospital-acquired conditions, especially urinary tract infections produced by catheters.

Interim Director of Quality Dr. Krisha Das reported that accreditation submissions to the Joint Commission would be completed by year-end, and that the recommended changes in practice have already been made. CCHHS is collaborating with the National Association of Public Hospitals in developing a quality protocol for safety-net hospitals requested by the Center for Medicare and Medicaid Services.

Nurse-led teams at Stroger coached by an outside expert (Ed Mendez RN/MPH) are developing systems to reduce pressure ulcers and falls, while Provident addresses medication errors and various thromboses. These teams are part of CCHHS’s participation in the national Hospital Engagement Network focused on safety, which provides training and technical assistance and measures outcomes. The system, "Reliability for Quality and Safety," seeks to prevent harms in nine specific areas. American health care currently is not reliable; acquired infections affect 5-10% of patients nationally, while 1.5 million are injured annually by medication errors. To become an HRO (High Reliability Organization), a health care system needs leadership, a culture of safety (meaning participants willing to identify problems), and good processes. Leadership includes the Board’s spending 25% of its time on quality issues, basing executive compensation on safety results, and continuous monitoring of safety outcomes.

Using a handout, Mendez explained that failure in 20% of cases is considered "chaotic," so CCHHS’s 60% compliance rate in washing hands demonstrates reliability even lower than Level 1. Level 1 systems use only vigilance and hard work to assure safe outcomes. Level 2 reliability, a 95% success rating, depends on  reliability engineering, including redundancy, checklists, and having the desired action be the default setting, while Level 3 (99%) required sophisticated behavioral designs such as "dangerous until proven safe" or "any system participant is authorized to interrupt the process when safety is threatened."

Michael asked if the proposed goals (40% reduction in infections, 20% in readmissions) were realistic. Mendez replied they were reasonable over two years: a 10% reduction in harm every 6 months was achievable. Michael, noting that the #1 cause of preventable deaths is failure to follow procedures, argued that reliability improvement will require simplification of processes; "if compliance is burdensome, no amount of training will work." He also pointed out that a shortage of nurses limits the amount of time they can spend improving procedures because they’re constantly at bedsides.

Michael then turned to CCHHS’s own goals. Averaging results for patient satisfaction, hospital readmission and hospital-acquired infections, the system serves 61% of patients properly. 83% of the nation’s hospitals do better than this. The staff recommends prioritizing hospital cleanliness, nurse communication skills and ER wait times but Michael asked if these were the right three areas to produce significant overall improvement. As for readmission, CCHHS doesn’t yet have the necessary data, and once again Michael pointed out that readmission could be driven by factors beyond the hospital’s control. But Dr. Das pointed out that readmission data are drawn from a Medicaid population, so all the hospitals being compared are dealing with poor people and with consequences of poverty beyond their control. CCHHS will begin generating its own readmission data next month.

Michael once again urged collecting only a limited number of data points to avoid confusion, but Dr. Das reminded him that the Federal government requires the hospital to keep track of all these data, so it’s a matter of choosing to pay attention to the most relevant. Mendez reminded the group of the need to evaluate the whole system because most patients are seen outside the hospital; Michael assured him the Public Health Strategic Plan addressed that issue. Likewise Chief Medical Officer Dr. Mason noted the importance of distinguishing outcomes in the public health system from those in the ambulatory care setting from those in the hospital itself. Das pointed out that the Medicaid waiver requires the system to monitor and assure quality of care provided by contractors as well as employees.

The Board then received the Department of Public Health Strategic Plan. Michael noted that the Department is part of the state public health system; the Department on its own might have chosen other areas of concentration but in conjunction with the state system has chosen access, teen pregnancy, youth violence and cardiovascular health. DPH will create multidisciplinary teams including outside agencies to measure and improve performance in these areas. Stroger Chief Medical Officer Dr. Goldberg reported that the hospital must prepare for a 2013 site visit to renew its National Cancer Institute designation as a certified cancer hospital. Stroger staff is working on reducing times to treatment and increasing reliability of data entry.

--Submitted by Kelly Kleiman

January 16, 2013 Cook County Board Meeting

Contracts, Electronic Monitoring, Gun Control

Commissioners absent:  Suffredin, Gorman

This first Cook County Board meeting of 2013 enlisted some procedural changes:  committee meetings (Finance, Roads & Bridges, Zoning) at 10:00am followed by the regular board meeting at 11:00am.  After waiting awhile to get enough commissioners for a quorum, the committee meetings were completed in about 15 minutes with a long wait for the regular meeting to begin.  Useful for those in the audience, President Preckwinkle made sure all agenda items were explained briefly.  Some last-minute errata and new items were not available to the audience.

Contracts
There was a lot of discussion and questioning of the Interim Chief Procurement Officer, Shannon Andrews, regarding the extension of time and expansion of money to current contracts without a re-bidding of these contracts or more favorable discounts.  The current concerns were regarding a contract to InterPark Co. for parking of Cook County vehicles, Integrys Electric for county electricity,  and NAPA for machine and auto parts.  Ms. Andrews stated that current usage by various departments will help determine future needs and therefore enable better leverage for the county.   At the request of the Board, quarterly reviews on purchasing, contract savings will continue.

Electronic Monitoring
Commissioner Gainer expressed concern over the drop in use of electronic monitoring for arrestees, detainees and non-violent criminals.  Increased use would be a large cost savings to the county and more importantly enable low-risk offenders to continue work, school, family matters while awaiting trial.  The big controversy was between the Sheriff's Office stating it is not getting information from the Chief Judge's Office regarding risk assessment, address and other information to determine if someone should be able to use electronic monitoring.  The Chief Judge's office blames the form used and its confusing interpretation regarding state law by the nine bail bond judges.  This issue was brought up at  December's board meeting, with no change in result since that time.  It appears that communication between these two offices is not ideal.  It was agreed at this meeting that the form would be re-done and input from the Sheriff's Office would be given.  This change is expected by February's board meeting.

Gun Control
A resolution urging the state General Assembly to ban assault weapons & high capacity ammunition magazines, close gun show loopholes on background checks and require registration of existing firearm owners passed the Cook County Board after much discussion and various opinions given.   Several commissioners questioned the effectiveness of the resolution, the definitions of various words in the resolution ("assault weapon") and the requirement of gun registration.  The Board will later decide on an ordinance brought by President Preckwinkle regarding guns in Cook County.