Chairman Hill Hammock called the meeting to order at
9am
Board and Committee Reports minutes were approved
A) Board of Directors meeting minutes 1-30-15 approved
B) Quality and Patient Safety Committee meeting 2-17-15
i. Metrics: Director Gugenheim provided a lengthy overview
of the QPS Committee organizational structure using a powerpoint [powerpoints
presented at BoD meetings are now posted on-line on the CCHHS website under
Governance section,click on BoD meetings—this is new and extremely valuable to
BoD observers ] A list of
future presentations to the BoD (quarterly) and annually to the QPS Committee
were provided.
ii.
Focus Area Presentation: A 5 year Accreditation Timetable listing all
agencies that accredit any component of CCHHS, and scheduled upcoming/past inspections
listed. In 2015: the following inspections are expected: Stroger Hospital (JCAHO); ACHN (Primary Care Medical Home certification);
Provident Hospital lab (College of
American Pathologists); Stroger
blood bank ( FDA); Stroger Hospital
medical training programs (Graduate Medical Education).
One of the
Directors asked why GME accreditation, which is partially funded by Medicare,
should be an issue at CCHHS which sees relatively few Medicare patients. Dr.
Krishna Das, Chief Quality Officer, noted that despite few Medicare patients,
the CMS licenses payments which applies to the entire Hospital. Dr. Shannon indicated that JCAHO’s
inspection will be unannounced and they will be bringing 5 surveyors for 4 days
of inspections and over 1000 questions on the checklist. JCAHO has deemed status for CMS conditions of
participation. Dr. Das displayed the
table of teams that have been organized by discipline/category to prepare for
the JCAHO inspection. A Director asked
whether the BoD would be involved in the Leadership Standards component of the
JCAHO. Yes, the Board members may be
interviewed and were also invited to the Leadership Team meetings.
The
PCMH inspection allows CCHHS to choose the clinic (from ACHN) that is inspected (Dr. Das said
they would choose the Prieto Clinic which is the best run with staunch loyalty
of patients to the Clinic). Director
Gugenheim questioned that approach “why shouldn’t we try to improve the quality
of all of the Clinics?” (see powerpoint
posted on CCHHS web site for detailed information)
Director
Gugenheim reported a recent unannounced
IDPH survey triggered by a patient complaint for which CCHHS had to provide
the Metrics: how do we reach certification goals 1)patient and staff education
2) patient self-management 3) access to care
4) referral management 5)quality performance improvement team approach
at the Clinic level.
C)
Audit and Compliance Committee Meeting 2-19-15
Director Velasquez and Chief Compliance Officer, Cathy
Bodnar reported that the CCHHS Internal Audit Charter was
audited by the Firm Mcgladrey and Board Rules were reviewed. A lengthy powerpoint of the CCHHS Compliance Program Operations Plan was
presented including graphs of the number of corporate compliance issues
investigated/determined violations which are increasing in number. A Director asked what the most common
violations were and it was reported that HIPPA breaches (determined to be
unintentional, not malicious) associated with electronic transmission of patient
data. Corrective action includes encryption of all e-mails.
CountyCare Compliance Plan
presented including monitoring of Fraud,Waste and Abuse. Metrics provided included incidence of
1) upcoding 2) boilerplate coding
3) allegation that individual ineligible for CountyCare. Director Marsh suggested that there should
be random routine audits of charts for all health care providers (not to blame
but to educate on coding issues etc.)
D) Managed Care
Committee meeting 2-19-15
Director
Lerner and Exec. Dir. of Managed Care, Steven Glass presented an update of
CountyCare. Goal of enrolled members is
124,318, at the end of Jan. 2015 it was 96,508 which is an improvement from
Dec.2014 : 86,562. Issues discussed included the CountyCare redetermination
process, IL State funding of Medicaid, and prescription utilization by CountyCare
members. It was noted that members do
not tend to use CCHHS pharmacies. Dir.
Wiese reported an incident of poor customer service in the redetermination
process and wondered if this type of issue was responsible for lagging
redetermination for eligibility in CountyCare.
E) Human Resources Committee Meeting, 2-20-15
Director
Wiese and HR Director Ms. Lopez reported that the goal was to reduce the Jan.
2015 vacancies of 1018 to 600 by year
end with a decrease in the time to hire to 94 days. One of the Directors wondered if there were
excess positions which may not need to
be filled. Brief discussion on the cost
of replacing vacancy (HR time etc.)
F) Finance
Committee Meeting 2-20-15
Doug Elwell Deputy CEO Finance & Strategy noted
that the financial metrics reviewed by the committee revealed a small operating
surplus at the end of the Quarter with 93 days of cash on hand (good). Dir. Collens responded that “We [CCHHS] are
nowhere close to showing a profit”; and that the timing of reporting of
various figures may not reflect the full picture.
National
Metrics are planned to be accessed to compare CCHHS financial data to similar hospitals nationally (County/Academic hospitals of comparable size) and to set
up goals/measures /targets and benchmarking.
The Committee in the future will look for benchmarking of CCHHS to all
hospitals (not just County ones) because Chicago is a town with numerous
hospitals that CCHHS must compete with.
Dir. Collens stated that it would be
interesting to know what FTEs unit/work are at CCHHS vs other hospitals. “Maybe we could decrease FTEs because they
are in excess already.”
It was reported that they were looking at services
that could be brought in house which would save money. Collective bargaining negotiations with the CCHHS
unions ran into a sticking point with a “work rule issue of monitoring phone
calls made for quality purposes”. This has been resolved and the Union dropped
their objection when it was documented that monitoring calls was a national
standard.
Action Items BoD approved all contracts except one which
had not yet been reviewed by the Finance Committee.
Report of Chair of the Board Chair Hammock
referred all to his written report.
Report of CEO Dr. Shannon noted that there
were 5 responses to the RFP for the Central Campus redevelopment project. These will be reviewed and eliminated to 3 in
the next few months which will undergo further assessment.
Dr. Shannon reported on legislative issues at the
State level including the Governor’s budget calling for cuts to Medicaid which
will adversely affect CCHHS. He
mentioned that a continued conversation with State and Federal Legislators on
Medicaid funding would be important to advocate against cuts to the Medicaid funding.
Meeting
adjourned to Closed Session at 12:15 pm
Submitted by Susan Kern
