Cook County Board Meeting June 19, 2013

The meeting was called to order at 11:15 am by President Preckwinkle after an extended Finance Committee meeting. All commissioners with the exception of Commissioners Tobolski and Garcia were in attendance.

The first order of business was to refer three agenda items regarding amendments to the recently-adopted Source of Income Amendment to the Human Relation Cods to the Human Relations Committee. The speakers for the issue will be given notice of the new meeting time and date.

USE TAX
J. Thomas Johnson from the Taxpayers Federation spoke concerning his view about constitutional problems that might occur with the county's proposed tax levy for personal property. The County's plan is to tax on the value of property rather than on the purchase price. Without amending the municipal tax laws, he feels that this would be unconstitutional and an unfair burden. It would require citizens to file with the state, county, and city.

HONORS
Rules were suspended for the purpose of moving to item 18 on the agenda: a resolution honoring injured Silver Star Family War Veterans in Cook County. Presentations were made by all board members for those in their districts. Veterans included: 2 from the Korean War, 14 from the Viet Nam War, 1 from Desert Storm, 5 from the War in Iraq and 1 from the War in Afghanistan. Names were read for those not present, including one from World War II.

AGENDA
The consent Calendar was approved.  The commissioners then voted to go into closed session to discuss litigation.  The meeting resumed at 12:30.

Interesting discussion took place on the relief of overcrowding at Cook County Jail. Chosen inmates are sent to other facilities in-state for the purposes of safety and cost. There are currently 9,904 in custody. $143 is spent per day on each. 83% are arrested for violent crimes.

A lengthy discussion took place concerning the costs for a disparity study required every 5 years for the Forest Preserves, Hospitals, and Professional Services. Cost for this is shared with the state. It was approved.

Commissioner Daley moved to suspend remaining agenda items to proceed to New Business. All New Business Items were moved to committees.

The meeting adjourned at 3:30 pm.

--Submitted by Pat Lind  

June 12, 2013 Proceedings of the CCHHS Quality Assurance and Patient Safety Committee

Headline News: Edward Michael, QA Committee chair, leaves that post at the end of June to assume an as-yet-unspecified, but apparently paid, role with CCHHS.

Subordinate headline: CCHHS is preparing to hire a "Patient Safety Officer," though Dr. Das (head of Quality Assurance) and her new boss Dr. Shannon (Director of Clinical Integration, including overseeing patient safety) are both already charged with this role.

These items came up as asides at a meeting consisting entirely of "Committee Education," a lecture from Das on how the hospital does and/or should respond to adverse events, ones "leading to the serious injury or death of a patient unrelated to the patient’s underlying illness." (The Joint Commission uses the term "sentinel events.") To deal with these events, hospitals search for correctable systemic flaws rather than punishing care providers.

Issues in dealing with medical error:

• If/when to disclose errors to the patient and if/when to report them to the public: the Joint Commission favors disclosure and reporting, and the State of Illinois requires reporting "but that law is never enforced."
• Three categories of error: violations (intentional), lapses (habitual because tired) and mistakes (cognitive). To handle the latter two, hospitals search for "error traps" and eliminate them or build in redundancies, so only 10% of errors reach patients. Of these, half are preventable.
• Common types of error: adverse drug reactions, procedural complications and hospital acquired conditions. In addition to "Sentinel Events," the Joint Commission publishes a list of 29 "Never Events," occurrences which will prevent reimbursement of the hospital by Medicare/Medicaid.
• CCHHS catches errors when they’re reported by providers, by phone or through the MERS computer system. It also uses surveillance, reviewing all deaths and serious injuries for signs of error. At the time of an event, the doctor calls the Medical Director who assembles a team to talk to the patient and notifies Risk Management and Quality Assurance (Das).

The System take five steps to manage an event:

1. Care for the patient. Be empathetic and apologize but don't admit liability.  Only 1/4 of errors are disclosed, but after disclosure patients perceive they’re receiving higher-quality care.
2. Conduct initial fact-finding.
3. Care for the care-giver, who’s probably upset about the error.
4. Notify the insurance company.
5. Conduct a root cause analysis.

The Joint Commission provides a detailed outline of how to conduct root cause analysis so that all potential sites of error can be identified.: the provider, communications systems, work environment, organizational culture. Unless the error is intentional, the approach avoids blaming a single provider. Experience shows that removing individuals doesn’t solve the problem, and providers won’t report errors at all if they’re punished for doing so. If there’s no problem of criminality or substance abuse, the key test for responsibility is whether another provider faced with the same situation would have done the same thing.

• The System corrects errors using strong interventions (like technology and work flow). Though it talks about avoiding weak interventions like counseling providers, counseling is actually what the System uses most often.
• Solutions are designed collaboratively, responsibility is assigned, and the initial reporters of the incident are informed of results to reinforce their willingness to report.

When Michael asked how to determine if interventions are effective, Das responded that it was too much work to find out (though the Joint Commission requires some investigation so "we try to do it:), and Shannon noted that with only 7% of adverse incidents coming to the System's attention, there's too little data to tell.

When pressed, Das said the anti-error initiatives they’ve devised will require more staffing. Shannon offered that CCHHS’s electronic systems were better than most (for data-crunching) and that this month the System will begin a baseline "culture-of-safety" survey. Michael urged them to work with Dr. Hoda (IT) to determine what enhancements to the system will catch problems automatically. Das noted there are standard interventions already in place concerning allergies and prescriptions but argued that each site requires a system tailored to its activities.

Shannon added that the System uses the "time out" technique, starting every procedure by having participants identify themselves and review their understanding of what they’re going to do, a practice which substantially reduces errors. There is one right way to do many medical procedures and using a checklist based on that right way keeps doctors from having to reinvent the wheel and risk harming the patient.

Dr. Ukoha from Stroger reported great progress in providing translation services there: the hospital now uses a phone interpretation service covering more languages than before, as well as video interpretation and interpreters on-site. Though certain "strategic areas" require a person on the spot, video and audio can plug many of the gaps. The task now is to make sure the entire medical staff is aware of the availability of this service.

--Submitted by Kelly Kleiman

Cook County Board and Committee Meetings of May 29, 2013

A Public Hearing of the Finance Committee concerning a proposed amendment to the Cook County Parking Lot and Garage Operation Tax Ordinance was scheduled to begin at 9am but was delayed as a quorum was not present until 9:15am.

After Chairperson Daley called the meeting to order he announced that the amendment had been withdrawn but did allow those who were in attendance to give their testimony on the issue. A person representing parking lot owners and managers stated that much work had been done to change state law so that a percentage tax would be used and not a flat rate. Implementation was supposed to be revenue neutral though and the proposed amendment included a percentage tax that would increase revenue and thus increase rates. The 3 speakers representing the hotel and parking industries were not in favor of the amendment as proposed. Chairman Daley stated the administration would be back with a new proposal at a later time.

Several other committee meetings were then held prior to the board meeting. The only item of note was during the Finance Committee meeting when John Cookinham, CFO for CCHHS, stated that the first payment for those persons qualified for Medicaid under the 1115 Waiver was received in April. Monthly 1115 Waiver payments will be coming in now and will include retroactive payment to the date of application for those who qualify.

The board meeting was called to order promptly at 11am by President Preckwinkle. Public comment now begins all of the committee meetings and the Board Meeting. Items from the Consent Calendar that were highlighted included memorials to Cal Sutker, a previous CC Commissioner, and Sister Sheila Lyne, a recently retired member of the CCHHS Board.

At 12noon Comm. Steele stepped in as President Pro Tempore to preside over the remainder of the meeting. Each agenda item was moved, seconded, summarized, and voted on in short order with minimal discussion. Highlights: The start time for board meetings was changed from 11am to 10:45am beginning with the next board meeting in June. Another item that was approved was a change to the board rules that clarifies how an item can be divided from a committee report for a vote. (Agenda item #7) According to Comm. Suffredin this is now known as the “Fritchey Rule”, resulting from a parliamentary disagreement at a previous board meeting.

There were 9 items on the New Items agenda, 3 of which could be acted on as they had been posted more than 48 hours before the meeting. An item that was referred to the Finance Committee was an amendment to the CC Procurement Code that will require social service contract providers to submit an annual performance report to the Board of Commissioners. A contract extension was granted to Northwestern for $1.8m to manage the Juvenile Court Clinic for another 18months while an evaluation of this court is undertaken. An RFP was issued a year ago and is considered still active while this evaluation takes place and is intended to result in a new plan by December of 2014. Another new item was the proposed appointment of 4 members to the CCHHS Board. If appointed the new members will include M. Hill Hammock, Wayne M. Lerner, and Lewis M. Collins for 4 year terms ending on June 30, 2017 and Ada Mary Gugenheim until June 30, 2014 to fill Quin Golden’s unexpired term. The appointments were referred to the Legislative and Intergovernmental Affairs Committee for consideration.

The meeting was adjourned at 12:30pm.

Submitted by Cynthia Schilsky, LWVCC Observer

CCHHS Finance Committee Meeting, May 24, 2013

The meeting was called to order by Chairman O’Donnell at 8:05 a.m.  Directors Carvalho, Michaels, and Ramirez were also present.

During the public comment period, a citizen complained about the lack of African-American Directors on the Board and the lack of representation and contracts for African-American citizens.

Gina Besenhofer, Supply Chain Operations, Executive Manager, presented contracts to be paid from appropriations:

1. $18,500,000 for 3^rd party administrative services for the 1115 Waiver for $18,500,000 to be paid to Automated Health Systems (AHS). 
2. $12,000,000 for pharmacy benefits and management services for $12,000,000 to be paid to Catamaran.   
3. $1,460,000 for amending and increasing a contract with Siemens for professional services, utilization, and recurring fee.
4. $549,557 for perinatal software maintenance from GE Healthcare, and 
5. $184,040 for service maintenance and repair for cooking, warehouse, and waste disposal equipment to Emerald Restaurant Services.

The Committee approved all contracts.

John Cookinham, CFO, reported on the Year-to-Date Financial Reports. He said amounts for free care were approximately $20,000,000 per month.  In Accounts Receivable, the outstanding days of Revenue Outstanding (Patient Days) was 116 days at the beginning of the year with a big improvement down to 110 days.  As of this last Friday it was 97 Days.  Currently self-pay statements are being suspended until County Care payments are fully payable and paid.

Mr. Cookinham pointed out that 30% of Medicaid patients had been converted to County Care (the Affordable Care Act 1115 Waiver) and that Commercial patients (those patients with their own personal insurance) was “really growing.”  Self Pay and Free Care patients stayed about the same.

Mr. Cookinham said the way to attract more Commercial patients was to improve Patient Experience by trying to schedule appointments, giving more telephone responses, giving more free service such as group screenings, and giving employee incentives to use hospital services.  Director Michaels echoed the need for excellent patient satisfaction as County Care enrolls people.

Mr. Cookinham noted that the Adjusted Patient Days are a little below budget due to the 14% decline in Patient Days.  Dr. Jay Shannon noted that when patients were there for observation they cannot charge them as a Patient Day.  Further discussion ensued on the low use of Provident Hospital because ambulance runs are not served there, and acutely ill patients are transferred to Stroger.  Mr. Cookinham further noted that ER was right on budget and Oak Forest was slightly below budget.

Board discussion ensued regarding patient length of stay.  Some patients are kept because they have no place to go.  The longest length of stay is from Commercial patients.  Provident is an outlier with some patients in need of continuous care.  Stoger has many long term patients in trauma and burn units.  Dr. Shannon said there would be improvement in patient length of stay if the records were better recorded.  This would affect Case Management which would impact Quality and Safety and Case modality.  Dr. Shannon said they need clarification each day on coding, which in the end, pays for itself.

Director Carvalho said the Case Mix Index is derived from coding and that there was some dissonance between data and incidents.  Dr. Shannon replied that Case Mix drives reimbursement. 

Susan Greene, Susan Greene Associates, stated that it would take a real cultural change to maintain the rate of patients choosing CCHHS as their medical home.  The Finance Committee agreed that Patient Satisfaction was paramount. Patients are signing up patients for the 1115 Waiver, but then going elsewhere.  Chairman O’Donnell said it is not acceptable that patients don’t like the way they are treated.

Susan Greene continued by saying that the good news is that they have signed up 56,000 applicants for the 1115 Waiver at the rate of 500 per day, and 8,450 in the first 24 days of May.  She said that in April the State of Illinois had 50 persons examining applications, and they have just added 17 more people, and that by June and July, the State will have 100 persons on the staff to process applications.  Ms. Greene stated that County Care members want and demand accurate diagnosis and really good care. To avoid no-show applicants for the Waiver, applicant workers try to fit into the patient’s schedule rather than the reverse situation.

Ms. Greene said that she hopes to transition her 1115 Waiver training team out by July.  She continued that 27% of approved applicants are couples new to the County and FQHC System, and they want to stay in the CCHH System.  Ms. Greene said there was a high demand for good Care and Coverage, and people were finding CCHHS.  She continued that the age distribution was constant with only 20% of applicants under the age of 25 and more women applying than men.  Race and ethnicity were not known.  Ms. Greene stated that older people need more health care and that those who need care sign up first.

                                                                                                                    

Ms. Besenhofer gave an update on Global Healthcare Exchange (GHX) and the need for full integration and said they will still need two to three years to fully implement the process.  She added that the double work was not sustainable much longer, but that the integration with County Care was easy. She hoped that HHS would have the same system as the County.  Dr. Hota said that Meaningful Use was over $15,000,000 for stations processing Medicaid and Medicare and that they need to increase the number of Procedures since they were dependant on Medical payers and providers.                                         

Mr. Cookinham gave a report on the gross changes in payer. The financial amounts paid by Commerical Insurance had dropped from 2.7% to 2.3%, even though the percentage of Commercial patients was rapidly growing.  The Medicaid and Medicare Managed Care are not growing, but they do not pay as much.  Dr. Raju reported that most of Medicare Managed Care will be moved to County Care, and that it was essential to have a good Managed Care department.  Director Carvalho stated that under the 1115 Waiver everyone is assigned to a Managed Care hospital and may not be assigned to CCHHS, but they want to come to CCHHS for opinions and special care so CCHHS must have a strategy for this situation.  Dr. Raju said the ER must serve patients that are not enrolled here, but then they must go to their home hospital.

Cookinham continued that CCHHS is ahead of the budget by $8,000,000 for collections over expenses. In the Operating Budget, they need to fill more positions.  Director Michaels said it was difficult to project Revenues and that made it necessary to manage the Expense side better.

The meeting was adjourned at 10 a.m..

---Submitted by Eleanor Prince, CCHHS Finance Board Observer

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