packet - quality, patient care and paitent experience committee meeting … · 2019. 3. 22. · -...

AGENDA

Quality, Patient Care and Patient Experience Committee Meeting of the El Camino Hospital Board

Monday, September 15, 2014, 5:30 p.m. El Camino Hospital, Conference Room E & F

2500 Grant Road Mountain View, California

Elizabeth Joyce Freeman will be participating via teleconference from: Hilton Arlington

950 N. Stafford St., Arlington, VA 22203 Purpose: The purpose of the Quality, Patient Care and Patient Experience Committee (“Quality Committee”) is to advise and assist the El Camino Hospital (ECH) Board of Directors (“Board”) in constantly enhancing and enabling a culture of quality and safety at ECH, and to ensure delivery of effective, evidence-based care for all patients. The Quality Committee helps to assure that excellent patient care and exceptional patient experience are attained through monitoring organizational quality and safety measures, leadership development in quality and safety methods and assuring appropriate resource allocation to achieve this purpose.

AGENDA ITEM PRESENTED BY

1. CALL TO ORDER David Reeder, Chair Quality Committee

5:30 – 5:31 p.m.

2. ROLL CALL David Reeder, Chair

Quality Committee 5:31

3. POTENTIAL CONFLICT OF

INTEREST DISCLOSURES David Reeder, Chair Quality Committee

5:31 – 5:32

4. CONSENT CALENDAR ITEMS:

Any Committee Member may pull an item for discussion before a motion is made.

David Reeder, Chair Quality Committee

public comment

motion required 5:32 – 5:36

Approval: a. Minutes of Quality Committee Meeting

- August 18, 2014 Information: b. “Reducing Hospital Length of Stay with

EMRs and Other Information Technologies” Article

c. “6 Ways Hospitals Can Reduce Length of Stays” Article

ATTACHMENT 4

5. FY15 CORPORATE SCORECARD

DRAFT ATTACHMENT 5

Eric Pifer, MD, Chief Medical Officer Mick Zdeblick, Chief Operating Officer

public comment

possible motion 5:36 – 5:46

A copy of the agenda for the Regular Committee Meeting will be posted and distributed at least seventy-two (72) hours prior to the meeting. In observance of the Americans with Disabilities Act, please notify us at 650-988-7504 prior to the meeting so that we may provide the agenda in alternative formats or make disability-related modifications and accommodations.

Agenda: El Camino Hospital Quality, Patient Care, and Patient Experience Committee Meeting September 15, 2014 Page 2


6. QUALITY DRILL DOWN: LENGTH OF STAY (LOS)

ATTACHMENT 6

Diane Anderson, RN Director, Care Coordination

information 5:46 – 6:00

7. APPROVE FY2015

ORGANIZATIONAL GOALS ATTACHMENT 7

Mick Zdeblick, Chief Operating Officer Pepe Greenlee, RN, Interim Sr. Director, Clinical Quality and Patient Safety

public comment


8. UPDATE ON PaCT PLAN ATTACHMENT 8

Eric Pifer, MD, Chief Medical Officer Mick Zdeblick, Chief Operating Officer

public comment


9. PUBLIC COMMUNICATION David Reeder, Chair

Quality Committee 6:35 – 6:40

10. ADJOURN TO CLOSED SESSION 6:40 11. POTENTIAL CONFLICT OF INTEREST DISCLOSURES


6:40 – 6:45

12. CONSENT CALENDAR Any Committee Member may pull an item for discussion before a motion is made.



Approval: Meeting Minutes of the Closed Session (August 18, 2014) Gov’t Code Section 54957.2. Information: Report involving health care facility trade secrets, Health and Safety Code Section 32106(b)

- FY 2015 Pacing Plan

13. Report related to medical staff quality assurance matters, Health and Safety Code

Section 32155. - Red Alert Policy Draft

Eric Pifer, MD Chief Medical Officer Pepe Greenlee, RN, Interim Senior Director, Clinical Quality and Patient Safety


Agenda: El Camino Hospital Quality, Patient Care, and Patient Experience Committee Meeting September 15, 2014 Page 3


14. Report related to medical staff quality assurance matters, Health and Safety Code Section 32155. - Year-End Review of RCA’s

Eric Pifer, MD Chief Medical Officer Pepe Greenlee, RN, Interim Senior Director, Clinical Quality and Patient Safety


15. RECONVENE OPEN SESSION/REPORT OUT


7:30

To report any required disclosures regarding permissible actions taken during Closed Session.

16. ADJOURNMENT David Reeder, Chair

Quality Committee 7:31 p.m.

Upcoming Quality Committee Meetings: October 27, 2014 (PLEASE NOTE: 4TH Monday in October) Quality Committee Members to attend November 12th Board Meeting November 17, 2014

Separator Page

Attach 4- Open Consent Calendar.pdf

Minutes of the Open Session

Quality, Patient Care and Patient Experience Committee

Monday August 18, 2014

El Camino Hospital, 2500 Grant Road, Mountain View, California

Conference Rooms E&F

And

3021 East Banner Gateway Dr.

Gilbert, AZ 85234

1. Call to Order. The meeting of the Quality, Patient Care and Patient Experience

Committee of El Camino Hospital (the “Committee”) was called to order by Committee Chair,

Dave Reeder, at 5:34 p.m.

2. Roll Call.

Members present: Dave Reeder, Patricia Einarson, MD, Lisa Freeman (via phone

conference), Jeffrey Davis, MD, Katie Anderson, Julia Miller, and Robert Pinsker, MD.

3. Potential Conflict of Interests Disclosures. Chair Reeder asked if any

Committee member or anyone in the audience believes that a Committee member may have a

conflict of interest on any of the items on the agenda. No conflict of interest was reported.

4. Consent Calendar. Chair Reeder asked if any Committee member had any

corrections to the consent calendar items.

Motion: To approve the consent calendar (Minutes of the June 16, 2014).

Movant: Anderson

Second: Davis

Ayes: Einarson, Freeman, Pinsker, Miller, and Davis

Noes: None

Abstentions: None

Absent: None

Recused: None

5. Corporate Scorecard Review. Chair Reeder started the discussion with the

organizational goals and stated that 5 of the 7 goals have been met and exceeded the maximum.

Eric Pifer, MD, CMO, discussed the cover memo which all Committee members had access to

before the meeting. There was discussion primarily around the lowest marks on the corporate

scorecard, which included pneumonia mortality, mislabeled specimens, medical-surgical length

of stay, total operating expense per CMI adjusted discharge, financial viability and employee

well-being. Dr. Einarson asked the Committee if an iCare update would be beneficial for all and

it was decided that it would be brought back to the Quality Committee for a future meeting. Dr.

Pifer also stated that he would discuss in further detail the length of stay improvement

opportunity at a future meeting.

DRAFT

Minutes: Quality Patient Care and Patient Experience Committee

August 18, 2014

Page 2

6. Corporate Scorecard Format. Dr. Pifer briefly discussed the cover memo that

was in the packet and the Committee members discussed various ways to improve the format of

the corporate scorecard. The Committee members expressed general agreement around using

color on the corporate scorecard; using green (on target), red (underperforming) and possibly

yellow (within 105 of goal/benchmark). There was also discussion about whether trending

should be shown on the corporate scorecard. There was consensus that some metrics should

have trends listed while others do not need the trend listed. A discussion ensued about whether

the positive metrics should be grouped together, followed by the negative metrics so that it is

easier on the eye. There was also some discussion around the role of benchmarks. Dr. Pifer will

take the Committee’s feedback back to the management team and bring a revised draft of the

corporate scorecard at the next Committee meeting.

7. Quality and Governance Consultation Discussion. Chair Reeder informed the

Committee that ECH has engaged national experts Dr. Jim Reinersten and Jamie Orlikoff to do a

review of the quality programs the Quality Committee and the Board’s governance of quality.

He invited the Quality Committee members to the November 12, 2014 Joint Meeting of the

Board and the Quality Committee that Mr. Orlikoff will be facilitating. Marina Kipnis will send

an invite via Outlook to the Committee members.

9. Public Communication. None

10. Adjourn to Closed Session.

Motion: To adjourn to closed session

Movant: Miller

Second: Einarson

Ayes: Pinsker, Freeman, Davis and Anderson

Noes: None

Abstentions: None

Absent: None

Recused: None

Agenda Item 11, 12, and 13 were completed in Closed Session.

14. Reconvene Open Session. Open session was reconvened at 7:22 pm. Chair

Reeder reported that the committee approved the amended Closed Session minutes of the

Committee’s June 16, 2014 meeting.

15. Adjournment.

Motion: To adjourn the meeting at 7:27 pm.

Movant: Miller

Second: Anderson

Ayes: Einarson, Freeman, Davis, Reeder and Pinsker

Noes: None

Abstentions: None

Absent: None

Recused: None

Minutes: Quality Patient Care and Patient Experience Committee

August 18, 2014

Page 3

Attest as to the approval of the

Foregoing minutes by the Quality

Committee and by the Board of

Directors of El Camino Hospital

______________________________ ______________________________

David Reeder Patricia A. Einarson, MD

Chair, ECH Quality, Patient Care ECH Board Secretary

And Patient Experience Committee

Separator Page

Attach 4b- Reducing LOS article.pdf

Separator Page

Attach 4c- 6 ways hospitals can reduce LOS article.pdf

Separator Page

Attach 5- FY15 Draft Corp Scorecard.pdf

Date: September 15, 2014

To: Board Quality Committee

From: Re:

Eric Pifer, MD, CMO and Mick Zdeblick, COO

FY15 Corporate Scorecard Draft

Dear Committee, The management team has taken another look at the metrics on the corporate scorecard. We have made some decisions that we believe are consistent with the direction we have gotten from the committee and the board and we have made some other practical decisions that we believe will strengthen the message of the corporate scorecard. In prior meetings we have discussed the need to simplify the number of metrics, as well as the value of using a full year of trending data versus using the fourth quarter of the fiscal year. In today’s discussion, we are sharing the metrics, goals and formatting changes in draft mode. In addition to this discussion with the Quality Committee, we will be advancing these drafts to the next Finance Committee. Quality Metrics Core measure composite removed. Explanation: 1. We have performed near 100% for over 1 year on these metrics. 2. The core measures have taken on less importance in the value based purchasing metrics. 3. Small changes in the core measures performance will result in big swings in the percentile performance and we should not over-react to them. 4. Other metrics are more important. PSI Composite has been elevated. Explanation: 1. Safety is our top priority. 2. The composite has taken increasing importance in Value Based Purchasing. 3. It is an easy to understand metric with a good benchmark. Post-Surgical Mortality has been removed. Explanation: 1. The mortality will be very low and thus it will swing widely with a small number of unexpected deaths.

2. It will be difficult to engineer solutions with such a small number of cases and is better done when a cluster occurs rather than tracking it on the dashboard. 3. Risk adjustment is very difficult when expected mortality is so low and the numbers will lack meaning. CHF Mortality and Sepsis have remained. Explanation: 1. Mortality is high enough that it lends itself to tracking. 2. Risk adjustment methods are better established and the metric is more meaningful for a hospital based entity. Morbidity after PCI and NSQIP blended post-operative complication rate have been removed. Explanation: 1. Incidence will be low and one will see wide swings in performance. 2. The data lags by at least several months and in many cases can't be compiled more than a few times per year. Surgical Site Infection Incidence has been added. Explanation: 1. We had a cluster of cases in 2013 and early 2014. This is a problem. 2. It is easy to track raw numbers and we are striving for zero. Worked hours and expense metric have been changed to adjusted day rather than adjusted discharge. Explanation: 1. Adjustment for CMI adjusted discharge is merely a surrogate for length of stay, which is already on the dashboard. 2. The finance committee has changed their dashboard to adjusted day, so the scorecard should be consistent. Also, based on our discussion at the last quality committee, we are recommending 3 changes to the format of the corporate scorecard. 1. We recommend removal of the trend (“spark”) line. It takes up too much real estate and is felt to be confusing by many who view the scorecard. 2. We recommend outline in red any metrics that are below their annual target or are “off track” for performance against that annual target (see attached). 3. We recommend using the smiling face for any metric that is above the benchmark standard and using a frowning face for any metric that is below the benchmark standard. At each board meeting, the team should discuss only those metrics that are both red and have frowning faces. Thank you.

Separator Page

Attach 5- FY15 Draft Corp Scorecard.pptx

1

Key Performance Indicator Status

vs. Goal

Current

Available

Period

Previous

Available

Period

FY14

Baseline

FY15

Goal

Status vs.

Benchmark

Bench

mark

Benchmark

Standard

Quality

Patient Safety (90 Day lag)Jan-Mar

2014

Oct-Dec

2013

Patient Safety Indicator 90 Composite-CMS Defined < 0.393 0.424 NA yet 0.452 J 0.452CM S VBP Top

Decile

Safety EventsMay-Jul

2014

Apr-Jun

2014

# Stage 3-4 Hospital Acquired Reported Pressure Ulcers < 2 2 5 0 L 0 NDNQI best Decile

Med/Surg/CC Falls /1000 CALNOC Pt Days < 1.51 1.50 1.45 1.35 L 0.73CALNOC best

Decile

Medication Errors / 1000 Adj Acute Pt Days < 1.40 1.36 1.69 1.08 None

# Mislabeled Specimens / Month < 25 25 26 20 None

Complications Apr-Jun

2014

Jan-Mar

2014

Surgical Site Infections/100 Surgical Procedures per Quarter < 0.22 0.26 0.19 0.12 None

Service (45 day lag) Apr-Jun

2014

Mar-May

2014

Communication with Nurses > 77.7% 77.2% 78.0% 79.5% L 82.0%CM S Top 25%: 10/12-

9/13

Responsiveness of Hospital Staff > 66.9% 65.6% 67.0% 68.0% L 73.0%CM S Top 25%: 10/12-

9/13

Communication About Medicines > 71.6% 71.5% 65.9% 71.6% L 72.0%CM S Top 10%: 10/12-

9/13

# of Composites (max 8) Above Threshold (50th %ile) > 5 5 5 7 None

Outcomes

Mortality (90 day lag)Mar-May

2014

Jan-Mar

2014

based on

Benchmark

Mortality: CHF (Observed / Expected Ratio) < 0.67 0.60 0.46 0.66 L 0.66Premier Quality

Advisor Peer

Performance

Mortality: Sepsis (Observed / Expected Ratio) < 0.91 1.04 0.95 0.75 L 0.75Premier Quality

Advisor Peer

Performance

Corporate Scorecard DRAFT

2

Key Performance Indicator Status

vs. Goal

Current

Available

Period

Previous

Available

Period

FY14

Baseline

FY15

Goal

Status vs.

Benchmark

Bench

mark

Benchmark

Standard

Affordability

Efficiency (10 Day lag)YTD - Jul

2014FY14

Medical-Surgical Length of Stay Improvement Opportunity (FYTD) < 0.51 0.50 0.48 0.38 L 0.0 CMS GMLOS

(10 Day lag)May-Jul

2014

Apr-Jun

2014

Worked Hours per Adjusted Patient Day < 30.1 29.9 29.7 30.4 NA Yet FY 14 Truven 40th

Operating Expense per Adjusted Patient Day < 4,548 4,592 4,470 4,723 NA Yet FY 14 Truven 40th

Financial Viability (1 quarter lag)Apr-Jun

2014

Jan-Mar

2014

Inpatient Operating Margin (excludes settlement) > -4.0% -7.0% -4.0% -1.0% None

Outpatient Operating Margin (excludes settlement) > 27.0% 26.0% 27.0% 25.0% None

(1 quarter lag)May-Jul

2014

Apr-Jun

2014

Total Operating Margin > 11.3% 8.9% 9.4% 7.1% J 3.0% S&P A Rating

Total Days Cash on Hand (average/mo) > 385 375 381 364 J 236 S&P A Rating

Continuum of Care (30 day lag) May-Jul

2014

Apr-Jun

2014

Enterprise 30 Day Medicare Unplanned Readmission ( +- 0.3%) < 9.05% 8.71% 8.90% 8.70% J 17.40%HSAG Regional All

Cause

Apr-Jun

2014

Jan-Mar

2014

PCMH 1: % Diabetic Patient with HbA1c less than 8% > 65% 80% 79% 80% L 83%HEDIS M edicare

(CBP) 75th %ile

PCMH 2: % 30 Day Unplanned Readmission Rate for PCMH

Medicare Patients< 14% 0% 14% 7% J 19%

HEDIS M edicare

(CBP) 50th %ile

YTD - Jul

2014

PCMH 3: # of Medicare and Medicare Advantage Patients (YTD) > 520 520 650 None

Employee Wellbeing (1 calendar quarter lag)Apr-Jun

2014

Jan-Mar

2014

OSHA Recordable Patient Transfer Injuries / 100 FTEs < 3.7 4.0 3.9 3.5 J 6.6Natl Bureau of

Labor & Statistics

(2012)

Separator Page

Attach 6- LOS PP.ppt

Care Coordination Report

Length of Stay Focus

Diane Andersen, RN

ECH Board Quality Committee

September 15, 2014

Overview

• Department reports to the Director Care Coordination

• Team is comprised of three groups that come together to

produce results:

- RN Case Managers

- Medical Social Workers

- Transitional Care

• We are responsible for hospital revenue

• Our projects include

- Provision of medical necessity information to payers

- On time, well orchestrated, supportive discharge planning

- Reduction in readmissions

2

Performance Metrics

• The metrics we will be considering this evening include:

- Average Length of Stay (ALOS) – as recorded

- Geometric Mean Length of Stay (GMLOS) – expected LOS

- The gap between these measures

• These metrics will be considered in terms of:

- Medicare reimbursed patient cases

- Patient cases from all payers

3

Trends

The ALOS has trended up the past two fiscal years:

Medicare cases: from 4.7 days to 4.8 days

All payer cases: from 4.19 days to 4.35 days

The GMLOS or case expected average length of stay has

widened:

Medicare cases: from 0.6 to 0.7

All payer cases: from 0.3 to 0.5

6

Analysis

These trends indicate that as an enterprise:

1. We have an excess of outlier cases (stays of 7 or more

days)

2. We are not managing our inlier cases as efficiently as we

might

Since April outlier cases (inpatient 11 or more days) has

averaged between 18 and 24 or approximately 20% of total

census.

A recent inlier opportunity estimate indicates an index of

0.68.

7

Goals for LOS and the Gap

Reduce the % of outlier patients to 15% or less

Reduce the LOS/GMLOS gap from 0.7 to 0.3

Create an accurate Inlier Opportunity Index report –

establish an average index of 0 or less

8

Challenges - Current department staffing configured as 5 days per week

very short staffed on weekends – slow patient discharge

process

- Access case management staffing is minimal at 10 am to

6pm in the Emergency Department (direct admits are not

addressed)

- Uneven staffing day to day on weekdays – Mondays and

Fridays previously consistently short staffed

- A case management orientation to their work as “business

as usual”

9

Planned Interventions/Implementation

1) Revision of the scheduling process – putting patient

paramount ensuring even staffing numbers Monday

through Friday – implemented August 3, 2014

2) Increase staffing on holidays & weekends to ensure

needs are met at the same level 7 days/week – requires

an increase of approximately 3.5 FTEs (not budgeted) –

implementation next fiscal year(?)

3) Increased case management and social work presence in

the Emergency Department from 8 hours/day to 16

hours – requires an increase of approximately 2.8 FTEs

(not budgeted) implementation next fiscal year (?)

10

Planned Interventions/Implementation

- Increased oversight of case management and discharge

planning functions including:

- Establishment of a weekly outlier meeting (all patients with 7 or more day stay (first meeting time and date 1100 September 4, 2014)

- Review of documentation – both medical record and medical necessity review – initiated May 1, 2014

- Renewed focus on patient satisfaction – daily CM and/or SW patient face to face interaction with documented

11

Closing Discussion

Questions?

Suggestions?

Thank you!

12

Separator Page

Attach 7- FY15 Org Goals.pptx

Organizational Goals

1

Organizational Goal FY14 Minimum Target MaximumEvaluation

Timeframe

FY15 thru

July

Regulatory Compliance

Joint Commission Accreditation Met FY Met

Financial Viability

Budgeted Operating Margin Met FY Met

Operating Margin re Budget 1.5% meet 0.5% > Budgeted

1.0% > Budgeted

FY 6.4%

Quality and Patient Safety

1.45 1.42 1.40 FY

1.45 1.40 1.35 Apr-Jun 2015

Service

Improve 3 Service metrics on the Corporate Scorecard

(Based on CMS Qualified Methodology)

- Improve RN Communication (Stretch)

- Improve Staff Responsiveness (Drive)

- Improve Medication Communication (Maintain)

78.0%

67.0%

65.9%

78.0%

67.0%

65.9%

79.0%

67.5%

67.0%

79.5%

68.0%

71.6%

Apr-Jun 2015

Apr-Jun 2015

FY

Apr-Jun 2014

pulled 8/22/14

77.7%

66.9%

71.6%

Average of 3 Service Goals 70.3% 70.3% 71.2% 73.0% 72.1%Efficiency

Medical / Surgical Length of Stay Improvement

Opportunity (Fiscal YTD)0.48 0.48 0.42 0.38 FY

YTD - 7/2014

0.51

Continuum of Care

30 Day Medicare Unplanned Readmission (Enterprise)**Margin of Error +/- 0.3%

8.9% 8.9% 8.8% 8.7% FYJul 2014

9.23%

EPIC

Validate EPIC Foundation and Complete System Design N/A by 6/2015 by 5/2015 by 4/2015 Jun 2015

Rate of Med/Surg/Critical Care Patient Falls 1.45Q4 CALNOC

Performance Measurement

Full Accreditation

90% of Budgeted

1.62

Separator Page

Attach 8- PaCT Plan Update.doc

Date: September 15, 2014

To: Board Quality Committee

From: Re:

Eric Pifer, MD, CMO & Mick Zdeblick, COO

PaCT Plan Update

Overall: The organization continues to make very strong steps toward education of our managers, staff and directors regarding Lean techniques and process improvement. We are beginning to see early signs of improved empowerment at the staff and local level. While this change is underway, we continue to sustain very strong performance in process and outcomes of care including readmissions, procedural morbidity and overall and disease specific length of stay and mortality. In the past year we have made substantial steps forward in service metrics, conversely, we have slipped a bit in overall and risk adjusted length of stay. Our performance on efficiency metrics has been variable with strong gains in some areas and sustained performance in others. PaCT Goals:

1. Transform our Culture

1,240 of staff and managers have received lean and /or PaCT service training. We continue

to perform Kaizen events and grow this program. Now our focus is shifting to the iCare EMR

project and we will continue to emphasize our cultural transformation as we move along.

The recent culture of safety and employee engagement surveys is instructive with regard to

progress on transforming our culture. While we are in a good place with regard to

engagement and we are continuing to improve opinions of employees related to

engagement we have some work to do with opinions of local management. We are

conducting focus groups in September and October to delve more deeply in to these issues.

2. Develop a “CQI” culture using Lean principles

We are making progress as described above.

3. Develop leadership competencies that support CQI

212 of staff and managers have been trained on Lean techniques.

4. Improve and sustain quality outcomes by reducing variability

General and disease focused quality outcomes have improved. The heart failure program

instituted under the auspices of our heart and vascular institute can serve as a model for a

disease centric approach to care.

5. Improve efficiency in process and render care more affordable

Efficiency outcomes are being tracked and many are improving.

Metric Baseline Current

MBU % Patients

discharged before

11a/12p

% before 11 - 8%

% before 12 - 39%

% before 11-32% % before 12-74% (5/1/2014)

ED Median Time to

Provider (MV) 18 minutes 11 minutes

ED Median Time to

Admit (MV) 300 minutes 272 minutes

Dimension Specific Progress: Dimension 1: Patient Centered Care Goal: Specific goal setting on the AHA survey of patient centered care within 3 years.

Organizationally, we are committed to patient centered care. We have deployed many

aspects of best practice; for example, Patient Family Focus Groups, Staff Centric Service

Training programs, etc. However, we have delayed the use of the AHA survey tool at this

moment in our journey towards patient centered care.

Dimension 2: Patient Safety Goal: Within 3 years, harm will come to patients only by random or unpreventable circumstances. We will build harm objectives in to all of the work that we do through the PaCT system.

In FY 14 there was an overall reduction of 18% in Total Harm events since FY13 with focused

reduction in Falls with Harm (Fractures) to zero, HAPUs decreased from 9 to 3 and CAUTIs

decreased from 5 to one. There were 49 preventable harm events in FY 14, with the largest

identified in Surgical Site infections as compared to xx in FY13.

Dimension 3: Effectiveness Goal: Top-decile performance on Value Based Purchasing Metrics (VRB)

The VBP metrics are currently based on four domains: Clinical Process of Care; Patient Experience of Care; Outcomes; and Efficiency. CMS calculates an achievement and an improvement score in a performance period for each quality measure. The calculation that results in the higher of the two scores is the one that will be used for determining the

measure scores. For CY 2013, the Total Performance Score for El Camino Hospital is 50.39, with the state total performance score was 39.82, and national total performance score was 41.70. The Value-Based Percentage Payment is estimated at 1.0048568737% out of 1.5%.

Dimension 4: Efficiency Goal: Achieve within 10% of the lowest cost providers in our market.

Management will update this goal at our upcoming meetings.

Other Dimensions: Timeliness and Equitability: We have not focused heavily on these dimensions. These are open for discussion.

AGENDA - Quality Committee Meeting 8-18-14ATTACHMENT 4Attach 4b- Reducing LOS articleAttach 4c- 6 ways hospitals can reduce LOS articleATTACHMENT 5Attach 5- FY15 Draft Corp ScorecardATTACHMENT 6ATTACHMENT 7ATTACHMENT 8

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