pharmacy and therapeutics committee, · khadijah tribble committee chair led the discussion. •...

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Not-For-Profit Hospital Corporation

General Board Meeting Minutes February 22, 2017

Present: Chair Chris Gardiner, Girume Ashenafi, Jacqueline Bowens, Dr. Julian Craig, Dr. Konrad Dawson, Malika Fair, MD, Luis Hernandez, CEO, Maria Gomez, Steve Lyons, Virgil McDonald, Sean Ponder, Khadijah Tribble, Dr. Mina Yacoub, Donna Freeman, Corporate Secretary Excused: Guests: Brian Flowers, Board of Ethics and Government Accountability (BEGA), Charletta Y. Washington, COO, David Thompson, Director of Marketing, Eric Johnson, Director of Human Resources, David Boucree, and Dr. Diane Kelly, Veritas of Washington, LLC

Agenda Item Discussion Action Item Call to Order The meeting was called to order at 9:12 a.m.

Determination of a Quorum

A quorum was determined by Donna Freeman, Corporate Secretary.

Approval of the Agenda

The agenda was approved with one change: The Board Portal training will not occur.

Approval of Minutes

The meeting minutes of January 17, 2017 were approved as written.

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Consent Agenda The consent agenda was approved. Second. Passed unanimously.

Audited Financials for FY

2016

Ms. Pamela Gray, Audit Partner of SB & Company presented UMC’s Audited Financials for FY 2016 period ending September 30, 2016. (Report presented to Board Members)

• An unmodified opinion. • No material weaknesses were found. • A summary of the results were presented which included no instances of

fraud. • A majority of “green” which means the current processes are effective. • Successful implementation of the recommendations from FY 2015 audit. • A detailed report was given to the Audit Committee on February 6th. • Lilian Chukwuma and staff were congratulated for a job well done.

Executive Management

Reports

Luis A. Hernandez, CEO presented the CEO Report. (Report presented to Board Members) Board moved to accept and approve the CEO report. Second. Passed unanimously. The following highlights were discussed:

• Mr. Hernandez provided an update on the Certificate of Need which includes the ED and the Ambulatory Center. ▫ An extensive discussion continued on the effect of the delay. ▫ The recommendation is to delay – and the responses will be provided.

• What is UMC’s relationship with the FQHC’s? ▫ How can we collaborate with those that are established? ▫ UMC needs to build the infrastructure to work with the FQHC’s. ▫ What is the analysis of the medical staff – below 50 years of age.

• The diversion rate of the ED was discussed. • Diversion rates by the week and weekend were requested. • David Boucree led the discussion regarding Materials Management.

Khadijah Tribble requested from Mr. Hernandez a date when the responses to the CON would be returned.

Dr. Malika Fair requested the LOS data in the future BOD reports be broken down by weekdays vs. weekend discharges.

David Boucree will provide monthly reports to the BOD starting March 2017.

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• Revenue Cycle and status of the transition were discussed. • The funding for the revenue cycle will be returned to the District. • The functionality and use of CRISP were discussed. • UMC’s organizational chart was requested by the BOD.

▫ David Boucree is the VP of Planning and Analysis ▫ Maria Costino reports directly to Luis Hernandez. ▫ Ms. Gomez requested an update on the nurses contract at the next BOD meeting.

Khadijah Tribble requested updates on material management be included in future reports.

Committee

Reports

Governance Committee Report : Virgil McDonald, Committee Chair, highlighted the following:

• The Board, Medical Executive and Executive Team Retreat are scheduled on Saturday, March 25, 2017. The Retreat will be held at Matthews Memorial Baptist Church in SE Washington, DC.

• There will not be a regular meeting in March however a board book is requested.

• Ms. J. Lewis will be one of speakers and will update UMC at the retreat on the Affordable Care Act.

• Review the Evaluation Summary Report enclosed. • Board stationery was presented to the BOD. • Complete the evaluations of this meeting.

Patient Safety & Quality Committee: Maria Gomez Committee Chair led the discussion. The following highlights were noted:

• Maria Costino is becoming acclimated with UMC in her new role. • Ms. Costino is now reporting to Mr. Hernandez. • Ms. Gomez is reorganizing the committee and will meet with Mr.

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Hernandez to get his direction/focus for the staff regarding patient safety and quality at UMC.

• The PSQ committee did not meet in February. Strategic Planning Committee: Khadijah Tribble Committee Chair led the discussion.

• The reporting tool for the standard process for which we measure the performance of our operator.

• Dr. Dawson expressed the concern over the board’s expertise to evaluate the operator.

• Mr. McDonald explained the role of the board in their decision making duties.

• Chair Gardiner clarified the specific duties of the performance evaluation process.

A motion to use the performance tool as the standard for evaluating the operator. Second. The vote: Girume Ashenafi Yes Maria Gomez Yes Sean Ponder Yes Konrad Dawson, MD No Steve Lyons Yes Khadijah Tribble Yes Malika Fair, MD Yes Virgil McDonald Yes Chair C. Gardiner Yes Finance Committee The discussion was led by Steve Lyons, Finance Committee Chair. The highlights included:

• The IT needs to be updated to provide more efficient reporting and budget accountability.

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• Revenue Cycle transition and the blending of staff were reviewed. • Skilled Nursing Facility received a negative report from the DOH survey.

The infraction may lead to a financial impact if the decision is imposed. • An extensive discussion continued.

A motion to accept the committee reports. Second. Passed unanimously. Old Business None New Business None Executive Closed

Session A motion to begin closed session was made. Second. Passed unanimously. Chairman Gardiner convened Executive Session to discuss personnel and contract matters pursuant to D.C. Official Code § 2-575(b)(2) at 10:55 a.m.

Reconvene Public Session

Chairman Chris Gardiner reconvened the public General Board Meeting at 1:25 p.m.

Announcement The next meeting will be the Retreat on Saturday, March 25, 2017 at 8:30 a.m. to be held at the Matthews Memorial Baptist Church, 2616 Martin Luther King, Jr., Avenue, SE, Washington, DC 20020

The meeting was adjourned at 1:30 p.m.

The Not-for-Profit Hospital Corporation, commonly known as United Medical Center or UMC, is a District of Columbia government hospital (not a private 501(c)(3) entity) serving Southeast DC and surrounding

Maryland communities

Our Mission: United Medical Center is dedicated to the health and well-being of individuals and communities entrusted in our care.

Our Vision: UMC is an efficient, patient-focused, provider of high quality healthcare the community needs.

UMC will employ innovative approaches that yield excellent experiences.

UMC will improve the lives of District residents by providing high value, integrated and patient-centered

services.

UMC will empower healthcare professionals to live up to their potential to benefit our patients.

UMC will collaborate with others to provide high value, integrated and patient-centered services.

April 2017

Chief Medical Officer Board Report

Medical Executive Committee Meeting, Dr. Mina Yacoub, Chief of Staff The Medical Staff Executive Committee (MEC) provides oversight of care, treatment, and services provided by practitioners with privileges on the UMC medical staff. The committee provides for a uniform quality of patient care, treatment, and services, and reports to and is accountable to the Governing Board. The Medical Staff Executive Committee acts as liaison between the Governing Board and Medical Staff.

Peer-Review Committee, Dr. Gilbert Daniel, Committee Chairman

The purpose of peer review is to promote continuous improvement of the quality of care provided by the Medical Staff. The role of the Medical Staff is to provide evaluation of performance to ensure the effective and efficient assessments and education of the practitioner and to promote excellence in medical practices and procedures. The peer review function applies to all practitioners holding independent clinical privileges.

Pharmacy and Therapeutics Committee, Dr. Anthony Jones, Committee Chairman

The Pharmacy and Therapeutics Committee discusses all policies, procedures, and forms regarding patient care, medication reconciliation, and formulary medications prior to submitting to the Medical Executive Committee for approval.

Credentials Committee, Dr. Barry Smith, Committee Chairman

The Credentials Committee is comprised of physicians who review all credential files to ensure all items such as applications, dues payment, etc. are appropriate. Once approved through Credentials Committee, files are submitted to the Medical Executive Committee and the Governing Board.

Medical Education Committee, Dr. Christian Paletta, Committee Chairman

The Medical Education Committee was formed to review all upcoming Grand Rounds presentations. The committee discusses improvements and new ideas for education of clinical staff.

Performance Improvement Committee, Committee Chairman

The Performance Improvement Committee is comprised of 1-2 representatives from each department who report monthly on the activity of each department based on standards established by the Joint Commission, the Department of Health, and the Centers for Medicare and Medicaid Services (CMS).

Bylaws Committee, Dr. David Reagin, Committee Chairman

Members include physicians who meet to discuss implementation of new policies and procedures for bylaws, as it pertains to physician conduct. The Medical Staff Bylaws, Rules and Regulations have been revised in preparation for the upcoming Joint Commission inspection. The changes were reviewed, discussed and approved by the Bylaws Committee and will be forwarded to the Medical Executive Committee and then the Board of Directors for review and approval.

Physician IT Committee

Members include physicians who meet to discuss the implementation of the new hospital-wide Meditech upgrade, as well as the physician documentation for ICD-10.

Medical Staff Committee Meetings

DEpArTMENT CHAirpErSONS

Anesthesiology .............................................................................................. ...Dr. Amaechi Erondu

Critical Care .......................................................................................................... Dr. Mina Yacoub

Emergency Medicine ....................................................................................... Dr. Mehdi Sattarian

Medicine ............................................................................................................... Dr. Musa Momoh

Obstetrics and Gynecology ............................................................................. Dr. Sylvester Booker

Pathology ......................................................................................................................... Dr. Eric Li

Pediatrics ....................................................................................... Dr. Marilyn McPherson-Corder

Psychiatry ............................................................................................................... Dr. Lisa Gordon

Radiology ................................................................................................................ Dr. Raymond Tu

Surgery ............................................................................................................ Dr. Gregory Morrow

Departmental Reports

Julian Craig, MD Chief Medical Officer March was both a reflective and challenging month for the medical staff at the United Medical Center (UMC). The Board of Directors held its annual Board Retreat on March 25th at the Mathews Memorial Baptist Church. The meeting was very productive and enlightening as members of the medical staff leadership were able to meet with several of our city officials and board members for the first time. Guest speakers throughout the day were; Council Member and Chairman of the Committee on Health, Vincent Gray; Director of Healthcare Finance, Wayne Turnage; Medical Director for the Department of Health, LaQuandra Nesbitt MD; Regional executive of the American Hospital Association, Joan Lewis; DC Health Exchange Executive Director, Mila Kofman and Director of Marketing, David Thompson. Dr. Nesbitt’s presentation entitled ‘Quality of Healthcare at United Medical Center’ was indeed sobering for many in attendance, and I hope will be used as a rallying cry for more resources to be directed towards the quality department. Some very astute observations were made in Dr. Nesbitt’s report as she stated, “to have an impact on population health and health equity, high quality healthcare services must be delivered by the institutions (UMC) who have that as their primary mission….any efforts to increase volume/revenue that do not first focus on improving patient safety and quality will fail.” In closing, Dr. Nesbit made several recommendations to the board and medical executive team that I take very seriously and are highlighted as follows: Review the patient safety and quality infrastructure at UMC and ensure that the efforts are led by the

CMO/CNO with real-time measurement of patient outcomes.

Review the health professional credentialing process such that criteria for maintaining privileges at the hospital include metrics for quality and not simply adherence to compliance and risk metrics.

Review the existing service lines of the hospital and determine if quality care can be provided with the

existing medical and clinical staff. Following close on the heels of the board retreat, UMC celebrated Doctors Day on March 30th. Board chairman, Mr. Chris Gardiner in his report, thanked the medical staff for its continued efforts to provide quality care for the hospital, and that the board was committed to doing everything in its power to ensure that the hospital has the resources required to deliver safe, quality care. The key note speaker for the event was Chief of Staff, Dr. Mina Yacoub. In an excellent presentation entitled ‘Physicians in the Healthcare Drivers Seat’, Dr. Yacoub methodically went over medical staff initiates and achievements. It was clearly a challenge for the medical staff to redouble its efforts and take the lead on patient safety and quality as well as achieve excellence in documentation which not only has clinical benefits but also is the foundation for a successful revenue cycle. To that end, the medical staff, led by Dr. Yacoub, and the quality department has identified several physician quality metrics for potential tracking and reporting to the Ongoing Professional Practice Evaluations (OPPE) committee. Measured metrics include the following: Volume of Clinical Documentation Improvement (CDI) queries by physician Response rate to CDI queries Number of peer review referrals/focus reviews Core measure outliers Number of staff complaints/patient complaints Quality trends such as surgical infection rates or returns to the operating room. Increased length of stay

In addition, there are several other initiatives currently underway to improve clinical documentation:

Weekly morning meetings by Dr. Yacoub with house staff to discuss specific cases and find

opportunities for improvement. Clinical Documentation Improvement queries with requirements for physicians to complete queries

within 24-48 hours. Creation of new and updating substandard templates within Meditech Ongoing education regarding short stays and documentation to comply with the 2 midnight rule.

The medical staff will require significant support from the Quality, HIM and IT departments to achieve its goals. These departments must be provided with the necessary resources if the United Medical Center is to succeed.

On March 31st, UMC was pleased to host a tour of the facility by the City Administrator, Rashad Young, the Deputy Mayor for Health and Human Services, SyeSook Chung, the Medical Director for the Department of Health, LaQuandra Nesbitt MD, and her Chief of Staff, Dr. Jacqueline Watson. Areas toured by the group included the newly room refreshed medical/surgical unit on the 8th floor, the emergency department (ED) and the ambulatory care center. The visitors were made aware of the desire to expand existing space in the ED and ambulatory care center to enhance patient throughput, safety and satisfaction. For continued growth and development of these service lines, medical staff members that work in these departments, see this as an immediate need that is not aligned with the time frame estimated to build a new hospital.

ANESTHESIOLOGY DEPARTMENT Amaechi Eroundu, M.D. Chairman

PERFORMANCE SUMMARY: The surgical cases for the month of February were 97 (February:87), while Endoscopy cases were 79 (February: 94). The case volume variations have remained unchanged with slight increase in overall annual percentage over the past 3 years. Late surgical cases (Elective and Emergency) after 17:30 remain a challenge, with most late cases occurring between 17:30 and 19:30. We continue to work with Surgery department to ensure adequate utilization during regular OR hours for elective cases. See Attached 2 QUALITY INITIATIVES AND OUTCOME: SCIP protocol is consistently ensured for all our patients with no fall outs. Review of the facility anesthesia performance benchmarked with Age and co-morbidity compares well with other facilities. MORTALITY & MORBIDITY REVIEWS: No anesthesia related surgical mortality and No anesthesia related morbidity was recorded. EVIDENCE-BASED PRACTICE: Anesthesia department is continuing to review all current policies and update them to align with the best practices. Our Providers continuously provide evidence based practice and peer review to ensure quality patient care SERVICE (HCAHPS) SATISFACTION: The Anesthesia Providers continue to provide quality service to our patients. We continue to provide real-time performance assessment of the anesthesia providers. We provide standardized service that ensures patient satisfaction. We are in the process to acquire the Plexus (Anesthesia Information Management System) to stream line the entire process of Preoperative, Intraoperative and Postoperative anesthesia information including, Pharmacy and Billing into a portable system that is Meditech adaptable. When deployed and fully functional, it would expedite the throughput of the entire department and patient care experience. BILLING AND REVENUE CYCLE MANAGEMENT: We have ensured that our providers are oriented to the ICD 10 requirements for both the anesthesia and hospital billing portions. We monitor closely documents and chart by our providers to ensure chart completion at the appropriate time.

CRITICAL CARE DEPARTMENT Mina Yacoub, M.D., Chairman

PERFORMANCE SUMMARY: In March 2017, the Intensive Care Unit had 57 admissions, 60 discharges, and 354 Patient Days. ICU Average Length of Stay (ALOS) was 5.9 days in March. CORE MEASURES PERFORMANCE: ICU continues to meet target goals for Venous ThromboEmbolism (VTE) prophylaxis, and Influenza and Pneumonia vaccinations. ICU is continuing to work with Quality Department and monitoring performance. MORBIDITY & MORBIDITY REVIEWS: ICU had 8 deaths for the month of March, with a total of 65 patients managed, for a mortality rate of 12.3%. Mortality data is presented and reviewed in the Critical Care Committee meeting. CODE BLUE/RAPID RESPONSE TEAMS (RRT) OUTCOMES: ICU continues to lead, monitor and manage the Rapid Response and Code Blue Teams at UMC. Monthly reports are reviewed in Critical Care Committee. Goal is to increase utilization of Rapid Response Teams in order to decrease cardiac arrest episodes on the medical floors. UMC had 7 Code Blue and 14 Rapid Response calls on the Medical/Surgical floors in March. This is a relative increase in Code Blue calls for the month.

VENTILATOR ASSOCIATED EVENT (VAE) BUNDLE: ICU continues to implement evidence-based best practices for patients on mechanical ventilators and the ICU has had no VAEs for the month of March.

INFECTION CONTROL DATA: For the month of March, the ICU had no Ventilator Associated Pneumonias (VAPs), no Central Line Associated Blood Stream Infections (CLABSIs), and no Catheter Associated Urinary Tract Infections (CAUTIs). ICU infection control data is reported regularly to the National Healthcare Safety Network (NHSN). For March, there were 234 ventilator days with no VAPs, 245 central line days with no CLABSIs and 268 foley catheter days with no CAUTIs. ICU infection rates continue to be below national benchmarks. The ICU has had 1261 days with no VAP, and the CAUTI, and CLABSI rates are well below the NHSN rates. CARE COORDINATION/READMISSIONS: For March, 65 patients were managed in the ICU. There were three readmissions to the ICU within 72 hours of transfer out. Cases are to be reviewed in Critical Care Committee meeting April 10th.

EVIDENCE-BASED PRACTICE (Protocols/Guidelines): Evidence based practices continue to be implemented in ICU with multidisciplinary team rounding, ventilator weaning, infection control practices, and patient centered practices.

GROWTH/VOLUMES: March saw less patient volume compared to last year. ICU is staffed 24/7 with in-house physicians and has a 16 bed capacity and is looking forward to operating at full capacity and full potential. Nursing staffing ratios have improved in March. STEWARDSHIP: ICU continues to implement and monitor practices to keep ICU ALOS low and to keep hospital acquired infections and complications low. ICU continues to precept George Washington University Physician Assistant students during their clinical rotations in UMC ICU. ICU is working with ED, nursing, Lab, education, and Quality Department, to improve on Sepsis measures performance. FINANCIALS: ICU continues to operate within its projected budget. ACTIVE STEPS TO IMPROVE PERFORMANCE: Goal is to continue to provide safe and high quality patient care, caring for patients with increased illness acuity, providing best evidence based practice, all while keeping ALOS low and preventing Hospital Acquired infections and complications. Working closely with Quality Department and Infection preventionist to ensure we continue to meet benchmarks. Working with new Chief Information Officer to improve efficiency of Clinical Physician Order Entry (CPOE) and Physician Documentation (PDOC).

EMERGENCY MEDICINE DEPARTMENT Mehdi Sattarian, M.D., Chairman PERFORMANCE SUMMARY: Emergency department had a census of 5,159 patients. March 2017 department metrics: Patient Volumes: 5,159 % Change from 2016: 2.0 % decrease Ambulance Volume: 1,474 (28.5% of ED Census) Left without Being Seen (LWBS): 63 (1.2%) Left prior to Triage: 302 (5.8%) Admission: 536 (10.3%) Transfers: 64 (1.3%) Turnaround Time for Discharged Patients 212 minutes Turnaround Time for Admitted Patients 581 minutes Boarding time for admitted patients 320 minutes

Improving the provider productivity: 2.1 patient per hour Improving throughput process including:

Door – Provider: 75 minutes Door – Disposition (Discharged): 188 minutes Door – Disposition (Admitted): 220 minutes

Adverse events (i.e. elopement, suicide attempts, assaults, etc.):

Elopement Rate: 39 patients (0.7%) Suicide attempts: 0

Readmissions within 72h: 12 Cases (0.23%)

AMA rate: 66 cases (1.3%)

LWBS rate: 1.2%

Transferred Patients: Total transfer of 64 patients (1.3%).

These are the main category of transferred patients:

• Trauma • Psychiatric • Cardiology • Kaiser

Emergency Department Achievements and Challenges: In March 2017, emergency department had a census of 5,159 (166.5 patients/day), this has showed a decrease of 2.0% in census compare to 2016. Also some of ED throughput metrics increased, including the number of patients that left prior to getting triage. There major factors external and internal factors that are affecting the emergency department throughput, census and patients’ experience. Emergency department staffing: The most important factor is to maintain the steady and persistent staffing of emergency department at all times. Considering the high demand, high number of patients and small physical space in ED, appropriate and consistent staffing is vital to ED throughput.

An ideal staffing for ED should be including 2 nurses in fast track and 2 nurses at triage at all times. Also, maintaining a ratio of 4 to 1 nurse in the core and 3 to 1 nurse in code bay would be extremely crucial considering the acutely of ED patient population. Also having the adequate supporting staff including technicians and transporter would be extremely important and helpful.

Boarding of admitted patients: Boarding of admitted patients in emergency department has been detrimental to ED throughput and has been significantly increased in last few months compared to 2016. Here is a quick comparison of boarding time of admitted patients (in minutes) for 2016 versus 2017:

Again considering the high demand and small physical space of ED, transferring the admitted patients to their appropriate ward is extremely important. Also, boarding of admitted patients in ED will expose them to an uncomfortable space, will generate the gap in their continuity of care and has a negative impact on their overall experience.

Ambulance Diversion

a. UMC leadership has spent significant time in the last two years to improve the relationship with both DC and PG EMS system with promises of improving the ambulances throughput and decreasing the offloading time. Unfortunately the recent increase in diversion hours has been against the UMC promises of improving the service to the patients that are using ambulance transport mode.

b. The ED capability and capacity of accepting ambulances has been significantly decreased as the result of increase in diversion hours. This has significant affect in ED census and our acuity of patients. Almost all of patients who require ICU care or surgical procedures get transported to ED by ambulance. Following table shows just the ED diversion hours (Yellow alert) just for PG EMS in last few months:

Month Diversion Hours

January 153

February 287

March 210

Emergency department staff and leadership will continue working closely with the hospital leadership to overcome these challenges and provide the best possible emergency care to our patients.

Month 2016 2017

January 101 307

February 92 332

March 94 320

INTERNAL MEDICINE DEPARTMENT Musa Momoh, M.D., Chairman

ADMISSIONS/DISCHARGES/LENGTH OF STAY:

• Hospital Admissions – 559 • Department of Medicine Discharges – 403 • Percentage – 72%

• Hospital Discharges – 556 • Department of Medicine Discharges – 402 • Percentage – 72%

• Hospital Observation – 195 • Department of Medicine Observation – 90 • Percentage – 46%

• Length of Stay for Hospital – 6.1 days • Length of Stay for Department of Medicine – 6.7 days

PROCEDURES: • EGDs – 44 • Colonoscopies – 40 • Bronchoscopies – 1 • ERCP – 1 • Dialysis – 187

APPOINTMENTS/SATISFACTION SCORES: • No new appointments • No report available for satisfaction scores

OBSTETRICS & GYNECOLOGY DEPARTMENT Sylvester Booker, M.D., Chairman

Indicator JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Breastfeeding 48% 39% 53%

IMC Admission 1 2 1

NICU Admission 2 1 1

Infant on Vent 1 0 1

# of infant transferred 1 1 1

# of infant on IV Therapy

2 2 1

Infant on Antibiotic Therapy 2 1 1

Phototherapy 1 1 0

Circumcision 15 6 15

Infant (+) Substance Abuse

7 4 5

Boarding Baby 2 2 0

Failed Hearing Screen 0 0 0

# of Bili scan 36 26 22

# of CCHD Screening 36 26 22

GYN patients 8 6 7

Premature babies receiving steroids prior to birth*

1 0 0

Code Purple 24 19 16

Neonatal Death 1 0 0

INDICATOR JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Total Deliveries 39 28 24

Vaginal Deliveries 34 24 19 Vacuum assisted deliveries

3 2 1

Primary C-Section 1 3 4 Repeat C-Section 4 1 1 VBAC Attempt 1 0 1

VBAC Successful 0 0 1

# of Induction of Labor

0 1 0

# of Aug. of Labor 1 2 3

HIV + Mom 0 0 0

HIV + Babies 0 0 0 Mother + for Substance

7 4 5

Abuse Still Birth 1 1 1 No Prenatal Care 6 4 2 Mother to ICU 1 1 0 Multiple Gestation 0 0 0 HTN/PIH 2 2 2 Placenta Abruption 2 0 0 Placenta Previa 0 0 0 Meconium 8 6 5 MRSA + Carrier 0 0 0 Maternal Transfer 0 0 0 PP Hemorrhage 1 0 0 Cord Prolapsed 1 0 0 Epidural Anesthesia 9 11 Spinal Anesthesia 4 3 4 General Anesthesia 1 1 1 Diabetic 0 0 0 Eclampsia 0 0 1 HELLP Syndrome 0 0 0

TOTAL TRIAGE PATIENTS

185 129 158

PATHOLOGY DEPARTMENT Eric Li, M.D., Chairman LABORATORY PRODUCTIVITY RESULTS: We developed performance indicators we use to improve quality and productivity.

Turnaround Time: Turnaround time is a critical factor that directly influences customer satisfaction.

Customer Satisfaction: The key to business is providing great customer service, superior quality, and creating a unique customer experience.

Complaints: Complaints are an important metric for evaluating the quality of our laboratory processes.

Equipment down time: It is important that laboratories track, monitor, and evaluate equipment failure rates and down time.

Month 01 02 03 04 05 06 07 08 09 10 11 12 Reference Lab test – Urine Protein 90% 3 days

100%

16/16

100%

23/23

90%

18/20

Reference Lab specimen Pickups 90% 3 daily/2 weekend/holiday

95%

76/80

96%

74/77

92%

71/77

Review of Performed ABO Rh confirmation for Patient with no Transfusion History

Benchmark 90%

100% 100% 100%

Review of Satisfactory/Unsatisfactory Reagent QC Results

Benchmark 90%

100% 100% 100%

Review of Unacceptable Blood Bank specimen

Goal 90%

99% 99% 99%

Review of Daily Temperature Recording for Blood Bank Refrigerator/Freezer/incubators

Benchmark <90%

100% 100% 100%

Utilization of Red Blood Cell Transfusion/ CT Ratio – 1.0 – 2.0

1.3 1.2 1.3

Wasted/Expired Blood and Blood Products

Goal 0

0 1 1

Measure number of critical value called with documented Read Back 98 or >

100% 100% 100%

Hematology Analytical PI

Body Fluid

100%

12/12

100%

14/14

100%

10/10

Sickle Cell

0/0 0/0 2/2

ESR Control 100%

31/31

100%

20/20

100%

25/25

Delta Check Review 100%

180/180

100%

215/215

100%

184/184

PEDIATRICS DEPARTMENT Marilyn McPherson-Corder M.D., Chairman

Performance Summary: For the month of March, 23 babies were admitted to the nursery. One infant was transferred to Children’s National Medical Center due to prematurity. One preterm infant, with a birth weight of 660 grams was born, stabilized and transported to CNMC. The infant is critical, but remains in stable condition. No infant deaths. On the average length of stay was 2 days for NSVD and 3.5 days for C-sections. The year-to-date total number of newborns admitted to the nursery is 88.

The Departmental meeting was held on March 7, 2017. Dr. Marilyn Corder continues to work with the hospital staff to prepare the site for the Stork’s Nest Program. Work has been completed on the flooring and other minor work is to be done. We have begun to receive donations from the community and Zeta Phi Beta Sorority to stock the program.

Core Measures Performance: The Department of Pediatrics continues to meet the Core Measures Performance.

Morbidity and Mortality Reviews: No fetal deaths. All infants were cared for in the UMC nursery and discharged home with planned follow up care.

EVIDENCE BASED PRACTICE (Protocols/Guidelines): Neonatal resuscitations guidelines continue to be followed resulting in no mortalities or morbidities. Increase education on the benefits of breastfeeding and skin-to-skin encouraged right after delivery of the infant with >60% breastfeeding rate within the first 24 hours. Hand washing encouraged repeatedly to prevent healthcare associated blood stream infections in the newborn. Zero incidence of healthcare associated bloodstream infections of the newborn. GROWTH/VOLUME: The Department continues to expand staff for coverage of the nursery and Ob support. The department continues to work to extend the breast feeding initiatives and to encourage pre and post natal care with all mothers. We are pushing forward to complete our certification as a “baby friendly” hospital.

STEWARDSHIP: The Pediatric Contract has provided financial stability and has maintained operation below the budgeted expenses. ACTIVITIES: The Pediatric Department is planning for the Easter Basket Give-Aways on April 15, 2017 for the community.

PSYCHIATRY DEPARTMENT Lisa Gordon, M.D., Chairman Performance Summary: For the month of March please see the table below. The year to date total number of admissions was 240. Our average length of stay for March was 5.90 and YTD was 6.29 days. The ALOS for the month and YTD were below the target of 7 as a result of more effective and efficient discharge and care planning by the Treatment Team.

CORE MEASURES PERFORMANCE:

Description Jan. Feb. March Avg YTD MTD % YTD %ALO S 8.12 4.85 5.9 6.29UMC Admissions Legal Status-Voluntary 42 35 28 105 32% 43.6%UMC Admissions Legal Status-InVoluntary 31 46 59 136 68% 56.4%

Total Admissions 73 81 87 241 100% 100.0%Referral Source:CPEP 17 23 33 73 28.4% 30.3%Other (UMC ED) 49 47 44 140 58.0% 58.1%GWU 0 1 5 6 1.2% 2.5%Providence 0 1 1 1.2% 0.4%Georgetown 1 2 1 4 2.5% 1.7%Sibley 1 3 4 3.7% 1.7%UMC Medical Surgical unit 3 2 5 2.5% 2.1%Children's Hospital 0 0 0 0.0% 0.0%Howard 0 0 1 1 0.0% 0.4%Laurel Regional Hospital 0 0 0 0.0% 0.0%Washington Hospital Center 0 0 0 0.0% 0.0%Suburban Hospital 0 0 0 0.0% 0.0%All Others 0 0 1 1 0.0% 0.4%PIW 2 2 2 6 2.5% 2.5%

Total # of Patients 73 81 87 241 100.0% 100.0%

Description Jan. Feb. March TotalSt. Elizabeth Transfers 4 1 3 8Transfers with LOS over 15 days 4 1 3 8Number of Court Hearings 2 0 4 6

BHU is continuing to work with the PI team to improve the validity of the abstraction process for core measures. We receive daily reports on potential fall-outs. We are also preparing to institute new HBIPs quality measures.

BHU Admin. Director is conducting, on a concurrent basis, a 100% audit of Patient Charts who are administered a restraint (chemical or physical) or put in seclusion to ensure that BHU staff is doing the appropriate documentation. Any fall outs are being addressed with the concerned staff member to prevent a future recurrence.

In the 3rd week of March the open BHU Social Worker position was filled. As a result the unit had to operate with only one Social Worker for over 2 weeks- this resulted in the need to cap the unit census at 16 but additionally also negatively impacted treatment planning and psychosocial assessments.

In March we were only 97% compliant with the requirement for 7 days Post Discharge follow-up appointments. This was because of lack of SW coverage.

ADVERSE EVENTS (i.e. elopement, suicide attempts, sexual harassment, assaults, etc): There were no suicide attempts or other harassment complaints in the month of March. Aggressive patients continue to be managed safely by BHU staff. However, there has been an increase in the number of chemical restraints- as a result the CNO has agreed to provide the BHU with an additional 12 hour shift for an individual who will serve as a resource to lead in the de-escalation of patients. This will be implemented in April. SERVICE (HCAHPS PERFORMANCE/DOCTOR COMMUNICATION: BHU continues to work to implement a broader programming schedule to provide our patients more therapeutic groups. Group attendance is monitored daily. All staff is encouraging patients to attend groups. A second Full-time SW who started in the 3rd week of March. In the interim there is a part-time SW and a part-time SW associate who are filling in.

The Art Therapist-who is FT FTE, has resigned. Her last date is April 7, 2017. The recruitment for a FT replacement has been initiated. In the interim a request has been made for an Agency staff GROWTH/VOLUMES: BHU has two full time physicians who are covering for 20 patients and consults until April 7, 2017. The Psychiatric Nurse Practitioner, Dr. Evelyn Nuwordu, is now fully integrated with the BHU. Dr. Samuels has tendered her resignation; her last date is April 7, 2017. Dr. Gordon has also submitted her resignation. Her last day will be June 16, 2017. PIW is actively recruiting physicians to fill these vacancies. FINANCIALS: BHU is working with patient billing and admissions to reduce payment denials from insurance providers and a monthly meeting is in the process of being scheduled. The BHU has implemented an Authorization log which tracks all admissions and ensures all stays are authorized and all denials are appealed.

ACTIVE STEPS TO IMPROVE PERFORMANCE: The renovations began in October and are scheduled to be completed in June 2017.

RADIOLOGY DEPARTMENT Raymond Tu, M.D., Chairman

Performance Summary:

Core Measures Performance:

100% extra cranial carotid reporting using NASCET criteria 100% fluoroscopic time reporting 100% presence or absence hemorrhage, infarct, mass 100% reporting <10% BI RADS 3

Radiology staff continues to work to improve the turnaround of patients for CT and MRI of the brain through the department.

MORBIDITY & MORTALITY REVIEWS: There were no departmental deaths.

CODE BLUE/RAPID RESPONSE TEAMS (“RRTs”) OUTCOMES: none

EVIDENCE-BASED PRACTICE (Protocols/Guidelines): We continue to improve patient transportation into and out of the emergency department.

SERVICE (HCAHPS PERFORMANCE/DOCTOR COMMUNICATION): The radiology department’s new equipment has been very well received for by our clinical staff elevating the status of our hospital.

STEWARDSHIP: Dr. Tu continues to strongly recommend clinical decision support at the point of order entry to reduce unnecessary examinations and to aid in practioners to order the right test, the right time for the right patient.

Dr. Tu repsented radiology at the American Medical Association meeting in Washington DC in March pictured here teaching ultrasound to medical students from all medical schools in the US with the American College of Radiology.

FINANCIALS: Active Steps to Improve Performance: The active review of staff performance and history to be provided for radiologic interpretation continues with improvement. Proper protocols, judicious use of radiation emitting technology are continuing objectives in the department under the teamwork of excellent technologists and radiology directorship and front desk staff.

SURGERY DEPARTMENT Gregory Morrow, M.D., Chairman

For the month of March 2017, the Surgery Department performed 187 total procedures.

The chart and graft below show the monthly trends over the last 5 calendar years

2013 2014 2015 2016 2017

JAN 173 159 183 147 216 FEB 134 143 157 207 185 MAR 170 162 187 215 187 APRIL 157 194 180 166 MAY 174 151 160 176 JUNE 159 169 175 201 JULY 164 172 193 192 AUG 170 170 174 202 SEP 177 168 166 172 OCT 194 191 181 177 NOV 137 157 150 196 DEC 143 183 210 191 Annual Total 1952 2019 2116 2242 588

SURGERY SUMMARY REPORT FROM MARCH 2017

173

134

170 157

174 159 164 170 177

194

137 143 159

143 162

194

151 169 172 170 168

191

157

183 183

157

187 180 160

175 193

174 166 181

150

210

147

207 215

166 176

201 192

202

172 177

196 191

216

185 187

0

55

110

165

220

275

JAN FEB MAR APRIL MAY JUNE JULY AUG SEP OCT NOV DEC

UMC OPERATING ROOM CASES 2013 - 2017

2013 2014

2015 2016

2017

Our surgical volumes while experiencing a monthly downward trend, we are still on pace to having an annualized increase over three previous four years. We continue to work diligently to increase our efficiencies and productivity while, at the same time, delivering the highest quality of care.

We continue to meet and / or exceed the quality measures outlined for the Surgery Department.

SURGERY SUMMARY REPORT FROM MARCH 2017

In coordination with the Hospitalist service and Nursing, the vascular access (Midline and PICC line) service is operational with the goal to improve upon patient satisfaction and avoid delays in treatment due to lack of adequate intravenous access for therapies (i.e., pain medication, antibiotics) and procedures, especially as it pertains to surgery start delays.

The department is continuing its work on:

On-going evaluation of the service lines that will most benefit from implementation of best practices policies and procedures.

Moving the surgical assistant staff from under nursing to the medical staff to better utilize their skill sets and work-flow to best serve the OR and in-patient needs under direct physician supervision. The proposal has been submitted to the bylaws committee for review. In the meantime, an additional surgical assistant has been added to address the current needs in the OR.

Expanding availability of available OR time during regular business hours. We are working with the Anesthesia Department and Nursing to achieve these goals.

The department is completing the process of reviewing all subspecialty delineation of privileges to make certain that they are up-to-date and reflect advances that now considered integral parts of residency and fellowship training.

The OR committee has met and will continue to be the focal point of addressing the ongoing needs of the surgical services as it pertains to the day to day operations.

We have begun the final details for implementation our strategic plan to increase our operative volumes to accommodate the 4 new ORs. This will include broadening daytime anesthesia coverage to stepwise accommodate higher volumes and also to bolster the service lines that are lagging in volumes or non-existent; these specifically include Orthopedics and Bariatric Surgery.

MEDICAL AFFAIRS Sarah Davis, BSHA, CPMSM

April 2017 UMC Medical Affairs Monthly Report

APPLICATIONS IN PROCESS

(Applications received through March 31, 2017)

Department # of Application in Process

Allied Health Practitioners 3 Anesthesiology 0 Behavioral Health 0 Emergency Medicine 1 Medicine 1 Obstetrics & Gynecology 3 Pathology 0 Pediatrics/Neonatology 1 Radiology 1 Surgery 1

TOTAL 11

DEPARTMENT HIGHLIGHTS/ANNOUNCEMENTS United Medical Center celebrated the 2017 National Doctors Day on March 30th. Celebration began with a continental breakfast and was followed by a luncheon. The theme of the celebration was “Driving the Future of Healthcare”. Dr. Mina Yacoub, Chief of Staff gave a timely presentation focused on the physician as the driver in improving the quality of care at United Medical Center. Dr. Julian Craig was selected by his peers as the “2017 Doctor of the Year”. Members of the Medical Staff were honored for their commitment and service to the community we serve.

CONTINUING MEDICAL EDUCATION COMPARATIVE DATA 2013 – 2016

*NO GRAND ROUNDS WERE HELD JANUARY THROUGH MAY 2015*

CME DATA

2013 2014 *2015* 2016

Total Number of Grand Rounds

23 20 22 45

Total Number of Attendees

1,027 701 420 1,772

Total Grant Funding Received

$29,410.00 $28,600.00 $27,755.00 $26,905.00

ANNOUNCEMENTS

Medical Staff Meetings April

April 3, 2017 at 12:00 pm Peer Review Committee - CANCELED

April 10, 2017 at 12:00 pm Critical Care Committee

April 11, 2017 at 2:00 pm Pharmacy & Therapeutics Committee

April 13, 2017 at 12:00 pm Credentials Committee

April 13, 2017 at 12:30 pm Prevention & Control of Infections Committee

April 17, 2017 at 12:00 pm Medical Executive Committee

April 18, 2017 at 2:00 pm Health Information Management Committee

April 17, 2017 at 3:00 pm Performance Improvement Committee

April 19, 2017 at 5:00 pm Department of Medicine

April 20, 2017 at 1:00 pm Medical Education Committee

MEDICAL STAFF ACTIVITY

February & March 2017

NEW APPOINTMENTS

Luc Oke, M.D. (Medicine/Cardiology and Critical Care) *

Charles Roberson, M.D. (Surgery/Orthopedic Surgery)

Evelyn Nuwordu, DNP (Psychiatry/Allied Health)

REAPPOINTMENT

Harminder Sandhu, M.D. (Active)

Bulent Zaim, M.D. (Courtesy)

James Hammond, CRNA (Allied Health)

Michelle Rowe, CPNP (Allied Health)

Jhemika Watson, CRNA (Allied Health)

PROVISIONAL REVIEW

Ehsan Nobakht-Haghighi, M.D. (Provisional to Active)

Nwahiehie Onyeaghala, .D. (Provisional to Active)

RESIGNATION

Muhammad Amer, M.D. (Cardiology)

United Medical Center Management Report

Operations Summary – April 2017

QUALITY There is a web-conference scheduled for April 20th with KEPRO, the quality improvement organization that notified us of problems with our short stay admissions. During that webinar, specific cases will be reviewed with the physicians to highlight documentation issues and explain why these cases did not qualify for inpatient admissions. A physician on staff with KEPRO will be leading the discussion. On April 14, 2017, we received a statement of deficiency from the DOH regarding the cases discussed by Dr. Nesbitt at the retreat. This statement of deficiency is from a complaint review in November, 2016. The nursing department and the quality department are working together on the plan of correction, which is due April 28th. We continue to move forward with implementing the quality management infrastructure with a new reporting format to the Performance Improvement Committee. This will be the first month of the new reporting format with data. This is a work in process. The Quality Director has assumed responsibility for patient complaints and has developed a log to fulfill federal requirements for tracking grievances. All process issues identified will be fed back into the PI structure for follow-up and correction and then monitored for success. The data captured by this log will be presented to the PI Committee on a quarterly basis to identify trends. The draft 2017-18 PI Plan was presented to the Board committee on Quality and Patient Safety for comment and approval. Some minor revisions were suggested and, those being made, the Plan will be presented to the full Board for approval. The Quality Department is working closely with a workgroup led by Dr. Yacoub to improve our sepsis outcomes. We are in the process of analyzing the sepsis data to identify the areas for improvement in order to develop strategies to address them and improve our performance. We continue to work on validating the accuracy of the data being collected for various measures. This is a slow process as much of the data is collected manually and the staff has to backtrack through Meditech to ensure the data is being pulled from the correct fields and all fields where the information might be documented.

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PATIENT CARE SERVICES Clinical Practice & Quality:

• In an ongoing effort to continue to raise the bar with clinical practice and improved outcomes, a sub-committee of the critical care committee has been established to review the particulars of all code blues and rapid responses. This group will use quality management principles to determine root causes and identify areas for training and/or improvement.

• A new “code stork” policy will be presented to the Environment of Care committee this month to provide for house-wide alert of a patient who is imminently delivering a newborn outside of the L&D area. This will ensure that all of the necessary personnel and equipment are present to allow for the best possible outcomes for both the baby and mom.

• The CNO and CMO have increased collaboration to provide a uniformed message on clinical quality and strengthen the important relationship between physicians and nursing staff with a particular focus on communication between caregivers and patient experience.

• We are excited to celebrate another milestone for our ICU who ended March with 431 days without an instance of ventilator-acquired pneumonia, a first-class example of the difference evidence-based practice and diligent nursing care can make.

Maximum Nurse-to-Patient Ratios Set In response to staffing concerns and to ensure the safe delivery of patient care, the nursing staffing matrix was revised and it was decided that staffing ratios would be set forth at maximum limits on our medical-surgical and telemetry units. Understanding that higher ratios are linked to less favorable outcomes and higher staff turnover, this was a necessary step to ensure safe, prudent care. OPERATIONS The New 8th Floor Opens Earlier this month, the newly refurbished 8th floor opened to patient care. The new unit features completely refreshed patient rooms, two new state-of-the-art isolation rooms, central telemetry monitoring center and allows for nursing staff to be positioned throughput the unit vs. in the center core. So far, the patient response has been overwhelmingly positive. Also included in the new refresh is a state-of-the art nurse call system. Each room has the ability to accommodate two beds per room. The 5th floor refresh project is currently underway and is expected to last 3 months. Once completed, both units will be identical in layout and medical-surgical and telemetry patients can be located on either floor, allowing for flexibility for patient placement as well as staffing. Contracts:

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• Anesthesia – In response to our Request for Proposals (RFP) we received replies from two (2) of the three (3) providers – EmCare the current vendor, and Northrium, a small group serving two hospitals in FL. The initial pricing for both vendors were similar. We are conducting a best and final pricing review with both vendors. Northrium lowered their bid by approximately $150K. We are scheduled to meet with EmCare on Tuesday, April 25th for their best and final presentation.

• Vizient – We have finalized the agreement with Vizient, formerly MedAssets, for hospital supplies. The agreement is in the CFO’s office for fiscal sufficiency approval. Although we were also negotiating with Vizient for a Materials Manager candidate, their pricing was cost prohibited and we are proceeding with one of the two final candidates recruited by the hospital.

• Linen – We awarded the new contract for Linen Services to Crothall; however, the current vendor, FDR Services has submitted a protest stating their price was lower. Although pricing was not the sole determinant of the award to Crothall, FDR’s protest only compares the price of rental and cleaning. When the cost of lost linen is included, Crothall has a lower price than FDR Services. We are working with legal to properly address this protest so we can proceed with implementation.

• Hospitalist – We are currently negotiating an extension of the current Hospitalist group. We are expanding the quality and performance metrics included in the current agreement. We are also reviewing coverage and pricing to ensure we have appropriate coverage 24 hours / 7 days per week.

Personnel: • Materials Manager – We have narrowed the search to two (2) candidates and by the end

of the month we intend to offer the position to one of these candidates with a starting date of no later than May 1, 2017.

• Contract Manager – We have offered a candidate the position and are in the process of onboarding the candidate for a start date within the next 30 days.

MCO Agreement:

• AmeriHealth – On Friday, April 21st we have a conference with AmeriHealth to discuss the final redlines to the hospital’s provider agreement. Lawyers from both organizations will participate in the call in an attempt to expedite resolution to the remaining open contract terms.

Leapfrog Hospital Safety Grade After the Fall 2016 Leapfrog Safety Grade scores were published, Veritas spearheaded reviewing, completing and resubmitting the Leapfrog Hospital Safety Grade application. On the recently released Spring 2017 Safety Grade, UMC scored a C, the same as George Washington University Hospital and above the D scores for Providence Hospital of Washington, Medstar Washington Hospital Center and Howard University Hospital. The increased grade reflects UMC data from the Safety Grade section, Doctors order Medications through a Computer where UMC scored 100 of 100. This score is above the hospital average of 75.8 and indicates the robustness of UMC’s computerized physician order

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entry program (CPOE). In the section, Problems with Surgery, we discovered that the score for Dangerous Object Left in Surgery resulted from a coding error and suspect that the Serious Breathing Problem score was also a coding error. Because the current system of Leapfrog data collection from historical, publically reported data does not promote the ability to correct inaccuracies, these two indicators have brought down the UMC score. While many areas for improvement exist, of note is that UMC performs better than average on the infection prevention, dangerous bedsore and bubbles in the blood indicators. Lessons from the survey are being incorporated into the 2017 Management Action Plan and Hospital Quality Plan. The focus for 2017 is on strengthening safety practices within the hospital. Respiratory Therapy Improvement Veritas Respiratory Therapy Consultants conducted two onsite visits to United Medical Center on February 27 through March 3 and March 20 – March 24 during which time they: 1) developed annual department-specific clinical competencies plan and toolkit; 2) conducted competency assessment, training and validation of clinical knowledge and skills for department staff; 3) conducted preliminary demand and productivity analysis for respiratory services and developed tools to enable further analysis; 4) analyzed and recommended daily staffing plan to reduce use of agency staff; 5) identified opportunities for cost savings in supplies and equipment use; 6) identified opportunities to enhance evidence-based practice and supplied national guidelines for multiple areas. HUMAN RESOURCES Collective Bargaining Agreement With the end of the fiscal year 2017 quickly approaching, we are also approaching the end of three (3) of our four (4) Collective Bargaining Agreements, i.e. Service Employees International Union (SEIU), International Union of Engineers (IUOE) and the United Federation of Special Police Officers (UFSPO).

In preparation for our upcoming negotiations, we will continue to engage the services of the Office of Labor Relations and Collective Bargaining (OLRCB). They have been instrumental in the negotiation of our past Collective Bargaining Agreements with all four (4) labor unions.

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Our initial focus will be the SEIU labor union. Having recently received fiscal sufficiency for their contract, allowing the Hospital to execute retroactive contractual salary increases for Fiscal Year 15, 16 and 17, we are afforded the opportunity to enter the negotiations on a positive note. Potential Contractual issues:

• Wages and Benefits • Job Scope and their Fair Market Value (FMV) • Job Classifications • Position Compression • FTE vis-à-vis Union Membership • Leave • Wage Committee membership • Union Visitation • Hospital Flu requirements

By initiating the Strategic Planning process now, we afford ourselves the opportunity and time to successfully negotiate a mutually beneficial contract agreement that fully supports the Mission and future Vision of the Hospital. Recruiting Initiatives Hires and Terms – Nursing

January February MarchHires 1 4 3Terms 1 0 6

0

1

2

3

4

5

6

7

Hires/Terms - Nursing 2017

6

Hires and Terms – UMC

Key/Strategic Positions

Position Type Title FTE

Executive Level

No Openings 0.0

Total 0.0

Key Positions

Director of Materials Mgmt. 1.0

Director Radiology 1.0

Director of Nurses – SNF 1.0

Total 3.0

Hard To Fill

Art Therapist 1.0

Clinical Informatics 1.0

January February MarchHires 14 14 15Terms 7 1 10

0

2

4

6

8

10

12

14

16

Hires/Terms - UMC 2017

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Clinical Supervisor Asst. 1.0

Respiratory Therapist 1.0

RN – Dialysis 0.9

RN – ED 9.3

RN – ICU 1.2

RN – L&D 1.6

RN – Med/Surg. 0.3

RN – OR 1.7

RN (PCC) 1.0

RN (Radiology) 1.0

Surgical Assistant 1.0

Total 22.0

Open Positions

Administrative Supervisor 1.0

Cashier 0.5

Certified CT Tech 0.1

Certified Nursing Assistant 2.2

Cook I 0.5

Environmental Services 1.0

ER Coordinator 1.0

ER Tech 0.9

Food Service Worker 1.0

General Maintenance 2.0

HelpDesk Analyst 1.0

HR Generalist 1.0

L & D Tech 0.5

Licensed Practical Nurse 2.0

Med/Surge Technician 0.6

Medical Assistant n(Occ & PCC)

1.5

Medical Technologist 1.5

Patient Access Rep. 2.0

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Payroll/Staffing Coordinator 1.0

Physician’s Assistant 1.0

Project Coordinator 1.0

Psych Technician 1.2

SPO 2.0

Sr. Systems Analyst 1.0

Surgical Assistant 1.0

Unit Secretary – BHU 1.0

Utility Worker 0.5

X-ray Technician 0.1

Total 30.1

Total Open Positions 55.1 INFORMATION TECHNOLOGY AND SYSTEMS Assessment of Existing Systems and Services The work to complete a comprehensive assessment and long term plan specific to the use of Health Information Technology continues to be a major focal point. That work will continue over the next few months. Most recently, a draft “Strategic Plan for Health Information Technology at UMC” has been shared internally with the Executive Leadership team. The draft includes the charter and working structure of a “governance” committee for IT planning and purchasing. The draft will be reviewed and modified by the Leadership team as necessary to make it ready for formal adoption within the coming weeks/month(s). Once that is done, the Committee will be formed and their work will commence. The goal will be for UMC to have a formal strategic plan for information technology in place by July 2017. Near term, efforts to fill existing vacancies in IT have yielded little results, the reasons for which are not entirely clear. The overall compliment of staff in IT is definitely low, certainly. UMC’s older technology platform is likely a deterrent for many. Finally, the pay rates for IT at UMC are possibly well below market. A staffing assessment is underway with respect to both the number of FTE’s and salaries in IT. Certainly, compared to other like facilities, UMC’s spending for IT as a percentage of operations is well below average. In an industry that has long been criticized for spending “only” 3% of operations on IT, UMC currently spends far less still at only 2.1% while the industry is now at 3.4 - 3.8% and trending higher, annually, since 2010.

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Current Project “Highlights:” • The week of April 18, UMC’s current Hospital Information System vendor, Meditech,

conducted demonstrations of their new software at UMC. Such demonstrations can help leadership understand the potential benefit of newer, state-of-the-art technology products for UMC and the patients we serve; that understanding will play heavily into any discussions concerning UMC’s future strategies for Health Information Technology.

• Endoscopy (G-Gastro) – successfully implemented and the physician end-users seem pleased with the new systems reliability and features.

• Radiology (Merge PACS) – significant imaging system enhancements still on target for “go live” in May.

• Nursing (Rauland) – successfully implemented the new nurse-call system with the opening of the refurbished 8th floor nursing unit.

• Case Management (InterQual) – new patient assessment and acuity software is ready for “go live” as soon as end-user departments finalize workflow and training; still planned for April.

• Case Management (Curaspan) – new long-term-care bed-placement software to go live in 2017.

• Physicians (Medical Dragon) - Speech Recognition for EMR documentation has been delayed to September 2017 due to insufficient resources in IT.

• Health Information Exchange (CRISP) – significant new connectivity is being planned for 2017.

• Web Patient Portal (Meditech) – new patient health portal planned for go live in 2017. • Anesthesia Management (Plexis or Spectrum) – the search for an Anesthesia “EMR”

system has been expanded to include Spectrum. Spectrum’s Anesthesia Management System has already been integrated with Meditech’s 6.1 System so, there are likely inherent advantages for UMC to consider that over Plexis.

• Telemetry Interface – patient monitor “vitals” to be interfaced to electronic medical records in 2017.

• e-ClinicalWorks – The new ambulatory Practice Management / Electronic Medical Records system has had a significant setback. The ambulatory practice is now “back on paper”. The rollout of e-CW is to be re-designed, perhaps without the expectation to use Meditech to such a high degree for certain functionality that, in turn, requires some overly complex interface development for such things as patient scheduling on the front end and billing extracts on the back end.

PUBLIC RELATIONS AND COMMUNICATIONS Stakeholder Relations City Administrator Rashad Young, Deputy Mayor for Health and Human Services HyeSook Chung, and Department of Health Director LaQuandra Nesbitt visited United Medical Center on Friday, March 31, to gain a better understanding of the hospital’s needs and tour various areas in the hospital.

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CEO Luis Hernandez and CMO Dr. Julian Craig provided the city officials and their staffs with background information about the hospital. Dr. Craig reiterated that the hospital has hired a number physician specialists and expanded the number of Primary Care Physicians to address the needs of the community. He also spoke about the limited space in the Emergency Department that is available to treat the almost 60,000 patients that visit ED each year. Following remarks by Mr. Hernandez and Dr. Craig, the visitors went on a tour of our Emergency Department, Ambulatory Care Clinic, Wound Care Center, Department of Radiology, the medical/surgical unit on the 8th floor, and the Department of Obstetrics and Gynecology. Community Outreach:

• On Saturday, April 8, forty (40) Pastors, Associate Pastors, Deacons and other church leaders were at United Medical Center for the Ward 8 Faith Leaders monthly meeting. Eric Johnson, Director of Human Resources, provided an overview of the hospital and recent changes designed to improve the care provided to patients. Johnson spoke about the medical staff and how more physician specialists had been hired in addition to a major increase in the number of Primary Care Physicians. He also talked about the Wound Care Center, Diabetes Education Program, Sleep Center, the Oncology Clinic and the Care Center that treats people with HIV or Hep-C. Many of the Faith Leaders said they were unaware of some of the services UMC provides. Following Mr. Johnson, Dr. Joylene Thomas, a Primary Care Physician presented. Dr. Thomas spoke about some of the challenges she and other doctors in the Primary Care Clinic face on a daily basis. She spoke about how many patients that she sees have multiple conditions that must be treated and in some cases requires her to refer them to the Laboratory or the Radiology Department for more in-depth testing/screening. She also told the audience that it is important for patients to believe and trust that the care they receive at UMC is no different from the care delivered at hospitals in northwest D.C. or Maryland. After her presentation, the Faith Leaders were taken on a tour of the newly renovated 8th floor, the Sleep Center, and Wound Care Center.

• UMC made presentations about the hospital; distributed literature; and answered questions from members of the community at the following meetings:

1. ANC 8A meeting on April 4 (Ward 8) 2. Congress Heights Civic Association Meeting on April 10 (Ward 8) 3. ANC 7D Meeting (Ward 7) April 11 4. Birchwood City/Clearview Manor Community Association Meeting on April 13

in Oxon Hill, Maryland 5. 7th Annual Hop Into Health Event with Prince George’s County Councilmember

Karen Toles at the Hillcrest Heights Community Center. Our Mobile Health Clinic screened over 24 people. April 15

CORPORATE COMPLIANCE Compliance Updates:

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• The newly proposed Ethics & Compliance Program final draft has been reviewed by the Governance Committee. Once the overarching Ethics & Compliance Program receives Board approval, the revised Code of Conduct will be provided for final review.

• Compliance has completed the final draft of the Ethics & Compliance multi-year educational plan for training throughout the hospital. The plan will be submitted for CEO approval to provide to Governance Committee at the end of April 2017.

• Corporate compliance has started the process of notifying Confidential Filers within NFPHC that are mandated to complete financial disclosure statements as per the Board of Ethics and Government Accountability (BEGA) for 2016.

• Updated Corporate Compliance Initiatives: o Educational campaign rollout

Compliance collaborating with the Nursing Educator to augment some of the annual computer-based training modules to cover additional compliance areas for all employees’ training requirements.

o Compliance Program & HIPAA external risk assessments scheduled for April 2017 Risk Management audit services were provided by Pendulum, LLC,

reports anticipated in the upcoming weeks. • Physician Credentialing and Privileging Assessment completed

April 5, 2017. • OIG Compliance Program Baseline Assessment completed April

12, 2017. • Healthcare HIPAA Compliance Program Assessment completed

April 13, 2017. o Refresh whistleblower hotline and online reporting framework o Begin buildout of compliance homepage/intranet o Begin Ethics & Compliance Newsletter campaign.

Not-For-Profit Hospital Corporation Board of Directors

Governance Committee Agenda Virgil McDonald, Committee Chair

April 11, 2017 at 8:00 a.m.

I. CALL TO ORDER II. ROLL CALL III. CONSENT AGENDA REVIEW MINUTES OF MARCH 14, 2017 IV. BOARD, MEDICAL STAFF & EXECUTIVE TEAM RETREAT V. BOARD PORTAL Donna M. Freeman VI. OLD BUSINESS

A. Patient and Family Advisory Council B. Community Benefits Advisory Council C. Corporate Compliance Draft Manual

VII. NEW BUSINESS

A. Board Member Self-Assessment B. Annual Review of Bylaws

a. Suggested Dates: April 20th or 21st @ 11am VIII. NEXT MEETING – TUESDAY, MAY 9, 2017 AT 8:00 A.M. IX. ADJOURNMENT

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Not-For-Profit Hospital Corporation Governance Committee Meeting Minutes

March 14, 2017

Present: Virgil McDonald, Committee Chair, Steve Lyons, Khadijah Tribble, Luis Hernandez, Donna Freeman (Corporate Secretary) Excused: Guests: Agenda Item Discussion Action Item Call to Order The meeting was called to order by Committee Chair Virgil McDonald at 8:09 a.m. Determination of a Quorum

Donna Freeman, Corporate Secretary determined a quorum.


The agenda was approved as written.

Approval of Minutes

The minutes of February 14, 2017 were approved.

Discussions

Virgil McDonald led the discussion on the following: (Reports presented to the Board Members and filed in the Office of the Secretary of the Corporation) Virgil McDonald, Committee Chair led the discussion on the background and the discussion resulting from the Performance Hearing.

• Board Retreat ▪ March 25, 2017 – 8am-3pm ▪ Location: Matthews Memorial Baptist Church, 2616 Martin L. King, Jr. Ave., SE

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Washington, DC ▪ Confirmed speakers: Director Wayne Turnage, Joan H. Lewis and Councilmember Vincent Gray ▪ Chair Gardiner will give the “Perspective of the Board” – the BOD’s vision for UMC. ▪ An appreciation plaque will be given to former Board Chair – Bishop C. Matthew Hudson. ▪ Changes to the agenda were discussed and distributed. ▪ Councilmember Trayon White has not confirmed. ▪ Chair Gardiner will circulate his presentation to the entire board for comments. ▪ Virgil McDonald will be out of town on that day. ▪ K. Tribble shared her concern regarding the CON needed for capital expenses.

• Negative Reports ▪ Reports were presented at the Performance Hearing that are not reviewed during the General BOD meetings due to low community participation. ▪ K. Tribble asked for a status update on the Patient Advisory Board. ▪ Mr. Luis Hernandez will provide more information regarding the Advisory Board at the next Governance Committee meeting. ▪ Include a portion of the Bod meeting agenda for community Q &A ▪ There were questions on the structure and legality of the advisory board that that weren’t resolved.

• Newsletter ▪ Suggested a publication that will be distributed to the community. ▪ Mr. Hernandez is considering a quarterly newsletter being developed in the near future for the employees and the community. ▪ Consider electronic transfer of the newsletter to reduce cost of distribution.

• Board Portal

▪ Donna Freeman requested the board members log-on to the site. ▪ The documents have been uploaded on the site – board participation is required.

Donna Freeman was requested to research the Governance Committee minutes and obtain the steps taken towards the Advisory Board. Mr. Hernandez will investigate further on the cost and distribution of the newsletter.

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The next conference call will be held on Tuesday, April 11, 2017 @ 8:00 a.m. The meeting was adjourned at 9:05 a.m.

Not-For-Profit Hospital Corporation Governance Committee Meeting Minutes

April 11, 2017

Present: Virgil McDonald, Committee Chair, Steve Lyons, Khadijah Tribble, Luis Hernandez, Donna Freeman (Corporate Secretary) Excused: Guests: Agenda Item Discussion Action Item Call to Order The meeting was called to order by Committee Chair Virgil McDonald at 8:06am. Determination of a Quorum



The agenda was approved as written.

Approval of Minutes

The minutes of February 14, 2017 were approved.

Discussions

Virgil McDonald led the discussion on the following: (Reports presented to the Board Members and filed in the Office of the Secretary of the Corporation) Virgil McDonald, Committee Chair led the discussion regarding comments on the Board Retreat

• Board Retreat ▪ March 25, 2017 – 8am-3pm

▪ Location: Matthews Memorial Baptist Church, 2616 Martin L. King, Jr. Ave., SE WDC ▪ The tone of the retreat was changed as a result of the decision to retain the Affordable Care Act. ▪ Confirmed speakers: Director Wayne Turnage, Joan H. Lewis, Councilmember Vincent Gray, Director LaQuandra Nesbitt, and Mila Kofman. ▪ The board, staff and physicians were all engaged with questions and comments. ▪ Reviewed the pros and cons of the retreat ▪ The 2017 Retreat will be planned for Saturday, October 14, 2017

• Patient and Family Advisory Council/Community Benefits Advisory Council ▪ Steve Lyons shared the history of both councils which began in 2015. ▪ BEGA is expanding its legislation in the governmental role. ▪ The specific roles of the advisory councils had not been established. ▪ A specific term of service should be established. ▪ There were questions on the structure and legality of the advisory board that weren’t resolved in 2015. ▪ UMC may consider working with Ward 7 & 8 Health Alliance group.

• Corporate Compliance Manual ▪ No comments have been submitted from the BOD. ▪ The committee voted to move to the BOD for approval. ▪ Mr. Hernandez recommended a change: 234 acute care bed hospital with 120 beds for nursing facility.

• Board Portal

▪ Donna Freeman requested the board members to log-on to the site. ▪ The documents have been uploaded on the site – board participation is required.

• 2017 Annual Board Assessment ▪ The assessment will be distributed at the April 29th board meeting.

• Annual Review of Bylaws

Chair McDonald will discuss the two councils with Chair Gardiner and bring resolution to the BOD within 60 days.

▪ In-person meeting proposed on April 20th or 21st. The committee will confirm their availability.

The next conference call will be held on Tuesday, May 9, 2017 @ 8:00 a.m. The meeting was adjourned at 9:03 a.m.

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Thank you everyone for providing such valuable feedback. We can assure you that we will take your feedback in consideration in

planning our next board meeting to increase overall productivity.

Board of Directors Evaluation Summary February 22, 2017

Areas of Evaluation Average Response Rank

Proper notice was given to Board Members & community 4.0 The Board packet was received in a timely manner 3.6 The meeting agenda is appropriate. 3.8 The Board packet provided the appropriate information to support solid discussions and decisions.

2.8

Executive reports were concise, yet informative. 3.8 Directors’ discussions were on target and focused 3.1 Directors were prepared and involved. 3.5 All recommendations and decisions made by the Board are documented and monitored to ensure implementation.

3.6

Appropriate Board and staff assignments were made. 3.5 Board Members’ conduct was business-like, cordial, results-oriented and respectful of diversity.

3.0

Meeting ran on time. 3.2 I am satisfied with this meeting. 3.5 Board Member attendance: Present ___13__ Absent __0__ In the evaluation form, the board members were invited to provide feedback on three specific questions. Some of the comments received are summarized below. What aspects of this meeting were particularly good?

• Meeting ran effectively and well • Good discussion

What aspects of this meeting were particularly bad? CEO report should focus on issues that need remedy with detailed action to turn around.

• One board members decorum • A little long

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Thank you everyone for providing such valuable feedback. We can assure you that we will take your feedback in consideration in

planning our next board meeting to increase overall productivity.

Do you have any suggestions or comments about this meeting?

• Board material for CMO was provided at meeting only; this is very important material that needs to be reviewed.

Governing Board Patient Safety & Quality Committee Meeting Tuesday, April 11, 2017

Location: Foundation Board Room (2nd Floor)

Dial-In: 1.800.457.9859 Passcode: 9094323

Agenda

Purpose: To provide oversight and guidance for the delivery of high quality, safe, cost-

effective health care at Not-For-Profit Hospital Corporation.

I.

II.

Welcome Call to Order

All

M. Gomez

III.

Approval of Minutes

All

IV.

Old Business

A. Action Items from Previous Meeting B. Performance Improvement Draft

M. Gomez M. Costino

V.

New Business

A. Capital Expenditures and Budget Projections

M. Gomez

VI. Other Business All

Adjournment

Next Meeting: Tuesday, May 9, 2017 @ 4:30 p.m.


GB Patient Safety & Quality Committee Meeting Minutes March 14, 2017

Present: Maria Gomez, Committee Chair, Girume Ashenafi, Dr. Julian Craig, Dr. Malika Fair, Luis Hernandez, Maribel Torres, Maria Costino

Donna Freeman (Corporate Secretary) Excused: Dr. Mina Yacoub, Dr. Konrad Dawson Others: N/A

Agenda Item Discussion Action Item Call to Order The meeting was called to order at 4:38 p.m. Roll Call Attendance was determined by the Corporate Secretary, Donna Freeman. Call to Order The meeting was called to order by Maria Gomez, Committee Chair. Approval of Minutes

The minutes of January 10, 2017 were approved as written. Committee Chair Gomez addressed the action items. All items were submitted as requested. Three things to be discussed: The Retreat, the CMO being part-time and Ms. Costino should be considered part of the Executive Team.

Old Business

Highlights include: (Discussion materials have been filed in the Office of the Secretary of the Corporation)

1. Ms. Costino led the discussion on the scope of services her department provides:

• Quality, Regulatory and Patient Safety touches almost every are of the hospital.

• Frequent procedures, services, processes and functions were explained.

• Quality assessment and performance improvement. • Benchmark the organization against peer organizations • Lead effort to becoming a High Reliability Organization • Patient Safety which includes: environment of care rounds, failure mode

and effects analysis, performance improvements projects. • Regulatory Compliance is a priority. • Remain current with regulatory standards for inpatients, outpatients and

skilled nursing facility areas; ensure compliance with standards and educate staff regarding regulatory requirements.

• Identify regulatory issues for action plans and improvements. • Infection Control • Targeted surveillance of high risk area utilizing CDC NNIS definitions • Monitoring for outbreaks • Staff education on current standards for infection prevention. • Goals of Department • Monitor performance through data collection • Analyze current performance • Selected 11 goals for the department • Continued education for all departmental employees. • Q & A – do you have enough staff? • Mr. Hernandez reviewed the current staff ratio. • A discussion continued on the .5 and .8 FTE of CMO and the need for

additional staff to reach the goals Ms. Costino presented. • Chair Gomez stated patient quality and safety is directly linked to the

financial stability of the hospital. 2. Performance Improvement Document

• Ms. Costino neglected to put “draft” on the plan in error. This is a working document.

• The approach, structure, methodology and goals were reviewed. • The structure of the committee is reported as noted on page 6. • The reporting measures and reports were reviewed. • The involvement of the key executive teams promotes more

transparency, reduces redundancy and leads to more efficiency.

Maria Gomez requested a decision on the CMO .5 or .8 FTE and the addition of a co-director in Ms. Costino’s department be resolved by the next BOD meeting in April 2017.

• The departmental role in the PI program was reviewed. • Regulatory agency reporting • Patient Experience • Role of Risk Management • Priority Improvement Initiatives were reviewed. • Dr. Julian Craig reminded the committee; the former Quality Director

had an assistant director with the qualifications needed to assist with the high level work that needs to be done.

• Mr. Hernandez stated the Compliance Officer and Quality Director report monthly to the Senior Executive team.

• Chair Gomez mentioned her concerns about Ms. Costino not being part of the Executive Team weekly meetings.

• Chair Gomez asked that issues relating to Patient Quality & Regulatory be reviewed by Ms. Costino before any decisions are made.

•

Chair Gomez requested a copy of the most recent HCAHPS report. Chair Gomez asked if the Quality Director should be part of the Senior Executive Team.

New Business 3. Board Retreat • March 25th, 2017 8am-4pm • The theme revolves around patient safety and quality • How will the topic be covered during the meeting? • Who is leading the hospital? – Financial Stability vs. Leadership? • Chair Gardiner will be addressing the question during the retreat. • Implementing long term practices • How will the topics be addressed during the retreat? • Specify the needs of the hospitals. • During the retreat – how will quality be addressed? • The only key position not filled at the hospital – is purchasing and

materials management. • Mr. Hernandez to review all capital expenditures for FY 17 and FY 18. • Mr. Hernandez will provide the report to the BOD with a plan to facilitate

the needs to ensure patient care, safety & quality and medical needs to

Mr. Hernandez will provide the outline for the capital expenditures the committee by March 25th.

run the hospital.

Announcements The next meeting will be held on Tuesday, April 11, 2017 @ 4:30 p.m. The meeting was adjourned at 6:10 p.m.

1


GB Patient Safety & Quality Committee Meeting Minutes April 11, 2017

Present: Maria Gomez, Committee Chair, Girume Ashenafi, Dr. Julian Craig, Dr. Malika Fair, Dr. Musa Momoh, Dr. Mina Yacoub; Luis

Hernandez, Maribel Torres, Maria Costino; Donna Freeman (Corporate Secretary) Excused: Dr. Konrad Dawson Others: N/A

Agenda Item Discussion Action Item Call to Order The meeting was called to order at 4:36 p.m. Roll Call Attendance was determined by the Corporate Secretary, Donna Freeman. Call to Order The meeting was called to order by Maria Gomez, Committee Chair. Approval of Minutes

The minutes of March 11, 2017 were approved as written.

Action Items Chair Gomez confirmed the following items: 1. Maria Costino is now a member of the Senior Executive Team 2. Dr. J. Craig’s hours have been approved for .8 FTE; pending approval by the BOD

on April 29th. 3. The capital expenditure plan was sent to the committee by Mr. Hernandez prior

to the PSQ meeting. 4. Two major projects being reviewed are: expansion of the ED and the Ambulatory

Chair Gomez requested Ms. Costino to incorporate the HCAHPS in PIP for the future.

2

Center. Approval of the Agenda

Chair Gomez wishes to discuss the report from the Director of Health LaQuandra Nesbitt presented during the retreat. The item was added to the agenda and approved.

Old Business

Highlights include: (Discussion materials have been filed in the Office of the Secretary of the Corporation)

1. Ms. Costino led the discussion on the Performance Improvement and Patient Safety Plan 2017-2018

• Overview • UMC Mission and Vision • Purpose • Responsibility for Effecting the Performance Improvement Program • Methodology for Improving Organizational Performance • Staff Involvement in Performance Improvement • PI Program Structure • The Performance Improvement Committee

▪ Monthly meetings are planned ▪ A dashboard will be supplied to the BOD and senior management

• Departmental Role in the PI Program • Medical Staff • Performance Improvement Measures • Regulatory Agency Reporting • Patient Experience

The term Medical Board will be changed in the document to Medical Executive Committee which is the name of the committee at UMC. Dr. Fair suggested Equity measures are included in the program. Dr. Craig questioned if UMC is staffed for this program.

New Business 2. Board Retreat – Director LaQuandra Nesbitt’s Report • Truly exposed UMC’s weaker areas • Own it – improve in all areas reported.

3

• A reply will be submitted to the board explaining the underlying circumstances.

• Sentinel events will be a monthly item during the PSQ and PIP meetings. • Suggested improving the relationship between the DOH agency and UMC • The report is an indicator of the need for a Quality Officer being engaged

in every area of the hospital. • Specify the needs of the hospitals. • No excuses are acceptable for the outcomes. • The recommendations from Dr. Nesbitt are areas of quality being

improved at UMC. • Consider updating Dr. Nesbitt with the plan of action resulting from her

report. • Dr. Craig has a meeting scheduled with Dr. Nesbitt in the immediate

future to begin a continual communication bridge with her and UMC. • Chair Gomez requested a meeting be scheduled promptly with Dr. Nesbitt

to review the results of the report. 3. Chair Gomez would like to meet with Mr. Hernandez and the PSQ Committee to

discuss the future plans of patient quality for UMC and the level of investment expected.

4. The report from Howard University was a sobering article. It puts the priority of quality patient care in focus.

Mr. Hernandez suggested the Medical Director or the CEO to schedule the meeting with Director Nesbitt.

Announcements The next meeting will be held on Tuesday, May 9, 2017 @ 4:30 p.m. The meeting was adjourned at 6:12 p.m.

This document is protected under DC code 44-801 et. Seq. for all peer review, quality assurance and performance improvement activities. 1

United Medical Center

Performance Improvement and Patient Safety Plan 2017-2018

Overview United Medical Center (UMC) is dedicated to promoting health, wellness and quality of life in the communities served. Quality and safety are at the core of our daily work. UMC embraces quality improvement as an ongoing and organization‐wide commitment to meet and exceed the expectations of our community. UMC recognizes its responsibility to provide patients individually, and the community collectively, with safe healthcare services of the highest possible quality and in a patient centered manner. The Performance Improvement and Patient Safety Plan reflects the commitment of the governing body, leadership, medical staff, nursing staff and staff stakeholders in providing excellent care in a safe and evidence-based manner to meet the needs of our patients and their families. The Plan provides a framework for a systematic, organization-wide program to design, measure, assess and improve hospital performance in all departments and services. Multidisciplinary participation and communication are essential for the effective functioning of the program. The Plan further reflects processes that promote appropriate, consistent and safe care delivery for all patients in all settings and throughout all services. The Hospital's Quality Management Department has primary responsibility for implementation of the Performance Improvement Program. As the Hospital’s commitment to safety is exemplified by its performance improvement, risk management, and environment of care functions, the Hospital’s efforts to improve and ensure patient safety are integrated into the overall Performance Improvement Program, since these objectives are essentially indistinguishable. Performance improvement is a continuous multidisciplinary activity with direct relevance to the Hospital’s mission, vision, values and scope of services. The PI Program applies to all departments, services, and practitioners. The PI & Patient Safety Plan is designed to be a framework for the hospital as it begins its journey to become a “high reliability organization.” To achieve these goals, UMC proposes the adoption of a modified version of the Institute of Medicine’s dimensions of quality¹ to emphasize our goal of providing high VALUE care to our community:

1. Clinical Quality and Safety – effective care based on evidence, informed by patient values and preferences, with no needless death or injury for patients and staff.

2. Patient Experience – patient-centered care and service that honors the values, choices,

culture, and needs of each patient, and treats all patients equally.

3. Efficiency – care that reduces unnecessary utilization of resources, removes unnecessary steps in a process, and wastes no time, resources or effort.

1 Committee on Quality of Health Care in America, Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, (Washington, D.C: National Academies Press, 2001) pp 5-6.


VALUE = [Clinical Quality & Safety][Patient Experience]

Efficiency [Cost & Time] UMC Mission and Vision The UMC mission and vision is our roadmap to providing care to our patients and meeting their needs. Our Mission United Medical Center is dedicated to the health and well-being of individuals and communities entrusted in our care. Our Vision United Medical Center is an efficient, patient-focused provider of high quality healthcare the community needs. United Medical Center will employ innovative approaches that yield excellent experiences United Medical Center will improve the lives of District residents by providing high value, integrated and patient-centered services. United Medical Center will empower healthcare professionals to live up to their potential to benefit our patients. United Medical Center will collaborate with others to provide high value, integrated and patient-centered services. PURPOSE The purpose of performance improvement at UMC is to enable processes and people to uphold the highest standard of excellence in caring for the whole patient in mind, body, and spirit. It is the goal of this plan to provide the structure and processes through which comprehensive monitoring is established, opportunities to improve care are identified, and the effectiveness of corrective measures are assessed in a systematic and ongoing manner. The UMC PI Program provides a systematic approach for designing processes as well as monitoring, analyzing, improving, and sustaining improved performance. This systematic approach provides authority and accountability at all levels within the organization. The Hospital recognizes that to be effective in improving patient safety there must be an integrated and coordinated approach to reducing errors. On an annual basis the UMC PI & Patient Safety Plan is reviewed and updated to reflect priorities in providing quality care in a safe environment to all patients. Specific PI Program initiatives are directed at goals set by the Leadership, i.e. the Board of Trustees; and Hospital Administration; and the Medical, Nursing, and Allied Health Professional Staff Leadership, in accordance with the organization’s mission, vision, values, and strategic


plan. A robust performance improvement program is the foundation to becoming a high reliability organization. RESPONSIBILITY FOR EFFECTING THE PERFORMANCE IMPROVEMENT PROGRAM UMC Leadership is responsible for the achievement of the Hospital’s PI objectives. The Leadership:

• Is accountable and committed to performance improvement and patient safety activities at all levels to increase the probability of desired patient care and patient health outcomes;

• Designs processes that systematically measure, assess, and refine performance to

improve patients’ health outcomes and to enhance patient safety;

• Encourages the performance of Failure Mode and Effect Analysis (FMEA);

• Identifies key functions in the health and safety management of patients that most greatly require improvement based upon the incidence, severity, and/or detectability of potential defects in those functions;

• Shifts its focus solely from the performance of individuals to the performance of the

organization, its systems, and its processes, all the while seeking to ensure individual competence;

• Provides for continuous professional practice evaluation of the Medical Staff to ensure continued competency in medical & clinical knowledge, technical & clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism;

• Supports a “Just Culture” approach and enables Code of Professionalism reporting;

• Provides for proactive risk analysis;

• Establishes methods that support an immediate response to manage actual or

potential risks, including unintentional patient outcomes or events; • Ensures that patients and, when appropriate, their families are informed about

the outcomes of care, including unintentional patient outcomes and events; • Ensures the most stringent standards of confidentiality are maintained with

respect to patient, practitioner, and hospital interests; • Promotes a “just culture of safety,” fostering interdisciplinary collaboration, open

communications, and a system approach to patient safety; • Establishes accountability to clearly delineate responsibilities and the

relationships of all constituencies;


• Provides guidance and knowledge to individuals and groups on data interpretation and statistical process control techniques for improving processes in which they are involved;

• Provides the Board of Trustees with a comprehensive review and understanding

of quality data to fulfill its oversight responsibilities with regard to quality;

• Seeks to use internal and external comparative (benchmark) data to identify best practices beyond those of the organization;

• Designs and endorses programs to promote patient safety.

METHODOLOGY FOR IMPROVING ORGANIZATIONAL PERFORMANCE As described in the Health System’s Performance Improvement & Safety Plan, UMC utilizes the Institute for Healthcare Improvement (IHI) Model for Improvement as a framework for developing, testing and implementing changes that lead to improvement (Figure 2: The Model for Improvement). This improvement model is based on the principles of robust process improvement as well as Plan, Do, Study, Act (PDSA) Improvement Cycles that shall be used to develop, test and implement change across service lines and settings, for example: ambulatory care, behavioral health, critical care, emergency care and inpatient care. The model will be applied and disseminated to improve processes, products and services across the organization. Sequential tests of change (PDSAs) will be designed to test new processes of care, make predictions about change, analyze findings and draw conclusions from the results.


STAFF INVOLVEMENT IN PERFORMANCE IMPROVEMENT Employees at all levels are encouraged to participate in performance and quality improvement activities as appropriate and necessary. Also, staff are encouraged to participate by offering suggestions and recommendations for quality improvement projects through their involvement in event reviews, performance improvement initiatives, process re-design projects, departmental meetings, and other formal and informal means. Staff participating on committees, councils, or teams will be provided just-in-time training in the methods and techniques of the adopted improvement methodology. PI PROGRAM STRUCTURE Oversight of all performance improvement activities is shared among the leadership of the key structural bodies within the Hospital: the clinical departments, the ancillary departments, the Hospital-wide Performance Improvement Committee (described below), the Medical Board, and the Board of Trustees. The outcomes of reviews performed by operational department directors and medical staff leaders are submitted to the UMC PI Committee and, as indicated, to the


Medical Board for approval and action. The table, below, depicts the Hospital’s PI reporting structure.

THE PERFORMANCE IMPROVEMENT COMMITTEE The UMC Performance Improvement Committee (PI Committee) serves as a hospital-wide quality and patient safety committee. It is a high level standing committee of the organization comprised of the President of the Hospital, at least one member of the BOT, the Vice Presidents for Medical Affairs and Patient Care, the Director of Quality Management, the Chief Legal Officer (or designee), the President of the Medical Staff, physician leaders of the Medical Staff

Board of Trustees

Board Subcommittee on Quality and Patient Safety

Performance Improvement Committee

Clinical/Ancillary Departments

• Anesthesiology • Emergency Medicine • Internal Medicine • Surgery • Obstetrics & Gynecology • Psychiatry • Radiology • Neurology • Critical Care & Perioperative Care

• Information Management • Patient Care Services • Infection Prevention • Pharmacy • Imaging • Hospitalist Service • Physical and Occupational

Therapy • Case Management/Social Service

Periodic Updates

• IQR/OQR Process Measures • Sepsis Care Measures • Stroke Care Measures • Cancer Care Measures • Process Team Measures • Patient Experience Measures • Readmissions • Clinical Documentation

Improvement

• Infection Prevention Measures • Medication Safety Measures • PSI 90 Measures • Nursing Care Measures ( falls,

pressure ulcers) • Utilization Measures-LOS, denials • Survey Readiness/Follow up • Safety Events/RCAs/Sentinel events • Skilled Nursing Facility


and ancillary department leaders. The UMC PI Committee reports to the Board Subcommittee on Quality and Patient Safety who then reports to the Board of Trustees. The UMC PI Committee:

• Oversees, coordinates, and directs organizational performance improvement and patient safety activities

• Serves as a clearinghouse for all Hospital performance improvement activities, and

conducts an annual analysis to prioritize such activities

• Establishes key performance metrics, including but not limited to: ▪ Process of Care Measures (IQR/OQR) ▪ Stroke Care, Sepsis Care, Cancer Care Measures ▪ Program Effectiveness Measures (Wound Care, Colonoscopy,

Emergency Department) ▪ Imaging & Pathology Concordance Measures ▪ Mortality Rates ▪ Readmission Rates ▪ Antibiotic Stewardship ▪ PSI 90 & other HAC Measures ▪ Hospital-acquired Infection Rate (CLABSI, CA-UTI, VAP, SSI, C-diff,

MRSA) ▪ Medication Safety Measures (reconciliation, ADRs, Errors, controlled

substance management) ▪ Fall and Fall with injury Rates ▪ Hospital-acquired Pressure Ulcer Rates ▪ Critical Result Reporting Measures ▪ IT Measures (MU, e-CQMs, CPOE usage, BMV usage) ▪ Efficiency Measures (length of stay, ED flow, OR flow) ▪ Clinical Documentation Measures (HF, AKI, Malnutrition) ▪ Patient Experience Measures (HCAHPS, ED, BH, ASC)

• Establishes periodic reporting of Hospital priorities (Attachment A)

• Assists in decision-making, when appropriate, with regard to pursuing opportunities for

improvement, with approval by the Medical Board, as necessary;

• Reviews periodic reports from each department/service regarding process and outcomes indicators, sentinel events, and performance improvement initiatives;

• Reviews root cause analysis findings and risk reduction strategies derived from them that are then reviewed by the Medical Board;

• Approves processes submitted for FMEA, reviews the findings and generalizability of such findings, and directs the dissemination of those findings to all relevant areas;


• Through follow-up reporting, ensures that the necessary monitoring and evaluation of

corrective actions occur; and • Performs an annual evaluation of the Hospital’s Performance Improvement & Patient Safety

Plan The Medical Board plays a pivotal role in the Hospital’s PI Program. It reviews, evaluates, and approves the corrective actions, improvement strategies, and monitoring plans recommended by the PI Committee. It also weighs in on the PI Committee’s prioritization of improvement activities with regards to activities that involve providers. Furthermore, the Medical Board considers and recommends Medical Staff appointments and privileges, and oversees the processes to ensure ongoing individual Medical Staff member competence. DEPARTMENTAL ROLE IN THE PI PROGRAM

The Department Chiefs and Directors are responsible for their individual Departmental Performance Improvement initiatives, which follow the same principles of performance improvement as those of the Hospital. The clinical departments and service lines systematically monitor and evaluate the quality and appropriateness of patient care provided by their members within their inpatient and outpatient services, critical and special care units, and divisional activities. Such monitoring takes place at several levels: the individual practitioner, the procedure-type or care modality, and the division or care-group. In this manner, outlier events and system-based issues are both detectable, can be aggregated, and provide material for performance improvement initiatives. The Department Chiefs and Directors review the findings of quality management activities, including patient care and safety process and outcome measures, summary analyses, focused reviews, and an array of indicators, such as:

• Process measures (IQR/OQR/Stroke/Sepsis/Cancer Care) • Hospital-acquired infections • Nursing care measures • Procedure and treatment complications • Incident reports • Safety Rounds reports • Mortality Reviews • Readmissions • Medical record documentation reviews • Utilization management • Physician peer review • Patient Opportunity (complaint and grievance) reports • Patient Experience Data • Other statutory quality control indicators


This work is documented in the periodic reports that the departments and committees provide to the PI Committee and Medical Board. MEDICAL STAFF The Medical Staff, through the Department Chiefs and committees appointed by the Medical Board, promotes, monitors, and evaluates the quality and appropriateness of patient care and the clinical performance of all individuals with clinical privileges. Staff credentialing and re-credentialing are based on verification of previous training and competence, continuous professional practice evaluation, incident-based review of cases, and adherence to Medical Staff Bylaws, Medical Staff and Departmental Rules and Regulations, and Hospital and Medical Staff Policies and Procedures. The Medical Board recommends and the Board of Trustees approves all appointments and reappointments to the Medical Staff. The Medical Board has the ultimate authority and responsibility for Professional Practice Evaluation. The Physician Peer Review Committee provides oversight of the continuous performance review and incident-based case review process, and periodically reports to the Medical Board. For the newly privileged staff members, each relevant clinical department conducts a focused professional practice evaluation (FPPE) to assess current competency in exercising the newly granted privilege(s). Additionally, when there is a question regarding an existing staff member’s ability to provide high quality, safe care, and an initial investigation confirms these concerns, an FPPE is performed to determine if corrective action is needed. Each Department Chief may assign responsibility for the specific duties related to quality management and performance improvement to designated physicians in the Department. For larger departments, this responsibility may be split along the lines of divisional structure and assigned to the Division Chiefs. The Department of Patient Care Services, through the Chief Nurse Officer, assigns responsibility to the various Directors of Patient Care Services to partner in the Performance Improvement and Safety activities. Each ancillary/support service Department Director is responsible for the department's quality management/performance improvement program, including maintenance of quality control. Quality control programs exist in all applicable areas, including Engineering and Maintenance, Biomedical Engineering, Environmental Services, Laboratories, Health Information Management, Radiology, Radiation Medicine, Respiratory Therapy, Nuclear Medicine, Sterile Processing, Pharmacy, Environment of Care and Nutrition and Food Service. Ensuring assignment of quality control activities and ongoing monitoring of quality control data is the responsibility of the Department Chief and/or Director and is reflected in quality management or safety reports.


In prioritizing evaluation and improvement efforts, high volume, high risk, problem-prone clinical activities receive the greatest scrutiny. Low volume, high risk activities are also given priority, along with those that involve a new or modified process. PERFORMANCE IMPROVEMENT MEASURES Performance improvement measures must meet the following criteria:

• Clearly identifies the issue being targeted for improvement; • Has a defined numerator and a defined denominator to enable tracking over time and

comparison of varying sized populations; • Detects changes in performance over time and rapidly reveals undesirable performance

patterns; • Allows for comparison against benchmarks, either internal or external, whenever

possible; • Uses data that are able to be collected; • Reports results in a meaningful manner to all appropriate parties throughout the

organization. The Hospital collects data to monitor its performance using data gleaned via manual abstraction and data gathered from the Meditech EMR. An electronic database is to be determined at a future date. REGULATORY AGENCY REPORTING In order to improve organizational performance and to enhance safety, the Hospital must strive to eliminate factors that contribute to unanticipated adverse events and outcomes. Therefore, the Hospital encourages and directs its staff to:

• Recognize, acknowledge, act upon, and solicit disclosure of risks and unanticipated adverse events via incident reports or calls directly to the Quality Department;

• Report internally on risk reduction initiatives and their effectiveness; • Focus on process and system design, de-emphasizing individual blame, and prohibiting

retribution for involvement in an unanticipated adverse event; and • Investigate factors that contribute to unanticipated adverse events and to share that

acquired knowledge Despite the Hospital’s efforts to reduce and eliminate the occurrence of serious adverse events, such incidents will occur. Therefore, a standardized process has been established for addressing adverse events and reporting them to the relevant regulatory agencies. These agencies include the District of Columbia Department of Health and other relevant regulatory agencies. All adverse events are promptly disclosed to the patient and family. Whenever an adverse occurrence satisfies the definition of a sentinel event, the facts and circumstances are expeditiously gathered and reviewed by the appropriate parties, including a designated multidisciplinary team within the hospital. To identify all relevant facts associated


with a serious event, a formal debriefing with the individuals directly involved in the event is performed promptly. Subsequently, a timely root cause analysis is conducted and opportunities for improvement, along with risk reduction strategies, and effective measures of change implemented are reviewed and documented. The root cause analysis is thorough and credible, focusing on process and system factors. PATIENT EXPERIENCE Patient experience involves satisfaction of patients, families, employees, physicians, and all other parties active within the Hospital. A mechanism for measuring the needs and expectations of patients and their families exists through the Quality Management Department. Additionally, the Hospital utilizes standardized patient experience survey questionnaires, including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey developed by the Centers for Medicare and Medicaid Services. The data are incorporated into the performance improvement process via feedback to the relevant department(s).

ROLE OF RISK MANAGEMENT Risk management activities, aimed at loss control activities, are one component of an integrated Performance Improvement and Safety Program. The Risk Management Department works in collaboration with the Quality Management Department to:

• Assemble information related to negative healthcare outcomes and incidents resulting in injury

• Report the implementation of risk reduction strategies including safety management

activities to protect the financial assets of the hospital Patterns and trends identified through the measurement and assessment of quality improvement data are reported to the Risk Manager for review from a risk management perspective. Likewise, any patterns or trends of significance identified through the tracking of risk management data are reported to the Quality Management Department. An annual report providing a synopsis of actions undertaken by Risk Management is submitted to the UMC PI Committee.

ATTACHMENT A

UMC 2017-2018 Priority Improvement Initiatives

• Restructure the Performance Improvement program as defined in this plan. • Become a data driven organization utilizing data for decision making. • Decrease the average length of stay. • Improve reimbursement by addressing identified documentation issues through

education and training of all clinicians. • Begin the journey to becoming a high reliability organization. • Hardwire patient experience into all aspects of operations with the goal of improving

HCAHPS scores.


• Improve core measure performance to increase our value-based purchasing scoring. • Improve our performance in sepsis measures resulting in improved patient

outcomes.

Capital Projects

• Electrical System Repair • Telecommunication System Repair • Plumbing System Repair • Pharmacy, Critical Care, and Emergency Department Repairs • Equipment Replacement • Information Technology

Electrical System

• Electrical distribution system throughout the facility is original and reached the end of useful life (30 years)

• Electrical system is not clearly segregated into three distinct parts as defined by the National Electrical Code: emergency branch, critical branch, and equipment branch

• Electrical switchboard in its entirety is original and reached the end of useful life (30 years)

Telecommunication System Repair

• Infant abduction system needs to be rewired to tie into access control system

• Data / communication rooms are undersized, not code compliant, and do not meet the technology needs of the hospital

• FGI guidelines require communications rooms to be 12x14, many of the existing rooms are very small and don’t have adequate cooling to sustain any additional hardware

• Rooms do not support managed or uninterruptible power

• Fiber optic cabling and structured cabling need to be rewired to allow for flexibility and diverse path reliability

Plumbing

• Primary and secondary chilled water pumps are passed useful life and need to be replaced

• All components of the domestic hot water and the HVAC hot water reheat systems are passed useful life and are energy inefficient

• Plumbing fixtures are older and inefficient throughout the hospital

Pharmacy

• Intravenous room is not 797-compliant** for handling of intravenous drugs.

• ** US pharmacopeia 797 guidelines is the regulatory compliance requirement for compounding sterile preparation and sets the standard of infusion compounding.

• Software needed to address antimicrobial Stewardship The Joint Commission Standard MM 09.01.01 (currently non-compliant)

• Automated Dispensing Machines to replace current machine that are beyond service life and to secure medication distribution

• Department needs cameras and enhanced main entrance security

• Current walk-in box for storage is beyond service life, routinely breaking, and parts are becoming hard to find

•

Critical Care

• Renovation needed to patient rooms and general public areas to meet Joint Commission, ADA, DOH and building code standards

ED

• The current barriers and obstacles:

• Lack of a variety of treatment bays to address and treat the various levels of acuity.

• Lack of patient privacy and inadequate size for treatment / acuity levels (current treatment bays are all open with cubical curtains)

• Lack of compliant code resuscitation bay to perform basic required service

• No dedicated medications room

• No decontamination room within the ED treatment area

• Isolation Rooms do not meet current CDC and DOH requirements

• Poor lighting levels and lack of required critical emergency power supply and are not adequate for current regulations

• The poor flow of patient intake from front door to waiting to registration is confusing and lends unsafe environment to the patients and employees

Equipment Replacement

• Replacement of mission critical clinical equipment within the operating room and throughout the facility that have passed useful life and no longer meet medical best practice standards

Information Technology

• Information Technology Upgrades include

• Virtualization server replacement

• Replacement of network security posture

• Intrusion protection

• Intrusion prevention

• Incident monitoring

• Expansion of disaster recovery and business continuity solutions

• Internal wireless upgrade

• Mobile distribution network implementation

• Enterprise system to replace an outdated Financial Management and Health Information Management Coding System

• System needed to meet clinical documentation and medical record completion standards

• Current system does not provide a complete integrated systems across finance, clinical documentation, and reporting


Strategic Steering Committee April 18, 2017 at 8:00am

Khadijah Tribble – Committee Chair

AGENDA

Conference Call - Dial-In: 1 (800) 457-9859 Passcode: 8260653#

I. CALL TO ORDER

II. ROLL CALL

III. APPROVAL OF AGENDA

IV. APPROVAL OF MEETING MINUTES Committee Meeting Minutes of February 21, 2017

V. VERITAS PERFORMANCE EVALUATION

VI. ADJOURNMENT


Strategic Planning Committee Meeting Minutes February 21, 2017

Present: Khadijah Tribble, Committee Chair, Julian R. Craig, MD, Virgil McDonald, Steve Lyons, Sean Ponder, Luis Hernandez,

CEO, Chris G. Gardiner, Board Chair, Donna Freeman (Corporate Secretary) Excused: Guests: Agenda Item Discussion Action Item Call to Order The meeting was called to order at 8:03 a.m. by Committee Chair Khadijah Tribble. Determination of a Quorum



The agenda was approved with the following changes: Item # 7 - Review Adhoc Committee Recommendations to Evaluate our Vendor and our CEO. Virgil McDonald will update the committee on the evaluation of the CEO.

Approval of the Meeting Minutes

The minutes of January 17, 2017 were approved as written.

Discussions

Highlights included: Chair Tribble led the discussion regarding the following: Review and Approval of the Veritas Performance Tool:

• The tool was sent to the entire board for comments and edits.

• No comments and or edits were received from the BOD • Chair Tribble recommends the committee move forward and present to full

board in its current form. • Chris G. Gardiner, Board Chair reviewed the outcome of his meeting with the

Mayor. • The performance tool begins on October 2016 performance. • Chair Tribble hopes this tool will be used for future operator evaluations.

Chris G. Gardiner, Board Chair led the discussion regarding his meeting with Mayor Muriel Bowser.

• Mayor Bowser did not agree with the Board regarding the operator’s performance.

• Mayor Bowser stated the BOD may make recommendations. • The Mayor gave two choices – Keep the operator or send and RFP to replace

them. • The board recommendation will be made through Wayne Turnage’s office

during their monthly meetings with the operator. • The deadline to respond to the Mayor is the end of March. • The board recommendations will be made without an update from C. Price,

Project Director due to his inability to meet with the board due to a surgical procedure.

• A request for an extension from the Mayor was suggested.

Timeline for an Annual Review of Veritas’ Performance • Chair Tribble led the discussion regarding the timeline and documents that

will be needed to evaluate the performance of the • Chair Tribble reviewed the timeline and vendor performance materials. • The evaluation mechanism is an agreed upon document by both parties. • The Ad Hoc Committee would comprise of:

▫ Maria Gomez ▫ Steve Lyons ▫ Virgil McDonald ▫ Khadijah Tribble

• The Ad Hoc committee will be discussed in the full board meeting tomorrow. • Mr. Wayne Turnage will present his report he made to the Mayor’s

Executive team. • The Ad Hoc committee will have their final recommendations by March 28th,

2017. Review of the CEO Evaluation Tool

• The tool has been approved by the board. • The content was reviewed extensively in place since 2011. • At the time of the evaluation you are evaluating the board, the staff and the

CEO. • The goals and objectives will be specific to the Management Action Plan

( MAP) • Periodic reviews are done every four (4) months during the evaluation. • The entire board is responsible to evaluate the CEO. • This is a joint evaluation which involves the Governance Committee and the

CEO to come to a meeting of the minds to establish the goals. • The Governance committee will continue to evaluate the CEO and the Ad

Hoc committee will evaluate the performance of Veritas.

Areas of Concern from the CEO • The Revenue cycle being managed by OCFO’s office. • The District’s plan for the future capital expenditures.

Other Business The next conference call will be held on Tuesday, March 21, 2017 @ 8:00 a.m. The meeting was adjourned at 8:57 a.m.

April 18, 2017 2:30 PM Finance Committee Meeting

Committee of the Board of Directors| Not-For-Profit Hospital Corporation 1


Finance Committee Agenda

I. CALL TO ORDER II. ROLL CALL III. REVIEW OF MINUTES FROM LAST MEETING

• Action Items from last meeting

IV. FINANCIAL STATEMENT REVIEW • Second Quarter financial report

V. OTHER BUSINESS • Financial issues, pressures and adjustments impacting FY 2017 budget • Revenue Cycle Report (brief) • Contract approvals • Report on Council hearing • Other new business

VI. ANNOUNCEMENTS The next Finance Committee conference call will be May 16, 2017 at 2:30pm.

VII. ADJOURNMENT

The Not-For-Profit Hospital Corporation, in partnership with its Medical Staff, will promote a healthy community through the provision of a positive patient experience, wellness programs, health education and career training

opportunities, while building strategic relationships.

Not-For-Profit Hospital Corporation Finance Committee Meeting Minutes

March 21, 2017

Present: Steve Lyons, (Committee Chair), CFO, Malika Fair, MD, Sean Ponder, Lilian Chukwuma, Luis Hernandez, David Boucree and Donna Freeman (Corporate Secretary)

Excused: Public:

Agenda Item Discussion Action Item Call to Order The meeting was called to order at 2:34 p.m. by Steve Lyons, Committee Chair.

Determination of a Quorum

Quorum determined by Donna Freeman, Corporate Secretary.


The agenda was approved as printed.

Action Items Mr. Hernandez was asked by Sean Ponder to provide a reason for the decline in mobile unit visits. Response: One unit was out of service due to repairs resulting from a collision. The mobile unit was not at fault. Action Item: Resolution of the CMO’s hours. Response: A final decision will be reached in twenty four hours. Steve Lyons

requested a cover memo specifying the duties with the .5 or .8 FTE decision. Requested: resolution of the hours and his contract with a cover letter noting detailed changes. Preferred this not to be reviewed at the retreat on March 25th.

Approval of Minutes

The meeting minutes of February 21, 2017 were approved.

Financial

Statement Review

FINANCIAL REPORT Lilian Chukwuma, CFO presented the Summary of Operating Results for the month ending in February 2017. (Attachments presented to Committee members and filed in the Office of the Secretary of the Corporation) Discussion Highlights (Please refer to financial statements provided in Finance materials):

Report Summary Page (#15)

Revenue

• -34.5% ($3.5M) lower than the month of February 2017 budget and -9.0% ($4.3 M) lower fiscal year-to-date.

• -33.6% (487K) lower than February 2016 but 1.0% ($493K) higher than February 2016 fiscal year to date.

Contributing Factors • Lilian Chukwuma is formulating a plan to evaluate the loss and the

turnaround process. An action plan will be presented to the BOD in April 2017.

• Total Operating Revenue – affected by the booked reserves and culmination of the recorded adjustments for the past 18 months.

• Reviewed admissions which were 11 below budget and -2% against budget. • ER Room Visits: – 22% over budget and 9% over YTD.

A plan of action will be presented to the Finance Committee and BOD in April 2017 referencing the $3.5M deficit.

• Surgical procedures up 37% over budget • Net patient revenue: below budget. • DSH – was not budgeted in FY 2017. • CNMC: slightly over budget. • Other Revenue: Lilian Chukwuma led the detailed discussion.

Expenses

• -4.0% ($421K) lower than the month of February 2017 budget and on target for fiscal year to date.

• -8.0% ($794K) lower than February 2016 but -2% ($851K) lower than February 2016 fiscal year to date.

Contributing Factors

• Shortfall in staffing being covered by agency and contract labor. • Budgeted, but not incurred expenses for Revenue Cycle contract.

Cash on hand – 42.73 Days

Other Business Lilian Chukwuma led the discussion on the cash reserves of UMC.

New Business N/A Announcements The next Finance Committee conference call will be Tuesday, April 11, 2017 at

2:30 p.m.

Meeting adjourned at 3:54 p.m.

pharmacy and therapeutics committee, · khadijah tribble committee chair led the discussion. •...

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