august 20, 2015. call to order – charles ayscue - board chair approval of minutes from last...

ASH Governing Board3rd Quarter Meeting

August 20, 2015

Agenda• Call to Order – Charles Ayscue - Board

Chair• Approval of Minutes from Last

Meeting• Medical Staff Report• ASH Committee Reports and

Recommendations• Quality Assessment Performance

Improvement

Agenda• Utilization Review• Compliance/Risk Management• Financial Report• CEO Report• New Business• Old Business• Executive Session – if needed• Adjournment

Medical Staff and Policy & Procedure Approvals

Appointments/ReappointmentsNew Appointments / Re-Appointments approved by the Medical Exec. Committee- action required

Q2 Clinical Policies & Procedures – No Action Required

Formulary – Submitted for informationReviewed and approved by MEC, Dr. Jacobs, CEO, and Director of Nursing.

ASH Committee Reports/Recommendations

ASH Committee Minutes:◦MEC Minutes – 08/06/15 New locum- Dr. Agunobi

◦Safety Committee Minutes – 07/29/15 No loss of days to employee injuries April – 1 Workers Comp claim denied May & June - None

◦QAPI Meeting Minutes –07/29/15 Recommendation from Jill Hiers on contracts &

tracer activity.

KePro is the new QIO and UR will refer Medicare cases for independent review.

No HINN letters were issued

Pre-admission assessments & criteria reviews completed within 48 hours.

Continued stay criteria reviewed weekly

Utilization Review

Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region

0.90.95

11.05

1.11.15

1.2

1 11.06

1.1 1.11.14

1.1

1.2 1.2Case Mix Index Goal is >1.1


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

96.7%100.0%

91.7% 91.7% 91.2%90.5%

92.9% 92.5% 91.6%

3.3% 0.0%8.3% 8.3% 8.8% 9.6% 7.1% 7.6% 8.4%

Discharge Information Planned Unplanned

Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAHPS) Survey PATIENT SATISFACTION Oct – June 2015


0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

44.2%51.1%

33.3%

55.6%

56.6%

56.9%

51.8%

55.6%52.9%

Survey Return Rate


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

11.8% 12.8% 18.2%21.6% 22.3% 22.9% 18.2% 18.9% 23.7%

88.2% 83.0% 81.82%71.5% 70.4% 69.5% 74.7% 74.9% 68.4%

4.3% 7.0% 7.3% 7.6% 7.1% 6.2% 7.9%

Overall Rating Of Hospital Always Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

17.7%8.9%

18.2%22.4% 23.4% 22.4% 19.7% 20.0% 19.5%

82.4%91.1%

81.8% 73.7% 72.2% 73.2% 76.1% 77.0% 75.8%

4.0% 4.4% 4.4% 4.1% 3.0% 4.7%

Willingness To Recommend HospitalAlways Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

2.0% 0.7% 4.7% 4.9% 4.9% 4.9% 4.5% 4.4%11.8% 15.9% 9.1%

20.2% 20.5% 21.2% 18.5% 19.3% 20.9%

86.3% 83.3% 90.9%75.1% 74.6% 73.9% 76.6% 76.3% 74.7%

Nurse CommunicationAlways Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

2.9% 2.2% 4.5% 4.5% 4.6% 3.8% 3.2% 4.0%12.8% 15.2%

3.3%16.1% 16.3% 15.2% 15.5% 14.6% 14.4%

84.3% 82.6% 96.7% 79.5%79.2%

80.1% 80.7% 82.2% 81.6%

Physician CommunicationAlways Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

4.6% 12.1% 11.1% 16.4% 18.2% 19.7% 17.7% 20.2% 20.4%

38.6%37.9%

61.1%36.3% 36.3% 35.7% 32.0% 33.2% 33.3%

56.8% 50.0%27.8%

47.3% 45.5% 44.6% 50.3% 46.6% 46.3%

Responsiveness of Hospital StaffAlways Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

5.4% 1.3% 0.0% 6.2% 6.0% 5.8% 7.9% 5.9% 4.2%8.9% 16.7%

31.3% 24.0% 24.3% 23.1% 19.9% 21.0% 21.3%

85.7% 82.1%68.8% 69.8% 69.7% 71.0% 72.2% 73.2% 74.5%

Pain ManagementAlways Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

16.0% 12.5%22.2% 18.6% 18.2% 20.0% 17.6% 15.1% 19.2%

18.0%15.3%

27.8%20.3% 20.5% 19.7% 19.7% 20.1% 19.2%

66.0% 72.2%

50.0%61.0% 61.3% 60.3% 62.7% 64.8% 61.7%

Communication About MedsAlways Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

17.7%6.4% 0.0% 3.9% 4.3% 3.9% 3.4% 3.5% 2.3%

29.4%

14.9%18.2% 16.0% 16.0% 16.7% 14.9% 14.7% 13.9%

52.9%

78.7% 81.8% 80.1% 79.7% 79.4% 81.7% 81.8% 83.8%

Cleanliness Of Hospital Environment Always Usually Sometimes/Never


0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

9.1% 12.8% 9.1% 9.1% 10.1% 10.1% 7.3% 9.0% 8.3%

27.3%31.9% 36.4%

26.8% 25.9% 24.3% 23.9% 21.0% 21.5%

63.6% 55.3% 54.6%64.0% 64.0% 65.5% 68.8% 70.0% 70.3%

Quietness Of Hospital Environment Always Usually Sometimes/Never

Hospital Acquired Pressure Ulcers

HAPUs per 1,000 Patient Days

OCT NOV DEC JAN FEB MAR APR MAY JUN 0 4.1 0 1.1 3.8 0 0 1 2.5

OCT NOV DEC JAN FEB MAR APR MAY JUN

HAPUs -- Total # 0 3 0 1 3 0 0 1 2# of Patients with HAPUs 0 2 0 1 2 0 0 1 2

Risk Management

Jan Feb Mar Apr May JunQ2 Q3

0

1

2

3

4

5

6

7

Com-plaints

Jun -Billing Issue not related to patient care.

Falls Reduction – Falls with Injury 0.00/1,000

patient days. Green Condition. Goal is < 0.475

Reduce CLABSIs – Apr 1.8 –May 1.4-May 1.4 Q3

AVG 1.53 Goal is <0.65

Increase compliance with blood administration vital

sign compliance =93% compliant on hourly checks:

Up to 100% compliant on end of transfusion Goal is

>98.9%

Core Quality Measures Q3

Compliance Program LTCH-Quality Reporting Program

Compliant with CMS transmissions YTD.

ASHiCARE/ASH AlertLine & WebpageNo reports in Q3.

Annual Education-FY’15ICD-10 Training ASH Clinical Staff – In processCompliance Program Module- Sept ‘15Accountability Statements- Sept ‘15

Survey Readiness: Joint Commission Accreditation – Met with Consultant for 3rd review of gap analysis. ASH Leadership continues to implement Tracer analysis.

Hospital Compliance

CMS Hospital Recertification Survey

Tuesday, Aug 11, Representatives from NC Division of Health Service Regulation arrived at 9:00 a.m. to conduct a recertification survey on behalf of CMS. The survey lasted 3 days with an exit interview on Thursday, Aug. 13th.

The following Standard deficiencies were noted:QAPI – Action plans and Contractual performance measures

need improvement. All contracts must include performance measures including purchased services from Mission Hospital. §482.21 Condition of participation: Quality assessment and performance improvement program.

Life Safety/Physical Environment– No doors on Nutrition Stations and a lock on hallway door 4S ,Recycle bins out in hallway 4S. , ASH specific fire drills & log. Sprinkler heads not correct for area location, Lobby alarm in main box failed. §482.41 Condition of participation: Physical environment.

Infection Control- Telemetry monitors dirty, labeling of patient foods.

482.42 Condition of participation: Infection control

Hospital Recertification Survey

All Conditions of Participation for Acute Care Hospitals were surveyed. The following domains had No Issues:Subpart B—Administration§482.11 Condition of participation: Compliance with Federal, State and local laws.§482.12 Condition of participation: Governing body.§482.13 Condition of participation: Patient's rights.

Subpart C—Basic Hospital Functions§482.22 Condition of participation: Medical staff.§482.23 Condition of participation: Nursing services.§482.24 Condition of participation: Medical record services.§482.25 Condition of participation: Pharmaceutical services.§482.26 Condition of participation: Radiologic services.§482.27 Condition of participation: Laboratory services.§482.28 Condition of participation: Food and dietetic services.§482.30 Condition of participation: Utilization review.§482.43 Condition of participation: Discharge planning.§482.45 Condition of participation: Organ, tissue, and eye procurement.

Subpart D—Optional Hospital Services§482.51 Condition of participation: Surgical services.§482.52 Condition of participation: Anesthesia services.§482.53 Condition of participation: Nuclear medicine services.§482.55 Condition of participation: Emergency services.§482.56 Condition of participation: Rehabilitation services.§482.57 Condition of participation: Respiratory care services.

Hospital Recertification SurveyIssues found and corrected during survey:

Refrigerator temps in Nutrition StationsDietary: Soup Temps when delivering to

patient rooms, uncovered food trays in holding areas

HR – Documented verification of education for employee records.

CEO ReportFinancial, Medical Staff, Legislative,

Planning

Income Statement

Q1 Q2 Q3 Q3 Q3 YTD YTD YTD

Actual Actual Actual Budget Variance Actual Budget Variance

IncomeNet Operating Revenue $3,142,342 $3,495,357 $3,719,080 $3,559,347 $159,733 $10,356,784 $10,824,366 ($467,582)

ExpensesSalaries $1,430,856 $1,533,997 $1,624,291 $1,479,961 ($144,330) $4,592,376 $4,500,426 ($91,950)Contract Labor $139,202 $297,133 $299,741 $76,614 ($223,127) $738,442 $232,978 ($505,464)Benefits $354,421 $392,621 $404,504 $397,081 ($7,423) $1,151,849 $1,207,739 $55,890Professional Fees $15,100 $19,802 $13,140 $28,481 $15,341 $48,042 $85,863 $37,821Medical Supplies $322,093 $382,776 $423,371 $393,037 ($30,334) $1,128,238 $1,194,119 $65,881Purchased Services $641,739 $622,869 $665,227 $771,840 $106,613 $1,929,835 $2,330,019 $400,184Utilities $2,553 $5,045 $3,392 $4,202 $810 $10,990 $12,605 $1,615Other Expenses $244,353 $299,069 $288,909 $295,048 $6,139 $832,329 $887,909 $55,580Depreciation & Amort $27,032 $23,404 $22,091 $23,888 $1,797 $72,527 $76,883 $4,356Interest Expense $0 $0 $63 $6 ($57) $63 $18 ($45)Total Expenses $3,177,349 $3,576,716 $3,744,729 $3,470,158 ($274,571) $10,504,691 $10,528,559 $23,868

Net Income ($35,007) ($114,561) ($25,649) $89,189 ($114,838) ($147,907) $295,807 ($443,714)

July NI - $103,298 YTD ($44,615)CMI was up,, agency use dropped off and orientation is winding down.

Expenses: Salaries & Contract labor have been our biggest issue. In preparation for the new rules in October, we had to upgrade staff and staff competencies. High amount of orientation costs and agency use during this time.Agency nurses are now down to zero.

Revenue: Net Revenue YTD 4.3% below budget. Slow months in November & December are part of this and low CMI is the other factor. 3rd quarter revenues were up as was census and CMI.

Income Statement PPDQ1 Q2 Q3 Q3 Q3 YTD YTD YTD

Statistics Actual Actual Actual Budget Variance Actual Budget Variance

Patient Days 2,237 2,508 2,553 2,420 133 7,298 7,359 (61)ADC 24.3 27.9 28.1 26.6 1.5 26.7 27.0 (0.2)

Q1 Q2 Q3 Q3 Q3 YTD YTD YTD

Actual Actual Actual Budget Variance Actual Budget Variance

Net Revenue $1,405 $1,394 $1,457 $1,471 $1,201 $1,419 $1,471 ($52)

ExpensesSalaries $640 $612 $636 $612 ($25) $629 $612 ($18)Contract Labor $62 $118 $117 $32 ($86) $101 $32 ($70)Benefits $158 $157 $158 $164 $6 $158 $164 $6Professional Fees $7 $8 $5 $12 $7 $7 $12 $5Medical Supplies $48 $153 $166 $162 ($3) $155 $162 $8Purchased Services $287 $248 $261 $319 $58 $264 $317 $52Utilities $1 $2 $1 $2 $0 $2 $2 $0Other Expenses $109 $119 $113 $122 $9 $114 $121 $7Depreciation & Amort $12 $9 $9 $10 $1 $10 $10 $1Interest Expense $0 $0 $0 $0 ($0) $0 $0 ($0)Total Expenses $1,420 $1,426 $1,467 $1,434 ($33) $1,439 $1,431 ($9)

Net Income ($16) ($46) ($10) $37 ($47) ($20) $40 ($60)

Expenses: Salaries & Contract labor both high as previously discuss. Supply expense is due to medication expense. Jluy PPD expenses also dropped to $1,445 PPD from $1,467 in the 3rd quarter.

Revenue: 3rd quarter was our highest NI PPD. CMI has improved due to higher acutiy and bringing coding in-house. July NI PPD was $1,566.

Relocation Update5th Floor Mission Hospital

Space Details34-beds – larger rooms – all private5th floor of main campus3 floor plans under reviewAll clinical departments but pharmacy are on the unitPharmacy will only fit if some space from mother/baby

overflow unit given up. We have not looked into this yet.We would need about 3,400 – 4,000 square feet of

administrative and pharmacy space elsewhere in the building.

Reviewing internally and then will discuss with facilities for more accurate pricing. Expect somewhere in the $5 million range.

Existing Conditions

Scenario 1Pros:• Unit Visibility

and Security

• Decentralized Support Services for operational flow

• Centrally located PT / OT

Cons:• Lack of Storage

• No Emergency Treatment Space

• Separated Patient Rooms

Scenario 2Pros:• Observation

bed Configuration

• Patient Unit Configuration

• Safety and Security

Cons:• Unit Visibility /

Nurse Station Division

• Lack of Storage


Scenario 3Pros:• Observation

bed Configuration

• Patient Unit Configuration

• Safety and Security

Cons:• No Pharmacy

• Lack of Storage


If managed well this could present a great opportunity for us.

Summary of relevant proposed rule Must be discharge from and IPPS Acute Care

hospital, CAH do not count.Need a 3-day ICU stay or on prolonged mechanical

ventilation > 96 hours at LTCH.ICU is defined as all cases in Revenue Code Centers 20x

& 21x – Includes step down ICU unitsMedicare Advantage and "site neutral cases excluded

from 25-day LOS ruleAll cases (LTCH & Site neutral) are included in

25% rule (75% for ASH under market dominant)

Regulatory Update – LTCH Cases

Next two years it will be the lower of cost or blended IPPS/LTCH rates, then;

It is the lower of cost or IPPS per diem up to IPPS rate

Cases that did not have 3-day ICU stay Cases not admitted from an IPPS hospital

(Includes Observation admits) These cases will have to be managed

as any other ACH case

Regulatory Update: Non - LTCH Cases

Impact Analysis of New Rule(Assumes No Change in Cases or management of cases)

Baseline FY 2016 FY 2017 FY 2018

Cases FY 2015 PaymentsFY 2016 Payments

% Change Full Phase-In%

ChangeFully

Implemented %

ChangeOverall 133,356 $5,435,199,413 $5,301,188,560 -2.5% $4,966,896,504 -8.6% 4,357,719,924 -19.8%NALTH Membership Member 15,484 $665,665,604 $635,995,187 -4.5% $608,734,493 -8.6% $547,291,746 -17.8% Non-Member 117,872 $4,769,533,809 $4,665,193,373 -2.2% $4,358,162,011 -8.6% $3,810,428,178 -20.1%Location Type

Urban 127,693$5,233,120,440

$5,112,670,931 -2.3% $4,796,799,503 -8.3% $4,218,572,972 -19.4%

Rural 5,663 $202,078,973 $188,517,629 -6.7% $170,097,001 -15.8% $139,146,952 -31.1%Ownership Type For-Profit 113,816 $4,611,557,857 $4,508,041,727 -2.2% $4,203,992,662 -8.8% $3,668,859,204 -20.4% Non-Profit 17,319 $721,784,466 $693,226,707 -4.0% $665,755,297 -7.8% $599,057,158 -17.0%Bed size

0 to 24 Beds 2,523 $92,699,671 $89,643,956 -3.3% $82,683,959 -10.8% $69,955,783 -24.5%

25 to 49 Beds 45,031$1,775,179,757

$1,707,076,777 -3.8% $1,611,685,842 -9.2% $1,414,009,878 -20.3%

50 to 74 Beds 37,541 $1,564,340,585 $1,510,823,687 -3.4% $1,427,953,961 -8.7% $1,255,937,312 -19.7% 75 to 124 Beds 22,002 $945,426,815 $940,717,469 -0.5% $877,544,125 -7.2% $783,089,732 -17.2% 125 to 199 Beds 14,887 $589,244,925 $586,202,532 -0.5% $540,224,419 -8.3% $463,273,049 -21.4% 200 or more Beds 11,372 $468,307,660 $466,724,138 -0.3% $426,804,199 -8.9% $371,454,170 -20.7%Census Region South Atlantic 18,382 $777,156,317 $767,330,466 -1.3% $734,430,612 -5.5% $672,463,677 -13.5%

Asheville Specialty Hospital 261

$ 10,063,201

$ 9,545,038 -5.1%

$ 9,545,038 -5.1%

$ 8,814,452 -12.4%FY 2016 & 2017 is a blended transition rate between the

LTCH rates and IPPS rates. 2018 is the fully implemented new rates.

Impact by Payment Change TypePatient Category Cases FY 2015 Payments FY 2016 Payments Percent

Difference

Non-Qualifying 74 $ 2,784,738 $ 2,258,825 -18.9%

Regular LTCH-PPS 131 $ 5,996,813 $ 6,078,757 1.4%

SSO Case 38 $ 846,250 $ 872,567 3.1%

SSO Non-Qualifying 18 $ 435,399 $ 334,888 -23.1%

Total 261 $ 10,063,201 $ 9,545,038 -5.1%

1. Non-LTCH cases is where the biggest change will occur.2. LTCH case payments actually increase3. Assumes no changes in patient selection, CMI and

LOS.4. The more LTCH cases the better5. Improved flexibility to take short stay – non-LTCH

cases

Plan to Address New Rules LTCH patients

Focus on the three primary ICU groups, APA, Trauma, Cardiovascular

Target Step-down units for referrals - ?MMA/AHGWorking on plans to accept ICU admits 24/7

Make sure we are compliant with LTCH rules The 24/7 admits would be limited to Medicare part A

cases and possibly unfunded cases as all other insurers require precertification

Discussing LVAD payment bundle pilot that would allow for free movement between Mission and ASH.

Work through physician issues to do this.

Plan to Address New Rules Non-LTCH Cases

Targeting two programsPulmonary/COPD (ALOS 5-9 days)At best breakeven or

loose a little. Looking to be a direct admit option for APA Care Path to meet DRG

LOS guidelinesWound (ALOS 6-10 Days)- Biggest potential for improved

profitability Bringing in new wound physician group that also rounds at 30

nursing homes. Looking to do direct admits for wound care excisional debridement

and/or grafts and back to nursing home.Non-LTCH cases will have to be managed like IPPS casesWe could also admit from Mission ER during high occupancy,

including vent cases if there is physician support.

What has been done alreadyWe have upgraded staff capabilities through hiring

and training over the past 6-10 months.56% of staff have now been here < 2 yearsThis has been more costly then expected with agency

use and orientation expenses being very high.All nursing agency is now done45% of our RNs are ICU nurses and evenly split on

days and nights.We have had some intubated patients on the unit

recently.Liaisons are former ICU nurses from Mission

Physician Search is ongoingPhysician coming in October to interviewOne Local physician may be interested

Use of LocumsDr. Agor had to move closer to home due to

family issuesWe will be using some different locums over

the next 2 months to see how the recruiting goes.

Other Updates

New Business –

Old Business -

Executive Session – If Needed

Adjournment

august 20, 2015. call to order – charles ayscue - board chair approval of minutes from last...

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