cook county health and hospitals system presentation to inform … · 2019. 6. 4. · ongoing...

Cook County Health and Hospitals System Presentation to Inform Strategic Plan:

Medical Staff

Claudia M. Fegan, MD, FACP, CHCQMExecutive Medical Director

April 29, 2016

CCHHS Medical Staff I April 29, 20162

CCHHS Medical Leadership

. Chair Department Radiology

Mark Pisaneschi, MD

Chair Department of Pathology

Marion Sekosan, MD

Chair Department Pediatrics

Lisa Giordano, MD

Chair Department Psychiatry

Andrew Kulik, MD

Chair Department Surgery

Richard Keen, MD

Chair Department Trauma & Burn

Faran Bokhari, MD

CCHHS Executive Medical Director

Claudia Fegan, MD

Chair Department Anesthesiology & Pain

ManagementGennadiy Voronov, MD

Chair Department Correctional Health

Connie Mennella, MD

Chair Department Emergency Medicine

Jeffery Schaider, MD

Chair DepartmentFamily & Community

MedicineMark Loafman, MD

Chair Department Medicine

Suja Mathew, MD

Chair DepartmentObstetrics & Gynecology

Edward Linn, MD

Chair Department Oral Health

Jorelle Alexander, DMD

Director of Professional Education

John O'Brien, MD

Medical Director

Ambulatory Services

Vacant

Medical Director

ProvidentClifford Crawford, MD

Director of Employee Health

ServicePatricia Kelleher, MD

Interim


CCHHS Executive Medical Director

Claudia Fegan, MD

Chair Department Anesthesiology

Mark Krause, MD

Chair DepartmentEmergency Medicine

Pierre Wakim, DO

Chair Department Internal Medicine

Suja Mathew, MD

Chair DepartmentPathology

Marin Sekosan, MD

Chair Department Radiology

Kenneth Williams, MD

Chair DepartmentSurgery

Clifford Crawford, MD

Medical DirectorProvident

Clifford Crawford, MD

Provident Medical Leadership

Interim


Ambulatory Medical LeadershipCCHHS Executive Medical Director

Claudia M. Fegan, MD

Medical DirectorAmbulatory Services

VACANT

Associate Medical DirectorPrimary Care

Thomas Gavagan, MD

Community Based Clinics Lead Physicians

Attending Physicians

Fantus Based ClinicsLead Physicians


Associate Medical DirectorPediatrics

Denise Cunill, MD

Associate Medical DirectorSpecialty Care

VACANT

Stroger Based Clinics Lead Physicians


Medical Staff Functions

“The Medical Staff has the overall responsibility for the quality of medical care provided to patients, and for the professional practices and ethical conduct of its members, as well as accounting therefore to the Cook County Health and Hospitals System Board of Directors…”

Preamble, John H. Stroger, Jr. Hospital Bylaws

“The Medical Staff is responsible for the quality of medical care in the Hospital and accepts and discharges this responsibility subject to the ultimate authority of the Cook County Health and Hospitals System Board of Directors…”

Preamble, Provident Hospital Bylaws


Medical Staff Committees: Executive Medical Staff (EMS) Committee

• Represents and acts on behalf of the Medical Staff• Coordinates activities and general policies of the departments• Receives and acts on committee reports• Implements policies of the Medical Staff• Liaison between Medical Staff, COO, CEO and Board• Makes recommendations to the Board and Hospital Management on

appointment/reappointment…clinical privileges and corrective actions• Promotes professionally competent and ethical conduct by Medical Staff• Assists in implementing and enforcing policies and procedures approved

by the Board


EMS Committee Members• Officers of the Medical Staff• Chairs of all Medical Departments• Chair of Division of General Surgery• One member from each of 5 Divisions of Department of Medicine• One member from each of 4 Divisions of Department of Surgery• Two members each from OB/GYN and Pediatrics• One member each from Departments of Anesthesiology & Pain

Management, Correctional Health, Family & Community Medicine, Pathology, Psychiatry, Radiology, Trauma & Burn

• One member from FT non-member practitioners (selected by President)

• President of the House Staff• Ex-officio members: Immediate Past President, COO, Medical

Director, Associate Hospital Director, Director of Nursing Services



Stroger Hospital Executive Medical Staff Committee

2016-2017 Officers

Ozuru Ukoha, MD President

Trevor Lewis, MDVice-President

Juliet Bradley, MDSecretary

Aiman Tulaimat, MDTreasurer


Provident Hospital Medical Executive Committee2016-2018 Officers

Valerie Hansbrough, MD President

Anwer Hussain, DOVice-President

Julita McPherson, MDSecretary

Angel Leake, MDTreasurer

Medical Staff Committees

• Blood Bank and Transfusion Committee• Bylaws Committee• Cancer Committee• Credentials Committee• Critical Care Committee• Drug and Formulary Committee• Hospital Quality Improvement and Patient Safety Committee• Institutional Review Board (IRB)• Joint Conference Committee• Medical Education Committee • Medical Ethics Committee• Medical Information Committee• Operating Room Committee• Peer Review Committee• Resuscitation Committee• Surgical Function Review Committee• Ad Hoc Committees


CCHHS Medical Staff by CategoryStroger/Provident

790

446

189

0

100

200

300

400

500

600

700

800

900

Active Consulting Service Voluntary



*JHS and PH Active/Provisional only

Male55%

Female45%

Medical Staff Demographics*GENDER

Medical Staff Demographics*RACE**


*JHS and PH Active/Provisional only**Voluntary reporting

Black17%

White40%

Asian22%

Native Americanless than 1%

Pacific Islander1%

Other/No answer20%


Medical Staff Demographics*AGE

*JHS and PH, Active/Provisional only

Less than 300%

30-3921%

40-4929%

50-5933%

60-6914%

70+3%


0

20

40

60

80

100

120

140

160

180

<5 5-10 11-20 21-30 >30

156165 169

81

6

*JHS and PH, Active/Provisional only

Medical Staff Demographics*YEARS ON STAFF


Medical Staff Demographics*TOP NON-ENGLISH LANGUAGES SPOKEN**

*JHS and PH, Active/Provisional only**Voluntary reporting

B I / M U L T I - L I N G U A L

S P A N I S H

H I N D I

U R D U

F R E N C H

A R A B I C

R U S S I A N

G U J A R A T I

C H I N E S E / C A N T O N E S E / M A N D A R I N

P O L I S H

G R E E K

T A G A L O G

295

125

54

23

22

18

18

12

11

11

8

8

Bi/Multi-lingual

CCHHS Medical Staff by Department*

*JSH and PH, Active/Provisional onlyCCHHS Medical Staff I April 29, 201617

Anesthesiology, 30Pathology , 16

CorrHealth, 30

Emergency Med, 51

Family Med, 41

Medicine, 207

OB/Gyn, 20

Oral Health, 13

Pediatrics, 44

Psychiatry, 15

Radiology , 26

Surgery, 76

Trauma, 12

ACHN Budgeted* Physicians by Department

*FT Providers on ACHN budget, credentialed and privileged by respective departmentCCHHS Medical Staff I April 29, 201618

21

20

7

4

1 1

MED I C I NE FAMI LY MED I C I NE PED I ATRI CS ORAL HEALTH PSYCHI ATRY EMERG ENCY MED I C I NE

Physicians in Ambulatory Care

• PCPs/Specialists on ACHN Budget (credentialed and privileged by department of specialty)

• PCPs on Department of Medicine Budget

• PCPs on Department of Family Medicine Budget

• PCPs on Department of Pediatrics Budget

• Specialists on Budgets of Respective Departments


Quality Partnership


Clinical Department

Chairs

Credentials Committee

Executive Medical

Staff Committee

Peer Review

Committee

Quality PartnershipDepartment Chair• Recruits and hires• Recommends criteria for clinical privileges• Conducts Individual performance evaluation Focused Professional Practice Evaluations/

Ongoing Professional Practice Evaluations(FPPE/OPPE)• Ensures department compliance with Medical Staff Bylaws, Rules and Regulations• Develops policies and procedures governing department operations and clinical practice• Monitors, evaluates and reports on quality assurance activities

Credentials Committee• Performs detailed review of applications/re-applications, evaluations and related

documentation• Make recommendations to appoint/re-appoint to Executive Medical Staff/Medical Executive

Committee (EMS/MEC)

Peer Review Committee• Investigates complaints/concerns reported to the committee• Makes recommendations to EMS/EMC


The Review Process


Credentialing


Credentialing and Privileging

Primary Source Verification: verification from the original source

• Education• Training• Certification• Licensure• Experience (current/past program directors, chairs, peers)• Hospital Affiliations• Special Qualifications• Clinical Competency• External Queries (NPDB, OIG, SAMs)


Medical Staff Credentials CommitteeDuties

• Review the credentials of all Applicants and Members applying for initial appointment, reappointment, and clinical privileges. Review information on applications for appointment and reappointment and communicate with references where appropriate

• Review any reports referred by the Executive Medical Staff Committee, Medical Information Committee and the Hospital Quality Improvement and Patient Safety Committee that may concern the professional or clinical competence of Membersand…make recommendations to the Executive Medical Staff Committee regarding privileges of any Members



Duties cont.

• Review and recommend initially and biennially or more frequently, if the Committee determines this to be necessary, the extent to which Non-Member Practitioners will be permitted to exercise Collaborative Clinical Privileges in the Hospital

• Review requests for and make a written report to the Executive Medical Staff Committee on the initial and continued exercise of Collaborative Clinical Privileges for Non-Member Practitioners

• Identify any trends with OPPE that would trigger an FPPE and monitor compliance with FPPE

Medical Staff Credentials Committee

Professional Performance Evaluation:The Joint Commission

MS.08.01.01 The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s

professional performance

MS.08.01.03Ongoing professional practice evaluation information is

factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal


Peer Review


Peer Review:The Joint Commission

MS 09.01.01

The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on

reported concerns regarding a privileged practitioner’s clinical practice and/or competence


Medical Staff Peer Review Committee

DutyThe Peer Review Committee shall investigate all matters brought to its attention and shall issue a report on each matter to the Executive Medical

Staff Committee


Possible Peer Review Outcomes

• Dismiss allegations/concerns• Recommend restoration of clinical privileges following a suspension• Issue a letter of warning, admonition, censure or reprimand• Recommend specific remedial measures (e.g. training, education,

counseling)• Recommend proctorship or specific period of probation w/ appropriate

terms and conditions*• Recommend a reduction of clinical privileges*• Recommend a specific period of suspension or termination of clinical

privileges*• Recommend a specific period of suspension or termination of

membership*

* Member has right to hearing


The Evolving Medical Staff: Strategies for Transforming

Organization and Performance


The Drivers• Outpatient and community based care instead of hospital-centric care:

– Economics• Diagnosis Related Group/Ambulatory Payment Classification (DRG/APC)• Managed Care

– Evidence Based Practice– Technology and Other Innovations

• Affordable Care Act– More options– Consumer choice– Competition

• Improve Patient Experience– Better access– Standardized practices– Better throughput– Physician-Patient relationship

• Improve Provider Experience– Explicit expectations– Fulfill mission while acknowledging strengths and interests


Medical Staff Strategies1. Unified Medical Practice

• System/Enterprise View• Standard Requirements and Expectations• Staffing Flexibility

2. Clinical Effort Agreements• CART (Clinical, Administrative, Research, Teaching) Balance

3. Benchmarking Performance• Public Hospital Compare Groups• UHC Compare Group• Specialty-specific Compare Groups• Relative Value Units (RVUs)• Physician Scorecards


RVUs: Relative Value Units

• Medicare sets reimbursement rates for each Current Procedural Terminology (CPT) code assigned to every physician encounter

• Physicians’ services are counted in RVUs

• Based on:– Physician work (expertise, time and technical skill)– Practice expense (cost to operate a medical practice)– Professional liability insurance expense (relative risk of services/cost

to insure against the risk of loss in providing the service)


RVUs and Medical Practice

• RVUs can be used as a measure of physician performance in order to calculate physician compensation

• Advantages of using RVUs as a measure: – RVU is independent of physician charge schedules, patient

insurance coverage, reimbursement fee schedules assigned by any payor for any CPT code, or the practitioner ability to collect reimbursement for any physician encounter

– RVU method of measurement reflects the reality that every patient encounter is not equal


Medical Staff Strategies (cont.)

4. Branding and Marketing• Physician Group Identity

5. Provider Enrollment• Managed Care/Third Party Plans

6. Succession Planning• Recruitment• Retention• Professional Development


Challenges

• Rapidly Changing External Environment• Competitive Hiring Market• Culture and Buy-In• Lack of Incentivization• Separate Medical Staffs/Bylaws• Definition/Quantification of Effort • Reliable Data• Maintaining Momentum/Competing Priorities


Questions?


APPENDIX



Stroger Hospital Credentials CommitteeName SpecialtyFidel Abrego, MD Obstetrics & GynecologySteven Bonomo, MD General SurgeryGail Floyd, MD Family MedicinePeter Hart, MD (Chair) Internal Med/NephrologyKimberly Nagy, MD Trauma SurgeryZahra Naheed, MD Pediatric CardiologistIsam Nasr, MD Emergency MedicineThomas Patrianakos, DO OphthalmologyHarry Richter, MD General SurgeryMarin Sekosan, MD PathologyKyle Telander, PhD PsychiatryKwyon Yoo, MD Radiology


Provident Hospital Credentials CommitteeName SpecialtyCamille Billingslea, MD Family Medicine

Clifford Crawford, MD Medical Administration/Surgery

Valerie Hansbrough, MD Obstetrics & GynecologyAnwer Hussain, DO Emergency MedicineMark Krause, MD AnesthesiologyAngel Leake, MD Internal MedicineCharlene Luchsinger Medical Staff ServicesSuja Mathew, MD Internal MedicineFeinan Shi, MD PathologyPierre Wakim, DO (Chair) Emergency Medicine Javeria Qureshi, MD Surgery

Medical Staff Peer Review Committee

PH CommitteeAd hoc membership (3 or more; 2 medical staff members)

JHS Committee


Name SpecialtyMary Jo Atten, MD MedicineHelen Straus, MD Emergency MedicineJennifer Blumetti, MD SurgeryRosibell Arcia Diaz, MD PediatricsBenjamin Mba, MD MedicinePaul Severin, MD PediatricsAbayomi Akintorin, MD - Chair Anesthesiology

cook county health and hospitals system presentation to inform … · 2019. 6. 4. · ongoing...

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