ASH Governing Board Meeting 2nd. Quarter Meeting

ASH Governing Board1st Quarter Meeting March, 5 2015AgendaCall to Order Charles Ayscue - Board ChairWelcome new member _ Jerry McIntoshApproval of Minutes from Last MeetingMedical Staff ReportASH Committee Reports and RecommendationsQuality Assessment Performance ImprovementAgendaUtilization ReviewCompliance/Risk ManagementFinancial ReportCEO ReportNew BusinessOld BusinessExecutive Session if neededAdjournment

Medical Staff and Policy & Procedure Approvals Appointments/Reappointments (Action Required)New Appointments / Re-AppointmentsClinical Policies & Procedures (No action Q1)Formulary - MEC approved additions and deletions from ASH Formulary presented for information. 2015 QAPI Plan Approval (Action Required)4ASH Committee Reports/RecommendationsASH Committee Minutes:MEC Minutes 02/05/15 There is some discussion regarding the qualifications and fit for ASH. MAHEC and ASH are interviewing a resident for the FT position. Concerns were expressed among MEC members. Members advised ASH should search for a candidate with Internal Medicine background and at least 3 yrs. of experience. QAPI Meeting Minutes 01/28/15Finalize FY 2015 Department Quality IndicatorsPresent to Governing Board for approval.Safety Committee Minutes 01/22/15No equipment recallsQ1 - No Loss of Days to work related injuries.

CAUTIs ASH YTD = 0.41 compared to HCD/Truven trending 1.66 for running average of 8 quarters through 9/30/2013

CLABSIs ASH YTD = 0.32 compared to HCD/Truven trending 0.6524 for running average of 8 quarters through 9/30/2013Employee SafetyNo Equipment Recalls for 3Q.No Loss of Days to EmployeesNeedle Stick = 2 Back Strain =1

Safety/Infection Prevention UR Committee Minutes 08/01/2014LOS & HCO ReviewMedicare Payment Classification/Payer Mix ReviewNo HINN letters were issued

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

Continued stay criteria reviewed weekly

One QIO review Denial appeal submitted, no response yet

Utilization ReviewHospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey PATIENT SATISFACTION Q1 OCT DEC 2014

Quality Benchmarking at ASHLong Term Acute CareClinical Performance Report

1st Qtr. 2015

Hospital Acquired Pressure Ulcers2015HAPUs Q1 = 3 Total among 2 patients. OCT NOVDECHAPUs per 1000 patient days (Goal is < 1.00)04.150HAPUs -- Total # 030# of Patients with HAPUs020# of Stage 2020# of Stage 3 000# of Stage 4 000# Unstageable: Non-Removable Dressing 000# Unstageable: Slough/Eschar 010# Unstageable: Deep Tissue Injury 000HAPUs -- Total # Healed prior to D/C000HAPUs -- Total # Not Healed prior to D/C030Falls Reduction Falls with Injury Q1=0.00/1,000 patient days. Goal is < 0.475Reduce CLBSIs/1000 ppd Q1= 0.83 Goal is 98.9

CMI per month (goal > 1.1) Q1 Avg = 1.03Oct = 1.03Nov = 1.05 Dec = 1.02

Organization Key Quality Measures*Indicators that met or fell out of range for Q1 recorded in ASH Report Card.Compliance Program LTCH-Quality Reporting ProgramCompliant with CMS transmissions for fiscal year.ASHiCARE/ASH AlertLine & WebpageNo reports in Q1. Recent staff educ. on Alert line.Annual Education-FY15Compliance Program Module- Sept 15Accountability Statements- Sept 15Survey Readiness: Under consulting contract with Joint Commission Resources. Start Date Jan.1, 2015 Target Joint Commission Accreditation Survey- Oct, 2015.

Hospital Compliance

Risk ManagementDuplicate grievance for Nov/Dec. Case was reported to NC Div. of Facility Services. ASH anticipates a State Survey is imminent. CEO ReportFinancial, Medical Staff, Legislative, PlanningIncome Statement

Income Statement PPD

January Results

Met with Missions senior leadership team to discuss future location options.

Dr. Paulus feels we should be on the main campus.

This was supported by most of the leadership team.Relocation UpdateCON IssuesStaying on Mission CampusSubmit letter of no review request to CON sectionRelocation is exempt from review, regardless of cost. Require prior notification.Relocating in Buncombe CountyDevelop CON and submit application based on cost, need and access considerationsCan ask for declaratory ruling based on occupancy and immediate impact on bed demand. Relocating Outside Buncombe CountyRequires new CON application based on conversion of a portion of existing beds or a self-supporting need methodologyCON IssuesState took 43 beds away from Mission to approve expansion of NICU.

38 beds were approved for LTCH, current licensed 34-beds

Beds can not go to Mission's Provider Number if LTCH closes.

Separate State License will be required.

Could change focus of beds/license from LTCH to another program like pediatric hospital, cancer hospital. This would have to be verified with DHHSInitial Space Review5th Floor Center corridor (where the interim Peds wing was during renovation)Initial assessment:This area is fairly move-in ready and would be a good optionOnly 16 patient rooms, therefore, other space would be needed in conjunction with this area.We looked at 5 South(Equipment Transport & Storage) as an additional area This area is wide open on both sides of the corridor and can be converted to patient rooms if necessary.

5 West (Trauma Services)Exact number of patient rooms needed (34)Rooms are small; roughly 140-165sfThis area would not be an upgrade for ASH more of a like for like change, but a very feasible optionAlso, this option would require some additional space for rehab, conference room & some admin office space

3rd Floor South (CDOU)Nice unit with 19 rooms, therefore, other space would be needed in conjunction with this.All patient rooms would need a bathroom added Some rooms may be too small to add a bathroom (~140sf). Some current dual observation rooms would be fine to convert to LTACH needs as a bathroom would fit fine.3rd Floor Center corridorVery chopped up layout which would require a lot of renovation to convert to patient roomsNew congress means new legislative proposalsThere is a lot of discussion about post acute care bundling in Congress, CMS, and MedPacNew rules regarding last legislative changes are due out the end of April.Our association is looking at legislation to address wound care cases.We do need to focus on admits directly from ICU instead of ICU to step-down to ASH. Regulatory UpdateMAHEC has taken over the hospitalist program on January 1st.Recruiting to fill the vacant position has begun. There is discussion about qualifications ( Internal Med vs Family Prac.)Will Rodgers PharmD. has taken over as Pharmacy DirectorWe now have over 17 certified RNs with most being CCRNs spread about evenly on days and nights.Other UpdatesCurrent InitiativesLooking at Bundling options for Medicare AdvantageWe will conduct same survey Mission is doing for Safety & Engagement in MarchThe Joint Commission survey in FallDeveloping Peer-to-Peer Guidelines for physicians to use in commercial appeals (Sample in Packet)Working with MAHEC on Marketing , especially ICU units.New Business Old Business - Bylaws Review and Approval - Tabled Executive Session If NeededAdjournment