ASH Governing Board Meeting 2nd. Quarter Meeting

ASH Governing Board2nd Quarter Meeting May 21, 20151AgendaCall to Order Charles Ayscue - Board ChairApproval 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/ReappointmentsNew Appointments / Re-Appointments approved by the Medical Exec. Committee- action required

Q2 Clinical Policies & Procedures Reviewed and approved by Dr. Jacobs, CEO and DON (presented as information)

Formulary Reviewed and approved by MEC, Dr. Jacobs, CEO, and Director of Nursing.4ASH Committee Reports/RecommendationsASH Committee Minutes:MEC Minutes 05/07/15 MAHEC is extending an offer to Dr. Tsai of Arizona for the contracted hospitalist position at ASH. Dr. Jacobs and ASH leadership has met with Dr. Tsai. A report to MEC on Dr. Tsais decision will be made in our 3rd quarter meeting. May need to consider a headhunterQAPI Meeting Minutes 04/29/15Result of Grievance Investigation by NC Dept. of Health Service Regulation 4 complaint allegations were found unsubstantiated. No deficiencies cited.Safety Committee Minutes 04/23/152Q Employee injuries: Jan-2, Feb-3, March-0 No Loss of Days Q2Life Safety- Decrease in proper use of PPESecurity, Equip. Recalls, & Safety Educ.- No issues to report.

UR Committee Minutes 04/24/2015LOS & HCO Review LOS is up as are HCO cases. Area nursing homes can not handle complexity of some of our cases.Medicare Payment Classification/Payer Mix ReviewWe have gone from 80% Medicare/Advantage cases a year ago to 65%.Mission cases have doubled from 7% to 14%, but will decline with more cases going to CarePartners. The rest of the change is an increase in commercial & VA cases

No HINN letters were issued

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

Continued stay criteria reviewed weekly

Utilization ReviewHospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey PATIENT SATISFACTION Jan Mar 2015

Response rate improvingASH CMI Goal > 1.1

Excellent10Drop from first quarter, but still far better than nation & region11Very Good12Very Good13Ok, Better then others, but increase in negative responses14Excellent15Very Good16Significant Improvement Heading in the right direction17We will be looking into this in more detail and report back at next meeting18Very Good19Hospital Acquired Pressure Ulcers HAPUs per 1,000 Patient Days

OCT NOV DEC JAN FEB MAR 0% 4.1% 0% 1.1%3.8% 0%

HAPUs -- Total # 030130# of Patients with HAPUs020120OCTNOVDECJANFEBMARRisk ManagementNo grievances for Q2Falls Reduction - Q1 = 0 Q2 = 0. Goal is < 0.475Reduce unplanned discharges Q1= 7.9% Q2= 8.3%Goal is 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 CasesIt is the lower of cost or IPPS per diem up to IPPS rateCases that did not have 3-day ICU stayCases not admitted from an IPPS hospital (Includes Observation admits)These cases will have to be manged as any other ACH case

Regulatory Update: Non - LTCH CasesThe new rules narrows the focus to a few groups that deal primarily with ICU cases: APA, Trauma, Neuro, CVICU, Cardiology, General SurgeryThere were over 5,000 Medicare cases that met this criteria last year. Our LTCH capacity is about 420 discharges at 100% of 34-beds.There were 823 (107 cases 20+ days, 172 cases 15-19 days, and 544 cases 10-14 day) cases with an ICU/Step-down stay of 10 days or greater only 8.8% came to ASH. Most of those cases were in the > 15 day stay category.

SituationWe have piloted attend rounds once per week with the CVICU physicians (at their request) and have seen an increase in admits. We want to expand this to the other ICUs.Develop a clinical tool that IDs these cases early in the stay. Tool will be based on patient severity/mortality scores as well as LOS, ICU days and other measures.This issue has the attention of Dr. Paulus and senior leadership at Mission and they have asked for more detailed information. We will need your input and support as we move forward with these plans.Projected PlansDefine our role betterWe can provide the same if not better care than any step-down ICU at Mission. In addition to the nursing care, we have better RT staffing and far better rehab capabilities for these cases then Mission can provide.We have been upgrading our nursing staff on both days and nights with more ICU trained nurses, many from Missions ICU units.Projected Plans cont.We have brought our coding in-house.

I believe we performed the first fecal transplant on an inpatient in western Carolina for recurrent c-diff. It did work within a day. The patient did expire from other conditions, but it did help. Cost is about $500 ($250 for sample and $250 shipping) about 90% success rate. 81%-94% 10-week success rate over vancomycinCost of new c-diff drug (Fidaxomicin) for recurrent c-diff is about $2,215 for the 10-day treatment. Similar cure rates with vancomycin, but 10-week recurrence rate is lower. Other UpdatesProfessional Research Consultants Survey Outcomes2015 Patient Safety and Employee Engagement Survey Asheville Specialty HospitalPrepared by:Professional Research Consultants, Inc.

2015 PRC Hospital Survey on Patient Safety CultureAchieving Excellence from Your Employees Perspective

Asheville Specialty Hospital35Survey MethodologyInternet Survey of 90 Employees at Asheville Specialty Hospital51-Item AHRQ SurveyConducted by PRCInterview Period from April 6 to May 2, 2015Asheville Specialty HospitalGeneral FindingsAsheville Specialty HospitalComparison of Composite Frequenciesof Positive Responses2015ASHAHRQ NormOverall Perceptions of Safety73.3%66%Teamwork Within Units91.9%81%Management Support for Patient Safety86.1%72%Supervisor Expectations & Actions81.3%76%Organizational Learning79.4%73%Frequency of Events Reported74.6%66%Communication About Error72.6%67%Teamwork Across Units72.1%61%Communication Openness62.0%62%Staffing54.5%55%Handoffs & Transitions50.2%47%Nonpunitive Response to Error44.2%44%(By Category)Data in red is significantly lower thanthe AHRQ norm (-5.0 points/more)Data in blue is significantly higher thanthe AHRQ norm (+5.0 points/more)Asheville Specialty HospitalComparison of Composite Frequenciesof Positive Responses (ASH vs. AHRQ Norms)Asheville Specialty HospitalStrengths & Areasfor ImprovementAsheville Specialty Hospital

Survey ItemPositive ResponseASH % ResponsePeople support one another in this unit. (v3)Teamwork Within UnitsAgreement96.7%When a lot of work needs to be done quickly, we work together as a team to get the work done. (v5)Teamwork Within UnitsAgreement95.5%Hospital management provides a work climate that promotes patient safety. (v35)Management Support for Patient SafetyAgreement95.4%In this unit, people treat each other with respect. (v6)Teamwork Within UnitsAgreement92.2%We are actively doing things to improve patient safety. (v8)Organizational LearningAgreement92.1%Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items(Strongly Agree/Agree or Always/Most of the Time)Areas with 75.0% or Higher Disagreement with Negatively Worded Items(Strongly Disagree/Disagree or Never/Rarely)Asheville Specialty Hospital

Survey ItemPositive ResponseASH % ResponseThe actions of hospital management show that patient safety is a top priority. (v42)Management Support for Patient SafetyAgreement89.6%My supervisor/manager overlooks patient safety problems that happen over and over. (v24)Supervisor Expectations & ActionsNon-Agreement89.4%When a mistake is made that could harm the patient, but does not, how often is this reported? (v33)Frequency of Events ReportedAgreement (Always/Most of the Time)85.6%Whenever pressure builds up, my supervisor/ manager wants us to work faster, even if it means taking shortcuts. (v23)Supervisor Expectations & ActionsNon-Agreement84.7%Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items(Strongly Agree/Agree or Always/Most of the Time)Areas with 75.0% or Higher Disagreement with Negatively Worded Items(Strongly Disagree/Disagree or Never/Rarely)Asheville Specialty Hospital

Survey ItemPositive ResponseASH % ResponseWhen one area in this unit gets really busy, others help out. (v13)Teamwork Within UnitsAgreement83.1%Our procedures and systems are good at preventing errors from happening. (v20)Overall Perceptions of SafetyAgreement82.0%In this unit, we discuss ways to prevent errors from happening again. (v29)Communication About ErrorAgreement (Always/Most of the Time)81.6%After we make changes to improve patient safety, we evaluate their effectiveness. (v15)Organizational LearningAgreement79.3%Hospital units work well together to provide the best care for patients. (v44)Teamwork Across UnitsAgreement78.8%Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items(Strongly Agree/Agree or Always/Most of the Time)Areas with 75.0% or Higher Disagreement with Negatively Worded Items(Strongly Disagree/Disagree or Never/Rarely)Asheville Specialty Hospital

Survey ItemPositive ResponseASH % ResponseMy supervisor/manager seriously considers staff suggestions for improving patient safety. (v22)Supervisor Expectations & ActionsAgreement77.7%It is just by chance that more serious mistakes dont happen around here. (v12)Overall Perceptions of SafetyNon-Agreement75.3%Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items(Strongly Agree/Agree or Always/Most of the Time)Areas with 75.0% or Higher Disagreement with Negatively Worded Items(Strongly Disagree/Disagree or Never/Rarely)Asheville Specialty HospitalMain Findings: Areas for ImprovementAreas with 50.0% or Higher Non-Agreement with Positively Worded Items(Strongly Disagree/Disagree Combined with Neither or Never/Rarely)Areas with 50.0% or Higher Agreement with Negatively Worded Items(Strongly Agree/Agree or Always/Most of the Time)

Survey Item

ResponseASH % ResponseAsheville Specialty Hospital responses for this category did not meet or exceed 50.0%

Asheville Specialty HospitalEmployee Engagement

Workforce engagement refers to the extent of workforce commitment, both emotional and intellectual, to accomplishing the work, mission and vision of the organization. In general, members of the workforce feel engaged when they find personal meaning and motivation in their work and when they receive positive interpersonal and workplace support. -Baldrige National CriteriaWork Engagement DefinitionAsheville Specialty Hospital47Emotionally committed Intellectually committed Sense of fulfillment Willingness to invest thoughts and ideas Invested in the success of the hospital systemCharacteristics of EngagementThe most successful organizations with the most loyal customers (or patients) have focused first on an internal culture of engagement, where leadership shows a genuine interest in the growth and development of its people. Paul Spiegelman (2013), Patients Come SecondAsheville Specialty Hospital48Engagement Linked to the Patient ExperienceSupport the mission, vision, and valuesGo beyond the call of dutyInnovating instead of being satisfied with status quoDedicated to providing excellent care to patientsVolunteering and other citizenship behaviorsAdvocating and recruiting within the communityAsheville Specialty HospitalDemographicsAsheville Specialty HospitalSurvey MethodologyInternet Survey of 90 Asheville Specialty Hospital Employees from a List of 161 Eligible EmployeesParticipation Rate: All Staff 55.9%, Without PRN Staff: 73.77% Nursing Participation Rate: 66.25%Non Nursing Participation Rate: 88.10%Surveys Consisted of 40 QuestionsSurveys Completed Between April 6 and May 2, 2015Asheville Specialty HospitalTypically Have Direct Interaction/Contact with PatientsAsheville Specialty HospitalNumber of Hours Worked Per WeekAsheville Specialty HospitalLength of Time in Specialty/ProfessionAsheville Specialty HospitalYears of Servicen=90Asheville Specialty HospitalStaff PositionAsheville Specialty HospitalParticipation by Position

n=86Asheville Specialty HospitalAsheville Specialty Hospital is RespondentsPrimary Place of EmploymentAsheville Specialty HospitalRespondent Has Worked for Mission Hospitalor Any of Its Other Affiliates

Length of Time Since RespondentWorked for Mission Hospital or AffiliatesCurrently Working There33.3% (13)Within One Year23.1% (9)More Than One Year Ago43.6% (17)Asheville Specialty HospitalEmployee Engagement

Asheville Specialty Hospital60Summary of Key Driversof ExcellenceAsheville Specialty HospitalExcellent Percentile RankingsAsheville Specialty Hospital2015 Asheville Specialty Hospital(''Excellent'' Percentile Rankings)2015% Exc50th Percentile% Exc75th Percentile% Exc90th Percentile% Exc17.8%13.9%19.8%32.0%34.4%32.4%44.0%60.6%21.6%21.5%28.6%37.9%31.5%31.3%40.4%49.7%22.5%23.4%30.1%38.3%37.6%41.7%48.3%55.4%18.9%24.4%29.6%39.2%7.9%13.9%18.2%25.1%Asheville Specialty Hospital(''Excellent'' Percentile Rankings)2015 Asheville Specialty HospitalAsheville Specialty HospitalSummary of Key DriversKey Survey AreaKey Driver AspectAs a Place to WorkTraining and Development (#1)Immediate Supervisor (#2)Patient Care (#3)Training and DevelopmentLevel of Training Received to Achieve Career GoalsImmediate SupervisorSupervisor Providing Recognition and PraisePatient CareNurses SkillsCommunicationCommunication Between Management and StaffEmpowermentExtent to Which Your Opinions CountSenior LeadershipLevel of Trust in Leadership of HospitalTotal Compensation PackageBase Salary or Rate of PayAsheville Specialty HospitalAdditional QuestionsAsheville Specialty HospitalEmployees' Likelihood of RecommendingHospital as a Place to WorkAsheville Specialty HospitalEmployees' Likelihood of RecommendingHospital for Medical ServicesAsheville Specialty HospitalEmployees' Perceptions of Cooperation & TeamworkAcross All Mission Facilities in Providing Patient CareA PRC Mean Score and an Excellent Percentile Ranking are not available.Asheville Specialty HospitalOpen-Ended ResponsesAsheville Specialty HospitalWhat one thing do you like best aboutworking at Asheville Specialty Hospital?ResponseNumber of ResponsesCo-Workers24Teamwork16Patients6Scheduling3Autonomy3Supportive Supervisor2Friendly/Caring Staff2Other responses are not shown.Asheville Specialty HospitalIf there was one thing you could change in the work environment at ASH, what would that be?ResponseNumber of ResponsesMore CNAs4Well-Staffed3Better Pay3Nothing3Larger Patient Rooms2More Support Staff2Better Communication Between Units2More Hours2Equal Treatment of Employees2Other responses are not shown.Asheville Specialty HospitalNew Business Old Business - Bylaws Review and Approval - Tabled Executive Session If NeededAdjournment