Thursday, Aug 6, 2015. Review/Approval of 2Q Minutes: 05/07/2015 Medical Staff – Committee as a...

Medical Executive Committee Meeting

Thursday, Aug 6, 2015

Review/Approval of 2Q Minutes: 05/07/2015

Medical Staff – Committee as a Whole

Credentialing

ASH Committee Reports/Recommendations

QAPI/Compliance/Risk Management Update

CEO Report

Other

MEC AGENDA

MEDICAL STAFF Clinical Policies – Provided for information to Medical Staff.

◦ No Policies for Q3

Appointments/Reappointments – Action required.

Pharmacy & Therapeutics – William Rodgers

◦ 6 Adverse Drug Events.

◦ Therapeutic Substitutions

Provided to medical staff for information. (Handouts)

◦ PowerPlan Changes

◦ Formulary Changes- Additions/Deletions

Provided to medical staff for information. (Handouts)

Drug Shortages:◦ Haloperidol (Haldol®) injection◦ Levetiracetam (Keppra®) injection◦ Heparin 25,000 units/250 mL 1/2NS premix◦ Piperacillin/Tazobactam (Zosyn®)◦ Ampicillin/Sulbactam (Unasyn®)◦ Vecuronium (Norcuron®)

ASH Pharmacy Update

ASH Committee Minutes

◦QAPI Meeting Minutes –07/29/15

◦Safety Committee Minutes – 07/29/15

ASH Committee Reports-presented for information

No HINN letters were issued

Pre-admission assessments done within 48 hours

Criteria reviewed within 48 hours of admission

Continued stay criteria reviewed weekly

Utilization Review

CAP requires ASH Respiratory Services to answer the following survey question at each MEC meeting.

Regarding ASH’s ABG Lab services, since August 2013 have there been any concerns regarding quality, timeliness and reliability?

oQualityoTimelinessoReliabilityoOther?

Respiratory/ABG Lab Services

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey

PATIENT SATISFACTION Apr – Jun 2015

Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region

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


0.90.95

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%

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%

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


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


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% 81.8%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

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

Apr May Jun0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

ComplaintsGrievances 0 0 1

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 & Webpage No reports in Q3.

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

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)

Income Statement PPD


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)


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)

Relocation Update5th Floor

• 34 Rooms (Some Outboard Toilets) ( 1:3 or 1:4 Staffing)

• Some (8-10) high obs / ICU Like• Private bathrooms with Dialysis boxes • Pharmacy (600 SF)

• PT / OT Combined (Approx. 400 SF)

• Lab – small, with blood gas machine

• Equipment Storage (Vents, Beds, wheel chairs – Approx. 250 SF)

• Resp. Therapy Work Room

• Conference Room – for 15 – 20 (15 @ 25 SF = 375 SF)

• Conference Room / Report Room– Small for 8 – 10

• Waiting Room (10 People at 25 SF / person = 250 SF)

• Consultation Room (1 @ 90 SF)

• Storage (34 Rooms @ 12 SF / Bed = 408 SF)

• Stretcher / Wheelchair Alcove (80 SF)

• Janitor’s Closet (75 SF)

• Nurse Station / Charting

• Meds Room

• Clean Utility / Clean Linen

• Soiled Utility / Soiled Holding

• Nurse Toilet

• Nurse Locker / Break Room

• Nourishment Room

• Tub Room

• Emergency Treatment Room

• (Required? – 120 SF)

Offices on Unit:• Nurse Manager• Case Manager (2) can be a shared

office• Supervisor Office / Space• Wound Office• Physician On Call and Toilet / Shower -

160 SF Off Unit: (Approx. SF per availability)• Offices – CEO (150 SF)• HR / Adm Assist (110 SF)• DCM (110 SF)• Quality Risk (110 SF)• Infection Control / Employee Health

(Bathroom) 110 SF)• Shared Offices – Rehab, Resp.,

Dietician, Chaplin, Speech (160 SF)• HIM (110 SF)• Admin Coordinator (100 SF)• 3 Liaison, Shared Office – (120 SF)• Accounting 1 – Office – (110 SF)

Total SF Deficiencies: Approx. 3400 SF

Space Room List

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


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 units◦ Medicare Advantage and "site neutral cases

excluded from 25-day LOS rule◦ All cases (LTCH & Site neutral) are included in

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

Regulatory Update – LTCH Cases

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 manged as any other

ACH case

Regulatory Update: Non - LTCH Cases

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

Baseline FY 2016 FY 2017 FY 2018

Cases FY 2015 PaymentsFY 2016

Payments% Change Full Phase-In

% Change

Fully Implemented

% Change

Overall 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 Type

Patient 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.

Plan to Address New Rules LTCH patients

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

◦ Target Step-down units for referrals◦ Working 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

◦ Target two programs◦ Pulmonary/COPD (ALOS 5-9 days)

Looking to be a direct admit option for APA Care Path to meet DRG LOS guidelines

◦ Wound (ALOS 6-10 Days) 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

cases

What has been done already We have upgraded staff capabilities through

hiring and training over the past 6-10 months. This has been more costly then expected with

agency use and orientation expenses being very high.

All nursing agency is now done 45% 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 ongoing◦ Phone interview with physician in Colorado◦ One Local physician may be interested

Use of Locums◦ Dr. Agor had to move closer to home due to

family issues◦ We will be using some different locums over the

next 2 months to see how the recruiting goes.

Other Updates

Asheville Specialty Hospital

Prepared by:Professional Research Consultants, Inc.

◦ 2015 PRC Hospital Survey on Patient Safety Culture◦ Achieving Excellence from Your Employees’ Perspective

Survey Methodology• Internet Survey of 90 Employees at Asheville Specialty

Hospital

• 51-Item AHRQ Survey

• Conducted by PRC

• Interview Period from April 6 to May 2, 2015

General Findings

Nonpunitive Response to Error

Handoffs & Transitions

Staffing

Communication Openness

Teamwork Across Units

Communication About Error

Frequency of Events Reported

Organizational Learning

Supervisor Expectations & Actions

Management Support for Patient Safety

Teamwork Within Units

Overall Perceptions of Safety

0% 20% 40% 60% 80% 100%

44.0%

47.0%

55.0%

62.0%

61.0%

67.0%

66.0%

73.0%

76.0%

72.0%

81.0%

66.0%

44.2%

50.2%

54.5%

62.0%

72.1%

72.6%

74.6%

79.4%

81.3%

86.1%

91.9%

73.3%

ASH AHRQ Norm

Comparison of Composite Frequenciesof Positive Responses

(ASH vs. AHRQ Norms)

Strengths & Areasfor Improvement

Survey ItemPositive

ResponseASH %

Response

People support one another in this unit. (v3)Teamwork Within Units

Agreement 96.7%

When a lot of work needs to be done quickly, we work together as a team to get the work done. (v5)Teamwork Within Units

Agreement 95.5%

Hospital management provides a work climate that promotes patient safety. (v35)Management Support for Patient Safety

Agreement 95.4%

In this unit, people treat each other with respect. (v6)Teamwork Within Units

Agreement 92.2%

We are actively doing things to improve patient safety. (v8)Organizational Learning

Agreement 92.1%

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”)

Survey ItemPositive

ResponseASH %

Response

The actions of hospital management show that patient safety is a top priority. (v42)Management Support for Patient Safety

Agreement 89.6%

My supervisor/manager overlooks patient safety problems that happen over and over. (v24)Supervisor Expectations & Actions

Non-Agreement

89.4%

When a mistake is made that could harm the patient, but does not, how often is this reported? (v33)Frequency of Events Reported

Agreement (“Always/Mos

t 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 & Actions

Non-Agreement

84.7%




Survey ItemPositive

ResponseASH %

Response

When one area in this unit gets really busy, others help out. (v13)Teamwork Within Units

Agreement 83.1%

Our procedures and systems are good at preventing errors from happening. (v20)Overall Perceptions of Safety

Agreement 82.0%

In this unit, we discuss ways to prevent errors from happening again. (v29)Communication About Error

Agreement (“Always/Mos

t of the Time”)

81.6%

After we make changes to improve patient safety, we evaluate their effectiveness. (v15)Organizational Learning

Agreement 79.3%

Hospital units work well together to provide the best care for patients. (v44)Teamwork Across Units

Agreement 78.8%




Survey ItemPositive

ResponseASH %

Response

My supervisor/manager seriously considers staff suggestions for improving patient safety. (v22)Supervisor Expectations & Actions

Agreement 77.7%

It is just by chance that more serious mistakes don’t happen around here. (v12)Overall Perceptions of Safety

Non-Agreement

75.3%




Main 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 %

Response

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

Employee Engagement

Demographics

Survey Methodology• Internet Survey of 90 Asheville Specialty Hospital Employees

from a List of 161 Eligible Employees

• Participation 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 Questions

• Surveys Completed Between April 6 and May 2, 2015

Yes; 85.6%

No; 14.4%

Typically Have Direct Interaction/Contact with Patients

100 Hours/More

80 to 99 Hours

60 to 79 Hours

40 to 59 Hours

20 to 39 Hours

Fewer Than 20 Hours

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

0.0%

1.1%

1.1%

20.2%

68.5%

9.0%

Number of Hours Worked Per Week

21 Years/More

16 to 20 Years

11 to 15 Years

6 to 10 Years

1 to 5 Years

Less Than 1 Year

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

18.9%

11.1%

11.1%

22.2%

31.1%

5.6%

Length of Time in Specialty/Profession

16 Years or More

11-15 Years

6-10 Years

3-5 Years

1-2 Years

Less Than 1 Year

0.0% 10.0% 20.0% 30.0% 40.0% 50.0%

0.0% (0)

8.9% (8)

15.6% (14)

18.9% (17)

25.6% (23)

31.1% (28)

Years of Service

n=90

Other

Tech (e.g. EKG, Lab, Rad)

Unit Assistant/Clerk/Secretary

Administration/Management

Respiratory Therapist

Phys/Occ/Speech Therapist

Patient Care Assistant/Care Partner

Registered Nurse

0.0% 10.0% 20.0% 30.0% 40.0% 50.0%

7.1%

3.4%

4.6%

5.7%

9.2%

12.6%

12.6%

44.8%

Staff Position

Yes, 95.5%(85)

No, 4.5%(4)

Asheville Specialty Hospital is Respondent’sPrimary Place of Employment

Respondent Has Worked for Mission Hospitalor Any of Its Other Affiliates

Yes44.8%(

39)

No55.2% (48)

Length of Time Since RespondentWorked for Mission Hospital or Affiliates

Currently Working There 33.3% (13)

Within One Year 23.1% (9)

More Than One Year Ago 43.6% (17)

Employee Engagement

2015 High Percentile

2015 Percent High

Low

Medium

High

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

84.6

0.337

0.186

0.477

0.337

Summary of Key Driversof Excellence®

“Excellent” Percentile Rankings

2015 Asheville Specialty Hospital(''Excellent'' Percentile Rankings)

Total Compensation Package

Empowerment

Immediate Supervisor

Training and Development

As a Place to Work

Senior Leadership

Patient Care

Communication

0.0 20.0 40.0 60.0 80.0 100.0

19.4

28.8

35.8

44.0

50.4

50.8

54.0

67.0

2015% Exc

50th Percenti

le% Exc

75th Percenti

le% Exc

90th Percenti

le% Exc

17.8% 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%

Total Compensation Package

Empowerment

Senior Leadership

Immediate Supervisor

Training and Development

As a Place to Work

Patient Care

Communication

0.0 20.0 40.0 60.0 80.0 100.0

19.4

28.8

50.5

35.8

44.0

50.4

54.0

67.0

21.4

62.9

69.6

71.8

75.7

75.7

75.8

90.9

Ranked Against First-Time Clients Ranked Against All PRC Clients

(''Excellent'' Percentile Rankings)2015 Asheville Specialty Hospital

Summary of Key Drivers®

Key Survey Area Key Driver® Aspect

As a Place to Work Training and Development (#1)

Immediate Supervisor (#2)

Patient Care (#3)

Training and Development Level of Training Received to Achieve Career Goals

Immediate Supervisor Supervisor Providing Recognition and Praise

Patient Care Nurses’ Skills

Communication Communication Between Management and Staff

Empowerment Extent to Which Your Opinions Count

Senior Leadership Level of Trust in Leadership of Hospital

Total Compensation Package Base Salary or Rate of Pay

Additional Questions

ASH Exc Percentile

PRC Mean Score

ASH Mean Score

Poor

Fair

Good

Very Good

Excellent

0.0 20.0 40.0 60.0 80.0 100.0

48.9

77.6

80.2

0

5.7

21.6

38.6

34.1

Employees' Likelihood of RecommendingHospital as a Place to Work

ASH Exc Percentile

PRC Mean Score

ASH Mean Score

Poor

Fair

Good

Very Good

Excellent

0.0 20.0 40.0 60.0 80.0 100.0

66

1.2

17.9

41.7

28.6

10.7

Employees' Perceptions of Cooperation & Teamwork

Across All Mission Facilities in Providing Patient Care

A PRC Mean Score and an “Excellent” Percentile Ranking are not available.

Open-Ended Responses

“What one thing do you like best aboutworking at Asheville Specialty Hospital?”

ResponseNumber of Responses

Co-Workers 24

Teamwork 16

Patients 6

Scheduling 3

Autonomy 3

Supportive Supervisor 2

Friendly/Caring Staff 2

Other responses are not shown.

“If there was one thing you could change in the work environment at ASH, what would that be?”

ResponseNumber of Responses

More CNAs 4

Well-Staffed 3

Better Pay 3

Nothing 3

Larger Patient Rooms 2

More Support Staff 2

Better Communication Between Units 2

More Hours 2

Equal Treatment of Employees 2

Other responses are not shown.

Old Business New Business Executive Session

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Adjournment

Thursday, Aug 6, 2015. Review/Approval of 2Q Minutes: 05/07/2015 Medical Staff – Committee as a...

Documents

Transcript of Thursday, Aug 6, 2015. Review/Approval of 2Q Minutes: 05/07/2015 Medical Staff – Committee as a...