May 21, 2015

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

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

 Appointments/Reappointments  New 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.  Appointments/Reappointments  New 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.

ASH Committee Reports/Recommendations ASH 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. Tsai’s decision will be made in our 3 rd quarter meeting.  May need to consider a headhunter ◦ QAPI Meeting Minutes –04/29/15  Result of Grievance Investigation by NC Dept. of Health Service Regulation 4 complaint allegations were found unsubstantiated. No deficiencies cited. ◦ Safety Committee Minutes – 04/23/15  2Q Employee injuries: Jan-2, Feb-3, March-0 No Loss of Days Q2  Life Safety- Decrease in proper use of PPE  Security, Equip. Recalls, & Safety Educ.- No issues to report.

UR Committee Minutes –04/24/2015 LOS & 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 Review We 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 Review

PATIENT SATISFACTION Jan – Mar 2015

Response rate improving

ASH CMI Goal > 1.1

Hospital 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 # # of Patients with HAPUs OCTNOVDECJANFEBMAR

Risk Management No grievances for Q2

Falls Reduction - Q1 = 0 Q2 = 0. Goal is < Reduce unplanned discharges – Q1= 7.9% Q2= 8.3% Goal is <10% per Bed Day Reduce CLABSIs – Q1 = 0.83 reduced to 0 in Q2. Goal is <0.65 Increase compliance with blood administration vital sign compliance. Q1 = 100% compliant on hourly checks: Up to 100% compliant on end of transfusion. Q2 = 99% for same indicators. Goal is >98.9 Core Quality Measures Q2

Compliance Program LTCH-Quality Reporting Program Compliant with CMS transmissions for fiscal year. ASHiCARE/ASH AlertLine & Webpage No reports in Q2. Recent staff educ. on Alert line. Annual Education-FY’15 Compliance Program Module- Sept ‘15 Accountability Statements- Sept ‘15 Survey Readiness: Result of Grievance Investigation by NC Dept. of Health Service Regulation 4 complaint allegations were found unsubstantiated. No deficiencies cited including areas of recommendation from last survey. Joint Commission Accreditation – Met with Consultant for 2 nd review of gap analysis. ASH Leadership continues to implement standard’s gap analysis. Hospital Compliance

Financial, Medical Staff, Legislative, Planning

Income Statement Q1Q2 YTD Actual BudgetVarianceActualBudgetVariance Income Net Operating Revenue$3,142,342 $3,495,357$3,643,414($61,849)$6,637,699$7,264,769($627,070) Expenses Salaries$1,430,856$1,533,997$1,514,819($19,178)$2,964,853$3,020,465$55,612 Contract Labor$139,202$297,133$78,419($218,714)$436,335$156,364($279,971) Benefits$354,421$392,621$406,623$14,002$747,042$810,658$63,616 Professional Fees$15,100$19,802$28,722$8,920$34,902$57,382$22,480 Medical Supplies$322,093$382,776$419,575$36,799$704,869$801,082$96,213 Purchased Services$641,739$622,869$740,907$118,038$1,264,608$1,558,179$293,571 Utilities$2,553$5,045$5,371$326$7,598$8,403$805 Other Expenses$244,353$299,069$316,851$17,782$543,422$592,860$49,438 Depreciation & Amort$27,032$23,404$23,887$483$50,436$52,995$2,559 Interest Expense$0 Total Expenses$3,177,349$3,576,716$3,535,180($41,536)$6,754,065$7,058,400$304,335 Net Income($35,007)($114,561)$51,514($63,047)($116,363)$206,370($322,733) April had a Net Income of $112,000 so YTD we are now at about a $4,000 loss.

Income Statement PPD Q1Q2 YTD Statistics Actual BudgetVarianceActualBudgetVariance Patient Days2,2372,5082,477314,7454,939(194) ADC (1.0) Q1Q2 YTD Actual BudgetVarianceActualBudgetVariance Net Revenue$1,405$1,394$1,471($77)$1,399$1,471($72) Expenses Salaries$640$612 ($0)$625$612($13) Contract Labor$62$118$32($87)$92$32($60) Benefits$158$157$164$8$157$164$7 Professional Fees$7$8$12$4$7$12$4 Medical Supplies$48$153$169$17$149$162$14 Purchased Services$287$248$299$51$267$315$49 Utilities$1$2 $0$2 $0 Other Expenses$109$119$128$9$115$120$6 Depreciation & Amort$12$9$10$0$11 $0 Interest Expense$0 Total Expenses$1,420$1,426$1,427$1$1,423$1,429$6 Net Income($16)($46)$21($66)($25)$42($66)

No decisions made yet Mission is finalizing what is going where in the new tower and existing building One space being considered is 5 floor Central area where peds used to be and The south wing where there is storage, but used to be patient rooms Relocation Update

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

The new rules narrows the focus to a few groups that deal primarily with ICU cases: APA, Trauma, Neuro, CVICU, Cardiology, General Surgery There 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 days, and 544 cases 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. Situation

We 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 ID’s 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 Plans

Define our role better We 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 Mission’s 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 vancomycin Cost 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 Updates

2015 Patient Safety and Employee Engagement Survey

Asheville Specialty Hospital Prepared by: Professional Research Consultants, Inc PRC Hospital Survey on Patient Safety Culture Achieving Excellence from Your Employees’ Perspective

Asheville Specialty Hospital 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

Asheville Specialty Hospital General Findings

Asheville Specialty Hospital Comparison of Composite Frequencies of Positive Responses 2015 ASH AHRQ Norm Overall 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 than the AHRQ norm (-5.0 points/more) Data in blue is significantly higher than the AHRQ norm (+5.0 points/more)

Asheville Specialty Hospital Comparison of Composite Frequencies of Positive Responses (ASH vs. AHRQ Norms)

Asheville Specialty Hospital Strengths & Areas for Improvement

Asheville Specialty Hospital Survey Item Positive Response ASH % Response People support one another in this unit. (v3) Teamwork Within Units Agreement96.7% 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 Agreement95.5% Hospital management provides a work climate that promotes patient safety. (v35) Management Support for Patient Safety Agreement95.4% In this unit, people treat each other with respect. (v6) Teamwork Within Units Agreement92.2% We are actively doing things to improve patient safety. (v8) Organizational Learning Agreement92.1% Main Findings: Strengths Areas 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 Item Positive Response ASH % Response The actions of hospital management show that patient safety is a top priority. (v42) Management Support for Patient Safety Agreement89.6% 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/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 & Actions Non- Agreement 84.7% Main Findings: Strengths Areas 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 Item Positive Response ASH % Response When one area in this unit gets really busy, others help out. (v13) Teamwork Within Units Agreement83.1% Our procedures and systems are good at preventing errors from happening. (v20) Overall Perceptions of Safety Agreement82.0% In this unit, we discuss ways to prevent errors from happening again. (v29) Communication About Error Agreement (“Always/Most of the Time”) 81.6% After we make changes to improve patient safety, we evaluate their effectiveness. (v15) Organizational Learning Agreement79.3% Hospital units work well together to provide the best care for patients. (v44) Teamwork Across Units Agreement78.8% Main Findings: Strengths Areas 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 Item Positive Response ASH % Response My supervisor/manager seriously considers staff suggestions for improving patient safety. (v22) Supervisor Expectations & Actions Agreement77.7% 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: Strengths Areas 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 Main Findings: Areas for Improvement Areas 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 ItemResponse ASH % Response Asheville Specialty Hospital responses for this category did not meet or exceed 50.0%

Asheville Specialty Hospital “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 Criteria Work Engagement Definition

Asheville Specialty Hospital Emotionally committed Intellectually committed Sense of fulfillment Willingness to invest thoughts and ideas Invested in the success of the hospital system Characteristics of Engagement “The 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 Second

Asheville Specialty Hospital Engagement Linked to the Patient Experience Support the mission, vision, and values Go beyond the call of duty Innovating instead of being satisfied with status quo Dedicated to providing excellent care to patients Volunteering and other citizenship behaviors Advocating and recruiting within the community

Asheville Specialty Hospital Demographics

Asheville Specialty Hospital 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

Asheville Specialty Hospital Typically Have Direct Interaction/Contact with Patients

Asheville Specialty Hospital Number of Hours Worked Per Week

Asheville Specialty Hospital Length of Time in Specialty/Profession

Asheville Specialty Hospital Years of Service n=90

Asheville Specialty Hospital Staff Position

Asheville Specialty Hospital Participation by Position n=86

Asheville Specialty Hospital Asheville Specialty Hospital is Respondent’s Primary Place of Employment

Asheville Specialty Hospital Respondent Has Worked for Mission Hospital or Any of Its Other Affiliates Length of Time Since Respondent Worked for Mission Hospital or Affiliates Currently Working There33.3% (13) Within One Year23.1% (9) More Than One Year Ago43.6% (17)

Asheville Specialty Hospital Employee Engagement

Asheville Specialty Hospital Summary of Key Drivers of Excellence ®

Asheville Specialty Hospital “Excellent” Percentile Rankings

Asheville Specialty Hospital 2015 Asheville Specialty Hospital (''Excellent'' Percentile Rankings) 2015 % Exc 50th Percentile % Exc 75th Percentile % Exc 90th Percentile % 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%

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

Asheville Specialty Hospital Summary of Key Drivers ® Key Survey AreaKey Driver ® Aspect As a Place to WorkTraining and Development (#1) Immediate Supervisor (#2) Patient Care (#3) Training and DevelopmentLevel of Training Received to Achieve Career Goals Immediate SupervisorSupervisor Providing Recognition and Praise Patient CareNurses’ Skills CommunicationCommunication Between Management and Staff EmpowermentExtent to Which Your Opinions Count Senior LeadershipLevel of Trust in Leadership of Hospital Total Compensation PackageBase Salary or Rate of Pay

Asheville Specialty Hospital Additional Questions

Asheville Specialty Hospital Employees' Likelihood of Recommending Hospital as a Place to Work

Asheville Specialty Hospital Employees' Likelihood of Recommending Hospital for Medical Services

Asheville Specialty Hospital 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.

Asheville Specialty Hospital Open-Ended Responses

Asheville Specialty Hospital “What one thing do you like best about working at Asheville Specialty Hospital?” Response Number of Responses Co-Workers24 Teamwork16 Patients6 Scheduling3 Autonomy3 Supportive Supervisor2 Friendly/Caring Staff2 Other responses are not shown.

Asheville Specialty Hospital “If there was one thing you could change in the work environment at ASH, what would that be?” Response Number of Responses More CNAs4 Well-Staffed3 Better Pay3 Nothing3 Larger Patient Rooms2 More Support Staff2 Better Communication Between Units2 More Hours2 Equal Treatment of Employees2 Other responses are not shown.

New Business – Old Business - Bylaws Review and Approval - Tabled Executive Session – If Needed Adjournment