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

 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 Committee Minutes ◦ QAPI Meeting Minutes –07/29/15 ◦ Safety Committee Minutes – 07/29/15

 No HINN letters were issued  Pre-admission assessments done within 48 hours  Criteria reviewed within 48 hours of admission  Continued stay criteria reviewed weekly

 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? o Quality o Timeliness o Reliability o Other?

PATIENT SATISFACTION Apr – Jun 2015

HAPUs per 1,000 Patient Days OCT NOV DEC JAN FEB MAR APR MAY JUN OCT NOV DEC JAN FEB MAR APR MAY JUN HAPUs -- Total # # of Patients with HAPUs

 Falls Reduction – Falls with Injury 0.00/1,000 patient days. Green Condition. Goal is <  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 3 rd review of gap analysis. ASH Leadership continues to implement Tracer analysis.

Financial, Medical Staff, Legislative, Planning

5th 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 – SF = 375 SF) Conference Room / Report Room– Small for 8 – 10 Waiting Room (10 People at 25 SF / person = 250 SF) Consultation Room 90 SF) Storage (34 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 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 SF Space Room List

Existing Conditions

Scenar io 1 Pros: 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

Scenar io 2 Pros: Observation bed Configuration Patient Unit Configuration Safety and Security Cons: Unit Visibility / Nurse Station Division Lack of Storage No Emergency Treatment Space

Scenar io 3 Pros: Observation bed Configuration Patient Unit Configuration Safety and Security Cons: No Pharmacy Lack of Storage No Emergency Treatment Space

 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)

 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

Baseline FY 2016FY 2017FY 2018 CasesFY 2015 Payments FY 2016 Payments % ChangeFull Phase-In % Change Fully Implemented % Change Overall 133,356 $5,435,199,413$5,301,188, %$4,966,896, %4,357,719, % NALTH Membership Member15,484 $665,665,604$635,995, %$608,734, %$547,291, % Non-Member117,872 $4,769,533,809$4,665,193, %$4,358,162, %$3,810,428, % Location Type Urban127,693 $5,233,120,440$5,112,670, %$4,796,799, %$4,218,572, % Rural5,663 $202,078,973$188,517, %$170,097, %$139,146, % Ownership Type For-Profit113,816 $4,611,557,857$4,508,041, %$4,203,992, %$3,668,859, % Non-Profit17,319 $721,784,466$693,226, %$665,755, %$599,057, % Bed size 0 to 24 Beds2,523 $92,699,671$89,643, %$82,683, %$69,955, % 25 to 49 Beds45,031 $1,775,179,757$1,707,076, %$1,611,685, %$1,414,009, % 50 to 74 Beds37,541 $1,564,340,585$1,510,823, %$1,427,953, %$1,255,937, % 75 to 124 Beds22,002 $945,426,815$940,717, %$877,544, %$783,089, % 125 to 199 Beds14,887 $589,244,925$586,202, %$540,224, %$463,273, % 200 or more Beds11,372 $468,307,660$466,724, %$426,804, %$371,454, % Census Region South Atlantic18,382 $777,156,317$767,330, %$734,430, %$672,463, % Asheville Specialty Hospital261 $ 10,063,201 $ 9,545, % $ 9,545, % $ 8,814, % FY 2016 & 2017 is a blended transition rate between the LTCH rates and IPPS rates is the fully implemented new rates.

Patient CategoryCasesFY 2015 PaymentsFY 2016 Payments Percent Difference Non-Qualifying74 $ 2,784,738 $ 2,258, % Regular LTCH-PPS131 $ 5,996,813 $ 6,078,7571.4% SSO Case38 $ 846,250 $ 872,5673.1% SSO Non-Qualifying18 $ 435,399 $ 334, % Total261 $ 10,063,201 $ 9,545, % 1. Non-LTCH cases is where the biggest change will occur. 2.LTCH case payments actually increase 3.Assumes no changes in patient selection, CMI and LOS.

 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.

 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

 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.

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

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

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%

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/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 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/Mos t 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%

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%

Survey ItemResponse ASH % Response Asheville Specialty Hospital responses for this category did not meet or exceed 50.0%

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

Typically Have Direct Interaction/Contact with Patients

Number of Hours Worked Per Week

Length of Time in Specialty/Profession

Years of Service n=90

Staff Position

Asheville Specialty Hospital is Respondent’s Primary Place of Employment

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)

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%

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

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

Employees' Likelihood of Recommending Hospital as a Place to Work

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.

“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.

“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.

 Old Business  New Business  Executive Session