Thursday, Feb. 5, 2015

 Review/Approval of 4Q Minutes: 11/06/2014  Medical Staff – Committee as a Whole  Credentialing  ASH Committee Reports/Recommendations  QAPI/Compliance/Risk Management Update  CEO Report  Other

 Appointments/Reappointments – Action required  Clinical Policies –None for Q1  Pharmacy & Therapeutics – William ◦ Medical Reconciliation Update – 97% for Q1. Goal>95% 0 Adverse Drug Events. ◦ Formulary Changes- Action Required ◦ Mission Drug Shortages- Pharmacy to contact physicians for suitable alternatives. ◦ ASH Shortages : Ketorolac injection, Magnesium 2g premixed injection

 ASH Committee Minutes ◦ QAPI Meeting Minutes –01/28/15 ◦ Safety Committee Minutes – 01/22/15

 No HINN letters were issued  Pre-admission assessments done within 48 hours  Criteria reviewed within 48 hours of admission  Continued stay criteria reviewed weekly  One QIO review Denial – appeal submitted, no response yet

 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 OCT – DEC 2014

MONTHAPRMAYJUNJULAUGSEPTYTD # CALENDAR DAYS HAPUs -- Total # # of Patients with HAPUs We have gone from 5.5 HAPU/100 discharges in 2013 to 2.0/100 in HAPUs Q1 = 3 Total among 2 patients. WOUND MANAGEMENT ** Detail Added Post Mtg. Presentation OCTNOVDEC HAPUs -- Total #030 # of Patients with HAPUs020 # of Stage 2020 # of Stage 3000 # of Stage 4000 # Unstageable: Non-Removable Dressing000 # Unstageable: Slough/Eschar010 # Unstageable: Deep Tissue Injury000 HAPUs -- Total # Healed prior to D/C000 HAPUs -- Total # Not Healed prior to D/C030

GOAL < or = to 10.50

 Falls Reduction – Falls with Injury 0.00/1,000 patient days. Green Condition. Goal is <  Reduce unplanned discharges – Oct 4.3% Nov 8.8% Dec 10.5% Goal is < 9%  Reduce CLBSIs – Oct- 0 Nov Dec- 0 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 Goal is >98.9 Key Quality Measures Q1

 Compliance Program  LTCH-Quality Reporting Program  Compliant with CMS transmissions for fiscal year.  ASHiCARE/ASH AlertLine & Webpage  No reports in Q1. Recent staff educ. on Alert line.  Annual Education-FY’15  Compliance Program Module- Sept ‘15  Accountability Statements- Sept ‘15  Survey Readiness: Under consulting contract with Joint Commission Resources. Start Date Jan.1, 2015  Target Joint Commission Accreditation Survey Oct, 2015.

Financial, Medical Staff, Legislative, Planning

 Met with Mission’s 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.  We are now looking at all space options on the main campus, including, if needed building out part of the top floor which is open right now.  Value and cost will be the primary driver of the final decision.

 New congress means new legislative proposals  There is a lot of discussion about post acute care bundling in Congress, CMS, and MedPac  New 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.

 MAHEC has taken over the hospitalist program on January 1 st.  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 Director  We now have hired over 17 certified RNs with most being CCRNs spread about evenly on days and nights.

 Old Business  New Business  Executive Session if needed