1. March, 5 2015

2. Call to Order – Charles Ayscue - Board Chair Welcome new member _ Jerry McIntosh Approval of Minutes from Last Meeting Medical Staff Report ASH Committee Reports and Recommendations Quality Assessment Performance Improvement

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

4.  Appointments/Reappointments (Action Required)  New Appointments / Re-Appointments  Clinical Policies & Procedures (No action Q1)  Formulary - MEC approved additions and deletions from ASH Formulary presented for information.  2015 QAPI Plan Approval (Action Required)

5. ASH Committee Reports/Recommendations ASH Committee Minutes: ◦ MEC Minutes – 02/05/15  There is some discussion regarding the qualifications and fit for ASH. MAHEC and ASH are interviewing a resident for the FT position. Concerns were expressed among MEC members. Members advised ASH should search for a candidate with Internal Medicine background and at least 3 yrs. of experience. ◦ QAPI Meeting Minutes –01/28/15  Finalize FY 2015 Department Quality Indicators  Present to Governing Board for approval. ◦ Safety Committee Minutes – 01/22/15  No equipment recalls  Q1 - No Loss of Days to work related injuries.

6. CAUTIs – ASH YTD = 0.41 compared to HCD/Truven trending 1.66 for running average of 8 quarters through 9/30/2013 CLABSIs – ASH YTD = 0.32 compared to HCD/Truven trending 0.6524 for running average of 8 quarters through 9/30/2013 Employee Safety No Equipment Recalls for 3Q. No Loss of Days to Employees Needle Stick = 2 Back Strain =1 Safety/Infection Prevention

7. UR Committee Minutes – 08/01/2014 LOS & HCO Review Medicare Payment Classification/Payer Mix Review No HINN letters were issued Pre-admission assessments & criteria reviews completed within 48 hours. Continued stay criteria reviewed weekly One QIO review Denial – appeal submitted, no response yet Utilization Review

8. PATIENT SATISFACTION Q1 OCT – DEC 2014

19. Quality Benchmarking at ASH Long Term Acute Care Clinical Performance Report 1st Qtr. 2015

21. Hospital Acquired Pressure Ulcers 2015HAPUs Q1 = 3 Total among 2 patients. OCTNOVDEC HAPUs per 1000 patient days (Goal is < 1.00) 0 4.15 0 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

22. Falls Reduction – Falls with Injury Q1=0.00/1,000 patient days. Goal is < 0.475 Reduce CLBSIs/1000 ppd – Q1= 0.83 Goal is <0.65 Reduce CAUTIs/1000 ppd –Q1= 0 Goal is 0 Organization Key Quality Measures *Indicators that met or fell out of range for Q1 recorded in ASH Report Card.

23. Reduce unplanned discharges – Q1= 7.9%Goal is < 9% Oct 4.3% Nov 8.8% Dec 10.5% 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 CMI per month (goal > 1.1) Q1 Avg = 1.03 Oct = 1.03Nov = 1.05 Dec = 1.02 Organization Key Quality Measures * Indicators that met or fell out of range for Q1 recorded in ASH Report Card.

25. 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. Hospital Compliance

26. Risk Management Duplicate grievance for Nov/Dec. Case was reported to NC Div. of Facility Services. ASH anticipates a State Survey is imminent.

27. Financial, Medical Staff, Legislative, Planning

28. Income Statement

29. Income Statement PPD

30. January Results

31. 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. Relocation Update

32. CON Issues Staying on Mission Campus – Submit letter of no review request to CON section – Relocation is exempt from review, regardless of cost. Require prior notification. Relocating in Buncombe County – Develop CON and submit application based on cost, need and access considerations – Can ask for declaratory ruling based on occupancy and immediate impact on bed demand. Relocating Outside Buncombe County – Requires new CON application based on conversion of a portion of existing beds or a self-supporting need methodology

33. CON Issues State took 43 beds away from Mission to approve expansion of NICU. 38 beds were approved for LTCH, current licensed – 34-beds Beds can not go to Mission's Provider Number if LTCH closes. Separate State License will be required. Could change focus of beds/license from LTCH to another program like pediatric hospital, cancer hospital. – This would have to be verified with DHHS

34. Initial Space Review o 5 th Floor Center corridor (where the interim Peds wing was during renovation)  Initial assessment:  This area is fairly “move-in” ready and would be a good option  Only 16 patient rooms, therefore, other space would be needed in conjunction with this area.  We looked at 5 South(Equipment Transport & Storage) as an additional area – This area is wide open on both sides of the corridor and can be converted to patient rooms if necessary. o 5 West (Trauma Services)  Exact number of patient rooms needed (34)  Rooms are small; roughly 140-165sf  This area would not be an “upgrade” for ASH… more of a “like for like” change, but a very feasible option  Also, this option would require some additional space for rehab, conference room & some admin office space o 3 rd Floor South (CDOU)  Nice unit with 19 rooms, therefore, other space would be needed in conjunction with this.  All patient rooms would need a bathroom added… Some rooms may be too small to add a bathroom (~140sf). Some current “dual observation” rooms would be fine to convert to LTACH needs as a bathroom would fit fine. o 3 rd Floor Center corridor  Very “chopped up” layout which would require a lot of renovation to convert to patient rooms

35. 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. Regulatory Update

36. 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 over 17 certified RNs with most being CCRNs spread about evenly on days and nights. Other Updates

37. Current Initiatives Looking at Bundling options for Medicare Advantage We will conduct same survey Mission is doing for Safety & Engagement in March The Joint Commission survey in Fall Developing Peer-to-Peer Guidelines for physicians to use in commercial appeals (Sample in Packet) Working with MAHEC on Marketing, especially ICU units.

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