1. health and fitness

Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
1:00 p.m.
Agenda
Board Members
Terence McMahon, Chair, District 5
Mark Dewane, Vice Chair, District 2
Mary A. Harden, R.N., Director, District 1
Susan Gerard, Director, District 3
Elbert Bicknell, Director, District 4
AGENDA – Finance/Quality
Meeting
Maricopa County Special Health Care District
Board of Directors
President & Chief Executive Officer
Stephen A. Purves, FACHE
Clerk of the Board
Melanie Talbot
Meeting Location
Maricopa Medical Center
Administration Building
Auditoriums 1 and 2
2601 E. Roosevelt Street
Phoenix, AZ 85008
Mission Statement
Maricopa Integrated Health System (MIHS) is Maricopa County’s
only public teaching hospital and health care system. We are
committed to providing safe, comprehensive, high-quality physical
and behavioral health care in a patient-centric environment to the
communities we serve; and expanding the community’s available
pool of physicians and other health care professionals by offering
excellent academic programs.
Welcome
We welcome your interest and hope you will often attend Maricopa County Special Health Care District
Board of Directors meetings. Democracy cannot endure without an informed and involved electorate.
The Board of Directors is the governing body for Maricopa Integrated Health System. Each member
represents one of the five districts in Maricopa Country. Members of the Board are public officials,
elected by the voters of Maricopa Country. The Board of Directors sets policy and the President & Chief
Executive Officer, who is hired by the Board, directs staff to carry out the policies.
Meetings
The Board of Directors generally holds meetings at 1:00 p.m. on the second and fourth Wednesdays of
the month. Please visit http://mihs.org/governing-bodies/bod-calendar or call the District Clerk at 602344-5177 to confirm the date of the next regular meeting.
The meeting may appear to proceed quickly, with important decisions reached with little discussion.
However, the agenda and meeting material is available to the Board of Directors prior to the meeting,
giving them the opportunity to study every item and to ask questions of District staff members. If
no additional facts are presented at the meeting, action may be taken without further discussion.
How Citizens Can Participate
The Board of Directors values citizen comments and input. Citizens may appear before the Board of
Directors to express their views. Any member of the public will be given three minutes to address the
Board on issues of interest or concern to them. If you wish to address the Board, please complete a
Speaker’s Slip and deliver it to the Clerk of the Board. If you have anything that you wish distributed to
the Board and included in the official record, please hand it to the Clerk who will distribute the information
to the Board Members and Maricopa Integrated Health System Senior Staff.
Speakers will be called in the order in which requests to speak are received. Your name will be called
when the Call to Public has been opened or when the Board reaches the agenda item which you wish to
speak. As mandated by the Arizona Open Meeting Law, officials may not discuss items not on the
agenda, but may direct staff to follow-up with the citizen.
Agendas are available within 24 hours of each meeting in the Office of the Board, Maricopa Medical Center, Administration Bldg, 2nd Floor 2601 E. Roosevelt, Phoenix, AZ
85008, Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. and on the internet at http://mihs.org/governing-bodies/bod-calendar. Accommodations for
Individuals with Disabilities, alternative format materials, sign language interpretation, and assistive listening devices are available upon 72 hours advance notice through the
Office of the Board, Maricopa Medical Center, Administration Bldg, 2nd Floor 2601 E. Roosevelt, Phoenix, Arizona 85008, (602) 344- 5177. To the extent possible, additional
reasonable accommodations will be made available within the time constraints of the request.
3/19/2015 8:43 AM
When Speaking at the Podium
Please state your name and the city in which you reside. If you reside in Maricopa County, please state
the District you live in.
If you have an individual concern involving the District, you are encouraged to contact your District Board
member at 602-344-1241. We will do everything possible to be responsive to your individual requests.
Public Rules of Conduct
The Board Chair shall keep control of the meeting and require the speakers and audience to refrain from
abusive or profane remarks, disruptive outbursts, applause, protests, or other conduct which disrupts or
interferes with the orderly conduct of the business of the meeting. Personal attacks on Board members,
staff, or members of the public are not allowed. It is inappropriate to utilize the Call to Public or other
agenda item for purposes of making political speeches, including threats of political action. Engaging in
such conduct, and failing to cease such conduct upon request of the Board Chair will be grounds for
ending a speaker’s time at the podium or for removal of any disruptive person from the meeting room, at
the direction of the Board Chair.
Elbert Bicknell
602-344-1241
[email protected]
Susan Gerard
602-344-1241
[email protected]
Mark Dewane
602-344-1241
[email protected]
Mary A. Harden, R.N.
602-344-1241
[email protected]
2
Terence McMahon
602-344-1241
[email protected]
 Maricopa Medical Center  Administration Building  Auditoriums 1 and 2 
 2601 E. Roosevelt  Phoenix, AZ 85008 
Wednesday, March 25, 2015
1:00 p.m.
One or more of the members of the Board of Directors of the Maricopa County Special Health Care District may attend
telephonically. Board members attending telephonically will be announced at the meeting.
Pursuant to A.R.S. § 38-431.03(A)(3), or any applicable and relevant state or federal law, the Board may vote to recess into an
Executive Session for the purpose of obtaining legal advice from the Board’s attorney or attorneys on any matter listed on the
agenda. The Board also may wish to discuss any items listed for Executive Session discussion in General Session, or the Board
may wish to take action in General Session on any items listed for discussion in Executive Session. To do so, the Board will recess
Executive Session on any particular item and reconvene General Session to discuss that item or to take action on such item.
Call to Order
Roll Call
Pledge of Allegiance
Call to the Public
This is the time for the public to comment. The Board of Directors may not discuss items that are not specifically identified on the
agenda. Therefore, pursuant to A.R.S. § 38-431.01(H), action taken as a result of public comment will be limited to directing staff to
study the matter, responding to any criticism or scheduling a matter for further consideration and decision at a later date.
ITEMS MAY BE DISCUSSED IN A DIFFERENT SEQUENCE
General Session, Presentation, Discussion and Action:
1:05
1.
Motion to Recess General Session and Convene in Executive Session
Terence M. McMahon, Chairman, Board of Directors
Executive Session:
1:05
E-1
Legal Advice; Contracts Subject to Negotiations; Records Exempt by Law from Public Inspection;
1
A.R.S. § 38-431.03(A)(3); A.R.S. § 38-431.03(A)(4); and A.R.S. § 38-431.03(A)(2) : Maricopa
County Special Health Care District d.b.a. Maricopa Integrated Health System strategic plan
portfolio, options, implementation, initiatives and goals, including resources, clinical, behavioral,
financial, operational, business, and service line strategy options going forward 30 min
1
Exemptions based upon A.R.S. § 48-5541.01(M)(4) (c) and (d) including proprietary information provided by a non-governmental source,
records or other matters, the disclosure of which would cause demonstrable and material harm and would place the district at a competitive
disadvantage in the marketplace; or violate any exception, privilege or confidentiality granted or imposed by statute or common law.
Recess Executive Session and Reconvene in General Session
3
General Session, Presentation, Discussion and Action:
1:35
2.
Board Education - Cost Accounting 35 min
Kathy Benaquista, MIHS, Interim Chief Financial Officer
2:10
3.
Approval of Consent Agenda: 15 min
Note: Approval of contracts, minutes, IGA’s, proclamations, etc. Any matter on the Consent Agenda will be removed from the Consent Agenda and discussed as a
regular agenda item upon the request of any Board member.
a.
b.
Contracts:
i.
Approve Amendment #1 to the Intergovernmental Agreement with Arizona
Department of Health Services (90-14-228-1-01) to continue support for the Biorepository database.
ii.
Approve Amendment #3 to the contract with Ernst & Young, LLP (90-12-152-103) to extend the contract for one additional year to provide external auditing
services including financial statement and program audits.
iii.
Approve a new contract with UMR, Inc. (90-15-145-1) to provide administrative
services related to MIHS employee health benefit claims administration. Initial
term of the contract is for three years from July 1, 2014 through June 30, 2017.
iv.
Approve an increase to the Not-To-Exceed amount by an additional $500,000 to
the contract with Leidos Health, LLC (90-11-211-2-18) to support the continued
effort of Leidos Health, LLC in the performance of Revenue Cycle and Patient
Financial Services optimization. This increase also includes funding for additional
services that may be required by other MIHS departments to fulfill resource
needs.
Medical Staff:
i.
Approve MIHS Medical Staff Appointments, FPPEs, Reappointments, Change of
Privileges/Status, Waiver Requests, and Resignations for March 2015
ii.
Approve MIHS Allied Health Professional Staff Appointments, FPPEs,
Reappointments, and Resignations for March 2015
iii.
Approve Proposed Revisions to the Peer Review Policy
iv.
Approve Proposed Revisions to the Medical Staff Organizational Manual
_________________________End of Consent Agenda________________________
2:25
4.
Quarterly Patient Satisfaction Report 15 min
Sherry Stotler, R.N., MIHS, Chief Nursing Officer
2:40
5.
Discuss Uncompensated Care Report 20 min
Kathy Benaquista, MIHS, Interim Chief Financial Officer
3:00
6.
Report on the Affordable Care Act’s (ACA) Impact on Maricopa Integrated Health System;
Meritus Contribution Margin to Maricopa Integrated Health System 15 min
Kathy Benaquista, MIHS, Interim Chief Financial Officer
4
General Session, Presentation, Discussion and Action (cont.):
3:15
7.
Discussion on Maricopa Integrated Health System’s Payer/Revenue Contracts 15 min
Michael Zenobi, MIHS, Vice President, Managed Care Operations
3:30
8.
Discuss and Review February 2015 Maricopa Integrated Health System Key Indicator
Dashboards 15 min
Kathy Benaquista, MIHS, Interim Chief Financial Officer
Sherry Stotler, R.N., MIHS, Chief Nursing Officer
William F. Vanaskie, MIHS, Chief Operating Officer
3:45
9.
Concluding Items 15 min
a.
Old Business:
January 28, 2015 Formal Meeting
Chief Financial Officer Report
• On March 25, 2015 Agenda, Financial Assistance, Structure, Philosophy and
Implementation
•
Please provide the Board payer mix information every quarter (beginning in April
2015)
•
Please add KRONOS to the Strategic and Capital Improvements return on
investment Summary (separate out from EAS); initial review should occur July 2015;
one year after implementation
•
At April 22, 2015 meeting, please provide a progress report on opportunities for
improvement with Regional Behavioral Health Authority/MMIC discharge process
Dashboards
• Please add Patient Satisfaction Survey Return Rate to Quality Dashboard (numbers
will be available by March 25 meeting)
March 11, 2015 Formal Meeting
Contracts
• Please have not only revenues but expenses when submitting contracts/IGAs/Grants,
for Board approval
Margin Improvements/Revenue Cycle Improvements
• When reporting margin improvements, please separate out savings by one-time or
recurring/annualized
•
When reporting revenue cycle improvements, please add the overall liquidity
percentage (VBO cash collection compared to goal)
Bond Issuance
• When the time is appropriate, please provide the Board with a list of needs/proposal
of projects along with accompanying Board resolution to issue bonds.
Chief Financial Officer Report/Financials
• On financial statements, please use the terms Charity Care and Bad Debt instead of
Self-Pay and Bad Debt. Also, please separate out the two instead of combining into
one number
•
On March 25, 2015 agenda, please provide Board education on Cost Accounting
5
General Session, Presentation, Discussion and Action (cont.):
3:45
9.
Concluding Items (cont.)
a.
Old Business (cont.):
March 11, 2015 Formal Meeting (cont.)
Chief Financial Officer Report/Financials (cont.)
• On the Strategic Initiative/Capital Improvements spreadsheet, please add a column
with the final amount of project including how much over/under.
•
On March 25, 2015 agenda, have an item on impact the ACA has had on Maricopa
Integrated Health System; Meritus contribution margin to MIHS
b.
Board Member Requests for Future Agenda Items or Reports
c.
Comments
i.
Chairman and Member Closing Comment
a. Committee Reports
b. Summary of Educational Sessions
ii.
President & Chief Executive Officer Summary of Current Events
Adjourn
6
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 1.
No Handout
Recess General Session
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 2.
Board Education
Cost Accounting
03.25.15
Kathy Benaquista, Interim Chief Financial Officer
Overview
• Cost accounting or cost allocation is the process
where all organizational costs are allocated down to
the individual charge code level.
• Once cost is determined at the charge code level it is
first aggregated at the patient level then may be
grouped according to service or product lines, payor
contacts etc.
2
Allocation Methodology
Overhead
Departments
• Registration and admitting, billing and collections, coding
etc.
• Administration, dietary, finance, clinical support etc.
Overhead Pools
Patient Service
Departments
• Clinics, inpatient nursing units, laboratory, radiology etc.
• Office visit, room and board, supplies, cat scan, MRI etc.
Charge Codes
Patient Episodes
of Care
• Service or product lines
• Payor contracts
• Patient types
3
Overhead Departments – Indirect Cost
• Overhead pools include all departments that are not
directly involved in patient care.
• Costs from the Overhead Departments are allocated to the
patient care areas using an allocation statistic such as total
expenses or total patient revenue.
• Overhead departments are combined together into
“overhead pools” because they use the same allocation
statistic.
4
Overhead (Indirect) Pools
• MIHS uses the following Overhead Pools:
– ADMINISTRATION (Hospital Administration, Nursing
Administration, Compliance, Legal, etc.)
– DIETARY SERVICES
– FINANCE/PURCHASING/CONTRACTING
– CLINICAL SUPPORT (Case Management, Quality Management,
etc.)
– HUMAN RESOURCES
– INFORMATION TECHNOLOGY
– INTEREST AND CAPITAL
– FACILITIES SERVICES
– LINEN SERVICES
– ENVIRONMENTAL SERVICES
– REVENUE CYCLE (Billing & Collections, Coding, Registration &
Admitting)
5
Patient Service Department – “Direct
Cost”
• These are the departments that provide direct care to
patients. They include the clinics and inpatient nursing units
as well as ancillary departments such as the laboratory,
radiology and pharmacy.
• Patient service departments receive cost from the overhead
pools.
• Patient service departments generate charge codes that
represent the care given to patients.
6
Patient Service Department – “Direct
Cost”
• All of the patient service department’s direct cost plus their
allocated overhead or indirect cost, is allocated down to
these charge codes.
• Each charge code absorbs their share of direct and indirect
costs based on their relative % of the total charges
generated by the patient service department or what is
commonly referred to as the cost to charge ratio or CCR.
7
Patient Episodes of Care
• Once cost is determined at the charge level, that cost is
aggregated to determine the cost of each unique patient
episode of care such as an inpatient stay, an observation
stay, an ED visit, a clinic visit, an outpatient procedure or an
outpatient surgery.
• Patient episodes of care can then be grouped in various
ways depending upon how management wants to view the
data. Examples include:
– Service or product lines
– Payor Contracts
– Type of Patient
8
Report Groupings
• A service or product line may be defined in many different
ways. MIHS groups patients by diagnosis codes:
– Inpatients are grouped by DRG (Diagnostic Related
Group)
• DRG XXX – IP Trauma
• DRG XXX – IP General Surgery
– Outpatients are grouped by ICD-9 (International
Classification of Diseases, version 9) principal diagnosis
code
• ICD9 XXX – Op Oncology
• ICD9 XXX – OP Dermatology
• MIHS uses the service or product line grouping utilized by
the Navvis Group.
9
Report Groupings
• Reports can also be grouped by major division such as:
– Acute Care
– Mental Health
– Outpatient
• Or by patient type such as:
– Inpatient
– Emergency
– Observation
– Dialysis
– Newborn
10
Report Groupings
• Payor contract reports can be prepared at an aggregate
level such as AHCCCS, Medicare HMO, Commercial or Self
Pay.
• Or they can be reported on at the unique plan level such as:
– Mercy Care Plan (AHCCCS)
– Maricopa Care Advantage (Medicare HMO)
– Cigna (Commercial)
– Category 1 – Copa Care (Self Pay)
11
Cost vs. Financial Accounting
• Differences between the Cost Accounting and the
Financial statements include:
– Cost Accounting is patient centered & time periods are
defined by admit date.
– Cost Accounting aggregates both direct and indirect
costs at a charge level.
– Cost Accounting looks to total actual or expected
payments on a patient account as net patient revenue.
12
Cost vs. Financial Accounting
• Differences between the Cost Accounting and the
Financial statements include:
– The Financial Statements report financial activity in a
given period such as fiscal year or month.
– The Financial Statements use actual and estimates to
report costs in the period it occurred.
– The Financial Statements report cost at a department
level.
– The Financial statements uses actual and estimates to
report net patient revenue based on date of service at
an aggregate level.
13
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.a.i.
Contracts
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.a.ii.
Contracts
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.a.iii.
Contracts
From:
To:
Subject:
Date:
Compliance 360
Brian Maness
Contract has been Approved: Health Benefits Administrative Services Agreement
Friday, March 13, 2015 3:05:37 PM
Message Information
From Purves, Steve
To Maness, Brian;
Subject
Contract has been Approved: Health Benefits
Administrative Services Agreement
Contract Information
Status Pending Approval
Title Health Benefits Administrative Services Agreement
Contract Identifier
(Travel Type Board - New Contract
Dropdown)
MIHS Contract
90-15-145-1
Number
Primary Responsible
Maness, Brian D.
Party
Departments HUMAN RESOURCES
Product/Service Administrative Services Agreement for Employee
Description Medical Health Benefits
Approve a new contract with UMR, Inc. to provide
administrative services related to MIHS employee health
benefit claims adminstration. Initial term of the contract
Action/Background is for three years from July 1, 2014 through June 30,
2017.
Estimated annual expense is $1,600,000
Evaluation Process
Notes
Category
Effective Date 7/1/2014
Expiration Date 6/30/2017
Annual Value $1,600,000.00
Expense/Revenue Expense
Budgeted (Budget Bal
Yes
Dropdown Travel)
Procurement Number
Primary Vendor UMR, Inc.
Comments
Type
Approval
Classification
Date
3/12/2015
Approval
3/13/2015
Approval
3/13/2015
Employee
Demos, Martin C.
Benaquista,
Kathleen F.
Purves, Steve A.
Comments
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.a.iv.
Contracts
DATE:
March 17, 2015
TO:
Steve Purves, President & Chief Executive Officer
FROM:
Kathy Benaquista, Interim Chief Financial Officer
SUBJ:
Request to Increase NTE Amount for Leidos Health LLC
I am requesting an increase to the not to exceed (NTE) amount for the existing Leidos Health
LLC (Leidos) contract in the amount of $500,000.00. The increase will allow MIHS to continue
to contract with Leidos to provide project resources within Patient Financial Services through the
months of March and April. During this time I will meet with both PriceWaterhouseCoopers
(PwC) and Leidos to understand what they are recommending as next steps in their engagements,
what resources are needed, what is the cost and what is the expected return on the investment. I
plan on presenting a recommendation on whether to continue to contract with PwC and Leidos
for their services to the District Board at their April 22, 2015 meeting.
Leidos, along with PwC, is engaged to reorganize the revenue cycle. Leidos’ specific tasks were
to evaluate the operations of the business office itself to determine what, if any, operational or
Epic issues are interfering with an efficient and effective collection of revenues. In addition, due
to a lack of MIHS resources, Leidos is providing staff to perform day to day management and to
operationalize many of the PwC recommendations for improvements to the revenue cycle
including revenue performance management and establishing the pre-processing center. Board
approval to increase Leidos’ NTE will allow MIHS to continue paying for the following existing
project resources: Vice President of Revenue Cycle, Revenue Performance Management
Manager, Director Pre-Processing Center, Billing Supervisor, three dedicated Epic subject matter
experts (SMEs) to support accounts receivable reduction efforts and an allowance to request
additional Epic SMEs/Analysts to support Epic optimization and/or enhancements as needed.
Maricopa Integrated Health System
2601 E. Roosevelt
Phoenix, Arizona 85008
Tel (602) 344-5011
From:
To:
Subject:
Date:
Compliance 360
Brian Maness
Contract has been Approved: NTE Increase - March 2015
Friday, March 13, 2015 3:04:43 PM
Message Information
From Purves, Steve
To Maness, Brian; Subject Contract has been Approved: NTE Increase - March 2015
Contract Information
Status Pending Approval
Title NTE Increase - March 2015
Contract Identifier
(Travel Type Board - Amendment
Dropdown)
MIHS Contract
90-11-211-2-18
Number
Primary Responsible
Maness, Brian D.
Party
Departments
Request to increase NTE to cover continued Revenue
Product/Service
Cycle and Patient Financial Services ongoing
Description
optimization efforts.
Approve an increase to the Not-To-Exceed amount by an
additional $500,000 to support the continued effort of
Leidos Health, LLC in the performance of Revenue Cycle
Action/Background and Patient Financial Services optimization. This
increase also includes funding for additional services
that may be required by other MIHS departments to
fulfill resource needs.
Evaluation Process
Notes
Category
Effective Date 3/1/2015
Expiration Date 7/20/2016
Annual Value $0.00
Expense/Revenue Expense
Budgeted (Budget Bal
Yes
Dropdown Travel)
Procurement Number
Primary Vendor Leidos Health LLC (fka MaxIT Healthcare, LLC)
Comments
Type
Approval
Approval
Classification
Date
3/13/2015
3/13/2015
Employee
Benaquista,
Kathleen F.
Purves, Steve A.
Comments
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.b.i.
Medical Staff
Recommended by Credentials Committee: March 3, 2015
Recommended by Medical Executive Committee: March 10, 2015
Submitted to MSHCDB: March 25, 2015
MARICOPA INTEGRATED HEALTH SYSTEM
CREDENTIALS AND ACTION ITEMS REPORT
MEDICAL STAFF
The credentials of the following individuals including, current licensure, relevant training and experience, malpractice insurance, current competence and the ability to perform
the requested privileges have been verified.
NAME
Matthew James Welch, M.D.
CATEGORY
Courtesy
INITIAL MEDICAL STAFF APPOINTMENT
DEPARTMENT/SPECIALTY
APPOINTMENT DATES
Surgery (Ophthalmology)
4/01/2015 to 3/31/2017
COMMENTS
Interim Privileges granted on 02/11/2015
INITIAL/FOCUSED PROFESSIONAL PRACTICE EVALUATION
NAME
DEPARTMENT/SPECIALTY
RECOMMENDATION
EXTEND or PROPOSED STATUS
James Nathaniel Bogert, M.D.
Surgery (Critical Care/Trauma)
Successfully Completed FPPE
Wendy Mehler Carlton, M.D.
Pediatrics
Successfully Completed FPPE
Dino Cekro, M.D.
Internal Medicine
Successfully Completed FPPE
Karole Marie Davis, M.D.
Surgery (Critical Care/Trauma)
Successfully Completed FPPE
Christopher Natesan Eswar, M.D.
OB/GYN
Successfully Completed FPPE
John William Fitzharris, D.O.
Internal Medicine
Extension of FPPE
Erica Celina Garza, M.D.
OB/GYN
Successfully Completed FPPE
Tiffany Johnson, M.D.
Pediatrics (Emergency Medicine)
Successfully Completed FPPE
Arnold S. Morof, D.D.S., M.S.
Dentistry
Successfully Completed FPPE
COMMENTS*
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for General Surgery Core
and Advanced Laparoscopy Privileges.
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Pediatric &
Adolescent Core Privileges.
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement For Internal Medicine
Core Privileges.
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Advanced Surgical
Critical Care, Endoscopy, and Procedural Sedation Privileges.
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Gynecology Core
Privileges.
The Medical Executive Committee and Credentials Committee
concurred with the department chair’s recommendation for an
additional five charts to be reviewed.
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Gynecology Core
Privileges.
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement Advanced Pediatric &
Adolescent Emergency Medicine Core Privileges.
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for General Dentistry
Core Privileges (adult and pediatric).
1 of 3
Recommended by Credentials Committee: March 3, 2015
Recommended by Medical Executive Committee: March 10, 2015
Submitted to MSHCDB: March 25, 2015
Timothy John Ryan, D.O.
Kathleen M. Smith, M.D.
Zola N. Trotter, M.D.
Shannon Renee Ursu, M.D.
Lyndsay Jean Willmott, M.D.
INITIAL/FOCUSED PROFESSIONAL PRACTICE EVALUATION
Emergency Medicine
Successfully Completed FPPE
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Emergency Medicine
Core Procedural/Cognitive Privileges.
Pediatrics (Emergency Medicine)
Successfully Completed FPPE
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Advanced Pediatric &
Adolescent Emergency Medicine Core Privileges.
Pediatrics (Emergency Medicine)
Successfully Completed FPPE
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Advanced Pediatric &
Adolescent Emergency Medicine Core Privileges.
Internal Medicine
Successfully Completed FPPE
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Internal Medicine
Core Privileges.
OB/GYN
Successfully Completed FPPE
Chair has submitted documentation demonstrating practitioner has
successfully completed FPPE requirement for Laser Privileges.
REAPPOINTMENTS
NAME
CATEGORY
Thomas L. Bostwick, M.D.
Active
Linda R. Chambliss, M.D.
Sean P. Elliott, M.D.
Esmat Mufeed Mustafa, M.D.
Anil Nanda, M.D.
Lyndsay Jean Willmott, M.D.
Courtesy
Courtesy
Courtesy
Active
Courtesy
DEPARTMENT/SPECIALTY
Emergency Medicine and Pediatrics
(Emergency Medicine)
OB/GYN (Maternal & Fetal Medicine)
Pediatrics (Infectious Diseases)
Internal Medicine (Nephrology)
Internal Medicine (Geriatrics)
OB/GYN and Women’s Health Care
APPOINTMENT DATES
COMMENTS
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
CHANGE IN PRIVILEGES
NAME
Mary J. Connell, M.D.
DEPARTMENT/SPECIALTY
ADDITION / REVISION/ REDUCTION / WITHDRAWAL
Radiology
Addition: Cardiac CTAngiography Privileges
COMMENTS
Unsupervised
STAFF STATUS CHANGE
NAME
Thomas A. Eccles, M.D.
DEPARTMENT
Pediatrics
CHANGE FROM/TO
Active to Courtesy
COMMENTS*
Reduction in hours
RESIGNATIONS
NAME
Jaime Alkon, M.D.
Waqas Arslan, M.D.
J. Kipp Charlton, M.D.
DEPARTMENT/SPECIALTY
Pediatrics (Cardiology)
Internal Medicine (Hematology/Oncology)
Pediatrics (Nephrology)
Information Only
STATUS
Courtesy to Inactive
Courtesy to Inactive
Active to Inactive
REASON
No longer contracted with contracting agency (Effective 2/28/2015)
No longer contracted with contracting agency (Effective 3/31/2015)
Deceased
2 of 3
Recommended by Credentials Committee: March 3, 2015
Recommended by Medical Executive Committee: March 10, 2015
Submitted to MSHCDB: March 25, 2015
RESIGNATIONS
Information Only
Courtney E. De Jesso, M.D.
Audrey Sue Dickan, M.D.
M. Yousuf Khan, M.D.
Dennis W. Miller, M.D.
Muzna Mansoor Naqvi, M.D.
Nedall Samad, M.D.
Benjamin James Thompson, M.D.
Ana Vaughan, M.D.
Pediatrics
Pediatrics
Internal Medicine (Infectious Diseases)
Anesthesiology
Internal Medicine
Internal Medicine
Pediatrics
Pediatrics
Courtesy to Inactive
Courtesy to Inactive
Courtesy to Inactive
Courtesy to Inactive
Courtesy to Inactive
Active to Inactive
Courtesy to Inactive
Courtesy to Inactive
Resigned (Effective 2/7/2015)
No longer Contracted with Contracting Agency (Effective 3/31/2015)
Resigned (Effective 3/31/2015)
No longer contracted with contracting agency (Effective 3/31/2015)
Resigned (Effective 3/31/2015)
No longer contracted with contracting agency (Effective 02/28/2015)
Resigned (Effective 3/31/2015)
No longer contracted with contracting agency (Effective 2/10/2015)
CORRECTION TO THE JANUARY 28, 2015 MARICOPA SPECIAL HEALTH CARE DISTRICT BOARD MEETING
REAPPOINTMENTS
APPOINTMENT DATES
COMMENTS
Gene M. Garsha, D.M.D.
NAME
Active
Dentistry
3/01/2015 to 2/28/2017
Susan A. Geren, M.D.
William S. James, M.D.
Roy Jedeikin, M.D.
Gilbert R. Ortega, M.D.
Jesse Shriki, D.O.
Ziad M. Shehab, M.D.
Suhair N. Stipho-Majeed, M.D.
Bruce A. Takahashi, D.O.
Active
Active
Courtesy
Courtesy
Courtesy
Courtesy
Active
Active
Pediatrics
Psychiatry
Pediatrics (Cardiology)
Orthopedic Surgery
Emergency Medicine
Pediatrics (Infectious Diseases)
Internal Medicine
Internal Medicine
3/01/2015 to 2/28/2017
3/01/2015 to 2/28/2017
3/01/2015 to 2/28/2017
3/01/2015 to 2/28/2017
3/01/2015 to 2/28/2017
3/01/2015 to 2/28/2017
3/01/2015 to 2/28/2017
3/01/2015 to 2/28/2017
Reappointment dates for physicians listed
were inadvertently listed as 2/01/2015 to
1/31/2017. The correct reappointment
dates are 3/1/2015 to 2/28/2017 for
physicians as listed.
As above
As above
As above
As above
As above
As above
As above
As above
Definitions:
Active
Courtesy
Reappointments
FPPE
CATEGORY
DEPARTMENT/SPECIALTY
> 1,000 hours/year – Active members of the medical staff have voting rights and can serve on medical staff committees
< 1,000 hours/year – Courtesy members do not have voting rights and do not serve on medical staff committees
Renewal of appointment and privileges is for a period of two years unless otherwise specified for a shorter period of time.
Focused professional practice evaluation is a process by which the organization validates current clinical competence. This process may also be used when a question arises in practice patterns.
3 of 3
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.b.ii.
Medical Staff
Recommended by Credentials Committee: March 3, 2015
Recommended by Medical Executive Committee: March 10, 2015
Submitted to MSHCDB: March 25, 2015
MARICOPA INTEGRATED HEALTH SYSTEM
CREDENTIALS AND ACTION ITEMS REPORT
ALLIED HEALTH PROFESSIONAL STAFF
The credentials of the following individuals including, current licensure, relevant training and experience, malpractice insurance, current competence and the ability to perform
the requested privileges have been verified.
ALLIED HEALTH PROFESSIONALS - INITIAL APPOINTMENTS
DEPARTMENT
PRACTICE PRIVILEGES/
APPOINTMENT
SCOPE OF SERVICE
DATES
NAME
Tara Begay, F.N.P.
Rachel Elisabeth Patel, C.R.N.A.
Kelsy J. Rokey, P.A.-C
Heather Marie Wright, F.N.P.
Family and Community Medicine
Anesthesiology
Orthopedic Surgery
Family and Community Medicine
Practice Prerogatives on file
Practice Prerogatives on file
Practice Prerogatives on file
Practice Prerogatives on file
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
ALLIED HEALTH PROFESSIONALS – REAPPOINTMENTS
DEPARTMENT
PRACTICE PRIVILEGES/
APPOINTMENT
SCOPE OF SERVICE
DATES
NAME
Shiloh J. Danley, F.N.P.
Geri Ann Falconer-Ferneau, N.N.P.
Patricia Lannon Johnson, D.N.P., N.N.P.
Heidi Marie Quackenbush, P.A.-C
NAME
Shiloh J. Danley, F.N.P.
Internal Medicine and
Emergency Medicine (Urgent
Care)
Pediatrics (NICU)
Pediatrics (NICU)
Family and Community Medicine
DEPARTMENT
Internal Medicine
Practice Prerogatives on file
4/01/2015 to 3/31/2017
Practice Prerogatives on file
Practice Prerogatives on file
Practice Prerogatives on file
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
4/01/2015 to 3/31/2017
COMMENTS/SPONSORING PHYSICIAN
(if applicable)
Interim Privileges granted 2/10/2015
Interim Privileges granted 2/23/2015
Interim Privileges granted 3/4/2015
Interim Privileges granted 3/4/2015
COMMENTS/SPONSORING PHYSICIAN
(if applicable)
Supervising Physician is Kevin Lopez, M.D.
CHANGE IN PRIVILEGES
ADDITION / REDUCTION / WITHDRAWAL/CHANGES
Addition: Chest Tube Insertion/Removal Privileges
Addition: Paracentesis; Arthrocentsis; Lumbar Puncture; Central Line Placement; Intubation/Extubation
COMMENTS
Personal Supervision of 1st five (5) cases.
General Supervision
RESIGNATIONS
NAME
Freddy L. Montenegro, F.N.P.
Ruth Penno, F.N.P.
Erika Marie Percic, C.R.N.A.
General Definitions:
Allied Health
Professional Staff
Practice Prerogatives
Supervision Definitions:
(1) General Supervision
(2) Direct Supervision
(3) Personal Supervision
DEPARTMENT
Family and Community Medicine
Internal Medicine
Anesthesiology
Information Only
STATUS
Allied Health Professional to Inactive
Allied Health Professional to Inactive
Allied Health Professional to Inactive
REASON
Resigned (Effective 2/12/2015)
Resigned (Effective 2/13/2015)
Resigned (Effective as of 2/04/2015)
An Allied Health Professional (AHP) means a health care practitioner other than a Medical Staff member who is authorized by the Governing Body to provide patient care services at a MIHS facility, and who is
permitted to initiate, modify, or terminate therapy according to their scope of practice or other applicable law or regulation. Governing Body authorized AHPs are: Certified Registered Nurse Anesthetists; Certified
Registered Nurse Midwife; Naturopathic Physician; Optometrists; Physician Assistant; Psychologists (Clinical Doctorate Degree Level); Registered Nurse Practitioners.
Scopes of practice summarizing qualifications for the respective category, developed with input from the physician director of the clinical service and the observer/sponsor/responsible party of the AHP, Department
Chair, and other representatives of the Medical Staff, Hospital management, and other professionals.
The procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure or provision of the services.
The physician must be present in the office suite or on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that
the physician must be present in the room when the procedure is performed.
A physician must be in the room during the performance of the procedure.
1 of 1
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.b.iii.
Medical Staff
MARICOPA INTEGRATED
HEALTH SYSTEM
PEER REVIEW POLICY
DRAFT
March 2015
PEER REVIEW POLICY
TABLE OF CONTENTS
PAGE
1.
OBJECTIVES, SCOPE OF POLICY, COLLEGIAL EFFORTS,
DEFINITIONS, AND ACRONYMS ................................................................................1
1.A
1.B
1.C
1.D
1.E
2.
CLINICAL INDICATORS (A/K/A TRIGGERS) ..........................................................3
2.A
2.B
2.C
3.
Specialty-Specific Triggers ......................................................................................3
Reported Concerns ...................................................................................................3
(1)
Reported Concerns from Practitioners or MIHS Employees .......................3
(2)
Anonymous Reports.....................................................................................4
(3)
Unsubstantiated Reports/False Reports .......................................................4
(4)
Sharing Reported Concerns with Relevant Practitioner ..............................4
(5)
Self-Reporting ..............................................................................................4
Other Triggers ..........................................................................................................4
NOTICE TO AND INPUT FROM THE PRACTITIONER .........................................5
3.A
3.B
3.C
4.
Objectives ................................................................................................................1
Scope of Policy ........................................................................................................1
Collegial Efforts and Progressive Steps ...................................................................1
Definitions................................................................................................................2
Acronyms .................................................................................................................3
Notice .......................................................................................................................5
Input .........................................................................................................................5
Failure to Provide Requested Input..........................................................................6
INTERVENTIONS TO ADDRESS IDENTIFIED CONCERNS .................................6
4.A
4.B
4.C
4.D
Informational Letter .................................................................................................6
Educational Letter ....................................................................................................6
Collegial Intervention ..............................................................................................7
Performance Improvement Plan (“PIP”) .................................................................7
(1)
Additional Education/CME .........................................................................8
(2)
Focused Prospective Review .......................................................................8
(3)
Second Opinions/Consultations ...................................................................8
(4)
Concurrent Proctoring ..................................................................................8
(5)
Participation in a Formal Evaluation/Assessment Program.........................8
(6)
Additional Training ......................................................................................9
(7)
Educational Leave of Absence.....................................................................9
a
PAGE
(8)
5.
6.
Other ............................................................................................................9
STEP-BY-STEP PROCESS ..............................................................................................9
5.A
General Principles ....................................................................................................9
(1)
Time Frames for Review .............................................................................9
(2)
Request for Additional Information or Input .............................................10
(3)
No Further Review or Action Required .....................................................10
(4)
External Reviews .......................................................................................10
(5)
Referral to the Medical Executive Committee...........................................10
5.B
Quality Management (“QM”) ................................................................................11
(1)
Review .......................................................................................................11
(2)
Preparation of Case for Review .................................................................12
(3)
Referral of Case to Leadership Council .....................................................12
(4)
Referral to Appropriate Peer Review Committee ......................................12
(5)
Cases Involving Practitioners from Several Specialties
or Departments ...........................................................................................13
5.C
Leadership Council ................................................................................................13
(1)
Composition ...............................................................................................13
(2)
Function .....................................................................................................13
(3)
Review of Cases .........................................................................................13
(4)
Determinations and Interventions ..............................................................14
5.D
Review by Department Peer Review Committees .................................................14
5.E
Review by Specialized Peer Review Committees, including the
Trauma Multi-Disciplinary Peer Review Committee ............................................14
5.F
PPEC ......................................................................................................................15
(1)
Review of Prior Determinations ................................................................15
(2)
Cases Referred to the PPEC for Further Review .......................................16
(a)
Review ...........................................................................................16
(b)
Determinations and Interventions ..................................................17
PRINCIPLES OF REVIEW AND EVALUATION .....................................................17
6.A
6.B
6.C
6.D
Incomplete Medical Records .................................................................................17
Forms .....................................................................................................................17
Findings and Recommendations Supported by
Evidence-Based Research/Clinical Protocols or Guidelines .................................17
System Process Issues ............................................................................................17
b
PAGE
6.E
6.F
6.G
6.H
6.I
7.
Tracking of Reviews ..............................................................................................17
Educational Sessions ..............................................................................................18
Confidentiality .......................................................................................................18
(1)
Documentation ...........................................................................................18
(2)
Participants in the Peer Review Process ....................................................18
(3)
Peer Review Communications ...................................................................18
Conflict of Interest Guidelines ...............................................................................19
Legal Protection for Reviewers .............................................................................19
PEER REVIEW REPORTS ...........................................................................................19
7.A
7.B
7.C
Practitioner Peer Review History Reports .............................................................19
Reports to MEC and Board ....................................................................................19
Reports on Request ................................................................................................20
APPENDIX A:
Responsibilities of Assigned Reviewers
APPENDIX B:
Responsibilities of Department Peer Review Committees
APPENDIX C:
Responsibilities of Specialized Peer Review Committees, including the
Trauma Multi-Disciplinary Peer Review Committee
APPENDIX D:
Performance Improvement Plan Options Implementation Issues Checklist
APPENDIX E-1:
Detailed Flow Chart of Peer Review Process
APPENDIX E-2:
Simplified Flow Chart of Peer Review Process
APPENDIX F:
Conflict of Interest Guidelines
c
PEER REVIEW POLICY
1.
OBJECTIVES, SCOPE OF POLICY, COLLEGIAL EFFORTS, DEFINITIONS, AND
ACRONYMS
1.A
Objectives. The primary objectives of the professional practice evaluation process of
Maricopa Integrated Health System (“MIHS”) are to:
(1)
establish a positive, educational approach to performance issues and a culture of
continuous improvement;
(2)
fairly, effectively, and efficiently evaluate the care being provided by
practitioners, comparing it to established patient care protocols and benchmarks
whenever possible;
(3)
provide constructive feedback, education, and performance improvement
assistance to practitioners regarding the quality, appropriateness, and safety of
the care they provide;
(4)
establish and continually update triggers for peer review and quality data
elements that will facilitate a meaningful review of the care provided; and
(5)
define prospectively, to the extent possible, the expectations for patient care and
safety through patient care protocols.
1.B
Scope of Policy. This Policy applies to all practitioners who provide patient care
services at MIHS. When concerns are raised about a practitioner’s clinical practice, a
review shall be conducted in accordance with this Policy. Concerns regarding a
practitioner’s professional conduct shall be reported and directed for review in
accordance with the Medical Staff Professionalism Policy.
1.C
Collegial Efforts and Progressive Steps. This Policy encourages the use of collegial
efforts and progressive steps to address issues that may be identified in the peer review
process. The goal of those efforts is to arrive at voluntary, responsive actions by the
practitioner. Collegial efforts and progressive steps may include, but are not limited to,
informational letters, educational letters of counsel or guidance, collegial intervention,
sharing of comparative data, and Performance Improvement Plans as outlined in this
Policy.
All collegial efforts and progressive steps are part of MIHS’s confidential peer review
and patient safety evaluation activities and shall be within the discretion of the
Department Chairs, Leadership Council, and the Professional Practice Evaluation
Committee (“PPEC”).
MIHS Medical Staff Peer Review Policy – DRAFT: 03/2015: (Supersedes 10/2014)
Page 1
1.D
Definitions. The following definitions apply to terms used in this Policy:
ASSIGNED REVIEWER means a physician appointed by the Leadership Council or
the PPEC to review and assess the care provided in a particular case and report his/her
findings back to the committee that assigned the review. Duties and responsibilities of
assigned reviewers are described more fully in Appendix A.
DEPARTMENT CHAIR means the applicable Medical Staff Department Chair (e.g.,
Chair of Medicine).
DEPARTMENT PEER REVIEW COMMITTEE means the physicians in each
Medical Staff Department who are appointed by the Department Chair to conduct case
reviews, make determinations, send informational or educational letters and conduct
collegial interventions as described more fully in Section 5.D of this Policy and in
Appendix B. Each Department Peer Review Committee shall consist of at least three
members.
LEADERSHIP COUNCIL means the committee that:
(1)
determines the appropriate review process for clinical issues that are
administratively complex as described in Section 5.B(4) of this Policy; and
(2)
addresses administrative issues identified through the process, as deemed
necessary.such as development and approval of clinical guidelines, protocols,
and policies.
The composition and duties of the Leadership Council are described in Section 5.C of
this Policy.
MEDICAL STAFF LEADER means any Medical Staff officer, Department Chair, or
Committee Chair.
PRACTITIONER means:
(1)
a member of the Medical Staff; and
(2)
an Allied Health Professional who has been granted clinical privileges at MIHS.
PROFESSIONAL PRACTICE EVALUATION COMMITTEE (“PPEC”) means
the multi-specialty committee that oversees the peer review process and reviews care
provided within MIHS as described in this Policy. The composition and duties of the
PPEC are described in the Medical Staff Organizational Manual.
QUALITY MANAGEMENT (“QM”) means the MIHS personnel who support the
peer review process as described more fully in Section 5.B of this Policy.
MIHS Medical Staff Peer Review Policy – DRAFT: 03/2015: (Supersedes 10/2014)
Page 2
SPECIALIZED PEER REVIEW COMMITTEES means those committees that
have been established to review care provided in specific situations or units (e.g.,
hospital-acquired infections, burns, codes, etc.) and to make determinations, send
informational or educational letters and conduct collegial interventions as described
more fully in Section 5.E and Appendix C of this Policy.
TRAUMA MULTI-DISCIPLINARY PEER REVIEW COMMITTEE means the
committee that reviews cases involving trauma care based on the criteria for trauma
accreditation by the ACS. The Trauma Medical Director chairs the Trauma MultiDisciplinary Peer Review Committee. The Trauma Multi-Disciplinary Peer Review
Committee may make determinations, send informational or educational letters and
conduct collegial interventions as described more fully in Section 5.E and Appendix C
of this Policy.
1.E
Acronyms. Definitions of the acronyms used in this Policy are:
CMO
MEC
PIP
PPEC
QM
2.
Chief Medical Officer
Medical Executive Committee
Performance Improvement Plan
Professional Practice Evaluation Committee
Quality Management
CLINICAL INDICATORS (A/K/A TRIGGERS).
triggered by any of the following events:
The peer review process may be
2.A
Specialty-Specific Triggers. Each Department shall identify adverse outcomes, clinical
occurrences, or complications that will trigger the peer review process. The triggers
identified by the Departments shall be approved by the PPEC.
2.B
Reported Concerns.
(1)
Reported Concerns from Practitioners or MIHS Employees. Any practitioner
or MIHS employee may report to QM concerns related to:
(a)
the safety or quality of care provided to a patient by an individual
practitioner, which shall be reviewed through the process outlined in this
Policy;
(b)
professional conduct, which shall be reviewed and addressed in
accordance with the Medical Staff Professionalism Policy;
(c)
potential practitioner health issues, which shall be reviewed and
addressed in accordance with the Practitioner Health Policy;
MIHS Medical Staff Peer Review Policy – DRAFT: 03/2015: (Supersedes 10/2014)
Page 3
2.C
(d)
non-adherence with Medical Staff or MIHS policies, which shall be
reviewed through the process outlined in this Policy and/or in
accordance with the Medical Staff Professionalism Policy, whichever
QM, in consultation with the Vice President of Quality and Patient
Outcomes or his/her designee, as necessary, determines is more
appropriate based on the policies at issue; or
(e)
a potential system or process issue which shall be referred to the
appropriate individual, committee, or MIHS department for review.
(2)
Anonymous Reports. Practitioners and employees may report concerns
anonymously, but all individuals are encouraged to identify themselves when
making a report. This identification promotes an effective review of the
concern because it permits QM to contact the reporter for additional
information, if necessary.
(3)
Unsubstantiated Reports/False Reports. If a report cannot be substantiated, or
is determined to be without merit, the matter shall be closed as requiring no
further review and shall be reported to the PPEC. False reports will be grounds
for disciplinary action.
(4)
Sharing Reported Concerns with Relevant Practitioner. The substance of
reported concerns may be shared with the relevant practitioner as part of the
review process outlined in Section 5, but the identity of the individual who
reported the concern will not be provided to the practitioner. At the discretion
of the Department Chair, the actual report may be shared with the practitioner
provided the report has been redacted to protect the identity of the individual(s)
who reported the concern. Retaliation against an individual who reports a
concern will be addressed through the Medical Staff Professionalism Policy.
(5)
Self-Reporting. Practitioners will be encouraged to self-report their cases that
involve either a specialty-specific trigger or other review trigger or that they
believe would be an appropriate subject for an educational session as described
in Section 6.F. Self-reported cases will be reviewed as outlined in this Policy.
A notation will be made that the case was self-reported.
Other Triggers. In addition to specialty-specific triggers and reported concerns, other
events that may trigger the peer review process include, but are not limited to, the
following:
(1)
identification by a Medical Staff committee, Medical Staff Services, QM, a
Department Chair, the Leadership Council or PPEC of a clinical trend or
specific case or cases that require further review;
(2)
patient complaints referred by Risk Management that QM determines require
physician review;
MIHS Medical Staff Peer Review Policy – DRAFT: 03/2015: (Supersedes 10/2014)
Page 4
3.
(3)
cases identified as litigation risks that are referred by the Risk Management
Department;
(4)
practice concerns referred by the Utilization Review Committee or others;
(5)
sentinel events, as defined in the Sentinel Events Policy, involving an individual
practitioner’s professional performance;
(6)
referrals from system performance improvement initiatives;
(7)
a Department Chair’s determination, in conjunction with QM, that quality data
reveal a practice pattern or trend that requires further review as further
described in the Policy Regarding Quality Data; and
(8)
a trend of non-adherence with Medical Staff Rules and Regulations or other
policies, adopted clinical protocols, or other quality measures, as described in
Paragraph 4.A of this Policy and in Appendix A of the Policy Regarding
Quality Data.
NOTICE TO AND INPUT FROM THE PRACTITIONER. An opportunity for
practitioners to provide meaningful input into the review of the care they have provided is an
essential element of an educational and effective process.
3.A
3.B
Notice.
(1)
No intervention (informational or educational letter, collegial intervention, or
Performance Improvement Plan as defined in Section 4) shall be implemented
until the practitioner is first notified of the specific concerns identified and
given an opportunity to provide input. The notice to the practitioner shall
include a time frame for the practitioner to provide the requested input.
(2)
The practitioner shall also be notified of any referral to the PPEC or MEC.
(3)
Prior notice and an opportunity to provide input are not required before an
informational letter is sent to a practitioner, as described in Section 4.A of this
Policy.
Input. The practitioner may provide input through a written description and
explanation of the care provided, responding to any specific questions posed by the
Leadership Council, Department or Specialized Peer Review Committee, the Trauma
Multi-Disciplinary Peer Review Committee or PPEC, and/or by meeting in person with
individuals specified in the notice.
MIHS Medical Staff Peer Review Policy – DRAFT: 03/2015: (Supersedes 10/2014)
Page 5
3.C
4.
Failure to Provide Requested Input.
(1)
If the practitioner fails to provide input requested by the Leadership Council, the
Department or Specialized Peer Review Committee, or the Trauma MultiDisciplinary Peer Review Committee within the time frame specified, the
review shall proceed without the practitioner’s input. The practitioner’s failure
to respond to the request for input shall be noted in the Leadership Council’s or
applicable Committee’s report to the PPEC regarding the review and
determination.
(2)
If the practitioner fails to provide input requested by the PPEC within the time
frame specified, the practitioner will be required to attend a meeting with the
Leadership Council to discuss why the requested input was not provided.
Failure of the individual to either attend this meeting or provide the requested
information prior to the date of that meeting will result in the automatic
relinquishment of the practitioner’s clinical privileges until the requested input
is provided, in accordance with Section 6.E.4 of the Credentials Policy.
INTERVENTIONS TO ADDRESS IDENTIFIED CONCERNS. When concerns regarding
a practitioner’s clinical practice are identified through the process outlined in Section 5, the
following interventions may be implemented to address those concerns.
4.A
Informational Letter. For situations involving non-adherence with specified Medical
Staff Rules and Regulations or other policies, clinical protocols, or quality measures,
the Department Chair, Leadership Council, Department Peer Review Committee,
Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer
Review Committee, or PPEC may direct Medical Staff Services or QM to prepare an
informational letter reminding the practitioner of the applicable requirement and
offering assistance to the practitioner in complying with it.
A copy of the informational letter shall be placed in the practitioner’s confidential file,
and it shall be considered in the reappointment process and/or in the assessment of the
practitioner’s competence to exercise the clinical privileges granted.
If a pattern or trend of non-adherence by a practitioner is identified through
informational letters, the matter shall be subject to more focused review in accordance
with Section 5 of this Policy.
Informational letters may be signed by: The Department Chair, the Chair of the
Department Peer Review Committee or Specialized Peer Review Committee, the Chair
of PPEC, Leadership Council, or the Chief of Staff. The Department Chair shall be
copied on any Informational Letter that he/she does not personally sign.
4.B
Educational Letter. An educational letter may be sent to the practitioner involved that
describes the opportunities for improvement that were identified in the care reviewed
and offers specific recommendations for future practice. A copy of the letter will be
MIHS Medical Staff Peer Review Policy – DRAFT: 03/2015: (Supersedes 10/2014)
Page 6
included in the practitioner’s file along with any response that he or she would like to
offer.
Educational letters may be sent by: The Leadership Council, a Department Peer
Review Committee (and signed by the Department Chair), a Specialized Peer Review
Committee, including the Trauma Multi-Disciplinary Peer Review Committee (in
consultation with the Department Chair as described in Section 5.E) or the PPEC. The
practitioner’s Department Chair and PPEC will be apprised of, and have access to, any
educational letter that is sent to a practitioner, regardless of who sends it.
4.C
Collegial Intervention. Collegial intervention means a face-to-face discussion between
the practitioner and one or more Medical Staff Leaders, followed by a letter that
summarizes the discussion and, when applicable, the expectations regarding the
practitioner’s future practice at MIHS. A copy of the follow-up letter will be included
in the practitioner’s file along with any response that the practitioner would like to
offer.
A collegial intervention may be personally conducted by: The Leadership Council, the
Department Chair, a Department Peer Review Committee, a Specialized Peer Review
Committee, including the Trauma Multi-Disciplinary Peer Review Committee (in
consultation with the relevant Department Chair as described in Section 5.E) or the
PPEC or they may facilitate an appropriate and timely collegial intervention by
designees. The Department Chair shall be invited to participate in any collegial
intervention involving a practitioner in his/her Department. If, for any reason, the
Department Chair does not participate in a collegial intervention involving a
practitioner in his/her Department, he/she shall be informed of the substance of the
collegial intervention and the follow-up letter.
The Leadership Council and PPEC
shall be informed of the substance of any collegial intervention and the follow-up letter,
regardless of who conducts or facilitates it.
4.D
Performance Improvement Plan (“PIP”). The PPEC may determine that it is
necessary to develop a PIP for the practitioner.
To the extent possible, a PIP shall be for a defined time period or for a defined number
of cases. The plan shall specify how the practitioner’s compliance with, and results of,
the PIP shall be monitored. As deemed appropriate by the PPEC, the practitioner shall
have an opportunity to provide input into the development and implementation of the
PIP. The Department Chair shall also be asked for input regarding the PIP, and shall
assist in implementation of the PIP as requested by the PPEC.
One or more members of the PPEC (or their designees) will personally discuss the PIP
with the practitioner. The PIP will also be presented in writing, with a copy being
placed in the practitioner’s file, along with any statement he or she would like to offer.
The practitioner must agree in writing to constructively participate in the PIP. If the
practitioner refuses to do so, the matter shall be referred to the MEC for appropriate
review and recommendation pursuant to the Credentials Policy.
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Until the PPEC has determined that the practitioner has complied with all elements of
the PIP and that concerns about the practitioner’s practice have been adequately
addressed, the matter shall remain on the PPEC’s agenda and the practitioner’s progress
on the PIP shall be monitored. In the event that the practitioner is not making
reasonable and sufficient progress on completion of the PIP in a timely manner, the
PPEC shall refer the matter to the Medical Executive Committee.
A PIP may include, but is not limited to, the following:
(1)
Additional Education/CME which means that, within a specified period of
time, the practitioner must arrange for education or CME of a duration and type
specified by the PPEC. The educational activity/program may be chosen by the
PPEC or by the practitioner. If the activity/program is chosen by the
practitioner, it must be approved by the PPEC. If necessary, the practitioner
may be asked to voluntarily refrain from exercising all or some of his or her
clinical privileges or may be granted an educational leave of absence while
undertaking such additional education.
(2)
Focused Prospective Review which means that a certain number of the
practitioner’s future cases of a particular type will be subject to a focused
review (e.g., review of the next 10 similar cases performed or managed by the
practitioner).
(3)
Second Opinions/Consultations which means that before the practitioner
proceeds with a particular treatment plan or procedure, the practitioner must
obtain a second opinion or consultation from a Medical Staff member(s)
approved by the PPEC.
The practitioner providing the second
opinion/consultation must complete a Second Opinion/Consultation Report
form for each case, which shall be reviewed by the PPEC. If there is any
disagreement about the proper course of treatment, the practitioner must discuss
the matter with individuals identified by the PPEC before proceeding further.
(4)
Concurrent Proctoring which means that a certain number of the practitioner’s
future cases of a particular type (e.g., the practitioner’s next five vascular cases)
must be personally proctored by a Medical Staff member(s) approved by the
PPEC, or by an appropriately credentialed individual from outside of the
Medical Staff approved by the PPEC. The proctor must be present during the
relevant portions of the operative procedure or must personally assess the
patient and be available throughout the course of treatment. Proctor(s) must
complete the appropriate review form, which shall be reviewed by the PPEC.
(5)
Participation in a Formal Evaluation/Assessment Program which means that,
within a specified period of time, the practitioner must enroll in an assessment
program identified by the PPEC and must then complete the program within
another specified time period. The practitioner must execute a release to allow
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the PPEC to communicate information to, and receive information from, the
selected program. If necessary, the practitioner may be asked to voluntarily
refrain from exercising all or some of his or her clinical privileges or may be
granted an educational leave of absence while undertaking such formal
assessment.
(6)
Additional Training which means that, within a specified period of time, the
practitioner must arrange for additional training of a duration and type specified
by the PPEC. The training program must be approved by the PPEC. The
practitioner must execute a release to allow the PPEC to communicate
information to, and receive information from, the selected program. The
practitioner must successfully complete the training within another specified
period of time. The director of the training program or appropriate supervisor
must provide an assessment and evaluation of the practitioner’s current
competence, skill, judgment and technique to the PPEC. If necessary, the
practitioner may be asked to voluntarily refrain from exercising all or some of
his or her clinical privileges or may be granted an educational leave of absence
while undertaking such additional training.
(7)
Educational Leave of Absence which means that the practitioner voluntarily
agrees to a leave of absence during which time the practitioner completes an
education/training program of a duration and type specified by the PPEC.
(8)
Other elements not specifically listed may be included in a PIP. The PPEC has
wide latitude to tailor PIPs to the specific concerns identified, always with the
objective of helping the practitioner to improve his or her clinical practice and
to protect patients.
(Additional guidance regarding Performance Improvement Plan options and
implementation issues is found in Appendix D.)
5.
STEP-BY-STEP PROCESS. The peer review process is outlined in Appendix E-1 (Detailed
Flow Chart) and Appendix E-2 (Simplified Flow Chart). This Section describes each step in
that process.
5.A
General Principles.
(1)
Time Frames for Review. The time frames specified in this Section are
provided only as guidelines. However, all participants in the process shall use
their best efforts to adhere to these guidelines, with the goal of completing
reviews, from initial identification to final disposition, within 90 days.
As a general rule, the Leadership Council, Department Peer Review
Committees, and Specialized Peer Review Committees, including the Trauma
Multi-Specialty Peer Review Committee, shall conduct their reviews and make
their determinations or interventions within 45 days.
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If the Department Peer Review Committees or Specialized Peer Review
Committees, including the Trauma Multi-Specialty Peer Review Committee, do
not complete their reviews within this time frame, QM will send a reminder and
request for immediate review. If the review is not completed within one week
of the reminder, the matter shall be reported to the PPEC Chair.
(2)
Request for Additional Information or Input. At any point in the process
outlined in this Section, information or input may be requested from the
practitioner whose care is being reviewed as described in Section 3 of this
Policy, or from any other practitioner or MIHS employee with personal
knowledge of the matter.
(3)
No Further Review or Action Required. If, at any point in this process, a
determination is made that there are no clinical issues or concerns presented in
the case that require further review or action, the matter shall be closed. The
determination shall be reported to the PPEC. If information was sought from
the practitioner involved, the practitioner shall be notified of the determination.
(4)
External Reviews. An external review may be appropriate if:
(a)
there are ambiguous or conflicting findings by internal reviewers;
(b)
the clinical expertise needed to conduct a review is not available on the
Medical Staff; or
(c)
an outside review is advisable to prevent allegations of bias, even if
unfounded.
If a Department Peer Review Committee or Specialized Peer Review
Committee, including the Trauma Multi-Disciplinary Peer Review Committee,
determines that an external review is required, it shall refer the matter to the
Leadership Council. If the PPEC determines that an external review is required,
it shall consult with the Chief of Staff. If a decision is made to obtain an
external review, the practitioner involved shall be notified of that decision and
the nature of the external review.
(5)
Referral to the Medical Executive Committee.
(a)
By the Leadership Council. The Leadership Council may refer a matter
to the MEC if a pattern has developed despite prior attempts at collegial
intervention, the practitioner was already involved in a PIP, or for any
other reason as set forth in the Credentials Policy.
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(b)
(c)
By the PPEC. The PPEC may refer a matter to the MEC if:
(i)
the PPEC determines that a PIP may not be adequate to address
the issues identified;
(ii)
the individual refuses to participate in a PIP developed by the
PPEC;
(iii)
the practitioner fails to abide by a PIP;
(iv)
the practitioner fails to make reasonable and sufficient progress
on completing a PIP;
(v)
a pattern has developed despite prior attempts at collegial
intervention or prior participation in a performance improvement
plan;
(vi)
the matter involves a very serious incident; or
(vii)
any other concern is raised that would serve as the basis for a
referral under the Credentials Policy.
Pursuant to the Medical Staff Credentials Policy. This Policy outlines
collegial and progressive steps that can be taken to address clinical
concerns about a practitioner. However, a single incident or pattern of
care may be so unacceptable that more significant action is required.
Therefore, nothing in this Policy precludes an immediate referral of a
matter to the MEC.
The MEC shall conduct its review in accordance with the Medical Staff
Credentials Policy.
5.B
Quality Management (“QM”).
(1)
Review. All cases or issues identified for review shall be referred to QM. QM
shall conduct the initial fact-finding review, which may include, as necessary,
the following:
(a)
the relevant medical record;
(b)
interviews with, and information from MIHS employees, practitioners,
patients, family, visitors, and others who may have relevant information;
(c)
consultation with relevant Medical Staff or MIHS personnel;
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(2)
(3)
(4)
(d)
other relevant documentation; and
(e)
the practitioner’s peer review history.
Preparation of Case for Review. After conducting the initial fact-finding
review, QM shall prepare the case for physician review, which may include, as
appropriate, the following:
(a)
completion of the appropriate portions of the applicable review form
(i.e., general, surgical, medical, or obstetrical);
(b)
preparation of a time line or summary of the care provided; and
(c)
identification of relevant patient care protocols or guidelines.
Referral of Case to Leadership Council. Cases shall be referred to the
Leadership Council if they are administratively complex or if QM (in
consultation with the Vice President of Quality and Patient Outcomes, when
necessary) determines that review by the Leadership Council would be
appropriate. Administratively complex cases are those:
(a)
that involve serious clinical issues or that require expedited review as
determined by the Vice President of Quality and Patient Outcomes or
his/her designee (the relevant Department Chair will be notified of the
referral to the Leadership Council in these instances);
(b)
that involve a Department Chair;
(c)
that involve a refusal to cooperate with utilization oversight activities;
(d)
for which there are limited reviewers with the necessary clinical
expertise;
(e)
where there is a trend or pattern of informational letters as described in
Section 4.A of this Policy;
(f)
where a pattern of clinical care appears to have developed despite prior
attempts at collegial intervention/education; or
(g)
where prior participation in a performance improvement plan does not
seem to have addressed identified concerns.
Referral to Appropriate Peer Review Committee. Cases involving trauma care
shall be referred to the Trauma Multi-Disciplinary Peer Review Committee.
Cases involving specific units or situations for which a peer review committee
has been established shall be referred to the appropriate Specialized Peer
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Review Committee. All other cases shall be referred to the appropriate
Department Peer Review Committee.
(5)
5.C
Cases Involving Practitioners from Several Specialties or Departments. Cases
involving practitioners from several specialties or departments shall be referred
to the relevant Department Peer Review Committees for their review. Findings
and assessments of the respective Department Peer Review Committees shall be
forwarded to the PPEC through QM for review at its next regularly scheduled
meeting.
Leadership Council.
(1)
Composition. The Leadership Council shall consist of the Chief Medical
Officer, the Chief of Staff, the Vice Chief of Staff, the Vice President of Quality
and Patient Outcomes, and the Chair of the PPEC. The Chief Nursing Officer
and the Director of Medical Staff Services shall be ex officio members of the
Council, without vote, and their role will be to facilitate the Council’s activities
and determinations.
(2)
Function. The function of the Leadership Council is to triage cases and
expedite the review and evaluation process by determining the most efficient
and appropriate review procedure and to address administrative matters referred
to it, such as the development, review and revision of clinical protocols,
procedures, and policies for approval by the MEC. The Leadership Council may
also address certain matters directly.
(3)
Review of Cases. The Leadership Council shall review all cases referred to it,
including all supporting documentation assembled by QM. Based on its
preliminary review, the Leadership Council shall determine whether any
additional clinical expertise is needed for it to make an appropriate
determination or intervention.
If additional clinical expertise is needed, the Leadership Council may assign the
review to any of the following:
(a)
Medical Staff members who have the clinical expertise necessary to
evaluate the care provided, who shall conduct the review as described in
Appendix A;
(b)
an ad hoc committee composed of such practitioners who shall conduct
the review as described in Appendix A; or
(c)
an external reviewer, in accordance with Section 5.A(4) of this Policy.
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(4)
Determinations and Interventions. Based on its own review and the findings
of the assigned reviewer(s), if any, the Leadership Council may:
(a)
determine that no further review or action is required;
(b)
send an informational or educational letter;
(c)
conduct or facilitate a collegial intervention with the practitioner;
(d)
determine that the matter should be referred to one of the following for
their review and disposition:
(e)
5.D
5.E
(i)
applicable Department or Specialized Peer Review Committee;
(ii)
PPEC; or
(iii)
Medical Executive Committee;
refer the matter for review under the appropriate MIHS or Medical Staff
policy.
Review by Department Peer Review Committees. (A description of the responsibilities
of the Department Peer Review Committees is set forth in Appendix B.) When a
matter is referred to a Department Peer Review Committee, the Committee shall review
it and complete an appropriate review form. Following review of the matter, the
Department Peer Review Committee may:
(1)
determine that no further review or action is required;
(2)
send an informational or educational letter;
(3)
conduct or facilitate a collegial intervention with the practitioner; or
(4)
refer the matter to the:
(a)
Leadership Council; or
(b)
PPEC.
Review by Specialized Peer Review Committees, including the Trauma
Multi-Disciplinary Peer Review Committee. (A description of the responsibilities of
the Specialized Peer Review Committees, including the Trauma Multi-Disciplinary
Peer Review Committee, is set forth in Appendix C.) The Trauma Multi-Disciplinary
Peer Review Committee shall review all trauma cases, making sure that the Committee
representative from the specialty of the practitioner whose care is being reviewed is
involved in the review. Other Specialized Peer Review Committees shall review all
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cases referred to them. Following review (including completion of the appropriate
review form), a Specialized Peer Review Committee, including the Trauma MultiDisciplinary Peer Review Committee, may determine:
(1)
that no further review or action is required;
(2)
to send an informational or educational letter;
(3)
to conduct or facilitate a collegial intervention with the practitioner; or
(4)
to refer the matter to the:
(a)
Leadership Council; or
(b)
PPEC.
If a Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer
Review Committee, determines to send an informational or educational letter or
conduct a collegial intervention, it shall first notify the applicable Department Chair of
its determination and the reasons supporting it. Within 14 days, the Department Chair
shall then review the matter. If the Department Chair does not agree with the findings
and determination of the Specialized Peer Review Committee, the matter shall be
referred to the PPEC, which shall make the final determination on the matter.
Any informational or educational letter sent by a Specialized Peer Review Committee,
including the Trauma Multi-Disciplinary Peer Review Committee, shall be co-signed
by the applicable Department Chair. The relevant Department Chair shall be invited to
participate in any collegial intervention conducted by a Specialized Peer Review
Committee, including the Trauma Multi-Disciplinary Peer Review Committee.
5.F
PPEC.
(1)
Review of Prior Determinations. Each month the PPEC shall audit the
determinations and interventions made by one Department Peer Review
Committee or Specialized Peer Review Committee. In addition, the PPEC shall
review reports from QM, the Leadership Council, Department Peer Review
Committees, and Specialized Peer Review Committees, including the Trauma
Multi-Disciplinary Peer Review Committee, for all cases where it was
determined that (i) no further review or action was required, or (ii) an
informational letter, educational letter or collegial intervention was appropriate
to address the issues presented. The PPEC will also review potential trends
and/or significant occurrences.
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If the PPEC has concerns about any such determination, it may:
(2)
(a)
send the matter back to the Leadership Council or Committee that
conducted the initial review with its questions or concerns and ask that
the matter be reconsidered and findings reported back to it within 30
days; or
(b)
ask an individual Medical Staff member, another Medical Staff
committee or MIHS Department to review the matter and report back to
the PPEC within 30 days, as described in Appendix A; or
(c)
review the matter itself.
Cases Referred to the PPEC for Further Review.
(a)
Review. The PPEC shall review all other matters referred to it along
with all supporting documentation, review forms, findings, and
recommendations. The PPEC may request that one or more individuals
involved in the initial review of a case attend the PPEC meeting and
present the case to the committee. Based on its preliminary review, the
PPEC shall determine whether any additional clinical expertise is needed
to adequately identify and address concerns raised in the case. If
additional clinical expertise is needed, the PPEC may:
(i)
invite a specialist(s) with the appropriate clinical expertise to
attend a PPEC meeting(s) as a guest, without vote, to assist the
PPEC in its review of issues, determinations, and interventions;
(ii)
assign the review to any practitioner on the Medical Staff with
the appropriate clinical expertise, who shall conduct the review
as described in Appendix A;
(iii)
appoint a committee composed of such practitioners, who shall
conduct the review as described in Appendix A; or
(iv)
arrange for an external review in accordance with Section 5.A(4)
of this Policy.
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(b)
6.
Determinations and Interventions. Based on its review of all
information obtained, including input from the practitioner as described
in Section 3, the PPEC may:
(i)
determine that no further review or action is required;
(ii)
send an informational or educational letter;
(iii)
conduct or facilitate a collegial intervention with the practitioner;
(iv)
develop a Performance Improvement Plan; or
(v)
refer the matter to the MEC.
PRINCIPLES OF REVIEW AND EVALUATION
6.A
Incomplete Medical Records. One of the objectives of this Policy is to review matters
and provide feedback to practitioners in a timely manner. Therefore, if a matter
referred for review involves a medical record that is incomplete, the Department Chair
shall request the practitioner to complete the medical record within a specific time
frame.
6.B
Forms. The PPEC shall approve forms to implement this Policy. Such forms shall be
developed and maintained by QM, unless the PPEC directs that another office or
individual develop and maintain specific forms. Individuals performing a function
pursuant to this Policy shall use the form currently approved by the PPEC for that
function.
6.C
Findings and Recommendations Supported by Evidence-Based Research/Clinical
Protocols or Guidelines. Whenever possible, the findings of reviewers and the PPEC
shall be supported by evidence-based research, clinical protocols or guidelines.
6.D
System Process Issues. Quality of care and patient safety depend on many factors in
addition to practitioner performance. If system processes or procedures that may have
adversely affected, or could adversely affect, outcomes or patient safety are identified
through the process outlined in this Policy, the issue shall be referred to the appropriate
MIHS Department and/or QM.
6.E
Tracking of Reviews. QM shall track the processing and disposition of matters
reviewed pursuant to this Policy. The Leadership Council, Department Peer Review
Committees, Specialized Peer Review Committees, including the Trauma
Multi-Disciplinary Peer Review Committee, and the PPEC shall promptly notify QM of
their determinations, interventions and referrals.
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6.F
6.G
Educational Sessions. Educational sessions are an integral and component part of the
peer review process and assist practitioners in continuously improving the quality and
safety of the care they provide. Cases identified at any level of the peer review process
that reflect exemplary care, unusual clinical facts, or possible system issues or, for any
other reason, would be of educational value shall be referred to the appropriate
Department Chair(s) for the purpose of conducting an educational session in
accordance with this Section. .Specifically:
(1)
After the case(s) has been reviewed through the process outlined in Article 5,
the Department Chair(s) may arrange for presentation of the case(s) at a
Department Mortality & Morbidity “M & M” educational session, which will be
supported by QM.
(2)
The particular practitioner(s) who provided care in the case shall be informed, a
reasonable time in advance, that the case is to be presented in an educational
session at least seven days prior to the session. The practitioner shall be
encouraged to attend the session.
(3)
Information identifying the practitioner(s) shall be removed prior to the
presentation, unless the practitioner(s) requests otherwise.
(4)
The M&M Conferences will be conducted in a manner consistent with their
confidential and privileged status under the Arizona peer review law, and will
adhere to the specific guidance set forth in Section 6.G of this Policy.
(5)
Medical Staff members, Residents, and Students are encouraged and expected
to participate in the M&M Conferences in order to assess and continuously
improve the care they provide, but they shall be required to sign a
confidentiality statement before doing so.
(66)
M&M Conferences are intended to serve as an education forum to discuss cases
that have been presented in Peer Review. However, if any case is identified in
an M&M Conference that (i) raises questions or concerns with the clinical
practice or professional conduct of an individual practitioner, and (ii) has not
already been reviewed as part the peer review process, the case shall be referred
for review in accordance with Article 5 of this Policy.
Confidentiality. Maintaining confidentiality is a fundamental and essential element of
an effective peer review process.
(1)
Documentation. All documentation that is prepared in accordance with this
Policy shall be maintained in appropriate Medical Staff files.
This
documentation shall be accessible to authorized officials and Medical Staff
Leaders and committees having responsibility for credentialing and peer review
functions, and to those assisting them in those tasks. All such information shall
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otherwise be deemed confidential and kept from disclosure or discovery to the
fullest extent permitted by Arizona or federal law.
6.H
(2)
Participants in the Peer Review Process. All individuals involved in the peer
review process (Medical Staff and MIHS employees) will maintain the
confidentiality of the process. All such individuals shall sign an appropriate
Confidentiality Agreement on a yearly basis.
(3)
Peer Review Communications. Communications among those participating in
the peer review process, including communications with the individual
practitioner involved, shall be conducted in a manner reasonably calculated to
assure privacy.
(a)
Telephone and in-person conversations shall take place in private at
appropriate times and locations.
(b)
MIHS e-mail may be used to communicate between individuals
participating in the peer review process, including with assigned
reviewers and with the practitioner whose care is being reviewed.
Private, personal e-mail accounts shall not be used. Transmission of
confidential information via e-mail through the MIHS/District Medical
Group (DMG) network shall be done in accordance with MIHS Policy
#79752 and shall include “Privileged and Confidential Peer Review or
Quality Assurance”) in the subject line. As noted previously in this
Policy, any Performance Improvement Plan that may be developed for a
practitioner shall be hand-delivered and personally discussed with the
practitioner.
(c)
All correspondence (whether paper or electronic) shall be conspicuously
marked with the notation “Confidential Peer Review,” “Confidential, to
be Opened Only by Addressee” or words to that effect.
(d)
If it is necessary to e-mail medical records or other documents
containing a patient’s protected health information, MIHS policies
governing compliance with the HIPAA Security Rule shall be followed.
Conflict of Interest Guidelines. To protect the integrity of the review process, all those
involved must be sensitive to potential conflicts of interest. It is also important to
recognize that effective peer review involves “peers” and that the PPEC does not make
any recommendation that would adversely affect the clinical privileges of a practitioner
(which is only within the authority of the MEC). As such, the conflict of interest
guidelines outlined in Article 8 of the Credentials Policy shall be used in assessing and
resolving any potential conflicts of interest that may arise under this Policy.
Additional guidance pertaining to conflicts of interest principles can be found in
Appendix F.
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6.I
7.
Legal Protection for Reviewers. It is the intention of MIHS and the Medical Staff that
the peer review process outlined in this Policy be considered patient safety, professional
review, and peer review activity within the meaning of the Patient Safety Quality
Improvement Act of 2005, the federal Health Care Quality Improvement Act of 1986,
and Arizona law. In addition to the protections offered to individuals involved in
professional review activities under those laws, such individuals shall be covered under
MIHS’s Directors’ and Officers’ Liability insurance and/or will be indemnified by
MIHS when they act within the scope of their duties as outlined in this Policy and
function on behalf of MIHS.
PEER REVIEW REPORTS
7.A
Practitioner Peer Review History Reports. A practitioner peer review history report
shall be generated for each practitioner for consideration and evaluation by the
appropriate Department Chair and the Credentials Committee in the reappointment
process. Such reports shall include all cases within the previous two years that resulted
in an informational or educational letter, a collegial intervention or performance
improvement plan.
7.B
Reports to MEC and Board. QM shall prepare reports at least annually showing the
aggregate number of cases reviewed through the peer review process and the
dispositions of those matters.
7.C
Reports on Request. QM shall prepare reports as requested by the Leadership Council,
Department Chairs, Department or Specialized Peer Review Committees, including the
Trauma Multi-Disciplinary Peer Review Committee, PPEC, MEC, MIHS management,
or the Board.
Adopted by the MEC on March 10, 2015.
Adopted by the Maricopa Special Health Care District Board of Directors on ____________.
Approved: 11/09, 06/10, 03/11, 01/12, 01/13, 10/14, 03/15
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APPENDIX A
RESPONSIBILITIES OF ASSIGNED REVIEWERS
From time to time, the Leadership Council or the PPEC may assign the review and assessment of
the care provided in a particular case to a physician with the necessary clinical expertise.
The responsibilities of such Assigned Reviewers include the following:

Initial Review and Documentation
Review the pertinent parts of the medical record and all supporting documentation and
document his or her assessment and findings using the specific review form provided by
the committee that assigned the review. These forms have been developed by the PPEC
to facilitate an objective, consistent, and competent review of each case.

Time Frame
Assigned Reviewers shall submit completed review forms to the committee that assigned
the case within 30 days. A reminder will be sent if the review is not completed within
this time frame.

Review Process Following Assigned Reviewer’s Assessment
Review forms completed by an Assigned Reviewer will be reviewed and considered by
the committee that assigned the review. The Assigned Reviewer will be contacted if
additional information and expertise are necessary to facilitate the review. In certain
cases, an Assigned Reviewer may be requested to attend a Leadership Council or PPEC
meeting in order to discuss his or her findings and answer questions.

Confidentiality
Assigned Reviewers must maintain all information regarding a review in a strictly
confidential manner. Specifically, this is a peer review-protected activity and Assigned
Reviewers may not discuss matters under review with anyone outside of the process. If
an Assigned Reviewer has not signed a Confidentiality Agreement within the past 12
months, QM will ask the reviewer to do so before he or she performs the review.

Legal Protections
When performing a review, Assigned Reviewers are acting on behalf of MIHS and the
PPEC. As such, they have significant legal, bylaws, insurance, and indemnification
protections.
APPENDIX B
RESPONSIBILITIES OF DEPARTMENT PEER REVIEW COMMITTEES
The basic responsibilities of Department Peer Review Committees in the peer review process are
as follows, which supplement the provisions contained in the Peer Review Policy:
(1)
Review cases referred by the QM, the Leadership Council, or the PPEC. The
responsibilities of Department Peer Review Committees when directly reviewing a case
are the same as those outlined in Appendix A for Assigned Reviewers.
(2)
Obtain Input from a Practitioner Prior to Pursuing Any Intervention to address a concern
that has been identified.
(3)
Determine Appropriate Intervention/Referral. Following review, Department Peer
Review Committees shall make one of the following determinations:
(4)
(i)
no issue ̶ close case;
(ii)
prepare and send an informational or educational letter;
(iii)
conduct or facilitate a collegial intervention (face-to-face discussion);
(iv)
refer to the Leadership Council; or
(v)
refer and present case to the PPEC.
Report to PPEC. All determinations or interventions made by Department Peer Review
Committees shall be reported to the PPEC. Members of a Department Peer Review
Committee may be requested to attend a PPEC meeting in order to discuss the
committee’s findings and answer questions.
APPENDIX C
RESPONSIBILITIES OF SPECIALIZED PEER REVIEW COMMITTEES, INCLUDING
THE TRAUMA MULTI-DISCIPLINARY PEER REVIEW COMMITTEE
The basic responsibilities of Specialized Peer Review Committees, including the Trauma
Multi-Disciplinary Peer Review Committee, in the peer review process are as follows, which
supplement the provisions contained in the Peer Review Policy:
(1)
Review Cases Referred by the QM, the Leadership Council, or the PPEC. The
responsibilities of Specialized Peer Review Committees when directly reviewing a case
are the same as those outlined in Appendix A for Assigned Reviewers.
(2)
For Trauma Multi-Disciplinary Peer Review Committee Only: Involve in the review the
Committee representative from the specialty of the practitioner whose care is being
reviewed.
(3)
Obtain Input from a Practitioner Prior to Pursuing Any Intervention to address a concern
that has been identified.
(4)
Determine Appropriate Intervention/Referral. Following review, Specialized Peer
Review Committees shall make one of the following determinations:
(i)
no issue ̶ close case;
(ii)
prepare and send an informational or educational letter;
(iii)
conduct or facilitate a collegial intervention (face-to-face discussion);
(iv)
refer to the Leadership Council; or
(v)
refer and present case to the PPEC.
(5)
Notify Department Chair of Proposed Intervention. If the Specialized Peer Review
Committee, including the Trauma Multi-Disciplinary Peer Review Committee,
determines to send an informational or educational letter or conduct a collegial
intervention, it shall notify the relevant Department Chair of the preliminary intervention.
The Department Chair shall then have 14 days to provide input regarding the proposed
intervention.
(6)
Implement Intervention or Refer to PPEC. If the Specialized Peer Review Committee
and Department Chair agree on the appropriate intervention, the Committee may
implement the determination, including the Department Chair, as the Department Chair
deems appropriate. If the Specialized Peer Review Committee and Department Chair do
not agree on the appropriate intervention, the matter shall be referred to the PPEC for
final determination.
1
(7)
Report to PPEC. All determinations or interventions made by Specialized Peer Review
Committees, including the Trauma Multi-Disciplinary Peer Review Committee, shall be
reported to the PPEC. Members of a Specialized Peer Review Committee may be
requested to attend a PPEC meeting in order to discuss the committee’s findings and
answer questions.
2
APPENDIX D
PERFORMANCE IMPROVEMENT PLAN OPTIONS
(May be used individually or combined)
IMPLEMENTATION ISSUES CHECKLIST
(For use by the PPEC)
TABLE OF CONTENTS
PAGE
Additional Education/CME .............................................................................................................1
Prospective Monitoring ....................................................................................................................2
Second Opinions/Consultations .......................................................................................................3
Concurrent Proctoring ......................................................................................................................6
Formal Evaluation/Assessment Program .........................................................................................9
Additional Training ........................................................................................................................10
Educational Leave of Absence.......................................................................................................11
“Other” ...........................................................................................................................................12
PIP OPTION
Additional Education/CME
IMPLEMENTATION ISSUES
Scope of Requirement
 Be specific – what type?
Wide range of options
 Acceptable programs include:
 PPEC approval required before practitioner enrolls.
 Program approved:
 Date of approval:
 Time frames
 Practitioner must enroll by:
 CME must be completed by:





Who pays for the CME/course?
Practitioner subject to PIP
Medical Staff
MIHS
Combination:
 Documentation of completion must be submitted to PPEC.
 Date submitted:
Additional Safeguards
 Will the individual be asked to voluntarily refrain from exercising relevant clinical
privileges until completion of additional education?  Yes  No
Follow-Up
 After CME has been completed, how will monitoring be done to be sure that
concerns have been addressed/practice has improved? (Focused prospective
monitoring? Proctoring?)
1
PIP OPTION
Prospective Monitoring
100% focused review
of next X cases
(e.g., obstetrical cases,
laparoscopic surgery)
IMPLEMENTATION ISSUES
Scope of Requirement
 How many cases are subject to review?
 What types of cases are subject to review?
 Based on practitioner’s practice patterns, estimated time for completion of
monitoring?
 Does monitoring include more than review of medical record?
 Yes  No If yes, what else does it include?
 Review to be done:
 Post-discharge
 During admission
 Review to be done by:
 QM
 Department Chair
 CMO
 Other:
 Must practitioner notify reviewer of cases subject to requirement?
 Yes  No Other options?
Documentation of Review
 General Case Review Worksheet
 Surgical Review Worksheet
 Medical Review Worksheet
 Specific form developed for this review
 General summary by reviewer
 Other:
Results of Monitoring
 Who will review results of monitoring with practitioner?
 After each case
 After total # of cases subject to review
2
PIP OPTION
Second Opinions/
Consultations
Before the practitioner
proceeds with a particular
treatment plan or
procedure, he or she
obtains a second opinion or
consultation.
(This is not a “restriction”
of privileges that
triggers a hearing
and reporting,
if implemented correctly.)
IMPLEMENTATION ISSUES
Scope of Requirement
 How many cases subject to second opinion/consultation requirement?
 What types of cases are subject to second opinion/consultation requirement?
 Based on practice patterns, estimated time for completion of second
opinion/consultation requirement?
 Must consultant evaluate patient in person prior to treatment/procedure?
 Yes  No
Responsibilities of Practitioner
 Notify consultant when patient subject to requirement is admitted or procedure
is scheduled and all information necessary to provide consultation is available
in the medical record (H&P, results of diagnostic tests, etc.).
 What time frame for notice to consultant is practical and reasonable
(e.g., two days prior to scheduled, elective procedure)?
 If consultant must evaluate patient prior to treatment, inform patient that
consultant will be reviewing medical record and will examine patient.
 If consultant must evaluate patient prior to treatment, include general progress
note in medical record noting that consultant examined patient and discussed
findings with practitioner.
 Discuss proposed treatment/procedure with consultant.
3
PIP OPTION
Second
Opinions/Consultations
Before the practitioner
proceeds with a particular
treatment plan or
procedure, he or she
obtains a second opinion or
consultation.
(This is not a “restriction”
of privileges that
triggers a hearing
and reporting,
if implemented correctly.)
IMPLEMENTATION ISSUES
Qualifications of Consultant
 Consultant must have clinical privileges in
.
 Possible candidates include:
 The following individuals agreed to act as consultants and were approved by
the PPEC (or designees) on:
(date)
Responsibilities of Consultant (Information provided by PPEC; include discussion
of legal protections for consultant.)
 Review medical record prior to treatment or procedure.
 Evaluate patient prior to treatment or procedure, if applicable.
 Discuss proposed treatment/procedure with physician.
 Complete Second Opinion/Consultation Form and submit to
QM (not for inclusion in the medical record).
Disagreement Regarding Proposed Treatment/Procedure
If consultant and physician disagree regarding proposed treatment/procedure,
consultant notifies one of the following so that an immediate meeting can be
scheduled to resolve the disagreement:
 CMO
 Chief of Staff
 PPEC Chair
 Department Chair
 Other:
4
PIP OPTION
Second
Opinions/Consultations
Before the practitioner
proceeds with a particular
treatment plan or
procedure, he or she
obtains a second opinion or
consultation.
(This is not a “restriction”
of privileges that
triggers a hearing
and reporting,
if implemented correctly.)
IMPLEMENTATION ISSUES
Compensation for Consultant (consultant cannot bill for consultation)
 No compensation
 Compensation by:
 Practitioner subject to PIP
 Medical Staff
 MIHS
 Combination
Results of Second Opinion/Consultations
 Who will review results of second opinion/consultations with practitioner?
 After each case
 After total # of cases subject to review

Include consultants’ reports in practitioner’s quality file
Additional Safeguards
 Will practitioner be removed from some/all on-call responsibilities until second
opinion/consultation requirement is completed?  Yes  No
5
PIP OPTION
Concurrent
Proctoring
A certain number of the
practitioner’s future cases
of a particular type (e.g.,
vascular cases,
management of diabetic
patients) must be directly
observed.
(This is not a “restriction”
of privileges that
triggers a hearing
and reporting,
if implemented correctly.)
IMPLEMENTATION ISSUES
Scope of Requirement
 How many cases are subject to concurrent proctoring requirement?
 What types of cases are subject to proctoring requirement?
 Based on practice patterns, estimated time for completion of proctoring
requirement?
Responsibilities of Practitioner
 Notify proctor when patient subject to requirement is admitted or procedure is
scheduled and all information necessary for proctor to evaluate case is available
in the medical record (H&P; results of diagnostic tests, etc.).
 What time frame for notice to proctor is practical and reasonable
(e.g., two days prior to scheduled, elective procedure)?
 Procedures: Inform patient that proctor will be present during procedure, may
examine patient and may participate in procedure, and document patient’s
consent on informed consent form.
 Medical: If proctor will personally assess patient or will participate in patient’s
care, discuss with patient prior to proctor’s examination.
 Include general progress note in medical record noting that proctor examined
patient and discussed findings with practitioner, if applicable.
 Agree that proctor has authority to intervene, if necessary.
 Discuss treatment/procedure with proctor.
6
PIP OPTION
Concurrent
Proctoring
A certain number of the
practitioner’s future cases
of a particular type (e.g.,
vascular cases,
management of diabetic
patients) must be directly
observed.
(This is not a “restriction”
of privileges that
triggers a hearing
and reporting,
if implemented correctly.)
IMPLEMENTATION ISSUES
Qualifications of Proctor (PPEC must approve)
 Proctor must have clinical privileges in
.
(If proctor is not member of Medical Staff, credential and grant temporary
privileges.)
 Possible candidates include:
 The following individuals agreed to act as proctors and were approved by the
PPEC (or designees) on
:
(date)
Responsibilities of Proctor (information provided by PPEC; include discussion of
legal protections for proctor)
 Review medical record and:
 Procedure: Be present for the relevant portions of the procedure and
remain throughout procedure and be available post-op if complications
arise.
 Medical: Be available during course of treatment to discuss treatment plan,
orders, lab results, discharge planning, etc., and personally assess patient, if
necessary.
 Intervene in care if necessary to protect patient and document such intervention
appropriately in medical record.
 Discuss treatment plan/procedure with practitioner.
 Document review as indicated below and submit to QM.
Documentation of Review (not for inclusion in the medical record)
 General Case Review Worksheet
 Surgical Review Worksheet
 Medical Review Worksheet
 Specific form developed for this PIP
 Other:
7
PIP OPTION
Concurrent
Proctoring
A certain number of the
practitioner’s future cases
of a particular type (e.g.,
vascular cases;
management of diabetic
patients) must be directly
observed.
(This is not a “restriction”
of privileges that
triggers a hearing
and reporting,
if implemented correctly.)
IMPLEMENTATION ISSUES
Compensation for Proctor (proctor cannot bill for review of medical record or
assessment of patient and cannot act as first assistant)
 No compensation
 Compensation by:
 Practitioner subject to PIP
 Medical Staff
 MIHS
 Combination
Results of Proctoring
 Who will review results of proctoring with practitioner?
 After each case
 After total # of cases subject to review
 Include proctor reports in practitioner’s quality file
Additional Safeguards
 Will practitioner be removed from some/all on-call responsibilities until
proctoring is completed?  Yes  No
8
PIP OPTION
Formal Evaluation/
Assessment Program
Onsite multiple-day
programs that may include
formal testing, simulated
patient encounters, chart
review.
IMPLEMENTATION ISSUES
Scope of Requirement
 Acceptable programs include:
 PPEC approval required before practitioner enrolls
 Program approved:
 Date of approval:
 Who pays for the evaluation/assessment?
 Practitioner subject to PIP
 Medical Staff
 MIHS
 Combination:
Practitioner’s Responsibilities
 Sign release allowing PPEC to provide information to program (if necessary)
and program to provide report of assessment and evaluation to PPEC.
 Enroll in program by:
 Complete program by:
Additional Safeguards
 Will the individual be asked to voluntarily refrain from exercising relevant
clinical privileges until completion of evaluation/ assessment program?
 Yes  No
 Will practitioner be removed from some/all on-call responsibilities until
completion of evaluation/assessment program?  Yes  No
Follow-Up
 Based on results of assessment, what additional interventions are necessary, if
any?
 How will monitoring after assessment program/any additional interventions be
conducted to be sure that concerns have been addressed/practice has improved?
(Focused prospective review? Proctoring?)
9
PIP OPTION
Additional Training
Wide range of options from
hands-on CME to
simulation to repeat of
residency or fellowship.
IMPLEMENTATION ISSUES
Scope of Requirement
 Be specific – what type?
 Acceptable programs include:
 PPEC approval required before practitioner enrolls.
 Program approved:
 Date of approval:
 Who pays for the training?
 Practitioner subject to PIP
 Medical Staff
 MIHS
 Combination:
Practitioner’s Responsibilities
 Sign release allowing PPEC to provide information to training program (if
necessary) and program to provide detailed evaluation/assessment to PPEC
before resuming practice.
 Enroll in program by:
 Complete program by:
Additional Safeguards
 Will the individual be asked to voluntarily refrain from exercising relevant clinical
privileges until completion of additional training?  Yes  No
 Will practitioner be removed from some/all on-call responsibilities until
completion of additional training?  Yes  No
 Is LOA required?  Yes  No
Follow-Up
 After additional training is completed, how will monitoring be conducted to be
sure that concerns have been addressed/practice has improved? (Focused
prospective review? Proctoring?)
10
PIP OPTION
Educational Leave of Absence
IMPLEMENTATION ISSUES
 Who may grant the LOA? (Review Bylaws or applicable Policy)
 Specify conditions for reinstatement:
 What happens if the practitioner agrees to LOA, but…
 does not return to practice at MIHS? Will this be considered
resignation in return for not conducting an investigation and thus
be reportable?
 Yes  No
 moves practice across town? Must practitioner notify other
Hospital of educational leave of absence?
 Yes  No
11
PIP OPTION
IMPLEMENTATION ISSUES
“Other”
Wide latitude to utilize other
ideas as part of PIP, tailored to
specific concerns.
Examples:
• Participate in an educational session
at section or department meeting and
assess colleagues’ approach to case.
• Study issue and present grand
rounds.
• Design and use informed consent
forms approved by PPEC.
• Design and use indication forms
approved by PPEC.
• Limit inpatient census.
• Limit number of procedures in any
one day/block schedule.
• No elective procedures to be
performed after ___ p.m.
• All patient rounds done by certain
time of day – timely orders, tests,
length of stay concerns.
• Personally see each patient prior to
procedure (rather than using PA,
NP, or APRN).
• Personally round on patients –
cannot rely solely on PA, NP, or
APRN.
• Utilize individuals from other
specialties to assist in PIPs (e.g.,
cardiologist experiencing difficulties
with TEE technical complications
mentored by anesthesiologists).
12
APPENDIX F
CONFLICT OF INTEREST GUIDELINES
LEVELS OF PARTICIPATION
Committee Member
Provide
Information
Individual
Reviewer
Application/
Case
Family member
Y
N
Department,
Specialized,
or Trauma
MultiDisciplinary
Peer Review
R
Employment
relationship
with hospital
Y
Y
Partner
Y
Direct or
indirect
financial impact
Potential
Conflicts
Hearing
Panel
Board
N
N
R
Y
Y
Y
Y
Y
Y
N
N
R
Y
Y
Y
N
N
R
Y
Y
Y
Y
N
N
R
Y
Y
Y
Y
Y
N
N
R
Y
Y
Y
Y
Y
Y
N
N
R
Y
Y
Y
Y
Y
Y
Y
N
N
R
Reviewed at
prior level
Y
Y
Y
Y
Y
Y
Y
N
N
R
Raised the
concern
Y
Y
Y
Y
Y
Y
Y
N
N
R
Credentials
Leadership
Council
PPEC
MEC
Ad Hoc
Investigating
R
R
R
R
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Competitor
Y
Y
Y
History of
conflict
Y
Y
Close friends
Y
Personally
involved in care
of patient
1
Y
–
(green “Y”) means the Interested Member may serve in the indicated role, no extra precautions are necessary.
Y
–
(yellow “Y”) means the Interested Member may generally serve in the indicated role. It is legally-permissible for Interested Members to serve in these
roles because of the check and balance provided by the multiple levels of review and the fact that the Department Peer Review, Specialized Peer Review
Committee, Trauma Multi-disciplinary Peer Review Committee, Credentials Committee, Leadership Council, and PPEC have no disciplinary authority.
In addition, the Chair of the Credentials Committee, Department Peer Review, Specialized Peer Review Committee, Trauma Multi-disciplinary Peer
Review Committee, Leadership Council, or PPEC always has the authority and discretion to recuse a member in a particular situation if the Chair
determines that the Interested Member’s presence would inhibit the full and fair discussion of the issue before the committee, skew the recommendation
or determination of the committee, or otherwise be unfair to the practitioner under review.
Allowing Interested Members to participate in the credentialing or professional practice evaluation process underscores the importance of establishing
(i) objective threshold criteria for appointment and clinical privileges, (ii) objective criteria to review cases while performing peer review activities
(adopted protocols, etc.), and (iii) objective review and evaluation forms to be used by reviewers.
N
–
(red “N”) means the individual may not serve in the indicated role.
R
–
(red “R”) means the individual must be recused in accordance with the rules for recusal.
Rules for Recusal

Interested Members must leave the meeting room prior to the committee’s or Board’s final deliberation and determination, but may answer
questions and provide input before leaving.

Recusal shall be specifically documented in the minutes.

Whenever possible, the actual or potential conflict should be raised and resolved prior to the meeting by the committee or Board chair and the
Interested Member informed of the recusal determination in advance.

No Medical Staff member has the RIGHT to demand recusal – that determination is within the discretion of the Medical Staff Leaders.

Voluntarily choosing to refrain from participating in a particular situation is not a finding or an admission of an actual conflict or any improper
influence on the process.
2
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 3.b.iv.
Medical Staff
MEDICAL STAFF BYLAWS, POLICIES, AND
RULES AND REGULATIONS
OF
MARICOPA INTEGRATED HEALTH SYSTEM
MEDICAL STAFF
ORGANIZATION MANUAL
DRAFT
03/2015
TABLE OF CONTENTS
PAGE
1.
2.
3.
GENERAL ..........................................................................................................................1
1.A.
DEFINITIONS .........................................................................................................1
1.B.
TIME LIMITS .........................................................................................................2
1.C.
DELEGATION OF FUNCTIONS ..........................................................................2
CLINICAL DEPARTMENTS ..........................................................................................3
2.A.
LIST OF DEPARTMENTS .....................................................................................3
2.B.
FUNCTIONS AND RESPONSIBILITIES OF DEPARTMENTS .........................3
MEDICAL STAFF COMMITTEES................................................................................4
3.A.
MEDICAL STAFF COMMITTEES AND FUNCTIONS ......................................4
3.B.
MEETINGS, REPORTS AND RECOMMENDATIONS ......................................4
3.C.
BEHAVIOR PEER REVIEW COMMITTEE .........................................................4
3.D
CONTINUING MEDICAL EDUCATION……………………………………… 4
3.E.
CREDENTIALS COMMITTEE .............................................................................6
3.F.
GRADUATE MEDICAL EDUCATION COMMITTEE .......................................6
3.G.
MEDICAL EXECUTIVE COMMITTEE ...............................................................7
3.H.
PHARMACY AND THERAPEUTICS COMMITTEE ..........................................7
3.I.
PROFESSIONAL PRACTICE EVALUATION COMMITTEE ............................8
3.J.
PRACTITIONER WELLNESS COMMITTEE ......................................................9
3.K.
QUALITY MANAGEMENT COUNCIL (QMC) ................................................10
3.LK. TRAUMA MULTI-DISCIPLINARY PEER REVIEW COMMITTEE ...............10
MARICOPA INTEGRATED HEALTH SYSTEM
MEDICAL STAFF ORGANIZATIONAL MANUAL – Draft: 03/2015 (Supersedes 04/23/2014)
Page
i
PAGE
4.
AMENDMENTS ..............................................................................................................12
5.
ADOPTION ......................................................................................................................13
MARICOPA INTEGRATED HEALTH SYSTEM
MEDICAL STAFF ORGANIZATIONAL MANUAL – Draft: 03/2015 (Supersedes 04/23/2014)
Page
ii
ARTICLE 1
GENERAL
1.A: DEFINITIONS
The following definitions shall apply to terms used in this Manual:
(1)
"ALLIED HEALTH PROFESSIONALS" ("AHPs") means individuals other than
Medical Staff members who are authorized by law and by the Hospital to provide
patient care services.
(2)
"BOARD" means the Governing Body of the Maricopa County Special
Healthcare District (d.b.a., Maricopa Integrated Health System ("MIHS")), which
has the overall responsibility for the Hospital.
(3)
"CHIEF EXECUTIVE OFFICER" ("CEO") means the individual appointed by
the Board to act on its behalf in the overall management of the Hospital.
(4)
"CHIEF MEDICAL OFFICER" ("CMO") means the individual appointed by the
CEO to act as the Chief Medical Officer of the Hospital, in cooperation with the
Chief of Staff.
(5)
"CLINICAL PRIVILEGES" or "PRIVILEGES" means the authorization granted
by the Board to render specific patient care services, for which the Medical Staff
leaders and Board have developed eligibility and other privileging criteria and
focused and ongoing professional practice evaluation standards.
(6)
"DAYS" means calendar days.
(7)
"DENTIST" means a doctor of dental surgery ("D.D.S.") or doctor of dental
medicine ("D.M.D.").
(8)
"HOSPITAL" means the Maricopa Integrated Health System, which includes the
Maricopa Medical Center and all of its affiliated inpatient, ancillary, outpatient,
and licensed health services, facilities, departments and programs, including the
Desert Vista Behavioral Health Center, Comprehensive Healthcare Centers, and
Family Health Centers.
(9)
"MEDICAL EXECUTIVE COMMITTEE" or "MEC" means the Executive
Committee of the Medical Staff.
(10)
"MEDICAL STAFF" means all physicians, dentists, oral surgeons, and podiatrists
who have been appointed to the Medical Staff by the Board.
MARICOPA INTEGRATED HEALTH SYSTEM
MEDICAL STAFF ORGANIZATIONAL MANUAL – Draft: 03/2015 (Supersedes 04/23/2014)
Page
1
(11)
"MEDICAL STAFF LEADER" means any Medical Staff officer, department
chair, or committee chair.
(12)
"MEDICAL STAFF OFFICER" means the Medical Staff elected officers
consisting of Chief of Staff, Vice Chief of Staff, and Immediate Past Chief of
Staff.
(13)
"MEMBER" means any physician, dentist, oral surgeon, and podiatrist who has
been granted Medical Staff appointment by the Board to practice at the Hospital.
(14)
"NOTICE" means written communication by regular U.S. mail, e-mail, facsimile,
Hospital mail, or hand delivery.
(15)
"ORAL AND MAXILLOFACIAL SURGEON" means an individual with a
D.D.S. or a D.M.D. degree, who has completed additional training in oral and
maxillofacial surgery.
(16)
"PHYSICIAN" includes both doctors of medicine ("M.D.s") and doctors of
osteopathy ("D.O.s") (or equivalent).
(17)
"PODIATRIST" means a doctor of podiatric medicine ("D.P.M.").
(18)
"SPECIAL NOTICE" means hand delivery, certified mail (return receipt
requested), or overnight delivery service providing receipt.
1.B: TIME LIMITS
Time limits referred to in this Manual are advisory only and are not mandatory, unless it
is expressly stated that a particular right is waived by failing to take action within a
specified period.
1.C: DELEGATION OF FUNCTIONS
(1)
When a function is to be carried out by a member of Hospital management, by a
Medical Staff member, or by a Medical Staff committee, the individual, or the
committee through its chair, may delegate performance of the function to one or
more designees unless such delegation is expressly prohibited elsewhere in this
Manual or the related Medical Staff documents.
(2)
When a Medical Staff member is unavailable to perform a necessary function, one
or more of the Medical Staff Leaders may perform the function personally or
delegate it to another appropriate individual.
MARICOPA INTEGRATED HEALTH SYSTEM
MEDICAL STAFF ORGANIZATIONAL MANUAL – Draft: 03/2015 (Supersedes 04/23/2014)
Page
2
ARTICLE 2
CLINICAL DEPARTMENTS
2.A: LIST OF DEPARTMENTS
The following clinical departments are established:
Anesthesiology
Dentistry
Emergency Medicine
Family and Community Medicine
Internal Medicine
Obstetrics, Gynecology, and Women's Health
Orthopedic Surgery
Pathology
Pediatrics
Psychiatry
Radiology
Surgery
2.B: FUNCTIONS AND RESPONSIBILITIES OF DEPARTMENTS
The functions and responsibilities of departments and department chairs are set forth in
Article 4 of the Medical Staff Bylaws.
MARICOPA INTEGRATED HEALTH SYSTEM
MEDICAL STAFF ORGANIZATIONAL MANUAL – Draft: 03/2015 (Supersedes 04/23/2014)
Page
3
ARTICLE 3
MEDICAL STAFF COMMITTEES
3.A: MEDICAL STAFF COMMITTEES AND FUNCTIONS
(1)
This Article outlines the Medical Staff committees that carry out ongoing and
focused professional practice evaluations and other performance improvement
functions that are delegated to the Medical Staff by the Board.
(2)
Procedures for the appointment of committee chairs and members of the
committees are set forth in Article 5 of the Medical Staff Bylaws.
3.B: MEETINGS, REPORTS AND RECOMMENDATIONS
Unless otherwise indicated, each committee described in this Manual shall meet as
necessary to accomplish its functions, and shall maintain a permanent record of its
findings, proceedings, and actions. Each committee shall make a timely written report
after each meeting to the MEC and to other committees and individuals as may be
indicated in this Manual.
3.C: BEHAVIOR PEER REVIEW COMMITTEE
3.C.1. Composition:
The Behavior Peer Review Committee shall consist of at least five members of the
Medical Staff from various clinical specialties. The CMO shall also serve on the
committee, with vote.
3.C.2. Duties:
The Behavior Peer Review Committee shall review concerns regarding inappropriate
behavior by members of the Medical Staff and by Allied Health Professionals, in
accordance with the Medical Staff Professionalism Policy.
3.D. CONTINUING MEDICAL EDUCATION COMMITTEE
3.D.1. Composition
The Continuing Medical Education Committee shall consist of the VP of Academic
Affairs, Director of Academic Affairs, and at least two Active Staff members who are
broadly representative of the various departments of the Medical Staff. Representatives
from Quality Management, Risk Management, Patient Safety, Pharmacy, Education and
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Organizational Development, or other individuals with desired expertise may be
appointed to the committee by the chair, or serve as ad hoc members as needed. The
Director of Academic Affairs and the CME manager shall be an ex officio members of the
committee, without vote. All CME Coordinators are welcome and encouraged to attend
the committee meetings.
3.D.2 Duties
Continuing Medical Education is required for maintenance of a physician’s state licensure
in Arizona. Hospital accreditation now has a major pathway that encompasses both
quality measures and physician performance of national guidelines in patient care. Many
of these measures are compatible with a performance improvement initiative allowing
CME as the primary intervention for change.
The Continuing Medical Education program at MIHS is fully accredited by the
Accreditation Council on Continuing Medical Education, requiring our full compliance
with the national standards that are in force. Each department at MIHS that offers CME
programs must follow and stay current with these standards. Our CME Office and
committee facilitate and assist each department in the development of these programs,
while maintaining the criteria for full accreditation. By working closely with our Quality
and Patient Safety personnel and their active participation on the committee, we enhance
the DNV accreditation process for MIHS. The Continuing Medical Education Committee
is dedicated to providing assistance in developing programs that are valid and fully
compliant. In accordance with the ACCME standards, the CME committee will review
and approve the granting of Continuing Medical Education credit by the District for:
a. Internal conferences within the Medical Center
b. State, regional and national conferences involving providershipsponsorship by the
District
c. Compliance with ACCME standards will be monitored by:
i.
Review of the linkage between needs assessment and program presentations
ii. Annual assessment of education outcomes as measured in part by 1) Improved
participant knowledge (survey); and 2) Improved hospital or clinical quality
indicators
iii. Application process for Continuing Medical Education (CME) credits by each
department
iv. Attendee program evaluations
v.
Overall CME program evaluations
d. Rescind any CME credit granted if non-compliance with the ACCME Standards or the
District Policy on Continuing Medical Education are identified
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3.E: CREDENTIALS COMMITTEE
3.E.1. Composition:
The Credentials Committee shall consist of the CMO and the Chief of Staff (both with
vote) and at least seven Active Staff members, who are broadly representative of the
various departments of the Medical Staff. Particular consideration for the members is to
be given to physicians knowledgeable in the credentialing and quality improvement
processes. The Director of Medical Staff Services shall be an ex officio member of the
committee, without vote. Other individuals, such as the Chief Nursing Officer or the
Director of Quality Management, may be invited to attend on an ad hoc basis, as
applicable.
3.E.2. Duties:
The Credentials Committee shall:
(a)
in accordance with the Credentials Policy, review the credentials of all applicants
for Medical Staff appointment, reappointment, and clinical privileges, conduct a
thorough review of the applications, interview such applicants as may be
necessary, and make written reports of its findings and recommendations;
(b)
in accordance with the Policy on Allied Health Professionals, review the
credentials of all applicants seeking to practice as Licensed Independent
Practitioners and Advanced Dependent Practitioners, conduct a thorough review
of the applications, interview such applicants as may be necessary, and make
written reports of its findings and recommendations;
(c)
review, as may be requested by the MEC, all information available regarding the
current clinical competence and behavior of persons currently appointed to the
Medical Staff or Allied Health Professionals and, as a result of such review, make
a written report of its findings and recommendations; and
(d)
review and make recommendations regarding appropriate threshold eligibility
criteria for clinical privileges within the Hospital, including specifically as set
forth in Section 4.A.3 ("Clinical Privileges for New Procedures") and
Section 4.A.4 ("Clinical Privileges That Cross Specialty Lines") of the
Credentials Policy.
3.F: GRADUATE MEDICAL EDUCATION COMMITTEE
The Graduate Medical Education Committee is a Medical Staff committee. The
composition, charter, and meeting requirements of this committee are governed by the
ACGME and are maintained in a separate policy and procedure that is approved by the
Medical Executive Committee.
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3.G: MEDICAL EXECUTIVE COMMITTEE
The composition and duties of the MEC are set forth in Section 5.D of the Medical Staff
Bylaws.
3.H: PHARMACY AND THERAPEUTICS COMMITTEE
3.H.1. Composition:
The Pharmacy and Therapeutics Committee shall consist of at least one (1) Active Staff
representative from a majority of the clinical departments, one (1) representative from the
nursing service, nutrition, house staff, administration, and quality on a routine or ad hoc
basis; the Pharmacy Director, or his/her designee, and the Vice President of Medical
Affairs/Chief Medical Officer. Medical Staff members, pharmacy members, and the
Vice President of Medical Affairs/Chief Medical Officer will vote on matters involving
the formulary. All members may vote on other matters.
3.H.2. Duties:
The duties of the Pharmacy and Therapeutics Committee shall include:
(a)
assist in the formulation of professional practices and policies regarding the
continuing evaluation, appraisal, selection, procurement, storage, distribution, use,
safety procedures, and all other matters relating to drugs in the Hospital, including
antibiotic usage;
(b)
advise the Medical Staff and the pharmaceutical service on matters pertaining to
the choice of available drugs;
(c)
make recommendations concerning drugs to be stocked on the nursing unit floors
and by other services;
(d)
periodically develop and review a formulary or drug list for use in the Hospital;
(e)
evaluate clinical data concerning new drugs or preparations requested for use in
the Hospital;
(f)
establish standards concerning the use and control of investigational drugs and of
research in the use of recognized drugs;
(g)
maintain a record of all activities relating to pharmacy and therapeutics functions
and submit periodic reports and recommendations to the Medical Executive
Committee concerning those activities; and
(h)
review untoward drug reactions.
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3.H.3. Meetings:
The committee shall meet as often as necessary at the call of its chair, but at least
quarterly. It shall maintain a record of its proceedings and shall report its activities and
recommendations to the Medical Executive Committee as needed, but at least quarterly.
3.I: PROFESSIONAL PRACTICE EVALUATION COMMITTEE
3.I.1. Composition:
The Professional Practice Evaluation Committee ("PPEC") consists of the Immediate
Past Chief of Staff (who shall serve as chair), one physician from each department, and
the CMO (with vote). For the department representatives, particular consideration is to
be given to past department chairs and to other physicians knowledgeable in professional
practice evaluation activities. Each member shall serve for a term of two years, and there
is no limitation on the number of terms a member may serve.
3.I.2. Duties:
The PPEC shall:
(a)
oversee the implementation of the Peer Review Policy including the volume of
cases reviewed and the determinations made by each of the departments, with the
goal of improving the consistency of reviews and determinations across
departments and the effectiveness of interventions when issues are identified;
(b)
review and approve specialty-specific data elements for ongoing professional
practice evaluation and specialty-specific triggers for focused professional
practice evaluation that are identified by each department;
(c)
identify those variances from rules, regulations, policies, or protocols which do
not require physician review but for which the QOM Department may send an
informational letter to the practitioner involved in the case;
(d)
review and approve patient care protocols or guidelines adopted by departments
and the Quality and Outcomes Management Department ("QOM" Department);
(de)
review cases referred to it as outlined in the Peer Review Policy;
(ef)
develop, when appropriate, performance improvement plans for practitioners;
(fg)
submit reports of its actions and recommendations to the MEC on a regular basis;
and
(gh)
review the effectiveness of the Peer Review Policy at least yearly and recommend
revisions or modifications as may be necessary.
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3.I.3. Meetings:
The committee shall meet as often as necessary at the call of its chair, but at least
quarterly. It shall maintain a record of its proceedings and shall report its activities and
recommendations to the Medical Executive Committee.
3.J: PRACTITIONER WELLNESS COMMITTEE
3.J.1. Composition:
The Practitioner Wellness Committee shall consist of the Vice Chief of Staff (who shall
serve as chair) and at least four members of the Active Staff, at least one of whom shall
be a psychiatrist. The CMO shall also serve on the committee, with vote. The members'
terms shall be staggered as deemed appropriate by the MEC to achieve continuity.
3.J.2. Duties:
The Practitioner Wellness Committee addresses prevention of physical, psychiatric, or
emotional illness and facilitates confidential diagnosis, treatment, and rehabilitation,
rather than discipline, by assisting a practitioner to retain and regain optimal professional
functioning that is consistent with protection of patients. If at any time during the
diagnosis, treatment, or rehabilitation phase of the process it is determined that a
practitioner is unable to safely perform the privileges he or she has been granted, the
matter shall be forwarded for appropriate review and action in accordance with the
Credentials Policy. The Practitioner Wellness Committee shall:
(a)
as may be requested by the Credentials Committee, review the responses from
applicants for appointment or reappointment concerning physical or mental health
issues and recommend what, if any, reasonable accommodations may be indicated
in order to assure that the practitioner is able to perform the privileges and
practice prerogatives requested safely with or without accommodation;
(b)
strive to improve the quality of care for patients by helping to resolve matters
relating to the health, well-being, or impairment of Medical Staff members or
Allied Health Professionals before these evolve into significant patient care and/or
Medical Staff disciplinary problems;
(c)
perform those specific functions described in the Policy on Practitioner Health;
(d)
consider general matters related to the health and well-being of Medical Staff
members and Allied Health Professionals and develop educational programs or
related activities; and
(e)
meet at least annually.
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3.K: QUALITY MANAGEMENT COUNCIL (QMC)
3.K.1. Composition:
The Quality Management Council shall consist of such members as may be designated by
the Chief of Staff and include representation from the Medical Staff, the nursing service,
and administration.
3.K.2. Duties:
The Quality Management Council shall perform the following duties:
(a)
recommend for the approval of the MEC plans for maintaining quality patient
care within the Hospital. These may include mechanisms to:
(1)
establish systems to identify patient safety and quality issues in the
provision of patient care;
(2)
set priorities for action plans on patient safety and quality issues;
(3)
refer priority issues for assessment and performance improvement to
appropriate departments or committees;
(4)
monitor the results of quality assessment and improvement activities
throughout the Hospital; and
(5)
coordinate quality assessment and improvement activities;
(b)
submit regular confidential reports to the MEC on the quality of medical care
provided and on quality assessment and improvement activities conducted; and
(c)
meet at least quarterly.
3.L: TRAUMA MULTI-DISCIPLINARY PEER REVIEW COMMITTEE
3.L.1. Composition:
The Trauma Multi-Disciplinary Peer Review Committee shall consist of all core trauma
faculty, and representatives from Orthopedic Surgery, Neurosurgery, Anesthesia,
Emergency Medicine and Surgery.
The Trauma Medical Director shall chair the
committee and shall appoint its members.
3.L.2. Duties:
The Trauma Multi-Disciplinary Peer Review Committee shall:
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(a)
fulfill all of the duties and responsibilities required of it by the American College
of Surgeons as outlined in the current edition of the “Resources for Optimal Care
of the Injured Patient”; and
(b)
review specific trauma cases as outlined in the Peer Review Policy.
3.L.3. Meetings:
The Trauma Multi-Disciplinary Peer Review Committee shall meet monthly. It shall
maintain a record of its proceedings and shall report its activities, recommendations and
determinations to the Professional Practice Evaluation Committee as outlined in the Peer
Review Policy.
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ARTICLE 4
AMENDMENTS
(a)
An amendment to this Manual may be made by a majority vote of the members of
the MEC present and voting at any meeting of that committee where a quorum
exists.
(b)
Notice of all proposed amendments shall be provided to each voting member of
the Medical Staff at least 14 days prior to the MEC meeting when the vote is to
take place, and any voting member may submit written comments on the
amendments to the MEC.
(c)
No amendment shall be effective unless and until it has been approved by the
Board, which approval shall not be withheld unreasonably.
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ARTICLE 5
ADOPTION
This Medical Staff Organization Manual is adopted and made effective upon approval of
the Board, superseding and replacing any and all previous Medical Staff Bylaws and
policies pertaining to the subject matter herein.
Adopted by the Medical Staff:
March 10, 2015
Approved by the Board:
___________
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Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 4.
Quarterly Patient Satisfaction
Report
Patient Satisfaction Data
October – December 2014 (Final)
January – March 2015 (Preliminary)
3-25-2015
Jean Morris, Director of Quality and Care Management
Sherry Stotler, CNO
Q3 2015
Q2 2015
HCAHPS Overall - Q2-Q3 Scores Comparison
Overall Rating of Hospital
Staff took preferences into account
Got help as soon as wanted
Communication About Meds
Staff described med side effects
Quiet around room at night
Responsiveness of Hospital Staff
Care Transitions
Cleanliness / Quietness
Help going to bathroom as soon as…
Would Recommend Hospital
Would recommend hospital to family
Nurses explained things understandably
Pain Management
Room kept clean during stay
Did everything to help your pain
Understood purpose of medications
Pain well controlled during stay
Understood managing of health
Told what medicine was for
Communication with Nurses
Talked about help you would need
Discharge Information
Drs explained things understandably
Received info re: symptoms to look for
Treated w/courtesy/respect by Drs
Communication with Doctors
Drs listened carefully to you
Nurses listened carefully to you
Treated w/courtesy/respect by Nurses
0
Note: Q3 data not final - Chart values are for Q3 only
54.5
54.5
58.3
60
60.3
61.5
62.5
63.9
65.4
66.7
66.7
66.9
67.1
68.2
69.7
70
70
72.7
72.7
75.3
82.1
83.3
83.3
84.6
85.1
85.1
87.2
10
20
30
40
50
60
70
80
90
91.7
92.3
92.3
100
2
3
4
5
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 5.
Uncompensated Care
MARICOPA INTEGRATED HEALTH SYSTEM
SERVICE LINE PROFITABILITY
FY2015 YTD FEBRUARY 02/28/2015
SUMMARY ANALYSIS
Financial Class
Managed Care
Medicare
Medicare HMO
Commercial
Workers Compensation
RBHA
Maricopa Health Plan
Law Enforcement
Grants
AHCCCS Pending
AHCCCS
Other Government
Self Pay
Grand Total
Column Definitions:
Estimated Net Patient Revenue
Direct Cost
Contribution Margin
Indirect Cost
Net Margin before Subsidies
Subsidies
Net Margin after Subsidies
Estimated Net
Patient
Revenue
$ 29,529,900
28,326,782
24,244,388
11,957,680
7,794,230
15,326,681
16,418,941
4,202,323
1,356,730
1,716,564
51,370,586
16,415,526
5,767,526
$ 214,427,857
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Direct Cost
15,390,793
16,594,471
15,199,046
4,866,195
2,082,558
13,185,644
16,046,549
3,950,404
1,714,000
3,352,680
56,078,961
22,945,353
30,545,770
201,952,425
Contribution
Margin
Indirect Cost
$ 14,139,124 $ 7,875,053 $
11,732,320
9,013,786
9,045,355
7,900,140
7,091,485
2,765,078
5,711,672
951,093
2,141,037
9,176,619
372,422
8,315,581
251,922
1,936,460
(357,274)
762,420
(1,636,116)
1,578,101
(4,708,290)
27,794,814
(6,529,819)
10,347,169
(24,778,184)
15,994,675
$ 12,475,654 $ 104,410,989 $
Net Margin
Before
Net Margin
Subsidies
Subsidies
After Subsidies
6,264,064 $ 4,778,423 $ 11,042,482
2,718,532
4,308,603
7,027,129
1,145,207
3,881,622
5,026,825
4,326,407
1,125,700
5,452,106
4,760,579
600,265
5,360,844
(7,035,581)
1,867,216
(5,168,366)
(7,943,196)
5,045,076
(2,898,121)
(1,684,540)
1,485,287
(199,252)
(1,119,693)
850,010
(269,682)
(3,214,217)
1,000,429
(2,213,788)
(32,503,173)
17,290,634
(15,212,562)
(16,876,989)
6,702,095
(10,174,893)
10,153,913
(30,618,996)
(40,772,882)
(91,935,482) $ 59,089,273 $ (32,846,274)
Modeled expected payments based on patient type and insurance plan historical collections.
Patient service departments costs.
Estimated Net patient revenue less direct costs.
Overhead departments.
Contribution margin less Overhead.
Tax Levy, GME and non-operating revenues.
Net Margin before Subsidies less Subsidies.
MARICOPA INTEGRATED HEALTH SYSTEM
PAYOR CATEGORY - SELF PAY
FY2015 YTD FEBRUARY 02/28/2015
FINANCIAL ASSISTANCE PLANS
Major Division
Acute Care
Mental Health
Outpatient
Grand Total
Encounters with a Balance <= Zero
Paid in Full as a % of Total Encounters
Encounters
11,300
6
104,172
115,478
82,802
71.7%
Actual
Payments to
Days
Date
4,200 $ 1,332,745
46 $
$ 3,316,212
4,246 $ 4,648,956
Estimated Net
Patient
Revenue
$ 1,599,722
$
$ 4,167,804
$ 5,767,526
Actual Pmt %
83.3%
0.0%
79.6%
80.6%
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 6.
Affordable Care Act
Meritus Enrollment and Primary/Specialty Care Impact
Updated with March 11, 2015 Paid Enrollments
Initial
Assumptions
40,000
-4,000
36,000
x.35
12,600
x.80
10,080
X 2.5
25,200
X $140/visit
$3,528,000
Active Paid as
of 3/11/2015**
Comments
Anticipated # to Enroll in MIHS Plans in Calendar
Year 2015. Initial assumption that 40,000 will be
26,766 enrolled and will pay their first premium. We will
track this # and adjust this estimate based on
information from Meritus.
10% of members/patients may already be
established with MIHS. MIHS currently has 2,200
-2,677 Meritus members from Year 1 and this 10% is a
rough estimate of individuals already established at
MIHS.
24,089 Members/Patients
Based on Adult Care Coordinators experience of
calling AHCCCS members to schedule appointment,
0.35
we believe 35% will agree to schedule an
appointment at the time of the call.
8,431 Members/Patients
0.8 Ambulatory Care anticipates a 20% No Show rate
6,745 Members/Patients will have a first primary care visit
Estimated # of Visits Per Member. Based on
Ambulatory Care and Meritus data.
Visits (PCP, Specialty and Diagnostic visits). This
16,863
does not include an inpatient assumption
2.5
$140
Per visit based on historical payment information.
This reimbursement is based on primary care visit.
Increased revenue to the system. As we collect and
$2,360,761 analyze the data, we will adjust our assumptions
and report on actual findings.
Note: ** This is being monitored weekly. March 11th total is 4% higher than previous week.
Currently, 35,661 have enrolled and 26,766 have paid.
MARICOPA INTEGRATED HEALTH SYSTEM
SERVICE LINE PROFITABILITY - MERITUS PLANS ONLY
JANUARY 1, 2014 - FEBRUARY 28, 2015
Patient Type
Inpatient
Outpatient
Behavioral Health
Dialysis Series
Newborn
Therapies Series
Emergency
Observation
Grand Total
Encounters
74
11,989
1
7
2
59
196
37
12,365
Includes Insurance Plans:
Meritus HMO Silver Health Plan
Meritus Broad Network HMO
Meritus PPO Health Plan
Days
Est Total
Contribution
Payments
Direct Cost
Margin
Indirect Cost
Net Margin
292 $
979,376 $
725,043 $
254,333 $
302,363 $
(48,030)
2,214,716
2,152,464
62,251
1,187,363
(1,125,112)
10
13,569
6,337
7,232
4,475
2,757
23,970
22,500
1,470
8,628
(7,158)
4
1,501
2,777
(1,277)
1,105
(2,381)
11,815
22,661
(10,846)
8,183
(19,028)
61,108
72,449
(11,341)
38,684
(50,025)
3
84,515
168,840
(84,325)
70,242
(154,566)
309 $ 3,390,569 $ 3,173,071 $
217,498 $ 1,621,041 $ (1,403,543)
MARICOPA INTEGRATED HEALTH SYSTEM
SERVICE LINE PROFITABILITY - ACA PLANS
JANUARY 1, 2014 - FEBRUARY 28, 2015
SUMMARY - ALL PLANS
PATIENT TYPE
Inpatient
Behavioral Health
Emergency
Outpatient
Dialysis Series
Newborn
Therapies Series
Observation
Grand Total
Encounters
382
116
1,281
22,328
7
18
103
130
24,365
Est Total
Contribution
IP Days
Payments
Direct Cost
Margin
Indirect Cost
2,106 $ 10,384,521 $ 5,655,933 $ 4,728,588 $ 2,435,908
1,741
1,883,379
1,102,436
780,942
681,400
873,744
555,589
318,154
279,389
4,097,904
3,976,026
121,878
2,097,794
23,970
22,500
1,470
8,628
191
382,595
382,934
(339)
167,395
39,949
50,827
(10,878)
17,873
7
610,272
651,104
(40,832)
280,605
4,045 $ 18,296,332 $ 12,397,350 $ 5,898,982 $ 5,968,992
Includes Insurance Plans:
Blue Cross Blue Shield PPO*
Healthnet of Arizona
University Health Marketplace
Meritus HMO Silver Health Plan
Meritus Broad Network HMO
Meritus PPO Health Plan
*Note: Blue Cross Blue Shield PPO includes both the new ACA and status quo encounters
Net Margin
Before
Subsidies
$ 2,292,680
99,542
38,766
(1,975,916)
(7,158)
(167,735)
(28,751)
(321,438)
$
(70,009)
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 7.
Payer/Revenue Contracts
MIHS Managed Care
and Payor Contracting 2015
March 25, 2015
Michael Mayer, Senior Managed Care Administrator
MIHS Managed Care and Payor Contracting 2015
Market Segment – Contracted Commercial Insurance
•
Includes BCBSAZ, CIGNA, United Healthcare and Health Net
•
Revenue = $30.2 million (FYTD through March 9)
•
Paid percent of charges = 30.16%
•
Encounters = 43,835
•
Rates negotiated with each payer.
2
MIHS Managed Care and Payor Contracting 2015
Market Segment – Marketplace/Exchange
•
Meritus (Silver Plan) Exclusive to MIHS plus other networks
• 25,628 enrolled in MIHS only network
• 8,705 enrolled in other non-exclusive or provider network
•
Health Net (Broad network only) 26,634 Maricopa County
•
United (Broad network only) 5,221 Maricopa County
•
BCBSAZ (Broad network only) enrollment not reported
•
University of Arizona Health Plans (All products) enrollment not
reported
Enrollment reported on or about 2/1/2015
3
MIHS Managed Care and Payor Contracting 2015
Contracted Commercial Payers
Contracted Payers
Primary Payor Name
ENCOUNTERS ALL
TOTAL CHARGES
MODELED NET REVENUE*
PAID % OF
CHARGES
ARIZONA FOUNDATION FOR MEDICAL CARE
81 $
690,812.00
$
537,027.00
77.74%
BANNER PLAN ADMINISTRATION
56 $
246,130.00
$
116,062.00
47.15%
10,603 $
35,337,622.00
$
9,142,294.00
25.87%
CIGNA
2,871 $
8,330,368.00
$
2,624,350.00
31.50%
Health Net
1,664 $
5,336,232.00
$
2,047,084.00
38.36%
Meritus
13,887 $
17,930,796.00
$
2,786,331.00
15.54%
United
14,673 $
32,527,926.00
$
13,025,149.00
40.04%
Total Contracted
43,835 $
100,399,886.00
$
30,278,297.00
30.16%
BCBSAZ
*FYTD through March 9
For Comparison - Paid % of Charges
AHCCCS
Medicare
14.70%
29.00%
4
MIHS Managed Care and Payor Contracting 2015
Market Segment – Commercial Not Contracted
•
Aetna – MIHS terminated 2012, over aggressive denials and number of
cases requiring appeal. Aetna recently approached MIHS to re-contract.
Proposal due from Aetna.
•
Humana – Approached Humana regularly over the last 8 years and not
responsive. Approached again last summer. Proposal promised for
commercial but not yet received. Humana will not consider MIHS for
Medicare.
•
Network Access PPOs – Build networks and market to self-insured
employers and third party administrators. Includes companies like
Multiplan, First Health and Assurant. Declined because these entities do
not drive elective volume (discounts on emergency only) and do not
control client payer activity.
5
MIHS Managed Care and Payor Contracting 2015
Non-Contracted Commercial Payers
Non-Contracted Payers
Primary Payor Name
ENCOUNTERS ALL
TOTAL CHARGES
MODELED NET REVENUE*
PAID % OF CHARGES
1,300
$
9,069,493.00
$
4,590,847.00
50.62%
167
$
695,265.00
$
389,432.00
56.01%
All Other Non-contracted
1,467
$
9,764,758.00
$
4,980,279.00
51.00%
Total Non Contracted
2,934
$
19,529,516.00
$
9,960,558.00
51.00%
Aetna
Humana
*FYTD through March 9
For Comparison - Paid % of Charges
AHCCCS
Medicare
14.70%
29.00%
6
MIHS Managed Care and Payor Contracting 2015
PwC Initiatives
Rate Rationalization: PwC has shared report and findings compare to simple estimates
using contract modeler. CDM changes should produce annualized revenue increases
between $1 MM and $1.5 MM on contracts that have percent of charge terms, including
outliers
• Contracting: PwC Analyzed 3 major commercial payers (United, BCBSAZ and CIGNA) and
presented high level summary.
• Opportunities
•
o Remove “lesser of charges” provisions. – Already subject of revisions for APRDRG
(AHCCCS) and MSDRG terms. On list for removal whenever contracts convert to Case
Rates.
o Offset and Refund Policies – Modify terms to avoid comingling of accounts. MIHS already
seeking terms for detailed support for adjustments on prior accounts.
o Partial Termination – BCBS contract permits payer to terminate MIHS from individual
products. PWC recommending removal. Industry moving in other direction with limited
networks.
•
Beneficial Provisions
o PwC noted a number that will not be itemized in here but can be provided.
7
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 8.
Financial Statements
February 2015
MARICOPA COUNTY SPECIAL HEALTH DISTRICT
CONSOLIDATED
Balance Sheet
February 28, 2015
2/28/2015
6/30/2014
$19,350,393
57,079,683
$57,805,549
34,238,025
76,430,076
92,043,574
16,507,365
14,546,280
16,361,689
13,421,810
31,053,645
29,783,499
69,000,965
22,472,666
21,098,020
4,645,276
8,607,354
61,364,083
26,949,899
26,018,175
171,652
8,116,950
233,308,002
244,447,832
235,742,855
248,641,826
9,800,000
7,800,000
478,850,857
500,889,658
4,659,934
23,765,275
16,324,884
48,856,431
7,389
32,894,605
5,553,926
20,642,965
21,046,761
46,672,784
787,669
21,194,331
126,508,519
115,898,436
Long-term Debt
19,802,192
20,843,115
Other Liabilities
0
0
146,310,710
136,741,551
215,940,663
116,599,484
227,798,711
136,349,396
332,540,147
364,148,107
478,850,857
500,889,658
ASSETS
Current Assets
Cash and cash equivalents
General funds
Delivery system
Health Plans
Total cash and cash equivalents - general funds
Board designated for future obligations
Delivery system
Health Plans
Total cash and cash equivalents - board designated
Patient A/R, net of allowances
Other receivables and prepaid items
Estimated amounts due from third-party payors
Due from related parties
Other current assets
Total current assets
Capital Assets, Net
Other Assets
Total assets
LIABILITIES AND NET ASSETS
Current Liabilities
Current maturities of long-term debt
Accounts payable
Accrued payroll and expenses
Medical claims payable
Due to related parties
Other current liabilities
Total current liabilities
Total liabilities
Net Assets
Invested in capital assets, net of related debt
Unrestricted
Total net assets
Total liabilities and net assets
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
CONSOLIDATED
Statement of Revenues and Expenses
For the Eight Periods Ending February 28, 2015
Current Period
OPERATING REVENUE
Gross Patient Revenue
Total Deductions
Patient Service Revenue
Charity Care
Bad Debt
Net patient service revenue
Net Patient Service Revenue
Other revenue
Total operating revenues
OPERATING EXPENSES
Salaries and wages
Contract Labor
Employee Benefits
Medical service fees
Supplies
Purchased services
Medical Claims
Other expenses
Premium taxes
Depreciation
Total operating expenses
Operating Income
Nonoperating Revenues (Expenses)
Noncapital grants
Noncapital transfers from County
Investment income
Other nonoperating revenue (expenses)
Interest expense
Tax levy
Total nonoperating revenues (expenses)
Excess of Revenues Over Expenses
Before Extraordinary Items
Extraordinary Item
Increase in Net Assets
JAN 2015
Actual
FEB 2015
Actual
Prior Month
Variance
$161,417,990
(82,187,027)
$148,987,063
(86,462,429)
($12,430,928)
(4,275,403)
Year To Date
FEB 2015
Operating Budget
Operating Budget
Variance
$155,517,136
(105,665,808)
($6,530,073)
19,203,379
FEB 2015
Actual
$1,267,165,066
(804,311,218)
FEB 2015
Operating Budget
Operating Budget
Variance
FEB 2015
Strategic Budget
Strategic Budget
Variance
$1,288,372,103
(851,205,365)
($21,207,037)
46,894,147
$1,197,667,830
(758,691,714)
$69,497,236
(45,619,504)
79,230,964
62,524,633
(16,706,331)
49,851,328
12,673,305
462,853,848
437,166,738
25,687,110
438,976,116
23,877,732
(18,238,300)
(33,907,712)
(19,080,830)
(14,565,979)
(842,530)
19,341,733
(21,226,411)
(3,179,623)
2,145,581
(11,386,356)
(165,714,446)
(82,552,942)
(180,373,955)
(27,019,228)
14,659,510
(55,533,714)
(179,298,909)
(26,858,191)
13,584,464
(55,694,751)
27,084,952
28,877,825
1,792,872
25,445,294
3,432,531
214,586,461
229,773,555
(15,187,094)
232,819,016
(18,232,556)
27,084,952
28,877,825
1,792,872
25,445,294
3,432,531
214,586,461
229,773,555
(15,187,094)
232,819,016
(18,232,556)
28,331,324
23,959,483
(4,371,841)
27,662,624
(3,703,141)
226,122,416
222,198,732
3,923,684
229,185,125
(3,062,709)
55,416,276
52,837,307
(2,578,969)
53,107,918
(270,610)
440,708,877
451,972,287
(11,263,410)
462,004,142
(21,295,265)
18,723,003
172,019
4,948,147
5,491,624
4,873,920
4,899,378
21,537,598
1,481,844
1,016,457
2,507,143
16,330,331
301,176
5,590,515
5,780,655
4,416,831
4,205,564
15,557,528
2,293,332
980,910
2,113,572
2,392,672
(129,156)
(642,368)
(289,031)
457,089
693,814
5,980,070
(811,488)
35,547
393,571
16,995,460
147,563
5,659,492
6,024,591
5,075,074
5,005,604
19,763,881
2,544,389
988,655
2,429,749
665,129
(153,613)
68,978
243,936
658,243
800,040
4,206,353
251,056
7,745
316,177
145,726,158
2,129,663
43,845,986
45,887,345
40,213,485
38,616,383
162,203,025
19,569,277
7,988,413
18,667,952
148,787,138
1,869,833
48,263,754
49,304,713
43,730,290
37,145,161
161,278,441
23,252,184
7,925,288
19,426,176
3,060,981
(259,830)
4,417,768
3,417,368
3,516,805
(1,471,222)
(924,584)
3,682,907
(63,125)
758,223
142,874,637
3,339,111
43,431,573
49,161,192
38,958,747
32,720,605
161,279,409
20,063,986
7,925,288
17,128,000
(2,851,521)
1,209,448
(414,413)
3,273,847
(1,254,738)
(5,895,778)
(923,616)
494,709
(63,125)
(1,539,952)
65,651,134
57,570,414
8,080,720
64,634,458
7,064,044
524,847,686
540,982,977
16,135,291
516,882,548
(7,965,138)
(10,234,858)
(4,733,107)
5,501,751
(11,526,540)
6,793,433
(84,138,809)
(89,010,690)
4,871,881
(54,878,406)
(29,260,403)
677,611
2,916,667
23,601
31,402
(31,637)
5,427,009
597,788
416,667
21,581
(134,558)
(31,099)
5,427,009
(79,822)
(2,500,000)
(2,020)
(165,961)
538
0
631,832
416,667
13,482
(69,495)
(32,237)
5,427,009
(34,043)
0
8,099
(65,063)
1,138
0
4,750,669
3,333,333
163,003
(860,757)
(271,471)
43,416,072
4,563,062
3,333,333
143,012
(1,486,114)
(284,680)
43,416,072
187,607
0
19,991
625,357
13,209
0
4,333,333
0
320,989
(1,860,871)
(1,108,176)
43,416,072
417,336
3,333,333
(157,987)
1,000,114
836,705
0
9,044,653
6,297,388
(2,747,265)
6,387,257
(89,869)
50,530,849
49,684,685
846,164
45,101,347
5,429,502
(1,190,205)
1,564,281
2,754,486
(5,139,283)
(33,607,960)
(39,326,005)
(9,777,059)
(23,830,901)
0
0
$1,564,281
$2,754,486
0
($1,190,205)
0
($5,139,283)
6,703,564
0
$6,703,564
0
($33,607,960)
0
($39,326,005)
5,718,045
0
$5,718,045
0
($9,777,059)
0
($23,830,901)
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
CONSOLIDATED
Statement of Revenues and Expenses
For the Eight Periods Ending February 28, 2015
Current Period
JAN 2015
Actual
As a percent (%) of Gross Patient Revenue
Total Deductions
Charity Care
Bad Debt
Net Patient Revenue
FEB 2015
Actual
Prior Month
Variance
FEB 2015
Operating Budget
Operating Budget
Variance
67.9%
13.6%
2.0%
16.4%
(9.9%)
(.8%)
7.7%
3%
FEB 2015
Actual
FEB 2015
Operating Budget
Operating Budget
Variance
FEB 2015
Strategic Budget
Strategic Budget
Variance
63.5%
13.1%
6.5%
16.9%
66.1%
14%
2.1%
17.8%
(2.6%)
(.9%)
4.4%
(.9%)
63.3%
15%
2.2%
19.4%
.1%
(1.9%)
4.3%
(2.5%)
50.9%
11.3%
21.0%
16.8%
58%
12.8%
9.8%
19.4%
$3,884
($894)
($1,662)
$3,289
($1,004)
($766)
($595)
($110)
$896
$2,689
($1,145)
($172)
$599
$141
($595)
$2,881
($1,031)
($514)
$2,780
($1,147)
($172)
$101
$115
($342)
$2,805
($1,146)
($172)
$76
$114
($342)
$1,328
$1,519
$191
$1,373
$146
$1,336
$1,461
($125)
$1,487
($152)
Salaries
Benefits
Contract Labor
$18,723,003
$4,948,147
$172,019
$16,330,331
$5,590,515
$301,176
$2,392,672
($642,368)
($129,156)
$16,995,460
$5,659,492
$147,563
$665,129
$68,978
($153,613)
$145,726,158
$43,845,986
$2,129,663
$148,787,138
$48,263,754
$1,869,833
$3,060,981
$4,417,768
($259,830)
$142,874,637
$43,431,573
$3,339,111
($2,851,521)
($414,413)
$1,209,448
Total Labor Costs
$23,843,169
$22,222,021
$1,621,147
$22,802,515
$580,494
$191,701,806
$198,920,725
$7,218,919
$189,645,321
($2,056,486)
Supplies
Medical Service Fees
All Other
$4,873,920
$5,491,624
$28,935,043
$4,416,831
$5,780,655
$22,871,677
$457,089
($289,031)
$6,063,365
$5,075,074
$6,024,591
$28,200,796
$658,243
$243,936
$5,329,119
$40,213,485
$45,887,345
$227,244,869
$43,730,290
$49,304,713
$227,830,280
$3,516,805
$3,417,368
$585,411
$38,958,747
$49,161,192
$219,020,241
($1,254,738)
$3,273,847
($8,224,628)
Total Operating and Non Operating Expenses
*Excludes Depreciation
$39,300,586
$33,069,163
$6,231,424
$39,300,461
$6,231,298
$313,345,699
$320,865,283
$7,519,583
$307,140,179
($6,205,520)
Patient Days - Acute
Patient Days - Psych
5,667
5,477
5,019
4,914
(648)
(563)
5,455
4,946
(436)
(32)
44,072
42,231
44,435
42,223
(363)
8
44,731
42,223
(659)
8
Patient Days - Total
11,144
9,933
(1,211)
10,401
(468)
86,303
86,658
(355)
86,954
(651)
Adjusted Patient Days
APD Ratio
20,398
1.83
19,010
1.91
(1,388)
.08
18,536
1.78
475
.13
160,664
1.86
157,269
1.81
Average Daily Census - Acute
Average Daily Census - Psych
183
177
179
176
(4)
(1)
195
177
(16)
(1)
181
174
183
174
(1)
0
184
174
(3)
0
Average Daily Census - Total
359
355
(5)
371
(17)
355
357
(1)
358
(3)
Adjusted Occupied Beds
658
679
21
662
17
661
647
14
644
17
Paid FTEs - Payroll
Paid FTEs - Contract Labor
3,457
42
3,363
35
95
6
3,463
11
100
(25)
3,442
48
3,502
24
60
(24)
3,385
60
(57)
12
Paid FTEs - Total
3,499
3,398
101
3,473
75
3,491
3,526
36
3,445
(45)
FTEs per AOB
Salaries per FTE - Payroll
Salaries per FTE - Contract Labor
5.3
$5,415
$4,144
5.0
$4,856
$8,545
0.3
$559
($4,401)
5.2
$4,908
$13,897
0.2
$52
$5,352
5.3
$42,337
$43,918
5.4
$42,482
$77,442
0.2
$146
$33,524
5.3
$42,207
$55,381
0.1
($129)
$11,463
Benefits % of Salaries
26.4%
34.2%
(7.8%)
33.3%
(0.9%)
30.1%
32.4%
2.4%
30.4%
0.3%
Salaries & Contract Labor per APD
Supplies per APD
Medical Service Fees per APD
Other Expenses per APD
$926
$239
$269
$1,419
$875
$232
$304
$1,203
$51
$7
($35)
$215
$925
$274
$325
$1,521
$50
$41
$21
$318
$920
$250
$286
$1,414
$958
$278
$314
$1,449
$38
$28
$28
$34
$934
$249
$314
$1,399
$14
($1)
$28
($15)
Total Expenses per APD
$2,853
$2,614
$239
$3,045
$431
$2,871
$2,998
$128
$2,896
$26
Patient Service Revenue per APD
Charity Care
Bad Debt
Net Patient Service Revenue per APD
7.1%
1.5%
(11.2%)
2.6%
Year To Date
3,395
.05
156,518
1.80
4,146
.06
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
SERVICE LINE
Statement of Revenues, Expenses, and Changes in Net Assets
For the month ending February 28, 2015
Current Month - Actual
Ambulatory
Behavioral
Maricopa
Health
Clinics
Care Advantage
Acute
Hospital
Net Patient Service Revenue
Other revenue
Total operating revenues
Operating Expenses
Salaries and wages
Contract labor
Employee benefits
Medical service fees
Supplies
Purchased services
Medical claims
Other expenses
Premium taxes
Depreciation
Allocated ancillary/overheard expenses
Total operating expenses
Operating Income
Nonoperating Revenues (Expenses)
Noncapital grants
Noncapital transfers from County
Investment income
Other nonoperating revenue (expenses)
Interest expense
Tax levy
Total nonoperating revenues (expenses)
Excess of Revenues Over Expenses
Before Extraordinary Items
Extraordinary Item / Prior months adjustment
Increase in Net Assets
$
Maricopa
Health Plan
Current Month
Consolidated
Operating Budget
Consolidated
Actual
Actual
HomeAssist
Health
Variance
20,890,206
4,132,096
3,855,522
0
0
28,877,825
25,445,294
21,914,080
3,894,053
4,833
1,567,420
2,001,906
16,491,271
23,959,483
27,662,624
(3,703,141)
24,784,259
4,136,929
5,422,942
2,001,906
16,491,271
52,837,307
53,107,918
18,210,939
12,396,318
268,743
4,242,929
4,059,462
3,693,429
2,518,825
0
2,061,004
552,433
2,113,572
(4,623,413)
1,852,281
32,432
573,608
94,469
143,488
15,614
0
64,355
0
0
1,593,687
2,081,731
0
773,978
1,626,724
579,914
26,074
0
167,973
0
0
3,029,726
0
0
0
0
0
291,333
1,933,442
0
0
0
0
0
0
0
0
0
1,353,717
13,624,086
0
428,477
0
0
16,330,331
301,176
5,590,515
5,780,655
4,416,831
4,205,564
15,557,528
2,293,332
980,910
2,113,572
0
16,995,460
147,563
5,659,492
6,024,591
5,075,074
5,005,604
19,763,881
2,544,389
988,655
2,429,749
0
27,283,304
4,369,934
8,286,121
2,224,775
15,406,280
57,570,414
1,084,991
835,811
964,374
0
0
835,811
964,374
665,129
(153,613)
68,978
243,936
658,243
800,040
4,206,353
251,056
7,745
316,177
0
669,625
0
75,970
0
1,134
12,957
0
45,703
0
2,703
0
831,480
0
87,970
0
0
16,667
0
29,691
0
0
0
64,634,458
7,064,044
808,092
965,808
(4,733,107)
(11,526,540)
6,793,433
27,719
(2,499,045)
(233,005)
(2,863,179)
597,788
0
16,199
(134,558)
(26,823)
3,499,516
0
416,667
0
0
(1,144)
20,318
0
0
0
0
(3,132)
1,907,175
0
0
0
0
0
0
0
0
5,382
0
0
0
597,788
416,667
21,581
(134,558)
(31,099)
5,427,009
631,832
416,667
13,482
(69,495)
(32,237)
5,427,009
(34,043)
(0)
8,099
(65,063)
1,138
0
0
0
0
50
0
0
0
0
0
0
0
0
3,952,122
435,840
1,904,043
0
5,382
6,297,388
6,387,257
(89,869)
50
0
1,453,077
202,835
1,090,373
1,564,281
(5,139,283)
0
0
0
0
1,453,077
$
202,835
(959,135)
0
$
(959,135) $
(222,869)
Budget
HomeAssist
Health
(222,869)
0
(222,869) $
1,090,373
$
1,564,281
0
$
(5,139,283) $
6,703,564
27,769
0
0
6,703,564
$
27,769
(1,434)
(1,434)
0
$
(1,434)
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
SERVICE LINE
Statement of Revenues, Expenses, and Changes in Net Assets
For the Seven Months ending February 28, 2015
Acute
Hospital
Net Patient Service Revenue
Other revenue
Total operating revenues
Operating Expenses
Salaries and wages
Contract labor
Employee benefits
Medical service fees
Supplies
Purchased services
Medical claims
Other expenses
Premium taxes
Depreciation
Allocated ancillary/overheard expenses
Total operating expenses
Operating Income
Nonoperating Revenues (Expenses)
Noncapital grants
Noncapital transfers from County
Investment income
Other nonoperating revenue (expenses)
Interest expense
Tax levy
Total nonoperating revenues (expenses)
Excess of Revenues Over Expenses
Before Extraordinary Items
Maricopa
Health Plan
Year to Date
Consolidated
Operating Budget
Consolidated
Actual
Actual
HomeAssist
Health
Variance
34,004,061
34,927,439
0
0
214,586,461
229,773,555
(15,187,094)
28,282,125
44,629
13,281,883
14,932,394
169,581,385
226,122,416
222,198,732
3,923,684
173,937,085
34,048,691
48,209,322
14,932,394
169,581,385
440,708,877
451,972,287
111,593,034
1,876,387
32,788,460
33,694,439
34,228,402
22,005,643
0
17,683,242
4,419,467
18,667,952
(38,076,848)
15,977,520
234,386
4,867,098
183,677
1,442,891
313,295
0
431,614
0
0
13,492,161
18,155,604
18,889
6,190,428
12,009,230
4,542,192
233,236
0
1,454,421
0
0
24,584,687
0
0
0
0
0
2,272,830
15,314,150
0
0
0
0
0
0
0
0
0
13,791,379
146,888,875
0
3,568,946
0
0
145,726,158
2,129,663
43,845,986
45,887,345
40,213,485
38,616,383
162,203,025
19,569,277
7,988,413
18,667,952
0
238,880,178
36,942,640
67,188,688
17,586,980
164,249,200
(64,943,092)
(2,893,950)
(18,979,366)
(2,654,586)
4,750,669
0
128,194
(860,757)
(235,451)
31,924,953
0
3,333,333
0
0
(9,154)
224,407
0
0
0
0
(26,867)
11,266,712
35,707,608
3,548,587
11,239,845
0
$
Year to Date - Actual
Ambulatory
Maricopa
Clinics
Care Advantage
145,654,961
(29,235,484)
Extraordinary Item / Prior months adjustment
Increase in Net Assets
Behavioral
Health
(29,235,484) $
654,637
(7,739,521)
0
654,637
0
$
(7,739,521) $
Budget
HomeAssist
Health
7,020,904
7,714,992
0
0
(11,263,410)
7,020,904
7,714,992
148,787,138
1,869,833
48,263,754
49,304,713
43,730,290
37,145,161
161,278,441
23,252,184
7,925,288
19,426,176
0
3,060,981
(259,830)
4,417,768
3,417,368
3,516,805
(1,471,222)
(924,584)
3,682,907
(63,125)
758,223
(0)
5,870,992
0
628,390
0
17,443
162,326
0
272,309
0
22,884
0
6,651,840
0
703,760
0
0
133,336
0
237,528
0
0
0
524,847,686
540,982,977
16,135,291
6,974,343
7,726,464
5,332,185
(84,138,809)
(89,010,690)
4,871,881
46,561
0
0
0
0
0
0
0
0
34,809
0
0
0
4,750,669
3,333,333
163,003
(860,757)
(271,471)
43,416,072
4,563,062
3,333,333
143,012
(1,486,114)
(284,680)
43,416,072
187,607
(0)
19,991
625,357
13,209
0
0
0
0
1,470
0
0
0
0
0
0
0
0
0
34,809
50,530,849
49,684,685
846,164
1,470
0
(33,607,960)
(39,326,005)
5,718,045
48,031
0
0
(2,654,586)
0
(2,654,586) $
5,366,994
0
5,366,994
0
$
(33,607,960) $
0
(39,326,005) $
5,718,045
$
48,031
(11,472)
(11,472)
0
$
(11,472)
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
d/b/a MARICOPA MEDICAL CENTER
Volumes
For the Eight Periods Ending February 28, 2015
Actual
Admissions
Acute
Psych
Strategic Budget
Current Period
Variance
% Change
Last Year
% Change
Actual
Strategic Budget
Year to Date
Variance
% Change
Last Year
% Change
1,038
275
1,118
290
(80)
(15)
(7.2%)
(5.1%)
1,088
264
(4.6%)
4.2%
9,008
2,141
9,133
2,469
(125)
(328)
(1.4%)
(13.3%)
8,946
2,449
0.7%
(12.6%)
1,313
1,408
(95)
(6.7%)
1,352
(2.9%)
11,149
11,602
(453)
(3.9%)
11,395
(2.2%)
Admits to Observation
Total
395
475
(80)
(16.8%)
483
(18.2%)
2,939
3,577
(638)
(17.8%)
3,624
(18.9%)
Length of Stay
Acute
Psych
4.8
17.9
5.0
17.1
0.1
(0.8)
2.3%
(4.7%)
5.0
18.3
3.2%
2.6%
4.9
19.7
4.9
17.1
(0.0)
(2.6)
0.1%
(15.3%)
4.9
16.8
0.9%
(17.7%)
7.6
7.4
(0.1)
(1.6%)
7.6
0.5%
7.7
7.5
(0.2)
(3.3%)
7.5
(3.5%)
5,019
4,914
5,535
4,946
(516)
(32)
(9.3%)
(0.7%)
5,435
4,841
(7.7%)
1.5%
44,072
42,231
44,731
42,223
(659)
8
(1.5%)
0.0%
44,154
41,037
(0.2%)
2.9%
9,933
10,481
(548)
(5.2%)
10,276
(3.3%)
86,303
86,954
(651)
(0.7%)
85,191
1.3%
179
176
198
177
(18)
(1)
(9.3%)
(0.7%)
194
173
(7.7%)
1.5%
181
174
184
174
(3)
0
(1.5%)
0.0%
182
169
(0.2%)
2.9%
355
374
(20)
(5.2%)
367
(3.3%)
355
358
(3)
(0.7%)
351
1.3%
19,010
18,867
144
0.8%
160,664
156,518
151,792
5.8%
335
309
344
229
(9)
80
(2.6%)
34.9%
339
240
(1.2%)
28.8%
2,741
2,372
2,916
2,052
(175)
320
(6.0%)
15.6%
2,887
2,127
(5.1%)
11.5%
644
573
71
12.4%
579
11.2%
5,113
4,968
145
2.9%
5,014
2.0%
Inpatient Minutes
Outpatient Minutes
42,090
27,015
48,387
21,598
(6,297)
5,417
(13.0%)
25.1%
47,715
22,290
(11.8%)
21.2%
351,600
225,210
389,419
197,905
(37,819)
27,305
(9.7%)
13.8%
385,455
202,515
(8.8%)
11.2%
Total
69,105
69,985
(880)
(1.3%)
70,005
(1.3%)
576,810
587,324
(10,514)
(1.8%)
587,970
(1.9%)
192
207
(15)
(7.2%)
204
(5.9%)
2,047
1,887
160
8.5%
1,867
9.6%
3,924
2,590
126
3,792
1,796
82
132
794
44
3.5%
44.2%
53.7%
3,803
1,823
86
3.2%
42.1%
46.5%
32,227
15,007
1,262
32,142
12,262
869
85
2,745
393
0.3%
22.4%
45.2%
32,209
12,409
898
0.1%
20.9%
40.5%
6,640
5,670
970
17.1%
5,712
16.2%
48,496
45,273
3,223
7.1%
45,516
6.5%
2,417
2,248
169
7.5%
2,303
5.0%
17,942
17,610
332
1.9%
17,727
1.2%
17,149
13,213
2,265
16,110
12,905
2,053
1,039
308
212
6.4%
2.4%
10.3%
16,369
12,965
2,693
4.8%
1.9%
(15.9%)
139,334
106,796
18,441
129,591
101,612
17,055
9,743
5,184
1,386
7.5%
5.1%
8.1%
130,247
102,826
16,746
7.0%
3.9%
10.1%
32,627
31,068
1,559
5.0%
32,027
1.9%
264,571
248,258
16,313
6.6%
249,819
5.9%
Total
Total
Patient Days
Acute
Psych
Total
Average Daily Census
Acute
Psych
Total
Adjusted Patient Days
Total
Surgeries
Inpatient
Outpatient
Total
Deliveries
Total
ED Visits
Adult
Peds
Burn
Total
7th Ave Walk-In Clinic
Total
OP Visits
FHC
CHC
Dental
Total
18,113
5.0%
4,146
2.6%
Maricopa County Special Health Care District
dba Maricopa Integrated Health System
Capital Projects – Post Implementation Review and Update Schedule
March 25, 2015
1st Review
2nd Review
3rd Review
Final Review
$887,000
Sept 2013
Due Jan, 2014
Completed Jan, 2014
Feb, 2016
Feb, 2017
$5,162,000
January 2013
$5,162,000
March 2014
Due Jan, 2014
Completed Jan 2014
Jan, 2016
Jan, 2017
Nursing 4 East
Remodel
$1,500,000
January 2013
$1,780,000
Nov 2013
Due Jan, 2014
Completed Jan, 2014
Feb, 2016
Feb, 2017
Enterprise Application
Suite (EAS): Kronos
only
$2,556,000
original plus
$601,000
additional
request
June, 2013
$9,444,000
June 2013
Sept 2014
July, 2015
Due Feb, 2015
Completed Feb,
2015
Due Jan, 2015
Completed Jan
2015
Due Feb, 2015
Completed Feb,
2015
July, 2016
July, 2017
July, 2018
January 2015
July, 2015
July 2016
July 2017
July 2018
Project Description
Amount and
Date Originally
Approved
$550,000
January 2013
Actual Cost and
Completion
Date
On Hold
$2,111,000
January 2013
$900,000
August 2012
On Hold
MRI Imaging Facility
Nursing 5 West
Remodel
Wound Clinic
McDowell Clinic
Relocation
Enterprise Application
Suite (EAS):Hardware
for all EAS systems
plus the McKesson
Supply Chain and
Financial systems
acquisitions
pg. 1
Maricopa County Special Health Care District
dba Maricopa Integrated Health System
Capital Projects – Post Implementation Review and Update Schedule
March 25, 2015
Pendergast Clinic &
Dental
$499,000
May 2014
Jan 2015
August, 2015
August, 2016
August, 2017
August, 2018
Cath Lab/EP
equipment
$806,860
Sept 2014
Estimate
July 2015
Nov, 2015
Nov, 2016
Nov, 2017
Nov, 2018
pg. 2
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 8.
Key Indicator Dashboards
February 2015
Maricopa Integrated Health System
Key Indicator Dashboard
February 28, 2015
Maricopa Integrated Health System
Key Indicator Dashboard
Dashboard
Key Indicator Dashboard - Quality
Key Indicator Dashboard - Operational
Key Indicator Dashboard - Financial
Appendix A Definition of Financial Indicators
1
2
3
4
Maricopa Integrated Health System
Key Indicator Dashboard - Quality
February 28, 2015
Target
Process of Care Measures
Stroke (STK)
Venous Thromboembolism (VTE)
Emergency Department (ED)
Immunization (IMM)
Perinatal Care (PC)
Current Month
Month
Prior
Month
> 93%
> 90%
< 240 min
> 92%
< 5%
94%
95%
160
93%
10%
100%
96%
171
92%
0%
Outcome of Care Measures
30-Day Hospital-Wide Mortality
Central Line Associated Blood Stream Infection (CLABSI)
Catheter Associated Urinary Tract Infections (CAUTI)
Surgical Site Infections (SSI) - Colon Surgery
Surgical Site Infections (SSI) - Abdominal Hysterectomy
MRSA Bacteremia
Clostridium Difficile (C.Diff)
< 0.81
< 0.50
< 1.18
< 0.95
< 0.91
< 0.94
< 0.92
0.79
Low vol., no data
Low vol., no data
Low vol., no data
Low vol., no data
Low vol., no data
Low vol., no data
0.97
0.40
0.60
1.71
0.00
0.00
0.81
Patient Safety Indicator (PSI) -90
Patient Safety Indicator (PSI) -90
< 0.88
0.71
0.89
CMS Readmission Project
Hospital-Wide All-Cause Readmission
< 16%
8%
10%
Behavioral Health (bundle score)
Hospital-Based Inpatient Psychiatric Services (HBIPS)
> 90%
99%
93%
< 8%
7.8%
7.7%
Ambulatory
Average HbA1c for Diabetic Patients
Patient Satisfaction
Inpatient
Emergency Room (Adult)
Emergency Room (Pediatric)
Behavioral Health
Outpatient
Medical Practice (CHC & FHCs)
This data is currently unavailable. MIHS is transitioning
vendors from Press Ganey, to The National Research
Corporation (NRC).
Q2 data will be available March 30th, 2015
Legend
Greater than 100% of Target
Within 95% to 100% of Target
Less than 95% of Target
Page 1
Maricopa Integrated Health System
Key Indicator Dashboard - Operational
February 28, 2015
Actual
Acute
Admissions
Current Month
Strategic
Budget
Variance
Actual
CY Year to Date
Strategic
Budget
PY Year to Date
Variance
Actual
Variance
1,038
1,118
(80)
9,008
9,133
(125)
8,946
62
4.84
4.95
(0.12)
4.89
4.90
(0.01)
4.94
0.04
5,019
5,535
(516)
44,072
44,731
(659)
44,154
(82)
Acute - Observation Days and Admits
Observation Days
391
565
(175)
3,245
4,226
(980)
4,191
(946)
Admits to OBS
395
475
(80)
2,939
3,577
(638)
3,624
(685)
(308)
Length of Stay (LOS)
Patient Days
Behavioral Health
Admissions
275
290
(15)
2,141
2,469
(328)
2,449
Length of Stay (LOS)
17.9
17.1
0.8
19.7
17.1
(2.6)
16.8
4,914
4,946
(32)
42,231
42,223
8
41,037
1,194
16,182
967
13,213
30,362
15,328
782
12,905
29,015
854
185
308
1,347
131,591
7,743
106,796
246,130
123,315
6,276
101,612
231,203
8,276
1,467
5,184
14,927
123,929
6,318
102,826
233,073
7,662
1,425
3,970
13,057
Dental Clinics Visits
2,265
2,053
212
18,441
17,055
1,386
16,746
1,695
7th Ave Walk-In Clinic Visits
2,417
2,248
169
17,942
17,610
332
17,727
215
35,044
33,316
1,728
282,513
265,868
16,645
267,546
14,967
145
(10,514)
(5)
5,014
587,970
117
99
(11,160)
(4)
Patient Days
Ambulatory
Family Health Centers (FHC) Visits
Whole Health Home (WHH) Visits
Comprehensive Health Center (CHC) Visits
Subtotal :
Total Ambulatory Visits :
Hospital
Operating Room Utilization
78%
70%
8.0%
Cath Lab Utilization - Room 1
Cath Lab Utilization - Room 2
Cath Lab Utilization - IR
CCTA/Calcium Score
19%
25%
42%
15
45%
45%
45%
10
(26.0%)
(20.0%)
(3.0%)
5
Surgical Center (SURG) - Total IP & OP Surgeries
Surgical Center (SURG) - Total Surgical Minutes
Surgical Center (SURG) - Minutes per Case
Deliveries
Emergency Department (ED)
Adult ED
Peds ED
Burn ED
% of Total ED Visits Resulting in Admission Adult
% of Total ED Visits Resulting in Admission Peds
Left Without Treatment (LWOT) ADULT
Left Without Treatment (LWOT) PEDIATRICS
Overall ED Median Length of Stay (M-LOS) (minutes) ADULT
Overall ED Median Length of Stay (M-LOS) (minutes) PEDS
PSYCH ED Median LOS (minutes)
Median Time to Treatment (MTT) (minutes) ADULT
Median Time to Treatment (MTT) (minutes) PEDS
% of Acute Patients Admitted Through the ED
Labor
FTE/AOB WO Residents
Turnover Rate - Voluntary
Turnover Rate - Involuntary
Turnover Rate - Uncontrollable
Turnover Rate - Total
(3.0)
644
69,105
107
573
69,985
122
71
(880)
(15)
5,113
576,810
113
4,968
587,324
118
192
207
(15)
2,047
1,887
160
1,867
180
6,640
3,924
2,590
126
13.8%
6.1%
2.5%
0.4%
5,670
3,792
1,796
82
15.8%
7.7%
<3%
<3%
970
132
794
44
(2.0%)
(1.6%)
0.5%
2.6%
48,496
32,227
15,007
1,262
45,273
32,142
12,262
869
3,223
85
2,745
393
45,516
32,209
12,409
898
2,980
18
2,598
364
273
153
745
<240
<220
<0
26
38
52.2%
30
30
53.8%
4
(8)
(1.5%)
4.67
1.43%
0.21%
0.03%
1.67%
5.01
0.34
5.01
0.08
5.38
0.45
(33)
67
(745)
4.93
18.35%
4.27%
1.76%
24.38%
Membership Disenrollment Rate
Maricopa Health Plan (MHP)
AHCCCS Average
CY 13
CY 12
7%
2%
December
January
February
February Budget
Member Months
Maricopa Health Plan (MHP)
Maricopa Care Advantage (MCA)
83,949
1,408
82,004
1,526
82,299
1,587
80,847
1,484
Covered Lives
University Physicians Healthcare (UPH) Exchange Plan
Meritus Health Plan
62
16,306
475
24,412
604
35,215
CY 11
6%
2%
7%
2%
Legend
Greater than or equal to 100% of Budget
Within 95% to 100% of Budget
Less than 95% of Budget
Page 2
Maricopa Integrated Health System
Key Indicator Dashboard - Financial
February 28, 2015
Current Month
Strategic
Budget
Actual
Variance
CY Year to Date
Strategic
Budget
Actual
PY Year to Date
Variance
Actual
Variance
Consolidated Financials
Maricopa Medical Center
$
697
$
Maricopa Health Plan
$
1,090
$
Maricopa Care Advantage
$
Total Margin (000s)
$
Liquidity
Total Cash and Investments
(223) $
1,564
$
(2,768) $
1,021
$
(185) $
(1,932) $
3,465
$
69
$
(38)
$
(2,655) $
$
(33,608) $
3,496
(36,320) $
5,367
$
(11,510) $
(24,811)
$
(5,979) $
(30,341)
3,035
$
543
4,824
(599) $
(2,056)
$
(798) $
(1,857)
(9,777) $
(23,831)
$
(6,234) $
(27,374)
2,332
Actual - YTD
June 30, 2015
Strategic
Budget - YTD
June 30, 2015
$
$
107.5
115.5
$
Variance
$
Actual - YTD
June 30, 2014
121.8
(14.3)
(10.0)
51.6
56.2
(4.6)
61.6
Days in Account Receivable
77.0
65.0
(12.0)
77.0
Cash to Debt
Capital Structure
EBITDA Debt Service Coverage
Debt to Net Assets
41.9
542.79%
(5.7)
14.52%
Actual - YTD
June 30, 2015
51.9
785.50%
3.8
12.40%
Strategic
Budget - YTD
June 30, 2015
Variance
(8.0)
Total Days Cash on Hand
Cushion Ratio
$
(10.1)
(242.71%)
(9.5)
(2.12%)
Variance
29.9
584.50%
0.4
13.30%
Actual - YTD
June 30, 2014
12.0
(41.71%)
(6.1)
(1.22%)
Variance
Profitability
Operating Margin
Operating Income (Loss)
(19.09%)
($84,138,809)
(11.88%)
($54,878,406)
(7.21%)
($29,260,403)
(14.00%)
($50,120,801)
(5.09%)
($34,018,008)
EBITDA Margin
EBITDA
(3.27%)
($14,668,537)
1.82%
$8,459,117
(5.09%)
($23,127,654)
0.30%
$8,475,956
(3.57%)
($23,144,493)
Excess Margin
Increase in Net Asset
(7.50%)
($33,607,960)
(2.10%)
($9,777,059)
(5.40%)
($23,830,901)
(3.70%)
($6,234,185)
11.20%
($27,373,775)
Legend
Greater than or equal to 100% of Budget
Within 95% to 100% of Budget
Less than 95% of Budget
Page 3
Appendix A
Definition of Financial Indicators
Desired Position
Relative to
Trend
Median
Definition
Indicator
Total Days Cash on Hand
=
Cash + Short-Term Investments
(Operating Expenses Less - Depreciation) / YTD Days
Up
Above
Days in Accounts
Receivable
=
Net Patient Accounts Receivable (including Due/From)
Net Patient Service Revenue / YTD Days
Down
Below
Cushion Ratio
=
Cash + Short-Term Investments
Principal + Interest Expenses
Up
Above
Cash to Debt
=
Cash + Short-Term Investments
Long Term Debt
Up
Above
EBITDA Debt Service
Coverage
=
EBITDA
Principal + Interest Expenses
Up
Above
Debt to Net Assets
=
Long Term Debt
Long Term Debt + Unrestricted Assets
X 100
Down
Below
Operating Margin
=
Operating Income (Loss)
Operating Revenues
X 100
Up
Above
EBITDA Margin
=
EBITDA
Operating Revenues + Non Operating Revenues
X 100
Up
Above
Excess Margin
=
Net Income
Operating Revenues + Non Operating Revenues
X 100
Up
Above
X 100
Page 4
Maricopa County
Special Health Care District
Board of Directors
Finance/Quality Meeting
March 25, 2015
Item 9.
No Handout
Concluding Items