Chief Medical Officer Julian Craig, MD

Board Report January 2017

MEDICAL STAFF SUMMARY MEDICAL STAFF COMMITTEE MEETINGS

Medical Executive Committee Meeting, Dr. Mina Yacoub, Chief of Staff The Medical Staff Executive Committee (MEC) provides oversight of care, treatment, and services provided by practitioners with privileges on the UMC medical staff. The committee provides for a uniform quality of patient care, treatment, and services, and reports to and is accountable to the Governing Board. The Medical Staff Executive Committee acts as liaison between the Governing Board and Medical Staff.

Peer-Review Committee, Dr. Gilbert Daniel, Committee Chairman

The purpose of peer review is to promote continuous improvement of the quality of care provided by the Medical Staff. The role of the Medical Staff is to provide evaluation of performance to ensure the effective and efficient assessments and education of the practitioner and to promote excellence in medical practices and procedures. The peer review function applies to all practitioners holding independent clinical privileges.

Pharmacy and Therapeutics Committee, Dr. Anthony Jones, Committee Chairman

The Pharmacy and Therapeutics Committee discusses all policies, procedures, and forms regarding patient care, medication reconciliation, and formulary medications prior to submitting to the Medical Executive Committee for approval.

Credentials Committee, Dr. Barry Smith, Committee Chairman

The Credentials Committee is comprised of physicians who review all credential files to ensure all items such as applications, dues payment, etc. are appropriate. Once approved through Credentials Committee, files are submitted to the Medical Executive Committee and the Governing Board.

Medical Education Committee, Dr. Christian Paletta, Committee Chairman

The Medical Education Committee was formed to review all upcoming Grand Rounds presentations. The committee discusses improvements and new ideas for education of clinical staff.

Performance Improvement Committee, Committee Chairman

The Performance Improvement Committee is comprised of 1-2 representatives from each department who report monthly on the activity of each department based on standards established by the Joint Commission, the Department of Health, and the Centers for Medicare and Medicaid Services (CMS).

Bylaws Committee, Dr. David Reagin, Committee Chairman

Members include physicians who meet to discuss implementation of new policies and procedures for bylaws, as it pertains to physician conduct. The Medical Staff Bylaws, Rules and Regulations have been revised in preparation for the upcoming Joint Commission inspection. The changes were reviewed, discussed and approved by the Bylaws Committee and will be forwarded to the Medical Executive Committee and then the Board of Directors for review and approval.

Physician IT Committee

Members include physicians who meet to discuss the implementation of the new hospital-wide Meditech upgrade, as well as the physician documentation for ICD-10.

CHIEF MEDICAL OFFICER Julian Craig, M.D. The month of January ended with the onboarding of the last physician recruited by the United Medical Center (UMC) as part of the board approved strategic plan in 2013. The goals of this physician recruitment plan are to address the community’s healthcare needs, support the hospitals daily operations, fill current service gaps that will expand UMC’s primary care base and provide sustainable revenue inflows over the next 5 years. These goals are in line with community health needs assessment studies that have been commissioned by successive city administrations since 2006. A shift in focus from hospital centric to ambulatory care and patient centric has been identified in both the Rand Report (2008) and the McGladrey Report (2011). Now that UMC has the medical staff in place, the time has come to grow the various service lines. With almost 60,000 emergency room visits per year and a primary care center that has more than quadrupled its number of physician providers, UMC is now poised to develop its Patient Centered Medical Home (PCMH). The PCMH is described as a model of primary care that is patient centered, comprehensive, team based, coordinated, accessible and focused on quality and safety. In accordance with the Board of Directors strategic plan and the current management action plan, implementation of a comprehensive hospital based Ambulatory Center is paramount to the future success of the PCMH. Construction of the new Ambulatory Care Center on the first floor next to the main lobby, will yield a net increase in available space. The current space in the Medical Office Building, can no longer accommodate the increase in medical providers in a way that supports improvement in patient satisfaction and throughput. Maintaining funding for this initiative will be critical moving forward. The physician recruitment initiatives that began in 2013 were largely successful as a result of interest by physicians in participating in a dynamic PCMH model. Physicians eagerly anticipate its development, and delays could impact physician retention in the next fiscal year. The growth and development of the medical staff is dependent on progress being made in the expansion of the various service lines that are currently in place. Five years is a lifetime in healthcare, and retaining the interest of a dedicated medical staff should not be taken for granted. If a new hospital were to be built in 5 years, its success would largely depend on having a vibrant medical staff focused on quality, with a market share of the primary care base, available to move in.

DEPARTMENT CHAIRPERSONS Anesthesiology .............................................................................................. ...Dr. Amaechi Erondu

Critical Care .......................................................................................................... Dr. Mina Yacoub

Emergency Medicine........................................................................................ Dr. Mehdi Sattarian

Medicine ............................................................................................................... Dr. Musa Momoh

Obstetrics and Gynecology.............................................................................. Dr. Sylvester Booker

Pathology ......................................................................................................................... Dr. Eric Li

Pediatrics ....................................................................................... Dr. Marilyn McPherson-Corder

Psychiatry ............................................................................................................... Dr. Lisa Gordon

Radiology ................................................................................................................ Dr. Raymond Tu

Surgery ............................................................................................................ Dr. Gregory Morrow

DEPARTMENTAL REPORTS

ANESTHESIOLOGY DEPARTMENT Amaechi Erondu, M.D., (Medical Director)

Report by Patient Age

for EmCare North Division for Service Dates from 1/1/2016 through 9/30/2016

Date Site Benchmark Site Benchmark Site Benchmark Site Benchmark Less than 18 7 2619 0 17 0.00% 0.65% [0.00%-100.00%] [0.41%-0.97%] 18 to 30 169 7425 0 35 0.00% 0.47% [0.00%-100.00%] [0.35%-0.63%] 30 to 50 258 16625 3 111 1.16% 0.67% [0.32%-3.01%] [0.58%-0.79%] 50 to 65 569 21849 5 182 0.88% 0.83% [0.35%-1.85%] [0.74%-0.95%] 65 to 75 256 14545 0 124 0.00% 0.85% [0.00%-100.00%] [0.74%-1.00%] 75 to 85 101 8915 0 68 0.00% 0.76% [0.00%-100.00%] [0.62%-0.93%] 85 and greater 45 3369 0 23 0.00% 0.68% [0.00%-100.00%] [0.47%-0.97%] TOTALS 1405 75347 8 560 0.57% 0.74% [0.28%-1.03%] [0.70%-0.80%]

Report by Specialty Procedure for United Medical Center for EmCare

North Division for Service Dates from 1/1/2016 through 9/30/2016

United Medical Center Benchmark

Procedure Counts Event Counts Event Rates AE Range Item Site Benchmark Site Benchmark Site Benchmark Site Benchmark

<Not Coded> 209 6147 0 68 0.00% 1.11% [0.00%-100.00%] [0.90%-1.35%] Block 3 805 0 9 0.00% 1.12% [0.00%-100.00%] [0.58%-1.95%]

Epidural 70 2740 0 10 0.00% 0.36% [0.00%-100.00%] [0.20%-0.62%] General/TIVA 335 43603 6 424 1.79% 0.97% [0.78%-3.53%] [0.90%-1.06%]

MAC 763 18954 2 42 0.26% 0.22% [0.05%-0.83%] [0.17%-0.29%] Spinal 25 2936 0 14 0.00% 0.48% [0.00%-100.00%] [0.29%-0.75%]

> TOTALS 1405 75347 8 560 0.57% 0.74% [0.28%-1.03%] [0.70%-0.80%]

Report by Patient Age for United Medical Center for EmCare North Division for Service Dates from 1/1/2016 through 9/30/2016

United Medical Center Benchmark

Procedure Counts Event Counts Event Rates AE Range Item Site Benchmark Site Benchmark Site Benchmark Site Benchmark

Less than 18 7 2619 0 17 0.00% 0.65% [0.00%-100.00%] [0.41%-0.97%] 18 to 30 169 7425 0 35 0.00% 0.47% [0.00%-100.00%] [0.35%-0.63%] 30 to 50 258 16625 3 111 1.16% 0.67% [0.32%-3.01%] [0.58%-0.79%] 50 to 65 569 21849 5 182 0.88% 0.83% [0.35%-1.85%] [0.74%-0.95%] 65 to 75 256 14545 0 124 0.00% 0.85% [0.00%-100.00%] [0.74%-1.00%] 75 to 85 101 8915 0 68 0.00% 0.76% [0.00%-100.00%] [0.62%-0.93%]

85 and greater 45 3369 0 23 0.00% 0.68% [0.00%-100.00%] [0.47%-0.97%] TOTALS 1405 75347 8 560 0.57% 0.74% [0.28%-1.03%] [0.70%-0.80%]

CRITICAL CARE DEPARTMENT Mina Yacoub, M.D., Chairman PERFORMANCE SUMMARY In January 2017, the Intensive Care Unit had an ALOS of 4.3 days. In January, ICU had 71 admissions. ICU Patient Days in January was 300 days. We continue to work actively with nursing leadership to improve patient flow out of the ICU. QUALITY OUTCOMES Core Measures Performance ICU continues to meet target goals for Venous ThromboEmbolism (VTE) prophylaxis. ICU is continuing to work with Quality Department and is monitoring performance. Morbidity and Mortality Reviews Mortality data is presented and reviewed in the Critical Care Committee meeting.

Code Blue/Rapid Response Teams (RRT) Outcomes ICU continues to lead, monitor and manage the Rapid Response and Code Blue Teams at UMC. Monthly reports are reviewed in Critical Care Committee. Critical Care Department is partnering with Nursing Leadership to improve staff performance during Code Blues and Rapid Responses

Ventilator Associated Event (VAE) bundle ICU continues to implement evidence-based best practices for patients on mechanical ventilators and the ICU has had no (VAEs) for the month of January 2017. Infection Control Data For the month of January 2017, the ICU had no Ventilator Associated Pneumonias (VAPs), no Central Line Associated Blood Stream Infections (CLABSIs), and no Catheter Associated Urinary Tract Infections (CAUTIs). ICU infection control data is reported regularly to the National Healthcare Safety Network (NHSN). For January 2017, there were 164 ventilator days with no VAPs, 144 central line days with no CLABSI and 216 foley catheter days with no CAUTIs. ICU infection rates continue to be well below national benchmarks. The ICU has had 1230 days with no VAP, 313 days with no CLABSI, and 366 days with no CAUTI. The CLABSI rate continues to be well below the NHSN rate of 1.5. Care Coordination/Readmissions For January 2017, 74 patients were managed in the ICU. There were no readmissions to ICU within 72 hours of transfer out.

Evidence-Based Practice (Protocols/Guidelines)

Evidence based practices continue to be implemented in ICU with multidisciplinary team rounding, ventilator weaning, infection control practices, and patient centered practices. ICU is working with ED and Nursing to implement Sepsis Quality measures.

Growth/Volumes ICU is staffed 24/7 with in-house physicians and has a 16 bed capacity and is operating at close to full capacity during the winter months. Stewardship ICU continues to implement and monitor practices to keep ICU ALOS low and to keep hospital acquired infections and complications low. ICU continues to precept George Washington University Physician Assistant students during their clinical rotations in UMC ICU. Financials ICU continues to operate within its projected budget. We are looking forward to acquiring needed equipment and bed-side care with the 2017 budget. Active Steps to Improve Performance Goal is to continue to provide safe and high quality patient care, caring for patients with increased illness acuity, providing best evidence based practice, all while keeping ALOS low and preventing Hospital Acquired infections and complications. Working closely with Quality Department and Infection preventionist to ensure we continue to meet benchmarks. We continue to emphasize regular communication with patient`s families to ensure patient satisfaction. Working to improve patient flow is an ongoing and continuous effort.

EMERGENCY MEDICINE DEPARTMENT Mehdi Sattarian, M.D.

Performance Summary:

Emergency department had a census of 4,901 patients.

January 2016 department metrics:

Patient Volumes: 4,901

% Change from 2015: 1.2 % increase

Ambulance Volume: 1251 (25.5% of ED Census)

Median Left without Treatment: 104 (2.1 %)

Admission: 580 (11.8%)

Transfers: 67 (1.3%)

Turnaround Time for Discharged Patients 228 minutes

Turnaround Time for Admitted Patients 555 minutes

Boarding time for admitted patients 314 minutes

Quality Initiatives and Outcomes:

Improving the provider productivity - 2.1 patient per hour

Improving throughput process including Door – Provider: 76 minutes Door – Disposition (Discharged): 190 minutes Door – Disposition (Admitted): 236 minutes

Adverse events (i.e. elopement, suicide attempts, assaults, etc.)

Elopement Rate: 29 patients (0.59%) Suicide attempts: 0

Readmissions within 72h - 9 Cases (0.18%) AMA rate - 47 cases (0.9%)

LWBS rate - 2.1%

Transferred Patients: Total transfer of 67 patients (1.3%) These are the main category of transferred patients:

• Trauma • Psychiatric • Cardiology • Kaiser

ED Achievements and Challenges: Emergency department showed an increase of 1.2% in census in the month of January 2017 compare to 2016. Some of the major challenges for this month was as follow:

1. Ct Scan malfunction for 3 days, caused a major decrease in our ED census and also number of admission. Having a second CT Scan will essential and extremely helpful.

2. Significant increase in boarding time of admitted Med-Surgical patients. ED leadership will continue to monitor these metrics and address these problems.

INTERNAL MEDICINE DEPARTMENT Musa Momoh, M.D., Chairman

The Department of Medicine continues to be the main source of the hospitals’ admissions. There were 448 (71%) admissions and 425 (69%) discharges.

90 patients were admitted in observation status for the department. Total observation admissions for the whole hospital was 205.

The average length of stay for the hospital was 6.44 days for the department. Procedures performed by the department included 219 dialysis encounters, 346 EGDs, 59 Colonoscopies, and 1 Bronchoscopy, amongst others.

The patient satisfaction scores continue to trend upward. Preliminary results show a composite score of above 80%. There were no new appointments or resignations.

OBSTETRICS & GYNECOLOGY DEPARTMENT Sylvester Booker, M.D., Chairman

Indicator JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Breastfeeding 48%

IMC Admission 1

NICU Admission 2

Infant on Vent 1

# of infant transferred 1

# of infant on IV Therapy 2

Infant on Antibiotic Therapy 2

Phototherapy 1

Circumcision 15

Infant (+) Substance Abuse 7

Boarding Baby 2

Failed Hearing Screen 0

# of Bili scan 36

# of CCHD Screening 36

GYN patients 8

Premature babies receiving

steroids prior to birth*

1

Code Purple 24

Neonatal Death 1

INDICATOR JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Total Deliveries 39

Vaginal Deliveries 34

Vacuum assisted deliveries 3

Primary C-Section 1

Repeat C-Section 4

VBAC Attempt 1

VBAC Successful 0

# of Induction of Labor 0

# of Aug. of Labor 1

HIV + Mom 0

HIV + Babies 0

Mother + for Substance 7

Abuse

Still Birth 1

No Prenatal Care 6

Mother to ICU 1

Multiple Gestation 0

HTN/PIH 2

Placenta Abruption 2

Placenta Previa 0

Meconium 8

MRSA + Carrier 0

Maternal Transfer 0

PP Hemorrhage 1

Cord Prolapsed 1

Epidural Anesthesia

PATHOLOGY DEPARTMENT Eric Li, M.D., Chairman

We developed performance indicators we use to improve quality and productivity

Spinal Anesthesia 4

General Anesthesia 1

Diabetic 0

Eclampsia 0

HELLP Syndrome 0

TOTAL TRIAGE PATIENTS 185

Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Reference Lab test – Urine Protein 90% 3 days 100%

16/16

Reference Lab specimen Pickups 90% 3 daily/2 weekend/holiday

95%

76/80

Review of Performed ABO Rh confirmation for Patient with no Transfusion History

Benchmark 90%

100%

Review of Satisfactory/Unsatisfactory Reagent QC Results

Benchmark 90%

100%

Review of Unacceptable Blood Bank specimen

Goal 90%

99%

Review of Daily Temperature Recording for Blood Bank Refrigerator/Freezer/incubators

Benchmark <90%

100%

Utilization of Red Blood Cell Transfusion/ CT Ratio – 1.0 – 2.0

1.3

Wasted/Expired Blood and Blood Products

Goal 0

0

Measure number of critical value called with documented Read Back 98 or >

100%

Hematology Analytical PI

Body Fluid

100%

12/12

Turnaround Time: Turnaround time is a critical factor that directly influences customer satisfaction.

Customer Satisfaction: The key to business is providing great customer service, superior quality, and creating a unique customer experience.

Complaints: Complaints are an important metric for evaluating the quality of our laboratory processes.

Equipment down time: It is important that laboratories track, monitor, and evaluate equipment failure rates and down time.

PEDIATRICS DEPARTMENT Marilyn McPherson-Corder, M.D., Chairman Performance Summary: For the month of January, 38 babies were admitted to the nursery. One infant was transferred to Children’s National Medical Center due to neonatal complications. One fetal death due to extreme prematurity. On the average length of stay was 2 days for NSVD and 3.5 days for C-sections. The year-to-date total number of newborns admitted to the nursery is 38. The Departmental meeting was held on January 9, 2016. Dr. Marilyn Corder had several meetings with The March of Dimes and Zeta Phi Beta Sorority to continue to work on the joint project for the Stork’s Nest Program at UMC. Plans to open the Stork’s Nest Program are ongoing. Core Measures Performance: The Department of Pediatrics continues to meet the Core Measures Performance. Morbidity and Mortality Reviews: One fetal death and one infant transfer. All infants were cared for in the UMC nursery and discharged home with planned follow up care. Evidence-Based Practice (Protocols/Guidelines): Neonatal resuscitations guidelines continue to be followed resulting in no mortalities or morbidities. Increase education on the benefits of breastfeeding and skin-to-skin encouraged right after delivery of

Sickle Cell 0/0 ESR Control 100%

31/31

Delta Check Review 100%

180/180

the infant with >60% breastfeeding rate within the first 24 hours. Hand washing encouraged repeatedly to prevent healthcare associated blood stream infections in the newborn. Zero incidence of healthcare associated bloodstream infections of the newborn. Growth/Volumes: The Department continues to expand staff for coverage of the nursery and Ob support. Dr. Rehema Kutua is the latest member of our department. The department continues to work to extend the breast feeding initiatives and to encourage pre and postnatal care with all mothers. We are pushing forward to complete our certification as a “baby friendly” hospital. Stewardship: The Pediatric Contract has provided financial stability and has maintained operation below the budgeted expenses. Activities: The department is partnering with Breath DC, Children’s National Medical Center and Trusted Health Plan to initiate an Asthma Case Management Program.

PSYCHIATRY DEPARTMENT Lisa Gordon, M.D., Chairman

Performance Summary: For the month of January, please see the table below. The year to date total number of admissions was 73. Our average length of stay for January was 8.12. The ALOS for the month was above the target of 7 as we had several patients (4) who needed to be transferred to St. Elizabeth’s Hospital and one patient needed to be coordinated with a group home. Average length of stay has been negatively impacted by our inability to have patients transferred to St. Elizabeth’s Hospital and Group Homes for further inpatient treatment in a timely manner. We had (4) patients with LOS over 15 awaiting 15 days awaiting a bet at St. Elizabeth’s and another waiting for a Group Home.

Description Jan Feb Mar Avg. YTD MTD% YTD% ALOS 8.12 8.12 UMC Admissions Legal Status-Voluntary 42 42 58% 57.5% UMC Admissions Legal Status-In Voluntary 31 31 42% 42.5%

Total Admissions 73 0 0 73 100% 100.0% Referral Source: CPEP 17 Other (UMC ED) 49 GW U 0 Providence 0

Georgetown 1 Sibley 1 UMC Medical Surgical Unit 3 Children’s Hospital 0 Howard 0 Laurel Regional Hospital 0 Washington Hospital Center 0 Suburban Hospital 0 All Others 0 PIW 2

Total # of Patients 73 0 0 146 100.0% 100.0%

Description Jan Feb Mar Total St. Elizabeth Transfers 4 Transfers with LOS over 15 days 4 Number of Court Hearings 2 0 0 2

Quality Initiatives, Outcomes, etc. Core Measures Performance Behavioral Health Unit is continuing to work with the PI team to improve the validity of the abstraction process for core measures. We receive daily reports on potential fall-outs. We are also preparing to institute new HBIPs quality measures. To date, the BHU is in 100% compliance on the timely completion of multi-disciplinary treatment plan. In January we were 100% compliant for 7 days Post Discharge follow-up appointments. Adverse events (i.e. elopement, suicide attempts, sexual harassment, assaults, etc. There were no suicide attempts or other harassment complaints in the month of January. Aggressive patients continue to be managed safely by BHU staff. Staff has completed their re-certification of CCM training including all Physicians. Service (HCAHPS Performance/Doctor Communication) BHU continues to work to implement a broader programming schedule to provide our patients more therapeutic groups. Group attendance is monitored daily. All staff is encouraging patients to attend groups. Growth/Volumes BHU has two full time physicians who are covering for 20 patients and consults. A psychiatric Nurse Practitioner has been hired and tentatively scheduled to start services in March 2017. Financials BHU is working with patient billing and admissions to reduce payment denials from insurance providers and a monthly meeting is in the process of being scheduled. The BHU has implemented an Authorization Log which tracks all admissions and ensures all stays are authorized and all denials are appealed.

Active Steps to Improve Performance: The renovations began in October and are scheduled to be completed in June 2017.

RADIOLOGY DEPARTMENT Raymond Tu, M.D., Chairman

Performance Summary:

Quality Initiatives, Outcomes, etc.

Core Measures Performance 100% extra cranial carotid reporting using NASCET criteria 100% fluoroscopic time reporting 100% presence or absence hemorrhage, infarct, mass 100% reporting <10% BI RADS 3 Radiology staff continues to work to improve the turnaround of patients for CT and MRI of the brain through the department.

Morbidity and Mortality Reviews: There were no departmental deaths.

Code Blue/Rapid Response Teams (“RRTs”) Outcomes: 1 rapid response, full recovery. Evidence-Based Practice (Protocols/Guidelines): We continue to improve patient transportation into and out of the emergency department.

Service (HCAHPS Performance/Doctor Communication) The radiology department’s new equipment has been very well received for by our clinical staff elevating the status of our hospital.

Stewardship: Dr. Tu continues to strongly recommend clinical decision support at the point of order entry to reduce unnecessary examinations and to aid in practioners to order the right test, the right time for the right patient. Radiologists and staff thanks outgoing director Mr. Derrick Perkins at a staff party.

Radiology staff (left),

farewell cake

(middle) and Mr. Derrick Perkins (right)

Mr. Emmanuel Anye is serving as interim director of radiology and arranged additional training for CT technologists for high level CT training as this CT angiogram of the neck and brain arteries.

CT Angiography on the General Electric 128 slice Revolution EVO CT scanner

UMC radiology passed the Mammography Quality and Standards Act (MQSA) survey, thanks to the stewardship of Mammographer Ms. Tracy Williams, Secretary Ms. Jankeh Segnian and radiologist Riad Charafeddine MD. Financials: Active Steps to Improve Performance: The active review of staff performance and history to be provided for radiologic interpretation continues with improvement. Proper protocols, judicious use of radiation emitting technology are continuing objectives in the department under the teamwork of excellent technologists and radiology directorship and front desk staff.

SURGERY DEPARTMENT Gregory Morrow, M.D., Chairman For the month of January 2017, the Surgery Department performed 216 total procedures. This has been one of the best months volume-wise over the last 4 years. The chart and graft below show the monthly trends over the last 4 calendar years:

SURGERY SUMMARY REPORT FROM JANUARY 2017

2013 2014 2015 2016 2017 January 173 159 183 147 216 February 134 143 157 207 March 170 162 187 215 April 157 194 180 166 May 174 151 160 176 June 159 169 175 201 July 164 172 193 192 August 170 170 174 202 September 177 168 166 172 October 194 191 181 177 November 137 157 150 196 December 143 183 210 191 Annual 1952 2019 2116 2242 216

Our surgical volumes are experiencing a steady annualized upward trend. From 2013 thru 2016 there have been annual increases in volume of 3.34%, 4.8% and 5.95%. We continue to work diligently to increase our efficiencies and productivity while, at the same time, delivering the highest quality of care. We continue to meet and/or exceed the quality measures outlined for the Surgery Department. SURGERY SUMMARY REPORT FROM JANUARY 2017 In coordination with the Hospitalist service and Nursing, the vascular access (Midline and PICC line) service is operational with the goal to improve upon patient satisfaction and avoid delays in treatment due to lack of adequate intravenous access for therapies (i.e., pain medication, antibiotics) and procedures, especially as it pertains to surgery start delays. The department is continuing its work on:

- Ongoing evaluation of the service lines that will most benefit from implementation of best practices policies and procedures.

- Expanding availability of available OR time during regular business hours. We are working

with the Anesthesia Department, Nursing and Administration to achieve these goals.

- The department is in the process of reviewing all subspecialty delineation of privileges to make certain that they are up-to-date and reflect advances that now considered integral parts of residency and fellowship training. The update will be forwarded to the Credential Committee for approval in March.

- The OR committee has met and will continue to be the focal point of addressing the ongoing needs of the surgical services as it pertains to the day to day operations. We will also be reviewing current medical equipment as a part of standardization and review process for the Operating Room.

The OR renovations began in October 2016 with a late spring/early summer completion time. We have begun the final details for implementation our strategic plan to increase our operative volumes to accommodate the 4 new ORs. This will include broadening daytime anesthesia coverage to stepwise accommodate higher volumes and also to bolster the service lines that are lagging in volumes or non-existent; these specifically include Orthopedics and Bariatric Surgery. Regards,

MEDICAL AFFAIRS Sarah Davis, BSHA, CPMSM

UMC Medical Affairs Monthly Report

APPLICATIONS IN PROCESS

(Applications received through January 31, 2017) Department # of Application in Process

Allied Health Practitioners 3 Anesthesiology 0 Behavioral Health 0 Emergency Medicine 4 Medicine 0 Obstetrics & Gynecology 0 Pathology 0 Pediatrics/Neonatology 2 Radiology 1 Surgery 0

TOTAL 10

2016 MEDICAL AFFAIRS PERFORMANCE IMPROVEMENT

DEPARTMENT/INDICATOR Target 1Q16 2Q16 3Q16 4Q16 ANNUAL

MEDICAL STAFF OFFICE

Timely receipt of initial application with required ID (60 days) 100% 100% 100% 100% 100% 100%

All expirable documents are current (license, physical, PPD screening, influenza vaccine, DEA, CDS, liability insurance, etc.)

100% 87% 86% 80% 90% 86%

Complete credential files 100% 100% 100% 100% 100% 100%

Timely processing of re-appointment application following receipt (30) days 100% 100% 100% 100% 100% 100%

ANNOUNCEMENTS

Medical Staff Meetings February

February 6, 2017 at 12:00 pm Peer Review Committee February 7, 2017 at 12:30 pm Medical Education Committee February 9, 2017 at 12:30 pm Credentials Committee February 13, 2017 at 12:00 pm Critical Care Committee February 14, 2017 at 12:30 pm Prevention & Control of Infections

Committee

February 14, 2017 at 2:00 pm Pharmacy & Therapeutics Committee February 15, 2017 at 2:00 pm Health Information Management Committee February 20, 2017 at 12:00 pm Medical Executive Committee February 22, 2017 at 9:00 am Board of Directors

February 22, 2017 at 3:00 pm Performance Improvement Committee

February 23, 2017 at 5:00 pm Department of Medicine

United Medical Center Management Report

Operations Summary – February 2017

QUALITY Emergency: Phase I: Observation Status

As seen in the graphs below, the observation performance continues to move in the desired direction. Of note is the week of January 21-28 when several patients with complex social problems influenced the overall length of stay. We are currently redesigning the case management staffing plan to increase the number and time social workers are assigned to the ED.

29

20 21 23

28

24

13 11

20

11

34

18 19 17

11 12 14 13

24

12

8

16

9

0

5

10

15

20

25

30

35

40

Num

ber o

f Pat

ient

s

UMC Observation Status: Sept 2016- present Actual Number of Observation Patients per Week

2

Phase II: Front End Process Redesign

Phase II of the Emergency Department improvement effort is the redesign of the front end process which encompasses the time the patient enters the door to the time the patient is seen by the physician. The goals are to reduce door to doctor wait times, eliminate non-value-added activities, promote patient satisfaction, reduce patient tensions in the waiting room resulting from long waits, and utilize existing staff more effectively and efficiently. This front end process operates under two different conditions: when the ED is slow and when the ED is busy. The best practice, Pull to Full, which at present occurs sporadically, will be implemented as the standard

41

32.5

47

30

58.5

31

43

28 29

39 36.5 34.5 37 39

29

36.5 38.5 34

27.5

39

56.5

40

28

0

10

20

30

40

50

60

70N

umbe

r of h

ours

UMC Observation Status: Sept 2016 to present Median Length of Stay

Med-Surg 3rd and 5th floors (including outliers)

66%

75%

52%

91%

32%

71%

62% 64% 70%

64% 68% 67% 68%

82% 82%

67% 64% 69%

92%

75%

38%

75%

89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

UMC Observation Status: Sept 2016 - present Per Med-Surg 3rd and 5th floors (including outliers)

% of Total Observation Patients with Length of Stay <48 hours

3

process when the ED is slow. In conditions of high patient volumes the ED will also incorporate best practices to design its standard process. The target for implementation is early March. Physician Consultant: Dr. Stanley Boucree, Jr. MD, DDS, is leveraging his professional network to connect the CEO with local professionals for potential program development at UMC. Meetings between UMC management and the following physicians have been had to discuss their plans and needs:

• The Nerve, Bone and Joint Institute’s (NBJI) Dr. Shar Hashemi, a hand surgery

specialist, has expressed interest in UMC as a practice site. He is skilled in helping patients regain function particularly after accidents, such as those experienced by construction workers.

• Dr. Edwin Chapman, an addiction medicine specialist is also interested in a practice site

at UMC. He is looking for 900-2000 square feet of office space and is considering the UMC medical office building. An addiction medicine practice at UMC would be a valuable asset, especially by providing access for the ED’s patient population requiring these services. Dr. Chapman works closely with Rev. Dr. Frank Tucker whose large faith-based network support provides interdisciplinary support for people with numerous chronic diseases.

Patient Throughput:

The bedboard tracker and the daily throughput tracker provider real-time data about patient location and movement. We have developed and implemented additional daily work tools so daily utilization can also be data-driven. A process and daily work tool to identify, document, track, analyze and communicate reasons for discharge delays has been developed and implemented. A process and daily work tool that identifies and communicates LOS expectations to providers, hospital leaders, nurses and case managers has also been developed and implemented. Both of these tools are used daily and also roll up to summary operational, reporting, and management tools to better manage patient utilization.

Hospital management continues to meet weekly with physicians, nurse leaders and case management to identify and resolve operational barriers. Nurse leaders continue to actively work with physicians to promote timely discharges. Patient Satisfaction: After favorable performance since August, the Press Ganey questions, Rank the Hospital and Recommend the Hospital, dipped in performance during the month of December. We are investigating the contributing factors and will address them accordingly.

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PATIENT CARE SERVICES Emergency Department (ED) Highlights: Annual comparison for key ED metrics include overall visits increased by 1.24%, ED admissions by 6.38% and EMS traffic increased by 1.28%. Our work continues with our ED transformation project, “TransformED,” and we are currently underway with implementing the front-end processes that resulted from the weekly ED operational workgroup that was formed and includes representatives from all departments that support ED operations. The goal of the front-end process initiative is to reduce wait times for patients to be seen in the Core and our Fast Track area. We will decrease registration times and facilitate improved times for our patients to see the physicians.

36.8 38.3 48.6

31

44.1

64.2

50

30.4 39.1

52.1 52

38.5

0102030405060708090

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

% re

spso

nses

Press Ganey Inpatient Experience of Care December 2016

Rank the hosppital 1-10 Accessed 2/13/17

n = 38 47 39 29 34 28 20 23 23 29 25 26

42.1 38.8 44.7

32.1 42.4

50

22.2 26.1

39.1 46.4 44.4

30.8

0

20

40

60

80

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

% re

spon

ses

Press Ganey Inpatient Experience of Care December 2017

Recommend the Hospital Accessed 2/13/17

n= 38 47 28 28 33 28 18 23 28 28 27 26

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• Currently organizing re-launch of customer service skills awareness training to

coincide with annual competencies • We continue to improve communication with our patients. Nurses have been trained to

include patients in developing their plan of care. Families are also included in plan. Nurses are asking the patients to repeat what was discussed to validate their understanding

• Partnering with new Press Gainey liaison to establish simulated training related to hourly rounding and bedside report to coincide with the reopening of the 8th floor

Nursing Operations: Formalization of a vascular access program using existing resources to allow for timelier turnaround of orders and ultimately decreasing LOS and improving discharge timeliness OPERATIONS Materials Management Department: Product Review and Standardization Committee was created to assist with value analysis and standardization hospital wide. Meetings are held the 3rd Thursday of each month. Committee brings important stakeholders together for product value analysis and also serves as means to introduce new products into the hospital.

• Development of a paperless requisition system. This will create transparency in the purchasing process and also improve the efficiency in the amount of time it takes to complete three way match (ordering, purchasing, paying invoices).

• Meeting with Cardinal Director in order to facilitate a distribution agreement. The hospital spends approximately 4.5 million with Cardinal. If we signed a distribution deal with them, it would lower our mark up on Cardinal branded products from 13.25% to 0% and mark up on national branded products from 13.25% to 2.75%. Because 21% of the items we currently purchase are Cardinal branded, UMC would reap the benefits via rebate in Cardinal’s 360 Program. Signing a distribution deal will have a tremendous impact on UMC’s annual expenditures.

• Finalizing new Group Purchasing Organization (GPO) to facilitate increase savings in product spend.

• Currently recruiting for a full time Material and Supply Chain Manager.

Patient Access Services: The Patient Access Department/Admissions/Registration/Emergency Admitting and Centralized Scheduling is responsible for registering and scheduling patients for all services at the hospital. Patient Access registers patients being admitted directly into the hospital as well as patients

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arriving for outpatient procedures. Currently, there are a number of initiatives the department is in the process of implementing:

• Any patient who is deemed to be self-pay at the time of registration will have an opportunity to apply for Governmental Assistance or the Health Exchange Insurance through DECO Management Recovery Services. DECO staff is available Monday-Friday 8:00am - 8:00pm and Saturday-8:00am-4:30pm. Having these services available will accommodate our self-pay patient population and help meet the financial goals for the Hospital.

• Implementation of Relay Systems – Relay will focus on the areas of pre-service and point of service collection, insurance verification, propensity to pay, electronic notice of admissions, authorization, and medical necessity.

• Implementation of Meditech Authorization and Referral Management System – The functionality in Meditech scheduling and referral management solution provides a streamlined approach to administering authorizations and the referral process.

• Centralized Scheduling – This department focuses on scheduling all outpatient and ancillary services for the hospital. Call volumes are increasing due to the on-boarding of outpatient clinic physicians and services.

• Emergency Admitting – This department has initiated bedside registration for a more efficient patient flow. Due to the increase in patient volumes and overtime usage, staffing is currently being monitored and evaluated for appropriate optimization during peak hours.

Property Management: The Property Management Department is responsible for the operation, control, and oversight of leased spaces on the Hospital’s Campus.

• In September of 2016 all tenants on the Hospital’s Campus were reissued new or renewal leases. This effort was to ensure that all tenants had appropriate District approved leases and lease rates were at fair market value.

• In 2018, a Fair Market value assessment will be conducted to determine any potential lease adjustments for 2019 to maintain fair market value.

• To date 94% of the tenants on the campus have executed the new or renewal leases • Tenant Relationship – Beginning in April the Department will hold quarterly tenant

meetings to increase the line of communications between Hospital leadership and lease holders.

• Laboratory Corporation of America (LabCorp) has leased space in the hospital Medical Office Building. LabCorp’s presence will provide outpatient access to lab services to the thousands of patients seen in the Medical Office Building resulting in improved outcomes. This relationship will allow patients to have laboratory testing completed before leaving the campus preventing any delay in follow-up care. LabCorp is the contracted vendor for outpatient laboratory testing for all of the Managed Care Medicaid organizations in the District of Columbia.

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Safety and Security: The Hospital will hold its regulatory required “Active Shooter Training” on February 21st as part of the hospital’s emergency preparedness guidelines. The training will be completed by the Federal Bureau of Investigation.

• Active shooter events in a healthcare setting present unique challenges: a potentially large vulnerable patient population, hazardous materials (including infectious disease), locked units, special challenges such as weapons and Magnetic Resonance Imaging machines (MRI) (these machines contain large magnets which can cause issues with firearms, or remove it from the hands of law enforcement), as well as caregivers who can respond to treat victims.

Radiology Department:

• On January 19th the Radiology Department underwent the Mammography Quality Standards Act (MQSA) survey conducted by the US Food and Drug Administration. The MQSA survey assesses the quality of the Hospital’s mammography program and the hospital’s compliance with the practice of Mammography services as outlined in the Act.

• The hospital was found to be out of compliance with two (2) standards. A plan of correction was submitted and accepted by the FDA.

HUMAN RESOURCES Workforce Development: Employee Survey In March 2017, UMC will be conducting the 2017 Employee Survey. The survey will run from February 27th through March 17th. This year’s theme is “Collectively Rising Together”. The survey will be based on the 29 questions used in both the 2014 and 2015 survey, thus providing the organization a year-over-year perspective on its improvements and accomplishments. The focus for 2017’s survey will be the increase of employee participation through the implementation of various participation methods, i.e. Web-based, Hard Copy and distribution through Department/Unit meetings. By increasing the number of respondents, we broaden the perspectives by which the organization will base its focus on overall improvement.

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Recruiting Initiatives: Hires and Terms – Nursing

JanuaryHires 1Terms 1

0

0.2

0.4

0.6

0.8

1

1.2

Hires/Terms - Nursing 2017

9

Hires and Terms - UMC

January saw a slight spike in the number of Clinical hires, 8 out of the 14 hires, due to the reconciliation of staffing levels vis-à-vis Patient Census levels. Key/Strategic Positions:

Position Type Title FTE

Executive Level

No Openings 0.0

Total 0.0

Key Positions

Director of Materials Mgmt 1.0

Director Radiology 1.0

Total 2.0

Hard To Fill

Art Therapist 1.0

Respiratory Therapist 1.0

RN – ED 5.4

RN – ICU 1.2

JanuaryHires 14Terms 7

0

2

4

6

8

10

12

14

16

Hires/Terms - UMC 2017

10

RN – L&D 1.1

RN – OR 1.0

RN – Dialysis 0.9

Surgical Assistant 1.0

Total 12.6

Open Positions

Certified CT Tech 0.1

Certified Nursing Assistant 1.0

Environmental Services 2.5

HelpDesk Analyst 2.0

HR Generalist 1.0

Licensed Practical Nurse 2.0

Medical Assistant 1.0

Med/Surge Technician 0.6

Physician’s Assistant 1.0

Psych Technician 0.2

SPO 2.0

Sr. Systems Analyst 1.0

X-ray Technician 0.1

Cook II 0.5

Utility Worker 0.5

Cashier 0.5

General Maintenance 1.0

Food Service Worker 1.0

Payroll/Staffing Coordinator 1.0

Administrative Supervisor 1.0

Patient Access Rep. 1.0

Total 21.0

Total Open Positions 35.6

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INFORMATION TECHNOLOGY AND SYSTEMS Clinical and Financial Application Initiatives:

• InterQual – Patient Assessment and Classification Software • Goals:

Determine the most appropriate disposition from the Emergency Department for individual patients based on acuity. Decrease denials by documenting patient acuity level any care provided.

• Status: The go-live has tentatively been scheduled for late April 2017.

• Curaspan – Electronic Placement of Non-Acute Patients for Long-Term Care • Goals: Improve Case Management workflow and efficiency in dealing with long

term care facilities. • Status: Implementation planning phase initiated in February 2017. The target date

for go-live has yet to be determined.

• Nuance Voice Recognition for physician documentation • Goals: Improve physician workflow and efficiency.

Improve care by creating a more complete patient record. Increase revenue with more complete documentation of care provided.

• Status: The go-live has been delayed one month, to May 2017.

• gMed gastro Imaging and documentation System • Goals: Improve clinical documentation using system that combines images with

reporting capabilities. Improve physician satisfaction and retention by providing system to document care more efficiently.

• Status: This project has been delayed due, in part, to training issues. The new date for completion is April 2017. Meanwhile, the old system is still functional and (minimally) meeting our needs without impacting patient volumes.

• NurseCall System Replacement

• Goals: • Increase reliability of nurse call system • Improve staff answer times through better system communication and

workflow • Decrease noise level on units with direct communication to assigned nurse • Increase patient satisfaction scores through better communication and

response with patients. • Status: On target to meet the scheduled 5th and 8th floor openings.

• eClincalworks Outpatient EMR

• Goals: Improve clinical care in the clinics by creating an immediately available single patient record including evidenced based templates, drug interaction checking, allergy checks and readily available historical data. Increase revenue by using

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templates and documentation system to insure all aspects of each visit are properly documented and coded to insure proper payment is received.

• Status: The system is now ‘live’, however, we continue to work through a number of problems mostly having to do with the timeliness and the accuracy in the sharing of critical patient information between the two core systems, e-CW and Meditech.

• PACS System

• Goals: • Increase the efficiency and report turnaround for reading and creating reports for imaging studies • Improve patient care with readily available prior studies and faster results to providers • Increase system uptime by moving to the data center building in necessary redundancies.

• Status: The go-live has been delayed one month, to mid-March 2017. Operational Initiatives:

• Board Portal • Goals:

• Ensure all Board members have access to necessary information in a timely and secure manner

• Decrease time spent creating packets for Board and committee meetings • Decrease paper costs for all Board and Board committee meeting packets.

• Status: DirectorPoint configuration is complete as well as training for the Board members. From a technical perspective, systems and process are enabled as necessary to go paperless in February or March 2017 depending on user acceptance.

PUBLIC RELATIONS AND COMMUNICATION Community Outreach:

• UMC’s David Thompson spoke at Advisory Neighborhood Commission 8C’s meeting on February 1 at the RISE Center. Over 50 community residents from Ward 8 attended the meeting. Information about the hospital was provided to the attendees including brochures and pamphlets about services at UMC. The audience was provided updates on how the hospital was addressing concerns pertaining to the level of care provided individuals while at UMC.

• On Tuesday, February 7, Mr. Thompson spoke at the Overlook Senior Center in Ward 8. Two dozen elders received information about the hospital and the services that would be particular interest to them and their loved ones. Many of the seniors wanted more information about UMC’s hyperbaric chambers that treat patients with severe wounds since some people with diabetes develop wounds that will not properly heal. The seniors were also given information about Dr. Charlambides, UMC’s gerontology specialist, and encouraged them to utilize his services. The Senior Center wants to plan a

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major event for elders and single heads of households in early May for health screenings and clinical presentations.

• Mr. Thompson made a presentation to the Capital View Civic Association’s meeting at Hughes Memorial United Methodist Church in Ward 7 on February 20. He provided an overview of the hospital, discussed new physician specialists recently hired by UMC and emphasized services available to the community.

• Mr. Thompson spoke at the Fairlawn Civic Association at Anacostia Library on Tuesday, February 21. His presentation covered the recent renovations at the hospital, new physician specialists, and the new technology that the hospital uses. Pamphlets about UMC were distributed to the attendees and questions from the audience were answered.

• On Wednesday evening, January 25, Mr. Thompson spoke at the Apple Grove Squire Woods Citizens Association Meeting in Fort Washington, Maryland and provided an overview of the hospital’s services and changes at UMC. The Association said they want to plan an event for the Spring and have the mobile health clinic on site to assist in health screenings for the residents in the community.

Advertising:

• New radio advertisements began airing on Magic 102.3 and Praise 104.1 encouraging people to come to UMC and get screened for high blood pressure. February is American Heart Month and individuals in UMC’s service area have a higher incidence of hypertension and heart disease. The ad reminds people that hypertension should be addressed and tells them to call UMC to schedule an appointment.

• Print ads are appearing in the Washington Informer and East of the River Community newspapers. The ads promote American Heart Month and provide statistics on heart health while encouraging people to come to UMC to have their blood pressure checked.

• TV spots are running on NBC 4 and FOX 5 promoting the importance of “Primary Care” to the community. The advertisements show patients taking blood pressure tests, having their eyes examined, and other screenings. The ads also help to build the brand and help improve the overall image and reputation of United Medical Center.

Website and Social Media:

• The website is in its final revision and update phase. We will be meeting with the patient billing department, patient records manager, and IT to determine how billing and patient records will be accessed and secured. The updated website is slated for release in early March.

• We continue to populate the United Medical Center Facebook page with new content that demonstrates how the hospital is striving to provide the community with high quality care and information about activities, events and services that UMC clinicians and staffers are engaged in.

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CORPORATE COMPLIANCE

• The Corporate Compliance Officer is working in conjunction with the Governance Committee to request feedback on the final draft of the NFPHC Ethics and Compliance Program. The program contains a comprehensive plan that incorporates all required seven elements as mandated by the Office of the Inspector General.

• The Corporate Compliance Officer now serves as the Freedom of Information Act (FOIA) Officer for NFPHC. Two FOIA requests have been received; one has been processed and responded to in full and the other is also expected to be fulfilled by the deadline.

• The Corporate Compliance Officer has completed the following mandatory District training in the past 30 days:

o FOIA Training (Trainer: Traci Hughes, Esq.-BEGA) o HIPAA Awareness (Trainer: Tina Curtis, Esq.-OAG) o Agency Public Financial Disclosure Filing (Trainer: Janet Foster, Esq.-BEGA)

• The Code of Conduct continues to undergo revisions to update language and standards to overlay with the District’s guidance in the DC Code of Conduct. Anticipated completion of final draft is February 28, 2017.

• Compliance is finalizing the multi-year educational plan for compliance related training throughout the hospital. The plan will be submitted for CEO approval in early March.

Not-For-Profit Hospital Corporation Board of Directors

Governance Committee Agenda Virgil McDonald, Committee Chair

February 14, 2017 at 8:00 a.m.

I. CALL TO ORDER II. ROLL CALL III. CONSENT AGENDA REVIEW MINUTES OF THE JANUARY 10, 2017 MEETING IV. BOARD, MEDICAL STAFF & EXECUTIVE TEAM RETREAT • SATURDAY, MARCH 25, 2017 AT 8:00 A.M. • STATUS UPDATE V. NFPHC-BYLAWS

• CODE OF CONDUCT • CONFLICT OF INTEREST

VI. UPDATE – UMC MISSION, VISION AND VALUES STATEMENT • VIRGIL MCDONALD VII. ASSEMBLY OF A POLICY MANUAL FOR THE BOD VIII. ANNUAL BOARD OF ETHICS AND GOVERNMENT ACCOUNTABILITY TRAINING • DATE: WEDNESDAY, FEBRUARY 22, 2017 IX. NEXT MEETING – TUESDAY, MARCH 14, 2017 AT 8:00 A.M.

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Not-For-Profit Hospital Corporation

Governance Committee Meeting Minutes February 14, 2017

Present: Virgil McDonald, Committee Chair, Steve Lyons, Chris G. Gardiner, Board Chair, Khadijah Tribble, Luis Hernandez, Donna

Freeman (Corporate Secretary) Excused: Guests: Dr. Erica Alexander, Corporate Compliance Officer Agenda Item Discussion Action Item Call to Order The meeting was called to order by Committee Chair Virgil McDonald at 8:05 a.m. Determination of a Quorum

Donna Freeman, Corporate Secretary determined a quorum.

Approval of the Agenda

The agenda was approved with one addition: the Corporate Compliance presentation by Dr. Erica Alexander, Corporate Compliance Officer.

Approval of Minutes

The minutes of January 10, 2017 were approved.

Discussions

Virgil McDonald led the discussion on the following: (Reports presented to the Board Members and filed in the Office of the Secretary of the Corporation) Corporate Compliance Program for UMC presented by Dr. Erica Alexander

• Luis Hernandez, CEO introduced Dr. Alexander. • The Compliance Program will be presented to the board by way of the Governance

Committee. • Dr. Alexander highlighted the following:

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▪ Program is based on OIG’s Hospital Based Program ▪ Every hospital is required to have a compliance program ▪ The UMC program is based on the seven (7) pillars. ▪ The Eight (8) Essential Elements:

Administrative Structure & Oversight Monitoring and Auditing Standards of Conduct & Policies Investigation and Response Communication Enforcement and Discipline Education and Training Assessment of Program Effectiveness ▪ Seeking the input from the committee on the program. ▪ Committee is requested to: Review the document with comments by March 14th. Comments will be reviewed and present to the full board in March 2017.

• Board Retreat ▪ March 25, 2017 – 8am-3pm ▪ Location: Matthews Memorial Baptist Church, 2616 Martin L. King, Jr. Ave., SE Washington, DC ▪ Mayor Bowser unable to attend. ▪ Letters have been sent to the Medical Staff ▪ Photographer is scheduled on 2/15 and 2/22 for Exec. Team and Board. ▪ Save the Date announcement will be emailed Tuesday, Feb. 14th ▪ Ms. Joan Lewis, AHA confirmed her attendance as one of the speakers. ▪ Letters to the all participants will be mailed by February 20th. ▪ Mr. Corbett Price is requested to present a report (written and oral) on UMC’s current status and future goals.

• BEGA – Code of Ethics Training will occur during the February 22, 2017 BOD meeting. Chair Gardiner led the discussion regarding protocol and following same during the meetings.

Donna Freeman was requested to send Mr. Corbett Price an invitation to present a written and oral report on the state of the UMC and its future progress. Chair McDonald asked the committee to submit any and all questions regarding code of conduct to Donna Freeman by Friday, February 17th.

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• Appreciation for Bishop C. Matthew Hudson, Jr. Chair Gardiner suggested giving Bishop Hudson a form of appreciation for his service. The committee agreed and details will follow.

• Mission, Vision and Values Statements: The committee suggested and agreed to move the project to the Strategic Planning Committee. All submissions will be circulated to the committee.

• Policy Manual – Chair McDonald proposed having an electronic manual on the board portal. Dr. Erica Alexander suggested the following documents be included: Rules of meetings. Organizational Documents How to Request Time on the Board

Who is allowed to contact the media Commenting to the media Board’s reporting structure

Chair McDonald requested the committee to submit all suggestions for the electronic Policy Manual to Donna Freeman by Friday, February 24th.

Other Business Other Business: • Chair Gardiner discussed the task of making a recommendation to Mayor Bowser

by the end of March 2017 whether the board will seek another operator or extend the contract for the current operator in FY 18. The recommendation (which is based on their performance) will be led by the Strategic Planning Committee, chaired by Khadijah Tribble.

• Three (3) Options 1. Release Operator and hire CEO – Mayor Bowser declined that option 2. Contract would be put out to bid in the open market. 3. Continue with and finance the current Operator.

• Evaluation of the CEO The instrument was discussed – standardized process for hospitals.

The next conference call will be held on Tuesday, March 14, 2017 @ 8:00 a.m. The meeting was adjourned at 8:54 a.m.