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Medical Executive Committee Meeting
Thursday, Aug 6, 2015
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Review/Approval of 2Q Minutes: 05/07/2015
Medical Staff – Committee as a Whole
Credentialing
ASH Committee Reports/Recommendations
QAPI/Compliance/Risk Management Update
CEO Report
Other
MEC AGENDA
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MEDICAL STAFF Clinical Policies – Provided for information to Medical Staff.
◦ No Policies for Q3
Appointments/Reappointments – Action required.
Pharmacy & Therapeutics – William Rodgers
◦ 6 Adverse Drug Events.
◦ Therapeutic Substitutions
Provided to medical staff for information. (Handouts)
◦ PowerPlan Changes
◦ Formulary Changes- Additions/Deletions
Provided to medical staff for information. (Handouts)
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Drug Shortages:◦ Haloperidol (Haldol®) injection◦ Levetiracetam (Keppra®) injection◦ Heparin 25,000 units/250 mL 1/2NS premix◦ Piperacillin/Tazobactam (Zosyn®)◦ Ampicillin/Sulbactam (Unasyn®)◦ Vecuronium (Norcuron®)
ASH Pharmacy Update
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ASH Committee Minutes
◦QAPI Meeting Minutes –07/29/15
◦Safety Committee Minutes – 07/29/15
ASH Committee Reports-presented for information
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No HINN letters were issued
Pre-admission assessments done within 48 hours
Criteria reviewed within 48 hours of admission
Continued stay criteria reviewed weekly
Utilization Review
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CAP requires ASH Respiratory Services to answer the following survey question at each MEC meeting.
Regarding ASH’s ABG Lab services, since August 2013 have there been any concerns regarding quality, timeliness and reliability?
oQualityoTimelinessoReliabilityoOther?
Respiratory/ABG Lab Services
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Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey
PATIENT SATISFACTION Apr – Jun 2015
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
44.2%51.1%
33.3%
55.6%
56.6%
56.9%
51.8%
55.6%52.9%
Survey Return Rate
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.90.95
11.05
1.11.15
1.2
1 11.06
1.1 1.11.14
1.1
1.2 1.2Case Mix Index Goal is >1.1
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
2.0% 0.7% 4.7% 4.9% 4.9% 4.9% 4.5% 4.4%11.8% 15.9% 9.1%
20.2% 20.5% 21.2% 18.5% 19.3% 20.9%
86.3% 83.3% 90.9%75.1% 74.6% 73.9% 76.6% 76.3% 74.7%
Nurse CommunicationAlways Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
2.9% 2.2% 4.5% 4.5% 4.6% 3.8% 3.2% 4.0%12.8% 15.2%
3.3%16.1% 16.3% 15.2% 15.5% 14.6% 14.4%
84.3% 82.6% 96.7% 79.5%79.2%
80.1% 80.7% 82.2% 81.6%
Physician CommunicationAlways Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
4.6% 12.1% 11.1% 16.4% 18.2% 19.7% 17.7% 20.2% 20.4%
38.6%37.9%
61.1%36.3% 36.3% 35.7% 32.0% 33.2% 33.3%
56.8% 50.0%27.8%
47.3% 45.5% 44.6% 50.3% 46.6% 46.3%
Responsiveness of Hospital StaffAlways Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
5.4% 1.3% 0.0% 6.2% 6.0% 5.8% 7.9% 5.9% 4.2%8.9% 16.7%
31.3% 24.0% 24.3% 23.1% 19.9% 21.0% 21.3%
85.7% 82.1%68.8% 69.8% 69.7% 71.0% 72.2% 73.2% 74.5%
Pain ManagementAlways Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
16.0% 12.5%22.2% 18.6% 18.2% 20.0% 17.6% 15.1% 19.2%
18.0%15.3%
27.8%20.3% 20.5% 19.7% 19.7% 20.1% 19.2%
66.0% 72.2%
50.0%61.0% 61.3% 60.3% 62.7% 64.8% 61.7%
Communication About MedsAlways Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
96.7%100.0%
91.7% 91.7% 91.2%90.5%
92.9% 92.5% 91.6%
3.3% 0.0%8.3% 8.3% 8.8% 9.6% 7.1% 7.6% 8.4%
Discharge Information Planned Unplanned
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
17.7%6.4% 0.0% 3.9% 4.3% 3.9% 3.4% 3.5% 2.3%
29.4%
14.9%18.2% 16.0% 16.0% 16.7% 14.9% 14.7% 13.9%
52.9%
78.7% 81.8% 80.1% 79.7% 79.4% 81.7% 81.8% 83.8%
Cleanliness Of Hospital Environment Always Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
9.1% 12.8% 9.1% 9.1% 10.1% 10.1% 7.3% 9.0% 8.3%
27.3%31.9% 36.4%
26.8% 25.9% 24.3% 23.9% 21.0% 21.5%
63.6% 55.3% 54.6%64.0% 64.0% 65.5% 68.8% 70.0% 70.3%
Quietness Of Hospital Environment Always Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
11.8% 12.8% 18.2%21.6% 22.3% 22.9% 18.2% 18.9% 23.7%
88.2% 83.0% 81.8%71.5% 70.4% 69.5% 74.7% 74.9% 68.4%
4.3% 7.0% 7.3% 7.6% 7.1% 6.2% 7.9%
Overall Rating Of Hospital Always Usually Sometimes/Never
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Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3Facility Nation Region
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
17.7%8.9%
18.2%22.4% 23.4% 22.4% 19.7% 20.0% 19.5%
82.4%91.1%
81.8% 73.7% 72.2% 73.2% 76.1% 77.0% 75.8%
4.0% 4.4% 4.4% 4.1% 3.0% 4.7%
Willingness To Recommend HospitalAlways Usually Sometimes/Never
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Hospital Acquired Pressure Ulcers
HAPUs per 1,000 Patient Days
OCT NOV DEC JAN FEB MAR APR MAY JUN 0 4.1 0 1.1 3.8 0 0 1 2.5
OCT NOV DEC JAN FEB MAR APR MAY JUN
HAPUs -- Total # 0 3 0 1 3 0 0 1 2# of Patients with HAPUs 0 2 0 1 2 0 0 1 2
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Risk Management
Apr May Jun0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
ComplaintsGrievances 0 0 1
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Falls Reduction – Falls with Injury 0.00/1,000
patient days. Green Condition. Goal is < 0.475
Reduce CLABSIs – Apr 1.8 –May 1.4-May 1.4
Q3 AVG 1.53 Goal is <0.65
Increase compliance with blood administration vital
sign compliance =93% compliant on hourly checks:
Up to 100% compliant on end of transfusion Goal is
>98.9%
Core Quality Measures Q3
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Compliance Program LTCH-Quality Reporting Program
Compliant with CMS transmissions YTD.
ASHiCARE/ASH AlertLine & Webpage No reports in Q3.
Annual Education-FY’15 ICD-10 Training ASH Clinical Staff – In process Compliance Program Module- Sept ‘15 Accountability Statements- Sept ‘15
Survey Readiness: Joint Commission Accreditation – Met with Consultant for 3rd review of gap analysis. ASH Leadership continues to implement Tracer analysis.
Hospital Compliance
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CEO ReportFinancial, Medical Staff, Legislative,
Planning
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Income Statement
Q1 Q2 Q3 Q3 Q3 YTD YTD YTD
Actual Actual Actual Budget Variance Actual Budget Variance
IncomeNet Operating Revenue $3,142,342 $3,495,357 $3,719,080 $3,559,347 $159,733 $10,356,784 $10,824,366 ($467,582)
ExpensesSalaries $1,430,856 $1,533,997 $1,624,291 $1,479,961 ($144,330) $4,592,376 $4,500,426 ($91,950)Contract Labor $139,202 $297,133 $299,741 $76,614 ($223,127) $738,442 $232,978 ($505,464)Benefits $354,421 $392,621 $404,504 $397,081 ($7,423) $1,151,849 $1,207,739 $55,890Professional Fees $15,100 $19,802 $13,140 $28,481 $15,341 $48,042 $85,863 $37,821Medical Supplies $322,093 $382,776 $423,371 $393,037 ($30,334) $1,128,238 $1,194,119 $65,881Purchased Services $641,739 $622,869 $665,227 $771,840 $106,613 $1,929,835 $2,330,019 $400,184Utilities $2,553 $5,045 $3,392 $4,202 $810 $10,990 $12,605 $1,615Other Expenses $244,353 $299,069 $288,909 $295,048 $6,139 $832,329 $887,909 $55,580Depreciation & Amort $27,032 $23,404 $22,091 $23,888 $1,797 $72,527 $76,883 $4,356Interest Expense $0 $0 $63 $6 ($57) $63 $18 ($45)Total Expenses $3,177,349 $3,576,716 $3,744,729 $3,470,158 ($274,571) $10,504,691 $10,528,559 $23,868
Net Income ($35,007) ($114,561) ($25,649) $89,189 ($114,838) ($147,907) $295,807 ($443,714)
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Income Statement PPD
Q1 Q2 Q3 Q3 Q3 YTD YTD YTD
Statistics Actual Actual Actual Budget Variance Actual Budget Variance
Patient Days 2,237 2,508 2,553 2,420 133 7,298 7,359 (61)ADC 24.3 27.9 28.1 26.6 1.5 26.7 27.0 (0.2)
Q1 Q2 Q3 Q3 Q3 YTD YTD YTD
Actual Actual Actual Budget Variance Actual Budget Variance
Net Revenue $1,405 $1,394 $1,457 $1,471 $1,201 $1,419 $1,471 ($52)
ExpensesSalaries $640 $612 $636 $612 ($25) $629 $612 ($18)Contract Labor $62 $118 $117 $32 ($86) $101 $32 ($70)Benefits $158 $157 $158 $164 $6 $158 $164 $6Professional Fees $7 $8 $5 $12 $7 $7 $12 $5Medical Supplies $48 $153 $166 $162 ($3) $155 $162 $8Purchased Services $287 $248 $261 $319 $58 $264 $317 $52Utilities $1 $2 $1 $2 $0 $2 $2 $0Other Expenses $109 $119 $113 $122 $9 $114 $121 $7Depreciation & Amort $12 $9 $9 $10 $1 $10 $10 $1Interest Expense $0 $0 $0 $0 ($0) $0 $0 ($0)Total Expenses $1,420 $1,426 $1,467 $1,434 ($33) $1,439 $1,431 ($9)
Net Income ($16) ($46) ($10) $37 ($47) ($20) $40 ($60)
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Relocation Update5th Floor
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• 34 Rooms (Some Outboard Toilets) ( 1:3 or 1:4 Staffing)
• Some (8-10) high obs / ICU Like• Private bathrooms with Dialysis boxes • Pharmacy (600 SF)
• PT / OT Combined (Approx. 400 SF)
• Lab – small, with blood gas machine
• Equipment Storage (Vents, Beds, wheel chairs – Approx. 250 SF)
• Resp. Therapy Work Room
• Conference Room – for 15 – 20 (15 @ 25 SF = 375 SF)
• Conference Room / Report Room– Small for 8 – 10
• Waiting Room (10 People at 25 SF / person = 250 SF)
• Consultation Room (1 @ 90 SF)
• Storage (34 Rooms @ 12 SF / Bed = 408 SF)
• Stretcher / Wheelchair Alcove (80 SF)
• Janitor’s Closet (75 SF)
• Nurse Station / Charting
• Meds Room
• Clean Utility / Clean Linen
• Soiled Utility / Soiled Holding
• Nurse Toilet
• Nurse Locker / Break Room
• Nourishment Room
• Tub Room
• Emergency Treatment Room
• (Required? – 120 SF)
Offices on Unit:• Nurse Manager• Case Manager (2) can be a shared
office• Supervisor Office / Space• Wound Office• Physician On Call and Toilet / Shower -
160 SF Off Unit: (Approx. SF per availability)• Offices – CEO (150 SF)• HR / Adm Assist (110 SF)• DCM (110 SF)• Quality Risk (110 SF)• Infection Control / Employee Health
(Bathroom) 110 SF)• Shared Offices – Rehab, Resp.,
Dietician, Chaplin, Speech (160 SF)• HIM (110 SF)• Admin Coordinator (100 SF)• 3 Liaison, Shared Office – (120 SF)• Accounting 1 – Office – (110 SF)
Total SF Deficiencies: Approx. 3400 SF
Space Room List
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Existing Conditions
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Scenario 1Pros:• Unit Visibility
and Security
• Decentralized Support Services for operational flow
• Centrally located PT / OT
Cons:• Lack of Storage
• No Emergency Treatment Space
• Separated Patient Rooms
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Scenario 2Pros:• Observation bed
Configuration
• Patient Unit Configuration
• Safety and Security
Cons:• Unit Visibility /
Nurse Station Division
• Lack of Storage
• No Emergency Treatment Space
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Scenario 3Pros:• Observation bed
Configuration
• Patient Unit Configuration
• Safety and Security
Cons:• No Pharmacy
• Lack of Storage
• No Emergency Treatment Space
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Summary of relevant proposed rule ◦ Must be discharge from and IPPS Acute Care
hospital, CAH do not count.◦ Need a 3-day ICU stay or on prolonged
mechanical ventilation > 96 hours at LTCH.◦ ICU is defined as all cases in Revenue Code
Centers 20x & 21x – Includes step down ICU units◦ Medicare Advantage and "site neutral cases
excluded from 25-day LOS rule◦ All cases (LTCH & Site neutral) are included in
25% rule (75% for ASH under market dominant)
Regulatory Update – LTCH Cases
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It is the lower of cost or IPPS per diem up to IPPS rate
Cases that did not have 3-day ICU stay Cases not admitted from an IPPS hospital
(Includes Observation admits) These cases will have to be manged as any other
ACH case
Regulatory Update: Non - LTCH Cases
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Impact Analysis of New Rule(Assumes No Change in Cases)
Baseline FY 2016 FY 2017 FY 2018
Cases FY 2015 PaymentsFY 2016
Payments% Change Full Phase-In
% Change
Fully Implemented
% Change
Overall 133,356 $5,435,199,413 $5,301,188,560 -2.5% $4,966,896,504 -8.6% 4,357,719,924 -19.8%NALTH Membership Member 15,484 $665,665,604 $635,995,187 -4.5% $608,734,493 -8.6% $547,291,746 -17.8% Non-Member 117,872 $4,769,533,809 $4,665,193,373 -2.2% $4,358,162,011 -8.6% $3,810,428,178 -20.1%Location Type
Urban 127,693$5,233,120,440
$5,112,670,931
-2.3% $4,796,799,503 -8.3% $4,218,572,972 -19.4%
Rural 5,663 $202,078,973 $188,517,629 -6.7% $170,097,001 -15.8% $139,146,952 -31.1%Ownership Type For-Profit 113,816 $4,611,557,857 $4,508,041,727 -2.2% $4,203,992,662 -8.8% $3,668,859,204 -20.4% Non-Profit 17,319 $721,784,466 $693,226,707 -4.0% $665,755,297 -7.8% $599,057,158 -17.0%Bed size
0 to 24 Beds 2,523 $92,699,671 $89,643,956 -3.3% $82,683,959 -10.8% $69,955,783 -24.5%
25 to 49 Beds 45,031$1,775,179,757
$1,707,076,777
-3.8% $1,611,685,842 -9.2% $1,414,009,878 -20.3%
50 to 74 Beds 37,541 $1,564,340,585 $1,510,823,687 -3.4% $1,427,953,961 -8.7% $1,255,937,312 -19.7% 75 to 124 Beds 22,002 $945,426,815 $940,717,469 -0.5% $877,544,125 -7.2% $783,089,732 -17.2% 125 to 199 Beds 14,887 $589,244,925 $586,202,532 -0.5% $540,224,419 -8.3% $463,273,049 -21.4% 200 or more Beds 11,372 $468,307,660 $466,724,138 -0.3% $426,804,199 -8.9% $371,454,170 -20.7%Census Region South Atlantic 18,382 $777,156,317 $767,330,466 -1.3% $734,430,612 -5.5% $672,463,677 -13.5%
Asheville Specialty Hospital 261
$ 10,063,201
$ 9,545,038 -5.1%
$ 9,545,038 -5.1%
$ 8,814,452 -12.4%FY 2016 & 2017 is a blended transition rate between the
LTCH rates and IPPS rates. 2018 is the fully implemented new rates.
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Impact by Payment Change Type
Patient Category Cases FY 2015 Payments FY 2016 Payments Percent Difference
Non-Qualifying 74 $ 2,784,738 $ 2,258,825 -18.9%
Regular LTCH-PPS 131 $ 5,996,813 $ 6,078,757 1.4%
SSO Case 38 $ 846,250 $ 872,567 3.1%
SSO Non-Qualifying 18 $ 435,399 $ 334,888 -23.1%
Total 261 $ 10,063,201 $ 9,545,038 -5.1%
1. Non-LTCH cases is where the biggest change will occur.2. LTCH case payments actually increase3. Assumes no changes in patient selection, CMI and
LOS.
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Plan to Address New Rules LTCH patients
◦ Focus on the three primary ICU groups, APA, Trauma, Cardiovascular
◦ Target Step-down units for referrals◦ Working on plans to accept ICU admits 24/7
Make sure we are compliant with LTCH rules The 24/7 admits would be limited to Medicare part A
cases and possibly unfunded cases as all other insurers require precertification
Discussing LVAD payment bundle pilot that would allow for free movement between Mission and ASH.
Work through physician issues to do this.
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Plan to Address New Rules Non-LTCH Cases
◦ Target two programs◦ Pulmonary/COPD (ALOS 5-9 days)
Looking to be a direct admit option for APA Care Path to meet DRG LOS guidelines
◦ Wound (ALOS 6-10 Days) Bringing in new wound physician group that also
rounds at 30 nursing homes. Looking to do direct admits for wound care excisional
debridement and/or grafts and back to nursing home.◦ Non-LTCH cases will have to be managed like IPPS
cases
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What has been done already We have upgraded staff capabilities through
hiring and training over the past 6-10 months. This has been more costly then expected with
agency use and orientation expenses being very high.
All nursing agency is now done 45% of our RNs are ICU nurses and evenly split
on days and nights. We have had some intubated patients on the
unit recently. Liaisons are former ICU nurses from Mission
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Physician Search is ongoing◦ Phone interview with physician in Colorado◦ One Local physician may be interested
Use of Locums◦ Dr. Agor had to move closer to home due to
family issues◦ We will be using some different locums over the
next 2 months to see how the recruiting goes.
Other Updates
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Asheville Specialty Hospital
Prepared by:Professional Research Consultants, Inc.
◦ 2015 PRC Hospital Survey on Patient Safety Culture◦ Achieving Excellence from Your Employees’ Perspective
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Survey Methodology• Internet Survey of 90 Employees at Asheville Specialty
Hospital
• 51-Item AHRQ Survey
• Conducted by PRC
• Interview Period from April 6 to May 2, 2015
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General Findings
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Nonpunitive Response to Error
Handoffs & Transitions
Staffing
Communication Openness
Teamwork Across Units
Communication About Error
Frequency of Events Reported
Organizational Learning
Supervisor Expectations & Actions
Management Support for Patient Safety
Teamwork Within Units
Overall Perceptions of Safety
0% 20% 40% 60% 80% 100%
44.0%
47.0%
55.0%
62.0%
61.0%
67.0%
66.0%
73.0%
76.0%
72.0%
81.0%
66.0%
44.2%
50.2%
54.5%
62.0%
72.1%
72.6%
74.6%
79.4%
81.3%
86.1%
91.9%
73.3%
ASH AHRQ Norm
Comparison of Composite Frequenciesof Positive Responses
(ASH vs. AHRQ Norms)
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Strengths & Areasfor Improvement
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Survey ItemPositive
ResponseASH %
Response
People support one another in this unit. (v3)Teamwork Within Units
Agreement 96.7%
When a lot of work needs to be done quickly, we work together as a team to get the work done. (v5)Teamwork Within Units
Agreement 95.5%
Hospital management provides a work climate that promotes patient safety. (v35)Management Support for Patient Safety
Agreement 95.4%
In this unit, people treat each other with respect. (v6)Teamwork Within Units
Agreement 92.2%
We are actively doing things to improve patient safety. (v8)Organizational Learning
Agreement 92.1%
Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items
(“Strongly Agree/Agree” or “Always/Most of the Time”)Areas with 75.0% or Higher Disagreement with Negatively Worded Items
(“Strongly Disagree/Disagree” or “Never/Rarely”)
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Survey ItemPositive
ResponseASH %
Response
The actions of hospital management show that patient safety is a top priority. (v42)Management Support for Patient Safety
Agreement 89.6%
My supervisor/manager overlooks patient safety problems that happen over and over. (v24)Supervisor Expectations & Actions
Non-Agreement
89.4%
When a mistake is made that could harm the patient, but does not, how often is this reported? (v33)Frequency of Events Reported
Agreement (“Always/Mos
t of the Time”)
85.6%
Whenever pressure builds up, my supervisor/ manager wants us to work faster, even if it means taking shortcuts. (v23)Supervisor Expectations & Actions
Non-Agreement
84.7%
Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items
(“Strongly Agree/Agree” or “Always/Most of the Time”)Areas with 75.0% or Higher Disagreement with Negatively Worded Items
(“Strongly Disagree/Disagree” or “Never/Rarely”)
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Survey ItemPositive
ResponseASH %
Response
When one area in this unit gets really busy, others help out. (v13)Teamwork Within Units
Agreement 83.1%
Our procedures and systems are good at preventing errors from happening. (v20)Overall Perceptions of Safety
Agreement 82.0%
In this unit, we discuss ways to prevent errors from happening again. (v29)Communication About Error
Agreement (“Always/Mos
t of the Time”)
81.6%
After we make changes to improve patient safety, we evaluate their effectiveness. (v15)Organizational Learning
Agreement 79.3%
Hospital units work well together to provide the best care for patients. (v44)Teamwork Across Units
Agreement 78.8%
Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items
(“Strongly Agree/Agree” or “Always/Most of the Time”)Areas with 75.0% or Higher Disagreement with Negatively Worded Items
(“Strongly Disagree/Disagree” or “Never/Rarely”)
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Survey ItemPositive
ResponseASH %
Response
My supervisor/manager seriously considers staff suggestions for improving patient safety. (v22)Supervisor Expectations & Actions
Agreement 77.7%
It is just by chance that more serious mistakes don’t happen around here. (v12)Overall Perceptions of Safety
Non-Agreement
75.3%
Main Findings: StrengthsAreas with 75.0% or Higher Agreement with Positively Worded Items
(“Strongly Agree/Agree” or “Always/Most of the Time”)Areas with 75.0% or Higher Disagreement with Negatively Worded Items
(“Strongly Disagree/Disagree” or “Never/Rarely”)
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Main Findings: Areas for ImprovementAreas with 50.0% or Higher Non-Agreement with Positively Worded Items
(“Strongly Disagree/Disagree” Combined with “Neither” or “Never/Rarely”)Areas with 50.0% or Higher Agreement with Negatively Worded Items
(“Strongly Agree/Agree” or “Always/Most of the Time”)
Survey Item ResponseASH %
Response
Asheville Specialty Hospital responses for this category did not meet or exceed 50.0%
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Employee Engagement
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Demographics
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Survey Methodology• Internet Survey of 90 Asheville Specialty Hospital Employees
from a List of 161 Eligible Employees
• Participation Rate: All Staff 55.9%,
• Without PRN Staff: 73.77%
• Nursing Participation Rate: 66.25%
• Non Nursing Participation Rate: 88.10%
• Surveys Consisted of 40 Questions
• Surveys Completed Between April 6 and May 2, 2015
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Yes; 85.6%
No; 14.4%
Typically Have Direct Interaction/Contact with Patients
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100 Hours/More
80 to 99 Hours
60 to 79 Hours
40 to 59 Hours
20 to 39 Hours
Fewer Than 20 Hours
0.0% 20.0% 40.0% 60.0% 80.0% 100.0%
0.0%
1.1%
1.1%
20.2%
68.5%
9.0%
Number of Hours Worked Per Week
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21 Years/More
16 to 20 Years
11 to 15 Years
6 to 10 Years
1 to 5 Years
Less Than 1 Year
0.0% 20.0% 40.0% 60.0% 80.0% 100.0%
18.9%
11.1%
11.1%
22.2%
31.1%
5.6%
Length of Time in Specialty/Profession
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16 Years or More
11-15 Years
6-10 Years
3-5 Years
1-2 Years
Less Than 1 Year
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
0.0% (0)
8.9% (8)
15.6% (14)
18.9% (17)
25.6% (23)
31.1% (28)
Years of Service
n=90
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Other
Tech (e.g. EKG, Lab, Rad)
Unit Assistant/Clerk/Secretary
Administration/Management
Respiratory Therapist
Phys/Occ/Speech Therapist
Patient Care Assistant/Care Partner
Registered Nurse
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
7.1%
3.4%
4.6%
5.7%
9.2%
12.6%
12.6%
44.8%
Staff Position
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Yes, 95.5%(85)
No, 4.5%(4)
Asheville Specialty Hospital is Respondent’sPrimary Place of Employment
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Respondent Has Worked for Mission Hospitalor Any of Its Other Affiliates
Yes44.8%(
39)
No55.2% (48)
Length of Time Since RespondentWorked for Mission Hospital or Affiliates
Currently Working There 33.3% (13)
Within One Year 23.1% (9)
More Than One Year Ago 43.6% (17)
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Employee Engagement
2015 High Percentile
2015 Percent High
Low
Medium
High
0.0% 20.0% 40.0% 60.0% 80.0% 100.0%
84.6
0.337
0.186
0.477
0.337
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Summary of Key Driversof Excellence®
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“Excellent” Percentile Rankings
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2015 Asheville Specialty Hospital(''Excellent'' Percentile Rankings)
Total Compensation Package
Empowerment
Immediate Supervisor
Training and Development
As a Place to Work
Senior Leadership
Patient Care
Communication
0.0 20.0 40.0 60.0 80.0 100.0
19.4
28.8
35.8
44.0
50.4
50.8
54.0
67.0
2015% Exc
50th Percenti
le% Exc
75th Percenti
le% Exc
90th Percenti
le% Exc
17.8% 13.9% 19.8% 32.0%
34.4% 32.4% 44.0% 60.6%
21.6% 21.5% 28.6% 37.9%
31.5% 31.3% 40.4% 49.7%
22.5% 23.4% 30.1% 38.3%
37.6% 41.7% 48.3% 55.4%
18.9% 24.4% 29.6% 39.2%
7.9% 13.9% 18.2% 25.1%
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Total Compensation Package
Empowerment
Senior Leadership
Immediate Supervisor
Training and Development
As a Place to Work
Patient Care
Communication
0.0 20.0 40.0 60.0 80.0 100.0
19.4
28.8
50.5
35.8
44.0
50.4
54.0
67.0
21.4
62.9
69.6
71.8
75.7
75.7
75.8
90.9
Ranked Against First-Time Clients Ranked Against All PRC Clients
(''Excellent'' Percentile Rankings)2015 Asheville Specialty Hospital
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Summary of Key Drivers®
Key Survey Area Key Driver® Aspect
As a Place to Work Training and Development (#1)
Immediate Supervisor (#2)
Patient Care (#3)
Training and Development Level of Training Received to Achieve Career Goals
Immediate Supervisor Supervisor Providing Recognition and Praise
Patient Care Nurses’ Skills
Communication Communication Between Management and Staff
Empowerment Extent to Which Your Opinions Count
Senior Leadership Level of Trust in Leadership of Hospital
Total Compensation Package Base Salary or Rate of Pay
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Additional Questions
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ASH Exc Percentile
PRC Mean Score
ASH Mean Score
Poor
Fair
Good
Very Good
Excellent
0.0 20.0 40.0 60.0 80.0 100.0
48.9
77.6
80.2
0
5.7
21.6
38.6
34.1
Employees' Likelihood of RecommendingHospital as a Place to Work
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ASH Exc Percentile
PRC Mean Score
ASH Mean Score
Poor
Fair
Good
Very Good
Excellent
0.0 20.0 40.0 60.0 80.0 100.0
66
1.2
17.9
41.7
28.6
10.7
Employees' Perceptions of Cooperation & Teamwork
Across All Mission Facilities in Providing Patient Care
A PRC Mean Score and an “Excellent” Percentile Ranking are not available.
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Open-Ended Responses
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“What one thing do you like best aboutworking at Asheville Specialty Hospital?”
ResponseNumber of Responses
Co-Workers 24
Teamwork 16
Patients 6
Scheduling 3
Autonomy 3
Supportive Supervisor 2
Friendly/Caring Staff 2
Other responses are not shown.
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“If there was one thing you could change in the work environment at ASH, what would that be?”
ResponseNumber of Responses
More CNAs 4
Well-Staffed 3
Better Pay 3
Nothing 3
Larger Patient Rooms 2
More Support Staff 2
Better Communication Between Units 2
More Hours 2
Equal Treatment of Employees 2
Other responses are not shown.
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Old Business New Business Executive Session
Other Business
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Adjournment