SPECIAL BOARD OF DIRECTORS MEETING AGENDA

Monday, August 22, 2016 Graybill Auditorium 5:30 p.m. Buffet dinner for board members & invited guests Palomar Health Downtown Campus

6:00 p.m. Meeting 555 E. Valley Parkway, Escondido, CA 92025

PLEASE TURN OFF CELL PHONES OR SET THEM TO SILENT MODE UPON ENTERING THE MEETING ROOM

Form

A

Time Page Target

I. CALL TO ORDER 6:00

II. ESTABLISHMENT OF QUORUM…………………………………………………………………………. ..…2 6:02

III. PUBLIC COMMENTS1..…………………………………………..………………………………………... ….15 6:17

IV. * INFORMATION ITEMS

A. Customer Perspective Presentation (ADD A Pp2-4)……………………………............................ ……1

Physician Experience, Alan Conrad, MD (Pp5-24)………………………………………… ....40 6:57

Patient Experience, Jerry Kolins, MD (Pp25-46)……………………….........…………….. ....40 7:37

Quality, David Lee, MD (Pp47-63)…………………………………………………..………. ....40 8:17

V. ADJOURNMENT TO CLOSED SESSION…………………………………………….…………………. ….4 8:21

A. CLOSED SESSION REPORT INVOLVING Hospital Trade Secret Health & Safety Code Section 32106 – Concerns Potential new Program (estimated disclosure date: January 2017)…………..……………………………………….………

.…30 N/A 8:51

VI. RE-ADJOURNMENT TO OPEN SESSION………………………………………………………………. …...2 8:53

VII. ACTION RESULTING FROM CLOSED SESSION DISCUSSION – IF ANY………..............……… ...…3 8:56

VIII. PUBLIC COMMENTS1..…………………………………………..………………………..………………. ….15 9:11

IX. ADJOURNMENT 9:11

NOTE: If you have a disability, please notify us by calling 760-740-6375 72 hours prior to the event so that we may provide reasonable accommodations

__________________________________ Asterisks indicate anticipated action. Action is not limited to those designated items. 1 5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in

meeting room.

Strategic Planning | Palomar Health – Customer Perspective

Alan Conrad, MD – EVP Physician Alignment Jerry Kolins, MD – VP Patient Experience David Lee, MD – Medical Quality Officer

TO: Board of Directors MEETING DATE: August 22, 2016 FROM: Della K. Shaw, EVP Strategy Background: Presentation will provide an overview of our customers’

perspectives of performance, including our current state, future state requirements, gaps and risks.

Budget Impact: N/A Staff Recommendation: Informational

Committee Questions:

COMMITTEE RECOMMENDATION:

Motion: Individual Action: Information: Required Time:

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ADDENDUM A

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Customer Perspective Alan Conrad, MD, EVP, Physician Alignment

Jerry Kolins, MD, VP, Patient Experience David Lee, MD, Medical Quality Officer

Strategy & Facilities Committee | August 22, 2016

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Agenda | Customer Perspective

Physician Experience

Patient Experience

Quality

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Customer Perspective | Physician

The Physician Experience

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Physician Perspective | Engagement

Why is it important?

Positive physician experience enhances patient care and safety and leads to optimum operational and financial efficiencies, while helping meet healthcare regulatory requirements.

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Physician Experience & Satisfaction

Physician Experience

• Enhanced patient care and safety

• Supports physician’s natural workflow

• Operational and financial efficiencies

Physician Satisfaction

• Knowledgeable about the mission of their organization

• Aware of and involved in key activities driving organizational success

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Physician Engagement

• Engagement is a key factor in physician satisfaction and retention

• Engaged physicians linked to enhanced patient care, greater efficiency and lower costs, and improved quality and patient safety

• Strong physician relations are imperative for organization’s success

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Physician Engagement

Physician Engagement is pivotal for success with

• increasing demand for coordinated care

• new organizational structures

• value-based payment models

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Physician Engagement

Physician Engagement is high when physicians and executives are

• committed to organization’s mission, vision and values

• invest consistently in doing what is required for organization to succeed

• make positive contributions daily to maintain and enhance the performance of the organization

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State of the State | Physician Engagement

• Unit Based Medical Director-Nurse Director/Manager Dyads

• Academy of Applied Physician Leadership (AAPL)

• Monthly Medical Director Meeting

• Physicians’ Resource Allocation Committee (PRAC)—Cost

Savings Initiatives

• Meetings with local major medical groups and IPA

• Physician Voice Survey (Press–Ganey) once per year

• Physician Focus Groups

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Where we began: FY 13

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Applied Academy Physician Leadership (AAPL)

2012 2013 2014 2015

2012 • “Michael Memo” • Dyad Partnership at Unit Level • Created Medical Director role

2013 • Operational Initiative #3 • Chief Physician Leadership

Development Officer (CPLDO) • April 2013 Launch of AAPL • Metrics: Patient Satisfaction

by facility and communication with RN/MD

2014 Year #1 Celebration– Dyad projects Leap in Patient Satisfaction Scores National Recognition for Improvements VHA-IHI Bundle integrated CEO Turnover

2015 • Year 2 Finance and Business Focus • CPLDO Retirement • Business Projects – Shark Tank

Event • Downtown Closure Announced • ACHE Frontiers Article

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• Several engagement domains have shown improvements that are sustaining

• Introduction of on-boarding for providers

• Medical Director role getting more clearly defined and consistent

• Information Technology educations are available to address Electronic Health Record (EHR) need and performance

Engagement Percentile Key Domains

Engagement

Collaboration

Responsive to Medical Staff Needs

Involved in Decision Making

State of the State | Physician Perspective

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State of the State | Physician Perspective

State of the State | Physician Perspective

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State of the State | Physician Perspective

Engagement Alignment

4.00 3.58

39th Percentile 45th Percentile

(N/A) from 2015 (N/A) from 2015

Physician Voice Survey 2016

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State of the State | Physician Perspective

Domain Mean Score

Staff Organization Leadership Department

4.11

3.88

3.61

3.90

(N/A) from 2015

Physician Voice Survey 2016

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State of the State | Physician Perspective

Tier Breakdown – Palomar Health

10 9 6

40% 36% 24%

Tier 1 Tier 2 Tier 3

5.00 – 3.95 3.94 – 3.59 3.58 – 1.00

Physician Voice Survey 2016

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Physician Voice | Power Item Scores by Specialty

3.2 3.34

3.39 3.45

3.58 3.58 3.6 3.61

3.72 3.72

3.76 3.86 3.87 3.87

3.92 3.94 3.96

4.02 4.03 4.06

4.1 4.12

4.16 4.28 4.28 4.3

2 2.5 3 3.5 4 4.5 5

Ear, Nose and Throat (ENT) (Otolaryngology)

Obstetrics/Gynecology

Vascular Surgery

Cardiovascular Medicine

Orthopedic Surgery

General Surgery

Nephrology

Psychiatry

Radiology

Anesthesiology

Family Medicine

Pulmonology

Palomar Health 2016 Physician Voice Survey

Infectious Disease

Other Surgical Specialty

Plastic Surgery

Pediatric, General

Internal Medicine

Geriatric Medicine

Gastroenterology

Pathology

Critical Care Medicine

Other Medical Specialty

Ophthalmology

Emergency Medicine

Neurology

Tier 1

Tier 2

Tier 3

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Physician Voice | Survey Opportunities

• I am satisfied with the level of recognition I receive

• Hospital administration communicates important information effectively

• I get the tools and resources I need to provide the best care/service for our clients/patients

• This hospital treats physicians with respect

• Different departments work well together at this hospital

• I have confidence this hospital will be successful in the coming years

How to optimize physician’s work environment for safety and satisfaction?

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Physician Voice | Survey Opportunities

• Hospital administration is responsive to feedback from physicians

• I have adequate input into decisions that affect how I practice Medicine

• I can easily communicate any ideas/concerns I may have to hospital administration

• There is a climate of trust in this hospital

• I am satisfied with the level of collegiality among physicians at this hospital.

How to partner & create on-going dialogue/ problem solving MD – Administration?

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Future State| Physician Experience & Engagement

• Strengthen the Medical Director program

• Strengthen dyad relationships

• Continue to provide leadership education

• Provide support to the organized Medical Staff in succession planning

• Administrative Rounding on Physicians

• Ensure physicians have the tools to provide the highest quality and safe care

• Create a strong network of community physicians

• Improve interconnectivity to our community physicians

• Strengthen the continuum of care

• Understand what physicians need from us

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Key Takeaways | Physician Perspective

Engaged and Aligned Physicians are Critical for Success

• Primary Care essential to capture local market, provide community access, grow referral sources and manage population health

• Specialists essential for retention of patients within the system

• Expansion of our market share is dependent upon loyal physician hub and spoke network

• Physician leadership critical in leading change in our complex, changing healthcare environment

• Physician leadership critical in creating value through improvements in care management and quality

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Customer Perspective | Patient

The Patient Experience

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Patient Experience

“The best interest of the patient is the only interest to be considered...

- William J. Mayo, 1910

“When the patient feels safe, the patient experience is superb.”

- Jerry Kolins, 2016

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• The patient’s evaluation of the acute care experience is a surrogate marker for quality.

- NEJM, October 30, 2008

• The patients are telling us how good we are! Patients are especially talented in telling us how we did treating their:

1. Heart Attack

2. Congestive Heart Failure

3. Pneumonia

State of the State | Patient Experience

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• For every 100 patient surveys, how many patients would need to rate us top box in order for us to achieve a certain percentile ranking?

State of the State | Patient Experience

Rate Hospital 0-10

5th 10th 25th 50th 75th 90th 95th

57 60 66 72 77 83 87

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State of the State | Patient Experience

*Data Released from CMS July 27, 2016 29

State of the State | Patient Experience

*Data Released from CMS July 27, 2016 30

State of the State | Patient Experience

*Data Released from CMS July 27, 2016 31

Don’t ask

“What is the matter with you?”

Instead ask

“What matters to you?”

• Communication with Nurses

• Communication with Doctors

State of the State | Palomar Medical Center

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Don’t ask: What is the matter with you?

Instead ask: What matters to you?

– Communication with Nurses

– Communication with Doctors

State of the State | Pomerado Hospital

• Don’t ask: What is the matter with you?

• Instead ask: What matters to you?

– Communication with Nurses

– Communication with Doctors

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State of the State | Patient Experience

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State of the State | Patient Experience

Compassion and empathy

are in the eyes of the beholder.

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• Organizations and agencies will continue to issue conflicting versions of Patient Experience ratings.

• There will be discrepancies in survey results due to:

1. Different methods of analyzing the data

2. Different time periods in which the data are analyzed

3. Different metrics to assess the Patient Experience

Future State | Patient Experience

“It has been estimated that there are more than 1000 U.S. hospitals that are on one ‘Top 100’ list or another, and virtually all of them use these designations in their marketing.” - The Digital Doctor, Robert

Wachter, MD, page 40

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• Patients will feel safe in a hospital. Safety has not been guaranteed since 1999 with the publication of "To Err is Human."

• Staff will have Growth Mindset = Welcome feedback

• System “Patient First” thinking = Teamwork

• Culture transformation will focus on non-punitive response to error (Quality Review Reports)

Future State | Patient Experience

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• Culture of Accountability

–Balance Score Card / Leader Evaluation

–Goals are determined at the unit level

• Culture of Respect, Compassion and Humility

Future State | Patient Experience

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Future State | Patient Experience

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Future State | Patient Experience

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Stable Engaged Leadership:

• The patient feels safe when the staff feel safe.

• Leadership change is associated with staff uncertainty.

Current to Future State | Gaps Patient Experience

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“The manager is the dynamic, life-giving element in every business. Without his/her leadership the ‘resources of production’ remain resources and never become production. In a competitive economy, above all, the quality and performance of the managers determine the success of a business, indeed, they determine its survival. For the quality and performance of its managers is (sic) the only effective advantage an enterprise in a competitive economy can have.”

- Peter Drucker, The Practice of Management, 1954

Current to Future State | Gaps Patient Experience

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Current to Future State| Gaps Patient Experience

• Culture change will occur with education, training and experience.

• The importance of culture transformation is recognized by the creation of the VP, Culture and Talent Development role.

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Current to Future State | Gaps Patient Experience

Patient Family Advisor Committee and BQRC

Having two patient and family representatives as voting members of the quality committee of the board is a game changer. It’s a vital structural element that few board quality committees have in place today. Having them in the room changes the nature of the conversation, even if they do not speak. All normal excuses for the poor quality and safety begin to sound lame when the patient is in the room.

- The Governance Institute, Fall 2015

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Decision Analytics, Post Acute Care, and Health Coaches:

• Patient Health seeks the quadruple aim - patient experience, value (quality/cost), a healthy community, and employees who derive joy and meaning in their work.

• Patient unhappiness is expensive and partially defined as readmissions within 30, 60, or 90 days of discharge.

• Almost 50% of the cost of the patient’s experience occurs outside Palomar Health yet Palomar Health often responsible for this post discharge expense.

• Decision analytics help distinguish between post discharge choices that lead to high patient experience from choices that do not.

• Health Coaches (Community Care Transitions Program)

Current to Future State | Gaps Patient Experience

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• We perform well at Palomar Health. We are moving from good to great.

• Culture transformation is slow, deliberate and crucial.

• Stable engaged leadership promotes staff confidence.

• The patient experience does not end when the patient leaves our campus.

• Quality and safety improvements accelerate when patients and families participate on health system committees.

Key Takeaways | Patient Experience

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Customer Perspective | Quality

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How is quality defined?

• Best possible clinical outcomes, regardless of resources utilized?

• Ability to be seen by a doctor right away, to be treated courteously by the doctor and hospital staff, and to have the doctor spend lots of time with patient and family?

• Adherence to best-practice guidelines, irrespective of bedside manner?

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Difference Between Quality & Value

Value =𝑄𝑢𝑎𝑙𝑖𝑡𝑦

𝐶𝑜𝑠𝑡

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How does CMS define “Value”?

1. Hospital-acquired complications and infections

2. Patient survival (mortality)

3. Cost-efficient care

– Medicare Spending Per Beneficiary (MSPB)

– Readmissions

4. Patient experience

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State of the State| Quality

1. Hospital-acquired complications and infections

2. Patient survival (mortality)

3. Cost efficiency

– MSPB

– Readmissions

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State of the State | Hospital-acquired Complications & Infections

• Only a few years ago Palomar Health had been scoring in the bottom 25th percentile of hospitals

• In last year’s Hospital-Acquired Condition Reduction Program, Palomar Health scored just above the 25th percentile of hospitals

• We recognize the need for continued improvement in this area

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State of the State | Hospital-acquired Complications & Infections

• For years Palomar has performed well in demonstrating low rates of Central Line-Associated Blood Stream Infections (CLABSI)

• Recently, both Palomar and Pomerado have made tremendous improvements in reducing rates of Catheter-Associated Urinary Tract Infections (CAUTI)

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State of the State | CLABSI and CAUTI performance Q1-Q3 2015

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State of the State | Hospital-acquired Complications and Infections

• CMS has broadened their attention on the prevention of hospital-acquired infections beyond CLABSI and CAUTI to include other infections

• We have identified unacceptably high rates of Clostridium difficile (C. diff) infections in our health system, particularly at Pomerado

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State of the State | Patient Survival (Mortality)

Both campuses currently show mortality rates no different than the national rate for the various conditions and procedures reported on the Hospital Compare website

– AMI, COPD, HF, PN, STK, CABG

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State of the State | Cost Efficiency - MSPB

• Medicare Spending Per Beneficiary (MSPB) measures spending from 3 days prior to hospital admission through 30 days following hospital discharge

• Latest data show higher-than-average spending by the Home Health Agency, Hospice, and Skilled Nursing Facilities services following discharge (PMC & POM)

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State of the State | Cost Efficiency - Readmissions

• 30-day all-cause readmissions

• Historically, both Palomar and Pomerado have performed very well in this measure

• We recently identified a concerning trend of higher-than-expected hospital readmission rates in hip/knee replacement patients discharged from Pomerado Hospital

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Future State Quality

• There will be a growing number of organizations and agencies that offer their own versions of Quality ratings

• Metrics on which hospitals have learned to perform well will be sunsetted

• New metrics will continue to be introduced

• There will continue to be financial rewards for hospitals that perform well and financial penalties for hospitals that don’t

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Current State to Future State | Quality

Gaps

• Education - Care providers regarding appropriate documentation, Coders and chart reviewers regarding appropriate abstracting/coding

• Adequate resources to support labor-intensive chart reviews necessary for accurate reporting

• Partnership with post-discharge facilities to identify opportunities to increase efficiency and decrease costs

• Development of Information Technology solutions that can seamlessly supports health care providers in appropriate documentation and treatment of patients’ condition

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Current State to Future State | Quality

Risks • Understanding “rules of reporting”

• Appropriate Documentation

• Appropriate abstraction/coding of coders and chart reviewers

• Failure to invest the required resources to ensure a robust review process

• Lack of continual feedback to relevant stakeholders on the ever-evolving state of Quality

• Failure of stakeholders to take appropriate actions

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Key Takeaways | Quality

• Value =𝑄𝑢𝑎𝑙𝑖𝑡𝑦

𝐶𝑜𝑠𝑡

• There are various “definitions” of Quality

• Important to focus on Quality metrics that hold financial implications but must not forget that they are not the only measures of Quality

• Primary objective is to provide safe, quality care to our patients but must also master the “rules of reporting”

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Key Takeaways | Quality

We must invest the required resources to:

• Understand existing, new, and upcoming quality metrics

• Develop and support Quality Assurance Performance Improvement projects

• Ensure proper documentation and appropriate abstracting/reporting

• Continue to provide periodic performance updates to relevant stakeholders

• Hold both providers and leaders accountable for continuous quality improvement

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Discussion

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