UNIVERSITY OF VIRGINIA
BOARD OF VISITORS
MEETING OF THE
MEDICAL CENTER
OPERATING BOARD
FOR THE UNIVERSITY OF
VIRGINIA MEDICAL CENTER
NOVEMBER 12, 2015
UNIVERSITY OF VIRGINIA
MEDICAL CENTER OPERATING BOARD
November 12, 2015
8:45 a.m. – 2:00 p.m.
Auditorium of the Albert & Shirley Small
Special Collections Library, Harrison Institute
Committee Members:
L.D. Britt, M.D., Chair
Frank M. Conner III
Hunter E. Craig
William H. Goodwin Jr.
Victoria D. Harker
Michael M.E. Johns, M.D.
William P. Kanto Jr., M.D.
Constance R. Kincheloe
Charles W. Moorman
Tammy S. Murphy
The Hon. Lewis F. Payne
James V. Reyes
Frank E. Genovese, Advisor
Ex Officio Members:
Teresa A. Sullivan
Dorrie K. Fontaine
Robert S. Gibson, M.D.
David S. Wilkes, M.D.
Patrick D. Hogan
Thomas C. Katsouleas
Richard P. Shannon, M.D.
Pamela M. Sutton-Wallace
AGENDA
PAGE
I.
II.
III.
OPENING COMMENTS FROM THE CHAIR
REPORT FROM THE EXECUTIVE VICE PRESIDENT FOR HEALTH
AFFAIRS (Dr. Shannon)
1
MEDICAL CENTER FINANCE REPORT (Dr. Shannon to
introduce Mr. Larry L. Fitzgerald; Mr. Fitzgerald to
report)
2
•
IV.
V.
VI.
Discussion of Fiscal Year 2016 First Quarter
Consolidated Financials
REPORT FROM THE CHIEF EXECUTIVE OFFICER OF THE
MEDICAL CENTER, INCLUDING MEDICAL CENTER OPERATIONS
REPORT (Written Report)
A. Fiscal Year 2016 Operational Priorities
B. Continuum Home Health
PERFORMANCE DISCUSSION (Dr. Shannon to introduce Dr.
Tracey R. Hoke; Dr. Hoke to report)
A. U.S. News and World Report
B. Leapfrog
SCHOOL OF MEDICINE REPORT AND DISCUSSION (Dr. Shannon
to introduce Dr. David S. Wilkes; Dr. Wilkes to
report)
11
16
17
VII.
VIII.
IX.
HEALTH SYSTEM DEVELOPMENT REPORT (Written Report)
18
ANNUAL COMPLIANCE REPORT (Written Report)
20
EXECUTIVE SESSION
• Discussion of proprietary, business-related
information pertaining to the operations of the
Medical Center, where disclosure at this time would
adversely affect the competitive position of the
Medical Center, specifically:
– Strategic personnel, financial, investment,
market and resource considerations and efforts;
potential joint ventures or affiliations;
innovative efforts; other marketing and clinical
growth efforts that support the strategic
initiatives of the Medical Center and the Health
system, including employee performance and other
proprietary metrics;
– Confidential information and data related to the
adequacy and quality of professional services,
competency, and qualifications for professional
staff privileges, and patient safety in clinical
care, for the purpose of improving patient care;
– Consultation with legal counsel regarding
compliance with relevant federal and state legal
requirements, licensure, legislative, and
accreditation standards; all of which will
involve proprietary business information and
evaluation of the performance of specific
personnel.
The relevant exemptions to the Virginia Freedom of
Information Act authorizing the discussion and
consultation described above are provided for in
Section 2.2-3711(A)(1), (6), (7), (8) and (22) of the
Code of Virginia. The meeting of the Medical Center
Operating Board is further privileged under Section
8.01-581.17 of the Code of Virginia.
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
November 12, 2015
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II. Report from the Executive Vice President
for Health Affairs
ACTION REQUIRED:
None
BACKGROUND: Richard P. Shannon, M.D., is the Executive Vice
President for Health Affairs for the University of Virginia.
Before joining the University, he served as the Frank Wister
Thomas Professor of Medicine at the University of Pennsylvania
Perelman School of Medicine and as chairman of the Department of
Medicine of the University of Pennsylvania Health System. An
internist and cardiologist, Dr. Shannon is widely recognized for
his work on patient safety.
DISCUSSION: The Executive Vice President for Health Affairs
will inform the Medical Center Operating Board (MCOB) of recent
events that do not require formal action.
1
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
November 12, 2015
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
III.
ACTION REQUIRED:
None
Medical Center Finance Report
BACKGROUND: The Medical Center prepares a periodic financial
report and reviews it with University leadership before
submitting the report to the Medical Center Operating Board.
Larry L. Fitzgerald is the Health System’s Chief Financial
and Business Development Officer. He has held similar positions
with the University of Pittsburgh Medical Center and American
Medical International. He has extensive experience with health
care mergers and acquisitions, the Medicare and Medicaid
programs, and strategic planning.
FINANCE REPORT
School of Medicine – Academic
After three months of operations in Fiscal Year 2016, the
operating income for the School of Medicine was $11.8M.
Operating income was $13.6M greater than the budgeted loss of
$1.8M due to timing of hiring new faculty and their anticipated
lab start-up packages. The budget is not trended, and
historically new hires and related expenses occur in the latter
part of the fiscal year. We anticipate the positive budget
variance will diminish during the remainder of the fiscal year
as new faculty are brought onboard.
The operating income was $10.4M greater than the prior
year. This is due to two factors. First, there was an increase
in endowment distributions, research funding and gifts. Second,
there was a decrease in purchased services.
School of Medicine – UPG
The University of Virginia Physicians Group (UPG) financial
results through the first quarter of Fiscal Year 2016 yielded a
$2.8M operating loss, in line with the budget. The loss was
driven by start-up expenses with increased clinical revenues
anticipated for later in the year. Patient care revenues
typically ramp up in the latter half of the fiscal year as newly
2
hired clinical faculty are fully integrated into patient care,
and patient demand increases after the winter months. Financial
results are expected to improve in the latter part of the year
based on historical trends.
Results in the first quarter reflected year over year
growth in patient care volumes of nearly 5%. This was on target
with expectation, though shifts occurred in the specialty mix,
with surgical specialties higher than expected and medical
specialties lower than expected. Unfilled clinical faculty
positions in the medical specialties contributed to the budget
variances.
The first quarter results included a $9.4M investment in
the academic mission, as clinical revenue was used to fund
academic activities related to teaching and research. This level
of academic mission support was slightly higher than planned
through the first quarter. Expenses also included an increase
in faculty pension plan expense, greater than expected. The
increase in costs to fund these defined benefit plans was
primarily driven by updates in actuarial tables for life
expectancy. Planning is underway to mitigate the rising cost of
the defined benefit plans while still providing competitive
benefits for the faculty through the group practice.
Medical Center
After three months of operations in Fiscal Year 2016, the
operating income for all business units was $12.2M resulting in
a 3.2% operating margin. Operating income was 12.8% lower than
budget due to lower inpatient volumes, Main Operating Room
surgeries, and Outpatient Surgery Center volumes. The operating
income was $2.8M lower than the prior year with the operating
margin declining from 4.5% to 3.2%. The operating margin for
the overall clinical enterprise is supported by continued strong
results from our dialysis, imaging, and infusion centers which
averaged an operating margin of 28%. At the end of September,
cash reserves totaled 179 days.
The following analysis provides a “same store” look at
performance for Fiscal Year 2016, eliminating results for UVA
Culpeper Hospital which was acquired on October 1, 2014.
Operating income of $11.7M in Fiscal Year 2016 was below the
prior year’s results of $15.0M. Total operating revenue was
$357.4M for Fiscal Year 2016, 7.1% higher than the prior year as
the Medicare case mix index increased from 2.19 in Fiscal Year
2015 to 2.22 in Fiscal Year 201. Inpatient admissions were down
22 from the prior year; however, clinic visits were up 5.0%.
Case mix adjusted average length of stay was 2.93 days, on par
3
with the prior year’s 2.92 days. Total operating expenses were
8.5% above Fiscal Year 2015 expenses; 4.7% above when adjusting
for volume and patient acuity (Fiscal Year 2016 cost per CMI
adjusted discharge of $11,554 compared to the prior year of
$11,040).
Total paid employees for all business units, including
contracted employees, were 188 above budget.
FY 2015
Employee FTEs
Salary, Wage and
Benefit Cost per
FTE
Contract Labor FTEs
Total FTEs
FY 2016
7,122
8,204
$78,868
$80,804
2016 Budget
8,022
$83,343
198
221
215
7,320
8,425
8,238
Key Financial Projects
The Health System has continued to focus on phase 2 of the
conversion to EPIC. The planned conversion date is July 1,
2017. Phase 2 is a conversion to EPIC revenue cycle, operating
room, laboratory, and home health information systems.
After a lengthy negotiation the Health System has reached
an agreement that provides Humana members in-network access to
UVA hospitals, physicians and clinics in Charlottesville,
Culpeper, and throughout Central Virginia. The new network
agreement includes all of Humana’s Medicare Advantage plans and
Humana’s Commonwealth Coordinated Care Plan for those eligible
for both Medicare and Medicaid.
4
University of Virginia Health System Consolidated Income Statement
For the three months ended Sept. 30, 2015
(in millions of dollars)
Med Ctr
UPG
SOM
Library
Elim
Actual Budget Actual Budget Actual Budget Actual Budget Actual Budget Actual
Academic Revenue
Clinical Revenue
Total operating revenues
Labor
Supplies
Medical Center Contracts
Purchased Services
Interest
Depreciation
Total operating expenses
Operating Income/(Deficit)
80.8
379.7
379.7
389.4
389.4
100.7
100.7
100.3
100.3
80.6
80.6
170.8
88.0
27.8
50.1
5.0
25.8
367.5
171.8
88.7
29.6
54.3
5.1
25.9
375.4
82.0
2.7
5.3
12.3
0.2
0.9
103.5
80.4
2.4
5.2
13.8
0.2
1.0
103.0
35.8
7.8
19.2
1.4
4.6
68.8
12.2
14.0
(2.8)
(2.7)
11.8
(1.7)
(0.2)
(0.1)
0.0
(0.1)
21.1
9.4
11.6
3.2%
3.6%
-2.8%
-2.7%
14.6%
-2.1%
-5.4%
-5.9%
0.0%
0.2%
4.0%
1.8%
2.2%
80.8
42.1
6.7
28.4
0.7
4.6
82.5
2.9
2.9
0.7
0.0
2.3
0.1
3.0
1.3
Budget
Var
% Var
F / (U) F / (U)
1.3
0.7
0.7
1.4
(10.6)
(31.8)
(42.3)
(11.5)
(34.9)
(46.4)
73.0
448.6
521.6
70.6
454.8
525.4
2.4
(6.2)
(3.8)
(2.7)
(0.7)
(27.7)
(11.1)
(0.2)
(42.3)
(2.7)
(0.6)
(31.8)
(11.0)
(0.2)
(46.3)
286.7
97.9
5.3
72.8
6.5
31.4
500.5
292.3
97.2
3.0
86.2
5.8
31.5
516.0
1.9%
5.6
(0.7) -0.7%
(2.3) -78.1%
15.5%
13.4
(0.7) -12.3%
0.4%
0.1
15.4
3.0%
3.4%
-1.4%
-0.7%
123.5%
University of Virginia Medical Center
Income Statement
(Dollars in Millions)
Most Recent Three Fiscal Years
Description
Sep-14
Net patient revenue
Other revenue
Total operating revenue
Operating expenses
Depreciation
Interest expense
Total operating expenses
Sep-15
Sep-16
Budget/Target
Sep-16
$297.4
$324.1
$368.2
$377.9
11.3
9.5
11.5
11.5
$308.7
$333.6
$379.7
$389.4
264.0
292.6
336.7
344.4
20.3
21.0
25.8
25.9
3.6
5.0
5.0
5.1
$287.9
$318.6
$367.5
$375.4
Operating income (loss)
$20.7
$15.0
$12.2
$14.0
Principal payment
$3.8
$4.1
$4.5
$4.5
6
University of Virginia Medical Center
Balance Sheet
(Dollars in Millions)
Most Recent Three Fiscal Years
Description
Sep-14
Sep-15
Sep-16
Assets
$221.2
$287.0
$310.0
Patient accounts receivables
131.5
159.0
157.1
Property, plant and equipment
795.8
835.6
855.1
Depreciation reserve and other investments
211.0
201.1
198.6
Endowment Funds
462.1
533.0
551.0
Other assets
212.1
240.8
293.7
$2,033.7
$2,256.5
$2,365.6
Current portion long-term debt
$14.5
$15.0
$14.8
Accounts payable & other liab
117.3
114.5
132.4
Long-term debt
421.0
466.4
448.4
Accrued leave and other LT liab
164.3
199.2
281.2
$717.2
$795.2
$876.9
$1,316.5
$1,461.3
$1,488.7
$2,033.7
$2,256.5
$2,365.6
Operating cash and investments
Total Assets
Liabilities
Total Liabilities
Fund Balance
Total Liabilities & Fund Balance
7
University of Virginia Medical Center
Financial Ratios
Most Recent Three Fiscal Years
Description
Sep-14
Sep-15
Sep-16
Budget/Target
Sep-16
Operating margin (%)
6.7%
4.5%
3.2%
3.6%
Current ratio (x)
2.7
3.4
3.2
2.4
203.4
212.9
178.4
190.0
Gross accounts receivable (days)
45.5
47.5
46.5
45.0
Annual debt service coverage (x)
5.9
6.0
2.4
5.2
33.0%
33.4%
32.4%
31.8%
8.3%
8.2%
8.4%
8.3%
Days cash on hand (days)
Debt-to-capitalization (%)
Capital expense (%)
University of Virginia Medical Center
Operating Statistics
Most Recent Three Fiscal Years
Description
Sep-14
Acute Admissions
Sep-16
Sep-16
7,421
7,160
7,930
8,054
42,967
45,017
47,636
47,484
822
1,150
1,201
1,158
5.55
5.96
5.93
5.75
197,922
206,389
218,382
215,116
15,015
15,517
15,926
15,334
2.06
2.19
2.22
2.10
6,883
7,320
8,425
8,238
Patient days
Observation Patients - MC only
Average length of stay - MC
Clinic visits
Sep-15
Budget/Target
ER visits - MC only
Medicare case mix index - MC
FTE's (including contract labor)
8
University of Virginia Medical Center
SUMMARY OF OPERATING STATISTICS AND FINANCIAL PERFORMANCE MEASURES
Fiscal Year to Date with Comparative Figures for Prior Year to Date -September FY2016
OPERATING STATISTICAL MEASURES - September
ADMISSIONS and CASE MIX - Year to Date
Actual
Budget
OTHER INSTITUTIONAL MEASURES - Year to Date
% Variance
Prior Year
ADMISSIONS:
Adult
Pediatrics
Psychiatric
Transitional Care
Culpeper
Subtotal Acute
6,036
698
302
102
792
7,930
6,136
734
314
110
760
8,054
(1.6%)
(4.9%)
(3.8%)
(7.3%)
4.2%
(1.5%)
6,064
726
290
80
7,160
Observation
1,534
1,515
1.3%
1,150
9,464
9,569
(1.1%)
8,310
16,895
17,177
(1.6%)
14,213
Total Admissions
Adjusted Admissions
CASE MIX INDEX:
All Acute Inpatients - MC
Medicare Inpatients - MC
2.03
2.22
2.04
2.10
(0.7%)
5.5%
2.04
2.19
Actual
ACUTE INPATIENTS:
Inpatient Days
All Payor CMI Adjusted ALOS - MC
Average Daily Census
Births
OUTPATIENTS:
Clinic Visits
Average Daily Visits
Emergency Room Visits - MC
Emergency Room Visits - CRH
SURGICAL CASES
UVA Main Hospital Operating Room (IP and OP)
UVA Outpatient Surgery Center
Culpeper Hospital
Culpeper Outpatient Surgery Center
Total
Budget
% Variance
Prior Year
47,636
2.93
518
569
47,484
2.82
516
538
0.3%
3.9%
0.4%
5.8%
45,017
2.92
490
452
218,382
3,787
15,926
8,062
215,116
3,724
15,334
7,864
1.5%
1.7%
3.9%
2.5%
206,389
3,467
15,517
-
4,390
2,889
464
832
8,575
4,493
3,079
507
885
8,964
(2.3%)
(6.2%)
(8.5%)
(6.0%)
(4.3%)
4,512
2,505
7,017
OPERATING FINANCIAL MEASURES - June 2015 (Unaudited)
9
REVENUES and EXPENSES - Year to Date
($s in thousands)
NET REVENUES:
Net Patient Service Revenue
Other Operating Revenue
Total
EXPENSES:
Salaries, Wages & Contract Labor
Supplies
Contracts & Purchased Services
Depreciation
Interest Expense
Total
Operating Income
Operating Margin %
Actual
$
$
$
$
Budget
OTHER INSTITUTIONAL MEASURES - Year to Date
% Variance
Prior Year
368,231
11,508
379,740 $
377,923
11,506
389,429
(2.6%)
0.0%
(2.5%) $
324,110
9,466
333,576
170,842 $
87,995
77,899
25,767
5,035
367,539 $
12,200 $
3.2%
171,771
88,675
83,920
25,929
5,136
375,431
13,998
3.6%
0.5% $
0.8%
7.2%
0.6%
2.0%
2.1% $
(12.8%) $
144,429
77,484
70,677
21,028
4,955
318,573
15,003
4.5%
($s in thousands)
NET REVENUE BY PAYOR:
Medicare
Medicaid
Commercial Insurance
Anthem
Aetna
Other
Total Paying Patient Revenue
OTHER:
Collection % of Gross Billings
Days of Revenue in Receivables (Gross)
Cost per CMI Adjusted Admission
Total F.T.E.'s (including Contract Labor)
F.T.E.'s Per CMI Adjusted Admission
Actual
$
$
$
Budget
% Variance
116,762 $
73,982
59,428
76,193
24,197
17,670
368,231 $
117,290
77,293
60,639
77,549
25,922
19,230
377,923
(0.5%) $
(4.3%)
(2.0%)
(1.7%)
(6.7%)
(8.1%)
(2.6%) $
29.21%
46.5
11,188 $
8,425
23.59
29.32%
45.0
11,106
8,238
22.42
(0.4%)
(3.3%)
(0.7%) $
(2.3%)
(5.2%)
Prior Year
96,987
66,584
54,525
63,597
24,084
18,333
324,110
29.06%
47.5
11,040
7,320
23.34
University of Virginia Medical Center
SUMMARY OF OPERATING STATISTICS AND FINANCIAL PERFORMANCE MEASURES
Fiscal Year to Date with Comparative Figures for Prior Year to Date - September 30, 2015
Assumptions - Operating Statistical Measures
Admissions and Case Mix Assumptions
Admissions include all admissions except normal newborns
Pediatric cases are those discharged from 7 West, 7 Central, 7 North, NICU and PICU
Psychiatric cases are those discharged from 5 East
TCH cases are those discharged from the TCH, excluding any Medicare interrupted stays
All other cases are reported as Adult
Short Stay Admissions include both short stay and post procedure patients
Case Mix Index for All Acute Inpatients is All Payor Case Mix Index from Stat Report
Other Institutional Measures Assumptions
Patient Days, ALOS and ADC figures include all patients except normal newborns
Surgical Cases are the number of patients/cases, regardless of the number of procedures performed on that patient
10
Assumptions - Operating Financial Measures
Revenues and Expenses Assumptions:
Medicaid out of state is included in Medicaid
Medicaid HMOs are included in Medicaid
Physician portion of DSH is included in Other
Non-recurring revenue is included
Other Institutional Measures Assumptions
Collection % of Gross Billings includes appropriations
Days of Revenue in Receivables (Gross) is the BOV definition
Cost per CMI Adjusted Discharge uses All Payor CMI to adjust
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
November 12, 2015
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
IV. Report from the Chief Executive Officer
of the Medical Center
ACTION REQUIRED:
None
BACKGROUND: Pamela Sutton-Wallace is the Chief Executive
Officer of the University of Virginia Medical Center. Before
assuming this position on July 1, 2014, she served as Senior
Vice President for Hospital Operations of Duke University
Hospital where she was responsible for several key operational
areas, including Perioperative, Emergency/Trauma, Diagnostic,
Medical-Surgical Critical Care, and Facility and Support
Services. Ms. Sutton-Wallace joined Duke in 1997 as an
administrative fellow and held several management positions
during her 17-year tenure at the Duke University Health System.
DISCUSSION: The Chief Executive Officer of the Medical Center
will inform the MCOB of recent events that do not require formal
action. In addition, the following describes significant
operations of the Medical Center, focused on our Fiscal Year
2016 priorities of healing, serving, engaging, and building,
occurring since the last MCOB meeting. The annual report for
Continuum Home Health is also included.
A. FISCAL YEAR 2016 OPERATIONAL PRIORITIES
HEALING: Clinical Quality and Safety
During September, eight active 90-day Be Safe Coalitions
completed their work. Each Coalition focused on a Be Safe “Big
6” metric, in addition to support for Cardiac Value Stream and
the Supply Chain improvements. Lessons learned identified
several principles that are essential for ongoing improvement
work. Specifically, all improvement initiatives should have a
designated senior leader substantively participating with front
line team members, and just-in-time training on lean methods
should be built into all improvement event plans.
11
The Be Safe Team also initiated its next generation
education curriculum by offering core Lean training to the
broader Health System on an ongoing basis. Topics include
advanced problem-solving methodology using an A3 and Value
Stream Mapping, as well as leading in a Lean environment and
developing leader Standard Work.
Upcoming 90-day goals were determined by the Medical
Center’s Fiscal Year 2016 Work Plan and Be Safe Steering
Committee:
•
•
•
•
Continuation of several current Coalition efforts in order
to ensure improvements that have been implemented via
Standard Work (SW) are being sustained and fully
operationalized;
Increasing Unit-based Leadership (UBL) education in the
Ancillary and Procedural areas;
Development of the next-generation Be Safe curriculum;
Focus on Patient Progression, Medication Reconciliation,
and Readmission value streams to address high-impact
opportunities.
SERVING: Patient Experience
An inpatient team is focusing on noise at night,
cleanliness, and reintroducing the patient experience bundle
(i.e., hourly rounding, bedside shift report, etc.). The Noise
at Night team has identified the primary causes of noise as
alarms, roommate activity, medication delivery, and monitoring
vital signs. The team is developing counter measures to be
implemented in the spring.
The Emergency Department team has launched an A3 to improve
communication and have learned that patients want to know more
about their care plan and want to be kept better informed about
delays. Standard work is being developed to meet patient
expectations for deployment in the spring.
To support improvement across all service areas, a crossfunctional group of team members and leaders is developing
behavior standards aligned with our RISE values. These
behaviors will be the basis of updated human resource systems
such as job descriptions and performance evaluations.
ENGAGING: Team Member Engagement
Learning & Organizational Development partnered with senior
leadership to round in areas that scored lowest on the recent
12
Team Member Engagement Survey. They have synthesized their
findings and are formulating an action plan, with plans to
communicate the systematic plan to the larger organization in
November. Simultaneously, local units are continuing to discuss
and formulate action plans within their immediate span of
control.
The next Uteam Leadership Forum, in January 2016, will
build upon the RISE values work we started in June, with a
primary focus on Integrity and Stewardship. Ultimately, this
will lead to increased alignment in key areas such as Be Safe,
performance management, patient experience, and internal
branding.
BUILDING: Growth and Stewardship
The Medical Center has initiated Service Line deployment in
a number of key areas, including Heart and Vascular, Oncology,
Transplant, Orthopedics, Women’s and Children’s, Neurosciences
and Psychiatry, and Digestive Health. The transition to service
lines will facilitate strategic growth and development in
selected clinical areas, as well as reinforce operational
accountability across the continuum of care.
The upgrade of our Epic electronic medical record (EMR)
will go live on November 21, offering significant new
functionality and easier use for our clinicians. This is also
the version of the software upon which we will build the Epic
Phase 2 modules to go live in the summer of 2017. These modules
include Scheduling, Revenue Cycle, OR/Anesthesia, Labs and Home
Health.
The Medical Center has begun a project to replace all its
infusion pumps with a model that will be connected to our Epic
EMR and offer safety and manageability benefits. The project
will be complete before the end of December.
Construction of the Education Resource Center continues on
schedule. Excavation is complete and foundation walls are in
place. Steel erection began in mid-October and will last for
approximately two months. Work on the building envelope will
follow and we expect the building to be dried-in to allow for
the commencement of interior trade work by the beginning of
March 2016. The center will provide lecture space and a
procedural center for residents and fellows in all departments,
and will be the only University area dedicated to multispecialty Graduate Medical Education.
13
Schematic design and design development are 100% complete
and we have commenced construction documents for the new
hospital expansion. Design development set is currently
undergoing the Value Management process. Utility work on Lee
Street will commence in November and on Crispell Drive the third
quarter of 2016. We expect the work on the building site to
begin the first quarter of 2016.
Recent Designations & Re-certifications
•
•
•
Baby-Friendly designated birth facility by Baby-Friendly
USA for promoting breastfeeding as the most complete source
of nutrition for infants.
2015 Women’s Choice Award for Best Hospital for both
Orthopedics and Patient Safety.
Joint Commission Disease-Specific Certification for Heart
Failure, Primary Stroke Center, and Total Joint
Replacement: Knee and Hip.
B. CONTINUUM HOME HEALTH CARE FISCAL YEAR 2015 ANNUAL REPORT
Overview
Continuum Home Health Care (CHHC) provides in-home care to
people of all ages who are disabled, chronically or terminally
ill, or recovering from an acute illness. Structured as a
department of the Medical Center, CHHC has two primary lines of
business.
Home Health provides direct provision of skilled nursing,
physical therapy, occupational therapy, speech therapy, aides,
and social work. Home Infusion provides infusion therapy and
clinical pharmacy services.
CHHC also offers a variety of specialty services
(Psychiatric, Pediatric, and Interdisciplinary Wound Care
Programs) over a broad service area that includes 11 local
counties and infusion services as far away as North Carolina.
Patient Satisfaction
Home Health exceeded both State and National Home Health
Care Consumer Assessment of Healthcare Providers and Systems
(HHCAHPS) patient satisfaction benchmarks on all five CMS
publicly reported questions. Home Infusion hit a high of 98% on
its patient satisfaction survey, averaging 97% for the year.
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CHHC consistently demonstrates improvement in patient
reported pain and improvement in dyspnea that exceed the
national CMS benchmarks.
Quality & Outcomes
CHHC reduced its 60-day readmission rate from 18.6% to
17.5% and its 30-day readmission rate to 16.9% (compared to
state and national rates of 19.6% and 15.8%, respectively).
Through efforts focused on reducing the occurrence of avoidable
30-day readmissions and Emergency Department (ED) visits, CHHC
reduced ED visits related to concerns about wounds to 0.90% as
compared to the national rate of 1.31%.
Despite having its own infusion services and managing an
average daily census of approximately 500 patients, many with
central lines, CHHC experienced only seven Central lineassociated bloodstream infections (CLABSI) infections in Fiscal
Year 2015.
CHHC received a perfect report – no findings – during the
triennial CMS home health survey and also had a highly
successful Joint Commission survey. We continue to outperform
all local area home health agencies in CMS publicly reported
outcomes and process measures.
Employee Engagement & Recognition
Continuum’s employee engagement results were in the highest
percentile category, at 85%, as compared to Gallup’s healthcare
database.
A Continuum Registered Nurse was awarded the 2014 Home
Health Nurse of the Year for the State of Virginia by the
National Association for Home Care & Hospice.
CMS just implemented a new five-star rating system for home
health and CHHC achieved four-stars, a rating only 15% of
agencies receive out of more than 12,000 agencies nationwide.
CHHC’s Administrator was elected to the Board of Directors
for the National Association for Home Care & Hospice.
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UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
November 12, 2015
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
V. Performance Discussion
ACTION REQUIRED:
None
BACKGROUND: The MCOB Quality Subcommittee is charged with
reviewing, making recommendations, and providing strategic
oversight for the quality and performance improvement clinical
activities within the Medical Center, including patient safety.
The Subcommittee meets quarterly and serves as a link between
the MCOB and senior management to assist the Health System in
meeting its overall goals of being the safest place to receive
care, having the healthiest work environment, and providing the
highest level of clinical care.
DISCUSSION: The Chief Quality and Performance Improvement
Officer will provide an update of the Medical Center’s
performance regarding U.S. News and World Report rankings and
Leapfrog scorecard.
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UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
November 12, 2015
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
VI. School of Medicine Report and Discussion
ACTION REQUIRED:
None
BACKGROUND: David S. Wilkes, M.D. is the Dean of the University
of Virginia School of Medicine. Dr. Wilkes is a nationally
recognized specialist in pulmonary disease and critical care
medicine. Before coming to U.Va., Dr. Wilkes served as
executive associate dean for research affairs at the Indiana
University School of Medicine.
DISCUSSION: The Dean will provide a report on significant
recruitments of research faculty and other matters of importance
related to the School of Medicine.
17
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
November 12, 2015
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
VII. Health System Development Report
ACTION REQUIRED:
None
BACKGROUND: Health System Development will provide reports of
recent activity to the Medical Center Operating Board from time
to time.
DISCUSSION:
SIGNIFICANT GIFTS
July 1 – August 31, 2015
A University alumnus and friend of the Health System
documented a $2 million bequest to the School of Nursing to fund
general scholarships.
A friend of the Health System documented a $1 million
bequest in support of cardiovascular research initiatives in
honor of Dr. Amy Tucker.
A grateful patient has pledged $10,000 annually for the
remainder of his lifetime and is also planning to donate a gift
of property valued at $150,000 - $200,000. The funds will
likely be designated to support cancer initiatives.
An anonymous donor contributed $100,000 in support of
tuberous sclerosis research being conducted in Pediatric
Neurology.
A School of Medicine alumnus pledged $100,000 to create a
named scholarship fund.
A friend of the Health System pledged $100,000 to support
melanoma research in memory of a family member.
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Other gifts and pledges received include:
•
•
•
A $75,000 expectancy for scholarships in the School of
Medicine;
A $50,000 pledge in support of immunotherapy treatment,
cancer research, and resources for pediatric cancer patients
and their families; and
A $25,000 pledge for the UVA Children’s Hospital Main Event,
which will support the Child Health Research Center.
CAMPAIGN PROGRESS THROUGH AUGUST 31, 2015
New gifts
New pledges (payable within 5 years)
Total new commitments
(excludes pledge payments on
previously booked pledges)
$40,000,000
$6,000,000
$46,000,000
FY 16
Progress to
date
$5,358,215
$42,844
$5,401,059
New expectancies (future support)
Total new gifts, pledges, and
expectancies
$9,000,000
$55,000,000
$2,150,000
$7,771,059
FY 16 to Date (7/1/15 - 8/31/15)
FY 16
Annual Goal
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Compare FY
15 (through
8/31/14)
$3,351,800
$17,277
$3,369,077
$0
$3,369,077
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
November 12, 2015
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
VIII. Annual Compliance Report
ACTION REQUIRED:
None
BACKGROUND: The Board of Visitors authorized the President of
the University to establish a Corporate Compliance Program
(“Program”) for the Medical Center in 1997 in order to ensure
the Medical Center operates in full compliance with applicable
laws. The Office of Corporate Compliance and Privacy (“Office”)
prepares an annual project schedule based on potential
organizational risks for noncompliance with Federal or State law
or other regulations and in alignment with the strategic goals
of the UVA Health System. The Office reports quarterly to the
Corporate Compliance Steering Committee and to the Audit,
Compliance, and Risk Committee of the Board of Visitors where it
seeks approval of the annual project plan, provides updates on
completed projects, and informs those groups of significant
compliance or privacy risks. The Office also reports annually
to the MCOB.
DISCUSSION:
Overview of the Program: The Medical Center’s Compliance
Program incorporates the seven elements of an effective
compliance program as first identified in the 1991 Federal
Sentencing Guidelines: standards and procedures, oversight,
education and training, monitoring and auditing, reporting,
enforcement and discipline, and response and prevention. The
Office of the Inspector General (OIG) Compliance Program
Guidance Documents, first released in 1997, are also a roadmap
for the Program and include the seven elements reflected as:
written policies and procedures, designation of a compliance
officer and a compliance committee, conducting effective
training and education, developing effective lines of
communication, enforcing standards through well-publicized
disciplinary guidelines, auditing and monitoring, responding to
detected offenses, and developing corrective action initiatives.
The Compliance Code of Conduct is a key component of the
Program which defines the principles that the Medical Center,
its clinical staff, employees, and agents must follow. The Code
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is based on the mission, vision, and values of the UVA Health
System and aligns with the strategic initiatives and goals of
the Medical Center.
The annual Office project schedule is derived from risk
assessment models that identify potential financial or
reputational risks for the Medical Center, and from Federal,
State, and other regulatory agencies’ enforcement priorities
identified in the annual Department of Health and Human Services
OIG Work Plan, industry publications, and fraud alert reports.
The project schedule also includes follow-up on work performed
in prior years. Projects are selected based on the Medical
Center’s areas of risk for fraud and abuse and privacy
violations, with input from management and senior leadership.
Auditing and monitoring is an element of an effective
compliance program. Demonstrating alignment with the Health
System goal to be the safest place to receive care, the Office
conducts auditing of medical records and hospital billing claims
for compliance with the Medical Center’s commitments to maintain
its patients’ right to privacy and to bill only for medically
necessary services. Documentation, coding, and billing audits
of inpatient, outpatient, and procedure area claims are
performed to confirm that the documentation supports the
submitted claims and that the services provided are medically
necessary. Varying types of privacy audits are done to assess
the Medical Center’s compliance with privacy laws and to ensure
the confidentiality of our patients’ health information. The
Office includes hours for unanticipated projects to allow the
Program to adapt to changing needs of the organization, such as
overseeing new hospital billing compliance requirements and
addressing privacy inquiries from regulatory agencies; offering
guidance on policies and procedures, changes in regulations and
billing rules, new ventures, and clinical research issues; and
preparing and delivering education in response to new compliance
concerns.
Issues Affecting the Program: On October 1, 2015, the
International Classification of Diseases (ICD) Ninth Revisions
code sets used to report medical diagnoses and inpatient
procedures was replaced by the ICD Tenth Revision (ICD-10) code
sets. The transition to ICD-10 was required for everyone
covered by the Health Insurance Portability and Accountability
Act. The ICD-10 Executive and Oversight Committee and Project
Teams’ vision was to produce meaningful complete and accurate
clinical documentation to support the Medical Center and the
University Physicians Group mission of delivering innovative and
superlative quality patient care, training of health
professionals, and the creating and sharing of health knowledge.
21
The transition to ICD-10 has the potential for significant
financial and operational impacts for the Medical Center.
Diagnosis codes expanded from 13,000 to 68,000 codes and
procedure codes expanded from 11,000 to 87,000 codes, with the
latter for use only in the United States inpatient hospital
settings. It is early in the process and payer adjudication
with no significant issues to report at this time.
Connolly Healthcare, the Medical Center’s Medicare Recovery
Auditor, has been mostly inactive this past year as contracts
between Medicare Recovery Auditors and Centers for Medicare and
Medicaid Services continue to be renegotiated. The primary
purpose of a recovery auditor is to audit for improper payments
made by Medicare, focusing on medical necessity and inpatient
coding validation. The majority of the payments that have been
taken back by Palmetto, the Medical Center’s Medicare
Administrative Contractor, as a result of the recovery auditor
process are at the Administrative Law Judge level of appeal with
claims dating back to 2009.
Despite the introduction of electronic medical records,
health care continues to involve a significant number of paper
documents with health information. The Department of Health and
Human Services Office for Civil Rights (OCR) reports nationwide
findings of increased numbers of small-scale breaches due to
loss or misdirection of paper documents. In an effort to reduce
the number of instances of papers with health information
inadvertently being given to the wrong patient at the Medical
Center, the Office is working with an outpatient department,
with the support of senior leadership, to establish standard
work using the A3, a BeSafe problem solving tool.
As reported to the MCOB in 2013, the Medical Center
reported to the OCR the loss of an unencrypted hand-held device
used by Continuum Home Infusion on-call pharmacists that
contained health information for approximately 1,800
individuals. OCR notified the Medical Center on October 8, 2015
that the matter has been successfully resolved through the
voluntary compliance actions and the mitigation efforts of the
Medical Center. Therefore, OCR is closing the case with no
further actions required and no penalties assessed.
Education is a crucial element of effective compliance
programs. Educating our team members and developing trusting
relationships to enhance a culture of compliance continue to be
critical factors impacting the effectiveness of the Medical
Center’s Program.
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