UNIVERSITY OF VIRGINIA
BOARD OF VISITORS
MEETING OF THE
MEDICAL CENTER
OPERATING BOARD
December 4, 2003
UNIVERSITY OF VIRGINIA
MEDICAL CENTER OPERATING BOARD
Thursday, December 4, 2003
2:00– 5:00 p.m.
Medical Center Dining Conference Rooms 1, 2 and 3
Committee Members:
E. Darracott Vaughan, Jr. M.D., Chair
H. Christopher Alexander, III, M.D. William H. Goodwin, Jr.
William G. Crutchfield, Jr.
Lewis F. Payne
Eugene V. Fife
Gordon F. Rainey, Jr.
John I. Gallin, M.D.
Katherine L. Smallwood, M.D.
Ex Officio Members:
George A. Beller, M.D.
Arthur Garson, Jr., M.D.
R. Edward Howell
Leonard W. Sandridge
AGENDA
I.
II.
ACTION ITEM
• Medical Center Rate Adjustments (Mr. Howell)
REPORTS BY THE VICE PRESIDENT AND CHIEF EXECUTIVE
OFFICER OF THE MEDICAL CENTER (Mr. Howell)
A.
Vice President’s Remarks
B.
Finance, Write-offs and Operations
(Mr. Howell to introduce Mr. Larry L.
Fitzgerald and Ms. Margaret M. Van Bree –
Mr. Fitzgerald to report on Finance and
Write-offs; Ms. Van Bree to report on
Operations)
C.
Capital Projects
D.
Reports Required for Joint Commission on
Accreditation of Health Care Organizations
(Ms. Van Bree)
E.
Magnet Recognition for Excellence in Nursing
Services (Mr. Howell to introduce Ms. Pamela F.
Cipriano; Ms. Cipriano to report)
F.
Coding Analysis (Mr. Fitzgerald)
PAGE
1
2
3
14
17
22
26
III. REPORT BY THE PRESIDENT OF THE CLINICAL STAFF OF
THE MEDICAL CENTER (Dr. Beller)
30
IV.
COMPLIANCE TRAINING AND REPORT (Mr. Howell to
introduce Mr. Ralph W. Traylor; Mr. Traylor
to report)
31
V.
EXECUTIVE SESSION
•
ACTION ITEM - To consider proposed personnel actions
regarding the appointment, reappointment, resignation,
assignment, performance, and credentialing of specific
medical staff and health care professionals, as provided
for in Section 2.2-3711 (A) (1) of the Code of Virginia.
•
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 resource and market considerations in setting
appropriate reserves, rates and compensation incentives;
-
Impact analysis of federal regulatory proposals upon
business and billing operations; and
Additionally, consultation with legal counsel regarding
the Medical Center's joint venture with HealthSouth, and
its compliance with relevant federal reimbursement
regulations and accreditation standards, which will also
involve proprietary business information of the Medical
Center and evaluation of the performance of specific
Medical Center 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), (7), (8) and (23) of the Code of Virginia.
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
I. Medical Center Rate Adjustments
BACKGROUND: The Medical Center Operating Board is the
governing body of the Medical Center. The Medical Center
seeks authority to adjust its rates from time to time to
remain competitive.
DISCUSSION: The Medical Center’s annual budget includes the
rates it charges for patient care services. From time to
time, the Medical Center may need to adjust its rates for
certain services in order to remain competitive in the
marketplace and to assure that the Medical Center operates
within the Board of Visitors’ approved annual revenue budget.
ACTION REQUIRED:
Board
Approval by the Medical Center Operating
MEDICAL CENTER RATE ADJUSTMENTS
WHEREAS, from time to time the University of Virginia Medical
Center may need to adjust some or all of its rates in order
to remain competitive;
RESOLVED that the Medical Center is authorized to adjust its
rates from time to time with the prior approval of the
Executive Vice President and Chief Operating Officer of the
University and the Chair of the Medical Center Operating
Board, and provided that any such adjustment shall be
reported to the Medical Center Operating Board at its next
regular meeting.
1
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.A.
ACTION REQUIRED:
None
Vice President’s Remarks
DISCUSSION: The Vice President and Chief Executive Officer
of the Medical Center will inform the Medical Center
Operating Board of recent events that do not require formal
action, but of which it should be made aware.
2
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.B.
ACTION REQUIRED:
None
Finance, Write-offs and Operations
BACKGROUND: The Medical Center prepares a financial report,
including write-offs of bad debt and indigent care, and
reviews it with the Executive Vice President and Chief
Operating Officer before submitting the report to the Medical
Center Operating Board of the Board of Visitors. In
addition, the Medical Center provides an update of
significant operations of the Medical Center occurring since
the last Medical Center Operating Board meeting.
DISCUSSION:
FINANCE
The first quarter of Fiscal Year 2004 ended with an
operating margin of 6.1 percent, which was above the goal of
5 percent. Total operating revenue was slightly above budget
and the prior year. Total operating expenses were below
budget but above prior year.
For the first quarter of Fiscal Year 2004, inpatient
admissions were 7.1 percent above budget and 8.3 percent
above prior year. Patient days were 7.6 percent above
budget, and 9.5 percent above prior year. Length of stay was
5.6 days, which was below budget. With the exception of
psychiatry, admissions for most hospital services were above
prior year. The most significant increases in inpatient
admissions occurred in neurology, neurosurgery, general
surgery and family medicine. Same day patients were 18.9
percent below budget and 23.8 percent below prior year. The
Medical Center adopted a new process to improve the
appropriateness of classifying patients between “admissions”
and “same day” status that has resulted in classifying some
patients as “admissions” who historically would have been
classified as “same day” patients.
3
Total operating revenue for the first quarter of Fiscal
Year 2004 was 0.5 percent above budget and 10.6 percent above
prior year.
Total operating expenses for the first quarter of Fiscal
Year 2004 were .7 percent below the $165.0 million budget and
12.4 percent above prior year expenses. Salaries and wages
were below budget but above prior year expenses. Supplies
and contracts were above both budget and prior year expenses.
Purchased services were slightly below budget but above prior
year expenses.
The number of full-time equivalent employees (FTEs) was
207 below budget and 70 above prior year. FTEs and salary
and wage cost per FTE were:
FTEs
Annualized
Salary and Wage
Cost per FTE
FY 2003
FY 2004
5,052
5,122
$43,440
$45,891
2004 Budget
5,329
$44,440
The operating margin through the first quarter of Fiscal
Year 2004 was 6.1 percent, which is above the budgeted margin
of 5.0 percent but below the operating margin for the first
quarter of the prior year of 7.7 percent.
WRITE-OFF OF BAD DEBTS AND INDIGENT CARE
Indigent care charges totaling $13.0 million for the
period July 1, 2003, through August 31, 2003, have been
written off. Recoveries during this period totaled $1.7
million.
Bad debt charges totaling $3.8 million for the first two
months of the fiscal year have been written off. During this
same period, $2.1 million was recovered through suits,
collection agencies, and Virginia refund set-off.
OPERATIONS
In September, the University of Virginia Medical Center
was notified of its selection for the 2002 Solucient 100 Top
4
Hospitals award. The Solucient Institute annually performs
an objective statistical analysis on publicly available data
from more than 5,600 acute care general hospitals to identify
the 100 Top Hospitals, and from this determines the new
national benchmarks in clinical outcomes, operational
efficiency, financial results, and adaptation to
environmental change. The University of Virginia Medical
Center has received this honor for five consecutive years.
The Medical Center emergency preparedness plans were
tested in September during Hurricane Isabel. The Medical
Center responded to the news of the impending hurricane
expected on Thursday and Friday, September 18th and 19th, with
a series of briefings for the management staff and
communication to the entire staff regarding plans for
operations during the storm. One day before the hurricane,
the Medical Center decided to close outpatient clinics and
outpatient diagnostic procedures for Friday but to continue
the operating room surgery schedule as planned. The Medical
Center contacted patients scheduled for surgery on Thursday
and Friday to confirm their intention to have surgery despite
the storm and to assure that patients had lodging near or at
the hospital before or after their surgery. Only six
patients cancelled their operating room procedure prior to
the storm.
Because of the rapid movement of the storm on Thursday,
the outpatient clinics closed at 2:00 p.m. Nonetheless,
prior to the closing, all clinic patients scheduled that day
were seen through the efforts of the physicians and clinic
employees.
Employees scheduled for Thursday evening and
Friday shifts arrived at the Medical Center by late Thursday
afternoon and were offered shelter within the facility to
assure that the Medical Center had adequate staffing during
and immediately after Hurricane Isabel. Early into the
storm, the Medical Center lost power and was forced to
operate with only emergency power for approximately 11 hours.
Despite the inconvenience of reduced power, the Medical
Center continued to provide a full range of inpatient
services, feed and house hundreds of extra people, and meet
the needs of patients and their families.
Inpatient demand continued to be strong during the
hurricane. The operating room performed a total of 102
surgery cases on Thursday and Friday of the storm,
representing only a slight decline from the usual schedule.
5
The inpatient census was slightly higher than expected for a
typical Thursday and Friday. By Friday afternoon, the
majority of the Medical Center was back to regular
operations, with outpatient clinics resuming operations on
the following Monday. The Medical Center experienced minor
damage to buildings due to wind and rain.
The Medical Center has continued the bi-monthly employee
meetings. September’s Employee Forum focused on patient
satisfaction and featured improvement activities in pain
management, food service and the emergency room. November’s
Employee Forum will focus on employee benefits and
compensation.
In October, a team from the American Society of HealthSystem Pharmacists (ASHP) conducted an accreditation survey
of the institution's pharmacy residency programs. These
residency programs included the pharmacy practice residency
(4 positions, accredited in 1991), the drug information
practice residency (1 position, accredited in 1998), and the
critical care pharmacy practice residency (1 position,
accreditation pending). While on site, survey team members
conducted a thorough review of each residency program, as
well as interviews with pharmacy staff, residents,
administrators, nurses, and physicians. Based on the results
of the site visit, the survey team recommended continued
accreditation of the pharmacy practice and drug information
practice residencies and conditional (initial) accreditation
of the critical care pharmacy practice residency. These
recommendations will be presented to the ASHP Commission on
Credentialing at its meeting in March 2004.
6
University of Virginia Medical Center
Income Statement
(Dollars in Millions)
Most Recent Three Fiscal Years
Description
Net patient revenue
Sep FY02
Sep FY03
Sep FY04
Budget/Target
Sep FY04
$140.7
$155.4
$171.5
$169.8
2.4
2.3
2.9
3.8
$143.1
$157.7
$174.4
$173.6
131.2
135.7
153.5
153.8
Depreciation
8.5
8.7
9.1
10.0
Interest expense
1.2
1.2
1.1
1.2
$140.9
$145.6
$163.7
$165.0
$2.2
$12.1
$10.7
$8.6
Other revenue
Total operating revenue
Operating expenses
Total operating expenses
Operating income (loss)
Non-operating income (loss)
($9.6)
$2.1
$4.7
Net income (loss)
($7.4)
$14.2
$15.4
Principal payment
$1.1
$1.2
$1.5
7
$2.0
$10.6
$1.5
University of Virginia Medical Center
Balance Sheet
(Dollars in Millions)
Most Recent Three Fiscal Years
Description
Sep FY02
Sep FY03
Sep FY04
Assets
Operating cash and investments
$66.4
$18.5
$100.0
Patient accounts receivables
88.3
97.9
102.0
Property, plant and equipment
228.4
236.2
255.7
Depreciation reserve investments
169.7
205.5
237.7
25.2
27.2
44.6
$578.0
$585.3
$740.0
Current portion long-term debt
$4.2
$4.5
$6.5
Accounts payable & other liab
55.2
36.8
116.1
Long-term debt
88.7
85.2
123.7
Accrued leave and other LT liab
18.5
19.3
21.2
$166.6
$145.8
$267.5
$411.4
$439.5
$472.5
$578.0
$585.3
$740.0
Other assets
Total Assets
Liabilities
Total Liabilities
Fund Balance
Total Liabilities & Fund Balance
8
University of Virginia Medical Center
Financial Ratios
Most Recent Three Fiscal Years
Description
Sep FY02
Operating margin (%)
Sep FY03
Sep FY04
Budget/Target
Sep FY04
1.5%
7.7%
6.1%
5.0%
Total margin (%)
-5.5%
8.9%
8.6%
6.0%
Current ratio (x)
2.6
2.8
1.6
4.0
168.2
154.6
204.7
190.0
Gross accounts receivable (days)
78.3
69.8
67.9
60.0
Average payment period (days)
41.3
27.8
73.0
30.6
1.0
10.3
9.8
8.1
Days cash on hand (days)
Annual debt service coverage (x)
Debt-to-capitalization (%)
Capital expense (%)
9
17.7%
16.2%
20.7%
20.0%
6.9%
6.8%
6.2%
6.8%
University of Virginia Medical Center
Operating Statistics
Most Recent Three Fiscal Years
Description
Admissions
Sep FY02
Sep FY03
Sep FY04
Budget/Target
Sep FY04
6,704
6,798
7,364
6,878
38,178
37,856
41,449
38,534
1,813
2,097
1,598
1,971
5.7
5.5
5.6
5.8
127,552
135,602
134,974
147,065
ER visits
14,556
15,150
15,111
14,854
Medicare case mix index
1.8757
1.8334
1.7949
1.9075
Patient days
SS/PP Patients
Average length of stay
Clinic visits
Net Revenue by Payor
Medicare %
Medicaid %
Managed care %
Commercial %
Other
Total
FTE's
40.6%
15.5%
7.4%
10.3%
26.1%
100%
5,227
10
35.0%
17.6%
6.7%
11.7%
29.0%
100%
5,052
34.3%
16.8%
7.3%
12.3%
29.2%
100%
5,122
33.5%
15.7%
6.8%
12.8%
31.3%
100%
5,329
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, 2003
OPERATING STATISTICAL MEASURES - September 2003
ADMISSIONS and CASE MIX - Year to Date
FY 03
OTHER INSTITUTIONAL MEASURES - Year to Date
FY 04
% Change
ADMISSIONS:
Surgical
Medical
Transplant
Obstetrics
Pediatrics
Psychiatric
Subtotal Acute
2,600
2,802
38
376
481
501
6,798
2,749
3,204
46
390
523
452
7,364
5.7%
14.3%
21.1%
3.7%
8.7%
(9.8%)
8.3%
Short Stay
Total Admissions
2,097
8,895
1,598
8,962
(23.8%)
0.8%
CASE MIX INDEX:
All Acute Inpatients
Medicare Inpatients
1.7312
1.8334
1.6823
1.7949
(2.8%)
(2.1%)
FY 03
FY 04
% Change
ACUTE INPATIENTS:
Inpatient Days
Average Length of Stay
Average Daily Census
Births
37,856
5.5
411
335
41,449
5.6
451
363
9.5%
1.8%
9.7%
8.4%
OUTPATIENTS:
Clinic Visits
Average Daily Visits
Emergency Room Visits
135,602
2,356
15,150
134,974
2,392
15,111
(0.5%)
1.5%
(0.3%)
3,173
672
3,845
3,425
724
4,149
SURGICAL CASES
Inpatient
Outpatient
Total
7.9%
7.7%
7.9%
OPERATING FINANCIAL MEASURES - September 2003
REVENUES and EXPENSES - Year to Date
11
FY 03
OTHER INSTITUTIONAL MEASURES - Year to Date
FY 04
% Change
NET REVENUES:
Total Patient Rev.
Appropriations
Misc Revenue
Total
146,614,308
8,780,085
2,317,275
157,711,668
162,692,105
8,780,085
2,941,755
174,413,945
11.0%
0.0%
26.9%
10.6%
EXPENSES:
Salaries and Wages
Supplies and Contracts
Purchased Services
Bad Debts
Depreciation
Interest Expense
Total
Operating Margin
Operating Margin %
Non-Operating Revenue
67,589,054
39,848,698
22,820,606
5,453,501
8,700,777
1,191,967
145,604,603
12,107,065
7.7%
2,085,220
73,195,782
47,409,516
27,432,182
5,488,865
9,116,052
1,067,484
163,709,881
10,704,064
6.1%
4,721,047
8.3%
19.0%
20.2%
0.6%
4.8%
(10.4%)
12.4%
(11.6%)
(20.1%)
126.4%
14,192,285
15,425,111
Net Income
8.7%
FY 03
FY 04
% Change
NET REVENUE BY PAYOR:
Medicare
Medicaid
Managed Care
Commercial Insurance
Anthem
Southern Health
Tricare CHAMPUS
Other
Total Paying Patient Rev.
51,317,298
25,750,771
9,865,201
17,103,170
25,941,142
6,626,434
1,365,679
8,644,613
146,614,308
55,871,965
27,388,242
11,905,814
20,085,554
29,039,667
6,953,023
1,949,743
9,498,097
162,692,105
8.9%
6.4%
20.7%
17.4%
11.9%
4.9%
42.8%
9.9%
11.0%
Managed Care
Non-Managed Care
Total Paying Patient Rev.
9,865,201
136,749,107
146,614,308
11,905,814
150,786,291
162,692,105
20.7%
10.3%
11.0%
OTHER:
Collection % of Gross Billings
Days of Revenue in Receivables (Gross)
Cost per CMI & OP-Adj Discharge
Cost per CMI & OP-Adj Day
Cost per Outpatient Visit
Total F.T.E.'s
F.T.E.'s Per Adjusted Occupied Bed
65.57%
69.8
6,862
1,232
75.89
5,052
7.21
62.53%
67.9
7,530
1,338
67.57
5,122
6.91
(4.6%)
(2.7%)
9.7%
8.6%
(11.0%)
1.4%
(4.2%)
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, 2003
Assumptions - Operating Statistical Measures
Admissions and Case Mix Assumptions
Admissions include all admissions except normal newborns
Pediatric surgery cases are included in Pediatrics admissions
Obstetrics surgery cases are included in Obstetrics admissions
Transplant surgery cases are included in Transplant admissions
Transplants include all solid organ transplants and bone marrow transplants
All other surgery cases are counted as Surgical admissions
Surgical cases are defined by DRG
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
12
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
Split of surgical cases into inpatient and outpatient based on discharges from the Surgical Admission Suite
Inpatient surgical cases include both inpatients and short stay/post procedure patients
Outpatient surgical cases do not include those performed at VASC
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 & OP-Adj Discharge and Day uses Medicare CMI to adjust
Costs for Cost per Outpatient Visit come from clinic income statement
OP visits used in calculation of Cost per Outpatient Visit are provider based clinic visits only
FTEs are Medical Center FTEs only, does not include contract labor FTEs
MEDICAL CENTER
ACCOUNTS COMMITTEE REPORT
(Dollars in Thousands)
Year to Date
August
2003-04
INDIGENT CARE (IC)
Net Charge Write-Off
11,989
Percentage of Net Write-Offs to Revenue
6.38%
Net Medical Center IC Charges Factored to Cost
8,616
Medicaid Unreimbursed Cost
(134)
Total Indigent Care Cost
Annual Activity
Estimated
2003-04
2002-03
87,190
7.90%
51,695
(806)
69,241
7.19%
48,888
(371)
8,482
50,889
48,517
0.00
0.00
0.00
Medicaid Disproportionate Share Adjustment Payment (Note 1)
7,755
46,530
46,680
Total Indigent Care Cost Funding
7,755
46,530
46,680
State Appropriation
Total Indigent Care Cost Funding as % of Total Indigent Care Cost
91%
Unfunded Indigent Cost
726
Year to Date
August
2003-04
BAD DEBT (Note 2)
Net Charge Write-Offs
3,042
Percentage of Net Write-Offs to Revenue
1.65%
91%
4,359
96%
1,837
Annual Activity
Estimated
2003-04
2002-03
26,569
2.41%
22,860
2.37%
Notes:
1. In addition to the Enhanced Disproportionate Share Adjustment payment above, $5,494,594 was received and transferred
to the School of Medicine to partially offset their indigent care costs.
2. A provision for bad debt write-offs is recorded for financial statement purposes based on the overall collectibility of the patient accounts
receivable. This provision differs from the actual write-offs of bad debts which occurs at the time an individual account is written off.
13
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.C.
ACTION REQUIRED:
None
Capital Projects Report
BACKGROUND: The Medical Center is constantly improving and
renovating its facilities. We will provide a status report
of these capital projects at each Medical Center Operating
Board meeting.
DISCUSSION: The current Medical Center capital projects
report is set forth in the following table.
14
The University of Virginia Medical Center
Capital Projects Report
Scope
PRE-CONSTRUCTION
Cancer CenterInfusion Center expand existing
outpatient cancer
center clinic and
infusion center.
South Garage
Expansion – provide
419 additional
parking spaces to
replace those lost by
construction,
potential loss of a
leased lot and for
reserved parking
expansion.
Budget
Funding
Source
BOV
Approval
Date
Projected
Completion
Date
$1.25 M
Bonds
Jan '02
April '03 (March
'04- revised)
$8.5 M
Bonds
Oct '00
May '04
15
UNDER CONSTRUCTION
Hospital Expansion
Project-horizontal
expansion of
University Hospital
and renovation of
entire second floor
to accommodate
complete rebuilding
Bonds @ $54 M
and expansion of the
$58 M
($58.7 M Perioperative
($62.7 M - revised) Hospital
Services and Heart
revised) Operating Revenues
Center. Additional
@ $4 M
renovations and
expansion for
Interventional
Radiology and
Clinical Laboratory.
Scope change (3/03)
to include additional
floor for Heart
Center faculty
offices.
March
'99
Sept '05(March
'06 –revised)
Clinical Office
Building - Fontaine fitout for
Otolaryngology
Clinic.
Part of
$16.75 M
in
Completed
Section
Bonds
Jan '02
Oct '03 (Feb '04revised)
(Otolaryngology)
Critical Care Unit
Expansion - Phase I
additional 2 beds to
the STICU in
University Hospital
CONSTRUCTION
COMPLETED
$3.25 M
($2.7 M revised)
Phase I
and II
Medical Center
Annual Capital
Budget
Oct '00
March '03 (April
'04-revised)
Oct '00
April '03 (May
'03 - revised)
COMPLETED:
June '03
Oct '00
March '03 (Dec
'03 - revised)
COMPLETED:
May '03
Breast Care Center renovate 7,200 sq.ft.
for a new Breast Care
Center that combines
breast imaging and
breast cancer therapy
Critical Care Unit
Expansion - Phase II
additional 4 beds to
the MICU in
University Hospital
Clinical Office
Building - Fontaine provide space for
additional imaging
and clinical care,
including
consolidation of the
Endocrinology Clinic
$1.4 M
Bonds
$3.25 M
($2.7 M revised)
Phase I
and II
Medical Center
Annual Capital
Budget
$16.75 M
Bonds
16
June '03 (shell,
imaging &
Jan '02 Endocrinology)
COMPLETED:
June '03
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.D. Reports Required for Joint
Commission on Accreditation of Health
Care Organizations
ACTION REQUIRED:
None
BACKGROUND: The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) accredits the University of
Virginia Medical Center, as well as over 19,000 other health
care organizations. The JCAHO requires that an annual report
be presented to the governing body of the Medical Center
describing major performance improvement activities in key
areas.
DISCUSSION: Safety and Security – The JCAHO requires the
Medical Center to maintain a safe and secure environment of
care. The Safety and Security Subcommittee of the Medical
Center conducts an annual evaluation of the Medical Center’s
environment of care plans or programs that are essential to
providing a safe and secure environment. The annual
evaluation of the prior year’s plan includes a review of the
scope of services, goals, and selected performance indicators
to determine effectiveness and to identify the goals and
indicators for the coming year. Based on the annual
evaluations and data analysis conducted in December 2002, the
Medical Center selected environment of care indicators for
calendar year 2003 for each of the following nine safety
management programs:
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Equipment Management
Hazardous Materials and Wastes Management
Utilities Management
Life Safety Management
Security Management
Emergency Management
General Safety Management
Infection Control
Employee Health
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Within Equipment Management, the selected indicators
chosen for monitoring included infusion device programming
errors, incorrect traction set-ups and overall rate of
preventive maintenance inspections completed. Indicators for
the Hazardous Materials and Wastes Management focused on the
number of hazardous waste violations reported and security of
locations where hazardous materials are used or stored.
The Utilities Management indicators were critical
utility preventive maintenance completion rate for inpatient
facilities and elevator entrapments within the hospital. The
indicators for Life Safety Management included problems
identified during fire drills, the number of preventable
alarms and staff response to alarms. Security Management
indicators included the Crime Index report which measures
crimes against people and property on Medical Center premises
and Code 9 (infant abduction) drills.
Within Emergency Management, the Medical Center engages
in various drills and simulated emergency situations in order
to train and prepare for an actual emergency. Indicators
included problems identified during emergency management
drills, such as response time and internal communications.
The General Safety Management indicators covered not
only general safety issues, such as percentage of hazardous
surveillance surveys completed and returned by managers and
compliance in checking of code carts, but also Employee
Health and Infection Control issues as well. Indicators for
Employee Health included work injuries and blood/body fluid
exposures, while Infection Control indicators focused on
infectious disease exposures.
The Medical Center Safety and Security Subcommittee
tracked and reviewed the indicators monthly. Based on
analysis of data and trending, appropriate action was taken
to address the problems that were identified. For example,
employee injuries related to patient handling (i.e., lifting,
transferring, moving, etc.) were high volume and problematic.
After evaluating the data and potential resolutions, the
Safety and Security Subcommittee recommended the purchase of
patient lifting equipment, including training thereon,
designed to reduce employee injuries by sixty percent;
Medical Center leadership agreed.
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Another example of the way the Medical Center monitors
performance is in the area of preventive maintenance
completion rates within the Equipment Management and the
Utilities Management programs.
The 2002 JCAHO survey
identified a problem with preventive maintenance completion
rates of medical equipment and utilities systems,
respectively. Actions were taken in early 2003 to address
these issues, and indicators were selected to monitor
performance. The monthly overall rate of preventive
maintenance completions now meets or exceeds the ninety-five
percent rate required by JCAHO.
Human Resource Competency – The JCAHO requires each
accredited organization to regularly collect and analyze
aggregate data from a variety of sources to assess staff
competence and pinpoint training needs. The Medical Center
collected data, including performance appraisal results,
disciplinary actions, turnover trends and nursing career
ladder challenges to identify competency patterns and trends.
In addition, the Medical Center documented the orientation
and training programs that were developed in response to
these trends and to ensure staff competence, and conducted
special educational activities in response to specific
competency events.
For the performance appraisal year that ended October
31, 2002, over 98% of all Medical Center staff received a
performance rating of “commendable” or higher on their annual
performance appraisal. The Medical Center used a combination
of data from clinical/service screening and human resource
screening indicators to assess staffing effectiveness.
The Medical Center developed and presented training
programs for employees on a wide variety of topics with a
total annual attendance of over 20,000. Training programs
included the following: General Employee Orientation for
1,051 new hires, Patient Care Services Orientation for 425
new hires, and Critical Care Orientation for 168
participants. Clerical and service staff received 208
classroom hours of Medical Information System training. In
response to patient safety indicators, training was provided
to targeted employees in non-violent crisis intervention,
identification and reporting of patient abuse or neglect, and
assessment and documentation of pain.
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Staffing Effectiveness - In addition to competencies,
the JCAHO requires the Medical Center to evaluate, measure
and assess staffing effectiveness and its impact on patient
health outcomes. During the past year, the Medical Center
chose for study patient falls, medication errors, blood
stream infections, urinary tract infections and pneumonias.
The Medical Center selected total worked hours and turnover
rate as the Human Resource indicators.
Data was compiled from Quality Reports (QRs), Infection
Control reports, the Human Resources PeopleSoft System and
Press Ganey Patient Satisfaction reports. Data analysis
revealed general positive correlations between staffing
levels and medication error QRs. Similar analyses indicated
that there is a negative correlation between the reporting
rate for falls and staffing levels on adult units while the
opposite appears true in pediatric units. Data also
suggested that high staff turnover rates may be associated
with higher levels of reporting of falls. However, no
statistically significant results were found at the
individual unit level. This information is being shared with
operation managers for additional assessment.
As a result of the staffing effectiveness analysis, in
early 2003 the Medical Center created an interdisciplinary
steering committee to oversee compliance with the JCAHO
staffing effectiveness standard. The scope of this
committee’s responsibility includes quarterly review of data,
identification of action plans required based on data
results, additions and deletion of indicators to be studied,
modifications in definitions of care-givers, and on-going
monitoring of improvement in data aggregation and reporting.
Continuum Home Health Care (CHHC) – CHHC, a division of
the Medical Center, provides home health and home infusion
services, including skilled nursing, physical, occupational
and speech therapies, home health aides and medical social
work. Additionally, CHHC offers specialty care through its
Psychiatric Service, Pediatric Service and Wound Care Team.
CHHC serves patients residing in the counties of
Albemarle, Greene, Madison, Orange, Louisa, Fluvanna,
Buckingham, Nelson, Amherst, Augusta, and Rockingham.
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Continuum’s ability to provide a full complement of
services has greatly increased its marketability to payors
and to external referral sources. In Fiscal Year 2003, CHHC
admitted 2,321 new patients, maintaining an average daily
census of between 560-600 patients receiving direct care
services. Home infusion admitted an additional 436 patients
for pharmacy-only services, a growth of 32% in “product only”
patients.
For all four quarters of Fiscal Year 2003, CHHC received
overall mean patient satisfaction scores of 89.5 - 90.6 with
the last quarter receiving the highest rating of “very good”
on 71% of all questions. CHHC continued to work on a number
of quality and patient safety initiatives, including the
implementation of a bereavement program coupled with a
training program for nurses and therapists on “end of life”
care facilitated by the Palliative Care Service and the
development of a falls risk assessment tool.
In addition, CHHC formed a team to establish best
practice related to patient outcomes and cost. The team has
completed its preliminary work on and is beginning to define
clinical interventions and associated service utilization
strategies.
Continuum continued to work with Virginia Health Quality
in the development and implementation of Medicare’s Outcome
Based Quality Initiative and Outcome Based Quality Management
programs. A component of the Outcome Based Quality
Initiative resulted in the development of a home health
report card, with publication in local newspapers of agency
performance slated for November 2003.
Finally, CHHC implemented both an adult and a pediatric
asthma disease management program
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UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.E. Magnet Recognition for Excellence
in Nursing Services
ACTION REQUIRED:
None
BACKGROUND: In the current national nursing shortage,
competition for recruiting and retaining professional nurses
is intense. The wealth of talented nurses at the University
of Virginia is an extraordinary strength for the Medical
Center, the University and for the community. It is
essential that the focus continue to be on seeking and
achieving ever-higher standards to retain this precious
resource. One strategy that is internationally respected and
supported by outcomes research is the Magnet Recognition
Program for Excellence in Nursing Services established by the
American Nurses Credentialing Center (ANCC).
The concept of Magnet Hospitals originated in the early
1980's by the American Academy of Nursing when 41 hospitals
were studied to determine why their organizations were able
to successfully recruit and retain nurses during the shortage
experienced at that time. Subsequent research identified
crucial organizational traits and characteristics found to
support and enhance the professional environment of nurses.
Nurse researchers have demonstrated that Magnet Hospitals
report better patient outcomes than do hospitals without
Magnet status. These hospitals have:
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Higher patient satisfaction rates;
Lower rates of mortality;
Lower rates of nurse turnover;
Cost-efficiency;
Shorter lengths of stay in the hospital and in intensive
care units;
High percentages of nurses prepared at the baccalaureate
and masters level;
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High levels of nurses with specialty certification; and
Nurses who report high levels of job satisfaction,
control over their practice, and the ability to provide
high quality patient care.
In 1993, the American Nurses Association, through ANCC,
established a formal program to acknowledge excellence in
nursing services known today as the Magnet Recognition
Program. It has recently attained international status, and
85 health care institutions have received Magnet Recognition
as of October 2003.
Regardless of the health care organization's size,
setting, or location, achieving Magnet Recognition
designation serves to attract and retain quality employees.
Magnet designation helps consumers locate health care
organizations that have a proven level of excellence in
nursing care and demonstrated quality outcomes.
DISCUSSION: University of Virginia Magnet Application
Process - The University of Virginia Medical Center process
for seeking Magnet Recognition began through a grass roots
effort based on the desire of staff nurses to achieve
national recognition for excellence in nursing and leadership
of the Professional Nursing Staff Organization (PNSO).
In 1999, the Magnet Recognition Exploratory Committee
conducted a gap analysis to assess the Medical Center and
PNSO’s ability to meet the requisite criteria. In May 2000,
the Nursing Cabinet formally recommended that the PNSO seek
Magnet Recognition. Additional support was solicited from
Medical Center Managers, Administrators and Executive
Management.
In September 2000, the Medical Center established the
Magnet Recognition Steering Committee, comprised of staff
nurses, to guide the effort. The Medical Center conducted
the first Nursing Worklife Survey in November 2000 to assess
the professional and worklife satisfaction of Medical Center
nurses. Each year these survey results are analyzed by the
Medical Center and PNSO leadership and shared with nurses,
Executive Management, physicians, patient care unit staff
and committees to allow key issues to be addressed.
In January 2001, the Medical Center submitted to the
ANCC the official Letter of Intent to seek Magnet
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Recognition, and the Medical Center established the Magnet
Recognition Application Committee in April 2001. The
Committee is made up of staff nurses who assist in
collecting evidence in support of the Magnet Application.
In March 2002, the Medical Center developed the Nursing
Demographic Database as a requirement for the application.
Demographic data points collected include: education,
certification, professional associations, continuing
education activities, and community service. Also in 2002,
the Magnet Committees coordinated public recognition events.
“Showcasing Nursing Excellence” and “Shining the Light on
Patient Care Excellence” are two events that highlight
individual nurses and health care teams that contribute to
patient care excellence and improve system processes.
Throughout 2002, partnerships across nursing were forged and
strengthened to serve as conduits of information sharing,
goal setting, and problem solving on all aspects associated
with nursing, patient care, and Medical Center issues. In
October 2002, the Medical Center began to submit quality
data to the National Database of Nursing Quality Indicators.
This national repository contains data from all Magnet
institutions on a variety of core indicators related to
patient safety and quality of nursing care.
In March 2003, the third Worklife Survey occurred, with
a 68% response rate, and a total of 987 nurse respondents,
and Magnet Champions were identified from various patient
care areas to assist with disseminating information. June
2003 brought together Magnet Champions for a Training Day
featuring Leonard Sandridge, Ed Howell, Pamela Cipriano, and
Coach Al Groh as keynote speakers. In August 2003, the
Medical Center mailed the 2200 page Magnet Application to
the ANCC. Appraisers are reviewing the evidence, and
confirmation of a site visit is pending. Fall 2003 is
filled with events to educate and inform all Medical Center
staff and employees about the benefits of achieving Magnet
Recognition.
Regional Competition for Magnet Designation - Just over
1% of American hospitals have achieved Magnet status. Inova
Fairfax Hospital is the first Magnet designated hospital in
Virginia. Carilion Medical Center had its site visit in July
2003, and Mary Washington Hospital completed its site visit
in August 2003. Both institutions are awaiting a decision by
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the ANCC commission in November. The Johns Hopkins Hospital
and Georgetown University Hospital are awaiting their site
visits. Martha Jefferson Hospital has begun their evidence
collection, with plans for written documentation submission.
Comparison to other Magnet Organizations - Recent
comparative data about organizations with Magnet status
reveal that the University of Virginia Medical Center
compares favorably in percentage of direct care RNs to total
RNs. The Medical Center exceeds the average for RN years of
employment and percentage of direct care RNs with additional
certification. While the Medical Center’s turnover rate is
above the Magnet average, its vacancy rate is in line. The
Medical Center also is in line with RN skill mix (RN to
assistive personnel ratio). One area where the Medical
Center is below the Magnet average is the percentage of RNs
who have attended continuing education offerings.
Conclusion - The process of seeking and achieving Magnet
Recognition is an opportunity to continually assess the
practice environment and to improve aspects of the
organization that affect nurse recruitment, retention and
satisfaction. The vision of the Medical Center is that its
professional nursing staff will be recognized as leaders in
providing innovative, research-based nursing services in an
environment that supports professional development and
excellence. Being a Magnet Organization means the Medical
Center reflects the "gold standard" of nursing care and
promotes recruitment and retention of the highest caliber of
nursing professionals. Achieving Magnet Recognition also is
consistent with our value of Clinical Excellence and the
Decade Plan goal of vision to achieve top status by 2010.
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UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.F.
ACTION REQUIRED:
None
Coding Analysis
In order to bill for patient care services
BACKGROUND:
provided within the Medical Center, the services must be
properly coded based on the diagnosis or procedure. In
addition, coding information is being used with regularity
for other purposes, such as quality and performance metrics
and accreditation scores.
DISCUSSION:
Department of Coding Services
The Medical Center’s Department of Coding Services is
responsible for analyzing patient medical charts for the
assignment of diagnosis and procedure codes for statistical
and reimbursement purposes. Abstracted coding data also is
used for various purposes within the facility to include
performance improvement, utilization management, provider
credentialing, and decision support. The coding staff
processes approximately 85-100 inpatient and 150 outpatient
records each day.
The Department of Coding Services is a critical element
in the Medical Center’s revenue cycle, but historically, it
has been viewed within the organization as an isolated
component of that process. However, the Department is now
undergoing a transformation in importance since many of the
activities performed are vital to external reporting agencies
and internal strategic initiatives, such as the Joint
Commission on Accreditation of Healthcare Organizations
(JCAHO), US News and World Report rankings, the Anthem
contract, Medical Center marketing initiatives and compliance
with reimbursement laws and regulations. As more fully
described below, this increased level of importance has
placed greater emphasis on the quality of the coding staff,
including upgrading the Director position from a manager to
an administrator level.
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To ensure that the coding staff meets professional
standards of excellence, they are required to be certified by
the American Health Information Management Association
(AHIMA). AHIMA members earn credentials through a
combination of education and experience and finally through
performance on national certification exams. Following their
initial certification, members must maintain their
credentials and thereby the highest level of competency
through rigorous continuing education requirements. The
Medical Center coding staff is comprised of Certified Coding
Specialists, Certified Professional Coders, Registered Health
Information Technicians and a Registered Health Information
Administrator.
Attracting and retaining qualified professional coders
is challenging for hospitals across the country.
The
Medical Center is currently conducting a national search for
a Director of Coding Services. Recruiting a highly qualified
and experienced Director is essential to maintaining the high
productivity and quality standards for the Department. In
addition, the Medical Center is also recruiting five coding
and reimbursement specialists.
In order to continue to retain and attract highly
qualified coders, the Medical Center recently enhanced the
salaries of the existing coding staff, offered retention
bonuses and is working aggressively to implement a homebound
coding program as more fully described below. These measures
were necessary to better align compensation and programs to
those of other organizations competing for the specialized
skill set that coders possess.
Improving Data Process Quality and Flow
The Department of Coding Services seeks continuously to
improve its operations and data reporting to ensure that all
medical records are coded with accuracy and efficiency. In
order to strengthen the quality of its services and improve
its processes, the Department, with the support of the senior
leadership, has entered into a number of initiatives designed
to enhance both quality and efficiency.
Implementation of the All Patient Refined (APR)-DRG
System -With the recent publication of the US News and World
Report rankings, the signing of a contract with Anthem for
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the Quality Hospital Insights Program, and the increasing
popularity of other public reporting systems, there have been
numerous inquiries into the quality of the data that are
being used to calculate quality indicators for benchmarking
purposes and external reporting. In response, the Medical
Center is making improvements to ensure that the most
pertinent codes are sent outside the institution, which will
result in more accurate quality indicators without adversely
affecting financial reimbursement. The most significant
change will be to install the 3M All-Patient-Refined DRG
(APRDRG) Grouper software and database. APRDRGs more
accurately reflect clinical complexity of patient care than
its predecessors. This grouper combined with the
benchmarking database will allow the Medical Center to track
variances and trends for charges, length-of-stay, mortality
and complications. It also allows for trending of severity
of illness and risk of mortality distributions for comparison
to national norms.
The Medical Center is one of only a few institutions
nation-wide who are at the forefront of using APRDRGs to
strategically assess its patient population. Using this
leading edge technology will better position the Medical
Center to assess proactively the impact that coding has on
its reimbursement and reporting to external parties.
Consolidated Coding - The Medical Center is piloting a
program to synchronize the charge capture and coding
processes for physician and technical services provided in
the Emergency Department. Under this program, an individual
coder is assigned the responsibility for coding both the
physician and hospital components of the visit. This
specialization ensures a more accurate and efficient coding
process.
The Medical Center plans to expand the consolidated
coding program to other high dollar areas such as
Neurosurgery, Angiography, Cardiac Catherization and
Electrophysiology.
Focused Chart Reviews - The Coding Department
participates in on-going detailed reviews of Heart Center
medical records in order to more accurately capture the
diagnosis of severity of its heart patients. These reviews
have identified areas for improvements including more robust
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documentation standards and result in a more thorough
understanding of the specialization of Heart Center coding.
Coding Templates - The Department of Health Information
Services, which is charged with the responsibility for
transcribing dictation, is improving the process by piloting
transcription templates in selected outpatient clinics. The
new enterprise dictation and transcription system includes an
option for document creation that is called ChartScriptMD.
This tool allows a clinician to create, edit and complete
patient documentation through dictation, automated text
selection and/or typing. This streamlines documentation and
increases documentation consistency with the use of
customizable templates and text inserts.
The templates can
be created to assure inclusion of elements that are necessary
to meet regulatory requirements for documentation
and accurate coding for reimbursement. It is expected that
the use of templates will speed the process and further
enhance overall coding.
Homebound Coding - In order to find and retain
certified, quality coders, decrease coding backlogs, reduce
costs associated with coding, and to improve productivity and
quality, the Medical Center is implementing a home based
coding program. By implementing this type of program, the
organization can better recruit and retain coders, eliminate
the geographical boundaries associated with coder employment
and provide new career options. This program will allow
coders to access a medical record via the internet, code the
record and then submit the diagnosis and procedure codes
directly to the facility in a variety of ways. The remote
coding program should alleviate costly contract coding
companies, increase retention, increase morale, and improve
the overall performance of the Department. This program is
currently in the planning phase and implementation is
scheduled for January, 2003.
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UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
III.
ACTION REQUIRED:
None
Clinical Staff President’s Remarks
DISCUSSION: The President of the Clinical Staff of the
Medical Center will inform the Medical Center Operating Board
of recent events regarding the Clinical Staff, of which the
Medical Center Operating Board should be made aware, but
which do not require formal action.
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UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
December 4, 2003
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
IV.
ACTION REQUIRED:
None
Compliance Training and Report
BACKGROUND: On September 13, 2003, the University of
Virginia Medical Center began the third year of a Corporate
Compliance Agreement with the Office of the Inspector General
– United States Department of Health and Human Services.
This Agreement requires the annual training of staff and
management of the University of Virginia Medical Center,
including the Medical Center Operating Board of the Board of
Visitors.
BACKGROUND: The mandatory training reviews the Corporate
Compliance Agreement, highlights changes to the Compliance
Code of Conduct, and emphasizes significant compliance
policies and regulatory initiatives. Mr. Ralph Traylor,
Corporate Compliance Officer, will make the presentation. At
the end of the training, each Medical Center Operating Board
member will be asked to sign an attestation of compliance
training. In addition, Mr. Traylor will update the Medical
Center Operating Board on the completion of the second year
of the Corporate Compliance Agreement.
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