VANDERBILT UNIVERSITY MEDICAL STAFF & VANDERBILT MEDICAL GROUP ANNUAL MEETING Thursday, June 28, 2012 4:30 – 6 pm 208 Light Hall.

VANDERBILT UNIVERSITY MEDICAL STAFF & VANDERBILT MEDICAL GROUP

ANNUAL MEETINGThursday, June 28, 2012

4:30 – 6 pm208 Light Hall

VANDERBILT UNIVERSITY MEDICAL STAFF ANNUAL MEETING

AGENDA• Welcome

C. Lee Parmley, MDChair, Medical Center Medical Board (MCMB)

• Proposed Amendments to Medical Staff Bylaws, Rules & Regulations and Policies & Procedures

• MCMB Membership Elections

• Adjournment

PROPOSED AMENDMENTS TO MEDICAL STAFF BYLAWS, RULES & REGULATIONS

AND POLICIES & PROCEDURES

• Goals of Proposed Revisions:

– To comply with evolving CMS, Joint Commission and NCQA standards

– To streamline Medical Staff Bylaws, Rules & Regulations, Policies & Procedures and VUMC policies and to create internal consistency

– To address and codify evolution of VUMC staffing and clinical practice

AMENDMENT REVIEW AND APPROVAL PROCESS

• Administrative Affairs Committee– identification of CMS, Joint Commission and NCQA

requirements, inconsistencies, and other needs for additions/revisions/deletions

• Executive Committee of MCMB & full MCMB– review recommendations of Administrative Affairs

Committee, amend and endorse as appropriate• VUMC Medical Staff

– approval of amendments at Annual Meeting• Medical Center Affairs Committee (Board of Trust

Committee)– final approval

AMENDMENTS TO MEDICAL STAFF BYLAWS AND RULES & REGULATIONS

• Article XII – Corrective Action– Proposal to add verbiage requiring providers to inform

their Chair of the initiation of any disciplinary action by another hospital, licensing board, etc. and to keep informed as to the progress and outcomes of such action and proceedings

• Article VII – Clinical Services– Add Physical Medicine & Rehabilitation

• Article VI – Privileged Professional Staff – Change all references in Medical Staff Bylaws and Rules

& Regulations “Professional Staff with Privileges”

AMENDMENTS TO MEDICAL BYLAWS ANDRULES & REGULATIONS

• Article III – General Qualifications for Appointment– Add verbiage that defines an “approved residency” as

one accredited by ACGME, American Osteopathic Association, College of Family Physicians of Canada CFPC and/or Royal College of Physicians and Surgeons of Canada

– Add verbiage that refers all allegations of discrimination in the credentialing decision-making process to EAD with periodic audits of all denials to ensure that providers are not discriminated against

• Rules & Rags – History & Physical Section– Change verbiage to include Anesthesiologists as

“attending” for the purpose of taking histories and performing physical examinations

AMENDMENTS TO MEDICAL STAFF BYLAW AND RULES & REGULATIONS

• Article III – Appointment and Reappointment– Modify board certification requirements as indicated to

become compliant with Joint Commission standards and current practice:

• When the applicant possesses comparable training, experience and competence but (1) Board Certification was not applicable at the time the applicant’s training was completed or (2) the applicant is only certified in a non-U.S. or non-Canadian Board or 3) the board certification is in a specialty other than the primary division (department), the applicable Chief of Service may submit a written request for a waiver of this requirement to the Credentials Committee Chairman for action by the Credentials Committee with subsequent approval by the MCMB and MCAC. However, Physicians must maintain their Certification by board whatever re-certification process is outlined by their applicable

ACTION POINT

• Approval of proposed amendments to Medical Staff Bylaws, Rules & Regulations, and Policies & Procedures Required

MCMB MEMBERSHIP UPDATES & ELECTIONS

• At-Large Members (3) elected annually

Nominees:

– Andre Churchwell, MD

– A. Alex Jahangir, MD

– James “Pete” Powell, MD

ACTION POINTS

• At-Large Member Elections require a majority vote of the voting members present

• Adjournment of Medical Staff Meeting

VANDERBILT MEDICAL GROUPANNUAL MEETING

AGENDA

• VMGVMG Finance Committee – Roland Eavey, MD

•  

• VMG Credentialing – Steven Meranze, MD

•  

• VMG Billing Office –Meredith Marwill

•  

• Contracting Update – Beverly Coccia

•  

• VMG Quality Council – Racy Peters

•  

• Physician Council on Clinical Service Excellence – Gaye Smith

•  

• Hitch and Other Operational Initiatives – Margaret Head

•  

• Economic Repositioning – David Posch

VMG Finance Group

06/26/2012

Committee Members

• Dan Beauchamp• Marc Bennett• Brian Carlson• Sandy Cherry• Keith Churchwell• Titus Daniels• Marilyn Dubree• Roland Eavey• Phyllis Ekdall• Janice Fruci• Denis Gallagher• Sheri Haun

• Margaret Head• Stephan Heckers• Tommy Hollinden• Mack Howell• Mark Hubbard• Howard Jones• Mike Laposata• John Manning• Steve Meranze• Derek Miller• Colin Mothupi• Robin Mutz• Mike Neuss

• Jim Newman• Bill Obremskey• David Posch• Pete Powell• Margaret Rush• Warren Sandberg• Diane Seloff• Janice Smith• Robin Steaban• Cindy Sullivan• Paul Sternberg• Reid Thompson• Dell Yarbrough

Identity

Historically - an audit committee

Contemporary needs •$400M budget re-engineering over upcoming years•Comfortable conversation to align our values/missions with our economic forces•Grow revenues plus reduce expenses•Process > Product

Meeting 1: Provider Compensation Model

• “Medicare cutting reimbursements”

Sensitive elephant

• “Officially” discussed compensation modeling with reduced dollars (our values, process examples, leadership)

November 30, 2011

• Bring up the sensitive topic

• Valued ingredients re compensation

• Time frame

Meeting 2: TOOLSCost Reduction = Quality Increase

• Lost/Cost Awareness Tools– (SLA) Service Line Analytics (MD level

utilization)– WebMD (local/national institutions) – UHC (AMCs)– Healthcare Quality Calculator (utility)

December 7, 2011

Meeting 3: Strategic Growth Tools

• Investment information: THA, HSDA, UHC, JAR, Thompson Reuters

• Finance: Where we are/Where we want to be Medipac/Epic/TSI

SLA/Crimson/UHC

Tracking Team…..ROI view

January 12, 2012

• Valve Data Analysis…Cost/LOS/Readmission• Parking

January 31, 2012

Meeting 4: Cost Homework and Parking

Meeting 5: Optimal Resource Management

• Teams (MD/RN/MBA)• Departmental variance• Inpatient/Outpatient

May 29, 2012

Meeting 6: Optimal Resource Management

• Why haven’t we fixed Fridays?

Vanderbilt University Medical Staffand Vanderbilt Medical Group MeetingJune 28, 2012

Credentials Committee Report

Steven Meranze, M.D.

Organizational Structure

• The Credentials Committee (Steven Meranze)

Participating sub-committees

• Children’s Hospital Credentials Committee (Gregory Mencio)

• Joint Practice Committee (Clare Thomson-Smith)

• Provider Support Services Office (Danielle Midgett)

Credentials Committee• Representation of the major clinical specialties, including behavioral health,

the hospital-based specialties and the Medical Staff at large

• Meets monthly

• Synopsis of duties (see Bylaws): A. To evaluate the credentials and performance of all applicants for Medical Staff membership and

reappointment

B. To review recommendations from the Joint Practice Committee regarding the credentials, performance, and supervisory arrangements of all Certified Nurse Practitioners, Certified Nurse Midwives, Physician Assistants, Certified Registered Nurse Anesthetists and Allied Health Practitioners who apply for privileges to practice at VUMC.

C. To report to the Medical Center Medical Board on each applicant for Medical Staff or other professional staff recommendation to the Medical Center Affairs Committee (MCAC). Reports and recommendations regarding Medical Staff and other professional staff appointment and delineation of practice privileges shall include consideration of any recommendations from the Service in which the candidate requests privileges;

D. To investigate any breach of ethics that is reported to it.

E. To review reports of Medical Staff or other professional staff member performance or conduct issues that are referred to it, and to provide peer review in response to competence or performance inquiries.

Timeliness of File Review and Approval

• Influenced by many factors– Licensure and DEA– Verification (all education, hospital affiliations and work history)– Faculty appointment– Trust coverage/ Claims history– Competency documentation– Incomplete application

• Affects practice planning (personal and division)• Enrollment considerations (NCQA)• Increased need for expedited credentials committee

meetings

National Committee on Quality Assurance (NCQA) certified Credentials Verification Organization (CVO)

• Develop delegated credentialing agreements with managed care organizations (MCO)

• Delegate MCO credentialing activities to Vanderbilt. VMG providers who are approved through the VUMC Credentials Committee review process are “automatically” enrolled in ~43 managed care plans versus each provider completing and submitting separate applications to each of these organizations

• Creates an additional layer of complexity and scrutiny to credentialing activities

• Files >120 days are considered “expired” and require re-submission and re-verification

Expedited Credentialing

• Expedited credentialing: Provider is reviewed and approved for privileges by an agent (subcommittee) of the governing body (MCAC)

• Defined exclusion criteria

• Legitimate action to answer immediate needs (e.g. critical staffing issues)

• Large number may reflect system limitations

Future Initiatives

• Paperless credentialing– E-file “secure transfer “(Accellion)– Electronic signature - “Pronto System”– Phased implementation

• Improved interface with the Faculty Information System for Faculty Appointments

VMG Business Office UpdatePresented by Meredith Marwill

Associate Director of Physician Billing Services

Faculty Practice Solutions Center Billing Office SurveyFY2010 Top 10 Performers

1. University of Pittsburgh Medical Center2. UMass Memorial Medical Group3. University of Minnesota Physicians4. Massachusetts General Physician Organization5. The Medical College of Wisconsin6. University of Wisconsin Medical Foundation7. Vanderbilt Medical Group7. University of Texas Medical Branch (Galveston)9. University of Virginia Physicians Group10. Fletcher Allen Health Care/University of Vermont

• VMG ranked 7th overall in benchmark performance indicators reported by 56 academic institutions through University Healthcare Consortium (UHC).

33

Gross Professional Charges

Charges have increased 10.9% from prior fiscal year.

34

Annual Cash Collections

Collections have increased 7.9% from prior fiscal year.

35

Total RVU Volume

Total RVUs have increased 8.7% from prior fiscal year.

36

Collections Per RVU

Collections/RVU has decreased 0.7% from prior fiscal year.

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Days in A/R / Charge Lag

UHC FY 2011 Survey

Days in A/R

25th percentile = 47.4 days

Median = 41.2 days

75th percentile = 36.9 days

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Cost to Collectas percent of Net Collections

10.6%11.1%

10.8%9.8%

8.8% 8.3%7.9%

*2012 FYTD through May

7.4% 7.0% 6.3%

Cost to Collect has remained stable this past fiscal year.

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6.3%

2012

Projects and Opportunities for FY 2013

• Continue to improve patient collections• Expand Point of Service collection program to address

increasing patient out of pocket requirements• Develop vendor partnership to allow for combined

patient collection activities with VUMC• Continue to redesign work flow processes and systems to

enhance the revenue cycle• Migrate toward a paperless work environment in the

revenue cycle through further development of EPIC workqueues and other technology enhancements

• Developing best practice documentation to move towards more consistent work processes within all areas of the revenue cycle

• ICD10 Training and Preparation 40

Contracting 2012Highlights

VMG Quality Reporting

2012 VMG Annual Faculty MeetingJune 28, 2012

426/28/2012

The Mission of VMG is to improve the health

of the people in the communities we serve

through evidence-based, personalized,

compassionate care, research and education.

436/28/2012

Hand Hygiene

FY 2012 Goal Hand Hygiene

FY 2012 1st

Quarter

FY 2012 2nd

Quarter

FY 2012 3rd

Quarter

FY 2012 Threshold

FY 2012 Target

FY 2012 Reach

VMG Adult 93% 95% 95% 88% 92% 95%

VMG Peds 95% 94% 95% 88% 92% 95%

446/28/2012

Adult Anticoagulation Clinic

456/28/2012

Adult Anticoagulation Clinic

466/28/2012

New Patient Access

476/28/2012

Publicly Reported Measures: OPPS

• Timing and appropriateness of antibiotic prophylaxis in outpatient procedures

FY-2012 2nd Qtr Threshold Target Reach

OPS - Appropriate Care 90.0% 91% 94% 99%

OPS 6 - Timing of Antibiotic Prophylaxsis 97.0% 80% 85% 90%

OPS 7-Prophylactic Antibiotic Selection 91.5% 80% 85% 90%

486/28/2012

Publicly Reported Measures: PQRS

• Voluntary quality reporting program

• Provides incentive payments of 1% of all Medicare Part B billings for each eligible provider (EP)

• Reporting Period: full calendar year 2011

• Data will not be publicly reported for 2011 or 2012

496/28/2012

Publicly Reported Measures: PQRS

• Incentive timeline and amounts: • 2012: 0.5 % • 2013: 0.5 %• 2014: 0.5 %

• Penalty timeline and amounts: • 2015: 1.5 % (will be based on 2013 submission)• 2016 and each subsequent year: 2.0 %

• Data will be publicly reported beginning 2013 or 2014 (exact year still TBD)

506/28/2012

PQRS Measure #1: Hemoglobin A1c Poor Control in Diabetes % of Pts Aged 18-75 with Diabetes Mellitus with Most Recent

Hemoglobin A1c >9.0%

516/28/2012

Measure #2: Low Density Lipoprotein (LDL-C) Control in Diabetes

% of Pts Aged 18-75 with Diabetes Mellitus who had Most Recent LDL-C Level in Control (<100 mg/dl)

526/28/2012

Measure #3: High Blood Pressure Control in Diabetes % of Pts Aged 18 -75 with Diabetes Mellitus who had Most

Recent Blood Pressure In Control (<140/90 mmHg)

536/28/2012

Measure # 5: Heart Failure: ACE Inhibitor or ARB Therapy for LVSD

% of Pts Aged 18+ with Heart Failure and LVSD (LVEF < 40%) who were Prescribed an ACE inhibitor or ARB Therapy

546/28/2012

Measure #6: Oral Antiplatelet Therapy Prescribed for Patients with CAD

% of Pts Aged 18+ with a Diagnosis of CAD who were Prescribed Oral Antiplatelet Therapy

556/28/2012

Measure #7: Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)

% of Pts Aged 18+ with a Diagnosis of CAD and prior MI who were Prescribed Beta-Blocker Therapy

566/28/2012

Measure #8: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

% of Pts Aged 18+ with a Diagnosis of Heart Failure who also have LVSD (LVEF < 40%) and who were Prescribed Beta-Blocker Therapy

576/28/2012

New VMG Medical Director for Quality: Barron Patterson, MD

6/28/2012 58

Physician Council for Clinical Service Excellence

June, 2012

Patient Experience & Service Council Structure

Physician Council for Clinical Service Excellence

• Began meeting in March of 2011

• Meets monthly

• Membership represents 14 clinical departments plus Williamson County– 28 physician members– Chair: Paul Sternberg, M.D.– Co Chairs: Andre Churchwell, M.D. and Leah Harris,

M.D.– Facilitators: Lynn Webb, Ph.D.; Gaye Smith

Physician Council Members

• John (Jake) Block, Radiology

• Nathaniel Clark, Psychiatry

• Anthony Cmelak, Radiation Oncology

• Marta Crispens, OB-GYN

• Titus Daniels, Medicine

• Jesse Ehrenfeld, Anesthesiology

• James Felch, Ophthalmology

• Brent Graham, Pediatrics

• Rob Hood, Medicine

• Alex Hughes, Anesthesiology

• Ian Jones, Emergency Med

• Eric Lambright, Surgical Sciences

• Mike Laposata, Pathology

• Tracy McGregor, Pediatrics

• Steven Meranze, Radiology

• Paul Moore, Pediatrics

• Melinda New, OB-GYN

• David Parra, Pediatrics

• John Peach, Medicine

• Jan Price, Medicine

• Russell Ries, Otolaryngology

• Henry (Hank) Russell, W'mson Co - VMG

• John Scott, W'mson Co - VMG

• Carmen Solorzano, Surgical Sciences

• David Uskavitch, Neurology

• Douglas Weikert, Orthopaedics

• Patty Wright, Medicine

• Kelly Wright, Surgical Sciences

Key Topics Discussed

• Why a Physician Council?

• PRC Patient Satisfaction Surveys – (use of % excellent vs. percentiles in Service Pillar goals)

• HITECH Meaningful Use implications for clinical practices and work flow

• Studer Physician Institute: “Practicing Excellence: Engaging Physicians to Execute System Performance”

• Patient and Family “Always Promise”

• Use of a video on effective communication between physicians and patients

• Provided input for process improvement in patient complaint mgmt– Renaming Patient Affairs “Advocates” to Patient Relations

“Specialists”

• Ways to formally recognize Clinical Excellence

Operations Update

Margaret Head, RN, MSN, MBA

Chief Operating Officer/Chief Nursing Officer

2012 Clinic Expansions and Acquisitions

• VEI acquisition of Lebanon Eye Associates• VOI Clinic expansion to Mt. Juliet• Williamson County School District contract for

athletic trainers• Franklin Cardiology expansion• Maternal Fetal Medicine rotation in Columbia• DOT 10 floor completion

VMG Nursing Updates

• VMG Staff Turnover Rate 9.88%• 32 RN’s and 9 LPN’s advanced in the nursing clinical

ladder program• Significant work in developing nursing triage and RX

star renewal protocols• Received special recognition during the Magnet Survey

Status of Meaningful Use Implementation

Cohort Training Timeline

8/1/2011 9/30/2012

9/1/2011 10/1/2011 11/1/2011 12/1/2011 1/1/2012 2/1/2012 3/1/2012 4/1/2012 5/1/2012 6/1/2012 7/1/2012 8/1/2012 9/1/2012

8/1/2011 - 8/31/2011Complete Pilot

of Star Tools

9/1/2011 - 10/14/20111st Cohort Training

10/3/2011 - 12/30/20112nd Cohort Training

1/2/2012 - 3/30/20123rd Cohort Training

4/2/2012 - 6/29/20124th Cohort Training

7/2/2012 - 9/30/20125th Cohort Training

HITECH Faculty and Staff Trained

• Eligible Providers – Eligible Provider trained

671– Eligible Provider remaining to be trained 187– Total Eligible Providers

858• Providers Trained - 963• Staff Trained - 1055• Total Trained to date - 2018

HITECH PHASE II/ICD-10• HITECH Phase II

– Vanderbilt Outpatient Order Management (VOOM)• Pilots under way in several clinics• Staged roll out to begin in Oct 2012

• ICD-10– Tools being developed to help with transition from ICD-9

to ICD-10– Pilots have begun on these tools with expected rollout to

being in Spring of 2013

Economic RepositioningDavid Posch

June, 2012

72

Mitch EdgeworthChief Operating Officer

Vanderbilt University Hospital

Coordinating Care

Disease

Clinic Procedure ICU Inpatient Discharge Post Acute Home Self

Redesign fundamental Care Processes to improve efficiency and effectiveness

Redesign the infrastructure to improve efficiency and effectiveness across all care transitions

Inpatient Care CoordinationModel

Huddle Care Plan 1.0

Post Discharge Phone Call

Post Discharge Clinic Visit

Post Discharge Intermediate

Care

MedicationReconciliation

Risk Stratification

Economic Repositioning

Top 5 represent ~$22MM of the

$30MM built into FY’13 Budget

Top 5 Projects1) MEOC Initiatives FY132) 340B Contract Pharmacies3) Specialty Pharmacy4) Care Partner Redesign5) Case Scripting

FY’12Forecast Savings

FY’13 Savings in Budget

FY’13 Anticipated Savings

$8 million $30 million $32 million

> 200 Ideas submitted

~ 40 active projects

Manpower

May ‘12 Actual

FY’12 Budget

FY’13 Budget

FTEs (Adult)

8,912.6 8,968.0 9,147.0

246 FTE reductions were made through attrition and repurposing of positions