Minutes of the meeting of the Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System held Friday, January 18, 2019 at the hour of 10:00 A.M. at 1950 W. Polk Street, in Conference Room 5301, Chicago, Illinois. I. Attendance/Call to Order Chair Gugenheim called the meeting to order. Present: Chair Ada Mary Gugenheim and Director Mary Driscoll, RN, MPH (2) Board Chair M. Hill Hammock (ex-officio) and Directors Heather M. Prendergast, MD, MS, MPH and Mary B. Richardson-Lowry Karen Kim, MD and Patricia Merryweather (Non-Director Members) Telephonically Present: Patrick T. Driscoll, Jr. (Non-Director Member) Absent: Director Layla P. Suleiman Gonzalez, PhD, JD (1) Additional attendees and/or presenters were: Debra Carey – Deputy Chief Executive Officer, Deborah Santana – Secretary to the Board Operations John Jay Shannon, MD – Chief Executive Officer Trevor Lewis, MD – John H. Stroger, Jr. Hospital Ronald Wyatt, MD – Chief Quality Officer of Cook County Kent Ray – Associate General Counsel II. Public Speakers Chair Gugenheim asked the Secretary to call upon the registered public speakers. The Secretary called upon the following registered public speaker: 1. George Blakemore Concerned Citizen III. Report from Chief Quality Officer A. Regulatory and Accreditation Updates B. Metrics (Attachment #1) Dr. Ronald Wyatt, Chief Quality Officer, provided an overview of the metrics. The Committee reviewed and discussed the information. IV. Action Items A. Approve appointments and reappointments of Stroger Hospital Department Chair(s) and Division Chair(s) There were no appointments/reappointments presented for the Committee’s consideration. Page 1 of 54 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, January 18, 2019 Page 2 IV. Action Items (continued) B. Executive Medical Staff (EMS) Committees of Provident Hospital of Cook County and John H. Stroger, Jr. Hospital of Cook County i. Receive reports from EMS Presidents ii. Approve Medical Staff Appointments/Reappointments/Changes (Attachment #2) Dr. Trevor Lewis, President of the EMS of John H. Stroger, Jr. Hospital of Cook County, presented the medical staff appointments/reappointments/changes for the Committee’s consideration. He reminded the Committee that the annual meeting of the Medical Staff will be held on January 22nd at 4:00 P.M. Dr. Valerie Hansbrough, President of the EMS of Provident Hospital of Cook County, was unable to attend the meeting. Director Driscoll, seconded by Chair Gugenheim, moved to approve the Medical Staff Appointments/Re-appointments/Changes for John H. Stroger, Jr. Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. Director Driscoll, seconded by Chair Gugenheim, moved to approve the Medical Staff Appointments/Re-appointments/Changes for Provident Hospital of Cook County. THE MOTION CARRIED UNANIMOUSLY. C. Minutes of the Quality and Patient Safety Committee Meeting, December 14, 2018 Director Driscoll, seconded by Chair Gugenheim, moved to accept the Minutes of the Quality and Patient Safety Committee Meeting of December 14, 2018. THE MOTION CARRIED UNANIMOUSLY. D. Any items listed under Sections IV and VI V. Recommendations, Discussion / Information Item A. Strategic planning discussion: Quality Measures (Attachment #3) Dr. Wyatt provided an overview of the presentation, which included information on the following subjects: • Definition of Health Care Quality • Meaningful Measures – Framework, Goals and Objectives • Most Critical Measures Areas • Aim: Promote Effective Prevention and Treatment of Chronic Disease • Centers for Medicare and Medicaid Services (CMS) Star Ratings – Measures and Data • Star Quality Action Plan • Star Quality Steering Committee • CMS Measure Focused Finding Workgroup • Proposed Structure • Next Steps Page 2 of 54 Minutes of the Meeting of the Quality and Patient Safety Committee Friday, January 18, 2019 Page 3 V. Recommendations, Discussion / Information Item A. Strategic planning discussion: Quality Measures (continued) During the review of the measures and data, Board Chair Hammock recommended that the column in the data charts that show the comparison to national mean should instead reflect whether Stroger Hospital’s results are better or otherwise than the national mean, rather than “above” or “below.” Following the discussion, Board Chair Hammock observed that this is a great programmatic approach; however, he did not hear a lot about financial impact. He thinks the organization has to be realistic in the following two (2) ways: 1) each initiative needs to have a candid cost benefit review; and 2) in cooperation with the Chief Financial Officer, the administration should determine a sum of money that could be used to fund key initiatives, and get that on the budget prospect for the year. VI. Closed Meeting Items A. Medical Staff Appointments/Re-appointments/Changes B. Claims, Litigation and Quality and Patient Safety Matters C. Matters protected under the federal Patient Safety and Quality Improvement Act of 2005 and the Health Insurance Portability and Accountability Act of 1996 The Committee did not recess into a closed meeting. VII. Adjourn As the agenda was exhausted, Chair Gugenheim declared the meeting ADJOURNED. Respectfully submitted, Quality and Patient Safety Committee of the Board of Directors of the Cook County Health and Hospitals System XXXXXXXXXXXXXXXXXXXXXX Ada Mary Gugenheim, Chair Attest: XXXXXXXXXXXXXXXXXXXXXX Deborah Santana, Secretary Requests/follow-up: Request: A request was made regarding the column in the strategic planning presentation data charts that show the comparison to national mean - they should instead reflect whether Stroger Hospital’s results are better or otherwise than the national mean, rather than “above” or “below.” Page 3 Page 3 of 54 Cook County Health and Hospitals System Quality and Patient Safety Committee Meeting Friday, January 18, 2019 ATTACHMENT #1 Page 4 of 54 QPS Quality Dashboard January 18, 2019 Page 5 of 54 Illinois Avg. National Avg. 16 15 Page 6 of 54 2 Page 7 of 54 3 Page 8 of 54 4 Page 9 of 54 5 Page 10 of 54 6