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Community Hospital Board of Directors Met August 19

August 31, 2015

McCook, Nebraska—During the Community Hospital Board of Directors meeting on August 19, directors heard the fourth quarter 2015 balanced scorecard report. The overall score surpassed goal at 6.50 out of ten. Of the 16 measures, two were up, four were down and ten remained the same. Reports from the four seed champions, People, Service, Quality and Finance, were also presented.

People Seed

Action plans underway in the People Seed include preparing Just Culture training in September for all directors and supervisors. The interview process team was formed in March to incorporate best practices and consistency into the interview process. Under succession planning, each department director will take the Healthcare Source Leadership assessment in conjunction with their annual evaluation over the next year and incorporate a leadership competency into their annual goal for the next year. Next steps are building a library of leadership books based on the ten leadership competencies.

For the second quarter of 2015, 130 employees participated in the hospital’s Wellness for Life quarterly reward program earning money for quarter points, quarter challenges and online interventions. Wellness week took place July 6-10. Various educational and group exercise classes were offered throughout the week including a Super Heroes walk/run to raise money for adult and juvenile diabetic research and diabetes patient supplies. A new employee/spouse wellness portal, FitThumb Portal, will be implemented this fall.

Service Seed

The Service Seed reported Christopher Ihle, M.D., a board certified orthopedic surgeon began working at Community Hospital on June 22. He has purchased a home in McCook and conducts surgery and clinic at the hospital four days a week. Dr. Laroy Williams, an urologist from Kearney, began his outreach clinic in McCook in June. He plans to see patients at Community Hospital one day a month, but because of the large volume of patients he has already seen, he scheduled two days to see patients in August.

In other Service seed news, the hospital formed a Patient Family Advisory Council. Nine people are invited to the August meeting where they will be asked to provide input on a number of topics.

Community education included Lunch and Learn programs on occupational therapy and gardening, skin cancer education, diabetes education and back pain, the Trenton Health Fair in Trenton, Community Hospital health fair, volunteer luncheon, a coaches lunch and Learn featuring Dr. Ihle and an ice cream social for the Sterling Connection. A lunch and learn on flu prevention will be held September 1.

Community Hospital’s Wellness for Life wellness program is working on expanding its services beyond employees to include spouses of employees as well as other businesses and individuals in the community. The new wellness portal, FitThumb, could also include members of the public.

Community Hospital has collaborated with other smaller critical access hospitals in the region to identify some non-patient care areas of business where the hospital could lend expertise and assistance. Some of these areas include oversight help in laboratories, laundry services, management consulting, accounting and finance as well as pharmacy.

Quality Seed

The composite score for patients rating their experience of overall level of safety of all departments for the four quarters of fiscal year 2015 was 69.91% of patients giving the hospital an excellent score, exceeding the hospital’s goal by 4.81%. For fiscal year 2015, Community Hospital inpatients gave the hospital a composite score of 80.39% excellence in “how would you rate this hospital during your stay?” This was is 11.07% over goal.

Productivity of employees is measured on the balanced scorecard. Community Hospital’s composite score for fiscal year 2015 is 103.99%, exceeding the measure.

Finance Seed

Community Hospital is in a small group of hospitals in the United States who has completed Stage 2 of the Meaningful Use regulations from the HITECH Act which was a part of the Stimulus Bill of 2009 and is now preparing for Stage 3. Stage 3 will require Community Hospital to achieve more aggressive goals regarding the use of computerized order entry and the requirement for hospitals to communicate medical information to patients and other providers electronically. To manage the large projects necessary to achieve Stage 3 goals, Community Hospital has formed a monthly steering committee.

Strategic Planning Update

The directors learned that the financial audit review will be presented by Seim Johnson on September 9. Steve Shaner, Strategic Planning Manager, presented the mid-year market assessment.

Review of Activities

Terri Shipshock, Executive Director of the Community Hospital Health Foundation, presented the foundation’s quarterly report. The foundation and Community Hospital sponsored the Tough Enough to Wear Pink event at the Red Willow County Fair rodeo in July. Fifteen volunteers handed out 480 pink bandanas and promoted Community Hospital’s cancer services. An appreciation dinner for Heritage Society members will be September 30. An Evening for Hospice is scheduled for November 22. The foundation hosted a jeans day and an ice cream event, Scoops for Scholarships, for employees in August. The event raised awareness and funds for Community Hospital’s Education Assistance program.

The quarterly quality/performance improvement, patient safety and risk management reports were given by Joleen Bradley, Patient Safety and Performance Improvement director. She reported the hospital laboratory had a successful Joint Commission survey in July. Community Hospital had an 88% participation rate among employees taking the Hospital Survey on Patient Safety Culture (HSOPS). One of the key strengths identified is all 12 survey composites increased by 5% or more since the survey was first taken by employees in 2012. Four dimensions improved by 10% or more.

Jessica Johnson, Medical Staff Coordinator and Compliance Officer presented the quarterly compliance report to the board. Three major projects are underway: Document and record retention planning, policy management including creating “writing guidelines” and HIPAA policies were created and revised. Mandatory HIPAA training for employees will be conducted in August.

Consent Agenda

Minutes were approved from the June 17 regular meeting of the board of directors. The board did not meet in July. Also approved were minutes and reports from the June 11 regular meeting of the medical staff and the August 5 meeting of the policy, personnel, and planning committee.

Action to be Taken

Under Action to be Taken, the board approved the following privileges: Active Medical Staff-reappointment, Consulting Medical Staff-Appointment, Consulting Medical Staff-Reappointment and Allied Health Staff-Reappointment. Three revised employee policies were approved.

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