Board of Directors Formal Meeting. October 29, :00 p.m. Agenda

Transcription

1 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, :00 p.m. Agenda

2 Board Members Terence McMahon, Chair, District 5 Mark Dewane, Vice Chair, District 2 Mary A. Harden, R.N., Director, District 1 Susan Gerard, Director, District 3 Elbert Bicknell, Director, District 4 AGENDA Formal Meeting Maricopa County Special Health Care District Board of Directors President & Chief Executive Officer Stephen A. Purves, FACHE Clerk of the Board Melanie Talbot Meeting Location Maricopa Medical Center Administration Building Auditoriums 1 and E. Roosevelt Street Phoenix, AZ Mission Statement Maricopa Integrated Health System (MIHS) is Maricopa County s only public teaching hospital and health care system. We are committed to providing safe, comprehensive, high-quality physical and behavioral health care in a patient-centric environment to the communities we serve; and expanding the community s available pool of physicians and other health care professionals by offering excellent academic programs. Welcome We welcome your interest and hope you will often attend Maricopa County Special Health Care District Board of Directors meetings. Democracy cannot endure without an informed and involved electorate. The Board of Directors is the governing body for Maricopa Integrated Health System. Each member represents one of the five districts in Maricopa Country. Members of the Board are public officials, elected by the voters of Maricopa Country. The Board of Directors sets policy and the President & Chief Executive Officer, who is hired by the Board, directs staff to carry out the policies. Formal meetings The Board of Directors generally holds a regular monthly meeting at 1:00 p.m. on the fourth Wednesday of the month. Please visit or call the District Clerk at to confirm the date of the next regular meeting. The meeting may appear to proceed quickly, with important decisions reached with little discussion. However, the agenda and meeting material is available to the Board of Directors the Thursday prior to the meeting, giving them the opportunity to study every item and to ask questions of District staff members. If no additional facts are presented at the meeting, action may be taken without further discussion. How Citizens Can Participate The Board of Directors values citizen comments and input. Citizens may appear before the Board of Directors to express their views. Any member of the public will be given three minutes to address the Board on issues of interest or concern to them. If you wish to address the Board, please complete a Speaker s Slip and deliver it to the Clerk of the Board. If you have anything that you wish distributed to the Board and included in the official record, please hand it to the Clerk who will distribute the information to the Board Members and Maricopa Integrated Health System Senior Staff. Speakers will be called in the order in which requests to speak are received. Your name will be called when the Call to Public has been opened or when the Board reaches the agenda item which you wish to speak. As mandated by the Arizona Open Meeting Law, officials may not discuss items not on the agenda, but may direct staff to follow-up with the citizen. Agendas are available within 24 hours of each meeting in the Office of the Board, Maricopa Medical Center, Administration Bldg, 2 nd Floor 2601 E. Roosevelt, Phoenix, AZ 85008, Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. and on the internet at Accommodations for Individuals with Disabilities, alternative format materials, sign language interpretation, and assistive listening devices are available upon 72 hours advance notice through the Office of the Board, Maricopa Medical Center, Administration Bldg, 2 nd Floor 2601 E. Roosevelt, Phoenix, Arizona 85008, (602) To the extent possible, additional reasonable accommodations will be made available within the time constraints of the request. 10/23/ :26 AM

3 When Speaking at the Podium Please state your name and the city in which you reside. If you reside in Maricopa County, please state the District you live in. If you have an individual concern involving the District, you are encouraged to contact your District Board member at We will do everything possible to be responsive to your individual requests. Public Rules of Conduct The Board Chair shall keep control of the meeting and require the speakers and audience to refrain from abusive or profane remarks, disruptive outbursts, applause, protests, or other conduct which disrupts or interferes with the orderly conduct of the business of the meeting. Personal attacks on Board members, staff, or members of the public are not allowed. It is inappropriate to utilize the Call to Public or other agenda item for purposes of making political speeches, including threats of political action. Engaging in such conduct, and failing to cease such conduct upon request of the Board Chair will be grounds for ending a speaker s time at the podium or for removal of any disruptive person from the meeting room, at the direction of the Board Chair. Elbert Bicknell Elbert.Bicknell@mihs.org Susan Gerard Susan.Gerard@mihs.org Mark Dewane Mark.Dewane@mihs.org Mary A. Harden, R.N Mary.Harden2@mihs.org Terence McMahon Terence.McMahon@mihs.org 2

4 Maricopa Medical Center Administration Building Auditoriums 1 and E. Roosevelt Phoenix, AZ Wednesday, October 29, :00 p.m. One or more of the members of the Board of Directors of the Maricopa County Special Health Care District may attend telephonically. Board members attending telephonically will be announced at the meeting. Pursuant to A.R.S (A)(3), or any applicable and relevant state or federal law, the Board may vote to recess into an Executive Session for the purpose of obtaining legal advice from the Board s attorney or attorneys on any matter listed on the agenda. The Board also may wish to discuss any items listed for Executive Session discussion in General Session, or the Board may wish to take action in General Session on any items listed for discussion in Executive Session. To do so, the Board will recess Executive Session on any particular item and reconvene General Session to discuss that item or to take action on such item. Call to Order Roll Call Pledge of Allegiance Call to the Public This is the time for the public to comment. The Board of Directors may not discuss items that are not specifically identified on the agenda. Therefore, pursuant to A.R.S (H), action taken as a result of public comment will be limited to directing staff to study the matter, responding to any criticism or scheduling a matter for further consideration and decision at a later date. ITEMS MAY BE DISCUSSED IN A DIFFERENT SEQUENCE General Session, Presentation, Discussion and Action: 1. Approval of Consent Agenda: 15 min Note: Approval of contracts, minutes, IGA s, proclamations, etc. Any matter on the Consent Agenda will be removed from the Consent Agenda and discussed as a regular agenda item upon the request of any Board member. a. Minutes: Approve Special Health Care District Board of Directors Meeting Minutes dated: i. September 22, 2014 ii. September 24, 2014 b. Contracts: i. Approve a new contract ( ) with SoftBank for the replacement of blood bank transfusion inventory system (hardware and software), to include billing and information management and will interface with EPIC. 3

5 General Session, Presentation, Discussion and Action (cont.): 1. Approval of Consent Agenda (cont.): b. Contracts (cont.): ii. iii. iv. Approve Amendment #18 ( ) with EPIC Systems Corporation for the replacement of Anatomic Pathology applications, which will include software, hardware, and data conversion. Approve Amendment #1 ( ) to the Intergovernmental Agreement with Maricopa County to extend agreement for lab services. Approve a new contract ( ) with Phoenix Health Plan (PHP), including Abrazo Advantage Health Plan, for medical services to PHP members under the AHCCCS and Abrazo Medicare Advantage plans. v. Approve a new contract ( ) with Integrated Health Management Services for medical eligibility and verification services. vi. Approve Amendment #11 ( ) to the Professional Services agreement between Maricopa Integrated Health System and District Medical Group to accommodate changes in the language to reflect clarification on the Chart Completion Performance Standard, additional physician FTEs, Emergency Department Professional Billing transition from MIHS to DMG, and Clarification in the Meaningful Use Language. c. Governance: i. Approve No-objection letter for the City of Goodyear proposed Foreign Trade Zone The Cookson Company, 1901 S. Litchfield Road, Goodyear, AZ Parcel Number ii. iii. iv. Approve the Amended and Restated Bylaws of Mercy Maricopa Integrated Care and Approve the Consent in Lieu of Special Meeting of Members of Mercy Maricopa Integrated Care and the appointment of the Jim Beckmann, Jeff Jackson, and Michael Zenobi to the MMIC Finance Committee and the MMIC Audit & Compliance Committee Approve Board of Directors Resolution No and Affidavit of Compliance Regarding the November 2014 Bond Election. Ratify the Appointment of Dr. Anthony Dunnigan as Maricopa Integrated Health System Chief Medical Information Officer d. Medical Staff: i. Approve MIHS Medical Staff Appointments, FPPEs, Reappointments, Change of Privileges/Status, and Resignations for October 2014 ii. iii. iv. Approve MIHS Allied Health Professional Staff Appointments, FPPEs, Reappointments, and Resignations for October 2014 Approve revisions to the MIHS Peer Review Policy Approve revisions to the Radiology Privileges specifically for Radiology Core Privileges and Mammography and Breast Interventional Core Privileges 4

6 General Session, Presentation, Discussion and Action (cont.): 1. Approval of Consent Agenda (cont.): d. Medical Staff (cont.): v. Approve new Neonatal Nurse Practitioner Privileges and Practice Prerogatives End of Consent Agenda 2. Presentation, Discussion and Possible Action on MIHS: Social Return on Investment Analysis 15 min Dr. Dennis Hoffman, Dr. Kent Hill, and Dr. Anthony Evans, L William Seidman Research Institute, W.P. Carey School of Business, Arizona State University 3. Discussion and Action on the Selection and/or Appointment of Members to the Board of Directors Finance Committee 15 min Board of Directors 4. Discuss and Review the Protocols in Place to Address Possible Ebola Exposure 15 min Mike Robertson, MIHS, Vice President of Marketing & Public Affairs Robert E. Fromm, Jr., M.D., M.P.H., MIHS, Chief Medical Officer 5. Discuss, Review and Accept the Maricopa Health Plan and the Maricopa Care Advantage Plan Audited Financial Statements for Fiscal Year min Michael D. Ayres, MIHS, Chief Financial Officer 6. Discuss, Review and Possible Action on the Monthly Chief Financial Officer Report; Discuss and Review September 2014 MIHS Key Indicator Dashboards 15 min Michael D. Ayres, MIHS, Chief Financial Officer Robert E. Fromm, Jr., M.D., M.P.H., MIHS, Chief Medical Officer William F. Vanaskie, MIHS, Chief Operating Officer 7. Maricopa Integrated Health System Risk Management Program Report: 2014 Calendar Year to Date 15 min Robert E. Fromm, Jr., M.D., M.P.H., MIHS, Chief Medical Officer 8. Discussion and Possible Action on Maricopa Integrated Health System Employee Benefits 15 min Terence M McMahon, Chairman, Board of Directors 9. Discuss, Review and Approve Revisions to the Following Board Policy Statements: 10 min a. Cellular Telephones, Service and Reimbursement b. Call to the Public: Addressing the Board at a Meeting Melanie Talbot, MIHS, Executive Director of Board Operations 10. Consideration, Discussion, and Possible Action on the Performance Evaluation for Fiscal Year 2014 for Melanie Talbot, Executive Director of Board Operations 10 min Board of Directors 5

7 General Session, Presentation, Discussion and Action (cont.): 11. Consideration, Discussion, and Possible Action on the Chief Executive Officer Performance Goals for Fiscal Year 2015 Board of Directors 12. Reports to the Board of Directors; Discussion and Possible Action: 5 min a. MIHS Media Report b. Graduate Medical Education Board of Directors 13. Concluding Items 5 min a. Old Business: August 27, 2014 Formal Meeting Chief Financial Officer Report Accurate revenue reporting by October 2014 for the first quarter of FY 2015 Same and Opposite Sex Domestic Benefits A report of the actual costs associated with the implementation; options for costsaving measures to offset the $317,000 assumed costs for implementation. REMINDER Effective Date January 1, Concluding Items Quarterly reports from HomeAssist Health (HAH) and Mercy Maricopa Integrated Care (MMIC) beginning January 1, 2015 at the latest. September 24, 2014 Formal Meeting Finance Committee Charter Bring forward a list of recommendations for membership Key Indicator Dashboards A report of the improvements in the cath lab six months after the implementation of new equipment A financial report on the return on investment one-year post implementation of the new equipment in the cath lab Cath lab volumes to be added to the monthly operational dashboards A report on the efforts by Mercy Maricopa Integrated Care to address the behavioral health capacity issue Economic Impact Analysis Phase III to be presented in October 6

8 Concluding Items A review of the Board of Directors Bylaws in November 2014 b. Board Member Requests for Future Agenda Items or Reports c. Comments i. Chairman and Member Closing Comment ii. President & Chief Executive Officer Summary of Current Events Adjourn 7

9 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.a.i. Minutes

10 Minutes Maricopa County Special Health Care District Board of Directors Meeting Maricopa Medical Center Navajo East and West Rooms September 22, :00 p.m. Present: Terence McMahon, Chairman, District 5 Mark Dewane, Vice Chairman, District 2 Mary A. Harden, R.N., Director, District 1 Susan Gerard, Director, District 3 telephonically, beginning at 2:23 p.m., excused herself at 3:04 p.m. Elbert Bicknell, Director, District 4 Others Present: Steve Purves, MIHS, President & Chief Executive Officer Wilma Acosta, MIHS, Chief Compliance Officer Louis B. Gorman, MIHS, District Counsel Recorded by: Melanie Talbot, MIHS, Executive Director of Board Operations Cynthia Cornejo, MIHS, Deputy Clerk of the Board Call to Order Chairman McMahon called the meeting to order at 1:00 p.m. Roll Call Ms. Talbot called roll. Following roll call, it was noted that four of the five voting members of the Maricopa County Special Health Care District Board of Directors were present, which represents a quorum. Director Gerard participated telephonically during executive session item E-2. Call to the Public Chairman McMahon called for public comment. There were no comments from the public. Mission Statement Director Harden read the mission statement aloud. General Session, Presentation, Discussion and Action: 1. Board Education Compliance: The Office of Inspector General and its Compliance Expectations of the Board Ms. Acosta reminded the Board of the eight elements of an effective compliance program. She shared a video featuring Mr. Greg Demske of the Office of Inspector General (OIG). The video noted the Board s role in healthcare organizations; which is to promote economy, efficiency, and effectiveness. The goal is for the Board to set the tone of the organization from the top, guide and support the executive leadership, understand legal fiduciary duties, and recognize their legal responsibility for quality.

11 Special Health Care District Board of Directors Meeting Minutes General Session September 22, 2014 General Session, Presentation, Discussion and Action (cont.): 1. Board Education Compliance: The Office of Inspector General and its Compliance Expectations of the Board, cont. Director Bicknell questioned if the Chief Compliance Officer (CCO) should report directly to the Board, as suggested in the video. Ms. Acosta stated that the OIG makes suggestions; however, it is appropriate for the CCO to report to the Chief Executive Officer (CEO) and have direct access to the Board. She stated that Mr. Purves encourages engagement between herself and the Board; as a result, she meets regularly with the Chairman. She continued that the message from the OIG included that the Board is to understand the rules, regulations, and consequences related to potential fraud, waste, and abuse. There is also an expectation for the Board to be accountable, receive education, and be informed of any regulatory changes that may impact the system. She explained the OIG exclusion and stated that the best practice is to conduct a monthly check of all employees, including Board members. Director Harden said that the Board members are elected officials. She questioned what corrective actions would be taken if an elected official appeared on the exclusion list. Ms. Talbot stated that should that particular situation present itself, the Maricopa County Elections Department and Judicial Departments would intervene. Vice Chairman Dewane asked if there is an attestation for employees to complete annually. Ms. Acosta said all employees complete a Conflict of Interest at new hire; however, it was not completed annually. The OIG exclusion list report is scheduled to run on a monthly basis. Vice Chairman Dewane questioned at what point is the CEO responsible for the actions of the employees outside of their professional capacity. Ms. Acosta said that it was difficult to monitor actions of all employees. There may be processes and systems in place; however, human behavior is not easily controlled. She stated that there are expected revisions to specific processes, including the Conflict of Interest requirement and the Code of Conduct and Ethics. There are current discussions taking place on whether or not Maricopa Integrated Health System (MIHS) should require a signed Conflict of Interest form on an annual basis. The MIHS Code of Conduct and Ethics is under review and will be updated. She stated that the OIG encourages the establishment of Board committees to ensure there are strong, effective processes surrounding the finances, audit, and compliance of the organization. She noted that the Board is expected to be assertive in respect to the oversight of the audit process and the effectiveness of the compliance program. It is recommended that an organization consider an ombudsman that will confidentially investigate and mitigate employee work relations. Mr. Purves said that healthcare organizations with an ombudsman are likely to have lower legal expenses, as many potential legal situations are resolved through mediation or arbitration. The selection of the ombudsman is critical to the success of the position. The ombudsman would work closely with compliance and legal departments, while reporting to the Chief Executive Officer. Director Bicknell questioned the authority this position would have. Mr. Purves said that an ombudsman would have an extraordinary amount of influence in the organization. Any situation involving the ombudsman would be confidential. Chairman McMahon asked if the ombudsman would be involved in both internal and external situations. 2

12 Special Health Care District Board of Directors Meeting Minutes General Session September 22, 2014 General Session, Presentation, Discussion and Action (cont.): 1. Board Education Compliance: The Office of Inspector General and its Compliance Expectations of the Board Mr. Purves said the primary responsibility of this position would be for internal situations; however, there may be instances involving hospital processes that may benefit from the ombudsman involvement. Director Bicknell asked how the ombudsman would maintain confidentiality while reporting to the CEO. Mr. Purves said that he would recommend receiving high-level reports, omitting names and departments. Should a circumstance arise where specifics are needed, the situation would be approached appropriately. Chairman McMahon suggested a proposal for this position be brought for consideration at a future Board meeting. Ms. Acosta concluded that the Board is responsible for quality, including the basic duty of care, the oversight of the compliance programs, and has a duty of obedience to the corporate mission. The Board is expected to provide objectivity, stay informed on current best practices, and be accountable for quality with the establishment of a quality committee; which may be a management committee, not a Board committee. Director Bicknell requested a clarification of a management committee as compared to a Board committee. Ms. Acosta stated that a management committee would report to the Board through management; whereas a Board committee would be incorporated in the Bylaws with a committee charter, and would be subject to all applicable Arizona Open Meeting Laws. She stated the next education module would focus on the updates to the various laws and regulations that have occurred over the past year. MOTION: Vice Chairman Dewane moved to recess general session and convene in executive session at 1:44 p.m. Director Harden seconded. Motion passed by voice vote. General Session, Presentation, Discussion and Action: Chairman McMahon reconvened the general session at 4:36 p.m. Adjourn MOTION: Director Harden moved to adjourn the September 22, 2014 Special Health Care District Board of Directors Executive Session and Informal Meeting. Vice Chairman Dewane seconded. Motion passed by voice vote. Meeting adjourned at 4:37 p.m. Terence M. McMahon, Chairman Special Health Care District Board of Directors 3

13 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.a.ii. Minutes

14 Minutes Maricopa County Special Health Care District Board of Directors Meeting Maricopa Medical Center Auditoriums 1 and 2 September 24, :00 p.m. Present: Terence McMahon, Chairman, District 5 Mark Dewane, Vice Chairman, District 2 Mary A. Harden, R.N., Director, District 1 Susan Gerard, Director, District 3 telephonically, excused herself at 3:54 p.m. Elbert Bicknell, Director, District 4 Others Present: Steve Purves, MIHS, President & Chief Executive Officer Bill Vanaskie, MIHS, Chief Operating Officer Michael Ayres, MIHS, Chief Financial Officer Robert E. Fromm, Jr., M.D., M.P.H., MIHS, Chief Medical Officer Sherry Stotler, R.N., M.S.N., MIHS, Chief Nursing Officer Louis B. Gorman, MIHS, District Counsel Guest Presenters: Michael Grossman, M.D., MIHS, Vice President, Academic Affairs Dan W. Hobohm, M.D., MIHS, Vice President of Quality Outcomes Denise Atwood, R.N., J.D., MIHS, Vice President Hospital Operations Anthony Evans, Ph.D., L William Seidman Research Institute, W.P. Carey School of Business, Arizona State University, Senior Research Fellow Recorded by: Melanie Talbot, MIHS, Executive Director of Board Operations Cynthia Cornejo, MIHS, Deputy Clerk of the Board Call to Order Chairman McMahon called the meeting to order at 1:01 p.m. Roll Call Ms. Talbot called roll. Following roll call, it was that all five voting members of the Maricopa County Special Health Care District Board of Directors were present, which represents a quorum. Director Gerard participated telephonically. For the benefit of those participating telephonically, Ms. Talbot named the individuals present and asked presenters to announce themselves prior to speaking. Pledge of Allegiance The Pledge of Allegiance was led by Vice Chairman Dewane. Call to the Public Chairman McMahon called for public comment. There were no comments from the public.

15 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 Call to the Public, cont. Chairman McMahon acknowledged Mr. Purves one-year anniversary and presented him with a plaque of appreciation. Mission Statement Vice Chairman Dewane read the Mission Statement aloud. General Session, Presentation, Discussion and Action: 1. Maricopa Integrated Health System Department Spotlight Academic Affairs Dr. Grossman introduced the employees of Academic Affairs. He stated that the department was responsible for requirements of undergraduate and graduate medical education, continuing medical education for physicians, nursing education, allied health education, and medical students. Maricopa Integrated Health System (MIHS) is accredited by the Accredited Council for Graduate Medical Education and requires the formation of a Graduate Medical Education committee. This committee is comprised of members of senior leadership, all residency program directors, employees from quality and patient safety, and peer-selected medical residents. He stated that MIHS sponsors 12 medical residency programs, nine of which are specialty programs, with several of the programs integrated with other institutions. He noted that MIHS also hosts 14 additional institutions across the country and allow their medical residents rotations. The result was 526 medical residents rotated through the institution last year. Dr. Grossman noted that MIHS hosts numerous students in various areas, including medical students, nursing students, allied health, pharmacy, and legal. He noted that the Academic Affairs department processes every student that rotates through MIHS and includes conducting a background check, ensuring all immunizations are up to date, conduct a TB screening, and complete training required by regulatory agencies. 2. Approval of Consent Agenda: a. Minutes: Approve Special Health Care District Board of Directors Meeting Minutes dated: i. August 15, 2014 ii. August 25, 2014 iii August 27, 2014 b. Contracts: i. Approve Amendment #2 ( ) to the Intergovernmental Agreement with Maricopa County by and through the Ryan White Part A Program to include Treatment Adherence Counseling Services ii. Approve Amendment #1 ( ) for an extension of the current lease agreement with Konica-Minolta for Copier Fleet Services (Lease, Supplies, Maintenance Services) 2

16 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session, Presentation, Discussion and Action (cont.): 2. Approval of Consent Agenda: b. Contracts, cont.: iii. Approve Amendment #10 ( ) to the Professional Services agreement between Maricopa Integrated Health System and District Medical Group for the addition of a Nurse Practitioner for Wards/Med Consults, a Physician s Assistant for Cardiology, the Surgical Critical Care Program Director and a revised Mid-level compensation for Comprehensive Health Center general Internal Medicine c. Governance: i. Authorize the District to respond to the appeal filed by Arizona Public Integrity Alliance, Inc. and Pace Ellsworth in Maricopa County Superior Court Cause # ; Authorize Dickinson Wright PC to file the answering brief in the appeal and otherwise represent the District and Directors Bicknell, Dewane, Gerard, Harden, and McMahon and former Maricopa Integrated Health System President and Chief Executive Officer Betsey Bayless in the appeal and to take any further legal action related thereto d. Medical Staff: i. Approve MIHS Medical Staff Appointments, FPPEs, Reappointments, Change of Privileges/Status, and Resignations for September 2014 ii. Approve MIHS Allied Health Professional Staff Appointments, FPPEs, Reappointments, and Resignations for September 2014 Director Harden requested item 2.b.iii. be removed from the consent agenda. Director Bicknell requested item 2.d.i. be removed from the consent agenda. MOTION: Director Harden moved to approve the consent agenda minus 2.b.iii. and 2.d.i. Director Bicknell seconded. Motion passed by voice vote. Director Harden referred to item 2.b.iii. and stated that she had a concern with increasing the number of full time employees (FTEs) as patient volumes continue to decease throughout the system. Mr. Vanaskie noted the propose amendment included the addition of 1.6 FTE, which fulfills three different positions. Of the three positions, 0.2 FTE is allocated for the fellowship director of critical care; a current physician will serve in this role, not adding an employee. The remaining allocation would create two new positions; a physician s assistant to the cardiology clinic and a nurse practitioner in internal medicine. The physician s assistant is justified due to the increased volumes in the cardiology clinic and the anticipation of expanding cardiology services to five Family Health Centers (FHC). The nurse practitioner will assist in patient consults and rounds, in an effort to expedite patient orders and discharges. MOTION: Director Bicknell moved to approve item 2.b.iii. Vice Chairman Dewane seconded. Motion passed by voice vote. 3

17 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session, Presentation, Discussion and Action (cont.): 2. Approval of Consent Agenda, (cont.): Director Bicknell referred to item 2.d.i., in particular page two, Staff Status Change. He questioned the circumstances surrounding the relinquishment of privileges of the provider. He then asked if those actions placed MIHS at risk. Dr. Fromm stated the physician incurred a driving under the influence (DUI) charge, which resulted in an immediate limitation on their medical license. The physician has since been re-instated. MIHS was not at risk for any liability in this matter. MOTION: Director Bicknell moved to approve item 2.d.i. Vice Chairman Dewane seconded. Motion passed by voice vote. 3. Discussion and Possible Action on the Creation of a Maricopa County Special Health Care District Board of Directors Finance Committee; Discussion and Possible Action on a Finance Committee Charter; Discussion and Possible Action on Finance Committee Membership Chairman McMahon stated that there had been several discussions surrounding the formation of a Board Finance Committee. Should it be decided to create the committee, the Board would then review the proposed Charter and discuss committee membership. MOTION: Director Bicknell moved to approve the creation of a Maricopa County Special Health Care District Board of Directors Finance Committee. Director Harden seconded. Motion passed by voice vote. Director Bicknell referred to the proposed Charter and noted he was pleased with the direction in which the Finance Committee was created. Director Harden clarified that the Finance Committee was a committee of the Board and would be subject to the Arizona Open Meeting Laws. Mr. Gorman confirmed. MOTION: Vice Chairman Dewane moved to approve the Finance Committee Charter. Director Bicknell seconded. Motion passed by voice vote. Chairman McMahon reviewed the membership requirements, as detailed in the Charter, and requested suggestions for possible members. Mr. Purves stated that senior administration will compile a list of possible candidates to serve on the committee, as well as solicit input from the Board. The list will be submitted for Board approval in October. 4. Presentation on Performance Improvement and Quality Management; Approval of Maricopa Integrated Health System s Annual Performance Improvement Plan for Fiscal Year 2015 and Approve Indicators on which to Measure Quality for Fiscal Year 2015 Dr. Hobohm reviewed the Annual Performance Improvement Plan and the Quality Dashboard, which incorporated the suggestions made by the Board members. 4

18 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session, Presentation, Discussion and Action (cont.): 4. Presentation on Performance Improvement and Quality Management; Approval of Maricopa Integrated Health System s Annual Performance Improvement Plan for Fiscal Year 2015 and Approve Indicators on which to Measure Quality for Fiscal Year 2015 (cont.): He noted there needed to be modifications made to the draft quality dashboard that was presented to the Board in the Board packets as a result of revised thresholds just released today by Hospital Compare, a U.S. Government website that has information about the quality of care at Medicare-certified hospitals. Dr. Hobohm continued to review the dashboard indicators and noted the core measures for psychiatric services were new; therefore, a calculated benchmark of 90% was determined. Chairman McMahon asked for clarification. Dr. Hobohm stated that there were several core measures grouped in the psychiatric indicator, including restraints, medications at discharge, multiple medication justification, post discharge continuing care, and post discharge continuing treatment plan. The goal would be 90% of all measures combined. MOTION: Vice Chairman Dewane moved to approve the Maricopa Integrated Health System s Annual Performance Improvement Plan for Fiscal Year Director Bicknell seconded. Motion passed by voice vote. MOTION: Vice Chairman Dewane moved to approve the Maricopa Integrated Health System s quality dashboard, modifying the benchmarks for the following indicators: emergency department from 285 to 240, perinatal care from 7% to 5%, patient safety indicator from 0.61 to 0.88, central line associated blood stream infection from 0.62 to 0.503, catheter associated urinary tract infections from 1.26 to 1.184, surgical site infections colon surgery from 1.15 to 0.945, surgical site infections abdominal hysterectomy from 1.02 to 0.909, MRSA bacteremia from 0.94 to 0.939, and clostridium difficile from 1.11 to Director Bicknell seconded. Motion passed by voice vote. Mr. Purves thanked Dr. Hobohm for the leadership he provides. 5. Discuss, Review and Approve a new Contract ( ) with GE Healthcare to Purchase a new Cath Lab Hemodynamics System (Hardware, Software and Capital) Director Harden expressed her concern with the utilization rate of the cath lab and the justification for investing more capital in this service line. Mr. Vanaskie referred to the documentation provided and noted the driving factors for the request. The cath lab is required to maintain the Level 1 status as an American College of Surgeons (ACS) verified trauma center and the current equipment is outdated and unstable. The volumes of the cath lab are improving due to the increased activity in the cardiology clinic. He stated that there are also discussions with outside cardiology groups who are interested in using the cath lab for their patients. Director Harden asked which locations are included in the expanded cardiology services. Ms. Atwood said the locations include Avondale, Glendale, Mesa, Chandler, and El Mirage. She noted that there has been a delay with approval from Health Resources and Services Administration (HRSA) to expand services. Chairman McMahon questioned the reason for the delay for approval. 5

19 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session, Presentation, Discussion and Action (cont.): 5. Discuss, Review and Approve a new Contract ( ) with GE Healthcare to Purchase a new Cath Lab Hemodynamics System (Hardware, Software and Capital) (cont.): Mr. Vanaskie stated that HRSA was working on their systems and that caused the delay for the approval process. Chairman McMahon noted the amount for the contract was $564,000; he questioned the other costs indicated on the documentation. Ms. Atwood said that in an effort for transparency, the documentation included the total cost of the project, including the equipment needed from another vendor. She also noted a typographical error in the documents provided to the Board. The purchased, if approved, will occur in October 2014, not October MOTION: Director Bicknell moved to approve contract ( ) with GE Healthcare to purchase a new cath lab hemodynamics systems, hardware, software, and capital. Vice Chairman Dewane seconded. Motion passed by voice vote. 6. Discuss, Review and Possible Action on the Monthly Chief Financial Officer Report; Discuss and Review August 2014 MIHS Key Indicator Dashboards Mr. Ayres reviewed the Chief Financial Officer report and discussed the actions taken to address the problem concerning revenue capture and reporting. He noted that an in-depth review was nearly complete; however, not complete enough to draw any major conclusions. He stated that for fiscal year 2014, the physician billing details were 98% correct over the year, with additional work needed to locate the anomalies. While reviewing the hospital billing, the first eight periods (months) are 100% correct, with the remaining periods not yet reviewed. He then stated that the current financial statements were prepared using a significantly different methodology than used before. Director Bicknell said that MIHS converted to Epic in March 2012; however, discrepancies went unnoticed until January He questioned the delay in recognizing a problem. Mr. Ayres stated that there were concerns in the fall of calendar year 2012; however, it was believed to be in conjunction with the implementation of the new system. By the spring of calendar year 2014, the concerns remained and a further review by PricewaterhouseCooper began. Director Bicknell asked how PricewaterhouseCooper was able to conduct a review in six weeks and conclude the estimated missed opportunity; while MIHS had been monitoring for two years with no conclusion. Mr. Ayres said that there were two different items. The first dealt with the overall application installation of Epic and determining the optimization scheme. In that review, four areas were identified; one of the areas addressed involved a set of processes called work queue. He noted that MIHS received an audit for fiscal year 2013 without adjustments or any material weaknesses. The internal auditors reviewed the charge description master; some issues were noted however, they were not of significance. In January 2014, the magnitude of error became so great it could no longer be ignored. The captured revenue was not being allocated to the correct month. The information reported appears to be materially correct, with no change to the figures reported for the end of the fiscal year. He stated that PricewaterhouseCooper identified the level of lost opportunity due to the inefficiency created over the past several months. Director Bicknell asked if those months included January 2014 going forward. 6

20 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session, Presentation, Discussion and Action (cont.): 6. Discuss, Review and Possible Action on the Monthly Chief Financial Officer Report; Discuss and Review August 2014 MIHS Key Indicator Dashboards, cont. Mr. Ayres said the inefficiency began prior to January; however, the variability from the beginning of the calendar year compounded the problem. The conclusion reached by May 2014 indicated that the problem lay in Accounts Receivable. Director Bicknell asked if the revenue had been captured. Mr. Ayres said that there was a solution that was to be discussed later in the agenda. Director Bicknell said that he received information that noted the cost of the Epic implementation was approximately $65 million. He asked how the problem occurred. Mr. Ayres said that the project was bigger than anticipated. MIHS went from a manual system to a fully integrated system in a very short time frame. The clinical documentation aspect of the system performed as anticipated. The financial aspect of the system has to be accepted by staff as the core tool for operations for the organization. He reviewed the financial statements and noted the information was gathered by reviewing individual transactions with the capture rates and revenues. He stated that the major issue effecting the statements continues to be the decline in patient volumes. The payer mix improved over prior year, however, not to the anticipated levels. Director Harden asked for clarification on contract labor. Mr. Vanaskie said that contract staffing is utilized in support services, such as information technology, dietary, and environmental services; with very few contract or agency staff on the patient care units. Director Harden questioned the data for HomeAssist Health, as it was no longer part of the District budget as the beginning of the current fiscal year. Mr. Ayres said that was provided for informational purposes only. Director Harden said that since the volumes for the cath lab were anticipated to increase, she requested that data be added to the operational dashboard. Director Gerard said that it may be difficult to monitor improvement on a monthly basis and suggested receiving a report six months after the implemented improvements. She asked when the improvements would be completed. Ms. Atwood said the project is expected to be completed six to eight months from the time of purchase. Director Harden said it would establish the baseline to compare the increases to later. Mr. Purves said the cath lab volumes would be added to the operational dashboard. There will also be a financial report on the return on investment presented to the Board one year after implementation. Mr. Ayres noted that on October 1, Arizona Health Care Cost Containment System (AHCCCS) transitions their payment methodology to diagnostic related groups (DRG). This will result in a single payment for a diagnosis related prudent price. He stated that MIHS conducted tests on claims submitted to prepare for any change in reimbursement. Dr. Fromm reviewed the quality dashboard for the month of August. He noted there were no patient falls, medication errors, or pressure ulcers for the month. The restraint episodes continue to be higher than the target and there was a slight rise in the readmission rate. 7

21 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session, Presentation, Discussion and Action (cont.): 6. Discuss, Review and Possible Action on the Monthly Chief Financial Officer Report; Discuss and Review August 2014 MIHS Key Indicator Dashboards, cont. Director Harden asked if there were any reasons for the increase in the readmission rates. Dr. Fromm said that the rate fluctuates due to the patient population served. He concluded that the process of care measures indicators were all 100%, and the patient satisfaction survey results were fairly good. Mr. Vanaskie reviewed the operational dashboard for August. Admissions for the month were less than budget, the length of stay (LOS) was better than budget. Behavioral health admissions were less than budget, with the LOS approaching 20 days as opposed to a budget of 13 days. This appears to be a systemic issue and resounds through the system. He stated that the Regional Behavioral Health Authority (RBHA) was working on a solution. Mr. Purves said that there were many hospitals reporting a lack of capacity for this population, including Phoenix Children s Hospital. Mr. Vanaskie stated the ambulatory volumes were near budget. The operating room utilization and deliveries were better than budget. The admission rate from the adult emergency room dropped to 14.9%. The rate of those that left without treatment also dropped to 2.2%. There was significant progress made in the door to doc time in both the adult and pediatric emergency departments, with both less than thirty minutes. Director Bicknell asked if there was an increase in court ordered evaluations. Mr. Vanaskie said that MIHS is the only authorized organization to conduct court ordered evaluations in Maricopa County. Should a provider choose to conduct court ordered evaluations, they must file an application with the RBHA. Chairman McMahon requested a report on how MMIC is addressing the behavioral health capacity issue. Mr. Purves stated the problem with behavioral health is multi-faceted; including the lack of capacity, patient throughput, and administrative issues with the insurance. He stated that a report would be supplied to the Board. Break from 2:34 p.m. to 2:45 p.m. 8. Reports to the Board of Directors; Discussion and Possible Action: a. MIHS Media Report This item was not discussed. MOTION: Director Harden moved to recess general session and convene in executive session at 2:46 p.m. Vice Chairman Dewane seconded. Motion passed by voice vote. 8

22 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session Presentation, Discussion and Action: Chairman McMahon reconvened the general session at 3:43 p.m. 10. Approve Amendment #4 ( ) to the Master Services Agreement with PricewaterhouseCooper to increase the annual Not-To-Exceed Amount to add additional deliverables MOTION: Vice Chairman Dewane moved to approve amendment #4 ( ) to the master services agreement with PricewaterhouseCooper to increase the annual Not-To- Exceed amount to add additional deliverable. Director Harden seconded. Motion passed by voice vote. 9. Approve Amendment #2 ( ) to the contact with Leidos Health, LLC to increase the Not-To-Exceed amount for the contract and approve the additional deliverables MOTION: Vice Chairman Dewane moved to approve amendment #2 ( ) to the contract with Leidos Health, LLC to increase the Not-To-Exceed amount for the contract and approve the additional deliverables. Director Harden seconded. Motion passed by voice vote. 7. Presentation, Discussion and Possible Action on MIHS: Economic Impact Analysis, Dr. Evans stated this phase of the economic impact analysis focused on the economic impact of MIHS in the years , should voters approve the proposed bond measure. He stated the method used for this analysis was the partial gross/partial net method; which considered the positive impact of MIHS employment, wages and supplied purchases as well the how the organization is financed through governmental sources. He reviewed the data included in the partial gross analysis, including the estimated number of full time employees in 2015, wages, and some non-labor expenditures associated with it. He also reviewed the non-residential capital expenditures and equipment and noted the amount was equivalent to $935 million. The result of that analysis estimated that over the course of the twenty-eight years the potential number of jobs created would range from 12,221 to 15,747 in any one year; with up to 14,300 being in the private sector. The gross state product would be $47.1 billion, cumulative over the twenty-eight years; with the majority of the impact remaining in Maricopa County. The data included in the partial net analysis utilized the same categories and incorporated the financing from the federal government and the debt repayment of $1.4 billion. This provided a net analysis of the benefit of MIHS and estimated the employment created in any one year ranged from 9,160 to 12,910 jobs, with as much as 11,700 being in the private sector. The potential gross state profit would be approximately $37 billion, with over $24 billion in real disposable income. Vice Chairman Dewane questioned how to address opponents stating that this is not the appropriate time to issue debt. Dr. Evans said that the bond measure is needed in order to make a net contribution to the economy as a whole. The third phase of the analysis will focus on the social return on investment, review the impact of people treated at MIHS, and their contribution to the economy as a result. He concluded that the bond measure would supply MIHS with $935 million out of the local population and the system would supply more to the local economy as a result. Chairman McMahon asked for the estimated completion date for the final phase. Dr. Evan stated the final phase would be presented in October. 9

23 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session Presentation, Discussion and Action (cont.): 7. Presentation, Discussion and Possible Action on MIHS: Economic Impact Analysis, (cont.): Director Bicknell stated that the analysis highlighted many positive impacts. He questioned if there were any negative aspects related to imposing the bond measure. Dr. Evans speculated that some may suggest that the bond initiative be a form of state intervention; however, the question to be addressed is, do people have the right to seek treatment and healthcare. 11. Concluding Items a. Old Business: August 15, 2014 Special Meeting Performance Improvement Plan for Fiscal Year 2015 Page 22. D. Service Line Committees. Please add credentials and titles Page 6. B.3. MIHS Administrative Leadership. Governance should not be included in this paragraph. Leadership does not have oversight of the governing body (Board of Directors) Page 7. IV. Quality Strategy. Do you mean excel? Page 17. A.1.a. (4) Do you mean worth continuing? Page 19. A. The last two bullets should be reversed. Page 19. B.1.b.6. Midas Live this is a new product that will be implemented in November Will be or was? Or 2015 instead of 2013? Page 20. B. Committee Structure Objectives. Hospital wide or system wide? It should be consistent. Indicators on which to Measure Quality for Fiscal Year 2015 Please add one additional column to the dashboard that states which of the six IOM dimensions is the primary dimension for each indicator listed. August 27, 2014 Formal Meeting Finance Committee Charter Revise the charter to include external audit functions in the Function and Responsibilities section Chief Financial Officer Report Results of the forensic accounting review including potential recovery and the costs associated with correcting the error Accurate revenue reporting by October 2014 for the first quarter of FY

24 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 General Session Presentation, Discussion and Action (cont.): 11. Concluding Items (cont.): a. Old Business (cont.): August 27, 2014 Formal Meeting (cont.): The total cost of Epic System and money spent on Epic since its implementation A return on investment on the corrective action plan regarding the revenue capture issues Same and Opposite Sex Domestic Benefits A report of the actual costs associated with the implementation; options for costsaving measures to offset the $317,000 assumed costs for implementation. Concluding Items Quarterly reports from HomeAssist Health (HAH) and Mercy Maricopa Integrated Care (MMIC) beginning January 1, 2015 at the latest. b. Board Member Requests for Future Agenda Items or Reports c. Comments i. Chairman and Member Closing Comment ii. President & Chief Executive Officer Summary of Current Events Chairman McMahon noted that the agenda will contain all old business and previous requests from the Board until addressed. Ms. Talbot reviewed the old business and confirmed outstanding items were on track for completion. She then reviewed requests discussed during the course of the current meeting. Director Harden requested a review of the Board of Directors Bylaws in November. Chairman McMahon recalled a discussion regarding a review of the major decisions made by the Board and questioned when that would be complete. Ms. Talbot stated that the information is recorded and can be provided as needed; however, it was suggested to be provided annually. Mr. Purves noted that MIHS physicians are providing their expertise to the public via media outlets, such as television and radio. He highlighted coverage on the possible health effects of children playing in the rainwater due to the recent storms and new technology available at MIHS to treat tendonitis, which is only available at one other hospital in Arizona. Adjourn MOTION: Director Harden moved to adjourn the September 24, 2014 Special Health Care District Board of Directors Formal Meeting. Vice Chairman Dewane seconded. Motion passed by voice vote. Meeting adjourned at 4:16 p.m. 11

25 Special Health Care District Board of Directors Meeting Minutes General Session September 24, 2014 Terence M. McMahon, Chairman Special Health Care District Board of Directors 12

26 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.b. Contracts

27 Maricopa County Special Health Care District Summary of Contract Approval Requests Date: October 29, 2014 Contract With New or Amendment Contract Provides ROI or Benefit Financial Impact Automates the billing and inventory Initial Year 1 expense is Replacement of Blood Bank management aspect of blood bank services for SoftBank $550, Annual New ( BB ) transfusion inventory the provision of blood components throughout ( ) expense for Year 2-5 is system the hospital. Interface with EPIC is also $20, provided with this tool. EPIC ( ) Maricopa County ( ) Phoenix Health Plan ( ) Integrated Health Management Services ( IHMS ) ( ) Amendment Amendment New New Replacement of Anatomical Pathology ( AP ) applications Month to Month Extension of contract for Lab services to Maricopa County to extend agreement for a period of 6 months. Facility agreement for provision of medical services to Phoenix Health Plan members (Replaces Letter of Agreement [LOA]) The purpose of this agreement is to assist patients applying for all medical assistance programs offered by the State of Arizona. Current anatomical pathology application with Cerner is at end of life. EPIC contains a module that will replace the Cerner application and allow MIHS to continue to support clinical anatomical pathology service needs throughout the hospital as well as maintain College of American Pathology (CAP) and Clinical Laboratory Improvement Amendments (CLIA) certifications. Extension to allow Maricopa County to issue an RFP in order to obtain a new contract for this service. MIHS intends to respond to the RFP when it is issued. MIHS will continue to provide medical services to Phoenix Health Plan (PHP) members under the AHCCCS and Abrazo Medicare Advantage plans. Allows MIHS to identify eligible patients and assist with enrollment efforts in these programs so MIHS may receive payment for medical services rendered. $573,000 one-time expense. Annual revenue of $7,200 Annual Revenue: PHP: $4.43M Abrazo Advantage: $1.5M Annual estimated expense of $1.3M 1 P age

28 6. DMG Amendment #11 ( ) Amendment Maricopa County Special Health Care District Summary of Contract Approval Requests Date: October 29, 2014 To revise Exhibit B, Sections II, III, IV, and Appendix H of the agreement. This amendment revises the Exhibit B, Sections II, III, IV, and Appendix H of the agreement to accommodate necessary changes in the language to reflect clarification on the Chart Completion Performance Standard, additional physician FTEs for the South Central FHC and the CHC, Emergency Department Professional Billing transition from MIHS to DMG, and Clarification in the Meaningful Use Language. Total Financial Impact: $250,198 (+To be determined once the ED baseline for collections is set). (Total Net Revenue for MIHS per Approved Arizona Children s Center Proforma: $1,643,899) Total FTE impact: Addition of 1.0 FTE 2 P age

29 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.b.i. Contracts

30 From: Compliance 360 To: Brian Maness Subject: Contract Approval Request: Blood Bank Application **Sole Source Award** SCC: Softbank Date: Wednesday, October 15, :29:43 AM Message Information From Purves, Steve To Maness, Brian; Contract Approval Request: Blood Bank Application Subject **Sole Source Award** SCC: Softbank Indicate whether you approve or reject by clicking the Approve or Reject button. Additional Information Add comments as necessary. Approve/Reject Contract Click here to approve or reject the Contract. Contract Information Status Pending Approval Title Blood Bank Application **Sole Source Award** Contract Identifier (Travel Type Board - New Contract Dropdown) MIHS Contract Number Primary Responsible Melton, Christopher C. Party Departments Product/Service Replacement of Cerner Classic Blood Bank due to endof-life. Description Current application is at end of life in December of 2015 and will not be supporting the sytem. Action/Background The purpose of this agreement is to contract with SoftBank for the Blood Bank Application to provide a bloodbank transfusion inventory systems to include billing and information management with interfacing to the EPIC medical records system. Blood Bank supports the transfusion needs across the service lines of the hospital. A review of available vendors with blood bank management systems has identified SoftBank as the only vendor that offers the critical feature of autointerpretation for ABO/RH typing. MIHS is not aware of any other vendor that possesses the performance capabilities, product scientific design or service scope required by MIHS for these services. Based on the reasons set forth, and through our Sole Source Justification process, award has been recommended to SoftBank.

31 Evaluation Process Notes Category 0 Effective Date 9/1/2014 Expiration Date 8/30/2019 The anticipated YR1 expense will be for a total of $550,058.20, and $20, annually for YR2 thru YR5. Annual Value $550, Expense/Revenue Expense Budgeted (Budget Bal Dropdown Travel) Procurement Number SSP Primary Vendor SCC: Softbank Responses Member Name Status Comments Maness, Brian D. Approved Ok to route for approval Otis, Dan F. Atwood, Denise A. Gorman, Louis B. Approved Approved Approved Vanaskie, Bill F. Ayres, Michael D. Approved May need to finance. Purves, Steve A. Approved Maness, Brian D. Current

32 MIHS Information Technology Business Justification Document Project Information Name of Proposed Project: Department Leader responsible for this Proposal: Executive Sponsor: Location of Proposed Project: End-of-Life Due-Diligence for Cerner Blood Bank and Anatomical Pathology Applications Carol Heyse - LIS Administrator Mary Travis BB Supervisor Dan Otis Director of Clinical Lab Dr. Hobohm Medical Director for Clinical and Pathology Lab Denise Atwood, VP Hospital Operations MIHS Lab Department Context Description The ability of MIHS to deliver quality care is predicated upon many factors with one being systems applications. Currently MIHS is faced with losing vendor application support for two critical clinical functions, Cerner Classic Blood Bank (BB) & Cerner Classic Anatomical Pathology (AP). Cerner s support of these two applications will cease December As a result of this, MIHS will be unable to accommodate any future enhancement requests, break-fix support, or meet additional Regulatory requirements (it is important to note that this type of support is highly specialized and resources are extremely limited nationwide). From an AP point of view, MIHS offers full service post-surgical and other procedure specimen analysis for Emergency Services, Obstetrics (OB) Services, Surgical Services, Trauma and the Burn service lines which are a requirement for an organization of this size. The impending lack of application support would place the College of American Pathologists (CAP) & Clinical Laboratory Improvement Amendments (CLIA) accreditations at risk to perform this service which would have an adverse impact on both the quality of patient care and undoubtedly revenue. Equally important to the organization are the services of BB. This ancillary service not only supports the various lines of business called out above, but also operates in more of a real-time (sometimes STAT) status that is required to meet the needs of a Level 1 Trauma facility and a Burn service line. In addition to the latter, BB also accommodates OB work-ups, the Level III Nursery, and identical to AP, is accredited by both CAP and CLIA. It is also important to note that BB is also regulated by the Food and Drug Administration (FDA) and by the American Association of Blood Banks (AABB). A budget request was submitted to replace these systems in FY15 (as part of a capital loan), but due to the risk and patient safety concerns, funding is being requested to proceed with replacement beginning in FY15. Market Demand Due-Diligence The Lab Team comprised of Dr. Hobohm, Arlene Arnpriester, Carol Heyse and Mary Travis travelled to Forest General located in Hattiesburg, Mississippi during April of 2014, to review the implemented Epic AP Beaker. The feedback of Epic AP Beaker was positive in that the integration with other Epic functions is beneficial and aligns 1

33 MIHS Information Technology with one of the architecture and engineering guiding principles. With regard to BB, vendor demos and vendor reference calls were completed for three vendor solutions, SoftBank, SafeTrace and HCLL (Epic does not incorporate a BB solution as part of their application mix). As a result of the Lab Department s due diligence, the following preferences have been identified: Preferences of AP solutions to date are: 1) Epic AP Preferences of BB solutions to date are: 1) SoftBank, 2) SafeTrace, 3) HCLL Recommended Solution Benefits that will be Realized Immediate benefits would include continuity of care due to integration with Clinical Lab Beaker, increased revenue capture, efficiency gains associated with streamlined workflows & advances in functionality. Patient safety improvements with blood administration would add another level of transfusion safety and compliance. Accreditation requirements which require physician transfusion statistics would be met. Recommended Solution Project Management Once Board approval is received and funding identified, implementation is anticipated to commence October 2014 for Blood Bank and February 2015 for Anatomic Pathology. Implementation from purchase to install (including training) is anticipated to take 9 months for each implementation. Recommended Solution Financial Assumptions Cost analysis for AP & BB Equipment Capital Cost Estimate AP Epic Beaker $503,000 BB - SoftBank $530,000 Total $1,033,000 Maintenance Operational Contracts Cost Estimate over 5 years AP System for 5 years $000,000* BB System for 5 years $288,120 Total $288,120 Contract Implementation Support Cost Estimate over 5 months (if needed) AP System for 5 months $70,000 BB System for 5 months $70,000 Total $140,000 *Confirmed that additional Epic maintenance will not be required with the inclusion of AP. Project Management Purchase is anticipated to occur in October, Installment payments, in lieu of paying for the entire project up front, were requested. SoftBank provided the following payment option: Software Licensing Agreement: 25% at contract signing; 25% upon installation of software; 25% upon completion of dictionary set-up; 15% acceptance/live date; and 10% 30 days post live date. Hardware Purchase Agreement: 50% at contract signing and 50% at time of delivery. At that time this business justification document was submitted, Epic Beaker had not provided an installment payment plan. The team is following up with Epic Beaker to secure installment payment. 2

34 MIHS Information Technology Recommended Solution Risks, Sensitivity Analysis As stated above, the biggest impact and risk would be the lack of vendor support post December Other options such as delay or do nothing were considered but were deemed not viable to pursue due to the criticality of the clinical applications that are required to support an organization of MIHS size and breadth of service offerings and maintaining CAP and CLIA accreditation status. 3

35 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.b.ii. Contracts

36 From: Compliance 360 To: Brian Maness Subject: Contract Approval Request: Anatomic Pathology (AP) EPIC Systems Corporation Date: Friday, October 10, :23:45 AM Message Information From Purves, Steve To Maness, Brian; Contract Approval Request: Anatomic Pathology (AP) Subject EPIC Systems Corporation Indicate whether you approve or reject by clicking the Approve or Reject button. Additional Information Add comments as necessary. Approve/Reject Contract Click here to approve or reject the Contract. Contract Information Status Pending Approval Title Anatomic Pathology (AP) Contract Identifier (Travel Type Board - Amendment Dropdown) MIHS Contract Number C Primary Responsible Melton, Christopher C. Party Departments Product/Service Amendment#18 - Anatomic Pathology applications Description Approve expenditure to the contract with EPIC Systems Corporation for Anatomic Pathology applications. Action/Background Approve an expenditure of $573,000 to implement a replacement of the Cerner Anatomic Pathology application in the Laboratory, which will include software, hardware, data conversion, and contract labor. Immediate benefits include continuity of care due to integration with Clinical Lab Beaker, increased revenue capture, efficiency gains associated with streamlined workflow, and advances in functionality. Licensing and modules have already been procured through our existing agreement with Epic Systems Corporation under MIHS Contract#C This approval will enable the already purchased licensed and modules, and other Epic functions, to be integrated with the Anatomical Pathology Beaker applications. Current Cerner Anatomic Pathology application will be at end-of-life on December MIHS offers full service post-surgical and other procedure specimen analysis for Emergency Services, Obstetrics Services, Surgical

37 Services, Trauma and the Burn service lines. The impending lack of application support would place the College of American Pathologists (CAP) and Clinical Laboratory Improvement Amendments (CLIA) accreditations at risk to perform services which would have an adverse impact on both the quality of patient care and revenue. The anticipated annual expense is $573,000. Evaluation Process Notes Category Effective Date 11/1/2014 Expiration Date 10/31/2015 Annual Value $573, Expense/Revenue Expense Budgeted (Budget Bal Dropdown Travel) Yes Procurement Number Primary Vendor EPIC Systems Corporation Responses Member Name Status Comments Maness, Brian D. Approved Ok to route for approval Otis, Dan F. Approved Atwood, Denise A. Approved Gorman, Louis B. Approved Vanaskie, Bill F. Ayres, Michael D. Approved Need the payment schedlue. We may have to find a financing tool. Purves, Steve A. Approved Maness, Brian D. Current

38 MIHS Information Technology Business Justification Document Project Information Name of Proposed Project: Department Leader responsible for this Proposal: Executive Sponsor: Location of Proposed Project: End-of-Life Due-Diligence for Cerner Blood Bank and Anatomical Pathology Applications Carol Heyse - LIS Administrator Mary Travis BB Supervisor Dan Otis Director of Clinical Lab Dr. Hobohm Medical Director for Clinical and Pathology Lab Denise Atwood, VP Hospital Operations MIHS Lab Department Context Description The ability of MIHS to deliver quality care is predicated upon many factors with one being systems applications. Currently MIHS is faced with losing vendor application support for two critical clinical functions, Cerner Classic Blood Bank (BB) & Cerner Classic Anatomical Pathology (AP). Cerner s support of these two applications will cease December As a result of this, MIHS will be unable to accommodate any future enhancement requests, break-fix support, or meet additional Regulatory requirements (it is important to note that this type of support is highly specialized and resources are extremely limited nationwide). From an AP point of view, MIHS offers full service post-surgical and other procedure specimen analysis for Emergency Services, Obstetrics (OB) Services, Surgical Services, Trauma and the Burn service lines which are a requirement for an organization of this size. The impending lack of application support would place the College of American Pathologists (CAP) & Clinical Laboratory Improvement Amendments (CLIA) accreditations at risk to perform this service which would have an adverse impact on both the quality of patient care and undoubtedly revenue. Equally important to the organization are the services of BB. This ancillary service not only supports the various lines of business called out above, but also operates in more of a real-time (sometimes STAT) status that is required to meet the needs of a Level 1 Trauma facility and a Burn service line. In addition to the latter, BB also accommodates OB work-ups, the Level III Nursery, and identical to AP, is accredited by both CAP and CLIA. It is also important to note that BB is also regulated by the Food and Drug Administration (FDA) and by the American Association of Blood Banks (AABB). A budget request was submitted to replace these systems in FY15 (as part of a capital loan), but due to the risk and patient safety concerns, funding is being requested to proceed with replacement beginning in FY15. Market Demand Due-Diligence The Lab Team comprised of Dr. Hobohm, Arlene Arnpriester, Carol Heyse and Mary Travis travelled to Forest General located in Hattiesburg, Mississippi during April of 2014, to review the implemented Epic AP Beaker. The feedback of Epic AP Beaker was positive in that the integration with other Epic functions is beneficial and aligns 1

39 MIHS Information Technology with one of the architecture and engineering guiding principles. With regard to BB, vendor demos and vendor reference calls were completed for three vendor solutions, SoftBank, SafeTrace and HCLL (Epic does not incorporate a BB solution as part of their application mix). As a result of the Lab Department s due diligence, the following preferences have been identified: Preferences of AP solutions to date are: 1) Epic AP Preferences of BB solutions to date are: 1) SoftBank, 2) SafeTrace, 3) HCLL Recommended Solution Benefits that will be Realized Immediate benefits would include continuity of care due to integration with Clinical Lab Beaker, increased revenue capture, efficiency gains associated with streamlined workflows & advances in functionality. Patient safety improvements with blood administration would add another level of transfusion safety and compliance. Accreditation requirements which require physician transfusion statistics would be met. Recommended Solution Project Management Once Board approval is received and funding identified, implementation is anticipated to commence October 2014 for Blood Bank and February 2015 for Anatomic Pathology. Implementation from purchase to install (including training) is anticipated to take 9 months for each implementation. Recommended Solution Financial Assumptions Cost analysis for AP & BB Equipment Capital Cost Estimate AP Epic Beaker $503,000 BB - SoftBank $530,000 Total $1,033,000 Maintenance Operational Contracts Cost Estimate over 5 years AP System for 5 years $000,000* BB System for 5 years $288,120 Total $288,120 Contract Implementation Support Cost Estimate over 5 months (if needed) AP System for 5 months $70,000 BB System for 5 months $70,000 Total $140,000 *Confirmed that additional Epic maintenance will not be required with the inclusion of AP. Project Management Purchase is anticipated to occur in October, Installment payments, in lieu of paying for the entire project up front, were requested. SoftBank provided the following payment option: Software Licensing Agreement: 25% at contract signing; 25% upon installation of software; 25% upon completion of dictionary set-up; 15% acceptance/live date; and 10% 30 days post live date. Hardware Purchase Agreement: 50% at contract signing and 50% at time of delivery. At that time this business justification document was submitted, Epic Beaker had not provided an installment payment plan. The team is following up with Epic Beaker to secure installment payment. 2

40 MIHS Information Technology Recommended Solution Risks, Sensitivity Analysis As stated above, the biggest impact and risk would be the lack of vendor support post December Other options such as delay or do nothing were considered but were deemed not viable to pursue due to the criticality of the clinical applications that are required to support an organization of MIHS size and breadth of service offerings and maintaining CAP and CLIA accreditation status. 3

41 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.b.iii. Contracts

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44 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.b.iv. Contracts

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47 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.b.v. Contracts

48 From: Compliance 360 To: Brian Maness Subject: Contract Approval Request: Medical Eligibility and Verification Services Integrated Health Management Services, LLC Date: Tuesday, October 14, :36:48 AM Message Information From Purves, Steve To Maness, Brian; Contract Approval Request: Medical Eligibility and Subject Verification Services Integrated Health Management Services, LLC Indicate whether you approve or reject by clicking the Approve or Reject button. Additional Information Add comments as necessary. Approve/Reject Contract Click here to approve or reject the Contract. Contract Information Status Pending Approval Title Medical Eligibility and Verification Services Contract Identifier (Travel Type Board - New Contract Dropdown) MIHS Contract Number Primary Responsible Melton, Christopher C. Party Departments PATIENT REGISTRATION ADMITTING Product/Service Medical Eligibility and Verification Services Description Approve new agreement with Integrated Health Management Services for Medical Eligibility and Verification Services. Action/Background The purpose of this agreement is to assist patients applying for all medical assistance programs offered by the State of Arizona. Contractor will provide education to patients regarding Arizona Health Care Cost Containment System (AHCCCS), Department of Economic Security (DES), all Federal Programs including the Federal Marketplace aka Federal Exchange, Supplemental Security Income (SSI) and Medicaid requirements and regulations. Contractor will also assist Maricopa Integrated Health System with enrollment efforts under the Affordable Care Act during the open enrollment periods, as well as Special Enrollment Periods or when identifying any Qualifying Event. The contract term shall become effective upon both parties signature and shall remain in effect for three (3)

49 years, and may extend for additional periods, not to exceed a total term of five (5) years from effective date. Contract Management issued a RFP ( RFP) for Medical Eligibility and Verification Services and Seven (7) responses were evaluated. The Evaluation Committee has recommended awarding the contract to Integrated Health Management Services based on their cost effective ability to meet all of our requirements. The estimated annual expense is $1,300,000. In prior years, medical eligibility and verification services have been provided by Integrated Health Management Services with an annual expense of $1,322,670. Evaluation Process Notes Category Effective Date 12/1/2014 Expiration Date 11/30/2017 Annual Value $1,300, Expense/Revenue Expense Budgeted (Budget Bal Dropdown Travel) Yes Procurement Number RFP Primary Vendor Integrated Health Management Services, LLC Responses Member NameStatus Comments Maness, Brian D. Current Atencio, Lori F. Approved Gorman, Louis B. Approved This is a key vendor in our attempt to ensure eligibility and enrollment Ayres, Michael D. Approved into the AHCCCS program. Purves, Steve A. Approved Maness, Brian D. Current

50 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.b.vi. Contracts

51 Brian Maness From: Compliance 360 Sent: Friday, October 17, :09 PM To: Brian Maness Subject: Contract has been Approved: Amendment #11 Message Information From Purves, Steve To Maness, Brian; Subject Contract has been Approved: Amendment #11 Contract Information Status Pending Approval Title Amendment #11 Contract Identifier (Travel Type Board - Amendment Dropdown) MIHS Contract Number Primary Responsible Maness, Brian D. Party Departments HOSPITAL ADMINISTRATION Product/Service Amendment #11 Description Action/Background Approve Amendment #11 to the contract between Maricopa County Special Health Care District ("MIHS") and District Medical Group ("DMG") to revise Exhibit B, Sections II, III, IV, and Appendix H of the agreement. This amendment revises the Exhibit B, Sections II, III, IV, and Appendix H of the agreement to accommodate necessary changes in the language to reflect clarification on the Chart Completion Performance Standard, additional physician FTEs for the South Central FHC and the CHC, Emergency Department Professional Billing transition from MIHS to DMG, and Clarification in the Meaningful Use Language. I. Exhibit B, Section II, Table II-4 on page 35 (Chart Completion Performance Standard) Financial Impact to MIHS-DMG Contract: None FTE Impact: None II. Exhibit B, Section III, Table III-Ion page 40 (FHC Additional Peds Physicians) Financial Impact to MIHS-DMG Contract: $100,079 FTE Impact: 0.4 FTE Total Net Revenue for MIHS per Approved ProForma: $204,614 III. Exhibit B, Section III, Table on page 50 (CHC Additional Peds Physicians) Financial Impact: $150,119 1

52 FTE Impact: 0.6 FTE Total Net Revenue for MIHS per Approved ProForma: $1,439,285 IV. Exhibit B, Section IV. A. 2 (b) on page 54 (Adult ED Billing) Financial Impact: To Be Determined FTE Impact: None V. Exhibit B, Section IV. B. 2 (b) on page 56 (Pediatric ED Billing) Financial Impact: To Be Determined FTE Impact: None VI. Exhibit B, Section IV. C. 4 on page 58 (Adult ED Triage Billing) Financial Impact: To Be Determined FTE Impact: None VII. Appendix H (Meaningful Use) Financial Impact: None FTE Impact: None Total Financial Impact: $250,198 (+To be determined once the ED baseline for collections is set) (Total Net Revenue for MIHS per Approved Arizona Children's Center Proforma: $1,643,899) Total FTE Impact: Addition of 1.0 FTE Evaluation Process Notes Category Effective Date 11/1/2014 Expiration Date 6/30/2017 Annual Value $250, Expense/Revenue Expense Budgeted (Budget Bal Dropdown Travel) Yes Procurement Number Primary Vendor District Medical Group (DMG) Comments Type Classification Date Employee Comments Approval 10/17/2014 Gorman, Louis B. Approval 10/17/2014 Vanaskie, Bill F. Approval 10/17/2014 Ayres, Michael D. Approval 10/18/2014 Purves, Steve A. 2

53 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.c.i. Governance

54 Board of Directors Chairman Terence McMahon District 5 Maricopa Medical Center 2601 E. Roosevelt Street Phoenix, Arizona Phone: Fax: Vice Chairman Mark Dewane District 2 Maricopa Medical Center 2601 E. Roosevelt Street Phoenix, Arizona Phone: Fax: October 29, 2014 Mr. Andrew McGilvray Executive Secretary Foreign Trade-Zone Board U.S. Department of Commerce 1401 Constitution Avenue, NW, Room Washington, D.C Re: Foreign Trade-Zone-The Cookson Company, 1901 S. Litchfield Road, Goodyear, AZ Parcel Number Director Mary A. Harden, R.N. District 1 Maricopa Medical Center 2601 E. Roosevelt Street Phoenix, Arizona Phone: Fax: Director Susan Gerard District 3 Maricopa Medical Center 2601 E. Roosevelt Street Phoenix, Arizona Phone: Fax: Director Elbert Bicknell District 4 Maricopa Medical Center 2601 E. Roosevelt Street Phoenix, Arizona Phone: Fax: Executive Director of Board Operations and Clerk of the Board Melanie Talbot Maricopa Medical Center 2601 E. Roosevelt Street Phoenix, Arizona Phone: Fax: Dear Mr. McGilvray: The Maricopa County Special Health Care District Board of Directors submits this letter to express no-objection to the proposed FTZ designation for The Cookson Company. We believe that this FTZ designation will result in a positive economic impact for Maricopa County. The no-objection is submitted on behalf of the: Maricopa County Special Health Care District Board of Directors. We are aware that as an activated user of the FTZ, the designated property will be reclassified as a Class 6 property and we are comfortable with revenues that will come from such classification. We support the Application for inclusion of The Cookson Company s facility as a FTZ site within the Greater Maricopa Foreign Trade Zone, Inc. s General-Purpose Zone No Sincerely, Terence M. McMahon Chairman, Board of Directors Maricopa County Special Health Care District

55 FOREIGN TRADE ZONE REQUEST FOR NON-OBJECTION THE COOKSON COMPANY Foreign-Trade Zones (FTZs) are designated areas licensed by the Foreign-Trade Zones Board at which special customs procedures may be used. The FTZ program was established to encourage and expedite U.S. participation in international trade and is a mechanism for companies to manage their duty payments. Foreign-Trade Zones are considered outside the U.S. Customs territory so goods received into FTZs are generally not subject to duties, tariffs, or quotas until, and if, they leave the zone. Public benefits of an FTZ include helping to facilitate international trade, providing special customs procedures to help firms conduct international business, encouraging and facilitating exports, and helping create local employment opportunities. Property Tax Impact In Arizona, Real property and personal property located within the boundaries of an activated foreign-trade zone or subzone are covered by Class 6(1). In accordance with A.R.S , all Class 6 property is taxed at the rate of 5% of assessed valuation. The FTZ applicant must obtain letters of support or non-objection from the affected taxing entities to be submitted along with the application to the Foreign Trade-Zone Board. THE COOKSON COMPANY Summary from the owner s representative, Scott O Conner: Cornell Cookson, as the name on the door now reads, is the merged entity after Cornell Iron Works (Mountaintop, PA), acquired the The Cookson Company, of Phoenix. Both were family owned companies, and Cornell Cookson remains family owned by the Cornell family. It has been owned and operated by the Cornells since before the Civil War! Andrew Cornell is the fifth family member to serve as CEO. They are the largest manufacturer of industrial and commercial rolling doors. Rolling doors are distinct from sectional doors, which are cheaper to make and have shorter life spans. The range of product sizes begins with teller window, and ends up with the rolling door that allows the football field at University of Phoenix Stadium to travel in and out of the building. The new plant, on South Litchfield Road in Goodyear, will, generally speaking, supply everything west of the Mississippi, while the Mountaintop plant will serve the eastern US. Most of the product components are made from raw materials at the plant. However, motors and actuators are imported, principally from Taiwan, but also from China. It is this part of the product mix that generates the need for a foreign trade zone at the plant. Cornell Cookson is the overall brand. The occupant of the plant will be The Cookson Company Inc. The owner is Cactus Realty, LLC, a wholly owned subsidiary of CIW Enterprises, the parent holding company.

56 Facts: Goodyear recently entered into a five year development agreement with The Cookson Company June/July 2014 Adding 110 new jobs for a total job base of $13.2M in payroll. $50k/per year New equipment purchased in Maricopa County - $4.2M Construction costs - $11M. Building on 14.5 acre vacant commercial parcel located at Litchfield Road east of the Goodyear Airport Economic and Revenue Impact prepared by GPEC. Total for Goodyear over five years is estimated at $746K. Total for Maricopa County is estimated at $371K, which is more than the property tax without FTZ approval. See below. The Cookson Company is seeking to designate this property as a Foreign Trade-Zone within the Greater Maricopa Foreign Trade Zone Inc. s Zone No The two affected school districts have approved the FTZ request. City of Goodyear is committed to do so as part of our economic development agreement. Cookson is still waiting on WestMec and MIHS. Property Tax Impact - The Cookson Company Currently, the estimated value for the Cookson property is $508K. Assessment ratio of 16% and 2013 taxes of $11,415 (County $1,042). It is estimated that after the company s investment, the value will increase to approximately $15M for personal and real property. If the FTZ is approved, even with the lower assessment ratio of 5% there will be an increase in revenue to the taxing districts from this property based on the baseline taxes. It is estimated that total tax collections with the FTZ in Year 1 will be $110,553 ($84,747 real property + $25,806 personal property) compared to the 2013 Tax Bill on the property of $11,415. Without FTZ approval, taxes would be approximately $380K ($35k County). However, the revenue analysis prepared by GPEC shows the impact of the FTZ approval will result in an estimated $371K in direct and indirect revenues to Maricopa County.

57 Cookson Door Sales of Arizona Economic and Fiscal Impact Study PREPARED FOR THE CITY OF GOODYEAR BY: ESI CORPORATION 5635 N. Scottsdale Rd Suite 170 (602) April 2014 ESI Corporation January 29, 2009 A i ADESA, Inc. Economic and Fiscal Impact Study

58 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear TABLE OF CONTENTS 1. Background... 1 Introduction... 1 Study Assumptions... 1 Methodology... 2 Fiscal Impact Analysis... 3 Economic Impact Analysis Study Findings... 6 Fiscal Impact Analysis... 6 Economic Impact Analysis... 7 Industrial Linkages... 8 Appendix A Exhibits 1 and 2, Fiscal and Economic Impact Analysis by Year... A 1 April 2014 ESI Corp i

59 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear LIST OF TABLES Table 1 Study Assumptions... 2 Table 2 Cookson Door Annual Expenditures and Employment... 3 Table 3 Cookson Door Fiscal Impact Summary Tax Collections by Year... 6 Table 4 Cookson Door Direct, Indirect and Induced Economic Impact... 7 Table 5 Top 10 Industries Affected by Cookson Door Operations... 8 April 2014 ESI Corp ii

60 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear 1. BACKGROUND INTRODUCTION The Cookson Company is a U.S. leader in the manufacturing of rolling doors for a variety of applications, including residential, commercial, industrial, institutional and retail facilities. The Cookson Door Sales of Arizona has been serving the metro Phoenix market since 1991 by manufacturing and repairing rolling doors. Cookson Door is in an expansion mode and has identified the City of Goodyear as the location for the construction of their new 160,000 square foot facility, to be located on 14 acres south and east of Yuma and Litchfield Roads. Cookson Door is currently located in Tempe, Arizona and employs 155 people, who will be relocating to the new facility. In addition, Cookson Doors will also be hiring additional people and expect to employ 265 people within five years. The average wage for all employees is nearly $45,000 per person and grows to $50,000 by STUDY ASSUMPTIONS It was necessary to make several assumptions in order to provide an analysis of the fiscal and economic impacts resulting from the siting of this business. Due to the proprietary nature of the proposed operation, the information and data provided by the company, through the City staff, is not encompassing of their entire proposed operation. Consequently the economic impact findings are probably understated. Although many of the assumptions used in the analysis were provided by Cookson Doors and the City of Goodyear, some information came from outside sources. The primary assumptions employed in the analysis are summarized in Table 1. April 2014 ESI Corp 1

61 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear Table 1 Study Assumptions Value Data Source Cookson Door Operations Building size 160,000 SF Cookson Door Construction Cos $11,000,000 Cookson Door Employment by 2018: Existing 155 Cookson Door New 110 Cookson Door Total Employment 265 Cookson Door Annual payroll at full employment $13,200,000 Cookson Door Existing Equipment $940,000 Cookson Door New Equipment $4,182,000 Cookson Door Electric usage (5 years) $551,978 Cookson Door Tax Rates State of Arizona Construction TPT 5.6% Arizona Department of Revenue City of Goodyear Construction TPT 3.5% Arizona Department of Revenue City of Goodyear State Shared TPT Revenue 1.3% Arizona Department of Revenue City of Goodyear Personal Property Tax (P&S) $1.90 Maricopa County Treasurer's Office City of Goodyear Utility and Franchise Tax 4.5% APS Other Facility will be located in a FTZ Maricopa County Assessor's Office Personal Property falls under "other class" 10 yr life Maricopa County Assessor's Office Real and personal property tax assessment ratio 5% Maricopa County Assessor's Office METHODOLOGY The methodology employed in this analysis was straightforward and intuitive. Fiscal and economic impacts were measured over a five year time horizon. Construction of the building will take place over a seven month timeframe in 2014, with the facility operational beginning December The impacts that were analyzed included: construction, equipment, payroll of personnel, and utility taxes. Inputs to the economic and fiscal impact modeling are noted in Table 2 and show expenditures by year. April 2014 ESI Corp 2

62 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear When Cookson Door begins operations in Goodyear the end of 2014, they will employ 163 people with an average annual wage of $44,049. By 2018 they will employ 265 people with an annual payroll of $13.2 million amounting to an average wage of nearly $49,811. Table 2 Cookson Door Annual Expenditures and Employment Nominal Total (5 yrs) 2014 (1 mo) Total Jobs 1, Existing Jobs $ New Jobs $ Total Payroll $46,163,333 $763,333 $9,300,000 $10,850,000 $12,050,000 $13,200,000 Existing Payroll $31,083,333 $583,333 $7,250,000 $7,500,000 $7,750,000 $8,000,000 New Payroll $15,080,000 $180,000 $2,050,000 $3,350,000 $4,300,000 $5,200,000 Building Construction $11,000,000 $11,000,000 $0 $0 $0 $0 Existing Equipment $940,000 $940,000 New Equipment $4,182,000 $3,582,000 $0 $0 $300,000 $300,000 Electricity Cost $551,978 $10,283 $130,797 $134,498 $136,966 $139,434 Over the five years of operations, the combined total of expenditures for payroll, acquisition of new equipment, utilities, and construction is $61.8 million. A methodological breakdown of the fiscal and economic impacts of this analysis is summarized below. Fiscal Impact Analysis The fiscal impact analysis provides an understanding of the direct sales tax impact derived by the City of Goodyear. Tax revenue was estimated to be generated from four sources: construction sales tax, personal property tax, real property tax, and utility tax. Estimating construction sales tax was found by following the standard procedure for calculating sales taxes and state shared revenue. Personal property taxes were based on the original value of the new equipment and the depreciated value of the existing equipment, and applying the depreciation and assessment ratio formulas and the City s tax rate. Real and personal property tax collections lag by one year. Utility tax was derived by applying the appropriate city s tax rate. Economic Impact Analysis The economic impact analysis takes the direct inputs of the fiscal analysis (construction value and payroll) and measures the indirect and inducted impacts (multiplier effect) that would likely accrue to an area. ESI Corp utilizes the IMPLAN econometric model 1 to effectively estimate the economic impact of Cookson Door's potential expansion. The IMPLAN model is a computerized input output model which analyzes regions by county. Regional information gathered from federal data sets is used to develop custom models for each individual study area. Study areas typically include single counties, multi county 1 IMPLAN stands for Impact Analysis for Planning. The software was created and is distributed by the Minnesota IMPLAN Group (MIG) out of Stillwater, Minnesota. April 2014 ESI Corp 3

63 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear regions, one or more states, or the entire national economy. For modeling purposes, Cookson Door was classified as metal products manufacturer. The IMPLAN econometric model operates by estimating the direct impacts, indirect impacts, and induced impacts of specific economic activity: Direct economic impacts are those attributable to the initial economic activity. For example, an operation with ten full time employees creates ten direct jobs. Indirect economic impacts are those economic activities undertaken by vendors and suppliers within the supply chain of the direct activity as a result of the initial economic activity. For example, suppliers of goods, materials, and services used in the direct activities produce indirect economic impacts. Induced economic impacts result from the spending of wages paid to employees in local industries involved in direct and indirect activities. These wages, which are analogous to household spending, support additional local activities, such as the purchase of goods and services within the region. In turn, that portion of spending that accrues to local businesses and employees is once again recirculated within the local economy, producing additional activity. The following chart is a depiction of the modeling process and the subsequent analysis. The model measures the amount of economic activity in each round of spending until all of the spending within the local region has been leaked outside the study area. The categories of impacts which were analyzed in the modeling process include: Employment impact this represents the full and part time jobs, including self employed. Earnings impact wages paid to personnel associated with the industry. Includes total wage and salary including benefits of the direct, indirect and induced employees Economic Output this represents the spending or gross receipts for goods or services generated by the facilities operations. April 2014 ESI Corp 4

64 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear Spending estimates supplied by Cookson Door and the City of Goodyear staff were used as inputs to the economic impact model; specifically, the number of employees, associated payroll, as well as the value of construction, equipment acquisition, and utility spending. For the fiscal impact model, estimates for real and personal property, utility usage, and estimated construction costs were utilized. April 2014 ESI Corp 5

65 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear 2. STUDY FINDINGS FISCAL IMPACT ANALYSIS Fiscal impacts (tax collections) of the operation are presented in Table 3. As can be seen, impacts are measured in detail over a five year time horizon, with an aggregate total for the five years. Fiscal impacts were broken down by source of tax revenue: construction, personal property tax (equipment), real property tax (building), and utility tax. It is estimated that construction of Cookson Door manufacturing and sales facility in Goodyear will generate $235,508 in construction sales tax to the city. When examining the ongoing operations over 5 years, property tax on the building will generate 37,602, personal property tax on equipment is estimated to yield $12,079 and electric utility tax $24,839. Total tax collections over the 5 years are estimated at $311,029. Exhibit 1, appended to this report, provides a year by year analysis of the fiscal impacts. Table 3 Cookson Door Fiscal Impact Summary Tax Collections by Year Nominal Total (5 yrs) Construction Sales Tax $235,508 $235,508 $0 $0 $0 $0 Personal Property Tax $13,079 $0 $3,762 $3,411 $3,048 $2,858 Real Property Tax $37,602 $0 $8,360 $8,862 $9,659 $10,722 Utility Tax $24,839 $463 $5,886 $6,052 $6,163 $6,275 Totals $311,029 $235,971 $18,008 $18,325 $18,871 $19,854 Note: Property tax collections lag by one year; 2014 utilities is for one month April 2014 ESI Corp 6

66 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear ECONOMIC IMPACT ANALYSIS ESI measured the direct, indirect and induced economic impacts of construction and Cookson Door's operation on the local economy. Impacts included the construction of the facility, number of employees and compensation of employees. Table 4 below is a summary of the total economic impact. Exhibit 2 appended to this report provides a year by year analysis of the economic impacts. During construction of the building, an estimated 63 direct jobs will be created for a total payroll of $4.1 million. When including the direct and induced jobs generated from the construction activity there are another 52 jobs supported, for a total of 115 jobs. Output of the local construction industry would be boosted by an estimated $17.7 million. The planned operational spending (payroll and equipment) by Cookson Door in Goodyear implies additional contributions to the local economy. Over the 5 years of operational spending, the total direct payroll equals $45.9 million with an employment level of 1,128 cumulative jobs. When examining the combined totals of direct, indirect and induced impacts, 1,991 jobs are estimated to be supported over the five years with total economic output of $284.8 million. Equipment acquisition will generate a $2.2 million in economic output, supporting a total of 12 jobs. Exhibit 2, appended to this report, provides a year by year analysis of the economic impacts. Table 4 Cookson Door Direct, Indirect and Induced Economic Impact Construction Economic Impact 2014 Earnings Jobs Output Direct $4,142, $11,000,000 Indirect and Induced $2,648, $6,718,120 Total $6,790, $17,718,120 Operational Economic Impact of Payroll ( ) Earnings Jobs Output Direct $45,998,333 1,128 $174,147,718 Indirect and Induced $41,658, $112,750,069 Total $87,656,855 1,991 $284,821,295 Operational Economic Impacts of Equipment Acquisition ( ) Earnings Jobs Output Direct $326,941 6 $1,302,693 Indirect and Induced $326,941 6 $899,685 Total $652, $2,202,378 Total Economic Impact ( ) Earnings Jobs Output Direct $50,467,904 1,197 $186,450,411 Indirect and Induced $44,633, $120,367,874 Source: IMPLAN Grand Total $95,100,184 2,119 $304,741,793 April 2014 ESI Corp 7

67 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear Industrial Linkages Industries buy goods and services in the local marketplace, which contributes to the multiplier effect that stimulates secondary spending and employment. It is interesting to note which industries in the region will be the primary beneficiaries of Cookson Door's operational spending, and thus generate additional spending. The top 10 industries affected by Cookson Door are noted in Table 5 and include a combination of industries including metal product manufacturing, food services, to private hospitals. Table 5 Top 10 Industries Affected by Cookson Door Operations Description Ornamental and architectural metal products manufacturing Food services and drinking places Wholesale trade businesses Real estate establishments Accounting, tax preparation, bookkeeping, and payroll services Employment services Services to buildings and dwellings Securities, commodity contracts, investments, and related activities Offices of physicians, dentists, and other health practitioners Private hospitals Source: IMPLAN April 2014 ESI Corp 8

68 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear APPENDIX A EXHIBITS 1 AND 2, FISCAL AND ECONOMIC IMPACT ANALYSIS BY YEAR April 2014 ESI Corp A 1

69 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear EXHIBIT 1 COOKSON DOOR FISCAL IMPACT ANALYSIS Nominal Total CONSTRUCTION TAX GENERATION Sales Tax Construction Costs $11,000,000 $11,000,000 $0 $0 $0 $0 Taxable Amount $6,721,820 $6,721,820 $0 $0 $0 $0 State Sales Tax $376,422 $376,422 $0 $0 $0 $0 Goodyear Share of State Sales Taxes $245 $245 $0 $0 $0 $0 Goodyear Sales Tax $235,264 $235,264 $0 $0 $0 $0 Total Construction Tax Collections $235,508 $235,508 $0 $0 $0 $0 PROPERTY TAX GENERATION Real Property Tax (Building) (collections lag by 1 yr) Estimated Value of Building $0 $11,000,000 $11,660,000 $12,709,400 $14,107,434 Assessor's Valuation (80%) $0 $8,800,000 $9,328,000 $10,167,520 $11,285,947 Assessment Ratio 5% $0 $440,000 $466,400 $508,376 $564,297 Total Property Tax Collections $37,602 $0 $8,360 $8,862 $9,659 $10,722 Personal Property Tax (Equipment) (collections lag by 1 yr) Existing Equipment (RCLND) $0 $700,290 $617,240 $521,970 $443,110 New Equipment (RCNLD) $0 $3,259,620 $2,973,060 $2,686,500 $2,565,480 Total Equipment Value (RCLND) $0 $3,959,910 $3,590,300 $3,208,470 $3,008,590 Assessment Ratio 5% $0 $197,996 $179,515 $160,424 $150,430 Total Personal Property Tax Collections $13,079 $0 $3,762 $3,411 $3,048 $2,858 UTILITY TAX GENERATION Electric Generation Revenue (1 mo) Utility amount $551,978 $10,283 $130,797 $134,498 $136,966 $139,434 Goodyear Utility Tax Rate 4.5% 4.5% 4.5% 4.5% 4.5% Total Utility Tax Collections $24,839 $463 $5,886 $6,052 $6,163 $6,275 TOTAL TAX COLLECTIONS $311,029 $235,971 $18,008 $18,325 $18,871 $19,854 April 2014 ESI Corp A 2

70 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear EXHIBIT 2 COOKSON DOOR ECONOMIC IMPACT ANALYSIS Nominal Total OPERATIONAL IMPACTS (1 mo) Earnings from Operation Estimated Direct Output $172,071,226 $188, $35,209,401 $41,077,635 $45,620,783 $49,974,634 Total Direct Earnings $45,998,333 $598,333 $9,300,000 $10,850,000 $12,050,000 $13,200,000 Indirect + Induced Earnings $41,134,592 $47,630 $8,700,164 $9,944,570 $10,825,137 $11,617,092 Total Direct, Indirect, and Induced Earnings $87,132,926 $645,963 $18,000,164 $20,794,570 $22,875,137 $24,817,092 Jobs from Operations Estimated Direct Output $172,071,226 $188,772 $35,209,401 $41,077,635 $45,620,783 $49,974,634 Direct Job Creation 1, Indirect + Induced Job Creation Total Job Creation 1, Output from Operations Estimated Direct Output $172,071,226 $188,772 $35,209,401 $41,077,635 $45,620,783 $49,974,634 Indirect and Induced Output $112,750,069 $130,846 $23,944,618 $27,166,524 $29,627,493 $31,880,588 Total Direct, Indirect, and Induced Output $284,821,295 $319,618 $59,154,020 $68,244,159 $75,248,276 $81,855,222 CONSTRUCTION IMPACTS Earnings from Construction Construction Expenditures $11,000,000 $11,000,000 $0 $0 $0 $0 Total Direct Earnings $4,142,630 $4,142,630 $0 $0 $0 $0 Indirect/Induced Earnings $2,648,329 $2,648,329 $0 $0 $0 $0 Total Direct, Indirect, and Induced Earnings $6,790,959 $6,790,959 $0 $0 $0 $0 Jobs from Construction Construction Expenditures $11,000,000 $11,000,000 $0 $0 $0 $0 Total Direct Jobs Indirect/Induced Jobs Total Direct, Indirect, and Induced Jobs Total Output from Construction Construction Expenditures $11,000,000 $11,000,000 $0 $0 $0 $0 Indirect and Induced Output $6,718,120 $6,718,120 $0 $0 $0 $0 Total Direct, Indirect, and Induced Output $17,718,120 $17,718,120 $0 $0 $0 $0 April 2014 ESI Corp A 3

71 Cookson Door Sales of Arizona Economic and Fiscal Impact Study City of Goodyear EXHIBIT 2 COOKSON DOORS ECONOMIC IMPACT ANALYSIS (Continued) Nominal Total NEW EQUIPMENT IMPACTS Earnings from Equipment Equipment Expenditures $4,182,000 $3,582,000 $0 $0 $300,000 $300, Local Purchase Percentage 31.15% 31.15% 31.15% 31.15% 31.15% Total Direct Earnings $326,941 $282,840 $0 $0 $22,277 $21,824 Indirect + Induced Earnings $325,429 $281,531 $0 $0 $22,174 $21,723 Total Direct, Indirect, and Induced Earnings $652,370 $564,371 $0 $0 $44,452 $43,548 Jobs from Equipment Equipment Expenditures $4,182,000 $3,582,000 $0 $0 $300,000 $300,000 Local Purchase Percentage 31.15% 31.15% 31.15% 31.15% 31.15% Total Direct Jobs Indirect/Induced Jobs Total Direct, Indirect, and Induced Jobs Output from Equipment Equipment Expenditures $4,182,000 $3,582,000 $0 $0 $300,000 $300,000 Local Purchase Percentage 31.15% 31.15% 31.15% 31.15% 31.15% Indirect and Induced Output $899,685 $777,139 $0 $0 $61,803 $60,744 Total Direct, Indirect, and Induced Output $2,202,378 $1,892,932 $0 $0 $155,253 $154,194 TOTAL DIRECT, INDIRECT AND INDUCED ECONOMIC IMPACTS Jobs 2, Payroll $94,576,254 $8,001,293 $18,000,164 $20,794,570 $22,919,588 $24,860,640 Output $304,741,793 $19,930,669 $59,154,020 $68,244,159 $75,403,529 $82,009,416 April 2014 ESI Corp A 4

72 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.c.ii. Governance

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75 AMENDED AND RESTATED BYLAWS OF MERCY MARICOPA INTEGRATED CARE, an Arizona nonprofit corporation (as adopted, 2013amended through, 2014) ARTICLE I ORGANIZATION 1.1 Name. The name of the corporation is Mercy Maricopa Integrated Care (the Corporation ). The Corporation also may do business under one or more trade names approved by the Managing Member as designated in these Bylaws. 1.2 Principal Office and Other Offices. The initial known place of business of the Corporation is 4350 E. Cotton Center Blvd., Bldg. D, Phoenix, Arizona The Corporation may change its principal office, or adopt other and additional offices, either within or outside Arizona, as the Managing Member may designate from time to time. 1.3 Corporate Seal. No instrument executed by or on behalf of the Corporation shall require a corporate seal for validity, but if a corporate seal is used, the Members, as defined in Section 3.1, shall approve its form. 1.4 Statutory Agent. The name and address of the initial statutory agent of the Corporation is CSB Service Entity LLC, whose street address is 2800 N. Central Avenue, Suite 1200, Phoenix, Arizona The Managing Member may change the statutory agent of the Corporation at any time. ARTICLE II PURPOSES AND CHARACTER OF AFFAIRS 2.1 Purposes. The Corporation shall have the purposes set out in its Articles of Incorporation, as amended from time to time (the Articles ). 2.2 Initial Character of Affairs. The Corporation is formed to provide physical and behavioral health care services on an integrated basis to Medicaid eligible adults with serious mental illness, and to operate as the Regional Behavioral Health Authority ( RBHA ) to coordinate the delivery of health care services to eligible persons in Maricopa County, Arizona, and to perform all obligations under the RBHA Contracts as defined in Section 2 of the Articles. The Corporation also may transact any and all other lawful business for which an insurance corporation may be incorporated under the laws of the State of Arizona, as they may be amended from time to time, subject to the provisions of Arizona Revised Statutes Title 20, including, but not limited to, as a Health Care Services Organization under Chapter 4, Article 9, of said Title 20. This statement of initial intent shall not limit the exact scope of activities that the Corporation ultimately conducts so long as the Corporation engages only in activities permitted { } 1

76 by nonprofit corporations under Arizona law that constitute charitable and educational purposes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the Code ). 2.3 Exempt Organization Restrictions. As required under the Code: (a) No part of the net earnings of the Corporation shall inure to the benefit of, or be distributable to, its members, trustees, officers, or other private persons, except that the Corporation shall be authorized and empowered to pay reasonable compensation for services rendered and to make payments and distributions in furtherance of the purposes of the Corporation. No substantial part of the activities of the Corporation shall be the carrying on of propaganda, or otherwise attempting to influence legislation, and the Corporation shall not participate in, or intervene in (including the publishing or distribution of statements) any political campaign on behalf of any candidate for public office. Notwithstanding any other provision of these Bylaws, the Corporation shall not carry on any other activities not permitted to be carried on (i) by an organization exempt from federal income tax under Section 501(c)(3) of the Code, or (ii) by an organization, contributions to which are deductible under Section 170(c)(2) of the Code, or corresponding section of any future federal tax code. (b) Upon the dissolution of the Corporation, assets shall be distributed for one or more exempt purposes within the meaning of Section 501(c)(3) of the Code, or corresponding section of any future federal tax code, or shall be distributed to the federal government, or to a state or local government, for a public purpose. 2.4 Grants, Awards, and Payments by the Corporation. Notwithstanding any other provision of these Bylaws, from time to time the Corporation may make grants or other awards to exempt organizations under Section 501(c)(3) of the Code, or a governmental entity whose functions include the provision of healthcare, which entities may be, or be affiliated with or for the benefit of, one or more Members, provided that any such grants or awards are made in accordance with all applicable laws and in furtherance of the purposes of the Corporation. The Corporation may also make payments to individuals or entities which provide goods or services to the Corporation, pursuant to written contracts entered into by the Corporation, provided that such contracts are in furtherance of the purposes of the Corporation. 2.5 Distribution Options. (a) The Corporation may pay distributions to Members in advance of dissolution of the Corporation as provided in Section 2 of the Articles, if permitted under applicable law and the RBHA Contracts. A Member may direct that the Corporation pay any or all of such interim (pre-dissolution) distributions to an assignee of the Member s membership interest in the Corporation, or to a person or entity to which the Member has assigned some or all of its right to distributions, if any, as permitted under a membership agreement to which all Members are parties (a Membership Agreement ). From time to time, a Member also may (i) request or accept awards or grants from the Corporation; or (ii) accept payments for goods and/or services provided under one or more separate contracts with the Corporation; or (iii) direct the Corporation to accrue some or all distributions otherwise payable to the Member, for payment on dissolution of the Corporation (a Dissolution Event ). In a Dissolution Event, if permitted by applicable law, amounts accrued for a Member in connection with Member distributions but not { } 2

77 previously paid will be paid first, prior to paying other payments or distributions to other Members, or as provided in a Membership Agreement. (b) In no event shall the Corporation make any distribution to a Member unless the Corporation determines that such distribution is permitted by applicable law. If the Managing Member, after consultation with counsel for the Corporation and/or the affected Member, makes a good faith determination that a Member is not legally permitted to receive an interim distribution, then the affected Member shall not be permitted to make any election or otherwise exercise any control over the sum of money or other property intended for distribution, and such sum of money or other property shall instead be held by the Corporation for the benefit of the affected Member until such time as a Dissolution Event occurs, or such Member is otherwise legally permitted to receive a distribution. (c) Distributions not paid to a Member pursuant to Section 2.5(a) or not distributable by the Corporation under Section 2.5(b) shall be held by the Corporation in one or more Dissolution Reserve Accounts as defined in a Membership Agreement. The foregoing notwithstanding, upon dissolution, each Member is entitled to receive (or have received) the same amount for each distribution percentage point (as reflected in a Membership Agreement, as such may be amended from time-to-time, and as further explained in this Section. The required adjustment/equalizing payment is hereinafter referred to as a True-Up. In determining the distributions to be made at dissolution and any required True-Up adjustments thereto: (i) the amount of any interim distributions previously received; (ii) the principal amount of any Dissolution Reserve Account of such Member; and (iii) any awards or grants received by or for the benefit of such Member from the Corporation during its term, shall be considered and included. Other payments received by a Member for goods or services provided to the Corporation pursuant to contract (e.g., pursuant to a behavioral health services provider contract) shall not be considered or included in the True-Up calculation. By way of illustration only, if Member A has received $10,000 in grants and $20,000 in interim distributions and has a 10% distribution percentage, then Member A has received a total of $30,000 for each distribution percentage. If all other Members have received $5,000 for each distribution percentage, then Member A is entitled to a $20,000 adjusting/equalizing True-Up distribution ($2,000 x 10 distribution percentage points) before further distributions are made to the Members in accordance with their respective distribution percentages as reflected in a Membership Agreement, as such may be amended from time to time. (d) Upon dissolution, all funds held in a Dissolution Reserve Account for the benefit of a Member (including interest thereon at the Prime Rate as defined in a Membership Agreement from the date of deposit or credit to such account through the date of purchase of the Member s Interest or distribution to the Member upon dissolution) will be paid first, prior to determination of the value of the Member s Interest for purchase, or in dissolution, prior to other distributions to other Members and to the Members generally, or as provided in a Membership Agreement. The intent of this Section is to assure that a Member which does not receive a distribution from the Corporation on the same basis and at the same time as that applied to the { } 3

78 other Members is treated fairly and in a manner economically comparable to the manner in which the other Members are treated. ARTICLE III RIGHTS AND OBLIGATIONS OF MEMBERS 3.1 Members. The Corporation has four (4) members (collectively, the Members, and each, a Member ), as follows: Southwest Catholic Healthcare Network Corporation dba Mercy Care ( Mercy Care ) 4350 E. Cotton Center Blvd., Bldg. D Phoenix, Arizona Dignity Health dba St. Joseph s Hospital and Medical Center ( Dignity ) 3030 N. Central Avenue, Suite 1402 Phoenix, Arizona Maricopa County Special Health Care District ( District ) 2601 E. Roosevelt Phoenix, Arizona Carondelet Health Network ( Carondelet ) 2202 N. Forbes Blvd. Tucson, Arizona Each Member has agreed to make the initial financial contribution to the Corporation as listed on Schedule Qualifications of Members. A Member of the Corporation must be either (a) recognized as an exempt entity under Section 501(c)(3) of the Code, or (b) a governmental entity whose functions include the provision of healthcare. 3.3 Additional Members or Classes of Members. The Corporation initially shall have one (1) class of Members. The Members may decide to admit new Members, or to create additional classes of memberships for organizations qualified for membership and working with the Corporation or affiliated with its goals, on such terms and conditions, and with such rights and obligations, as the Members shall determine. However, no new Member may be admitted to the Corporation, and no existing Member may have its rights diminished or obligations increased, by creation of a new class of Members without unanimous consent of all existing Members. Thus, a new Member, or any new class of Members, will not have any voting rights as a Member, or any ability to appoint directors to the Board, unless all existing Members agree to admission of the new Member or to establishment of a new class of Members with such rights and privileges. The foregoing notwithstanding, any Member may transfer its interest, in whole or in part, to an affiliate which meets the qualifications set forth in Section 3.2 of these Bylaws (including, without limitation, a nonprofit foundation or other nonprofit entity created for the sole purpose of furthering the purposes and mission of the Member, including supporting or furthering, through grants or otherwise, the provision of healthcare services to the medically underserved), and such affiliate shall be admitted as an additional or alternative Member of the Corporation, holding all or part of the Member s interest, voting power, and right to the Member s portion of any distributions as the Member and its affiliate may agree in writing. Further, the affiliate shall not have any purpose that is inconsistent with the purpose of the Corporation or the Member that designates such affiliate as an additional or alternative Member of the Corporation. { } 4

79 3.4 No Stock; Transfer of Membership Prohibited. The Corporation shall not have capital stock. In addition, membership is not assignable or transferable, by operation of law or otherwise, except as otherwise provided in the Articles, these Bylaws, or in a Membership Agreement. 3.5 Special Assessments. The Members may impose special assessments from time to time on Members to provide capital required for operations or to defray unanticipated expenses of the Corporation only as permitted under a Membership Agreement. 3.6 Resignation. Any Member may resign, for any reason, by submitting a written resignation to the Corporation. Resignation shall not, however, relieve a Member of the obligation to pay any assessments or other charges accrued and unpaid prior to submitting the resignation. 3.7 Managing Member. The Members have appointed Mercy Care as the Managing Member. The Managing Member may not be changed without unanimous consent of the Members. The Managing Member shall have those powers specified in these Bylaws, and such other and additional powers as may be approved or ratified by a majority vote of the Members. 3.8 Decisions Reserved to the Managing Member. The following decisions are reserved to the Managing Member and do not require any further approval or vote of the Members, or as otherwise provided in a Membership Agreement: service areas; (a) expansion of the Corporation s business activities to other products and (b) determining that a distribution shall be made to Members eligible to receive interim distributions, and setting aside funds for a distribution on dissolution or otherwise for Members not eligible to receive interim distributions, pursuant to the formula or process for setting distributions set forth in a Membership Agreement; (c) merger, consolidation with, or acquisition of another entity or organization, the formation of a new corporation, partnership, or other business entity, and the dissolution and distribution of any corporation, partnership or other business entity in which the Corporation is financially interested; (d) borrowing of money in excess of $5,000, for any purpose, or a series of borrowings for a single purpose, the cumulative sum of which exceeds that amount; (e) approval of the standards, policies and directives for management of the investment of funds of any health plan ( Plan ) operated by or for the Corporation; and (f) selection of the plan administrator ( Administrator ) of any Plan. 3.9 Decisions Reserved to the Members. The following decisions (the Reserved Powers ) are reserved to the Members, although the Members may agree to allow some or all of these Reserved Powers to be exercised by the Managing Member, the Board, or by the Administrator of any Plan, as appropriate, in certain, specific, or general cases: { } 5

80 (a) (b) any Capital Budget; (c) approval or disapproval of an annual Strategic Plan and Audit Plan; approval, disapproval or modification of the annual Operating Budget and approval and removal of President and CEO; (d) review and consultation regarding succession planning for senior leadership, including CEO, COO, CFO, and CMO (or equivalents); (e) approval of contracts with payors; (f) approval of provider payment policies in effect from time to time 1 ; (g)(e) selection of the Corporation or any Plan auditors; (h)(f) approval of the Business Disruption Plan; (i)(g) amendments, restatements, or changes to the Articles or these Bylaws; (j)(h) appointment of one or more compliance officers and a compliance committee to oversee Plan compliance activities specifically for Medicare or other government healthcare Plans as and to the extent required by law; and (k)(i) establishment or amendment of the philosophy, the objectives and purposes, or the long-range goals of a Plan; (l)(j) establishing policy and procedures for the functioning of the operations of the Corporation, including, if not otherwise specifically addressed in these Bylaws, policies regarding the size and types of expenditures, obligations or contracts that require Managing Member, Member, or Board approval or approvals; (m)(k) extension of the term of the Corporation as stated in the Articles, or any amendment of the Articles which makes the duration of the Corporation perpetual; and (n)(l) approval or disapproval of the purchase by the Corporation of the interest of any Member and the terms of such repurchase, except as provided in a Membership Agreement. ARTICLE IV MEMBER VOTING AND MEETINGS 4.1 Voting Power of Members. All matters submitted to a vote of the Members, whether as a Reserved Power or otherwise, shall be determined based on each Member having one (1) vote, or as otherwise provided in a Membership Agreement. 1 Deletion of clauses (e) and (f), and subsequent renumbering, by Amendment #1, February, 2014 { } 6

81 4.2 Meetings of Members; Annual Meeting. Meetings of the Members may be called by or at the request of the managing Managing member Member or at least two (2) Members entitled to vote. The Board and Board Chair may request that the Members hold a meeting but calling any meeting of the Members requires the act or consent of at least two (2) Members. Meetings of the Members may be held separately, by written consent, or by mail ballot or electronic means as provided in Section 4.3 of these Bylaws, or may be held together with meetings of the Board. The Members shall designate one meeting as the annual meeting of the Members, at which the Members shall elect the members of the Board not appointed by a Member under Section 5.3 of these Bylaws, to serve terms ending at the next annual meeting of the Members. 4.3 Voting by Mail or Electronic Means; Proxies Permitted. Members may vote by mail, by ballot, by electronic means, or by proxy. 4.4 Quorum. A majority of the voting Members then in good standing, provided that each of Carondelet, Dignity, and District, if then in good standing, are present in person whether present at any meeting or represented by proxy, shall constitute a quorum for the transaction of business. If a quorum is not present at the meeting, a majority of the Members entitled to vote present at the meeting may adjourn and reconvene the meeting from time to time without further notice. 4.5 Notice of Meetings. Notice of any actual meeting of the Members shall be given to each Member at least forty-eight (48) hours but not more than sixty (60) days prior to the date of the meeting by a writing delivered personally, mailed, or sent by fax or other electronic means, such as , to the Members. If mailed, such notice shall be deemed to be delivered when deposited, postage prepaid, with the United States Postal Service, addressed to the Member at the Member s address as it appears on the records of the Corporation. If faxed or sent by other electronic means, such notices shall be deemed delivered when confirmation of receipt is received by the sending party. In addition to the notice of meeting, at least forty-eight (48) hours prior to the meeting, each Member shall be sent an agenda and materials required for the meeting. Unless waived by all Members entitled to vote, only items on the agenda may be considered at the meeting. The attendance of a Member at a meeting, in person or represented by proxy, shall constitute a waiver of notice of such meeting, except in the case of a Member who attends a meeting for the express purpose of objecting to the transaction of any business because the meeting is not lawfully called or convened. Notice of any meeting or of consideration of any matter not on the agenda may be waived by a Member, whether in advance, during, or after a meeting. 4.6 Manner of Acting. A majority of the votes of all Members, whether present or represented at a meeting, shall be necessary for the adoption of any action, unless a greater proportion is required by law or these Bylaws. 4.7 Permitted Attendance by Other Means of Communication. Any Member may participate in a meeting by any means of communication by which all persons representing Members participating in the meeting may communicate with each other simultaneously. Any Member participating in a meeting by such method shall be considered present in person at the meeting. { } 7

82 4.8 Action by Written Consent. Any action which may be taken at any meeting of the Members may be taken without a meeting if a consent in writing, setting forth the action so taken, is distributed to all of the Members at least forty-eight (48) hours in advance (unless waived by all of the Members, including through a waiver in the consent itself) and is signed by Members representing a majority of the voting power of all the Members entitled to vote. ARTICLE V BOARD OF DIRECTORS 5.1 General Powers. Subject to the limitations of the Articles, these Bylaws, the Reserved Powers reserved to the Members, and Arizona and federal law, the Board shall make and determine policy for the Corporation, manage its affairs, and exercise (or direct the exercise of) all corporate powers of the Corporation. The Board is the governing body with oversight of the Corporation, and is responsible for establishing policies and objectives, ensuring the availability of adequate financial resources, and overseeing organizational performance. 5.2 Limitations on Authority. No director, officer, committee member, employee, or agent of the Corporation shall: (a) authorize or allow any corporate funds to be expended for any purposes other than as set forth in the Articles, these Bylaws, or Policies and Procedures approved pursuant to Section 3.9(l) of these Bylaws or for reasonably incidental purposes, or cause or permit the Corporation to engage in any activity not consistent with the Corporation s purposes; (b) take any action in governing or operating the Corporation that would require the Corporation to act in a manner that is not consistent with its charitable status or not in furtherance of the Corporation s charitable purposes, or which would jeopardize the exempt status of the Corporation under Section 501(c)(3) of the Code. Each Member acknowledges that Mercy Care, Dignity, and Carondelet at all times will act, and will cause the Corporation at all times to act, consistent with the Ethical and Religious Directives for Catholic Health Care Services, as promulgated and as the same may be amended from time to time by the United States Conference of Catholic Bishops (the Religious Directives ) and otherwise as deemed appropriate by them to further the intent and purposes of the Religious Directives; provided, however, that no Member will have any cause of action or other remedy for any effect, financial or otherwise, of a decision made or vote taken, or not made or taken, by any Member, director, officer, committee member, employee, or agent of the Corporation with reference to the Religious Directives; (c) knowingly do any act which would make it impossible for the Corporation to carry on its regular business, except as provided in these Bylaws, or knowingly do any act prohibited by Arizona or federal law, the Articles, or these Bylaws; (d) possess property of the Corporation, or assign rights in specific property of the Corporation, other than for a Corporation purpose; (e) knowingly perform any corporate act that would subject any director, Member, officer, or agent of the Corporation to personal liability; or { } 8

83 (f) cause the Corporation to acquire any equity or debt securities of any director, officer, or agent of the Corporation or any affiliate of a director, officer, or agent of the Corporation. 5.1 Number; Appointment. Pursuant to A.R.S (B)(6), the Board shall consist of at least five (5) but no more than fifteen (15) directors, all of whom shall be either appointed by an individual Member or, in the case of Peer directors as defined below, elected by the Members collectively. The Board shall consist of equal numbers of representatives of District, Carondelet, Dignity, and persons who are or who have been active participants in the Maricopa County Behavioral Health System, or members of the families of such persons ( Peers ). Temporary deviations shall be permitted as directors resign or are removed, or to allow for a transition between outgoing and new directors, but at least twenty five percent (25%) of the membership of the Board shall be consist of Peers. Mercy Care shall not have representatives on the Board. Directors who are representatives of a Member shall be designated by the Member, and may be replaced at any time, and a new director designated, by the Member appointing the director. Peer directors shall be elected by the Members, and may be replaced at any time, and a new Peer director elected, by the Members collectively. The Members collectively also may elect additional directors representing community or healthcare provider interests in addition to the Member-designated and Peer directors, so long as Peer directors represent at least twenty five percent (25%) of the Board membership, each Member appointing directors has an equal number of representatives on the Board, and the Members appointing directors collectively hold at least a majority of the Board seats. In addition, the President/CEO of the Corporation, if not already a director, shall be an ex officio non-voting participant in Board meetings but, as a non-voting participant, shall not be counted as a director representative of District, Carondelet, or Dignity or in determining that Peer directors represent at least twenty five percent (25%) of the membership of the Board. The Members collectively also may designate additional non-voting participants in Board meetings representing community, provider, or other interests involved with the Maricopa County Behavioral Health System, but such non-voting participants also shall not be counted as a director representative of District, Carondelet, or Dignity or in determining that Peer directors represent at least twenty five percent (25%) of the membership of the Board Voting Rights; Attendance. Each director shall have one (1) vote on all matters submitted to a vote of the Board, and equal and full responsibilities as members of the Board. The Board may adopt attendance policies and standards for excused absences which shall apply to all directors, the violation of which shall be deemed to constitute resignation or removal from the Board. 5.3 Terms; No Term Limits. Directors appointed by Members are designated for three (3) year terms, from one annual meeting of the Members to the next. Peer directors are designated for one (1) year terms, from one annual meeting of the Members to the next. Directors may serve multiple consecutive terms, without limit. 5.4 Resignation. A director may resign at any time, either by oral tender of resignation at any meeting of the Board or by giving written notice at any time to the 2 Both sentences added by Amendment #2, April, 2014 { } 9

84 Corporation. A director appointed by Dignity, District, or Carondelet who is removed by the Member appointing the director shall be deemed to have resigned effective on the date specified by the Member. Any resignation by a director shall take effect prospectively at the time specified in the notice and, unless otherwise specified in the notice, the acceptance of such resignation shall not be necessary to make it effective. If no time is specified, the resignation is effective upon receipt by the Corporation. 5.5 Regular and Special Meetings. Unless otherwise provided by resolution of the Board, adopting a schedule for meetings for no more than one (1) year in advance and for which no additional notice shall be required, all meetings of the Board may be called by or at the request of a majority of the Board or by the Board Chair, Vice Chair, or President, and shall be held at such place and time as the notice of meeting shall specify. 5.6 Notice. Notice of meetings of the Board other than previously-scheduled meetings shall be given at least five (5) but not more than sixty (60) days prior to the date of the meeting by a writing delivered personally, mailed, or sent by electronic means to each director. If mailed, such notice shall be deemed to be delivered when deposited, postage prepaid, with the United States Postal Service, addressed to the director at the director s address as it appears on the records of the Corporation. If sent electronically, such notices shall be deemed delivered when the sending party receives confirmation of receipt. A director s attendance at a meeting shall constitute a waiver of notice of such meeting, except where a director at the beginning of the meeting or promptly on arrival objects to holding or transacting business at the meeting, and thereafter does not vote for or assent to action taken at the meeting. Unless otherwise required by law or specified by the Articles or the Bylaws, neither the business to be transacted nor the purpose of any meeting of the Board need be specified in the notice or the waiver of notice of such meeting. Any or all of the directors may waive notice of any meeting. 5.7 Quorum; Attendance by Directors; Proxy Voting. A majority of the number of directors then in office shall constitute a quorum for the transaction of business of any meeting of the Board. The directors may continue to transact business during a meeting at which a quorum is initially present, regardless of the withdrawal of directors, if any action is approved by at least the number of directors required to approve the action under these Bylaws, the Articles, or applicable law. Directors may vote by mail, ballot, , or electronic means. Directors also may vote by proxy, but the proxy holder must be another director. 5.8 Manner of Acting. The act of a majority of the number of directors then in office (and not those present or represented at a meeting) shall be required for the Board to act, unless Arizona or federal law, the Articles, or these Bylaws requires a greater number. 5.9 Compensation. Directors shall not receive compensation, but may receive reimbursement for their expenses, if any, of service as directors, including any expenses of attending meetings. The Members may establish a policy for the reimbursement of expenses. No director shall be precluded from serving the Corporation in any other capacity and receiving compensation for such other services. The Members shall establish the amount or rate of such compensation and reimbursement. { } 10

85 5.10 Action without Meeting. Any action required or permitted at a meeting of the Board may be taken without a meeting, without prior notice, and without a vote, pursuant to A.R.S , as amended from time to time, which currently requires action by all of the directors. Action taken in this manner is effective as provided in A.R.S , unless the consent specifies a different effective date. A consent signed in this manner has the effect of a vote at a proper meeting of the Board. Consents may be executed by fax, scanned, or electronic signatures, or by transmission of an , text message, or other communication inscribed on a tangible medium or that is stored in an electronic or other medium and that is retrievable in perceivable form from the director indicating approval of a written consent Permitted Attendance by Other Means of Communication. Any director may participate in a meeting by any means of communication (such as conference telephone call, or webcast) by which all directors participating may communicate with each other simultaneously. Any director participating in a meeting by such method shall be considered present in person at the meeting Minutes. Written minutes of the business conducted at meetings of the Board shall be kept, open for inspection by any director or Member at all reasonable times Presumption of Assent. A director who is present at a meeting of the Board at which action on any matter is taken shall be presumed to have assented to the action taken, unless the director s dissent shall be entered in the minutes of the meeting, or unless the director files a written dissent to such action with the Secretary of the meeting before its adjournment, or shall file such dissent in writing with the Corporation by 5:00 p.m. on the next business day after the adjournment of the meeting. Such right to dissent shall not apply to a director who voted in favor of such action. ARTICLE VI OFFICERS 6.1 Offices and Officers; Terms. The Members shall appoint a Board Chair, Vice Chair, Secretary, and Treasurer of the Corporation, each of whom serves at the pleasure of the Members. The Board may designate any additional offices of the Corporation, and choose the person or persons to service in each office, each of whom serves at the pleasure of the Board, subject to the Reserved Powers of the Members. The Members, or the Board, may combine any number of offices for holding by the same person, and any individual may hold more than one office simultaneously (such as a Secretary/Treasurer); in addition, the Board may appoint officers designated by the Members to serve in other offices designated by the Board at the same time. Officers appointed by the Board must be directors of the Corporation, shall be elected annually for one (1) year terms, and may serve multiple terms, without limit. Officers designated by the Members do not need to be directors and also may serve multiple terms, without limit. 6.2 Removal; Vacancies. Any officer appointed by the Board may be removed, with or without cause, at any time by the Board or by the Members. Any officer designated by the Members may be removed, with or without cause, at any time only by the Members. Any such removal shall be without prejudice to the contract rights, if any, of the officers so removed or of the Corporation. The Board may fill a vacancy in any office appointed or created by the Board, { } 11

86 however caused, at any time for the unexpired portion of the term of such office. The Members also may fill a vacancy in any office appointed by the Members, however caused, at any time. 6.3 Resignation. Any officer may resign at any time by giving written notice to the Corporation. A resignation shall take effect prospectively at the time specified in the notice and, unless otherwise specified in the notice, the acceptance of such resignation shall not be necessary to make it effective. Any resignation is without prejudice to the contract rights, if any, of the Corporation. 6.4 Compensation and Expenses. Officers shall not receive any compensation for services as an officer, but may receive reimbursement for their expenses, if any, on behalf of the Corporation. However, an officer may serve the Corporation in another capacity, as an employee, independent contractor, or otherwise, and receive compensation for such other services, so long as approved by the Members. No officer shall be prevented from receiving a salary or reimbursement of expenses by fact that he or she is also a director, committee member, agent, or employee of the Corporation. However, if an officer or director of the Corporation is to receive compensation from the Corporation in any capacity other than reimbursement of expenses, then: (a) the individuals on the Board that approve compensation arrangements shall follow the conflicting interest provisions of these Bylaws; (b) any compensation arrangement must be approved by the Board in advance of paying compensation; (c) the Board shall document in writing the date and terms of each approved compensation arrangement; (d) the Board shall record in writing the decision made by each individual who decided or voted on each compensation arrangement; (e) the Board will approve compensation arrangements based on information on compensation paid by similarly-situated taxable or tax-exempt organizations, current compensation surveys complied by independent firms, or actual written offers from similarlysituated organizations; and (f) the Board will record in writing both the information on which the Board relied to base the compensation decision as well as its source. 6.5 Authority. The Board, in determining the offices and officers each year reserved to the Board under these Bylaws, may designate which officers shall have primary authority for which areas or actions, and may designate alternates or multiple officers in order of priority to carry out particular activities or corporate functions. However, unless otherwise determined by the Board, any officer have the power and authority to sign documents and instruments requiring execution on behalf of the Corporation, subject to policies established by the Board; to preside at meetings of the Board; and to keep minutes, records, and financial records of the Corporation. { } 12

87 ARTICLE VII COMMITTEES 7.1 Executive Committee and Other Standing Committees. The Corporation shall have an Executive Committee, a Governance Committee, and the other standing committees (the Standing Committees ) as provided on Schedule 7.1 as then in effect. The Members entitled to appoint directors shall determine the members and authority of the Executive Committee, all subcommittees of the Executive Committee (whether or not Standing Committees), and the Governance Committee, and the authority of all other Standing Committees; the members of the other Standing Committees shall be appointed by the Board. Voting members of the Executive Committee and Standing Committees designated as subcommittees of the Executive Committee 3 must be directors appointed by the Members entitled to appoint directors, except that the CEO of the Corporation shall be a non-voting ex officio member of the Executive Committee; Peer directors are not eligible to serve on the Executive Committee or any subcommittees of the Executive Committee. Each Standing Committee shall include at least one (1) director appointed by each Member entitled to appoint directors. The CEO, and other officers, may serve as voting members of the Governance Committee. 7.2 Additional Committees. The Board, by resolution, may designate and appoint one or more additional committees with authority over specific areas of management and responsibility not already allocated to the a Standing Committees by the Members entitled to appoint directors or in these Bylaws as the Board, acting as a body, may determine. The Board also may designate and appoint one or more advisory committees, working groups, or ad hoc committees to carry out such tasks or investigate such issues as the Board may determine. Members of such Board-designated committees, including any officers of a committee, need not be directors; however, each committee authorized by the Board shall include at least one (1) director. 7.3 Limitation on Committee Authority. No committee shall have authority to: (a) authorize distributions; (b) approve or propose to Members any action that the Arizona Nonprofit Corporation Act requires to be approved by Members; (c) fill vacancies on the Board or on any committee, or appoint officers, which the Board is authorized to fill or to appoint; or (d) fix the compensation of directors for serving on the Board or any committee of the Board. 7.4 Removal; Authority of Board. The body appointing a member of a committee (the Members entitled to appoint directors for Standing Committees, the Board for Board-created committees) may remove any member of a committee, or in the case of a Board-created committee, may dissolve such a committee, at any time, with or without cause. In addition, any 3 Deleted by Amendment #2, April, 2014 { } 13

88 action of a Board-created committee is subject to amendment, modification, or repeal at the next annual or regular meeting of the Board, and any action of a Standing Committee is subject to amendment, modification, or repeal by action of the Members under their Reserved Powers. 7.5 Term. Each member of a Board-created committee shall continue as such until the next annual meeting of the Board, unless the Board establishes a shorter term in its resolution creating the committee, removes the member, or terminates the committee. Each member of a Standing Committee appointed by the Members shall continue in office until removed by the Members. Committee members may serve consecutive terms without limitation. 7.6 Procedures. The procedures established in these Bylaws for meetings of the Board regarding notice, quorum, voting, presence, and other such matters shall apply to meetings of committees as applicable. ARTICLE VIII CONFLICTING INTEREST TRANSACTIONS 8.1 Loans to Directors and Officers Prohibited. The Corporation shall not lend money to nor use its credit to assist its directors, officers, or agents, whether or not employees. Any director or officer who assents to or participates in the making of any such loan or use of credit shall be liable to the Corporation for the cost of such use of credit or for the amount of such loan until the repayment of the loan. 8.2 Conflicting Interests Transactions. Any proposed or effected transaction involving the Corporation, or any subsidiary or substantial affiliate of the Corporation, in which a Member, director, officer, or committee member, or a person related to such person (an Interested Person ) has a beneficial financial interest or any other link to the transaction that would reasonably be expected to exert an influence on an Interested Person s judgment, is a Conflicting Interest transaction. Conflicting Interest transactions also include transactions involving (a) entities with which an Interested Person is affiliated, (b) persons who control entities with which an Interested Person is affiliated, and (c) persons who are general partners, principals, or employers of an Interested Person. Interested Persons must disclose Conflicting Interests to the Board where the conflicting interest transaction is brought before the Board or of a significance normally brought before the Board, unless the Interested Person is not a party to the contract creating the Conflicting Interest and has a duty of confidentiality regarding the information (such as an attorney). If the Interested Person cannot make full disclosure, then he or she must disclose the existence and nature of the conflicting interest, inform the Board of the confidential relationship, and cannot play any direct or indirect role in the deliberations or vote on the matter. 8.3 Procedures. A Qualified Director is a director or committee member who does not have a Conflicting Interest nor any familial, financial, professional, or employment relationship with an Interested Person if that relationship, under the circumstances, would reasonably be expected to exert an influence when voting on the Conflicting Interest transaction. A majority of the Qualified Directors, but in no event less than two, must approve any Conflicting Interest transaction. A majority of the Qualified Directors, provided at least two, is a quorum for consideration of the transaction; Interested Persons need not be included for purposes { } 14

89 of determining a quorum. Approval of a Conflicting Interest transaction may occur in advance or after the transaction has occurred. 8.4 Exempt Organization Transactions. Persons appointed as directors, officers, or committee members of the Corporation by the Members, or a person related to such person, also may hold a position with a Member engaging in a transaction with the Corporation. So long as the Member involved is either an organization exempt under Section 501(c)(3) of the Code or a governmental entity whose functions include the provision of healthcare, and provided that the person has no personal financial stake in a transaction (e.g., a decision by the Managing Member to make a distribution to all eligible Members pursuant to Section 3.8(b) above, or a decision by a Member to vote for or against a special assessment pursuant to Section 3.5 above), the Member or person appointed by the Member is not required to recuse himself or herself, and the Member or person may participate in the decision-making process. 8.5 Conflict of Interest Policies. The Corporation shall adopt and revise, from time to time as appropriate, policies to inform and survey all directors, key employees, and members of committees annually for disclosure of situations potentially giving rise to Conflicting Interests in matters involving the Corporation and to avoid conflicts of interest in Corporation matters. The Board (or a committee designated by the Board) shall review the policies and reporting requirements at appropriate intervals based on the Corporation s activities and developments in nonprofit entity compliance standards. ARTICLE IX GENERAL PROVISIONS 9.1 Amendment or Repeal. These Bylaws may be adopted initially by a vote of the Members, and may be altered, amended or repealed, and substitute, restated, or new Bylaws may be adopted only by a vote of the Members. 9.2 Gifts. The Board may accept on behalf of the Corporation any contribution, gift, bequest, or devise for the general purposes or for any special purpose of the Corporation. 9.3 Grants and Loans. Subject to the provisions of Section 2.4 of these Bylaws, the Corporation may make grants and loans to any of its Members or affiliates of Members provided that all Members consent to such grant or loan on a case-by-case basis. All grants and loans shall be made to a specific Member who must be either recognized as an exempt entity under Section 501(c)(3) of the Code or a governmental entity whose functions include the provision of healthcare for purposes reasonably intended to further the goals, purpose, and mission of the Member and of the Corporation, and particularly the goal of providing healthcare services to traditionally underserved populations in the community. Grants and loans may be made on such terms as the Members may deem to be reasonable under the circumstances, with or without interest and subject to other conditions as the Members believe will serve the purposes of the Corporation and the purposes of the recipient Member. By way of example and not as a limitation, the Corporation may make grants, or loans, to Members ineligible to receive distributions from the Corporation to allow such Members the opportunity to accomplish charitable or public purposes for which early deployment of such funds, in advance of the { } 15

90 dissolution of the Corporation, would serve the purposes of the Corporation and the recipient Member. 9.4 Fiscal Year. The fiscal year of the Corporation shall be from July 1 to June 30 of the following calendar year. 9.5 Required Communication with Members. The Board and management of the Corporation periodically will brief the Members on the retention of Corporation counsel and shall not engage any attorneys to represent the Corporation who are reasonably determined by the Members to be unacceptable. Any conflicts of interest involving a member of the Board of Directors shall be promptly disclosed to the Members. The Members reserve the right to retain independent counsel whenever it deems such action would be in the best interests of the Corporation. In addition, any actions reserved to the Members in the Corporation s Articles shall be reserved to the Members notwithstanding any provision of these Bylaws to the contrary. 9.6 Construction and Interpretation. The Members shall have the power and authority to interpret these Bylaws. Any reasonable interpretation of these Bylaws by the Members shall be conclusive and binding on the Corporation and any third party. In interpreting these Bylaws, words in the present tense include the future as well as the present; words in the singular number include the plural and words in the plural number include the singular; words of the masculine gender include the feminine and the neuter gender, and words of the feminine gender include the masculine and the neuter gender. 9.7 Procedure. Meetings of the Corporation s Board and committees shall be conducted in a manner which permits a majority to accomplish the group s mission within a reasonable period of time, while allowing the minority a reasonable opportunity to express its views. Every member at a meeting has rights equal to every other member. The will of the majority shall prevail, but the minority must be heard and have its rights protected. Finally, only one topic will be considered at a time. If these principles do not resolve any procedural question regarding conduct of a meeting, the most current edition of Robert s Rules of Order shall be consulted. 9.8 Indemnification. The Corporation shall indemnify, defend, and hold harmless, to the fullest extent allowed by Arizona law as it now exists or may be amended, any person who incurs liability to any person for any action taken, or any failure to take any action as an officer, director, employee, or agent of the Corporation. This indemnification shall be mandatory in all circumstances in which indemnification is permitted by Arizona law. Any repeal or modification of this provision shall be prospective only, and shall not affect adversely any right or protection of an officer, director, employee, or agent of the Corporation with respect to any act or omission occurring prior to the time of such repeal or modification. 9.9 Public Financial Statements. The RBHA Contracts require that the Corporation provide specified quarterly financial statements for posting on the website of the Division of Behavioral Health Services of the Arizona Department of Health Services ( However, if this requirement is dropped from the RBHA Contracts, then the Corporation shall make its annual financial statements, including at least a balance sheet, annual income statement, and most recent Return of Organization Exempt from Tax (IRS { } 16

91 Form 990), available to the public by posting on the Corporation s website, or in another method acceptable under the Code Promissory Note. The Promissory Note referred to in Schedule 3.1 to these Bylaws shall be unsecured and non-interest-bearing, and shall be due and payable in full one (1) year after the implementation of the RBHA Contract with the Arizona Department of Health Services. CERTIFICATION I certify that I am the Secretary of Mercy Maricopa Integrated Care, an Arizona nonprofit corporation (the Corporation ), and have been designated by the Board of Directors of the Corporation to be the officer directed to prepare minutes of the directors meetings and for authenticating records of the Corporation; that the foregoing Amended and Restated Bylaws have been adopted as the Bylaws of the Corporation effective as of, , and that these Bylaws, as of the date of this Certificate, have not been repealed, altered, amended, restated, or superseded, and remain in full force and effect. DATED, Secretary { } 17

92 SCHEDULE 3.1 INITIAL FINANCIAL CONTRIBUTIONS OF MEMBERS As of, September 9, 2013 MEMBER FINANCIAL CONTRIBUTION Mercy Care $80,000,000 District $5,000, cash and $5,000, Promissory Note Dignity 0 Carondelet 0 { }

93 As of, SCHEDULE 7.1 STANDING COMMITTEES The Corporation shall have the following Standing Committees, including the following committees (in bold), subcommittees (underlined), sub-subcommittees (in italics), and sub-subsubcommittees (bold italics): I. Executive Committee: The members of the Executive Committee and of subcommittees of the Executive Committee shall be appointed as provided in Section 7.1 of these Bylaws. The Executive Committee shall have all the powers and authority of the Board, and shall act as the Board s compensation committee and nominating committee if the Board has not appointed separate committees to review executive compensation and to provide nominations for directors and officers. The Members have designated the Executive Committee to exercise all powers and authority regarding financial, audit, compensation, and compliance matters referred to the Executive Committee and its subcommittees, and the decisions of the Executive Committee regarding such matters shall be final and not require Board review or approval. A. Subcommittees of the Executive Committee: 1. Finance Committee: The Finance Committee s primary responsibility is to continuously review and make recommendations for improvement, where needed, concerning the Corporation s fiscal affairs. The Committee provides recommendations to the Executive Committee and to the Governance Committee on the annual budget and business plan. The Finance Committee meets 12 times per year. 2. Audit & Compliance Committee: The Audit & Compliance Committee is responsible for overseeing the Corporation s audit and compliance functions in support of legal and regulatory requirements as well as quality of care and ethical business practices. The Committee reviews, monitors, and ensures compliance with the organization's policies, procedures, and practices. The Audit & Compliance Committee meets monthly through the Corporation s first year of operations, and thereafter as necessary. II. Governance Committee: The Governance Committee is the central internal governance pathway for the Corporation s response to the Arizona Department of Health Services contract to provide acute and behavioral health care services on an integrated basis to Medicaid eligible adults with serious mental illness, and to operate as the Regional Behavioral Health Authority ( RBHA ) to coordinate the delivery of healthcare services to eligible persons in Maricopa County, Arizona. The Governance Committee is the principal forum through which concerns about the services and programs are systematically addressed and, performance is reviewed, and changes made as necessary as the Committee oversees an extensive committee structure, reviewing and harmonizing the work of the numerous committees that report, directly or indirectly, to the Committee. The Governance Committee is designed, in part, to directly support the transformation goals of the State of Arizona and the Corporation, and will include { } 1

94 community and stakeholder representatives currently involved in planning the State s transformation efforts wherever possible. The Governance Committee meets 6 times per year. A. Subcommittees of the Governance Committee: 1. Implementation Committee: The Implementation Committee ensures the smooth and seamless implementation of programs, which includes monitoring progress on milestones, achievement of goals, and deliverables. The Committee makes recommendations related to necessary resources, systems and procedures necessary to ensure a successful implementation. The Implementation Committee meets weekly. 2. Integrated Clinical Care and Quality Management Committee: The ICC/QM Committee s primary purpose is to integrate clinical care and quality activities throughout the organization, among its departments, contractors, and stakeholders. The Committee oversees clinical and quality activities and makes recommendations to the Governance Committee. The ICC/QM Committee meets monthly. (a) Committees of the ICC/QM Committee: (i) Quality Management Committee: The QM Committee evaluates quality improvement activities and performance measure data to provide recommendations for improvement of member care and services. The Committee also reviews and approves studies, standards, clinical guidelines, and trends identified in measured outcomes as well as results of provider medical record reviews and satisfaction surveys. The QM Committee meets monthly. Committee: A. Committees of the Quality Management (1) Quality Improvement Committee: The QI Committee advises the Chief Medical Officer and Chief Operating Officer on quality improvement strategies. The Committee oversees compliance with AHCCCS and Medicare quality improvement strategies. Additional responsibilities include Performance Improvement Projects, AHCCCS performance measures, HEDIS, member and provider satisfaction surveys, health literacy, cultural competency, member grievances, and service performance measures. The QI Committee meets biweekly. (2) Credentialing/Recredentialing Committee: The Credentialing/Recredentialing Committee evaluates credentialing and recredentialing information to recommend selection, approval, or denial of healthcare providers for participation in the network. The Committee also reviews policies related to credentialing/recredentialing and analyzes health facility site reviews and medical record reviews. The Credentialing/Recredentialing Committee meets monthly. (3) Children s QM Committee: The Children s QM Committee evaluates quality improvement activities and performance measure data to improve the quality of care provided to children. The Committee also reviews trends identified in { } 2

95 measured outcomes as well as results of CFT reviews. The Children s QM Committee meets 6 times per year. (4) Adult QM Committee: The Adult QM Committee evaluates quality improvement activities and performance measure data to provide recommendations related to the services provided to adults with a serious mental illness and adults with a general mental health/substance abuse issue. The Committee also reviews the results of provider medical record reviews, fidelity audits (ACT, supported employment, consumer operated services, and peer support) and satisfaction surveys. The Adult QM Committee meets 6 times per year. (5) Peer Review Committee: The Peer Review Committee makes recommendations to the Chief Medical Officer related to actions to be taken in response to quality of care reviews and investigations related to specific providers. The findings from this Committee are presented to the Credentialing/Recredentialing Committee for consideration/actions. The Peer Review Committee meets quarterly. (6) Delegation Oversight Committee: The Delegation Oversight Committee provides recommendations to the QM Committee on a variety of activities, communications, program interventions, and services. The Committee also reviews outreach plans, cultural competency plans, and education materials to assess content and readability. In addition, the Committee provides advice on performance improvement and quality improvement projects. The Delegation Oversight Committee is also responsible for prevention programs and satisfaction survey tools. (ii) Continuous Innovation Committee: The Continuous Innovation Committee strives to identify cutting-edge solutions and best practices to improve programs, processes, and systems. The Committee is responsible for researching and evaluating emerging innovations, resources, and tools that provide value to member care and services. The Continuous Innovation Committee meets 6 times per year. Committee: A. Committees of the Continuous Innovation (1) Adult Provider Workgroup: The purpose of the Adult Provider Workgroup is to educate providers on services delivered to adult members. The Workgroup also offers an opportunity for providers to network, communicate, and facilitate real-time discussions, and bring up issues or concerns. The Adult Provider Workgroup meets 6 times per year. (2) Children s Provider Workgroup: The purpose the Children s Provider Workgroup is to provide education and information on services related to children and adolescent behavioral health services. The Workgroup also offers an opportunity for providers to network, communicate, and facilitate real-time discussions, and bring up issues or concerns. The Children s Provider Workgroup meets 6 times per year. (3) Provider Integration Group: The Provider Integration Group consists of physical and behavioral health providers who review member- { } 3

96 specific cases to identify and resolve systemic issues related to integration of care. The Group also makes recommendations to overcome cultural barriers and promote consistency in practices across all providers. The Provider Integration Group shall meet as necessary. (iii) Medical Management/Utilization Management Committee: The Medical Management/Utilization Management Committee evaluates new technologies, utilization management decisions, and clinical review criteria for approval, adoption, and implementation. The Committee also reviews and makes recommendations for performance improvement activities related to trends in complaints, grievances and appeals, and quality of care concerns, as well as overseeing provider medical record reviews and satisfaction surveys. The Medical Management/Utilization Management Committee meets monthly. Management Committee: A. Committees of the Medical Management/Utilization (1) Utilization Management Intra- Departmental Committee: The UM Intra-Departmental Committee is a multi-disciplinary committee made up of representatives from within the Corporation, including Provider Services, Member Services, Medical Management, and Utilization Management. The Committee reviews trends in complaints, grievances and appeals, potential quality of care issues, and trends in utilization and develops initiatives to make improvements to internal processes. The Utilization Management Intra-Department Committee meets biweekly. (2) Pharmacy and Therapeutics Committee: The P&T Committee advises and makes recommendations regarding the Corporation s pharmacy program. The Committee s responsibilities include developing and updating the Corporation s Preferred Drug List and reviewing drug utilization data as well as evaluating member and provider educational programs and materials. The Committee also evaluates new technology related to pharmacy and reviews information related to contracted pharmacy services. The Pharmacy and Therapeutics Committee meets 4 times per year. (3) Member Advisory Committee: The Member Advisory Committee also serves as a committee of the Quality Management Committee. 3. Member Advocacy Committee: The Member Advocacy Committee meets is to advise, assist, and give guidance to the Corporation related to clinical programs and the service delivery system. The vision of the Committee is to provide the Corporation with input and feedback on behavioral health programs and to advocate for individuals with behavioral health needs. The Member Advocacy Committee meets 6 times a year. 4. Youth Leadership Council: The Youth Leadership Council is a forum for youth to provide leadership and input into the behavioral health system. The Council provides recommendations to the Governance Committee on program development, implementation, and enhancement to promote recovery and resiliency in children, youth, and families. The Youth Leadership Council meets monthly. 5. CLAS Committee: The Cultural and Linguistically Appropriate Services Committee is responsible for overseeing the Corporation s adherence to CLAS standards and { } 4

97 development of initiatives to reduce health disparities. Committee representatives include specialty providers, community representatives, peers, and family members. The CLAS Committee meets monthly. { } 5

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100 JEFFREY P. JACKSON, CPA FINANCIAL PROFESSIONAL / VICE PRESIDENT OF FINANCE Action-oriented leader with a strong track record of performance in a multi-facility healthcare organization Utilize keen analysis, insights, and team approach to drive organizational improvements and implementation of best practices. Outstanding interpersonal skills, capable of managing multiple and complex issues and managing staff to peak performance. PROFESSIONAL EXPERIENCE Dignity Health St. Joseph s Hospital and Medical Center Vice President of Financial Operations - April 2013 Present Oversee operations of hospital finance, case management, materials management and biomedical departments. Responsible for managing the vendor relationship and ensuring key performance metrics are obtained for outsourced revenue cycle functions including admitting, medical records, billing and collections. Work collaboratively with executive leadership team on development of long-term strategic plan and review of joint venture and service line growth opportunities. Notable achievements: Oversaw the conversion of the finance section of the clinical informatics systems to Cerner. Developed decision support team to serve the Arizona market. Worked with all levels of management to open St. Joseph s Westgate Hospital. Dignity Health Chandler Regional Medical Center/Mercy Gilbert Medical Center Controller & Director of Finance - January 2007 April 2013 Direct daily operations of hospital finance teams at both hospitals including six direct reports and seven indirect reports. Oversee the preparation of monthly financial statements and supporting schedules. Provide direction and guidance on multiple multi-disciplinary committees. Coordinate staff efforts for internal and external financial and process audits. Actively assist frontline managers in clinical operations. Prepare and present monthly narrative to corporate office, including detailed analysis and trends impacting key drivers of financial performance. Present monthly financial results to the hospitals Finance Committee and Foundation Board of Directors. Notable achievements: Implemented management reporting tool to assist frontline managers in controlling their expenses. Developed financial assistance teams designed to coach clinical directors in budget and productivity management. Developed numerous reports to identify trends and potential cost saving opportunities.

101 JEFFREY P. JACKSON, CPA page 2 SMI Imaging, LLC Interim CFO - August 2010 November 2011 Directed the operations of the finance function including Accounts Payable and Payroll. Developed monthly operating budgets for the 28 imaging centers. Prepared detailed analysis on future acquisitions and center expansions. Presented financial performance to the physician owners and board of directors. Notable achievements: Led team in general ledger software conversion to meet the needs of enterprise growth. Implemented center level financial statements to assist in strategic planning. Implemented statistical and productivity measures to improve efficiency and profitability; Worked with lending institutions to establish lines of credit to ensure cash availability for operations and capital expenditures. Dignity Health Chandler Regional Medical Center Financial Operations Manager - October 1999 December 2006 Managed weekly operating income and statistical projection process and reporting. Worked closely with unit managers to develop operational budgets and monitor monthly performance. Led schedule preparation for annual external audit and Medicare cost report. Managed annual operating budget creation process. Prepared monthly database for corporate office and reconciled corporate reports to internal statements. Presented hospital census and statistical data to the Finance Committee. Scottsdale Community College Managerial Accounting Instructor - August 2004 May 2013 (Concurrent) Instruct students on the key concepts of managerial accounting including operating and capital budgeting, cost structure and behavior, cost-volume-profit analysis, labor, materials and overhead variance analysis. Mentor students considering careers and accounting and/or healthcare administration. Clinical Diagnostic Radiology and Nuclear Medicine, Ltd. Phoenix, Arizona Controller - December 1998 October 1999 Prepared and presented financial statements to physician shareholders. Served as member of the Finance Committee of the board of directors. Reviewed and analyzed weekly income projections and monthly detailed income reports. Wood Lane Industries Bowling Green, Ohio Staff Accountant - January 1996 October 1998 Wood County Board of Mental Retardation and Developmental Disabilities Bowling Green, Ohio Residential Assistant - April 1993 December 1995 United States Marine Corp Camp Pendleton, California Sergeant - May 1986 December 1992

102 JEFFREY P. JACKSON, CPA page 3 EDUCATION Master of Business Administration, Bowling Green State University, Master of Accountancy, Bowling Green State University, Bachelor of Science in Business Administration, Bowling Green State University, Magna Cum Laude CERTIFICATIONS AND PROFESSIONAL AFFILIATIONS Certified Public Accountant since 1999 (Licensed in Ohio) Chandler Gilbert YMCA Board of Directors August Chandler Gilbert YMCA Finance Committee Chair August

103 MICHAEL S. ZENOBI HEALTHCARE EXECUTIVE PROFILE MBA / SIX-SIGMA CERTIFIED Revenue Optimization and Cost Containment through Analytics Accomplished, forward-thinking healthcare executive with notable public sector Medicaid and Medicare managed care program. Driving force for developing integrated healthcare delivery initiatives, developing and executing high-impact solutions to maximize cash flow, operational performance, and boost efficiencies. Strategic Planning & Implementation Cost Reduction and Containment Operations Analysis / Process Redesign Budget Administration / Management Integrated Delivery Solutions Turnaround / Crisis Management PROFESSIONAL EXPERIENCE MARICOPA INTEGRATED HEALTH SYSTEM (MIHS) Phoenix, AZ Vice President Managed Care Operations (August 2014 to Present) Working under the direction of the CFO, lead the implementation of expanded managed care service lines for MIHS and assist MIHS in establishing policies, procedures and functions that will direct the systems managed-care contracts and coordinate clinically integrated services with payer and provider partners. Responsibilities Include: Collaborating with Sr. Leaders and Physician partners, develops and implements the Managed Care strategy leading to the establishment of a process to negotiate, operationalize the systems managed care contracts. Functions as an internal consultant and subject matter expert on the new managed care service line and organization to build consensus for implementation among key stakeholders and leaders. Oversees organizational development, management and tasks required to advance clinical integration strategies, provider networks and engagement activities and payer relationships. Provide assistance in the development and implementation for: clinical integration of strategies to improve health outcomes; the patient experience; and healthcare value including risk stratification methods; data management and tracking; case management across the care continuum; development of care models for high risk populations including; and feedback to physicians on outcomes and utilization UNIVERSITY OF ARIZONA HEALTH NETWORK (UAHN) Tucson, AZ Chief Financial Officer (January 2013 to July 2014) Serve as an executive leader for the UAHN s health plan operations overseeing all Finance and Accounting functions with interim responsibilities for Information Services, Contracting and Network Development, Medicare and Commercial (risk, TPA and management services Selected Contributions: Introduced and implemented provider master service agreements allowing for simplified product and service amendments. Developed and implementing risk adjustment to ensure the plan will optimize the revenues associated with the health care services provided to our membership. Also supports the appropriate collection of member health diagnoses ensuring the appropriate coordination of care through case management and member outreach. Manages financial relationship with internal, senior leadership, Board of Directors, MIHS leadership and related business relationships.

104 MICHAEL S. ZENOBI Page 2 DELOITTE CONSULTING, LLP Phoenix, AZ Senior Manager (January 2012 to November 2012) Served as a senior manager in Deloitte s Health Plan practice and one of Deloitte s financial subject matter expert in public sector managed care programs. Selected Contributions: Research and development of financial modeling and applications supporting state and health plan efforts to meet the ACA Health Information Exchange (HIX) requirements. Responsible for the development of a health plan Medicaid revenue and cost containment solutions that identifies opportunities through compliance reviews, membership SSI conversion potential, risk adjustment and member encounter maximization analyses. UNITED COMMUNITY & STATE (UNITED HEALTHCARE, FORMERLY AMERICHOICE) Phoenix, AZ Director Business Development (2008 to 2011) Evaluate the financial and operational viability of State and Federal based programs procurements. The evaluations encompass actuarial based methodologies, competitive analysis through SEC and regulatory filings and internal experience providing a thorough presentation of the RFP risks and opportunities. Selected Contributions: Successfully led the development of financial prospectus for nearly 85% of new state RFP Developed a consensus based, efficient model related to the determination of SG&A expense impact requirements on new and expanded business opportunities within United Community and State. Raised organizational awareness, eliminating redundancy and ambiguity regarding pro forma estimates of direct, indirect and intersegment SG&A for reimbursement rates and pro forma generating enhanced opportunity reviews and leading to well-informed decisions. Director Revenue Cycle Management (March 2008 to June 2009) Re-engineered and implemented an accrual-based revenue system for capitated and supplemental revenue to address and improve on significant membership eligibility, revenue and claim payment accuracy issues and primarily accomplished through an audit of all state contracts for financial terms, and reconciled for completeness, accuracy, and untapped opportunities. In addition to automated process enhancements, created interim workarounds which combined resulted in significant in-hand increases to both base capitation and supplemental revenues and claim cost avoidance of $38M. Selected Contributions: Through an organization-wide review of state program contract terms identified and realized approximately $38 million in enhanced and recouped revenues or cost avoidance opportunities. This resulted in a $38.6M or $1.69 PMPM return on activities versus a budgeted target of $0.25 PMPM. Improved reinsurance (RI) recoveries by 5 points or $4M, up to 93% on an annual gross opportunity of $80M+. GERIATRIC SOLUTIONS / DESERT OASIS HOSPICE / DESERT OASIS HOME HEALTH Phoenix, AZ Chief Operating Officer (COO) (2007 to 2008) Executive for a multi-specialty practice responsible for developing strategies to increase market penetration. Selected Contributions: Initiated the design of an integrated care model emphasizing a case management based program with centralized point of contact for associated therapy services and activities including physician and nursing services, physical and recreational therapy to transportation requirements to and from medical appointments and day care facilities. Negotiated a multi-year fiscal settlement with Mercy Care Health Plan, an AHCCCS Medicaid contractor eliminating nearly 85% of Geriatric Solution s outstanding claims receivable balance.

105 MICHAEL S. ZENOBI Page 3 FOUNDATION FOR SENIOR LIVING Phoenix, AZ Chief Administrative Officer (CAO) (2005 to September 2007) Senior executive for one of Arizona s largest 501(c)3 non-profit holding company serving seniors, adults with disabilities and their family caregivers serving as the architect of change, assessing operations / key functions, identifying gaps, and devising turnaround plan. Integrated program metrics in budgeting process and create activity-based (ABC) operating budgets to closely monitor performance. Maintain positive relations with financial institutions and investors. Selected Contributions: Organizational champion developing an integrated care model designed to enhance through the provision of exceptional services, education and advocacy the preservation of the independence and dignity of one of our country s most vulnerable populations, our senior citizens, while enhancing their quality of life. The model, similar to a PACE program, was based on a case management service program with centralized point of contact for associated well checks, physical exams, physical and recreational therapy services through an adult day care facility and clinic including physician and nursing clinical and in-home services. Reengineered finance and management-information-systems infrastructure incorporating staff reassignments and introduction of new policies / procedures to increase reporting efficiency of critical information and expedite identification and resolution of emerging issues. Deliver Board of Director presentations on finances and other operating activities. CVS / CAREMARK (FORMERLY ADVANCEPCS) Scottsdale, AZ Senior Consulting Analyst (2003 to 2004) Provided contract analysis of corporate-liability reserves and enhanced financial effectiveness of clientcontract-rebate program with annual value of over $1B. Selected Contributions: Indentified and recovered $50M in cost savings by analyzing and minimizing guaranteed-rebate liability of the organization's clients, completing thorough contract review, teaming with legal counsel, and working with staff pharmacists and trade operations on pharmacy formulary analysis. MERCER GOVERNMENT HEALTHCARE CONSULTING Phoenix, AZ National Reporting / Actuarial Practice Leader (1997 to 2003) Practice leader for healthcare (Medicare / Medicaid) Consulting organization serving as a client leader and subject-matter expert on client, actuarial and financial matters. Led new-business-development efforts, ensured the provision of positive client relations, oversaw multi-disciplinary project teams, and planned / executed complex financial / actuarial client projects. Selected Contributions: Established new-practice guidelines for utilizing financial, statistical and encounter data to develop actuarially and financially based, pricing strategies--including risk-adjusted rates (RAR) ensuring compliance with regulatory requirements while supporting sales and customer support. Avoided invalid rate increase demands for state Medicaid programs across client base through assessment of governmental MCO contractors and executing plans to heighten efficiency related to actuarially sound, reimbursement rates, operations, and financial reporting. Conducted cost-trend analyses, identified best practices, established competitive pricing, reimbursement, and contract strategies as well as completed financial and marketing feasibility studies to strategically position clients and implement operational infrastructure. Hired, developed and managed financial, clinical and program professionals including the core training of managed care concepts programmatic, financial and statistical related to the Medicaid and Medicare opportunities.

106 MICHAEL S. ZENOBI Page 4 UNITED HEALTHCARE Phoenix, AZ Finance Director / CFO Commercial (1994 to 1997) Directed healthcare financial operations for the AZ, NM & NV tri-state region. Provided strategic guidance and sound decision making to drive sales while ensuring favorable reimbursement rates with local healthcare hospitals and additional medical facilities. Administered operating budgets to support corporate vision and performance objectives. Selected Contributions: Interfaced with management to coordinate projects/analyses across key functions and projects. Presented PHO and IPA groups managed care contract insights, proposals and working models to build consensus and support for industry contracting trends. CLEVELAND CLINIC FOUNDATION Cleveland, OH Finance Administrator / Director (1990 to 1993) Oversaw financial management of Hospital Division of the Foundation s hospital and clinic system. Provided fresh perspective and solutions and facilitated change, instituting for-profit business model to minimize bureaucracy while driving fiscal and operational functions of $300 million operating unit within $1.4 billion hospital division. Provided project oversight of large-scale construction and renovation projects, oversaw capital expenditures, assessed operations, and identified best practices. Selected Contributions: Instrumental as the finance lead in a multi-functional team charged with the design and presentation of a satellite network of physician practices, clinics and ultimately the acquisition or co-ownership of community hospitals to serve as a feeder network driving severely acute patients to the main campus while creating a convenient local presence for less severe or routine services. This model provides a regional presence in Ohio stretching across northern Ohio and south to Columbus, Ohio. Increased net-operating margins in excess of $40M by executing revenue enhancement and costcontainment projects based on findings from analyses of reimbursement regulations, internal charge and pricing practices, contract analysis, medical care utilization and productivity studies. Created and introduced productivity reporting system to measure staff utilization and available capacity of 7,500 patient-care and administrative personnel, leading to proper resource allocation across functional areas, programs, and activities. Developed and implemented organization performance metrics to improve business activities and developed costing models, resulting in heightened accuracy of flexible budgeting and the analysis of patient care diagnosis (DRGs) to support effectiveness of clinical case-management initiatives. Coached medical professionals to be part of the solution by educating on the analysis of financial and statistical reports to ensure sound financial decisions at the program and department level including equipment used was in the long-term best interest of the patient and economically justified. EDUCATION & CREDENTIALS Master of Business Administration (MBA) Baldwin- Wallace College Cleveland, OH Bachelor of Science Accounting Chancellor University Cleveland, OH Graduated Summa Cum Laude Professional Certifications: Six Sigma Certification, Villanova University Health System Executive Certification, Case Western Reserve University, Cleveland, OH Computer Skills: MS Office (Word, Excel, Outlook, PowerPoint)

107 James K. Beckmann President and Chief Executive Officer Carondelet Health Network James K. Beckmann is President and Chief Executive Officer of Carondelet Health Network, a notfor-profit, Catholic healthcare system that is based in Tucson, Ariz., and employs more than 4,100 people. Carondelet is comprised of two acute care medical centers, each with a specialty care institute on campus; one critical access hospital along the U.S./Mexico border; a robust primary care practice; imaging centers; and outpatient services. Since his arrival in October 2011, Beckmann has introduced the organization to a vision of providing access to excellent care while focusing on the expansion of four key services lines: neurological, cardiovascular, orthopedic, and breast cancer care. Prior to coming to Tucson, Beckmann served as Senior Vice President for System Support Services at Ascension Health. In that role, James had national executive management responsibility for supply chain, risk management, corporate responsibility, operational resources, and the Facility Resources Group. Beckmann is currently a member of Tucson Regional Economic Opportunities Chairman s Circle, Southern Arizona Leadership Council, Tucson Metro Chamber of Commerce Board of Directors, Mercy Maricopa Integrated Care Board of Directors, and Mercy Care Board of Directors.

108 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.c.iii. Governance

109 MEMORANDUM TO Maricopa County Special Health Care District Board of Directors FROM Joseph A. Kanefield DATE October 20, 2014 RE Affidavit of Election Compliance A.R.S In addition to federal election law, there are several statutes in Arizona s election code (Title 16) that govern elections held by special districts established in Title 48, including the Maricopa Integrated Health System ( MIHS ). The most relevant statutes begin at A.R.S through -229, and set forth the general date, notice and publication requirements. Section of the Arizona Revised Statutes requires the governing body of a special district, to submit to the Board of Supervisors an affidavit certifying compliance with the applicable federal and state election laws not later than five days before the nonpartisan election. Your counsel recently recommended to MIHS staff that it consider presenting to its Board of Directors (the Board ) a draft affidavit of compliance pursuant to A.R.S , certifying that the upcoming bond election (Proposition 480) is in compliance with all federal and state election laws. The affidavit, if approved, would be presented by the Board to the Maricopa County Board of Supervisors in advance of the October 30, 2014 deadline. A careful reading of A.R.S (B) suggests that these requirements may not apply to Proposition 480 because this election is being held concurrently with the general election. Although the law does not explain the rationale for this apparent exemption, it makes sense with respect to Proposition 480 because this election is being administered by Maricopa County Elections under supervision of the Board of Supervisors in accordance with A.R.S (A). This means that the Board of Supervisors has assumed most (but not all) responsibilities for conducting the election, including printing, tabulating and canvassing the election results. Nevertheless, out of an abundance of caution, your counsel recommends that this affidavit be presented to the Board of Supervisors to provide a record of compliance with all applicable election laws, including the printing and distribution of the Voter Information Pamphlet, which is MIHS s responsibility. DMWEST # v2

110 To date, the MIHS staff has scrupulously adhered to the election law requirements in preparing Proposition 480 for presentation to the Maricopa County voters on November 4, Thus, filing a A.R.S affidavit of compliance with the Board of Supervisors will eliminate any question of whether such compliance is necessary while also documenting compliance by the Board with all applicable election laws. Please let me know if you have any questions. I can be reached at (602) or kanefieldj@ballardspahr.com. cc: Louis B. Gorman Martin C. Demos JAK/lb DMWEST # v2 2

111 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT RESOLUTION NO October 29, 2014 WHEREAS, the Maricopa County Special Health Care District ( District ) through its Board of Directors ( District Board ) provides for the care and maintenance of the sick in Maricopa County ( County ) and maintains a hospital, health care facilities, staff and other resources for such purposes, pursuant to A.R.S et. seq.; and WHEREAS, on May 28, 2014, the District Board adopted Resolution applying to the Board of Supervisors of Maricopa County to order a bond election to be held on November 4, 2014 (the Election ) submitting to the qualified electors of the District the question of authorizing the issuance of not exceeding $935,000,000 of general obligation bonds to meet community need for healthcare facilities throughout Maricopa County; and WHEREAS, A.R.S requires a special district under certain circumstances to submit an affidavit to the County Board of Supervisors certifying compliance with all applicable federal and state election laws in connection with a nonpartisan election; and WHEREAS, although there is a statutory argument that the affidavit requirement of A.R.S does not apply to the Election, the Board nevertheless desires to voluntarily submit such affidavit. NOW, THEREFORE, BE IT RESOLVED that the Maricopa County Special Health Care District and its Board of Directors hereby (i) approves the Affidavit of Compliance set forth on Exhibit 1 and (ii) directs the Chief Executive Officer of the District to submit such affidavit to the Maricopa County Board of Supervisors. Entered this 29 th day of October, 2014 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT BOARD OF DIRECTORS Terence M. McMahon, Board Chair ATTEST: Melanie Talbot, Clerk of the Board

112 Affidavit of Compliance by Maricopa County Special Health Care District Board of Directors Pursuant to Arizona Revised Statutes Section , the Maricopa County Special Healthcare District Board of Directors hereby certifies to the Maricopa County Board of Supervisors compliance with the applicable federal and state election laws for the November 4, 2014 bond election. PASSED, ADOPTED, AND APPROVED by the Board of Directors of the Maricopa County Special Health Care District on October 29, Terence M. McMahon, Board Chair Attest: Melanie Talbot, Clerk of the Board CERTIFICATION I, Melanie Talbot, the duly appointed Clerk of the Board of Directors of the Maricopa County Special Health Care District, do hereby certify that the above and foregoing affidavit was duly approved by the Board of Directors at a regular meeting held on October 29, 2014, the vote was ayes and nays and that a quorum of the Board of Directors was present thereat. Melanie Talbot, Clerk of the Board

113 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.c.iv. Governance

114 CURRICULUM VITAE Anthony M. Dunnigan, MD, MBI February 1, 2014 Current Position: Special Advisor, Clinical Informatics Integrated Electronic Health Record Office Office of Informatics and Analytics Veterans Health Administration Phoenix, Arizona Professional Education 9/2008 3/2013 Master of Biomedical Informatics (MBI) Clinical Informatics Track Oregon Health and Science University Portland, Oregon 6/2007 6/2008 Certificate in Healthcare Information Technology University of Connecticut Storrs, Connecticut 8/1995 5/1999 Doctor of Medicine (MD) Uniformed Services University of the Health Sciences Bethesda, Maryland 8/ /1993 Bachelor of Science (BS) with Departmental Distinction Major: Biochemistry University of Washington Seattle, Washington Clinical Postgraduate Training 7/2000 7/2002 Internal Medicine Residency Carl T. Hayden VA Medical Center/Good Samaritan Regional Medical Center Combined Residency Program Phoenix, Arizona

115 7/1999 7/2000 Internal Medicine Internship Carl T. Hayden VA Medical Center/Good Samaritan Regional Medical Center Combined Residency Program Phoenix, Arizona Professional Experience 1/2013 present Special Advisor, Clinical Informatics Veterans Health Administration Phoenix, Arizona Responsibilities: Special Advisor to the director of the Integrated Electronic Health Record (iehr) project. Provide clinical informatics input into joint VA/Department of Defense (DoD) strategic plans. VHA Clinical co-lead for the Veterans Health Information System Technology Architecture (VistA) Modernization project. Develop strategies for obtaining and assessing evidence for value in healthcare resulting from use of clinical information systems and associated functional processes. Principal subject matter expert in health information standardization for interagency health information sharing and system development. Co-chair of the Health Policy Subgroup of the Interagency Clinical Informatics Board. Clinical champion in maximizing the impact of health information technology services to improve patient outcomes. Provide expertise in gap analysis, requirements elicitation, knowledge representation, informatics architecture, interface design, decision support, evaluation, implementation, and training. Facilitate the definition of clinical decision support requirements for the iehr. Provide input to the design and development of clinical registries. 5/2012 1/2013 Chief Medical Information Officer Adelante Healthcare Phoenix, Arizona Responsibilities: Create, optimize and study elements of NextGen ambulatory EMR which impact providers and support staff on a daily basis, including documents, document generation, templates, protocols, and order modules. Implement Dashboard application and create dashboards for evaluating data at provider, practice, and enterprise levels. Develop protocols for use with the EMR to ensure needed tests and activities are carried out effectively based on appropriate needs. 2

116 Develop and implement best practices for both providers and support staff in dealing with workflow surrounding use of the EMR, including encounters, test results, referrals, and communication. Lead activities surrounding Meaningful Use attestation and data collection. Implement the NextGen patient portal. 5/2005 5/2012 Director of Medical Informatics Phoenix Indian Medical Center Phoenix, Arizona Responsibilities: Evaluate, plan, and implement technological projects impacting clinical care. Act as a liaison between administration, the medical staff, the medical records department, and the information technology department. Coordinate all Meaningful Use activities including software deployment, inclusion of certified components into EHR design, registration of the hospital and 140 providers, attestation, and tracking of reimbursement. Chairman of the Information Management Committee, leading a weekly session with a multidisciplinary group consisting of administration, information technology, medical staff, nursing, pharmacy, laboratory, staff development, billing, coding, data entry, and medical records. Lead physician on the Electronic Health Record (EHR) Implementation Team. Conduct campus-wide hardware and networking assessments. Plan, purchase, and coordinate IT needs surrounding hardware/ infrastructure/networking enhancements needed for implementation. Redesign the EHR Graphical User Interface for optimal efficiency at PIMC. Identify and train users and department super-users. Create and present to leadership an implementation strategy for PIMC. Create the implementation timeline and coordinate training and go live dates with department leaders. Active primary care physician with a shared panel of 1100 patients; member of the Innovations in Planned Care team, implementing changes to create a new care team model, focused on a medical home for primary care patients. 2/2004 5/2005 Deputy Chief, Department of Internal Medicine Phoenix Indian Medical Center Phoenix, AZ Responsibilities Created a Hospitalist-based system, resulting in dramatically increased continuity for inpatient and outpatient providers, a significant factor in retention of internal medicine physicians. Recruitment of staff, filling all open positions in the department. 3

117 Designed, piloted and implemented the first advanced access appointment system in primary care, reducing no-show rates from 35% to 9% and decreasing wait time for an appointment from three months to one week. Ran weekly Institute for Healthcare Improvement team meetings, designed to incorporate 21 st Century health care concepts into clinical practice, and led group to two national sessions in Boston and Atlanta. Designed and implemented the PCC+ encounter form in Primary Care Clinic. Conducted departmental peer review and presented compiled data to the medical executive committee. Member, Critical Care Committee and Pharmacy/Primary Care Workgroup Physician champion, outpatient anemia clinic; implemented a protocol utilizing Darbepoetin in anemia patients with chronic kidney disease. Piloted a new pharmacy in-room screening process in Primary Care Clinic, significantly reducing patient waiting times after the provider encounter. 6/2002 2/2004 Staff Physician, Department of Internal Medicine Phoenix Indian Medical Center Phoenix, AZ Full-time patient care divided between the outpatient and inpatient (including ICU) settings. Took on many additional responsibilities such as creating order sets, committee and workgroup participation, and conducting education sessions for colleagues. Licensure Medical Licensure: Arizona Medical Board, current through Apr 2015 Certification Board Certification: American Board of Preventative Medicine Clinical Informatics, through January 2024 Board Certification: American Board of Internal Medicine, through Dec 2022 Professional Memberships Member, American Medical Informatics Association Member, Healthcare Information and Management Systems Society Member, American College of Physicians Past Member, USPHS Commissioned Officers Association Awards Healthcare Informatics Innovators Award Finalist,

118 PHS Achievement Medal, 2010 Indian Health Service Director s Award, PHS Unit Commendation, 2007 PHS Citation, 2007 PHS BOTC/IOTC Completion Ribbon, 2007 PHS Achievement Medal, 2004 PIMC Positive Action Award, 2003 PHS Regular Corps Ribbon, 1999 PHS Bicentennial Unit Commendation, 1998 Additional Activities Presentation to VA Field-Based Health Informatics Leadership iehr Update February 2013 Medical Consultant, Arizona Medical Board, 2005-present Graduate, American Medical Informatics Association 10 x 10 Program, May 2006 Past Member, IHS Clinicians Information Management Technology Advisory Council Past Member, Arizona Clinical Informatics Society Presenting Faculty, IHS Advances in Indian Health Conference, Past Member, Indian Health Service Innovations in Planned Care Collaborative, Deployed with Rapid Deployment Force-5 to San Antonio, Texas in response to Hurricane Dean, August 19-23, 2007 Past Member, RPMS-EHR Change Control Board Past Member, Institute for Healthcare Improvement, Office Practice and Outpatient Settings Domain, Publications and Presentations Dunnigan, A. Veterans Health Administration: informatics update. Lecture presented at: American Medical Informatics Association Annual Symposium; 2013 November 18; Washington DC. Dunnigan A, Nichol P, Anderson C, Rhodes C, Coyle M. Veterans Administration s VistA product roadmap. Panel presentation at: Annual Open Source Electronic Health Record Agent (OSEHRA) Summit; 2013 September 6; Bethesda, MD. Taylor M, Reilley B, Tulloch S, Winscott M, Dunnigan A, et al. Identifying opportunities for Chlamydia screening among American Indian women. Sexually Transmitted Diseases. 2011; 38(10): Dunnigan A, John K, Scott A, Von Bibra L, Walling J. An implementation case study. Implementation of the Indian Health Service s Resource and Patient Management System- Electronic Health Record in the ambulatory care setting at the Phoenix Indian Medical Center. Journal of Healthcare Information Management. 2010;24(2):

119 Dunnigan A, Peyketewa A. Automated appointment reminder service: benefits and drawbacks. Poster session presented at: Annual USPHS Scientific and Training Symposium; 2010 May 24-27; San Diego, CA. Dunnigan A. Incorporating telephone care into your clinical practice: an informatics perspective. Poster session presented at: Healthcare 2010 and Beyond: Opportunities, Choices, Changes, Challenges, & Solutions. Annual Conference of the Indian Health Service Office of Information Technology; 2010 May 10-14; Scottsdale, AZ. Dunnigan A. Electronic health record documentation for providers. Lecture presented at: 10 th Annual Advances in Indian Health Conference; 2010 Apr 27; Albuquerque, NM. Dunnigan A. A reply to Keane, et al, regarding the article, Intercepting the safety pitfalls of the Electronic Health Record (The IHS Primary Care Provider.2009; 34(9): ). The IHS Primary Care Provider. 2009;34(10):299. Dunnigan A. Electronic heath record templates. Lecture presented at: 9 th Annual Advances in Indian Health Conference; 2009 Apr 22; Albuquerque, NM. Personal Information Birthplace: Seattle, WA; December 28, 1970 Spouse: Diana Dunnigan (Pediatrician at Phoenix Indian Medical Center) Children: son Aidan, born Nov 2001; son Quentin, born May

120 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.d.i. Medical Staff

121 Recommended by Credentials Committee: September 30, 2014 Recommended by Medical Executive Committee: October 07, 2014 Submitted to MSHCDB: October 29, 2014 MARICOPA INTEGRATED HEALTH SYSTEM CREDENTIALS AND ACTION ITEMS REPORT MEDICAL STAFF The credentials of the following individuals including, current licensure, relevant training and experience, malpractice insurance, current competence and the ability to perform the requested privileges have been verified. INITIAL MEDICAL STAFF APPOINTMENT NAME CATEGORY DEPARTMENT/SPECIALTY APPOINTMENT DATES COMMENTS Kamaldeen Toyosi Aderibigbe, M.D. Courtesy Orthopedic Surgery 11/01/2014 to 10/31/2016 Interim Privileges granted as of 9/08/2014 Mohanad Turki Ali Al-Qaisi, M.D. Courtesy Internal Medicine 11/01/2014 to 10/31/2016 Interim Privileges granted as of 9/17/2014 Christopher Keith Crowe, M.D. Courtesy Emergency Medicine 11/01/2014 to 10/31/2016 Interim Privileges granted 10/09/2014 Courtney E. De Jesso, M.D. Courtesy Pediatrics (Neonatal-Perinatal Medicine) 11/01/2014 to 10/31/2016 Christopher Natesan Eswar, M.D. Courtesy OB/Gyn and Women s Health Care 11/01/2014 to 10/31/2016 Erica Celina Garza, M.D. Courtesy OB/Gyn and Women s Health Care 11/01/2014 to 10/31/2016 Arnold S. Morof, D.D.S., M.S. Courtesy Dentistry 11/01/2014 to 10/31/2016 INITIAL/FOCUSED PROFESSIONAL PRACTICE EVALUATION NAME DEPARTMENT/SPECIALTY RECOMMENDATION COMMENTS* EXTEND or PROPOSED STATUS Amir Asifuddin, M.D. Internal Medicine FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Internal Medicine Core Privileges. William Hoyt Betz, D.O. Emergency Medicine FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Emergency Medicine Cognitive/Procedural Privileges. Beth Robin Furman, D.O. Family and Community Medicine FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Pediatrics, Adolescent and Adult Core Privileges. Jason L. Grimsman, D.O. Emergency Medicine FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Emergency Medicine Cognitive/Procedural Privileges and Emergency Ultrasound Privileges. Patricia R. Halpe, M.D., F.A.A.P. Pediatrics FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Pediatric & Adolescent Core Privileges. Madhuri Kadiyala, M.D. Internal Medicine (Hematology- Oncology) FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Hematology/Oncology Core. Edward K. Rhee, M.D. Internal Medicine (Cardiology) FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Automatic Implantable Cardioverter Defibrillator; Electrophysiology Studies (EPS); CRT (BiVentricular) Pacemaker; Permanent Pacemaker Insertions; and Procedural Sedation Privileges. 1 of 3

122 Recommended by Credentials Committee: September 30, 2014 Recommended by Medical Executive Committee: October 07, 2014 Submitted to MSHCDB: October 29, 2014 INITIAL/FOCUSED PROFESSIONAL PRACTICE EVALUATION Thomas Frank Sawyer, II, M.D. Anesthesiology FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Anesthesia Core to include both adult and pediatric (older than 3 months of age) Privileges. Charles Bennett Stauffer, M.D. Internal Medicine FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Internal Medicine Core Privileges. Pierrette Marie Ange Tantchou Dsamou, M.D. Internal Medicine FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Internal Medicine Core Privileges. Maria Antonia Verso, M.D. Internal Medicine (Endocrinology) FPPE Successfully Completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Endocrinology/Metabolism Core Privileges. REAPPOINTMENTS NAME CATEGORY DEPARTMENT/SPECIALTY APPOINTMENT DATES COMMENTS Bradley S. Butler, M.D. Active Emergency Medicine 11/01/2014 to 10/31/2016 Adnan Celjo, M.D. Active Psychiatry 11/01/2014 to 10/31/2016 Harikrishna R. Dave, M.D. Active Pathology 11/01/2014 to 10/31/2016 Ibrahim IIsmail Ghannam, D.O. Active Anesthesiology 11/01/2014 to 10/31/2016 Kamiar Massrour, M.D. Courtesy Radiology 11/01/2014 to 10/31/2016 Daniel K. Merrill, M.D. Courtesy Psychiatry 11/01/2014 to 10/31/2016 Marc A. Merroto, M.D. Active Internal Medicine (Neurology) 11/01/2014 to 10/31/2016 Abdul Nadir, M.D. Active Internal Medicine (Gastroenterology) 11/01/2014 to 10/31/2016 Linda Robin Nelson, M.D. Courtesy OB/Gyn and Women s Health 11/01/2014 to 10/31/2016 Craig W. Pool, D.D.S. Active Dentistry 11/01/2014 to 10/31/2016 CHANGE IN PRIVILEGES NAME DEPARTMENT/SPECIALTY ADDITION / REVISION/ REDUCTION / WITHDRAWAL COMMENTS Ahmad Nazih Chebbo, M.D. Internal Medicine (Critical Care) Addition: Dialysis: Continuous Renal Replacement Therapy (CRRT) With Concurrent/Direct Supervision of the first two cases by a member of the MIHS medical staff with like/unsupervised privileges. Pejman Hedayati, M.D. Radiology Addition: Cardiac CT Angiography Unsupervised Poya Hedayati, M.D. Radiology Addition: Cardiac CT Angiography Unsupervised Gholamabbas Amin Ostovar, M.D. Pediatrics Addition: Basic Pediatric & Adolescent Emergency Medicine Core Privileges Unsupervised 2 of 3

123 Recommended by Credentials Committee: September 30, 2014 Recommended by Medical Executive Committee: October 07, 2014 Submitted to MSHCDB: October 29, 2014 WAIVER REQUEST NAME DEPARTMENT/SPECIALTY CATEGORY COMMENTS Laura Elizabeth Dalton, D.O. OB/GYN (Family Practice) Courtesy Physician is requesting waivers of the Threshold Eligibility Critieria requirements from the OB/GYN residency training and board certification. Confirmed with Family Practice Residency Program Director that OB/GYN training was included. Practitioner is board certified with the American Board of Family Medicine and meeting MOC requirements. STAFF STATUS CHANGE NAME DEPARTMENT CHANGE FROM/TO COMMENTS* Ali Shaheen Al-Yaqoobi, M.D. Internal Medicine Active to Courtesy Reduction in hours Susan L. Morton-Pradhan, M.D. OB/GYN Automatic Relinquishment of Reinstatement of membership and privileges Privileges to Courtesy Madhumita Sinha, M.D. Pediatrics (Emergency Medicine) Active to Courtesy Reduction in hours RESIGNATIONS Information Only NAME DEPARTMENT/SPECIALTY STATUS REASON Maria I. Aguilar, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Dan J. Capampangan, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) John A. Carroll, M.D. Internal Medicine Active to Inactive No longer contracted with contracting agency (Effective 9/19/2014) Andrea Lee Chen, M.D. OB/GYN and Women s Health Courtesy to Inactive No longer contracted with contracting agency (Effective 10/31/2014) Bart M. Demaerschalk, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) David W. Dodick, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Christopher V. Fanale, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Marie F. Grill, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Matthew Torres Hoerth, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Cumara Barahona O'Carroll, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Bert B. Vargas, M.D. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Holly Marie Yancy, D.O. Internal Medicine (Neurology-Telemetry) Courtesy to Inactive No longer contracted with contracting agency (Effective 7/16/2014) Definitions: Active Courtesy Reappointments FPPE > 1,000 hours/year Active members of the medical staff have voting rights and can serve on medical staff committees < 1,000 hours/year Courtesy members do not have voting rights and do not serve on medical staff committees Renewal of appointment and privileges is for a period of two years unless otherwise specified for a shorter period of time. Focused professional practice evaluation is a process by which the organization validates current clinical competence. This process may also be used when a question arises in practice patterns. 3 of 3

124 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.d.ii. Medical Staff

125 Recommended by Credentials Committee: September 30, 2014 Recommended by Medical Executive Committee: October 07, 2014 Submitted to MSHCDB: October 29, 2014 MARICOPA INTEGRATED HEALTH SYSTEM CREDENTIALS AND ACTION ITEMS REPORT ALLIED HEALTH PROFESSIONAL STAFF The credentials of the following individuals including, current licensure, relevant training and experience, malpractice insurance, current competence and the ability to perform the requested privileges have been verified. ALLIED HEALTH PROFESSIONALS - INITIAL APPOINTMENTS NAME DEPARTMENT PRACTICE PRIVILEGES/ SCOPE OF SERVICE APPOINTMENT DATES COMMENTS/SPONSORING PHYSICIAN (if applicable) Ruth Penno, F.N.P. Internal Medicine Practice Prerogatives on file 11/01/2014 to 10/31/2016 Interim Privileges granted as of 9/16/2014 INITIAL/FOCUSED PROFESSIONAL PRACTICE EVALUATION NAME DEPARTMENT RECOMMENDATION EXTEND or PROPOSED STATUS COMMENTS* Andrea Kay Brock, A.C.N.P. Internal Medicine FPPE successfully completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Nurse Practitioner Core Privileges. Larissa Christine Franchuk, P.A.-C Internal Medicine (Dermatology) FPPE successfully completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Physician Assistant Core Privileges. Katherine M. Handley, P.A.-C Internal Medicine (Cardiology) FPPE successfully completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Physician Assistant Core Privileges. Tina Workman McClain, C.R.N.A. Anesthesiology FPPE successfully completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Certified Registered Nurse Anesthetist Core Privileges. Kathleen Ann Piotrowski, C.R.N.A. Anesthesiology FPPE successfully completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Certified Registered Nurse Anesthetist Core Privileges. Jenna Christine Snyder, F.N.P. Jenna Christine Snyder, F.N.P. FPPE successfully completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Nurse Practitioner Core Privileges. Tyler Eugene Watkins, F.N.P. Family and Community Medicine FPPE successfully completed Chair has submitted documentation demonstrating practitioner has successfully completed FPPE requirement for Nurse Practitioner Core Privileges. ALLIED HEALTH PROFESSIONALS REAPPOINTMENTS NAME DEPARTMENT PRACTICE PRIVILEGES/ SCOPE OF SERVICE APPOINTMENT DATES Frank J. Bevacqua, Ph.D. Psychiatry Practice Prerogatives on file 11/01/2014 to 10/31/2016 COMMENTS/SPONSORING PHYSICIAN (if applicable) Heather Nell Crotty, C.R.N.A. Anesthesiology Practice Prerogatives on file 11/01/2014 to 10/31/2015 Reappointment for one year Arlene Hanic Karlin, C.N.M. OB/GYN Practice Prerogatives on file 11/01/2014 to 10/31/2016 Dawn Elizabeth Laprade, F.N.P. Family and Community Medicine Practice Prerogatives on file 11/01/2014 to 10/31/ of 2

126 Recommended by Credentials Committee: September 30, 2014 Recommended by Medical Executive Committee: October 07, 2014 Submitted to MSHCDB: October 29, 2014 ALLIED HEALTH PROFESSIONALS REAPPOINTMENTS Jo-Ann Marie MacKinnon, C.R.N.A. Anesthesiology Practice Prerogatives on file 11/01/2014 to 10/31/2016 Sydney Ann Mahaffay, C.R.N.A. Anesthesiology Practice Prerogatives on file 11/01/2014 to 10/31/2016 Erika Marie Percic, C.R.N.A. Anesthesiology Practice Prerogatives on file 11/01/2014 to 10/31/2016 Carol Hensley Williams, F.N.P. Internal Medicine Practice Prerogatives on file 11/01/2014 to 10/31/2016 RESIGNATIONS Information Only NAME DEPARTMENT STATUS REASON Larissa Christine Franchuk, P.A.-C Internal Medicine (Dermatology) Allied Health Professional to Inactive No longer contracted with contracting agency (Effective 7/31/2014) General Definitions: Allied Health Professional Staff Practice Prerogatives An Allied Health Professional (AHP) means a health care practitioner other than a Medical Staff member who is authorized by the Governing Body to provide patient care services at a MIHS facility, and who is permitted to initiate, modify, or terminate therapy according to their scope of practice or other applicable law or regulation. Governing Body authorized AHPs are: Certified Registered Nurse Anesthetists; Certified Registered Nurse Midwife; Naturopathic Physician; Optometrists; Physician Assistant; Psychologists (Clinical Doctorate Degree Level); Registered Nurse Practitioners. Scopes of practice summarizing qualifications for the respective category, developed with input from the physician director of the clinical service and the observer/sponsor/responsible party of the AHP, Department Chair, and other representatives of the Medical Staff, Hospital management, and other professionals. Supervision Definitions: (1) General Supervision The procedure is furnished under the physician s overall direction and control, but the physician s presence is not required during the performance of the procedure or provision of the services. (2) Direct Supervision The physician must be present in the office suite or on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (3) Personal Supervision A physician must be in the room during the performance of the procedure. 2 of 2

127 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.d.iii. Medical Staff

128 October 29, 2014 Summary of Proposed Peer Review Policy revisions: Added Section, 1.D. Definitions. Leadership Council responsibilities revised: o o Removed review of professional conduct and practitioner health issues, as those are handled through the Medical Staff Professional Policy and Practitioner Wellness Committee, respectively Expanded responsibilities to include the review of administrative issues such as development and approval of clinical guidelines, protocols, and policies; review of patterns of informational letters; pattern of clinical care despite prior attempts at collegial intervention/education; review of cases where there are limited reviewers with the necessary clinical expertise (external review may be required); review of refusal to cooperate with utilization oversight activities; and preview cases where prior participation in a performance improvement plan does not seem to have identified concerns. Sections 2.B and 2.C expands the triggers for peer review, including potential system or process issues; potential clinical trends, and a trend of non-adherence to Medical Staff Rules and Regulations, and other policies, adopted clinical protocols, or other quality measures. Section 5.A, (1) added timeline to have final disposition of a matter Section 5.A, (4) added requirement for the decision to obtain an external review upon approval of the Leadership Council (formerly approved by Chief of Staff). Section 5.A, (5) expanded triggers for referral to the Medical Executive Committee Section 5.B, (3) expanded triggers for referral to Leadership Council Section 5.D revised to require Department Peer Review Committees of at least three (3) members (see definitions). Section 5.E expanded role of Specialized Peer Review Committees and Trauma Multi-Disciplinary Peer Review Committee Section 5.F expanded the role of the Professional Practice Evaluation Committee (PPEC) to include monthly audits of Department Peer Review Committee activities, and the review of potential trends and/or significant occurrences. Appendix C added to clarify (i.e., the review of hospital-acquired infections, burns, codes) and the Trauma Multi-Disciplinary Peer Review Committee basic responsibilities. The role of Specialized Peer Review Committees and Trauma Multi-Disciplinary Peer Review Committee are expanded the ability to take action (i.e., issue informational or education letters, collegial intervention, etc.) in consultation with the respective Department Chairs.

129 MARICOPA INTEGRATED HEALTH SYSTEM PEER REVIEW POLICY Proposed Revisions October 29, 2014

130 PEER REVIEW POLICY TABLE OF CONTENTS PAGE 1. OBJECTIVES, SCOPE OF POLICY, COLLEGIAL EFFORTS, DEFINITIONS, AND ACRONYMS A Objectives B Scope of Policy C Collegial Efforts and Progressive Steps D Definitions E Acronyms CLINICAL INDICATORS (A/K/A TRIGGERS) A Specialty-Specific Triggers B Reported Concerns...3 (1) Reported Concerns from Practitioners or MIHS Employees...3 (2) Anonymous Reports...4 (3) Unsubstantiated Reports/False Reports...4 (4) Sharing Reported Concerns with Relevant Practitioner...4 (5) Self-Reporting C Other Triggers NOTICE TO AND INPUT FROM THE PRACTITIONER A Notice B Input C Failure to Provide Requested Input INTERVENTIONS TO ADDRESS IDENTIFIED CONCERNS A Informational Letter B Educational Letter C Collegial Intervention D Performance Improvement Plan ( PIP )...7 (1) Additional Education/CME...8 (2) Focused Prospective Review...8 (3) Second Opinions/Consultations...8 (4) Concurrent Proctoring...8 (5) Participation in a Formal Evaluation/Assessment Program...8 (6) Additional Training...9 (7) Educational Leave of Absence

131 PAGE (8) Other STEP-BY-STEP PROCESS A General Principles...9 (1) Time Frames for Review...9 (2) Request for Additional Information or Input...10 (3) No Further Review or Action Required...10 (4) External Reviews...10 (5) Referral to the Medical Executive Committee B Quality Management ( QM )...11 (1) Review...11 (2) Preparation of Case for Review...12 (3) Referral of Case to Leadership Council...12 (4) Referral to Appropriate Peer Review Committee...12 (5) Cases Involving Practitioners from Several Specialties or Departments C Leadership Council...13 (1) Composition...13 (2) Function...13 (3) Review of Cases...13 (4) Determinations and Interventions D Review by Department Peer Review Committees E Review by Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee F PPEC...15 (1) Review of Prior Determinations...15 (2) Cases Referred to the PPEC for Further Review...16 (a) Review...16 (b) Determinations and Interventions PRINCIPLES OF REVIEW AND EVALUATION A Incomplete Medical Records B Forms C Findings and Recommendations Supported by Evidence-Based Research/Clinical Protocols or Guidelines D System Process Issues

132 PAGE 6.E Tracking of Reviews F Educational Sessions G Confidentiality...18 (1) Documentation...18 (2) Participants in the Peer Review Process...18 (3) Peer Review Communications H Conflict of Interest Guidelines I Legal Protection for Reviewers PEER REVIEW REPORTS A Practitioner Peer Review History Reports B Reports to MEC and Board C Reports on Request...20 APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D: APPENDIX E-1: APPENDIX E-2: APPENDIX F: Responsibilities of Assigned Reviewers Responsibilities of Department Peer Review Committees Responsibilities of Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee Performance Improvement Plan Options Implementation Issues Checklist Detailed Flow Chart of Peer Review Process Simplified Flow Chart of Peer Review Process Conflict of Interest Guidelines

133 PEER REVIEW POLICY 1. OBJECTIVES, SCOPE OF POLICY, COLLEGIAL EFFORTS, DEFINITIONS, AND ACRONYMS 1.A Objectives. The primary objectives of the professional practice evaluation process of Maricopa Integrated Health System ( MIHS ) are to: (1) establish a positive, educational approach to performance issues and a culture of continuous improvement; (2) fairly, effectively, and efficiently evaluate the care being provided by practitioners, comparing it to established patient care protocols and benchmarks whenever possible; (3) provide constructive feedback, education, and performance improvement assistance to practitioners regarding the quality, appropriateness, and safety of the care they provide; (4) establish and continually update triggers for peer review and quality data elements that will facilitate a meaningful review of the care provided; and (5) define prospectively, to the extent possible, the expectations for patient care and safety through patient care protocols. 1.B Scope of Policy. This Policy applies to all practitioners who provide patient care services at MIHS. When concerns are raised about a practitioner s clinical practice, a review shall be conducted in accordance with this Policy. Concerns regarding a practitioner s professional conduct shall be reported and directed for review in accordance with the Medical Staff Professionalism Policy. 1.C Collegial Efforts and Progressive Steps. This Policy encourages the use of collegial efforts and progressive steps to address issues that may be identified in the peer review process. The goal of those efforts is to arrive at voluntary, responsive actions by the practitioner. Collegial efforts and progressive steps may include, but are not limited to, informational letters, educational letters of counsel or guidance, collegial intervention, sharing of comparative data, and Performance Improvement Plans as outlined in this Policy. All collegial efforts and progressive steps are part of MIHS s confidential peer review and patient safety evaluation activities and shall be within the discretion of the Department Chairs, Leadership Council, and the Professional Practice Evaluation Committee ( PPEC ). MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 1

134 1.D Definitions. The following definitions apply to terms used in this Policy: ASSIGNED REVIEWER means a physician appointed by the Leadership Council or the PPEC to review and assess the care provided in a particular case and report his/her findings back to the committee that assigned the review. Duties and responsibilities of assigned reviewers are described more fully in Appendix A. DEPARTMENT CHAIR means the applicable Medical Staff Department Chair (e.g., Chair of Medicine). DEPARTMENT PEER REVIEW COMMITTEE means the physicians in each Medical Staff Department who are appointed by the Department Chair to conduct case reviews, make determinations, send informational or educational letters and conduct collegial interventions as described more fully in Section 5.D of this Policy and in Appendix B. Each Department Peer Review Committee shall consist of at least three members. LEADERSHIP COUNCIL means the committee that: (1) determines the appropriate review process for clinical issues that are administratively complex as described in Section 5.B(4) of this Policy; and (2) addresses administrative issues such as development and approval of clinical guidelines, protocols, and policies. The composition and duties of the Leadership Council are described in Section 5.C of this Policy. MEDICAL STAFF LEADER means any Medical Staff officer, Department Chair, or Committee Chair. PRACTITIONER means: (1) a member of the Medical Staff; and (2) an Allied Health Professional who has been granted clinical privileges at MIHS. PROFESSIONAL PRACTICE EVALUATION COMMITTEE ( PPEC ) means the multi-specialty committee that oversees the peer review process and reviews care provided within MIHS as described in this Policy. The composition and duties of the PPEC are described in the Medical Staff Organizational Manual. QUALITY MANAGEMENT ( QM ) means the MIHS personnel who support the peer review process as described more fully in Section 5.B of this Policy. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 2

135 SPECIALIZED PEER REVIEW COMMITTEES means those committees that have been established to review care provided in specific situations or units (e.g., hospital-acquired infections, burns, codes, etc.) and to make determinations, send informational or educational letters and conduct collegial interventions as described more fully in Section 5.E and Appendix C of this Policy. TRAUMA MULTI-DISCIPLINARY PEER REVIEW COMMITTEE means the committee that reviews cases involving trauma care based on the criteria for trauma accreditation by the ACS. The Trauma Medical Director chairs the Trauma Multi- Disciplinary Peer Review Committee. The Trauma Multi-Disciplinary Peer Review Committee may make determinations, send informational or educational letters and conduct collegial interventions as described more fully in Section 5.E and Appendix C of this Policy. 1.E Acronyms. Definitions of the acronyms used in this Policy are: CMO MEC PIP PPEC QM Chief Medical Officer Medical Executive Committee Performance Improvement Plan Professional Practice Evaluation Committee Quality Management 2. CLINICAL INDICATORS (A/K/A TRIGGERS). The peer review process may be triggered by any of the following events: 2.A Specialty-Specific Triggers. Each Department shall identify adverse outcomes, clinical occurrences, or complications that will trigger the peer review process. The triggers identified by the Departments shall be approved by the PPEC. 2.B Reported Concerns. (1) Reported Concerns from Practitioners or MIHS Employees. Any practitioner or MIHS employee may report to QM concerns related to: (a) (b) (c) (d) the safety or quality of care provided to a patient by an individual practitioner, which shall be reviewed through the process outlined in this Policy; professional conduct, which shall be reviewed and addressed in accordance with the Medical Staff Professionalism Policy; potential practitioner health issues, which shall be reviewed and addressed in accordance with the Practitioner Health Policy; non-adherence with Medical Staff or MIHS policies, which shall be reviewed through the process outlined in this Policy and/or in MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 3

136 accordance with the Medical Staff Professionalism Policy, whichever QM, in consultation with the Vice President of Quality and Patient Outcomes or his/her designee, as necessary, determines is more appropriate based on the policies at issue; or (e) a potential system or process issue which shall be referred to the appropriate individual, committee, or MIHS department for review. (2) Anonymous Reports. Practitioners and employees may report concerns anonymously, but all individuals are encouraged to identify themselves when making a report. This identification promotes an effective review of the concern because it permits QM to contact the reporter for additional information, if necessary. (3) Unsubstantiated Reports/False Reports. If a report cannot be substantiated, or is determined to be without merit, the matter shall be closed as requiring no further review and shall be reported to the PPEC. False reports will be grounds for disciplinary action. (4) Sharing Reported Concerns with Relevant Practitioner. The substance of reported concerns may be shared with the relevant practitioner as part of the review process outlined in Section 5, but the identity of the individual who reported the concern will not be provided to the practitioner. At the discretion of the Department Chair, the actual report may be shared with the practitioner provided the report has been redacted to protect the identity of the individual(s) who reported the concern. Retaliation against an individual who reports a concern will be addressed through the Medical Staff Professionalism Policy. (5) Self-Reporting. Practitioners will be encouraged to self-report their cases that involve either a specialty-specific trigger or other review trigger or that they believe would be an appropriate subject for an educational session as described in Section 6.F. Self-reported cases will be reviewed as outlined in this Policy. A notation will be made that the case was self-reported. 2.C Other Triggers. In addition to specialty-specific triggers and reported concerns, other events that may trigger the peer review process include, but are not limited to, the following: (1) identification by a Medical Staff committee, Medical Staff Services, QM, a Department Chair, the Leadership Council or PPEC of a clinical trend or specific case or cases that require further review; (2) patient complaints referred by Risk Management that QM determines require physician review; MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 4

137 (3) cases identified as litigation risks that are referred by the Risk Management Department; (4) practice concerns referred by the Utilization Review Committee or others; (5) sentinel events, as defined in the Sentinel Events Policy, involving an individual practitioner s professional performance; (6) referrals from system performance improvement initiatives; (7) a Department Chair s determination, in conjunction with QM, that quality data reveal a practice pattern or trend that requires further review as further described in the Policy Regarding Quality Data; and (8) a trend of non-adherence with Medical Staff Rules and Regulations or other policies, adopted clinical protocols, or other quality measures, as described in Paragraph 4.A of this Policy and in Appendix A of the Policy Regarding Quality Data. 3. NOTICE TO AND INPUT FROM THE PRACTITIONER. An opportunity for practitioners to provide meaningful input into the review of the care they have provided is an essential element of an educational and effective process. 3.A Notice. (1) No intervention (informational or educational letter, collegial intervention, or Performance Improvement Plan as defined in Section 4) shall be implemented until the practitioner is first notified of the specific concerns identified and given an opportunity to provide input. The notice to the practitioner shall include a time frame for the practitioner to provide the requested input. (2) The practitioner shall also be notified of any referral to the PPEC or MEC. (3) Prior notice and an opportunity to provide input are not required before an informational letter is sent to a practitioner, as described in Section 4.A of this Policy. 3.B Input. The practitioner may provide input through a written description and explanation of the care provided, responding to any specific questions posed by the Leadership Council, Department or Specialized Peer Review Committee, the Trauma Multi-Disciplinary Peer Review Committee or PPEC, and/or by meeting in person with individuals specified in the notice. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 5

138 3.C Failure to Provide Requested Input. (1) If the practitioner fails to provide input requested by the Leadership Council, the Department or Specialized Peer Review Committee, or the Trauma Multi- Disciplinary Peer Review Committee within the time frame specified, the review shall proceed without the practitioner s input. The practitioner s failure to respond to the request for input shall be noted in the Leadership Council s or applicable Committee s report to the PPEC regarding the review and determination. (2) If the practitioner fails to provide input requested by the PPEC within the time frame specified, the practitioner will be required to attend a meeting with the Leadership Council to discuss why the requested input was not provided. Failure of the individual to either attend this meeting or provide the requested information prior to the date of that meeting will result in the automatic relinquishment of the practitioner s clinical privileges until the requested input is provided, in accordance with Section 6.E.4 of the Credentials Policy. 4. INTERVENTIONS TO ADDRESS IDENTIFIED CONCERNS. When concerns regarding a practitioner s clinical practice are identified through the process outlined in Section 5, the following interventions may be implemented to address those concerns. 4.A Informational Letter. For situations involving non-adherence with specified Medical Staff Rules and Regulations or other policies, clinical protocols, or quality measures, the Department Chair, Leadership Council, Department Peer Review Committee, Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee, or PPEC may direct Medical Staff Services or QM to prepare an informational letter reminding the practitioner of the applicable requirement and offering assistance to the practitioner in complying with it. A copy of the informational letter shall be placed in the practitioner s confidential file, and it shall be considered in the reappointment process and/or in the assessment of the practitioner s competence to exercise the clinical privileges granted. If a pattern or trend of non-adherence by a practitioner is identified through informational letters, the matter shall be subject to more focused review in accordance with Section 5 of this Policy. Informational letters may be signed by: The Department Chair, the Chair of the Department Peer Review Committee or Specialized Peer Review Committee, the Chair of PPEC, Leadership Council, or the Chief of Staff. The Department Chair shall be copied on any Informational Letter that he/she does not personally sign. 4.B Educational Letter. An educational letter may be sent to the practitioner involved that describes the opportunities for improvement that were identified in the care reviewed and offers specific recommendations for future practice. A copy of the letter will be MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 6

139 included in the practitioner s file along with any response that he or she would like to offer. Educational letters may be sent by: The Leadership Council, a Department Peer Review Committee (and signed by the Department Chair), a Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee (in consultation with the Department Chair as described in Section 5.E) or the PPEC. The practitioner s Department Chair and PPEC will be apprised of, and have access to, any educational letter that is sent to a practitioner, regardless of who sends it. 4.C Collegial Intervention. Collegial intervention means a face-to-face discussion between the practitioner and one or more Medical Staff Leaders, followed by a letter that summarizes the discussion and, when applicable, the expectations regarding the practitioner s future practice at MIHS. A copy of the follow-up letter will be included in the practitioner s file along with any response that the practitioner would like to offer. A collegial intervention may be personally conducted by: The Leadership Council, the Department Chair, a Department Peer Review Committee, a Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee (in consultation with the relevant Department Chair as described in Section 5.E) or the PPEC or they may facilitate an appropriate and timely collegial intervention by designees. The Department Chair shall be invited to participate in any collegial intervention involving a practitioner in his/her Department. If, for any reason, the Department Chair does not participate in a collegial intervention involving a practitioner in his/her Department, he/she shall be informed of the substance of the collegial intervention and the follow-up letter. The Leadership Council and PPEC shall be informed of the substance of any collegial intervention and the follow-up letter, regardless of who conducts or facilitates it. 4.D Performance Improvement Plan ( PIP ). The PPEC may determine that it is necessary to develop a PIP for the practitioner. To the extent possible, a PIP shall be for a defined time period or for a defined number of cases. The plan shall specify how the practitioner s compliance with, and results of, the PIP shall be monitored. As deemed appropriate by the PPEC, the practitioner shall have an opportunity to provide input into the development and implementation of the PIP. The Department Chair shall also be asked for input regarding the PIP, and shall assist in implementation of the PIP as requested by the PPEC. One or more members of the PPEC (or their designees) will personally discuss the PIP with the practitioner. The PIP will also be presented in writing, with a copy being placed in the practitioner s file, along with any statement he or she would like to offer. The practitioner must agree in writing to constructively participate in the PIP. If the practitioner refuses to do so, the matter shall be referred to the MEC for appropriate review and recommendation pursuant to the Credentials Policy. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 7

140 Until the PPEC has determined that the practitioner has complied with all elements of the PIP and that concerns about the practitioner s practice have been adequately addressed, the matter shall remain on the PPEC s agenda and the practitioner s progress on the PIP shall be monitored. In the event that the practitioner is not making reasonable and sufficient progress on completion of the PIP in a timely manner, the PPEC shall refer the matter to the Medical Executive Committee. A PIP may include, but is not limited to, the following: (1) Additional Education/CME which means that, within a specified period of time, the practitioner must arrange for education or CME of a duration and type specified by the PPEC. The educational activity/program may be chosen by the PPEC or by the practitioner. If the activity/program is chosen by the practitioner, it must be approved by the PPEC. If necessary, the practitioner may be asked to voluntarily refrain from exercising all or some of his or her clinical privileges or may be granted an educational leave of absence while undertaking such additional education. (2) Focused Prospective Review which means that a certain number of the practitioner s future cases of a particular type will be subject to a focused review (e.g., review of the next 10 similar cases performed or managed by the practitioner). (3) Second Opinions/Consultations which means that before the practitioner proceeds with a particular treatment plan or procedure, the practitioner must obtain a second opinion or consultation from a Medical Staff member(s) approved by the PPEC. The practitioner providing the second opinion/consultation must complete a Second Opinion/Consultation Report form for each case, which shall be reviewed by the PPEC. If there is any disagreement about the proper course of treatment, the practitioner must discuss the matter with individuals identified by the PPEC before proceeding further. (4) Concurrent Proctoring which means that a certain number of the practitioner s future cases of a particular type (e.g., the practitioner s next five vascular cases) must be personally proctored by a Medical Staff member(s) approved by the PPEC, or by an appropriately credentialed individual from outside of the Medical Staff approved by the PPEC. The proctor must be present during the relevant portions of the operative procedure or must personally assess the patient and be available throughout the course of treatment. Proctor(s) must complete the appropriate review form, which shall be reviewed by the PPEC. (5) Participation in a Formal Evaluation/Assessment Program which means that, within a specified period of time, the practitioner must enroll in an assessment program identified by the PPEC and must then complete the program within another specified time period. The practitioner must execute a release to allow MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 8

141 the PPEC to communicate information to, and receive information from, the selected program. If necessary, the practitioner may be asked to voluntarily refrain from exercising all or some of his or her clinical privileges or may be granted an educational leave of absence while undertaking such formal assessment. (6) Additional Training which means that, within a specified period of time, the practitioner must arrange for additional training of a duration and type specified by the PPEC. The training program must be approved by the PPEC. The practitioner must execute a release to allow the PPEC to communicate information to, and receive information from, the selected program. The practitioner must successfully complete the training within another specified period of time. The director of the training program or appropriate supervisor must provide an assessment and evaluation of the practitioner s current competence, skill, judgment and technique to the PPEC. If necessary, the practitioner may be asked to voluntarily refrain from exercising all or some of his or her clinical privileges or may be granted an educational leave of absence while undertaking such additional training. (7) Educational Leave of Absence which means that the practitioner voluntarily agrees to a leave of absence during which time the practitioner completes an education/training program of a duration and type specified by the PPEC. (8) Other elements not specifically listed may be included in a PIP. The PPEC has wide latitude to tailor PIPs to the specific concerns identified, always with the objective of helping the practitioner to improve his or her clinical practice and to protect patients. (Additional guidance regarding Performance Improvement Plan options and implementation issues is found in Appendix D.) 5. STEP-BY-STEP PROCESS. The peer review process is outlined in Appendix E-1 (Detailed Flow Chart) and Appendix E-2 (Simplified Flow Chart). This Section describes each step in that process. 5.A General Principles. (1) Time Frames for Review. The time frames specified in this Section are provided only as guidelines. However, all participants in the process shall use their best efforts to adhere to these guidelines, with the goal of completing reviews, from initial identification to final disposition, within 90 days. As a general rule, the Leadership Council, Department Peer Review Committees, and Specialized Peer Review Committees, including the Trauma Multi-Specialty Peer Review Committee, shall conduct their reviews and make their determinations or interventions within 45 days. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 9

142 If the Department Peer Review Committees or Specialized Peer Review Committees, including the Trauma Multi-Specialty Peer Review Committee, do not complete their reviews within this time frame, QM will send a reminder and request for immediate review. If the review is not completed within one week of the reminder, the matter shall be reported to the PPEC Chair. (2) Request for Additional Information or Input. At any point in the process outlined in this Section, information or input may be requested from the practitioner whose care is being reviewed as described in Section 3 of this Policy, or from any other practitioner or MIHS employee with personal knowledge of the matter. (3) No Further Review or Action Required. If, at any point in this process, a determination is made that there are no clinical issues or concerns presented in the case that require further review or action, the matter shall be closed. The determination shall be reported to the PPEC. If information was sought from the practitioner involved, the practitioner shall be notified of the determination. (4) External Reviews. An external review may be appropriate if: (a) (b) (c) there are ambiguous or conflicting findings by internal reviewers; the clinical expertise needed to conduct a review is not available on the Medical Staff; or an outside review is advisable to prevent allegations of bias, even if unfounded. If a Department Peer Review Committee or Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee, determines that an external review is required, it shall refer the matter to the Leadership Council. If the PPEC determines that an external review is required, it shall consult with the Chief of Staff. If a decision is made to obtain an external review, the practitioner involved shall be notified of that decision and the nature of the external review. (5) Referral to the Medical Executive Committee. (a) By the Leadership Council. The Leadership Council may refer a matter to the MEC if a pattern has developed despite prior attempts at collegial intervention, the practitioner was already involved in a PIP, or for any other reason as set forth in the Credentials Policy. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 10

143 (b) By the PPEC. The PPEC may refer a matter to the MEC if: (i) (ii) (iii) (iv) (v) (vi) (vii) the PPEC determines that a PIP may not be adequate to address the issues identified; the individual refuses to participate in a PIP developed by the PPEC; the practitioner fails to abide by a PIP; the practitioner fails to make reasonable and sufficient progress on completing a PIP; a pattern has developed despite prior attempts at collegial intervention or prior participation in a performance improvement plan; the matter involves a very serious incident; or any other concern is raised that would serve as the basis for a referral under the Credentials Policy. (c) Pursuant to the Medical Staff Credentials Policy. This Policy outlines collegial and progressive steps that can be taken to address clinical concerns about a practitioner. However, a single incident or pattern of care may be so unacceptable that more significant action is required. Therefore, nothing in this Policy precludes an immediate referral of a matter to the MEC. The MEC shall conduct its review in accordance with the Medical Staff Credentials Policy. 5.B Quality Management ( QM ). (1) Review. All cases or issues identified for review shall be referred to QM. QM shall conduct the initial fact-finding review, which may include, as necessary, the following: (a) (b) (c) the relevant medical record; interviews with, and information from MIHS employees, practitioners, patients, family, visitors, and others who may have relevant information; consultation with relevant Medical Staff or MIHS personnel; MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 11

144 (d) (e) other relevant documentation; and the practitioner s peer review history. (2) Preparation of Case for Review. After conducting the initial fact-finding review, QM shall prepare the case for physician review, which may include, as appropriate, the following: (a) (b) (c) completion of the appropriate portions of the applicable review form (i.e., general, surgical, medical, or obstetrical); preparation of a time line or summary of the care provided; and identification of relevant patient care protocols or guidelines. (3) Referral of Case to Leadership Council. Cases shall be referred to the Leadership Council if they are administratively complex or if QM (in consultation with the Vice President of Quality and Patient Outcomes, when necessary) determines that review by the Leadership Council would be appropriate. Administratively complex cases are those: (a) (b) (c) (d) (e) (f) (g) that involve serious clinical issues or that require expedited review as determined by the Vice President of Quality and Patient Outcomes or his/her designee (the relevant Department Chair will be notified of the referral to the Leadership Council in these instances); that involve a Department Chair; that involve a refusal to cooperate with utilization oversight activities; for which there are limited reviewers with the necessary clinical expertise; where there is a trend or pattern of informational letters as described in Section 4.A of this Policy; where a pattern of clinical care appears to have developed despite prior attempts at collegial intervention/education; or where prior participation in a performance improvement plan does not seem to have addressed identified concerns. (4) Referral to Appropriate Peer Review Committee. Cases involving trauma care shall be referred to the Trauma Multi-Disciplinary Peer Review Committee. Cases involving specific units or situations for which a peer review committee has been established shall be referred to the appropriate Specialized Peer MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 12

145 Review Committee. All other cases shall be referred to the appropriate Department Peer Review Committee. (5) Cases Involving Practitioners from Several Specialties or Departments. Cases involving practitioners from several specialties or departments shall be referred to the relevant Department Peer Review Committees for their review. Findings and assessments of the respective Department Peer Review Committees shall be forwarded to the PPEC through QM for review at its next regularly scheduled meeting. 5.C Leadership Council. (1) Composition. The Leadership Council shall consist of the Chief Medical Officer, the Chief of Staff, the Vice Chief of Staff, the Vice President of Quality and Patient Outcomes, and the Chair of the PPEC. The Chief Nursing Officer and the Director of Medical Staff Services shall be ex officio members of the Council, without vote, and their role will be to facilitate the Council s activities and determinations. (2) Function. The function of the Leadership Council is to triage cases and expedite the review and evaluation process by determining the most efficient and appropriate review procedure and to address administrative matters referred to it, such as the development, review and revision of clinical protocols, procedures, and policies for approval by the MEC. The Leadership Council may also address certain matters directly. (3) Review of Cases. The Leadership Council shall review all cases referred to it, including all supporting documentation assembled by QM. Based on its preliminary review, the Leadership Council shall determine whether any additional clinical expertise is needed for it to make an appropriate determination or intervention. If additional clinical expertise is needed, the Leadership Council may assign the review to any of the following: (a) (b) (c) Medical Staff members who have the clinical expertise necessary to evaluate the care provided, who shall conduct the review as described in Appendix A; an ad hoc committee composed of such practitioners who shall conduct the review as described in Appendix A; or an external reviewer, in accordance with Section 5.A(4) of this Policy. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 13

146 (4) Determinations and Interventions. Based on its own review and the findings of the assigned reviewer(s), if any, the Leadership Council may: (a) (b) (c) (d) determine that no further review or action is required; send an informational or educational letter; conduct or facilitate a collegial intervention with the practitioner; determine that the matter should be referred to one of the following for their review and disposition: (i) (ii) (iii) applicable Department or Specialized Peer Review Committee; PPEC; or Medical Executive Committee; (e) refer the matter for review under the appropriate MIHS or Medical Staff policy. 5.D Review by Department Peer Review Committees. (A description of the responsibilities of the Department Peer Review Committees is set forth in Appendix B.) When a matter is referred to a Department Peer Review Committee, the Committee shall review it and complete an appropriate review form. Following review of the matter, the Department Peer Review Committee may: (1) determine that no further review or action is required; (2) send an informational or educational letter; (3) conduct or facilitate a collegial intervention with the practitioner; or (4) refer the matter to the: (a) (b) Leadership Council; or PPEC. 5.E Review by Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee. (A description of the responsibilities of the Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee, is set forth in Appendix C.) The Trauma Multi-Disciplinary Peer Review Committee shall review all trauma cases, making sure that the Committee representative from the specialty of the practitioner whose care is being reviewed is involved in the review. Other Specialized Peer Review Committees shall review all MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 14

147 cases referred to them. Following review (including completion of the appropriate review form), a Specialized Peer Review Committee, including the Trauma Multi- Disciplinary Peer Review Committee, may determine: (1) that no further review or action is required; (2) to send an informational or educational letter; (3) to conduct or facilitate a collegial intervention with the practitioner; or (4) to refer the matter to the: (a) (b) Leadership Council; or PPEC. If a Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee, determines to send an informational or educational letter or conduct a collegial intervention, it shall first notify the applicable Department Chair of its determination and the reasons supporting it. Within 14 days, the Department Chair shall then review the matter. If the Department Chair does not agree with the findings and determination of the Specialized Peer Review Committee, the matter shall be referred to the PPEC, which shall make the final determination on the matter. Any informational or educational letter sent by a Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee, shall be co-signed by the applicable Department Chair. The relevant Department Chair shall be invited to participate in any collegial intervention conducted by a Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee. 5.F PPEC. (1) Review of Prior Determinations. Each month the PPEC shall audit the determinations and interventions made by one Department Peer Review Committee or Specialized Peer Review Committee. In addition, the PPEC shall review reports from QM, the Leadership Council, Department Peer Review Committees, and Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee, for all cases where it was determined that (i) no further review or action was required, or (ii) an informational letter, educational letter or collegial intervention was appropriate to address the issues presented. The PPEC will also review potential trends and/or significant occurrences. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 15

148 If the PPEC has concerns about any such determination, it may: (a) (b) (c) send the matter back to the Leadership Council or Committee that conducted the initial review with its questions or concerns and ask that the matter be reconsidered and findings reported back to it within 30 days; or ask an individual Medical Staff member, another Medical Staff committee or MIHS Department to review the matter and report back to the PPEC within 30 days, as described in Appendix A; or review the matter itself. (2) Cases Referred to the PPEC for Further Review. (a) Review. The PPEC shall review all other matters referred to it along with all supporting documentation, review forms, findings, and recommendations. The PPEC may request that one or more individuals involved in the initial review of a case attend the PPEC meeting and present the case to the committee. Based on its preliminary review, the PPEC shall determine whether any additional clinical expertise is needed to adequately identify and address concerns raised in the case. If additional clinical expertise is needed, the PPEC may: (i) (ii) (iii) (iv) invite a specialist(s) with the appropriate clinical expertise to attend a PPEC meeting(s) as a guest, without vote, to assist the PPEC in its review of issues, determinations, and interventions; assign the review to any practitioner on the Medical Staff with the appropriate clinical expertise, who shall conduct the review as described in Appendix A; appoint a committee composed of such practitioners, who shall conduct the review as described in Appendix A; or arrange for an external review in accordance with Section 5.A(4) of this Policy. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 16

149 (b) Determinations and Interventions. Based on its review of all information obtained, including input from the practitioner as described in Section 3, the PPEC may: (i) (ii) (iii) (iv) (v) determine that no further review or action is required; send an informational or educational letter; conduct or facilitate a collegial intervention with the practitioner; develop a Performance Improvement Plan; or refer the matter to the MEC. 6. PRINCIPLES OF REVIEW AND EVALUATION 6.A Incomplete Medical Records. One of the objectives of this Policy is to review matters and provide feedback to practitioners in a timely manner. Therefore, if a matter referred for review involves a medical record that is incomplete, the Department Chair shall request the practitioner to complete the medical record within a specific time frame. 6.B Forms. The PPEC shall approve forms to implement this Policy. Such forms shall be developed and maintained by QM, unless the PPEC directs that another office or individual develop and maintain specific forms. Individuals performing a function pursuant to this Policy shall use the form currently approved by the PPEC for that function. 6.C Findings and Recommendations Supported by Evidence-Based Research/Clinical Protocols or Guidelines. Whenever possible, the findings of reviewers and the PPEC shall be supported by evidence-based research, clinical protocols or guidelines. 6.D System Process Issues. Quality of care and patient safety depend on many factors in addition to practitioner performance. If system processes or procedures that may have adversely affected, or could adversely affect, outcomes or patient safety are identified through the process outlined in this Policy, the issue shall be referred to the appropriate MIHS Department and/or QM. 6.E Tracking of Reviews. QM shall track the processing and disposition of matters reviewed pursuant to this Policy. The Leadership Council, Department Peer Review Committees, Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee, and the PPEC shall promptly notify QM of their determinations, interventions and referrals. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 17

150 6.F Educational Sessions. Cases identified at any level of the review process that reflect exemplary care, unusual clinical facts, or possible system issues or, for any other reason, would be of educational value shall be referred to the appropriate Department Chair(s). With the support of QM, the Department Chair(s) may arrange for presentation of such cases at a Department meeting or other M & M -style educational session. The particular practitioner(s) who provided care in the case shall be informed that the case is to be presented in an educational session at least seven days prior to the session. Information identifying the practitioner(s) shall be removed prior to the presentation, unless the practitioner(s) requests otherwise. 6.G Confidentiality. Maintaining confidentiality is a fundamental and essential element of an effective peer review process. (1) Documentation. All documentation that is prepared in accordance with this Policy shall be maintained in appropriate Medical Staff files. This documentation shall be accessible to authorized officials and Medical Staff Leaders and committees having responsibility for credentialing and peer review functions, and to those assisting them in those tasks. All such information shall otherwise be deemed confidential and kept from disclosure or discovery to the fullest extent permitted by Arizona or federal law. (2) Participants in the Peer Review Process. All individuals involved in the peer review process (Medical Staff and MIHS employees) will maintain the confidentiality of the process. All such individuals shall sign an appropriate Confidentiality Agreement on a yearly basis. (3) Peer Review Communications. Communications among those participating in the peer review process, including communications with the individual practitioner involved, shall be conducted in a manner reasonably calculated to assure privacy. (a) (b) Telephone and in-person conversations shall take place in private at appropriate times and locations. MIHS may be used to communicate between individuals participating in the peer review process, including with assigned reviewers and with the practitioner whose care is being reviewed. Private, personal accounts shall not be used. Transmission of confidential information via through the MIHS/District Medical Group (DMG) network shall be done in accordance with MIHS Policy #79752 and shall include Privileged and Confidential Peer Review or Quality Assurance ) in the subject line. As noted previously in this Policy, any Performance Improvement Plan that may be developed for a practitioner shall be hand-delivered and personally discussed with the practitioner. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 18

151 (c) (d) All correspondence (whether paper or electronic) shall be conspicuously marked with the notation Confidential Peer Review, Confidential, to be Opened Only by Addressee or words to that effect. If it is necessary to medical records or other documents containing a patient s protected health information, MIHS policies governing compliance with the HIPAA Security Rule shall be followed. 6.H Conflict of Interest Guidelines. To protect the integrity of the review process, all those involved must be sensitive to potential conflicts of interest. It is also important to recognize that effective peer review involves peers and that the PPEC does not make any recommendation that would adversely affect the clinical privileges of a practitioner (which is only within the authority of the MEC). As such, the conflict of interest guidelines outlined in Article 8 of the Credentials Policy shall be used in assessing and resolving any potential conflicts of interest that may arise under this Policy. Additional guidance pertaining to conflicts of interest principles can be found in Appendix F. 6.I Legal Protection for Reviewers. It is the intention of MIHS and the Medical Staff that the peer review process outlined in this Policy be considered patient safety, professional review, and peer review activity within the meaning of the Patient Safety Quality Improvement Act of 2005, the federal Health Care Quality Improvement Act of 1986, and Arizona law. In addition to the protections offered to individuals involved in professional review activities under those laws, such individuals shall be covered under MIHS s Directors and Officers Liability insurance and/or will be indemnified by MIHS when they act within the scope of their duties as outlined in this Policy and function on behalf of MIHS. 7. PEER REVIEW REPORTS 7.A Practitioner Peer Review History Reports. A practitioner peer review history report shall be generated for each practitioner for consideration and evaluation by the appropriate Department Chair and the Credentials Committee in the reappointment process. Such reports shall include all cases within the previous two years that resulted in an informational or educational letter, a collegial intervention or performance improvement plan. 7.B Reports to MEC and Board. QM shall prepare reports at least annually showing the aggregate number of cases reviewed through the peer review process and the dispositions of those matters. MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 19

152 7.C Reports on Request. QM shall prepare reports as requested by the Leadership Council, Department Chairs, Department or Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee, PPEC, MEC, MIHS management, or the Board. Adopted by the MEC on October 21, Adopted by the Maricopa Special Health Care District Board of Directors on, Approved: 11/09, 06/10, 03/11, 01/12, 01/13, Draft: 10/14 MIHS MEDICAL STAFF PEER REVIEW POLICY DRAFT 10/2014 (Supersedes 01/30/2013) Page 20

153 APPENDIX A RESPONSIBILITIES OF ASSIGNED REVIEWERS From time to time, the Leadership Council or the PPEC may assign the review and assessment of the care provided in a particular case to a physician with the necessary clinical expertise. The responsibilities of such Assigned Reviewers include the following: Initial Review and Documentation Review the pertinent parts of the medical record and all supporting documentation and document his or her assessment and findings using the specific review form provided by the committee that assigned the review. These forms have been developed by the PPEC to facilitate an objective, consistent, and competent review of each case. Time Frame Assigned Reviewers shall submit completed review forms to the committee that assigned the case within 30 days. A reminder will be sent if the review is not completed within this time frame. Review Process Following Assigned Reviewer s Assessment Review forms completed by an Assigned Reviewer will be reviewed and considered by the committee that assigned the review. The Assigned Reviewer will be contacted if additional information and expertise are necessary to facilitate the review. In certain cases, an Assigned Reviewer may be requested to attend a Leadership Council or PPEC meeting in order to discuss his or her findings and answer questions. Confidentiality Assigned Reviewers must maintain all information regarding a review in a strictly confidential manner. Specifically, this is a peer review-protected activity and Assigned Reviewers may not discuss matters under review with anyone outside of the process. If an Assigned Reviewer has not signed a Confidentiality Agreement within the past 12 months, QM will ask the reviewer to do so before he or she performs the review. Legal Protections When performing a review, Assigned Reviewers are acting on behalf of MIHS and the PPEC. As such, they have significant legal, bylaws, insurance, and indemnification protections

154 APPENDIX B RESPONSIBILITIES OF DEPARTMENT PEER REVIEW COMMITTEES The basic responsibilities of Department Peer Review Committees in the peer review process are as follows, which supplement the provisions contained in the Peer Review Policy: (1) Review cases referred by the QM, the Leadership Council, or the PPEC. The responsibilities of Department Peer Review Committees when directly reviewing a case are the same as those outlined in Appendix A for Assigned Reviewers. (2) Obtain Input from a Practitioner Prior to Pursuing Any Intervention to address a concern that has been identified. (3) Determine Appropriate Intervention/Referral. Following review, Department Peer Review Committees shall make one of the following determinations: (i) (ii) (iii) (iv) (v) no issue close case; prepare and send an informational or educational letter; conduct or facilitate a collegial intervention (face-to-face discussion); refer to the Leadership Council; or refer and present case to the PPEC. (4) Report to PPEC. All determinations or interventions made by Department Peer Review Committees shall be reported to the PPEC. Members of a Department Peer Review Committee may be requested to attend a PPEC meeting in order to discuss the committee s findings and answer questions

155 APPENDIX C RESPONSIBILITIES OF SPECIALIZED PEER REVIEW COMMITTEES, INCLUDING THE TRAUMA MULTI-DISCIPLINARY PEER REVIEW COMMITTEE The basic responsibilities of Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee, in the peer review process are as follows, which supplement the provisions contained in the Peer Review Policy: (1) Review Cases Referred by the QM, the Leadership Council, or the PPEC. The responsibilities of Specialized Peer Review Committees when directly reviewing a case are the same as those outlined in Appendix A for Assigned Reviewers. (2) For Trauma Multi-Disciplinary Peer Review Committee Only: Involve in the review the Committee representative from the specialty of the practitioner whose care is being reviewed. (3) Obtain Input from a Practitioner Prior to Pursuing Any Intervention to address a concern that has been identified. (4) Determine Appropriate Intervention/Referral. Following review, Specialized Peer Review Committees shall make one of the following determinations: (i) (ii) (iii) (iv) (v) no issue close case; prepare and send an informational or educational letter; conduct or facilitate a collegial intervention (face-to-face discussion); refer to the Leadership Council; or refer and present case to the PPEC. (5) Notify Department Chair of Proposed Intervention. If the Specialized Peer Review Committee, including the Trauma Multi-Disciplinary Peer Review Committee, determines to send an informational or educational letter or conduct a collegial intervention, it shall notify the relevant Department Chair of the preliminary intervention. The Department Chair shall then have 14 days to provide input regarding the proposed intervention. (6) Implement Intervention or Refer to PPEC. If the Specialized Peer Review Committee and Department Chair agree on the appropriate intervention, the Committee may implement the determination, including the Department Chair, as the Department Chair deems appropriate. If the Specialized Peer Review Committee and Department Chair do not agree on the appropriate intervention, the matter shall be referred to the PPEC for final determination

156 (7) Report to PPEC. All determinations or interventions made by Specialized Peer Review Committees, including the Trauma Multi-Disciplinary Peer Review Committee, shall be reported to the PPEC. Members of a Specialized Peer Review Committee may be requested to attend a PPEC meeting in order to discuss the committee s findings and answer questions

157 APPENDIX D PERFORMANCE IMPROVEMENT PLAN OPTIONS (May be used individually or combined) IMPLEMENTATION ISSUES CHECKLIST (For use by the PPEC) TABLE OF CONTENTS PAGE Additional Education/CME...1 Prospective Monitoring...2 Second Opinions/Consultations...3 Concurrent Proctoring...6 Formal Evaluation/Assessment Program...9 Additional Training...10 Educational Leave of Absence...11 Other

158 PIP OPTION Additional Education/CME Wide range of options Scope of Requirement Be specific what type? IMPLEMENTATION ISSUES Acceptable programs include: PPEC approval required before practitioner enrolls. Program approved: Date of approval: Time frames Practitioner must enroll by: CME must be completed by: Who pays for the CME/course? Practitioner subject to PIP Medical Staff MIHS Combination: Documentation of completion must be submitted to PPEC. Date submitted: Additional Safeguards Will the individual be asked to voluntarily refrain from exercising relevant clinical privileges until completion of additional education? Yes No Follow-Up After CME has been completed, how will monitoring be done to be sure that concerns have been addressed/practice has improved? (Focused prospective monitoring? Proctoring?)

159 PIP OPTION Prospective Monitoring 100% focused review of next X cases (e.g., obstetrical cases, laparoscopic surgery) IMPLEMENTATION ISSUES Scope of Requirement How many cases are subject to review? What types of cases are subject to review? Based on practitioner s practice patterns, estimated time for completion of monitoring? Does monitoring include more than review of medical record? Yes No If yes, what else does it include? Review to be done: Post-discharge During admission Review to be done by: QM Department Chair CMO Other: Must practitioner notify reviewer of cases subject to requirement? Yes No Other options? Documentation of Review General Case Review Worksheet Surgical Review Worksheet Medical Review Worksheet Specific form developed for this review General summary by reviewer Other: Results of Monitoring Who will review results of monitoring with practitioner? After each case After total # of cases subject to review

160 PIP OPTION Second Opinions/ Consultations Before the practitioner proceeds with a particular treatment plan or procedure, he or she obtains a second opinion or consultation. (This is not a restriction of privileges that triggers a hearing and reporting, if implemented correctly.) Scope of Requirement IMPLEMENTATION ISSUES How many cases subject to second opinion/consultation requirement? What types of cases are subject to second opinion/consultation requirement? Based on practice patterns, estimated time for completion of second opinion/consultation requirement? Must consultant evaluate patient in person prior to treatment/procedure? Yes No Responsibilities of Practitioner Notify consultant when patient subject to requirement is admitted or procedure is scheduled and all information necessary to provide consultation is available in the medical record (H&P, results of diagnostic tests, etc.). What time frame for notice to consultant is practical and reasonable (e.g., two days prior to scheduled, elective procedure)? If consultant must evaluate patient prior to treatment, inform patient that consultant will be reviewing medical record and will examine patient. If consultant must evaluate patient prior to treatment, include general progress note in medical record noting that consultant examined patient and discussed findings with practitioner. Discuss proposed treatment/procedure with consultant

161 PIP OPTION Second Opinions/Consultations Before the practitioner proceeds with a particular treatment plan or procedure, he or she obtains a second opinion or consultation. (This is not a restriction of privileges that triggers a hearing and reporting, if implemented correctly.) Qualifications of Consultant IMPLEMENTATION ISSUES Consultant must have clinical privileges in. Possible candidates include: The following individuals agreed to act as consultants and were approved by the PPEC (or designees) on: (date) Responsibilities of Consultant (Information provided by PPEC; include discussion of legal protections for consultant.) Review medical record prior to treatment or procedure. Evaluate patient prior to treatment or procedure, if applicable. Discuss proposed treatment/procedure with physician. Complete Second Opinion/Consultation Form and submit to QM (not for inclusion in the medical record). Disagreement Regarding Proposed Treatment/Procedure If consultant and physician disagree regarding proposed treatment/procedure, consultant notifies one of the following so that an immediate meeting can be scheduled to resolve the disagreement: CMO Chief of Staff PPEC Chair Department Chair Other:

162 PIP OPTION Second Opinions/Consultations Before the practitioner proceeds with a particular treatment plan or procedure, he or she obtains a second opinion or consultation. (This is not a restriction of privileges that triggers a hearing and reporting, if implemented correctly.) IMPLEMENTATION ISSUES Compensation for Consultant (consultant cannot bill for consultation) No compensation Compensation by: Practitioner subject to PIP Medical Staff MIHS Combination Results of Second Opinion/Consultations Who will review results of second opinion/consultations with practitioner? After each case After total # of cases subject to review Include consultants reports in practitioner s quality file Additional Safeguards Will practitioner be removed from some/all on-call responsibilities until second opinion/consultation requirement is completed? Yes No

163 PIP OPTION Concurrent Proctoring A certain number of the practitioner s future cases of a particular type (e.g., vascular cases, management of diabetic patients) must be directly observed. Scope of Requirement IMPLEMENTATION ISSUES How many cases are subject to concurrent proctoring requirement? What types of cases are subject to proctoring requirement? Based on practice patterns, estimated time for completion of proctoring requirement? (This is not a restriction of privileges that triggers a hearing and reporting, if implemented correctly.) Responsibilities of Practitioner Notify proctor when patient subject to requirement is admitted or procedure is scheduled and all information necessary for proctor to evaluate case is available in the medical record (H&P; results of diagnostic tests, etc.). What time frame for notice to proctor is practical and reasonable (e.g., two days prior to scheduled, elective procedure)? Procedures: Inform patient that proctor will be present during procedure, may examine patient and may participate in procedure, and document patient s consent on informed consent form. Medical: If proctor will personally assess patient or will participate in patient s care, discuss with patient prior to proctor s examination. Include general progress note in medical record noting that proctor examined patient and discussed findings with practitioner, if applicable. Agree that proctor has authority to intervene, if necessary. Discuss treatment/procedure with proctor

164 PIP OPTION Concurrent Proctoring A certain number of the practitioner s future cases of a particular type (e.g., vascular cases, management of diabetic patients) must be directly observed. (This is not a restriction of privileges that triggers a hearing and reporting, if implemented correctly.) IMPLEMENTATION ISSUES Qualifications of Proctor (PPEC must approve) Proctor must have clinical privileges in. (If proctor is not member of Medical Staff, credential and grant temporary privileges.) Possible candidates include: The following individuals agreed to act as proctors and were approved by the PPEC (or designees) on : (date) Responsibilities of Proctor (information provided by PPEC; include discussion of legal protections for proctor) Review medical record and: Procedure: Be present for the relevant portions of the procedure and remain throughout procedure and be available post-op if complications arise. Medical: Be available during course of treatment to discuss treatment plan, orders, lab results, discharge planning, etc., and personally assess patient, if necessary. Intervene in care if necessary to protect patient and document such intervention appropriately in medical record. Discuss treatment plan/procedure with practitioner. Document review as indicated below and submit to QM. Documentation of Review (not for inclusion in the medical record) General Case Review Worksheet Surgical Review Worksheet Medical Review Worksheet Specific form developed for this PIP Other:

165 PIP OPTION Concurrent Proctoring A certain number of the practitioner s future cases of a particular type (e.g., vascular cases; management of diabetic patients) must be directly observed. (This is not a restriction of privileges that triggers a hearing and reporting, if implemented correctly.) IMPLEMENTATION ISSUES Compensation for Proctor (proctor cannot bill for review of medical record or assessment of patient and cannot act as first assistant) No compensation Compensation by: Practitioner subject to PIP Medical Staff MIHS Combination Results of Proctoring Who will review results of proctoring with practitioner? After each case After total # of cases subject to review Include proctor reports in practitioner s quality file Additional Safeguards Will practitioner be removed from some/all on-call responsibilities until proctoring is completed? Yes No

166 PIP OPTION Formal Evaluation/ Assessment Program Onsite multiple-day programs that may include formal testing, simulated patient encounters, chart review. Scope of Requirement Acceptable programs include: IMPLEMENTATION ISSUES PPEC approval required before practitioner enrolls Program approved: Date of approval: Who pays for the evaluation/assessment? Practitioner subject to PIP Medical Staff MIHS Combination: Practitioner s Responsibilities Sign release allowing PPEC to provide information to program (if necessary) and program to provide report of assessment and evaluation to PPEC. Enroll in program by: Complete program by: Additional Safeguards Will the individual be asked to voluntarily refrain from exercising relevant clinical privileges until completion of evaluation/ assessment program? Yes No Will practitioner be removed from some/all on-call responsibilities until completion of evaluation/assessment program? Yes No Follow-Up Based on results of assessment, what additional interventions are necessary, if any? How will monitoring after assessment program/any additional interventions be conducted to be sure that concerns have been addressed/practice has improved? (Focused prospective review? Proctoring?)

167 PIP OPTION Additional Training Wide range of options from hands-on CME to simulation to repeat of residency or fellowship. IMPLEMENTATION ISSUES Scope of Requirement Be specific what type? Acceptable programs include: PPEC approval required before practitioner enrolls. Program approved: Date of approval: Who pays for the training? Practitioner subject to PIP Medical Staff MIHS Combination: Practitioner s Responsibilities Sign release allowing PPEC to provide information to training program (if necessary) and program to provide detailed evaluation/assessment to PPEC before resuming practice. Enroll in program by: Complete program by: Additional Safeguards Will the individual be asked to voluntarily refrain from exercising relevant clinical privileges until completion of additional training? Yes No Will practitioner be removed from some/all on-call responsibilities until completion of additional training? Yes No Is LOA required? Yes No Follow-Up After additional training is completed, how will monitoring be conducted to be sure that concerns have been addressed/practice has improved? (Focused prospective review? Proctoring?)

168 PIP OPTION Educational Leave of Absence IMPLEMENTATION ISSUES Who may grant the LOA? (Review Bylaws or applicable Policy) Specify conditions for reinstatement: What happens if the practitioner agrees to LOA, but does not return to practice at MIHS? Will this be considered resignation in return for not conducting an investigation and thus be reportable? Yes No moves practice across town? Must practitioner notify other Hospital of educational leave of absence? Yes No

169 PIP OPTION IMPLEMENTATION ISSUES Other Wide latitude to utilize other ideas as part of PIP, tailored to specific concerns. Examples: Participate in an educational session at section or department meeting and assess colleagues approach to case. Study issue and present grand rounds. Design and use informed consent forms approved by PPEC. Design and use indication forms approved by PPEC. Limit inpatient census. Limit number of procedures in any one day/block schedule. No elective procedures to be performed after p.m. All patient rounds done by certain time of day timely orders, tests, length of stay concerns. Personally see each patient prior to procedure (rather than using PA, NP, or APRN). Personally round on patients cannot rely solely on PA, NP, or APRN. Utilize individuals from other specialties to assist in PIPs (e.g., cardiologist experiencing difficulties with TEE technical complications mentored by anesthesiologists)

170 APPENDIX E-1: DETAILED FLOW CHART OF PEER REVIEW PROCESS Department Peer Review Committee Events That Trigger Review 1. Specialty-specific triggers 2. Reported concerns 3. Others defined in Peer Review Policy Quality Management (QM) 1. Log in referral 2. Initial fact-finding review and case preparation 3. Referral A. Department Peer Review Committee B. Specialized Peer Review Committee, including Trauma Multi-Disciplinary Peer Review Committee C. Leadership Council if administratively complex as defined in Peer Review Policy 1. Obtain additional information, including input from practitioner, if needed 2. Review case, complete appropriate review form 3. Determinations A. No further review or action required B. Informational letter C. Educational letter D. Collegial intervention E. Further review required. Refer to: i. Leadership Council ii. PPEC (Notify practitioner of review and request input prior to any intervention. Notify practitioner of referral to PPEC. Report determination to PPEC.) Leadership Council (Triage) 1. Obtain additional information considered relevant, including input from practitioner, if needed 2. Obtain additional clinical expertise, if needed 3. Determinations A. No further review or action required B. Informational letter C. Educational letter D. Collegial intervention E. Further review required. Refer to: i. Appropriate Peer Review Committee ii. PPEC iii. MEC (Notify practitioner of review and request input prior to any intervention. Notify practitioner of referral to PPEC. Report determination to PPEC.) Assigned Reviewer, Ad Hoc Committee, External Review 1. Review case 2. Complete appropriate review form 3. Report findings to Leadership Council Specialized Peer Review Committees, including Trauma Multi-Disciplinary Peer Review Committee 1. Obtain additional information, including input from practitioner, if needed 2. Review case, complete appropriate review form 3. Determinations A. No further review or action required B. Informational letter C. Educational letter D. Collegial intervention E. Further review required. Refer to: i. Leadership Council ii. PPEC (Notify practitioner of review and request input prior to any intervention. Notify Department Chair of any proposed intervention and provide opportunity for input. If Committee and Department Chair do not agree on proposed intervention, refer to PPEC. Notify practitioner of any referral to PPEC. Report all determinations to PPEC.) Assigned Reviewer, Ad Hoc Committee, External Review 1. Review case 2. Complete appropriate review form 3. Report findings to PPEC Multi-Specialty Professional Practice Evaluation Committee (PPEC) 1. Review determinations from prior levels of review (Each month also PPEC reviews determinations of one Department or Specialized Peer Review Committee.) 2. Obtain additional clinical expertise, if necessary 3. Notify practitioner of any preliminary issues/concerns and request input prior to determination 4. Determinations A. No further review required B. Informational letter C. Educational letter D. Collegial intervention E. Develop Performance Improvement Plan (PIP) as defined in Peer Review Policy F. Refer to MEC MEC Possible determinations same as for PPEC as well as those outlined in Credentials Policy Practitioner Whose Care is Under Review Possible system issues identified at ANY LEVEL shall be referred to the appropriate MIHS department and/or QM. Cases identified as appropriate to be presented in an Educational Session shall be referred to the appropriate Department Chair after the peer review process is complete.

171 APPENDIX E-2: SIMPLIFIED FLOW CHART OF PEER REVIEW PROCESS Events That Trigger Review Department Peer Review Committee Assigned Reviewer, Ad Hoc Committee, External Review Quality Management (QM) Leadership Council (Triage) Multi-Specialty Professional Practice Evaluation Committee (PPEC) Assigned Reviewer, Ad Hoc Committee, External Review MEC Practitioner Whose Care is Under Review Specialized Peer Review Committees, including Trauma Multi-Disciplinary Peer Review Committee Possible system issues identified at ANY LEVEL shall be referred to the appropriate MIHS department and/or QM. Cases identified as appropriate to be presented in an Educational Session shall be referred to the appropriate Department Chair after the peer review process is complete.

172 APPENDIX F CONFLICT OF INTEREST GUIDELINES Potential Conflicts Provide Information Individual Reviewer Application/ Case Department, Specialized, or Trauma Multi- Disciplinary Peer Review LEVELS OF PARTICIPATION Committee Member Credentials Leadership Council PPEC MEC Ad Hoc Investigating Hearing Panel Family member Y N R R R R R N N R Employment relationship with hospital Y Y Y Y Y Y Y Y Y Y Partner Y Y Y Y Y Y Y N N R Direct or indirect financial impact Y Y Y Y Y Y Y N N R Competitor Y Y Y Y Y Y Y N N R History of conflict Y Y Y Y Y Y Y N N R Close friends Y Y Y Y Y Y Y N N R Personally involved in care of patient Reviewed at prior level Raised the concern Y Y Y Y Y Y Y N N R Y Y Y Y Y Y Y N N R Y Y Y Y Y Y Y N N R Board

173 Y (green Y ) means the Interested Member may serve in the indicated role, no extra precautions are necessary. Y (yellow Y ) means the Interested Member may generally serve in the indicated role. It is legally-permissible for Interested Members to serve in these roles because of the check and balance provided by the multiple levels of review and the fact that the Department Peer Review, Specialized Peer Review Committee, Trauma Multi-disciplinary Peer Review Committee, Credentials Committee, Leadership Council, and PPEC have no disciplinary authority. In addition, the Chair of the Credentials Committee, Department Peer Review, Specialized Peer Review Committee, Trauma Multi-disciplinary Peer Review Committee, Leadership Council, or PPEC always has the authority and discretion to recuse a member in a particular situation if the Chair determines that the Interested Member s presence would inhibit the full and fair discussion of the issue before the committee, skew the recommendation or determination of the committee, or otherwise be unfair to the practitioner under review. Allowing Interested Members to participate in the credentialing or professional practice evaluation process underscores the importance of establishing (i) objective threshold criteria for appointment and clinical privileges, (ii) objective criteria to review cases while performing peer review activities (adopted protocols, etc.), and (iii) objective review and evaluation forms to be used by reviewers. N (red N ) means the individual may not serve in the indicated role. R (red R ) means the individual must be recused in accordance with the rules for recusal. Rules for Recusal Interested Members must leave the meeting room prior to the committee s or Board s final deliberation and determination, but may answer questions and provide input before leaving. Recusal shall be specifically documented in the minutes. Whenever possible, the actual or potential conflict should be raised and resolved prior to the meeting by the committee or Board chair and the Interested Member informed of the recusal determination in advance. No Medical Staff member has the RIGHT to demand recusal that determination is within the discretion of the Medical Staff Leaders. Voluntarily choosing to refrain from participating in a particular situation is not a finding or an admission of an actual conflict or any improper influence on the process

174 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.d.iv. Medical Staff

175 Department of Radiology I. Proposed Revision to Mammography Privileges Requested MAMMOGRAPHY AND BREAST INTERVENTIONAL CORE PRIVILEGES Includes: Screening and Diagnostic Mammography; Breast Ultrasound; Breast Tomosynthesis; Breast MRI Interpretation; as well as Interventional Breast Procedures that include: (If you wish to exclude any procedures, please strike through those procedures which you do not wish to request, initial, and date.) Cyst Aspiration, Core biopsy (i.e., Stereotactic or Ultrasound guided) Duct injection, Needle breast localization. and Pre-operative wire localization Initial Appointment Criteria: Certification by the American Board of Radiology in diagnostic radiology or the American Osteopathic Board of Radiology in diagnostic radiology or equivalent; or successful completion of an ACGME accredited Radiology Residency Training Program within the past two (2) years; OR If more than two (2) years out of an ACGME accredited Radiology Residency Training Program, documentation of 300 mammography interpretations in the past twelve (12) months; and completion of fifteen (15) Category One CME in Mammography within the past two (2) years; AND Completion of eight (8) hours of training in tomosynthesis, or the completion of residency training that included training in tomosynthesis, or documentation of experience in tomosynthesis interpretation deemed acceptable by the Department Chair of Radiology. Applicant must regularly participate in mammography continuing medical education (CME) programs. If applicant is more than five (5) years out of residency or fellowship training, documentation of 40 hours of CME credits in mammography is required. Focus Professional Practice Evaluation: Retrospective review of a minimum of 2 five (5) cases with satisfactory performance. Reappointment Criteria: Performance Interpret of 960 mammographic exams combined primary and secondary mammography cases within the past 24 months, AND completion of 10fifteen (15) Category One hours of CME in diagnostic mammography obtained within the past 24 monthsin a 36-month period. II. PROPOSED REVISION TO MRI PRIVILEGES (Neuro and Total Body) (Remove from Non-Core to Core) Requested GENERAL RADIOLOGY CORE PRIVILEGES Perform and interpret medical images for outpatients and inpatients within the Maricopa Integrated Health System. The core privileges in this specialty include those procedures listed and such other procedures that are extensions of the same techniques and skills. If you wish to exclude any procedures, please strike through those procedures which you do not wish to request, initial, and date. Image guided drainage from internal body locations; Medical images: o Diagnostic Radiology o Ultrasound (total body) o Computerized Tomography (Neuro and Total Body) o Magnetic Resonance Imaging (MRI-Neuro and Total Body) Perform Minor Invasive privileges: o Needle Breast Localization and Preoperative Wire Localization, o Venography, o Arthrography and Myelography Radiology Ultrasound (Total Body) Diagnostic Nuclear Medicine including Scans and/or Interpretations (excluding therapeutic nuclear radiology and PET/CT) Computerized Tomography (Neuro and Total Body) Ultrasound guided biopsies

176 Requested MRI PRIVILEGES (Neuro and Total Body) NON-CORE SPECIAL PROCEDURES Initial Appointment Criteria: Requesting practitioner will be required to submit documentation to support one of the following options: Letter from the Director of the physician s Residency Program documenting adequate training of Neuro and Total Body MRI procedures; OR For physicians who completed residency training prior to 1982, submission of a certificate documenting completion of a short-term fellowship training program in MRI procedures is required. Focus Professional Practice Evaluation: Retrospective review of a minimum of 2 cases with satisfactory performance. Reappointment Criteria: Performance of 100 cases reflective of the scope of privileges requested within the past 24 months as a results of ongoing professional practice evaluation activities and outcomes. Pending MIHS Board of Directors Approval: 10/2014

177 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 1.d.v. Medical Staff

178 Maricopa Integrated Health System NEONATOLOGY NURSE PRACTITIONER Privileges and Practice Prerogatives RESPONSIBLE PARTY: PROFESSIONAL PRACTICE DEFINITION: DEFINITION(S): Department Chair, or his/her designee A Nurse Practitioner (NP) is an advanced practice nurse who provides primary health care and specialized health services to individuals and families. The Nurse Practitioner is employed or contracted to provide services to inpatients and outpatients in the Maricopa Integrated Health System. "COLLABORATION" means the collaboration with (or supervision of) a Category II practitioner by a Collaborating Physician, that may or may not require the actual presence of the Collaborating Physician, but that does require, at a minimum, that the Collaborating Physician be readily available for consultation. The requisite level of supervision (general, direct, or personal)* shall be determined at the time each Category II practitioner is credentialed and shall be consistent with any applicable written supervision or collaboration agreement that may exist. PREROGATIVES: SUPERVISION means under the general supervision of an attending physician unless otherwise instructed. Shall practice within his/her scope of practice, training and experience to independently assess, diagnose, plan, and treat illnesses by using and adhering to departmental protocols governing patient management, in accordance with Arizona Nursing Board, Arizona Statutes and Arizona Administrative Code. Shall practice in collaboration with an Attending Physician who has unrestricted privileges and medical staff membership in good standing at the Maricopa Integrated Health System and seek appropriate consultation when necessary. Shall participate in quality assurance review on a periodic basis, including systematic review of records and treatment plans Shall make appropriate referrals to other health professionals and community agencies. Shall participate in CME and other Department educational conferences. May write admitting orders on behalf of a designated member of the Medical Staff to initiate a patient s entry into a Maricopa Integrated Health System inpatient facility. All admitting orders must be authenticated by the designated medical staff member. May prescribe and dispense medications within guidelines approved by the Arizona State Board of Nursing and the Drug Enforcement Administration and Arizona State Board of Pharmacy. May assist in research activities within their respective MIHS Department. May not write Do Not Resuscitate or Discontinue Life Support orders. Page 1 of 3

179 Education/Licensure Board Certification Insurance Clinical Activity Guidelines for Initial Appointment Maricopa Integrated Health System NEONATOLOGY NURSE PRACTITIONER Privileges and Practice Prerogatives Criteria-Based Core Privileges INITIAL APPLICANTS Completion of a master s, post-master s, or doctorate from an NP program accredited by the Commission on the Collegiate of Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLNAC) with emphasis on the NP s specialty area; and Current active licensure to practice as an advanced practice registered nurse in the NP category in the State of Arizona. Certified by a national certifying body that is accredited by the National Commission for Certifying Agencies, the American Board of Nursing Specialties, or an equivalent organization as determined by the Rules of the Arizona State Board of Nursing. As per the Arizona State Board of Nursing, national certification prior to July 1, 2004 was not requirement for licensure. Provide proof of general and professional liability insurance coverage at the standards specified by the Maricopa Hospital & Health System Board. Applicants for initial appointment must be able to demonstrate provision of neonatology services, for at least 50 patients, reflective of the scope of privileges requested, during the past 12 months in a setting similar in scope and complexity to MIHS; or demonstrate successful completion of an accredited college or university formal masters program or a postmasters program in nursing with a concentration in an advanced practice registered nursing category and specialty (as defined under R of the Rules of the State Board of Nursing ) within the past 12 months. FOCUSED PROFESSIONAL PRACTICE EVALUATION Minimum of 5 representative cases shall be reviewed (additional records may be reviewed to assess the scope of practice has been covered) to include evaluation of chief complaint; history & physical; use of ancillary services; appropriateness of diagnosis; and discharge/instruction and completed in accordance with the MIHS Focused Professional Practice Evaluation to Confirm Practitioner Competence Policy. REAPPOINTMENT Current demonstrated competence and current experience with acceptable results for 30 patients reflective of the scope of privileges requested for the past 24 months as a result of ongoing professional practice evaluation activities and outcomes. Requested NEONATOLOGY CORE PRIVILEGES *Perform history and physical examination, evaluate, diagnose, and provide care, treatment, and services consistent with neonatal/perinatal practice for newborn babies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills. If you wish to exclude any procedures, please strike through those procedures that you do not wish to request, initial, and date. 1. Evaluate newborn babies. Discriminate between normal and abnormal findings on the physical examination, record these findings, and form an impression of the infant s status/disposition. Confer with an attending physician on abnormal finding and disposition. 2. Order and obtain samples for appropriate studies and discuss results with neonatologist. Institute appropriate action subsequent to conference with the neonatologist 3. Order diagnostic testing and therapeutic modalities such as laboratory tests, medications, treatments, X-ray, EKG, IV fluids and electrolytes, etc. 4. Order the use and discontinuation of phototherapy subsequent to conference with the neonatologist 5. Perform field infiltrations of anesthetic solutions 6. Perform newborn physical examinations using the techniques of observation, inspection, auscultation, palpation, and percussion 7. Perform arterial punctures for blood sampling, cultures, and IV catheterization 8. Provide immediate supportive care of the newborn in the delivery room *Inpatient history and physical examinations are the responsibility of and require review and countersignature by a member of the MIHS medical staff. Page 2 of 3

180 Maricopa Integrated Health System NEONATOLOGY NURSE PRACTITIONER Privileges and Practice Prerogatives Requested NEONATOLOGY INTENSIVE CARE CORE PRIVILEGES Evaluate, diagnose, treat, provide consultation to newborns presenting with severe and complex life-threatening problems such as respiratory failure, shock, congenital abnormalities, and sepsis, and provide consultation to mothers with high-risk pregnancies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. Includes Nurse Practitioner Neonatology Core Privileges. If you wish to exclude any procedures, please strike through those procedures that you do not wish to request, initial, and date. Initial Appointment: Applicant must satisfy the qualification requirements for nurse practitioner in neonatology; AND Hold current Neonatal Resuscitation Program certification; AND Demonstrate provision of care, treatment, or services reflective of the scope of privileges requested to at least twenty-five (25) patients in the past 12 months, OR demonstrate completion of master s or post-master s degree program in the past 12 months. Focused Professional Practice Evaluation: Minimum of 5 representative cases shall be reviewed (additional records may be reviewed to assess the scope of practice has been covered) and completed in accordance with the MIHS Focused Professional Practice Evaluation to Confirm Practitioner Competence Policy. Reappointment: Current demonstrated competence and current experience with acceptable results for twenty (20) patients reflective of the scope of privileges requested for the past 24 months as a result of ongoing professional practice evaluation activities and outcomes. 1. Assist in management of neonates 2. Attend Cesarean-section and high-risk deliveries 3. Conduct comprehensive patient review and chart notes for patients deemed appropriate by the neonatologist 4. Develop and implement an initial plan for patients in collaboration with the neonatologist 5. Write and effectively communicate orders in accordance with management protocols 6. Perform diagnostic and therapeutic procedures including, but not limited to: A. Perform emergency needle thoracentesis B. Perform endotracheal intubation C. Perform lumbar punctures D. Assist attending physician in performing exchange transfusions E. Initiate cardiopulmonary resuscitation/code arrest F. Insert and manage percutaneous arterial catheters G. Insert and manage percutaneous venous catheters H. Insert and manage umbilical artery and venous catheters I. Performing laryngoscopy and suction J. Ventilator management for newborns and infants K. Perform Diagnostic and Therapeutic procedures that include: Emergency Thoracotomy and Chest Tube Insertion Acknowledgement of Applicant I have requested only those practice prerogatives for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at The Maricopa Integrated Health System, and I understand that: a. In exercising any practice prerogatives granted, I am constrained by Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation. b. Any restriction on the practice prerogatives granted to me is waived in an emergent situation and in such situation; my actions are governed by the applicable section of the Medical Staff Bylaws or related documents. Signed Applicant Date Pending MIHS Board of Directors Approval: 10/2014 Page 3 of 3

181 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 2. Social Return on Investment

182 MARICOPA INTEGRATED HEALTH SYSTEM: Part 3: Social Return on Investment, Dr. Dennis Hoffman, Dr. Kent Hill, and Dr. Anthony Evans, L William Seidman Research Institute, W. P. Carey School of Business, Arizona State University FINAL REPORT October 20, 2014

183 L. WILLIAM SEIDMAN RESEARCH INSTITUTE The L. William Seidman Research Institute serves as a link between the local, national, and international business communities and the W. P. Carey School of Business at Arizona State University (ASU). First established in 1985 to serve as a center for applied business research and a consultancy resource for the Arizona business community, Seidman collects, analyzes and disseminates information about local economies, benchmarks industry practices, and identifies emerging business research issues that affect productivity and competitiveness. Using tools that support sophisticated statistical modeling and planning, supplemented by an extensive understanding of the local, state and national economies, Seidman today offers a host of economic research and consulting services, including economic impact analyses, economic forecasting, general survey research, attitudinal and qualitative studies, and strategic analyses of economic development opportunities. Working on behalf of government agencies, regulatory bodies, public or privately owned firms, academic institutions, and non profit organizations, Seidman specializes in studies at the city, county or state wide level. Recent and current clients include: Arizona Commerce Authority (ACA) Arizona Corporation Commission (ACC) Arizona Department of Health Services Arizona Department of Mines and Mineral Resources Arizona Hospital and Health Care Association Arizona Investment Council (AIC) Arizona Mining Council Arizona Public Service Corporation (APS) Arizona School Boards Association Arizona Town Hall ASU Athletics The Boeing Company The Central Arizona Project (CAP) DeMenna & Associates Epic Rides/City of Prescott Envision Health Care/AMR Excelsior Mining Executive Budget Office State of Arizona First Things First Freeport McMoran Glendale Community College Goodwill Industries Maricopa Integrated Health System Intel Corporation istate Inc. The McCain Institute The Morrison Institute Navajo Nation Div. Economic Development Phoenix Convention Center Phoenix Sky Harbor International Airport Public Service New Mexico (PNM) Raytheon Rosemont Copper Mine Salt River Project (SRP) Science Foundation Arizona (SFAZ) The Tillman Foundation Turf Paradise Valley METRO Light Rail Twisted Adventures Inc. Vote Solar Initiative Waste Management Inc.

184 INTRODUCTION This is the third of three reports quantifying the economic impact of Maricopa Integrated Health System (MIHS). Seidman s first two reports estimated the economic impact of MIHS for two distinct time horizons: CY2013, and CY The CY2013 analysis drew from the most recent historical data provided by MIHS. The second analysis estimated the future construction and operational economic impacts of MIHS, CY , if a $935 million issuance of General Obligation Bonds to finance several strategic capital projects is ballot approved by voters. The primary objective of this third and final report is to explore the social return on investment (SROI) associated with having a healthier population, as a result of MIHS successful clinical interventions. The report is divided into three sections. Section 1 provides a general overview of the magnitude of potential benefits that can accrue from the prevention and cure of diseases and chronic conditions. Section 2 describes the methodology used by Seidman to estimate the benefits and/or cost reductions of particular healthcare interventions. Section 3 offers a range of estimates to demonstrate the potential benefits of MIHS, dependent on the success rates of different scenarios. 1. THE POTENTIAL BENEFITS OF PREVENTING AND CURING DISEASES AND CHRONIC CONDITIONS Investments directed towards the cure and prevention of disease can potentially improve the quality of life for millions of Americans. However, these benefits extend far beyond improvements in the human condition. People with improved health outcomes invariably require less costly ongoing treatment, and become more productive workers. The potential monetary benefits of successful health care intervention are well documented. In 2011, the Center for Disease Control and Prevention (CDC) published a white paper explaining how modest improvements in the health status of U.S. workers could have positive implications for the nation s GDP. 2 Focusing specifically on the benefits for business, the CDC concluded that investments in disease and chronic illness prevention could: Lower Health Care costs and insurance premiums; Increase worker productivity via lower absentee rates; Positively impact national GDP and global competitiveness; and 1 CY = calendar year. 2 CDC, (2011). Investing in Prevention Improves Productivity and Reduces Employer Costs, available at: 1

185 Engender healthier communities of appeal to new residents, tourism and other businesses, thereby broadening the size of local markets. Examples of preventative programs and savings cited by the CDC included: A reduction in medical costs of $3.37, and absenteeism costs of $2.73, for every dollar spent on workplace wellness programs; A $3.7 billion annual saving in medical costs if tobacco cessation screening, alcohol abuse screening, and aspirin use programs were implemented at 90% of the recommended level; and A productivity increase of $200 $440 per worker if asthma, high blood pressure, smoking and obesity risk programs were introduced at 90% recommended levels. An earlier seminal study by the Milken Institute also concluded that an increase in preventive health measures targeted at seven common chronic illnesses offered significant potential for economic growth. 3 The seven illnesses studied by the Milken Institute were cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions, and mental disorders. Noting that more than 109 million Americans suffered from one or more of the chronic diseases in 2003, the Milken Institute conservatively estimated an annual loss of $1.1 trillion productivity, and $277 billion expenditure on treatment nationwide. By 2023, they projected that million non institutionalized Americans could suffer from one or more of the seven chronic illnesses, resulting in a $4.2 trillion cost for treatment and lost economic output. However, if modest improvements in prevention and treatment were implemented, the Milken Institute also estimated that 40 million cases of chronic disease could be avoided by 2023, treatment costs could fall by $218 billion a year, and the nation s gross domestic product could increase by $905 billion. A significant part of the Milken study was devoted to the prevention of behavioral health diseases such as obesity and smoking. However, it also emphasized the economic benefits of improved health outcomes associated with preventative care measures, some of which could result from the provision of new health care facilities. Table 1: Current and Avoidable Costs of Seven Chronic Diseases Geography Number of Cases of Chronic Disease (Thousands) Total Cases (Current Path) Avoided Cases (Alternative Path) Percent Cases Avoided in 2023 Economic Burden of Economic Disease (US$ Billions) Total Avoided Percent Burden Burden Economic (Current (Alternative Burden Path) Path) Avoided in 2023 Arizona 5, % % State Average 4, % % USA Total 230,724 40, % 4,153 1, % Source: The Milken Institute (2007) 3 The Milken Institute, (2007). An Unhealthy America: The Economic Burden of Chronic Disease Charting a New Course to Save Lives and Increase Productivity and Economic Growth. Prepared by Ross DeVol and Armen Bedroussian, Santa Monica. 2

186 Table 1 compares the Milken Institute s potential avoidable costs for Arizona with a U.S. state average. The table estimates that the economic burden of the seven chronic diseases studied in Arizona could be as high as $97 billion in 2023 if no new preventative measures are introduced. However, a modest preventative strategy could reduce the loss to the Arizona economy by up to $26 billion. Increasing the range of preventative medicine options offered by MIHS, including particular public access to the programs, could undoubtedly make a positive contribution to the Milken Institute s potential $26 billion reduction in the economic burden of chronic disease. The CDC and Milken studies clearly illustrate the significant costs to the local and national economy associated with chronic diseases, alongside the potential economic gains emanating from interventions that lead to improved health outcomes. Section 2 will now propose a method for estimating the benefit/cost reductions of health care interventions at MIHS. 2. ESTIMATING BENEFIT/COST REDUCTIONS OF HEALTH CARE INTERVENTIONS METHODOLOGY In June 2009, the Seidman Institute in association with the Morrison Institute at ASU, proposed a means of measuring the economic cost of poor health as part of a detailed analysis of healthcare in the State of Arizona. 4 This approach is based on three categories of economic costs associated with poor health, and it will be implemented in the current study. Seidman s on three categories of economic cost are: The resource costs associated with the treatment of a condition or disease including the costs of physician s visits, tests, medication, and surgical procedures; The loss of output, or decline in productivity, when poor health interferes with a person s ability to work, either through absenteeism or presenteeism; 5 and The loss of life or decline in quality of life because of a disease. 2.1 Treatment Costs Persons suffering from a disease generate a variety of costs associated with diagnosis, management, and treatment of that disease. Examples include the costs of a physician s visit for a checkup, medication for management of hypertension or cardiovascular disease, psychiatric appointments for people suffering from depression, surgery to repair a broken leg, or the regular blood work necessary to monitor AIDS patients. Based on 2003 national data, the cost of treating chronic diseases can range from a high of $5,700 per year for stroke victims, to a low of $900 per year for those afflicted with asthma or hypertension. The average cost of treating cancer patients in this data set is $4,500 per year. The total cost of treating any chronic disease is dependent on two key components: the cost per case, and also the incidence of that disease in the population. The number of U.S. residents suffering from asthma, for example, is 4½ times as high as the number suffering from cancer, and 20 times as high as those who have had a stroke. 4 ASU, (2009). Truth and Consequences: Gambling, Shifting, and Hoping in Arizona Health Care. 5 Presenteeism refers to people who suffer from poor health but still attend work, which frequently lowers their productivity. 3

187 Figure 1: Average Treatment Costs for Chronic Diseases in Arizona and the U.S., 2003 (costs per person reporting condition) $6,000 $5,667 $5,000 $4,917 $4,538 $ Per Person $4,000 $3,000 $2,000 $3,716 $3,370 $2,940 $1,978 $1,752 $1,512 $1,559 $1,000 $919 $761 $883 $790 $0 US AZ Source: The Milken Institute (2007) Figure 1 estimates the total treatment expenditures for seven types of chronic disease in the United States in Approximately $277 billion was estimated to be spent on treating these diseases in This represented 2.5% of U.S. gross domestic product at that time. The category with the highest treatment costs was heart disease with costs of $65 billion. Other categories with high treatment costs were cancer ($48 billion) and asthma ($45 billion). Total treatment costs for the seven chronic diseases in Arizona in 2003 were estimated at $4.2 billion. This represented 2.3% of Arizona gross state product in Productivity Losses Workforce productivity losses occur through absenteeism and presenteeism. Absenteeism refers to the economic costs associated with lost work days due to illness. The Washington Employers Association (2005) has issued guidelines for measuring rates of absenteeism and their associated costs. They suggest that absenteeism costs should include lost wages and other forms of compensation, premium pay for temporary help, premium pay for overtime work, and any losses associated with substandard production. Presenteeism refers to employees who attend work but are unable to function at a normal level because of their illness or disease. Common afflictions which give rise to significant presenteeism costs include depression, arthritis, and lower back pain. The principal difficulty in estimating the costs of presenteeism is finding a valid way to measure the decline in worker productivity. 4

188 One credible estimate of the costs of absenteeism and presenteeism for ten chronic conditions was provided by the MEDSTAT Group at Cornell University. 6 Their costs, shown in Table 2, were based on two assumptions an average hourly wage of $23.15, and an average working year of 240 days. Table 2: Estimating the Individual Costs of Absenteeism and Presenteeism for Chronic Diseases in the U.S. Condition Absenteeism Presenteeism Days Absent Per Year Per Case Annual Dollar Impact Per Case (2001 $) Hours Lost Per Day Per Case Annual Dollar Impact Per Case (2001 $) Allergy 8.2 1, ,889 5,000 Arthritis 5.9 1, ,778 5,000 Asthma , ,334 5,000 Cancer , ,111 3,889 Diabetes ,111 5,000 Heart Disease 6.8 1, ,778 Hypertension ,334 Mental Disorder , ,889 6,667 Migraine , ,889 8,890 Respiratory Disorders , ,556 7,778 Source: The MEDSTAT Group (2004) Looking first at the costs of absenteeism, MEDSTAT estimated that people suffering from mental disorders missed on average around 26 days of work per year at an annual cost of $4,700. People with cancer missed an average of 17 days of work per year at a cost of $3,100. Employees suffering from hypertension missed on average 0.9 days of work a year at a cost of $170. MEDSTAT provided ranges of hours lost per day and annual dollar impacts per case for presenteeism. The lowest figure for each chronic condition represented their low estimate. The upper figure represented their average estimate. Table 2 illustrates that the costs of presenteeism were significantly greater than the costs of absenteeism for eight of the ten chronic diseases studied. Individuals suffering from hypertension, for example, missed only one full day of work per year and lost a maximum 0.6 hours per day in diminished productivity. However, hypertension s annual dollar impact for presenteeism was considerably higher that is, up to $3,334 per case compared to an absenteeism cost of only $170 per case. It is important to note that Table 2 s cost estimates were exclusively for the loss of individual productivity. If an individual suffering from a chronic disease works in a team, they can also affect the productivity of their colleagues. The extent to which this productivity loss extends to other people is dependent on the nature of the work. For some occupations, such as waiters, fast food cooks, and non residential construction workers, the spillover effects are negligible. However, team effects are more important for professions such as paralegals, mechanical engineers who work in groups, and motor vehicle salesmen, increasing the estimated absence 6 Goetzel, Long, Ozminkowski, Hawkins, Wang, and Lynch, (2004). Health, Absence, Disability, and Presenteeism Cost Estimates of Certain Physical and Mental Health Conditions Affecting U.S. Employees, Journal of Occupational and Environmental Medicine, Vol. 46:

189 multiplier by 1.5 to 2 times. A 2005 study at Dow Corning, for example, estimated a mean absence multiplier of 1.61 for 35 types of job, and a median of Mortality and Lower Quality of Life For many people, the most important consequence of poor health is that it may reduce life expectancy and lower the quality of those years remaining. Life and quality of life are difficult to value. Nevertheless, economists and healthcare professionals have developed a quality adjusted life year (QALY) system that can be used to make tough decisions involving the rationing of scarce health care resources, or the setting of reasonable standards in safety regulations. A QALY is a number between 0 and 1, where 0 indicates death and 1 is a state of perfect health. Three different methods have been used to assign value to QALY for a person in a given state of health: One method involves a time trade off, where respondents choose between remaining in a state of less than perfect health for a certain period of time, compared to living in perfect health for a shorter period. A second method uses a visual analogue scale, where respondents rate different health alternatives ranging from 0 (death) to 100 (perfect health). A third method, called the standard gamble, presents a person with the possibility of undergoing a medical procedure that will either restore him to perfect health or result in his death. The probabilities of the two outcomes are adjusted until the person is indifferent between choosing the procedure and remaining in his current condition. The probability of a complete recovery can be used to define QALY. Aside from the quality issue, the value of a life also needs to be measured. The approach frequently used to assign a monetary value to a year of life is to identify how much money people are willing to spend to reduce their chances of dying. For example, when airbags were an optional extra in car purchases, the market price was $300. For the marginal buyer, the value of the additional safety provided by the airbag was therefore perceived to be $300. The chance that an airbag would save the life of a driver was 1 in 10,000. Multiplying 10,000 by the cost of one air bag establishes a value for a statistical life of at least $3 million. It is commonly accepted that the value of a life generally falls within the range of $3 million to $7 million per person. 8 Adjusting for the average age of individuals, the value of another year of life is therefore between $75,000 and $150, ESTIMATING THE SOCIAL RETURNS ON INVESTMENT ASSOCIATED WITH MIHS The previous Section has identified three critical components for estimating the economic benefits that can accrue from prevention and treatment programs designed to foster healthy outcomes. The current Section will now apply this method to patient care estimates provided by MIHS management team, to quantify in 2013 dollars (2013 $) the SROI of the health care programs and health care efficiency gains if the bond request is voter approved and implemented. 7 Nicholson, Pauly, Polsky, Baase, Billotti, Ozminkowski, Berger, and Sharda, (2005). How to Present the Business Case for Healthcare Quality to Employers, Applied Health Economics & Health Policy, Vol. 4 (4): For example: Viscusi, (1993). The Value of Risks to Life and Health, Journal of Economic Literature, Vol. 31:

190 Table 3 shows the updated 2013 $ medical treatment, absenteeism, and presenteeism values used by Seidman for the State of Arizona in their calculations. Two sets of figures are used to quantify presenteeism the lowest value represents the low cost estimate, and the highest value the average cost estimate. Table 3: Current Estimates of the Costs of Medical Treatment, Individual Absenteeism and Individual Presenteeism for Select Chronic Diseases in the State of Arizona Condition Medical Treatment Costs Per Diseased Patient Case (2013 $) Days Absent Per Year Per Case Absenteeism Annual Dollar Impact Per Case (2013 $) Hours Lost Per Day Per Case Presenteeism Average Annual Dollar Impact Per Case (2013 $) Allergy , ,523 7,101 Arthritis 1, , ,945 7,101 Asthma 1, , ,734 7,101 Cancer 4, , ,578 5,523 Diabetes 3, ,578 7,101 Heart Disease 17, , ,945 Hypertension 1, ,734 Mental Disorder 2, , ,523 9,467 Migraine 1, , ,523 12,623 Respiratory Disorders 21, , ,890 11,045 Average All 10 Diseases 5, , ,629 7,574 Source: Authors The County Health Rankings and Roadmaps program uses data from the Behavioral Risk Factor Surveillance Systems (BRFSS) to measure vital health factors at a state and county basis throughout the U.S., and provide a snapshot of how health is influenced by where people live, learn, work and play. The current 2014 County Health data for the State of Arizona estimates that people experience poor physical ill health on average 3.5 days in every 30, and poor mental health on average 3.4 days in every For Maricopa County, this drops to 3.2 days in every 30 for both measures. A conservative assumption that workplace productivity is only adversely impacted on half of these days, thereby taking into account the fact that not every patient is in employment, therefore suggests that up to 36 days a year can be lost through illness; and the estimated loss to the economy from this absence is approximately $12 billion (2013 $). Access to quality health care facilities can offer workers the opportunity to obtain treatment to mitigate some of this lost income; and the approval and implementation of a $935 million bond will ensure that MIHS not only continues to offer, but also makes more widely available these types of facilities. To further illustrate the potential importance of MIHS enhanced facilities if the $935 million bond request is voterapproved, Seidman has sourced unique patient clinic encounter records for MIHS s Comprehensive Health Center (CHC) and Family Health Center (FHC) in FY2014 by type of condition. The data is shown in Table 4. In FY2014, MIHS CHC handled 79,709 unique out patients; and their FHC looked after 14,235 unique out patients. 9 Source: County Health Rankings & Roadmaps, (2014). and 7

191 8 of the 25 conditions listed in Table 4 can be matched with chronic diseases listed in Table 3 to estimate the cost of individual absenteeism and presenteeism for MIHS FY2014 clinics. Table 3 s average costs can also be applied to a further 15 of the conditions listed in Table 4. The neonatal and newborn cases listed in Table 4 have been excluded from Seidman s calculations because the patients are not part of the labor force. Table 4: Summary of MIHS Healthcare Provision in FY2014 by Center and Unique Out Patient Condition Community Health Center Family Health Center OP Aftercare/Follow Up 3, OP All Other 13 1 OP Behavioral Health OP Benign Neoplasms 1, OP Burns 80 5 OP Cancer 2, OP Cardiovascular 3,056 1,435 OP Dermatology 3, OP Digestive 3, OP Endocrine 5,718 2,218 OP ENT 1, OP General Medicine 7,908 1,478 OP Gynecology 2, OP Infectious Disease 2, OP Neonates OP Nephroplogy OP Neurosciences 5,422 1,029 OP Newborn OP Obstetrics 4, OP Opthamology 6, OP Orthopedics 6, OP Pulmonary 3, OP Rheumatology 1, OP Screenings/Exam 8,715 2,596 OP Urology 2, Total 79,709 14,235 Source: MIHS Table 5 conservatively estimates the productivity gains and medical cost savings associated with successful interventions at MIHS s CHC and FHC in FY2014. Two success rate levels are illustrated a 25% success rate and a 50% success rate. These two success rate levels are conservative to reflect the fact that not every patient at MIHS is currently employed in the State of Arizona. Table 5 estimates that the productivity gains associated with a 25% success rate at the CHC and FHC could range from $142 to $235.3 million per year (2013 $). 8

192 Table 5: Economic Estimates of Successful MIHS Clinic Interventions 10 Clinic Annual Patients Individual Productivity Gains (Millions 2013 $) Medical Savings (Millions 2013 $) 25% Success Rate CHC 79, % Success Rate % Success Rate 50% Success Rate Total Economic Value (Millions 2013 $) 25% Success Rate % Success Rate FHC 14, Total 93, Source: MIHS Table 5 also estimates that the productivity gains associated with a 50% success rate at the CHC and FHC could range from $284 to $470.7 million per year (2013 $). These productivity gains are on an individual basis only. They do not take into account any productivity impacts for patients workplace colleagues, because the occupation profile of out patients is confidential. Seidman s productivity estimates therefore clearly err on the side of caution. The ranges for each type of clinic provided in Table 5 also reflect the low and average cost estimates for presenteeism. The medical cost savings associated with the future avoidance of healthcare could range from $125.4 million at a 25% success rate to $250.7 million at a 50% success rate (2013 $). The estimated total economic value associated with a 25% success rate at the CHC and FHC could therefore range from $267.4 to $360.7 million (2013 $). The estimated total economic value associated with a 50% success rate at the CHC and FHC could range from $534.7 to $721.4 million (2013 $). It is important to note that these SROI estimates are based on FY2014 unique out patient data for MIHS CHC and FHC. If the $935 million bond request is voter approved, the strategic capital improvements will include the renovation and expansion of Family Health Centers, the expansion of the current Comprehensive Health Center, the addition of two new Comprehensive Health Centers in the East and West Valley, and a new behavioral health hospital. MIHS capital investment program will also allow for the replacement of an acute care hospital, and increased ambulatory capacity. It would be presumptuous to predict with any degree of accuracy the likely increase in MIHS out patient clinic encounters if the $935 million bond request is ballot approved. Nevertheless, this Section has demonstrated the significant annual value already provided by MIHS clinics. To put it into perspective, the SROI associated with MIHS current clinics for just one year is already equivalent to a conservative value ranging from a quarter to a half of the total value of the bond proposal currently under review by the local population. Given the level of capital investment planned for MIHS clinics if the bond proposal is 10 Totals may not tally exactly due to rounding up. 9

193 voter approved, it is fair to assume that the SROI associated with the new and/or improved facilities at MIHS will be even higher. The SROI estimate is also in addition to the economic impacts associated with the proposed construction and revised operation of MIHS. 10

194 L. WILLIAM SEIDMAN RESEARCH INSTITUTE 660 S MILL AVENUE, SUITE 300 TEMPE AZ Tel: (480) Fax: (480)

195 Maricopa Integrated Health System: Social Return on Investment, 2013 October 29, 2014

196 Introduction Seidman = consultancy arm of W. P. Carey School of Business, ASU Commissioned by MIHS to implement 3 analyses: Economic Impact of MIHS in 2013 Economic Impact of MIHS, Social ROI analysis Today s presentation focuses on the Social ROI analysis

197 Partial Net Analysis: Annual Statewide Results $1.3 B. 8,327 8,527 to 11,718 $834 M. $844 M. $456 M. $86 M. $37 M. Job Years Gross State Product Real Disposable Personal Income State Tax Revenue Total Private Non-Farm Employment CY2013 Total Private Non-Farm Employment CY CY Ratio of 1 MIHS job:1.13 PNFE jobs CY Ratio of 1 MIHS job:1.4 PNFE jobs

198 Seidman s Method Cost of diagnosis, management and treatment Economic cost of underperforming workers due to illness Economic Cost of Ill Health = Medical Cost Cost of + + Absenteeism Cost of Presenteeism Economic cost of lost work days due to illness

199 Economic Metrics: State of Arizona Condition Medical Treatment Costs Per Patient (2013 $) Absenteeism Annual $ Impact Per Patient (2013 $) Presenteeism Average Annual $ Impact Per Patient (2013 $) Allergy 979 2,160 5,523-7,101 Arthritis 1,399 1,546 3,945-7,101 Asthma 1,954 3,154 4,734-7,101 Cancer 4,695 4,449 1,578-5,523 Diabetes 3, ,578-7,101 Heart Disease 17,452 1,785 3,945 Hypertension 1, ,734 Mental Disorder 2,296 6,732 5,523-9,467 Migraine 1,261 2,823 5,523-12,623 Respiratory Disorders 21,761 3,872 7,890-11,045 Average All 10 Diseases 5,720 2,728 3,629-7,574 Sources: Milken Institute; MEDSTAT Group

200 MIHS 2013 Unique Out-Patient Data Condition CHC FHC OP Aftercare/Follow Up 3, OP All Other 13 1 OP Behavioral Health OP Benign Neoplasms 1, OP Burns 80 5 OP Cancer 2, OP Cardiovascular 3,056 1,435 OP Dermatology 3, OP Digestive 3, OP Endocrine 5,718 2,218 OP ENT 1, OP General Medicine 7,908 1,478 OP Gynecology 2, Condition CHC FHC OP Infectious Disease 2, OP Neonates OP Nephroplogy OP Neurosciences 5,422 1,029 OP Newborn OP Obstetrics 4, OP Opthamology 6, OP Orthopedics 6, OP Pulmonary 3, OP Rheumatology 1, OP Screenings/Exam 8,715 2,596 OP Urology 2, Total 79,709 14,235 Source: MIHS

201 MIHS Economic Cost Estimates, % Success Rate = $ $360.7 Million 50% Success Rate = $ $721.4 Million

202 Caveats and Conclusions Previous estimates are conservative Use 25% and 50% successful intervention rates Based on MIHS 2013 CHC and FHC out-patients In SROI alone, MIHS could justify the total repayment of the Bond in approximately 2-5 years MIHS facility improvements, and potential for greater patient intervention success, post-bond could increase the SROI

203 660 South Mill Avenue, Suite 300 Tempe AZ

204 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 3. No Information Available at This Time Finance Committee Membership

205 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 4. Ebola Preparedness

206 Ebola Robert Fromm, MD CMO

207 Ebola History Ebola virus disease (also known as Ebola hemorrhagic fever) is a severe, often-fatal disease caused by infection with a species of Ebola virus. The first Ebola virus species was discovered in 1976 in what is now the Democratic Republic of the Congo near the Ebola River. Since then, outbreaks have appeared sporadically. 2

208 3

209 4

210 Transmission Close contact with an infected person. Ebola is spread through direct contact with: blood or body fluids (such as saliva, sweat, semen, stool or urine) of an infected person or animal or through contact with objects that have been contaminated with the blood or other body fluids of an infected person. 5

211 Symptoms The incubation period ranges from 2 to 21 days (most commonly 8-10 days) Early symptoms include sudden fever, chills, and muscle aches. Nausea, vomiting, chest pain, sore throat, abdominal pain, and diarrhea may follow. Symptoms become increasingly severe mental confusion, bleeding inside and outside the body, shock, and multi-organ failure. 6

212 Treatment Standard treatment for Ebola HF is still limited to supportive therapy. Experimental drug therapy Passive immunity Vaccines in development 7

213 Prevention Identification Isolation Personal Protective Equipment Environmental and Waste Management 8

214 MIHS Ebola Virus Evaluation Algorithm Has the patient been outside of the country in the past 3-4 weeks? Yes Has the patient been in a country within past 21 days where there has been a confirmed case of Ebola? (Guinea, Liberia, Sierra Leone, Nigeria)* No Has the patient had direct unprotected contact with blood, other bodily fluids, secretions, or excretions of a person or animal with Ebola or been exposed to a patient with known Ebola Virus? ** No Ebola Virus Disease less likely: patient needs to be monitored for development of symptoms. Contact the attending. No symptoms Yes Does the patient have a fever ( 38.6)? Does the patient have a fever ( 38.6)? No No NO FEVER but otherwise concerning illness for Ebola Virus without alternate diagnosis: severe headache, diarrhea, vomiting, abdominal pain, joint and muscle aches, unexplained hemorrhage, rash, chest pain, easy bruising? Yes Yes Yes 1. Immediately place patient in isolation: contact and droplet precautions: Single room with bathroom with door closed and log of all persons entering patient room PPE required: gloves, gown, eye protection, facemask at minimum Dedicated patient care equipment when possible Limit use of needles and sharps as much as possible and handle these with extreme care Avoid all aerosol generating procedures, such as oral intubation, open suctioning of airways, and BiPAP unless absolutely necessary 2. Call attending physician and infection control Attending physician will call Maricopa Department of Health: *IMPORTANT See CDC website for clinical, infection control, and laboratory guidance and list of currently affected countries: ** Consider notification of Maricopa County Department of Health (MCDPH) if this history is obtained even if patient is asymptomatic. If this is initial contact with the health system isolation may be indicated until MCDPH is contacted. Courtesy of OB/GYN and IP&C departments. 10/06/2014 9

215 PPE Guidelines No skin exposed Impervious gown Boot covers N95 respirator mask Fit tested Face shield or goggles Double gloves 10

216 PPE Guidelines Staff training Trained observer/buddy system On-site manager 11

217 Planning Continued All entry points included Trained teams for Ebola care All staff to be educated Town Halls in process Designated area (4E) Waste management plan 12

218 Preparedness Preparedness is a journey, not a destination. We are learning more about Ebola management daily and our planning and training will be continual. 13

219 Maricopa County Special Health Care District Board of Directors Formal Meeting October 29, 2014 Item 4. Ebola Communication

220 Sent to Board on Friday 10/17/14 by Steve Purves Dear Members of the Board: As I indicated in my on Wednesday (see below), MIHS played a major role Thursday in a national effort by Gannett, owner of Channel 12 and the Arizona Republic, to insert some balance back into the national discussion about Ebola. Channel 12 anchor Mark Curtis broadcast live from Maricopa Medical Center from 4 p.m. to 6:30 p.m. as part of Gannett s Facts Not Fear program to stop the spread of panic over Ebola. Appearing in a mock isolation room, Curtis interviewed Dr. Robert Fromm and our infection control specialists, Dorinne Gray, RN, and Gail Kane, RN, about Ebola and our preparations for a possible case. Dorinne and Gail also demonstrated how MIHS personnel would don and remove personal protective equipment. You can view with interviews online: news/2014/10/16/12news-hospital-demonstrates-ebola-patient-processing/ / During the broadcast, Gannett social media journalists fielded questions from viewers. Dr. Fromm and Dr. Amin Ostovar, MIHS Medical Director of Infection Control, provided online responses. This gave viewers direct access to our experts. Gannett journalists nationwide promoted the discussion on Twitter with a unified hashtag, #FactsNotFear. During this broadcast, the MIHS twitter account was viewed by over 3,400 users. The MIHS Facebook page also surged with traffic, as over 4,500 users were driven to our page by the MIHS interaction on the 12 News feed. This was great exposure for MIHS and recognition of the proactive nature MIHS has taken with the media in regards to Ebola preparation. Dorinne Gray already had appeared on Channel 12 and every other local TV news station discussing how MIHS is preparing for this possible threat. In addition, Dr. Fromm spoke to KJZZ radio earlier this week.

221 HICS INCIDENT ACTION PLAN (IAP) QUICK START COMBINED HICS A 1. Incident Name 2014 Ebola Planning 2. Operational Period (# 2 ) DATE: FROM: _10/20/14 TO: 10/20/14 TIME: FROM: _0730 TO: Situation Summary HICS 201 With the extensive media coverage and current public perception of the Ebola Virus Disease, MIHS has decided to implement a basic HIMT Command Structure to capture planning and training efforts while providing focus and a holistic, organizational approach. Additionally, this process will ensure appropriate communication with internal and external stakeholders. CDC Guidance continues to be fluid, with further PPE recommendations pending. Assumptions 1. Ebola or another infectious disease response may be necessary at MIHS. 2. CDC Guidance is fluid and MIHS planning must be prepared to evolve as necessary. 3. Routes of entry into the health system could include patient presenting at one of the Family Health Centers, 7 th Ave Walk-In Clinic, the Comprehensive Health Center, Adult and/or Pediatric EDs, Burn ED, Desert Vista or the 2619 Building. 4. Community perception and expectation is that MIHS is prepared and proficient in handling infectious disease patients, including Ebola. 5. Employee, Provider, patient, and visitor safety is extremely important to MIHS. 6. Staff will be concerned about disease, processes, and PPE. 7. Standard of Care is expected to be maintained even if contingency methods need to be deployed. Crisis Standards of Care will not apply until a Governor s Declaration is made and the State Disaster Medical Advisory Committee provides guidance (per ADHS). 4. Current Hospital Incident Management Team (fill in additional positions as appropriate) HICS 201, 203 Public Information Officer Mike Robertson & Team Liaison Officer Keith Fehr Incident Commander Keith Fehr Medical-Technical Specialists Dorinne Gray & Team Safety Officer Ken Bourdo Operations Section Chief Planning Section Chief Logistics Section Chief Finance / Administration Section Chief Purpose: Origination: Copies to: Short form combining HICS Forms 201, 202, 203, 204, and 215A Incident Commander or Planning Section Chief Command Staff, Section Chiefs, and Documentation Unit Leader IAP Quick Start Page 1 of 2

222 HICS INCIDENT ACTION PLAN (IAP) QUICK START COMBINED HICS A 5. Health and Safety Briefing Identify potential incident health and safety hazards and develop necessary measures (remove hazard, provide personal protective equipment, warn people of the hazard) to protect responders from those hazards. HICS 202, 215A Safety Considerations for Planning: - Screening tools exist at entry points to determine isolation need. - Contact Precautions PPE is available for staff. - Staff providing care to suspect or confirmed Ebola patient must be limited to only those immediately necessary. - PPE process includes the use of a don/doff assistant and door monitor. - Ante-rooms will need to be constructed at room entrances to provide PPE don/doff location. - Employee Health will provide surveillance process for employees that provide care to patient. - Cleaning and disinfecting guidelines will follow or exceed current CDC guidance. 6. Incident Objectives HICS 202, 204 6a. OBJECTIVES 6b. STRATEGIES / TACTICS 6c. RESOURCES REQUIRED 6d. ASSIGNED TO Command and Control Internal Communication Conduct daily planning meetings to ensure readiness via action plan Document minutes of daily planning meetings Document action plan Determine location of Incident Command Develop regular MIHS E- news flash Ebola Updates Distribute regular MIHS E-news flash with Ebola Updates Conduct Town Hall-type meetings Respond to Ask the Forum questions regarding Ebola Disseminate information regarding action planning to all MIHS and DMG Develop and post signage regarding possible Ebola in applicable areas Appropriate Staff, Meeting Room, 1 hour Meeting Staff, continued Internal Communications capability Keith Fehr/Dorinne Gray Dorinne Gray Mike Robertson & Staff Dr. Fromm, Dr. Ostovar, D. Gray Dr. Fromm, Dr. Ostovar, D. Gray Mike Robertson & Staff Mike Robertson & Staff External Communication Coordinate media inquiries and community questions Response as necessary Mike Robertson & Staff, Designated Spokesperson/SME Purpose: Origination: Copies to: Short form combining HICS Forms 201, 202, 203, 204, and 215A Incident Commander or Planning Section Chief Command Staff, Section Chiefs, and Documentation Unit Leader IAP Quick Start Page 2 of 2

223 HICS INCIDENT ACTION PLAN (IAP) QUICK START COMBINED HICS A Screening Process Develop and implement standardized screening process throughout all navigators in the Epic electronic health record Train staff on screening process for consistent completion of screen, isolation of patient, notification of healthcare provider(s), and activation of incident command Ensure proper fit-testing and training on N-95 respirator / PAPR use for Ebola response team Develop plans for construction of temporary Ante-room Ensure equipment and materials are staged for immediate deployment Ensure proper negative airflow Continued planning, consistent training process, proficiency verification process, documentation of competency Kim Yedowitz Managers/Directors Negative Airflow/Ante- Room Placement Continued planning, consistent training process, proficiency verification process, documentation of competency Anna Doyle Pete Fulling Patient Care Develop multidisciplinary Ebola response team Prepare for and ensure appropriate staffing to include dedicated nurses, runner/buddy system, door monitor, and secure limited access to isolation room Access to medical consultation Process for medication administration, including spiking of IV fluids, multidose medications, etc. Sharps procedures Consistent departmental communication of isolation status during hand offs / transfers of care, etc. Processes for respiratory support and ventilator management Continued planning, consistent training process, proficiency verification process, documentation of competency Managers / Directors / Physicians Managers / Directors / Physicians / Security Dr. Amin Ostovar / Dr. Robert Fromm James Sanders Anna Doyle / M. Teeman, J. Bosse M. Teeman / J. Bosse Jo-el Detzel / Mark Hibbert Purpose: Origination: Copies to: Short form combining HICS Forms 201, 202, 203, 204, and 215A Incident Commander or Planning Section Chief Command Staff, Section Chiefs, and Documentation Unit Leader IAP Quick Start Page 3 of 2

224 HICS INCIDENT ACTION PLAN (IAP) QUICK START COMBINED HICS A PPE & Hand Hygiene Current CDC recommendation are communicated Develop two-tiered processes with criteria for transition to higher level of PPE Disseminate PPE criteria Provide training and competency of PPE donning and doffing of Ebola response team Provide a Response Cart/packs with appropriate PPE Procure and ensure appropriate inventory and availability of PPE, dedicated equipment, and biohazard waste supplies Procure and ensure appropriate inventory and availability of supplies for hand hygiene Procure and ensure adequate inventory and availability of disinfecting agents, including spray Coordinate and ensure terminal cleaning followed by Ultra Violet disinfection Ensure proper training and competency of staff performing cleaning and disinfection Identify testing required to minimize risk of contamination Ensure POC testing and appropriate training of staff on POC procedures Continued planning, consistent training process, proficiency verification process, documentation of competency, PPE Transition Algorithm, Response Cart for MMC and Response Packs for FHCs, Min/Max Levels for inventory Dorinne Gray / Mike Robertson & staff Dr. Ostovar / Dr. Fromm Mike Robertson & staff Managers, Directors, CPEs Pat Kardos, Managers and Directors Paul Dereadt David McNutt Cleaning and Disinfection Continued planning, consistent training process, proficiency verification process, documentation of competency David McNutt David McNutt / Infection Prevention & Control David McNutt Lab Testing/Human Remains Continued planning, consistent training process, proficiency verification process, documentation of competency Drs. Ostovar and Fromm Dan Otis Purpose: Origination: Copies to: Short form combining HICS Forms 201, 202, 203, 204, and 215A Incident Commander or Planning Section Chief Command Staff, Section Chiefs, and Documentation Unit Leader IAP Quick Start Page 4 of 2

225 HICS INCIDENT ACTION PLAN (IAP) QUICK START COMBINED HICS A Waste Handling Identify vendor for biohazard waste removal Develop internal processes to fulfill vendor requirements for biohazard waste removal Identify City requirements for sewage Develop internal process to fulfill City requirements for sewage Educate and train Ebola response team regarding biohazard waste removal and sewage requirements Continued planning, consistent training process, proficiency verification process, documentation of competency, feedback from City of Phoenix Waste Water and HazMat Transport Vendor. Keith Fehr / Ken B. Keith Fehr / Ken B. Keith Fehr / Ken B. Keith Fehr / Ken B. Keith Fehr / Ken B. / Managers / Directors Employee Health Develop / ensure process for employee follow-up, including documenting screening staff temperature at determined intervals, sharp injury, and work restrictions. Review and revise, as applicable, sick leave policies Continued planning, consistent training process, proficiency verification process, documentation of competency Anna Doyle Anna Doyle 7. Prepared by PRINT NAME: Keith Fehr SIGNATURE: DATE/TIME: 10/20/ hrs FACILITY: MIHS Purpose: Origination: Copies to: Short form combining HICS Forms 201, 202, 203, 204, and 215A Incident Commander or Planning Section Chief Command Staff, Section Chiefs, and Documentation Unit Leader IAP Quick Start Page 5 of 2

226 HICS INCIDENT ACTION PLAN (IAP) QUICK START COMBINED HICS A PURPOSE: The Incident Action Plan (IAP) Quick Start is a short form combining HICS Forms 201, 202, 203, 204 and 215A. It can be used in place of the full forms to document initial actions taken or during a short incident. Incident management can expand to the full forms as needed. ORIGINATION: COPIES TO: NOTES: Prepared by the Incident Commander or Planning Section Chief. Duplicated and distributed to Command and General staff positions activated. All completed original forms must be given to the Documentation Unit Leader. If additional pages are needed for any form page, use a blank HICS IAP Quick Start and repaginate as needed. Additions may be made to the form to meet the organization s needs. NUMBER TITLE INSTRUCTIONS 1 Incident Name Enter the name assigned to the incident. 2 Operational Period Enter the start date (m/d/y) and time (24-hour clock) and end date and time for the operational period to which the form applies. 3 Situation Summary Enter brief situation summary. 4 Current Hospital Incident Management Team Enter the names of the individuals assigned to each position on the Hospital Incident Management Team (HIMT) chart. Modify the chart as necessary, and add any lines/spaces needed for Command staff assistants, agency representatives, and the organization of each of the General staff sections. 5 Health and Safety Summary of health and safety issues and instructions. Briefing 6 Incident Objectives 6a. Objectives Enter each objective separately. Adjust objectives for each operational period as needed. 6b. Strategies / Tactics For each objective, document the strategy/tactic to accomplish that objective. 6c. Resources Required For each strategy/tactic, document the resources required to accomplish that objective. 6d. Assigned to For each strategy/tactic, document the Branch or Unit assigned to that strategy/tactic. 7 Prepared by Enter the name and signature of the person preparing the form. Enter date (m/d/y), time prepared (24-hour clock), and facility. HICS 2014

227 Subject: Epic Updates - Ebola Screening Date: Friday, October 17, 2014 at 5:35:55 PM Mountain Standard Time From: Rob K. Lyle Priority: High A+en-on All Epic Users: On October 17th, changes were made in Epic that will impact your area. Brief statements abou the changes are listed below. If you have any ques-ons about these changes, please call the IT Service Desk at ext Release To: All Epic Users Release ID: Epic.A Date: 10/17/2014 Contact: IT Service Desk Phone: Ext Rob.Lyle@mihs.org Epic was updated today to provide a way for staff to document Ebola screening. This screening is required when a paxent presents to any MIHS facility unxl further noxce. The screening process is universal, but access to the screening tool diffe applicaxon within Epic. Use the links below to find job aides to guide you in the process. Ambulatory Ebola Screening InpaXent and Hospital OutpaXent Departments Ebola Screening RegistraXon Ebola Screening (IP & OP) Radiology Ebola Screening (MMC & Ambulatory) IR and Cath Lab Ebola Screening OpTime, Endo, Anesthesia Ebola Screening Emergency Department Ebola Screening Lab RegistraXon Screening results will also be available: In ALL ED Providers Notes, H&P Notes, Consults Notes, and Ambulatory Progress by Monday. On the paxent header in the IsolaXon and InfecXon topics in all areas Visible on the Physician and Nurse Index page under Page 1 of 2

228 Every effort has been made to ensure that all staff members who have inixal contact with paxents have this funcxonality. find that you need it but do not have it, please contact the ServiceDesk at ext If you have any quesxons about these changes, please contact the IT Service Desk at ext Communica<on Title: Epic Updates Ebola Screening Communica<on Release Informa<on: This communica<on was released via e- mail on October 17, and distributed to th following groups and individuals: All MIHS; All DMG Page 2 of 2

229 If you are having trouble viewing this with images, click here. Please add to your address book to ensure our s reach your inbox. Ebola Prevention Update Healthcare providers should be alert for and evaluate any patients suspected of having Ebola virus disease. MIHS policy # S, Prevention of Ebola Hemorrhagic Fever Transmission, has been approved and will be posted to the Copanet soon. Patients who present to an ambulatory clinic, FHC, urgent care, direct admit, emergency department or labor and delivery should have Ebola Virus Disease screening completed as soon as possible. MIHS is currently working on updates to Epic. In the interim, please perform screening and document in progress notes. Symptoms and risk factor screening criteria include: AND 1. Clinical criteria, which includes fever greater than or equal to 38.6 degrees Celsius or degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, stomach pain and lack of appetite, and bleeding. 2. Travel to West Africa (including but not limited to, Guinea, Liberia, Nigeria, Senegal, Sierra Leone or other countries where Ebola transmission has been reported) within 21 days (3 weeks) of symptom onset, OR unprotected contact with persons who have known or suspected Ebola. Persons who have consistent symptoms and risk factors shall be considered suspected of having Ebola. If both criteria are met, then the patient should be moved immediately to a private room and standard, contact, and droplet precautions shall be implemented and followed during further assessment. Airborne precautions should be followed during aerosolizing procedures. Required Personal Protective Equipment (PPE):

230 All persons entering the room of a suspected Ebola patient shall wear at a minimum: Gloves Gown (fluid resistant or impermeable) Eye protection (goggles or face shield) Facemask Additional PPE may be required in certain situations, such as copious amounts of blood, other body fluids, vomit, or feces present in the environment. Additional PPE may include but is not limited to: Double gloving Disposable shoe covers Impervious boot covers Please download the important documents below for more information: Poster Sequence for putting on Personal Protective Equipment MIHS Ebola Virus Evaluation Algorithm CDC Form Ebola Virus Disease (EVD) Screening CDC Fact Sheet CDC Checklist for Patients Being Evaluated for Ebola Virus Disease Notify Infection Control via e mail at InfectionControl@hs.maricopa.gov and Maricopa County and State Public Health Authorities of persons under suspicion for Ebola viral disease. If you do not wish to receive these s, simply click here.

231 If you are having trouble viewing this with images, click here. Please add to your address book to ensure our s reach your inbox. Ebola Prevention Update The safety and well being of our staff are of utmost importance to MIHS. That commitment includes educating our employees and keeping them informed about our preparedness efforts. In a follow up to the first MIHS Ebola Prevention message Oct. 8, we would like to stress that MIHS infection control experts have been working on this issue since early August. That includes adopting protocols and procedures for isolating patients, implementing screening questions in Epic and developing a screening algorithm for any first patient contact area. If you are in a first patient contact area and you have not seen the respective Epic Travel Screening documentation by 5pm today, please contact the IT Service Desk at x Infection control processes are a part of our continuing educational efforts for healthcare team members and the organization is rolling out additional training and updated protocols based on changing recommendations from the CDC and other experts. The senior management team is reviewing our preparedness plans and examining additional training and resource needs of our staff. Because many of you have questions, we will be conducting two open meetings with a panel, including Chief Medical Officer Dr. Robert Fromm and infection control and infectious disease specialists, for all MIHS and DMG employees next week: Tuesday, Oct. 21, 8 a.m. to 9 a.m. in Auditoriums 1 and 2 Wednesday, Oct. 22, 7:30 p.m. to 8:30 p.m., Auditoriums 1 and 2 These meetings will be videotaped and made available on the Copanet. In the meantime, if you have questions, you may submit them to the Ask the Forum on the Copanet and they will be addressed by our clinical experts. In addition, we will be sending out weekly Ebola specific updates to keep you informed. In our commitment to safety, MIHS is following the Centers for Disease Control and Prevention (CDC) guidelines to detect potential cases, protect our employees and respond appropriately. We are continually monitoring the situation to adjust as needed. Prevention & Control recommends the following PPE be utilized while caring for a suspect / confirmed Ebola Viral Disease patient: Boot covers for lower extremities Yellow impermeable gown Bouffant cap Face shield with mask (or mask and goggles) Double gloves N 95 respirator (during aerosolizing procedures, such as suctioning, bronchoscopy, or intubation) PLEASE NOTE: As more information from CDC is received, the PPE requirements may change.

232 The following video published on the Texas Medical Association website provides a video of proper donning and doffing of PPE. Please watch the video below. Further training will be forthcoming soon. Also, MIHS played a major role Thursday in a national effort by Gannett, owner of Channel 12 and the Arizona Republic, to insert some balance back into the national discussion about Ebola. Channel 12 anchor Mark Curtis broadcast live from Maricopa Medical Center from 4 p.m. to 6:30 p.m. as part of Gannett s Facts Not Fear program to stop the spread of panic over Ebola. Appearing in a mock isolation room, Curtis interviewed Dr. Robert Fromm and our infection control specialists, Dorinne Gray, RN, and Gail Kane, RN, about Ebola and our preparations for a possible case. Dorinne and Gail also demonstrated how MIHS personnel would don and remove personal protective equipment. You can view with interviews online: news/2014/10/16/12news hospital demonstrates ebola patient processing/ / During the broadcast, Gannett social media journalists fielded questions from viewers. Dr. Fromm and Dr. Amin Ostovar, MIHS Medical Director of Infection Control, provided online responses. This gave viewers direct access to our experts. Gannett journalists nationwide promoted the discussion on Twitter with a unified hashtag, #FactsNotFear. During this broadcast, the MIHS twitter account was viewed by over 3,400 users. The MIHS Facebook page also surged with traffic, as over 4,500 users were driven to our page by the MIHS interaction on the 12 News feed. This was great exposure for MIHS and a recognition of the proactive nature MIHS has taken with the media in regards to Ebola preparation. Dorinne Gray already had appeared on Channel 12 and every other local TV news station discussing how MIHS is preparing for this possible threat. In addition, Dr. Fromm spoke to KJZZ radio earlier this week. If you do not wish to receive these s, simply click here.

233

234 If you are having trouble viewing this with images, click here. Please add to your address book to ensure our s reach your inbox. Ebola Prevention Update MIHS Ebola Preparation Meeting Because many of you have questions regarding Ebola and MIHS response, we will be conducting two open meetings with a panel, including Chief Medical Officer Dr. Robert Fromm and infection control and infectious disease specialists, for all MIHS and DMG employees this week: Tuesday, Oct. 21, 8 a.m. to 9 a.m. in Auditoriums 1 and 2 Wednesday, Oct. 22, 7:30 p.m. to 8:30 p.m., Auditoriums 1 and 2 These meetings will be videotaped and made available on the Copanet. In the meantime, if you have questions, you may submit them to the Ask the Forum on the Copanet and they will be addressed by our clinical experts. If you do not wish to receive these s, simply click here.