1. VANDERBILT UNIVERSITY MEDICAL STAFF & VANDERBILT MEDICAL GROUP ANNUAL MEETING Thursday, June 28, :30 – 6 pm 208 Light Hall 1

2. VANDERBILT UNIVERSITY MEDICAL STAFF ANNUAL MEETING AGENDA
Welcome
C. Lee Parmley, MD
Chair, Medical Center Medical Board (MCMB)
Proposed Amendments to Medical Staff Bylaws, Rules & Regulations and Policies & Procedures
MCMB Membership Elections
Adjournment 2

3. PROPOSED AMENDMENTS TO MEDICAL STAFF BYLAWS, RULES & REGULATIONS AND POLICIES & PROCEDURES
Goals of Proposed Revisions:
To comply with evolving CMS, Joint Commission and NCQA standards
To streamline Medical Staff Bylaws, Rules & Regulations, Policies & Procedures and VUMC policies and to create internal consistency
To address and codify evolution of VUMC staffing and clinical practice 3

4. AMENDMENT REVIEW AND APPROVAL PROCESS
Administrative Affairs Committee
identification of CMS, Joint Commission and NCQA requirements, inconsistencies, and other needs for additions/revisions/deletions
Executive Committee of MCMB & full MCMB
review recommendations of Administrative Affairs Committee, amend and endorse as appropriate
VUMC Medical Staff
approval of amendments at Annual Meeting
Medical Center Affairs Committee (Board of Trust Committee)
final approval 4

5. AMENDMENTS TO MEDICAL STAFF BYLAWS AND RULES & REGULATIONS
Article XII – Corrective Action
Proposal to add verbiage requiring providers to inform their Chair of the initiation of any disciplinary action by another hospital, licensing board, etc. and to keep informed as to the progress and outcomes of such action and proceedings
Article VII – Clinical Services
Add Physical Medicine & Rehabilitation
Article VI – Privileged Professional Staff
Change all references in Medical Staff Bylaws and Rules & Regulations “Professional Staff with Privileges” 5

6. AMENDMENTS TO MEDICAL BYLAWS AND RULES & REGULATIONS
Article III – General Qualifications for Appointment
Add verbiage that defines an “approved residency” as one accredited by ACGME, American Osteopathic Association, College of Family Physicians of Canada CFPC and/or Royal College of Physicians and Surgeons of Canada
Add verbiage that refers all allegations of discrimination in the credentialing decision-making process to EAD with periodic audits of all denials to ensure that providers are not discriminated against
Rules & Rags – History & Physical Section
Change verbiage to include Anesthesiologists as “attending” for the purpose of taking histories and performing physical examinations 6

7. AMENDMENTS TO MEDICAL STAFF BYLAW AND RULES & REGULATIONS
Article III – Appointment and Reappointment
Modify board certification requirements as indicated to become compliant with Joint Commission standards and current practice:
When the applicant possesses comparable training, experience and competence but (1) Board Certification was not applicable at the time the applicant’s training was completed or (2) the applicant is only certified in a non-U.S. or non-Canadian Board or 3) the board certification is in a specialty other than the primary division (department), the applicable Chief of Service may submit a written request for a waiver of this requirement to the Credentials Committee Chairman for action by the Credentials Committee with subsequent approval by the MCMB and MCAC. However, Physicians must maintain their Certification by board whatever re-certification process is outlined by their applicable 7

8. ACTION POINT
Approval of proposed amendments to Medical Staff Bylaws, Rules & Regulations, and Policies & Procedures Required 8

9. MCMB MEMBERSHIP UPDATES & ELECTIONS
At-Large Members (3) elected annually
Nominees:
Andre Churchwell, MD
A. Alex Jahangir, MD
James “Pete” Powell, MD
ACTION POINTS
At-Large Member Elections require a majority vote of the voting members present
Adjournment of Medical Staff Meeting

10. VANDERBILT MEDICAL GROUP ANNUAL MEETING AGENDA
VMGVMG Finance Committee – Roland Eavey, MD
VMG Credentialing – Steven Meranze, MD
VMG Billing Office –Meredith Marwill
Contracting Update – Beverly Coccia
VMG Quality Council – Racy Peters
Physician Council on Clinical Service Excellence – Gaye Smith
Hitch and Other Operational Initiatives – Margaret Head
Economic Repositioning – David Posch

11. VMG Finance Group
06/26/2012

12. Committee Members Dan Beauchamp Marc Bennett Brian Carlson
Sandy Cherry
Keith Churchwell
Titus Daniels
Marilyn Dubree
Roland Eavey
Phyllis Ekdall
Janice Fruci
Denis Gallagher
Sheri Haun
Margaret Head
Stephan Heckers
Tommy Hollinden
Mack Howell
Mark Hubbard
Howard Jones
Mike Laposata
John Manning
Steve Meranze
Derek Miller
Colin Mothupi
Robin Mutz
Mike Neuss
Jim Newman
Bill Obremskey
David Posch
Pete Powell
Margaret Rush
Warren Sandberg
Diane Seloff
Janice Smith
Robin Steaban
Cindy Sullivan
Paul Sternberg
Reid Thompson
Dell Yarbrough

13. Identity Historically - an audit committee Contemporary needs
$400M budget re-engineering over upcoming years
Comfortable conversation to align our values/missions with our economic forces
Grow revenues plus reduce expenses
Process > Product

14. Meeting 1: Provider Compensation Model
“Medicare cutting reimbursements”
Sensitive elephant
“Officially” discussed compensation modeling with reduced dollars (our values, process examples, leadership)
November 30, 2011

15. Bring up the sensitive topic
Valued ingredients re compensation
Time frame

16. Meeting 2: TOOLS Cost Reduction = Quality Increase
Lost/Cost Awareness Tools
(SLA) Service Line Analytics (MD level utilization)
WebMD (local/national institutions)
UHC (AMCs)
Healthcare Quality Calculator (utility)
December 7, 2011

17. Meeting 3: Strategic Growth Tools
Investment information: THA, HSDA, UHC, JAR, Thompson Reuters
Finance: Where we are/Where we want to be Medipac/Epic/TSI
SLA/Crimson/UHC
Tracking Team…..ROI view
January 12, 2012

18. Meeting 4: Cost Homework and Parking
Valve Data Analysis…Cost/LOS/Readmission
Parking
January 31, 2012

19. Meeting 5: Optimal Resource Management
Teams (MD/RN/MBA)
Departmental variance
Inpatient/Outpatient
May 29, 2012

20. Meeting 6: Optimal Resource Management
Why haven’t we fixed Fridays?

21. Credentials Committee Report Steven Meranze, M.D.
Vanderbilt University Medical Staff and Vanderbilt Medical Group Meeting June 28, 2012
Credentials Committee Report
Steven Meranze, M.D.

22. Organizational Structure
The Credentials Committee (Steven Meranze)
Participating sub-committees
Children’s Hospital Credentials Committee (Gregory Mencio)
Joint Practice Committee (Clare Thomson-Smith)
Provider Support Services Office (Danielle Midgett)
The credentials committee is “The” committee and Children’s and Joint Practice are the sub-committees. My last name does not end with an e and it should be “joint practice” with the s.

23. Credentials Committee
Representation of the major clinical specialties, including behavioral health, the hospital-based specialties and the Medical Staff at large
Meets monthly
Synopsis of duties (see Bylaws):
To evaluate the credentials and performance of all applicants for Medical Staff membership and reappointment
To review recommendations from the Joint Practice Committee regarding the credentials, performance, and supervisory arrangements of all Certified Nurse Practitioners, Certified Nurse Midwives, Physician Assistants, Certified Registered Nurse Anesthetists and Allied Health Practitioners who apply for privileges to practice at VUMC.
To report to the Medical Center Medical Board on each applicant for Medical Staff or other professional staff recommendation to the Medical Center Affairs Committee (MCAC). Reports and recommendations regarding Medical Staff and other professional staff appointment and delineation of practice privileges shall include consideration of any recommendations from the Service in which the candidate requests privileges;
To investigate any breach of ethics that is reported to it.
To review reports of Medical Staff or other professional staff member performance or conduct issues that are referred to it, and to provide peer review in response to competence or performance inquiries.

24. 1739

26. Timeliness of File Review and Approval
Influenced by many factors
Licensure and DEA
Verification (all education, hospital affiliations and work history)
Faculty appointment
Trust coverage/ Claims history
Competency documentation
Incomplete application
Affects practice planning (personal and division)
Enrollment considerations (NCQA)
Increased need for expedited credentials committee meetings
Verification encompasses all education, hospital affiliations and work history.
License and DEA are both problematic

27. National Committee on Quality Assurance (NCQA) certified Credentials Verification Organization (CVO)
Develop delegated credentialing agreements with managed care organizations (MCO)
Delegate MCO credentialing activities to Vanderbilt. VMG providers who are approved through the VUMC Credentials Committee review process are “automatically” enrolled in ~43 managed care plans versus each provider completing and submitting separate applications to each of these organizations
Creates an additional layer of complexity and scrutiny to credentialing activities
Files >120 days are considered “expired” and require re-submission and re-verification

28. Number files met 90

29. Expedited Credentialing
Expedited credentialing: Provider is reviewed and approved for privileges by an agent (subcommittee) of the governing body (MCAC)
Defined exclusion criteria
Legitimate action to answer immediate needs (e.g. critical staffing issues)
Large number may reflect system limitations
MCBEC-BOT is no longer the correct term for the Board. It should be MCAC.

31. Future Initiatives Paperless credentialing
E-file “secure transfer “(Accellion)
Electronic signature - “Pronto System”
Phased implementation
Improved interface with the Faculty Information System for Faculty Appointments
Our credentialing documents have always been standardized…..now they are able to be disseminated and completed electronically. Submission of them with an electronic signature is the future state.
E-file is too closely associated with activities we currently perform. I would re-word to “secure transfer” through Accellion or something similar.
I would refer to Faculty Affairs initiative as interface with the Faculty Information System for Faculty Appointments.

32. VMG Business Office Update
Presented by Meredith Marwill
Associate Director of Physician Billing Services

33. 7. Vanderbilt Medical Group
Faculty Practice Solutions Center Billing Office Survey FY2010 Top 10 Performers
VMG ranked 7th overall in benchmark performance indicators reported by 56 academic institutions through University Healthcare Consortium (UHC).
1. University of Pittsburgh Medical Center
2. UMass Memorial Medical Group
3. University of Minnesota Physicians
4. Massachusetts General Physician Organization
5. The Medical College of Wisconsin
6. University of Wisconsin Medical Foundation
7. Vanderbilt Medical Group
7. University of Texas Medical Branch (Galveston)
9. University of Virginia Physicians Group
10. Fletcher Allen Health Care/University of Vermont

34. Gross Professional Charges
2012 Charges have increased 10.9%.
2011 Charges increased 6.7%
2010 Charges increased 17.2%
2009 Charges increased 11.0%
2008 Charges increased 8.1%
2008 – 2012 Charges increased 54.0%
Charges in the last five-months of this fiscal year (Jan-May) are running 7.0% higher than in the first-six months (July-Dec) of the fiscal year – Anesthesiology, Medicine, Pediatrics, and VHI make up 62% of the increase.
Charges have increased 10.9% from prior fiscal year. 34

35. Annual Cash Collections
2012 Collections have increased 7.9%.
2011 Collections increased 9.6%
2010 Collections increased 16.5%
2009 Collections increased 11.4%
2008 Collections increased 11.3%
2008 – 2012 Collections increased 53.4%
Collections have increased 7.9% from prior fiscal year. 35

36. Total RVU Volume **Confirm all prior years are restated to new year**
2012 Total RVUs have increased 8.7%
2011 Total RVUs increased 6.1%
2010 Total RVUs increased 12.6%
2009 Total RVUs increased 6.1%
2008 Total RVUs increased 5.1%
2008 – 2012 Total RVUs increased 37.8%
Prior year RVUs have been restated to 2012 RVUs.
RVUs generated for FY12 are estimated at 11.3M compared to 10.4M last year. This represents a 8.7% increase in RVUs generated.
Total RVUs have increased 8.7% from prior fiscal year. 36

37. Collections Per RVU
**Confirm all prior years are restated to new year**
FY12 Collections per RVU has decreased to $48.13
From 2011 to 2012 the Collections/RVU for Medicare declined 4%. The Collections/RVU for TennCare declined 2%. Blue Shield increased 2% and Commercial increased 5% to help offset the decline from Medicare and TennCare. The Medicare Payor Mix has shifted from 26% in 2011 to 27% in 2012.
Collections/RVU has decreased 0.7% from prior fiscal year. 37

38. Days in A/R / Charge Lag UHC FY 2011 Survey
Days in AR are estimated to be at 31 days with Charge Lag at 5.0 days at the close of this fiscal year.
UHC FY 2011 Survey
Days in A/R
25th percentile = 47.4 days
Median = 41.2 days
75th percentile = 36.9 days 38

39. Cost to Collect as percent of Net Collections
11.1%
10.6%
10.8%
Cost to Collect has remained stable this past fiscal year.
9.8%
8.8%
8.3%
7.9%
7.4%
7.0%
6.3%
6.3%
The Cost to Collect remained the same at 6.3% for FY12 as of May 31, 2012.
The Business Office, Physician Billing, Coding and Provider Support Services represent 4.4% of this percentage (FY11-4.6%). The FY12 budgeted expenses for these four areas is projected to be below 4.3%.
The cost is the same despite the 8-10% growth in volume. The cost to collect over the past three years has remained unchanged even as charges have increased from 2009 – 2012 by 38.7%.
2012
*2012 FYTD through May 39

40. Projects and Opportunities for FY 2013
Continue to improve patient collections
Expand Point of Service collection program to address increasing patient out of pocket requirements
Develop vendor partnership to allow for combined patient collection activities with VUMC
Continue to redesign work flow processes and systems to enhance the revenue cycle
Migrate toward a paperless work environment in the revenue cycle through further development of EPIC workqueues and other technology enhancements
Developing best practice documentation to move towards more consistent work processes within all areas of the revenue cycle
ICD10 Training and Preparation
Add note on ICD 10 implementation date…..may want to add it to the slide for all to see

41. Contracting 2012 Highlights

42. 2012 VMG Annual Faculty Meeting June 28, 2012
VMG Quality Reporting
2012 VMG Annual Faculty Meeting
June 28, 2012
6/28/2012

43. The Mission of VMG is to improve the health of the people
in the communities we serve
through
evidence-based, personalized, compassionate
care, research and education.
6/28/2012

44. Hand Hygiene
6/28/2012

45. Adult Anticoagulation Clinic
6/28/2012

46. Adult Anticoagulation Clinic
6/28/2012

47. New Patient Access
6/28/2012

48. Publicly Reported Measures: OPPS
Timing and appropriateness of antibiotic prophylaxis in outpatient procedures
6/28/2012

49. Publicly Reported Measures: PQRS
Voluntary quality reporting program
Provides incentive payments of 1% of all Medicare Part B billings for each eligible provider (EP)
Reporting Period: full calendar year 2011
Data will not be publicly reported for 2011 or 2012
6/28/2012

50. Publicly Reported Measures: PQRS
Incentive timeline and amounts:
2012: 0.5 %
2013: 0.5 %
2014: 0.5 %
Penalty timeline and amounts:
2015: 1.5 % (will be based on 2013 submission)
2016 and each subsequent year: 2.0 %
Data will be publicly reported beginning 2013 or 2014 (exact year still TBD)
6/28/2012

51. PQRS Measure #1: Hemoglobin A1c Poor Control in Diabetes % of Pts Aged with Diabetes Mellitus with Most Recent Hemoglobin A1c >9.0%
6/28/2012

52. Measure #2: Low Density Lipoprotein (LDL-C) Control in Diabetes % of Pts Aged with Diabetes Mellitus who had Most Recent LDL-C Level in Control (<100 mg/dl)
6/28/2012

53. Measure #3: High Blood Pressure Control in Diabetes % of Pts Aged with Diabetes Mellitus who had Most Recent Blood Pressure In Control (<140/90 mmHg)
6/28/2012

54. Measure # 5: Heart Failure: ACE Inhibitor or ARB Therapy for LVSD % of Pts Aged 18+ with Heart Failure and LVSD (LVEF < 40%) who were Prescribed an ACE inhibitor or ARB Therapy
6/28/2012

55. Measure #6: Oral Antiplatelet Therapy Prescribed for Patients with CAD % of Pts Aged 18+ with a Diagnosis of CAD who were Prescribed Oral Antiplatelet Therapy
6/28/2012

56. Measure #7: Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) % of Pts Aged 18+ with a Diagnosis of CAD and prior MI who were Prescribed Beta-Blocker Therapy
6/28/2012

57. Measure #8: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) % of Pts Aged 18+ with a Diagnosis of Heart Failure who also have LVSD (LVEF < 40%) and who were Prescribed Beta-Blocker Therapy
6/28/2012

58. New VMG Medical Director for Quality: Barron Patterson, MD
6/28/2012

59. Physician Council for Clinical Service Excellence
June, 2012

60. Patient Experience & Service Council Structure

61. Physician Council for Clinical Service Excellence
Began meeting in March of 2011
Meets monthly
Membership represents 14 clinical departments plus Williamson County
28 physician members
Chair: Paul Sternberg, M.D.
Co Chairs: Andre Churchwell, M.D. and Leah Harris, M.D.
Facilitators: Lynn Webb, Ph.D.; Gaye Smith

62. Physician Council Members
John (Jake) Block, Radiology
Nathaniel Clark, Psychiatry
Anthony Cmelak, Radiation Oncology
Marta Crispens, OB-GYN
Titus Daniels, Medicine
Jesse Ehrenfeld, Anesthesiology
James Felch, Ophthalmology
Brent Graham, Pediatrics
Rob Hood, Medicine
Alex Hughes, Anesthesiology
Ian Jones, Emergency Med
Eric Lambright, Surgical Sciences
Mike Laposata, Pathology
Tracy McGregor, Pediatrics
Steven Meranze, Radiology
Paul Moore, Pediatrics
Melinda New, OB-GYN
David Parra, Pediatrics
John Peach, Medicine
Jan Price, Medicine
Russell Ries, Otolaryngology
Henry (Hank) Russell, W'mson Co - VMG
John Scott, W'mson Co - VMG
Carmen Solorzano, Surgical Sciences
David Uskavitch, Neurology
Douglas Weikert, Orthopaedics
Patty Wright, Medicine
Kelly Wright, Surgical Sciences

63. Key Topics Discussed Why a Physician Council?
PRC Patient Satisfaction Surveys
(use of % excellent vs. percentiles in Service Pillar goals)
HITECH Meaningful Use implications for clinical practices and work flow
Studer Physician Institute: “Practicing Excellence: Engaging Physicians to Execute System Performance”
Patient and Family “Always Promise”
Use of a video on effective communication between physicians and patients
Provided input for process improvement in patient complaint mgmt
Renaming Patient Affairs “Advocates” to Patient Relations “Specialists”
Ways to formally recognize Clinical Excellence

64. Chief Operating Officer/Chief Nursing Officer
Operations Update
Margaret Head, RN, MSN, MBA
Chief Operating Officer/Chief Nursing Officer

65. 2012 Clinic Expansions and Acquisitions
VEI acquisition of Lebanon Eye Associates
VOI Clinic expansion to Mt. Juliet
Williamson County School District contract for athletic trainers
Franklin Cardiology expansion
Maternal Fetal Medicine rotation in Columbia
DOT 10 floor completion

66. VMG Nursing Updates VMG Staff Turnover Rate 9.88%
32 RN’s and 9 LPN’s advanced in the nursing clinical ladder program
Significant work in developing nursing triage and RX star renewal protocols
Received special recognition during the Magnet Survey

67. Status of Meaningful Use Implementation

68. Cohort Training Timeline

69. HITECH Faculty and Staff Trained
Eligible Providers
Eligible Provider trained
Eligible Provider remaining to be trained 187
Total Eligible Providers
Providers Trained
Staff Trained
Total Trained to date

70. HITECH PHASE II/ICD-10 HITECH Phase II
Vanderbilt Outpatient Order Management (VOOM)
Pilots under way in several clinics
Staged roll out to begin in Oct 2012
ICD-10
Tools being developed to help with transition from ICD-9 to ICD-10
Pilots have begun on these tools with expected rollout to being in Spring of 2013

71. Economic Repositioning David Posch
June, 2012

72. Chief Operating Officer Vanderbilt University Hospital
Mitch Edgeworth
Chief Operating Officer
Vanderbilt University Hospital

73. Coordinating Care
Redesign fundamental Care Processes to improve efficiency and effectiveness
Disease
Clinic
Procedure
ICU
Inpatient
Discharge
Post Acute
Home
Self
Disjointed care coordination or lack thereof across the continuum
Failure to reliably apply and execute known science every patient every time
Extraordinary variability in quality and cost
Failure to effectively engage patients and their extended care givers in their care process
Estimates exist that solving these problems could remove 30% of health care cost
Health care remains fragmented-MDs in single specialty private practice, disconnected from each other and hospitals, duplicative testing, poor sharing of patient data, no common IT infrastructure, not knowing problems, prior procedures, allergies , drugs-source of error
While consolidation is occurring-look under the covers-is care coordination occurring or just bargaining strength?
Redesign the infrastructure to improve efficiency and effectiveness across all care transitions

74. Inpatient Care Coordination Model
Risk
Stratification
Medication
Reconciliation
Huddle
Care Plan 1.0
Post Discharge Intermediate Care
Post Discharge Phone Call
Post Discharge Clinic Visit

75. Economic Repositioning
Top 5 Projects
MEOC Initiatives FY13
340B Contract Pharmacies
Specialty Pharmacy
Care Partner Redesign
Case Scripting
> 200 Ideas submitted
~ 40 active projects
Top 5 represent ~$22MM of the $30MM built into FY’13 Budget
Detail is on the next slide.
FY’12
Forecast Savings
FY’13
Savings in Budget
Anticipated Savings
$8 million
$30 million
$32 million

76. Manpower May ‘12 Actual FY’12 Budget FY’13 Budget FTEs (Adult) 8,912.6
8,968.0
9,147.0
246 FTE reductions were made through
attrition and repurposing of positions
Detail is on the next slide.