Minutes Meeting of the Academic Medical Centers and Hospitals Committee of the Board of Trustees of the State University of New York May 9, 2012 The Academic Medical Centers and Hospitals Committee of the Board of Trustees of the State University of New York held a meeting on May 9, 2012. Committee Members Present: Mr. John Murad(Chair) Ms. Eunice A. Lewin Dr. Marshall Lichtman Mr. Cary Staller Mr. H. Carl McCall, Chairman Committee Members Ms. Linda Sanford Not Present: Mr. Stephen Hunt Committee Liaison Present: Ms. Kathy Preston Others Present: Chancellor Nancy Zimpher Executive Vice Chancellor and Provost David Lavalle Mr. Carl Spielvogel Mr. Ronald Ehrenberg Mr. William Howard Dr. Thomas Bodenberg Dr. Michael Lucchesi Mr. Fred Matthews The Academic Medical Centers and Hospitals Committee meeting was called to order by Trustee John Murad at 1:30 p.m. on Wednesday, May 9, 2012 at SUNY System Administration in Albany. . * Mr. Murad stated that the Committee would be hearing a presentation on one of its core functions, patient quality. Mr. Murad stated that in past the committee has spent a significant amount of time on presentations from all three hospitals on quality issues. * Mr. Murad noted that the past presentations allow all three hospitals to present areas of concern and allow for the sharing best practices across all three hospitals. However, today’s presentation will be for Downstate only, and will give Downstate a chance to present specific programs in place to maintain and improve quality of care and patient safety. Dr. Michael Lucchesi and Dr. Thomas Bodenberg from Downstate will be presenting on behalf of Downstate. * Dr. Lucchesi thanked the Committee for the opportunity to present some of the issues that Downstate is focused on in regards to quality. Dr. Lucchesi stated that he is the medical director and is responsible for quality of care. * Dr. Lucchesi noted that they provide data to the University Health Consortium (UHC). UHC will provide data to the federal Centers of Medicare and Medicaid services (CMS) who requires this information from all hospitals. * Dr. Lucchesi noted that Downstate’s record on core measures was “lukewarm”. He further noted that these measures will be factored into reimbursement in the future. * Dr. Lucchesi noted that major efforts have been underway to improve core measure metrics reported to CMS. Dr. Lucchesi stated that significant improvements have resulted from these efforts. Dr. Lucchesi noted that Downstate’s Joint Commission Accountability score was 98.85%, which puts them in the top fifth of all UHC hospitals. * Mr. Murad asked what the movement in the pneumonia score represented. * Dr. Lucchesi stated that this is a combined indicator. A lot of the movement had to do with better documentation. Dr. Bodenberg noted that Downstate has several documentation improvement projects underway. * Dr. Lucchesi discussed another quality improvement initiative related to sepsis. He noted that sepsis is a life threatening blood borne illness. * Dr. Lucchesi outlined that a committee was formed and that in some cases a root case analysis will be performed to identify the cause of the sepsis. * Dr. Lucchesi noted that Greater NY Hospital Association (GNYHA) started this project for improvement of care related to sepsis with 57 hospitals throughout New York, including Downstate. * Dr. Lucchesi noted that Downstate developed a sepsis brochure for hospital-wide training and education. In addition, the School of Medicine grants CME and a sepsis screening tool has been implemented in the emergency department. * Dr. Lucchesi noted that sepsis cases in the six month period declined from 9 to 3. * Dr. Lucchesi noted that the next step is a formal assessment of intensive care and medical/surgical units. * Dr. Lucchesi noted that all staff members may alert the appropriate staff that they have concerns regarding a patient, including non-medical personnel. * The next project discussed by Dr. Lucchesi was an effort to reduce the time between when a patient presents at the emergency department and is admitted as an inpatient to the hospital. It important to admit a patient as soon as possible. * Dr. Lucchesi noted that they piloted two medical units and telemedicine units. * Dr. Lichtman asked if the hospital was full. Dr. Lucchesi noted that occupancy was about 85% to 90%. * Dr. Lucchesi noted that they were working on flowcharts that break down the admission process. * Dr. Lucchesi noted that they are working to identify bottlenecks, in addition using Navicare software more effectively. They have also implemented a beep system to be for nursing staff and environmental services. * Dr. Lucchesi noted that the last initiative is related to electronic medical records (EMR). He stated that it takes approximately 18 to 24 months to have a functional EMR system implemented. * Dr. Lucchesi stated that EMR implementation should result in fewer patient errors. In addition, the federal Department of Health and Human Services (HHS) has financial incentives for implementation. * Mr. Murad asked how reimbursement was linked to EMR. * Dr. Lucchesi explained that in order to qualify for “medical use” funding from HHS, certain EMR functions must be in place to qualify for additional reimbursement. * Mr. Murad made a motion to go in to executive session at 2:16 pm. * Mr. John Murad made a motion to end the meeting. 1 | Page