state of maryland - patient safety authoritypatientsafety.pa.gov/authorityevents/documents/final...

VERBATIM MINUTES

MEETING OF:

PATIENT SAFETY AUTHORITY

ONE HACC DRIVEWILDWOOD CONFERENCE CENTERHARRISBURG, PENNSYLVANIA

TIME: 10:00 a.m.

DATE: January 27, 2009

York Stenographic Services, Inc.34 North George St., York, PA 17401 - (717) 854-0077

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***

Patient Safety Authority

January 27, 2009

Ana Pujols-McKee, M.D., ChairStanton Smullens, M.D. (absent)Gary A. Merica, R.Ph. (phone)Anita Fuhrman, R.N., B.S.Joan Garzarelli, R.N., MSN (phone)Marshall W. Webster (absent)Cliff Rieders, Esquire (phone)Lorina Marshall-Blake (phone)William F. Goodrich, Esquire (phone)Roosevelt Hairston, Esquire (absent)

Also Present:

Mike Doering, Executive DirectorWilliam Marella, PA-PSRS Project ManagerBarbara Holland, Esquire, Board CounselLaurene M. Baker, Communications DirectorTeresa Plesce, Administrative AssistantFran Charney, Director of Educational ProgramsStacy Mitchell, Department of Health


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January 27, 2009

DR. MCKEE:

Welcome back everyone. We have on the phone

-- can the folks on the phone please say --

good morning to each of you and we

understand that you made wise decisions as

to not expose yourself to potentially

hazardous roadway conditions, so we’re glad

you’re safe and we’re glad you’re on the

phone. Could each of you say good morning

to us, and tell us your name?

MR. GOODRICH:

Bill Goodrich. Good morning.

DR. MCKEE:

Good morning.

MS. GARZARELLI:

Joan Garzarelli. Good morning everyone.

DR. MCKEE:

Good morning, Joan.

MR. RIEDERS:

Cliff Rieders. Hi there from the cold

north.


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DR. MCKEE:

Hi. Good morning, Cliff.

MR. RIEDERS:

Good morning.

MR. MERICA:

Gary Merica. Good morning from the equally

cold south, I guess.

DR. MCKEE:

Oh, Gary, of course. Good morning, Gary.

MR. MERICA:

Good morning.

DR. MCKEE:

So around the table we have -- do you want

to introduce Teresa?

MR. DOERING:

Sure. The first thing I’d like to do is

welcome Teresa Plesce. She is our new

assistant so she runs the office, and Terri

joined us from Holy Spirit and she has so

far been a very valuable contribution. And

we’re happy she’s here and so welcome to

Terri.

DR. MCKEE:


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Welcome, Terri.

MR. DOERING:

And I’m Mike Doering.

DR. MCKEE:

And I’m Ana McKee. Good morning.

MS. BAKER:

Laurie Baker. I’m the Communications

Director.

MS. FUHRMAN:

Anita Fuhrman.

DR. MCKEE:

Okay. So good morning. Well, we’re going

to begin by the review of the minutes

followed by a request for approval. Are

there any comments or changes made to the

minutes as they stand? Hearing none, I will

ask for a motion to approve.

MS. FUHRMAN:

So moved.

DR. MCKEE:

And seconded by anyone?

MR. MERICA:

This is Gary. I’ll second.


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DR. MCKEE:

Thank you, Gary. Okay. So, all those in

favor of approving the minutes as they stand

without any corrections, say aye. They

stand approved. There is no report from the

Chair. We’re going to go right to the

report of the Executive Director, and Mike

will walk us through his report.

MR. DOERING:

Thank you, Ana. Good morning everyone. I’m

just going to go through a couple of things.

I do have a large Executive Director’s

report, but a lot of the things will be

discussed during the meeting later on. Our

December patient safety advisory did go out

on January 12, 2009, a couple of very

interesting articles, one, on living wills

and DNR orders. We also had one about

multi-drug resistant organisms. And I’m

going to stop here just for a second. We

had someone join us.

MS. MARSHALL-BLAKE:

Lorina.


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MR. DOERING:

Hi, Lorina.

MS. MARSHALL-BLAKE:

Hi, how are you?

DR. MCKEE:

Good morning, Lorina.

MS. MARSHALL-BLAKE:

Good morning, Ana.

MR. DOERING:

So a lot of interesting things in this

quarter’s advisory. In terms of PA-PSRS,

we’re working hard on the nursing home HAI

reporting applications. That’s where all of

our IT resources are going towards

currently, and we are working on coding it.

We are testing the portion of the data base

that is kind of a facility portion, if you

will, and we’re working on the reporting

portion right now. Annual report, I’m

actually excited about what the annual

report is going to look like this year. I

did send out to you. Bill will be giving a

presentation regarding the survey that we’re


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doing of facilities on process measures

which will feed into the annual report. I

also sent out the outline for the annual

report and Bill is going to talk about that

a little bit later. In terms of education,

training, and outreach communication, the

web site is up and it looks great. I’m

hoping you’ve all used it. We have received

nothing but great comments about it and just

this morning I was given statistics. The

day it went live , we got 2,100 visits to

the PSA web site. This is not the reporting

web site. This is our informational web

site. And it appears in the last week and a

half or so we’ve been averaging

approximately over 600 visits a day from --

you know, that could be anyone. So, that’s

very good traffic on our site. Continuing

education credits, that’s something we

talked about a few Board meetings ago. We

had meetings with the Pennsylvania Medical

Society. We’re going to continue our

relationship for getting CMEs to physicians


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through the Medical Society. We also met

with the Pennsylvania State Nurse

Association and the Pennsylvania Pharmacy

Association and we’re going to be doing a

cooperative arrangement with them as well to

make sure their members can get continuing

education credits through our advisory

articles, so that’s good news. Fran Charney

is going to give kind of an overview of

where we are with our education program

right now, so I’m not going to talk a lot

about that. I’m going to let her go into

all that. Going on to initiative

implementation, I know the Board members, if

you have read the Executive Director’s

report, it’s obvious we have a ton of things

going on in HAI and nursing homes, and I’m

going to let Joan talk about that in a

moment when she gives that update. We are

also going to talk about standardization and

all of the serious event activities. We’re

going to talk about two things later. One

is going to be the standardization


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principles. I believe Stacy Mitchell from

the Department of Health, she’s not here

yet, is going to be here as well today to

take part in that discussion. And I’ll tell

you just a little bit about the letters that

we did send out to some of the low reporting

facilities. Staffing, I already talked

about Terri, and we are going to go over, we

need to do the assessment of the hospitals,

and so I’m going to go over some of the

budget information with you later on. As I

said, we have a lot going on right now, and

since Fran has gotten here she’s helped to

begin a lot of new initiatives, some of

which she’s going to talk about today. The

patient safety liaison program is going

ahead, and we’re trying to hire several

people to enhance that program, so things

are moving and we’re pleased about it. We

have a lot to do with the HAI for nursing

homes implementation including 30 training

sessions around the state. There’s a lot to

do and it takes a lot of manpower, but we


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have almost 1,200 people signed up to get

that training, and so that’s going to be a

good item. In any event, we have an annual

report that we’re beginning to write, all of

our measurement surveys, so a lot of new,

good, exciting things that are moving

forward. With that, I’ll just turn the

agenda back over to you.

MR. MERICA:

Mike, this is Gary. Could I have one

comment/question about your report?

MR. DOERING:

Yes, sir.

MR. MERICA:

Under continuing education credits, I wonder

-- well, I’d like to suggest that we also

reach out to the Pennsylvania Society of

Health Systems pharmacists, which as I’m

sure you know is the professional society

for more hospital-based pharmacists.

MR. DOERING:

Yes, that’s a great idea.

MR. MERICA:


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Okay. I mean my assumption is if we get

ACBE (air-contrast barium enema ) credits

regardless of what society we reach out to,

but it might be good so they can reach out

to their members once we get the CE credits

for pharmacists.

MR. DOERING:

Absolutely. We’re not done. These are just

the folks we’ve talked to so far, so we will

most certainly do that, Gary.

MR. MERICA:

Thank you, Mike.

MR. DOERING:

Thank you.

DR. MCKEE:

The other thing I would recommend is because

the hospital board education project is in

concert with HAP that maybe at our next

meeting we can have kind of a summary

presentation...

MR. DOERING:

Absolutely.

DR. MCKEE:


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tplesce, 02/17/09,

Not sure if this is what this means.

...of the progress that’s being done. Okay,

great. All right. So we have some

committee reports, the first of them being

the HAI initiative, and that’s going to be

presented by...

MR. DOERING:

Joan.

MS. GARZARELLI:

Good morning everybody. I’m going to

provide a little bit more detail about the

HAI, the nursing home implementation

initiative that Mike mentioned in his

report. As he said, the Authority staff has

really been focusing on a smooth

implementation of the nursing home

reporting. And just to remind you all, the

mandatory reporting begins for the eastern

region June 1, the central region June 15,

and the western region June 22, so all their

work is really geared to a smooth transition

for that to start on time. We started back

in December with the Webinar that was

attended by over 600 conference lines and


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the feedback on that was very good. There

are 30 sessions scheduled for February and

March for training for the field, just a lot

of work with the implementation steps to get

everybody ready to do reporting. They’re

also going to do a pilot test of six nursing

homes April 22 through May 6. And when I

think about this implementation versus our

initial work we did when we first went live,

it’s amazing this is so fast and so

efficient, so we learned some lessons when

we went with the hospitals, I guess. In

addition to the nursing homes there are a

couple other issues. They are dealing with

developing an advisory article on MRSA

reduction success stories. Hopefully that’s

going to be published in March. They are

also working on some of the issues with the

NHSN (National Healthcare Safety Network)

reporting, with the hospitals working with

the help desk and with the Department of

Health on definitions and some of those

kinds of things so a lot of activities


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around the HAI implementation since we met

last.

DR. MCKEE:

Very good. Are there any particular

impediments, barriers that you see we should

kind of either be aware of or try to assist

in eliminating at this point?

MS. GARZARELLI:

I don’t know, Mike, if you see anything. It

looks like everything is kind of moving

straightforward.

MR. DOERING:

There’s nothing I know of at this time. Of

course, we have to get the system completed

which we intend to do. I think we’re being

very proactive with the training. No, I

don’t think there’s anything the Board has

to assist with at this time.

MS. MARSHALL-BLAKE:

Mike.

MR. DOERING:

Yeah.

MS. MARSHALL-BLAKE:


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It’s Lorina. Based on, I’d say, the success

of the patient safety liaisons, and I saw in

your report we’re anticipating hiring some

new people, do we have any idea when we’re

going to do that or what, you know, the time

table or time frame is on that?

MR. DOERING:

Yeah. Fran is going to, I think, go over

that in the report.

MS. MARSHALL-BLAKE:

Okay.

MR. DOERING:

At least she’s going to mention it but we

have ads out now.

MS. MARSHALL-BLAKE:

Okay.

MR. DOERING:

And our goal is within a couple of months to

get some folks hired.

DR. MCKEE:

Okay. Very good. Unless there’s any

questions, we’re going to move on to the

second, the PSA presence, the liaison.


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Who’s going to...

MR. DOERING:

Gary, that was yours but I think you’re

going to kind of defer to Fran.

MR. MERICA:

Yeah. I had the pleasure of being the Board

champion for a program that’s being managed

exceptionally well, I think, by Authority

staff. Megan Shetterly, our first patient

safety liaison, and by Fran Charney, our new

Director of Educational Programming, so

rather than have me muck things up, I will

defer to Fran, who I’m sure will do an

outstanding job carrying that information

during her presentation.

MR. DOERING:

And if you remember at the last Board

meeting Megan and Fran did a whole thing on

the patient safety liaison program, and Fran

will mention it in her education remarks

today.

DR. MCKEE:

Okay. Between that is sandwiched the PA-


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PSRS update though so why don’t we -- Bill,

would you like to come forward and give us

your presentation?

MR. DOERING:

For the Board members who are on the phone,

I sent you a presentation about the

measurement of safety that Bill is going to

give, and I also sent you a file which I

think was a Word document which has the

outline of the annual report in it, so those

are the two documents Bill is going to be

discussing.

MR. MARELLA:

Can everyone on the phone hear me okay? For

those of you who were here at the last Board

meeting, the first couple of slides are the

same. For those of you who were not here,

what we had proposed to do was to do a

statewide survey of patient safety officers

to find out what practices we have suggested

in the advisory over the past several years

have been adopted, and we specifically

focused on things related to some of the


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national patient safety goals, the CMS non-

payment events, things people are already

paying attention to and working on. And

what we wanted to do was to use the domains

in the survey to serve as a framework for

the annual report. Now the annual report, I

think, for the last several years has sort

of become a little bit routine. It follows

the same format every year and, to be

honest, other than the number of reports

going up the data doesn’t change all that

much when you’re looking at it at that level

so we want to try and take a little bit of a

different approach this year and make it

more about what the hospitals and ASFs and

other facilities are doing in terms of the

types of events we’re monitoring. So

basically the incentive for the facilities

to participate in addition to being able to

contribute their own data to sort of our

view at the statewide level is that we will

give people back a consulting type report

that will give them feedback on where their


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responses stand in relation to the responses

we got from facilities like theirs. If we

get a sizable enough participation from the

subsets of hospitals we might be able to

break it out by hospitals sub-type,

otherwise, we’ll just look at the main sort

of facility types.

MR. MERICA:

Bill, this is Gary. Could I comment?

MR. MARELLA:

Sure, please.

MR. MERICA:

I don’t know how transferable this is to

other organizations, but I will tell you in

mine before we even completely submitted the

survey, we’ve already had two groups work on

implementing some of these safe practices we

identified on the survey that we did not

have in place, so I think at least again in

my own facility it’s already having a

positive impact just through the process of

going through the survey.

MR. MARELLA:


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That’s great. Thank you, Gary. I

appreciate hearing that.

MR. RIEDERS:

This is Cliff. I’m glad to hear from Gary

because I’ve always been skeptical of

surveys and participated in writing a lot of

them and even responding for organizations,

and, you know, there’s always a tendency to

be somewhat on an organizational level to be

somewhat self-serving and to say, yeah,

we’re doing our job, whatever organization

that is. I’ve seen it with legal groups

too. And I’ve always thought when I

discussed it with the technical people after

surveys come in that, you know, it tends to

be very soft in terms of how you can use any

information or data you may get from it.

One of the things I would like to see, and I

don’t know if there’s, you know, time to do

this, I think there is, between now and the

annual report, would be to address the

evolution of denominators which we’ve been

discussing for many years and that is how


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you measure success whether we’ve had

success by virtue of the reporting we get

and the feedback we give. I know Roosevelt

has been interested in that over the years,

and Dr. Clarke and others have discussed

that, and I was hoping at some annual report

we would sort of look at that development.

MR. MARELLA:

Well, I think you’re absolutely right about

your criticisms of the survey method. I

mean it does have limitations. What we try

to do is to focus on practices that are

fairly obvious and not necessarily subject

to a whole lot of interpretation. In other

words, focus on things that are pretty

objective, things people sort of look at,

and it’s pretty clear whether or not you

meet the standard or not. You try to do

that to the extent you can but you’re

absolutely right there is always some sort

of bias associated with any kind of method.

The other thing we’ve talked about doing

with Megan is because she’s going to be in a


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lot of these facilities, we may be able to

look at how we might go about validating

this survey after we see the initial year’s

results if we find this is what we want to

continue to do over the next several years.

We could start to talk about how we might

validate the findings we get on the survey

by having an objective person go into the

facility and see if they would agree and

would have given the same answer. The other

thing we’re doing, you mentioned

denominators. I’ll get to this in a minute,

but the other things we’re doing in the

annual report is to try and round out the

survey results with sort of two other areas

of information. One is the ARHQ (Agency for

Healthcare Research and Quality) patient

safety indicators, and we’re looking at

getting data from HC-4 (PA Health Care Cost

Containment Council) that will allow us to

calculate some of the ARHQ patient safety

indicators at the state level, so that’s

sort of a different way of trying to get the


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same information. And a third way is by

looking at the reports in PSRS, so what I

want to do is to structure the annual report

around concepts in patient safety like

medication safety, device safety, safe

surgery, and triangulate those issues with

data from the surveys, data from the ARHQ

indicators, and data from the PA-PSRS system

itself. So those are some of the ways we’re

trying to minimize the bias inherent in

whatever method or methods we would wind up

adopting.

MR. RIEDERS:

I’m sure you’ll cover those limitations as

well as what you’re trying to accomplish in

the annual report, the survey, wherever it

appears.

MR. MARELLA:

Sure.

MR. RIEDERS:

It will be important. Okay.

MR. MARELLA:

The next two slides are basically just


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examples of what the consulting reporting

might look like or the form it might take

that we would get back to the facilities so

they would be able to see how the statistics

broke down at the state level and where they

stand in comparison. The kinds of domains

we’re looking at, and these may change a bit

based on the results we get from some of the

other indicators, but we want to look at

leadership so it’s things like does your

patient safety officer attend the board of

trustees meetings, have you done patient

safety walk- arounds. Medication safety, is

another big area. Safe surgery, we’ve

obviously done a lot of work here,

particularly wrong site surgery, but we’re

going beyond that in the kinds of questions

we’re asking. Infection prevention,

obviously a big focus right now, device

safety, and we have a couple other

indicators that don’t kind of fit into any

neat category but they may be fairly easy to

get at and so I want to at least get a sense


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of what the results look like. In terms of

the time line for the survey, the survey has

been out since January 12th, and we asked

people to give us their results by January

30th at the end of the month. We can extend

that by a week or so. It looks like that

will be useful to do. February and March,

we’ll be analyzing the data and writing up

the results and then obviously in April

we’ll be publishing the annual report where

that will be the first public viewing of

those results. And after the annual report

is put to bed, then we’ll get to focusing on

the facility reports.

MR. MERICA:

This is Gary again, and I’m sure you’ll make

good judgments about whether to extend that

or not. I would just say it’s a bit of a

struggle to get all the answers we need from

all the folks in the organization, so I’m

sure you’ll look at the numbers you get and

I for one would say a little bit of an

extension but I’m sure you’ll use good


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judgment on that.

MR. MARELLA:

Yeah, okay. I appreciate the feedback. In

fact, I’m going to show you where we are

right now, and I’m not totally happy with

the results we’re getting, and it’s hard to

tell whether that’s because people are still

busy collecting the information internally

or whether the response rate is indicative

of where we’re going to wind up, and we got

a couple suggestions for how we might boost

the response rate as well. We basically got

about 16 percent of the hospitals which is

much lower than what I’d like to see. I’d

like to see us get to 40 percent of the

minimum. And I’m actually kind of surprised

at how many of the ASFs and other facility

types have participated. I think that’s a

very good thing. We didn’t do a specific

analysis of this but just kind of scanning

the names of the facilities that are

participating, my sense was a lot of them

are in Megan’s region so I think she’s


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already done a lot of outreach in that area

and I think we’re reaping the benefits of it

in terms of the response we’ll get from her

region.

MS. GARZARELLI:

Bill, was this survey sent by mail or e-

mail?

MR. MARELLA:

We sent it by a couple methods. We sent the

solicitation letter by e-mail both to CEOs

of facilities and also the patient safety

officers, and then we sent it separately to

the patient officers when it was time to

actually -- well, there were three. One was

here’s the tool we’re going to use, feel

free to start working on this if you want to

participate. The second communication was,

okay, we’re ready to accept the results when

you are so here’s the length of the survey

tool and then third was we just sent out a

reminder the other day which brought in

quite a few more participants than we had

before.


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MS. GARZARELLI:

Is the survey available on your web site? I

just haven’t heard anything about it coming

to my particular organization, which is kind

of surprising to me, so I just want to make

sure somebody didn’t get the e-mail and not

respond or something like that.

MR. MARELLA:

Yes. Joan, are you still the patient safety

officer for your facility?

MS. GARZARELLI:

Yes.

MR. MARELLA:

Okay. I’ll have to look into why you didn’t

get it.

MS. GARZARELLI:

Okay. I’m actually one of two so it’s

possible another person got it.

MR. MARELLA:

Okay. I will look into it. On the next

slide is about ways we wanted to try to

boost participation in the survey. I

mentioned Megan already as helping us in her


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region. I also wanted to make a personal

appeal to the Board members to encourage the

patient safety officers in the facilities

you’re affiliated with to participate. And

I believe Mike is going to send an e-mail to

that effect so you can easily edit it and

forward to whoever appropriate. We also

contacted some other organizations to enlist

their assistance. The PASHRM (Philadelphia

Area Society for Healthcare Risk Management)

group, holds their meetings at ECRI

Institute so Denise Martindale, one of our

analysts, went down and put in a plug for it

last week at their meeting, and Fran has

done some similar essential area CPAHCRM

(Central PA Association of Healthcare Risk

Management)group. We expect that the IHI

(Institute for Health Care Improvement)

foundation is going to be sending out a

message probably in the next day or so and

Fran is going to be asking HAP (Hospital and

Healthsystem of PA) to send out a similar

message to their members.


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MS. FUHRMAN:

Bill, may I suggest PASA, (Pennsylvania

Ambulatory Surgery Association)? They do

have a web site and you can contact me if

you don’t have any success in reaching them.

MR. MARELLA:

Okay, great. Thank you.

DR. MCKEE:

What is the average time it takes to -- you

know, how labor intensive is this survey?

MR. MARELLA:

Well, we tested it, again with Megan’s help,

we tested it with about six facilities and

they said it took about 90 minutes. About

half of those were ASFs, so for them, they

probably know the answers to those questions

off the top of their heads as opposed to

people who have to call other department

heads. Gary, did you want to comment on

that? I don’t know if you heard Ana’s

question. She asked about how long it takes

to answer the survey.

MR. MERICA:


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Well, I can comment again just from my own

experiences that you just alluded to, Bill,

in an organization my size. I forget,

there’s 30 some questions, probably...

MR. MARELLA:

I’m sorry, Gary. I think you cut out again.

MR. MERICA:

The other 10 to 15 I had to contact content

experts within the organization, and as you

can imagine busy people, some of those

people I had to contact multiple times. In

fact, there is three that I’m still awaiting

answers for to get it in by the end of the

week, but it’s not terribly cumbersome.

Very honestly, content experts should be

able to look at the questions I’ve posed to

them and answer in a minute. I mean it’s in

their laboratory, what have you done to

analyze hemolyzed specimens. A quality

manager in a laboratory would know the

answer off the top of their head so I don’t

think it’s particularly cumbersome just

waiting for responses from content experts.


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MR. MARELLA:

Okay.

DR. MCKEE:

I think in the world I live in a 90-minute

investment in a survey is very unrealistic.

I understand, you know, the

comprehensiveness of the survey, but whether

I would have 90 minutes would be the issue.

You know, most of us are working in

organizations where this is one of many,

many surveys. For example, right now we’re

going through a leadership 360 degrees

assessment so I have maybe seven or eight

surveys on individuals that are falling

within this time, and each of them is going

to take me about 20 or 30 minutes a piece in

addition to, you know, all the other things

I’m doing. So I think consideration for the

time this takes is going to be as we move

along perhaps the best key to our success.

You know, I think one of the best intentions

even though Gary has said, you know, he can

distribute it, that’s just an issue for -- I


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know it would be for me and for people

inside my organization.

MR. MARELLA:

I’m hoping the consulting report that

they’ll get back is enough of an incentive

to make them want to do it, but obviously if

it was just a routine survey like our annual

satisfaction survey that will go out after

this, yes, that we try to keep to ten

minutes or less.

MR. MERICA:

I sort of lost everybody.

MR. MARELLA:

I’m sorry. Dr. McKee was talking about the

amount of time it takes to invest in

something like this and my response was that

I said I was hoping the consulting report

would be an adequate incentive to get people

to invest the time it would take to find out

this information in their facility and if

this were a usual survey that we’re all used

to getting e-mailed about those you would

try to keep to ten minutes or less if you


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want to get any kind of a response rate but

for something like this where it’s a

consulting report, we’re trying to make it

feel more like a collaborative than just a

survey.

MR. MERICA:

Bill, this is Gary. I really lost a lot

there but it’s clear now. Again from the

time standpoint, I would say, I probably

personally as a patient safety officer, so

far spent maybe an hour on this total and

again I’m just waiting for responses from

some others. Again, I don’t think it’s

fairly time consuming, and I’m frankly

really looking forward to the report back.

MR. MARELLA:

Okay. Great. In terms of the next slide I

have up is the one titled annual report

structure. I kind of touched on this a

little bit in response to Cliff’s question,

but basically each domain in the annual

report or each section will follow a similar

pattern, basically a discussion of why we’re


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even talking about safety leadership or

medication safety, a summary of the relevant

data from PA-PSRS that bears on it, the

survey results and other indicators. We

will present a case study either in the form

of an abstract from an advisory article that

relates to that domain or a case study maybe

just showing one report from the database

and kind of digging into the lessons learned

in it, and also obviously we’ll refer to all

the relevant advisory articles and consumer

tips that have been published over the past

year relating to that domain. In terms of

the schedule normally we try to link our

work on the annual report with the Board

meetings that are scheduled during that time

for your convenience. This year we’re much

more pressed for time because of the HAI

(Healthcare Associated Infections) roll out

is a significant drain on our resources at

the moment, and we’re also doing a lot of,

sort of prep work to collect information

that will go into the annual report that we


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haven’t done in the past. So basically we

got a very compressed schedule here. We’re

looking at distributing the initial report

to the Board committee that deals with the

annual report near the end of March, March

25, and the report, we’ve got one round of

review in there, and we would distribute the

report to the full Board on April 8. So

basically we’re asking you when you get the

report to read it and kind of come up with

your comments or questions within about a

week which is tighter than we would normally

ask. And Mike and I have talked about

having to have maybe public meetings by

conference call in between the normal public

meetings to just deal with the annual report

in the times that we’re looking at here.

MR. DOERING:

And the reason for that is because between

now and when we have to have this report

out, we have two Board meetings, one is at

the beginning of March and the other one is

at the end of April, and if we wait until


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the end of April we’ve waited too long so

that’s why we may have to do something a

little bit different in terms of getting

everyone on the phone.

MR. MARELLA:

And I think that was it. Does anyone have

any other questions?

MR. DOERING:

Can you go over just briefly -- we have sent

out the outline of the annual report. It is

obviously going to be different than the

previous...

UNIDENTIFIED SPEAKER:

Mike, it’s really hard to hear you.

MR. DOERING:

I’m sorry. We have sent out the outline of

the annual report. It is quite a bit

different than in the previous years, and so

we just wanted to make sure no one had any

issues with it because -- right now at least

this is the path we’re going to be going

down.

MR. RIEDERS:


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Can I ask you a question, Mike, under the

reporting system and the outline you have

definitions. Is that the same thing as

standardization, is it the same thing as

serious event reporting?

MR. DOERING:

Can you ask your question again, Cliff? I’m

sorry.

MR. RIEDERS:

I’m sorry. You were asking about the

outline, correct, if we have any questions,

further questions, about it?

MR. DOERING:

Yes, sir.

MR. RIEDERS:

Okay. My question is under reporting system

on the second page we have the word

definitions. Is the same as standardization

which is the same as serious event

reporting?

MR. DOERING:

I think this was a hold over from previous

years where we just kind of put down the


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definitions of what is a serious event and

what is an incident, and I don’t know that

we get into or we would get into any of the

standardization stuff in terms of what the

principles were. In a little bit here,

we’re going to talk about the principles and

until we kind of put those out publicly that

will be the deciding factor on what we can

say in this report.

MR. RIEDERS:

I do think we need to give a status update.

We now...

MR. DOERING:

Absolutely. I don’t disagree with you. I

think we need to give as much update as we

can in terms of where we are.

MR. RIEDERS:

Right. You mentioned it in two prior

reports. Okay.

MR. DOERING:

No, I don’t want to shy away from it at all.

I think we do need to mention it and

hopefully after today we’ll be further down


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the road in getting something finalized.

MR. RIEDERS:

Okay. Thanks.

MR. DOERING:

Any other questions about the annual report

or the measurement survey?

DR. MCKEE:

I think the outline looks good. I think

it’s much more functional in terms of, you

know...

MR. DOERING:

You may have to speak up, Ana.

DR. MCKEE:

I was just commenting I thought the -- I was

looking at the outline. I thought the

outline was in a format that was much more

functional in terms of looking at it from a

provider or facility and trying to focus on

areas of interest. I think this has a lot

more promise, so we’ll see how the public

responds to it, but I did like the format.

MS. FUHRMAN:

Just out of curiosity with the past annual


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reports, did you receive many questions,

comments?

MR. DOERING:

We don’t get anything. We send out those

past annual reports and it’s like we send

them to a vacuum somewhere honestly. Bill,

do you get anything?

MR. MARELLA:

I think there have been maybe a handful of

times where we’ve had reporters ask for

various specific statistics and if it’s

something that was in the annual report, we

can easily refer them to it. But, no, I’ve

never seen any significant press coverage of

the annual report. I think, frankly, I

think it’s just too much information.

MR. DOERING:

And I think what we’re doing here is if we

can build on this annually to be able to

show this is where, you know -- this is

where facilities are now. Let’s look at it

next year. Where are they now? What

advancements have we made? What types of


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things have we focused on? How did that

translate into the responses that we’re

getting? And, frankly, as Bill says, we

only have 100 facilities that have sent back

the survey now or 90 or whatever it is, but

I still think we should move forward because

I think it’s going to be a much more

interesting and dynamic report but also if

you walked into a state and said I’d like to

do a survey, I think I’ll do it on 50

hospitals, and if you got information on 50

hospitals, I think you’d feel pretty good

about it. And it would give you good solid

information and I’m hoping with what we’re

going to be giving back to facilities that

next year we will have even more

participation, et cetera, et cetera. So I’m

actually very excited about it.

DR. MCKEE:

Yeah, I think we should use a little bit of

time to think about how the distribution --

how we can change the distribution or the

roll out of the annual report to have


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greater impact or to use it as a way of

either working closely with HAP to try to

get some -- to get more engagement around

the report and around the advisories. You

know, I’m concerned we haven’t made -- I

just sense there’s this big gap between the

hospital community and us, and we’ve got

great information, great detail, and, you

know, I could go to a course in Harvard

where I was and speak to the chair of

medicine who looked at the advisory and

went, wow, if we had this here. You know,

we’re not getting that wow factor here, and

so I know it’s a public relations sort of

issue but it’s also an educational issue,

and I think we’ve got to figure out how to,

you know, how to have more engagement around

all the materials we’re sending.

MS. FUHRMAN:

Hopefully, the liaisons can help with that

and stimulate some of it as we move forward

also and hearing the response the

organizations had with that relationship.


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Hopefully that will happen.

MR. DOERING:

I think if you think about the types of

things we’re doing, one, the PSLs being out

there, being in the field. I know Fran and

Megan talked to the C suite (Chief Executive

Officers) of a large ASF yesterday. We’re

touching a lot more people out in the field,

not just patient safety officers but the

higher clinical folks, the administrative

folks, and we’re going to be getting to the

trustee members. We also put up a new web

site to try to have more traffic and tried

to get it in the hands of more people. We

have -- I think a lot of the initiatives

we’re doing right now are just for that.

Even this survey we just talked about, we

sent it to the CEO. We’re going to be

sending information back to the CEO, so we

really are trying to do things to attract

the attention and to get the attention of

the right folks, not just the patient safety

officers who only have so much pull and


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power within their own facilities.

MS. BAKER:

I will say with the new web site I’ve been

in contact with several organizations and

associations, and it makes it easier for me

to be able to say go to this discipline or

type a word into the search engine and have

all these articles come up and send them

those articles which apply to their

organization membership so they can then see

what we have to offer. It’s just, I think,

the web site has made a huge difference

already as far as knowing what we have out

there for them.

MR. DOERING:

The other one was continuing education

credits. That’s another venue for a lot

more people to be able to start to see our

stuff because what are they going to read?

They’re going to read stuff that allows them

to meet their career requirements or their

job and licensure requirements so hopefully

-- I understand what you’re saying, Ana.


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DR. MCKEE:

And I do believe we’re going in the right

direction. We clearly are.

MR. MERICA:

Mike.

MR. DOERING:

Yes, sir.

MR. MERICA:

This is Gary. I don’t know whether other

folks on the phone, I can hear you crystal

clear. I can barely hear anybody else in

the room.

MR. DOERING:

I tend to talk louder than everybody else so

I’m going to have to ask everyone else to

make sure they speak up.

MR. MERICA:

I didn’t know whether it was the mike you

were talking to or whatever, and maybe

nobody else was having that problem but

that’s what I’m hearing.

MR. DOERING:

Okay. We’ll do our best.


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DR. MCKEE:

It helps that Mike is hogging the microphone

right in front of him.

MR. DOERING:

One of the microphones.

DR. MCKEE:

One of the microphones but, no, in all

seriousness we will make -- we will do

better at using the microphone. Can you

hear me?

MR. MERICA:

That’s much better now, Ana. Thank you.

MR. DOERING:

And I told Terri that one of her things

she’ll be evaluated on this year is trying

to figure out how to get four mikes in here.

MR. MERICA:

There you go.

DR. MCKEE:

Okay. So any other questions for Bill? If

not, we’re going to go on to the next agenda

item, and thank you, Bill, for that. Fran,

you were going to come up. We’re going to


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do some old business on the patient safety

education program. We’re going to receive

an update.

MS. CHARNEY:

Can you hear me on the phone?

MR. MERICA:

Yes.

MS. CHARNEY:

Pardon my back, but you might have the best

view. I’m going to give you an update of

the last six weeks of what we’ve been doing

with the educational highlights.

MR. DOERING:

So for the Board members on the phone,

there’s a presentation we sent out. I don’t

know what the file name was, but it is a

Power Point presentation of the education

program.

MS. CHARNEY:

And we’re going to start with the continuing

education credits. We met with the

Pennsylvania Medical Society. We have an

ongoing relationship with them where we


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offer category one, CME credits for

physicians, and we’ve actually tweaked that,

and I think it’s actually going to be better

as we move forward. We also had the

opportunity to meet with the Pennsylvania

State Nurse’s Association. This is a new

mandatory requirement for licensures of

registered nurses and other like

professionals. They need 30 continuing

educational credits by their license renewal

date of October 31, 2010, so we are moving

forward with them. We’re going to look at

retrospective and prospective articles.

We’re going to go back and actually use some

of the articles that have already been

written for the advisory. We also had the

opportunity to meet with the Pennsylvania

Pharmacists Association. There is a new

quality requirement for licensures of

pharmacists, and timing was of the essence.

They had just lost their other partner so

they’re looking forward to partnering with

us. And, Gary, I will contact that other


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entity as well.

MR. MERICA:

Thank you, Fran.

MS. MARSHALL-BLAKE:

Fran.

MS. CHARNEY:

Yes.

MS. MARSHALL-BLAKE:

Lorina. Just a quick question. If I am a

nurse working for like an independent Blue

Cross, does that also mean I fall into that

category meaning I still have to fulfill

those credits?

MS. CHARNEY:

If you carry a nursing license, yes.

MS. MARSHALL-BLAKE:

Okay. Just curious. Okay. Thank you.

MS. CHARNEY:

You’re welcome. Moving to the next slide,

slide two, the patient safety officer basic

curriculum. This is something Megan has

seen as a need as she’s doing her patient

safety liaison visits. There are patient


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safety officers who haven’t had the

opportunity to have a med tour or some

grooming so we’re taking that opportunity to

actually offer a basic curriculum. The

audience will be new and some existing

patient safety officers. The program

contact is actually going to go back to the

ION (InterOrganization Network) report and

then move forward with a definite flavor for

Pennsylvania.

MR. DOERING:

And we actually have this scheduled, right?

MS. CHARNEY:

We do. That’s an upcoming slide.

MR. DOERING:

Oh, I’m sorry.

MS. Holland:

I will make my standard criticism...

MR. DOERING:

Act 13.

MS. Holland:

Act 13 does not even include Chapter 4,

which is on infections, and it is not a


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complete expression of Chapter 3.

MS. HOLLAND:

So let’s like figure out another way to

refer to this thing.

DR. MCKEE:

What do you recommend?

MS. HOLLAND:

I recommend Chapters 3 and 4, the Mcare act,

because that will cover what is currently in

those chapters.

MS. CHARNEY:

And we can most certainly do that.

MR. DOERING:

Hence forth it shall be known -- okay,

Chapters 3 and 4 of Mcare.

MS. CHARNEY:

What we’ve done with the basic curriculum,

we have developed a registration process,

the objectives, the agenda, the scope of the

program where it’s going to be delivered

over six hours. There’s an interactive

component about how would you report this

event. The program curriculum has been


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developed. We are going to provide lunch

and learning materials. There will be no

fee to the patient safety officers for this

curriculum. And we’ve also developed an

evaluation process once the program is

completed. On slide four our first class

will be February 6 and then...

MR. DOERING:

26.

MS. CHARNEY:

February 26, and beyond the basics

curriculum will follow where we’ll talk

about human factors, et cetera.

MS. MARSHALL-BLAKE:

Fran, another quick question for you. What

if someone else has an interest in attending

this, would there be a fee?

MS. CHARNEY:

We haven’t discussed that.

MS. MARSHALL-BLAKE:

Because I could see other possibilities for

this. That’s the reason I was asking.

MS. CHARNEY:


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We are looking at utilizing this in some

other regional collaboratives that are going

on so I’m not really sure we’ll cut the

attendance off at patient safety officers.

MS. MARSHALL-BLAKE:

Okay. Just curious again.

MR. DOERING:

And we could definitely consider putting it

on for a particular group as well, Lorina.

MS. MARSHALL-BLAKE:

Right.

MR. DOERING:

We want to make sure patient safety

officers, sometimes they feel more

comfortable with their own crowd.

MS. MARSHALL-BLAKE:

Okay, with their own kind. Okay.

MR. DOERING:

But we will certainly explore other

opportunities. Like Fran said, we already

know of one other situation where we’re

going to do this for a specific health

system.


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MS. MARSHALL-BLAKE:

Okay, because that’s what I was thinking.

Okay.

MS. CHARNEY:

Moving on to regional educational offerings,

there’s a hospital in the northeastern

region who’s doing a hospital wide patient

safety liaison program. We in collaboration

with PA-PSRS did a presentation to the

facility of all the new patient safety

liaisons for that facility. We encourage

the patient safety liaison program. It’s

actually focused on multi-disciplinary

communication and patient safety is

everyone’s responsibility. And that was

very well received. Most of them were there

voluntarily. Some were forced, but most

were voluntary, and the audience was

probably about 30 patient safety liaisons

ranking from environmental services and

physicians were present and the C suite.

Also, we’re doing collaborations with

facilities to improve mis-labeling of


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specimens. This was a facility which

stepped forward and would like to run that

collaboration, and the patient safety

liaison will also be part of it. This is

the entity of which Mike was referring to,

special need to educate hospital staff

regarding patient safety. We’re going to

use the patient safety officer basic

curriculum in that fashion. This is mainly

a punitive environment and they want to

start moving forward to a just culture.

MR. DOERING:

Can I add something, Fran, if you don’t

mind? What this came out of was we sent a

low reporter letter around to various

facilities, to the CEOs, to the patient

safety officers, et cetera, and for a

variety of reasons a facility could get one

of those letters, but basically it said

you’re either not reporting very many

serious events or you’re not reporting very

many incidents. And we weren’t saying, you

know, get with it. What we were saying is


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you need to consider that and you need to

consider if your facility is really patient

safety centered and we’re here to help, et

cetera. And this facility did call Ana, and

Fran and I have talked to them as well, and

they said they would like some assistance

and some help moving their facility more

into a patient safety culture, and so that’s

what we’re working out with them right now

is how can we help them do that. And we

talked about a bunch of things and they said

what would the charge be for that, and I

said there’s no charge. This is why we’re

here. And so we’re going to go out to their

facility and help them, so again with a lot

of the things we’re doing, whether it’s the

PSL (Patient Safety Liaison) program or some

other things, we’re actually touching the

facilities a lot more.

DR. MCKEE:

Yes. And I think the opportunity to do more

of that is on our side now. Hospitals are

really managing very tightly to their bottom


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line and consultation dollars are not going

to be available. A lot of the services

we’re doing will fall under basically a free

consultative service so we should take

advantage of this opportunity. That was a

great way of -- and I think this is a great

response to that particular facility. Let’s

see how we can capitalize on the fact we are

basically a consultant educative type arm in

which we could start sort of presenting

ourselves as that type of resource to

organizations and getting that way, you

know, with them being the ones who are

saying we want you to come in versus open up

the door and let us in. I think we’re

getting close to a change in the tide as to

how we can start to work with the hospitals.

MS. CHARNEY:

And we see that a lot with the patient

safety liaison program. When I go out in

the field with Megan, it’s amazing. You can

see -- you can literally see the walls fall

down after about ten minutes and they’re


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like this is wonderful, can I call you?

Absolutely, here’s our number. So we’re

seeing more and more of that happening. In

collaboration with the Pennsylvania Hospital

and Health System Association, we are

working with the national project to reduce

CLABS (cental line-associated bloodstream

infection in ICUs. This is a three-year

program set forth by ARHQ. Dr. John Combes

is the principal investigator. To

participate in this national study we need

at least ten hospitals. In the first call

we had 30 or a small number above that.

Hospitals have to come in, as I understand

it, at the end of February to move forward

with the collaborative. We may be able to

assist them in data facets. The trustee

education is moving forward and we’ll

elaborate on that in the near future, and

we’re also presenting to small hospital

council meeting on February 24 at the

request of HAP because of the services we

have available and limited resources as well


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as others. We’re also moving forward with

statewide education initiative on

disclosure. The goal of the disclosure is

to enable and educate the opportunity for

participants to gain the knowledge and

teaching tools and effective communication

in high quality disclosure, and if you’ve

ever been part of a disclosure there is a

significant difference on who is delivering

that disclosure and how well it goes. The

methodology will be to train-the-trainer,

and the targeted audience is patient safety

officers as well as others listed on slide

eight. The program points are to introduce

the benefits of disclosure. Some of the

hospitals that have called us are saying is

disclosure working. Well, we have some data

we can support that disclosure hopefully had

some impact in the degree of litigation in

hospitals so we’re using that data to

present facts regarding disclosure approach

and its decreased liability risk and to

strengthen the relationship between the


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facility and the caregivers. Identify

characteristics of high and low quality

disclosures, development of a tool kit so

when you leave you can actually go back to

your facility and actually teach others to

be at least confident in disclosure, and

develop a level of self assurance. There is

nothing more impact as a patient safety

officer when you meet with a physician and

you say we’re going to go disclose and they

have an uncomfortable or an unwillingness to

do that. Hopefully this disclosure

education will get rid of one of those

barriers. Statewide health care associated

infection training, we’re moving forward

with this. It’s been quite the process to

watch, and PA-PSRS needs to be commended on

how this process is going forward, and it’s

my pleasure to be part of it. The nursing

home facilities education is moving forward.

We have 30 educational offerings throughout

the state. We’re going to start on February

2 and run into March 19. We have 1,050


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registrants and as of mid-week last week,

and approximately 700 or 700 of the 724

facilities taking that data, and even if we

allow for 2 percent they’re a margin because

people from Patient Safety Authority, the

Hospital Association, as well as the

Department of Health are attending, and they

have registered. Penetration is to 95

percent of those entities. The other 5

percent who cannot attend one of the 30

sessions is being addressed through the

manual. There will be a manual and also a

DVD video of which still has yet to be seen,

so they’ll still be able to obtain that

education. The regional patient safety

liaison program is moving forward. It is

indeed one of the most pleasurable things in

my role at the Patient Safety Authority is

to go out in the field and meet with these

individuals. It’s amazing, and I probably

would do it myself. When we show up the

troops are rallied around the table, a bit

nervous, and within ten minutes you can see


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that trust building, and by the time we

leave they seem to have no problem calling

us in follow up. We’re moving forward with

three additional patient safety liaisons,

one of which will be in the northwest one in

the southwest and one in southcentral. We

have placed newspaper articles along with

other advertising modalities. We are

receiving applications. The cut off date

according to the newspaper is January 30.

We’ll extend that probably by two weeks.

Again, I’d like to do phone interviews and

then bring the top four to five candidates

in for a group interview. I would love to

have them in place as early as spring. The

new web site, I can’t tell you enough about

this. Actually in the meeting that I was in

on Friday at HAP with patient safety

officers and risk managers it was actually

unsolicited that they came forward and said

your web site is great, you all need to go

and look at it because if you haven’t been

there lately you need to see it. They


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really like the way they can search

according to discipline and in particular

article sets. If they want to look at falls

they just type in falls now and all those

articles come up. It’s very user friendly,

and we’ve had extreme user feedback in a

very positive way. It was a team effort and

my first opportunity to work with EDS and

PA-PSRS and the Authority together and this

is extremely successful, so thank you.

That’s the end of the presentation. Is

there any questions or anything I can answer

for you on what we’ve done in the last six

to eight weeks? Thank you.

MR. DOERING:

Thanks, Fran.

DR. MCKEE:

Well, okay. I think following Fran’s

presentation, we want to have a discussion.

Mike is going to lead us through a budget

discussion and a standardization discussion,

and we’ve already begun to tap on the issue

of the low reporting, the letter of low


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reporting.

MR. DOERING:

Give me a second to get back up to the

front. What we need to do, and I sent some

information to you yesterday that has to do

with some of the financials. And we have

not -- DOH has not assessed the facilities,

the hospital’s, ASFs, et cetera, facilities

for the 08-09 fiscal year. And we need to

-- or they need to do that soon, and if we

can just kind of get some consensus, I

guess, as to what we should do with the

assessment, that would be great. I put

together a couple of pages for you. It’s a

word document I sent you yesterday, and I

think the title has it as the budget. The

purpose is really to show you -- if you

would go to the second page there is what

looks like a spread sheet, and in column A

this is what our budget for 08-09 was that

you all approved last year some time.

Column B is the actual expenditures. Column

C is what we anticipate we’re going to spend


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for the remainder of the year. And again

this is on a cash basis, not an accrual.

Column D is anticipated total expenditures

so it’s really columns B plus column C, and

column E is the balance, whether we’re going

to overspend or under spend in that

particular category. So if you go way over

to the left and you go to the column marked

description, I’ll just take you down to one.

It says go down to total personnel. Our

budget for total personnel was $787,000.

Through December 31, 2008, we had spent

207,000. Our anticipated remaining

expenditures was 433,000. That’s what we

plan to spend from cash from now until the

end of June, so if you go to column D that

means we spent $641,000 for the year, and

our balance is what we would be under by

about $145,000, and the reason that we would

be under by $145,000 is some of the

positions we hired, including Megan and

Fran, were hired a couple of months later

than we had budgeted for. Also, Judy and


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myself moved from contract to PSA employees,

and that happened a few months later than we

had anticipated and also the hiring of the

PSLs is going to happen just a couple months

later than we anticipated as well. So our

salary expenditure, our personnel

expenditure for this year is going to be

less than we had anticipated. That was just

an example. The biggest difference, if you

go -- let’s go to the bottom line. Grand

total, we said we rebudgeted $5.7 million.

To date we’ve spent around 2 million. We

believe for the remainder of this fiscal

year we’re going to spend another 3 million.

That means the total expenditures would be

approximately $5 million, which means we

would under spend our budget by about

$700,000. The biggest difference, if you go

up about halfway up the page is something

called specialized services, and that

difference is about $447,000. And the

majority of that is $340,000 we had set

aside for the trustee program. We are going


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to spend $100,000 of that this year. It

does not look like we are going to spend the

other 240,000 this year but if it gets into

the budget for next year, we would spend it

then. We also have $100,000 for Fran’s

education programs. I believe we’re only

going to spend 50,000 of that as opposed to

100,000, and I think we had something in

there for HAI we’re not going to spend so --

that and the personnel is where the most

significant differences come from.

MR. RIEDERS:

This is Cliff. I just want to ask you for

some additional information. I always get

real nervous when I look at budgets prepared

by other people, and I’m on a board

exercising fiduciary duties so pardon my

saying this but I think it would be

appropriate, and other organizations do

this, for us to have a break down of the

five largest expenditures. Forget about the

salaries, even if it’s just a list of

employees, no salaries. Specialized


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services you’ve explained, and that’s good.

But I think you ought to go through the five

largest expenditures. Legal services have

always seemed ridiculously high to me unless

that’s somebody’s salary pay. We ought to

know if that’s an hourly thing or a salary

paid for and for what, so I would

respectfully suggest before I can vote on

this as a fiduciary of this Board, I would

like to see a bit more detail. And I’m not

questioning, by the way, that any of this is

totally legitimate. Of course, I’m always

delighted to see any budget come in under

budget. It’s part of my responsibility to

have a little bit more detail.

MR. DOERING:

Sure. I would -- let’s see here. I can

send you some of that information. I’ll

tell you in terms of the legal that’s the

portion of Barbara’s salary is what we pay

in terms of we have an agreement with the

Office of General Counsel for that. And I

can give you more of the information. The


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contractors is primarily our contract we

have with ECRI Institute. And with the

personnel, I can certainly send you the

salaries of the folks we have in the Patient

Safety Authority. And again I don’t know

that I’m asking you to vote on anything here

in terms of the budget, and we’re not asking

to approve a budget for next year or

anything. I was just trying to show you

where we were. I do think we need to come

up with some kind of rationale for what

we’re going to assess the facilities for

this year.

MR. RIEDERS:

Yes, that’s kind of where I was going.

MR. DOERING:

I’ll most certainly send some of that

information around to the Board.

MR. RIEDERS:

I don’t think any hospital will call me and

ask why you’re being assessed what they are,

but I just think it’s information we should

have in the back of our minds.


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MR. DOERING:

Sure. So my own suggestion just to give you

a little more background, Chapter 3 of the

Mcare Act of 2002 does state that we are

allowed to assess the hospitals, ASFs, et

cetera, $5 million a year plus a -- there’s

an annual kicker on top of that that gets

applied each year so the total amount we

could assess for this year is somewhere in

the neighborhood of $5.9 million. Last year

we assessed $5.4 million. In terms of our

cash right now, I received something from

our controller yesterday -- or this morning

that says as of December 31, 2008, we have

$4 million in our trust fund. As you can

see, my estimate here is we’re going to

spend a little north of $3 million in cash

between now and June. We have not assessed

the facilities for fiscal year 2008-09. The

Department of Health does the assessment and

in the law I forget exactly how it’s stated

but it says something about assessing based

on the budget of the Authority. My own


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belief is we should consider an assessment

of around $5 million, which is what we’re

going to spend this year. This is about 8

percent less than we assessed facilities

last year and about 16, 17 percent less than

the ceiling in terms of what the assessment

could be, but I’ll leave it open to your

discussion.

MR. MERICA:

Mike, this is Gary. Do you or anyone have a

rough figure, I think, that’s based on

hospitals? The assessment then would be

broken out per bed, is that correct?

MR. DOERING:

Yes, sir.

MR. MERICA:

Do you have any sense at all -- I seem to

remember before when we assessed around the

5 million that came out somewhere around

$100 per licensed bed. Do you know if

that’s true? Do you have any sense of that?

MR. DOERING:

I’m going to have to only say that’s what I


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believe it is. I’m going to look to Fran or

somebody else. Stacy is not in here right

now. She just stepped out.

UNIDENTIFIED SPEAKER:

I think it’s a bit more than that. I think

it’s between 120 and 140 is what we budget

for a bed.

DR. MCKEE:

One of the things I’d like us to do is find

out whether there is a change in the number

of licensed beds across the state. I know

the state department has -- the health

department has been really looking at the

bed counts, the licensed bed count, and

making adjustments so that might have an

impact. Also, we have ambulatory centers

that were not part of the formula and I

don’t know how this suspends to nursing

homes, if it does at all, so there may be...

MR. DOERING:

The impact on -- Stacy, we’re talking about

the assessment and there’s been a question

about how much the assessment is per bed,


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and there was another question just getting

to ASFs the overall impact of reduction or

increase of an ASF is very small because

they’re just done based on their ORs, and so

for an ASF if they have two ORs it’s like

getting two beds. For a hospital who has

500 beds if you say 500 beds versus 400 beds

there’s a much bigger impact. You were

asking a question about those changes.

DR. MCKEE:

Yeah. Is there a change in the number of

licensed beds year over year because that

would impact the revenue coming in. It

seems to me the licensing has been --

relicensing surveys have really been looking

at the bed count and making adjustments so

is there a way to find out what that bed

count looks like one year to the next and

what that delta is that will have an impact

on...

MS. MITCHELL:

I can find that information for you. I

think it doesn’t swing that much, quite


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frankly, because it’s a big rigmarole to

take them off and to put them back on again,

so they generally tend to keep them if they

have them. They may not be using them but

to take them off the license and then to go

back in requires a while and a new survey.

So I don’t think there’s quite that much

swing in the beds. Now we have had one

hospital that went down this past year, so

that would be 80 beds lost off of the total

count but...

MR. DOERING:

Which again it wouldn’t affect our money

coming in. It would affect the per bed

rate...

MS. MITCHELL:

The amount per facility.

MR. DOERING:

...that DOH would charge facilities.

DR. MCKEE:

Right. And I think we need to be sensitive

to that in the fact of what hospitals are

going through -- are preparing themselves


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for a lengthy struggle so, you know, we

wouldn’t want to add salt to a wound if

we’re not careful looking at that aspect of

it.

MS. MITCHELL:

Okay. I’ll get you some information on

that.

MR. MERICA:

Ana, that was exactly the nature of my

question, what figure would the per bed be

for our assessment, exactly what you just

reiterated.

DR. MCKEE:

Okay. So we’re not -- it sounds like we’re

establishing the framework of the kind of

information the Board members would like to

see moving forward into the decision making

and the recommendation, so I’m hearing

appropriately, requests for more detail

around the salaries, around some of the

higher cost items on the budget. And we

will also get some information on the impact

to the hospitals on the per bed size looking


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at, you know, one hospital closing or

adjustments being done to the total number

of licensed beds across the state. And I

think it’ll be easier for the Board when

it’s time to come up with a recommendation

to be able to do so. Am I reflecting

everybody’s thoughts about their concerns

about how to move forward on this?

MS. HOLLAND:

I guess I have a -- this is Barbara. I have

another concern, and that is I guess given

the likelihood of the impact especially as I

read this, Mike is proposing that maybe we

think about a reduced aggregate assessment.

The impact on overall per bed charge is

going to be probably minimal. What is the

impact on hospitals budgeting if we delay

the notice of the assessment? I guess

that’s the question.

DR. MCKEE:

Right. Right.

MS. HOLLAND:

That needs to be -- did I hear you right,


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Mike, you want to try to put out the notice

of the assessment sooner rather than later?

MR. DOERING:

Yes.

MS. HOLLAND:

Okay.

MR. DOERING:

I think we are in fiscal 2008-09 which ends

June 30. I think it would be good to get it

out to the hospitals as soon as possible.

MS. HOLLAND:

Do most hospitals have a calendar year

budget or a fiscal year budget?

DR. MCKEE:

Fiscal year budget begins July at most

hospitals and frankly the budget season is

now, and budgets are usually submitted to

boards by their April-May board meeting so

by February-March they are looking for

specific figures. Now we are talking about

an assessment payable when?

MR. DOERING:

This fiscal year.


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DR. MCKEE:

It’s too late. We can only help them with a

budget that would be due -- payments that

would be due for next year around this time.

MS. MITCHELL:

Well, last year we did the assessment in

January and then in June, correct?

MR. DOERING:

Yes.

MS. MITCHELL:

So we got both of the amounts -- we split it

into two payments so we got the full amount

on last year’s fiscal year so hopefully they

budgeted for that same amount this year.

They’re just waiting for the bill.

MS. FUHRMAN:

I was going to say my sense having done a

budget in the past is you expect it’s going

to be there. And, Gary, maybe you can

respond to that.

MR. MERICA:

Yes, that’s my assumption too. This is

obviously something we’ve been assessing


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facilities for a number of years now, and

although I can’t speak for everybody

obviously I think it probably just becomes a

standard part of your budget even though it

may change from year to year to just put

that marker in.

MR. DOERING:

That was my understanding as well is folks

had it in their budget for this year and

it’s a question of when we ask them for the

money.

DR. MCKEE:

Okay. So we’re going to move on. I think

we know there’s more work that needs to be

done on that. And, Mike, do you want to

lead us through the standardization

discussion and then follow that into the

reaction to the low reporting letter?

MR. DOERING:

Actually can I flip those around?

DR. MCKEE:

Yes, you may.

MR. DOERING:


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Because then I’m going to ask Bill to help

do the standardization letter. In terms of

the low reporting, and I’m going to say a

little bit of what I said before, which is

we did send that letter out. It went out to

about 50 different hospitals, and it was

based on facilities that either did not

submit a single serious event in 2007 or if

it didn’t in 2008. The same thing if they

didn’t submit an incident in 2007 or in

2008. Also, if they were less than, I think

it was 10 percent of the mean in terms of

the number of incidents for serious events

they reported. And we did have 50

facilities that fell into that category for

a variety of reasons, and a letter was

drafted, signed by Ana and went to all those

facilities identifying that they were kind

of a low reporter. We did get some

response. I told you already of the one

facility contacted us and wants us to work

with them in terms of improving their own

culture of safety. We had another facility


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that wants to work with us towards an

interface because they say they’re

collecting the information but it’s not

being entered into PA-PSRS and they keep it

in their own system. So we’ve had some

response from them but just wanted to give

you an idea of really where we were. I

probably would have expected a little bit

more response than we got but we will

certainly do the same data collection at

another time to see if we’ve seen any kind

of change in the reporting.

MR. MERICA:

Mike, this is Gary. I can’t recall. Did

the letter ask for a response or not?

MR. DOERING:

It didn’t specifically ask for a response,

no.

MR. MERICA:

Okay. Just curious.

DR. MCKEE:

So I have a recommendation. I think we’ve

got to be persistent on this. I think


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perhaps a follow up letter should go out and

be more explicit about wanting a response

and wanting a dialogue with that

organization and offering ourselves to be

able to help them in either education or

assisting them in looking at their reporting

process showing them the best practice from

a little organization but being more

specific about what actions we want them to

take. I think -- I just think we need to

just continue to push. You know, I think

the letter, by the way, I don’t know how

many of the Board members saw the letter, it

was not confrontational at all. I think it

had a very good tone. It was a very

productive way of having a dialogue but I

think we should continue to write and, you

know, the writing campaign should continue.

MR. DOERING:

All right. Going back to the -- we’re going

now to the standardization. At the last

Board meeting, we started to have dialogue

on the, what is it, 19, I guess, principles


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of the standardization, what is reportable

and what’s reportable as a serious event. I

had discussions with Stacy Mitchell from the

Department of Health since then. She is

here today. The Board asked that we clean

up the document a little bit, which I did.

I took out all the edit marks on it and all

the markups. I also took out some stuff in

the back that was more kind of suggestion or

alternative kind of things. And I did

resend it to the Board members last week

asking all of you to send in any types of

questions or discussion points you may have.

I did receive a discussion point from Gary.

I didn’t get any others but I’m sure there

probably are some today. We really want to

do something with this, and we want to be

able to have a little bit more standardized

-- not a little bit, just have more

standardized reporting. But we’ve been

suggesting we may want to hear what the

public response is as well. Now this group,

being our Board, can either come to


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consensus on these principles or not, but I

think we should have a discussion, and I do

think it would be -- it could be very

beneficial to take these principles and put

them out for public comment and then have

another meeting on this. I think Stacy and

I, that’s something we discussed. The

alternative to that is for ourselves and the

department to say here’s the principles and

this is what you have to live by. So that’s

something we could do. I don’t know if it

is the most palatable way for the folks out

there.

MR. RIEDERS:

But to get this moving because it’s been so

long in the making, while I also see issues

with it, I know we could talk it to death, I

think we should have an up or down vote so

maybe it’ll say -- maybe nobody agrees with

me, but I’m going to make a motion now, I’d

like to make a motion, we’re at a public

meeting, that we circulate these to the

hospitals, we circulate these principles to


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the hospitals. That’s the entirety of the

motion.

MR. DOERING:

Cliff, in a draft or a final form?

MR. RIEDERS:

In a final form.

MR. DOERING:

We can’t do that without the -- we can

suggest, but I don’t think we can do that

without DOH’s concurrence.

MR. RIEDERS:

Well, I think we ought to -- the motion is

that we do it, and we ask for DOH’s

concurrence. I don’t know if there’s any

reason they would not concur but that we --

I’ll modify the motion to say that we

circulate this to the hospitals but request

DOH’s concurrence in so doing.

MR. MERICA:

Just so I understand your motion, so you’re

not moving that we circulate it for a

comment period. You’re, I think, suggesting

we circulate it as kind of an official


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distribution from the Authority, is that

correct?

MR. RIEDERS:

Correct. I think if you get into a comment

period and it becomes -- actually in this

way I’m being liberal to the hospital. If

you go through a comment period and it

becomes, in essence, kind of regulations, I

think they’re ambiguous enough that as

regulations you may regret it, but I think

we may eventually want to make it a

regulation if it works. I think the thing

to do is get it out there to the hospitals

and see if it changes anything, and then at

some later point we may want to go through

comment period and make it more official,

but I just think it’s important to get this

out there.

MS. HOLLAND:

Just for clarification, Cliff, I know you

know this but for others, the Authority does

not have any power to make regulations, and

just to clarify for everybody frequently


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items are published in the Pennsylvania

Bulletin for comment when the final product

is not viewed as set in stone, but it’s just

a way of, you know, acknowledging that

sometimes more minds are better than, well,

in this case, what, 15, and that maybe

comments from people who are dealing with

these principles in operation on a daily

basis might have something beneficial to

contribute, and that’s the reason for the

comment period.

MR. RIEDERS:

Well, Barbara, if it would make this motion

pass to have it published in the

Pennsylvania Bulletin for comment first, I

certainly would not oppose that. I just

want to keep the ball rolling.

DR. MCKEE:

Okay. That sounds like a modification of

your proposal -- of your motion. Anybody

second that?

MR. GOODRICH:

I would second that. This is Bill Goodrich.


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DR. MCKEE:

Okay. So any discussion? We have the...

MR. MERICA:

This is Gary. I just want to be clear. Can

somebody restate the motion?

MR. RIEDERS:

I’ll restate it since it’s my motion. My

motion is to publish for comment in the

Pennsylvania Bulletin the principles in

connection with serious event reporting and

thereafter consider those comments and to

issue these principles to the hospital with

whatever changes those comments might

dictate, if any.

MR. MERICA:

And just as further point of discussion, I

just want to go on record, I can support

that motion, I just want to go on record,

Mike said I did submit a form for discussion

and we don’t need to discuss it here today

because I made this clear before. I just

disagree with principle number three which

says there may be a serious event even if


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there was no error. As I pointed out to

Mike the title of the legislation says

Medical Care Availability and Reduction of

Error Act, so I just disagree with that but

I can support the motion to submit it for

comment to the patient safety officer of

organizations.

DR. MCKEE:

Okay. Any other comments, any other

discussion? Hearing none, I’ll ask for a

vote, and the roll call will be by Terri.

MS. PLESCE:

Fuhrman.

MS. FUHRMAN:

Yes.

MS. PLESCE:

Garzarelli.

MS. GARZARELLI:

Yes.

MS. PLESCE:

Goodrich.

MR. GOODRICH:

Yes.


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MS. PLESCE:

Hairston is not here. Marshall.

MS. MARSHALL-BLAKE:

Yes.

MS. PLESCE:

Marshall-Blake. Merica. Gary.

MR. MERICA:

Yes.

MS. PLESCE:

Cliff.

MR. RIEDERS:

Yes.

MS. PLESCE:

And Ana -- oh, no, Ana doesn’t vote.

DR. MCKEE:

I don’t get a vote.

MS. PLESCE:

And Stan and Webster aren’t here.

DR. MCKEE:

Okay. So moved and so we’ll proceed with

making that available to the Bulletin. And

what is the time line we should have

responses back and bring this back to our


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Board meeting? Are we talking a March

meeting or too short?

MR. DOERING:

Too short because we need to get it out into

the Pennsylvania Bulletin. It takes at

least a week and a half to get it into the

Bulletin. Once we get it into the Bulletin

there will be a 30-day comment period. We

would receive the comments and then we would

have to do some -- put together an analysis

of the comments. The problem we have right

now is we’re all going to be doing HAI

nursing home training sessions and annual

report, et cetera, so it’s not going to be a

one-day turnaround on comments, so it’ll

take us a little while so I think we would

be looking at the April Board meeting.

DR. MCKEE:

Okay. All right. We have one last item

agenda, and that is to approve an advisory

board member for the Healthcare Acquired

Infection Initiative. So in your packets

there’s the -- this was a position made


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available as a result of the resignation

from P.J. Brennan. And we have a Dr. Neil

Fishman, whose CV is there for your review.

He is a hospital epidemiologist at the

University of Pennsylvania Health System,

Associate Professor of Medicine. I would

like a confirmation vote.

MR. DOERING:

Yes, you’d like a confirmation vote. Dr.

Fishman did attend some of our meetings in

Dr. Brennan’s place. Dr. Brennan, because

of time requirements, has stepped down. We

did talk to our commission of champions who

is Joan and Marshall Webster and Stan

Smullens and all of them said, yes, let’s

nominate this person to replace Dr. Brennan.

So that’s why I sent the CV to you all.

DR. MCKEE:

Okay. Do I hear a motion to...

MS. GARZARELLI:

I make a motion that we receive Dr. Fishman.

DR. MCKEE:

Okay. Anyone second it?


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MS. FUHRMAN:

Second.

DR. MCKEE:

Okay. Do we need a roll call or can we all

say...

MR. DOERING:

I think we can do an aye and nay on this

one.

DR. MCKEE:

Okay. All those in favor, say aye. Any

nays? Any abstentions? Okay. So he stands

confirmed. Unless there’s any new business,

I believe we are at the end of our agenda.

And our next meeting is in March.

MR. DOERING:

Yes. It’s the second Tuesday of March.

DR. MCKEE:

And hopefully the weather will be pleasant

so we will see our colleagues face to face.

Have a safe end of winter, and we’ll see you

in March. Thank you everyone.

***

[The meeting adjourned at 11:35 a.m.]


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jeh


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