BayCare Board quality orientation

BAYCARE BOARD QUALITY ORIENTATION st 1 Edition – 11/2/2016

Table of Contents Board Essentials .............................................................................................................................3 BayCare Board Quality Committee Charter ........................................................................................... 3 Board Portal Access Instructions ........................................................................................................... 4 Board’s Role in Quality ...................................................................................................................5 Best Practices for Board Quality Committees, Barry S. Bader (Appendix A) ......................................... 5 Governance Accountabilities in the Quest for Quality (Appendix B)..................................................... 5 2013-2015 Board Quality Annual Self Survey Results: .......................................................................... 5 - Mission, Vision, Values and Strategic Priorities ..............................................................................7 Mission, Vision and Values..................................................................................................................... 7 Strategic Priorities .................................................................................................................................. 7 Quality Model (Figure 2) .................................................................................................................9 Quality Philosophy ................................................................................................................................. 9 Quality Process....................................................................................................................................... 9 Quality Improvement ........................................................................................................................... 10 Promoters of a Quality Culture ............................................................................................................ 10 Linking It All Together (figure 3) .......................................................................................................... 11 - Quality Measurement................................................................................................................. 13 Benchmarking ...................................................................................................................................... 13 Types of Measurement and Adjusting for Risk .................................................................................... 13 Key Performance Indicators/Team Award Goal Development............................................................ 14 TRUVEN MEASURES ............................................................................................................................. 15 Rating Agencies .................................................................................................................................... 15 Quality Improvement ................................................................................................................... 17 Performance Improvement ................................................................................................................. 17 Patient Safety ....................................................................................................................................... 17 Quality Sharing Day .............................................................................................................................. 18 Quality Organizational Structure ................................................................................................... 19 The Board of Trustees .......................................................................................................................... 19 Board Quality and safety committee ................................................................................................... 19 QUALITY VALUE COUNCIL (QVC) .......................................................................................................... 19 CLINICAL LEADERSHIP COUNCIL ............................................................... Error! Bookmark not defined. Hospital division Board Quality & Safety Committees......................................................................... 20 Medical Executive Committee (MEC) .................................................................................................. 20

Quality Reporting ......................................................................................................................... 21 Board Quality Dashboards ................................................................................................................... 21 Division Dashboards (Figure 7): ................................................................................................... 21 Key Performance Indicator/Team Award Goal Report ........................................................................ 22 Key Performance Indicator Executive Summary .................................................................................. 23 Public Quality Reporting ...................................................................................................................... 24 Resources .................................................................................................................................... 25 Meeting Calendars – 2016 -2017 ......................................................................................................... 25 Board Membership .............................................................................................................................. 27 – Appendices .............................................................................................................................. 29 BayCare Board Resolution on Quality – 5-1-2015 – Appendix A ......................................................... 29 Best Practices for Board Quality Committees by Barry S. Bader - Appendix B .................................... 29 Governance Accountabilities in the Quest for Quality – Appendix C .................................................. 29 Glossary of Terms – Appendix D .......................................................................................................... 29

Board Essentials BayCare Board Quality Committee Charter Purpose: To assist the BayCare Board of Trustees in fulfilling its responsibilities for BayCare Health System’s quality and safety performance and programs. Authority: The BayCare Board Quality Committee derives its authority from the BayCare Board of Trustees. Members are nominated by the Chairman of the BayCare Board and approved by the BayCare Board of Trustees. Meetings: The Committee meets at least quarterly with the authority to convene additional meetings if needed. Meeting agendas will be prepared and provided in advance to members along with appropriate materials. Materials are confidential and proceedings are protected per Florida Statutes regarding peer review. Responsibilities: Promote quality and safety of patient care in BayCare. Quality oversight responsibilities include: • Provide input into establishing the strategic direction for quality and safety efforts including development and implementation of a BayCare Quality and Safety Strategic Plan. Consider areas such as alignment with BayCare’s mission, vision and values; community responsibility; proactive response to changing health care needs; efficiency and effectiveness of services, including evidence- based practices and national benchmarks; and aligning technology with quality. • Evaluate and recommend quality and safety metrics to be utilized in BayCare’s performance incentive programs. • Recommend quality and safety metrics which accelerate measureable and continuous improvements and are used to establish system-wide initiatives (e.g., BayCare’s Key Performance Indicators and Quality and Safety Plan Goals). • Monitor quality and safety resources and expenditures. Self-Assessment: The Committee will evaluate its performance on an annual basis. BayCare Board Quality Committee Membership Chair • BayCare Board Vice Chair Members • Chair, Morton Plant Mease Board Quality Committee • Chair, St. Joseph’s Baptist Board Quality Committee • Chair, St. Anthony’s Board Quality Committee • Chair, Winter Haven Board Quality Committee • Chair, BayCare Physician Partners and BayCare Medical Groups Quality Committees • BayCare Physician Representative • Sponsor or Community Representative • President / CEO, BayCare • At large members as appointed by chair

Board Portal Access Instructions When signing in, if you do not have an updated version of Internet Explorer, you may have to access the site via Google Chrome. Signing In To Portal: 1. Go to the website: https://baycarebot.boardeffect.com/login?destination=%2F 2. Enter Username: (first initial and last name – all one word) 3. Enter Password: password1 (unless you have already signed in before and revised your password, then use your new password) Utilizing the Portal: 1. On the left side of the screen, under My BoardEffect and under Workrooms, select “BC Quality Committee”. 2. On the top of the screen, select “Workroom Files”. 3. You will see the “Visible Books”. In the section of the current packet, select “View/Download PDF”. 4. On the left side of your screen, you will see an arrow pointing downward. This indicates that your pdf file/packet is available at the bottom of your screen. Either double click on the pdf version, or right click and then click Open. This will allow you to view the packet. To close the packet, close that tab on the internet. 5. To view upcoming events, once you have signed in, click “Workroom Events”. This will give you information about upcoming events, allow you to save (export) to your calendar and/or print a list of upcoming events. NOTE: You will be sent an e-mail once meeting packets have been uploaded and ready for viewing. Logging out of the Portal/Changing Personal Profile: 1. To log out, you will see your name at the top right corner of the screen, click on the down chevron and then click “Logout”. This is also where you can change your personal profile. To do this, click on the down chevron by your name, in the upper left corner. Click Edit Profile, make changes and click on Save Changes.

Board’ s Role in Quality Best Practices for Board Quality Committees, Barry S. Bader (Appendix A) • Committee used as forum for Education • Adopt and monitor annual performance improvement plan with measurable goals • Ask why? – Why results vary from targets or benchmarks, seek explanations of root causes • Focus on a few key goals • Set the bar high • Integrate financial, strategic and quality planning • Support and reward quality Governance Accountabilities in the Quest for Quality (Appendix B) 2013-2015 Board Quality Annual Self Survey Results: BC Board Quality Annual Self-Assessment Survey: Strongly Agree 80% 71% 70% 64% 67% 67% 63% 60% 56% 57% 56% 57% 56% 57% 50% 50% 43% 50% 40% 30% 25% 22% 25% 25% 25% 20% 22% 13% 10% 0% Asks the right questions Effectively governs and Adequately invests in Evaluates and Monitors efficiency and Provides input into Promotes the quality and does not manage continuous learning of recommends quality and effectiveness of services, establishing the strategic safety of patient care in quality, patient safety and safety metrics which including use of evidence- direction for quality and BayCare service issues accelerate measurable based practices, safety efforts in alignment and continuous performance against with BayCare's Mission, 2013 Percent Strongly Agree N= 14 improvements that are national benchmarks and Vision and Values used to establish system- health care costs 2014 Percent Strongly Agree N= 9 wide initiatives 2015 Percent Strongly Agree N= 8 Qualitative Questions: What quality education topics would you like to cover in 2016? • I am more interested in how we are going to translate/correlate the BC goal of top decile performance to the local hospitals. • Truven • What risk adjustment methodologies are most useful in stratifying populations. • Better understanding of how we get the physicians to participate better with Quality • Seamless Patient care: entry to discharge and beyond Besides Ohio Health- other systems and their process for improvement Please share any additional specific feedback: • There is still a disconnect between BC Quality Committee and what is happening in the hospitals. • Very complex. Very difficult for a once a month board member to be effective. Suggest additional training be made available to lay board members. • Maintain the focus on improving and best performance throughout the system.

• We need to be consistently strong in getting the message to employees that this is not a choice but a requirement that we are going to be the best Quality provider. Highlighting Best of the Best practices across the system that are working 'Communication with the Physicians' need more focus and accountability

- Mission, Vision, Values and Strategic Priorities Mission, Vision and Values Mission – Our purpose for existence BayCare Health System will improve the health of all we serve through community-owned health care services that set the standard for high-quality, compassionate care. Vision – A strategic statement outlining the organizations future for the next 3-5 years. BayCare is an extraordinary team leading the way to high-quality care and personalized, customer- centered health. Values – Important beliefs or ideals shared by members of the organization. The values of BayCare Health System are trust, respect and dignity and reflect our responsibility to achieve health care excellence for our communities) Figure 1 Strategic Priorities (Figure 1) BayCare’s ultimate destination is to be recognized as one of the leading healthcare companies in the country. We will serve our communities with an integrated care model that combines convenient access and exceptional customer experience with an extensive network of high-quality providers. Achieving this destination is more than a five-year journey, both for the market at large, and for BayCare. BayCare Health System’s newly revised vision statement lays out 6 strategic categories necessary to attain our Vision over the next five years. It says: “BayCare is an extraordinary team leading the way to high-quality care and personalized, customer-centered health.” We will achieve this vision by: • Creating and providing an exception customer experience

• Driving clinical quality in all that we do • Providing high value care for all of the lives we manage • Managing our network footprint to support and drive this vision Because this is a people-driven business and vision, we will engage proactively in physician relations and BayCare team member engagement – both essential to reaching our goal.

Quality Model (Figure 2) Figure 2 Promoters of Quality Culture Quality Process Quality Philosophy Quality Philosophy Our Quality Philosophy has three elements: Customer Needs - Defined as “serving the needs of our customers”. All efforts will be aimed at serving the needs of the customer in a safe care environment and improving the patient experience through excellence in both clinical outcomes and perception of care. Customers can be defined as both internal and external and their needs categorized into service, outcome and cost. Process Focus – Improvement efforts are targeted towards improving processes while reducing process variation and risk to patients. Our focus remains on the process and not on the person. Continuous Improvement - Continuous improvement is an attitude required by our team members to constantly strive to improve the work processes used to deliver products and services and to prevent harm to our patients. In order to sustain real improvement, the individuals doing the work must be involved in developing and implementing the process. Quality Process The Quality Process involves planning, assessing, reporting and improving existing processes. Quality Planning - Quality planning defines the strategy used to meet customer needs and to achieve the vision of the organization. The quality planning process provides the framework for innovation and the creation of new services and to identify and improve existing services. Opportunities for improvement are prioritized by high volume, high risk, problem prone processes, patient safety, service, outcome and cost issues. Organization-wide Key Performance Indicators (KPIs) and Team Award Goals (TAGs) are established through the quality planning process to align with organizational priorities. The department level goals are aligned with the organizational KPIs and TAGs.

Quality Assessment and Reporting - Quality assessment and reporting, measures current process capability, progress of improvement and the stability of the new process. This encompasses a cascade of metrics that begin with the organization’s Key Performance Indicators and ends with departmental indicators that measure the capability of our processes to meet the needs of our customers. (See Figure 2) Data is systematically collected and assessed to identify opportunities to improve quality and safety Quality Improvement Quality improvement is the action taken to design or improve the systems and/or processes used to deliver the products and services to our customers. Quality improvement actions are focused on identified priorities. When an opportunity to improve is identified and prioritized, BayCare facilities may utilize methodologies such as Six Sigma DMAIC, Workout, Lean, Design for Six Sigma or FOCUS/PDSA methodology for process improvement or process design and re-design. In addition, we may utilize process improvement teams or task forces as needed. Promoters of a Quality Culture A Quality Culture encompasses the work environment that supports quality improvement and values patient safety. Promoters of a Quality Culture include four components which include leadership, communication, education/training, reward and recognition. Success in supporting a culture of quality and safety requires physician involvement, education and training to support the quality process, effective and planned communication between team members and customers, and recognition for those who role model quality in the organization. The responsibility for a quality culture is delegated to the Leadership and Management.

Linking It All Together (figure 3) Key Performance Indicators – quality measures are developed annually to measure the system’s performance on the identified priorities of the organization. Based on our philosophy of continuous improvement, measures are established based on previous performance and provide for three levels of achievement (Threshold, Target and Stretch). Threshold, Target and Stretch are determined based on the amount of effort and capability of the organization to attain that level of performance (Threshold 90%, Target 50%-60% and Stretch 10% attainable). FIGURE 3 Team Award Goals – A subset of Key Performance Indicators are selected annually to engage our team members in the performance improvement of our organization. Team Members are financially awarded when established Team Award Goals reach a level of Threshold or Target. The award is weighted on importance and partial credit given for Threshold performance and full credit for attaining Target. Department Goals – Each unit is asked to establish department level goals that align with the organizations Key Performance Indicators and Team Award Goals. Individual Contribution – Each team member has individual goals identified at time of annual performance evaluation that when consistently executed will together help the organization meet their goals of providing quality patient care and service to our customers. This function directly aligns with BayCare’ s belief that all team members must demonstrate personal accountability and encourage personal accountability in others to reach our Key Result of Top Decile performance. Team Map – Team Map is a reporting tool developed for the purpose of departmental reporting of performance on their Department Goals. The tool has the capability for departments to create action plans and report their performance for the entire department to follow. In addition, Team Map provides

a searchable database that allows other similar departments to see out high performing units and best practice. Leadership Award The Leadership Award Program was created to align quality improvement efforts around those items identified as a priority by way of the Key Performance Indicators and Individual Goals. The program provides a monetary award to recognize individual performance and leadership in achieving the stated goals. Annually the Compensation Committee of the Board reviews the previous year’s results and determines the appropriate award. The final payout is a percentage of the individual’s base pay rate at the end of the performance year.

- Quality Measurement The BayCare Health System Quality Model identifies the importance of both assessment and reporting. Reporting of quality performance is accomplished through development of metrics that measure the structure, process and outcomes of the organization. Ideally, measures are developed using the most real-time data and information possible. Structure Measures – assess the features of a delivery system, capabilities of the staff or environment (i.e. the ability of clinicians to prescribe medications electronically, use of surgical checklist prior to procedure). It usually is a “yes” or “no” response to the measure. These assessments are often queries by outside agencies and are shown to be best practices. Process Measures – process measures assess the activities carried out by the health care professional. They too are usually guided by evidenced-based clinical guidelines shown to improve outcomes. Process measures are useful in measuring the overall adoption of evidence based or best practice initiatives. (i.e. percent of compliance with hand hygiene according to World Health Organization, percent of compliance with Central Line Maintenance). Outcome Measures – represent the end state as a result of health care (i.e. Mortality, Infection, Length of Stay, or Readmission). Outcomes are experienced by the patients and impact morbidity, mortality, quality of life and costs to patients and health care providers. Benchmarking National external comparatives are used whenever possible. External benchmarking allows us to measure against recognized standards to ensure consistency in how we measure. Additionally, we are able to use percentile ranks to gauge where our performance lies within the range of like providers. Using National data also allows us to analyze the pace of change within our industry which is equally important as measuring our individual performance against others. While our performance may improve, if the national pace of improvement is faster or greater, our improvement will appear as declining regardless of the progress we made. Often called benchmarking, we then take the best performers nationally to set targets for our organization. These benchmark performers are often able to show consistent performance through use of best practices. Sources of information may include national databases, normative databases provided by healthcare analytic agencies, pertinent literature such as peer reviewed studies, sentinel event alerts, and practice guidelines. Types of Measurement and Adjusting for Risk Various types of measurement are used to express performance and are specific to standardized national performance measures. Examples are percent compliance, compliance indices per 1000 or 10,000 patients, risk adjusted or risk standardized rates, and observed to expected ratios. Some metrics such as ‘never events’ may be counted in simple events or occurrences. Risk adjustment is the preferred methodology as this approach accounts for variations in patients’ severity of illness when predicting an outcome. In practice, certain hospitals may truly see ‘sicker patients’ and this methodology is able to adjust the expected outcomes based on characteristics such as preexisting conditions, emergent or urgent conditions, age or in some cases what type of care the patient requires (i.e. intensive care unit). Risk adjusted or risk standardized rate and observed to expected ratios are two types of risk adjusted measurement. Similar to counts, raw rates, and indices per 1000, risk adjusted or risk standardized rates are useful but need to be compared to other risk adjusted rates to be fully understood. Conversely, observed to

expected ratios (OE ratios) allow performance to be analyzed to a degree within the measure. For this reason, they are often used within BayCare. The observed measure is the actual incidence and the expected measure is a prediction based on research of like patients to determine what the chance of a given outcome will be. Once the two measures are divided the ratio is produced. A score of 1 indicates the outcomes were just as expected; less than 1 represents better than expected performance; and a score greater 1 represents an opportunity for improvement. Example using a group of patients with Heart Failure being readmitted: 20% of our patients were readmitted Research shows that nationally, similar Heart Failure patients were readmitted 18% of the time OE: 20% / 18% = 1.11 We have an opportunity to reduce admissions by 11% to meet the national average Example using length of stay for a group of patients who had a knee replacement: Our knee replacement patients had an average length of stay of 2.7 days Research shows that nationally, similar patients had a length of stay of 3.2 days OE: 2.7 days / 3.2 days = 0.84 We have performed better than expected by 16% Key Performance Indicators/Team Award Goal Development Utilizing the Benchmarking process stated above our Key Performance Indicators and Team Award Goals are adopted annually and are presented as recommendations to the Board of Trustees for final approval by the end of the year (See Figure 4) Figure 4

TRUVEN MEASURES BayCare Health System benchmarks against the Truven Top Health System and 100 Top Hospital Performance measures to demonstrate progress toward Top Decile performance. They include a set of 12 measures that provide a balanced view of the organization's overall performance and align with our customer needs of Service, Outcome and Costs (See Appendix I). The measures currently include the list below and are subject to change annually based on available public data and changes determined by Truven: • Overall Composite Score • Mortality (Hospital Inpatient) • Complications • Emergency Center Throughput • Core Measures • 30 day Mortality in high risk chronic conditions (Currently Heart Attack, Heart Failure, Pneumonia, Open Heart Surgery (CABG), COPD and Stroke) • 30 day Readmissions in high risk chronic conditions (Currently same as above in addition to Hip / Knee Replacements) • Average Length of Stay • HCAHPS – Inpatient Experience • Cost per Case • Operating Margin • Medicare Spending per Beneficiary • Other measures under consideration for 2017: Hospital Acquired Infections and 30 Day Episodic Payments for Heart Attack, Heart Failure and Pneumonia). Rating Agencies As health care consumers become more health care literate and have ready access to health care data, public and private agencies are creating and publishing quality reports intended to educate consumers on which health outcomes are important and guide them to the best providers. In an effort to simplify the information, these agencies often create unique composite measures and can include cost information to indicate the value of care. The uniquely created composite measures between agencies can result in confusing or conflicting ratings, thus requiring inspection and explanation for consumer and providers to understand the final ratings. In some cases, the reports are created for the healthcare industry only with the intent on benchmarking and improving national performance among providers. Truven Top Health Systems and Hospitals is one such report. Examples of current publically available quality reports include: Consumer Reports, CareChex, CMS Hospital, Nursing Home, and Home Care Compare, Healthgrades, Truven 100 Top Hospital and Health Systems, Leapfrog, The Joint Commission, FloridaHealthFinders, and US News and World reports. All of these reports utilize publically available data that can be accessed at no charge or purchased from CMS; therefore, they do not require health care facilities to ‘opt in’ when producing the report. They are also similar in that the publically available data is limited to the Medicare population or data that is published as part of our Medicare participation. This results in many metrics being limited to the Medicare population and reports being produced containing the same quality measures calculated in different ways.

A few of the reports allow volunteers to supplement the information with data provided to the agency in the form of a survey. An example of this type of report is Leapfrog. Healthgrades for example, heavily weights reputational survey data provided by physicians. Typically, when facility performance exceeds the national average and approaches top quartile (top 25%) and top decile (top 10%), all reports will recognize the health care provider quality rating as favorable. Quality Improvement

Quality Improvement Performance Improvement The BayCare Performance Improvement (PI) program kicked off in late 2004. The current PI team is composed of 23 FTEs with broad depth of experience across healthcare and other industries. The team utilizes a variety of different improvement methodologies, including Lean and Six Sigma. PI provides value to BayCare by eliminating waste and improving and optimizing processes, reducing defects, facilitating strategic improvement initiatives, and providing training to the organization. Improvement project submissions are assessed for alignment with key performance indicators and other strategic actions. Project teams are cross-functional, and senior leaders are most often the sponsors or champions. Best practices identified during projects are spread across the organization, and process metrics established to assess compliance. Patient Safety BayCare Health System is dedicated to being a highly reliable organization that consistently provides a safe environment for both our patients and team members. We have a strategic goal to continuously improve our processes to reach “zero preventable” harm. Our strategic initiative incorporates High Reliability science and “Just Culture” principles, both support personal accountability for all team members. High Reliability – is a proven science first identified in industries outside of health care. The methods and characteristic of a highly reliable organization drive down errors, increase standardization and decrease variation in practices. It supports all components of our Quality Model. Just Culture – Provides leadership with tools and skills necessary to promote team member personal accountability and consistent response to errors across the organization. Team Resources provides the infrastructure to assure consistent leadership response to errors. Leadership’s goal should be to analyze and gain an understanding of the underlying variables that could have led to the error or “at- risk” behavior that caused the event and respond appropriately. This approach will create a learning environment (learning from events to improve) and trust that leadership’s response will be fair, and equitable. Learning Culture – A component of both High Reliability and “Just Culture” is the ability to learn from our mistakes. Team Members are encouraged to report all actual/potential errors/events in order to provide necessary insight in day to day practices that could lead to harm. Creating an infrastructure to further analyze and respond to actual or potential risks allows the organization to learn from past performance. BayCare defines harm as an unintended physical, emotional, psychological injury or impairment resulting from or contributed to by medical care. Serious Safety Event – A serious safety event represents a deviation from Standard of Care that results in severe harm to our patients. All harm events are reviewed for compliance with the standard of care that when performed as expected can prevent harm to our patients.

Quality Sharing Day Quality Sharing Day celebrates BayCare’s Commitment to Quality and provides an opportunity to learn about successful process improvements and best practices implemented in clinical and operational areas throughout the system. Teams across BayCare share their projects through storyboard displays and select number of team presentations. The Frank Murphy Quality Lecture Series contributes to the day by bringing nationally recognized key note speakers on motivational and quality related topics

Quality Organizational Structure BayCare Health System participates in a planned, systematic approach to designing, measuring, assessing/reporting and improving performance through the following structure (See Figure 5 and 6). The Board of Trustees The Board of Trustees bears the ultimate responsibility for the safety of patients and the quality of care provided by the organization and all health care providers associated with the organization. Board Quality and safety committee The Board Quality & Safety Committee derives its authority from the Board of Trustees. The Committee has been delegated the responsibility for oversight of the continuous improvement of the organizations processes. BayCare Board Quality & Safety Committee Charter (Appendix D) Figure 5 Quality Value Council (QVC) Engage clinical leadership in strategic planning, alignment and adoption of ongoing and future quality and value based initiatives across the health system. Establish Institutional aims, drive care delivery priorities and provide a venue to monitor and engage in constructive dialogue around our health system key performance and team award indicators. Facilitate ongoing, two-way communication that best enables a shared understanding by all parties, of infrastructure requirements for sustaining a health system culture of continuous performance improvement; operationalizing a commitment to high value care. Clinical Leadership Committee (CLC) To provide clinical leadership across BayCare through facilitation, collaboration, and shared decision making on matters relating to standard of care, patient safety and the patient experience. In addition to serving as the primary management committee for reviewing and vetting all materials relative to BayCare Board Quality, CLC is recognized as final authority for system related clinical standards outside of hospital medical staff, service line and network responsibilities to oversee quality of care delivery.

Hospital division Board Quality & Safety Committees Local Board Quality & Safety Committee provides oversight of the continuous improvement efforts at the hospital/community health alliance level. Quality Oversight Reports are reported up to the local Board of Trustees. Medical Executive Committee (MEC) The Medical Staff Executive Committee provides oversight of general quality and safety of medical care rendered to our patients. They collaborate with hospital administration to continuously improve services available to our community through participation in committees, and performance improvement teams. The MEC makes recommendations to the Board of Trustees on medical staff appointments, reappointments and clinical privileges. Figure 6

Quality Reporting Board Quality Dashboards BayCare Health System has developed quality dashboards for all divisions across the continuum of care. These dashboards are designed to show a comprehensive overview of the division’s key outcome/process measures. Measures are selected to accurately represent their current ability to meet the needs of our customers. Whenever possible we provide national benchmarks for comparison. Division Dashboards (Figure 7): • Acute Care Dashboard – Hospital Division Report • Ambulatory Surgery Centers – Quality Dashboard for free-standing Ambulatory Surgical Facilities and Hospital Outpatient Surgery Facilities • Behavioral Health Consolidated Dashboard – Quality Dashboard for all Inpatient Behavioral Health Units/Centers and Outpatient Behavioral Health Centers • Homecare Dashboard – Quality Dashboard for Home Care • Laboratory Dashboard – Quality Dashboard for Inpatient Laboratory Services • Outpatient Imaging – Quality Dashboard for Community Outpatient Imaging Centers • Post Acute Care Dashboard – Quality Dashboard for all Rehabilitation/Skill Nursing Facilities Figure 7 All Dashboards are designed to have a similar display. • Blue Bars represent current performance • Yellow bars behind are the benchmark • Direction of Arrow depicts the direction for positive performance ( - lower scores are better; - Higher scores are better)

Key Performance Indicator/Team Award Goal Report Annually we identify the organization’s priorities for the coming year and develop Key Performance Indicators (KPI) that allow us to effectively manage our improvement efforts. A KPI report provides the ability to maintain a constant vigilance on these priorities. The report is updated frequently (weekly, monthly). The report provides a baseline for each entity from the previous year for reference. The report is color coded to visually demonstrate our progress towards our established targets. Metrics that are performing at or worse than the previous year’s baseline are displayed as red. Metrics that are showing improvement are color coded in respect to their performance against the established threshold, target and stretch metrics. Threshold is displayed as yellow, target is green and stretch is blue. (Figure 8) Team Award Goals are displayed similarly, but do not have a stretch metric. Figure 8

Key Performance Indicator Executive Summary An Executive Summary Report provides an overview of each Key Performance Indicator and the corresponding Performance Improvement activity designed to improve the metric. The report provides an overview of the KPI, Senior Leader Champion, Threshold, Target and Stretch metrics, trend (flat, improving, declining), current status and next steps planned to improve. The *Status colors reflect the anticipated end of year performance (Figure 9). Figure 9

Public Quality Reporting BayCare Health System believes in the importance of transparency in our performance and providing accurate and honest information related to the performance of our leading not-for-profit hospitals. We accomplish this by publicly reporting nationally defined quality metrics on our baycare.org website. On our website provides performance data that coincides with the most current reporting period that is publicly displayed on the Center for Medicare Services (CMS) Hospital Compare website. This allows us to compare our performance with the U.S. Average and employ statistical formulas to depict when we are significantly higher or lower. Because the metrics reported on the government website can be from one to two years in arrears, we also provide the public with more recent data. When we identify opportunities to improve, we publish our current action plan to improve our performance. This data is only available on the baycare.org/quality-report-card web page. Other Public Reporting Sites Center for Medicare Services (CMS) - https://www.medicare.gov/hospitalcompare/search.html? Truven 100 Top Hospitals - http://100tophospitals.com/ The Joint Commission Quality Check - https://www.qualitycheck.org/ Leap Frog Group - http://www.leapfroggroup.org/ Health Grades - http://100tophospitals.com/ US News and World Report Best Hospitals - http://health.usnews.com/best-hospitals .

Resources Meeting Calendars – 2016 -2017 2016 – 2017 BAYCARE BOARD QUALITY MEETINGS November 15 – BSO Board Room February 27 - BSO Board Room May 24 – BSO Board Room July 26 – BSO Board Room September 27 – BSO Board Room November 16 – BSO Board Room Local Board Quality & Safety Committee Schedules Month MPM SJB SAH WHH BRMC 7:30am – 8:45am 12:00pm – 2:00pm 5:30pm – 7 :00pm 12:00pm – 1:30pm 11:30am-12:30pm MPH/MCH Board SJH Board Room SAH Board Room WHH Board Room BRMC Board Room Room November 2016 Nov. 1, 2016 Nov. 16, 2016 December 2016 Dec. 6, 2016 Dec. 20, 2016 Dec. 21, 2016 Dec. 13, 2016 MPH Board Room January 2017 Jan. 3, 2017 Jan. 17, 2017 Jan. 17, 2017 Jan. 10, 2017 MCH Board Room February 2017 Feb. 7, 2017 Feb. 21, 2017 Feb. 15, 2017 MPH Board Room March 2017 Mar. 7, 2017 Mar. 15, 2017 Mar. 14, 2017 MCH Board Room April 2017 Apr. 4, 2017 Apr. 18, 2017 Apr. 19, 2017 MPH Board Room May 2017 May 2, 2017 May 16, 2017 May 17, 2017 May 9, 2017 MCH Board Room June 2017 Jun. 6, 2017 Jun. 20, 2017 June 21, 2017 MPH Board Room July 2017 TBD July 19, 2017 July 11, 2017 MPH Board Room August 2017 Aug. 1, 2017 Aug. 15, 2017 Aug. 15, 2017 Aug. 16, 2017 MCH Board Room

September 2017 Sept. 5, 2017 Sept. 20, 2017 Sept. 12,2017 MPH Board Room October 2017 Oct. 3, 2017 Oct. 17, 2017 Oct. 17, 2017 Oct. 18, 2017 MCH Board Room November 2017 Nov. 7, 2017 Nov. 15, 2017 Nov. 14, 2017 MPH Board Room December 2017 Dec. 5, 2017 Dec. 19, 2017 Dec. 20, 2017 MCH Board Room

Board Membership Chair 2017 Contact BayCare Board Vice Chair Eric Obeck 2909 Bayshore Court Tampa, FL 33611 813-998-2880 Members Chair, MPM Board Quality Jim Cantonis 855 Pine St. Committee P.O. Box 338 Tarpon Springs, FL 34688 727-937-3222 Chair, SJB Board Quality Tracy Halme, MD (radiology) 5147 W. San Jose Street Committee Tampa, FL 33629 Home: 813-282-7411 Cell: 813-205-4835 Chair, SAH Board Quality Shri Goyal 104 Masters Lane Committee Safety Harbor, FL 34695 727-638-0327 Chair, WHH Board Quality Bill Murrell P. O. Box 832, Mountain Lake Committee Lake Wales, FL 33859-0832 Home: 863-676-4706 Cell: 863-559-9140 Chair, BPP/BMG Clin. Perf.& Laura Arline, MD (med/peds) 8787 Bryan Dairy Road Quality Comm’s Suite 275 Largo, FL 33777 727-394-5650 BayCare Physician Representative Mahesh Amin, MD (cardiology) 1107 South Myrtle Ave Clearwater, FL 33756 727-441-8663 Sponsor or Community TBD Representative President / CEO, BayCare Tommy Inzina [email protected] 727-820-8004 At large member as appointed by Scott Mantel, MD 430 Morton Plant St chair (anesthesiology) Suite 210 Clearwater, FL 33756 727-441-1524 At Large member as appointed by Garry Goldstein, MD (P&Tcom - 3890 Tampa Rd chair med/ped) Suite 102 Palm Harbor, FL 34684 Office: 727-789-5811 At Large member as appointed by A Ramsakal, MD (hospitalist) [email protected] chair 813-321-6237 At Large board member as Gay Lancaster appointed by chair

Additional Participants CQO Teri Sholder, RN [email protected] COO/ EVP System Glenn Waters [email protected] 727-754-9222 CMO/EVP Physician Services Bruce Flareau, MD [email protected] 727-519-1252 CMO – Hospital Services TBD VPPS Pinellas Market North Jeff Jensen, DO [email protected] 727-462-7415 VPPS Hillsborough Market Mark Vaaler, MD [email protected] 813-870-4704 VPPS Polk Market Khurram Kamran, MD [email protected] 937-266-9445 VPPS Pinellas Market South Jim McClintic, MD [email protected] 727-825-1679 CMIO Greg Hindahl, MD [email protected] 727-467-4790 CFO John Gantner [email protected] 727-51-1219 CNO Lisa Johnson [email protected] 727-754-9222

– Appendices BayCare Board Resolution on Quality – 5-1-2015 – Appendix A Best Practices for Board Quality Committees by Barry S. Bader - Appendix B Governance Accountabilities in the Quest for Quality – Appendix C Glossary of Terms – Appendix D