Negotiations between SUNY DMC and HHC/KCHC concluded late last May with all parties signing the Comprehensive Affiliation Contract document. Because SUNY DMC is part of the State University System, all large contracts must be reviewed and approved by the New York State Attorney General and the New York State Comptroller. The Attorney General reviews the contract to assure that it does not violate any NYS law, while the Comptroller reviews the financial terms of the contract for it’s impact on the state budget. Prior to these approvals the contract is voidable. SUNY DMC staff held a number of review sessions with the staff of the Attorney General’s Office and the Comptroller’s Office to review the contract. On September 21, 2001 the SUNY-DMC Office of Affiliations was notified that the contract had passed all state reviews and was in full effect retroactive to January 1, 2000.

Affiliation Contract Signed !

Office Staff Changes

The SUNY Office of Affiliations is pleased to announce that:
Ms. Michelle Fraser has been promoted from Staff Assistant to Staff Associate. In her new position Ms. Fraser will be responsible for management of the Language Competency Training Program, Recruitment and Staff Change Processing, KCHC and SUNY Full Time equivalent (FTE) Tracking and preparation of Target Staffing Change Requests. Ms. Mahdiyya (Dia) Abdur-Raheem has joined our staff as a Staff Assistant. Dia will be responsible for processing the monthly assignment schedules submitted by the clinical departments, scheduling meetings, preparation of the Affiliation Advisory Newsletter and general office management. Ms. Abdur-Raheem, comes from the SUNY Department of Expenditure Processing. The Office of Affiliations is currently recruiting a second Staff Associate to assist in the management of the affiliation contract. Please join me in congratulating Ms. Fraser and welcoming Ms. Abdur-Raheem.

Impediment Hotline 718-270-6333
2
Office changes
2
Joint Oversight Committee Established
2
Performance Indicators
3
Performance Indicators Continued
4

Inside this issue:

Affiliations

SUNY HSCB office of affiliation 450 Clarkson ave box 1251

Volume 1, Issue 1

October 16, 2001

Communications with the clinical and administrative staff is key to the success of the Affiliation contract. The SUNY Office of Affiliations has established an impediment hotline in order to facilitate communications The Impediment Hotline can be reached by dialing 718-270-6333. The phone line is equipped with an answering machine that is operational 24 hours a day. Clinicians, managers and staff are encouraged to report any issues that might affect productivity, quality of care, third party denials, quality indicators or other issues related to the physician staff management at KCHC. Individuals can also use the hotline to request clarification on KCHC/SUNY DMC affiliation issues governed by the contract. (Please note that this hotline is not intended for clinical emergencies). An individual reporting an issue to the hotline will receive a call from the SUNY Affiliations Office staff on the next business day responding to your question or issue.
If you have an issue or questions please do not hesitate to dial the hotline number: 718-270-6333.

As per the Affiliation Contract SUNY DMC and KCHC have established a Joint Oversight Committee. The membership representatives are: SUNY DMC— Eugene Feigelson, M.D. (Dean & Sr. VP), Michael Zenilman, M.D. (Chairman of Surgery), Howard Nelson (AVP Affiliations), John O’Hara (CFO), Mr. Ross Clinchy, Ph.D. (Special Assistant to the President). KCHC– George Proctor (CFO/COO), Audrey Caesar-Phillips (DED Quality Mgt), Kathie Rones, M.D. (Medical Director), Michele Welcome ( Associate Director of Affiliations). The JOC will meet on a regular basis to review: Performance Indicators, Staffing Target Compliance, Productivity, RVU implementation and resolve other contract issues. By gathering the clinical and administrative leaders from both institutions the objective is to develop a forum to work out the many difficult issues related to the comprehensive affiliation agreement.

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Office Staff Changes Con’t

Impediment Hotline 718-270-6333

Joint Oversight Committee Established (JOC)

Affiliations

Volume 1, Issue 1

The affiliation contract has established 39 Performance Indicators which will be used to monitor performance under the Comprehensive Affiliation Contract. The indicators cover a range of clinical items such as, the ordering of pediatric immunizations and glaucoma screening exams, as well as clinical administrative issues such as physician on time rates, medical record completion and KCHC staff re-appointments. The indicators are standard across all Health and Hospital Corporation facilities and are implemented according to a standardized sampling methodologies data collection protocols. Performance thresholds have been established for each indicator. Data is gathered and analyzed on a quarterly basis. If the performance threshold is not reached, SUNY DMC is subject to a financial penalty ranging from $4,000 to $8,000 per quarter. A copy of the preliminary Quarterly report on the Performance Indicators for April—June 2001 appears on the last page of this newsletter.
Once an indicator is found to be out of compliance, the SUNY Office of Affiliations in conjunction with the department will investigate the issue and in conjunction with the clinical managers develop a plan of corrective action. Corrective actions can include: Chart reviews to assure that the data collection was accurate and to identify documentation issues; Wide or narrow focused physician education; Modification of administrative systems if necessary to obtain required performance; Ongoing physician notification of performance indicator problem cases; Physician counseling by clinical leadership and as appropriate progressive discipline. If indicated progressive discipline will be conducted as prescribed by KCHC operating procedure 20-10 as well as the KCHC/Doctors Council Collective Bargaining Agreement. The SUNY Office of Affiliations will make every effort to assure that accurate data is collected and that physicians have an opportunity to provide additional information.
The JOC agreed to concentrate on the following 4 indicators for this quarter:
Mammograms for women between 51-64:
Women between 51 and 64 years of age who have received primary care at the facility during the quarter will have a mammogram order written in their patient record during the last months.
Required compliance 100%
Penalty $5,000/QTR
Performance 3rd Quarter 2001: 90%
A total of 50 charts were reviewed by KCHC to identify the non-compliant charts to assure the accuracy of the performance computation .
Notice of discharge pending:
Notice of pending discharge will be indicated in the patient record 24 hours before discharge:
Required Compliance: 100%
Penalty: $5,000/QTR
Performance 3rd Quarter 2001: 78%
A total of 50 charts were reviewed and 11 charts were found to be non-complaint. Given the high rate of non-compliance, an across the board educational effort was undertaken. A copy of the discharge notification policy was sent to all Clinical Chairs who were asked to duplicate the policy materials and distribute it to all Division Chiefs and Unit Directors. They were also asked to review the policy and procedures at their upcoming clinical management meetings. In addition the policy was mailed to the home addresses of all members of the KCHC medical staff. Next quarter we will begin to analyze individual non-compliant cases.
O.R. On-Time Rate:
Physician providers will be on time
Required compliance: =>95%
Penalty $ 5000/QTR
Performance 3rd Quarter 2001: 90.5%
A total of 169 first start surgical cases were reviewed by KCHC. Sixteen cases were found to be non-compliant. SUNY DMC has requested detailed information on the non-compliant cases in order to identify any patterns and in order to notify individual physicians of the problem. SUNY DMC will track non-compliant cases and notify individual surgeons as well as department chairs of the problem.
Psychiatric Group Treatment:
All psychiatric outpatients are to be evaluated for the appropriateness of group visits and, if so indicated, such visits shall be ordered. Evaluation and orders, as indicated, shall be documented in the medical record.
Required Compliance: 90%
Penalty: $ 5,000/QTR
Performance 3rd Quarter 2001: 41.7%
A total of 12 records were reviewed. Seven cases were found to be non-compliant. SUNY DMC has requested detailed information on these cases in order to determine if this is a documentation issue. In the future the sample will be increased to a minimum of 50. SUNY DMC intends to review the records for the non-compliant cases in order to develop a plan of corrective action.

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Performance Indicators Con’t

Performance Indicators

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Affiliations

actions can include chart reviews to assure that the data collection was accurate and to identify documentation issues, wide or narrow focused physician education, modification of administrative systems if necessary to obtain required performance, Ongoing physician notification of performance indicator problem cases, physician counseling by clinical leadership and as appropriate progressive discipline. If indicated progressive discipline will be conducted as prescribed by KCHC operating procedure 20-10 as well as the KCHC/Doctors Council Collective Bargaining Agreement. The SUNY Office of Affiliations will make every effort to assure that accurate data are collected and that physicians have an opportunity to provide additional information.
The JOC agreed to concentrate on the following 4 indicators for this quarter: Mammograms for women between 51 and 64, Notices of Pending Discharges, OR Provider On Time Rate and Evaluation and Orders for Psychiatric Group Treatment.

actions can include chart reviews to assure that the data collection was accurate and to identify documentation issues, wide or narrow focused physician education, modification of administrative systems if necessary to obtain required performance, Ongoing physician notification of performance indicator problem cases, physician counseling by clinical leadership and as appropriate progressive discipline. If indicated progressive discipline will be conducted as prescribed by KCHC operating procedure 20-10 as well as the KCHC/Doctors Council Collective Bargaining Agreement. The SUNY Office of Affiliations will make every effort to assure that accurate data are collected and that physicians have an opportunity to provide additional information.
The JOC agreed to concentrate on the following 4 indicators for this quarter: Mammograms for women between 51 and 64, Notices of Pending Discharges, OR Provider On Time Rate and Evaluation and Orders for Psychiatric Group Treatment.