Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Governance Board - Governance Board Responsibilities
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The membership of the Board is defined by the Medical Staff Bylaws but will include:

Voting Members:

  • All Partners of the Organization which as defined by State Statute can only be licensed physicians
  • Chief Operating Officer  

Non-Voting Members:

  • Chief Information Officer
  • Chief Financial Officer
  • Director of Operations
  • Chief Clinical Systems Engineer
  • Chief Hospital/Clinic Liaison Officer

The Board will meet at the call of the chief executive or the chief operating officer, but in no case will it meet less than semi-annually.

The Governance Board, with the leadership of the CEO, COO and CIO, is responsible for promoting and assuring the maintenance of the SETMA Model of Care which includes:

  1. The tracking by each provider on each patient of the provider’s performance on preventive care, screening care and quality standards for acute and chronic care. SETMA"s design is such that tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the personal provider, nurse, clerk, management, etc.
  2. The auditing of performance on the same standards either of the entire practice, of each individual clinic, and of each provider on a population, or of a panel of patients. SETMA believes that this is the piece missing from most healthcare programs.
  3. The statistical analyzing of the above audit-performance in order to measure improvement by practice, by clinic or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, payer class, socio-economic groupings, education, frequency of visit, frequency of testing, etc. This allows SETMA to look for leverage points through which SETMA can improve the care we provide.
  4. The public reporting by provider of performance on hundreds of quality measures. This places pressure on all providers to improve, and it allows patients to know what is expected of them. The disease management tool “plans of care” and the medical-home-coordination document summarizes a patient’s state of care and encourages them to ask their provider for any preventive or screening care which has not been provided. Any such services which are not completed are clearly identified for the patient. We believe this is the best way to overcome provider and patient “treatment inertia.”
  5. The design of Quality Assessment and Permanence Improvement (QAPI) Initiatives - this year SETMA"s initiatives involve the elimination of all ethnic diversities of care in diabetes, hypertension and dyslipidemia. Also, we have designed a program for reducing preventable readmissions to the hospital. We have completed a Business Intelligence (BI) Report which allows us to analyze our hospital care carefully.

Passing the Baton

Key to the work of the Governance Board is the realization that while healthcare provider performance is important for excellent care of a patient’s health, there are 8,760 hours in a year. A patient who receives an enormous amount of care in a year is in a provider’s office or under the provider’s direct care less than 60 hours a year. This makes it clear that the patient is responsible for the overwhelming amount of their own care which includes adherence with formal healthcare initiatives and with lifestyle choices which support their health.

If responsibility for a patient’s healthcare is symbolized by a baton, the healthcare provider carries the baton for .68% of the time. That is less than 1% of the time. The patient carries the baton 99.32% of the time. The coordination of the patient’s care between healthcare providers is important but the coordination of patient care between healthcare providers and
patients is imperative.

Often, it is forgotten that the member of the healthcare delivery team who carries the “baton" for the majority of the time is the patient and/or the family member who is the principal caregiver. If the „baton" is not effectively transferred to the patient or caregiver, then the patient’s care will suffer.

Firmly in the providers hand
the baton -- the care and treatment plan --
Must be confidently and securely grasped by the patient,

 If change is to make a difference
8,760 hours a year.

The poster illustrates:

  1. That the healthcare-team relationship, which exists between the patient and the healthcare provider, is key to the success of the outcome of quality healthcare.
  2. That the plan of care and treatment plan, the “baton,” is the engine through which the knowledge and power of the healthcare team is transmitted and sustained.
  3. That the means of transfer of the “baton” which has been developed by the healthcare team is a coordinated effort between the provider and the patient.
  4. That typically the healthcare provider knows and understands the patient’s healthcare plan of care and the treatment plan, but that without its transfer to the patient, the provider’s knowledge is useless to the patient.
  5. That the imperative for the plan - the “baton” - is that it be transferred from the provider to the patient, if change in the life of the patient is going to make a difference in the patient’s health.
  6. That this transfer requires that the patient “grasps” the “baton,” i.e., that the patient accepts, receives, understands and comprehends the plan, and that the patient is equipped and empowered to carry out the plan successfully.
  7. That the patient knows that of the 8,760 hours in the year, he/she will be responsible for “carrying the baton,” longer and better than any other member of the healthcare team.

The genius and the promise of the Patient-Centered Medical Home are symbolized by the “baton.” Its display will continually remind the provider and will inform the patient, that to be successful, the patient’s care must be coordinated, which must result in coordinated care. In 2011, as we expand the scope of SETMA"s Department of Care Coordination, we know that coordination begins at the points of “transitions of care,” and that the work of the healthcare team - patient and provider - is that together they evaluate, define and execute that care.

The Governance Board will:

  1. Review the financial state of the organization including:
    1. The Daily Cash Flow report, which each member of the Governance Board will receive daily.
      The Daily Cash Flow will report the cash balances, the short-term and long-term dept of the practice.  It will additionally give a year-to-date statement of the financial status of the practice.
    1. Quarterly, the Board will review the Annualized Budget of the practice with profit/last statement for each department and including a summation as to whether each department is meeting budget, exceeding budget of over spending the budget.
    2. SETMA’s Chief Financial Office, a CPA, will prepare monthly financial statement with quarterly summations for the review and approval of the Governance Board.
    3. Because of the nature of the practice, the Board will discuss any cash flow issues which are pending and/or extant.
  1. Review the report of the quality assurance committee including:
    1. Review the report of the Care Coordination Department as to complaints filed in the previous quarter and the resolution of those complaints by the Department and the CEO.
    2. Review quality improvement projects and their outcomes.
    3. Review public reporting of provider performance on quality metrics.
    4. Review of provider performance on patient care.
  1. Strategic Planning
    1. Participate in an annual strategic planning initiative in order to:
      1. Evaluate the organization’s performance
      2. In fulfilling the mission statement
      3. In moving forward in fulfilling its vision
      4. Plan for the coming year
    1. Discuss initiatives for new healthcare strategies
    2. Discuss recruitment needs for new providers
    3. Review Business Analytics reports for leverage opportunities to improve care.
    4. Discuss performance of various departments including:
      1. I-Care
      2. Hospital Service Team
      3. HCAPHs  performance for hospital care
      4. CAPHS outcomes for ambulatory care
    1. Meaningful Use I, II, III
    2. Maintenance of Patient-Centered Medical Home Certification from
      1. National Committee for Quality Assurance
      2. Accreditation Association for Ambulatory Healthcare
      3. URAC
      4. Joint Commission
    1. External Relationships
      1. Joslin Diabetes Center Affiliate
      2. National Quality Foundation membership
      3. Institute of Healthcare Improvement
      4. HIMSS Innovation Committee
  1. Annually Review the Performance of the Executive Management Team and Interview and Elect Replacements when Necessary
    1. Chief Executive Officer
    2. Managing Partner
    3. Chief Operating Office
    4. Chief Information Office
    5. Chief Medical Officer
    6. Chief Financial Officer
  1. Review, evaluate, and assess the organization on the basis of safety, quality of care, treatment and appropriate expansion of care geographically and professionally.
  2. To support and enforce the Mission Statement of the Human Resources Department of Southeast Texas Medical Associates, LLP which is:
    “To support the mission of SETMA, which is to provide a workplace free of prejudice, sexual harassment, or discrimination and a workplace which complies with all State and Federal regulations governing employee rights, responsibilities and compensation.  Also, to honor and protect the confidentiality of personnel information and records, and to provide a forum through which employee grievances can be heard.”
  1. To lead the organization to fulfill the vision and goals of SETMA as described in the following:
    1. Public Motto:  Healthcare where your health is the only care!  This means that SETMA will undertake no plans or programs, which do not have at their foundation the best interest of our patients.  And, SETMA will participate in no healthcare payment plan, which either by its intent or design neglects the best interest of our patients.
    2. Private Motto:  Doing good while we are doing well!  This means that while SETMA is a for-profit organization, SETMA will always concentrate on doing “good,” i.e.,  helping others and providing quality healthcare even for those who cannot afford it,  while SETMA is doing well, i.e., providing financial support for our employees and their families, and providing income and benefits for the healthcare providers who work with and for SETMA.

The following is generic agenda for the Governance Board Meeting

Southeast Texas Medical Associates Governing Board Agenda

  1. Rights of Patients.
  2. Bylaws.
  3. Rules and Regulations.
  4. Quality Improvement Initiatives.
    1. Review of Previous Year
    2. Review Current Quarter
  1. Credentialing- Appointment of new staff.
  2. Peer Review.
  3. Safety Plan.
  4. Risk Management, Safety, and Infection Control.
  5. Policies and Procedures.
  6. Review Previous Year Financials