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COMMITTEE RECOMENDATIONS

The committee makes the following recommendations for further improvements in edical Center Operations.

A. Departmental Improvements

• 1) Labor and Delivery Unit Procedures: There is an extra adult identification wrist band in the packages with the new umbilical clamp, besides the wristband intended for use by the mother. Since the Medical Center has stopped allowing fathers and other visitors to transport babies within Labor and Delivery, this second adult wristband is not needed. The procedures in place when the committee did its investigation called for the attending nurse to dispose of this extra wristband, but there was no procedure for documenting the disposal. If the wristband is not properly disposed of, it could be used by an unauthorized individual to procure a baby from the nursery or to have access to a baby without the mother's knowledge. Recommendation: The Medical Center should purchase packages with only one adult wristband. The committee believes this would decrease the possibility of unauthorized persons having access to an infant. Until the new packages of wristbands are obtained, disposal of the second adult wristband must be documented in the patient's medical record.
• 2) Morgue Administration: When the committee reviewed the procedures for releasing remains ftom the Morgue, it discovered that no one person or department was charged with responsibility for release. Bodies were being given to funeral homes and families by transport workers, rather than by an individual specifically designated and trained for this task.
• Recommendation: The committee recommends that all releases of remains from the Morgue be performed by a designated person or persons. The ideal situation would be to centralize Autopsy and the Morgue in one room so that transfers from area to area would be minimized. Also, we would recommend that one person be responsible for this area and for ensuring that the inventory of bodies, organs, and products of conception is accurate and complete. This person would also be responsible for releasing remains under routine circumstances.

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  Additionally, an individual or individuals should be charged with ensuring that fetal remains that might be claimed by the family make it safely from Labor and Delivery to the Morgue. Designating specific persons to be responsible for these tasks should improve consistency in their performance. During each move between departments, accountability must be ensured by means of a "check-in" and "check-out" system within each department.
• We also recommend that when remains are released to a family (a rare occurrence), they be offered the help of a chaplain or bereavement counselor, which the family could accept or decline. With few exceptions, all releases of remains should be done during designated business hours, and a designated administrator should personally handle both after-hours releases and unusual cases, including release of remains to families. All persons handling fetal remains, including products of conception, should receive sensitivity training so that proper consideration is given to the handling of these remains and to the families involved.

B. Medical Center-Wide Improvements

• 1)Compliance Officer Position: The Compliance Officer position recently authorized for the Medical Center has yet to be filled. An initial advertisement and round of interviews produced no acceptable candidates; a second round is now planned. The Compliance Officer will be responsible for assisting healthcare professionals in complying with federal and state regulations applicable to medical centers, including the vast array of Medicare and Medicaid billing rules.
• Recommendation: The committee feels quite strongly that the Compliance Officer position should be re-advertised and filled promptly with a qualified candidate. This individual should be responsible for helping healthcare providers conduct their billing and other activities in accordance with regulatory requirements. This position will help to ensure that the Medical Center is accountable to outside agencies and programs such as Medicare and Medicaid, as well as to the taxpayers. The committee supports the proposal that the Compliance Officer report directly to the Executive Vice President and Chief Financial Officer.

• 2)BOV Oversight: As a final step in its review, the committee considered the relationship between the Medical Center and the body responsible for its oversight, the Board of Visitors. Currently this responsibility is exercised primarily through the Health

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  Affairs Committee of the Board. That committee's meetings are relatively brief and infrequent, considering the complexity of the institution it is monitoring. Moreover, its current structure does not give the committee easy access to independent, specialized expertise in healthcare matters, which it could use to do its job most effectively. At present there is only one member of the committee (and of the entire Board) with significant experience in the healthcare industry.
• Recommendation: The committee recommends that the Rector restructure the Health Affairs Committee to include, in an advisory capacity, professionals from relevant sectors of the business community, including the healthcare industry. The Health Affairs Committee should be comprised of five board members: three appointed at large, the Health Affairs Committee Chair, and the Finance Committee Chair. In addition, at least three outside experts should be appointed by the Rector and act in an advisory capacity as nonvoting members. Persons with experience and expertise in relevant business sectors, particularly in fields such as managed care and medical insurance, should be the types of individuals who would serve as advisors to the Health Affairs Committee.
• The committee also recommends that there be a direct link to the Healthcare Partners Board of Trustees from the Board of Visitors. Two voting Board members of the Health Affairs Committee should serve on the Healthcare Partners board to ensure a cross-fertilization of deliberations and plans. We further recommend that the three outside experts appointed by the Rector to advise the Health Affairs Committee should also be members of the Healthcare Partners Board. To round out that membership, the Health Services Foundation should have one representative. Our proposed structure would ensure that the Board of Visitors, which is the ultimate decision maker about, for example, acquisition of outlying businesses, is informed of proposed ventures in a more timely manner and can have a more immediate impact on Medical Center operations.
• It is our hope that the Health Affairs Committee, restructured as described above, would assist the Medical Center in a more direct way. This also would require the Health Affairs Committee to meet frequently enough to address issues on a timely basis. The meetings should be long enough to give the members a deeper understanding of Medical Center operations.