Change Starts at the Top in Date: Santa Clara Valley Medical Center Resuscitation

R1A

– The County should require that SCVMC stay within the budget to avoid future unplanned subsidies from the General Fund. SCVMC agrees in concept. Each year, SCVMC presents its budget plan that is intended to lead to a balanced budget, which usually requires a General Fund subsidy to address the uncompensated costs addressed in the background section of this response. Increases to the subsidy are never planned and are never desired. The County has always required SCVMC to stay within budget. SCVMC Administration, Finance and managers work to stay within budget each year. The challenge lies in managing to the changing financial models (both Federal and State), Federal and State budget issues, unpredictable fluctuations with inpatient and outpatient volumes and payer mix, and working within the constraints of union contracts and County processes. For example there was a significant decrease in the average daily census for medical patients and we were unable to redistribute staff for several months. This resulted in a higher than desirable level of staff related to constraints of union contracts. Page The Santa Clara County Board of Supervisors governs and oversees the operations of the County through a Committee structure. The Health and Hospital Committee has as its members two of the Board of Supervisors. This Committee meets monthly during which detailed financial information is presented by the SCVHHS Chief Financial Officer for discussion, review and approval. In the instance of the SCVMC requiring an increased subsidy in FY 2011-12, the County Executive continually informed the Board of Supervisors of the financial status of SCVMC leading up to the request for additional General Fund support. The approval of additional funds included specific direction SCVMC that the support was one- time in nature rather than an ongoing increase to the subsidy. As referenced earlier, SCVMC has a process in place whereby the FPR Committee is monitoring and taking action to address poor performance and negative variances. These efforts are being expanded on in FY13. Significant strides have been made. SCVMC is preparing for better financial performance in the future.

R1B

— The County should require that hospital leadership runs SCVMC as a business and require leadership to make appropriate financial decisions using the data the hospital systems generate. SCVMC partially agrees. The County has always required SCVMC leadership to run SCVMC as a business and in accordance with the County's mission. The challenge lies in managing to the changing financial models (both Federal and State), Federal and State budget issues, fluctuations with inpatient and outpatient volumes and payer mix, and working within the constraints of union contracts and County processes. SCVMC is implementing a new cost accounting system as well as expanding its analytical and decision support capabilities. These efforts will provide better financial data to support timely and effective analysis and financial decisions. This type of data-driven approach is critical to the effectiveness of the FPR Committee and SCVMC management teams. The SCVMC Administration will continue to manage and operate SCVMC in a manner consistent with the direction, policies and decisions of the Board of Supervisors as led by the County's Chief Executive Officer. SCVMC recognizes that General Funds allocated to support the operations of the hospital become unavailable to other core functions of the County including Public Safety and Social Services. SCVMC Administration continues to implement the Revenue Cycle and other improvements described in the Grand Jury Report to minimize the size of the subsidy.

R2

– the County should implement systems to increase productivity in reaching break- even financial performance. SCVMC agrees. Steps have already been taken to increase productivity and the number of patients seen. In January 2012, SCVMC Administration began a detailed review of all provider schedules in the scheduling system to maximum its visit capacity. Provider schedules were standardized to reflect a certain number of appointment slots in the morning, afternoon and evening. These changes were made to schedules in Primary Care Medicine, Primary Care Pediatrics, Ob/Gyn and various specialty areas. The provider schedules now reflect 10 appointment slots per half day for all providers in Primary Care Medicine, 11 appointment slots per half day for all providers in Primary Care Pediatrics and 10 appointment slots per half day for all providers in Ob/Gyn.

R3

- Regardless of how HCRA may be affected by the United States Supreme Court decision, the County should adopt performance measures consistent with the HCRA indicators because they can lead to improved SCVMC performance. SCVMC agrees. With regard to adopting performance measurements related to improved access and capacity, Ambulatory clinics have been consistently tracking metrics such as appointment availability, no show rates and number of patients seen per day in order to monitor performance. An interdisciplinary committee for improving the patient experience was formed in 2010 and a regular report on this subject is provided to the Health and Hospital Committee. Although in the aggregate we must improve the patient experience we have several areas that excel in patient satisfaction. The Burn and the Rehabilitation Centers received national recognition for patient satisfaction this past year. In addition, through the California Association of Public Hospitals we are participating in the delivery system incentive plan, including a focus on multiple areas of improvement identified by CMS as important. SCVMC has extensive quality improvement and measurement processes in place related to these measures, and also includes regular reports to HHC.

R4

— The County should develop and implement an interface between SCVMC and the County systems to ensure data consistency, in accordance with generally accepted accounting principles. SCVMC partially agrees. SCVHHS Finance has been working with the County Controller's ASAP team to develop an interface and reconciliation process between the County's general ledger and SCVHHS's general ledger since 2010. Monthly reconciliation files are sent to SAP after SCVHHS finalizes its monthly financial statements. Reconciliations have been completed for fiscal years 2010, 2011 and monthly through May 2012. SCVHHS Finance will continue to work with the County Controller's Office to improve SCVMC reporting.

R5

- The County should require SCVMC consolidated financial statement reported as part of the CAFR. SCVMC partially agrees. The SCVHHS Enterprise Funds are audited as part of the County's annual financial audit. A separate audit and annual report for SCVMC is prepared each year. SCVHHS Finance will provide access to this report in the future. In addition, the year-end financials presented to HHC along with other related reports provide a complete picture of SCVMC's financial performance. and the second second second second second second second second second second second second second second second second second second second second second second second second second second second second second second seco . . . 8 | Page . Health care operations and finance are complicated areas. Seasoned healthcare analysts are challenged when reviewing and projecting financial performance. SCVHHS Finance will continue to improve and supplement its financial reporting for the Board's and public's benefit. In addition, SCVMC will work with the County Information Services Department to more prominently post SCVMC financial reports to the public.

R6

– The County should give SCVMC's implementation of EpicCare top priority to meet the scheduled May 2013 date. SCVMC agrees and appreciates the involvement of County Information Services Department and the County's Executive's Office in making HealthLink (SCVMC's name for its Epic system) a top priority.

R7

– The County should establish a marketing function directed at increasing public awareness of the services SCVMC offers. SCVMC partially agrees. There is a small office within SCVHHS that works on marketing and increasing public awareness. In addition, the Rehabilitation Center has a Rehabilitation Marketing Manager and has invested in a new website and marketing materials; thus such a function exists. Should additional funding become available, marketing efforts could increase. In the meantime, the VMC Foundation is assisting in marketing the Rehabilitation Center. Currently, conducts small amounts of marketing and relies on targeted awareness efforts, media relations, use of social media, and providing information to patients to promote and raise awareness about SCVMC's services and specialties. A short description of the more recent marketing and awareness efforts is included for reference: Pediatrics - A comprehensive Pediatric Provider Directory was produced to provide referral information, as well as a listing of SCVMC's specialties and sub-specialties in the following area: Maternal-Fetal Medicine, Newborn Medicine, Centers of Excellence (Rehab and Burn), South Bay Regional Genetics Center, Pediatric Healthy Lifestyle Clinic, High-Risk Infant Clinic, Behavioral & Developmental Disorders Specialties, and Pediatric Specialty Services. Physician profiles were listed by specialty and contact information was provided. The Pediatric Provider Directory with a cover letter from Dr. Stephen Harris, Chair of the Pediatrics Department, was mailed and/or delivered to Santa Clara County pediatricians, health plans and health insurance providers. Catastrophic Injury Services - A brochure was developed to highlight the comprehensive care SCVMC can provide to catastrophic illness or injury cases. The brochure featured: Emergency Medicine and Trauma 9 Page Services; Burn Care; Spinal and Neurological Injuries; the Rehabilitation Center; the Rehabilitation Trauma Center; Pediatric Trauma, Intensive Care and Rehabilitation; High-Risk Pregnancy and Neonatal Intensive Care; Palliative Care. The brochure was distributed to referral sources that included physician groups, health plans and health insurance providers. Rehabilitation - In November 2011, the VMC Foundation launched an effort to increase the visibility of SCVMC's nationally-recognized SCI/TBI Rehab Center. A plan was launched to attract a greater percentage of privately-paying patients to the Rehab Center of Excellence. Between January and August 21, 2012, various projects have been undertaken on behalf of these efforts. Among them are: Production and release of a 12-page "advertorial" in the Silicon Valley Business Journal, ¼ of • which focused on the features of the Rehabilitation Center at SCVMC. Positioning of Dr. Steven McKenna, Chief of SCVMC's Rehab Trauma Center, as a national pioneer of regenerative medicine, in local/regional speaking engagements. Development of outreach materials to promote the Rehab Center, clinical outcomes, and . ongoing research. Creation, planning and marketing of two Rehab conferences; one focusing on regenerative . medicine (in October, regional in scale) and one on traumatic brain injury (in February 2013, national in scale). Six videos have been produced to highlight the work and excellence of the Rehab Center. Most are available to view on the newly-developed, outside-funded website www.scvmcrehab.org Media Relations - Local newspaper, television stations and radio stations coverage on a story about SCVMC programs is one of the best ways to make the community aware about the services offered and the expertise of SCVMC's staff. There have been hundreds of articles and news broadcasts about services, programs and staff, including those that have featured accreditations or verifications by third- party organizations, awards and significant research. Programs and services that have been featured in news stories include: Burn Center, Cardiac Care System, Diabetes Center, Emergency services, HIV/Aids Program, Neonatal Intensive Care Unit, Palliative Care Program, overall Pediatric services and specialties, Rehabilitation Center, and Women's Health services. Additionally, by providing medical staff for interviews on a variety of topics, SCVMC not only helps to raise awareness about a health issue or service, but also positions itself as having some of the best experts in the field. In addition to the topics mentioned above, SCVMC medical staff has also conducted interviews, to cite a few examples: First clinical trial of human embryonic stem cells in patients with spinal cord injuries How progesterone may improve the recovery of patients with traumatic brain injuries Treating infants with a whole body (or therapeutic) cooling technique Benefits of a tai chi program for patients in wheelchairs Childhood nutrition Chronic diseases ............ 10 | Page Heat related injuries • Traumatic brain injuries Vehicle back-over injury prevention • In addition, the participation of medical staff, nursing staff, allied health professionals and other medical center staff in outside programs provide an opportunity to expose the public to SCVMC. There are many publications and presentations made at national and international conferences that expose the public to the work of SCVMC. In addition, the Trauma, Burn, Rehabilitation and Neonatology services regularly host regional professional conferences that highlight many of the medical center's teams. Social Media - Since 2011, SCVMC has had a social media presence on Facebook. While a many of the postings provide health tips to the community, including a number of anti-smoking tips in support of Public Health Department activities, other postings have covered SCVMC services and specialties: The current trend is that more people are turning away from traditional news sources, using less and less printed formats for information, going to Web based sources for information, and moving to a more social Web. SCVMC will stay abreast of these trends and consider how best to communicate with patients, the medical community and the residents of our county. Moving in that direction, SCVMC now shares a Twitter account with the Public Health Department, the Mental Health Department, and the Department of Alcohol & Drug Services. SCVMC and the Public Health Department are beginning to use YouTube and exploring what other social media tools would be helpful in raising awareness about health programs and issues. Information to Patients - "Word-of-mouth" is one of the most credible forms of advertising. Along with providing good service and great care, information given to patients can be used when our patients talk with family and friends. When people talking about the care or services they received don't stand to gain personally, it makes the message very powerful. Here are some examples of the information SCVMC provide to patient, typically in English, Spanish and Vietnamese: Burn Center: patient/family & referral materials • Diabetes Center materials New Parent Guide • Palliative Care brochure . Pediatrics materials, including NICU physicians piece and Pediatric Healthy Lifestyles brochure • and flyer Prevent Scalds brochure Primary Care Services brochure Rehabilitation Center: brochure, technology and outcomes flyers ٠ 11 | Page