public notice city of alameda health care district …
TRANSCRIPT
PUBLIC NOTICE
CITY OF ALAMEDA HEALTH CARE DISTRICT
BOARD OF DIRECTORS
AGENDA
Monday, October 11, 2010 – 6:00 p.m.
Location: Alameda Hospital (Dal Cielo Conference Room)2070 Clinton Avenue, Alameda, CA 94501
Office of the Clerk: (510) 814-4001
Special Meeting
Members of the public who wish to comment on agenda items will be given an opportunity before or during the considerationof each agenda item. Those wishing to comment must complete a speaker card indicating the agenda item that they wish toaddress and present to the District Clerk. This will ensure your opportunity to speak. Please make your comments clear andconcise, limiting your remarks to no more than three (3) minutes.
I. Call to Order (6:00 p.m. – 2 East Board Room) Jordan Battani
II. Roll Call Kristen Thorson
III. Adjourn into Executive Closed Session
IV. Closed Session Agenda
A. Public Employee Performance Evaluation Title: Chief ExecutiveOfficer
Gov’t Code Sec 54957
B. Discussion of Report Involving Trade Secrets
1. Discussion of Hospital Trade Secrets applicable to development ofnew hospital services, programs and facilities. No action will be taken
H & S Code Sec. 32106
V. Reconvene to Public Session (Expected to start at 7:30 p.m. – Dal Cielo Conference Room)
A. Announcements from Closed Session Jordan Battani
VI. Consent Agenda
A. Approval of 2009-2013 Goals and Objectives – FYE 2011 Update ACTION ITEM [enclosure](PAGES 3-16)
1
City of Alameda Health Care DistrictAgenda –October 11, 2010
2 of 2
VII. Regular Agenda
A. President’s Report Jordan Battani
B. Chief Executive Officer’s Report Deborah E. Stebbins
1) Approval of Recommendations for FY 2010 ExecutiveIncentive Compensation Pay-out ACTION ITEM [enclosure](PAGES 17-32)
2) Approval of FY 2011Executive Performance MetricsACTION ITEM [enclosure] (PAGES 33-37)
C. Facilities Report Kerry Easthope
1) Seismic
2) New Program Development – Wound Care
VIII. General Public Comments
IX. Board Comments
X. Adjourn into Executive Closed Session
XI. Closed Session Agenda
A. Instructions to Bargaining Representatives Regarding Salaries,Fringe Benefits and Working Conditions
Gov’t Code Sec. 54957.6
XII. Reconvene to Public Session (2 East Board Room)
A. Announcements from Closed Session Jordan Battani
XIII. Adjournment
2
Oct
ober
11,
201
0
City
of A
lam
eda
Hea
lth C
are
Dis
trict
2009
-201
3 G
oals
and
Obj
ectiv
esFY
E 2
011
Upd
ate
3
Fin
an
cia
l S
tre
ng
th
Ach
ieve
long
-term
fina
ncia
l via
bilit
yM
easu
res o
f su
ccess:
A
chie
vem
ent o
f pos
itive
ope
ratin
g m
argi
n =
3% o
f net
reve
nues
by
2013
G
ener
ate
oper
atin
g pr
ofita
bilit
y le
vels
nec
essa
ry to
sup
port
capi
tal n
eeds
/ser
vice
deb
t
R
aise
$50
0,00
0 pe
r yea
r thr
ough
Fou
ndat
ion
fund
rais
ing
initi
ativ
es
S
hift
relia
nce
on p
arce
l tax
from
sup
port
of o
pera
tions
to s
uppo
rt fo
r cap
ital i
nves
tmen
ts a
nd s
trate
gic
deve
lopm
ent p
roje
cts
S
usta
in P
erfo
rman
ce v
is-à
-vis
ope
ratin
g be
nchm
arks
at 9
0thpe
rcen
tile
leve
ls (e
.g.,
FTE
/Adj
. Occ
upie
d B
ed, L
engt
h of
Sta
y, C
osts
per
UO
S)
Init
iati
ves
Sta
tus
(A)
ST
RA
TE
GY
: E
nh
an
ce fin
an
cia
l an
d s
trate
gic
rela
tio
nsh
ip w
ith
payers
■A
chie
ve a
vera
ge ra
te in
crea
se fo
r priv
ate
payo
rcon
tract
s of
8%
(Hea
lthne
t, In
terp
lan)
■P
rom
ote
publ
ic a
war
enes
s of
new
Med
iCal
cont
ract
, inc
ludi
ng li
nkag
es w
ith p
artn
er p
rovi
ders
(La
Cln
ica,
Fru
itval
e pr
imar
y pr
actic
es, F
amily
Brid
ges,
Chi
nato
wn
prac
tices
, etc
)■
Ear
ly, e
ffect
ive
man
agem
ent o
f sel
f-pay
and
Med
iCal
elig
ible
pat
ient
s■
Rea
pply
for I
nter
gove
rnm
enta
l Tra
nsfe
r mat
chin
g m
oney
to s
uppl
emen
t Med
iCal
cont
ract
in e
arly
FY
201
1
■E
nhan
ce re
latio
nshi
p w
ith lo
cal I
PA
’s■
Iden
tify
and
corr
ect c
ontra
ct re
latio
nshi
p ga
ps th
at im
pede
refe
rral
s fro
m n
ew p
hysi
cian
s■
Ach
ieve
rapi
d en
rollm
ent o
f 120
6(b)
phy
sici
ans
on k
ey p
lans
■Id
entif
y pe
rcei
ved
or re
al c
ontra
ctin
g ba
rrie
rs in
fluen
cing
pat
ient
refe
rral
s.■
Form
ulat
e lo
nger
term
phy
sici
an a
llian
ce s
trate
gy to
pre
pare
for s
ucce
ssfu
l ope
ratio
n un
der b
undl
ed p
aym
ent
stru
ctur
e
(B)
ST
RA
TE
GY
: S
eek c
on
tracti
ng
op
po
rtu
nit
ies to
in
cre
ase v
olu
me a
nd
im
pro
ve f
inan
cia
l sta
nd
ing
Fo
rmal
ize
serv
ice
offe
rings
to p
erso
nnel
and
dep
ende
nts
of C
oast
Gua
rd (C
G Is
land
)
Exp
lore
exp
andi
ng v
olum
e of
ser
vice
s pr
ovid
ed to
VA
ben
efic
iarie
s
Eva
luat
e pr
ovis
ion
of s
ubac
ute
serv
ices
(thr
u ex
pans
ion
or a
cqui
sitio
n) fo
r SF
hosp
ital c
onso
rtium
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
110
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
4
Fin
an
cia
l S
tre
ng
th
Ach
ieve
long
-term
fina
ncia
l via
bilit
yIn
itia
tives
Sta
tus
(C)
ST
RA
TE
GY
: P
erf
orm
an
d m
ain
tain
a p
ort
foli
o a
naly
sis
of
serv
ice lin
e p
rofi
tab
ilit
y; cre
ate
serv
ice lin
e p
lan
s t
hat
matc
h o
ur
targ
et
po
pu
lati
on
, ad
dre
ss s
erv
ice lin
es t
hat
are
no
t p
erf
orm
ing
up
to
exp
ecta
tio
ns
P
rofit
abili
ty a
naly
sis
for s
ervi
ce li
nes
(LTC
, Inf
usio
n, G
I, an
d O
ncol
ogy)
A
naly
ze fi
nanc
ial im
pact
of i
ncre
ases
in IN
P c
ensu
s by
5 p
atie
nt in
crem
ents
M
onito
r fin
anci
al im
pact
of s
ervi
ces
to M
edi-C
al p
atie
nts
M
onito
r pro
duct
ivity
and
util
izat
ion
of 1
206(
b) p
hysi
cian
s
(D)
ST
RA
TE
GY
: M
ain
tain
ou
r p
osit
ion
in c
ost/
exp
en
ses a
s c
om
pare
d t
o lo
cal/
nati
on
al b
en
ch
mark
s
P
atie
nt F
inan
cial
Ser
vice
s pe
rform
ance
of g
ross
day
s in
AR
of 5
0 da
ys a
nd 3
% b
ad d
ebt w
rite
off
(E)
ST
RA
TE
GY
: E
nh
an
ce f
un
dra
isin
g a
cti
vit
ies a
nd
pro
gra
ms
In
crea
se $
1,00
0 co
ntrib
utor
s by
20%
or
9 co
ntrib
utor
s
Est
ablis
h 3
prom
isin
g lo
cal l
arge
cor
pora
te re
latio
nshi
ps
Incr
ease
Fou
ndat
ion
curr
ent m
ailin
g da
taba
se (1
,776
) by
10%
(F)
ST
RA
TE
GY
: C
om
mu
nic
ate
valu
e/b
en
efi
ts o
f p
arc
el ta
x t
hro
ug
h t
ran
sp
are
ncy a
nd
acco
un
tab
ilit
y to
th
e c
om
mu
nit
y
P
rese
nt p
ositi
ve c
ase
for P
arce
l Tax
D
evel
op a
nd d
isse
min
ate
quar
terly
com
mun
ity re
port
card
with
fina
ncia
l and
qua
lity
indi
cato
rs.
(H)
ST
RA
TE
GY
: E
valu
ate
an
d f
org
e b
eg
inn
ing
of
on
e s
trate
gic
all
ian
ce
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
210
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
5
Gro
wth
Pur
sue
fisca
lly re
spon
sibl
e gr
owth
in s
ervi
ces
that
targ
et th
e m
ost p
ress
ing
acut
e an
d no
n-ac
ute
heal
thca
re n
eeds
of t
he c
omm
unity
.M
easu
res o
f su
ccess:
■M
arke
t sha
re g
row
th■
From
31.
25 p
erce
nt to
35.
0 pe
rcen
t –A
lam
eda
Isla
nd (Z
IP C
odes
945
01 a
nd 9
4502
)■
From
0.9
4 pe
rcen
t to
1.10
per
cent
-O
ff-Is
land
■S
ervi
ce lin
e gr
owth
: vol
ume
targ
ets
defin
ed b
y se
rvic
e lin
e
■D
evel
opm
ent o
f new
acc
ess
poin
ts a
nd lo
catio
ns
■In
crea
se in
patie
nt c
ensu
s by
5 A
DC
by
2013
to o
ffset
loss
of K
aise
r rev
enue
and
to s
uppo
rt ba
sic
INP
/ER
infra
stru
ctur
e.
Init
iati
ves
Sta
tus
(A)
ST
RA
TE
GY
: U
sin
g p
ort
foli
o a
naly
sis
as a
gu
ide, p
rio
riti
ze s
erv
ice lin
e d
evelo
pm
en
t an
d d
evelo
p s
pecif
ic p
lan
s f
or
gro
wth
■In
crea
se p
roce
dura
l/sur
gica
l ser
vice
s th
at w
ill im
prov
e ou
r fin
anci
al re
sults
(orth
o, p
ain
man
agem
ent,
plas
tics,
car
diac
, ot
her)
■Im
plem
ent W
ound
Car
e C
ente
r■
Com
plet
e ev
alua
tion
of A
cute
Reh
ab C
ente
r■
Con
duct
/bui
ld v
s. b
uy a
naly
sis
on b
est o
ptio
n fo
r exp
ansi
on o
f SN
F an
d S
ubac
ute
prog
ram
s■
Eva
luat
e an
d im
plem
ent n
ew o
r exp
ande
d ni
che
prog
ram
s th
at a
ttrac
t pat
ient
s fro
m o
utsi
de th
e D
istri
ct (e
.g. s
ubac
ute,
lo
ng te
rm c
are
serv
ices
, wou
nd c
ente
r, ac
ute
reha
b, re
tinal
sur
gery
, joi
nt re
plac
emen
t cen
ter,
aest
hetic
med
icin
e)■
Eva
luat
e w
ays
to im
prov
e th
e co
ntin
uum
of s
ervi
ces
offe
red
to s
enio
rs in
ser
vice
are
a■
Trac
k ac
tivity
and
eva
luat
e w
ays
to im
prov
e ef
fect
iven
ess
of A
sian
Out
reac
h pr
ogra
m■
Inst
itute
org
aniz
ed c
usto
mer
con
tact
and
ser
vice
s to
com
mun
ity sk
illed
nur
sing
faci
litie
s in
Ala
med
a an
d su
rrou
ndin
g O
akla
nd n
eigh
borh
oods
(B)
ST
RA
TE
GY
: U
sin
g p
ort
folio
an
aly
sis
as a
gu
ide, p
rio
riti
ze s
erv
ice l
ine d
ev
elo
pm
en
t an
d d
ev
elo
p s
pecif
ic p
lan
s f
or
gro
wth
E
valu
ate
Con
cent
ra re
latio
nshi
p to
see
if m
axim
um p
oten
tial b
eing
ach
ieve
d
Exp
lore
clo
ser l
inka
ges
with
Por
t of O
akla
nd
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
310
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
6
Gro
wth
Pur
sue
fisca
lly re
spon
sibl
e gr
owth
in s
ervi
ces
that
targ
et th
e m
ost p
ress
ing
acut
e an
d no
n-ac
ute
heal
thca
re n
eeds
of t
he c
omm
unity
.In
itia
tiv
es
Sta
tus
(C)
ST
RA
TE
GY
: T
arg
et
serv
ice a
rea p
op
ula
tio
n, t
o lim
it o
utm
igra
tio
n o
f re
sid
en
ts w
ho
can
be c
are
d f
or
at
Ala
med
a H
osp
ital
■C
ontin
ue to
eva
luat
e w
ays
to e
nhan
ce m
arke
t sha
re a
nd s
ervi
ce to
resi
dent
s of
Bay
Far
m■
Eval
uate
Mar
ina
Villa
ge lo
catio
n fo
r sel
ecte
d O
P se
rvic
es, i
nclu
ding
long
er te
rm re
loca
tion
of o
ffice
s/se
rvic
es
loca
ted
in 1
925
build
ing
(D)
ST
RA
TE
GY
: D
ev
elo
p s
erv
ices a
nd
to
ols
th
at
wo
uld
make u
s m
ore
accessib
le t
o o
ur
co
mm
un
ity
■In
crea
se a
cces
sibi
lity
to lo
cal r
esid
ents
thro
ugh
trans
porta
tion,
com
mun
icat
ion,
etc
.■
Incr
ease
our
dra
w o
f off-
isla
nd re
side
nts
(acc
ess
poin
ts, a
esth
etic
ser
vice
s)■
Stre
ngth
en c
olla
bora
tive
rela
tions
hips
with
Fam
ily B
ridge
s, C
hina
tow
n pr
actic
es, F
ruitv
ale
prac
tice
and
Alam
eda
Allia
nce
to m
axim
ize
acce
ss fo
r pat
ient
s un
der t
he n
ew M
edi-C
al c
ontra
ct■
Org
aniz
e m
enu
of h
ealth
care
ser
vice
s an
d ed
ucat
ion
to o
ffer t
o lo
cal b
usin
esse
s/bu
sine
ss a
ssoc
iatio
ns■
Esta
blis
h th
ree
form
aliz
ed re
latio
nshi
ps w
ith la
rger
Ala
med
a ba
sed
corp
orat
ions
.
(E)
ST
RA
TE
GY
: E
nh
an
ce
ge
ne
ral p
ub
lic
co
mm
un
ica
tio
n r
eg
ard
ing
se
rvic
es, q
ua
lity
ou
tco
me
s
Ta
rget
Bay
Far
m p
opul
atio
n, to
incr
ease
aw
aren
ess
of A
lam
eda
Hos
pita
l
Esta
blis
h bu
sine
ss p
artn
ersh
ip m
odel
for s
mal
l bus
ines
ses
thro
ugh
form
aliz
ing
com
mun
icat
ion
with
Ala
med
a bu
sine
ss a
ssoc
iatio
ns.
D
evel
op th
ree
linka
ges
to la
rger
Ala
med
a-ba
sed
com
pani
es
Expa
nd o
utre
ach
serv
ices
and
inte
rface
with
Ala
med
a Sc
hool
s (e
.g. t
rain
ers,
edu
catio
n)
Take
lead
in in
itiat
ing
a Bu
ildin
g a
Hea
lthie
r Ala
med
a ca
mpa
ign
with
sch
ools
, pub
lic s
ervi
ce s
ecto
r, C
ity
Gov
ernm
ent
(F)
ST
RA
TE
GY
: T
arg
et
recru
itm
en
t o
f p
hysic
ian
s f
rom
are
as t
hat
are
vu
lnera
ble
to
ch
an
ge
M
onito
r evo
lvin
g Sa
n Le
andr
o m
arke
t
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
410
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
7
Gro
wth
Pur
sue
fisca
lly re
spon
sibl
e gr
owth
in s
ervi
ces
that
targ
et th
e m
ost p
ress
ing
acut
e an
d no
n-ac
ute
heal
thca
re n
eeds
of t
he c
omm
unity
.In
itia
tive
sS
tatu
s
(G)
ST
RA
TE
GY
: Fo
rmul
ate
stra
tegy
for L
ong
Term
Car
e Se
rvic
e Li
ne D
evel
opm
ent
■In
stitu
te s
yste
m o
f rou
tine
mar
ketin
g an
d co
ntac
t with
loca
l nur
sing
hom
es to
sol
idify
refe
rral
rela
tions
hips
and
im
prov
e co
ntin
uity
of c
are
for r
esid
ents
■St
reng
then
ties
to S
enio
r Cen
ter
(H)
ST
RA
TE
GY
: E
nco
ura
ge f
ocu
sed
gro
wth
in
Med
i-C
al b
usin
ess
Thro
ugh
the
prom
otio
n of
pub
lic a
war
enes
s of
new
Med
iCal
cont
ract
, inc
ludi
ng li
nkag
es w
ith p
artn
er p
rovi
ders
(La
Cln
ica,
Fru
itval
e pr
imar
y pr
actic
es, F
amily
Brid
ges,
Chi
nato
wn
prac
tices
, etc
)
(I)
ST
RA
TE
GY
: C
ollab
ora
te w
ith
Ed
en
Jo
int
Co
mm
issio
n a
ccre
dit
ed
Str
oke C
en
ter
to b
eco
me a
part
of
their
netw
ork
an
d
pro
toco
ls in
ord
er
to m
ain
tain
ou
r ab
ilit
y t
o r
eceiv
e p
ote
nti
al str
oke p
ati
en
ts in
ou
r E
R.
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
510
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
8
Fa
cil
itie
s a
nd
Te
ch
no
log
y
Enh
ance
our
faci
lity
and
tech
nolo
gica
l cap
abili
ties
to fo
ster
the
achi
evem
ent o
f our
goa
ls.
Me
asu
res o
f su
cc
ess:
■P
erce
ntag
e of
phy
sici
ans
who
sig
n up
for e
lect
roni
c ac
cess
■V
olum
e of
hits
to h
ospi
tal w
ebsi
te
■Fu
nd d
epre
ciat
ion
to T
BD
% in
ord
er to
cre
ate
capi
tal r
eser
ve fu
nd
Init
iati
ve
sS
tatu
s
(A)
ST
RA
TE
GY
: E
nsu
re t
ha
t o
ur
tec
hn
olo
gic
al in
ve
stm
en
ts i
nc
lud
e e
nh
an
ce
me
nt
of
ho
sp
ita
l -
ph
ysic
ian
co
nn
ec
tivit
y a
nd
c
on
ne
cti
vit
y w
ith
co
mm
un
ity
■C
ontin
ue to
enh
ance
inte
ract
ive
use
of w
ebsi
te a
nd e
xplo
ratio
n of
sel
ectiv
e so
cial
net
wor
king
app
roac
h to
m
arke
ting;
est
ablis
h pr
oact
ive
emai
l pro
gram
■C
ontin
ue to
pur
sue
EH
R m
eani
ngfu
l use
tim
etab
le th
roug
h pa
ralle
l exp
lora
tion
of e
nhan
cing
Med
itech
usag
e or
pur
chas
ing
IT c
apab
ilitie
s fro
m p
artn
er o
rgan
izat
ion
(B)
ST
RA
TE
GY
: Id
en
tify
org
an
iza
tio
ns t
ha
t c
an
be
co
lla
bo
rati
ve
pa
rtn
ers
in d
eve
lop
ing
/ex
pa
nd
ing
fa
cilit
ies:
e.g
., r
ea
l e
sta
te,
VA
, o
the
r a
rea
he
alt
hc
are
syste
ms,
oth
er
dis
tric
ts
C
ontin
ue s
trate
gic
eval
uatio
n by
Boa
rd o
f opp
ortu
nitie
s w
ith o
ther
pro
vide
rs fo
r mut
ual p
rogr
am
deve
lopm
ent a
nd a
lignm
ent.
Pur
sue
follo
w-u
p w
ith o
ther
org
aniz
atio
ns a
s id
entif
ied
in p
artn
ersh
ip s
trate
gy
(C)
ST
RA
TE
GY
: D
eve
lop
a f
ac
ilit
y m
aste
r p
lan
th
at
pre
pa
res f
or
sta
te s
eis
mic
re
qu
ire
me
nts
an
d p
rog
ram
/se
rvic
e p
lan
s
C
ompl
ete
pla
n su
bmis
sion
, con
tract
or s
elec
tion,
bid
ding
and
City
ent
itlem
ent p
roce
ss fo
r ren
ovat
ion
of
Step
hens
and
Wes
t Win
g fo
r com
plia
nce
with
SB
1953
.
Rev
iew
and
mak
e de
cisi
ons
on a
ppro
ach
to fi
nanc
ing
seis
mic
reno
vatio
n in
pos
sibl
e co
mbi
natio
n w
ith fi
nanc
ing
othe
r pro
gram
dev
elop
men
t
Educ
ate
City
offi
cial
s an
d ke
y co
mm
unity
sta
keho
lder
s on
sei
smic
pla
ns
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
610
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
9
Fa
cil
itie
s a
nd
Te
ch
no
log
y
Enh
ance
our
faci
lity
and
tech
nolo
gica
l cap
abili
ties
to fo
ster
the
achi
evem
ent o
f our
goa
ls.
Init
iati
ve
sS
tatu
s
(D)
ST
RA
TE
GY
: A
ssu
re s
yste
ma
tic
re
vie
w o
f fa
cilit
y:
flo
w,
ap
pe
ara
nc
e, s
afe
ty
Id
entif
y lo
w-c
ost/h
igh-
yiel
d re
nova
tion
proj
ects
that
will
impr
ove
our i
mag
e (e
.g. c
osm
etic
upg
rade
of 2
S lo
bby)
(F)
ST
RA
TE
GY
: U
tili
ze t
ech
no
log
y to
im
pro
ve q
uali
ty a
nd
en
han
ce c
lin
ical s
erv
ices a
nd
to
pro
vid
e t
he c
om
mu
nit
y w
ith
access t
oin
form
ati
on
rela
tin
g to
ou
r serv
ices a
nd
perf
orm
an
ce.
Ev
alua
te u
se o
f web
site
as
vehi
cle
for p
atie
nt p
re-r
egis
tratio
n
Prov
ide
mon
thly
web
site
upd
ates
on
hosp
ital s
ervi
ces/
pro
gram
s
Im
plem
ent P
ACS
syst
em a
nd Im
agin
g D
epar
tmen
t upg
rade
s by
Dec
embe
r, 20
10; i
mpl
emen
t com
mun
icat
ions
an
d m
arke
ting
plan
to in
trodu
ce te
chno
logy
to p
hysi
cian
s an
d co
mm
unity
in o
rder
to a
chie
ve 1
2% in
crea
se in
ou
tpat
ient
imag
ing
volu
me
(G)
ST
RA
TE
GY
: D
evelo
p c
ap
ital p
lan
th
at
su
pp
ort
s s
erv
ice lin
e s
trate
gie
s, f
acil
itie
s a
nd
tech
no
log
y r
eq
uir
em
en
ts
D
evel
op a
nnua
l and
rolli
ng fi
ve-y
ear b
udge
t
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
710
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
10
Ph
ys
icia
ns
Ens
ure
that
the
Hos
pita
l attr
acts
qua
lifie
d an
d ca
pabl
e ph
ysic
ians
thro
ugh
colla
bora
tion
and
alig
nmen
t.M
ea
su
res o
f su
cc
ess:
In
crea
se n
umbe
r and
redu
ce a
vera
ge a
ge o
f act
ive
phys
icia
ns th
roug
h ta
rget
ed re
crui
tmen
t
A
chie
ve a
nnua
l rec
ruitm
ent g
oals
In
crea
se v
olum
e of
wor
k by
Ala
med
a su
rgeo
ns Init
iati
ve
sS
tatu
s
(A)
ST
RA
TE
GY
: C
on
tin
ue
re
cru
itm
en
t o
f n
ew
ph
ysic
ian
s t
o A
lam
ed
a M
ed
ica
l O
ffic
es (
12
06
B)
as e
mp
loye
es o
r ti
me
sh
are
te
na
nts
A
dd o
ne a
dditi
onal
PC
P o
n 2
½ d
ays/
wee
k
Set
up
syst
em fo
r mon
itorin
g an
d in
crea
sing
phy
sici
an p
rodu
ctiv
ity
Ass
ess
effe
ctiv
enes
s of
med
ical
offi
ce b
illing
ser
vice
s
(B)
ST
RA
TE
GY
: D
eve
lop
sta
nd
ard
IT
co
nn
ec
tivit
y p
ac
ka
ge
fo
r p
hysic
ian
s
A
ddre
ss p
hysi
cian
con
nect
ivity
thro
ugh
EH
R s
trate
gic
deve
lopm
ent
or o
rgan
izat
iona
l affi
liatio
n
Incr
ease
d us
e of
e-m
ail f
or c
omm
unic
atio
n w
ith p
hysi
cian
s
(C)
ST
RA
TE
GY
: C
on
sid
er
alig
nm
en
t w
ith
mu
ltip
le m
ed
ica
l g
rou
ps/IP
As
P
artic
ipat
e in
Hos
pita
l Cou
ncil
eval
uatio
n of
dev
elop
ing
a M
aste
r Med
ical
Fou
ndat
ion
(MM
F) a
s ph
ysic
ian
alig
nmen
t stra
tegy
for n
on-s
yste
m h
ospi
tals
.
(D)
ST
RA
TE
GY
: C
on
tin
ue
to
pu
rsu
e p
hysic
ian
co
mm
un
ity d
eve
lop
me
nt
pla
n:
id
en
tify
co
mm
un
ity n
ee
ds a
nd
wa
ys t
o f
ill
ga
ps e
ith
er
thro
ug
h d
ire
ct
rec
ruit
me
nt
or
co
lla
bo
rati
on
wit
h o
the
r g
rou
ps.
C
ontin
ued
phys
icia
n re
crui
tmen
t in
orth
oped
ics,
pla
stic
sur
gery
, uro
logy
, EN
T, s
elec
tive
prim
ary
care
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
810
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
11
Ph
ysic
ian
s
Ens
ure
that
the
Hos
pita
l attr
acts
qua
lifie
d an
d ca
pabl
e ph
ysic
ians
th
roug
h co
llabo
ratio
n an
d al
ignm
ent.
Init
iati
ve
sS
tatu
s
(E)
ST
RA
TE
GY
: D
eve
lop
dir
ec
ted
str
ate
gie
s t
o s
tre
ng
the
n a
ffilia
ted
ph
ysic
ian
pra
cti
ce
s (
pri
ma
ry c
are
, sp
ec
ialt
y s
erv
ice
s):
e
.g.,
gro
up
de
ve
lop
me
nt,
jo
int
ve
ntu
res;
eva
lua
te p
ote
nti
al o
f im
ple
me
nti
ng
co
lla
bo
rati
ve
str
ate
gie
s w
ith
oth
er
he
alt
hc
are
o
rga
niz
ati
on
s t
o e
nh
an
ce
ph
ysic
ian
ne
two
rk a
nd
ac
ce
ss t
o s
pe
cia
lists
fo
r o
ur
co
mm
un
ity
Im
plem
ent p
hysi
cian
pra
ctic
e bu
ildin
g in
itiat
ives
with
exi
stin
g pr
actic
es
Adv
ertis
ing
cam
paig
n to
focu
s on
the
Med
ical
Sta
ff
Enh
ance
d w
ebsi
te to
pro
vide
in d
epth
info
rmat
ion
on p
hysi
cian
s
(F)
ST
RA
TE
GY
: E
va
lua
te o
ff-i
sla
nd
ph
ysic
ian
s f
or
alig
nm
en
t o
pp
ort
un
itie
s t
ha
t w
ill
he
lp u
s e
xp
an
d o
ur
vis
ibilit
y a
nd
re
ferr
al
ba
se
C
ontin
ue re
crui
tmen
t of o
ff-is
land
spe
cial
ists
to e
stab
lish
a pr
esen
ce in
Ala
med
a
Con
tinue
to m
onito
r and
resp
ond
to p
ossi
ble
clos
ure
of S
an L
eand
ro H
ospi
tal
D
evel
op p
hysi
cian
recr
uitm
ent s
trate
gies
to s
uppo
rt de
velo
pmen
t of n
ew n
iche
pro
gram
s
(G)
ST
RA
TE
GY
: Im
ple
me
nt
ou
tre
ac
h s
tra
teg
y, in
clu
din
g e
va
lua
tio
n o
f fe
asib
ilit
y o
f sa
tellit
e l
oc
ati
on
s
C
ontin
ue to
exp
lore
sat
ellit
e m
edic
al o
ffice
spa
ce a
t Bay
Far
m.
E
valu
ate
rem
ote
plac
emen
t of p
hysi
cian
offi
ces
and
outp
atie
nt p
rogr
ams
(inc
ludi
ng W
ound
Cen
ter)
in
Mar
ina
Villa
ge
(H)
ST
RA
TE
GY
: E
ng
ag
e p
hysic
ian
s a
s c
en
tra
l p
art
icip
an
ts in
th
e le
ad
ers
hip
of
the
Ho
sp
ita
l
C
ontin
ue e
ngag
emen
t of p
hysi
cian
lead
ersh
ip in
IT S
teer
ing
Com
mitt
ee
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
910
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
12
Qu
ali
ty/S
erv
ice
Ach
ieve
sup
erio
r clin
ical
and
ser
vice
resu
lts o
n a
cons
iste
nt b
asis
.M
ea
su
res o
f su
cc
ess:
P
atie
nt s
atis
fact
ion
(pat
ient
exp
erie
nce)
as
mea
sure
d by
95%
or m
ore
willi
ng to
reco
mm
end
hosp
ital t
o a
frien
d
Jo
int C
omm
issi
on C
ore
Mea
sure
com
plia
nce
Jo
int C
omm
issi
on/C
MS
/CD
PH
Acc
redi
tatio
n
Q
I/Ris
k R
epor
ts th
at d
emon
stra
te im
prov
emen
t in
prob
lem
are
as
Im
prov
e ac
cura
cy o
f inf
orm
atio
n co
llect
ion
at ti
me
of re
gist
ratio
n
Init
iati
ve
sS
tatu
s
(A)
ST
RA
TE
GY
: C
rea
te a
cu
ltu
re o
f q
ua
lity
an
d s
erv
ice
th
at
is a
ime
d a
t h
elp
ing
us a
ch
ieve
ou
r g
oa
ls
■C
ontin
ue m
onito
ring
stre
amlin
ed s
truct
ure
of fu
nctio
nal a
nd d
epar
tmen
tal
perfo
rman
ce im
prov
emen
t at
the
man
agem
ent a
nd B
oard
leve
ls w
ith fo
cuse
d ac
tion
plan
s ap
poin
ted
to a
ddre
ss k
ey p
robl
em a
reas
(B)
ST
RA
TE
GY
: E
va
lua
te a
ll a
cc
ess p
oin
ts t
o t
he
org
an
iza
tio
n t
o im
pro
ve
th
e p
ati
en
ts/v
isit
or
ex
pe
rie
nc
e: e
.g.,
sc
he
du
lin
g,
ad
mis
sio
n,
an
d b
illin
g
E
valu
ate
adva
nce
on-li
ne re
gist
ratio
n an
d sc
hedu
ling
syst
em
(C)
ST
RA
TE
GY
: C
rea
te p
rog
ram
s t
ha
t c
ele
bra
te e
xe
mp
lary
se
rvic
e/q
ua
lity
pe
rfo
rma
nc
e/r
esu
lts
C
reat
e a
dash
boar
d re
port,
that
hig
hlig
hts
both
the
obje
ctiv
es a
nd th
e ou
tcom
es o
f our
qua
lity
and
serv
ice
initi
ativ
es
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
1010
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
13
Qu
ali
ty/S
erv
ice
Ach
ieve
sup
erio
r clin
ical
and
ser
vice
resu
lts o
n a
cons
iste
nt b
asis
.In
itia
tive
sS
tatu
s
(D)
ST
RA
TE
GY
: R
estr
uc
ture
pe
rfo
rma
nc
e e
xp
ec
tati
on
s a
nd
tra
inin
g t
o h
igh
lig
ht
qu
ality
an
d s
erv
ice
M
aint
ain
empl
oyee
eva
luat
ion
cycl
e at
14
mon
ths
with
agg
rega
te re
porti
ng to
Boa
rd
(E)
ST
RA
TE
GY
: W
ork
co
lla
bo
rati
ve
ly w
ith
me
dic
al sta
ff le
ad
ers
hip
to
assu
re p
hysic
ian
en
ga
ge
me
nt
in q
ua
lity
/sa
fety
in
itia
tive
s
D
evel
op a
nd in
itiat
e a
stre
amlin
ed, i
nter
disc
iplin
ary
patie
nt d
isch
arge
pro
cess
In
itiat
e or
gani
zed
phys
icia
n –
nurs
e ro
undi
ng
(F)
ST
RA
TE
GY
: E
ng
ag
e H
osp
ita
l sta
ff a
cro
ss a
ll le
ve
ls i
n a
cti
ve
de
ve
lop
me
nt
of
Ala
me
da
Ho
sp
ita
l C
ult
ure
E
nrol
l sta
ff in
cus
tom
er s
ervi
ce tr
aini
ng to
impr
ove
patie
nt e
xper
ienc
es th
roug
hout
thei
r sta
y at
our
faci
lity
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
1110
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
14
Pe
op
le
Fost
er a
cul
ture
of e
xem
plar
y pe
rform
ance
thro
ugh
recr
uitm
ent a
nd re
tent
ion
prac
tices
that
are
foun
ded
on a
dher
ence
to c
ore
perfo
rman
ce s
tand
ards
and
the
cont
inua
l dev
elop
men
t and
ce
lebr
atio
n of
our
em
ploy
ees.
Me
asu
res o
f su
cc
ess:
In
crea
se n
umbe
r of S
taff
Nur
se II
I am
ong
nurs
ing
staf
f by
2 in
FY
2010
-11
and
by 1
eac
h ye
ar th
erea
fter (
4 S
N II
I in
FY 2
010)
M
aint
ain
empl
oyee
vac
ancy
rate
s be
low
regi
onal
ben
chm
arks
D
evel
op a
nd m
onito
r em
ploy
ee s
atis
fact
ion
surv
eys
Tu
rnov
er ra
tes
of 1
5% o
r les
s (Q
4200
9 =
3.58
%)
Le
ss c
omm
ents
abo
ut n
on-E
nglis
h in
the
wor
kpla
ce
A
nnua
l per
form
ance
eva
luat
ions
incl
ude
aggr
egat
e m
easu
rem
ent o
f ser
vice
exc
elle
nce
Init
iati
ves
Sta
tus
(A)
ST
RA
TE
GY
: M
ain
tain
a c
om
pe
nsa
tio
n a
nd
be
ne
fit
str
ate
gy t
ha
t is
co
mp
eti
tive
an
d r
ew
ard
s d
esir
ed
pe
rfo
rma
nc
e
■C
ondu
ct a
bas
elin
e co
mpe
nsat
ion
stud
y fo
r non
-repr
esen
ted
and
exem
pt
(B)
ST
RA
TE
GY
: E
sta
blish
pe
rfo
rma
nc
e s
tan
da
rds t
ha
t a
re c
om
pre
he
nsiv
e:
ca
pa
bilit
ies,
se
rvic
e, c
itiz
en
sh
ip
C
ontin
ue w
ork
of S
ervi
ce E
xcel
lenc
e C
omm
ittee
to fo
ster
rein
forc
emen
t of C
AR
E v
alue
s an
d ad
dres
s fe
edba
ck fr
om p
atie
nt s
urve
ys
(C)
ST
RA
TE
GY
: E
sta
blish
re
cru
itm
en
t a
nd
hir
ing
sta
nd
ard
s t
ha
t a
re c
on
sis
ten
t w
ith
pe
rfo
rma
nc
e e
xp
ec
tati
on
s
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
1210
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
15
Pe
op
le
Fost
er a
cul
ture
of e
xem
plar
y pe
rform
ance
thro
ugh
recr
uitm
ent a
nd re
tent
ion
prac
tices
that
are
foun
ded
on a
dher
ence
to c
ore
perfo
rman
ce s
tand
ards
and
the
cont
inua
l dev
elop
men
t and
ce
lebr
atio
n of
our
em
ploy
ees.
Init
iati
ves
Sta
tus
(D)
ST
RA
TE
GY
: In
vest
in o
ur
sta
ff t
hro
ug
h a
nn
ual tr
ain
ing
an
d e
du
cati
on
pro
gra
ms:
serv
ice,
cap
ab
ilit
ies,
man
ag
em
en
t
Im
plem
ent o
nlin
e m
anda
tory
ann
ual t
rain
ing
(MAT
) for
all
staf
f
(E)
ST
RA
TE
GY
: C
reate
a r
eco
gn
itio
n p
rog
ram
to
cele
bra
te t
op
perf
orm
ers
in
are
as s
uch
as g
row
th, q
uality
, an
d s
erv
ice
C
ontin
ue d
evel
opm
ent o
f in
nova
tive
reco
gniti
on p
rogr
ams
(F)
ST
RA
TE
GY
: T
ailo
r o
rien
tati
on
pro
gra
m t
o m
ake s
ure
new
sta
ff h
av
e c
lear
un
ders
tan
din
g o
f w
hat
is e
xp
ecte
d o
f th
em
, an
d t
hat
cele
bra
tes t
heir
ad
dit
ion
to
th
e A
lam
ed
a H
osp
ital T
eam
En
hanc
ed o
rient
atio
n an
d tra
inin
g fo
r all
new
ly h
ired
empl
oyee
s of
the
orga
niza
tion
Ex
pans
ion
of o
rient
atio
n to
add
ition
al d
ay fo
r Nur
sing
Sta
ff to
revi
ew M
edic
atio
n Ad
min
istra
tion,
Wou
nd
Man
agem
ent,
Falls
, Res
train
ts, E
quip
men
t, Pr
otoc
ols,
Qua
lity
Initi
ativ
es…
laun
ched
May
200
9.
Con
tinue
to h
old
annu
al b
enef
its a
nd s
afet
y fa
ir
2009
-201
3 G
oals
–FY
E 2
011
Upd
ate
1310
/11/
10 –
Dis
trict
Boa
rd M
eetin
g
16
Date: October 11, 2010 To: City of Alameda Health Care District Board of Directors From: Deborah E. Stebbins, Chief Executive Officer Subject: Recommendations for FY 2010 Executive Incentive Compensation Pay-out Recommendation: That the Board of Directors approves the following:
1. The detailed assessment of the performance against the FY 2010 metrics and the recommended scores contained in this memorandum, and
2. The payment of the incentive outlined above to the CEO, in accordance with the executive incentive plan approved by the Board in 2009, and
3. Authorize the CEO to approve similar incentive amounts to the other participating executives.
Note: All of the proposed incentive compensation amounts were budgeted for and accrued in the actual financial results for FY 2010. Summary: The following memorandum summarizes management’s recommendations regarding a pay-out of executive incentive compensation within the parameters established for FY 2010. We are recommending a total payout of 29.38% at the CEO level with a payout for the Associate Administrator and Chief Financial Officer to be determined by the Chief Executive Officer. Background: The structure of the FY 2010 Executive Performance Metrics were approved in June 2010 and is attached to this memorandum (Attachment A). The first tripwire for whether any incentive payment should be made is achievement of the budgeted revenue in excess of expenses or a bottom line of $358,000. Two other levels of financial performance if achieved, “target” and “high”, can provide for an additional incentive payment. The annual revenue in excess of expenses required to achieve the “target” level is $543,000 and the “high” level is $1 million or greater. Note that these levels were developed assuming a full year of the Kaiser contract. Incentives have been calculated based on actual results for the year, despite the loss of the Kaiser
17
volume on April 1, 2010. Once the tripwire level of excess revenue over expenses is achieved, financial performance in FY 2010 drives 50% of the total base bonus. The remaining incentive potential is distributed over the four other areas of goals and measures: Quality/Satisfaction, Workforce Success, Operational Success and Business Development/Long Term Financial Viability. Management has assessed the achievement of each of these measures as outlined on Attachment B. Stretch Incentive Components
1. Achievement of Target Net Margin of $543,000 = Additional 6.25%
2. Achievement of High Net Margin of $1 million = Additional 13.00% Therefore, the payment for the base incentives would be calculated for the CEO of:
93% x (Base Annual Salary with 5% reduction) x Approved Base Incentive 25%
In addition, management recommends that the net excess of revenue over expense reported in the FY 2010 audit be amended to exclude the IGT income impact ($2.017 million), and the Non-Operating Contributions and the Grants for Equipment ($194,000), but to add back the repayment of overpayments by CMS from prior years ($652,000). This calculation is summarized on Attachment C and results in an amended net excess of revenue of expense of $558,000 for purposes of incentive payment calculation. Since this figure exceeds the “target” stretch objective of $543,000, this would result in the payout of an additional Target Level 6.25% x Base Annual Salary with 5% reduction.
18
\\ALA
ME
DA
-SQ
L\A
DM
IN F
ILE
S\K
RIS
TEN
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TRIC
T\C
EO
\201
0 IN
CE
NTI
VE
, CO
NTR
AC
T &
PE
RFO
RM
AN
CE
REV
IEW
\FY2
010
EXE
CU
TIV
E IN
CE
NTI
VE
CO
MP
EN
SA
TIO
N W
ITH
BO
AR
D R
EV
ISIO
NS
.06.
07.1
0.D
OC
X
Page
1 o
f 6
Cit
y o
f A
lam
ed
a H
ea
lth
Ca
re D
istr
ict
FY
2010 E
xecu
tive P
erf
orm
an
ce M
etr
ics
INT
RO
DU
CT
ION
Rev
ised
- 06
.07.
2010
Pa
ymen
t of a
ny in
cent
ive
com
pens
atio
n to
an
exec
utiv
e is
pre
dica
ted
upon
a p
erfo
rman
ce e
valu
atio
n of
"mee
ts e
xpec
tatio
ns" o
r abo
ve.
The
base
per
cent
age
bonu
s (b
ased
on
% b
ase
com
pens
atio
n) fo
r the
Chi
ef E
xecu
tive
Offi
cer i
s es
tabl
ishe
d by
the
Boar
d. T
he
ince
ntiv
e co
mpe
nsat
ion
leve
ls fo
r oth
er p
artic
ipat
ing
exec
utiv
es a
re e
stab
lishe
d by
the
CEO
. An
nual
met
rics
are
appr
oved
eac
h ye
ar b
y th
e Bo
ard,
incl
udin
g an
y ta
rget
or h
igh
stre
tch
finan
cial
obj
ectiv
es.
Inc
entiv
e C
ompe
nsat
ion
as %
Bas
e S
alar
y
Th
resh
old
Targ
et
Hig
h C
EO
25%
6.25
%
6
.25%
The
Chi
ef E
xecu
tive
Offi
cer (
CEO
) is
resp
onsi
ble
for r
ecom
men
ding
add
ition
al e
xecu
tive
parti
cipa
nts
in a
n in
cent
ive
Plan
to th
e Bo
ard.
Th
e C
EO is
resp
onsi
ble
for s
truct
urin
g th
e te
rms
of th
eir i
ncen
tive
in a
man
ner c
onsi
sten
t with
the
exec
utiv
e in
cent
ive
com
pens
atio
n sy
stem
. In
FY
2010
the
full
ince
ntiv
e co
mpe
nsat
ion
targ
et fo
r the
CEO
and
oth
er p
artic
ipat
ing
exec
utiv
es w
as b
udge
ted
and
has
been
ac
crue
d at
the
"targ
et" f
inan
cial
leve
l and
at f
ull a
chie
vem
ent o
f the
oth
er th
ree
area
s to
ens
ure
that
the
ince
ntiv
e pa
ymen
ts a
re
appr
opria
tely
fund
ed.
The
exc
ess
reve
nue
over
exp
ense
will
incl
ude
the
Hos
pita
l and
Sou
th S
hore
onl
y an
d ex
clud
e C
WS
and
the
501(
c)3
corp
orat
ion.
For
pur
pose
s of
cla
rifyi
ng e
xact
tim
e fra
mes
ass
ocia
ted
with
met
rics,
FY
2010
is th
e pe
riod
betw
een
July
1, 2
009
and
June
30,
201
0.
The
prop
ortio
n of
pay
-out
of t
he b
onus
is b
ased
on
the
achi
evem
ent o
f the
met
rics
outli
ned
belo
w in
the
follo
win
g ar
eas:
W
eigh
ting
Fi
nanc
ial S
ucce
ss
50%
Q
ualit
y / S
atis
fact
ion
10%
W
orkf
orce
Suc
cess
10
%
O
pera
tiona
l Suc
cess
20
%
Bu
sine
ss D
evel
opm
ent /
Lon
g Te
rm F
inan
cial
Via
bilit
y
10%
To
tal
100%
19
\\ALA
ME
DA
-SQ
L\A
DM
IN F
ILE
S\K
RIS
TEN
\DIS
TRIC
T\C
EO
\201
0 IN
CE
NTI
VE
, CO
NTR
AC
T &
PE
RFO
RM
AN
CE
REV
IEW
\FY2
010
EXE
CU
TIV
E IN
CE
NTI
VE
CO
MP
EN
SA
TIO
N W
ITH
BO
AR
D R
EV
ISIO
NS
.06.
07.1
0.D
OC
X
Page
2 o
f 6
Fin
an
cia
l S
ucc
es
s
We
igh
tin
g
Po
ints
Go
als
A
cti
on
s
Me
as
ure
s
50
Ac
hie
ve
ou
r F
Y1
0
Fin
an
cia
l T
arg
ets
&
Go
als
Tri
pw
ire
: E
xc
ess
Re
ve
nu
e o
ve
r E
xp
en
se
. M
us
t m
ee
t th
res
ho
ld
or
no
in
ce
nti
ve
co
mp
en
sa
tio
n
pa
id
Thre
shol
d Ta
rget
H
igh
50
$358
,000
(F
Y 20
10 B
udge
t) $5
43,0
00
$1M
or >
Qu
ality
/ S
ati
sfa
cti
on
Su
cc
es
s
We
igh
tin
g
Po
ints
G
oa
ls
Ac
tio
ns
M
ea
su
res
10
Imp
rove
Cu
sto
me
r S
ati
sfa
cti
on
, E
ng
ag
em
en
t &
R
efe
ren
ce
ab
ilit
y
Esta
blis
h an
d di
ssem
inat
e C
ode
of
Con
duct
(200
9)
Patie
nt s
atis
fact
ion
HC
HAP
S sc
ores
for "
clea
nlin
ess
of
faci
lity"
impr
oved
sig
nific
antly
from
55%
(Q3)
to 6
4%
(Q4)
and
59%
(Q1)
. C
once
rn a
bout
noi
se o
n nu
rsin
g un
its im
prov
ed in
2
quar
ters
and
dec
lined
in 2
qua
rters
.
4
Ove
rall
Qu
ali
ty
O
rgan
ize
prep
arat
ion
for 2
010
Join
t Com
mis
sion
Sur
vey,
in
clud
ing
orie
ntat
ion
man
ual,
biw
eekl
y tra
cer r
evie
ws,
or
ient
atio
n bo
okle
t (C
ompa
ss),
lead
ersh
ip p
ract
ice
sess
ions
and
TJ
C F
air f
or s
taff.
Reo
rgan
ized
the
perfo
rman
ce
impr
ovem
ent p
roce
ss to
iden
tify,
ad
dres
s an
d re
port
on m
ost
impo
rtant
qua
lity/
safe
ty is
sues
in
func
tiona
l and
dep
artm
enta
l ar
eas.
Hos
pita
l gra
nted
full
accr
edita
tion
in A
pril,
201
0.
Hos
pita
l Boa
rd n
ow re
ceiv
es a
mor
e co
ncis
e an
d fo
cuse
d m
onth
ly re
port
on q
ualit
ativ
e is
sues
. R
apid
in
terv
entio
n th
roug
h PI
C (P
erfo
rman
ce Im
prov
emen
t C
omm
ittee
) act
ion
team
s of
are
as o
f hig
h co
ncer
n or
pr
iorit
y. (e
.g. r
educ
tion
of H
APU
) 4
20
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ME
DA
-SQ
L\A
DM
IN F
ILE
S\K
RIS
TEN
\DIS
TRIC
T\C
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\201
0 IN
CE
NTI
VE
, CO
NTR
AC
T &
PE
RFO
RM
AN
CE
REV
IEW
\FY2
010
EXE
CU
TIV
E IN
CE
NTI
VE
CO
MP
EN
SA
TIO
N W
ITH
BO
AR
D R
EV
ISIO
NS
.06.
07.1
0.D
OC
X
Page
3 o
f 6
Qu
ality
/ S
ati
sfa
cti
on
Su
cc
es
s (
co
nti
nu
ed
) W
eig
hti
ng
P
oin
ts
Sp
ec
ific
Qu
ali
ty
Im
plem
ent c
usto
mer
/ em
ploy
ee
serv
ice
exce
llenc
e pr
ogra
m.
Es
tabl
ish
Med
icat
ion
Erro
r R
educ
tion
Prog
ram
(MER
P).
In
stal
latio
n of
Pyx
is P
rofil
e fo
r m
edic
atio
n er
ror r
educ
tion.
Com
preh
ensi
ve w
ound
car
e m
anag
emen
t pro
gram
im
plem
ente
d
Med
icat
ion
erro
rs re
duce
d by
from
4.0
7 (Q
2), 3
.45
(Q3)
, 3.3
(Q4)
inci
dent
s pe
r 100
0 pa
tient
day
s.
Inci
denc
e of
hos
pita
l acq
uire
d pr
essu
re u
lcer
s (H
APU
's) r
educ
ed fr
om 5
.02%
(Q3)
to 3
.22%
(Q4)
in
acut
e ca
re.
2
Wo
rkfo
rce
Su
cce
ss
W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
10
Inve
st
in e
mp
loye
e
tra
inin
g,
de
ve
lop
me
nt
a
nd
en
ga
ge
me
nt
Es
tabl
ish
or s
elec
t a c
omm
erci
ally
av
aila
ble
empl
oyee
sat
isfa
ctio
n to
ol.
Mea
sure
bas
elin
e (2
009)
: Ba
selin
e re
sults
wer
e ov
eral
l wel
l abo
ve v
endo
r dat
a ba
se a
vera
ges.
Are
as
iden
tifie
d fo
r im
prov
emen
t inc
lude
redu
ctio
n of
em
ploy
ee p
erce
ptio
n th
at id
entif
icat
ion
of e
rror
s ca
n le
ad to
pun
itive
con
sequ
ence
s in
wor
k pl
ace.
Not
able
w
as h
igh
leve
l of s
atis
fact
ion
by e
mpl
oyee
s w
ith q
ualit
y of
com
mun
icat
ion
in h
ospi
tal a
nd th
eir d
epar
tmen
ts
5
R
epor
ted
resu
lts o
f 200
9 su
rvey
to
em
ploy
ees
in to
wn
hall
mee
tings
and
to B
oard
Targ
et 2
% (1
2.7%
to 1
4.7%
) im
prov
emen
t in
empl
oyee
sa
tisfa
ctio
n w
ith tr
aini
ng o
ppor
tuni
ties
(low
sco
re o
n 20
09 s
urve
y).
D
esig
n em
ploy
ee re
war
d /
reco
gniti
on p
rogr
am g
eare
d to
co
de o
f con
duct
Em
ploy
ee tu
rnov
er ra
tes
< Ba
y Ar
ea a
vera
ge.
Seco
nd
year
of p
rese
ntat
ion
of F
lore
nce
Nig
htin
gale
Bes
t N
urse
Aw
ard.
In
crea
se o
f Sta
ff N
urse
III f
rom
thre
e (2
008)
to s
ix
(200
9) to
five
(201
0) (d
ue to
1 re
sign
atio
n; le
ft ar
ea).
St
aff N
urse
III C
omm
ittee
org
aniz
ed to
wor
k on
spe
cial
pr
ojec
ts a
nd e
ncou
rage
add
ition
al s
taff
Nur
se II
I de
velo
pmen
t.
21
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ME
DA
-SQ
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ILE
S\K
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TRIC
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\201
0 IN
CE
NTI
VE
, CO
NTR
AC
T &
PE
RFO
RM
AN
CE
REV
IEW
\FY2
010
EXE
CU
TIV
E IN
CE
NTI
VE
CO
MP
EN
SA
TIO
N W
ITH
BO
AR
D R
EV
ISIO
NS
.06.
07.1
0.D
OC
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Page
4 o
f 6
Wo
rkfo
rce
Su
cce
ss
(c
on
tin
ue
d)
We
igh
tin
g
Po
ints
G
oa
ls
Ac
tio
ns
M
ea
su
res
Incr
ease
opp
ortu
nitie
s fo
r em
ploy
ee tr
aini
ng
Red
esig
ned
gene
ral o
rient
atio
n fo
r em
ploy
ees
and
nurs
ing
orie
ntat
ion,
leng
then
ing
prog
ram
s an
d ad
ding
ad
ditio
nal m
ater
ial.
Ret
rain
ed e
ntire
EVS
sta
ff on
bas
ic
clea
ning
tech
niqu
es.
Reg
ular
all
hosp
ital t
own
hall
mee
tings
and
nur
sing
foru
ms
held
.
Safe
ty a
nd J
oint
Com
mis
sion
Fai
rs w
ere
very
wel
l at
tend
ed b
y st
aff.
Auto
mat
ed a
nnua
l man
dato
ry tr
aini
ng p
rogr
am (H
CC
S)
for a
ll ho
spita
l em
ploy
ees
Bu
ild
th
e s
tre
ng
th a
nd
d
ep
th o
f o
ur
lead
ers
hip
te
am
s t
o s
up
po
rt f
utu
re
gro
wth
Im
plem
ent m
iddl
e m
anag
er
train
ing
prog
ram
(200
9-20
10)
Wel
l ove
r 75%
exe
cutiv
es a
nd m
iddl
e m
anag
ers
com
plet
ed o
ne y
ear t
rain
ing
by 2
010
5
Op
era
tio
nal S
uc
ce
ss
We
igh
tin
g
Po
ints
G
oa
ls
Ac
tio
ns
M
ea
su
res
20
De
ve
lop
Cri
tic
al
Ca
pa
bilit
ies i
n P
lan
nin
g,
Pro
du
ct
De
ve
lop
me
nt
&
Ma
rke
tin
g E
ffe
cti
ve
ne
ss
As
sess
key
ser
vice
line
s to
de
term
ine
appr
opria
tene
ss fo
r gr
owth
, con
tract
ion
or c
losu
re.
In
stal
led
Allia
nce
exec
utiv
e de
cisi
on m
akin
g sy
stem
Iden
tify
and
eval
uate
new
re
venu
e pr
oduc
ing
prog
ram
s
PAC
S sy
stem
sel
ecte
d an
d fin
anci
ng c
lose
to b
eing
sec
ured
Com
plet
ed s
ervi
ce li
ne a
naly
ses
on:
Kais
er O
P Su
rger
y im
pact
, Car
dioF
it, N
ucle
ar M
edic
ine,
ex
pans
ion
of S
ubac
ute,
IGT/
CM
AC C
ontra
ct
Dev
elop
com
mun
ity c
linic
mod
el a
s ph
ysic
ian
recr
uitm
ent v
ehic
le, a
ddin
g 3
new
phy
sici
ans
plus
tim
e sh
are
arra
ngem
ents
for 5
spe
cial
ists
. Al
lianc
e fa
cilit
ates
bet
ter d
ecis
ion
mak
ing
and
eval
uatio
n of
3rd
par
ty p
ayor
con
tract
s (e
.g. A
lam
eda
Allia
nce)
; sys
tem
use
d fo
r FY
2011
Bud
get.
3
22
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ME
DA
-SQ
L\A
DM
IN F
ILE
S\K
RIS
TEN
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TRIC
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EO
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CE
NTI
VE
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NTR
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T &
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AN
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IEW
\FY2
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CU
TIV
E IN
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NTI
VE
CO
MP
EN
SA
TIO
N W
ITH
BO
AR
D R
EV
ISIO
NS
.06.
07.1
0.D
OC
X
Page
5 o
f 6
Op
era
tio
nal S
uc
ce
ss (
co
nti
nu
ed
) W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
Sim
pli
fy C
ore
Bu
sin
es
s
Pro
ce
ss
es
an
d B
uil
d a
S
ca
lab
le,
Co
st-
Eff
icie
nt
Infr
as
tru
ctu
re
Es
tabl
ish
mar
ketin
g pr
ogra
m
dire
cted
to B
ay F
arm
resi
dent
s (2
009)
Esta
blis
h ou
treac
h pr
ogra
ms
targ
eted
at A
sian
mar
ket,
San
Lean
dro
and
sele
cted
resi
dent
s of
94
501
Mar
ket S
hare
gro
wth
in B
ay F
arm
Are
a by
2%
(201
0):
actu
al m
arke
t sha
re o
f adm
issi
on fr
om B
ay F
arm
de
clin
ed in
201
0; o
vera
ll Al
amed
a ad
mis
sion
s in
crea
sed.
D
evel
oped
and
impl
emen
ted
a m
ulti-
face
ted
actio
n pl
an to
resp
ond
to th
e 9.
8 (1
4% n
et re
venu
es) l
oss
of
Kais
er re
venu
e.
3
Re
du
ce
Wa
ste
& D
rive
O
pe
rati
on
al
Eff
icie
nc
y
Fa
cilit
y M
aste
r Pla
n fin
aliz
ed
(200
9)
D
evel
oped
fina
l app
roac
h to
SB
1953
com
plia
nce
by 2
013
OSH
PD a
ppro
ved
appl
icat
ion
for N
PC re
med
iatio
n Ki
tche
n de
sign
and
SPC
rem
edia
tion
final
ized
and
co
st p
roje
cted
; pla
n is
to s
ubm
it ap
plic
atio
n by
Jun
e 20
10
Com
plet
ed b
usin
ess
anal
ysis
and
sec
ured
fina
ncin
g fo
r Dia
gnos
tic Im
agin
g D
epar
tmen
t upg
rade
, inc
ludi
ng
PAC
S.
Inte
rvie
wed
con
stru
ctio
n m
anag
emen
t firm
s fo
r pro
ject
m
anag
emen
t of r
emed
iatio
n w
ork
Orie
nted
Boa
rd to
fina
ncin
g op
tions
; cur
rent
ly
iden
tifyi
ng fi
nanc
ing
alte
rnat
ives
for s
eism
ic.
4
To
tal O
pera
ting
Volu
me
and
Rev
enue
N
et R
even
ue (J
uly
2009
- Jun
e 30
, 201
0) m
ust m
eet o
r ex
ceed
orig
inal
bud
get l
evel
s 4
Mon
thly
Sur
gery
Vol
ume
from
Ala
med
a su
rgeo
ns
betw
een
April
-Jun
e 20
10 to
exc
eed
June
200
9-M
arch
20
10 m
onth
ly a
vera
ges
by 1
0%
6
23
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ME
DA
-SQ
L\A
DM
IN F
ILE
S\K
RIS
TEN
\DIS
TRIC
T\C
EO
\201
0 IN
CE
NTI
VE
, CO
NTR
AC
T &
PE
RFO
RM
AN
CE
REV
IEW
\FY2
010
EXE
CU
TIV
E IN
CE
NTI
VE
CO
MP
EN
SA
TIO
N W
ITH
BO
AR
D R
EV
ISIO
NS
.06.
07.1
0.D
OC
X
Page
6 o
f 6
Bu
sin
ess
De
velo
pm
en
t /
Lo
ng
-Term
Fin
an
cia
l V
iab
ilit
y
We
igh
tin
g
Po
ints
G
oa
ls
Ac
tio
ns
M
ea
su
res
10
De
ve
lop
ne
w b
us
ine
ss
a
nd
pro
gra
m
de
ve
lop
me
nt
pro
jec
ts
wh
ich
are
cli
nic
all
y
be
ne
fic
ial a
nd
fin
an
cia
lly
via
ble
in
ord
er
to w
ork
to
wa
rd i
nc
rea
sin
g o
ur
an
nu
l fi
na
nc
ial
pe
rfo
rma
nc
e t
o
ge
ne
rati
ng
a r
es
po
ns
ible
m
arg
in,
the
reb
y
red
uc
ing
re
lia
nc
e o
n u
se
o
f th
e p
arc
el
tax
fo
r o
pe
rati
on
al
pu
rpo
ses
a
nd
en
su
rin
g t
he
lo
ng
te
rm v
iab
ilit
y o
f th
e
Ho
sp
ita
l
N
ew M
edic
al S
taff
Prac
tice
Mod
el a
t Ala
med
a To
wne
Cen
tre
MO
B to
sup
port
phys
icia
n re
crui
tmen
t.
Esta
blis
hed
126(
b) c
linic
; rec
ruite
d 1
OB-
GYN
, 1
Gen
eral
Sur
geon
, 1 In
tern
ist,
attra
cted
mul
tiple
sp
ecia
lists
to ti
me
shar
e 3
D
evel
op a
ppro
ach
to p
rovi
de
acce
ss fo
r Med
ic-C
al p
atie
nts
on
a fin
anci
ally
via
ble
basi
s.
Con
clud
ed n
egot
iatio
ns w
ith C
MAC
for M
edi-C
al
cont
ract
incl
udin
g su
pple
men
tary
pay
men
t thr
ough
go
vern
men
tal t
rans
fer
4
Ev
alua
te n
ew p
rogr
ams
that
will
in
crea
se v
olum
e of
refe
rral
s fro
m
beyo
nd im
med
iate
ser
vice
are
a.
Feas
ibili
ty s
tudi
es fo
r acu
te re
hab,
sub
acut
e ex
pans
ion
and
new
wou
nd c
are
prog
ram
s
3
24
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Reco
mm
enda
tions
for F
Y 20
10 E
xecu
tive
Com
pens
atio
n Pa
y-ou
t M
anag
emen
t Sel
f Ran
king
A
ttac
hmen
t B
Page
1 o
f 7
Fin
an
cia
l S
ucc
es
s
We
igh
tin
g
Po
ints
M
an
ag
em
en
t S
elf
Ra
nk
ing
Go
als
A
cti
on
s
Me
as
ure
s
Ac
hie
ve
ou
r F
Y1
0
Fin
an
cia
l T
arg
ets
&
Go
als
Tri
pw
ire
: E
xc
ess
Re
ve
nu
e
ove
r E
xp
en
se
. M
us
t m
ee
t th
res
ho
ld o
r n
o i
nc
en
tive
c
om
pe
ns
ati
on
pa
id
Thre
shol
d Ta
rget
H
igh
50%
50%
$3
58,0
00
(FY
201
0 B
udge
t) $5
43,0
00
$1M
or >
TO
TA
L
50
%
50
%
Qu
ality
/ S
ati
sfa
cti
on
Su
cc
es
s
We
igh
tin
g
Po
ints
M
an
ag
em
en
t S
elf
Ra
nk
ing
Go
als
A
cti
on
s
Me
as
ure
s
Imp
rove
Cu
sto
me
r S
ati
sfa
cti
on
, E
ng
ag
em
en
t &
R
efe
ren
ce
ab
ilit
y
Esta
blis
h an
d di
ssem
inat
e C
ode
of
Con
duct
(200
9)
Patie
nt s
atis
fact
ion
HC
HAP
S sc
ores
fo
r "cl
eanl
ines
s of
faci
lity"
impr
oved
si
gnifi
cant
ly fr
om 5
5% (Q
3) to
64%
(Q
4) a
nd 5
9% (Q
1).
Con
cern
abo
ut n
oise
on
nurs
ing
units
im
prov
ed in
2 q
uarte
rs a
nd d
eclin
ed
in 2
qua
rters
. H
CA
HPS
scor
e on
“W
ould
reco
mm
end
hosp
ital t
o fa
mily
” in
crea
sed
from
55.
9%
in Q
2 to
64.
9% in
Q4.
4%
3%
25
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Reco
mm
enda
tions
for F
Y 20
10 E
xecu
tive
Com
pens
atio
n Pa
y-ou
t M
anag
emen
t Sel
f Ran
king
A
ttac
hmen
t B
Page
2 o
f 7
Qu
ality
/ S
ati
sfa
cti
on
Su
cc
es
s (
co
nti
nu
ed
) W
eig
hti
ng
P
oin
ts
Ma
na
ge
me
nt
Se
lf R
an
kin
g
Go
als
A
cti
on
s
Me
as
ure
s
Ove
rall
Qu
ali
ty
O
rgan
ize
prep
arat
ion
for 2
010
Join
t C
omm
issi
on S
urve
y, in
clud
ing
orie
ntat
ion
man
ual,
biw
eekl
y tra
cer
revi
ews,
orie
ntat
ion
book
let
(Com
pass
), le
ader
ship
pra
ctic
e se
ssio
ns a
nd T
JC F
air f
or s
taff.
Reo
rgan
ized
the
perfo
rman
ce
impr
ovem
ent p
roce
ss to
iden
tify,
ad
dres
s an
d re
port
on m
ost
impo
rtant
qua
lity/
safe
ty is
sues
in
func
tiona
l and
dep
artm
enta
l are
as.
Hos
pita
l gra
nted
full
accr
edita
tion
in
April
, 201
0. H
ospi
tal B
oard
now
re
ceiv
es a
mor
e co
ncis
e an
d fo
cuse
d m
onth
ly re
port
on q
ualit
ativ
e is
sues
. R
apid
inte
rven
tion
thro
ugh
PIC
(P
erfo
rman
ce Im
prov
emen
t C
omm
ittee
) act
ion
team
s of
are
as o
f hi
gh c
once
rn o
r prio
rity.
(e.g
. re
duct
ion
of H
APU
)
4%
4%
Sp
ec
ific
Qu
ali
ty
Im
plem
ent c
usto
mer
/ em
ploy
ee
serv
ice
exce
llenc
e pr
ogra
m.
Es
tabl
ish
Med
icat
ion
Erro
r R
educ
tion
Prog
ram
(MER
P).
In
stal
latio
n of
Pyx
is P
rofil
e fo
r m
edic
atio
n er
ror r
educ
tion.
Com
preh
ensi
ve w
ound
car
e m
anag
emen
t pro
gram
impl
emen
ted
Med
icat
ion
erro
rs re
duce
d by
from
4.
07 (Q
2), 3
.45
(Q3)
, 3.3
(Q4)
in
cide
nts
per 1
000
patie
nt d
ays.
In
cide
nce
of h
ospi
tal a
cqui
red
pres
sure
ulc
ers
(HAP
U's
) red
uced
fro
m 5
.02%
(Q3)
to 3
.22%
(Q4)
in
acut
e ca
re.
2%
2%
TO
TA
L
10
%
9%
26
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Reco
mm
enda
tions
for F
Y 20
10 E
xecu
tive
Com
pens
atio
n Pa
y-ou
t M
anag
emen
t Sel
f Ran
king
A
ttac
hmen
t B
Page
3 o
f 7
Wo
rkfo
rce
Su
cce
ss
W
eig
hti
ng
P
oin
ts
Ma
na
ge
me
nt
Se
lf R
an
kin
g
Go
als
A
cti
on
s
Me
as
ure
s
Inve
st
in e
mp
loye
e
tra
inin
g,
de
ve
lop
me
nt
a
nd
en
ga
ge
me
nt
Es
tabl
ish
or s
elec
t a c
omm
erci
ally
av
aila
ble
empl
oyee
sat
isfa
ctio
n to
ol.
Mea
sure
bas
elin
e (2
009)
: Ba
selin
e re
sults
wer
e ov
eral
l wel
l abo
ve
vend
or d
ata
base
ave
rage
s. A
reas
id
entif
ied
for i
mpr
ovem
ent i
nclu
de
redu
ctio
n of
em
ploy
ee p
erce
ptio
n th
at id
entif
icat
ion
of e
rror
s ca
n le
ad to
pu
nitiv
e co
nseq
uenc
es in
wor
k pl
ace.
N
otab
le w
as h
igh
leve
l of s
atis
fact
ion
by e
mpl
oyee
s w
ith q
ualit
y of
co
mm
unic
atio
n in
hos
pita
l and
thei
r de
partm
ents
5%
4%
R
epor
ted
resu
lts o
f 200
9 su
rvey
to
empl
oyee
s in
tow
n ha
ll m
eetin
gs
and
to B
oard
Targ
et 2
% (1
2.7%
to 1
4.7%
) im
prov
emen
t in
empl
oyee
sa
tisfa
ctio
n w
ith tr
aini
ng o
ppor
tuni
ties
(low
sco
re o
n 20
09 s
urve
y).
D
esig
n em
ploy
ee re
war
d /
reco
gniti
on p
rogr
am g
eare
d to
cod
e of
con
duct
Em
ploy
ee tu
rnov
er ra
tes
< Ba
y Ar
ea
aver
age.
Sec
ond
year
of
pres
enta
tion
of F
lore
nce
Nig
htin
gale
Be
st N
urse
Aw
ard.
In
crea
se o
f Sta
ff N
urse
III f
rom
thre
e (2
008)
to s
ix (2
009)
to fi
ve (2
010)
(d
ue to
1 re
sign
atio
n; le
ft ar
ea).
St
aff N
urse
III C
omm
ittee
org
aniz
ed
to w
ork
on s
peci
al p
roje
cts
and
enco
urag
e ad
ditio
nal s
taff
Nur
se II
I de
velo
pmen
t.
27
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Reco
mm
enda
tions
for F
Y 20
10 E
xecu
tive
Com
pens
atio
n Pa
y-ou
t M
anag
emen
t Sel
f Ran
king
A
ttac
hmen
t B
Page
4 o
f 7
Wo
rkfo
rce
Su
cce
ss
(c
on
tin
ue
d)
We
igh
tin
g
Po
ints
M
an
ag
em
en
t S
elf
Ra
nk
ing
Go
als
A
cti
on
s
Me
as
ure
s
Incr
ease
opp
ortu
nitie
s fo
r em
ploy
ee
train
ing
Red
esig
ned
gene
ral o
rient
atio
n fo
r em
ploy
ees
and
nurs
ing
orie
ntat
ion,
le
ngth
enin
g pr
ogra
ms
and
addi
ng
addi
tiona
l mat
eria
l. R
etra
ined
ent
ire
EVS
staf
f on
basi
c cl
eani
ng
tech
niqu
es.
Reg
ular
all
hosp
ital t
own
hall
mee
tings
and
nur
sing
foru
ms
held
.
Safe
ty a
nd J
oint
Com
mis
sion
Fai
rs
wer
e ve
ry w
ell a
ttend
ed b
y st
aff.
Auto
mat
ed a
nnua
l man
dato
ry tr
aini
ng
prog
ram
(HC
CS)
for a
ll ho
spita
l em
ploy
ees
Bu
ild
th
e s
tre
ng
th a
nd
d
ep
th o
f o
ur
lead
ers
hip
te
am
s t
o s
up
po
rt
futu
re g
row
th
Im
plem
ent m
iddl
e m
anag
er tr
aini
ng
prog
ram
(200
9-20
10)
Wel
l ove
r 75%
exe
cutiv
es a
nd m
iddl
e m
anag
ers
com
plet
ed o
ne y
ear
train
ing
by 2
010
5%
5%
TO
TA
L
10
%
9%
28
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Reco
mm
enda
tions
for F
Y 20
10 E
xecu
tive
Com
pens
atio
n Pa
y-ou
t M
anag
emen
t Sel
f Ran
king
A
ttac
hmen
t B
Page
5 o
f 7
Op
era
tio
nal S
uc
ce
ss
We
igh
tin
g
Po
ints
M
an
ag
em
en
t S
elf
Ra
nk
ing
Go
als
A
cti
on
s
Me
as
ure
s
De
ve
lop
Cri
tic
al
Ca
pa
bilit
ies i
n
Pla
nn
ing
, P
rod
uc
t D
eve
lop
me
nt
&
Ma
rke
tin
g
Eff
ec
tive
ne
ss
As
sess
key
ser
vice
line
s to
de
term
ine
appr
opria
tene
ss
for g
row
th, c
ontra
ctio
n or
cl
osur
e.
In
stal
led
Allia
nce
exec
utiv
e de
cisi
on m
akin
g sy
stem
Iden
tify
and
eval
uate
new
re
venu
e pr
oduc
ing
prog
ram
s
PAC
S sy
stem
sel
ecte
d an
d fin
anci
ng c
lose
to b
eing
se
cure
d
Com
plet
ed s
ervi
ce li
ne a
naly
ses
on:
Kais
er
OP
Surg
ery
impa
ct, C
ardi
oFit,
Nuc
lear
M
edic
ine,
exp
ansi
on o
f Sub
acut
e,
IGT/
CM
AC C
ontra
ct
Dev
elop
com
mun
ity c
linic
mod
el a
s ph
ysic
ian
recr
uitm
ent v
ehic
le, a
ddin
g 3
new
ph
ysic
ians
plu
s tim
e sh
are
arra
ngem
ents
for
5 sp
ecia
lists
. Al
lianc
e fa
cilit
ates
bet
ter d
ecis
ion
mak
ing
and
eval
uatio
n of
3rd
par
ty p
ayor
con
tract
s (e
.g. A
lam
eda
Allia
nce)
; sys
tem
use
d fo
r FY
2011
Bud
get.
3%
3%
Sim
pli
fy C
ore
B
us
ine
ss
Pro
ce
ss
es
a
nd
Bu
ild
a S
ca
lab
le,
Co
st-
Eff
icie
nt
Infr
as
tru
ctu
re
Es
tabl
ish
mar
ketin
g pr
ogra
m
dire
cted
to B
ay F
arm
re
side
nts
(200
9)
Es
tabl
ish
outre
ach
prog
ram
s ta
rget
ed a
t Asi
an m
arke
t, Sa
n Le
andr
o an
d se
lect
ed
resi
dent
s of
945
01
Mar
ket S
hare
gro
wth
in B
ay F
arm
Are
a by
2%
(201
0): a
ctua
l mar
ket s
hare
of
adm
issi
on fr
om B
ay F
arm
dec
lined
in 2
010;
ov
eral
l Ala
med
a ad
mis
sion
s in
crea
sed.
D
evel
oped
and
impl
emen
ted
a m
ulti-
face
ted
actio
n pl
an to
resp
ond
to th
e 9.
8 (1
4% n
et
reve
nues
) los
s of
Kai
ser r
even
ue.
3%
2%
29
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Reco
mm
enda
tions
for F
Y 20
10 E
xecu
tive
Com
pens
atio
n Pa
y-ou
t M
anag
emen
t Sel
f Ran
king
A
ttac
hmen
t B
Page
6 o
f 7
Op
era
tio
nal S
uc
ce
ss (
co
nti
nu
ed
) W
eig
hti
ng
P
oin
ts
Ma
na
ge
me
nt
Se
lf R
an
kin
g
Go
als
A
cti
on
s
Me
as
ure
s
Re
du
ce
Wa
ste
& D
rive
O
pe
rati
on
al
Eff
icie
nc
y
Faci
lity
Mas
ter P
lan
final
ized
(2
009)
Dev
elop
ed fi
nal a
ppro
ach
to
SB 1
953
com
plia
nce
by
2013
OSH
PD a
ppro
ved
appl
icat
ion
for N
PC
rem
edia
tion
Kitc
hen
desi
gn a
nd S
PC re
med
iatio
n fin
aliz
ed a
nd c
ost p
roje
cted
; pla
n/ap
plic
atio
n w
as s
ubm
itted
Jun
e 20
10
Com
plet
ed b
usin
ess
anal
ysis
and
sec
ured
fin
anci
ng fo
r Dia
gnos
tic Im
agin
g D
epar
tmen
t up
grad
e, in
clud
ing
PAC
S.
Inte
rvie
wed
con
stru
ctio
n m
anag
emen
t firm
s fo
r pro
ject
man
agem
ent o
f rem
edia
tion
wor
k O
rient
ed B
oard
to fi
nanc
ing
optio
ns;
curr
ently
iden
tifyi
ng fi
nanc
ing
alte
rnat
ives
for
seis
mic
.
4%
4%
To
tal O
pera
ting
Volu
me
and
Rev
enue
N
et R
even
ue (J
uly
2009
- Jun
e 30
, 201
0)
mus
t mee
t or e
xcee
d or
igin
al b
udge
t lev
els
(see
atta
ched
cal
cula
tion)
4
%
0%
Mon
thly
Sur
gery
Vol
ume
from
Ala
med
a su
rgeo
ns b
etw
een
April
-Jun
e 20
10 to
ex
ceed
Jun
e 20
09-M
arch
201
0 m
onth
ly
aver
ages
by
10%
(see
atta
ched
cal
cula
tion)
6
%
6%
TO
TA
L
20
%
15
%
30
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Reco
mm
enda
tions
for F
Y 20
10 E
xecu
tive
Com
pens
atio
n Pa
y-ou
t M
anag
emen
t Sel
f Ran
king
A
ttac
hmen
t B
Page
7 o
f 7
Bu
sin
ess
De
velo
pm
en
t /
Lo
ng
-Term
Fin
an
cia
l V
iab
ilit
y
We
igh
tin
g
Po
ints
M
an
ag
em
en
t S
elf
Ra
nk
ing
Go
als
A
cti
on
s
Me
as
ure
s
De
ve
lop
ne
w b
us
ine
ss
a
nd
pro
gra
m
de
ve
lop
me
nt
pro
jec
ts
wh
ich
are
cli
nic
all
y
be
ne
fic
ial a
nd
fi
na
nc
iall
y v
iab
le i
n
ord
er
to w
ork
to
wa
rd
inc
rea
sin
g o
ur
an
nu
l fi
na
nc
ial
pe
rfo
rma
nc
e
to g
en
era
tin
g a
re
sp
on
sib
le m
arg
in,
the
reb
y r
ed
uc
ing
re
lia
nc
e o
n u
se
of
the
p
arc
el
tax
fo
r o
pe
rati
on
al
pu
rpo
ses
a
nd
en
su
rin
g t
he
lo
ng
te
rm v
iab
ilit
y o
f th
e
Ho
sp
ita
l
N
ew M
edic
al S
taff
Prac
tice
Mod
el a
t Ala
med
a To
wne
C
entre
MO
B to
sup
port
phys
icia
n re
crui
tmen
t.
Esta
blis
hed
126(
b) c
linic
; rec
ruite
d 1
OB-
GYN
, 1 G
ener
al S
urge
on, 1
Inte
rnis
t, at
tract
ed m
ultip
le s
peci
alis
ts to
tim
e sh
are
3%
3%
D
evel
op a
ppro
ach
to
prov
ide
acce
ss fo
r Med
ic-
Cal
pat
ient
s on
a fi
nanc
ially
vi
able
bas
is.
Con
clud
ed n
egot
iatio
ns w
ith C
MAC
for
Med
i-Cal
con
tract
incl
udin
g su
pple
men
tary
pa
ymen
t thr
ough
gov
ernm
enta
l tra
nsfe
r 4%
4%
Ev
alua
te n
ew p
rogr
ams
that
w
ill in
crea
se v
olum
e of
re
ferra
ls fr
om b
eyon
d im
med
iate
ser
vice
are
a.
Feas
ibili
ty s
tudi
es fo
r acu
te re
hab,
sub
acut
e ex
pans
ion
and
new
wou
nd c
are
prog
ram
s
3%
3%
TO
TA
L
10
%
10
%
GR
AN
D T
OT
AL
1
00
%
93
%
31
Attachment C
Alameda HospitalFY 2010 Incentive Compensation PlanCalculation of Specific Items:
Tripwire:Changes in net assets per Audited Financial Statements 2,017$
Less: Contributions and Grants for Equipment (194) Plus:
Excess incentive comp accrual included in audited financial statements(accural $175K recommended $154) 21
Adjusted Revenues in Excess of Expenses (173)
Revenues in excess of expenses 1,844
Adjustments:Less: IGT Transfer 2,166 IGT Consultant Fees (43)
(2,123) Plus:Repayment of CMS Overpayments 652
Unbudgeted $1,000 Bonus to Unrepresented Management and Staff 185
Excess of Revenues over expenses 558$
Threshold 358$ Target 543$ 543$
High > $1M
Threshold Achieved
Net Revenue Goal
Net Patient Revenue per audited financial statements 67,779$
Adjustments:Less: IGT Transfer 2,166 IGT Consultant Fees 43
(2,123) Plus:Repayments of CMS Overpayments 652
Calculated Amount 66,308$
Goal 67,659$
Not Met
Surgery Volume Goal
Alameda Physician Surgeries (Post Kaiser) - Apr - Jun 10 # Months # Cases3 533 178
Alameda Physician Surgeries (Pre Kaiser) - Jul 09 - Mar 10 # Months # Cases9 1,422 158
Percentage Change 13%
Goal 10%
Goal Achieved
32
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Page
1 o
f 5
Cit
y o
f A
lam
ed
a H
ea
lth
Ca
re D
istr
ict
FY
2011 E
xecu
tive P
erf
orm
an
ce M
etr
ics
INT
RO
DU
CT
ION
Pa
ymen
t of a
ny in
cent
ive
com
pens
atio
n to
an
exec
utiv
e is
pre
dica
ted
upon
a p
erfo
rman
ce e
valu
atio
n of
"mee
ts e
xpec
tatio
ns" o
r abo
ve.
The
base
per
cent
age
bonu
s (b
ased
on
% b
ase
com
pens
atio
n) fo
r the
Chi
ef E
xecu
tive
Offi
cer i
s es
tabl
ishe
d by
the
Boar
d. T
he in
cent
ive
com
pens
atio
n le
vels
for o
ther
par
ticip
atin
g ex
ecut
ives
are
est
ablis
hed
by th
e C
EO.
The
Chi
ef E
xecu
tive
Offi
cer (
CEO
) is
resp
onsi
ble
for r
ecom
men
ding
add
ition
al e
xecu
tive
parti
cipa
nts
in a
n in
cent
ive
plan
to th
e Bo
ard.
Th
e C
EO is
resp
onsi
ble
for s
truct
urin
g th
e te
rms
of th
eir i
ncen
tive
in a
man
ner c
onsi
sten
t with
the
exec
utiv
e in
cent
ive
com
pens
atio
n sy
stem
. In
FY
2011
the
full
ince
ntiv
e co
mpe
nsat
ion
targ
et fo
r the
CEO
and
oth
er p
artic
ipat
ing
exec
utiv
es w
as b
udge
ted
at th
e "ta
rget
" fin
anci
al le
vel a
nd a
t clo
se to
full
achi
evem
ent o
f the
oth
er th
ree
area
s to
ens
ure
that
the
ince
ntiv
e pa
ymen
ts a
re a
ppro
pria
tely
fund
ed.
Th
e ex
cess
reve
nue
over
exp
ense
will
incl
ude
the
Hos
pita
l, So
uth
Shor
e an
d an
y ne
w b
usin
ess
entit
y or
loca
tion
whi
ch th
e ho
spita
l may
op
erat
e un
der i
ts li
cens
e, o
nly
and
excl
ude
CW
&S a
nd th
e 50
1(c)
3 co
rpor
atio
n. F
or p
urpo
ses
of c
larif
ying
exa
ct ti
me
fram
es a
ssoc
iate
d w
ith m
etric
s, F
Y 20
11 is
the
perio
d be
twee
n Ju
ly 1
, 201
0 an
d Ju
ne 3
0, 2
011.
The
prop
ortio
n of
pay
-out
of t
he b
onus
is b
ased
on
the
achi
evem
ent o
f the
met
rics
outli
ned
belo
w in
the
follo
win
g ar
eas:
FY
201
1 FY
201
0
W
eigh
ting
Wei
ghtin
g*
Fi
nanc
ial S
ucce
ss
40%
50
%
G
row
th
25%
10
%
Q
ualit
y / S
atis
fact
ion
5%
10%
Ph
ysic
ians
10
%
(not
sep
arat
e ca
tego
ry)
O
pera
tiona
l Suc
cess
15
%
20%
W
orkf
orce
Suc
cess
5%
10
%
To
tal
100%
10
0%
*F
or R
efer
ence
: The
pro
porti
on o
f pay
-out
for F
Y 20
10 is
als
o lis
ted.
33
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Page
2 o
f 5
FIN
AN
CIA
L S
UC
CE
SS
W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
40
Ac
hie
ve
ou
r F
Y1
1 F
ina
nc
ial
Ta
rge
ts &
Go
als
Tr
ipw
ire: E
xces
s R
even
ue o
ver
Expe
nse.
Mus
t mee
t thr
esho
ld o
r no
ince
ntiv
e co
mpe
nsat
ion
paid
Thre
shol
d Ta
rget
H
igh
37
$490
,853
(F
Y 20
11 B
udge
t) $7
50,0
00
$1.8
mill
ion
Op
tim
ize
3rd
Pa
rty R
efe
rra
l R
ela
tio
ns
hip
s a
nd
Co
ntr
ac
ts
3
GR
OW
TH
W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
25
Re
pla
ce
po
rtio
n o
f s
urg
ical
vo
lum
e l
os
s d
ue
to
e
xp
ira
tio
n o
f K
ais
er
co
ntr
ac
t
Bloc
k sc
hedu
ling
Phys
icia
n R
ecru
itmen
t 10
% in
crea
se in
“Ala
med
a” m
ajor
sur
gery
( no
n-ey
e / G
I) ov
er a
vera
ge o
f Jul
y 20
09-M
arch
201
0 le
vels
(pre
-Kai
ser)
3
20%
in m
inor
pro
cedu
res
1
Es
tab
lis
h C
om
pre
he
ns
ive
W
ou
nd
Ca
re C
en
ter
Iden
tify
phys
icia
n pa
nel
Ope
n pr
ogra
m
Com
plia
nce
with
ram
p-up
pro
form
a vo
lum
e pr
ojec
tions
. 4
Inc
rea
se
In
-pa
tie
nt
Ce
ns
us
At
tract
add
ition
al M
edi-C
al p
atie
nts
thro
ugh
outre
ach
to c
omm
unity
cl
inic
s Fo
rge
rela
tions
hips
with
Ala
med
a Al
lianc
e
50%
incr
ease
in in
patie
nt M
edi-C
al v
olum
e 2
Targ
et: I
ncre
ase
ADC
by
5 ac
ute
patie
nts
by fi
scal
ye
ar e
nd.
4
Inc
rea
se
ou
tpati
en
t a
nc
illa
ry
vo
lum
e
Mar
ket D
iagn
ostic
Imag
ing
capa
bilit
ies
12%
incr
ease
in Im
agin
g vo
lum
e ov
er F
Y 20
10
leve
ls
1
34
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Page
3 o
f 5
GR
OW
TH
(co
nti
nu
ed
) W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
E
va
lua
te a
t le
as
t 2 n
ew
p
rog
ram
s o
r s
erv
ice
s f
or
fea
sib
ilit
y
Form
ulat
e st
rate
gy fo
r Lon
g Te
rm C
are
Serv
ice
Line
Dev
elop
men
t D
eter
min
e be
st m
echa
nism
for s
ubac
ute
expa
nsio
n Ev
alua
te o
rtho
serv
ice
line
deve
lopm
ent
Iden
tific
atio
n of
sou
rce
to g
ener
ate
at le
ast
$1 m
illio
n in
add
ition
al n
et re
venu
e
6
Se
ek
Str
ate
gic
Pa
rtn
er
Org
an
iza
tio
n
Mee
tings
and
pre
sent
atio
n to
at l
east
2
targ
et o
rgan
izat
ions
as
iden
tifie
d at
Jul
y 23
, 201
0 Sp
ecia
l Boa
rd M
eetin
g
Boar
d de
velo
pmen
t of m
ore
defin
ed
stra
tegy
on
deve
lopm
ent o
f stra
tegi
c pa
rtner
ship
4
Qu
ality
/ S
ati
sfa
cti
on
Su
cc
es
s
We
igh
tin
g
Po
ints
Go
als
A
cti
on
s
Me
as
ure
s
5
Imp
rove
Co
re M
ea
su
re s
co
res
in
all
In
dic
ato
rs
Con
tinue
to tr
ack
core
mea
sure
s
Educ
ate
Med
ical
Sta
ff an
d N
ursi
ng S
taff
on c
ompl
ianc
e an
d im
porta
nce
of s
core
s
Each
indi
cato
r at 9
0% o
r gre
ater
3
Re
du
ce
ra
te o
f i
nc
ide
nc
e f
or
Fa
lls
an
d H
os
pit
al
Ac
qu
ire
d
Pre
ss
ure
Ulc
ers
(H
AP
U)
Con
tinue
per
form
ance
impr
ovem
ent
plan
s fo
r fal
l red
uctio
ns a
nd s
kin
care
pr
otoc
ols.
Sc
ore
in
HA
PU
an
d F
all
s t
o b
e b
ett
er
tha
t th
e C
alN
oc
“li
ke
ho
sp
ital”
me
an
HAP
U 2
009
Mea
n =
2.01
Alam
eda
Hos
pita
l to
be c
onsi
sten
tly b
elow
2.
0 fo
r FY
2011
1
Falls
200
9 M
ean
= 3.
21
Alam
eda
Hos
pita
l to
be c
onsi
sten
tly b
elow
2.
5 fo
r FY
2011
. Sh
ould
con
tinue
PI f
ocus
on
redu
cing
rate
of f
alls
resu
lting
in in
jury
.
1
35
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Page
4 o
f 5
Ph
ys
icia
ns
We
igh
tin
g
Po
ints
Go
als
A
cti
on
s
Me
as
ure
s
10
Pre
pa
re O
rga
niz
ati
on
to
p
art
icip
ate
in
an
Ac
co
un
tab
le
Ca
re O
rga
niz
ati
on
in
a
nti
cip
ati
on
of
He
alt
h C
are
R
efo
rm
Con
tinue
to s
tream
line
proc
esse
s to
sup
port
effic
ient
cas
e an
d ut
iliza
tion
man
agem
ent
Sust
ain
orie
ntat
ion
and
prep
arat
ion
for
valu
e ba
sed
paym
ent s
yste
m to
be
impl
emen
ted
unde
r hea
lth c
are
refo
rm.
2
Wor
k w
ith m
edic
al c
omm
unity
to e
valu
ate
optio
nal r
elat
ions
hips
with
phy
sici
an
orga
niza
tions
Opt
ions
for p
refe
rred
phys
icia
n or
gani
zatio
nal s
truct
ure
disc
usse
d in
de
pth
Co
mp
lete
pre
pa
rati
on
of
ph
ys
icia
n o
rde
r e
ntr
y i
n F
Y
20
12
Com
plet
e or
ient
atio
n of
Med
ical
Sta
ff to
pa
tient
car
e sy
stem
(PC
S)
Orie
ntat
ion
com
plet
ed b
y Ju
ne 2
011
2
Co
nti
nu
ed
re
cru
itm
en
t o
f n
ew
p
hys
icia
ns
in
pri
ma
ry c
are
an
d
se
lec
ted
sp
ec
ialt
ies
Mar
ket p
ract
ices
est
ablis
hed
in 1
206(
b)
com
mun
ity c
linic
Prim
ary
care
OB-
GYN
Gen
eral
Sur
gery
25%
incr
ease
in 1
206
(b) c
omm
unity
cl
inic
vis
its d
urin
g FY
201
1 ov
er F
Y 20
10.
6
Op
era
tio
nal S
uc
ce
ss
W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
15
Co
nc
lud
e s
eis
mic
re
tro
fit
pro
jec
t th
rou
gh
eit
he
r:
Secu
ring
finan
cing
and
com
plet
ing
cont
ract
or
sele
ctio
n an
d in
itiat
ing
proj
ect (
pend
ing
OSH
PD’s
revi
ew a
nd is
suan
ce o
f per
mit)
or
Id
entif
ying
that
fina
ncin
g at
this
tim
e is
not
fe
asib
le a
nd s
eeki
ng e
xten
sion
on
2013
se
ism
ic s
tand
ards
Secu
re fi
nanc
ing
or e
xten
sion
for
seis
mic
retro
fit
7
36
Oct
ober
11,
201
0 D
istr
ict B
oard
Mee
ting
Page
5 o
f 5
Op
era
tio
nal S
uc
ce
ss (
co
nti
nu
ed
) W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
10
Co
nti
nu
e t
o a
dva
nc
e IT
p
lan
nin
g t
o p
rep
are
fo
r “m
ea
nin
gfu
l u
se
” s
tatu
s b
y
20
13
Com
plet
e al
l pla
nnin
g, d
esig
n an
d tra
inin
g fo
r Pat
ient
Car
e Sy
stem
(PC
S)
phas
e
PCS
phas
e ‘g
o liv
e’ b
y th
e en
d of
Jun
e 20
11
6
Imp
lem
en
t P
AC
S a
nd
Im
ag
ing
U
pg
rad
e
Com
plet
e PA
CS
and
imag
ing
upgr
ade
inst
alla
tion
“Go
Live
” by
Mar
ch 2
011
2
Wo
rkfo
rce
Su
cce
ss
W
eig
hti
ng
P
oin
ts
Go
als
A
cti
on
s
Me
as
ure
s
3
Inc
rea
se
em
plo
ye
e s
ati
sfa
cti
on
le
ve
ls r
eg
ard
ing
tra
inin
g /
d
eve
lop
me
nt
op
po
rtu
nit
ies
2nd E
mpl
oyee
Sat
isfa
ctio
n Su
rvey
C
ontin
ue in
crea
ses
deve
lopm
ent
oppo
rtuni
ties
Incr
ease
in tr
aini
ng s
atis
fact
ion
scor
e ov
er
last
sur
vey
of 6
2.4%
by
10%
2
En
ha
nc
e c
om
pli
an
ce
wit
h
ho
sp
ita
l c
us
tom
er
se
rvic
e
po
lic
y t
ha
t d
ire
cts
sta
ff t
o
sp
ea
k E
ng
lis
h i
n a
ll p
ati
en
t c
are
are
as
, ro
om
, h
all
wa
ys
a
dja
ce
nt
to p
ati
en
t ro
om
s,
an
d
oth
er
are
as
wh
ere
pa
tie
nts
are
p
res
en
t.
Reo
rient
atio
n to
impo
rtanc
e of
Eng
lish
only
bei
ng s
poke
n in
pat
ient
car
e ar
eas
Red
uctio
n in
neg
ativ
e co
mm
ents
from
pa
tient
s an
d vi
sito
rs o
n th
is p
robl
em
1
37