| FORM 990, PART III, LINE 3 |
JOHN MUIR HEALTH'S RESPONSE TO COVID-19 INCLUDED IMMEDIATE ACTIONS TO MAINTAIN CONTINUITY OF ESSENTIAL OPERATIONS, WHILE ALSO TAKING STEPS TO SUPPORT THE HEALTH AND SAFETY OF PATIENTS, EMPLOYEES, AND THE COMMUNITIES THAT IT SERVES. TO ENSURE CONTINUED ADEQUATE SAFETY MEASURES THROUGH OUT THE PANDEMIC, ADHERE TO SOCIAL DISTANCING RECOMMENDATIONS, AND MEET THE PATIENTS AND COMMUNITY NEEDS, JOHN MUIR HEALTH: - EXTENDED THE USE OF TELEHEALTH APPOINTMENTS VIA VIDEO AND PHONE; - CANCELED OR POSTPONED ALL NON-EMERGENT PROCEDURES; - MINIMIZED OR TEMPORARILY CLOSED SERVICES AT PHYSICIANS' OFFICES TO ALLOW FOR PRESERVATION OF PERSONAL PROTECTIVE EQUIPMENT TO LIMIT EXPOSURE TO COVID-19 FOR PATIENTS AND EMPLOYEES; - INVESTED IN ADDITIONAL EQUIPMENT AND SUPPLIES, EXPANDED TESTING RESOURCES, AND CREATED ADDITIONAL CAPACITY TO CARE FOR COVID-19 PATIENTS; - DEPLOYED COVID-19 SPECIFIC SAFETY MEASURES REQUIRED BY THE PUBLIC HEALTH DEPARTMENT TO KEEP PATIENTS AND EMPLOYEES SAFE; -TRANSITIONED MANY NON-CLINICAL OFFICE BASED STAFF TO A TEMPORARY REMOTE WORK ENVIRONMENT. |
| FORM 990, PART III, LINE 4D, PROGRAM SERVICE ACCOMPLISHMENTS: |
OTHER SERVICES OFFERED AT JOHN MUIR HEALTH (JMH) ARE: REHABILITATION SERVICES BOTH INPATIENT AND OUTPATIENT, IN 2021 CONTINUED TO SUPPORT THE HEALTH SYSTEM IN DELIVERING HIGH QUALITY THERAPY REHABILITATION CARE AS PART OF THE EFFORT TO FIGHT THE COVID-19 PANDEMIC. JOHN MUIR HEALTH'S REHABILITATION DEPARTMENT SUCCESSFULLY NAVIGATED THE PUBLIC HEALTH EMERGENCY COVID WAIVERS, WE THE DEPARTMENT WERE ABLE TO MANAGE ONGOING REHAB SERVICES WHILE ALSO SUPPORTING THE MEDICAL-SURGICAL NEEDS OF THE ACUTE INPATIENT HOSPITAL, ESPECIALLY DURING CENSUS SURGE WITHIN THE ACUTE CARE SETTING. THE OUTPATIENT DIVISION, BY QUARTER 4, SAW A NEAR FULL RESUMPTION OF SERVICES AND VOLUMES COMMENSURATE TO PRE-PANDEMIC STATUS. THE NEW TICE VALLEY ROSSMOOR OUTPATIENT CLINIC PARTICIPATE IN THE FALL PREVENTION AWARENESS EVENT FOR THE ROSSMOOR COMMUNITY. JOHN MUIR HEALTH'S INPATIENT REHABILITATION UNIT ADMITTED 479 PATIENTS IN 2021, WITH STROKE REPRESENTING THE HIGHEST ADMITTING DIAGNOSIS AT 40.6%, WITH 88.2% DISCHARGING TO HOME; FOLLOWED BY NON TRAUMATIC SPINAL CORD INJURY AT 14.8%, NON TRAUMATIC BRAIN INJURY AT 10.6%. THE AVERAGE LENGTH OF STAY IN 2021 WAS 13.5 DAYS. TOTAL REHAB POPULATION IN 2021 DISPOSITION AT DISCHARGE TO COMMUNITY WAS AT 85.4%. WE CONTINUE TO EXCEED REGIONAL AND NATIONAL OUTCOMES FOR MEDICARE QUALITY INDICATOR MEASURES AS PUBLISHED ON THE MEDICARE CARE COMPARE WEBSITE: INPATIENT REHABILITATION FACILITY PATIENT ASSESSMENT INSTRUMENT (IRF-PAI) DATA COMPLETENESS; DISCHARGE IN MOBILITY; SKIN INTEGRITY-PRESSURE ULCER/INJURY; AND FALLS. QUALITY MEASURES FOR SELF-CARE AND PATIENT MOBILITY SCORES ARE ALSO AREAS WHERE JMH'S REHAB IRF EXCELLED IN. INPATIENT ACUTE REHABILITATION ALSO UNDERWENT MEDICARE REVIEW AUDITS IN 2021 BY TWO DIFFERENT REVIEWER SUBCONTRACTORS. REHABILITATION SUCCESSFULLY PASSED BOTH AUDITS WITH ZERO FINDINGS. DEVELOPMENT OF CANCER NETWORK IN PARTNERSHIP WITH UCSF - JANUARY 21, 2021, DIABLO VALLEY ONCOLOGY, PACIFIC UROLOGY AND WEST COAST SURGICAL ASSOCIATES CAME INTO AGREEMENT TO JOIN JOHN MUIR HEALTH. THIS IS A SIGNIFICANT STEP FORWARD TOWARD REALIZING OUR CANCER NETWORK VISION WITH UCSF HEALTH TO CONQUER CANCER BY IMPROVING PREVENTION, DIAGNOSIS, TREATMENT, AND CARE COORDINATION FOR PATIENTS CLOSE TO HOME. - THE ADDITION OF THESE OUTSTANDING PROVIDER GROUPS WILL CONTINUE THE GROWTH, CAPABILITIES, AND EXCELLENCE OF JOHN MUIR HEALTH'S MEDICAL ONCOLOGY, RADIATION ONCOLOGY, HEMATOLOGY, UROLOGY AND GENERAL AND SPECIALIZED SURGICAL SERVICES. THEY WILL BE INSTRUMENTAL IN THE DEVELOPMENT OF THE UCSF-JOHN MUIR HEALTH CANCER NETWORK, WHICH INCLUDES THE BERKELEY OUTPATIENT CENTER AND THE BUILDING OF A NEW CANCER CENTER ON OUR WALNUT CREEK MEDICAL CENTER CAMPUS. DIABLO VALLEY ONCOLOGY, PACIFIC UROLOGY AND WEST COAST SURGICAL ASSOCIATES HAVE LONG-STANDING AND DEEP COMMITMENTS TO THEIR PATIENTS, JOHN MUIR HEALTH AND THE COMMUNITIES WE SERVE. CANCER CENTER DESIGN/DEVELOPMENT ON WALNUT CREEK CAMPUS IS IN PROGRESS WITH BUILDING SCHEDULED FOR COMPLETION IN FEBRUARY 2024. QUALITY/COMMUNICATION/ACCESS/RESEARCH/EDUCATION (QCARE) LAUNCH PLANS DECEMBER - QCARE STEERING CHARTERED AND MEMBERS CONFIRMED. - WORKGROUP STRUCTURE AND COMPOSITION DRAFTED. - JMH & UCSF WORKGROUP LEADERS MEETING TO DISCUSS HIGH LEVEL PLANS FOR IMPLEMENTATION. ALREADY BEGUN: - PHASE 1 CO-BRANDING DISCUSSIONS FOR MEDICAL ONCOLOGY AND INFUSION CLINICS. - UCSF HEMATOLOGY AND ONCOLOGY CONFERENCE INVITES FOR JOHN MUIR HEALTH CANCER MEDICAL GROUP. ONCOLOGY AND SPECIALTY SERVICES THORACIC PROGRAM - JOHN MUIR HEALTH'S THORACIC PROGRAM WILL BE 1 OF 2 CENTERS IN THE COUNTRY AND THE ONLY ONE IN THE WESTERN US TO BE ASKED TO PARTICIPATE IN JOHNSON AND JOHNSON'S LUNG CANCER INITIATIVE'S CLEAR STUDY. - THORACIC STUDIES OPEN AND ENROLLING FOR BOTH TREATMENT TRIALS AND BIOMARKER STUDIES. - PENDING 2 NEW LUNG CANCER STUDIES. - CESSATION AND SCREENING TO SAVE LIVES (CASTL) SMOKING CESSATION STUDY DONE IN CONJUNCTION WITH MEMORIAL SLOAN KETTERING FOR CURRENT SMOKER IN THE LUNG CANCER SCREENING PROGRAM HAS NOW CLOSED TO ACCRUAL. NEW TECHNOLOGY - AQUYRE BIOSCIENCES CELTIVITY PURCHASED AND FIRST CASE DONE IN 10/2021 ALLOWING FOR BIOPSY RESULTS TO BE AVAILABLE WITHIN 2 MINUTES. MARKETING /SOCIAL MEDIA ACTIVITY - KTVU INTERVIEW LUNG CANCER AWARENESS MONTH 11/10/2021. - BBC INTERVIEW 5/2021. - SOCIAL MEDIA POSTING FOREGUT CENTER OF EXCELLENCE - 5/2021. - SOCIAL MEDIA POSTING ESOPHAGEAL CANCER AWARENESS MONTH 4/2021. - JOHNSON & JOHNSON MONARCH COMMERCIAL FEATURING DR. TSAI. - CELEBRATION ON 5/5/2021 TO ACKNOWLEDGE DR. TSAI'S 1000 ROBOTIC SURGERIES. PHYSICIAN EDUCATION - A CLOSER LOOK ROBOTIC-ASSISTED BRONCHOSCOPY" WEBINAR ON 4/29/2021. - STAGING, AND TREATMENT OF LUNG CANCER AT JOHN MUIR HEALTH." WEBINAR ON 11/19/2021. PULMONARY PROGRAM (PNP) - 536 EXAMS WERE ADDED FOR 422 PATIENTS. LUNG CANCER SCREENING PROGRAM - 593 ANNUAL LUNG CANCER SCREENING EXAMS. - 50 INTERIM EXAMS COMPLETED FOR A 3 OR 6 MONTH FOLLOW UP. - 7 PATIENTS SENT FOR A BIOPSY. - 6 PATIENTS DIAGNOSED. ROBOTIC ASSISTED BRONCHOSCOPY (MONARCH) - 43 ROBOTIC NAVIGATIONAL BRONCHOSCOPY CASES USING THE MONARCH SYSTEM IN 2021. WITH AN AVERAGE OF 3 HOURS. - ADDITIONAL PHYSICIANS TRAINED AND RECEIVED PRIVILEGES, 3 PULMONOLOGISTS. - FOREGUT CENTER OF EXCELLENCE - MENTORING SITE 15 PHYSICIANS ATTENDED. APHERESIS PROGRAM - 2021 TOTAL: 151 APHERESIS TREATMENTS FOR BOTH WCMC AND CMC. - PHYSICIAN EDUCATION, DECEMBER 9, 2021, BY DR. JAN HOFMANN ON FH, ELEVATED LP(A), FSGS, AND THE EFFICACY OF LIPOPROTEIN APHERESIS: 2019 ASFA APHERESIS GUIDELINES AND UNMET NEED. LIPID APHERESIS IS USED TO TREAT PATIENTS WITH SEVERE HYPERLIPIDEMIA IN CASES WHERE STANDARD MEDICATION DOES NOT WORK. THESE PATIENTS ARE AT HIGH RISK OF CARDIAC EVENT. CLINICAL RESEARCH ONCOLOGY - CLINICAL TRIAL PORTFOLIO EXPANSION: ACCRUAL OF 8% ANALYTIC CASES 2021 (INTEGRATED NETWORK CANCER PROGRAM STANDARD > 6% ACCRUAL). GENETIC COUNSELING PROGRAM - GENETIC COUNSELING, PATIENTS SEEN 2035, OTHER ENCOUNTERS 193. BREAST HEALTH SERVICES PROGRAM / NURSE PRACTITIONER AND NURSE NAVIGATION - NURSE NAVIGATOR /PRACTITIONER SERVICES: 3,345 ENCOUNTERS. - PATIENT EDUCATION & SUPPORT FROM SCREENING, DIAGNOSIS, THROUGH SURVIVORSHIP. - ASSIST PATIENTS DURING VISITS TO MEDICAL IMAGING, HOSPITALS, AND/OR BREAST HEALTH CENTERS. - FACILITATE THE COORDINATION OF DIAGNOSIS & TREATMENT. - COORDINATE WEEKLY PRETREATMENT PLANNING CONFERENCES & BREAST TUMOR BOARDS. - COUNSEL ON MEDICATIONS & SIDE EFFECT MANAGEMENT. - ASSIST PATIENTS WITH ACCESS OR INFORMATION TO THE FOLLOWING PROGRAMS: - GENETIC COUNSELING/TESTING & CANCER RISK ASSESSMENT. - HIGH-RISK CANCER PROGRAM. - CLINICAL TRIALS. - PHYSICAL THERAPY & LYMPHEDEMA PROGRAM. INTENTIONAL CHARITY CARE/ UNDERSERVED SCREENING/TREATMENT PROGRAM EXPANSION: INPATIENT/OUTPATIENT SPECIALTY CARE: UNINSURED / UNDERSERVED INDIVIDUALS REFERRED - PATIENT CENTRIC SERVICES: BREAST NURSE NAVIGATION=1,640. HIGH RISK CANCER PROGRAM CONSULTS=304. - INTENTIONAL CHARITY CARE / UNDERSERVED CANCER SCREENING PROGRAM EXPANSION: INPATIENT/OUTPATIENT SPECIALTY CARE: UNINSURED / UNDERSERVED INDIVIDUALS REFERRED FROM LA CLINICA RECEIVE ALL DIAGNOSTIC AND TREATMENT AT JMH. STARTED NOV 2011. 295 REFERRALS; 763 VISITS; NURSE NAVIGATION PROVIDED. - "EVERY WOMAN COUNTS" (BREAST AND CERVICAL CANCER SCREENING FOR UNINSURED/UNDERSERVED POPULATIONS) PROGRAM: 260 VISITS; NURSE NAVIGATION PROVIDED. SURVIVORSHIP PROGRAM SERVICES SURVIVORSHIP CARE PLANS - 334 CARE PLANS PROVIDED TO PATIENTS, WITH MAJORITY GIVEN IN RADIATION ONCOLOGY. REHAB SERVICES - 332 TOTAL PATIENT VISITS. OVER HALF VISITS ARE FOR BREAST CANCER POPULATION. - SERVICES INCLUDE LYMPHEDEMA, OT, PT, PELVIC FLOOR PROGRAM, AND SPEECH THERAPY. SURVIVORSHIP SUPPORT GROUPS AND WORKSHOPS - 110 JMH SURVIVORSHIP ATTENDEES SUPPORT GROUPS WITH EATING FOR HEALING, EATING THE MEDITERRANEAN WAY, AND YOGA AS THE MOST ATTENDED. (THESE THREE VITAL PROGRAMS ARE AVAILABLE THROUGH OUR PARTNERSHIP WITH THE CANCER SUPPORT COMMUNITY.) |
| CONTINUED... |
PSYCHOSOCIAL DISTRESS SCREENING CONTINUED INVOLVEMENT WITH JMH PRIMARY CARE RESIDENCY PROGRAM: - JOHN MUIR HEALTH SELECTED THE NCCN DISTRESS THERMOMETER AS OUR VALIDATED TOOL FOR SCREENING ONCOLOGY PATIENTS, WITH A SCORE OF 4 OR GREATER ACTIVATING REFERRAL TO APPROPRIATE RESOURCES. THE NCCN DISTRESS THERMOMETER AND THE LEVEL OF 4 IDENTIFYING DISTRESS WERE VOTED ON AND APPROVED AT OUR JANUARY 2020 COMMISSION ON CANCER MEETING. - JMH IS NOW SCREENING PATIENTS IN INPATIENT ONCOLOGY AND SURGICAL ONCOLOGY, DIAGNOSTIC IMAGING FOR BREAST PATIENTS, AND IN OUR RADIATION ONCOLOGY DEPARTMENTS ON BOTH CAMPUSES. - WE HAVE REPORTS AVAILABLE THROUGH EPIC-EMR NOW. - IN ADDITION TO OUR JMH ONSITE RESOURCES, PATIENTS ARE REFERRED TO OUR COMMUNITY PARTNERS: THE CANCER SUPPORT COMMUNITY, AND THE AMERICAN CANCER SOCIETY, AS WELL AS ADDITIONAL WEB-BASED TUMOR SITE ORGANIZATIONS AND RESOURCES. TOTAL NUMBER OF PATIENTS SCREENED: 1669 TOTAL NUMBER OF PATIENT SCREENED OVER A SCORE OF 4: 672 NUMBER OF PATIENTS REFERRED AND TYPES OF REFERRAL: 647 -REFERRAL TO REGISTERED NURSE 609 -REFERRAL TO SOCIAL WORKER 200 -REFERRAL TO DIETICIAN 126 -REFERRAL TO CHAPLAIN 12 -REFERRAL TO PHYSICAL THERAPY 30 -REFERRAL TO SPEECH THERAPY 4 -REFERRAL TO OCCUPATIONAL THERAPY 13 -REFERRAL TO OTHER 2 CASE MANAGEMENT AND PALLIATIVE CARE DIGESTIVE HEALTH SERVICES 2021 ACCOMPLISHMENTS: I. ONBOARDED HEPATOBILIARY AND PANCREATIC (HPB) SURGEON JOHN MUIR HEALTH TOOK A SIGNIFICANT STEP FORWARD IN THE GROWTH AND EXPANSION OF OUR ONCOLOGY AND DIGESTIVE HEALTH SERVICE LINES WITH THE ADDITION OF AN ON-SITE HEPATOBILIARY AND PANCREATIC (HPB) SURGICAL SPECIALIST. ON JUNE 21, 2021, CARLOS CORVERA, MD, CHIEF OF HEPATOBILIARY AND PANCREATIC SURGERY AT UCSF BEGAN PROVIDING HEPATOBILIARY SERVICES AT JOHN MUIR HEALTH. HE ALSO SERVES AS MEDICAL DIRECTOR FOR THE HEPATIC PANCREATIC BILIARY PROGRAM. II. CONTINUED GROWTH GASTROENTEROLOGY / ENDOSCOPY 9 JMHSMG GASTROENTEROLOGISTS AND 3 NURSE PRACTITIONERS SUPPORT THE CONTINUED GROWTH OF GASTROENTEROLOGY AND ENDOSCOPY SERVICES UNDER LEADERSHIP AND GUIDANCE OF DREW SCHEMBRE, MD, MEDICAL DIRECTOR DIGESTIVE HEALTH SERVICES. JMHSMG DIGESTIVE HEALTH SERVICES ARE OFFERED IN BRENTWOOD, BERKELEY, AND SAN RAMON. ENDOSCOPIC PROCEDURES ARE OFFERED AT JMMC WALNUT CREEK, JMMC CONCORD, ASPEN SURGERY CENTER, TRESANTI ASC AND EAST BAY ENDOSCOPY CENTER (BERKELEY). III. CONTINUED GROWTH OF HOSPITAL ENDOSCOPY VOLUME A. JMMC-WALNUT CREEK ENDOSCOPY 1. FACILITATED BY GI HOSPITALIST PROGRAM INTRODUCED IN 2016, JMHSMG PHYSICIANS PROVIDED 79% ALL ENDOSCOPIC PROCEDURES PERFORMED IN THE JMMC-WC ENDOSCOPY UNIT. 2. MUCH OF THE 2021 OUTPATIENT JMMC-WC ENDOSCOPY GROWTH RESULTED FROM PATIENT AND REFERRING PROVIDER RECOGNITION OF JMH AS THE REFERRAL DESTINATION OF CHOICE FOR THERAPEUTIC AND ADVANCED GI AND ENDOSCOPY SERVICES IN THE EAST BAY. 3. BETWEEN 2019 AND 2021, THERAPEUTIC ENDOSCOPIC PROCEDURES ERCP (ENDOSCOPIC RETROGRADE CHOLANGIO PANCREATOGRAPHY) AND EUS (ENDOSCOPIC ULTRASOUND) GREW FROM 23% TO 29% OF TOTAL PROCEDURES AT JMMC-WC. THIS CONTINUED GROWTH OF THERAPEUTIC ENDOSCOPY PROCEDURES FURTHER SUPPORTED THE ADDITION OF AN ON-SITE HEPATOBILIARY PANCREATIC (HBP) SURGICAL SPECIALIST IN 2021, AS WELL AS THE CONSTRUCTION OF THE THIRD INTERVENTIONAL ENDOSCOPY PROCEDURE ROOM, SLATED FOR OPENING IN 2024. EAST BAY PATIENTS NO LONGER HAVE TO CROSS A BRIDGE TO HAVE THESE, AND OTHER INTERVENTIONAL ENDOSCOPIC PROCEDURES USED TO DIAGNOSE AND TREAT DISEASES THAT ARE TYPICALLY BEYOND THE SCOPE OF REGULAR ENDOSCOPIC TECHNIQUES. BY COMBINING ADVANCED IMAGING AND DEVICE TECHNOLOGY WITH TECHNICAL EXPERTISE, PATIENTS CAN AVOID MORE INVASIVE TRADITIONAL TREATMENT APPROACHES SUCH AS SURGERY. B. JMMC-CONCORD ENDOSCOPY 1. POST PANDEMIC PRIMARY ENDOSCOPIC PROCEDURE VOLUME CONTINUED AN UPWARD TRAJECTORY IN 2021. 2. VOLUME GREW 20% BETWEEN 2020 AND 2021 FOSTERED BY JMHSMG PROVIDING 50% GI HOSPITALIST COVERAGE WHICH BEGAN IN 2020. JMHSMG PHYSICIANS PROVIDED 46% ALL PRIMARY ENDOSCOPIC PROCEDURES. C. CROSS-CAMPUS ENDOSCOPY SKILLS FAIR, AUGUST 27, 2021 IN BALL AUDITORIUM 22 ENDOSCOPY STAFF MEMBERS FROM BOTH CAMPUSES ROTATED THROUGH 15 HANDS-ON STATIONS TO DEMONSTRATE COMPETENCIES IN DEVICE AND INSTRUMENT HANDLING AND KNOWLEDGE OF NURSING POLICIES AND PROCEDURES. TO MAINTAIN ITS POSITION AS A REGIONAL REFERRAL ENDOSCOPY CENTER, THERE IS A NEED TO CONSTANTLY UPDATE PRACTICE AND KNOWLEDGE TO ENSURE THAT PATIENTS RECEIVE THE HIGHEST STANDARD OF CARE. ADDITIONALLY, AS OUR ENDOSCOPY UNITS STRIVE TO REDUCE COSTS, IT IS IMPORTANT THAT ENDOSCOPY NURSES DEMONSTRATE COMPETENCE DEVICES NOW STANDARDIZED TO BOTH CAMPUSES. IV. OPEN ACCESS COLONOSCOPY PROGRAM OPEN ACCESS ALLOWS PATIENTS WHO MEET CERTAIN CRITERIA TO SCHEDULE A SCREENING COLONOSCOPY WITHOUT THE NEED FOR A FULL IN-PERSON GASTROINTESTINAL CONSULTATION. OPEN ACCESS IS APPROPRIATE FOR HEALTHY PATIENTS WHO HAVE NO SERIOUS MEDICAL CONDITIONS. V. MARCH IS NATIONAL COLORECTAL CANCER AWARENESS MONTH ACTIVITIES A. 3/29/2021: AS PART OF PHYSICIAN OUTREACH EFFORTS, 42 ATTENDEES INCLUDING 33 PROVIDERS ATTENDED JMHSMG SHIREEN GHORBANI, MD ZOOM VIDEO LUNCH AND LEARN PRESENTATION: "A CLOSER LOOK COLORECTAL CANCER SCREENING." B. FACEBOOK TESTIMONIALS FROM 2 JMH POST COLORECTAL CANCER SURGERY PATIENTS GARNERED A 21% ENGAGEMENT SCORE, MEANING 21% OF PEOPLE WHO SAW THE POST, REACTED BY "SHARING," "LIKING, OR COMMENTING ON THE STORY. TYPICALLY, OUR POSTS HAVE A 4% ENGAGEMENT. C. OUTREACH EFFORTS INCLUDED CRC INFOGRAPHIC AS PART OF TARGETED OUTREACH CAMPAIGN. VI. PHYSICIAN OUTREACH AND EDUCATION: JMH GI ONCOLOGY AUTUMN ZOOM AUTUMN LUNCH AND LEARN ONE HOUR EACH CME SERIES DEVELOPED BY DRS. SAM OOMMEN AND PIYUSH AGGARWAL. TARGET AUDIENCE: JOHN MUIR PHYSICIANS AND OTHER INTERESTED ALLIED HEALTH CARE PROFESSIONS OF JOHN MUIR HEALTH. AS THE JM GI ONCOLOGY PROGRAM GROWS, IT IS IMPORTANT TO EDUCATE CLINICIANS ON LATEST ADVANCES IN SURGICAL AND NOON-SURGICAL TREATMENT OF COLORECTAL AND OTHER GI CANCERS. A. SEPTEMBER 9, 2021: "UPDATES IN THE MANAGEMENT OF GI AND PANCREAS NEUROENDOCRINE NEOPLASMS (GEPNENS)," EMILY BERGSLAND, MD, DIRECTOR FOR NEUROENDOCRINE TUMORS, UCSF B. SEPTEMBER 23, 2021: "UPDATE: SURGICAL MANAGEMENT OF METASTATIC COLON CANCER TO THE LIVER," CARLOS CORVERA, MD, CHIEF OF HEPATOBILIARY AND PANCREAS SURGERY, UCSF DIRECTOR, JOHN MUIR HEALTH MEDICAL DIRECTOR HEPATOBILIARY SERVICES. C. OCTOBER 14, 2021: "NON-OPERATIVE MANAGEMENT OF RECTAL CANCER THE MEMORIAL SLOAN KETTERING CANCER CENTER (MSKCC) EXPERIENCE," J. JOSHUA SMITH, MD, PHD, FACS, SURGICAL ONCOLOGIST, MSKCC. VII. BARIATRIC SERVICES ON MAY 27, 2021, THE JOHN MUIR METABOLIC AND BARIATRIC SURGERY CENTER, HOUSED ON JMCC CAMPUS, WAS SUCCESSFULLY SURVEYED FOR ACCREDITATION BY THE AMERICAN COLLEGE OF SURGEONS METABOLIC AND BARIATRIC SURGERY ACCREDITATION AND QUALITY IMPROVEMENT PROGRAM (MBSAQIP). FINDING NO ISSUES, THE CENTER WAS AWARDED 3-YEAR ACCREDITATION. |
| FORM 990, PART VI, SECTION A, LINE 2 |
FAMILY OR BUSINESS RELATIONSHIP BOARD MEMBERS TAEJOON AHN, M.D. AND RAVI HUNDAL, M.D. HAVE A BUSINESS RELATIONSHIP. |
| FORM 990, PART VI, SECTION A, LINE 3 |
MANAGEMENT COMPANY JOHN MUIR HEALTH HAS ENGAGED OPTUM TO MANAGE NON CLINICAL FUNCTIONS, INCLUDING INFORMATION TECHNOLOGY, REVENUE CYCLE MANAGEMENT, ANALYTICS, PURCHASING AND CLAIMS PROCESSING. OPTUM BRINGS AN EXTENSIVE SET OF CAPABILITIES, INCLUDING OPERATIONAL TECHNOLOGIES, ANALYTIC SOLUTIONS AND TOOLS, AND ADMINISTRATIVE SERVICE EXPERTISE TO HELP JOHN MUIR HEALTH FURTHER ADVANCE ITS CLINICAL AND OPERATIONAL PERFORMANCE. |
| FORM 990, PART VI, SECTION A, LINE 7B |
GOVERNANCE DECISIONS SUBJECT TO APPROVAL THE BYLAWS OF JOHN MUIR HEALTH PROVIDE THAT JOHN MUIR HEALTH MAY NOT, WITHOUT THE PRIOR WRITTEN CONSENT OF THE MT. DIABLO HEALTHCARE DISTRICT, A POLITICAL SUBDIVISION OF THE STATE OF CALIFORNIA, AND THE JOHN MUIR ASSOCIATION, A CALIFORNIA NONPROFIT CORPORATION: (I) SELL, TRANSFER, OR OTHERWISE DISPOSE OF ALL OR SUBSTANTIALLY ALL THE ASSETS OF JOHN MUIR HEALTH; (II) ISSUE MEMBERSHIP IN JOHN MUIR HEALTH TO ANY PERSON OR ENTITY; (III) MERGER; WITH ANY OTHER PERSON OR ENTITY, UNLESS JOHN MUIR HEALTH IS THE SURVIVING CORPORATION IN THE MERGE: OR (IV) AMEND SECTION 5.6 OF THE BYLAWS OF JOHN MUIR HEALTH (WHICH OBLIGES JOHN MUIR HEALTH TO AMONG OTHER THINGS, PROVIDE AT LEAST ONE MILLION DOLLARS ($1,000,000) ANNUALLY TO FUND CERTAIN COMMUNITY BENEFIT PROJECTS SPONSORED BY THE JOHN MUIR/MT. DIABLO COMMUNITY HEALTH FUND AND REASONABLE FUNDING FOR ADMINISTRATION, UP TO A MAXIMUM OF $200,000 PER YEAR. |
| FORM 990, PART VI, SECTION B, LINE 11B |
REVIEW OF FORM 990 BY THE GOVERNING BODY THE COMPLETED FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS SUFFICIENTLY IN ADVANCE OF THE FILING DEADLINE TO ENABLE A DETAILED AND CONSCIENTIOUS REVIEW BY ALL MEMBERS. AN OVERVIEW OF THE FORM 990, WITH SUFFICIENT DETAIL, IS PRESENTED TO THE BOARD WITH THE COMPLETED FORM 990. ALL QUESTIONS AND CONCERNS OF THE BOARD OF DIRECTORS WILL BE ADDRESSED BY THE CHIEF FINANCIAL OFFICER AND HIS DESIGNEE AND INCORPORATED INTO THE FORM 990 AS APPROPRIATE. AFTER ALL OF THE INPUT FROM THE BOARD OF DIRECTORS HAS BEEN APPROPRIATELY ADDRESSED, SENIOR MANAGEMENT OF JOHN MUIR HEALTH WILL FILE THE FINAL FORM 990 AS REQUIRED. |
| FORM 990, PART VI, SECTION B, LINE 12C |
CONFLICT OF INTEREST MONITORING ANNUALLY, THE JOHN MUIR HEALTH (JMH) BOARD CONFLICT OF INTEREST POLICY IS DISTRIBUTED TO BOARD MEMBERS, ALONG WITH A CONFLICT OF INTEREST DISCLOSURE FORM REQUIRED TO BE COMPLETED AND SIGNED. DISCLOSED CONFLICTS ARE COMPILED IN A DOCUMENT AND REVIEWED BY THE BOARD CHAIR, PRESIDENT/CEO, AND GENERAL COUNSEL. TOGETHER, THESE INDIVIDUALS MONITOR ANY POTENTIAL CONFLICTS AND THE GENERAL COUNSEL ATTEND BOARD MEETINGS TO ENSURE COMPLIANCE WITH THE POLICY. TRANSACTIONS INVOLVING A POTENTIAL CONFLICT ARE REVIEWED AND APPROVED IN ADVANCE BY THE GENERAL COUNSEL, GOVERNANCE COMMITTEE AND FOR CERTAIN TRANSACTIONS WITH THE CURRENT BOARD MEMBERS, THE BOARD. THE POLICY ALSO REQUIRES BOARD MEMBERS TO DISCLOSE CONFLICTS DURING THE YEAR END RECUSE THEMSELVES FROM VOTING ON ANY MATTERS RELATED TO A CONFLICT. AS QUESTIONS ABOUT POTENTIAL CONFLICTS ARISE DURING THE YEAR, THE GENERAL COUNSEL REVIEWS THEM WITH THE AFFECTED BOARD MEMBER, THE PRESIDENT/CEO AND THE BOARD CHAIR. TO ENSURE THE ORGANIZATION OPERATES IN A MANNER CONSISTENT WITH CHARITABLE PURPOSES AND DOES NOT ENGAGE IN ACTIVITIES THAT COULD JEOPARDIZE ITS TAX-EXEMPT STATUS, PERIODIC REVIEWS SHALL BE CONDUCTED, INCLUDING PERIODIC REVIEWS OF ITS TRANSACTIONS OR ARRANGEMENTS WITH ITS OFFICERS AND BOARD MEMBERS, AND ANY OTHER INDIVIDUAL OR ENTITIES THAT MAY HAVE A SUBSTANTIAL INFLUENCE OVER THE BUSINESS AND AFFAIRS OF THE ORGANIZATION. |
| FORM 990, PART VI, SECTION B, LINE 15 |
EXECUTIVE COMPENSATION COMPENSATION FOR THE CHIEF EXECUTIVE OFFICER, OTHER OFFICERS AND KEY EMPLOYEES ARE ESTABLISHED ANNUALLY BY THE COMPENSATION COMMITTEE OF JOHN MUIR HEALTH. THE COMPENSATION COMMITTEE IS A STANDING COMMITTEE OF THE BOARD OF DIRECTORS COMPRISED OF NO LESS THAN 5 VOTING DIRECTORS, NONE OF WHICH HAS A CONFLICT OF INTEREST WITH RESPECT TO THE COMPENSATION TRANSACTIONS UNDER CONSIDERATION. THE COMPENSATION COMMITTEE UTILIZES AN OUTSIDE EXPERT COMPENSATION CONSULTANT. THE OUTSIDE CONSULTANT PROVIDES MARKET DATA OF SIMILARLY SITUATED ORGANIZATIONS FOR EACH INDIVIDUAL BASED UPON THEIR LEVEL OF RESPONSIBILITES. THAT DATA IS USED BY THE COMPENSATION COMMITTEE TO ESTABLISH THE ANNUAL COMPENSATION PACKAGE FOR EACH INDIVIDUAL. IT IS THE PHILOSOPHY OF THE ORGANIZATION TO ESTABLISH A COMPENSATION PACKAGE FOR EACH INDIVIDUAL THAT REFLECTS THE MEDIAN OF THE MARKET AS ESTABLISHED BY THE OUTSIDE CONSULTANT. THE COMMITTEE'S DELIBERATIONS AND DECISIONS REGARDING THESE COMPENSATION ARRANGEMENTS ARE DOCUMENTED IN THE COMMITTEE MINUTES THAT ARE REVIEWED AT ITS NEXT MEETING. THE DOCUMENTED MINUTES INCLUDE (1) TERMS OF THE COMPENSATION ARRANGEMENT, INCLUDING DATE IT WAS APPROVED; (2) A DESCRIPTION OF THE COMPARABLE DATA RELIED UPON BY THE COMMITTEE AND HOW IT WAS OBTAINED; (3) A LIST OF THE MEMBERS PRESENT DURING THE DELIBERATIONS AND HOW THE MEMBERS VOTED; (4) ANY ACTIONS TAKEN WITH RESPECT TO CONSIDERATION OF ANY MEMBER OF THE COMMITTEE WHO HAD A POTENTIAL CONFLICT OF INTEREST WITH RESPECT TO THE TRANSACTION. |
| FORM 990, PART VI, SECTION C, LINE 19 |
DOCUMENTS AVAILABLE TO THE PUBLIC AUDITED FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE FROM THE JOHN MUIR HEALTH LEGAL DEPARTMENT UPON REQUEST. |
| FORM 990, PART IX, LINE 11G |
MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 102,010,451. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 102,010,451. HOSPITAL PROVIDER FEE: PROGRAM SERVICE EXPENSES 57,738,550. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 57,738,550. CAPITATED SERVICES: PROGRAM SERVICE EXPENSES 42,462,612. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 42,462,612. PHYSICIAN NTWRK PURCHASED SVS: PROGRAM SERVICE EXPENSES 15,972,322. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 15,972,322. |
| FORM 990, PART XI, LINE 9: |
CHANGE IN UNAMORTIZED LOSS ON PENSION PLANS 63,180,141. |
Attach to Form 990 or 990-EZ.