Title
a. Authorize the Chief Executive Officer for Natividad Medical Center (NMC) or his designee to execute a Hospital Participation Agreement with American College of Surgeons (ACS) for participation in the ACS Trauma Quality Improvement Program for an amount not to exceed $111,400 with an agreement term July 1, 2021 through June 30, 2026.
b. Approve the NMC Chief Executive Officer’s recommendation to accept non-standard indemnification, insurance, no warranty, limitations on liability, and governing laws within the agreement.
c. Authorize the Chief Executive Officer for NMC or his designee to execute up to three (3) future amendments to the agreement, which do not significantly alter the scope of work and do not cause an increase of more than ten percent (10%) ($11,140) of the original cost of the agreement.
Report
RECOMMENDATION:
It is recommended the Board of Supervisors:
a. Authorize the Chief Executive Officer for Natividad Medical Center (NMC) or his designee to execute a Hospital Participation Agreement with American College of Surgeons (ACS) for participation in the ACS Trauma Quality Improvement Program for an amount not to exceed $111,400 with an agreement term July 1, 2021 through June 30, 2026.
b. Approve the NMC Chief Executive Officer’s recommendation to accept non-standard indemnification, insurance, no warranty, limitations on liability, and governing laws within the agreement.
c. Authorize the Chief Executive Officer for NMC or his designee to execute up to three (3) future amendments to the agreement, which do not significantly alter the scope of work and do not cause an increase of more than ten percent (10%) ($11,140) of the original cost of the agreement.
SUMMARY/DISCUSSION:
On February 5, 2013, the Board of Supervisors approved (A-12391) Natividad Medical Center’s (NMC) Hospital Participation Agreement with the American College of Surgeons to participate in their National Surgical Quality Improvement Program. This Agreement is very similar and allows NMC to participate in ACS’s Trauma Quality Improvement Program (ACS TQIP).
The ACS TQIP is a database and reporting system that provides NMC with fact-based information needed to make quick, confident decisions in support of the hospital’s quality improvement initiatives. The database and reporting system allow NMC to evaluate our performance compared to other Level II Trauma Centers and evaluate our outcomes, complications, and risk-adjusted mortality. The database and reporting system allow NMC to improve performance through comparative analysis of outcomes across appropriately risk-adjusted populations and compare patient-care patterns among physicians. ACS TQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of trauma care. Participation in ACS TQIP will satisfy the American College of Surgeons - Committee on Trauma’s requirement (CD15-5), “All trauma centers must use a risk-adjusted benchmarking system to measure performance and outcomes”. The ACS TQIP database and reporting system is used by many public and private trauma centers in California and throughout the nation, such as Santa Clara Valley Medical Center and Stanford Hospital.
NMC’s Information Technology Department has reviewed the database and reporting system and found that it does not pose a security risk.
ACS has provided an ACORD Certificate of Liability Insurance for Commercial General (GL) in the amount of $1,000,000 each occurrence and $2,000,000 in the general aggregate. NMC requests that the Board of Supervisors (BOS) authorize a modification of the County’s insurance requirements, as ACS will not agree to provide the additional insured or primary and non-contributory language for the GL, as well as provide the Worker’s Compensation certificate. In addition, NMC requests that the BOS accept non-standard indemnification, warranty and governing law language. NMC does not believe this Agreement exposes County to a significant risk of liability.
OTHER AGENCY INVOLVEMENT:
The Office of County Counsel has reviewed and approved this agreement as to form, and the Auditor-Controller has reviewed and approved as to payment provisions. The agreement was reviewed and approved by NMC’s Special Board of Trustees on June 14, 2021.
FINANCING:
The cost for this agreement is $111,400 (plus audit fees at $2,500 per audit) of which $22,657 is included in the Fiscal Year 2020-21 Adopted Budget. Amounts for remaining years of the agreement will be included in those budgets as appropriate.
BOARD OF SUPERVISORS STRATEGIC INITIATIVES:
Natividad is a Level II American College of Surgeons verified trauma center. In order to meet the requirements for verification, the organization must go through a stringent review process to ensure all ACS required criteria are met. Natividad is responsible to maintain the ACS criteria in order to remain as a designated and verified trauma center. One of these criteria is participation in a benchmark program which allows Natividad to compare care provided and outcomes with peers and focus quality improvement initiatives on areas of opportunity. Participation in the American College of Surgeons’ Trauma Quality Improvement Program (TQIP) satisfies this requirement.
__ Economic Development
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Prepared by: Julie Ramirez, Trauma Program Manager, 772-7350
Approved by: Gary R. Gray, DO, Chief Executive Officer, 783-2553
Attachments:
American College of Surgeons Agreement
Attachments on file with the Clerk of the Board