Title
a. Authorize the Deputy Purchasing Agent for Natividad Medical Center (NMC) to execute the Renewal Hospital Participation Agreement with the American College of Surgeons (ACS) for NMC’s participation in the ACS National Surgical Quality Improvement Program (ACS NSQIP), for a total Agreement amount not to exceed $60,500 for the period retroactive from January 1, 2014 through December 31, 2017; and
b. Accept non-standard Insurance, Warranty, Indemnification language, Governing Law and Payment Provisions per the ACS NSQIP Renewal Hospital Participation Agreement as recommended by the NMC Chief Executive Officer.
Report
RECOMMENDATION:
It is recommended the Board of Supervisors:
a. Authorize the Deputy Purchasing Agent for Natividad Medical Center (NMC) to execute the Renewal Hospital Participation Agreement with the American College of Surgeons (ACS) for NMC’s participation in the ACS National Surgical Quality Improvement Program (ACS NSQIP), for a total Agreement amount not to exceed $60,500 for the period retroactive from January 1, 2014 through December 31, 2017; and
b. Accept non-standard Insurance, Warranty, Indemnification language, Governing Law and Payment Provisions per the ACS NSQIP Renewal Hospital Participation Agreement as recommended by the NMC Chief Executive Officer.
SUMMARY/DISCUSSION:
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) is a database and reporting system that provides Natividad Medical Center (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 allows NMC to: evaluate performance as compared to peer hospitals; and evaluate outcomes, complications, and risk-adjusted mortality. The database and reporting system allows NMC to compare patient-care patterns among physicians and compare expected results to observed results. ACS NSQIP® is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in the private sector. Participation in ACS NSQIP® will satisfy the Centers for Medicare and Medicaid Services (CMS) surgical quality measure requirement (NQF #0493) to be implemented in 2014, “Participation in a Systematic Clinical Database Registry for General Surgery.” The ACS NSQIP® database and reporting system is used by many public and private hospitals in California and throughout the nation, such as Riverside County Regional Medical Center and the University of California Irvine Medical Center.
NMC's participation in the ACS NQSIP® database and reporting system commenced in October, 2013, after NMC's Quality Nurse completed the mandatory training associated with use of the database and reporting system. This was ten months after execution the signed agreement. This renewal agreement assures that NMC's participation in the ACS NSQIP® program described above continues. There was a delay in obtaining the necessary documentation from the vendor in time to request approval of an Amendment to the Agreement in January, 2014. However, due to continued services by the vendor, it is necessary to back date the Agreement term and request approval of this Renewal and Amendment.
The Natividad Medical Center Information Technology Department has reviewed the database and reporting system and found that it does not pose a security risk. County Counsel has not approved the Agreement as to risk provisions. NMC requests that the BOS authorize a modification of the County’s requirement for commercial general liability insurance as vendor’s insurance carrier will not agree to provide a Certificate of Insurance or Endorsements stating that such insurance is primary and that County’s insurance/self-insurance shall not be called upon to contribute to a loss covered by vendor’s insurance. NMC also requests the BOS accept modifications to the standard County Indemnification and Warranty Language. NMC does not believe there is inherent risk of liability exposure.
OTHER AGENCY INVOLVEMENT:
County Counsel has reviewed and approved this Agreement as to legal form. Auditor-Controller has reviewed and approved this Agreement as to fiscal provisions. The Agreement has also been reviewed and approved by NMC’s Finance committee and by its Board of Trustees.
FINANCING:
The cost for this Renewal Hospital Participation Agreement is $30, 000. $10,000 is included in the Fiscal Year 2014/2015 Approved Budget. . Amounts for remaining years of the Renewal Hospital Participation Agreement will be included in those budgets as appropriate. There is no impact to the General Fund.
Prepared by: Jane Finney, NMC Quality Director, 783-2502
Approved by: Kelly O’Keefe, M.D., Interim Chief Executive Officer, 783-2553
Attachments: Renewal Hospital Participation Agreement, Original Agreement, Sole Source Form, NMC IT Risk Assessment, Business Associate Agreement, Spend Sheet.
Attachments on file with the Clerk to the Boards Office