July 2015 ICAHN Newsletter

ICAHN Newsletter

July 2015
MOMENTUM
You’re
Invited!
Moving critical access hospitals and their rural communities forward
2015 Vendor Fair
Creating a Culture of Teamwork:
2015 Vendor Fair speaker line-up, video contest announced
‘Coming together is a beginning. Keeping together is progress. Working together moves you over the line to success.’
Learn how to be the game
changer for your team and your
community by joining us
in Springfield on Wednesday,
August 19th for a day of education and team building designed
for your hospital’s clerical and
operations staff. Attendees will
have an opportunity to explore
all the latest products and
services from more than 60
vendors and business partners
at our annual trade show.
‘TEAM PLAYER’
Music Video Contest
MVP
Video
Award
New to this year’s Vendor Fair!
ICAHN hospitals are invited to showcase their departments, their team spirit, and their service excellence in
a music video of their own creation.
Your hospital could win $500!
The Vendor Fair will be held on Wednesday,
August 19th, from 7:30 a.m. to 3:30 p.m.
at the Crowne Plaza, Springfield, IL.
Business office staff, hospital
department managers, plant
and materials managers, quality
managers, respiratory, lab, rehab, compliance,
and imaging staff are invited to attend. Those
participating will have the opportunity to
network with peers, and engage in education,
training, and team-building while also gaining
face-time with more than 60 vendors.
The agenda includes:
• 7:30 a.m. Registration/Breakfast/Exhibits
• 8:30 - 9:00 a.m. Peer Group Networking
• 9:00 - 9:15 a.m. Opening/Welcome
• 9:15 - 10:45 a.m. Carla Andrews,
B.S.I.E., C.S.T.F., F.D.A.C., a John
Maxwell Keynote speaker, coach, and
business strategist, who will be addressing
the topic of ‘Creating a Culture of Teamwork.’ Ms. Andrews will communicate the
message of positive-driven leadership,
organizational culture in business, and
value-based life through communications.
• 10:45 - 11:30 a.m. Exhibit Visits
• 11:30 a.m. - 12:15 p.m. Andrew
Buffenbarger, Director of Risk Management, Compliance, and Human
Resources, for Kirby Medical Center.
Mr. Buffenbarger will present ‘Compliance
Program Essentials.’ This compliance
overview will offer helpful tips for getting
your compliance program off the ground
and keeping it running. The discussion
will help focus your efforts on the key
risk areas, offer tips for minimizing your
time investment in compliance program
maintenance, and provide an inside look
at what critical access hospitals are doing
to stay in compliance.
• 12:15 - 2:15 p.m. Lunch/Exhibit Visits/
Drawings
• 2:15 - 3:00 p.m. Scott Richards,
Associate Advisor-Security, Purdue
Healthcare Advisors, will present ‘Mobile
Security for Both Work and Personal
Devices.’ Having the gift of being able to
easily explain technology to non-technical
people, Mr. Richards guides physicians,
dentists, and their practice managers to
select computers and handheld devices
that best suit the needs of each particular
practice. He works with hospitals, practices, and clinics to ensure their technology
is HIPAA compliant.
• 3:00 - 3:30 p.m. Video Award Presentation/Final Drawings/Wrap Up/Evaluations
Additional individual and team prizes will be
awarded throughout the day. There is a nominal
$25 per individual charge for ICAHN members
to attend the event, which will be held at the
Crowne Plaza in Springfield. Vendors and those
interested in sponsoring the event are encouraged to visit vendorfair.events.icahn.org.
IN THIS ISSUE:
Think outside the box on how to incorporate the criteria
items listed below. They just have to ‘appear’ somewhere
noticeable in your video. An .mp4 or .wmv file is preferred, and the deadline for submission to scartwright@
icahn.org is Friday, August 7th. Voting begins on ICAHN’s
Facebook page on Monday, August 10th. The team
creating the video that receives the highest number of
‘likes’ between August 10th and 3 p.m. on August 19th
will receive $500. The second place prize will be $250.
Criteria and Guidelines
•
•
•
•
Must represent your organization, service
excellence, and team engagement
Must be between 1 and 3 minutes in length
You may select your own music, but it is necessary
to be included in the video
Your video must include the following person,
symbol, and word.
Person: Your Hospital CEO
Symbol: Your Hospital Logo
Word: Team
Bonus: Pat Schou, ICAHN Executive Director,
and/or your Mayor/Village President
You must submit a signed release form for ICAHN’s use
of your video. Visit vendorfair.events.icahn.org to
obtain the release and see sample videos. You
can fax the release to Stephanie Cartwright, ICAHN
Communications and Media Specialist, at (815) 8752990 or mail to ICAHN, Team Player Video Contest,
245 Backbone Road East, Princeton, IL 61356.
Your video will be shown prior to the announcement of
the winners at the close of business day on Wednesday,
August 19th.
• Valley West Community Hospital unveils successful Community Health Network program – Page 2
• New Chief Executive Officers named at Illinois critical access hospitals – Pages 5-6
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ICAHN Newsletter
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July 2015
Valley West Hospital in Sandwich serves as a pilot site for their Community Health Network. Among its many attributes are pastor/liaison congregational volunteers, the ‘Healthy Schools’ program, ‘Know Your Numbers,’ smoking cessation classes, mom and baby classes, physician-led programs,
and the Valley West Employee Garden in which employees receive free fruits and vegetables with all excess product donated to the food pantry.
Valley West Hospital’s
Community Health Network connects patients to health systems
Valley West Hospital’s Community Wellness Department was created to address the health needs of the
people it serves, and it continues to be the cornerstone of all they do, according to Preventative Health
Educator Beckie Frieders, MPH, CHES, CPH, at the
Sandwich critical access hospital.
“Years ago, we would learn of community needs
and offer one-time programming and health fairs,
and through that, ‘community wellness’ was born,”
said Frieders. “Because of the Affordable Care Act,
we have really changed our focus, putting a great
deal of resources into face-to-face interaction with
our community, schools, organizations, businesses,
and churches. Our most recent efforts are targeted,
utilizing data gathered from our Community Health
Needs Assessment (CHNA) and focusing on gaps in
service that need to be met.”
Transformed by policy and system change, Valley
West Hospital’s Community Wellness Department
implemented the ‘Healthy Schools’ Program, ‘Know
Your Numbers,’ smoking cessation programs, mom
and baby classes, physician-led programs, child/teen
health programs, LiveFit Team Challenges with the
local YMCA, 10K-a-Day Walking Challenge, the Valley
West Hospital Employee Garden, and its most recent
addition, the Community Health Network (CHN).
The CHN is a faith and evidence-based program
model that originated in Memphis in 2007 and
involved 500 Tennessee churches. This model
creates a partnership between the hospital and the
church using volunteers in lieu of hiring paid hospital
employees. It also engages pastors and the liaisons
in each participating church to take an active role in
their congregation’s health.
Currently, six Sandwich-area churches are participating in Valley West Hospital’s CHN, in addition to three
food pantries and one senior center. The program
functions in three complementing areas: providing
“Patients receive non-medical support
from neighbors and friends they know,
and it’s a ‘win-win’ from all sides. We
hope to utilize the CHN system-wide
next year, but for now, it’s a pilot project
with Valley West Hospital.”
– Heidi Carlson, CHN Coordinator
Beckie Frieders (left) and Heidi Carlson
tools and resources to create a healthier environment;
linking members with education, community resources, and primary care to reduce the risk of chronic
disease; and mobilizing trained volunteer liaisons to
meet the non-medical needs of their members when
ill or hospitalized. The program utilizes the Congregational Health Index, an evidence-based tool that
identifies strengths and weaknesses, and creates an
action plan for creating a healthier environment.
“Sometimes the strengths of a program are best told
in one of its successes,” said Heidi Carlson, CHN
coordinator. “We had an 85-year-old woman whose
husband had been placed in skilled nursing and was
now alone in her home. Whenever she became short
of breath walking her dog, she called emergency services to transport her to the Emergency Department
at Valley West Hospital. In a 45-day stretch, she had
been in the ED five times.”
Once this was discovered, Carlson visited her and
listened to her needs. From this visit, Carlson reached
out to the liaison from the church which provided a
volunteer to walk her dog and another volunteer to
wash dishes, make her bed, and straighten up a bit.
The liaison also arranged for volunteers to occasionally pick her up and take her to visit her husband, and
Illinois Critical Access Hospital Network • www.icahn.org
attend family and other social engagements. A social
worker also met with her to evaluate other needs.
“We found out she hadn’t discussed any of her needs
with the church, and they were more than happy to
help,” said Carlson. “We found a gap in non-medical
service, we fixed it, and now, she is healthier, happier,
and no longer needing our ED.”
Carlson further noted, “The synergy of community
outreach lies in the trusted relationship between the
hospitals and the community. The CHN is the binding
tie that connects all entities. It is nice to see that we
have the support from the community as well as from
within our health system,” she concluded. “Our nurses
see this volunteerism as an asset to patient care just
as our social workers see its merits. Patients receive
non-medical support from neighbors and friends they
know, and it’s a ‘win-win’ from all sides. We hope to
utilize the CHN system-wide next year, but for now,
it’s a pilot project with Valley West Hospital,” said Carlson. “It is essential to continue care for our patients
outside the four walls of the hospital to maintain the
health of the community.”
For more information about the CHN at Valley West
Hospital or KishHealth System’s Community Wellness
programs, contact Beckie Frieders or Heidi Carlson at
815.786.3962 or visit www.kishprograms.org.
ICAHN Newsletter
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July 2015
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FEATURE STORY
‘Muggles, Magic, and Mayhem’
St. Joseph’s Julie LaFrance takes
population health to a mystical level
Julie LaFrance may be St. Joseph’s Hospital’s Director
of Planning and Operations by day, but just a few short
weeks ago, you would be shocked and amazed by
what her itinerary includes at night.
“Donning a cape and a sorting hat has been nothing
new for me the past few years as I – and so many
other volunteers – put on ‘Muggles, Magic, and
Mayhem’ for the Girl Scouts,” said LaFrance who, in her
fifth year as Camp Director saw more than 130 K-12th
grade girls participate in June’s evening camp at Silver
Lake Park in Highland. “This Harry Potter-themed Girl
Scout camp is designed to introduce girls to the world
of science, especially astronomy and chemistry in this
case, and to show them that girls can do, learn, and
be anything that boys can do, learn, and be. The goal
is to empower them in the process while having a ton
of fun.”
This ‘ton of fun’ has come in all shapes and sizes
throughout the years, from Tri-Wizard Tournament mazes to rousing games of Quidditch and the occasional
Potter-themed SWAP craft … and it doesn’t take a
dip in the pensieve to foresee that LaFrance has an
imagination that could cast a spell on any child.
“It just takes a little time, thought, volunteerism, and
money to spark interest. For example, corn starch and
water mixed with baking soda makes for a perfectly
safe, yet highly effective exploding potion, and butter
beer – Harry, Hermione, and Ron’s favorite drink from
the Harry Potter series – is merely cream soda and
butterscotch syrup,” said LaFrance. “Add some liquid
nitrogen in a Styrofoam cup to some marshmallows or
sprinkle some edible glitter on popcorn, and you have
all the makings for a mystical evening under the stars.”
of their own time to make this such a success. I’ve
been particularly thrilled, however, for the work Thole
Fabrication and Welding here in Highland did to make
us a set of Quidditch rings and to the Mt. Vernon Lions
Club which brings their train each year so we have
transportation to the Great Hall.”
LaFrance became involved in what initially was going
to be a two-hour craft day for some younger kids after
attending just one Girl Scout meeting and raising her
hand as a volunteer. And the rest, as they say, is history.
“It took on a life of its own and became so wildly
popular that the Boy Scouts were practically drooling
to get involved,” LaFrance laughed. “So we made a bit
of a concession. Still no older boys, but we decided
the siblings of Girl Scouts under the age of five could
participate as house elves for Moms who volunteer for
the week, complete with a sewn sock on the back of
their shirts, reminiscent of Dobby.
“We tried very hard to be inventive and bring in new
events each year, and I have to admit with all the books
and movies already out and the series being finished,
this may be our last year,” she concluded. “Regardless,
it’s been a wonderful ride, and if I decide to close the
chapter, it’s been worth every minute seeing the girls
gain confidence, becoming empowered in their own
skills and thoughts, and having so much fun making
new friends.”
Throw in a horcrux scavenger hunt; herbology classes,
including the study of trees and plants indigenous to
the Highland area; some magical creatures including
words of wisdom from Tie Dye the Iguana Guy or World
Bird Sanctuary; wizard’s chess to challenge the mind;
a spirited game of Kiss the Dementors’ freeze tag; and
you’ve already got a learning experience worthy of the
hallowed Highland Hogwarts Great Hall.
“Physical fitness, education, crafts, and socializing are
all added benefits of the week,” said LaFrance, who
accredits her dedicated volunteer base including other
Girl Scout moms from St. Joseph’s who work in Nursing and Coding, St. Joseph’s Hospital who provides
meeting space to plan the event, and other businesses
in the community for their work in bringing population
health to this age group. “It’s a huge community effort
from start to finish, and I can’t say enough about the
team of moms in our service unit who commit hours
Illinois Critical Access Hospital Network • www.icahn.org
Julie LaFrance (right) with Southern Illinois
Council of Girl Scouts CEO Villie Appoo
This past year’s camping session for Service Unit 110
concluded June 6th and over the past five years has
involved girls from Highland, Edwardsville, Columbia,
Godfrey, Alton, Effingham, Medora, Mt. Olive, Trenton,
DeSoto, and Benton.
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ICAHN Newsletter
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July 2015
Mercy Harvard’s Nurse Practice Council upholds Magnet directives
Nurses band together to organize Harvard Health and Safety Fair
Mercy Harvard Hospital is a Magnet Hospital. The designation of Magnet includes, but is not limited to, shared decision-making plus the formation
of organized councils comprised of direct care nurses providing the ability to guide professional practice. Mercy Harvard’s Nurse Practice Council
is a particularly active council which includes an equally active Harvard community task force.
“As a critical access hospital, we are required to have
an advisory board that identifies community health
needs and we share them with the critical access
hospital outcomes,” said Theresa Hollinger, Director of
Nursing and Patient Care Services for Mercy Harvard
Hospital of the Mercy Rockford Health System. “The
Advisory Committee included the mayor, members of
the school board, the school nurse, and several other
community members. During the annual report to the
Advisory Board, they relayed community concerns.”
As Harvard has a higher population of homeless
individuals and families without access to care, Ms.
Hollinger presented this information to the Nurse
Practice Council’s community task force. In response,
the nurses banded together to create and organize
the Harvard Community Health and Safety Fair.
“We had a vast array of involvement from about 30
community businesses and non-profit organizations
including the hospital, of course, but also partners like
the McHenry County Health Department, the Rock
Valley blood bank, our local police, fire, and EMS
providers, New Balance, and so many more,” said
Hollinger about the event held May 30th. “Our phy-
sicians’ offered low-cost sports
and school physicals expressly
targeted for low income families,
plus the hospital offered information on smoking cessation, fall
risk assessments, blood pressure
and blood glucose screenings,
proper handwashing, a ‘buildyour-own’ first aid kit, glitter germ
station, bicycle safety education,
face-painting, and kids’ games.
We plan on doing it again next
year as we were really happy
with the results.”
Following this successful venture, Harvard’s nurses
participated in the Harvard Community Milk Days
Festival parade, representing all departments and also
their ‘Magnet Nurse’ status and what that means for
the community they serve.
“Magnet is about the professional engagement of
nursing. Nurses no longer come to work and just
punch in and punch out. Nursing is so much more
than that,” said Hollinger. “Our nurses support the
Magnet theory of nurse engagement, governing our
own, and learning how to best care for our patients,
our community, and ourselves.
“Showing that sign of solidarity was evident in the
parade and in the time and effort each and every one
put into making the Harvard Community Health and
Safety Fair a success,” she added. More information
on the Magnet Nurse designation will be provided in
the next newsletter.
Appellate Court reinforces broad protection for
hospital credentialing and privileging decisions
Submitted by Greg Rastatter
[email protected]
In a recent decision (Larsen v. Provena Hospitals),
the Illinois Appellate Court held that for a physician
whose medical staff membership was not renewed to
survive dismissal in a subsequent action against the
hospital, he or she must allege and prove the hospital
actually or deliberately intended to physically harm
the physician. This decision reinforced a prior ruling
from 2005 (Lo v. Provena Covenant Med. Ctr.) with
respect to the protection afforded to hospitals under §
10.2 of the Illinois Hospital Licensing Act, 210 ILCS
85/10.2.) While this interpretation of the statute is
perhaps overly literal, the case highlights the types of
claims brought by aggrieved physicians and the analysis undertaken by courts in addressing those claims.
Despite the broad protection afforded by the statute,
providers should continue to ensure compliance with
their internal bylaws, policies, rules, and regulations
and to also ensure that credentialing/privileging
decisions are properly documented.
The Hospital Licensing Act provides immunity to
hospitals and others with respect to peer review
decisions. Because the candid and conscientious
evaluation of clinical practices is essential to the
provision of adequate hospital care, it is the policy of
this state to encourage peer review by healthcare providers. Therefore, no hospital and no individual who is
a member, agent, or employee of a hospital, hospital
medical staff, hospital administrative staff, or hospital
governing board shall be liable for civil damages as a
result of the acts, omissions, decisions, or any other
conduct, except those:
• involving willful or wanton misconduct of a
medical utilization committee, medical review
committee, patient care audit committee, medical
care evaluation committee, quality review
committee, credential committee, peer review
committee, or any other committee or individual
whose purpose, directly or indirectly, is internal
quality control or medical study to reduce morbidity or mortality, or for improving patient care
within a hospital, or the improving or benefiting
of patient care and treatment, whether within a
hospital or not, or for the purpose of professional
discipline, including institution of a summary
suspension in accordance with Section 10.4 of
this Act [21 ILCS 85/10.4] and the medical staff
bylaws.
Nothing in this Section shall relieve any individual
or hospital from liability arising from treatment of a
patient.
In May 2011,
CORPORATE SPONSOR
the defendant,
education provided by:
Provena Hospitals (Provena)
declined to
renew the
medical staff
membership
and clinical privileges of the plaintiff, L. Royce Larsen,
M.D., which Provena and its predecessors had
renewed essentially biennially for the previous 31
years. Dr. Larsen filed a four-count complaint against
the hospital, alleging a cause of action for retaliation
under the Whistleblower Act and seeking damages as
a result of Provena’s “willful and wanton misconduct”
in harming his medical practice and professional
reputation.
Provena moved to dismiss the complaint, arguing Dr.
Larsen failed to sufficiently plead willful and wanton
misconduct, and that the Whistleblower Act did not
apply absent an allegation that Provena received state
funding. Dr. Larsen argued that because he alleged
harm to his medical practice and professional reputation as a result of Provena’s denial, which occurred
without a hearing and in violation of the contractual
medical staff bylaws, he had sufficiently pleaded willful
Continued on Page 6
Illinois Critical Access Hospital Network • www.icahn.org
ICAHN Newsletter

July 2015
5
New Chief Executive Officers named at Illinois CAHs
Several new Chief Executive Officers were named to leadership roles at their respective hospitals within the last few months. They include Kim
Bourne at Taylorville Memorial Hospital; Alisa Coleman at Ferrell Hospital; Jennifer Junis at OSF Saint Paul Medical Center; John Kessler at Salem
Township Hospital; Sue Odle at St. Joseph Memorial Hospital; Greg Sims at Hamilton Memorial Hospital District; and Bob Stolba at Mason District
Hospital.
Kim Bourne was named
President/CEO of Taylorville
Memorial Hospital in January.
Kim began her career with
Memorial Medical Center in
1989 as Associate Director
of Clinical Nutrition and was
named Senior Associate
Director in 1993. The following year, she was chosen as
the director of the hospital’s food and nutrition services
department, a position she held for 19 years until
being named System Director of Patient Safety.
In 2011, she received the Woody Hester Legacy of
Leadership Award, which recognizes Memorial Health
System leaders who guide others. She is a certified
Lean Six Sigma Black Belt and a member of the
American College of Healthcare Executives.
“Having grown up in Christian County, I feel a real connection to this community and consider it a privilege to
serve them,” said Ms. Bourne, whose daughter, Avery,
was recently named State Representative for the 95th
District. “We both truly care about the health of the
people we serve, and I’m particularly excited about
working in her district. I feel I’ve hit the ground running
these past few months as we’ve closed the skilled
nursing unit to better utilize our swing bed capabilities,
and we are now embarking on a facility renovation and
upgrade to modernize our inpatient capabilities. We
hope to present our progress on this plan to the board
by the end of the year.”
Alisa Coleman was named
CEO at Ferrell Hospital,
Eldorado, in June. Holding
multiple positions at the Ohio
County Hospital Corporation in
Hartford, KY, over an 11-year
period, she then accepted the
position of CEO at Trigg County Hospital, Inc., in Cadiz, KY.
She served in this capacity for
a further 10 years before accepting the CEO position
at Ferrell Hospital.
“I am from a small town in rural Kentucky and have
always worked in a small town. I think having that
background makes for an easy transition to Ferrell.
I understand rural healthcare and the challenges we
face in providing access to care to the communities
we serve,” said Ms. Coleman. “I think you have to
accept the fact that providing care in a small hospital
does not equate to sub-par care. Great care can and
is being provided in small rural facilities all across
Illinois. Our goal here at Ferrell is simple: we aspire
to be a great critical access hospital because good
is no longer enough. I have embraced Quint Studer’s
principles so that our objectives will align with the five
pillars of excellence: quality, finance, people, quality,
and growth.” Coleman is also excited about her hospital’s partnership with Deaconess Health System, noting
that Deaconness provides the clinical integration and
attention to quality Ferrell can bring to the communities served in and around Eldorado and Saline County.
Jennifer Junis, RN, MSN,
was named President of OSF
Saint Paul Medical Center,
Mendota, in April. She served
as Chief Nurse Officer at
Kewanee Hospital/OSF
Saint Luke Medical Center,
Kewanee, from June 2007
to March 31, 2015. In her
almost eight years at Kewanee
Hospital, Ms. Junis had the opportunity to be part
of the administrative team that saw the building of a
new hospital and its ensuing culture change, plus its
integration of the OSF HealthCare System.
“I was excited for Mendota Community Hospital to
join the OSF family. Since I had been a part of helping
integrate Kewanee hospital into OSF over the last
year, I thought my experience could help in leading
the transition of Mendota Community Hospital into
the OSF system,” said Ms. Junis. “Mendota is a great
community, the hospital is beautiful, and they have
a great team of providers and staff. OSF Saint Paul’s
goals are to provide an excellent patient experience
with quality clinical outcomes from a highly engaged
team of providers and staff. We want to grow the
population of patients we care for and achieve affordability and sustainability. With that in mind, the biggest
changes of the past include the integration to the OSF
HealthCare System and the new hospital being built
and occupied, while the most immediate actions for
me are building a framework for communication and
leadership development of the managers. As with any
new position, there will be challenges, but I consider
myself blessed for having this opportunity to serve the
community of Mendota and the Sisters of OSF.”
John Kessler was named
President/CEO at Salem
Township Hospital in June.
Having served 15 years in
management positions, he
first worked at Mercy Hospital,
Washington, MO, and was
then named Chief Operating
Officer of Lincoln County
Medical Center, now Mercy
Hospital, of which he converted a 61-bed hospital into
a critical access hospital.
From there, he went to Memorial Hospital in Belleville,
IL, serving as VP of General Services, and then as
VP of Operations. Following a brief stint with Express
Illinois Critical Access Hospital Network • www.icahn.org
Scripts, St. Louis, MO, he accepted the CEO position
at Salem Township Hospital.
“My early focus here at Salem will be on physician
recruitment, which was identified as a huge need. I
also sense that ICD-10 implementation will hit before
we know it, and I want to make sure we’re ready.
Additionally, I have an interest in IT and will be very
involved in MU Attestation to Stage 2 for EMR,” said
Kessler. “In this job, I’m particularly encouraged that
Salem is in a committed community as that’s the only
way any critical access hospital survives. I have been
told the community and the hospital are excited to
see what I can do for them, especially since the Board
of Directors and I have a shared vision where I can
operate as a leader and not just a caretaker. It’s a nice
challenge to have and I’m looking forward to it.”
Sue Odle, RN, MSN, was
named Administrator at St.
Joseph Memorial Hospital,
Murphysboro, on May 8. She
has worked in rural hospitals
for more than 30 years as an
RN across most areas of the
hospital. Her first experience
working in a CAH began at
Red Bud Regional Hospital in
2005, where she initially served as Director of Quality
Management and Regulatory Compliance.
Additional departments, such as lab, imaging, and
rehab therapy services began reporting to her, and
she played a large role in the creation of a swing bed
program at the hospital. Later named Chief Nurse
Officer, her focus was on stabilizing nursing and having
the hospital become TJC accredited. In 2010, she
was named Quality Manager at St. Joseph Memorial
Hospital and helped initiate both the swing bed and
hospitalist programs. After completing her master’s
degree, she was named Administrator.
“Interestingly, since the day of my interview in 2010,
I felt like this hospital was ‘home.’ It has all of the
small hospital benefits such as dedicated staff and
physicians, loyal patients, and the fortune to be
growing outpatient services. SJMH is part of a small
hospital system that is growing service lines in areas of
cardiovascular, oncology, and neurology.
“Our sister hospital’s growth has brought some shifting
of outpatient surgery cases, allowing us to expand the
procedure area this year. We also opened up a wound
care center and Infusion Center, and we utilize LEAN
in our daily work to address problem areas,” said Ms.
Odle. “A few goals for the hospital would be to utilize
our surgical area more, become TJC accredited, and
expand/remodel our ED.”
Continued on Page 6
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ICAHN Newsletter
NEW CEOS CONTINUED FROM PAGE 5
Greg Sims, MBA, was
named CEO at Hamilton
Memorial Hospital District,
McLeansboro, in February.
His past hospital experience
includes serving as Director
of Plant Operations and
Business Development at
Marion Memorial Hospital; as
Assistant CEO and then CEO
at Crossroads Community Hospital; and as VP of the
Medical Group and Executive Director of the PHO for
St. Mary’s Good Samaritan, Inc.
“My healthcare experience as well as my previous
management experience has given me insights into
working with people and developing teamwork to
provide the best possible care to our patients,” said
Mr. Sims. “Our goals are to promote the hospital and
CREDENTIALING CONTINUED FROM PAGE 4
and wanton misconduct, and that the hospital’s receipt
of Medicaid reimbursement satisfied the state funding
requirement under the Whistleblower Act.
The trial court partially granted Provena’s motion,
holding that harm to a physician’s medical practice
and professional reputation was “not the type of
harm required to state a claim for willful and wanton
misconduct” under the Licensing Act. The court,
however, upheld the retaliation claim, finding that: (1)
the immunity provided by § 10.2 of the Licensing Act
did not preclude that claim; and (2) the Whistleblower
Act applied because Provena received state funding
in the form of Medicaid payments. The appellate court
affirmed the dismissal but reversed the trial court’s
determination on the Medicaid issue.
In Lo, the plaintiff physician brought similar claims,
arguing the medical center involuntarily restricted his
clinical privileges without a hearing, thereby violating
the contractual agreement between the parties as
provided by the medical staff bylaws. The trial court
dismissed the complaint, which was affirmed on
appeal, because the plaintiff had “alleged no facts,
and... offered no evidence, from which [the court]
could reasonably infer that defendant ‘actually or deliberately intended to harm’ him.” The physician’s ‘own
safety’ was never at issue in this case. Accordingly, the
Licensing Act barred recovery for breach of contract.
Relying on Lo, the Larsen court reasoned that, due to

July 2015
the services we offer, to bring specialists into a rural
area so patients can get treatment close to home, and
to grow the access to care beyond just McLeansboro
and into other service areas to give patients more
options.
sition at Jackson County Hospital in Maquoketa, IA.
From there he served as CFO at Community Memorial
in Monmouth, then the CFO position at Galesburg
Cottage Hospital, and in 2001, was named the CFO
at Mason District Hospital. He was officially named
Mason District Hospital’s CEO on June 24.
“Working with the excellent staff, physician, mid-levels,
and Board of Directors here at this hospital and clinics
makes this job rewarding. My goal now is to remain
forward-thinking and make sure we are situated for
the changes in healthcare expected over the next five
to 10 years.”
“Forty years in the industry has led itself to helping
critical access hospitals survive and expand. My main
emphasis is to enhance communication between
management and the employees and also between
management and the physician staff,” said Mr. Stolba.
Bob Stolba began his career
in public accounting in 1975,
working for University General
Hospital, Seminole, FL. After
moving to Iowa in 1977, he
was first named CFO and CEO
at Dewitt Community Hospital,
and later took the CFO po-
“Goals include additional physician recruiting, even
though we’ve already recruited one physician that’s
coming in August and two additional mid-level practitioners. We’re also looking into getting a hospitalist
program and expanding some additional rural clinics.
The most dire need we have now if getting a CFO as
I am doing both jobs at the moment. I look forward to
the challenge, however.”
reporting requirements, a credentialing committee’s
decision not to renew a physician’s privileges always
and necessarily involves reputational harm to that
physician. Dr. Larsen’s interpretation that this type of
harm is actionable would destroy the Licensing Act’s
stated goal of encouraging “’candid and conscientious
evaluation of clinical practices’ to improve patient care
by encouraging ‘peer review by health care providers.’” In other words, “if merely denying a physician
hospital privileges could result in civil liability for the
medical facility or members of a credentialing committee, candid reviews would likely cease.”
Thus, “absent allegations of intentional physical harm
or a showing that the committee at issue consciously
disregarded the aggrieved physician’s safety, the
immunity afforded by that section remains intact.” The
court recognized physical harm was unlikely to ever
result from a credentialing decision, but stated it was
merely interpreting the plain language of the statute.
The legislature’s silence implies that—at a minimum—it is not displeased with the conclusion in Lo
that an allegation of reputational harm does not “fit
within the specialized definition of ‘[willful] and wanton
misconduct’ in section 10.2 [of the Hospital Act].”
[Citation omitted.] Given that the medical profession
is well-represented and influential within the legislative
halls of the General Assembly, we would expect that if
our interpretation in Lo of section 10.2 of the Hospital
Act were erroneous, as Larsen contends, legislative
action to correct that misinterpretation would have
been forthcoming.
While this inCORPORATE SPONSOR
terpretation of
the statute may education provided by:
be curtailed or
corrected by
future cases
and/or legislative action,
the broad protection of the Licensing Act is likely to
remain intact. A more balanced interpretation of §
10.2 would protect credentialing decisions that have
some underlying rational basis while allowing claims
where the decision was motivated solely by the intent
to damage the physician.
Thus, as with many aspects in the healthcare field,
providers should seek to ensure proper procedures
are undertaken with respect to credentialing/privileging
decisions, and that the underlying rationale for such
decisions is properly documented. Where a provider
complies with its own bylaws, policies, rules and
regulations, and where its records reflect a rational
basis to support a credentialing/privileging decision,
the provider is on solid footing.
Heyl Royster’s Healthcare Practice Group regularly
counsels hospitals on Medical Staff Credentialing
Privileging and Medical Studies Act issues.
Please feel free to contact Roger Clayton (309-6760400, [email protected]) or Greg Rastatter
(309-676-0400, [email protected]) for
more information.
2015 Preferred Partners
Illinois Critical Access Hospital Network • www.icahn.org