2024-08-14T08:55:52-05:00 2023-09-30 990 2022-10-01 060646966 Windham Community Memorial Hospital Inc WIND 8606963530 112 Mansfield Avenue Willimantic CT 06226 Anthony Mastroianni VP, Finance 8606963530 2024-08-14 0 2022 2024-08-08 14:25:15Z Donna Handley 112 Mansfield Avenue Willimantic CT 06226 129571014 0 X www.windhamhospital.org X 1908 CT The mission of Windham Community Memorial Hospital is to offer comprehensive services in an environment where innovation and teaching are integral to care; where we are proud to serve patients and one another; where meeting the challenge of complex medical needs is viewed as a defining competency; and where quality and safety of care are a constant. 9 5 731 53 -173556 0 655689 688385 135678616 127669572 183379 365273 524696 474495 137042380 129197725 6250 43536 0 0 51613511 52715759 0 0 72680 71345165 77669950 122964926 130429245 14077454 -1231520 90989065 89755387 61991825 61746484 28997240 28008903 X The mission of Windham Community Memorial Hospital is to offer comprehensive services in an environment where innovation and teaching are integral to care; where we are proud to serve patients and one another; where meeting the challenge of complex medical needs is viewed as a defining competency; and where quality and safety of care are a constant. 0 0 19371889 14460714 Cancer Center:Hartford HealthCare is Connecticut's most comprehensive healthcare network. Our fully integrated health system includes a tertiary-care teaching hospital, an acute-care community teaching hospital, an acute-care hospital and trauma center, two community hospitals. The Cancer Institute, headed by a visionary leadership team, offers the same high-quality care you'd get at an academic health system but delivered in convenient community settings. Advanced treatments and services are available in offices and centers across our system all offered by fellowship-trained experts in various types of cancer. These community efforts are enhanced by our membership in the Memorial Sloan Kettering Alliance. This connection offers invaluable access to current research trials that can connect you with the latest medications and treatments for your cancer. Often, you can join research trials from the convenience of your local Cancer Institute site. This distinctive cancer care and clinical research partnership means the Hartford HealthCare Cancer Institute brings the most innovative, evidence-based cancer care from MSK directly into community settings across our state. Previously, patients had to travel to New York to get this level of care.Partnering with MSK has helped Hartford HealthCare expand its research portfolio to include more cancer types than ever before, and to add a Cancer Care Innovation Unit at Hartford Hospital. The unit enables Hartford HealthCare to provide Phase I clinical trials to patients, meaning they have access to the most promising drugs in the development pipeline.We've also drafted standards that guarantee you will receive the same high level of care no matter which location you visit or provider you see. Our community approach to cancer treatment has been recognized nationally. In 2017, the Cancer Institute became one of only a few U.S. systems to earn the American College of Surgeons' Commission on Cancer accreditation. Historically, such approval was only given to individual locations. This distinctive cancer care and clinical research partnership means the Hartford HealthCare Cancer Institute brings the most innovative, evidence-based cancer care from MSK directly into community settings across our state. Previously, patients had to travel to New York to get this level of care.The Hartford HealthCare Cancer Institute encompasses comprehensive cancer centers at seven hospitals across Connecticut Hartford Hospital, The Hospital of Central Connecticut, Backus Hospital, Midstate Medical Center, Windham Hospital, Charlotte Hungerford Hospital and St Vincent's Medical Center. Collectively, the cancer programs within the Cancer Institute treat about 6,000 new cancer patients per year while caring for tens of thousands of existing patients, offering a full range of innovative, evidence-based and personalized treatments designed to meet the needs of each individual patient. Our innovative Institute approach is unlike any other in the state and is among the most highly regarded in the nation. Through our Institute, which is organized around a specific disease and not necessarily location, we can apply best practices throughout our system so that patients receive the same high standards of care no matter where they live or which Hartford HealthCare cancer center they choose. For all of our patients, a dedicated team of oncologists, surgeons, radiologists, pathologists, nurses, clinical researchers, technicians and others collaborate to provide the exact course of care they need. The Institute's multidisciplinary disease management teams meet and collaborate regularly to lend expertise and insight on numerous cancer types, translating into exceptional coordinated care. The Institute's accomplished, fellowship-trained physicians are nationally recognized for their level of sophisticated care in areas such as radiation oncology, medical oncology and surgical oncology. Patients are also cared for in an environment that emphasizes compassion and personal connections, with a team of trained nurse navigators who provide guidance and support to patients and families, from diagnosis to recovery. The Institute also boasts a thriving survivorship program. In 2017, the Institute was accredited as a network by the American College of Surgeons Commission on Cancer, one of a select few institutes nationwide to be recognized as a system, rather than individual cancer centers. For patients coming through our doors with a cancer diagnosis, that means three things: standardized care, more options and more hope.More than four years after the Hartford HealthCare Cancer Institute became the charter member of the Memorial Sloan Kettering (MSK) Cancer Alliance, cancer patients now have unprecedented access to the world's most advanced clinical trials. And more than ever before, physicians, nurses, pharmacists and researchers are working collaboratively to implement cancer treatment standards and protocols developed at MSK, the premier cancer treatment center in the country. For FY23, the approximate number of cases treated were as follows:Hartford Hospital: 2,886Hospital of Central Connecticut: 1,3331Backus Hospital: 959Midstate Medical Center: 405Windham Hospital: 70Charlotte Hungerford Hospital: 267St Vincent's Medical Center: 736The five most common types of cancer diagnosed by teams of specialists at the Hartford HealthCare Cancer Institute are cancers of the Breast, Lung, Prostate, Bladder & Colon. Each patient has a unique scenario requiring a personalized plan.Approximately 1,662 Breast Cancer cases were treated across the system as follows:Hartford Hospital: 622Hospital of Central Connecticut: 363Backus Hospital: 256Midstate Medical Center: 152Windham Hospital: 16Charlotte Hungerford Hospital: 72St Vincent's Medical Center: 181Approximately 732 Lung Cancer cases were treated across the system as follows:Hartford Hospital: 298Hospital of Central Connecticut: 165Backus Hospital: 141Midstate Medical Center: 42Windham Hospital: 9Charlotte Hungerford Hospital: 23St Vincent's Medical Center: 54Approximately 807 Prostate Cancer cases were treated across the system as follows:Hartford Hospital: 325Hospital of Central Connecticut: 140Backus Hospital: 122Midstate Medical Center: 46Windham Hospital: 1Charlotte Hungerford Hospital: 57St Vincent's Medical Center: 116 Approximately 408 Bladder Cancer cases were treated across the system as follows:Hartford Hospital: 154Hospital of Central Connecticut: 62Backus Hospital: 89Midstate Medical Center: 40 Windham Hospital: 3Charlotte Hungerford Hospital: 27St Vincent's Medical Center: 33Approximately 330 Colon Cancer cases were treated across the system as follows:Hartford Hospital: 130Hospital of Central Connecticut: 56Backus Hospital: 52Midstate Medical Center: 23Windham Hospital: 2Charlotte Hungerford Hospital: 20St Vincent's Medical Center: 47As always, Hartford HealthCare is creating a better future for healthcare in Connecticut and beyond. We are a community of caregivers engaged in developing a coordinated, consistent high standard of care. We use research and education as partners in care delivery. We create and engage in meaningful alliances to enhance access to services. We invest in technology and training to develop new pathways to improve the timeliness, efficiency and accuracy of our services. 14102400 17077118 Digestive Health:Committed to excellence in quality and service for the region, Windham Community Memorial Hospital boasts a state-of-the-art Emergency Department that consistently ranks in the highest percentiles of customer satisfaction. The hospital also offers convenient and modern satellite services including two Physical Therapy and Rehabilitation Clinics and a Center for Women's Health offering mammography, bone density, and integrative health. The medical staff brings specialties and diagnostic disciplines in the areas of Surgery, Orthopedics and Sports Medicine, Obstetrics and Gynecology, Critical Care, Diagnostic and Interventional Radiology, Oncology, Endocrinology, Cardiology, Gastroenterology (GI), Neurology, Nephrology, Sleep Medicine, and Pain Management. The hospital is committed to providing its patients with up-to-date treatment options for gastroenterological disorders with the sole purpose of improving quality of life.Gastroenterologists perform many specialized tests, such as endoscopy, to diagnose or treat diseases. When necessary, they may consult with surgeons. At the completion of the Fiscal Year FY23, the Division of Gastroenterology had 7,720 cases with an average length of stay of 3.3 days. 12521105 12749778 Bone & Joint (Orthopedics):The Orthopedics Department at Windham community Memorial Hospital offers the community a full range of services, including Hand and Upper Extremity, Total Joint Care, Sports Medicine, Physical Therapy and Advanced Imaging. As a member of Hartford HealthCare Corporation's network, the hospital has access to the integrated health network's recognized expertise, ongoing research studies that evaluate new treatments and one of the nation's top training centers for robot-assisted surgery. Windham Community Memorial Hospital surgeons are the first in Windham County to Utilize Mako robotic arm-assisted technology for total hip and knee replacement. Our Specialties include:Advanced ImagingFoot & AnkleHand & Upper ExtremityHipKneeOsteoporosisShoulderSpine CareSports MedicineTotal ReplacementsJoint Replacement Pre-Op classesAt the completion of FY23, the Division of Orthopedics had 12,827 cases with an average length of stay of 3.0 days. 73563675 43536 83555518 73563675 43536 83555518 119559069 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 72 0 1 731 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CT X Anthony Mastroianni 8604566821 112 Mansfield Avenue Willimantic CT 06226 Mary Barry MD Director 1.00 39.00 X 0 44239 1548 Donna Handley Director/President 30.00 30.00 X X 0 850885 65046 Stephen Larcen MD Director 1.00 2.00 X 0 0 0 Mark Tramontozzi MD Vice Chair 2.00 58.00 X X 0 273740 46017 Kristen Gildersleeve Director 1.00 59.00 X 0 234074 51015 Henry Beck Director 1.00 2.00 X 0 0 0 Mark DePonte Director (Thru 10/22) 1.00 2.00 X 0 0 0 Lee-Ann Gomes Director 1.00 2.00 X 0 0 0 Anthony Joyce III Chair 2.00 4.00 X X 0 0 0 Anita Lee Director 1.00 2.00 X 0 0 0 Carina Vora Director 1.00 2.00 X 0 0 0 Anthony Mastroianni VP, Finance 30.00 30.00 X 0 308879 60158 Matthew Kaufman VP, Operations 30.00 30.00 X 0 302117 53959 Abbie Courtemanche MD VP, Medical Affairs (Thru 09/23) 30.00 30.00 X 0 446694 54610 Mohammed Qureshi MD VP, Medical Affairs 30.00 30.00 X 0 378691 57435 Colleen Desai VP, Patient Care Services 30.00 30.00 X 0 162865 10103 Michael Bontempo VP, Human Services 30.00 30.00 X 0 273686 44383 Julian Munoz MD Physician 60.00 X 382073 0 30926 Melisha Cumberland MD Physician 60.00 X 506747 0 22917 Michael Keenan MD Hospitalist 60.00 X 375566 0 41682 Kyle Finnegan MD Hospitalist 60.00 X 376985 0 30158 Deborah Coggeshall Registered Nurse Clinical III 60.00 X 293692 0 48073 Kismatkumar Detroja MD Former Highest Comp. EE 0.00 0.00 X 139140 0 7412 2074203 3275870 625442 86 1 1 0 ORIGIN INCORPORATED 1800 SW 1st Street STE 510 Portland OR 97201 Staffing Service 2733816 MORRISON MANAGEMENT SP INC ACUTE CA 400 Northbridge Road Sandy Springs GA 30350 Food Service 906583 ANESTHESIA ASSOCIATES OF WILLIMANTI 1185 Main Street Willimantic CT 06226 Medical Service 840762 BERSTEIN-MAGOON-GAY LLC PO Box 61323 King of Prussia PA 19406 Laundry Service 582120 ALLIANCE HEALTHCARE SERVICES INC 3810 Winchester Road Memphis TN 38118 Medical Service 500873 24 688385 688385 Inpatient & Outpatient services 621400 127843128 127843128 Income From JV 900003 -173556 -173556 127669572 310761 310761 847784 373289 474495 474495 474495 54512 0 54512 54512 54512 129197725 127843128 -173556 839768 43536 43536 42923663 40038365 2828991 56307 3011878 2809422 198505 3951 3496558 3261522 230449 4587 3283660 3062935 216418 4307 26515 26515 4438 4438 11657189 11657189 676 676 1022753 746118 274711 1924 7397883 3920878 3477005 2417278 2157761 259517 41682 41220 353 109 43121 42770 26 325 1065485 649946 415539 12777065 11371588 1405477 3588145 2719196 868949 871722 871722 Medical Supplies 23635756 23635756 Hospital Provider User 6276956 6276956 Purchase Services 3946388 3562822 383566 Repairs Maintenance 2427143 2371895 54570 678 469755 317472 151791 492 130429245 119559069 10797496 72680 423588 113178 7622 8237 10816711 9268026 1735463 1700025 243712 168602 115984101 83480795 34306173 32503306 74954 1078512 8529729 9056193 5205 34851113 35854103 90989065 89755387 9838513 9704776 6906859 5957642 45246453 46084066 61991825 61746484 X 22885026 21746628 6112214 6262275 28997240 28008903 90989065 89755387 X -1231520 1063970 -820787 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 26515 0 0 26515 0 Part II-B, Line 1: Windham Community Memorial Hospital paid dues to McDermott Will & Emery LLP that provided lobbying services on behalf of the organization during the fiscal year. Efforts mainly include the lobbying of Connecticut State Legislators in the interest of tax exempt hospitals in the State of Connecticut. The Organization also paid annual dues to Connecticut Hospital Association (CHA). CHA conducts lobbying activities on behalf of its members. CHA allocates a portion of their dues as lobbying expenses. The portion of dues allocated as lobbying expenses is calculated under current Medicare rules. CHA conducts lobbying activities under current Medicare rules. The total amount of all dues allocated for lobbying expenses for FY23 was $26,515. 3805000 217000 4022000 3989147 -184000 3805000 3097147 892000 3989147 2867147 230000 3097147 2795147 72000 2867147 0.30000 0.70000 0 1 1 1409017 1409017 67297233 46405137 20892096 1221970 1108173 113797 41345303 35967485 5377818 4710578 4710578 32503306 Assets Held In Trust 5069308 C Invest. Endowment - TEMP 2745434 C Invest. Endowment - PERM 1091855 C Investment in Endowment 149596 C 9056193 Due from Affiliates 16842469 Other Non Current Assets 15119354 Other Assets 3892280 35854103 LT Debt HHC - Interco. Bonds 26658924 Accrued Post Retirement Pension 9994678 Other Liabilities 6139154 Accrued Malpractice 1057579 Hospital Provider User Fee 1569239 SERP Liability 227742 Bond Billing Control 436750 46084066 Part V, Line 4: The Hospital has adopted investment and spending policies for Endowment assets that attempt to provide a predictable stream of funding to mission related programs such as those described in Part III, lines 4a-d while seeking to maintain purchasing power of the endowment assets. Endowment assets include those assets of donor-restricted funds that the Hospital must hold in perpetuity or for a donor-specific period(s). Under this policy, as approved by the Board of Directors, the Endowment assets are invested in a manner that is intended to produce a real return, net of inflation and investment management costs, of a least 4% over the long term. Actual returns in any given year may vary from this amount. The Hospital's Endowment consists of hundreds of individual funds established for a variety of purposes. Net assets associated with Endowment funds are classified and reported based on the existence or absence of donor-imposed restrictions. The income generated by the funds are used mainly for capital expenses. 1 1 1 X 250.000000000000 1 X 1 1 1 0 0 1823694 1823694 0.01400 31402115 19342571 12059544 0.09250 33225809 19342571 13883238 0.10650 502362 502362 0.00390 256575 256575 0.00200 2160915 388359 1772556 0.01360 37088 37088 0.00030 2956940 388359 2568581 0.01980 36182749 19730930 16451819 0.12630 44184 44184 0.00030 44184 44184 0.00030 0 4724768 0 19015767 18551766 464001 X 1 1 1 1 Windham Community Memorial Hospital 112 Mansfield Avenue Willimantic CT 06226 www.wcmh.org 0061 X X X Windham Community Memorial Hospital 1 0 0 1 X X X X X X X X X 22 1 1 0 1 X See Part V, Page 8 X X 1 22 1 See Part V, Page 8 0 1 X 250.000000000000 400.000000000000 X X X X 1 1 X X X X X 1 X See Part V, Page 8 X See Part V, Page 8 X See Part V, Page 8 X X X X X X X 1 X 0 X X X 1 X 0 0 Windham Community Memorial Hospital Part V, Section B, Line 5: The Community Health Needs Assessment is a systematic, data-driven approach to determining the health status, behaviors and needs of residents in Hartford HealthCare's service areas. The information garnered from the assessment may be used by Hartford HealthCare to inform decisions and guide efforts to improve community health and wellness. Hartford HealthCare operates in five Community Benefit regions Central Region (Hospital of Central Connecticut & Midstate Medical Center), East Region (Backus Hospital, Natchaug Hospital & Windham Hospital), Hartford Region (Hartford Hospital), Northwest Region (Charlotte Hungerford Hospital) and Fairfield Region (St. Vincent's Medical Center).The regional approach includes partners within and across regions, hospital services areas, and community-based health equity champions. Recognizing the need to reduce and eliminate health disparities and to increase diversity at the leadership and governance levels of health care and other local organizations is a central and necessary first step in community health improvement. The second step to improving health equity is to collect and use data about race, ethnicity, and language preference to develop a shared understanding of the challenges in the community. Education about cultural sensitivity is also required. The HHC regional teams involved a team of health "Equity Champions" representing multiracial or other marginalized communities to help ensure the research is reflective of the community perspectives.Windham Hospital worked closely with health service area collaboratives including local public health departments to complete its CHNA. At a minimum, local public health worked with Windham Hospital to review hospital, state and local data and help define 2022 CHNA priorities. Additionally, to increase their understanding of community members' perspectives on identified health issues and ideas for addressing them, staff solicited input from individuals representing the broad interests of the community such as staff from social service and public health organizations and community residents. Staff collected feedback through a range of methods, including focus groups and interviews. Community input came from diverse groups in terms of age, race/ethnicity, cultural group, and other demographics. A special effort was made to reach historically underserved communities including, but not limited to: low-income, elderly, and racial/ethnic minority populations. Where possible, the hospital aligned their process with assessments being conducted by local public health and other community agencies. Input from persons representing the broad interests of the community was taken into account through key informant interviews with twelve (12) individuals. Stakeholders included: individuals with special knowledge of or expertise in public health; local public health departments; hospital staff and providers; representatives of social service organizations; and leaders, representatives, and members of medically underserved, low-income, and minority populations. Data from multiple sources were gathered and assessed, including secondary data published by others and primary data obtained through community input. Input from the community was received through key stakeholder interviews. Interviewees represented the broad interests of the community and included individuals with special knowledge of or expertise in public health as listed below; Center for Healthy Aging CHR (Community Health Resources) Connecticut Alliance for Basic Human Needs Eastern Highlands Health District FoodShare/CT Food Bank Generations Family Health Center, Inc. North Central District Health Department United Way of Central and Northeastern Connecticut Windham Area Interfaith Ministry Windham Public Schools Certain community health needs were determined to be "significant" if they were identified as problematic in at least two of the following three data sources: (1) the most recently available secondary data regarding the community's health and (2) input from community stakeholders who participated in the interview process. In addition, data were gathered to evaluate the impact of various services and programs identified in the hospital's previous CHNA process. Significant Community Health Needs were determined by analyzing secondary community health data and gathering input provided by community stakeholders. Windham Community Memorial Hospital Part V, Section B, Line 6a: For this community health assessment, Windham Community Memorial Hospital collaborated with the following Hartford Healthcare hospitals: The William W. Backus Hospital, Charlotte Hungerford Hospital, Hartford Hospital, The Hospital of Central Connecticut, Midstate Medical Center, and Natchaug Hospital. These facilities collaborated by gathering and assessing secondary data together, scheduling and conducting interviews together, and by relying on shared methodologies, report formats, and staff to manage the CHNA process. Windham Community Memorial Hospital:Part V, Section B, Line 7a:https://windhamhospital.org/community-health-needs-assessment Windham Community Memorial Hospital Part V, Section B, Line 7d: The needs assessment was published in September 2022 and is available on the Hospital's website. In addition, electronic copies are available upon request.Windham Community Memorial Hospital:Part V, Section B, Line 10a:https://windhamhospital.org/community-health-needs-assessment Windham Community Memorial Hospital Part V, Section B, Line 11: The 2021 Community Health Needs Assessment ("CHNA") for Windham Hospital, part of Hartford HealthCare's (HHC) East Region, leveraged numerous sources of local, regional, state and national data along with input from community-based organizations and individuals to provide insight into the current health status, health-related behaviors and community health needs for the Hospital service area. In addition to assessing traditional health status indicators, the 2022 CHNA took a close look at social determinants of health (SDH) such as poverty, housing, transportation, education, fresh food availability, and neighborhood safety and contains an Equity Profile. These two enhancements are in response to the lessons of COVID and in recognition of an emerging national priority to identify and address health disparities and inequities. HHC and Windham Hospital are committed to addressing these disparities and inequities through its Community Health Improvement Plan (CHIP). The intent of our CHIP is to be responsive to community needs and expectations and create a plan that can be effectively executed to leverage the best of the system resources, regional hospital and network resources, and community partners. The CHIP supports HHC's mission "to improve the health and healing of the people and communities we serve and is part of HHC's vision to be "most trusted for personalized coordinated care." More specifically, this CHIP is collectively aimed at living our Value of Equity which reminds us all to do the just thing.The 2022 assessment identified promoting healthy behaviors and lifestyles, reducing the burden of chronic disease, improving health equity, social determinants of health and access to and coordination of care and services, and enhancing community-based behavioral health services as priority needs for 2022-25 across all Windham Hospital geography. Prioritized communities:- disadvantaged communities, people of color, and others who have historically lacked adequate access to services.Objective/goal progress:- Promote Healthy Behaviors and Lifestyles* RX For Health- This Program provides vouchers for fresh produce to individuals in need of nutritional support. Funded by Windham Hospital, vouchers are distributed in various settings such as pediatrician offices, soup kitchens, women's health centers, Head Start Programs, etc. Windham Hospital collaborates with local community partners to identify families and individuals who would benefit. Vouchers are currently exchanged at the Willimantic Farmers' Market, Willimantic Food Co-op and Windham hospital's farm stand. HHC dietitian provides ongoing nutritional support to families. Through this program, more than $2,100 has been reimbursed to farmers and local partners whom accepted the vouchers for payment.Reduce the Burden of Chronic Disease:* Universal Screening- This program is designed to meet the underserved members of our community where they are. Multiple hospital departments provide free chronic disease screenings in a variety of environments and locations. During testing, participants will be given education regarding the disease that they have been screened for and how to achieve a "normal" range. Participants will be given information about Primary Care Physicians (PCPs) as well as Urgent Care if needed.Improve Health Equity, Social Determinants of Health, and Access to and Coordination of Care and Services:* Diaper Connections- HHC has partnered with Windham Women's Health Center and Willi Wellness, as a Co-chair of the Diaper Connections Program for the State of CT. Between these two partnerships, 91,200 diapers have been distributed amongst 248 families. Willi Wellness operates on a reduced cost lease at the professional building on Windham Hospital campus to store and distribute diapers. They are also utilizing this commercial space as their headquarters for Special Olympic athletes of Eastern Ct, and dementia friendly and intellectual disability creative and art-based programs.* Outpatient Services For Cancer Patients- In collaboration with the Integrative Medicine Department, cancer patients were able to benefit from five free sessions of Therapeutic Massage, Reflexology and Energy Therapy. Research has shown that relaxation techniques through integrative medicine may help to decrease anxiety, strengthen the immune system, diminish pain, and accelerate healing. Sessions are approximately 60 minutes.* Pipeline Strategy- In efforts to continue to promote careers in the health care sector and to address the pipeline issues that many students from diverse and underserved backgrounds face when it comes to education and training, Hartford Healthcare continues to conduct a series of health care career events & opportunities within local high schools. Schools with established certification programs i.e. CNA, EMT, etc. will be given specific focus as partnerships with high schools can lead students to open positions at Windham hospital resolving department staffing need. Students will have exposure to different career pathways through interactions with department representatives to educate them about specific job roles and responsibilities within a given department. We will approach these interactions through a diversity and equity lens and whenever possible have staff members that can relate culturally to the students with whom they are interacting. Enhance Community-Based Behavioral Health Services:* Neighborhood Health- was developed in collaboration with trusted community partners. These innovative health clinics continue to be adaptable, flexible, and open to feedback to ensure access to needed services and programs. Mobile "Care-Vans" visit and operate daytime health clinics at specifically chosen locations every week. They offer a variety of health services including screenings, mental health counseling, medical referrals, education and support. FY 2023- 2 Health Fairs, 20 clinics, 51 referrals made to local community providers. 100 Flu vaccines were conducted at Prides Corner Farms in Lebanon to underrepresented workers. Net Expense- $83,031 (Losses associated with delivering Neighborhood Health program in the community).All strategies proposed in the 2023 CHIP have shown progress in identifying CHNA needs with the exception of Mental Health and Substance Use Support Groups support groups. Strategies slow to start or requiring special mention are listed below. * Waste Not 2.0 Windham - Partnering organizations include CT Foodshare, Covenant Soup Kitchen, and North Central Health District. Although this program has not been fully implemented, in FY '23 there have been numerous meetings for this initiative. Criteria and requirements set forth by Health Districts are unattainable at this time.In FY '24, HHC will be researching other hospitals to discover standard work and best practices that may be able to be utilized at Windham, and with local health district. * Mental Health and Substance Use Support Groups- Due to setbacks from the pandemic, some of these groups are slow to start up again, or have been operating via digital meeting platforms. Community based Mental health Agencies are also struggling with staff and resources which makes the opportunity to host/run support groups limited. * Healthy Beginnings (Windham)- Healthy Beginnings was a program developed to connect new mothers and their babies who use the Windham Women's Health Center for pre and post-natal care to community services and resources. The program's inception in 2021 has led to the initiative's full scope of work being adopted into the day to day work of the women's health center in 2023. While the Healthy beginnings program is no longer a stand-alone program, the fact that the programs core tenants have been absorbed into the everyday work of the Women's health center shows major progress. In FY '23, this program completed 46 referrals to community resources. 10 Initial assessments were provided. CHW and translator hours totaled to 9.5. Windham Community Memorial Hospital Part V, Section B, Line 13h: Family eligibility criteria for Financial Assistance also include family size, employment status, financial obligations, and amount and frequency of health care expenses. Windham Community Memorial Hospital Part V, Section B, Line 15e: In addition, patients may ask a nurse, physician, chaplain, or staff member from Patient Registration, Patient Financial Services, Case Coordination, or Social Services about initiating the Financial Assistance Application process.Part V, Line 16a, FAP website:https://windhamhospital.org/patients-visitors/for-patients/financial-assistancePart V, Line 16b, FAP Application website:https://windhamhospital.org/patients-visitors/for-patients/financial-assistancePart V, Line 16c, FAP Plain Language Summary website:https://windhamhospital.org/patients-visitors/for-patients/financial-assistance Windham Community Memorial Hospital Part V, Section B, Line 16j: Patients are informed directly by staff of the availability of the Financial Assistance Policy. 6 1 - Windham Middle School Health Center 123 Quarry Street Willimantic CT 06226 In-Depth Health and Mental Health Assessment 2 - Windham High School Wellness Center 355 High Street Willimantic CT 06226 In-Depth Health and Mental Health Assessment 3 - Charles H Barrows STEM Academy 141 Tuckie Road North Windham CT 06256 School Based Health Center 4 - Windham Hospital Family Health Center 5 Founders Avenue Suite 201 Willimantic CT 06226 Patient Rehabilitation 5 - The Center for Women's Health 7 Ledgebrook Drive Mansfield CT 06250 Women's Health Services 6 - Storrs Physical Therapy Clinic 1244 Storrs Road Mansfield CT 06250 Patient Rehabilitation Part I, Line 3c: The Organization uses Federal Poverty Guidelines (FPG) to determine eligibility. In addition to the FPG, the Hospital also utilizes other eligibility criteria, such as asset level, medical indigence and insurance status. Part I, Line 6a:Although the Organization does not prepare a formal Community Benefit Report, it submits a quarterly report to The Connecticut Hospital Association and Form 990 is submitted to the Connecticut Office of Health Strategy (OHS) annually. Part I, Line 7: The Organization utilized an overall cost to charge ratio, (RCC), developed from the Medicare Cost Report. Total expense was adjusted for: medicaid provider taxes, directly identified community benefit expense and community building expenses. The methodology used to capture costs on Line 7a was updated to better reflect the cost of care provided to our patient population. This cost to charge ratio was used to calculate costs for Part I lines 7b & g. The costs associated with the activities reported on Part I, Line 7e were captured using actual time multiplied by an average salary rate. The costs associated with Line 7h, were the actual costs reported in the organization's general ledger less any industry funded studies. These costs were removed from the calculations above to avoid duplication. Costs reported in Part III, Section B6, were calculated from the Medicare cost report and reduced for Medicare costs previously reported on Part I Lines 7f and g. Part I, Line 7g: No physician clinic costs were included in the Subsidized Health Services cost calculations. Part II, Community Building Activities: Windham Community Memorial Hospital coordinates with various organizations to perform community building activities that addresses issues related to Social Determinants of Health, and as such, the hospital interacts with the community to address these needs and facilitates appropriate responses. The total expenditure for FY23 is $44,184. Part III, Line 3: During the fiscal year, a pre bad debt financial assistance screening is performed. The purpose of the screening is to identify patients that may have been eligible for financial assistance. Pre bad debt accounts that were identified as meeting the requirements for financial assistance were adjusted and designated as charity care. Therefore, any other bad debt expense that could be attributable to charity is immaterial. Part III, Line 4: Please see the text of the footnote that describes bad debt expense beginning on page 25 of the Audited Financial Statement. Part III, Line 8: Cost Reports were used to report Medicare allowable costs. Medicare defines allowable costs as those appropriate and helpful in developing and maintaining the operation of patient care facilities and activities. It specifically excludes certain costs that are not directly related to patient care. The hospital incurs additional expense related to the provision of care to Medicare patients that Medicare has deemed non-allowable. This additional expense includes costs of physician services (emergency on-call fees, Hospitalist Programs, recruitment, etc.), advertising costs, cafeteria costs for meals sold to visitors, etc. The Hospital attempts to collect coinsurance and deductibles from Medicare beneficiaries. To the extent collection efforts are unsuccessful, Medicare reimburses the hospital at 65% of unpaid amounts. The table reconciles the shortfall or surplus from Line 7 to the actual surplus or shortfall. The additional costs were allocated to Medicare based upon Medicare's percentage of total allowable costs. The unpaid coinsurance/deductibles were estimated using historical collection results. Any shortfall amounts have not been treated as Community Benefits. Part III, Line 9b: The Windham Community Memorial Hospital has adopted the Financial Assistance Policy of its Parent Company, Hartford HealthCare Corporation. The following is included in the Financial Assistance Policy: Patients who are deemed ineligible for financial assistance or who receive a partial discount and do not pay their bills may be subject to the following Extraordinary Collection Action (ECAs):*Wage Garnishments*Liens on primary and secondary residences, bank or investment accounts, or other assets*Legal actions and reporting the matter to one or more credit rating agencies*Other ECAs not listed aboveIf an individual has not submitted an application within the first 120 days from the date on which Hartford HealthCare first issues its first, post-discharge billing statement, then Hartford HealthCare may begin engaging in the ECAs described above.ECAs may begin after the first 120 days from the date on which Hartford HealthCare issues its first, post-discharge billing statement. If the patient applies for assistance within 240 days from the first notification of the self-pay balance, and is granted assistance, Hartford HealthCare will take all reasonable available measures to remove any collection actions such as negative reporting to a credit bureau or liens that have been filed.Before Hartford HealthCare initiates any collection actions, it will issue a written notice to the last known address of record for the patient (or his/her family) that describes the specific collection activities it intends to initiate (or resume), provides a deadline after which such action(s) will be initiated (or resumed), and includes a plain language summary of this Policy. ECAs can begin no sooner than 30 days from the date written notice is transmitted. Patients who are ineligible for financial assistance, or qualify for partial financial assistance and who are cooperating in good faith to resolve the outstanding accounts, may be offered extended payment plans. No further collection action will be taken as long as the patient continues to meet the terms of the payment plan. Part VI, Line 2: The Hartford HealthCare Community Health Needs Assessment (CHNA) serves as a component in the overall efforts to improve community health and health equity in each of the seven-hospital service areas. It is a process that provides a means of identifying and collecting community data while engaging community members in both the data collection and the prioritization of collaborative efforts for improving the well-being of the area. The ultimate purpose of the HHC CHNA is to improve community health and to do so in an effective and efficient way. The supporting objectives are to do the following: 1. Enhance Community Engagement and Better Incorporate the Consumer's Voice - CHNA/CHIP process leads to continuous and trusting feedback loops with diverse populations and enhances our methods for on-going engagement with the communities we serve. 2. Grow and Sustain our Community-based Partnerships - CHNA/CHIP process leads to more formalized partnerships with regional and community organizations and collaborations, and more meaningful relationships with key community opinion leaders. 3. Align Community Health with our Equity Value and Across the Regions - CHNA/CHIP process leads to a greater sense of team and purpose within HHC, assures each region is equitably resourced, and that collectively we know and understand more about identifying community health needs and improving health outcomes. 4. Bring Greater Clarity and Social Impact to our Community Health Work - CHNA/CHIP process leads to more effective, justified, measurable, and reportable interventions across our collective CHIPs and inspires and informs our social investment, sponsorship, and donation activities.Approach:The major pieces of the assessment helped to assemble a large list of needs. Major assessment activities are listed below. Note that the survey and qualitative research numbers refer to HHC system CHNA activities not solely this hospital. * Data analysis an extensive set of Hospital Service Area (HSA) data tables reflecting demographics, Social Influencers of Health, lifestyle characteristics, disease incidence (morbidity and mortality) and others * Qualitative research an in-depth series of 100 stakeholder interviews and 30 focus group discussions * Survey research a bilingual community survey with approximately 600 responses Interestingly, ALL of the needs are important, yet to achieve the ultimate goal of the CHNA, HHC leaders deployed a needs prioritization process to identify a granular list of 12 needs. The prioritization process and other assessment activities are described in the body of this CHNA.Categories of needs:In order to truly affect change and address high-priority needs, needs were identified and categorized into the following groups: * Ones with the greatest opportunity for immediate impact (i.e., the "low hanging fruit" issues for which HHC can take a leadership role and rapidly deploy activities and resources) * Issues supported by the data that have the greatest impact on health outcomes * Needs identified by community as urgent or high-priority concerns * Issues that present the greatest opportunity for collaboration and policy changeThe CHNA is formulated in a way to ultimately impact individuals and families in the service area. To accomplish this, HHC leaders will take CHNA results and deploy a systematic approach to developing the Community Health Improvement Plan (CHIP) an activity critical to achieving this ultimate goal. Some of the initial, well-defined steps to develop and deploy the CHIP include the following: STEP 1 - Culling the Findings Brainstorming with your local collaboratives by answering the following questions: CHNA Immediate Impact findings where is the low hanging fruit? CHNA Greatest Impact findings -- what will most influence health outcomes? CHNA Most Desired Change findings - what change does the community most want? CHNA Forging Opportunities findings - where are the greatest opportunities for partnership? STEP 2 - Organizing the focus areas and assembling your rationale for action STEP 3 - Selecting your Strategies and Interventions STEP 4 Executing and EvaluationAssessment Approach & Methodology:Hartford HealthCare (HHC) worked with its assessment partners Crescendo Consulting Group and DataHaven to formalize and deploy a highly inclusive assessment framework. The framework was structured to be welcoming to priority communities and others, steeped in best practices, and designed to triangulate insights. At the conclusion of the process, the local stakeholders developed a succinct, prioritized list of community needs. To do this, the methodology included a mixed modality approach quantitative, qualitative, and technology-based techniques to learn about the human stories and voices while weaving them with the best available data. Crescendo engaged community partners, used data analytics, and invited others to join the discovery process to help describe a positive cycle of change. The assessment activities meet the following goals: * Identify community resources, strengths, and barriers. * Develop a deeper understanding of community health equity and inequalities. * Enable the community to coalesce around, and act upon, the opportunities for population health improvement.The assessment involved substantial qualitative data gathering to highlight local knowledge and expertise, and support outreach efforts for community engagement. The primary qualitative mixed-mode approach engaged policy leaders, key stakeholders, non-profit organizations, health care consumers, the criminal justice system, diversity representatives, people experiencing homelessness, and others throughout the hospital service area. * Health Equity Champions Outreach * Stakeholder One-to-One Interviews * Focus Group Discussions Systemwide, 100 interviews and 30 focus group discussions were held. Conversations with community stakeholders helped us identify weaknesses of programs and resources in the community. Part VI, Line 3: Windham Community Memorial Hospital provides information about its Financial Assistance Policy as follows:(1) Provides signage, brochures and/or a written plain language summary describing the policy along with financial assistance contact information in the emergency department, discharge paperwork, other patient registration/admission areas, as well as in billing and collection communication.(2) Makes paper copies of the policy, financial assistance application, and plain language summary of the policy available upon request and without charge, by mail.(3) Posts the policy, plain language summary and financial assistance application on the website with clear linkage to such documents on the Hartford HealthCare and each affiliated hospital's home page.(4) Educates all admission and registration personnel, financial counselors, billing and collection specialists and social workers regarding the policy so that they can serve as an informational resource to patients.(5) Includes the tag line "Please ask about our Financial Assistance Policy" in applicable Hartford HealthCare written publications. Part VI, Line 4: Windham Hospital is a 130-private bed, not-for-profit acute care community hospital that has continuously provided inpatient, outpatient, rehabilitation, and emergency services in Northeastern Connecticut for over 75 years. The hospital also has a Cancer Institute with a state-of-the-art infusion center and The Center for Healthy Aging to provide care resources for seniors and their caregivers. For more information, please visit www.windhamhospital.orgWindham Hospital is a member of Hartford HealthCare. Hartford HealthCare operates seven acute-care hospitals, airambulance services, behavioral health and rehabilitation services, a physician group and clinical integration organization, skilled nursing and home health services, and a comprehensive range of services for seniors, including senior-living facilities. For more information, please visit https://hartfordhealthcare.org/-The Windham Hospital Service Area is a region of 80,421 residents, 30% of whom are people of color. The regions population has decreased by 3% since 2010.-Of the regions 26,339 households, 68% are homeowner households.-Thirty-six percent of the Windham Hospital HSAs households are cost-burdened, meaning they spend at least 30% of their total income on housing costs.-Among the regions adults ages 25 and up, 35% have earned a bachelors degree or higher.-The Windham Hospital HSA is home to 26,317 jobs, with the largest share in the Health Care and Social Assistance sector. The median household income in the Windham Hospital HSA is $76,359. The Windham Hospital HSAs average life expectancy is 79.8 years.-Fifty-seven percent of adults in the Windham Hospital HSA say they are in excellent or very good health. In 2020, 27 people in the Windham Hospital HSA died of drug overdoses.-Eighty-six percent of adults in the Windham Hospital HSA are satisfied with their area, and 56% say their local government is responsive to residents needs.-In the 2020 presidential election, 78% of registered voters in the Windham Hospital HSA voted.-Forty percent of adults in the Windham Hospital HSA report having stores, banks, and other locations in walking distance of their home, and 40% say there are safe sidewalks and crosswalks in their neighborhood. Part VI, Line 5: Windham Community Memorial Hospital was formed to serve its community in 1933 and has been an important resource for nearly 87 years. A Regional Board governs Natchaug, Windham, and Backus Hospitals. The Board is responsible for maintaining outstanding quality services and credentials its medical staff. The majority of Hospital's governing board is comprised of persons who either reside or work in its primary service area, and they are neither employees nor contractors of the Hospital.The Windham Hospital Foundation, a related organization, raises funds to assure that the latest advancements in technology are available to our patients, as well as a range of community benefit programs that are not funded by other sources. We are a true community resource as we offer space for other community groups to meet at no charge, bring together other health providers for health fairs and educational sessions for the community, and encourage the involvement of our staff on various boards and councils that promote the overall health of the community. Part VI, Line 6: Hartford Healthcare Corporation (HHC) is organized as a support organization to govern, manage and provide support services to its affiliates. HHC, through its affiliates including Windham Community Memorial Hospital, strives to improve health using the "Triple Aim" model: improving quality and experience of care; improving health of the population (population health) and reducing costs. HHC and its affiliates including all supported organizations, develop and implement programs to improve the future of health care in our Southern New England region. This includes initiatives to improve the quality and accessibility of health care; create efficiency on both our internal operations and the utilization of health care; and provide patients with the most technically advanced and compassionate coordinated care. In addition, HHC continues to take important steps toward achieving its vision of being "nationally respected for excellence in patient care and most trusted for personalized, coordinated care. The affiliation with HHC creates a strong, integrated health care delivery system with a full continuum of care across a broader geographic area. This allows small communities easy and expedient access to the more extensive and specialized services the larger hospitals are able to offer. This includes continuing education of health care professionals at all the affiliated institutions through the Center of Education, Simulation and Innovation located at Hartford Hospital.The affiliation further enhances the affiliates' abilities to support their missions, identity, and respective community roles. This is achieved through integrated planning and communication to meet the changing needs of the region. This includes responsible decision making and appropriate sharing of services, resources and technologies, as well as cost containment strategies. Part VI, Line 7, Reports Filed With States CT 1 St Vincent De Paul Place 120 Cliff Street Norwich CT 06360 371639042 8536 0 To support the mission to serve those in Norwich and the surrounding areas who are physically, mentally, or spiritually impoverished. Bleeding Blue for Good 21 Tuckahoe Rd Trumbull CT 06611 883621334 10000 0 To empower UConn student-athletes to become champions in their sport. University of Connecticut Foundation Inc 2390 Alumni Drive Unit 3206 Storrs CT 06269 066070722 25000 0 To support Werth Insitute's Entrepreneurial Innvoation in Community Healthcare Program 3 0 Part I, Line 2: Upon issuing the grant, the hospital attaches a letter that restricts the use of the funds for a specific purpose. All of the grants are made to public charities to assist in funding their exempt programs. Therefore, extensive monitoring of the use of these funds by these entities is not warranted. 0 1 0 0 0 0 0 1 0 Donna Handley Director/President 0 510285 0 248265 0 92335 0 21350 0 43696 0 915931 0 0 Melisha Cumberland MD Physician 460530 0 43727 0 2490 0 21350 0 1567 0 529664 0 0 0 Abbie Courtemanche MD VP, Medical Affairs (Thru 09/23) 0 355629 0 90261 0 804 0 21350 0 33260 0 501304 0 0 Mohammed Qureshi MD VP, Medical Affairs 0 306559 0 71100 0 1032 0 21350 0 36085 0 436126 0 0 Michael Keenan MD Hospitalist 345656 0 29269 0 641 0 21350 0 20332 0 417248 0 0 0 Julian Munoz MD Physician 340392 0 41460 0 221 0 21350 0 9576 0 412999 0 0 0 Kyle Finnegan MD Hospitalist 314616 0 62170 0 199 0 21350 0 8808 0 407143 0 0 0 Anthony Mastroianni VP, Finance 0 228921 0 77684 0 2274 0 21006 0 39152 0 369037 0 0 Matthew Kaufman VP, Operations 0 224736 0 76924 0 457 0 20387 0 33572 0 356076 0 0 Deborah Coggeshall Registered Nurse Clinical III 283245 0 8025 0 2422 0 21350 0 26723 0 341765 0 0 0 Mark Tramontozzi MD Vice Chair 0 264559 0 7597 0 1584 0 17202 0 28815 0 319757 0 0 Michael Bontempo VP, Human Services 0 219469 0 51250 0 2967 0 19496 0 24887 0 318069 0 0 Kristen Gildersleeve Director 0 232994 0 350 0 730 0 17231 0 33784 0 285089 0 0 Colleen Desai VP, Patient Care Services 0 114527 0 48000 0 338 0 0 0 10103 0 172968 0 0 Kismatkumar Detroja MD Former Highest Comp. EE 121592 0 17486 0 62 0 6964 0 448 0 146552 0 0 0 Part I, Line 3 The Independent Executive Compensation Committee (Committee) of the Board of Directors of Hartford HealthCare, on behalf of Windham Community Memorial Hospital, hires an outside consultant, Human Resources and Compensation Consulting Practice of Gallagher, to determine best practices in governing executive compensation. Please refer to compensation narrative reported on Schedule O. Part I, Line 4b Hartford Healthcare Corporation, a related organization, maintains a 457(f) Supplemental Executive Retirement Plan (SERP). Participants include certain officers and key employees at the President & CEO, Executive Vice President and Senior Vice President levels that are reported by Windham Community Memorial Hospital on its Form 990, Part VII. Contributions are made by Hartford HealthCare Corporation to the plan based on a percentage of the participant's compensation. Participants vest in the plan at the earlier of reaching age 55 and having 5 years of service, death, disability, involuntary separation without reasonable cause, upon reaching age 65 or the occurrence of a change in control. Each participant ceases to be eligible for further contributions by Hartford Healthcare Corporation on the date of the participant's separation from service. Participants receive a one-time lump sum payment of the accumulated amount during the 30-day period following the participant's separation from service. 2022 SERP Payouts were made on behalf of the following individual: Donna Handley $48,307* * For this individual, vesting occurred, causing taxable income. This portion of the vested amount was used to pay the associated tax liability. The remaining balance was deposited into the employee SERP account. Part I, Line 7 Hartford HealthCare Corporation, a related organization, has a Compensation At Risk Plan that encourages and rewards achievements of significant functional goals. These goals contribute to the organization's strategic and financial direction. The plan utilizes market practice alignment to ensure competitive recruitment and retention. Awards are based on CEO and/or Hartford HealthCare Corporation's Compensation Committee discretionary assessment of overall organization performance and individual contribution to results. Form 990, Part VI, Section A, line 6 Windham Community Memorial Hospital is organized as a non-stock not for profit entity. Hartford HealthCare Corporation is the sole member. Form 990, Part VI, Section A, line 7a The sole member of the organization has the authority to approve/remove members of the governing body. Form 990, Part VI, Section A, line 7b The sole member of the organization has the right to review, approve, disapprove and deny significant transactions such as mergers, acquisitions, dissolutions etc. Form 990, Part VI, Section B, line 11b The Form 990 was prepared by Hartford HealthCare's Tax Department. It was then forwarded to the VP of Finance for review. The final Form was provided to the entire Board prior to submission to the Internal Revenue Services (IRS). Once the entire review process was completed, the Form was signed by the VP of Finance and then filed with the IRS. Form 990, Part VI, Section B, line 12c The hospital's board has adopted the policy of the member, Hartford HealthCare Corporation (HHC). HHC's Conflict of Interest Policy (Policy) requires all covered individuals, including board members and officers, to provide a disclosure of relationships that create or have the appearance of creating a conflict of interest or commitment. The Policy requires updates if changes in circumstances arise during the year that either (a) create a new potential conflict of interest or commitment or (b) change or eliminate a conflict of interest or commitment previously disclosed. Conflict of interest disclosure statements are maintained by the HHC Office of Compliance and Integrity (OCI). Employee and physician disclosures are reviewed by OCI in collaboration with the Covered Individuals' supervisor, when deemed appropriate, to determine if there is a potential conflict. Conflict mitigation plans are developed by OCI. Other individuals who may review potential conflicts of interest and approve conflict management plans include: the SVP/EVP of the department/area in which the individual works, the Institute Physician-In-Chief, the Medical Group Physician-In-Chief, the Regional Vice President of Medical Affairs, and/or the HHC Legal Department. Board member disclosures are reported to the HHC Nominating and Governance Committee for determinations of conflicts and the management of them, where applicable. Form 990, Part VI, Section B, line 15 The Independent Executive Compensation Committee (Committee) of the Board of Directors of Hartford HealthCare on behalf of Windham Community Memorial Hospital, hires an outside consultant, Human Resources and Compensation Consulting Practice of Gallagher, to determine best practices in governing executive compensation. The following steps were taken: - The use of an Independent Executive Compensation Committee (Committee) of the Board of Directors of Hartford HealthCare, on behalf of Windham Community Memorial Hospital, established and regularly reviews Executive Compensation Philosophy; - The Committee regularly reviews scope and depth of positions taking into account complexity and the financial impact and accountability of all "disqualified persons; - National peer groups are selected for comparative purposes based on organizational size, operating revenue, geography and other relevant factors; - Analysis of current total compensation versus market is performed by independent third party compensation consulting firm and is then reviewed by the committee; - Recommendations are made based on market data analysis to ensure appropriate competitive positioning within parameters of compensation philosophy; - The President & CEO compensation is reviewed by the Committee and is based on comparative market information and organizational performance; - All changes are reviewed and approved by the Executive Compensation Committee; The compensation determination process for the President & CEO is reviewed on an annual basis. All other executive compensation is regularly reviewed for scope and depth of positions taking into account complexity and the financial impact and accountability. Form 990, Part VI, Section C, line 18 The Hospital's Form 990, 990T and form 1023 and its attachments are available upon request. Form 990, Part VI, Section C, line 19 The Hospital's Financial Statements, Governing Documents and the Conflict of Interest Policy are available for inspection upon request at the Organization's address. Form 990, Part XI, line 9: Transfer to Affiliated Entities 132,820. Change in pension and post-retirement funding obligation -1,127,163. K-1 Income (Loss) Pass Thru Entities 173,556. 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