2020-07-15T10:02:15-05:00 2019-06-30 470617373 COMMONSPIRIT HEALTH 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2018-07-01 760458535 BAYLOR ST LUKE'S MEDICAL GROUP BAYL 8323555575 6624 FANNIN ST 1100 HOUSTON TX 77030 MARK TERESI INTERIM CHIEF FINANCIAL OFFICER 2020-07-15 true ANGELA NOEL P01051055 3032989100 2018 2020-09-23 17:36:50Z T DOUGLAS LAWSON 6624 FANNIN ST 1100 HOUSTON TX 77030 151233967 false X http://www.chistlukeshealth.org X 1996 TX To nurture the healing ministry of the Roman Catholic Church by bringing it new life, energy, and viability in the Twenty-First Century. Fidelity to the Gospel urges us to emphasize human dignity and social justice as it moves toward the creation of healthier communities. 10 5 543 9 0 0 0 127182303 150473390 17498 31149 1515636 729428 128715437 151233967 13825 35300 0 22615147 39304578 0 0 140969236 173122720 163598208 212462598 -34882771 -61228631 39711257 38832433 130050615 190400422 -90339358 -151567989 As an affiliate of CommonSpirit Health, we make the healing presence of God known in our world by improving the health of the people we serve, especially those who are vulnerable, while we advance social justice for all. false false 197154907 35300 150473390 BAYLOR ST. LUKE'S MEDICAL GROUP ("BSLMG") SERVES TO PROMOTE HEALTH CARE SERVICES AND HIGH QUALITY HEALTH CARE TO HOUSTON AND SURROUNDING COMMUNITIES BY PROVIDING HOSPITAL BASED AND COMMUNITY BASED CLINICS AS WELL AS OTHER HOSPITAL BASED PHYSICIAN SERVICES. BSLMG EMPLOYED 261 PHYSICIANS IN THE AREAS OF ANESTHESIOLOGY, HEMATOLOGY, ONCOLOGY, AND INTERNAL MEDICINE. APPROXIMATELY 740,837 PATIENT ENCOUNTERS WITH SLMG PHYSICIANS TOOK PLACE DURING THE PERIOD ENDED JUNE 30, 2019. 197154907 true false false false false false false false false true false false false true true false true false false false false false false false false false true false true false false false false false false false false false false false false false true false false false true X 0 0 543 true false false false false false false true false false false false false X 10 5 false false false false true true true true true false false true true true true true true false true false X MARK TERESI 8323552885 6624 FANNIN STREET STE 2505 HOUSTON TX 77030 JOEL KNEITZ MD Board Member/Vice Chair 50.0 0 X X 0 0 0 ferenc markos MD BOARD MEMBER/President/Chair 50.0 0 X X 0 0 0 Peter Bigler MD Board Member 1.0 49.0 X 0 0 0 Shayan Izaddoost MD Board MEMBER 1.0 0 X 0 0 0 Daniel Murphy MD Board MEMBER 1.0 0 X 0 0 0 QUOCDAI D PARK MD Board MEMBER 50.0 0 X 0 55000 0 MITESH PATEL MD Board Member 1.0 0 X 0 0 0 Mohamad Anis Sidani MD board MEMBER 1.0 0 X 0 0 0 Rachael Sullivan DO BOARD MEMBER 1.0 40.0 X 0 0 0 Roger J Zoorob MD Board Member 1.0 0 X 0 0 0 SAM FULTON TREASURER 50.0 0 X 229791 0 38632 T DOUGLAS LAWSON PHD CEO OF CHI ST. LUKE'S HEALTH SYSTEM 1.0 49.0 X 0 1355710 146269 MARK MCGINNIS CFO of CHI St. Luke's Health System 1.0 49.0 X 0 757960 70777 BRET ADAMS SECRETARY 50.0 0 X 67074 0 23753 JAMES ANTON ANESTHESIOLOGIST 50.0 0 X 477276 0 45657 PAUL BROCK JR ANESTHESIOLOGIST 50.0 0 X 456786 0 46074 LIQIAN CHEN ANESTHESIOLOGIST 50.0 0 X 462834 0 36797 JOSHUA COHEN ANESTHESIOLOGIST 50.0 0 X 453807 0 46074 MANU SETHI ANESTHESIOLOGIST 50.0 0 X 454169 0 45657 JENNY BARNETT-SARPALIUS FORMER CFO of CHI St. Luke's Health System 0.0 0.0 X 0 550000 0 Michael Covert FORMER CEO OF CHI ST. LUKE'S HEALTH SYSTEM 1.0 90.0 X 0 1280995 18328 2601737 3999665 518018 26 true true false BAYLOR COLLEGE OF MEDICINE 1 Baylor Plaza Houston TX 77030 Physician Services 91591908 HEART INSTITUTE OF EAST TEXAS 310 Gaslight Blvd Lufkin TX 75904 Physician Services 12650551 ENHANCED REVENUE SOLUTIONS 25700 Interstate 45 N The Woodlands TX 77386 Consulting/Billing Services 1576328 OPTIMUM COMPUTER SOLUTIONS INC 780 Westridge Rd The Woodlands TX 77380 Medical Billing Services 920348 ABEO INC 7301 N State Hwy 161 Suite 136 Irving TX 75039 Medical Billing Services 816898 28 0 0 0 0 0 0 0 0 Net Patient Services 900099 149394163 149394163 0 0 Medical Services 621300 1079227 1079227 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 150473390 31149 0 0 31149 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Intercompany Allocations 900099 668378 0 0 668378 Medical Records Revenue/Transcription 541200 61050 0 0 61050 0 0 0 0 0 0 0 0 729428 151233967 150473390 0 760577 X 35300 35300 272181 239519 32662 31856128 28033393 3822735 1247656 1097938 149718 4040839 3555938 484901 1887774 1661241 226533 2345 1876 469 121852084 113322438 8529646 0 269665 250788 18877 2513834 2337866 175968 15213691 14148733 1064958 332666 309380 23286 132305 123043 9262 3951 3675 276 1819884 1692492 127392 3682642 3424857 257785 217885 202633 15252 Medical Supplies 24546892 24546892 Miscellaneous Expenses 1453906 1161600 292306 Repairs and maintenance 675000 627750 47250 Recruitment and relocation 156378 145432 10946 249592 232123 17469 0 212462598 197154907 15307691 0 487203 0 5153741 2937039 0 0 25831182 25549084 0 0 0 202759 0 0 382980 312970 770903 18558396 9389848 7672276 9168548 0 0 0 0 0 0 51126 23879 39711257 38832433 19897070 20522001 0 0 307435 950078 0 0 0 0 0 0 0 0 0 109846110 168928343 130050615 190400422 X -90339358 -151567989 0 0 0 0 -90339358 -151567989 39711257 38832433 -61228631 0 X false true X true false X 0 0 3212332 1954112 1258220 6641006 2334431 4306575 6201453 5101305 1100148 2503605 0 2503605 9168548 INTERCOMPANY PAYABLES 168501851 UNCLAIMED PROPERTY 16115 Check Clearing Other Liabilities 260257 Misc Liability 107522 Retainage for CIP 42598 168928343 X Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote Baylor St. Luke's Medical Group's financial information is included in the consolidated audited financial statements of CommonSpirit Health, a related organization. CommonSpirit Health's FIN 48 (ASC 740) footnote for the year ended June 30, 2019, reads as follows: "CommonSpirit has established its status as an organization exempt from income taxes under the Internal Revenue Code Section 501(c)(3) and the laws of the states in which it operates, and as such, is generally not subject to federal or state income taxes. However, CommonSpirit's exempt organizations are subject to income taxes on net income derived from a trade or business, regularly carried on, which does not further the organizations' exempt purposes. No significant income tax provision has been recorded in the accompanying consolidated financial statements for net income derived from unrelated trade or business. CommonSpirit's for-profit subsidiaries account for income taxes related to their operations. The for-profit subsidiaries recognize deferred tax assets and liabilities for temporary differences between the financial reporting basis and the tax basis of their assets and liabilities, along with net operating loss and tax credit carryovers, for tax positions that meet the more-likely-than-not recognition criteria. Changes in recognition or measurement are reflected in the period in which the change in judgement occurs. Income tax interest and penalties are recorded as income tax expense. For the years ended June 30, 2019 and 2018, CommonSpirit's taxable entities recorded an immaterial amount of interest and penalties as part of the provision for income taxes. CommonSpirit's taxable entities did not have any material unrecognized income tax benefits as of June 30, 2019 and 2018. CommonSpirit reviews its tax positions quarterly and has determined that there are no material uncertain tax positions that require recognition in the accompanying consolidated financial statements". true American Heart Association 7272 Greenville Avenue Dallas TX 75231 135613797 501(c)(3) 15000 0 N/A N/A GENERAL SUPPORT THE HEART INSTITUTE OF EAST TEXAS 310 GASLIGHT BLVD LUFKIN TX 75904 751893084 16575 0 N/A N/A GENERAL SUPPORT 1 1 Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds. THE ORGANIZATION GRANTS FUNDS TO OTHER ORGANIZATIONS AND REQUIRES ALL GRANT RECIPIENTS TO MEASURE THEIR SUCCESS IN ATTAINING PROGRAM GOALS. true true false false false false false true false JENNY BARNETT-SARPALIUS FORMER CFO of CHI St. Luke's Health System 0 0 0 0 0 550000 0 0 0 0 0 550000 0 0 Michael Covert FORMER CEO OF CHI ST. LUKE'S HEALTH SYSTEM 0 145959 0 108433 0 1026603 0 15934 0 2394 0 1299323 0 0 SAM FULTON TREASURER 217745 0 9112 0 2934 0 10148 0 28484 0 268423 0 0 0 T DOUGLAS LAWSON PHD CEO OF CHI ST. LUKE'S HEALTH SYSTEM 0 733582 0 443750 0 178378 0 126625 0 19644 0 1501979 0 0 MARK MCGINNIS CFO of CHI St. Luke's Health System 0 549815 0 127460 0 80685 0 41025 0 29752 0 828737 0 0 JAMES ANTON ANESTHESIOLOGIST 450826 0 25190 0 1260 0 16375 0 29282 0 522933 0 0 0 PAUL BROCK JR ANESTHESIOLOGIST 441242 0 10000 0 5544 0 16375 0 29699 0 502860 0 0 0 LIQIAN CHEN ANESTHESIOLOGIST 447290 0 10000 0 5544 0 16375 0 20422 0 499631 0 0 0 JOSHUA COHEN ANESTHESIOLOGIST 443051 0 10000 0 756 0 16375 0 29699 0 499881 0 0 0 MANU SETHI ANESTHESIOLOGIST 442909 0 10000 0 1260 0 16375 0 29282 0 499826 0 0 0 Schedule J, Part I, Line 3 METHODS USED TO ESTABLISH CEO COMPENSATION Compensation for the top management official was established and paid by Catholic Health Initiatives (CHI), a related organization. CHI used the following to establish the top management official's compensation: (1) Compensation Committee; (2) Independent Compensation Consultant; (3) Written Employment Contracts; (4) Compensation Survey or Study; (5) Approval by the Board or Compensation Committee. Schedule J, Part I, Line 4a Severance or change-of-control payment During the calendar year 2018, post-termination payments were addressed in executive employment agreements for Catholic Health Initiatives and related organizations' employees at the level of Vice President and above, including the MBO CEOs. These employment agreements require that in order for the executive to receive post-termination payments, these individuals must execute a general release and settlement agreement. Post-termination payment arrangements are periodically reviewed for overall reasonableness in light of the executive's overall compensation package. The following reportable individuals received severance payments from Catholic Health Initiatives (a Related Organization) during the 2018 calendar year, and these severance payments were included in the individual's W-2 income and reportable compensation on Schedule J: Jennifer Barnett-Sarpalius - $550,000 Michael Covert - $1,008,106 Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan During the 2018 calendar year, Catholic Health Initiatives ("CHI"), a related organization, maintained a supplemental non-qualified deferred compensation plan for MBO CEOs/Presidents and other CHI employees at the level of Senior Vice President and above. Due to the "super" vesting rules under the CHI deferred compensation plan, participants who had met certain requirements such as involuntary termination without cause, age, age and years of service, or more than 5 years of plan participation were eligible to receive their 2018 contributions in cash during the calendar year. These cash payouts are included in the participant's reportable compensation in column (iii) Other Reportable Compensation on Schedule J Part II. During 2018, the following contributions and any associated investment income, gain or loss that would have been made by CHI to the deferred compensation plan were paid in cash: Michael Covert - $15,395 Schedule J, Part I, Line 7 Non-fixed payments ST. LUKE'S EXECUTIVES AND MEMBERS OF MANAGEMENT HAVE A NUMBER OF ANNUAL AND LONG TERM GOALS. FINANCIAL PERFORMANCE, QUALITY, PEOPLE, CUSTOMER SERVICE, AND GROWTH ARE EXAMPLES OF AREAS WHERE PERFORMANCE INDICATORS MAY BE ESTABLISHED. PERFORMANCE ON ALL GOALS IS EXAMINED BY THE SYSTEM BOARD AND AN AWARD LEVEL IS DETERMINED BASED ON OVERALL PERFORMANCE AGAINST TARGETS OR GOALS. IF AN AWARD IS GRANTED, IT IS EXPRESSED AS A PERCENTAGE OF THE INDIVIDUAL'S BASE INCOME. Form 990, Part V, Line 1a FORM 1096 REPORTING PAYMENTS TO VENDORS FOR ENTITIES THAT ARE PART OF CATHOLIC HEALTH INITIATIVES (CHI) ARE MADE BY CHI. THEREFORE NO FORM 1099S ARE ISSUED BY THE ORGANIZATION. CHI FILES THE FORM 1099S AND COMPLIES WITH THE BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS. THE 1099S ISSUED BY CHI ON BEHALF OF THE ORGANIZATION ARE REPORTED TO THE IRS. Form 990, Part VI, Line 14 WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY ST LUKE'S HEALTH SYSTEM CORPORATION AND RELATED ENTITIES HAVE A WRITTEN GENERAL POLICY RELATED TO DOCUMENT RETENTION AND DESTRUCTION. DOCUMENTS AND RECORDS ARE RETAINED FOR VARIOUS FEDERAL, STATE OR OTHER JURISDICTION STATUTES FOR MEDICAL OR FINANCIAL REVIEW ON A DEPARTMENT-BY-DEPARTMENT BASIS. Form 990, Part VI, Line 15a PROCESS FOR DETERMINING COMPENSATION - TOP MANAGEMENT OFFICIAL The organization's top management official's compensation was paid by Catholic Health Initiatives ("CHI"), a related organization. CHI had a defined compensation philosophy. Both the executive and non-executive compensation structures and ranges were reviewed annually in comparison to market data. Catholic Health Initiatives used Korn Ferry as the independent third party to assess executive compensation programs and to ensure the reasonableness of actual salaries and total compensation packages. Compensation of the senior most executives was reviewed annually. Korn Ferry reviewed both cash and total compensation for overall reasonableness, for adherence to Catholic Health Initiatives' compensation philosophy, and for comparability to the not-for-profit healthcare market. This independent review was delivered by Korn Ferry to the CHI HR committee of the Board of Stewardship Trustees annually at their September meeting and minutes shared with the full board at the December meeting. The last review was September 25, 2018. In addition, Korn Ferry completed a comprehensive review of all positions at the level of vice president and above in the fall of 2014 to determine and validate appropriate compensation levels. These levels were reviewed annually and revised based on market data, where applicable. Form 990, Part VI, Line 12c Conflict of Interest Policy b) Board evaluation of transactions involving an officer / board member conflict of interest - I. The board carefully scrutinizes and must in good faith approve or disapprove any transaction in which CHI or a CHI entity is a party and in which the trustee or a corporate officer either: 1. Has a material financial interest; or 2. Is a trustee or corporate officer of the other party (other than a CHI affiliated organization). II. The board must approve the transaction by a majority of the trustees on the board (not counting any interested trustee). In reviewing such transactions between CHI or CHI entities and vendors or other contractors who are, or are affiliated with, trustees or corporate officers, the board acts no more or less favorably than it would in reviewing transactions with unrelated third parties. The transaction is not approved unless the board determines that the transaction is fair to CHI or the CHI entity. III. A conflicted trustee or corporate officer is not permitted to use his or her personal influence with respect to the approval or disapproval of the conflicted transaction. However, if requested, such trustee or corporate officer is not prevented from briefly stating his or her position in the matter, nor from answering pertinent questions from trustees, as his or her knowledge may be relevant. The trustee or corporate officer is excused from the meeting during discussion and vote on the conflict of interest. c) Board evaluation of non-transactional conflicts - I. The board carefully reviews and scrutinizes any non-transactional conflict of interest (e.g., disclosure of nonpublic information, competition with CHI or a CHI entity, failure to disclose a corporate opportunity, excessive gifts or entertainment, etc.). II. In such circumstances, by a majority vote of the disinterested trustees, the board takes whatever action is deemed appropriate with respect to the trustee or corporate officer under the circumstances (including possible disciplinary or corrective action) to best protect the interests of CHI or the CHI entity. The board is encouraged to consult with the general counsel of CHI or his or her designee when considering disciplinary or corrective action. III. The conflicted trustee or corporate officer is not permitted to use his or her personal influence with respect to the conflict matter. However, if requested, such trustee or corporate officer is not prevented from briefly stating his or her position in the matter, nor from answering pertinent questions from trustees, as his or her knowledge may be relevant. The trustee or corporate officer is excused from the meeting during discussion and vote on the conflict of interest. d) Record of proceedings - with respect to board member and officer conflicts of interest, minutes of the board are expected to reflect the identity of the individual making the disclosure, the nature of the disclosure, discussion regarding any proposed transaction, the decision made by the board, and that the interested trustee or corporate officer was excused during the discussion, and that the interested trustee abstained from voting. D. Conflicts reporting: All conflicts of interest are reported by CHI as required by law, regulations, and policy. Form 990, Part VI, Line 6 Classes of members or stockholders According to the bylaws of Baylor St. Luke's Medical Group, the entity's sole member is ST. LUKE'S HEALTH SYSTEM CORPORATION, A TEXAS NONPROFIT CORPORATION. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body According to the organization's bylaws, ALL DIRECTORS SHALL BE ELECTED BY THE SOLE MEMBER, ST. LUKE'S HEALTH SYSTEM CORPORATION. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders According to Sec. 5.4.1 of the By-laws, the corporate member shall have the right to approve any of the actions set forth below: - Any change in the mission or philosophy of the Corporation; - Any amendment to the Certificate of Formation; -The removal, with or without cause, of any member of the Board of Directors of the Corporation; - Subject to consultation with the Board, the incurrence of debt, including without limitation, borrowings, guarantees, loans, encumbrances, operating leases, and capital leases, in excess of thresholds and within the limits established from time to time by the Corporate Member; - Any joint venture to which the Corporation is a party; - The creation of a new corporation, partnership or limited liability company by the Corporation; - Any merger or consolidation to which the Corporation is a party; - The sale or disposition of all or substantially all of the assets of the Corporation; - The adoption of long range and strategic plans; - Subject to consultation with the Board, the adoption of operating and capital budgets and amendments thereto; and -Subject to consultation with the Board, any variations from previously approved operating and/or capital budgets, in excess of thresholds established by the Corporate Member. Form 990, Part VI, Line 11b Review of form 990 by governing body THE RETURN WAS MADE AVAILABLE TO THE OFFICERS AND DIRECTORS BEFORE FILING. Form 990, Part VI, Line 12c Conflict of interest policy The organization has a conflicts of interest ("COI") policy (the "policy") in place to maintain the integrity of its activities. Through February 7, 2019, conflicts were administered solely through Catholic Health Initiatives' ("CHI") Governance Policy No. 1 (described below). On February 8, 2019, in connection with the alignment of the Catholic Health Ministries of CHI and Dignity Health, the CommonSpirit Health Board of Stewardship Trustees approved CommonSpirit Health Corporate Responsibility Policy No. G-001, a CommonSpirit Health conflicts of interest policy. This policy stipulates that, at minimum, the pre-closing CHI COI policies and pre-closing Dignity Health COI policies identify the individuals that are covered under the new policy. In addition, subject to certain exceptions, pre-closing CHI COI policies shall continue to apply to the CHI entities and the individuals who were subject to the Pre-Closing CHI COI policies; and the Pre-Closing Dignity Health COI policies shall continue to apply to the Dignity Health entities and the individuals who were subject to the Pre-Closing Dignity Health COI policies. Until CommonSpirit Health adopts a single process for identifying and managing conflicts of interest for all system entities, the following individuals shall be subject to the Pre-Closing CHI COI policies from and after the effective date of Corporate Responsibility Policy No. G-001: 1. Members of the CommonSpirit Health Board of Stewardship Trustees and members of the committees of the Board of Stewardship Trustees; 2. Corporate officers of CommonSpirit Health; 3. Members of the Board of Directors of Dignity Health and members of the committees of the Board of Directors of Dignity Health. CHI Governance Policy No. 1: The policy applies to the following persons: members of the CHI board of stewardship trustees and its committees; members of any CHI direct affiliate or subsidiary (each a CHI entity) board and their committees; employees of CHI entities, and all CHI researchers (as defined in the policy). Disclosure, review and management of perceived, potential or actual conflicts of interest are accomplished through a defined COI disclosure review process. A. Disclosure obligations: 1. Ongoing: Each person is required to promptly and fully disclose to his/her direct manager, supervisor, medical staff office, board or board committee chair any situation or circumstance that may create a conflict of interest. The person must disclose the actual or potential conflict as soon as she/he becomes aware of it. In any situation in which the person is in doubt it is expected that full disclosure be made to permit an impartial and objective determination as to the existence of a conflict. 2. Periodic written: In addition to the ongoing disclosure obligation, periodic written conflict of interest disclosure forms must be completed as follows: a) Initially: 1) Upon hiring (employees), 2) Appointment (board / committee members), 3) Upon consideration of affiliation with research sponsor (researchers). b) Annually: 1) Board / committee members, 2) Employees at the level vice president or above, 3) Researchers, 4) Supply chain employees at the level of vice president and above and those employees involved in contracting regardless of employment level, 5) Other employees as determined by CommonSpirit Health leadership. 3. Failure to disclose - an individual who fails to disclose a perceived, potential, or actual conflict of interest, or all material facts surrounding an actual or potential conflict or fails to abide by the final decision regarding the conflict may be subject to disciplinary or corrective actions such as termination of employment, removal from a board or committee, loss or restriction of clinical privileges, or restrictions on research activities in accordance with applicable laws, regulations, rules, contracts, and bylaws. B. Conflicts review: 1. No disclosed conflicts: In the absence of perceived, potential or actual conflicts of interest, no follow-up conflicts review is required or performed. 2. Disclosure of perceived, potential or actual conflicts: a) Are initially reviewed by national or regional legal or corporate responsibility team members (depending upon the role of the individual disclosing the actual or potential conflict) to determine whether an actual or potential for a conflict may exist. b) If it is determined that a potential or actual conflict may exist, I. In the case of board or committee members or officers, issues are elevated to the executive committee of the board or board chair. II. In the case of other persons, conflicts issues are elevated to the conflicts of interest review committee ("C-CIRC"). C. Conflicts determination and management: 1. Matters elevated to C-CIRC: a) The C-CIRC determines whether a disclosed or otherwise identified interest is a conflict of interest. If the C-CIRC determines that a COI exists, and adequate controls are not in place to mitigate the conflict, the C-CIRC facilitates development of a COI management plan designed to mitigate the conflict. Designated entity staff are responsible for monitoring the COI management plan and for documenting monitoring activities. Notwithstanding the foregoing, at its sole discretion, an entity may reject a person's request to enter into the relationship in question, or require the relationship be sufficiently altered to avoid a potential conflict of interest. b) Appeal - if a person does not agree with a determination made by the C-CIRC, its interpretation of the COI policy, still seeks an exemption or exception, or seeks further clarification of the C-CIRC 's decision, the individual may appeal the decision through his or her manager for reconsideration by the C-CIRC, and the C-CIRC will review and issue a final determination based upon any new or additional information presented. 2. Matters elevated to the executive committee or board chair: a) Determination of existence of conflict - the board chair or his or her designee performs any further investigation of any conflict of interest disclosures as he or she may deem appropriate. If the conflict involves the board chair, the vice chair assumes the chair's role outlined in the COI policy. Based on review and evaluation of the relevant facts and circumstances, the board chair makes an initial determination as to whether a conflict of interest exists and whether, pursuant to the COI policy, review and approval or other action by the board is required. A written record of the board chair's determination, including relevant facts and circumstances, is made. The board chair then makes an appropriate report to the executive committee of the board concerning the COI review, evaluation and determination. If a difference of opinion exists between the board chair and another trustee as to whether the facts and circumstances of a given situation constitute a conflict of interest or whether board review and approval or other action is required under the COI policy, the matter is submitted to the board's executive committee, which makes a final determination as to the matter presented. That determination, including relevant facts and circumstances, is reflected in the executive committee minutes and is reported to the board. (Continued on Schedule O) Form 990, Part VI, Line 15b Process to establish compensation of other employees BAYLOR ST. LUKE'S MEDICAL GROUP DOES NOT COMPENSATE ITS OFFICERS, DIRECTORS AND KEY EMPLOYEES DIRECTLY. ST. LUKE'S HEALTH SYSTEM CORPORATION (SLHS) PAYS COMPENSATION TO THE OFFICERS, DIRECTORS AND KEY EMPLOYEES. THE SLHS COMPENSATION COMMITTEE MEETS AS NEEDED, BUT TYPICALLY MEETS TWO TIMES PER YEAR. THIS COMMITTEE CONSISTS OF THREE OUTSIDE DIRECTORS. ITS FUNCTION IS TO MAKE RECOMMENDATIONS/DECISIONS ON SALARY AND BENEFITS FOR KEY EXECUTIVES. VARIOUS DATA ARE UTILIZED IN DECISION-MAKING INCLUDING COMPENSATION CONSULTANTS, MANAGEMENT'S LEVEL OF ACHIEVEMENT OF STIPULATED PERFORMANCE TARGETS, EXTERNAL SURVEYS, AND LOCAL MARKET CONDITIONS. PERMANENT MINUTES ARE PREPARED AND REVIEWED BY COMPENSATION COMMITTEE MEMBERS PRIOR TO THEIR RATIFICATION. THESE MINUTES ARE SUFFICIENTLY DETAILED TO PROVIDE SUBSTANTIATION OF THE DECISIONS MADE BY THE COMMITTEE WITH REGARD TO EACH KEY EXECUTIVE'S COMPENSATION AND BENEFITS. A REPORT IS MADE TO THE FULL BOARD BY THE COMPENSATION COMMITTEE CHAIR AT WHICH TIME RATIFICATION OF COMMITTEE ACTION IS VOTED BY THE BOARD. Form 990, Part VI, Line 19 Required documents available to the public The organization's financial statements, conflict of interest policy and governing documents are available to the public upon request. The organization's financial statements are included in CommonSpirit Health's consolidated audited financial statements that are available at www.commonspirit.org or www.catholichealthinitiatives.org. Form 990, Part IX, Line 11g Other Fees Contracted Medical Professionals - Total Expense: 94269217, Program Service Expense: 87670372, Management and General Expenses: 6598845, Fundraising Expenses: 0; Purchased Services - Total Expense: 26230357, Program Service Expense: 24394232, Management and General Expenses: 1836125, Fundraising Expenses: 0; Contract Services - Total Expense: 959041, Program Service Expense: 891908, Management and General Expenses: 67133, Fundraising Expenses: 0; Contract Labor - Total Expense: 293657, Program Service Expense: 273101, Management and General Expenses: 20556, Fundraising Expenses: 0; Consulting - Total Expense: 99812, Program Service Expense: 92825, Management and General Expenses: 6987, Fundraising Expenses: 0; Schedule A, Part I, Line 3 SCHEDULE H NOT REQUIRED BAYLOR ST. LUKE'S MEDICAL GROUP IS RECOGNIZED AS A HOSPITAL BY THE INTERNAL REVENUE SERVICE UNDER IRC SECTION 170(B)(1)(A)(III). HOWEVER, BAYLOR ST. LUKE'S MEDICAL GROUP DOES NOT CURRENTLY OPERATE ANY LICENSED HOSPITAL FACILITIES; THEREFORE, NO SCHEDULE H IS REQUIRED. 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CENTER 2801 FRANCISCAN DRIVE BRYAN TX 77802 742759890 HOSPITAL TX 501(c)(3) 3 SJSC false BURLESON ST JOSEPH MANOR 2801 FRANCISCAN DRIVE BRYAN TX 77802 742913931 HEALTHCARE TX 501(c)(3) 10 SJSC false California Hospital Medical Center Foundation 1401 South Grand Avenue Los Angeles CA 90015 954000909 FUNDRAISING FOUNDATION CA 501(c)(3) Type I DCC false CARRINGTON HEALTH CENTER 800 N 4TH ST CARRINGTON ND 58421 450227311 HOSPITAL ND 501(c)(3) 3 CSH false CATHOLIC HEALTH INITIATIVES - COLORADO 9100 East Mineral Circle Centennial CO 80112 840405257 HOSPITAL CO 501(c)(3) 3 CSH false CATHOLIC HEALTH INITIATIVES - IOWA CORP 1111 6TH AVE DES MOINES IA 50314 420680448 HOSPITAL IA 501(c)(3) 3 CSH false CATHOLIC HEALTH INITIATIVES COLORADO FOUNDATION 1150 Kelly Johnson Blvd 204 COLORADO SPRINGS CO 80920 840902211 FUNDRAISING FOUNDATION CO 501(c)(3) 7 CHIC false CATHOLIC HEALTH INITIATIVES NATIONAL FOUNDATION 1150 Kelly Johnson Blvd 204 COLORADO SPRINGS CO 80920 270930004 HEALTHCARE CO 501(c)(3) Type I CSH false CATHOLIC HEALTH INITIATIVES VIRTUAL HEALTH SERVICES 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 460992796 PHYSICIANS CO 501(c)(3) Type I CHINS false CENTENNIAL MEDICAL GROUP INC 2700 STEWART PKWY ROSEBURG OR 97471 263946191 SURGERY CENTER OR 501(c)(3) 10 MMC false CENTRAL KANSAS MEDICAL CENTER 3515 BROADWAY GREAT BEND KS 67530 480543724 HOSPITAL KS 501(c)(3) 3 CSH false CHI HEALTH CONNECT AT HOME - FARGO 4816 AMBER VALLEY PKWY S FARGO ND 58104 271966847 FUNDRAISING FOUNDATION MN 501(c)(3) 10 CSH false CHI HEALTH FOUNDATION 12809 W DODGE RD OMAHA NE 68154 470648586 FUNDRAISING FOUNDATION NE 501(c)(3) 7 ACH false CHI INSTITUTE FOR RESEARCH AND INNOVATION 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 271050565 HEALTHCARE CO 501(c)(3) Type I CSH false CHI KENTUCKY INC 3900 OLYMPIC BLVD STE 400 ERLANGER KY 41018 202741651 HEALTHCARE KY 501(c)(3) Type I CSH false CHI LIVING COMMUNITIES 5942 RENAISSANCE PLACE STE A TOLEDO OH 43623 341892096 HEALTHCARE OH 501(c)(3) Type II SFH 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