2013-05-13T09:12:06-05:00 2012-06-30 KPMG LLP 55 SECOND STREET SUITE 1400 SAN FRANCISCO CA 94105 990 2011-07-01 943006034 Dignity Health Hospital and Professional Liability Self-Insurance Trust % MARY CONNICK FINANCE DEPT DIGN 4154385500 185 Berry Street San Francisco CA 94107 MARY CONNICK 2013-05-10 true 4159635100 2011 2016-02-24 21:20:13Z MICHAEL BLASZYK 185 BERRY STREET SAN FRANCISCO CA 94107 332033513 false X www.dignityhealth.org X 1986 CA SELF-INSURANCE PROGRAM FOR RELATED EXEMPT ORGANIZATIONS. 0 0 0 0 0 0 0 0 66407220 165268022 19034433 7455654 0 0 85441653 172723676 0 0 0 0 0 0 0 0 0 186317908 109825919 186317908 109825919 -100876255 62897757 172973404 216288642 276490614 260754005 -103517210 -44465363 SELF-INSURANCE PROGRAM FOR RELATED EXEMPT ORGANIZATIONS. false false 99347162 0 165268022 ADMINISTRATION OF PROFESSIONAL AND GENERAL LIABILITY SELF-INSURANCE PROGRAM AND OBTAINMENT OF OTHER GROUP INSURANCE COVERAGE FOR AFFILIATED CHARITABLE HEALTHCARE ORGANIZATIONS. 99347162 true false false false false false false false false false false true false false true false false true false false true false false false false false false false false true false false false false false false false false false false false false false true false false false false true X 604 0 true 0 true true true CJ false false false false false false false false X 0 0 true false true false false true true true true false false false true true true true true false false false CA X MARY CONNICK FINANCE DEPT 4154385500 185 BERRY STREET SAN FRANCISCO CA 94107 X STATE STREET 0.0 X 118624 591601 0 Michael D Blaszyk 2.0 X 0 2266439 633670 Derek F Covert 2.0 X 0 1230665 118738 Lloyd H Dean 2.0 X 0 4882756 1127670 Mary Connick 2.0 X 0 578433 66982 Hillery Trippe 20.0 X 0 390980 54119 Robert Wiebe 2.0 X 0 1336440 250894 118624 11277314 2252073 1 false true false La Follette Johnson DeHaas Fesler 865 South Figueroa St LOS ANGELES CA 900175431 Defense Counsel Serv 1250985 Lewis Brisbois Bisgaard Smith LLP 221 N Figueroa St Ste 1200 LOS ANGELES CA 90012 Defense Counsel Serv 1150911 Alverson Taylor Mortensen Sanders 7401 W Charleston Blvd LAS VEGAS NV 891171401 Defense Counsel Serv 1055100 Ubaldi McPherson LLP 455 University Ave Suite 360 SACRAMENTO CA 95825 Defense Counsel Serv 885526 Carroll Kelly Trotter Franzen PO Box 22636 LONG BEACH CA 908015636 Defense Counsel Serv 863286 34 0 MANAGEMENT SERVICES FOR SELF-INSURANCE CLAIMS & 900099 165268022 165268022 0 0 EXPENSES 165268022 4851979 0 0 4851979 0 0 0 0 0 0 0 0 0 0 161913512 0 159309837 0 2603675 0 2603675 2603675 0 0 0 0 172723676 165268022 0 7455654 0 0 0 0 0 0 0 0 0 0 0 45163 45163 57355 57355 0 0 841565 841565 9482883 158295 9324588 0 42746 42746 0 0 0 0 0 0 0 0 0 99188867 99188867 TAXES AND LICENSES 3607 0 3607 0 LETTER OF CREDIT FEES 95924 0 95924 0 EXCISE TAXES 67130 0 67130 0 SURETY BONDS 679 0 679 0 109825919 99347162 10478757 0 10788046 13745864 9828327 10673893 0 0 0 0 0 0 0 0 0 0 0 0 17515073 9267160 0 124329925 156660383 7622345 23240337 0 0 0 0 2889688 2701005 172973404 216288642 78070658 70457005 0 0 0 0 0 0 0 0 0 0 0 0 0 0 198419956 190297000 276490614 260754005 X -103517210 -44465363 0 0 0 0 -103517210 -44465363 172973404 216288642 X 62897757 -3845910 X false true true X false X X X false false false DIGNITY HEALTH 941196203 03 true true true 109825919 1 109825919 The Trust provided or purchased for the benefit of Dignity Health, various services, facilities and goods. See Form 990, Part IX for further details. POOLED INVESTMENT 23240337 F 23240337 0 HOSPITAL PROFESSIONAL AND 190297000 190297000 Central America and the Caribbean 0 0 Program Services CAPTIVE INSURANCE 8145020 Central America and the Caribbean 0 0 Investments N/A 11143291 0 0 0 0 19288311 19288311 true false true true false false Sch F, Part I, Column (f) Premium amounts are recorded to prepaid insurance and amortized over the twelve month period of January through December. false true false false false false false false false Michael D Blaszyk 0 865377 0 1099787 0 301275 0 576026 0 57644 0 2900109 0 280662 Derek F Covert 0 535662 0 676397 0 18606 0 73182 0 45556 0 1349403 0 0 Lloyd H Dean 0 1387651 0 2510407 0 984698 0 1052285 0 75385 0 6010426 0 960524 Mary Connick 0 357087 0 211306 0 10040 0 40070 0 26912 0 645415 0 0 Hillery Trippe 0 269474 0 106670 0 14836 0 29318 0 24801 0 445099 0 0 Robert Wiebe 0 590330 0 737725 0 8385 0 223760 0 27134 0 1587334 0 0 Part I, Line 3, 4a & 4b PART I, LINE 3 The Organization relied on a related organization, Dignity Health, that used one or more of the methods described in Schedule J, Part I, Line 3, to establish the Organization's top management official's compensation. See Schedule O disclosure for Form 990, Part VI, Section B, Line 15 for additional information. PART I, LINE 4a Dignity Health Hospital & Professional Liability Self-Insurance Trust's officers and key employees participate in a severance plan that provides market-standard compensation, ranging from payments of 6 months to 2 years of base compensation, depending on the executive's position, in the event of a position elimination or other involuntary termination, in accordance with the guidelines of the plan. No payments were made to any officers and key employees during 2011 pursuant to this plan. PART I, LINE 4B Dignity Health Hospital & Professional Liability Self-Insurance Trust's certain officers and key employees are eligible to participate in one of two non-qualified 457(f) plans that are subject to substantial risk of forfeiture, as required by the IRS. The 2007 Executive Deferred Compensation Plan is for executives hired prior to June 30, 2006. The benefit is intended to bridge the difference, if any, between the benefit provided under the Dignity Health Excess Benefit Plan had benefit service not been frozen at January 1, 2008, and the benefits provided from all other qualified and non-qualified plans. No benefit under this formula will vest under this 457(f) plan before the attainment of age 62 or the completion of 15 years of service. The 2010 Executive Deferred Compensation Plan is for certain key employees who are not eligible to participate in the Dignity Health Excess Benefit Plan or the 2007 Executive Deferred Compensation Plan described above. This benefit provides an annual accrual of 10% of total compensation and is payable annually on July 1 once vested, which is age 62 with 5 years of service. No payments were made under this plan during 2011. Certain officers and key employees participate in the Dignity Health Excess Benefit Plan, a nonqualified supplemental benefit plan limited to participants in the Dignity Health Retirement Plan whose benefits are affected by the limitations imposed by sections 401(a)(17) and 415 of the Internal Revenue Code. Benefit service under this plan was frozen as of January 1, 2008. No payments were made under this plan during 2011. Certain listed persons participate in the Dignity Health Key Employee Share Option Plan (KeySOP), which was frozen in May 2002. The KeySOP program was established in 2001 with the purpose of providing income deferral opportunities to employees eligible for the company's key employee retention program. No payments were made under this plan during 2011. Certain officers and key employees participate in the Dignity Health Supplemental Executive Retention/Retirement Plan, a nonqualified supplemental benefit plan which in 2002 was offered to members of the executive management team by the Dignity Health Board of Directors and would be paid only if the executives stayed with the organization for a specified number of years as the primary purpose of this plan is to provide for the retention and retirement of the participants. The executive management team was recruited from stable careers in organizations from across the country and from various industries to engineer and lead a financial and operational turnaround after the organization had lost nearly $1 billion in net operating performance. The calculation for the payments to each executive is based on the value of a final average pay annuity benefit based on retirement age and service years to the organization. Distribution occurs each July 1 if the plan formula warrants a payment. Vested amounts are reported as deferred compensation in the year vesting occurs (Schedule J, Part II, column C) and are reflected again as reportable compensation in the year paid (Schedule J, Part II, column B(iii)). Payments made during 2011 pursuant to this plan include $960,524 to L. Dean and $280,662 to M. Blaszyk. Part II - additional information Dignity Health's executive compensation philosophy is designed to assist Dignity Health in attracting and retaining the caliber of executives required to enable Dignity Health to fulfill its mission of providing high quality healthcare for all persons regardless of their ability to pay for services, improving the quality of life in the communities Dignity Health serves, promoting patient and employee satisfaction, and ensuring financial stability. A substantial portion of executive compensation is performance based and is linked to organizational goals approved in advance by the Human Resources and Compensation Committee. These goals include attainment of annual and long-term financial performance, certain healthcare quality standards and Dignity Health's commitment to serving the poor and disenfranchised in the communities it serves. Total compensation, which includes base salary, annual and long-term incentive compensation, targets the 75th percentile of the market in which Dignity Health competes for executives, commensurate with the size and complexity of the organization. FORM 990, PART V, VI AND XI FORM 990, PART V, Line 2 The organization does not have employees. The organization operates as the administration company of the professional and general liability self-insurance program for the supported organization, Dignity Health and its related entities. FORM 990, PART VI, SECTION A, LINE 2 Officer D. Covert has a family relationship with key employee M. Connick. FORM 990, PART VI, SECTION A, LINE 4 The organization revised its governing documents (trust agreement) to reflect its change of name from CHW Hospital Professional Liability Self-Insurance Trust to Dignity Health Hospital and Professional Liability Self-Insurance Trust. FORM 990, PART VI, SECTION A, LINE 7a Dignity Health, the Trustor of the organization, has the power to appoint and remove the institutional trustee. FORM 990, PART VI, SECTION A, LINE 7b The Trustor may amend, alter or revoke the trust agreement in whole or in part at any time. FORM 990, PART VI, SECTION B, LINE 11A The organization's SVP Finance & Corporate Controller reviewed the form 990. In addition, the supported organization's VP of financial services and reporting worked closely with an independent, outside accounting firm engaged to review the form 990. The final version of the form 990 was not provided to the institutional trustee before the return was filed. FORM 990, PART VI, SECTION B, LINE 12C The Board of Directors delegated to the Audit and Compliance Committee responsibility for monitoring conflicts of interest disclosures and for addressing any potential or actual conflicts. Dignity Health's policies related to conflicts of interest charge the EVP/General Counsel with responsibility for reviewing and validating disclosures, and maintaining adequate records of disclosures. Pursuant to these policies, an annual conflict of interest disclosure statement, aimed at determining any family and business relationships and transactions, or other transactions that may pose a potential conflict, is distributed to all covered persons (e.g., board members, officers and executive leadership, key employees and all management personnel whose responsibilities include business decisions which may give rise to conflicts of interest). Covered persons are also required to disclose real or potential conflicts at the time such conflicts arise. When an individual becomes a covered person and annually thereafter, each covered person is required to submit an updated disclosure statement and to sign a statement affirming that he/she: (1) has received a copy of the policy applicable to their position; (2) has read the policy and understands said policy; and (3) agrees to comply with all requirements of the policy, including completing the conflicts of interest disclosure statement. As required by the policy, the President/CEO and EVP/General Counsel prepare annual reports of reported conflicts of interest which are provided to the Board of Directors, Committee Chairs, and key leaders of the organization to enable responsible individuals to monitor and manage disclosed conflicts of interest in the organization's best interests. The procedures for addressing any conflict of interest related to a proposed transaction include, but are not limited to, the following: (1) the conflicting interest is fully disclosed to the Board; (2) the interested person responds to factual questions related to the substance of the transaction or arrangement being considered, after which he/she shall leave the meeting; (3) the person with the conflict of interest is excluded from the discussion and approval of such transaction; (4) if warranted, alternatives to the proposed transaction are investigated, and competitive bids or comparable valuations are obtained; (5) the transaction or action must be approved by a majority of disinterested persons, based on certain criteria; and (6) any conflicting issues arising during the course of a Board meeting which cannot be resolved may be referred to an independent committee of the Board of Directors. FORM 990, PART VI, SECTION B, LINE 15 Although the organization does not directly employ any personnel, the supported organization's Board of Directors annually appoints a Human Resources and Compensation Committee, comprised solely of directors, who are independent with respect to executive compensation, to be accountable for setting reasonable compensation packages for each officer and key employee (including the President/CEO). The Human Resources and Compensation Committee approves, consistent with the organization's philosophy and principles, the annual performance goals and criteria to be used in determining merit increases and variable compensation criteria for officers and key employees. The Human Resources and Compensation Committee also engages outside legal counsel as necessary and a qualified independent compensation and benefits specialist (independent expert) to review, analyze and provide benchmarking data for the total compensation and benefits packages of officers and key executives. Appropriate comparability data is obtained from the independent experts, e.g., total economic benefits paid by similarly situated organizations (both taxable and tax-exempt) for similar job responsibilities. Key deliberations of the Committee are documented in meeting minutes which are approved at the next Committee meeting and provided to the Board of Directors. The documentation of the decision includes (a) the terms of the transaction that was approved and the date it was approved, (b) the members of the Committee who were present during discussion of the transaction that was approved and those who voted on it, and (c) the comparability data obtained and relied upon by the Committee and how the data was obtained. FORM 990, PART VI, SECTION C, LINE 19 Federal tax laws do not mandate that the organization's governing documents, conflict of interest policy and financial statements be made available for public inspection. The organization is included in Dignity Health and subordinate corporations' consolidated financial statements which are available on Dignity Health's website and upon request. FORM 990, PART XI, LINE 5 Change in unrealized loss; ($5,155,126) Book/Tax difference K-1 investments; $1,309,216 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Michael D Blaszyk TITLE:SEVP Chief Financial Officer HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Derek F Covert TITLE:EVP Legal Services/General Cou HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Lloyd H Dean TITLE:President/ CEO HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mary Connick TITLE:VP Finance Corp Controller HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Hillery Trippe TITLE:VP Risk Services HOURS:20 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert Wiebe TITLE:EVP Chief Medical Officer HOURS:40 DIGNITY HEALTH 185 Berry Street San Francisco CA 94107 941196203 Hospital CA 501(C)(3) 3 NA false Dignity Health Workers' Compensation 185 Berry Street San Francisco CA 94107 946612446 administratio CA 501(c)(3) 11A Dignity Heal false false false false false false false false false false false true true false false false false false false NONE