2017-11-10T13:07:38-06:00 2016-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1400 Bellevue WA 98004 990 2016-01-01 911041617 PROVIDENCE GENERAL FOUNDATION PROV 4252587500 PO Box 1067 Everett WA 98206 Lori Kloes Executive Director 4252587500 2017-11-10 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 170.173.0.16 2017-11-10 11:07:24 PS P C5F3CFF4C26DED891B80F887CA75C12EDBBE0CDF C5F3CFF4C26DED891B80F887CA75C12EDBBE0CDF 2016 2021-01-29 14:40:06Z Lori Kloes PO Box 1067 Everett WA 98206 14442072 0 X washington.providence.org/donate X 1978 WA Support of Snohomish County Regional Health Care System. 24 23 0 200 0 0 2444487 2585432 0 0 1104686 1222780 -154468 -117444 3394705 3690768 3582580 3198857 0 0 630090 736103 12000 24000 777191 411395 459097 4636065 4418057 -1241360 -727289 20497497 19078315 1955877 1715519 18541620 17362796 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Support of Snohomish County Regional Health Care System. 0 0 2126000 2126000 0 Funding in 2016 supported several key initiatives including building out another operating room in the Cymbaluk Medical Tower. The project also included building out six pre and post op rooms on the third floor and adding an EP Hemodynamic System. The construction is driven by the need for more capacity to accommodate a very rapidly growing community. The medical center is experiencing more trauma cases and operating room accessibility was necessary to meet the demands for increasingly complex and emergent cases. 590387 590387 0 The board also voted to support the growth of Children's Services including funding for the Providence Autism Center operations. The Center continued to grow and reimbursements did not cover the cost of care for this vulnerable population. Support was also granted to the Children's Center for Camp Prov - a day camp for children with disabilities and their siblings. The majority of the children who attend are not able to pay for camp and attend on scholarship. The Patient Simulation team received a new sim "preemie" which allows the clinical team to practice critical procedures in simulation to enhance excellence in patient care. 320862 320862 0 Heart and Vascular Services was a focus of support in 2016 with the purchase of equipment for the Cardiac Imaging Center in South Snohomish County. The Center will provide ECHO, vascular, nuclear medicine, stress testing and other imaging services. 121608 121608 0 Support was also provided to Cancer Services, Comprehensive Breast Center, Intervention Center for Assault and Abuse, Providence Everett Healthcare Clinic, Nursing Education and the Employee Helping Hand fund. 40000 40000 0 Support was provided for programs in partnership with Everett Gospel Mission, Project Access NW, and Citrine Health. 161608 161608 0 3198857 1 1 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 X 34 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 24 23 1 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 0 0 0 WA X Karl E Fritschel CPA 4255253339 1801 Lind Ave SW Renton WA 98057 X Ayers Shirley Director 1.00 0.00 X 0 0 0 Bavasi Margaret Director 1.00 0.00 X 0 0 0 Bell Doug Director 1.00 0.00 X 0 0 0 Brandt Tony Director 1.00 0.00 X 0 0 0 Cymbaluk Jeff Director 1.00 0.00 X 0 0 0 Duffy Mark Treasurer 1.00 0.00 X X 0 0 0 Finley Jim MD Director 1.00 0.00 X 0 0 0 Gaffney Jan Director 1.00 0.00 X 0 0 0 Hall Andy Director 1.00 0.00 X 0 0 0 Hall Lynne Director 1.00 0.00 X 0 0 0 Harkins Dan Second Vice Chair 1.00 0.00 X X 0 0 0 Hunter Kathy First Vice Chair 1.00 0.00 X X 0 0 0 Jubie Harvey Director 1.00 0.00 X 0 0 0 Jubie Larry Board Chair 1.00 0.00 X X 0 0 0 Kloes Lori Executive Director 50.00 0.00 X X 157990 0 27475 Langford Michael Director 1.00 0.00 X 0 0 0 Larson Gail Secretary 1.00 0.00 X X 0 0 0 Messner Jean Director 1.00 0.00 X 0 0 0 Pieper Kevin MD Director 1.00 0.00 X 0 0 0 Rodland Carol Director 1.00 0.00 X 0 0 0 Sheldon Mel Director 1.00 0.00 X 0 0 0 Simmons Preston Director 1.00 0.00 X 0 0 0 Wharton Marcia MD Director 1.00 0.00 X 0 0 0 White Sharron Director 1.00 0.00 X 0 0 0 157990 0 27475 1 0 1 1 Tulalip Resort & Casino 10200 Quil Ceda Blvd Tulalip WA 98271 Catering Services 159957 Merrill Lynch 2707 Colby Avenue Suite 1401 Everett WA 98201 Investment Management Services 113456 2 17527 1053827 1514078 23162 2585432 347967 347967 11259314 10384501 874813 874813 874813 213909 1053827 366803 -152894 -152894 35450 0 35450 35450 3690768 0 0 1105336 3077249 3077249 121608 121608 173565 42350 131215 441373 107647 333726 83399 27274 56125 37766 8705 29061 32084 32084 24000 24000 144533 144533 42315 4225 38090 2046 2046 108944 38010 70934 53329 8340 44989 4924 4924 3912 3763 149 Donor/Board Recog. 53926 9272 44654 Dues and Subscriptions 12367 10882 1485 Bad Debts 717 717 4418057 3198857 442009 777191 551647 924773 1426568 1064072 150 34257 8653 17280820 15860268 1204055 1220549 20497497 19078315 5767 229000 19050 1440316 1439588 286561 251114 1955877 1715519 X 4500000 4774077 13255307 11802406 786313 786313 18541620 17362796 20497497 19078315 X -727289 -451539 4 X X 0 1 X 1 0 X 2725279 2838779 2887378 2444487 2585432 13481355 2725279 2838779 2887378 2444487 2585432 13481355 104107 13377248 363414 321484 361922 348977 347967 1743764 15225119 0.87860 0.69350 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 1248436 37318 1285754 1305423 9856 66843 1248436 1296785 73570 64932 1305423 2003210 25 161863 868313 1296785 1860587 142623 2003210 0.24110 0.61160 0.14730 0 0 0 Life Interest in Real Property 140074 Cash Surrender Value of Life Insurance 496784 Beneficial Interest in Assets Held in Trusts 583691 1220549 CGA Obligation 251114 251114 3644967 -451539 38934 -412605 4057572 -366804 -366804 3690768 4823791 38934 366803 405737 4418054 3 3 4418057 Part IV, Line 2b: During 2010, Providence Regional Medical Center transferred assets, as an agency transaction, to the Foundation to be held on its behalf. Part V, Line 4: Primary uses are for Women's and Children's Services and the Cancer Center. Part XI, Line 4b - Other Adjustments: Special Event Expenses -366,803. Rounding -1. Part XII, Line 2d - Other Adjustments: Special Event Expenses 366,803. Part XII, Line 4b - Other Adjustments: Rounding 3. X X X X X 1 Optimus Fundraising 601 Union Street Suite 4200 Seattle WA 98101 Consulting 0 0 24000 -24000 24000 -24000 WA Festival of Trees 1028998 855739 173259 26835 141555 3898 153086 The Epicurean Affair 144025 125131 18894 3320 32089 4 94713 72957 21756 164 5856 1267736 1053827 213909 26835 145039 3898 191031 366803 -152894 35450 1 1.00000 35450 35450 WA 1 0 0 0 1.00000 Ashley Bontje 916 Pacific Avenue Everett WA 98201 0 Ashley Bontje 0 Foundation Staff oversees volunteers that facilitate the raffles at the Foundation fundraising events. X 0 1 PH & S - WA dba Providence Regional Medical Center Everett 916 Pacific Avenue Everett WA 98201 510216586 501(c)(3) 2647543 Fund capital expenditures and equipment for Providence Regional Medical Center Everett. PH & S - WA dba Providence Regional Medical Center Everett 916 Pacific Avenue Everett WA 98201 510216586 501(c)(3) 386706 Help multiple programs in the medical center and Healthcare Clinic including staffing, equipment, educational conferences, patient education and support, screening and prevention. Project Access Northwest 1111 Harvard Avenue Seattle WA 98122 204377921 501(c)(3) 10000 Funding for community-based initiatives to improve health and reduce costs. Everett Gospel Mission 222 52nd Street Everett WA 98203 910780146 501(c)(3) 10000 Funding for designated beds at the shelter to allow homeless patients a safe place to rest and recover after treatment. Citrine Health 2940 W Marine View Dr Everett WA 98201 911717603 501(c)(3) 20000 Funding to create, maintain and support healthcare, social services and disease prevention programs for women and their families. 4 0 Cancer Patient Assistance 182 63761 Cost Assists cancer patients experiencing financial hardships as a result of their cancer diagnosis. Funds help pay for food, rent, utilities, prescriptions and other critical expenses when they are out of work or strapped by unplanned medical expenses. Scholarship and Education Assistance 49 25698 5355 Cost Nursing and Medical Staff Education Scholarships Helping Hands 19 16039 Cost Offers a place for Providence Regional Medical Center Everett employees to turn when a financial or medical emergency occurs. Newspaper 80665 10755 Cost Newspapers available for staff, patients and visitors Part I, Line 2: In the application for support, we request a detailed explanation of the kind of services provided to the community along with specific financial data. If the application for support is approved, we send a letter indicating the amount of the support along with a request for documentation of how the funds were used. A majority of the grants are made to the Medical Center, so the Foundation has access to the financial records and can review them for appropriate use. The scholarships and education assistance provided to nurses are merit and criteria-based. The nursing council reviews and approves the applications for support based on the type of conference, education or certification sought, whether employees are in good standing, and the availability of funds. Other grants are monitored through review of receipts provided and approved. X 1 1 0 0 0 0 0 0 0 0 0 Kloes Lori Executive Director 141824 0 14801 0 1365 0 15576 0 11899 0 185465 0 0 0 Part I, Line 1a The Foundation maintains an annual membership at the Everett Golf & Country Club for the Executive Director. This membership is used to cultivate donors, board members and volunteers and is not considered a taxable benefit to the Executive Director. FORM 990, SCHEDULE J, PART II - COMPENSATION The entire balance of compensation for Lori Kloes is paid through Providence Regional Medical Center Everett. FORM 990, SCHEDULE J, PART II - EXECUTIVE INCENTIVE PROGRAM The Providence Executive Incentive Program provides a lump sum award annually as a percent of the executive's base pay. Percent opportunities are aligned with our total compensation philosophy as outlined in Part VI, Section B, Line 15 (Process for determining compensation of top management, officers & key employees). For Providence leaders, the performance award is based on the level of accomplishment of annual system and functional (or market) objectives. In 2016, 60 percent of the participant awards were based on pre-determined organizational goals consistent with Providence's strategic priorities. In 2016 the percent allocation for each of these strategic priorities was as outlined below: System Goals: First-year Turnover - 10% Inpatient Experience - 5% Patient Experience - 5% Medical Group Patient Experience - 5% Community Benefit - 10% Clinical Excellence - 15% Free Cash Flow - 10% The remaining 40% was based on a robust set of function specific goals designed to align critical mission and business drivers. Form 990, Part VI, Section A, line 2 Larry Jubie and Harvey Jubie have a family relationship. Form 990, Part VI, Section A, line 7b A member of the Board of Directors may be removed at the request of the Board of Directors of Providence Regional Medical Center Everett if the latter, in its absolute discretion, deems such member to be unqualified in any respect, provided no more than one member of the Board shall be removed pursuant to this provision in any one calendar year. Form 990, Part VI, Section B, line 11b The Form 990 is prepared internally by experienced staff of Providence Health & Services - Washington and reviewed by the internal PH&S Director of Taxes and external tax advisors. The Executive Director reviewed the Form 990 in detail. Once approved, an electronic copy of the Form 990 is emailed to the Board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c All members of the Governing Board respond to and sign a Conflict of Interest Policy Statement at the January Board meeting annually. Members disclose any actual or apparent conflict of interest in the disclosure document and also orally to the other Board members at the annually meeting. Conflicts are noted and members are excused from decision that are in conflict with private interests. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its officers, including our senior executives. Salaries for senior executives are reviewed by the Providence St. Joseph Health Committee and approved by the full Board of Directors, none of whom is a Providence employee. The Board retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultant's role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Additionally, Providence's labor market continues to spread across health care and into general industry. Because of this, Providence also takes into consideration general industry for-profit market data, where applicable. Base salaries for Providence executives are generally targeted to the median level of the market, as identified by the independent consultant and reviewed with the Executive Compensation Committee. Performance incentives allow executives to earn additional compensation if they achieve specific organizational goals for furthering Providence operating commitments and strategic objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate market practices. Based on the above principles and guidelines, an annual salary review is handled by the HR Department of Providence Regional Medical Center Everett. The Board's process for executive compensation fully complies with IRS standards and mirrors best practices. Form 990, Part VI, Section C, line 19 These documents are made available on request through the Business Office. Form 990, Part XI, line 9: Rounding 4. FORM 990, PART XII, LINE 2C - AUDIT & COMPLIANCE The Board Treasurer and Finance Committee assists the Board of Directors with the oversight of the integrity of the financial statements and reporting, the audit process and the internal financial controls and policies; compliance with ethical, legal and regulatory standards and requirements; the independence, qualifications and performance of the internal and external auditors; the investment committee; and informs the Board of Directors of critical risk areas and recommended mitigation. FORM 990, PART I, LINE 5 & PART V, LINE 2A - EMPLOYEE COMPENSATION The employees working at the Foundation are paid by Providence Health & Services - WA. dba Providence Regional Medical Center Everett. Therefore, no W-2s are issued by the reporting organization. FORM 990, PART I, LINE 6 - VOLUNTEERS Services provided were in support of various Foundation-related programs and a variety of tasks including: * Special events organizers/support workers * Third-party event volunteers Their service was tied to the following Foundation programs: * The Epicurean Affair (special event) * Festival of Trees (special event) * Friends of Providence Donor Society (membership event) FORM 990, SCHEDULE R - PROVIDENCE AFFILIATION Providence General Foundation is affiliated with PH & S - WA. dba Providence Regional Medical Center Everett and provides a majority of its grants to this organization. However, based on the Articles of Incorporation and Bylaws of the Foundation, PH & S - WA. dba Providence Regional Medical Center Everett does not exercise enough control of the Foundation to be considered a related organization. Therefore, no Schedule R is required for the Foundation.