Norman Regional Hospital Authority

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting June 27, 2022 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, June 27, 2022 at 5:30p.m. in the Porter Board Room . The meeting Agenda was posted June 23, 2022 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley James Chappel Joan Greenleaf Kevin Pipes Jerome (Jerry) Weber, Ph.D. Diane Chambers, MD Muhammad Anwar, MD Others Present: Richie Splitt, President & CEO John Manfredo, COO Brittni McGill, CNO Ken Hopkins, CFO Paula Price, VP Strategy & Growth Meegan Cater, VP Population Health & Wellness Aaron Boyd, MD Joe Voto, MD, Chief of Medical Staff James Bond, MD Jenny Anderson, Administrative Director Quality & Performance Larry Harden, Administrative Director, Risk Management Kelly Dexter, Manager, Education Center & Media Services Kelly Wells, Director, Planning and Communications Amy Arnold, Nurse Manager, Clinical Education Kathy Foster, Clinical Education Specialist Susan Beam, Manager, Pastoral Care Nick Napoli, Manager, Pastoral Care Erin Barnhart, NRHS Foundation President Sherri Coale, Foundation Helen Grant Leslie Bonebreak Members Absent: Mary Womack Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the June 27, 2022, Norman Regional Hospital Authority business  NRHA Board Minutes 2 June 27, 2022 meeting to order at 5:33p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. July 2022 Healer of the Month – Kathy Foster, Clinical Education Specialist Mr. Cubberley introduced Ms. Amy Arnold, Nurse Manager, Clinical Education. Ms. Arnold shared Ms. Foster is known among her coworkers as hardworking and always prepared. She has a wonderful sense of humor, brightening the day of her fellow healers. Ms. Foster was born at Norman Regional so she was meant to be a part of the NRHS family. Ms. Foster has worked in several areas including Orthopedics, the Norman Heart and Vascular Clinic and the infectious disease and rheumatology clinic as a clinic manager. During this time, she decided to pursue a Masters degree in Nursing Education and in 2017 became the Care Coordinator in the internal medicine clinic. In 2019 she joined the clinical education team as clinical education specialist. Ms. Foster loves working with fellow healers, providing new and innovative resources in clinical education. She always provides a flexible and positive outlook each day. Ms. Foster shared she is overwhelmed with the lovely comments from her fellow healers and is thankful for the honor. She stated this is her dream job and can’t imagine working anywhere else. Mr. Cubberley congratulated and thanked Ms. Foster on behalf of the Board for her outstanding dedication, professionalism, compassion and positive attitude that continues to make Norman Regional Health System a caring, high quality system. Ms. Arnold and Ms. Foster left the meeting at 5:40pm. Mr. Splitt recognized Kelly Wells, Director of Planning & Communications for her dedication and service to NRHS. Ms. Wells has been a loyal supporter of Norman Regional and will be greatly missed as she begins an exciting new career in the banking industry. Agenda Item III. Board Education: NRHS Spiritual Care Ms. Susan Beam, Manager Pastoral Care and Mr. Nick Napoli, Manger Pastoral Care presented an update on Norman Regional Spiritual Care services. Ms. Beam shared The Pastoral Care department will be soon changing it’s name to Spiritual Care. Spirituality transcends a person’s religious practices or beliefs, including  NRHA Board Minutes 3 June 27, 2022 the search for meaning, purpose, and truth in life, the beliefs and values by which a person lives, and feelings of hope, connection and inner peace. Spiritual Care seeks to nurture the inner resources that allow a person to connect with others, the environment and a power greater than themselves. To become a part of the Spiritual Program, Clinical Healthcare chaplains are required to have completed a minimum of a Master of Divinity degree from an accredited Seminary and a minimum of 4 units/1 year full time of Clinical Pastoral Education from an accredited CPE training program in the hospital setting. Each of these clergy/ministers may represent a specific faith or religious belief system, but are trained to specially offer support to people of all faith backgrounds, showing respect for each individual’s personal faith journey. Our Chaplains develop a very global, objective perspective within the hospital system because they serve as mediators and liaison between a wide variety of individuals, families, employees and situations. Chaplains provide many services to our patients and their families. Some of these services include:  Advance care planning discussions  Assistance in completing Advance Directives, No Not Resuscitate (DNR), Healthcare Power of Attorney (HPOA) forms  Family/physician conferences  Grief facilitation & bereavement care  Addressing ethical dilemmas & facilitating requests to meet with Ethics committee  Provision of sacraments and other religious rituals/rites  Addressing spiritual questions  Employee/Healer support  Trauma & crisis support  Critical incident stress debriefing The change to Spiritual Care will better align us nationally with best practice and model of care, as well as provide a more accurate description of the scope and reach of the services provided. This will allow the creation of new opportunities to provide further effective care throughout a CPE program, cancer support, and ongoing grief support groups for RNs and clinical staff, mitigating the effects of burnout and increasing a sense of well-being. Ms. Price thanked Ms. Beam for her 24 years of dedication and services to NRHS patients and healers and to the community. Ms. Beam elevated the professionalism of our chaplain services by requiring clinical pastoral certification in order to provide the best form of care for patients and healers. She was also instrumental in establishing peer support training to provide assistance to healers when needed. Ms. Beam, Mr. Napoli and Ms. Wells left the meeting at 6:01pm. Agenda Item IV. Approval of May 23, 2022, Norman Regional Hospital Authority Board Meeting Minutes  NRHA Board Minutes 4 June 27, 2022 A. Mr. Cubberley asked for approval of the May 23, 2022 Board Meeting Minutes ACTION TAKEN: Mr. Pipes made the motion to approve the May 23, 2022 Board Meeting Minutes. Dr. Anwar seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr Chambers and Dr. Anwar. Agenda Item V. Foundation Update Ms. Erin Barnhart, NRHS Foundation President announced the kick off for the Foundations “Equipped for Tomorrow” campaign. This campaign supports Norman Regionals current Inspire Health building project by raising funds from the community for medical equipment and renovations. Ms. Barnhart introduced Ms. Sherri Coale, NRHS Foundation Campaign Chairwoman. Ms. Coale, former University of Oklahoma Women’s basketball coach and 33 year resident of Norman, shared she was honored to be asked to chair this campaign. Both of her children were born at Norman Regional and she spent many years with injured student athletes receiving wonderful care from NRHS. Ms. Coale shared how most of the community doesn’t think about the hospital and until they need it. Norman Regional is the heart and healer of the community. This campaign will fund those well-needed tools and instruments needed to provide the best care available to Norman citizens and surrounding communities. Ms. Barnhart, Ms. Coale and Ms. Dexter left the meeting at 6:24pm Agenda Item VI. Performance Update Ms. Anderson, Administrative Director Quality & Performance, presented an update on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Hospital Survey participation update and presented the FY2023 Quality & Performance Improvement Plan as well as the FY2023 Patient Safety Plan. The Quality & Performance Improvement (QPI) Plan is modeled after the Institute of Medicine (IOM) aims for health care quality. Goals are set using the basic factors of safety, effectiveness, patient-centered, timely, efficient and equitable. The objective of the QPI Plan is to instill an organizational philosophy that builds a customer-driven, patient and family-centered learning organization dedicated to customer satisfaction and quality outcomes. Ms. Anderson reviewed the goals met and plans to continue to reach goals on remaining objectives. The FY2023 Patient Safety Plan objectives are to focus on the culture of safety, validate methods to improve processes and systems, standardize ways for interdisciplinary teams to communicate and collaborate and safety integrated technologies. To reach these objectives, NRHS will implement the five traits of High Reliability Organizations. These steps include preoccupations with failure, reluctance to simplify, sensitivity to  NRHA Board Minutes 5 June 27, 2022 operations, commitment to resilience and deference to expertise. Ms. Anderson reviewed the FY2022 goals met. Agenda Item VII. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on June 8, 2022. MEC covered a number of topics including – Surgery and Cardiovascular update, Medical Credentialing report and Department/Committee reports. Agenda Item VIII. Patient Quality & Safety Committee Meeting A. Mr. Cubberley announced a summary of the Patient Quality & Safety Committee Meeting is included in the board packet. Ms. Greenleaf is available to address questions. B. Recommend Approval for the FY2023 Quality & Performance Improvement Plan ACTION TAKEN: Dr. Weber made a motion to approve the FY2023 Quality & Performance Improvement Plan as recommended by the Patient Quality & Safety Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr.Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. C. Recommend Approval for the FY2023 Patient Safety Plan ACTION TAKEN: Dr. Weber made a motion to approve the FY2023 Patient Safety Plan as presented by the Patient Quality & Safety Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr.Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Agenda Item IX. Finance Committee A. Mr. Hopkins reported the Finance Committee met June 20, 2022. B. Mr. Hopkins presented the Norman Regional Health System Financial report for May 2022: May 2022 Financial Performance  Gross Revenues .................................. (Budget $215,341,746)............ $199,851,824  Net Patient Revenue .............................. (Budget $45,213,775).............. $42,261,786  Total Operating Expenses ..................... (Budget $44,863,530).............. $48,642,086  Total Operating Revenues ...................... (Budget $45,595,211).............. $43,657,909  Operating Income ....................................... (Budget $731,681).............. ($4,984,177)  NRHA Board Minutes 6 June 27, 2022  Non-Operating Revenues (Expenses) ........ (Budget $968,184).............. ($3,043,179)  Excess Revenues over Expenses ............ (Budget $1,699,865).............. ($8,027,356) Year-to-Date  Operating Income .................................... (Budget $7,276,526)............ ($31,135,323)  Non-Operating Revenues (Expenses) ... (Budget $10,650,008).............. ($8,759,817)  Excess Revenues over Expenses .......... (Budget $17,926,534)............ ($39,895,140)  Accounts Receivable Days ............................ (Budget 48 Days).................. 50.2 Days  Days Cash on Hand…………………………………………………………….175.9 Days ACTION TAKEN: Dr. Weber motioned to approve the May 2022 NRHS Financial Statements. Mr. Pipes seconded the motion. May 2022 Financials were approved unanimously with aye votes from Mr. Cubberley, Mr.Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. C. Mr. Hopkins presented for approval 15 capital request items totaling $2,616,785: a. Transmitter: $155,208 b. Microscopes: $120,873 c. Ventilators: $60,492 d. Resting Workstations: $72,374 e. Imaging Equipment: $383,308 f. Surgical Light: $63,734 g. Exercise Testing System: $88,002 h. Battery Block Heaters: $99,857 i. Ultrasound: $58,950 j. X-ray Equipment: $142,000 k. Anesthesia Equipment: $73,442 l. Coding Equipment: $185,211 m. Telesitter Cameras: $106,858 n. Wireless Phone Upgrades: $549,187 o. Clinic Electronic Upgrades: $457,290 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $2,616,785 as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr.Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. D. Recommend Approval of the FY2023 Budget ACTION TAKEN: Dr. Weber made a motion to approve the FY2023 Budget as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr.Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar.  NRHA Board Minutes 7 June 27, 2022 Ms. Grant and Ms. Bonebreak left the meeting at 6:46pm Agenda Item X. Old Business Mr. Splitt provided a Medicare Managed Care update. Agenda Item XI. New Business A. Legislative Update Ms. Karen Rieger, attorney at Crowe and Dunlevy provided information on updated regulations for competitive bidding requirements and related procedures for public trusts. Agenda Item XII. Administrative Report Mr. Splitt announced Paula Roberts is slated to be considered for appointment to the NRHS Board of Trustees at Tuesday night’s Norman City Council meeting. Mr. Hopkins provided an update on the Captive Insurance plan. He also provided an update on the Recovery & Transformation process. Mr. Manfredo thanked the board for attending the HealthPlex topping out event. He provided an update on the HealthPlex construction, Norman Regional Nine and the Porter campus. Mr. Manfredo provided an update on the Surgery department. Ms. Anderson left the meeting at 7:26pm. Agenda Item XIII Proposed Executive Session A. Proposed Vote to Convene an Executive Session Pursuant to 25 Okla. Stat. Section 307 B.4. to Discuss with Legal Counsel Pending Internal Peer Review/Credentialing Investigation Regarding the Medical Staff Members/Applicants Listed Below; ACTION TAKEN: Dr. Weber made a motion to adjourn into Executive Session. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-4 Below. NRHA Board Minutes 8 June 27, 2022 1. Recommend New Provisional Medical Staff Appointments: a. Junaid Riaz, DO – Emergency Medicine – Active b. Jesse Ream, MD – Anesthesia – Active c. John Tedrow, MD – Medicine – Active d. David Cochran, MD – Surgery – Active e. Kyra Boler, APRN-CNP – Allied Health 2. Recommend Advancement of Medical Staff from Provisional Status: a. Kristen Innes, MD – OB/GYN – Active b. Sunil Mathew, MD – Cardiovascular Medicine – Active c. Kevin Schubach, PA-C – Radiology – Allied Health d. Edward Fogarty, MD – Radiology – Privileges Only e. Kevin Marcum, MD – Radiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Jeffrey Crook, MD – Cardiovascular Medicine – Active b. Michael Sellers, MS – Cardiovascular Medicine – Active c. Lubna Mirza, MD – Medicine – Active d. Matthew Malony, MD – Pediatrics – Active e. Robert McArthur, MD – Medicine – Consulting f. Angela Vines, APRN-CNS – Cardiovascular Medicine – Allied Health g. Lauren Donaldson, PA-C – Pediatrics – Allied Health 4. Information Only: a. Nathan White, PA-C has completed proctored cased for Arthrogram b. Christopher Smith, DO requesting Emergency Medicine privileges c. Dylan Rommel, DO requesting Emergency Medicine privileges C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session. Ms. Greenleaf seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Mr. Cubberley noted the Board returned to regular session. There were no decisions or votes taken except to return to regular session and any information shared during the Executive Session is privileged and needs to remain in Executive Session. Mr. Splitt rejoined the Board after returning to regular session. A. Proposed Vote to Approve or Disapprove the Medical Executive Committee Recommendations Regarding Credentialing of the Referenced Medical Staff Members as Listed in XII B 1-4. ACTION TAKEN: Dr. Weber motioned to approve credentialing items as recommended by Medical Executive Committee and Credentials Committee of all referenced Medical Staff members listed in XII B 1-4. Mr. Pipes seconded, and the motion was approved with  NRHA Board Minutes 9 June 27, 2022 unanimous aye votes from Mr. Cubberley, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Agenda Item XIV. Board Open Discussion The Executive team and Board Trustees discussed a recent patient experience related to billing. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:46pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary