Norman Regional Hospital Authority

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting February 26, 2024 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, February 26, 2024 at 5:30p.m. in the Norman Regional Porter Board Room. The meeting Agenda was posted February 22, 2024 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf James Chappel Jerome (Jerry) Weber, Ph.D. Mary Womack Paula Roberts Muhammad Anwar, MD Others Present: Richie Splitt, President & CEO John Manfredo, VP, Chief Operations Officer Brittni McGill, VP, Chief Nursing Officer Elaine Purvis, VP, Chief Strategy Officer Rick Wagner, VP, Chief Financial Officer Dr. James Bond, MD, Chief of Medical Staff Bruce Parker, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Larry Harden, Administrative Director, Risk & Compliance Ray Leyva, Multimedia & Video Specialist, Media Services Garrett Fergeson, Manager, Integrated Marketing Gavin Nation, OU’s JC Penny Leadership Fellow Tracy Mills, Manager, Labor Delivery & Recovery Heather Tennison, Charge Nurse, Labor & Delivery Annette Troxell, Director, Women & Children Services Temo Ibarra, Director, Clinic Operations & Growth Shane Cohea, Director, Safety & Security Mike Nabors, Manager, Safety & Security Angie Bruce, Security Officer Members Absent: Dianne Chambers, MD Kevin Pipes Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the February 26, 2024 Norman Regional Hospital Authority business meeting at 5:32 p.m.  NRHA Board Minutes 2 February 26, 2024 Agenda Item II. Introduction and Recognition of Outstanding Healers A. March 2024 Healer of the Month – Heather Tennison, Charge Nurse, Labor & Delivery Mr. Cubberley introduced to the board Tracy Mills, Manager, Labor & Delivery Ms. Mills shared Ms. Tennison grew up in South Dakota and moved to Oklahoma 20 years ago to pursue a career in accounting. After 14 years in the accounting field, she decided to make a career change and earned an associate’s degree in nursing from Oklahoma City Community College. She began working at NRHS in 2018 as a labor delivery nurse, becoming a full time charge nurse in 2022. Her fellow healers shared that Ms. Tennison is not someone who wants a lot of recognition, but someone who certainly deserves it. She is always cool, calm, collected and willing to assist others. She makes her fellow healers feel comfortable and answers their questions, no matter how big or small. Ms. Tennison has been a wonderful addition to the Labor and Delivery team. Ms. Tennison thanked everyone for the opportunity to work at NRHS. Being a nurse has offered her the ability to help others and work in a true family environment. Mr. Cubberley, on behalf of the Board, extended a heartfelt congratulations and gratitude to Ms. Tennison. Her steadfast dedication, professionalism, boundless compassion, and consistently positive attitude contribute significantly to advancing Norman Regional as a caring and high-quality health system. Ms. Mills, Ms. Tennison and Ms. Troxell left the meeting at 5:37pm Mr. Cohea, Mr. Nabors, Ms. Bruce and Porter the pup arrived at 5:45pm Agenda Item III. Board Education: VaxCare Mr. Ibarra, Director, Primary Care Clinic Operations presented an overview of a new process for maintaining and administering vaccines in our Norman Regional Outpatient Clinics (NROC): VaxCare. Vaxcare simplifies, optimizes and elevates vaccination workflow for primary care practices and staff, providing consistent monitoring of inventory levels and expiration dates. VaxCare technology automates countless tedious manual tasks, saving provider’s time while minimizing errors. IN the end, our new partner will help NRHS raise immunization rates and improve community health. Mr. Splitt proudly introduced NRHS’s newest “fur-time” employee, Porter, a 9 ½ week  NRHA Board Minutes 3 February 26, 2024 old Goldendoodle, along with his handler, Angie Bruce, from NRHS Security. Porter is embarking on a journey to become a certified therapy dog in the next 18-24 months. Research supports the positive impact of pet therapy, demonstrating its ability to up0life spirits, reduce blood pressure, and other additional comfort and healing during interactions with patients and healers. Beyond medical benefits, therapy dogs like Porter contribute to alleviating loneliness and brightening someone’s day. Ms. Bruce and Porter will soon become regular visitors on campus, providing support and joy to both patents and healers. Mr. Cohea, Mr. Nabors, Ms. Bruce, Porter and Mr. Leyva left the meeting at 5:55pm. Agenda Item IV. Approval of January 25, 2024 Norman Regional Hospital Authority Board Meeting Minutes and February 10, 2024 Board Study Session Minutes A. Mr. Cubberley asked for approval of the January 25, 2024 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the January 25, 2024 Board Meeting Minutes. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar. B. Mr. Cubberley asked for approval of the February 10, 2024 Board Study Session Minutes ACTION TAKEN: Dr. Weber made the motion to approve the February 10, 2024 Board Meeting Minutes. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar. Agenda Item V. Performance Update Ms. Jenny Anderson, Administrative Director, Patient Quality, provided a review of CY2023 Infection Prevention goals and results and a CMS Star Ratings update. Ms. Anderson shared the CY2023 Infection Prevention data, goals and outcomes. She provided a 6-month update on the mortality data and goals for CY2023 and initiatives in place for accurate data compilation for expected and observed mortality. Ms. Anderson provided updated HCAHPS/Patient Experience data and reviewed various initiatives.  NRHA Board Minutes 4 February 26, 2024 Agenda Item VI. Medical Staff A. Dr. Bond presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on February 12, 2024. MEC covered a number of topics including – High Sensitivity Troponin, Infection Prevention Plan and Evaluation, Transfusion Guideline update, Inspire Health update, Medical Credentialing, Department Committee Reports and Executive Team updates. Agenda Item VII. Patient Quality & Safety Committee 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. Annual Review & Revision to the 2024 Infection Prevention Plan ACTION TAKEN: Dr. Weber made the motion to approve the 2024 Infection Prevention Plan as presented by the Patient Quality & Safety Committee. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Ms. Roberts, Dr. Weber and Dr. Anwar and Ms. Womack. Agenda Item VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met February 22, 2024. B. Mr. Wagner presented the NRHS Financial report for January 2024: January 2024 Financial Performance  Gross Revenues .................................. (Budget $221,145,399)............ $212,530,077  Net Patient Revenue .............................. (Budget $48,864,188).............. $47,865,962  Total Operating Expenses ..................... (Budget $51,260,101).............. $52,700,804  Total Operating Revenues ...................... (Budget $49,842,565).............. $48,820,526  Operating Income .................................... (Budget $1,417,536).............. ($3,880,277)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. $(1,615,601)  Excess Revenues over Expenses ............... (Budget $182,214).............. ($2,264,676) Year-to-Date  Operating Income ..................................... (Budget $9,521,751............ ($27,656,893)  Non-Operating Revenues (Expenses) ..... (Budget $8,647,254).............. ($7,233,329)  Excess Revenues over Expenses ............... (Budget $874,497)............ ($20,423,564)  Accounts Receivable Days ...................................................... . .................. 67.3 Days  Days Cash on Hand…………………………………………………………..….87.1 Days  NRHA Board Minutes 5 February 26, 2024 ACTION TAKEN: Dr. Weber made a motion to approve the January 2024 NRHS Financial Statements. Ms. Roberts seconded the motion. January 2024 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar. C. Mr. Wagner presented for approval two capital request items totaling $439,150 a. Biopsy Guidance System: $213,516 b. Robotic Arm for Imaging: $225,634 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $439,150 as recommended by the Finance Committee. Ms. Roberts seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar. D. Mr. Wagner presented for approval the Retirement Plan Amendment and Resolution ACTION TAKEN: Dr. Weber made a motion to approve the Retirement Plan Amendment and Resolution as recommended by the Finance Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar. Agenda Item IX. Old Business None Agenda Item X. New Business None Agenda Item XI. Administrative Report Mr. Splitt shared: o Board Advance surveys were sent to Trustees for feedback. o Ambulatory Surgery considerations are currently under review. o Congressman Tom Cole visited and toured the HealthPlex expansion. We thanked him for his continued support of the health system and community, and discussed other key initiatives important to NRHS. o NHealth Provider Networking Event was hosted at the Young Family Athletic Center with great attendance by providers.  NRHA Board Minutes 6 February 26, 2024 o Education Center renovations are underway on the Porter campus and will continue for the next 6 months or so. Dr. Boyd shared the recent ED Residency re-accreditation visit went very well. The program has performed extremely well under the leadership of Dr. Patrick Cody. Dr. Cody will be leaving to pursue a new teaching position. Dr. Jessica Meador will take the lead beginning this summer. Ms. McGill shared: o Construction has progressed nicely for the Behavioral Health facility on the Porter Health Village campus. It is targeted to open June of this year, and trustee tours are being coordinated for April. o NRHS and the OU College of Nursing formed a partnership to host the ROTC military nursing program Ms. Anderson and Mr. Fergeson left the meeting at 6:42pm. Agenda Item XII. 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, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-3 Below. 1. Recommend New Provisional Medical Staff Appointments: a. Helen Harris, DO – Emergency Medicine - Active 2. Recommend Advancement of Medical Staff from Provisional Status: a. Mary “Kate” Nixon, MD – OB/GYN – Active b. John Hotchkiss, MD – Teleradiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Ting Chen, MD – Anesthesia – Active b. Ryan Winfrey, DO – Hospital Medicine – Active c. Chun Kwan, MD – Anesthesia – Active d. Arun Philip, DO – Hospital Medicine – Active e. Katherine Hays, MD – Cardiovascular Medicine – Active f. Norman “Paul” Ayers, MD – Cardiovascular Medicine – Active g. Richard Wedel, MD – Radiology – Active  NRHA Board Minutes 7 February 26, 2024 h. Satish Arora, MD – Medicine – Active i. Cuong Nguyen, MD – Medicine – Active j. Dustin Tedesco, MD – Medicine – Active k. Joshua Powell, MD – Surgery – Active l. Gary Larson, MD – Medicine – Consulting m. Tan Pham, MD – Medicine – Consulting n. Garrett Wardlow, PA-C – Surgery – Allied Health o. Martha Royall, APRN-CNP – Pediatrics – Allied Health 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. Roberts seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts 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. E. Proposed Vote to Approve or Disapprove the Medical Executive Committee Recommendations Regarding Credentialing of the Referenced Medical Staff Members as Listed in XII B 1-3 ACTION TAKEN: Mr. 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 1-3. Mr. Chappel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar. Agenda Item XIII. Board Open Discussion Mr. Chappel shared additional information on the tour of the HealthPlex with Congressman Cole. Trustees provided general feedback for the Board Study Session. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:55pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Ms. Roberts and Dr. Anwar.  NRHA Board Minutes 8 February 26, 2024 Respectfully Submitted, Mary Womack, Vice-Chair/Secretary