Norman Regional Hospital Authority

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting June 24, 2024 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, June 24, 2024 at 5:30p.m. in the Norman Regional Board Room. The meeting Agenda was posted June 20, 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 Paula Roberts Kevin Pipes Muhammad Anwar, MD Dianne Chambers, MD Others Present: Richie Splitt, President & CEO John Manfredo, VP, Chief Operations Officer Brittni McGill, VP, Chief Nursing Officer Keith Minnis, VP, Chief People Officer Elaine Purvis, VP, Chief Strategy Officer Rick Wagner, VP, Chief Financial Officer Dr. James Bond, MD, Chief of Medical Staff Dr. Bruce Parker, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Larry Harden, Administrative Director, Risk & Compliance Melissa Herron, Director, Integrated Marketing Garrett Fergeson, Manager, Integrated Marketing Gavin Nation, OU’s JC Penny Leadership Fellow Lisa White, Manager QPI, Patient Quality & Safety Tracy Mills, Manager, Labor Delivery & Recovery Jennifer Martin, Project Manager, Quality & Performance Jamison Martin, Guest Greta Morgan, RN, Labor, Delivery & Recovery Annette Troxell, Director, Women & Children Services Members Absent: Mary Womack Jerome (Jerry) Weber, Ph.D Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the June 24, 2024 Norman Regional Hospital Authority  NRHA Board Minutes 2 June 24, 2024 business meeting at 5:30 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. July 2024 Healer of the Month – Katherine Phillips, RN, Nursing Float-Flex Mr. Cubberley introduced to the board William Hoffman, Manager Flex Pool, Nursing Resources. Mr. Hoffman shared for those who know “Kat” its comes as no surprise that NRHS is recognizing her as the July Healer of the Month. It was at this time 10 years ago that she was being recognized as the “OU School of Nursing 2014 Outstanding BSN student of the Year” for her compassion for others and her exemplary nursing skills. Ms. Phillips started her career firmly from that point on. Ms. Phillips positive attitude is contagious whether it’s interacting with patients, working alongside her colleagues, or contributing her thoughts, ideas or concerns at staff meetings. Ms. Phillips is always willing to help no matter what the situation and is a great source of knowledge, she always cares for her patients as if they were family. Mr. Hoffman thanked Ms. Phillips for her compassion and dedication to the values of NRHS. Ms. Phillips achievements and unwavering commitment to quality patient care make her an exceptional role model for all healers. Ms. Phillips shared she is a lifelong “Normanite” and can’t imagine working anywhere else. Over the last year, she became a patient herself when she was diagnosed with cancer. Ms. Phillips believes being a patient has provided her the opportunity to share knowledge with patients and encourage screenings for early detection. Ms. Phillips expressed gratitude to NRHS for providing a caring and safe environment for herself and other patients as well. Mr. Cubberley, on behalf of the Board, extended a heartfelt congratulations and gratitude to Ms. Phillips. 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. Phillips, Mr. Phillips, Mr. Dilbeck, Ms. Meyers, Ms. Meyers, Ms. Meyers, Ms. Chavez, Ms. Chavez, Mr. Hoffman, Ms. Gray, Ms. Largent, and Mr. Bond left the meeting at 5:36pm. Agenda Item III. Board Education: HPX Transitioning & Activation Mr. John Manfredo, VP & COO and Ms. Brittni McGill, RN, VP & CNO presented an overview of the “Transition & Activation Services” plan for the Inspire Health relocation of patients from the Porter campus to the new Norman Regional Hospital.  NRHA Board Minutes 3 June 24, 2024 Phase One of the plan prepared our healers to ensure a safe, successful move and smooth operations from occupancy and onward. Since the beginning of the project, NRHS has been working with two outside companies for actual move planning. Their combined expertise in helping hospitals all over the country to move successfully has been instrumental in building confidence and ensuring safety in the overall plan. Phase Two of the plan was Transition Planning. This phase involves:  Monthly meeting with all departments going into the new space  Through discussions touching every process  Staffing conversations  Technology & Equipment integration  Multi-disciplinary teams discussing what will be changing  Action plans to hold departments accountable Phase Three of the plan involves the Activation Phase:  Monthly meetings with the education & training committee  Creation of the education & training schedule for department & vendors  Running Day in the Life practice scenarios  Creating schedule for equipment, art, furniture and signage will arrive in the building Phase Four is Move Planning  Tours in each department experiencing a move  Move manual creation  Patient Move committee initiated  Running a mock move scenario  Establishing the Command Center  Create a “Before You Go” checklist Phase Five is a Recap, Adjust and look at what’s next. Leadership will look back at the challenges we have overcome during the phases of Inspire Health and what is still to come after the big move in day. Agenda Item IV. Approval of May 20, 2024 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the May 20, 2024 Board Meeting Minutes ACTION TAKEN: Ms. Greenleaf made the motion to approve the May 20, 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, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. Agenda Item V. Performance Update  NRHA Board Minutes 4 June 24, 2024 Ms. Jenny Anderson, Administrative Director, Patient Quality, presented an evaluation of the FY2024 Performance Improvement Plan and the FY2024 Patient Safety Plan and presented the FY2025 Performance Improvement and Patient Safety Plan Summary. Ms. Anderson reviewed the goals and results for the FY2024 Performance Improvement Plan, noting measures met and details on measures still needing improvement. Ms. Anderson reviewed the FY2024 Patient Safety Plan noting all metrics were met. All Patient Safety Plan metrics will remain for FY2025 as we strive for continuous quartile improvement. The FY2025 Performance Improvement Plan and the Patient Safety Plan will be presented for approval following the Patient Quality and Safety Committee report. Agenda Item VI. Medical Staff A. Dr. Bond presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on June 10, 2024. MEC covered a number of topics including – Community Survey Results, FY2025 Patient Safety Plan and FY2025 Quality & Performance Improvement Plan, 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. Recommend Approval for the FY2025 Quality & Performance Improvement Plan ACTION TAKEN: Ms. Greenleaf made a motion to approve the FY2025 Quality & Performance Improvement Plan as recommended by the Patient Quality & Safety Committee. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. C. Recommend Approval for the FY2025 Patient Safety Plan ACTION TAKEN: Ms. Greenleaf made a motion to approve the FY2025 Patient Safety Plan as Recommended by the Patient Quality & Safety Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers.  NRHA Board Minutes 5 June 24, 2024 Agenda Item VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met June 20, 2024. B. Mr. Wagner presented the NRHS Financial report for April 2024: April 2024 Financial Performance  Gross Revenues .................................. (Budget $219,367,214)............ $231,549,818  Net Patient Revenue .............................. (Budget $48,963,753).............. $48,693,957  Total Operating Expenses ..................... (Budget $52,239,277).............. $52,318,521  Total Operating Revenues ...................... (Budget $49,865,992).............. $49,661,421  Operating Income .................................... (Budget $2,373,285).............. ($2,657,100)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. ($1,535,158)  Excess Revenues over Expenses ............ (Budget $1,137,963).............. ($4,192,258) Year-to-Date  Operating Income ................................... (Budget $17,014,316............ ($37,575,936)  Non-Operating Revenues (Expenses) ... (Budget $12,353,231).............. ($9,772,503)  Excess Revenues over Expenses ............ (Budget $4,661,085)............ ($27,803,433)  Accounts Receivable Days ...................................................... . .................. 71.4 Days  Days Cash on Hand…………………………………………………………….74.2 Days ACTION TAKEN: Mr. Pipes made a motion to approve the April 2024 NRHS Financial Statements. Mr. Chappel seconded and the motion to approve the April 2024 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. C. Mr. Wagner presented the Financial report for May 2024: May 2024 Financial Performance  Gross Revenues .................................. (Budget $222,779,410)............ $242,423,877  Net Patient Revenue .............................. (Budget $49,483,827).............. $49,327,464  Total Operating Expenses ..................... (Budget $52,832,480).............. $52,881,964  Total Operating Revenues ...................... (Budget $50,089,273).............. $50,035,897  Operating Income .................................... (Budget $2,743,207).............. ($2,846,068)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. $(1,158,825)  Excess Revenues over Expenses ............ (Budget $1,507,885).............. ($1,687,242) Year-to-Date  Operating Income .................................. (Budget $19,757,523) ............ ($40,422,004)  Non-Operating Revenues (Expenses) ... (Budget $13,588,553)............ ($10,931,328)  Excess Revenues over Expenses ............ (Budget $6,168,970)............ ($29,490,675)  Accounts Receivable Days ...................................................... . .................. 72.6 Days  Days Cash on Hand………………………………………………………………66.6 Days  NRHA Board Minutes 6 June 24, 2024 ACTION TAKEN: Mr. Pipes made a motion to approve the May 2024 NRHS Financial Statements. Mr. Chappel seconded and the motion to approve the May 2024 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. D. Mr. Wagner presented for approval two capital request items totaling $251,634 a. Automated Endoscope Reprocessor: $69,651 b. Ultrasound System: $181,982 ACTION TAKEN: Mr. Chappel made a motion to approve the Capital Equipment Request at a total cost of $251,634 as recommended by the Finance Committee. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. E. Mr. Wagner presented for approval the FY2025 budget ACTION TAKEN: Mr. Pipes made a motion to approve the FY2025 Budget 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, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. Agenda Item IX. Old Business None Agenda Item X. New Business None Agenda Item XI. Administrative Report Mr. Splitt shared: o The Cancer Center Topping Out Ceremony is Tuesday, June 25th at 10am o The Norman Regional Hospital (formerly known as the HealthPlex) Ribbon Cutting is Friday, July 19th at 2pm o The Community Open House is Saturday, July 20th from 9am – 12pm. Ms. Purvis shared:  NRHA Board Minutes 7 June 24, 2024 o The children of PrimRose Child Care Center created a book in honor of our new facilities o The Marketing team is working on a new commercial for Norman Regional o New Mission Statement was reveled: Personalized health care with compassion and excellence Mr. Minnis shared an update on the Healer Referral Program and the new video to be shared at new healer orientation. Dr. Boyd provided an update on the Porter Campus: o Emergency Room update o Provider updates Mr. Manfredo provided an update on the new group of autonomous cleaning Robots that will be deployed inside the new Norman Regional Hospital. Ms. Anderson and Mr. Fergeson left the meeting at 7:09pm. 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; and (ii) CEO Evaluation. ACTION TAKEN: Mr. Chappel 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, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-4 Below. 1. Recommend New Provisional Medical Staff Appointments: a. Austin Ederer, PA-C – Surgery – Allied Health 2. Recommend Advancement of Medical Staff from Provisional Status: a. David Fish, MD – Emergency Medicine – Active b. Kimberly Mai, DO – Emergency Medicine – Active c. Mary “Kaitlyn” Parks, DO – Emergency Medicine – Active d. Dylan Roberts, DO – Hospital Medicine – Active e. Joshua Vollsteadt, DO – Medicine - Active 3. Recommended Medical Staff Reappointments: a. Sunil Mathew, MD – Cardiovascular Medicine – Active b. Jeffrey Crook, MD – Cardiovascular Medicine – Active c. Muhammad Anwar, MD = Cardiovascular Medicine – Active  NRHA Board Minutes 8 June 24, 2024 d. Michael Sellers, MD – Cardiovascular Medicine – Active e. M. Dianne Chambers, MD – OB/GYN – Active f. Rachelle Haning, DO – Emergency Medicine – Active g. Reba Beard, MD – Pediatrics – Active 4. Information Only a. Robert Kramer, III, DO – Requests Emergency Medicine Privileges b. Natalie Siegfried, DO – Requests Emergency Medicine Privileges c. Derek Hill, DO – Requests Emergency Medicine Privileges d. Kara Hatlevoll, DO – Requests Emergency Medicine Privileges C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Mr. Pipes made a motion to adjourn out of Executive Session. Mr. Chappel seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. 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. D. 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: Ms. Roberts 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 unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Mr. Pipes and Ms. Roberts. Dr. Anwar and Dr Chambers abstained. Agenda Item XIII. Board Open Discussion Mr. Chappel and Mr. Splitt shared information on the Vizient Trustee Summit they attended along with Dr. Weber. The summit, held in Nashville, TN, gave Trustees insight on emerging issues for board governance, financial health of the hospital industry and an overall view of the national healthcare landscape. Agenda Item XIV. Adjournment  NRHA Board Minutes 9 June 24, 2024 ACTION TAKEN: Mr. Pipes made a motion to adjourn the meeting at 7:20pm. Ms. Greenleaf seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel Mr. Pipes, Ms. Roberts, Dr. Anwar and Dr. Chambers. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary