Norman Regional Hospital Authority

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting August 26, 2024 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, August 26, 2024 at 5:30p.m. in the Norman Regional Hospital Board Room. The meeting Agenda was posted August 22, 2024 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley James Chappel Kevin Pipes Dianne Chambers, MD Mary Womack Jerome (Jerry) Weber, Ph.D Muhammad Anwar, MD Paula Roberts Joan Greenleaf Others Present: Richie Splitt, President & CEO John Manfredo, VP, Chief Operations Officer Brittni McGill, VP, Chief Nursing Officer Keith Minnis, VP, Chief People Officer Rick Wagner, VP, Chief Financial Officer Elaine Purvis, VP Chief Strategy Officer Dr. Aaron Boyd, MS, Chief Physician Executive 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 & Media Services Ray Leyva, Multimedia & Video Specialist Amber Browning, Specialist Health Promotion Amanda Jones, Director, Accommodation Services Teresa Brown, Director, Strategy & Business Growth Kyle Hurley, Director, EMSSTAT Teagan Hawkins, Paramedic, EMSSTAT Shelby Hawkins, Guest Bobbi Hawkins, Guest Charlie Hawkins, Guest Lorelai Hawkins, Guest Sean Lauderdale, Coordinator, EMSSTAT Quality Outcomes Olivia Cormier, OU’s JC Penny Leadership Fellow Members Absent: None  NRHA Board Minutes 2 August 26, 2024 Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the August 26, 2024 Norman Regional Hospital Authority business meeting at 5:30 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. September 2024 Healer of the Month – Teagan Hawkins, Paramedic, EMSSTAT Mr. Cubberley introduced to the board Kyle Hurley, Director, EMSSTAT. Mr. Hurley shared Mr. Hawkins began working at Norman Regional in 2017. Mr. Hawkins is no stranger to public safety or healthcare; his father is a police captain in Norman and his wife is a paramedic and a registered nurse at Norman Regional. Mr. Hawkins also doubles as a field training officer and a relief-crew chief. Mr. Hawkins always advocates for the rights and safety of patients to ensure positive outcomes. He is also a member of the NRHS Healer Support Team (HST). The HST consists of a group of healers trained to provide critical incident stress defusing and debriefing after an unusually traumatic incident. Over the years, Mr. Hawkins has been very engaged with his fellow EMSSTAT team members during critical times to support mental health and well being needs. His peers state that he is easy to talk to and takes time to visit with those experiencing a crisis – that was especially evidenced when NRHS lost one of our fellow healers. Mr. Hawkins commented that this honor is very special for him as he, his wife and children were all born at Norman Regional. He stated he works with amazing people and he has grown and learned so much while working at NRHS. Mr. Cubberley, on behalf of the Board, extended a heartfelt congratulations and gratitude to Mr. Hawkins. His steadfast dedication, professionalism, boundless compassion, and consistently positive attitude contribute significantly to advancing Norman Regional as a caring and high-quality health system Mr. Hurley, Mr. Lauderdale, Mr. Hawkins, Ms. Hawkins, Ms. Hawkins and children left the meeting at 5:37pm. Mr. Splitt recognized trustee Dr. Anwar’s July birthday. Mr. Splitt introduced Olivia Cormier, the University of Oklahoma JC-Penny Leadership Fellow. Ms. Cormier will be joining us for the remainder of the school year for all board meetings. Ms. Cormier is a senior at OU and is working on a  NRHA Board Minutes 3 August 26, 2024 dual undergraduate degree in Marketing and HealthCare business with a minor in Management. Agenda Item III. Board Education: Well at Work Ms. Amber Browning, Specialist, Health Promotion and Ms. Amanda Jones, Director, Accommodation Services presented an overview of the Well at Work program. Ms. Jones shared the Well at Work program was started 21 years ago. The Mission of the Well at Work program is:  Enhance organization health by fostering interest in wellness and encouraging healers to initiate or expand healthier lifestyles  Offer diverse wellness programs which meet a wide range of personal health needs  Provide recognition to healers for participating in healthier lifestyle activities  Decrease burnout and improve mental well-being  Develop a positive health system culture that is focused on celebrating and improving the quality of life all healers Ms. Jones shared 3 of the 6 goals for FY2024 were achieved. She reviewed a few of the Healer Well at Work events which included Meet & Greet Pet Therapy, Financial Literacy Month, Get Moving Challenge, The Annual OKC Memorial Marathon, the Spirit of Wellness awards, the free lipid/HbA1c and the Biggest Winner competition. Ms. Browning shared information on their collaboration with the Nurse Residency Program over the last 3 years. For NRHS to be an Accredited Transition Program, Wellness must be included in the residency curriculum. Ms. Browning and Ms. Cassie Chaffin created a presentation covering the Wellness as Work program and were selected as winners at the 2023 ANCC Transition to Practice Symposium in Florida. This year was the first year of the “You Matter Campaign”, a vital tool as part of the suicide prevention awareness program. This campaign kicked off with an Alpaca Yoga event at the Porter campus. A Healthcare Burnout Survey has been sent out to Healers and will continue to be a tool used to assess healers stressors. Ms. Jones concluded the presentation by reviewing the FY2025 Goals for the Well at Work Program: Ms. Browning, Ms. Jones, Ms. Brown and Mr. Leyva left the meeting at 5:57pm. Agenda Item IV. Approval of July 22, 2024 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the July 22, 2024 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the July 22, 2024 Board  NRHA Board Minutes 4 August 26, 2024 Meeting Minutes. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Chambers, Dr. Weber, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Ms. Roberts and Dr. Anwar. B. Mr. Cubberley asked for approval of the August 17, 2024 Board Study Session Minutes ACTION TAKEN: Dr. Weber made the motion to approve the August 17, 2024 Board Study Session Minutes. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Chambers, Dr. Weber, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Ms. Roberts and Dr. Anwar. Agenda Item V. Performance Update Ms. Jenny Anderson, Administrative Director, Patient Quality, presented an update on Star Ratings and Value Based Program FY2025 goals. Ms. Anderson shared the new ratings were just released. Norman Regional maintained a 3 Star Rating. More details will be available at the September Board Trustee meeting. NRHS has 3 value-based programs including Hospital Readmission Reduction Program (HRRP), Hospital Acquired Conditions (HAC) Reduction Program and VBP Program. Ms. Anderson reviewed the areas we received reimbursements and areas making progress. Agenda Item VI. Medical Staff A. Dr. Bond presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on August 12, 2024. MEC covered a number of topics including – Hemodialysis Catheters, Blood Culture Bottle shortages, Medical Credentialing, Department Committee Reports and Executive Team updates. Agenda Item VII. Strategic Planning Committee A. Mr. Cubberley announced a summary of the Patient Quality and Safety Committee Meeting is included in the board packet. Ms. Greenleaf is available to address questions. Agenda Item VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met August 22, 2024.  NRHA Board Minutes 5 August 26, 2024 B. Mr. Wagner presented the NRHS Financial report for July 2024: July 2024 Financial Performance  Gross Revenues .................................. (Budget $224,858,172)............ $226,073,859  Net Patient Revenue .............................. (Budget $50,144,589).............. $46,966,746  Total Operating Expenses ..................... (Budget $54,820,355).............. $54,030,709  Total Operating Revenues ...................... (Budget $51,101,015).............. $47,902,909  Operating Income .................................... (Budget $3,719,340).............. ($6,127,800)  Non-Operating Revenues (Expenses) ........ (Budget $629,332).............. $(1,195,497)  Excess Revenues over Expenses ............ (Budget $3,090,008).............. ($4,932,303) Year-to-Date  Operating Income .................................... (Budget $3,719,340).............. ($6,127,800)  Non-Operating Revenues (Expenses) ........ (Budget $629,332).............. ($1,195,497)  Excess Revenues over Expenses ............ (Budget $3,090,008).............. ($4,932,303)  Accounts Receivable Days ...................................................... . .................. 77.5 Days  Days Cash on Hand………………………………………………………………63.4 Days ACTION TAKEN: Dr. Weber made a motion to approve the July 2024 NRHS Financial Statements. Mr. Pipes seconded and the motion to approve the July 2024 Financials were approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Mr. Pipes, Dr. Chambers, Dr. Weber, Ms. Womack, Ms. Greenleaf, Ms. Roberts and Dr. Anwar. C. Mr. Wagner presented for approval two capital request items totaling $658,417 a. Catalyst Switches (HIT): $464,644 b. Ambulance Remount: $193,773 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $658,417 as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Mr. Pipes, Dr. Chambers, Dr. Weber, Ms. Womack, Ms. Greenleaf, Dr. Anwar and Ms. Roberts. D. 1st Amendment to the Eligible Deferred Compensation Plan ACTION TAKEN: Dr. Weber made a motion to approve the 1st Amendment to the Eligible Deferred Compensation Plan. Mr. Chappel seconded the motion and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Mr. Pipes, Dr. Chambers, Dr. Weber, Ms. Womack, Dr. Anwar, Ms. Greenleaf and Ms. Roberts. E. 2nd Amendment to the Consolidated Retirement Plan  NRHA Board Minutes 6 August 26, 2024 ACTION TAKEN: Dr. Weber made a motion to approve the 2nd Amendment to the Consolidated Retirement Plan. Mr. Pipes seconded the motion and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Mr. Pipes, Dr. Chambers, Dr. Weber, Ms. Womack, Ms. Greenleaf, Dr. Anwar and Ms. Roberts. Agenda Item IX. Old Business None Agenda Item X. New Business Ms. Purvis shared the Build-a-Brain program has launched. Build-a-Brain is an educational program for new mom’s and dad’s that helps them understand their role in their child’s early language and brain development. Build a Brain, Build a Life and Build a Community works with hospitals and community agencies to help educate parents and caregivers about the crucial role they play in helping their child’s brain and the importance of talk and interaction to fuel healthy brain development in the first three years of a child’s life. A resource bag called the “Brain Bag” is handed out to new parents, which includes a developmental milestone booklet called “Baby Step’s”. This booklet helps parents track their baby’s development from birth to kindergarten, including milestones and screen time. Agenda Item XI. Administrative Report Ms. McGill shared healers and public safety crews are preparing to staff the Gomer Jones Medical Center for the Oklahoma Sooners football game on Friday night. Larger crowds are anticipated outside the stadium due to the new tailgating guidelines with the SEC conference. Due to the anticipated larger crowds, additional medics will be on bicycles and able to move thru the crowded areas quicker. Dr. Boyd provided an update on the Urgent Care Clinics on the Porter Campus, Goldsby and West Moore locations. Mr. Manfredo provided an update on the new temporary kitchen location on the Main campus. This kitchen will serve healers and patients while the main kitchen and dining room are remodeled. Ms. Anderson, Ms. Herron, Mr. Garrett left the meeting at 6:36pm. 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 NRHA Board Minutes 7 August 26, 2024 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. Christopher Foster, MD – Surgery – Active b. Geetha Kandimala, MD – Medicine – Active c. Laurence Lenz, DO – Hospital Medicine 0 Active d. Tamie Babb, MD – OB/GYN – Active e. Courtney Bisson, MD – Pediatrics – Active f. Bushra Siddique, MD – Medicine – Consulting 2. Recommend Advancement of Medical Staff from Provisional Status: a. Jessica Schumann, DO – Emergency Medicine – Active b. Nicole Hughey, APRN-CNP – Cardiology – Allied Health c. Hilary Mahoney, PA-C – Hospital Medicine – Cardiology d. Sunil Gujrathi, MD – Teleradiology – Privileges Only e. Anthony Mohabir, MD – Teleradiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Allen Baughman, DO – Emergency Medicine – Active b. Ernest “Byron” Foster, II – DO – Emergency Medicine – Active c. Andrew Phillips, DO – Emergency Medicine – Active d. Ryan Carter, MD – Hospital Medicine – Active e. Geo-Phillips Chacko, MD – Hospital Medicine – Active f. Joel Kardokus, MD – Hospital Medicine – Active g. Vijay Kolli, MD – Medicine – Active h. James Fields, MD – Pediatrics – Active i. Melissa Jennings, MD – Anesthesia – Active j. Matthew Carson, DPM – Surgery – Consulting k. Sobia Ahmad, MD – Medicine – Courtesy l. Blakely Hamit, APRN-CNP – Pediatrics – Allied Health m. Winter Bathe, PA-C – Surgery – Allied Health n. Kelsey Olsen, PA-C – Surgery – Allied Health o. Ashley Billings, APRN-CRNA – Anesthesia – Allied Health p. Desiree Herring, APRN-CRNA – Anesthesia – Allied Health q. Kendall Hurley, APRN-CRNA – Anesthesia – Allied Health 4. Information Only a. Physicians of Norman Pediatric Associates request to change from  NRHA Board Minutes 8 August 26, 2024 Active to Courtesy Staff – Donna Jackson, MD; Matthew Malony, MD; Michael Milligan, DO; Tadgy Stacy, MD; Julia Stoltenberg, MD; Cynthia West, DO. b. Removing Core Neonatal Privileges from the General Pediatrics privilege form. Neonatal-Perinatal has its own form. 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. Mr. Chappel seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Mr. Chappel, Mr. Pipes, Dr. Chambers, Dr. Weber, Ms. Womack, Dr. Anwar, Ms. Greenleaf and Ms. Roberts. 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: 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. Ms. Chappel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Chappel, Mr. Pipes, Dr. Chambers, Dr. Weber, Ms. Womack, Dr, Anwar, Ms. Greenleaf and Ms. Roberts. Agenda Item XIII. Board Open Discussion Board Trustees thanked the Executive team for great open discussion and an informative and comprehensive presentation at the Board Study Session held on August 17th. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:45pm. Ms. Roberts seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel Mr. Pipes, Dr. Chambers, Dr. Weber, Ms. Womack, Dr. Anwar, Ms. Greenleaf and Ms. Roberts.  NRHA Board Minutes 9 August 26, 2024 Respectfully Submitted, Mary Womack, Vice-Chair/Secretary