Norman Regional Hospital Authority

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting November 25, 2024 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, November 25, 2024 at 5:30p.m. in the Norman Regional Hospital Board Room. The meeting Agenda was posted November 21, 2024 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley James Chappel Mary Womack Jerome (Jerry) Weber, Ph.D Muhammad Anwar, MD Joan Greenleaf Kelley Lobb, MD Kevin Pipes Others Present: Rick Wagner, CEO & Chief Financial Officer Dr. Aaron Boyd, MD, CEO & Chief Physician Executive Brittni McGill, VP, Chief Nursing Officer Keith Minnis, VP, Chief People Officer Elaine Purvis, VP Chief Strategy Officer Dr. James Bond, MD, Chief of Medical Staff Dr. Bruce Parker, MD, Chief of Medical Staff Elect Dr. Joe Voto, MD, Chief Medical Officer Larry Harden, Administrative Director, Risk & Compliance Melissa Herron, Director, Integrated Marketing Garrett Fergeson, Manager, Integrated Marketing & Media Services Ray Leyva, Multimedia & Video Specialist Olivia Cormier, OU’s JC Penny Leadership Fellow Paul Jones, Director Clinic Operations & Growth Chris Miller, System Manager, Surgical Service Line Dawn Miles, RN, ACC – Same Day Surgery Members Absent: Paula Roberts Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the November 25, 2024 Norman Regional Hospital Authority business meeting at 5:30 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers  NRHA Board Minutes 2 November 25, 2024 A. December 2024 Healer of the Month Dawn Miles, RN, ACC – Same Day Surgery Mr. Cubberley introduced to the board Chris Miller, System Manager, Surgical Service Line. Mr. Miller shared Ms. Miles is a native of Omaha, Nebraska. Ms. Miles was raised in the suburbs of St. Louis and graduated Nursing school at Deaconess Hospital. Soon thereafter, her husband was transferred to Tinker Air Force Base. Ms. Miles started her nursing career as an Oncology nurse, transitioning into the Charge Nurse position and working for various clinics in the area before joining her husband at his own clinic. After her husband passed away, Ms. Miles worked with Norman Regional to assist their patients in finding a new provider. Shortly thereafter, Ms. Miles began her career at NRHS working on 3NW for 5 years and eventually transitioned to Surgical Services. Ms. Miles coworkers can’t say enough about her dedication to patients while always displaying a cheerful, positive attitude. Ms. Miles is quick to respond to her coworker and patient needs with the highest level of integrity. Her 43-year career has not dulled her compassion and commitment in caring for her patients. Ms. Miles thanked everyone for the honor. Mr. Cubberley, on behalf of the Board, extended a heartfelt congratulations and gratitude to Ms. Miles. Her steadfast dedication, professionalism, boundless compassion, and consistently positive attitude contribute significantly to advancing Norman Regional as a caring and high-quality health system. Agenda Item III. Board Education: Oklahoma Breast Center Mr. Paul Jones, Director Clinic Operations & Growth presented an update on the Oklahoma Breast Center. Mr. Jones shared the most recent data on breast cancer risks:  1 out of 8 women have a lifetime risk of developing breast cancer  1 out of 39 women will die from breast cancer  1 out of every 726 men have a lifetime risk of developing breast cancer  Oklahoma ranks 2nd highest of all states for death from breast  Oklahoma ranks 42nd out of the 50 states for breast cancer screening Norman Regional realized they had a great opportunity to provide the exceptional care this community needed for breast health. NRHS put together a team of highly skilled professionals to promote wellness and breast healthcare. This exceptional team is lead by Dr.’s Denise Rable and Reconstructive Surgeon Dr. James Magnusson. Over the last 12 months, NRHS has increased breast care imaging by 23%. Imaging data gathered strictly from the Norman Regional Nine and Moore locations has met or exceeded anticipated volumes at both locations. On the Clinic side, clinic visits are at 156% of budget and surgeries are at 120% of budget.  NRHA Board Minutes 3 November 25, 2024 NRHS is also focusing on genetic testing for patients. Jeneice Miller, APRN is the only nurse in the state of Oklahoma that is certified in cancer genetic testing. From August 2023 thru August 2024, 241 genetic tests were taken by patients. Of those 241 tests, 61% resulted in gene positive or high-risk negative results. NRHS worked with these patients to provide managed medical changes with either additional screenings or follow up visits. Key areas of focus for 2025 are:  Growth in Staffing  Implementing High Risk breast program software  Breast Navigator to follow up with higher risk patients  Future Growth  MRI availability NRHS continues to see a local market shift with patients seeking care in their own community. Patient experience scores continue to see improvement and exceeding Would Recommend Quartile goals. During the month of October’s Breast Cancer Awareness Month proved a great opportunity to highlight NRHS healers, our breast cancer awareness blog, Project 31, support groups, community banners and television interviews highlighting awareness of breast screenings. Agenda Item IV. Approval of October 28, 2024 Norman Regional Hospital Authority Board Meeting Minutes and the November 4, 2024 Norman Regional Hospital Authority Special Board Meeting Minutes A. Mr. Cubberley asked for approval of the October 28, 2024 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the October 28, 2024 Board Meeting Minutes. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Lobb, Dr. Weber, Ms. Womack, Ms. Greenleaf, Ms. Roberts, Dr. Anwar and Mr. Pipes. B. Mr. Cubberley asked for approval of the November 4, 2024 Special Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the November 4, 2024 Special Board Meeting Minutes. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Lobb, Dr. Weber, Ms. Womack, Ms. Greenleaf, Ms. Roberts, Dr. Anwar and Mr. Pipes. Agenda Item V. Performance Update  NRHA Board Minutes 4 November 25, 2024 Ms. McGill provided several updates: o Emergency Department SWAT:  Left without being seen dropped below 1%  Grievances decreased by 50%  Door to Dock time decreased by 25 minutes  Hold hours are down by 30%  Overnight Case Management is in the implementation process o The Joint Commission extension survey went well. They were very complimentary and no resurvey needed. o NRHS and Moore Norman Vo-tech cohosted a Healthcare Pathway tour for 25 Norman Public School students. The tour took students to the Young Family Activity Center, Norman Regional Nine and the main campus. Students were given the opportunity to experience several disciplines and ask questions as they went along. The event was very popular and will be held again in the future. o NRHS is 1 of 5 birthing hospitals in the state to earn the “Gold Level” award from the Oklahoma Quality Peri-natal Improvement Collaborative. o Oceans Behavioral Health Facility opened Outpatient beds on November 4 th. o NRHS was the presenting sponsor at the March of Dimes Nurse of the Year Event. There were a record 955 nominations from across the State. NRHS had 4 1st place winners of the 91 finalists. o The Medical Staff has added an additional annual award to honor clinicians. o The National Kidney Foundation and Becker’s contacted NRHS in regards to abstracts related to our dialysis program. o Conservation measures are in place for IV Fluids. NRHS is working with alternate vendors to secure additional supplies. Dr. Voto shared updates from the Operating Room – Nov 18th was a recording breaking day with 59 surgeries and 15 endoscopy procedures. Continual up-trend in surgeries every day since. Mr. Minnis provided an update on EVS.  All long-term vacant EVS positions have been filled. Working with HR to continue looking for potential EVS new hires to keep up with increased patient throughput.  Working with Talent management for a preceptor program for new EVS healers  Dist/trans process improvement continues as we search for avenues for better transport options. Agenda Item VI. Medical Staff A. Dr. Bond presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on November 11, 2024. MEC covered a number of topics including – Medical Credentialing, Department Committee Reports and Executive Team updates. Agenda Item VII. Strategic Planning Committee  NRHA Board Minutes 5 November 25, 2024 A. Mr. Cubberley announced a summary of the November 4th Strategic Planning Committee Meeting is included in the board packet. Dr. Weber is available to address questions. Agenda Item VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met November 21, 2024. B. Mr. Wagner presented the NRHS Financial report for October 2024: October 2024 Financial Performance  Gross Revenues .................................. (Budget $229,602,155)............ $239,913,407  Net Patient Revenue .............................. (Budget $51,586,460).............. $51,821,428  Total Operating Expenses ..................... (Budget $54,353,126).............. $56,062,188  Total Operating Revenues ...................... (Budget $52,498,027).............. $52,698,612  Operating Income .................................... (Budget $1,855,099).............. ($3,363,576)  Non-Operating Revenues (Expenses) ........ (Budget $629,332)................. $(896,531)  Excess Revenues over Expenses ............ (Budget $1,225,757).............. ($4,260,107) Year-to-Date  Operating Income .................................... (Budget $9,987,144)............ ($21,961,581)  Non-Operating Revenues (Expenses) ..... (Budget $2,517,328).............. ($3,866,103)  Excess Revenues over Expenses ............ (Budget $7,469,816)............ ($18,095,478)  Accounts Receivable Days ...................................................... . .................. 72.7 Days  Days Cash on Hand………………………………………………………………41.1 Days ACTION TAKEN: Mr. Pipes made a motion to approve the October 2024 NRHS Financial Statements. Dr. Weber seconded and the motion to approve the October 2024 Financials were approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Lobb, Dr. Weber, Ms. Womack, Ms. Greenleaf, Dr. Anwar and Mr. Pipes. C. Mr. Cubberley presented for approval two capital request items totaling $403,474 a. Integrated Surgical Equipment: $85,757 b. Ultrasound Machines: $317,718 ACTION TAKEN: Mr. Pipes made a motion to approve the Capital Equipment Request at a total cost of $403,474 as recommended by the Finance Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Lobb, Dr. Weber, Ms. Womack, Ms. Greenleaf, Dr. Anwar and Mr. Pipes. Agenda Item IX. Old Business  NRHA Board Minutes 6 November 25, 2024 None Agenda Item X. New Business None Agenda Item XI. Administrative Report Mr. Purvis shared a few updates:  Each Trustee was provided a handout covering Patient Satisfaction survey scores from NRC, Google reviews and Patient Liaison patient interactions. Our Patient Liaison visited with over 600 patients during September and October. Ms. Purvis stressed the continued Team work from healers associated with acquiring these ratings.  The Trey Young Family has been financially supportive in the purchase of supplies for the Inpatient Occupational Therapy kitchen. Candace Young and Sherri Coale helped shop for the kitchen supplies and early last week, Ms. Young was invited to assist in a pie making class. At that time, it was revealed that the kitchen was named after her.  A Healer Remembrance Garden is now located next to the pond to honor fellow healers who have passed away.  Healers have been invite to participate in focus groups thru the end of December. These groups have been focusing on culture, communication and other specific topics  With much thought and discussion, the NMotion clinic at the YFAC is closing. The practice will phase into the NROC Primary Care clinic division.  The Holiday Cheer on HealthPlex Parkway will be December 6th. It is the open for Healers and the community. There will be train rides, hot cocoa station, crafts, photos with Santa and vendors for shopping. Mr. Minnis shared the following updates:  Porter the “Pup” now has handouts for patients and Healers. The handout shares fun facts about Porter and a questionnaire on how people felt prior to the interaction with him and afterwards. Dr. Boyd shared the following updates:  The “Left without being Seen” numbers have dropped drastically  Cash collections have improved  The Porter Urgent Care has been very successful  Radiology has increased volume output  Updates on construction and remodel on the Main campus  New Physicians onboard  The Executive Team has accepted the challenge of the fast and intense path we are moving on and have the needed support from fellow healers  NRHA Board Minutes 7 November 25, 2024 Ms. Herron, Mr. Fergeson and Ms. Cormier left the meeting at 6:42pm. Agenda Item XII. Proposed Executive Session A. Proposed Vote to Convene an Executive Session Pursuant to 25 O.S. Sec. 307 B.4. to Hold a Privileged Discussion with Legal Counsel (i) Pending Internal Peer Review/Credentialing Investigation Regarding the Medical Staff Members/Applicants Listed Below; and (ii) pursuant to 25 O.S. Sec. 307.B.1; ACTION TAKEN: Dr. Weber made a motion to adjourn into Executive Session. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Ms. Womack, Dr. Weber, Dr. Anwar, Dr. Lobb and Mr. Pipes. 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. Ross Gillum, MD – Surgery – Active b. Gustavo Del Toto, DO – Hospital Medicine – Active c. Fransen McGinley, PA-C – Medicine – Allied Health d. Jaime Johnson, PA-C – Surgery – Allied Health 2. Recommend Advancement of Medical Staff from Provisional Status: a. Pooja Singhal, MD – Medicine – Consulting b. Carrie Vincent, APRN-CNP – Pediatrics – Allied Health c. Ajay Singh, MD – Teleradiology – Privileges Only d. Philip Eisinger, DO – Teleradiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Lesa Mulligan, MD – OB/GYN – Active b. Archana Gautam, MD – Cardiovascular Medicine – Active c. Saud Ahmed, MD – Medicine – Active d. Namalie Pierson, MD – Medicine – Active e. Kristin Thorp, MD – Medicine – Active f. Muhammad Ishaq, MD – Behavioral Medicine – Active g. Jeff Raines, DO – Emergency Medicine – Active h. Sergio Garcia, MD – Medicine – Consulting i. Tadgy Stacy, MD – Pediatrics – Courtesy j. Jayesh Panchal, MD – Surgery – Courtesy k. Dezaray Preuninger, APRN-CNP – Pediatrics – Allied Health l. Keri Houck, APRN-CNS – Hospital Medicine – Allied Health m. Jana McDonald, RNFA – Surgery – Allied Health n. Jennifer Enteshary, APRN-CRNA – Anesthesia – Allied Health 4. Information Only  NRHA Board Minutes 8 November 25, 2024 a. Hannah Elliott, PA-C – completed proctored cases for Pleurx drains C. Request to Adjourn Our of Executive Session and Return to Regular Session ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session. Mr. Pipes seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Mr. Chappel, Dr. Lobb, Dr. Weber, Ms. Womack, Dr. Anwar, Ms. Greenleaf and Mr. Pipes. 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. Mr. Chappel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Chappel, Dr. Lobb, Dr. Weber, Ms. Womack, Dr. Anwar, Ms. Greenleaf, and Mr. Pipes. Agenda Item XIII. Board Open Discussion Mr. Chappel thanked the Executive Team for all their hard work. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:48pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel Dr. Lobb, Dr. Weber, Ms. Womack, Dr. Anwar, Ms. Greenleaf and Mr. Pipes. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary