Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY June 26, 2017 5:30 p.m. Norman Regional 901 N. Porter 2nd Floor Board Room AGENDA I. Call to Order ................................................................................................................Mr. Clote II. Introduction and Recognition of Outstanding Employees ...........................................Mr. Clote A. July 2017 Employee of the Month, Sheldeen Jenkins, RN Prem IV, Surgical Services – Amy Bass, Director of Surgery III. Approval of the May 22, 2017 Board Meeting and May 31, 2017 Special Board Meeting Minutes ............................ ..........................................................................Mr. Clote (Pgs. 6-21) ACTION NEEDED: Approve or Amend Minutes as Circulated ACTION TAKEN: ___________________________________ IV. Performance Updates ................................................................................. Dr. Smith (Pgs. 22-42) ACTION NEEDED: None, Information Item Only V. Approval of the May 2017, Norman Regional Health System Financial Statements ................................................................................................................ Mr. Hopkins (Pgs. 43-92) ACTION NEEDED: Approve or Disapprove May 2017 NRHS Financial Statements ACTION TAKEN: ____________________________________ VI. Medical Staff .......................................................................................................... Dr. Williams A. Report from the June 14 2017 Medical Executive Committee B. Recommend Approval of the 2018 Patient Safety Plan ............................... (Pgs. 93-105) ACTION NEEDED: Approve or Disapprove the 2018 Patient Safety Plan as Recommended by the Medical Executive Committee ACTION TAKEN: ____________________________________ NRHA Agenda 2 June 26, 2017 C. Recommend Approval of the Revised Norman Regional Health System FY 2018 Quality and Performance Improvement Plan ..............................................(Pgs. 106-129) ACTION NEEDED: Approve or Disapprove the Revised Norman Regional Health System FY 2018 Quality and Performance Improvement Plan as Recommended by the Medical Executive Committee ACTION TAKEN: ____________________________________ VII. Patient Quality and Safety Committee ..............................................................Ms. Greenleaf Report from June 12, 2017 Patient Quality and Safety Committee ACTION NEEDED: None, Information Item Only VIII. Strategic Planning Committee ............................................................... Dr. Weber/Ms. Price Report from June 7, 2017 Strategic Planning Committee ACTION NEEDED: None, Information Item Only IX. Finance Committee ............................................................................................... Mr. Cubberley A. Report from the June 19, 2017, Finance Committee ACTION NEEDED: None, Information Item Only B. Recommend Approval of the FY 2018 Budget ............................................ (Pgs. 130-161) ACTION NEEDED: Approve or Reject the FY 2018 Budget as Recommended by the Finance Committee ACTION TAKEN: _____________________________________ C. Recommend Approval of Capital Equipment Purchase Requests ..............(Pgs. 162-195) ACTION NEEDED: Approve or Disapprove Capital Equipment Purchase Requests as Recommended by the Finance Committee ACTION TAKEN: _____________________________________ X. Old Business .............................................................................................................. Mr. Clote & Mr. Splitt XI. New Business ..........................................................................................Mr. Clote & Mr. Splitt A. Proposed Revisions to the 2016-2017 Risk Management Plan ......................(Pgs. 196-215) NRHA Agenda 3 June 26, 2017 ACTION NEEDED: Approve or Disapprove the Revisions to the 2016-2017 Risk Management Plan as submitted ACTION TAKEN: _____________________________________ XII. Administrative Report ................................................................ Mr. Splitt ACTION NEEDED: None, Information Item Only XIII. Proposed Executive Session. A. Proposed Vote to Convene an Executive Session Pursuant to 25 Okla. Stat. § 307.B.4 to Discuss with Legal Counsel Pending Internal Peer Review/Credentialing Investigation Regarding the Medical Staff Members/Applicants Listed Below ACTION NEEDED: Move to Convene into Executive Session to Discuss with Legal Counsel the Above Referenced Medical Staff Items ACTION TAKEN: ____________________________________ B. Medical Staff Recommendations Regarding the Medical Staff Members/Applicants as Listed in XIII.B 1-5 Below. 1. Recommend New Provisional Medical Staff Appointments: a) Sameer Mohammed, MD, Active Staff – b) Joel Kardokus, MD, Active Staff – Hospital Medicine Department c) Ryan Carter, MD, Active Staff – Hospital Medicine Department d) Steven Roberts, DO, Active Staff – Emergency Medicine Department e) Vijay Kolli, MD, Consulting Staff – Medicine Department f) Arveitta Edge, MD, Active-Affiliate Staff – Medicine Department g) Winter Bathe, PA-C, Allied Health Staff – Surgery Department h) Serina Madden, ARNP, FNP-C, Allied Health Staff – Pediatrics Dept. 2. Recommend Advancement of Medical Staff from Provisional Status: a) Jennifer Enteshary, APRN-CRNA – Anesthesia Department 3. Recommend Medical Staff Reappointments: a) Richard Kirkpatrick, MD, Active Staff – Surgery Department b) Jeremy Moore, MD, Active Staff – Surgery Department c) Benjamin Panter, MD, Active Staff – Surgery Department d) Vincent Gonzalez, MD, Active Staff – Emergency Medicine Department e) Marshall Rea, DO, Active Staff – Emergency Medicine Department f) James Williams, DO, Active Staff – Emergency Medicine Department g) Lance Williams, DO, Active Staff – Emergency Medicine Department h) Stephen Ingels, MD, Active Staff – Pathology Department i) Robert Littlejohn, MD, Active Staff – Pathology Department j) Rosalie LaVon, MD, Active Staff – Medicine Department NRHA Agenda 4 June 26, 2017 k) Joe Riddle, MD, Active Staff – Medicine Department l) Christian Sieck, MD, Active Staff – Medicine Department m) Joel Holloway, MD, Consulting Staff – Medicine Department n) Amanda Lewis, PA-C, Allied Health Staff – Surgery Department o) Stephanie Porter, PA-C, Allied Health Staff – Surgery Department p) Deborah Reed, PA-C, Allied Health Staff – Emergency Medicine Department 4. Recommend Request for Additional Clinical Privileges a) James Neel, MD, is Requesting to add Independent Cardiothoracic Robotic Surgery Privileges C. Corrections to previous MEC Credentials Date Original Correction November 1, 2016 A. Alvin Bradford, MD A. Alvin Bradford, DO B. Nancy Brown, MD B. Nancy Brown, DO January 2, 2017 A. Reid Breckwoldt, MD A. Reid Breckwoldt, MD  Recommendation:  Recommendation: Approval of Advancement from reappointment and Provisional Status to renewal of clinical Teleradiology privileges privileges only B. Shrilekha Parikh, MD B. Shrilekha Parikh, MD  Recommendation:  Recommendation: Approval of Approval of advancement advancement to Active to Active-Affiliate Staff Staff and renewal of clinical privileges C. Bilal Ahmad, MD C. Bilal Ahmad, MD  Active Staff  Consulting Staff April 4, 2017 A. Lana Nelson, MD A. Lana Nelson, DO B. Patrick Livingston, MD B. Patrick Livingston, DO May 2, 2017 A. Stephen Lindsey, MD A. Stephen Lindsey, MD  Staff Category:  Staff Category: Active- Consulting Affiliate Staff D. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION NEEDED: Approve or Disapprove Adjournment of Any Executive Session and Return to Regular Session ACTION TAKEN: ____________________________________ E Proposed Vote to Approve or Disapprove the Medical Executive Committee Recommendations Regarding Credentialing of the Referenced Medical Staff Members [As Listed in XIII B 1-4] NRHA Agenda 5 June 26, 2017 ACTION NEEDED: Approve or Disapprove the Medical Executive Committee Recommendations Regarding Credentialing of the Referenced Medical Staff Members [As Listed in XIII B 1-4] ACTION TAKEN: _______________________________________ F. Proposed Vote to Approve or Reject the Corrections to Previous MEC Credentials as Recommended by the Credentials and Medical Executive Committees ACTION NEEDED: Approve or Disapprove Corrections to Previous MEC Credentials as Recommended by the Credentials and Medical Executive Committees ACTION TAKEN: ____________________________________ XIV. Board Education Session: Provider Compensation: Minimize Risk & Maximize Collaboration” ................................................................. Mr. Manfredo (Pgs. 216-232) XV. Board Open Discussion XVI. Closing Comments XVII. Adjourn ACTION NEEDED: Motion to Adjourn the Meeting ACTION TAKEN: _______________________________________. July 24, 2017 Board Education Topic: Medical Staff Categories and Functions – Dr. Boyd & Dr. Smith August 28, 2017 Board Education Topic: Physician Engagement – Mr. Splitt, Dr. Boyd, & Ms. Carter Disruptive Behavior Mission: To serve our community as the leader in health and wellness care. Vision: To be the provider of choice to improve the health and well-being of our regional communities.