Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting April 23, 2018 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, April 23, 2018, at 5:30 p.m., in the Norman Regional Hospital Board Room. The meeting Agenda was posted April 19, 2018, on the NRHS and Norman websites and at the entrance to Norman Regional Hospital. Members Present: Tom Clote, Chair Muhammad Anwar, MD Diane Chambers, MD James (Jeff) Kimpel, Ph.D. Tom Sherman Jerome (Jerry) Weber, Ph.D. Doug Cubberley, Vice Chair/Secretary Kevin Pipes Member Absent: Joan Greenleaf Others Present: Robin Mantooth, MD, Chief of Staff Farhan Jawed, MD, Chief of Staff-Elect Richie Splitt, President and CEO Ken Hopkins, CFO Meegan Carter, VP Population Health & Wellness Paula Price, VP Strategy & Growth Dr. Aaron Boyd, MD, CMO Brittni McGill, Interim CNO Susie Graves, Interim CNO Karen Rieger, Crowe & Dunlevy Jenny Anderson, Director QPI & Medical Staff Services Lisa White, Manager PI & Medical Staff Services Molly McCool-Hare, Business Planning/Operations Specialist Cindy Gilmore, LEAN Specialist Debbie Oliphant, Patient Liaison Courtney Blau, Admin. Dir. Risk Management & Compliance Kelly Wells, Director Health Promotion & Community Relations Joy Hampton, Journalist Norman Transcript Robert Muzny, Director Decision Support Mike Nabors, Manager Security Brian Loftus, Business Planning/LEAN Specialist Cheryl McKinley, Manager 4N/Inpatient Wound Care Paul Jones, Director Med/Surg. Critical Care James Murunga, RN 4-North Recorder: Doris Gonzalez, Executive Assistant  NRHA Board Minutes 2 April 23, 2018 Agenda Item I. Meeting Called to Order Mr. Clote called the April 23, 2018, Norman Regional Hospital Authority meeting to order at 5:36 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. May 2018 Healer of the Month, James Murunga, RN, 4-North – Cheryl McKinley, Manager 4-North/Inpatient Wound Care Mr. Clote introduced Ms. McKinley who presented Mr. Murunga as the Outstanding Healer for May 2018. Ms. McKinley noted that Mr. Murunga has had a long- standing involvement with Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) awareness programs in Kenya. He came to the United States in 2003 through an exchange program sponsored by the US Department of Education to learn about HIV and AIDS. He returned to Kenya for a year to teach what he learned here. He has a goal to acquire old, outdated equipment and work with someone to refurbish that equipment and send to Kenya. He became a US Citizen January 30, 2018. Ms. McKinley he started to work on 4- North in 2014 and shortly became the relief Charge Nurse. She shared the employee’s accomplishments, outstanding teamwork, positive attitude, excellent clinical skills, and his compassion toward patients, families and co-workers. He is truly an asset to 4-North and Norman Regional Health System and well deserving of this honor. Mr. Murunga thanked his co-workers for their endless assistance and support. He thanked Ms. McKinley for always believing in him, Mr. Jones for his leadership as we navigate through healthcare changes, the executives for their strategic plan that facilitates our moving forward, and to everyone here thank you for the Outstanding Healer recognition. Mr. Clote congratulated and thanked Mr. Murunga on behalf of the Board for her outstanding dedication, professionalism and positive attitude that continues to make Norman Regional Health System a caring, high quality system. Mr. Murunga, Mr. Jones, and Ms. McKinley left the meeting at 5:40 p.m. The minutes will reflect the order of discussion. Agenda Item III. Approval of the March 26, 2018, Board Meeting Minutes Mr. Clote asked for approval of the March 26, 2018, Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the March 26, 2018, Board Meeting Minutes as submitted. Mr. Sherman seconded the motion, and the motion unanimously approved with aye votes from Dr. Anwar, Dr. Chambers, Mr. Clote, Mr. Cubberley, Dr. Kimpel, Mr. Pipes, Mr. Sherman, and Dr. Weber.  NRHA Board Minutes 3 April 23, 2018 Agenda Item IV. Performance Updates Ms. Anderson provided a Quality & Patient Safety Update highlighting the following:  Patient Safety o Leapfrog Update  Leapfrog focuses on measuring and publicly reporting hospital performance through the annual Leapfrog Hospital Survey.  Data gathered from Leapfrog Survey:  Hospital Acquired Infections  Problems from surgery/procedure  Safe Practices to prevent errors  Falls/Bed Sores  Effective Leadership  Effective Communication  The survey updates measures and specifications annually and must be submitted by June 30, however, may be updated at any time after submitting.  Data entered by August 31 will be used for the Fall Grade  Data entered by January 31 will be used for the Spring Grade  Both Norman Regional Hospital and HealthPlex received “A” Spring Safety Grades  Quality and Performance Improvement o Stroke Program Update  Early recognition and treatment leads to better outcomes  Code Stroke now called in the Emergency Room Triage  Labs being done on I-stat machine at bedside for quicker turn-around times  Goal for door to tPA is less than 60 minutes  4th quarter 2017, five of eight patients met goal of less than 60 minutes  One patient in December met door to tPA in 22 minutes  Average door to tPA in 4th quarter 2017 was 50.13 minutes  The Stroke Program started in 2012 and had four patients that qualified for tPA, and in 2017, we had 57 patients.  Employee Engagement o NEWs Wall Update  100% of our NEWs Walls are up and reporting metrics  Most have a media score of two metrics being measured within the department  We have met the goal of everyone having at least one metric.  Patient Experience o Responsiveness of Staff (2nd Month above target) – Celebrating that success Thursday with Ice Cream Sundaes o Real-Time Survey Trends (Clinics/Outpatient Services)  Each fiscal quarter for 2018 Outpatient Services has increased their percentage as it relates to “would recommend hospital to family”  Promoting the survey by handing out cards with the tech’s name as well as posters in those areas  The clinics for the 3rd & 4th quarter of 2018 has increased their percentages  NRHA Board Minutes 4 April 23, 2018 Agenda Item V. Approval of the March 2018 Norman Regional Health System Financial Statements Mr. Hopkins noted that March had very strong inpatient volumes and highlighted the following from the March 2018 NRHS Financial Statement:  March Hospital Inpatient Volumes – Admits were 9% favorable to budget and discharges were 13% favorable to budget. Inpatient days were 7.6 favorable to budget with strong inpatient surgery and Cath lab volumes, which helped improve the Case Mix Index.  March Hospital Outpatient Registrations – Hospital Outpatient volumes were very strong. Overall Outpatient visit were 8% higher than budget and included outpatient surgeries that were 2% higher than budget. However, outpatient Cath Lab volumes were 8% below budget. Clinics registrations were on budget. March 2018 Financial Performance  Gross Revenues .................................. (Budget $158,337,666)............ $172,050,138  Net Patient Revenue .............................. (Budget $35,071,078).............. $38,678,729  Total Operating Expenses ..................... (Budget $33,790,038).............. $36,280,088  Total Operating Revenues ...................... (Budget $35,483,721).............. $39,113,856  Operating Income .................................... (Budget $1,693,683)................ $2,833,769  Non-Operating Revenues (Expenses) ........ (Budget $587,918).................. -$708,178  Excess Revenues over Expenses ............ (Budget $2,281,601)................ $2,125,591 Year-to-Date  Operating Income .................................. (Budget $12,579,317).............. $12,334,530  Non-Operating Revenues (Expenses) ..... (Budget $5,108,262)................ $9,880,607  Excess Revenues over Expenses .......... (Budget $17,687,579).............. $22,215,137 ACTION TAKEN: Mr. Pipes motioned to approve the March 2018 NRHS Financial Statements. Mr. Sherman seconded and the motion was approved unanimously with aye votes from Dr. Chambers, Mr. Clote, Dr. Anwar, Dr. Kimpel, Mr. Sherman, Mr. Cubberley, Mr. Pipes, and Dr. Weber. Agenda Item VI. Medical Staff A. Report from the April 11, 2018, Medical Executive Committee (MEC) Dr. Mantooth reported that MEC met April 11, 2018, and highlighted the following:  Dr. Thompson proposed changing the upper limit for reporting critical pHs on ABGs from 7.5 to 7.6, which many other institutions use.  Approved moving the lower limit for reporting critical Potassium back to 3.0 from the recently changed 2.5.  Approved the multiple additions to Critical Values/Life Altering Values Policy as submitted.  Approved including AST (Aspartate Aminotransferase) and TBIL (Total Bilirubin) testing on reactive HCVs (Hepatitis C Virus) as part of the laboratory’s protocol for reflex testing.  Discussed the C. diff protocol noting it is a good protocol and should remain in place; but more education is needed for physicians and nurses.  Approved the Bylaws Committee proposal to change the credentialing category NRHA Board Minutes 5 April 23, 2018 of Active-Affiliate to Associate and make this the 4th tier.  The Bylaws Committee proposed adding Recusal Language and Conflict of Interest paragraph to the Bylaws. After a lengthy discussion, the proposal to add Recusal Language and Conflict of Interest paragraph to the Bylaws was tabled.  The Bylaws Committee proposed adding an Advanced Practice Provider (APP) to the Credentials Committee and Medical Executive Committee. Approved adding an APP as a voting member to the Credentials Committee and adding an APP as a non-voting member to the Medical Executive Committee.  Department/Committee Reports o Hospital Medicine Department – Dr. Shahsavari reported they reviewed the new Diabetic Ketoacidosis (DKA) Order Sets all Hospitalists have Health Information Exchanges (HIE) logins and passwords. Discussed the newly revised Stroke Order Set. Discussed the National Institute of Health Stroke Scale (NIHSS) and when the second score should be documented. This now can be done electronically in Meditech. Reported on the ongoing discussion regarding the amount of time for a patient to be seen by the admitting service once the patient arrives on the floor. o Health-System Quality and Patient Safety Committee – Dr. Camp reported the following:  April 8, began the pilot of the ICOUGH Program due to the sepsis numbers going down and post hip surgery re-admission increasing.  ICOUGH stand for  I – Incentive Spirometry  C – Cough and Deep Breathe  O – Oral Care  U – Understand  G – Get out of Bed  H – Head of Bed Elevated.  Increase in single Unit Blood, which was the goal o Emergency Medicine Department – Dr. Hoos-Reinke stated all OB patients arriving via EMSStat would stop in the ED to be evaluated by the ED physician before going to Labor & Delivery (L&D). All ED providers have HIE logins and passwords. o OB/GYN Department – Dr. Parker noted the department would be meeting with OB Hospitalist Group (OBHG) Christi Acker, Director of Hospital Operations in May.  Reports from the Vice President – o There has been no Central Line Associated Blood Stream Infections (CLABSI) since the Vascular Access Team (VAST) expanded their procedures. o A new nurse resident group will be starting soon. o A new Neurologist would start in June 2018. o The new Oncologist Clinic and Moore Breast Care Center will open in July 2018. o All teachers were offered a free Norman Regional Health System Virtual Visit for a limited time. o The Lab has new equipment for Blood Cultures  NRHA Board Minutes 6 April 23, 2018 Agenda Item VII Patient Quality and Safety Committee Ms. Anderson reported the Patient Quality and Safety Committee met Monday, April 2, and highlighted the following:  Mr. Gruszka, Cardiopulmonary Rehab Supervisor, presented a broad overview of the Cardiopulmonary Rehab Program and reviewed the 2016-2017 consult/referrals totals.  Mr. Hughes, Pharmacy Clinical Specialist, presented an Antimicrobial Stewardship update noting Opioid Stewardship would be the next big project. Agenda Item VIII. Finance Committee A. Report from the April 16, 2018, Finance Committee Mr. Cubberley reported the Finance Committee met April 16, 2018, and highlighted the following:  Mr. Hopkins provided an in-depth March 2018 Financial Report  Charity Care for March was $950,543 and YTD the System provided $7,297,351  Bad Debt for March was $1,278,769 and YTD was $13,759,244  Community Contributions for March was $104,983 and YTD was $947,359  Mr. Manfredo provided the Committee an update to the FY 2018 Budget Action Plans and highlighted the following: o Recruitment of Physical Medicine and Rehabilitation (PM&R) Medical Director, Dr. Saveikar. He started in September 2017 with a revenue of $84K for the department and in March 2018, the revenues have grown to $573K. Will also realize an expense savings > $600K from not utilizing Locum PM&R. o Expanded Outpatient Imaging Services at Norman Regional Moore by adding Echocardiography Ultrasound and would start early April offering OP Mammography and Bone Densitometry. o Efficiency opportunities that need to be implemented, with enhancement to schedule and block utilization, Created Scorecards with the top findings, working with surgeons to implement new workflows. o Recruitment of Adult Hospitalist, Dr. Meltzer joining our group April 15, 2018. o Moving our Oncology Clinic to its new location July 2018 o Continue to watch worked FTE hours  Mr. Hopkins reported an overall decreasing trend in legal fee expense. Reviewed the legal fees and they are down $200K from FY2017 and down $100K compared to FY 2016. Ms. Blau and her staff are working diligently to control legal fees.  Eight capital requests were presented for approvals: o Progressive Care Unit $865,264 – Patient room renovations o Trios Surgical System $63,377 – o MALDI-TOF $404,615 – Lab equipment used to identify microorganisms in samples o Cart/Washer Installation $97,299 – Installation preparation for the new Cart Washing System which has already been purchased o Sleep Recliners X 22 $58,092 – Replacement of old outdated recliners for HealthPlex Ortho Spine Department  NRHA Board Minutes 7 April 23, 2018 o Code Required OB ED Revisions $59,438 – This allows us to make code- required revisions to accommodate the new Obstetrical Emergency Department o Giraffe Omnibed Carestation $79,215 – Microenvironment to aid in healing babies and includes incubator and radiant warmer. This is needed to meet increase in census. o Bariatric Surgery practice Acquisition $160,590 – Acquisition of Dr. Keith’s practice was needed for the retention and growth of the bariatric surgery service line. B. Recommend Approval of Capital Equipment Purchase Requests ACTION TAKEN: Mr. Cubberley made a motion to approve the Capital Equipment Requests totaling $1,787,890 as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Clote, Dr. Anwar, Dr. Chambers, Dr. Kimpel, Mr. Sherman, Mr. Cubberley, Mr. Pipes, and Dr. Weber. Agenda Item IX. Old Business Mr. Splitt thanked Mr. Clote, Dr. Weber, Dr. Mantooth, Dr. Boyd, Dr. Jawed, Dr. Whalen, Executive Team, Directors and Managers for being very patient and thorough in the Chief Nursing Officer interview process. He announced Ms. Brittni McGill as the Chief Nursing Officer. He thanked Ms. Graves for her undying commitment to the process, how steadfast she was to the organization and Ms. McGill, and how well they worked together to serve our patients and the organization. Agenda Item X. New Business There was none. Agenda Item XI. Administrative Report Mr. Splitt provided an update on the following:  During the teachers’ walk out, NRHS offered to all teachers in Oklahoma access to our Virtual Care Services. We were able to communicate to them free access to our care during that process and extended that offer through the month of April. Only three required actual access with a physician. Received very positive feedback from the Oklahoma Education Association as well as our partners in Norman, Moore and Noble.  He asked the Board members to stop by and see him before they left for home tonight to pick up their new ID badges.  He thanked everyone for attending the NRHA Board Advance with Marian Jennings. She left our meeting and went on vacation. She has returned and we are organizing a time to discuss next steps.  NRHA Board Minutes 8 April 23, 2018 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 Pursuant to 25 Okla. Stat. Section 307 B.1. ACTION TAKEN: Dr. Anwar made a motion to adjourn into Executive Session. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Dr. Chambers, Mr. Clote, Dr. Anwar, Dr. Kimpel, Mr. Sherman, Mr. Cubberley, Mr. Pipes, and Dr. Weber. Ms. Anderson, Ms. White, Ms. Gilmore, Ms. McCool-Hare, Ms. Oliphant, Ms. Blau, Mr. Loftus, Ms. Wells, Mr. Muzny, Mr. Nabors, Ms. Hampton, and all other guests left the meeting at 6:15 p.m. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XII.B 1-3 Below 1. Recommend New Provisional Medical Staff Appointments: a) Rebecca “Becky” Graham, Active Staff – OB/GYN Department 2. Recommend Advancement of Medical Staff from Provisional Status: a) Todd Gleaves, MD, Active Staff – Anesthesia Department b) Kevin McKeown, MD, Active Staff – Anesthesia Department c) Julia Rygaard, MD, Active Staff – Anesthesia Department d) Christi Pendergraft, MD, Active-Affiliate Staff – Medicine Department e) Beau Burton, PA-C, Allied Health Staff – Surgery Department f) Lauren Hill, PA-C, Allied Health Staff – Surgery Department g) Cheryl Montgomery, RNFA, Allied Health Staff – Surgery Department h) Johanna Moses, PA, Allied Health Staff Medicine Department 3. Recommend Medical Staff Reappointments: a) Amy Bacchus, MD, Active Staff – Medicine Department b) Brett Dees, MD, Active Staff – Medicine Department c) Marilyn Appiah, DO, Active Staff – OB/GYN Department d) John Cherry, DO, Active Staff – OB/GYN Department e) Allison Huebert, MD, Active Staff – OB/GYN Department f) Betty Harmon, MD, Active Staff – Pediatrics Department g) Michael Milligan, DO, Active Staff – Pediatrics Department h) Nicole Jarvis, MD, Active-Affiliate Staff – OB/GYN Department i) Stacy Boothe, APRN-CNS, Allied Health Staff – Cardiovascular Med. j) Angela Matthews, APRN-CNS, Allied Health Staff – Cardiovascular Med. k) April Whalen, APRN-CNS, Allied Health Staff – Hospital Medicine Dept. l) Amy Meiser, APRN-CNP, Allied Health Staff – Pediatrics Department . C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session  NRHA Board Minutes 9 April 23, 2018 ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session and return to regular session. Dr. Anwar seconded, and the motion was approved with aye votes from Dr. Chambers, Mr. Clote, Dr. Anwar, Dr. Kimpel, Mr. Sherman, Mr. Cubberley, Mr. Pipes, and Dr. Weber. Mr. Clote 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 1-3 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 1-3. Dr. Kimpel seconded, and the motion was approved with aye votes from Dr. Chambers, Mr. Cubberley, Mr. Clote, Dr. Anwar, Dr. Kimpel, Mr. Sherman, Mr. Pipes, and Dr. Weber. Agenda Item XIII Board Open Discussion Mr. Clote encouraged Board members that have misgivings regarding the current situation and how it is being handled to please speak-up now. Agenda Item XIV. Closing Comments There was none. Agenda Item XV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn at 6:20 p.m. Dr. Kimpel seconded, and the motion passed unanimously with aye votes from Dr. Chambers, Mr. Clote, Dr. Anwar, Dr. Kimpel, Mr. Sherman, Mr. Cubberley, Mr. Pipes, and Dr. Weber. Respectfully Submitted, Doug Cubberley, Vice-Chair/Secretary