Norman Regional Hospital Authority Meeting

Norman Regional Hospital Authority Board Business Meeting August 27, 2018 5:30 p.m. Norman Regional Hospital 901 N. Porter Ave. nd 2 Floor Board Room AGENDA I. Call to Order ......................................................................................... Mr. Cubberley II. Introduction and Recognition of Outstanding Healer ........................... Mr. Cubberley September 2018 Healer of the Month, Brett Mendenhall, Exercise Physiologist, Cardiac Rehab – Jeff Neff, Manager Cardiopulmonary/ Non-Invasive Cardiology/Cardiopulmonary Rehab and Larry Gruszka, Supervisor Cardiac Rehab (Video) III. Recognition and Introduction................................................................ Mr. Cubberley A. Joy Hampton, Journalist Norman Transcript B. Makenzie Sork, NRHA Board Fellow, University of Oklahoma JC Penny Leadership Program Recipient C. Doris Gonzalez, Executive Assistant to President & CEO – 44+ years of Service IV. Board Education Session: Reducing Maternal Morbidity and Mortality ................. ................................................................................................................ Ms. Graves V. Approval of July 23, 2018 NRHA Board meeting minutes .... Mr. Cubberley (Pgs. 6-19) ACTION NEEDED: Approve or Amend Minutes as Circulated ACTION TAKEN: ___________________________________ VI. Performance Updates ........................................................ Ms. Anderson (Pgs. 20-33) ACTION NEEDED: None, Information Item Only VII. Approval of the July 2018, Norman Regional Health System Financial Statements  NRHA Agenda 2 August 27, 2018 ...................................................................................................... Mr. Hopkins (Pgs. 34-71) ACTION NEEDED: Approve or Disapprove July 2018 NRHS Financial Statements ACTION TAKEN: ____________________________________ VIII. Medical Staff ......................................................................................... Dr. Mantooth A. Report from the August 8, 2018 Medical Executive Committee B. Recommend Approval of the FY2019 Patient Safety Plan............. (Pgs. 72-100) ACTION NEEDED: Approve or Disapprove the FY2019 Patient Safety Plan as Recommended by the Medical Executive Committee ACTION TAKEN: ____________________________________ C. Recommend Approval of the Revised Norman Regional Health System FY2019 Quality and Performance Improvement Plan ..................(Pgs. 101-124) ACTION NEEDED: Approve or Disapprove the Revised Norman Regional Health System FY2019 Quality and Performance Improvement Plan as Recommended by the Medical Executive Committee ACTION TAKEN: ____________________________________ D. Recommend Approve to Add Tracheostomy to the General Surgery Privileges Form ..................................................................... (Pgs. 125-142) ACTION NEEDED: Approve or Disapprove to Add Tracheostomy to the General Surgery Privilege Form as Recommended by the Credentialing and Medical Executive Committees ACTION TAKEN: ____________________________________ E. Proposed Changes/Additions to the Medical Staff Bylaws – Adding language regarding: Disruptive Behavior, Physician Board Certification, Recusal Language, and Allied Health Staff members to MSEC (non-voting) and Credentials (voting). Changing the staff category from Active-Affiliate to Associate Staff and reordering of categories within document (Pgs. 143-163) ACTION NEEDED: Approve or Disapprove the Proposed Changes/Additions to the Medical Staff Bylaws as approved by the Medical Staff and Medical Executive Committee ACTION TAKEN: ____________________________________  NRHA Agenda 3 August 27, 2018 IX. Patient Quality and Safety Committee .................................................................... Report from the August 6, 2018 Patient Quality and Safety Committee ACTION NEEDED: None, Information Item Only X. Finance Committee Meeting ................................................................................... A. Report from the August 20, 2018, Finance Committee B. 2018 Gainsharing Acquisition .......................................................... (Pg. 164) ACTION NEEDED: Approve or Disapprove the Gainsharing Acquisition as Recommended by the Finance Committee ACTION TAKEN: ___________________________________________ C. Recommend Capital Equipment Purchase Request ......................... (Pg. 165) ACTION NEEDED: Approve or Disapprove Capital Equipment Purchase Requests as Recommended by the Finance Committee ACTION TAKEN: ___________________________________________ XI. Old Business .........................................................................Mr. Cubberley & Mr. Splitt XII. New Business ...................................................................... Mr. Cubberley & Mr. Splitt XIII. Administrative Report XIV. 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 and § 307.B.3 to Discuss the Potential Purchase and/or Appraisal of Real Property ACTION NEEDED: Move to Convene into Executive Session to Discuss with Legal Counsel the Above Referenced Medical Staff Items and Discuss the Potential Purchase and/or Appraisal of Real Property ACTION TAKEN: ____________________________________ B. Medical Staff Recommendations Regarding the Medical Staff Members /Applicants as Listed in XV.B 1-4 Below. NRHA Agenda 4 August 27, 2018 1. Recommend New Provisional Medical Staff Appointments: a) Greg Rohde, DPM, Active Staff – Surgery Department b) Mohammad Farukhi, MD, Active Staff – Surgery Department c) Benjamin Collins, MD, Active Staff – Surgery Department d) Trent Fogelman, MD, Active Staff – OB\/Gyn Department e) Leslie Yonemoto, MD, Active Staff – Medicine Department f) Stephanie Leiker, RNFA, Allied Health Staff – Surgery Department g) Hillarie Kessler, PA-C, Allied Health Staff – Surgery Department 2. Recommend Advancement of Medical Staff from Provisional Status: a) Scott de la Garza, MD, Active Staff – Surgery Department b) Steven Roberts, DO, Active Staff – Emergency Medicine Department c) Ryan Carter, MD, Active Staff – Hospital Medicine Department d) Joel Kardokus, MD, Active Staff – Hospital Medicine Department e) Sameer Mohammed, MD, Active Staff – Behavior Medicine Department f) Vijay Kolli, MD, Consulting Staff – Medicine Department g) Arveitta Edge, MD, Associate Staff – Medicine Department h) Winter Bathe, PA-C, Allied Health Staff – Surgery Department i) Blakeley Hamit, APRN-CNS, Allied Health Staff – Pediatrics Department j) Christina Stuart, APRN-CNS, Allied Health Staff – Medicine Department k) Stephanie Silva, PA-C, Allied Health Staff – Medicine Department l) Kelsey Olsen, PA-C, Allied Health Staff – Surgery Department 3. Recommend Medical Staff Reappointments: a) Geo-Philips Chacko, MD, Active Staff – Hospital Medicine Department b) Tony Tran, MD, Active Staff – Medicine Department c) John McCarter, MD, Active Staff – Medicine Department d) Lydia “Rene” Ballard, MD, Active Staff – Medicine Department e) Victor Wilson, MD, Active Staff – Pediatrics Department f) Thomas Kuhls, MD, Active Staff – Pediatrics Department g) Donna Jackson, MD, Active Staff – Pediatrics Department h) Cynthia West, DO, Active Staff – Pediatrics Department i) Justin Fields, MD, Active Staff – Pediatrics Department j) James “Rick” McCurdy, MD, Active Staff – Surgery Department k) Carol Anderson, DO, Active Staff – OB/Gyn Department l) John Taylor, MD, Consulting Staff – Medicine Department m) Michael Confer, MD, Consulting Staff – Medicine Department n) Julia Irwin, MD, Associate Staff – Behavioral Medicine o) Sarah Smith, APRN-CNP, Allied Health Staff – Pediatrics Department 4. Recommend Dr. Keith’s Request for the Following Additional Clinical Privileges a) Metabolic and Bariatric Banding b) Metabolic and Bariatric Stapled c) Metabolic and Bariatric Stapled Revisional d) Transoral Endoluminal Tissue Approximation of the Native Stomach or Anatomically Altered Stomach e) Placement and Removal of Endogastric Balloon f) Diagnostic Upper GI Endoscopy and Biopsy C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session  NRHA Agenda 5 August 27, 2018 ACTION NEEDED: Approve or Disapprove Adjournment of Any Executive Session and Return to Regular Session ACTION TAKEN: ____________________________________ D. Proposed Vote to Approve or Disapprove the Medical Executive Committee (MEC) Recommendations Regarding Credentialing of the Referenced Medical Staff Members As Listed in XV B 1-4 ACTION NEEDED: Approve or Disapprove the MEC Recommendations Regarding Credentialing of the Referenced Medical Staff Members As Listed in XV B 1-4 ACTION TAKEN: _______________________________________ E. Recommend Approval of Dr. Ronnie Keith’s Request for the Following Additional Clinical Privileges: a) Metabolic and Bariatric Banding b) Metabolic and Bariatric Stapled c) Metabolic and Bariatric Stapled Revisional d) Transoral Endoluminal Tissue Approximation of the Native Stomach or Anatomically Altered Stomach e) Placement and Removal of Endogastric Balloon f) Diagnostic Upper GI Endoscopy and Biopsy ACTION NEEDED: Approve or Disapprove Dr. Keith’s Request for the Additional Clinical Privileges Listed Above as recommended by the Credentials and Medical Executive Committees ACTION TAKEN: _______________________________________ F. Proposed Vote to Take Action Based Upon the Discussion of the Potential Purchase and/or Appraisal of Real Property in Executive Session. ACTION NEEDED: Move to Take Action Based Upon the Discussion of the Potential Purchase and/or Appraisal of Real Property in Executive Session ACTION TAKEN: _______________________________________ XV. Board Open Discussion XVI. Adjourn ACTION NEEDED: Motion to Adjourn the Meeting NRHA Agenda 6 August 27, 2018 ACTION TAKEN: _______________________________________. 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.