Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting September 24, 2018 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, September 24, 2018, at 5:30 p.m., in the Norman Regional Hospital Board Room. The meeting Agenda was posted September 21, 2018, on the NRHS and Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chair Tom Sherman, Vice Chair/Secretary Muhammad Anwar, MD Diane Chambers, MD Joan Greenleaf James (Jeff) Kimpel, Ph.D. Kevin Pipes Jerome (Jerry) Weber, Ph.D. Others Present: Robin Mantooth, MD, Chief of Staff Farhan Jawed, MD, Chief of Staff-Elect Richie Splitt, President and CEO Ken Hopkins, CFO John Manfredo, COO Brittni McGill, CNO Paula Price, VP Strategy & Growth Karen Rieger, System Attorney Crowe & Dunlevy Mackenzie Sork, NRHA Board Fellow Courtney Blau, Admin. Dir. Risk Management & Compliance Kelly Wells, Director Health Promotion & Community Relations Jenny Anderson, Director QPI & Medical Staff Services Cindy Gilmore, LEAN Specialist Brian Loftus, Business Planning LEAN Specialist Molly McCool-Hare, Business Planning/Operations Specialist Irene Massad, RN, Coordinator Performance Improvement Lori Maynard, RN, Critical Care Clinical Outcomes Specialist Shannon Largent, Director Clinical Education Sherry Jo Johnson, Manager Oncology Palliative Care Tina Walden, RN, Oncology Palliative Care Shane Cohea, Director Eddie Sims, Manager EMSStat Gavin Beck, EMSStat PRN Paramedic (orientation) Josh Ou, EMSStat Paramedic Steve Yarbrough, EMSStat Paramedic John Sweatt, Director Finance Carley Williams, BKD Becky Robbins, BKD NRHA Board Minutes 2 September 24, 2018 Jessica Elsberry, BKD Mary Womack Recorder: LaRue Putman, Department Assistant Prior to the Board Meeting, flu shots were made available by the Performance Improvement department to all in attendance. Ms. Massad and Ms. Maynard left the meeting at 5:34 p.m. Agenda Item I. Call to Order Mr. Cubberley called the September 24, 2018, Norman Regional Hospital Authority meeting to order at 5:34 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healer October 2018 Healer of the Month, Tina Walden, RN, Oncology Palliative Care – Sherry Jo Johnson, Manager Oncology Palliative Care Mr. Cubberley introduced Ms. Johnson who presented Ms. Walden as the Outstanding Healer for October 2018. Mr. Johnson stated Ms. Walden exhibits her love for her patients and her co-workers, initiates tasks, volunteers to teach new staff, and possesses incredible leadership skills. Ms. Walden embodies The Norman Way. Ms. Walden stated it is a huge privilege to be honored as Healer of the Month. Mr. Cubberley congratulated and thanked Ms. Walden 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. Ms. Largent, Ms. Johnson, and Ms. Walden left the meeting at 5:38 p.m. Agenda Item III. Employee Safety Initiatives – Stryker Publication Mr. Cohea presented information related to the recent national publication by Stryker Medical Equipment. The article emphasized the partnership between Norman Regional Health System and Stryker’s innovative, power cot and fastener systems. The equipment helps make the lives of EMS teams easier, safer and more efficient. The Powered System assists in loading and unloading a cot at the touch of a button. EMSStat paramedics demonstrated for the board the ease of use of the Stryker Power- PRO XT cot. Since deployment, the EMSStat ambulance service has experienced a 100% reduction in cot related injuries. This injury-related reduction represents a savings of $545,500. It also promotes career longevity for the EMSStat first responders. Since deployment in August 2013, EMSStat has experienced a 42% increase in call volume and added seven ambulances to their fleet. Even with that growth, EMSStat has not experienced a single cot-related injury. NRHA Board Minutes 3 September 24, 2018 Mr. Sims stated the Stryker Power-LOAD cot fastening system is necessary for increased patient safety. If an ambulance is involved in a significant accident while transporting a patient, there is a risk of being ejected from the vehicle. This cot fastening system greatly diminishes that risk for our patients. An additional benefit is the maximum weight limit of the Stryker system (700 pounds). Mr. Cohea, Mr. Sims, Mr. Beck, Mr. Ou, and Mr. Yarbrough left the meeting at 5:46 p.m. Agenda Item IV. Approval of the August 27, 2018, Board Meeting Minutes Mr. Cubberley asked for approval of the August 27, 2018, Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the August 27, 2018, Board Meeting Minutes as submitted. Dr. Anwar seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Chambers, Ms. Greenleaf, Dr. Kimpel, Mr. Pipes, Mr. Sherman, Dr. Weber, and Dr. Anwar. Agenda Item V. June 30, 2018, and 2017 Audit Presentation Mr. Cubberley introduced BKD representatives Carley Williams, Becky Robbins, and Jessica Elsberry. Mr. Williams presented audit results as presented to the Finance Committee last week. BKD issued an unmodified or clean opinion of the financial statements ending June 30, 2018, and congratulated the CEO and CFO, noting only about 20% of his clients achieve this level. In review of ratio analysis and benchmarks, he indicated the average age of plant continues to rise and is higher than comparison groups primarily because of the age of the Porter campus, even though equipment replacement and reinvesting back into the facility are appropriate. ACTION TAKEN: Mr. Pipes made the motion to approve the June 30, 2018, and 2017 Audit Presentation as submitted. Dr. Weber seconded the motion, and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Sherman, Mr. Cubberley, Ms. Greenleaf, Dr. Kimpel, Mr. Pipes, Dr. Chambers, and Dr. Weber. Mr. Sweatt, Mr. Williams, Ms. Robbins, and Ms. Elsberry left the meeting at 6:14 p.m. Agenda Item VI. Performance Updates Ms. Anderson provided the Quality & Patient Safety Report highlighting the following:  Patient Safety o The first Patient Safety Council occurred today using Leapfrog as a guide. o Safety Huddle trial with Clinical Directors began the week of September 17 and are scheduled weekdays at 10 a.m. covering both patient and staff safety issues. o The “Good Catch” Program recognizes staff for catching potential errors and keeps patient safety top of mind. NRHA Board Minutes 4 September 24, 2018  Quality and Performance Improvement o Critical Results policy updates include creation of a guideline for calling results to physicians. o C.Diff – a new 3-step lab test is now in place with batch testing at 10 a.m. daily. Infection Prevention receives a daily report or orders and confirms that the patient meets guidelines for ordering. We have had success in canceling orders that did not meet those guidelines. o CLABSI – all patients with a central line will now get a daily CHG (Chlorhexidine gluconate or Hibiclens) bath. o CAUTI – new external female catheters were trialed on a couple of units and will be going housewide in two weeks. This will decrease the use of indwelling catheters and lower our CAUTI rates. o “Go Live Week” is a program that coordinates the scheduling of all process/policy/product education for units. This change funnels all of these changes into a single week each month instead of deploying multiple changes at multiple times throughout the month. Participating departments include Pharmacy, Patient Care Services, Food and Nutrition Services, EMSStat, and Diagnostic Imaging. o Patient Experience: NRC Real Time Update – we have received over 54,000 surveys with a current “would recommend” score of 81.5%. Agenda Item VII. Approval of the August 2018 Norman Regional Health System Financial Statements Mr. Hopkins presented the August 2018 Norman Regional Health System Financial Statement Summary highlighting the following:  August System Inpatient Volumes – Inpatient volumes improved tracking with budget. With Case Mix Index tracking with budget and Length of Stay slightly below budget, we experienced slightly improved reimbursement.  August System Outpatient Registrations – volumes were below budget  Surgical Volume for August was below budget level  Cath Lab Volume for August remained above budget August 2018 Financial Performance  Gross Revenues .................................. (Budget $176,602,114)............ $179,172,438  Net Patient Revenue .............................. (Budget $36,913,636).............. $37,321,343  Total Operating Expenses ..................... (Budget $35,824,174).............. $36,168,965  Total Operating Revenues ...................... (Budget $37,316,163).............. $37,755,164  Operating Income .................................... (Budget $1,491,989)................ $1,586,199  Non-Operating Revenues (Expenses) ........ (Budget $910,548)................... $995,289  Excess Revenues over Expenses ............ (Budget $2,402,537)................ $2,581,488 Year-to-Date  Operating Income .................................... (Budget $2,365,532)................ $1,607,628  Non-Operating Revenues (Expenses) ..... (Budget $1,821,079)................... $512,141  Excess Revenues over Expenses ............ (Budget $4,186,611)................ $2,119,770  Accounts Receivable Days ............................ (Budget 43 Days).................. 41.6 Days  Days Cash on Hand .................................................................. ................ 219.1 Days NRHA Board Minutes 5 September 24, 2018 ACTION TAKEN: Dr. Weber motioned to approve the July 2018 NRHS Financial Statements. Dr. Kimpel seconded and the motion was approved unanimously with aye votes from Mr. Pipes, Dr. Anwar, Mr. Cubberley, Dr. Chambers, Mr. Sherman, Ms. Greenleaf, Dr. Kimpel, and Dr. Weber. Agenda Item VIII. Medical Staff Report from the August 8, 2018, Medical Executive Committee (MEC) Dr. Mantooth reported that MEC met August 8, 2018, and highlighted the following:  Ms. McGill presented ICARE award to Dr. Amy Bacchus, Pulmonary Disease/ Critical Care Medicine, recognizing her for exceptional care with a patient and family from outside our service area. Ms. McGill also recognized Dr. Kate Cook for her Facebook video on pediatric drowning, which went “viral” with over 32,000 views.  Mr. Hopkins gave the Financial Presentation reflecting a 4.1% operating margin for the health systems performance in FY2018.  Ms. McGill reported the 3-month trial of female external catheters in the PCU went well and these will now go house-wide in October 2018.  Department/Committee Reports o Residency Update – Dr. Cody announced the Residency Program recently submitted a required annual update to the ACGME and highlighted the following:  The Residency Program provided 250 hours of didactics to residents and visiting medical students, hosted a 2–day conference with 200 attendees on the subject of pre-hospital and disaster medicine, and received 365 applications for admission with 60 interviews for potential candidates for 6 spots.  The Program faculty has provided 24 hours of out-of-house lectures related to emergency medicine, pre-hospital care, and emergency medicine education as well as authored 3 peer-reviewed publications. o Pediatric Hospitalist Update – Dr. Kate Cook reported a higher percentage of pediatric patients being admitted to the hospital. She is working to establish a Pediatric MIT at HealthPlex including order sets, which will be brought to the Pediatric Department meeting and MEC for approval. Dr. Cook is expanding Pediatric TeleMedicine into Norman Public Schools. o Hospital Medicine Department – Dr. Shahsavari reported on the Acute Coronary Syndrome (ACS) order sets and the Case Management tool to help stop overutilization of SNFs. o OR Committee/Surgery Department – Dr. McCurdy reported better efficiency with on-time starts and are working on block utilization. o Medicine Department – Dr. Tedesco noted they decided to keep 30-day readmission and mortality for AMI/HF/COPD/Stroke/Pneumonia as their department indicators. o Emergency Medicine Department – Dr. Hoos-Reinke reviewed the OBED process. Dr. Sidarov, head of the Stroke Department at OU, gave a very good presentation over strokes and interventions. o Physician Advisory Committee – Dr. Mantooth reported discussion of separation of discharge and summary, complications related to ordering of sputum samples, a Meditech update causing interruption of medication, and work to have patient’s resuscitation status on the top line of Meditech. Dr. Mantooth expressed appreciation to the Moore ED for excellent job in caring for a major NRHA Board Minutes 6 September 24, 2018 head bleed in a pediatric patient who was appropriately diagnosed and transferred very quickly to a pediatric trauma facility. o Cardiovascular Medicine Department – Dr. Gautam discussed correct ACS order set and a shorter ED order set. She reported that STEMI numbers look good with first medical contact to PCI in 48 minutes, which is better than the national average. Here have been 20 Code Stemi activations with no outliers, which is better than the national average. Code Stroke tPA average is 40 minutes, which is also better than the national average. o Medical Staff Report – Dr. Boyd discussed moving Endoscopy under the OR Committee, work towards a House Officer position at Porter to be filled by third and fourth year residents and APPS, which should decrease patient wait time improving patient satisfaction as well as care. Work is continuing on the onboarding physician process towards centralization.  Reports from Vice-Presidents/CNO & President o Ms. McGill announced PCU will be returning to their original location on 3 rd floor October 9. Project Search has doubled in size, covering both HealthPlex and Porter campuses. o Mr. Manfredo announced reviewed recently approved capital equipment and announced there was 113% increase in front line employee satisfaction from January to June 2018. o Mr. Splitt announced a great financial year resulting in a 4.1% operating margin. He also reported weekly calls with Navigant and expects final report in December 2018. Agenda Item IX. Strategic Planning Committee Dr. Weber reported the Strategic Planning Committee met on September 10, 2018, with focus on the following:  LEAN  Code Stroke dramatic improvements  Paramedics and ED RNs  Strategic Planning research into primary service area.  Opportunities for improvement with increase in access points Agenda Item X. Finance Committee Meeting A. Report from the September 17, 2018, Finance Committee Mr. Sherman reported the Finance Committee met September 17, 2018, and highlighted the following:  BKD presented the in-depth audit results, reporting a “clean” audit.  HCF MapAPP benchmarks of 88 hospitals were compared.  Mr. Hopkins presented the Finance Report.  Two capital requests were presented for approval totaling $394,672: o Passport Electronic Signature Solution – $244,672 o Summit Exchange, Provider Exchange, Scripting Tool – $150,000 B. Recommend Approval of Capital Equipment Purchase Requests ACTION TAKEN: Ms. Greenleaf made a motion to approve the Capital Equipment Requests totaling $394,672 as recommended by the Finance NRHA Board Minutes 7 September 24, 2018 Committee. Dr. Kimpel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Chambers, Mr. Sherman, Dr. Anwar, Mr. Pipes, Dr. Weber, Ms. Greenleaf, and Dr. Kimpel. Agenda Item XI. Old Business There was none. Agenda Item XII. New Business Mr. Splitt announced the Oncology Clinic has moved into their new area (the old Breast Care Center). The ribbon cutting will be Wednesday at 3:30 p.m. City of Norman Mayor Lynne Miller is scheduled to present the first State of the City address. We have submitted a NRHS update for her consideration. Members of the Executive Team will attend. Norman Virtual Kids, with Dr. Kate Cook serving as medical director, is serving Norman Public Schools students at Washington Elementary and Irving Middle School. Kids Are Special People is following a 35-year tradition of inviting 3rd graders to Norman Regional to teach them about health and healthy choices, and to inspire their parents to healthier choices, too. About 1200 students are expected to participate this year, from both the Moore and Norman public schools. Fall Fun Fest recognizing the good and hard work of our healers will be October 1-5. Agenda Item XIII. Administrative Report Mr. Splitt announced that, with adoption of the audit, NRHS met financial, quality and service goals/thresholds that make possible the incentive compensation and gainsharing programs for our healers. It will go out as approved at last month’s NRHA Board Meeting. Mr. Hopkins also detailed the long-term incentive compensation plan, which measures across a rolling 3-year period with our first full reporting in the fall of 2020. Mr. Splitt reported that a personal friend of his texted him during the most recent MEC meeting that he and his family truly appreciated the care and compassion delivered by our NRHS healers. Mr. Splitt announced the City Manager for the City of Moore is planning a program of opioid awareness for the City of Moore and has requested participation by Norman Regional. Mr. Splitt has passed this along to Dr. Jawed for follow up. Agenda Item XIV. 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 NRHA Board Minutes 8 September 24, 2018 ACTION TAKEN: Dr. Weber made a motion to adjourn into Executive Session. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Sherman, Dr. Kimpel, Mr. Pipes, Ms. Greenleaf, Dr. Chambers, Dr. Weber, and Dr. Anwar. Ms. Anderson, Ms. Gilmore, Mr. Loftus, Ms. McCool-Hare, Ms. Blau, Ms. Wells, and Ms. Womack left the meeting at 7:08 p.m. 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) Douglas Bober, MD, Teleradiology Staff b) Kathryn Jarrett, MD, Teleradiology Staff c) Duane Wilson, MD, Teleradiology Staff 2. Recommend Advancement of Medical Staff from Provisional Status: a) Stephen Eichert, MD, Active Staff – Surgery Department b) Christopher Parker, MD, Consulting – Medicine Department c) Laure DeMattia, DO, Associate – Medicine Department d) Serina Madden, ARNP-FNP, Allied Health – Pediatrics e) Deborah LaBrie, PA-C, Allied Health – Surgery Department f) Elaine Khatod, MD, Clinical Privileges Only – Teleradiology g) Chikaodili Logie, MD, Clinical Privileges Only – Teleradiology h) Jason Akrami, MD, Clinical Privileges Only – Teleradiology i) Joshua Blunk, DO, Clinical Privileges Only – Teleradiology j) David Burdett, MD, Clinical Privileges Only – Teleradiology k) Karen Caldemeyer, MD, Clinical Privileges Only – Teleradiology l) Sam Cheng, MD, Clinical Privileges Only – Teleradiology m) Jay Donohoo, MD, Clinical Privileges Only – Teleradiology n) James Faliszek, MD, Clinical Privileges Only – Teleradiology o) Thomas Fiorito, MD, Clinical Privileges Only – Teleradiology p) John Nwankwo, MD, Clinical Privileges Only – Teleradiology q) Donald Nicell, MD, Clinical Privileges Only – Teleradiology r) Snchal More, MD, Clinical Privileges Only – Teleradiology s) Trudy Moore, MD, Clinical Privileges Only – Teleradiology t) Patricia McFarlane, MD, Clinical Privileges Only – Teleradiology u) Mary Phillips, MD, Clinical Privileges Only – Teleradiology 3. Recommend Medical Staff Reappointments: a) Aaron Boyd, MD, Active Staff – Medicine Department b) Robert Gaston, DO, Active Staff – Medicine Department c) Saria Refai, MD, Active Staff – Medicine Department d) Julia Stoltenberg, MD, Active Staff – Pediatrics Department e) James Fields, MD, Active Staff – Pediatrics Department f) Eileen Fox, MD, Active Staff – Pediatrics Department g) Rajkumar Reddy, MD, Active Staff – Pediatrics Department h) Thomas Thurston, MD, Active Staff – Pediatrics Department i) Stephanie Carter, MD, Active Staff – OB/GYN Department NRHA Board Minutes 9 September 24, 2018 j) Lisa Waterman, DO, Active Staff – OB/GYN Department k) Shelba Bethel, MD, Associate Staff – OB/GYN Department l) Wesley Hinz, MD, Associate Staff – Medicine Department m) Serena Mitroo, MD, Associate Staff – Medicine Department n) Brian Herb, PA-C, Allied Health Staff – Emergency Medicine Department C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Dr. Kimpel made a motion to adjourn out of Executive Session and return to regular session. Dr. Weber seconded, and the motion was approved with aye votes from Mr. Cubberley, Dr. Chambers, Mr. Pipes, Ms. Greenleaf, Mr. Sherman, Dr. Anwar, Dr. Weber, and Dr. Kimpel. 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 (MEC) Recommendations Regarding Credentialing of the Referenced Medical Staff Members as Listed in XIV 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 XIV B 1-3. Dr. Anwar seconded, and the motion was approved with aye votes from Mr. Cubberley, Mr. Sherman, Dr. Chambers, Dr. Kimpel, Mr. Pipes, Ms. Greenleaf, Dr. Weber, and Dr. Anwar. Agenda Item XV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn the meeting. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Kimpel, Mr. Pipes, Mr. Sherman, and Dr. Anwar.