Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting October 22, 2018 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, October 22, 2018, at 5:30 p.m., in the Norman Regional Hospital Board Room. The meeting Agenda was posted October 18, 2018, on the NRHS and Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chair Joan Greenleaf Muhammad Anwar, MD Tom Sherman, Vice Chair/Secretary Diane Chambers, MD James (Jeff) Kimpel, Ph.D. Jerome (Jerry) Weber, Ph.D. Member Absent: Kevin Pipes Others Present: Robin Mantooth, MD, Chief of Staff Farhan Jawed, MD, Chief of Staff-Elect Richie Splitt, President and CEO Meegan Carter, VP Population Health & Wellness Paula Price, VP Strategy & Growth John Manfredo, COO Brittni McGill, CNO Ken Hopkins, CFO Dr. Arron Boyd, CMO Jenny Anderson, Director QPI & Medical Staff Services Lisa White, Manager PI & Medical Staff Services Molly McCool-Hare, Business Planning/Operations Specialist Courtney Blau, Admin. Dir., Risk Management & Compliance, Compliance/Privacy Officer Kelly Wells, Director Health Promotion & Community Relations Karen Rieger, System Attorney Crowe & Dunlevy Barry Deal, RN 4-North Cheryl McKinley, Manager 4-North/IP Wound Care Paul Jones, Director Medical Surgical/Critical Care Mary Womack, Community Member Recorder: Doris Gonzalez, Executive Assistant  NRHA Board Minutes 2 October 22, 2018 Agenda Item I. Meeting Called to Order Mr. Cubberley called the October 22, 2018, Norman Regional Hospital Authority meeting to order at 5:37 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. November 2018 Healer of the Month, Barry Deal, RN, 4-North, – Cheryl McKinley, Manager 4-North/Inpatient Wound Care and Paul Jones, Director Medical Surgical/Critical Care Mr. Cubberley introduced Ms. McKinley who presented Mr. Deal as the Outstanding Healer for November 2018. Ms. McKinley shared the employee’s work history and accomplishments along with his attributes: outstanding teamwork, work ethic, professionalism, incredible leadership skills, positive attitude, and his compassion toward patients, families, and co-workers, stating that, “He demonstrates every day his devotion/commitment to his job. He is truly an asset to the 4-North department and Norman Regional Health System. He exemplifies the ‘Norman Way’ and is well deserving of this honor.” Mr. Deal stated he is honored to be recognized as Healer of the Month. He is grateful and proud to work with the very best healers and leaders ever and looks forward to working at Norman Regional Health System for years to come. Mr. Cubberley congratulated and thanked Mr. Deal on behalf of the Board for his outstanding dedication, professionalism, compassion, and positive attitude that continues to make Norman Regional Health System a caring, high quality system. Mr. Deal, Ms. McKinley, and Mr. Jones left the meeting at 5:42 p.m. Agenda Item III. Approval of September 24, 2018, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the September 24, 2018, Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the September 24, 2018, Board Meeting Minutes as submitted. Mr. Sherman seconded the motion, and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman. Agenda Item IV. Performance Updates Ms. Anderson provided the Quality & Patient Safety Update highlighting the following:  Patient Safety o Reportable Events  A push from the Quality Industry for Hospitals to look at harm (hospital acquired) across the board – NRHS began measuring these events at the end of FY2014.  NRHA Board Minutes 3 October 22, 2018  NRHS uses these events for internal improvement opportunities to reduce that number yearly as much as possible. We had a goal to reduce these events starting in FY2015. Currently NRHS measures 35 event types, which may change due to the national measure definitions changing. Some events require staff to report.  NRHS experienced a downward trend until FY18.  The Top four (4) Reportable Events in FY18 were medication errors with harm, Clostridium-difficile (C.diff), falls with Injury, and pressure ulcers. 1. Medication Errors with Harm  This event has been inconsistent. The Sentinel Event Determination Team (SEDT) implemented an action plan that has decreased these type of medication errors 2. Clostridium-difficile (C.diff)  Reviewed the FY2014 through August 2018 data, which reflected a downward trend in C.diff infections due to the implementation of the Xenex (bug zapping robots) and the assistance from the Infectious Disease physicians. 3. Patient Falls with Injury  FY2015 saw an increase in falls with injury above where we wanted to be. We learned about a John Hopkins program and initiated a Falls Lean Team. They assembled several initiatives recommended through the program and we saw a vast downward trend. In the 3 rd Quarter 2018, we started seeing an upward trend. The Falls Lean Team reconvened to ensure we were following the program. They made minor changes and we are again seeing a downward trend. 4. Pressure Ulcers  Examined pressure ulcers not present when the patient was admitted. Pressure ulcers are staged 1-4 with four being the worse.  CY2017 saw an increase in the number of pressure ulcers. We had a team who reconvened and reviewed our Save Our Skin (SOS) program, which are interventions to help decrease the chances of patients getting pressure ulcers. We are updating and revamping the program in an effort to decrease pressure ulcers prevalence. We anticipate improvement.  Quality and Performance Improvement o ICOUGH Program  ICOUGH (I – Incentive Spirometry, C – Cough and Deep Breathe, O – Oral Care, U – Understand Patient Education, G – Get out of Bed, and H – Head of Bed Elevated) is a pulmonary care program that includes early and frequent mobilization, lung exercises, oral hygiene, and education to reduce postoperative complications.  In April 2018, the ICOUGH pilot was implemented on four units and we have been below our target for two and a half quarters.  House-wide roll out will be next week.  Hospital Acquired DVT (Deep Vein Thrombosis) and PE (Pulmonary Embolism) -- Quarter to Date  Only one incident this quarter; will continue to monitor  NRHA Board Minutes 4 October 22, 2018  Patients Requiring Ventilation greater than 24 hours  This patient population has been discharged and subsequently returned to the hospital within 30 days of discharge with a PE in the leg or lung. NRHS is performing well and below our target.  Patient Experience – Inpatient HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) July 2018 o Initiated house-wide Inpatient HCAHPS “Real Time” survey process in July 2018. July HCAHPS data revealed an improvement in our scores for clean and quiet, communication about meds, communication with doctors, responsiveness of staff, and overall rating of hospital. NRHS continues to send paper HCAHPS surveys to patients in order to meet CMS (Centers for Medicare and Medicaid Services) requirements. Agenda Item V. Approval of the September 2018 Norman Regional Health System Financial Statements Mr. Hopkins presented the September 2018 Norman Regional Health System Financial report highlighted the following:  Inpatient Volumes – September’s Inpatient volumes were down by 100 cases or 7% from prior month. The weaker inpatient volumes were due to weaker CMI (Case Mix Index), which was probably down because of weak inpatient surgery volumes.  Average Length of Stay (ALOS) – September’s ALOS improved slightly  Inpatient Surgeries were 150 cases below prior month, and 150 cases below September budget.  Outpatient Volumes – Outpatient volumes were 3% below budget and 9% weaker than August.  Outpatient Surgeries were 14% below budget and prior month.  Outpatient Cath Lab Volumes were at budget but dropped 26% from prior month.  Clinic Outpatient Visits were down 21% from August, but slightly favorable to September budget. September 2018 Financial Performance  Gross Revenues .................................. (Budget $169,848,868)............ $162,240,654  Net Patient Revenue .............................. (Budget $35,698,903).............. $35,012,380  Total Operating Expenses ..................... (Budget $35,073,230).............. $35,284,894  Total Operating Revenues ...................... (Budget $36,098,363).............. $35,427,633  Operating Income .................................... (Budget $1,025,133)................... $142,739  Non-Operating Revenues (Expenses) ........ (Budget $909,356)................ $2,334,967  Excess Revenues over Expenses ............ (Budget $1,934,489)................ $2,477,705 Year-to-Date  Operating Income .................................... (Budget $3,390,665)................ $1,750,367  Non-Operating Revenues (Expenses) ..... (Budget $2,730,435)................ $2,847,108  Excess Revenues over Expenses ............ (Budget $6,121,100)................ $4,597,475  Accounts Receivable Days ............................ (Budget 43 Days).................. 42.6 Days  Days Cash on Hand .................................................................. ................ 220.3 Days  NRHA Board Minutes 5 October 22, 2018 ACTION TAKEN: Dr. Weber motioned to approve the September 2018 NRHS Financial Statements. Dr. Kimpel seconded and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman. Agenda Item VI. Medical Staff A. Report from the October 10, 2018, Medical Executive Committee (MEC) Dr. Mantooth reported MEC met October 10, 2018, and highlighted the following:  Dr. Mantooth reminded everyone that we will be moving toward paperless charts and working toward removal of the boxes on the floors used by providers to put hand written orders, H&Ps and notes. Discussed getting point-of-care scanners for the pre-op areas for H&Ps to be scanned into patient charts in a timely manner.  Pharmacy reviewed new legislation that will go into effect November 1, 2018, limiting opioid prescriptions to a 7-day supply for acute pain. HIT has built order strings for opioids that the physician can use so they do not over prescribe medications. At some point, it will be mandatory that all narcotics be e- prescribed.  Discussed whether physician consults should be done provider-to-provider or by using the generic consult order, which could potentially not be seen by the consulted physician. This will be discussed further at the November Medical Executive Committee meeting.  Ms. McGill announced Progressive Care Unit has moved back to its original location and that 5-North will be ready for use in a few weeks as an overflow unit providing 15 extra beds. Agenda Item VII Patient Quality and Safety Committee Ms. Greenleaf thanked Dr. Weber for chairing the Committee in her absence. The Patient Quality and Safety Committee met on October 1, 2018, noting that Ms. Anderson’s comprehensive Quality and Safety report covered the items discussed at the meeting and she had nothing to add. Agenda Item VIII. Finance Committee A. Report from the October 15, 2018, Finance Committee Mr. Sherman reported the Finance Committee met October 15, 2018, and highlighted the following:  Ms. Blau introduced Ms. Diane Zellner as the new Risk Manager and provided an overview of the 4th Quarter Risk and Compliance Report. Mr. Sherman highlighted the following from her report: o NRHS Total Variances – There were 632 total variances for the 4th quarter and on a steady decline o Falls – All categories of injury falls are declining. o Medication Errors – Are the lowest in two years and continue trending downward. o Patient Experiences  NRHA Board Minutes 6 October 22, 2018  Overall, compliments from patients are slightly up,  Physicians received the most compliments,  Both Porter and HealthPlex EDs made big patient experience gains for this quarter compared to the previous quarter,  Patient concerns are down, and  No concerns regarding billing or policies.  Mr. Splitt announced that Ms. Blau is now certified in Healthcare Compliance.  Mr. Manfredo presented for approval six capital requests totaling $5,854,919: o Patient Monitoring Upgrade – $3,715,619 – Replaces all outdated patient bedside monitoring units, telemetry boxes, portable Wi-Fi capable patient transport monitors, and software for all three campuses for standardization and increases patient safety and satisfaction. o Patient Record Coding Enhancement Software – $82,950 – This will replace the current paper process, which will be more proficient. o EVIS EXERA III Gastroscopes – $1,202,533 – this new technology allows the Endo and surgery departments to grow volume with the new surgeons and increases patient safety. o Pinnacle Professional (Radiation Oncology Treatment Planning Network Server System) – $115,963 – Current system has reached end of life status and is no longer supported by the vendor. This replacement request is critical need and ties to all strategic categories. o Axiom (Budgeting, Productivity, Financial Planning Cost Accounting, Decision Support Software) – $265,300 – NRHS currently contracts four vendors for Financial and Decision Support products. Upgrading the current suite of Kaufman Hall products to their common platform provides upgraded tools and the system remains cloud-based. This allows the Decision Support staff to more effectively cross-train, as they will all be working with the same database. The 5-year cost savings total is $314,000. o Schedule Maximizer (Patient and Physician Office Self Scheduler for Diagnostic Imaging Procedures online) – $472,554 – SCI Solutions Schedule Maximizer allows physician offices and patients to self-schedule diagnostic imaging procedures by using their phone or computer rather than calling the Centralized Scheduling Department. SCI Solutions Schedule Maximizer will send text and email appointment reminders to patients. B. Recommend Approval of Capital Equipment Purchase Requests ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests totaling $5,854,919 as recommended by the Finance Committee. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman. Agenda Item IX. Old Business Mr. Cubberley announced the Norman City Council met last week and appointed Mary Womack as a member of the NRHA Board. They also reappointed Dr. Anwar and Dr. Chambers as members of the NRHA Board for another 3-year term.  NRHA Board Minutes 7 October 22, 2018 Agenda Item X. New Business Approval of FY19 Incentive Compensation and Gainsharing Goals Mr. Cubberley stated the Compensation Committee met and revisited the goals from the previous year (FY18) along with the goals for this fiscal year (FY19). Mr. Hopkins stated we are trying to drive the organization forward by aligning compensation with service, clinical, operational and team goals. We are building on the model already approved and not making major changes. We developed a system-wide plan that includes all healers and it is similar to the Annual and the Long-Term Incentive Plans already approved by the board. The new Gainsharing Plan will be performance oriented and based on specific goals. Goal achievement will determine the scores used to assess any financial gainsharing opportunity for our healers. Mr. Cubberley provided a detailed review of the changes. ACTION TAKEN: Mr. Sherman made a motion to approve the FY19 Incentive Compensation and Gainsharing Goals as recommended by the Governance and Finance Committees. Dr. Weber seconded and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman. Agenda Item XI. Administrative Report Mr. Splitt provided an update on the following:  He invited and encouraged the Board members to attend the December 5-7, 2018 Annual Oklahoma Hospital Association (OHA) Convention. Please look at the conference agenda and find some time to hear keynote speakers or attend a session in which you have an interest. Please send your choice(s) to Keli Foster- Nicks and she will register you for that session(s. Dr. Mantooth will be on an “Opioid Panel” and Ms. Rieger will be on a “Trending Legal Issues Panel”.  We had our first two Norman Regional Kids Virtual Care visits, one at Washington Elementary and one at Irving Middle School. That went very well. There were other opportunities, but the parents of those students/patients had not completed and returned to the schools their participation agreements.  Asked that Ms. Price provide an update on “Boo to the Flu” event at Norman Regional Moore and Kids Are Special People at Moore and Norman.  Ms. Price noted that fall is always a busy time for community events and Saturday, October 20, the Norman Regional Health Foundation hosted the annual Boo to the Flu event at Norman Regional Moore. This is the 3 rd year for the event and we are starting to recognize our returning community members who appreciate the service. There were 290 flu vaccines given in the span of 2 hours of which 160 were children under the age of 18 and 130 were adults. One adult received his very first flu vaccine, and a 95-year old man drove from Norman to receive his flu shot in Moore.  October is Kids are Special People month for Moore and Norman Elementary Schools. Kids are Special People is a 32-year program sponsored by the Norman Regional Auxiliary. At Norman Regional Moore, our Volunteers and Health System  NRHA Board Minutes 8 October 22, 2018 staff hosted 1,200 4th graders from 16 Moore Elementary Schools. Norman Regional Hospital, hosted 1,240 3rd graders from 18 Norman Elementary Schools, Community Christian School, and All Saints. Students rotate through six (15-minute) sessions conducted by Norman Regional staff that focused on Healthy Lifestyles, Tobacco Dangers, Exercise, Hand Hygiene, Technology Safety, Stroke/Heart Attack Awareness, and Ambulance Tours. This program is a lot of fun and our volunteers and staff conduct the rotations. The students and teachers love the program and our volunteers and staff enjoy participating.  Asked Ms. Carter to provide an update on the Employee Provider Networking Event Ms. Carter announced the next offsite quarterly Employee Provider Networking Event is Thursday, October 25, 2018, at Madison Square. Five speakers will be presenting updates on specific topics at this event: Mr. Wilson, Executive Director of United Way, update on the United Way; Dr. Swearingen update on the BHAG project; Danny Kelley, Administration Director HIT, update on the transition of e- Clinical Works technical support from the clinics back to HIT; Dr. Pearson, Oncologist, update on the Oncology Service Line; and Dr. Cook, update on the Norman Regional Kids pilot program. These networking events started in 2017. The first 30-minutes to an hour is for networking, which provides all the providers an opportunity to meet each other and discuss relevant activities and/or initiatives going on within the Health System. These events have been well received and attended in the past. She encouraged the Board members to attend. If you would like to start receiving invitations to these events, just let her know and she will ask Ms. Foster- Nicks to forward them to you.  He asked that Ms. McGill provide a Board Education Session “Patient Safety Huddle” update at the November Board Meeting.  He asked Mr. Manfredo to give an update on his Meditech Conference. Mr. Manfredo stated that Mr. Kelley and he attended an annual Meditech meeting and a message he took away was there are some strong emotions around Electronic Medical Records (EMRs) and physicians. It was a good conference with all Meditech users in attendance. We were able to sit and talk with people who had been through a recent installation and those who are planning the same. We gained a lot of good points of contact AND information one of the newest functionalities known physician voice command. This allows providers to dictate important patient information into the EMR without physically typing. It should be a game changer for EMR documentation and physician satisfaction. Mr. Splitt noted the importance of that technology to the organization and we are staying engaged and have an eye to the future about when that investment is appropriate. Navigant is also working with us as we think about our Big Hairy Audacious Goal (BHAG), where we are going and how the EMR fits into that goal. We are excited to have viable options with our current EMR partner. 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  NRHA Board Minutes 9 October 22, 2018 ACTION TAKEN: Dr. Kimpel made a motion to adjourn into Executive Session. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman. Ms. Anderson, Ms. White, Ms. McCool-Hare, and Ms. Wells left the meeting at 6:51 p.m. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XII.B 1-4 Below. 1. Recommend New Provisional Medical Staff Appointments: a) Joseph Saveika III, MD, Active Staff – Medicine Department b) Paul Le, MD, Active Staff – Anesthesia Department c) Sheila Stanek, DO, Associate Staff– Medicine Department d) Paul Sarai, MD, Teleradiology – Clinical Privileges Only, Teleradiology – Radiology Dept. e) James Sloves, MD, Teleradiology – Clinical Privileges Only, Teleradiology – Radiology Dept. f) William Zinn, MD, Teleradiology – Clinical Privileges Only, Teleradiology – Radiology Dept. g) Kevin Mason, PA-C, Allied Health Staff – Surgery Department 2. Recommend Advancement of Medical Staff from Provisional Status: a) Laurel Jordan, DO, Active Staff – OB/GYN Department 3. Recommend Medical Staff Reappointments: a) Saud Ahmed, MD, Active Staff – Medicine Department b) Mark Camp, MD, Active Staff – Medicine Department c) Roy Mullins, MD, Active Staff – Medicine Department d) David Williams, MD, Active Staff – Medicine Department e) Ajay Verma, MD, Active Staff – Pediatrics Department f) Leslie Ollar-Shoemake, DO, Active Staff – OB/GYN Department g) Sanober Malik, MD, Consulting Staff – Medicine Department h) John Stanley III, MD, Consulting Staff – OB/GYN Department i) Charles Mirabile, MD, Consulting Staff – OB/GYN Department j) Shrilekha Parikh, MD, Associate Staff – Medicine Department k) Jamie Lynch, APRN-CNP, Allied Health Staff – Medicine Department l) Storm Eagle, APRN-CNP, Allied Health Staff – Medicine Department m) Matthew McGill, APRN-CNS, Allied Health Staff – Medicine Department n) Laura Velez, APRN-CNS, Allied Health Staff – Cardiovascular Med. Dept. o) Lauren Haymans, PA-C, Allied Health Staff – Surgery Department 4. Recommend Additional Privileges of Medical Staff: a) Ronni Farris, MD, OB/GYN Robotic Privileges C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session  NRHA Board Minutes 10 October 22, 2018 ACTION TAKEN: Dr. Kimpel 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. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman. 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. Dr. Kimpel seconded, and the motion was approved with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman. Agenda Item XIV Board Open Discussion A. Calendar Review . Mr. Cubberley noted that on the 2019 calendar of the NRHA Board Meetings, we have the recommendation for the May meeting to be the day after Memorial Day. After a brief discussion, recommended to have the May meeting on Monday, May 20, 2019 at 5:30 p.m. The December meeting will be on December 16, 2018. Agenda Item XIII. Board Education: Vizient Leadership Conference Summary Mr. Cubberley reported that Board members and Executive Staff attended the Vizient OK/AR Trustee/Physician/CEO Leadership Conference October 10-12 in Lost Pines, Texas. There was discussion of the frictions and disruptions of today. We know there are disruptors coming in many forms, such as technology, large corporations attempting to take away business by creating ways to get around the perceived hospital friction points for consumers, patients and even health professionals. They have found a better way to do our business and slowly over time, if we are not cognizant of it and step out to get ahead of it, we may find our business chipped away slowly over time. A speaker consumer friction points in health care including 55% of consumers are frustrated by coordinating various aspects of care, 53% are frustrated by their lack of understanding of the cost of care provided, and 50% percent struggle to understand health care benefits. Not sure, we can resolve them immediately, but someone is going to and we are being pushed toward transparency. Others (CVS and Walgreens) are adding patient care to their facilities and thereby taking away business – you can get flu shots there. Others are finding small ways to move care delivery away from hospitals and physicians and, in many aspects, they are under-cutting the health systems. Billing is a huge issue in terms of cost. Currently, we do not have the ability to tell our consumers what it costs to receive a hip replacement at one of our facilities (too difficult to calculate due to multiple variables like insurance coverage and/or comorbidities). We have an  NRHA Board Minutes 11 October 22, 2018 idea, but we cannot give them a specific fee. There are places out there that are willing to do that now. We have to move in that direction. The key they were trying to instill was that traditional hospitals have to be more innovative, consumer oriented, aware of the competitive trends where the business is going. NRHS must understand and work to get out front of these developments. There was a presentation on Declining Operating Margins for Hospitals. This is not a surprise to any of us because we have seen the decline in hospital operating margins over the last 20 years, but especially over the last 4-5 years. The presenter said, “Do not expect it to improve, if at all.” Insurance companies are paying less, CMS is paying less, and operating margins are going to continue to decline. We must finds ways to become more efficient with care delivery. They mentioned FTEs our largest operating expense. We are going to have to be increasingly more comfortable working smarter with less. Social Determinants of Health (SDoH) is a new phrase within the health industry that Health Systems have to be aware of and put resources toward. Those are outside factors that may affect health and are beyond physical health. For example, lacking food, inadequate housing, not having transportation to get to doctor’s appointment, etc. We all know those things impact us, but now more than ever, there is increasing pressure on health systems to help solve this problem. At the same time, we are experiencing decreasing reimbursement for services. How we solve it may be through partnerships or working with other non-profits or government agencies. Dr. Weber noted that he found the SDoH discussion depressing because it is real, it is impactful, and requires resources we do not have. Furthermore, there is no easy or affordable solution as to how we balance that all out. There was one local presentation – Ms. Rieger spoke to the legal landscape, which was eloquently and effectively presented. Ms. Carter stated the discouraging thing about the presentations was that well-funded organizations like Apple, Google, Amazon and others are coming into segments of health care because they generate very large profit margins in other areas. They have significant funds to put toward health care initiatives that do not involve comorbidities and emergency rooms. It is encouraging to know that NRHS is already doing things to collaborate with other providers within our community in order to improve care delivery and health outcomes. For example, Case Management and Transitions of Care meet monthly with community providers to discuss the challenges they face in caring for patients when discharged from the hospital. Our work with the CJR and BPCI Advance initiatives also position us to positively influence post-acute relationships and patient outcomes. We probably need to do a better job in identifying grants or other funding for use to help with some of those initiatives Mr. Splitt distributed the Blue Zones Summary regarding author Dan Buettner’s discovery of the five healthiest places in the world to live. They are in Greece, Japan, Sardinia, Loma Linda, California, and Cost Rica. The best way to influence a healthy lifestyle is to do these three things. 1) The right lifestyle can add a decade to your life, 2) drink more water, eat less, and 3) put your family first. The purpose behind the SDoH is to connect people with the right resources. How do we find the funding to make that happen?  NRHA Board Minutes 12 October 22, 2018 Agenda Item XV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn the meeting at 7:21 p.m. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Weber, Dr. Kimpel, Ms. Greenleaf, and Mr. Sherman.