Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting November 26, 2018 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, November 26, 2018, at 5:30 p.m., in the Norman Regional Hospital Board Room. The meeting Agenda was posted November 16, 2018, on the NRHS and Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chair Muhammad Anwar, MD Diane Chambers, MD Joan Greenleaf James (Jeff) Kimpel, Ph.D. Kevin Pipes Jerome (Jerry) Weber, Ph.D. Mary Womack Member Absent: Tom Sherman, Vice Chair/Secretary 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. Aaron Boyd, CMO Courtney Blau, Admin. Dir., Risk Management & Compliance, Compliance/Privacy Officer Karen Rieger, System Attorney Crowe & Dunlevy Mackenzie Sork, NRHA Board Fellow Jenny Anderson, Director QPI & Medical Staff Services Lisa White, Manager PI & Medical Staff Services Molly McCool-Hare, Business Planning/Operations Specialist Brian Loftus, Business Planning LEAN Specialist Kelly Wells, Director Health Promotion & Community Relations Sharon Sanderson, Analyst Lab Performance Improvement and Point of Care Testing, Laboratory Calvin Bohanan, System Manager Laboratory Services Recorder: LaRue Putman, Department Assistant  NRHA Board Minutes 2 November 26, 2018 Agenda Item I. Meeting Called to Order Mr. Cubberley called the October 22, 2018, Norman Regional Hospital Authority meeting to order at 5:34 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. December 2018 Healer of the Month, Sharon Sanderson, Analyst Lab Performance Improvement and Point of Care Testing, Laboratory – Calvin Bohanan, System Manager Laboratory Services Mr. Cubberley introduced Mr. Bohanan who presented as the Outstanding Healer for December 2018. Mr. Bohanan shared comments from Ms. Sanderson’s co- workers citing her caring, challenging, passion and commitment, noting that she exemplifies the ‘Norman Way’. Ms. Sanderson stated she is honored to be recognized for doing what she is supposed to do. Mr. Cubberley congratulated and thanked Ms. Sanderson on behalf of the Board for her outstanding dedication, compassion, and positive attitude that continues to make Norman Regional Health System a caring, high quality system. Ms. Sanderson and Mr. Bohanan left the meeting at 5:44 p.m. Agenda Item III. Approval of October 22, 2018, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the October 22, 2018, Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the October 22, 2018, Board Meeting Minutes as submitted. Dr. Kimpel seconded the motion, and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Ms. Greenleaf, Mr. Pipes, Ms. Womack, Dr. Weber, and Dr. Kimpel. Agenda Item IV. Performance Updates Ms. Anderson provided the Quality & Patient Safety Update highlighting the following:  Patient Safety o Reportable Events  C.diff Infections are showing a marked decline; hits, misses, barriers, and key learning were reviewed.  Medication Errors with Harm are also showing a marked decline; hits, misses, barriers, and key learning related to Heparin were reviewed.  Quality and Performance Improvement  NRHA Board Minutes 3 November 26, 2018 o 2X12 Initiative for Patient Throughput  Learned at a Vizient Conference, the Nurse Manager identifies two patients each day that will be discharged and leave the facility by noon the following day. These two patients are reported to Director, who then reports to Leadership Safety Huddle. The planned discharge requires communication with physician, case manager, patient’s family, and transportation. The following day (day of discharge), the Director reports the results, i.e., patient was (or will be) discharged as planned, or patient was not discharged and here is the reason(s). o Heart Failure Mortality  Data was reviewed indicating only one Heart Failure Mortality this fiscal year.  Patient Experience o Positive comments were briefly reviewed. o Real-Time Data Analysis was briefly reviewed. Mr. Cubberley welcomed and introduced Mary Womack to fill a position on the Norman Regional Hospital Authority Board of Trustees. Agenda Item V. Approval of the October 2018 Norman Regional Health System Financial Statements Mr. Hopkins presented the October 2018 Norman Regional Health System Financial report highlighting the following:  Inpatient Volumes – October’s Inpatient volumes rebounded from prior month by 1,500 cases. However, inpatient charges were below budget, probably because inpatient surgery cases were below budget. CMI (Case Mix Index) was down 2% from budget.  Inpatient Surgeries were 3.8% below budget.  Outpatient Volumes – Very strong improvement in outpatient volumes and clinics were up similarly.  Outpatient Surgeries rebounded, but were still 1.7% below budget.  Labor efficiency improved from prior month and was 1.9% better than budget.  Total Operating Expenses included some high drug costs due to stocking a new PYXIS on one unit and two snakebite cases requiring expensive antivenin. Other costs high repair costs at Porter campus, due to age of the facility. October 2018 Financial Performance  Gross Revenues .................................. (Budget $176,822,639)............ $180,134,202  Net Patient Revenue .............................. (Budget $37,081,811).............. $37,721,109  Total Operating Expenses ..................... (Budget $36,001,208).............. $36,544,396  Total Operating Revenues ...................... (Budget $37,484,338).............. $38,186,933  Operating Income .................................... (Budget $1,483,130)................ $1,642,537  Non-Operating Revenues (Expenses) ........ (Budget $910,010)............... $-3,651,351  Excess Revenues over Expenses ............ (Budget $2,393,140)............... $-2,008,814 Year-to-Date  Operating Income .................................... (Budget $4,873,795)................ $3,392,904  Non-Operating Revenues (Expenses) ..... (Budget $3,640,445).................. $-804,243  Excess Revenues over Expenses ............ (Budget $8,514,240)................ $2,588,661  NRHA Board Minutes 4 November 26, 2018  Accounts Receivable Days ............................ (Budget 43 Days).................. 42.6 Days  Days Cash on Hand .................................................................. ................ 222.5 Days ACTION TAKEN: Dr. Weber motioned to approve the September 2018 NRHS Financial Statements. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Dr. Kimpel, Mr. Pipes, Ms. Womack, Dr. Weber, and Ms. Greenleaf. Agenda Item VI. Medical Staff A. Report from the November 2018, Medical Executive Committee (MEC) Dr. Jawed reported MEC met November 14, 2018, and highlighted the following:  Ms. McGill presented Dr. Toal the World Tour Award.  Mr. Hopkins gave financial presentation reflecting on a negative quarter as expenses were up while volumes were down. New Medicare payment increases are expected in 2019, which should be in our favor.  Provider-to-provider physician consults were discussed and suggested to take back to Medical Staff Departments and back to MEC in January. Discussion included the need for providers to review and update their information on smart web. It was also discussed to get a texting app for providers. John Manfredo will take this suggestion to PAC.  Dr. Jawed reminded everyone to follow Bylaws regarding rotation of department chairs every two years. A reminder letter will go out to department chairs.  Dr. Jawed reminded about the 2018 Provider Holiday social December 14, including the physician of the year and nurse of the year presentations.  Credentials were voted on via email because a quorum was not present at the meeting.  Reports were received from the Hospital Medicine Department, OR Committee/Surgery Department, Emergency Medicine Department, Physician Advisory Committee, Pediatric Department, Infection Committee, Pathology Department, Transfusion Safety Committee, OB/GYN Department, and Behavioral Health Department.  Ms. McGill reported clinical continuing education under nursing has moved to an every other month teach week, which identifies system-wide topics so that every clinical area receives the same education at the same time. The month of December will be a refresher month, assuring everything is in place. Ms. McGill invited providers to supply topics to be added.  Ms. Price reminded of the upcoming Nurse of the Year award and the need for donations.  Mr. Manfredo presented the Provider Wellness Self-Assessment. The committee approved sending out the Provider Wellness Self-Assessment and the employee assistance program information to all providers via mail. This Self-Assessment will provide us with a baseline from which to plan.  Mr. Splitt stated a group will be going to the Oklahoma Hospital Association in January related to Medical Marijuana. Norman Regional is a tobacco-free campus, but will be adding smoke-free campus to include marijuana and vaping.  NRHA Board Minutes 5 November 26, 2018  Mr. Splitt updated the group on the BHAG and expressed appreciation to physicians involved with the Navigant project.  Mr. Cubberley announced the Board approved $3.7 million for patient care monitors and software as well as three large software upgrades. One software package will allow physician offices to schedule their patients’ imaging procedures.  Mr. Cubberly announced the appointment of new Board member Mary Womack. Agenda Item VII Strategic Planning Committee Dr. Weber reported the Strategic Planning Committee met on November 5, 2018, and discussed the 2019 review and 1st quarter results and service line. The Strategy and Growth Team’s evaluation based on hits, misses, barriers, and lessons learned identifies continual improvement. It’s good to hear the compliments, which are the result of a plan not gathering dust, but being actual and practical. Agenda Item VIII. Finance Committee A. Report from the November 2018 Finance Committee Mr. Cubberley reported the Finance Committee met November 15, 2018, and highlighted the following:  Ms. LeAnn Richardson reported on bundled payment programs, noting there are 22 to start.  Ms. Price gave the quarterly strategic planning update.  Ms. Blau gave the quarterly update for risk and compliance/privacy noting a trend down in medication errors.  Mr. Hopkins presented the financial update indicating we are down for the year, similar to last year, and hope to meet or exceed the target and get to 4% again.  Mr. Manfredo presented for approval six capital requests totaling $1,370,821 with five of the requests approved at $470,821: o QL220 Plus Labeling/expand Mobilab availability – $107,230 – for use in the Rehabilitation Center o Moore Signage – $93,231 – to upgrade our exterior signage for the Moore campus o Dr. Livingston’s Renovation – $100,470 o Dr. O’Brien’s Relocation – $75,000 – From Findlay Plaza to Robinson Medical Plaza o Dr. Layne’s Practice Acquisition – $94,890 B. Recommend Approval of Capital Equipment Purchase Requests ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests totaling $470,821 as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Ms. Greenleaf, Dr. Kimpel, Ms. Womack, Dr. Weber, and Mr. Pipes.  NRHA Board Minutes 6 November 26, 2018 Agenda Item IX. Old Business There was none. Agenda Item X. New Business There was none. Agenda Item XI. Administrative Report Mr. Splitt provided an update on the following:  He welcomed Ms. Mary Womack to her first official Board meeting.  He updated the group on the Norman Regional Kids Virtual Care at Washington Elementary and Irving Middle Schools. There are 50 enrollees and we have had 7 visits with Dr. Cook including guardians/parents. Five of these students then returned to class and 2 received prescriptions. We are continuing to learn and improve.  He announced we were on capacity alert today at the HealthPlex and also experienced ED divert today at the HealthPlex, noting the undersized emergency room at the HealthPlex and the need to expand that space. He expressed appreciation to staff working to get all patients to the correct venue of care.  The Executives Community Tour was today. We visited our clinics, referring clinics, and competition in our areas. This is a valuable process and enlightening to all of us.  He expressed appreciation for responses he has received for the next Board Advance, scheduled for February 23.  He reiterated the Provider Survey is a means to find the right tool and get it into the hands of the physicians. 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 ACTION TAKEN: Dr. Kimpel made a motion to adjourn into Executive Session. Dr. Kimpel seconded and the motion was approved unanimously with aye votes from Dr. Anwar, Mr. Cubberley, Dr. Chambers, Ms. Greenleaf, Mr. Pipes, Ms. Womack, Dr. Weber, and Dr. Kimpel. Ms. Anderson, Ms. White, Ms. McCool-Hare, Mr. Loftus, and Ms. Wells left the meeting at 6:25 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:  NRHA Board Minutes 7 November 26, 2018 a) Parina Cho, MD, Teleradiology b) Kavita Garg, MD, Teleradiology c) Anoosh Montaser, MD, Teleradiology d) Maria Thomas, MD, Teleradiology e) Stephanie Badaroux, PA-C, Allied Health – Emergency Medicine f) Juliet Franklin, APRN-FNP-C, Allied Health – Cardiovascular Medicine g) Elizabeth Eaton, APRN-CNP, Allied Health – Pediatrics 2. Recommend Advancement of Medical Staff from Provisional Status: a) Lawrence Carter, MD, Active Staff – Hospital Medicine Department b) Ayesha Farhan, MD, Active Staff – Behavioral Medicine Department c) David Deschamps, MD, Consulting – OB/GYN Department d) Stephanie Runyan, DO, Teleradiology e) Gregory Wolfe, MD, Teleradiology f) Christina Highley, MD, Associate – Medicine Department g) Thomas Jarvis, DO, Associate – Medicine Department h) Keri Houck, APRN-CNS, Allied Health – Hospital Medicine Department 3. Recommend Medical Staff Reappointments: a) Kristin Thorp, MD, Active Staff – Medicine Department b) Tadgy Stacy, MD, Active Staff – Pediatrics Department c) Lorry Krous, MD, Active Staff – Pediatrics Department d) Lesa Mulligan, MD, Active Staff – OB/GYN Department e) Archana Gautam, MD, Active Staff – Cardiovascular Department f) Ahmad Sarwar, MD, Active Staff – Cardiovascular Department g) Mehran Shahsavari, MD, Active Staff – Hospital Medicine Department h) Senthil Raju, MD, Active Staff – Hospital Medicine Department i) Gautam Dehadrai, MD, Active Staff – Radiology Department j) Muhammad Ishaq, MD, Active Staff – Behavioral Medicine Department k) Mohammad Razaq, MD, Consulting Staff – Medicine Department l) Sergio Garcia, MD, Consulting Staff – Medicine Department m) Nancy Brown, DO, Associate Staff – Medicine Department n) Amanda Wright, MD, Associate Staff – Medicine Department o) Rodney McCrory, DO, Associate Staff – Medicine Department p) Karen Tyndall, Ph.D, Allied Health Staff – Medicine Department q) Jennifer Enteshary, APRN-CRNA, Allied Health Staff – Anesthesia Department 4. Recommend change from Active Staff to Consulting Staff: a) Kimberly Wise, MD, Ophthalmology Department C. Provider property, medical records, acquisition and employment D. Norman Regional Hospital Authority Charter E. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session and return to regular session. Dr. Chambers seconded, and the  NRHA Board Minutes 8 November 26, 2018 motion was approved with aye votes from Dr. Anwar, Mr. Cubberley, Mr. Pipes, Dr. Kimpel, Ms. Greenleaf, Ms. Womack, Dr. Weber, and Dr. Chambers. 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. F. Proposed Vote to Approve or Disapprove the Provider property, medical records, acquisition and employment ACTION TAKEN: Dr. Weber motioned to approve Provider property, medical records, acquisition and employment. Ms. Greenleaf seconded, and the motion was approved with aye votes from Dr. Anwar, Mr. Pipes, Mr. Cubberley, Dr. Chambers, Dr. Kimpel, Ms. Womack, Dr. Weber, and Ms. Greenleaf. G. Proposed Vote to Approve or Disapprove a Resolution to modify the Norman Regional Hospital Authority Charter for possible consideration by City Council ACTION TAKEN: Dr. Weber motioned to approve a Resolution to modify the Norman Regional Hospital Authority Charter for possible consideration by City Council. Dr. Kimpel seconded, and the motion was approved with aye votes from Dr. Anwar, Mr. Cubberley, Mr. Pipes, Dr. Chambers, Ms. Greenleaf, Ms. Womack, Dr. Weber, and Dr. Kimpel. H. 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, Mr. Pipes, Ms. Greenleaf, Ms. Womack, Dr. Weber, and Dr. Kimpel. Agenda Item XIII. Board Education: Leadership Safety Huddles Ms. McGill presented a summary of the Leadership Safety Huddles noting they were piloted with a clinical group and then went system wide mid-October this year. The purpose is to open two-way, system-wide communication centered on patient safety throughout the health system. This improves inter-departmental relationships, shares existing and potential safety issues and concerns, increases engagement and enhances awareness while promoting teamwork. Huddles foster a culture of safety, driving accountability and ensuring follow up.  NRHA Board Minutes 9 November 26, 2018 The Safety Huddles are conducted weekdays utilizing one meeting room at each campus with a secure line. They typically take only 10-15 minutes. All participants are expected to attend or send a representative (we average 90% attendance) even if there is nothing to report because it is a learning opportunity for everyone. Topics have included patient and family concerns, staffing, patient flow, security, community relations, IT, infection prevention, equipment, facilities, pharmacy, variances, disruptive behavior, and unexpected injuries. Next steps include a safety topic of the week, real- time HAI reports to our NEWs, 2X12, and medical staff involvement. Ms. McGill presented the related Good Catch program, noting the personal note cards and presentations at Safety Huddles. Examples of their use include Heparin drip, Arctic Sun weight based dosing, narcotic keys, DHS, EMSStat>OBED>L&D>NICU, and blood patches. Agenda Item XIV Board Open Discussion There was none. Agenda Item XV. Adjournment ACTION TAKEN: Having completed the Agenda, Mr. Cubberley declared the meeting adjourned at 7:19 p.m.