Norman Regional Hospital Authority Meeting

NORMAN REGI ONAL Health Syst em NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting October 28, 2019 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, October 28, 2019, at 5:30 p.m., in the Norman Regional Hospital Board Room. The meeting Agenda was posted October 24, 2019 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chairman Muhammad Anwar, MD Tom Sherman, Vice Chair/Secretary James (Jeff) Kimpel, Ph.D. Jerome (Jerry) Weber, Ph.D. Diane Chamber, MD Kevin Pipes Mary Womack Others Present: Richie Splitt, President & CEO John Manfredo, COO Brittni McGill, CNO Paula Price, VP Strategy & Growth Ken Hopkins, CFO Karen Rieger, Attorney, Crowe & Dunlevy Dr. Farhan Jawed, MD Chief of Staff-Elect Dr. Robin Mantooth, MD Emergency Department Lisa White, Manager Performance Improvement Kelley Wells, Director Planning & Communications Larry Harden, Administrative Director Compliance Danny Kelley, Administrative Director HIT Brian Loftus, Business Planning Specialist Sherri Jo Johnson, Manager, Oncology - Palliative Care Sharron Largent, Administrative Director of Patient Care Services & Accreditation Hanna Segele, Unit Secretary, Oncology - Palliative Care Susie Graves, Director Labor, Delivery & Recovery Tonya Faires, Manager New Born Transition Team Barry Deal, RN , Surgical Unit Cheryl McKinley, Manager, Surgical Unit Courtney Stark, RN , Coordinator Stroke Jan Emmons, Director Emergency Services Christie Swanson, Editor, Norman Transcript Paul Jones, Director, Intensive Care Unit Mari Newcomer, Manager Women's & Children's Health Ryan Neafcy, JC Penny Leadership Board Fellow Bryce Ell, Administrative Fellow  NRHA Board Minutes 2 October 28, 2019 Members Absent: Joan Kemmet-Greenleaf Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the October 28, 2019, Norman Regional Hospital Authority meeting to order at 5:33 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. November 2019 Healer of the Month - Hanna Segele, Unit Secretary Oncology/Palliative Care, introduced by Sherri Jo Johnson, Nurse Manager. Mr. Cubberley introduced Ms. Johnson who presented Ms. Segele as the Outstanding Healer for November 2019. Ms. Johnson stated Ms. Segele has been a healer at Norman Regional for 28 years. She was in Ortho for 16 years and has been in Oncology for 12 years. Ms. Johnson realizes she may be the official manager, but they all know it is Ms. Segele who runs the place and does it well. She keeps them all organized, keeps the department running smoothly and they all would be lost without her. Ms. Segele thanked her department and everyone at Norman Regional for the honor. She believes her coworkers are her family and they help her be a better person. She looks to Ms. Johnson as a mentor and is thankful to know her. Mr. Cubberley congratulated and thanked Mrs. Segele 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. B. Mr. Cubberley introduced Ms. McGill, CNO for the 2019 March of Dimes Nurse of the Year presentation. Ms. McGill reported that the March of Dimes (MOD), a nonprofit organization, committed to supporting healthy moms and babies. The MOD fights for the health of all moms and babies, advocates for policies to protect them, and works to improve the health care they receive . Each year the March of Dimes pays tribute to the nursing profession by recognizing extraordinary nurses throughout the state. Through the MOD Nurse of the Year program, the remarkable efforts of nurses are honored for making a difference in the lives of so many. NRHS supports and contributes to the MOD program. This year, with over 600 nominations from across the state, NRHS was represented in multiple categories. Barry Dill was a finalist in the MedSurg category, Courtney Stark, stroke coordinator won in a specialty category and Debbie Foster won the lactation award and the Nurse of the Year for the State of Oklahoma. These awards honor extraorginary NRHS nurses who go above and beyond to deliver compassionate care. Ms. McGill presented a video featuring Ms.  NRHA Board Minutes 3 October 28, 20 19 Foster that was shown at the awards ceremony. Sherri Jo Johnson, Shannon Largent, Hanna Segele, Susie Graves, Tonya Faires, Barry Deal, Cheryl McKinley, Courtney Stark, Jan Emmons, Paul Jones, Mari Newcomer left the meeting at 5:41 pm. Mr. Splitt announced and welcomed Larry Harden as the new Administrative Director of Compliance and Risk Management. He also welcomed Christie Swanson, editor from the Norman Transcript. Agenda Item Ill. Approval of September 2019, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the September 23, 2019, Board Meeting Minutes. ACTION TAKEN: Dr. Weber made the motion to approve the September 23, 2019, Board Meeting Minutes as presented. Dr. Kimpel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Dr. Kimpel, Mr. Pipes, Ms. Womack, Dr. Chambers and Mr. Sherman. Agenda Item IV. Performance Updates Ms. Anderson presented a Plan, Do, Study, Act (PDSA) update from the January board meeting. Shannon Largent, Administrative Director of Patient Care Services & Accreditation and Tressa Lyon, Manager Health Information Management chair the Outcomes & Efficiencies Strategic team. The goal is to extend continuous improvement efforts across the entire system, so as to support better care, improved health, lower costs and better outcomes. The PDSA Plan is simple, easy to learn and use. It helps with rapid cycle improvement, accountability and sustainability. Ms. Anderson explained a few differences between an Average Organization to a High Reliability Organization when implementing the PDSA model. • Instead of quality only in terms of compliance - an organization realizes quality is continuous and systematic improvement; have a preoccupation with failure • Instead of using data to assess or knee jerk reactions - use data to make rapid sustainable improvement and not accepting simple explanations for problems • Instead of top down approach of "we say, you do" - defer to expertise and look to those performing the work • Instead of a culture of blame - support a culture of safety and accountability The majority of time of the PDSA should be spent in the "Plan" phase. This allows  NRHA Board Minutes 4 October 28, 2019 for sustainable improvement and not temporary solutions. PDSA Lunch and Learns are facilitated by members of the Outcomes & Efficiencies Strategic Team on a monthly basis and have now expanded to both campuses. They have facilitated over 40 projects, had over 50 participants and attendees range from about 25 different departments. Agenda Item V. Approval of the September 2019 Norman Regional Health System Financial Statements Mr. Hopkins presented the September 2019 Norman Regional Health System Financial report - September 2019 Financial Performance • Gross Revenues ..... ........ ................ ..... (Budget $184,807,224) .... .. .. .. .. $192,784,827 • Net Patient Revenue .. ..... ... ................... (Budget $40,114,225) .............. $39,438,117 • Total Operating Expenses .. .... .. .. .......... . (Budget $39,417,333) ..... .... ..... $39,010,270 • Total Operating Revenues ................ ... .. (Budget $40,437,042) ... ........... $39,870,413 • Operating Income ........... ............. ... ..... .... (Budget $1,247,864) ....... .. .......... $510,387 • Non-Operating Revenues (Expenses) ..... (Budget $1 ,119,709) ... ......... ..... ($860, 143) • Excess Revenues over Expenses ........ ... (Budget $2,274,016) ......... ..... ($1,722,200) Year-to-Date • Operating Income ... ......... ........................ (Budget $3,427,292) ................... $967,647 • Non-Operating Revenues (Expenses) ..... (Budget $3,462,921) .. ............ ($2,679,810) • Excess Revenues over Expenses ........... (Budget $6,890,213) ................ $3,647,457 • Accounts Receivable Days ............ ......... .... ... (Budget 43 Days) ....... .. ........ .44.0 Days • Days Cash on Hand ....... .. ......... ..... .... ... ....... ..... .... ........................ 212.4 Days ACTION TAKEN : Dr. Weber motioned to approve the September 2019 NRHS Financial Statements. Dr. Kimpel seconded the motion. September financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Dr. Kimpel, Mr. Pipes, Ms. Womack, Dr. Chambers and Mr. Sherman. Agenda Item VI. Medical Staff Dr. Mantooth presented the Medical Staff report. She stated the MEC met on October 9, 2019. Old Business: Discussed the status of the LUA application. The medical staff has vetted several companies and will be signing with a company soon.  NRHA Board Minutes 5 October 28, 20 19 New Business: • Dr. Kolli stated they are discussing C-Diff rates and protocols to ensure staff are following guidelines. Discussed Surgical Site Infection Rates and continue exploring changes and recommendations that protect our patients. Department Reports: • Emergency Department - Dr. Hoos-Reinke reported a focus on staffing and appropriate use criteria. Dr. Costner was appointed the pediatric liaison for the Emergency Department to help improve the pediatric experience. • HQPSC - Ms. White presented on PDSA Cycles. Sepsis mortality and Sepsis bundle compliance have improved. Mrs. Graves reported on Perinatal Care Certification. • OB/GYN - Dr. Parker reported adjustments are being made to antibiotic dosing to determine effects on C-Section infection rates. The Cleveland County Health Department received a grant to begin a community Doula program. We will find out more information on the program. Dr. Krous reviewed changes with infant antibiotic usage in relation to length of stay. • Physician Advisory Committee - Continued discussions regarding secure texting options. • Radiology Department - Dr. Narotam reported the dose management project was discussed regarding the software that tracks radiation dosing. Discussed screening procedure policies regarding discrepancies and proper follow up. They reviewed preliminary reports on the Teleradiology company taking over in December and discussed a new MRI supervisor and their role in the department. Administrative Reports: • Ms. McGill reported dialysis services will be transitioning from Moore Nephrology to DeVita. • Mr. Splitt read an email from the spouse of a former NRHS patient and the great experience they had in the Emergency Department, surgery and on the patient floor. Mr. Splitt and the Executive Team presented an update on Inspire Health. Agenda Item VII. Patient Quality & Safety Committee A. No report from the Committee was provided. Agenda Item VIII. Finance Committee A. Report from the October 21 , 2019 Finance Committee Mr. Sherman reported an update on the Healer Engagement process. The Gallup 012 survey was initiated in January 2017. Since then, 3 surveys have been completed. The next survey is scheduled for December 3-16. Since starting the Healer Engagement Survey, scored have improved each time. Scores are showing favorable engagement by our healers.  NRHA Board Minutes 6 October 28, 2019 Mr. Sherman provided an update on the Optum Admissions Status Reports in process with CMS Rules. B. Mr. Manfredo presented for approval two capital items totaling $2,878,230: a. Laparoscopic Tower Systesm - $2,604,230 b. HIT Equipment for standardizing clinic hardware and equipment - $274,000 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request, cost $2,878,230 as recommended by the Finance Committee. Dr. Kimpel seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Mr. Pipes, Mr. Sherman, Dr, Kimpel, Ms. Womack and Dr. Chambers. Agenda Item IX. Old Business Mr. Cubberley thanked everyone in the room and the entire staff for attending each of the Inspire Health meetings in the hospital and in the community. He encouraged everyone to attend the Norman City Council meeting on November 12th at 7pm. Agenda Item X. New Business Mr. Splitt asked the room if everyone had received their flu shots this season. Ms. White and Ms. Anderson were there to provide shots for anyone who needed one. Flu Shots will be administered during a break prior to the Executive Session. Agenda Item XI. Administrative Report Mr. Splitt reported he and the Executive team have presented the Inspire Health vision throughout the community over 105 times at various Community Forums, Ward Meetings and other group meetings. Healer Forums begin October 29th . There will be a Norman City Council Study Session the evening of October 29th . This session will provide an Inspire Health update for City Council Members. Mr. Manafredo provided an update on the planning side of Inspire Health. Selections have been made for the Architect & Engineering firm , Construction Manager and a national consultant to assist with our Behavioral Health planning. Mr. Splitt provided a DRAFT rendering drawn by an AGO Architecture that provides a visual concept for the proposed Porter Health Village.  NRH A Board Minutes 7 October 28, 20 I 9 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. Weber made a motion to adjourn into Executive Session. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Mr. Pipes, Dr. Kimpel, Ms. Womack, Dr. Chambers and Mr. Sherman. Ms. Wells, Ms. White, Ms. Anderson, Mr. Loftus, Mr. Kelley and Ms. Swanson left the meeting at 6:40pm. Flu shots were administered before the Executive Session began. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-3 Below. 1. Recommend New Provisional Medical Staff Appointments a. Danie Dittu, MD - Emergency Medicine b. Thomas Wolf, MD - Surgery c. Benjamin Bigbie, MD- Medicine d. Amy Manfredo, APRN-CNP - Pediatrics e. Micki Richardson, APRN-FNP - Emergency Medicine f. Morgan Gossen, PA-C - Surgery g. Tracye Fowler, APRN-FNP - Emergency Medicine h. Gordon Archibald , MD - Teleradiology i. Deborah Corson, MD - Teleradiology j . Tasneem Khimji, MD - Teleradiology 2. Recommend Advancement of Medical Staff from Provisional Status: a. Benjamin Collins, MD - Surgery b. Emily Benham, MD - Surgery c. Ronni Farris, MD - OB/GYN 3. Recommend Medical Staff Reappointments: a. Shelly Zimmerson, DO - Emergency Medicine b. James Bond, MD - Surgery c. Thomas Thurston, MD - Pediatrics d. Corey Ponder, MD - Surgery e. Blake Forcina, MD - Surgery Mr. Splitt, Mr. Manfredo, Mrs. Carter, Mr. Hopkins, Mrs. McGill, Mrs. Price, Mr. Ell, Mr. Neafcy, Dr. Mantooth and Dr. Jawed left the meeting at 7pm.  NRHA Board Mi nutes 8 October 28, 2019 C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Mr. Sherman made a motion to adjourn out of Executive Session and return to regular session. Dr. Kimpel seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Dr. Kimpel, Dr. Chambers, Ms. Womack, Mr. Pipes 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 XI I B 1-3. ACTION TAKEN: Dr. Anwar 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. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Anwar, Dr. Kimpel, Dr. Chambers, Ms. Womack, Mr. Pipes and Mr. Sherman. E. Proposed Vote to Approve or Reject the Resolution for Land Owned by the City of Norman on Porter Campus ACTION TAKEN: Dr. Kimpel made a motion to Approve the Resolution for Land Owned by the City of Norman on the Porter Campus. Mr. Sherman seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Mr. Pipes, Dr. Kimpel, Ms. Womack, Dr. Chambers and Mr. Sherman. / F. Proposed Vote to Approve or Reject the Resolution for Land located at 2201-2251- 2281 36th Avenue NW in Norman ACTION TAKEN: Mr. Pipes made a motion to Approve the Resolution to Purchase Land located at 2201-2251 -2281 36 th Avenue NW in Norman. Dr. Kimpel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Mr. Pipes, Dr. Kimpel, Ms. Womack, Dr. Chambers and Mr. Sherman. G. CEO Evaluation  NRHA Board Minutes 9 October 28, 2019 ACTION TAKEN: Mr. Pipes made a motion to accept the CEO Evaluation as presented . Dr. Weber seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Mr. Pipes, Dr. Kimpel, Ms. Womack, Dr. Chambers and Mr. Sherman. Agenda Item XIII. Board Open Discussion A. Calendar Review The dates for the 2020 Board meetings were reviewed. The May Board meeting date will be moved from the 25 th for Memorial Day to the 18th • The dates will be voted on in November. ACTION TAKEN: None, Information Only. B. Board Self-Assessment The Board reviewed the Board Self-Assessment results and discussed the comments, goals and educational topics raised by the Trustees. ACTION TAKEN: None, Information Only. Agenda Item XIV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn the meeting at 7:25p.m. Mr. Pipes seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Anwar, Dr. Weber, Mr. Pipes, Dr. Kimpel, Ms. Womack, Dr. Chambers and Mr. Sherman. Tom Sherman, Vice-Chair/Secretary