Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting December 16, 2019 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, December 16, 2019, at 5:30 p.m. , in the Norman Regional Hospital Board Room. The meeting Agenda was posted December 12, 2019 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chairman 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 Meegan Carter, VP Population Health & Wellness Dr. Robin Mantooth, MD Emergency Department Kelley Wells, Director Planning & Communications Larry Harden, Administrative Director Compliance Danny Kelley, Administrative Director HIT Teresa Brown, Strategic Planning Specialist Bryce Ell, Administrative Fellow Jan Emmons, Director Emergency Department Jenny Anderson, Administrative Director Quality & Performance Lisa White, Manager Performance Improvement & Medical Staff Services Annette Troxell, Nurse Manager Labor, Delivery & Recovery Mari Newcomer, Nurse Manager Women's & Children's Health Tonya Faires, Nurse Manager New Born Transition Team Van McKnight, Director Patient Care Service CVICU Susie Graves, Director Patent Care Services Labor Delivery & Recovery Jeff Neff, Manager Cardiopulmonary Services Rusty Kubitscheck, Respiratory Therapist Cardiopulmonary Jamie Fuller, Coordinator Medical Staff Services Amanda Jessie, Specialist Credentials Medical Staff Services Members Absent: Muhammad Anwar, MD  N RH A Board Minu tes 2 November 25 , 2019 Joan Kemmet-Greenleaf Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the December 16, 2019, Norman Regional Hospital Authority meeting to order at 5:34 p.m. Mr. Splitt thanked Amanda Jones, Director Accommodation Services Food and Nutrition, Executive Chef Ben Robinett and his staff Vanessa Tiger and Jan Kenniston for the work they have done all year and especially during the month of December. They have prepared and served meals for holiday catering, the Christmas meals served to our Healers (both on and off the campus) and the other special requests that come with the holiday season . They performed exceedingly well! Agenda Item II. Introduction and Recognition of Outstanding Healers A. January 2020 Healer of the Month - Rusty Kubitscheck , Respiratory Therapist, Cardiopulmonary Services, introduced by Jeff Neff, Manager Cardiopulmonary Services. Mr. Cubberley introduced Mr. Neff who presented Mr. Kubitscheck as the Outstanding Healer for January 2020. Mr. Neff announced Mr. Kubitscheck has been a therapist for 22 years, 4 of those being at Norman Regional. He is one of our "go-to" NICU/Pediatric Specialists. Mr. Neff read a few comments from coworkers and patients: "Thank you for escorting a pediatric patient transport to OU Medcine." "Thanks for your help preserving our newborn daughter's life. Your skill, professionalism and friendless during our emergent delivery and subsequent NCIU stay shown thru. " Thanks for your training in NICU" "Thank you for all your help in training and deliveries. You are a Rock Star for always going well above and beyond ." He is one of our go to people, always assisting with new healers and we are very happy to have him . Mr. Kubitscheck thanked everyone for the honor. Mr. Cubberley congratulated and thanked Mr. Kubitscheck 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. Neff, Mr. Kubitscheck, Ms. Jones, Mr. Robinett, Ms. Tiger and Ms. Kenniston left the meeting at 5:39pm. B. Oklahoma Hospital Association Spirit Award winner Susie Graves, Director of Patient Care Services Labor, Delivery and Recovery presented by Brittni McGill, CNO. Ms. McGill announced the Oklahoma Hospital Association award, the Spirit of  N RHA Board Minutes 3 November 25, 2019 Legacy Award, was given to Ms. Susie Graves, Director of Patient Care Services Labor, Delivery and Recovery. Ms. Graves has worked for Norman Regional for over 40 years. The criteria for this award require nominees to: • Be exceptional individuals in the hospital community by exemplary leadership • Dedication to significantly enhance patient care within their organization and communities • Be the heart and soul of the organization • Live the values and the mission of the organization thru attitude, comm itment and personal values • Exemplify the organizations history by inspiring their colleagues and encouraging new employees to do the same Ms. Graves thanked everyone. She stated this means more to her than she could ever express. Ms. Graves, Ms. Newcomer, Ms. Faires, Ms. Troxell and Mr. McKnight left the meeting at 5:41pm. C. Recognition of Dr. Robin Mantooth, for her service as Chief of Staff presented by Dr. Aaron Boyd, Chief Medical Officer. Dr. Boyd announced he and Dr. Mantooth began her journey as Chief of Staff 24 months ago. Dr. Mantooth has always handled everything with the patient first and with the highest quality and upmost integrity. He thanked her for her hard work through some of the toughest times. We all look forward to many more years of working together to improve the health and wellness of our patients. Dr. Mantooth thanked everyone for the honor. Ms. Jessie and Ms. Fuller left the meeting at 5:43pm. Agenda Item Ill. Emergency Department Services Update Dr. Mantooth provided an update on the Emergency Department (ED). NRHS is approximately 5 months into staffing the ED. Overall the transition has gone very well. The healers who stayed on are very pleased with the NRHS employment model. Many of these healers have worked here a very long time and plan to be here for our patents for many more years. Dr. Mantooth reported they are still seeking to fill a few positions in some areas but have healers potentially transferring to NRHS over the next 6 months. Great providers are wanting to work here. Dr. Boyd added this has helped our Residency Program tremendously. Ms. Emmons commented the nursing staff is also encouraged with the changes and the level of engagement across the department. The atmosphere of teamwork is very positive. Ms. Emmons left the meeting at 5:54pm.  NRH A Board Minutes 4 November 25, 20 19 Agenda Item IV. Approval of November 2019, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the November 25, 2019, Board Meeting Minutes. ACTION TAKEN: Dr. Kimpel made the motion to approve the November 25, 2019 Board Meeting Minutes as presented. Dr. Weber seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Dr. Kimpel , Mr. Pipes, Ms. Womack, Dr. Chambers and Mr. Sherman. Agenda Item V. Performance Updates Ms. Anderson provided information on the National Early Warning System (NEWS). The Agency for Healthcare Research and Quality Explains that "Although not every complication of medical care is preventable, health care systems should be able to rapidly identify and treat complications when they occur." NRHS has specific interventions in place to respond quickly to prevent Failure to Rescue: • Rapid response team called MIT (Medical Intervention Team) • Code Stroke • Code STEMI • National Early Warning Signs (NEWS) The goal is to decrease cardiac arrest outside of the ICE, thereby reducing overall mortality. Expectations of implementing this criteria were realized in: • An increase in MIT calls (166% increase) • At risk patients will be recognized earlier and transferred to the ICU • Code Blue calls outside the ICU declined. (37% decrease) • Overall Mortality (4.6% decrease) Agenda Item VI. Approval of the November 2019 Norman Regional Health System Financial Statements Mr. Hopkins presented the November 2019 Norman Regional Health System Financial report - November 2019 Financial Performance • Gross Revenues .... ................ ... ... .... .. .. (Budget $184,981 ,587) ............ $186,075,614 • Net Patient Revenue .. ................. .... ....... (Budget $40,225,059) .............. $40,190,148 • Total Operating Expenses ......... .. .......... (Budget $39,492,444) ........... .. . $39,784,023 • Total Operating Revenues ........... .. ......... (Budget $40,647,876) .............. $40,667,504 • Operating Income .... ... .... ..................... .... (Budget $1 ,155,432) ................... $883,481 • Non-Operating Revenues (Expenses) ........ (Budget $154,307) .............. ($2,147,852) • Excess Revenues over Expenses .... ........ (Budget $1,309,739) .............. ($3,031,334)  NRHA Board Minutes 5 November 25 , 2019 Year-to-Date • Operating Income ....... ............... .............. (Budget $6,007,658) .... .. ... ....... $3,397,740 • Non-Operating Revenues (Expenses) ..... (Budget $4,771,535) .............. ($7,176,495) • Excess Revenues over Expenses .......... (Budget $10,779,193) .............. $10,574,236 • Accounts Receivable Days .... .................. ...... (Budget 43 Days) ...... ............ 45.5 Days • Days Cash on Hand ......... ..................... .... ... .. ............ ....... ........ .... 201.7 Days ACTION TAKEN: Dr. Weber motioned to approve the November 2019 NRHS Financial Statements. Mr. Pipes seconded the motion. November financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Dr. Kimpel, Mr. Pipes, Ms. Womack, Dr. Chambers and Mr. Sherman. Agenda Item VII. Medical Staff Dr. Mantooth presented the Medical Staff report. She stated the MEC met on December 11, 2019. Old Business: • Dr. Mantooth reported TigerConnect is now being used for secure provider communications between Providers. New Business: • Discussed Physician Assistant privileges. It was agreed to send back to the Credentials Committee for further review. Department Reports: • Behavior Medicine Department - Dr. Jawed reported the department reviewed the Inspire Health plans for behavioral health. He reviewed the upcoming changes at the Norman Regional Moore Senior Counseling Center. • Cardiovascular Medicine - Dr. Gautam reported they reviewed privileges and voted for approval of the new program Trans Aortic Valve Replacement (TAVR). Dr. Gautam will continue as the chair. • Emergency Department - Dr. Porter reported discussion of extending privileges to Internal Residents for moonlighting at the Porter Campus under supervision. The privilege list will be reviewed as discussion continues. They also discussed streamlining order sets and nursing staff retention . • Hospital Medicine - Dr. Whalen reported they discussed call schedule, secure texting and quality measures. • HQPSC - Dr. Tedesco announced iCOUGH is preparing a Deep Dive into this initiative for smaller more achievable goals. • OB/GYN - Dr. Parker reported they discussed clear liquids during labor and new orders sets. • Pharmacy & Therapeutics - Dr. Carter reported in order to have a new drug approved, the individual must attend the meeting to support its approval.  NRH A Board Minutes 6 November 25, 2019 • Physician Advisory Committee - Dr. Jawed reported updates on Meditech and Beta Blocker documentation. • Radiology - Dr. Narotam reported they discussed procedure orders and the physician assistant position. • Residency Update - Dr. Cody reported there were 650 applicants for the residency program, conducted 90 interviews for 6 positions. Agenda Item VIII. Patient Quality & Safety Committee Ms. Anderson reported for the Patient Strategic Planning Committee which met on December 2 nd . • Approved meeting dates for 2020. • 2 presentations: o Perinatal group - discussed each of their services lines as they prepare for The Joint Commission Certification. o NEWS Presentation - shared tonight by Ms. Anderson . • Focusing on 3 specific areas within the hospitals: o Sepsis Mortality - reviewed the PDSA. Noted severe sepsis was on the rise while septic shock was trending down. The committee put together a team to review all Sepsis coding and documentation opportunities as well as clinical care opportunities to help improve this trend . Severe Sepsis Mortaility is rending down as of 4 th Quarter 2019. o Hospital Acquired Infections (HAI) - MRSA is trending up over last year. They are revisiting with Xenex the standards and reviewing procedures. There were 7 CDif cases, down this calendar year from last year's total of 42. o Overall hospital Inpatient Mortality o iCOUGH - taking each tenant as an individual PDSA. • Mr. Harden presented statistics on falls which are improving and trending in the right direction. Agenda Item IX. Finance Committee A. Report from the December 16, 2019 Finance Committee Tom Sherman reported the Bond is complete and was very successful. The sale was oversubscribed by 1000%; which resulted in favorable changes to the expected rate. B. Mr. Manfredo presented for approval capital items totaling $1 ,272,029: a. Roof Repairs at Porter - $450,000 b. Patient Room Recliners - $83,995 c. Hip Sets to support Dr. Knutson 's new volumes - $97,330 d. LOGIQ E10 Ultrasound units - $229,467 e. RV & Trailer from OSOi Foundation, removal and reapply wraps - $81 ,800 f. 2 SUV's & Truck - $115,017  NRHA Board Minutes 7 Novem ber 25, 2019 g. API Healthcare System Phase 2 - $214,421 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request, cost $1,272,029 as recommended by the Finance Committee. Dr. Kimpel seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Mr. Sherman, Dr, Kimpel, Ms. Womack and Dr. Chambers. C. Proposed Vote to Approve or Disapprove the Resolution to Change Master and Bond Trustee ACTION TAKEN: Mr. Cubberley stated this resolution is tabled to clarify language within the resolution. D. Proposed Vote to approve or Disapprove the Resolution for Asset Acquisition of Oklahoma Sports & Orthopedic Institute, P.L.L.C. and Greater Norman Surgery Center, L.L.C. ACTION TAKEN: Dr. Weber made a motion to approve the Resolution for Asset Acquisition of Oklahoma Sports & Orthopedic Institute, P.L.L.C. and Greater Norman Surgery Center, L.L.C. as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Mr. Sherman, Dr, Kimpel, Ms. Womack and Dr. Chambers. Agenda Item X. Old Business Mr. Splitt reported the Gallup Q12+ Healer Engagement survey opened December 3rd and closes on December 17th . Our goal is to reach 70% participation rate. We are at 68% as of today. Three new questions were added to the survey. Those questions focus upon accountability; accountability for leadership to act on the feedback provided by our Healers. We will share those results once the results are available. Agenda Item XI. New Business No New Business items. Agenda Item XII. Administrative Report Mr. Splitt reminded the board and attendees this year marks our 10th year at the HealthPlex. This past weekend, we celebrated the anniversary with a "Cookies with Santa" event providing crafting activities, cookies, photos with Santa and visits with 2 therapy dogs. About 300 children were in attendance. The children also were able to make a Christmas card that will be handed out to patients on Christmas day.  N RH A Board Minutes 8 November 25. 2019 Mr. Manfredo provided an Inspire Health update. The architects will be back on site December 17th . A report out and feedback session will be held during that time. Super User groups will begin meeting this week to look over designs and provide feedback. Physicians have been invited to the session on Wednesday evening to also review and provide input. Mr. Splitt reported conversations with the City of Norman have begun regarding the purchase of the city owned property located on the Porter campus. Ms. Price announced NRHS received 4 Women's Choice Awards in America 's Best Hospitals in the categories of Heart, Stroke, Orthopedics and Bariatric Surgery. These awards are based on quality metrics and patents experience. We are proud to share the recognition in January 2020. Mr. Splitt announced he is looking forward to Dr. Jawed's leadership as Chief of Staff knowing he has been very well prepared by his predecessor, Dr. Mantooth. He thanked Dr. Mantooth for her leadership, compassion, courage, mentorship and engagement in patient care during the past 2 years. Agenda Item XIII. Proposed Executive Session A. Proposed Vote to Convene an Executive Session Pursuant to 25 Okla. Stat. Section 307 8.4. to Discuss with Legal Counsel Pending Internal Peer Review/Credentialing Investigation Regarding the Medical Staff Members/Applicants Listed Below; ACTION TAKEN: Mr. Sherman made a motion to adjourn into Executive Session . Dr. Weber seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Kimpel , Ms. Womack, Dr. Chambers and Mr. Sherman. Ms. Wells, Ms. Anderson , Ms. White and Mr. Kelley left the meeting at 6:51pm . 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. F. Clark Sauls, MD - Emergency Medicine b. Erin Powers-Kinney, DO - Emergency Medicine c. Megan Meyer-Hanner, DO - Emergency Medicine d. Rhiannon Baker, APRN-FNP - Pediatrics e. Veronica Ruvo, DO - Teleradiology f. Stanley Smith, MD - Teleradiology g. Alexander Serra, MD - Teleradiology h. Shannon St. Clair, MD - Teleradiology i. Shawn Stone, MD - Teleradiology j. Allison Summers, MD - Teleradiology 2. Recommend Advancement of Medical Staff from Provisional Status: NRHA Board Minutes 9 November 25, 2019 a. Mohammad Farukhi, MD - Surgery b. Laurel Jordan, DO - OB/GYN c. Stephanie Leiker, RNFA - Allied Health - Surgery 3. Recommend Medical Staff Reappointments: a. David Miller, DDS - Surgery b. Joel Razook, MD - Surgery c. Brandon Pierson, MD - Surgery d. Ronnie Keith, DO - Surgery e. Joe Voto, MD -Anesthesia f. Mark Lau , MD -Anesthesia g. Andrew Crabbe, MD - Anesthesia h. Mark Fine, MD -Anesthesia i. Jennifer Hunter, MD - Pediatrics j. Michael Kalcich, MD - Emergency Medicine k. Theodore Boehm , MD - Family Medicine I. Steven Cox, MD - Family Medicine m.Kelley Lobb, MD - Medicine n. Tracy Ratzlaff, RNFA- Surgery o. Jennifer Fleck, APRN-CRNA - Anesthesia p. Daniel Leiker, APRN-CRNA - Anesthesia q. Amber Moser, APRN-CRNA - Anesthesia r. Tina Stinson, PA-C - Pediatrics s. Glen Diaz, APRN-CNP - Pediatrics 4. Recommended Advancement to Active Staff and Renewal of Clinical Privileges: a. Jeff Bivens, PA-C - Radiology Physician Assistant C. 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. Kimpel seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, 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 XII B 1-4. ACTION TAKEN : Mr. Sherman motioned to approve credentialing items as recommended by Medical Executive Committee and Credentials  N RH A Board Minu tes 10 November 25 , 20 19 Committee of all referenced Medical Staff members listed in XII B 1-4. Dr. Kimpel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Kimpel, Dr. Chambers, Ms. Womack , Mr. Pipes and Mr. Sherman. Agenda Item XIV. Board Open Discussion Mrs. Womack reported a fellow church member was treated at the HealthPlex over the weekend and was very impressed with her care and the Healers addressing her concerns. She thanked the healers involved with her care with candy. Mrs. Womack reported questions she had heard in regard to land ownership for the Porter campus. Ms. Price stated NRHS is working with the City of Norman and the Norman Transcript to ensure information continues to be accurately communicated to the community. Agenda Item XV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn the meeting at 6:58p.m. Mr. Pipes seconded , and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Kimpel, Ms. Womack, Dr. Chambers and Mr. Sherman. Res~ : y ubmitted, Tom Sherman, Vice-Chair/Secretary