Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting June 22, 2020 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, June 22, 2020 at 5:30p.m. via WebEx. The meeting Agenda was posted June 18, 2020 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present via WebEx: Doug Cubberley, Chairman Jerome (Jerry) Weber, Ph.D. Diane Chambers, MD Kevin Pipes Muhammad Anwar, MD Joan Kemmet-Greenleaf Tom Sherman Mary Womack Others Present Via Webex: Richie Splitt, President & CEO John Manfredo, COO Paula Price, VP Strategy & Growth Ken Hopkins, CFO Aaron Boyd, MD, Chief Medical Officer Steven Sheriff, Network Infrastructure Architect Dr. Farhan Jawed, MD, Chief of Medical Staff Dr. Joe Voto, MD, Chief of Medical Staff-elect Lisa White, Manager Performance Improvement & Medical Staff Services Larry Harden, Administrative Director, Compliance Jan Emmons, Director Emergency Services Karen Rieger, Attorney, Crowe & Dunlevy Neal Risenhover, Supervisor Media Services Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the June 22, 2020, Norman Regional Hospital Authority meeting to order at 5:34p.m. Mr. Cubberley reviewed the rules for the WebEx meeting participation. Claudia Todd took roll call. Agenda Item II. Consent Items  NRHA Board Minutes 2 June 22, 2020 A. July 2020 Healer of the Month – Janet Sherman, Radiologic Technologist, Imaging B. May 18, 2020 NRHA Board Meeting Minutes ACTION TAKEN: Dr. Weber motioned to approve Consent Items A-B. Mr. Pipes seconded the motion. Consent Items were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mrs. Womack, Mr. Pipes and Mr. Sherman. Agenda Item III. Board Education: EMSStat Update Ms. Emmons, Director Emergency Services presented the Annual EMSStat Update. EMSStat employs over 100 dedicated Paramedic and EMT Healers and is the 3rd largest EMS service in the state. They provide services to Oklahomans in Norman, Moore and the immediate surrounding areas, which is just over 400 square miles. The fleet of 21 ambulances provide services including intercampus transfers, mutual aid to neighboring communities, availability at public events and a continuum of care when transporting to other facilities. Ms. Emmons reported the Five Year Call volume increased from 16,757 in 2014 to 27,159 in 2019 and the Five Year Intercampus volume increased from 2,631 in 2014 to 4,655 in 2019. Ms. Emmons provided information on awards and recognitions:  Awarded the 2019 AHA Mission: Lifeline EMS Gold Plus (STEMI)  HealthPlex Chest Pain Center Accreditation  Porter Stroke Center Accreditation  Recognized by OSHD for Trauma Care  Chief Eddie Sims is a leader in State EMS Regulations  Beginning CAAS Accreditation journey Norman Regional’s EMSStat was approved to participate in the new CMS Emergency Triage, Treat and Transport (ET3) Program. This program allows EMS providers greater flexibility in treating & transporting Medicare patients to most appropriate care sites, providing person centered care, appropriate utilization of services and efficiencies. Agenda Item IV. Performance Update Ms. White, Manager Performance Improvement & Medical Staff Services presented information on the FY2021 Quality & Performance Improvement Plan and the FY2021 Patient Safety Plan. Ms. White shared the Patient Safety Plan Goals will focus on:  Service Excellence: Establish a structure to obtain feedback from patients about NRHS patient safety performance.  Operational Excellence: Employ systematic and regular assessment of resource  NRHA Board Minutes 3 June 22, 2020 allocations to key systems to ensure performance in patient safety.  Clinical Excellence: Define and improve the culture of safety at NRHS, providing feedback to all levels of the organization and undertaking interventions that generate improvements to reduce patient harm.  Team Excellence: Establish a proactive and systematic approach to developing team-based care. Ms. White reported the Quality & Performance Improvement Plan set measurable goals in the following areas:  Patient Experience  Perinatal  Code Blue  Sepsis  AMI Mortality  Restraint Reduction  ICOUGH  Medical Staff Documentation  BMS  Quality Reporting Agenda Item V. Approval of the May 2020 Norman Regional Health System Financial Statements Mr. Hopkins presented the May 2020 Norman Regional Health System Financial report: May 2020 Financial Performance  Gross Revenues .................................. (Budget $188,292,800)............ $158,240,253  Net Patient Revenue .............................. (Budget $40,832,374).............. $34,914,758  Total Operating Expenses ..................... (Budget $40,619,497).............. $38,505,961  Total Operating Revenues ...................... (Budget $41,255,191).............. $35,244,505  Operating Income ....................................... (Budget $635,694).............. ($3,261,456)  Non-Operating Revenues (Expenses) ..... (Budget $1,154,307)................ $6,160,020  Excess Revenues over Expenses ............ (Budget $1,790,001)................ $2,777,381 Year-to-Date  Operating Income .................................. (Budget $11,036,861)............ ($19,381,980)  Non-Operating Revenues (Expenses) ... (Budget $11,697,377).............. ($6,085,794)  Excess Revenues over Expenses .......... (Budget $22,734,238).............. ($3,109,499)  Accounts Receivable Days ............................ (Budget 43 Days).................. 58.9 Days  Days Cash on Hand…………………………………………………………….186.8 Days ACTION TAKEN: Dr. Weber motioned to approve the May 2020 NRHS Financial Statements. Ms. Greenleaf seconded the motion. May Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Agenda Item VI. Patient Quality & Safety Ms. Greenleaf reported the committee met June 1st. The FY2021 Quality & Performance Improvement Plan and the FY2021 Patient Safety Plan were the main discussion for the meeting this month.  NRHA Board Minutes 4 June 22, 2020 A. Proposed Vote to Approve or Disapprove the FY2021 Quality & Performance Improvement Plan as Recommended by the Patient Quality & Safety Committee ACTION TAKEN: Dr. Weber made a motion to approve the FY2021 Quality & Performance Improvement Plan as recommended. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. B. Proposed Vote to Approve or Disapprove the FY2021 Patient Safety Plan as Recommended by the Patient Quality & Safety Committee ACTION TAKEN: Dr. Weber made a motion to approve the FY2021 Patient Safety Plan as recommended. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Agenda Item VII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on June 10, 2020. New Business:  COVID-19 – Open discussion was held covering COVID-19 testing, the City of Norman’s reopening phases, visitation updates and Emergency Department numbers. Department Reports:  Reports were provided by Cardiovascular Medicine, Emergency Medicine, Hospital Medicine, Hospital Quality & Patient Safety Committee (HQPSC), Pediatrics, Pharmacy & Therapeutics, Radiology, Residency Program, and Medical Staff. Administrative Reports:  Ms. McGill reported the virtual waiting room has launched. To assist patients with family members who are out of town, or unable to visit their loved ones. A new Nursing professional development program will begin July 1st for our nurse healers.  Ms. Carter provided a physician recruitment update.  Mr. Manfredo provided an update on the search for a Director of Surgery. A site plan was selected for the HealthPlex and the freestanding ED (FSED) in southeast Norman. The FSED will be presented to the Norman City Council for final approval on July 28th.  Mr. Splitt reported the Gallup Healer Engagement Survey will be open for healers from June 16th - June 30th. The 12 basic questions will help determine healer engagement and improving the overall workplace experience. Seven additional questions have been added, and four are  NRHA Board Minutes 5 June 22, 2020 specifically related to NRHS’s the COVID-19 response. Mr. Splitt reported voters will be able to decide on Medicaid expansion with State Question 802 on the June 30th ballot. Agenda Item VIII. Finance Committee A. Report from the June 15, 2020 Finance Committee Mr. Sherman reported committee discussions focused mainly on the FY2021 Budget preparations and the financial impact of COVID-19 on the end of year performance. B. Recommend Approval of FY2021 Budget ACTION TAKEN: Dr. Weber made a motion to approve the FY2021 Budget as Recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. C. Mr. Manfredo presented for approval two capital request items totaling $436,965: a. Digital X-ray Unit: $69,815 b. HP Servers: $367,150 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $436,965 as recommended by the Finance Committee. Dr. Anwar seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. D. Recommend Approval of the Retirement Plan Charter ACTION TAKEN: Dr. Weber made a motion to approve the Retirement Plan Charter as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. E. Recommend Approval of the Retirement Plan Amendment ACTION TAKEN: Dr. Weber made a motion to approve the Retirement Plan Amendment as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack.  NRHA Board Minutes 6 June 22, 2020 Agenda Item IX. Old Business None Agenda Item X. New Business Mr. Cubberley acknowledged the events taking place in communities across the nation calling for a renewed focus on equality and justice for all individuals. Norman Regional has always strived to be a leader in the industry for diversity and inclusion for our patients and healers. As we continue to practice diversity and inclusion, the NRHS Diversity and Inclusion committee will meet to review existing policies and practices remain up-to-date and appropriate. Mr. Cubberley reported a new bylaws sub-committee will begin reviewing NRHA Board of Trustees Bylaws. The goal is to thoroughly access and amend existing bylaws. After review, the committee will present all proposed changes to the full Board at an upcoming meeting for final approval. Agenda Item XI. Administrative Report Mr. Splitt reported the following:  SQ 802 will be on the State ballot on June 30th. Similar to the State Chamber, the Norman Chamber of Commerce has prepared a letter in support of the health and economic benefit of the measure.  Dr. Boyd will represent NRHS at the virtual Reboot Norman Business Meeting on Thursday, June 25th.  The annual HIPAA Compliance test from Board Trustees is due. Please turn in to Mr. Harden or Ms. Todd.  The Gallup Healer Engagement survey is underway through June 30 th. The survey includes 19 total questions with 4 of them related to our COVID-19 response.  Administrative Fellow Adrian Francisco, OU MHA graduate, starts July 6th.  As part of OU’s return to work requirements, NRHS will conduct a pilot program to test for COVID-19. 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. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mr. Sherman and Ms. Womack. NRHA Board Minutes 7 June 22, 2020 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. Ernest Tako, MD, Active Staff – OB/GYN b. Chelsea Rommel, DO, Active Staff – Hospital Medicine c. Eric Sparks, DO, Active Staff – Emergency Medicine d. Max Cieminski, DO, Active Staff – Emergency Medicine e. Amanda Lowry, APRN-CNP, Allied Health Staff – Pediatrics f. Janet Kuo, MD, Teleradiology – Teleradiology 2. Recommend Medical Staff Reappointments: a. Kathryn Cook, MD, Active Staff – Pediatric Hospitalist b. Reba Beard, MD, Active Staff – Pediatrics c. Lubna Mirza, MD, Active Staff – Medicine d. Charles Lackey, MD, Active Staff – Medicine e. Nigam Sheth, MD, Active Staff – Anesthesia f. Jeffrey Crook, MD, Active Staff – Cardiovascular Medicine g. Muhammad Anwar, MD, Active Staff – Cardiovascular Medicine h. James Thorp, MD, Active Staff – Radiology i. Robert McArthur, MD, Consulting Staff – Medicine j. Jonathan Bryan, DO, Associate Staff – Medicine k. John Krodel, MD, Associate Staff – Medicine l. Brittany Wicks, APRN-FNP, Allied Health Staff – Hospital Medicine 3. Recommend Advancement of Medical Staff from Provisional Status: a. Brittney Roberts, PA-C – Surgery b. Kristina Valentino, APRN-CNP – Pediatrics 4. Recommend Medical Staff Reappointments – Ortho Central m. Jennifer Fleck, APRN-CRNA n. Daniel Valentino, APRN-CRNA 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. Anwar seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Dr. Weber, Dr. Chambers, Mr. Pipes, Dr. Anwar, Ms. Greenleaf, Mr. Sherman and Ms. Womack. 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  NRHA Board Minutes 8 June 22, 2020 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. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Chambers, Mr. Pipes, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Dr. Anwar abstained. Agenda Item XIII. Board Open Discussion None Agenda Item XIV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn the meeting at 7:40p.m. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Pipes, Dr. Chambers and Dr. Anwar, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary