Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting July 27, 2020 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, July 27, 2020 at 5:30p.m. via WebEx. The meeting Agenda was posted July 23, 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 Muhammad Anwar, MD Joan Kemmet-Greenleaf Tom Sherman Mary Womack James Chappel Others Present Via Webex: Richie Splitt, President & CEO John Manfredo, COO Paula Price, VP Strategy & Growth Meegan Carter, VP Population Health & Wellness Brittni McGill, CNO Ken Hopkins, CFO Aaron Boyd, MD, Chief Medical Officer Adrian Francisco, Administrative Fellow Steven Sheriff, Network Infrastructure Architect Dr. Farhan Jawed, MD, Chief of Medical Staff Dr. Joe Voto, MD, Chief of Medical Staff-elect Jenny Anderson, Administrative Director Quality & Performance Larry Harden, Administrative Director, Compliance Danny Kelley, Administrative Director, HIT Jan Emmons, Director Emergency Services Karen Rieger, Attorney, Crowe & Dunlevy Neal Risenhover, Supervisor Media Services Kelly Wells, Director Planning & Communications Karen Rieger, Attorney, Crowe & Dunlevy Lianna Gray, Mindy Wood, Norman Transcript Members Absent: Kevin Pipes Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 June 22, 2020 Agenda Item I. Meeting Called to Order Mr. Cubberley called the July 27, 2020, Norman Regional Hospital Authority meeting to order at 5:35p.m. Mr. Cubberley reviewed the rules for the WebEx meeting participation. Claudia Todd took roll call. Agenda Item II. Consent Items A. August 2020 Healer of the Month – Melissa Whitaker, Technologist, Imaging Services B. June 22, 2020 NRHA Board Meeting Minutes ACTION TAKEN: Dr. Anwar motioned to approve Consent Items A-B. Dr. Weber 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. Chappel and Mr. Sherman. Agenda Item III. Board Education: Community Benefit Ms. Paula Price, Vice President Strategy & Growth presented the FY2020 Year in Review. Items to note:  In the Community and By The Numbers- o 18,591 Telehealth Visits o 390,522 Community Support Encounters o $2,326,966 Community Contributions  COVID-19 Care Coordination (From March till the end of June) o 3,377 Hotline calls (24/7) o 3,264 mobile clinic visits o 16,795 COVID-19 tests o 2,300 COVID-19 Antibody tests  Leadership Involvement: o 494 hours of service to civic and social board of directors o 1,875 hours of service to 44 civic, social and faith-based community groups o 1,723 hours of service to 52 professional associations and boards  Awards for 2019-2020 o Women’s 2020 Choice Awards – Bariatric Surgery, Heart Care, Orthopedics and Stroke Center o Journal Record’s Most Admired CEO and CFO o Journal Record’s Health Care Hero - Non-Profit CEO o 2019 Certified Healthy Business Excellence Certification o Leapfrog Hospital Safety Grade “A” o Behavior Health Quality Improvement Award:  1 Gold Award & 3 Silver Awards for Depression Screening  8 Gold Awards & 2 Silver Awards in Alcohol Screening  NRHA Board Minutes 3 June 22, 2020 o Cribs for Kids Silver Safe Sleep Leader o American Heart Association Gold Elite Plus for Stroke, Gold Plus Level EMS Award, Gold Plus Receiving Quality Achievements Award and Gold Non-STEMI (Non-ST-elevation myocardial infarction) o Norman Chamber Large Business of the Year 2019 o Norman Public Schools – 2020 Public Education Ambassador of the Year Award o 2020 National Lab of the Year Runner Up o 2019 Nationally Accredited Cardiopulmonary Rehab Program o Action Registry Gold Performance Achievement Award Agenda Item IV. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented a few Quality of Care Achievements from the past year.  Service Excellence: Inpatient HCAHPS Clean & Quiet questions are averaging above the 65th percentile.  Patient Experience: NR Moore Emergency Department achieved the 95th Percentile in the Would Recommend Rating category. This information is provided by the NRC Real Time survey given to patients after visiting our facilities.  Certified by The Joint Commission Stroke Certification Program as an Advanced Primary Stroke Center  Stroke Gold Plus Quality Achievement Award, the Stroke Honor Roll Elite Award and the Diabetes Award for 2020 from the American Heart Association (AHA).  Women’s Choice Award Winner for Stroke Center in 2017, 2018 & 2020.  EMS Gold Plus Award from the AHA. Ms. Anderson presented an update on Patient Safety:  Journey to Just Culture – Under the Just Culture concept, safety is promoted by facilitating open communication within an organization in addition to a system of accountability for safe behavioral choices among staff. Just Culture is about holding human beings accountable, but it is also about digging deeper and looking at the system to determine why a particular error occurred. The official launch of the program to start very soon with the goal of improving processes in the following areas: o Accountability o Transparency o Responsive o Communication o See Something Say Something o Follow Safe Practices Agenda Item V. Approval of the June 2020 Norman Regional Health System Financial Statements Mr. Hopkins presented the June 2020 Norman Regional Health System Financial report:  NRHA Board Minutes 4 June 22, 2020 June 2020 Financial Performance  Gross Revenues .................................. (Budget $185,752,880)............ $198,568,908  Net Patient Revenue .............................. (Budget $40,614,364).............. $45,943,024  Total Operating Expenses ..................... (Budget $39,742,153).............. $45,915,332  Total Operating Revenues ...................... (Budget $41,037,199).............. $46,314,792  Operating Income .................................... (Budget $1,295,046)................. ($399,460)  Non-Operating Revenues (Expenses) ..... (Budget $1,154,314)................ $4,945,689  Excess Revenues over Expenses ............ (Budget $5,345,150)................ $2,449,360 Year-to-Date  Operating Income .................................. (Budget $12,331,907)............ ($18,982,519)  Non-Operating Revenues (Expenses) ... (Budget $12,851,691)............ ($11,031,484)  Excess Revenues over Expenses .......... (Budget $25,183,598).............. ($2,235,651)  Accounts Receivable Days ............................ (Budget 43 Days).................. 48.5 Days  Days Cash on Hand…………………………………………………………….188.1 Days ACTION TAKEN: Dr. Weber motioned to approve the June 2020 NRHS Financial Statements. Ms. Greenleaf seconded the motion. June Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Agenda Item VI. Strategic Planning Committee Dr. Weber reported the committee met July 6th. Donna Avila, Director of Care Coordination presented an update on the Community Call Center’s Plan, Do, Study, Act (PDSA). Two problems had been identified: 50% off community calls received were hang ups due to no live person answering the calls and the call center was less than optimal in creating new patient appointments. The result of the PDSA provided a full time staff member to answer calls from 8-4:30pm and a return call policy for messages left after hours. Improvements have been noted. Ms. Sara Raney, Strategic Planning Specialist presented on Social determinants of Health and food distributions from the food pharmacy. Ms. Raney noted Cleveland County is slightly above the average rate (12.5%) for food insecurity. Patients who answer “yes” to any of the food insecurity questions during the patient intake conversation, received a Healthy Living Pantry Box at discharge. These pantry boxes contain shelf-stable food. Strategy & Growth is working to collaborate with the Regional Food Bank of Oklahoma, NRHS Food & Nutrition, Case Management, NRH Foundation and Volunteer Services to develop the inpatient “Food Pharmacy” when the diagnosis is chronic hunger. Next steps for the Food Pharmacy include applying grant funding, build a stronger partnership with the Regional Food Bank and launch the pilot program by the fall of 2020 at the Porter Campus. Mr. Brian Loftus, Business Planning Specialist presented market share data on Orthopedics, Gastro Intestinal (GI), Cardiovascular and Weight loss (Bariatric) Surgery.  NRHA Board Minutes 5 June 22, 2020 Ms. Sally Benn, Director Provider Development & Integration provided a FY21 provider recruitment update. Ms. Brittni McGill, CNO provided an update on COVID-19. She and Mr. Splitt participated in a COVID-19 Study Session with the Norman City Council. During the study session, they described these (Pandemic) times as the “No Normal” because nothing seems to be normal. They also answered questions and provided clarity regarding NRHS processes, hospitalizations, ICU beds and COVID-19 surge plans. Agenda Item VII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on July 8, 2020. New Business:  COVID-19: Open discussion was held covering COVID-19 testing, ICU/Surge plan, PPE supplies, the sterilization processes and the continuation of timely Emerging Infectious Disease (EID) Team updates.  Physician Satisfaction Survey – reviewed results. Department Reports:  Reports were provided by Emergency Medicine, Pediatric Hospitalists, Physician Advisory Committee, Radiology, Emergency Medicine Residency Program and Surgery. Administrative Reports:  Ms. McGill reported weekly EID emails are being shared with all staff.  Ms. Carter provided an update on the COVID Hotline. The call line is staffed 24 hours a day/7 days a week.  Mr. Manfredo reviewed the recent results from the Provider Satisfaction survey. He provided an update on Inspire Health.  Mr. Splitt announced the mask mandate passed by the City Council of Norman. NRHS will encourage mask wearing through a “gotmaskOK.org” Public Service campaign. It is designed to raise awareness, prevent community spread and will feature many healers from NRHS. Agenda Item VIII. Finance Committee A. Report from the July 20, 2020 Finance Committee Mr. Sherman reported committee discussions focused mainly on the FY2020 year-end reports. Mr. Harden provided a quarterly report from Risk Management. B. Mr. Manfredo presented for approval four capital request items totaling $2,265,837: a. 25 Patient Beds 9for Mother/Baby): $190,622 b. Unltrasound Machine: $75,000 c. PACS Workstation: $93,281  NRHA Board Minutes 6 June 22, 2020 d. MRI & C-Arm: $1,906,933 ACTION TAKEN: Ms. Greenleaf made a motion to approve the Capital Equipment Requests at a total cost of $2,265,837 as recommended by the Finance Committee. Ms. Womack seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Agenda Item IX. Old Business None Agenda Item X. New Business A. Proposed Vote to Approve or Disapprove the Resolution to Slow The Spread of COVID-19 ACTION TAKEN: Dr. Weber made a motion to approve the Resolution to Slow the Spread of COVID-19. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. B. Proposed Vote to Approve or Disapprove the Resolution to Uphold Diversity and Inclusion ACTION TAKEN: Dr. Weber made a motion to approve the Resolution to Uphold Diversity and Inclusion. Ms. Womack seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. C. Proposed Vote to Approve or Disapprove the Utilization Review Plan ACTION TAKEN: Dr. Weber made a motion to approve the Resolution to Uphold Diversity and Inclusion. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Agenda Item XI. Administrative Report Mr. Splitt presented information on COVID-19  Ms. McGill reported healers have kept up with the demands and needs presented with COVID-19. Implementing Flex plans and moving around supplies as needed to be responsive to the needs of our patients. Our Healer Support NRHA Board Minutes 7 June 22, 2020 Group was initiated to provide support for some of our front line healers involved in a heartrending patient care situation.  Ms. Carter reported the COVID hotline is operational 24 hour a day, 7 days a week and has received 3,377 calls since its inception in March. The mobile testing clinic established at the Southeast EMSStat facility is operational 5 days a week. The testing site provides symptomatic patients COVID-19 testing, PCR Lab tests, x-rays and hands on clinical assessment when needed by a nurse, while keeping them out of clinics and emergency rooms.  Mr. Splitt shared “No Normal” slides presented at City Council. We are encouraging patients to continue Social Distancing, but Stop Medical Distancing. Patients should not delay care when they can return safely to their healthcare provider(s) face-to-face or via Telehealth.  United Way Pacesetters campaign started July 27th. This year’s theme is “It’s a Beautiful Day to be a Giver”. We have established a very aggressive goal during this public health challenge.  Jenny Anderson and Brittni McGill have been asked to participate at a Vizient National Quality Leadership Series (NQLS). Their presentation is titled “Developing and Implementing a High Reliability and Performance Improvement”. The presentation will focus on NRHS’s journey from the NEWs Walls, linkage of our strategic plans and will tie back to healer engagement throughout every level of the organization.  The Governor’s COVID Surge Plan will be announced in a press conference next week. Norman Regional will join 5 other local hospitals in the greater metropolitan OKC area to provide 20 COVID beds at each health system. The COVD Surge plan is a distributed model of care and provides 120 COVID beds across the metro. It allows multiple health systems to manage COVID patients within a region while providing care closer to home.  The Healer of the Year 2020 was Jeremy Laws Rodriguez. Mr. Laws Rodriguez is a Nursing Assistant in the Progressive Care Unit.  “Mask Up OKLA” is a collaborative marketing campaign between metropolitan areas hospitals. It is designed to promote mask wearing while in public spaces. NRHA is designing our own unique campaign to align with this larger promotion.  An additional campaign “Social Distancing – Yes, Medical Distancing – No” will also be promoted by Norman Regional. Ms. Price and her team will work to design a campaign to align with this national promotion.  Last week NRHS participated in the ground breaking ceremony for the Well at Cleveland County’s healthy living block, located near the courthouse in downtown Norman. NRHS’s 800 square foot space will provide integrated medicine and/or meeting space for the community.  August 1st is World Lung Cancer Day. NRHS will have a social media campaign rolling out soon.  Due to delays associated with COVID-19, the first project of Inspire Health will be the Free Standing Emergency Department plus (FSED+) in southeast Norman. The rezoining change will be presented for approval by the City Council on July 28th. Mr. Manfredo provided a list of requested changes made by neighbors and the Planning Commission. Mr. Manfredo also shared an image of the updated master plan for the HealthPlex expansion.  The US Senate just released its version of the next coronavirus relief package called the Health Economic Assistance Liability Protection and Schools (HEALS)  NRHA Board Minutes 8 June 22, 2020 Act. It will provide $1 Trillion in aide including stimulus checks for those who have lost their jobs and funds for schools to reopen. Now it moves to the House for review and/or negotiations. 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. Chappel, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mr. Sherman and Ms. Womack. 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. Pierre Ruhlmann, MD, Active Staff – Pediatrics 2. Recommend Medical Staff Reappointments: a. Matthew Malony, MD, Active Staff – Pediatrics b. Mahammad Salim, MD, Active Staff – Cardiovascular Medicine c. Michael Sellers, MD, Active Staff – Cardiovascular Medicine d. Bilal Ahmad, MD, Consulting Staff – Medicine e. Thomas Urice, MD, Associate Staff – Medicine f. Thomas Merrill, MD, Associate Staff – Medicine g. Paul Plusquellec, MD, Associate Staff – Medicine h. Gary Ratliff, MD, Associate Staff – Medicine i. Angela Vines, APRN-CNS, Allied Health Staff – Cardiovascular Medicine 3. Recommend Advancement of Medical Staff from Provisional Status: a. Wayland Billings, DO, Active – OB/GYN b. Joseph West, MD, Active – Hospital Medicine c. Lauren Donaldson, PA-C, Allied Health – Pediatrics C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Dr. Anwar made a motion to adjourn out of Executive Session and return to regular session. Ms. Greenleaf seconded, and the motion was approved unanimous aye votes from Mr. Cubberley,  NRHA Board Minutes 9 June 22, 2020 Dr. Weber, Dr. Chambers, Mr. Chappel, 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 Members as Listed in XII B 1-3. 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 1-3. Ms. Greenleaf seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Chambers, Dr. Anwar, Mr. Chappel, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Agenda Item XIII. Board Open Discussion Mr. Splitt announced Mr. Chappel and Andy Rieger are co-chairs for this year’s United Way Campaign in Norman. Ms. McGill shared 2 success stories in Cardiology and Orthopedics. The Cardiovascular Service Lines launched the Trans Vascular Aortic Valve Replacement (TAVR) program with very good patient outcomes. The Orthopedic Service Line performed our first robotic total knee replacement with great success. Agenda Item XIV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn the meeting at 7:29p.m. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers and Dr. Anwar, Ms. Greenleaf, Mr. Sherman and Ms. Womack. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary