Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting September 28, 2020 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, September 28, 2020 at 5:40p.m. in the Porter Campus Auditorium. The meeting Agenda was posted September 24, 2020 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chairman Jerome (Jerry) Weber, Ph.D. Diane Chambers, MD Muhammad Anwar, MD Joan Kemmet-Greenleaf Tom Sherman Mary Womack James Chappel Kevin Pipes Others Present: 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 Dr. Farhan Jawed, MD, Chief of Medical Staff Dr. Joe Voto, MD, Chief of Medical Staff-elect Jenny Anderson, Administrative Director Quality & Performance Lisa White, Manager Performance Improvement & Medical Staff Services Larry Harden, Administrative Director, Compliance Karen Rieger, Attorney, Crowe & Dunlevy Neal Risenhover, Supervisor Media Services Shannon Largent, Administrative Director Patient Care Services Cheryl McKinley, Nurse Manager, Med-Surg Unit 4 North Kathy Brougham, Patient Care Tech, Med-Surg Unit 4 North Sandi Sharp-Hayes, Nurse Manager, Centers of Excellence Gina Morgan, Director Finance Shane Cohea, Director Safety & Security Kelly Wells, Director Planning & Communications Barry Deal, Charge Nurse, Med-Surg Unit 4 North Carley Williams, CPA, BKD Rebecca Robins, CPA, BKD  NRHA Board Minutes 2 September 28, 2020 Jessica Ellsberry, CPA, BKD Matthew Mays, Board Fellow Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the September 28, 2020, Norman Regional Hospital Authority meeting to order at 5:36p.m. Agenda Item II. Swearing in of Mr. James Chappel, Trustee Mr. Cubberley swore in Mr. Chappel as the newest Board Trustee for Norman Regional Hospital Authority. Agenda Item III. Consent Items A. October 2020 Healer of the Month – Kathy Brougham, Patient Care, Med-Surg Unit 4 North introduced by Cheryl McKinley, Nurse Manager, Med-Surg Unit 4 North. Mr. Cubberley introduced Ms. McKinley who presented Ms. Brougham as the Outstanding Healer for October 2020. Ms. McKinley has been a healer at NRHS for 7 ½ years. She has an excellent relationship with her peers, physicians and the ancillary departments. Every clinic that works with her would love to steal her away. She is the first one to arrive in the morning always greeting everyone with a smile and a “good morning”. She takes pride in her work and is dedicated to learning new processes and assisting others learn them as well. She is the first to sign up to assist with the United Way, Feed the Children, Salvation Army bell ringing and encourages everyone to participate in the Healer Engagement Surveys. She loves to ride motorcycles and participate in billiard tournaments. Ms. Brougham thanked everyone. Since she began working at NRHS over 7 years ago, she stated she has strived each day to work hard in order to one day earn the honor of Healer of the Month. Mr. Cubberley congratulated and thanked Mrs. Brougham on behalf of the Board for her outstanding dedication, professionalism, compassion, and positive attitude that continues to make Norman Regional Health System a caring, high quality Health System. Ms. Brougham and Ms. McKinley left the meeting at 5:47pm. B. August 24, 2020 NRHA Board Meeting Minutes ACTION TAKEN: Dr. Weber motioned to approve Consent Items A-B. Ms. Greenleaf 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, Mr. Pipes and Mr. Sherman.  NRHA Board Minutes 3 September 28, 2020 Agenda Item IV. Board Education: Centers of Excellence Ms. McGill introduced Ms. Sharp-Hayes, Nurse Manager, Centers of Excellence. Ms. Sharp-Hayes defined a Center of Excellence (COE) as a team of dedicated individuals who operate across departments focusing on the patient quality and experience for the Health System. This is achieved by providing thought leadership, establishing and promoting best practices, engaging in research and development, providing support and education and optimizing resources of the Health System to the benefit of the community. NRHS assures that any program which carries the COE title is either nationally accredited or certified. A COE is the best opportunity to align our service lines with NRHS strategic plans. The “WHY” of becoming a COE include:  Clinical Excellence - the COE support and provide the best evidence-based practice we can find.  Operational Excellence – attract physicians, staff and patients based upon the outstanding care we provide and to contribute in a positive way to financial relationships and negotiations.  Team Excellence – every COE is focused on team input and Healer engagement.  Service Excellence – always ask what is right for the patient and keep them the center of all efforts. The “How” of becoming a Center of Excellence:  Commit to the idea of becoming a COE for a particular service line. A COE team is dedicated to guiding the process and embraces change and innovation.  Assure we have the right ”stuff” to successfully complete the journey. This is done by making certain we have the assets available to sustain the program and making certain that motivation is centered on improving quality.  Invest our time and resources to cultivate environment where best practices thrive via research, learning and developing clinical guidelines, algorithms and order sets that support them.  Once certified, turn around and do it all again. This is part of our ongoing commitment, continuous improvement and excellence. NRHS currently has several Centers of Excellence:  2008 Advanced Primary Stroke Center  2010 Orthopedic Center  2012 Metabolic And Bariatric Center  2013 Chest Pain Management NRHS has several COE programs in various phases of development:  Perinatal Center  Pediatric Asthma Center  Colorectal Surgery Center  Endocrine Center  NRHA Board Minutes 4 September 28, 2020  Headache Center NRHS is working to implement an innovative concept known as a Medical Neighborhood, where multiple department and agencies connect patient care services for those in need. Ms. Sharp-Hayes & Ms. Largent left the meeting at 5:47pm. Agenda Item V. 2020 Audit Presentation Mr. Cubberley introduced Carley Williams, CPA of BKD, an outside auditor. Mr. Williams introduced Jessica Elsberry and Becky Robins, also from BKD. Mr. Elsberry reported that BKD issued an unmodified “clean” opinion for NRHS as they have every year. Areas reviewed were Management Override of Controls, Revenue Recognition, Patient Accounts Receivables, 3rd Party Payer Elements, Reserves in Workers Compensation and Health Insurance, General and Professional Liability, Defined Benefit Pension Plan Estimates, Government Grants and Transactions under the CARES Act. Mr. Williams presented the ratio analysis and reported three components used to compare operating results for NRHS with Peer organizations:  All Urban Hospitals with similar revenue size  All Near West Region hospitals (geographically similar)  A-rated S&P ratings Mr. Williams briefly reviewed the Balance Sheet and Income Statement within the Audit. He reported no significant changes from years past. ACTION TAKEN: Mr. Pipes motioned to approve the 2020 Audit Report as recommended by the Finance Committee. Dr. Weber seconded the motion. The motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes and Ms. Womack. Agenda Item VI. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented the proposed FY2021 Clinical Excellence NEWS Wall Metrics. The Five Metrics are:  Sepsis Bundle Care - This is an all or nothing measure and requires total coordination between the ED and inpatient care.  Falls With Injury - A patient fall is defined as an unplanned descent to the floor with or without injury to the patient.  Central Line Days” - A Central Line Day is a daily count of every patient in the health system that has a Central Line Catheter. The fewer line days a patient has, the lower the risk of a CLABSI (Central Line Associated Blood Stream Infection).  NRHA Board Minutes 5 September 28, 2020  Surgical Site Infections - A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery was performed. SSI is one of the most common healthcare associated infections.  Needle Stick Injuries: A needle stick injury is an injury to an employee caused by the accidental stick from a needle used in patient care. Approximately 385,000 health care workers accidentally stick themselves with needles every year putting them at risk for a blood-borne pathogen exposure. Agenda Item VII. Approval of the August 2020 Norman Regional Health System Financial Statements Mr. Hopkins presented the August 2020 Norman Regional Health System Financial report: August 2020 Financial Performance  Gross Revenues .................................. (Budget $212,745,757)............ $199,112,586  Net Patient Revenue .............................. (Budget $43,866,125).............. $41,224,298  Total Operating Expenses ..................... (Budget $43,725,862).............. $42,552,259  Total Operating Revenues ...................... (Budget $44,297,738).............. $43,473,079  Operating Income ....................................... (Budget $571,876)................... $920,819  Non-Operating Revenues (Expenses) ..... (Budget $1,091,252)................ $5,577,157  Excess Revenues over Expenses ............ (Budget $1,663,128)................ $6,497,976 Year-to-Date  Operating Income .................................... (Budget $1,042,657)..................... $85,692  Non-Operating Revenues (Expenses) ..... (Budget $2,182,504).............. $10,114,168  Excess Revenues over Expenses .............. (Budget 3,225,161).............. $10,199,860  Accounts Receivable Days ............................ (Budget 43 Days).................. 48.5 Days  Days Cash on Hand…………………………………………………………….187.8 Days Mr. Hopkins recognized and thanked Ms. Gina Morgan, Director Finance for her assistance in preparing the Audit. ACTION TAKEN: Dr. Weber motioned to approve the June 2020 NRHS Financial Statements. Mr. Pipes seconded the motion. August Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes and Ms. Womack. Agenda Item VIII. Strategic Planning Committee Dr. Weber reported the committee met September 14th. Mr. Brian Loftus, Business Planning Specialist and Heather Kuklinski, Director Ortho Central reported NRHS and Ortho Central combined efforts to add outpatient-imaging services thus providing greater patient access. This imaging center will provide lower costs options and extended hours.  NRHA Board Minutes 6 September 28, 2020 The following services lines presented updates: Wound Care, General Surgery, Cardiovascular, Women’s & Children’s, Telehealth, Emergency Department, Clinics, Oncology and Behavioral Medicine. Mr. Loftus reviewed data obtained with the market analysis tool, ESRI. Data mapping was conducted to understand the demographic details for patients in our primary service area. This allows NRHS to better address the needs of our patients and their families. Ms. Sally Benn, Director Provider Development and Integration reported on the Recruitment/Onboarding Survey taken by recently recruited providers from July 1, 2019 to June 30, 2020. The total ratings average was 4.5/5.0. Ms. Benn also shared the list of FY21 providers, pending start dates and current recruitment efforts. Mr. Manfredo provided an update on Inspire Health. Agenda Item IX. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on September 9, 2020 via Webex. New Business:  COVID-19: Open discussion was held covering COVID-19 testing, PPE supplies, testing turnaround times and state COVID cases.  Flu testing kit production lagging due to COVID-19. Testing kits are being ordered as supplies are made available.  Ms. McGill reported the new updated CDC guidelines for COVID-19.  Dr. Jawed reported Mobile Clinic nursing staff were given access to TigerConnect.  Flu shots for NRHS healers will be available beginning late September. Trustees were encouraged to take advantage of the vaccine.  Mr. Manfredo reported on the most recent Provider Satisfaction Survey.  Mr. Manfredo provided an update on Inspire Health. Schematic Designs (SD) are being reviewed by Super User groups. The final SD meetings occur October 5-9.  Dr. Cook provided an update on the Norman FORWARD initiative. Department Reports:  Reports were provided by Anesthesia, Cardiovascular Medicine, Emergency Medicine, Hospital Quality Patient Safety Committee (HQPSC), Pathology, Pediatric Hospitalists, Physician Advisory Committee, Radiology, Emergency Department Residency, Surgery and Transfusion Safety.  Dr. Aaron Boyd, MD presented the Medical Staff Report. He thanked the Medical Executive Committee members for their hard work. Administrative Reports:  NRHA Board Minutes 7 September 28, 2020  Ms. McGill announced Cardiovascular Imaging received reaccreditation. NRHS is now within The Joint Commission survey window and are awaiting CMS approval for possible virtual site visits.  Ms. Carter provided a payor update for Aetna Health. The NHealth CME events have been scheduled for mid-November.  Mr. Splitt provided an update on Medical Park West properties. Mr. Splitt shared that 2 Norman FORWARD projects are being discussed by city officials. The Indoor Aquatics & Multi-Sports Complex and Senior Wellness Center may be able to move forward despite the recent GO Bond defeat last August. Mr. Splitt again thanked the physicians for all they do throughout the Health System. Agenda Item X. Finance Committee A. Report from the September 21, 2020 Finance Committee Mr. Sherman reported the committee discussed the Audit, August financials, Healer Gainsharing goals and Capital Items. B. Proposed Healer Gainsharing Goals for FY21 Mr. Hopkins reported the Healer Gainsharing Goals are linked directly to our strategies for growth and improvement. Minor changes were made to the Clinical Excellence category – including Central Line Days, Sepsis Bundle Compliance and Surgical Site Infections. ACTION TAKEN: Dr. Weber made a motion to approve the Proposed Healer Gainsharing Goals for FY21 as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman, Mr. Pipes and Ms. Womack. C. Mr. Hopkins presented for approval seven capital request items totaling $1,366,737: a. Laser: $136,000 b. Flexible Ureterscopes & Cysto Wapplers: $111,244 c. ERCP Scopes: $98,598 d. Low Temperature Sterilization Systems: $266,029 e. Temperature Monitors, Probes, Power Supply: $131,451 f. CT Scanner, Injector and Construction: $515,293 g. Synergy Servers: $108,122 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $1,366,737 as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman, Mr. Pipes and Ms. Womack.  NRHA Board Minutes 8 September 28, 2020 Agenda Item XI. Old Business Mr. Splitt reported the AED’s (Automated External Defibrillators) were donated and presented to The Ranch Steakhouse in North Oklahoma City and Norman. Sara McMillan, Chest Pain Program Coordinator, Centers of Excellence provided training to the Ranch staff on how to use the AEDs. Agenda Item XII. New Business A. Mr. Splitt reported NRHS closed on the 30-acre property on Highway 9 and 24th Avenue SE. This is the future site of the Free Standing Emergency Department Plus (FSED+). B. Mr. Shane Cohea, Director of Safety & Security presented the Environment of Care Management Plan – 2019 Annual Evaluation. Every 12 months, The Joint Commission requires a Board review and update on Policy and Procedures related to Hazardous Waste, Potential for Fire, Use of Medical Equipment, Utility Systems and Safety & Security. Mr. Cohea reviewed the Executive Summary and entertained questions. ACTION TAKEN: Dr. Weber made a motion to accept the Environment of Care Management Plan – 2019 Annual Evaluation. Ms. Greenleaf seconded and the plan was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Ms. Greenleaf, Mr. Sherman, Mr. Pipes and Ms. Womack. Mr. Cohea left the meeting at 7:05pm. Agenda Item XIII. Administrative Report Mr. Splitt shared photos celebrating NRHS healers who are retiring. Linda Rickner, Manager Ortho Spine/IP Rehab - 39 years, Susie Graves, Director Maternal Child Service Line - 40 years and Neal Risenhoover, Supervisor Media Services - 34 years. Ms. Price introduced Mr. Risenhoover to the Board and presented him with a small token of appreciation for setting up the board meetings with audio & video services every month and the many functions held across the Health System. Mr. Risenhoover was instrumental in the design of the education center. Mr. Risenhoover helped produce over 20,000 new baby tapes for new families at NRHS. Mr. Risenhoover expressed his gratefulness for being fortunate to work at NRHS for 34 years. Mr. Splitt reported that NRHS and five other OKC metro hospitals are in the process of renegotiating the state’s COVID-19 Hospital Surge Plan. Weeks ago, NRHS submitted information to the State to assist in the distribution and administration of COVID-19 vaccines when they become available. Mr. Splitt attended the memorial service of NRH Foundation Board member and city leader, Randy Laffoon. Mr. Laffoon was a strong supporter of NRHS and was  NRHA Board Minutes 9 September 28, 2020 instrumental in raising roughly $#M to build the Norman Regional HealthPlex. He was a pillar in the community and he will be missed. Mr. Manfredo reported on Inspire Health, sharing updated exterior designs and floor plans for the HealthPlex expansion. Ms. Carter provided an update regarding Aetna. Medical Staff providers, healers and community partners are being notified of the pending termination. Mr. Splitt announced October is Paint the Town Pink month. Outside lighting and pink flags will be flying across all three Norman Regional campuses in order to increase breast cancer awareness. The NRH Foundation has been highly active in bringing other community partners along in this campaign. Ms. McGill presented an update on COVID-19. Ms. McGill explained the burn rate calculator used for medications, PPE and lab supplies to forecast our 30, 60 and 90 day utilization rate for these supplies. She also updated the Board on the patient volumes and the impact COVID care” is having on our healers. The demands are great and we are concerned about our healer’s wellness. Mr. Splitt thanked the Board of Trustees for their continued support of our healers. Agenda Item XIV. 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. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes and Ms. Womack. Mr. Deal and Ms. Wells left the meeting at 7:36pm. 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. Casey Liston, DO – Active Staff – Emergency Medicine b. Jason Taylor, DO – Associate Staff – Family Medicine c. Mark Sauerwald, DO – Privileges Only – Hospital Medicine 2. Recommend Medical Staff Reappointments: a. Victor Wilson, MD – Active Staff – Pediatrics b. James Fields, MD – Active Staff – Pediatrics c. Justin Fields, MD – Active Staff – Pediatrics d. Cynthia West, DO – Active Staff – Pediatrics e. Donna Jackson, MD – Active Staff – Pediatrics NRHA Board Minutes 10 September 28, 2020 f. Eileen Fox, MD – Active Staff – Pediatrics g. Tony Tran, MD – Active Staff – Medicine h. Saria Refai, MD – Active Staff – Medicine i. Joseph Saveika, III, MD – Active Staff – Medicine j. Stephen Eichert, DO – Active Staff – Surgery k. Stephanie “Allison” Carter, MD – Active Staff – OB/GYN l. Geo-Phillips Chacko, MD – Active Staff – Hospital Medicine m. Michael Confer, MD – Consulting Staff – Medicine n. John Taylor, MD – Consulting Staff – Medicine o. Christopher Parker, MD – Consulting Staff – Medicine p. John McCarter, MD – Associates Staff – Medicine q. Laure DeMattia, DO – Associate Staff – Medicine r. Lydia Ballard, MD – Associate Staff – Medicine s. Serena Mitroo, MD – Associate Staff – Medicine t. Julia Irwin, MD – Associates Staff – Behavioral Medicine u. Melissa Jennings, MD – Ortho Central v. Jordan Hobbs, PA-C – Ortho Central w. Tony Tran, MD – West Norman Endoscopy & Medical Plaza Endoscopy 3. Recommend Advancement of Medical Staff from Provisional Status: a. Allen Baughman, DO – Active – Emergency Medicine b. Ernest Foster II, MD – Active – Emergency Medicine c. Melissa Jennings, MD – Active – Anesthesia d. Matthew Carson, DPM – Consulting – Surgery e. Kathryn Hall, DO – Associate – Medicine f. Jordan Hobbs, PA-C – Allied Health – Surgery 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. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes 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. Dr. Anwar seconded, and the motion was approved with  NRHA Board Minutes 11 September 28, 2020 unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Chambers, Dr. Anwar, Mr. Chappel, Ms. Greenleaf, Mr. Sherman, Mr. Pipes and Ms. Womack. Agenda Item XV. Board Open Discussion Mr. Manfredo introduced Matthew Mays as the University of Oklahoma JC Penny Leadership Program Board Fellow. Mr. Mays will be attending the Board meetings through the end of May 2021. Mr. Splitt wished Ms. McGill an early and Happy Birthday. Agenda Item XVI. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:41p.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, Mr. Pipes and Ms. Womack. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary