Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting October 26, 2020 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, October 26, 2020 at 4:30p.m. via WebEx. The meeting Agenda was posted October 22, 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 Tom Sherman Mary Womack James Chappel Kevin Pipes 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 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 Judy Stuart, Director Patient Safety & Accreditation Shannon Largent, Administrative Director Patient Care Services Karen Rieger, Attorney, Crowe & Dunlevy Lianna Gray, Supervisor Volunteer Services Wendy Fiebrich, Executive Director Volunteer Services Matt Mays, Board Fellow Members Absent: Joan Kemmet-Greenleaf Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the October 26, 2020, Norman Regional Hospital Authority meeting to order at 4:33p.m. Mr. Cubberley reviewed the rules for the WebEx meeting  NRHA Board Minutes 2 October 26, 2020 participation. Claudia Todd took roll call. Agenda Item II. Consent Items A. November 2020 Healer of the Month – Liana Gray, Supervisor Volunteer Services Mr. Cubberley introduced Wendy Fiebrich, Executive Director Volunteer Services who presented Ms. Gray. This honor coincides with her 10 year employment anniversary with NRHS. Ms. Gray started as a coordinator with Volunteer Services and 4 years ago was promoted to Supervisor. Members of Volunteer Services provided a few comments that Ms. Fiebrich shared – including Liana is always caring, happy, continually prepared, encouraging, making sure volunteers have the support and appreciation they need. Ms. Gray oversees schedules, training, programs and the annual education classes for over 400 volunteers across the Health System. Since COVID impacted our community and Health System, Ms. Gray was asked to assist with the training of 350 employees to staff 12 entry points for our 3 campus sites to assist with visitor and Healer screening. She sent over 50 daily text reminders to employees and volunteers prior to their shifts, reminding them of what to wear, the times and location they were to work. Ms. Gray expressed her appreciation of of NRHS and all we do for our healers. She is thankful to be a part of the NRHS family. Mr. Cubberley congratulated and thanked Ms. Gray 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 system. Ms. Fiebrich and Ms. Gray left the meeting at 4:42pm. B. September 28, 2020 NRHA Board Meeting Minutes ACTION TAKEN: Dr. Weber motioned to approve Consent Items A-B. Ms. Womack seconded the motion. Consent Items were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Dr. Chambers, Dr. Anwar, Mrs. Womack, Mr. Chappel and Mr. Sherman. Agenda Item III. The Joint Commission Ms. Judy Stewart, Director Patient Safety & Accreditation presented background information and requirements from The Joint Commission (TJC). TJC was founded in 1951 as an independent, not-for-profit organization which sets standards for accreditation and certification of healthcare facilities. Healthcare facilities undergo an on-site survey to assess compliance with the TJC standards every 3 years to earn and maintain The Gold Seal of Approval for quality healthcare services. NRHS has maintained the Gold Seal of Approval consistently since 1951. Benefits of TJC Accreditation are:  NRHA Board Minutes 3 October 26, 2020  Organize and strengthen patient safety efforts  Strengthen community confidence in the quality and safety of care, treatment and services  Improves risk management and risk reduction  Provides professional advice and counsel, enhancing staff education  Provides a customized, intensive review  Provides deeming authority for Medicare certification  Provides a framework for organizational structure and management  Provides practical tools to strengthen or maintain performance excellence The Foundational Standards are set into 4 sections:  Leadership Structure: identifies and defines the various leadership groups and their responsibilities  Leadership Relationships: address the leaders combined accountabilities and communication among leaders, conflict management and the development of the hospital’s mission, vision and goals  Organization Culture and System Performance Expectation: address the framework for the hospital’s culture and systems and demonstrate how leaders help shape the culture of the hospital and its effect on important systems in the hospital  Operations: address the functions that are important to patient safety and high quality care, treatment and services Ms. Stuart suggested potential TJC survey questions may focus in the areas of High Reliability, Patient Safety, Patient Safety Culture, Just Culture, Leadership/Board and COVID-19 responses. Ms. Stuart left the meeting at 4:57pm. Agenda Item IV. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented the history of Hospital Accreditation and TJC data. In 1913 the American College of Surgeons (ACS) was founded by Franklin H Martin, MD, FACS. Dr. Martin pushed for the group to develop a minimum standard for hospitals and become the foundation for all subsequent standards. This group recruited Dr. John G. Bowman, PhD as the Director for the ACS. The initial American College of Surgeons Standards focused on five areas:  Physicians and surgeons privileged to practice in the hospital be organized as a definite group or staff  Membership upon the staff be restricted to physicians and surgeons who are: o Full graduates of medicine in good standing and legally licensed to practice in their respective states or provinces o Competent in their respective fields o Worthy of character and in matters of professional ethics  Staff adopt rules, regulations and policies that specifically provide – o Staff meetings be held at least once each month  NRHA Board Minutes 4 October 26, 2020 o Staff review and analyze at regular intervals their clinical experience in various departments of the hospital o The critical records of patients be the basis for such review and analyses  Accurate and complete records be written for all patients and filed in an accessible manner  Diagnostic equipment and therapeutic services be available, at least Clinical laboratory & X-ray department ACS began on-site inspections in 1918. At that time, only 89 of 692 hospitals surveyed met the requirements of the Minimum Standard. In 1951, The American College of Physicians, the American Hospital Association, the American Medical Association and the Canadian Medical Association joined with the ACS to create what is now known today as The Joint Commission (TJC). NRHSis within TJC’s survey window; which means surveyors could arrive at any times. NRHS strives to stay in continuous readiness and does so by conducting Environment of Care Rounds, Infection Prevention Rounds and Tracers for specific units to review questions. Agenda Item V. Approval of the September 2020 Norman Regional Health System Financial Statements Mr. Hopkins presented the September 2020 Norman Regional Health System Financial report: September 2020 Financial Performance  Gross Revenues .................................. (Budget $206,592,963)............ $203,821,885  Net Patient Revenue .............................. (Budget $42,737,307).............. $42,607,747  Total Operating Expenses ..................... (Budget $42,733,476).............. $44,216,524  Total Operating Revenues ...................... (Budget $43,218,771).............. $43,999,923  Operating Income ....................................... (Budget $485,295)................. ($216,600)  Non-Operating Revenues (Expenses) ..... (Budget $1,091,252)................. ($441,597)  Excess Revenues over Expenses ............ (Budget $1,576,547)................. ($658,197) Year-to-Date  Operating Income .................................... (Budget $1,527,952)................. ($130,908)  Non-Operating Revenues (Expenses) ..... (Budget $3,273,756)................ $9,672,572  Excess Revenues over Expenses ............ (Budget $4,801,708)................ $9,541,663  Accounts Receivable Days ............................ (Budget 43 Days).................. 48.1 Days  Days Cash on Hand…………………………………………………………….186.1 Days ACTION TAKEN: Dr. Weber motioned to approve the September 2020 NRHS Financial Statements. Mr. Pipes seconded the motion. September Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Mr. Pipes, Mr. Sherman and Ms. Womack. Agenda Item VI. Patient Quality & Safety Committee  NRHA Board Minutes 5 October 26, 2020 Ms. Greenleaf was unable to attend. The Patient Quality & Safety report will be presented in November. Agenda Item VII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on October 14, 2020. Old Business:  Dr. Jawed reminded providers the deadline to receive the flu vaccine and have it documented is October 31st. New Business:  COVID-19: Open discussion was held covering COVID-19 testing, combined efforts with ED for focus on patent and staff safety, PPE supplies and the continuation of timely Emerging Infectious Disease (EID) Team updates.  Ms. McGill reported NRHS is working with the state of Oklahoma and the Oklahoma Hospital Association to ensure thorough communication across the board in regards to public and national heath disasters.  Tiger Connect – Dr. Jawed reported efforts continue to register providers for the communication service.  Medical Staff Member at Large nominations opened on October 15th. Department Reports:  Reports were provided by Accreditation & Bylaws, Behavioral Medicine, Emergency Medicine, General Medical Education, Hospital Medicine, Hospital Quality & Patient Safety, OB/GYN, Pediatric Hospitalists, Pharmacy & Therapeutics Committee, Physician Advisory Committee, Radiology, and Emergency Medicine Residency Program.  Medical Staff Report: Dr. Boyd thanked everyone for their leadership and ongoing patient care efforts. Administrative Reports:  Ms. McGill thanked healers for their collaboration throughout COVID-19  Ms. Price provided a report and presentation on the newly formed Food Pharmacy program.  Mr. Manfredo announced Brian Timmeman as the new Surgery Director. Mr. Manfredo provided an Inspire Health update.  Mr. Splitt thanked all healers for bringing their compassion, courage and strength to work and for working as a team to provide great care for our patients. Mr. Splitt thanked everyone for participating in the annual United Way campaign. Mr. Splitt reported greater OKC metropolitan health systems are continuing to coordinate and collaborate COVID-19 services within the communities served – establishing an evidence-based and standardized community of care.  NRHA Board Minutes 6 October 26, 2020 Agenda Item VIII. Finance Committee A. Report from the October 19, 2020 Finance Committee Mr. Pipes reported the committee discussed COVID surge plan updates and its impact on the financial outlook. Mr. Harden provided a Risk Management update. Ms. Price presented information on the new Food Pharmacy program. Agenda Item IX. Old Business A. Proposed Vote to Reaffirm Prior Approval of the Resolution to Add Non-Norman Trustees to the NRHA Board ACTION TAKEN: Dr. Weber made a motion to Reaffirm Prior Approval of the Resolution to Add Non-Norman Trustees to the NRHA Board (with grammatical corrections). Ms. Womack seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Mr. Pipes and Ms. Womack. Agenda Item X. New Business A. Proposed Vote to Approve or Disapprove the Resolution for The Well ACTION TAKEN: Mr. Pipes made a motion to approve the Resolution for The Well. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers and Ms. Womack. B. Proposed Vote to Amend the 2020 Meeting Calendar for the NRHA Authority ACTION TAKEN: Dr. Weber made a motion to Amend the 2020 Meeting Calendar for the NRHA Authority. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Mr. Pipes and Ms. Womack. Agenda Item XI. Administrative Report A. Mr. Splitt presented an update on October’s Cancer Awareness Month that was spearheaded by the NRH Foundation and NRHS. Paint the Town Pink, the Premier Golf Tournament, City Proclamations presented by the Mayors of Norman, Moore and Noble and numerous presentations at Civic clubs were held in an effort to raise cancer awareness and raise funds to support cancer related services, programs and patient comforts. Mr. Splitt reported the Norman City Council appears to be moving forward with plans for the senior wellness center on the Porter Health Village campus – incliding the cleanup of property ownership. The Indoor aquatics and Multi-sport Facility appears to be in progressing as well.  NRHA Board Minutes 7 October 26, 2020  Ms. Carter provided an update related to ongoing payor discussions. NRHS partnered with ClobalHea;th to provides the Generations Medicare Advantage Plan.  Mr. Manfredo provided an update on Inspire Health including schematic designs for the HealthPlex, fencing for the FSED+ site and master planning options on the Porter campus.  Ms. McGill provided an update on COVID-19 – including the NRHA patient representatives process, healer and visitor screening plans, PPE burn rate calculations, Emerging Infectious Disease Updates and State of Oklahoma surge and vaccination planning. 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. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Mr. Pipes and Ms. Womack. Ms. Anderson, Ms. Largent left the meeting at 6:54pm 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. Meghan Saumur, MD – Active Staff – Surgery b. Mahrukh Ali, MD – Active Staff – Hospital Medicine c. Jason Taylor, DO – Associate Staff – Family Medicine d. Jessica Franklin, APRN-CRNA – Allied Health Staff – Anesthesia e. Kelly White, APRN-CNP – Allied Health Staff – Cardiovascular Medicine 2. Recommend Medical Staff Reappointments: a. Julia Stoltenberg, MD – Active Staff – Pediatrics b. Rajkumar Reddy, MD – Active Staff – Pediatrics c. Ajay Verma, MD – Active Staff – Pediatrics d. Aaron Boyd, MD – Active Staff – Medicine e. Robert Gaston, DO – Active Staff – Medicine f. Paul Le, MD – Active Staff – Anesthesia g. Lisa Waterman, DO – Active Staff – OB/GYN h. Laura Velez, APRN-CNS – Allied Health Staff – Cardiovascular Medicine i. Kevin Mason, PA-C – Allied Health Staff - Surgery 3. Recommend Advancement of Medical Staff from Provisional Status: a. Trent Fogleman, MD – Active – OB/GYN  NRHA Board Minutes 8 October 26, 2020 b. Marcia Gillespie. MD – Active – OB/GYN c. Keith Layne, DO – Associate - Medicine 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, 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 unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Chambers, Dr. Anwar, Mr. Chappel, Mr. Pipes and Ms. Womack. Agenda Item XIII. Board Open Discussion None Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:02pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Mr. Pipes, Dr. Anwar, and Ms. Womack. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary