Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting November 23, 2020 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, November 23, 2020 at 5:30p.m. in the Porter Education Center. The meeting Agenda was posted November 19, 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 Mary Womack James Chappel Kevin Pipes Joan Greenleaf 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 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 Karen Rieger, Attorney, Crowe & Dunlevy Ty Woodward, Case Management Kristen ONeal, Manager Population Health Donna Avila, Director Care Coordination Teresa Brown, Strategic Planning Specialist Danny Kelley, Administrative Director HIT Stephen Sheriff, Network Infrastructure Architect HIT Members Absent: Tom Sherman Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order  NRHA Board Minutes 2 November 23, 2020 Mr. Cubberley called the November 23, 2020, Norman Regional Hospital Authority meeting to order at 5:34p.m. Agenda Item II. Consent Items A. December 2020 Healer of the Month – Ty Woodward, Care Coordination Associate, Case Management Mr. Cubberley introduced Kristen ONeal, Manager Population Health who presented Ms. Woodward. Ms. Woodward has been employed at NRHS since July 2017. She started in registration at Moore Medical Center before joining the Care Coordination team on the Porter campus. She is one of the brightest stars on the team. Throughout the nomination process, one statement was consistent – her willingness to go above and beyond helping patients and the department. During COVID, she transferred to the mobile clinic during the summer to assist with COVID testing. Since transitioning back to the department, she has fully embraced the Food Pharmacy program, ensuring patients in need receive a box of food items upon discharge. She also follows up with the patients making sure they are assisted beyond being discharged. She is a healer with heart and epitomizes the ICARE standards. Ms. Woodward expressed her appreciation for the honor and stated that she loves working at NRHS. Mr. Cubberley congratulated and thanked Ms. Woodward 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. Woodward, Ms. ONeal, Ms. Avila and Ms. Brown left the meeting at 5:40pm. B. October 26, 2020 NRHA Board Meeting Minutes ACTION TAKEN: Dr. Weber motioned to approve Consent Items A-B. Dr. Anwar seconded the motion. Consent Items were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Dr. Chambers, Dr. Anwar, Mrs. Womack, Mr. Chappel, Mr. Pipes and Ms. Greenleaf. Agenda Item III. Board Education: Cyber-security Update Mr. Danny Kelley, Chief Information Officer and Mr. Stephen Sheriff, Information Security Officer presented an update on NRHS Cyber-security assessment. Mr. Kelley shared beginning in 2018, NRHS established a framework for cyber security and began building a best practice security platform. Using the National Institute of Standards of Technology (NIST) the company “Fortified Health Security (FHS) was chosen as our partner based on a subset of standards, which provide tools needed to create secure, control-driven best practices. FHS is 100% healthcare focused and a recognized leader in cybersecurity. FHS has partnered with over 150 healthcare systems across the country and were named the Healthcare Cyber-security company of  NRHA Board Minutes 3 November 23, 2020 the year. Mr. Sheriff explained FHS helped NRHS identify risks, improve critical infrastructure, reduce cyber security risks and foster more effective cyber security communications within the HIT department and across our health system. The program is designed around 5 basic functions: Identify, Protect, Detect, Respond and Recover. FHS provided an assessment across the entire health care system, analyzing and scrutinizing departments for levels of protection/security as well as evaluating policies and procedures. Mr. Don Kelly, Virtual Information Security Officer with FHS joined the meeting virtually. Mr. Kelly provided background information on the tests conducted and overall results. Mr. Kelly praised and congratulated the HIT team (and NRHS) for robust efforts to maintain very high cybersecurity standards, processes and practices. Mr. Kelley and Mr. Sheriff left the meeting at 5:58pm. Agenda Item IV. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented an update on the NRC survey results and NEWs Wall Highlights. NRC is the real time patient satisfaction survey vendor used by NRHS. Ms. Anderson shared comments from patients who received care from Laboratory services, Clinics, Radiology/Breast Care, Surgery, Emergency Department and Inpatient Services. Patients expressed their appreciation for care received, attention to details when explaining options for treatments and follow-up care and making patients feel at ease. NEWs Wall Gemba Walks were conducted by members of the NRHS Strategy Team. The “reviewers” wanted to assess how NEWs Walls were being applied within departments across the health system. Ms. Anderson highlighted the NEWS Walls for the HealthPlex Monitor Room, Radiation/Oncology and Centralized Scheduling. These departments were emphasized purposely because they were sharing information within their areas exceptionally well – including adding a section to capture improvement ideas and Inspire Health updates. The Strategy Team plans to use this information to determine NEWs Wall effectiveness and opportunities for improvements. The goal is to keep this communication tool relevant and meaningful to our healers. Agenda Item V. Approval of the October 2020 Norman Regional Health System Financial Statements Mr. Hopkins presented the October 2020 Norman Regional Health System Financial report: October 2020 Financial Performance  Gross Revenues .................................. (Budget $213,630,266)............ $206,123,333  Net Patient Revenue .............................. (Budget $44,817,630).............. $44,187,036  Total Operating Expenses ..................... (Budget $43,845,954).............. $43,662,348  Total Operating Revenues ...................... (Budget $45,265,493).............. $44,569,950  NRHA Board Minutes 4 November 23, 2020  Operating Income .................................... (Budget $1,419,539)................. ($907,602)  Non-Operating Revenues (Expenses) ..... (Budget $1,091,252).............. ($2,057,582)  Excess Revenues over Expenses ............ (Budget $2,510,791).............. ($1,149,980) Year-to-Date  Operating Income .................................... (Budget $2,947,491)................. ($776,694)  Non-Operating Revenues (Expenses) ..... (Budget $4,365,008)................ $7,614,990  Excess Revenues over Expenses ............ (Budget $7,312,499)................ $8,391,684  Accounts Receivable Days ............................ (Budget 43 Days).................. 46.9 Days  Days Cash on Hand…………………………………………………………….178.5 Days ACTION TAKEN: Dr. Weber motioned to approve the October 2020 NRHS Financial Statements. Ms. Greenleaf seconded the motion. October Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Mr. Pipes, Ms. Greenleaf and Ms. Womack. Agenda Item VI. Strategic Planning Committee Dr. Jerry Weber presented a report from the November 2nd meeting. Ms. Brittni McGill, CNO, provided an update on the COVID Care Standard of Practice. Mr. Larry Harden, Administrative Director and Chief Compliance Officer presented the results of the Compliance Committee Review. Ms. Teresa Brown, Strategic Planning Specialist provided an overview of the 2020 Sg2 Consumer Survey Report. This report identifies 4 key areas consumers are focused on for Healthcare Services – including: Access, Value, Integration and Personalization. Mr. Brian Loftus, Business Planning Specialist provided first quarter updates in surgical and cardiovascular services. Ms. Sara Rainey, Strategic Planning Specialist provided an update on the NRHS Food Pharmacy. Data gathered from both Porter and HealthPlex campuses combined between May 2020 – October 2020 indicated 80 patients had food insecurities. The Food Pharmacy began serving patients on October 19th. This program has resonated with NRHS Healers and an internal food drive will be held prior to the holidays. Ms. Sally Benn, Director Provider Development & Integration, provided an update on provider recruiting priorities for 2021. Ms. McGill presented an emergency capital item for an EMS Dispatch System to be utilized by the City of Moore’s Police & Fire Communications enter (911 Center). This new system will standardize dispatch systems being used by the City’s of Moore and Norman. Mr. Manfredo provided an Inspire Health update.  NRHA Board Minutes 5 November 23, 2020 Ms. Carter provided a provider update. Mr. Splitt provided a CEO/Health System update. Agenda Item. VII. Patient Quality & Safety Committee Ms. Greenleaf reported the Patient Quality & Safety Committee meet on October 5th. Ms. Sara McMillan, Cardiovascular Accreditation and Quality Coordinator shared a presentation she prepared for the American College of Cardiology (ACC) Summit. The presentation illustrated how NRHS improved patient care outcomes through more effective and timely communication between NRHS’s ambulance service (EMSStat0 – and other EMS providers – and the health system. This collaboration not only benefited patients and NRHS, it positively impacted other EMS agencies. Handouts from the Summit were provided. Ms. McGill reviewed the Year One - Nurse Extern Program, which began in June 2019. This program offers nursing students the opportunity to enhance their professional growth in the nursing field with on-the-job teaching and guidance within a multi-campus system health system that has multiple with Centers of Excellence designations and nationally accredited programs. Ms. McGill reported a 100% retention rate with the Year One group. Ms. McGill provided an update for the clinical Simulation lab. This Auxiliary funded Lab provides state-of-the-art mannequins that include scenario software to enhance the learning process for clinical skills. This program has helped improve interpersonal communication skills during the patient-transfer process between one department or healer to another. It has also increased team performance in the overall management of crisis situations. The Simulation Lab has been instrumental in providing superior educational opportunities for our healers. Ms. Jenny Anderson, Administrative Director Quality & Performance presented the FY 2020 Focus Priorities for Board Quality – including Sepsis, Hospital Acquired Infections and Mortality Rates. Agenda Item VIII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on November 11, 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 cases in Cleveland County, combined efforts for focus on patent and staff safety,  NRHA Board Minutes 6 November 23, 2020 Personal Protective Equipment (PPE) supplies and the continuation of timely Emerging Infectious Disease (EID) Team updates.  Ms. McGill provided an update on the EID communications and the surge plan.  Mr. Foster provided an update for COVID-19 vaccine planning. He reviewed the tentative timeline and phase approach.  Ms. Stemm presented the pneumonia and sepsis order set revisions. These order sets were approved by MEC.  Dr. Ashfaq and Ms. Stemm presented COVID-19 oder sets. They were approved by MEC.  Dr. Jawed thanked administration for the UpToDate software which interfaces with Meditech and eClinical Works. UpToDate is a software that helps NRHS healers to reduce variability in patient care by more effectively aligning decision-making across care teams and patients.  Mr. Manfredo presented an update on Inspire Health. Creditials Report:  Dr. Mullins presented the credential report for recommended approval. Department Reports:  Reports were provided by Anesthesia, Emergency Medicine, Hospital Medicine, Infection Committee, Pathology, Pediatric Hospitalists, Pediatrics, Physician Advisory Committee, Radiology, Surgery and Emergency Medicine Residency Program. Administrative Reports:  Ms. Carter provided an update related to ongoing payor discussions. NRHS partnered with GlobalHealth to provide the Generations Medicare Advantage Plan.  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. In recognition of Veteran’s Day, Mr. Splitt read a poem expressing thanks to those healers and veterans who have served our country heroically.  Mr. Cubberley reported the Board had reviewed a presentation overview of the upcoming Joint Commission (TJC) Survey. The Board stands ready to support our healers and health system through the approaching TJC examination. Agenda Item IX. Finance Committee A. Report from the November 16, 2020 Finance Committee Mr. Hopkins reported the committee discussed COVID surge plan updates and its impact on NRHS’s financial outlook. Mr. Manfredo provided an Inspire Health update. Ms. Carter provided a Payer Contracting report. Corporate budgets for Inspire Health will be presented at the January Board meeting.  NRHA Board Minutes 7 November 23, 2020 B. Mr. Hopkins presented for approval 5 capital request items totaling $493,954: a. Endoscopy Tower: $74,135 b. Van with ramp: $50,699 c. Pro QA Medical licenses, training & implementation: $91,155 d. HIT Servers: $77,965 e. Switchboard Software: $200,000 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $493,954 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, Mr. Pipes and Ms. Womack. Agenda Item X. Old Business Mr. Splitt announced the Bylaws Committee is planning to present the revised Bylaws for approval at the January Board meeting. Agenda Item XI. New Business A. Proposed Vote to Establish Dates and Times for 2021 Authority Meetings Section 933 of the Oklahoma Open Meeting Act requires the Authority to submit the date and time of its regular meetings for the coming calendar year. NRHA meetings have been scheduled for 5:30 p.m. on the fourth Monday of the month this past year. The schedule below describes similar dates and times for the Authority’s monthly meetings in 2021 Note: There is no monthly meeting scheduled for the month of December January 25 April 26 July 26 October 25 February 22 May 24 August 23 November 22 March 22 Junes 28 September 27 ACTION TAKEN: Dr. Weber made a motion to approve the 2021 Authority meeting dates and times as submitted. Mr. Chappel seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Mr. Pipes, Ms. Greenleaf and Ms. Womack. B. Recommend Approval of the Proposed Resolution for a Community Contribution to the Norman Public School District  NRHA Board Minutes 8 November 23, 2020 ACTION TAKEN: Dr. Weber made a motion to Approve the Resolution for a Community Contribution to the Norman Public School District. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Mr. Pipes, Ms. Greenleaf and Ms. Womack. C. Recommend Approval of Compliance Plan and Compliance Policies – including Compliance Officer, Compliance Committee, Code of Conduct and Vendor Gifts ACTION TAKEN: Dr. Weber made a motion to Approve the Compliance Plan, Compliance Officer Policy, Compliance Committee Policy, Code of Conduct Policy and Vendor Gifts Policy as presented. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Dr. Chambers, Mr. Pipes, Ms. Greenleaf and Ms. Womack. Agenda Item XII. Administrative Report A. Mr. Splitt shared the CMS Innovation project called ET3 – (Emergency Triage, Triage, Treat and Transport) will be the Community/Board Education topic in January 2021.  Ms. McGill provided a COVID-19 update. She reviewed the surge plan tiers and NRHS status; which is reviewed and updated daily. A statewide and NRHS-specific Vaccine Plan has been submitted to the state of Oklahoma. NRHS is collaborating with the Oklahoma State Department of Health to finalize the distribution plan. A COVID outpatient infusion center was recently opened to care for patients outside the hospital setting. The clinic provides monoclonal antibodies to those who are at high risk for progressing to severe COVID-19 – including those who are 65 years of age or older or who have certain chronic medical conditions. The purpose of this outpatient clinic is to begin treatment of the virus early and more aggressively, before the severity of the virus’s symptoms worsen. These outpatient therapeutics have been effective in averting hospitalizations, decreasing the length of the disease and diminishing symptoms.  Mr. Manfredo provided an update on Inspire Health including Design Development for patient rooms, renderings of the building design for the HealthPlex and the Freestanding ED.  Mr. Splitt shared letters from patients and community members praising and thanking our healers for the work they do daily. Agenda Item XIII. 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; NRHA Board Minutes 9 November 23, 2020 ACTION TAKEN: Dr. Weber made a motion to adjourn into Executive Session. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Dr. Anwar, Mr. Pipes, Ms. Greenleaf 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. Joshua Powell. MD – Active Staff – Surgery b. Sumit Som, MD – Associate Staff – Family Medicine c. Jamie Steichen, PA – Allied Health – Radiology d. Elizabeth Richardson, DO – Privileges Only – Hospital Medicine 2. Recommend Medical Staff Reappointments: a. Lorry Krous, MD – Active Staff – Pediatrics b. Saud Ahmed, MD – Active Staff – Medicine c. Roy “Curtis” Mullins, MD – Active Staff – Medicine d. David Williams, MD – Active Staff – Medicine e. Lawrence Carter, MD – Active Staff – Hospital Medicine f. Senthil Raju, MD – Active Staff – Hospital Medicine g. Leslie Ollar-Shoemake, DO – Active Staff – OB/GYN h. Archana Gautam, MD – Active Staff – Cardiovascular Medicine i. Ahmad Sarwar, MD – Active Staff – Cardiovascular Medicine j. Ayesha Farhan, MD – Active Staff – Behavioral Medicine k. Muhammad Ishaq, MD – Active Staff – Behavioral Medicine l. Sanober Malik, MD – Consulting Staff - Medicine m. Mohammad Razaq, MD – Consulting Staff – Medicine n. John Stanley III, MD – Consulting Staff – OB/GYN o. David Deschamps, MD – Consulting Staff – OB/GYN p. Charles Mirabile, MD – Consulting Staff – OB/GYN q. Christine Highley, MD – Associate Staff – Medicine r. Storm Eagle, APRN-CNP – Allied Health Staff – Medicine s. Keri Houck, APRN-CNS – Allied Health Staff – Hospital Medicine t. Lauren Haymans, PA-C – Allied Health Staff – Surgery 3. Recommend Advancement of Medical Staff from Provisional Status: a. Elizabeth Eaton, APRN-CNP – Allied Health Staff – Pediatrics b. Jackson Laizure, APRN-CNP – Allied Health Staff – 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. Dr. Anwar seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Dr. Weber, Dr. Chambers, Mr. Chappel, Dr. Anwar, Mr. Pipes, Ms. Greenleaf and Ms. Womack.  NRHA Board Minutes 10 November 23, 2020 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, Mr. Pipes, Ms. Greenleaf and Ms. Womack. E. Proposed Vote to Convene an Executive Session Pursuant to 25 Okla. Stat. Section 307 B.4. to Discuss (i) CEO Evaluation; ACTION TAKEN: Dr. Weber made a motion to adjourn into Executive Session. Mr. Chappel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Chambers, Dr. Anwar, Mr. Chappel, Mr. Pipes, Ms. Greenleaf and Ms. Womack. Mr. Splitt, Mr. Manfredo, Mr. Hopkins, Ms. Carter, Ms. McGill, Ms. Price, Ms. Todd, Mr. Harden, Dr. Boyd, Dr. Jawed, Dr. Voto, Ms. Rieger left the meeting at 7:30pm. F. Request to Adjourn out of Executive Session and Return to Regular Session ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Chambers, Dr. Anwar, Mr. Chappel, Mr. Pipes, Ms. Greenleaf and Ms. Womack. G. Proposed Vote to Approve or Disapprove the CEO Evaluation ACTION TAKEN: Dr. Weber made a motion to approve the CEO Evaluation. Ms. Greenleaf seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Chambers, Dr. Anwar, Mr. Chappel, Mr. Pipes, Ms. Greenleaf and Ms. Womack. Agenda Item XV. Board Open Discussion None  NRHA Board Minutes 11 November 23, 2020 Agenda Item XVI. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 9:10pm. MNs. Greenleaf seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Chambers, Mr. Pipes, Dr. Anwar, Ms. Greenleaf and Ms. Womack. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary