Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting March 22, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, March 22, 2021 at 5:30p.m. in the Porter Auditorium. The meeting Agenda was posted March 18, 2021 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. Muhammad Anwar, MD James Chappel Joan Greenleaf Diane Chambers, MD 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 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 Adrian Francisco, Administrative Fellow Matt Mays, Board Fellow Sharon Reddig, Clinic Care Coordinator, Internal Medicine Doctor’s Park Elise Grein, Manager, Clinics Care Coordination Erin Barnhart, Director, NRHS Foundation Sara Raney, Strategic Planning Specialist Calvin Bohanan, Director, Laboratory Jim Beyer, Admin Director, Human Resources LeAnn Richardson, Admin Director, Population Health Darnell Burgess, Admin Director, Ambulatory Services Donna Avila, Director, Acute Care Coordination Richard Spray, Director, Patient Financial Services Shannon Largent, Admin Director, Patient Care Services Amanda Jones, Director, Accommodation Services Teresa Brown, Strategic Planning Specialist Clyde Brawner, Director, Environmental Services & Transportation Wendy Fiebrich, Executive Director, Volunteer Services  NRHA Board Minutes 2 March 22, 2021 Members Absent: Tom Sherman Mary Womack Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the March 22, 2021, Norman Regional Hospital Authority meeting to order at 5:31p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. April 2021 Healer of the Month – Sharon Reddig, Clinic Care Coordinator – Internal Medicine Doctor’s Park Mr. Cubberley introduced Elise Grein, Manager Clinic Care Coordination who presented Ms. Reddig. Ms. Grein shared Ms. Reddig has worked for Norman Regional for 18 years. She began her career as an RN in the Critical Care Unit short stay department. Over the years, she has served as manager for 2 West Telemetry, 4 Northwest Tele- Ortho Neurosurgery post op, 3 Northwest Ortho-Spine, Nurse manager liaison for 2 patient dialysis units and for the past 3 ½ years has been Clinical Care Coordinator for the Internal Medicine Department. Ms. Reddig is known for her caring heart and can-do attitude, doing anything within her power to make sure her patients’ needs have been met. This was never more evident than over this last year as she cared for patients who tested positive for COVID. Her fellow healers describe her as a wealth of knowledge and a compassionate and caring hearer who calls on her patients daily to reassure them and remind them they are not alone. Several patients noted that if it wasn’t for Ms. Reddig, they don’t believe they would have recovered from COVID. Ms. Reddig states she has the best coworkers and friends at Norman Regional and has been honored to help serve them. Ms. Reddig thanked everyone for the opportunity for the honor. Mr. Cubberley congratulated and thanked Ms. Reddig on behalf of the Board for his outstanding dedication, professionalism, compassion, and positive attitude that continues to make Norman Regional Health System a caring, high quality system. Ms. Reddig and Ms. Grein left the meeting at 5:35pm. B. Special Board Presentation to Trustees Ms. Erin Barnhart, Director NRHS Foundation and the Healers Helping Healers  NRHA Board Minutes 3 March 22, 2021 committee members presented each NRHA Trustee with a Norman Regional glass sculpture created by Art Fusion of Oklahoma City in appreciation for their support and guidance over the past year. Ms. Shannon Largent, Healers Helping Healers (HHH) committee member reported over the past year, the HHH committee distributed to all healers many gifts of gratitude, meals, “High 5” Celebrations and programs focused on mental health and wellness. This was made possible with over $175,000 in contributions from the Health System, the NRHS Foundation and the NRHS Auxiliary. The HHH committee, Director’s Council, the NRHS Foundation and the Auxiliary also presented each Executive Team member with a glass tree sculpture inscribed with the phrase “Rooted and Inspired Thanks to You” followed by a video of appreciation from NRHS Directors. Other HHH committee members in attendance included: Ms. Barnhart, Ms. Raney, Mr. Bohanan, Mr. Beyer, Ms. Avila, Mr. Spray, Ms. Largent, Ms. Jones, Mr. Brawner and Ms. Fiebrich. All left the meeting at 5:56pm. Agenda Item III. Board Education A. TeleHealth Update Mr. Bryce Ell, Manager Telehealth Service Line presented an overview of NRHS Telehealth services. Mr. Ell provided an overview of the last 12 months of Telehealth services. He highlighted a nearly 50% increase in telehealth clinic visits from March 2020 to April 2020. Utilization of virtual/telehealth visits has been relatively constant and sustained over the past few months. At the beginning of the COVID-19 pandemic, Norman Regional Health System recognized that patients needed an easier way to receive care while self-isolating. As a result, NRHS leveraged their Norman Regional Virtual Care App, by enrolling 173 new providers for service. Those remarkable efforts were regc0gnized nationally by NRHS’s virtual care platform partner Amwell. American Well (Amwell), a national vendor serving hundreds of clients across the nation, recently awarded NRHS with the Pandemic Activation and Acceleration Award. This national award provided the opportunity for Mr. Ell and Ms. West, Manager of Telehealth, to speak at multiple online forums to healthcare leaders across the nation on how NRHS was able to quickly and effectively activate the NRHS Virtual Care App to provide more convenient access to care and to promote greater connectedness to NRHS providers as well as the health system. Thru grant writing efforts, NRHS received from the US Federal Communications Commission (FCC) over $900,000 thru the Cares Act funding to purchase I-pads for providers, carts for acute-care consultations, Remote Patients Monitoring Software and Bluetooth Pulse Oximeters, Hospital-at-home kits and Tytocare  NRHA Board Minutes 4 March 22, 2021 Remote Exam Kits. The Remote Patient monitoring allows for earlier interventions, reduces ED visits, hospital readmissions and directs patients to the right care, at the right time and in the right place. Since November 2020, NRHS has monitored more than 30 COVID-19 patients through the remote patient monitoring program. During this same time, the Inpatient Tele-Specialty Consult Service was activated. The goal of the program is to decrease wait time for consultations and promote provider efficiency. The program is achieving expectations. Additionally, Ms. Carter recognized Ms. Richardson and Ms. Burgess in their effects to meet our communities’ health and wellness needs. Together they researched areas to hold the 4 different COVID vaccine clinics in order to distribute the inoculations. Ms. Richardson and Ms. Burgess worked closely with the City of Norman to coordinate the clinics. Ms. Richardson, Ms. Burgess and Mr. Ell left the meeting at 6:11pm. Agenda Item IV. Approval of February 22, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the February 22, 2021 Board Meeting Minutes ACTION TAKEN: Mr. Chappel made the motion to approve the February 22, 2021 Board Meeting Minutes. Dr. Weber seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item V. Performance Updates Ms. Anderson, Administrative Director, Quality & Performance presented an overview of the strengths, weaknesses, opportunities and threats (SWOT) analysis & Clinical Excellence Measures and Continued Preparedness for Accreditation. A SWOT is an analysis used to evaluate a team and/or a process in healthcare. A SWOT is broken down as follows:  Strengths – what is working?  Weaknesses – What is halting progress?  Opportunities – What can be done/changed to improve progress?  Threats – What is harming or has the potential to harm progress? A SWOT analysis drives us to look at the big picture and helps to compile, analyze, and evaluate significant influences on our objectives or goals. This begins by examining the details of Structure, Process and Outcome:  Start with the data from each measure  Do an analysis of each type of measurement using Structure, Process and  NRHA Board Minutes 5 March 22, 2021 Outcome measures  Use matrix provided by Strategy & Growth  Perform analysis and make decisions o Be specific o Be objective o Be realistic o Apply content o Keep it simple Accreditation Readiness is on going as The Joint Commission has resumed in-person visits. We are preparing for this pending visit by conducting Environment of Care rounds, Gemba Walks, high level disinfection rounds and unit specific tracers. Agenda Item VI. Approval of the February 2021 Norman Regional Health System Financial Statements Mr. Hopkins presented the February 2021 Norman Regional Health System Financial report: February 2021 Financial Performance  Gross Revenues .................................. (Budget $194,279,202)............ $164,594,615  Net Patient Revenue .............................. (Budget $40,881,590).............. $34,535,215  Total Operating Expenses ..................... (Budget $41,430,432).............. $40,433,196  Total Operating Revenues ...................... (Budget $41,327,579).............. $34,823,696  Operating Income ....................................... (Budget $102,853).............. ($5,609,500)  Non-Operating Revenues (Expenses) ..... (Budget $1,091,247).............. ($3,246,864)  Excess Revenues over Expenses ............... (Budget $988,394).............. ($2,362,606) Year-to-Date  Operating Income .................................... (Budget $4,959,786).............. ($6,295,206)  Non-Operating Revenues (Expenses) ..... (Budget $8,730,011).............. $44,045,040  Excess Revenues over Expenses .......... (Budget $13,689,797).............. $37,749,834  Accounts Receivable Days ............................ (Budget 43 Days).................. 53.1 Days  Days Cash on Hand…………………………………………………………….202.0 Days ACTION TAKEN: Dr. Weber motioned to approve the February 2021 NRHS Financial Statements. Mr. Pipes seconded the motion. February Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item VII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on March 10, 2021.  NRHA Board Minutes 6 March 22, 2021 New Business:  COVID-19: Ms. McGill presented an update on the COVID-19 Hospital Plan and focus remains on patent and healer safety.  Ms. Price provided an update on the ongoing collaboration with the City of Norman and COVID vaccine clinics.  Dr. Carter provided a presentation on ED Criteria for Admission with Utilization Review.  Mr. Manfredo provided an Inspire Health update for all 3 campuses. Creditials Report:  Dr. Voto presented the credential report for recommended approval. Department Reports:  Reports were provided by Anesthesia, Cardiovascular Medicine, Hospital Medicine, Medicine Department, Pediatric Hospitalist, Physician Advisory Committee, Surgery Department and Transfusion Safety Committee. Medical Staff Report: None Administrative Reports:  Mr. Splitt announced Dr. Swearingen will be leaving NRHS the end of March and expressed appreciation for Dr. Swearingen’s leadership and service to NRHS and his patients.  Mr. Splitt reviewed possible upcoming Medicaid changes. Hospital Board Chair Report:  Mr. Cubberley provided a review of the February Board of Trustees educational meeting held February 22nd. Agenda Item VIII. Strategic Planning Committee Dr. Weber presented a report from the March 1, 2021 meeting. Mr Hopkins provided an update on the proposed Most Favored Nation Drug Pricing model for providers in the United States. Ms. Sara Rainey provided an update on the Social Determinants of Health Food Pharmacy. This update included the results of a survey related to COVID-19. Ms. Raney noted greater than 80% of the survey participants indicated they wanted to receive the vaccine when available to them. Ms. Kelly Wells provided an update on the Health Engagement Survey conducted in January 2021. 66% of healers participated in the survey and department actions plans are being developed now. Ms. McGill provided an update on NRHS COVID-19 status and supplies.  NRHA Board Minutes 7 March 22, 2021 Mr. Manfredo provided an Inspire Health project status on all 3 campuses. Agenda Item IX. Finance Committee A. Mr. Hopkins reported the Finance Committee met on Wednesday, March 15th. The committee presented the Resolution for Consolidated Retirement Plan and two capital items. B. Recommend Approval of the Resolution for Consolidated Retirement Plan ACTION TAKEN: Dr. Weber made a motion to approve the Resolution for Consolidated Retirement Plan. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Mr. Pipes, Dr. Anwar, Dr. Chambers and Ms. Greenleaf. C. Mr. Hopkins presented for approval two capital requests totaling $217,645: a. Peripherally Inserted Central Catheter (PICC) Ultrasound: $119,010 b. Washer Disinfector: $98,635 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $217,645 as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Mr. Pipes, Dr. Chambers and Ms. Greenleaf. Agenda Item X. Old Business None Agenda Item XI. New Business None Agenda Item XII. Administrative Report A. Ms. Price presented an overview of the Vaccine Clinics held around the City of Norman in March – including Irving Recreation Center, Lexington Crossing Mobile Home Park, Community Missionary Baptist Church and the Iglesia Pueblo de Dios Church. Each of these locations were selected in order to reach some of the most vulnerable members of the community. The City of Norman provided translators to assist with communication as needed.  NRHA Board Minutes 8 March 22, 2021 Ms. Brown and Ms. Anderson left the meeting at 6:46pm. 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; 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. Anwar, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. 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. William Hinojosa, DO – Surgery – Active b. Jason Divito, DO – Teleradiology – Privileges Only c. Aly El Banayosy, MD – ECMO – Privileges Only d. Michael Harper, MD – ECMO – Privileges Only e. Mircea Mihu, MD – ECMO – Privileges Only f. Laura Sweant, DO – ECMO – Privileges Only 2. Recommend Medical Staff Reappointments: a. Preeti Jhaveri, MD – OB/GYN – Active b. Kenneth Watson, DO – Emergency Medicine – Active c. Alyssa Ohs, MD – OB/GYN – Active d. Ronan Bakker, MD – OB/GYN – Consulting e. Girish Murthy, MD – Medicine – Consulting f. Dustin Wade, APRN-FNP – Emergency Medicine – Allied Health 3. Recommend Advancement of Medical Staff from Provisional Status: a. Anderson Greenhaw, MD – Anesthesiology – Active b. John “Buck” Hill, DO – Anesthesiology – Active c. Quentin Lobb. MD – Anesthesia – Active d. Daniel Cochran, MD – Surgery – Active e. Tom Connally, MD – Surgery – Active f. Amanda Ward, DDS – Surgery – Active g. Michael Padilla, MD – Surgery – Active h. Robin Mantooth, MD – Emergency Medicine – Active i. Stephanie Barnhart, DO – Emergency Medicine – Active j. Angela Carrick, DO – Emergency Medicine – Active k. Gary Wells, DO – Emergency Medicine – Active l. Terry Hill, DO – Emergency Medicine – Active m. Richard Brock, DO – Emergency Medicine – Associate n. Sheryl Ronne-Dellinger, APRN-CRNA – Anesthesiology – Allied  NRHA Board Minutes 9 March 22, 2021 Health o. Kent Bays, PA-C – Surgery – Allied Health p. Veronica Worrell, PA-C – Surgery – Allied Health q. Alexis Stinnett, APRN-CNS – Medicine – Allied Health r. Jorge Gorton, PA-C – Medicine – Allied Health s. Anderson Greenhaw, MD – Ortho Central t. Quentin Lobb, MD – Ortho Central u. Sheryl Ronne-Dellinger, APRN-CRNA – Ortho Central 4. Information Only: a. Jamie Steichen, PA-C – has completed required proctored cases for Thoracentesis, Lumbar Puncture and Liver/Kidney Biopsy b. Kevin Schubach, PA-C completed required proctored cases for Paracentesis and superficial aspiration biopsy privileges. C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Mr. Weber made a motion to adjourn out of Executive Session. Ms. Greenleaf seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. 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 1-4. ACTION TAKEN: Mr. Pipes 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. Dr. Anwar seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Anwar, Mr. Chappel, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item XIV. Board Open Discussion Mr. Cubberley shared “mini-evaluation” survey results from the February Board meeting. The board “mini-evaluation” tool supports NRHS’s commitment to the Pan-Do- Study-Act (PDSA) cycle. PDSA is an acronym for testing a change – by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining modifications to be made to the test or process (Act). This scientific method will be used for action-orientated learning and improvement in overall board performance. As such, Trustees were asked to share  NRHA Board Minutes 10 March 22, 2021 additional input on board meeting length, board packet content and consent agenda items. Feedback provided will be used to maintain the momentum of continuous governance improvement. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:02pm. Ms. Greenleaf seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary