Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting April 26, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, April 26, 2021 at 5:30p.m. in the Porter Auditorium. The meeting Agenda was posted April 22, 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. Tom Sherman Muhammad Anwar, MD Kevin Pipes James Chappel Joan Greenleaf Diane Chambers, MD 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 Karen Rieger, Attorney, Crowe & Dunlevy Lisa White, Manager Performance Improvements & Medical Staff Services Jenny Anderson, Administrative Director Quality & Performance Improvement Kelly Wells, Director Planning & Communications Jim Beyer, Administrative Director, Human Resources Julie McCurley-Smith, Manager Infection Prevention Adrian Francisco, Administrative Fellow Matt Mays, Board Fellow John McFadden, Director Rehabilitation Services Lisa Robertson, Manager Physical Therapy Stacy Pattillo, Assistant Physical Therapy Scott Williams, Guest Members Absent: Mary Womack  NRHA Board Minutes 2 April 26, 2021 Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the April 26, 2021, Norman Regional Hospital Authority meeting to order at 5:35p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. May 2021 Healer of the Month – Stacy Pattillo, Assistant Physical Therapy Mr. Cubberley introduced John McFadden, Director, Rehabilitation Services and Lisa Robertson, Manager, Physical Therapy who presented Ms. Pattillo. Mr. McFadden shared Ms. Pattillo is a joy to be around and she defines the ICARE philosophy. She is the most trusted healer in the department, a great communicator and the most passionate and kind individual. Ms. Pattillo always looks for solutions to any obstacle she may come across. Ms. Robertson states the department would not run as smoothly as it does without Ms. Pattillo, especially during the early months of COVID-19. She made a point to support and assist all her fellow healers, keeping them motivated and anchored. Her peers state she easily communicates with others, patients ask for her by name and she motivates them while singing and dancing with them. Ms. Pattillo shared she is humbled with the Healer of the Month honor. After leaving another health system in 1991 and joining Norman Regional, she knew she was where she needed to be – serving in her community. She hopes to continue as a part-time healer once she retires. Mr. Cubberley congratulated and thanked Ms. Pattillo 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. Mr. McFadden, Ms. Robertson and Ms. Pattillo left the meeting at 5:43pm. Agenda Item III. Board Education: Just Culture Ms. Jim Beyer, Administrative Director Human Resources presented an overview of Just Culture. Just Culture refers to a values-supportive model of shared accountability that drives continuous improvement. It’s a culture that holds organizations accountable for the systems they design and for how they respond to behaviors fairly and justly. Just Culture holds individuals accountable for the “quality of their choices” within a framework that considers human capacity, human fallibility, and demands improvement, not perfection. Just Culture evaluates the quality of the choice and the factors that influenced that  NRHA Board Minutes 3 April 26, 2021 choice. Those factors to consider can include:  Human error  At-risk behavior  Reckless behavior  Knowledge that harm would occur  Purpose to cause harm NRHS partnered with Outcomes Ingenuity to help train, build and sustain accountability for a Just Culture at NRHS. Combining their training and algorithms to evaluate influence, we can begin to determine if a behavior choice is blame worthy or blameless. Looking at Human error, quality of choices is examined. Depending on the outcome of the quality of choice, accountability is examined. Accountability can include:  Coaching  Remedial training and education  Progressive disciplinary action  Punitive action  At-will separation from employment  Discharge for misconduct Through a Just Culture, NRHS will better determine appropriate responses to conduct involved in adverse events, thereby promoting an open learning culture and a high degree of personal accountability. Mr. Beyer left the meeting at 6:03pm. Agenda Item IV. Approval of March 22, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the March 22, 2021 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the March 22, 2021 Board Meeting Minutes. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes & Dr. Chambers. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented an update on Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis and presented the CY 2021 Infection Prevention Plan for approval. This Performance Update is a follow-up to last month’s SWOT Analysis presentation. Teams were challenged to use the SWOT analysis:  Start with the data  Do an analysis of each type of measurement  Use matrix provided by the Strategy and Growth team  Perform analysis and make decisions  NRHA Board Minutes 4 April 26, 2021 Ms. Anderson presented an example from the ICOUGH team. [ ICOUGH is an acronym and national program that is designed to reduce pulmonary complications. The ICOUGH program emphasizes Incentive spirometry, Coughing and deep breathing, Oral care (brushing teeth and using mouthwash twice daily), Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation] Using the SWOT Analysis, the ICOUGH team came up with several interventions in each category and were able to determine if those were process, outcomes or structural measures. To date, structure of meetings and processes have been recurring themes. The next steps for the teams are to use SWOT Analysis to develop FY 2022 Clinical Strategic Plans. This can be achieved by:  Developing Goals  Providing Tactics and Timelines to meet desired goals  Challenge team to begin thinking about the key implementation strategy  Provide 2-3 tactics that are priorities for the team Ms. Anderson presented a review of the 2020 Infection Prevention Plan. The noted improvements were in Vancomycin Resistant Enterococcus (VRE) infections, NRHS Healer Flu Vaccine Compliance, Clostridium difficile (C Diff) goal and Surgical Site infections. The CY 2021 Infection Prevention Plan proposed changes (based on Risk Assessment of CY 2020) will be voted on in New Business. Agenda Item VI. Approval of the March 2021 Norman Regional Health System Financial Statements Mr. Hopkins presented the March 2021 Norman Regional Health System Financial report: March 2021 Financial Performance  Gross Revenues .................................. (Budget $213,843,061)............ $208,846,112  Net Patient Revenue .............................. (Budget $45,064,120).............. $43,943,074  Total Operating Expenses ..................... (Budget $44,117,875).............. $43,501,410  Total Operating Revenues ...................... (Budget $45,495,733).............. $44,304,577  Operating Income .................................... (Budget $1,377,858)................. ($803,167)  Non-Operating Revenues (Expenses) ..... (Budget $1,091,252).............. ($3,536,160)  Excess Revenues over Expenses ............ (Budget $2,469,110).............. ($4,339,327) Year-to-Date  Operating Income .................................... (Budget $6,337,644).............. ($5,492,039)  Non-Operating Revenues (Expenses) ..... (Budget $9,821,263).............. $47,581,201  Excess Revenues over Expenses .......... (Budget $16,158,907).............. $42,089,161  Accounts Receivable Days ............................ (Budget 43 Days).................. 50.0 Days  Days Cash on Hand…………………………………………………………….210.9 Days  NRHA Board Minutes 5 April 26, 2021 ACTION TAKEN: Mr. Pipes motioned to approve the March 2021 NRHS Financial Statements. Dr. Weber seconded the motion. March Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes & Dr. Chambers. Agenda Item VII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on April 14, 2021. New Business:  Ms. McGill provided an update on the health system’s COVID-19 atatus and vaccination plan – including the Johnson & Johnson vaccine.  Ms. McGill provided an update on the surgical site infection reduction initiatives completed by the Antimicrobial Stewardship Committee.  Dr. Jawed presented the recommended changes in verbiage to the Medical Staff Bylaws.  Mr. Manfredo presented an Inspire Health update on the proposed designs for the Porter Health Village and current construction stages at the HealthPlex. Creditials Report:  Dr. Mullins presented the credential report for recommended approval. Department Reports:  Reports were provided by Behavioral Medicine, Emergency Medicine, Hospital Medicine, Pediatric Hospitalist, Pharmacy & Therapeutics and Radiology. Medical Staff Report:  Dr. Boyd announced 153 total providers participated in Doctor’s Day. He announced the transition of duties for the Graduate Medical Education and Residency programs to Jamie Fuller, Amanda Jessie and Brooke Chatham. The Joint Commission site survey window is open and a visit is expected any time. Administrative Reports:  Ms. McGill announced NRHS was successfully accredited by The Joint Commission’s Center of Excellence program Total Joint/Total Knee.  Ms. Price announced the Norman Regional Foundations “iGive” Campaign ended in March and NRHS Healers raised over $200K. The Foundation Ambassador Ball is June 4th. The Norman Regional Nine Freestanding ED groundbreaking is scheduled for May 20th at 10:00am.  Ms. Carter provided a Physician update.  Mr. Splitt announced the plan approval for Norman Regional Nine from the City of Norman. He provided an update on the Porter Health Village plans.  NRHA Board Minutes 6 April 26, 2021 Mr. Splitt provided an update on Medicaid expansion in the State of Oklahoma. Hospital Board Chair Report:  Mr. Cubberley reviewed the Telehealth presentation presented at the NRHA Board meeting. B. Recommend Approval of Proposed Changes to the Medical Staff Bylaws. ACTION TAKEN: Dr. Weber made a motion to approve the proposed changes to the Medical Staff Bylaws as presented by the Medical Executive Committee. Ms. Greenleaf seconded the motion and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes & Dr. Chambers. Agenda Item VIII. Patient Quality & Safety Committee Ms. Greenleaf thanked Ms. Anderson and Ms. White for preparing the new summary reports for the board packets. This summary will be in the board packets as Patient Quality & Safety meetings occur. Ms. Greenleaf asked Trustees to notify the committee if there is any additional information they would like to see in the summaries. Agenda Item IX. Finance Committee A. Mr. Hopkins reported the committee met April 19th. The committee discussed the Bond Rating calls, Capital items and the Contract Process Policy. B. Mr. Hopkins presented for approval 2 capital request items totaling $186,682: a. Satellite Clinic: $108,700 b. HIT Servers: $77,982 ACTION TAKEN: Mr. Sherman made a motion to approve the Capital Equipment Requests at a total cost of $186,682 as recommended by the Finance Committee. Dr. Weber seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Mr. Sherman, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. C. Recommend Approval of the Contract Process Policy ACTION TAKEN: Mr. Pipes made a motion to approve the Contract Process Policy for 2021 as recommended by the Finance Committee. Dr. Weber seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes & Dr. Chambers.  NRHA Board Minutes 7 April 26, 2021 Agenda Item X. Old Business A. None Agenda Item XI. New Business A. Proposed Revisions to the 2021 Infection Prevention Plan Policy ACTION TAKEN: Ms. Greenleaf made a motion to approve 2021 Infection Prevention Policy as recommended by the Patient Quality & Safety Committee. Dr. Weber seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes & Dr. Chambers. B. Mr. Cubbereley announced a survey will be sent out to the Trustees from Ms. Price. This survey will consist of questions related to Trustees interest in attending Board education conferences this fall and next spring. Agenda Item XII. Administrative Report A. Mr. Splitt announced NRHS is expecting The Joint Commission (TJC) to visit NRHS at any time. TJC accredited organizations undergo unannounced surveys within 18-36 months of its previous survey, and NRHS is within that window. The purpose of the survey is to help participating healthcare organizations focus on providing safe, high quality care at all times. B. Mr. Manfredo presented an update on Inspire Health including:  Norman Regional Nine Freestanding ED construction fence will begin to go up on the border of the property.  Porter Health Village property transaction between NRHS and the City of Norman is progressing.  Three new parking lots are being prepared at the HealthPlex. The temporary entrances for the ED and main patient entrance are also advancing. C. Ms. McGill provided an update on the following:  COVID-19 patient hospitalizations are in the single digits currently and continue declining.  The Johnson & Johnson vaccine has been re-released for the single dose vaccination. NRHS will continue to administer all three COVID-19 vaccines as appropriate.  A new NRHS Satellite Clinic opened in Purcell in February. D. Ms Carter announced the “Friday Clinic” COVID-19 vaccines offered at the Porter campus will begin to phase out in May. We will transition to a provider clinic vaccine distribution process.  NRHA Board Minutes 8 April 26, 2021 E. Ms. Price announced the City of Norman approved use of Cares Act funds to cover the costs associated with supplies and labor at the Community Vaccine Clinics. Ms. Price presented a review of integrated marketing for the last quarter:  The Inspire Health website (InspireHealthOK.com) is now available for public access  New Logo designs for Norman Regional Nine and Porter Health Village have been finalized  Providing continual updates to healer communication boards  Monthly Inspire Health construction updates emailed to healers  Ortho Central website refreshed  NRHS 75th anniversary celebration is well underway  Business Development continues working with independent and employed providers for promotional marketing  Telligen QI Connect recognized the NRHS Population Health team with the Community Quality Champion Award for work during the COVID-19 pandemic. Telligen QI Connect is a quality improvement organization for Oklahoma, Colorado, Illinois and Iowa. This designation signifies efforts to address high priority health issues during the pandemic – including opioid misuse, increasing access to behavioral health services, ensuring smooth patient transitions with changes in level of care, patient safety, chronic disease prevention and self-care. The award also demonstrates Norman Regional’s continued commitment toward the overall health of it communities.  Adrian Francisco & Emily Bendick recognized Norman’s “Next under 40”. Norman NEXT is an organization for young professionals, 21-40 years of age, working or living in the Norman community. NEXT’s mission is to be the leading influence in making Norman the community where young professionals want to live, work and play. Through leadership, mentoring, networking and volunteerism, Norman NEXT cultivates and inspires young professionals to BE A POSITIVE agent of change for Norman. F. Mr. Splitt thanked Matt Mays, OU’s JC Penney Board Fellow for routine attendance to NRHA Board meetings this year. Ms. Anderson, Ms. White and Ms. Wells left the meeting at 7:04pm 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. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Mr. Sherman, Dr. Anwar, Ms. Greenleaf, Mr. Pipes & Dr. Chambers. NRHA Board Minutes 9 April 26, 2021 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. Sunil Mathew, MD – Cardiovascular Medicine – Active b. Kristen Innes, MD – OB/GYN – Active c. Rawel Randhawa, MD – Medicine – Active d. Edward Fogarty, MD – Teleradiology – Privileges Only e. Michelle Rossman, MD – Teleradiology – Privileges Only f. Kevin Marcum, MD – Teleradiology – Privileges Only g. Robert Schoaps, MD – ECMO – Privileges Only h. Mark Maybauer, MD – ECMO – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Ahmed Awab, MD – Medicine – Active b. Sabrina Young, DO – Medicine Active c. Nzube Okonkwo, MD – Hospital Medicine – Active d. Seth Brooks, DDS – Surgery – Active e. Thomas Wolf, MD – Surgery – Associate f. Benjamin Bigbie, MD – Medicine – Associate g. Nicole Alvarez, APRN-CRNA – Anesthesia – Allied Health h. Trayce Fowler, APRN-FNP – Emergency Medicine – Allied Health i. Taylor Herzer, PA-C – Emergency Medicine – Allied Health j. Amy Manfredo, APRN-CNP – Pediatrics – Allied Health k. Deanna Prufert, APRN-FNP – Emergency Medicine – Allied Health l. Micki Richardson, APRN-FNP – Emergency Medicine – Allied Health m. Spencer Baird, DO – Hospital Medicine – Privileges Only n. Madison Kilbury, DO – Hospital Medicine – Privileges Only 3. Recommend Medical Staff Reappointments: a. J. Patrick Sullivan, MD – Anesthesia – Active b. Robert Vogel, DO – Surgery – Active c. Clifton Whitesell, MD – Surgery – Active d. Kevin Penwell, DO – Emergency Medicine – Active to Associate e. Ryan Turner, MD – Medicine – Associate f. Marilyn Campbell, APRN-CRNA – Anesthesiology – Allied Health g. Lindsey Lightner, APRN-CRNA – Anesthesiology – Allied Health h. Stephen Isernhagen, PA-C – Surgery – Allied Health i. Michael Crawford, PA-C – Surgery – Allied Health j. Mary Underhill, Psy. D – Surgery – Allied Health k. Kasey DeGiusti, APRN-CNP, RNFA – Ortho Central l. Jennifer Enteshary, APRN-CRNA – Ortho Central 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. Mr. Pipes seconded, and the motion was approved unanimous aye  NRHA Board Minutes 10 April 26, 2021 votes from Mr. Cubberley, Dr. Weber, Mr. Sherman, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes & 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 1-3. 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. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Mr. Sherman, Dr. Anwar, Mr. Chappel, Ms. Greenleaf, Mr. Pipes & Dr. Chambers. Agenda Item XIV. Board Open Discussion Mr. Splitt reported Ms. Price will send out two online surveys to Trustees this week. One survey will inquire about trustee readiness for upcoming education sessions. The second survey will be the monthly Board meeting evaluation survey for the April meeting. Agenda Item XV. Adjournment ACTION TAKEN: Mr. Sherman made a motion to adjourn the meeting at 7:08pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Mr. Sherman, Dr. Anwar, Ms. Greenleaf, Mr. Pipes & Dr. Chambers. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary