Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting May 24, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, May 24, 2021 at 5:30p.m. in the Porter Auditorium. The meeting Agenda was posted May 20, 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 Kevin Pipes James Chappel Joan Greenleaf Members Present via Webex: Tom Sherman Mary Womack 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, Karen Rieger, Attorney, Crowe & Dunlevy Lisa White, Manager Performance Improvements & Medical Staff Services Kelly Wells, Director Planning & Communications Adrian Francisco, Administrative Fellow Gina Morgan, Director Finance Rachael Laib, Project Search Sherri Sturgill, Recruiter, Human Resources Troy Glover, Director, Facilities and Construction Roy Pendergraft, Mechanic Operations, Engineering Services Ron Cates, Manager, Engineering Services Members Absent: Diane Chambers, MD  NRHA Board Minutes 2 May 24, 2021 Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the May 24, 2021, Norman Regional Hospital Authority meeting to order at 5:35p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. June 2021 Healer of the Month – Roy Pendergraft, Mechanic Operations, Engineering Services Mr. Cubberley introduced Mr. Glover, Director of Facilities & Construction who presented Mr. Pendergraft. Mr. Glover shared Mr. Pendergraft is a lifelong resident of Norman and worked at Norman Regional for 9 years. He began his career as a plumber and was recently promoted to operations mechanic at the HealthPlex. In February, Norman experienced a storm of epic proportions – 9 straight days of sub-zero temperatures. Mr. Pendergraft and the entire engineering team worked 10 hour days, keeping sidewalks and parking lots cleared of ice. By the end of the week when the temperatures started to rise, pipes began to thaw and burst. Four straight nights, Mr. Pendergraft was called in the middle of the night to return to work for emergency repairs. Each time, he responded to the calls quickly, enthusiastically and professionally. One large repair required him to walk straight into a full stream of water to install a valve on a broken line while the water continued to flow. Mr. Pendergraft thanked everyone for the honor and his fellow healers who backed him and up and stepped up to assist. Mr. Cubberley congratulated and thanked Mr. Pendergraft 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. Mr. Glover, Mr. Pendergraft and Mr. Cates left the meeting at 5:41pm. Agenda Item III. Board Education: Project Search Ms. Sherri Sturgill, Recruiter, Human Resources and Ms. Rachael Laib, Project Search Instructor presented an update of the Project Search program. The partnership between Moore Public Schools (MPS) and NRHS began 5 years ago. Project Search is a program designed to provide adults with disabilities an opportunity to learn work and social skills and become productive members of society. The internship lasts one year and follows the MPS calendar. Interns are given the opportunity to work and train in several departments during their internship. Twenty-six students have graduated from the program over the first five years and Project Search  NRHA Board Minutes 3 May 24, 2021 will welcome seven new students in August. Ms. Sturgill shared a video prepared as a “Thank you” for the Oklahoma Education Association (OEA). The Project Search Program was awarded the Tuskahoma Brown Miller Award by OEA. Ms. Laib thanked NRHS for their support and allowing the students to work in departments across the Health System. Ms. Sturgill and Ms. Laib left the 5:46pm. Agenda Item IV. Approval of April 26, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the April 26, 2021 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the April 26, 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 & Ms. Womack. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented an update on “6S” Clinical Managers Projects and an update on FY2021 Performance Improvement Goals. 6S is about eliminating waste and maximizing value-added work. This process is used to create and maintain an organized, clean, safe and efficient setting that enables the highest level of value-added performance. 6S translates to: 1. Sort – Reduce, Re-use & Recycle. A messy workplace + difficult to work environment, non-value for time spent searching for supplies: Time = cost. 2. Straighten – Organize – label frequently used items. A place for everything, everything in its place. 3. Shine – Clean & Solve – ask yourself - how do we keep it organized, who is responsible for this, what is the process to restock and what is the cleaning? 4. Standardize – Make Consistent – visual instructions up to date and standard processes understood and performed by all. 5. Sustain – Self-discipline, Accountability and Audit – visualize and provide feedback. 6. Safety – Top Priority – Impact on healer and patient safety, avoid unnecessary hazards, relive stress and always “See Something, Say Something”. Ms. Anderson shared before and after photos of a storage room that was reorganized using the 6S model. Ms. Anderson reviewed Performance Improvement Plan Updates for FY 2021.  NRHA Board Minutes 4 May 24, 2021 Agenda Item VI. Approval of the April 2021 Norman Regional Health System Financial Statements Mr. Hopkins introduced Gina Morgan, Director Finance. Ms. Morgan may be presenting Financial Statement reports at future meetings. Mr. Hopkins presented the April 2021 Norman Regional Health System Financial report: April 2021 Financial Performance  Gross Revenues .................................. (Budget $207,889,937)............ $202,667,410  Net Patient Revenue .............................. (Budget $43,846,488).............. $41,176,537  Total Operating Expenses ..................... (Budget $43,120,469).............. $43,526,255  Total Operating Revenues ...................... (Budget $44,277,452).............. $41,541,020  Operating Income .................................... (Budget $1,156,983).............. ($1,985,235)  Non-Operating Revenues (Expenses) ..... (Budget $1,091,252).............. ($4,559,048)  Excess Revenues over Expenses ........... (Budget $2,2,48,235).............. ($2,573,813) Year-to-Date  Operating Income .................................... (Budget $7,494,627).............. ($7,477,274)  Non-Operating Revenues (Expenses) ... (Budget $10,912,515).............. $52,140,249  Excess Revenues over Expenses .......... (Budget $18,407,142).............. $44,662,975  Accounts Receivable Days ............................ (Budget 43 Days).................. 49.6 Days  Days Cash on Hand……………………………………………………………….205 Days ACTION TAKEN: Mr. Pipes motioned to approve the April 2021 NRHS Financial Statements. Dr. Weber seconded the motion. April Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes & Ms. Womack. Agenda Item VII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on May 12, 2021. New Business:  Mr. Hopkins provided a financial update.  Ms. McGill provided an update on the COVID-19 Hospital Plan.  Dr. Jawed lead the discussion of urine cultures.  Mr. Manfredo presented an Inspire Health update and reported June 21, 2021 is the new date for parking lot changes at the HealthPlex. Creditials Report:  Dr. Mullins presented the credential report with a recommendation for approval. Department Reports:  NRHA Board Minutes 5 May 24, 2021  Reports were provided by Anesthesia, Infection Committee, Medicine, Pathology, Pediatrics, Physician Advisory Committee, Radiology, Residency Program, Surgery and Transfusion Safety Committee. Administrative Reports:  Ms. Price announced the Provider Portal is now accessible for Employed and Independent Providers through the Health System’s website. The Norman Regional Nine Freestanding ED ground breaking is scheduled for May 20th, pending weather conditions.  Ms. Carter provided an update on Ambulatory Care and a post-COVID Recovery Program for patients experiencing lingering effects.  Mr. Manfredo provided an update regarding multi-factor authentication for system/network users.  Mr. Splitt announced Nurses week and Hospital week activities were a great success and well received by healers. Mr. Splitt provided an update regarding proposed Medicaid Managed Care changes. Agenda Item VIII. Strategic Planning Committee Dr. Weber announced a summary of the Strategic Planning Committee meetings is included in the board packet. Please contact Dr. Weber if you have additional questions. Dr. Weber noted the NRHS Foundation “I-Give” healer-driven campaign raised over $200,000 which will assist healers in their efforts to help improve the health and wellness of the community through Foundation projects and grants. Agenda Item IX. Finance Committee A. Mr. Hopkins reported the committee met May 17th. The committee discussed the Capital Items and calls with two Bond Rating agencies. Mr. Hopkins thanked Mr. Splitt and Ms. Gina Morgan for their assistance with those calls. B. Mr. Hopkins presented for approval 2 capital request items totaling $823,026: a. Clinic Renovation: $466,406 b. HIT Server Updates: $356,620 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $823,026 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, Mr. Sherman, Ms. Greenleaf, Mr. Pipes and Ms. Womack. Agenda Item X. Old Business A. Mr. Cubberley reminded the Trustees of an upcoming opportunity for a virtual leadership summit being offered by the American Hospital Association. An email containing information about the summit will be sent to Trustees for consideration.  NRHA Board Minutes 6 May 24, 2021 Agenda Item XI. New Business A. None Agenda Item XII. Administrative Report A. Mr. Splitt reported:  Healer Forums and Hospital Week wrapped up about 2 weeks ago. While participant feedback was positive, attendance was lower than previous forums. In the future, a virtual option will likely be added to Healer Forums.  Update on Medicaid Managed Care and Senate bills. B. Ms. Carter provided an update on:  Comprehensive Joint Replacement (CJR) 5 year program. For Program Year 5 – an increased earning over 2019 Program Year.  TMF Health Quality Institute, CMS’s Hospital Quality Improvements Contractor, has invited NRHS to participate in a voluntary case study for complicated patients due to our top 25% status for readmissions. This is a great recognition for the areas of Acute, post-Acute and Transitions of Care teams. C. Mr. Manfredo presented an update on Inspire Health that included:  Parking Lot transitions at the HealthPlex are scheduled to go into effect on June 21st. Fences are being installed around the construction sites.  A layout and tentative timeline of the Porter Health Village was reviewed.  Norman Regional Nine Freestanding ED groundbreaking has been delayed due to the continuous rain. The new date for groundbreaking is June 3rd.  An interior Art Consultant will be announced soon for all campuses. D. Ms. Price provided an update on the following:  The new groundbreaking for Norman Regional Nine is Thursday, June 3rd at 10:00. Due to heavy rains, the ceremony will likely take place on a nearby site. More information to follow.  The Norman Regional Hospital 75th Anniversary is scheduled for Monday, June 7th from 4-6pm.  The NRHS Provider Portal website is now live. Independent and Employed Providers will have access and are encouraged to provide feedback as this site continues to be refined. Ms. Anderson, Ms. White and Ms. Wells left the meeting at 6:44pm 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 NRHA Board Minutes 7 May 24, 2021 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 & 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 from Provisional Status a. Jennifer Baker, MD – Pediatrics – Active b. F. Clark Sauls, MD – Medicine – Active c. Megan Meyer-Hanner, DO – Medicine – Associate d. Ashley Helmbrecht, APRN-CNP – Pediatrics – Allied Health e. Paige Puryear, APRN-CRNA – Anesthesia – Allied Health f. Rhiannon Baker, APRN-FNP – Pediatrics – Allied Health g. Allison Nguyen, PA-C – Medicine – Allied Health h. Kathryn Cambron, MD – Radiology-Teleradiolgy – Privileges Only i. Shannon Calhoun, DO – Radiology-Teleradiology – Privileges Only j. Allison Summers, MD – Radiology-Teleradiology – Privileges Only k. Shawn Stone, MD – Radiology-Teleradiology – Privileges Only l. Shannon St. Clair, MD – Radiology–Teleradiology – Privileges Only m. Stanley Smith, MD – Radiology–Teleradiology – Privileges Only n. Veronica Ruvo, DO – Radiology–Teleradiology – Privileges Only o. Eugene Chang, MD – Radiology–Teleradiology – Privileges Only p. Timothy Conner, MD – Radiology–Teleradiology – Privileges Only q. David Henley, MD – Radiology–Teleradiology – Privileges Only r. Jason Grennan, MD – Radiology–Teleradiology – Privileges Only s. Jonathan Jaksha, MD – Radiology–Teleradiology – Privileges Only t. Farukh Mian, MD – Radiology-Teleradiology – Privileges Only u. Matthew Mendlick, MD – Radiology-Teleradiology – Privileges Only v. Steven McCormack, MD – Radiology-Teleradiology – Privileges Only w. Andrew Phillips, DO – Radiology-Teleradiology – Privileges Only 2. Recommend Medical Staff Reappointments: a. Michael Mullins, MD – Anesthesia – Active b. Scott Proctor, MD – Anesthesia – Active c. David Bobb, MD – Surgery – Active d. Lana Nelson, DO – Surgery – Active e. Michael Saumur, DDS – Surgery – Active f. Phillip Bird, MD – Medicine – Active NRHA Board Minutes 8 May 24, 2021 g. Michael Porter, MD – Emergency Medicine – Active h. Eric Thompson, MD – Pathology – Active i. Christopher Paskowski, MD – Surgery – Active j. Gordon Bean, DPM – Surgery – Consulting k. M. Sean O’Brien, DO – Surgery – Consulting l. Nicholas Plants, DPM – Surgery – Consulting m. Christopher Espinoza-Ervin, MD – Surgery – Courtesy n. Stephen Connery, MD – Medicine – Associate o. Christopher Edge, DO – Medicine – Associate p. Patrick Livingston, DO – Medicine – Associate q. Michelle Barnes, MD – Medicine – Associate r. Rebecca Greenwood, APRN-CRNA – Anesthesiology - Allied Health s. Kimberly Franks-Martens, APRN-CNP – Surgery – Allied Health t. Lauren Pratt, PA-C – Hospital Medicine – Allied Health u. Rebecca Gatewood, APRN-CRNA – Ortho Central – Allied Health 3. Information Only: a. David Miller, MD requests Privilieges for Transcatheter Aortic Valve Replacement (TAVR) b. Kevin Schubach, PA-C has completed required proctored cases for solid organ/core biopsy deep c. Jamie Steichen, PA-C ahs completed required proctored cases for bone/bone marrow biopsy and arthrogram 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. Ms. Greenleaf seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Dr. Weber, Mr. Sherman, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes & 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, Mr. Sherman, Dr. Anwar, Mr. Chappel, Ms. Greenleaf, Mr. Pipes & Ms. Womack.  NRHA Board Minutes 9 May 24, 2021 Agenda Item XIV. Board Open Discussion Mr. Cubberley requested additional input from Trustees related to the monthly Board meeting surveys. Trustees were asked to provide further details that would improve Board packet information and other suggestions for Board Education. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:51pm. 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 & Ms. Womack. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary