Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting June 28, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, June 28, 2021 at 5:30p.m. in the Porter Board Room. The meeting Agenda was posted June 24, 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 Mary Womack 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 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 Risk Management Jenny Odom, Staff Attorney, Risk Management Heather McDade, Manager Nursing Resources Reynaldo Hernandez, Patient Sitter Shannon Largent, Administrative Director Patient Care Services Lisa White, Manager Performance Improvements & Medical Staff Services Kelly Wells, Director Planning & Communications Adrian Francisco, Administrative Fellow Gina Morgan, Director Finance Jim Beyer, Administrative Director, Human Resources Members Absent: Tom Sherman Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 June 28, 2021 Agenda Item I. Meeting Called to Order Mr. Cubberley called the June 28, 2021, Norman Regional Hospital Authority meeting to order at 5:35p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. July 2021 Healer of the Month – Renaldo Hernandez, Patient Sitter Mr. Cubberley introduced Ms. Heather McDade, Manager Nursing Resources who presented Mr. Hernandez. Ms. McDade shared Mr. Hernandez has worked at Norman Regional for 1 year. Not only is he a patient sitter, but he is also a monitor tech, monitoring up to 9 patients at a time. His peers describe him as kind, humble and caring. He enjoys reading and drawing. He is very active in his church and is leaving the board meeting to teach Vacation Bible School. Mr. Hernandez recently transitioned from a patient sitter, to training to become a patient care technician (PCT) in ortho-spine. Ms. McDade stated his peers truly appreciate what he does, keeping our patients safe every day and doing it with pride. Mr. Cubberley congratulated and thanked Mr. Hernandez 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 health system. Mr. Hernandez and Ms. McDade left the meeting at 5:37pm. Agenda Item III. Community and Board Education: BRAVO Mr. Jim Beyer, Administrative Director of Human Resources presented an overview of the new employee healer recognition program “BRAVO”. B.R.A.V.O. stands for Bringing Recognition and Value to Others. The program name was selected by healers via a naming contest. BRAVO replaced the former recognition program in November of 2020 as a new way for all healers to recognize their peers for doing a great job at work. This recognition program is accessible to all healers through the NRHS intranet system. The BRAVO program offers 3 methods of recognition:  Peer to peer: recognition sent directly to another healer for a job well done, assistance or just a thank you.  Leadership recognition: leaders are allocated points each quarter that can be given out to healers for recognition. Healers can redeem points at any time or bank those points to be saved for larger prizes. A comprehensive prize catalog is offered online. Healers select a prize, cash in their points and the prize is sent  NRHA Board Minutes 3 June 28, 2021 directly to them from a preselected vendor. Points do not expire and may be accumulated over time.  BRAVO on the Go: This program is in the design process. This program will allow patients or visitors to recognize healers for their care and compassion. An app is being considered for download to assist with posting the praises. Mr. Beyer provided a step-by-step walkthrough of the program, reviewing the types of categories offered, the levels of recognition, birthday and anniversary recognition and an overview of the prizes offered. A healer my also self-report community involvement. Ms. Largent left the meeting at 5:50pm. Agenda Item IV. Approval of May 24, 2021, Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the May 24, 2021 Board Meeting Minutes with the corrected departure time of 6:44pm for individuals leaving the meeting before the Board adjourned into Executive session. ACTION TAKEN: Mr. Pipes made the motion to approve the May 24, 2021 Board Meeting Minutes with the amended correction. 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, Ms. Womack and Dr. Chambers. B. Mr. Cubberley asked for approval of the June 8, 2021 Special Study Session Minutes ACTION TAKEN: Dr. Weber made the motion to approve the June 8, 2021 Special Session 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. Pipes, Ms. Womack and Dr. Chambers. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Quality & Performance presented an update on CMS Value Based Programs which includes Value-Based Purchasing Program (VBP), Hospital Readmissions Reduction Program (HRRP) and Hospital Acquired Conditions Program (HAC). Quality & Safety is measured in healthcare to provide optimal outcomes for patients and patient safety. Since 1980, statistics have shown the gap has widened between US health spending and that of other countries and the life expectancy in the US has dropped compared to those who spend less on healthcare. VBP is a budget neutral item for CMS participants. Hospitals that perform better will receive the 2% withhold of Medicare dollars. Performance is based on Clinical  NRHA Board Minutes 4 June 28, 2021 Outcomes, Patient Experience, Safety and Efficiency. NRHS has experienced an improvement each year on “earned” amounts since starting in FY2016. HRRP is a penalty or no penalty program. This program measures 30 day All Cause Readmissions for Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Bypass Graph (CABG) and Hip/Knee. This is calculated using a predetermined Risk Ratio (actual/expected). To avoid penalty, ratios need to be better than expected. Since FY2017, NRHS has experienced consistent improvement, lessening the penalty over this time to just 0.06%. HAC Program measures Hospital Acquired Infections (HAI) and Patient Safety indicators. HAI’s carry a heavier weight in scoring and are also measured in the VBP. Health systems who perform in the bottom quartile will experience a 1% loss. For FY2022, CMS has proposed changing measurement periods so as not to include COVID. Broken down, the measures allow 6% of Medicare dollars at risk in VBP and 2% of Medicare dollars at risk for failure to report required metrics. NRHS balances those risks with continued improvement in quality of healthcare and patient safety. Agenda Item VI. Approval of the May 2021 Norman Regional Health System Financial Statements Mr. Hopkins presented the May 2021 Norman Regional Health System Financial report: May 2021 Financial Performance  Gross Revenues .................................. (Budget $212,063,457)............ $198,526,380  Net Patient Revenue .............................. (Budget $44,089,727).............. $41,447,754  Total Operating Expenses ..................... (Budget $43,879,379).............. $43,381,544  Total Operating Revenues ...................... (Budget $44,521,340).............. $41,793,389  Operating Income ....................................... (Budget $641,961).............. ($1,588,155)  Non-Operating Revenues (Expenses) ..... (Budget $1,091,252).............. ($1,662,416)  Excess Revenues over Expenses ............ (Budget $1,733,213)................... ($74,261) Year-to-Date  Operating Income .................................... (Budget $8,136,588).............. ($9,065,429)  Non-Operating Revenues (Expenses) ... (Budget $12,003,767).............. $53,802,665  Excess Revenues over Expenses .......... (Budget $20,140,355).............. $44,737,236  Accounts Receivable Days ............................ (Budget 43 Days).................. 43.2 Days  Days Cash on Hand………………………………………………………….…202.9 Days ACTION TAKEN: Mr. Pipes motioned to approve the May 2021 NRHS Financial Statements. Dr. Weber seconded the motion. May Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Sherman, Mr. Pipes, Ms. Womack and Dr. Chambers.  NRHA Board Minutes 5 June 28, 2021 Agenda Item VII. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on June 9, 2021. New Business:  Ms. Anderson presented the Quality Performance Improvement Plan and the Patient Safety Plan for the next year. The plans were approved by MEC.  Dr. Carter reviewed the Code Capacity Alert notifications.  Mr. Manfredo presented an Inspire Health update on the parking lot changes, new entrances at the HealthPlex and the Make Ready Plan.  Dr. Jawed reviewed the dress code policy. Creditials Report:  Dr. Mullins presented the credential report with a recommendation for approval. Department Reports:  Reports were provided by Behavioral Medicine, Cardiovascular Medicine, Hospital Quality Patient Safety Committee (HQPSC), OB/GYN, Pediatric Hospitalists, Pharmacy & Therapeutics, Radiology and Residency Program. Administrative Reports:  Ms. Price announced the “75 Years of Norman Regional” book has been released and is part of the health system’s “thank-you” to the community.  Ms. Carter provided an update on Managed Medicaid.  Mr. Splitt announced the Freestanding ED groundbreaking was June 3 and the HealthPlex groundbreaking is July 15th. Mr. Beyer left the meeting at 6:19pm. Agenda Item VIII. Patient Quality & Safety Committee A. Ms. Greenleaf announced a summary of the Patient Quality & Safety Committee meeting is included in the board packet. Please contact Ms. Greenleaf if you have additional questions. Ms. Greenleaf shared Maternal Child leadership provided a wonderful presentation to the committee on Amniotic Fluid Embolism. B. Recommend Approval of the FY2022 Quality & Performance Improvement Plan ACTION TAKEN: Dr. Weber made a motion to approve the FY2022 Quality & Performance Improvement Plan as recommended by the Patient Quality & Safety Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Ms. Womack and Cr. Chambers.  NRHA Board Minutes 6 June 28, 2021 C. Recommend Approval of the FY2022 Patient Safety Plan ACTION TAKEN: Dr. Weber made a motion to approve the FY2022 Patient Safety Plan as recommended by the Patient Quality & Safety Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Ms. Womack and Cr. Chambers. Agenda Item IX. Finance Committee A. Mr. Hopkins reported the committee met June 21st. The FY2022 budget was the main discussion topic. B. Recommend Approval of the FY2022 Budget ACTION TAKEN: Dr. Weber made a motion to approve the FY2022 Budget 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, Ms. Greenleaf, Mr. Pipes, Ms. Womack and Cr. Chambers. C. Mr. Hopkins presented for approval 4 capital request items totaling $816,594: a. Mobile C-ARM: $193,518 b. Infection Prevention Robot: $105,000 c. Mammography Unit: $437,340 d. Pulmonary Function Test Machine: $80,736 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $816,594 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, Ms. Greenleaf, Mr. Pipes, Ms. Womack and Dr. Chambers. Agenda Item X. Old Business Mr. Cubberley reminded the Trustees to fill out the monthly Board meeting surveys. Trustees were asked to provide further details that would improve Board packet information. Agenda Item XI. New Business A. Resolution to Insure Property Risk in a Captive ACTION TAKEN: Dr. Weber made a motion to approve the Resolution to Insure Property Risk in a Captive. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr.  NRHA Board Minutes 7 June 28, 2021 Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Ms. Womack and Dr. Chambers. Agenda Item XII. Administrative Report A. Mr. Splitt announced tonight is Adrian Francisco’s last Board Meeting as an Administrative Fellow. He has accepted a Clinic Managers position within NHRS. Mr. Splitt thanked him for being open to learning, listening and training. He thanked him for a job well done. B. Ms. McGill provided an update on the weeklong Joint Commission (TJC) reaccreditation survey visit. Healers designated as Guides & Scribes will be working directly with the surveyors, taking notes and pulling policies during the entire process. They will summarize and share their experience with the hospital’s TJC team at the end of each day. Multiple Life Safety and Environment of Care checks and a very detailed and thorough documentation review will occur throughout the week and across the entire health system. End of day debriefs will serve to review opportunities for improvement, correct appropriate finding and to prepare for the next day. C. Mr. Manfredo provided a Inspire Health update:  June 21st the “Make Ready plan” was launched for the HPX. Parking lots and entries were switched over to the temporary construction locations and new signage for way finding were revealed. This is the last step before the groundbreaking on July 15th.  Norman Regional Nine location has a on-site camera mounted to view the property and construction process 24 hours a day. The new fencing installation continues along the southern end of the property.  The Go-Live timeline was reviewed by phase for each project. This timeline includes new construction and remodel of existing structures. D. Mr. Splitt provided an update on the following:  The “Swag Bags” at each Trustee’s seat contains commemorative items from the 75th Anniversary Celebration at Porter and the Free-Standing ED (FSED) groundbreaking.  The HealthPlex groundbreaking is scheduled for July 15th at 9am.  The Young Family Athletic Center groundbreaking is scheduled for July 21st .  Friday, June 25th was the Emergency Medicine Residents graduation celebration. Six physicians graduated.  Some health systems across the country have made COIVD-19 Vaccines requirements as a condition of employment. NRHS is watching these developments closely. Research indicates existing COVID vaccines are effective against the coronavirus and new “delta variant”. Ms. White, Ms. Wells and Ms. Morgan left the meeting at 7:17pm Agenda Item XIII. Proposed Executive Session NRHA Board Minutes 8 June 28, 2021 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. Anwar, Ms. Greenleaf, Mr. Pipes, Ms. Womack 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. Vincent Petros, DO – Medicine – Active b. Lindsey Hannah, MD – Pediatrics – Active c. Sydney Boothe, APRN-CNP – Pediatrics – Allied Health 2. Recommend Advancement of Medical Staff from Provisional Status: a. Mahate Parker, MD – OB/GYN – Active b. Lane Tinsley, MD – Medicine – Active c. Jacinto Zambrano, MD – Medicine – Active d. Ted Jeffers, APRN-CNP – Pediatrics – Allied Health e. Julie Kramer, APRN-CNP – Pediatrics – Allied Health f. Mohammed Quraishi, MD – Teleradiology – Privileges Only g. Gregory Peters, MD – Teleradiology – Privileges Only h. Jonathan Reed, MD – Teleradiology – Privileges Only i. Ammar Taha, MD – Teleradiology – Privileges Only 3. Recommend Medical Staff Reappointments: a. Karen Sargent, MD – OB/GYN – Active b. Jeremy Moore, MD – Surgery – Active c. Richard Kirkpatrick, MD – Surgery – Active d. Stephen Ingels, MD – Pathology – Active e. James Seay, MD – Pathology – Active f. Christian Sieck, MD – Medicine – Associate g. Lisa Connery, MD – Medicine – Associate h. Valerie Manning, DO – Medicine – Associate i. Amanda Lewis, PA-C – Surgery – Allied Health j. Jeremiah Mattox, PA-C – Emergency Medicine – Allied Health k. Jordan Shuart, PA-C – Hospital Medicine – Allied Health l. Hillarie Kessler, PA-C – Ortho Central 4. Information Only: a. Rachelle Haning, DO requests Emergency Medicine privileges b. Andy Phillips, DO requests Emergency Medicine privileges c. Kate Petrilla, DO requests Emergency Medicine privileges C. Request to Adjourn Out of Any Such Executive Session and Return to Regular  NRHA Board Minutes 9 June 28, 2021 Session ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session. Mr. Pipes seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Ms. Womack 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: 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 1-4. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Anwar, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Ms. Womack and Dr. Chambers. Agenda Item XIV. Board Open Discussion Mr. Splitt shared Mr. Eddie Simms retirement party was held last week. He was a bridge and trust builder with the City of Moore and City of Norman and many others in the emergency responders community. He will be greatly missed. Mr. Splitt shared a video from Media Services promoting the COVID vaccine. This video will air on social media to encourage more individuals to consult with their physician for the vaccine. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:25pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Greenleaf, Mr. Pipes, Ms. Womack and Dr. Chambers. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary