Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting August 23, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, August 23, 2021 at 5:30p.m. in the Porter Education Center. The meeting Agenda was posted August 19, 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 Mary Womack Joan Greenleaf Kevin Pipes Others Present: Richie Splitt, President & CEO John Manfredo, COO 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 Karen Rieger, Attorney, Crowe & Dunlevy Lisa White, Manager Performance Improvements & Medical Staff Services Kelly Wells, Director, Planning & Communications Austin Gailey, Administrative Fellow Matthew Ohman, JC Penny Board Fellow Lisa Robertson, Manager Acute Care Rehabilitation John McFadden, Director Rehabilitation Service Line Cathy Snapp, Coordinator Quality Rehabilitation Service Line Rob Hoisington, Attorney, Foliart Huff Ottaway & Bottom Members Absent: Tom Sherman Diane Chambers, MD Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 August 23, 2021 Agenda Item I. Meeting Called to Order Mr. Cubberley called the August 23, 2021, Norman Regional Hospital Authority meeting to order at 5:36p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. August 2021 Healer of the Month – Cathy Snapp, Coordinator, Quality Rehab Service Line Mr. Cubberley introduced Ms. Lisa Robertson, Manger, Acute Care Rehabilitation. Ms. Robertson shared Cathy has worked at Norman Regional Health System (NRHS) for 21 years. She started the Orthopedic Center of Excellence in 2010 and continuously looks for ways to improve quality of care and maintains the Centers of Excellence status for NRHS’s orthopedics service line. She places the wellbeing of others before herself and is always ready to assist wherever the need is greatest. She works tirelessly to organize the therapy students and coordinates with the schools throughout the state. Ms. Snapp thanked the board for the honor. When she began working at NRHS 21 years ago, she accepted a job here thinking it would only be temporary until she could find a position closer to her home in Midwest City. 21 years later, she is still here due to her coworkers and the friendly environment she works in. Mr. Cubberley congratulated and thanked Ms. Snapp 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. Kristina Thai, September 2021 Healer of the Month was unable to attend the meeting. Ms. Thai will be recognized at next month’s meeting. Ms. Snapp, Ms. Robertson and Mr. McFadden left the meeting at 5:40pm. Mr. Splitt introduced Matthew Ohman, the new JC Penny Leadership Board Fellow. Mr. Ohman will be joining us thru the end of the school year in April 2022. Agenda Item III. Approval of July 26, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the July 26, 2021 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the July 26, 2021 Board Meeting Minutes. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf and Mr. Pipes.  NRHA Board Minutes 3 August 23, 2021 Agenda Item IV. Performance Update Ms. Anderson, Administrative Director, Quality & Performance Improvement, presented an update on FY2021 Clinical Excellence Measures and the Net Promoter Score metric for measuring Service Excellence. Clinical Excellence Measures for FY2021 were set to improve compliance with Sepsis Bundle, reduce falls with injury, reduce Healers needle sticks, reduce Central Line Days and reduce Surgical Site Infections. In the midst of still dealing with the pandemic, NRHS did not attain all of their final goals but did see overall improvements. Departments continue to implement the Plan, Do, Study, Act (PDSA) team goals for improvement. The Improvement Goals set for FY2022 are:  Sepsis Bundle Compliance: 57% (National Average)  Falls with Injury: 1.8 per 100 beds  Needle Stick Injuries to Healers: Revamping reporting system to capture all data accurately. Work to promote Healer knowledge and training in safety devices  Central Line Days: Standard Utilization Rate of <1.0 and below  Surgical Site Infections: Met FY2021 Goal and. Continue decrease in FY2022 Service Excellence has been using the real-time patient scored for the “Would Recommend” counts for 9’s or 10’s. Switching to a Net Promoter Score is a simpler way to measure singular metrics that track customer loyalty. This method takes patient satisfaction responses of 9’s and 10’s and subtracts answers in the 0-6 range. The goal is provide a more accurate ratings and perceptions that considers all scores. Agenda Item V. Approval of the July 2021 Norman Regional Health System Financial Statements Mr. Hopkins presented the July 2021 Norman Regional Health System Financial report: July 2021 Financial Performance  Gross Revenues .................................. (Budget $214,601,991)............ $211,182,879  Net Patient Revenue .............................. (Budget $44,675,085).............. $41,559,496  Total Operating Expenses ..................... (Budget $44,439,174).............. $44,023,350  Total Operating Revenues ...................... (Budget $45,056,521).............. $41,955,491  Operating Income ....................................... (Budget $617,347).............. ($2,247,859)  Non-Operating Revenues (Expenses) ........ (Budget $968,184).............. ($1,417,653)  Excess Revenues over Expenses ............ (Budget $1,585,531)................. ($830,206) Year-to-Date  Operating Income ....................................... (Budget $617,347).............. ($2,247,859)  Non-Operating Revenues (Expenses) ........ (Budget $968,184)................ $1,417,653  Excess Revenues over Expenses ............ (Budget $1,585,531)................... $830,206  Accounts Receivable Days ............................ (Budget 43 Days).................. 49.0 Days  Days Cash on Hand………………………………………………………….…214.0 Days  NRHA Board Minutes 4 August 23, 2021 ACTION TAKEN: Mr. Pipes motioned to approve the July 2021 NRHS Financial Statements. Dr. Anwar seconded the motion. July Financials were approved unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf and Mr. Pipes. Agenda Item VI. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on August 11, 2021. New Business:  The Utilization Review Plan was presented an approved. The Plan will be submitted to the NRHA Board of Trustees for review and approval.  Mr. Bohanan presented the Urinalysis Reflex criteria. Further discussion is needed before approval.  Mr. Hopkins presented the Financial Report.  Dr. Jawed announced the Memorandum of Understanding for the proposed restructuring of the Porter Campus Health Village will be on the City Council docket for approval on August 10th. Creditials Report:  Dr. Mullins presented the credential report with a recommendation for approval. Department Reports:  Reports were provided by GMEC/Residency Update, Hospital Medicine, Infection Committee, OB/GYN, Pathology, Pediatrics, Pediatric Hospitalist, Physician Advisory Committee, Radiology and Transfusion Safety Committee. Administrative Reports:  Dr. Boyd provided a reminder for COVID-19 testing locations.  Ms. McGill provided an update on the visitors policy. Same day testing clinics will be reopening.  Ms. Carter reported on the COVID-19 (monoclonal antibody) Infusion Centers.  Mr. Manfredo provided an Inspire Health Update. The Freestanding ED is expected to open in about 12 months.  Mr. Splitt thanked the physicians for their continuous hard work, compassion, understanding and thoughtfulness as they continue to care for our patients. Agenda Item VII. Patient Quality & Safety Committee A. Ms. Greenleaf announced a summary of the Patient Quality & Safety Committee is included in the board packet. Please contact Ms. Greenleaf is you have additional questions.  NRHA Board Minutes 5 August 23, 2021 Agenda Item VIII. Finance Committee A. Mr. Hopkins reported the committee met August 16th. The committee reviewed the financial report for July and discussed a change to the Defined Benefits Plan Year-end date. B. Recommended Approval of Resolution to Change Defined Benefits Plan Year- end date ACTION TAKEN: Dr. Weber made a motion to approve the Resolution to Change the Defined Benefits Plan Year-end date 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. Womack, Ms. Greenleaf and Mr. Pipes. C. Mr. Hopkins presented for approval 3 capital request items totaling $266,271: a. Infectious Disease Testing Equipment: $112,500 b. Arch: $59,640 c. Surgical Power Tools: $94,131 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $266,271 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. Womack, Ms. Greenleaf and Mr. Pipes. Agenda Item IX. Old Business Ms. McGill announced The Joint Commission (TJC) follow-up visit is on hold due to the COVID-19 resurgence in Oklahoma. No return visit date has been announced. Mr. Cubberley requested Trustee input regarding the monthly Board meeting survey. He asked if monthly assessments continue to be helpful or a quarterly survey preferred. Trustees agreed to continue with monthly Board meeting surveys. Agenda Item X. New Business A. Proposed Vote to Approve or Disapprove the FY2022 Utilization Review Plan. ACTION TAKEN: Dr. Weber made a motion to approve the FY2022 Utilization Review Plan. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf and Mr. Pipes.  NRHA Board Minutes 6 August 23, 2021 Agenda Item XI. Administrative Report A. Ms. Splitt introduced Rob Hoisington, attorney, who provides legal consulting services to NRHS. Mr. Hoisington will attend the Executive Session. B. Mr. Manfredo provided an Inspire Health update on the following:  New Entrances at the HealthPlex  Freestanding ED starting construction  Porter Health Village and the Behavioral Health facility progress  Budget overview C. Mr. Splitt announced Ms. Paula Price was not in attendance because she was at Norman High School assisting with COVID vaccines. Additional opportunities will be provided at Norman North High School, Longfellow Middle School and other upcoming activities. D. Dr. Boyd will be attending the next Norman City Council on behalf of NRHS to provide a COVID-19 update to Council members. Ms. White, Ms. Wells and Ms. Anderson left the meeting at 6:22pm Agenda Item XII. 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; and (ii) for the Purpose of Confidential Communications Between a Public Body and its Attorney Concerning Patricia Thompson v. NRHS, et al. 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. Womack, Ms. Greenleaf and Mr. Pipes. 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. Jeremiah Maupin, MD – Surgery – Active b. Caleb McCormick, MD – Anesthesiology – Active c. Luanne Solis, DO – OB/GYN – Active d. Dezaray Preuninger, APRN-CNP – Pediatrics – Allied Health e. Natalie Siegfried, DO – Nocturnist-Procedure Team – Privileges Only f. Derek Hill, Do – Nocturnist-Procedure Team – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: NRHA Board Minutes 7 August 23, 2021 a. Kendral Knight, MD – Medicine – Active b. Kimberly Cheatham, MD – OB/GYN – Active c. Dylan Shockley, APRN-CNP – Medicine – Allied Health d. Michelle Spehr, APRN-CNP – Pediatrics – Allied Heath e. Katie Dudley, APRN-CNP – Surgery – Allied Health 3. Recommend Medical Staff Reappointments: a. Juliana Bizzell, DO – Emergency Medicine – Active b. Matthew Davis, DO – Emergency Medicine – Active c. Shelly Zimmerman, DO – Emergency Medicine – Active d. James “Rick” McCurdy, MD – Surgery – Active e. Marvin “Dan” Isbell, MD – Surgery – Active f. Benjamin Collins, MD – Surgery – Active g. Emily Benham, MD – Surgery – Active h. John Chace, MD – Surgery – Active i. Brian Clowers, MD – Surgery – Active j. Zakary Knutson, MD – Surgery – Active k. Smaranda Galis, MD – Medicine – Active l. Ryan Davis, MD – Radiology – Active m. Ronnie Farris, MD – OB/GYN – Active n. Steven Jimerson, MD – OB/GYN – Active o. Kimberly Wise, MD – Surgery – Consulting p. Quang Tu, MD – Surgery – Courtesy q. Jason Falconer, APRN-CRNA – Anesthesia – Allied Health r. Stephanie Parsons, APRN-CNP – Pediatrics – Allied Health s. John Chace, MD – Ortho Central t. Brian Clowers, MD – Ortho Central u. Zakary Knutson, MD – Ortho Central v. Jason Falconer, APRN-CRNA – Ortho Central 4. Information Only a. Kevin Schubach, PA-C has met he required proctored cases for Arthogram and Bone/Bone Marrow biopsies. C. Discussion of Confidential Communications Between a Public Body and its Attorney Concerning Patricia Thompson v. NRHS, et al. D. 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 votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf and Mr. Pipes. 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.  NRHA Board Minutes 8 August 23, 2021 E. 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. Dr. Anwar seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Weber, Dr. Anwar, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. Ms. Wells returned to the meeting at 6:41pm. Agenda Item XIII. Board Education Ms. McGill, Ms. Carter and Mr. Splitt presented an update on COVID-19. The update included information on:  Potential Vaccine Booster shots  Flu Vaccine timeline  No Patient Left Alone Act  Pre-op Testing/screening process  Restricted hospital entrances  Employee Assistance Program (EAP) and Healer Support  COVID-19 infusion therapy treatments  Continued promotion of COVID vaccines  Healer COVID-19 Vaccine Program review Agenda Item XIV. Board Open Discussion None Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:45pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Dr. Weber, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf and Mr. Pipes. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary