Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting September 27, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, September 27, 2021 at 5:30p.m. in the Porter Education Center. The meeting Agenda was posted September 23, 2021 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chairman Muhammad Anwar, MD Diane Chambers, MD James Chappel Mary Womack Joan Greenleaf Kevin Pipes Others Present: Richie Splitt, President & CEO John Manfredo, COO 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 Kelly Wells, Director, Planning & Communications Gina Morgan, Director, Finance Delinda Wheeler, Manager, Finance Austin Gailey, Administrative Fellow Kelly Dexter, Manager, Education Center & Media Services Matthew Ohman, JC Penny Board Fellow Lisa Robertson, Manager Acute Care Rehabilitation John McFadden, Director Rehabilitation Service Line Kristina Thai, Physical Therapist, Physical Rehabilitation Steven Sheriff, Network Infrastructure Architect, Health Information Services Carley Williams, CPA, BKD Jessica Elsberry, CPA, BKD Becky Robins, CPA, BKD Members Absent: Jerome (Jerry) Weber, Ph.D. Tom Sherman Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 September 27, 2021 Agenda Item I. Meeting Called to Order Mr. Cubberley called the September 27, 2021, Norman Regional Hospital Authority meeting to order at 5:43p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. September 2021 Healer of the Month – Kristina Thai, Physical Therapist, Physical Rehabilitation Mr. Cubberley introduced Ms. Lisa Robertson, Manger, Acute Care Rehabilitation. Ms. Robertson shared Ms. Thai has been a healer at NRHS since the summer of 2019 and is a great asset to the Physical Rehabilitation Department. Ms. Thai has fearlessly assisted her fellow therapists in providing quality patient care while navigating their role in the COVID-19 pandemic. She is a joy to be around and is a strong patient advocate. NRHS patients benefit daily from her compassion and quality of care. Mr. Cubberley congratulated and thanked Ms. Thai 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. B. October Healer of the Month - Steven Sheriff, Network Infrastructure Architect, Health Information Services. Mr. Cubberley introduced Danny Kelley, Administrative Director & Chief Information Officer. Mr. Kelley Shared Mr. Sheriff has been with NRHS for 15 years and is currently the Senior Network Architect and Cyber Security Officer. Mr. Sheriff began his NRHS career as a Desk Top Engineer, moving into Network Design and Support before earning his Certification as an Information Systems Security Professional. When not a work, Mr. Sheriff stays busy with his wife and 3 daughters, volleyball, fishing and is an Eagle Scout. His coworkers state he always does what is best for NRHS, providing a wealth of information and dedication. He is enjoyable to work with and has a great sense of humor. Mr. Cubberley congratulated and thanked Mr. Sheriff 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. Thai, Ms. Robertson and Mr. McFadden left the meeting at 5:48pm.  NRHA Board Minutes 3 September 27, 2021 Agenda Item III. Board Education: Inclusion & Diversity Ms. Shumate, Mr. Francisco and Mr. Vandaveer presented an overview of the formation of the Inclusion and Diversity Council. The Inclusion and Diversity Council was formed to build an atmosphere of inclusivity and diversity of thoughts, opinions and people. The Council acts as an advocacy group and advisory board to ensure systemic implementation of inclusion and diversity with bidirectional communication with the Executive Team. The Council utilized a consultant Renea Butler-King, PhD, MSW for guidance. Dr. Butler-King recommended a 3-prong approach:  Establish a baseline competency of the Council  Grow relationships within the Council to strengthen trust  Formalize plan for Council development/growth The Council developed a PDSA (Plan, Do, Study, Act) project to collect information, perform mock interviews, study data and reflect on the process and create an annual project plan. Several areas were highlighted including encouraging awareness of cultural distinctions thru social media platforms and promoting specific cultural recognition days. The Council has developed an Intercultural Development Plan. This plan focuses on the Individual and Collective group plans, continued team building, intentional rest and reflection and developing a collective vision. The Council continues collaborating with local organizations throughout the Norman Regional Health System, Norman Public Schools and the Norman Police Department. Agenda Item IV. Approval of August 23, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the August 23, 2021 Board Meeting Minutes ACTION TAKEN: Ms. Greenleaf made the motion to approve the August 23, 2021 Board Meeting Minutes. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item V. 2021 Audit Presentation Mr. Cubberley introduced Carley Williams, CPA of BKD, Jessica Elsberry and Becky Robins, also from BKD. Ms. Elsberry reported that BKD issued an unmodified “clean” opinion for NRHS as they have every year. Areas reviewed were Management Override of Controls, Revenue Recognition, Patient Accounts Receivables, Third-party Payer Elements, Reserves in Workers Compensation and Health Insurance, General and Professional Liability,  NRHA Board Minutes 4 September 27, 2021 Defined Benefit Pension Plan Estimates, Provider Relief Funds and Government Grants and Transactions under the CARES Act. Mr. Williams presented the ratio analysis and reported three components used to compare operating results for NRHA with Peer organizations.  All Urban Hospitals with similar revenue size  All Near West Region hospitals (geographically similar)  A-rated S&P ratings Mr. Williams briefly reviewed the Balance Sheet and Income Statement within the Audit. He reported no significant changes from years past. ACTION TAKEN: Mr. Pipes made the motion to approve the 2021 Audit Report as recommended by the Finance Committee. Dr. Chambers seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item VI. Performance Update Ms. Anderson, Administrative Director, Quality & Performance Improvement, presented an update on rule changes in relation to COVID & Quality & Patient Safety measures, Quality Analytics in Health Information Management (HIM) and the Lean Project with Foundation and Auxiliary Grant process. Ms. Anderson reported there are three recent CMS Program changes in relation to COVID-19. Those changes include:  Hospital Acquired Condition (HAC) Program Federal Fiscal Year (FFY)2022 and FFY2023 will have a shorten reporting period to exclude Calendar Year 2020 data  FFY2023 will have suppressed a Pneumonia 30-day Mortality and Pneumonia 30-day Readmissions reporting measure from all value-based programs.  FFY2023 Mortality & Readmission Measures will exclude patients with a primary or secondary COVID diagnosis Present on Admission (POA). Ms. Anderson provided an update on the evolution of the Quality Analysis process for Health Information Management (HIM). In 2018, NRHS’s HIM Manager inquired about the possible benefit from the Quality Analysis process. At that time, the process entailed verifying all documents were present and each had appropriate signatures. As part of the Quality Analysis process, HIM now:  All documents are verified present per checklist  All documents have the required elements and signatures required  All document appropriately timed and dated  All documents completed within timeframes per bylaws, rules and regulations and The Joint Commission (TJC) standards.  NRHA Board Minutes 5 September 27, 2021  If a “No” answer to any of the above, an incomplete record is assigned as warranted and Provider Education on incomplete or insufficient records as needed The benefits of a Quality Analysis assures 100% medical record review, increased knowledge of incomplete medical records, more timely record reviews, zero medical staff documentation findings on most recent TJC survey, a more complete and accurate medical record for our patients and a dramatic decrease in number of Physician Suspension days. The Norman Regional Foundation recently asked for assistance with their current PDSA project examining their Grant Process using the Lean Process. The PDSA/Lean process helps streamline the process, looking for ways to make the process more timely and with less steps. This began by mapping out their process from start to finish: identifying areas with known issues including the request process, committee pre- review, special purpose requisition process, secondary department involvement and preparedness and delivery expectations. The new Target Process is in place and the committee plans to report back on how it has helped. Agenda Item VII. Approval of the August 2021 Norman Regional Health System Financial Statements Mr. Hopkins presented the August 2021 Norman Regional Health System Financial report: August 2021 Financial Performance  Gross Revenues .................................. (Budget $215,347,183)............ $217,544,778  Net Patient Revenue .............................. (Budget $44,892,739).............. $43,860,419  Total Operating Expenses ..................... (Budget $44,325,099).............. $47,213,316  Total Operating Revenues ...................... (Budget $45,274,221).............. $44,267,483  Operating Income ....................................... (Budget $949,122).............. ($2,945,833)  Non-Operating Revenues (Expenses) ........ (Budget $968,184).............. ($2,044,459)  Excess Revenues over Expenses ............ (Budget $1,917,306)................. ($901,374) Year-to-Date  Operating Income .................................... (Budget $1,566,469).............. ($5,193,692)  Non-Operating Revenues (Expenses) ..... (Budget $1,936,368)................ $3,462,112  Excess Revenues over Expenses ............ (Budget $3,502,837)................ $1,731,580  Accounts Receivable Days ............................ (Budget 45 Days).................. 50.7 Days  Days Cash on Hand………………………………………………………….…206.2 Days ACTION TAKEN: Mr. Pipes motioned to approve the August 2021 NRHS Financial Statements. Dr. Anwar seconded the motion. August Financials were approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item VII. Medical Staff  NRHA Board Minutes 6 September 27, 2021 A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on September 8, 2021. New Business:  Mr. Manfredo and Krista Cohen, Project Lead for CBRE provided an update on the each projects timeline for construction, transition and activation. (CBRE is the consulting firm selected by NRHS to assist with eh transition and activation planning required for Inspire Health.) Creditials Report:  Dr. Mullins presented the credential report with a recommendation for approval. Department Reports:  Reports were provided by Cardiology, Medicine Department, Physican Advisory Committee, Radiology and Surgery Departments. diatrics, Pediatric Hospitalist, Physician Advisory Committee, Radiology and Transfusion Safety Committee. Administrative Reports:  Dr. Boyd provided information on the upcoming COVID-19 Booster shot and Flu shot program.  Ms. Price announced the Vaccine clinic at Norman Public Schools has vaccinated 143 students aged 12-18. Agenda Item IX. Strategic Planning Committee A. Mr. Cubberley announced a summary of the Strategic Planning Committee is included in the board packet. Please contact Dr. Weber if you have additional questions. Agenda Item X. Finance Committee A. Mr. Hopkins reported the Committee reviewed the Audit and Proposed Gainsharing Goals for FY2022 B. Mr. Hopkins presented for approval 1 capital request item totaling $57,234: a. Ultrasound System: $57,234 (-$57,234 Foundation Grant) ACTION TAKEN: Mr. Pipes made a motion to approve the Capital Equipment Request at a total cost of $57,234 as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. C. Recommended Approval of Proposed Healer Gainsharing Goals for FY2022  NRHA Board Minutes 7 September 27, 2021 ACTION TAKEN: Mr. Pipes made a motion to approve the Proposed Gainsharing Goals for FY22. Mr. Chappel seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item XI. Old Business Ms. McGill provided an update on COVID-19 vaccine boosters, monoclonal antibody infusions and upcoming flu shot clinics. Ms. McGill announced a successful Cath Lab virtual site visit by the American College of Cardiology (ACC). NRHS received notification on September 27th of the Cath Lab’s Certification approval. Follow-up requirements from the health systems’ Spring 2021 Joint Commissions (TJC) visit have been accepted. The next TJC visit is for NRHS’s Stroke Program reaccreditation. It will be a virtual visit by TJC, and it will be closely followed by Inpatient Rehab and Perinatal Care certification site visits. Mr. Splitt thanked Dr. Anwar, his fellow healers and Ms. McGill for their hard work in obtaining the ACC recertification in the Cath Lab. Agenda Item XII. New Business A. Proposed Vote to Approve or Disapprove Resolution Authorizing the Filing of Grant Application with the Oklahoma Department of Transportation. ACTION TAKEN: Mr. Pipes made a motion to approve the Resolution Authorizing the Filing of Grant Application with the Oklahoma Department of Transportation. Mr. Chappel seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item XIII. Administrative Report A. Mr. Splitt announced a combined initiative with the Oklahoma Hospital Association (OHA) to request a portion of the >1.8 Billion COVID-19 relief funds received by the State of Oklahoma. Specifically, OHA members are exploring options to assist with expenses associated with clinical premium, retention and agency staffing pay. B. Mr. Manfredo provided an Inspire Health update on the following:  Current foundation-level construction at the HealthPlex  Freestanding ED starting vertical construction  Porter Health Village master plan and potential timing of project construction start dates Ms. Wells and Ms. Anderson left the meeting at 7:24pm  NRHA Board Minutes 8 September 27, 2021 Agenda Item XIV. 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: Mr. Pipes made a motion to adjourn into Executive Session. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, s. Womack, 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. Garrett Scott, MD – Anesthesia – Active b. Tarek Kanaa, MD – Behavioral Medicine – Active c. Marcia Gillespie, MD – OB/GYN – Active d. Jana McDonald, APRN-RNFA – Surgery – Allied Health e. Nikole Mackey, APRN-CRNA – Anesthesia – Allied Health f. Shawn Mayhew, APRN-CRNA – Anesthesia – Allied Health g. Jensen Atkinson, ARNN-CRNA – Anesthesia – Allied Health h. Kassi Stockert, MD – Medicine – Consulting Staff 2. Recommend Advancement of Medical Staff from Provisional Status: a. Sweatha Kasala, MD – Pediatrics – Active b. Sarah Walsh, APRN-CNS – Cardiology – Allied Health c. Amy Pedlow, PA-C – Surgery – Allied Health d. Jarret Kuo, MD – Teleradiology – Privileges Only 3. Recommend Medical Staff Reappointments: a. Kyle Toal, MD – Surgery – Active b. S. Edwards Dakil, MD – Surgery – Active c. Ryan Wilson, DO – Emergency Medicine – Active d. Lucas Trigler, MD – Surgery – Consulting e. Charles Anderson, DPM – Surgery – Consulting f. Blake Forcine, MD – Surgery – Consulting g. Leighann Price, APRN-CRNA – Anesthesia – Allied Halth 4. Information Only a. Archana Gautam, MD and Muhammad Salim, MD are requesting privileges for Transcatheter Mitral Valve Repair and Left Atrial Appendage Occluder privileges. C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session  NRHA Board Minutes 9 September 27, 2021 ACTION TAKEN: Ms. Greenleaf made a motion to adjourn out of Executive Session. Mr. Chappel seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, 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. C. 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: Ms. Greenleaf 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, Dr. Anwar, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Agenda Item XV. Board Open Discussion Mr. Cubberley announced the Trustees survey results from the September Board meeting were emailed to Trustees this afternoon. Trustees were asked to continue to provide details that will improve Board performance and Board meeting content. Agenda Item XVI. Adjournment ACTION TAKEN: Ms. Greenleaf made a motion to adjourn the meeting at 7:33pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes and Dr. Chambers. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary