Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting October 25, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, October 25, 2021 at 5:30p.m. in the Porter Board Room. The meeting Agenda was posted October 21, 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 Jerome (Jerry) Weber, Ph. D. 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 Lisa White, Manager, Quality & Performance Improvement Larry Harden, Administrative Director, Risk Management Karen Rieger, Attorney, Crowe & Dunlevy Kelly Wells, Director, Planning & Communications Austin Gailey, Administrative Fellow Kelly Dexter, Manager, Education Center & Media Services Matthew Ohman, JC Penny Board Fellow Catherine Sison, Supervising Nurse, Med/Surg Tracee Barton, Nurse Manager, Med/Surg Rachel Minatee, Manager Population Health LeAnn Richardson, Administrative Director, Population Health Terra Collie, Director Patient Care Services Shannon Largent, Administrative Director, Patient Care Services & Accreditation Members Absent: 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 October 25, 2021, Norman Regional Hospital Authority meeting to order at 5:30p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. November 2021 Healer of the Month – Catherine Sison, Supervising Nurse, 4 North Med/Surg Mr. Cubberley introduced Ms. Tracee Barton, Nurse Manager, 4 North Med/Surg. Ms. Barton shared Ms. Sison has been a healer at NRHS for 21 years. In May of this year, she accepted her Nursing supervisor role and has never looked back. She has built an outstanding relationship with her fellow hears, becoming the go- to-person of the unit and the first person physicians reach out to. Her fellow healers describe her as dedicated, strong, kind, a natural leader, compassionate and dependable. Ms. Sison expressed her appreciation for the honor. She arrived in the United States 26 years ago on a working Visa, feeling blessed to be able to come to this country. Coming to America was a blessing, but this honor is the cherry on top. Mr. Cubberley congratulated and thanked Ms. Sison 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. Sison and Ms. Barton left the meeting at 5:34pm. Agenda Item III. Board Education: Merit-Based Incentive Payment System (MIPS) Ms. Minatee, Manager Population Health presented an overview of the Merit-Based Incentive Payment System (MIPS). MIPS is combination of the Value Based Payment Modifier, Physician Quality Reporting Program, Medicare EHR Incentive Program (aka Meaningful Use) and Merit Based Incentive Payment System. In 2015, the process was started to streamline and combine these programs and in 2017 MIPS was created. MIPS is a program that awards annual Medicare Part B performance payment adjustments for eligible clinicians based on the group Tax Identification Number (TIN) or National Provider Identifier (NPI). It has a 100- ppoint performance scale based on 4 categories with the final score resulting in a Composite Performance Score (CPS). Participation is based on either Merit-based Incentive Payment System or Alternative Payment Models. MIPS is divided into 4 categories:  NRHA Board Minutes 3 September 27, 2021  Quality – 40%  Cost – 20%  Improvement Activities – 15%  Promoting Interoperability – 25% MIPS changes to streamline the process for health systems of all sizes include:  Meaningful Measures: Eliminate measures that are redundant, not clinically relevant, and increase patient-centeredness of the measures  Burden Reduction: Reduce data collection and reporting burden on health systems and providers  Alignment Initiatives: Align measures across value-based programs and partners to allow health systems and providers to sharpen focus and narrow scope. Ms. Minatee, Ms. Richardson, Ms. Largent and Ms. Collie left the meeting at 5:49pm Agenda Item IV. Approval of September 27, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the September 27, 2021 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the September 27, 2021 Board Meeting Minutes. Ms. Greenleaf 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, Dr. Chambers and Dr. Weber. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Quality & Performance Improvement, presented a quarterly update on NEWs Wall metrics from Service and Clinical Excellence. With over 26,000 responses year to date, the Net Promoter Score ratings continues to move upward and above target. Recent changes to the NEWs Wall aim to make metrics, data and graphs easy to read and understand. The Clinical Excellence Quarterly Update measures are as follows:  Sepsis Bundle Compliance – the NRHS goal is 57%, matching the National Average. Upcoming changes to assist in reaching this goal by December 31 st include revising Inpatient and ED (Emergency Department) order sets to create better flow, update triage screenings in the ED and additional educational opportunities.  Central Line Utilization – Our goal is 1.1. Steps to improve performance include an increase in utilization during the COVID surge, Insertion Criteria has been established and reasons for central lines are assessed daily.  Foley Catheter Utilization – The goal is to be at 1.34. Steps to improve perfomran include an ongoing trial of external catheters, updating indwelling Foley catheter  NRHA Board Minutes 4 September 27, 2021 insertion criteria and daily assessments for need of catheters.  Restraint Days – This is a new clinical excellence measure. A group is being formed to begin looking at measures to reduce the number of falls. Goal is to be at 35 or less per 1000 patient days.  Falls with Injury – This measure has seen continued improvement since July and is within the goal range. This improvement is due to an increase in bed/chair alarm compliance with at-risk patients. Ms. Anderson provided an update on the Centers for Medicare and Medicaid Services (CMS) for reporting employee Flu and COVID-19 vaccine status. Agenda Item VI. Medical Staff A. Dr. Jawed presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on October 13, 2021. New Business:  Mr. Grandstaff presented information on new diet orders at discharge Meditech view.  Dr. Jawed discussed the new law allowing Physician Assistants to prescribe Schedule 2 drugs.  The Chief of Staff Election will be in November. Creditials Report:  Dr. Mullins presented the credential report with a recommendation for approval. Department Reports:  Reports were provided by Anesthesia, Behavioral Medicine, Emergency Medicine, GMEC, Hospital Medicine, Hospital Quality Patient Safety Committee (HQPSC), Pharmacy & Therapeutics, Physician Advisory Committee and Radiology. Administrative Reports:  Ms. Carter announced the Respiratory clinic space in Moore is no longer being utilized and will become the new location for the monoclonal antibody infusions.  Ms. Price announced the topping out ceremony for Norman Regional Nine will be on November 11th.  Mr. Manfredo provided an Inspire Health update.  Mr. Splitt shared an overview of the Vizient conference that he and Ms. Carter attended in Phoenix, AZ. They were there to present Inspire Health to conference attendees.  Norman Regional and the other Oklahoma Hospital Association members are coordinating a request for funds from the State of Oklahoma’s American Rescue Plan disbursement.  NRHA Board Minutes 5 September 27, 2021 Board Chairmen’s Report:  Mr. Cubberley shared the Board approved the clean 2021 audit for the health system and discussed the COVID Vaccine mandate. Agenda Item VII. Patient Quality & Safety Committee A. Mr. Cubberley announced a summary of the Patient Quality & Safety Committee is included in the board packet. Please contact Ms. Greenleaf if you have additional questions. Agenda Item VIII. Finance Committee A. Mr. Hopkins reported the Finance Committee met October 18, 2021. B. Mr. Hopkins presented the September 2021 Norman Regional Health System Financial report: August 2021 Financial Performance  Gross Revenues .................................. (Budget $208,575,596)............ $225,140,034  Net Patient Revenue .............................. (Budget $43,672,424).............. $46,345,651  Total Operating Expenses ..................... (Budget $43,528,530).............. $46,818,494  Total Operating Revenues ...................... (Budget $44,048,897).............. $46,723,333  Operating Income ....................................... (Budget $520,367)................... ($95,162)  Non-Operating Revenues (Expenses) ........ (Budget $968,184).............. ($2,764,425)  Excess Revenues over Expenses ............ (Budget $1,488,551).............. ($2,859,586) Year-to-Date  Operating Income .................................... (Budget $2,086,836).............. ($5,453,870)  Non-Operating Revenues (Expenses) ..... (Budget $2,904,552)................... $697,688  Excess Revenues over Expenses ............ (Budget $4,991,388)................ $4,756,183  Accounts Receivable Days ............................ (Budget 48 Days).................. 50.6 Days  Days Cash on Hand………………………………………………………….…196.5 Days ACTION TAKEN: Mr. Pipes motioned to approve the September 2021 NRHS Financial Statements. Dr. Weber seconded the motion. September Financials were approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. C. Mr. Hopkins presented for approval 2 capital request items totaling $133,760: a. Surgical Drills: $52,726.38 b. Windows 10 Upgrades: $81,033.33 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $133,760 as recommended by the  NRHA Board Minutes 6 September 27, 2021 Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes,Dr. Chambers and Dr. Weber. D. Recommended Approval of Charity Care Financial Assistance Policy ACTION TAKEN: Dr. Weber made a motion to approve the Charity Care Financial Assistance Policy as presented by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. E. Recommend Approval of Administrative Adjustments Policy ACTION TAKEN: Dr. Weber made a motion to approve the Administrative Adjustments Policy as presented by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. Agenda Item IX. Old Business None Agenda Item X. New Business A. Proposed Vote to Establish Dates and Times for 2022 Authority Meetings. ACTION TAKEN: Dr. Weber made a motion to approve the Dates and Times for the 2022 Authority Meetings. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. B. NRHS Trustee Officer Elections – Mr. Cubberley announced the Trustee Board Officer elections will be in November. A slate of officers will be submitted by the Governance Committee for consideration. C. CEO Annual Evaluation – Mr. Cubberley announced the CEO and Board evaluation will be conducted at the next board meeting. Both evaluations will be sent to trustees within the next 2 weeks. D. Proposed Vote to Approve and Disapprove Changes to the NRHA Board of Trustee Bylaws ACTION TAKEN: Dr. Weber made a motion to approve the Changes to the NRHA  NRHA Board Minutes 7 September 27, 2021 Board of Trustee Bylaws amending sentence wording in Article IV, Section 3, pertaining to term limits in sentence 1 and 3. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. Agenda Item XIII. Administrative Report A. Mr. Splitt shared the following:  A new partnership with the University of Oklahoma College of Nursing and Norman Regional. This partnership will incorporate clinical rotations and a curriculum for a bachelorette program for OU nursing students. Classes will be held on Norman Regional campuses. Mr. Splitt thanks Ms. McGill for her efforts to complete this important and beneficial initiative.  Within the last 2 weeks, the first outpatient partial knee surgery was performed by Dr. Maupin and the first colorectal surgery with the newest Da Vinci robot was performed by Dr. Kahanda.  NRHS is continuing to work with the Oklahoma Hospital Association to request ARPA funds (American Rescue Plan Act) from the State of Oklahoma. B. Mr. Manfredo provided an Inspire Health update on the Porter Health Village. C. Ms. McGill provided an update on The Joint Commission status for Stroke recertification, Peri-natal intra-cycle update and the survey from this summers’ for Hospital Accreditation and Behavioral Medicine. Ms. Wells, Ms. White and Ms. Anderson left the meeting at 7:23pm 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. Dr. Weber seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, s. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. 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. Annette Ntsama, MD – Hospital Medicine – Active NRHA Board Minutes 8 September 27, 2021 b. Kara Hatlevoll, DO – Hospital Medicine – Privileges Only c. Lucy Lane, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Chelsea Rommel, DO – Hospital Medicine – Active b. Pierre Ruhlmann, MD – Pediatrics – Active c. Eric Sparks, DO – Emergency Medicine – Active d. Amanda Lowry, APRN-CNP – Pediatric – Allied Health 3. Recommend Medical Staff Reappointments: a. David Miller, DDS – Surgery – Active b. Greg Rohde, DPM – Surgery – Active c. Joel Razook, MD – Medicine – Active d. Mohammad Farukhi, MD – Surgery – Active e. James Bond, MD – Surgery – Active f. Jason Leonard, MD – Anesthesia – Active g. Mark Scott, MD – Surgery – Consulting h. Meghan Scears, MD – Medicine – Consulting i. Ronald “Hal” Bays, APRN-CRNA – Anesthesia – Allied Health j. Jennifer Fleck, APRN-CRNA – Anesthesia – Allied Health k. Amber Moser, APRN-CRNA – Anesthesia – Allied Health 4. Information Only a. William Hinojosa, DO requesting Robotic Privileges b. Kevin Schubach, PA-C has met the required proctored cases for Arthogram and Bone/Bone Marrow biopsies c. Joseph Karan, MD proctored temporary privileges to assist William Hinojosa, DO 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 votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. 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  NRHA Board Minutes 9 September 27, 2021 1-4. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Dr. Anwar, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. Agenda Item XV. Board Open Discussion Dr. Weber asked for clarification of the COVID Vaccine Mandate survey. Mr. Splitt explained the survey process and will provide an update at a future board meeting. Agenda Item XVI. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:52pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Dr. Anwar, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Chambers and Dr. Weber. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary