Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting November 22, 2021 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, November 22, 2021 at 5:30p.m. in the Porter Board Room. The meeting Agenda was posted November 18, 2021 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley, Chairman James Chappel Mary Womack Joan Greenleaf Kevin Pipes Others Present: Richie Splitt, President & CEO John Manfredo, COO Brittni McGill, CNO Ken Hopkins, CFO Dr. Joe Voto, MD, Chief of Medical Staff 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 Danny Kelley, Administrative Director, HIT Steven Sheriff, Network Infrastructure Architect, HIT Debbie Oliphant, Patient Liaison, Risk Management Lisa Kerr, Manager, Risk Management Kevin D. Shepherd, Guest Members Absent: Tom Sherman Jerome (Jerry) Weber, Ph.D. Muhammad Anwar, MD Diane Chambers, MD Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called the November 22, 2021, Norman Regional Hospital Authority meeting to order at 5:35p.m.  NRHA Board Minutes 2 November 22, 2021 Agenda Item II. Introduction and Recognition of Outstanding Healer A. December 2021 Healer of the Month – Debbie Oliphant, Patient Liaison, Risk Management Mr. Cubberley introduced Mr. Larry Harden, Administrative Director, Risk Management & Compliance. Mr. Harden shared Ms. Oliphant has been a NRHS healer for 42 years. She is an absolute pleasure to work with and is the heart and soul of the Risk Management department. She handles the patient complaints, comments and requests with grace, care and compassion; a task that is not always easy. A gentleman called today to give Ms. Oliphant a compliment due to her efforts to go above and beyond his request. Her vast amount of experience and knowledge is a true asset for Norman Regional. Ms. Oliphant expressed her appreciation for the honor and has enjoyed her journey working with great healers. Mr. Cubberley congratulated and thanked Ms. Oliphant 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. Oliphant, Mr. Shepherd and Ms. Kerr left the meeting at 5:40pm. Agenda Item III. Board Education: Cyber Security Mr. Danny Kelley, Administrative Director, HIT and Mr. Steven Sheriff, Network Infrastructure Architect, HIT presented the annual Cyber Security Risk Assessment. Because cyber threats continue to disrupt all types of industries across the world, NRHS remains fully committed to ongoing investment that modernize and protect our electronic information and assets form unauthorized access, use and disclosure. Cybersecurity remains a chief focus for NRHS. NRHS partners with aleading security firm to help mitigate cybersecurity and complianc risks. Our partner is 100% healthcare-focused; which enables NRHS to continuously evaluate risks, strengthen our cybersecurity posture and improve security operations. During the month of October, NRHS participated in the national Cybersecurity Awareness month activities. The promotion encouraged users to create stronger passwords, to be cyber smart when visiting websites and never use the same passwords for personal accounts and work accounts.  NRHA Board Minutes 3 November 22, 2021 Agenda Item IV. Approval of October 25, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the October 25, 2021 Board Meeting Minutes ACTION TAKEN: Ms. Greenleaf made the motion to approve the October 25, 2021 Board Meeting Minutes. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Quality & Performance Improvement, presented an update on the Total Joint Replacement Program and PDSA for Post-Op Emergency Department Visits and Readmission Rates. Total Joint Replacement Program: the Hospital Readmission Reduction Program (HRRP) is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmission. The program support the national goal of improving health care for Americans by linking payment to the quality of hospital care. The HRRP 30-day risk standardized unplanned readmission measures include:  Unplanned readmission that happen within 30 days of discharge from the index (i.e. initial) admission.  Patients who are readmitted to the same hospital, or another applicable acute care hospital for any reason. Readmission to any applicable acute care hospital are counted, no matter what the principal diagnosis was. NRHS participates in the Centers of Medicare and Medicaid Services (CMS) 30-day readmission reporting requirement for all Total Joint Replacements (TJR). This data is shared publicly on the Care Compare website. Due to COVID-19, the in-person pre-operative education classes specific to Total Knee and Total Hip Replacements were halted temporarily. During that time, NRHS experienced an increase in TJR readmissions for some patients in the Emergency Department. A Patient Advisory Panel was formed to help construct a Plan, Do, Study, Act (PDSA) project to address the issues. In June 2021, the mandatory, online pre- operative education class was activated. PDSA results showed a reduction in ED visits and readmission for those attending the educational session. The majority of patients who returned to the ED or were readmitted did not attend a pre-operative TJR education class; demonstrating the value of in-person education for TJR procedures. Starting in 2022, the mandatory, online pre-operative education classes will focus on the following highlights:  Develop tracking system for patients to confirm they viewed the video. Tracking  NRHA Board Minutes 4 November 22, 2021 must be on a real-time basis. (completed)  Working to obtain additional tablets to allow patients to view video before or after pre-registration process. (in process)  Call patients and offer to send them DVD or emails links to appropriate videos. (completed)  Formulate the timeline to postpone surgery if pre-operative is not completed. (in process) Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on November 10, 2021. New Business:  Mr. Manfredo presented the Provider Wellness Initiative.  Mr. Hopkins presented the Finance Report.  Mr. Hughes presented an update on changes to the Perioperative antibiotic order set.  Dr. Jawed requested a Bylaws change regarding the timing of Chief of Staff elections. Creditials Report:  Dr. Mullins presented the credentials report with a recommendation for approval. Department Reports:  Reports were provided by Hospital Medicine, Infection Committee, Medicine, Pathology, Pediatrics, Pediatric Hospitalist, Physician Advisory Committee, Radiology and Surgery. Medical Staff Report:  Dr. Boyd provided an update on COVID-19 vaccine mandate. Administrative Reports:  Ms. Price announced the grand opening of The Well on November 12th. Board Chairmen’s Report:  Mr. Cubberley shared the Board report. Open Discussion:  Members thanks Dr. Jawed for his Chief of Staff services the past 2 years. Mr. Kelley and Mr. Sheriff left the meeting at 6:21pm. Agenda Item VII. Strategic Planning Committee  NRHA Board Minutes 5 November 22, 2021 A. Mr. Cubberley announced a summary of the Strategic Planning Committee is included in the board packet. Please contact Dr. Weber with additional questions. Agenda Item VIII. Finance Committee A. Mr. Hopkins reported the Finance Committee met November 15, 2021. B. Mr. Hopkins presented the Norman Regional Health System Financial report for October 2021: October 2021 Financial Performance  Gross Revenues .................................. (Budget $215,308,607)............ $211,198,019  Net Patient Revenue .............................. (Budget $45,242,490).............. $44,736,788  Total Operating Expenses ..................... (Budget $44,654,678).............. $46,821,907  Total Operating Revenues ...................... (Budget $45,623,926).............. $45,120,276  Operating Income ....................................... (Budget $969,248).............. ($1,701,631)  Non-Operating Revenues (Expenses) ........ (Budget $968,184).............. ($2,347,333)  Excess Revenues over Expenses ............ (Budget $1,937,432)................. ($645,701) Year-to-Date  Operating Income .................................... (Budget $3,056,084).............. ($7,155,501)  Non-Operating Revenues (Expenses) ..... (Budget $3,872,736)................ $3,045,020  Excess Revenues over Expenses ............ (Budget $6,928,820)................ $4,110,481  Accounts Receivable Days ............................ (Budget 48 Days).................. 50.1 Days  Days Cash on Hand………………………………………………………….…201.2 Days ACTION TAKEN: Mr. Pipes motioned to approve the October 2021 NRHS Financial Statements. Ms. Greenleaf seconded the motion. October Financials were approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. C. Mr. Hopkins presented for approval 3 capital request items totaling $1,059,450: a. Portable Patient Transport Monitors: $88,524 b. HIT Grid Cards: $593,426 c. Healer Communication Platform/App: $377,500 ACTION TAKEN: Ms. Greenleaf made a motion to approve the Capital Equipment request at a total cost of $1,059,450 as recommended by the Finance Committee. Ms. Womack seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. D. Modified FY22 Incentive Compensation Resolution ACTION TAKEN: Ms. Greenleaf made a motion to approve the Modified FY22 Incentive Compensation Resolution as presented by the Finance  NRHA Board Minutes 6 November 22, 2021 Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. E. Declaration of Official Intent for Reimbursement ACTION TAKEN: Mr. Pipes made a motion to approve the Declaration of Official Intent for Reimbursement as presented by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. Agenda Item IX. Old Business A. Proposed Vote to Changes in the NRHA Board Of Trustee Bylaws ACTION TAKEN: Mr. Pipes made a motion to approve the Changes in the NRHA Board of Trustee Bylaws. Mr. Chappel seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. Agenda Item X. New Business A. Risk & Compliance Update Mr. Larry Harden, Administrative Director of Risk Management & Compliance presented an update for the First Quarter, FY 2022. The update focused on the following areas:  Risk Management – compliance and patient confidentially remains a top priority for NRHS. A review of the July-September HIPPA Security Audit was provided.  Claims Management – provided an overview of insurance claims as of 11/03/2021.  Patient Experience – A statical analysis of patient complaints, compliments and service recovery was provided by type and department. Mr. Harden welcomed Adelaide Risberg to the staff as a Risk Management & Compliance Paralegal. B. NRHA Trustee Officer Elections ACTION TAKEN: Ms. Greenleaf made a motion to elect Mr. Doug Cubbereley as Chairman and Ms. Mary Womack as Vice Chairman/Secretary. Mr. Chappel seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes.  NRHA Board Minutes 7 November 22, 2021 Mr. Ohman left the meeting at 7:00pm Agenda Item XIII. Administrative Report A. Ms. Price reported Norman Regional Health System has been recognized for the 18th year in a row as a Certified Healthy Business – Excellence status. This is the highest award to be handed out by the Oklahoma State Department of Health. The second recognition is from the Oklahoma Hospital Association. Norman Regional was awarded the Healthy Hospital - Platinum Status for both the HealthPlex and Porter Campus. NRHS was recognized for our innovative approaches to health in the workplace. B. Mr. Splitt announced the photos being shared on the TV monitors were from the Norman Regional Nine Freestanding ED topping out ceremony and the No Hunger Holidays Events for Norman and Moore Public Schools. In a partnership with Feed the Children, NRHA healers handed out 1,600 boxes of food, personal hygiene items and toys. NRHS is currently working with Feed the Children to provide the same opportunity for Noble Public Schools in December. C. Ms. McGill reported NRHS’s first outpatient total knee replacement was performed this month by Dr. Maupin and was very successful. D. Mr. Manfredo provided an Inspire Health update including information on the HealthPlex construction, Freestanding ED and Porter Health Village. A monthly newsletter goes out to healers with updates on the entire project. Ms. Wells, Ms. White and Ms. Anderson left the meeting at 7:11pm 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; and CEO Evaluation ACTION TAKEN: Mr. Chappel made a motion to adjourn into Executive Session. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-3 Below. 1. Recommend Advancement of Medical Staff from Provisional Status: a. Hannah Holasek, PA-C - Pediatrics NRHA Board Minutes 8 November 22, 2021 2. Recommend Medical Staff Reappointments: a. Vincent Montgomery, DMD – Surgery – Active b. Mark Moses, MD – Surgery – Active c. Chintan Parikh, MD – Medicine – Active d. Tarig Mahmood, MD – Medicine – Active e. Michael Merkey, MD – Medicine – Active f. Holly Costner, DO – Emergency Medicine – Active g. Allen Rohde, DPM – Surgery – Consulting h. Andrew Goldberg, MD – Medicine – Consulting i. Daniel Leiker, APRN-CRNA – Anesthesia – Allied Health j. Tina Stinson, PA-C – Pediatrics – Allied Health k. Glen Diaz, APRN-CNP – Pediatrics – Allied Health l. Daniel Leiker, APRN-CRNA – Ortho Central 3. Information Only a. William Hinojosa, DO requesting full Robotic Privileges, Proctored cases completed C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: MR. Chappel made a motion to adjourn out of Executive Session. Ms. Womack seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Mr. Chappel, 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. 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 1-3. 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 1-3. Mr. Chappel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. F. CEO Evaluation ACTION TAKEN: Ms. Womack made a motion to postpone the CEO Evaluation until January 2022. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes.  NRHA Board Minutes 9 November 22, 2021 Agenda Item XV. Board Open Discussion Mr. Cubberley noted the Board Self-Assesment will be postponed until January 2022 when more trustees are in attendance. Ms. Greenleaf noted the Patient Quality and Safety Committee will meet in December and provide a report at the January 24, 2022 NRHA Board Meeting. Ms. Womack recognized Case Management for their great assistance to her family over the past month. Agenda Item XVI. Adjournment ACTION TAKEN: Ms. Greenleaf made a motion to adjourn the meeting at 7:16pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf and Mr. Pipes. Respectfully Submitted, Tom Sherman, Vice-Chair/Secretary