Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting January 24, 2022 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, January 24, 2022 at 5:30p.m. in the Porter Education Center. The meeting Agenda was posted January 22, 2022 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 Jerome (Jerry) Weber, Ph.D. Diane Chambers, MD Muhammad Anwar, MD Tom Sherman Others Present: Richie Splitt, President & CEO John Manfredo, COO Brittni McGill, CNO Ken Hopkins, CFO Dr. Joe Voto, MD, Chief of Medical Staff 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 Jim Goldsbury, Multimedia & Video Specialist Matthew Ohman, JC Penny Board Fellow Clyde Brawner, Director, Environmental Services Nick Skinner, Manager, Environmental Services Andy Smith, Lead Technician, Environmental Services Annette Troxell, Director, Patient Care Services Tracy Mills, Nurse Manager, Labor, Delivery & Recovery Charlotte May, RN, PRN 1, Labor, Delivery & Recovery James Gibson, Guest Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order  NRHA Board Minutes 2 January 24, 2022 Mr. Cubberley called the January 24, 2022, Norman Regional Hospital Authority meeting to order at 5:33p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. January 2022 Healer of the Month – Charlotte May, BSN, RNC-OB, C-EFM, RN2, Labor, Delivery & Recovery. Mr. Cubberley introduced Ms. Tracy Mills, MSN, RNC-OB, Nurse Manager, Labor, Delivery & Recovery. Ms. Mills shared Ms. May graduated with a BSN from East Central University in 2015. She has been a nurse for over 6 years, working in Med-Surg, Oncology before her transferring to Labor and Delivery 3 years ago. Ms. May has had the privilege of attending 303 deliveries to date. She chose nursing because she loves being present for patients during some of the best and worst times of their lives. Ms. May recently achieved national certifications in Inpatient Obstetrics and Electronic Fetal Monitoring. Co-healers of Ms. May shared that she is the most approachable nurse they have ever encountered and she is always quick to jump in to help during emergencies. She just knows what needs to be done. It is so reassuring to have a coworker like that on your shift. Ms. May expressed her appreciation for the honor and her admiration of her fellow healers. Mr. Cubberley congratulated and thanked Ms. Mills 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. May and Mr. Gibson left the meeting at 5:36pm. B. February 2022 Healer of the Month – Andy Smith, Environmental Services, Technician, Environmental Services. Mr. Cubberley introduced Mr. Andy Smith, Environmental Services Technician, Environmental Services (EVS), presented by Clyde Brawner, Director, Environmental Services and Distribution/Transportation Services. Mr. Brawner shared Mr. Smith has worked at NRHS for 6 years. His fellow workers admire him and had previously selected him as the Healer of the Quarter for the EVS department. Mr. Smith takes great care in his day-to-day work focusing on the proper removal of general and medical waste and carpet care throughout the Porter campus. His peers noted that he works hard. Departments throughout the hospital never  NRHA Board Minutes 3 January 24, 2022 have to request additional pick-ups because he is always reliable and thorough, and he quickly volunteers to assist others outside of his daily tasks. Mr. Smith expressed his appreciation for the honor and is grateful to work at Norman Regional. Mr. Cubberley congratulated and thanked Mr. Smith 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. Mr. Smith, Mr. Brawner, Mr. Skinner, Ms. Troxell and Ms. Mills left the meeting at 5:39pm C. Recognition of Dr. Farhan Jawed, for his service as Chief of Staff presented by Dr. Joe Voto. Dr. Voto shared Dr. Jawed has been an amazing leader for the past 2 years. No one has ever served as Chief of Staff during a pandemic and he lead with passion and commitment. Dr. Voto thanked Dr. Jawed for his guidance, leadership and devotion to the medical staff and patients at Norman Regional. Mr. Splitt thanked Dr. Jawed for his service, leadership and inspiration during this unprecedented time and presented him with an award. Dr. Jawed expressed his gratitude for the honor of serving as Chief of Staff for the past 2 years. He expressed thanks for the fellowship and the experience gained while serving in this capacity. Dr. Jawed thanked the Trustees and executive staff for their support over the last 2 years. He looks forward to continuing to work within this great community and serving patients at Norman Regional. Larry Harden, Administrative Director Risk Management & Compliance introduced Luke Moyer, Privacy & Compliance Staff Attorney. Luke graduated first in his class from the University of Tulsa College of Law. He comes to us from the Department of the Army, Office of General Counsel where he worked in the Pentagon as a member of the Army’s Privacy Breach Response Team. Dr. Jawed left the meeting at 5:45pm. Agenda Item III. Board Education: Clinical & Technological Advancements Ms. Brittni McGill, CNO presented information related to the Clinical and Technological Advancements throughout Norman Regional. Ms. McGill shared that traditional invasive procedures and surgeries are shifting to more minimally invasive procedures (e.g. robotics). Surgeons use a variety of technologies and techniques that provide patients smaller incisions, less blood loss, shorter recovery  NRHA Board Minutes 4 January 24, 2022 times, and shorter lengths of stay in the hospital (if an overnight hospital stay is required at all). Technology today can provide 3D visualization which improves surgical site observation as well as image magnification. Dexterity is also improves by many of the surgical instruments. Patients are seeking less invasive surgical options. Less invasive techniques have become a standard in surgical/procedural training programs and aligns with the CMS (Centers for Medicare and Medicaid) Triple Aim: improving patient experience, clinical quality and decreasing costs. They often provide notable precision, flexibility and control to perform many types of procedures. These smart systems and instruments help reduce variability in surgery and deliver high quality and safe surgical care. Norman Regional currently implements these minimally invasive procedures in General and Gastrointestinal Surgery, Urology, Pulmonology, Cath Lab, Orthopedics and Robotic Surgeries. Agenda Item IV. Approval of November 22, 2021, Norman Regional Hospital Authority Board Meeting Minutes Mr. Cubberley asked for approval of the November 22, 2021 Board Meeting Minutes with the correction and amendment of the noted motion made in Agenda Item VIII, D. The motion made was changed from Dr. Weber to Ms. Greenleaf. ACTION TAKEN: Dr. Weber made the motion to approve the November 22, 2021 Board Meeting Minutes with the correction to amend the motion made in Agenda Item VIII, D, from Dr. Weber to Ms. Greenleaf. Ms. Womack seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr. Sherman. Agenda Item V. Performance Update Ms. White, Manager, Quality & Performance Improvement, presented an update on the FY2022 Performance Improvement Plan and the CY2021 Infection Prevention Plan. The Performance Improvement Plan currently reflects 6 of the 14 measures exceeding the FY2022 goals. The committee anticipates these numbers will improve before the end of the fiscal year. The Infection Prevention Plan evaluation has not yet been finalized for CY2021, however, NRHS is currently meeting 5 of the 13 measures. A Plan, Do, Study Act (PDSA) is ongoing for each measure as well as a review of possible barriers that can prevent NRHS from reaching goals. Agenda Item VI. Medical Staff  NRHA Board Minutes 5 January 24, 2022 A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on January 4, 2022. New Business:  Mr. Manfredo presented an Inspire Health Update  Mr. McFadden presented the Six Club Mobility Protocol Presentation Credentials Report:  Dr. Mullins presented the credentials report with a recommendation for approval. Department Reports:  Reports were provided by Anesthesia, Cardiovascular Medicine, Emergency Medicine, GMEC/Residency Update, Hospital Medicine, Medicine Department, OB/GYN, Pharmacy & Therapeutics, Physician Advisory Committee, Radiology Department and Surgery. Medical Staff Report:  Dr. Boyd provided an update on COVID-19. Administrative Reports:  Mr. Splitt thanked all healers for their continued work with patient care. Mr. Splitt thanked Dr. Jawed for his service as Chief of Staff for the past 2 years. Board Chairmen’s Report:  Mr. Cubberley shared the Board report. B. Recommend Approval of Hospital Medicine Privilege Request Form ACTION TAKEN: Mr. Sherman made a motion to approve the Hospital Medicine Privilege Request Form as presented by the Medical Executive Committee. Dr. Weber seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr.Sherman. Agenda Item VII. Patient Quality & Safety Meeting A. Mr. Cubberley announced a summary of the Patient Quality & Safety Committee is included in the board packet. Please contact Ms. Greenleaf with additional questions. Agenda Item VIII. Strategic Planning Committee A. Mr. Cubberley announced a summary of the Strategic Planning Committee is included in the board packet. Please contact Dr. Weber with additional questions.  NRHA Board Minutes 6 January 24, 2022 Agenda Item IX. Finance Committee A. Mr. Hopkins reported the Finance Committee met January 17, 2022. B. Mr. Hopkins presented the Norman Regional Health System Financial report for January 2021: December 2021 Financial Performance  Gross Revenues .................................. (Budget $215,295,509)............ $228,845,790  Net Patient Revenue .............................. (Budget $45,357,696).............. $48,358,786  Total Operating Expenses ..................... (Budget $44,761,531).............. $48,588,927  Total Operating Revenues ...................... (Budget $45,739,132).............. $48,783,661  Operating Income ....................................... (Budget $977,601)................. ($194,733)  Non-Operating Revenues (Expenses) ........ (Budget $968,184).............. ($8,162,522)  Excess Revenues over Expenses ............ (Budget $1,945,785).............. ($8,357,255) Year-to-Date  Operating Income .................................... (Budget $4,881,733).............. ($8,335,821)  Non-Operating Revenues (Expenses) ..... (Budget $5,809,104).............. $13,312,315  Excess Revenues over Expenses .......... (Budget $10,690,837)................ $4,976,494  Accounts Receivable Days ............................ (Budget 48 Days).................. 46.3 Days  Days Cash on Hand………………………………………………………….…206.2 Days ACTION TAKEN: Mr. Pipes motioned to approve the December 2021 NRHS Financial Statements. Ms. Greenleaf seconded the motion. December 2021 Financials were approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr.Sherman. C. Mr. Hopkins presented for approval 4 capital request items totaling $2,955,896: a. Lab Draw Station: $56,925 b. Hospital Grade Televisions: $100,329 c. Foundation Grant for Televisions: -$100,329 d. Relocation of Endocrinology Clinic: $37710,599 e. NMotion Clinic - Phase I Payment: $2,188,372 ACTION TAKEN: Mr. Pipes made a motion to approve the Capital Equipment request at a total cost of $2,955,896 as recommended by the Finance Committee. Dr. Weber seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr. Sherman. Agenda Item X. Old Business None  NRHA Board Minutes 7 January 24, 2022 Agenda Item XI. New Business A. Ms. McGill presented an update on COVID patient hospitalizations and “No Patient Left Alone” Act. Through a Norman Regional Foundation grant, Norman Regional has been able to provide iPads on rolling stands for families to use for virtual visitations and a Translation App to assist with communicating between patients, families and healers. Agenda Item XII. Administrative Report A. Mr. Splitt thanked the Executive team, leaders and healers for their continuous standard of going above and beyond to care for NRHS patients. Mr. Splitt specifically acknowledged Ms. McGill for her creativity in providing staffing resources during times of the most recent COVID surge. Mr. Splitt reminded trustees of 2 upcoming events for the Board to attend including the Oklahoma Hospital Association webinar, “Governance Megatrends” on January 26th and the Board Advance study session on February 12th. B. Mr. Splitt provided a Medicaid Managed Care update. C. Ms. Price introduced Jim Goldsbury from Media Services. Mr. Goldsbury is the newest healer in the Media Services department. Ms. Price reported that NRHS expanded the No Hunger Holidays campaign last December to Noble Public Schools. In partnership with Feed the Children, we were able to provide boxed food and personal hygiene items to 400 students and their families. Additionally, NRHS donated numerous food items to the Food Pantry of Noble High School to assist with multiple families in need. Agenda Item XIII 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: Dr. Weber made a motion to adjourn into Executive Session. Mr. Sherman seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr. Sherman. Mr. Splitt, Mr. Manfredo, Ms. Carter, Mr. Hopkins, Ms. Price, Ms. McGill, Dr. Bonds, Dr. Voto, Mr. Harden, Ms. Rieger, Ms. Dexter, Mr. Goldsbury, Ms. Wells, NRHA Board Minutes 8 January 24, 2022 Ms. White, Mr. Gailey, Ms. Todd and Mr. Ohman left the meeting at 7:01pm to allow the Board to discuss Peer Review/Credentialing and CEO Evaluation. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-3 Below. 1. Recommend New Provisional Medical Staff Appointments: a. Belinda Broady-Symes, MD – OB/GYN/ - Active b. Muhammad Kaleem Ishaq, MD – Medicine – Active c. Tera Santistevan, DPM – Surgery – Active d. Paul Stevenson, MD – Medicine – Active e. Alfred Husen, DO – Emergency Medicine f. Peter Diaz, MD – OB/GYN – Active g. Erin Kelly, MD – Emergency Medicine – Active h. Summer Crawford, APRN-CNP – Hospital Medicine – Allied Health i. Nathan White, PA-C – Radiology – Allied Health j. Lindsey Lancaster, APRN-CNP – Pediatrics – Allied Health k. Tori Hendrix, APRN-FNP – Pediatrics – Allied Health l. Taylor, Tamage, PA-C – Surgery – Allied Health m. Carly Ferguson, PA-C – Surgery – Allied Health 2. Recommend Advancement of Medical Staff from Provisional Status: a. Meaghan Saumur, MD – Surgery – Active b. Jacquelyn MacIntosh, DO – OB/GYN – Active c. Mahrukh Ali, MD – Hospital Medicine – Active d. Kelly White, APRN-CNP – Cardiology – Allied Health e. Jessica Franklin, APRN-CRNA – Anesthesia – Allied Health f. Fang Yu, MD – Teleradiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Ronnie Keith, DO – Surgery – Active b. Brandon Pierson, MD – Surgery Active c. Joe Voto, MD – Anesthesia – Active d. Mark Lau, MD – Anesthesia – Active e. Andrew Crabbe, MD – Anesthesia – Active f. Merl Kardokus, MD – Radiology – Active g. Jennifer Hunter, MD – Pediatrics – Active h. Joe Womble, MD – Hospital Medicine – Active i. Laurel Jordan, DO – OB/GYN – Active j. Mark Fine, MD – Anesthesia – Active k. Barbara Landaal, MD – Radiology – Active l. Kumar Ennamuri, MD – Medicine – Active m. Cuong Nguyen, MD – Medicine – Active n. Ahmad Ashfaq, MD – Medicine – Active o. Farhan Jawed, MD – Behavioral Medicine – Active p. Norman “Paul” Ayers, MD – Cardiovascular Medicine – Active q. Tracy Ratzlaff, RNFA – Surgery – Allied Health r. Kela Lindsey, APRN-CNP – Cardiovascular Medicine – Allied Health s. Monica Lawson, APRN-CNP – Medicine – Allied Health  NRHA Board Minutes 9 January 24, 2022 t. Nichole Womble, APRN-CNP – Hospital Medicine – Allied Health u. Lucius Doh, MD – Medicine – Consulting v. Sumbal Nabi, MD – Medicine – Consulting w. Jennifer Smith, MD – OB/GYN – Consulting x. Rita Hancock, MD – Medicine - Courtesy 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, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr. Sherman. 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. Mr. Splitt rejoined the Board after returning to regular 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 1-3. 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 1-3. Ms. Greenleaf seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr. Sherman. E. Proposed Vote to Approve or Disapprove the CEO Evaluation ACTION TAKEN: Mr. Chappel made a motion to approve the CEO Evaluation. Ms. Womack seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr. Sherman. Agenda Item XIV. Board Open Discussion The Trustees reviewed the Board Self-Assessment results and discussed the comments and goals raised by trustees. The purpose of the self-assessment is to confirm Trustees are fulfilling their duties and responsibilities and that appropriate processes are in place to ensure the board is conveying due diligence to planning and oversight over the organization.  NRHA Board Minutes 10 January 24, 2022 Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 8:17pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar and Mr. Sherman. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary