Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting February 28, 2022 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, February 28, 2022 at 5:30p.m. in the Porter Education Center. The meeting Agenda was posted February 24, 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 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 Toby Branum, Director Ambulatory Services Darnell Burgess, Administrative Director Ambulatory Services Jennifer Davis, RN, Supervising Nurse Kyle Hurley, Director EMS Joshua Ou, Paramedic Kylie Sterling, EMT Shelby Darnold, EMT Richard Spray, Director Patient Financial Services Jana Goins, Director Patient Services Members Absent: Tom Sherman Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 February 28, 2022 Agenda Item I. Meeting Called to Order Mr. Cubberley called the February 28, 2022, Norman Regional Hospital Authority business meeting to order at 5:34p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. March 2022 Healer of the Month – Jennifer Davis, RN Supervising Nurse Mr. Cubberley introduced Mr. Toby Branum, Director Ambulatory Services. Mr. Branum shared Ms. Davis has been a healer at Norman Regional for over 7 years. She began working as a treatment nurse in the outpatient infusion center and was promoted to supervisor in 2017. She is an excellent leader and she loves to care for and treat cancer patients. She is very active in fundraising activities for various cancer support organizations. In November 2020, Norman Regional operationalized a new COVID Outpatient Infusion Center. This clinic was set up in less than 72 hours so that monoclonal antibodies could be administered to COVID positive patients. Although Ms. Davis had recently lost her mother to COVID, she insisted she be involved, knowing how much this treatment could help patients recover from COVID-19. From the start, she has assisted in the care and treatment of more than 2,300 COVID patients. Ms. Davis said this opportunity has renewed her passion for nursing and love of helping people. Ms. Davis expressed her appreciation for the honor and the opportunity to grow and work in a place she can call her home. Mr. Cubberley congratulated and thanked Ms. Davis 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. Mr. Branum, Ms. Burgess and Ms. Davis left the meeting at 5:37pm. B. EMSStat Crimestopper’s Joshua Ou, Paramedic of the Year 2021-2022 and Kylie Sterling, EMT of the Year 2021-2022. Mr. Cubberley introduced Mr. Kyle Hurley, Director of EMS. Mr. Hurley introduced Joshua Ou as Crimestopper’s Paramedic of the Year 2021-2022. Mr. Ou started with EMSStat in 2015 as an EMT. In 2017 he completed paramedic school and became a full-time paramedic. Mr. Ou is also a bike medic. In 2021 he attended more than 900 emergency calls – That was more than anyone other EMSStat healer. Mr. Hurley shared his fellow healers describe Mr. Ou as kind, compassionate, always on time and will stay late when needed. EMT’s prefer to work with him  NRHA Board Minutes 3 February 28, 2022 because he teaches well and he exemplifies the Norman Way. Mr. Ou expressed his appreciation for the honor. He expressed his gratitude for his co-healers and the opportunity to serve the community. Mr. Hurley introduced Kylie Sterling, as the Crimestopper’s EMT of the Year 2021-2022. Ms. Sterling started with Norman Regional as a housekeeper in 1995. She enrolled in Unit Secretary School and began working on the PCU floor. Over time, she has worked on 2W, 3NW, 4NW and ended up in Same Day Surgery where she works currently. In 2011, she advanced her professional career by enrolling in an EMT program. Ms. Sterling started with EMSStat in 2013. Her co-healers describe her as having a “can-do approach”, great work ethic, helpful towards others, hard worker and someone who never complains. Ms. Sterling thanked everyone for the honor. She has worked at Norman Regional for over half her life and is grateful for the opportunity. Mr. Cubberley congratulated and thanked Mr. Ou and Ms. Sterling on behalf of the Board for their outstanding dedication, professionalism, compassion and positive attitude that continues to make Norman Regional Health System a caring, high quality system. Mr. Hurley, Mr. Ou, Ms. Sterling and Ms. Darnold left the meeting at 5:45pm. C. Black History Month Healer Tribute: Bianca Braxton, APRN-FNP-C Mr. Splitt shared February is Black History Month. During February, Media Services created several videos highlighting healers at Norman Regional. Trustees Ms Womack and Mr. Chappel were just two of the healers highlighted in the series. Ms. Price emailed a link to Trustees to view all the Black History Month videos. The Healer spotlight presented at the meeting featured Bianca Braxton, APRN, FNP-C. Ms. Braxton is a Nurse Practioner at the Noble Primary Care Clinic. Agenda Item III. Board Education: Price Transparency Mr. Richard Spray, Director Patient Financial Services, presented information related to Price Transparency and No Surprises Act (NSA) implemented on January 1, 2022. The NSA establishes new federal protections against surprise medical bills Surprise medical bills arise when patients receive care from out-of-network hospitals, doctors, or other providers they did not chose. The NSA ensures patients the ability to shop outpatient services and be aware of the estimated costs for a scheduled service. Mr. Spray reviewed the basic NSA requirements of a Health Care Provider:  Provide 300 shoppable services (230 chosen by the provider and 70 CMS defines)  Standard list of charges in a machine readable format  NRHA Board Minutes 4 February 28, 2022  Publicly accessible on the facility website and no more than 2 clicks from the original facility home page Mr. Spray shared how patients are easily able to request a good faith estimate of expected charges for services, find information for Balance Billing and patient rights documents on the Norman Regional website. This information is also displayed prominently at the facilities where patients check-in or pay bills. Norman Regional formed a multi-disciplinary committee of healers to ensure the ongoing NSA requirements continue to be met. This group is comprised of Patient Access, Payor Contracting, Patient Financial Services and Provider/Clinic Leadership. Mr. Spray reviewed the changes in the Provider Reimbursement process for contracted and non-contracted care. Ms. Dexter left the meeting at 6:00pm Mr. Spray and Ms. Goins left the meeting at 6:21pm Agenda Item IV. Approval of January 24, 2022, Norman Regional Hospital Authority Board Meeting Minutes, January 26, 2022 NRHA Board Webinar Minutes and February 12, 2022 NRHA Board Advance Minutes A. Mr. Cubberley asked for approval of the January 24, 2022 Board Meeting Minutes, January 26, 2022 NRHA Board Webinar Minutes - with the noted correction replacing the name Tom Sherman for Mary Womack as Vice Chair/Secretary - and February 12, 2022 NRHA Board Advance Minutes. ACTION TAKEN: Mr. Pipes made the motion to approve the January 24, 2022 Board Meeting Minutes, January 26, 2022 NRHA Board Webinar Minutes with the noted correction replacing Tom Sherman for Mary Womack as Vice Chair/Secretary and the February 12, 2022 NRHA Board Advance minutes. Ms. Greenleaf 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 and Dr. Anwar. Agenda Item V. Performance Update Ms. Anderson, Administrative Director Quality & Performance, presented a Quarterly update on Service and Clinical Excellence. Quality/Reliability and Service Excellence have teamed up to teach departments how to better understand and learn from the NRC data received from patient feedback. NRS data enables NRHS to understand what matters most to each patient served, and is used to identify areas where we do well and areas we have the opportunity for  NRHA Board Minutes 5 February 28, 2022 improvement. Current data indicates we are exceeding target measures in one area, meeting threshold in four areas and are slightly below threshold in one area. Trends indicate continued performance improvement over the same timeframe as last year. Standardized processes already in place, early identification of at risk patents and continued education will assist in meeting Service Excellence goals. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on February 9, 2022. New Business:  Mr. Bohanan presented the Urine Culture Reflex Protocol.  Dr. Ashfaq provided an update on COVID-19 inpatient and outpatient treatments.  Mr. Manfredo presented an Inspire Health Update. Credentials Report:  Dr. Mullins presented the credentials report with a recommendation for approval. Department Reports:  Reports were provided by Behavioral Medicine, Cardiovascular Medicine, Infection Committee, OB/GYN, Pathology, Pediatrics, Physician Advisory Committee, Radiology and Transfusion Safety Committee. Medical Staff Report:  Dr. Boyd provided an update on COVID-19. Administrative Reports:  Ms. Price reviewed a new partnership program with Norman Public Schools to engage junior and senior students who want to learn about a career in healthcare through administrative and clinical rotations.  Mr. Manfredo provided a surgery schedule update.  Mr. Splitt provided an update on the future of Medicaid Managed Care in Oklahoma and reviewed current strategies for staff retention. B. Recommend Approval of the Special Privilege Robotic Assisted Surgery Form ACTION TAKEN: Dr. Weber made a motion to approve the Special Privilege Robotic Assisted Surgery Form as presented by the Medical Executive Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar.  NRHA Board Minutes 6 February 28, 2022 C. Recommend Approval of the Cardiovascular Medicine Privileges Form ACTION TAKEN: Dr. Weber made a motion to approve the Cardiovascular Medicine Privileges Form as presented by the Medical Executive Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. 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. B. Proposed Revisions to the 2022 Infection Prevention Plan Policy ACTION TAKEN: Ms. Greenleaf made a motion to 2022 Infection Prevention Plan Policy as presented by the Patient Quality & Safety Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Agenda Item VIII. Finance Committee A. Mr. Hopkins reported the Finance Committee met February 21, 2022. B. Mr. Hopkins presented the Norman Regional Health System Financial report for January 2022: January 2022 Financial Performance  Gross Revenues .................................. (Budget $215,303,035)............ $197,579,713  Net Patient Revenue .............................. (Budget $45,265,036).............. $41,005,897  Total Operating Expenses ..................... (Budget $45,394,381).............. $47,899,307  Total Operating Revenues ...................... (Budget $45,646,472).............. $41,415,214  Operating Income ....................................... (Budget $252,091).............. ($6,484,093)  Non-Operating Revenues (Expenses) ........ (Budget $968,184).............. ($3,947,382)  Excess Revenues over Expenses ............ (Budget $1,220,275)............ ($10,431,475) Year-to-Date  Operating Income .................................... (Budget $5,133,824)............ ($14,819,915)  Non-Operating Revenues (Expenses) ..... (Budget $6,777,288)................ $9,364,933  Excess Revenues over Expenses .......... (Budget $11,911,112)................ $5,454,981  Accounts Receivable Days ............................ (Budget 48 Days).................. 47.5 Days  Days Cash on Hand…………………………………………………………….205.9 Days  NRHA Board Minutes 7 February 28, 2022 ACTION TAKEN: Dr. Weber motioned to approve the January 2022 NRHS Financial Statements. Mr. Pipes seconded the motion. January 2022 Financials were approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. C. Mr. Hopkins presented for approval 2 capital request items totaling $153,796: a. Robotic guidance system for Craniotomies: $80,185 b. Mobile Xray: $73,611 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment request at a total cost of $153,796 as recommended by the Finance Committee. Dr. Anwar seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. D. Resolution to Increase the Inspire Health Budget ACTION TAKEN: Dr. Weber made a motion to approve the Resolution to Increase the Inspire Health Budget as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. E. Resolution Authorizing Use of Investments for Inspire Health ACTION TAKEN: Dr. Weber made a motion to approve the Resolution Authorizing Use of Investments for Inspire Health as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Agenda Item IX. Old Business None Agenda Item XI. New Business None Agenda Item XII. Administrative Report  NRHA Board Minutes 8 February 28, 2022 A. Mr. Splitt provided an update on Medicaid. B. Ms. McGill reported the Certificate of Need application has been filed for the Behavioral Health Facility to be built on the Porter Health Village. Once final approval is received, the architectural design can be finalized and the construction phase can begin. The anticipated opening of the facility is late 2023. C. Ms. Price announced Norman Regional received recognition form the American Hospital Association (AHA) for our efforts for vaccine distribution in the Norman community. Ms. Price emphasized the combined work between the City of Norman, Norman Police Department and Norman Regional healers – especially LeAnn Richardson, Darnell Burgess and Wendy Fiebrich - for their logistical planning for these clinics. From April to August 2021, Norman Regional administered over 2200 COVID vaccines to the community. The AHA has invited Norman Regional to share with groups across the nation about how our program and logistics planning worked as well as efforts to engage with our community partners. 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; 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, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Ms. White and Ms. Anderson left the meeting at 7:12pm. 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. Pouya Javadian, MD – OB/GYN – Active b. Marcia Moore, MD – Medicine – Active c. Caroline Trommels, APRN-FNP – Pediatrics – Allied Health d. Aaron Ruger, PA-C – Hospital Medicine – Allied Health e. Joseph Brewer, DO – ECMO – Privileges Only f. Ammar Sharif, ECMO – Privileges Only g. David Lin, MS – Teleradiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Ali Ashraf, MD – Medicine – Active b. Joshua Powell, MD – surgery – Active NRHA Board Minutes 9 February 28, 2022 c. Arun Philip, DO Hospital Medicine – Active d. Brian Milman, MD – Emergency Medicine – Active e. John Ruth, MD – Pediatrics – Active f. Candyse Brewer, APRN-CNS – Cardiovascular Medicine – Allied Health g. Alexandria Howell, APRN-CRNA – Anesthesia – Allied Health h. Frank Welte, MD – Teleradiology – Provisional Privileges Only i. Karen Phillips, MD – Teleradiology – Provisional Privileges Only 3. Recommended Medical Staff Reappointments: a. Brian Ellis, MD – Pediatrics – Active b. Katherine Hays, MD – Cardiovascular Medicine – Active c. Satish Arora, MD – Medicine – Active d. Robert Holbrook, MD – Medicine – Active e. Dustin Tedesco, MD – Medicine – Active f. Joshua Whorton, MD – Medicine – Active g. Richard Wedel, MD – Radiology – Active h. Sanjay Narotam, MD – Radiology – Active i. Tan Pham, MD – Medicine – Consulting Staff j. Martha Royall, APRN-CNP – Pediatrics – Allied Health k. Hillarie Kessler, PA-C – Surgery – Allied Health 4. Information Only: a. Tarek Kanaa, MD is requesting privileges for Child and Adolescent Core Psychiatry privileges. 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. Dr. Anwar seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. 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 1-4. 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. Ms. Greenleaf seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Mr. Chappel, Ms.  NRHA Board Minutes 10 February 28, 2022 Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Agenda Item XIV. Board Open Discussion Mr. Chappel requested information about the new Professional Development program and partnership with Norman Public Schools. Ms. McGill shared the program is scheduled to start August 2022. Junior and Senior students who are interested in pursuing a career in the medical profession will be shadowing healers in various departments across our health system. Mr. Cubberley reminded the Trustees to fill out the monthly Board Meeting surveys. Trustees were asked to continue providing details that would help improve Board meetings and discussions. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:19pm. Ms. Greenleaf seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Womack, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers and Dr. Anwar. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary