Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting October 24, 2022 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, September 26, 2022 at 5:30p.m. in the Conference Room at Norman Regional Nine. The meeting Agenda was posted October 20, 2022 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf Kevin Pipes Jerome (Jerry) Weber, Ph.D. Dianne Chambers, MD Muhammad Anwar, MD Mary Womack Paula Roberts James Chappel Others Present: Richie Splitt, President & CEO John Manfredo, COO Brittni McGill, CNO Ken Hopkins, CFO Meegan Carter, VP Population Health & Wellness Paula Price, VP Strategy & Growth Aaron Boyd, MD, Chief Medical Officer James Bond, MD, Chief of Medical Staff Elect Kara Cornell, Administrative Fellow Jack DeLester, JC Penny Leadership Fellow Lisa White, Manager, Performance Improvement Larry Harden, Administrative Director, Risk Management Karen Rieger, Attorney, Crowe & Dunlevy Melissa Herron, Director, Integrated Marketing Ray Leyva, Multimedia & Video Specialist Teresa Brown, Director, Strategy & Business Growth Rachel Nabors, Manager Education Center Mike Nabors, Manager, Security Services Recorder: Cyndi Bloom, Executive Secretary Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the October 24, 2022, Norman Regional Hospital Authority business meeting at 5:30p.m.  NRHA Board Minutes 2 August 22, 2022 Agenda Item II. Introduction and Recognition of Outstanding Healers A. November 2022 Healer of the Month – Rachel Nabors, Manager, Education Center Mr. Cubberley introduced Teresa Brown, Director, Strategy Business & Growth. Ms. Brown shared Ms. Nabors is one of those people that she and her department cannot imagine being without. Ms. Nabors has been a healer at NRHS since 2005. Her roles have evolved over time as she continually takes on new and all tasks presented to her. She is responsible for the scheduling and coordination of events in the Education Center, community class schedules as well as staffing, coordinating and decorating receptions and celebration events. She is the chair of the Celebration sub-committee for Team Excellence and maintains notifications for the American Heart Association Resuscitation Quality Improvement (RQI) compliance for the health system. It’s not always what you do, but how you do it. Ms Brown shared comments from the person who nomintaed Ms. Nabors. In her nomination, Ms. Tonya Faires shared Ms. Nabors is a wealth of helpful knowledge to the entire health system. She is kind in person, by phone and by email, and she’s quick to respond to requests for help. She demonstrates the Norman Regional I.C.A.R.E. values at all times. It is a pleasure to have her as a fellow healer and she makes my job easier. Ms Nabors thanked everyone for the honor and appreciates the support from fellow healers. Mr. Cubberley congratulated and thanked Ms. Nabors 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. Splitt introduced Cyndi Bloom, Executive Assistant assisting with the meeting minutes tonight. Ms. Nabors and Mr. Nabors left the meeting at 5:34pm. Agenda Item III. Board Education: Healer Wellness Update Ms. Amanda Jones, Director, Accommodation Services and Amber Browning, Specialist, Health Promotions presented an update on the Healer Well-being and the Well at Work program. The Wellness team was established in 2002 and has over 15 departments represented. NRHS ia a member of the Oklahoma Hospital Association Work Healthy Hospital Initiative and have received a Certificate of Excellence for a Oklahoma Certified Healthy Business.  NRHA Board Minutes 3 August 22, 2022 The Well-being has been defined as “helping healers find the joy in life by creating a strong sense of contentment with one’s mental, physical and spiritual health, which produces a sustainable well balanced life both personally and professionally.” This includes seven elements: environmental, spiritual, social, financial, emotional, learning and physical. Wellness is an important component of Well Being. The NRHS Well at Work program focuses on getting us all to a healthier place. Healthy behaviors lead to lower health risks, which led to less chronic disease and fewer health care costs. Studies show wellness programs at work improve productivity, encourage healthy lifestyle choices and higher levels of engagement. The Well at Work Mission is:  Enhance organizational health by fostering interest in wellness and encouraging healers to initiate or expand healthy lifestyles  Offer diverse wellness program options that meet a wide range of personal health needs  Recognize healers for participating in healthier lifestyle activities  Decrease burnout and improve mental well-being  Develop a positive culture in the health system that is focused on celebrating and improving the quality of life for all healers Ms. Browning shared data from the Wellness program 2021 survey. Over 80% of respondents reported value in annual wellness visits. They also favored free lipid profiles. The 2022 Healer Wellness goals and additional Wellness Team offerings were reviewed – including the OKC Marathon, Spirit of Wellness Awards and Biggest Winner contest. Ms. Jones & Ms. Browning left the meeting at 5:56pm. Agenda Item IV. Approval of September 26, 2022, Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the September 26, 2022 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the September 26, 2022 Board Meeting Minutes. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel. Agenda Item V. Performance Update Ms. White, Manager, Performance Improvement & Medical Staff Services, presented an update on FY2023 NEWs Wall metrics.  NRHA Board Minutes 4 August 22, 2022 Ms. White shared The four pillars of the NEWs wall remain Service Excellence, Clinical Excellence, Operational Excellence and Team Excellence. Service Excellence measures every interaction with a patient/visitor within our health system using net promoter scores or “would recommend” – including outpatient services, clinics, emergency services and inpatient services. Clinical Excellence retained four measures from last year:  Sepsis bundle  Central Line Use  Restraint Reduction  Increase Use of Primary Care Physicians (PCP) to improve the provision of coordinated, high quality patient care. Operational Excellence focuses on the Recovery & Transformation (R&T) efforts associated with the impact of COVID-19. Team Excellence focus on the Gallup Survey participation. Ms. White left at 6:02pm. Agenda Item VI. Medical Staff A. Dr. Bond presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on October 12, 2022. MEC covered a number of topics including – possible revenue opportunities, Inspire Health updates, Medical Credentialing report and Department/Committee reports. B. Proposed Vote to Approve or Disapprove the FY2023 Utilization Review Plan ACTION TAKEN: Dr. Weber made a motion to approve the FY2023 Utilization Review Plan. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel. Agenda Item VII. Patient Quality & Safety Committee Meeting A. Mr. Cubberley announced a summary of the Patient Quality & Safety Committee Meeting is included in the board packet. Ms. Greenleaf is available to address questions. Agenda Item VIII. Finance Committee A. Mr. Hopkins reported the Finance Committee met October 17, 2022.  NRHA Board Minutes 5 August 22, 2022 B. Mr. Hopkins presented the Norman Regional Health System Financial report for September 2022: September 2022 Financial Performance  Gross Revenues .................................. (Budget $230,464,036)............ $216,857,261  Net Patient Revenue .............................. (Budget $46,339,954).............. $43,531,039  Total Operating Expenses ..................... (Budget $47,740,043).............. $48,189,693  Total Operating Revenues ...................... (Budget $46,768,224).............. $44,000,100  Operating Income ....................................... (Budget $971,819).............. ($4,189,594)  Non-Operating Revenues (Expenses) ........ (Budget $860,878).............. ($9,830,077)  Excess Revenues over Expenses ............... (Budget $110,941)............ ($14,019,671) Year-to-Date  Operating Income .................................... (Budget $1,980,275)............ ($14,228,023)  Non-Operating Revenues (Expenses) ..... (Budget $2,583,507).............. ($5,193,135)  Excess Revenues over Expenses ............... (Budget $625,232)............ ($19,421,158)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 46.8 Days  Days Cash on Hand…………………………………………………………….135.9 Days C. Mr. Hopkins provided an informational update regarding NRHSs Recovery & Transformation process. Efforts continue to reduce costs, grow revenue and prepare for our transition to a new model of healthcare delivery (Inspire Health). ACTION TAKEN: Dr. Weber motioned to approve the September 2022 NRHS Financial Statements. Ms. Roberts seconded the motion. September 2022 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel. D. Mr. Hopkins presented for approval 3 capital request items totaling $6,902,872 a. Ultrasound Equipment: $594,934 b. Ambulance Remount: $536,420 c. NMotion at the Young Family Athletic Center: $5,771,518 ACTION TAKEN: Mr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $6,902,872 as recommended by the Finance Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel. Mr. Leyva left the meeting. Agenda Item IX. Old Business Ms. McGill provided an update on the Vizient Mock Joint Commission Survey  NRHA Board Minutes 6 August 22, 2022 results. The mock survey results provide us with the opportunity to “see what we don’t see” day in and day out as we prepare for the actual TJC survey. The TJC “survey window” opens in January 2023. Agenda Item X. New Business Dr. Boyd provided an update on the CDC masking wearing guidelines. Ms. Carter provided an update on Medicare Advantage program for FY2022 and continued discussions around insurance plans. Agenda Item XI. Administrative Report Ms. Splitt shared the following:  Board Advance/Study Session date is targeting mid to late February 2023.  The Oklahoma Hospital Association CONNECT 2023 is November 9-11. This conference is free to trustees. Please see Claudia Todd to register. Ms. Carter provided an update on Medicaid Managed Care request for proposal. Mr. Hopkins provided a Recovery & Transformation update. Mr. Splitt announced 70 flu shots were administered on Saturday at the Norman Regional 9 (NR9) Open House. Ms. McGill shared today was the first patient day at NR9. Ms. Herron and Ms. Brown left the meeting. Agenda Item XII. 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, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel. 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: NRHA Board Minutes 7 August 22, 2022 a. Eric Porritt, DO – Surgery – Active b. Catherine Bolton, DO – Emergency Medicine – Active c. Kahlene Christenson, APRN-CNP – Pediatrics – Allied Health d. Lois Baez, APRN-CNP – Pediatrics – Allied Health e. Robert Maxey, MD – Radiology – Privileges Only f. Roi Lotan, MD – Radiology – Privileges Only g. Evelyn Lorents, MD – Radiology – Privileges Only h. Kambrie Kato, MD – Radiology – Privileges Only i. David Karlin, MD – Radiology – Privileges Only j. Leonard Mornueau, MD – Radiology – Privileges Only k. Justin McCoy, MD – Radiology – Privileges Only l. Michael Klein, MD – Radiology – Privileges Only m. Gregory Thalken, MD – Radiology – Privileges Only n. James Summa, MD – Radiology – Privileges Only o. Ravinder Sohal, MD – Radiology – Privileges Only p. Zachary Roeder, MD – Radiology – Privileges Only q. Shareef Riad, MD – Radiology – Privileges Only r. James Wolff, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Marcia Gillespie, MD – OB/GYN – Active b. Luanne Solis, DO – OB/GYN – Active c. Tarek Kanaa, MD – Behavioral Medicine, Active d. Jeremiah Maupin, MD – Surgery – Active e. Caleb McCormick, MD – Anesthesia – Active f. Annette Ntsama, MD – Hospital Medicine – Active g. Kassi Stockert, MD – Medicine – Consulting h. Nikole Mackey, APRN-CRNA – Anesthesia – Allied Health i. Derek Hill, DO – Nocturnist/Procedure Team – Privileges Only j. Elizabeth Richardson, DO – Nocturnist/Procedure Team – Privileges Only 3. Recommended Medical Staff Reappointments: a. Archana Gautam, MD – Cardiovascular Medicine – Active b. Aaron Boyd, MD – Medicine – Active c. Saud Ahmed, MD – Medicine – Active d. Robert Gaston , DO – Medicine – Active e. David Williams, MD – Medicine – Active f. Ajay Verma, MD – Pediatrics – Active g. Rajkumar Reddy, MD – Pediatrics – Active h. Leslie Ollar-Shoemake, DO – OB/GYN – Active i. John Stanley, MD – OB/GYN – Consulting j. Charles Mirabile, MD – OB/GYN – Consulting k. David Deschamps, MD – OB/GYN – Consulting l. Laura Velez, APRN-CNS – Cardiovascular Medicine – Allied Health m. Keri Houck, APRN-CNS – Hospital Medicine – Allied Health 4. Information Only a. Hannah Elliott, PA-C has completed proctured cases for the following  NRHA Board Minutes 8 August 22, 2022 privileges: Superficial Aspiration Biopsies/Thoracentesis/Lumbar puncture/Paracentesis. b. Change to Emergency Medicine – Moonlighting privilege form. 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, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel. 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. A. 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. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel. Agenda Item XIII. Board Open Discussion Mr. Weber, Ms. Greenleaf, Ms. Womack and Mr. Chappel presented a recap of the various sessions they attended during a recent Vizient conference for trustees. They described some of the key topics – like building a highly reliable organization – and other experiences from the conference. Mr. Cubberley discussed the importance of Recovery & Transformation efforts and emphasized the timely implementation of recommendation. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:30pm. Ms. Greenleaf seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack, Ms. Roberts and Mr. Chappel.  NRHA Board Minutes 9 August 22, 2022 Respectfully Submitted, Mary Womack, Vice-Chair/Secretary