Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting November 28, 2022 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, November 28, 2022 at 5:30p.m. in the Board Room at Norman Regional Hospital. The meeting Agenda was posted November 24, 2022 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf Jerome (Jerry) Weber, Ph.D. Dianne Chambers, MD Muhammad Anwar, MD Mary Womack 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 Joe Voto, MD, Chief of Medical Staff James Bond, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Kara Cornell, Administrative Fellow Jack DeLester, JC Penny Leadership Fellow Larry Harden, Administrative Director, Risk Management Karen Rieger, Attorney, Crowe & Dunlevy Maggie Martin, Attorney, Crowe & Dunlevy Melissa Herron, Director, Integrated Marketing Kelley Dexter, Manager, Education Services & Media Services Drew Hill, Multi- Media and Audio/Visual Specialist Erin Barnhart, Director, NRHS Foundation Brett Dees, MD, Neurologist Clint Miller, Manager, Clinics Paul Jones, Director, Clinic Operations Lauren Hill, PA, Allied Health Leah Unrein, MA Amber Parris, MA Sandy Kline, Clinic Supervisor Stephanie Gonzales, PA Teresa Brown, Director, Strategy & Business Growth  NRHA Board Minutes 2 November 28, 2022 Member Absent: Kevin Pipes Paula Roberts Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the November 28, 2022, Norman Regional Hospital Authority business meeting at 5:32p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. December 2022 Healer of the Month – Amber Parris, Medical Assistant, Oklahoma Surgical Associates (OSA). Mr. Cubberley introduced Ms. Lauren Hill, PA, Oklahoma Surgical Associates. Ms. Hill started Ms. Parris is always amazing and a great asset to the OSA clinic. Ms. Hill shared a recent patients experience with Ms. Parris. Ms. Parris had spoken with the patient over the phone concerning some issues she was experiencing a few weeks post-surgery. After listening to the patient describe her condition, Ms. Parris did not hesitate to recommend the patient seek immediate medical care at the Norman Regional ER. The patient did indeed require care, and wrote a letter thanking Ms. Parris for her encouragement and persistence to seeking additional care. Ms Parris thanked her fellow healers for their support and honoring her with the nomination. Mr. Cubberley congratulated and thanked Ms. Parris 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 presented Karen Rieger with the “End of the Trail” award. After 33 years of service as legal counsel to Norman Regional Hospital Authority, Ms. Rieger is transitioning her current healthcare practice, but will be available to NRHS for special projects. Ms. Rieger thanked the board for placing their trust in her all these years and introduced Maggie Martin, JD. Ms. Martin is a member of Crowe & Dunlevy’s Healthcare Practice Group. She will assume the role and function of Ms. Rieger. Mr. Splitt announced Meegan Carter would be leaving Norman Regional to join Lifecare Health Services as their VP of Operations. Ms. Carter will continue to help Norman Regional and other Lifecare member hospitals to create synergy and innovative approaches to the delivery of healthcare. Mr. Splitt thanked Ms.  NRHA Board Minutes 3 November 28, 2022 Carter for her 16 years of service to Norman Regional, our patients and our community. Paula Price, current VP Chief Strategy Officer will be retiring at the end of December 2022. Mr. Splitt presented Ms. Price with an “End of the Trail” award and announced she will serve as the honorary “CEO for the Night”. Ms. Price’s retirement celebration is scheduled for December 9th from 2-4pm. Ms. Elaine Purvis, our new Vice President and Chief Strategy Officer will attend her first board meeting in January 2023. Mr. Miller, Mr. Jones, Ms. Hill, Ms. Unrein, Ms. Parris, Ms. Kline and Ms. Gonzales left the meeting at 5:35pm. Agenda Item III. Board Education: Healer Wellness Update Dr. Brett Dees, Neurologist and Ms. Erin Barnhart, Executive Director Norman Regional Health Foundation (NRHF) presented inspiring information on the Oklahoma Headache Center. In 2016, The Norman Regional Oklahoma Headache Center became Oklahoma’s first and only comprehensive headache and facial pain treatment center. The dedicated team of Neurologists and Advanced Practice Providers (APP) at NRHS work together to determine an individual treatment plan to ensure each patient gets the best treatment for their specific needs. The vision of the Headache Center is to be a Center of Excellence with patient-focused, holistic emphasis with innovative treatments based on sound scientific principles allowing them to advance the field of headache medicine through high quality clinical and non-clinical research. According to the World Health Organization, migraine headache is the second most disabling medical disorder in the world. The Oklahoma Headache Center strives each day to combat migraine headaches – focusing heavily on empowering patients to take control of their disorder. Ms. Barnhart shared in January 2022, a grateful patient challenged the NRHF to raise $1 million through new donations to enhance treatment services through the Oklahoma Headache Center. The Foundation has developed a multi-channel fundraising and awareness campaign in order to meet the challenge and generous gift of the grateful patent. Dr. Dees and Ms. Barnhart left the meeting at 5:44pm. Agenda Item IV. Approval of October 24, 2022, Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the October 24, 2022 Board Meeting  NRHA Board Minutes 4 November 28, 2022 Minutes ACTION TAKEN: Dr. Weber made the motion to approve the October 24, 2022 Board Meeting Minutes. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel. Agenda Item V. Annual Compliance Plan ACTION TAKEN: Dr. Weber made the motion to approve the proposed Changes to the Annual Plan. Dr. Anwar seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel. Agenda Item VI. Performance Update Ms. Anderson, Administrative Director, Patient Quality & Performance Improvement, presented an update on the Service Excellence Net Promoter Scores and Hospital Acquired Conditions (HAC) Scores. Ms. Anderson reviewed Net Promoter Scores for System level, Outpatient, Clinic, Inpatient and Emergency. All CMS Data is benchmarked nationally, and is publicly reported as part of the CMS Star Ratings metrics. Data reported includes new Electronic Clinical Quality Measures (eCQM). ECQMs are tools that help measure and track the quality of health care services that eligible hospitals provide, as generated by a provider’s electronic health record (EHR). This reportable data includes mortality, readmission, safety of care, patient experience and timely and effectiveness of care ratios. One new measure is the Healthcare COVID Vaccination Coverage, where Norman Regional outperformed the state averages by 8-10%. The most current data will be released in January 2023 for the Q1 2022. These evidence-based measures help ensure hospitals provide safe, high-quality care. Achieving favorable outcomes in these measures can increase efficiency and thereby provide cost savings to hospitals and patients. Agenda Item VII. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on November 9, 2022. MEC covered a number of topics including – Inspire Health updates, quarterly finance report, Medical Credentialing report and Department/Committee reports. Agenda Item VIII. Strategic Planning Committee Meeting  NRHA Board Minutes 5 November 28, 2022 A. Mr. Cubberley announced a summary of the Strategic Planning Committee Meeting is included in the board packet. Dr. Weber is available to address questions. Agenda Item IX. Finance Committee A. Mr. Hopkins reported the Finance Committee met November 21, 2022. B. Mr. Hopkins presented the Norman Regional Health System Financial report for October 2022: October 2022 Financial Performance  Gross Revenues .................................. (Budget $236,149,820)............ $214,630,413  Net Patient Revenue .............................. (Budget $48,679,520).............. $44,293,426  Total Operating Expenses ..................... (Budget $49,023,749).............. $50,293,762  Total Operating Revenues ...................... (Budget $49,113,661).............. $50,293,762  Operating Income ......................................... (Budget $89,912).............. ($5,573,576)  Non-Operating Revenues (Expenses) ........ (Budget $774,307).............. ($1,172,103)  Excess Revenues over Expenses ............... (Budget $864,219).............. ($4,401,473) Year-to-Date  Operating Income .................................... (Budget $1,868,363)............ ($19,801,599)  Non-Operating Revenues (Expenses) ..... (Budget $3,357,814).............. ($4,021,032)  Excess Revenues over Expenses ............ (Budget $1,489,451)............ ($23,822,632)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 47.2 Days  Days Cash on Hand…………………………………………………………….140.4 Days ACTION TAKEN: Dr. Weber motioned to approve the October 2022 NRHS Financial Statements. Mr. Chappel seconded the motion. October 2022 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel. C. Mr. Hopkins presented for approval 3 capital request items totaling $478,545 a. Radiology Software: $76,965 b. Clinical Workflow Server: $124,269 c. Video Processor: $277,311 ACTION TAKEN: Mr. Weber made a motion to approve the Capital Equipment Requests at a total cost of $478,545 as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel.  NRHA Board Minutes 6 November 28, 2022 D. Recommend Approval of Consolidated Retirement Plan Amendment ACTION TAKEN: Dr. Weber made a motion to approve the Consolidated Retirement Plan Amendment as recommended by the Finance Committee. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel. Agenda Item X. Old Business Mr. Splitt reported an update on Recruitment and Retention efforts will be provided at an upcoming board meeting. Agenda Item XI. New Business A. Proposed Care to Establish Date and Times for 2023 Authority Meetings ACTION TAKEN: Dr. Weber made a motion to approve the Dates and Times for the 2023 Authority Meetings. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel. Mr. Manfredo provided an update on the Trimedex (formerly Service Master) contract. Trimedex helps NRHS manage and optimize the performance of clinical equipment through the department of Clinical Engineering under the new Clinical Asset management program. Trimedex worked to drive greater financial savings while maximizing device availability. The program has been in place roughly 18 months and has indeed resulted in meaningful cost savings. Mr. Hopkins provided an update to the Board regarding a recent Kaufman Hall report. The report was commissioned by the Oklahoma Hospital Association and it provided an alarming overview of the financial impact on hospitals due to the lingering effects of COVID-19. Ms. McGill provided an update on a recent Oklahoma State Department of Health (OSDH) visit to the HeathPlex. Officials assessed a patient complaint related to the potential failure to follow established policies and procedures. The visit was very professional and cordial, and was resolved without incident. Agenda Item XII. Administrative Report Ms. Price provided an update on the Feed the Children No Hunger Holiday events held in conjunction with our Public Schools partners in Norman, Moore and Noble. NRHS healers handed out boxes of food, personal care items and toys to over 1200  NRHA Board Minutes 7 November 28, 2022 families. Additionally, the successful NRHS Food Pharmacy program will be expanding its service to NRHS healers and their families just before Christmas. Mr. Manfredo provided an update on Norman Regional 9 volumes. Mr. Manfredo shared the upcoming parking changes at the Porter campus as we begin the construction phase of the new behavioral health center. A parking plan has been prepared to help healers adjust to the new parking requirements. The plan includes shuttle services for healers. Ms. McGill shared the Oklahoma Hospital Association (OHA) presented its Excellence in Quality for Innovation award to NRHS on Nov. 9 at its annual convention. The Excellence in Quality award recognizes exceptional efforts to improve outcomes in clinical quality performance practices, capabilities and results. The award represents the highest level of professional acknowledgement from the OHA Council on Quality & Patient Safety. The innovation category was the first of its kind for OHA, and was created specifically for NRHS in order to recognize the originality and exceptional outcomes. The Emergency Medicine residency program – led by Dr. Patrick Cody, Dr. Robin Mantooth and emergency department leadership – were instrumental in the design, implementation and overall success of the program. Mr. Hopkins provided an update on the 340B Drug pricing program for outpatient drugs. The program allows hospitals to stretch limited federal resources to reduce the price of outpatient pharmaceuticals for patients and expand health services to the patients and communities they serve. It appears NRHS will qualify for the program. If NRHS’s application is approved by the Health Resources and Services Administration (HRSA) – the federal agency responsible for administering the program – implementation could begin in the Spring/Summer of 2023. Ms. Herron, Ms. Anderson and Ms. Brown left the meeting at 7:09pm. 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. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack 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: a. Megan Hutcherson, PA-C – Cardio vascular Medicine – Allied Health NRHA Board Minutes 8 November 28, 2022 b. Haley Corgan, APRN-CRNA – Anesthesia – Allied Health c. Jeremy Theisen, MD – Radiology – Privileges Only d. Tae Ro, MD – Radiology – Privileges Only e. Ryan Jean-Baptiste, MD – Radiology – Privileges Only f. James Frencher, MD – Radiology – Privileges Only g. Robert Farrell, MD – Radiology – Privileges Only h. Andrew Martin, MD – Radiology – Privileges Only i. Theresa Yuh, MD – Radiology – Privileges Only j. Shota Yamamoto, MD – Radiology – Privileges Only k. Artin Aharonian, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Jensen Atkinson, APRN-CRNA – Anesthesia b. Sydney Boothe, APRN-CNP – Pediatrics c. Shawn Mayhew, APRN-CRNA – Anesthesia d. Jana McDonald, APRN-RNFA – Surgery e. Dezaray Preuninger, APRN-CNP - Pediatrics 3. Recommended Medical Staff Reappointments: a. Ahmad Sarwar, MD – Cardiovascular Medicine – Active b. Namali Pierson, MD – Medicine – Active c. Kristen Thorp, MD – Medicine – Active d. Tadgy Stacy, MD – Pediatrics – Active e. Lorry Krous, MD – Pediatrics – Active f. Mehran Shahsavari, MD – Hospital Medicine – Active g. Ayesha Farhan, MD – Behavioral Medicine – Active h. Muhammad Ishaq, MD – Hospital Medicine - Active i. Lawrence Cater, MD – Hospital Medicine – Active j. Mohammad Razaq, MD – Medicine – Consulting k. Sanober Malik, MD – Medicine – Consulting l. Sergio Garcia, MD – Medicine – Consulting m. Jayesh Panchal, MD – Surgery – Courtesy n. Kristen Sweet, APRN-CNP – Allied Health o. Lauren Haymans, PA-C – Surgery – Allied Health p. Kerri Baker, PA-C – Surgery – Allied Health q. Gregory Dinwiddie – PA-C – Surgery – Allied Health r. Jennifer Enteshary, APRN-CRNA – Anesthesia – Allied Health 4. Information Only a. Hannah Elliott, PA-C has completed proctored cases for Arthrogram and Bone Marrow Biopsy 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  NRHA Board Minutes 9 November 28, 2022 votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack 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. Dr. Anwar seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel. Agenda Item XIV. Board Open Discussion Mr. Splitt thanked Ms. Rieger, Ms. Carter and Ms. Price for their years of service and dedication to Norman Regional. Mr. Splitt announced Norman Regional has engaged a consultant to help address these times of uncertainty and opportunity in healthcare. Priorities include the improvement of financial performance, exploring effective strategy decisions, and achieving transformative outcomes for our health system. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:15pm. Ms. Greenleaf seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Weber, Dr. Chambers, Dr. Anwar, Ms. Womack and Mr. Chappel. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary