Norman Regional Hospital Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting January 25, 2024 MINUTES The Norman Regional Hospital Authority met in monthly session Thursday, January 25, 2024 at 5:30p.m. in the Norman Regional Porter Board Room. The meeting Agenda was posted January 22, 2024 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf James Chappel Jerome (Jerry) Weber, Ph.D. Mary Womack Paula Roberts Kevin Pipes Muhammad Anwar, MD Others Present: Richie Splitt, President & CEO John Manfredo, VP, Chief Operations Officer Brittni McGill, VP, Chief Nursing Officer Keith Minnis, VP, Chief People Officer Elaine Purvis, VP, Chief Strategy Officer Rick Wagner, VP, Chief Financial Officer Dr. James Bond, MD, Chief of Medical Staff Dr. Bruce Parker, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Larry Harden, Administrative Director, Risk & Compliance Ray Leyva, Multimedia & Video Specialist, Media Services Melissa Herron, Director, Integrated Marketing Garrett Fergeson, Manager, Integrated Marketing Gavin Nation, OU’s JC Penny Leadership Fellow Lisa White, Manager QPI, Patient Quality & Safety Tracy Mills, Manager, Labor Delivery & Recovery Jennifer Martin, Project Manager, Quality & Performance Jamison Martin, Guest Greta Morgan, RN, Labor, Delivery & Recovery Annette Troxell, Director, Women & Children Services Members Absent: Dianne Chambers, MD Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the January 25, 2024 Norman Regional Hospital Authority  NRHA Board Minutes 2 January 25, 2024 business meeting at 5:33 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. January 2024 Healer of the Month – Jennifer Martin, Project Manager, Quality & Performance Improvement Mr. Cubberley introduced to the board Jenny Anderson, Administrative Director Quality Performance & Improvement. Ms. Anderson shared Ms. Martin has been a healer at NRHS for 2 ½ years and has already made a great impression with her peers. She joined NRHS after completing a 25-year career in the Air Force and while serving, earned her Masters in Health Administration. Ms. Martin’s last position with the Air Force was as Senior Enlisted Advisor to the Surgeon General of the United States transportation command at Scott Air Force Base in Illinois. In this capacity, she functioned as the primary senior enlisted advisor for 110 joint staff service members while overseeing operations at three Transcom Patient Movement Requirement centers. She also spent five years active duty as a drill instructor. Her fellow healers shared that Ms. Martin strives for the highest level of integrity and work ethics. She is extremely respectful to everyone, committed to helping others succeed and taking on challenges. She is generous with her time, willing to assist healers and always approachable with questions. When asked what she likes most about working at NRHS, Ms. Martin stated the most rewarding part of her job is the opportunity to collaborate with our dedicated teams of Healers. It allows her to witness firsthand their commitment to providing exceptional patient care. The collaborative and purpose-driven atmosphere at NRHS is truly one of the best aspects of her role, making each day fulfilling and motivating. Ms. Martin thanked everyone for the opportunity to work at NRHS. When searching for a place to work after leaving the Air Force, the NRHS ICARE values really appealed to her and she knew this was where she needed to be. Mr. Cubberley, on behalf of the Board, extended a heartfelt congratulations and gratitude to Ms. Martin. Her steadfast dedication, professionalism, boundless compassion, and consistently positive attitude contribute significantly to advancing Norman Regional as a caring and high-quality health system. B. February 2024 Healer of the Month – Greta Morgan, RN, Labor, Delivery & Recovery Mr. Cubberley introduced Ms. Tracy Mills, Manager, Labor, Delivery & Recovery. Ms. Mills shared Ms. Morgan is a super star healer. She has been a nurse since  NRHA Board Minutes 3 January 25, 2024 the age of 19, earning her associates degree first, her bachelor’s degree in 2014 and a Master’s in Education in 2023. Ms. Morgan joined NRHS in March of 2011. Since 2016, she has been the Unit Adjunct Educator and is now a member of the NRHS Education Council. She is a member of Sigma Theta Tau Honor Society, Phi Kappa Phi Honor Society and Golden Key. Ms. Mills shared the following compliments from Ms Morgan’s fellow healers:  She is the calm in the storm for the entire unit, always keeping us focused and moving forward  No matter how crazy the evening shift can be, Ms. Morgan never leaves the unit until she makes sure the area is clean and in order for the next shift  She is reliable and always focuses on elevating the level of care for our patients  She is a fantastic relief charge nurse. Don’t know what we would do without her Ms. Morgan thanked everyone and shared she is honored to be here and thankful for a supportive work environment. Mr. Cubberely, on behalf of the Board, extended a heartfelt congratulations and gratitude to Ms. Morgan. Her steadfast dedication, professionalism, boundless compassion, and consistently positive attitude contribute significantly to advancing Norman Regional as a caring and high-quality health system. Ms. Martin, Ms. Mills, Ms. Morgan, Ms. Troxell and Ms. Martin left the meeting at 5:44pm Agenda Item III. Board Education: Medicaid Managed Care Mr. Wagner presented an overview of SoonerSelect, the Oklahoma Managed Medicaid Program. Most members will receive healthcare services covered through this new program in 2024. This new model is called SoonerSelect. The Oklahoma Health Care Authority selected three health plans to provide coordinated, whole-person care for enrollees. Instead of the state monitoring and paying for services, three insurance companies were selected to manage the new Medicaid plan. They include – Oklahoma Complete Health, Humana Healthy Horizons of Oklahoma and Aetna Better Health of Oklahoma. NRHS is partnering with all three state Medicaid payor’s thru the LifeCare Value Network. Agenda Item IV. Approval of November 27, 2023 Norman Regional Hospital Authority Board Meeting Minutes  NRHA Board Minutes 4 January 25, 2024 A. Mr. Cubberley asked for approval of the November 27, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the November 27, 2023 Board Meeting Minutes. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Mr. Pipes, Ms. Womack, Ms. Roberts and Dr. Anwar. Agenda Item V. Performance Update Ms. Jenny Anderson, Administrative Director, Patient Quality, provided an update on NRHS’s journey to excellence by striving to become a High Reliability Organization (HRO). Ms. Anderson also reviewed information related to the SCORE Survey, CMS Star rating, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Mortality. Ms. Anderson reminded everyone that the HRO program focuses on the science of operating highly complex systems with the constant threat of catastrophic error while maintaining safety levels and striving for failure free operations – “Chasing Zero”. The continuous mindfulness has four stages: beginning, developing, advancing and approaching. NRHS is entering the advancing stage of the HRO process. High reliability is not something that is implemented, but achieved. The NRHS HRO Academy group has completed 6 of the 10 sessions. The sessions examine the 4 domains: Culture, Knowledge, Learning and Leadership. The focus of the first 5 sessions was on the Culture Domain, which is the foundation of any HRO. Each piece of the framework requires personal accountability within each domain. Ms. Anderson shared the SCORE survey results for Personal Accountability, Teamwork & Collaboration and Healthy Environment. Ms. Anderson shared updated Star Ratings for the Mortality and HCAHPS dashboards. NRC will be visiting to discuss correlations and opportunities for improvement with the HCAHPS score. Agenda Item VI. Medical Staff A. Dr. Bond presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on January 10, 2024. MEC covered a number of topics including – 2023 Provider and Nursing Award Recipients, Inspire Health update, Medical Credentialing, Department Committee Reports and Executive Team updates.  NRHA Board Minutes 5 January 25, 2024 Agenda Item VII. Patient Quality & Safety Committee 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. Strategic Planning Committee 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. Retirement Plan Amendment and Resolution ACTION TAKEN: Dr. Weber motioned to approve the Retirement Plan Amendment and Resolution. Mr. Pipes seconded the motion and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar. Agenda Item X. Finance Committee A. Mr. Wagner reported the Finance Committee met January 18, 2024. B. Mr. Wagner presented the NRHS Financial report for December 2023: December 2023 Financial Performance  Gross Revenues .................................. (Budget $214,724,486)............ $215,477,580  Net Patient Revenue .............................. (Budget $47,342,665).............. $47,094,688  Total Operating Expenses ..................... (Budget $49,250,474).............. $50,284,372  Total Operating Revenues ...................... (Budget $48,021,032).............. $47,840,559  Operating Income .................................... (Budget $1,229,442).............. ($2,443,813)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. $(6,007,827)  Excess Revenues over Expenses ................... (Budget $5,880).............. ($3,564,015) Year-to-Date  Operating Income ..................................... (Budget $8,104,215............ ($23,776,615)  Non-Operating Revenues (Expenses) ..... (Budget $7,411,932).............. ($5,617,728)  Excess Revenues over Expenses ............... (Budget $692,283)............ ($18,158,888)  Accounts Receivable Days ...................................................... . .................. 65.1 Days  Days Cash on Hand…………………………………………………………….79.2 Days ACTION TAKEN: Dr. Weber made a motion to approve the December 2023 NRHS Financial Statements. Dr. Anwar seconded and the motion. December 2023 Financials were approved unanimously with aye  NRHA Board Minutes 6 January 25, 2024 votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar. C. Mr. Wagner presented for approval three capital request items totaling $3,915,397 a. Cardiolab: $999,409 b. Ultrasound System: $184,710 c. HIT Servers & Equipment: $2,731,278 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $3,915,397 as recommended by the Finance Committee. Ms. Roberts seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar. Agenda Item XI. Old Business None Agenda Item XII. New Business Mr. Splitt shared the Healer Happenings monthly newsletter is in the packet. The newsletter provides updates and stories about NRHS healers, recruitment and retention efforts and other vital information. Agenda Item XIII. Administrative Report Mr. Splitt shared: The NRHS Foundation board meeting was last week. Mr. Splitt shared the power point presentation shown at the luncheon and other highlights: o Mr. Splitt shared information related to our new 0% financing options for patients in need. This program eliminates the barrier to healthcare for patients who find themselves in financial situations that prevent them from seeking the care they need. o NRHS is preparing to launch a new program called, “Build-a-Brain”. Children who hear fewer words before age 3 face challenges in developing language and reading skills they will need to succeed in school. This program will be established within our maternity program. The purpose is to build a better brain by encouraging patents to talk to their child. All the time. Every day. o NRHS will be selecting and training a new FTE or “Fur-Time” Employee to serve our health system as a certified Therapy Dog. The Goldendoodle  NRHA Board Minutes 7 January 25, 2024 will be named Porter in honor of our 77-year legacy of providing lifesaving care on the Porter campus. The NRHA January board meeting was rescheduled due to icy conditions. As a result: Ms. McGill shared the volume of patients seen for falls and fractures during the ice event: o EMSStat conducted 26 ice related ambulance runs o Emergency Departments treated 23 patients on Sunday, 97 on Monday and 39 on Tuesday for ice related falls and potential fractures. This does not include patients who went directly to a provider for help. Mr. Manfredo shared the NRHS Security and Engineering departments working long hours preparing the hospital campuses for the icy conditions. They made multiple runs to pick up healers who needed transportation assistance to work. Mr. Manfredo provided an update on Inspire Health: o Cancer Center construction continues on schedule o 80 truckloads of cement were poured for 2 radiation therapy vaults located inside the new the cancer center o Air handlers for the Ambulatory Care Center and HealthPlex hospital have been installed o Targeting the end July for nearly all Porter inpatient services and healers to relocate to the HealthPlex Ms. Anderson, Ms. Herron, Mr. Fergeson and Ms. Brown left the meeting at 7:03pm. 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 (ii) CEO Evaluation. ACTION TAKEN: Ms. Roberts made a motion to adjourn into Executive Session. Dr. Weber seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar. 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. LaToya Smith, DO 0 OB/GYN – Active b. Larry Houk, MD – OB/GYN – Active NRHA Board Minutes 8 January 25, 2024 c. Robin Singh, MD – Cardiovascular Medicine – Active d. Samuel Le, PA-C – Surgery – Allied Health e. Morgan Gossen, PA-C – Surgery – Allied Health f. Matthew Thomson, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Jacob Witmer, DO – Emergency Medicine – Active b. Lawrence Cater, MD – Hospital Medicine – Active c. Azure Adkins, MD – Surgery – Active d. Brenda Lawrie, APRN-CNS – Cardiovascular Medicine – Allied Health e. Kailee Anderson, APRN-CNP, RNFA – Surgery – Allied Health f. Stefanie Gonzales, PA-C – Surgery – Allied Health g. Adeyinka Owoyele, MD – Radiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Joe Womble, MD – Hospital Medicine – Active b. Jacquelyn MacIntosh, DO – OB/GYN – Actve c. Mark Lau, MD – Anesthesia – Active d. Barbara Landaal, MD – Radiology – Active e. Farhan Jawed, MD – Behavioral Medicine – Active f. Merl Kardokus, MD – Radiology – Active g. Chintan Parikh, MS – Medicine – Active h. Ahmad Ashfaq, MD – Medicine – Active i. Brian Ellis, MD – Pediatrics – Active j. Jennifer Hunter, MD – Pediatrics – Active k. Andrew Crabbe, MD – Anesthesia – Active l. Mark Fine, MD – Anesthesia – Active m. Sumbal Nabi, MD – Medicine – Consulting n. Jennifer Smith, MD – OB/GYN – Consulting o. Lucius Doh, MD – Medicine – Consulting p. Tariq Mahmood, MD – Medicine – Consulting q. Kumar Ennamuri, MD – Medicine – Courtesy r. Rita Hancock, MD – Medicine – Courtesy s. Nichole Womble, APRN-CNP – Hospital Medicine – Allied Health t. Hillarie Kessler, PA-C – Surgery – Allied Health u. Jessica Franklin, APRN-CRNA – Anesthesia – Allied Health v. Glen Diaz, APRN-CNP – Pediatrics – Allied Health Mr. Splitt, Ms. McGill, Mr. Manfredo, Mr. Wagner, Mr. Minnis, Ms. Purvis, Ms. Todd, Dr. Bond, Dr. Parker and Mr. Nation left the meeting at 7:06pm. 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, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar.  NRHA Board Minutes 9 January 25, 2024 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. 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: Mr. 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. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar. E. Proposed Vote to Approve or Disapprove the CEO Evaluation ACTION TAKEN: Dr. Weber motioned to approve the CEO Evaluation. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar. Agenda Item XV. Board Open Discussion The Board provided feedback to Mr. Splitt regarding the CEO Evaluation. Agenda Item XVI. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 8:45pm. Mr. Pipes seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Mr. Pipes, Ms. Roberts and Dr. Anwar. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary