Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting February 27, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, February 27, 2023 at 5:30p.m. in the Board Room at Norman Regional Hospital. The meeting Agenda was posted February 23, 2023 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf Dianne Chambers, MD James Chappel Paula Roberts Jerome (Jerry) Weber, Ph.D. Kevin Pipes Others Present: Richie Splitt, President & CEO John Manfredo, Chief Operations Officer Brittni McGill, VP, Chief Nursing Officer Rick Wagner, VP, Chief Financial Officer Keith Minnis, VP Chief People Officer Elaine Purvis, VP Chief Strategy Officer Aaron Boyd, MD, Chief Medical Executive Joe Voto, MD, Chief of Medical Staff James Bond, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Shannon Largent, Administrative Director, Patient Care Services & Accreditation Kara Cornell, Administrative Fellow Larry Harden, Administrative Director, Risk & Compliance Maggie Martin, Attorney, Crowe & Dunlevy Melissa Herron, Director, Integrated Marketing Ray Leyva, Multimedia and Video Specialist Jack DeLester, OU’s JC Penny Leadership Fellow Gavin Nation, OU’s JC Penny Leadership Center Annette Troxell, Director Patient Care Services Michael Combs, Supervisor, EMSStat Tasha Schmidt, Paramedic, EMSStat Thomas Wood, Paramedic, EMSStat Shae Orcutt- Richardson, Paramedic, EMSStat Trish Crow, Coordinator, NRHS Foundation Lana Nelson, DO, Surgeon John McFadden, Director, Rehabilitation Services Lisa Robertson, RN, Rehabilitation Services Charissa Gowens, RN, Charge Nurse  NRHA Board Minutes 2 November 28, 2022 Tracy Mills, Nurse Manager Jason Milam, Director, Emergency Services Chris Miller, Manager, Surgical Service Line Jamie Barnes-Polski, RN, Nurse Manager Sheila Monson, RN, Emergency Department Diana Hughes, LPN, Clinics Katie Gilmore, RN, Charge Nurse Paul Jones, Director, Clinic Operations & Growth Jack Jewell, Department Assistant, Rehabilitation Services Amy Hawley, RN, Supervising Nurse Members Absent: Muhammad Anwar, MD Mary Womack Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the February 27, 2023, Norman Regional Hospital Authority business meeting at 5:30p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. March 2023 Healer of the Month – Jack Jewell, Department Assistant, Physical Rehabilitation. Mr. Cubberley introduced Ms. Lisa Robertson, Manager, Physical Rehabilitation. Ms. Robertson shared Mr. Jewell started at NRHS in September 2017 as a lead technician at Porter. Mr. Jewel’s fellow healers state he is a joy to work with and is always willing to lend a hand to help a fellow healer. There is no job too small or no job too big for Mr. Jewell to take on. His patients are always happy they are healing but are disappointed they won’t be able to see Mr. Jewell any longer. His positive attitude keeps everyone wanting to work with him. Mr. Jewell thanked his fellow healers for their support and honoring him with the nomination. Mr. Cubberley congratulated and thanked Mr. Jewell 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. Ms. Robertson, Mr. McFadden and Mr. Jewell left the meeting at 5:33pm. B. EMSStat Crimestopper’s Paramedic of the Year 2022-2023 Tasha Schmidt and EMT of the Year 2022-2023 Shae Orcutt-Richardson. NRHA Board Minutes 3 November 28, 2022 Mr. Cubberley introduced Mr. Michael Combs, EMSStat Operations Supervisor. Mr. Combs introduced Ms. Schmidt and shared that she began working for EMSStat in December of 2014. Her fellow healers describe her as a great mentor and educator; she is a shining example of the Norman Way and is a tireless advocate for patients and families. Ms. Schmidt has faced some of the most difficult situations a paramedic could face. No matter the circumstance, she approaches each situation with dignity and grace. Ms. Schmidt sets a high bar for others to meet and pushes those she works with to do their best. Mr. Combs introduced Ms. Shae Orcutt-Richardson. Mr. Combs shared Ms. Orcutt-Richardson began working with EMSStat in July 2021. Her fellow healers describe her as reliable, honest and genuine. Her dedication to learning and natural inquisitiveness make her a standout healer that everyone wants to work along side. From her first day on the job, Ms. Orcutt-Richardson was determined to become a paramedic. She was accepted into the first class of EMT’s to participate in the NRHS Paramedic Extern Program and will graduate in May 2023. C. Nurse of the Year Awards Mr. Cubberley introduced Dr. Lana Nelson, DO. Dr. Nelson shared the idea for the Nurse of the Year award was created by the Physicians Committee in 2010 to honor NRHS’s most outstanding nurses. Nominee Amy Hawley works in Labor and Delivery and has been with NRHS since 2007. She demonstrates excellence in nursing leadership, is a champion of patient advocacy and asks for little in return. Nominee Charissa Gowens works in Same Day Surgery and has been with NRHS since 1998. Her training and leadership skills help her to remain calm in the midst of a busy ambulatory surgery unit. Her fellow healers agree that it is her commitment to and compassion for patients that exemplify the Nroman Way to the rest of the nursing staff. Katie Gilmore works in the flex pool and has been with NRHS since 2015. She is amazing, smart and calm under pressure. She is always willing to go the extra mile and gives 100% no matter which department she is working. Runner up for Nurse of the Year is Diana Hughes. Ms. Hughes has worked for NRHS since 1994. Over the years, Diana has worked in internal medicine, the emergency department and is currently working in the Headache Center. Patients in the clinic are constantly complimenting her for going above and beyond each and every day.  NRHA Board Minutes 4 November 28, 2022 Nurse of the Year is Sheila Monson. Ms. Monson has worked at NRHS since 2009 and is a first-rate example of the Norman Way. She devotes time to making sure the work place is better for all healers. She’s contributed significantly to the development and overall success for the Human Trafficking program in the Emergency Departments at NRHS. Mr. Splitt introduced Gavin Nation, University of Oklahoma student, who is participating in the JC Penny Leadership Program “C-suite for the Day” program. Mr. Nation will observe the Board meeting as part of the program. Mr. Combs, Ms. Schmidt, Ms. Orcutt-Richardson, Dr. Nelson, Ms. Monson, Ms. Hughes, Ms. Hawley, Ms. Gowens, Ms. Gilmore, Mr. Jones Mr. Milam, Mr. Miller, Ms. Barnes- Polski, Ms. Crow, Ms. Mills, Ms. Troxell, Mr. Leyva and Mr. Wood left the meeting at 5:44pm. Agenda Item III. Board Education: High Reliability Metrics and Processes Ms. Jenny Anderson, Administrative Director, Patient Quality, Shannon Largent, Administrative Director, Patient Care Services & Accreditation and Larry Harden, Administrative Director, Risk & Compliance presented an overview of the metrics and processes of NRHS’s journey toward becoming a High Reliability Organization (HRO). Ms. Anderson provided a short summary of the January 2023 board presentation on High Reliability Organization traits and principles. NRHS’s journey began with the development of a Strategic Plan in 2017. From there, a Process Improvement tool from the Outcomes & Efficiencies Strategic Team was introduced in 2019 and the Just Culture Strategic team followed officially in 2022. The Joint Commission has established four stages of an HRO Maturity:  Beginning – everyone is doing something, but no one is on the same page.  Developing – people within each group practice “silo thinking”. Each may be doing great work but starting to look outside the immediate work group.  Advancing – a strategic plan is developed with standardized work, connections and integrated work and strategies. You start to see the use of the components of the HRO framework of leadership, culture, knowledge and learning.  Approaching – moving towards a Just Culture, we will see the number of good catches increase as the process becomes routine and automatic. Mr. Harden shared that Reliability depends on the waning of unwanted, unanticipated, and unexplainable variances in performance. A “variance” is an irregularity associated with the care of a patient, visitor or staff. As part of the Advancing stage, however, those variances should increase as healers become more comfortable reporting them and, more importantly, addressing and preventing them from occurring in the future – thus leading to a stronger culture of safety. The Risk & Patient Safety Committee meets weekly to review any variances and determine if it warrants further investigation. Further investigation may include a Root Cause Analysis& Action Plan (RCA2), a Swarm  NRHA Board Minutes 5 November 28, 2022 response (a novel, rapid approach for analyzing patient care) or Sentinel Event Determination Team Review (SEDT). All of these reviews is carried out in a blame-free environment and while the incident is still fresh in every one’s mind. Ms. Largent shared the SEDT meets monthly to review and discuss any high level variances, identify trends, and determine which situations need further action. The group consists of clinical leaders, Risk, Patient Safety, Quality & Performance Improvement. Using the Just Culture Investigation questions and algorithms, the team can determine if an Action Plan is needed. Using these teams to support the self- reporting process reinforces our commitment to do everything we can to prevent an unexpected and potentially harmful occurrence from happening, which promotes greater patient safety and efficient healthcare delivery. Agenda Item IV. Approval of January 23, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the January 23, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the January 23, 2023 Board Meeting Minutes. Ms. Greenleaf seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Mr. Pipes. Agenda Item V. Performance Update The monthly Performance Update was presented by Ms. Anderson as part of the Board Education topic: High Reliability Metrics and Processes. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on February 8, 2023. MEC covered a number of topics including – automatic dispensing updates, 340B drug pricing program, quarterly finance report, Medical Credentialing report, Department/Committee reports and Executive team updates. 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. B. Annual Review & Revision to the 2023 Infection Prevention Plan Policy  NRHA Board Minutes 6 November 28, 2022 ACTION TAKEN: Dr. Weber made the motion to approve the 2023 Infection Prevention Plan Policy as presented by the Patient Quality & Safety Committee. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Mr. Pipes. Agenda Item VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met February 20, 2023. B. Mr. Wagner presented the NRHS Financial report for January 2023: January 2023 Financial Performance  Gross Revenues .................................. (Budget $236,590,346)............ $218,918,138  Net Patient Revenue .............................. (Budget $48,591,259).............. $47,081,322  Total Operating Expenses ..................... (Budget $49,762,105).............. $51,161,538  Total Operating Revenues ...................... (Budget $49,022,868).............. $47,513,459  Operating Income ....................................... (Budget $739,237).............. ($3,648,078)  Non-Operating Revenues (Expenses) ......... (Budget $566540).............. ($5,646,684)  Excess Revenues over Expenses ............... (Budget $172,697).............. ($1,998,605) Year-to-Date  Operating Income ..................................... (Budget $2,158,487............ ($25,549,740)  Non-Operating Revenues (Expenses) ..... (Budget $5,473,025).............. ($9,650,898)  Excess Revenues over Expenses ............ (Budget $3,314,538)............ ($15,898,843)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 47.1 Days  Days Cash on Hand…………………………………………………………….138.5 Days ACTION TAKEN: Mr. Pipes motioned to approve the January 2023 NRHS Financial Statements. Mr. Chappel seconded the motion. January 2023 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Mr. Pipes. C. Mr.Wagner presented for approval two capital request items totaling $572,380 a. Newborn Infant Warmer: $392,250 b. NICU Infant Warmer: $180,130 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $572,380 as recommended by the Finance Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Mr. Pipes.  NRHA Board Minutes 7 November 28, 2022 Agenda Item IX. Old Business None. Agenda Item X. New Business None. Agenda Item XI. Administrative Report Mr. Splitt shared information on:  340B Drug Pricing: NRHS is continuing plans to implement the program and its positive benefit for our patients. This program will reduce the cost of drugs and allow NRHS to reinvest any savings in programs important to our patients.  Medicaid Private Led Entities (PLE): Discussions continue on the Medicaid expansion and Managed Care Organization (MCO) assignments. NRHS plans to participate in all MCO’s individually and collectively through LifeCare.  HealthPlex: There is continued development on the vacant lots surrounding the HealthPlex campus. Several new businesses are either starting development or will be in the near future. Mr. Manfredo provided an update on the minimal tornado damage experienced at the Norman Regional 9 location. He also reviewed an updated construction timeline for the HealthPlex. Ms. Herron, Ms. Anderson, Ms. Largent, Mr. Nation left the meeting at 6:48pm. 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: Mr. 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, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Mr. Pipes. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-4 Below. NRHA Board Minutes 8 November 28, 2022 1. Recommend New Provisional Medical Staff Appointments: a. Kate Arnold, MD – OB/GYN – Active b. Jacob Witmer, DO – Emergency Medicine – Active c. Shelby Wagner, DO – Emergency Medicine – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Belinda Broady-Symes, MD – OB/GYN – Active b. Tera Santistevan, DPN – Surgery – Active c. Paul Stevenson, MD – Medicine – Active d. Devorah Archer-Webb, PA-C – Surgery – Allied Health e. Carly Ferguson, PA-C – Surgery – Allied Health f. Taylor Tamage, PA-C – Surgery – Allied Health g. Tori Hendrix, APRN-CNP – Pediatrics – Allied Health h. Lindsey Lancaster, APRN-CNP – Pediatrics – Allied Health i. Nathan White, PA-C – Radiology – Allied Health j. Brent Lamb, APRN-FNP – Emergency Medicine – Allied Health 3. Recommended Medical Staff Reappointments: a. Shannon Haenel, DO – Medicine – Active b. Alyssa Ohs, MD – OB/GYN – Active c. Jeffrey Butyen, MD – Surgery – Active d. Amanda Ward, DDS – Surgery – Active e. Tom Connally, MD – Surgery – Active f. Rahal Kahanda, MD – Surgery – Active g. Anderson Greenhaw, MD – Anesthesia – Active h. Mason Lawrence, MD – Anesthesia – Active i. Sean Dossett, DO – Anesthesia – Active j. Quentin Lobb, MS – Anesthesia – Active k. Patrick Cody, DO – Emergency Medicine – Active l. Robert Cunningham III, MD – Emergency Medicine – Active m. Marcia Hoos-Reinke, MD – Emergency Medicine – Active n. Ronan Bakker, MD – OB/GYN – Consulting o. Girish Murthy, MD – Hospital Medicine – Consulting p. Alexis Stinnett, APRN-CNS – Medicine – Allied Health q. Veronica Worrell, PA-C – Surgery – Allied Health r. Josie Dean, PA-C – Surgery – Allied Health s. Jeffrey Fredrick, PA-C – Surgery – Allied Health t. Kent Bays, PA-C – Surgery – Allied Health u. Deanne Givens, APRN-CRNA – Anesthesia – Allied Health v. Sheryl Ronne-Dellinger, APRN-CRNA- Anesthesia – Allied Health w. Dustin Wade, APRN-FNP – Emergency Medicine – Allied Health 4. Information Only a. Robert Kramer, DO requests Emergency Medicine Moonlighting privileges b. Tariq Mahmmod, MD requests to change from Active Staff to Consulting Staff  NRHA Board Minutes 9 November 28, 2022 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. Ms. Greenleaf seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Mr. Pipes. 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 1-4 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 1-4, with correction of Ronan Bakker, MD from Pediatrics to OB/GYN. Mr. Pipes seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber & Mr. Pipes. Agenda Item XIII. Board Open Discussion The Board provided feedback related to the Board Advance held Saturday, February 18th. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:57pm. Ms. Roberts seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber & Mr. Pipes. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary