Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting March 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. Mary Womack Muhammad Anwar, MD 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 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 Ron Cates, Manager Engineering Services Eugene Brown, General Repair Worker II, Engineering Services Debbie Brown, Guest Members Absent: Kevin Pipes Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the March 27, 2023, Norman Regional Hospital Authority business meeting at 5:30p.m.  NRHA Board Minutes 2 March 27, 2023 Agenda Item II. Introduction and Recognition of Outstanding Healers A. April 2023 Healer of the Month – Eugene Brown, General Repair Worker II, Engineering Services. Mr. Cubberley introduced Mr. Ron Cates, Manager, Engineering Services. Mr. Cates shared Mr. Brown started at NRHS in October 2000. Mr. Brown is currently a Communications Tech handling then nurse call systems and th pneumatic tube systems. His responsibilities also include electrical, plumbing, light replacement, code blue system, PA speakers and anything else that pops up throughout the day. Mr. Brown doesn’t shy away from challenges. At the end of the day, he walks away knowing he did everything he could to make sure our patients are safe and comfortable. Mr. Brown thanked his fellow healers for their support and honoring him with the nomination. Mr. Cubberley congratulated and thanked Mr. Brown 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. Mr. Cates, Mr. Brown and Ms. Brown left the meeting at 5:32pm. Agenda Item III. Board Education: Vizient Clinical Database Ms. Jenny Anderson, Administrative Director, Patient Quality presented an overview of the Vizient Clinical Database (CDB) Ms. Anderson shared the implementation of the CDB began in August 2022. NRHS has spent the last few months learning the database and report generation. The Vizient Clinical Data Base (CBD) is a healthcare analytics platform used for performance improvement. CDB provides high-quality, accurate and transparent data on patient outcomes – such as mortality, length of stay, complication and readmission rates, and hospital-acquired conditions – that enable NRHS to benchmark against peers; identify, accelerate and sustain improvement; reduce variation; and expedite data collection to fulfill agency reporting requirements. Clinical benchmarking tools such as dashboards, simulation calculators, and template and customizable reports will enable us to quickly identify improvement opportunities and their potential impact. NRHS will submit data monthly through an automated, secure intake process. All information is examined and thousands of data points are compiled into a Data Quality Report and Scorecard. This report will help establish the FY23 Process Improvement Goals and Focus Goals that are reviewed and approved by the Board. The CDB is just another important tool to be used in our High Reliability Organization  NRHA Board Minutes 3 March 27, 2023 (HRO) and Baldrige journey. NRHS has several departments involved in this process, meeting monthly to continue to increase our knowledge of the database and form a plan to operationalize and integrate the process across the health system. Agenda Item IV. Approval of February 27, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the February 27, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the February 27, 2023 Board Meeting Minutes. Ms. Roberts 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, Ms. Womack and Dr. Anwar. Agenda Item V. Performance Update The monthly Performance Update was presented by Ms. Anderson as part of the Board Education topic: Vizient Clinical Database (CDB). Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on March 8, 2023. MEC covered a number of topics including – Pharmacist Ordering of MRSA Nasal Swabs, quarterly finance report, Medical Credentialing report, Department/Committee reports and Executive team updates. Agenda Item VII. 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 VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met March 20, 2023. B. Mr. Wagner presented the NRHS Financial report for February 2023: February 2023 Financial Performance  Gross Revenues .................................. (Budget $217,124,854)............ $194,822,954  Net Patient Revenue .............................. (Budget $45,114,653).............. $41,173,529  NRHA Board Minutes 4 March 27, 2023  Total Operating Expenses ..................... (Budget $46,033,618).............. $45,453,944  Total Operating Revenues ...................... (Budget $45,528,372).............. $41,754,370  Operating Income ....................................... (Budget $505,246).............. ($3,699,573)  Non-Operating Revenues (Expenses) ........ (Budget $566,548)................... ($52,600)  Excess Revenues over Expenses ................. (Budget $61,302).............. ($3,752,173) Year-to-Date  Operating Income ..................................... (Budget $2,663,733............ ($29,249,314)  Non-Operating Revenues (Expenses) ..... (Budget $6,039,573).............. ($9,598,298)  Excess Revenues over Expenses ............ (Budget $3,375,840)............ ($19,651,016)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 49.5 Days  Days Cash on Hand…………………………………………………………….130.2 Days ACTION TAKEN: Dr. Weber motioned to approve the February 2023 NRHS Financial Statements. Mr. Chappel seconded the motion. February 2023 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack & Dr. Anwar. C. Mr.Wagner presented the Audit Proposal for approval ACTION TAKEN: Dr. Weber made the motion to approve the Audit Proposal. Ms. Roberts 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, Ms. Womack and Dr. Anwar. Agenda Item IX. Old Business None. Agenda Item X. New Business None. Agenda Item XI. Administrative Report Ms. McGill provided an update on the Cardio Vascular service line. Ms. McGill shared the Obstetrics Emergency Department (OBED) service line will soon have its initial accreditation survey and the Perinatal service line will also complete their reaccreditation process during the upcoming weeks. Mr. Manfredo provided an update on the Recovery and Transformation committee’s accomplishments to date. Mr. Manfredo provided an update on the Healthplex parking garage and plans/timeline to begin using it. Mr. Manfredo shared construction crews began pouring concrete today in the HealthPlex circle drive.  NRHA Board Minutes 5 March 27, 2023 Mr. Splitt shared he will be travelling to Washington DC for an American Hospital Association meeting in April. Mr. Splitt plans to visit with every available federal delegate from Oklahoma. He plans to tell the NRHS story as it relates to the ongoing impact of COVID-19 and the associated financial headwinds. Mr. Splitt shared the Oklahoma Hospital Association is continuing to work with state legislators to find possible financial relief for Oklahoma hospitals. Ms. Splitt thanked Ms. McGill for the planning and preparation of Dr. Toal’s celebration of life and tribute. CrossPointe Church located across the street from Norman Regional Nine hosted a Community Day this past weekend. The event celebrated and honored individuals and organizations who assisted in the aftermath of the recent tornado outbreak in Southeast Norman. Governor Stitt and Mayor Heikkila were in attendance, and Mr. Splitt proudly represented the healers of Norman Regional Health System. Ms. Herron, Ms. Anderson, Mr. Leyva left the meeting at 6:12pm. 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. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack and Dr. Anwar. 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. Kailee Anderson, APRN-CNP – Surgery – Allied Health b. Adeyinka Owoyele, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Pouya Javadian, MD – OB/GYN – Active b. Ammar Sharif, MD – Cardiovascular Medicine – Privileges Only c. Robert Schoaps. MD – ECMO – Cardiovascular Medicine – Privileges Only d. Joseph Brewer, DO – ECMO – Cardiovascular Medicine – Privileges Only 3. Recommended Medical Staff Reappointments: a. Ahmed Awab, MD – Medicine – Active NRHA Board Minutes 6 March 27, 2023 b. Sabrina Young, DO – Medicine – Active c. F. Clark Sauls, MD – Medicine – Active d. Lane Tinsley, MD – Medicine – Active e. Jennifer Baker, MD – Pediatrics – Active f. Seth Brooks, DDS – Surgery – Active g. Lana Nelson, DO – Surgery – Active h. Daniel “Clay” Cochran, MD – Surgery – Active i. Michael Padilla, MD – Surgery – Active j. Robert “Brad” Vogel, DO – Surgery – Active k. Michael Saumur, DDS – Surgery – Active l. John “Buck” Hill, DO – Anesthesia – Active m. J. Patrick Sullivan, MD – Anesthesia – Active n. Stephanie Barnhart, DO – Emergency Medicine – Active o. Gary Wells, DO- Emergency Medicine – Active p. Terry Hill, DO – Emergency Medicine – Active q. Robin Mantooth, MD – Emergency Medicine – Active r. Nzube Okonkwo, MD – Hospital Medicine – Active s. Eric Thompson, MD – Pathology – Active t. James Seay, MD – Pathology – Active u. Gordon Bean, DPM – Surgery – Consulting v. Christopher Espinoza-Ervin, MD – Surgery – Courtesy w. Amy Manfredo, APRN-CNP – Pediatrics – Allied Health x. Ashley Helmbrecht, APRN-CNP – Pediatrics – Allied Health y. Rhiannon Baker, APRN-CNP – Pediatrics – Allied Health z. Michael Crawford, PA-C – Surgery – Allied Health aa. Mary Underhill, PsyD – Surgery – Allied Health bb. Stephen Isernhagen, PA-C – Surgery – Allied Health cc. Kimberly Franks-Martens – APRN-CNP – Anesthesia – Allied Health dd. Nicole Alvarez, APRN-CRNA – Anesthesia – Allied Health ee. Marilyn Campbell, APRN-CRNA – Anesthesia – Allied Health ff. Lindsey Lightner, APRN-CRNA – Anesthesia – Allied Health gg. Lauren Pratt, PA-C – Hospital Medicine – Allied Health 4. Information Only a. Hannah Elliott, PA-C completed proctored cases for Nephrostomy Tube 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. Chappel seconded, and the motion was approved unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack 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.  NRHA Board Minutes 7 March 27, 2023 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. Mr. Chappel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack & Dr. Anwar. Agenda Item XIII. Board Open Discussion Mr. Manfredo provided a brief update on the Oklahoma Quality Award/Baldrige application process. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:28pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack & Dr. Anwar. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary