Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting April 24, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, April 24, 2023 at 5:30p.m. in the Conference Room at Norman Regional Nine. The meeting Agenda was posted April 20, 2023 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Mary Womack Joan Greenleaf Dianne Chambers, MD James Chappel Paula Roberts Jerome (Jerry) Weber, Ph.D. Muhammad Anwar, MD Kevin Pipes Others Present: 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 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 Drew Hill, Multimedia and Audio/Video Specialist Jack DeLester, OU’s JC Penny Leadership Fellow Jason Milam, Director, Emergency Services Stephanie Gehrke, Manager, Chest Pain Center Melissa Scarberry, RN, Chest Pain Center Members Absent: Doug Cubberley Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Ms. Womack called to order the April 24, 2023, Norman Regional Hospital Authority business meeting at 5:30p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers  NRHA Board Minutes 2 April 24, 2023 A. May 2023 Healer of the Month – Melissa Scarberry, RN, HPX Emergency Department. Ms. Womack introduced Ms. Stephanie Gehrke, Manager, HPX Emergency Department. Ms. Gehrke shared Ms. Scarberry is an RN and Paramedic. Ms. Scarberry started with NRHS in 2015 as an EMT. She quickly earned her Paramedic license in 2016 and continued working for EMSStat as a Paramedic. Continuing her education, Ms. Scarberry graduated from nursing school in December 2020, earning her RN and began working in the HealthPlex Emergency Department in January 2021. She quickly exceeded all expectations, and was promoted to a charge nurse role in November 2022. Ms. Scarberry has continued to push herself and others to be their best. She has boundless energy and doesn’t waste a spare moment. If she isn’t caring for a patient, she can be found with a broom in her hand cleaning the floor or reorganizing the supply room. Her fellow healers call her a diamond in the rough, because the emergency room can be a rough place to work, and Ms. Scarberry stands out like a diamond. She has a great attitude, is a strong advocate for her patients and always has a smile on her face. She leads others and provides controlled, seamless care in every situation. Mr. Scarberry thanked the EMSStat crews for teaching her how to serve with integrity and passion for patients. She thanked her fellow healers for their support and honoring her with the nomination. Ms. Womack congratulated and thanked Ms. Scarberry 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. Milam, Ms. Gerhrke and Ms. Scarberry left the meeting at 5:35pm. Agenda Item III. Board Education: Recruitment & Retention: Quarterly Review Mr. Keith Minnis, VP & Chief People Officer and Ms. Brittni McGill, VP & Chief Nursing Officer presented an overview of NRHS’s Recruitment & Retention (R&R) efforts. Mr. Minnis shared a staffing crisis is prevalent and persistent in healthcare across the nation. As part of NRHS’s R&R efforts, Mr. Minnis shared the “Big 4” Strategic Initiatives for 2023:  Human Resources & Learning Resources Structure, Strategy & Operations  Talent Acquisition & Talent Management (R&R)  Labor Management – Contract Labor Compensation Structure  Technology – Leverage our hiring platform, Timekeeping, Staffing & Scheduling and Human Capital Management  NRHA Board Minutes 3 April 24, 2023 Talent Acquisition & Talent Management is the first and major focus of the R&R committee. Even though hiring numbers remains consistent, we need to find ways to reduce the turnover rate, through increased retention and engage workforce. Enhancements in the hiring platform design create a better candidate experience from the application process to the communication from Human Resources. Additional steps were taken to promote our Healer referral program. A new appearance for the Career Site provides a fresh and exciting first impression for potential candidates. Within the career site, the R&R team will be able to track site hits, visits, clicks, and progress of applications. Measurement of this activity will assist with a more targeting social media campaign. Ms. McGill shared plans are in place to increase partnerships with local universities. NRHS has executed several clinical affiliation agreements across multiple disciplines. The Paramedic Externs and Respiratory Tech programs hve been very helpful in creating new partnerships with various academic centers. The Retention campaign kicked off in February 2023. The first of the quarterly campaigns began with “Why I Stay”. Additional efforts include: new reward and recognition options, new and established Healer breakfast events and well-being partnership programs. Mr. Minnis shared HR is working to increase exit survey participation and feedback options from healers. A revised enterprise-wide compensation review is under way for salary grades. Agenda Item IV. Approval of March 27, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Ms. Womack asked for approval of the March 27, 2023 Board Meeting Minutes ACTION TAKEN: Mr. Chappel made the motion to approve the March 27, 2023 Board Meeting Minutes. Dr. Weber seconded the motion, and the motion was approved unanimously with aye votes from Ms. Greenleaf, Dr Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Patient Quality, presented information on the required CMS data reporting as it ties into CMS Star Ratings. CMS requires data to be publicly reported. New Electronic Clinical Quality Measures (ECQM) requires 4 of 6 measures be shared and these measures become a part of the CMS Star Ratings. Data included in the reports are Safe Use of Opioids and 3 Stroke Care criteria (discharged on Antithrombotic therapy, Anticoagulation for Afib/Aflutter and  NRHA Board Minutes 4 April 24, 2023 discharged on a Statin medication). Additional CMS Measures included are 30-Day Mortality, Readmissions, Safety of Care, Patient Experience and Timely & Effective Care. These measures are determined by evidence-based protocols centered on Higher Quality Care, Safer Care and Lower Costs for patients. They are also benchmarked nationally. A preview of the star ratings for July 2023 indicate improvements for NRHS in 5 of 7 domains. The increase in the reporting data measures is expected to result in a 3 star rating. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on April 12, 2023. MEC covered a number of topics including – Updated Lactic Orders, Sepsis Lab Forms, Code Stroke Order Sets, finance report, Medical Credentialing report, Department/Committee reports and Executive team updates. Agenda Item VII. Patient Quality & Safety Committee A. Ms. Womack 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. Wagner reported the Finance Committee met April 17, 2023. B. Mr. Wagner presented the NRHS Financial report for March 2023: March 2023 Financial Performance  Gross Revenues .................................. (Budget $242,998,460)............ $220,028,023  Net Patient Revenue .............................. (Budget $49,889,284).............. $44,293,329  Total Operating Expenses ..................... (Budget $49,235,772).............. $48,656,356  Total Operating Revenues ...................... (Budget $50,320,290).............. $44,947,504  Operating Income .................................... (Budget $1,084,518).............. ($3,708,852)  Non-Operating Revenues (Expenses) ........ (Budget $566,582)................ $1,883,595  Excess Revenues over Expenses ............ (Budget $1,651,100).............. ($1,825,257) Year-to-Date  Operating Income ..................................... (Budget $1,579,215............ ($32,958,165)  Non-Operating Revenues (Expenses) ..... (Budget $6,605,155)............ ($11,481,893)  Excess Revenues over Expenses ............ (Budget $5,026,940)............ ($21,476,273)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 51.1 Days  Days Cash on Hand…………………………………………………………….117.8 Days  NRHA Board Minutes 5 April 24, 2023 ACTION TAKEN: Dr. Weber motioned to approve the March 2023 NRHS Financial Statements. Dr. Anwar seconded the motion. March 2023 Financials were approved unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. C. Mr.Wagner presented for approval one capital request items totaling $231,181 a. Wireless Syringe Infusion Pump: $231,181 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $231,181 as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. Mr. Hill left the meeting at 6:25pm. Agenda Item IX. Old Business None. Agenda Item X. New Business None. Agenda Item XI. Administrative Report Ms. McGill provided an update on the Center for Improvement in Healthcare Quality (CIHQ) on the accreditation survey for the OB Emergency Department (OBED). NRHS should be the first in the nation to be accredited as an OBED. Two days later, the Perinatal reaccreditation visit took place. We are awaiting approval on both. Ms. Purvis shared NRHS, the City of Moore and Moore Public Schools will host a remembrance ceremony at the Norman Regional Moore location on May 19 th at 10am. The ceremony marks the 10-year anniversary of the deadly EF-5 tornado that tore through Moore, Oklahoma, destroying Norman Regional’s Moore Medical Center. Invitations will be sent out next week. Mr. Manfredo provided an update on Inspire Health timelines for department activations. The parking garage is anticipated to open this summer and parking changes for healers will take place at that time. The Behavioral Health groundbreaking is scheduled for May 31st.  NRHA Board Minutes 6 April 24, 2023 Ms. Herron and Ms. Anderson left the meeting at 6:35pm. 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: Ms. Roberts made a motion to adjourn into Executive Session. Dr. Weber seconded and the motion was approved unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. 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. Manal Schoellermna, MD – Radiology – Privileges Only b. Demetrice Davis, MD – Radiology – Privileges Only c. Evan Johnson, MD – Radiology – Privileges Only d. Anthony Mohabir, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Dylan Rommel, DO – Emergency Medicine – Active b. Azure Adkins, MD – Surgery – Active c. David Cochran, MD – Surgery – Active d. Kelli Bryan, APRN-FNP – Pediatrics – Allied Health 3. Recommended Medical Staff Reappointments: a. Christopher Paskowski, MD – Surgery – Active b. Mahate Parker, MD – OB/GYN – Active c. Matthew Bonner, MD – Emergency Medicine – Active d. Jeremy Moore, MD – Surgery – Active e. David Bobb, MD – Surgery – Active f. Michael Porter, MD – Emergency Medicine – Active g. Michael “Sean” O’Brien, DO – Surgery – Consulting h. Rebecca McKinley, APRN-CRNA – Anesthesia – Allied Health i. Tedd Jeffers, APRN-CNP – Pediatrics – Allied Health j. Amanda Lewis, PA-C – Surgery – Allied Health 4. Information Only a. Derek Hill, DO requests privileges for Emergency Medicine - Moonlighting C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session  NRHA Board Minutes 7 April 24, 2023 ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session. Ms. Roberts seconded, and the motion was approved unanimous aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. Ms. Womack 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. Mr. Chappel seconded, and the motion was approved with unanimous aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. Agenda Item XIII. Board Open Discussion None Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:37pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary