Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting May 22, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, May 22, 2023 at 5:30p.m. in the Conference Room at Norman Regional Nine. The meeting Agenda was posted May 17, 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. 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 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 & Video Specialist, Media Services Joe Mankin, Director, Supply Chain Management Ted Sanderson, Materials Clerk, Supply Chain Management Sharon Sanderson, Analyst, Performance Improvement David Findley, Manager, Logistics & Operations Members Absent: Mary Womack Kevin Pipes Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Dr. Weber called to order the May 22, 2023, Norman Regional Hospital Authority business meeting at 5:36p.m.  NRHA Board Minutes 2 May 22, 2023 Agenda Item II. Introduction and Recognition of Outstanding Healers A. June 2023 Healer of the Month – Ted Sanderson, Materials Clerk, Supply Chain. Dr. Weber introduced Mr. Mankin, Director, Supply Chain Management and Mr. Findley, Manager, Logistics and Operations. Mr. Findley shared Mr. Sanderson takes care of all the clinics in the NRHS health system. He is a great asset to the Supply Chain Department. His customer service skills and personality make him well liked by the various vendors he works with. His fellow healer share that he goes out of his way to make sure every single person he encounters has a great day. In addition, his coworkers appreciate his outgoing and warm personality so much, that 15 of his fellow healers nominated Mr. Sanderson for the Healer of the Month recognition. Mr. Sanderson thanked his fellow healers for the nomination and conveyed this has been the most satisfying job he has ever had. Dr. Weber congratulated and thanked Mr. Sanderson 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. Mankin, Mr. Findley, Mr. Sanderson and Mrs. Sanderson left the meeting at 5:39pm. B. Foundation Ambassador of Health Scholarship – Brittni McGill, Vice President & Chief Nursing Officer Each year the Norman Regional Health Foundation awards over $50,000 in scholarships to healers at NRHS. Mr. Chappel, Board liason for the NRH Foundation presented Ms. McGill with the Foundation Ambassador of Health Scholarship. This scholarship is awarded annually to benefit a NRHS healer who exemplifies outstanding leadership qualities in health care. Agenda Item III. Board Education: Healer Safety Overview: Safety, Security & Emergency Preparedness Mr. Shane Cohea, Director of Safety and Security presented a Healer Safety Overview for the health system. The State of Oklahoma has recently provided new regulatory compliance guidelines that strengthen laws dealing with violence against people who work in hospitals and health care facilities. New signage is being placed inside all NRHS facilities to make known the new State laws. NRHS takes a personal approach to security when implementing policies and  NRHA Board Minutes 3 May 22, 2023 procedures for patients, guests and healers. The NRHS security team has traveled across the state to study leading practices in health care and other businesses. This practice helps to ensure NRHS can better protect our healers, while raising awareness and increasing accountability. NRHS engaged with Lockton, an industry leading insurance company, to perform an assessment of our risk needs. Lockton representatives met with several NRHS Directors and performed a site visit at all campuses and clinic locations to help determine strengths and weaknesses. Workplace safety encompasses a broad range of health system services and areas – including construction zones, ergonomic worksite evaluations, indoor air quality and pandemic preparedness, to name a few. NRHS places a significant focus on early action as a preventative tool for workplace safety measures. For example, during the winter months, bags of de-ice material were made available at numerous entrances throughout our health system. Healers and guests were encouraged to use those bags of de-icer in the parking lots as an additional and convenient safety measure. NRHS leadership is encouraged to fully engage with preemptive prevention efforts by providing training and closing the loop on proposed solutions. Proactive Safety Measures implemented include:  Annual Health Stream education modules for all healers  Mandt training (prevention, de-escalation and intervening)  “One Button” lockdown options  Use of panic/duress buttons  Geo Safe  Installation of state-of-the-art security camera & video systems  Reporting of safety & security events/concerns to NRHS leadership  Over 1200 healers trained in Active Shooter Training & Response Planning: Run, Hide, Fight Agenda Item IV. Approval of April 27, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Dr. Weber asked for approval of the April 27, 2023 Board Meeting Minutes ACTION TAKEN: Ms. Roberts made the motion to approve the April 27, 2023 Board Meeting Minutes. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Ms. Greenleaf, Dr Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Dr. Anwar. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Patient Quality, presented an update on the Journey to Excellence Award and the Vizient Patient Safety Organization Conference.  NRHA Board Minutes 4 May 22, 2023 The Journey to Excellence is a project of the Outcomes & Efficiencies Strategic Team. It represents a cycle of learning within the organization. Previously known as the Dr. Jerry Leu Quality Award, it was recently renamed the “Innovation Award”. Goals of the process improvement is to:  Highlight Journey of Excellence Award applicants to a broader audience: project posters were on display during hospital week at Porter and the HealthPlex. Healers were encouraged to visit the boards in person or view on Healer Hub and vote for the “Healers Choice Award”.  Encourage award recipients to submit for regional/national awards and presentations: Cathy Snapp, Rehab Service Line Quality Coordinator submitted 3 poster projects for the National Association for Healthcare Quality (NAHQ) annual conference. The NAHQ requested 2 of the 3 submissions to be presented at the conference.  Align terminology and fundamental nature of the Journey to Excellence framework of Baldrige.  Increase the number of applicants in FY23 by 50% - applicants increased from 10 to 25. In order to share with a broader audience, project posters were displayed during hospital week at Porter and the HealthPlex. Healers were encouraged to visit the boards in person or view them on the Healer Hub and vote for the “Healers Choice Award”. Ms. Anderson presented the “Measuring and Improving Health Equity in Ambulatory Care” at a Vizient conference in Chicago, IL. The presentation highlighted NRHS’s efforts to improve health equity by assessing and addressing Social Determinants of Health (SDoH) – through community outreach. Following the presentation, multiple requests for follow up information were received so that similar programs could be initiated by other health systems. Outcomes from this SDoh program resulted in:  Increased number of successful patient contacts  Initiated the Community Health Worker in January 2023  43% decrease in 30-day readmissions of high-risk populations after-putting into practice Ms. Anderson shared the Quality Performance Improvement and Patient Safety Plans will be presented for approval next month. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on May 10, 2023. MEC covered a number of topics including – Diabetes Documentation for Stroke Discharge, Physician Status Boards, Physician Round List Update, Health System Finances, Medical Credentialing, Department Committee Reports and Executive Team updates.  NRHA Board Minutes 5 May 22, 2023 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. Splitt reported the Finance Committee met May 15, 2023. B. Mr. Splitt presented the NRHS Financial report for April 2023: April 2023 Financial Performance  Gross Revenues .................................. (Budget $228,702,409)............ $205,427,296  Net Patient Revenue .............................. (Budget $47,212,656).............. $42,000,047  Total Operating Expenses ..................... (Budget $47,469,952).............. $46,952,222  Total Operating Revenues ...................... (Budget $47,637,474).............. $42,936,011  Operating Income ....................................... (Budget $167,522).............. ($4,016,211)  Non-Operating Revenues (Expenses) ........ (Budget $481,687)................ $2,452,701  Excess Revenues over Expenses ............... (Budget $649,209).............. ($1,563,510) Year-to-Date  Operating Income ..................................... (Budget $1,411,693............ ($36,974,377)  Non-Operating Revenues (Expenses) ..... (Budget $7,087,842)............ ($13,934,594)  Excess Revenues over Expenses ........... (Budget $5,6,76,149)............ ($23,039,783)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 54.5 Days  Days Cash on Hand…………………………………………………………….119.2 Days ACTION TAKEN: Dr. Weber motioned to approve the April 2023 NRHS Financial Statements. Ms. Greenleaf seconded the motion. April 2023 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Dr. Anwar. C. Mr. Splitt presented for approval two capital requests totaling $241,622 a. CV Upgrades: $323,459 b. Birthing Beds (4): $231,181 (NRH Foundation Grant: $140,000 for Birthing Beds) ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $241,622 as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Dr. Anwar.  NRHA Board Minutes 6 May 22, 2023 Agenda Item IX. Old Business None. Agenda Item X. New Business None. Agenda Item XI. Administrative Report Mr. Splitt shared several updates:  Nurses Week and Hospital Week were very well received by our healers. Next week is EMS “EMSStat” week.  Our partner, OU Stephenson Cancer Center was reaccredited with the “gold standard” NCI designated Cancer Center recognition.  Recovery & Transformation efforts are still under way – including the implementation of a new digital/online patient-billing program.  The implementation of the 340B drug pricing program started April 1st and our patients are beginning to experience the benefits of the program.  Norman Regional is an active participant in the One Norman Visioning process. Several meetings have occurred and w more will be held at the NRHS Education Center.  The Oklahoma Hospital Association continues working with state legislators to authorize “gap funding” for Oklahoma hospitals. Ms. McGill shared several updates:  The Joint Commission (TJC) visited the Norman Regional Nine facility this past Friday. NRHS anticipates full accreditation from TJC.  The” Team Birth” initiative is a program initiated through the Oklahoma Perinatal Quality Forum, It ensures mother’s giving birth and the clinicians who are caring for them have shared input and understanding into decisions during labor and delivery. Oklahoma will be the first state in the nation to have all delivering hospitals participating in this innovative program.  Norman Regional received the TSET Champion of Health award for our smoking cessation education program. NRHS has a high number of referrals to the program and a high success rate for patients who participated. Mr. Manfredo reported:  Trustees are scheduled to tour the HealthPlex construction areas on May 24th.  May 31st is the groundbreaking/topping out ceremony for the new Behavioral Health center being constructed on the Porter Health Village site.  Parking Advisors met with the executive team to determine the best tools for managing patient, guest and healer parking.  NRHA Board Minutes 7 May 22, 2023 Mr. Minnis shared the following:  The annual Healer Engagement Survey is now complete and NRHS attained a participation rate of 81%, our highest participation rate ever. The Healer Engagement scores increased overall by 0.4%.  The Project SEARCH graduation occurred on May 18th at Norman Regional Moore. The program graduated 4 Moore Public School students and completed it’s 6th year at NRHS. Claudia Todd, Executive Assistant to the CEO, received the first annual “Claudia Todd Advocacy Achievement Award” for her support of the program. Ms. Purvis thanked Ms. Melissa Herron for her efforts to organize the Moore Remembrance Ceremony. Ms. Purvis shared the OBED Press event is May 24th with a tour to follow. The Behavioral Health “ground topping” ceremony is scheduled for May 31st. Dr. Boyd provided an update on clinics, providers and patient volumes. Ms. Herron and Ms. Anderson left the meeting at 6:54pm. 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: Dr. Weber made a motion to adjourn into Executive Session. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber 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. Elias Solomon, MD – Surgery, Active b. Denise Rable, MD – Surgery – Active c. Eric Royston, DO – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. John Tedrow, MD – Medicine – Active b. Summer Crawford, APRN-CNP – Hospital Medicine – Allied Health c. Robert “Tre” Kramer, DO – Nocturnist/Procedure Team – Hospital Medicine – Privileges Only 3. Recommended Medical Staff Reappointments: a. Benjamin Panter, MD – Surgery – Active b. Michael Mullins, MD – Anesthesia – Active  NRHA Board Minutes 8 May 22, 2023 c. Scott Proctor, MD – Anesthesia – Active d. Robert Littlejohn, MD – Pathology – Active e. Philip Bird, MD – Medicine – Active f. Nicholas Plants, DPM – Surgery – Consulting g. Christopher Travis, PA-C – Surgery – Allied Health h. Paige Puryear, APRN-CRNA – Anesthesia – Allied Health 4. Information Only a. Nathan White, PA-C completed proctored cases for Pleurex Drain Catheter privileges b. Michael Martin, MD completed proctored cases for Kyphoplasty c. Natalie Siegfried, DO requests privileges for Emergency Medicine – moonlighting 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, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber 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. 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. Dr. Anwar seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Dr. Anwar. Agenda Item XIII. Board Open Discussion Mr. Chappel provided an update on the NRH Foundation “Equipped for Tomorrow” campaign. More than half of the goal has been pledged, and the public launch won’t occur until June 9th at the Ambassador’s Ball. Dr. Weber complimented the executive team and the NRHS healers who have worked so hard to continue moving the health system in the right direction financially. Agenda Item XIV. Adjournment  NRHA Board Minutes 9 May 22, 2023 ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:00pm. Ms. Roberts seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber and Dr. Anwar. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary