Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting June 26, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, June 26, 2023 at 5:30p.m. in the Conference Room at Norman Regional Moore. The meeting Agenda was posted June 23, 2023 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Joan Greenleaf Dianne Chambers, MD James Chappel Paula Roberts Jerome (Jerry) Weber, Ph.D. Muhammad Anwar, MD Mary Womack 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 Aaron Boyd, VP, Chief Physician 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 Brad Foster, Director, Pharmacy Services Kara Cornell, Manager, 340B Program Erin Barnhart, Director, Norman Regional Foundation Melissa Herron, Director, Integrated Marketing Drew Hill, Multimedia & Video Specialist, Media Services Alicia Hill, guest Garrett Fergeson, Digital Marketing Specialist, Media Services Members Absent: Doug Cubberley Kevin Pipes Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Ms. Greenleaf called to order the June 26, 2023, Norman Regional Hospital Authority business meeting at 5:30 p.m.  NRHA Board Minutes 2 June 26, 2023 Agenda Item II. Introduction and Recognition of Outstanding Healers A. July 2023 Healer of the Month – Drew Hill, Network Admin, Multi-Media & A/V Specialist. Ms. Greenleaf introduced Melissa Herron, Director Integrated Marketing. Ms. Herron shared Mr. Hill is an amazing example of the Norman Way. His job capturing video really tells the story of Norman Regional. His kindness and compassion shines thru on every project he undertakes. He always remains calm, earning the trust and respect of the individuals he is assigned to cover and makes them feel comfortable. When Mr. Hill was asked about his favorite assignment, he shared the story of a cardiac arrest survivor he had the privilege to interview. This young patient and his spouse shared their unique and inspiring story with Mr. Hill. When captured on film, these types of stories shared by patients can provide the opportunity to save more lives when they are shared across our community. Mr. Hill thanked everyone for the honor to be a part of Norman Regional and the opportunity to share the stories he has been able to capture. He is thankful for the fellow healers who allow him to do what he does every day. Ms. Greenleaf congratulated and thanked Mr. Hill 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. Hill and Ms. Hill left the meeting at 5:34pm. B. Foundation Update Ms. Erin Barnhart, Director Norman Regional Foundation provided an FY23 update and goals for the upcoming year. The Norman Regional Health Foundation (NRHF) is celebrating its 40th anniversary this month. To celebrate this occasion, the foundation will be handing out cupcakes at lunch at the Porter and the Healthplex campuses this week. For over 40 years, the Foundation has raised and distributed just over $21.5 million:  Nearly $1 million in scholarships to 535 students in the medical or health care field  More than $3.3 million has been disbursed thru grants to NRHS internal departments for medical equipment, training and patient comfort.  Over $6 million has been raised for capital projects  $1.4 million has been awarded to Norman Public Schools in support of nurses and health assistants since 2016 to ensure each school has a  NRHA Board Minutes 3 June 26, 2023 health program  Over $5 million in external grants have been secured by the NRHF for the health system. Each year the Foundation hosts several events to raise funds. Those events include the Ambassador Ball, golf tournament and many other social events. The annual iGive campaign increased healer participation by 4%. This past year, NRHF awarded:  $50,000 in scholarships to 28 applicants; 20 of those scholarships were awarded thru endowment donation funds.  $151,000 in grants were awarded to healers for medical equipment, training certification and other needs within the departments. The “$1M Match Campaign” for the Headache Center campaign continues advancing. The foundation recently hosted an informative lunch with over 80 attendees who learned more about the benefits of the potential headache center and the healers who make it all possible. The Inspire Health “Equipped for Tomorrow” campaign is more than halfway to it’s $4 million goal. Funds that have already been raised are being distributed now. The public phase of their campaign kicked off June 9th. During the FY24 year, NRHF priorities include scholarships, grants, support for the Norman Public School’s nurses and health program and the Inspire Health “Equipped for Tomorrow” campaign. Agenda Item III. Board Education: 340B Drug Pricing Mr. Brad Foster, Director Pharmacy Services and Ms. Kara Cornell, Manager 340B Program presented an overview of the new 340B Drug Pricing Program. NRHS officially qualified for the 340B Drug Pricing program in October 2022. The program went live with HRSA in April 2023. This was a remarkably swift and impressive journey toward implementation. Ms. Cornell shared in 1990, the US Congress created the Medicaid Drug Rebate program to lower the cost of pharmaceuticals reimbursed by state Medicaid agencies. In 1992, Congress enacted section 340B of the Public Health Service Act. Under this act, participating pharmaceutical manufacturers agreed to provide frontend discounts on covered outpatient drugs purchased by specific providers. Eligible providers are called “Covered Entities” and the covered entities serve the nation’s most vulnerable patient populations. The 340B program is not a charity program. The goal of the program is to improve access to affordable medication by vulnerable patient populations. The federal program requires drug manufacturers to provide discounted prices on outpatient prescription drugs to eligible healthcare organizations, such as qualified safety-net hospitals and  NRHA Board Minutes 4 June 26, 2023 clinics serving low-income and uninsured individuals. By reducing drug costs, the program aims to expand healthcare services and increase medication affordability for underserved communities, ultimately enhancing patient care and promoting equitable access to essential medications. NRHS has been designated a Disproportionate Share Hospital (DSH. The DSH program is a federal program that provides financial assistance to hospitals serving a high proportion of low-income and uninsured patients. DSH hospitals receive additional funding to help offset the costs associated with caring or vulnerable patient populations. It aims to ensure hospitals can continue providing essential healthcare services to those who may not have the means to pay for their, care, thereby promoting access to quality medical services for underserved communities. The DSH program and the 340B drug pricing program work together to support NRHS meet the needs of our patients. DSH provide financial assistance to hospitals serving a high proportion of low-income and uninsured patients, helping to offset the costs of providing essential healthcare services. On the other hand, the 340B programs requires drug manufacturers to offer discounted prices on outpatient prescription drugs to NRHS. By reducing drug costs, the 340B program enables NRHS to stretch resources further and increase access to affordable medications for out patients. Together, these two programs contribute to our financial stability, enhance our ability to serve the underserved in our community, and ensure our patients receive the necessary care and medications needed. Mr. Foster shared the process for program maintenance and reviewed program savings to our patients through May 2023. Agenda Item IV. Approval of May 22, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Ms. Greenleaf asked for approval of the May 22, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the May 22, 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 and Dr. Weber. Dr. Anwar arrived at the meeting at 5:50pm. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Patient Quality, presented an update on the CMS Star Rating Strategy Plans. The Quality Department’s role in the health system is to ensure the delivery of high- quality and safe healthcare services to patients. This department is also responsible for developing and implementing quality improvement initiatives, monitoring performance  NRHA Board Minutes 5 June 26, 2023 indicators, and analyzing data to identify areas for improvement. It works closely with NRHS providers and healers to establish and maintain rigorous standards of care, protocols, and best practices. The Department of Quality also plays a vital role in promoting patient safety, reducing medical errors, and enhancing patient outcomes and experiences. It conducts regular audits, facilitates healer education and training, and fosters a culture of continuous quality improvement. Currently, NRHS has a 3-star CMS rating. CMS’s star rating is based on various quality measures, including clinical outcomes, patient satisfaction, patient safety, and care coordination. These measures are used to assess the performance of hospitals/health systems on a scale of one to five stars, with higher star ratings indication better quality scores within the system. There are 5 groups in the Star rating program: Mortality, Safety, Readmissions, Patient Experience and Timely and Effective Care. Each measure group contributes a specific weight towards the overall rating. As we enter the next phase of Inspire Health, we are focusing on improvement. Our model will join together, Physician leaders, Hospital Administrators and Quality leasers (The Triad) to fast-track strategic priorities. The essential elements of an effective triad leadership model include: effective communication, working as a high-performance team, ability to solve complex problems and respect from and by their peers. Each participant has specific expectations:  Quality – drives system wide quality results, organizes programs to include data collection, leads and collaborates with Clinical and Non-clinical teams, and serve as the resource to administration, staff, board and physicians.  Physician – Provide medical staff direction by reporting data, evaluate clinical outcomes and communicate opportunities for improvement and supports and uses the Triad model to improve performance.  Administrators – Provide direction on strategy, goals and priorities, coordinate necessary group functions to improve performance indicators, and supports and uses the Triad model.  Shared expectations – Develop and implement strategies and associated action plans, promote, monitor and report progress towards goals, and foster culture of collaboration and process improvement. To accelerate and assist with the overall strategic plan, Physicians, Quality, Executives and other key individuals will continue reporting awareness and progress on a daily, weekly, monthly and yearly basis. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on June 14, 2023. There was no new business. MEC covered a number of topics including – Inspire Health Updates, Medical Credentialing, Department Committee Reports and Executive Team updates.  NRHA Board Minutes 6 June 26, 2023 Agenda Item VII. Patient Quality & Safety Committee A. Ms. Greenleaf announced a summary of the Patient Quality & Safety Committee Meeting is included in the board packet. Ms. Greenleaf is available to address questions. Ms. Womack arrived at the meeting at 6:31pm. Agenda Item VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met June 19, 2023. B. Mr. Wagner presented the NRHS Financial report for May 2023: May 2023 Financial Performance  Gross Revenues .................................. (Budget $240,207,727)............ $216,824,844  Net Patient Revenue .............................. (Budget $49,297,323).............. $45,667,919  Total Operating Expenses ..................... (Budget $49,172,757).............. $46,329,305  Total Operating Revenues ...................... (Budget $49,727,676).............. $46,343,069  Operating Income ....................................... (Budget $554,919)................... ($13,764)  Non-Operating Revenues (Expenses) ........ (Budget $481,709)................. $(604,453)  Excess Revenues over Expenses ............ (Budget $1,036,628)................. ($590,689) Year-to-Date  Operating Income ....................................... (Budget $856,774)............ ($36,960,612)  Non-Operating Revenues (Expenses) ..... (Budget $7,569,551)............ ($13,330,141)  Excess Revenues over Expenses ............ (Budget $6,712,777)............ ($23,630,471)  Accounts Receivable Days ............................ (Budget 48 Days).................. 54.3 Days  Days Cash on Hand…………………………………………………………….115.0 Days ACTION TAKEN: Dr. Weber motioned to approve the May 2023 NRHS Financial Statements. Mr. Chappel seconded the motion. May 2023 Financials were approved unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar and Ms. Womack. C. Mr. Manfredo presented for approval seven capital requests totaling $2,049,383 a. New Cafeteria Menu software: $131,348 b. Germ-zapping robots: $211,000 c. Cath Lab Intravascular Ultrasound (IVUS) equipment: $543,575 d. Chest Compression System (AMSStat): $64,460 e. Clinic build out (Purcell): $215,000 f. Clinic build out (Goldsby): $509,000 g. Urgent Care Clinic build out: $375,000  NRHA Board Minutes 7 June 26, 2023 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $2,049,383 as recommended by the Finance Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar and Ms. Womack. Agenda Item IX. Old Business None. Agenda Item X. New Business Mr. Splitt shared Mr. Cubberley has requested a temporary leave of absence from the NRHA Board following the loss of his beloved wife. The Board expressed their continued support for Mr. Cubberley during this difficult time. Ms. Womack, as Vice Chair and Secretary, will temporarily act as a Chairman during Mr. Cubberley’s leave. Agenda Item XI. Administrative Report Mr. Splitt shared several updates:  Ms. Purvis is attending the OHA Leadership Forum in Grove, OK  The Korn Ferry/Compliance Solutions Championship Golf Tournament was held this past week at the University of Oklahoma’s Jimmie Austin Golf course in Norman. NRHS healers provided outstanding medical services and support for the players and fans.  The NRHF Ambassador Ball was held June 9th. Mr. Splitt thanked Dr. Bond for being the emcee for the evening. Dr Kate Cook is the incoming Chair for the Foundation.  The Healer Forums summer series was successful. The next Healer Forum series will be held in the fall.  The City of Norman still discussing “ues plans” for the building across from the Porter Health Village. City Council is contemplating use as a Temporary Warming Shelter for the homeless population.  The Oklahoma Hospital Association continues working to encourage the Oklahoma Health Care Authority (OHCA) to release the legislatively approved “gap funding” for Oklahoma hospitals.  CMS is contemplating changes to the current Site Neutral Payment program. Proposed changes could reduce payments to NRHS resulting in a negative impact on financial performance and health system stability. It could even reduce access to care. The proposed changes fail to account for the unique challenges and higher costs experienced by NRHS (and other hospitals/health systems) as we deliver complex, specialized care for the broader communities we serve. By reducing reimbursement rates, hospitals  NRHA Board Minutes 8 June 26, 2023 across the country, including NRHS, will be forced to rethink those services, and may put at further risk already thin margins and financial viability. Mr. Manfredo reported:  Provided an update on the HealthPlex garage construction and first patient day dates at the ACC and Cancer Center. Ms. McGill shared:  The annual Oklahoma State Department of Health audit was held last week. Awaiting results of the audit.  On June 23rd 2023, six emergency medicine residents graduated, two will remain with NRHS. Mr. Minnis shared the following:  The “Welcome Home” campaign for returning physicians and nurses has been very successful. We have been averaging 8-10 healers per week at New Healer orientation.  The Compensation Review Committee is making great progress reviewing and researching adjustments for healer pay. Dr. Boyd shared information on:  Upcoming provider networking event  Physician updates  Strategic Planning goals  Primary Care visit numbers Ms. Herron, Ms. Anderson and Mr. Fergeson left the meeting at 7:18pm. 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. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar and Ms. Womack. 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. Montana Keller, MD – Pediatrics – Active b. Mary “Kaitlin” Parks, DO – Emergency Medicine – Active c. Prasanna Fernando, MD – OB/GYN – Active d. Matthew Ryan, MD – Medicine – Active NRHA Board Minutes 9 June 26, 2023 e. Carlton Fernandes, MD – Surgery – Active f. Emily Muns, MD – Emergency Medicine – Active g. Tyler Gutschenritter, MD – Medicine – Consulting h. Mila Duke, AUD - Pediatrics – Allied Health i. Elizabeth Grim, AUD – Pediatrics – Allied Health j. Allyson Pinkley, PA-C – Surgery – Allied Health k. Marcin Kopec, MD – Radiology – Privileges Only l. Austin Zearley, DO – Emergency Medicine – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. John Delcambre, MD – Medicine – Active b. Kimberly Bowman, MD – OB/GYN – Active c. Joshua Wilson, MD – Surgery – Active d. Hitesh Patel, MD – Pediatrics – Active e. Blair Kirkpatrick, MD – Medicine – Active f. Jay Jennings, MD – Surgery – Active g. Kyra Boler, APRN-CNP – Pediatrics – Allied Health h. Bethany Browne, PA-C – Surgery – Allied Health 3. Recommended Medical Staff Reappointments: a. Stephen Ingels, MD – Pathology – Active b. Kimberly Wise, MD – Surgery – Consulting c. Michelle Hensley, APRN-CNP – Pediatrics – Allied Heath d. Dylan Shockley, APRN-CNP – Medicine – Allied Health 4. Information Only a. Shelby Wagner, DO requests privileges for Emergency Medicine b. Kimberly Montell, DO requests privileges for Emergency Medicine c. Kara Hatlevoll, 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. Mr. Chappel seconded, and the motion was approved unanimous aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar and Ms. Womack. Ms. Greenleaf 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  NRHA Board Minutes 10 June 26, 2023 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, Dr. Anwar and Ms. Womack. Agenda Item XIII. Board Open Discussion None Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:21pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar and Ms. Womack. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary