Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting July 24, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, July 24, 2023 at 5:30p.m. in the Conference Room at Norman Regional Nine. The meeting Agenda was posted July 20, 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 Mary Womack Kevin Pipes 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 Maggie Martin, Attorney, Crowe & Dunlevy Ray Leyva, Multimedia & Video Specialist, Media Services Garrett Fergeson, Digital Marketing Specialist, Media Services Tonya Faires, Program Administrator, Perinatal Centers of Excellence Tracy Mills, Manager Labor, Delivery, Recovery/OBED Nick Skinner, Manager Environmental Services Samantha Ballard, Lead Environmental Service Technician Betty Chism, guest Payton Herring, guest Garrett Fergeson, Digital Marketing Specialist, Media Services Barbara O’Brien, University of Oklahoma Health Science Center Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order  NRHA Board Minutes 2 July 24, 2023 Mr. Cubberley called to order the July 24, 2023, Norman Regional Hospital Authority business meeting at 5:30 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. August 2023 Healer of the Month – Samantha Ballard, Lead Environmental Service Technician. Mr. Cubberley introduced Nick Skinner, Manager Environmental Services. Mr. Skinner shared Ms. Ballard is a Lawton native who has worked at NRHS for 2 years. Before joining NRHS, Ms. Ballard worked for a cleaning company servicing homes and businesses in the McKinney, Texas area. In 2021, Ms. Ballard began working for NRHS at the Porter campus on 3NW. She was quickly promoted and transferred to the HealthPlex where she was selected to lead the EVS department at Norman Regional Nine. Ms. Ballard is thankful for the relationships she has built while working at NRHS. Her goal is to provide a clean and safe environment for all our patients. Ms. Ballard, her husband and 3 children enjoy hiking and spending time outdoors as a family. She strives to follow her hopes and dreams while being the best version of herself. Mr. Cubberley congratulated and thanked Ms. Ballard 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. Skinner, Ms. Ballard, Ms. Herring and Ms. Chism left the meeting at 5:33pm. Agenda Item III. Board Education: Fourth Trimester: A Comprehensive Perinatal Care Program Ms. Barbara O’Brien, MS, RN, Director of the Oklahoma Perinatal Quality Improvement Collaborative (OPQIC) presented of the Comprehensive Perinatal Care Program. Ms. O’Brien shared the OPQIC works to create a culture of excellence, safety and equity in perinatal care in Oklahoma. Since 2014, the OPQIC has partnered with hospitals, clinicians and others to improve outcomes in maternal and infant health. Ms. O’Brien thanked NRHS, Ms. Tonya Faires and Ms. Tracy Mills, for being leaders in perinatal care and setting a great example for other health systems to follow. The landscape of Maternal and Infant Health care in Oklahoma is as follows:  OPQIC currently works with 44 birthing hospitals in the state of Oklahoma  48% of the hospitals are in a rural location  52% of the hospitals are in an urban location  NRHA Board Minutes 3 July 24, 2023  48,000 annual births in the state – 2,500 at NRHS  75% of those births occur in an urban hospital  25% of those births occur in a rural hospital  56% of births are covered by Medicaid  3 are tribal birthing hospitals  1 HIS birthing hospitals  7 Level III or IV NICUs NRHS’s Neonatal Intensive Care Unit (NICU) is a Level III facility and the only NICU in Cleveland County. The 4th Trimester program not only focuses on new baby care, but the mothers and their postpartum recovery. OPQIC monitors pregnancy postpartum related deaths each year. Approximately 700 women die in the United States each year from pregnancy complications; approximately 3 in 5 or 70% of these deaths were preventable. In Oklahoma, 64% of these deaths were preventable. The current recommendation is for women to have an initial contact with an obstetrician/gynecologist or other obstetric provider within 3 weeks after giving birth, followed by ongoing care as needed. They should also have a comprehensive postpartum visit on later than 12 weeks after delivery. Beginning January 1, 2023, the Oklahoma Health Care Authority (OHCA) expanded coverage for most SoonerCare members receiving pregnancy and postpartum services for up to 12 months of continuous postpartum coverage. Effective July 1, 2023 OHCA began covering doula services. A doula is a person who provides emotional and physical support during pregnancy and childbirth. They do not deliver babies or provide medical care. A certified doula has taken a training program and passed an exam on how to help pregnant women and their families during their birthing journey. OPQIC has been working with NRHS to design and provide education and materials for empowering patients. This toolkit provides pregnant and postpartum patients materials and contact information to ask questions and seek care when they have concerns or complications. For communities to thrive, the mothers and families within them must also thrive. We have a shared interest in working together to provide robust support for our community. Agenda Item IV. Approval of June 26, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the June 26, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the June 26, 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, Ms. Womack, Dr. Anwar and Mr. Pipes.  NRHA Board Minutes 4 July 24, 2023 Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Patient Quality, presented updates on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Mortality Data, Star Ratings Update and the Journey to Excellence Celebration. Ms. Anderson reviewed the current HCAHPS dashboard, highlighting the current 12- month values and the improvement targets. The Care Transitions team met to review and update questions asked during discharge phone calls. Ms. Anderson provided an update on the CMS star ratings for NRHS. Star ratings for hospitals summarize quality information on important topics, like readmissions and deaths after heart attacks or pneumonia. The overall rating, between 1 and 5 stars, summarizes a variety of measures across 5 areas of quality (Mortality, Safety of Care, Readmission, Patient Experience and Timely & Effective Care) and aggregates them into a single star rating for each hospital. NRHS will work on continuous improvement in all measure groups, but will have a specific focus on Patient Experience and Mortality. The current ratings are based on July 2023 CMS preview report and should update quarterly. Recently, NRHS hosted the Journey to Excellence Celebration. The following awards were given:  Commitment Level – 7 projects  Achievement Level – 16 projects  Healer’s Choice – Respiratory Assessment  Excellence Level – 2 winners: Early Mobilization in the Total Joint Population and the Call Center 405-515-5000 Agenda Item VI. Medical Staff A. Dr. Voto announced the Medical Executive Committee (MEC) did not meet in July. Medical Credentialing was approved via email. 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 July 17, 2023. B. Mr. Wagner presented the NRHS Financial report for June 2023:  NRHA Board Minutes 5 July 24, 2023 June 2023 Financial Performance  Gross Revenues .................................. (Budget $234,104,197)............ $211,271,105  Net Patient Revenue .............................. (Budget $48,437,339).............. $46,464,668  Total Operating Expenses ..................... (Budget $48,005,102).............. $47,061,876  Total Operating Revenues ...................... (Budget $48,861,876).............. $47,233,469  Operating Income ....................................... (Budget $856,774)................. ($171,593)  Non-Operating Revenues (Expenses) ........ (Budget $481,732).............. $(4,067,960)  Excess Revenues over Expenses ............ (Budget $1,338,506).............. ($4,239,553) Year-to-Date  Operating Income .................................................. (Budget $0)............ ($36,789,019)  Non-Operating Revenues (Expenses) ..... (Budget $8,051,283)............ ($17,398,101)  Excess Revenues over Expenses ............ (Budget $8,051,283)............ ($19,390,918)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 52.0 Days  Days Cash on Hand…………………………………………………………….118.5 Days ACTION TAKEN: Dr. Weber motioned to approve the June 2023 NRHS Financial Statements. Mr. Chappel seconded the motion. June 2023 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar, Ms. Womack and Mr. Pipes. C. Mr. Wagner presented for approval one capital request item totaling $872,940 a. Hemodialysis Delivery system: $872,940 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $872,940 as recommended by the Finance Committee. 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, Dr. Anwar, Ms. Womack and Mr. Pipes. Agenda Item IX. Old Business None. Agenda Item X. New Business Mr. Splitt suggested a location change for the remaining NRHA Board Meetings. Due to start time of the board meeting, construction parking restrictions at the Porter campus should no longer be a major factor. Notification of the location change will be sent to the City of Norman.  NRHA Board Minutes 6 July 24, 2023 Agenda Item XI. Administrative Report Mr. Splitt shared several updates:  Earlier this month, Ms. Donna Avila presented NRHS’s ongoing efforts to the “Social Determinants of Health” during a Congressional Briefing in Washington DC. Her presentation was so impressive that she was invited to return to “the Hill” to share our efforts with another Congressional group. Ms. Avila will provide an update to the Board at a future meeting.  Trustees are invited to attend the Healer of the Year ceremony, Tuesday, July 25th at 11:30am in the Porter Auditorium.  The American Rescue Plan Act (ARPA) funding agreement will be completed and signed very soon. The ARPA funds are part of an award granted by Cleveland County commissioners to be used for pandemic readiness in the Emergency Department on the HealthPlex campus. We sincerely appreciate the commissioner’s support for our health system. These ARPA funds will allow NRHS to better serve our community, and we are tremendously grateful. Ms. Purvis reported:  A national patient advocacy group is challenging many U.S. hospitals including Norman Regional, for alleged noncompliance with CMS hospital price transparency regulations. Norman Retinal responded by providing the group with links verifying our compliance with the CMS requirements. Ms. McGill shared:  Cardio vascular surgery was on a 48 hour divert status recently due to an unexpected physician illness. NRHS has also added an accomplished CV surgeon to help lead our cardiovascular program. He will begin October 2023. Mr. Minnis shared the following:  Our “Welcome Home” campaign to bring back former staff has been very successful, with an average of over 20 former healers rehired monthly. This campaign helped significantly reduce our reliance on contracted nurses by focusing closely on recruiting and welcoming back talented former team members. Mr. Manfredo shared an Inspire Health update:  The parking garage is scheduled to open for healer parking on August 21 st.  Due to significant production delays with the Air Handling Unit, the first patient day for the HealthPlex remains July 2024. Mr. Fergeson and Ms. Anderson left the meeting at 6:53pm. 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 NRHA Board Minutes 7 July 24, 2023 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 Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar, Ms. Womack 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. Garrett Nix, MD – Emergency Medicine – Active b. David Fish, MD – Emergency Medicine – Active c. James Trina, DO – Emergency Medicine – Active d. Alex Coshow, MD – Pediatrics – Active e. Dylan Roberts, DO – Hospital Medicine – Active f. Joshua Vollstaedt, DO – Medicine – Active g. Mehmood Cheema, MD – Hospital Medicine – Active h. Kelly Grimes, DO – Medicine – Active i. Scott Rogers, MD - Emergency Medicine – Active j. Gabriel Vidal, MD – Medicine – Consulting k. Sarah Cain, AUD – Pediatrics – Allied Health l. Shelby Stephenson, AUD – Pediatrics – Allied Health m. Stephanie Browning, AUD – Pediatrics – Allied Health n. Jo Lang, APRN-CNP – Pediatrics – Allied Health o. Kim Abernathy, APRN-CNP – Hospital Medicine – Allied Health 2. Recommend Advancement of Medical Staff from Provisional Status: a. Jesse Ream, MD – Anesthesia – Active b. Christopher Smith, DO – Emergency Medicine – Active c. Lacey Becker, APRN-CNP – Pediatrics – Allied Health 3. Recommended Medical Staff Reappointments: a. Richard Kirkpatrick, MD – Surgery – Active b. Zachary Knutson, MD – Surgery – Active c. James “Rick” McCurdy, MD – Surgery – Active d. Brian Clowers, MD – Surgery – Active e. John Chace, MD – Surgery – Active f. Kendral Knight, MD – Medicine – Active g. Kinde Aquilar, MD – OB/GYN – Active h. Karen Sargent, MD – OB/GYN – Active i. Wayland Billings, MD – OB/GYN – Active j. Steven Jimerson, MD – OB/GYN – Active k. Juliana Bizzell, DO – Emergency Medicine – Active l. Theresa White, DDS – Surgery – Consulting m. Brooke Cromer (Siebenman), PA-C- Surgery – Allied Health n. Katie Dudley, APRN-FNP – Surgery – Allied Health  NRHA Board Minutes 8 July 24, 2023 o. Amy Pedlow, PA-C – Surgery – Allied Health p. Jason Falconer, APRN-CRNA – Anesthesia – Allied Health q. Jordan Shuart, PA-C – Hospital Medicine – Allied Health 4. Information Only a. Kate Cook, MD requests Circumcision privileges 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, Dr. Anwar, Ms. Womack 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. 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, Dr. Anwar, Ms. Womack and Mr. Pipes. Agenda Item XIII. Board Open Discussion Mr. Splitt announced the flag pole at Norman Regional 9, damaged in recent storms, has been replaced. Additionally, the first-ever digital billboard on Highway 9 ahs been installed and is operational in front of NR9. The future usage of the city-owned 718 building across from Norman Regional Porter remains undetermined at this time. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:57pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Ms. Roberts, Dr. Weber, Dr. Anwar, Ms. Womack and Mr. Pipes.  NRHA Board Minutes 9 July 24, 2023 Respectfully Submitted, Mary Womack, Vice-Chair/Secretary