Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting August 28, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, August 28, 2023 at 5:30p.m. in the Norman Regional Porter Board Room. The meeting Agenda was posted August 24, 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 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 Jenny Anderson, Administrative Director, Patient Quality Larry Harden, Administrative Director, Risk & Compliance Maggie Martin, Attorney, Crowe & Dunlevy Ray Leyva, Multimedia & Video Specialist, Media Services Melissa Herron, Director, Integrated Marketing Danny Kelley, Administrative Director, HIT Steven Sheriff, Network Infrastructure Architect, HIT Gavin Nation, OU’s JC Penny Leadership Fellow Members Absent: Paula Roberts Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order 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  NRHA Board Minutes 2 August 28, 2023 A. September 2023 Healer of the Month – Gayle Doyle, Health Information Management. Ms. Doyle was unable to attend the August 28, NRHA Board meeting and will be recognized at the Board meeting on September 25, 2023. Mr. Splitt introduced Gavin Nation, the University of Oklahoma JC Penny Leadership Fellow. Mr. Nation will be joining us for the next year at the board meetings to gain first-hand experience in board service. Mr. Nation is pursuing a degree in Accounting. Agenda Item III. Board Education: Cybersecuirty Risk Review Mr. Danny Kelley, Administrative Director HIT and Steven Sheriff, Network Infrastructure Architect, HIT presented the FY2023 Cybersecurity Risk Review. Mr. Kelley reported NRHS once again engaged the services of Fortified Health Security for the annual review. Fortified Security is 100% healthcare focused managed security service provider assisting healthcare organizations evaluate their unique risk appetite, strengthen their cybersecurity posture and improve operations throughout their security journey. Through a grant, NRHS collaborated with the Cybersecurity & Infrastructure Security Agency (CISA) for additional evaluation assistance. Ransomware attacks continue to a major risk across the globe, and email continues to be the most common attack vector used by those seeking to steal patient data. Malicious cyber actors target the healthcare sector with malware, often leading to ransomare attacks, data theft, and the disruption of healthcare services; usually intended for financial gain. Mr. Kelley reviewed the national statistics of breaches reported in the healthcare field, entities affected by breaches in healthcare and causes of breaches. The top three email threats in all industries is:  Phishing - $4.9M  Business Email compromise - $4.9M  Vulnerability in 3rd- party software - $4.5M In a typical month, NRHS receives approximately 1.7M emails; with nearly 70% being considered threat messages. In a proactive way and in an attempt to avoid becoming a victim, NRHS initiated an email training campaign to help familiarize healers with the appropriate identification of potentially fraudulent emails. More than 4,300 recipients received the bogus email. Approximately 2% of the recipients clicked on the “fraudulent link”. Each individual lured into the controlled phishing scan immediately received a retraining email to help reduce unintentional errors. Mr. Kelley reviewed the new and easily accessed Outlook email button that healers can use to report suspicious emails. The National Institute for Standards and Technology (NIST) provides a Cybersecurity Framework (CSF) that is a voluntary guidance program, based on existing standards, guidelines, and practices for critical infrastructure organizations to better manage and reduce cybersecurity risk. The NIST CSF scoring model approach is used to assess the level of organizational maturity given control across five areas: Policy, Procedure,  NRHA Board Minutes 3 August 28, 2023 Implementation, Testing and Integration. NRHS scores have continually improved since implementation of the program in 2019. This year, NRHS is using CISA’s Federal Vulnerability Scanning (CyHy) program to search out vulnerabilities in all cyber systems. Mr. Kelley reviewed the results of the enterprise-wide drills and shared the future strategies for continued cyber security. Mr. Kelley and Mr. Sheriff left the meeting at 5:52pm. Agenda Item IV. Approval of Proposed Amendment to the June 26, 2023 Norman Regional Hospital Authority Board Meeting Minutes and Approval of the July 24, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval to amend the June 26, 2023 Board Meeting Minutes to reflect the approval of the FY2024 Budget. ACTION TAKEN: Dr. Weber made the motion to approve the request to amend the June 26, 2023 Board Meeting Minutes to reflect the approval of the FY2024 Budget. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr Chambers, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. B. Mr. Cubberley asked for approval of the July 24, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the July 24, 2023 Board Meeting Minutes. Mr. Pipes seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr Chambers, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Anwar and Mr. Pipes. Mr. Leyva left the meeting at 5:56pm. Agenda Item V. Performance Update Ms. Anderson, Administrative Director, Patient Quality, presented the proposed Quality & Performance Improvement FY2024 Plan, the Patient Safety FY2024 Plan and provided a CMS Star Rating update. Ms. Anderson provided a review of the FY2023 Quality & Performance Improvement Plan (QPIP) noting improvements and goals met. She also shared the QPIP goals for FY2024. Ms. Anderson provided a review of the FY2023 Patient Safety Plan, and reviewed the new goals the FY2024 Patient Safety Plan.  NRHA Board Minutes 4 August 28, 2023 Ms. Anderson reviewed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) dashboard, highlighting the current 12-month values and the improvement targets. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on August 9, 2023. MEC covered a number of topics including – Acute Ischemic Stroke plan, Medical Credentialing, Department Committee Reports and Executive Team updates. Agenda Item VII. Patient Quality & Safety Committee A. Mr. Cubberley announced a summary of the Patient Quality & Safety Committee Meeting is included in the board packet. Ms. Greenleaf is available to address questions. B. Recommend Approval for the FY2024 Quality & Performance Improvement Plan ACTION TAKEN: Dr. Weber made a motion to approve the FY2024 Quality & Performance Improvement Plan as recommended by the Patient Quality & Safety Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Ms. Womack and Dr. Anwar. C. Recommend Approval for the FY2024 Patient Safety Plan ACTION TAKEN: Dr. Weber made a motion to approve the FY2024 Patient Safety Plan as recommended by the Patient Quality & Safety Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Mr. Chappel, Ms. Greenleaf, Mr. Pipes, Dr. Weber, Dr. Chambers, Ms. Womack and Dr. Anwar. Agenda Item VIII. Finance Committee A. Mr. Wagner reported the Finance Committee met August 21, 2023. B. Mr. Wagner presented the NRHS Financial report for July 2023: July 2023 Financial Performance  Gross Revenues .................................. (Budget $213,686,197)............ $204,071,939  Net Patient Revenue .............................. (Budget $46,723,824).............. $42,709,140  Total Operating Expenses ..................... (Budget $49,140,286).............. $47,766,550  Total Operating Revenues ...................... (Budget $47,702,191).............. $43,685,918  NRHA Board Minutes 5 August 28, 2023  Operating Income .................................... (Budget $1,438,095).............. ($4,080,632)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. $(2,032,671)  Excess Revenues over Expenses ............... (Budget $202,773).............. ($2,047,961) Year-to-Date  Operating Income .................................... (Budget $1,438,095).............. ($4,080,632)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. ($2,032,671)  Excess Revenues over Expenses ............... (Budget $202,773).............. ($2,047,961)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 52.2 Days  Days Cash on Hand…………………………………………………………….116.6 Days ACTION TAKEN: Dr. Weber motioned to approve the July 2023 NRHS Financial Statements. Mr. Pipes seconded the motion. July 2023 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Mr. Pipes. C. Mr. Wagner presented for approval four capital request item totaling $971,941 a. Gait & Balance System: $272,415 b. Ambulance Remounts: $491,580 c. Transport Ventilator for EMSStat: $51,546 d. Surgical Console & Controller: $156,400 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $971,941 as recommended by the Finance Committee. Mr. Chappel seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Mr. Pipes. Agenda Item IX. Old Business None. Agenda Item X. New Business None. Agenda Item XI. Administrative Report Mr. Splitt shared several updates:  The Medicaid Managed Care negotiations are ongoing.  The United Way Pacestter campaign kicked off last week. The NRHS internal theme this year is “The Sandlot”.  NRHA Board Minutes 6 August 28, 2023  The City of Norman Planning Commission did not approve the relocation of the overnight emergency shelter from its current location at 109 W. Gray Street to the 718 N. Porter building. Ms. Purvis provide an update on the following: A. Highlights of the FY2023 Year-end Review and Awards and Recognition:  Over 98,000 Emergency Department Visits.  Over $2,000,000 in community contributions and over $60,000,000+ in community uncompensated care and bad debt.  Over 2,700 hours of services to 77 business, social services and faith-based organizations, and over 1,000 hours of community service with 29 professional associations.  Achieving the Joint Commission Advanced Certification in Perinatal Care.  Norman Regional HealthPlex Obstetrical Emergency Department (OBED) received the first-in-the-nation accreditation by the Center for Improvement in Healthcare Quality (CIHQ) as a Center of Excellence. B. The City of Norman Adult Wellness Center on the Porter Health Village campus will be operated by Claire Dowers-Nichols, Executive Director of Healthy Living OKC. The Center will have an extensive list of activities, fitness classes, social groups, planned day trips and so much more. Norman Regional will collaborate with the facility, providing assistance with various classes and health and wellness educational opportunities. Mr. Manfredo provided an Inspire Health Update:  The parking garage is open and construction is underway on the new Cancer Center facility.  Norman Regional 9 received certification from the College of American Pathologists and laboratory medicine. iCAP inspectors were very complimentary of the people, the building and the facilities bright open spaces. Ms. McGill shared:  Norman Regional 9 received certification from The Joint Commission. Dr. Boyd Provided an update on provider retention and recruitment efforts. Ms. Herron and Ms. Anderson left the meeting at 6:48pm. 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; NRHA Board Minutes 7 August 28, 2023 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, Dr. Weber, Dr. Anwar, Ms. Womack and Mr. Pipes. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-3 Below. 1. Recommend New Provisional Medical Staff Appointments: a. Jessica Schumann, DO - Emergency Medicine – Active b. David Smith, MD - Emergency Medicine – Active c. Hillary Mahoney, PA-C – Hospital Medicine – Allied Health d. Nicole Hughey, APRN-CNP – Cardiovascular Medicine – Allied Health e. Sunil Gujrathi, MD – Radiology Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Khairuddin Memon, MD – Radiology – Active b. Michael Martin, MD – Surgery – Active c. Hannah Elliott, PA-C – Radiology – Allied Health d. Hunter Graham, APRN-CRNA – Anesthesia – Allied Health e. Tracy Mast, APRN-CNP – Pediatrics – Allied Health f. Courtney Smith, APRN-CRNA – Anesthesia – Allied Health g. Aaron Ruger, PA-C – Hospital Medicine – Allied Health h. Caroline Trommels, APRN-FNP – Pediatrics – Allied Health i. Neil Anand, MD – Teleradiology – Radiology – Privileges Only j. Clayne Benson, MS – ECMO – Cardiology – Privileges Only k. Shannon Bownds, MD – Teleradiology – Radiology – Privileges Only l. Jonathan Coll, MD – Teleradiology – Radiology – Privileges Only m. Ryan Frederiksen, MD – Teleradiology – Radiology – Privileges Only n. Jill Furubayashi, MD – Teleradiology – Radiology – Privileges Only o. Xavier Garcia-Rojas, MD – Teleradiology – Radiology – Privileges Only p. Matthew Hermann, MD – Teleradiology – Radiology – Privileges Only q. Jeremiah Jansen, MD – Teleradiology – Radiology – Privileges Only r. Michael Karachalios, MD – Teleradiology – Radiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Marvin “Dan” Isbell, MD – Surgery – Active b. Samuel “Edward” Dakil, MD – Surgery – Active c. James Bond, MD - Surgery – Active d. Smaranda Galis, MD – Medicine – Active e. Pierre “Andre” Ruhlmann, MD – Pediatrics – Active f. Ronni Farris, MD – OB/GYN – Active g. Eric Sparks, DO – Emergency Medicine – Active h. Lucas Trigler, MD – Surgery – Consulting i. Quang Tu, MD – Surgery - Courtesy  NRHA Board Minutes 8 August 28, 2023 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, and the motion was approved unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, 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 1-3 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 1-3. Mr. Chappel seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Mr. Pipes. Agenda Item XIII. Board Open Discussion Ms. Greenleaf shared The Norman Transcript published a letter written by a Norman resident praising EMSStat and their exceptional services. The citizen was very complimentary of their experience. Agenda Item XIV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:52pm. Mr. Chappel seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Mr. Pipes. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary