Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting September 25, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, September 25, 2023 at 5:30p.m. in the Norman Regional Porter Board Room. The meeting Agenda was posted September 21, 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 Paula Roberts 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 Dr. James Bond, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Lisa White, Manager, Patient Safety Larry Harden, Administrative Director, Risk & Compliance Maggie Martin, Attorney, Crowe & Dunlevy Ray Leyva, Multimedia & Video Specialist, Media Services Melissa Herron, Director, Integrated Marketing Heather Kuklinski, Director, Ortho Central Maria Griffin, Director, Documentation Integrity Tressa Lyon, Manager, Health Information Management Gayle Doyle, Clerk, Health Information Management Garrett Fergeson, Manager, Integrated Marketing Gavin Nation, OU’s JC Penny Leadership Fellow Members Absent: Kevin Pipes Recorder: Claudia Todd, Executive Assistant Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the September 25, 2023, Norman Regional Hospital Authority business meeting at 5:31 p.m.  NRHA Board Minutes 2 September 25, 2023 Agenda Item II. Introduction and Recognition of Outstanding Healers A. September 2023 Healer of the Month – Gayle Doyle, Health Information Management (HIM). Mr. Cubberley introduced Tressa Lyon, Manager Health Information Management, to introduce Ms. Doyle to the Board. Ms. Lyon shared the HIM department is a much better department because of Ms. Doyle. Ms. Doyle is the resident expert of NRHS’s patient portal. She is the lighthouse in the fog for patients who may need assistance. Such is her dedication that, even in a recent incident where she found herself locked out of her house while working remotely, her initial call was not for help but to ensure Ms. Lyons was informed, proving a glimpse of her steadfast commitment to our patients. Ms. Doyle thanked everyone for the honor and shared she is very humbled to be recognized. Mr. Cubberely congratulated and thanked Ms. Doyle on behalf of the Board for her outstanding dedications, professionalism, compassion and positive attitude that continues to make Norman Regional Health System a caring, high-quality system. B. October 2023 Healer of the Month – Tammy Adkins, LPN, NHealth Ms. Adkins was unable to attend the September 25, 2023 NRHA Board meeting and will be recognized at the Board meeting on October 23, 2023. Agenda Item III. Board Education: NMotion at the YFAC Ms. Heather Kuklinski, Director, Ortho Central presented an update on the Ortho Central and NMotion facility at the Young Family Athletic Center (YFAC). The YFAC will have 8 basketball courts, 12 volleyball courts and 25-meter competition pool plus a warm up/cool down pool. NRHS will house three entities at the YFAC: the Ortho Central Orthopedics Clinic, Ortho Central Physical Therapy and the NMotion Sports Medicine Clinic. The project allows NRHS to improve access to care by expanding capacity. Ms. Kuklinksi provided an overview of the building/facility design including services to be provided there. This project is a testament to the noteworthy synergy between the City of Norman, Norman Regional, and the (Trae) Young Family Foundation, demonstrating the power  NRHA Board Minutes 3 September 25, 2023 of collaborative effort. The support and historical vote of approval from the city’s residents for this community-enhancing amenity exemplify the civic pride and forward- thinking spirit that define Norman. It is a reflection of the community’s commitment to the health and well-being of its residents and their dedication to advancing sports and healthcare in our vibrant city. The YFAC is sure to be a transformative force, not only propelling health and wellness in our community to the next level, but also contributing to the growth of our city’s sports landscape and economic prosperity. Ms. Purvis, VP and Chief Strategy Officer presented an update on the City of Norman’s Adult Wellness Education Center. The building will be home to a heated saltwater pool, fully equipped fitness center, outdoor pickleball courts, group exercise studio, therapy sessions, numerous classes and scheduled events. The Healthy Living OKC will be operating the facility as Health Living Norman and will offer a variety of membership options, day passes and discounts with some insurance options available – including Silver Sneakers. The VIP Opening is scheduled for November 9th and will be followed by the ribbon cutting and grand opening on November 13th. Norman Regional will be hosting educational events each month featuring various physicians and topics. Mr. Splitt praised Ms. Kuklinski and the remarkable Ortho Central and NMotion teams, commending their dedication and extraordinary efforts in bringing this visionary project to fruition. The impact of these projects/services is sure to be felt for many years to come. Ms. Kuklinski left the meeting at 6:05pm. Agenda Item IV. Approval of August 28, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the August 28, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the August 28, 2023 Board Meeting Minutes. Ms. Roberts 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 Ms. Roberts. Agenda Item V. 2023 Audit Presentation Mr. Cubberley introduced Mr. Tyler Bernier, partner at Eide Bailey accounting firm. Mr. Bernier reported that Eide Bailey anticipates issuing an unmodified “clean” opinion for NRHS. Mr. Bernier reviewed accounting policies, financial statement disclosures, audit adjustments and areas of emphasis, required communications, revenue  NRHA Board Minutes 4 September 25, 2023 recognition, and management override of controls. Mr. Bernier briefly reviewed the Balance Sheet and Income Statement within the Audit. He reported no significant changes. ACTION TAKEN: Dr. Weber made the motion to approve the 2023 Audit Report as recommended by the Finance Committee. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberly, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Anwar, and Ms. Roberts. Agenda Item VI. Performance Update Ms. Anderson, Administrative Director, Patient Quality, provided an update on the High Reliability Organization (HRO) journey and a Star Ratings Update. Ms. Anderson reported the SCORE (Safety, Communication, Operational Risk, Resilience/Burnout and Engagement) Culture and Engagement Survey for Healers is open through October 9th. The survey can help the hospital identify cultural strengths, as well as determine areas where improvement may be needed. To date, 40% of healers have responded to the anonymous survey. The goal is to reach 60%. Ms. Anderson shared the High Reliability Foundation is successful with 3 key factors: a. Support from the Top - The hospital board is clearly interested and supportive and our CEO continues to promote its value to our patients and healers. b. Process Improvement Resources in Organization – The organization has an Outcomes and Efficiencies strategic team leading the focus on the Journey to Excellence Award and have the Plan, Do, Study, Act (PDSA) standardized tools in place. c. Psychological Safety – The Just Culture mindset is in place for Culture Accountability and healers feel more and more safe to speak up about concerns in patient care. The NRHS High Reliability Journey continues with the implementation of the Executive Leadership Academy. NRHS will have 15 healers participating in the Academy – including one trustee, Ms. Greenleaf - to review and discuss key concepts to real-world experiences, using reflection, discussion and breakout session to determine how HRO concepts are put into practice. 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 VII. Medical Staff  NRHA Board Minutes 5 September 25, 2023 A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on September 13, 2023. MEC covered a number of topics including – Discontinuation of Telemetry Protocol, VAST Team CVC line information, Medical Credentialing, Department Committee Reports and Executive Team updates. Agenda Item VIII. 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 IX. Finance Committee A. Mr. Wagner reported the Finance Committee met September 21, 2023. B. Mr. Wagner presented the NRHS Financial report for August 2023: August 2023 Financial Performance  Gross Revenues .................................. (Budget $222,757,548)............ $225,283,470  Net Patient Revenue .............................. (Budget $48,167,056).............. $49,012,383  Total Operating Expenses ..................... (Budget $49,953,942).............. $50,882,541  Total Operating Revenues ...................... (Budget $48,845,437).............. $49,723,995  Operating Income .................................... (Budget $1,108,505).............. ($1,158,546)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. $(1,030,139)  Excess Revenues over Expenses ............... (Budget $126,817).............. ($2,188,686) Year-to-Date  Operating Income .................................... (Budget $2,546,600).............. ($5,239,179)  Non-Operating Revenues (Expenses) ..... (Budget $2,470,644).............. ($1,002,531)  Excess Revenues over Expenses ................. (Budget $75,956).............. ($4,236,647)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 51.3 Days  Days Cash on Hand………………………………………………………….…..98.9 Days ACTION TAKEN: Dr. Weber motioned to approve the August 2023 NRHS Financial Statements. Ms. Roberts seconded the motion. August 2023 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. C. Mr. Wagner presented for approval four capital request item totaling $631,867 a. Temperature Management System: $302,680 b. Surgical Navigation System: $182,074 c. Billing Software: $90,045  NRHA Board Minutes 6 September 25, 2023 d. Surgical Tables: $57,068 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $631,867 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 Ms. Roberts. D. Recommend Approval of Consolidated Retirement Plan Amendment ACTION TAKEN: Dr. Weber made a motion to approve the Consolidated Retirement Plan Amendment 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 Ms. Roberts. E. Recommend Approval of Healer Incentive Plan FY2024 ACTION TAKEN: Dr. Weber made a motion to approve the Healer Incentive Plan FY2024 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 Ms. Roberts. Agenda Item X. Old Business None. Agenda Item XI. New Business None. Agenda Item XII. Administrative Report Mr. Splitt shared several updates:  The possible relocation of Griffin Memorial Hospital from Norman to Oklahoma City has not been finalized.  NRHS may be partnering with other LifeCare Network members to apply for the state’s Opioid Abatement Grant. Funds can be used to support treatment and recovery programs, assistance with co-occurring disorders and mental health issues, opioid abuse education and prevention, efforts to ensure proper prescribing of opioids, and strategies for decreasing the supply of narcotics in the state.  Planning for the annual Board/Trustee Advance is underway; targeting February 2024  NRHA Board Minutes 7 September 25, 2023  The Trey Young street dedication is tentatively scheduled for September 29 th. More information to follow  Our Annual Service Awards, held on September 19th, was a momentous occasion where our dedicated healers were recognized for thir commitment to our health system. The honorees collectively represented an stounding 4,000 years of service, showcasing remarkable dedication within our organization. It was a truly exceptional privilege to single out and honor one of our devoted healers, who has tirelessly served our patients and health system for an impressive 50 years. Their contributions are a shining example of the profound impact our healers make on the well being of our community. Mr. Minnis provided an update on the Payactive phone app. This app allows hourly paid healers to access their paychecks for time already worked during the current pay period. This service is part of our efforts to proactively address financial health and wellness for our healers. Mr. Manfredo provided an Inspire Health Update:  The air conditioning systems have started to arrive at the HealthPlex.  The Cancer Center construction is moving along well. We are now working on a date for the ground breaking. More information to follow.  Norman Regional Nine has now been open for one year. Ms. Herron, Ms. Anderson and Mr. Fergeson left the meeting at 6:52pm. Agenda Item XIII. 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 Mr. Cubberley, Ms. Greenleaf, Dr. Chambers, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. 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. Scott Lucas, MD – Surgery – Active b. Mitchell Bloomquist, DPM – Surgery – Active c. Awaad Khan, MD – Hospital Medicine – Active d. Sarah Brown, MD – Hospital Medicine – Active e. Michelle Brotherton, MD – OB/GYN – Active f. Robert Behrmann, DO – OB/GYN – Active g. Michael Cannon, MD – Surgery - Active NRHA Board Minutes 8 September 25, 2023 2. Recommend Advancement of Medical Staff from Provisional Status: a. Eric Porritt, DO – Surgery – Active b. Lois Baez, APRN-CNP – Pediatrics – Allied Health c. Kahlene Christenson, APRN-CNP – Pediatrics – Allied Health d. Ashton Johnson, PA-C – Surgery – Allied Health e. James Wolff, MD – Radiology – Privileges Only f. Gregory Thalken, MD – Radiology – Privileges Only g. James Summa, MD – Radiology – Privileges Only h. Zachary Roeder, MD – Radiology – Privileges Only i. Shareef Riad, MD – Radiology – Privileges Only j. Roi Lotan, MD – Radiology – Privileges Only k. Evelyn Lorents, MD – Radiology – Privileges Only l. Michael Klein, MD – Radiology – Privileges Only m. Kambrie Kato, MD – Radiology – Privileges Only n. David Karlin, MD – Radiology – Privileges Only o. Robert Maxey, MD – Radiology – Privileges Only p. Justin McCoy, MD – Radiology – Privileges Only q. Leonard Morneau, MD – Radiology – Privileges Only 3. Recommended Medical Staff Reappointments: a. Benjamin Collins, MD – Surgery – Active b. Chelsea Rommel, DO – Hospital Medicine – Active c. Jason Leonard, MD – Anesthesia – Active d. Matthew Davis, DO – Emergency Medicine – Active e. Ryan Davis, MD – Radiology – Active f. Blake Forcina, MD – Surgery – Consulting g. Amanda Lowry, APRN-CNP – Pediatrics – Allied Health h. Leighann Price, APRN-CRNA – Anesthesia – Allied Health i. Sarah Walsh, APRN-CNS – Cardiovascular Medicine – Allied Health 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 Ms. Roberts. 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. F. 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  NRHA Board Minutes 9 September 25, 2023 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 Ms. Roberts. Agenda Item XIV. Board Open Discussion None Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 6:54pm. 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 Ms. Roberts. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary