Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting November 27, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, November 27, 2023 at 5:30p.m. in the Norman Regional Porter Board Room. The meeting Agenda was posted November 22, 2023 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf James Chappel Jerome (Jerry) Weber, Ph.D. Mary Womack Paula Roberts Kevin Pipes Dianne Chambers, 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 Dr. Aaron Boyd, MD, VP & Chief Physician Executive Rick Wagner, VP, Chief Financial Officer Joe Voto, MD, Chief of Medical Staff Dr. James Bond, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Larry Harden, Administrative Director, Risk & Compliance Ray Leyva, Multimedia & Video Specialist, Media Services Melissa Herron, Director, Integrated Marketing Garrett Fergeson, Manager, Integrated Marketing LeAnn Richardson, Administrative Director, Population Health Gavin Nation, OU’s JC Penny Leadership Fellow Donna Avila, Director, Clinic Operations & Growth Dian Carmody, Administrative Director Patient Care Services Liz Love, Perioperative Admin Support Kourtney Bell, Manager, Lab Outreach Outpatient Services Emerald Dolan, Clerk Lab Assistant Kristen Magerkurth, Charge Nurse Tammie Murphy, Supervisor Perioperative Admin Support Russ Drive, Guest Elisa Thomas, Guest Members Absent: Muhammad Anwar, MD Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 November 27, 2023 Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the November 27, 2023, Norman Regional Hospital Authority business meeting at 5:34 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. November 2023 Healer of the Month – Liz Love, Perioperative Admin Support, Same Day Surgery Mr. Cubberley introduced Dian Carmody, Administrative Director Patient Care Services, to introduce Ms. Love to the Board. Ms. Carmody shared Ms. Love worked in a nursing home for the last 17 years before joining NRHS in June 2021. She is married and has 2 adult children. The I.C.A.R.E. values are easy to define when using Ms. Love as an example:  Integrity - She always has a great spiritual ruder and a smile for everyone. She is always on time to work and is the picture of accountability.  Communication – She is the guardian of the secure door leading into the same day surgery area. She greets every person who passes thru with a smile and compassion. She eases our patient’s fears and gives them comfort.  Attitude – She loves her job and this shows with her smile and attitude even at 5:30 in the morning when she greets the day’s first patient.  Results - She does he job with finesse and ease. She chat with patients and families, taking the time to get listen and get to know them, all while getting them registered. The Same-Day Surgery nurses rely on her extraordinary organizing skills to keep things running smoothly.  Engagement – She is engaged in every aspect of her job. Her fellow healers claim they would be lost without her. Ms. Love thanked everyone for the honor. She stated she loves her team and feels like she truly belongs at NRHS. Mr. Cubberley, on behalf of the Board, extended a heartfelt congratulations and gratitude to Ms. Love. Her steadfast dedication, professionalism, boundless compassion, and consistently positive attitude contribute significantly to advancing Norman Regional as a caring and high-quality health system. Ms. Carmody, Ms. Love, Ms. Murphy and Ms. Magerkurth left the meeting at 5:42pm. B. December 2023 Healer of the Month – Emerald Dolan, Clerk – Lab Assistant, Lab Outreach.  NRHA Board Minutes 3 November 27, 2023 Mr. Cubberley introduced Ms. Kourtney Bell, Manager, Lab Outreach Outpatient Services to introduce Ms. Dolan. Ms. Bell shared Ms. Dolan began working at NRHS 4 years ago in the COVID drive-thru clinic. She has also worked in the offsite labs in Outpatient Services at Porter, HealthPlex and Moore. She was born in Mangum, Oklahoma and has lived in both Texas and Oklahoma all her life. When Ms. Dolan was asked what she likes most about working at NRHS, she shared she enjoys taking care of her patients and team members like they were family. Patients in the patient satisfaction surveys consistently recognize her. In one month, she personally received over 20 compliments from patients. One patient, in particular, shared that during a blood draw administered by Ms. Dolan, she did not feel a thing, except for her kindness. Ms. Dolan is one of our most skilled, versatile and flexible nurses. She is willing to work wherever she is needed and picks up extra shifts when the need arises. Her service, skillset and presence is greatly appreciated by all. Ms. Dolan thanked NRHS for allowing her to work for the health system, but specifically the Porter campus. She loves what she does, her fellow healers and her patients. Mr. Cubberely, on behalf of the Board, extended a heartfelt congratulations and gratitude to MS. Dolan. Her steadfast dedication, professionalism, boundless compassion, and consistently positive attitude contribute significantly to advancing Norman Regional as a caring and high-quality health system. Ms. Bell, Ms. Dolan and Ms. Thomas left the meeting at 5:49pm. C. Recognition of Dr. Joe Voto, for his service as Chief of Staff presented by Dr. Aaron Boyd. Dr. Boyd shared it has been a pleasure to work alongside Dr. Voto over the last four years, first as Chief of Staff elect and then as Chief of Staff. Dr. Voto takes the time needed to be present and diplomatic with physicians. He has shown an enormous amount of insight into the daily issues this leadership role brings. He is a fantastic clinician and has become a great friend and confidant. He began his tenure as Chief of Staff during the pandemic and he has tirelessly led with confidence and a calm demeanor. Dr. Voto shared it’s been an honor and a privilege to do this job and represent the medical staff. He thanked the Board, the Executive Team and Medical Staff Services for their continued support. Mr. Leyva left the meeting at 5:52pm. Mr. Chappel and Ms. Womack arrived at the meeting at 5:56pm.  NRHA Board Minutes 4 November 27, 2023 Agenda Item III. Board Education: Health Equity – Beyond the Four Walls of NRHS Ms. Avila shared NRHS was one of three health systems from across the nation who were invited by Vizient to participate in a Congressional Briefing on Capitol Hill to highlight how each is addressing Social Determinants of Health (SDoH) in their communities. The July 2023 briefing was attended by more than 75 congressional staff members. Each panelist reinforced their hospitals’ commitment to serving their communities, despite the ongoing workforce and financial challenges they face. Fifty-percent of hospital re-admissions are the result of a SDoH. The Impact of SDoH is divided into two parts:  80% of individual’s health equity outcomes are based on food insecurity, transportation, health literacy, unstable housing, utilities, interpersonal safety and medication adherence.  20% is based on quality health care and access A Vizient SDoH Benchmarking Study in 2020 determined Oklahoma ranked 5th in the Nation for food insecurity. Key takeaways from this study indicate:  The need for standardized SDoH screenings across all levels of care  Identify greatest areas of need to focus community efforts and partnership  How can we improve Patient access to timely medical care?  What actions can we take to promote Health Equity? In October 2020, NRHS rolled out an acute care patient questionnaire and extended it to other departments over the next 3 years. From these surveys, it was determined over 3,100 patients in a 12 month timeframe were positive for at least one SDoH criteria. Interestingly, the highest percentage of patients experiencing food insecurity were ages 50-64. In order to promote health equity and assist in removing the barriers related to SDoH, NRHS implemented numerous programs including:  NRHS Food Pharmacy  NRHS Transportation Program  NRHS Care Champions  NRHS Resource Closet  NRHS Community Call Line  NRHS Community Health Worker  NRHS at-risk Flu Vaccines  NRHS Remote Patient Monitoring  NRHS Inclusion and Diversity Council Specifically, the NRHS Food Pharmacy has made the biggest impact with patients. Distribution of food thru the clinics has helped foster trust with patients and helps to facilitate the establishment of their personal medical preventive health journey. Other results include:  NRHA Board Minutes 5 November 27, 2023  Reduction in readmissions  Identified additional health equity needs thorough follow-up phone calls  Increased patient connections to long-term resources – including Primary Care providers Combined, these valuable resources are promoting greater health equity in our community:  1,900+ Provider visits scheduled  71,000+ Meals on Wheels prepared  1,728+ Home Run van transports  339,000+ Community Support encounters  2,650+ In-kind and imaging tests  3,700+ Leader Community volunteer hours  350+ Food Pharmacy boxes  6,375+ Calls received  100+ At-risk Flu Shots  >$2 million in Community contributions Agenda Item IV. Approval of October 23, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the October 23, 2023 Board Meeting Minutes ACTION TAKEN: Dr. Weber made the motion to approve the October 23, 2023 Board Meeting Minutes. Ms. Roberts seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Mr. Pipes, Dr. Chambers, Ms. Womack, and Ms. Roberts. Agenda Item V. Performance Update Ms. Jenny Anderson, Administrative Director, Patient Quality, provided an update on Star rating, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Mortality. Ms. Anderson reminded everyone most of the Star Ratings are updated quarterly, except for Mortality and Readmissions, which are revised annually. Each time a preview report is released, data is plugged into the Star Ratings calculator. NRHS has maintained a 3-Star Rating. All data released by CMS and included in this report is prior to our fiscal year 2024 strategic plan implementation that addresses specific opportunities for imprvement. Ms. Anderson reviewed the HCAHPS dashboard, highlighting the current 12-month performance and targets.  NRHA Board Minutes 6 November 27, 2023 Efforts to enhance patient satisfaction through HCAHPS initiatives are well underway. Weekly rounding, initiated in September with 60 patients visited per week, focuses on Cleanliness, Quiet around the room at night, and room cleanliness during the stay. Nurses and leadership are actively engaged in intentional rounding with a revised format being implemented. A long-term format and expectations for this initiative are in development. The re-implementation of Medication Teaching Sheets for improved medication communication is progressing. Patient Relations rounding, piloted in 3NE since November 27th, reflecting our commitment to continuous improvement in patient experience. Ms. Anderson provided an update on Mortality action items and clinical documentation opportunities. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on November 8, 2023. MEC covered a number of topics including – Professional Practice Evaluation Policies, Unassigned ED call, Medical Credentialing, Department Committee Reports and Executive Team updates. B. Recommended Approval of the Utilization Review Plan. The purpose of the plan is to ensure the delivery of efficient and effective health care, to reduce the misuse of impatient services, and to promote high quality and safe patient care while in our health system. ACTION TAKEN: Dr. Weber motioned to approve the Utilization Review Plan. Mr. Pipes seconded the motion and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chamber, Mr. Pipes and Ms. Roberts. Ms. Avila and Mr. Richardson left the meeting at 6:38pm. 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. Annual Compliance Work Plan ACTION TAKEN: Dr. Weber motioned to approve the changes to the Annual Compliance Work Plan. Mr. Chappel seconded the motion and the motion was approved unanimously with aye votes from Mr.  NRHA Board Minutes 7 November 27, 2023 Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes and Ms. Roberts. Agenda Item IX. Finance Committee A. Mr. Wagner reported the Finance Committee met November 20, 2023. B. Mr. Wagner shared NRHS made a switch to a new accounting firm October 1 st which delayed the release of the October 2023 NRHS Financial Reports. The October and November financial reports will be available for review at the January 2024 Board of Trustees meeting. C. Mr. Wagner presented for approval three capital request items totaling $2,545,494 a. Endoscopy Equipment: $610,750 b. Surgical Robot System: $1,865,000 c. Orthopedic Surgery Tools: $69,744 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $2,545,494 as recommended by the Finance Committee. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes and Ms. Roberts. D. Letter of Resolution in Support of an Additional Ambulatory Care Site ACTION TAKEN: Dr. Weber made a motion to approve the Letter of Resolution in Support of an Additional Ambulatory Care Site. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes and Ms. Roberts. Agenda Item X. Old Business Mr. Cubberley reminded Trustees the CEO annual evaluation was sent out today and will be reviewed at the January 2024 Board meeting. Agenda Item XI. New Business A. Proposed Approval to Establish Dates and Times for 2024 Authority Meetings ACTION TAKEN: Dr. Weber made a motion to approve Dates and Times for the 2024 Authority Meetings. Mr. Pipes seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms.  NRHA Board Minutes 8 November 27, 2023 Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes and Ms. Roberts. B. NRHA Trustee Officer Election ACTION TAKEN: Dr. Weber made a motion to elect Mr. Doug Cubberley as Chairman. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes and Ms. Roberts. Mr. Cubberley abstained. ACTION TAKEN: Mr. Pipes made a motion to elect Ms. Mary Womack as Vice Chairman/ Secretary. Ms. Roberts seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Chambers, Mr. Pipes and Ms. Roberts. MS. Womack abstained. Agenda Item XII. Administrative Report Mr. Splitt shared several updates:  Healers participated in several activities over the last month: o Healer Forums o Thanksgiving Pie Distribution o Feed the Children “No Hunger Holiday” partnership with Norman and Moore Public Schools. Over 800 families were served thru this program. o December will see our Healers participating in the Holiday meals, Salvation Army Angel Tree distribution, Bell ringing and Healer Christmas families  Maggie Martin has accepted a new role as the Chief Legal Counsel for the Oklahoma Hospital Association (OHA). Crowe & Dunlevy is actively searching for her replacement.  The Board Study Session is scheduled for February 10th at Norman Regional Moore in order to learn and discuss issues in a less formal environment and no action is taken.  OHA Connect 2023 is next week. Trustees are encouraged to attend the informative sessions and to network with other health system board members. NRHS will be recognized for our efforts to address food insecurities thru our Food Pharmacy program.  The City of Norman is exploring strategies to engage in constructive discussion about the escalating issue of homelessness. Mr. Manfredo provided an update on Inspire Health:  Air handlers for the ACC and HealthPlex expansion will arrive this week  Interior construction continues to progress  Cancer Center construction continues on schedule  NRHA Board Minutes 9 November 27, 2023 Mr. Minnis provided an update on the new Earned Wage Access PayActive app. This app provides our healers the flexibility to access the money they’ve earned prior to the transitional bi-weekly paycheck timetable. Ms. McGill provided an executive summary of the Joint Commission elements for trustees. NRHS recently received 86 new patient beds. These are comfortable and technologically adavncs beds that include USB charging ports in the bed rails. Dr. Boyd provide an update on the following:  Our new Purcell clinic is open and the official grand opening will be held in January 2024.  Dr. James Bond begins his duties of Chief of Staff in January 2024. Dr. Bruce Parker is the new Chief of Staff-elect. Ms. Anderson, Ms. Herron, Mr. Fergeson and Mr. Driver left the meeting at 7:19pm. 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, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes 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. Alexia Wright, MD – Medicine – Active b. Pooja Singhal, MD – Medicine – Consulting c. Carrie Vincent, APRN-CNP – Pediatrics – Allied Health d. Philip Eisinger, DO – Radiology – Privileges Only e. Ajay Singh, MD – Radiology – Privileges Only 2. Recommend Advancement of Medical Staff from Provisional Status: a. Brandon Pierson, MD – Surgery – Active b. Mohammad Farukhi, MD – Surgery – Active c. Joel Razook, MD – Surgery – Active d. Michael Merkey, MD – Medicine – Active e. Laurel Jordan, DO – OB/GYN – Active f. Allen Rohde, DPM – Surgery – Consulting g. Mark Scott, MD – Surgery – Consulting h. Meghan Scears, MD – Medicine – Consulting i. Tracy Ratzclaff, RNFA – Surgery – Allied Health  NRHA Board Minutes 10 November 27, 2023 j. Jennifer Fleck, APRN-CRNA – Anesthesia – Allied Health k. Daniel Leiker, APRN-CRNA – Anesthesia – Allied Health l. Tina Stinson, PA – Allied Health 3. Recommended Medical Staff Reappointments: a. Lincoln Patel, MD – Radiology – Privileges Only b. Archana Lucchesi, MD – Radiology – Privileges Only c. Amy Kirby, MD – Radiology – Privileges Only d. Jason Burns, DO – Radiology – Privileges Only e. Amber Fox, APRN-CNP – Pediatrics – Privileges Only 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, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes 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. E. 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, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes 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 7:23pm. Ms. Roberts seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Chambers, Mr. Pipes and Ms. Roberts.  NRHA Board Minutes 11 November 27, 2023 Respectfully Submitted, Mary Womack, Vice-Chair/Secretary