1/42. I. CALL TO ORDER Jerry McDowell, Chair, UNM Hospital Board of Trustees ANNOUNCEMENTS ADOPTION OF AGENDA

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1 UNM Hospital Board of Trustees OPEN SESSION AMENDED AGENDA Friday, November 17, 2017 at 9:00 AM Barbara and Bill Richardson Pavilion Conference Room 1500 I. CALL TO ORDER Jerry McDowell, Chair, UNM Hospital Board of Trustees II. III. IV. ANNOUNCEMENTS ADOPTION OF AGENDA CONSENT APPROVAL/INFORMATIONAL AGENDA Consent/Approval Items (Approval) Kaufman Hall & Associates Stryker / OSIS OR Integration and Lighting Upgrade Stryker / Main OR Lighting and Boom Upgrade Eco-Tex Healthcare Linen Service Corp Carrie Tingley Hospital (CTH) Re-Roof V. PUBLIC INPUT VI. VII. VIII. IX. APPROVAL OF THE MINUTES October 27, UNMH Board of Trustees Meeting Minutes Michael Chicarelli, DNP, RN, CEN (Approval) OCTOBER ACTION ITEMS UNMH Management to keep Board of Trustees informed on how the implementation of the Financial Assistance Policy, Discount Program Policy, and Patient Payment Policy is progressing Sara Frash to invite a couple of DYAD Partners to give a presentation A Day in the Life at a future Board of Trustees Meeting Once finalized, the Physician and Leadership Engagement results along with graphs will be posted on BoardVantage DYAD partners to be showcased at ME: Leading To Excellence Dr. Richards will be presenting this information at the next LTE Efficiency Curve presentation at a future Board of Trustees Meeting Dr. Perryman Collins Fontaine will send November date and time of the Quality & Safety Committee Meeting to Board Members Dr. Crowell to give a condensed version of the Quality Report he presents to the Quality & Safety Committee to the Board of Trustees at a future meeting Board of Trustee Members to discuss with their committees about having a Board of Trustee representative from their committee make a full recommendation to the Board for approval of items listed on agenda Scot Sauder to research changing the wording during a motion from approval to acknowledge receipt of and report his finding to the Board of Trustees Quality to create a cheat sheet for Board Members in the event The Joint Commission (TJC) requests a Board Member be interviewed during one of their visits to UNMH UNMH Management to keep Board of Trustees updated on MOU issues as the process moves forward. UNMH Management to draft an update/report on Larry Gages s recommendations for Board of Trustees review. Mike Chicarelli and Jerry McDowell will coordinate/review prior to bringing to the Board of Trustees Dr. Roth s office will send list of CEO Search Committee Members to Board of Trustees Members BOARD INITIATIVES Chairman s Report Jerry McDowell, Chair Larry Gage s Recommendations Michael Chicarelli, DNP, RN, CEN Patient Payment Policy Michael Chicarelli, DNP, RN, CEN Mission Excellence Update Sara Frasch ADMINISTRATIVE REPORTS Chancellor for Health Sciences - Paul Roth, MD CEO Report UNM Hospitals Michael Chicarelli, DNP, RN, CEN CMO Report UNM Hospitals Irene Agostini, MD UNM Board of Regents Update Michael Chicarelli, DNP, RN, CEN X. COMMITTEE REPORTS Quality and Safety Committee Dr. Raymond Loretto Finance, Audit & Compliance Committee Terry Horn Native American Services Committee Jerry McDowell, Chair XI. XII. XIII. OTHER BUSINESS CLOSED SESSION: Vote to close the meeting and to proceed in Closed Session. a. Discussion and determination where appropriate of limited personnel matters pursuant to Section H (2), NMSA. b. Discussion and determination, where appropriate, of matters subject to the attorney-client privilege regarding pending or threatened litigation in which UNMH is or may become a participant pursuant to Section H (7), NMSA. c. Discussion of matters involving strategic and long-range business plans or trade secrets of UNMH pursuant to Section H (9), NMSA. d. Vote to re-open the meeting Certification that only those matters described in Agenda Item XII were discussed in Closed Session; consideration of, and action on the specific limited personnel matters discussed in Closed Session. 1/42

2 Separator Page Stryker / OSIS OR Integration and Lighting Upgrade 2/42

3 CAPITAL PROJECT APPROVAL Outpatient Surgical Imaging Services (OSIS) Operating Room (OR) Integration and Lighting Upgrade November 2017 REQUESTED ACTION: As required by Section 7.12 of Board of Regents Policy Manual, the New Mexico Higher Education Department and the New Mexico State Board of Finance, capital project approval is requested for OSIS OR Integration and Lighting Upgrade. DESCRIPTION: This project is to replace existing Operating Room surgical light booms in the six Operating Rooms with new tandem suspension with a Teletom equipment management system / two LED / Field Point. This will require extensive modifications to the existing structure to support design loads of new equipment, additional electrical circuits, medical gas modification and the installation of the new Imagestream system. RATIONALE REPLACEMENT: OSIS is fully integrating its 6 Operating Rooms with the Imagestream integration system as well as replacing lights and booms. The integration system will allow for better patient care and improvements in using space resources in the OR by having all 6 rooms laparoscopic procedure capable. This is the Second phase of OR integration which began with the BBRP pediatric OR in As well the integration allows for the control of equipment from a single terminal and the uploading of images to the Electronic Medical Record for proper patient documentation. Current lighting is over 10 years old and does not meet the needs of our surgical faculty performing procedures. The new lights will reduce cost in maintenance as they are year LED systems. Currently OSIS does over 5,000 outpatient procedures annually and has been growing at a pace above 6%. This infrastructure is needed to help OSIS keep pace in the quality of care it is able to provide to the community. FUNDING: The total project budget is estimated at $1,698,000 with $1,098,000 funded by UNM Hospital Capital Equipment Budget and $600,000 funded from the UNM Hospital Renovation Capital Budget. 3/42

4 Separator Page Stryker / Main OR Lighting and Boom Upgrade 4/42

5 CAPITAL PROJECT APPROVAL UNMH Main Operating Room (OR) Lighting and Boom Upgrade November 2017 REQUESTED ACTION: As required by Section 7.12 of Board of Regents Policy Manual, the New Mexico Higher Education Department and the New Mexico State Board of Finance, capital project approval is requested for UNMH Main OR Lighting and Boom Upgrade. DESCRIPTION: This project is to replace existing Operating Room surgical lights and booms in the 15 ORs. This project will require modification to the existing structural supports, additional electrical circuits as well as medical gas modification. RATIONALE REPLACEMENT: UNMH Main OR is in need of replacing lights and booms in its 15 ORs. Current systems are constantly failing creating surgical delays and costly repairs. Lighting is over 10 years of age in most ORs. Lighting solution proposed will standardize lights throughout surgical services which will lead to more cost efficient repair and maintenance in the future. UNMH Main OR currently houses over ten specialties and the case volume exceeds 10,000 cases annually. Surgical Services bills out over $250,000,000 of gross revenues for UNMH hospitals. This project will also provide critical safety items such as drop down lead shield to decrease radiation exposure. FUNDING: The total project budget is estimated at $1,570,000 with $970,000 funded by UNM Hospital Capital Equipment Budget and $600,000 funded from the UNM Hospital Renovation Capital Budget. 5/42

6 Separator Page Eco-Tex Healthcare Linen Service Corp 6/42

7 UNM Hospital Board of Trustees Recommendation to HSC Committee November 2017 Approval 1) Eco-Tex Healthcare Linen Service Corp Ownership: Officers Information: Eco-Tex Healthcare Linen Service Corp. President and CEO: Randy Bartsch 1115 E 25 th Vice President: Bryan Bartsch Tacoma, WA Source of Funds: UNM Hospitals Operating Budget Description: Request an eight year agreement with Eco-Tex Healthcare Laundry Services, Inc. to provide laundry services for UNM Hospitals through October 31, UNM Hospital processes approximately four million pounds of linen annually. Services are provided for all medical laundry including the following: sheets, pillow cases, blankets, towels, patient gowns and surgical scrubs. Services include inhospital soiled linen pick up twice daily, seven days per week. Eco-Tex will provide at no charge linen management software for computerized tracking and reporting of unit par levels and usage. Additional services include storage of UNM Hospitals pandemic linen supply for emergency requirements. New agreement pricing is as follows: Launder and Deliver Clean Linen: Soiled Linen Pick Up: Receive and Breakdown New Linen: Store Overflow and Pandemic Linen: Offsite Delivery Fee $0.354/lb. $0.420/lb. $510.00/month $10,185.00/ month $ 9,687.00/month Pricing will be held firm for the first five years of the agreement with subsequent escalators no greater than the CPI-U Medical Services annual rate capitated at no more than 2.5% and upon mutual written agreement. Process: RFP P RFP Respondents: There were 2 respondents to the RFP: 1. Mission Linen Supply 2. Eco-Tex Healthcare Laundry Selection Criteria: The RFP committee members which consisted of Florencio Gallegos, Executive Director of Material Management, Yvonne Trujillo, Director of Value Analysis & Material Handling and Jessie Montoya, Distribution Manager reviewed and scored all proposals based on vendor oral presentation, interview and 7/42

8 written proposal submittals and the vendor determined to bring the best value to UNM Hospitals was selected via highest score. Mission Eco Tex Relevant Experience and References Ability to Perform Services IT Security Plan Cost Contract Term: Initial term of five (5) years with an option to extend for three additional years, not to exceed eight (8) years. Termination Provision: Either party may terminate this agreement with 180 days written notice. Previous Contract: Eco-Tex Healthcare Linen Service Corp. Previous Term: Eight Years Previous Contract Amount: $1,928,270 Projected Annual Cost: (Dependent on volumes) $1,910,372 Based on current volumes, the estimated cost savings is $17,898 per year or $89,448 for the initial five year term. (2) Kaufman, Hall & Associates LLC Ownership: Officers Information: 5202 Old Orchard Rd, Suite N700 CEO: Therese Wareham Skokie, IL Source of Funds: UNM Hospital Capital Fund Description: Request approval to purchase from Kaufman, Hall & Associates, LLC (Kaufman) an Enterprise Wide Health Care Cost Accounting System. This system will provide comprehensive costing of healthcare services across the UNM Health System. The system will include the following: 1) Costing of hospital-based as well as professional services; 2) Reporting of costs, productivity, and profitability across the Health System by encounter, by provider, by third-party payer, by service line, etc.; 3) Allow for source data feeds from multiple patient financial services systems, general ledger systems, and the UNMH electronic EMR and Population Health Management system; and 4) Allow for import of external claims data from third-party payers or partner providers to allow for analysis under bundled payment and capitation scenarios. The ideal system will also allow for flex budgeting and interfacing with the Health System s operating and capital budgeting tools. Contract Term: The term of the contract shall not exceed eight (8) years in duration. Process: RFP P Respondents: 8/42

9 1) Kaufman 2) Strat Decision Technology Previous Contract: N/A Previous Term: N/A Previous Contract Amount: N/A Selection Criteria: The RFP Evaluation Committee members were comprised of: Bonnie White, Executive Director Finance Planning & Analysis John-Paul Montoya, Revenue Cycle Director, CRTC Fiscal Services Rodney F. McNease, Executive Director BH Finance, BHO - Revenue Cycle Ops Darlene L. Fernandez, Chief Financial Officer of SRMC Marjorie Goldstein, Vice President Finance and CFO, UNM Medical Group Selection was based upon highest scores for the following criteria: Experience, quality, stability, and reputation of the Offeror. 5 Points Possible IT Security Requirements 5 Points Possible Product Functionalities 40 Points Possible Integration/Implementation Work Plan 25 Points Possible Services, Ongoing Support Model 10 Points Possible Price Proposal 15 Points Possible TOTAL 100 Points Possible Total Cost: $1,410,000 9/42

10 Separator Page Carrie Tingley Hospital (CTH) Re-Roof 10/42

11 CAPITAL PROJECT APPROVAL Carrie Tingley Hospital CTH Re-Roof November 2017 REQUESTED ACTION: As required by Section 7.12 of Board of Regents Policy Manual, the New Mexico Higher Education Department and the New Mexico State Board of Finance, capital project approval is requested for Carrie Tingley Hospital CTH Re-Roof DESCRIPTION: This project is to replace existing failed roofing system. The scope of work is to remove existing EPDM (Ethylene Propylene Diene Terpolymer) roofing assembly to Deck roofing. Project will include new insulation, flashings, gutters and downspouts. The new roofing will be topped with new two-ply field membrane utilizing a base layer and a cap sheet with mineral surface. RATIONALE REPLACEMENT: The existing roof in the areas of replacement is over 20 years of age. There are many failed areas that have been repaired repeatedly to extend the life of the roof. In that process many hours have been spent replacing wet ceiling tiles as well as spot repairs. New roof will carry a 30 year high performance built up roofing system no dollar limit warranty. FUNDING: The total project budget is estimated at $380,000 from the UNM Hospital Capital Budget. 11/42

12 Separator Page October 27, UNMH Board of Trustees Meeting Minutes 12/42

13 UNM Hospital Board of Trustees October 27, 2017 Barbara and Bill Richardson Pavilion 1500 Agenda Item Subject/Discussion Action/Responsible Person Voting Members Present Ex-Officio Members Present County Officials Present Jerry McDowell, Erik Lujan, Nick Estes, Christine Glidden, Joseph Alarid, Terry Horn, and Dr. Aimee Smidt Dr. Paul Roth, Dr. Michael Richards, Dr. Michael Chicarelli, Dr. Jennifer Phillips, Ava Lovell, and Chaukoui Abdallah Timothy Olivas I. Call to Order A quorum being established, Mr. Jerry McDowell, Chair, called the meeting to order at 9:08 AM II. Announcements Mr. Jerry McDowell, Chair, welcomed Ex-Officio Members, Ms. Ava Lovell and Mr. Chaukou Abdallah to the Board Meeting. III. Adoption of Agenda IV. Public Input Dr. Michael Chicarelli reported UNMH was recognized in the 2018 Edition of U.S. News & World Report 2017 Best Hospitals for delivering evidence-based treatment guidelines to improve quality of care for heart disease and stroke patients (copy in packet). Dr. Jennifer Phillips presented a Chief of Staff Update (report in packet). Mr. Jerry McDowell, Chair, requested a modification to the Agenda Move Chairman s Report to first item under Board Initiatives. Mr. Jerry McDowell, Chair, requested a motion to adopt the agenda with the requested change. Public Input was given by Ms. Siressa Manne, NM Center on Law and Poverty, and Ms. Michelle Melendez, Ele Valle, in reference to the Patient Payment Policy, the Financial Assistance Policy and on the 138 public comments received by Bernalillo County on the MOU. Mr. Nick Estes made a motion to adopt the agenda with the identified modification. Mr. Joseph Alarid seconded the motion. Motion passed with no objections. V. Consent Approval No Consent Items Presented. VI. Approval of Minutes Mr. Jerry McDowell, Chair, requested a motion to approve the September 29, 2017 UNMH Board of Trustees Meeting Minutes. Mr. Jerry McDowell, Chair, requested a motion to approve the October 3, 2017 Special UNMH Board of Trustee Meeting Minutes. Mr. Nick Estes made a motion to approve the September 29, 2017 UNMH Board of Trustees Meeting Minutes. Mr. Terry Horn seconded motion. The motion passed unanimously. Ms. Christine Glidden made a motion to approve the October 3, 2017 Special UNMH Board of Trustees Meeting Minutes. Mr. Erik Lujan seconded motion. The motion passed unanimously. UNM Hospital Board of Trustees Minutes October 27, /42 1

14 UNM Hospital Board of Trustees October 27, 2017 Barbara and Bill Richardson Pavilion 1500 Agenda Item Subject/Discussion Action/Responsible Person VII. Board Initiatives Mr. Jerry McDowell, Chair, reported the following: o o o o o Action items from Board of Trustees Meetings will be tracked and listed in the following month s agenda. In a future meeting, management will present thoughts on how they would like to proceed in reference to Larry Gage s recommendations. Mr. McDowell recently met with Commissioner Hart-Stebbins and will set up a meeting with Interim President Abdallah. Mr. McDowell has been asked to Co-Chair the CEO Search there have been two good orientation sessions held and they are in the process of gathering input with a decision expected in early There was a link at one of the orientation sessions with a wonderful video of the hospital, which would be beneficial for the Board of Trustees to review. Mr. McDowell thanked Dr. Mike Chicarelli for taking on the responsibilities in the Interim role as the search unfolds. Mr. McDowell is interested in seeing Mission Excellence proceed. Dr. Michael Chicarelli and Mr. Scot Sauder explained the changes/modifications made to the Patient Payment Policy and Financial Assistance Policy and the new proposed Discount Program Policy. Mr. Nick Estes suggested a statement is included on the Discount Program Policy that would indicate a monthly amount would be set by the patient s family income and size and be put on a schedule. Upon discussion, Mr. Jerry McDowell, Chair, entertained a motion to approve all three policies as presented with the understanding that Board Member, Nick Estes, has raised an issue which may be addressed at a future date as an amendment to the Discount Program Policy. The Board of Trustees requested to be updated on how the implementation of the policies proceeds. Mr. Joseph Alarid made a motion to approve the Patient Payment Policy, Financial Assistance Policy and the Discount Program Policy as entertained by Chair McDowell. Dr. Aimee Smidt seconded motion. The motion passed unanimously. Ms. Sara Frasch presented an update on Mission Excellence (report in packet). Mr. Jerry McDowell, Chair, requested a presentation by DYAD partners. Dr. Michael Richards will showcase DYAD Partners at the next Mission Excellence Leading to Excellence. VIII. Administrative Reports Chancellor for Health Sciences Report: Dr. Paul Roth reported that he recently met with Legislative Committee. Dr. Roth stated the five UNM President candidates have been interviewed and the committee will meet next week to discuss interviews and make a decision. Announcement is expected to take place by November 5 th. There is an active search for two of the three Dean candidates with the assistance of an outside search firm. CEO Report: The CEO (report in the packet). CMO Report: The CMO (report in the packet). UNM Board of Regents Report: No report. UNM Hospital Board of Trustees Minutes October 27, /42 2

15 UNM Hospital Board of Trustees October 27, 2017 Barbara and Bill Richardson Pavilion 1500 Agenda Item Subject/Discussion Action/Responsible Person IX. Updates N/A X. Committee Reports Quality and Safety (formerly POCEC) Committee: The Quality and Safety Committee met on October 20, Ms. Christine Glidden gave a brief summary. XI. Other Business XII. Closed Session Finance, Audit & Compliance Committee: The Finance, Audit & Compliance Committee met on October 25, Mr. Erik Lujan gave a brief summary. Native American Services Committee: The Native American Services Committee met on October 25, Mr. Erik Lujan gave a brief summary. Executive Committee: No report. September Financials: Dr. Michael Chicarelli gave an update on the September Financials. At 11:14 AM Mr. Jerry McDowell, Chair, requested a motion to close the Open Session of the meeting. Mr. Nick Estes made a motion to move to Close Session. Mr. Erik Lujan seconded the motion. The motion passed unanimously. XIII. Certification After discussion and determination where appropriate, of limited personnel matters per Section H (2); and discussion and determination, where appropriate of matters subject to the attorney-client privilege regarding pending or threatened litigation in which UNMH is or may become a participant, pursuant to Section H (7); and discussion of matters involving strategic and long-range business plans or trade secrets of UNMH pursuant to Section H (9), NMSA, the Board certified that no other items were discussed, nor were actions taken. XIV. Vote to Re-Open Meeting At 1:05 PM, Mr. Jerry McDowell, Chair, requested a motion be made to return the meeting to Open Session. Ms. Christine Glidden made a motion to return to Open Session. Mr. Terry Horn seconded the motion. The motion passed unanimously. Mr. Jerry McDowell, Chair, requested a motion be made to approve the September 20, 2017 Medical Executive Committee (MEC) Meeting Minute as presented in the Closed Session to acknowledge, for the record, that those minutes were, in fact, presented to, reviewed, and accepted by the Board and for the Board to accept/approve the recommendations of those Committees as set forth in the minutes of those committees meetings and to ratify the actions taken in Closed Session. Mr. Nick Estes made a motion to approve the Medical Executive Committee Meeting Minutes. Mr. Joseph Alarid seconded the motion. The motion passed unanimously. Mr. Jerry McDowell, Chair, requested a motion be made to approve the September 22, 2017 Quality and Safety Committee Meeting Minutes as presented in Closed Session to acknowledge, for the record, that those minutes were, in fact, presented to, reviewed, and accepted by the Board and for the Board to accept/approve the recommendations of those Committees as set forth in the minutes of those committees meetings and to ratify the actions taken in Closed Session. Ms. Christine Glidden made a motion to approve the Quality and Safety Meeting Minutes. Mr. Terry Horn seconded the motion. The motion passed unanimously. UNM Hospital Board of Trustees Minutes October 27, /42 3

16 UNM Hospital Board of Trustees October 27, 2017 Barbara and Bill Richardson Pavilion 1500 Agenda Item Subject/Discussion Action/Responsible Person XV. Adjournment Mr. Jerry McDowell, Chair, requested a motion be made to approve the Credentialing and the Clinical Privileges as presented in Closed Session: The next scheduled Board of Trustees Meeting will take place on Friday, November 17, 9:00 AM at the University of New Mexico Hospitals in the Barbara & Bill Richardson Pavilion (BBRP) There being no further business, Mr. Jerry McDowell, Chair, requested a motion to adjourn the meeting. Dr. Aimee Smidt made a motion to approve the Credentialing and Clinical Privileges as presented in Closed Session. Mr. Joseph Alarid. The motion passed unanimously. Ms. Christine Glidden made a motion to adjourn the meeting. Mr. Joseph Alarid seconded the motion. The motion passed unanimously. The meeting was adjourned at 1:05 PM. Dr. Raymond Loretto, Secretary UNM Hospital Board of Trustees UNM Hospital Board of Trustees Minutes October 27, /42 4

17 Board of Trustees Meeting Friday, November 17, 2017 Board Enhancement (Gage Recommendations) 17/42 1

18 Recommendations for Consideration Reduce Board of Trustee Meetings to six per year (once every two months), with much of the work between meetings done in committees. With a reduced number of meetings, management should be able to provide Board materials at least one week in advance of each meeting. Implementation Strategy: Develop Board Committee structure and schedule Consider timing of Board meetings to coincide with critical operational timelines such as budget submission Consider length of Board meetings Revise Hospital and Board policies to reflect edits 18/42

19 Recommendations for Consideration UNMH and the BOT, in consultation with the Regents and County Commission, shall develop a process for identifying gaps in Trustee experience and identifying potential Trustee candidates. Implementation Strategy: Stakeholders develop desired criteria for Board members based on professional experience, community experience and interpersonal style. Review with stakeholders annually Revise Hospital and Board policies to reflect edits 19/42

20 Recommendations for Consideration Three Board of Trustees on each Committee, with each Board of Trustee serving on a maximum of two Committees. Non-Trustees with requisite skills and experience should be included on Committees where appropriate. Implementation Strategy: Review current Board Committee assignments Assess skill set of members as it relates to a specific committee and consider assignment/re-assignment Revise Hospital and Board policies to reflect edits 20/42

21 Recommendations for Consideration Reorganize Committee Structure, which would spread the workload more broadly and provide more opportunities for Board of Trustees to participate in Committee work (Budget and Finance, Audit and Compliance, Patient Care Quality and Safety, Strategic Planning and Community Engagement, Native American Services). Implementation Strategy: Development of the committee structure to include members Revise Hospital and Board policies to reflect edits 21/42

22 Recommendations for Consideration If the frequency of Board of Trustee Meetings is reduced, delegate the Quality Committee to assume Credentialing and Privileging responsibilities between Board of Trustee Meetings. Implementation Strategy: Review with OUC Required for a change in Full Board meeting schedule (every other month) Revise Hospital and Board policies to reflect edits Hold brief Executive Sessions at the end of each Board of Trustee Meeting (with or without presence of Ex-Officio Trustees), provided that such meetings are consistent with applicable Open Meeting requirements and major issues addressed in Executive Sessions are communicated by the Chair to CEO for follow-up purposes. Implementation Strategy: Review with OUC Revise Hospital and Board policies to reflect edits 22/42

23 Recommendations for Consideration Provide increased opportunities for engaging Board of Trustees in major UNMH initiatives such as educating members about important health industry developments, including developments affecting quality and financial performance. Implementation Strategy: Review with OUC Revise Hospital and Board policies to reflect edits Develop mechanisms for communicating effectively with Board of Trustees between meetings (retreats, social events and educational sessions). 23/42

24 Recommendations for Consideration UNMH undertaking a strategic planning process to identify the challenges and goals unique to UNMH within the overall context of UNM and UNM Health Sciences. Expand the use of Board of Trustee self-evaluation mechanisms. 24/42

25 Recommendations Held in Abeyance Reduce the current number of Ex-Officio Trustees Requires By-Law Amendment Increase voting Board of Trustees Members by three. Requires Lease Amendment If voting Board Members is increased by three, have the Hospital CEO become an Ex-Officio voting member of the Board Requires Lease Amendment 25/42

26 Separator Page Patient Payment Policy 26/42

27 Policy Implementation Update UNM Hospitals Board of Trustees October 27, /42

28 2 New Policy Documents Approved by UNM Board of Trustees 10/27/17 Financial Assistance Policy Patient Payment Policy Discount Program Policy ( New) 28/42

29 3 Internal Roll Out Plan Task Leads Front Line Education to put new policies on-line. Kris Sanchez Sandra Mora Present at Supervisor Forum on 11/14/17. Kris Sanchez Sandra Mora Create a Quick reference Guide (QRG) for explaining policies. Kris Sanchez Sandra Mora Determine who needs to be educated. Kris Sanchez Sandra Mora Update FRONTLINE Manual. Kris Sanchez Sandra Mora 29/42

30 4 Internal Roll Out Plan` Task Lead Update scripting for frontline staff around co-pay and down-payment obligations. Kris Sanchez Sandra Mora Three Financial Services documents need to be updated. Molly Chavez Create a sign-in log for training all PSRs, PCCs and Financial Counselors Molly Chavez Send BHO PCCs to training JoAnne Loporto Get the revised polies to the Financial Counselors and explain changes. Raquel Bennett Christi Davies Present new policies at Financial Counselor forum. Raquel Bennett Christi Davies 30/42

31 5 Internal Roll Out Plan Task Have Financial Counselors contact any patients they have worked with, but have not already had the procedure performed and update the patient according to the revised policy. Leads Raquel Bennett Christi Davies Present new policies at PCC forum. Raquel Bennett Christi Davies Create binder with copies of all Policy documents, sign-off sheets, QRGs, and training materials. Craig Klappauf Update management in Surgery and Admitting about the three policies. Sherry Pinkston Raquel Bennett Create a summary of changes document for presenting to all staff. Rodney McNease 31/42

32 6 Internal Roll Out Plan Task Leads Need to clarify with UNMMG and SRMC how they relate to these new policies Rodney McNease Clarify with SRMC that this is effective if there is a UH referral or a UH Capacity problem. Rodney McNease 32/42

33 7 External Outreach Plan Update all Public documents and Website with updated policy information Send new policies to community list serves and community navigators such as pathways Outreach to community navigators on in person training around new policies Update Community Partners such as First Choice, First Nations, Healthcare for the Homeless etc. 33/42

34 8 Questions? 34/42

35 Separator Page Mission Excellence Update 35/42

36 Mission: Excellence Update In alignment with the Execution Framework for Studer Group s Evidence Based Leadership, current activity continues to focus on aligning goals across the Health System entities. Leadership goals have been entered into the Leader Evaluation Manager. Leaders were trained and asked to review their goals, validate the target metrics and assign a weight to total 100% (performance). We have started to enter the first quarter metrics into the system, and are planning a goal equity session the first week of December. The Accountability team has been meeting with School of Medicine Department chairs to ensure alignment of goals, and advise on cascading goals to Vice Chair and Medical Directors. The Clinical Leadership Dyad Education (CLDE) launched on October 31. Medical Director and Unit Directors from three clinical areas (six participants) provided feedback during a pilot session to refine content and process for this training program. Three of the five modules have been developed, with December 13 providing an opportunity for dyads to attend three of the five module linkage labs. CLDE content and requirements will be populated on all dyad learning plans the first week of December, so that dyad partners know they have this resource available. The Communication Team is now providing ALL staff with updates via newsletter. This newsletter focuses on how our team members are exemplifying the new Behaviors of Excellence, contests, recognitions, and other engagement updates. Planning for the December LEADing to Excellence session is ongoing, with a draft agenda receiving approval from Health System leadership on November 13. Content will focus on improving our performance by learning about high and low performing organizations, reviewing our employee and physician engagement scores, training our leaders on how to communicate and action plan around results and improve retention. 36/42

37 Separator Page CEO Report 37/42

38 MEMORANDUM To: From: Board of Trustees Michael Chicarelli Interim Chief Executive Officer Date: November 17 th, 2017 Subject: Monthly Activity Update The Hospital has been involved in a variety of activities and this report will focus on services delivered through October Quality: Due to the timing of the Board meeting, the quality indicators for October are not available. Management will present the October results in the December meeting. Statistics: UNMH finances through October 2017 have not been released at this time and close is expected to take place early next week. Financial: UNMH finances through October 2017 have not been released at this time and close is expected to take place early next week. Strategic Planning: Planning continues related to the replacement hospital design that has been approved by the Regents. The request for proposals (RFP) was initiated on 9/29/2017 and will close today. Following the close of the RFP a multi-stakeholder team will score the bids and name an awardee. Once awarded, planning is expected to begin within a month with a total time line of months. Management will continue to update the Board as progress continues. Human Resources: The turnover rates are now around 16% for the full workforce and 15.5% for nurses as a subset, about the same for the past year. UNMH has 5920 employee which is 321 less FTE s than the budgeted FTE allocation. The total FTE count for nurses is 1869 which is 79 less than the FY 18 budget. Native American Liaison: The Native American Liaison Committee continues to review compliance with the condition of the 1952 Contract, the Lease and the two Consents to amend the Lease. Work continues on the review of the Hospital compliance with the 100 bed provision of the Contract. We have provided a legal opinion about UNM s interpretation of the provision and are waiting for an opportunity to engage in a dialogue on the matter. On November 10 th, the HSC hosted the All Pueblo Council of Governors, State and IHS officials at the UNM Cancer Center. The event had a noteworthy attendance and management had an opportunity to discuss hospital performance, UNM Cancer Center innovation and respond to questions from the attendees. Bernalillo County: Management continues to interact with the County, Indian Health Service and the Board of Trustees on the Memorandum of Understanding (MOU). At this time there is no new information to share with the Board. I will continue to update the Board as progress occurs. If there are any questions on this or other matters, please feel free to contact me. 38/42

39 Separator Page CMO Report 39/42

40 To: From: Board of Trustees Irene Agostini, MD UNMH Chief Medical Officer Date: November 17, 2017 Subject: Monthly Medical Staff and Hospital Activity Update 1. The average wait time for a patient from the Adult Emergency Department to be placed after admission for the month of October was 12 hours. In October of 2016 the placement time was 5 hours and 48 minutes UNMH Remains greater than 90% capacity. We sent 33 patients to an SRMC Inpatient unit instead of placing at UNM Hospital. 2. The Community Partnership with Lovelace Health system continues to be successful in putting the needs of the Patient First, allowing continued access to those patients that can only be cared for by UNMH. In the month of November: 72 patients were triaged from the UNM Health System to Lovelace inpatient units. 3. Our ALOS (average length of stay) for October 2017 was 7.22 as compared to October 2016 which was We continue to hardwire our new processes to decrease our ALOS despite accepting higher acuity patients. 4. Our LEADing to Excellence quarterly retreat will occur on December 14, 2017 to close out the year. The Key Takeaways to Hardwiring Excellence will include the following: Quality and Safety as our number one priority Cascading goal alignment Behavioral expectations for all Dyad partnerships We are in this together, removing the us vs. them mentality 40/42

41 Separator Page Native American Services Committee 41/42

42 UNM HOSPITAL BOARD OF TRUSTEES NATIVE AMERICAN LIAISON COMMITTEE Date October 25, 2017 Time 1:00 PM Location CEO Conference Room, UNM Hospital Administration Meeting Attendees Christine Glidden, Rodney McNease, Erik Lujan, Misty Salaz, Kori Beech, Scot Sauder, Michael Chicarelli, Minutes Agenda # /Subject Status / Discussion I. Call To Order I. Ms. Glidden brought the meeting to order Action / Next Step Responsible Party II. Approval of Agenda- Motion made by Ms. Glidden Approved III. Approval of Minutes Motion made by Ms. Glidden Approved IV. Public Comment- There was no Public Comment V. Mr. Sauder gave an update on the status of the 100 bed language. Currently Indian Health Service is reviewing the proposed language and UNMH is awaiting their feedback in order to finalize. Scot Sauder, Pablo Padilla VI. VII. Discussion of 100% FMAP status. UNMH has worked with IHS, and the Human Service Department related to implementation of the required care coordination agreement. UNMH is completing the necessary operational steps to move forward with implementation in December UNMH has provided a legal opinion to HSD in order for them to review and submit to CMS related to considering UNMH as an IHS like facility. Discussion of Tribal Consultation meeting and agenda. The Tribal Consultation has been moved back to November 10 th. The committee reviewed the final proposed agenda. Accepted as information Kristina Sanchez, Misty Salaz VIII. Bernalillo County Update- Brief discussion of the status of the Accepted as information proposed MOU with Bernalillo County and that the County has provided additional information to UNMH and IHS for consideration based on public comment received on the document.. IX. New Business- There was no new business Accepted as information X. Adjournment Meeting was adjourned 42/42