Regular Meeting Page 1 of 6 CALL TO ORDER PRESENT ALSO PRESENT OPPORTUNITY FOR PUBLIC COMMENT CONSENT AGENDA CHIEF OF STAFF REPORT The meeting was called to order at 5:30 pm by Denise Hayden, President. Denise Hayden, President Peter Watercott, Vice President M.C. Hubbard, Secretary John Ungersma, MD, Treasurer Mary Mae Kilpatrick, Member at Large Kevin S. Flanigan MD, MBA, Chief Executive Officer Joy Engblade MD, Chief of Staff Kelli Huntsinger, Chief Operating Officer Carrie Petersen, Chief of Fiscal Services Maria Sirois, Chief Performance Excellence Officer Alison Murray, Interim Chief Human Relations Officer Tracy Aspel RN, Interim Chief Nursing Officer Sandy Blumberg, Executive Assistant Ms. Hayden announced at this time persons in the audience may speak on any items not on the agenda on any matter within the jurisdiction of the District Board. Members of the audience will have an opportunity to address the Board on every item on the agenda and speakers will be limited to a maximum of three minutes each. Comments were heard from the following: - Dave Young - Leigh Shamboo - Vickie LaBraque, RN Ms. Hayden called attention to the consent agenda for this meeting which contained the following items: - Approval of minutes of the September 21, 2016 regular meeting - Financial and statistical reports for August 2016 It was moved by Peter Watercott, seconded by John Ungersma MD, and unanimously passed to approve both consent agenda items as presented. Chief of Staff Joy Engblade MD reported following careful review, consideration, and approval by the appropriate committees the Medical Executive Committee recommends approval of the following Medical Staff advancements, appointments, and privileging: Sarah Zuger MD (Family Medicine and OB/Gyn), Provisional Active Medical Staff Kinsey Pillsbury MD (Radiology), Provisional Consulting Medical Staff Jay Harness MD (Breast Surgery), Provisional Active Medical Staff Doctor Engblade additionally reported the Medical Executive Committee recommends acceptance of the Medical Staff resignation of Andrew
Regular Meeting Page 2 of 6 Abrass, MD (Emergency Medicine) effective August 22, 2016. It was moved by Mr. Watercott, seconded by M.C. Hubbard, and unanimously passed to approve all Medical Staff appointments, privileging, and resignations as presented. CHIEF EXECUTIVE OFFICER'S REPORT Chief Executive Officer Kevin S. Flanigan MD, MBA provided a monthly report which included the following: - Representatives fromwipfli LLP will be in attendance at the November meeting of the District Board in order to present their audit findings for the fiscal year ending June 30 2016 - Northern Inyo Hospital (NIH) recently underwent a California Board of Pharmacy annual survey and was cited for not correcting a finding from the prior year visit. The citation was in regard to ventilation of the pharmacy s chemotherapy mixing room, and although management believed it was enough to have a correction plan was in place it was determined that the correction should have been made by the time the following survey took place. NIH was additionally cited for the mixing room not being painted with non-porous paint, even though the paint in the room had passed all previous inspections. Since receiving the Board of Pharmacy s findings, Hospital staff has moved quickly to correct the deficiencies noted and it is expected that the pharmacy will be in full compliance by the end of this week. A re-survey will take 4 to 6 months to accomplish (until such time as surveyors are able to schedule a site visit) and the Hospital expects to be granted a waiver to operate during that time. As of January 1 2017 additional pharmacy regulations go into effect, and more will become effective on January 1 2018. Because of the upcoming (stricter) regulations, Dwayne s Pharmacy will shut down their chemo mixing program effective January 1 2017, leaving NIH as the only compounding pharmacy between Lancaster and Reno. NIH is preparing to meet all upcoming regulations and expects that the Board of Pharmacy will work with us in an effort to ensure that area residents may continue to receive chemotherapy services. Doctor Flanigan noted that because of receiving a repeat violation NIH may receive a Letter of Admonition which could be attached to its pharmacy license for a period of up to three years, or the District may be required to pay a fine. Dr. Flanigan will continue to update the Board on further correspondences received from the California Board of Pharmacy. - Northern Inyo Healthcare District (NIHD) will collaborate with Toiyabe Indian Health Project and the County of Inyo in support of a Toiyabe project intended to provide behavioral health and telemedicine services in this area - NIHD s Moonlight Mammogram event was a resounding success, and 18 woman were connected to breast health services as a result
Regular Meeting Page 3 of 6 - Recruitment continues for a permanent outpatient clinics and Rural Health Clinic (RHC) director to replace Paul Connolly, who has moved on to his next temporary assignment. For the time being the Clinic is being managed by a team consisting of Dr. Flanigan, Jannalyn Lawrence RN, Stacey Brown MD, Dan David RN, and Sarah Starosta PA. - The November regular Board meeting will be held on Wednesday November 16, and the December meeting will be moved up one week to December 14 in order to avoid the Christmas holiday CHIEF OF FISCAL SERVICES REPORT CHIEF OPERATING OFFICER REPORT CHIEF PERFORMANCE EXCELLENCE OFFICER REPORT CHIEF NURSING OFFICER REPORT Chief of Fiscal Services Carrie Petersen reported the District realized a profit of approximately $892,000 in the month of August, largely due to the receipt of Intergovernmental Transfer Funds (IGT) for provision of Medicaid services. Additional IGT funds are expected to be received in the month of October. Chief Operating Officer Kelli Huntsinger provided an overview of the NIHD Cardiopulmonary Services Department as a continuation of her monthly introduction to service lines within the Hospital, and in preparation for Respiratory Therapy Week. Ms. Huntsinger introduced Cardiopulmonary Department Manager Kevin Christensen and reviewed the department s employee skill set, education, and extensive years of experience. She additionally noted that Asao Kamei MD functions as Medical Director of the Cardiopulmonary Services Department. Chief Performance Excellence Officer Maria Sirois provided a monthly Patient Experience Report and update on Performance Excellence activities, which included the following: - Joint Commission Accreditation Focused Standards Assessment efforts continue - California Department of Public Health survey readiness efforts continue - Service excellence trainings are ongoing for Hospital staff - A Workplace Violence Assessment and Improvement Plan is in progress - The District s Radiology Services Procurement process is moving forward, and the Request For Proposal (RFP) for Radiology Services has been published - The District s Pillars of Excellence data collection metrics are being expanded Interim Chief Nursing Officer Tracy Aspel, RN requested approval of the following Nursing Department policies and procedures: - Perinatal Outpatient Evaluation and Management Level of Care Worksheet - American Heart Association Training Center Policies and Procedures It was moved by Mr. Watercott, seconded by Doctor Ungersma, and
Regular Meeting Page 4 of 6 unanimously passed to approve the Nursing Department hospital wide policies and procedures as presented. CHIEF HUMAN RELATIONS OFFICER REPORT NEW BUSINESS NIHD COMPLIANCE PROGRAM; COMPLIANCE RESOLUTION; AND COMPLIANCE AND BUSINESS ETHICS COMMITTEE CHARTER LOCKDOWN POLICY APPROVAL Interim Chief Human Relations Officer Alison Murray reported she has looked into the pay of NIHD Phlebotomy staff in response to an employee concern raised at the September Board meeting. Ms. Murray found that phlebotomy staff pay scales were reviewed in 2014 (along with the rest of the departments within the hospital) and at that time it was determined that NIHD phlebotomy wages were above the market standard. At that time the pay of employees being paid over market was frozen to increases, yet no employees received a reduction to their pay. As market trends fluctuate upwards over time it is likely that the affected employees will have their pay un-frozen when market rates catch up to their rate of pay. Compliance Officer Patty Dickson called attention to a proposed Compliance Program for NIHD which helps specify guidelines regarding how the District complies with applicable state and federal laws, and how it acts to prevent waste, fraud, and abuse, and establish ethical standards and practices. Establishing a Compliance Program helps the District to define its high standards of practice and to prevent wrongdoing before it occurs. Two key elements of the program are to establish a Compliance Resolution, and to develop a Compliance and Business Ethics Committee Charter, which were also presented for approval at this meeting. Following review of the information provided, Director Hubbard asked that a correction be made to last line of the General Policy paragraph on page 11 of the Compliance Program to direct employees, medical staff, the Governing Board, and affiliates to discuss any concern with the Compliance Officer or your supervisor rather than discussing them with the Compliance Officer or directly with District legal counsel. It was moved by Mary Mae Kilpatrick, seconded by Ms. Hubbard, and unanimously passed to approve the proposed NIHD Compliance Program, Compliance Resolution, and the NIHD Compliance and Business Ethics Committee Charter as presented, including the change of wording specified by Director Hubbard. NIHD Property Manager (and Safety Committee Chair) Scott Hooker called attention to a proposed Lockdown Policy and Procedure for the hospital facility, the intent of which is to ensure a safe and secure environment for patients, visitors, and staff. The proposed policy is the result of many months of effort and research (including collaboration with local law enforcement), as well as careful evaluation of the success and shortcomings of prior lockdown events. Following review of the information provided it was moved by Mr. Watercott, seconded by Ms. Kilpatrick, and unanimously passed to approve the proposed Lockdown Policy and Procedure as presented.
Regular Meeting Page 5 of 6 CELTIC LEASE BUYOUT NIHD PEPRA RETIREMENT PLAN, TRUST AGREEMENT, AND BOARD RESOLUTION EXTENSION OF PHYSICIAN AGREEMENTS BOARD MEMBER REPORTS Doctor Flanigan called attention to a proposed buyout of an equipment lease with Celtic Leasing, which would eliminate costly monthly equipment lease payments and result in a significant cost savings for the District. The proposed buyout price is $385,000 (a non budgeted expense) which has been negotiated down from more than twice that amount. It was moved by Dr. Ungersma, seconded by Ms. Hubbard, and unanimously passed to approve the buyout of the equipment lease with Celtic Leasing as presented. Dr. Flanigan called attention to a proposed Public Employees Pension Reform Act (PEPRA) retirement plan for present and future Chief Executive Officers (CEO s) of Northern Inyo Healthcare District (NIHD). The proposed Plan would be added to the benefit package for the Hospital CEO from this point forward, and as a means to enhance the CEO recruitment package and allow NIHD to extend more competitive employment offers to CEO s in the future. The proposed plan specifies a maximum annual payout limit of $210,000, with vesting to occur after a five year minimum term of employment. Dr. Flanigan additionally noted the proposed Plan parallels the existing employee defined benefit retirement plan, and it was designed by the same law firm and actuarial firm that handled the District s previous retirement plans. Following review of the information provided it was moved by Ms. Hubbard seconded by Doctor Ungersma and unanimously passed to establish the proposed PEPRA retirement plan for the CEO, and to establish a Trust Agreement and Board Resolution in support of the retirement plan as requested. Dr. Flanigan then called attention to proposed extensions of the following physician agreements through December 31, 2016 until such time as final details for physician agreement offers from the Robbin Cromer-Tyler MD Inc. group have been determined: - Stacey Brown MD, Medical Director of the NIHD Rural Health Clinic - Stacey Brown, MD; Rural Health Clinic Staff Physician Agreement - Robbin Cromer-Tyler MD; Private Practice Physician Income Guarantee and Practice Management Agreement - Joy Engblade, MD; Chief Hospitalist Agreement - Anne Gasior, MD; Rural Health Clinic Staff Physician Agreement - Catherine Leja MD, Rural Health Clinic Physician Agreement It was moved by Ms. Hubbard, seconded by Ms. Kilpatrick, and unanimously passed to approve all six physician agreement extensions through December 31 2016 as requested. Ms. Hayden asked if any members of the Board of Directors wished to report on any items of interest. The following reports were made:
Regular Meeting Page 6 of 6 - Doctor Ungersma provided a report on the Association of California Healthcare Districts (ACHD) advocacy meeting, and provided dates for 2017 ACHD meetings - Director Watercott reported the NIHD Foundation employee and physician recognition dinner will take place on November 5 - Director Kilpatrick expressed her appreciation of the outstanding employees who work for the District, stating she is proud to be a member of the Board of Directors No other reports were heard. CLOSED SESSION RETURN TO OPEN SESSION AND REPORT OF ACTION TAKEN ADJOURNMENT At 7:56 pm Ms. Hayden announced the meeting would adjourn to closed session to allow the Board of Directors to: A. Hear reports on the hospital quality assurance activities from the responsible department head and the Medical Staff Executive Committee (Section 32155 of the Health and Safety Code, and Section 54962 of the Government Code). B. Confer with Legal Counsel regarding pending and threatened litigation, existing litigation and significant exposure to litigation (pursuant to Government Code Section 54956.9). C. Confer with Legal Council regarding pending and threatened litigation, existing litigation, and significant exposure to litigation (2nd case) (pursuant to Government Code Section 54956.9). D. Discussion of a personnel matter (pursuant to Government Code Section 54957). E. Conduct the CEO Annual Performance Evaluation (Government Code Section 54957). At 9:31 pm the meeting returned to open session. Ms. Hayden reported the Board took no reportable action. The meeting was adjourned at 9:32 pm. Denise Hayden, President Attest: M.C. Hubbard, Secretary