SOUTHERN COOS HEALTH DISTRICT Board of Directors Regular Meeting February 22, 2018 Southern Coos Hospital & Health Center 7:00 p.m. AGENDA I. Call to Order II. III. IV. Public Input Consent Agenda A. Minutes 01/25/2018 B. Foundation Report Staff/Committee Reports A. CEO Report 1. Monthly Education-Revenue Cycle & AIDET B. CFO Report C. Medical Staff Report D. Performance Improvement Committee V. Old Business A. South Coast Orthopedic Collaboration VI. VII. VIII. New Business A. Patient Satisfaction Surveys B. Readmission Rate C. Bandon Pool Committee Letter of Support D. Elmira Building Residential Care Facility Letter of Support E. Medical Staff Bylaws Amendment Executive Session under ORS 192.660(2)(f) to consider information or records that are exempt from disclosure by law Open Discussion Adjournment Next Regular Meeting March 22, 2018 SCHHC 1
CONSENT AGENDA Minutes January 25, 2018 2
Southern Coos Health District Board of Directors Regular Meeting Minutes January 25, 2018 7:00 p.m. I. Call to Order This regular meeting of the Board of Directors for Southern Coos Health District was called to order at 7:00 p.m. by Esther Williams, Board Chair. Members Present: Esther Williams, Board Chair; Tom Bedell, Secretary; Brian Vick, Treasurer; Carol Acklin and David Allen, Directors. Administration: JoDee Tittle, CEO; Robin Triplett, CFO; Rachel Beissel, CNO; Megan Holland, MD; Kim Russell, Executive Assistant. Other staff present: Kalen Mills, Amy Fine, Scott McEachern, Stacey Thorsen. Public: None II. Public Input None. III. Consent Agenda David Allen moved to approve the Consent Agenda. Brian Vick seconded the motion. All in favor. Discussion: Congratulations to the Foundation for exceeding fundraising goals. The Foundation-sponsored 5/10K and Fun Run at Bullard s Beach on January 7 had over 100 participants. Unanimous decision. IV. Staff Reports A. CEO Report JoDee Tittle presented a review of her CEO Report from the Board Packet, adding the number of hospital influenza cases, with 31 tested in December; 2 were confirmed Type A and 4 confirmed with Type B. Dr. Holland added that when patients call on the telephone presenting symptoms, phone triage is used to avoid exposing others. In summary: Accolades & Recognition: Complimentary letters from patients were shared with the Board. A new employee recognition program is underway including peer to peer and employee of the month awards. January 21-27 we recognize Certified Registered Nurse Anesthetist (CRNA) Week. Staff have expressed appreciation for the boardapproved $100 holiday bonus. Medical Staff Bylaws: JoDee acknowledged Dr. Megan Holland, Kathleen Kelly CRNA, Maggie McLain FNP-C and Stacey Thorsen, HIS Director for their work to review and update the medical staff bylaws to be considered by the Board at this meeting. 2018 Healthcare Service Excellence Conference: Heather Edwards, Quality and Risk Coordinator, was awarded a scholarship from the Oregon Office of Rural Health to attend the 2018 SCHD Board of Directors Meeting Minutes Page 1 of 4 January 25, 2018 3
Healthcare Service Excellence Conference this month in San Antonio, Texas. Conference registration and expenses are covered by the scholarship. Western Oregon Advanced Health Incubator Grants: Two grants have been received by the Southern Coos Health Foundation from Western Oregon Advanced Health; $3,500 for colon cancer screening, and $3,999 for vaccines for children. Oregon Association of Hospitals and Health Systems: JoDee will represent the Coast Region s hospitals by serving on the Small and Rural Hospital Committee (SRC). The SRC provides a forum for representation, advocacy, education and outreach and evaluates issues affecting small and rural hospitals. Carena Virtual Care Clinic: Implementation of virtual care is underway to be introduced as AnyTime Care at Southern Coos. Access to AnyTime Care will be available through the Southern Coos Hospital and Health Center web-site with a public live-date in late spring. Employee visitors to the site will pay $20 per visit and public visitors will pay $35. Mobile Health Services-Paramedic Level Services, Bay Cities Ambulance: JoDee reviewed a new opportunity to help reduce hospital readmissions and lower emergency room utilization. Patients assigned to Dr. Holland and Elizabeth Ogunnaike, NP, have been selected to participate in a mobile health services program with experienced paramedics who will provide personal patient care with in home assessments once per week for 30 days, bridging the gap between discharge and the start of any home services Marketing: January marketing efforts include development of the multi-platform roll-out of AnyTime Care @ Southern Coos including dedicated page website page with education on on-line access and by personal phone device, and promotion of SCH providers, Dr. Reed, Dr. Noel Pense, and Dr. Baharloo. Dr. Reed and Dr. N. Pense will also be introduced at Women s Health Day on February 3. The recent grant from WOAH will support marketing of colorectal screening and colonoscopies, a service available at Southern Coos. B. CFO Report Robin Triplett reviewed the CFO Report for the month of December provided in the Board Packet and available on the hospital website, www.southerncoos.org In summary, the month of December saw an increase in inpatient days at 120, compared to 41 in November. The month closed at $66,530 with gross revenue up 18.2%; YTD closing at -$143,000. Gross expenses included a number of one-time budgeted expenses and expenses related to a new provider and travelers required in Lab and Radiology. The month of January is seeing an increase in both inpatient and outpatient services. Expense-saving efforts include combining several departments, reducing dietary expenses, lowered overtime with low census, and modifying lobby weekend hours. The month closed with Cash on Hand at 66.70 days and $3.446M in the State Pool. Hospitalist, Dr. Noel Pense, DO, is also seeing clinic patients ½ day per week and is the only provider in Bandon to perform osteopathic manipulation. Clinic providers now include 2 internal medicine MDs, 1 Nurse Practitioner, 1 Podiatrist, 1 General Surgeon, and 1 Licensed Clinical Social Worker, with visiting specialists to include Dr. Qadir, a Nephrologist and potential providers from South Coast Orthopedic. SCHD Board of Directors Meeting Minutes Page 2 of 4 January 25, 2018 4
C. Medical Staff Report Dr. Holland presented the Medical Staff Report for the month of January. Consideration for 6 month Provisional Privileges Brenda Smith, MD (Emcare) Brian Vick moved to approve the Medical Staff Report as presented. Carol Acklin seconded the motion. All in favor. Unanimous decision. V. Old Business None. VI. New Business A. Consideration of Medical Staff Bylaws Discussion of review process and legal review. Bylaws approved by Medical Staff on January 9. Tom Bedell moved to approve the bylaws as presented. Brian Vick seconded the motion. Further discussion: clarification provided on provider appeal process. All in favor. Unanimous decision. B. Infection Control Plan This plan helps SCHHC meet CMS conditions of participation and includes the hiring an Infection Prevention Specialist shared with Coquille Valley, Lower Umpqua and Bay Area hospitals. C. Performance Improvement Committee Formation of this committee aligns SCHHC with CMS conditions of participation. A charter has been developed and includes metrics from the strategic plan. A single Board member is requested to attend each meeting on a rotational schedule. D. South Coast Orthopedics Collaboration Discussion of possible collaboration. To be paid by RVU (relative value units). JoDee would like to conduct a proforma report. Board provided positive feedback to proceed with the report. VII. Executive Session under ORS 162.660(2)(i) to review and evaluate the performance of an officer At 7:55 p.m. the Board excused members of the public to enter Executive Session. SCHD Board of Directors Meeting Minutes Page 3 of 4 January 25, 2018 5
The Board reconvened to Open Session at 8:40 p.m. In recognition of a positive first-year performance by CEO JoDee Tittle, Tom Bedell moved to approve a 10% salary increase retroactive to January 1. Brian Vick seconded the motion. All in favor. Unanimous decision. VIII. Open Discussion Board members reflected on satisfaction of CEO performance for the year, and other positive contributions by CEO, management and staff. Revenue Cycle, and Bandon pool to be added to February agenda. Adjournment With no further discussion, Ms. Williams adjourned the meeting at 8:50 p.m. The next regular meeting of the Southern Coos Health District Board of Directors will be held on Thursday, February 22 at 7:00 p.m. in the Hospital Conference Room. Esther Williams, Board Chair Tom Bedell, Secretary SCHD Board of Directors Meeting Minutes Page 4 of 4 January 25, 2018 6
Foundation Report 7
Southern Coos Health Foundation February 2018 Women s Health Day 2018 The 15 th Annual Women s Health Day took place on February 3, 2018. The event was a great success and over 160 people attended, including vendors and volunteers. Several members of our medical community took part in the day, including Dr. Kelly Reed, Dr. Noel Pense, and nonopioid pain management specialist Dr. Croson, along with Tristan Pruett, managing partner at Southwest Physical Therapy. We took videos of several of the presentations and will post these and other educational pieces on the community health education page on the hospital website at www.southerncoos.org/communityhealth. Year-End Campaign As I reported previously, the Southern Coos Health Foundation received a $5,000 grant from the Coquille Tribal Community Fund for our year-end campaign that raised funds to purchase IV pumps and an instrument cleaner for the OR. Two of the Foundation board members will attend a check presentation ceremony at the Mill Casino on March 2. Katelin Wirth, Rachel Beissel, Cori Valet, Nicki Stafford and the rest of the nursing team are working diligently to determine the best equipment at the right price. We anticipate making a decision in the next week or so. New Foundation Board Member We recently accepted the resignation of David Kimes from the SCHF Board of Directors. On behalf of the rest of the Board of Directors, I thank David for his service to the Southern Coos Hospital & Health Center community. We are extraordinarily fortunate to invite Carol Meijer to join the SCHF board of directors. Carol, as you know, served as the most recent Chief Nursing Officer at SCHHC, retiring in April 2017. Carol has a long track record of philanthropy and service, volunteering at many hospital and foundation events as well as at other community events throughout Bandon and elsewhere. Carol will be formally introduced as a new board member at the next Foundation Board Meeting on March 8, 2018. 8
CEO REPORT 9
Accolades CEO REPORT February 2018 Over the last month, we have received accolades from patients. Copies of those compliments will be shared at the meeting. Recognition Events In alignment with our strategic plan, we have incorporated recognition events accordingly. The following activities support our development of a peer recognition program focused on creating an environment that demonstrates our values. In January, we recognized the following departments and employees: January 21 st - 27 th Certified Registered Nurse Anesthetist January Clinical Employee of the Month, Ed Shoecraft -Radiology Technologist- January Non-Clinical Employee of the Month, Pam Decell -Lead Coder- In February we have recognized the following: February 12-16 Healthcare Human Resources Week There are no department specific recognitions during the month of March. AIDET In alignment with our strategic plan, we have begun the process to roll out AIDET. AIDET is a communication framework for healthcare professionals to communicate with patients and each other in a way that decreases patient anxiety, increases patient compliance, and improves clinical outcomes. The acronym AIDET stands for five communication behaviors: Acknowledge, Introduce, Duration, Explanation, and Thank You. Mammography Accreditation We received our Mammography accreditation from the American College of Radiology (ACR). Accreditation is granted when a facility has met all of the testing criteria established by the ACR Committee for clinical image quality and phantom image quality. Oregon Association of Hospitals and Health Systems-Apprise Health Insights I have been selected to serve on the Apprise Health Insights Board of Directors. Apprise Health Insights is a subsidiary of the Oregon Association of Hospitals and Health Systems (OAHHS). Apprise Health Insights is the data and information services subsidiary of the Oregon Association of Hospitals and Health Systems, Apprise is uniquely positioned to collect hospital and health system data, aggregate it, and provide meaningful analysis essential for informed decisionmaking. Patient Satisfaction Results In 2017, we contracted with Illinois Critical Access Hospital Network (ICAHN) to serve as our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Vendor. In addition, we are utilizing Phreesia to track the satisfaction of our clinic patients. We are actively evaluating the feedback we have received and developing processes to incorporate the data into our standard work. 10
Team STEPPS Training On February 27 th from 8:30am to 4:00pm a group of individuals from Health Insights will be at the Bandon Public Library to lead our staff in a training program. We were awarded a small hospital improvement grant to cover the cost of the trainers through the Oregon Office of Rural Health. TeamSTEPPS is an evidence-based, comprehensive teamwork training system designed to improve quality and safety in health care and is rooted in more than three decades of research in high-stress, high-risk industries, such as military aviation. TeamSTEPPS is based on a framework of four teachable-learnable core teamwork skills: communication, leadership, situation monitoring, and mutual support. Team-related knowledge, as well as specific tools and strategies to support the core skills, are delivered to an organization through a customizable course. Marketing Women s Health Day 2018 - As reported in the Southern Coos Health Foundation report, the 15 th Annual Women s Health Day took place on February 3, 2018. From a marketing and public relations point of view, the event was a great success as over 160 people heard from and interacted with several members of our medical community. Dr. Kelly Reed gave a talk on chronic pain management. Dr. Noel Pense offered the group a primer on osteopathic medicine; his wife, Lisa, made a wonderful handout that we included in the attendee bags. Finally, non-opioid pain management specialist Dr. Croson gave an introductory talk on pain and techniques to manage it. Many thanks to all of the providers for participating in Women s Health Day. Gorse Blossom Festival - Southern Coos Hospital & Health Center represented at the 2 nd annual Gorse Blossom Festival on Friday and Saturday, February 16 & 17. The festival offers local organizations timeslots at the GBF Community Booth, and SCHHC staffed the booth on Friday from 3-5p and on Saturday from 2-4pm. We offered handouts describing our various services as well as one-sheets on our new providers. Along with several SCHHC volunteers, Dr. Reed staffed the booth on Saturday. Over the course of the two days, many people stopped by the booth, including several couples who had recently relocated to Bandon and were looking for a primary care provider. 11
CFO REPORT 12
13
14
15
16
17
18
19
20
21
22
23
MEDICAL STAFF REPORT 24
MEDICAL STAFF REPORT February 13, 2018 Consideration for 6 Months Privileges: Susan Haney, MD (EmCare) Dr. S. Pense motion to approve Dr. Keizer second Motion Passed 25
NEW BUSINESS 26
27
28
29