[Editor's Note: This again was done from a recording, and sometimes it is difficult to hear everyone.The information about Dr. Lash leaving is absolutely INCORRECT. It has been removed from this article. He is not leaving and is still seeing patients.]

By Mary Alice Murphy

The Gila Regional Medical Center Board of Trustees held its regular monthly meeting On Friday, Feb. 23, 2018.

The first item of business was to hear the Safety Moment, which continues to be presented at each meeting at the beginning.

Chief Nursing Officer Peggy White said occurrence reporting has mainly, up to now, been paper shuffling, rather than an investigation into what happened and how to address it. "Determining the cause will be a focus going forward."

Chief Executive Officer Taffy Arias introduced new employees to the leadership team.

"Our new permanent Chief Financial Officer is Richard Stokes," Arias said.

"I'm Richard. I've been here about 15 or so days," Stokes said. "I've spent 21 years in health care and seven years in public accounting before that. I have mostly worked in rural hospitals because I have a passion for good rural health care. For a community to thrive, it needs three things-schools, law enforcement and health care. Back in North Carolina, where I'm from, I've seen the demise of rural hospitals and the impact it had on those communities. It happened to my hometown hospital."

He said he had been taking a look at and evaluating the revenue cycle, "because it's a major issue. It's what I was asked to look at. I thank Mrs. Arias for allowing JoBeth to stay on for this transition. JoBeth handles the day-to-day activities, which has given me a chance to concentrate on the revenue cycle. I'm really glad to be here."

Trustee Tony Trujillo said he had the great fortune to meet the CFO. "He has big shoes to fill, but I'm looking forward to working with him."

Dr. Ronald Dalton, chief medical officer, was also introduced.

Board President Jeremiah Garcia thanked Arias for allowing "Mrs. Vance to transition. That is what we should always be doing. It's very important to give to you, Mr. Stokes, all the tools you need to make your job a good succession."

Arias also introduced the new Chief Quality Officer Tanya Carroccio, who was unable to attend the meeting. "She has hit the ground running. She is reorganizing her department and is setting goals already, as well as outlining requirements."

Trujillo said he met her in the Quality Improvement Committee meeting. "She is very qualified and has roots in the community, with her parents living in Deming, I think. She hits a home run for us."

In recognitions, Garcia said Kamala Golden has provided 15 years of service to Gila Regional in the operating room. She was not present but will receive a certificate of appreciation.

Garcia also recognized Hallie Richwine, in the audience, who said: "I help Mary Alice with the Grant County Beat."

Also recognized was Dan Otero, Hidalgo Medical Services chief executive officer, who brought Dr. Neal Bowen, the HMS chief mental health officer.

In attendance was also a former Board of Trustees member, Dr. Donald Stinar.

In public input, Stinar was the first to speak. "I am an internist here. It's good to see morale at the hospital going up. The dip is being rectified. I want an answer, not necessarily now. I've been studying what critical access means, but have been unable to find out, other than the word reasonable, how much Medicare pays. If it's not two or three times what Medicare pays now, it's not worth it. Because what Medicare pays now is not reasonable."

Arias noted that Stinar is also the head of the Ethics Committee.

Otero said the main reason he had attended was to give an update on Tu Casa (a substance abuse treatment facility currently under construction). "The construction is on schedule. Our team has been working in collaboration with Gila Regional representatives, who have been coming to meetings once a month. It's a really big project. A lot of items with startups are fragile, from funding reimbursement to referral services and primarily, in getting a quality work force in to make it work. Our initial goal was to open in April, but because of the time it's taking for permitting, it's more likely July 1. Substance abuse, opioid abuse are national problems. We wanted to express our gratitude to all of you for your support."

Bowen said the recent legislative session had passed a crisis triage bill. "It does expand our services and will be useful in any crisis, not just for substance abuse."

Trujillo said he has observed the progression of this project from his time on the Grant County Community Health Council. "It's been about five years. The core group kept it going. It was spearheaded by then-Commissioner Ron Hall, with help from Mike Carillo of the Detention Center, my wife Susie and Chris DeBolt. Watching all the entities coming together, it's just a perfect example of, if we want to get something done, it gets done if we work together."

Otero extended his gratitude to the county, too, who provided the funding for the construction.

Under reports, the first one was the Auxiliary, but no one was present to give it. Trujillo said he looked at the wish list of what the Auxiliary planned to donate to the hospital. "Along with the GRMC Foundation and the Auxiliary, they have a list of what will be awarded to the hospital. I thank them for the work they do and for keeping an eye on our needs."

White said she is very appreciative of the awards. "Nursing will definitely benefit from this list."

Garcia noted the more than 500 hours the auxilians volunteer during each month.

Trustee Jeannie Miller asked if volunteers still take patients out after discharge.

"We've been doing training," White said. "We are starting the assistance again."

In the Foundation report, president Alfred Sedillo said the foundation will have its first meeting, since being back under the hospital, on Tuesday, Feb. 27 at noon. "The doors are open to anyone wanting to attend. We are looking for some new members. Two interested ones will attend, and we need a couple more. I met with Doug (Oakes, director of marketing), and he is already anxious to get going. We are looking for a new director."

Arias presented her CEO report. "On the service side, on Feb. 19, we had a going away party for Dr. Friedman, who is moving away." 

[Editor's Note: MISUNDERSTOOD AND INCORRECT INFORMATION REMOVED]

"We did have an interview with a urologist on site," Arias continued. "We made him an offer, which he was pleased with. He said he would let us know after discussing it with his family. We made an offer to an ENT, but he declined it for personal reasons. We have another ENT coming to visit in March. For the cancer center, we have a potential full-time oncologist coming to interview on March 1. We are pleased and excited. Radiation will start up the first week in April."

She said the clinics are still looking at payment reimbursement for third parties. "We have an internal medicine candidate coming in to interview, as well as a family practice physician."

"Our chief quality officer has already given us opportunities to work with Peggy (White, Chief Nursing Officer)," Arias said. "She wants to make sure we are in compliance on JCAHO (Joint Commission on Accreditation, Health Care and Certification)."

She said the transition and cutting of ties from Vance to a permanent CFO will be "bittersweet. It's a transition, and I thank JoBeth for her outstanding work. And I believe Richard is up to the job."

Miller asked about the Cancer Center support groups and who the leaders are. Arias said the groups are for patients and their families, whether the patients are in remission or continuing to undergo treatment. "The leaders are Christine McIntosh and Kelly Rodriguez."

Garcia said the groups are important, because the community does not have many support groups. "My wife has become an advocate for other patients."

"I am also very interested in starting grief counseling services," Arias said. "If we can find a suitable building for them. Spouses of those who have died, whether here or somewhere else, and children are most affected, if they lose a parent or a grandparent or teacher. The services would be open to the community."

Miller asked a question on reimbursement. "When are you going to negotiate with third-party payers?"

Arias noted the contracts are separate from hospital negotiations. Stokes said if the payers can go back and renegotiate, the clinics and the hospital might get less.

"I'm not clear," Miller said. "If I go to an independent surgeon, how does he negotiate?"

Stokes said the hospital is the anchor organization. "The hospital can negotiate on behalf of the independent surgeon, and the hospital gets reimbursed and negotiations determine how to divide up the payment pie. We will enter into negotiations with the physician or home health, for instance."

Trustee Dr. Victor Nwachuku said the system is changing. "If I do surgery, I have a contract with Blue Cross Blue Shield, for instance. The hospital has a separate contract with Blue Cross Blue Shield. Some payers give a lump sum that has to be divided. We have to have other organizations to look at this issue. It's complex and we're not there yet."

Miller asked if most of the independent physicians belong to the Independent Physicians Alliance and Nwachuku said most do.

Trujillo reminded Arias to talk about the hospital's recent award.

"We recently were mentioned as one of the top 100 rural hospitals in the U.S. and the only one in New Mexico," Arias said.

Trujillo said he read and liked what Arias said: ""This achievement is very gratifying and validates our daily commitment to providing the best health care possible to our community."

Oakes noted the decision is based on a compilation of statistics from the Centers for Medicare and Medicaid and publically available data. "It's not something we pay for. It is a third-party organization recognizing us. The group sent a nice letter of recognition."

Trustee Joel Schram said he believes these awards help Gila Regional attract better talent. "We have a urologist interested in coming here, who is also a transplant surgeon."

"He was amazing," Trujillo agreed. "If he accepts the offer, he will be a huge addition."

White gave her CNO report. "The award was also based on HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores and value-based surveys."

"We have created a transition team to help patients transition from the hospital to community medical care, whether at home or in rehab," White said.

Miller said she liked the new format of the report and had several questions.

White answered the difference between different care transitions. "For care transition, a patient comes in and stays for a while then goes home or to rehabilitation. Our team will follow up with them for 90 days. It's the most significant time following discharge. The team will help them feel comfortable at home and ask if they can do more to help. It is us networking with the community-based health care programs, so we're not siloed."

To a question about how nurses work with physicians, White said: "Before I, as a nurse, call a physician, I have to know a lot about the labs, the patient assessment and treatment plan. It makes the connection between the nurse and the physician clearer."

Miller asked about helping that communication.

Dalton said he has worked all over the country and "and this is the best nursing staff I have ever worked with."

Miller asked about in the recovery area and the physician coming out to tell the family about the treatment and next steps. "How do we make that work better?"

"That's what this is for," White said. "Every patient has the right to name their lay caregiver, whether a family member, a neighbor, or just good friend. That person will be there to get the instructions and will be at home with the patient. We have limited space in the recovery area. How we do the discharge instructions will be something we are working on for the whole year."

Miller asked about the paperwork for Level 4 Trauma.

"It's at least a two-year process," White said. "We have sent a letter of intent, and they sent an application. We are working on it and we are all looking at possible needs to policy changes. It's very intensive, and two of the items listed are related to this process."

Miller asked about the item requiring someone in the Emergency Department to handle pedes [pediatric]. "Our emergency physicians are contract physicians. How do we manage that?"

"That is more of a focus on nursing," White said. "The physicians are board-certified and their company keeps them trained. We will bring in training for the physicians and the nurses. We will also have training for trauma nurses, as well as pre-trauma training."

Miller asked if the same team responds to an all-code call.

"The Code Team is responsible for policy and procedures," White explained. "We are looking for training for that, too, because everyone responds to codes."

Trujillo asked about the conference calls with UNM's pediatric cardiologist and the first draft for that service.

"That is driven by Dr. Etheridge, a local pediatrician to get focused training on pediatric cases," White said. "It's a low volume, but when we have it, it's very much a crisis. The contract with the cardiologist would allow us to do the echo-cardiogram on the pediatric patients here, but the pediatric cardiologist would read and interpret the reports."

White said a couple of nurses new to the hospital have commented on the high severity in disease processes in this community. "They didn't expect this in this size community. We have been seeing some very sick patients. The only time you will see any patients in a hallway would be in the emergency room. We do not put patients in the halls of any other part of the hospital."

Garcia commended White on strategically moving in the right direction.

"We keep the focus on the patients," White said.

Garcia asked about how the hospital plans to help and provide services with Tu Casa.

"We don't think any money will be flowing to us, unless something changes," White said. "If someone comes into this hospital, we will refer them to Tu Casa. It will lighten the load on the emergency room and the Behavioral Health Unit. Tu Casa can refer them back to us. It is a collaborative effort and another piece of our networking with the community. It is important for us to be involved."

Vance gave the monthly CFO report. She said the hospital had admitted 232 in January and had 732 outpatients. The ER saw 1,452. Surgeries were up at 416. The gross patient revenue was $17.9 million, with net revenue at $6.4 million. Expenses were $5.8 million, leaving an excess of revenue over expenses of $202,085, as compared to an $810,000 loss last year for January. Year-to-date the total is a negative $4.2 million as compared to a negative $6.2 million last year.

"We had $4.4 million in cash collection; we have 43.3 days of cash, and $182,551 daily expenses," Vance said. "Last year the daily expenses were $205,000. The average length of stay for an inpatient was 3.02 days. We had a CMI (case mix index) of 1.2 for the month."

"We will continue going in the right direction," Garcia said. "You will be able to go with a big smile that you've been able to actually do what you wanted to do."

"This is due to the Gila Regional team," Vance said. "I'm just the one who reports out."

She noted that bills are going out and, if denied, go out again.

Schram said it's nice to see the days in cash go up.

Stokes noted that when the hospital has a spike of patients, it will get paid in 30 to 60 days. "Accounts receivable is a trailing effect."

Schram said he noted that cardiology visits had almost doubled. Vance said EKGs are counted as a visit, so they had not risen that much.

"Are we comfortable with the safety net care pool amount?" Schram asked.

Vance said she and Alfredo (Pacheco, controller) would look at it to make sure they are comfortable with it.

"It is music to my ears to see days in cash increase," Trujillo said. "This month it is 43.3 as compared to 41.3 last month."

Miller noted the change in daily expenses shows that the hospital is reining in costs.

Dalton gave the Chief of Staff report. He said the Medical Executive Committee had recognized several nurses in the emergency department for their outstanding jobs.

"What about bonuses and raises for staff who haven't had any in years?" he asked. "I've worked for 40 years in this country and five other countries and this is the best group of nurses I've ever worked with. We don't want to lose them, and we are losing some."

In department reports, he said the perinatal department has a new director.

"We got a new nurse who came from Tucson Northwest," White said. "She has 20 years of experience, and she's already turned around a bunch and is excited about working here."

Dalton said Dr. Gregory Koury is looking at an online application process for privileging. "We're excited about that."

He noted that whether a physician puts documentation or an operative note into Meditech 6, it needs to be an appropriate note and has to be updated every 24 hours. The Meditech 6 issues are ongoing. "We're getting them sorted out."

White said it will be an ongoing every day process as things change.

"In my practice, I'm using five different electronic medical records systems," Dalton said. "This is the second best of those I'm using, and it still sucks. What is really good about it is when you read about a patient, you know what's going on. This provides an appropriate informational flow."

White said what is difficult is that Meditech is a different build from the work flow. "We have to adjust one or the other. We're continuing to polish and fix."

Dalton agreed that it will be for forever, as requirements and regulations change.

White said the Meditech Super Users team was pulled back together to look at little things to determine whether it is education or tweaks that need to be done.

"I think we have to challenge ourselves to make Meditech one of the top ones," Trujillo said.

White said IT is heavily involved every day.

Stokes confirmed there is a flow issue within the system from nursing that has to move through the system. "I worked with one group that works only with Meditech to fix the system. We're concentrating on the revenue flow. In accounts receivable, every day that goes by, we don't get claims resolved, it falls off the end."

"Next month we will have an update," he continued. "As we find problems and identify them, we fix them. Within 60 days, I expect a better revenue flow. The next area will be physician issues. The physicians and the nurses are the drivers of the rest of the system. Now we have an expert source to help guide our staff. Currently we have specific people for specific parts of the system, but there's no over-arching control or monitoring as a whole for the whole picture."

Dalton said Meditech is not a bad system. "Our upfront work really paid off to get the appropriate information at the other end."

Nwachuku asked for approval to bylaws for primary privileging changes, which was given, The only changes were to make it easier to read and to improve the through flow.

In board committee reports, the Executive Committee met to approve the agenda.

For the Quality Improvement Committee report, White said the projects came directly off the dashboard. "The format will change with Tanya's help to make it more meaningful. It will be reworked to eliminate some of the white noise."

Several contracts were up for approval at the request of the Finance Committee. Trustees approved a family practice provider employment agreement renewal between the hospital and Certified Nurse Practitioner Cynthia Moreno. A second contract was a locum tenens agreement for Advanced Registered Nurse Practitioner Vickie Moore Alvarez to provide weekend services in the Behavioral Health Unit for one year, with a potential for a two-year renewal. The third was a physician employment agreement through May 31, 2021, between Dr. Adam Gough and GRMC for podiatry services.

Schram gave the Plant and Facilities Committee report. "It seems to me the ongoing topics are the challenges to IT and the condition of the facilities. When we get the finances turned around, we can address facilities maintenance."

Miller said she likes being on the committee. "I think facilities maintenance doesn't get addressed enough."

"We have a responsibility to the public to ensure good facilities and good IT," Trustee Mike Morones said. "The problem is one of the most important especially for those not medically oriented. Due to the high quality of people we have in maintenance, this is a very well-functioning facility. The staff would, of course, prefer everything to be brand new, but that is not possible. They realize it's like a classic car that is perfectly maintained. It's amazing what they do with what we have."

Miller said she has asked for the work plan, and Garcia said the hospital used to have a five-year plan. Morones said the plan is to bring it back with details.

Garcia said maintenance does an "amazing job of keeping the 30-plus year-old classic car moving down the road."

Trujillo gave the Human Resources Committee report. He highlighted that Gila Regional had 630 employees in January, which includes full-time, part-time and PRNs (in Latin, pro re nata, meaning when necessary). "We still have a lot leaving, with 16 leaving in January. We are all on the same page when it comes to looking at a pay raise. There are a lot of vacancies and we are trying to find qualified candidates. It's a continuing challenge. Through exit interviews, we try to find out why people are leaving, but it's hard to capture it. We have to figure out how to get the information. We also had a slight decrease in overtime hours."

Stokes said he had read that in January more people changed jobs across the country than they have done in multiple years. "We are in that cycle now. There's a feeling that economic activity is picking up."

White congratulated the Human Resources Department, which had a career fair the previous Wednesday. "We hired four new people for housekeeping, a CNA (Certified Nursing Assistant) and we have a couple of more CNAs who are interested. It was held at the chamber and it was highly successful."

"I feel like recruitment should be continuing," Oakes said.

With no board bylaws changes, the board members took a short break and then went into executive session.

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