[Editor's Note: This author was out of town when the meeting took place. Thanks to Sandra Michaud for recording it for purposes of this article.]
By Mary Alice Murphy
Trustee Mike Morones served his first meeting as chairman of the board and welcomed recently appointed new member, Ed Wilmot.
Chief Executive Officer Taffy Arias said she had "somewhat" of a safety moment. "One of our buildings did not have a security system and three computers were stolen. We need for everyone in the hospital to do a risk assessment for their area. We have found some security issues that need to be addressed. We need to do them before things are stolen. We need to be proactive, not reactive after they happen."
During recognitions, the board members recognized Jesse Altamirano of the information technology (IT) department for his 15 years of service, as well as the two who were present, Tommy Chavez and Troy Lane, for their 15 years each in the emergency medical services (EMS) department.
"The beauty of recognizing these individuals, especially after a year of controversy," Morones said, "in which in many cases our trust has been called into question, shows that the trust of our caregivers has been topnotch. That's has never wavered."
Lane said it has been the best 15 years of his life.
In public input, Linda Pafford of Mimbres, congratulated the hospital "for staying with us. We will have more public monitoring of your meetings, so the community knows who to ask questions of."
Wilmot asked how the board members could help.
Morones answered and said: "We ask the public to bring your concerns. We have to be careful of debates if the issue is not on the agenda. We want people to know we welcome inquiry, and we can get answers."
Trustee Tony Trujillo read a letter from Chris DeBolt, who regularly gives public input at the meetings, but was unable to attend that day.
"Three days ago, she called me and asked me to read this letter," Trujillo said. He read from it. She gave her "heartfelt thanks (to the board and administration) for your courage in the face of daunting odds, standing up for truth and never giving up. You and all of us have defied the odds, which are not in favor of rural hospitals. Despite the slings and arrows, you have carried on for all of us as a true embodiment of what hospital care should look like, with care and compassion. How professional the caregivers behave with care and compassions for our patients and lives that are at the core of your work. As one who treasures this little gem in the high desert and have had a chance to work alongside some of the finest people I've ever known in the worst of times, I see what you accomplished when hope seemed lost. We are here for you, and all you have to do is ask."
In board input, Morones started off the conversation by saying it is a chance for the members to talk about what they hear in the community. "We appreciate Chris. She's an advocate, but she also challenges us and makes sure we stay on the right path. It's good to be here and we can get to work. I think all the public is rooting for us, wants to work with us, and will push us. We want to answer your questions. We want our goal to be to inform the public as much as possible while within the rules."
Trujillo welcomed Wilmot and said he was already up and running. "Overall, I want to thank the Commission for their vote of support and for their listening to the community. To the financial people, I want to say that you are getting the public's attention. People are calling me and telling me they just got a bill for a procedure done 11 months ago or six months ago. They had never gotten a bill, even though they had asked for one. I’m getting lots of feedback."
Trustee Jeannie Miller thanked the community, the staff and the press "for helping keep us local. I thank Mike for taking on the difficult role of chairman. I welcome Ed. He has already been active and involved. I thank Mike for reassigning us to other committees. It's helpful to see what other things are happening. We have much to do."
Trustee Joel Schram said: "I commend the commissioners for making the right choice. We found out after the decision that Lifepoint was being sold to Apollo Global Management," which owns things like Red Box, McGraw-Hill's educational assets, entertainment companies, restaurants and others such as private equity and credit companies. "We might have been sold to a company not in the health care business. I thank the administration for staying with us. Without you, this wouldn't have happened."
Trustee Dr. Victor Nwachuku said he was very appreciative of everyone's contributions to staying independent. "One of the issues we've had is trust. I think we're going to change that for a better relationship with the public. Our biggest point of concern right now is finances. We know the work we have to do. It's important to keep the hospital viable and create trust between us and the Commission and the public."
Wilmot said he was excited to be on the board. "I would like to emphasize my concern about transparency and trust. I'm excited to see what I've seen. I saw so many individual heroes we need to recognize. So many exciting things are happening, but I never want us to be satisfied. Thank you for what you do today, but also for what you are doing tomorrow. I see opportunities."
Morones said the staff is really where the true trust of the public lies. "I include the administration. Each of the employees plays a role. This administrative team is the cherry on top. The core is there. Doug (Oakes, marketing director) is telling our story. The administration is working at a high level. This board is getting to where we understand the numbers because you're (to Chief Executive Officer Richard Stokes) presenting them in a way the public is also beginning to understand the numbers. I thank all of you."
No one attended to give an Auxiliary or Foundation report, so Arias presented the CEO report.
"Our surgeon who had signed a contract withdrew, but we have three excellent candidates to interview," Arias said. "Richard and I have worked on lease arrangements to put family clinics in surrounding areas. I thank Tanya (Carroccio, chief quality officer) and Denise (Baird) for tidying up the loose ends of the Joint Commission visit. We did well. Things that we had hanging out three years ago, five years ago are fixed. I'm so grateful."
Miller asked about the patient volume in the Cancer Center. "Our treatment patients increased. Are we at full capacity?"
"We can accommodate more as soon as we get a full-time oncologist," Arias said. "Chemotherapy is separate. Until we have a full-time physician, we are looking at filling the slots being filled by Dr. Tawnower."
Chief Nursing Officer Peggy White said that, in order to made it better for full-body PET scans, they have to be accommodated in oncology, where it is set up more efficiently.
Miller said she was glad to see the memorandum of understanding with the Silver City Fire Department for drug replenishment in the ambulances.
"It has to go back to the attorney, because (assistant town manager) James Marshall wanted some changes to the agreement," Arias said.
Wilmot asked Arias what her top two focuses are.
"I, and especially Richard, am working to clean up finances," Arias said. "My second priority is recruiting for specialties and the family clinics. I don't worry about things I used to worry about. The team is focused. They have been given permission to question us. I feel comfortably uncomfortable, so we are going in the right direction. I'm feeling good about the direction we're going."
Trujillo said the board trusts the CEO's team. "From my standpoint, we want her to tell us about staffing. That's why you'll hear about recruiting, as well as the quality and safety aspects, the community and the Cancer Center."
"It's been driven by the history of what we've come through," Morones said. "Her report is telling us what we want to hear."
Miller said she appreciates that Arias gives her team direction, and "she doesn't block our access to the team. It is open and comfortable."
"We expect to hear questions," Morones said. "It takes thousands of questions and ideas to effect change."
White congratulated Morones as chairman and welcomed Wilmot. She said the items on the dashboard listed in red are the priorities of the nursing department. "We have implemented internships for new nursing graduate. It's working well and the next one will begin in January."
Miller asked if she had gotten anyone from ads that had been placed.
"We are getting inquiries from New Mexico State University and Doña Ana Community College," White said. "The internship is for any nurse just coming out of training.
Wilmot said the scuttlebutt in the community is that the internship program started but was broken.
"Yes, we started it," White said, "as a bridge of transition from school to the hospital. However, during the turmoil of CEOs and financial problems, we lost the funding. We redesigned it and began it again. We will tweak it again for January, as we continue to learn."
White said the Quality Improvement Committee is making connections with patients after discharge. "We have gaps from discharge to the patient being seen by their physician. We are working with the clinics, including HMS, Cassie's, Silver Health Care, as well as trying to make connections with Dr. Stinar's office directly, to make sure the patients discharged have appointments with their primary physicians or specialists after discharge."
"We have hospitalists going into the patient rooms, as well as their surgeons," White continued. "We're encouraging nursing to be there with the surgeon, too, in case the patients have questions. We're also working on having the surgeon in on the outpatient discharge, too, but that's not always possible."
Nwachuku confirmed that his group talks to patients and families during discharge.
"The patients are dependent on getting the right medications after surgery," White said. "The processes we are starting are to have everyone in the room."
Trujillo asked White what the feeling of the nurses is after the decision to remain independent.
"Lots of relief and appreciation for the wage increases," White said. "They are recruiting their friends to come to the hospital or come back to the hospital."
She noted the addendum in her packet with updates on the strategic plan. "We did not wait for the commissioners' decision but kept moving forward." She added that a nurse works closely with the ER director.
Miller asked about the ER work flow.
"We got some new staff and we will work on the Fast Track through the ER," White said. "It is going to start in September."
Wilmot asked White about the issues her department is struggling with.
"We all work together," White said. "My biggest focus was the care transition. Now it's going well, so we're working on the ER."
Miller asked about urgent care in the facility.
"If a person comes into the ER, they will stay in the ER system, but the Fast Track will take care of the ones that are less of an emergency," White said. "Fast Track is to get them in and out of the ER within an hour. Urgent care is in a standalone building."
Stokes explained the hospital has primary care in the clinics, urgent care in a separate building and the ER. "Each one, as you go up from primary to ER gets more expensive, so we want all the options for patients."
Miller asked if the triage person in the ER is a nurse.
Chief of Staff Dr. Gregory Koury said the triage person has to be a nurse, because he or she is the one that determines the needed level of care.
"We must support all levels of care," White said. "If a person is a level 3 or 4, the triage person can send that patient to Fast Track, in order to allow physicians to take care of the direst emergencies."
Arias added that every person coming into the ER must receive a medical screening.
Carroccio said it was a pleasure to have Wilmot at the QIC meeting and to learn of his expertise in liability issues. "I appreciate having his organizational experience. For my CQO report, I want to focus in on the first section and what we are looking at to get to the 5-star quality rating and where we have options. We are also in alignment for keeping our A rating and at Leapfrog and will be looking at all of them in the QIC."
She said the contract process is about 90 percent to 95 percent ready to roll out to better comply with standards.
"In the Quality Assurance Committee, we have lots of opportunities," Carroccio said. "Most are not too far off of national benchmarks."
Miller asked about the electronic clinical quality measures.
"In the eCQM efforts, we didn't follow all of the best practices when we did the last Meditech update," Carroccio said. "We're doing better with this update and making few changes on the recommendations. We will change our processes to meet the recommendations."
Nwachuku said they are trying to find ways to correct where the hospital is deficient in Meditech.
Morones said he is very comfortable that Gila Regional will meet the 5-star rating. "We're coming off a lot of transition, so I expect a drop at first."
Carroccio agreed that there is likely to be a drop, which she expected last month. "We anticipate the next update in October. We may go to 3-star because of the turmoil, but we won't stay there long. Our goal is to be back at 4-star and on toward 5-star."
CFO Stokes presented his report. "We reported on June a little early at the Commission meeting because they needed to know what was going on. "We did end with a $621,923 loss, bringing our loss year-to-date to $1.52 million. We are going through accounts receivable and culling out what has not been billed. We have made a fair amount of administrative adjustments. We also had a fairly significant drop in activity at the hospital in June and we expect it to continue in July. The year-to-date loss at the end of fiscal year 2017 was $2.62 million, so we cut it in almost in half for FY 2018. We thought we were trending toward a $7 million loss, which we were, but we pulled it up.
"Both (Controller) Alfredo (Pacheco) and I came subsequent to the start of fiscal year 2018," Stokes continued. "How did we have a $4.5 million positive month last year in June? A lot of entries went through the audit. Things on the books that were not exactly correct to the tune of $4 million, so it was an audit adjustment. Alfredo has gone through them this year, and we will continue to go through them. We have tried to go through every item, but we still have about 30 small items to consider. We expect to have them done close to the auditor's coming here. Our goal is to have very few audit entries this year. The auditor said we need to clean the balance sheet bottom line. We don't want any surprises. Our No. 1 concern is how we calculate our contractuals. We have vetted them. The audits will look at claims outstanding. I rarely have audit adjustments. I think we will have minor issues."
Wilmot said it seems to him that Stokes and Pacheco are doing good things. "Do you have some way of accounting what was there when you got here and what you're doing now?"
Stokes said as soon as he walked into the door of the business office, "I knew there were major problems. They led to the decision to go with HRG for help. The staff was not following the Meditech recommendations and tried to make the computer work like the old ones did. It was always a failure."
Wilmot asked how Stokes knew the coding was working.
"Our coding hasn't been the problem," Stokes replied. "It was getting them to work within the system correctly. For instance, in the pharmacy, it could be coded correctly, but they haven't been working correctly in the system. Every week we are stepping through the revenue cycle."
Morones gave some history to Wilmot. "Just prior to Alfredo and well before Richard, we had four million to the positive but a couple of million to the negative. The adjustments were not minor, not major, but in the direction they flowed through the system needed substantial changes. JoBeth (Vance, interim CFO) recognized severe issues in the accounting department and asked the auditor to look at specific things. We probably should have picked them up in the first audit, but in the first audit, we relied on previous staff input. Alfredo and JoBeth said to the auditors to go deep, which led to a lot of corrections. I think I heard in your question, Ed, how do we benchmark stages. We have brand-new benchmarks."
Stokes continued his report and said the hospital had $5.247 million unbilled when he came in. "We were at 10 days for accounts receivable. That's way too high. We are now at $1.591 unbilled and 3.1 days in AR. My goal is three days. We're below that and at about $750,000 unbilled. We know what's going on and have resolved the vast majority of the problems. We had 4,198 denials in May and 5,041 denials in June. We expected the denials to go up as we continue to address issues. In March, we were at 27 percent collection; by May 23 we were at 30 percent collected and in June at 32 percent. Year-to-date, we are at an average of 30 percent and we're seeing it go in the right direction."
He said he had met with Navan-Haffty, the consultant helping with Meditech. "We determined it is reasonable to proceed on Aug. 22 to go live. We have had a lot of concern in and outside of the hospital that we are doing another update. The difference this time is that we brought in a national consultant that does only Meditech. We want the board to know there is not a lot of enthusiasm among the staff on the update. We've had two meetings with them. But Meditech is one of the biggest safety practices we have. There will be problems when we go live, but we have taken care of the major problems."
Morones noted that last year's Meditech change was a major upgrade. "This is a relatively mild update."
"We are correcting the errors of the past," Stokes said. "We will adopt Meditech best practices. We will make sure we get everyone up to speed. This is an update on steroids."
Wilmot asked if the best practices will require significant change to the organization with all the process changes.
"It's a process change, rather than the way we do things," Stokes said. "We're solidifying the environment we work in now."
In a continuation of his report, Stokes said the hospital had 153 admissions as compared to last June's 164, and 381 patient days as compared to 512 last year. "I want to comment on the length of stay, which was 3.2 days last year and 2.5 this year. Taffy and I have had conversations on whether we're moving patients out too fast. But I would like to note that many come in under observation and spend a day or two under observation before they are moved to acute care. We will be looking at how we classify patients. It will be driven by the physicians."
This June, the hospital saw 1,213 visits to the ER as compared to last year's 1,083. Gila Regional physicians performed 295 surgeries as compared to last year's 334. Key performance indicators stood at $4.2 million, with 66 days of cash. Accounts receivable are at 73 days and accounts payable at 52. Full-time employees are 455. Overtime was at 3.6 and holds steady. The case mix is at 4.66 and dropped slightly. "People were a little less sick this month."
Miller noted that the raises to acute care nurses will see a jump in expenditures.
Stokes said it would be about a $600,000 impact a year. "Oncology visits continue to move up, although we can expect a dip in July. In July, although we have not closed the books, we had about 151 patient admissions. The ER projection for July is 1,305 and 373 for oncology. In the summer months, we expect a lull. It was the opposite in South Carolina where we had huge months in July and August, on par with January and February."
For the HRG report, Stokes said the days in AR went down in June to 73.5, collection was at 33.8 percent in June. "I'm comfortable at 32 percent collection. My primary job is to grow net revenue. The goal is to get us to a sustainable 35 percent collection rate. The AR days target is 45. We were at 73, so it's clear we have a lot of work to do. We are looking at the third-party payments that have aged over 90 days. Our target is 19 percent collection in that category. We sent about 3,000 self-pay statements out. The bad news is that we didn't send them out before. It's good news for us, but maybe bad news for you. You'll be getting bills. We've had to make corrections."
"We have talked about a 30 percent discount for self-pay," Stokes said. "It has been well received."
Miller asked if they included payment plans.
"It's 30 percent off if paid in full within 60 days," Stokes said. "It can be $100 this week and $50 next week if it's all paid off within 60 days.
"I want the board to know that we do a ton of stuff in Excel," he continued. "We have to get our reports out to give us time to think about what's causing problems. We want to dig into the data. Some things we've moved ahead on; other initiatives were waiting for the decision. We're moving on them next week. We are also going to work the strategic plan really hard."
Morones said there are lots of opportunities in Excel for the information in one cell to be gone. "People are in trouble if they don't update their cells."
Stokes said: "When we get to the system, we know we want to let you have the ability to see what our underlying data is under the top number."
Koury presented his chief of staff report. "I'm appreciating Delicia (Dimberg, director of medical staff services) joining us. We're working on credentialing and doing it in a better system. For staff use, we are stepping up to code and key in correctly. I’m staying on them. I am suggesting you have reports from the UR (utilization review) Committee that reports directly to the board and comes through me. They work the nickels and dimes. It is a key committee to the hospital. In maternal and child, Octavia (Janque, MATCH director) is doing a great job."
Miller asked whether there is one or two medical staff coordinators.
"We had one, but we will have two," Koury said. "We had a credentialing specialist and an administrative assistant. With two coordinators, we will be up to standards. There will also be an educational requirement."
Stokes made an observation "about our positions, especially Dr. Koury. I've worked at multiple hospitals, and I've not seen a medical staff so willing to accept change. Thanks to the medical staff for accepting things they can change."
Morones said he appreciates that "we need everyone to work together."
Miller asked about the Meditech Medical Advisory Committee. Koury said the committee met to address issues related to the update.
"We have a whole list of post updates to work," Stokes said. "One thing, we have already resolved is keeping this list."
Miller asked if the hospital were seeing improvements in the specific quality issues in staff queries.
"We will see improvements," Koury said. "This is my fourth hospital and it had always been my concern to see medical staff when they were at odds with the administration and the board. My priority is not to have a divide. We reassured the Commission we will stay together and stick together. Rennie (Mariscal, director of discharge planning) is my right hand. We support the services that may not make a buck but are absolutely critical to our community. Mental health is trying to break even. That's how we are helping the hospital."
Morones said he would add the UR Committee report to the agenda.
Nwachuku said he was impressed with the way the physicians worked together to keep the hospital independent. "I thank Dr. Koury and the Medical Executive Committee."
In board committee reports, Morones said the Executive Committee created the agenda and talked about moving into the commissioners' final vote and how "we could inform them."
Miller is the new chairman of the Quality Improvement Committee. "Ed sat in on it, too. It was my first real QIC meeting. Tanya has written out a meaty report on quality changes. There is a lot of accountability in it. I'm chairing the QIC and the Plant and Facility committees. I'm seeing the other side of finances. Quality and facilities are also important, or we will have no patients."
She noted the plan to put links on the dashboard for trustees, so they can jump to the documents instead of scrolling. "The survey had a 66 percent response. The opportunities will be reviewed. The QAC (Quality Assurance Committee) will review them. A more common thread for safety is communication of information to everyone involved. How can we include safety? Rennie Mariscal reported on the quality initiatives, and how to reach out into the community. It seems to be going well. We are increasing communication with the community and the staff. We are considering emailing the patient satisfaction survey, so people don't just toss it aside. We have a lot of new graphs that you don't yet see. We need to fix the dashboard."
Stokes said Tanya's department, "doesn't just help finances. It leads finances."
Trujillo said one of the highlights of Wilmot's comments were when he said there are a lot of heroes in this organization. "You said there was a lot of work to get to quality."
"Your team is working as a team," Wilmot said.
Schram presented the Finance Committee report. He noted the unbilled number of days in June is at 3.1 days. "In February, it was 12 days. That drop results in more earnings. Collections have risen to almost 34 percent, and you're comfortable at 32 percent. HRG is reporting detailed earnings before interest, appreciation and amortization. That is what drives cash. We reached a low of 52 days of cash and have gone up to 71 days of cash. We have had a $2.5 million swing from last year. We're generating revenue."
Nwachuku said the Finance Committee is an important one. "We have done well in a lot of areas and it's getting better. I've been here 18 years, and Mr. Stokes is the best CFO I've seen. There's a lot of work. Accounts that are more than 90 days old you can't collect. The community is dependent on us to get the hospital right. We've tried to make revenue right before. We've had consultants that didn't get it to work. We're not there yet in finances, and we have to monitor outsourcing. We have to look deeply into finances. We have to do better in my practice, too. We have to change what we're doing."
Three contracts were up for approval. The first was a physician member agreement between Gila Regional and Dr. Michelle Diaz to serve on the Ongoing Professional Practice Evaluation Committee for two years through July 31, 2020 at $150 an hour.
Wilmot asked about the next two, which had interim contracts. Nwachuku explained that the contract format would be changing to new contracts.
Koury will be extended for two months, until the new contracts are ready, for on-call specialty service coverage.
A similar interim contract was approved for Dr. Donald Stinar for on-call specialty services in pulmonary cases.
The Plant and Facility Committee report by Miller said that Mr. Stone has told them of shortages in IT staff, who are installing security updates. "They are either underqualified or want more money than we can pay. They are beginning the risk management of all systems to determine the risk. Medical equipment had no breakdowns this month, and the behavioral health unit upgrades are completed. The facilities personnel are doing ongoing reviews of things to fix. In security, an active shooter drill was held strictly in house with no law enforcement present. It went fairly well, and they are reviewing it. A future drill will involve law enforcement and someone playing an active shooter role."
Wilmot said: "I thought we were doing too well. It makes me nervous."
Morones asked him if he had taken a tour of the facility yet, which Wilmot had not.
"Coming off that committee, I want to say the tour was amazing," Morones said. "Considering the age of the building, it is phenomenal how well maintenance is keeping it up. There are concerns because of its age."
Miller noted that the way the facility is set up could be more efficient.
The Human Resources Committee did not meet, but reports could be seen on the dashboard. "Things are static except for contract dollars," Trujillo reported.
Nwachuku said the Board Bylaws Committee did not meet and there was nothing new to report.
At about 2:30 p.m., the trustees took a 15-minute break and then went into executive session.