By Mary Alice Murphy

The Gila Regional Medical Center Board of Trustees met on Friday, Aug. 31, 2018, to hear updates from hospital administrators.

The first item of business was the Safety Moment. Chief Nursing Officer Peggy White said her department has been focusing on communication, using the SBAR (situation-background-assessment-recommendation) tool. "We are hoping to tighten up communication, always with safety in mind."

Chief Financial Officer Richard Stokes said communication was key to the recent Meditech 6.15 update. He said the implementation went live one minute past their target time. "We had a couple of dozen issues that were fixed within the first day. One has yet to be resolved, so we turned it off. The smooth implementation prevented any impacts to the hospital."

He introduced Tom Dingus.

"I am in my third year as the auditor for the hospital," Dingus said. "I am working on the audit with the new team. Neither Richard nor Alfredo (Pacheco, controller) were here last year. I will be back in October to present the audit, in order to get it to the state by October 15."

Board Chairman Mike Morones recognized Commissioner Billy Billings for being at the meeting.

"Now it's time to talk about our service recognitions," Morones said.

The board members recognized Robert "B.J." Agnew for his 15 years of service to EMS in the Cliff-Gila area. Morones also recognized his father, Arthur Morones, for 15 years of service with EMS, as well as Lynn Myers for 15 years of service at EMS. Also recognized were Fredina Rogers for 15 years in Infusion, and Michelle Carillo for 25 years in materials management.

"Part of what keeps us going is due to the fact of so many high-quality providers that stick around," Morones said. "We appreciate all of you."

No one gave public input. For board input, Trustee Joel Schram said it had come up in the Finance Committee that "we intend to develop a reporting system to keep the schedule of our strategic plan going."

Morones said Trustee Ed Wilmot has sent his apologies of missing his second meeting because he had a vacation planned before he was appointed. Wilmot asked Morones to convey that he would love to have a separate strategic plan for the board members, with their role and their goals.

In reports and updates, the first was from Jennifer Yost, Auxiliary president.

She reported that membership was down slightly. She reported 1,129 volunteer hours from auxilians during the first month of the fiscal year—July. "Our value for service has gone up. The gift shop is doing very well. We brought in $1,000 last week. We wanted to express our appreciations to the staff members who support the shop."

Allen Townsend, GRMC Foundation member, said the Foundation wished to offer its congratulations to the hospital for staying county-owned. "The golf tournament was very successful, with more than $15,000 profit. We are already working on the one for next year. We recruited two new board members and are still looking for two more. We are in the process of creating a job description for a director, which will be a part-time position. We will soon move into an office in the hospital. We are happy to be a team and working together again."

Morones said when the ties weren't strong between the hospital and the foundation, in the recent past, it seemed to him to correlate with hospital problems.

Chief Executive Officer Taffy Arias began her report by highlighting that immediately after the decision to keep the hospital county-owned, the administration has had multiple interviews with potential recruits to the hospital.

"We interviewed a full-time oncologist, who will finish her fellowship in June," Arias said. "She is extremely qualified and highly recommended. We would love to be her mentor in her beginning years of practice."

Arias said an offer had been made to a general surgeon, who has a significant other—a nurse practitioner. "We received her CV and hopefully can set up an interview."

A podiatrist has accepted an offer and will move to Gila Regional in mid-October. "His parents are from Japan. He has five children, aged 5 years to 10 years. His wife is a professional singer. We are still recruiting for a urologist, an ENT (ear, nose and throat), a family practitioner, a nurse practitioner and a pediatrician."

"We can't afford them all at once," Arias explained. "It's not just their salaries, but all the other expenses involved in setting up the practices. We're doing everything our plan says."

Trustee Jeannie Miller asked about filling the slot Dr. Tarnower from the University of New Mexico Cancer Center would be leaving.

"It will be filled by a replacement from UNM," Arias said.

Miller also asked about the two-to-three-week delay from a cancer patient being referred to the GRMC Cancer Center before being seen by a physician.

"Yes, that is the case," Arias said, "but it is not acceptable. We want to see them as quickly as possible. If we cannot accommodate them, they will go elsewhere. But I'm guessing, it's probably about the same as other facilities. But it cannot be our standard."

Trustee Dr. Tsering Sherpa confirmed that schedules could be moved around depending on the acuity of the case.

Miller also asked who referred patients to GRMC for PET scans. Stokes said Gila Regional recently did a scan on a patient from Las Cruces, but "most are local referrals."

Miller asked about what the potential was for an agreement with the Grant County Community Health Council. Arias replied that it was in the very early stages. "We haven't even had a formal request from the county. We have discussed some operational aspects through the Quality Department that it could help with getting necessary things done. But we are in the early talking phase. The county will house the financial burden and any money coming in."

This author, who is one of the co-chairs of the health council, explained that the council provides resources to the community. "We have a continually updated resource directory for health services throughout the community. We have held forums on issues in the past, such as addressing Fort Bayard outcomes and the sewage issue when it was in a crisis stage. We are a clearinghouse for addressing such issues. We are completing an assessment. We are in the process of inputting the results, so a report can be created and shared with community stakeholders. This report and data are used by just about every non-profit in the community for writing grants."

Arias noted that there had been a question about whether the health council would continue. "That's when Mary Alice came to me about it. We are the hub of health care, and we didn't want it to go away. The health council provides continuing education and addresses community deficits. It fits into our strategy of outreach."

Morones commented on the Cancer Center. "Because the transition has taken longer than the board and the public wanted, I want to say that it is falling within the timetable that the professionals said it would take—12-to-24 months to transition fully. So, are we at half capacity?"

Arias said that with providers only once or twice a week, "if we have a full-time five-days-a-week oncologist, we can see more patients."

"But fixed costs will be covered," Morones clarified.

Miller asked if the radiologic oncologist would continue once a week. Arias confirmed the radiologic oncologist would continue to come to Gila Regional once a week. "In addition, when we have five days a week staffed, the volumes will increase. All the infrastructure is in place. It's there; it's ours; the records are ours; the systems are ours. The money is ours."

"I equate it to balancing a plate on a stick," Arias said. "Two years ago, we had one plate on one stick and were keeping it up in the air. How many can we keep up in the air when we are fully staffed?"

White highlighted in her report that thanks to the outreach by Marketing and Human Resources, "we had a very successful job fair. We were able to recruit a nurse, CNAs (certified nursing assistant), EMS personnel and housekeepers."

Miller asked about the referral process for patients and how a pharmacist shows up at the bedside. White said if a patient is being discharged with new medications, the pharmacist will explain how to take them. "Sometimes, it is prompted by the patient, but typically by the nurse on the floor. We have started with inpatients but will expand it to outpatients."

"What is the Stepping Up Program?" Miller asked.

"It is a separate program focusing on those in the law enforcement system with mental health issues," White said. "The person may be in our behavioral health unit or somewhere else in the system. We are working with the Detention Center to help them with resources for anyone in their system, whether it be with counseling, medications, follow up with physician visits or wherever they need help. (Jail Administrator) Mike Carillo and I have both had our frustrations. We have been talking a lot about the logistics between CareLinks, Stepping Up and with our Care Transition program. We are connecting the dots for services and where they are needed."

Stokes added that Press Ganey consultants "recognized our care transition program and have been sharing the model with others. We had a teleconference with a facility in Ohio, and they will be using the model."

White said she has received requests from two other facilities wanting to know about the program. "They are anxious to take what we're doing and make it work in their hospitals."

Sherpa noted that a case manager from Deming had spent a week at Gila Regional and took back the information learned about the program.

"It's not helping just us locally," Stokes said. "We are expanding to share our story with others."

Miller asked if the hospital had an urgent care facility yet. "Not yet," White replied, "Fast-Track isn't working as quickly as we wanted. Everyone is now out of orientation, so it should be going a lot faster, from the provider side and the nursing side."

"What about civility training?" Miller asked.

"We are reminding the staff how we treat one another," White said, "with professionalism, compassion and respect. I think we should do the training periodically. The director of Maternal and Child services oversees it. There are lots of pieces—communication, interaction and how to treat a person professionally."

To a question about lateral violence, Chief Quality Officer Tanya Carroccio said: "For some reason, we eat our young. It is getting better across the country. There are a lot of theories behind it. If we can teach communication skills and show people how they can be more intelligent about how they come across to people, hopefully we can nip it."

Morones asked if it referred to the turnover with new nurses. Carroccio said that was exactly the problem. "If we can mentor them so they are more accepted, it will help them grow as nurses."

Miller noted the internship program is part of that initiative, and Carroccio agreed.

Carroccio, in her CQO report, said the focus is on reducing readmission. "Renny (Mariscal, discharge planning director) wrote up a report on how we were looking for quality enhancements in our organization through the Care Transition program. I asked him to submit it to the New Mexico Hospital Association to look for a quality award. About an hour ago, I learned we made it to honorable mention and will receive $1,200 in education, either on the infection control side or the quality side. We have so much work happening on the readmission issue."

She said the Quality Department in undergoing restructuring, with some positions moving out or combining. Tammy Harris, quality assistant, will be promoted to Medical Staff Services coordinator.

"Taffy has given me the go ahead to look for an RN-based quality, risk and compliance coordinator," Carroccio said. "It is an entry level nursing position who will learn about quality improvements. It also sets us up for succession planning, so if someone leaves, we don't have a gap."

She said the Quality Department will be under the Regulatory Department, effectively combining them and absorbing the quality piece. Carroccio reported on the culture of safety survey results. "Our overall perception of safety is rated at 61.4, below the national benchmark of 66. We know we have room for improvement. We want people to feel safe and comfortable going to their director or leadership to report safety issues. The positive areas are 76.1 in the supervisor promoting safety and 76.3 on teamwork support within the unit. We have an opportunity of safe hand-offs and transitions and making sure communication is working to adjust the culture that errors not receive punitive responses. We also find not as much teamwork across hospital units, although it's good within units.

"We will be focusing on those below the national benchmarks and will be talking about it in the Quality Improvement Committee meetings," Carroccio said. "Oh, and last week we got the official letter that we are fully accredited by the Joint Commission."

Carroccio said a pilot program beginning with housekeeping is looking at their learning to acknowledge the patients with a greeting, what his or her role is and how long he or she will be there and to leave with a thank you. "Between nutritional services and housekeeping, they're front-line people. They're excited about getting to be a pilot."

Miller asked about patient safety indicators.

Carroccio said it is an index that gives "us a point in time when you fall on safety indicators. We must make sure the documentation is correct. For instance, if a patient comes into the ER with C. diff (Clostridium difficile, a diarrhea-causing bacterium), we must document that it was community-acquired, not hospital acquired or we get dinged."

Sherpa said if it is reported two weeks after the patient is discharged, "then we get dinged because it was deemed hospital acquired."

"With the Meditech Quality module, which we are working on implementing, it will be so helpful, because we will learn about it in real time," Carroccio said. "Right now, we have abstractors doing the documentation. Because it will be a part of Meditech, we can get notifications in real time. We will have documentation and practice opportunities to fix it before the patient goes home."

Stokes said he has the proposal from Meditech. "We will address it next week. The quality module will allow real time care for the patients."

Miller asked about the infection prevention position. Carroccio said it is a vacant position, but the gaps are being addressed.

Miller also asked about the measure for staff to get certain immunizations.

Carroccio said the hospital is measured on what percentage of staff get immunizations, for instance for the flu.

"We should be at 100 percent on the flu vaccine, but we are very low," Carroccio said. "We will make sure to have significant education before the coming flu season."

Stokes said the hospital has a history of not implementing technology well. "This is about teaching the organization about how to implement tech in a disciplined way. When we were going through the update, we heard a lot of 'we didn't think we could do it," but slowly but surely, they came on board. We will continue the discipline into the next upcoming update."

He presented the financial summary for July, the last full month of reporting prior to the meeting and the first month of the fiscal year.

"At the end of July, we reported a negative revenue over expenses of $514,039," Stokes said. "That compares to a loss of $1.55 million at the end of July in 2017."

He explained the loss this year as being tied to lower volumes in July, in addition to lower volumes in June.

On the EBIDA line (earnings before interest, depreciation and amortization), Gila Regional had a loss of $112,539, compared to last year's negative $1,191,702. "That means we spent $112,000 more than we took in," Stokes said. "We aren’t happy, but that's what happened. Intuitively, I can't help but think when the hospital is in the paper every day it has to cause questions in people's minds—'Should I go elsewhere?'"

Morones noted that June and July are always the worst months for Gila Regional. "Our fiscal year will always end on a bad note and start on a bad month. Even if we are profitable, those will be our lowest months."

Stokes agreed and said a year at Gila Regional is like a Bell Curve.

Under notes of interest, he said there is a known issue with unbilled reporting through Meditech. "We’ve been watching it. It came to our attention in March. We, according to the Meditech report, had $5 million unbilled, but we got it down to $1.95 million unbilled. It shows in the report that we have $3 million unbilled for July, but the real number was $1.5 million unbilled. We still have challenges with how late charges come into the system. We took the time to go through the calculations to determine the true unbilled amount. If we have a late charge tacked onto the bill, in the system, the entire bill gets turned back into unbilled. We're working on it. I told my staff not to redo the calculations. That we would explain it. It's better than last month and will be better next month. And to put it in perspective, $1.5 million is about three days of accounts receivable, which is our target. Our cash collection percentage was at 28 percent, down from 33 percent last month. As we continue to work through the cleanup of the AR, we found we had more than the normal adjustments going through contractuals. But in July, we collected 110 percent of net revenue as compared to June. We always know that net revenue is what we expect to turn into cash."

He said the hospital, in the Meditech update, had a known issue with the pharmacy module, which produced more line item denials. "We're watching to make sure they are billing correctly. The Meditech update went live Tuesday night. By Wednesday night, we had completed the review of the denial codes. We have fixed the majority on the billing side. We had five denial codes that were billed incorrectly. It hid the fact that secondary insurance wasn't being billed correctly. We needed to bill the insurance and the patient got billed incorrectly. We fixed that Wednesday. It's not a revenue opportunity, but a cash collection opportunity. We also found out how the organization had been billing radiation therapy incorrectly. We were putting multiple encounters on one bill, but the payers were paying for only one encounter. That was corrected this week, too. We continue to find things. As we peel a layer back to fix a problem we find two other problems. We find two and that turns into four. It continues to multiply. I want to make sure you understand that we have really talented people working on these issues. The people in medical records are finding issues."

Stokes said: "We found a problem with United Healthcare. We used a DRG (diagnosis-related group) and they said: 'No, we think it should be this DRG.' I called the director of the New Mexico Hospital Association and told her: 'This impacts not only us, but all your hospital members.' Within about 30 minutes, I had a response from United Health. We're working on the issue. I tell you the bad stuff, but I want you to know the good stuff, too. We have people on site, who know what to do. My job as CFO is to manage net revenue."

To continue with his report, Stokes said July 2018 had 151 admissions, with 429 patient days, compared to 167 and 511 in 2017. "This year the average length of stay was 2.8 days, which is an improvement over last year's 3.1 days. We're keeping them for less time." ER visits were down to 1,216 from last year's 1,289, but outpatient visits were up in 2018 to 4,522, compared to 2017's 3,935. Clinic visits in 2018 were 1.443, compared to 2017's 1,574. Surgeries were down at 258 from 365. Oncology visits were up in 2018 to 339 from 323 in 2017. Births stood at 30 this year, compared to 36 last year.

In key production indicators (KPIs), cash collections in 2018 were $4.1 million compared to 2017's 3.5 million. Days cash on hand were 70, compared to 2017's 61. "My goal is 100 days of cash on hand."

"The days in AR went up to 76.4," Stokes said. "I directed HRG to work harder on the commercial classes. They have a 90-day window for billing, while Medicare has a 120-day window."

A chart of oncology activity showed that last August and September were the lows, but the number of visits has been increasing fairly steadily since then to a high in June and a very slight dip in July.

In a look ahead, as of Aug. 27, 2018, the patient admissions stood at 144, with an expectation of 160. As of that date, gross revenue was $13,362,616, with an expected $14,847,351 by Aug. 31. "We expect to be above net revenue at the end of August from last month."

Arias talked about the layers of problems being like an onion. "We cry a lot, but there should be excitement as we fix each issue. It's better than not knowing about them. Things we are finding, we are being able to address more quickly."

Morones agreed. "Every time we find an issue, it gives us the opportunity to fix it and benefit from it."

Stokes said, as an organization, the administration has agreed to add a pharmacy infomatics position. "What we fixed this week was the first step. It makes sense to have someone dedicated to the biggest module in the system. HRG is going through growing pains. I'm not satisfied with the improvements. We will have some serious conversations. We'll take care of that."

Schram said the days in cash on hand in May were 61 and in July, the number is 70. "That is a testament to cash collections. I commend Richard for it."

"If we are looking at critical access, we will need cash," Morones said.

Chief of Staff Dr. Greg Koury said his report was in the packet. Miller said she was confused by the new report. "What does providers mean? Is that everyone?

Koury said it includes all personnel with privileges.

Delicia Dimberg, Medical Staff Services director, said she is putting together the data.

Sherpa said five surgeons were listed. "Does that include the locums?"

Koury said yes. Plus, the ER doctors are from Innova.

Dimberg said the report by Koury and the list of providers were approved by the Medical Executive Committee "with lots of questions."

Morones asked how the physicians feel about Meditech.

Sherpa said there weren't many changes for the physicians. "More were for the nurses."

"The changes were subtle for physicians," Koury said. "They made it better. From the physicians' side it was a smooth transition."

"That was by design," Stokes said. "We weren't going to impact the physicians. What the new update has are enhancements. Delicia has a whole list of things to communicate with the providers before we turn it on. We will get with the providers."

Arias said: "I have the greatest appreciation for Dr. Koury for his leadership with the medical staff. It is second to none."

Stokes echoed it with: "Having a strong, engaged chief of staff is key. It's great to work with a person who gets down in the weeds."

It was mentioned that Koury is termed out at the end of his term, according to the bylaws.

"I will be glad to continue," Koury said. "We would have to change the bylaws. But Delicia has a plan." As he left to go back to medical duties, he said: "Thank you for all you do. Keep it going in the right direction."

Morones gave the Executive Committee report and said they brought the agenda.

The Quality Improvement Committee' business was mostly covered in Carroccio's report. "We will be working on the quality and assessment improvement process, which we will bring to you next month," Miller said.

Schram presented the Finance Committee report. "We had a very good discussion on cash collections. And we have two contracts to approve."

Sherpa said the first is a physician consulting agreement between Gila Regional and Dr. Donald Stinar for two years for the OPPE (ongoing professional practice evaluation) from Sept. 01, 2018 to Aug. 31, 2020.

The second contract was the first amendment to extend the professional service agreement for on-call specialty coverage between GRMC and Dr. Amos Lash from Sept. 26, 2018-Oct. 25, 2018 because of dissolution of the Independent Physicians' Association contract and renegotiation of the contract.

Both were approved.

Miller presented the Plant and Facility Committee report. "Information technology was very pleased with the support across the organization for the Meditech update. They also reported that recruitment in IT is very difficult in the higher-level positions. Our salaries and benefits are not competitive, but Ken Stone feels comfortable with the Navan Haffty training. It is being documented, so when they leave, we will still have the knowledge. We also had a discussion about contingency planning for the physical plant and critical equipment and looking at possible ways we can do contingency planning. There are some things we have to look at the budget for what needs to be done. And there is a downward trend in employee injuries."

Morones gave the Human Resource Committee report. "Contract labor is up a bit and it will be up here on out, but staff will be down in a comparable amount." Stokes said it was primarily driven by Cardinal, which has taken over the pharmacy.

He also said Navan Haffty was at the hospital for two purposes, a capital event in the Meditech update and a second purpose was an operating expense for continuing the optimization of Meditech. "One Navan Hathy asset has already disengaged. A couple of more will leave in September. The ones working on the revenue cycle will continue through October."

Morones noted that a lot fewer people are leaving the organization, and a higher percentage of them are agreeing to exit interviews. "We are finding out why they are leaving and adjusting where we need to adjust."

The members took a short recess before going into executive session, to address among other things, the financial audit.