By Mary Alice Murphy

Gila Regional Medical Center Board of Trustees members recognized two long-serving employees and the Foundation scholarship winners at their monthly meeting on Oct. 25, 2019.

Employee Rollane Collyge received a certificate of recognition for 25 years of service in the Ultrasound department. Denise McNutt was recognized for 35 years of service in the operating room.

For an article on the scholarship recipients, please visit
https://www.grantcountybeat.com/community/community-news/54052-grmc-auxiliary-and-grmc-foundation-scholarship-awards-presented-102519 

For the monthly safety moment, Chief Quality Officer Tanya Carroccio said although the safety moment usually focuses on clinical issues, "the parking lot can become unsafe. Staff should not park in the patient parking areas. We are focusing on it for everyone's safety."

After approval of the agenda and before hearing public input, board input, and a few updates, the trustees made a decision to go into executive session to hear from the auditor, Tom Dinguss, and to hear a presentation from Community Hospital Corporation for future planning.

Chris DeBolt, former GRMC employee, was unable to attend the meeting, but she sent a letter of thanks to the hospital for its participation in the Mimbres Valley Harvest Festival, of which she is one of the organizers.

"I am writing to express my deep appreciation for GRMC's participation in the Health Fair as part of the Mimbres Valley Harvest Festival," Chairman Tony Trujillo read from the letter. She specified several who took part, including Chief Executive Officer Taffy Arias, Chief Nursing Officer Rose Lopez, as well as Emergency Medical Services, Flight for Life and the Stop the Bleed and stroke presentations. She also thanked Dr. James "Butch" Rosser for his presentation. "I want to relay how much your being there was noticed and appreciated by residents of this area to again make them aware of the outreach of our hospital. You all made me proud."

In board input, Trustee Joel Schram said he would comment later.

Trustee Ed Wilmot recommended the book, The Price We Pay by Marty Makary, M.D.

Trustees James Marshall and Cynthia Moreno passed on their chances to give input.

Trujillo said he was stopped at the local Walmart by someone who had recently had surgery. "He was full of compliments about Gila Regional."

"Our Lt. Gov. Howie Morales gave a beautiful eulogy and talked about the care his father received in his last moments at Gila Regional," Trujillo said. "I've also seen Facebook comments about the excellent care people have received."

Marilyn McCracken, GRMC Auxiliary president, said she is often asked what the Auxiliary does. "We do PR; We smile: we direct people and escort patients; we as a non-profit do fundraising for hospital-related projects. We have the gift shop. Almost everyone works on the fundraisers. Just our popcorn machine raises enough for one scholarship every seven years. We have our wish-list project. We write to the departments asking what they really want. We do this project a lot. We have a small budget, about $8,000 a year, but the items can be important, such as cotton covers for mammograms. As of this month, we have 47 active members. Unfortunately, we have 65 available slots a week, so we need a few more good men and women. We need every member we have. It's hard to hold onto members, because, well, because we're old."

"Monday (Oct. 28), we will hold our 50th anniversary reception from 2-4 p.m.," McCracken said. "It's our final hurrah for our 50th anniversary."

Trujillo said: "On behalf of the board, we want to tell you how much we appreciate everything you do. You are an important face for our patients."

Trustee Moreno said: "You step in when we need help."

Representing the GRMC Foundation, Vicky Schram said the foundation has approved 18 turkeys for Thanksgiving baskets. "Thanks to the auxiliary for their help with scholarships. We are still looking for a foundation coordinator, and we are changing our monthly meeting to the second Wednesday of the month. We have gone through applications and interviews, but we still haven't found the right candidate for the coordinator."

Trustee Joel Schram said First American Bank had agreed to be the title sponsor for the golf tournament next year and will sponsor a scholarship.

The board went into their first executive session and came out at 3:05 p.m.

Arias said for her CEO report, she would cede time for two reports from staff.

Rennie Mariscal, Clinical Services director, said: "I want to highlight Dr. Rosser, His specialized equipment is here, and he will start procedures on Nov. 6. I also want to self-report a mistake in the legend for my report. It was off."

He said the Deming Clinic levels are low. "We are making visits to businesses and have occupational therapy ready to go there."

Marshall noted that the grmc.org website needs work.

Wilmot said Memorial Medical Center of Las Cruces also has a clinic in Deming. "They put out an ad. Are we complementary to their services? Memorial looks like formidable competition."

Mariscal said the Gila Regional clinic is working in Deming with smaller businesses. "Our occupational medicine will be for the trucker companies and others, and we want to use the facility for tests. We also want to do women's health at our clinic there."

Arias: "We are doing a lot of preparation work. We will have specialists rotating through the Deming clinic.

"We will also have a telemedicine component, too," Mariscal said, "including with Dr. Rosser."

Trujillo said: "We need to keep an eye on Deming. Let's see where it goes. I think the plans will give us some opportunities."

"We need to be aggressive on our marketing and outreach," Mariscal agreed. "Our diabetes education program is going now."

Moreno: "Have you set benchmarks and are you creating relationships?"

Arias noted that only one provider was in the clinic at present.

"I would like to look at trends, " Marshall said. "This is ugly."

"We need to give it our best shot to make it work," Mariscal said. "If you have ideas, run them by me."

Trujillo said if anybody "can rally anyone, it's Rosser."

Mariscal said they have done radio spots, billboards and spoken to the Chamber of Commerce in Deming.

Trustee Dr. Victor Nwachuku said he knows it takes a while to build a new practice. "It depends on who the provider is and what the community knows about the clinic."

Mariscal said he has gotten calls about service.

Wilmot noted that new patients in the Cancer Center seems to be an issue, too.

"We need to continue to nurture our local providers and those in the region," Mariscal said. "We need an oncology nurse practitioner to make office visits to let physicians know what we offer. We have not only medical oncology, but also radiation oncology and a cancer support group."

Eloy Medina, Emergency Medical Services director, said EMS has a new initiative. "We partnered with Blue Cross Blue Shield on a paramedicine program, which includes psychiatric, obstetrics, and high-risk patients."

"We will do in-home assessments," Medina said. "Crews will go on home calls to assess fall risks, for example. We have identified high-risk individuals. Blue Cross Blue Shield sees high utilization of the ER and reports them to us. We have identified 72 people that could use the community paramedicine program. It is not really revenue generating, but the high-users often turn into bad debt. So, our goal is to limit that. We've gotten approval for the program. We have a signed contract. We are doing the training in house. It is an opportunity for seasoned EMTs to advance."

Medina said the charge would be $135 per home visit. "Albuquerque, when it launched its paramedicine program made money as it grew. We assess things such as no running water in a home. Blue Cross Blue Shield has local referrals for the services."

Nwachuku asked about transport.

"If we see a need for the person to see a provider, we will call 911," Medina said.

Wilmot asked if the program has criteria for success.

"We may look at a different path," Medina said. "I'm looking for how to save this organization money. My goal is to see a reduction in repeat users of the ER."

Marshall said, six years ago, when he was with EMS, "we did a sample. We took a look at ones that were coming multiple times to the ER. They were the same ones. We created a program with Hidalgo Medical Services, and we went into homes`` and would document what we found. We used 12 patients as the sample, and none were repeaters after that. HMS was doing it on a grant and then there was no more funding."

"We call them and let them know we are coming," Medina said. "They have to agree to our coming to visit. It can be billable. We got a lot of support on this initiative from administration. It will benefit us as an organization. Even billable, it's not going to be money-making, but it will keep resources for the real emergency room needs."

Trujillo asked about liability issues.

"We don't need consent as long as Blue Cross Blue Shield is referring them," Medina said. "We do have concerns about sending only one person out. We will have a call sign when we're going and coming. We also have concerns about where there is no cell service. Paramedics will do a set of vitals at the beginning and at the end of the visit. It's all within the scope of the practice of paramedical providers."

The providers will have a 23-page evaluation form to fill out during a one-hour 20-minute visit.

Nwachuku noted that Blue Cross Blue Shield would benefit by saving money. "We need them to share with us."

Trujillo said he still had concerns about liability once the provider gets into the homes.

Medina said the program is already in Albuquerque and Rio Rancho. "New Mexico is behind. It's all over the nation. That's not to say we won't face accusations, but the direction we're headed is to have cameras on the EMTs."

Arias noted that liability is already covered by the hospital.

"I had a meeting with Cindy Stout at Texas Tech University's Children's Hospital," Arias said. "They have oncology to neurology to brain surgery. The services they offer are extensive. We are looking at a relationship as another referral. I also will have a meeting with Charlie Alfero to develop a residency program. I'm actually more interested in how we can help Hidalgo Medical Services develop more residency programs. It will be Charlie, Dr. Darrick Nelson and I at the meeting. We are working on getting the meeting together."

Nwachuku asked her to present it to the next medical staff meeting.

"I'm exploring ways not to duplicate but to share," Arias said.

Chief Nursing Officer Rose Lopez said she had held an orientation the previous day. "We are inching up in scores. I am working with Western New Mexico University. We have directors and doctors going there to present to the students. It's an exciting time. We have students happy to come here and it will continue."

Wilmot asked how the hospital is addressing sepsis.

"That is part of my report," Lopez said. "We have seen so much improvement on sepsis. We call a sepsis alert when we bring in a patient. We give antibiotics if we suspect it. We've been doing it for about a month."

Carroccio said she was pretty excited about the regulatory process for contracts. "We came up with a system about a year ago for contract management. The management process we've found almost mimics what we created. We are a Beta for the process. I think, by the time we get to Phase 2, it will be a robust process. It's all online until we print it and get a signature. In a couple of weeks, we'll be doing training on it. We also have a surveillance and quality module to alert us to sepsis or other problems to see who is at risk, and it has an early warning trigger."

"I compliment Rose and Tanya for working together," Wilmot said.

Marshall asked Carroccio what the term governing body meant in the report.

"The item is delegated to the C-suite, and we will identify how the board will interact with us," she replied.

"I guess we're making sure you're doing the process," Marshall said.

Trustee Schram remarked: "As we move more online, we have to make sure the vendors have security in place, too."

Carroccio said the hospital, specifically Ken Stone of internet technology, vets all vendors. "If a vendor doesn't meet all criteria, it's not a good fit for us. IT is involved every step of the way."

Chief Financial Officer Richard Stokes said a new solution has been blocking phishing efforts. "We are happy with the new software, but we had to tweak it to get what it called fake emails, that weren't, to go through."

In his financial report, he said that September at Gila Regional saw a $1.2 million loss, with a year-to-date loss of $1.48 million. "We had a lot of turnover in accounts payable. We found papers in drawers and lots of invoices that had never been sent. There were invoices that said they were entered, but they weren't, and they hadn't been sent. We are in a clean-up process. The loss is not significantly different from this time last year. Last year, we were receiving a lot more safety net care pool funding. Still a $1.4 million loss is too much. I've tasked department heads with finding $250,000 each in cost avoidance. I have received some good ideas. Certain things take time to dig through. After the strategic planning meeting next week, we'll have a better idea of things. Cost containment and revenue enhancement are going forward. I know these are bad numbers, but one of the biggest benefits for me is that we have the right people in the accounting area now. We've been building infrastructure up in the organization for the past year."

"This organization for some reason declined to build a statistical module in Meditech," Stokes said. "Jennifer and I, in addition to our Axiom training for budgeting purposes will start to look back and build the statistical module. We are also working with the BCA (business clinical analysis) model. We had a number that came out of Meditech of actual and canceled cases. We don't care about the canceled cases. Well, we do care about them, because we have identified about half a million in avoidance that are a result of canceled cases, but having said that, we are building out and vetting the BCA data. It will make the organization be forced to make decisions that may be uncomfortable but will be coming by the end of the year. One of the best ways to increase net revenue is how to work denials. This product will allow us to file electronically the request for authorization on the date of admission, so we have an auditable trail for the insurance company. We expect to see denials for lack of authorization decrease, which will result in additional net revenue."

He said the hospital has a zero-balance project. "We signed a contract for a vendor, and we expect to send them the data next week, so they can fight for us. Accounts that have gone to zero are a big issue. We have to carve costs out of the organization and increase cash collections. We are still working on the loss of $7 million in safety net care pool contributions. Our cash collections were as 32 percent, which is fairly stable. Our cash collection to net revenue was 121 percent over the last month"

"We had a softer month in September," Stokes said. "We had $14.2 million in gross charges, after $14.8 million in August and more than $15 million in July. It was driven in both the in-patient and out-patient settings. Last month, we had 409 visits to oncology, but we expect 471 in October. Dr. Fontelonga is getting settled in. Another thing that significantly hurt the hospital for the quarter was decreased surgery numbers. Now that Dr. Rosser has his equipment, he has 67 cases backlogged relating to advanced heartburn treatment. He is also starting to do more surgical procedures."

Arias said: "When Dr. Rosser is on call, he doesn't say I'll see you tomorrow. He will come in on whatever case and do the procedure right away."

Stokes said he was recently on a call about the successor to the safety net care pool. "Of course, I got the data 15 minutes before the call. It was clear to me on the call that the large hospitals had access to the data before we do. I put in a request to the Hospital Association and the Rural Hospital Group to create a program for the smaller hospitals. We need to understand where the data comes from, so I can validate what the state says we did. We want to make sure our internal processes will maximize the data. When I look at the larger hospitals, I see they were working the S-10 forms. At the smaller hospital, there was not a lot of emphasis placed on the forms. That's a big disadvantage to the smaller ones. I fully expect them to weave in the data. Southwest Consulting is helping us build the S-10 form for fiscal year 2019. We are concentrating on getting the form correct, so it will be accurate when we file the report. We are already doing things better than we were."

"How do we characterize charity care?" he posed the question. "We got it out of bad debt and into charity care. We are working charity cases with active policy changes. We have to pull costs out of the organization, and we will continue our efforts to enhance revenue collection."

Marshall thanked Stokes for "answering most of my notes. But it seems like we are losing about $45,000 a day."

"October is looking better," Stokes said.

Marshall asked when working denials would get better.

"It's hard to say when," Stokes said. "Last year was building the foundation. When we get the system running for authorization, it will make a difference from Day 1. For instance, when a nurse starts an infusion, we need the start and end times. Both have to be recorded. This is getting into the weeds, but not having both times turns a $200 reimbursement into a $14 reimbursement. We also have a lot of documentation issues in the Emergency Department. We are looking at a bolt-on system to Meditech, called a T-system. We get the documentation, how it will get billed, and it will give us a consistent billing level. We will see changes in the distribution of charging levels as a result of the system. What about the coder? The system will automate the documentation and the other side of billing. The coders will be able to sample and won't have to deal with every document. We are trying to identify process that can make the hospital more efficient in removing costs and enhancing revenue."

On the issue of cancelled cases, "I asked myself why someone would cancel a case. The impact of cancelled cases is about half a million dollars a year. We have staff dedicated to the case; supplies have been opened, so a bunch of money has been incurred. There are lots of opportunities to improve."

Nwachuku said sometimes in cancer cases, patients don't show up. "We try to call and reschedule the surgery. We do that all the time. It would be nice to have a mechanism to reach out to reschedule."

Stokes said they had a recent incident where a patient came in for a procedure. "Certain things have to be done before the procedure. If we knew on Wednesday, for instance for a Friday procedure, that the prior work had not been done, we could fix it. I'm suggesting to staff that they determine three days in advance of the procedure whether the prior work has been completed. If not, call them and ask the patient to get them done and reschedule. Can you imagine coming in for a procedure and being told to go home? That's not good customer service. 99 percent of the time, we do a good job."

Marshall said he appreciated the depth Stokes went into. "At what point, and in how many months, do we quit seeing red?"

"It's all driven on volumes," Stokes said. "We are looking at a lot of projects. When we started the turnaround, there were not one or two things, there were 30 or 40, maybe a hundred. When we work on labor productivity systems, it can be 90 days before we can implement them. We have to learn how to live on the volume we run through the hospital without the safety net care pool. That's the cream on top. I can't give you an exact date. We can get into the weeds if you want to come talk to me. There are decisions coming that are not going to be popular, but we will not have a layoff or reduction in force."

Arias confirmed that layoffs and RIFs are "the last thing we want to do. We will work and refine the system. This has been a real journey. It's uncomfortable, but we know the outcome will be worth it. We will try multiple things, ones that we can vet. Health care has to be purposed to withstand the downs. If we have 19 patients and 650 people to take care of them, we have to realign people where they belong."

Marshall said there was a lot of discussion in the human resources meeting the prior day about how it seemed every position hired took the hospital to a greater loss, and everyone not replaced makes the numbers smaller. "Rose has done good work getting the nursing level down to a more appropriate level. The County Commission and the community are tired of seeing brackets around the numbers. We need to set a goal, for instance, on the clinic in Deming. We may not have the cash to carry it for a year. We have to be cautious and make sure we are serving a gap that needs to be filled. I see positive numbers coming out of the business office. If they get collected before 90 days, that's good. I'm uncomfortable with where we're at, but I appreciate the work you are doing. Rose using national standards is very good."

Wilmot said he was distressed by "today's numbers. It's the unknowns that you expected were done. You thought the foundations were there, but then there are the unknowns of someone's desk drawer."

Nwachuku presented the Chief of Staff report in Dr. Brian Robinson's absence. "There was a dictation service change recently. The medical staff was very concerned how it was working out, and if there was an option to call."

Stokes said the new service has gone live.

Nwachuku said Dr. Michelle Diaz had complaints about microbiology tests taking too long.

"I talked to Dr. Capek about the micro work," Stokes said. "He said if it's drawn today, it takes 24 hours to get it back."

Nwachuku agreed that it should take 24-48 hours, "but it's not." He said with the new dictation system there were more problems now that it was a backend system. "We are still recruiting for microbiology techs, but there are no candidates. It will cost us $200,000 to get a couple of travelers in. Is it worth spending that much? I need Dr. Capek to talk to Robinson or Assistant Chief of Staff Dr. Colicia Meyerowitz. If there's an infection, it's nice to know which bacteria it is."

Moreno said it needed to be determined if the delay was rare or consistent.

Nwachuku said the CRNA delineation privileges policy needs approval.

In committee reports, the executive committee met and approved agendas.

The Quality Improvement Committee spent time talking about risk management, according to Carroccio. "(Trustee) Jeannie (Miller) and I will meet. We will try to turn it around quickly. Once we have the review done, we need a way to expedite it. If we can get it approved by November, or January, if necessary, it would be good."

The Finance Committee met and had considerable discussion about numbers, according to committee chairman Schram.

He asked for approval of a three-month extension to a contract, as well as a policies and procedures approval.

"Why are we just extending the contract?" Wilmot asked.

Arias replied: "We are looking at a contract with Morrison on food. It will present two different charges and we will decide which is better."

Schram said there was a summary of the contract changes for policies and procedures in the packet.

"What did it look like before the changes?" Moreno asked.

Carroccio said the limits were the same. The contract policy added steps "to match our actual process. Do you think we should table this approval?"

Moreno asked why the board wasn't approving physician contracts. Carroccio said the board had delegated the authority to the C-team.

Nwachuku said that was part of the process that changed.

Moreno asked to see the old approval chart.

"We are trying to streamline the process," Nwachuku said.

It was moved and approved to table the item to the next meeting.

Trujillo clarified that the board members would still see and review the contracts. "If we don't have trust in the CEO to approve them, we have a big problem. But it is incumbent on us to know about the contracts."

Wilmot reported the Plant and Facility Committee did not meet in October but would meet in November. "It will be an issues-focused meeting. We will hold meetings as needed, but at a minimum quarterly."

Marshall gave the Human Resources Committee report. "We had a lengthy discussion on the employee survey. It is closed and the administration is going through it. There was discussion on the confidentiality being assured. Having the employee put their employee number on it gives the perception that it is not confidential. We expect to see the number of job postings drop."

Nwachuku said the Bylaws Committee did not meet.

The board went into the second executive session of the day.