By Mary Alice Murphy
On July 30, 2020, the Gila Regional Medical Center Governing Board, composed of Grant County Commissioners, held the monthly meeting to hear from administrators about the current state of the hospital. Some changes in the administration were presented at the meeting.
At the beginning of the meeting, Board Chair Alicia Edwards explained that County Manager Charlene Webb was on a call with the state on how the CARES Act can help local entities. "It's an important call and she will join us when she can."
Edwards introduced the new Interim Chief Executive Officer Scott Landrum. "I'm happy to be here," Landrum said. "HealthTechS3 moved me here from a Montana site. You have a very vibrant facility here. I hope to continue with the fine work that has already been accomplished."
The next introduction was of Dick Alesch, interim chief financial officer, from the Atlanta area. " I also have two daughters in health care, and my wife is a schoolteacher. I'm glad to be here. Looking forward to working with everybody."
Edwards also acknowledged that Mike Lieb, vice president of interim services, and Neil Todhunter, president of HealthTechS3, were in attendance.
She also thanked Scott Manis, interim CEO who has been in town since May and was attending his last meeting. "Thank you for being here. You've done a great job of getting us stood up in the past three months. We appreciate all your effort, time, energy, and hard work in getting some things done. We really appreciate it."
Manis acknowledged with a "Thank you."
Board member Harry Browne said it was well said. Board member Billy Billings also said Thank you to Manis, as did board member Chris Ponce. Board member Javier "Harvey" Salas thanked Manis "for steering the bullet away from us because it was a very scary time. I'm glad we had you there."
They then went into a brief executive session.
After approving minutes from the last meeting, Manis began his report. He thanked the commissioners, the hospital staff, doctors and nurses and the community "for the warm welcome to me over these past three months. It has been a real pleasure for me to serve. The staff and the providers have been tremendously responsive to the momentum we have built up."
"I want to give a brief COVID update," Manis continued. "We continue under restricted and limited access within state regulations, but we have partially opened visitation, which is going well. We now have some Remdesivir on hand to give patients that need it. We have recently reached out to Silver Schools and Western New Mexico University to determine how we can serve as a community resource with them as they reactivate their services. The training of nurses at Western is vital overall. They now know how to get in touch with us.
"The critical access transition is moving forward," Manis said. "We received our critical access hospital designation as of July 1. We are still waiting on the onsite visit from the Joint Commission. We don't know when that will happen, but we always have to be in a state of readiness anyway. We are still awaiting the provider number from Medicaid and Medicare. That's our next hurdle to overcome. We know where it is sitting, and we expect it to be awarded within the next 45 days or so. Then that will launch us into the financial transition components when we notify our managed care providers of our new provider number and new price points for our critical access patients. We are also continuing to pursue swing beds. We are recommending 10 swing beds for the hospital. We have an implementation plan underway with our target for readiness on Nov. 1, if not a bit sooner. There's a lot of documentation and policies, including training and education on what it means for the hospital. Denise Baird is leading this initiative. We thank her for what she's doing. We will also open a small observation unit of five beds. These will be outpatient beds for those waiting for tests or clearance and such that don't need admission to the hospital. (Interim Chief Nursing Officer) Kelly (Rodriguez) is leading that, and we hope to have them in place by mid-September."
He said the Rural Health Clinic application is completed and the clinic is awaiting the state survey, a virtual one, which will be the next step toward designation for the Family Health Clinic as a rural health clinic. The Trauma Level 4 designation application has been submitted to the state. "We have already been notified of receipt of a grant for $53,000 for the trauma services to support us in our pursuit of becoming a Level 4 Trauma Center for this fiscal year rather than the $7,000 or $8,000 we had been getting. We received $48,000 plus about $5,000 for high school education on trauma. We expect the survey in October. Following that survey completion, we will be designated as a Level 4 Trauma Center."
Manis also announced that Dr. Lawrence Gibson had come on as a new general surgeon. "He comes with a lot of experience from Illinois and is a very engaging gentleman, and I know he will be a great fit for the community. With that I have no further announcements."
Browne thanked Manis for his reports and work at the hospital and wished him good luck in Dallas, where he is evidently headed next.
Interim Chief Nursing Officer Kelly Rodriguez highlighted the actions being done as a result of the critical access designation. "We are looking every day at the population and the volumes to make sure we are moving them through the facility with the utmost safety and quality in mind. As Scott (Manis) spoke to, we are beginning the process on an observation unit. This will benefit our inpatient unit. We are also working with Denise Baird on the swing bed unit for our patients who need rehabilitation longer than our 96-hour stay. We are looking at many of our documentation pieces that directly reflect nursing and so that our revenue capture reflects it to make sure it's there in the documentation rather than a separate charge sheet. We are working on bedside procedures at this point. I want to talk a little bit about our hospital through-put program. With the new critical access designation, we are setting new benchmarks, looking at our procedures now, whether it be getting a new patient up from the emergency room or emergency room visits itself. I'm looking with a team of people from admissions to our quality department to our inpatient units on new benchmarks there. I want to recognize two of my staff members Gwen Burns and Max (name inaudible). They both can work anywhere in the hospital as nurses. They are very agile. They can come in when needed and can float through almost every department in the hospital. That much dedication is valued in our organization."
The next item was the CFO report from Alesch. He noted that discharges were down in June compared to last June. "Some of that is due to the closing of the BHU (behavioral health unit), which averaged about 30 discharges a month. Other volumes are coming back, with elective surgeries going up. Cash collections are up from the previous two months. Net operating income approximated the budget. Net operating costs were a bit higher, particularly with the increased supplies costs. We have cash available of $12 million, but we are awaiting the letter forgiving the PPP (Payment Protection Program) loan. We are estimating that about $5 million (from the PPP) that we will put into income."
Manis presented the Chief of Staff report for Dr. Brian Robinson, as he had patients to see. Robinson had reported that medical staff meetings continue, even though most are virtual. "I appreciate their resiliency and their commitment to being part of these meetings. At the Medical Executive Committee meeting they unanimously approved a letter to support the Level 4 Trauma designation. They also re-appointed Dr. Michelle Diaz to the Peer Review Committee. I had a meeting with Dr. Robinson and the general surgeons to talk about the implications of a Level 4 Trauma designation and they were very supportive. They and the Emergency Department physicians will be most impacted by it."
He noted the Peer Review Committee was working at increasing efficiency, while remaining effective, and other committees are also meeting. At the medicine committee meeting, they talked about medications and Remdesivir and how best to utilize it.
The HealthTechS3 report was next. Lieb said since the agreement between the hospital and HTS3 had been put in place, the management team has been working hard. "They have put in an enormous amount of effort. Critical access will be a huge part of success in the hospital, as will the rural health clinic designation for the Family Medicine Clinic. We've had team members here for the past two months. The response of the staff to what we've been doing is quite positive. We are working on a broad productivity tool kit to right-size the organization making sure we have the correct skill set, the right number of people on staff for the volumes you serve."
He said they were trying to capture Medicaid collections to get more revenue from those "you've been serving but have been unable to collect for. The telepsychiatry has been implemented and we are looking at supply chain pieces. You'll be seeing financial templates, which will be easy to follow and will have benchmarks comparing to other hospitals we touch all over the place. We are doing a coding review across the institution. We've been fortunate to have had Manis in place as the interim CEO and are excited to work with Scott Landrum. We have kicked off a search for a permanent CEO and a permanent CFO. Peter Goodspeed, our executive recruiter, will be working on that. We want to make sure that Gila Regional can stand on its own feet for the long haul, so heavy focus is on the cash flow. We have identified about $12 million in improvements and critical access is half of that. We have a large number of initiatives underway. As part of the process, we've been looking at the overall staffing numbers and getting it to the right configuration. There have been reductions in work hours and there have been pretty significant resignations and attritions since June 1. They are not being refilled at this point. We have a planned reduction in force coming up."
[Editor's Note: See hospital news release posted Monday, Aug. 3— https://www.grantcountybeat.com/news/news-articles/59385-grmc-announces-organizational-changes ]
Lieb continued to say that they are offloading contract employees, including travelers not being renewed. "We are trying to maintain the hometown permanent staff. And we plan to add back about 20 positions or realign some. About 32 positions, including passport nurses, are going away, but we are adding where we need to and putting them in the right buckets. We look forward to streamlining the operation."
Browne asked if the searches for CEO and CFO would run simultaneously.
Lieb said they would likely look for a CFO first, because they may be easier to find.
Browne asked if it shouldn’t be the CEO first and then let that position pick its CFO.
"During a transition, difficult decisions need to be made and sometimes it's easier for the interim CEOs to work with the CFO, and the new CEO can come in kind of untarnished," Lieb said. "Ideally you would like the permanent CEO to pick his or her own team, but you could change either later, and if they happen at the same time, that's batter, but we are starting the searches right away."
Browne asked how heavily department heads had been involved in the right-sizing.
Lieb said they had been heavily involved with HTS3 team members, Carolyn St. Charles and John Freeman, both in face-to-face and telephone calls. Rodriguez has participated in many of them. "Many of the recommendations for right-sizing came from within the departments themselves. The approach is to treat each department as its own business. Do you have the right folks you need? And when you ask, they say, OK, we could probably do it this way. Our process is to codify that and give them a way to measure against going forward."
Todhunter had a follow up on staffing. "Once we have it in place, we can always come back and readdress it. It's not unusual. We're still trying to reach benchmarks tied to the national industry. I just want to say a bunch of thank yous—to Scott Manis particularly. He has done a lot of heavy lifting. He's been a real treasure for us to work with. I want to extend a huge thank you to him. And I also want to thank the commissioners. You have put in a ton of time, stepping in as the hospital board. We have identified a number of things in the two months, three months with Scott working here, and that's not done. Now comes the implementation phase moving forward. With Scott Landrum here, we will be pushing forward to get them done now that we have identified them. I want to thank Kelly and Denise on the observation and swing beds. They are vital for critical access to work. The typical revenue from the swing beds is about $25,000 per patient, so that's very positive going forward. Observation allows the flexibility for critical access patients. Jennifer and Wanda in the business office have been putting in a lot of effort and Joann, as well, with pedal to the metal. I'm looking forward to good things going forward. We're still thinking six to seven months out we will see the light that we are heading in the right direction. We firmly believe we can get there. We will."
Salas asked when the timetable with the SWOT and the management plan.
Todhunter replied that some is happening now, but probably beginning September for the full plan. "We have to do a deeper dive on the coding and the revenue cycle and then the supply chain is a big component. We will present the SWOT to you, maybe toward the end of September, with your meeting dates."
Ponce said: "We want to thank you also for all the time you've put into this. We appreciate what you've done and staff coming to visit with us."
Todhunter said it goes both ways. "Kelly can pick up the phone and talk to Carolyn at any time. We want to be behind the scenes, but we want to head in the right way."
No old business.
New business had 10 action items.
The first was to give signing authority to Scott Landrum as the interim CEO, so banking can go on as needed. The appointment of Landrum is effective Aug. 1, but the signing authority was immediate upon approval of the board, which was accomplished.
The second item was the appointment and signing authority to the Interim CFO Alesch. That too was effective immediately after the board approved it.
Browne said in his experience, the CFO is not a signer due to the potential of malfeasance.
Manis noted that almost nothing is manual signing any longer but is all electronic signatures, with two signators, which is typical for hospitals today. Todhunter said it was common and always subject to audit.
Edwards said as she understood it, the signing could be done by the CEO and CFO up to $50,000 for a check. Anything over that has to be approved by the governing board.
It was approved.
The next item was appointment of the GRMC compliance officer. Manis said hospitals are required to have a compliance officer to initiate and maintain a corporate compliance program. The officer reports to the CEO and the governing board. "We recommend Angelina Peyton as compliance officer. She has a certification in risk management and has already identified training she can go to for this position. Some of the role is to be the point of contact for compliance issues. She will report at least annually to the governing board on the compliance plan and ongoing actions. It's not in any way a gotcha role but is vital for the checks and balances within the organization. Although the requirement is an annual report, she will be ramping up to report to you more often. The position will also determine training within the hospital and what a compliance plan looks like."
Salas said he would like frequent reports to the board. Ponce said he would like to meet people before they are approved.
Todhunter said they had talked about having her come to the board to talk about compliance. "The hospital probably needs a compliance audit by a legal professional, looking at policies and standards. We're done a fair bit, but we need it to continue."
Edwards said it seems like a powerful and important position. "If we are relying on this person, it seems like the reporting only to the CEO is a little odd. Yet, we're relying on this person to bring up compliance issues."
Todhunter said it is not unusual to have this position reporting to the CEO and also to the board.
Browne suggested that with inspectors general being dismissed by the person they are looking at for compliance, it might not be a bad idea to have the person not be able to be dismissed without knowledge of the board.
Todhunter said that could be considered. He noted that some contractual, payment relationships had been uncovered with no contract in place.
The appointment of the compliance officer was approved.
The following item addressed the licensure change of the hospital.
Manis said the hospital license is at present for 62 beds, but critical access allows 25 beds, so that license has to be changed. The 25 inpatient beds will include four beds for post-partum and gynecology, 13 med surg beds, six intensive care beds and two beds for Level 2 ICU newborns. "It's frankly the parameters we've been operating under for the past four or five months, but we need to change the license. We will also recommend the 10 swing beds incorporated in the 25-bed capacity, and then continue to keep the 10 psychiatric beds, which is actually 35, with 25 critical access and 10 psychiatric beds."
Edwards said and asked if the 10 swing beds are included in the 25 skilled nursing beds, "if we have four patients in the 13 beds as swing patients and something tragic happens and we have 15 people who need those med surg beds, what happens?"
Manis said: "We would evaluate our overall census. We currently can put overflow patients from med surg into ICU and we can use the med ICU bed as a med surg bed. We could also backflow into the post-partum-gyn area and can front-flow from post-partum into med surg. Even now, it's a dance for Kelly and her team. If we are at bed capacity, we might have to transfer but that is the last resort. We don't expect to get to the need for 10 swing beds and expect the census to be three or four. The state thinks 10 beds gives us enough flexibility."
Edwards said she wanted it made clear that the beds do not move around and the patient doesn't move around.
Manis said it is basically how the patient was admitted. Observation beds are outpatient, in a distinct area of the hospital. The criteria for a swing bed are that somebody was admitted and subsequently needs more rehabilitation services, so the person remains in the same bed, but is receiving more treatments or rehab as a swing bed. "They can do their rehab here or conceivably, they could have had surgery in Las Cruces, be discharged there and have the acute rehabilitation therapy here, admitted into one of the swing beds."
Tdohunter said things have relaxed under the Covid situation, with CMS (Centers for Medicare and Medicaid) allowing more than 25 beds to be utilized if needed.
The 25 beds and the 96-hour stays are averages. As Todhunter said: "It's a very flexible model."
The submission of the license change was approved.
The submission of the Level 4 Trauma designation application was also approved.
The next item considered the medical staff credentials board report.
Billings asked how involved management gets in credentialing.
Maris said he has attended every credentialing meeting. It would be expected for the medical services director, Brianna Romo, to attend them, also. She reports to the CEO. The Medical Executive Committee also reviews the credentialing. "There are a number of steps along the way."
The report was approved.
The next item was a review of the credentialing manual, which Manis said had been reviewed and nothing had changed dramatically, but "since the board approves credentialing personnel, I figured you should also approve the credentialing manual."
The board approved the manual.
The following item was the general surgery delineation of privileges, which is used by the medical services office and outlines the training, experience, and licensure of general surgeons. Manis said the delineation has changed with recommendations of the department of surgery to the credentialing committee and to the medical executive committee, all of which had approved the changes.
Browne asked about the cover letter, and Manis explained it would be attached to the surgeons' applications for surgical credentialing. "It is on the general application, tied to their truthfulness around their experience and of what they are trained to do."
The ninth item under consideration was the fiscal year 2020-21 hospital operating budget and resolution. Alesch noted that it needed to be approved for submission by the next day.
Browne said he looked forward to having a better understanding of it, because he didn't know where some of the things came from.
Alesch said things can be changed and built out, but approval was required. The board approved it.
The last item under Action Items was the fourth quarter report on the fiscal year 2019-20 budget, which was also due the following day. The board approved it.
Under contracts and summary, the first item was an agreement for the family practice residency program with Hidalgo Medical Services. Manis said he and Dan Otero, HMS CEO, have been working to renew the contract. "We support the residents throughout the hospital. They are rotating residencies up to four at a time. This is a three-year agreement to continue the service. We are happy to continue the relationship. HMS has already approved it."
Browne said he was really happy to see the continuation of the agreement but noted that the amount was higher than in previous years.
Manis said it is $10,000, with a possibility of up to $40,000 for the hospital. "The first year it is $10,000 but will increase in years two and three to $15,000. The residents work hand in hand with the emergency department. We have a very strong reciprocal relationship, and we want to continue to grow it."
The board approved the agreement.
The second agreement was an extension to the food service operating agreement, the fifth amendment with Morrison Management Specialists Inc. "I have had sufficient conversations with Morrison. It's a two-year renewal. I have worked with them to come to cost reductions of about $75,000."
Edwards noted the agreement was eliminating a cook and a chef. Manis said the group had already been reduced, partly due to census reduction, so the positions were no longer needed.
The board approved the renewal.
Manis discussed three professional services agreement for Dr. Ronald Dalton to continue as chief medical officer, to serve on-call specialty services in pediatrics and for pediatric services. "He is very valued at the hospital as the CMO, he serves on call in pediatrics, and specialty services up to now. Upon recommendation, we are breaking it up into three agreements—his compensation and hours having changed appreciably except he will serve fewer hours as chief medical officer. The hospital has agreed to pick up $5,000 of his liability insurance. The agreements are one year with the potential for two additional one-year extensions."
Edwards asked what the difference was between the chief medical officer and chief of staff.
"The chief of staff is elected by the medical staff and his responsibility is to advocate for the medical state and to be a conduit of recommendations for medical staff to the administration and the governing board," Manis said. "The chief medical officer is a contracted role and is a member of the administrative team. I asked him to take a look at medical staff for the Joint Commissioner survey. He also deals with behavior of staff. They speak medical better than I do."
The board approved all three agreements.
The sixth item was an agreement with Dr. Donald Stinar to serve as medical director for the special care unit (SCU). "You just approved it last month, but Dr. Stinar asked for some small changes in reimbursement, and it effectively reduces his hours."
The board approved the new agreement.
The seventh item was a renewal of a lease of the ambulance bay in Bayard. "We have a good relationship with Bayard, and we want to continue that relationship. This is a four-year renewal. We won't pay them $14,000. They will manage the bay and it has already been approved by Bayard."
Edwards said she appreciated Bayard stepping up to the plate.
The board approved the lease renewal.
The final item was consideration of an agreement/resolution to work with the Southwest New Mexico Council of Governments.
"Gila Regional has been a member for a number of years," Manis said. "Priscilla Lucero (SWNMCOG executive director) runs an amazing operation. It's only $400 a year and she has been very supportive of the hospital. We recommend approval."
The board approved it.
Edwards asked what is happening with the 340B program for the pharmacy. "It's all mud to me."
Manis said the 340B is a pharmaceutical program through the federal government for discounted costs for outpatient medications. "We've been participating, but part of our evaluation is how to maximize our participation. Also, we can collaborate with local pharmacies. There is more to come. I think we have not maximized the potential."
Edwards said she believes it is under threat by the president and congress.
Todhunter said the proposed changes appear to apply only to federal qualified health centers, such as HMS, and insulin.
"I think we need to work on the collaboration with local pharmacies," he said. "They can buy from us at a discounted rate and we each get a bit of profit. The pharmaceutical manufacturers don't like it and hospitals don't like it, so more remains to be seen. My understanding is the executive order is being evaluated."
Edwards said: "Our lower-income diabetics have not been impacted at this point."
Todhunter said such a change in plans would usually require a comment period and clarifications.
Billings said he wanted to also thank Scott Manis "and all of your work and you're being here and working hard. I welcome Scott Landrum and Dick Alesch. I quote Manis: 'The finances were terrible, and it was necessary and what we have to do.' I appreciated what the lieutenant governor said this morning. He was up to speed and acknowledged that we were doing what we had to do. Thanks to the whole Health TechS3 team. To Mike Lieb, I appreciated what he said about the quality of care being due to the staff. I'm glad Kelly and the others have someone to call. We were moving too slowly, but I appreciate your openness, and I want to assure the community and people who work with the hospital that I'm seeing a picture of accountability that we haven't seen before."
Salas said it seems like "our bold move has been vindicated. It seems like you care. I saw the resignation of Ed Wilmot from the board of trustees. I feel bad for us. I think it will be more difficult without the existing board members."
Ponce said he appreciated the hard work. "We have community members who want to go out-of-town for medical services. I want to tell them, please give our hospital a chance. If you still have concerns, reach out to the CFO, the CEO or us and we will try to address them. I think we're on the right path."
The meeting adjourned.