By Mary Alice Murphy

After coming back from executive session during the Gila Regional Medical Center Governing Board Chair Alicia Edwards, who is also Grant County District 3 commissioner and Commission vice chair, noted that the members in the executive session discussed only those items that were previously noticed at the end of the prior part of the meeting and that no action was taken.

To view the first part of the meeting, check this link: https://www.grantcountybeat.com/news/news-articles/59833-grmc-governing-board-met-to-address-agenda-082720-part-1

Interim Chief Executive Officer Scott Landrum gave the CEO report. "We have our new financials, which you have seen, and we will report on later. We're working on the productivity piece and we're getting the kinks out over three payrolls. We are still waiting for the critical access billing numbers and will forward them to our payment intermediary Novitas, then we'll have to pay back and rebill some items. We have been notified that the virtual survey for the rural health clinic designation will be the week of Sept. 8, and we're expecting the virtual survey for the Level 4 Trauma to take place on Sept. 14. Our swing beds will be available as soon as we get the critical access billing numbers. We are in the process of opening the observation unit. We are very happy to be working with Ms. Lucero. We have been working with ESS, our hospitalist provider, on an amendment to extend the contract while we decide what we're going to do with the hospitalist and ER contracts. Our IT will be leased. We are running the latest MediTech and had the latest patch on it, which is basically an update. We are not planning to go to their cloud-based system, called Expanse, but will be changing out some servers, also lease based. We have communicated with our physician recruiter and are doing urology and ENT recruitment. We are in the process of changing our GPO (group purchasing organization) from HRG to Vizient. We need to go to centralized scheduling for radiology, laboratory, rehab, etc. It's a few people in a room in front of computers punching in the appointments. We are going toward that. I wish it was a simple as flipping a switch. We realize that are scheduling issues in radiology. We're working on that. We hit, shall we call it an iceberg, earlier this week when we were trying get MRs scheduled, but couldn't get hold of the physician to get orders. On our end, we're going to be taking it a step further by going to the insurance company because we've had some artificial barriers in place, and that's probably the same issue with labs, etc. Our AP (accounts payable) continues on a 30-day basis. We will be monitoring that closely because there will be some cash needs during the transition in billing from PPO (preferred provider organization) to critical access from a PPS (prospective payment system) facility to a critical access hospital."

Governing Board Member and District 5 Commissioner Harry Browne asked if the scheduling changes would address the concerns heard in public input.

"Yes, sir," Landrum replied. "I have communicated with that physician at least twice and by email about the issue. I think it was also discussed in a medical executive committee the last time I was there that we were looking at some reform there."

Browne said he has heard the same concerns about scheduling from another physician at that practice probably for 10 years.

Landrum said he believes it has been a long-term problem and with the resources from HealthTech that will "help us get past the barriers the hospital has had in the past."

Interim Chief Nursing Officer Kelly Rodriguez said her report was in the packet received by the governing board members, and she highlighted a few items.

"Recruitment of a permanent Emergency Room director has been successful," Rodriguez said. "Payton Hare, R.N. will start on Sept. 14. This position has been vacant since October 2018 and we've had various interims in that time. I am very excited to work with Payton, as is Dr. (Steve) Kotch, our emergency department medical director. I will also begin discussions with our interim MATCH (Maternal and Child Department) director, who has been in place since last November, with the position being vacant since June 2019, to see where her position is on becoming the permanent MATCH director. Our surgical services department is being heavily reviewed by our new Operating Room Director Jeff Rushing as it relates to needed equipment. We've been able to move some things through in the way of equipment for our surgeons and our patients. Our clinical competency program through our clinical education department and with our clinical educator Angie Cox continues throughout the year. It is proving to be effective. We are seeing great changes in our staff clinical skill set. I'm extremely happy about that. I'm also working with Robin Stewart, one of our registered nurses on the floor, to get our nursing peer review committee reestablished. Our go live for nursing peer review will be on Oct. 5. We will be awarding our very first Daisy Award recipient at Gila Regional in October. Our nominations will conclude Sept. 1 and we will take those nominations to determine who we will be awarding in October. It's an international award for extraordinary nurses. It homes in on the skillful and passionate care that nurses provide every day. For our medication reconciliation project, we have seen sort of a competitive spirit when we talk about process improvement and patient safety. When we provide information to the nurses, they jump right on things. In July we were seeing only 56 percent completing their medication reconciliation, however, to this date in August, we've gotten to 76 percent completion. Just educating the nurses on why these key components are important is huge. Our observation units are about 50 percent complete, with flooring, blinds and IT drops will be coming in in the next couple of weeks. Medication overrides is a project that I started last year, and it sort of fell off with the change in administration. We began working on medication overrides again in April and I'm happy to report that the national standard is no more than 3 percent, and Gila Regional stands at 2.5 percent, so this is a huge safety mechanism that's in place so we do not give the wrong medication to the wrong patient. We are using the systems in place, including the MAR (medication administration record) and the scanning system so we are not putting patients at potential harm. Additionally, we continue to be ready for our Joint Commission survey, and also, we are due for a Cleo survey for our bedside glucose monitoring as well as our moderate complexity lab for cardio-pulmonary ABGs (arterial blood gases). We are patiently waiting for those things to happen. Some things that will happen in the near future are a virtual Level 4 trauma center survey starting on Sept. 14, and then we will wait on the onsite survey as well. The Baby Friendly Survey will hopefully be in October. I also think that will be virtual. This is based on the department and this is a re-designation year for us. It is primarily a lot of policy revision process."

Edwards said she has heard from more than one person that the current MATCH director is the best one the hospital has had in a while. She also said she presumed the hospital will hold a celebration for the Daisy Award and that the governing board is in support and would like to be invited.

Rodriguez said: "We are trying to figure out how to celebrate. We've decided we will make it yearly in October, and it's still fairly warm the first part of October, so we hope to be able to do it in the courtyard, where people can socially distance."

Interim Chief Financial Officer Richard Alesch presented a brief financial report. "Our operating revenues were higher in July than in June primarily because of increased outpatient surgery volumes. Our operating expenses were higher, primarily because of previous expenses that had not been booked. We had a loss in operations of $2 million, although we anticipate future improvements in our operations, due to an increase of 5 percent that was implemented the first of August. In addition to that, we have a new general surgeon on staff, Dr. Laurence Gibson, and we anticipate productivity improvements going forward. Our cash balance went from $12 million to $11 million in July. We continue to see volume increases in our family practice clinic, as well as in our specialty care clinic. Things are improving there. As Scott mentioned, we are going to have a cash shortfall, once Medicare starts taking back their cash from the PPS billing and we can't bill under critical access until they take their payments back. So, we'll have to watch our cash and probably extend accounts payable aging beyond the 30 days for a couple of months probably."

Browne said questioningly: "You don't anticipate problems with that for a couple of months."

"We'll have to watch our cash," Alesch said. "We expect to extend some of our payables. We will have to monitor it on a daily basis."

Edwards said she liked hearing that "improving" word.

Dr. Brian Robinson's Chief of Staff report was presented by Landrum. "Under the heading of the Medical Executive Committee, there were no new reports. Under the Credentialing Committee, the credentialing report and red flag report were available for executive session. Under the Peer Review Committee, they are focusing on enhancing practitioner quality and addressing system issues. The Bylaws Committee has not met and neither has the CME (continuing medical education) Committee. Under the heading medicine, perinatal and surgery departments they have not met since the last board meeting. And that concludes Dr. Robinson's report."

Edwards asked if the committees didn't meet on a regular basis.

"They do meet on a regular basis," Landrum said. "Covid has had an impact. Since I've been here, I've attended a surgery ad hoc meeting this morning; I've attended a medical executive committee and two peer review meetings. Sometimes, they don't meet because there is no new business to discuss."

Todhunter presented the HealthTechS3 report. "I have a few things to report. I think we're very fortunate to have someone with Priscilla's expertise (Priscilla Lucero, Southwest New Mexico Council of Governments executive director, who presented earlier in the meeting) on board. I expect she will help us quite a bit. As you talked about the (ICIP – infrastructure capital improvement plan) list and the order, Kelly and Scott have already been looking into the labor and delivery plan. We have a concern about the number and the age of the plan. We will dig into it and try to come up with a better number for the governing board. I have some concern about the staging issue. I don't want to get some funding and not have something functional. We will bear down on that. I wanted to follow up on the swing beds. That will be meaningful for this hospital. It will help people who need care, but not hospital care to stay in our environment. It will allow the patient to stay here, the family to stay in the community. It will also allow patients who may have received care elsewhere to come back to Gila Regional, and we can meet their needs here. On the financial side of that, for the average case for our hospital we will normally see revenue of $25,000-$27,000 per swing bed. So, you can see the impact it will have on our hospital. It should be a very positive thing for our patients going forward. We have a first cut on our productivity numbers. We are having some challenges getting the right numbers and statistics, so we're working on that. Hopefully, by next month we'll have a better feel about how accurate the numbers are."

"Julie Haynes of our staff is working on market share development," Todhunter continued. "What that means is the demographics of the organization, the break down by age, location and then look at the actual market share that Gila Regional actually receives by service line. It's so we can begin to figure out where there is out-migration to other areas and what we can do to bring that service here and enhance that service to begin to maintain those patients here. It's part of the SWOT (strengths, weaknesses, opportunities and threats) analysis we will present in September. We're lining up someone to come in from HealthTech to work with your supply chain person, so we can do that transition effectively. Carolyn St. Charles, who was here quite a bit in June with Kelly, I will try to get her back in September to review the productivity. Hopefully if there are any changes, it will be through attrition. On the radiology issue, Scott and I met with Dr. Robinson. Our radiology group is retiring in the fall, so we are in the process of replacing those radiologists and evaluating what direction we will go. When I asked Dr. Robinson about registration, blocks, not enough time, he said: 'Yeah, it's all of the above.' We are trying to get all of that resolved. Lastly, I wanted to mention that Scott and I met with Dan Otero (chief executive officer) of HMS (Hidalgo Medical Services). We had about an hour meeting that was very productive. We think there are some real opportunities with partnering with them on radiology, labs, and we spent a fair amount of time talking about behavioral health. We don't know what the model is, but we think there is a model out there that we can work with Dan, his group and the hospital to come back to you with a proposal. Scott, Dan and I were optimistic that we can put together a meaningful program for behavioral health."

Edwards thanked Todhunter and Landrum for meeting with HMS and addressing the behavioral health issue.

Governing Board Member and District 4 Commissioner Billy Billings noted that Otero had presented to the commission, maybe a couple of years ago, ideas about how GRMC and HMS could partner to the benefit of both organizations. He also asked about radiology.

Todhunter said one of the groups they are looking at to provide radiology is a group that HMS uses. "The things that HMS doesn't do, we could potentially arrange with a contractual agreement with Gila Regional to provide those services, as well as some of the laboratory aspects. There are some opportunities there to perhaps keep them in our hospital."

Governing Board Member and District 1 Commissioner and Commission Chairman Chris Ponce said he had no question, but just a comment. "I like the direction Gila Regional is heading. I think a lot of things are long overdue. And I thank you for partnering with HMS and the schools."

"Our goal is to make the hospital as strong as possible in the community," Todhunter replied.

With no old business, the governing board members went into the new business.

The first item was an amendment to a contract with ESS Hospitalists LLC, which provides hospitalists to Gila Regional to extend for one year.

Landrum said they kind of walked into a situation. "In this hospital, ESS and emergency room providers actually work pretty well together. There may be once in a while a little strife, but not a lot. I've seen other places where there is a lot of strife, but not here. In the interest of looking at saving money and still providing quality care, one of the things that we are looking at is both of these contracts going forward. Until we have time to evaluate them, we are asking for the extension and I believe they have agreed to do that."

The one-year contract extension was approved.

Item A under resolutions was the capital outlay request for the roof replacement. Edwards said it was the paperwork necessary to move forward with getting the money for roof replacement.

Landrum said: "The only change we made was to add the word Center in Medical Center."

The motion authorized Landrum to move forward. It was seconded and approved.

The next item addressed using CARES Act funding for roof replacement, with the addition of "and HVAC" to the application to the Economic Development Administration. The resolution was approved.

The third item was adoption of the ICIP. Landrum said the first part has no changes, but the second part is what the board had a considerable amount of discussion on earlier in the meeting. "I think that's where Priscilla will get us an extension. I think we should go ahead and approve the resolution. We can work on getting the items correct and in the correct order. I would just like to add that I talked to Kelly on the phone last night, and she found all the documentation on labor and delivery yesterday. We are way far along on the labor and delivery project. We are making phone calls right now to get the waiver on the square footage. Could she say just a few words about what she found?"

Rodriguez said the estimate from early 2017 was when the hospital wanted to do a complete reconstruction of the labor and delivery section. "That had since been abandoned. A letter was sent to the Department of Health in December 2018 to move from what we have in our current area of 168 square-feet to our medical-surgical unit that is not being utilized at this time, which would actually give us 246 square-feet for a mom and her baby. The letter of intent was accepted in February 2019. I reached out last year and contacted a fellow at the Department of Health and he explained that I would have to provide our current plans in our grandfathered space and what we proposed to move into. That's about the time our previous CNO took over and took the project down her path. I cannot find documentation of her plans, but I can reach back out to Mr. Rodriguez at the state Department of Health and if we can just provide the old plans and what we plan on doing. What I can see of merging labor and delivery into the med-surg unit is that we would need to look at our infant security system and our nurse call system. That's what we need upgrades to. Other than that, it's cosmetic items of patching and painting walls. Each one of the rooms where we want to move L and D to already have piped in oxygen, suction and have windows and a private bathroom. Those are important things to have when you're having a baby. I'm hoping those minor things will cost nowhere near $4 million. It's getting acclimated back with the Department of Health to see if those are our next steps."

Browne said he would like to see it on the ICIP for 2022. "Do you have any sense of how much it will cost?"

Rodriguez said for the infant security systems, they are upwards of $130,000. "So that's one piece of this plan. I cannot tell you how much the nurse call system would cost. I will have to walk around with the plant and facilities director to see what painting and such would cost. The highest costs will be the infant security and nurse call system, the rest are minor details." She said she hoped she could get a quote fairly quickly from the biomed gentleman at the hospital. "I already have the quotes for the infant security and then it would just be a walk through."

"So potentially we could get this before the deadline?" Billings asked. And Rodriguez agreed.

"When Priscilla said the delegation is looking for a shovel-ready project, this seems shovel-ready," Landrum said.

Rodriguez agreed. She noted that the unit where they plan to move the labor and delivery already has the post-partum and the nursery on the unit. "They are already there. All of the staff would be together instead of having to staff two locations, which is a huge help. The infant security system is already there, but it is end of life. In fact, it is one of the pieces of medical equipment in that medical equipment line item on the ICIP, as well. The nurse call system has to be ready to go, so a patient can call for her nurse."

Ponce said he is looking at a resolution that needs to be voted on, "but when I look at the ICIP, I don't have the numbers or details to justify passing the resolution."

Rodriguez said she worked with Jennifer Klotz to get a breakdown on the items of medical equipment and their estimates. "For me, infant security was top of the list. Then there are rolling computers for the nurses, urine monitoring equipment and fetal health monitoring."

Landrum said he anticipated having the estimates for the HVAC equipment by Monday. "Maybe on Sept. 8 or 9, if Priscilla gets the extension, we can re-order the ICIP items and vote on it."

Ponce said Lucero seemed pretty sure she could get the extension.

Browne suggested a special meeting as part of their already scheduled executive session at 4:30 on Sept. 8.

Edwards asked if Rodriguez had been in communication with the physicians involved in OB/GYN practices.

"Yes, in the previous plan, we met with Dr. (Michelle) Diaz and Dr. (Victor) Nwachuku, and they wanted windows and bathrooms," Rodriguez said. "The staff wanted more space, and they were the ones who decided what the unit would look like. I'm also closely working with the facilities director and biomed person. All the department are involved, including finance."

Browne moved to table the motion, and tasked administrative assistant JoAnn Holguin with making sure the extension is granted. "And if there is trouble getting the extension, then we can have a meeting on Thursday, Sept. 3, the day before the deadline."

On item 3, Governing Board Member and District 2 Commissioner Javier "Harvey" Salas asked that the lease proposal for IT hardware also be moved to the special meeting.

Alesch addressed Item 4, an audit engagement letter to Dingus/ZareCor and Associates for the annual hospital audit. "I believe this is the last year for this audit firm." He asked for authorization to have Landrum and Edwards sign for the audit.

Edwards said she had questions. "It says that audits do not include CMS abuse. What that says to me is that auditors are not responsible for assuring that billing is done properly."

Landrum said the hospital has internal auditors that look at how billing is done for risk compliance. Auditors that do the external audit only audit on what they can see. "We are responsible for a lot of it."

Todhunter said he believes the hospital needs to find an external auditor to do a compliance audit. "That would give us assurance. In regards to the cost report, that is done by a third party. Management reports to the board."

Edwards suggested that administration bring a previous cost report to the board, probably in executive session.

"We will probably do a cost report internally as part of the transition to critical access," Todhunter replied.

Edwards asked if action would be required by the board for a compliance risk report.

"It is already on our action list," Todhunter said. "We will come back with quotes for how much it will cost. We will bring the cost report to you with the past costs. It's always an auditing firm that does the cost report. Not too many hospitals are doing the critical access transition right now. I'm not aware of past cost reports, but it's not that critical. Usually the biggest issue is whether there is a contract. We will do an educational presentation on compliance."

Edwards asked for clarification on the cost of the audit. "It will cost $40,000 for the general audit and an extra $7,500 to audit the spending of the CARES Act funding."

Landrum said: "That is very much in the ballpark of audits."

The medical staff credentialing report was approved as presented.

The governing board adjourned.

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