By Mary Alice Murphy
The Gila Regional Medical Center Governing Board met in its regular monthly meeting on Sept. 24, 2020. Members of the governing board are also Grant County commissioners. The board chair is Alicia Edwards, vice chair is Gerald "Billy" Billings and the other members are Chris Ponce, Javier "Harvey" Salas and Harry Browne.
Edwards said the hospital just had a CLIA (Clinical Laboratory Improvement Amendments) through the Joint Commission, and it had no findings, which she said was "amazing." She recognized those involved, including Rexine Sierra, Darla Allen, and Paula Donet, as well as Desirae Provencio, and Kelly Rodriguez, interim chief nursing officer.
She then recognized and invited Carolyn St. Charles to the podium, as the chief clinical officer for HealthTechS3, the company hired to manage the hospital.
"Her primary responsibility has been to ensure high clinical quality in HealthTech hospitals," Edwards said. "Carolyn has been doing evaluation work at the hospital since June. She is here today to give a presentation on credentialing and privileging."
"I will provide some basics and best practices for credentialing and privileging," St. Charles said. She showed a slide that had a list of webinars that HealthTech provides for those wanting to learn more about a subject. She said they are recorded for viewing when one can.
"Credentialing and privileging are different," St. Charles said. "Credentialing is the process of reviewing education, licenses and training to make sure a potential recruit has the minimum requirements for the job. Privileging is what procedures they can provide. The core responsibility for the governing board is that you have the legal authority to approve, limit or deny credentials or privileges. The members provide oversight to protect the patient and that there is a fair and consistent process. Negligent credentialing is not frequent, but it does happen."
The hospital can be found negligent if the hospital had a sound credentialing process but failed to follow it or it followed its credentialing process, but the process was inadequate.
She noted that for critical access hospitals, the Joint Commission has multiple regulatory credentialing criteria. The governing board will appoint individual practitioners with the advice of the medical staff. If the medical staff recommends why the requirements are not sufficient, the issue stops at the governing board. "It's not always easy. You're probably not doctors; you may not speak medical; and physicians can feel threatened."
The medical staff and the governing board have different roles and responsibilities. "Probably the most important is that the governing board provides oversight of the medical staff. The governing board makes sure the process is consistent and has integrity. The medical staff develops the credentialing process and ensures the privileges reflect the type of services provided and develops methods to evaluate the providers. And it makes recommendations to the governing board."
Every application should have 14 items, St. Charles said, plus two more that are recommended. "If a provider applies and you deny the application, it is reportable to the national practitioner database. The pre-application process is strongly recommended, as it can stop the process early if red flags are found. It is not reportable in the pre-application process and you do have the pre-application process here. It's more of a conversation than an application."
She noted that the reappointment review covers some of the same elements as the initial application. The medical staff looks at continuing education, sufficient volumes, certifications, and the like. Because the hospital now has some history with the provider some red flags can prevent reappointment. "I always recommend that a profile for each provider be given to the governing board. There is a form for volumes, a form for certification and training, a form for peer review outcomes and a form for performance criteria categories. It is important that performance criteria are uniform for everyone in a specialty. You always have a chief of staff review that looks at the provider profile. For the governing board, it's important to review every profile to see if it's complete. If you see red flags, you can always send it back to medical staff with questions."
St. Charles urged the board members not to simply rubber stamp the recommendations. "This is all similar for telemedicine provers and mid-level skilled practitioners. Denial is negotiable."
She noted the Joint Commission requires FPPE (focused professional practice evaluation) and OPPE (ongoing professional practice evaluation). FPPE requires a period of review when privileges are first granted or when issues with performance are identified. OPPE is ongoing for each provider based in indications developed by medical staff. She said Gila Regional collects and reviews OPPE data every six months.
St. Charles said the governing board must not abdicate its duties.
Salas asked if they would receive a packet. St. Charles said it is available on the portal and should be reviewed prior to an applicant being approved, either for the first time or for reappointment.
Edwards asked if a paper packet could be provided for executive sessions.
Executive Assistant JoAnn Holguin said what each governing board receives is a summary. St. Charles said more information is available on the portal.
Interim Chief Executive Scott Landrum said paper could be provided, but it would be retrieved at the end of the session.
Browne asked for more information on how to get to that part of the portal, "because I've failed."
Salas said if they receive paper, then it's proof "we've looked at it."
St. Charles said because the information is confidential, any paper will be retrieved.
Edwards said she assumes that delegated credentialing means the telemedicine contractor did it.
St. Charles confirmed that the telemedicine provider can provide the credentialing information by doing the leg work, and the contractor can tell the hospital what privileges the person should have. "However, it still has to be available to the board to review so they can approve it. It does take the work away from the hospital."
Landrum said it is typical for all contracted groups to have done the work, but "we still have the responsibility to do our due diligence and assure the information is correct."
Edwards clarified some more. "So, we can assume that the telemedicine contractor has done its due diligence and Gila Regional has done its due diligence, and it's available for us to review so we can approve it."
No public input had been received. The governing board went into executive session.
When the board came out of executive session, having taken no action, it approved the consent agenda of several meetings.
Landrum gave the CEO report. "I'll be giving you an update on what's going on. We did receive our trauma survey and got a 1-year approval. After that we they will come back to survey us for a two-year approval, and after that, it should be renewed every three years. We are waiting for the paperwork, but this approval gives some extra money to the hospital. It is Trauma Level 4. The Joint Commission survey has been mentioned, and we did very well. I met with our practice manager yesterday (Sept. 23) and all of the preliminary part of the Rural Health Clinic designation has been sent. We expect the virtual meeting next week. HealthTech is still working on the SWOT (strengths, weaknesses, opportunities and threats). We are continuing to improve our financial reporting. Our productivity system is being working on. It's one of the things that Carolyn is doing. It is an Excel spreadsheet with benchmarks on it. Then we plug in the volumes and then each hospital has to custom tailor the benchmarks. That's what Carolyn is doing, meeting with the departments. We are getting it to be meaningful, so when we change something or open a new service, we can incorporate the information. We did another coding survey and we are digesting the data and moving forward."
Interim Chief Nursing Officer Kelly Rodriguez said that Diana Perea, the director of the Beginning Years program, reported a 70 percent return on the annual survey. It showed a 90% or above for services provided. "That is a huge piece for Beginning Years, especially during COVID restrictions when we've become 100 percent telephonic. Our home visitors have been very agile. We have 134 families in the Beginning Years program. The clinical competency schedule continues through the calendar year and is proving to be a great success. I commend Angie Cox, our clinical educator, for putting a new spin on things. This year, it was 'an essential line escape room.' It was so much fun. The nursing staff was so enthusiastic. It tests your clinic knowledge to come up with a way to get out of the room. I and my two cohorts were one of the fastest groups, I just have to say. Our nursing peer review committee headed by Robin Stewart is getting back on track. We finished up the policy related to Safe Harbor and we will be putting an application process for the peer review committee back into play. I'm really excited about our Daisy Award, being integrated into Gila Regional, so we can acknowledge our excellent nurses. We are also beginning to implement a 'good catch' program, based on our nurses' mitigation of errors based on their clinical knowledge. Last quarter, one of our directors got the award when she got a patient the care he needed. Our recipient this quarter is a brand-new nurse, Anna Leen, who did a phenomenal job catching a consent error and mitigating the issue. They get a wooden fish. We are revamping our code team, as well as our regulatory bodies. As Mr. Landrum said the trauma survey was excellent, with minimal things we have to correct within the next 90 days. Our trauma coordinator, Robert Berry, was commended highly by the surveyors. We have a lot of projects going on and they are going well."
She said the call-back program was going back to the drawing board, because finding time to make the calls was difficult. "We are working on it, so it can be successful. Last month I forgot to recognize the excellent nurses. Carmen Molina is the med surg charge nurse and she keeps the flow going. Also last month I wanted to recognize Clay Donovan, who has kept the ER moving for the past two years when we didn't have a director. This month, I want to recognize Diedre Truet, a CNA in the ER. She is a hustler. She is all over the ER taking care of things. And Denise McNutt in the OR keeps us in line with all the outtakes. A lot of our staff members take on extra duties."
The next report was from Interim Chief Financial Officer Richard Alesch. "Revenue for August was $14.8 million, which exceeded our budget by $870,000 due to an increase in outpatient surgery volumes, with $600,000 more than budgeted. The outpatient volumes made up more than 80 percent of our gross revenues. Our operating expenses were also up by $325,000, due to purchase and supply expenses due to the increased outpatient surgeries. Our inpatient level was about 8 patients a day, compared to July, with 11-12. We had about 35 ER visits a day. We had 281 surgeries, 33 percent more than budgeted. Our clinical visits continue to grow, at 36 percent higher than the previous month and 20 percent higher than last year. Our case mix exceeded the budget this year as well as last year. Our cash balance is $11.5 million, $600,000 more than last month."
Landrum presented the Chief of Staff report, as Dr. Brian Robinson was unable to attend. "The Medical Executive Committee is bringing forward nominations for Chief of Staff, Vice Chief of Staff and Secretary in November to be voted on at the December Medical General Staff meeting. The Credentials Committee board report and red flag report were discussed in executive session. The Peer Review Committee had no new reports. The Bylaws Committee will meet in October to review any changes that need to be made to the Medical Staff bylaws, rule and regulations. And the Continuing Medical Education Committee has not met and there haven't been any CMEs due to COVID. Under medicine, prenatal and surgery departments, there is no new report because they meet quarterly."
Browne asked who the current vice chief of staff is, and Landrum said it is Dr. Colicia Meyerowitz and the secretary is Dr. Norman Ratliff.
Browne said he asked because it made sense for the vice chief to move into the chief of staff position. Landrum said he has been discussing the issue. "It takes a lot of time for these committees. We have a very active medical staff, and sometimes, they say, OK, it's your turn to do this. I heard Dr. Robinson kind of waver this morning that he might do it again, but I've also heard him say it was time for someone else to do it."
The HealthTechS3 report was next. Landrum said that Neil Todhunter and Michael Lieb had left that morning.
St Charles said HeathTechS3 is facilitating and helping with the CEO and the CFO search, which is ongoing. "HealthTech also shared some market share data to the governing board. It will help as you move forward with your strategic plan. As Scott mentioned, I'm here to continue developing the productivity system. John Freeman and I will be back in two weeks to talk to the remaining departments. We are on track for the swing beds, which is skilled nursing care. My conversations with Denice Baird said we are on track for some time around the first week in November to start taking patients. The process, however, is you have to admit patients and then request a survey and only after the survey are you licensed for swing beds. I think the Joint Commission will be doing that."
"Can you retroactively bill for that service?" Browne asked.
St. Charles said she had heard that you couldn't rebill, but she wasn't sure.
Landrum said: "We will attempt to bill, but we have to do it right and legally."
With no old business, the board turned to new business, where several action items were addressed.
Although the item for medical director for the sleep lab, with Dr. Donald Stinar, was approved in June 2020, it was not ratified by the physician, so it went through the process again. It was approved.
The medical director for the laboratory was a renewal. "You always have to have a medical pathologist who is overseeing your laboratory, so this is a renewal, because this one will expire on October 31." The governing board approved it.
The following one was an extension for the revenue cycle management agreement with AVEC. Landrum said the hospital already uses AVEC for its billing and this extension was for a year and included outsourcing coding. It was approved.
Also up for renewal was a revolving line of credit with First American Bank. Alesch said it had not been used since he has been at Gila Regional. Edwards noted that the interest rate had gone down, "which is good" and that Stokes was being taken off as a signer and Landrum and Alesch were being added. The renewal was approved.
Salas asked where the hospital does its banking and was told it was Wells Fargo and First American Bank. "Wells Fargo is corporate, but that's a discussion for another day."
A letter requesting bond issuance and need certification for the New Mexico Finance Authority related to the cigarette tax revenue bonds. "This directs the board chairman, which is myself, to sign the letter, so we can move forward to tap cigarette tax bonds."
Landrum said the money will be used to update the hospital medical electronic record to be better able to serve the cancer center and the second part is to pay a large part of the laboratory renovation which is used to compound drugs in the treatment of cancer. The letter was approved.
The next item was the list of the nominees to help the council in the CEO search. They include Ed Wilmot, Dan Otero, James Marshall, John Stanley, Holley Hudgins, Evangeline Zamora, Gail Stamler, Kelsie Skee, George Peru and Priscilla Lucero.
Browne said: "This is an all-star cast. I feel honored that those people accepted our invitation."
The list was approved.
The following item addressed the consideration and change of the CEO contract approval and signing limit. Landrum handed out a sheet with the details of the motion. Salas made the motion to change the contract as presented, with a CEO signing limit of $50,000, the CFO limit at $25,000, and requiring the CEO and board chair to sign if it's over $50,000. Emergency spending would be $100,000 by CEO or CFO, with the board chair's signature. The contract must have board approval.
Browne seconded the motion and noted that the CEO may sign contracts up to a total of $200,000 a year. "Our budget has already approved that item. I would like to add, 'as long as state procurement code had been followed,' because the previous board did not enforce that, and I would like it to be clear that we are." It was approved with the change.
The next to last item was the approval of the medical staff credentialing report. It was approved as presented by the Chief of Staff in his report.
The meeting adjourned as the final item on the agenda.