[Editor's Note: This is part 2 and the final article on the GRMC Governing Board meeting on April 27, 2023. It begins the reports and updates from leadership.]

By Mary Alice Murphy

The first report at the Gila Regional Medical Center Governing Board meeting on April 27, 2023 came from Interim Chief Nursing Officer Cynthia Lewis. "Our focus has been on community needs, social determinants of health and some of the entities that support community health while working with the team members in the organization. You have a great group of folks at Gila Regional working with the leaders, working at the patient level and understanding what the patient needs are. We continue to identify gaps to better meet the patient needs so they choose to come to the organization. One of the things we are working on is to increase the throughput through the Emergency Department. National studies show that the increase of behavioral health or brain chemistry disorders with associated addictive diseases increased the ED length of stay by 30 percent. We are working on ways to decrease that and better meet the patients' needs. Our organization is spending a fair amount of time on the Meditech Expanse upgrade. And we continue to spend time on identifying gaps where we may have some improvement opportunities."

Governing Board Member Harry Browne asked about the wait time for behavioral health patients.

"Yes, for those with the behavioral health or brain chemistry disorders with associated addictive diseases, their wait times increased by about 30 percent," Lewis replied. "They are social determinants we need to analyze and better understand for the community."

She noted that it is that way across the country, often because the resources are limited for the behavioral health or brain chemistry disorders and/or associated addictive diseases and because they are more complicated and recurring. Those with the behavioral health issues do wait longer, but it also affects the wait time for other patients. Identifying ways to help process this group will benefit the hospital and the whole community. She also stated that recent data from the hospital matches the nationwide data at an increase of about 30 percent from 2020 until now. "We spoke about the impact of Covid and how the population reacts in conjunction with the shutdowns and such. It is why it is so important for the hospital to understand the social determinants in order to meet its mission."

Interim Chief Executive Officer Margie Molitor clarified that the data shows an increase of 30 percent of this population in the Emergency Department, not in the hospital overall.

Governing Board Vice Chair Billy Billings, who led the meeting, asked what some of the solutions are.

Lewis said she and Heather [Morrison-Bean, ER director] are working on better educating the team on how to de-escalate any situations. "We are also having more conversations on the referral pattern and with Hidalgo Medical Services on the issues. There's a lot more to come with educating the community and our physicians. It takes a lot of commitment, and it's not unique to Silver City. It's a societal issue. It's going to require a societal commitment. Our educational focus is on meeting the needs of those with brain chemistry disorders and/or associated addictive diseases."

Governing Board Member Chris Ponce asked about educating the team and determining how to get people taken care of more quickly.

"It's about educating the team to deal with the challenges those with brain chemistry disorders face," Lewis said. "The hospital emergency department does understand how to deal with the patients."

Billings noted that at a recent ED visit by a friend of his who was having some mental health issues, "I decided it was serious enough that I would meet him up there. While we were sitting there waiting, a police officer brought in another person with mental health issues and things began to escalate. I think training, the education you're talking about would have really helped, because the patient I was with, understanding, because he has his own mental health issues, actually got up to intervene and calmed the other patient down, where the police officer couldn't. I think education on what not to do to escalate a situation with those you are talking about would be advantageous."

Lewis said the hospital is already offering that sort of education across the hospital, but the program they are looking at would do exactly "what you're talking about with those who are suffering with brain chemistry disorders and/or associated addictive diseases."

Billings said he gets comments and has been in the ED when there is a disturbance. "It seems like it's putting the medical issues in the same environment as those with the issues you're talking about. We used to have a behavioral health unit, but unfortunately it is no longer viable for our size of community."

Lewis agreed that conditions are often worse in rural areas because of a lack of resources.

Chief Financial Officer Patrick Banks said: "We were elated to see state funding for the Hidalgo Medical Services crisis stabilization center. We're hopeful that an effort like that can provide the care needed. We're looking to be partners with the program. The hospital doesn't and shouldn't solve it on our own, but we can help out."

Billings asked if Banks had a Crisis Stabilization Center timeline.

"No, I don't, because we're not part of it," Banks said.

Banks then presented his CFO report. "As usual we're almost a month behind. I'm reporting on the month ending March 31, 2023. It's the quarter end. Over the past couple of months, we're approaching operating margins that have broken even. It's worth mentioning because of what an achievement it is for a community hospital and because it helps us be able to provide for our own capital needs. Our discharge level included several more complicated cases. Our levels look pretty steady. The team worked hard on the 134 discharges with a really rather full house in March. Managing staffing is just as hard as when the facility is empty, because the needs of the patients can't always be anticipated. Seeing us at a breakeven in a month with fluctuating volumes like we haven't seen in recent months is a true credit to the team."

The hospital had a "modest" surplus of $89,000 in March. "We're still sitting on a negative operating surplus for the year, but we're picking away at it. We want to try to avoid the trough that we hit earlier this year."

He said ratios continue to be consistent, and net AR (accounts receivable) days are decreasing. "That's good," he said. "We have 111 days of cash on hand. It's been going up since October. It's reflective of something going right. It shows that our hospital, 40 years old, but with great bones, has a lot of old equipment that we can make a decision to replace without worrying about the health of the hospital and the safety of patients."

Browne said what he was about to say was hard to phrase and might be hard to answer. "The operating surplus is around even. We're covering depreciation with operating revenue, which makes me feel better. Are we generating capital to replace the old plant?"

"No," Banks said. "I feel that it is an incredible improvement from where we were five years ago. I focus on the incredible focus and rigor that has gotten us to where we are today. I do feel strongly that the age of the plant isn't entirely the reason why posting a basically zero surplus is sort of a long-term issue. While the plant is old and some of the equipment is old, we don't settle for taking care of patients with equipment that we shouldn't. Depreciation reflects what we're using today. My concern would be inflation, because it inflates the cost of something bought 10 years ago, 20 years ago. Traditionally, a facility like ours could throw out a 10 percent operating margin, put some aside for profit, which in our case is reinvestment, which in our case is critical for a public-owned not-for-profit hospital. We should also put some aside for inflation for capital equipment costs. Ultimately extraordinary performance today would be 4-5 percent operating margins. Hospitals are being destroyed around the country. I would be extremely confident if the hospital posted zero percent surplus next year, fiscal year 2024, that we were going in the direction we need to be, where with modest support from the outside world to make up for the lower margins, largely caused by our payer mix, we could pay for our own equipment. I would be ecstatic with consistent 3 percent operating margins."

Browne said he suspects some assets are fully depreciated.

Banks said some depreciation is paid for through the operating budget, such as small purchases that don't meet the threshold for capitalization. "We transition from software that used to be depreciated, but now it's a service. More than the breakeven is the goal, but you really can get there with grants, if that funding is available." He continued that at other hospitals where he has worked some have community support. "On the other hand, our operating revenue comes from the patients we serve who live here. One way or the other the hospital is taking care of the patients it needs to, whether through insurance payments or continuing to look for grant support, so we can accomplish the same thing."

The next report came from Molitor. "I continue to look for my replacement. I think it will be easier with our board (of trustees) in place. We are also actively looking for a permanent chief nursing officer. We appreciate Cynthia's talents, but it's time to find a permanent CNO. Dustin Knowles is our new human resources person. He has been a welcome addition to our facility. Everyone is happy to have the expertise back in our walls again. We continue to focus on our department employee engagement plans to improve the engagement at our organization. Every department developed one after our survey in October. We also have a group of staff, nominated by their peers, who have developed a policy with standards of behavior that will be rolled out throughout the organization. It's wonderful that it was developed by staff peers. It will help set the tone and culture for the organization. Under operations, our Joint Commission Survey plan of correction is due by May 19. Ramona Wilson is doing an awesome job on that. On the Meditech Expanse we have three physician champions to help us with this. It is important to have physician buy-in. They are Dr. Sam Rhayem, Dr. Tsering Sherpa and Dr. Brian Robinson. Dr. Robinson has agreed to attend the three-day training for the process. The go live is scheduled for November. I wanted to touch a bit on scheduling. Jonathan Long, our patient financial services director, is doing a lot of great work around scheduling and putting in a lot more rigor into it. If you've had something faxed or an order sent over, we are trying to get that follow up within 24 hours for getting it scheduled. If you had an order sent over or you dropped it off, if you have not heard within three days, please call and talk to Jonathan."

She said, under growth of services, "we are now offering anterior hip replacement. Most people prefer it because it is muscle sparing with a faster recovery time. On recruitment, Dr. Shaheen will hopefully be in a long-term contract status. He will work with Dr. Durando in medical oncology. Dr. Hayostek, radiation oncology, is leaving in September. We have three applicants waiting to replace her. We are putting in an offer to one of the radiation oncologists. We are very pleased to be platinum sponsor of the Tour of the Gila. Our EMS team is providing several units every day of the event and that's a huge commitment. Nurses' Week is May 6-12, and Hospital Week is May 7-13. They always overlap. We will have ads in the newspapers and online."

Billings thanked Molitor and Jonathan Long for the improvements in scheduling. "Hopefully the physicians know there is a new standard so they can let patients know if they haven't heard in three days, they need to call."

Molitor said she would make sure they knew.

Scott Manis, Health Tech regional vice president, presented the management report.

"I will pick up where Patrick left off, about the general challenges in health care a bit more broadly and dial into where we are here," Manis said. "Many rural hospitals are facing enormous financial challenges that haven't been seen previously. Covid exposed the financial cracks in the system. We've weathered it well here, with financial rigor, discipline and very good management overall. I'm pleased with the executive team and the progress they continue to make on the overall strategy. We're just about to conclude three years here. I arrived three years ago as the first interim CEO. We've been through a lot of challenges, but we're in a much better position than we were three years ago. We're not where we want to be, but we've made substantial progress.

"I wanted to remind the public that over the eight years before Health Tech arrived that Gila Regional had lost $47 million in aggregate," Manis continued." Since then, we have stabilized the finances and continue to grow services. We were millions behind in accounts payable. I had vendors calling me, as the CEO, wondering when they were going to get payment. We've made substantial improvements in the revenue process. We've improved the days cash on hand from 9 days a few days before our arrival to now 111 days cash on hand. We've been able to fund new projects from the bottom line. There were no employee raises for five years, but now we are market competitive. We continue to work on improvements in employee engagement and recruitment. We know we're not there yet, but it is a higher focus for us. We have just concluded a successful Joint Commission survey. In 2020, we had our first Joint Commission survey as a critical access hospital. This recent survey was very successful and finally gave us approval for our swing bed program. We've maintained throughout this time our 4-Star rating on Hospital Compare. That's something to be commended. We continue to work on our budget for fiscal year 2024 and our five-year-capital improvement plan to continue to look forward on capital needs for the hospital. We're still working on growing services and balancing that with an aging plant. The actual building is more than 40 years old. Many of the systems are original, so we have to plan for the future. I see a bright future, but we're not without challenges. We look forward to a new board and the recruitment of a permanent CEO and permanent CNO."

During governing board member comments, Ponce apologized for his late arrival. "I completely spaced it. I have no excuse, and I'm sorry for being late."

Browne said: "It happens to all of us."

Billings kind of chuckled and said he wouldn't feel quite as bad when he texts to say: "I'm running 10 minutes late."

The meeting adjourned.

To read the previous article, visit: https://www.grantcountybeat.com/news/news-articles/77981-grmc-governing-board-met-042723-part-1 .

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